hospital_name,last_updated_on,version,hospital_location,hospital_address,license_number|CA,"To the best of its knowledge and belief, the hospital has included all applicable standard charge information in accordance with the requirements of 45 CFR 180.50, and the information encoded is true, accurate, and complete as of the date indicated.",general_contract_provisions,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Margaretville Hospital,12/17/2024,2.1.0,"Margaretville Hospital|Margaretville, NY","42084 State Highway 28, Margaretville, NY 12455",1226701C|New York,TRUE,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
description,code|1,code|1|type,modifiers,code|2,code|2|type,code|3,code|3|type,code|4,code|4|type,setting,drug_unit_of_measurement,drug_type_of_measurement,standard_charge|gross,standard_charge|discounted_cash,standard_charge|discounted_cash|negotiated_percentage,standard_charge|discounted_cash|negotiated_algorithm,estimated_amount|discounted_cash,standard_charge|discounted_cash|methodology,additional_payer_notes|discounted_cash,standard_charge|Medicare_Advantage|negotiated_dollar,standard_charge|Medicare_Advantage|negotiated_percentage,standard_charge|Medicare_Advantage|negotiated_algorithm,estimated_amount|Medicare_Advantage,standard_charge|Medicare_Advantage|methodology,additional_payer_notes|Medicare_Advantage,standard_charge|Aetna|HMO_PPO|negotiated_dollar,standard_charge|Aetna|HMO_PPO|negotiated_percentage,standard_charge|Aetna|HMO_PPO|negotiated_algorithm,estimated_amount|Aetna|HMO_PPO,standard_charge|Aetna|HMO_PPO|methodology,additional_payer_notes|Aetna|HMO_PPO,standard_charge|Aetna|High_Performance_Network|negotiated_dollar,standard_charge|Aetna|High_Performance_Network|negotiated_percentage,standard_charge|Aetna|High_Performance_Network|negotiated_algorithm,estimated_amount|Aetna|High_Performance_Network,standard_charge|Aetna|High_Performance_Network|methodology,additional_payer_notes|Aetna|High_Performance_Network,standard_charge|Blue_Cross|HMO_PPO|negotiated_dollar,standard_charge|Blue_Cross|HMO_PPO|negotiated_percentage,standard_charge|Blue_Cross|HMO_PPO|negotiated_algorithm,estimated_amount|Blue_Cross|HMO_PPO,standard_charge|Blue_Cross|HMO_PPO|methodology,additional_payer_notes|Blue_Cross|HMO_PPO,standard_charge|Blue_Cross|Access|negotiated_dollar,standard_charge|Blue_Cross|Access|negotiated_percentage,standard_charge|Blue_Cross|Access|negotiated_algorithm,estimated_amount|Blue_Cross|Access,standard_charge|Blue_Cross|Access|methodology,additional_payer_notes|Blue_Cross|Access,standard_charge|Blue_Cross|Connection|negotiated_dollar,standard_charge|Blue_Cross|Connection|negotiated_percentage,standard_charge|Blue_Cross|Connection|negotiated_algorithm,estimated_amount|Blue_Cross|Connection,standard_charge|Blue_Cross|Connection|methodology,additional_payer_notes|Blue_Cross|Connection,standard_charge|CDPHP|HMO_Exchange|negotiated_dollar,standard_charge|CDPHP|HMO_Exchange|negotiated_percentage,standard_charge|CDPHP|HMO_Exchange|negotiated_algorithm,estimated_amount|CDPHP|HMO_Exchange,standard_charge|CDPHP|HMO_Exchange|methodology,additional_payer_notes|CDPHP|HMO_Exchange,standard_charge|Emblem|Exchange|negotiated_dollar,standard_charge|Emblem|Exchange|negotiated_percentage,standard_charge|Emblem|Exchange|negotiated_algorithm,estimated_amount|Emblem|Exchange,standard_charge|Emblem|Exchange|methodology,additional_payer_notes|Emblem|Exchange,standard_charge|Fidelis|Exchange|negotiated_dollar,standard_charge|Fidelis|Exchange|negotiated_percentage,standard_charge|Fidelis|Exchange|negotiated_algorithm,estimated_amount|Fidelis|Exchange,standard_charge|Fidelis|Exchange|methodology,additional_payer_notes|Fidelis|Exchange,standard_charge|Emblem_GHI|HMO|negotiated_dollar,standard_charge|Emblem_GHI|HMO|negotiated_percentage,standard_charge|Emblem_GHI|HMO|negotiated_algorithm,estimated_amount|Emblem_GHI|HMO,standard_charge|Emblem_GHI|HMO|methodology,additional_payer_notes|Emblem_GHI|HMO,standard_charge|Emblem_GHI|PPO_CBP|negotiated_dollar,standard_charge|Emblem_GHI|PPO_CBP|negotiated_percentage,standard_charge|Emblem_GHI|PPO_CBP|negotiated_algorithm,estimated_amount|Emblem_GHI|PPO_CBP,standard_charge|Emblem_GHI|PPO_CBP|methodology,additional_payer_notes|Emblem_GHI|PPO_CBP,standard_charge|Emblem_GHI|CBP|negotiated_dollar,standard_charge|Emblem_GHI|CBP|negotiated_percentage,standard_charge|Emblem_GHI|CBP|negotiated_algorithm,estimated_amount|Emblem_GHI|CBP,standard_charge|Emblem_GHI|CBP|methodology,additional_payer_notes|Emblem_GHI|CBP,standard_charge|Emblem_HIP|HMO|negotiated_dollar,standard_charge|Emblem_HIP|HMO|negotiated_percentage,standard_charge|Emblem_HIP|HMO|negotiated_algorithm,estimated_amount|Emblem_HIP|HMO,standard_charge|Emblem_HIP|HMO|methodology,additional_payer_notes|Emblem_HIP|HMO,standard_charge|Emblem_HIP|PPO|negotiated_dollar,standard_charge|Emblem_HIP|PPO|negotiated_percentage,standard_charge|Emblem_HIP|PPO|negotiated_algorithm,estimated_amount|Emblem_HIP|PPO,standard_charge|Emblem_HIP|PPO|methodology,additional_payer_notes|Emblem_HIP|PPO,standard_charge|Magnacare|Preferred|negotiated_dollar,standard_charge|Magnacare|Preferred|negotiated_percentage,standard_charge|Magnacare|Preferred|negotiated_algorithm,estimated_amount|Magnacare|Preferred,standard_charge|Magnacare|Preferred|methodology,additional_payer_notes|Magnacare|Preferred,standard_charge|Magnacare|Standard|negotiated_dollar,standard_charge|Magnacare|Standard|negotiated_percentage,standard_charge|Magnacare|Standard|negotiated_algorithm,estimated_amount|Magnacare|Standard,standard_charge|Magnacare|Standard|methodology,additional_payer_notes|Magnacare|Standard,standard_charge|MVP|HMO|negotiated_dollar,standard_charge|MVP|HMO|negotiated_percentage,standard_charge|MVP|HMO|negotiated_algorithm,estimated_amount|MVP|HMO,standard_charge|MVP|HMO|methodology,additional_payer_notes|MVP|HMO,standard_charge|MVP|Exchange|negotiated_dollar,standard_charge|MVP|Exchange|negotiated_percentage,standard_charge|MVP|Exchange|negotiated_algorithm,estimated_amount|MVP|Exchange,standard_charge|MVP|Exchange|methodology,additional_payer_notes|MVP|Exchange,standard_charge|Oxford|HMO_PPO|negotiated_dollar,standard_charge|Oxford|HMO_PPO|negotiated_percentage,standard_charge|Oxford|HMO_PPO|negotiated_algorithm,estimated_amount|Oxford|HMO_PPO,standard_charge|Oxford|HMO_PPO|methodology,additional_payer_notes|Oxford|HMO_PPO,standard_charge|Oxford|Metro|negotiated_dollar,standard_charge|Oxford|Metro|negotiated_percentage,standard_charge|Oxford|Metro|negotiated_algorithm,estimated_amount|Oxford|Metro,standard_charge|Oxford|Metro|methodology,additional_payer_notes|Oxford|Metro,standard_charge|United_Healthcare|HMO_PPO|negotiated_dollar,standard_charge|United_Healthcare|HMO_PPO|negotiated_percentage,standard_charge|United_Healthcare|HMO_PPO|negotiated_algorithm,estimated_amount|United_Healthcare|HMO_PPO,standard_charge|United_Healthcare|HMO_PPO|methodology,additional_payer_notes|United_Healthcare|HMO_PPO,standard_charge|United_Healthcare|Compass|negotiated_dollar,standard_charge|United_Healthcare|Compass|negotiated_percentage,standard_charge|United_Healthcare|Compass|negotiated_algorithm,estimated_amount|United_Healthcare|Compass,standard_charge|United_Healthcare|Compass|methodology,additional_payer_notes|United_Healthcare|Compass,standard_charge|Medicaid_Advantage|negotiated_dollar,standard_charge|Medicaid_Advantage|negotiated_percentage,standard_charge|Medicaid_Advantage|negotiated_algorithm,estimated_amount|Medicaid_Advantage,standard_charge|Medicaid_Advantage|methodology,additional_payer_notes|Medicaid_Advantage,standard_charge|Child_Health_PLus|negotiated_dollar,standard_charge|Child_Health_Plus|negotiated_percentage,standard_charge|Child_Health_Plus|negotiated_algorithm,estimated_amount|Child_Health_Plus,standard_charge|Child_Health_Plus|methodology,additional_payer_notes|Child_Health_Plus,standard_charge|Fidelis|Child_Health_PLus|negotiated_dollar,standard_charge|Fidelis|Child_Health_Plus|negotiated_percentage,standard_charge|Fidelis|Child_Health_Plus|negotiated_algorithm,estimated_amount|Fidelis|Child_Health_Plus,standard_charge|Fidelis|Child_Health_Plus|methodology,additional_payer_notes|Fidelis|Child_Health_Plus,standard_charge|United_Healthcare|Child_Health_PLus|negotiated_dollar,standard_charge|United_Healthcare|Child_Health_Plus|negotiated_percentage,standard_charge|United_Healthcare|Child_Health_Plus|negotiated_algorithm,estimated_amount|United_Healthcare|Child_Health_Plus,standard_charge|United_Healthcare|Child_Health_Plus|methodology,additional_payer_notes|United_Healthcare|Child_Health_Plus,standard_charge|Essential_3_&_4|negotiated_dollar,standard_charge|Essential_3_&_4|negotiated_percentage,standard_charge|Essential_3_&_4|negotiated_algorithm,estimated_amount|Essential_3_&_4,standard_charge|Essential_3_&_4|methodology,additional_payer_notes|Essential_3_&_4,standard_charge|CDPHP|Essential_1_&_2|negotiated_dollar,standard_charge|CDPHP|Essential_1_&_2|negotiated_percentage,standard_charge|CDPHP|Essential_1_&_2|negotiated_algorithm,estimated_amount|CDPHP|Essential_1_&_2,standard_charge|CDPHP|Essential_1_&_2|methodology,additional_payer_notes|CDPHP|Essential_1_&_2,standard_charge|Empire_HealthPlus|Essential_1_&_2|negotiated_dollar,standard_charge|Empire_HealthPlus|Essential_1_&_2|negotiated_percentage,standard_charge|Empire_HealthPlus|Essential_1_&_2|negotiated_algorithm,estimated_amount|Empire_HealthPlus|Essential_1_&_2,standard_charge|Empire_HealthPlus|Essential_1_&_2|methodology,additional_payer_notes|Empire_HealthPlus|Essential_1_&_2,standard_charge|Empire_HealthPlus|Exchange|negotiated_dollar,standard_charge|Empire_HealthPlus|Exchange|negotiated_percentage,standard_charge|Empire_HealthPlus|Exchange|negotiated_algorithm,estimated_amount|Empire_HealthPlus|Exchange,standard_charge|Empire_HealthPlus|Exchange|methodology,additional_payer_notes|Empire_HealthPlus|Exchange,standard_charge|Fidelis|Essential_1_&_2|negotiated_dollar,standard_charge|Fidelis|Essential_1_&_2|negotiated_percentage,standard_charge|Fidelis|Essential_1_&_2|negotiated_algorithm,estimated_amount|Fidelis|Essential_1_&_2,standard_charge|Fidelis|Essential_1_&_2|methodology,additional_payer_notes|Fidelis|Essential_1_&_2,standard_charge|HealthFirst|Essential_1_&_2|negotiated_dollar,standard_charge|HealthFirst|Essential_1_&_2|negotiated_percentage,standard_charge|HealthFirst|Essential_1_&_2|negotiated_algorithm,estimated_amount|HealthFirst|Essential_1_&_2,standard_charge|HealthFirst|Essential_1_&_2|methodology,additional_payer_notes|HealthFirst|Essential_1_&_2,standard_charge|HealthFirst|Exchange|negotiated_dollar,standard_charge|HealthFirst|Exchange|negotiated_percentage,standard_charge|HealthFirst|Exchange|negotiated_algorithm,estimated_amount|HealthFirst|Exchange,standard_charge|HealthFirst|Exchange|methodology,additional_payer_notes|HealthFirst|Exchange,standard_charge|MVP|Essential_1_&_2|negotiated_dollar,standard_charge|MVP|Essential_1_&_2|negotiated_percentage,standard_charge|MVP|Essential_1_&_2|negotiated_algorithm,estimated_amount|MVP|Essential_1_&_2,standard_charge|MVP|Essential_1_&_2|methodology,additional_payer_notes|MVP|Essential_1_&_2,standard_charge|MVP|Essential_3_&_4|negotiated_dollar,standard_charge|MVP|Essential_3_&_4|negotiated_percentage,standard_charge|MVP|Essential_3_&_4|negotiated_algorithm,estimated_amount|MVP|Essential_3_&_4,standard_charge|MVP|Essential_3_&_4|methodology,additional_payer_notes|MVP|Essential_3_&_4,standard_charge|United_Healthcare|Essential_1_to_4|negotiated_dollar,standard_charge|United_Healthcare|Essential_1_to_4|negotiated_percentage,standard_charge|United_Healthcare|Essential_1_to_4|negotiated_algorithm,estimated_amount|United_Healthcare|Essential_1_to_4,standard_charge|United_Healthcare|Essential_1_to_4|methodology,additional_payer_notes|United_Healthcare|Essential_1_to_4,standard_charge|min,standard_charge|max,additional_generic_notes
0.45% SODIUM CHLORIDE 500ML,,,,80000002,CDM,250,RC,264780210,NDC,both,24,ML,1.22,0.48,39.4668,,0.48,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.41,34,,0.41,percent of total billed charges,"Drugs, Inpatient Only",0.41,34,,0.41,percent of total billed charges,"Drugs, Inpatient Only",0.41,34,,0.41,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.85,70,,0.85,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.41,,,0.41,Other,Drug Cost,0.41,,,0.41,Other,Drug Cost,0.41,,,0.41,Other,Drug Cost,0.41,,,0.41,Other,Drug Cost,0.41,,,0.41,Other,Drug Cost,0.41,,,0.41,Other,Drug Cost,0.91,,,0.91,Other,225% of Medicaid,0.57,,,0.57,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.87,,,0.87,Other,215% Medicaid APG methodology,0.87,,,0.87,Other,215% Medicaid APG methodology,0.51,,,0.51,Other,125% Medicaid APG methodology,0.01,0.91,
ABACAVIR 300 MG TAB,,,,80000005,CDM,250,RC,31722055760,NDC,both,60,EA,0.84,0.33,39.4668,,0.33,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.28,34,,0.28,percent of total billed charges,"Drugs, Inpatient Only",0.28,34,,0.28,percent of total billed charges,"Drugs, Inpatient Only",0.28,34,,0.28,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.59,70,,0.59,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.28,,,0.28,Other,Drug Cost,0.28,,,0.28,Other,Drug Cost,0.28,,,0.28,Other,Drug Cost,0.28,,,0.28,Other,Drug Cost,0.28,,,0.28,Other,Drug Cost,0.28,,,0.28,Other,Drug Cost,0.63,,,0.63,Other,225% of Medicaid,0.39,,,0.39,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.6,,,0.6,Other,215% Medicaid APG methodology,0.6,,,0.6,Other,215% Medicaid APG methodology,0.35,,,0.35,Other,125% Medicaid APG methodology,0.01,0.63,
ABSORBABLE GELATIN FILM,,,,80000007,CDM,250,RC,9029703,NDC,both,6,EA,689.58,272.16,39.4668,,272.16,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,234.46,34,,234.46,percent of total billed charges,"Drugs, Inpatient Only",234.46,34,,234.46,percent of total billed charges,"Drugs, Inpatient Only",234.46,34,,234.46,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,482.71,70,,482.71,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,229.86,,,229.86,Other,Drug Cost,229.86,,,229.86,Other,Drug Cost,229.86,,,229.86,Other,Drug Cost,229.86,,,229.86,Other,Drug Cost,229.86,,,229.86,Other,Drug Cost,229.86,,,229.86,Other,Drug Cost,517.19,,,517.19,Other,225% of Medicaid,321.8,,,321.8,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,494.2,,,494.2,Other,215% Medicaid APG methodology,494.2,,,494.2,Other,215% Medicaid APG methodology,287.33,,,287.33,Other,125% Medicaid APG methodology,0.01,517.19,
ACETAMINOPHEN 325 MG TAB,,,,80000016,CDM,250,RC,536132701,NDC,both,100,EA,0.03,0.01,39.4668,,0.01,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.02,70,,0.02,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.02,,,0.02,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,0.02,
ACETAMINOPHEN 325 MG SUPP,,,,80000017,CDM,250,RC,51672211602,NDC,both,6,EA,0.12,0.05,39.4668,,0.05,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.04,34,,0.04,percent of total billed charges,"Drugs, Inpatient Only",0.04,34,,0.04,percent of total billed charges,"Drugs, Inpatient Only",0.04,34,,0.04,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.08,70,,0.08,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.09,,,0.09,Other,225% of Medicaid,0.05,,,0.05,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.08,,,0.08,Other,215% Medicaid APG methodology,0.08,,,0.08,Other,215% Medicaid APG methodology,0.05,,,0.05,Other,125% Medicaid APG methodology,0.01,0.09,
ACETAMINOPHEN 650MG ORAL SUSP,,,,80000019,CDM,250,RC,121197100,NDC,both,20.3,ML,1.74,0.69,39.4668,,0.69,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.59,34,,0.59,percent of total billed charges,"Drugs, Inpatient Only",0.59,34,,0.59,percent of total billed charges,"Drugs, Inpatient Only",0.59,34,,0.59,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1.22,70,,1.22,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.58,,,0.58,Other,Drug Cost,0.58,,,0.58,Other,Drug Cost,0.58,,,0.58,Other,Drug Cost,0.58,,,0.58,Other,Drug Cost,0.58,,,0.58,Other,Drug Cost,0.58,,,0.58,Other,Drug Cost,1.3,,,1.3,Other,225% of Medicaid,0.81,,,0.81,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,1.25,,,1.25,Other,215% Medicaid APG methodology,1.25,,,1.25,Other,215% Medicaid APG methodology,0.72,,,0.72,Other,125% Medicaid APG methodology,0.01,1.3,
ACETAZOLAMIDE 250 MG,,,,80000025,CDM,250,RC,23155028801,NDC,both,100,EA,0.11,0.04,39.4668,,0.04,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.04,34,,0.04,percent of total billed charges,"Drugs, Inpatient Only",0.04,34,,0.04,percent of total billed charges,"Drugs, Inpatient Only",0.04,34,,0.04,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.08,70,,0.08,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.08,,,0.08,Other,225% of Medicaid,0.05,,,0.05,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.08,,,0.08,Other,215% Medicaid APG methodology,0.08,,,0.08,Other,215% Medicaid APG methodology,0.04,,,0.04,Other,125% Medicaid APG methodology,0.01,0.08,
ACETAZOLAMIDE 500 MG CAP ER,,,,80000026,CDM,250,RC,51285075402,NDC,both,100,EA,25.14,9.92,39.4668,,9.92,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,8.55,34,,8.55,percent of total billed charges,"Drugs, Inpatient Only",8.55,34,,8.55,percent of total billed charges,"Drugs, Inpatient Only",8.55,34,,8.55,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,17.6,70,,17.6,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,8.38,,,8.38,Other,Drug Cost,8.38,,,8.38,Other,Drug Cost,8.38,,,8.38,Other,Drug Cost,8.38,,,8.38,Other,Drug Cost,8.38,,,8.38,Other,Drug Cost,8.38,,,8.38,Other,Drug Cost,18.85,,,18.85,Other,225% of Medicaid,11.73,,,11.73,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,18.02,,,18.02,Other,215% Medicaid APG methodology,18.02,,,18.02,Other,215% Medicaid APG methodology,10.47,,,10.47,Other,125% Medicaid APG methodology,0.01,18.85,
ACETIC ACID 0.25% IRRIGATION S,,,,80000028,CDM,250,RC,264230400,NDC,both,1000,ML,5.26,2.08,39.4668,,2.08,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1.79,34,,1.79,percent of total billed charges,"Drugs, Inpatient Only",1.79,34,,1.79,percent of total billed charges,"Drugs, Inpatient Only",1.79,34,,1.79,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,3.68,70,,3.68,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1.75,,,1.75,Other,Drug Cost,1.75,,,1.75,Other,Drug Cost,1.75,,,1.75,Other,Drug Cost,1.75,,,1.75,Other,Drug Cost,1.75,,,1.75,Other,Drug Cost,1.75,,,1.75,Other,Drug Cost,3.94,,,3.94,Other,225% of Medicaid,2.45,,,2.45,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,3.77,,,3.77,Other,215% Medicaid APG methodology,3.77,,,3.77,Other,215% Medicaid APG methodology,2.19,,,2.19,Other,125% Medicaid APG methodology,0.01,3.94,
ACETONE 120ML,,,,80000032,CDM,250,RC,395001994,NDC,both,1,ML,26.13,10.31,39.4668,,10.31,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,8.88,34,,8.88,percent of total billed charges,"Drugs, Inpatient Only",8.88,34,,8.88,percent of total billed charges,"Drugs, Inpatient Only",8.88,34,,8.88,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,18.29,70,,18.29,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,8.71,,,8.71,Other,Drug Cost,8.71,,,8.71,Other,Drug Cost,8.71,,,8.71,Other,Drug Cost,8.71,,,8.71,Other,Drug Cost,8.71,,,8.71,Other,Drug Cost,8.71,,,8.71,Other,Drug Cost,19.6,,,19.6,Other,225% of Medicaid,12.19,,,12.19,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,18.73,,,18.73,Other,215% Medicaid APG methodology,18.73,,,18.73,Other,215% Medicaid APG methodology,10.89,,,10.89,Other,125% Medicaid APG methodology,0.01,19.6,
ACETYECYSTENE 20% 4 ML,,,,80000033,CDM,250,RC,63323069404,NDC,both,25,ML,10.06,3.97,39.4668,,3.97,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,3.42,34,,3.42,percent of total billed charges,"Drugs, Inpatient Only",3.42,34,,3.42,percent of total billed charges,"Drugs, Inpatient Only",3.42,34,,3.42,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,7.04,70,,7.04,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,3.35,,,3.35,Other,Drug Cost,3.35,,,3.35,Other,Drug Cost,3.35,,,3.35,Other,Drug Cost,3.35,,,3.35,Other,Drug Cost,3.35,,,3.35,Other,Drug Cost,3.35,,,3.35,Other,Drug Cost,7.54,,,7.54,Other,225% of Medicaid,4.69,,,4.69,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,7.21,,,7.21,Other,215% Medicaid APG methodology,7.21,,,7.21,Other,215% Medicaid APG methodology,4.19,,,4.19,Other,125% Medicaid APG methodology,0.01,7.54,
ACETYLCHOLINE 1% OPTH INJ,,,,80000035,CDM,250,RC,24208053920,NDC,both,1,EA,65.43,25.82,39.4668,,25.82,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,22.25,34,,22.25,percent of total billed charges,"Drugs, Inpatient Only",22.25,34,,22.25,percent of total billed charges,"Drugs, Inpatient Only",22.25,34,,22.25,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,45.8,70,,45.8,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,21.81,,,21.81,Other,Drug Cost,21.81,,,21.81,Other,Drug Cost,21.81,,,21.81,Other,Drug Cost,21.81,,,21.81,Other,Drug Cost,21.81,,,21.81,Other,Drug Cost,21.81,,,21.81,Other,Drug Cost,49.07,,,49.07,Other,225% of Medicaid,30.53,,,30.53,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,46.89,,,46.89,Other,215% Medicaid APG methodology,46.89,,,46.89,Other,215% Medicaid APG methodology,27.26,,,27.26,Other,125% Medicaid APG methodology,0.01,49.07,
ACETYLCYSTEINE 200 MG/ML 30 ML,,,,80000037,CDM,250,RC,409330803,NDC,both,3,ML,22.21,8.77,39.4668,,8.77,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,7.55,34,,7.55,percent of total billed charges,"Drugs, Inpatient Only",7.55,34,,7.55,percent of total billed charges,"Drugs, Inpatient Only",7.55,34,,7.55,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,15.55,70,,15.55,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,7.4,,,7.4,Other,Drug Cost,7.4,,,7.4,Other,Drug Cost,7.4,,,7.4,Other,Drug Cost,7.4,,,7.4,Other,Drug Cost,7.4,,,7.4,Other,Drug Cost,7.4,,,7.4,Other,Drug Cost,16.66,,,16.66,Other,225% of Medicaid,10.36,,,10.36,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,15.92,,,15.92,Other,215% Medicaid APG methodology,15.92,,,15.92,Other,215% Medicaid APG methodology,9.25,,,9.25,Other,125% Medicaid APG methodology,0.01,16.66,
ACIDOPH-PECTIN 1 CAPSULE,,,,80000040,CDM,250,RC,43292050022,NDC,both,100,EA,0.08,0.03,39.4668,,0.03,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.03,34,,0.03,percent of total billed charges,"Drugs, Inpatient Only",0.03,34,,0.03,percent of total billed charges,"Drugs, Inpatient Only",0.03,34,,0.03,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.06,70,,0.06,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.06,,,0.06,Other,225% of Medicaid,0.04,,,0.04,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.06,,,0.06,Other,215% Medicaid APG methodology,0.06,,,0.06,Other,215% Medicaid APG methodology,0.03,,,0.03,Other,125% Medicaid APG methodology,0.01,0.06,
ACTIVATED CHARCOAL 25 G/120 ML,,,,80000041,CDM,250,RC,574052174,NDC,both,1,ML,25.14,9.92,39.4668,,9.92,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,8.55,34,,8.55,percent of total billed charges,"Drugs, Inpatient Only",8.55,34,,8.55,percent of total billed charges,"Drugs, Inpatient Only",8.55,34,,8.55,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,17.6,70,,17.6,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,8.38,,,8.38,Other,Drug Cost,8.38,,,8.38,Other,Drug Cost,8.38,,,8.38,Other,Drug Cost,8.38,,,8.38,Other,Drug Cost,8.38,,,8.38,Other,Drug Cost,8.38,,,8.38,Other,Drug Cost,18.86,,,18.86,Other,225% of Medicaid,11.73,,,11.73,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,18.02,,,18.02,Other,215% Medicaid APG methodology,18.02,,,18.02,Other,215% Medicaid APG methodology,10.48,,,10.48,Other,125% Medicaid APG methodology,0.01,18.86,
ACTIVATED CHARCOAL 50 G/240 ML,,,,80000042,CDM,250,RC,66689020108,NDC,both,1,ML,6.51,2.57,39.4668,,2.57,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2.21,34,,2.21,percent of total billed charges,"Drugs, Inpatient Only",2.21,34,,2.21,percent of total billed charges,"Drugs, Inpatient Only",2.21,34,,2.21,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,4.56,70,,4.56,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2.17,,,2.17,Other,Drug Cost,2.17,,,2.17,Other,Drug Cost,2.17,,,2.17,Other,Drug Cost,2.17,,,2.17,Other,Drug Cost,2.17,,,2.17,Other,Drug Cost,2.17,,,2.17,Other,Drug Cost,4.88,,,4.88,Other,225% of Medicaid,3.04,,,3.04,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,4.67,,,4.67,Other,215% Medicaid APG methodology,4.67,,,4.67,Other,215% Medicaid APG methodology,2.71,,,2.71,Other,125% Medicaid APG methodology,0.01,4.88,
ACYCLOVIR 200 MG,,,,80000045,CDM,250,RC,904578961,NDC,both,10,EA,2.15,0.85,39.4668,,0.85,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.73,34,,0.73,percent of total billed charges,"Drugs, Inpatient Only",0.73,34,,0.73,percent of total billed charges,"Drugs, Inpatient Only",0.73,34,,0.73,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1.51,70,,1.51,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.72,,,0.72,Other,Drug Cost,0.72,,,0.72,Other,Drug Cost,0.72,,,0.72,Other,Drug Cost,0.72,,,0.72,Other,Drug Cost,0.72,,,0.72,Other,Drug Cost,0.72,,,0.72,Other,Drug Cost,1.61,,,1.61,Other,225% of Medicaid,1,,,1,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,1.54,,,1.54,Other,215% Medicaid APG methodology,1.54,,,1.54,Other,215% Medicaid APG methodology,0.9,,,0.9,Other,125% Medicaid APG methodology,0.01,1.61,
ACYCLOVIR 400 MG,,,,80000046,CDM,250,RC,31722077701,NDC,both,100,EA,0.12,0.05,39.4668,,0.05,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.04,34,,0.04,percent of total billed charges,"Drugs, Inpatient Only",0.04,34,,0.04,percent of total billed charges,"Drugs, Inpatient Only",0.04,34,,0.04,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.09,70,,0.09,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.09,,,0.09,Other,225% of Medicaid,0.06,,,0.06,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.09,,,0.09,Other,215% Medicaid APG methodology,0.09,,,0.09,Other,215% Medicaid APG methodology,0.05,,,0.05,Other,125% Medicaid APG methodology,0.01,0.09,
ALBUTEROL 2MG,,,,80000055,CDM,250,RC,53489017601,NDC,both,100,EA,0.55,0.22,39.4668,,0.22,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.19,34,,0.19,percent of total billed charges,"Drugs, Inpatient Only",0.19,34,,0.19,percent of total billed charges,"Drugs, Inpatient Only",0.19,34,,0.19,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.39,70,,0.39,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.18,,,0.18,Other,Drug Cost,0.18,,,0.18,Other,Drug Cost,0.18,,,0.18,Other,Drug Cost,0.18,,,0.18,Other,Drug Cost,0.18,,,0.18,Other,Drug Cost,0.18,,,0.18,Other,Drug Cost,0.41,,,0.41,Other,225% of Medicaid,0.26,,,0.26,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.39,,,0.39,Other,215% Medicaid APG methodology,0.39,,,0.39,Other,215% Medicaid APG methodology,0.23,,,0.23,Other,125% Medicaid APG methodology,0.01,0.41,
ALBUTEROL 2.5MG/3ML,,,,80000057,CDM,250,RC,76204020030,NDC,both,30,ML,0.32,0.13,39.4668,,0.13,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.11,34,,0.11,percent of total billed charges,"Drugs, Inpatient Only",0.11,34,,0.11,percent of total billed charges,"Drugs, Inpatient Only",0.11,34,,0.11,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.22,70,,0.22,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.11,,,0.11,Other,Drug Cost,0.11,,,0.11,Other,Drug Cost,0.11,,,0.11,Other,Drug Cost,0.11,,,0.11,Other,Drug Cost,0.11,,,0.11,Other,Drug Cost,0.11,,,0.11,Other,Drug Cost,0.24,,,0.24,Other,225% of Medicaid,0.15,,,0.15,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.23,,,0.23,Other,215% Medicaid APG methodology,0.23,,,0.23,Other,215% Medicaid APG methodology,0.13,,,0.13,Other,125% Medicaid APG methodology,0.01,0.24,
ALBUTEROL METERED DOSE INHALER,,,,80000060,CDM,250,RC,781729685,NDC,both,1,GM,10.38,4.1,39.4668,,4.1,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,3.53,34,,3.53,percent of total billed charges,"Drugs, Inpatient Only",3.53,34,,3.53,percent of total billed charges,"Drugs, Inpatient Only",3.53,34,,3.53,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,7.27,70,,7.27,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,3.46,,,3.46,Other,Drug Cost,3.46,,,3.46,Other,Drug Cost,3.46,,,3.46,Other,Drug Cost,3.46,,,3.46,Other,Drug Cost,3.46,,,3.46,Other,Drug Cost,3.46,,,3.46,Other,Drug Cost,7.79,,,7.79,Other,225% of Medicaid,4.84,,,4.84,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,7.44,,,7.44,Other,215% Medicaid APG methodology,7.44,,,7.44,Other,215% Medicaid APG methodology,4.33,,,4.33,Other,125% Medicaid APG methodology,0.01,7.79,
ALLOPURINOL 100MG,,,,80000065,CDM,250,RC,603211521,NDC,both,100,EA,0.04,0.02,39.4668,,0.02,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.02,34,,0.02,percent of total billed charges,"Drugs, Inpatient Only",0.02,34,,0.02,percent of total billed charges,"Drugs, Inpatient Only",0.02,34,,0.02,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.03,70,,0.03,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.03,,,0.03,Other,225% of Medicaid,0.02,,,0.02,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.03,,,0.03,Other,215% Medicaid APG methodology,0.03,,,0.03,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,125% Medicaid APG methodology,0.01,0.03,
ALLOPURINOL 300 MG,,,,80000066,CDM,250,RC,603211621,NDC,both,100,EA,0.04,0.02,39.4668,,0.02,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.03,70,,0.03,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.03,,,0.03,Other,225% of Medicaid,0.02,,,0.02,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.03,,,0.03,Other,215% Medicaid APG methodology,0.03,,,0.03,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,125% Medicaid APG methodology,0.01,0.03,
ALPRAZOLAM 0.25 MG,,,,80000068,CDM,250,RC,65862067601,NDC,both,100,EA,0.03,0.01,39.4668,,0.01,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.02,70,,0.02,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.02,,,0.02,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,0.02,
ALPRAZOLAM 0.5 MG,,,,80000069,CDM,250,RC,228202910,NDC,both,100,EA,0.03,0.01,39.4668,,0.01,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.02,70,,0.02,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.02,,,0.02,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,0.02,
AMANTADINE 100 MG,,,,80000075,CDM,250,RC,832101500,NDC,both,100,EA,0.03,0.01,39.4668,,0.01,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.02,70,,0.02,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.02,,,0.02,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,0.02,
AMANTADINE 50MG/5ML,,,,80000076,CDM,250,RC,121064610,NDC,both,100,ML,0.27,0.11,39.4668,,0.11,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.09,34,,0.09,percent of total billed charges,"Drugs, Inpatient Only",0.09,34,,0.09,percent of total billed charges,"Drugs, Inpatient Only",0.09,34,,0.09,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.19,70,,0.19,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.09,,,0.09,Other,Drug Cost,0.09,,,0.09,Other,Drug Cost,0.09,,,0.09,Other,Drug Cost,0.09,,,0.09,Other,Drug Cost,0.09,,,0.09,Other,Drug Cost,0.09,,,0.09,Other,Drug Cost,0.2,,,0.2,Other,225% of Medicaid,0.13,,,0.13,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.19,,,0.19,Other,215% Medicaid APG methodology,0.19,,,0.19,Other,215% Medicaid APG methodology,0.11,,,0.11,Other,125% Medicaid APG methodology,0.01,0.2,
AMINOCAP ACID 250MG/ML,,,,80000087,CDM,250,RC,409434673,NDC,both,25,ML,6.25,2.47,39.4668,,2.47,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2.13,34,,2.13,percent of total billed charges,"Drugs, Inpatient Only",2.13,34,,2.13,percent of total billed charges,"Drugs, Inpatient Only",2.13,34,,2.13,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,4.38,70,,4.38,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2.08,,,2.08,Other,Drug Cost,2.08,,,2.08,Other,Drug Cost,2.08,,,2.08,Other,Drug Cost,2.08,,,2.08,Other,Drug Cost,2.08,,,2.08,Other,Drug Cost,2.08,,,2.08,Other,Drug Cost,4.69,,,4.69,Other,225% of Medicaid,2.92,,,2.92,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,4.48,,,4.48,Other,215% Medicaid APG methodology,4.48,,,4.48,Other,215% Medicaid APG methodology,2.6,,,2.6,Other,125% Medicaid APG methodology,0.01,4.69,
AMINOCAPOROIC ACID (AMICAR) 500 MG,,,,80000088,CDM,250,RC,69238163703,NDC,both,30,EA,0.07,0.03,39.4668,,0.03,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.02,34,,0.02,percent of total billed charges,"Drugs, Inpatient Only",0.02,34,,0.02,percent of total billed charges,"Drugs, Inpatient Only",0.02,34,,0.02,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.05,70,,0.05,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.05,,,0.05,Other,225% of Medicaid,0.03,,,0.03,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.05,,,0.05,Other,215% Medicaid APG methodology,0.05,,,0.05,Other,215% Medicaid APG methodology,0.03,,,0.03,Other,125% Medicaid APG methodology,0.01,0.05,
AMIODARONE 150MG/100ML,,,,80000097,CDM,250,RC,43066015010,NDC,both,12,ML,55.14,21.76,39.4668,,21.76,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,18.75,34,,18.75,percent of total billed charges,"Drugs, Inpatient Only",18.75,34,,18.75,percent of total billed charges,"Drugs, Inpatient Only",18.75,34,,18.75,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,38.6,70,,38.6,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,18.38,,,18.38,Other,Drug Cost,18.38,,,18.38,Other,Drug Cost,18.38,,,18.38,Other,Drug Cost,18.38,,,18.38,Other,Drug Cost,18.38,,,18.38,Other,Drug Cost,18.38,,,18.38,Other,Drug Cost,41.36,,,41.36,Other,225% of Medicaid,25.73,,,25.73,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,39.52,,,39.52,Other,215% Medicaid APG methodology,39.52,,,39.52,Other,215% Medicaid APG methodology,22.98,,,22.98,Other,125% Medicaid APG methodology,0.01,41.36,
AMIODARONE 200 MG TAB,,,,80000098,CDM,250,RC,51672402504,NDC,both,60,EA,0.13,0.05,39.4668,,0.05,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.04,34,,0.04,percent of total billed charges,"Drugs, Inpatient Only",0.04,34,,0.04,percent of total billed charges,"Drugs, Inpatient Only",0.04,34,,0.04,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.09,70,,0.09,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.1,,,0.1,Other,225% of Medicaid,0.06,,,0.06,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.09,,,0.09,Other,215% Medicaid APG methodology,0.09,,,0.09,Other,215% Medicaid APG methodology,0.05,,,0.05,Other,125% Medicaid APG methodology,0.01,0.1,
AMITRIPTYLINE 10MG,,,,80000099,CDM,250,RC,16729017101,NDC,both,100,EA,0.03,0.01,39.4668,,0.01,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.02,70,,0.02,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.02,,,0.02,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,0.02,
AMITRIPTYLINE 25 MG,,,,80000100,CDM,250,RC,16729017201,NDC,both,100,EA,0.03,0.01,39.4668,,0.01,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.02,70,,0.02,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.02,,,0.02,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,0.02,
AMITRIPTYLINE 50MG TABLET,,,,80000102,CDM,250,RC,16729017301,NDC,both,100,EA,0.03,0.01,39.4668,,0.01,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.02,70,,0.02,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.02,,,0.02,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,0.02,
AMLODIPINE 10MG TAB,,,,80000107,CDM,250,RC,67877019990,NDC,both,90,EA,0.03,0.01,39.4668,,0.01,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.02,70,,0.02,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.02,,,0.02,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,0.02,
AMLODIPINE 2.5MG TAB,,,,80000108,CDM,250,RC,69152068,NDC,both,90,EA,0.03,0.01,39.4668,,0.01,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.02,70,,0.02,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.02,,,0.02,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,0.02,
AMLODIPINE 5MG TAB,,,,80000109,CDM,250,RC,69097012705,NDC,both,90,EA,0.03,0.01,39.4668,,0.01,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.02,70,,0.02,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.02,,,0.02,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,0.02,
AMMONIUM LACTATE (LAC-HYDRIN) 12% LOTN,,,,80000111,CDM,250,RC,904598426,NDC,both,1,GM,9.6,3.79,39.4668,,3.79,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,3.26,34,,3.26,percent of total billed charges,"Drugs, Inpatient Only",3.26,34,,3.26,percent of total billed charges,"Drugs, Inpatient Only",3.26,34,,3.26,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,6.72,70,,6.72,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,3.2,,,3.2,Other,Drug Cost,3.2,,,3.2,Other,Drug Cost,3.2,,,3.2,Other,Drug Cost,3.2,,,3.2,Other,Drug Cost,3.2,,,3.2,Other,Drug Cost,3.2,,,3.2,Other,Drug Cost,7.2,,,7.2,Other,225% of Medicaid,4.48,,,4.48,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,6.88,,,6.88,Other,215% Medicaid APG methodology,6.88,,,6.88,Other,215% Medicaid APG methodology,4,,,4,Other,125% Medicaid APG methodology,0.01,7.2,
AMMONIUM LACTATE 140GM,,,,80000112,CDM,250,RC,45802049383,NDC,both,2,GM,11.04,4.36,39.4668,,4.36,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,3.75,34,,3.75,percent of total billed charges,"Drugs, Inpatient Only",3.75,34,,3.75,percent of total billed charges,"Drugs, Inpatient Only",3.75,34,,3.75,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,7.73,70,,7.73,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,3.68,,,3.68,Other,Drug Cost,3.68,,,3.68,Other,Drug Cost,3.68,,,3.68,Other,Drug Cost,3.68,,,3.68,Other,Drug Cost,3.68,,,3.68,Other,Drug Cost,3.68,,,3.68,Other,Drug Cost,8.28,,,8.28,Other,225% of Medicaid,5.15,,,5.15,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,7.91,,,7.91,Other,215% Medicaid APG methodology,7.91,,,7.91,Other,215% Medicaid APG methodology,4.6,,,4.6,Other,125% Medicaid APG methodology,0.01,8.28,
AMOXICILLIN 250 MG,,,,80000118,CDM,250,RC,781202001,NDC,both,100,EA,0.03,0.01,39.4668,,0.01,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.02,70,,0.02,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.03,,,0.03,Other,225% of Medicaid,0.02,,,0.02,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,0.03,
AMOXICILLIN 500 MG,,,,80000122,CDM,250,RC,781261305,NDC,both,500,EA,0.06,0.02,39.4668,,0.02,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.02,34,,0.02,percent of total billed charges,"Drugs, Inpatient Only",0.02,34,,0.02,percent of total billed charges,"Drugs, Inpatient Only",0.02,34,,0.02,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.04,70,,0.04,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.05,,,0.05,Other,225% of Medicaid,0.03,,,0.03,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.04,,,0.04,Other,215% Medicaid APG methodology,0.04,,,0.04,Other,215% Medicaid APG methodology,0.03,,,0.03,Other,125% Medicaid APG methodology,0.01,0.05,
AMOXICILLIN-POT CLAV  250MG TABLET,,,,80000123,CDM,250,RC,781187431,NDC,both,30,EA,2.07,0.82,39.4668,,0.82,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.7,34,,0.7,percent of total billed charges,"Drugs, Inpatient Only",0.7,34,,0.7,percent of total billed charges,"Drugs, Inpatient Only",0.7,34,,0.7,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1.45,70,,1.45,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.69,,,0.69,Other,Drug Cost,0.69,,,0.69,Other,Drug Cost,0.69,,,0.69,Other,Drug Cost,0.69,,,0.69,Other,Drug Cost,0.69,,,0.69,Other,Drug Cost,0.69,,,0.69,Other,Drug Cost,1.55,,,1.55,Other,225% of Medicaid,0.97,,,0.97,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,1.48,,,1.48,Other,215% Medicaid APG methodology,1.48,,,1.48,Other,215% Medicaid APG methodology,0.86,,,0.86,Other,125% Medicaid APG methodology,0.01,1.55,
AMOXICILLIN-POT CLAV 400MG/5ML 50 ML,,,,80000126,CDM,250,RC,143998250,NDC,both,1,ML,3.27,1.29,39.4668,,1.29,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1.11,34,,1.11,percent of total billed charges,"Drugs, Inpatient Only",1.11,34,,1.11,percent of total billed charges,"Drugs, Inpatient Only",1.11,34,,1.11,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2.29,70,,2.29,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1.09,,,1.09,Other,Drug Cost,1.09,,,1.09,Other,Drug Cost,1.09,,,1.09,Other,Drug Cost,1.09,,,1.09,Other,Drug Cost,1.09,,,1.09,Other,Drug Cost,1.09,,,1.09,Other,Drug Cost,2.45,,,2.45,Other,225% of Medicaid,1.53,,,1.53,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,2.34,,,2.34,Other,215% Medicaid APG methodology,2.34,,,2.34,Other,215% Medicaid APG methodology,1.36,,,1.36,Other,125% Medicaid APG methodology,0.01,2.45,
AMOXICILLIN-POT CLAV 500 MG,,,,80000127,CDM,250,RC,65862050220,NDC,both,20,EA,0.32,0.12,39.4668,,0.12,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.11,34,,0.11,percent of total billed charges,"Drugs, Inpatient Only",0.11,34,,0.11,percent of total billed charges,"Drugs, Inpatient Only",0.11,34,,0.11,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.22,70,,0.22,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.11,,,0.11,Other,Drug Cost,0.11,,,0.11,Other,Drug Cost,0.11,,,0.11,Other,Drug Cost,0.11,,,0.11,Other,Drug Cost,0.11,,,0.11,Other,Drug Cost,0.11,,,0.11,Other,Drug Cost,0.24,,,0.24,Other,225% of Medicaid,0.15,,,0.15,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.23,,,0.23,Other,215% Medicaid APG methodology,0.23,,,0.23,Other,215% Medicaid APG methodology,0.13,,,0.13,Other,125% Medicaid APG methodology,0.01,0.24,
AMOXICILLIN-POT CLAV 875 MG,,,,80000128,CDM,250,RC,65862050301,NDC,both,100,EA,0.35,0.14,39.4668,,0.14,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.12,34,,0.12,percent of total billed charges,"Drugs, Inpatient Only",0.12,34,,0.12,percent of total billed charges,"Drugs, Inpatient Only",0.12,34,,0.12,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.24,70,,0.24,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.12,,,0.12,Other,Drug Cost,0.12,,,0.12,Other,Drug Cost,0.12,,,0.12,Other,Drug Cost,0.12,,,0.12,Other,Drug Cost,0.12,,,0.12,Other,Drug Cost,0.12,,,0.12,Other,Drug Cost,0.26,,,0.26,Other,225% of Medicaid,0.16,,,0.16,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.25,,,0.25,Other,215% Medicaid APG methodology,0.25,,,0.25,Other,215% Medicaid APG methodology,0.15,,,0.15,Other,125% Medicaid APG methodology,0.01,0.26,
AMPHETINE SALT COMBO 10MG TAB,,,,80000132,CDM,250,RC,555097202,NDC,both,100,EA,0.19,0.08,39.4668,,0.08,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.06,34,,0.06,percent of total billed charges,"Drugs, Inpatient Only",0.06,34,,0.06,percent of total billed charges,"Drugs, Inpatient Only",0.06,34,,0.06,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.13,70,,0.13,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.06,,,0.06,Other,Drug Cost,0.06,,,0.06,Other,Drug Cost,0.06,,,0.06,Other,Drug Cost,0.06,,,0.06,Other,Drug Cost,0.06,,,0.06,Other,Drug Cost,0.06,,,0.06,Other,Drug Cost,0.14,,,0.14,Other,225% of Medicaid,0.09,,,0.09,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.14,,,0.14,Other,215% Medicaid APG methodology,0.14,,,0.14,Other,215% Medicaid APG methodology,0.08,,,0.08,Other,125% Medicaid APG methodology,0.01,0.14,
ANALGESIC CREAM 30 GM (OINTMENT),,,,80000148,CDM,250,RC,41167008709,NDC,both,1,GM,17.76,7.01,39.4668,,7.01,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,6.04,34,,6.04,percent of total billed charges,"Drugs, Inpatient Only",6.04,34,,6.04,percent of total billed charges,"Drugs, Inpatient Only",6.04,34,,6.04,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,12.43,70,,12.43,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,5.92,,,5.92,Other,Drug Cost,5.92,,,5.92,Other,Drug Cost,5.92,,,5.92,Other,Drug Cost,5.92,,,5.92,Other,Drug Cost,5.92,,,5.92,Other,Drug Cost,5.92,,,5.92,Other,Drug Cost,13.32,,,13.32,Other,225% of Medicaid,8.29,,,8.29,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,12.73,,,12.73,Other,215% Medicaid APG methodology,12.73,,,12.73,Other,215% Medicaid APG methodology,7.4,,,7.4,Other,125% Medicaid APG methodology,0.01,13.32,
ANASTROZOLE 1MG,,,,80000149,CDM,250,RC,16729003510,NDC,both,30,EA,0.03,0.01,39.4668,,0.01,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.02,70,,0.02,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.02,,,0.02,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,0.02,
APAP 120MG,,,,80000154,CDM,250,RC,45802073230,NDC,both,12,EA,0.38,0.15,39.4668,,0.15,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.13,34,,0.13,percent of total billed charges,"Drugs, Inpatient Only",0.13,34,,0.13,percent of total billed charges,"Drugs, Inpatient Only",0.13,34,,0.13,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.27,70,,0.27,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.13,,,0.13,Other,Drug Cost,0.13,,,0.13,Other,Drug Cost,0.13,,,0.13,Other,Drug Cost,0.13,,,0.13,Other,Drug Cost,0.13,,,0.13,Other,Drug Cost,0.13,,,0.13,Other,Drug Cost,0.29,,,0.29,Other,225% of Medicaid,0.18,,,0.18,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.27,,,0.27,Other,215% Medicaid APG methodology,0.27,,,0.27,Other,215% Medicaid APG methodology,0.16,,,0.16,Other,125% Medicaid APG methodology,0.01,0.29,
APAP 650MG SUPP,,,,80000155,CDM,250,RC,45802073030,NDC,both,12,EA,0.44,0.18,39.4668,,0.18,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.15,34,,0.15,percent of total billed charges,"Drugs, Inpatient Only",0.15,34,,0.15,percent of total billed charges,"Drugs, Inpatient Only",0.15,34,,0.15,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.31,70,,0.31,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.15,,,0.15,Other,Drug Cost,0.15,,,0.15,Other,Drug Cost,0.15,,,0.15,Other,Drug Cost,0.15,,,0.15,Other,Drug Cost,0.15,,,0.15,Other,Drug Cost,0.15,,,0.15,Other,Drug Cost,0.33,,,0.33,Other,225% of Medicaid,0.21,,,0.21,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.32,,,0.32,Other,215% Medicaid APG methodology,0.32,,,0.32,Other,215% Medicaid APG methodology,0.19,,,0.19,Other,125% Medicaid APG methodology,0.01,0.33,
ARIPIPRAZOLE (ABILIFY) 10MG,,,,80000164,CDM,250,RC,65162089803,NDC,both,30,EA,0.21,0.08,39.4668,,0.08,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.07,34,,0.07,percent of total billed charges,"Drugs, Inpatient Only",0.07,34,,0.07,percent of total billed charges,"Drugs, Inpatient Only",0.07,34,,0.07,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.15,70,,0.15,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.07,,,0.07,Other,Drug Cost,0.07,,,0.07,Other,Drug Cost,0.07,,,0.07,Other,Drug Cost,0.07,,,0.07,Other,Drug Cost,0.07,,,0.07,Other,Drug Cost,0.07,,,0.07,Other,Drug Cost,0.16,,,0.16,Other,225% of Medicaid,0.1,,,0.1,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.15,,,0.15,Other,215% Medicaid APG methodology,0.15,,,0.15,Other,215% Medicaid APG methodology,0.09,,,0.09,Other,125% Medicaid APG methodology,0.01,0.16,
ARIPIPRAZOLE (ABILIFY) 2MG TAB,,,,80000166,CDM,250,RC,65862066130,NDC,both,30,EA,0.11,0.04,39.4668,,0.04,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.04,34,,0.04,percent of total billed charges,"Drugs, Inpatient Only",0.04,34,,0.04,percent of total billed charges,"Drugs, Inpatient Only",0.04,34,,0.04,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.08,70,,0.08,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.08,,,0.08,Other,225% of Medicaid,0.05,,,0.05,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.08,,,0.08,Other,215% Medicaid APG methodology,0.08,,,0.08,Other,215% Medicaid APG methodology,0.05,,,0.05,Other,125% Medicaid APG methodology,0.01,0.08,
ARIPIPRAZOLE (ABILIFY) 5MG,,,,80000167,CDM,250,RC,65162089703,NDC,both,30,EA,0.2,0.08,39.4668,,0.08,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.07,34,,0.07,percent of total billed charges,"Drugs, Inpatient Only",0.07,34,,0.07,percent of total billed charges,"Drugs, Inpatient Only",0.07,34,,0.07,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.14,70,,0.14,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.07,,,0.07,Other,Drug Cost,0.07,,,0.07,Other,Drug Cost,0.07,,,0.07,Other,Drug Cost,0.07,,,0.07,Other,Drug Cost,0.07,,,0.07,Other,Drug Cost,0.07,,,0.07,Other,Drug Cost,0.15,,,0.15,Other,225% of Medicaid,0.09,,,0.09,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.14,,,0.14,Other,215% Medicaid APG methodology,0.14,,,0.14,Other,215% Medicaid APG methodology,0.08,,,0.08,Other,125% Medicaid APG methodology,0.01,0.15,
ARIPIPRAZOLE 1 MG/ML SOLN,,,,80000170,CDM,250,RC,65162089374,NDC,both,1,ML,62.55,24.69,39.4668,,24.69,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,21.27,34,,21.27,percent of total billed charges,"Drugs, Inpatient Only",21.27,34,,21.27,percent of total billed charges,"Drugs, Inpatient Only",21.27,34,,21.27,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,43.79,70,,43.79,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,20.85,,,20.85,Other,Drug Cost,20.85,,,20.85,Other,Drug Cost,20.85,,,20.85,Other,Drug Cost,20.85,,,20.85,Other,Drug Cost,20.85,,,20.85,Other,Drug Cost,20.85,,,20.85,Other,Drug Cost,46.91,,,46.91,Other,225% of Medicaid,29.19,,,29.19,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,44.83,,,44.83,Other,215% Medicaid APG methodology,44.83,,,44.83,Other,215% Medicaid APG methodology,26.06,,,26.06,Other,125% Medicaid APG methodology,0.01,46.91,
ARMOUR THYROID 30MG,,,,80000172,CDM,250,RC,42192032901,NDC,both,100,EA,0.34,0.13,39.4668,,0.13,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.11,34,,0.11,percent of total billed charges,"Drugs, Inpatient Only",0.11,34,,0.11,percent of total billed charges,"Drugs, Inpatient Only",0.11,34,,0.11,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.24,70,,0.24,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.11,,,0.11,Other,Drug Cost,0.11,,,0.11,Other,Drug Cost,0.11,,,0.11,Other,Drug Cost,0.11,,,0.11,Other,Drug Cost,0.11,,,0.11,Other,Drug Cost,0.11,,,0.11,Other,Drug Cost,0.25,,,0.25,Other,225% of Medicaid,0.16,,,0.16,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.24,,,0.24,Other,215% Medicaid APG methodology,0.24,,,0.24,Other,215% Medicaid APG methodology,0.14,,,0.14,Other,125% Medicaid APG methodology,0.01,0.25,
ARMOUR THYROID 60MG,,,,80000173,CDM,250,RC,456045901,NDC,both,100,EA,0.66,0.26,39.4668,,0.26,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.22,34,,0.22,percent of total billed charges,"Drugs, Inpatient Only",0.22,34,,0.22,percent of total billed charges,"Drugs, Inpatient Only",0.22,34,,0.22,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.46,70,,0.46,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.22,,,0.22,Other,Drug Cost,0.22,,,0.22,Other,Drug Cost,0.22,,,0.22,Other,Drug Cost,0.22,,,0.22,Other,Drug Cost,0.22,,,0.22,Other,Drug Cost,0.22,,,0.22,Other,Drug Cost,0.5,,,0.5,Other,225% of Medicaid,0.31,,,0.31,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.47,,,0.47,Other,215% Medicaid APG methodology,0.47,,,0.47,Other,215% Medicaid APG methodology,0.28,,,0.28,Other,125% Medicaid APG methodology,0.01,0.5,
ASPIRIN 300 MG,,,,80000180,CDM,250,RC,574703412,NDC,both,12,EA,2.11,0.83,39.4668,,0.83,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.72,34,,0.72,percent of total billed charges,"Drugs, Inpatient Only",0.72,34,,0.72,percent of total billed charges,"Drugs, Inpatient Only",0.72,34,,0.72,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1.47,70,,1.47,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.7,,,0.7,Other,Drug Cost,0.7,,,0.7,Other,Drug Cost,0.7,,,0.7,Other,Drug Cost,0.7,,,0.7,Other,Drug Cost,0.7,,,0.7,Other,Drug Cost,0.7,,,0.7,Other,Drug Cost,1.58,,,1.58,Other,225% of Medicaid,0.98,,,0.98,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,1.51,,,1.51,Other,215% Medicaid APG methodology,1.51,,,1.51,Other,215% Medicaid APG methodology,0.88,,,0.88,Other,125% Medicaid APG methodology,0.01,1.58,
ASPIRIN 325 MG,,,,80000181,CDM,250,RC,536105429,NDC,both,100,EA,0.03,0.01,39.4668,,0.01,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.02,70,,0.02,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.02,,,0.02,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,0.02,
ASPIRIN 81MG,,,,80000183,CDM,250,RC,904675180,NDC,both,1000,EA,0.02,0.01,39.4668,,0.01,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,70,,0.01,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.02,,,0.02,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,0.02,
ASPIRIN EC 325 MG TAB,,,,80000184,CDM,250,RC,536123201,NDC,both,100,EA,0.03,0.01,39.4668,,0.01,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.02,70,,0.02,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.03,,,0.03,Other,225% of Medicaid,0.02,,,0.02,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,0.03,
ATENOLOL 25 MG,,,,80000185,CDM,250,RC,93078701,NDC,both,100,EA,0.03,0.01,39.4668,,0.01,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.02,70,,0.02,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.02,,,0.02,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,0.02,
ATOVAQUONE-PROGUANIL 250 MG-100 MG TAB,,,,80000190,CDM,250,RC,173067502,NDC,both,24,EA,4.31,1.7,39.4668,,1.7,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1.47,34,,1.47,percent of total billed charges,"Drugs, Inpatient Only",1.47,34,,1.47,percent of total billed charges,"Drugs, Inpatient Only",1.47,34,,1.47,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,3.02,70,,3.02,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1.44,,,1.44,Other,Drug Cost,1.44,,,1.44,Other,Drug Cost,1.44,,,1.44,Other,Drug Cost,1.44,,,1.44,Other,Drug Cost,1.44,,,1.44,Other,Drug Cost,1.44,,,1.44,Other,Drug Cost,3.23,,,3.23,Other,225% of Medicaid,2.01,,,2.01,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,3.09,,,3.09,Other,215% Medicaid APG methodology,3.09,,,3.09,Other,215% Medicaid APG methodology,1.8,,,1.8,Other,125% Medicaid APG methodology,0.01,3.23,
ATROVASTATIN (LIPITOR) 10MG TAB,,,,80000199,CDM,250,RC,378395077,NDC,both,90,EA,0.03,0.01,39.4668,,0.01,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.02,70,,0.02,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.02,,,0.02,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,0.02,
ATROVASTATIN (LIPITOR) 20MG TAB,,,,80000200,CDM,250,RC,378395177,NDC,both,90,EA,0.03,0.01,39.4668,,0.01,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.02,70,,0.02,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.02,,,0.02,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,0.02,
ATROVASTATIN (LIPITOR) 40MG TAB,,,,80000201,CDM,250,RC,378395277,NDC,both,90,EA,0.03,0.01,39.4668,,0.01,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.02,70,,0.02,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.03,,,0.03,Other,225% of Medicaid,0.02,,,0.02,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,0.03,
AZITHROMYCIN 200MG/5ML,,,,80000207,CDM,250,RC,59762312001,NDC,both,1,ML,0.42,0.17,39.4668,,0.17,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.14,34,,0.14,percent of total billed charges,"Drugs, Inpatient Only",0.14,34,,0.14,percent of total billed charges,"Drugs, Inpatient Only",0.14,34,,0.14,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.29,70,,0.29,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.14,,,0.14,Other,Drug Cost,0.14,,,0.14,Other,Drug Cost,0.14,,,0.14,Other,Drug Cost,0.14,,,0.14,Other,Drug Cost,0.14,,,0.14,Other,Drug Cost,0.14,,,0.14,Other,Drug Cost,0.32,,,0.32,Other,225% of Medicaid,0.2,,,0.2,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.3,,,0.3,Other,215% Medicaid APG methodology,0.3,,,0.3,Other,215% Medicaid APG methodology,0.18,,,0.18,Other,125% Medicaid APG methodology,0.01,0.32,
BACITRACIN PACKET,,,,80000215,CDM,250,RC,45802006070,NDC,both,144,GM,0.14,0.06,39.4668,,0.06,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.05,34,,0.05,percent of total billed charges,"Drugs, Inpatient Only",0.05,34,,0.05,percent of total billed charges,"Drugs, Inpatient Only",0.05,34,,0.05,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.1,70,,0.1,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.11,,,0.11,Other,225% of Medicaid,0.07,,,0.07,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.1,,,0.1,Other,215% Medicaid APG methodology,0.1,,,0.1,Other,215% Medicaid APG methodology,0.06,,,0.06,Other,125% Medicaid APG methodology,0.01,0.11,
BACITRACIN-POLYMYXIN B 3.5 GM OPHTH OINT,,,,80000217,CDM,250,RC,24208055555,NDC,both,1,GM,13.83,5.46,39.4668,,5.46,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,4.7,34,,4.7,percent of total billed charges,"Drugs, Inpatient Only",4.7,34,,4.7,percent of total billed charges,"Drugs, Inpatient Only",4.7,34,,4.7,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,9.68,70,,9.68,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,4.61,,,4.61,Other,Drug Cost,4.61,,,4.61,Other,Drug Cost,4.61,,,4.61,Other,Drug Cost,4.61,,,4.61,Other,Drug Cost,4.61,,,4.61,Other,Drug Cost,4.61,,,4.61,Other,Drug Cost,10.37,,,10.37,Other,225% of Medicaid,6.45,,,6.45,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,9.91,,,9.91,Other,215% Medicaid APG methodology,9.91,,,9.91,Other,215% Medicaid APG methodology,5.76,,,5.76,Other,125% Medicaid APG methodology,0.01,10.37,
BACLOFEN 10 MG,,,,80000220,CDM,250,RC,172409660,NDC,both,100,EA,0.05,0.02,39.4668,,0.02,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.02,34,,0.02,percent of total billed charges,"Drugs, Inpatient Only",0.02,34,,0.02,percent of total billed charges,"Drugs, Inpatient Only",0.02,34,,0.02,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.03,70,,0.03,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.03,,,0.03,Other,225% of Medicaid,0.02,,,0.02,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.03,,,0.03,Other,215% Medicaid APG methodology,0.03,,,0.03,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,125% Medicaid APG methodology,0.01,0.03,
BENZOCAINE 20% (ANBESOL),,,,80000232,CDM,250,RC,50024043201,NDC,both,1,ML,15.9,6.28,39.4668,,6.28,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,5.41,34,,5.41,percent of total billed charges,"Drugs, Inpatient Only",5.41,34,,5.41,percent of total billed charges,"Drugs, Inpatient Only",5.41,34,,5.41,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,11.13,70,,11.13,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,5.3,,,5.3,Other,Drug Cost,5.3,,,5.3,Other,Drug Cost,5.3,,,5.3,Other,Drug Cost,5.3,,,5.3,Other,Drug Cost,5.3,,,5.3,Other,Drug Cost,5.3,,,5.3,Other,Drug Cost,11.93,,,11.93,Other,225% of Medicaid,7.42,,,7.42,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,11.4,,,11.4,Other,215% Medicaid APG methodology,11.4,,,11.4,Other,215% Medicaid APG methodology,6.63,,,6.63,Other,125% Medicaid APG methodology,0.01,11.93,
BENZOCAINE/MENTHOL (DERMOPLAST) 56 ML,,,,80000234,CDM,250,RC,16864068003,NDC,both,1,GM,14.61,5.77,39.4668,,5.77,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,4.97,34,,4.97,percent of total billed charges,"Drugs, Inpatient Only",4.97,34,,4.97,percent of total billed charges,"Drugs, Inpatient Only",4.97,34,,4.97,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,10.23,70,,10.23,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,4.87,,,4.87,Other,Drug Cost,4.87,,,4.87,Other,Drug Cost,4.87,,,4.87,Other,Drug Cost,4.87,,,4.87,Other,Drug Cost,4.87,,,4.87,Other,Drug Cost,4.87,,,4.87,Other,Drug Cost,10.96,,,10.96,Other,225% of Medicaid,6.82,,,6.82,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,10.47,,,10.47,Other,215% Medicaid APG methodology,10.47,,,10.47,Other,215% Medicaid APG methodology,6.09,,,6.09,Other,125% Medicaid APG methodology,0.01,10.96,
BENZOCAINE/MENTHOL LOZENGE,,,,80000235,CDM,250,RC,904625549,NDC,both,18,EA,0.21,0.08,39.4668,,0.08,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.07,34,,0.07,percent of total billed charges,"Drugs, Inpatient Only",0.07,34,,0.07,percent of total billed charges,"Drugs, Inpatient Only",0.07,34,,0.07,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.15,70,,0.15,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.07,,,0.07,Other,Drug Cost,0.07,,,0.07,Other,Drug Cost,0.07,,,0.07,Other,Drug Cost,0.07,,,0.07,Other,Drug Cost,0.07,,,0.07,Other,Drug Cost,0.07,,,0.07,Other,Drug Cost,0.16,,,0.16,Other,225% of Medicaid,0.1,,,0.1,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.15,,,0.15,Other,215% Medicaid APG methodology,0.15,,,0.15,Other,215% Medicaid APG methodology,0.09,,,0.09,Other,125% Medicaid APG methodology,0.01,0.16,
BENZOIN COMPOUND 30ML,,,,80000236,CDM,250,RC,395024392,NDC,both,1,ML,21.6,8.52,39.4668,,8.52,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,7.34,34,,7.34,percent of total billed charges,"Drugs, Inpatient Only",7.34,34,,7.34,percent of total billed charges,"Drugs, Inpatient Only",7.34,34,,7.34,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,15.12,70,,15.12,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,7.2,,,7.2,Other,Drug Cost,7.2,,,7.2,Other,Drug Cost,7.2,,,7.2,Other,Drug Cost,7.2,,,7.2,Other,Drug Cost,7.2,,,7.2,Other,Drug Cost,7.2,,,7.2,Other,Drug Cost,16.2,,,16.2,Other,225% of Medicaid,10.08,,,10.08,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,15.48,,,15.48,Other,215% Medicaid APG methodology,15.48,,,15.48,Other,215% Medicaid APG methodology,9,,,9,Other,125% Medicaid APG methodology,0.01,16.2,
BENZONATATE 100MG,,,,80000237,CDM,250,RC,42806071405,NDC,both,500,EA,0.08,0.03,39.4668,,0.03,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.03,34,,0.03,percent of total billed charges,"Drugs, Inpatient Only",0.03,34,,0.03,percent of total billed charges,"Drugs, Inpatient Only",0.03,34,,0.03,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.06,70,,0.06,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.06,,,0.06,Other,225% of Medicaid,0.04,,,0.04,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.06,,,0.06,Other,215% Medicaid APG methodology,0.06,,,0.06,Other,215% Medicaid APG methodology,0.03,,,0.03,Other,125% Medicaid APG methodology,0.01,0.06,
BENZOYL PEROXINE GEL 10%,,,,80000239,CDM,250,RC,536105656,NDC,both,1,GM,6.69,2.64,39.4668,,2.64,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2.27,34,,2.27,percent of total billed charges,"Drugs, Inpatient Only",2.27,34,,2.27,percent of total billed charges,"Drugs, Inpatient Only",2.27,34,,2.27,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,4.68,70,,4.68,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2.23,,,2.23,Other,Drug Cost,2.23,,,2.23,Other,Drug Cost,2.23,,,2.23,Other,Drug Cost,2.23,,,2.23,Other,Drug Cost,2.23,,,2.23,Other,Drug Cost,2.23,,,2.23,Other,Drug Cost,5.02,,,5.02,Other,225% of Medicaid,3.12,,,3.12,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,4.79,,,4.79,Other,215% Medicaid APG methodology,4.79,,,4.79,Other,215% Medicaid APG methodology,2.79,,,2.79,Other,125% Medicaid APG methodology,0.01,5.02,
BENZTROPINE 0.5 MG,,,,80000240,CDM,250,RC,68084038101,NDC,both,10,EA,1.97,0.78,39.4668,,0.78,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.67,34,,0.67,percent of total billed charges,"Drugs, Inpatient Only",0.67,34,,0.67,percent of total billed charges,"Drugs, Inpatient Only",0.67,34,,0.67,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1.38,70,,1.38,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.66,,,0.66,Other,Drug Cost,0.66,,,0.66,Other,Drug Cost,0.66,,,0.66,Other,Drug Cost,0.66,,,0.66,Other,Drug Cost,0.66,,,0.66,Other,Drug Cost,0.66,,,0.66,Other,Drug Cost,1.48,,,1.48,Other,225% of Medicaid,0.92,,,0.92,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,1.41,,,1.41,Other,215% Medicaid APG methodology,1.41,,,1.41,Other,215% Medicaid APG methodology,0.82,,,0.82,Other,125% Medicaid APG methodology,0.01,1.48,
BENZTROPINE 1 MG TAB,,,,80000241,CDM,250,RC,69315013701,NDC,both,100,EA,0.09,0.03,39.4668,,0.03,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.03,34,,0.03,percent of total billed charges,"Drugs, Inpatient Only",0.03,34,,0.03,percent of total billed charges,"Drugs, Inpatient Only",0.03,34,,0.03,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.06,70,,0.06,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.06,,,0.06,Other,225% of Medicaid,0.04,,,0.04,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.06,,,0.06,Other,215% Medicaid APG methodology,0.06,,,0.06,Other,215% Medicaid APG methodology,0.04,,,0.04,Other,125% Medicaid APG methodology,0.01,0.06,
BERACTANT 100MG/4ML,,,,80000244,CDM,250,RC,74104004,NDC,both,1,ML,745.74,294.32,39.4668,,294.32,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,253.55,34,,253.55,percent of total billed charges,"Drugs, Inpatient Only",253.55,34,,253.55,percent of total billed charges,"Drugs, Inpatient Only",253.55,34,,253.55,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,522.02,70,,522.02,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,248.58,,,248.58,Other,Drug Cost,248.58,,,248.58,Other,Drug Cost,248.58,,,248.58,Other,Drug Cost,248.58,,,248.58,Other,Drug Cost,248.58,,,248.58,Other,Drug Cost,248.58,,,248.58,Other,Drug Cost,559.31,,,559.31,Other,225% of Medicaid,348.01,,,348.01,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,534.45,,,534.45,Other,215% Medicaid APG methodology,534.45,,,534.45,Other,215% Medicaid APG methodology,310.73,,,310.73,Other,125% Medicaid APG methodology,0.01,559.31,
BETAMETHASONE DIPROP 0.05 % CREAM,,,,80000250,CDM,250,RC,472038015,NDC,both,1,GM,5.52,2.18,39.4668,,2.18,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1.88,34,,1.88,percent of total billed charges,"Drugs, Inpatient Only",1.88,34,,1.88,percent of total billed charges,"Drugs, Inpatient Only",1.88,34,,1.88,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,3.86,70,,3.86,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1.84,,,1.84,Other,Drug Cost,1.84,,,1.84,Other,Drug Cost,1.84,,,1.84,Other,Drug Cost,1.84,,,1.84,Other,Drug Cost,1.84,,,1.84,Other,Drug Cost,1.84,,,1.84,Other,Drug Cost,4.14,,,4.14,Other,225% of Medicaid,2.58,,,2.58,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,3.96,,,3.96,Other,215% Medicaid APG methodology,3.96,,,3.96,Other,215% Medicaid APG methodology,2.3,,,2.3,Other,125% Medicaid APG methodology,0.01,4.14,
BETAMETHASONE VALERATE 15GM 0.1% CREAM,,,,80000253,CDM,250,RC,168004015,NDC,both,1,GM,4.14,1.63,39.4668,,1.63,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1.41,34,,1.41,percent of total billed charges,"Drugs, Inpatient Only",1.41,34,,1.41,percent of total billed charges,"Drugs, Inpatient Only",1.41,34,,1.41,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2.9,70,,2.9,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1.38,,,1.38,Other,Drug Cost,1.38,,,1.38,Other,Drug Cost,1.38,,,1.38,Other,Drug Cost,1.38,,,1.38,Other,Drug Cost,1.38,,,1.38,Other,Drug Cost,1.38,,,1.38,Other,Drug Cost,3.11,,,3.11,Other,225% of Medicaid,1.93,,,1.93,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,2.97,,,2.97,Other,215% Medicaid APG methodology,2.97,,,2.97,Other,215% Medicaid APG methodology,1.73,,,1.73,Other,125% Medicaid APG methodology,0.01,3.11,
BETAXOLOL 0.5% 5ML OPHTH SOLN,,,,80000255,CDM,250,RC,61314024502,NDC,both,1,ML,104.43,41.22,39.4668,,41.22,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,35.51,34,,35.51,percent of total billed charges,"Drugs, Inpatient Only",35.51,34,,35.51,percent of total billed charges,"Drugs, Inpatient Only",35.51,34,,35.51,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,73.1,70,,73.1,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,34.81,,,34.81,Other,Drug Cost,34.81,,,34.81,Other,Drug Cost,34.81,,,34.81,Other,Drug Cost,34.81,,,34.81,Other,Drug Cost,34.81,,,34.81,Other,Drug Cost,34.81,,,34.81,Other,Drug Cost,78.32,,,78.32,Other,225% of Medicaid,48.73,,,48.73,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,74.84,,,74.84,Other,215% Medicaid APG methodology,74.84,,,74.84,Other,215% Medicaid APG methodology,43.51,,,43.51,Other,125% Medicaid APG methodology,0.01,78.32,
BETHANECHOL 5 MG TAB,,,,80000256,CDM,250,RC,832051000,NDC,both,100,EA,0.04,0.01,39.4668,,0.01,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.02,70,,0.02,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.03,,,0.03,Other,225% of Medicaid,0.02,,,0.02,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.03,,,0.03,Other,215% Medicaid APG methodology,0.03,,,0.03,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,0.03,
BETHANECHOL CL 25MG,,,,80000258,CDM,250,RC,832051201,NDC,both,10,EA,2.18,0.86,39.4668,,0.86,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.74,34,,0.74,percent of total billed charges,"Drugs, Inpatient Only",0.74,34,,0.74,percent of total billed charges,"Drugs, Inpatient Only",0.74,34,,0.74,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1.52,70,,1.52,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.73,,,0.73,Other,Drug Cost,0.73,,,0.73,Other,Drug Cost,0.73,,,0.73,Other,Drug Cost,0.73,,,0.73,Other,Drug Cost,0.73,,,0.73,Other,Drug Cost,0.73,,,0.73,Other,Drug Cost,1.63,,,1.63,Other,225% of Medicaid,1.02,,,1.02,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,1.56,,,1.56,Other,215% Medicaid APG methodology,1.56,,,1.56,Other,215% Medicaid APG methodology,0.91,,,0.91,Other,125% Medicaid APG methodology,0.01,1.63,
BICALUTAMIDE (CASODEX) 50MG,,,,80000259,CDM,250,RC,47335048583,NDC,both,30,EA,0.3,0.12,39.4668,,0.12,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.1,34,,0.1,percent of total billed charges,"Drugs, Inpatient Only",0.1,34,,0.1,percent of total billed charges,"Drugs, Inpatient Only",0.1,34,,0.1,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.21,70,,0.21,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.1,,,0.1,Other,Drug Cost,0.1,,,0.1,Other,Drug Cost,0.1,,,0.1,Other,Drug Cost,0.1,,,0.1,Other,Drug Cost,0.1,,,0.1,Other,Drug Cost,0.1,,,0.1,Other,Drug Cost,0.22,,,0.22,Other,225% of Medicaid,0.14,,,0.14,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.21,,,0.21,Other,215% Medicaid APG methodology,0.21,,,0.21,Other,215% Medicaid APG methodology,0.12,,,0.12,Other,125% Medicaid APG methodology,0.01,0.22,
BISACODYL 10MG SUPPOSITORY,,,,80000262,CDM,250,RC,574705012,NDC,both,12,EA,0.3,0.12,39.4668,,0.12,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.1,34,,0.1,percent of total billed charges,"Drugs, Inpatient Only",0.1,34,,0.1,percent of total billed charges,"Drugs, Inpatient Only",0.1,34,,0.1,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.21,70,,0.21,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.1,,,0.1,Other,Drug Cost,0.1,,,0.1,Other,Drug Cost,0.1,,,0.1,Other,Drug Cost,0.1,,,0.1,Other,Drug Cost,0.1,,,0.1,Other,Drug Cost,0.1,,,0.1,Other,Drug Cost,0.23,,,0.23,Other,225% of Medicaid,0.14,,,0.14,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.22,,,0.22,Other,215% Medicaid APG methodology,0.22,,,0.22,Other,215% Medicaid APG methodology,0.13,,,0.13,Other,125% Medicaid APG methodology,0.01,0.23,
BISACODYL 5 MG,,,,80000263,CDM,250,RC,904674860,NDC,both,100,EA,0.03,0.01,39.4668,,0.01,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.02,70,,0.02,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.02,,,0.02,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,0.02,
BISOPROLOL 5MG,,,,80000265,CDM,250,RC,29300012613,NDC,both,30,EA,0.03,0.01,39.4668,,0.01,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.02,70,,0.02,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.02,,,0.02,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,0.02,
BREVIBLOC 10MG/ML 10ML,,,,80000272,CDM,250,RC,55150019410,NDC,both,25,ML,4.44,1.75,39.4668,,1.75,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1.51,34,,1.51,percent of total billed charges,"Drugs, Inpatient Only",1.51,34,,1.51,percent of total billed charges,"Drugs, Inpatient Only",1.51,34,,1.51,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,3.11,70,,3.11,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1.48,,,1.48,Other,Drug Cost,1.48,,,1.48,Other,Drug Cost,1.48,,,1.48,Other,Drug Cost,1.48,,,1.48,Other,Drug Cost,1.48,,,1.48,Other,Drug Cost,1.48,,,1.48,Other,Drug Cost,3.33,,,3.33,Other,225% of Medicaid,2.07,,,2.07,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,3.19,,,3.19,Other,215% Medicaid APG methodology,3.19,,,3.19,Other,215% Medicaid APG methodology,1.85,,,1.85,Other,125% Medicaid APG methodology,0.01,3.33,
BRIMONIDINE 0.002,,,,80000274,CDM,250,RC,61314014305,NDC,both,1,ML,3.54,1.4,39.4668,,1.4,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1.2,34,,1.2,percent of total billed charges,"Drugs, Inpatient Only",1.2,34,,1.2,percent of total billed charges,"Drugs, Inpatient Only",1.2,34,,1.2,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2.48,70,,2.48,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1.18,,,1.18,Other,Drug Cost,1.18,,,1.18,Other,Drug Cost,1.18,,,1.18,Other,Drug Cost,1.18,,,1.18,Other,Drug Cost,1.18,,,1.18,Other,Drug Cost,1.18,,,1.18,Other,Drug Cost,2.66,,,2.66,Other,225% of Medicaid,1.65,,,1.65,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,2.54,,,2.54,Other,215% Medicaid APG methodology,2.54,,,2.54,Other,215% Medicaid APG methodology,1.48,,,1.48,Other,125% Medicaid APG methodology,0.01,2.66,
BRIMONIDINE 0.15% OPHTHALMIC SOL,,,,80000275,CDM,250,RC,61314014405,NDC,both,1,ML,72.18,28.49,39.4668,,28.49,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,24.54,34,,24.54,percent of total billed charges,"Drugs, Inpatient Only",24.54,34,,24.54,percent of total billed charges,"Drugs, Inpatient Only",24.54,34,,24.54,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,50.53,70,,50.53,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,24.06,,,24.06,Other,Drug Cost,24.06,,,24.06,Other,Drug Cost,24.06,,,24.06,Other,Drug Cost,24.06,,,24.06,Other,Drug Cost,24.06,,,24.06,Other,Drug Cost,24.06,,,24.06,Other,Drug Cost,54.14,,,54.14,Other,225% of Medicaid,33.68,,,33.68,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,51.73,,,51.73,Other,215% Medicaid APG methodology,51.73,,,51.73,Other,215% Medicaid APG methodology,30.08,,,30.08,Other,125% Medicaid APG methodology,0.01,54.14,
BRIMONIDINE TATRATE (ALPHAGAN P) 0.1%,,,,80000276,CDM,250,RC,23932105,NDC,both,1,ML,528.42,208.55,39.4668,,208.55,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,179.66,34,,179.66,percent of total billed charges,"Drugs, Inpatient Only",179.66,34,,179.66,percent of total billed charges,"Drugs, Inpatient Only",179.66,34,,179.66,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,369.89,70,,369.89,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,176.14,,,176.14,Other,Drug Cost,176.14,,,176.14,Other,Drug Cost,176.14,,,176.14,Other,Drug Cost,176.14,,,176.14,Other,Drug Cost,176.14,,,176.14,Other,Drug Cost,176.14,,,176.14,Other,Drug Cost,396.32,,,396.32,Other,225% of Medicaid,246.6,,,246.6,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,378.7,,,378.7,Other,215% Medicaid APG methodology,378.7,,,378.7,Other,215% Medicaid APG methodology,220.18,,,220.18,Other,125% Medicaid APG methodology,0.01,396.32,
BROMOCRIPTINE 2.5MG,,,,80000280,CDM,250,RC,574010601,NDC,both,100,EA,1,0.39,39.4668,,0.39,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.34,34,,0.34,percent of total billed charges,"Drugs, Inpatient Only",0.34,34,,0.34,percent of total billed charges,"Drugs, Inpatient Only",0.34,34,,0.34,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.7,70,,0.7,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.33,,,0.33,Other,Drug Cost,0.33,,,0.33,Other,Drug Cost,0.33,,,0.33,Other,Drug Cost,0.33,,,0.33,Other,Drug Cost,0.33,,,0.33,Other,Drug Cost,0.33,,,0.33,Other,Drug Cost,0.75,,,0.75,Other,225% of Medicaid,0.46,,,0.46,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.71,,,0.71,Other,215% Medicaid APG methodology,0.71,,,0.71,Other,215% Medicaid APG methodology,0.41,,,0.41,Other,125% Medicaid APG methodology,0.01,0.75,
BUDESONIDE 0.25 MG/2 ML INH,,,,80000283,CDM,250,RC,93681573,NDC,both,30,ML,2.76,1.09,39.4668,,1.09,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.94,34,,0.94,percent of total billed charges,"Drugs, Inpatient Only",0.94,34,,0.94,percent of total billed charges,"Drugs, Inpatient Only",0.94,34,,0.94,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1.93,70,,1.93,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.92,,,0.92,Other,Drug Cost,0.92,,,0.92,Other,Drug Cost,0.92,,,0.92,Other,Drug Cost,0.92,,,0.92,Other,Drug Cost,0.92,,,0.92,Other,Drug Cost,0.92,,,0.92,Other,Drug Cost,2.07,,,2.07,Other,225% of Medicaid,1.29,,,1.29,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,1.98,,,1.98,Other,215% Medicaid APG methodology,1.98,,,1.98,Other,215% Medicaid APG methodology,1.15,,,1.15,Other,125% Medicaid APG methodology,0.01,2.07,
BUDESONIDE 0.5 MG/2 ML INH,,,,80000284,CDM,250,RC,93681673,NDC,both,30,ML,1.07,0.42,39.4668,,0.42,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.36,34,,0.36,percent of total billed charges,"Drugs, Inpatient Only",0.36,34,,0.36,percent of total billed charges,"Drugs, Inpatient Only",0.36,34,,0.36,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.75,70,,0.75,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.36,,,0.36,Other,Drug Cost,0.36,,,0.36,Other,Drug Cost,0.36,,,0.36,Other,Drug Cost,0.36,,,0.36,Other,Drug Cost,0.36,,,0.36,Other,Drug Cost,0.36,,,0.36,Other,Drug Cost,0.8,,,0.8,Other,225% of Medicaid,0.5,,,0.5,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.77,,,0.77,Other,215% Medicaid APG methodology,0.77,,,0.77,Other,215% Medicaid APG methodology,0.45,,,0.45,Other,125% Medicaid APG methodology,0.01,0.8,
BUMETANIDE 1 MG,,,,80000287,CDM,250,RC,185012901,NDC,both,100,EA,0.16,0.06,39.4668,,0.06,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.06,34,,0.06,percent of total billed charges,"Drugs, Inpatient Only",0.06,34,,0.06,percent of total billed charges,"Drugs, Inpatient Only",0.06,34,,0.06,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.11,70,,0.11,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.12,,,0.12,Other,225% of Medicaid,0.08,,,0.08,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.12,,,0.12,Other,215% Medicaid APG methodology,0.12,,,0.12,Other,215% Medicaid APG methodology,0.07,,,0.07,Other,125% Medicaid APG methodology,0.01,0.12,
BUPIVACAINE 0.25% 10ML,,,,80000289,CDM,250,RC,409115901,NDC,both,25,ML,1.58,0.62,39.4668,,0.62,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.54,34,,0.54,percent of total billed charges,"Drugs, Inpatient Only",0.54,34,,0.54,percent of total billed charges,"Drugs, Inpatient Only",0.54,34,,0.54,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1.1,70,,1.1,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.53,,,0.53,Other,Drug Cost,0.53,,,0.53,Other,Drug Cost,0.53,,,0.53,Other,Drug Cost,0.53,,,0.53,Other,Drug Cost,0.53,,,0.53,Other,Drug Cost,0.53,,,0.53,Other,Drug Cost,1.18,,,1.18,Other,225% of Medicaid,0.74,,,0.74,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,1.13,,,1.13,Other,215% Medicaid APG methodology,1.13,,,1.13,Other,215% Medicaid APG methodology,0.66,,,0.66,Other,125% Medicaid APG methodology,0.01,1.18,
BUPIVACAINE 0.25% INJECTION,,,,80000290,CDM,250,RC,409158750,NDC,both,1,ML,12.78,5.04,39.4668,,5.04,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,4.35,34,,4.35,percent of total billed charges,"Drugs, Inpatient Only",4.35,34,,4.35,percent of total billed charges,"Drugs, Inpatient Only",4.35,34,,4.35,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,8.95,70,,8.95,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,4.26,,,4.26,Other,Drug Cost,4.26,,,4.26,Other,Drug Cost,4.26,,,4.26,Other,Drug Cost,4.26,,,4.26,Other,Drug Cost,4.26,,,4.26,Other,Drug Cost,4.26,,,4.26,Other,Drug Cost,9.59,,,9.59,Other,225% of Medicaid,5.96,,,5.96,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,9.16,,,9.16,Other,215% Medicaid APG methodology,9.16,,,9.16,Other,215% Medicaid APG methodology,5.33,,,5.33,Other,125% Medicaid APG methodology,0.01,9.59,
BUPIVACAINE 0.5% 30 ML,,,,80000291,CDM,250,RC,55150017030,NDC,both,25,ML,4.23,1.67,39.4668,,1.67,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1.44,34,,1.44,percent of total billed charges,"Drugs, Inpatient Only",1.44,34,,1.44,percent of total billed charges,"Drugs, Inpatient Only",1.44,34,,1.44,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2.96,70,,2.96,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1.41,,,1.41,Other,Drug Cost,1.41,,,1.41,Other,Drug Cost,1.41,,,1.41,Other,Drug Cost,1.41,,,1.41,Other,Drug Cost,1.41,,,1.41,Other,Drug Cost,1.41,,,1.41,Other,Drug Cost,3.18,,,3.18,Other,225% of Medicaid,1.98,,,1.98,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,3.03,,,3.03,Other,215% Medicaid APG methodology,3.03,,,3.03,Other,215% Medicaid APG methodology,1.76,,,1.76,Other,125% Medicaid APG methodology,0.01,3.18,
BUPIVACAINE 0.5% 50 ML,,,,80000292,CDM,250,RC,409116301,NDC,both,25,ML,5.95,2.35,39.4668,,2.35,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2.02,34,,2.02,percent of total billed charges,"Drugs, Inpatient Only",2.02,34,,2.02,percent of total billed charges,"Drugs, Inpatient Only",2.02,34,,2.02,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,4.16,70,,4.16,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1.98,,,1.98,Other,Drug Cost,1.98,,,1.98,Other,Drug Cost,1.98,,,1.98,Other,Drug Cost,1.98,,,1.98,Other,Drug Cost,1.98,,,1.98,Other,Drug Cost,1.98,,,1.98,Other,Drug Cost,4.46,,,4.46,Other,225% of Medicaid,2.78,,,2.78,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,4.26,,,4.26,Other,215% Medicaid APG methodology,4.26,,,4.26,Other,215% Medicaid APG methodology,2.48,,,2.48,Other,125% Medicaid APG methodology,0.01,4.46,
BUPIVACAINE 0.5% INJECTION,,,,80000293,CDM,250,RC,409116201,NDC,both,25,ML,1.8,0.71,39.4668,,0.71,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.61,34,,0.61,percent of total billed charges,"Drugs, Inpatient Only",0.61,34,,0.61,percent of total billed charges,"Drugs, Inpatient Only",0.61,34,,0.61,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1.26,70,,1.26,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.6,,,0.6,Other,Drug Cost,0.6,,,0.6,Other,Drug Cost,0.6,,,0.6,Other,Drug Cost,0.6,,,0.6,Other,Drug Cost,0.6,,,0.6,Other,Drug Cost,0.6,,,0.6,Other,Drug Cost,1.35,,,1.35,Other,225% of Medicaid,0.84,,,0.84,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,1.29,,,1.29,Other,215% Medicaid APG methodology,1.29,,,1.29,Other,215% Medicaid APG methodology,0.75,,,0.75,Other,125% Medicaid APG methodology,0.01,1.35,
BUPIVACAINE 0.75% INJECTION 10ML,,,,80000294,CDM,250,RC,63323047217,NDC,both,25,ML,1.96,0.77,39.4668,,0.77,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.67,34,,0.67,percent of total billed charges,"Drugs, Inpatient Only",0.67,34,,0.67,percent of total billed charges,"Drugs, Inpatient Only",0.67,34,,0.67,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1.37,70,,1.37,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.65,,,0.65,Other,Drug Cost,0.65,,,0.65,Other,Drug Cost,0.65,,,0.65,Other,Drug Cost,0.65,,,0.65,Other,Drug Cost,0.65,,,0.65,Other,Drug Cost,0.65,,,0.65,Other,Drug Cost,1.47,,,1.47,Other,225% of Medicaid,0.91,,,0.91,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,1.4,,,1.4,Other,215% Medicaid APG methodology,1.4,,,1.4,Other,215% Medicaid APG methodology,0.82,,,0.82,Other,125% Medicaid APG methodology,0.01,1.47,
BUPIVACAINE 0.75% INJECTION SPINAL 2ML,,,,80000295,CDM,250,RC,409361301,NDC,both,10,ML,5.49,2.17,39.4668,,2.17,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1.87,34,,1.87,percent of total billed charges,"Drugs, Inpatient Only",1.87,34,,1.87,percent of total billed charges,"Drugs, Inpatient Only",1.87,34,,1.87,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,3.85,70,,3.85,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1.83,,,1.83,Other,Drug Cost,1.83,,,1.83,Other,Drug Cost,1.83,,,1.83,Other,Drug Cost,1.83,,,1.83,Other,Drug Cost,1.83,,,1.83,Other,Drug Cost,1.83,,,1.83,Other,Drug Cost,4.12,,,4.12,Other,225% of Medicaid,2.56,,,2.56,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,3.94,,,3.94,Other,215% Medicaid APG methodology,3.94,,,3.94,Other,215% Medicaid APG methodology,2.29,,,2.29,Other,125% Medicaid APG methodology,0.01,4.12,
BUPIVACAINE PF 0.25%  30ML,,,,80000298,CDM,250,RC,55150016830,NDC,both,25,ML,4.6,1.82,39.4668,,1.82,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1.56,34,,1.56,percent of total billed charges,"Drugs, Inpatient Only",1.56,34,,1.56,percent of total billed charges,"Drugs, Inpatient Only",1.56,34,,1.56,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,3.22,70,,3.22,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1.53,,,1.53,Other,Drug Cost,1.53,,,1.53,Other,Drug Cost,1.53,,,1.53,Other,Drug Cost,1.53,,,1.53,Other,Drug Cost,1.53,,,1.53,Other,Drug Cost,1.53,,,1.53,Other,Drug Cost,3.45,,,3.45,Other,225% of Medicaid,2.15,,,2.15,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,3.3,,,3.3,Other,215% Medicaid APG methodology,3.3,,,3.3,Other,215% Medicaid APG methodology,1.92,,,1.92,Other,125% Medicaid APG methodology,0.01,3.45,
BUPIVACAINE/EPI 0.25% 10 ML,,,,80000299,CDM,250,RC,409904201,NDC,both,10,ML,1.47,0.58,39.4668,,0.58,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.5,34,,0.5,percent of total billed charges,"Drugs, Inpatient Only",0.5,34,,0.5,percent of total billed charges,"Drugs, Inpatient Only",0.5,34,,0.5,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1.03,70,,1.03,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.49,,,0.49,Other,Drug Cost,0.49,,,0.49,Other,Drug Cost,0.49,,,0.49,Other,Drug Cost,0.49,,,0.49,Other,Drug Cost,0.49,,,0.49,Other,Drug Cost,0.49,,,0.49,Other,Drug Cost,1.1,,,1.1,Other,225% of Medicaid,0.69,,,0.69,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,1.05,,,1.05,Other,215% Medicaid APG methodology,1.05,,,1.05,Other,215% Medicaid APG methodology,0.61,,,0.61,Other,125% Medicaid APG methodology,0.01,1.1,
BUPIVACAINE/EPI 0.5%  10 ML,,,,80000301,CDM,250,RC,409904501,NDC,both,10,ML,1.54,0.61,39.4668,,0.61,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.52,34,,0.52,percent of total billed charges,"Drugs, Inpatient Only",0.52,34,,0.52,percent of total billed charges,"Drugs, Inpatient Only",0.52,34,,0.52,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1.08,70,,1.08,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.51,,,0.51,Other,Drug Cost,0.51,,,0.51,Other,Drug Cost,0.51,,,0.51,Other,Drug Cost,0.51,,,0.51,Other,Drug Cost,0.51,,,0.51,Other,Drug Cost,0.51,,,0.51,Other,Drug Cost,1.15,,,1.15,Other,225% of Medicaid,0.72,,,0.72,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,1.1,,,1.1,Other,215% Medicaid APG methodology,1.1,,,1.1,Other,215% Medicaid APG methodology,0.64,,,0.64,Other,125% Medicaid APG methodology,0.01,1.15,
BUPRENORPHINE-NALOXONE 8 MG-2 MG TAB,,,,80000307,CDM,250,RC,54018913,NDC,both,30,EA,0.92,0.36,39.4668,,0.36,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.31,34,,0.31,percent of total billed charges,"Drugs, Inpatient Only",0.31,34,,0.31,percent of total billed charges,"Drugs, Inpatient Only",0.31,34,,0.31,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.64,70,,0.64,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.31,,,0.31,Other,Drug Cost,0.31,,,0.31,Other,Drug Cost,0.31,,,0.31,Other,Drug Cost,0.31,,,0.31,Other,Drug Cost,0.31,,,0.31,Other,Drug Cost,0.31,,,0.31,Other,Drug Cost,0.69,,,0.69,Other,225% of Medicaid,0.43,,,0.43,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.66,,,0.66,Other,215% Medicaid APG methodology,0.66,,,0.66,Other,215% Medicaid APG methodology,0.38,,,0.38,Other,125% Medicaid APG methodology,0.01,0.69,
BUPROPION 100 MG,,,,80000308,CDM,250,RC,60505015701,NDC,both,100,EA,0.14,0.06,39.4668,,0.06,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.05,34,,0.05,percent of total billed charges,"Drugs, Inpatient Only",0.05,34,,0.05,percent of total billed charges,"Drugs, Inpatient Only",0.05,34,,0.05,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.1,70,,0.1,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.11,,,0.11,Other,225% of Medicaid,0.07,,,0.07,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.1,,,0.1,Other,215% Medicaid APG methodology,0.1,,,0.1,Other,215% Medicaid APG methodology,0.06,,,0.06,Other,125% Medicaid APG methodology,0.01,0.11,
BUPROPION 75 MG,,,,80000309,CDM,250,RC,60505015801,NDC,both,100,EA,0.12,0.05,39.4668,,0.05,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.04,34,,0.04,percent of total billed charges,"Drugs, Inpatient Only",0.04,34,,0.04,percent of total billed charges,"Drugs, Inpatient Only",0.04,34,,0.04,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.08,70,,0.08,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.09,,,0.09,Other,225% of Medicaid,0.06,,,0.06,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.09,,,0.09,Other,215% Medicaid APG methodology,0.09,,,0.09,Other,215% Medicaid APG methodology,0.05,,,0.05,Other,125% Medicaid APG methodology,0.01,0.09,
BUPROPION XL 150MG TAB,,,,80000310,CDM,250,RC,68180031909,NDC,both,90,EA,0.07,0.03,39.4668,,0.03,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.02,34,,0.02,percent of total billed charges,"Drugs, Inpatient Only",0.02,34,,0.02,percent of total billed charges,"Drugs, Inpatient Only",0.02,34,,0.02,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.05,70,,0.05,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.05,,,0.05,Other,225% of Medicaid,0.03,,,0.03,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.05,,,0.05,Other,215% Medicaid APG methodology,0.05,,,0.05,Other,215% Medicaid APG methodology,0.03,,,0.03,Other,125% Medicaid APG methodology,0.01,0.05,
BUSPIRONE 15MG,,,,80000312,CDM,250,RC,93100301,NDC,both,100,EA,0.05,0.02,39.4668,,0.02,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.02,34,,0.02,percent of total billed charges,"Drugs, Inpatient Only",0.02,34,,0.02,percent of total billed charges,"Drugs, Inpatient Only",0.02,34,,0.02,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.03,70,,0.03,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.04,,,0.04,Other,225% of Medicaid,0.02,,,0.02,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.03,,,0.03,Other,215% Medicaid APG methodology,0.03,,,0.03,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,125% Medicaid APG methodology,0.01,0.04,
BUSPIRONE 5 MG,,,,80000313,CDM,250,RC,64380074106,NDC,both,100,EA,0.03,0.01,39.4668,,0.01,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.02,70,,0.02,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.02,,,0.02,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,0.02,
CACO3 ANTACID 500MG,,,,80000319,CDM,250,RC,904641292,NDC,both,150,EA,0.03,0.01,39.4668,,0.01,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.02,70,,0.02,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.02,,,0.02,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,0.02,
CACO3 SUSP 1250 MG/5 ML,,,,80000320,CDM,250,RC,121476605,NDC,both,40,ML,1.23,0.48,39.4668,,0.48,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.42,34,,0.42,percent of total billed charges,"Drugs, Inpatient Only",0.42,34,,0.42,percent of total billed charges,"Drugs, Inpatient Only",0.42,34,,0.42,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.86,70,,0.86,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.41,,,0.41,Other,Drug Cost,0.41,,,0.41,Other,Drug Cost,0.41,,,0.41,Other,Drug Cost,0.41,,,0.41,Other,Drug Cost,0.41,,,0.41,Other,Drug Cost,0.41,,,0.41,Other,Drug Cost,0.92,,,0.92,Other,225% of Medicaid,0.57,,,0.57,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.88,,,0.88,Other,215% Medicaid APG methodology,0.88,,,0.88,Other,215% Medicaid APG methodology,0.51,,,0.51,Other,125% Medicaid APG methodology,0.01,0.92,
CAFFEINE-SOD BENZ 250MG/ML,,,,80000321,CDM,250,RC,517250210,NDC,both,10,ML,8.75,3.45,39.4668,,3.45,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2.97,34,,2.97,percent of total billed charges,"Drugs, Inpatient Only",2.97,34,,2.97,percent of total billed charges,"Drugs, Inpatient Only",2.97,34,,2.97,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,6.12,70,,6.12,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2.92,,,2.92,Other,Drug Cost,2.92,,,2.92,Other,Drug Cost,2.92,,,2.92,Other,Drug Cost,2.92,,,2.92,Other,Drug Cost,2.92,,,2.92,Other,Drug Cost,2.92,,,2.92,Other,Drug Cost,6.56,,,6.56,Other,225% of Medicaid,4.08,,,4.08,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,6.27,,,6.27,Other,215% Medicaid APG methodology,6.27,,,6.27,Other,215% Medicaid APG methodology,3.64,,,3.64,Other,125% Medicaid APG methodology,0.01,6.56,
CALAMINE 120ML,,,,80000322,CDM,250,RC,904253321,NDC,both,1,ML,3.96,1.56,39.4668,,1.56,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1.35,34,,1.35,percent of total billed charges,"Drugs, Inpatient Only",1.35,34,,1.35,percent of total billed charges,"Drugs, Inpatient Only",1.35,34,,1.35,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2.77,70,,2.77,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1.32,,,1.32,Other,Drug Cost,1.32,,,1.32,Other,Drug Cost,1.32,,,1.32,Other,Drug Cost,1.32,,,1.32,Other,Drug Cost,1.32,,,1.32,Other,Drug Cost,1.32,,,1.32,Other,Drug Cost,2.97,,,2.97,Other,225% of Medicaid,1.85,,,1.85,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,2.84,,,2.84,Other,215% Medicaid APG methodology,2.84,,,2.84,Other,215% Medicaid APG methodology,1.65,,,1.65,Other,125% Medicaid APG methodology,0.01,2.97,
CALCITRIOL 0.25 MCG,,,,80000326,CDM,250,RC,54000713,NDC,both,30,EA,0.03,0.01,39.4668,,0.01,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.02,70,,0.02,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.02,,,0.02,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,0.02,
CALCIUM ACETATE (PHOSLO) 667 MG CAP,,,,80000328,CDM,250,RC,781208102,NDC,both,200,EA,0.12,0.05,39.4668,,0.05,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.04,34,,0.04,percent of total billed charges,"Drugs, Inpatient Only",0.04,34,,0.04,percent of total billed charges,"Drugs, Inpatient Only",0.04,34,,0.04,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.08,70,,0.08,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.09,,,0.09,Other,225% of Medicaid,0.05,,,0.05,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.08,,,0.08,Other,215% Medicaid APG methodology,0.08,,,0.08,Other,215% Medicaid APG methodology,0.05,,,0.05,Other,125% Medicaid APG methodology,0.01,0.09,
CALCIUM CITRATE 950 MG TAB,,,,80000329,CDM,250,RC,80681014000,NDC,both,100,EA,0.06,0.03,39.4668,,0.03,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.02,34,,0.02,percent of total billed charges,"Drugs, Inpatient Only",0.02,34,,0.02,percent of total billed charges,"Drugs, Inpatient Only",0.02,34,,0.02,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.04,70,,0.04,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.05,,,0.05,Other,225% of Medicaid,0.03,,,0.03,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.05,,,0.05,Other,215% Medicaid APG methodology,0.05,,,0.05,Other,215% Medicaid APG methodology,0.03,,,0.03,Other,125% Medicaid APG methodology,0.01,0.05,
CALCIUM CL SYRINGE 10ML,,,,80000330,CDM,250,RC,409163110,NDC,both,10,ML,1.24,0.49,39.4668,,0.49,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.42,34,,0.42,percent of total billed charges,"Drugs, Inpatient Only",0.42,34,,0.42,percent of total billed charges,"Drugs, Inpatient Only",0.42,34,,0.42,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.87,70,,0.87,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.41,,,0.41,Other,Drug Cost,0.41,,,0.41,Other,Drug Cost,0.41,,,0.41,Other,Drug Cost,0.41,,,0.41,Other,Drug Cost,0.41,,,0.41,Other,Drug Cost,0.41,,,0.41,Other,Drug Cost,0.93,,,0.93,Other,225% of Medicaid,0.58,,,0.58,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.89,,,0.89,Other,215% Medicaid APG methodology,0.89,,,0.89,Other,215% Medicaid APG methodology,0.52,,,0.52,Other,125% Medicaid APG methodology,0.01,0.93,
CALCIUM POLYCARBOPHIL (FIBERCON) 625 MG,,,,80000333,CDM,250,RC,536430608,NDC,both,60,EA,0.09,0.03,39.4668,,0.03,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.03,34,,0.03,percent of total billed charges,"Drugs, Inpatient Only",0.03,34,,0.03,percent of total billed charges,"Drugs, Inpatient Only",0.03,34,,0.03,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.06,70,,0.06,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.06,,,0.06,Other,225% of Medicaid,0.04,,,0.04,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.06,,,0.06,Other,215% Medicaid APG methodology,0.06,,,0.06,Other,215% Medicaid APG methodology,0.04,,,0.04,Other,125% Medicaid APG methodology,0.01,0.06,
CAPSAICIN 0.025% CREAM,,,,80000339,CDM,250,RC,536252525,NDC,both,1,GM,6.45,2.55,39.4668,,2.55,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2.19,34,,2.19,percent of total billed charges,"Drugs, Inpatient Only",2.19,34,,2.19,percent of total billed charges,"Drugs, Inpatient Only",2.19,34,,2.19,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,4.52,70,,4.52,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2.15,,,2.15,Other,Drug Cost,2.15,,,2.15,Other,Drug Cost,2.15,,,2.15,Other,Drug Cost,2.15,,,2.15,Other,Drug Cost,2.15,,,2.15,Other,Drug Cost,2.15,,,2.15,Other,Drug Cost,4.84,,,4.84,Other,225% of Medicaid,3.01,,,3.01,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,4.62,,,4.62,Other,215% Medicaid APG methodology,4.62,,,4.62,Other,215% Medicaid APG methodology,2.69,,,2.69,Other,125% Medicaid APG methodology,0.01,4.84,
CARBACHOL 0.01% OPTH SOLN,,,,80000343,CDM,250,RC,65002315,NDC,both,12,ML,1.85,0.73,39.4668,,0.73,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.63,34,,0.63,percent of total billed charges,"Drugs, Inpatient Only",0.63,34,,0.63,percent of total billed charges,"Drugs, Inpatient Only",0.63,34,,0.63,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1.29,70,,1.29,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.62,,,0.62,Other,Drug Cost,0.62,,,0.62,Other,Drug Cost,0.62,,,0.62,Other,Drug Cost,0.62,,,0.62,Other,Drug Cost,0.62,,,0.62,Other,Drug Cost,0.62,,,0.62,Other,Drug Cost,1.39,,,1.39,Other,225% of Medicaid,0.86,,,0.86,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,1.32,,,1.32,Other,215% Medicaid APG methodology,1.32,,,1.32,Other,215% Medicaid APG methodology,0.77,,,0.77,Other,125% Medicaid APG methodology,0.01,1.39,
CARBAMAZEPINE 100 MG,,,,80000345,CDM,250,RC,13668027101,NDC,both,100,EA,0.1,0.04,39.4668,,0.04,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.03,34,,0.03,percent of total billed charges,"Drugs, Inpatient Only",0.03,34,,0.03,percent of total billed charges,"Drugs, Inpatient Only",0.03,34,,0.03,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.07,70,,0.07,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.08,,,0.08,Other,225% of Medicaid,0.05,,,0.05,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.07,,,0.07,Other,215% Medicaid APG methodology,0.07,,,0.07,Other,215% Medicaid APG methodology,0.04,,,0.04,Other,125% Medicaid APG methodology,0.01,0.08,
CARBAMAZEPINE 100 MG ER TABLET,,,,80000346,CDM,250,RC,78051005,NDC,both,100,EA,0.03,0.01,39.4668,,0.01,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.02,70,,0.02,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.02,,,0.02,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,0.02,
CARBAMAZEPINE 200 MG ER TABLET,,,,80000348,CDM,250,RC,51672412401,NDC,both,100,EA,0.02,0.01,39.4668,,0.01,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.02,70,,0.02,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.02,,,0.02,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,0.02,
CARBAMAZEPINE 200 MG TAB,,,,80000349,CDM,250,RC,51672400501,NDC,both,100,EA,0.01,0.01,39.4668,,0.01,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,70,,0.01,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,0.02,
CARBAMAZEPINE XR 400MG,,,,80000357,CDM,250,RC,78051205,NDC,both,100,EA,0.03,0.01,39.4668,,0.01,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.02,70,,0.02,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.02,,,0.02,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,0.02,
CARBAMIDE PEROXIDE EAR DROPS 15ML,,,,80000359,CDM,250,RC,904662735,NDC,both,1,ML,2.76,1.09,39.4668,,1.09,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.94,34,,0.94,percent of total billed charges,"Drugs, Inpatient Only",0.94,34,,0.94,percent of total billed charges,"Drugs, Inpatient Only",0.94,34,,0.94,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1.93,70,,1.93,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.92,,,0.92,Other,Drug Cost,0.92,,,0.92,Other,Drug Cost,0.92,,,0.92,Other,Drug Cost,0.92,,,0.92,Other,Drug Cost,0.92,,,0.92,Other,Drug Cost,0.92,,,0.92,Other,Drug Cost,2.07,,,2.07,Other,225% of Medicaid,1.29,,,1.29,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,1.98,,,1.98,Other,215% Medicaid APG methodology,1.98,,,1.98,Other,215% Medicaid APG methodology,1.15,,,1.15,Other,125% Medicaid APG methodology,0.01,2.07,
CARBIDOPA/ LEVODOPA (CABIDOPA) 10/100,,,,80000361,CDM,250,RC,50228045701,NDC,both,100,EA,0.11,0.04,39.4668,,0.04,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.04,34,,0.04,percent of total billed charges,"Drugs, Inpatient Only",0.04,34,,0.04,percent of total billed charges,"Drugs, Inpatient Only",0.04,34,,0.04,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.08,70,,0.08,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.08,,,0.08,Other,225% of Medicaid,0.05,,,0.05,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.08,,,0.08,Other,215% Medicaid APG methodology,0.08,,,0.08,Other,215% Medicaid APG methodology,0.05,,,0.05,Other,125% Medicaid APG methodology,0.01,0.08,
CARBIDOPA-LEVO 25-100MG,,,,80000364,CDM,250,RC,93970201,NDC,both,100,EA,0.13,0.05,39.4668,,0.05,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.04,34,,0.04,percent of total billed charges,"Drugs, Inpatient Only",0.04,34,,0.04,percent of total billed charges,"Drugs, Inpatient Only",0.04,34,,0.04,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.09,70,,0.09,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.1,,,0.1,Other,225% of Medicaid,0.06,,,0.06,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.09,,,0.09,Other,215% Medicaid APG methodology,0.09,,,0.09,Other,215% Medicaid APG methodology,0.05,,,0.05,Other,125% Medicaid APG methodology,0.01,0.1,
CARBIDOPA-LEVO 50-200MG,,,,80000366,CDM,250,RC,68084028201,NDC,both,10,EA,11.67,4.61,39.4668,,4.61,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,3.97,34,,3.97,percent of total billed charges,"Drugs, Inpatient Only",3.97,34,,3.97,percent of total billed charges,"Drugs, Inpatient Only",3.97,34,,3.97,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,8.17,70,,8.17,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,3.89,,,3.89,Other,Drug Cost,3.89,,,3.89,Other,Drug Cost,3.89,,,3.89,Other,Drug Cost,3.89,,,3.89,Other,Drug Cost,3.89,,,3.89,Other,Drug Cost,3.89,,,3.89,Other,Drug Cost,8.75,,,8.75,Other,225% of Medicaid,5.45,,,5.45,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,8.36,,,8.36,Other,215% Medicaid APG methodology,8.36,,,8.36,Other,215% Medicaid APG methodology,4.86,,,4.86,Other,125% Medicaid APG methodology,0.01,8.75,
CARBIDOPA-LEVO ER 25-100MG,,,,80000367,CDM,250,RC,62756046188,NDC,both,100,EA,0.06,0.02,39.4668,,0.02,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.02,34,,0.02,percent of total billed charges,"Drugs, Inpatient Only",0.02,34,,0.02,percent of total billed charges,"Drugs, Inpatient Only",0.02,34,,0.02,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.04,70,,0.04,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.05,,,0.05,Other,225% of Medicaid,0.03,,,0.03,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.04,,,0.04,Other,215% Medicaid APG methodology,0.04,,,0.04,Other,215% Medicaid APG methodology,0.03,,,0.03,Other,125% Medicaid APG methodology,0.01,0.05,
CARBOPROST 250 MCG/ML INJECTION,,,,80000372,CDM,250,RC,9085608,NDC,both,10,ML,50.65,19.99,39.4668,,19.99,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,17.22,34,,17.22,percent of total billed charges,"Drugs, Inpatient Only",17.22,34,,17.22,percent of total billed charges,"Drugs, Inpatient Only",17.22,34,,17.22,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,35.45,70,,35.45,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,16.88,,,16.88,Other,Drug Cost,16.88,,,16.88,Other,Drug Cost,16.88,,,16.88,Other,Drug Cost,16.88,,,16.88,Other,Drug Cost,16.88,,,16.88,Other,Drug Cost,16.88,,,16.88,Other,Drug Cost,37.99,,,37.99,Other,225% of Medicaid,23.64,,,23.64,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,36.3,,,36.3,Other,215% Medicaid APG methodology,36.3,,,36.3,Other,215% Medicaid APG methodology,21.1,,,21.1,Other,125% Medicaid APG methodology,0.01,37.99,
CARISOPRODOL 350 MG,,,,80000374,CDM,250,RC,16571078101,NDC,both,100,EA,0.09,0.03,39.4668,,0.03,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.03,34,,0.03,percent of total billed charges,"Drugs, Inpatient Only",0.03,34,,0.03,percent of total billed charges,"Drugs, Inpatient Only",0.03,34,,0.03,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.06,70,,0.06,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.07,,,0.07,Other,225% of Medicaid,0.04,,,0.04,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.06,,,0.06,Other,215% Medicaid APG methodology,0.06,,,0.06,Other,215% Medicaid APG methodology,0.04,,,0.04,Other,125% Medicaid APG methodology,0.01,0.07,
CARVEDILOL (COREG) 12.5MG,,,,80000376,CDM,250,RC,68382009405,NDC,both,500,EA,0.03,0.01,39.4668,,0.01,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.02,70,,0.02,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.02,,,0.02,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,0.02,
CARVEDILOL (COREG) 25MG,,,,80000377,CDM,250,RC,68382009501,NDC,both,100,EA,0.04,0.02,39.4668,,0.02,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.03,70,,0.03,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.03,,,0.03,Other,225% of Medicaid,0.02,,,0.02,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.03,,,0.03,Other,215% Medicaid APG methodology,0.03,,,0.03,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,125% Medicaid APG methodology,0.01,0.03,
CARVEDILOL (COREG) 6.25MG,,,,80000379,CDM,250,RC,904630161,NDC,both,10,EA,0.36,0.14,39.4668,,0.14,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.12,34,,0.12,percent of total billed charges,"Drugs, Inpatient Only",0.12,34,,0.12,percent of total billed charges,"Drugs, Inpatient Only",0.12,34,,0.12,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.25,70,,0.25,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.12,,,0.12,Other,Drug Cost,0.12,,,0.12,Other,Drug Cost,0.12,,,0.12,Other,Drug Cost,0.12,,,0.12,Other,Drug Cost,0.12,,,0.12,Other,Drug Cost,0.12,,,0.12,Other,Drug Cost,0.27,,,0.27,Other,225% of Medicaid,0.17,,,0.17,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.26,,,0.26,Other,215% Medicaid APG methodology,0.26,,,0.26,Other,215% Medicaid APG methodology,0.15,,,0.15,Other,125% Medicaid APG methodology,0.01,0.27,
CEFUROXIME AXETIL 250 MG,,,,80000408,CDM,250,RC,67877021560,NDC,both,60,EA,0.03,0.01,39.4668,,0.01,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.02,70,,0.02,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.02,,,0.02,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,0.02,
CELECOXIB (CELEBREX) 200MG CAPS,,,,80000409,CDM,250,RC,69097042107,NDC,both,100,EA,0.09,0.04,39.4668,,0.04,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.03,34,,0.03,percent of total billed charges,"Drugs, Inpatient Only",0.03,34,,0.03,percent of total billed charges,"Drugs, Inpatient Only",0.03,34,,0.03,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.06,70,,0.06,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.07,,,0.07,Other,225% of Medicaid,0.04,,,0.04,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.06,,,0.06,Other,215% Medicaid APG methodology,0.06,,,0.06,Other,215% Medicaid APG methodology,0.04,,,0.04,Other,125% Medicaid APG methodology,0.01,0.07,
CELECOXIB (CELEBREX) 100MG CAPS,,,,80000410,CDM,250,RC,25152031,NDC,both,100,EA,0.03,0.01,39.4668,,0.01,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.02,70,,0.02,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.02,,,0.02,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,0.02,
CEPHALEXIN 250 MG,,,,80000412,CDM,250,RC,93314501,NDC,both,100,EA,0.09,0.03,39.4668,,0.03,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.03,34,,0.03,percent of total billed charges,"Drugs, Inpatient Only",0.03,34,,0.03,percent of total billed charges,"Drugs, Inpatient Only",0.03,34,,0.03,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.06,70,,0.06,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.06,,,0.06,Other,225% of Medicaid,0.04,,,0.04,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.06,,,0.06,Other,215% Medicaid APG methodology,0.06,,,0.06,Other,215% Medicaid APG methodology,0.04,,,0.04,Other,125% Medicaid APG methodology,0.01,0.06,
CEPHALEXIN 250MG/5ML,,,,80000413,CDM,250,RC,93417773,NDC,both,1,ML,5.73,2.26,39.4668,,2.26,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1.95,34,,1.95,percent of total billed charges,"Drugs, Inpatient Only",1.95,34,,1.95,percent of total billed charges,"Drugs, Inpatient Only",1.95,34,,1.95,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,4.01,70,,4.01,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1.91,,,1.91,Other,Drug Cost,1.91,,,1.91,Other,Drug Cost,1.91,,,1.91,Other,Drug Cost,1.91,,,1.91,Other,Drug Cost,1.91,,,1.91,Other,Drug Cost,1.91,,,1.91,Other,Drug Cost,4.3,,,4.3,Other,225% of Medicaid,2.67,,,2.67,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,4.11,,,4.11,Other,215% Medicaid APG methodology,4.11,,,4.11,Other,215% Medicaid APG methodology,2.39,,,2.39,Other,125% Medicaid APG methodology,0.01,4.3,
CEPHALEXIN 500 MG,,,,80000414,CDM,250,RC,93314701,NDC,both,100,EA,0.11,0.04,39.4668,,0.04,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.04,34,,0.04,percent of total billed charges,"Drugs, Inpatient Only",0.04,34,,0.04,percent of total billed charges,"Drugs, Inpatient Only",0.04,34,,0.04,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.08,70,,0.08,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.09,,,0.09,Other,225% of Medicaid,0.05,,,0.05,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.08,,,0.08,Other,215% Medicaid APG methodology,0.08,,,0.08,Other,215% Medicaid APG methodology,0.05,,,0.05,Other,125% Medicaid APG methodology,0.01,0.09,
CHLORDIAZEPOXIDE 25 MG,,,,80000425,CDM,250,RC,555015902,NDC,both,100,EA,0.14,0.06,39.4668,,0.06,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.05,34,,0.05,percent of total billed charges,"Drugs, Inpatient Only",0.05,34,,0.05,percent of total billed charges,"Drugs, Inpatient Only",0.05,34,,0.05,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.1,70,,0.1,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.11,,,0.11,Other,225% of Medicaid,0.07,,,0.07,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.1,,,0.1,Other,215% Medicaid APG methodology,0.1,,,0.1,Other,215% Medicaid APG methodology,0.06,,,0.06,Other,125% Medicaid APG methodology,0.01,0.11,
CHLORHEXIDINE GLUCONATE ORAL R,,,,80000427,CDM,250,RC,116200116,NDC,both,1,ML,7.62,3.01,39.4668,,3.01,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2.59,34,,2.59,percent of total billed charges,"Drugs, Inpatient Only",2.59,34,,2.59,percent of total billed charges,"Drugs, Inpatient Only",2.59,34,,2.59,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,5.33,70,,5.33,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2.54,,,2.54,Other,Drug Cost,2.54,,,2.54,Other,Drug Cost,2.54,,,2.54,Other,Drug Cost,2.54,,,2.54,Other,Drug Cost,2.54,,,2.54,Other,Drug Cost,2.54,,,2.54,Other,Drug Cost,5.72,,,5.72,Other,225% of Medicaid,3.56,,,3.56,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,5.46,,,5.46,Other,215% Medicaid APG methodology,5.46,,,5.46,Other,215% Medicaid APG methodology,3.18,,,3.18,Other,125% Medicaid APG methodology,0.01,5.72,
CHLOROPROCAINE HCL MPF 3%  20 ML,,,,80000428,CDM,250,RC,63323047827,NDC,both,25,ML,30.38,11.99,39.4668,,11.99,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,10.33,34,,10.33,percent of total billed charges,"Drugs, Inpatient Only",10.33,34,,10.33,percent of total billed charges,"Drugs, Inpatient Only",10.33,34,,10.33,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,21.27,70,,21.27,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,10.13,,,10.13,Other,Drug Cost,10.13,,,10.13,Other,Drug Cost,10.13,,,10.13,Other,Drug Cost,10.13,,,10.13,Other,Drug Cost,10.13,,,10.13,Other,Drug Cost,10.13,,,10.13,Other,Drug Cost,22.79,,,22.79,Other,225% of Medicaid,14.18,,,14.18,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,21.78,,,21.78,Other,215% Medicaid APG methodology,21.78,,,21.78,Other,215% Medicaid APG methodology,12.66,,,12.66,Other,125% Medicaid APG methodology,0.01,22.79,
CHLOROPROCAINE MPF 2% 20ML,,,,80000429,CDM,250,RC,63323047727,NDC,both,25,ML,24.3,9.59,39.4668,,9.59,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,8.26,34,,8.26,percent of total billed charges,"Drugs, Inpatient Only",8.26,34,,8.26,percent of total billed charges,"Drugs, Inpatient Only",8.26,34,,8.26,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,17.01,70,,17.01,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,8.1,,,8.1,Other,Drug Cost,8.1,,,8.1,Other,Drug Cost,8.1,,,8.1,Other,Drug Cost,8.1,,,8.1,Other,Drug Cost,8.1,,,8.1,Other,Drug Cost,8.1,,,8.1,Other,Drug Cost,18.22,,,18.22,Other,225% of Medicaid,11.34,,,11.34,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,17.41,,,17.41,Other,215% Medicaid APG methodology,17.41,,,17.41,Other,215% Medicaid APG methodology,10.12,,,10.12,Other,125% Medicaid APG methodology,0.01,18.22,
CHLORPROMAZINE HCL 25 MG,,,,80000439,CDM,250,RC,50268016315,NDC,both,5,EA,44.68,17.63,39.4668,,17.63,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,15.19,34,,15.19,percent of total billed charges,"Drugs, Inpatient Only",15.19,34,,15.19,percent of total billed charges,"Drugs, Inpatient Only",15.19,34,,15.19,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,31.27,70,,31.27,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,14.89,,,14.89,Other,Drug Cost,14.89,,,14.89,Other,Drug Cost,14.89,,,14.89,Other,Drug Cost,14.89,,,14.89,Other,Drug Cost,14.89,,,14.89,Other,Drug Cost,14.89,,,14.89,Other,Drug Cost,33.51,,,33.51,Other,225% of Medicaid,20.85,,,20.85,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,32.02,,,32.02,Other,215% Medicaid APG methodology,32.02,,,32.02,Other,215% Medicaid APG methodology,18.62,,,18.62,Other,125% Medicaid APG methodology,0.01,33.51,
CHLORTHALIDONE 25 MG,,,,80000443,CDM,250,RC,57664064888,NDC,both,100,EA,0.11,0.04,39.4668,,0.04,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.04,34,,0.04,percent of total billed charges,"Drugs, Inpatient Only",0.04,34,,0.04,percent of total billed charges,"Drugs, Inpatient Only",0.04,34,,0.04,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.08,70,,0.08,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.08,,,0.08,Other,225% of Medicaid,0.05,,,0.05,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.08,,,0.08,Other,215% Medicaid APG methodology,0.08,,,0.08,Other,215% Medicaid APG methodology,0.05,,,0.05,Other,125% Medicaid APG methodology,0.01,0.08,
CHOLECALCIFEROL 400 INT. UNITS TAB,,,,80000444,CDM,250,RC,904582360,NDC,both,100,EA,0.03,0.01,39.4668,,0.01,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.02,70,,0.02,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.02,,,0.02,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,0.02,
CHOLESTYRAMINE 4GRAM PACKETS,,,,80000445,CDM,250,RC,68382052960,NDC,both,60,EA,1.02,0.4,39.4668,,0.4,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.35,34,,0.35,percent of total billed charges,"Drugs, Inpatient Only",0.35,34,,0.35,percent of total billed charges,"Drugs, Inpatient Only",0.35,34,,0.35,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.71,70,,0.71,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.34,,,0.34,Other,Drug Cost,0.34,,,0.34,Other,Drug Cost,0.34,,,0.34,Other,Drug Cost,0.34,,,0.34,Other,Drug Cost,0.34,,,0.34,Other,Drug Cost,0.34,,,0.34,Other,Drug Cost,0.76,,,0.76,Other,225% of Medicaid,0.47,,,0.47,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.73,,,0.73,Other,215% Medicaid APG methodology,0.73,,,0.73,Other,215% Medicaid APG methodology,0.42,,,0.42,Other,125% Medicaid APG methodology,0.01,0.76,
CHROMIUM CHLORIDE 4 MCG/ML 10 ML INJ,,,,80000447,CDM,250,RC,409409301,NDC,both,25,ML,10.33,4.08,39.4668,,4.08,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,3.51,34,,3.51,percent of total billed charges,"Drugs, Inpatient Only",3.51,34,,3.51,percent of total billed charges,"Drugs, Inpatient Only",3.51,34,,3.51,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,7.23,70,,7.23,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,3.44,,,3.44,Other,Drug Cost,3.44,,,3.44,Other,Drug Cost,3.44,,,3.44,Other,Drug Cost,3.44,,,3.44,Other,Drug Cost,3.44,,,3.44,Other,Drug Cost,3.44,,,3.44,Other,Drug Cost,7.75,,,7.75,Other,225% of Medicaid,4.82,,,4.82,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,7.4,,,7.4,Other,215% Medicaid APG methodology,7.4,,,7.4,Other,215% Medicaid APG methodology,4.3,,,4.3,Other,125% Medicaid APG methodology,0.01,7.75,
CILOSTAZOL 50 MG,,,,80000451,CDM,250,RC,60505252101,NDC,both,60,EA,0.12,0.05,39.4668,,0.05,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.04,34,,0.04,percent of total billed charges,"Drugs, Inpatient Only",0.04,34,,0.04,percent of total billed charges,"Drugs, Inpatient Only",0.04,34,,0.04,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.08,70,,0.08,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.09,,,0.09,Other,225% of Medicaid,0.05,,,0.05,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.08,,,0.08,Other,215% Medicaid APG methodology,0.08,,,0.08,Other,215% Medicaid APG methodology,0.05,,,0.05,Other,125% Medicaid APG methodology,0.01,0.09,
CIPRODEX OTIC SOLN,,,,80000452,CDM,250,RC,781618667,NDC,both,1,ML,68.07,26.87,39.4668,,26.87,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,23.14,34,,23.14,percent of total billed charges,"Drugs, Inpatient Only",23.14,34,,23.14,percent of total billed charges,"Drugs, Inpatient Only",23.14,34,,23.14,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,47.65,70,,47.65,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,22.69,,,22.69,Other,Drug Cost,22.69,,,22.69,Other,Drug Cost,22.69,,,22.69,Other,Drug Cost,22.69,,,22.69,Other,Drug Cost,22.69,,,22.69,Other,Drug Cost,22.69,,,22.69,Other,Drug Cost,51.05,,,51.05,Other,225% of Medicaid,31.77,,,31.77,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,48.78,,,48.78,Other,215% Medicaid APG methodology,48.78,,,48.78,Other,215% Medicaid APG methodology,28.36,,,28.36,Other,125% Medicaid APG methodology,0.01,51.05,
CIPROFLOXACIN 0.3% (CILOXIN)2.5ML,,,,80000455,CDM,250,RC,61314065625,NDC,both,1,ML,1.86,0.73,39.4668,,0.73,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.63,34,,0.63,percent of total billed charges,"Drugs, Inpatient Only",0.63,34,,0.63,percent of total billed charges,"Drugs, Inpatient Only",0.63,34,,0.63,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1.3,70,,1.3,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.62,,,0.62,Other,Drug Cost,0.62,,,0.62,Other,Drug Cost,0.62,,,0.62,Other,Drug Cost,0.62,,,0.62,Other,Drug Cost,0.62,,,0.62,Other,Drug Cost,0.62,,,0.62,Other,Drug Cost,1.4,,,1.4,Other,225% of Medicaid,0.87,,,0.87,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,1.33,,,1.33,Other,215% Medicaid APG methodology,1.33,,,1.33,Other,215% Medicaid APG methodology,0.78,,,0.78,Other,125% Medicaid APG methodology,0.01,1.4,
CIPROFLOXACIN 250 MG TAB,,,,80000456,CDM,250,RC,143992701,NDC,both,100,EA,0.09,0.03,39.4668,,0.03,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.03,34,,0.03,percent of total billed charges,"Drugs, Inpatient Only",0.03,34,,0.03,percent of total billed charges,"Drugs, Inpatient Only",0.03,34,,0.03,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.06,70,,0.06,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.07,,,0.07,Other,225% of Medicaid,0.04,,,0.04,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.06,,,0.06,Other,215% Medicaid APG methodology,0.06,,,0.06,Other,215% Medicaid APG methodology,0.04,,,0.04,Other,125% Medicaid APG methodology,0.01,0.07,
CIPROFLOXACIN 500MG TAB,,,,80000457,CDM,250,RC,143992801,NDC,both,100,EA,0.18,0.07,39.4668,,0.07,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.06,34,,0.06,percent of total billed charges,"Drugs, Inpatient Only",0.06,34,,0.06,percent of total billed charges,"Drugs, Inpatient Only",0.06,34,,0.06,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.12,70,,0.12,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.06,,,0.06,Other,Drug Cost,0.06,,,0.06,Other,Drug Cost,0.06,,,0.06,Other,Drug Cost,0.06,,,0.06,Other,Drug Cost,0.06,,,0.06,Other,Drug Cost,0.06,,,0.06,Other,Drug Cost,0.13,,,0.13,Other,225% of Medicaid,0.08,,,0.08,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.13,,,0.13,Other,215% Medicaid APG methodology,0.13,,,0.13,Other,215% Medicaid APG methodology,0.07,,,0.07,Other,125% Medicaid APG methodology,0.01,0.13,
CISATRACURIUM 2 MG/ML INJECTION 5ML,,,,80000462,CDM,250,RC,74437805,NDC,both,10,ML,42.61,16.82,39.4668,,16.82,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,14.49,34,,14.49,percent of total billed charges,"Drugs, Inpatient Only",14.49,34,,14.49,percent of total billed charges,"Drugs, Inpatient Only",14.49,34,,14.49,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,29.83,70,,29.83,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,14.2,,,14.2,Other,Drug Cost,14.2,,,14.2,Other,Drug Cost,14.2,,,14.2,Other,Drug Cost,14.2,,,14.2,Other,Drug Cost,14.2,,,14.2,Other,Drug Cost,14.2,,,14.2,Other,Drug Cost,31.96,,,31.96,Other,225% of Medicaid,19.88,,,19.88,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,30.54,,,30.54,Other,215% Medicaid APG methodology,30.54,,,30.54,Other,215% Medicaid APG methodology,17.75,,,17.75,Other,125% Medicaid APG methodology,0.01,31.96,
CITALOPRAM (CELEXA) 10MG,,,,80000464,CDM,250,RC,378623101,NDC,both,100,EA,0.03,0.01,39.4668,,0.01,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.02,70,,0.02,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.02,,,0.02,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,0.02,
CITALOPRAM (CELEXA) 20MG,,,,80000465,CDM,250,RC,378623201,NDC,both,100,EA,0.03,0.01,39.4668,,0.01,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.02,70,,0.02,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.02,,,0.02,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,0.02,
CLARITHROMYCIN 500MG,,,,80000475,CDM,250,RC,65862022660,NDC,both,60,EA,0.43,0.17,39.4668,,0.17,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.15,34,,0.15,percent of total billed charges,"Drugs, Inpatient Only",0.15,34,,0.15,percent of total billed charges,"Drugs, Inpatient Only",0.15,34,,0.15,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.3,70,,0.3,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.14,,,0.14,Other,Drug Cost,0.14,,,0.14,Other,Drug Cost,0.14,,,0.14,Other,Drug Cost,0.14,,,0.14,Other,Drug Cost,0.14,,,0.14,Other,Drug Cost,0.14,,,0.14,Other,Drug Cost,0.32,,,0.32,Other,225% of Medicaid,0.2,,,0.2,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.31,,,0.31,Other,215% Medicaid APG methodology,0.31,,,0.31,Other,215% Medicaid APG methodology,0.18,,,0.18,Other,125% Medicaid APG methodology,0.01,0.32,
CLINDAMYCIN (CLEOCIN) 300MG/2ML VIAL,,,,80000477,CDM,250,RC,9087026,NDC,both,25,ML,0.05,0.02,39.4668,,0.02,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.02,34,,0.02,percent of total billed charges,"Drugs, Inpatient Only",0.02,34,,0.02,percent of total billed charges,"Drugs, Inpatient Only",0.02,34,,0.02,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.04,70,,0.04,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.04,,,0.04,Other,225% of Medicaid,0.03,,,0.03,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.04,,,0.04,Other,215% Medicaid APG methodology,0.04,,,0.04,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,125% Medicaid APG methodology,0.01,0.04,
CLINDAMYCIN HCL 150 MG CAPS,,,,80000480,CDM,250,RC,63304069201,NDC,both,100,EA,0.14,0.06,39.4668,,0.06,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.05,34,,0.05,percent of total billed charges,"Drugs, Inpatient Only",0.05,34,,0.05,percent of total billed charges,"Drugs, Inpatient Only",0.05,34,,0.05,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.1,70,,0.1,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.11,,,0.11,Other,225% of Medicaid,0.07,,,0.07,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.1,,,0.1,Other,215% Medicaid APG methodology,0.1,,,0.1,Other,215% Medicaid APG methodology,0.06,,,0.06,Other,125% Medicaid APG methodology,0.01,0.11,
CLINDAMYCIN PHOS GEL 30 GM,,,,80000481,CDM,250,RC,59762374301,NDC,both,1,GM,8.22,3.24,39.4668,,3.24,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2.79,34,,2.79,percent of total billed charges,"Drugs, Inpatient Only",2.79,34,,2.79,percent of total billed charges,"Drugs, Inpatient Only",2.79,34,,2.79,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,5.75,70,,5.75,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2.74,,,2.74,Other,Drug Cost,2.74,,,2.74,Other,Drug Cost,2.74,,,2.74,Other,Drug Cost,2.74,,,2.74,Other,Drug Cost,2.74,,,2.74,Other,Drug Cost,2.74,,,2.74,Other,Drug Cost,6.17,,,6.17,Other,225% of Medicaid,3.84,,,3.84,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,5.89,,,5.89,Other,215% Medicaid APG methodology,5.89,,,5.89,Other,215% Medicaid APG methodology,3.43,,,3.43,Other,125% Medicaid APG methodology,0.01,6.17,
CLINIMIX 5/20 1000ML,,,,80000485,CDM,250,RC,338113803,NDC,both,6,ML,37.43,14.77,39.4668,,14.77,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,12.72,34,,12.72,percent of total billed charges,"Drugs, Inpatient Only",12.72,34,,12.72,percent of total billed charges,"Drugs, Inpatient Only",12.72,34,,12.72,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,26.2,70,,26.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,12.48,,,12.48,Other,Drug Cost,12.48,,,12.48,Other,Drug Cost,12.48,,,12.48,Other,Drug Cost,12.48,,,12.48,Other,Drug Cost,12.48,,,12.48,Other,Drug Cost,12.48,,,12.48,Other,Drug Cost,28.07,,,28.07,Other,225% of Medicaid,17.47,,,17.47,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,26.82,,,26.82,Other,215% Medicaid APG methodology,26.82,,,26.82,Other,215% Medicaid APG methodology,15.59,,,15.59,Other,125% Medicaid APG methodology,0.01,28.07,
CLINIMIX E AA/20% 1000ML,,,,80000488,CDM,250,RC,338114803,NDC,both,6,ML,40.14,15.84,39.4668,,15.84,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,13.65,34,,13.65,percent of total billed charges,"Drugs, Inpatient Only",13.65,34,,13.65,percent of total billed charges,"Drugs, Inpatient Only",13.65,34,,13.65,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,28.1,70,,28.1,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,13.38,,,13.38,Other,Drug Cost,13.38,,,13.38,Other,Drug Cost,13.38,,,13.38,Other,Drug Cost,13.38,,,13.38,Other,Drug Cost,13.38,,,13.38,Other,Drug Cost,13.38,,,13.38,Other,Drug Cost,30.11,,,30.11,Other,225% of Medicaid,18.73,,,18.73,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,28.77,,,28.77,Other,215% Medicaid APG methodology,28.77,,,28.77,Other,215% Medicaid APG methodology,16.73,,,16.73,Other,125% Medicaid APG methodology,0.01,30.11,
CLOBETASOL  0.05% CREAM 15 GM,,,,80000490,CDM,250,RC,51672125801,NDC,both,1,GM,0.69,0.27,39.4668,,0.27,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.23,34,,0.23,percent of total billed charges,"Drugs, Inpatient Only",0.23,34,,0.23,percent of total billed charges,"Drugs, Inpatient Only",0.23,34,,0.23,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.48,70,,0.48,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.23,,,0.23,Other,Drug Cost,0.23,,,0.23,Other,Drug Cost,0.23,,,0.23,Other,Drug Cost,0.23,,,0.23,Other,Drug Cost,0.23,,,0.23,Other,Drug Cost,0.23,,,0.23,Other,Drug Cost,0.52,,,0.52,Other,225% of Medicaid,0.32,,,0.32,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.49,,,0.49,Other,215% Medicaid APG methodology,0.49,,,0.49,Other,215% Medicaid APG methodology,0.29,,,0.29,Other,125% Medicaid APG methodology,0.01,0.52,
CLOBETASOL  0.05% OINT 45 GM,,,,80000491,CDM,250,RC,51672125901,NDC,both,1,GM,0.21,0.08,39.4668,,0.08,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.07,34,,0.07,percent of total billed charges,"Drugs, Inpatient Only",0.07,34,,0.07,percent of total billed charges,"Drugs, Inpatient Only",0.07,34,,0.07,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.15,70,,0.15,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.07,,,0.07,Other,Drug Cost,0.07,,,0.07,Other,Drug Cost,0.07,,,0.07,Other,Drug Cost,0.07,,,0.07,Other,Drug Cost,0.07,,,0.07,Other,Drug Cost,0.07,,,0.07,Other,Drug Cost,0.16,,,0.16,Other,225% of Medicaid,0.1,,,0.1,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.15,,,0.15,Other,215% Medicaid APG methodology,0.15,,,0.15,Other,215% Medicaid APG methodology,0.09,,,0.09,Other,125% Medicaid APG methodology,0.01,0.16,
CLOMIPRAMINE 25MG TAB,,,,80000494,CDM,250,RC,51672401106,NDC,both,30,EA,1.36,0.54,39.4668,,0.54,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.46,34,,0.46,percent of total billed charges,"Drugs, Inpatient Only",0.46,34,,0.46,percent of total billed charges,"Drugs, Inpatient Only",0.46,34,,0.46,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.95,70,,0.95,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.45,,,0.45,Other,Drug Cost,0.45,,,0.45,Other,Drug Cost,0.45,,,0.45,Other,Drug Cost,0.45,,,0.45,Other,Drug Cost,0.45,,,0.45,Other,Drug Cost,0.45,,,0.45,Other,Drug Cost,1.02,,,1.02,Other,225% of Medicaid,0.63,,,0.63,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.97,,,0.97,Other,215% Medicaid APG methodology,0.97,,,0.97,Other,215% Medicaid APG methodology,0.57,,,0.57,Other,125% Medicaid APG methodology,0.01,1.02,
CLONAZEPAM 0.5 MG,,,,80000495,CDM,250,RC,93083201,NDC,both,100,EA,0.03,0.01,39.4668,,0.01,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.02,70,,0.02,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.02,,,0.02,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,0.02,
CLONIDINE (CATAPRES) 0.1 MG PATCH,,,,80000497,CDM,250,RC,378087199,NDC,both,4,EA,8.68,3.42,39.4668,,3.42,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2.95,34,,2.95,percent of total billed charges,"Drugs, Inpatient Only",2.95,34,,2.95,percent of total billed charges,"Drugs, Inpatient Only",2.95,34,,2.95,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,6.07,70,,6.07,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2.89,,,2.89,Other,Drug Cost,2.89,,,2.89,Other,Drug Cost,2.89,,,2.89,Other,Drug Cost,2.89,,,2.89,Other,Drug Cost,2.89,,,2.89,Other,Drug Cost,2.89,,,2.89,Other,Drug Cost,6.51,,,6.51,Other,225% of Medicaid,4.05,,,4.05,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,6.22,,,6.22,Other,215% Medicaid APG methodology,6.22,,,6.22,Other,215% Medicaid APG methodology,3.62,,,3.62,Other,125% Medicaid APG methodology,0.01,6.51,
CLONIDINE (CATAPRES) 0.2 MG PATCH,,,,80000498,CDM,250,RC,591350904,NDC,both,4,EA,11.17,4.41,39.4668,,4.41,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,3.8,34,,3.8,percent of total billed charges,"Drugs, Inpatient Only",3.8,34,,3.8,percent of total billed charges,"Drugs, Inpatient Only",3.8,34,,3.8,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,7.82,70,,7.82,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,3.72,,,3.72,Other,Drug Cost,3.72,,,3.72,Other,Drug Cost,3.72,,,3.72,Other,Drug Cost,3.72,,,3.72,Other,Drug Cost,3.72,,,3.72,Other,Drug Cost,3.72,,,3.72,Other,Drug Cost,8.38,,,8.38,Other,225% of Medicaid,5.21,,,5.21,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,8,,,8,Other,215% Medicaid APG methodology,8,,,8,Other,215% Medicaid APG methodology,4.65,,,4.65,Other,125% Medicaid APG methodology,0.01,8.38,
CLONIDINE (CATAPRES) 0.3MG PATCH,,,,80000499,CDM,250,RC,378087399,NDC,both,4,EA,15.29,6.03,39.4668,,6.03,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,5.2,34,,5.2,percent of total billed charges,"Drugs, Inpatient Only",5.2,34,,5.2,percent of total billed charges,"Drugs, Inpatient Only",5.2,34,,5.2,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,10.7,70,,10.7,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,5.1,,,5.1,Other,Drug Cost,5.1,,,5.1,Other,Drug Cost,5.1,,,5.1,Other,Drug Cost,5.1,,,5.1,Other,Drug Cost,5.1,,,5.1,Other,Drug Cost,5.1,,,5.1,Other,Drug Cost,11.46,,,11.46,Other,225% of Medicaid,7.13,,,7.13,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,10.95,,,10.95,Other,215% Medicaid APG methodology,10.95,,,10.95,Other,215% Medicaid APG methodology,6.37,,,6.37,Other,125% Medicaid APG methodology,0.01,11.46,
CLONIDINE 0.1 MG,,,,80000500,CDM,250,RC,52817018010,NDC,both,100,EA,0.03,0.01,39.4668,,0.01,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.02,70,,0.02,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.02,,,0.02,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,0.02,
CLOTRIMAZOLE 1% 10 ML,,,,80000503,CDM,250,RC,51672126003,NDC,both,1,ML,23.82,9.4,39.4668,,9.4,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,8.1,34,,8.1,percent of total billed charges,"Drugs, Inpatient Only",8.1,34,,8.1,percent of total billed charges,"Drugs, Inpatient Only",8.1,34,,8.1,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,16.67,70,,16.67,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,7.94,,,7.94,Other,Drug Cost,7.94,,,7.94,Other,Drug Cost,7.94,,,7.94,Other,Drug Cost,7.94,,,7.94,Other,Drug Cost,7.94,,,7.94,Other,Drug Cost,7.94,,,7.94,Other,Drug Cost,17.87,,,17.87,Other,225% of Medicaid,11.12,,,11.12,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,17.07,,,17.07,Other,215% Medicaid APG methodology,17.07,,,17.07,Other,215% Medicaid APG methodology,9.93,,,9.93,Other,125% Medicaid APG methodology,0.01,17.87,
CLOTRIMAZOLE 10 MG,,,,80000506,CDM,250,RC,54414622,NDC,both,70,EA,0.42,0.17,39.4668,,0.17,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.14,34,,0.14,percent of total billed charges,"Drugs, Inpatient Only",0.14,34,,0.14,percent of total billed charges,"Drugs, Inpatient Only",0.14,34,,0.14,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.29,70,,0.29,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.14,,,0.14,Other,Drug Cost,0.14,,,0.14,Other,Drug Cost,0.14,,,0.14,Other,Drug Cost,0.14,,,0.14,Other,Drug Cost,0.14,,,0.14,Other,Drug Cost,0.14,,,0.14,Other,Drug Cost,0.31,,,0.31,Other,225% of Medicaid,0.2,,,0.2,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.3,,,0.3,Other,215% Medicaid APG methodology,0.3,,,0.3,Other,215% Medicaid APG methodology,0.17,,,0.17,Other,125% Medicaid APG methodology,0.01,0.31,
CLOTRIMAZOLE 15GM,,,,80000507,CDM,250,RC,45802043401,NDC,both,1,GM,2.1,0.83,39.4668,,0.83,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.71,34,,0.71,percent of total billed charges,"Drugs, Inpatient Only",0.71,34,,0.71,percent of total billed charges,"Drugs, Inpatient Only",0.71,34,,0.71,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1.47,70,,1.47,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.7,,,0.7,Other,Drug Cost,0.7,,,0.7,Other,Drug Cost,0.7,,,0.7,Other,Drug Cost,0.7,,,0.7,Other,Drug Cost,0.7,,,0.7,Other,Drug Cost,0.7,,,0.7,Other,Drug Cost,1.58,,,1.58,Other,225% of Medicaid,0.98,,,0.98,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,1.51,,,1.51,Other,215% Medicaid APG methodology,1.51,,,1.51,Other,215% Medicaid APG methodology,0.88,,,0.88,Other,125% Medicaid APG methodology,0.01,1.58,
CLOTRIMAZOLE-BETAMETHASONE CRM,,,,80000509,CDM,250,RC,472037915,NDC,both,1,GM,2.94,1.16,39.4668,,1.16,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1,34,,1,percent of total billed charges,"Drugs, Inpatient Only",1,34,,1,percent of total billed charges,"Drugs, Inpatient Only",1,34,,1,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2.06,70,,2.06,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.98,,,0.98,Other,Drug Cost,0.98,,,0.98,Other,Drug Cost,0.98,,,0.98,Other,Drug Cost,0.98,,,0.98,Other,Drug Cost,0.98,,,0.98,Other,Drug Cost,0.98,,,0.98,Other,Drug Cost,2.21,,,2.21,Other,225% of Medicaid,1.37,,,1.37,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,2.11,,,2.11,Other,215% Medicaid APG methodology,2.11,,,2.11,Other,215% Medicaid APG methodology,1.23,,,1.23,Other,125% Medicaid APG methodology,0.01,2.21,
CLOZAPINE 100 MG,,,,80000510,CDM,250,RC,60687041501,NDC,both,10,EA,9.38,3.7,39.4668,,3.7,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,3.19,34,,3.19,percent of total billed charges,"Drugs, Inpatient Only",3.19,34,,3.19,percent of total billed charges,"Drugs, Inpatient Only",3.19,34,,3.19,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,6.57,70,,6.57,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,3.13,,,3.13,Other,Drug Cost,3.13,,,3.13,Other,Drug Cost,3.13,,,3.13,Other,Drug Cost,3.13,,,3.13,Other,Drug Cost,3.13,,,3.13,Other,Drug Cost,3.13,,,3.13,Other,Drug Cost,7.04,,,7.04,Other,225% of Medicaid,4.38,,,4.38,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,6.73,,,6.73,Other,215% Medicaid APG methodology,6.73,,,6.73,Other,215% Medicaid APG methodology,3.91,,,3.91,Other,125% Medicaid APG methodology,0.01,7.04,
CLOZAPINE 25 MG,,,,80000511,CDM,250,RC,904708961,NDC,both,10,EA,7.39,2.92,39.4668,,2.92,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2.51,34,,2.51,percent of total billed charges,"Drugs, Inpatient Only",2.51,34,,2.51,percent of total billed charges,"Drugs, Inpatient Only",2.51,34,,2.51,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,5.17,70,,5.17,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2.46,,,2.46,Other,Drug Cost,2.46,,,2.46,Other,Drug Cost,2.46,,,2.46,Other,Drug Cost,2.46,,,2.46,Other,Drug Cost,2.46,,,2.46,Other,Drug Cost,2.46,,,2.46,Other,Drug Cost,5.54,,,5.54,Other,225% of Medicaid,3.45,,,3.45,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,5.29,,,5.29,Other,215% Medicaid APG methodology,5.29,,,5.29,Other,215% Medicaid APG methodology,3.08,,,3.08,Other,125% Medicaid APG methodology,0.01,5.54,
CODEINE SULFATE 15 MG TABLET,,,,80000516,CDM,250,RC,54024324,NDC,both,10,EA,8.78,3.47,39.4668,,3.47,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2.99,34,,2.99,percent of total billed charges,"Drugs, Inpatient Only",2.99,34,,2.99,percent of total billed charges,"Drugs, Inpatient Only",2.99,34,,2.99,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,6.15,70,,6.15,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2.93,,,2.93,Other,Drug Cost,2.93,,,2.93,Other,Drug Cost,2.93,,,2.93,Other,Drug Cost,2.93,,,2.93,Other,Drug Cost,2.93,,,2.93,Other,Drug Cost,2.93,,,2.93,Other,Drug Cost,6.59,,,6.59,Other,225% of Medicaid,4.1,,,4.1,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,6.3,,,6.3,Other,215% Medicaid APG methodology,6.3,,,6.3,Other,215% Medicaid APG methodology,3.66,,,3.66,Other,125% Medicaid APG methodology,0.01,6.59,
COLCHICINE 0.6 MG,,,,80000521,CDM,250,RC,43598037201,NDC,both,100,EA,0.21,0.08,39.4668,,0.08,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.07,34,,0.07,percent of total billed charges,"Drugs, Inpatient Only",0.07,34,,0.07,percent of total billed charges,"Drugs, Inpatient Only",0.07,34,,0.07,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.15,70,,0.15,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.07,,,0.07,Other,Drug Cost,0.07,,,0.07,Other,Drug Cost,0.07,,,0.07,Other,Drug Cost,0.07,,,0.07,Other,Drug Cost,0.07,,,0.07,Other,Drug Cost,0.07,,,0.07,Other,Drug Cost,0.16,,,0.16,Other,225% of Medicaid,0.1,,,0.1,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.15,,,0.15,Other,215% Medicaid APG methodology,0.15,,,0.15,Other,215% Medicaid APG methodology,0.09,,,0.09,Other,125% Medicaid APG methodology,0.01,0.16,
COMPAZINE SUPP 25 MG,,,,80000527,CDM,250,RC,574722612,NDC,both,12,EA,4.49,1.77,39.4668,,1.77,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1.52,34,,1.52,percent of total billed charges,"Drugs, Inpatient Only",1.52,34,,1.52,percent of total billed charges,"Drugs, Inpatient Only",1.52,34,,1.52,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,3.14,70,,3.14,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1.5,,,1.5,Other,Drug Cost,1.5,,,1.5,Other,Drug Cost,1.5,,,1.5,Other,Drug Cost,1.5,,,1.5,Other,Drug Cost,1.5,,,1.5,Other,Drug Cost,1.5,,,1.5,Other,Drug Cost,3.36,,,3.36,Other,225% of Medicaid,2.09,,,2.09,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,3.21,,,3.21,Other,215% Medicaid APG methodology,3.21,,,3.21,Other,215% Medicaid APG methodology,1.87,,,1.87,Other,125% Medicaid APG methodology,0.01,3.36,
CONJ ESTROGENS  42.5 GM CREAM,,,,80000529,CDM,250,RC,46087221,NDC,both,1,GM,0.81,0.32,39.4668,,0.32,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.28,34,,0.28,percent of total billed charges,"Drugs, Inpatient Only",0.28,34,,0.28,percent of total billed charges,"Drugs, Inpatient Only",0.28,34,,0.28,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.57,70,,0.57,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.27,,,0.27,Other,Drug Cost,0.27,,,0.27,Other,Drug Cost,0.27,,,0.27,Other,Drug Cost,0.27,,,0.27,Other,Drug Cost,0.27,,,0.27,Other,Drug Cost,0.27,,,0.27,Other,Drug Cost,0.61,,,0.61,Other,225% of Medicaid,0.38,,,0.38,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.58,,,0.58,Other,215% Medicaid APG methodology,0.58,,,0.58,Other,215% Medicaid APG methodology,0.34,,,0.34,Other,125% Medicaid APG methodology,0.01,0.61,
CONJ ESTROGENS 0.625 MG TAB,,,,80000531,CDM,250,RC,46110291,NDC,both,1000,EA,0.03,0.01,39.4668,,0.01,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.02,70,,0.02,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.02,,,0.02,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,0.02,
CORTISPORIN 1% OTIC SOLUTION,,,,80000533,CDM,250,RC,24208063110,NDC,both,1,ML,32.22,12.72,39.4668,,12.72,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,10.95,34,,10.95,percent of total billed charges,"Drugs, Inpatient Only",10.95,34,,10.95,percent of total billed charges,"Drugs, Inpatient Only",10.95,34,,10.95,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,22.55,70,,22.55,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,10.74,,,10.74,Other,Drug Cost,10.74,,,10.74,Other,Drug Cost,10.74,,,10.74,Other,Drug Cost,10.74,,,10.74,Other,Drug Cost,10.74,,,10.74,Other,Drug Cost,10.74,,,10.74,Other,Drug Cost,24.17,,,24.17,Other,225% of Medicaid,15.04,,,15.04,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,23.09,,,23.09,Other,215% Medicaid APG methodology,23.09,,,23.09,Other,215% Medicaid APG methodology,13.43,,,13.43,Other,125% Medicaid APG methodology,0.01,24.17,
COSOPT OPTH SOLN 10 ML,,,,80000534,CDM,250,RC,61314003002,NDC,both,1,ML,18.57,7.33,39.4668,,7.33,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,6.31,34,,6.31,percent of total billed charges,"Drugs, Inpatient Only",6.31,34,,6.31,percent of total billed charges,"Drugs, Inpatient Only",6.31,34,,6.31,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,13,70,,13,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,6.19,,,6.19,Other,Drug Cost,6.19,,,6.19,Other,Drug Cost,6.19,,,6.19,Other,Drug Cost,6.19,,,6.19,Other,Drug Cost,6.19,,,6.19,Other,Drug Cost,6.19,,,6.19,Other,Drug Cost,13.93,,,13.93,Other,225% of Medicaid,8.67,,,8.67,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,13.31,,,13.31,Other,215% Medicaid APG methodology,13.31,,,13.31,Other,215% Medicaid APG methodology,7.74,,,7.74,Other,125% Medicaid APG methodology,0.01,13.93,
CROMOLYN 10 MG/ML SOL,,,,80000537,CDM,250,RC,172640649,NDC,both,60,ML,2.65,1.04,39.4668,,1.04,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.9,34,,0.9,percent of total billed charges,"Drugs, Inpatient Only",0.9,34,,0.9,percent of total billed charges,"Drugs, Inpatient Only",0.9,34,,0.9,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1.85,70,,1.85,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.88,,,0.88,Other,Drug Cost,0.88,,,0.88,Other,Drug Cost,0.88,,,0.88,Other,Drug Cost,0.88,,,0.88,Other,Drug Cost,0.88,,,0.88,Other,Drug Cost,0.88,,,0.88,Other,Drug Cost,1.99,,,1.99,Other,225% of Medicaid,1.24,,,1.24,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,1.9,,,1.9,Other,215% Medicaid APG methodology,1.9,,,1.9,Other,215% Medicaid APG methodology,1.1,,,1.1,Other,125% Medicaid APG methodology,0.01,1.99,
CYANOCOBALAMIN 1000MCG TAB,,,,80000538,CDM,250,RC,20555000600,NDC,both,5,EA,4.01,1.58,39.4668,,1.58,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1.36,34,,1.36,percent of total billed charges,"Drugs, Inpatient Only",1.36,34,,1.36,percent of total billed charges,"Drugs, Inpatient Only",1.36,34,,1.36,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2.81,70,,2.81,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1.34,,,1.34,Other,Drug Cost,1.34,,,1.34,Other,Drug Cost,1.34,,,1.34,Other,Drug Cost,1.34,,,1.34,Other,Drug Cost,1.34,,,1.34,Other,Drug Cost,1.34,,,1.34,Other,Drug Cost,3.01,,,3.01,Other,225% of Medicaid,1.87,,,1.87,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,2.88,,,2.88,Other,215% Medicaid APG methodology,2.88,,,2.88,Other,215% Medicaid APG methodology,1.67,,,1.67,Other,125% Medicaid APG methodology,0.01,3.01,
CYANOCOBALAMIN 100MCG TAB,,,,80000539,CDM,250,RC,50268085215,NDC,both,5,EA,4.22,1.66,39.4668,,1.66,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1.43,34,,1.43,percent of total billed charges,"Drugs, Inpatient Only",1.43,34,,1.43,percent of total billed charges,"Drugs, Inpatient Only",1.43,34,,1.43,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2.95,70,,2.95,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1.41,,,1.41,Other,Drug Cost,1.41,,,1.41,Other,Drug Cost,1.41,,,1.41,Other,Drug Cost,1.41,,,1.41,Other,Drug Cost,1.41,,,1.41,Other,Drug Cost,1.41,,,1.41,Other,Drug Cost,3.16,,,3.16,Other,225% of Medicaid,1.97,,,1.97,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,3.02,,,3.02,Other,215% Medicaid APG methodology,3.02,,,3.02,Other,215% Medicaid APG methodology,1.76,,,1.76,Other,125% Medicaid APG methodology,0.01,3.16,
CYCLOBENZAPRINE 10 MG,,,,80000541,CDM,250,RC,69097084615,NDC,both,1000,EA,0.03,0.01,39.4668,,0.01,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.02,70,,0.02,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.02,,,0.02,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,0.02,
CYCLOBENZAPRINE 5 MG,,,,80000542,CDM,250,RC,72888001201,NDC,both,100,EA,0.03,0.01,39.4668,,0.01,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.02,70,,0.02,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.02,,,0.02,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,0.02,
CYCLOPENTOLATE (CYCLOGYL) 1% 2ML,,,,80000543,CDM,250,RC,61314039601,NDC,both,1,ML,3.33,1.31,39.4668,,1.31,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1.13,34,,1.13,percent of total billed charges,"Drugs, Inpatient Only",1.13,34,,1.13,percent of total billed charges,"Drugs, Inpatient Only",1.13,34,,1.13,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2.33,70,,2.33,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1.11,,,1.11,Other,Drug Cost,1.11,,,1.11,Other,Drug Cost,1.11,,,1.11,Other,Drug Cost,1.11,,,1.11,Other,Drug Cost,1.11,,,1.11,Other,Drug Cost,1.11,,,1.11,Other,Drug Cost,2.5,,,2.5,Other,225% of Medicaid,1.55,,,1.55,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,2.39,,,2.39,Other,215% Medicaid APG methodology,2.39,,,2.39,Other,215% Medicaid APG methodology,1.39,,,1.39,Other,125% Medicaid APG methodology,0.01,2.5,
CYCLOPENTOLATE (CYCLOGYL) 2% 2ML,,,,80000544,CDM,250,RC,65039702,NDC,both,1,ML,46.44,18.33,39.4668,,18.33,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,15.79,34,,15.79,percent of total billed charges,"Drugs, Inpatient Only",15.79,34,,15.79,percent of total billed charges,"Drugs, Inpatient Only",15.79,34,,15.79,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,32.51,70,,32.51,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,15.48,,,15.48,Other,Drug Cost,15.48,,,15.48,Other,Drug Cost,15.48,,,15.48,Other,Drug Cost,15.48,,,15.48,Other,Drug Cost,15.48,,,15.48,Other,Drug Cost,15.48,,,15.48,Other,Drug Cost,34.83,,,34.83,Other,225% of Medicaid,21.67,,,21.67,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,33.28,,,33.28,Other,215% Medicaid APG methodology,33.28,,,33.28,Other,215% Medicaid APG methodology,19.35,,,19.35,Other,125% Medicaid APG methodology,0.01,34.83,
CYCLOSPORINE (NEORAL) 100MG/ML SOL,,,,80000550,CDM,250,RC,172731320,NDC,both,1,ML,185.82,73.34,39.4668,,73.34,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,63.18,34,,63.18,percent of total billed charges,"Drugs, Inpatient Only",63.18,34,,63.18,percent of total billed charges,"Drugs, Inpatient Only",63.18,34,,63.18,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,130.07,70,,130.07,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,61.94,,,61.94,Other,Drug Cost,61.94,,,61.94,Other,Drug Cost,61.94,,,61.94,Other,Drug Cost,61.94,,,61.94,Other,Drug Cost,61.94,,,61.94,Other,Drug Cost,61.94,,,61.94,Other,Drug Cost,139.37,,,139.37,Other,225% of Medicaid,86.72,,,86.72,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,133.17,,,133.17,Other,215% Medicaid APG methodology,133.17,,,133.17,Other,215% Medicaid APG methodology,77.43,,,77.43,Other,125% Medicaid APG methodology,0.01,139.37,
CYCLOSPORINE (NEORAL) 25MG CAP,,,,80000551,CDM,250,RC,51862045847,NDC,both,30,EA,1.02,0.4,39.4668,,0.4,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.35,34,,0.35,percent of total billed charges,"Drugs, Inpatient Only",0.35,34,,0.35,percent of total billed charges,"Drugs, Inpatient Only",0.35,34,,0.35,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.71,70,,0.71,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.34,,,0.34,Other,Drug Cost,0.34,,,0.34,Other,Drug Cost,0.34,,,0.34,Other,Drug Cost,0.34,,,0.34,Other,Drug Cost,0.34,,,0.34,Other,Drug Cost,0.34,,,0.34,Other,Drug Cost,0.76,,,0.76,Other,225% of Medicaid,0.47,,,0.47,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.73,,,0.73,Other,215% Medicaid APG methodology,0.73,,,0.73,Other,215% Medicaid APG methodology,0.42,,,0.42,Other,125% Medicaid APG methodology,0.01,0.76,
CYPROHEPTADINE 4MG TAB,,,,80000556,CDM,250,RC,115175701,NDC,both,100,EA,0.05,0.02,39.4668,,0.02,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.02,34,,0.02,percent of total billed charges,"Drugs, Inpatient Only",0.02,34,,0.02,percent of total billed charges,"Drugs, Inpatient Only",0.02,34,,0.02,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.04,70,,0.04,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.04,,,0.04,Other,225% of Medicaid,0.02,,,0.02,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.04,,,0.04,Other,215% Medicaid APG methodology,0.04,,,0.04,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,125% Medicaid APG methodology,0.01,0.04,
D 5-1/2 NS + KCL 20 MEQ 1000ML,,,,80000563,CDM,250,RC,264763500,NDC,both,12,ML,3.59,1.42,39.4668,,1.42,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1.22,34,,1.22,percent of total billed charges,"Drugs, Inpatient Only",1.22,34,,1.22,percent of total billed charges,"Drugs, Inpatient Only",1.22,34,,1.22,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2.51,70,,2.51,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1.2,,,1.2,Other,Drug Cost,1.2,,,1.2,Other,Drug Cost,1.2,,,1.2,Other,Drug Cost,1.2,,,1.2,Other,Drug Cost,1.2,,,1.2,Other,Drug Cost,1.2,,,1.2,Other,Drug Cost,2.69,,,2.69,Other,225% of Medicaid,1.68,,,1.68,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,2.57,,,2.57,Other,215% Medicaid APG methodology,2.57,,,2.57,Other,215% Medicaid APG methodology,1.5,,,1.5,Other,125% Medicaid APG methodology,0.01,2.69,
D5 - 1/2 NS + KCL 10 MEQ 1000 ML,,,,80000564,CDM,250,RC,264763400,NDC,both,1000,ML,2.88,1.14,39.4668,,1.14,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.98,34,,0.98,percent of total billed charges,"Drugs, Inpatient Only",0.98,34,,0.98,percent of total billed charges,"Drugs, Inpatient Only",0.98,34,,0.98,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2.02,70,,2.02,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.96,,,0.96,Other,Drug Cost,0.96,,,0.96,Other,Drug Cost,0.96,,,0.96,Other,Drug Cost,0.96,,,0.96,Other,Drug Cost,0.96,,,0.96,Other,Drug Cost,0.96,,,0.96,Other,Drug Cost,2.16,,,2.16,Other,225% of Medicaid,1.35,,,1.35,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,2.07,,,2.07,Other,215% Medicaid APG methodology,2.07,,,2.07,Other,215% Medicaid APG methodology,1.2,,,1.2,Other,125% Medicaid APG methodology,0.01,2.16,
D5 - 1/2 NS + KCL 40 MEQ 1000 ML,,,,80000566,CDM,250,RC,264763800,NDC,both,12,ML,2.58,1.02,39.4668,,1.02,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.88,34,,0.88,percent of total billed charges,"Drugs, Inpatient Only",0.88,34,,0.88,percent of total billed charges,"Drugs, Inpatient Only",0.88,34,,0.88,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1.81,70,,1.81,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.86,,,0.86,Other,Drug Cost,0.86,,,0.86,Other,Drug Cost,0.86,,,0.86,Other,Drug Cost,0.86,,,0.86,Other,Drug Cost,0.86,,,0.86,Other,Drug Cost,0.86,,,0.86,Other,Drug Cost,1.94,,,1.94,Other,225% of Medicaid,1.2,,,1.2,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,1.85,,,1.85,Other,215% Medicaid APG methodology,1.85,,,1.85,Other,215% Medicaid APG methodology,1.08,,,1.08,Other,125% Medicaid APG methodology,0.01,1.94,
D5-LR WITH 20MEQ KCL,,,,80000567,CDM,250,RC,338081104,NDC,both,1000,ML,9.61,3.79,39.4668,,3.79,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,3.27,34,,3.27,percent of total billed charges,"Drugs, Inpatient Only",3.27,34,,3.27,percent of total billed charges,"Drugs, Inpatient Only",3.27,34,,3.27,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,6.72,70,,6.72,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,3.2,,,3.2,Other,Drug Cost,3.2,,,3.2,Other,Drug Cost,3.2,,,3.2,Other,Drug Cost,3.2,,,3.2,Other,Drug Cost,3.2,,,3.2,Other,Drug Cost,3.2,,,3.2,Other,Drug Cost,7.2,,,7.2,Other,225% of Medicaid,4.48,,,4.48,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,6.88,,,6.88,Other,215% Medicaid APG methodology,6.88,,,6.88,Other,215% Medicaid APG methodology,4,,,4,Other,125% Medicaid APG methodology,0.01,7.2,
D5W 100 ML (500 ML = 1 UNIT),,,,80000569,CDM,250,RC,264151032,NDC,both,64,ML,3.78,1.49,39.4668,,1.49,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1.29,34,,1.29,percent of total billed charges,"Drugs, Inpatient Only",1.29,34,,1.29,percent of total billed charges,"Drugs, Inpatient Only",1.29,34,,1.29,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2.65,70,,2.65,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1.26,,,1.26,Other,Drug Cost,1.26,,,1.26,Other,Drug Cost,1.26,,,1.26,Other,Drug Cost,1.26,,,1.26,Other,Drug Cost,1.26,,,1.26,Other,Drug Cost,1.26,,,1.26,Other,Drug Cost,2.84,,,2.84,Other,225% of Medicaid,1.76,,,1.76,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,2.71,,,2.71,Other,215% Medicaid APG methodology,2.71,,,2.71,Other,215% Medicaid APG methodology,1.58,,,1.58,Other,125% Medicaid APG methodology,0.01,2.84,
D5W WITH KCL 20MEQ 1000ML,,,,80000573,CDM,250,RC,990790509,NDC,both,12,ML,8.56,3.38,39.4668,,3.38,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2.91,34,,2.91,percent of total billed charges,"Drugs, Inpatient Only",2.91,34,,2.91,percent of total billed charges,"Drugs, Inpatient Only",2.91,34,,2.91,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,5.99,70,,5.99,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2.85,,,2.85,Other,Drug Cost,2.85,,,2.85,Other,Drug Cost,2.85,,,2.85,Other,Drug Cost,2.85,,,2.85,Other,Drug Cost,2.85,,,2.85,Other,Drug Cost,2.85,,,2.85,Other,Drug Cost,6.42,,,6.42,Other,225% of Medicaid,3.99,,,3.99,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,6.13,,,6.13,Other,215% Medicaid APG methodology,6.13,,,6.13,Other,215% Medicaid APG methodology,3.57,,,3.57,Other,125% Medicaid APG methodology,0.01,6.42,
D5W-NS WITH 20MEQ KCL 1000ML,,,,80000574,CDM,250,RC,264765200,NDC,both,12,ML,3.77,1.49,39.4668,,1.49,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1.28,34,,1.28,percent of total billed charges,"Drugs, Inpatient Only",1.28,34,,1.28,percent of total billed charges,"Drugs, Inpatient Only",1.28,34,,1.28,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2.64,70,,2.64,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1.26,,,1.26,Other,Drug Cost,1.26,,,1.26,Other,Drug Cost,1.26,,,1.26,Other,Drug Cost,1.26,,,1.26,Other,Drug Cost,1.26,,,1.26,Other,Drug Cost,1.26,,,1.26,Other,Drug Cost,2.83,,,2.83,Other,225% of Medicaid,1.76,,,1.76,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,2.7,,,2.7,Other,215% Medicaid APG methodology,2.7,,,2.7,Other,215% Medicaid APG methodology,1.57,,,1.57,Other,125% Medicaid APG methodology,0.01,2.83,
D5W-NS WITH 40MEQ KCL 1000ML,,,,80000575,CDM,250,RC,338080704,NDC,both,1000,ML,10.24,4.04,39.4668,,4.04,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,3.48,34,,3.48,percent of total billed charges,"Drugs, Inpatient Only",3.48,34,,3.48,percent of total billed charges,"Drugs, Inpatient Only",3.48,34,,3.48,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,7.17,70,,7.17,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,3.41,,,3.41,Other,Drug Cost,3.41,,,3.41,Other,Drug Cost,3.41,,,3.41,Other,Drug Cost,3.41,,,3.41,Other,Drug Cost,3.41,,,3.41,Other,Drug Cost,3.41,,,3.41,Other,Drug Cost,7.68,,,7.68,Other,225% of Medicaid,4.78,,,4.78,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,7.34,,,7.34,Other,215% Medicaid APG methodology,7.34,,,7.34,Other,215% Medicaid APG methodology,4.27,,,4.27,Other,125% Medicaid APG methodology,0.01,7.68,
DABIGATRAN 150MG CAP,,,,80000576,CDM,250,RC,597036082,NDC,both,60,EA,2.25,0.89,39.4668,,0.89,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.76,34,,0.76,percent of total billed charges,"Drugs, Inpatient Only",0.76,34,,0.76,percent of total billed charges,"Drugs, Inpatient Only",0.76,34,,0.76,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1.57,70,,1.57,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.75,,,0.75,Other,Drug Cost,0.75,,,0.75,Other,Drug Cost,0.75,,,0.75,Other,Drug Cost,0.75,,,0.75,Other,Drug Cost,0.75,,,0.75,Other,Drug Cost,0.75,,,0.75,Other,Drug Cost,1.68,,,1.68,Other,225% of Medicaid,1.05,,,1.05,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,1.61,,,1.61,Other,215% Medicaid APG methodology,1.61,,,1.61,Other,215% Medicaid APG methodology,0.94,,,0.94,Other,125% Medicaid APG methodology,0.01,1.68,
DABIGATRAN 75 MG CAP,,,,80000577,CDM,250,RC,597035556,NDC,both,10,EA,13.48,5.32,39.4668,,5.32,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,4.58,34,,4.58,percent of total billed charges,"Drugs, Inpatient Only",4.58,34,,4.58,percent of total billed charges,"Drugs, Inpatient Only",4.58,34,,4.58,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,9.44,70,,9.44,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,4.49,,,4.49,Other,Drug Cost,4.49,,,4.49,Other,Drug Cost,4.49,,,4.49,Other,Drug Cost,4.49,,,4.49,Other,Drug Cost,4.49,,,4.49,Other,Drug Cost,4.49,,,4.49,Other,Drug Cost,10.11,,,10.11,Other,225% of Medicaid,6.29,,,6.29,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,9.66,,,9.66,Other,215% Medicaid APG methodology,9.66,,,9.66,Other,215% Medicaid APG methodology,5.62,,,5.62,Other,125% Medicaid APG methodology,0.01,10.11,
DANAZOL,,,,80000579,CDM,250,RC,555063402,NDC,both,100,EA,2.54,1,39.4668,,1,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.86,34,,0.86,percent of total billed charges,"Drugs, Inpatient Only",0.86,34,,0.86,percent of total billed charges,"Drugs, Inpatient Only",0.86,34,,0.86,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1.78,70,,1.78,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.85,,,0.85,Other,Drug Cost,0.85,,,0.85,Other,Drug Cost,0.85,,,0.85,Other,Drug Cost,0.85,,,0.85,Other,Drug Cost,0.85,,,0.85,Other,Drug Cost,0.85,,,0.85,Other,Drug Cost,1.91,,,1.91,Other,225% of Medicaid,1.19,,,1.19,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,1.82,,,1.82,Other,215% Medicaid APG methodology,1.82,,,1.82,Other,215% Medicaid APG methodology,1.06,,,1.06,Other,125% Medicaid APG methodology,0.01,1.91,
DANTROLENE (DANTRIUM) 20MG INJ,,,,80000580,CDM,250,RC,42023012306,NDC,both,6,EA,132.63,52.34,39.4668,,52.34,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,45.09,34,,45.09,percent of total billed charges,"Drugs, Inpatient Only",45.09,34,,45.09,percent of total billed charges,"Drugs, Inpatient Only",45.09,34,,45.09,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,92.84,70,,92.84,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,44.21,,,44.21,Other,Drug Cost,44.21,,,44.21,Other,Drug Cost,44.21,,,44.21,Other,Drug Cost,44.21,,,44.21,Other,Drug Cost,44.21,,,44.21,Other,Drug Cost,44.21,,,44.21,Other,Drug Cost,99.47,,,99.47,Other,225% of Medicaid,61.89,,,61.89,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,95.05,,,95.05,Other,215% Medicaid APG methodology,95.05,,,95.05,Other,215% Medicaid APG methodology,55.26,,,55.26,Other,125% Medicaid APG methodology,0.01,99.47,
DANTROLENE 25 MG CAPS,,,,80000581,CDM,250,RC,115441101,NDC,both,100,EA,0.35,0.14,39.4668,,0.14,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.12,34,,0.12,percent of total billed charges,"Drugs, Inpatient Only",0.12,34,,0.12,percent of total billed charges,"Drugs, Inpatient Only",0.12,34,,0.12,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.24,70,,0.24,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.12,,,0.12,Other,Drug Cost,0.12,,,0.12,Other,Drug Cost,0.12,,,0.12,Other,Drug Cost,0.12,,,0.12,Other,Drug Cost,0.12,,,0.12,Other,Drug Cost,0.12,,,0.12,Other,Drug Cost,0.26,,,0.26,Other,225% of Medicaid,0.16,,,0.16,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.25,,,0.25,Other,215% Medicaid APG methodology,0.25,,,0.25,Other,215% Medicaid APG methodology,0.15,,,0.15,Other,125% Medicaid APG methodology,0.01,0.26,
DAPSONE 100MG TAB,,,,80000582,CDM,250,RC,70954013610,NDC,both,30,EA,1.44,0.57,39.4668,,0.57,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.49,34,,0.49,percent of total billed charges,"Drugs, Inpatient Only",0.49,34,,0.49,percent of total billed charges,"Drugs, Inpatient Only",0.49,34,,0.49,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1.01,70,,1.01,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.48,,,0.48,Other,Drug Cost,0.48,,,0.48,Other,Drug Cost,0.48,,,0.48,Other,Drug Cost,0.48,,,0.48,Other,Drug Cost,0.48,,,0.48,Other,Drug Cost,0.48,,,0.48,Other,Drug Cost,1.08,,,1.08,Other,225% of Medicaid,0.67,,,0.67,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,1.03,,,1.03,Other,215% Medicaid APG methodology,1.03,,,1.03,Other,215% Medicaid APG methodology,0.6,,,0.6,Other,125% Medicaid APG methodology,0.01,1.08,
DAPSONE 25 MG TAB,,,,80000583,CDM,250,RC,70954013510,NDC,both,30,EA,0.76,0.3,39.4668,,0.3,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.26,34,,0.26,percent of total billed charges,"Drugs, Inpatient Only",0.26,34,,0.26,percent of total billed charges,"Drugs, Inpatient Only",0.26,34,,0.26,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.53,70,,0.53,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.25,,,0.25,Other,Drug Cost,0.25,,,0.25,Other,Drug Cost,0.25,,,0.25,Other,Drug Cost,0.25,,,0.25,Other,Drug Cost,0.25,,,0.25,Other,Drug Cost,0.25,,,0.25,Other,Drug Cost,0.57,,,0.57,Other,225% of Medicaid,0.35,,,0.35,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.54,,,0.54,Other,215% Medicaid APG methodology,0.54,,,0.54,Other,215% Medicaid APG methodology,0.32,,,0.32,Other,125% Medicaid APG methodology,0.01,0.57,
DESMOPRESSIN ACETATE (DDAVP) 0.1 MG TAB,,,,80000601,CDM,250,RC,69918010101,NDC,both,100,EA,0.31,0.12,39.4668,,0.12,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.11,34,,0.11,percent of total billed charges,"Drugs, Inpatient Only",0.11,34,,0.11,percent of total billed charges,"Drugs, Inpatient Only",0.11,34,,0.11,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.22,70,,0.22,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.1,,,0.1,Other,Drug Cost,0.1,,,0.1,Other,Drug Cost,0.1,,,0.1,Other,Drug Cost,0.1,,,0.1,Other,Drug Cost,0.1,,,0.1,Other,Drug Cost,0.1,,,0.1,Other,Drug Cost,0.23,,,0.23,Other,225% of Medicaid,0.14,,,0.14,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.22,,,0.22,Other,215% Medicaid APG methodology,0.22,,,0.22,Other,215% Medicaid APG methodology,0.13,,,0.13,Other,125% Medicaid APG methodology,0.01,0.23,
DESMOPRESSIN ACETATE (DDAVP) SPRAY,,,,80000602,CDM,250,RC,60505081500,NDC,both,1,ML,34.11,13.46,39.4668,,13.46,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,11.6,34,,11.6,percent of total billed charges,"Drugs, Inpatient Only",11.6,34,,11.6,percent of total billed charges,"Drugs, Inpatient Only",11.6,34,,11.6,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,23.88,70,,23.88,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,11.37,,,11.37,Other,Drug Cost,11.37,,,11.37,Other,Drug Cost,11.37,,,11.37,Other,Drug Cost,11.37,,,11.37,Other,Drug Cost,11.37,,,11.37,Other,Drug Cost,11.37,,,11.37,Other,Drug Cost,25.58,,,25.58,Other,225% of Medicaid,15.92,,,15.92,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,24.45,,,24.45,Other,215% Medicaid APG methodology,24.45,,,24.45,Other,215% Medicaid APG methodology,14.21,,,14.21,Other,125% Medicaid APG methodology,0.01,25.58,
DESVENLAFAXINE 50 MG TABLET,,,,80000607,CDM,250,RC,68180059206,NDC,both,30,EA,0.41,0.16,39.4668,,0.16,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.14,34,,0.14,percent of total billed charges,"Drugs, Inpatient Only",0.14,34,,0.14,percent of total billed charges,"Drugs, Inpatient Only",0.14,34,,0.14,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.29,70,,0.29,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.14,,,0.14,Other,Drug Cost,0.14,,,0.14,Other,Drug Cost,0.14,,,0.14,Other,Drug Cost,0.14,,,0.14,Other,Drug Cost,0.14,,,0.14,Other,Drug Cost,0.14,,,0.14,Other,Drug Cost,0.31,,,0.31,Other,225% of Medicaid,0.19,,,0.19,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.3,,,0.3,Other,215% Medicaid APG methodology,0.3,,,0.3,Other,215% Medicaid APG methodology,0.17,,,0.17,Other,125% Medicaid APG methodology,0.01,0.31,
DEXTRAN (LOW M.W.) 10%-5% INJ,,,,80000616,CDM,250,RC,409741803,NDC,both,12,ML,37.17,14.67,39.4668,,14.67,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,12.64,34,,12.64,percent of total billed charges,"Drugs, Inpatient Only",12.64,34,,12.64,percent of total billed charges,"Drugs, Inpatient Only",12.64,34,,12.64,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,26.02,70,,26.02,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,12.39,,,12.39,Other,Drug Cost,12.39,,,12.39,Other,Drug Cost,12.39,,,12.39,Other,Drug Cost,12.39,,,12.39,Other,Drug Cost,12.39,,,12.39,Other,Drug Cost,12.39,,,12.39,Other,Drug Cost,27.88,,,27.88,Other,225% of Medicaid,17.35,,,17.35,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,26.64,,,26.64,Other,215% Medicaid APG methodology,26.64,,,26.64,Other,215% Medicaid APG methodology,15.49,,,15.49,Other,125% Medicaid APG methodology,0.01,27.88,
DEXTROSE (GLUTCOSE 15) 40% GEL,,,,80000622,CDM,250,RC,574006915,NDC,both,1,GM,9.45,3.73,39.4668,,3.73,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,3.21,34,,3.21,percent of total billed charges,"Drugs, Inpatient Only",3.21,34,,3.21,percent of total billed charges,"Drugs, Inpatient Only",3.21,34,,3.21,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,6.62,70,,6.62,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,3.15,,,3.15,Other,Drug Cost,3.15,,,3.15,Other,Drug Cost,3.15,,,3.15,Other,Drug Cost,3.15,,,3.15,Other,Drug Cost,3.15,,,3.15,Other,Drug Cost,3.15,,,3.15,Other,Drug Cost,7.09,,,7.09,Other,225% of Medicaid,4.41,,,4.41,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,6.77,,,6.77,Other,215% Medicaid APG methodology,6.77,,,6.77,Other,215% Medicaid APG methodology,3.94,,,3.94,Other,125% Medicaid APG methodology,0.01,7.09,
DEXTROSE 20% 500ML,,,,80000624,CDM,250,RC,990793519,NDC,both,12,ML,13.59,5.36,39.4668,,5.36,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,4.62,34,,4.62,percent of total billed charges,"Drugs, Inpatient Only",4.62,34,,4.62,percent of total billed charges,"Drugs, Inpatient Only",4.62,34,,4.62,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,9.51,70,,9.51,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,4.53,,,4.53,Other,Drug Cost,4.53,,,4.53,Other,Drug Cost,4.53,,,4.53,Other,Drug Cost,4.53,,,4.53,Other,Drug Cost,4.53,,,4.53,Other,Drug Cost,4.53,,,4.53,Other,Drug Cost,10.19,,,10.19,Other,225% of Medicaid,6.34,,,6.34,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,9.74,,,9.74,Other,215% Medicaid APG methodology,9.74,,,9.74,Other,215% Medicaid APG methodology,5.66,,,5.66,Other,125% Medicaid APG methodology,0.01,10.19,
DEXTROSE 25% 10ML ABBOJECT,,,,80000626,CDM,250,RC,409177510,NDC,both,10,ML,26.23,10.35,39.4668,,10.35,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,8.92,34,,8.92,percent of total billed charges,"Drugs, Inpatient Only",8.92,34,,8.92,percent of total billed charges,"Drugs, Inpatient Only",8.92,34,,8.92,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,18.36,70,,18.36,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,8.74,,,8.74,Other,Drug Cost,8.74,,,8.74,Other,Drug Cost,8.74,,,8.74,Other,Drug Cost,8.74,,,8.74,Other,Drug Cost,8.74,,,8.74,Other,Drug Cost,8.74,,,8.74,Other,Drug Cost,19.67,,,19.67,Other,225% of Medicaid,12.24,,,12.24,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,18.8,,,18.8,Other,215% Medicaid APG methodology,18.8,,,18.8,Other,215% Medicaid APG methodology,10.93,,,10.93,Other,125% Medicaid APG methodology,0.01,19.67,
DEXTROSE 5% LACTATED RINGERS 1000ML,,,,80000628,CDM,250,RC,264775100,NDC,both,12,ML,2.81,1.11,39.4668,,1.11,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.95,34,,0.95,percent of total billed charges,"Drugs, Inpatient Only",0.95,34,,0.95,percent of total billed charges,"Drugs, Inpatient Only",0.95,34,,0.95,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1.96,70,,1.96,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.94,,,0.94,Other,Drug Cost,0.94,,,0.94,Other,Drug Cost,0.94,,,0.94,Other,Drug Cost,0.94,,,0.94,Other,Drug Cost,0.94,,,0.94,Other,Drug Cost,0.94,,,0.94,Other,Drug Cost,2.1,,,2.1,Other,225% of Medicaid,1.31,,,1.31,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,2.01,,,2.01,Other,215% Medicaid APG methodology,2.01,,,2.01,Other,215% Medicaid APG methodology,1.17,,,1.17,Other,125% Medicaid APG methodology,0.01,2.1,
DEXTROSE 5%-1/2 NS 1000ML,,,,80000629,CDM,250,RC,264761200,NDC,both,1000,ML,2.49,0.98,39.4668,,0.98,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.85,34,,0.85,percent of total billed charges,"Drugs, Inpatient Only",0.85,34,,0.85,percent of total billed charges,"Drugs, Inpatient Only",0.85,34,,0.85,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1.74,70,,1.74,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.83,,,0.83,Other,Drug Cost,0.83,,,0.83,Other,Drug Cost,0.83,,,0.83,Other,Drug Cost,0.83,,,0.83,Other,Drug Cost,0.83,,,0.83,Other,Drug Cost,0.83,,,0.83,Other,Drug Cost,1.87,,,1.87,Other,225% of Medicaid,1.16,,,1.16,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,1.78,,,1.78,Other,215% Medicaid APG methodology,1.78,,,1.78,Other,215% Medicaid APG methodology,1.04,,,1.04,Other,125% Medicaid APG methodology,0.01,1.87,
DEXTROSE 5%-1/4 NS 1000ML,,,,80000630,CDM,250,RC,264761600,NDC,both,1000,ML,2.49,0.98,39.4668,,0.98,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.85,34,,0.85,percent of total billed charges,"Drugs, Inpatient Only",0.85,34,,0.85,percent of total billed charges,"Drugs, Inpatient Only",0.85,34,,0.85,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1.74,70,,1.74,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.83,,,0.83,Other,Drug Cost,0.83,,,0.83,Other,Drug Cost,0.83,,,0.83,Other,Drug Cost,0.83,,,0.83,Other,Drug Cost,0.83,,,0.83,Other,Drug Cost,0.83,,,0.83,Other,Drug Cost,1.87,,,1.87,Other,225% of Medicaid,1.16,,,1.16,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,1.78,,,1.78,Other,215% Medicaid APG methodology,1.78,,,1.78,Other,215% Medicaid APG methodology,1.04,,,1.04,Other,125% Medicaid APG methodology,0.01,1.87,
DEXTROSE 50% 50ML ABBOJ,,,,80000632,CDM,250,RC,409490234,NDC,both,10,ML,18,7.1,39.4668,,7.1,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,6.12,34,,6.12,percent of total billed charges,"Drugs, Inpatient Only",6.12,34,,6.12,percent of total billed charges,"Drugs, Inpatient Only",6.12,34,,6.12,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,12.6,70,,12.6,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,6,,,6,Other,Drug Cost,6,,,6,Other,Drug Cost,6,,,6,Other,Drug Cost,6,,,6,Other,Drug Cost,6,,,6,Other,Drug Cost,6,,,6,Other,Drug Cost,13.5,,,13.5,Other,225% of Medicaid,8.4,,,8.4,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,12.9,,,12.9,Other,215% Medicaid APG methodology,12.9,,,12.9,Other,215% Medicaid APG methodology,7.5,,,7.5,Other,125% Medicaid APG methodology,0.01,13.5,
DIAZEPAM 2 MG TAB,,,,80000636,CDM,250,RC,172392560,NDC,both,100,EA,0.03,0.01,39.4668,,0.01,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.02,70,,0.02,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.02,,,0.02,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,0.02,
DIAZEPAM 5 MG TAB,,,,80000637,CDM,250,RC,172392660,NDC,both,100,EA,0.03,0.01,39.4668,,0.01,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.02,70,,0.02,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.02,,,0.02,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,0.02,
DIAZOXIDE 50 MG/ML SUSP,,,,80000638,CDM,250,RC,575620030,NDC,both,1,ML,0.81,0.32,39.4668,,0.32,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.28,34,,0.28,percent of total billed charges,"Drugs, Inpatient Only",0.28,34,,0.28,percent of total billed charges,"Drugs, Inpatient Only",0.28,34,,0.28,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.57,70,,0.57,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.27,,,0.27,Other,Drug Cost,0.27,,,0.27,Other,Drug Cost,0.27,,,0.27,Other,Drug Cost,0.27,,,0.27,Other,Drug Cost,0.27,,,0.27,Other,Drug Cost,0.27,,,0.27,Other,Drug Cost,0.61,,,0.61,Other,225% of Medicaid,0.38,,,0.38,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.58,,,0.58,Other,215% Medicaid APG methodology,0.58,,,0.58,Other,215% Medicaid APG methodology,0.34,,,0.34,Other,125% Medicaid APG methodology,0.01,0.61,
DICLOFENAC SOD 75 MG TAB,,,,80000642,CDM,250,RC,228255111,NDC,both,100,EA,0.18,0.07,39.4668,,0.07,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.06,34,,0.06,percent of total billed charges,"Drugs, Inpatient Only",0.06,34,,0.06,percent of total billed charges,"Drugs, Inpatient Only",0.06,34,,0.06,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.12,70,,0.12,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.06,,,0.06,Other,Drug Cost,0.06,,,0.06,Other,Drug Cost,0.06,,,0.06,Other,Drug Cost,0.06,,,0.06,Other,Drug Cost,0.06,,,0.06,Other,Drug Cost,0.06,,,0.06,Other,Drug Cost,0.13,,,0.13,Other,225% of Medicaid,0.08,,,0.08,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.13,,,0.13,Other,215% Medicaid APG methodology,0.13,,,0.13,Other,215% Medicaid APG methodology,0.07,,,0.07,Other,125% Medicaid APG methodology,0.01,0.13,
DICLOFENAC SODIUM 25 MG EC TAB,,,,80000643,CDM,250,RC,16571020310,NDC,both,100,EA,1.42,0.56,39.4668,,0.56,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.48,34,,0.48,percent of total billed charges,"Drugs, Inpatient Only",0.48,34,,0.48,percent of total billed charges,"Drugs, Inpatient Only",0.48,34,,0.48,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1,70,,1,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.47,,,0.47,Other,Drug Cost,0.47,,,0.47,Other,Drug Cost,0.47,,,0.47,Other,Drug Cost,0.47,,,0.47,Other,Drug Cost,0.47,,,0.47,Other,Drug Cost,0.47,,,0.47,Other,Drug Cost,1.07,,,1.07,Other,225% of Medicaid,0.66,,,0.66,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,1.02,,,1.02,Other,215% Medicaid APG methodology,1.02,,,1.02,Other,215% Medicaid APG methodology,0.59,,,0.59,Other,125% Medicaid APG methodology,0.01,1.07,
DICLOXACILLIN SODIUM 250 MG CAPS,,,,80000644,CDM,250,RC,93312301,NDC,both,100,EA,0.32,0.12,39.4668,,0.12,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.11,34,,0.11,percent of total billed charges,"Drugs, Inpatient Only",0.11,34,,0.11,percent of total billed charges,"Drugs, Inpatient Only",0.11,34,,0.11,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.22,70,,0.22,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.11,,,0.11,Other,Drug Cost,0.11,,,0.11,Other,Drug Cost,0.11,,,0.11,Other,Drug Cost,0.11,,,0.11,Other,Drug Cost,0.11,,,0.11,Other,Drug Cost,0.11,,,0.11,Other,Drug Cost,0.24,,,0.24,Other,225% of Medicaid,0.15,,,0.15,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.23,,,0.23,Other,215% Medicaid APG methodology,0.23,,,0.23,Other,215% Medicaid APG methodology,0.13,,,0.13,Other,125% Medicaid APG methodology,0.01,0.24,
DICYCLOMINE 20 MG TAB,,,,80000646,CDM,250,RC,591079501,NDC,both,100,EA,0.03,0.01,39.4668,,0.01,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.02,70,,0.02,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.02,,,0.02,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,0.02,
DICYCOMINE 10 MG TAB,,,,80000647,CDM,250,RC,591079401,NDC,both,100,EA,0.13,0.05,39.4668,,0.05,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.04,34,,0.04,percent of total billed charges,"Drugs, Inpatient Only",0.04,34,,0.04,percent of total billed charges,"Drugs, Inpatient Only",0.04,34,,0.04,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.09,70,,0.09,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.1,,,0.1,Other,225% of Medicaid,0.06,,,0.06,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.09,,,0.09,Other,215% Medicaid APG methodology,0.09,,,0.09,Other,215% Medicaid APG methodology,0.05,,,0.05,Other,125% Medicaid APG methodology,0.01,0.1,
DIGOXIN (LANOXIN) 0. 25 MG TAB,,,,80000650,CDM,250,RC,904592261,NDC,both,10,EA,26.45,10.44,39.4668,,10.44,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,8.99,34,,8.99,percent of total billed charges,"Drugs, Inpatient Only",8.99,34,,8.99,percent of total billed charges,"Drugs, Inpatient Only",8.99,34,,8.99,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,18.51,70,,18.51,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,8.82,,,8.82,Other,Drug Cost,8.82,,,8.82,Other,Drug Cost,8.82,,,8.82,Other,Drug Cost,8.82,,,8.82,Other,Drug Cost,8.82,,,8.82,Other,Drug Cost,8.82,,,8.82,Other,Drug Cost,19.84,,,19.84,Other,225% of Medicaid,12.34,,,12.34,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,18.95,,,18.95,Other,215% Medicaid APG methodology,18.95,,,18.95,Other,215% Medicaid APG methodology,11.02,,,11.02,Other,125% Medicaid APG methodology,0.01,19.84,
DIGOXIN (LANOXIN) 0.125 MG TAB,,,,80000651,CDM,250,RC,57664043788,NDC,both,100,EA,0.02,0.01,39.4668,,0.01,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,70,,0.01,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,0.02,
DIGOXIN 250MCG/5ML SOLN,,,,80000652,CDM,250,RC,54005746,NDC,both,1,ML,24.66,9.73,39.4668,,9.73,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,8.38,34,,8.38,percent of total billed charges,"Drugs, Inpatient Only",8.38,34,,8.38,percent of total billed charges,"Drugs, Inpatient Only",8.38,34,,8.38,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,17.26,70,,17.26,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,8.22,,,8.22,Other,Drug Cost,8.22,,,8.22,Other,Drug Cost,8.22,,,8.22,Other,Drug Cost,8.22,,,8.22,Other,Drug Cost,8.22,,,8.22,Other,Drug Cost,8.22,,,8.22,Other,Drug Cost,18.5,,,18.5,Other,225% of Medicaid,11.51,,,11.51,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,17.67,,,17.67,Other,215% Medicaid APG methodology,17.67,,,17.67,Other,215% Medicaid APG methodology,10.28,,,10.28,Other,125% Medicaid APG methodology,0.01,18.5,
DILTIAZEM HCL 240MG ER CAPS,,,,80000659,CDM,250,RC,10370083111,NDC,both,30,EA,0.15,0.06,39.4668,,0.06,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.05,34,,0.05,percent of total billed charges,"Drugs, Inpatient Only",0.05,34,,0.05,percent of total billed charges,"Drugs, Inpatient Only",0.05,34,,0.05,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.1,70,,0.1,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.11,,,0.11,Other,225% of Medicaid,0.07,,,0.07,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.1,,,0.1,Other,215% Medicaid APG methodology,0.1,,,0.1,Other,215% Medicaid APG methodology,0.06,,,0.06,Other,125% Medicaid APG methodology,0.01,0.11,
DILTIAZEM HCL 300 MG SR CAPS,,,,80000660,CDM,250,RC,24979002907,NDC,both,90,EA,0.2,0.08,39.4668,,0.08,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.07,34,,0.07,percent of total billed charges,"Drugs, Inpatient Only",0.07,34,,0.07,percent of total billed charges,"Drugs, Inpatient Only",0.07,34,,0.07,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.14,70,,0.14,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.07,,,0.07,Other,Drug Cost,0.07,,,0.07,Other,Drug Cost,0.07,,,0.07,Other,Drug Cost,0.07,,,0.07,Other,Drug Cost,0.07,,,0.07,Other,Drug Cost,0.07,,,0.07,Other,Drug Cost,0.15,,,0.15,Other,225% of Medicaid,0.09,,,0.09,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.15,,,0.15,Other,215% Medicaid APG methodology,0.15,,,0.15,Other,215% Medicaid APG methodology,0.08,,,0.08,Other,125% Medicaid APG methodology,0.01,0.15,
DILTIAZEM HCL 30MG TAB,,,,80000661,CDM,250,RC,93031801,NDC,both,100,EA,0.05,0.02,39.4668,,0.02,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.02,34,,0.02,percent of total billed charges,"Drugs, Inpatient Only",0.02,34,,0.02,percent of total billed charges,"Drugs, Inpatient Only",0.02,34,,0.02,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.03,70,,0.03,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.04,,,0.04,Other,225% of Medicaid,0.02,,,0.02,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.03,,,0.03,Other,215% Medicaid APG methodology,0.03,,,0.03,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,125% Medicaid APG methodology,0.01,0.04,
DILTIAZEM HCL 5MG/ML 5ML INJ,,,,80000662,CDM,250,RC,641601310,NDC,both,10,ML,2.55,1.01,39.4668,,1.01,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.87,34,,0.87,percent of total billed charges,"Drugs, Inpatient Only",0.87,34,,0.87,percent of total billed charges,"Drugs, Inpatient Only",0.87,34,,0.87,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1.79,70,,1.79,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.85,,,0.85,Other,Drug Cost,0.85,,,0.85,Other,Drug Cost,0.85,,,0.85,Other,Drug Cost,0.85,,,0.85,Other,Drug Cost,0.85,,,0.85,Other,Drug Cost,0.85,,,0.85,Other,Drug Cost,1.91,,,1.91,Other,225% of Medicaid,1.19,,,1.19,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,1.83,,,1.83,Other,215% Medicaid APG methodology,1.83,,,1.83,Other,215% Medicaid APG methodology,1.06,,,1.06,Other,125% Medicaid APG methodology,0.01,1.91,
DILTIAZEM HCL CD 180MG CAPS,,,,80000663,CDM,250,RC,187079642,NDC,both,90,EA,0.03,0.01,39.4668,,0.01,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.02,70,,0.02,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.02,,,0.02,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,0.02,
DILTIAZEM HCL ER 120MG CAPS,,,,80000664,CDM,250,RC,10370082909,NDC,both,90,EA,0.14,0.05,39.4668,,0.05,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.05,34,,0.05,percent of total billed charges,"Drugs, Inpatient Only",0.05,34,,0.05,percent of total billed charges,"Drugs, Inpatient Only",0.05,34,,0.05,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.09,70,,0.09,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.1,,,0.1,Other,225% of Medicaid,0.06,,,0.06,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.1,,,0.1,Other,215% Medicaid APG methodology,0.1,,,0.1,Other,215% Medicaid APG methodology,0.06,,,0.06,Other,125% Medicaid APG methodology,0.01,0.1,
DINOPROSTONE (CERVIDIL) 10 MG,,,,80000670,CDM,250,RC,55566280001,NDC,both,1,EA,427.8,168.84,39.4668,,168.84,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,145.45,34,,145.45,percent of total billed charges,"Drugs, Inpatient Only",145.45,34,,145.45,percent of total billed charges,"Drugs, Inpatient Only",145.45,34,,145.45,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,299.46,70,,299.46,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,142.6,,,142.6,Other,Drug Cost,142.6,,,142.6,Other,Drug Cost,142.6,,,142.6,Other,Drug Cost,142.6,,,142.6,Other,Drug Cost,142.6,,,142.6,Other,Drug Cost,142.6,,,142.6,Other,Drug Cost,320.85,,,320.85,Other,225% of Medicaid,199.64,,,199.64,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,306.59,,,306.59,Other,215% Medicaid APG methodology,306.59,,,306.59,Other,215% Medicaid APG methodology,178.25,,,178.25,Other,125% Medicaid APG methodology,0.01,320.85,
DIPHENHYDRAMINE 50MG CAPS,,,,80000674,CDM,250,RC,904530760,NDC,both,100,EA,0.04,0.01,39.4668,,0.01,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.03,70,,0.03,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.03,,,0.03,Other,225% of Medicaid,0.02,,,0.02,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.03,,,0.03,Other,215% Medicaid APG methodology,0.03,,,0.03,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,125% Medicaid APG methodology,0.01,0.03,
DIPHENHYDRAMINE 12.5MG/5ML LIQ 5 ML,,,,80000676,CDM,250,RC,50580053404,NDC,both,1,ML,19.62,7.74,39.4668,,7.74,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,6.67,34,,6.67,percent of total billed charges,"Drugs, Inpatient Only",6.67,34,,6.67,percent of total billed charges,"Drugs, Inpatient Only",6.67,34,,6.67,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,13.73,70,,13.73,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,6.54,,,6.54,Other,Drug Cost,6.54,,,6.54,Other,Drug Cost,6.54,,,6.54,Other,Drug Cost,6.54,,,6.54,Other,Drug Cost,6.54,,,6.54,Other,Drug Cost,6.54,,,6.54,Other,Drug Cost,14.72,,,14.72,Other,225% of Medicaid,9.16,,,9.16,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,14.06,,,14.06,Other,215% Medicaid APG methodology,14.06,,,14.06,Other,215% Medicaid APG methodology,8.18,,,8.18,Other,125% Medicaid APG methodology,0.01,14.72,
DIPHENHYDRAMINE HCL 25MG CAPS,,,,80000677,CDM,250,RC,904723761,NDC,both,10,EA,0.36,0.14,39.4668,,0.14,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.12,34,,0.12,percent of total billed charges,"Drugs, Inpatient Only",0.12,34,,0.12,percent of total billed charges,"Drugs, Inpatient Only",0.12,34,,0.12,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.25,70,,0.25,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.12,,,0.12,Other,Drug Cost,0.12,,,0.12,Other,Drug Cost,0.12,,,0.12,Other,Drug Cost,0.12,,,0.12,Other,Drug Cost,0.12,,,0.12,Other,Drug Cost,0.12,,,0.12,Other,Drug Cost,0.27,,,0.27,Other,225% of Medicaid,0.17,,,0.17,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.26,,,0.26,Other,215% Medicaid APG methodology,0.26,,,0.26,Other,215% Medicaid APG methodology,0.15,,,0.15,Other,125% Medicaid APG methodology,0.01,0.27,
DIPHENHYDRAMINE(BENADRYL) ANTI-ITCH 28GM,,,,80000678,CDM,250,RC,45802035803,NDC,both,1,GM,2.31,0.91,39.4668,,0.91,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.79,34,,0.79,percent of total billed charges,"Drugs, Inpatient Only",0.79,34,,0.79,percent of total billed charges,"Drugs, Inpatient Only",0.79,34,,0.79,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1.62,70,,1.62,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.77,,,0.77,Other,Drug Cost,0.77,,,0.77,Other,Drug Cost,0.77,,,0.77,Other,Drug Cost,0.77,,,0.77,Other,Drug Cost,0.77,,,0.77,Other,Drug Cost,0.77,,,0.77,Other,Drug Cost,1.73,,,1.73,Other,225% of Medicaid,1.08,,,1.08,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,1.66,,,1.66,Other,215% Medicaid APG methodology,1.66,,,1.66,Other,215% Medicaid APG methodology,0.96,,,0.96,Other,125% Medicaid APG methodology,0.01,1.73,
DIPYRIDAMOLE 25MG TAB,,,,80000681,CDM,250,RC,64980013301,NDC,both,100,EA,0.17,0.07,39.4668,,0.07,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.06,34,,0.06,percent of total billed charges,"Drugs, Inpatient Only",0.06,34,,0.06,percent of total billed charges,"Drugs, Inpatient Only",0.06,34,,0.06,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.12,70,,0.12,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.06,,,0.06,Other,Drug Cost,0.06,,,0.06,Other,Drug Cost,0.06,,,0.06,Other,Drug Cost,0.06,,,0.06,Other,Drug Cost,0.06,,,0.06,Other,Drug Cost,0.06,,,0.06,Other,Drug Cost,0.12,,,0.12,Other,225% of Medicaid,0.08,,,0.08,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.12,,,0.12,Other,215% Medicaid APG methodology,0.12,,,0.12,Other,215% Medicaid APG methodology,0.07,,,0.07,Other,125% Medicaid APG methodology,0.01,0.12,
DIPYRIDAMOLE/ASPIRIN (AGGRENOX 200-25 MG,,,,80000682,CDM,250,RC,43598033960,NDC,both,60,EA,0.77,0.3,39.4668,,0.3,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.26,34,,0.26,percent of total billed charges,"Drugs, Inpatient Only",0.26,34,,0.26,percent of total billed charges,"Drugs, Inpatient Only",0.26,34,,0.26,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.54,70,,0.54,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.26,,,0.26,Other,Drug Cost,0.26,,,0.26,Other,Drug Cost,0.26,,,0.26,Other,Drug Cost,0.26,,,0.26,Other,Drug Cost,0.26,,,0.26,Other,Drug Cost,0.26,,,0.26,Other,Drug Cost,0.58,,,0.58,Other,225% of Medicaid,0.36,,,0.36,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.55,,,0.55,Other,215% Medicaid APG methodology,0.55,,,0.55,Other,215% Medicaid APG methodology,0.32,,,0.32,Other,125% Medicaid APG methodology,0.01,0.58,
DISULFIRAM 250 MG TAB,,,,80000686,CDM,250,RC,47781060730,NDC,both,30,EA,1.98,0.78,39.4668,,0.78,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.67,34,,0.67,percent of total billed charges,"Drugs, Inpatient Only",0.67,34,,0.67,percent of total billed charges,"Drugs, Inpatient Only",0.67,34,,0.67,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1.39,70,,1.39,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.66,,,0.66,Other,Drug Cost,0.66,,,0.66,Other,Drug Cost,0.66,,,0.66,Other,Drug Cost,0.66,,,0.66,Other,Drug Cost,0.66,,,0.66,Other,Drug Cost,0.66,,,0.66,Other,Drug Cost,1.48,,,1.48,Other,225% of Medicaid,0.92,,,0.92,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,1.42,,,1.42,Other,215% Medicaid APG methodology,1.42,,,1.42,Other,215% Medicaid APG methodology,0.82,,,0.82,Other,125% Medicaid APG methodology,0.01,1.48,
DIVALPROEX SODIUM (DEPAKOTE) 250MG TAB,,,,80000687,CDM,250,RC,62756079788,NDC,both,100,EA,0.1,0.04,39.4668,,0.04,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.03,34,,0.03,percent of total billed charges,"Drugs, Inpatient Only",0.03,34,,0.03,percent of total billed charges,"Drugs, Inpatient Only",0.03,34,,0.03,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.07,70,,0.07,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.07,,,0.07,Other,225% of Medicaid,0.05,,,0.05,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.07,,,0.07,Other,215% Medicaid APG methodology,0.07,,,0.07,Other,215% Medicaid APG methodology,0.04,,,0.04,Other,125% Medicaid APG methodology,0.01,0.07,
DIVALPROEX SODIUM (DEPAKOTE) 500MG TAB,,,,80000688,CDM,250,RC,62756079888,NDC,both,100,EA,0.16,0.06,39.4668,,0.06,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.05,34,,0.05,percent of total billed charges,"Drugs, Inpatient Only",0.05,34,,0.05,percent of total billed charges,"Drugs, Inpatient Only",0.05,34,,0.05,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.11,70,,0.11,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.12,,,0.12,Other,225% of Medicaid,0.07,,,0.07,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.11,,,0.11,Other,215% Medicaid APG methodology,0.11,,,0.11,Other,215% Medicaid APG methodology,0.07,,,0.07,Other,125% Medicaid APG methodology,0.01,0.12,
DIVALPROEX SODIUM ER (DEPAKOTE ER) 250MG,,,,80000689,CDM,250,RC,904636361,NDC,both,10,EA,24.29,9.59,39.4668,,9.59,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,8.26,34,,8.26,percent of total billed charges,"Drugs, Inpatient Only",8.26,34,,8.26,percent of total billed charges,"Drugs, Inpatient Only",8.26,34,,8.26,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,17,70,,17,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,8.1,,,8.1,Other,Drug Cost,8.1,,,8.1,Other,Drug Cost,8.1,,,8.1,Other,Drug Cost,8.1,,,8.1,Other,Drug Cost,8.1,,,8.1,Other,Drug Cost,8.1,,,8.1,Other,Drug Cost,18.22,,,18.22,Other,225% of Medicaid,11.33,,,11.33,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,17.41,,,17.41,Other,215% Medicaid APG methodology,17.41,,,17.41,Other,215% Medicaid APG methodology,10.12,,,10.12,Other,125% Medicaid APG methodology,0.01,18.22,
DIVALPROEX SODIUM ER (DEPAKOTE ER) 500MG,,,,80000690,CDM,250,RC,55111053401,NDC,both,100,EA,0.21,0.08,39.4668,,0.08,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.07,34,,0.07,percent of total billed charges,"Drugs, Inpatient Only",0.07,34,,0.07,percent of total billed charges,"Drugs, Inpatient Only",0.07,34,,0.07,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.14,70,,0.14,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.07,,,0.07,Other,Drug Cost,0.07,,,0.07,Other,Drug Cost,0.07,,,0.07,Other,Drug Cost,0.07,,,0.07,Other,Drug Cost,0.07,,,0.07,Other,Drug Cost,0.07,,,0.07,Other,Drug Cost,0.15,,,0.15,Other,225% of Medicaid,0.1,,,0.1,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.15,,,0.15,Other,215% Medicaid APG methodology,0.15,,,0.15,Other,215% Medicaid APG methodology,0.09,,,0.09,Other,125% Medicaid APG methodology,0.01,0.15,
DIVALPROEX SODIUM SPRIN (DEPAKOTE) 125MG,,,,80000691,CDM,250,RC,68382010601,NDC,both,100,EA,0.21,0.08,39.4668,,0.08,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.07,34,,0.07,percent of total billed charges,"Drugs, Inpatient Only",0.07,34,,0.07,percent of total billed charges,"Drugs, Inpatient Only",0.07,34,,0.07,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.15,70,,0.15,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.07,,,0.07,Other,Drug Cost,0.07,,,0.07,Other,Drug Cost,0.07,,,0.07,Other,Drug Cost,0.07,,,0.07,Other,Drug Cost,0.07,,,0.07,Other,Drug Cost,0.07,,,0.07,Other,Drug Cost,0.16,,,0.16,Other,225% of Medicaid,0.1,,,0.1,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.15,,,0.15,Other,215% Medicaid APG methodology,0.15,,,0.15,Other,215% Medicaid APG methodology,0.09,,,0.09,Other,125% Medicaid APG methodology,0.01,0.16,
DOCUSATE 100 MG CAP,,,,80000697,CDM,250,RC,57896040101,NDC,both,100,EA,0.06,0.02,39.4668,,0.02,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.02,34,,0.02,percent of total billed charges,"Drugs, Inpatient Only",0.02,34,,0.02,percent of total billed charges,"Drugs, Inpatient Only",0.02,34,,0.02,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.04,70,,0.04,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.05,,,0.05,Other,225% of Medicaid,0.03,,,0.03,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.04,,,0.04,Other,215% Medicaid APG methodology,0.04,,,0.04,Other,215% Medicaid APG methodology,0.03,,,0.03,Other,125% Medicaid APG methodology,0.01,0.05,
DOCUSATE SOD 50MG/5ML LIQ 10ML UD,,,,80000698,CDM,250,RC,121093540,NDC,both,40,ML,0.14,0.05,39.4668,,0.05,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.05,34,,0.05,percent of total billed charges,"Drugs, Inpatient Only",0.05,34,,0.05,percent of total billed charges,"Drugs, Inpatient Only",0.05,34,,0.05,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.1,70,,0.1,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.1,,,0.1,Other,225% of Medicaid,0.06,,,0.06,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.1,,,0.1,Other,215% Medicaid APG methodology,0.1,,,0.1,Other,215% Medicaid APG methodology,0.06,,,0.06,Other,125% Medicaid APG methodology,0.01,0.1,
DONEPEZIL (ARICEPT) 5 MG,,,,80000703,CDM,250,RC,43547027509,NDC,both,90,EA,0.06,0.02,39.4668,,0.02,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.02,34,,0.02,percent of total billed charges,"Drugs, Inpatient Only",0.02,34,,0.02,percent of total billed charges,"Drugs, Inpatient Only",0.02,34,,0.02,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.04,70,,0.04,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.04,,,0.04,Other,225% of Medicaid,0.03,,,0.03,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.04,,,0.04,Other,215% Medicaid APG methodology,0.04,,,0.04,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,125% Medicaid APG methodology,0.01,0.04,
DONNATAL 16.2MG TAB,,,,80000704,CDM,250,RC,50742066701,NDC,both,100,EA,1.18,0.46,39.4668,,0.46,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.4,34,,0.4,percent of total billed charges,"Drugs, Inpatient Only",0.4,34,,0.4,percent of total billed charges,"Drugs, Inpatient Only",0.4,34,,0.4,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.82,70,,0.82,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.39,,,0.39,Other,Drug Cost,0.39,,,0.39,Other,Drug Cost,0.39,,,0.39,Other,Drug Cost,0.39,,,0.39,Other,Drug Cost,0.39,,,0.39,Other,Drug Cost,0.39,,,0.39,Other,Drug Cost,0.88,,,0.88,Other,225% of Medicaid,0.55,,,0.55,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.84,,,0.84,Other,215% Medicaid APG methodology,0.84,,,0.84,Other,215% Medicaid APG methodology,0.49,,,0.49,Other,125% Medicaid APG methodology,0.01,0.88,
DORNASE ALFA 2.5 MG/2.5 ML INHALATION,,,,80000711,CDM,250,RC,50242010040,NDC,both,30,ML,352.97,139.31,39.4668,,139.31,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,120.01,34,,120.01,percent of total billed charges,"Drugs, Inpatient Only",120.01,34,,120.01,percent of total billed charges,"Drugs, Inpatient Only",120.01,34,,120.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,247.08,70,,247.08,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,117.66,,,117.66,Other,Drug Cost,117.66,,,117.66,Other,Drug Cost,117.66,,,117.66,Other,Drug Cost,117.66,,,117.66,Other,Drug Cost,117.66,,,117.66,Other,Drug Cost,117.66,,,117.66,Other,Drug Cost,264.73,,,264.73,Other,225% of Medicaid,164.72,,,164.72,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,252.96,,,252.96,Other,215% Medicaid APG methodology,252.96,,,252.96,Other,215% Medicaid APG methodology,147.07,,,147.07,Other,125% Medicaid APG methodology,0.01,264.73,
DORZOLAMIDE OPHTH 10ML,,,,80000712,CDM,250,RC,61314001910,NDC,both,1,ML,10.26,4.05,39.4668,,4.05,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,3.49,34,,3.49,percent of total billed charges,"Drugs, Inpatient Only",3.49,34,,3.49,percent of total billed charges,"Drugs, Inpatient Only",3.49,34,,3.49,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,7.18,70,,7.18,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,3.42,,,3.42,Other,Drug Cost,3.42,,,3.42,Other,Drug Cost,3.42,,,3.42,Other,Drug Cost,3.42,,,3.42,Other,Drug Cost,3.42,,,3.42,Other,Drug Cost,3.42,,,3.42,Other,Drug Cost,7.7,,,7.7,Other,225% of Medicaid,4.79,,,4.79,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,7.35,,,7.35,Other,215% Medicaid APG methodology,7.35,,,7.35,Other,215% Medicaid APG methodology,4.28,,,4.28,Other,125% Medicaid APG methodology,0.01,7.7,
DOXAZOSIN 1 MG TAB,,,,80000714,CDM,250,RC,93207001,NDC,both,100,EA,0.34,0.13,39.4668,,0.13,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.11,34,,0.11,percent of total billed charges,"Drugs, Inpatient Only",0.11,34,,0.11,percent of total billed charges,"Drugs, Inpatient Only",0.11,34,,0.11,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.24,70,,0.24,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.11,,,0.11,Other,Drug Cost,0.11,,,0.11,Other,Drug Cost,0.11,,,0.11,Other,Drug Cost,0.11,,,0.11,Other,Drug Cost,0.11,,,0.11,Other,Drug Cost,0.11,,,0.11,Other,Drug Cost,0.25,,,0.25,Other,225% of Medicaid,0.16,,,0.16,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.24,,,0.24,Other,215% Medicaid APG methodology,0.24,,,0.24,Other,215% Medicaid APG methodology,0.14,,,0.14,Other,125% Medicaid APG methodology,0.01,0.25,
DOXAZOSIN 4MG TAB,,,,80000715,CDM,250,RC,60505009500,NDC,both,100,EA,0.08,0.03,39.4668,,0.03,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.03,34,,0.03,percent of total billed charges,"Drugs, Inpatient Only",0.03,34,,0.03,percent of total billed charges,"Drugs, Inpatient Only",0.03,34,,0.03,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.06,70,,0.06,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.06,,,0.06,Other,225% of Medicaid,0.04,,,0.04,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.06,,,0.06,Other,215% Medicaid APG methodology,0.06,,,0.06,Other,215% Medicaid APG methodology,0.03,,,0.03,Other,125% Medicaid APG methodology,0.01,0.06,
DOXEPIN 10 MG CAP,,,,80000717,CDM,250,RC,378104901,NDC,both,100,EA,0.43,0.17,39.4668,,0.17,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.14,34,,0.14,percent of total billed charges,"Drugs, Inpatient Only",0.14,34,,0.14,percent of total billed charges,"Drugs, Inpatient Only",0.14,34,,0.14,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.3,70,,0.3,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.14,,,0.14,Other,Drug Cost,0.14,,,0.14,Other,Drug Cost,0.14,,,0.14,Other,Drug Cost,0.14,,,0.14,Other,Drug Cost,0.14,,,0.14,Other,Drug Cost,0.14,,,0.14,Other,Drug Cost,0.32,,,0.32,Other,225% of Medicaid,0.2,,,0.2,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.31,,,0.31,Other,215% Medicaid APG methodology,0.31,,,0.31,Other,215% Medicaid APG methodology,0.18,,,0.18,Other,125% Medicaid APG methodology,0.01,0.32,
DOXEPIN 25 MG CAP,,,,80000718,CDM,250,RC,378312501,NDC,both,100,EA,0.64,0.25,39.4668,,0.25,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.22,34,,0.22,percent of total billed charges,"Drugs, Inpatient Only",0.22,34,,0.22,percent of total billed charges,"Drugs, Inpatient Only",0.22,34,,0.22,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.45,70,,0.45,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.21,,,0.21,Other,Drug Cost,0.21,,,0.21,Other,Drug Cost,0.21,,,0.21,Other,Drug Cost,0.21,,,0.21,Other,Drug Cost,0.21,,,0.21,Other,Drug Cost,0.21,,,0.21,Other,Drug Cost,0.48,,,0.48,Other,225% of Medicaid,0.3,,,0.3,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.46,,,0.46,Other,215% Medicaid APG methodology,0.46,,,0.46,Other,215% Medicaid APG methodology,0.27,,,0.27,Other,125% Medicaid APG methodology,0.01,0.48,
DOXYCYCLINE 100 MG INJ,,,,80000726,CDM,250,RC,63323013011,NDC,both,10,EA,32.52,12.84,39.4668,,12.84,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,11.06,34,,11.06,percent of total billed charges,"Drugs, Inpatient Only",11.06,34,,11.06,percent of total billed charges,"Drugs, Inpatient Only",11.06,34,,11.06,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,22.77,70,,22.77,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,10.84,,,10.84,Other,Drug Cost,10.84,,,10.84,Other,Drug Cost,10.84,,,10.84,Other,Drug Cost,10.84,,,10.84,Other,Drug Cost,10.84,,,10.84,Other,Drug Cost,10.84,,,10.84,Other,Drug Cost,24.39,,,24.39,Other,225% of Medicaid,15.18,,,15.18,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,23.31,,,23.31,Other,215% Medicaid APG methodology,23.31,,,23.31,Other,215% Medicaid APG methodology,13.55,,,13.55,Other,125% Medicaid APG methodology,0.01,24.39,
DOXYCYCLINE 100MG TAB,,,,80000727,CDM,250,RC,53489012002,NDC,both,50,EA,0.01,0.01,39.4668,,0.01,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,70,,0.01,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,0.02,
DRONADERONE 400MG TAB,,,,80000730,CDM,250,RC,24414260,NDC,both,60,EA,0.12,0.05,39.4668,,0.05,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.04,34,,0.04,percent of total billed charges,"Drugs, Inpatient Only",0.04,34,,0.04,percent of total billed charges,"Drugs, Inpatient Only",0.04,34,,0.04,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.08,70,,0.08,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.09,,,0.09,Other,225% of Medicaid,0.05,,,0.05,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.08,,,0.08,Other,215% Medicaid APG methodology,0.08,,,0.08,Other,215% Medicaid APG methodology,0.05,,,0.05,Other,125% Medicaid APG methodology,0.01,0.09,
DULOXETINE (CYMBALTA) 20 MG,,,,80000732,CDM,250,RC,27241009706,NDC,both,60,EA,0.05,0.02,39.4668,,0.02,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.02,34,,0.02,percent of total billed charges,"Drugs, Inpatient Only",0.02,34,,0.02,percent of total billed charges,"Drugs, Inpatient Only",0.02,34,,0.02,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.03,70,,0.03,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.04,,,0.04,Other,225% of Medicaid,0.02,,,0.02,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.03,,,0.03,Other,215% Medicaid APG methodology,0.03,,,0.03,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,125% Medicaid APG methodology,0.01,0.04,
DULOXETINE (CYMBALTA) 30 MG,,,,80000733,CDM,250,RC,57237001890,NDC,both,90,EA,0.11,0.04,39.4668,,0.04,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.04,34,,0.04,percent of total billed charges,"Drugs, Inpatient Only",0.04,34,,0.04,percent of total billed charges,"Drugs, Inpatient Only",0.04,34,,0.04,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.08,70,,0.08,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.08,,,0.08,Other,225% of Medicaid,0.05,,,0.05,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.08,,,0.08,Other,215% Medicaid APG methodology,0.08,,,0.08,Other,215% Medicaid APG methodology,0.04,,,0.04,Other,125% Medicaid APG methodology,0.01,0.08,
DULOXETINE (CYMBALTA) 60 MG,,,,80000734,CDM,250,RC,57237001930,NDC,both,30,EA,0.19,0.07,39.4668,,0.07,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.06,34,,0.06,percent of total billed charges,"Drugs, Inpatient Only",0.06,34,,0.06,percent of total billed charges,"Drugs, Inpatient Only",0.06,34,,0.06,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.13,70,,0.13,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.06,,,0.06,Other,Drug Cost,0.06,,,0.06,Other,Drug Cost,0.06,,,0.06,Other,Drug Cost,0.06,,,0.06,Other,Drug Cost,0.06,,,0.06,Other,Drug Cost,0.06,,,0.06,Other,Drug Cost,0.14,,,0.14,Other,225% of Medicaid,0.09,,,0.09,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.13,,,0.13,Other,215% Medicaid APG methodology,0.13,,,0.13,Other,215% Medicaid APG methodology,0.08,,,0.08,Other,125% Medicaid APG methodology,0.01,0.14,
DUTASTERIDE (AVODART) 0.5MG,,,,80000737,CDM,250,RC,31722013130,NDC,both,30,EA,0.21,0.08,39.4668,,0.08,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.07,34,,0.07,percent of total billed charges,"Drugs, Inpatient Only",0.07,34,,0.07,percent of total billed charges,"Drugs, Inpatient Only",0.07,34,,0.07,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.14,70,,0.14,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.07,,,0.07,Other,Drug Cost,0.07,,,0.07,Other,Drug Cost,0.07,,,0.07,Other,Drug Cost,0.07,,,0.07,Other,Drug Cost,0.07,,,0.07,Other,Drug Cost,0.07,,,0.07,Other,Drug Cost,0.15,,,0.15,Other,225% of Medicaid,0.1,,,0.1,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.15,,,0.15,Other,215% Medicaid APG methodology,0.15,,,0.15,Other,215% Medicaid APG methodology,0.09,,,0.09,Other,125% Medicaid APG methodology,0.01,0.15,
EMTRICITABINE (EMTRIVA) 200 MG CAPS,,,,80000746,CDM,250,RC,61958060101,NDC,both,30,EA,28.16,11.11,39.4668,,11.11,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,9.57,34,,9.57,percent of total billed charges,"Drugs, Inpatient Only",9.57,34,,9.57,percent of total billed charges,"Drugs, Inpatient Only",9.57,34,,9.57,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,19.71,70,,19.71,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,9.39,,,9.39,Other,Drug Cost,9.39,,,9.39,Other,Drug Cost,9.39,,,9.39,Other,Drug Cost,9.39,,,9.39,Other,Drug Cost,9.39,,,9.39,Other,Drug Cost,9.39,,,9.39,Other,Drug Cost,21.12,,,21.12,Other,225% of Medicaid,13.14,,,13.14,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,20.18,,,20.18,Other,215% Medicaid APG methodology,20.18,,,20.18,Other,215% Medicaid APG methodology,11.73,,,11.73,Other,125% Medicaid APG methodology,0.01,21.12,
ENALAPRIL 1.25MG/ML 2ML INJECTION,,,,80000747,CDM,250,RC,143978610,NDC,both,10,ML,10.13,4,39.4668,,4,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,3.44,34,,3.44,percent of total billed charges,"Drugs, Inpatient Only",3.44,34,,3.44,percent of total billed charges,"Drugs, Inpatient Only",3.44,34,,3.44,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,7.09,70,,7.09,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,3.38,,,3.38,Other,Drug Cost,3.38,,,3.38,Other,Drug Cost,3.38,,,3.38,Other,Drug Cost,3.38,,,3.38,Other,Drug Cost,3.38,,,3.38,Other,Drug Cost,3.38,,,3.38,Other,Drug Cost,7.6,,,7.6,Other,225% of Medicaid,4.73,,,4.73,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,7.26,,,7.26,Other,215% Medicaid APG methodology,7.26,,,7.26,Other,215% Medicaid APG methodology,4.22,,,4.22,Other,125% Medicaid APG methodology,0.01,7.6,
ENALAPRILAT 1.25MG/1ML INJ,,,,80000750,CDM,250,RC,143978710,NDC,both,10,ML,1.92,0.76,39.4668,,0.76,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.65,34,,0.65,percent of total billed charges,"Drugs, Inpatient Only",0.65,34,,0.65,percent of total billed charges,"Drugs, Inpatient Only",0.65,34,,0.65,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1.34,70,,1.34,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.64,,,0.64,Other,Drug Cost,0.64,,,0.64,Other,Drug Cost,0.64,,,0.64,Other,Drug Cost,0.64,,,0.64,Other,Drug Cost,0.64,,,0.64,Other,Drug Cost,0.64,,,0.64,Other,Drug Cost,1.44,,,1.44,Other,225% of Medicaid,0.89,,,0.89,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,1.37,,,1.37,Other,215% Medicaid APG methodology,1.37,,,1.37,Other,215% Medicaid APG methodology,0.8,,,0.8,Other,125% Medicaid APG methodology,0.01,1.44,
ENTACAPONE (COMTAN) 200MG,,,,80000759,CDM,250,RC,65862065401,NDC,both,100,EA,0.37,0.14,39.4668,,0.14,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.12,34,,0.12,percent of total billed charges,"Drugs, Inpatient Only",0.12,34,,0.12,percent of total billed charges,"Drugs, Inpatient Only",0.12,34,,0.12,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.26,70,,0.26,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.12,,,0.12,Other,Drug Cost,0.12,,,0.12,Other,Drug Cost,0.12,,,0.12,Other,Drug Cost,0.12,,,0.12,Other,Drug Cost,0.12,,,0.12,Other,Drug Cost,0.12,,,0.12,Other,Drug Cost,0.27,,,0.27,Other,225% of Medicaid,0.17,,,0.17,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.26,,,0.26,Other,215% Medicaid APG methodology,0.26,,,0.26,Other,215% Medicaid APG methodology,0.15,,,0.15,Other,125% Medicaid APG methodology,0.01,0.27,
EPHEDRINE 50MG/ML,,,,80000760,CDM,250,RC,42023021625,NDC,both,25,ML,11.03,4.35,39.4668,,4.35,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,3.75,34,,3.75,percent of total billed charges,"Drugs, Inpatient Only",3.75,34,,3.75,percent of total billed charges,"Drugs, Inpatient Only",3.75,34,,3.75,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,7.72,70,,7.72,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,3.68,,,3.68,Other,Drug Cost,3.68,,,3.68,Other,Drug Cost,3.68,,,3.68,Other,Drug Cost,3.68,,,3.68,Other,Drug Cost,3.68,,,3.68,Other,Drug Cost,3.68,,,3.68,Other,Drug Cost,8.27,,,8.27,Other,225% of Medicaid,5.15,,,5.15,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,7.91,,,7.91,Other,215% Medicaid APG methodology,7.91,,,7.91,Other,215% Medicaid APG methodology,4.6,,,4.6,Other,125% Medicaid APG methodology,0.01,8.27,
EPINEPHRINE HCL (ADRENALIN) 0.1% NASAL,,,,80000762,CDM,250,RC,42023010301,NDC,both,1,ML,680.97,268.76,39.4668,,268.76,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,231.53,34,,231.53,percent of total billed charges,"Drugs, Inpatient Only",231.53,34,,231.53,percent of total billed charges,"Drugs, Inpatient Only",231.53,34,,231.53,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,476.68,70,,476.68,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,226.99,,,226.99,Other,Drug Cost,226.99,,,226.99,Other,Drug Cost,226.99,,,226.99,Other,Drug Cost,226.99,,,226.99,Other,Drug Cost,226.99,,,226.99,Other,Drug Cost,226.99,,,226.99,Other,Drug Cost,510.73,,,510.73,Other,225% of Medicaid,317.79,,,317.79,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,488.03,,,488.03,Other,215% Medicaid APG methodology,488.03,,,488.03,Other,215% Medicaid APG methodology,283.74,,,283.74,Other,125% Medicaid APG methodology,0.01,510.73,
ERGOCALCIFEROL 50000 INTL UNITS CAP,,,,80000774,CDM,250,RC,69452015120,NDC,both,100,EA,0.1,0.04,39.4668,,0.04,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.03,34,,0.03,percent of total billed charges,"Drugs, Inpatient Only",0.03,34,,0.03,percent of total billed charges,"Drugs, Inpatient Only",0.03,34,,0.03,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.07,70,,0.07,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.07,,,0.07,Other,225% of Medicaid,0.04,,,0.04,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.07,,,0.07,Other,215% Medicaid APG methodology,0.07,,,0.07,Other,215% Medicaid APG methodology,0.04,,,0.04,Other,125% Medicaid APG methodology,0.01,0.07,
ERYTHROMYCIN 1 GM OPHTH OINT,,,,80000781,CDM,250,RC,24208091019,NDC,both,50,GM,5.04,1.99,39.4668,,1.99,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1.71,34,,1.71,percent of total billed charges,"Drugs, Inpatient Only",1.71,34,,1.71,percent of total billed charges,"Drugs, Inpatient Only",1.71,34,,1.71,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,3.53,70,,3.53,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1.68,,,1.68,Other,Drug Cost,1.68,,,1.68,Other,Drug Cost,1.68,,,1.68,Other,Drug Cost,1.68,,,1.68,Other,Drug Cost,1.68,,,1.68,Other,Drug Cost,1.68,,,1.68,Other,Drug Cost,3.78,,,3.78,Other,225% of Medicaid,2.35,,,2.35,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,3.61,,,3.61,Other,215% Medicaid APG methodology,3.61,,,3.61,Other,215% Medicaid APG methodology,2.1,,,2.1,Other,125% Medicaid APG methodology,0.01,3.78,
ERYTHROMYCIN 2% TOPICAL SOLN 60 ML,,,,80000783,CDM,250,RC,45802003846,NDC,both,1,ML,26.49,10.45,39.4668,,10.45,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,9.01,34,,9.01,percent of total billed charges,"Drugs, Inpatient Only",9.01,34,,9.01,percent of total billed charges,"Drugs, Inpatient Only",9.01,34,,9.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,18.54,70,,18.54,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,8.83,,,8.83,Other,Drug Cost,8.83,,,8.83,Other,Drug Cost,8.83,,,8.83,Other,Drug Cost,8.83,,,8.83,Other,Drug Cost,8.83,,,8.83,Other,Drug Cost,8.83,,,8.83,Other,Drug Cost,19.87,,,19.87,Other,225% of Medicaid,12.36,,,12.36,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,18.98,,,18.98,Other,215% Medicaid APG methodology,18.98,,,18.98,Other,215% Medicaid APG methodology,11.04,,,11.04,Other,125% Medicaid APG methodology,0.01,19.87,
ERYTHROMYCIN 3.5 GM OPHTH OINT,,,,80000785,CDM,250,RC,24208091055,NDC,both,1,GM,12.84,5.07,39.4668,,5.07,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,4.37,34,,4.37,percent of total billed charges,"Drugs, Inpatient Only",4.37,34,,4.37,percent of total billed charges,"Drugs, Inpatient Only",4.37,34,,4.37,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,8.99,70,,8.99,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,4.28,,,4.28,Other,Drug Cost,4.28,,,4.28,Other,Drug Cost,4.28,,,4.28,Other,Drug Cost,4.28,,,4.28,Other,Drug Cost,4.28,,,4.28,Other,Drug Cost,4.28,,,4.28,Other,Drug Cost,9.63,,,9.63,Other,225% of Medicaid,5.99,,,5.99,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,9.2,,,9.2,Other,215% Medicaid APG methodology,9.2,,,9.2,Other,215% Medicaid APG methodology,5.35,,,5.35,Other,125% Medicaid APG methodology,0.01,9.63,
ERYTHROMYCIN ETHYLSUCCINAT 200 200MG/5ML,,,,80000786,CDM,250,RC,24338013402,NDC,both,1,ML,526.35,207.73,39.4668,,207.73,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,178.96,34,,178.96,percent of total billed charges,"Drugs, Inpatient Only",178.96,34,,178.96,percent of total billed charges,"Drugs, Inpatient Only",178.96,34,,178.96,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,368.45,70,,368.45,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,175.45,,,175.45,Other,Drug Cost,175.45,,,175.45,Other,Drug Cost,175.45,,,175.45,Other,Drug Cost,175.45,,,175.45,Other,Drug Cost,175.45,,,175.45,Other,Drug Cost,175.45,,,175.45,Other,Drug Cost,394.76,,,394.76,Other,225% of Medicaid,245.63,,,245.63,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,377.22,,,377.22,Other,215% Medicaid APG methodology,377.22,,,377.22,Other,215% Medicaid APG methodology,219.31,,,219.31,Other,125% Medicaid APG methodology,0.01,394.76,
ESCITALOPRAM (LEXAPRO) 10MG TAB,,,,80000788,CDM,250,RC,456201001,NDC,both,100,EA,0.03,0.01,39.4668,,0.01,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.02,70,,0.02,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.02,,,0.02,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,0.02,
ESTRADIOL 1MG TAB,,,,80000789,CDM,250,RC,555088602,NDC,both,100,EA,0.07,0.03,39.4668,,0.03,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.02,34,,0.02,percent of total billed charges,"Drugs, Inpatient Only",0.02,34,,0.02,percent of total billed charges,"Drugs, Inpatient Only",0.02,34,,0.02,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.05,70,,0.05,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.05,,,0.05,Other,225% of Medicaid,0.03,,,0.03,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.05,,,0.05,Other,215% Medicaid APG methodology,0.05,,,0.05,Other,215% Medicaid APG methodology,0.03,,,0.03,Other,125% Medicaid APG methodology,0.01,0.05,
ETOMIDATE (AMIDATE) 2MG/ML 10 ML,,,,80000800,CDM,250,RC,143950610,NDC,both,10,ML,3.84,1.52,39.4668,,1.52,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1.31,34,,1.31,percent of total billed charges,"Drugs, Inpatient Only",1.31,34,,1.31,percent of total billed charges,"Drugs, Inpatient Only",1.31,34,,1.31,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2.69,70,,2.69,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1.28,,,1.28,Other,Drug Cost,1.28,,,1.28,Other,Drug Cost,1.28,,,1.28,Other,Drug Cost,1.28,,,1.28,Other,Drug Cost,1.28,,,1.28,Other,Drug Cost,1.28,,,1.28,Other,Drug Cost,2.88,,,2.88,Other,225% of Medicaid,1.79,,,1.79,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,2.75,,,2.75,Other,215% Medicaid APG methodology,2.75,,,2.75,Other,215% Medicaid APG methodology,1.6,,,1.6,Other,125% Medicaid APG methodology,0.01,2.88,
ETOMIDATE (AMIDATE) 2MG/ML 20 ML,,,,80000801,CDM,250,RC,409669502,NDC,both,10,ML,15.1,5.96,39.4668,,5.96,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,5.13,34,,5.13,percent of total billed charges,"Drugs, Inpatient Only",5.13,34,,5.13,percent of total billed charges,"Drugs, Inpatient Only",5.13,34,,5.13,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,10.57,70,,10.57,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,5.03,,,5.03,Other,Drug Cost,5.03,,,5.03,Other,Drug Cost,5.03,,,5.03,Other,Drug Cost,5.03,,,5.03,Other,Drug Cost,5.03,,,5.03,Other,Drug Cost,5.03,,,5.03,Other,Drug Cost,11.32,,,11.32,Other,225% of Medicaid,7.05,,,7.05,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,10.82,,,10.82,Other,215% Medicaid APG methodology,10.82,,,10.82,Other,215% Medicaid APG methodology,6.29,,,6.29,Other,125% Medicaid APG methodology,0.01,11.32,
ETRAVIRINE (INTELENCE) 100MG TAB,,,,80000803,CDM,250,RC,59676057001,NDC,both,120,EA,14.1,5.57,39.4668,,5.57,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,4.8,34,,4.8,percent of total billed charges,"Drugs, Inpatient Only",4.8,34,,4.8,percent of total billed charges,"Drugs, Inpatient Only",4.8,34,,4.8,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,9.87,70,,9.87,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,4.7,,,4.7,Other,Drug Cost,4.7,,,4.7,Other,Drug Cost,4.7,,,4.7,Other,Drug Cost,4.7,,,4.7,Other,Drug Cost,4.7,,,4.7,Other,Drug Cost,4.7,,,4.7,Other,Drug Cost,10.58,,,10.58,Other,225% of Medicaid,6.58,,,6.58,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,10.11,,,10.11,Other,215% Medicaid APG methodology,10.11,,,10.11,Other,215% Medicaid APG methodology,5.88,,,5.88,Other,125% Medicaid APG methodology,0.01,10.58,
EXEMESTANE 25 MG,,,,80000804,CDM,250,RC,59762285801,NDC,both,30,EA,0.62,0.24,39.4668,,0.24,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.21,34,,0.21,percent of total billed charges,"Drugs, Inpatient Only",0.21,34,,0.21,percent of total billed charges,"Drugs, Inpatient Only",0.21,34,,0.21,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.43,70,,0.43,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.21,,,0.21,Other,Drug Cost,0.21,,,0.21,Other,Drug Cost,0.21,,,0.21,Other,Drug Cost,0.21,,,0.21,Other,Drug Cost,0.21,,,0.21,Other,Drug Cost,0.21,,,0.21,Other,Drug Cost,0.46,,,0.46,Other,225% of Medicaid,0.29,,,0.29,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.44,,,0.44,Other,215% Medicaid APG methodology,0.44,,,0.44,Other,215% Medicaid APG methodology,0.26,,,0.26,Other,125% Medicaid APG methodology,0.01,0.46,
EYE WASH 120ML,,,,80000805,CDM,250,RC,10119000252,NDC,both,1,EA,11.13,4.39,39.4668,,4.39,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,3.78,34,,3.78,percent of total billed charges,"Drugs, Inpatient Only",3.78,34,,3.78,percent of total billed charges,"Drugs, Inpatient Only",3.78,34,,3.78,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,7.79,70,,7.79,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,3.71,,,3.71,Other,Drug Cost,3.71,,,3.71,Other,Drug Cost,3.71,,,3.71,Other,Drug Cost,3.71,,,3.71,Other,Drug Cost,3.71,,,3.71,Other,Drug Cost,3.71,,,3.71,Other,Drug Cost,8.35,,,8.35,Other,225% of Medicaid,5.19,,,5.19,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,7.98,,,7.98,Other,215% Medicaid APG methodology,7.98,,,7.98,Other,215% Medicaid APG methodology,4.64,,,4.64,Other,125% Medicaid APG methodology,0.01,8.35,
FAMOTIDINE 10 MG/ML 2ML INJ,,,,80000811,CDM,250,RC,63323073912,NDC,both,25,ML,1.03,0.41,39.4668,,0.41,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.35,34,,0.35,percent of total billed charges,"Drugs, Inpatient Only",0.35,34,,0.35,percent of total billed charges,"Drugs, Inpatient Only",0.35,34,,0.35,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.72,70,,0.72,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.34,,,0.34,Other,Drug Cost,0.34,,,0.34,Other,Drug Cost,0.34,,,0.34,Other,Drug Cost,0.34,,,0.34,Other,Drug Cost,0.34,,,0.34,Other,Drug Cost,0.34,,,0.34,Other,Drug Cost,0.77,,,0.77,Other,225% of Medicaid,0.48,,,0.48,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.74,,,0.74,Other,215% Medicaid APG methodology,0.74,,,0.74,Other,215% Medicaid APG methodology,0.43,,,0.43,Other,125% Medicaid APG methodology,0.01,0.77,
FAMOTIDINE 10MG,,,,80000812,CDM,250,RC,904552987,NDC,both,30,EA,0.13,0.05,39.4668,,0.05,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.04,34,,0.04,percent of total billed charges,"Drugs, Inpatient Only",0.04,34,,0.04,percent of total billed charges,"Drugs, Inpatient Only",0.04,34,,0.04,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.09,70,,0.09,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.1,,,0.1,Other,225% of Medicaid,0.06,,,0.06,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.09,,,0.09,Other,215% Medicaid APG methodology,0.09,,,0.09,Other,215% Medicaid APG methodology,0.05,,,0.05,Other,125% Medicaid APG methodology,0.01,0.1,
FAMOTIDINE 20 MG TAB,,,,80000814,CDM,250,RC,172572870,NDC,both,500,EA,0.04,0.01,39.4668,,0.01,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.02,70,,0.02,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.03,,,0.03,Other,225% of Medicaid,0.02,,,0.02,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.03,,,0.03,Other,215% Medicaid APG methodology,0.03,,,0.03,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,0.03,
FAMOTIDINE 20MG/50ML INJ,,,,80000815,CDM,250,RC,338519741,NDC,both,24,ML,11.52,4.55,39.4668,,4.55,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,3.92,34,,3.92,percent of total billed charges,"Drugs, Inpatient Only",3.92,34,,3.92,percent of total billed charges,"Drugs, Inpatient Only",3.92,34,,3.92,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,8.06,70,,8.06,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,3.84,,,3.84,Other,Drug Cost,3.84,,,3.84,Other,Drug Cost,3.84,,,3.84,Other,Drug Cost,3.84,,,3.84,Other,Drug Cost,3.84,,,3.84,Other,Drug Cost,3.84,,,3.84,Other,Drug Cost,8.64,,,8.64,Other,225% of Medicaid,5.37,,,5.37,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,8.25,,,8.25,Other,215% Medicaid APG methodology,8.25,,,8.25,Other,215% Medicaid APG methodology,4.8,,,4.8,Other,125% Medicaid APG methodology,0.01,8.64,
FENOFIBRATE 160MG TABLET,,,,80000821,CDM,250,RC,27241011703,NDC,both,90,EA,0.09,0.04,39.4668,,0.04,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.03,34,,0.03,percent of total billed charges,"Drugs, Inpatient Only",0.03,34,,0.03,percent of total billed charges,"Drugs, Inpatient Only",0.03,34,,0.03,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.06,70,,0.06,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.07,,,0.07,Other,225% of Medicaid,0.04,,,0.04,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.06,,,0.06,Other,215% Medicaid APG methodology,0.06,,,0.06,Other,215% Medicaid APG methodology,0.04,,,0.04,Other,125% Medicaid APG methodology,0.01,0.07,
FENOFIBRATE 54MG TABLET,,,,80000823,CDM,250,RC,70756021490,NDC,both,90,EA,0.08,0.03,39.4668,,0.03,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.03,34,,0.03,percent of total billed charges,"Drugs, Inpatient Only",0.03,34,,0.03,percent of total billed charges,"Drugs, Inpatient Only",0.03,34,,0.03,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.05,70,,0.05,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.06,,,0.06,Other,225% of Medicaid,0.04,,,0.04,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.06,,,0.06,Other,215% Medicaid APG methodology,0.06,,,0.06,Other,215% Medicaid APG methodology,0.03,,,0.03,Other,125% Medicaid APG methodology,0.01,0.06,
FENTANYL (DURAGESIC) 12MCG/HR PATCH,,,,80000824,CDM,250,RC,378911998,NDC,both,5,EA,4.51,1.78,39.4668,,1.78,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1.53,34,,1.53,percent of total billed charges,"Drugs, Inpatient Only",1.53,34,,1.53,percent of total billed charges,"Drugs, Inpatient Only",1.53,34,,1.53,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,3.16,70,,3.16,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1.5,,,1.5,Other,Drug Cost,1.5,,,1.5,Other,Drug Cost,1.5,,,1.5,Other,Drug Cost,1.5,,,1.5,Other,Drug Cost,1.5,,,1.5,Other,Drug Cost,1.5,,,1.5,Other,Drug Cost,3.38,,,3.38,Other,225% of Medicaid,2.11,,,2.11,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,3.23,,,3.23,Other,215% Medicaid APG methodology,3.23,,,3.23,Other,215% Medicaid APG methodology,1.88,,,1.88,Other,125% Medicaid APG methodology,0.01,3.38,
FENTANYL 100MCG/HR PATCH,,,,80000826,CDM,250,RC,378912498,NDC,both,5,EA,26.4,10.42,39.4668,,10.42,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,8.98,34,,8.98,percent of total billed charges,"Drugs, Inpatient Only",8.98,34,,8.98,percent of total billed charges,"Drugs, Inpatient Only",8.98,34,,8.98,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,18.48,70,,18.48,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,8.8,,,8.8,Other,Drug Cost,8.8,,,8.8,Other,Drug Cost,8.8,,,8.8,Other,Drug Cost,8.8,,,8.8,Other,Drug Cost,8.8,,,8.8,Other,Drug Cost,8.8,,,8.8,Other,Drug Cost,19.8,,,19.8,Other,225% of Medicaid,12.32,,,12.32,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,18.92,,,18.92,Other,215% Medicaid APG methodology,18.92,,,18.92,Other,215% Medicaid APG methodology,11,,,11,Other,125% Medicaid APG methodology,0.01,19.8,
FERREX 150 FORTE 1EA,,,,80000838,CDM,250,RC,51991020311,NDC,both,100,EA,0.43,0.17,39.4668,,0.17,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.14,34,,0.14,percent of total billed charges,"Drugs, Inpatient Only",0.14,34,,0.14,percent of total billed charges,"Drugs, Inpatient Only",0.14,34,,0.14,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.3,70,,0.3,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.14,,,0.14,Other,Drug Cost,0.14,,,0.14,Other,Drug Cost,0.14,,,0.14,Other,Drug Cost,0.14,,,0.14,Other,Drug Cost,0.14,,,0.14,Other,Drug Cost,0.14,,,0.14,Other,Drug Cost,0.32,,,0.32,Other,225% of Medicaid,0.2,,,0.2,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.31,,,0.31,Other,215% Medicaid APG methodology,0.31,,,0.31,Other,215% Medicaid APG methodology,0.18,,,0.18,Other,125% Medicaid APG methodology,0.01,0.32,
FERROUS  SULFATE 325MG,,,,80000841,CDM,250,RC,904759160,NDC,both,100,EA,0.03,0.01,39.4668,,0.01,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.02,70,,0.02,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.02,,,0.02,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,0.02,
FERROUS 300MG/5ML SOLN 5ML UD,,,,80000842,CDM,250,RC,121053005,NDC,both,100,ML,8.07,3.18,39.4668,,3.18,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2.74,34,,2.74,percent of total billed charges,"Drugs, Inpatient Only",2.74,34,,2.74,percent of total billed charges,"Drugs, Inpatient Only",2.74,34,,2.74,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,5.65,70,,5.65,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2.69,,,2.69,Other,Drug Cost,2.69,,,2.69,Other,Drug Cost,2.69,,,2.69,Other,Drug Cost,2.69,,,2.69,Other,Drug Cost,2.69,,,2.69,Other,Drug Cost,2.69,,,2.69,Other,Drug Cost,6.05,,,6.05,Other,225% of Medicaid,3.77,,,3.77,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,5.78,,,5.78,Other,215% Medicaid APG methodology,5.78,,,5.78,Other,215% Medicaid APG methodology,3.36,,,3.36,Other,125% Medicaid APG methodology,0.01,6.05,
FERROUS GLUC 324 MG TAB,,,,80000844,CDM,250,RC,574050801,NDC,both,100,EA,0.14,0.06,39.4668,,0.06,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.05,34,,0.05,percent of total billed charges,"Drugs, Inpatient Only",0.05,34,,0.05,percent of total billed charges,"Drugs, Inpatient Only",0.05,34,,0.05,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.1,70,,0.1,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.11,,,0.11,Other,225% of Medicaid,0.07,,,0.07,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.1,,,0.1,Other,215% Medicaid APG methodology,0.1,,,0.1,Other,215% Medicaid APG methodology,0.06,,,0.06,Other,125% Medicaid APG methodology,0.01,0.11,
FIDAXOMICIN 200MG TAB,,,,80000846,CDM,250,RC,52015008001,NDC,both,20,EA,118.44,46.74,39.4668,,46.74,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,40.27,34,,40.27,percent of total billed charges,"Drugs, Inpatient Only",40.27,34,,40.27,percent of total billed charges,"Drugs, Inpatient Only",40.27,34,,40.27,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,82.91,70,,82.91,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,39.48,,,39.48,Other,Drug Cost,39.48,,,39.48,Other,Drug Cost,39.48,,,39.48,Other,Drug Cost,39.48,,,39.48,Other,Drug Cost,39.48,,,39.48,Other,Drug Cost,39.48,,,39.48,Other,Drug Cost,88.83,,,88.83,Other,225% of Medicaid,55.27,,,55.27,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,84.88,,,84.88,Other,215% Medicaid APG methodology,84.88,,,84.88,Other,215% Medicaid APG methodology,49.35,,,49.35,Other,125% Medicaid APG methodology,0.01,88.83,
FINASTERIDE 5MG TAB,,,,80000849,CDM,250,RC,43598030330,NDC,both,30,EA,0.05,0.02,39.4668,,0.02,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.02,34,,0.02,percent of total billed charges,"Drugs, Inpatient Only",0.02,34,,0.02,percent of total billed charges,"Drugs, Inpatient Only",0.02,34,,0.02,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.03,70,,0.03,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.03,,,0.03,Other,225% of Medicaid,0.02,,,0.02,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.03,,,0.03,Other,215% Medicaid APG methodology,0.03,,,0.03,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,125% Medicaid APG methodology,0.01,0.03,
FLECAINIDE ACETATE 50MG TAB,,,,80000852,CDM,250,RC,53746064101,NDC,both,100,EA,0.12,0.05,39.4668,,0.05,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.04,34,,0.04,percent of total billed charges,"Drugs, Inpatient Only",0.04,34,,0.04,percent of total billed charges,"Drugs, Inpatient Only",0.04,34,,0.04,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.08,70,,0.08,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.09,,,0.09,Other,225% of Medicaid,0.06,,,0.06,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.09,,,0.09,Other,215% Medicaid APG methodology,0.09,,,0.09,Other,215% Medicaid APG methodology,0.05,,,0.05,Other,125% Medicaid APG methodology,0.01,0.09,
FLUCONAZOLE 100 MG TAB,,,,80000857,CDM,250,RC,68462010230,NDC,both,30,EA,0.33,0.13,39.4668,,0.13,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.11,34,,0.11,percent of total billed charges,"Drugs, Inpatient Only",0.11,34,,0.11,percent of total billed charges,"Drugs, Inpatient Only",0.11,34,,0.11,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.23,70,,0.23,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.11,,,0.11,Other,Drug Cost,0.11,,,0.11,Other,Drug Cost,0.11,,,0.11,Other,Drug Cost,0.11,,,0.11,Other,Drug Cost,0.11,,,0.11,Other,Drug Cost,0.11,,,0.11,Other,Drug Cost,0.25,,,0.25,Other,225% of Medicaid,0.16,,,0.16,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.24,,,0.24,Other,215% Medicaid APG methodology,0.24,,,0.24,Other,215% Medicaid APG methodology,0.14,,,0.14,Other,125% Medicaid APG methodology,0.01,0.25,
FLUCONAZOLE 50 MG TAB,,,,80000858,CDM,250,RC,70710113703,NDC,both,30,EA,0.16,0.06,39.4668,,0.06,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.06,34,,0.06,percent of total billed charges,"Drugs, Inpatient Only",0.06,34,,0.06,percent of total billed charges,"Drugs, Inpatient Only",0.06,34,,0.06,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.11,70,,0.11,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.12,,,0.12,Other,225% of Medicaid,0.08,,,0.08,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.12,,,0.12,Other,215% Medicaid APG methodology,0.12,,,0.12,Other,215% Medicaid APG methodology,0.07,,,0.07,Other,125% Medicaid APG methodology,0.01,0.12,
FLUDROCORTISONE 0.1 MG TAB,,,,80000863,CDM,250,RC,115703301,NDC,both,100,EA,0.34,0.14,39.4668,,0.14,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.12,34,,0.12,percent of total billed charges,"Drugs, Inpatient Only",0.12,34,,0.12,percent of total billed charges,"Drugs, Inpatient Only",0.12,34,,0.12,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.24,70,,0.24,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.11,,,0.11,Other,Drug Cost,0.11,,,0.11,Other,Drug Cost,0.11,,,0.11,Other,Drug Cost,0.11,,,0.11,Other,Drug Cost,0.11,,,0.11,Other,Drug Cost,0.11,,,0.11,Other,Drug Cost,0.26,,,0.26,Other,225% of Medicaid,0.16,,,0.16,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.25,,,0.25,Other,215% Medicaid APG methodology,0.25,,,0.25,Other,215% Medicaid APG methodology,0.14,,,0.14,Other,125% Medicaid APG methodology,0.01,0.26,
FLUMAZENIL 0.1MG/ML 10ML INJ,,,,80000864,CDM,250,RC,143978310,NDC,both,10,ML,15.81,6.24,39.4668,,6.24,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,5.38,34,,5.38,percent of total billed charges,"Drugs, Inpatient Only",5.38,34,,5.38,percent of total billed charges,"Drugs, Inpatient Only",5.38,34,,5.38,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,11.07,70,,11.07,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,5.27,,,5.27,Other,Drug Cost,5.27,,,5.27,Other,Drug Cost,5.27,,,5.27,Other,Drug Cost,5.27,,,5.27,Other,Drug Cost,5.27,,,5.27,Other,Drug Cost,5.27,,,5.27,Other,Drug Cost,11.86,,,11.86,Other,225% of Medicaid,7.38,,,7.38,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,11.33,,,11.33,Other,215% Medicaid APG methodology,11.33,,,11.33,Other,215% Medicaid APG methodology,6.59,,,6.59,Other,125% Medicaid APG methodology,0.01,11.86,
FLUMAZENIL 0.1MG/ML 5ML INJ,,,,80000865,CDM,250,RC,143978410,NDC,both,10,ML,7.63,3.01,39.4668,,3.01,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2.59,34,,2.59,percent of total billed charges,"Drugs, Inpatient Only",2.59,34,,2.59,percent of total billed charges,"Drugs, Inpatient Only",2.59,34,,2.59,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,5.34,70,,5.34,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2.54,,,2.54,Other,Drug Cost,2.54,,,2.54,Other,Drug Cost,2.54,,,2.54,Other,Drug Cost,2.54,,,2.54,Other,Drug Cost,2.54,,,2.54,Other,Drug Cost,2.54,,,2.54,Other,Drug Cost,5.72,,,5.72,Other,225% of Medicaid,3.56,,,3.56,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,5.47,,,5.47,Other,215% Medicaid APG methodology,5.47,,,5.47,Other,215% Medicaid APG methodology,3.18,,,3.18,Other,125% Medicaid APG methodology,0.01,5.72,
FLUOCINONIDE 0.05% CRM 15 GM,,,,80000868,CDM,250,RC,93026215,NDC,both,1,GM,12,4.74,39.4668,,4.74,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,4.08,34,,4.08,percent of total billed charges,"Drugs, Inpatient Only",4.08,34,,4.08,percent of total billed charges,"Drugs, Inpatient Only",4.08,34,,4.08,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,8.4,70,,8.4,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,4,,,4,Other,Drug Cost,4,,,4,Other,Drug Cost,4,,,4,Other,Drug Cost,4,,,4,Other,Drug Cost,4,,,4,Other,Drug Cost,4,,,4,Other,Drug Cost,9,,,9,Other,225% of Medicaid,5.6,,,5.6,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,8.6,,,8.6,Other,215% Medicaid APG methodology,8.6,,,8.6,Other,215% Medicaid APG methodology,5,,,5,Other,125% Medicaid APG methodology,0.01,9,
FLUOCINONIDE 0.05% OINT 60 GM,,,,80000871,CDM,250,RC,51672126403,NDC,both,1,GM,19.35,7.64,39.4668,,7.64,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,6.58,34,,6.58,percent of total billed charges,"Drugs, Inpatient Only",6.58,34,,6.58,percent of total billed charges,"Drugs, Inpatient Only",6.58,34,,6.58,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,13.55,70,,13.55,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,6.45,,,6.45,Other,Drug Cost,6.45,,,6.45,Other,Drug Cost,6.45,,,6.45,Other,Drug Cost,6.45,,,6.45,Other,Drug Cost,6.45,,,6.45,Other,Drug Cost,6.45,,,6.45,Other,Drug Cost,14.51,,,14.51,Other,225% of Medicaid,9.03,,,9.03,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,13.87,,,13.87,Other,215% Medicaid APG methodology,13.87,,,13.87,Other,215% Medicaid APG methodology,8.06,,,8.06,Other,125% Medicaid APG methodology,0.01,14.51,
FLUOCINONIDE 0.05% SOLN 60 ML,,,,80000872,CDM,250,RC,51672127302,NDC,both,1,ML,3.42,1.35,39.4668,,1.35,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1.16,34,,1.16,percent of total billed charges,"Drugs, Inpatient Only",1.16,34,,1.16,percent of total billed charges,"Drugs, Inpatient Only",1.16,34,,1.16,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2.39,70,,2.39,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1.14,,,1.14,Other,Drug Cost,1.14,,,1.14,Other,Drug Cost,1.14,,,1.14,Other,Drug Cost,1.14,,,1.14,Other,Drug Cost,1.14,,,1.14,Other,Drug Cost,1.14,,,1.14,Other,Drug Cost,2.57,,,2.57,Other,225% of Medicaid,1.6,,,1.6,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,2.45,,,2.45,Other,215% Medicaid APG methodology,2.45,,,2.45,Other,215% Medicaid APG methodology,1.43,,,1.43,Other,125% Medicaid APG methodology,0.01,2.57,
FLUORESCEIN 10% SOLN 5 ML,,,,80000873,CDM,250,RC,17478025310,NDC,both,12,ML,122.3,48.27,39.4668,,48.27,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,41.58,34,,41.58,percent of total billed charges,"Drugs, Inpatient Only",41.58,34,,41.58,percent of total billed charges,"Drugs, Inpatient Only",41.58,34,,41.58,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,85.61,70,,85.61,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,40.77,,,40.77,Other,Drug Cost,40.77,,,40.77,Other,Drug Cost,40.77,,,40.77,Other,Drug Cost,40.77,,,40.77,Other,Drug Cost,40.77,,,40.77,Other,Drug Cost,40.77,,,40.77,Other,Drug Cost,91.72,,,91.72,Other,225% of Medicaid,57.07,,,57.07,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,87.65,,,87.65,Other,215% Medicaid APG methodology,87.65,,,87.65,Other,215% Medicaid APG methodology,50.96,,,50.96,Other,125% Medicaid APG methodology,0.01,91.72,
FLUORESCEIN 1MG STRIP,,,,80000874,CDM,250,RC,17238090030,NDC,both,300,EA,0.32,0.13,39.4668,,0.13,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.11,34,,0.11,percent of total billed charges,"Drugs, Inpatient Only",0.11,34,,0.11,percent of total billed charges,"Drugs, Inpatient Only",0.11,34,,0.11,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.23,70,,0.23,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.11,,,0.11,Other,Drug Cost,0.11,,,0.11,Other,Drug Cost,0.11,,,0.11,Other,Drug Cost,0.11,,,0.11,Other,Drug Cost,0.11,,,0.11,Other,Drug Cost,0.11,,,0.11,Other,Drug Cost,0.24,,,0.24,Other,225% of Medicaid,0.15,,,0.15,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.23,,,0.23,Other,215% Medicaid APG methodology,0.23,,,0.23,Other,215% Medicaid APG methodology,0.13,,,0.13,Other,125% Medicaid APG methodology,0.01,0.24,
FLUOROMETHOLONE 0.1% OPHTH DROP 5ML,,,,80000875,CDM,250,RC,60758088005,NDC,both,1,ML,0.15,0.06,39.4668,,0.06,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.05,34,,0.05,percent of total billed charges,"Drugs, Inpatient Only",0.05,34,,0.05,percent of total billed charges,"Drugs, Inpatient Only",0.05,34,,0.05,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.11,70,,0.11,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.11,,,0.11,Other,225% of Medicaid,0.07,,,0.07,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.11,,,0.11,Other,215% Medicaid APG methodology,0.11,,,0.11,Other,215% Medicaid APG methodology,0.06,,,0.06,Other,125% Medicaid APG methodology,0.01,0.11,
FLUOXETINE 10MG CAPS,,,,80000879,CDM,250,RC,50111064701,NDC,both,100,EA,0.04,0.02,39.4668,,0.02,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.03,70,,0.03,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.03,,,0.03,Other,225% of Medicaid,0.02,,,0.02,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.03,,,0.03,Other,215% Medicaid APG methodology,0.03,,,0.03,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,125% Medicaid APG methodology,0.01,0.03,
FLUOXETINE 20MG,,,,80000880,CDM,250,RC,50111064801,NDC,both,100,EA,0.04,0.02,39.4668,,0.02,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.03,70,,0.03,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.03,,,0.03,Other,225% of Medicaid,0.02,,,0.02,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.03,,,0.03,Other,215% Medicaid APG methodology,0.03,,,0.03,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,125% Medicaid APG methodology,0.01,0.03,
FLUOXETINE 20MG/5ML SOLN,,,,80000881,CDM,250,RC,121072104,NDC,both,1,ML,8.91,3.52,39.4668,,3.52,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,3.03,34,,3.03,percent of total billed charges,"Drugs, Inpatient Only",3.03,34,,3.03,percent of total billed charges,"Drugs, Inpatient Only",3.03,34,,3.03,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,6.24,70,,6.24,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2.97,,,2.97,Other,Drug Cost,2.97,,,2.97,Other,Drug Cost,2.97,,,2.97,Other,Drug Cost,2.97,,,2.97,Other,Drug Cost,2.97,,,2.97,Other,Drug Cost,2.97,,,2.97,Other,Drug Cost,6.68,,,6.68,Other,225% of Medicaid,4.16,,,4.16,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,6.39,,,6.39,Other,215% Medicaid APG methodology,6.39,,,6.39,Other,215% Medicaid APG methodology,3.71,,,3.71,Other,125% Medicaid APG methodology,0.01,6.68,
FLUPHENAZINE 2.5 MG/ML,,,,80000884,CDM,250,RC,63323028110,NDC,both,1,ML,280.77,110.81,39.4668,,110.81,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,95.46,34,,95.46,percent of total billed charges,"Drugs, Inpatient Only",95.46,34,,95.46,percent of total billed charges,"Drugs, Inpatient Only",95.46,34,,95.46,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,196.54,70,,196.54,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,93.59,,,93.59,Other,Drug Cost,93.59,,,93.59,Other,Drug Cost,93.59,,,93.59,Other,Drug Cost,93.59,,,93.59,Other,Drug Cost,93.59,,,93.59,Other,Drug Cost,93.59,,,93.59,Other,Drug Cost,210.58,,,210.58,Other,225% of Medicaid,131.03,,,131.03,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,201.22,,,201.22,Other,215% Medicaid APG methodology,201.22,,,201.22,Other,215% Medicaid APG methodology,116.99,,,116.99,Other,125% Medicaid APG methodology,0.01,210.58,
FLUPHENAZINE 5MG TAB,,,,80000885,CDM,250,RC,527179001,NDC,both,100,EA,0.11,0.04,39.4668,,0.04,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.04,34,,0.04,percent of total billed charges,"Drugs, Inpatient Only",0.04,34,,0.04,percent of total billed charges,"Drugs, Inpatient Only",0.04,34,,0.04,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.08,70,,0.08,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.08,,,0.08,Other,225% of Medicaid,0.05,,,0.05,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.08,,,0.08,Other,215% Medicaid APG methodology,0.08,,,0.08,Other,215% Medicaid APG methodology,0.05,,,0.05,Other,125% Medicaid APG methodology,0.01,0.08,
FLUPHENAZINE HCL 2.5 MG/5 ML ELIXIR,,,,80000887,CDM,250,RC,121065402,NDC,both,1,ML,9.09,3.59,39.4668,,3.59,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,3.09,34,,3.09,percent of total billed charges,"Drugs, Inpatient Only",3.09,34,,3.09,percent of total billed charges,"Drugs, Inpatient Only",3.09,34,,3.09,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,6.36,70,,6.36,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,3.03,,,3.03,Other,Drug Cost,3.03,,,3.03,Other,Drug Cost,3.03,,,3.03,Other,Drug Cost,3.03,,,3.03,Other,Drug Cost,3.03,,,3.03,Other,Drug Cost,3.03,,,3.03,Other,Drug Cost,6.82,,,6.82,Other,225% of Medicaid,4.24,,,4.24,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,6.51,,,6.51,Other,215% Medicaid APG methodology,6.51,,,6.51,Other,215% Medicaid APG methodology,3.79,,,3.79,Other,125% Medicaid APG methodology,0.01,6.82,
FLUPHENAZINE HCL 5MG/ML ORAL CONC,,,,80000888,CDM,250,RC,121065304,NDC,both,1,ML,266.91,105.34,39.4668,,105.34,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,90.75,34,,90.75,percent of total billed charges,"Drugs, Inpatient Only",90.75,34,,90.75,percent of total billed charges,"Drugs, Inpatient Only",90.75,34,,90.75,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,186.84,70,,186.84,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,88.97,,,88.97,Other,Drug Cost,88.97,,,88.97,Other,Drug Cost,88.97,,,88.97,Other,Drug Cost,88.97,,,88.97,Other,Drug Cost,88.97,,,88.97,Other,Drug Cost,88.97,,,88.97,Other,Drug Cost,200.18,,,200.18,Other,225% of Medicaid,124.56,,,124.56,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,191.29,,,191.29,Other,215% Medicaid APG methodology,191.29,,,191.29,Other,215% Medicaid APG methodology,111.21,,,111.21,Other,125% Medicaid APG methodology,0.01,200.18,
FLUTICASONE 50MCG/16GM NSL INHAL,,,,80000893,CDM,250,RC,54327099,NDC,both,1,GM,7.35,2.9,39.4668,,2.9,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2.5,34,,2.5,percent of total billed charges,"Drugs, Inpatient Only",2.5,34,,2.5,percent of total billed charges,"Drugs, Inpatient Only",2.5,34,,2.5,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,5.15,70,,5.15,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2.45,,,2.45,Other,Drug Cost,2.45,,,2.45,Other,Drug Cost,2.45,,,2.45,Other,Drug Cost,2.45,,,2.45,Other,Drug Cost,2.45,,,2.45,Other,Drug Cost,2.45,,,2.45,Other,Drug Cost,5.51,,,5.51,Other,225% of Medicaid,3.43,,,3.43,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,5.27,,,5.27,Other,215% Medicaid APG methodology,5.27,,,5.27,Other,215% Medicaid APG methodology,3.06,,,3.06,Other,125% Medicaid APG methodology,0.01,5.51,
FLUTICASONE PRO/SALMETEROL DISKUS 250-50,,,,80000895,CDM,250,RC,173069604,NDC,both,14,EA,0.91,0.36,39.4668,,0.36,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.31,34,,0.31,percent of total billed charges,"Drugs, Inpatient Only",0.31,34,,0.31,percent of total billed charges,"Drugs, Inpatient Only",0.31,34,,0.31,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.64,70,,0.64,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.3,,,0.3,Other,Drug Cost,0.3,,,0.3,Other,Drug Cost,0.3,,,0.3,Other,Drug Cost,0.3,,,0.3,Other,Drug Cost,0.3,,,0.3,Other,Drug Cost,0.3,,,0.3,Other,Drug Cost,0.68,,,0.68,Other,225% of Medicaid,0.43,,,0.43,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.65,,,0.65,Other,215% Medicaid APG methodology,0.65,,,0.65,Other,215% Medicaid APG methodology,0.38,,,0.38,Other,125% Medicaid APG methodology,0.01,0.68,
FLUVOXAMINE 50 MG TAB,,,,80000902,CDM,250,RC,62559015901,NDC,both,100,EA,0.21,0.08,39.4668,,0.08,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.07,34,,0.07,percent of total billed charges,"Drugs, Inpatient Only",0.07,34,,0.07,percent of total billed charges,"Drugs, Inpatient Only",0.07,34,,0.07,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.15,70,,0.15,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.07,,,0.07,Other,Drug Cost,0.07,,,0.07,Other,Drug Cost,0.07,,,0.07,Other,Drug Cost,0.07,,,0.07,Other,Drug Cost,0.07,,,0.07,Other,Drug Cost,0.07,,,0.07,Other,Drug Cost,0.16,,,0.16,Other,225% of Medicaid,0.1,,,0.1,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.15,,,0.15,Other,215% Medicaid APG methodology,0.15,,,0.15,Other,215% Medicaid APG methodology,0.09,,,0.09,Other,125% Medicaid APG methodology,0.01,0.16,
FOLIC ACID 1 MG TAB,,,,80000904,CDM,250,RC,69315012710,NDC,both,1000,EA,0.03,0.01,39.4668,,0.01,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.02,70,,0.02,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.02,,,0.02,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,0.02,
FOLIC ACID 5 MG/ML 10ML INJ,,,,80000906,CDM,250,RC,63323018410,NDC,both,1,ML,44.49,17.56,39.4668,,17.56,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,15.13,34,,15.13,percent of total billed charges,"Drugs, Inpatient Only",15.13,34,,15.13,percent of total billed charges,"Drugs, Inpatient Only",15.13,34,,15.13,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,31.14,70,,31.14,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,14.83,,,14.83,Other,Drug Cost,14.83,,,14.83,Other,Drug Cost,14.83,,,14.83,Other,Drug Cost,14.83,,,14.83,Other,Drug Cost,14.83,,,14.83,Other,Drug Cost,14.83,,,14.83,Other,Drug Cost,33.37,,,33.37,Other,225% of Medicaid,20.76,,,20.76,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,31.88,,,31.88,Other,215% Medicaid APG methodology,31.88,,,31.88,Other,215% Medicaid APG methodology,18.54,,,18.54,Other,125% Medicaid APG methodology,0.01,33.37,
FUROSEMIDE 20 MG TAB,,,,80000920,CDM,250,RC,54429725,NDC,both,100,EA,0.03,0.01,39.4668,,0.01,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.02,70,,0.02,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.02,,,0.02,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,0.02,
FUROSEMIDE 40 MG TAB,,,,80000921,CDM,250,RC,54429931,NDC,both,1000,EA,0.03,0.01,39.4668,,0.01,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.02,70,,0.02,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.02,,,0.02,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,0.02,
FUROSEMIDE 40MG/5ML SOLN UD,,,,80000922,CDM,250,RC,68094086762,NDC,both,30,ML,4.21,1.66,39.4668,,1.66,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1.43,34,,1.43,percent of total billed charges,"Drugs, Inpatient Only",1.43,34,,1.43,percent of total billed charges,"Drugs, Inpatient Only",1.43,34,,1.43,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2.95,70,,2.95,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1.4,,,1.4,Other,Drug Cost,1.4,,,1.4,Other,Drug Cost,1.4,,,1.4,Other,Drug Cost,1.4,,,1.4,Other,Drug Cost,1.4,,,1.4,Other,Drug Cost,1.4,,,1.4,Other,Drug Cost,3.16,,,3.16,Other,225% of Medicaid,1.97,,,1.97,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,3.02,,,3.02,Other,215% Medicaid APG methodology,3.02,,,3.02,Other,215% Medicaid APG methodology,1.76,,,1.76,Other,125% Medicaid APG methodology,0.01,3.16,
GABAPENTIN 100 MG CAPS,,,,80000923,CDM,250,RC,67877022201,NDC,both,100,EA,0.04,0.02,39.4668,,0.02,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.03,70,,0.03,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.03,,,0.03,Other,225% of Medicaid,0.02,,,0.02,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.03,,,0.03,Other,215% Medicaid APG methodology,0.03,,,0.03,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,125% Medicaid APG methodology,0.01,0.03,
GABAPENTIN 300 MG CAPS,,,,80000924,CDM,250,RC,67877022305,NDC,both,500,EA,0.06,0.03,39.4668,,0.03,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.02,34,,0.02,percent of total billed charges,"Drugs, Inpatient Only",0.02,34,,0.02,percent of total billed charges,"Drugs, Inpatient Only",0.02,34,,0.02,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.05,70,,0.05,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.05,,,0.05,Other,225% of Medicaid,0.03,,,0.03,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.05,,,0.05,Other,215% Medicaid APG methodology,0.05,,,0.05,Other,215% Medicaid APG methodology,0.03,,,0.03,Other,125% Medicaid APG methodology,0.01,0.05,
GABAPENTIN 400 MG CAPS,,,,80000925,CDM,250,RC,65162010310,NDC,both,100,EA,0.06,0.02,39.4668,,0.02,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.02,34,,0.02,percent of total billed charges,"Drugs, Inpatient Only",0.02,34,,0.02,percent of total billed charges,"Drugs, Inpatient Only",0.02,34,,0.02,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.04,70,,0.04,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.04,,,0.04,Other,225% of Medicaid,0.03,,,0.03,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.04,,,0.04,Other,215% Medicaid APG methodology,0.04,,,0.04,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,125% Medicaid APG methodology,0.01,0.04,
GELATIN SPONGE ABSORBABLE 12-7(GELFOAM),,,,80000932,CDM,250,RC,9031508,NDC,both,12,EA,16.29,6.43,39.4668,,6.43,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,5.54,34,,5.54,percent of total billed charges,"Drugs, Inpatient Only",5.54,34,,5.54,percent of total billed charges,"Drugs, Inpatient Only",5.54,34,,5.54,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,11.4,70,,11.4,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,5.43,,,5.43,Other,Drug Cost,5.43,,,5.43,Other,Drug Cost,5.43,,,5.43,Other,Drug Cost,5.43,,,5.43,Other,Drug Cost,5.43,,,5.43,Other,Drug Cost,5.43,,,5.43,Other,Drug Cost,12.22,,,12.22,Other,225% of Medicaid,7.6,,,7.6,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,11.67,,,11.67,Other,215% Medicaid APG methodology,11.67,,,11.67,Other,215% Medicaid APG methodology,6.79,,,6.79,Other,125% Medicaid APG methodology,0.01,12.22,
GELATIN SPONGE ABSORBABLE SIZE100,,,,80000933,CDM,250,RC,9034201,NDC,both,6,EA,59.09,23.32,39.4668,,23.32,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,20.09,34,,20.09,percent of total billed charges,"Drugs, Inpatient Only",20.09,34,,20.09,percent of total billed charges,"Drugs, Inpatient Only",20.09,34,,20.09,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,41.37,70,,41.37,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,19.7,,,19.7,Other,Drug Cost,19.7,,,19.7,Other,Drug Cost,19.7,,,19.7,Other,Drug Cost,19.7,,,19.7,Other,Drug Cost,19.7,,,19.7,Other,Drug Cost,19.7,,,19.7,Other,Drug Cost,44.32,,,44.32,Other,225% of Medicaid,27.58,,,27.58,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,42.35,,,42.35,Other,215% Medicaid APG methodology,42.35,,,42.35,Other,215% Medicaid APG methodology,24.62,,,24.62,Other,125% Medicaid APG methodology,0.01,44.32,
GENTAMICIN 0.1% OINT 15 GM,,,,80000939,CDM,250,RC,45802004635,NDC,both,1,GM,7.68,3.03,39.4668,,3.03,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2.61,34,,2.61,percent of total billed charges,"Drugs, Inpatient Only",2.61,34,,2.61,percent of total billed charges,"Drugs, Inpatient Only",2.61,34,,2.61,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,5.38,70,,5.38,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2.56,,,2.56,Other,Drug Cost,2.56,,,2.56,Other,Drug Cost,2.56,,,2.56,Other,Drug Cost,2.56,,,2.56,Other,Drug Cost,2.56,,,2.56,Other,Drug Cost,2.56,,,2.56,Other,Drug Cost,5.76,,,5.76,Other,225% of Medicaid,3.58,,,3.58,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,5.5,,,5.5,Other,215% Medicaid APG methodology,5.5,,,5.5,Other,215% Medicaid APG methodology,3.2,,,3.2,Other,125% Medicaid APG methodology,0.01,5.76,
GENTAMICIN 0.3% OPTH SOLN 5ML,,,,80000941,CDM,250,RC,61314063305,NDC,both,1,ML,3.27,1.29,39.4668,,1.29,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1.11,34,,1.11,percent of total billed charges,"Drugs, Inpatient Only",1.11,34,,1.11,percent of total billed charges,"Drugs, Inpatient Only",1.11,34,,1.11,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2.29,70,,2.29,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1.09,,,1.09,Other,Drug Cost,1.09,,,1.09,Other,Drug Cost,1.09,,,1.09,Other,Drug Cost,1.09,,,1.09,Other,Drug Cost,1.09,,,1.09,Other,Drug Cost,1.09,,,1.09,Other,Drug Cost,2.45,,,2.45,Other,225% of Medicaid,1.53,,,1.53,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,2.34,,,2.34,Other,215% Medicaid APG methodology,2.34,,,2.34,Other,215% Medicaid APG methodology,1.36,,,1.36,Other,125% Medicaid APG methodology,0.01,2.45,
GENTIAN VIOLET,,,,80000944,CDM,250,RC,395100392,NDC,both,1,ML,18.06,7.13,39.4668,,7.13,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,6.14,34,,6.14,percent of total billed charges,"Drugs, Inpatient Only",6.14,34,,6.14,percent of total billed charges,"Drugs, Inpatient Only",6.14,34,,6.14,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,12.64,70,,12.64,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,6.02,,,6.02,Other,Drug Cost,6.02,,,6.02,Other,Drug Cost,6.02,,,6.02,Other,Drug Cost,6.02,,,6.02,Other,Drug Cost,6.02,,,6.02,Other,Drug Cost,6.02,,,6.02,Other,Drug Cost,13.55,,,13.55,Other,225% of Medicaid,8.43,,,8.43,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,12.94,,,12.94,Other,215% Medicaid APG methodology,12.94,,,12.94,Other,215% Medicaid APG methodology,7.53,,,7.53,Other,125% Medicaid APG methodology,0.01,13.55,
GLYCOPYRROLATE 0.2 MG/ML 1ML INJ,,,,80000960,CDM,250,RC,143968225,NDC,both,25,ML,1.45,0.57,39.4668,,0.57,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.49,34,,0.49,percent of total billed charges,"Drugs, Inpatient Only",0.49,34,,0.49,percent of total billed charges,"Drugs, Inpatient Only",0.49,34,,0.49,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1.01,70,,1.01,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.48,,,0.48,Other,Drug Cost,0.48,,,0.48,Other,Drug Cost,0.48,,,0.48,Other,Drug Cost,0.48,,,0.48,Other,Drug Cost,0.48,,,0.48,Other,Drug Cost,0.48,,,0.48,Other,Drug Cost,1.09,,,1.09,Other,225% of Medicaid,0.68,,,0.68,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,1.04,,,1.04,Other,215% Medicaid APG methodology,1.04,,,1.04,Other,215% Medicaid APG methodology,0.6,,,0.6,Other,125% Medicaid APG methodology,0.01,1.09,
GOLYTELY 4000ML,,,,80000962,CDM,250,RC,52268010001,NDC,both,1,ML,20.76,8.19,39.4668,,8.19,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,7.06,34,,7.06,percent of total billed charges,"Drugs, Inpatient Only",7.06,34,,7.06,percent of total billed charges,"Drugs, Inpatient Only",7.06,34,,7.06,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,14.53,70,,14.53,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,6.92,,,6.92,Other,Drug Cost,6.92,,,6.92,Other,Drug Cost,6.92,,,6.92,Other,Drug Cost,6.92,,,6.92,Other,Drug Cost,6.92,,,6.92,Other,Drug Cost,6.92,,,6.92,Other,Drug Cost,15.57,,,15.57,Other,225% of Medicaid,9.69,,,9.69,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,14.88,,,14.88,Other,215% Medicaid APG methodology,14.88,,,14.88,Other,215% Medicaid APG methodology,8.65,,,8.65,Other,125% Medicaid APG methodology,0.01,15.57,
GUAIAFENESIN 600MG ER TAB,,,,80000968,CDM,250,RC,63824000850,NDC,both,500,EA,0.76,0.3,39.4668,,0.3,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.26,34,,0.26,percent of total billed charges,"Drugs, Inpatient Only",0.26,34,,0.26,percent of total billed charges,"Drugs, Inpatient Only",0.26,34,,0.26,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.53,70,,0.53,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.25,,,0.25,Other,Drug Cost,0.25,,,0.25,Other,Drug Cost,0.25,,,0.25,Other,Drug Cost,0.25,,,0.25,Other,Drug Cost,0.25,,,0.25,Other,Drug Cost,0.25,,,0.25,Other,Drug Cost,0.57,,,0.57,Other,225% of Medicaid,0.35,,,0.35,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.54,,,0.54,Other,215% Medicaid APG methodology,0.54,,,0.54,Other,215% Medicaid APG methodology,0.31,,,0.31,Other,125% Medicaid APG methodology,0.01,0.57,
GUANFACINE 1MG TAB,,,,80000971,CDM,250,RC,53746071101,NDC,both,100,EA,0.23,0.09,39.4668,,0.09,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.08,34,,0.08,percent of total billed charges,"Drugs, Inpatient Only",0.08,34,,0.08,percent of total billed charges,"Drugs, Inpatient Only",0.08,34,,0.08,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.16,70,,0.16,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.08,,,0.08,Other,Drug Cost,0.08,,,0.08,Other,Drug Cost,0.08,,,0.08,Other,Drug Cost,0.08,,,0.08,Other,Drug Cost,0.08,,,0.08,Other,Drug Cost,0.08,,,0.08,Other,Drug Cost,0.17,,,0.17,Other,225% of Medicaid,0.11,,,0.11,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.16,,,0.16,Other,215% Medicaid APG methodology,0.16,,,0.16,Other,215% Medicaid APG methodology,0.1,,,0.1,Other,125% Medicaid APG methodology,0.01,0.17,
HAEMOPH B POLYSAC CONJ-TET TOX (ACTHIB),,,,80000972,CDM,250,RC,49281054503,NDC,both,5,EA,35.32,13.94,39.4668,,13.94,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,12.01,34,,12.01,percent of total billed charges,"Drugs, Inpatient Only",12.01,34,,12.01,percent of total billed charges,"Drugs, Inpatient Only",12.01,34,,12.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,24.73,70,,24.73,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,11.77,,,11.77,Other,Drug Cost,11.77,,,11.77,Other,Drug Cost,11.77,,,11.77,Other,Drug Cost,11.77,,,11.77,Other,Drug Cost,11.77,,,11.77,Other,Drug Cost,11.77,,,11.77,Other,Drug Cost,26.49,,,26.49,Other,225% of Medicaid,16.48,,,16.48,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,25.31,,,25.31,Other,215% Medicaid APG methodology,25.31,,,25.31,Other,215% Medicaid APG methodology,14.72,,,14.72,Other,125% Medicaid APG methodology,0.01,26.49,
HALOPERIDOL 0.5 MG TAB,,,,80000975,CDM,250,RC,378035101,NDC,both,100,EA,0.14,0.06,39.4668,,0.06,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.05,34,,0.05,percent of total billed charges,"Drugs, Inpatient Only",0.05,34,,0.05,percent of total billed charges,"Drugs, Inpatient Only",0.05,34,,0.05,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.1,70,,0.1,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.11,,,0.11,Other,225% of Medicaid,0.07,,,0.07,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.1,,,0.1,Other,215% Medicaid APG methodology,0.1,,,0.1,Other,215% Medicaid APG methodology,0.06,,,0.06,Other,125% Medicaid APG methodology,0.01,0.11,
HALOPERIDOL 1 MG TAB,,,,80000976,CDM,250,RC,378025710,NDC,both,1000,EA,0.04,0.02,39.4668,,0.02,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.02,34,,0.02,percent of total billed charges,"Drugs, Inpatient Only",0.02,34,,0.02,percent of total billed charges,"Drugs, Inpatient Only",0.02,34,,0.02,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.03,70,,0.03,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.03,,,0.03,Other,225% of Medicaid,0.02,,,0.02,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.03,,,0.03,Other,215% Medicaid APG methodology,0.03,,,0.03,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,125% Medicaid APG methodology,0.01,0.03,
HALOPERIDOL 2 MG TAB,,,,80000977,CDM,250,RC,51079073520,NDC,both,10,EA,11.25,4.44,39.4668,,4.44,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,3.83,34,,3.83,percent of total billed charges,"Drugs, Inpatient Only",3.83,34,,3.83,percent of total billed charges,"Drugs, Inpatient Only",3.83,34,,3.83,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,7.88,70,,7.88,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,3.75,,,3.75,Other,Drug Cost,3.75,,,3.75,Other,Drug Cost,3.75,,,3.75,Other,Drug Cost,3.75,,,3.75,Other,Drug Cost,3.75,,,3.75,Other,Drug Cost,3.75,,,3.75,Other,Drug Cost,8.44,,,8.44,Other,225% of Medicaid,5.25,,,5.25,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,8.06,,,8.06,Other,215% Medicaid APG methodology,8.06,,,8.06,Other,215% Medicaid APG methodology,4.69,,,4.69,Other,125% Medicaid APG methodology,0.01,8.44,
HALOPERIDOL 5 MG TAB,,,,80000978,CDM,250,RC,378032701,NDC,both,100,EA,0.03,0.01,39.4668,,0.01,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.02,70,,0.02,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.02,,,0.02,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,0.02,
HALOPERIDOL LACTATE 2MG/ML 5ML UD,,,,80000982,CDM,250,RC,121058105,NDC,both,100,ML,0.29,0.12,39.4668,,0.12,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.1,34,,0.1,percent of total billed charges,"Drugs, Inpatient Only",0.1,34,,0.1,percent of total billed charges,"Drugs, Inpatient Only",0.1,34,,0.1,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.21,70,,0.21,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.1,,,0.1,Other,Drug Cost,0.1,,,0.1,Other,Drug Cost,0.1,,,0.1,Other,Drug Cost,0.1,,,0.1,Other,Drug Cost,0.1,,,0.1,Other,Drug Cost,0.1,,,0.1,Other,Drug Cost,0.22,,,0.22,Other,225% of Medicaid,0.14,,,0.14,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.21,,,0.21,Other,215% Medicaid APG methodology,0.21,,,0.21,Other,215% Medicaid APG methodology,0.12,,,0.12,Other,125% Medicaid APG methodology,0.01,0.22,
HEPARIN SODIUM 10000 UNIT/ML INJ,,,,80000993,CDM,250,RC,25021040301,NDC,both,25,ML,3.05,1.2,39.4668,,1.2,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1.04,34,,1.04,percent of total billed charges,"Drugs, Inpatient Only",1.04,34,,1.04,percent of total billed charges,"Drugs, Inpatient Only",1.04,34,,1.04,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2.13,70,,2.13,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1.02,,,1.02,Other,Drug Cost,1.02,,,1.02,Other,Drug Cost,1.02,,,1.02,Other,Drug Cost,1.02,,,1.02,Other,Drug Cost,1.02,,,1.02,Other,Drug Cost,1.02,,,1.02,Other,Drug Cost,2.28,,,2.28,Other,225% of Medicaid,1.42,,,1.42,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,2.18,,,2.18,Other,215% Medicaid APG methodology,2.18,,,2.18,Other,215% Medicaid APG methodology,1.27,,,1.27,Other,125% Medicaid APG methodology,0.01,2.28,
HEPARIN SODIUM 2000 UNIT/2ML INJ,,,,80000995,CDM,250,RC,63323027602,NDC,both,25,ML,14.35,5.66,39.4668,,5.66,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,4.88,34,,4.88,percent of total billed charges,"Drugs, Inpatient Only",4.88,34,,4.88,percent of total billed charges,"Drugs, Inpatient Only",4.88,34,,4.88,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,10.04,70,,10.04,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,4.78,,,4.78,Other,Drug Cost,4.78,,,4.78,Other,Drug Cost,4.78,,,4.78,Other,Drug Cost,4.78,,,4.78,Other,Drug Cost,4.78,,,4.78,Other,Drug Cost,4.78,,,4.78,Other,Drug Cost,10.76,,,10.76,Other,225% of Medicaid,6.7,,,6.7,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,10.28,,,10.28,Other,215% Medicaid APG methodology,10.28,,,10.28,Other,215% Medicaid APG methodology,5.98,,,5.98,Other,125% Medicaid APG methodology,0.01,10.76,
HYDRALAZINE 10 MG TAB,,,,80001006,CDM,250,RC,31722051901,NDC,both,100,EA,0.03,0.01,39.4668,,0.01,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.02,70,,0.02,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.03,,,0.03,Other,225% of Medicaid,0.02,,,0.02,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,0.03,
HYDRALAZINE 25MG TAB,,,,80001007,CDM,250,RC,50111032701,NDC,both,100,EA,0.03,0.01,39.4668,,0.01,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.02,70,,0.02,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.02,,,0.02,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,0.02,
HYDROCHLOROTHIAZIDE 12.5 MG TAB,,,,80001009,CDM,250,RC,69315015501,NDC,both,100,EA,0.05,0.02,39.4668,,0.02,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.02,34,,0.02,percent of total billed charges,"Drugs, Inpatient Only",0.02,34,,0.02,percent of total billed charges,"Drugs, Inpatient Only",0.02,34,,0.02,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.04,70,,0.04,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.04,,,0.04,Other,225% of Medicaid,0.03,,,0.03,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.04,,,0.04,Other,215% Medicaid APG methodology,0.04,,,0.04,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,125% Medicaid APG methodology,0.01,0.04,
HYDROCHLOROTHIAZIDE 25 MG TAB,,,,80001010,CDM,250,RC,172208380,NDC,both,1000,EA,0.03,0.01,39.4668,,0.01,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.02,70,,0.02,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.02,,,0.02,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,0.02,
HYDROCOD/APAP 10-325MG TAB,,,,80001011,CDM,250,RC,53746011001,NDC,both,100,EA,0.17,0.07,39.4668,,0.07,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.06,34,,0.06,percent of total billed charges,"Drugs, Inpatient Only",0.06,34,,0.06,percent of total billed charges,"Drugs, Inpatient Only",0.06,34,,0.06,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.12,70,,0.12,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.06,,,0.06,Other,Drug Cost,0.06,,,0.06,Other,Drug Cost,0.06,,,0.06,Other,Drug Cost,0.06,,,0.06,Other,Drug Cost,0.06,,,0.06,Other,Drug Cost,0.06,,,0.06,Other,Drug Cost,0.13,,,0.13,Other,225% of Medicaid,0.08,,,0.08,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.12,,,0.12,Other,215% Medicaid APG methodology,0.12,,,0.12,Other,215% Medicaid APG methodology,0.07,,,0.07,Other,125% Medicaid APG methodology,0.01,0.13,
HYDROCOD/APAP 5-325MG TAB,,,,80001012,CDM,250,RC,53746010901,NDC,both,100,EA,0.08,0.03,39.4668,,0.03,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.03,34,,0.03,percent of total billed charges,"Drugs, Inpatient Only",0.03,34,,0.03,percent of total billed charges,"Drugs, Inpatient Only",0.03,34,,0.03,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.06,70,,0.06,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.06,,,0.06,Other,225% of Medicaid,0.04,,,0.04,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.06,,,0.06,Other,215% Medicaid APG methodology,0.06,,,0.06,Other,215% Medicaid APG methodology,0.04,,,0.04,Other,125% Medicaid APG methodology,0.01,0.06,
HYDROCOD/APAP 7.5-325MG TAB,,,,80001013,CDM,250,RC,406012401,NDC,both,100,EA,0.14,0.06,39.4668,,0.06,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.05,34,,0.05,percent of total billed charges,"Drugs, Inpatient Only",0.05,34,,0.05,percent of total billed charges,"Drugs, Inpatient Only",0.05,34,,0.05,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.1,70,,0.1,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.11,,,0.11,Other,225% of Medicaid,0.07,,,0.07,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.1,,,0.1,Other,215% Medicaid APG methodology,0.1,,,0.1,Other,215% Medicaid APG methodology,0.06,,,0.06,Other,125% Medicaid APG methodology,0.01,0.11,
HYDROCORTISONE (ANUCORT-HC) 25MG,,,,80001021,CDM,250,RC,713050312,NDC,both,12,EA,1.91,0.75,39.4668,,0.75,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.65,34,,0.65,percent of total billed charges,"Drugs, Inpatient Only",0.65,34,,0.65,percent of total billed charges,"Drugs, Inpatient Only",0.65,34,,0.65,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1.34,70,,1.34,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.64,,,0.64,Other,Drug Cost,0.64,,,0.64,Other,Drug Cost,0.64,,,0.64,Other,Drug Cost,0.64,,,0.64,Other,Drug Cost,0.64,,,0.64,Other,Drug Cost,0.64,,,0.64,Other,Drug Cost,1.43,,,1.43,Other,225% of Medicaid,0.89,,,0.89,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,1.37,,,1.37,Other,215% Medicaid APG methodology,1.37,,,1.37,Other,215% Medicaid APG methodology,0.8,,,0.8,Other,125% Medicaid APG methodology,0.01,1.43,
HYDROCORTISONE (CORTEF) 10MG,,,,80001022,CDM,250,RC,59762007401,NDC,both,100,EA,0.22,0.09,39.4668,,0.09,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.07,34,,0.07,percent of total billed charges,"Drugs, Inpatient Only",0.07,34,,0.07,percent of total billed charges,"Drugs, Inpatient Only",0.07,34,,0.07,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.15,70,,0.15,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.07,,,0.07,Other,Drug Cost,0.07,,,0.07,Other,Drug Cost,0.07,,,0.07,Other,Drug Cost,0.07,,,0.07,Other,Drug Cost,0.07,,,0.07,Other,Drug Cost,0.07,,,0.07,Other,Drug Cost,0.16,,,0.16,Other,225% of Medicaid,0.1,,,0.1,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.16,,,0.16,Other,215% Medicaid APG methodology,0.16,,,0.16,Other,215% Medicaid APG methodology,0.09,,,0.09,Other,125% Medicaid APG methodology,0.01,0.16,
HYDROCORTISONE (CORTEF) 5MG,,,,80001023,CDM,250,RC,9001201,NDC,both,50,EA,0.03,0.01,39.4668,,0.01,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.02,70,,0.02,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.02,,,0.02,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,0.02,
HYDROCORTISONE 1% CRM 28 GM,,,,80001026,CDM,250,RC,472032126,NDC,both,1,GM,1.77,0.7,39.4668,,0.7,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.6,34,,0.6,percent of total billed charges,"Drugs, Inpatient Only",0.6,34,,0.6,percent of total billed charges,"Drugs, Inpatient Only",0.6,34,,0.6,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1.24,70,,1.24,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.59,,,0.59,Other,Drug Cost,0.59,,,0.59,Other,Drug Cost,0.59,,,0.59,Other,Drug Cost,0.59,,,0.59,Other,Drug Cost,0.59,,,0.59,Other,Drug Cost,0.59,,,0.59,Other,Drug Cost,1.33,,,1.33,Other,225% of Medicaid,0.83,,,0.83,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,1.27,,,1.27,Other,215% Medicaid APG methodology,1.27,,,1.27,Other,215% Medicaid APG methodology,0.74,,,0.74,Other,125% Medicaid APG methodology,0.01,1.33,
HYDROCORTISONE 1% OINT 30GM,,,,80001027,CDM,250,RC,45802027603,NDC,both,1,GM,2.52,0.99,39.4668,,0.99,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.86,34,,0.86,percent of total billed charges,"Drugs, Inpatient Only",0.86,34,,0.86,percent of total billed charges,"Drugs, Inpatient Only",0.86,34,,0.86,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1.76,70,,1.76,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.84,,,0.84,Other,Drug Cost,0.84,,,0.84,Other,Drug Cost,0.84,,,0.84,Other,Drug Cost,0.84,,,0.84,Other,Drug Cost,0.84,,,0.84,Other,Drug Cost,0.84,,,0.84,Other,Drug Cost,1.89,,,1.89,Other,225% of Medicaid,1.18,,,1.18,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,1.81,,,1.81,Other,215% Medicaid APG methodology,1.81,,,1.81,Other,215% Medicaid APG methodology,1.05,,,1.05,Other,125% Medicaid APG methodology,0.01,1.89,
HYDROCORTISONE 2.5%  OINT 20GM,,,,80001028,CDM,250,RC,168014630,NDC,both,1,GM,2.55,1.01,39.4668,,1.01,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.87,34,,0.87,percent of total billed charges,"Drugs, Inpatient Only",0.87,34,,0.87,percent of total billed charges,"Drugs, Inpatient Only",0.87,34,,0.87,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1.79,70,,1.79,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.85,,,0.85,Other,Drug Cost,0.85,,,0.85,Other,Drug Cost,0.85,,,0.85,Other,Drug Cost,0.85,,,0.85,Other,Drug Cost,0.85,,,0.85,Other,Drug Cost,0.85,,,0.85,Other,Drug Cost,1.91,,,1.91,Other,225% of Medicaid,1.19,,,1.19,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,1.83,,,1.83,Other,215% Medicaid APG methodology,1.83,,,1.83,Other,215% Medicaid APG methodology,1.06,,,1.06,Other,125% Medicaid APG methodology,0.01,1.91,
HYDROCORTISONE 2.5% CRM 30 GM,,,,80001029,CDM,250,RC,168008031,NDC,both,1,GM,2.4,0.95,39.4668,,0.95,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.82,34,,0.82,percent of total billed charges,"Drugs, Inpatient Only",0.82,34,,0.82,percent of total billed charges,"Drugs, Inpatient Only",0.82,34,,0.82,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1.68,70,,1.68,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.8,,,0.8,Other,Drug Cost,0.8,,,0.8,Other,Drug Cost,0.8,,,0.8,Other,Drug Cost,0.8,,,0.8,Other,Drug Cost,0.8,,,0.8,Other,Drug Cost,0.8,,,0.8,Other,Drug Cost,1.8,,,1.8,Other,225% of Medicaid,1.12,,,1.12,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,1.72,,,1.72,Other,215% Medicaid APG methodology,1.72,,,1.72,Other,215% Medicaid APG methodology,1,,,1,Other,125% Medicaid APG methodology,0.01,1.8,
HYDROMORPHONE 2 MG TAB,,,,80001033,CDM,250,RC,406324301,NDC,both,100,EA,0.12,0.05,39.4668,,0.05,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.04,34,,0.04,percent of total billed charges,"Drugs, Inpatient Only",0.04,34,,0.04,percent of total billed charges,"Drugs, Inpatient Only",0.04,34,,0.04,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.08,70,,0.08,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.09,,,0.09,Other,225% of Medicaid,0.05,,,0.05,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.08,,,0.08,Other,215% Medicaid APG methodology,0.08,,,0.08,Other,215% Medicaid APG methodology,0.05,,,0.05,Other,125% Medicaid APG methodology,0.01,0.09,
HYDROMORPHONE 4 MG TAB,,,,80001034,CDM,250,RC,42858030225,NDC,both,4,EA,5.12,2.02,39.4668,,2.02,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1.74,34,,1.74,percent of total billed charges,"Drugs, Inpatient Only",1.74,34,,1.74,percent of total billed charges,"Drugs, Inpatient Only",1.74,34,,1.74,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,3.59,70,,3.59,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1.71,,,1.71,Other,Drug Cost,1.71,,,1.71,Other,Drug Cost,1.71,,,1.71,Other,Drug Cost,1.71,,,1.71,Other,Drug Cost,1.71,,,1.71,Other,Drug Cost,1.71,,,1.71,Other,Drug Cost,3.84,,,3.84,Other,225% of Medicaid,2.39,,,2.39,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,3.67,,,3.67,Other,215% Medicaid APG methodology,3.67,,,3.67,Other,215% Medicaid APG methodology,2.13,,,2.13,Other,125% Medicaid APG methodology,0.01,3.84,
HYDROPHILIC OINT,,,,80001038,CDM,250,RC,72140045231,NDC,both,1,EA,16.56,6.54,39.4668,,6.54,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,5.63,34,,5.63,percent of total billed charges,"Drugs, Inpatient Only",5.63,34,,5.63,percent of total billed charges,"Drugs, Inpatient Only",5.63,34,,5.63,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,11.59,70,,11.59,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,5.52,,,5.52,Other,Drug Cost,5.52,,,5.52,Other,Drug Cost,5.52,,,5.52,Other,Drug Cost,5.52,,,5.52,Other,Drug Cost,5.52,,,5.52,Other,Drug Cost,5.52,,,5.52,Other,Drug Cost,12.42,,,12.42,Other,225% of Medicaid,7.73,,,7.73,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,11.87,,,11.87,Other,215% Medicaid APG methodology,11.87,,,11.87,Other,215% Medicaid APG methodology,6.9,,,6.9,Other,125% Medicaid APG methodology,0.01,12.42,
HYDROPHOR 100GM OINT,,,,80001040,CDM,250,RC,536114397,NDC,both,1,GM,5.82,2.3,39.4668,,2.3,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1.98,34,,1.98,percent of total billed charges,"Drugs, Inpatient Only",1.98,34,,1.98,percent of total billed charges,"Drugs, Inpatient Only",1.98,34,,1.98,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,4.07,70,,4.07,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1.94,,,1.94,Other,Drug Cost,1.94,,,1.94,Other,Drug Cost,1.94,,,1.94,Other,Drug Cost,1.94,,,1.94,Other,Drug Cost,1.94,,,1.94,Other,Drug Cost,1.94,,,1.94,Other,Drug Cost,4.37,,,4.37,Other,225% of Medicaid,2.72,,,2.72,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,4.17,,,4.17,Other,215% Medicaid APG methodology,4.17,,,4.17,Other,215% Medicaid APG methodology,2.43,,,2.43,Other,125% Medicaid APG methodology,0.01,4.37,
HYDROXYCHLOROQ 200 MG TAB,,,,80001041,CDM,250,RC,43598072101,NDC,both,100,EA,0.21,0.08,39.4668,,0.08,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.07,34,,0.07,percent of total billed charges,"Drugs, Inpatient Only",0.07,34,,0.07,percent of total billed charges,"Drugs, Inpatient Only",0.07,34,,0.07,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.14,70,,0.14,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.07,,,0.07,Other,Drug Cost,0.07,,,0.07,Other,Drug Cost,0.07,,,0.07,Other,Drug Cost,0.07,,,0.07,Other,Drug Cost,0.07,,,0.07,Other,Drug Cost,0.07,,,0.07,Other,Drug Cost,0.15,,,0.15,Other,225% of Medicaid,0.1,,,0.1,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.15,,,0.15,Other,215% Medicaid APG methodology,0.15,,,0.15,Other,215% Medicaid APG methodology,0.09,,,0.09,Other,125% Medicaid APG methodology,0.01,0.15,
HYDROXYUREA 500MG,,,,80001042,CDM,250,RC,49884072401,NDC,both,100,EA,0.27,0.11,39.4668,,0.11,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.09,34,,0.09,percent of total billed charges,"Drugs, Inpatient Only",0.09,34,,0.09,percent of total billed charges,"Drugs, Inpatient Only",0.09,34,,0.09,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.19,70,,0.19,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.09,,,0.09,Other,Drug Cost,0.09,,,0.09,Other,Drug Cost,0.09,,,0.09,Other,Drug Cost,0.09,,,0.09,Other,Drug Cost,0.09,,,0.09,Other,Drug Cost,0.09,,,0.09,Other,Drug Cost,0.21,,,0.21,Other,225% of Medicaid,0.13,,,0.13,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.2,,,0.2,Other,215% Medicaid APG methodology,0.2,,,0.2,Other,215% Medicaid APG methodology,0.11,,,0.11,Other,125% Medicaid APG methodology,0.01,0.21,
HYDROXYZINE HCL 25 MG TAB,,,,80001044,CDM,250,RC,23155050101,NDC,both,100,EA,0.04,0.02,39.4668,,0.02,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.03,70,,0.03,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.03,,,0.03,Other,225% of Medicaid,0.02,,,0.02,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.03,,,0.03,Other,215% Medicaid APG methodology,0.03,,,0.03,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,125% Medicaid APG methodology,0.01,0.03,
HYDROXYZINE HCL 25MG/ML 1ML INJ,,,,80001045,CDM,250,RC,517420125,NDC,both,25,ML,1.7,0.67,39.4668,,0.67,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.58,34,,0.58,percent of total billed charges,"Drugs, Inpatient Only",0.58,34,,0.58,percent of total billed charges,"Drugs, Inpatient Only",0.58,34,,0.58,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1.19,70,,1.19,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.57,,,0.57,Other,Drug Cost,0.57,,,0.57,Other,Drug Cost,0.57,,,0.57,Other,Drug Cost,0.57,,,0.57,Other,Drug Cost,0.57,,,0.57,Other,Drug Cost,0.57,,,0.57,Other,Drug Cost,1.27,,,1.27,Other,225% of Medicaid,0.79,,,0.79,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,1.22,,,1.22,Other,215% Medicaid APG methodology,1.22,,,1.22,Other,215% Medicaid APG methodology,0.71,,,0.71,Other,125% Medicaid APG methodology,0.01,1.27,
HYDROXYZINE PAMOATE 25 MG CAPS,,,,80001047,CDM,250,RC,185067401,NDC,both,100,EA,0.06,0.02,39.4668,,0.02,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.02,34,,0.02,percent of total billed charges,"Drugs, Inpatient Only",0.02,34,,0.02,percent of total billed charges,"Drugs, Inpatient Only",0.02,34,,0.02,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.04,70,,0.04,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.04,,,0.04,Other,225% of Medicaid,0.03,,,0.03,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.04,,,0.04,Other,215% Medicaid APG methodology,0.04,,,0.04,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,125% Medicaid APG methodology,0.01,0.04,
HYDROXYZINE PAMOATE 50 MG CAPS,,,,80001048,CDM,250,RC,115180401,NDC,both,100,EA,0.09,0.04,39.4668,,0.04,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.03,34,,0.03,percent of total billed charges,"Drugs, Inpatient Only",0.03,34,,0.03,percent of total billed charges,"Drugs, Inpatient Only",0.03,34,,0.03,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.06,70,,0.06,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.07,,,0.07,Other,225% of Medicaid,0.04,,,0.04,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.06,,,0.06,Other,215% Medicaid APG methodology,0.06,,,0.06,Other,215% Medicaid APG methodology,0.04,,,0.04,Other,125% Medicaid APG methodology,0.01,0.07,
HYOSCYAMINE 0.125MG SL TAB,,,,80001051,CDM,250,RC,68047025301,NDC,both,100,EA,0.35,0.14,39.4668,,0.14,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.12,34,,0.12,percent of total billed charges,"Drugs, Inpatient Only",0.12,34,,0.12,percent of total billed charges,"Drugs, Inpatient Only",0.12,34,,0.12,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.24,70,,0.24,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.12,,,0.12,Other,Drug Cost,0.12,,,0.12,Other,Drug Cost,0.12,,,0.12,Other,Drug Cost,0.12,,,0.12,Other,Drug Cost,0.12,,,0.12,Other,Drug Cost,0.12,,,0.12,Other,Drug Cost,0.26,,,0.26,Other,225% of Medicaid,0.16,,,0.16,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.25,,,0.25,Other,215% Medicaid APG methodology,0.25,,,0.25,Other,215% Medicaid APG methodology,0.15,,,0.15,Other,125% Medicaid APG methodology,0.01,0.26,
IBUPROFEN 100MG/5ML 5ML UD,,,,80001054,CDM,250,RC,68094049458,NDC,both,50,ML,1.64,0.65,39.4668,,0.65,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.56,34,,0.56,percent of total billed charges,"Drugs, Inpatient Only",0.56,34,,0.56,percent of total billed charges,"Drugs, Inpatient Only",0.56,34,,0.56,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1.15,70,,1.15,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.55,,,0.55,Other,Drug Cost,0.55,,,0.55,Other,Drug Cost,0.55,,,0.55,Other,Drug Cost,0.55,,,0.55,Other,Drug Cost,0.55,,,0.55,Other,Drug Cost,0.55,,,0.55,Other,Drug Cost,1.23,,,1.23,Other,225% of Medicaid,0.77,,,0.77,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,1.18,,,1.18,Other,215% Medicaid APG methodology,1.18,,,1.18,Other,215% Medicaid APG methodology,0.68,,,0.68,Other,125% Medicaid APG methodology,0.01,1.23,
IBUPROFEN 200 MG TAB,,,,80001055,CDM,250,RC,904791259,NDC,both,100,EA,0.04,0.02,39.4668,,0.02,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.03,70,,0.03,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.03,,,0.03,Other,225% of Medicaid,0.02,,,0.02,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.03,,,0.03,Other,215% Medicaid APG methodology,0.03,,,0.03,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,125% Medicaid APG methodology,0.01,0.03,
IBUPROFEN 400MG TAB,,,,80001056,CDM,250,RC,67877031901,NDC,both,100,EA,0.05,0.02,39.4668,,0.02,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.02,34,,0.02,percent of total billed charges,"Drugs, Inpatient Only",0.02,34,,0.02,percent of total billed charges,"Drugs, Inpatient Only",0.02,34,,0.02,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.03,70,,0.03,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.03,,,0.03,Other,225% of Medicaid,0.02,,,0.02,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.03,,,0.03,Other,215% Medicaid APG methodology,0.03,,,0.03,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,125% Medicaid APG methodology,0.01,0.03,
IBUPROFEN 600MG TAB,,,,80001057,CDM,250,RC,67877032005,NDC,both,500,EA,0.07,0.03,39.4668,,0.03,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.02,34,,0.02,percent of total billed charges,"Drugs, Inpatient Only",0.02,34,,0.02,percent of total billed charges,"Drugs, Inpatient Only",0.02,34,,0.02,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.05,70,,0.05,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.05,,,0.05,Other,225% of Medicaid,0.03,,,0.03,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.05,,,0.05,Other,215% Medicaid APG methodology,0.05,,,0.05,Other,215% Medicaid APG methodology,0.03,,,0.03,Other,125% Medicaid APG methodology,0.01,0.05,
IMIPRAMINE 10 MG TAB,,,,80001066,CDM,250,RC,64380016901,NDC,both,100,EA,0.09,0.04,39.4668,,0.04,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.03,34,,0.03,percent of total billed charges,"Drugs, Inpatient Only",0.03,34,,0.03,percent of total billed charges,"Drugs, Inpatient Only",0.03,34,,0.03,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.06,70,,0.06,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.07,,,0.07,Other,225% of Medicaid,0.04,,,0.04,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.07,,,0.07,Other,215% Medicaid APG methodology,0.07,,,0.07,Other,215% Medicaid APG methodology,0.04,,,0.04,Other,125% Medicaid APG methodology,0.01,0.07,
IMIPRAMINE HCL 25 MG TAB,,,,80001068,CDM,250,RC,64380017001,NDC,both,100,EA,0.08,0.03,39.4668,,0.03,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.03,34,,0.03,percent of total billed charges,"Drugs, Inpatient Only",0.03,34,,0.03,percent of total billed charges,"Drugs, Inpatient Only",0.03,34,,0.03,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.06,70,,0.06,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.06,,,0.06,Other,225% of Medicaid,0.04,,,0.04,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.06,,,0.06,Other,215% Medicaid APG methodology,0.06,,,0.06,Other,215% Medicaid APG methodology,0.03,,,0.03,Other,125% Medicaid APG methodology,0.01,0.06,
IMIQUIMOD (ALDARA) 5%,,,,80001069,CDM,250,RC,45802036853,NDC,both,12,EA,4.1,1.62,39.4668,,1.62,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1.39,34,,1.39,percent of total billed charges,"Drugs, Inpatient Only",1.39,34,,1.39,percent of total billed charges,"Drugs, Inpatient Only",1.39,34,,1.39,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2.87,70,,2.87,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1.37,,,1.37,Other,Drug Cost,1.37,,,1.37,Other,Drug Cost,1.37,,,1.37,Other,Drug Cost,1.37,,,1.37,Other,Drug Cost,1.37,,,1.37,Other,Drug Cost,1.37,,,1.37,Other,Drug Cost,3.07,,,3.07,Other,225% of Medicaid,1.91,,,1.91,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,2.93,,,2.93,Other,215% Medicaid APG methodology,2.93,,,2.93,Other,215% Medicaid APG methodology,1.71,,,1.71,Other,125% Medicaid APG methodology,0.01,3.07,
INDOMETHACIN 25 MG CAPS,,,,80001078,CDM,250,RC,68462040601,NDC,both,100,EA,0.05,0.02,39.4668,,0.02,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.02,34,,0.02,percent of total billed charges,"Drugs, Inpatient Only",0.02,34,,0.02,percent of total billed charges,"Drugs, Inpatient Only",0.02,34,,0.02,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.04,70,,0.04,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.04,,,0.04,Other,225% of Medicaid,0.02,,,0.02,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.04,,,0.04,Other,215% Medicaid APG methodology,0.04,,,0.04,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,125% Medicaid APG methodology,0.01,0.04,
INSULIN GLARAGIN (LANTUS) 100 U/ML,,,,80001086,CDM,250,RC,88222033,NDC,both,1,ML,0.27,0.11,39.4668,,0.11,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.09,34,,0.09,percent of total billed charges,"Drugs, Inpatient Only",0.09,34,,0.09,percent of total billed charges,"Drugs, Inpatient Only",0.09,34,,0.09,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.19,70,,0.19,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.09,,,0.09,Other,Drug Cost,0.09,,,0.09,Other,Drug Cost,0.09,,,0.09,Other,Drug Cost,0.09,,,0.09,Other,Drug Cost,0.09,,,0.09,Other,Drug Cost,0.09,,,0.09,Other,Drug Cost,0.2,,,0.2,Other,225% of Medicaid,0.13,,,0.13,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.19,,,0.19,Other,215% Medicaid APG methodology,0.19,,,0.19,Other,215% Medicaid APG methodology,0.11,,,0.11,Other,125% Medicaid APG methodology,0.01,0.2,
INTRALIPID 20% IV 250ML,,,,80001088,CDM,250,RC,338051909,NDC,both,10,ML,6.8,2.68,39.4668,,2.68,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2.31,34,,2.31,percent of total billed charges,"Drugs, Inpatient Only",2.31,34,,2.31,percent of total billed charges,"Drugs, Inpatient Only",2.31,34,,2.31,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,4.76,70,,4.76,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2.27,,,2.27,Other,Drug Cost,2.27,,,2.27,Other,Drug Cost,2.27,,,2.27,Other,Drug Cost,2.27,,,2.27,Other,Drug Cost,2.27,,,2.27,Other,Drug Cost,2.27,,,2.27,Other,Drug Cost,5.1,,,5.1,Other,225% of Medicaid,3.17,,,3.17,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,4.87,,,4.87,Other,215% Medicaid APG methodology,4.87,,,4.87,Other,215% Medicaid APG methodology,2.83,,,2.83,Other,125% Medicaid APG methodology,0.01,5.1,
IODINE TINCTURE 2% 30ML,,,,80001092,CDM,250,RC,869385110,NDC,both,1,ML,7.68,3.03,39.4668,,3.03,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2.61,34,,2.61,percent of total billed charges,"Drugs, Inpatient Only",2.61,34,,2.61,percent of total billed charges,"Drugs, Inpatient Only",2.61,34,,2.61,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,5.38,70,,5.38,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2.56,,,2.56,Other,Drug Cost,2.56,,,2.56,Other,Drug Cost,2.56,,,2.56,Other,Drug Cost,2.56,,,2.56,Other,Drug Cost,2.56,,,2.56,Other,Drug Cost,2.56,,,2.56,Other,Drug Cost,5.76,,,5.76,Other,225% of Medicaid,3.58,,,3.58,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,5.5,,,5.5,Other,215% Medicaid APG methodology,5.5,,,5.5,Other,215% Medicaid APG methodology,3.2,,,3.2,Other,125% Medicaid APG methodology,0.01,5.76,
IPRATROPIUM ALBUTERAL INHL SLN,,,,80001095,CDM,250,RC,69097084087,NDC,both,30,ML,0.26,0.1,39.4668,,0.1,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.09,34,,0.09,percent of total billed charges,"Drugs, Inpatient Only",0.09,34,,0.09,percent of total billed charges,"Drugs, Inpatient Only",0.09,34,,0.09,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.18,70,,0.18,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.09,,,0.09,Other,Drug Cost,0.09,,,0.09,Other,Drug Cost,0.09,,,0.09,Other,Drug Cost,0.09,,,0.09,Other,Drug Cost,0.09,,,0.09,Other,Drug Cost,0.09,,,0.09,Other,Drug Cost,0.19,,,0.19,Other,225% of Medicaid,0.12,,,0.12,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.18,,,0.18,Other,215% Medicaid APG methodology,0.18,,,0.18,Other,215% Medicaid APG methodology,0.11,,,0.11,Other,125% Medicaid APG methodology,0.01,0.19,
IPRATROPIUM BROMIDE (ATROVENT) HFA 17MCG,,,,80001096,CDM,250,RC,597008717,NDC,both,1,GM,0.36,0.14,39.4668,,0.14,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.12,34,,0.12,percent of total billed charges,"Drugs, Inpatient Only",0.12,34,,0.12,percent of total billed charges,"Drugs, Inpatient Only",0.12,34,,0.12,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.25,70,,0.25,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.12,,,0.12,Other,Drug Cost,0.12,,,0.12,Other,Drug Cost,0.12,,,0.12,Other,Drug Cost,0.12,,,0.12,Other,Drug Cost,0.12,,,0.12,Other,Drug Cost,0.12,,,0.12,Other,Drug Cost,0.27,,,0.27,Other,225% of Medicaid,0.17,,,0.17,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.26,,,0.26,Other,215% Medicaid APG methodology,0.26,,,0.26,Other,215% Medicaid APG methodology,0.15,,,0.15,Other,125% Medicaid APG methodology,0.01,0.27,
IPRATROPIUM BROMIDE 0.02% SOLN,,,,80001097,CDM,250,RC,378797093,NDC,both,30,ML,0.25,0.1,39.4668,,0.1,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.08,34,,0.08,percent of total billed charges,"Drugs, Inpatient Only",0.08,34,,0.08,percent of total billed charges,"Drugs, Inpatient Only",0.08,34,,0.08,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.17,70,,0.17,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.08,,,0.08,Other,Drug Cost,0.08,,,0.08,Other,Drug Cost,0.08,,,0.08,Other,Drug Cost,0.08,,,0.08,Other,Drug Cost,0.08,,,0.08,Other,Drug Cost,0.08,,,0.08,Other,Drug Cost,0.18,,,0.18,Other,225% of Medicaid,0.11,,,0.11,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.18,,,0.18,Other,215% Medicaid APG methodology,0.18,,,0.18,Other,215% Medicaid APG methodology,0.1,,,0.1,Other,125% Medicaid APG methodology,0.01,0.18,
IRON POLYSACCHARIDE COMPLEX  150MG CAPS,,,,80001101,CDM,250,RC,51991019811,NDC,both,100,EA,0.26,0.1,39.4668,,0.1,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.09,34,,0.09,percent of total billed charges,"Drugs, Inpatient Only",0.09,34,,0.09,percent of total billed charges,"Drugs, Inpatient Only",0.09,34,,0.09,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.18,70,,0.18,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.09,,,0.09,Other,Drug Cost,0.09,,,0.09,Other,Drug Cost,0.09,,,0.09,Other,Drug Cost,0.09,,,0.09,Other,Drug Cost,0.09,,,0.09,Other,Drug Cost,0.09,,,0.09,Other,Drug Cost,0.2,,,0.2,Other,225% of Medicaid,0.12,,,0.12,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.19,,,0.19,Other,215% Medicaid APG methodology,0.19,,,0.19,Other,215% Medicaid APG methodology,0.11,,,0.11,Other,125% Medicaid APG methodology,0.01,0.2,
ISONIAZID 100 MG/ML INJ,,,,80001105,CDM,250,RC,781305670,NDC,both,1,ML,729.15,287.77,39.4668,,287.77,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,247.91,34,,247.91,percent of total billed charges,"Drugs, Inpatient Only",247.91,34,,247.91,percent of total billed charges,"Drugs, Inpatient Only",247.91,34,,247.91,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,510.41,70,,510.41,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,243.05,,,243.05,Other,Drug Cost,243.05,,,243.05,Other,Drug Cost,243.05,,,243.05,Other,Drug Cost,243.05,,,243.05,Other,Drug Cost,243.05,,,243.05,Other,Drug Cost,243.05,,,243.05,Other,Drug Cost,546.86,,,546.86,Other,225% of Medicaid,340.27,,,340.27,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,522.56,,,522.56,Other,215% Medicaid APG methodology,522.56,,,522.56,Other,215% Medicaid APG methodology,303.81,,,303.81,Other,125% Medicaid APG methodology,0.01,546.86,
ISONIAZID 300 MG,,,,80001106,CDM,250,RC,555007101,NDC,both,30,EA,0.19,0.08,39.4668,,0.08,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.07,34,,0.07,percent of total billed charges,"Drugs, Inpatient Only",0.07,34,,0.07,percent of total billed charges,"Drugs, Inpatient Only",0.07,34,,0.07,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.13,70,,0.13,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.06,,,0.06,Other,Drug Cost,0.06,,,0.06,Other,Drug Cost,0.06,,,0.06,Other,Drug Cost,0.06,,,0.06,Other,Drug Cost,0.06,,,0.06,Other,Drug Cost,0.06,,,0.06,Other,Drug Cost,0.14,,,0.14,Other,225% of Medicaid,0.09,,,0.09,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.14,,,0.14,Other,215% Medicaid APG methodology,0.14,,,0.14,Other,215% Medicaid APG methodology,0.08,,,0.08,Other,125% Medicaid APG methodology,0.01,0.14,
ISOSORBIDE DINITRATE 10MG TAB,,,,80001110,CDM,250,RC,143177101,NDC,both,100,EA,0.1,0.04,39.4668,,0.04,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.03,34,,0.03,percent of total billed charges,"Drugs, Inpatient Only",0.03,34,,0.03,percent of total billed charges,"Drugs, Inpatient Only",0.03,34,,0.03,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.07,70,,0.07,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.08,,,0.08,Other,225% of Medicaid,0.05,,,0.05,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.07,,,0.07,Other,215% Medicaid APG methodology,0.07,,,0.07,Other,215% Medicaid APG methodology,0.04,,,0.04,Other,125% Medicaid APG methodology,0.01,0.08,
ISOSORBIDE DINITRATE 20 MG TAB,,,,80001111,CDM,250,RC,781169501,NDC,both,100,EA,0.39,0.16,39.4668,,0.16,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.13,34,,0.13,percent of total billed charges,"Drugs, Inpatient Only",0.13,34,,0.13,percent of total billed charges,"Drugs, Inpatient Only",0.13,34,,0.13,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.28,70,,0.28,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.13,,,0.13,Other,Drug Cost,0.13,,,0.13,Other,Drug Cost,0.13,,,0.13,Other,Drug Cost,0.13,,,0.13,Other,Drug Cost,0.13,,,0.13,Other,Drug Cost,0.13,,,0.13,Other,Drug Cost,0.29,,,0.29,Other,225% of Medicaid,0.18,,,0.18,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.28,,,0.28,Other,215% Medicaid APG methodology,0.28,,,0.28,Other,215% Medicaid APG methodology,0.16,,,0.16,Other,125% Medicaid APG methodology,0.01,0.29,
ISOSORBIDE MONO 20MG TAB,,,,80001112,CDM,250,RC,228262011,NDC,both,100,EA,0.24,0.09,39.4668,,0.09,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.08,34,,0.08,percent of total billed charges,"Drugs, Inpatient Only",0.08,34,,0.08,percent of total billed charges,"Drugs, Inpatient Only",0.08,34,,0.08,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.17,70,,0.17,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.08,,,0.08,Other,Drug Cost,0.08,,,0.08,Other,Drug Cost,0.08,,,0.08,Other,Drug Cost,0.08,,,0.08,Other,Drug Cost,0.08,,,0.08,Other,Drug Cost,0.08,,,0.08,Other,Drug Cost,0.18,,,0.18,Other,225% of Medicaid,0.11,,,0.11,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.17,,,0.17,Other,215% Medicaid APG methodology,0.17,,,0.17,Other,215% Medicaid APG methodology,0.1,,,0.1,Other,125% Medicaid APG methodology,0.01,0.18,
ISOSORBIDE MONO 30MG ER TAB,,,,80001113,CDM,250,RC,13668010401,NDC,both,100,EA,0.04,0.02,39.4668,,0.02,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.03,70,,0.03,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.03,,,0.03,Other,225% of Medicaid,0.02,,,0.02,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.03,,,0.03,Other,215% Medicaid APG methodology,0.03,,,0.03,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,125% Medicaid APG methodology,0.01,0.03,
ISOSORBIDE MONO 60MG ER TAB,,,,80001114,CDM,250,RC,23155017801,NDC,both,100,EA,0.06,0.02,39.4668,,0.02,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.02,34,,0.02,percent of total billed charges,"Drugs, Inpatient Only",0.02,34,,0.02,percent of total billed charges,"Drugs, Inpatient Only",0.02,34,,0.02,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.04,70,,0.04,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.05,,,0.05,Other,225% of Medicaid,0.03,,,0.03,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.05,,,0.05,Other,215% Medicaid APG methodology,0.05,,,0.05,Other,215% Medicaid APG methodology,0.03,,,0.03,Other,125% Medicaid APG methodology,0.01,0.05,
ITRACONAZOLE 100MG CAPSULE,,,,80001116,CDM,250,RC,10147170003,NDC,both,30,EA,1.18,0.46,39.4668,,0.46,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.4,34,,0.4,percent of total billed charges,"Drugs, Inpatient Only",0.4,34,,0.4,percent of total billed charges,"Drugs, Inpatient Only",0.4,34,,0.4,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.82,70,,0.82,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.39,,,0.39,Other,Drug Cost,0.39,,,0.39,Other,Drug Cost,0.39,,,0.39,Other,Drug Cost,0.39,,,0.39,Other,Drug Cost,0.39,,,0.39,Other,Drug Cost,0.39,,,0.39,Other,Drug Cost,0.88,,,0.88,Other,225% of Medicaid,0.55,,,0.55,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.84,,,0.84,Other,215% Medicaid APG methodology,0.84,,,0.84,Other,215% Medicaid APG methodology,0.49,,,0.49,Other,125% Medicaid APG methodology,0.01,0.88,
IVERMECTIN 3MG TAB,,,,80001117,CDM,250,RC,6003220,NDC,both,20,EA,9.6,3.79,39.4668,,3.79,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,3.27,34,,3.27,percent of total billed charges,"Drugs, Inpatient Only",3.27,34,,3.27,percent of total billed charges,"Drugs, Inpatient Only",3.27,34,,3.27,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,6.72,70,,6.72,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,3.2,,,3.2,Other,Drug Cost,3.2,,,3.2,Other,Drug Cost,3.2,,,3.2,Other,Drug Cost,3.2,,,3.2,Other,Drug Cost,3.2,,,3.2,Other,Drug Cost,3.2,,,3.2,Other,Drug Cost,7.2,,,7.2,Other,225% of Medicaid,4.48,,,4.48,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,6.88,,,6.88,Other,215% Medicaid APG methodology,6.88,,,6.88,Other,215% Medicaid APG methodology,4,,,4,Other,125% Medicaid APG methodology,0.01,7.2,
KALETRA 200-50MG TAB,,,,80001119,CDM,250,RC,42385093412,NDC,both,120,EA,8.66,3.42,39.4668,,3.42,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2.95,34,,2.95,percent of total billed charges,"Drugs, Inpatient Only",2.95,34,,2.95,percent of total billed charges,"Drugs, Inpatient Only",2.95,34,,2.95,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,6.07,70,,6.07,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2.89,,,2.89,Other,Drug Cost,2.89,,,2.89,Other,Drug Cost,2.89,,,2.89,Other,Drug Cost,2.89,,,2.89,Other,Drug Cost,2.89,,,2.89,Other,Drug Cost,2.89,,,2.89,Other,Drug Cost,6.5,,,6.5,Other,225% of Medicaid,4.04,,,4.04,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,6.21,,,6.21,Other,215% Medicaid APG methodology,6.21,,,6.21,Other,215% Medicaid APG methodology,3.61,,,3.61,Other,125% Medicaid APG methodology,0.01,6.5,
KALETRA 400-100MG/5ML SOLN 160 ML,,,,80001120,CDM,250,RC,74395646,NDC,both,1,ML,1002.3,395.58,39.4668,,395.58,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,340.78,34,,340.78,percent of total billed charges,"Drugs, Inpatient Only",340.78,34,,340.78,percent of total billed charges,"Drugs, Inpatient Only",340.78,34,,340.78,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,701.61,70,,701.61,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,334.1,,,334.1,Other,Drug Cost,334.1,,,334.1,Other,Drug Cost,334.1,,,334.1,Other,Drug Cost,334.1,,,334.1,Other,Drug Cost,334.1,,,334.1,Other,Drug Cost,334.1,,,334.1,Other,Drug Cost,751.73,,,751.73,Other,225% of Medicaid,467.74,,,467.74,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,718.32,,,718.32,Other,215% Medicaid APG methodology,718.32,,,718.32,Other,215% Medicaid APG methodology,417.63,,,417.63,Other,125% Medicaid APG methodology,0.01,751.73,
KETAMINE (KETALAR) 50MG/ML 10ML INJ,,,,80001122,CDM,250,RC,409205310,NDC,both,10,ML,8.13,3.21,39.4668,,3.21,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2.76,34,,2.76,percent of total billed charges,"Drugs, Inpatient Only",2.76,34,,2.76,percent of total billed charges,"Drugs, Inpatient Only",2.76,34,,2.76,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,5.69,70,,5.69,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2.71,,,2.71,Other,Drug Cost,2.71,,,2.71,Other,Drug Cost,2.71,,,2.71,Other,Drug Cost,2.71,,,2.71,Other,Drug Cost,2.71,,,2.71,Other,Drug Cost,2.71,,,2.71,Other,Drug Cost,6.1,,,6.1,Other,225% of Medicaid,3.79,,,3.79,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,5.83,,,5.83,Other,215% Medicaid APG methodology,5.83,,,5.83,Other,215% Medicaid APG methodology,3.39,,,3.39,Other,125% Medicaid APG methodology,0.01,6.1,
KETOROLAC 10MG TAB,,,,80001126,CDM,250,RC,93031401,NDC,both,100,EA,0.11,0.04,39.4668,,0.04,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.04,34,,0.04,percent of total billed charges,"Drugs, Inpatient Only",0.04,34,,0.04,percent of total billed charges,"Drugs, Inpatient Only",0.04,34,,0.04,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.08,70,,0.08,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.08,,,0.08,Other,225% of Medicaid,0.05,,,0.05,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.08,,,0.08,Other,215% Medicaid APG methodology,0.08,,,0.08,Other,215% Medicaid APG methodology,0.05,,,0.05,Other,125% Medicaid APG methodology,0.01,0.08,
KETOROLAC TROMETHAMINE (ACULAR) 10ML,,,,80001127,CDM,250,RC,61314012605,NDC,both,1,ML,12.21,4.82,39.4668,,4.82,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,4.15,34,,4.15,percent of total billed charges,"Drugs, Inpatient Only",4.15,34,,4.15,percent of total billed charges,"Drugs, Inpatient Only",4.15,34,,4.15,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,8.55,70,,8.55,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,4.07,,,4.07,Other,Drug Cost,4.07,,,4.07,Other,Drug Cost,4.07,,,4.07,Other,Drug Cost,4.07,,,4.07,Other,Drug Cost,4.07,,,4.07,Other,Drug Cost,4.07,,,4.07,Other,Drug Cost,9.16,,,9.16,Other,225% of Medicaid,5.7,,,5.7,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,8.75,,,8.75,Other,215% Medicaid APG methodology,8.75,,,8.75,Other,215% Medicaid APG methodology,5.09,,,5.09,Other,125% Medicaid APG methodology,0.01,9.16,
KETOROLAC TROMETHAMINE (ACULAR) 5ML,,,,80001129,CDM,250,RC,60505100301,NDC,both,1,ML,6.51,2.57,39.4668,,2.57,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2.21,34,,2.21,percent of total billed charges,"Drugs, Inpatient Only",2.21,34,,2.21,percent of total billed charges,"Drugs, Inpatient Only",2.21,34,,2.21,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,4.56,70,,4.56,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2.17,,,2.17,Other,Drug Cost,2.17,,,2.17,Other,Drug Cost,2.17,,,2.17,Other,Drug Cost,2.17,,,2.17,Other,Drug Cost,2.17,,,2.17,Other,Drug Cost,2.17,,,2.17,Other,Drug Cost,4.88,,,4.88,Other,225% of Medicaid,3.04,,,3.04,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,4.67,,,4.67,Other,215% Medicaid APG methodology,4.67,,,4.67,Other,215% Medicaid APG methodology,2.71,,,2.71,Other,125% Medicaid APG methodology,0.01,4.88,
LABETALOL 100 MG TAB,,,,80001131,CDM,250,RC,68382079801,NDC,both,100,EA,0.27,0.11,39.4668,,0.11,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.09,34,,0.09,percent of total billed charges,"Drugs, Inpatient Only",0.09,34,,0.09,percent of total billed charges,"Drugs, Inpatient Only",0.09,34,,0.09,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.19,70,,0.19,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.09,,,0.09,Other,Drug Cost,0.09,,,0.09,Other,Drug Cost,0.09,,,0.09,Other,Drug Cost,0.09,,,0.09,Other,Drug Cost,0.09,,,0.09,Other,Drug Cost,0.09,,,0.09,Other,Drug Cost,0.2,,,0.2,Other,225% of Medicaid,0.13,,,0.13,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.19,,,0.19,Other,215% Medicaid APG methodology,0.19,,,0.19,Other,215% Medicaid APG methodology,0.11,,,0.11,Other,125% Medicaid APG methodology,0.01,0.2,
LABETALOL 200 MG TAB,,,,80001132,CDM,250,RC,591060601,NDC,both,100,EA,0.16,0.06,39.4668,,0.06,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.05,34,,0.05,percent of total billed charges,"Drugs, Inpatient Only",0.05,34,,0.05,percent of total billed charges,"Drugs, Inpatient Only",0.05,34,,0.05,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.11,70,,0.11,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.12,,,0.12,Other,225% of Medicaid,0.07,,,0.07,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.11,,,0.11,Other,215% Medicaid APG methodology,0.11,,,0.11,Other,215% Medicaid APG methodology,0.07,,,0.07,Other,125% Medicaid APG methodology,0.01,0.12,
LABETALOL 5 MG/ML 20ML INJ,,,,80001133,CDM,250,RC,409226720,NDC,both,1,ML,3.81,1.5,39.4668,,1.5,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1.3,34,,1.3,percent of total billed charges,"Drugs, Inpatient Only",1.3,34,,1.3,percent of total billed charges,"Drugs, Inpatient Only",1.3,34,,1.3,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2.67,70,,2.67,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1.27,,,1.27,Other,Drug Cost,1.27,,,1.27,Other,Drug Cost,1.27,,,1.27,Other,Drug Cost,1.27,,,1.27,Other,Drug Cost,1.27,,,1.27,Other,Drug Cost,1.27,,,1.27,Other,Drug Cost,2.86,,,2.86,Other,225% of Medicaid,1.78,,,1.78,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,2.73,,,2.73,Other,215% Medicaid APG methodology,2.73,,,2.73,Other,215% Medicaid APG methodology,1.59,,,1.59,Other,125% Medicaid APG methodology,0.01,2.86,
LACOSAMIDE 50 MG,,,,80001136,CDM,250,RC,62332017160,NDC,both,60,EA,0.15,0.06,39.4668,,0.06,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.05,34,,0.05,percent of total billed charges,"Drugs, Inpatient Only",0.05,34,,0.05,percent of total billed charges,"Drugs, Inpatient Only",0.05,34,,0.05,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.11,70,,0.11,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.12,,,0.12,Other,225% of Medicaid,0.07,,,0.07,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.11,,,0.11,Other,215% Medicaid APG methodology,0.11,,,0.11,Other,215% Medicaid APG methodology,0.06,,,0.06,Other,125% Medicaid APG methodology,0.01,0.12,
LACTASE (LACTAID) 3MU CAPS,,,,80001138,CDM,250,RC,904522452,NDC,both,60,EA,0.12,0.05,39.4668,,0.05,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.04,34,,0.04,percent of total billed charges,"Drugs, Inpatient Only",0.04,34,,0.04,percent of total billed charges,"Drugs, Inpatient Only",0.04,34,,0.04,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.08,70,,0.08,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.09,,,0.09,Other,225% of Medicaid,0.06,,,0.06,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.09,,,0.09,Other,215% Medicaid APG methodology,0.09,,,0.09,Other,215% Medicaid APG methodology,0.05,,,0.05,Other,125% Medicaid APG methodology,0.01,0.09,
LACTULOSE (CONSTULOSE) 10G/15ML 946ML,,,,80001142,CDM,250,RC,45963043965,NDC,both,1,ML,25.71,10.15,39.4668,,10.15,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,8.74,34,,8.74,percent of total billed charges,"Drugs, Inpatient Only",8.74,34,,8.74,percent of total billed charges,"Drugs, Inpatient Only",8.74,34,,8.74,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,18,70,,18,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,8.57,,,8.57,Other,Drug Cost,8.57,,,8.57,Other,Drug Cost,8.57,,,8.57,Other,Drug Cost,8.57,,,8.57,Other,Drug Cost,8.57,,,8.57,Other,Drug Cost,8.57,,,8.57,Other,Drug Cost,19.28,,,19.28,Other,225% of Medicaid,12,,,12,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,18.43,,,18.43,Other,215% Medicaid APG methodology,18.43,,,18.43,Other,215% Medicaid APG methodology,10.71,,,10.71,Other,125% Medicaid APG methodology,0.01,19.28,
LAMIVUDINE 150 MG TABLET,,,,80001144,CDM,250,RC,33342000109,NDC,both,60,EA,0.53,0.21,39.4668,,0.21,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.18,34,,0.18,percent of total billed charges,"Drugs, Inpatient Only",0.18,34,,0.18,percent of total billed charges,"Drugs, Inpatient Only",0.18,34,,0.18,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.37,70,,0.37,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.18,,,0.18,Other,Drug Cost,0.18,,,0.18,Other,Drug Cost,0.18,,,0.18,Other,Drug Cost,0.18,,,0.18,Other,Drug Cost,0.18,,,0.18,Other,Drug Cost,0.18,,,0.18,Other,Drug Cost,0.4,,,0.4,Other,225% of Medicaid,0.25,,,0.25,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.38,,,0.38,Other,215% Medicaid APG methodology,0.38,,,0.38,Other,215% Medicaid APG methodology,0.22,,,0.22,Other,125% Medicaid APG methodology,0.01,0.4,
LAMOTRIGINE (LAMICTAL) 100MG TAB,,,,80001145,CDM,250,RC,51672413101,NDC,both,100,EA,0.05,0.02,39.4668,,0.02,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.02,34,,0.02,percent of total billed charges,"Drugs, Inpatient Only",0.02,34,,0.02,percent of total billed charges,"Drugs, Inpatient Only",0.02,34,,0.02,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.04,70,,0.04,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.04,,,0.04,Other,225% of Medicaid,0.02,,,0.02,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.04,,,0.04,Other,215% Medicaid APG methodology,0.04,,,0.04,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,125% Medicaid APG methodology,0.01,0.04,
LAMOTRIGINE (LAMICTAL) 25MG TAB,,,,80001146,CDM,250,RC,65862022701,NDC,both,100,EA,0.03,0.01,39.4668,,0.01,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.02,70,,0.02,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.02,,,0.02,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,0.02,
LANTHANUM CARBONATE (FOSRENOL) 500 MG,,,,80001147,CDM,250,RC,69097093498,NDC,both,2,EA,100.86,39.81,39.4668,,39.81,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,34.29,34,,34.29,percent of total billed charges,"Drugs, Inpatient Only",34.29,34,,34.29,percent of total billed charges,"Drugs, Inpatient Only",34.29,34,,34.29,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,70.6,70,,70.6,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,33.62,,,33.62,Other,Drug Cost,33.62,,,33.62,Other,Drug Cost,33.62,,,33.62,Other,Drug Cost,33.62,,,33.62,Other,Drug Cost,33.62,,,33.62,Other,Drug Cost,33.62,,,33.62,Other,Drug Cost,75.65,,,75.65,Other,225% of Medicaid,47.07,,,47.07,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,72.28,,,72.28,Other,215% Medicaid APG methodology,72.28,,,72.28,Other,215% Medicaid APG methodology,42.03,,,42.03,Other,125% Medicaid APG methodology,0.01,75.65,
LATANOPROST OPHTH,,,,80001148,CDM,250,RC,13830304,NDC,both,1,ML,0.09,0.04,39.4668,,0.04,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.03,34,,0.03,percent of total billed charges,"Drugs, Inpatient Only",0.03,34,,0.03,percent of total billed charges,"Drugs, Inpatient Only",0.03,34,,0.03,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.06,70,,0.06,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.07,,,0.07,Other,225% of Medicaid,0.04,,,0.04,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.06,,,0.06,Other,215% Medicaid APG methodology,0.06,,,0.06,Other,215% Medicaid APG methodology,0.04,,,0.04,Other,125% Medicaid APG methodology,0.01,0.07,
LEFLUNOMIDE (ARAVA) 10 MG,,,,80001149,CDM,250,RC,23155004303,NDC,both,30,EA,0.32,0.13,39.4668,,0.13,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.11,34,,0.11,percent of total billed charges,"Drugs, Inpatient Only",0.11,34,,0.11,percent of total billed charges,"Drugs, Inpatient Only",0.11,34,,0.11,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.22,70,,0.22,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.11,,,0.11,Other,Drug Cost,0.11,,,0.11,Other,Drug Cost,0.11,,,0.11,Other,Drug Cost,0.11,,,0.11,Other,Drug Cost,0.11,,,0.11,Other,Drug Cost,0.11,,,0.11,Other,Drug Cost,0.24,,,0.24,Other,225% of Medicaid,0.15,,,0.15,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.23,,,0.23,Other,215% Medicaid APG methodology,0.23,,,0.23,Other,215% Medicaid APG methodology,0.13,,,0.13,Other,125% Medicaid APG methodology,0.01,0.24,
LETROZOLE (FEMARA) 2.5MG TAB,,,,80001151,CDM,250,RC,93762056,NDC,both,30,EA,0.03,0.01,39.4668,,0.01,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.02,70,,0.02,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.03,,,0.03,Other,225% of Medicaid,0.02,,,0.02,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,0.03,
LEUCOVORIN CALCIUM 5MG TAB,,,,80001155,CDM,250,RC,555048401,NDC,both,30,EA,0.5,0.2,39.4668,,0.2,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.17,34,,0.17,percent of total billed charges,"Drugs, Inpatient Only",0.17,34,,0.17,percent of total billed charges,"Drugs, Inpatient Only",0.17,34,,0.17,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.35,70,,0.35,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.17,,,0.17,Other,Drug Cost,0.17,,,0.17,Other,Drug Cost,0.17,,,0.17,Other,Drug Cost,0.17,,,0.17,Other,Drug Cost,0.17,,,0.17,Other,Drug Cost,0.17,,,0.17,Other,Drug Cost,0.37,,,0.37,Other,225% of Medicaid,0.23,,,0.23,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.36,,,0.36,Other,215% Medicaid APG methodology,0.36,,,0.36,Other,215% Medicaid APG methodology,0.21,,,0.21,Other,125% Medicaid APG methodology,0.01,0.37,
LEVETIRACETAM (KEPPRA) 250MG TAB,,,,80001161,CDM,250,RC,68180011216,NDC,both,120,EA,0.05,0.02,39.4668,,0.02,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.02,34,,0.02,percent of total billed charges,"Drugs, Inpatient Only",0.02,34,,0.02,percent of total billed charges,"Drugs, Inpatient Only",0.02,34,,0.02,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.03,70,,0.03,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.04,,,0.04,Other,225% of Medicaid,0.02,,,0.02,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.03,,,0.03,Other,215% Medicaid APG methodology,0.03,,,0.03,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,125% Medicaid APG methodology,0.01,0.04,
LEVETIRACETAM (KEPPRA) 500MG TAB,,,,80001162,CDM,250,RC,68180011316,NDC,both,120,EA,0.03,0.01,39.4668,,0.01,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.02,70,,0.02,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.02,,,0.02,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,0.02,
LEVOBUNOLOL 0.5% OPTH SOLN  5ML,,,,80001166,CDM,250,RC,24208050505,NDC,both,1,ML,7.53,2.97,39.4668,,2.97,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2.56,34,,2.56,percent of total billed charges,"Drugs, Inpatient Only",2.56,34,,2.56,percent of total billed charges,"Drugs, Inpatient Only",2.56,34,,2.56,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,5.27,70,,5.27,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2.51,,,2.51,Other,Drug Cost,2.51,,,2.51,Other,Drug Cost,2.51,,,2.51,Other,Drug Cost,2.51,,,2.51,Other,Drug Cost,2.51,,,2.51,Other,Drug Cost,2.51,,,2.51,Other,Drug Cost,5.65,,,5.65,Other,225% of Medicaid,3.51,,,3.51,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,5.4,,,5.4,Other,215% Medicaid APG methodology,5.4,,,5.4,Other,215% Medicaid APG methodology,3.14,,,3.14,Other,125% Medicaid APG methodology,0.01,5.65,
LEVOCARNITINE (CARNITOR) 330MG,,,,80001167,CDM,250,RC,54482014407,NDC,both,90,EA,2.35,0.93,39.4668,,0.93,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.8,34,,0.8,percent of total billed charges,"Drugs, Inpatient Only",0.8,34,,0.8,percent of total billed charges,"Drugs, Inpatient Only",0.8,34,,0.8,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1.65,70,,1.65,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.78,,,0.78,Other,Drug Cost,0.78,,,0.78,Other,Drug Cost,0.78,,,0.78,Other,Drug Cost,0.78,,,0.78,Other,Drug Cost,0.78,,,0.78,Other,Drug Cost,0.78,,,0.78,Other,Drug Cost,1.77,,,1.77,Other,225% of Medicaid,1.1,,,1.1,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,1.69,,,1.69,Other,215% Medicaid APG methodology,1.69,,,1.69,Other,215% Medicaid APG methodology,0.98,,,0.98,Other,125% Medicaid APG methodology,0.01,1.77,
LEVOFLOXACIN 250 MG TAB,,,,80001169,CDM,250,RC,55111027950,NDC,both,50,EA,0.21,0.08,39.4668,,0.08,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.07,34,,0.07,percent of total billed charges,"Drugs, Inpatient Only",0.07,34,,0.07,percent of total billed charges,"Drugs, Inpatient Only",0.07,34,,0.07,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.15,70,,0.15,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.07,,,0.07,Other,Drug Cost,0.07,,,0.07,Other,Drug Cost,0.07,,,0.07,Other,Drug Cost,0.07,,,0.07,Other,Drug Cost,0.07,,,0.07,Other,Drug Cost,0.07,,,0.07,Other,Drug Cost,0.16,,,0.16,Other,225% of Medicaid,0.1,,,0.1,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.15,,,0.15,Other,215% Medicaid APG methodology,0.15,,,0.15,Other,215% Medicaid APG methodology,0.09,,,0.09,Other,125% Medicaid APG methodology,0.01,0.16,
LEVOFLOXACIN 500 MG TAB,,,,80001172,CDM,250,RC,55111028050,NDC,both,50,EA,0.2,0.08,39.4668,,0.08,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.07,34,,0.07,percent of total billed charges,"Drugs, Inpatient Only",0.07,34,,0.07,percent of total billed charges,"Drugs, Inpatient Only",0.07,34,,0.07,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.14,70,,0.14,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.07,,,0.07,Other,Drug Cost,0.07,,,0.07,Other,Drug Cost,0.07,,,0.07,Other,Drug Cost,0.07,,,0.07,Other,Drug Cost,0.07,,,0.07,Other,Drug Cost,0.07,,,0.07,Other,Drug Cost,0.15,,,0.15,Other,225% of Medicaid,0.09,,,0.09,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.14,,,0.14,Other,215% Medicaid APG methodology,0.14,,,0.14,Other,215% Medicaid APG methodology,0.08,,,0.08,Other,125% Medicaid APG methodology,0.01,0.15,
LEVOFLOXACIN 750 MG TAB,,,,80001174,CDM,250,RC,55111028130,NDC,both,30,EA,0.49,0.19,39.4668,,0.19,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.17,34,,0.17,percent of total billed charges,"Drugs, Inpatient Only",0.17,34,,0.17,percent of total billed charges,"Drugs, Inpatient Only",0.17,34,,0.17,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.35,70,,0.35,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.16,,,0.16,Other,Drug Cost,0.16,,,0.16,Other,Drug Cost,0.16,,,0.16,Other,Drug Cost,0.16,,,0.16,Other,Drug Cost,0.16,,,0.16,Other,Drug Cost,0.16,,,0.16,Other,Drug Cost,0.37,,,0.37,Other,225% of Medicaid,0.23,,,0.23,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.35,,,0.35,Other,215% Medicaid APG methodology,0.35,,,0.35,Other,215% Medicaid APG methodology,0.21,,,0.21,Other,125% Medicaid APG methodology,0.01,0.37,
LEVOPHED 1MG/ML 4ML INJ,,,,80001177,CDM,250,RC,409337504,NDC,both,10,ML,5,1.97,39.4668,,1.97,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1.7,34,,1.7,percent of total billed charges,"Drugs, Inpatient Only",1.7,34,,1.7,percent of total billed charges,"Drugs, Inpatient Only",1.7,34,,1.7,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,3.5,70,,3.5,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1.67,,,1.67,Other,Drug Cost,1.67,,,1.67,Other,Drug Cost,1.67,,,1.67,Other,Drug Cost,1.67,,,1.67,Other,Drug Cost,1.67,,,1.67,Other,Drug Cost,1.67,,,1.67,Other,Drug Cost,3.75,,,3.75,Other,225% of Medicaid,2.33,,,2.33,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,3.58,,,3.58,Other,215% Medicaid APG methodology,3.58,,,3.58,Other,215% Medicaid APG methodology,2.08,,,2.08,Other,125% Medicaid APG methodology,0.01,3.75,
LEVOTHYROXINE 100MCG TAB,,,,80001178,CDM,250,RC,378180977,NDC,both,90,EA,0.06,0.02,39.4668,,0.02,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.02,34,,0.02,percent of total billed charges,"Drugs, Inpatient Only",0.02,34,,0.02,percent of total billed charges,"Drugs, Inpatient Only",0.02,34,,0.02,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.04,70,,0.04,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.04,,,0.04,Other,225% of Medicaid,0.03,,,0.03,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.04,,,0.04,Other,215% Medicaid APG methodology,0.04,,,0.04,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,125% Medicaid APG methodology,0.01,0.04,
LEVOTHYROXINE 112MCG TAB,,,,80001179,CDM,250,RC,378181177,NDC,both,90,EA,0.07,0.03,39.4668,,0.03,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.02,34,,0.02,percent of total billed charges,"Drugs, Inpatient Only",0.02,34,,0.02,percent of total billed charges,"Drugs, Inpatient Only",0.02,34,,0.02,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.05,70,,0.05,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.05,,,0.05,Other,225% of Medicaid,0.03,,,0.03,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.05,,,0.05,Other,215% Medicaid APG methodology,0.05,,,0.05,Other,215% Medicaid APG methodology,0.03,,,0.03,Other,125% Medicaid APG methodology,0.01,0.05,
LEVOTHYROXINE 125MCG TAB,,,,80001180,CDM,250,RC,378181377,NDC,both,90,EA,0.07,0.03,39.4668,,0.03,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.02,34,,0.02,percent of total billed charges,"Drugs, Inpatient Only",0.02,34,,0.02,percent of total billed charges,"Drugs, Inpatient Only",0.02,34,,0.02,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.05,70,,0.05,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.05,,,0.05,Other,225% of Medicaid,0.03,,,0.03,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.05,,,0.05,Other,215% Medicaid APG methodology,0.05,,,0.05,Other,215% Medicaid APG methodology,0.03,,,0.03,Other,125% Medicaid APG methodology,0.01,0.05,
LEVOTHYROXINE 137 MCG TAB,,,,80001181,CDM,250,RC,68180097209,NDC,both,90,EA,0.03,0.01,39.4668,,0.01,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.02,70,,0.02,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.02,,,0.02,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,0.02,
LEVOTHYROXINE 150MCG TABLETS,,,,80001182,CDM,250,RC,378181577,NDC,both,90,EA,0.07,0.03,39.4668,,0.03,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.02,34,,0.02,percent of total billed charges,"Drugs, Inpatient Only",0.02,34,,0.02,percent of total billed charges,"Drugs, Inpatient Only",0.02,34,,0.02,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.05,70,,0.05,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.05,,,0.05,Other,225% of Medicaid,0.03,,,0.03,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.05,,,0.05,Other,215% Medicaid APG methodology,0.05,,,0.05,Other,215% Medicaid APG methodology,0.03,,,0.03,Other,125% Medicaid APG methodology,0.01,0.05,
LEVOTHYROXINE 175MCG TAB,,,,80001183,CDM,250,RC,378181777,NDC,both,90,EA,0.07,0.03,39.4668,,0.03,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.02,34,,0.02,percent of total billed charges,"Drugs, Inpatient Only",0.02,34,,0.02,percent of total billed charges,"Drugs, Inpatient Only",0.02,34,,0.02,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.05,70,,0.05,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.05,,,0.05,Other,225% of Medicaid,0.03,,,0.03,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.05,,,0.05,Other,215% Medicaid APG methodology,0.05,,,0.05,Other,215% Medicaid APG methodology,0.03,,,0.03,Other,125% Medicaid APG methodology,0.01,0.05,
LEVOTHYROXINE 25MCG TAB,,,,80001184,CDM,250,RC,68180096509,NDC,both,90,EA,0.03,0.01,39.4668,,0.01,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.02,70,,0.02,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.02,,,0.02,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,0.02,
LEVOTHYROXINE 50MCG TAB,,,,80001187,CDM,250,RC,378180377,NDC,both,90,EA,0.05,0.02,39.4668,,0.02,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.02,34,,0.02,percent of total billed charges,"Drugs, Inpatient Only",0.02,34,,0.02,percent of total billed charges,"Drugs, Inpatient Only",0.02,34,,0.02,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.03,70,,0.03,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.04,,,0.04,Other,225% of Medicaid,0.02,,,0.02,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.04,,,0.04,Other,215% Medicaid APG methodology,0.04,,,0.04,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,125% Medicaid APG methodology,0.01,0.04,
LEVOTHYROXINE 75MCG TAB,,,,80001188,CDM,250,RC,378180577,NDC,both,90,EA,0.05,0.02,39.4668,,0.02,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.02,34,,0.02,percent of total billed charges,"Drugs, Inpatient Only",0.02,34,,0.02,percent of total billed charges,"Drugs, Inpatient Only",0.02,34,,0.02,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.04,70,,0.04,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.04,,,0.04,Other,225% of Medicaid,0.03,,,0.03,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.04,,,0.04,Other,215% Medicaid APG methodology,0.04,,,0.04,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,125% Medicaid APG methodology,0.01,0.04,
LEVOTHYROXINE 88MCG TAB,,,,80001189,CDM,250,RC,378180777,NDC,both,90,EA,0.06,0.02,39.4668,,0.02,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.02,34,,0.02,percent of total billed charges,"Drugs, Inpatient Only",0.02,34,,0.02,percent of total billed charges,"Drugs, Inpatient Only",0.02,34,,0.02,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.04,70,,0.04,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.05,,,0.05,Other,225% of Medicaid,0.03,,,0.03,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.04,,,0.04,Other,215% Medicaid APG methodology,0.04,,,0.04,Other,215% Medicaid APG methodology,0.03,,,0.03,Other,125% Medicaid APG methodology,0.01,0.05,
LIDOCAINE 1% 20ML INJ,,,,80001190,CDM,250,RC,63323048527,NDC,both,25,ML,2.39,0.94,39.4668,,0.94,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.81,34,,0.81,percent of total billed charges,"Drugs, Inpatient Only",0.81,34,,0.81,percent of total billed charges,"Drugs, Inpatient Only",0.81,34,,0.81,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1.67,70,,1.67,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.8,,,0.8,Other,Drug Cost,0.8,,,0.8,Other,Drug Cost,0.8,,,0.8,Other,Drug Cost,0.8,,,0.8,Other,Drug Cost,0.8,,,0.8,Other,Drug Cost,0.8,,,0.8,Other,Drug Cost,1.79,,,1.79,Other,225% of Medicaid,1.12,,,1.12,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,1.71,,,1.71,Other,215% Medicaid APG methodology,1.71,,,1.71,Other,215% Medicaid APG methodology,1,,,1,Other,125% Medicaid APG methodology,0.01,1.79,
LIDOCAINE 1% 30ML INJ,,,,80001191,CDM,250,RC,63323049227,NDC,both,25,ML,0.3,0.12,39.4668,,0.12,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.1,34,,0.1,percent of total billed charges,"Drugs, Inpatient Only",0.1,34,,0.1,percent of total billed charges,"Drugs, Inpatient Only",0.1,34,,0.1,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.21,70,,0.21,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.1,,,0.1,Other,Drug Cost,0.1,,,0.1,Other,Drug Cost,0.1,,,0.1,Other,Drug Cost,0.1,,,0.1,Other,Drug Cost,0.1,,,0.1,Other,Drug Cost,0.1,,,0.1,Other,Drug Cost,0.22,,,0.22,Other,225% of Medicaid,0.14,,,0.14,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.21,,,0.21,Other,215% Medicaid APG methodology,0.21,,,0.21,Other,215% Medicaid APG methodology,0.12,,,0.12,Other,125% Medicaid APG methodology,0.01,0.22,
LIDOCAINE 1% 50ML INJ,,,,80001192,CDM,250,RC,63323048557,NDC,both,25,ML,5.98,2.36,39.4668,,2.36,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2.03,34,,2.03,percent of total billed charges,"Drugs, Inpatient Only",2.03,34,,2.03,percent of total billed charges,"Drugs, Inpatient Only",2.03,34,,2.03,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,4.18,70,,4.18,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1.99,,,1.99,Other,Drug Cost,1.99,,,1.99,Other,Drug Cost,1.99,,,1.99,Other,Drug Cost,1.99,,,1.99,Other,Drug Cost,1.99,,,1.99,Other,Drug Cost,1.99,,,1.99,Other,Drug Cost,4.48,,,4.48,Other,225% of Medicaid,2.79,,,2.79,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,4.28,,,4.28,Other,215% Medicaid APG methodology,4.28,,,4.28,Other,215% Medicaid APG methodology,2.49,,,2.49,Other,125% Medicaid APG methodology,0.01,4.48,
LIDOCAINE 2% 20ML INJ,,,,80001194,CDM,250,RC,63323048617,NDC,both,25,ML,1.52,0.6,39.4668,,0.6,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.52,34,,0.52,percent of total billed charges,"Drugs, Inpatient Only",0.52,34,,0.52,percent of total billed charges,"Drugs, Inpatient Only",0.52,34,,0.52,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1.07,70,,1.07,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.51,,,0.51,Other,Drug Cost,0.51,,,0.51,Other,Drug Cost,0.51,,,0.51,Other,Drug Cost,0.51,,,0.51,Other,Drug Cost,0.51,,,0.51,Other,Drug Cost,0.51,,,0.51,Other,Drug Cost,1.14,,,1.14,Other,225% of Medicaid,0.71,,,0.71,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,1.09,,,1.09,Other,215% Medicaid APG methodology,1.09,,,1.09,Other,215% Medicaid APG methodology,0.63,,,0.63,Other,125% Medicaid APG methodology,0.01,1.14,
LIDOCAINE 2% 5 ML MPF INJ,,,,80001195,CDM,250,RC,143959425,NDC,both,25,ML,1.67,0.66,39.4668,,0.66,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.57,34,,0.57,percent of total billed charges,"Drugs, Inpatient Only",0.57,34,,0.57,percent of total billed charges,"Drugs, Inpatient Only",0.57,34,,0.57,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1.17,70,,1.17,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.56,,,0.56,Other,Drug Cost,0.56,,,0.56,Other,Drug Cost,0.56,,,0.56,Other,Drug Cost,0.56,,,0.56,Other,Drug Cost,0.56,,,0.56,Other,Drug Cost,0.56,,,0.56,Other,Drug Cost,1.25,,,1.25,Other,225% of Medicaid,0.78,,,0.78,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,1.2,,,1.2,Other,215% Medicaid APG methodology,1.2,,,1.2,Other,215% Medicaid APG methodology,0.7,,,0.7,Other,125% Medicaid APG methodology,0.01,1.25,
LIDOCAINE 4% (LMX 4 PLUS) 5GM CRM,,,,80001198,CDM,250,RC,24357070106,NDC,both,5,GM,7.34,2.9,39.4668,,2.9,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2.49,34,,2.49,percent of total billed charges,"Drugs, Inpatient Only",2.49,34,,2.49,percent of total billed charges,"Drugs, Inpatient Only",2.49,34,,2.49,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,5.14,70,,5.14,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2.45,,,2.45,Other,Drug Cost,2.45,,,2.45,Other,Drug Cost,2.45,,,2.45,Other,Drug Cost,2.45,,,2.45,Other,Drug Cost,2.45,,,2.45,Other,Drug Cost,2.45,,,2.45,Other,Drug Cost,5.5,,,5.5,Other,225% of Medicaid,3.42,,,3.42,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,5.26,,,5.26,Other,215% Medicaid APG methodology,5.26,,,5.26,Other,215% Medicaid APG methodology,3.06,,,3.06,Other,125% Medicaid APG methodology,0.01,5.5,
LIDOCAINE 4% 5ML INJ,,,,80001199,CDM,250,RC,409428301,NDC,both,25,ML,7.05,2.78,39.4668,,2.78,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2.4,34,,2.4,percent of total billed charges,"Drugs, Inpatient Only",2.4,34,,2.4,percent of total billed charges,"Drugs, Inpatient Only",2.4,34,,2.4,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,4.93,70,,4.93,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2.35,,,2.35,Other,Drug Cost,2.35,,,2.35,Other,Drug Cost,2.35,,,2.35,Other,Drug Cost,2.35,,,2.35,Other,Drug Cost,2.35,,,2.35,Other,Drug Cost,2.35,,,2.35,Other,Drug Cost,5.28,,,5.28,Other,225% of Medicaid,3.29,,,3.29,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,5.05,,,5.05,Other,215% Medicaid APG methodology,5.05,,,5.05,Other,215% Medicaid APG methodology,2.94,,,2.94,Other,125% Medicaid APG methodology,0.01,5.28,
LIDOCAINE HCL 2% 5 ML UROJET,,,,80001201,CDM,250,RC,25021067376,NDC,both,10,ML,8.12,3.21,39.4668,,3.21,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2.76,34,,2.76,percent of total billed charges,"Drugs, Inpatient Only",2.76,34,,2.76,percent of total billed charges,"Drugs, Inpatient Only",2.76,34,,2.76,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,5.68,70,,5.68,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2.71,,,2.71,Other,Drug Cost,2.71,,,2.71,Other,Drug Cost,2.71,,,2.71,Other,Drug Cost,2.71,,,2.71,Other,Drug Cost,2.71,,,2.71,Other,Drug Cost,2.71,,,2.71,Other,Drug Cost,6.09,,,6.09,Other,225% of Medicaid,3.79,,,3.79,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,5.82,,,5.82,Other,215% Medicaid APG methodology,5.82,,,5.82,Other,215% Medicaid APG methodology,3.38,,,3.38,Other,125% Medicaid APG methodology,0.01,6.09,
LIDOCAINE HCL 4% 50 ML TOP,,,,80001203,CDM,250,RC,54350547,NDC,both,1,ML,2.61,1.03,39.4668,,1.03,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.89,34,,0.89,percent of total billed charges,"Drugs, Inpatient Only",0.89,34,,0.89,percent of total billed charges,"Drugs, Inpatient Only",0.89,34,,0.89,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1.83,70,,1.83,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.87,,,0.87,Other,Drug Cost,0.87,,,0.87,Other,Drug Cost,0.87,,,0.87,Other,Drug Cost,0.87,,,0.87,Other,Drug Cost,0.87,,,0.87,Other,Drug Cost,0.87,,,0.87,Other,Drug Cost,1.96,,,1.96,Other,225% of Medicaid,1.22,,,1.22,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,1.87,,,1.87,Other,215% Medicaid APG methodology,1.87,,,1.87,Other,215% Medicaid APG methodology,1.09,,,1.09,Other,125% Medicaid APG methodology,0.01,1.96,
LIDOCAINE INJECTION 1% 10 ML VIAL,,,,80001205,CDM,250,RC,55150025110,NDC,both,25,ML,2.8,1.1,39.4668,,1.1,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.95,34,,0.95,percent of total billed charges,"Drugs, Inpatient Only",0.95,34,,0.95,percent of total billed charges,"Drugs, Inpatient Only",0.95,34,,0.95,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1.96,70,,1.96,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.93,,,0.93,Other,Drug Cost,0.93,,,0.93,Other,Drug Cost,0.93,,,0.93,Other,Drug Cost,0.93,,,0.93,Other,Drug Cost,0.93,,,0.93,Other,Drug Cost,0.93,,,0.93,Other,Drug Cost,2.1,,,2.1,Other,225% of Medicaid,1.3,,,1.3,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,2,,,2,Other,215% Medicaid APG methodology,2,,,2,Other,215% Medicaid APG methodology,1.17,,,1.17,Other,125% Medicaid APG methodology,0.01,2.1,
LIDOCAINE VISCOUS 2% 100 ML,,,,80001206,CDM,250,RC,54350049,NDC,both,1,ML,4.71,1.86,39.4668,,1.86,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1.6,34,,1.6,percent of total billed charges,"Drugs, Inpatient Only",1.6,34,,1.6,percent of total billed charges,"Drugs, Inpatient Only",1.6,34,,1.6,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,3.3,70,,3.3,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1.57,,,1.57,Other,Drug Cost,1.57,,,1.57,Other,Drug Cost,1.57,,,1.57,Other,Drug Cost,1.57,,,1.57,Other,Drug Cost,1.57,,,1.57,Other,Drug Cost,1.57,,,1.57,Other,Drug Cost,3.53,,,3.53,Other,225% of Medicaid,2.2,,,2.2,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,3.38,,,3.38,Other,215% Medicaid APG methodology,3.38,,,3.38,Other,215% Medicaid APG methodology,1.96,,,1.96,Other,125% Medicaid APG methodology,0.01,3.53,
LIDOCAINE-EPI 1% 20ML INJ,,,,80001208,CDM,250,RC,63323048217,NDC,both,25,ML,1.71,0.68,39.4668,,0.68,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.58,34,,0.58,percent of total billed charges,"Drugs, Inpatient Only",0.58,34,,0.58,percent of total billed charges,"Drugs, Inpatient Only",0.58,34,,0.58,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1.2,70,,1.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.57,,,0.57,Other,Drug Cost,0.57,,,0.57,Other,Drug Cost,0.57,,,0.57,Other,Drug Cost,0.57,,,0.57,Other,Drug Cost,0.57,,,0.57,Other,Drug Cost,0.57,,,0.57,Other,Drug Cost,1.28,,,1.28,Other,225% of Medicaid,0.8,,,0.8,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,1.23,,,1.23,Other,215% Medicaid APG methodology,1.23,,,1.23,Other,215% Medicaid APG methodology,0.71,,,0.71,Other,125% Medicaid APG methodology,0.01,1.28,
LIDOCAINE-EPI 2% 20 ML INJ,,,,80001210,CDM,250,RC,63323048327,NDC,both,25,ML,1.47,0.58,39.4668,,0.58,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.5,34,,0.5,percent of total billed charges,"Drugs, Inpatient Only",0.5,34,,0.5,percent of total billed charges,"Drugs, Inpatient Only",0.5,34,,0.5,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1.03,70,,1.03,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.49,,,0.49,Other,Drug Cost,0.49,,,0.49,Other,Drug Cost,0.49,,,0.49,Other,Drug Cost,0.49,,,0.49,Other,Drug Cost,0.49,,,0.49,Other,Drug Cost,0.49,,,0.49,Other,Drug Cost,1.1,,,1.1,Other,225% of Medicaid,0.68,,,0.68,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,1.05,,,1.05,Other,215% Medicaid APG methodology,1.05,,,1.05,Other,215% Medicaid APG methodology,0.61,,,0.61,Other,125% Medicaid APG methodology,0.01,1.1,
LIDOCAINE-PRILOC 30 GM CRM,,,,80001211,CDM,250,RC,168035755,NDC,both,5,GM,1.34,0.53,39.4668,,0.53,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.46,34,,0.46,percent of total billed charges,"Drugs, Inpatient Only",0.46,34,,0.46,percent of total billed charges,"Drugs, Inpatient Only",0.46,34,,0.46,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.94,70,,0.94,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.45,,,0.45,Other,Drug Cost,0.45,,,0.45,Other,Drug Cost,0.45,,,0.45,Other,Drug Cost,0.45,,,0.45,Other,Drug Cost,0.45,,,0.45,Other,Drug Cost,0.45,,,0.45,Other,Drug Cost,1.01,,,1.01,Other,225% of Medicaid,0.63,,,0.63,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.96,,,0.96,Other,215% Medicaid APG methodology,0.96,,,0.96,Other,215% Medicaid APG methodology,0.56,,,0.56,Other,125% Medicaid APG methodology,0.01,1.01,
LIDODERM 5% 1 PATCH,,,,80001213,CDM,250,RC,603188016,NDC,both,30,EA,1.94,0.77,39.4668,,0.77,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.66,34,,0.66,percent of total billed charges,"Drugs, Inpatient Only",0.66,34,,0.66,percent of total billed charges,"Drugs, Inpatient Only",0.66,34,,0.66,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1.36,70,,1.36,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.65,,,0.65,Other,Drug Cost,0.65,,,0.65,Other,Drug Cost,0.65,,,0.65,Other,Drug Cost,0.65,,,0.65,Other,Drug Cost,0.65,,,0.65,Other,Drug Cost,0.65,,,0.65,Other,Drug Cost,1.46,,,1.46,Other,225% of Medicaid,0.91,,,0.91,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,1.39,,,1.39,Other,215% Medicaid APG methodology,1.39,,,1.39,Other,215% Medicaid APG methodology,0.81,,,0.81,Other,125% Medicaid APG methodology,0.01,1.46,
LINEZOLID 600MG TAB,,,,80001216,CDM,250,RC,67877041920,NDC,both,20,EA,1.96,0.77,39.4668,,0.77,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.67,34,,0.67,percent of total billed charges,"Drugs, Inpatient Only",0.67,34,,0.67,percent of total billed charges,"Drugs, Inpatient Only",0.67,34,,0.67,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1.37,70,,1.37,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.65,,,0.65,Other,Drug Cost,0.65,,,0.65,Other,Drug Cost,0.65,,,0.65,Other,Drug Cost,0.65,,,0.65,Other,Drug Cost,0.65,,,0.65,Other,Drug Cost,0.65,,,0.65,Other,Drug Cost,1.47,,,1.47,Other,225% of Medicaid,0.92,,,0.92,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,1.41,,,1.41,Other,215% Medicaid APG methodology,1.41,,,1.41,Other,215% Medicaid APG methodology,0.82,,,0.82,Other,125% Medicaid APG methodology,0.01,1.47,
LIOTHYRONINE SODIUM (CYTOMEL) 25 MCG TAB,,,,80001219,CDM,250,RC,62756059088,NDC,both,100,EA,0.1,0.04,39.4668,,0.04,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.03,34,,0.03,percent of total billed charges,"Drugs, Inpatient Only",0.03,34,,0.03,percent of total billed charges,"Drugs, Inpatient Only",0.03,34,,0.03,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.07,70,,0.07,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.07,,,0.07,Other,225% of Medicaid,0.05,,,0.05,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.07,,,0.07,Other,215% Medicaid APG methodology,0.07,,,0.07,Other,215% Medicaid APG methodology,0.04,,,0.04,Other,125% Medicaid APG methodology,0.01,0.07,
LIOTHYRONINE SODIUM (CYTOMEL) 5 MCG TABS,,,,80001220,CDM,250,RC,60793011501,NDC,both,100,EA,0.03,0.01,39.4668,,0.01,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.02,70,,0.02,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.02,,,0.02,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,0.02,
LISINOPRIL 10 MG TAB,,,,80001222,CDM,250,RC,68180098001,NDC,both,100,EA,0.03,0.01,39.4668,,0.01,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.02,70,,0.02,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.02,,,0.02,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,0.02,
LISINOPRIL 2.5 MG TAB,,,,80001223,CDM,250,RC,68180051201,NDC,both,100,EA,0.02,0.01,39.4668,,0.01,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.02,70,,0.02,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.02,,,0.02,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,0.02,
LISINOPRIL 20 MG TAB,,,,80001224,CDM,250,RC,68180098101,NDC,both,100,EA,0.03,0.01,39.4668,,0.01,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.02,70,,0.02,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.02,,,0.02,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,0.02,
LITHIUM CARBONATE 150 MG CAPS,,,,80001227,CDM,250,RC,54252625,NDC,both,100,EA,0.09,0.03,39.4668,,0.03,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.03,34,,0.03,percent of total billed charges,"Drugs, Inpatient Only",0.03,34,,0.03,percent of total billed charges,"Drugs, Inpatient Only",0.03,34,,0.03,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.06,70,,0.06,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.07,,,0.07,Other,225% of Medicaid,0.04,,,0.04,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.06,,,0.06,Other,215% Medicaid APG methodology,0.06,,,0.06,Other,215% Medicaid APG methodology,0.04,,,0.04,Other,125% Medicaid APG methodology,0.01,0.07,
LITHIUM CARBONATE 300 MG CAPS,,,,80001228,CDM,250,RC,68462022101,NDC,both,100,EA,0.12,0.05,39.4668,,0.05,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.04,34,,0.04,percent of total billed charges,"Drugs, Inpatient Only",0.04,34,,0.04,percent of total billed charges,"Drugs, Inpatient Only",0.04,34,,0.04,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.08,70,,0.08,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.09,,,0.09,Other,225% of Medicaid,0.06,,,0.06,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.09,,,0.09,Other,215% Medicaid APG methodology,0.09,,,0.09,Other,215% Medicaid APG methodology,0.05,,,0.05,Other,125% Medicaid APG methodology,0.01,0.09,
LITHIUM CARBONATE 300 MG SR TB,,,,80001229,CDM,250,RC,62559028001,NDC,both,100,EA,0.03,0.01,39.4668,,0.01,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.02,70,,0.02,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.02,,,0.02,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,0.02,
LITHIUM CARBONATE 450 MG ER TAB,,,,80001230,CDM,250,RC,54002025,NDC,both,100,EA,0.21,0.08,39.4668,,0.08,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.07,34,,0.07,percent of total billed charges,"Drugs, Inpatient Only",0.07,34,,0.07,percent of total billed charges,"Drugs, Inpatient Only",0.07,34,,0.07,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.15,70,,0.15,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.07,,,0.07,Other,Drug Cost,0.07,,,0.07,Other,Drug Cost,0.07,,,0.07,Other,Drug Cost,0.07,,,0.07,Other,Drug Cost,0.07,,,0.07,Other,Drug Cost,0.07,,,0.07,Other,Drug Cost,0.16,,,0.16,Other,225% of Medicaid,0.1,,,0.1,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.15,,,0.15,Other,215% Medicaid APG methodology,0.15,,,0.15,Other,215% Medicaid APG methodology,0.09,,,0.09,Other,125% Medicaid APG methodology,0.01,0.16,
LOMOTIL 2.5-0.025MG TAB,,,,80001232,CDM,250,RC,25006131,NDC,both,100,EA,0.03,0.01,39.4668,,0.01,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.02,70,,0.02,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.02,,,0.02,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,0.02,
LOPERAMIDE 2 MG CAPS,,,,80001237,CDM,250,RC,93031101,NDC,both,100,EA,0.2,0.08,39.4668,,0.08,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.07,34,,0.07,percent of total billed charges,"Drugs, Inpatient Only",0.07,34,,0.07,percent of total billed charges,"Drugs, Inpatient Only",0.07,34,,0.07,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.14,70,,0.14,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.07,,,0.07,Other,Drug Cost,0.07,,,0.07,Other,Drug Cost,0.07,,,0.07,Other,Drug Cost,0.07,,,0.07,Other,Drug Cost,0.07,,,0.07,Other,Drug Cost,0.07,,,0.07,Other,Drug Cost,0.15,,,0.15,Other,225% of Medicaid,0.09,,,0.09,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.14,,,0.14,Other,215% Medicaid APG methodology,0.14,,,0.14,Other,215% Medicaid APG methodology,0.08,,,0.08,Other,125% Medicaid APG methodology,0.01,0.15,
LOPRESSOR 25 MG TAB,,,,80001238,CDM,250,RC,378001801,NDC,both,100,EA,0.03,0.01,39.4668,,0.01,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.02,70,,0.02,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.02,,,0.02,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,0.02,
LOPRESSOR 50 MG TAB,,,,80001239,CDM,250,RC,378003210,NDC,both,1000,EA,0.03,0.01,39.4668,,0.01,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.02,70,,0.02,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.02,,,0.02,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,0.02,
LORAZEPAM 0.5 MG TAB,,,,80001242,CDM,250,RC,69315090405,NDC,both,500,EA,0.03,0.01,39.4668,,0.01,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.02,70,,0.02,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.02,,,0.02,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,0.02,
LORAZEPAM 1 MG TAB,,,,80001243,CDM,250,RC,13107008405,NDC,both,500,EA,0.03,0.01,39.4668,,0.01,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.02,70,,0.02,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.02,,,0.02,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,0.02,
LORAZEPAM INTENSOL 2 MG/ML 30ML CONC,,,,80001246,CDM,250,RC,54353244,NDC,both,1,ML,0.87,0.34,39.4668,,0.34,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.3,34,,0.3,percent of total billed charges,"Drugs, Inpatient Only",0.3,34,,0.3,percent of total billed charges,"Drugs, Inpatient Only",0.3,34,,0.3,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.61,70,,0.61,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.29,,,0.29,Other,Drug Cost,0.29,,,0.29,Other,Drug Cost,0.29,,,0.29,Other,Drug Cost,0.29,,,0.29,Other,Drug Cost,0.29,,,0.29,Other,Drug Cost,0.29,,,0.29,Other,Drug Cost,0.65,,,0.65,Other,225% of Medicaid,0.41,,,0.41,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.62,,,0.62,Other,215% Medicaid APG methodology,0.62,,,0.62,Other,215% Medicaid APG methodology,0.36,,,0.36,Other,125% Medicaid APG methodology,0.01,0.65,
LOSARTAN 50 MG TAB,,,,80001247,CDM,250,RC,65862020290,NDC,both,90,EA,0.04,0.02,39.4668,,0.02,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.03,70,,0.03,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.03,,,0.03,Other,225% of Medicaid,0.02,,,0.02,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.03,,,0.03,Other,215% Medicaid APG methodology,0.03,,,0.03,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,125% Medicaid APG methodology,0.01,0.03,
LOSARTAN POTASSIUM (COZAAR) 25 MG,,,,80001248,CDM,250,RC,65862020190,NDC,both,90,EA,0.03,0.01,39.4668,,0.01,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.02,70,,0.02,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.02,,,0.02,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,0.02,
LOVASTATIN 20 MG TAB,,,,80001251,CDM,250,RC,61442014201,NDC,both,100,EA,0.23,0.09,39.4668,,0.09,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.08,34,,0.08,percent of total billed charges,"Drugs, Inpatient Only",0.08,34,,0.08,percent of total billed charges,"Drugs, Inpatient Only",0.08,34,,0.08,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.16,70,,0.16,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.08,,,0.08,Other,Drug Cost,0.08,,,0.08,Other,Drug Cost,0.08,,,0.08,Other,Drug Cost,0.08,,,0.08,Other,Drug Cost,0.08,,,0.08,Other,Drug Cost,0.08,,,0.08,Other,Drug Cost,0.17,,,0.17,Other,225% of Medicaid,0.11,,,0.11,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.17,,,0.17,Other,215% Medicaid APG methodology,0.17,,,0.17,Other,215% Medicaid APG methodology,0.1,,,0.1,Other,125% Medicaid APG methodology,0.01,0.17,
LOXAPINE 25MG CAP,,,,80001252,CDM,250,RC,591037101,NDC,both,100,EA,0.58,0.23,39.4668,,0.23,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.2,34,,0.2,percent of total billed charges,"Drugs, Inpatient Only",0.2,34,,0.2,percent of total billed charges,"Drugs, Inpatient Only",0.2,34,,0.2,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.41,70,,0.41,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.19,,,0.19,Other,Drug Cost,0.19,,,0.19,Other,Drug Cost,0.19,,,0.19,Other,Drug Cost,0.19,,,0.19,Other,Drug Cost,0.19,,,0.19,Other,Drug Cost,0.19,,,0.19,Other,Drug Cost,0.43,,,0.43,Other,225% of Medicaid,0.27,,,0.27,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.42,,,0.42,Other,215% Medicaid APG methodology,0.42,,,0.42,Other,215% Medicaid APG methodology,0.24,,,0.24,Other,125% Medicaid APG methodology,0.01,0.43,
LOXAPINE SUCCINATE 10MG CAPS,,,,80001253,CDM,250,RC,591037001,NDC,both,100,EA,0.06,0.02,39.4668,,0.02,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.02,34,,0.02,percent of total billed charges,"Drugs, Inpatient Only",0.02,34,,0.02,percent of total billed charges,"Drugs, Inpatient Only",0.02,34,,0.02,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.04,70,,0.04,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.04,,,0.04,Other,225% of Medicaid,0.03,,,0.03,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.04,,,0.04,Other,215% Medicaid APG methodology,0.04,,,0.04,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,125% Medicaid APG methodology,0.01,0.04,
MAG AL PLUS 1200MG/120MG/30ML UD,,,,80001256,CDM,250,RC,121176130,NDC,both,100,ML,1.47,0.58,39.4668,,0.58,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.5,34,,0.5,percent of total billed charges,"Drugs, Inpatient Only",0.5,34,,0.5,percent of total billed charges,"Drugs, Inpatient Only",0.5,34,,0.5,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1.03,70,,1.03,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.49,,,0.49,Other,Drug Cost,0.49,,,0.49,Other,Drug Cost,0.49,,,0.49,Other,Drug Cost,0.49,,,0.49,Other,Drug Cost,0.49,,,0.49,Other,Drug Cost,0.49,,,0.49,Other,Drug Cost,1.1,,,1.1,Other,225% of Medicaid,0.69,,,0.69,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,1.05,,,1.05,Other,215% Medicaid APG methodology,1.05,,,1.05,Other,215% Medicaid APG methodology,0.61,,,0.61,Other,125% Medicaid APG methodology,0.01,1.1,
MAGIC MOUTHWASH,,,,80001257,CDM,250,RC,65628005001,NDC,both,1,ML,339.72,134.08,39.4668,,134.08,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,115.5,34,,115.5,percent of total billed charges,"Drugs, Inpatient Only",115.5,34,,115.5,percent of total billed charges,"Drugs, Inpatient Only",115.5,34,,115.5,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,237.8,70,,237.8,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,113.24,,,113.24,Other,Drug Cost,113.24,,,113.24,Other,Drug Cost,113.24,,,113.24,Other,Drug Cost,113.24,,,113.24,Other,Drug Cost,113.24,,,113.24,Other,Drug Cost,113.24,,,113.24,Other,Drug Cost,254.79,,,254.79,Other,225% of Medicaid,158.54,,,158.54,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,243.47,,,243.47,Other,215% Medicaid APG methodology,243.47,,,243.47,Other,215% Medicaid APG methodology,141.55,,,141.55,Other,125% Medicaid APG methodology,0.01,254.79,
MAGNESIUM 1GM/D5W 100 ML,,,,80001258,CDM,250,RC,338170940,NDC,both,40,ML,3.23,1.27,39.4668,,1.27,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1.1,34,,1.1,percent of total billed charges,"Drugs, Inpatient Only",1.1,34,,1.1,percent of total billed charges,"Drugs, Inpatient Only",1.1,34,,1.1,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2.26,70,,2.26,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1.08,,,1.08,Other,Drug Cost,1.08,,,1.08,Other,Drug Cost,1.08,,,1.08,Other,Drug Cost,1.08,,,1.08,Other,Drug Cost,1.08,,,1.08,Other,Drug Cost,1.08,,,1.08,Other,Drug Cost,2.42,,,2.42,Other,225% of Medicaid,1.51,,,1.51,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,2.31,,,2.31,Other,215% Medicaid APG methodology,2.31,,,2.31,Other,215% Medicaid APG methodology,1.35,,,1.35,Other,125% Medicaid APG methodology,0.01,2.42,
MAGNESIUM OXIDE 400MG TAB,,,,80001261,CDM,250,RC,603020922,NDC,both,120,EA,0.06,0.03,39.4668,,0.03,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.02,34,,0.02,percent of total billed charges,"Drugs, Inpatient Only",0.02,34,,0.02,percent of total billed charges,"Drugs, Inpatient Only",0.02,34,,0.02,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.04,70,,0.04,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.05,,,0.05,Other,225% of Medicaid,0.03,,,0.03,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.05,,,0.05,Other,215% Medicaid APG methodology,0.05,,,0.05,Other,215% Medicaid APG methodology,0.03,,,0.03,Other,125% Medicaid APG methodology,0.01,0.05,
MECLIZINE 25 MG TAB,,,,80001271,CDM,250,RC,50268052315,NDC,both,5,EA,12.32,4.86,39.4668,,4.86,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,4.19,34,,4.19,percent of total billed charges,"Drugs, Inpatient Only",4.19,34,,4.19,percent of total billed charges,"Drugs, Inpatient Only",4.19,34,,4.19,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,8.63,70,,8.63,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,4.11,,,4.11,Other,Drug Cost,4.11,,,4.11,Other,Drug Cost,4.11,,,4.11,Other,Drug Cost,4.11,,,4.11,Other,Drug Cost,4.11,,,4.11,Other,Drug Cost,4.11,,,4.11,Other,Drug Cost,9.24,,,9.24,Other,225% of Medicaid,5.75,,,5.75,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,8.83,,,8.83,Other,215% Medicaid APG methodology,8.83,,,8.83,Other,215% Medicaid APG methodology,5.14,,,5.14,Other,125% Medicaid APG methodology,0.01,9.24,
MEDROXYPROGEST 2.5 MG TAB,,,,80001272,CDM,250,RC,555087202,NDC,both,100,EA,0.15,0.06,39.4668,,0.06,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.05,34,,0.05,percent of total billed charges,"Drugs, Inpatient Only",0.05,34,,0.05,percent of total billed charges,"Drugs, Inpatient Only",0.05,34,,0.05,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.11,70,,0.11,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.11,,,0.11,Other,225% of Medicaid,0.07,,,0.07,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.11,,,0.11,Other,215% Medicaid APG methodology,0.11,,,0.11,Other,215% Medicaid APG methodology,0.06,,,0.06,Other,125% Medicaid APG methodology,0.01,0.11,
MEDROXYPROGEST 5 MG TAB,,,,80001273,CDM,250,RC,555087302,NDC,both,100,EA,0.17,0.07,39.4668,,0.07,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.06,34,,0.06,percent of total billed charges,"Drugs, Inpatient Only",0.06,34,,0.06,percent of total billed charges,"Drugs, Inpatient Only",0.06,34,,0.06,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.12,70,,0.12,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.06,,,0.06,Other,Drug Cost,0.06,,,0.06,Other,Drug Cost,0.06,,,0.06,Other,Drug Cost,0.06,,,0.06,Other,Drug Cost,0.06,,,0.06,Other,Drug Cost,0.06,,,0.06,Other,Drug Cost,0.13,,,0.13,Other,225% of Medicaid,0.08,,,0.08,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.12,,,0.12,Other,215% Medicaid APG methodology,0.12,,,0.12,Other,215% Medicaid APG methodology,0.07,,,0.07,Other,125% Medicaid APG methodology,0.01,0.13,
MEGESTROL 40 MG/ML SUSP 10ML UD,,,,80001274,CDM,250,RC,121094500,NDC,both,100,ML,1.51,0.6,39.4668,,0.6,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.51,34,,0.51,percent of total billed charges,"Drugs, Inpatient Only",0.51,34,,0.51,percent of total billed charges,"Drugs, Inpatient Only",0.51,34,,0.51,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1.06,70,,1.06,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.5,,,0.5,Other,Drug Cost,0.5,,,0.5,Other,Drug Cost,0.5,,,0.5,Other,Drug Cost,0.5,,,0.5,Other,Drug Cost,0.5,,,0.5,Other,Drug Cost,0.5,,,0.5,Other,Drug Cost,1.14,,,1.14,Other,225% of Medicaid,0.71,,,0.71,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,1.08,,,1.08,Other,215% Medicaid APG methodology,1.08,,,1.08,Other,215% Medicaid APG methodology,0.63,,,0.63,Other,125% Medicaid APG methodology,0.01,1.14,
MEGESTROL 40MG TAB,,,,80001275,CDM,250,RC,64380015901,NDC,both,100,EA,0.27,0.11,39.4668,,0.11,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.09,34,,0.09,percent of total billed charges,"Drugs, Inpatient Only",0.09,34,,0.09,percent of total billed charges,"Drugs, Inpatient Only",0.09,34,,0.09,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.19,70,,0.19,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.09,,,0.09,Other,Drug Cost,0.09,,,0.09,Other,Drug Cost,0.09,,,0.09,Other,Drug Cost,0.09,,,0.09,Other,Drug Cost,0.09,,,0.09,Other,Drug Cost,0.09,,,0.09,Other,Drug Cost,0.2,,,0.2,Other,225% of Medicaid,0.12,,,0.12,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.19,,,0.19,Other,215% Medicaid APG methodology,0.19,,,0.19,Other,215% Medicaid APG methodology,0.11,,,0.11,Other,125% Medicaid APG methodology,0.01,0.2,
MELOXICAM TABLETS 7.5MG,,,,80001278,CDM,250,RC,69097015807,NDC,both,100,EA,0.03,0.01,39.4668,,0.01,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.02,70,,0.02,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.02,,,0.02,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,0.02,
MEMANTINE 10MG TAB,,,,80001280,CDM,250,RC,68180023007,NDC,both,60,EA,0.07,0.03,39.4668,,0.03,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.02,34,,0.02,percent of total billed charges,"Drugs, Inpatient Only",0.02,34,,0.02,percent of total billed charges,"Drugs, Inpatient Only",0.02,34,,0.02,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.05,70,,0.05,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.05,,,0.05,Other,225% of Medicaid,0.03,,,0.03,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.05,,,0.05,Other,215% Medicaid APG methodology,0.05,,,0.05,Other,215% Medicaid APG methodology,0.03,,,0.03,Other,125% Medicaid APG methodology,0.01,0.05,
MEMANTINE 5MG TAB,,,,80001281,CDM,250,RC,29300017116,NDC,both,60,EA,0.04,0.02,39.4668,,0.02,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.03,70,,0.03,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.03,,,0.03,Other,225% of Medicaid,0.02,,,0.02,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.03,,,0.03,Other,215% Medicaid APG methodology,0.03,,,0.03,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,125% Medicaid APG methodology,0.01,0.03,
MEPRON 750 MG/5ML,,,,80001299,CDM,250,RC,173054700,NDC,both,42,ML,90.11,35.56,39.4668,,35.56,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,30.64,34,,30.64,percent of total billed charges,"Drugs, Inpatient Only",30.64,34,,30.64,percent of total billed charges,"Drugs, Inpatient Only",30.64,34,,30.64,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,63.07,70,,63.07,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,30.04,,,30.04,Other,Drug Cost,30.04,,,30.04,Other,Drug Cost,30.04,,,30.04,Other,Drug Cost,30.04,,,30.04,Other,Drug Cost,30.04,,,30.04,Other,Drug Cost,30.04,,,30.04,Other,Drug Cost,67.58,,,67.58,Other,225% of Medicaid,42.05,,,42.05,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,64.58,,,64.58,Other,215% Medicaid APG methodology,64.58,,,64.58,Other,215% Medicaid APG methodology,37.54,,,37.54,Other,125% Medicaid APG methodology,0.01,67.58,
MERCAPTOPURINE ORAL 50 MG,,,,80001300,CDM,250,RC,54458111,NDC,both,25,EA,1.13,0.45,39.4668,,0.45,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.39,34,,0.39,percent of total billed charges,"Drugs, Inpatient Only",0.39,34,,0.39,percent of total billed charges,"Drugs, Inpatient Only",0.39,34,,0.39,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.79,70,,0.79,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.38,,,0.38,Other,Drug Cost,0.38,,,0.38,Other,Drug Cost,0.38,,,0.38,Other,Drug Cost,0.38,,,0.38,Other,Drug Cost,0.38,,,0.38,Other,Drug Cost,0.38,,,0.38,Other,Drug Cost,0.85,,,0.85,Other,225% of Medicaid,0.53,,,0.53,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.81,,,0.81,Other,215% Medicaid APG methodology,0.81,,,0.81,Other,215% Medicaid APG methodology,0.47,,,0.47,Other,125% Medicaid APG methodology,0.01,0.85,
MESALAMINE 250 MG CAP,,,,80001304,CDM,250,RC,54092018981,NDC,both,240,EA,0.03,0.01,39.4668,,0.01,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.02,70,,0.02,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.02,,,0.02,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,0.02,
MESALAMINE 4 GM/60 ML ENEMA,,,,80001307,CDM,250,RC,45802009851,NDC,both,7,ML,10.03,3.96,39.4668,,3.96,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,3.41,34,,3.41,percent of total billed charges,"Drugs, Inpatient Only",3.41,34,,3.41,percent of total billed charges,"Drugs, Inpatient Only",3.41,34,,3.41,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,7.02,70,,7.02,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,3.34,,,3.34,Other,Drug Cost,3.34,,,3.34,Other,Drug Cost,3.34,,,3.34,Other,Drug Cost,3.34,,,3.34,Other,Drug Cost,3.34,,,3.34,Other,Drug Cost,3.34,,,3.34,Other,Drug Cost,7.52,,,7.52,Other,225% of Medicaid,4.68,,,4.68,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,7.19,,,7.19,Other,215% Medicaid APG methodology,7.19,,,7.19,Other,215% Medicaid APG methodology,4.18,,,4.18,Other,125% Medicaid APG methodology,0.01,7.52,
METFORMIN 500 MG TAB,,,,80001311,CDM,250,RC,70010006301,NDC,both,100,EA,0.03,0.01,39.4668,,0.01,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.02,70,,0.02,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.02,,,0.02,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,0.02,
METHADONE 10 MG TAB,,,,80001315,CDM,250,RC,406577162,NDC,both,10,EA,1.07,0.42,39.4668,,0.42,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.36,34,,0.36,percent of total billed charges,"Drugs, Inpatient Only",0.36,34,,0.36,percent of total billed charges,"Drugs, Inpatient Only",0.36,34,,0.36,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.75,70,,0.75,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.36,,,0.36,Other,Drug Cost,0.36,,,0.36,Other,Drug Cost,0.36,,,0.36,Other,Drug Cost,0.36,,,0.36,Other,Drug Cost,0.36,,,0.36,Other,Drug Cost,0.36,,,0.36,Other,Drug Cost,0.8,,,0.8,Other,225% of Medicaid,0.5,,,0.5,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.76,,,0.76,Other,215% Medicaid APG methodology,0.76,,,0.76,Other,215% Medicaid APG methodology,0.44,,,0.44,Other,125% Medicaid APG methodology,0.01,0.8,
METHADONE 40MG TAB,,,,80001318,CDM,250,RC,66689089840,NDC,both,100,EA,0.69,0.27,39.4668,,0.27,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.24,34,,0.24,percent of total billed charges,"Drugs, Inpatient Only",0.24,34,,0.24,percent of total billed charges,"Drugs, Inpatient Only",0.24,34,,0.24,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.48,70,,0.48,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.23,,,0.23,Other,Drug Cost,0.23,,,0.23,Other,Drug Cost,0.23,,,0.23,Other,Drug Cost,0.23,,,0.23,Other,Drug Cost,0.23,,,0.23,Other,Drug Cost,0.23,,,0.23,Other,Drug Cost,0.52,,,0.52,Other,225% of Medicaid,0.32,,,0.32,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.5,,,0.5,Other,215% Medicaid APG methodology,0.5,,,0.5,Other,215% Medicaid APG methodology,0.29,,,0.29,Other,125% Medicaid APG methodology,0.01,0.52,
METHADONE 5 MG TAB,,,,80001319,CDM,250,RC,406575562,NDC,both,10,EA,0.85,0.33,39.4668,,0.33,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.29,34,,0.29,percent of total billed charges,"Drugs, Inpatient Only",0.29,34,,0.29,percent of total billed charges,"Drugs, Inpatient Only",0.29,34,,0.29,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.59,70,,0.59,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.28,,,0.28,Other,Drug Cost,0.28,,,0.28,Other,Drug Cost,0.28,,,0.28,Other,Drug Cost,0.28,,,0.28,Other,Drug Cost,0.28,,,0.28,Other,Drug Cost,0.28,,,0.28,Other,Drug Cost,0.63,,,0.63,Other,225% of Medicaid,0.39,,,0.39,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.61,,,0.61,Other,215% Medicaid APG methodology,0.61,,,0.61,Other,215% Medicaid APG methodology,0.35,,,0.35,Other,125% Medicaid APG methodology,0.01,0.63,
METHENAMINE 1G TAB,,,,80001321,CDM,250,RC,42799010601,NDC,both,100,EA,8.15,3.22,39.4668,,3.22,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2.77,34,,2.77,percent of total billed charges,"Drugs, Inpatient Only",2.77,34,,2.77,percent of total billed charges,"Drugs, Inpatient Only",2.77,34,,2.77,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,5.71,70,,5.71,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2.72,,,2.72,Other,Drug Cost,2.72,,,2.72,Other,Drug Cost,2.72,,,2.72,Other,Drug Cost,2.72,,,2.72,Other,Drug Cost,2.72,,,2.72,Other,Drug Cost,2.72,,,2.72,Other,Drug Cost,6.11,,,6.11,Other,225% of Medicaid,3.8,,,3.8,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,5.84,,,5.84,Other,215% Medicaid APG methodology,5.84,,,5.84,Other,215% Medicaid APG methodology,3.4,,,3.4,Other,125% Medicaid APG methodology,0.01,6.11,
METHENAMINE 500MG TAB,,,,80001322,CDM,250,RC,42799010501,NDC,both,100,EA,4.08,1.61,39.4668,,1.61,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1.39,34,,1.39,percent of total billed charges,"Drugs, Inpatient Only",1.39,34,,1.39,percent of total billed charges,"Drugs, Inpatient Only",1.39,34,,1.39,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2.85,70,,2.85,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1.36,,,1.36,Other,Drug Cost,1.36,,,1.36,Other,Drug Cost,1.36,,,1.36,Other,Drug Cost,1.36,,,1.36,Other,Drug Cost,1.36,,,1.36,Other,Drug Cost,1.36,,,1.36,Other,Drug Cost,3.06,,,3.06,Other,225% of Medicaid,1.9,,,1.9,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,2.92,,,2.92,Other,215% Medicaid APG methodology,2.92,,,2.92,Other,215% Medicaid APG methodology,1.7,,,1.7,Other,125% Medicaid APG methodology,0.01,3.06,
METHERGINE 0.2 MG TAB,,,,80001324,CDM,250,RC,93365522,NDC,both,12,EA,8.62,3.4,39.4668,,3.4,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2.93,34,,2.93,percent of total billed charges,"Drugs, Inpatient Only",2.93,34,,2.93,percent of total billed charges,"Drugs, Inpatient Only",2.93,34,,2.93,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,6.03,70,,6.03,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2.87,,,2.87,Other,Drug Cost,2.87,,,2.87,Other,Drug Cost,2.87,,,2.87,Other,Drug Cost,2.87,,,2.87,Other,Drug Cost,2.87,,,2.87,Other,Drug Cost,2.87,,,2.87,Other,Drug Cost,6.46,,,6.46,Other,225% of Medicaid,4.02,,,4.02,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,6.18,,,6.18,Other,215% Medicaid APG methodology,6.18,,,6.18,Other,215% Medicaid APG methodology,3.59,,,3.59,Other,125% Medicaid APG methodology,0.01,6.46,
METHIMAZOLE 5MG TAB,,,,80001326,CDM,250,RC,23155007001,NDC,both,100,EA,0.08,0.03,39.4668,,0.03,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.03,34,,0.03,percent of total billed charges,"Drugs, Inpatient Only",0.03,34,,0.03,percent of total billed charges,"Drugs, Inpatient Only",0.03,34,,0.03,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.06,70,,0.06,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.06,,,0.06,Other,225% of Medicaid,0.04,,,0.04,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.06,,,0.06,Other,215% Medicaid APG methodology,0.06,,,0.06,Other,215% Medicaid APG methodology,0.03,,,0.03,Other,125% Medicaid APG methodology,0.01,0.06,
METHOCARBAMOL 500MG TAB,,,,80001327,CDM,250,RC,70010075401,NDC,both,100,EA,0.04,0.01,39.4668,,0.01,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.03,70,,0.03,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.03,,,0.03,Other,225% of Medicaid,0.02,,,0.02,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.03,,,0.03,Other,215% Medicaid APG methodology,0.03,,,0.03,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,125% Medicaid APG methodology,0.01,0.03,
METHYLPHENIDATE 10MG TAB,,,,80001336,CDM,250,RC,16729047901,NDC,both,100,EA,0.15,0.06,39.4668,,0.06,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.05,34,,0.05,percent of total billed charges,"Drugs, Inpatient Only",0.05,34,,0.05,percent of total billed charges,"Drugs, Inpatient Only",0.05,34,,0.05,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.1,70,,0.1,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.11,,,0.11,Other,225% of Medicaid,0.07,,,0.07,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.11,,,0.11,Other,215% Medicaid APG methodology,0.11,,,0.11,Other,215% Medicaid APG methodology,0.06,,,0.06,Other,125% Medicaid APG methodology,0.01,0.11,
METHYLPHENIDATE 5MG TAB,,,,80001337,CDM,250,RC,10702010001,NDC,both,100,EA,0.1,0.04,39.4668,,0.04,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.03,34,,0.03,percent of total billed charges,"Drugs, Inpatient Only",0.03,34,,0.03,percent of total billed charges,"Drugs, Inpatient Only",0.03,34,,0.03,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.07,70,,0.07,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.07,,,0.07,Other,225% of Medicaid,0.05,,,0.05,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.07,,,0.07,Other,215% Medicaid APG methodology,0.07,,,0.07,Other,215% Medicaid APG methodology,0.04,,,0.04,Other,125% Medicaid APG methodology,0.01,0.07,
METOCLOPRAMIDE 10MG TAB,,,,80001344,CDM,250,RC,93220301,NDC,both,100,EA,0.06,0.02,39.4668,,0.02,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.02,34,,0.02,percent of total billed charges,"Drugs, Inpatient Only",0.02,34,,0.02,percent of total billed charges,"Drugs, Inpatient Only",0.02,34,,0.02,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.04,70,,0.04,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.05,,,0.05,Other,225% of Medicaid,0.03,,,0.03,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.05,,,0.05,Other,215% Medicaid APG methodology,0.05,,,0.05,Other,215% Medicaid APG methodology,0.03,,,0.03,Other,125% Medicaid APG methodology,0.01,0.05,
METOCLOPRAMIDE 5MG TAB,,,,80001345,CDM,250,RC,93220401,NDC,both,100,EA,0.05,0.02,39.4668,,0.02,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.02,34,,0.02,percent of total billed charges,"Drugs, Inpatient Only",0.02,34,,0.02,percent of total billed charges,"Drugs, Inpatient Only",0.02,34,,0.02,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.04,70,,0.04,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.04,,,0.04,Other,225% of Medicaid,0.02,,,0.02,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.04,,,0.04,Other,215% Medicaid APG methodology,0.04,,,0.04,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,125% Medicaid APG methodology,0.01,0.04,
METOCLOPRAMIDE 5MG/5ML LIQ,,,,80001346,CDM,250,RC,121157610,NDC,both,100,ML,0.84,0.33,39.4668,,0.33,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.29,34,,0.29,percent of total billed charges,"Drugs, Inpatient Only",0.29,34,,0.29,percent of total billed charges,"Drugs, Inpatient Only",0.29,34,,0.29,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.59,70,,0.59,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.28,,,0.28,Other,Drug Cost,0.28,,,0.28,Other,Drug Cost,0.28,,,0.28,Other,Drug Cost,0.28,,,0.28,Other,Drug Cost,0.28,,,0.28,Other,Drug Cost,0.28,,,0.28,Other,Drug Cost,0.63,,,0.63,Other,225% of Medicaid,0.39,,,0.39,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.6,,,0.6,Other,215% Medicaid APG methodology,0.6,,,0.6,Other,215% Medicaid APG methodology,0.35,,,0.35,Other,125% Medicaid APG methodology,0.01,0.63,
METOLAZONE 2.5 MG TAB,,,,80001347,CDM,250,RC,378617201,NDC,both,100,EA,0.09,0.03,39.4668,,0.03,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.03,34,,0.03,percent of total billed charges,"Drugs, Inpatient Only",0.03,34,,0.03,percent of total billed charges,"Drugs, Inpatient Only",0.03,34,,0.03,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.06,70,,0.06,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.07,,,0.07,Other,225% of Medicaid,0.04,,,0.04,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.06,,,0.06,Other,215% Medicaid APG methodology,0.06,,,0.06,Other,215% Medicaid APG methodology,0.04,,,0.04,Other,125% Medicaid APG methodology,0.01,0.07,
METOPROLOL 5MG/5ML INJ,,,,80001348,CDM,250,RC,143966010,NDC,both,10,ML,1.41,0.56,39.4668,,0.56,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.48,34,,0.48,percent of total billed charges,"Drugs, Inpatient Only",0.48,34,,0.48,percent of total billed charges,"Drugs, Inpatient Only",0.48,34,,0.48,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.99,70,,0.99,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.47,,,0.47,Other,Drug Cost,0.47,,,0.47,Other,Drug Cost,0.47,,,0.47,Other,Drug Cost,0.47,,,0.47,Other,Drug Cost,0.47,,,0.47,Other,Drug Cost,0.47,,,0.47,Other,Drug Cost,1.06,,,1.06,Other,225% of Medicaid,0.66,,,0.66,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,1.01,,,1.01,Other,215% Medicaid APG methodology,1.01,,,1.01,Other,215% Medicaid APG methodology,0.59,,,0.59,Other,125% Medicaid APG methodology,0.01,1.06,
METOPROLOL SUCCINATE 25 MG TAB,,,,80001349,CDM,250,RC,45963070911,NDC,both,100,EA,0.03,0.01,39.4668,,0.01,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.02,70,,0.02,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.02,,,0.02,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,0.02,
METOPROLOL SUCCINATE 50 MG TAB,,,,80001350,CDM,250,RC,45963067611,NDC,both,100,EA,0.04,0.02,39.4668,,0.02,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.03,70,,0.03,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.03,,,0.03,Other,225% of Medicaid,0.02,,,0.02,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.03,,,0.03,Other,215% Medicaid APG methodology,0.03,,,0.03,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,125% Medicaid APG methodology,0.01,0.03,
METRONIDAZOLE 250 MG TAB,,,,80001352,CDM,250,RC,29300022601,NDC,both,100,EA,0.07,0.03,39.4668,,0.03,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.02,34,,0.02,percent of total billed charges,"Drugs, Inpatient Only",0.02,34,,0.02,percent of total billed charges,"Drugs, Inpatient Only",0.02,34,,0.02,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.05,70,,0.05,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.05,,,0.05,Other,225% of Medicaid,0.03,,,0.03,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.05,,,0.05,Other,215% Medicaid APG methodology,0.05,,,0.05,Other,215% Medicaid APG methodology,0.03,,,0.03,Other,125% Medicaid APG methodology,0.01,0.05,
METRONIDAZOLE 500MG/100ML INJ,,,,80001353,CDM,250,RC,264553532,NDC,both,24,ML,2.6,1.03,39.4668,,1.03,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.88,34,,0.88,percent of total billed charges,"Drugs, Inpatient Only",0.88,34,,0.88,percent of total billed charges,"Drugs, Inpatient Only",0.88,34,,0.88,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1.82,70,,1.82,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.87,,,0.87,Other,Drug Cost,0.87,,,0.87,Other,Drug Cost,0.87,,,0.87,Other,Drug Cost,0.87,,,0.87,Other,Drug Cost,0.87,,,0.87,Other,Drug Cost,0.87,,,0.87,Other,Drug Cost,1.95,,,1.95,Other,225% of Medicaid,1.21,,,1.21,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,1.86,,,1.86,Other,215% Medicaid APG methodology,1.86,,,1.86,Other,215% Medicaid APG methodology,1.08,,,1.08,Other,125% Medicaid APG methodology,0.01,1.95,
METRONIDAZOLE TOP GEL 0.75%,,,,80001354,CDM,250,RC,51672411606,NDC,both,1,GM,6.12,2.42,39.4668,,2.42,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2.08,34,,2.08,percent of total billed charges,"Drugs, Inpatient Only",2.08,34,,2.08,percent of total billed charges,"Drugs, Inpatient Only",2.08,34,,2.08,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,4.28,70,,4.28,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2.04,,,2.04,Other,Drug Cost,2.04,,,2.04,Other,Drug Cost,2.04,,,2.04,Other,Drug Cost,2.04,,,2.04,Other,Drug Cost,2.04,,,2.04,Other,Drug Cost,2.04,,,2.04,Other,Drug Cost,4.59,,,4.59,Other,225% of Medicaid,2.86,,,2.86,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,4.39,,,4.39,Other,215% Medicaid APG methodology,4.39,,,4.39,Other,215% Medicaid APG methodology,2.55,,,2.55,Other,125% Medicaid APG methodology,0.01,4.59,
METRONIDAZOLE VAG GEL 0.75%,,,,80001355,CDM,250,RC,45802013970,NDC,both,1,GM,8.16,3.22,39.4668,,3.22,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2.77,34,,2.77,percent of total billed charges,"Drugs, Inpatient Only",2.77,34,,2.77,percent of total billed charges,"Drugs, Inpatient Only",2.77,34,,2.77,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,5.71,70,,5.71,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2.72,,,2.72,Other,Drug Cost,2.72,,,2.72,Other,Drug Cost,2.72,,,2.72,Other,Drug Cost,2.72,,,2.72,Other,Drug Cost,2.72,,,2.72,Other,Drug Cost,2.72,,,2.72,Other,Drug Cost,6.12,,,6.12,Other,225% of Medicaid,3.81,,,3.81,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,5.85,,,5.85,Other,215% Medicaid APG methodology,5.85,,,5.85,Other,215% Medicaid APG methodology,3.4,,,3.4,Other,125% Medicaid APG methodology,0.01,6.12,
MEXILETINE 150 MG CAP,,,,80001356,CDM,250,RC,527410737,NDC,both,100,EA,0.36,0.14,39.4668,,0.14,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.12,34,,0.12,percent of total billed charges,"Drugs, Inpatient Only",0.12,34,,0.12,percent of total billed charges,"Drugs, Inpatient Only",0.12,34,,0.12,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.25,70,,0.25,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.12,,,0.12,Other,Drug Cost,0.12,,,0.12,Other,Drug Cost,0.12,,,0.12,Other,Drug Cost,0.12,,,0.12,Other,Drug Cost,0.12,,,0.12,Other,Drug Cost,0.12,,,0.12,Other,Drug Cost,0.27,,,0.27,Other,225% of Medicaid,0.17,,,0.17,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.26,,,0.26,Other,215% Medicaid APG methodology,0.26,,,0.26,Other,215% Medicaid APG methodology,0.15,,,0.15,Other,125% Medicaid APG methodology,0.01,0.27,
MEXILETINE 200 MG CAP,,,,80001357,CDM,250,RC,93874001,NDC,both,100,EA,0.28,0.11,39.4668,,0.11,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.1,34,,0.1,percent of total billed charges,"Drugs, Inpatient Only",0.1,34,,0.1,percent of total billed charges,"Drugs, Inpatient Only",0.1,34,,0.1,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.2,70,,0.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.09,,,0.09,Other,Drug Cost,0.09,,,0.09,Other,Drug Cost,0.09,,,0.09,Other,Drug Cost,0.09,,,0.09,Other,Drug Cost,0.09,,,0.09,Other,Drug Cost,0.09,,,0.09,Other,Drug Cost,0.21,,,0.21,Other,225% of Medicaid,0.13,,,0.13,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.2,,,0.2,Other,215% Medicaid APG methodology,0.2,,,0.2,Other,215% Medicaid APG methodology,0.12,,,0.12,Other,125% Medicaid APG methodology,0.01,0.21,
MEXILETINE 250 MG CAP,,,,80001358,CDM,250,RC,93874101,NDC,both,100,EA,0.65,0.26,39.4668,,0.26,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.22,34,,0.22,percent of total billed charges,"Drugs, Inpatient Only",0.22,34,,0.22,percent of total billed charges,"Drugs, Inpatient Only",0.22,34,,0.22,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.46,70,,0.46,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.22,,,0.22,Other,Drug Cost,0.22,,,0.22,Other,Drug Cost,0.22,,,0.22,Other,Drug Cost,0.22,,,0.22,Other,Drug Cost,0.22,,,0.22,Other,Drug Cost,0.22,,,0.22,Other,Drug Cost,0.49,,,0.49,Other,225% of Medicaid,0.3,,,0.3,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.47,,,0.47,Other,215% Medicaid APG methodology,0.47,,,0.47,Other,215% Medicaid APG methodology,0.27,,,0.27,Other,125% Medicaid APG methodology,0.01,0.49,
MIACALCIN 3.7 ML NASAL SPRAY,,,,80001359,CDM,250,RC,60505082306,NDC,both,1,ML,42.36,16.72,39.4668,,16.72,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,14.4,34,,14.4,percent of total billed charges,"Drugs, Inpatient Only",14.4,34,,14.4,percent of total billed charges,"Drugs, Inpatient Only",14.4,34,,14.4,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,29.65,70,,29.65,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,14.12,,,14.12,Other,Drug Cost,14.12,,,14.12,Other,Drug Cost,14.12,,,14.12,Other,Drug Cost,14.12,,,14.12,Other,Drug Cost,14.12,,,14.12,Other,Drug Cost,14.12,,,14.12,Other,Drug Cost,31.77,,,31.77,Other,225% of Medicaid,19.77,,,19.77,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,30.36,,,30.36,Other,215% Medicaid APG methodology,30.36,,,30.36,Other,215% Medicaid APG methodology,17.65,,,17.65,Other,125% Medicaid APG methodology,0.01,31.77,
MICONAZOLE 2% (LOTRIMIN AF) POWDER,,,,80001363,CDM,250,RC,11701003816,NDC,both,1,GM,20.94,8.26,39.4668,,8.26,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,7.12,34,,7.12,percent of total billed charges,"Drugs, Inpatient Only",7.12,34,,7.12,percent of total billed charges,"Drugs, Inpatient Only",7.12,34,,7.12,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,14.66,70,,14.66,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,6.98,,,6.98,Other,Drug Cost,6.98,,,6.98,Other,Drug Cost,6.98,,,6.98,Other,Drug Cost,6.98,,,6.98,Other,Drug Cost,6.98,,,6.98,Other,Drug Cost,6.98,,,6.98,Other,Drug Cost,15.71,,,15.71,Other,225% of Medicaid,9.77,,,9.77,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,15.01,,,15.01,Other,215% Medicaid APG methodology,15.01,,,15.01,Other,215% Medicaid APG methodology,8.73,,,8.73,Other,125% Medicaid APG methodology,0.01,15.71,
MICONAZOLE 3 200MG SUPP,,,,80001365,CDM,250,RC,472173803,NDC,both,3,EA,22.14,8.74,39.4668,,8.74,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,7.53,34,,7.53,percent of total billed charges,"Drugs, Inpatient Only",7.53,34,,7.53,percent of total billed charges,"Drugs, Inpatient Only",7.53,34,,7.53,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,15.5,70,,15.5,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,7.38,,,7.38,Other,Drug Cost,7.38,,,7.38,Other,Drug Cost,7.38,,,7.38,Other,Drug Cost,7.38,,,7.38,Other,Drug Cost,7.38,,,7.38,Other,Drug Cost,7.38,,,7.38,Other,Drug Cost,16.61,,,16.61,Other,225% of Medicaid,10.33,,,10.33,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,15.87,,,15.87,Other,215% Medicaid APG methodology,15.87,,,15.87,Other,215% Medicaid APG methodology,9.23,,,9.23,Other,125% Medicaid APG methodology,0.01,16.61,
MICONAZOLE 7% VAG CREAM,,,,80001366,CDM,250,RC,51672203506,NDC,both,1,GM,7.95,3.14,39.4668,,3.14,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2.7,34,,2.7,percent of total billed charges,"Drugs, Inpatient Only",2.7,34,,2.7,percent of total billed charges,"Drugs, Inpatient Only",2.7,34,,2.7,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,5.57,70,,5.57,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2.65,,,2.65,Other,Drug Cost,2.65,,,2.65,Other,Drug Cost,2.65,,,2.65,Other,Drug Cost,2.65,,,2.65,Other,Drug Cost,2.65,,,2.65,Other,Drug Cost,2.65,,,2.65,Other,Drug Cost,5.96,,,5.96,Other,225% of Medicaid,3.71,,,3.71,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,5.7,,,5.7,Other,215% Medicaid APG methodology,5.7,,,5.7,Other,215% Medicaid APG methodology,3.31,,,3.31,Other,125% Medicaid APG methodology,0.01,5.96,
MICROFIBRILLAR COLLAGEN HEMOSTAT,,,,80001368,CDM,250,RC,53276101002,NDC,both,6,GM,456.46,180.15,39.4668,,180.15,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,155.2,34,,155.2,percent of total billed charges,"Drugs, Inpatient Only",155.2,34,,155.2,percent of total billed charges,"Drugs, Inpatient Only",155.2,34,,155.2,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,319.52,70,,319.52,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,152.15,,,152.15,Other,Drug Cost,152.15,,,152.15,Other,Drug Cost,152.15,,,152.15,Other,Drug Cost,152.15,,,152.15,Other,Drug Cost,152.15,,,152.15,Other,Drug Cost,152.15,,,152.15,Other,Drug Cost,342.34,,,342.34,Other,225% of Medicaid,213.01,,,213.01,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,327.13,,,327.13,Other,215% Medicaid APG methodology,327.13,,,327.13,Other,215% Medicaid APG methodology,190.19,,,190.19,Other,125% Medicaid APG methodology,0.01,342.34,
MIDAZOLAM 2MG/ML SYRUP,,,,80001371,CDM,250,RC,54356699,NDC,both,1,ML,72.84,28.75,39.4668,,28.75,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,24.77,34,,24.77,percent of total billed charges,"Drugs, Inpatient Only",24.77,34,,24.77,percent of total billed charges,"Drugs, Inpatient Only",24.77,34,,24.77,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,50.99,70,,50.99,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,24.28,,,24.28,Other,Drug Cost,24.28,,,24.28,Other,Drug Cost,24.28,,,24.28,Other,Drug Cost,24.28,,,24.28,Other,Drug Cost,24.28,,,24.28,Other,Drug Cost,24.28,,,24.28,Other,Drug Cost,54.63,,,54.63,Other,225% of Medicaid,33.99,,,33.99,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,52.2,,,52.2,Other,215% Medicaid APG methodology,52.2,,,52.2,Other,215% Medicaid APG methodology,30.35,,,30.35,Other,125% Medicaid APG methodology,0.01,54.63,
MIDODRINE 2.5 MG TAB,,,,80001372,CDM,250,RC,245021111,NDC,both,100,EA,0.11,0.04,39.4668,,0.04,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.04,34,,0.04,percent of total billed charges,"Drugs, Inpatient Only",0.04,34,,0.04,percent of total billed charges,"Drugs, Inpatient Only",0.04,34,,0.04,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.08,70,,0.08,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.08,,,0.08,Other,225% of Medicaid,0.05,,,0.05,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.08,,,0.08,Other,215% Medicaid APG methodology,0.08,,,0.08,Other,215% Medicaid APG methodology,0.05,,,0.05,Other,125% Medicaid APG methodology,0.01,0.08,
MIDODRINE 5 MG TAB,,,,80001373,CDM,250,RC,60505132101,NDC,both,100,EA,0.14,0.06,39.4668,,0.06,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.05,34,,0.05,percent of total billed charges,"Drugs, Inpatient Only",0.05,34,,0.05,percent of total billed charges,"Drugs, Inpatient Only",0.05,34,,0.05,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.1,70,,0.1,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.11,,,0.11,Other,225% of Medicaid,0.07,,,0.07,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.1,,,0.1,Other,215% Medicaid APG methodology,0.1,,,0.1,Other,215% Medicaid APG methodology,0.06,,,0.06,Other,125% Medicaid APG methodology,0.01,0.11,
MILK OF MAGNESIA 400MG/5ML,,,,80001375,CDM,250,RC,121043130,NDC,both,100,ML,1.17,0.46,39.4668,,0.46,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.4,34,,0.4,percent of total billed charges,"Drugs, Inpatient Only",0.4,34,,0.4,percent of total billed charges,"Drugs, Inpatient Only",0.4,34,,0.4,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.82,70,,0.82,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.39,,,0.39,Other,Drug Cost,0.39,,,0.39,Other,Drug Cost,0.39,,,0.39,Other,Drug Cost,0.39,,,0.39,Other,Drug Cost,0.39,,,0.39,Other,Drug Cost,0.39,,,0.39,Other,Drug Cost,0.88,,,0.88,Other,225% of Medicaid,0.55,,,0.55,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.84,,,0.84,Other,215% Medicaid APG methodology,0.84,,,0.84,Other,215% Medicaid APG methodology,0.49,,,0.49,Other,125% Medicaid APG methodology,0.01,0.88,
MINOXIDIL 10MG TAB,,,,80001381,CDM,250,RC,49884025701,NDC,both,100,EA,0.14,0.06,39.4668,,0.06,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.05,34,,0.05,percent of total billed charges,"Drugs, Inpatient Only",0.05,34,,0.05,percent of total billed charges,"Drugs, Inpatient Only",0.05,34,,0.05,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.1,70,,0.1,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.11,,,0.11,Other,225% of Medicaid,0.07,,,0.07,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.1,,,0.1,Other,215% Medicaid APG methodology,0.1,,,0.1,Other,215% Medicaid APG methodology,0.06,,,0.06,Other,125% Medicaid APG methodology,0.01,0.11,
MINOXIDIL 2.5 MG TAB,,,,80001382,CDM,250,RC,53489038601,NDC,both,100,EA,0.12,0.05,39.4668,,0.05,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.04,34,,0.04,percent of total billed charges,"Drugs, Inpatient Only",0.04,34,,0.04,percent of total billed charges,"Drugs, Inpatient Only",0.04,34,,0.04,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.08,70,,0.08,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.09,,,0.09,Other,225% of Medicaid,0.05,,,0.05,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.08,,,0.08,Other,215% Medicaid APG methodology,0.08,,,0.08,Other,215% Medicaid APG methodology,0.05,,,0.05,Other,125% Medicaid APG methodology,0.01,0.09,
MIRAPEX 0.25MG,,,,80001384,CDM,250,RC,68462033190,NDC,both,90,EA,0.03,0.01,39.4668,,0.01,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.02,70,,0.02,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.02,,,0.02,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,0.02,
MIRTAZAPINE 15 MG,,,,80001386,CDM,250,RC,13107003134,NDC,both,30,EA,0.09,0.03,39.4668,,0.03,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.03,34,,0.03,percent of total billed charges,"Drugs, Inpatient Only",0.03,34,,0.03,percent of total billed charges,"Drugs, Inpatient Only",0.03,34,,0.03,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.06,70,,0.06,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.07,,,0.07,Other,225% of Medicaid,0.04,,,0.04,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.06,,,0.06,Other,215% Medicaid APG methodology,0.06,,,0.06,Other,215% Medicaid APG methodology,0.04,,,0.04,Other,125% Medicaid APG methodology,0.01,0.07,
MISOPROSTOL (CYTOTEC) 100MCG TAB,,,,80001387,CDM,250,RC,25145160,NDC,both,60,EA,0.03,0.01,39.4668,,0.01,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.02,70,,0.02,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.02,,,0.02,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,0.02,
MISOPROSTOL 200 MCG TAB,,,,80001388,CDM,250,RC,59762500802,NDC,both,100,EA,0.58,0.23,39.4668,,0.23,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.2,34,,0.2,percent of total billed charges,"Drugs, Inpatient Only",0.2,34,,0.2,percent of total billed charges,"Drugs, Inpatient Only",0.2,34,,0.2,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.41,70,,0.41,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.19,,,0.19,Other,Drug Cost,0.19,,,0.19,Other,Drug Cost,0.19,,,0.19,Other,Drug Cost,0.19,,,0.19,Other,Drug Cost,0.19,,,0.19,Other,Drug Cost,0.19,,,0.19,Other,Drug Cost,0.43,,,0.43,Other,225% of Medicaid,0.27,,,0.27,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.42,,,0.42,Other,215% Medicaid APG methodology,0.42,,,0.42,Other,215% Medicaid APG methodology,0.24,,,0.24,Other,125% Medicaid APG methodology,0.01,0.43,
MODAFINIL 100MG TAB,,,,80001393,CDM,250,RC,62332038530,NDC,both,30,EA,0.17,0.07,39.4668,,0.07,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.06,34,,0.06,percent of total billed charges,"Drugs, Inpatient Only",0.06,34,,0.06,percent of total billed charges,"Drugs, Inpatient Only",0.06,34,,0.06,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.12,70,,0.12,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.06,,,0.06,Other,Drug Cost,0.06,,,0.06,Other,Drug Cost,0.06,,,0.06,Other,Drug Cost,0.06,,,0.06,Other,Drug Cost,0.06,,,0.06,Other,Drug Cost,0.06,,,0.06,Other,Drug Cost,0.13,,,0.13,Other,225% of Medicaid,0.08,,,0.08,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.12,,,0.12,Other,215% Medicaid APG methodology,0.12,,,0.12,Other,215% Medicaid APG methodology,0.07,,,0.07,Other,125% Medicaid APG methodology,0.01,0.13,
MORPHINE (MS CONTIN)  100MG SR TAB,,,,80001397,CDM,250,RC,42858080401,NDC,both,100,EA,0.67,0.26,39.4668,,0.26,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.23,34,,0.23,percent of total billed charges,"Drugs, Inpatient Only",0.23,34,,0.23,percent of total billed charges,"Drugs, Inpatient Only",0.23,34,,0.23,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.47,70,,0.47,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.22,,,0.22,Other,Drug Cost,0.22,,,0.22,Other,Drug Cost,0.22,,,0.22,Other,Drug Cost,0.22,,,0.22,Other,Drug Cost,0.22,,,0.22,Other,Drug Cost,0.22,,,0.22,Other,Drug Cost,0.5,,,0.5,Other,225% of Medicaid,0.31,,,0.31,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.48,,,0.48,Other,215% Medicaid APG methodology,0.48,,,0.48,Other,215% Medicaid APG methodology,0.28,,,0.28,Other,125% Medicaid APG methodology,0.01,0.5,
MORPHINE (MS CONTIN)  15MG SR TAB,,,,80001398,CDM,250,RC,42858080101,NDC,both,100,EA,0.28,0.11,39.4668,,0.11,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.09,34,,0.09,percent of total billed charges,"Drugs, Inpatient Only",0.09,34,,0.09,percent of total billed charges,"Drugs, Inpatient Only",0.09,34,,0.09,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.19,70,,0.19,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.09,,,0.09,Other,Drug Cost,0.09,,,0.09,Other,Drug Cost,0.09,,,0.09,Other,Drug Cost,0.09,,,0.09,Other,Drug Cost,0.09,,,0.09,Other,Drug Cost,0.09,,,0.09,Other,Drug Cost,0.21,,,0.21,Other,225% of Medicaid,0.13,,,0.13,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.2,,,0.2,Other,215% Medicaid APG methodology,0.2,,,0.2,Other,215% Medicaid APG methodology,0.12,,,0.12,Other,125% Medicaid APG methodology,0.01,0.21,
MORPHINE (MS CONTIN)  30MG SR TAB,,,,80001399,CDM,250,RC,406833062,NDC,both,10,EA,6.02,2.38,39.4668,,2.38,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2.05,34,,2.05,percent of total billed charges,"Drugs, Inpatient Only",2.05,34,,2.05,percent of total billed charges,"Drugs, Inpatient Only",2.05,34,,2.05,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,4.22,70,,4.22,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2.01,,,2.01,Other,Drug Cost,2.01,,,2.01,Other,Drug Cost,2.01,,,2.01,Other,Drug Cost,2.01,,,2.01,Other,Drug Cost,2.01,,,2.01,Other,Drug Cost,2.01,,,2.01,Other,Drug Cost,4.52,,,4.52,Other,225% of Medicaid,2.81,,,2.81,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,4.32,,,4.32,Other,215% Medicaid APG methodology,4.32,,,4.32,Other,215% Medicaid APG methodology,2.51,,,2.51,Other,125% Medicaid APG methodology,0.01,4.52,
MORPHINE (MS IR) 15MG TAB,,,,80001401,CDM,250,RC,54023525,NDC,both,100,EA,0.15,0.06,39.4668,,0.06,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.05,34,,0.05,percent of total billed charges,"Drugs, Inpatient Only",0.05,34,,0.05,percent of total billed charges,"Drugs, Inpatient Only",0.05,34,,0.05,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.1,70,,0.1,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.11,,,0.11,Other,225% of Medicaid,0.07,,,0.07,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.1,,,0.1,Other,215% Medicaid APG methodology,0.1,,,0.1,Other,215% Medicaid APG methodology,0.06,,,0.06,Other,125% Medicaid APG methodology,0.01,0.11,
MORPHINE (MS IR) 30MG TAB,,,,80001402,CDM,250,RC,54023625,NDC,both,100,EA,0.19,0.07,39.4668,,0.07,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.06,34,,0.06,percent of total billed charges,"Drugs, Inpatient Only",0.06,34,,0.06,percent of total billed charges,"Drugs, Inpatient Only",0.06,34,,0.06,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.13,70,,0.13,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.06,,,0.06,Other,Drug Cost,0.06,,,0.06,Other,Drug Cost,0.06,,,0.06,Other,Drug Cost,0.06,,,0.06,Other,Drug Cost,0.06,,,0.06,Other,Drug Cost,0.06,,,0.06,Other,Drug Cost,0.14,,,0.14,Other,225% of Medicaid,0.09,,,0.09,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.13,,,0.13,Other,215% Medicaid APG methodology,0.13,,,0.13,Other,215% Medicaid APG methodology,0.08,,,0.08,Other,125% Medicaid APG methodology,0.01,0.14,
MOXIFLOXACIN (AVELOX) 400 MG TAB,,,,80001414,CDM,250,RC,65862060330,NDC,both,30,EA,2.3,0.91,39.4668,,0.91,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.78,34,,0.78,percent of total billed charges,"Drugs, Inpatient Only",0.78,34,,0.78,percent of total billed charges,"Drugs, Inpatient Only",0.78,34,,0.78,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1.61,70,,1.61,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.77,,,0.77,Other,Drug Cost,0.77,,,0.77,Other,Drug Cost,0.77,,,0.77,Other,Drug Cost,0.77,,,0.77,Other,Drug Cost,0.77,,,0.77,Other,Drug Cost,0.77,,,0.77,Other,Drug Cost,1.72,,,1.72,Other,225% of Medicaid,1.07,,,1.07,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,1.65,,,1.65,Other,215% Medicaid APG methodology,1.65,,,1.65,Other,215% Medicaid APG methodology,0.96,,,0.96,Other,125% Medicaid APG methodology,0.01,1.72,
MULTIVITAMIN (INFUVITE) INJ,,,,80001418,CDM,250,RC,54643564901,NDC,both,5,ML,0.27,0.11,39.4668,,0.11,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.09,34,,0.09,percent of total billed charges,"Drugs, Inpatient Only",0.09,34,,0.09,percent of total billed charges,"Drugs, Inpatient Only",0.09,34,,0.09,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.19,70,,0.19,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.09,,,0.09,Other,Drug Cost,0.09,,,0.09,Other,Drug Cost,0.09,,,0.09,Other,Drug Cost,0.09,,,0.09,Other,Drug Cost,0.09,,,0.09,Other,Drug Cost,0.09,,,0.09,Other,Drug Cost,0.2,,,0.2,Other,225% of Medicaid,0.13,,,0.13,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.19,,,0.19,Other,215% Medicaid APG methodology,0.19,,,0.19,Other,215% Medicaid APG methodology,0.11,,,0.11,Other,125% Medicaid APG methodology,0.01,0.2,
MURO 128 2% OPHTH SOLN,,,,80001422,CDM,250,RC,24208027615,NDC,both,1,ML,37.56,14.82,39.4668,,14.82,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,12.77,34,,12.77,percent of total billed charges,"Drugs, Inpatient Only",12.77,34,,12.77,percent of total billed charges,"Drugs, Inpatient Only",12.77,34,,12.77,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,26.29,70,,26.29,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,12.52,,,12.52,Other,Drug Cost,12.52,,,12.52,Other,Drug Cost,12.52,,,12.52,Other,Drug Cost,12.52,,,12.52,Other,Drug Cost,12.52,,,12.52,Other,Drug Cost,12.52,,,12.52,Other,Drug Cost,28.17,,,28.17,Other,225% of Medicaid,17.53,,,17.53,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,26.92,,,26.92,Other,215% Medicaid APG methodology,26.92,,,26.92,Other,215% Medicaid APG methodology,15.65,,,15.65,Other,125% Medicaid APG methodology,0.01,28.17,
NADOLOL 20 MG TAB,,,,80001427,CDM,250,RC,68382073201,NDC,both,100,EA,0.11,0.04,39.4668,,0.04,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.04,34,,0.04,percent of total billed charges,"Drugs, Inpatient Only",0.04,34,,0.04,percent of total billed charges,"Drugs, Inpatient Only",0.04,34,,0.04,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.08,70,,0.08,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.08,,,0.08,Other,225% of Medicaid,0.05,,,0.05,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.08,,,0.08,Other,215% Medicaid APG methodology,0.08,,,0.08,Other,215% Medicaid APG methodology,0.05,,,0.05,Other,125% Medicaid APG methodology,0.01,0.08,
NADOLOL 40 MG TAB,,,,80001428,CDM,250,RC,69238112409,NDC,both,90,EA,0.3,0.12,39.4668,,0.12,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.1,34,,0.1,percent of total billed charges,"Drugs, Inpatient Only",0.1,34,,0.1,percent of total billed charges,"Drugs, Inpatient Only",0.1,34,,0.1,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.21,70,,0.21,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.1,,,0.1,Other,Drug Cost,0.1,,,0.1,Other,Drug Cost,0.1,,,0.1,Other,Drug Cost,0.1,,,0.1,Other,Drug Cost,0.1,,,0.1,Other,Drug Cost,0.1,,,0.1,Other,Drug Cost,0.23,,,0.23,Other,225% of Medicaid,0.14,,,0.14,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.22,,,0.22,Other,215% Medicaid APG methodology,0.22,,,0.22,Other,215% Medicaid APG methodology,0.13,,,0.13,Other,125% Medicaid APG methodology,0.01,0.23,
NAFCILLIN 1GM INJ,,,,80001429,CDM,250,RC,63323032710,NDC,both,10,EA,18.92,7.47,39.4668,,7.47,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,6.43,34,,6.43,percent of total billed charges,"Drugs, Inpatient Only",6.43,34,,6.43,percent of total billed charges,"Drugs, Inpatient Only",6.43,34,,6.43,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,13.24,70,,13.24,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,6.31,,,6.31,Other,Drug Cost,6.31,,,6.31,Other,Drug Cost,6.31,,,6.31,Other,Drug Cost,6.31,,,6.31,Other,Drug Cost,6.31,,,6.31,Other,Drug Cost,6.31,,,6.31,Other,Drug Cost,14.19,,,14.19,Other,225% of Medicaid,8.83,,,8.83,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,13.56,,,13.56,Other,215% Medicaid APG methodology,13.56,,,13.56,Other,215% Medicaid APG methodology,7.88,,,7.88,Other,125% Medicaid APG methodology,0.01,14.19,
NAFCILLIN 2GM INJ,,,,80001430,CDM,250,RC,44567022210,NDC,both,10,EA,23.7,9.35,39.4668,,9.35,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,8.06,34,,8.06,percent of total billed charges,"Drugs, Inpatient Only",8.06,34,,8.06,percent of total billed charges,"Drugs, Inpatient Only",8.06,34,,8.06,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,16.59,70,,16.59,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,7.9,,,7.9,Other,Drug Cost,7.9,,,7.9,Other,Drug Cost,7.9,,,7.9,Other,Drug Cost,7.9,,,7.9,Other,Drug Cost,7.9,,,7.9,Other,Drug Cost,7.9,,,7.9,Other,Drug Cost,17.77,,,17.77,Other,225% of Medicaid,11.06,,,11.06,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,16.98,,,16.98,Other,215% Medicaid APG methodology,16.98,,,16.98,Other,215% Medicaid APG methodology,9.87,,,9.87,Other,125% Medicaid APG methodology,0.01,17.77,
NALTREXONE 50 MG TAB,,,,80001434,CDM,250,RC,47335032683,NDC,both,30,EA,0.83,0.33,39.4668,,0.33,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.28,34,,0.28,percent of total billed charges,"Drugs, Inpatient Only",0.28,34,,0.28,percent of total billed charges,"Drugs, Inpatient Only",0.28,34,,0.28,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.58,70,,0.58,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.28,,,0.28,Other,Drug Cost,0.28,,,0.28,Other,Drug Cost,0.28,,,0.28,Other,Drug Cost,0.28,,,0.28,Other,Drug Cost,0.28,,,0.28,Other,Drug Cost,0.28,,,0.28,Other,Drug Cost,0.62,,,0.62,Other,225% of Medicaid,0.39,,,0.39,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.59,,,0.59,Other,215% Medicaid APG methodology,0.59,,,0.59,Other,215% Medicaid APG methodology,0.34,,,0.34,Other,125% Medicaid APG methodology,0.01,0.62,
NAPHAZOLINE-PHENIRAMINE OPTH SOLN,,,,80001435,CDM,250,RC,65008515,NDC,both,1,ML,15.9,6.28,39.4668,,6.28,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,5.41,34,,5.41,percent of total billed charges,"Drugs, Inpatient Only",5.41,34,,5.41,percent of total billed charges,"Drugs, Inpatient Only",5.41,34,,5.41,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,11.13,70,,11.13,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,5.3,,,5.3,Other,Drug Cost,5.3,,,5.3,Other,Drug Cost,5.3,,,5.3,Other,Drug Cost,5.3,,,5.3,Other,Drug Cost,5.3,,,5.3,Other,Drug Cost,5.3,,,5.3,Other,Drug Cost,11.93,,,11.93,Other,225% of Medicaid,7.42,,,7.42,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,11.4,,,11.4,Other,215% Medicaid APG methodology,11.4,,,11.4,Other,215% Medicaid APG methodology,6.63,,,6.63,Other,125% Medicaid APG methodology,0.01,11.93,
NAPROXEN 250MG TAB,,,,80001436,CDM,250,RC,68462018801,NDC,both,100,EA,0.06,0.02,39.4668,,0.02,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.02,34,,0.02,percent of total billed charges,"Drugs, Inpatient Only",0.02,34,,0.02,percent of total billed charges,"Drugs, Inpatient Only",0.02,34,,0.02,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.04,70,,0.04,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.04,,,0.04,Other,225% of Medicaid,0.03,,,0.03,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.04,,,0.04,Other,215% Medicaid APG methodology,0.04,,,0.04,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,125% Medicaid APG methodology,0.01,0.04,
NAPROXEN 375MG TAB,,,,80001438,CDM,250,RC,68462018901,NDC,both,100,EA,0.07,0.03,39.4668,,0.03,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.02,34,,0.02,percent of total billed charges,"Drugs, Inpatient Only",0.02,34,,0.02,percent of total billed charges,"Drugs, Inpatient Only",0.02,34,,0.02,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.05,70,,0.05,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.05,,,0.05,Other,225% of Medicaid,0.03,,,0.03,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.05,,,0.05,Other,215% Medicaid APG methodology,0.05,,,0.05,Other,215% Medicaid APG methodology,0.03,,,0.03,Other,125% Medicaid APG methodology,0.01,0.05,
NASAL SALINE 0.65% 45 ML,,,,80001440,CDM,250,RC,904386575,NDC,both,1,ML,1.92,0.76,39.4668,,0.76,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.65,34,,0.65,percent of total billed charges,"Drugs, Inpatient Only",0.65,34,,0.65,percent of total billed charges,"Drugs, Inpatient Only",0.65,34,,0.65,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1.34,70,,1.34,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.64,,,0.64,Other,Drug Cost,0.64,,,0.64,Other,Drug Cost,0.64,,,0.64,Other,Drug Cost,0.64,,,0.64,Other,Drug Cost,0.64,,,0.64,Other,Drug Cost,0.64,,,0.64,Other,Drug Cost,1.44,,,1.44,Other,225% of Medicaid,0.9,,,0.9,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,1.38,,,1.38,Other,215% Medicaid APG methodology,1.38,,,1.38,Other,215% Medicaid APG methodology,0.8,,,0.8,Other,125% Medicaid APG methodology,0.01,1.44,
NEO-BAC-POLY-HC 3.5GM OPHTH,,,,80001445,CDM,250,RC,24208078555,NDC,both,1,GM,28.02,11.06,39.4668,,11.06,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,9.53,34,,9.53,percent of total billed charges,"Drugs, Inpatient Only",9.53,34,,9.53,percent of total billed charges,"Drugs, Inpatient Only",9.53,34,,9.53,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,19.61,70,,19.61,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,9.34,,,9.34,Other,Drug Cost,9.34,,,9.34,Other,Drug Cost,9.34,,,9.34,Other,Drug Cost,9.34,,,9.34,Other,Drug Cost,9.34,,,9.34,Other,Drug Cost,9.34,,,9.34,Other,Drug Cost,21.02,,,21.02,Other,225% of Medicaid,13.08,,,13.08,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,20.08,,,20.08,Other,215% Medicaid APG methodology,20.08,,,20.08,Other,215% Medicaid APG methodology,11.68,,,11.68,Other,125% Medicaid APG methodology,0.01,21.02,
NEOMYCIN 500 MG TAB,,,,80001447,CDM,250,RC,93117701,NDC,both,100,EA,1.4,0.55,39.4668,,0.55,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.48,34,,0.48,percent of total billed charges,"Drugs, Inpatient Only",0.48,34,,0.48,percent of total billed charges,"Drugs, Inpatient Only",0.48,34,,0.48,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.98,70,,0.98,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.47,,,0.47,Other,Drug Cost,0.47,,,0.47,Other,Drug Cost,0.47,,,0.47,Other,Drug Cost,0.47,,,0.47,Other,Drug Cost,0.47,,,0.47,Other,Drug Cost,0.47,,,0.47,Other,Drug Cost,1.05,,,1.05,Other,225% of Medicaid,0.65,,,0.65,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,1,,,1,Other,215% Medicaid APG methodology,1,,,1,Other,215% Medicaid APG methodology,0.58,,,0.58,Other,125% Medicaid APG methodology,0.01,1.05,
NEO-POLY-BAC UD PACKET,,,,80001448,CDM,250,RC,904880567,NDC,both,144,GM,0.07,0.03,39.4668,,0.03,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.02,34,,0.02,percent of total billed charges,"Drugs, Inpatient Only",0.02,34,,0.02,percent of total billed charges,"Drugs, Inpatient Only",0.02,34,,0.02,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.05,70,,0.05,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.05,,,0.05,Other,225% of Medicaid,0.03,,,0.03,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.05,,,0.05,Other,215% Medicaid APG methodology,0.05,,,0.05,Other,215% Medicaid APG methodology,0.03,,,0.03,Other,125% Medicaid APG methodology,0.01,0.05,
NEO-POLY-DEXAMETH 5ML OPHTH,,,,80001450,CDM,250,RC,24208083060,NDC,both,1,ML,9.33,3.68,39.4668,,3.68,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,3.17,34,,3.17,percent of total billed charges,"Drugs, Inpatient Only",3.17,34,,3.17,percent of total billed charges,"Drugs, Inpatient Only",3.17,34,,3.17,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,6.53,70,,6.53,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,3.11,,,3.11,Other,Drug Cost,3.11,,,3.11,Other,Drug Cost,3.11,,,3.11,Other,Drug Cost,3.11,,,3.11,Other,Drug Cost,3.11,,,3.11,Other,Drug Cost,3.11,,,3.11,Other,Drug Cost,7,,,7,Other,225% of Medicaid,4.35,,,4.35,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,6.69,,,6.69,Other,215% Medicaid APG methodology,6.69,,,6.69,Other,215% Medicaid APG methodology,3.89,,,3.89,Other,125% Medicaid APG methodology,0.01,7,
NEO-POLY-GRAMICIDIN 10ML OPHTH,,,,80001451,CDM,250,RC,24208079062,NDC,both,1,ML,31.98,12.62,39.4668,,12.62,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,10.87,34,,10.87,percent of total billed charges,"Drugs, Inpatient Only",10.87,34,,10.87,percent of total billed charges,"Drugs, Inpatient Only",10.87,34,,10.87,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,22.39,70,,22.39,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,10.66,,,10.66,Other,Drug Cost,10.66,,,10.66,Other,Drug Cost,10.66,,,10.66,Other,Drug Cost,10.66,,,10.66,Other,Drug Cost,10.66,,,10.66,Other,Drug Cost,10.66,,,10.66,Other,Drug Cost,23.99,,,23.99,Other,225% of Medicaid,14.92,,,14.92,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,22.92,,,22.92,Other,215% Medicaid APG methodology,22.92,,,22.92,Other,215% Medicaid APG methodology,13.33,,,13.33,Other,125% Medicaid APG methodology,0.01,23.99,
NICARDIPINE (CARDENE) 25MG/10ML INJ,,,,80001461,CDM,250,RC,143968910,NDC,both,10,ML,23.97,9.46,39.4668,,9.46,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,8.15,34,,8.15,percent of total billed charges,"Drugs, Inpatient Only",8.15,34,,8.15,percent of total billed charges,"Drugs, Inpatient Only",8.15,34,,8.15,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,16.78,70,,16.78,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,7.99,,,7.99,Other,Drug Cost,7.99,,,7.99,Other,Drug Cost,7.99,,,7.99,Other,Drug Cost,7.99,,,7.99,Other,Drug Cost,7.99,,,7.99,Other,Drug Cost,7.99,,,7.99,Other,Drug Cost,17.98,,,17.98,Other,225% of Medicaid,11.19,,,11.19,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,17.18,,,17.18,Other,215% Medicaid APG methodology,17.18,,,17.18,Other,215% Medicaid APG methodology,9.99,,,9.99,Other,125% Medicaid APG methodology,0.01,17.98,
NICARDIPINE 20 MG CAP,,,,80001462,CDM,250,RC,42806050109,NDC,both,90,EA,1.67,0.66,39.4668,,0.66,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.57,34,,0.57,percent of total billed charges,"Drugs, Inpatient Only",0.57,34,,0.57,percent of total billed charges,"Drugs, Inpatient Only",0.57,34,,0.57,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1.17,70,,1.17,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.56,,,0.56,Other,Drug Cost,0.56,,,0.56,Other,Drug Cost,0.56,,,0.56,Other,Drug Cost,0.56,,,0.56,Other,Drug Cost,0.56,,,0.56,Other,Drug Cost,0.56,,,0.56,Other,Drug Cost,1.25,,,1.25,Other,225% of Medicaid,0.78,,,0.78,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,1.2,,,1.2,Other,215% Medicaid APG methodology,1.2,,,1.2,Other,215% Medicaid APG methodology,0.7,,,0.7,Other,125% Medicaid APG methodology,0.01,1.25,
NICARDIPINE IN SALINE 20MG/200ML,,,,80001464,CDM,250,RC,43066000910,NDC,both,10,ML,49.52,19.54,39.4668,,19.54,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,16.84,34,,16.84,percent of total billed charges,"Drugs, Inpatient Only",16.84,34,,16.84,percent of total billed charges,"Drugs, Inpatient Only",16.84,34,,16.84,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,34.66,70,,34.66,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,16.51,,,16.51,Other,Drug Cost,16.51,,,16.51,Other,Drug Cost,16.51,,,16.51,Other,Drug Cost,16.51,,,16.51,Other,Drug Cost,16.51,,,16.51,Other,Drug Cost,16.51,,,16.51,Other,Drug Cost,37.14,,,37.14,Other,225% of Medicaid,23.11,,,23.11,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,35.49,,,35.49,Other,215% Medicaid APG methodology,35.49,,,35.49,Other,215% Medicaid APG methodology,20.63,,,20.63,Other,125% Medicaid APG methodology,0.01,37.14,
NICOTINE 14MG/ 24HR PATCH,,,,80001465,CDM,250,RC,43598044774,NDC,both,14,EA,1.82,0.72,39.4668,,0.72,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.62,34,,0.62,percent of total billed charges,"Drugs, Inpatient Only",0.62,34,,0.62,percent of total billed charges,"Drugs, Inpatient Only",0.62,34,,0.62,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1.28,70,,1.28,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.61,,,0.61,Other,Drug Cost,0.61,,,0.61,Other,Drug Cost,0.61,,,0.61,Other,Drug Cost,0.61,,,0.61,Other,Drug Cost,0.61,,,0.61,Other,Drug Cost,0.61,,,0.61,Other,Drug Cost,1.37,,,1.37,Other,225% of Medicaid,0.85,,,0.85,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,1.31,,,1.31,Other,215% Medicaid APG methodology,1.31,,,1.31,Other,215% Medicaid APG methodology,0.76,,,0.76,Other,125% Medicaid APG methodology,0.01,1.37,
NICOTINE 21MG/ 24HR PATCH,,,,80001466,CDM,250,RC,43598044870,NDC,both,7,EA,1.81,0.71,39.4668,,0.71,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.61,34,,0.61,percent of total billed charges,"Drugs, Inpatient Only",0.61,34,,0.61,percent of total billed charges,"Drugs, Inpatient Only",0.61,34,,0.61,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1.27,70,,1.27,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.6,,,0.6,Other,Drug Cost,0.6,,,0.6,Other,Drug Cost,0.6,,,0.6,Other,Drug Cost,0.6,,,0.6,Other,Drug Cost,0.6,,,0.6,Other,Drug Cost,0.6,,,0.6,Other,Drug Cost,1.36,,,1.36,Other,225% of Medicaid,0.84,,,0.84,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,1.3,,,1.3,Other,215% Medicaid APG methodology,1.3,,,1.3,Other,215% Medicaid APG methodology,0.75,,,0.75,Other,125% Medicaid APG methodology,0.01,1.36,
NICOTINE 7MG/ 24HR PATCH,,,,80001467,CDM,250,RC,43598044674,NDC,both,14,EA,1.83,0.72,39.4668,,0.72,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.62,34,,0.62,percent of total billed charges,"Drugs, Inpatient Only",0.62,34,,0.62,percent of total billed charges,"Drugs, Inpatient Only",0.62,34,,0.62,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1.28,70,,1.28,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.61,,,0.61,Other,Drug Cost,0.61,,,0.61,Other,Drug Cost,0.61,,,0.61,Other,Drug Cost,0.61,,,0.61,Other,Drug Cost,0.61,,,0.61,Other,Drug Cost,0.61,,,0.61,Other,Drug Cost,1.38,,,1.38,Other,225% of Medicaid,0.86,,,0.86,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,1.31,,,1.31,Other,215% Medicaid APG methodology,1.31,,,1.31,Other,215% Medicaid APG methodology,0.76,,,0.76,Other,125% Medicaid APG methodology,0.01,1.38,
NICOTINE POLACRILEX 2 MG GUM,,,,80001468,CDM,250,RC,536311201,NDC,both,100,EA,0.41,0.16,39.4668,,0.16,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.14,34,,0.14,percent of total billed charges,"Drugs, Inpatient Only",0.14,34,,0.14,percent of total billed charges,"Drugs, Inpatient Only",0.14,34,,0.14,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.29,70,,0.29,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.14,,,0.14,Other,Drug Cost,0.14,,,0.14,Other,Drug Cost,0.14,,,0.14,Other,Drug Cost,0.14,,,0.14,Other,Drug Cost,0.14,,,0.14,Other,Drug Cost,0.14,,,0.14,Other,Drug Cost,0.31,,,0.31,Other,225% of Medicaid,0.19,,,0.19,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.29,,,0.29,Other,215% Medicaid APG methodology,0.29,,,0.29,Other,215% Medicaid APG methodology,0.17,,,0.17,Other,125% Medicaid APG methodology,0.01,0.31,
NICOTINE POLACRILEX 4 MG GUM,,,,80001469,CDM,250,RC,536303023,NDC,both,110,EA,0.32,0.13,39.4668,,0.13,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.11,34,,0.11,percent of total billed charges,"Drugs, Inpatient Only",0.11,34,,0.11,percent of total billed charges,"Drugs, Inpatient Only",0.11,34,,0.11,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.22,70,,0.22,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.11,,,0.11,Other,Drug Cost,0.11,,,0.11,Other,Drug Cost,0.11,,,0.11,Other,Drug Cost,0.11,,,0.11,Other,Drug Cost,0.11,,,0.11,Other,Drug Cost,0.11,,,0.11,Other,Drug Cost,0.24,,,0.24,Other,225% of Medicaid,0.15,,,0.15,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.23,,,0.23,Other,215% Medicaid APG methodology,0.23,,,0.23,Other,215% Medicaid APG methodology,0.13,,,0.13,Other,125% Medicaid APG methodology,0.01,0.24,
NIFEDIPINE 10 MG CAP,,,,80001470,CDM,250,RC,23155019401,NDC,both,100,EA,0.25,0.1,39.4668,,0.1,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.09,34,,0.09,percent of total billed charges,"Drugs, Inpatient Only",0.09,34,,0.09,percent of total billed charges,"Drugs, Inpatient Only",0.09,34,,0.09,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.18,70,,0.18,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.08,,,0.08,Other,Drug Cost,0.08,,,0.08,Other,Drug Cost,0.08,,,0.08,Other,Drug Cost,0.08,,,0.08,Other,Drug Cost,0.08,,,0.08,Other,Drug Cost,0.08,,,0.08,Other,Drug Cost,0.19,,,0.19,Other,225% of Medicaid,0.12,,,0.12,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.18,,,0.18,Other,215% Medicaid APG methodology,0.18,,,0.18,Other,215% Medicaid APG methodology,0.1,,,0.1,Other,125% Medicaid APG methodology,0.01,0.19,
NIFEDIPINE 30 MG ER TAB,,,,80001472,CDM,250,RC,50742062001,NDC,both,100,EA,0.13,0.05,39.4668,,0.05,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.04,34,,0.04,percent of total billed charges,"Drugs, Inpatient Only",0.04,34,,0.04,percent of total billed charges,"Drugs, Inpatient Only",0.04,34,,0.04,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.09,70,,0.09,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.09,,,0.09,Other,225% of Medicaid,0.06,,,0.06,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.09,,,0.09,Other,215% Medicaid APG methodology,0.09,,,0.09,Other,215% Medicaid APG methodology,0.05,,,0.05,Other,125% Medicaid APG methodology,0.01,0.09,
NISOLDIPINE 20 MG ER TAB,,,,80001477,CDM,250,RC,378222201,NDC,both,100,EA,10.26,4.05,39.4668,,4.05,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,3.49,34,,3.49,percent of total billed charges,"Drugs, Inpatient Only",3.49,34,,3.49,percent of total billed charges,"Drugs, Inpatient Only",3.49,34,,3.49,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,7.18,70,,7.18,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,3.42,,,3.42,Other,Drug Cost,3.42,,,3.42,Other,Drug Cost,3.42,,,3.42,Other,Drug Cost,3.42,,,3.42,Other,Drug Cost,3.42,,,3.42,Other,Drug Cost,3.42,,,3.42,Other,Drug Cost,7.7,,,7.7,Other,225% of Medicaid,4.79,,,4.79,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,7.35,,,7.35,Other,215% Medicaid APG methodology,7.35,,,7.35,Other,215% Medicaid APG methodology,4.28,,,4.28,Other,125% Medicaid APG methodology,0.01,7.7,
NITROFURANTOIN 100MG CAP,,,,80001479,CDM,250,RC,47781030301,NDC,both,100,EA,0.36,0.14,39.4668,,0.14,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.12,34,,0.12,percent of total billed charges,"Drugs, Inpatient Only",0.12,34,,0.12,percent of total billed charges,"Drugs, Inpatient Only",0.12,34,,0.12,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.25,70,,0.25,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.12,,,0.12,Other,Drug Cost,0.12,,,0.12,Other,Drug Cost,0.12,,,0.12,Other,Drug Cost,0.12,,,0.12,Other,Drug Cost,0.12,,,0.12,Other,Drug Cost,0.12,,,0.12,Other,Drug Cost,0.27,,,0.27,Other,225% of Medicaid,0.17,,,0.17,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.26,,,0.26,Other,215% Medicaid APG methodology,0.26,,,0.26,Other,215% Medicaid APG methodology,0.15,,,0.15,Other,125% Medicaid APG methodology,0.01,0.27,
NITROGLYCERIN 0.1MG/HR,,,,80001482,CDM,250,RC,378910293,NDC,both,30,EA,0.69,0.27,39.4668,,0.27,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.24,34,,0.24,percent of total billed charges,"Drugs, Inpatient Only",0.24,34,,0.24,percent of total billed charges,"Drugs, Inpatient Only",0.24,34,,0.24,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.49,70,,0.49,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.23,,,0.23,Other,Drug Cost,0.23,,,0.23,Other,Drug Cost,0.23,,,0.23,Other,Drug Cost,0.23,,,0.23,Other,Drug Cost,0.23,,,0.23,Other,Drug Cost,0.23,,,0.23,Other,Drug Cost,0.52,,,0.52,Other,225% of Medicaid,0.32,,,0.32,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.5,,,0.5,Other,215% Medicaid APG methodology,0.5,,,0.5,Other,215% Medicaid APG methodology,0.29,,,0.29,Other,125% Medicaid APG methodology,0.01,0.52,
NITROGLYCERIN 0.2MG/HR,,,,80001483,CDM,250,RC,378910493,NDC,both,30,EA,0.7,0.27,39.4668,,0.27,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.24,34,,0.24,percent of total billed charges,"Drugs, Inpatient Only",0.24,34,,0.24,percent of total billed charges,"Drugs, Inpatient Only",0.24,34,,0.24,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.49,70,,0.49,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.23,,,0.23,Other,Drug Cost,0.23,,,0.23,Other,Drug Cost,0.23,,,0.23,Other,Drug Cost,0.23,,,0.23,Other,Drug Cost,0.23,,,0.23,Other,Drug Cost,0.23,,,0.23,Other,Drug Cost,0.52,,,0.52,Other,225% of Medicaid,0.32,,,0.32,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.5,,,0.5,Other,215% Medicaid APG methodology,0.5,,,0.5,Other,215% Medicaid APG methodology,0.29,,,0.29,Other,125% Medicaid APG methodology,0.01,0.52,
NITROGLYCERIN 0.4MG SL TAB,,,,80001488,CDM,250,RC,59762330403,NDC,both,4,EA,2.87,1.13,39.4668,,1.13,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.97,34,,0.97,percent of total billed charges,"Drugs, Inpatient Only",0.97,34,,0.97,percent of total billed charges,"Drugs, Inpatient Only",0.97,34,,0.97,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2.01,70,,2.01,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.96,,,0.96,Other,Drug Cost,0.96,,,0.96,Other,Drug Cost,0.96,,,0.96,Other,Drug Cost,0.96,,,0.96,Other,Drug Cost,0.96,,,0.96,Other,Drug Cost,0.96,,,0.96,Other,Drug Cost,2.15,,,2.15,Other,225% of Medicaid,1.34,,,1.34,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,2.05,,,2.05,Other,215% Medicaid APG methodology,2.05,,,2.05,Other,215% Medicaid APG methodology,1.19,,,1.19,Other,125% Medicaid APG methodology,0.01,2.15,
NITROGLYCERIN 0.6 MG/HR,,,,80001489,CDM,250,RC,378911693,NDC,both,30,EA,1.08,0.43,39.4668,,0.43,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.37,34,,0.37,percent of total billed charges,"Drugs, Inpatient Only",0.37,34,,0.37,percent of total billed charges,"Drugs, Inpatient Only",0.37,34,,0.37,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.76,70,,0.76,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.36,,,0.36,Other,Drug Cost,0.36,,,0.36,Other,Drug Cost,0.36,,,0.36,Other,Drug Cost,0.36,,,0.36,Other,Drug Cost,0.36,,,0.36,Other,Drug Cost,0.36,,,0.36,Other,Drug Cost,0.81,,,0.81,Other,225% of Medicaid,0.5,,,0.5,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.77,,,0.77,Other,215% Medicaid APG methodology,0.77,,,0.77,Other,215% Medicaid APG methodology,0.45,,,0.45,Other,125% Medicaid APG methodology,0.01,0.81,
NITROGLYCERIN 2% 1GM OINT,,,,80001490,CDM,250,RC,281032608,NDC,both,48,GM,3.46,1.37,39.4668,,1.37,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1.18,34,,1.18,percent of total billed charges,"Drugs, Inpatient Only",1.18,34,,1.18,percent of total billed charges,"Drugs, Inpatient Only",1.18,34,,1.18,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2.42,70,,2.42,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1.15,,,1.15,Other,Drug Cost,1.15,,,1.15,Other,Drug Cost,1.15,,,1.15,Other,Drug Cost,1.15,,,1.15,Other,Drug Cost,1.15,,,1.15,Other,Drug Cost,1.15,,,1.15,Other,Drug Cost,2.59,,,2.59,Other,225% of Medicaid,1.61,,,1.61,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,2.48,,,2.48,Other,215% Medicaid APG methodology,2.48,,,2.48,Other,215% Medicaid APG methodology,1.44,,,1.44,Other,125% Medicaid APG methodology,0.01,2.59,
NITROGLYCERIN 2% 30GM OINT,,,,80001491,CDM,250,RC,281032630,NDC,both,1,GM,92.55,36.53,39.4668,,36.53,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,31.47,34,,31.47,percent of total billed charges,"Drugs, Inpatient Only",31.47,34,,31.47,percent of total billed charges,"Drugs, Inpatient Only",31.47,34,,31.47,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,64.79,70,,64.79,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,30.85,,,30.85,Other,Drug Cost,30.85,,,30.85,Other,Drug Cost,30.85,,,30.85,Other,Drug Cost,30.85,,,30.85,Other,Drug Cost,30.85,,,30.85,Other,Drug Cost,30.85,,,30.85,Other,Drug Cost,69.41,,,69.41,Other,225% of Medicaid,43.19,,,43.19,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,66.33,,,66.33,Other,215% Medicaid APG methodology,66.33,,,66.33,Other,215% Medicaid APG methodology,38.56,,,38.56,Other,125% Medicaid APG methodology,0.01,69.41,
NITROGLYCERIN 200MCG/ML 250ML,,,,80001492,CDM,250,RC,338104902,NDC,both,12,ML,6.8,2.68,39.4668,,2.68,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2.31,34,,2.31,percent of total billed charges,"Drugs, Inpatient Only",2.31,34,,2.31,percent of total billed charges,"Drugs, Inpatient Only",2.31,34,,2.31,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,4.76,70,,4.76,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2.27,,,2.27,Other,Drug Cost,2.27,,,2.27,Other,Drug Cost,2.27,,,2.27,Other,Drug Cost,2.27,,,2.27,Other,Drug Cost,2.27,,,2.27,Other,Drug Cost,2.27,,,2.27,Other,Drug Cost,5.1,,,5.1,Other,225% of Medicaid,3.17,,,3.17,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,4.87,,,4.87,Other,215% Medicaid APG methodology,4.87,,,4.87,Other,215% Medicaid APG methodology,2.83,,,2.83,Other,125% Medicaid APG methodology,0.01,5.1,
NITROGLYCERIN 5 MG/ML 10ML INJ,,,,80001493,CDM,250,RC,517481025,NDC,both,25,ML,17.76,7.01,39.4668,,7.01,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,6.04,34,,6.04,percent of total billed charges,"Drugs, Inpatient Only",6.04,34,,6.04,percent of total billed charges,"Drugs, Inpatient Only",6.04,34,,6.04,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,12.43,70,,12.43,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,5.92,,,5.92,Other,Drug Cost,5.92,,,5.92,Other,Drug Cost,5.92,,,5.92,Other,Drug Cost,5.92,,,5.92,Other,Drug Cost,5.92,,,5.92,Other,Drug Cost,5.92,,,5.92,Other,Drug Cost,13.32,,,13.32,Other,225% of Medicaid,8.29,,,8.29,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,12.73,,,12.73,Other,215% Medicaid APG methodology,12.73,,,12.73,Other,215% Medicaid APG methodology,7.4,,,7.4,Other,125% Medicaid APG methodology,0.01,13.32,
NITROPRUSSIDE 50MG/2ML INJ,,,,80001496,CDM,250,RC,70436002880,NDC,both,1,ML,9.6,3.79,39.4668,,3.79,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,3.26,34,,3.26,percent of total billed charges,"Drugs, Inpatient Only",3.26,34,,3.26,percent of total billed charges,"Drugs, Inpatient Only",3.26,34,,3.26,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,6.72,70,,6.72,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,3.2,,,3.2,Other,Drug Cost,3.2,,,3.2,Other,Drug Cost,3.2,,,3.2,Other,Drug Cost,3.2,,,3.2,Other,Drug Cost,3.2,,,3.2,Other,Drug Cost,3.2,,,3.2,Other,Drug Cost,7.2,,,7.2,Other,225% of Medicaid,4.48,,,4.48,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,6.88,,,6.88,Other,215% Medicaid APG methodology,6.88,,,6.88,Other,215% Medicaid APG methodology,4,,,4,Other,125% Medicaid APG methodology,0.01,7.2,
NORETHINDNONE 5MG TAB,,,,80001506,CDM,250,RC,68462030450,NDC,both,50,EA,0.29,0.11,39.4668,,0.11,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.1,34,,0.1,percent of total billed charges,"Drugs, Inpatient Only",0.1,34,,0.1,percent of total billed charges,"Drugs, Inpatient Only",0.1,34,,0.1,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.2,70,,0.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.1,,,0.1,Other,Drug Cost,0.1,,,0.1,Other,Drug Cost,0.1,,,0.1,Other,Drug Cost,0.1,,,0.1,Other,Drug Cost,0.1,,,0.1,Other,Drug Cost,0.1,,,0.1,Other,Drug Cost,0.22,,,0.22,Other,225% of Medicaid,0.13,,,0.13,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.21,,,0.21,Other,215% Medicaid APG methodology,0.21,,,0.21,Other,215% Medicaid APG methodology,0.12,,,0.12,Other,125% Medicaid APG methodology,0.01,0.22,
NORTRIPTYLINE 10 MG CAP,,,,80001508,CDM,250,RC,93081001,NDC,both,100,EA,0.07,0.03,39.4668,,0.03,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.02,34,,0.02,percent of total billed charges,"Drugs, Inpatient Only",0.02,34,,0.02,percent of total billed charges,"Drugs, Inpatient Only",0.02,34,,0.02,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.05,70,,0.05,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.05,,,0.05,Other,225% of Medicaid,0.03,,,0.03,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.05,,,0.05,Other,215% Medicaid APG methodology,0.05,,,0.05,Other,215% Medicaid APG methodology,0.03,,,0.03,Other,125% Medicaid APG methodology,0.01,0.05,
NORTRIPTYLINE 25 MG CAP,,,,80001509,CDM,250,RC,93081101,NDC,both,100,EA,0.1,0.04,39.4668,,0.04,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.03,34,,0.03,percent of total billed charges,"Drugs, Inpatient Only",0.03,34,,0.03,percent of total billed charges,"Drugs, Inpatient Only",0.03,34,,0.03,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.07,70,,0.07,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.07,,,0.07,Other,225% of Medicaid,0.05,,,0.05,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.07,,,0.07,Other,215% Medicaid APG methodology,0.07,,,0.07,Other,215% Medicaid APG methodology,0.04,,,0.04,Other,125% Medicaid APG methodology,0.01,0.07,
NORTRIPTYLINE 50 MG CAP,,,,80001510,CDM,250,RC,93081201,NDC,both,100,EA,0.13,0.05,39.4668,,0.05,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.04,34,,0.04,percent of total billed charges,"Drugs, Inpatient Only",0.04,34,,0.04,percent of total billed charges,"Drugs, Inpatient Only",0.04,34,,0.04,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.09,70,,0.09,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.1,,,0.1,Other,225% of Medicaid,0.06,,,0.06,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.09,,,0.09,Other,215% Medicaid APG methodology,0.09,,,0.09,Other,215% Medicaid APG methodology,0.05,,,0.05,Other,125% Medicaid APG methodology,0.01,0.1,
NYSTATIN 15 GM CREAM,,,,80001513,CDM,250,RC,51672128901,NDC,both,1,GM,1.02,0.4,39.4668,,0.4,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.35,34,,0.35,percent of total billed charges,"Drugs, Inpatient Only",0.35,34,,0.35,percent of total billed charges,"Drugs, Inpatient Only",0.35,34,,0.35,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.71,70,,0.71,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.34,,,0.34,Other,Drug Cost,0.34,,,0.34,Other,Drug Cost,0.34,,,0.34,Other,Drug Cost,0.34,,,0.34,Other,Drug Cost,0.34,,,0.34,Other,Drug Cost,0.34,,,0.34,Other,Drug Cost,0.77,,,0.77,Other,225% of Medicaid,0.48,,,0.48,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.73,,,0.73,Other,215% Medicaid APG methodology,0.73,,,0.73,Other,215% Medicaid APG methodology,0.43,,,0.43,Other,125% Medicaid APG methodology,0.01,0.77,
NYSTATIN POWDER 15 GRAMS,,,,80001518,CDM,250,RC,832046515,NDC,both,1,GM,2.97,1.17,39.4668,,1.17,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1.01,34,,1.01,percent of total billed charges,"Drugs, Inpatient Only",1.01,34,,1.01,percent of total billed charges,"Drugs, Inpatient Only",1.01,34,,1.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2.08,70,,2.08,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.99,,,0.99,Other,Drug Cost,0.99,,,0.99,Other,Drug Cost,0.99,,,0.99,Other,Drug Cost,0.99,,,0.99,Other,Drug Cost,0.99,,,0.99,Other,Drug Cost,0.99,,,0.99,Other,Drug Cost,2.23,,,2.23,Other,225% of Medicaid,1.39,,,1.39,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,2.13,,,2.13,Other,215% Medicaid APG methodology,2.13,,,2.13,Other,215% Medicaid APG methodology,1.24,,,1.24,Other,125% Medicaid APG methodology,0.01,2.23,
NYSTATIN-TRIAMCIN 15GM CREAM,,,,80001520,CDM,250,RC,51672126301,NDC,both,1,GM,4.53,1.79,39.4668,,1.79,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1.54,34,,1.54,percent of total billed charges,"Drugs, Inpatient Only",1.54,34,,1.54,percent of total billed charges,"Drugs, Inpatient Only",1.54,34,,1.54,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,3.17,70,,3.17,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1.51,,,1.51,Other,Drug Cost,1.51,,,1.51,Other,Drug Cost,1.51,,,1.51,Other,Drug Cost,1.51,,,1.51,Other,Drug Cost,1.51,,,1.51,Other,Drug Cost,1.51,,,1.51,Other,Drug Cost,3.4,,,3.4,Other,225% of Medicaid,2.11,,,2.11,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,3.25,,,3.25,Other,215% Medicaid APG methodology,3.25,,,3.25,Other,215% Medicaid APG methodology,1.89,,,1.89,Other,125% Medicaid APG methodology,0.01,3.4,
NYSTATIN-TRIAMCIN 30GM OINT,,,,80001522,CDM,250,RC,62332058515,NDC,both,1,GM,4.95,1.95,39.4668,,1.95,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1.68,34,,1.68,percent of total billed charges,"Drugs, Inpatient Only",1.68,34,,1.68,percent of total billed charges,"Drugs, Inpatient Only",1.68,34,,1.68,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,3.47,70,,3.47,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1.65,,,1.65,Other,Drug Cost,1.65,,,1.65,Other,Drug Cost,1.65,,,1.65,Other,Drug Cost,1.65,,,1.65,Other,Drug Cost,1.65,,,1.65,Other,Drug Cost,1.65,,,1.65,Other,Drug Cost,3.71,,,3.71,Other,225% of Medicaid,2.31,,,2.31,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,3.55,,,3.55,Other,215% Medicaid APG methodology,3.55,,,3.55,Other,215% Medicaid APG methodology,2.06,,,2.06,Other,125% Medicaid APG methodology,0.01,3.71,
OFLOXACIN (FLOXIN) 0.3% 5ML OTIC SOLN,,,,80001527,CDM,250,RC,24208041005,NDC,both,1,ML,4.92,1.94,39.4668,,1.94,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1.67,34,,1.67,percent of total billed charges,"Drugs, Inpatient Only",1.67,34,,1.67,percent of total billed charges,"Drugs, Inpatient Only",1.67,34,,1.67,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,3.44,70,,3.44,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1.64,,,1.64,Other,Drug Cost,1.64,,,1.64,Other,Drug Cost,1.64,,,1.64,Other,Drug Cost,1.64,,,1.64,Other,Drug Cost,1.64,,,1.64,Other,Drug Cost,1.64,,,1.64,Other,Drug Cost,3.69,,,3.69,Other,225% of Medicaid,2.3,,,2.3,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,3.53,,,3.53,Other,215% Medicaid APG methodology,3.53,,,3.53,Other,215% Medicaid APG methodology,2.05,,,2.05,Other,125% Medicaid APG methodology,0.01,3.69,
OFLOXACIN 0.3% 5ML OPHTH,,,,80001528,CDM,250,RC,24208043405,NDC,both,1,ML,10.65,4.2,39.4668,,4.2,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,3.62,34,,3.62,percent of total billed charges,"Drugs, Inpatient Only",3.62,34,,3.62,percent of total billed charges,"Drugs, Inpatient Only",3.62,34,,3.62,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,7.46,70,,7.46,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,3.55,,,3.55,Other,Drug Cost,3.55,,,3.55,Other,Drug Cost,3.55,,,3.55,Other,Drug Cost,3.55,,,3.55,Other,Drug Cost,3.55,,,3.55,Other,Drug Cost,3.55,,,3.55,Other,Drug Cost,7.99,,,7.99,Other,225% of Medicaid,4.97,,,4.97,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,7.63,,,7.63,Other,215% Medicaid APG methodology,7.63,,,7.63,Other,215% Medicaid APG methodology,4.44,,,4.44,Other,125% Medicaid APG methodology,0.01,7.99,
OLANZAPINE  2.5 MG,,,,80001530,CDM,250,RC,55111016330,NDC,both,30,EA,0.05,0.02,39.4668,,0.02,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.02,34,,0.02,percent of total billed charges,"Drugs, Inpatient Only",0.02,34,,0.02,percent of total billed charges,"Drugs, Inpatient Only",0.02,34,,0.02,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.03,70,,0.03,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.04,,,0.04,Other,225% of Medicaid,0.02,,,0.02,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.04,,,0.04,Other,215% Medicaid APG methodology,0.04,,,0.04,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,125% Medicaid APG methodology,0.01,0.04,
OLANZAPINE  5 MG,,,,80001531,CDM,250,RC,43598016430,NDC,both,30,EA,0.06,0.02,39.4668,,0.02,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.02,34,,0.02,percent of total billed charges,"Drugs, Inpatient Only",0.02,34,,0.02,percent of total billed charges,"Drugs, Inpatient Only",0.02,34,,0.02,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.04,70,,0.04,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.04,,,0.04,Other,225% of Medicaid,0.03,,,0.03,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.04,,,0.04,Other,215% Medicaid APG methodology,0.04,,,0.04,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,125% Medicaid APG methodology,0.01,0.04,
OLANZAPINE LONG-ACTING 10MG INJ,,,,80001533,CDM,250,RC,2759701,NDC,both,1,EA,27.72,10.94,39.4668,,10.94,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,9.42,34,,9.42,percent of total billed charges,"Drugs, Inpatient Only",9.42,34,,9.42,percent of total billed charges,"Drugs, Inpatient Only",9.42,34,,9.42,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,19.4,70,,19.4,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,9.24,,,9.24,Other,Drug Cost,9.24,,,9.24,Other,Drug Cost,9.24,,,9.24,Other,Drug Cost,9.24,,,9.24,Other,Drug Cost,9.24,,,9.24,Other,Drug Cost,9.24,,,9.24,Other,Drug Cost,20.79,,,20.79,Other,225% of Medicaid,12.94,,,12.94,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,19.87,,,19.87,Other,215% Medicaid APG methodology,19.87,,,19.87,Other,215% Medicaid APG methodology,11.55,,,11.55,Other,125% Medicaid APG methodology,0.01,20.79,
OPIUM 10MG/ML TINCTURE,,,,80001541,CDM,250,RC,62559015304,NDC,both,1,ML,563.91,222.56,39.4668,,222.56,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,191.73,34,,191.73,percent of total billed charges,"Drugs, Inpatient Only",191.73,34,,191.73,percent of total billed charges,"Drugs, Inpatient Only",191.73,34,,191.73,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,394.74,70,,394.74,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,187.97,,,187.97,Other,Drug Cost,187.97,,,187.97,Other,Drug Cost,187.97,,,187.97,Other,Drug Cost,187.97,,,187.97,Other,Drug Cost,187.97,,,187.97,Other,Drug Cost,187.97,,,187.97,Other,Drug Cost,422.93,,,422.93,Other,225% of Medicaid,263.16,,,263.16,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,404.14,,,404.14,Other,215% Medicaid APG methodology,404.14,,,404.14,Other,215% Medicaid APG methodology,234.96,,,234.96,Other,125% Medicaid APG methodology,0.01,422.93,
ORAJEL 10%,,,,80001543,CDM,250,RC,50486055032,NDC,both,1,GM,18.03,7.12,39.4668,,7.12,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,6.13,34,,6.13,percent of total billed charges,"Drugs, Inpatient Only",6.13,34,,6.13,percent of total billed charges,"Drugs, Inpatient Only",6.13,34,,6.13,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,12.62,70,,12.62,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,6.01,,,6.01,Other,Drug Cost,6.01,,,6.01,Other,Drug Cost,6.01,,,6.01,Other,Drug Cost,6.01,,,6.01,Other,Drug Cost,6.01,,,6.01,Other,Drug Cost,6.01,,,6.01,Other,Drug Cost,13.52,,,13.52,Other,225% of Medicaid,8.41,,,8.41,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,12.92,,,12.92,Other,215% Medicaid APG methodology,12.92,,,12.92,Other,215% Medicaid APG methodology,7.51,,,7.51,Other,125% Medicaid APG methodology,0.01,13.52,
OSELTAMIVIR 75 MG CAP,,,,80001544,CDM,250,RC,64380079901,NDC,both,10,EA,0.21,0.08,39.4668,,0.08,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.07,34,,0.07,percent of total billed charges,"Drugs, Inpatient Only",0.07,34,,0.07,percent of total billed charges,"Drugs, Inpatient Only",0.07,34,,0.07,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.15,70,,0.15,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.07,,,0.07,Other,Drug Cost,0.07,,,0.07,Other,Drug Cost,0.07,,,0.07,Other,Drug Cost,0.07,,,0.07,Other,Drug Cost,0.07,,,0.07,Other,Drug Cost,0.07,,,0.07,Other,Drug Cost,0.16,,,0.16,Other,225% of Medicaid,0.1,,,0.1,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.15,,,0.15,Other,215% Medicaid APG methodology,0.15,,,0.15,Other,215% Medicaid APG methodology,0.09,,,0.09,Other,125% Medicaid APG methodology,0.01,0.16,
OXCARBAZEPINE 150MG TAB,,,,80001549,CDM,250,RC,78045605,NDC,both,100,EA,0.03,0.01,39.4668,,0.01,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.02,70,,0.02,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.02,,,0.02,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,0.02,
OXCARBAZEPINE 300MG TAB,,,,80001550,CDM,250,RC,78033705,NDC,both,100,EA,0.03,0.01,39.4668,,0.01,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.02,70,,0.02,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.02,,,0.02,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,0.02,
OXYBUTYNIN 5MG TAB,,,,80001552,CDM,250,RC,832003800,NDC,both,100,EA,0.12,0.05,39.4668,,0.05,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.04,34,,0.04,percent of total billed charges,"Drugs, Inpatient Only",0.04,34,,0.04,percent of total billed charges,"Drugs, Inpatient Only",0.04,34,,0.04,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.08,70,,0.08,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.09,,,0.09,Other,225% of Medicaid,0.05,,,0.05,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.08,,,0.08,Other,215% Medicaid APG methodology,0.08,,,0.08,Other,215% Medicaid APG methodology,0.05,,,0.05,Other,125% Medicaid APG methodology,0.01,0.09,
OXYCODONE (OXYCONTIN) 10MG SR TAB,,,,80001553,CDM,250,RC,59011041010,NDC,both,100,EA,0.03,0.01,39.4668,,0.01,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.02,70,,0.02,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.02,,,0.02,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,0.02,
OXYCODONE (OXYCONTIN) 40MG SR TAB,,,,80001555,CDM,250,RC,59011044010,NDC,both,100,EA,0.03,0.01,39.4668,,0.01,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.02,70,,0.02,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.02,,,0.02,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,0.02,
OXYCODONE 10MG IMMED REL TAB,,,,80001557,CDM,250,RC,42858000201,NDC,both,100,EA,0.17,0.07,39.4668,,0.07,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.06,34,,0.06,percent of total billed charges,"Drugs, Inpatient Only",0.06,34,,0.06,percent of total billed charges,"Drugs, Inpatient Only",0.06,34,,0.06,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.12,70,,0.12,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.06,,,0.06,Other,Drug Cost,0.06,,,0.06,Other,Drug Cost,0.06,,,0.06,Other,Drug Cost,0.06,,,0.06,Other,Drug Cost,0.06,,,0.06,Other,Drug Cost,0.06,,,0.06,Other,Drug Cost,0.13,,,0.13,Other,225% of Medicaid,0.08,,,0.08,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.12,,,0.12,Other,215% Medicaid APG methodology,0.12,,,0.12,Other,215% Medicaid APG methodology,0.07,,,0.07,Other,125% Medicaid APG methodology,0.01,0.13,
OXYCODONE 5MG IMMED REL TAB,,,,80001558,CDM,250,RC,10702001801,NDC,both,100,EA,0.11,0.04,39.4668,,0.04,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.04,34,,0.04,percent of total billed charges,"Drugs, Inpatient Only",0.04,34,,0.04,percent of total billed charges,"Drugs, Inpatient Only",0.04,34,,0.04,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.08,70,,0.08,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.08,,,0.08,Other,225% of Medicaid,0.05,,,0.05,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.08,,,0.08,Other,215% Medicaid APG methodology,0.08,,,0.08,Other,215% Medicaid APG methodology,0.05,,,0.05,Other,125% Medicaid APG methodology,0.01,0.08,
OXYCODONE/APAP 5/325MG TAB,,,,80001559,CDM,250,RC,47781019601,NDC,both,100,EA,0.1,0.04,39.4668,,0.04,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.04,34,,0.04,percent of total billed charges,"Drugs, Inpatient Only",0.04,34,,0.04,percent of total billed charges,"Drugs, Inpatient Only",0.04,34,,0.04,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.07,70,,0.07,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.08,,,0.08,Other,225% of Medicaid,0.05,,,0.05,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.07,,,0.07,Other,215% Medicaid APG methodology,0.07,,,0.07,Other,215% Medicaid APG methodology,0.04,,,0.04,Other,125% Medicaid APG methodology,0.01,0.08,
OXYMETAZOLINE HCL (AFRIN) NASAL 15 ML,,,,80001560,CDM,250,RC,904700635,NDC,both,1,ML,3.6,1.42,39.4668,,1.42,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1.22,34,,1.22,percent of total billed charges,"Drugs, Inpatient Only",1.22,34,,1.22,percent of total billed charges,"Drugs, Inpatient Only",1.22,34,,1.22,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2.52,70,,2.52,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1.2,,,1.2,Other,Drug Cost,1.2,,,1.2,Other,Drug Cost,1.2,,,1.2,Other,Drug Cost,1.2,,,1.2,Other,Drug Cost,1.2,,,1.2,Other,Drug Cost,1.2,,,1.2,Other,Drug Cost,2.7,,,2.7,Other,225% of Medicaid,1.68,,,1.68,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,2.58,,,2.58,Other,215% Medicaid APG methodology,2.58,,,2.58,Other,215% Medicaid APG methodology,1.5,,,1.5,Other,125% Medicaid APG methodology,0.01,2.7,
OXYBUTYNIN ER (DITROPAN XL) 5MG TAB,,,,80001561,CDM,250,RC,62175027037,NDC,both,100,EA,0.15,0.06,39.4668,,0.06,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.05,34,,0.05,percent of total billed charges,"Drugs, Inpatient Only",0.05,34,,0.05,percent of total billed charges,"Drugs, Inpatient Only",0.05,34,,0.05,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.1,70,,0.1,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.11,,,0.11,Other,225% of Medicaid,0.07,,,0.07,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.11,,,0.11,Other,215% Medicaid APG methodology,0.11,,,0.11,Other,215% Medicaid APG methodology,0.06,,,0.06,Other,125% Medicaid APG methodology,0.01,0.11,
OYSTER SHELL CALCIUM 500MG TAB,,,,80001565,CDM,250,RC,904188361,NDC,both,10,EA,0.34,0.13,39.4668,,0.13,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.12,34,,0.12,percent of total billed charges,"Drugs, Inpatient Only",0.12,34,,0.12,percent of total billed charges,"Drugs, Inpatient Only",0.12,34,,0.12,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.24,70,,0.24,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.11,,,0.11,Other,Drug Cost,0.11,,,0.11,Other,Drug Cost,0.11,,,0.11,Other,Drug Cost,0.11,,,0.11,Other,Drug Cost,0.11,,,0.11,Other,Drug Cost,0.11,,,0.11,Other,Drug Cost,0.25,,,0.25,Other,225% of Medicaid,0.16,,,0.16,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.24,,,0.24,Other,215% Medicaid APG methodology,0.24,,,0.24,Other,215% Medicaid APG methodology,0.14,,,0.14,Other,125% Medicaid APG methodology,0.01,0.25,
OYSTER SHELL CALCIUM W/D 250MG TAB,,,,80001566,CDM,250,RC,904188260,NDC,both,100,EA,0.03,0.01,39.4668,,0.01,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.02,70,,0.02,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.02,,,0.02,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,0.02,
PAROXETINE HCL 10 MG TAB,,,,80001589,CDM,250,RC,68382009716,NDC,both,90,EA,0.05,0.02,39.4668,,0.02,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.02,34,,0.02,percent of total billed charges,"Drugs, Inpatient Only",0.02,34,,0.02,percent of total billed charges,"Drugs, Inpatient Only",0.02,34,,0.02,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.04,70,,0.04,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.04,,,0.04,Other,225% of Medicaid,0.02,,,0.02,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.04,,,0.04,Other,215% Medicaid APG methodology,0.04,,,0.04,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,125% Medicaid APG methodology,0.01,0.04,
PAROXETINE HCL 20 MG TAB,,,,80001590,CDM,250,RC,60505008302,NDC,both,100,EA,0.11,0.04,39.4668,,0.04,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.04,34,,0.04,percent of total billed charges,"Drugs, Inpatient Only",0.04,34,,0.04,percent of total billed charges,"Drugs, Inpatient Only",0.04,34,,0.04,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.07,70,,0.07,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.08,,,0.08,Other,225% of Medicaid,0.05,,,0.05,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.08,,,0.08,Other,215% Medicaid APG methodology,0.08,,,0.08,Other,215% Medicaid APG methodology,0.04,,,0.04,Other,125% Medicaid APG methodology,0.01,0.08,
PENICILLAMINE 250 MG CAP,,,,80001596,CDM,250,RC,25010070515,NDC,both,100,EA,0.03,0.01,39.4668,,0.01,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.02,70,,0.02,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.02,,,0.02,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,0.02,
PENICILLIN V 250 MG/5 ML 200ML SUSP,,,,80001598,CDM,250,RC,93412773,NDC,both,1,ML,4.23,1.67,39.4668,,1.67,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1.44,34,,1.44,percent of total billed charges,"Drugs, Inpatient Only",1.44,34,,1.44,percent of total billed charges,"Drugs, Inpatient Only",1.44,34,,1.44,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2.96,70,,2.96,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1.41,,,1.41,Other,Drug Cost,1.41,,,1.41,Other,Drug Cost,1.41,,,1.41,Other,Drug Cost,1.41,,,1.41,Other,Drug Cost,1.41,,,1.41,Other,Drug Cost,1.41,,,1.41,Other,Drug Cost,3.17,,,3.17,Other,225% of Medicaid,1.97,,,1.97,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,3.03,,,3.03,Other,215% Medicaid APG methodology,3.03,,,3.03,Other,215% Medicaid APG methodology,1.76,,,1.76,Other,125% Medicaid APG methodology,0.01,3.17,
PENICILLIN VK 250 MG TAB,,,,80001599,CDM,250,RC,143983701,NDC,both,100,EA,0.06,0.02,39.4668,,0.02,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.02,34,,0.02,percent of total billed charges,"Drugs, Inpatient Only",0.02,34,,0.02,percent of total billed charges,"Drugs, Inpatient Only",0.02,34,,0.02,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.04,70,,0.04,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.04,,,0.04,Other,225% of Medicaid,0.03,,,0.03,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.04,,,0.04,Other,215% Medicaid APG methodology,0.04,,,0.04,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,125% Medicaid APG methodology,0.01,0.04,
PENTAMIDINE 300MG INJ,,,,80001600,CDM,250,RC,63323011310,NDC,both,10,EA,113.19,44.67,39.4668,,44.67,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,38.49,34,,38.49,percent of total billed charges,"Drugs, Inpatient Only",38.49,34,,38.49,percent of total billed charges,"Drugs, Inpatient Only",38.49,34,,38.49,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,79.24,70,,79.24,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,37.73,,,37.73,Other,Drug Cost,37.73,,,37.73,Other,Drug Cost,37.73,,,37.73,Other,Drug Cost,37.73,,,37.73,Other,Drug Cost,37.73,,,37.73,Other,Drug Cost,37.73,,,37.73,Other,Drug Cost,84.89,,,84.89,Other,225% of Medicaid,52.82,,,52.82,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,81.12,,,81.12,Other,215% Medicaid APG methodology,81.12,,,81.12,Other,215% Medicaid APG methodology,47.16,,,47.16,Other,125% Medicaid APG methodology,0.01,84.89,
PENTOXIFYLLINE 400MG TAB,,,,80001603,CDM,250,RC,60505003306,NDC,both,100,EA,0.24,0.09,39.4668,,0.09,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.08,34,,0.08,percent of total billed charges,"Drugs, Inpatient Only",0.08,34,,0.08,percent of total billed charges,"Drugs, Inpatient Only",0.08,34,,0.08,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.17,70,,0.17,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.08,,,0.08,Other,Drug Cost,0.08,,,0.08,Other,Drug Cost,0.08,,,0.08,Other,Drug Cost,0.08,,,0.08,Other,Drug Cost,0.08,,,0.08,Other,Drug Cost,0.08,,,0.08,Other,Drug Cost,0.18,,,0.18,Other,225% of Medicaid,0.11,,,0.11,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.17,,,0.17,Other,215% Medicaid APG methodology,0.17,,,0.17,Other,215% Medicaid APG methodology,0.1,,,0.1,Other,125% Medicaid APG methodology,0.01,0.18,
PEPPERMINT SPIRIT 30ML,,,,80001604,CDM,250,RC,395224391,NDC,both,1,EA,20.31,8.02,39.4668,,8.02,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,6.91,34,,6.91,percent of total billed charges,"Drugs, Inpatient Only",6.91,34,,6.91,percent of total billed charges,"Drugs, Inpatient Only",6.91,34,,6.91,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,14.22,70,,14.22,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,6.77,,,6.77,Other,Drug Cost,6.77,,,6.77,Other,Drug Cost,6.77,,,6.77,Other,Drug Cost,6.77,,,6.77,Other,Drug Cost,6.77,,,6.77,Other,Drug Cost,6.77,,,6.77,Other,Drug Cost,15.23,,,15.23,Other,225% of Medicaid,9.48,,,9.48,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,14.56,,,14.56,Other,215% Medicaid APG methodology,14.56,,,14.56,Other,215% Medicaid APG methodology,8.46,,,8.46,Other,125% Medicaid APG methodology,0.01,15.23,
PERMETHRIN 1% LOTION,,,,80001607,CDM,250,RC,63736012002,NDC,both,1,ML,30,11.84,39.4668,,11.84,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,10.2,34,,10.2,percent of total billed charges,"Drugs, Inpatient Only",10.2,34,,10.2,percent of total billed charges,"Drugs, Inpatient Only",10.2,34,,10.2,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,21,70,,21,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,10,,,10,Other,Drug Cost,10,,,10,Other,Drug Cost,10,,,10,Other,Drug Cost,10,,,10,Other,Drug Cost,10,,,10,Other,Drug Cost,10,,,10,Other,Drug Cost,22.5,,,22.5,Other,225% of Medicaid,14,,,14,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,21.5,,,21.5,Other,215% Medicaid APG methodology,21.5,,,21.5,Other,215% Medicaid APG methodology,12.5,,,12.5,Other,125% Medicaid APG methodology,0.01,22.5,
PERMETHRIN 60GM CREAM,,,,80001608,CDM,250,RC,21922002107,NDC,both,1,GM,16.14,6.37,39.4668,,6.37,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,5.49,34,,5.49,percent of total billed charges,"Drugs, Inpatient Only",5.49,34,,5.49,percent of total billed charges,"Drugs, Inpatient Only",5.49,34,,5.49,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,11.3,70,,11.3,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,5.38,,,5.38,Other,Drug Cost,5.38,,,5.38,Other,Drug Cost,5.38,,,5.38,Other,Drug Cost,5.38,,,5.38,Other,Drug Cost,5.38,,,5.38,Other,Drug Cost,5.38,,,5.38,Other,Drug Cost,12.11,,,12.11,Other,225% of Medicaid,7.53,,,7.53,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,11.57,,,11.57,Other,215% Medicaid APG methodology,11.57,,,11.57,Other,215% Medicaid APG methodology,6.73,,,6.73,Other,125% Medicaid APG methodology,0.01,12.11,
PERPHENAZINE 4MG TAB,,,,80001612,CDM,250,RC,52536016401,NDC,both,100,EA,0.27,0.11,39.4668,,0.11,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.09,34,,0.09,percent of total billed charges,"Drugs, Inpatient Only",0.09,34,,0.09,percent of total billed charges,"Drugs, Inpatient Only",0.09,34,,0.09,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.19,70,,0.19,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.09,,,0.09,Other,Drug Cost,0.09,,,0.09,Other,Drug Cost,0.09,,,0.09,Other,Drug Cost,0.09,,,0.09,Other,Drug Cost,0.09,,,0.09,Other,Drug Cost,0.09,,,0.09,Other,Drug Cost,0.2,,,0.2,Other,225% of Medicaid,0.12,,,0.12,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.19,,,0.19,Other,215% Medicaid APG methodology,0.19,,,0.19,Other,215% Medicaid APG methodology,0.11,,,0.11,Other,125% Medicaid APG methodology,0.01,0.2,
PETROLATUM JELLY,,,,80001614,CDM,250,RC,904573182,NDC,both,1,GM,8.79,3.47,39.4668,,3.47,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2.99,34,,2.99,percent of total billed charges,"Drugs, Inpatient Only",2.99,34,,2.99,percent of total billed charges,"Drugs, Inpatient Only",2.99,34,,2.99,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,6.15,70,,6.15,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2.93,,,2.93,Other,Drug Cost,2.93,,,2.93,Other,Drug Cost,2.93,,,2.93,Other,Drug Cost,2.93,,,2.93,Other,Drug Cost,2.93,,,2.93,Other,Drug Cost,2.93,,,2.93,Other,Drug Cost,6.59,,,6.59,Other,225% of Medicaid,4.1,,,4.1,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,6.3,,,6.3,Other,215% Medicaid APG methodology,6.3,,,6.3,Other,215% Medicaid APG methodology,3.66,,,3.66,Other,125% Medicaid APG methodology,0.01,6.59,
PHENAZOPYRIDINE 100MG TAB,,,,80001616,CDM,250,RC,75826011410,NDC,both,100,EA,0.73,0.29,39.4668,,0.29,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.25,34,,0.25,percent of total billed charges,"Drugs, Inpatient Only",0.25,34,,0.25,percent of total billed charges,"Drugs, Inpatient Only",0.25,34,,0.25,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.51,70,,0.51,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.24,,,0.24,Other,Drug Cost,0.24,,,0.24,Other,Drug Cost,0.24,,,0.24,Other,Drug Cost,0.24,,,0.24,Other,Drug Cost,0.24,,,0.24,Other,Drug Cost,0.24,,,0.24,Other,Drug Cost,0.55,,,0.55,Other,225% of Medicaid,0.34,,,0.34,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.53,,,0.53,Other,215% Medicaid APG methodology,0.53,,,0.53,Other,215% Medicaid APG methodology,0.31,,,0.31,Other,125% Medicaid APG methodology,0.01,0.55,
PHENAZOPYRIDINE 200MG TAB,,,,80001617,CDM,250,RC,65162068210,NDC,both,100,EA,0.19,0.07,39.4668,,0.07,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.06,34,,0.06,percent of total billed charges,"Drugs, Inpatient Only",0.06,34,,0.06,percent of total billed charges,"Drugs, Inpatient Only",0.06,34,,0.06,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.13,70,,0.13,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.06,,,0.06,Other,Drug Cost,0.06,,,0.06,Other,Drug Cost,0.06,,,0.06,Other,Drug Cost,0.06,,,0.06,Other,Drug Cost,0.06,,,0.06,Other,Drug Cost,0.06,,,0.06,Other,Drug Cost,0.14,,,0.14,Other,225% of Medicaid,0.09,,,0.09,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.13,,,0.13,Other,215% Medicaid APG methodology,0.13,,,0.13,Other,215% Medicaid APG methodology,0.08,,,0.08,Other,125% Medicaid APG methodology,0.01,0.14,
PHENOL TOPICAL 1.4% SPRAY,,,,80001624,CDM,250,RC,904630521,NDC,both,1,ML,4.77,1.88,39.4668,,1.88,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1.62,34,,1.62,percent of total billed charges,"Drugs, Inpatient Only",1.62,34,,1.62,percent of total billed charges,"Drugs, Inpatient Only",1.62,34,,1.62,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,3.34,70,,3.34,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1.59,,,1.59,Other,Drug Cost,1.59,,,1.59,Other,Drug Cost,1.59,,,1.59,Other,Drug Cost,1.59,,,1.59,Other,Drug Cost,1.59,,,1.59,Other,Drug Cost,1.59,,,1.59,Other,Drug Cost,3.58,,,3.58,Other,225% of Medicaid,2.23,,,2.23,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,3.42,,,3.42,Other,215% Medicaid APG methodology,3.42,,,3.42,Other,215% Medicaid APG methodology,1.99,,,1.99,Other,125% Medicaid APG methodology,0.01,3.58,
PHENYLEPHRINE (HEMORRHOIDAL) SUPP,,,,80001626,CDM,250,RC,536118612,NDC,both,12,EA,0.35,0.14,39.4668,,0.14,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.12,34,,0.12,percent of total billed charges,"Drugs, Inpatient Only",0.12,34,,0.12,percent of total billed charges,"Drugs, Inpatient Only",0.12,34,,0.12,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.24,70,,0.24,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.12,,,0.12,Other,Drug Cost,0.12,,,0.12,Other,Drug Cost,0.12,,,0.12,Other,Drug Cost,0.12,,,0.12,Other,Drug Cost,0.12,,,0.12,Other,Drug Cost,0.12,,,0.12,Other,Drug Cost,0.26,,,0.26,Other,225% of Medicaid,0.16,,,0.16,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.25,,,0.25,Other,215% Medicaid APG methodology,0.25,,,0.25,Other,215% Medicaid APG methodology,0.14,,,0.14,Other,125% Medicaid APG methodology,0.01,0.26,
PHENYLEPHRINE 0.25% OPHTH,,,,80001627,CDM,250,RC,70756062925,NDC,both,1,ML,61.89,24.43,39.4668,,24.43,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,21.04,34,,21.04,percent of total billed charges,"Drugs, Inpatient Only",21.04,34,,21.04,percent of total billed charges,"Drugs, Inpatient Only",21.04,34,,21.04,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,43.32,70,,43.32,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,20.63,,,20.63,Other,Drug Cost,20.63,,,20.63,Other,Drug Cost,20.63,,,20.63,Other,Drug Cost,20.63,,,20.63,Other,Drug Cost,20.63,,,20.63,Other,Drug Cost,20.63,,,20.63,Other,Drug Cost,46.42,,,46.42,Other,225% of Medicaid,28.88,,,28.88,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,44.35,,,44.35,Other,215% Medicaid APG methodology,44.35,,,44.35,Other,215% Medicaid APG methodology,25.79,,,25.79,Other,125% Medicaid APG methodology,0.01,46.42,
PHENYTOIN (DILANTIN) 100 MG CAPS,,,,80001634,CDM,250,RC,71036924,NDC,both,100,EA,1.68,0.66,39.4668,,0.66,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.57,34,,0.57,percent of total billed charges,"Drugs, Inpatient Only",0.57,34,,0.57,percent of total billed charges,"Drugs, Inpatient Only",0.57,34,,0.57,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1.17,70,,1.17,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.56,,,0.56,Other,Drug Cost,0.56,,,0.56,Other,Drug Cost,0.56,,,0.56,Other,Drug Cost,0.56,,,0.56,Other,Drug Cost,0.56,,,0.56,Other,Drug Cost,0.56,,,0.56,Other,Drug Cost,1.26,,,1.26,Other,225% of Medicaid,0.78,,,0.78,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,1.2,,,1.2,Other,215% Medicaid APG methodology,1.2,,,1.2,Other,215% Medicaid APG methodology,0.7,,,0.7,Other,125% Medicaid APG methodology,0.01,1.26,
PHENYTOIN (DILANTIN) 30 MG CAPS,,,,80001635,CDM,250,RC,71374066,NDC,both,100,EA,1.44,0.57,39.4668,,0.57,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.49,34,,0.49,percent of total billed charges,"Drugs, Inpatient Only",0.49,34,,0.49,percent of total billed charges,"Drugs, Inpatient Only",0.49,34,,0.49,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1.01,70,,1.01,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.48,,,0.48,Other,Drug Cost,0.48,,,0.48,Other,Drug Cost,0.48,,,0.48,Other,Drug Cost,0.48,,,0.48,Other,Drug Cost,0.48,,,0.48,Other,Drug Cost,0.48,,,0.48,Other,Drug Cost,1.08,,,1.08,Other,225% of Medicaid,0.67,,,0.67,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,1.03,,,1.03,Other,215% Medicaid APG methodology,1.03,,,1.03,Other,215% Medicaid APG methodology,0.6,,,0.6,Other,125% Medicaid APG methodology,0.01,1.08,
PHENYTOIN (DILANTIN) INFA 50MG TAB,,,,80001636,CDM,250,RC,51672414601,NDC,both,100,EA,0.16,0.06,39.4668,,0.06,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.06,34,,0.06,percent of total billed charges,"Drugs, Inpatient Only",0.06,34,,0.06,percent of total billed charges,"Drugs, Inpatient Only",0.06,34,,0.06,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.11,70,,0.11,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.12,,,0.12,Other,225% of Medicaid,0.08,,,0.08,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.12,,,0.12,Other,215% Medicaid APG methodology,0.12,,,0.12,Other,215% Medicaid APG methodology,0.07,,,0.07,Other,125% Medicaid APG methodology,0.01,0.12,
PHOSPHORUS (K-PHOS NEUTRAL) 250MG TAB,,,,80001641,CDM,250,RC,64980010401,NDC,both,100,EA,0.22,0.09,39.4668,,0.09,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.08,34,,0.08,percent of total billed charges,"Drugs, Inpatient Only",0.08,34,,0.08,percent of total billed charges,"Drugs, Inpatient Only",0.08,34,,0.08,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.16,70,,0.16,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.07,,,0.07,Other,Drug Cost,0.07,,,0.07,Other,Drug Cost,0.07,,,0.07,Other,Drug Cost,0.07,,,0.07,Other,Drug Cost,0.07,,,0.07,Other,Drug Cost,0.07,,,0.07,Other,Drug Cost,0.17,,,0.17,Other,225% of Medicaid,0.1,,,0.1,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.16,,,0.16,Other,215% Medicaid APG methodology,0.16,,,0.16,Other,215% Medicaid APG methodology,0.09,,,0.09,Other,125% Medicaid APG methodology,0.01,0.17,
PILOCARPINE 1% OPHTH,,,,80001642,CDM,250,RC,61314020315,NDC,both,1,ML,60.72,23.96,39.4668,,23.96,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,20.64,34,,20.64,percent of total billed charges,"Drugs, Inpatient Only",20.64,34,,20.64,percent of total billed charges,"Drugs, Inpatient Only",20.64,34,,20.64,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,42.5,70,,42.5,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,20.24,,,20.24,Other,Drug Cost,20.24,,,20.24,Other,Drug Cost,20.24,,,20.24,Other,Drug Cost,20.24,,,20.24,Other,Drug Cost,20.24,,,20.24,Other,Drug Cost,20.24,,,20.24,Other,Drug Cost,45.54,,,45.54,Other,225% of Medicaid,28.34,,,28.34,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,43.52,,,43.52,Other,215% Medicaid APG methodology,43.52,,,43.52,Other,215% Medicaid APG methodology,25.3,,,25.3,Other,125% Medicaid APG methodology,0.01,45.54,
PILOCARPINE 5 MG TAB,,,,80001644,CDM,250,RC,527131301,NDC,both,100,EA,0.19,0.07,39.4668,,0.07,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.06,34,,0.06,percent of total billed charges,"Drugs, Inpatient Only",0.06,34,,0.06,percent of total billed charges,"Drugs, Inpatient Only",0.06,34,,0.06,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.13,70,,0.13,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.06,,,0.06,Other,Drug Cost,0.06,,,0.06,Other,Drug Cost,0.06,,,0.06,Other,Drug Cost,0.06,,,0.06,Other,Drug Cost,0.06,,,0.06,Other,Drug Cost,0.06,,,0.06,Other,Drug Cost,0.14,,,0.14,Other,225% of Medicaid,0.09,,,0.09,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.13,,,0.13,Other,215% Medicaid APG methodology,0.13,,,0.13,Other,215% Medicaid APG methodology,0.08,,,0.08,Other,125% Medicaid APG methodology,0.01,0.14,
PILOCARPINE HCL 2% OPHTH,,,,80001645,CDM,250,RC,61314020415,NDC,both,1,ML,17.13,6.76,39.4668,,6.76,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,5.82,34,,5.82,percent of total billed charges,"Drugs, Inpatient Only",5.82,34,,5.82,percent of total billed charges,"Drugs, Inpatient Only",5.82,34,,5.82,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,11.99,70,,11.99,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,5.71,,,5.71,Other,Drug Cost,5.71,,,5.71,Other,Drug Cost,5.71,,,5.71,Other,Drug Cost,5.71,,,5.71,Other,Drug Cost,5.71,,,5.71,Other,Drug Cost,5.71,,,5.71,Other,Drug Cost,12.85,,,12.85,Other,225% of Medicaid,7.99,,,7.99,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,12.28,,,12.28,Other,215% Medicaid APG methodology,12.28,,,12.28,Other,215% Medicaid APG methodology,7.14,,,7.14,Other,125% Medicaid APG methodology,0.01,12.85,
PILOCARPINE HCL 4% OPHTH,,,,80001646,CDM,250,RC,61314020615,NDC,both,1,ML,65.25,25.75,39.4668,,25.75,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,22.19,34,,22.19,percent of total billed charges,"Drugs, Inpatient Only",22.19,34,,22.19,percent of total billed charges,"Drugs, Inpatient Only",22.19,34,,22.19,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,45.68,70,,45.68,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,21.75,,,21.75,Other,Drug Cost,21.75,,,21.75,Other,Drug Cost,21.75,,,21.75,Other,Drug Cost,21.75,,,21.75,Other,Drug Cost,21.75,,,21.75,Other,Drug Cost,21.75,,,21.75,Other,Drug Cost,48.94,,,48.94,Other,225% of Medicaid,30.45,,,30.45,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,46.76,,,46.76,Other,215% Medicaid APG methodology,46.76,,,46.76,Other,215% Medicaid APG methodology,27.19,,,27.19,Other,125% Medicaid APG methodology,0.01,48.94,
PIMECROLIMUC (ELIDEL) CRM 30GM,,,,80001648,CDM,250,RC,187510001,NDC,both,1,GM,0.81,0.32,39.4668,,0.32,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.28,34,,0.28,percent of total billed charges,"Drugs, Inpatient Only",0.28,34,,0.28,percent of total billed charges,"Drugs, Inpatient Only",0.28,34,,0.28,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.57,70,,0.57,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.27,,,0.27,Other,Drug Cost,0.27,,,0.27,Other,Drug Cost,0.27,,,0.27,Other,Drug Cost,0.27,,,0.27,Other,Drug Cost,0.27,,,0.27,Other,Drug Cost,0.27,,,0.27,Other,Drug Cost,0.61,,,0.61,Other,225% of Medicaid,0.38,,,0.38,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.58,,,0.58,Other,215% Medicaid APG methodology,0.58,,,0.58,Other,215% Medicaid APG methodology,0.34,,,0.34,Other,125% Medicaid APG methodology,0.01,0.61,
PLAVIX 300MG TAB,,,,80001659,CDM,250,RC,69367019430,NDC,both,30,EA,10.71,4.23,39.4668,,4.23,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,3.64,34,,3.64,percent of total billed charges,"Drugs, Inpatient Only",3.64,34,,3.64,percent of total billed charges,"Drugs, Inpatient Only",3.64,34,,3.64,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,7.5,70,,7.5,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,3.57,,,3.57,Other,Drug Cost,3.57,,,3.57,Other,Drug Cost,3.57,,,3.57,Other,Drug Cost,3.57,,,3.57,Other,Drug Cost,3.57,,,3.57,Other,Drug Cost,3.57,,,3.57,Other,Drug Cost,8.03,,,8.03,Other,225% of Medicaid,5,,,5,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,7.67,,,7.67,Other,215% Medicaid APG methodology,7.67,,,7.67,Other,215% Medicaid APG methodology,4.46,,,4.46,Other,125% Medicaid APG methodology,0.01,8.03,
PLAVIX 75MG,,,,80001660,CDM,250,RC,904629461,NDC,both,10,EA,1.84,0.73,39.4668,,0.73,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.63,34,,0.63,percent of total billed charges,"Drugs, Inpatient Only",0.63,34,,0.63,percent of total billed charges,"Drugs, Inpatient Only",0.63,34,,0.63,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1.29,70,,1.29,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.61,,,0.61,Other,Drug Cost,0.61,,,0.61,Other,Drug Cost,0.61,,,0.61,Other,Drug Cost,0.61,,,0.61,Other,Drug Cost,0.61,,,0.61,Other,Drug Cost,0.61,,,0.61,Other,Drug Cost,1.38,,,1.38,Other,225% of Medicaid,0.86,,,0.86,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,1.32,,,1.32,Other,215% Medicaid APG methodology,1.32,,,1.32,Other,215% Medicaid APG methodology,0.77,,,0.77,Other,125% Medicaid APG methodology,0.01,1.38,
POLYETHYLENE GLYCOL (MIRALAX)  255 GM,,,,80001662,CDM,250,RC,45802086802,NDC,both,1,GM,6.48,2.56,39.4668,,2.56,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2.2,34,,2.2,percent of total billed charges,"Drugs, Inpatient Only",2.2,34,,2.2,percent of total billed charges,"Drugs, Inpatient Only",2.2,34,,2.2,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,4.54,70,,4.54,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2.16,,,2.16,Other,Drug Cost,2.16,,,2.16,Other,Drug Cost,2.16,,,2.16,Other,Drug Cost,2.16,,,2.16,Other,Drug Cost,2.16,,,2.16,Other,Drug Cost,2.16,,,2.16,Other,Drug Cost,4.86,,,4.86,Other,225% of Medicaid,3.02,,,3.02,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,4.64,,,4.64,Other,215% Medicaid APG methodology,4.64,,,4.64,Other,215% Medicaid APG methodology,2.7,,,2.7,Other,125% Medicaid APG methodology,0.01,4.86,
POLYETHYLENE GLYCOL (MIRALAX) 17 GM,,,,80001663,CDM,250,RC,51079030630,NDC,both,30,EA,2.84,1.12,39.4668,,1.12,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.96,34,,0.96,percent of total billed charges,"Drugs, Inpatient Only",0.96,34,,0.96,percent of total billed charges,"Drugs, Inpatient Only",0.96,34,,0.96,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1.99,70,,1.99,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.95,,,0.95,Other,Drug Cost,0.95,,,0.95,Other,Drug Cost,0.95,,,0.95,Other,Drug Cost,0.95,,,0.95,Other,Drug Cost,0.95,,,0.95,Other,Drug Cost,0.95,,,0.95,Other,Drug Cost,2.13,,,2.13,Other,225% of Medicaid,1.32,,,1.32,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,2.03,,,2.03,Other,215% Medicaid APG methodology,2.03,,,2.03,Other,215% Medicaid APG methodology,1.18,,,1.18,Other,125% Medicaid APG methodology,0.01,2.13,
POLYMYXIN B 500000 UNIT INJ,,,,80001664,CDM,250,RC,63323032110,NDC,both,10,EA,10.16,4.01,39.4668,,4.01,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,3.45,34,,3.45,percent of total billed charges,"Drugs, Inpatient Only",3.45,34,,3.45,percent of total billed charges,"Drugs, Inpatient Only",3.45,34,,3.45,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,7.11,70,,7.11,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,3.39,,,3.39,Other,Drug Cost,3.39,,,3.39,Other,Drug Cost,3.39,,,3.39,Other,Drug Cost,3.39,,,3.39,Other,Drug Cost,3.39,,,3.39,Other,Drug Cost,3.39,,,3.39,Other,Drug Cost,7.62,,,7.62,Other,225% of Medicaid,4.74,,,4.74,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,7.28,,,7.28,Other,215% Medicaid APG methodology,7.28,,,7.28,Other,215% Medicaid APG methodology,4.23,,,4.23,Other,125% Medicaid APG methodology,0.01,7.62,
POTASIUM CHLORIDE 10 MEQ TAB,,,,80001667,CDM,250,RC,832532411,NDC,both,100,EA,0.28,0.11,39.4668,,0.11,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.1,34,,0.1,percent of total billed charges,"Drugs, Inpatient Only",0.1,34,,0.1,percent of total billed charges,"Drugs, Inpatient Only",0.1,34,,0.1,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.2,70,,0.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.09,,,0.09,Other,Drug Cost,0.09,,,0.09,Other,Drug Cost,0.09,,,0.09,Other,Drug Cost,0.09,,,0.09,Other,Drug Cost,0.09,,,0.09,Other,Drug Cost,0.09,,,0.09,Other,Drug Cost,0.21,,,0.21,Other,225% of Medicaid,0.13,,,0.13,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.2,,,0.2,Other,215% Medicaid APG methodology,0.2,,,0.2,Other,215% Medicaid APG methodology,0.12,,,0.12,Other,125% Medicaid APG methodology,0.01,0.21,
POTASSIUM CHLORIDE (K-LOR) 20 MEQ TAB,,,,80001671,CDM,250,RC,245531990,NDC,both,90,EA,0.33,0.13,39.4668,,0.13,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.11,34,,0.11,percent of total billed charges,"Drugs, Inpatient Only",0.11,34,,0.11,percent of total billed charges,"Drugs, Inpatient Only",0.11,34,,0.11,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.23,70,,0.23,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.11,,,0.11,Other,Drug Cost,0.11,,,0.11,Other,Drug Cost,0.11,,,0.11,Other,Drug Cost,0.11,,,0.11,Other,Drug Cost,0.11,,,0.11,Other,Drug Cost,0.11,,,0.11,Other,Drug Cost,0.25,,,0.25,Other,225% of Medicaid,0.15,,,0.15,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.23,,,0.23,Other,215% Medicaid APG methodology,0.23,,,0.23,Other,215% Medicaid APG methodology,0.14,,,0.14,Other,125% Medicaid APG methodology,0.01,0.25,
POTASSIUM PHOS MONOBASIC 500MG TAB,,,,80001675,CDM,250,RC,486111101,NDC,both,100,EA,1.03,0.41,39.4668,,0.41,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.35,34,,0.35,percent of total billed charges,"Drugs, Inpatient Only",0.35,34,,0.35,percent of total billed charges,"Drugs, Inpatient Only",0.35,34,,0.35,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.72,70,,0.72,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.34,,,0.34,Other,Drug Cost,0.34,,,0.34,Other,Drug Cost,0.34,,,0.34,Other,Drug Cost,0.34,,,0.34,Other,Drug Cost,0.34,,,0.34,Other,Drug Cost,0.34,,,0.34,Other,Drug Cost,0.77,,,0.77,Other,225% of Medicaid,0.48,,,0.48,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.74,,,0.74,Other,215% Medicaid APG methodology,0.74,,,0.74,Other,215% Medicaid APG methodology,0.43,,,0.43,Other,125% Medicaid APG methodology,0.01,0.77,
PRASUGREL (EFFIENT) 10MG TABLET,,,,80001679,CDM,250,RC,65862083030,NDC,both,30,EA,0.29,0.12,39.4668,,0.12,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.1,34,,0.1,percent of total billed charges,"Drugs, Inpatient Only",0.1,34,,0.1,percent of total billed charges,"Drugs, Inpatient Only",0.1,34,,0.1,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.2,70,,0.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.1,,,0.1,Other,Drug Cost,0.1,,,0.1,Other,Drug Cost,0.1,,,0.1,Other,Drug Cost,0.1,,,0.1,Other,Drug Cost,0.1,,,0.1,Other,Drug Cost,0.1,,,0.1,Other,Drug Cost,0.22,,,0.22,Other,225% of Medicaid,0.14,,,0.14,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.21,,,0.21,Other,215% Medicaid APG methodology,0.21,,,0.21,Other,215% Medicaid APG methodology,0.12,,,0.12,Other,125% Medicaid APG methodology,0.01,0.22,
PRAVASTATIN 20MG TAB,,,,80001682,CDM,250,RC,60505016909,NDC,both,90,EA,0.07,0.03,39.4668,,0.03,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.02,34,,0.02,percent of total billed charges,"Drugs, Inpatient Only",0.02,34,,0.02,percent of total billed charges,"Drugs, Inpatient Only",0.02,34,,0.02,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.05,70,,0.05,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.05,,,0.05,Other,225% of Medicaid,0.03,,,0.03,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.05,,,0.05,Other,215% Medicaid APG methodology,0.05,,,0.05,Other,215% Medicaid APG methodology,0.03,,,0.03,Other,125% Medicaid APG methodology,0.01,0.05,
PRAZIQUANTEL (BILTRICIDE) 600 MG,,,,80001683,CDM,250,RC,50419074701,NDC,both,6,EA,0.03,0.01,39.4668,,0.01,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.02,70,,0.02,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.02,,,0.02,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,0.02,
PRAZOSIN 1 MG CAP,,,,80001684,CDM,250,RC,93406701,NDC,both,100,EA,0.06,0.02,39.4668,,0.02,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.02,34,,0.02,percent of total billed charges,"Drugs, Inpatient Only",0.02,34,,0.02,percent of total billed charges,"Drugs, Inpatient Only",0.02,34,,0.02,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.04,70,,0.04,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.04,,,0.04,Other,225% of Medicaid,0.03,,,0.03,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.04,,,0.04,Other,215% Medicaid APG methodology,0.04,,,0.04,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,125% Medicaid APG methodology,0.01,0.04,
PREDNISOLONE 1% OPHTH 10ML,,,,80001687,CDM,250,RC,61314063705,NDC,both,1,ML,19.35,7.64,39.4668,,7.64,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,6.58,34,,6.58,percent of total billed charges,"Drugs, Inpatient Only",6.58,34,,6.58,percent of total billed charges,"Drugs, Inpatient Only",6.58,34,,6.58,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,13.55,70,,13.55,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,6.45,,,6.45,Other,Drug Cost,6.45,,,6.45,Other,Drug Cost,6.45,,,6.45,Other,Drug Cost,6.45,,,6.45,Other,Drug Cost,6.45,,,6.45,Other,Drug Cost,6.45,,,6.45,Other,Drug Cost,14.51,,,14.51,Other,225% of Medicaid,9.03,,,9.03,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,13.87,,,13.87,Other,215% Medicaid APG methodology,13.87,,,13.87,Other,215% Medicaid APG methodology,8.06,,,8.06,Other,125% Medicaid APG methodology,0.01,14.51,
PREDNISOLONE-SOD SULFACET OPHTH SOL,,,,80001691,CDM,250,RC,24208031705,NDC,both,1,ML,20.82,8.22,39.4668,,8.22,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,7.08,34,,7.08,percent of total billed charges,"Drugs, Inpatient Only",7.08,34,,7.08,percent of total billed charges,"Drugs, Inpatient Only",7.08,34,,7.08,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,14.57,70,,14.57,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,6.94,,,6.94,Other,Drug Cost,6.94,,,6.94,Other,Drug Cost,6.94,,,6.94,Other,Drug Cost,6.94,,,6.94,Other,Drug Cost,6.94,,,6.94,Other,Drug Cost,6.94,,,6.94,Other,Drug Cost,15.62,,,15.62,Other,225% of Medicaid,9.72,,,9.72,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,14.92,,,14.92,Other,215% Medicaid APG methodology,14.92,,,14.92,Other,215% Medicaid APG methodology,8.68,,,8.68,Other,125% Medicaid APG methodology,0.01,15.62,
PREGABALIN  (LYRICA) 25MG CAPS,,,,80001698,CDM,250,RC,71101268,NDC,both,90,EA,0.03,0.01,39.4668,,0.01,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.02,70,,0.02,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.02,,,0.02,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,0.02,
PREGABALIN  (LYRICA) 50MG CAPS,,,,80001699,CDM,250,RC,71101368,NDC,both,90,EA,0.03,0.01,39.4668,,0.01,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.02,70,,0.02,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.02,,,0.02,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,0.02,
PREGABALIN  (LYRICA) 75MG CAPS,,,,80001700,CDM,250,RC,71101468,NDC,both,90,EA,0.03,0.01,39.4668,,0.01,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.02,70,,0.02,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.02,,,0.02,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,0.02,
PREGABALIN (LYRICA) 100 MG CAPS,,,,80001701,CDM,250,RC,71101568,NDC,both,90,EA,0.03,0.01,39.4668,,0.01,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.02,70,,0.02,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.02,,,0.02,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,0.02,
PRENATAL PLUS 1 TAB,,,,80001702,CDM,250,RC,39328010610,NDC,both,100,EA,0.16,0.06,39.4668,,0.06,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.06,34,,0.06,percent of total billed charges,"Drugs, Inpatient Only",0.06,34,,0.06,percent of total billed charges,"Drugs, Inpatient Only",0.06,34,,0.06,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.11,70,,0.11,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.12,,,0.12,Other,225% of Medicaid,0.08,,,0.08,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.12,,,0.12,Other,215% Medicaid APG methodology,0.12,,,0.12,Other,215% Medicaid APG methodology,0.07,,,0.07,Other,125% Medicaid APG methodology,0.01,0.12,
PREVACID 30 MG SOLU TAB,,,,80001704,CDM,250,RC,64764054411,NDC,both,10,EA,58.06,22.91,39.4668,,22.91,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,19.74,34,,19.74,percent of total billed charges,"Drugs, Inpatient Only",19.74,34,,19.74,percent of total billed charges,"Drugs, Inpatient Only",19.74,34,,19.74,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,40.64,70,,40.64,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,19.35,,,19.35,Other,Drug Cost,19.35,,,19.35,Other,Drug Cost,19.35,,,19.35,Other,Drug Cost,19.35,,,19.35,Other,Drug Cost,19.35,,,19.35,Other,Drug Cost,19.35,,,19.35,Other,Drug Cost,43.54,,,43.54,Other,225% of Medicaid,27.09,,,27.09,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,41.61,,,41.61,Other,215% Medicaid APG methodology,41.61,,,41.61,Other,215% Medicaid APG methodology,24.19,,,24.19,Other,125% Medicaid APG methodology,0.01,43.54,
PREVIDENT 5000 PLUS 51 GM,,,,80001707,CDM,250,RC,126028666,NDC,both,1,GM,51.96,20.51,39.4668,,20.51,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,17.67,34,,17.67,percent of total billed charges,"Drugs, Inpatient Only",17.67,34,,17.67,percent of total billed charges,"Drugs, Inpatient Only",17.67,34,,17.67,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,36.37,70,,36.37,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,17.32,,,17.32,Other,Drug Cost,17.32,,,17.32,Other,Drug Cost,17.32,,,17.32,Other,Drug Cost,17.32,,,17.32,Other,Drug Cost,17.32,,,17.32,Other,Drug Cost,17.32,,,17.32,Other,Drug Cost,38.97,,,38.97,Other,225% of Medicaid,24.25,,,24.25,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,37.24,,,37.24,Other,215% Medicaid APG methodology,37.24,,,37.24,Other,215% Medicaid APG methodology,21.65,,,21.65,Other,125% Medicaid APG methodology,0.01,38.97,
PREVIDENT 56 GM,,,,80001708,CDM,250,RC,126028802,NDC,both,1,GM,51.96,20.51,39.4668,,20.51,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,17.67,34,,17.67,percent of total billed charges,"Drugs, Inpatient Only",17.67,34,,17.67,percent of total billed charges,"Drugs, Inpatient Only",17.67,34,,17.67,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,36.37,70,,36.37,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,17.32,,,17.32,Other,Drug Cost,17.32,,,17.32,Other,Drug Cost,17.32,,,17.32,Other,Drug Cost,17.32,,,17.32,Other,Drug Cost,17.32,,,17.32,Other,Drug Cost,17.32,,,17.32,Other,Drug Cost,38.97,,,38.97,Other,225% of Medicaid,24.25,,,24.25,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,37.24,,,37.24,Other,215% Medicaid APG methodology,37.24,,,37.24,Other,215% Medicaid APG methodology,21.65,,,21.65,Other,125% Medicaid APG methodology,0.01,38.97,
PREZISTA TABLETS 600MG,,,,80001710,CDM,250,RC,59676056201,NDC,both,60,EA,31.24,12.33,39.4668,,12.33,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,10.62,34,,10.62,percent of total billed charges,"Drugs, Inpatient Only",10.62,34,,10.62,percent of total billed charges,"Drugs, Inpatient Only",10.62,34,,10.62,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,21.86,70,,21.86,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,10.41,,,10.41,Other,Drug Cost,10.41,,,10.41,Other,Drug Cost,10.41,,,10.41,Other,Drug Cost,10.41,,,10.41,Other,Drug Cost,10.41,,,10.41,Other,Drug Cost,10.41,,,10.41,Other,Drug Cost,23.43,,,23.43,Other,225% of Medicaid,14.58,,,14.58,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,22.39,,,22.39,Other,215% Medicaid APG methodology,22.39,,,22.39,Other,215% Medicaid APG methodology,13.01,,,13.01,Other,125% Medicaid APG methodology,0.01,23.43,
PRIMIDONE 250 MG,,,,80001712,CDM,250,RC,53746054501,NDC,both,100,EA,0.21,0.08,39.4668,,0.08,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.07,34,,0.07,percent of total billed charges,"Drugs, Inpatient Only",0.07,34,,0.07,percent of total billed charges,"Drugs, Inpatient Only",0.07,34,,0.07,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.14,70,,0.14,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.07,,,0.07,Other,Drug Cost,0.07,,,0.07,Other,Drug Cost,0.07,,,0.07,Other,Drug Cost,0.07,,,0.07,Other,Drug Cost,0.07,,,0.07,Other,Drug Cost,0.07,,,0.07,Other,Drug Cost,0.15,,,0.15,Other,225% of Medicaid,0.1,,,0.1,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.15,,,0.15,Other,215% Medicaid APG methodology,0.15,,,0.15,Other,215% Medicaid APG methodology,0.09,,,0.09,Other,125% Medicaid APG methodology,0.01,0.15,
PROMETHAZINE 25MG SUPP,,,,80001714,CDM,250,RC,713052612,NDC,both,12,EA,2.76,1.09,39.4668,,1.09,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.94,34,,0.94,percent of total billed charges,"Drugs, Inpatient Only",0.94,34,,0.94,percent of total billed charges,"Drugs, Inpatient Only",0.94,34,,0.94,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1.93,70,,1.93,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.92,,,0.92,Other,Drug Cost,0.92,,,0.92,Other,Drug Cost,0.92,,,0.92,Other,Drug Cost,0.92,,,0.92,Other,Drug Cost,0.92,,,0.92,Other,Drug Cost,0.92,,,0.92,Other,Drug Cost,2.07,,,2.07,Other,225% of Medicaid,1.29,,,1.29,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,1.98,,,1.98,Other,215% Medicaid APG methodology,1.98,,,1.98,Other,215% Medicaid APG methodology,1.15,,,1.15,Other,125% Medicaid APG methodology,0.01,2.07,
PROMETHAZINE 25MG TAB,,,,80001715,CDM,250,RC,68084015501,NDC,both,10,EA,1.95,0.77,39.4668,,0.77,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.66,34,,0.66,percent of total billed charges,"Drugs, Inpatient Only",0.66,34,,0.66,percent of total billed charges,"Drugs, Inpatient Only",0.66,34,,0.66,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1.37,70,,1.37,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.65,,,0.65,Other,Drug Cost,0.65,,,0.65,Other,Drug Cost,0.65,,,0.65,Other,Drug Cost,0.65,,,0.65,Other,Drug Cost,0.65,,,0.65,Other,Drug Cost,0.65,,,0.65,Other,Drug Cost,1.46,,,1.46,Other,225% of Medicaid,0.91,,,0.91,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,1.4,,,1.4,Other,215% Medicaid APG methodology,1.4,,,1.4,Other,215% Medicaid APG methodology,0.81,,,0.81,Other,125% Medicaid APG methodology,0.01,1.46,
PROPAFENONE 150MG TAB,,,,80001717,CDM,250,RC,59651025601,NDC,both,100,EA,0.11,0.04,39.4668,,0.04,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.04,34,,0.04,percent of total billed charges,"Drugs, Inpatient Only",0.04,34,,0.04,percent of total billed charges,"Drugs, Inpatient Only",0.04,34,,0.04,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.08,70,,0.08,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.08,,,0.08,Other,225% of Medicaid,0.05,,,0.05,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.08,,,0.08,Other,215% Medicaid APG methodology,0.08,,,0.08,Other,215% Medicaid APG methodology,0.05,,,0.05,Other,125% Medicaid APG methodology,0.01,0.08,
PROPRANOLOL 10MG,,,,80001722,CDM,250,RC,603548221,NDC,both,100,EA,0.03,0.01,39.4668,,0.01,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.02,70,,0.02,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.02,,,0.02,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,0.02,
PROPRANOLOL 20 MG TAB,,,,80001725,CDM,250,RC,603548321,NDC,both,100,EA,0.03,0.01,39.4668,,0.01,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.02,70,,0.02,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.02,,,0.02,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,0.02,
PROTONIX 40MG GRANULES,,,,80001733,CDM,250,RC,8084402,NDC,both,30,EA,2.6,1.03,39.4668,,1.03,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.88,34,,0.88,percent of total billed charges,"Drugs, Inpatient Only",0.88,34,,0.88,percent of total billed charges,"Drugs, Inpatient Only",0.88,34,,0.88,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1.82,70,,1.82,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.87,,,0.87,Other,Drug Cost,0.87,,,0.87,Other,Drug Cost,0.87,,,0.87,Other,Drug Cost,0.87,,,0.87,Other,Drug Cost,0.87,,,0.87,Other,Drug Cost,0.87,,,0.87,Other,Drug Cost,1.95,,,1.95,Other,225% of Medicaid,1.21,,,1.21,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,1.86,,,1.86,Other,215% Medicaid APG methodology,1.86,,,1.86,Other,215% Medicaid APG methodology,1.08,,,1.08,Other,125% Medicaid APG methodology,0.01,1.95,
PROTONIX 40MG TAB,,,,80001734,CDM,250,RC,31722071390,NDC,both,90,EA,0.05,0.02,39.4668,,0.02,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.02,34,,0.02,percent of total billed charges,"Drugs, Inpatient Only",0.02,34,,0.02,percent of total billed charges,"Drugs, Inpatient Only",0.02,34,,0.02,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.03,70,,0.03,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.04,,,0.04,Other,225% of Medicaid,0.02,,,0.02,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.03,,,0.03,Other,215% Medicaid APG methodology,0.03,,,0.03,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,125% Medicaid APG methodology,0.01,0.04,
PSEUDOEPHEDRINE 30 MG TAB,,,,80001735,CDM,250,RC,904505359,NDC,both,100,EA,0.03,0.01,39.4668,,0.01,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.02,70,,0.02,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.03,,,0.03,Other,225% of Medicaid,0.02,,,0.02,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,0.03,
PSYLLIUM 3.5 GM,,,,80001737,CDM,250,RC,38485080855,NDC,both,3.7,GM,0.76,0.3,39.4668,,0.3,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.26,34,,0.26,percent of total billed charges,"Drugs, Inpatient Only",0.26,34,,0.26,percent of total billed charges,"Drugs, Inpatient Only",0.26,34,,0.26,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.53,70,,0.53,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.25,,,0.25,Other,Drug Cost,0.25,,,0.25,Other,Drug Cost,0.25,,,0.25,Other,Drug Cost,0.25,,,0.25,Other,Drug Cost,0.25,,,0.25,Other,Drug Cost,0.25,,,0.25,Other,Drug Cost,0.57,,,0.57,Other,225% of Medicaid,0.36,,,0.36,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.55,,,0.55,Other,215% Medicaid APG methodology,0.55,,,0.55,Other,215% Medicaid APG methodology,0.32,,,0.32,Other,125% Medicaid APG methodology,0.01,0.57,
PYRAZINAMIDE 500 MG TAB,,,,80001738,CDM,250,RC,70954048420,NDC,both,90,EA,3.15,1.24,39.4668,,1.24,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1.07,34,,1.07,percent of total billed charges,"Drugs, Inpatient Only",1.07,34,,1.07,percent of total billed charges,"Drugs, Inpatient Only",1.07,34,,1.07,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2.2,70,,2.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1.05,,,1.05,Other,Drug Cost,1.05,,,1.05,Other,Drug Cost,1.05,,,1.05,Other,Drug Cost,1.05,,,1.05,Other,Drug Cost,1.05,,,1.05,Other,Drug Cost,1.05,,,1.05,Other,Drug Cost,2.36,,,2.36,Other,225% of Medicaid,1.47,,,1.47,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,2.25,,,2.25,Other,215% Medicaid APG methodology,2.25,,,2.25,Other,215% Medicaid APG methodology,1.31,,,1.31,Other,125% Medicaid APG methodology,0.01,2.36,
PYRIDOSTIGMINE 180 MG ER TAB,,,,80001739,CDM,250,RC,187301330,NDC,both,30,EA,0.03,0.01,39.4668,,0.01,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.02,70,,0.02,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.02,,,0.02,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,0.02,
PYRIDOSTIGMINE 60 MG TAB,,,,80001740,CDM,250,RC,187301030,NDC,both,100,EA,0.03,0.01,39.4668,,0.01,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.02,70,,0.02,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.02,,,0.02,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,0.02,
PYRIDOXINE 100 MG TAB,,,,80001741,CDM,250,RC,57896085401,NDC,both,100,EA,0.06,0.02,39.4668,,0.02,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.02,34,,0.02,percent of total billed charges,"Drugs, Inpatient Only",0.02,34,,0.02,percent of total billed charges,"Drugs, Inpatient Only",0.02,34,,0.02,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.04,70,,0.04,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.05,,,0.05,Other,225% of Medicaid,0.03,,,0.03,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.04,,,0.04,Other,215% Medicaid APG methodology,0.04,,,0.04,Other,215% Medicaid APG methodology,0.03,,,0.03,Other,125% Medicaid APG methodology,0.01,0.05,
PYRIDOXINE 50 MG TAB,,,,80001742,CDM,250,RC,77333094010,NDC,both,10,EA,3.37,1.33,39.4668,,1.33,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1.15,34,,1.15,percent of total billed charges,"Drugs, Inpatient Only",1.15,34,,1.15,percent of total billed charges,"Drugs, Inpatient Only",1.15,34,,1.15,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2.36,70,,2.36,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1.12,,,1.12,Other,Drug Cost,1.12,,,1.12,Other,Drug Cost,1.12,,,1.12,Other,Drug Cost,1.12,,,1.12,Other,Drug Cost,1.12,,,1.12,Other,Drug Cost,1.12,,,1.12,Other,Drug Cost,2.53,,,2.53,Other,225% of Medicaid,1.57,,,1.57,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,2.42,,,2.42,Other,215% Medicaid APG methodology,2.42,,,2.42,Other,215% Medicaid APG methodology,1.41,,,1.41,Other,125% Medicaid APG methodology,0.01,2.53,
PYRITHIONE ZINC (DHS ZINC) 240 ML,,,,80001743,CDM,250,RC,96073508,NDC,both,1,ML,27.3,10.77,39.4668,,10.77,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,9.28,34,,9.28,percent of total billed charges,"Drugs, Inpatient Only",9.28,34,,9.28,percent of total billed charges,"Drugs, Inpatient Only",9.28,34,,9.28,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,19.11,70,,19.11,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,9.1,,,9.1,Other,Drug Cost,9.1,,,9.1,Other,Drug Cost,9.1,,,9.1,Other,Drug Cost,9.1,,,9.1,Other,Drug Cost,9.1,,,9.1,Other,Drug Cost,9.1,,,9.1,Other,Drug Cost,20.48,,,20.48,Other,225% of Medicaid,12.74,,,12.74,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,19.57,,,19.57,Other,215% Medicaid APG methodology,19.57,,,19.57,Other,215% Medicaid APG methodology,11.38,,,11.38,Other,125% Medicaid APG methodology,0.01,20.48,
QUETIAPINE 200MG TAB,,,,80001745,CDM,250,RC,904664161,NDC,both,10,EA,2.41,0.95,39.4668,,0.95,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.82,34,,0.82,percent of total billed charges,"Drugs, Inpatient Only",0.82,34,,0.82,percent of total billed charges,"Drugs, Inpatient Only",0.82,34,,0.82,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1.69,70,,1.69,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.8,,,0.8,Other,Drug Cost,0.8,,,0.8,Other,Drug Cost,0.8,,,0.8,Other,Drug Cost,0.8,,,0.8,Other,Drug Cost,0.8,,,0.8,Other,Drug Cost,0.8,,,0.8,Other,Drug Cost,1.81,,,1.81,Other,225% of Medicaid,1.12,,,1.12,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,1.73,,,1.73,Other,215% Medicaid APG methodology,1.73,,,1.73,Other,215% Medicaid APG methodology,1,,,1,Other,125% Medicaid APG methodology,0.01,1.81,
QUETIAPINE 25MG TAB,,,,80001746,CDM,250,RC,67877024201,NDC,both,100,EA,0.03,0.01,39.4668,,0.01,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.02,70,,0.02,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.02,,,0.02,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,0.02,
QUINIDINE GLUCONATE 324MG TAB,,,,80001753,CDM,250,RC,53489014101,NDC,both,100,EA,8.29,3.27,39.4668,,3.27,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2.82,34,,2.82,percent of total billed charges,"Drugs, Inpatient Only",2.82,34,,2.82,percent of total billed charges,"Drugs, Inpatient Only",2.82,34,,2.82,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,5.8,70,,5.8,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2.76,,,2.76,Other,Drug Cost,2.76,,,2.76,Other,Drug Cost,2.76,,,2.76,Other,Drug Cost,2.76,,,2.76,Other,Drug Cost,2.76,,,2.76,Other,Drug Cost,2.76,,,2.76,Other,Drug Cost,6.22,,,6.22,Other,225% of Medicaid,3.87,,,3.87,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,5.94,,,5.94,Other,215% Medicaid APG methodology,5.94,,,5.94,Other,215% Medicaid APG methodology,3.45,,,3.45,Other,125% Medicaid APG methodology,0.01,6.22,
QUININE SULFATE 324MG CAP,,,,80001754,CDM,250,RC,68180056006,NDC,both,30,EA,1.1,0.44,39.4668,,0.44,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.38,34,,0.38,percent of total billed charges,"Drugs, Inpatient Only",0.38,34,,0.38,percent of total billed charges,"Drugs, Inpatient Only",0.38,34,,0.38,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.77,70,,0.77,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.37,,,0.37,Other,Drug Cost,0.37,,,0.37,Other,Drug Cost,0.37,,,0.37,Other,Drug Cost,0.37,,,0.37,Other,Drug Cost,0.37,,,0.37,Other,Drug Cost,0.37,,,0.37,Other,Drug Cost,0.83,,,0.83,Other,225% of Medicaid,0.52,,,0.52,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.79,,,0.79,Other,215% Medicaid APG methodology,0.79,,,0.79,Other,215% Medicaid APG methodology,0.46,,,0.46,Other,125% Medicaid APG methodology,0.01,0.83,
RALOXIFENE HCL (EVISTA) 60 MG TAB,,,,80001758,CDM,250,RC,65162005703,NDC,both,30,EA,0.28,0.11,39.4668,,0.11,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.1,34,,0.1,percent of total billed charges,"Drugs, Inpatient Only",0.1,34,,0.1,percent of total billed charges,"Drugs, Inpatient Only",0.1,34,,0.1,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.2,70,,0.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.09,,,0.09,Other,Drug Cost,0.09,,,0.09,Other,Drug Cost,0.09,,,0.09,Other,Drug Cost,0.09,,,0.09,Other,Drug Cost,0.09,,,0.09,Other,Drug Cost,0.09,,,0.09,Other,Drug Cost,0.21,,,0.21,Other,225% of Medicaid,0.13,,,0.13,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.2,,,0.2,Other,215% Medicaid APG methodology,0.2,,,0.2,Other,215% Medicaid APG methodology,0.12,,,0.12,Other,125% Medicaid APG methodology,0.01,0.21,
RALTERGRAVIR (ISENTRESS) 400MG TAB,,,,80001759,CDM,250,RC,6022761,NDC,both,60,EA,34.08,13.45,39.4668,,13.45,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,11.59,34,,11.59,percent of total billed charges,"Drugs, Inpatient Only",11.59,34,,11.59,percent of total billed charges,"Drugs, Inpatient Only",11.59,34,,11.59,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,23.85,70,,23.85,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,11.36,,,11.36,Other,Drug Cost,11.36,,,11.36,Other,Drug Cost,11.36,,,11.36,Other,Drug Cost,11.36,,,11.36,Other,Drug Cost,11.36,,,11.36,Other,Drug Cost,11.36,,,11.36,Other,Drug Cost,25.56,,,25.56,Other,225% of Medicaid,15.9,,,15.9,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,24.42,,,24.42,Other,215% Medicaid APG methodology,24.42,,,24.42,Other,215% Medicaid APG methodology,14.2,,,14.2,Other,125% Medicaid APG methodology,0.01,25.56,
RAMIPRIL 1.25MG CAP,,,,80001760,CDM,250,RC,65862047401,NDC,both,100,EA,0.07,0.03,39.4668,,0.03,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.02,34,,0.02,percent of total billed charges,"Drugs, Inpatient Only",0.02,34,,0.02,percent of total billed charges,"Drugs, Inpatient Only",0.02,34,,0.02,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.05,70,,0.05,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.05,,,0.05,Other,225% of Medicaid,0.03,,,0.03,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.05,,,0.05,Other,215% Medicaid APG methodology,0.05,,,0.05,Other,215% Medicaid APG methodology,0.03,,,0.03,Other,125% Medicaid APG methodology,0.01,0.05,
RAMIPRIL 10MG CAP,,,,80001761,CDM,250,RC,68180059101,NDC,both,100,EA,0.08,0.03,39.4668,,0.03,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.03,34,,0.03,percent of total billed charges,"Drugs, Inpatient Only",0.03,34,,0.03,percent of total billed charges,"Drugs, Inpatient Only",0.03,34,,0.03,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.05,70,,0.05,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.06,,,0.06,Other,225% of Medicaid,0.04,,,0.04,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.06,,,0.06,Other,215% Medicaid APG methodology,0.06,,,0.06,Other,215% Medicaid APG methodology,0.03,,,0.03,Other,125% Medicaid APG methodology,0.01,0.06,
RAMIPRIL 2.5MG CAP,,,,80001762,CDM,250,RC,68180058901,NDC,both,100,EA,0.06,0.02,39.4668,,0.02,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.02,34,,0.02,percent of total billed charges,"Drugs, Inpatient Only",0.02,34,,0.02,percent of total billed charges,"Drugs, Inpatient Only",0.02,34,,0.02,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.04,70,,0.04,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.04,,,0.04,Other,225% of Medicaid,0.03,,,0.03,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.04,,,0.04,Other,215% Medicaid APG methodology,0.04,,,0.04,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,125% Medicaid APG methodology,0.01,0.04,
RAMIPRIL 5MG,,,,80001763,CDM,250,RC,68180059001,NDC,both,100,EA,0.07,0.03,39.4668,,0.03,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.02,34,,0.02,percent of total billed charges,"Drugs, Inpatient Only",0.02,34,,0.02,percent of total billed charges,"Drugs, Inpatient Only",0.02,34,,0.02,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.05,70,,0.05,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.05,,,0.05,Other,225% of Medicaid,0.03,,,0.03,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.05,,,0.05,Other,215% Medicaid APG methodology,0.05,,,0.05,Other,215% Medicaid APG methodology,0.03,,,0.03,Other,125% Medicaid APG methodology,0.01,0.05,
RANOLAZINE 500MG TAB,,,,80001765,CDM,250,RC,70756070360,NDC,both,60,EA,0.16,0.06,39.4668,,0.06,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.06,34,,0.06,percent of total billed charges,"Drugs, Inpatient Only",0.06,34,,0.06,percent of total billed charges,"Drugs, Inpatient Only",0.06,34,,0.06,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.11,70,,0.11,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.12,,,0.12,Other,225% of Medicaid,0.08,,,0.08,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.12,,,0.12,Other,215% Medicaid APG methodology,0.12,,,0.12,Other,215% Medicaid APG methodology,0.07,,,0.07,Other,125% Medicaid APG methodology,0.01,0.12,
REGONOL 5 MG/ML INJ,,,,80001769,CDM,250,RC,781304095,NDC,both,10,ML,56.73,22.39,39.4668,,22.39,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,19.29,34,,19.29,percent of total billed charges,"Drugs, Inpatient Only",19.29,34,,19.29,percent of total billed charges,"Drugs, Inpatient Only",19.29,34,,19.29,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,39.71,70,,39.71,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,18.91,,,18.91,Other,Drug Cost,18.91,,,18.91,Other,Drug Cost,18.91,,,18.91,Other,Drug Cost,18.91,,,18.91,Other,Drug Cost,18.91,,,18.91,Other,Drug Cost,18.91,,,18.91,Other,Drug Cost,42.55,,,42.55,Other,225% of Medicaid,26.47,,,26.47,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,40.66,,,40.66,Other,215% Medicaid APG methodology,40.66,,,40.66,Other,215% Medicaid APG methodology,23.64,,,23.64,Other,125% Medicaid APG methodology,0.01,42.55,
RETROVIR 10 MG/ML,,,,80001777,CDM,250,RC,65862004824,NDC,both,1,ML,54.3,21.43,39.4668,,21.43,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,18.46,34,,18.46,percent of total billed charges,"Drugs, Inpatient Only",18.46,34,,18.46,percent of total billed charges,"Drugs, Inpatient Only",18.46,34,,18.46,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,38.01,70,,38.01,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,18.1,,,18.1,Other,Drug Cost,18.1,,,18.1,Other,Drug Cost,18.1,,,18.1,Other,Drug Cost,18.1,,,18.1,Other,Drug Cost,18.1,,,18.1,Other,Drug Cost,18.1,,,18.1,Other,Drug Cost,40.73,,,40.73,Other,225% of Medicaid,25.34,,,25.34,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,38.92,,,38.92,Other,215% Medicaid APG methodology,38.92,,,38.92,Other,215% Medicaid APG methodology,22.63,,,22.63,Other,125% Medicaid APG methodology,0.01,40.73,
RIBOFLAVIN 100 MG TAB,,,,80001779,CDM,250,RC,54629009501,NDC,both,100,EA,0.17,0.07,39.4668,,0.07,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.06,34,,0.06,percent of total billed charges,"Drugs, Inpatient Only",0.06,34,,0.06,percent of total billed charges,"Drugs, Inpatient Only",0.06,34,,0.06,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.12,70,,0.12,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.06,,,0.06,Other,Drug Cost,0.06,,,0.06,Other,Drug Cost,0.06,,,0.06,Other,Drug Cost,0.06,,,0.06,Other,Drug Cost,0.06,,,0.06,Other,Drug Cost,0.06,,,0.06,Other,Drug Cost,0.13,,,0.13,Other,225% of Medicaid,0.08,,,0.08,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.12,,,0.12,Other,215% Medicaid APG methodology,0.12,,,0.12,Other,215% Medicaid APG methodology,0.07,,,0.07,Other,125% Medicaid APG methodology,0.01,0.13,
RIFAMIXIN 200MG TAB,,,,80001781,CDM,250,RC,65649030103,NDC,both,30,EA,6.34,2.5,39.4668,,2.5,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2.15,34,,2.15,percent of total billed charges,"Drugs, Inpatient Only",2.15,34,,2.15,percent of total billed charges,"Drugs, Inpatient Only",2.15,34,,2.15,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,4.44,70,,4.44,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2.11,,,2.11,Other,Drug Cost,2.11,,,2.11,Other,Drug Cost,2.11,,,2.11,Other,Drug Cost,2.11,,,2.11,Other,Drug Cost,2.11,,,2.11,Other,Drug Cost,2.11,,,2.11,Other,Drug Cost,4.75,,,4.75,Other,225% of Medicaid,2.96,,,2.96,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,4.54,,,4.54,Other,215% Medicaid APG methodology,4.54,,,4.54,Other,215% Medicaid APG methodology,2.64,,,2.64,Other,125% Medicaid APG methodology,0.01,4.75,
RIFAMPIN 600MG,,,,80001783,CDM,250,RC,68059701,NDC,both,1,EA,485.28,191.52,39.4668,,191.52,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,165,34,,165,percent of total billed charges,"Drugs, Inpatient Only",165,34,,165,percent of total billed charges,"Drugs, Inpatient Only",165,34,,165,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,339.7,70,,339.7,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,161.76,,,161.76,Other,Drug Cost,161.76,,,161.76,Other,Drug Cost,161.76,,,161.76,Other,Drug Cost,161.76,,,161.76,Other,Drug Cost,161.76,,,161.76,Other,Drug Cost,161.76,,,161.76,Other,Drug Cost,363.96,,,363.96,Other,225% of Medicaid,226.46,,,226.46,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,347.78,,,347.78,Other,215% Medicaid APG methodology,347.78,,,347.78,Other,215% Medicaid APG methodology,202.2,,,202.2,Other,125% Medicaid APG methodology,0.01,363.96,
RISPERIDONE 0.25MG TAB,,,,80001787,CDM,250,RC,68084027001,NDC,both,10,EA,4.02,1.59,39.4668,,1.59,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1.37,34,,1.37,percent of total billed charges,"Drugs, Inpatient Only",1.37,34,,1.37,percent of total billed charges,"Drugs, Inpatient Only",1.37,34,,1.37,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2.81,70,,2.81,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1.34,,,1.34,Other,Drug Cost,1.34,,,1.34,Other,Drug Cost,1.34,,,1.34,Other,Drug Cost,1.34,,,1.34,Other,Drug Cost,1.34,,,1.34,Other,Drug Cost,1.34,,,1.34,Other,Drug Cost,3.01,,,3.01,Other,225% of Medicaid,1.87,,,1.87,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,2.88,,,2.88,Other,215% Medicaid APG methodology,2.88,,,2.88,Other,215% Medicaid APG methodology,1.67,,,1.67,Other,125% Medicaid APG methodology,0.01,3.01,
RISPERIDONE 0.5 MG,,,,80001788,CDM,250,RC,68382011314,NDC,both,60,EA,0.03,0.01,39.4668,,0.01,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.02,70,,0.02,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.02,,,0.02,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,0.02,
RISPERIDONE 0.5 MG M-TAB,,,,80001789,CDM,250,RC,59746001032,NDC,both,3,EA,7.49,2.96,39.4668,,2.96,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2.55,34,,2.55,percent of total billed charges,"Drugs, Inpatient Only",2.55,34,,2.55,percent of total billed charges,"Drugs, Inpatient Only",2.55,34,,2.55,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,5.24,70,,5.24,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2.5,,,2.5,Other,Drug Cost,2.5,,,2.5,Other,Drug Cost,2.5,,,2.5,Other,Drug Cost,2.5,,,2.5,Other,Drug Cost,2.5,,,2.5,Other,Drug Cost,2.5,,,2.5,Other,Drug Cost,5.62,,,5.62,Other,225% of Medicaid,3.5,,,3.5,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,5.37,,,5.37,Other,215% Medicaid APG methodology,5.37,,,5.37,Other,215% Medicaid APG methodology,3.12,,,3.12,Other,125% Medicaid APG methodology,0.01,5.62,
RISPERIDONE 1 MG TAB,,,,80001790,CDM,250,RC,50458030001,NDC,both,10,EA,58.72,23.17,39.4668,,23.17,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,19.96,34,,19.96,percent of total billed charges,"Drugs, Inpatient Only",19.96,34,,19.96,percent of total billed charges,"Drugs, Inpatient Only",19.96,34,,19.96,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,41.1,70,,41.1,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,19.57,,,19.57,Other,Drug Cost,19.57,,,19.57,Other,Drug Cost,19.57,,,19.57,Other,Drug Cost,19.57,,,19.57,Other,Drug Cost,19.57,,,19.57,Other,Drug Cost,19.57,,,19.57,Other,Drug Cost,44.04,,,44.04,Other,225% of Medicaid,27.4,,,27.4,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,42.08,,,42.08,Other,215% Medicaid APG methodology,42.08,,,42.08,Other,215% Medicaid APG methodology,24.47,,,24.47,Other,125% Medicaid APG methodology,0.01,44.04,
RISPERIDONE 1MG M-TAB,,,,80001791,CDM,250,RC,49884031555,NDC,both,5,EA,0.21,0.08,39.4668,,0.08,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.07,34,,0.07,percent of total billed charges,"Drugs, Inpatient Only",0.07,34,,0.07,percent of total billed charges,"Drugs, Inpatient Only",0.07,34,,0.07,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.15,70,,0.15,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.07,,,0.07,Other,Drug Cost,0.07,,,0.07,Other,Drug Cost,0.07,,,0.07,Other,Drug Cost,0.07,,,0.07,Other,Drug Cost,0.07,,,0.07,Other,Drug Cost,0.07,,,0.07,Other,Drug Cost,0.16,,,0.16,Other,225% of Medicaid,0.1,,,0.1,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.15,,,0.15,Other,215% Medicaid APG methodology,0.15,,,0.15,Other,215% Medicaid APG methodology,0.09,,,0.09,Other,125% Medicaid APG methodology,0.01,0.16,
RISPERIDONE 1MG/ML,,,,80001792,CDM,250,RC,50458030503,NDC,both,1,ML,0.81,0.32,39.4668,,0.32,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.28,34,,0.28,percent of total billed charges,"Drugs, Inpatient Only",0.28,34,,0.28,percent of total billed charges,"Drugs, Inpatient Only",0.28,34,,0.28,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.57,70,,0.57,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.27,,,0.27,Other,Drug Cost,0.27,,,0.27,Other,Drug Cost,0.27,,,0.27,Other,Drug Cost,0.27,,,0.27,Other,Drug Cost,0.27,,,0.27,Other,Drug Cost,0.27,,,0.27,Other,Drug Cost,0.61,,,0.61,Other,225% of Medicaid,0.38,,,0.38,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.58,,,0.58,Other,215% Medicaid APG methodology,0.58,,,0.58,Other,215% Medicaid APG methodology,0.34,,,0.34,Other,125% Medicaid APG methodology,0.01,0.61,
RISPERIDONE 2 MG TAB,,,,80001793,CDM,250,RC,50458032006,NDC,both,60,EA,9.75,3.85,39.4668,,3.85,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,3.32,34,,3.32,percent of total billed charges,"Drugs, Inpatient Only",3.32,34,,3.32,percent of total billed charges,"Drugs, Inpatient Only",3.32,34,,3.32,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,6.83,70,,6.83,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,3.25,,,3.25,Other,Drug Cost,3.25,,,3.25,Other,Drug Cost,3.25,,,3.25,Other,Drug Cost,3.25,,,3.25,Other,Drug Cost,3.25,,,3.25,Other,Drug Cost,3.25,,,3.25,Other,Drug Cost,7.32,,,7.32,Other,225% of Medicaid,4.55,,,4.55,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,6.99,,,6.99,Other,215% Medicaid APG methodology,6.99,,,6.99,Other,215% Medicaid APG methodology,4.06,,,4.06,Other,125% Medicaid APG methodology,0.01,7.32,
RIVAROXABAN 10MG TAB,,,,80001800,CDM,250,RC,50458058030,NDC,both,30,EA,0.03,0.01,39.4668,,0.01,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.02,70,,0.02,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.02,,,0.02,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,0.02,
ROPINIROLE 0.25MG,,,,80001806,CDM,250,RC,43547026810,NDC,both,100,EA,0.04,0.02,39.4668,,0.02,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.03,70,,0.03,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.03,,,0.03,Other,225% of Medicaid,0.02,,,0.02,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.03,,,0.03,Other,215% Medicaid APG methodology,0.03,,,0.03,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,125% Medicaid APG methodology,0.01,0.03,
ROPINIROLE 1 MG,,,,80001807,CDM,250,RC,68462025501,NDC,both,100,EA,0.04,0.01,39.4668,,0.01,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.03,70,,0.03,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.03,,,0.03,Other,225% of Medicaid,0.02,,,0.02,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.03,,,0.03,Other,215% Medicaid APG methodology,0.03,,,0.03,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,125% Medicaid APG methodology,0.01,0.03,
ROSUVASTATIN CALCIUM (CRESTOR) 5 MG,,,,80001818,CDM,250,RC,67877043990,NDC,both,90,EA,0.03,0.01,39.4668,,0.01,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.02,70,,0.02,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.02,,,0.02,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,0.02,
ROSUVASTATIN CALCIUM (CRESTOR0 20 MG,,,,80001819,CDM,250,RC,65862029590,NDC,both,90,EA,0.06,0.02,39.4668,,0.02,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.02,34,,0.02,percent of total billed charges,"Drugs, Inpatient Only",0.02,34,,0.02,percent of total billed charges,"Drugs, Inpatient Only",0.02,34,,0.02,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.04,70,,0.04,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.05,,,0.05,Other,225% of Medicaid,0.03,,,0.03,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.04,,,0.04,Other,215% Medicaid APG methodology,0.04,,,0.04,Other,215% Medicaid APG methodology,0.03,,,0.03,Other,125% Medicaid APG methodology,0.01,0.05,
ROXICODONE 20MG/ML,,,,80001821,CDM,250,RC,406800330,NDC,both,1,ML,11.7,4.62,39.4668,,4.62,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,3.98,34,,3.98,percent of total billed charges,"Drugs, Inpatient Only",3.98,34,,3.98,percent of total billed charges,"Drugs, Inpatient Only",3.98,34,,3.98,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,8.19,70,,8.19,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,3.9,,,3.9,Other,Drug Cost,3.9,,,3.9,Other,Drug Cost,3.9,,,3.9,Other,Drug Cost,3.9,,,3.9,Other,Drug Cost,3.9,,,3.9,Other,Drug Cost,3.9,,,3.9,Other,Drug Cost,8.78,,,8.78,Other,225% of Medicaid,5.46,,,5.46,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,8.39,,,8.39,Other,215% Medicaid APG methodology,8.39,,,8.39,Other,215% Medicaid APG methodology,4.88,,,4.88,Other,125% Medicaid APG methodology,0.01,8.78,
SARNA LOTION,,,,80001827,CDM,250,RC,496074804,NDC,both,1,ML,55.17,21.77,39.4668,,21.77,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,18.76,34,,18.76,percent of total billed charges,"Drugs, Inpatient Only",18.76,34,,18.76,percent of total billed charges,"Drugs, Inpatient Only",18.76,34,,18.76,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,38.62,70,,38.62,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,18.39,,,18.39,Other,Drug Cost,18.39,,,18.39,Other,Drug Cost,18.39,,,18.39,Other,Drug Cost,18.39,,,18.39,Other,Drug Cost,18.39,,,18.39,Other,Drug Cost,18.39,,,18.39,Other,Drug Cost,41.38,,,41.38,Other,225% of Medicaid,25.75,,,25.75,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,39.54,,,39.54,Other,215% Medicaid APG methodology,39.54,,,39.54,Other,215% Medicaid APG methodology,22.99,,,22.99,Other,125% Medicaid APG methodology,0.01,41.38,
SELEGILINE HCL 5MG CAP,,,,80001829,CDM,250,RC,60505005501,NDC,both,60,EA,1,0.39,39.4668,,0.39,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.34,34,,0.34,percent of total billed charges,"Drugs, Inpatient Only",0.34,34,,0.34,percent of total billed charges,"Drugs, Inpatient Only",0.34,34,,0.34,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.7,70,,0.7,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.33,,,0.33,Other,Drug Cost,0.33,,,0.33,Other,Drug Cost,0.33,,,0.33,Other,Drug Cost,0.33,,,0.33,Other,Drug Cost,0.33,,,0.33,Other,Drug Cost,0.33,,,0.33,Other,Drug Cost,0.75,,,0.75,Other,225% of Medicaid,0.47,,,0.47,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.72,,,0.72,Other,215% Medicaid APG methodology,0.72,,,0.72,Other,215% Medicaid APG methodology,0.42,,,0.42,Other,125% Medicaid APG methodology,0.01,0.75,
SENNA 8.6 MG,,,,80001832,CDM,250,RC,49483008010,NDC,both,1000,EA,0.03,0.01,39.4668,,0.01,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.02,70,,0.02,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.02,,,0.02,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,0.02,
SENNA-S 1 TAB,,,,80001833,CDM,250,RC,536124701,NDC,both,100,EA,0.04,0.02,39.4668,,0.02,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.03,70,,0.03,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.03,,,0.03,Other,225% of Medicaid,0.02,,,0.02,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.03,,,0.03,Other,215% Medicaid APG methodology,0.03,,,0.03,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,125% Medicaid APG methodology,0.01,0.03,
SERTRALINE 100MG TAB,,,,80001837,CDM,250,RC,68180035306,NDC,both,30,EA,0.03,0.01,39.4668,,0.01,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.02,70,,0.02,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.02,,,0.02,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,0.02,
SERTRALINE 25MG TAB,,,,80001838,CDM,250,RC,69097083305,NDC,both,90,EA,0.03,0.01,39.4668,,0.01,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.02,70,,0.02,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.02,,,0.02,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,0.02,
SERTRALINE 50MG TAB,,,,80001839,CDM,250,RC,68180035209,NDC,both,90,EA,0.03,0.01,39.4668,,0.01,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.02,70,,0.02,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.02,,,0.02,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,0.02,
SEVELAMER  800MG,,,,80001841,CDM,250,RC,55111078927,NDC,both,270,EA,0.03,0.01,39.4668,,0.01,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.02,70,,0.02,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.02,,,0.02,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,0.02,
SEVOFLURANE LIQ 250 ML,,,,80001842,CDM,250,RC,74445604,NDC,both,6,ML,97.87,38.62,39.4668,,38.62,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,33.27,34,,33.27,percent of total billed charges,"Drugs, Inpatient Only",33.27,34,,33.27,percent of total billed charges,"Drugs, Inpatient Only",33.27,34,,33.27,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,68.51,70,,68.51,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,32.62,,,32.62,Other,Drug Cost,32.62,,,32.62,Other,Drug Cost,32.62,,,32.62,Other,Drug Cost,32.62,,,32.62,Other,Drug Cost,32.62,,,32.62,Other,Drug Cost,32.62,,,32.62,Other,Drug Cost,73.4,,,73.4,Other,225% of Medicaid,45.67,,,45.67,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,70.14,,,70.14,Other,215% Medicaid APG methodology,70.14,,,70.14,Other,215% Medicaid APG methodology,40.78,,,40.78,Other,125% Medicaid APG methodology,0.01,73.4,
SILDENAFIL 20 MG TAB,,,,80001843,CDM,250,RC,69419068,NDC,both,90,EA,0.03,0.01,39.4668,,0.01,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.02,70,,0.02,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.02,,,0.02,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,0.02,
SILVER NITRATE STICK,,,,80001847,CDM,250,RC,12870000101,NDC,both,100,EA,2.05,0.81,39.4668,,0.81,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.7,34,,0.7,percent of total billed charges,"Drugs, Inpatient Only",0.7,34,,0.7,percent of total billed charges,"Drugs, Inpatient Only",0.7,34,,0.7,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1.43,70,,1.43,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.68,,,0.68,Other,Drug Cost,0.68,,,0.68,Other,Drug Cost,0.68,,,0.68,Other,Drug Cost,0.68,,,0.68,Other,Drug Cost,0.68,,,0.68,Other,Drug Cost,0.68,,,0.68,Other,Drug Cost,1.54,,,1.54,Other,225% of Medicaid,0.96,,,0.96,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,1.47,,,1.47,Other,215% Medicaid APG methodology,1.47,,,1.47,Other,215% Medicaid APG methodology,0.85,,,0.85,Other,125% Medicaid APG methodology,0.01,1.54,
SILVER NITRATE TOPICAL 0.5% SOLN,,,,80001848,CDM,250,RC,93961413,NDC,both,1,ML,53.94,21.29,39.4668,,21.29,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,18.34,34,,18.34,percent of total billed charges,"Drugs, Inpatient Only",18.34,34,,18.34,percent of total billed charges,"Drugs, Inpatient Only",18.34,34,,18.34,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,37.76,70,,37.76,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,17.98,,,17.98,Other,Drug Cost,17.98,,,17.98,Other,Drug Cost,17.98,,,17.98,Other,Drug Cost,17.98,,,17.98,Other,Drug Cost,17.98,,,17.98,Other,Drug Cost,17.98,,,17.98,Other,Drug Cost,40.46,,,40.46,Other,225% of Medicaid,25.17,,,25.17,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,38.66,,,38.66,Other,215% Medicaid APG methodology,38.66,,,38.66,Other,215% Medicaid APG methodology,22.48,,,22.48,Other,125% Medicaid APG methodology,0.01,40.46,
SILVER SULFADIAZINE 50 GM,,,,80001850,CDM,250,RC,67877012450,NDC,both,1,GM,4.56,1.8,39.4668,,1.8,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1.55,34,,1.55,percent of total billed charges,"Drugs, Inpatient Only",1.55,34,,1.55,percent of total billed charges,"Drugs, Inpatient Only",1.55,34,,1.55,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,3.19,70,,3.19,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1.52,,,1.52,Other,Drug Cost,1.52,,,1.52,Other,Drug Cost,1.52,,,1.52,Other,Drug Cost,1.52,,,1.52,Other,Drug Cost,1.52,,,1.52,Other,Drug Cost,1.52,,,1.52,Other,Drug Cost,3.42,,,3.42,Other,225% of Medicaid,2.13,,,2.13,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,3.27,,,3.27,Other,215% Medicaid APG methodology,3.27,,,3.27,Other,215% Medicaid APG methodology,1.9,,,1.9,Other,125% Medicaid APG methodology,0.01,3.42,
SIMETHICONE 30ML,,,,80001851,CDM,250,RC,70000005101,NDC,both,1,ML,10.29,4.06,39.4668,,4.06,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,3.5,34,,3.5,percent of total billed charges,"Drugs, Inpatient Only",3.5,34,,3.5,percent of total billed charges,"Drugs, Inpatient Only",3.5,34,,3.5,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,7.2,70,,7.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,3.43,,,3.43,Other,Drug Cost,3.43,,,3.43,Other,Drug Cost,3.43,,,3.43,Other,Drug Cost,3.43,,,3.43,Other,Drug Cost,3.43,,,3.43,Other,Drug Cost,3.43,,,3.43,Other,Drug Cost,7.72,,,7.72,Other,225% of Medicaid,4.8,,,4.8,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,7.37,,,7.37,Other,215% Medicaid APG methodology,7.37,,,7.37,Other,215% Medicaid APG methodology,4.29,,,4.29,Other,125% Medicaid APG methodology,0.01,7.72,
SIMETHICONE 80 MG,,,,80001852,CDM,250,RC,69618003301,NDC,both,100,EA,0.08,0.03,39.4668,,0.03,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.03,34,,0.03,percent of total billed charges,"Drugs, Inpatient Only",0.03,34,,0.03,percent of total billed charges,"Drugs, Inpatient Only",0.03,34,,0.03,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.06,70,,0.06,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.06,,,0.06,Other,225% of Medicaid,0.04,,,0.04,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.06,,,0.06,Other,215% Medicaid APG methodology,0.06,,,0.06,Other,215% Medicaid APG methodology,0.03,,,0.03,Other,125% Medicaid APG methodology,0.01,0.06,
SINGULAIR 10 MG,,,,80001855,CDM,250,RC,13668008105,NDC,both,500,EA,0.1,0.04,39.4668,,0.04,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.03,34,,0.03,percent of total billed charges,"Drugs, Inpatient Only",0.03,34,,0.03,percent of total billed charges,"Drugs, Inpatient Only",0.03,34,,0.03,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.07,70,,0.07,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.07,,,0.07,Other,225% of Medicaid,0.05,,,0.05,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.07,,,0.07,Other,215% Medicaid APG methodology,0.07,,,0.07,Other,215% Medicaid APG methodology,0.04,,,0.04,Other,125% Medicaid APG methodology,0.01,0.07,
SITAGLIPTIN PHOSPHATE  100 MG TAB,,,,80001859,CDM,250,RC,6027731,NDC,both,30,EA,0.03,0.01,39.4668,,0.01,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.02,70,,0.02,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.02,,,0.02,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,0.02,
SITAGLIPTIN PHOSPHATE 25MG TAB,,,,80001860,CDM,250,RC,6022131,NDC,both,30,EA,0.03,0.01,39.4668,,0.01,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.02,70,,0.02,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.02,,,0.02,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,0.02,
SOD BICARB 1MEQ/ML 50 ML,,,,80001862,CDM,250,RC,76329335201,NDC,both,10,ML,12.64,4.99,39.4668,,4.99,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,4.3,34,,4.3,percent of total billed charges,"Drugs, Inpatient Only",4.3,34,,4.3,percent of total billed charges,"Drugs, Inpatient Only",4.3,34,,4.3,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,8.85,70,,8.85,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,4.21,,,4.21,Other,Drug Cost,4.21,,,4.21,Other,Drug Cost,4.21,,,4.21,Other,Drug Cost,4.21,,,4.21,Other,Drug Cost,4.21,,,4.21,Other,Drug Cost,4.21,,,4.21,Other,Drug Cost,9.48,,,9.48,Other,225% of Medicaid,5.9,,,5.9,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,9.06,,,9.06,Other,215% Medicaid APG methodology,9.06,,,9.06,Other,215% Medicaid APG methodology,5.27,,,5.27,Other,125% Medicaid APG methodology,0.01,9.48,
SOD BICARB 650MG TAB,,,,80001863,CDM,250,RC,536104710,NDC,both,1000,EA,0.03,0.01,39.4668,,0.01,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.02,70,,0.02,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.02,,,0.02,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,0.02,
SOD POLY SULF 15 G/60ML,,,,80001866,CDM,250,RC,46287000660,NDC,both,10,ML,8.96,3.54,39.4668,,3.54,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,3.05,34,,3.05,percent of total billed charges,"Drugs, Inpatient Only",3.05,34,,3.05,percent of total billed charges,"Drugs, Inpatient Only",3.05,34,,3.05,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,6.27,70,,6.27,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2.99,,,2.99,Other,Drug Cost,2.99,,,2.99,Other,Drug Cost,2.99,,,2.99,Other,Drug Cost,2.99,,,2.99,Other,Drug Cost,2.99,,,2.99,Other,Drug Cost,2.99,,,2.99,Other,Drug Cost,6.72,,,6.72,Other,225% of Medicaid,4.18,,,4.18,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,6.42,,,6.42,Other,215% Medicaid APG methodology,6.42,,,6.42,Other,215% Medicaid APG methodology,3.74,,,3.74,Other,125% Medicaid APG methodology,0.01,6.72,
SOD POLY SULF 30G,,,,80001867,CDM,250,RC,46287000604,NDC,both,1,ML,17.94,7.08,39.4668,,7.08,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,6.1,34,,6.1,percent of total billed charges,"Drugs, Inpatient Only",6.1,34,,6.1,percent of total billed charges,"Drugs, Inpatient Only",6.1,34,,6.1,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,12.56,70,,12.56,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,5.98,,,5.98,Other,Drug Cost,5.98,,,5.98,Other,Drug Cost,5.98,,,5.98,Other,Drug Cost,5.98,,,5.98,Other,Drug Cost,5.98,,,5.98,Other,Drug Cost,5.98,,,5.98,Other,Drug Cost,13.46,,,13.46,Other,225% of Medicaid,8.37,,,8.37,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,12.86,,,12.86,Other,215% Medicaid APG methodology,12.86,,,12.86,Other,215% Medicaid APG methodology,7.48,,,7.48,Other,125% Medicaid APG methodology,0.01,13.46,
SOD THIOSULF 25% 50 ML,,,,80001869,CDM,250,RC,60267070550,NDC,both,1,ML,291,114.85,39.4668,,114.85,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,98.94,34,,98.94,percent of total billed charges,"Drugs, Inpatient Only",98.94,34,,98.94,percent of total billed charges,"Drugs, Inpatient Only",98.94,34,,98.94,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,203.7,70,,203.7,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,97,,,97,Other,Drug Cost,97,,,97,Other,Drug Cost,97,,,97,Other,Drug Cost,97,,,97,Other,Drug Cost,97,,,97,Other,Drug Cost,97,,,97,Other,Drug Cost,218.25,,,218.25,Other,225% of Medicaid,135.8,,,135.8,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,208.55,,,208.55,Other,215% Medicaid APG methodology,208.55,,,208.55,Other,215% Medicaid APG methodology,121.25,,,121.25,Other,125% Medicaid APG methodology,0.01,218.25,
SODIUM ACETATE 2MEQ/ML,,,,80001871,CDM,250,RC,409729973,NDC,both,25,ML,2.63,1.04,39.4668,,1.04,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.89,34,,0.89,percent of total billed charges,"Drugs, Inpatient Only",0.89,34,,0.89,percent of total billed charges,"Drugs, Inpatient Only",0.89,34,,0.89,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1.84,70,,1.84,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.88,,,0.88,Other,Drug Cost,0.88,,,0.88,Other,Drug Cost,0.88,,,0.88,Other,Drug Cost,0.88,,,0.88,Other,Drug Cost,0.88,,,0.88,Other,Drug Cost,0.88,,,0.88,Other,Drug Cost,1.97,,,1.97,Other,225% of Medicaid,1.23,,,1.23,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,1.88,,,1.88,Other,215% Medicaid APG methodology,1.88,,,1.88,Other,215% Medicaid APG methodology,1.09,,,1.09,Other,125% Medicaid APG methodology,0.01,1.97,
SODIUM BICARB 0.5 MEQ/ML 5 ML,,,,80001873,CDM,250,RC,63323008305,NDC,both,25,ML,25.41,10.03,39.4668,,10.03,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,8.64,34,,8.64,percent of total billed charges,"Drugs, Inpatient Only",8.64,34,,8.64,percent of total billed charges,"Drugs, Inpatient Only",8.64,34,,8.64,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,17.79,70,,17.79,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,8.47,,,8.47,Other,Drug Cost,8.47,,,8.47,Other,Drug Cost,8.47,,,8.47,Other,Drug Cost,8.47,,,8.47,Other,Drug Cost,8.47,,,8.47,Other,Drug Cost,8.47,,,8.47,Other,Drug Cost,19.06,,,19.06,Other,225% of Medicaid,11.86,,,11.86,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,18.21,,,18.21,Other,215% Medicaid APG methodology,18.21,,,18.21,Other,215% Medicaid APG methodology,10.59,,,10.59,Other,125% Medicaid APG methodology,0.01,19.06,
SODIUM BICARB 50 MEQ INJ,,,,80001874,CDM,250,RC,409662514,NDC,both,25,ML,17.42,6.88,39.4668,,6.88,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,5.92,34,,5.92,percent of total billed charges,"Drugs, Inpatient Only",5.92,34,,5.92,percent of total billed charges,"Drugs, Inpatient Only",5.92,34,,5.92,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,12.19,70,,12.19,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,5.81,,,5.81,Other,Drug Cost,5.81,,,5.81,Other,Drug Cost,5.81,,,5.81,Other,Drug Cost,5.81,,,5.81,Other,Drug Cost,5.81,,,5.81,Other,Drug Cost,5.81,,,5.81,Other,Drug Cost,13.07,,,13.07,Other,225% of Medicaid,8.13,,,8.13,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,12.48,,,12.48,Other,215% Medicaid APG methodology,12.48,,,12.48,Other,215% Medicaid APG methodology,7.26,,,7.26,Other,125% Medicaid APG methodology,0.01,13.07,
SODIUM CHLORIDE 0.45%/ KCL 20 MEQ,,,,80001875,CDM,250,RC,338070434,NDC,both,14,ML,8.37,3.3,39.4668,,3.3,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2.85,34,,2.85,percent of total billed charges,"Drugs, Inpatient Only",2.85,34,,2.85,percent of total billed charges,"Drugs, Inpatient Only",2.85,34,,2.85,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,5.86,70,,5.86,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2.79,,,2.79,Other,Drug Cost,2.79,,,2.79,Other,Drug Cost,2.79,,,2.79,Other,Drug Cost,2.79,,,2.79,Other,Drug Cost,2.79,,,2.79,Other,Drug Cost,2.79,,,2.79,Other,Drug Cost,6.28,,,6.28,Other,225% of Medicaid,3.9,,,3.9,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,6,,,6,Other,215% Medicaid APG methodology,6,,,6,Other,215% Medicaid APG methodology,3.49,,,3.49,Other,125% Medicaid APG methodology,0.01,6.28,
SODIUM CHLORIDE 0.9% 500ML IRRIGATION,,,,80001880,CDM,250,RC,264220110,NDC,both,16,ML,1.42,0.56,39.4668,,0.56,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.48,34,,0.48,percent of total billed charges,"Drugs, Inpatient Only",0.48,34,,0.48,percent of total billed charges,"Drugs, Inpatient Only",0.48,34,,0.48,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.99,70,,0.99,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.47,,,0.47,Other,Drug Cost,0.47,,,0.47,Other,Drug Cost,0.47,,,0.47,Other,Drug Cost,0.47,,,0.47,Other,Drug Cost,0.47,,,0.47,Other,Drug Cost,0.47,,,0.47,Other,Drug Cost,1.06,,,1.06,Other,225% of Medicaid,0.66,,,0.66,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,1.02,,,1.02,Other,215% Medicaid APG methodology,1.02,,,1.02,Other,215% Medicaid APG methodology,0.59,,,0.59,Other,125% Medicaid APG methodology,0.01,1.06,
SODIUM CHLORIDE 1 GRAM TAB,,,,80001881,CDM,250,RC,223176002,NDC,both,1000,EA,0.25,0.1,39.4668,,0.1,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.09,34,,0.09,percent of total billed charges,"Drugs, Inpatient Only",0.09,34,,0.09,percent of total billed charges,"Drugs, Inpatient Only",0.09,34,,0.09,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.18,70,,0.18,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.08,,,0.08,Other,Drug Cost,0.08,,,0.08,Other,Drug Cost,0.08,,,0.08,Other,Drug Cost,0.08,,,0.08,Other,Drug Cost,0.08,,,0.08,Other,Drug Cost,0.08,,,0.08,Other,Drug Cost,0.19,,,0.19,Other,225% of Medicaid,0.12,,,0.12,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.18,,,0.18,Other,215% Medicaid APG methodology,0.18,,,0.18,Other,215% Medicaid APG methodology,0.11,,,0.11,Other,125% Medicaid APG methodology,0.01,0.19,
SODIUM CHLORIDE 5% 3.5GM OINT,,,,80001884,CDM,250,RC,536125391,NDC,both,1,GM,17.46,6.89,39.4668,,6.89,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,5.94,34,,5.94,percent of total billed charges,"Drugs, Inpatient Only",5.94,34,,5.94,percent of total billed charges,"Drugs, Inpatient Only",5.94,34,,5.94,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,12.22,70,,12.22,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,5.82,,,5.82,Other,Drug Cost,5.82,,,5.82,Other,Drug Cost,5.82,,,5.82,Other,Drug Cost,5.82,,,5.82,Other,Drug Cost,5.82,,,5.82,Other,Drug Cost,5.82,,,5.82,Other,Drug Cost,13.1,,,13.1,Other,225% of Medicaid,8.15,,,8.15,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,12.51,,,12.51,Other,215% Medicaid APG methodology,12.51,,,12.51,Other,215% Medicaid APG methodology,7.28,,,7.28,Other,125% Medicaid APG methodology,0.01,13.1,
SODIUM CL 0.9% 10ML,,,,80001888,CDM,250,RC,63323018610,NDC,both,25,ML,0.54,0.21,39.4668,,0.21,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.18,34,,0.18,percent of total billed charges,"Drugs, Inpatient Only",0.18,34,,0.18,percent of total billed charges,"Drugs, Inpatient Only",0.18,34,,0.18,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.38,70,,0.38,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.18,,,0.18,Other,Drug Cost,0.18,,,0.18,Other,Drug Cost,0.18,,,0.18,Other,Drug Cost,0.18,,,0.18,Other,Drug Cost,0.18,,,0.18,Other,Drug Cost,0.18,,,0.18,Other,Drug Cost,0.41,,,0.41,Other,225% of Medicaid,0.25,,,0.25,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.39,,,0.39,Other,215% Medicaid APG methodology,0.39,,,0.39,Other,215% Medicaid APG methodology,0.23,,,0.23,Other,125% Medicaid APG methodology,0.01,0.41,
SODIUM CL 0.9% 500ML,,,,80001890,CDM,250,RC,264780010,NDC,both,24,ML,1.53,0.6,39.4668,,0.6,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.52,34,,0.52,percent of total billed charges,"Drugs, Inpatient Only",0.52,34,,0.52,percent of total billed charges,"Drugs, Inpatient Only",0.52,34,,0.52,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1.07,70,,1.07,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.51,,,0.51,Other,Drug Cost,0.51,,,0.51,Other,Drug Cost,0.51,,,0.51,Other,Drug Cost,0.51,,,0.51,Other,Drug Cost,0.51,,,0.51,Other,Drug Cost,0.51,,,0.51,Other,Drug Cost,1.15,,,1.15,Other,225% of Medicaid,0.71,,,0.71,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,1.1,,,1.1,Other,215% Medicaid APG methodology,1.1,,,1.1,Other,215% Medicaid APG methodology,0.64,,,0.64,Other,125% Medicaid APG methodology,0.01,1.15,
SODIUM CL 0.9% 50ML,,,,80001891,CDM,250,RC,338004931,NDC,both,96,ML,1.36,0.54,39.4668,,0.54,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.46,34,,0.46,percent of total billed charges,"Drugs, Inpatient Only",0.46,34,,0.46,percent of total billed charges,"Drugs, Inpatient Only",0.46,34,,0.46,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.95,70,,0.95,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.45,,,0.45,Other,Drug Cost,0.45,,,0.45,Other,Drug Cost,0.45,,,0.45,Other,Drug Cost,0.45,,,0.45,Other,Drug Cost,0.45,,,0.45,Other,Drug Cost,0.45,,,0.45,Other,Drug Cost,1.02,,,1.02,Other,225% of Medicaid,0.63,,,0.63,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.97,,,0.97,Other,215% Medicaid APG methodology,0.97,,,0.97,Other,215% Medicaid APG methodology,0.57,,,0.57,Other,125% Medicaid APG methodology,0.01,1.02,
SODIUM CL 5% 15ML OPHTH,,,,80001893,CDM,250,RC,536125494,NDC,both,1,ML,6.99,2.76,39.4668,,2.76,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2.38,34,,2.38,percent of total billed charges,"Drugs, Inpatient Only",2.38,34,,2.38,percent of total billed charges,"Drugs, Inpatient Only",2.38,34,,2.38,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,4.89,70,,4.89,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2.33,,,2.33,Other,Drug Cost,2.33,,,2.33,Other,Drug Cost,2.33,,,2.33,Other,Drug Cost,2.33,,,2.33,Other,Drug Cost,2.33,,,2.33,Other,Drug Cost,2.33,,,2.33,Other,Drug Cost,5.24,,,5.24,Other,225% of Medicaid,3.26,,,3.26,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,5.01,,,5.01,Other,215% Medicaid APG methodology,5.01,,,5.01,Other,215% Medicaid APG methodology,2.91,,,2.91,Other,125% Medicaid APG methodology,0.01,5.24,
SODIUM HYPOCHLORITE (DAKINS) 1/2 STR,,,,80001894,CDM,250,RC,39328006325,NDC,both,1,ML,34.62,13.66,39.4668,,13.66,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,11.77,34,,11.77,percent of total billed charges,"Drugs, Inpatient Only",11.77,34,,11.77,percent of total billed charges,"Drugs, Inpatient Only",11.77,34,,11.77,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,24.23,70,,24.23,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,11.54,,,11.54,Other,Drug Cost,11.54,,,11.54,Other,Drug Cost,11.54,,,11.54,Other,Drug Cost,11.54,,,11.54,Other,Drug Cost,11.54,,,11.54,Other,Drug Cost,11.54,,,11.54,Other,Drug Cost,25.97,,,25.97,Other,225% of Medicaid,16.16,,,16.16,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,24.81,,,24.81,Other,215% Medicaid APG methodology,24.81,,,24.81,Other,215% Medicaid APG methodology,14.43,,,14.43,Other,125% Medicaid APG methodology,0.01,25.97,
SODIUM HYPOCHLORITE (DAKINS) 1/4 STR,,,,80001895,CDM,250,RC,39328006412,NDC,both,1,ML,34.62,13.66,39.4668,,13.66,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,11.77,34,,11.77,percent of total billed charges,"Drugs, Inpatient Only",11.77,34,,11.77,percent of total billed charges,"Drugs, Inpatient Only",11.77,34,,11.77,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,24.23,70,,24.23,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,11.54,,,11.54,Other,Drug Cost,11.54,,,11.54,Other,Drug Cost,11.54,,,11.54,Other,Drug Cost,11.54,,,11.54,Other,Drug Cost,11.54,,,11.54,Other,Drug Cost,11.54,,,11.54,Other,Drug Cost,25.97,,,25.97,Other,225% of Medicaid,16.16,,,16.16,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,24.81,,,24.81,Other,215% Medicaid APG methodology,24.81,,,24.81,Other,215% Medicaid APG methodology,14.43,,,14.43,Other,125% Medicaid APG methodology,0.01,25.97,
SODIUM HYPOCHLORITE (DAKINS) FULL STR,,,,80001896,CDM,250,RC,39328006250,NDC,both,1,ML,34.62,13.66,39.4668,,13.66,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,11.77,34,,11.77,percent of total billed charges,"Drugs, Inpatient Only",11.77,34,,11.77,percent of total billed charges,"Drugs, Inpatient Only",11.77,34,,11.77,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,24.23,70,,24.23,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,11.54,,,11.54,Other,Drug Cost,11.54,,,11.54,Other,Drug Cost,11.54,,,11.54,Other,Drug Cost,11.54,,,11.54,Other,Drug Cost,11.54,,,11.54,Other,Drug Cost,11.54,,,11.54,Other,Drug Cost,25.97,,,25.97,Other,225% of Medicaid,16.16,,,16.16,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,24.81,,,24.81,Other,215% Medicaid APG methodology,24.81,,,24.81,Other,215% Medicaid APG methodology,14.43,,,14.43,Other,125% Medicaid APG methodology,0.01,25.97,
SOLIFNACIN 5 MG TAB,,,,80001897,CDM,250,RC,51248015001,NDC,both,30,EA,3.76,1.48,39.4668,,1.48,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1.28,34,,1.28,percent of total billed charges,"Drugs, Inpatient Only",1.28,34,,1.28,percent of total billed charges,"Drugs, Inpatient Only",1.28,34,,1.28,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2.63,70,,2.63,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1.25,,,1.25,Other,Drug Cost,1.25,,,1.25,Other,Drug Cost,1.25,,,1.25,Other,Drug Cost,1.25,,,1.25,Other,Drug Cost,1.25,,,1.25,Other,Drug Cost,1.25,,,1.25,Other,Drug Cost,2.82,,,2.82,Other,225% of Medicaid,1.75,,,1.75,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,2.69,,,2.69,Other,215% Medicaid APG methodology,2.69,,,2.69,Other,215% Medicaid APG methodology,1.57,,,1.57,Other,125% Medicaid APG methodology,0.01,2.82,
SORBITOL SOLN 70 % W/W 30ML,,,,80001902,CDM,250,RC,46287050030,NDC,both,10,ML,9.37,3.7,39.4668,,3.7,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,3.19,34,,3.19,percent of total billed charges,"Drugs, Inpatient Only",3.19,34,,3.19,percent of total billed charges,"Drugs, Inpatient Only",3.19,34,,3.19,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,6.56,70,,6.56,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,3.12,,,3.12,Other,Drug Cost,3.12,,,3.12,Other,Drug Cost,3.12,,,3.12,Other,Drug Cost,3.12,,,3.12,Other,Drug Cost,3.12,,,3.12,Other,Drug Cost,3.12,,,3.12,Other,Drug Cost,7.03,,,7.03,Other,225% of Medicaid,4.37,,,4.37,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,6.71,,,6.71,Other,215% Medicaid APG methodology,6.71,,,6.71,Other,215% Medicaid APG methodology,3.9,,,3.9,Other,125% Medicaid APG methodology,0.01,7.03,
SOTALOL 120 MG TAB,,,,80001903,CDM,250,RC,60505015900,NDC,both,100,EA,0.1,0.04,39.4668,,0.04,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.03,34,,0.03,percent of total billed charges,"Drugs, Inpatient Only",0.03,34,,0.03,percent of total billed charges,"Drugs, Inpatient Only",0.03,34,,0.03,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.07,70,,0.07,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.08,,,0.08,Other,225% of Medicaid,0.05,,,0.05,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.07,,,0.07,Other,215% Medicaid APG methodology,0.07,,,0.07,Other,215% Medicaid APG methodology,0.04,,,0.04,Other,125% Medicaid APG methodology,0.01,0.08,
SOTALOL 240 MG TAB,,,,80001905,CDM,250,RC,93106301,NDC,both,100,EA,0.67,0.27,39.4668,,0.27,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.23,34,,0.23,percent of total billed charges,"Drugs, Inpatient Only",0.23,34,,0.23,percent of total billed charges,"Drugs, Inpatient Only",0.23,34,,0.23,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.47,70,,0.47,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.22,,,0.22,Other,Drug Cost,0.22,,,0.22,Other,Drug Cost,0.22,,,0.22,Other,Drug Cost,0.22,,,0.22,Other,Drug Cost,0.22,,,0.22,Other,Drug Cost,0.22,,,0.22,Other,Drug Cost,0.51,,,0.51,Other,225% of Medicaid,0.31,,,0.31,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.48,,,0.48,Other,215% Medicaid APG methodology,0.48,,,0.48,Other,215% Medicaid APG methodology,0.28,,,0.28,Other,125% Medicaid APG methodology,0.01,0.51,
SOTALOL 80 MG,,,,80001906,CDM,250,RC,60505008000,NDC,both,100,EA,0.08,0.03,39.4668,,0.03,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.03,34,,0.03,percent of total billed charges,"Drugs, Inpatient Only",0.03,34,,0.03,percent of total billed charges,"Drugs, Inpatient Only",0.03,34,,0.03,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.05,70,,0.05,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.06,,,0.06,Other,225% of Medicaid,0.04,,,0.04,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.06,,,0.06,Other,215% Medicaid APG methodology,0.06,,,0.06,Other,215% Medicaid APG methodology,0.03,,,0.03,Other,125% Medicaid APG methodology,0.01,0.06,
SPIRONOLACTONE 25MG,,,,80001908,CDM,250,RC,53746051101,NDC,both,100,EA,0.06,0.02,39.4668,,0.02,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.02,34,,0.02,percent of total billed charges,"Drugs, Inpatient Only",0.02,34,,0.02,percent of total billed charges,"Drugs, Inpatient Only",0.02,34,,0.02,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.04,70,,0.04,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.04,,,0.04,Other,225% of Medicaid,0.03,,,0.03,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.04,,,0.04,Other,215% Medicaid APG methodology,0.04,,,0.04,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,125% Medicaid APG methodology,0.01,0.04,
STERILE WATER 10 ML,,,,80001912,CDM,250,RC,409488710,NDC,both,25,ML,1.37,0.54,39.4668,,0.54,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.46,34,,0.46,percent of total billed charges,"Drugs, Inpatient Only",0.46,34,,0.46,percent of total billed charges,"Drugs, Inpatient Only",0.46,34,,0.46,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.96,70,,0.96,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.46,,,0.46,Other,Drug Cost,0.46,,,0.46,Other,Drug Cost,0.46,,,0.46,Other,Drug Cost,0.46,,,0.46,Other,Drug Cost,0.46,,,0.46,Other,Drug Cost,0.46,,,0.46,Other,Drug Cost,1.02,,,1.02,Other,225% of Medicaid,0.64,,,0.64,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.98,,,0.98,Other,215% Medicaid APG methodology,0.98,,,0.98,Other,215% Medicaid APG methodology,0.57,,,0.57,Other,125% Medicaid APG methodology,0.01,1.02,
SUBOXONE 2-0.5MG,,,,80001916,CDM,250,RC,54018813,NDC,both,30,EA,0.34,0.13,39.4668,,0.13,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.12,34,,0.12,percent of total billed charges,"Drugs, Inpatient Only",0.12,34,,0.12,percent of total billed charges,"Drugs, Inpatient Only",0.12,34,,0.12,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.24,70,,0.24,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.11,,,0.11,Other,Drug Cost,0.11,,,0.11,Other,Drug Cost,0.11,,,0.11,Other,Drug Cost,0.11,,,0.11,Other,Drug Cost,0.11,,,0.11,Other,Drug Cost,0.11,,,0.11,Other,Drug Cost,0.25,,,0.25,Other,225% of Medicaid,0.16,,,0.16,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.24,,,0.24,Other,215% Medicaid APG methodology,0.24,,,0.24,Other,215% Medicaid APG methodology,0.14,,,0.14,Other,125% Medicaid APG methodology,0.01,0.25,
SUCRALFATE 1 G,,,,80001919,CDM,250,RC,59762040101,NDC,both,100,EA,0.23,0.09,39.4668,,0.09,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.08,34,,0.08,percent of total billed charges,"Drugs, Inpatient Only",0.08,34,,0.08,percent of total billed charges,"Drugs, Inpatient Only",0.08,34,,0.08,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.16,70,,0.16,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.08,,,0.08,Other,Drug Cost,0.08,,,0.08,Other,Drug Cost,0.08,,,0.08,Other,Drug Cost,0.08,,,0.08,Other,Drug Cost,0.08,,,0.08,Other,Drug Cost,0.08,,,0.08,Other,Drug Cost,0.17,,,0.17,Other,225% of Medicaid,0.11,,,0.11,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.16,,,0.16,Other,215% Medicaid APG methodology,0.16,,,0.16,Other,215% Medicaid APG methodology,0.1,,,0.1,Other,125% Medicaid APG methodology,0.01,0.17,
SULFACETAMIDE 10% OPHTH 15ML,,,,80001921,CDM,250,RC,24208067004,NDC,both,1,ML,48.03,18.96,39.4668,,18.96,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,16.33,34,,16.33,percent of total billed charges,"Drugs, Inpatient Only",16.33,34,,16.33,percent of total billed charges,"Drugs, Inpatient Only",16.33,34,,16.33,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,33.62,70,,33.62,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,16.01,,,16.01,Other,Drug Cost,16.01,,,16.01,Other,Drug Cost,16.01,,,16.01,Other,Drug Cost,16.01,,,16.01,Other,Drug Cost,16.01,,,16.01,Other,Drug Cost,16.01,,,16.01,Other,Drug Cost,36.02,,,36.02,Other,225% of Medicaid,22.41,,,22.41,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,34.42,,,34.42,Other,215% Medicaid APG methodology,34.42,,,34.42,Other,215% Medicaid APG methodology,20.01,,,20.01,Other,125% Medicaid APG methodology,0.01,36.02,
SULFATRIM 40-200 MG/ 5 ML SUSP,,,,80001923,CDM,250,RC,65862049647,NDC,both,1,ML,30.78,12.15,39.4668,,12.15,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,10.47,34,,10.47,percent of total billed charges,"Drugs, Inpatient Only",10.47,34,,10.47,percent of total billed charges,"Drugs, Inpatient Only",10.47,34,,10.47,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,21.55,70,,21.55,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,10.26,,,10.26,Other,Drug Cost,10.26,,,10.26,Other,Drug Cost,10.26,,,10.26,Other,Drug Cost,10.26,,,10.26,Other,Drug Cost,10.26,,,10.26,Other,Drug Cost,10.26,,,10.26,Other,Drug Cost,23.09,,,23.09,Other,225% of Medicaid,14.36,,,14.36,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,22.06,,,22.06,Other,215% Medicaid APG methodology,22.06,,,22.06,Other,215% Medicaid APG methodology,12.83,,,12.83,Other,125% Medicaid APG methodology,0.01,23.09,
SUMATRIPTAN SUCC (IMITREX) 100MG TAB,,,,80001925,CDM,250,RC,65862014836,NDC,both,9,EA,0.51,0.2,39.4668,,0.2,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.17,34,,0.17,percent of total billed charges,"Drugs, Inpatient Only",0.17,34,,0.17,percent of total billed charges,"Drugs, Inpatient Only",0.17,34,,0.17,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.36,70,,0.36,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.17,,,0.17,Other,Drug Cost,0.17,,,0.17,Other,Drug Cost,0.17,,,0.17,Other,Drug Cost,0.17,,,0.17,Other,Drug Cost,0.17,,,0.17,Other,Drug Cost,0.17,,,0.17,Other,Drug Cost,0.38,,,0.38,Other,225% of Medicaid,0.24,,,0.24,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.37,,,0.37,Other,215% Medicaid APG methodology,0.37,,,0.37,Other,215% Medicaid APG methodology,0.21,,,0.21,Other,125% Medicaid APG methodology,0.01,0.38,
SUMATRIPTAN SUCC (IMITREX) 25MG TAB,,,,80001926,CDM,250,RC,65862014636,NDC,both,9,EA,0.23,0.09,39.4668,,0.09,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.08,34,,0.08,percent of total billed charges,"Drugs, Inpatient Only",0.08,34,,0.08,percent of total billed charges,"Drugs, Inpatient Only",0.08,34,,0.08,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.16,70,,0.16,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.08,,,0.08,Other,Drug Cost,0.08,,,0.08,Other,Drug Cost,0.08,,,0.08,Other,Drug Cost,0.08,,,0.08,Other,Drug Cost,0.08,,,0.08,Other,Drug Cost,0.08,,,0.08,Other,Drug Cost,0.17,,,0.17,Other,225% of Medicaid,0.11,,,0.11,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.16,,,0.16,Other,215% Medicaid APG methodology,0.16,,,0.16,Other,215% Medicaid APG methodology,0.1,,,0.1,Other,125% Medicaid APG methodology,0.01,0.17,
TAMOXIFEN 10 MG TAB,,,,80001933,CDM,250,RC,378014491,NDC,both,60,EA,0.42,0.17,39.4668,,0.17,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.14,34,,0.14,percent of total billed charges,"Drugs, Inpatient Only",0.14,34,,0.14,percent of total billed charges,"Drugs, Inpatient Only",0.14,34,,0.14,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.3,70,,0.3,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.14,,,0.14,Other,Drug Cost,0.14,,,0.14,Other,Drug Cost,0.14,,,0.14,Other,Drug Cost,0.14,,,0.14,Other,Drug Cost,0.14,,,0.14,Other,Drug Cost,0.14,,,0.14,Other,Drug Cost,0.32,,,0.32,Other,225% of Medicaid,0.2,,,0.2,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.3,,,0.3,Other,215% Medicaid APG methodology,0.3,,,0.3,Other,215% Medicaid APG methodology,0.18,,,0.18,Other,125% Medicaid APG methodology,0.01,0.32,
TAMSULOSIN (FLOMAX) 0.4 MG CAPS,,,,80001934,CDM,250,RC,65862059801,NDC,both,100,EA,0.06,0.03,39.4668,,0.03,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.02,34,,0.02,percent of total billed charges,"Drugs, Inpatient Only",0.02,34,,0.02,percent of total billed charges,"Drugs, Inpatient Only",0.02,34,,0.02,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.05,70,,0.05,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.05,,,0.05,Other,225% of Medicaid,0.03,,,0.03,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.05,,,0.05,Other,215% Medicaid APG methodology,0.05,,,0.05,Other,215% Medicaid APG methodology,0.03,,,0.03,Other,125% Medicaid APG methodology,0.01,0.05,
TARSUM 120ML SHAMPOO,,,,80001937,CDM,250,RC,11086001101,NDC,both,1,ML,53.7,21.19,39.4668,,21.19,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,18.26,34,,18.26,percent of total billed charges,"Drugs, Inpatient Only",18.26,34,,18.26,percent of total billed charges,"Drugs, Inpatient Only",18.26,34,,18.26,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,37.59,70,,37.59,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,17.9,,,17.9,Other,Drug Cost,17.9,,,17.9,Other,Drug Cost,17.9,,,17.9,Other,Drug Cost,17.9,,,17.9,Other,Drug Cost,17.9,,,17.9,Other,Drug Cost,17.9,,,17.9,Other,Drug Cost,40.28,,,40.28,Other,225% of Medicaid,25.06,,,25.06,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,38.49,,,38.49,Other,215% Medicaid APG methodology,38.49,,,38.49,Other,215% Medicaid APG methodology,22.38,,,22.38,Other,125% Medicaid APG methodology,0.01,40.28,
TERBUTALINE 2.5 MG,,,,80001947,CDM,250,RC,115261101,NDC,both,100,EA,0.31,0.12,39.4668,,0.12,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.1,34,,0.1,percent of total billed charges,"Drugs, Inpatient Only",0.1,34,,0.1,percent of total billed charges,"Drugs, Inpatient Only",0.1,34,,0.1,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.21,70,,0.21,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.1,,,0.1,Other,Drug Cost,0.1,,,0.1,Other,Drug Cost,0.1,,,0.1,Other,Drug Cost,0.1,,,0.1,Other,Drug Cost,0.1,,,0.1,Other,Drug Cost,0.1,,,0.1,Other,Drug Cost,0.23,,,0.23,Other,225% of Medicaid,0.14,,,0.14,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.22,,,0.22,Other,215% Medicaid APG methodology,0.22,,,0.22,Other,215% Medicaid APG methodology,0.13,,,0.13,Other,125% Medicaid APG methodology,0.01,0.23,
TERBUTALINE 5 MG,,,,80001948,CDM,250,RC,115262201,NDC,both,100,EA,0.03,0.01,39.4668,,0.01,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.02,70,,0.02,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.02,,,0.02,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,0.02,
THERAPEUTIC MVI 1EA,,,,80001963,CDM,250,RC,904053061,NDC,both,10,EA,0.5,0.2,39.4668,,0.2,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.17,34,,0.17,percent of total billed charges,"Drugs, Inpatient Only",0.17,34,,0.17,percent of total billed charges,"Drugs, Inpatient Only",0.17,34,,0.17,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.35,70,,0.35,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.17,,,0.17,Other,Drug Cost,0.17,,,0.17,Other,Drug Cost,0.17,,,0.17,Other,Drug Cost,0.17,,,0.17,Other,Drug Cost,0.17,,,0.17,Other,Drug Cost,0.17,,,0.17,Other,Drug Cost,0.38,,,0.38,Other,225% of Medicaid,0.24,,,0.24,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.36,,,0.36,Other,215% Medicaid APG methodology,0.36,,,0.36,Other,215% Medicaid APG methodology,0.21,,,0.21,Other,125% Medicaid APG methodology,0.01,0.38,
THIAMINE HCL 100 MG TAB,,,,80001966,CDM,250,RC,54629005701,NDC,both,100,EA,0.13,0.05,39.4668,,0.05,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.04,34,,0.04,percent of total billed charges,"Drugs, Inpatient Only",0.04,34,,0.04,percent of total billed charges,"Drugs, Inpatient Only",0.04,34,,0.04,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.09,70,,0.09,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.1,,,0.1,Other,225% of Medicaid,0.06,,,0.06,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.09,,,0.09,Other,215% Medicaid APG methodology,0.09,,,0.09,Other,215% Medicaid APG methodology,0.05,,,0.05,Other,125% Medicaid APG methodology,0.01,0.1,
THROMBIN-JMI 20000 UNIT KIT,,,,80001969,CDM,250,RC,60793021720,NDC,both,1,EA,0.03,0.01,39.4668,,0.01,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.02,70,,0.02,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.02,,,0.02,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,0.02,
THROMBIN-JMI 5000 UNIT KIT,,,,80001970,CDM,250,RC,60793020505,NDC,both,1,EA,0.03,0.01,39.4668,,0.01,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.02,70,,0.02,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.02,,,0.02,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,0.02,
TICAGRELOR 90 MG TABLET,,,,80001972,CDM,250,RC,186077739,NDC,both,100,EA,4.46,1.76,39.4668,,1.76,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1.52,34,,1.52,percent of total billed charges,"Drugs, Inpatient Only",1.52,34,,1.52,percent of total billed charges,"Drugs, Inpatient Only",1.52,34,,1.52,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,3.12,70,,3.12,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1.49,,,1.49,Other,Drug Cost,1.49,,,1.49,Other,Drug Cost,1.49,,,1.49,Other,Drug Cost,1.49,,,1.49,Other,Drug Cost,1.49,,,1.49,Other,Drug Cost,1.49,,,1.49,Other,Drug Cost,3.34,,,3.34,Other,225% of Medicaid,2.08,,,2.08,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,3.2,,,3.2,Other,215% Medicaid APG methodology,3.2,,,3.2,Other,215% Medicaid APG methodology,1.86,,,1.86,Other,125% Medicaid APG methodology,0.01,3.34,
TIGABINE HCL (GABITRIL) 4MG TAB,,,,80001973,CDM,250,RC,62756022483,NDC,both,30,EA,4.53,1.79,39.4668,,1.79,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1.54,34,,1.54,percent of total billed charges,"Drugs, Inpatient Only",1.54,34,,1.54,percent of total billed charges,"Drugs, Inpatient Only",1.54,34,,1.54,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,3.17,70,,3.17,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1.51,,,1.51,Other,Drug Cost,1.51,,,1.51,Other,Drug Cost,1.51,,,1.51,Other,Drug Cost,1.51,,,1.51,Other,Drug Cost,1.51,,,1.51,Other,Drug Cost,1.51,,,1.51,Other,Drug Cost,3.39,,,3.39,Other,225% of Medicaid,2.11,,,2.11,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,3.24,,,3.24,Other,215% Medicaid APG methodology,3.24,,,3.24,Other,215% Medicaid APG methodology,1.89,,,1.89,Other,125% Medicaid APG methodology,0.01,3.39,
TIMOLOL 0.25% 5ML OPHTH,,,,80001977,CDM,250,RC,61314022605,NDC,both,1,ML,3.45,1.36,39.4668,,1.36,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1.17,34,,1.17,percent of total billed charges,"Drugs, Inpatient Only",1.17,34,,1.17,percent of total billed charges,"Drugs, Inpatient Only",1.17,34,,1.17,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2.42,70,,2.42,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1.15,,,1.15,Other,Drug Cost,1.15,,,1.15,Other,Drug Cost,1.15,,,1.15,Other,Drug Cost,1.15,,,1.15,Other,Drug Cost,1.15,,,1.15,Other,Drug Cost,1.15,,,1.15,Other,Drug Cost,2.59,,,2.59,Other,225% of Medicaid,1.61,,,1.61,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,2.47,,,2.47,Other,215% Medicaid APG methodology,2.47,,,2.47,Other,215% Medicaid APG methodology,1.44,,,1.44,Other,125% Medicaid APG methodology,0.01,2.59,
TIMOLOL 0.5% 10ML OPHTH,,,,80001979,CDM,250,RC,61314022705,NDC,both,1,ML,3.9,1.54,39.4668,,1.54,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1.33,34,,1.33,percent of total billed charges,"Drugs, Inpatient Only",1.33,34,,1.33,percent of total billed charges,"Drugs, Inpatient Only",1.33,34,,1.33,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2.73,70,,2.73,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1.3,,,1.3,Other,Drug Cost,1.3,,,1.3,Other,Drug Cost,1.3,,,1.3,Other,Drug Cost,1.3,,,1.3,Other,Drug Cost,1.3,,,1.3,Other,Drug Cost,1.3,,,1.3,Other,Drug Cost,2.93,,,2.93,Other,225% of Medicaid,1.82,,,1.82,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,2.8,,,2.8,Other,215% Medicaid APG methodology,2.8,,,2.8,Other,215% Medicaid APG methodology,1.63,,,1.63,Other,125% Medicaid APG methodology,0.01,2.93,
TIMOLOL 0.5% 5ML OPHTH,,,,80001980,CDM,250,RC,64980051405,NDC,both,1,ML,2.73,1.08,39.4668,,1.08,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.93,34,,0.93,percent of total billed charges,"Drugs, Inpatient Only",0.93,34,,0.93,percent of total billed charges,"Drugs, Inpatient Only",0.93,34,,0.93,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1.91,70,,1.91,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.91,,,0.91,Other,Drug Cost,0.91,,,0.91,Other,Drug Cost,0.91,,,0.91,Other,Drug Cost,0.91,,,0.91,Other,Drug Cost,0.91,,,0.91,Other,Drug Cost,0.91,,,0.91,Other,Drug Cost,2.05,,,2.05,Other,225% of Medicaid,1.27,,,1.27,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,1.96,,,1.96,Other,215% Medicaid APG methodology,1.96,,,1.96,Other,215% Medicaid APG methodology,1.14,,,1.14,Other,125% Medicaid APG methodology,0.01,2.05,
TIMOLOL 0.5% 5ML OPTH,,,,80001981,CDM,250,RC,61314022505,NDC,both,1,ML,118.83,46.9,39.4668,,46.9,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,40.4,34,,40.4,percent of total billed charges,"Drugs, Inpatient Only",40.4,34,,40.4,percent of total billed charges,"Drugs, Inpatient Only",40.4,34,,40.4,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,83.18,70,,83.18,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,39.61,,,39.61,Other,Drug Cost,39.61,,,39.61,Other,Drug Cost,39.61,,,39.61,Other,Drug Cost,39.61,,,39.61,Other,Drug Cost,39.61,,,39.61,Other,Drug Cost,39.61,,,39.61,Other,Drug Cost,89.12,,,89.12,Other,225% of Medicaid,55.45,,,55.45,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,85.16,,,85.16,Other,215% Medicaid APG methodology,85.16,,,85.16,Other,215% Medicaid APG methodology,49.51,,,49.51,Other,125% Medicaid APG methodology,0.01,89.12,
TIPRANAVIR (APTIVUS) 250 MG,,,,80001987,CDM,250,RC,597000302,NDC,both,120,EA,21.54,8.5,39.4668,,8.5,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,7.32,34,,7.32,percent of total billed charges,"Drugs, Inpatient Only",7.32,34,,7.32,percent of total billed charges,"Drugs, Inpatient Only",7.32,34,,7.32,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,15.08,70,,15.08,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,7.18,,,7.18,Other,Drug Cost,7.18,,,7.18,Other,Drug Cost,7.18,,,7.18,Other,Drug Cost,7.18,,,7.18,Other,Drug Cost,7.18,,,7.18,Other,Drug Cost,7.18,,,7.18,Other,Drug Cost,16.16,,,16.16,Other,225% of Medicaid,10.05,,,10.05,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,15.44,,,15.44,Other,215% Medicaid APG methodology,15.44,,,15.44,Other,215% Medicaid APG methodology,8.98,,,8.98,Other,125% Medicaid APG methodology,0.01,16.16,
TIZANIDINE 4 MG TAB,,,,80001988,CDM,250,RC,55111018015,NDC,both,150,EA,0.03,0.01,39.4668,,0.01,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.02,70,,0.02,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.03,,,0.03,Other,225% of Medicaid,0.02,,,0.02,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,0.03,
TOBRAMYCIN 1.2 GM INJ,,,,80001991,CDM,250,RC,63323030351,NDC,both,6,EA,122.59,48.38,39.4668,,48.38,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,41.68,34,,41.68,percent of total billed charges,"Drugs, Inpatient Only",41.68,34,,41.68,percent of total billed charges,"Drugs, Inpatient Only",41.68,34,,41.68,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,85.81,70,,85.81,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,40.86,,,40.86,Other,Drug Cost,40.86,,,40.86,Other,Drug Cost,40.86,,,40.86,Other,Drug Cost,40.86,,,40.86,Other,Drug Cost,40.86,,,40.86,Other,Drug Cost,40.86,,,40.86,Other,Drug Cost,91.94,,,91.94,Other,225% of Medicaid,57.21,,,57.21,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,87.85,,,87.85,Other,215% Medicaid APG methodology,87.85,,,87.85,Other,215% Medicaid APG methodology,51.08,,,51.08,Other,125% Medicaid APG methodology,0.01,91.94,
TOBRAMYCIN 5ML OPHTH,,,,80001992,CDM,250,RC,70069013101,NDC,both,1,ML,5.34,2.11,39.4668,,2.11,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1.82,34,,1.82,percent of total billed charges,"Drugs, Inpatient Only",1.82,34,,1.82,percent of total billed charges,"Drugs, Inpatient Only",1.82,34,,1.82,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,3.74,70,,3.74,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1.78,,,1.78,Other,Drug Cost,1.78,,,1.78,Other,Drug Cost,1.78,,,1.78,Other,Drug Cost,1.78,,,1.78,Other,Drug Cost,1.78,,,1.78,Other,Drug Cost,1.78,,,1.78,Other,Drug Cost,4.01,,,4.01,Other,225% of Medicaid,2.49,,,2.49,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,3.83,,,3.83,Other,215% Medicaid APG methodology,3.83,,,3.83,Other,215% Medicaid APG methodology,2.23,,,2.23,Other,125% Medicaid APG methodology,0.01,4.01,
TOBREX 0.3% 3.5GM OPHTH OINT,,,,80001994,CDM,250,RC,78081301,NDC,both,1,GM,0.12,0.05,39.4668,,0.05,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.04,34,,0.04,percent of total billed charges,"Drugs, Inpatient Only",0.04,34,,0.04,percent of total billed charges,"Drugs, Inpatient Only",0.04,34,,0.04,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.08,70,,0.08,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.09,,,0.09,Other,225% of Medicaid,0.06,,,0.06,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.09,,,0.09,Other,215% Medicaid APG methodology,0.09,,,0.09,Other,215% Medicaid APG methodology,0.05,,,0.05,Other,125% Medicaid APG methodology,0.01,0.09,
TOPAMAX 100MG TAB,,,,80001999,CDM,250,RC,68382014014,NDC,both,60,EA,0.05,0.02,39.4668,,0.02,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.02,34,,0.02,percent of total billed charges,"Drugs, Inpatient Only",0.02,34,,0.02,percent of total billed charges,"Drugs, Inpatient Only",0.02,34,,0.02,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.04,70,,0.04,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.04,,,0.04,Other,225% of Medicaid,0.02,,,0.02,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.04,,,0.04,Other,215% Medicaid APG methodology,0.04,,,0.04,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,125% Medicaid APG methodology,0.01,0.04,
TOPAMAX 25MG TAB,,,,80002000,CDM,250,RC,47335070786,NDC,both,60,EA,0.01,0.01,39.4668,,0.01,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,70,,0.01,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,0.02,
TORSEMIDE 20MG,,,,80002006,CDM,250,RC,31722053101,NDC,both,100,EA,0.09,0.04,39.4668,,0.04,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.03,34,,0.03,percent of total billed charges,"Drugs, Inpatient Only",0.03,34,,0.03,percent of total billed charges,"Drugs, Inpatient Only",0.03,34,,0.03,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.06,70,,0.06,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.07,,,0.07,Other,225% of Medicaid,0.04,,,0.04,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.06,,,0.06,Other,215% Medicaid APG methodology,0.06,,,0.06,Other,215% Medicaid APG methodology,0.04,,,0.04,Other,125% Medicaid APG methodology,0.01,0.07,
TRANSDERM-SCOP 1.5MG,,,,80002011,CDM,250,RC,10019055303,NDC,both,10,EA,4,1.58,39.4668,,1.58,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1.36,34,,1.36,percent of total billed charges,"Drugs, Inpatient Only",1.36,34,,1.36,percent of total billed charges,"Drugs, Inpatient Only",1.36,34,,1.36,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2.8,70,,2.8,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1.33,,,1.33,Other,Drug Cost,1.33,,,1.33,Other,Drug Cost,1.33,,,1.33,Other,Drug Cost,1.33,,,1.33,Other,Drug Cost,1.33,,,1.33,Other,Drug Cost,1.33,,,1.33,Other,Drug Cost,3,,,3,Other,225% of Medicaid,1.86,,,1.86,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,2.86,,,2.86,Other,215% Medicaid APG methodology,2.86,,,2.86,Other,215% Medicaid APG methodology,1.67,,,1.67,Other,125% Medicaid APG methodology,0.01,3,
TRAZODONE 100 MG TAB,,,,80002015,CDM,250,RC,50111056101,NDC,both,100,EA,0.13,0.05,39.4668,,0.05,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.04,34,,0.04,percent of total billed charges,"Drugs, Inpatient Only",0.04,34,,0.04,percent of total billed charges,"Drugs, Inpatient Only",0.04,34,,0.04,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.09,70,,0.09,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.1,,,0.1,Other,225% of Medicaid,0.06,,,0.06,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.09,,,0.09,Other,215% Medicaid APG methodology,0.09,,,0.09,Other,215% Medicaid APG methodology,0.05,,,0.05,Other,125% Medicaid APG methodology,0.01,0.1,
TRAZODONE 50 MG TAB,,,,80002016,CDM,250,RC,50111056001,NDC,both,100,EA,0.04,0.02,39.4668,,0.02,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.03,70,,0.03,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.03,,,0.03,Other,225% of Medicaid,0.02,,,0.02,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.03,,,0.03,Other,215% Medicaid APG methodology,0.03,,,0.03,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,125% Medicaid APG methodology,0.01,0.03,
TRIAMCINOLONE 0.1% DENTAL PASTE,,,,80002017,CDM,250,RC,713065540,NDC,both,1,GM,16.53,6.52,39.4668,,6.52,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,5.62,34,,5.62,percent of total billed charges,"Drugs, Inpatient Only",5.62,34,,5.62,percent of total billed charges,"Drugs, Inpatient Only",5.62,34,,5.62,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,11.57,70,,11.57,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,5.51,,,5.51,Other,Drug Cost,5.51,,,5.51,Other,Drug Cost,5.51,,,5.51,Other,Drug Cost,5.51,,,5.51,Other,Drug Cost,5.51,,,5.51,Other,Drug Cost,5.51,,,5.51,Other,Drug Cost,12.4,,,12.4,Other,225% of Medicaid,7.71,,,7.71,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,11.85,,,11.85,Other,215% Medicaid APG methodology,11.85,,,11.85,Other,215% Medicaid APG methodology,6.89,,,6.89,Other,125% Medicaid APG methodology,0.01,12.4,
TRIAMCINOLONE ACET 454GM CREAM,,,,80002019,CDM,250,RC,67877025145,NDC,both,1,GM,28.47,11.24,39.4668,,11.24,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,9.68,34,,9.68,percent of total billed charges,"Drugs, Inpatient Only",9.68,34,,9.68,percent of total billed charges,"Drugs, Inpatient Only",9.68,34,,9.68,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,19.93,70,,19.93,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,9.49,,,9.49,Other,Drug Cost,9.49,,,9.49,Other,Drug Cost,9.49,,,9.49,Other,Drug Cost,9.49,,,9.49,Other,Drug Cost,9.49,,,9.49,Other,Drug Cost,9.49,,,9.49,Other,Drug Cost,21.35,,,21.35,Other,225% of Medicaid,13.29,,,13.29,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,20.4,,,20.4,Other,215% Medicaid APG methodology,20.4,,,20.4,Other,215% Medicaid APG methodology,11.86,,,11.86,Other,125% Medicaid APG methodology,0.01,21.35,
TRIAMCINOLONE ACET CREAM  15GM,,,,80002020,CDM,250,RC,168000315,NDC,both,1,GM,1.02,0.4,39.4668,,0.4,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.35,34,,0.35,percent of total billed charges,"Drugs, Inpatient Only",0.35,34,,0.35,percent of total billed charges,"Drugs, Inpatient Only",0.35,34,,0.35,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.71,70,,0.71,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.34,,,0.34,Other,Drug Cost,0.34,,,0.34,Other,Drug Cost,0.34,,,0.34,Other,Drug Cost,0.34,,,0.34,Other,Drug Cost,0.34,,,0.34,Other,Drug Cost,0.34,,,0.34,Other,Drug Cost,0.77,,,0.77,Other,225% of Medicaid,0.48,,,0.48,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.73,,,0.73,Other,215% Medicaid APG methodology,0.73,,,0.73,Other,215% Medicaid APG methodology,0.43,,,0.43,Other,125% Medicaid APG methodology,0.01,0.77,
TRIAMCINOLONE ACET CREAM 80GM,,,,80002021,CDM,250,RC,168000380,NDC,both,1,GM,5.46,2.15,39.4668,,2.15,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1.86,34,,1.86,percent of total billed charges,"Drugs, Inpatient Only",1.86,34,,1.86,percent of total billed charges,"Drugs, Inpatient Only",1.86,34,,1.86,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,3.82,70,,3.82,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1.82,,,1.82,Other,Drug Cost,1.82,,,1.82,Other,Drug Cost,1.82,,,1.82,Other,Drug Cost,1.82,,,1.82,Other,Drug Cost,1.82,,,1.82,Other,Drug Cost,1.82,,,1.82,Other,Drug Cost,4.1,,,4.1,Other,225% of Medicaid,2.55,,,2.55,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,3.91,,,3.91,Other,215% Medicaid APG methodology,3.91,,,3.91,Other,215% Medicaid APG methodology,2.28,,,2.28,Other,125% Medicaid APG methodology,0.01,4.1,
TRIAMCINOLONE ACET OINT 15GM,,,,80002024,CDM,250,RC,45802005535,NDC,both,1,GM,0.81,0.32,39.4668,,0.32,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.28,34,,0.28,percent of total billed charges,"Drugs, Inpatient Only",0.28,34,,0.28,percent of total billed charges,"Drugs, Inpatient Only",0.28,34,,0.28,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.57,70,,0.57,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.27,,,0.27,Other,Drug Cost,0.27,,,0.27,Other,Drug Cost,0.27,,,0.27,Other,Drug Cost,0.27,,,0.27,Other,Drug Cost,0.27,,,0.27,Other,Drug Cost,0.27,,,0.27,Other,Drug Cost,0.61,,,0.61,Other,225% of Medicaid,0.38,,,0.38,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.58,,,0.58,Other,215% Medicaid APG methodology,0.58,,,0.58,Other,215% Medicaid APG methodology,0.34,,,0.34,Other,125% Medicaid APG methodology,0.01,0.61,
TRIAMCINOLONE ACET OINT 80GM,,,,80002025,CDM,250,RC,168000680,NDC,both,1,GM,9.24,3.65,39.4668,,3.65,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,3.14,34,,3.14,percent of total billed charges,"Drugs, Inpatient Only",3.14,34,,3.14,percent of total billed charges,"Drugs, Inpatient Only",3.14,34,,3.14,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,6.47,70,,6.47,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,3.08,,,3.08,Other,Drug Cost,3.08,,,3.08,Other,Drug Cost,3.08,,,3.08,Other,Drug Cost,3.08,,,3.08,Other,Drug Cost,3.08,,,3.08,Other,Drug Cost,3.08,,,3.08,Other,Drug Cost,6.93,,,6.93,Other,225% of Medicaid,4.31,,,4.31,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,6.62,,,6.62,Other,215% Medicaid APG methodology,6.62,,,6.62,Other,215% Medicaid APG methodology,3.85,,,3.85,Other,125% Medicaid APG methodology,0.01,6.93,
TRIAMCINOLONE ACETONIDE 0.1%,,,,80002026,CDM,250,RC,67877025115,NDC,both,1,GM,0.96,0.38,39.4668,,0.38,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.33,34,,0.33,percent of total billed charges,"Drugs, Inpatient Only",0.33,34,,0.33,percent of total billed charges,"Drugs, Inpatient Only",0.33,34,,0.33,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.67,70,,0.67,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.32,,,0.32,Other,Drug Cost,0.32,,,0.32,Other,Drug Cost,0.32,,,0.32,Other,Drug Cost,0.32,,,0.32,Other,Drug Cost,0.32,,,0.32,Other,Drug Cost,0.32,,,0.32,Other,Drug Cost,0.72,,,0.72,Other,225% of Medicaid,0.45,,,0.45,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.69,,,0.69,Other,215% Medicaid APG methodology,0.69,,,0.69,Other,215% Medicaid APG methodology,0.4,,,0.4,Other,125% Medicaid APG methodology,0.01,0.72,
TRIAMTERENE-HCTZ 37.5-25MG CAP,,,,80002030,CDM,250,RC,527163201,NDC,both,100,EA,0.09,0.04,39.4668,,0.04,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.03,34,,0.03,percent of total billed charges,"Drugs, Inpatient Only",0.03,34,,0.03,percent of total billed charges,"Drugs, Inpatient Only",0.03,34,,0.03,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.07,70,,0.07,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.07,,,0.07,Other,225% of Medicaid,0.04,,,0.04,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.07,,,0.07,Other,215% Medicaid APG methodology,0.07,,,0.07,Other,215% Medicaid APG methodology,0.04,,,0.04,Other,125% Medicaid APG methodology,0.01,0.07,
TRIHEXYPHENIDYL 2MG TAB,,,,80002037,CDM,250,RC,69452024120,NDC,both,100,EA,0.04,0.01,39.4668,,0.01,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.03,70,,0.03,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.03,,,0.03,Other,225% of Medicaid,0.02,,,0.02,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.03,,,0.03,Other,215% Medicaid APG methodology,0.03,,,0.03,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,125% Medicaid APG methodology,0.01,0.03,
TRIHEXYPHENIDYL 5MG TAB,,,,80002038,CDM,250,RC,591533701,NDC,both,100,EA,0.2,0.08,39.4668,,0.08,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.07,34,,0.07,percent of total billed charges,"Drugs, Inpatient Only",0.07,34,,0.07,percent of total billed charges,"Drugs, Inpatient Only",0.07,34,,0.07,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.14,70,,0.14,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.07,,,0.07,Other,Drug Cost,0.07,,,0.07,Other,Drug Cost,0.07,,,0.07,Other,Drug Cost,0.07,,,0.07,Other,Drug Cost,0.07,,,0.07,Other,Drug Cost,0.07,,,0.07,Other,Drug Cost,0.15,,,0.15,Other,225% of Medicaid,0.09,,,0.09,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.14,,,0.14,Other,215% Medicaid APG methodology,0.14,,,0.14,Other,215% Medicaid APG methodology,0.08,,,0.08,Other,125% Medicaid APG methodology,0.01,0.15,
TRIMETH-SULFAMETH 160-800MG TAB,,,,80002041,CDM,250,RC,65162027210,NDC,both,100,EA,0.09,0.03,39.4668,,0.03,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.03,34,,0.03,percent of total billed charges,"Drugs, Inpatient Only",0.03,34,,0.03,percent of total billed charges,"Drugs, Inpatient Only",0.03,34,,0.03,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.06,70,,0.06,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.07,,,0.07,Other,225% of Medicaid,0.04,,,0.04,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.06,,,0.06,Other,215% Medicaid APG methodology,0.06,,,0.06,Other,215% Medicaid APG methodology,0.04,,,0.04,Other,125% Medicaid APG methodology,0.01,0.07,
TRIPLE ANTIBIOTIC 30GM,,,,80002042,CDM,250,RC,45802014303,NDC,both,1,GM,3.42,1.35,39.4668,,1.35,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1.16,34,,1.16,percent of total billed charges,"Drugs, Inpatient Only",1.16,34,,1.16,percent of total billed charges,"Drugs, Inpatient Only",1.16,34,,1.16,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2.39,70,,2.39,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1.14,,,1.14,Other,Drug Cost,1.14,,,1.14,Other,Drug Cost,1.14,,,1.14,Other,Drug Cost,1.14,,,1.14,Other,Drug Cost,1.14,,,1.14,Other,Drug Cost,1.14,,,1.14,Other,Drug Cost,2.57,,,2.57,Other,225% of Medicaid,1.6,,,1.6,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,2.45,,,2.45,Other,215% Medicaid APG methodology,2.45,,,2.45,Other,215% Medicaid APG methodology,1.43,,,1.43,Other,125% Medicaid APG methodology,0.01,2.57,
TROPICAMIDE 1% OPHTH,,,,80002047,CDM,250,RC,61314035501,NDC,both,1,ML,6.54,2.58,39.4668,,2.58,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2.22,34,,2.22,percent of total billed charges,"Drugs, Inpatient Only",2.22,34,,2.22,percent of total billed charges,"Drugs, Inpatient Only",2.22,34,,2.22,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,4.58,70,,4.58,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2.18,,,2.18,Other,Drug Cost,2.18,,,2.18,Other,Drug Cost,2.18,,,2.18,Other,Drug Cost,2.18,,,2.18,Other,Drug Cost,2.18,,,2.18,Other,Drug Cost,2.18,,,2.18,Other,Drug Cost,4.91,,,4.91,Other,225% of Medicaid,3.05,,,3.05,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,4.69,,,4.69,Other,215% Medicaid APG methodology,4.69,,,4.69,Other,215% Medicaid APG methodology,2.73,,,2.73,Other,125% Medicaid APG methodology,0.01,4.91,
TUBERCULIN PPD INJ,,,,80002048,CDM,250,RC,42023010401,NDC,both,1,ML,0.03,0.01,39.4668,,0.01,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.02,70,,0.02,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.02,,,0.02,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,0.02,
UREA 20% CREAM,,,,80002051,CDM,250,RC,58980061030,NDC,both,1,GM,23.52,9.28,39.4668,,9.28,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,8,34,,8,percent of total billed charges,"Drugs, Inpatient Only",8,34,,8,percent of total billed charges,"Drugs, Inpatient Only",8,34,,8,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,16.46,70,,16.46,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,7.84,,,7.84,Other,Drug Cost,7.84,,,7.84,Other,Drug Cost,7.84,,,7.84,Other,Drug Cost,7.84,,,7.84,Other,Drug Cost,7.84,,,7.84,Other,Drug Cost,7.84,,,7.84,Other,Drug Cost,17.64,,,17.64,Other,225% of Medicaid,10.98,,,10.98,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,16.86,,,16.86,Other,215% Medicaid APG methodology,16.86,,,16.86,Other,215% Medicaid APG methodology,9.8,,,9.8,Other,125% Medicaid APG methodology,0.01,17.64,
UREA TOPICAL 40% CREAM,,,,80002052,CDM,250,RC,16477034003,NDC,both,1,GM,112.32,44.33,39.4668,,44.33,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,38.19,34,,38.19,percent of total billed charges,"Drugs, Inpatient Only",38.19,34,,38.19,percent of total billed charges,"Drugs, Inpatient Only",38.19,34,,38.19,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,78.62,70,,78.62,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,37.44,,,37.44,Other,Drug Cost,37.44,,,37.44,Other,Drug Cost,37.44,,,37.44,Other,Drug Cost,37.44,,,37.44,Other,Drug Cost,37.44,,,37.44,Other,Drug Cost,37.44,,,37.44,Other,Drug Cost,84.24,,,84.24,Other,225% of Medicaid,52.42,,,52.42,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,80.5,,,80.5,Other,215% Medicaid APG methodology,80.5,,,80.5,Other,215% Medicaid APG methodology,46.8,,,46.8,Other,125% Medicaid APG methodology,0.01,84.24,
UROCIT-K 10 1080MG,,,,80002053,CDM,250,RC,245007111,NDC,both,100,EA,0.28,0.11,39.4668,,0.11,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.1,34,,0.1,percent of total billed charges,"Drugs, Inpatient Only",0.1,34,,0.1,percent of total billed charges,"Drugs, Inpatient Only",0.1,34,,0.1,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.2,70,,0.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.09,,,0.09,Other,Drug Cost,0.09,,,0.09,Other,Drug Cost,0.09,,,0.09,Other,Drug Cost,0.09,,,0.09,Other,Drug Cost,0.09,,,0.09,Other,Drug Cost,0.09,,,0.09,Other,Drug Cost,0.21,,,0.21,Other,225% of Medicaid,0.13,,,0.13,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.2,,,0.2,Other,215% Medicaid APG methodology,0.2,,,0.2,Other,215% Medicaid APG methodology,0.12,,,0.12,Other,125% Medicaid APG methodology,0.01,0.21,
URSODIOL 300 MG CAP,,,,80002056,CDM,250,RC,69238154001,NDC,both,100,EA,0.45,0.18,39.4668,,0.18,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.15,34,,0.15,percent of total billed charges,"Drugs, Inpatient Only",0.15,34,,0.15,percent of total billed charges,"Drugs, Inpatient Only",0.15,34,,0.15,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.31,70,,0.31,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.15,,,0.15,Other,Drug Cost,0.15,,,0.15,Other,Drug Cost,0.15,,,0.15,Other,Drug Cost,0.15,,,0.15,Other,Drug Cost,0.15,,,0.15,Other,Drug Cost,0.15,,,0.15,Other,Drug Cost,0.34,,,0.34,Other,225% of Medicaid,0.21,,,0.21,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.32,,,0.32,Other,215% Medicaid APG methodology,0.32,,,0.32,Other,215% Medicaid APG methodology,0.19,,,0.19,Other,125% Medicaid APG methodology,0.01,0.34,
VALACYCLOVIR 500 MG TAB,,,,80002057,CDM,250,RC,63304090430,NDC,both,30,EA,0.19,0.07,39.4668,,0.07,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.06,34,,0.06,percent of total billed charges,"Drugs, Inpatient Only",0.06,34,,0.06,percent of total billed charges,"Drugs, Inpatient Only",0.06,34,,0.06,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.13,70,,0.13,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.06,,,0.06,Other,Drug Cost,0.06,,,0.06,Other,Drug Cost,0.06,,,0.06,Other,Drug Cost,0.06,,,0.06,Other,Drug Cost,0.06,,,0.06,Other,Drug Cost,0.06,,,0.06,Other,Drug Cost,0.14,,,0.14,Other,225% of Medicaid,0.09,,,0.09,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.13,,,0.13,Other,215% Medicaid APG methodology,0.13,,,0.13,Other,215% Medicaid APG methodology,0.08,,,0.08,Other,125% Medicaid APG methodology,0.01,0.14,
VALPROATE (DEPACON) 100MG/ML 5ML INJ,,,,80002058,CDM,250,RC,143978510,NDC,both,10,ML,6.68,2.63,39.4668,,2.63,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2.27,34,,2.27,percent of total billed charges,"Drugs, Inpatient Only",2.27,34,,2.27,percent of total billed charges,"Drugs, Inpatient Only",2.27,34,,2.27,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,4.67,70,,4.67,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2.23,,,2.23,Other,Drug Cost,2.23,,,2.23,Other,Drug Cost,2.23,,,2.23,Other,Drug Cost,2.23,,,2.23,Other,Drug Cost,2.23,,,2.23,Other,Drug Cost,2.23,,,2.23,Other,Drug Cost,5.01,,,5.01,Other,225% of Medicaid,3.12,,,3.12,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,4.78,,,4.78,Other,215% Medicaid APG methodology,4.78,,,4.78,Other,215% Medicaid APG methodology,2.78,,,2.78,Other,125% Medicaid APG methodology,0.01,5.01,
VALPROIC ACID 250MG/5ML SOL,,,,80002060,CDM,250,RC,121067585,NDC,both,1,ML,12.84,5.07,39.4668,,5.07,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,4.37,34,,4.37,percent of total billed charges,"Drugs, Inpatient Only",4.37,34,,4.37,percent of total billed charges,"Drugs, Inpatient Only",4.37,34,,4.37,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,8.99,70,,8.99,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,4.28,,,4.28,Other,Drug Cost,4.28,,,4.28,Other,Drug Cost,4.28,,,4.28,Other,Drug Cost,4.28,,,4.28,Other,Drug Cost,4.28,,,4.28,Other,Drug Cost,4.28,,,4.28,Other,Drug Cost,9.63,,,9.63,Other,225% of Medicaid,5.99,,,5.99,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,9.2,,,9.2,Other,215% Medicaid APG methodology,9.2,,,9.2,Other,215% Medicaid APG methodology,5.35,,,5.35,Other,125% Medicaid APG methodology,0.01,9.63,
VALSARTAN (DIOVAN) 40MG TAB,,,,80002062,CDM,250,RC,78042315,NDC,both,30,EA,0.03,0.01,39.4668,,0.01,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.02,70,,0.02,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.02,,,0.02,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,0.02,
VALSARTAN (DIOVAN) 80MG TAB,,,,80002063,CDM,250,RC,78035834,NDC,both,90,EA,0.03,0.01,39.4668,,0.01,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.02,70,,0.02,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.02,,,0.02,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,0.02,
VASOPRESSIN 20 U/ML,,,,80002073,CDM,250,RC,42023016425,NDC,both,25,ML,28.35,11.19,39.4668,,11.19,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,9.64,34,,9.64,percent of total billed charges,"Drugs, Inpatient Only",9.64,34,,9.64,percent of total billed charges,"Drugs, Inpatient Only",9.64,34,,9.64,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,19.85,70,,19.85,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,9.45,,,9.45,Other,Drug Cost,9.45,,,9.45,Other,Drug Cost,9.45,,,9.45,Other,Drug Cost,9.45,,,9.45,Other,Drug Cost,9.45,,,9.45,Other,Drug Cost,9.45,,,9.45,Other,Drug Cost,21.26,,,21.26,Other,225% of Medicaid,13.23,,,13.23,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,20.32,,,20.32,Other,215% Medicaid APG methodology,20.32,,,20.32,Other,215% Medicaid APG methodology,11.81,,,11.81,Other,125% Medicaid APG methodology,0.01,21.26,
VECURONIUM 10MG INJ,,,,80002074,CDM,250,RC,703291403,NDC,both,10,EA,17.12,6.76,39.4668,,6.76,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,5.82,34,,5.82,percent of total billed charges,"Drugs, Inpatient Only",5.82,34,,5.82,percent of total billed charges,"Drugs, Inpatient Only",5.82,34,,5.82,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,11.98,70,,11.98,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,5.71,,,5.71,Other,Drug Cost,5.71,,,5.71,Other,Drug Cost,5.71,,,5.71,Other,Drug Cost,5.71,,,5.71,Other,Drug Cost,5.71,,,5.71,Other,Drug Cost,5.71,,,5.71,Other,Drug Cost,12.84,,,12.84,Other,225% of Medicaid,7.99,,,7.99,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,12.27,,,12.27,Other,215% Medicaid APG methodology,12.27,,,12.27,Other,215% Medicaid APG methodology,7.13,,,7.13,Other,125% Medicaid APG methodology,0.01,12.84,
VENLAFAXINE HCL (EFFEXOR) 25 MG TAB,,,,80002075,CDM,250,RC,68382001801,NDC,both,100,EA,0.09,0.04,39.4668,,0.04,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.03,34,,0.03,percent of total billed charges,"Drugs, Inpatient Only",0.03,34,,0.03,percent of total billed charges,"Drugs, Inpatient Only",0.03,34,,0.03,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.06,70,,0.06,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.07,,,0.07,Other,225% of Medicaid,0.04,,,0.04,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.07,,,0.07,Other,215% Medicaid APG methodology,0.07,,,0.07,Other,215% Medicaid APG methodology,0.04,,,0.04,Other,125% Medicaid APG methodology,0.01,0.07,
VENLAFAXINE HCL (EFFEXOR) 75MG TAB,,,,80002077,CDM,250,RC,68382002101,NDC,both,100,EA,0.09,0.04,39.4668,,0.04,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.03,34,,0.03,percent of total billed charges,"Drugs, Inpatient Only",0.03,34,,0.03,percent of total billed charges,"Drugs, Inpatient Only",0.03,34,,0.03,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.06,70,,0.06,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.07,,,0.07,Other,225% of Medicaid,0.04,,,0.04,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.07,,,0.07,Other,215% Medicaid APG methodology,0.07,,,0.07,Other,215% Medicaid APG methodology,0.04,,,0.04,Other,125% Medicaid APG methodology,0.01,0.07,
VENLAFAXINE HCL ER (EFFEXOR XR) 37.5MG,,,,80002078,CDM,250,RC,65862052790,NDC,both,90,EA,0.09,0.04,39.4668,,0.04,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.03,34,,0.03,percent of total billed charges,"Drugs, Inpatient Only",0.03,34,,0.03,percent of total billed charges,"Drugs, Inpatient Only",0.03,34,,0.03,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.06,70,,0.06,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.07,,,0.07,Other,225% of Medicaid,0.04,,,0.04,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.06,,,0.06,Other,215% Medicaid APG methodology,0.06,,,0.06,Other,215% Medicaid APG methodology,0.04,,,0.04,Other,125% Medicaid APG methodology,0.01,0.07,
VENLAFAXINE HCL ER (EFFEXOR XR) 75MG CAP,,,,80002079,CDM,250,RC,65862052899,NDC,both,1000,EA,0.1,0.04,39.4668,,0.04,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.03,34,,0.03,percent of total billed charges,"Drugs, Inpatient Only",0.03,34,,0.03,percent of total billed charges,"Drugs, Inpatient Only",0.03,34,,0.03,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.07,70,,0.07,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.08,,,0.08,Other,225% of Medicaid,0.05,,,0.05,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.07,,,0.07,Other,215% Medicaid APG methodology,0.07,,,0.07,Other,215% Medicaid APG methodology,0.04,,,0.04,Other,125% Medicaid APG methodology,0.01,0.08,
VERAPAMIL 120 MG TAB,,,,80002080,CDM,250,RC,23155048601,NDC,both,100,EA,0.08,0.03,39.4668,,0.03,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.03,34,,0.03,percent of total billed charges,"Drugs, Inpatient Only",0.03,34,,0.03,percent of total billed charges,"Drugs, Inpatient Only",0.03,34,,0.03,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.06,70,,0.06,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.06,,,0.06,Other,225% of Medicaid,0.04,,,0.04,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.06,,,0.06,Other,215% Medicaid APG methodology,0.06,,,0.06,Other,215% Medicaid APG methodology,0.03,,,0.03,Other,125% Medicaid APG methodology,0.01,0.06,
VERAPAMIL 180 MG TAB,,,,80002081,CDM,250,RC,68462029301,NDC,both,100,EA,0.21,0.08,39.4668,,0.08,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.07,34,,0.07,percent of total billed charges,"Drugs, Inpatient Only",0.07,34,,0.07,percent of total billed charges,"Drugs, Inpatient Only",0.07,34,,0.07,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.15,70,,0.15,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.07,,,0.07,Other,Drug Cost,0.07,,,0.07,Other,Drug Cost,0.07,,,0.07,Other,Drug Cost,0.07,,,0.07,Other,Drug Cost,0.07,,,0.07,Other,Drug Cost,0.07,,,0.07,Other,Drug Cost,0.16,,,0.16,Other,225% of Medicaid,0.1,,,0.1,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.15,,,0.15,Other,215% Medicaid APG methodology,0.15,,,0.15,Other,215% Medicaid APG methodology,0.09,,,0.09,Other,125% Medicaid APG methodology,0.01,0.16,
VERAPAMIL 2.5MG/ML INJ,,,,80002082,CDM,250,RC,409114405,NDC,both,25,ML,13.31,5.25,39.4668,,5.25,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,4.53,34,,4.53,percent of total billed charges,"Drugs, Inpatient Only",4.53,34,,4.53,percent of total billed charges,"Drugs, Inpatient Only",4.53,34,,4.53,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,9.32,70,,9.32,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,4.44,,,4.44,Other,Drug Cost,4.44,,,4.44,Other,Drug Cost,4.44,,,4.44,Other,Drug Cost,4.44,,,4.44,Other,Drug Cost,4.44,,,4.44,Other,Drug Cost,4.44,,,4.44,Other,Drug Cost,9.98,,,9.98,Other,225% of Medicaid,6.21,,,6.21,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,9.54,,,9.54,Other,215% Medicaid APG methodology,9.54,,,9.54,Other,215% Medicaid APG methodology,5.55,,,5.55,Other,125% Medicaid APG methodology,0.01,9.98,
VERAPAMIL 240 MG TAB,,,,80002083,CDM,250,RC,68462026001,NDC,both,100,EA,0.2,0.08,39.4668,,0.08,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.07,34,,0.07,percent of total billed charges,"Drugs, Inpatient Only",0.07,34,,0.07,percent of total billed charges,"Drugs, Inpatient Only",0.07,34,,0.07,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.14,70,,0.14,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.07,,,0.07,Other,Drug Cost,0.07,,,0.07,Other,Drug Cost,0.07,,,0.07,Other,Drug Cost,0.07,,,0.07,Other,Drug Cost,0.07,,,0.07,Other,Drug Cost,0.07,,,0.07,Other,Drug Cost,0.15,,,0.15,Other,225% of Medicaid,0.09,,,0.09,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.14,,,0.14,Other,215% Medicaid APG methodology,0.14,,,0.14,Other,215% Medicaid APG methodology,0.08,,,0.08,Other,125% Medicaid APG methodology,0.01,0.15,
VERAPAMIL 40 MG TAB,,,,80002084,CDM,250,RC,23155005901,NDC,both,100,EA,0.12,0.05,39.4668,,0.05,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.04,34,,0.04,percent of total billed charges,"Drugs, Inpatient Only",0.04,34,,0.04,percent of total billed charges,"Drugs, Inpatient Only",0.04,34,,0.04,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.09,70,,0.09,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.09,,,0.09,Other,225% of Medicaid,0.06,,,0.06,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.09,,,0.09,Other,215% Medicaid APG methodology,0.09,,,0.09,Other,215% Medicaid APG methodology,0.05,,,0.05,Other,125% Medicaid APG methodology,0.01,0.09,
VIRACEPT,,,,80002091,CDM,250,RC,63010002770,NDC,both,120,EA,16.48,6.5,39.4668,,6.5,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,5.6,34,,5.6,percent of total billed charges,"Drugs, Inpatient Only",5.6,34,,5.6,percent of total billed charges,"Drugs, Inpatient Only",5.6,34,,5.6,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,11.53,70,,11.53,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,5.49,,,5.49,Other,Drug Cost,5.49,,,5.49,Other,Drug Cost,5.49,,,5.49,Other,Drug Cost,5.49,,,5.49,Other,Drug Cost,5.49,,,5.49,Other,Drug Cost,5.49,,,5.49,Other,Drug Cost,12.36,,,12.36,Other,225% of Medicaid,7.69,,,7.69,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,11.81,,,11.81,Other,215% Medicaid APG methodology,11.81,,,11.81,Other,215% Medicaid APG methodology,6.87,,,6.87,Other,125% Medicaid APG methodology,0.01,12.36,
VIRACEPT 250 MG,,,,80002092,CDM,250,RC,63010001030,NDC,both,300,EA,6.59,2.6,39.4668,,2.6,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2.24,34,,2.24,percent of total billed charges,"Drugs, Inpatient Only",2.24,34,,2.24,percent of total billed charges,"Drugs, Inpatient Only",2.24,34,,2.24,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,4.61,70,,4.61,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2.2,,,2.2,Other,Drug Cost,2.2,,,2.2,Other,Drug Cost,2.2,,,2.2,Other,Drug Cost,2.2,,,2.2,Other,Drug Cost,2.2,,,2.2,Other,Drug Cost,2.2,,,2.2,Other,Drug Cost,4.94,,,4.94,Other,225% of Medicaid,3.08,,,3.08,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,4.72,,,4.72,Other,215% Medicaid APG methodology,4.72,,,4.72,Other,215% Medicaid APG methodology,2.75,,,2.75,Other,125% Medicaid APG methodology,0.01,4.94,
VIRAMUNE 200 MG,,,,80002093,CDM,250,RC,31722050560,NDC,both,60,EA,0.22,0.09,39.4668,,0.09,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.08,34,,0.08,percent of total billed charges,"Drugs, Inpatient Only",0.08,34,,0.08,percent of total billed charges,"Drugs, Inpatient Only",0.08,34,,0.08,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.16,70,,0.16,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.07,,,0.07,Other,Drug Cost,0.07,,,0.07,Other,Drug Cost,0.07,,,0.07,Other,Drug Cost,0.07,,,0.07,Other,Drug Cost,0.07,,,0.07,Other,Drug Cost,0.07,,,0.07,Other,Drug Cost,0.17,,,0.17,Other,225% of Medicaid,0.1,,,0.1,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.16,,,0.16,Other,215% Medicaid APG methodology,0.16,,,0.16,Other,215% Medicaid APG methodology,0.09,,,0.09,Other,125% Medicaid APG methodology,0.01,0.17,
VIREAD 300 MG,,,,80002094,CDM,250,RC,61958040101,NDC,both,30,EA,28.46,11.23,39.4668,,11.23,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,9.68,34,,9.68,percent of total billed charges,"Drugs, Inpatient Only",9.68,34,,9.68,percent of total billed charges,"Drugs, Inpatient Only",9.68,34,,9.68,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,19.92,70,,19.92,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,9.49,,,9.49,Other,Drug Cost,9.49,,,9.49,Other,Drug Cost,9.49,,,9.49,Other,Drug Cost,9.49,,,9.49,Other,Drug Cost,9.49,,,9.49,Other,Drug Cost,9.49,,,9.49,Other,Drug Cost,21.35,,,21.35,Other,225% of Medicaid,13.28,,,13.28,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,20.4,,,20.4,Other,215% Medicaid APG methodology,20.4,,,20.4,Other,215% Medicaid APG methodology,11.86,,,11.86,Other,125% Medicaid APG methodology,0.01,21.35,
VITAMIN A & D OINTMENT,,,,80002097,CDM,250,RC,16784011502,NDC,both,144,GM,0.16,0.06,39.4668,,0.06,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.05,34,,0.05,percent of total billed charges,"Drugs, Inpatient Only",0.05,34,,0.05,percent of total billed charges,"Drugs, Inpatient Only",0.05,34,,0.05,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.11,70,,0.11,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.12,,,0.12,Other,225% of Medicaid,0.07,,,0.07,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.11,,,0.11,Other,215% Medicaid APG methodology,0.11,,,0.11,Other,215% Medicaid APG methodology,0.07,,,0.07,Other,125% Medicaid APG methodology,0.01,0.12,
VITAMIN B COMPLEX TAB,,,,80002098,CDM,250,RC,60258016001,NDC,both,100,EA,0.15,0.06,39.4668,,0.06,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.05,34,,0.05,percent of total billed charges,"Drugs, Inpatient Only",0.05,34,,0.05,percent of total billed charges,"Drugs, Inpatient Only",0.05,34,,0.05,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.1,70,,0.1,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.11,,,0.11,Other,225% of Medicaid,0.07,,,0.07,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.11,,,0.11,Other,215% Medicaid APG methodology,0.11,,,0.11,Other,215% Medicaid APG methodology,0.06,,,0.06,Other,125% Medicaid APG methodology,0.01,0.11,
VITAMIN C 500 MG TAB,,,,80002103,CDM,250,RC,904052360,NDC,both,100,EA,0.04,0.01,39.4668,,0.01,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.03,70,,0.03,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.03,,,0.03,Other,225% of Medicaid,0.02,,,0.02,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.03,,,0.03,Other,215% Medicaid APG methodology,0.03,,,0.03,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,125% Medicaid APG methodology,0.01,0.03,
VITAMIN D 1000 UNIT CAP,,,,80002105,CDM,250,RC,96295012848,NDC,both,200,EA,0.06,0.02,39.4668,,0.02,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.02,34,,0.02,percent of total billed charges,"Drugs, Inpatient Only",0.02,34,,0.02,percent of total billed charges,"Drugs, Inpatient Only",0.02,34,,0.02,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.04,70,,0.04,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.04,,,0.04,Other,225% of Medicaid,0.03,,,0.03,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.04,,,0.04,Other,215% Medicaid APG methodology,0.04,,,0.04,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,125% Medicaid APG methodology,0.01,0.04,
VITAMIN E 400 UNIT CAP,,,,80002107,CDM,250,RC,40985021245,NDC,both,110,EA,0.15,0.06,39.4668,,0.06,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.05,34,,0.05,percent of total billed charges,"Drugs, Inpatient Only",0.05,34,,0.05,percent of total billed charges,"Drugs, Inpatient Only",0.05,34,,0.05,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.1,70,,0.1,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.11,,,0.11,Other,225% of Medicaid,0.07,,,0.07,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.11,,,0.11,Other,215% Medicaid APG methodology,0.11,,,0.11,Other,215% Medicaid APG methodology,0.06,,,0.06,Other,125% Medicaid APG methodology,0.01,0.11,
VOLTAREN 2.5ML OPHTH,,,,80002109,CDM,250,RC,61314001425,NDC,both,1,ML,2.31,0.91,39.4668,,0.91,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.79,34,,0.79,percent of total billed charges,"Drugs, Inpatient Only",0.79,34,,0.79,percent of total billed charges,"Drugs, Inpatient Only",0.79,34,,0.79,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1.62,70,,1.62,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.77,,,0.77,Other,Drug Cost,0.77,,,0.77,Other,Drug Cost,0.77,,,0.77,Other,Drug Cost,0.77,,,0.77,Other,Drug Cost,0.77,,,0.77,Other,Drug Cost,0.77,,,0.77,Other,Drug Cost,1.73,,,1.73,Other,225% of Medicaid,1.08,,,1.08,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,1.66,,,1.66,Other,215% Medicaid APG methodology,1.66,,,1.66,Other,215% Medicaid APG methodology,0.96,,,0.96,Other,125% Medicaid APG methodology,0.01,1.73,
VORICONZAZOLE 200 MG TAB,,,,80002110,CDM,250,RC,68462057330,NDC,both,30,EA,0.64,0.25,39.4668,,0.25,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.22,34,,0.22,percent of total billed charges,"Drugs, Inpatient Only",0.22,34,,0.22,percent of total billed charges,"Drugs, Inpatient Only",0.22,34,,0.22,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.45,70,,0.45,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.21,,,0.21,Other,Drug Cost,0.21,,,0.21,Other,Drug Cost,0.21,,,0.21,Other,Drug Cost,0.21,,,0.21,Other,Drug Cost,0.21,,,0.21,Other,Drug Cost,0.21,,,0.21,Other,Drug Cost,0.48,,,0.48,Other,225% of Medicaid,0.3,,,0.3,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.46,,,0.46,Other,215% Medicaid APG methodology,0.46,,,0.46,Other,215% Medicaid APG methodology,0.27,,,0.27,Other,125% Medicaid APG methodology,0.01,0.48,
VORICONZAZOLE 50MG INJ,,,,80002111,CDM,250,RC,49317030,NDC,both,30,EA,3.11,1.23,39.4668,,1.23,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1.06,34,,1.06,percent of total billed charges,"Drugs, Inpatient Only",1.06,34,,1.06,percent of total billed charges,"Drugs, Inpatient Only",1.06,34,,1.06,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2.18,70,,2.18,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1.04,,,1.04,Other,Drug Cost,1.04,,,1.04,Other,Drug Cost,1.04,,,1.04,Other,Drug Cost,1.04,,,1.04,Other,Drug Cost,1.04,,,1.04,Other,Drug Cost,1.04,,,1.04,Other,Drug Cost,2.33,,,2.33,Other,225% of Medicaid,1.45,,,1.45,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,2.23,,,2.23,Other,215% Medicaid APG methodology,2.23,,,2.23,Other,215% Medicaid APG methodology,1.3,,,1.3,Other,125% Medicaid APG methodology,0.01,2.33,
WARFARIN SODIUM (COUMADIN) 1MG,,,,80002112,CDM,250,RC,93171201,NDC,both,100,EA,0.08,0.03,39.4668,,0.03,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.03,34,,0.03,percent of total billed charges,"Drugs, Inpatient Only",0.03,34,,0.03,percent of total billed charges,"Drugs, Inpatient Only",0.03,34,,0.03,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.05,70,,0.05,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.06,,,0.06,Other,225% of Medicaid,0.04,,,0.04,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.05,,,0.05,Other,215% Medicaid APG methodology,0.05,,,0.05,Other,215% Medicaid APG methodology,0.03,,,0.03,Other,125% Medicaid APG methodology,0.01,0.06,
WARFARIN SODIUM (COUMADIN) 2.5MG,,,,80002113,CDM,250,RC,65162076310,NDC,both,100,EA,0.03,0.01,39.4668,,0.01,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.02,70,,0.02,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.02,,,0.02,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,0.02,
WARFARIN SODIUM (COUMADIN) 2MG,,,,80002114,CDM,250,RC,832121201,NDC,both,10,EA,1.87,0.74,39.4668,,0.74,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.63,34,,0.63,percent of total billed charges,"Drugs, Inpatient Only",0.63,34,,0.63,percent of total billed charges,"Drugs, Inpatient Only",0.63,34,,0.63,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1.31,70,,1.31,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.62,,,0.62,Other,Drug Cost,0.62,,,0.62,Other,Drug Cost,0.62,,,0.62,Other,Drug Cost,0.62,,,0.62,Other,Drug Cost,0.62,,,0.62,Other,Drug Cost,0.62,,,0.62,Other,Drug Cost,1.4,,,1.4,Other,225% of Medicaid,0.87,,,0.87,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,1.34,,,1.34,Other,215% Medicaid APG methodology,1.34,,,1.34,Other,215% Medicaid APG methodology,0.78,,,0.78,Other,125% Medicaid APG methodology,0.01,1.4,
WARFARIN SODIUM (COUMADIN) 3MG,,,,80002115,CDM,250,RC,832121401,NDC,both,10,EA,2.08,0.82,39.4668,,0.82,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.71,34,,0.71,percent of total billed charges,"Drugs, Inpatient Only",0.71,34,,0.71,percent of total billed charges,"Drugs, Inpatient Only",0.71,34,,0.71,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1.46,70,,1.46,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.69,,,0.69,Other,Drug Cost,0.69,,,0.69,Other,Drug Cost,0.69,,,0.69,Other,Drug Cost,0.69,,,0.69,Other,Drug Cost,0.69,,,0.69,Other,Drug Cost,0.69,,,0.69,Other,Drug Cost,1.56,,,1.56,Other,225% of Medicaid,0.97,,,0.97,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,1.49,,,1.49,Other,215% Medicaid APG methodology,1.49,,,1.49,Other,215% Medicaid APG methodology,0.87,,,0.87,Other,125% Medicaid APG methodology,0.01,1.56,
WARFARIN SODIUM (COUMADIN) 5MG,,,,80002116,CDM,250,RC,832121600,NDC,both,100,EA,0.17,0.07,39.4668,,0.07,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.06,34,,0.06,percent of total billed charges,"Drugs, Inpatient Only",0.06,34,,0.06,percent of total billed charges,"Drugs, Inpatient Only",0.06,34,,0.06,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.12,70,,0.12,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.06,,,0.06,Other,Drug Cost,0.06,,,0.06,Other,Drug Cost,0.06,,,0.06,Other,Drug Cost,0.06,,,0.06,Other,Drug Cost,0.06,,,0.06,Other,Drug Cost,0.06,,,0.06,Other,Drug Cost,0.13,,,0.13,Other,225% of Medicaid,0.08,,,0.08,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.12,,,0.12,Other,215% Medicaid APG methodology,0.12,,,0.12,Other,215% Medicaid APG methodology,0.07,,,0.07,Other,125% Medicaid APG methodology,0.01,0.13,
ZETIA 10 MG,,,,80002122,CDM,250,RC,67877049030,NDC,both,30,EA,0.1,0.04,39.4668,,0.04,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.03,34,,0.03,percent of total billed charges,"Drugs, Inpatient Only",0.03,34,,0.03,percent of total billed charges,"Drugs, Inpatient Only",0.03,34,,0.03,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.07,70,,0.07,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.07,,,0.07,Other,225% of Medicaid,0.05,,,0.05,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.07,,,0.07,Other,215% Medicaid APG methodology,0.07,,,0.07,Other,215% Medicaid APG methodology,0.04,,,0.04,Other,125% Medicaid APG methodology,0.01,0.07,
ZIDORUDINE 100 MG CAPSULE,,,,80002124,CDM,250,RC,65862010701,NDC,both,100,EA,1.61,0.64,39.4668,,0.64,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.55,34,,0.55,percent of total billed charges,"Drugs, Inpatient Only",0.55,34,,0.55,percent of total billed charges,"Drugs, Inpatient Only",0.55,34,,0.55,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1.13,70,,1.13,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.54,,,0.54,Other,Drug Cost,0.54,,,0.54,Other,Drug Cost,0.54,,,0.54,Other,Drug Cost,0.54,,,0.54,Other,Drug Cost,0.54,,,0.54,Other,Drug Cost,0.54,,,0.54,Other,Drug Cost,1.21,,,1.21,Other,225% of Medicaid,0.75,,,0.75,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,1.15,,,1.15,Other,215% Medicaid APG methodology,1.15,,,1.15,Other,215% Medicaid APG methodology,0.67,,,0.67,Other,125% Medicaid APG methodology,0.01,1.21,
ZIDOVUDINE 300MG TAB,,,,80002127,CDM,250,RC,31722050960,NDC,both,60,EA,0.54,0.21,39.4668,,0.21,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.18,34,,0.18,percent of total billed charges,"Drugs, Inpatient Only",0.18,34,,0.18,percent of total billed charges,"Drugs, Inpatient Only",0.18,34,,0.18,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.38,70,,0.38,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.18,,,0.18,Other,Drug Cost,0.18,,,0.18,Other,Drug Cost,0.18,,,0.18,Other,Drug Cost,0.18,,,0.18,Other,Drug Cost,0.18,,,0.18,Other,Drug Cost,0.18,,,0.18,Other,Drug Cost,0.41,,,0.41,Other,225% of Medicaid,0.25,,,0.25,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.39,,,0.39,Other,215% Medicaid APG methodology,0.39,,,0.39,Other,215% Medicaid APG methodology,0.23,,,0.23,Other,125% Medicaid APG methodology,0.01,0.41,
ZINC 220MG CAP,,,,80002128,CDM,250,RC,20555004000,NDC,both,10,EA,3.92,1.55,39.4668,,1.55,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1.33,34,,1.33,percent of total billed charges,"Drugs, Inpatient Only",1.33,34,,1.33,percent of total billed charges,"Drugs, Inpatient Only",1.33,34,,1.33,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2.75,70,,2.75,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1.31,,,1.31,Other,Drug Cost,1.31,,,1.31,Other,Drug Cost,1.31,,,1.31,Other,Drug Cost,1.31,,,1.31,Other,Drug Cost,1.31,,,1.31,Other,Drug Cost,1.31,,,1.31,Other,Drug Cost,2.94,,,2.94,Other,225% of Medicaid,1.83,,,1.83,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,2.81,,,2.81,Other,215% Medicaid APG methodology,2.81,,,2.81,Other,215% Medicaid APG methodology,1.64,,,1.64,Other,125% Medicaid APG methodology,0.01,2.94,
ZINC GLUCONATE 50 MG TAB,,,,80002129,CDM,250,RC,30768000691,NDC,both,100,EA,0.12,0.05,39.4668,,0.05,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.04,34,,0.04,percent of total billed charges,"Drugs, Inpatient Only",0.04,34,,0.04,percent of total billed charges,"Drugs, Inpatient Only",0.04,34,,0.04,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.08,70,,0.08,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.09,,,0.09,Other,225% of Medicaid,0.06,,,0.06,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.09,,,0.09,Other,215% Medicaid APG methodology,0.09,,,0.09,Other,215% Medicaid APG methodology,0.05,,,0.05,Other,125% Medicaid APG methodology,0.01,0.09,
ZINC OXIDE (DESITIN) 113 GM,,,,80002130,CDM,250,RC,74300000300,NDC,both,1,GM,13.05,5.15,39.4668,,5.15,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,4.44,34,,4.44,percent of total billed charges,"Drugs, Inpatient Only",4.44,34,,4.44,percent of total billed charges,"Drugs, Inpatient Only",4.44,34,,4.44,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,9.14,70,,9.14,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,4.35,,,4.35,Other,Drug Cost,4.35,,,4.35,Other,Drug Cost,4.35,,,4.35,Other,Drug Cost,4.35,,,4.35,Other,Drug Cost,4.35,,,4.35,Other,Drug Cost,4.35,,,4.35,Other,Drug Cost,9.79,,,9.79,Other,225% of Medicaid,6.09,,,6.09,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,9.35,,,9.35,Other,215% Medicaid APG methodology,9.35,,,9.35,Other,215% Medicaid APG methodology,5.44,,,5.44,Other,125% Medicaid APG methodology,0.01,9.79,
ZINC OXIDE 30 GM OINT,,,,80002131,CDM,250,RC,75834017001,NDC,both,1,GM,2.73,1.08,39.4668,,1.08,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.93,34,,0.93,percent of total billed charges,"Drugs, Inpatient Only",0.93,34,,0.93,percent of total billed charges,"Drugs, Inpatient Only",0.93,34,,0.93,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1.91,70,,1.91,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.91,,,0.91,Other,Drug Cost,0.91,,,0.91,Other,Drug Cost,0.91,,,0.91,Other,Drug Cost,0.91,,,0.91,Other,Drug Cost,0.91,,,0.91,Other,Drug Cost,0.91,,,0.91,Other,Drug Cost,2.05,,,2.05,Other,225% of Medicaid,1.27,,,1.27,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,1.96,,,1.96,Other,215% Medicaid APG methodology,1.96,,,1.96,Other,215% Medicaid APG methodology,1.14,,,1.14,Other,125% Medicaid APG methodology,0.01,2.05,
ZIPRASIDONE HCL (GEODON) 20MG CAPS,,,,80002134,CDM,250,RC,55111025660,NDC,both,60,EA,0.14,0.06,39.4668,,0.06,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.05,34,,0.05,percent of total billed charges,"Drugs, Inpatient Only",0.05,34,,0.05,percent of total billed charges,"Drugs, Inpatient Only",0.05,34,,0.05,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.1,70,,0.1,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.11,,,0.11,Other,225% of Medicaid,0.07,,,0.07,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.1,,,0.1,Other,215% Medicaid APG methodology,0.1,,,0.1,Other,215% Medicaid APG methodology,0.06,,,0.06,Other,125% Medicaid APG methodology,0.01,0.11,
ZIPRASIDONE HCL (GEODON) 60MG CAPS,,,,80002135,CDM,250,RC,55111025860,NDC,both,60,EA,0.25,0.1,39.4668,,0.1,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.08,34,,0.08,percent of total billed charges,"Drugs, Inpatient Only",0.08,34,,0.08,percent of total billed charges,"Drugs, Inpatient Only",0.08,34,,0.08,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.17,70,,0.17,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.08,,,0.08,Other,Drug Cost,0.08,,,0.08,Other,Drug Cost,0.08,,,0.08,Other,Drug Cost,0.08,,,0.08,Other,Drug Cost,0.08,,,0.08,Other,Drug Cost,0.08,,,0.08,Other,Drug Cost,0.19,,,0.19,Other,225% of Medicaid,0.12,,,0.12,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.18,,,0.18,Other,215% Medicaid APG methodology,0.18,,,0.18,Other,215% Medicaid APG methodology,0.1,,,0.1,Other,125% Medicaid APG methodology,0.01,0.19,
ZIPRASIDONE HCL (GEODON) 80MG CAPS,,,,80002136,CDM,250,RC,55111025960,NDC,both,60,EA,0.23,0.09,39.4668,,0.09,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.08,34,,0.08,percent of total billed charges,"Drugs, Inpatient Only",0.08,34,,0.08,percent of total billed charges,"Drugs, Inpatient Only",0.08,34,,0.08,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.16,70,,0.16,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.08,,,0.08,Other,Drug Cost,0.08,,,0.08,Other,Drug Cost,0.08,,,0.08,Other,Drug Cost,0.08,,,0.08,Other,Drug Cost,0.08,,,0.08,Other,Drug Cost,0.08,,,0.08,Other,Drug Cost,0.18,,,0.18,Other,225% of Medicaid,0.11,,,0.11,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.17,,,0.17,Other,215% Medicaid APG methodology,0.17,,,0.17,Other,215% Medicaid APG methodology,0.1,,,0.1,Other,125% Medicaid APG methodology,0.01,0.18,
ZOCOR 10 MG,,,,80002138,CDM,250,RC,63739057110,NDC,both,10,EA,2.86,1.13,39.4668,,1.13,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.97,34,,0.97,percent of total billed charges,"Drugs, Inpatient Only",0.97,34,,0.97,percent of total billed charges,"Drugs, Inpatient Only",0.97,34,,0.97,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2,70,,2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.95,,,0.95,Other,Drug Cost,0.95,,,0.95,Other,Drug Cost,0.95,,,0.95,Other,Drug Cost,0.95,,,0.95,Other,Drug Cost,0.95,,,0.95,Other,Drug Cost,0.95,,,0.95,Other,Drug Cost,2.14,,,2.14,Other,225% of Medicaid,1.33,,,1.33,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,2.05,,,2.05,Other,215% Medicaid APG methodology,2.05,,,2.05,Other,215% Medicaid APG methodology,1.19,,,1.19,Other,125% Medicaid APG methodology,0.01,2.14,
ZOLPIDEM TATRATE (AMBIEN) 5MG,,,,80002143,CDM,250,RC,13668000701,NDC,both,100,EA,0.03,0.01,39.4668,,0.01,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.02,70,,0.02,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.02,,,0.02,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,0.02,
ZONISAMIDE 100 MG CAP,,,,80002144,CDM,250,RC,69097086107,NDC,both,100,EA,0.13,0.05,39.4668,,0.05,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.04,34,,0.04,percent of total billed charges,"Drugs, Inpatient Only",0.04,34,,0.04,percent of total billed charges,"Drugs, Inpatient Only",0.04,34,,0.04,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.09,70,,0.09,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.09,,,0.09,Other,225% of Medicaid,0.06,,,0.06,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.09,,,0.09,Other,215% Medicaid APG methodology,0.09,,,0.09,Other,215% Medicaid APG methodology,0.05,,,0.05,Other,125% Medicaid APG methodology,0.01,0.09,
ZONISAMIDE 25MG CAP,,,,80002145,CDM,250,RC,59651037801,NDC,both,100,EA,0.06,0.02,39.4668,,0.02,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.02,34,,0.02,percent of total billed charges,"Drugs, Inpatient Only",0.02,34,,0.02,percent of total billed charges,"Drugs, Inpatient Only",0.02,34,,0.02,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.04,70,,0.04,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.04,,,0.04,Other,225% of Medicaid,0.03,,,0.03,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.04,,,0.04,Other,215% Medicaid APG methodology,0.04,,,0.04,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,125% Medicaid APG methodology,0.01,0.04,
ZYRTEC 10MG,,,,80002147,CDM,250,RC,378363701,NDC,both,100,EA,0.12,0.05,39.4668,,0.05,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.04,34,,0.04,percent of total billed charges,"Drugs, Inpatient Only",0.04,34,,0.04,percent of total billed charges,"Drugs, Inpatient Only",0.04,34,,0.04,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.08,70,,0.08,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.09,,,0.09,Other,225% of Medicaid,0.05,,,0.05,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.08,,,0.08,Other,215% Medicaid APG methodology,0.08,,,0.08,Other,215% Medicaid APG methodology,0.05,,,0.05,Other,125% Medicaid APG methodology,0.01,0.09,
OXYBUTYNIN ER 10MG TAB,,,,80002149,CDM,250,RC,50268062815,NDC,both,5,EA,57.01,22.5,39.4668,,22.5,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,19.38,34,,19.38,percent of total billed charges,"Drugs, Inpatient Only",19.38,34,,19.38,percent of total billed charges,"Drugs, Inpatient Only",19.38,34,,19.38,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,39.9,70,,39.9,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,19,,,19,Other,Drug Cost,19,,,19,Other,Drug Cost,19,,,19,Other,Drug Cost,19,,,19,Other,Drug Cost,19,,,19,Other,Drug Cost,19,,,19,Other,Drug Cost,42.75,,,42.75,Other,225% of Medicaid,26.6,,,26.6,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,40.85,,,40.85,Other,215% Medicaid APG methodology,40.85,,,40.85,Other,215% Medicaid APG methodology,23.75,,,23.75,Other,125% Medicaid APG methodology,0.01,42.75,
ASPIRIN 81MG CHEWABLE TABLET,,,,80002151,CDM,250,RC,904679480,NDC,both,1000,EA,0.02,0.01,39.4668,,0.01,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.02,70,,0.02,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.02,,,0.02,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,0.02,
BUMETANIDE 0.5MG TABLETS,,,,80002154,CDM,250,RC,185012801,NDC,both,100,EA,0.11,0.04,39.4668,,0.04,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.04,34,,0.04,percent of total billed charges,"Drugs, Inpatient Only",0.04,34,,0.04,percent of total billed charges,"Drugs, Inpatient Only",0.04,34,,0.04,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.07,70,,0.07,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.08,,,0.08,Other,225% of Medicaid,0.05,,,0.05,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.08,,,0.08,Other,215% Medicaid APG methodology,0.08,,,0.08,Other,215% Medicaid APG methodology,0.04,,,0.04,Other,125% Medicaid APG methodology,0.01,0.08,
CEFDINIR 300MG CAPS,,,,80002156,CDM,250,RC,57237009960,NDC,both,60,EA,0.65,0.26,39.4668,,0.26,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.22,34,,0.22,percent of total billed charges,"Drugs, Inpatient Only",0.22,34,,0.22,percent of total billed charges,"Drugs, Inpatient Only",0.22,34,,0.22,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.46,70,,0.46,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.22,,,0.22,Other,Drug Cost,0.22,,,0.22,Other,Drug Cost,0.22,,,0.22,Other,Drug Cost,0.22,,,0.22,Other,Drug Cost,0.22,,,0.22,Other,Drug Cost,0.22,,,0.22,Other,Drug Cost,0.49,,,0.49,Other,225% of Medicaid,0.3,,,0.3,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.47,,,0.47,Other,215% Medicaid APG methodology,0.47,,,0.47,Other,215% Medicaid APG methodology,0.27,,,0.27,Other,125% Medicaid APG methodology,0.01,0.49,
CEFDINIR 125MG/5ML 60ML,,,,80002163,CDM,250,RC,67877054798,NDC,both,1,ML,7.11,2.81,39.4668,,2.81,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2.42,34,,2.42,percent of total billed charges,"Drugs, Inpatient Only",2.42,34,,2.42,percent of total billed charges,"Drugs, Inpatient Only",2.42,34,,2.42,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,4.98,70,,4.98,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2.37,,,2.37,Other,Drug Cost,2.37,,,2.37,Other,Drug Cost,2.37,,,2.37,Other,Drug Cost,2.37,,,2.37,Other,Drug Cost,2.37,,,2.37,Other,Drug Cost,2.37,,,2.37,Other,Drug Cost,5.33,,,5.33,Other,225% of Medicaid,3.32,,,3.32,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,5.1,,,5.1,Other,215% Medicaid APG methodology,5.1,,,5.1,Other,215% Medicaid APG methodology,2.96,,,2.96,Other,125% Medicaid APG methodology,0.01,5.33,
BUSPIRONE 10MG TABLET,,,,80002166,CDM,250,RC,93005401,NDC,both,100,EA,0.03,0.01,39.4668,,0.01,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.02,70,,0.02,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.02,,,0.02,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,0.02,
NEO/POLY B/HYDR OTIC SUSP,,,,80002179,CDM,250,RC,61314064511,NDC,both,1,ML,35.85,14.15,39.4668,,14.15,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,12.19,34,,12.19,percent of total billed charges,"Drugs, Inpatient Only",12.19,34,,12.19,percent of total billed charges,"Drugs, Inpatient Only",12.19,34,,12.19,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,25.1,70,,25.1,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,11.95,,,11.95,Other,Drug Cost,11.95,,,11.95,Other,Drug Cost,11.95,,,11.95,Other,Drug Cost,11.95,,,11.95,Other,Drug Cost,11.95,,,11.95,Other,Drug Cost,11.95,,,11.95,Other,Drug Cost,26.89,,,26.89,Other,225% of Medicaid,16.73,,,16.73,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,25.69,,,25.69,Other,215% Medicaid APG methodology,25.69,,,25.69,Other,215% Medicaid APG methodology,14.94,,,14.94,Other,125% Medicaid APG methodology,0.01,26.89,
PROCHLORPERAZINE 10MG TABLET,,,,80002183,CDM,250,RC,59746011506,NDC,both,100,EA,0.15,0.06,39.4668,,0.06,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.05,34,,0.05,percent of total billed charges,"Drugs, Inpatient Only",0.05,34,,0.05,percent of total billed charges,"Drugs, Inpatient Only",0.05,34,,0.05,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.1,70,,0.1,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.11,,,0.11,Other,225% of Medicaid,0.07,,,0.07,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.11,,,0.11,Other,215% Medicaid APG methodology,0.11,,,0.11,Other,215% Medicaid APG methodology,0.06,,,0.06,Other,125% Medicaid APG methodology,0.01,0.11,
PROCHLORPERAZINE 5MG TABLET,,,,80002184,CDM,250,RC,59746011306,NDC,both,100,EA,0.14,0.05,39.4668,,0.05,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.05,34,,0.05,percent of total billed charges,"Drugs, Inpatient Only",0.05,34,,0.05,percent of total billed charges,"Drugs, Inpatient Only",0.05,34,,0.05,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.1,70,,0.1,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.1,,,0.1,Other,225% of Medicaid,0.06,,,0.06,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.1,,,0.1,Other,215% Medicaid APG methodology,0.1,,,0.1,Other,215% Medicaid APG methodology,0.06,,,0.06,Other,125% Medicaid APG methodology,0.01,0.1,
OLANZAPINE 5MG ODT,,,,80002185,CDM,250,RC,60505327503,NDC,both,30,EA,0.19,0.07,39.4668,,0.07,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.06,34,,0.06,percent of total billed charges,"Drugs, Inpatient Only",0.06,34,,0.06,percent of total billed charges,"Drugs, Inpatient Only",0.06,34,,0.06,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.13,70,,0.13,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.06,,,0.06,Other,Drug Cost,0.06,,,0.06,Other,Drug Cost,0.06,,,0.06,Other,Drug Cost,0.06,,,0.06,Other,Drug Cost,0.06,,,0.06,Other,Drug Cost,0.06,,,0.06,Other,Drug Cost,0.14,,,0.14,Other,225% of Medicaid,0.09,,,0.09,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.14,,,0.14,Other,215% Medicaid APG methodology,0.14,,,0.14,Other,215% Medicaid APG methodology,0.08,,,0.08,Other,125% Medicaid APG methodology,0.01,0.14,
VALPROIC ACID 250MG CAPS,,,,80002188,CDM,250,RC,69452015020,NDC,both,100,EA,0.24,0.09,39.4668,,0.09,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.08,34,,0.08,percent of total billed charges,"Drugs, Inpatient Only",0.08,34,,0.08,percent of total billed charges,"Drugs, Inpatient Only",0.08,34,,0.08,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.17,70,,0.17,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.08,,,0.08,Other,Drug Cost,0.08,,,0.08,Other,Drug Cost,0.08,,,0.08,Other,Drug Cost,0.08,,,0.08,Other,Drug Cost,0.08,,,0.08,Other,Drug Cost,0.08,,,0.08,Other,Drug Cost,0.18,,,0.18,Other,225% of Medicaid,0.11,,,0.11,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.17,,,0.17,Other,215% Medicaid APG methodology,0.17,,,0.17,Other,215% Medicaid APG methodology,0.1,,,0.1,Other,125% Medicaid APG methodology,0.01,0.18,
FONDAPARINUX 10MG/0.8ML INJ,,,,80002191,CDM,250,RC,67457058508,NDC,both,10,ML,23.04,9.09,39.4668,,9.09,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,7.83,34,,7.83,percent of total billed charges,"Drugs, Inpatient Only",7.83,34,,7.83,percent of total billed charges,"Drugs, Inpatient Only",7.83,34,,7.83,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,16.13,70,,16.13,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,7.68,,,7.68,Other,Drug Cost,7.68,,,7.68,Other,Drug Cost,7.68,,,7.68,Other,Drug Cost,7.68,,,7.68,Other,Drug Cost,7.68,,,7.68,Other,Drug Cost,7.68,,,7.68,Other,Drug Cost,17.28,,,17.28,Other,225% of Medicaid,10.75,,,10.75,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,16.51,,,16.51,Other,215% Medicaid APG methodology,16.51,,,16.51,Other,215% Medicaid APG methodology,9.6,,,9.6,Other,125% Medicaid APG methodology,0.01,17.28,
FLUPHENAZINE DECANOATE 25MG/ML 5ML INJ,,,,80002192,CDM,250,RC,143952901,NDC,both,1,ML,101.22,39.95,39.4668,,39.95,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,34.41,34,,34.41,percent of total billed charges,"Drugs, Inpatient Only",34.41,34,,34.41,percent of total billed charges,"Drugs, Inpatient Only",34.41,34,,34.41,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,70.85,70,,70.85,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,33.74,,,33.74,Other,Drug Cost,33.74,,,33.74,Other,Drug Cost,33.74,,,33.74,Other,Drug Cost,33.74,,,33.74,Other,Drug Cost,33.74,,,33.74,Other,Drug Cost,33.74,,,33.74,Other,Drug Cost,75.92,,,75.92,Other,225% of Medicaid,47.24,,,47.24,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,72.54,,,72.54,Other,215% Medicaid APG methodology,72.54,,,72.54,Other,215% Medicaid APG methodology,42.18,,,42.18,Other,125% Medicaid APG methodology,0.01,75.92,
DEXMEDETOMIDINE 200MCG/2ML INJ,,,,80002193,CDM,250,RC,409163802,NDC,both,25,ML,0.83,0.33,39.4668,,0.33,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.28,34,,0.28,percent of total billed charges,"Drugs, Inpatient Only",0.28,34,,0.28,percent of total billed charges,"Drugs, Inpatient Only",0.28,34,,0.28,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.58,70,,0.58,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.28,,,0.28,Other,Drug Cost,0.28,,,0.28,Other,Drug Cost,0.28,,,0.28,Other,Drug Cost,0.28,,,0.28,Other,Drug Cost,0.28,,,0.28,Other,Drug Cost,0.28,,,0.28,Other,Drug Cost,0.62,,,0.62,Other,225% of Medicaid,0.39,,,0.39,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.59,,,0.59,Other,215% Medicaid APG methodology,0.59,,,0.59,Other,215% Medicaid APG methodology,0.35,,,0.35,Other,125% Medicaid APG methodology,0.01,0.62,
LIDOCAINE 2% W/EPI 30ML INJ,,,,80002197,CDM,250,RC,409318202,NDC,both,25,ML,8.4,3.31,39.4668,,3.31,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2.86,34,,2.86,percent of total billed charges,"Drugs, Inpatient Only",2.86,34,,2.86,percent of total billed charges,"Drugs, Inpatient Only",2.86,34,,2.86,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,5.88,70,,5.88,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2.8,,,2.8,Other,Drug Cost,2.8,,,2.8,Other,Drug Cost,2.8,,,2.8,Other,Drug Cost,2.8,,,2.8,Other,Drug Cost,2.8,,,2.8,Other,Drug Cost,2.8,,,2.8,Other,Drug Cost,6.3,,,6.3,Other,225% of Medicaid,3.92,,,3.92,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,6.02,,,6.02,Other,215% Medicaid APG methodology,6.02,,,6.02,Other,215% Medicaid APG methodology,3.5,,,3.5,Other,125% Medicaid APG methodology,0.01,6.3,
LIDOCAINE-MPF 2% W/EPI 10ML INJ,,,,80002198,CDM,250,RC,63323048917,NDC,both,25,ML,6.71,2.65,39.4668,,2.65,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2.28,34,,2.28,percent of total billed charges,"Drugs, Inpatient Only",2.28,34,,2.28,percent of total billed charges,"Drugs, Inpatient Only",2.28,34,,2.28,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,4.7,70,,4.7,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2.24,,,2.24,Other,Drug Cost,2.24,,,2.24,Other,Drug Cost,2.24,,,2.24,Other,Drug Cost,2.24,,,2.24,Other,Drug Cost,2.24,,,2.24,Other,Drug Cost,2.24,,,2.24,Other,Drug Cost,5.03,,,5.03,Other,225% of Medicaid,3.13,,,3.13,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,4.81,,,4.81,Other,215% Medicaid APG methodology,4.81,,,4.81,Other,215% Medicaid APG methodology,2.8,,,2.8,Other,125% Medicaid APG methodology,0.01,5.03,
DILTIAZEM 60MG TABLET,,,,80002202,CDM,250,RC,93031901,NDC,both,100,EA,0.08,0.03,39.4668,,0.03,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.03,34,,0.03,percent of total billed charges,"Drugs, Inpatient Only",0.03,34,,0.03,percent of total billed charges,"Drugs, Inpatient Only",0.03,34,,0.03,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.06,70,,0.06,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.06,,,0.06,Other,225% of Medicaid,0.04,,,0.04,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.06,,,0.06,Other,215% Medicaid APG methodology,0.06,,,0.06,Other,215% Medicaid APG methodology,0.04,,,0.04,Other,125% Medicaid APG methodology,0.01,0.06,
LEVOTHYROXINE 100MCG/VIAL,,,,80002204,CDM,250,RC,42023020101,NDC,both,1,EA,86.49,34.13,39.4668,,34.13,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,29.41,34,,29.41,percent of total billed charges,"Drugs, Inpatient Only",29.41,34,,29.41,percent of total billed charges,"Drugs, Inpatient Only",29.41,34,,29.41,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,60.54,70,,60.54,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,28.83,,,28.83,Other,Drug Cost,28.83,,,28.83,Other,Drug Cost,28.83,,,28.83,Other,Drug Cost,28.83,,,28.83,Other,Drug Cost,28.83,,,28.83,Other,Drug Cost,28.83,,,28.83,Other,Drug Cost,64.87,,,64.87,Other,225% of Medicaid,40.36,,,40.36,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,61.98,,,61.98,Other,215% Medicaid APG methodology,61.98,,,61.98,Other,215% Medicaid APG methodology,36.04,,,36.04,Other,125% Medicaid APG methodology,0.01,64.87,
HEPARIN 1000 UNIT/ML 30 ML VIAL,,,,80002205,CDM,250,RC,71288040231,NDC,both,25,ML,8.89,3.51,39.4668,,3.51,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,3.02,34,,3.02,percent of total billed charges,"Drugs, Inpatient Only",3.02,34,,3.02,percent of total billed charges,"Drugs, Inpatient Only",3.02,34,,3.02,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,6.22,70,,6.22,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2.96,,,2.96,Other,Drug Cost,2.96,,,2.96,Other,Drug Cost,2.96,,,2.96,Other,Drug Cost,2.96,,,2.96,Other,Drug Cost,2.96,,,2.96,Other,Drug Cost,2.96,,,2.96,Other,Drug Cost,6.67,,,6.67,Other,225% of Medicaid,4.15,,,4.15,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,6.37,,,6.37,Other,215% Medicaid APG methodology,6.37,,,6.37,Other,215% Medicaid APG methodology,3.7,,,3.7,Other,125% Medicaid APG methodology,0.01,6.67,
LIDOCAINE 2% 10ML W/ PRESERVATIVES,,,,80002210,CDM,250,RC,55150025410,NDC,both,25,ML,1.23,0.49,39.4668,,0.49,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.42,34,,0.42,percent of total billed charges,"Drugs, Inpatient Only",0.42,34,,0.42,percent of total billed charges,"Drugs, Inpatient Only",0.42,34,,0.42,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.86,70,,0.86,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.41,,,0.41,Other,Drug Cost,0.41,,,0.41,Other,Drug Cost,0.41,,,0.41,Other,Drug Cost,0.41,,,0.41,Other,Drug Cost,0.41,,,0.41,Other,Drug Cost,0.41,,,0.41,Other,Drug Cost,0.92,,,0.92,Other,225% of Medicaid,0.57,,,0.57,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.88,,,0.88,Other,215% Medicaid APG methodology,0.88,,,0.88,Other,215% Medicaid APG methodology,0.51,,,0.51,Other,125% Medicaid APG methodology,0.01,0.92,
METOPROLOL TARTRATE 100MG TABLET,,,,80002212,CDM,250,RC,378004701,NDC,both,100,EA,0.04,0.02,39.4668,,0.02,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.03,70,,0.03,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.03,,,0.03,Other,225% of Medicaid,0.02,,,0.02,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.03,,,0.03,Other,215% Medicaid APG methodology,0.03,,,0.03,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,125% Medicaid APG methodology,0.01,0.03,
METOPROLOL SUCCINATE 100MG TB24 (100MG),,,,80002214,CDM,250,RC,378459777,NDC,both,90,EA,0.29,0.12,39.4668,,0.12,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.1,34,,0.1,percent of total billed charges,"Drugs, Inpatient Only",0.1,34,,0.1,percent of total billed charges,"Drugs, Inpatient Only",0.1,34,,0.1,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.2,70,,0.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.1,,,0.1,Other,Drug Cost,0.1,,,0.1,Other,Drug Cost,0.1,,,0.1,Other,Drug Cost,0.1,,,0.1,Other,Drug Cost,0.1,,,0.1,Other,Drug Cost,0.1,,,0.1,Other,Drug Cost,0.22,,,0.22,Other,225% of Medicaid,0.14,,,0.14,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.21,,,0.21,Other,215% Medicaid APG methodology,0.21,,,0.21,Other,215% Medicaid APG methodology,0.12,,,0.12,Other,125% Medicaid APG methodology,0.01,0.22,
PANTOPRAZOLE 20MG DR TABLET,,,,80002215,CDM,250,RC,378668877,NDC,both,90,EA,0.04,0.02,39.4668,,0.02,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.03,70,,0.03,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.03,,,0.03,Other,225% of Medicaid,0.02,,,0.02,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.03,,,0.03,Other,215% Medicaid APG methodology,0.03,,,0.03,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,125% Medicaid APG methodology,0.01,0.03,
PENICILLIN 5MIL UNIT/100ML NS,,,,80002245,CDM,250,RC,49052083,NDC,both,10,EA,9.64,3.8,39.4668,,3.8,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,3.28,34,,3.28,percent of total billed charges,"Drugs, Inpatient Only",3.28,34,,3.28,percent of total billed charges,"Drugs, Inpatient Only",3.28,34,,3.28,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,6.75,70,,6.75,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,3.21,,,3.21,Other,Drug Cost,3.21,,,3.21,Other,Drug Cost,3.21,,,3.21,Other,Drug Cost,3.21,,,3.21,Other,Drug Cost,3.21,,,3.21,Other,Drug Cost,3.21,,,3.21,Other,Drug Cost,7.23,,,7.23,Other,225% of Medicaid,4.5,,,4.5,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,6.91,,,6.91,Other,215% Medicaid APG methodology,6.91,,,6.91,Other,215% Medicaid APG methodology,4.02,,,4.02,Other,125% Medicaid APG methodology,0.01,7.23,
TETRACAINE 0.5% OPHTH SOLN 4ML,,,,80002272,CDM,250,RC,65074114,NDC,both,12,ML,26.88,10.61,39.4668,,10.61,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,9.14,34,,9.14,percent of total billed charges,"Drugs, Inpatient Only",9.14,34,,9.14,percent of total billed charges,"Drugs, Inpatient Only",9.14,34,,9.14,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,18.81,70,,18.81,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,8.96,,,8.96,Other,Drug Cost,8.96,,,8.96,Other,Drug Cost,8.96,,,8.96,Other,Drug Cost,8.96,,,8.96,Other,Drug Cost,8.96,,,8.96,Other,Drug Cost,8.96,,,8.96,Other,Drug Cost,20.16,,,20.16,Other,225% of Medicaid,12.54,,,12.54,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,19.26,,,19.26,Other,215% Medicaid APG methodology,19.26,,,19.26,Other,215% Medicaid APG methodology,11.2,,,11.2,Other,125% Medicaid APG methodology,0.01,20.16,
ELECTROLYTE S 1000ML,,,,80002273,CDM,250,RC,338022104,NDC,both,14,ML,9.98,3.94,39.4668,,3.94,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,3.39,34,,3.39,percent of total billed charges,"Drugs, Inpatient Only",3.39,34,,3.39,percent of total billed charges,"Drugs, Inpatient Only",3.39,34,,3.39,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,6.98,70,,6.98,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,3.33,,,3.33,Other,Drug Cost,3.33,,,3.33,Other,Drug Cost,3.33,,,3.33,Other,Drug Cost,3.33,,,3.33,Other,Drug Cost,3.33,,,3.33,Other,Drug Cost,3.33,,,3.33,Other,Drug Cost,7.48,,,7.48,Other,225% of Medicaid,4.66,,,4.66,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,7.15,,,7.15,Other,215% Medicaid APG methodology,7.15,,,7.15,Other,215% Medicaid APG methodology,4.16,,,4.16,Other,125% Medicaid APG methodology,0.01,7.48,
"ZINC OXIDE BANDAGE 3"" (UNNA BOOT)",,,,80002276,CDM,250,RC,68455010763,NDC,both,1,EA,11.46,4.52,39.4668,,4.52,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,3.9,34,,3.9,percent of total billed charges,"Drugs, Inpatient Only",3.9,34,,3.9,percent of total billed charges,"Drugs, Inpatient Only",3.9,34,,3.9,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,8.02,70,,8.02,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,3.82,,,3.82,Other,Drug Cost,3.82,,,3.82,Other,Drug Cost,3.82,,,3.82,Other,Drug Cost,3.82,,,3.82,Other,Drug Cost,3.82,,,3.82,Other,Drug Cost,3.82,,,3.82,Other,Drug Cost,8.6,,,8.6,Other,225% of Medicaid,5.35,,,5.35,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,8.21,,,8.21,Other,215% Medicaid APG methodology,8.21,,,8.21,Other,215% Medicaid APG methodology,4.78,,,4.78,Other,125% Medicaid APG methodology,0.01,8.6,
NACL W/40MEQ KCL 1000ML,,,,80002277,CDM,250,RC,990711609,NDC,both,12,ML,9.7,3.83,39.4668,,3.83,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,3.3,34,,3.3,percent of total billed charges,"Drugs, Inpatient Only",3.3,34,,3.3,percent of total billed charges,"Drugs, Inpatient Only",3.3,34,,3.3,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,6.79,70,,6.79,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,3.23,,,3.23,Other,Drug Cost,3.23,,,3.23,Other,Drug Cost,3.23,,,3.23,Other,Drug Cost,3.23,,,3.23,Other,Drug Cost,3.23,,,3.23,Other,Drug Cost,3.23,,,3.23,Other,Drug Cost,7.28,,,7.28,Other,225% of Medicaid,4.53,,,4.53,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,6.95,,,6.95,Other,215% Medicaid APG methodology,6.95,,,6.95,Other,215% Medicaid APG methodology,4.04,,,4.04,Other,125% Medicaid APG methodology,0.01,7.28,
HUMULIN R INSULIN,,,,80002278,CDM,250,RC,2821501,NDC,both,1,ML,41.61,16.42,39.4668,,16.42,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,14.15,34,,14.15,percent of total billed charges,"Drugs, Inpatient Only",14.15,34,,14.15,percent of total billed charges,"Drugs, Inpatient Only",14.15,34,,14.15,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,29.13,70,,29.13,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,13.87,,,13.87,Other,Drug Cost,13.87,,,13.87,Other,Drug Cost,13.87,,,13.87,Other,Drug Cost,13.87,,,13.87,Other,Drug Cost,13.87,,,13.87,Other,Drug Cost,13.87,,,13.87,Other,Drug Cost,31.21,,,31.21,Other,225% of Medicaid,19.42,,,19.42,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,29.82,,,29.82,Other,215% Medicaid APG methodology,29.82,,,29.82,Other,215% Medicaid APG methodology,17.34,,,17.34,Other,125% Medicaid APG methodology,0.01,31.21,
AZITHROMYCIN 250MG TAB,,,,80002279,CDM,250,RC,50111078751,NDC,both,6,EA,0.03,0.01,39.4668,,0.01,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.02,70,,0.02,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.02,,,0.02,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,0.02,
BENZOCAINE 20% SPRAY (UNIT DOSE),,,,80002288,CDM,250,RC,283061026,NDC,both,25,ML,28.17,11.12,39.4668,,11.12,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,9.58,34,,9.58,percent of total billed charges,"Drugs, Inpatient Only",9.58,34,,9.58,percent of total billed charges,"Drugs, Inpatient Only",9.58,34,,9.58,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,19.72,70,,19.72,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,9.39,,,9.39,Other,Drug Cost,9.39,,,9.39,Other,Drug Cost,9.39,,,9.39,Other,Drug Cost,9.39,,,9.39,Other,Drug Cost,9.39,,,9.39,Other,Drug Cost,9.39,,,9.39,Other,Drug Cost,21.13,,,21.13,Other,225% of Medicaid,13.15,,,13.15,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,20.19,,,20.19,Other,215% Medicaid APG methodology,20.19,,,20.19,Other,215% Medicaid APG methodology,11.74,,,11.74,Other,125% Medicaid APG methodology,0.01,21.13,
BUPROPION HCL 100MG TAB SR,,,,80002289,CDM,250,RC,173094755,NDC,both,60,EA,0.51,0.2,39.4668,,0.2,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.17,34,,0.17,percent of total billed charges,"Drugs, Inpatient Only",0.17,34,,0.17,percent of total billed charges,"Drugs, Inpatient Only",0.17,34,,0.17,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.36,70,,0.36,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.17,,,0.17,Other,Drug Cost,0.17,,,0.17,Other,Drug Cost,0.17,,,0.17,Other,Drug Cost,0.17,,,0.17,Other,Drug Cost,0.17,,,0.17,Other,Drug Cost,0.17,,,0.17,Other,Drug Cost,0.38,,,0.38,Other,225% of Medicaid,0.24,,,0.24,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.37,,,0.37,Other,215% Medicaid APG methodology,0.37,,,0.37,Other,215% Medicaid APG methodology,0.21,,,0.21,Other,125% Medicaid APG methodology,0.01,0.38,
BUPIVACAINE/EPI 0.25-.0005 30ML VIAL,,,,80002292,CDM,250,RC,63323046837,NDC,both,25,ML,18.56,7.33,39.4668,,7.33,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,6.31,34,,6.31,percent of total billed charges,"Drugs, Inpatient Only",6.31,34,,6.31,percent of total billed charges,"Drugs, Inpatient Only",6.31,34,,6.31,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,12.99,70,,12.99,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,6.19,,,6.19,Other,Drug Cost,6.19,,,6.19,Other,Drug Cost,6.19,,,6.19,Other,Drug Cost,6.19,,,6.19,Other,Drug Cost,6.19,,,6.19,Other,Drug Cost,6.19,,,6.19,Other,Drug Cost,13.92,,,13.92,Other,225% of Medicaid,8.66,,,8.66,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,13.3,,,13.3,Other,215% Medicaid APG methodology,13.3,,,13.3,Other,215% Medicaid APG methodology,7.73,,,7.73,Other,125% Medicaid APG methodology,0.01,13.92,
BUPIVACAINE/EPI 0.5-0.0005 30M VIAL,,,,80002293,CDM,250,RC,409174929,NDC,both,10,ML,9.86,3.89,39.4668,,3.89,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,3.35,34,,3.35,percent of total billed charges,"Drugs, Inpatient Only",3.35,34,,3.35,percent of total billed charges,"Drugs, Inpatient Only",3.35,34,,3.35,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,6.9,70,,6.9,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,3.29,,,3.29,Other,Drug Cost,3.29,,,3.29,Other,Drug Cost,3.29,,,3.29,Other,Drug Cost,3.29,,,3.29,Other,Drug Cost,3.29,,,3.29,Other,Drug Cost,3.29,,,3.29,Other,Drug Cost,7.39,,,7.39,Other,225% of Medicaid,4.6,,,4.6,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,7.06,,,7.06,Other,215% Medicaid APG methodology,7.06,,,7.06,Other,215% Medicaid APG methodology,4.11,,,4.11,Other,125% Medicaid APG methodology,0.01,7.39,
DEXAMETHASONE SOD PHOS (PF) 10MG/ML VIAL,,,,80002302,CDM,250,RC,63323050601,NDC,both,25,ML,3.48,1.37,39.4668,,1.37,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1.18,34,,1.18,percent of total billed charges,"Drugs, Inpatient Only",1.18,34,,1.18,percent of total billed charges,"Drugs, Inpatient Only",1.18,34,,1.18,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2.43,70,,2.43,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1.16,,,1.16,Other,Drug Cost,1.16,,,1.16,Other,Drug Cost,1.16,,,1.16,Other,Drug Cost,1.16,,,1.16,Other,Drug Cost,1.16,,,1.16,Other,Drug Cost,1.16,,,1.16,Other,Drug Cost,2.61,,,2.61,Other,225% of Medicaid,1.62,,,1.62,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,2.49,,,2.49,Other,215% Medicaid APG methodology,2.49,,,2.49,Other,215% Medicaid APG methodology,1.45,,,1.45,Other,125% Medicaid APG methodology,0.01,2.61,
FLUPHENAZINE HCL 1MG TAB,,,,80002307,CDM,250,RC,527178801,NDC,both,100,EA,0.03,0.01,39.4668,,0.01,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.02,70,,0.02,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.02,,,0.02,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,0.02,
HEPARIN SOD (PORCINE) 100UNIT/ML 5ML,,,,80002314,CDM,250,RC,63807060005,NDC,both,100,ML,1.16,0.46,39.4668,,0.46,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.4,34,,0.4,percent of total billed charges,"Drugs, Inpatient Only",0.4,34,,0.4,percent of total billed charges,"Drugs, Inpatient Only",0.4,34,,0.4,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.81,70,,0.81,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.39,,,0.39,Other,Drug Cost,0.39,,,0.39,Other,Drug Cost,0.39,,,0.39,Other,Drug Cost,0.39,,,0.39,Other,Drug Cost,0.39,,,0.39,Other,Drug Cost,0.39,,,0.39,Other,Drug Cost,0.87,,,0.87,Other,225% of Medicaid,0.54,,,0.54,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.83,,,0.83,Other,215% Medicaid APG methodology,0.83,,,0.83,Other,215% Medicaid APG methodology,0.48,,,0.48,Other,125% Medicaid APG methodology,0.01,0.87,
HYDROMORPHONE HCL 4MG/ML 1ML DISP SYRG,,,,80002316,CDM,250,RC,409130431,NDC,both,10,ML,0.03,0.01,39.4668,,0.01,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.02,70,,0.02,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.02,,,0.02,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,0.02,
INS HUMULIN 70/30 100 UNITS/ML 3ML VIAL,,,,80002318,CDM,250,RC,2871501,NDC,both,1,ML,48.51,19.15,39.4668,,19.15,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,16.49,34,,16.49,percent of total billed charges,"Drugs, Inpatient Only",16.49,34,,16.49,percent of total billed charges,"Drugs, Inpatient Only",16.49,34,,16.49,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,33.96,70,,33.96,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,16.17,,,16.17,Other,Drug Cost,16.17,,,16.17,Other,Drug Cost,16.17,,,16.17,Other,Drug Cost,16.17,,,16.17,Other,Drug Cost,16.17,,,16.17,Other,Drug Cost,16.17,,,16.17,Other,Drug Cost,36.38,,,36.38,Other,225% of Medicaid,22.64,,,22.64,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,34.77,,,34.77,Other,215% Medicaid APG methodology,34.77,,,34.77,Other,215% Medicaid APG methodology,20.21,,,20.21,Other,125% Medicaid APG methodology,0.01,36.38,
INSULIN HUMULIN N 100UNITS/ML 3ML VIAL,,,,80002319,CDM,250,RC,2831501,NDC,both,1,ML,41.61,16.42,39.4668,,16.42,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,14.15,34,,14.15,percent of total billed charges,"Drugs, Inpatient Only",14.15,34,,14.15,percent of total billed charges,"Drugs, Inpatient Only",14.15,34,,14.15,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,29.13,70,,29.13,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,13.87,,,13.87,Other,Drug Cost,13.87,,,13.87,Other,Drug Cost,13.87,,,13.87,Other,Drug Cost,13.87,,,13.87,Other,Drug Cost,13.87,,,13.87,Other,Drug Cost,13.87,,,13.87,Other,Drug Cost,31.21,,,31.21,Other,225% of Medicaid,19.42,,,19.42,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,29.82,,,29.82,Other,215% Medicaid APG methodology,29.82,,,29.82,Other,215% Medicaid APG methodology,17.34,,,17.34,Other,125% Medicaid APG methodology,0.01,31.21,
LANOLIN PURIFIED (LANSINOH) CREAM (GM),,,,80002320,CDM,250,RC,44677010202,NDC,both,1,GM,7.44,2.94,39.4668,,2.94,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2.53,34,,2.53,percent of total billed charges,"Drugs, Inpatient Only",2.53,34,,2.53,percent of total billed charges,"Drugs, Inpatient Only",2.53,34,,2.53,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,5.21,70,,5.21,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2.48,,,2.48,Other,Drug Cost,2.48,,,2.48,Other,Drug Cost,2.48,,,2.48,Other,Drug Cost,2.48,,,2.48,Other,Drug Cost,2.48,,,2.48,Other,Drug Cost,2.48,,,2.48,Other,Drug Cost,5.58,,,5.58,Other,225% of Medicaid,3.47,,,3.47,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,5.33,,,5.33,Other,215% Medicaid APG methodology,5.33,,,5.33,Other,215% Medicaid APG methodology,3.1,,,3.1,Other,125% Medicaid APG methodology,0.01,5.58,
BUTALBITAL-ACETAMINOPHEN 50-325MG TAB,,,,80002322,CDM,250,RC,527169505,NDC,both,500,EA,0.2,0.08,39.4668,,0.08,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.07,34,,0.07,percent of total billed charges,"Drugs, Inpatient Only",0.07,34,,0.07,percent of total billed charges,"Drugs, Inpatient Only",0.07,34,,0.07,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.14,70,,0.14,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.07,,,0.07,Other,Drug Cost,0.07,,,0.07,Other,Drug Cost,0.07,,,0.07,Other,Drug Cost,0.07,,,0.07,Other,Drug Cost,0.07,,,0.07,Other,Drug Cost,0.07,,,0.07,Other,Drug Cost,0.15,,,0.15,Other,225% of Medicaid,0.09,,,0.09,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.14,,,0.14,Other,215% Medicaid APG methodology,0.14,,,0.14,Other,215% Medicaid APG methodology,0.08,,,0.08,Other,125% Medicaid APG methodology,0.01,0.15,
LIDOCAINE HCL 2% 20MG/ML 2ML AMPULE,,,,80002327,CDM,250,RC,63323049527,NDC,both,25,ML,1.06,0.42,39.4668,,0.42,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.36,34,,0.36,percent of total billed charges,"Drugs, Inpatient Only",0.36,34,,0.36,percent of total billed charges,"Drugs, Inpatient Only",0.36,34,,0.36,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.74,70,,0.74,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.35,,,0.35,Other,Drug Cost,0.35,,,0.35,Other,Drug Cost,0.35,,,0.35,Other,Drug Cost,0.35,,,0.35,Other,Drug Cost,0.35,,,0.35,Other,Drug Cost,0.35,,,0.35,Other,Drug Cost,0.79,,,0.79,Other,225% of Medicaid,0.49,,,0.49,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.76,,,0.76,Other,215% Medicaid APG methodology,0.76,,,0.76,Other,215% Medicaid APG methodology,0.44,,,0.44,Other,125% Medicaid APG methodology,0.01,0.79,
LIDOCAINE-MPF 1% 5ML AMPULE,,,,80002331,CDM,250,RC,55150016205,NDC,both,10,ML,2.53,1,39.4668,,1,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.86,34,,0.86,percent of total billed charges,"Drugs, Inpatient Only",0.86,34,,0.86,percent of total billed charges,"Drugs, Inpatient Only",0.86,34,,0.86,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1.77,70,,1.77,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.84,,,0.84,Other,Drug Cost,0.84,,,0.84,Other,Drug Cost,0.84,,,0.84,Other,Drug Cost,0.84,,,0.84,Other,Drug Cost,0.84,,,0.84,Other,Drug Cost,0.84,,,0.84,Other,Drug Cost,1.89,,,1.89,Other,225% of Medicaid,1.18,,,1.18,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,1.81,,,1.81,Other,215% Medicaid APG methodology,1.81,,,1.81,Other,215% Medicaid APG methodology,1.05,,,1.05,Other,125% Medicaid APG methodology,0.01,1.89,
LURASIDONE 20MG TABLET,,,,80002333,CDM,250,RC,67877063830,NDC,both,30,EA,0.06,0.02,39.4668,,0.02,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.02,34,,0.02,percent of total billed charges,"Drugs, Inpatient Only",0.02,34,,0.02,percent of total billed charges,"Drugs, Inpatient Only",0.02,34,,0.02,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.04,70,,0.04,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.05,,,0.05,Other,225% of Medicaid,0.03,,,0.03,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.05,,,0.05,Other,215% Medicaid APG methodology,0.05,,,0.05,Other,215% Medicaid APG methodology,0.03,,,0.03,Other,125% Medicaid APG methodology,0.01,0.05,
MELATONIN 1MG TAB,,,,80002336,CDM,250,RC,74312002832,NDC,both,180,EA,0.07,0.03,39.4668,,0.03,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.02,34,,0.02,percent of total billed charges,"Drugs, Inpatient Only",0.02,34,,0.02,percent of total billed charges,"Drugs, Inpatient Only",0.02,34,,0.02,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.05,70,,0.05,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.05,,,0.05,Other,225% of Medicaid,0.03,,,0.03,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.05,,,0.05,Other,215% Medicaid APG methodology,0.05,,,0.05,Other,215% Medicaid APG methodology,0.03,,,0.03,Other,125% Medicaid APG methodology,0.01,0.05,
MELATONIN 3MG TAB,,,,80002337,CDM,250,RC,96295012827,NDC,both,100,EA,0.07,0.03,39.4668,,0.03,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.02,34,,0.02,percent of total billed charges,"Drugs, Inpatient Only",0.02,34,,0.02,percent of total billed charges,"Drugs, Inpatient Only",0.02,34,,0.02,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.05,70,,0.05,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.05,,,0.05,Other,225% of Medicaid,0.03,,,0.03,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.05,,,0.05,Other,215% Medicaid APG methodology,0.05,,,0.05,Other,215% Medicaid APG methodology,0.03,,,0.03,Other,125% Medicaid APG methodology,0.01,0.05,
METHOCARBAMOL 750MG TABLET,,,,80002341,CDM,250,RC,70010077001,NDC,both,100,EA,0.05,0.02,39.4668,,0.02,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.02,34,,0.02,percent of total billed charges,"Drugs, Inpatient Only",0.02,34,,0.02,percent of total billed charges,"Drugs, Inpatient Only",0.02,34,,0.02,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.03,70,,0.03,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.04,,,0.04,Other,225% of Medicaid,0.02,,,0.02,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.04,,,0.04,Other,215% Medicaid APG methodology,0.04,,,0.04,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,125% Medicaid APG methodology,0.01,0.04,
HEPARIN SOD(PORCINE) 1000UNIT/ML 10ML VL,,,,80002342,CDM,250,RC,69005801,NDC,both,25,ML,0.27,0.11,39.4668,,0.11,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.09,34,,0.09,percent of total billed charges,"Drugs, Inpatient Only",0.09,34,,0.09,percent of total billed charges,"Drugs, Inpatient Only",0.09,34,,0.09,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.19,70,,0.19,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.09,,,0.09,Other,Drug Cost,0.09,,,0.09,Other,Drug Cost,0.09,,,0.09,Other,Drug Cost,0.09,,,0.09,Other,Drug Cost,0.09,,,0.09,Other,Drug Cost,0.09,,,0.09,Other,Drug Cost,0.2,,,0.2,Other,225% of Medicaid,0.13,,,0.13,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.19,,,0.19,Other,215% Medicaid APG methodology,0.19,,,0.19,Other,215% Medicaid APG methodology,0.11,,,0.11,Other,125% Medicaid APG methodology,0.01,0.2,
MINERAL OIL (MURI-LUBE) 10ML OIL,,,,80002345,CDM,250,RC,63323025410,NDC,both,25,ML,54.3,21.43,39.4668,,21.43,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,18.46,34,,18.46,percent of total billed charges,"Drugs, Inpatient Only",18.46,34,,18.46,percent of total billed charges,"Drugs, Inpatient Only",18.46,34,,18.46,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,38.01,70,,38.01,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,18.1,,,18.1,Other,Drug Cost,18.1,,,18.1,Other,Drug Cost,18.1,,,18.1,Other,Drug Cost,18.1,,,18.1,Other,Drug Cost,18.1,,,18.1,Other,Drug Cost,18.1,,,18.1,Other,Drug Cost,40.73,,,40.73,Other,225% of Medicaid,25.34,,,25.34,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,38.92,,,38.92,Other,215% Medicaid APG methodology,38.92,,,38.92,Other,215% Medicaid APG methodology,22.63,,,22.63,Other,125% Medicaid APG methodology,0.01,40.73,
MINERAL OIL 30ML CUP,,,,80002346,CDM,250,RC,48433020230,NDC,both,40,ML,5.83,2.3,39.4668,,2.3,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1.98,34,,1.98,percent of total billed charges,"Drugs, Inpatient Only",1.98,34,,1.98,percent of total billed charges,"Drugs, Inpatient Only",1.98,34,,1.98,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,4.08,70,,4.08,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1.94,,,1.94,Other,Drug Cost,1.94,,,1.94,Other,Drug Cost,1.94,,,1.94,Other,Drug Cost,1.94,,,1.94,Other,Drug Cost,1.94,,,1.94,Other,Drug Cost,1.94,,,1.94,Other,Drug Cost,4.37,,,4.37,Other,225% of Medicaid,2.72,,,2.72,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,4.18,,,4.18,Other,215% Medicaid APG methodology,4.18,,,4.18,Other,215% Medicaid APG methodology,2.43,,,2.43,Other,125% Medicaid APG methodology,0.01,4.37,
MULTIVITAMIN W MINERALS TAB,,,,80002353,CDM,250,RC,40985022368,NDC,both,130,EA,0.14,0.06,39.4668,,0.06,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.05,34,,0.05,percent of total billed charges,"Drugs, Inpatient Only",0.05,34,,0.05,percent of total billed charges,"Drugs, Inpatient Only",0.05,34,,0.05,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.1,70,,0.1,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.11,,,0.11,Other,225% of Medicaid,0.07,,,0.07,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.1,,,0.1,Other,215% Medicaid APG methodology,0.1,,,0.1,Other,215% Medicaid APG methodology,0.06,,,0.06,Other,125% Medicaid APG methodology,0.01,0.11,
MUPIROCIN 2% 15GM OINTMENT,,,,80002355,CDM,250,RC,51672131200,NDC,both,1,GM,4.02,1.59,39.4668,,1.59,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1.37,34,,1.37,percent of total billed charges,"Drugs, Inpatient Only",1.37,34,,1.37,percent of total billed charges,"Drugs, Inpatient Only",1.37,34,,1.37,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2.81,70,,2.81,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1.34,,,1.34,Other,Drug Cost,1.34,,,1.34,Other,Drug Cost,1.34,,,1.34,Other,Drug Cost,1.34,,,1.34,Other,Drug Cost,1.34,,,1.34,Other,Drug Cost,1.34,,,1.34,Other,Drug Cost,3.02,,,3.02,Other,225% of Medicaid,1.88,,,1.88,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,2.88,,,2.88,Other,215% Medicaid APG methodology,2.88,,,2.88,Other,215% Medicaid APG methodology,1.68,,,1.68,Other,125% Medicaid APG methodology,0.01,3.02,
PENICILLIN G BENZATHINE 2.4 MILLION SYRG,,,,80002362,CDM,250,RC,60793070210,NDC,both,10,ML,0.11,0.04,39.4668,,0.04,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.04,34,,0.04,percent of total billed charges,"Drugs, Inpatient Only",0.04,34,,0.04,percent of total billed charges,"Drugs, Inpatient Only",0.04,34,,0.04,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.08,70,,0.08,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.08,,,0.08,Other,225% of Medicaid,0.05,,,0.05,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.08,,,0.08,Other,215% Medicaid APG methodology,0.08,,,0.08,Other,215% Medicaid APG methodology,0.05,,,0.05,Other,125% Medicaid APG methodology,0.01,0.08,
POTASSIUM CHLORIDE 20MEQ/15ML LIQUID,,,,80002367,CDM,250,RC,603154258,NDC,both,1,ML,18.33,7.23,39.4668,,7.23,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,6.23,34,,6.23,percent of total billed charges,"Drugs, Inpatient Only",6.23,34,,6.23,percent of total billed charges,"Drugs, Inpatient Only",6.23,34,,6.23,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,12.83,70,,12.83,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,6.11,,,6.11,Other,Drug Cost,6.11,,,6.11,Other,Drug Cost,6.11,,,6.11,Other,Drug Cost,6.11,,,6.11,Other,Drug Cost,6.11,,,6.11,Other,Drug Cost,6.11,,,6.11,Other,Drug Cost,13.75,,,13.75,Other,225% of Medicaid,8.55,,,8.55,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,13.14,,,13.14,Other,215% Medicaid APG methodology,13.14,,,13.14,Other,215% Medicaid APG methodology,7.64,,,7.64,Other,125% Medicaid APG methodology,0.01,13.75,
PRIMIDONE 50MG TAB,,,,80002371,CDM,250,RC,53746054401,NDC,both,100,EA,0.07,0.03,39.4668,,0.03,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.02,34,,0.02,percent of total billed charges,"Drugs, Inpatient Only",0.02,34,,0.02,percent of total billed charges,"Drugs, Inpatient Only",0.02,34,,0.02,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.05,70,,0.05,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.05,,,0.05,Other,225% of Medicaid,0.03,,,0.03,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.05,,,0.05,Other,215% Medicaid APG methodology,0.05,,,0.05,Other,215% Medicaid APG methodology,0.03,,,0.03,Other,125% Medicaid APG methodology,0.01,0.05,
TACROLIMUS 0.5MG CAPSULE,,,,80002378,CDM,250,RC,16729004101,NDC,both,100,EA,0.16,0.06,39.4668,,0.06,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.06,34,,0.06,percent of total billed charges,"Drugs, Inpatient Only",0.06,34,,0.06,percent of total billed charges,"Drugs, Inpatient Only",0.06,34,,0.06,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.11,70,,0.11,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.12,,,0.12,Other,225% of Medicaid,0.08,,,0.08,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.12,,,0.12,Other,215% Medicaid APG methodology,0.12,,,0.12,Other,215% Medicaid APG methodology,0.07,,,0.07,Other,125% Medicaid APG methodology,0.01,0.12,
TOBRAMYCIN/DEXAMETH 0.3-0.1% 2.5ML SOLN,,,,80002381,CDM,250,RC,24208029525,NDC,both,1,ML,4.62,1.82,39.4668,,1.82,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1.57,34,,1.57,percent of total billed charges,"Drugs, Inpatient Only",1.57,34,,1.57,percent of total billed charges,"Drugs, Inpatient Only",1.57,34,,1.57,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,3.23,70,,3.23,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1.54,,,1.54,Other,Drug Cost,1.54,,,1.54,Other,Drug Cost,1.54,,,1.54,Other,Drug Cost,1.54,,,1.54,Other,Drug Cost,1.54,,,1.54,Other,Drug Cost,1.54,,,1.54,Other,Drug Cost,3.47,,,3.47,Other,225% of Medicaid,2.16,,,2.16,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,3.31,,,3.31,Other,215% Medicaid APG methodology,3.31,,,3.31,Other,215% Medicaid APG methodology,1.93,,,1.93,Other,125% Medicaid APG methodology,0.01,3.47,
TRIAMCINOLONE ACETONIDE 0.1% 80GM CREAM,,,,80002382,CDM,250,RC,45802006436,NDC,both,1,GM,3.9,1.54,39.4668,,1.54,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1.33,34,,1.33,percent of total billed charges,"Drugs, Inpatient Only",1.33,34,,1.33,percent of total billed charges,"Drugs, Inpatient Only",1.33,34,,1.33,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2.73,70,,2.73,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1.3,,,1.3,Other,Drug Cost,1.3,,,1.3,Other,Drug Cost,1.3,,,1.3,Other,Drug Cost,1.3,,,1.3,Other,Drug Cost,1.3,,,1.3,Other,Drug Cost,1.3,,,1.3,Other,Drug Cost,2.93,,,2.93,Other,225% of Medicaid,1.82,,,1.82,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,2.8,,,2.8,Other,215% Medicaid APG methodology,2.8,,,2.8,Other,215% Medicaid APG methodology,1.63,,,1.63,Other,125% Medicaid APG methodology,0.01,2.93,
TRIAMCINOLONE ACETONIDE 40MG/ML 1ML VL,,,,80002383,CDM,250,RC,70121104902,NDC,both,1,ML,8.07,3.18,39.4668,,3.18,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2.74,34,,2.74,percent of total billed charges,"Drugs, Inpatient Only",2.74,34,,2.74,percent of total billed charges,"Drugs, Inpatient Only",2.74,34,,2.74,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,5.65,70,,5.65,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2.69,,,2.69,Other,Drug Cost,2.69,,,2.69,Other,Drug Cost,2.69,,,2.69,Other,Drug Cost,2.69,,,2.69,Other,Drug Cost,2.69,,,2.69,Other,Drug Cost,2.69,,,2.69,Other,Drug Cost,6.05,,,6.05,Other,225% of Medicaid,3.77,,,3.77,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,5.78,,,5.78,Other,215% Medicaid APG methodology,5.78,,,5.78,Other,215% Medicaid APG methodology,3.36,,,3.36,Other,125% Medicaid APG methodology,0.01,6.05,
TUCKS MEDICATED PADS,,,,80002384,CDM,250,RC,50289325001,NDC,both,40,EA,0.17,0.07,39.4668,,0.07,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.06,34,,0.06,percent of total billed charges,"Drugs, Inpatient Only",0.06,34,,0.06,percent of total billed charges,"Drugs, Inpatient Only",0.06,34,,0.06,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.12,70,,0.12,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.06,,,0.06,Other,Drug Cost,0.06,,,0.06,Other,Drug Cost,0.06,,,0.06,Other,Drug Cost,0.06,,,0.06,Other,Drug Cost,0.06,,,0.06,Other,Drug Cost,0.06,,,0.06,Other,Drug Cost,0.12,,,0.12,Other,225% of Medicaid,0.08,,,0.08,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.12,,,0.12,Other,215% Medicaid APG methodology,0.12,,,0.12,Other,215% Medicaid APG methodology,0.07,,,0.07,Other,125% Medicaid APG methodology,0.01,0.12,
UNNA BOOT 4 INCH,,,,80002385,CDM,250,RC,68455010764,NDC,both,1,EA,13.05,5.15,39.4668,,5.15,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,4.44,34,,4.44,percent of total billed charges,"Drugs, Inpatient Only",4.44,34,,4.44,percent of total billed charges,"Drugs, Inpatient Only",4.44,34,,4.44,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,9.14,70,,9.14,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,4.35,,,4.35,Other,Drug Cost,4.35,,,4.35,Other,Drug Cost,4.35,,,4.35,Other,Drug Cost,4.35,,,4.35,Other,Drug Cost,4.35,,,4.35,Other,Drug Cost,4.35,,,4.35,Other,Drug Cost,9.79,,,9.79,Other,225% of Medicaid,6.09,,,6.09,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,9.35,,,9.35,Other,215% Medicaid APG methodology,9.35,,,9.35,Other,215% Medicaid APG methodology,5.44,,,5.44,Other,125% Medicaid APG methodology,0.01,9.79,
VENLAFAXINE HCL 50MG TAB,,,,80002388,CDM,250,RC,57237017401,NDC,both,100,EA,0.06,0.03,39.4668,,0.03,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.02,34,,0.02,percent of total billed charges,"Drugs, Inpatient Only",0.02,34,,0.02,percent of total billed charges,"Drugs, Inpatient Only",0.02,34,,0.02,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.05,70,,0.05,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.05,,,0.05,Other,225% of Medicaid,0.03,,,0.03,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.05,,,0.05,Other,215% Medicaid APG methodology,0.05,,,0.05,Other,215% Medicaid APG methodology,0.03,,,0.03,Other,125% Medicaid APG methodology,0.01,0.05,
VERAPAMIL HCL 2.5MG/ML 2ML VIAL,,,,80002389,CDM,250,RC,51754020302,NDC,both,5,ML,8.15,3.22,39.4668,,3.22,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2.77,34,,2.77,percent of total billed charges,"Drugs, Inpatient Only",2.77,34,,2.77,percent of total billed charges,"Drugs, Inpatient Only",2.77,34,,2.77,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,5.71,70,,5.71,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2.72,,,2.72,Other,Drug Cost,2.72,,,2.72,Other,Drug Cost,2.72,,,2.72,Other,Drug Cost,2.72,,,2.72,Other,Drug Cost,2.72,,,2.72,Other,Drug Cost,2.72,,,2.72,Other,Drug Cost,6.12,,,6.12,Other,225% of Medicaid,3.81,,,3.81,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,5.84,,,5.84,Other,215% Medicaid APG methodology,5.84,,,5.84,Other,215% Medicaid APG methodology,3.4,,,3.4,Other,125% Medicaid APG methodology,0.01,6.12,
WARFARIN SODIUM 7.5MG TAB,,,,80002394,CDM,250,RC,832121801,NDC,both,10,EA,2.08,0.82,39.4668,,0.82,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.71,34,,0.71,percent of total billed charges,"Drugs, Inpatient Only",0.71,34,,0.71,percent of total billed charges,"Drugs, Inpatient Only",0.71,34,,0.71,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1.45,70,,1.45,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.69,,,0.69,Other,Drug Cost,0.69,,,0.69,Other,Drug Cost,0.69,,,0.69,Other,Drug Cost,0.69,,,0.69,Other,Drug Cost,0.69,,,0.69,Other,Drug Cost,0.69,,,0.69,Other,Drug Cost,1.56,,,1.56,Other,225% of Medicaid,0.97,,,0.97,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,1.49,,,1.49,Other,215% Medicaid APG methodology,1.49,,,1.49,Other,215% Medicaid APG methodology,0.87,,,0.87,Other,125% Medicaid APG methodology,0.01,1.56,
ZONISAMIDE CAPSULES 50MG CAPSULE,,,,80002395,CDM,250,RC,62756025902,NDC,both,100,EA,0.21,0.08,39.4668,,0.08,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.07,34,,0.07,percent of total billed charges,"Drugs, Inpatient Only",0.07,34,,0.07,percent of total billed charges,"Drugs, Inpatient Only",0.07,34,,0.07,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.15,70,,0.15,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.07,,,0.07,Other,Drug Cost,0.07,,,0.07,Other,Drug Cost,0.07,,,0.07,Other,Drug Cost,0.07,,,0.07,Other,Drug Cost,0.07,,,0.07,Other,Drug Cost,0.07,,,0.07,Other,Drug Cost,0.16,,,0.16,Other,225% of Medicaid,0.1,,,0.1,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.15,,,0.15,Other,215% Medicaid APG methodology,0.15,,,0.15,Other,215% Medicaid APG methodology,0.09,,,0.09,Other,125% Medicaid APG methodology,0.01,0.16,
AMOXICILLIN 200MG/5ML SUSP 50ML,,,,80002397,CDM,250,RC,781615652,NDC,both,1,ML,1.35,0.53,39.4668,,0.53,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.46,34,,0.46,percent of total billed charges,"Drugs, Inpatient Only",0.46,34,,0.46,percent of total billed charges,"Drugs, Inpatient Only",0.46,34,,0.46,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.95,70,,0.95,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.45,,,0.45,Other,Drug Cost,0.45,,,0.45,Other,Drug Cost,0.45,,,0.45,Other,Drug Cost,0.45,,,0.45,Other,Drug Cost,0.45,,,0.45,Other,Drug Cost,0.45,,,0.45,Other,Drug Cost,1.01,,,1.01,Other,225% of Medicaid,0.63,,,0.63,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.97,,,0.97,Other,215% Medicaid APG methodology,0.97,,,0.97,Other,215% Medicaid APG methodology,0.56,,,0.56,Other,125% Medicaid APG methodology,0.01,1.01,
HYDROXYZINE HCL 10MG TAB,,,,80002400,CDM,250,RC,23155050001,NDC,both,100,EA,0.03,0.01,39.4668,,0.01,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.02,70,,0.02,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.02,,,0.02,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,0.02,
BALANCED SALT (BSS) 15ML OPHTH,,,,80002407,CDM,250,RC,65079515,NDC,both,36,ML,1.01,0.4,39.4668,,0.4,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.34,34,,0.34,percent of total billed charges,"Drugs, Inpatient Only",0.34,34,,0.34,percent of total billed charges,"Drugs, Inpatient Only",0.34,34,,0.34,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.7,70,,0.7,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.34,,,0.34,Other,Drug Cost,0.34,,,0.34,Other,Drug Cost,0.34,,,0.34,Other,Drug Cost,0.34,,,0.34,Other,Drug Cost,0.34,,,0.34,Other,Drug Cost,0.34,,,0.34,Other,Drug Cost,0.75,,,0.75,Other,225% of Medicaid,0.47,,,0.47,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.72,,,0.72,Other,215% Medicaid APG methodology,0.72,,,0.72,Other,215% Medicaid APG methodology,0.42,,,0.42,Other,125% Medicaid APG methodology,0.01,0.75,
BALANCED SALT-PLUS 500ML OPHTH,,,,80002408,CDM,250,RC,65080050,NDC,both,6,ML,24.35,9.61,39.4668,,9.61,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,8.28,34,,8.28,percent of total billed charges,"Drugs, Inpatient Only",8.28,34,,8.28,percent of total billed charges,"Drugs, Inpatient Only",8.28,34,,8.28,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,17.05,70,,17.05,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,8.12,,,8.12,Other,Drug Cost,8.12,,,8.12,Other,Drug Cost,8.12,,,8.12,Other,Drug Cost,8.12,,,8.12,Other,Drug Cost,8.12,,,8.12,Other,Drug Cost,8.12,,,8.12,Other,Drug Cost,18.26,,,18.26,Other,225% of Medicaid,11.36,,,11.36,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,17.45,,,17.45,Other,215% Medicaid APG methodology,17.45,,,17.45,Other,215% Medicaid APG methodology,10.15,,,10.15,Other,125% Medicaid APG methodology,0.01,18.26,
CALCIUM 600MG W/VIT D3 TAB,,,,80002409,CDM,250,RC,80681002900,NDC,both,60,EA,0.05,0.02,39.4668,,0.02,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.02,34,,0.02,percent of total billed charges,"Drugs, Inpatient Only",0.02,34,,0.02,percent of total billed charges,"Drugs, Inpatient Only",0.02,34,,0.02,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.03,70,,0.03,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.03,,,0.03,Other,225% of Medicaid,0.02,,,0.02,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.03,,,0.03,Other,215% Medicaid APG methodology,0.03,,,0.03,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,125% Medicaid APG methodology,0.01,0.03,
HEPARIN 25000 UNITS/0.45% NS 500ML,,,,80002410,CDM,250,RC,63323051877,NDC,both,24,ML,13.59,5.36,39.4668,,5.36,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,4.62,34,,4.62,percent of total billed charges,"Drugs, Inpatient Only",4.62,34,,4.62,percent of total billed charges,"Drugs, Inpatient Only",4.62,34,,4.62,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,9.51,70,,9.51,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,4.53,,,4.53,Other,Drug Cost,4.53,,,4.53,Other,Drug Cost,4.53,,,4.53,Other,Drug Cost,4.53,,,4.53,Other,Drug Cost,4.53,,,4.53,Other,Drug Cost,4.53,,,4.53,Other,Drug Cost,10.19,,,10.19,Other,225% of Medicaid,6.34,,,6.34,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,9.74,,,9.74,Other,215% Medicaid APG methodology,9.74,,,9.74,Other,215% Medicaid APG methodology,5.66,,,5.66,Other,125% Medicaid APG methodology,0.01,10.19,
HEPARIN 2000 UNITS/NS 1000ML,,,,80002411,CDM,250,RC,409762059,NDC,both,12,ML,11.68,4.61,39.4668,,4.61,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,3.97,34,,3.97,percent of total billed charges,"Drugs, Inpatient Only",3.97,34,,3.97,percent of total billed charges,"Drugs, Inpatient Only",3.97,34,,3.97,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,8.18,70,,8.18,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,3.89,,,3.89,Other,Drug Cost,3.89,,,3.89,Other,Drug Cost,3.89,,,3.89,Other,Drug Cost,3.89,,,3.89,Other,Drug Cost,3.89,,,3.89,Other,Drug Cost,3.89,,,3.89,Other,Drug Cost,8.76,,,8.76,Other,225% of Medicaid,5.45,,,5.45,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,8.37,,,8.37,Other,215% Medicaid APG methodology,8.37,,,8.37,Other,215% Medicaid APG methodology,4.87,,,4.87,Other,125% Medicaid APG methodology,0.01,8.76,
NS 5ML FLUSH,,,,80002417,CDM,250,RC,8290306545,NDC,both,30,ML,0.78,0.31,39.4668,,0.31,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.26,34,,0.26,percent of total billed charges,"Drugs, Inpatient Only",0.26,34,,0.26,percent of total billed charges,"Drugs, Inpatient Only",0.26,34,,0.26,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.55,70,,0.55,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.26,,,0.26,Other,Drug Cost,0.26,,,0.26,Other,Drug Cost,0.26,,,0.26,Other,Drug Cost,0.26,,,0.26,Other,Drug Cost,0.26,,,0.26,Other,Drug Cost,0.26,,,0.26,Other,Drug Cost,0.58,,,0.58,Other,225% of Medicaid,0.36,,,0.36,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.56,,,0.56,Other,215% Medicaid APG methodology,0.56,,,0.56,Other,215% Medicaid APG methodology,0.32,,,0.32,Other,125% Medicaid APG methodology,0.01,0.58,
NS 10ML FLUSH,,,,80002418,CDM,250,RC,8290306546,NDC,both,30,ML,0.71,0.28,39.4668,,0.28,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.24,34,,0.24,percent of total billed charges,"Drugs, Inpatient Only",0.24,34,,0.24,percent of total billed charges,"Drugs, Inpatient Only",0.24,34,,0.24,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.5,70,,0.5,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.24,,,0.24,Other,Drug Cost,0.24,,,0.24,Other,Drug Cost,0.24,,,0.24,Other,Drug Cost,0.24,,,0.24,Other,Drug Cost,0.24,,,0.24,Other,Drug Cost,0.24,,,0.24,Other,Drug Cost,0.53,,,0.53,Other,225% of Medicaid,0.33,,,0.33,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.51,,,0.51,Other,215% Medicaid APG methodology,0.51,,,0.51,Other,215% Medicaid APG methodology,0.3,,,0.3,Other,125% Medicaid APG methodology,0.01,0.53,
SOD BIPHOSPHATE-SOD PHOS(PED) ENEMA,,,,80002450,CDM,250,RC,132020220,NDC,both,1,ML,4.62,1.82,39.4668,,1.82,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1.57,34,,1.57,percent of total billed charges,"Drugs, Inpatient Only",1.57,34,,1.57,percent of total billed charges,"Drugs, Inpatient Only",1.57,34,,1.57,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,3.23,70,,3.23,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1.54,,,1.54,Other,Drug Cost,1.54,,,1.54,Other,Drug Cost,1.54,,,1.54,Other,Drug Cost,1.54,,,1.54,Other,Drug Cost,1.54,,,1.54,Other,Drug Cost,1.54,,,1.54,Other,Drug Cost,3.47,,,3.47,Other,225% of Medicaid,2.16,,,2.16,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,3.31,,,3.31,Other,215% Medicaid APG methodology,3.31,,,3.31,Other,215% Medicaid APG methodology,1.93,,,1.93,Other,125% Medicaid APG methodology,0.01,3.47,
PHENYLEPHRINE 0.5% NASAL SPRAY,,,,80002451,CDM,250,RC,225080547,NDC,both,1,ML,11.7,4.62,39.4668,,4.62,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,3.98,34,,3.98,percent of total billed charges,"Drugs, Inpatient Only",3.98,34,,3.98,percent of total billed charges,"Drugs, Inpatient Only",3.98,34,,3.98,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,8.19,70,,8.19,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,3.9,,,3.9,Other,Drug Cost,3.9,,,3.9,Other,Drug Cost,3.9,,,3.9,Other,Drug Cost,3.9,,,3.9,Other,Drug Cost,3.9,,,3.9,Other,Drug Cost,3.9,,,3.9,Other,Drug Cost,8.78,,,8.78,Other,225% of Medicaid,5.46,,,5.46,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,8.39,,,8.39,Other,215% Medicaid APG methodology,8.39,,,8.39,Other,215% Medicaid APG methodology,4.88,,,4.88,Other,125% Medicaid APG methodology,0.01,8.78,
PREDNISOLONE 1% OPTH SOLN,,,,80002453,CDM,250,RC,11980018005,NDC,both,1,ML,0.15,0.06,39.4668,,0.06,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.05,34,,0.05,percent of total billed charges,"Drugs, Inpatient Only",0.05,34,,0.05,percent of total billed charges,"Drugs, Inpatient Only",0.05,34,,0.05,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.11,70,,0.11,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.11,,,0.11,Other,225% of Medicaid,0.07,,,0.07,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.11,,,0.11,Other,215% Medicaid APG methodology,0.11,,,0.11,Other,215% Medicaid APG methodology,0.06,,,0.06,Other,125% Medicaid APG methodology,0.01,0.11,
NEFAZODONE 100MG TAB,,,,80002455,CDM,250,RC,93102406,NDC,both,60,EA,0.83,0.33,39.4668,,0.33,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.28,34,,0.28,percent of total billed charges,"Drugs, Inpatient Only",0.28,34,,0.28,percent of total billed charges,"Drugs, Inpatient Only",0.28,34,,0.28,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.58,70,,0.58,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.28,,,0.28,Other,Drug Cost,0.28,,,0.28,Other,Drug Cost,0.28,,,0.28,Other,Drug Cost,0.28,,,0.28,Other,Drug Cost,0.28,,,0.28,Other,Drug Cost,0.28,,,0.28,Other,Drug Cost,0.62,,,0.62,Other,225% of Medicaid,0.39,,,0.39,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.59,,,0.59,Other,215% Medicaid APG methodology,0.59,,,0.59,Other,215% Medicaid APG methodology,0.34,,,0.34,Other,125% Medicaid APG methodology,0.01,0.62,
SODIUM CHLORIDE 0.45% 1000ML,,,,80002456,CDM,250,RC,264780200,NDC,both,1000,ML,2.44,0.96,39.4668,,0.96,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.83,34,,0.83,percent of total billed charges,"Drugs, Inpatient Only",0.83,34,,0.83,percent of total billed charges,"Drugs, Inpatient Only",0.83,34,,0.83,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1.71,70,,1.71,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.81,,,0.81,Other,Drug Cost,0.81,,,0.81,Other,Drug Cost,0.81,,,0.81,Other,Drug Cost,0.81,,,0.81,Other,Drug Cost,0.81,,,0.81,Other,Drug Cost,0.81,,,0.81,Other,Drug Cost,1.83,,,1.83,Other,225% of Medicaid,1.14,,,1.14,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,1.75,,,1.75,Other,215% Medicaid APG methodology,1.75,,,1.75,Other,215% Medicaid APG methodology,1.02,,,1.02,Other,125% Medicaid APG methodology,0.01,1.83,
HEPATITIS B VACCINE (STATE),,,,80002463,CDM,250,RC,6498100,NDC,both,10,ML,76.06,30.02,39.4668,,30.02,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,25.86,34,,25.86,percent of total billed charges,"Drugs, Inpatient Only",25.86,34,,25.86,percent of total billed charges,"Drugs, Inpatient Only",25.86,34,,25.86,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,53.24,70,,53.24,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,25.35,,,25.35,Other,Drug Cost,25.35,,,25.35,Other,Drug Cost,25.35,,,25.35,Other,Drug Cost,25.35,,,25.35,Other,Drug Cost,25.35,,,25.35,Other,Drug Cost,25.35,,,25.35,Other,Drug Cost,57.04,,,57.04,Other,225% of Medicaid,35.49,,,35.49,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,54.51,,,54.51,Other,215% Medicaid APG methodology,54.51,,,54.51,Other,215% Medicaid APG methodology,31.69,,,31.69,Other,125% Medicaid APG methodology,0.01,57.04,
LANOLIN TOPICAL ONT,,,,80002466,CDM,250,RC,72140003868,NDC,both,1,EA,11.01,4.35,39.4668,,4.35,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,3.74,34,,3.74,percent of total billed charges,"Drugs, Inpatient Only",3.74,34,,3.74,percent of total billed charges,"Drugs, Inpatient Only",3.74,34,,3.74,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,7.71,70,,7.71,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,3.67,,,3.67,Other,Drug Cost,3.67,,,3.67,Other,Drug Cost,3.67,,,3.67,Other,Drug Cost,3.67,,,3.67,Other,Drug Cost,3.67,,,3.67,Other,Drug Cost,3.67,,,3.67,Other,Drug Cost,8.26,,,8.26,Other,225% of Medicaid,5.14,,,5.14,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,7.89,,,7.89,Other,215% Medicaid APG methodology,7.89,,,7.89,Other,215% Medicaid APG methodology,4.59,,,4.59,Other,125% Medicaid APG methodology,0.01,8.26,
POTASSIUM PHOSPHATE-SODIUM PHO PACK,,,,80002470,CDM,250,RC,80681017200,NDC,both,1.5,GM,0.84,0.33,39.4668,,0.33,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.28,34,,0.28,percent of total billed charges,"Drugs, Inpatient Only",0.28,34,,0.28,percent of total billed charges,"Drugs, Inpatient Only",0.28,34,,0.28,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.59,70,,0.59,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.28,,,0.28,Other,Drug Cost,0.28,,,0.28,Other,Drug Cost,0.28,,,0.28,Other,Drug Cost,0.28,,,0.28,Other,Drug Cost,0.28,,,0.28,Other,Drug Cost,0.28,,,0.28,Other,Drug Cost,0.63,,,0.63,Other,225% of Medicaid,0.39,,,0.39,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.6,,,0.6,Other,215% Medicaid APG methodology,0.6,,,0.6,Other,215% Medicaid APG methodology,0.35,,,0.35,Other,125% Medicaid APG methodology,0.01,0.63,
OXYCODONE 30MG TAB,,,,80002472,CDM,250,RC,406853001,NDC,both,100,EA,0.33,0.13,39.4668,,0.13,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.11,34,,0.11,percent of total billed charges,"Drugs, Inpatient Only",0.11,34,,0.11,percent of total billed charges,"Drugs, Inpatient Only",0.11,34,,0.11,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.23,70,,0.23,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.11,,,0.11,Other,Drug Cost,0.11,,,0.11,Other,Drug Cost,0.11,,,0.11,Other,Drug Cost,0.11,,,0.11,Other,Drug Cost,0.11,,,0.11,Other,Drug Cost,0.11,,,0.11,Other,Drug Cost,0.24,,,0.24,Other,225% of Medicaid,0.15,,,0.15,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.23,,,0.23,Other,215% Medicaid APG methodology,0.23,,,0.23,Other,215% Medicaid APG methodology,0.14,,,0.14,Other,125% Medicaid APG methodology,0.01,0.24,
OXYCODONE ER 20MG TAB,,,,80002473,CDM,250,RC,59011042010,NDC,both,100,EA,0.03,0.01,39.4668,,0.01,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.02,70,,0.02,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.02,,,0.02,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,0.02,
PENICILLIN 500MG TAB,,,,80002476,CDM,250,RC,93117401,NDC,both,100,EA,0.05,0.02,39.4668,,0.02,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.02,34,,0.02,percent of total billed charges,"Drugs, Inpatient Only",0.02,34,,0.02,percent of total billed charges,"Drugs, Inpatient Only",0.02,34,,0.02,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.03,70,,0.03,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.04,,,0.04,Other,225% of Medicaid,0.02,,,0.02,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.03,,,0.03,Other,215% Medicaid APG methodology,0.03,,,0.03,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,125% Medicaid APG methodology,0.01,0.04,
PREDNISONE 5MG/5ML SOLN,,,,80002479,CDM,250,RC,54372250,NDC,both,1,ML,57,22.5,39.4668,,22.5,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,19.38,34,,19.38,percent of total billed charges,"Drugs, Inpatient Only",19.38,34,,19.38,percent of total billed charges,"Drugs, Inpatient Only",19.38,34,,19.38,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,39.9,70,,39.9,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,19,,,19,Other,Drug Cost,19,,,19,Other,Drug Cost,19,,,19,Other,Drug Cost,19,,,19,Other,Drug Cost,19,,,19,Other,Drug Cost,19,,,19,Other,Drug Cost,42.75,,,42.75,Other,225% of Medicaid,26.6,,,26.6,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,40.85,,,40.85,Other,215% Medicaid APG methodology,40.85,,,40.85,Other,215% Medicaid APG methodology,23.75,,,23.75,Other,125% Medicaid APG methodology,0.01,42.75,
SELENIUM SULFIDE TOPICAL,,,,80002481,CDM,250,RC,45802004064,NDC,both,1,ML,10.02,3.95,39.4668,,3.95,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,3.41,34,,3.41,percent of total billed charges,"Drugs, Inpatient Only",3.41,34,,3.41,percent of total billed charges,"Drugs, Inpatient Only",3.41,34,,3.41,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,7.01,70,,7.01,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,3.34,,,3.34,Other,Drug Cost,3.34,,,3.34,Other,Drug Cost,3.34,,,3.34,Other,Drug Cost,3.34,,,3.34,Other,Drug Cost,3.34,,,3.34,Other,Drug Cost,3.34,,,3.34,Other,Drug Cost,7.52,,,7.52,Other,225% of Medicaid,4.68,,,4.68,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,7.18,,,7.18,Other,215% Medicaid APG methodology,7.18,,,7.18,Other,215% Medicaid APG methodology,4.18,,,4.18,Other,125% Medicaid APG methodology,0.01,7.52,
CINACALCET 30MG TAB,,,,80002482,CDM,250,RC,69097041002,NDC,both,30,EA,0.48,0.19,39.4668,,0.19,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.16,34,,0.16,percent of total billed charges,"Drugs, Inpatient Only",0.16,34,,0.16,percent of total billed charges,"Drugs, Inpatient Only",0.16,34,,0.16,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.34,70,,0.34,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.16,,,0.16,Other,Drug Cost,0.16,,,0.16,Other,Drug Cost,0.16,,,0.16,Other,Drug Cost,0.16,,,0.16,Other,Drug Cost,0.16,,,0.16,Other,Drug Cost,0.16,,,0.16,Other,Drug Cost,0.36,,,0.36,Other,225% of Medicaid,0.22,,,0.22,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.35,,,0.35,Other,215% Medicaid APG methodology,0.35,,,0.35,Other,215% Medicaid APG methodology,0.2,,,0.2,Other,125% Medicaid APG methodology,0.01,0.36,
SULFAMETHOXAZOLE-TRIMETHOPRIM INJ,,,,80002483,CDM,250,RC,67457077805,NDC,both,10,ML,9.52,3.76,39.4668,,3.76,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,3.24,34,,3.24,percent of total billed charges,"Drugs, Inpatient Only",3.24,34,,3.24,percent of total billed charges,"Drugs, Inpatient Only",3.24,34,,3.24,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,6.66,70,,6.66,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,3.17,,,3.17,Other,Drug Cost,3.17,,,3.17,Other,Drug Cost,3.17,,,3.17,Other,Drug Cost,3.17,,,3.17,Other,Drug Cost,3.17,,,3.17,Other,Drug Cost,3.17,,,3.17,Other,Drug Cost,7.14,,,7.14,Other,225% of Medicaid,4.44,,,4.44,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,6.82,,,6.82,Other,215% Medicaid APG methodology,6.82,,,6.82,Other,215% Medicaid APG methodology,3.97,,,3.97,Other,125% Medicaid APG methodology,0.01,7.14,
SODIUM PHOSPHATE 15MMOL/5ML INJ,,,,80002484,CDM,250,RC,409739172,NDC,both,25,ML,6.83,2.7,39.4668,,2.7,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2.32,34,,2.32,percent of total billed charges,"Drugs, Inpatient Only",2.32,34,,2.32,percent of total billed charges,"Drugs, Inpatient Only",2.32,34,,2.32,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,4.78,70,,4.78,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2.28,,,2.28,Other,Drug Cost,2.28,,,2.28,Other,Drug Cost,2.28,,,2.28,Other,Drug Cost,2.28,,,2.28,Other,Drug Cost,2.28,,,2.28,Other,Drug Cost,2.28,,,2.28,Other,Drug Cost,5.12,,,5.12,Other,225% of Medicaid,3.19,,,3.19,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,4.9,,,4.9,Other,215% Medicaid APG methodology,4.9,,,4.9,Other,215% Medicaid APG methodology,2.85,,,2.85,Other,125% Medicaid APG methodology,0.01,5.12,
FLECAINIDE 100MG TAB,,,,80002487,CDM,250,RC,50268032115,NDC,both,5,EA,15.47,6.11,39.4668,,6.11,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,5.26,34,,5.26,percent of total billed charges,"Drugs, Inpatient Only",5.26,34,,5.26,percent of total billed charges,"Drugs, Inpatient Only",5.26,34,,5.26,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,10.83,70,,10.83,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,5.16,,,5.16,Other,Drug Cost,5.16,,,5.16,Other,Drug Cost,5.16,,,5.16,Other,Drug Cost,5.16,,,5.16,Other,Drug Cost,5.16,,,5.16,Other,Drug Cost,5.16,,,5.16,Other,Drug Cost,11.61,,,11.61,Other,225% of Medicaid,7.22,,,7.22,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,11.09,,,11.09,Other,215% Medicaid APG methodology,11.09,,,11.09,Other,215% Medicaid APG methodology,6.45,,,6.45,Other,125% Medicaid APG methodology,0.01,11.61,
TRIAMCINOLONE ACETONIDE 0.5% CREAM,,,,80002488,CDM,250,RC,45802006535,NDC,both,1,GM,2.34,0.92,39.4668,,0.92,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.8,34,,0.8,percent of total billed charges,"Drugs, Inpatient Only",0.8,34,,0.8,percent of total billed charges,"Drugs, Inpatient Only",0.8,34,,0.8,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1.64,70,,1.64,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.78,,,0.78,Other,Drug Cost,0.78,,,0.78,Other,Drug Cost,0.78,,,0.78,Other,Drug Cost,0.78,,,0.78,Other,Drug Cost,0.78,,,0.78,Other,Drug Cost,0.78,,,0.78,Other,Drug Cost,1.76,,,1.76,Other,225% of Medicaid,1.09,,,1.09,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,1.68,,,1.68,Other,215% Medicaid APG methodology,1.68,,,1.68,Other,215% Medicaid APG methodology,0.98,,,0.98,Other,125% Medicaid APG methodology,0.01,1.76,
STERILE WATER 50ML VIAL,,,,80002492,CDM,250,RC,409488750,NDC,both,25,ML,5.63,2.22,39.4668,,2.22,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1.91,34,,1.91,percent of total billed charges,"Drugs, Inpatient Only",1.91,34,,1.91,percent of total billed charges,"Drugs, Inpatient Only",1.91,34,,1.91,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,3.94,70,,3.94,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1.88,,,1.88,Other,Drug Cost,1.88,,,1.88,Other,Drug Cost,1.88,,,1.88,Other,Drug Cost,1.88,,,1.88,Other,Drug Cost,1.88,,,1.88,Other,Drug Cost,1.88,,,1.88,Other,Drug Cost,4.22,,,4.22,Other,225% of Medicaid,2.63,,,2.63,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,4.03,,,4.03,Other,215% Medicaid APG methodology,4.03,,,4.03,Other,215% Medicaid APG methodology,2.35,,,2.35,Other,125% Medicaid APG methodology,0.01,4.22,
OSELTAMIVIR 30MG CAPS,,,,80002496,CDM,250,RC,68180067511,NDC,both,10,EA,0.74,0.29,39.4668,,0.29,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.25,34,,0.25,percent of total billed charges,"Drugs, Inpatient Only",0.25,34,,0.25,percent of total billed charges,"Drugs, Inpatient Only",0.25,34,,0.25,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.52,70,,0.52,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.25,,,0.25,Other,Drug Cost,0.25,,,0.25,Other,Drug Cost,0.25,,,0.25,Other,Drug Cost,0.25,,,0.25,Other,Drug Cost,0.25,,,0.25,Other,Drug Cost,0.25,,,0.25,Other,Drug Cost,0.56,,,0.56,Other,225% of Medicaid,0.35,,,0.35,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.53,,,0.53,Other,215% Medicaid APG methodology,0.53,,,0.53,Other,215% Medicaid APG methodology,0.31,,,0.31,Other,125% Medicaid APG methodology,0.01,0.56,
MORPHINE 10MG/5ML ORAL SOLN,,,,80002501,CDM,250,RC,54023749,NDC,both,1,ML,8.7,3.43,39.4668,,3.43,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2.96,34,,2.96,percent of total billed charges,"Drugs, Inpatient Only",2.96,34,,2.96,percent of total billed charges,"Drugs, Inpatient Only",2.96,34,,2.96,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,6.09,70,,6.09,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2.9,,,2.9,Other,Drug Cost,2.9,,,2.9,Other,Drug Cost,2.9,,,2.9,Other,Drug Cost,2.9,,,2.9,Other,Drug Cost,2.9,,,2.9,Other,Drug Cost,2.9,,,2.9,Other,Drug Cost,6.53,,,6.53,Other,225% of Medicaid,4.06,,,4.06,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,6.24,,,6.24,Other,215% Medicaid APG methodology,6.24,,,6.24,Other,215% Medicaid APG methodology,3.63,,,3.63,Other,125% Medicaid APG methodology,0.01,6.53,
FLUCONAZOLE 150MG TAB,,,,80002508,CDM,250,RC,57237000511,NDC,both,12,EA,0.49,0.19,39.4668,,0.19,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.17,34,,0.17,percent of total billed charges,"Drugs, Inpatient Only",0.17,34,,0.17,percent of total billed charges,"Drugs, Inpatient Only",0.17,34,,0.17,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.34,70,,0.34,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.16,,,0.16,Other,Drug Cost,0.16,,,0.16,Other,Drug Cost,0.16,,,0.16,Other,Drug Cost,0.16,,,0.16,Other,Drug Cost,0.16,,,0.16,Other,Drug Cost,0.16,,,0.16,Other,Drug Cost,0.37,,,0.37,Other,225% of Medicaid,0.23,,,0.23,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.35,,,0.35,Other,215% Medicaid APG methodology,0.35,,,0.35,Other,215% Medicaid APG methodology,0.2,,,0.2,Other,125% Medicaid APG methodology,0.01,0.37,
LUBRICANT EYE DROPS,,,,80002514,CDM,250,RC,23455430,NDC,both,30,ML,0.83,0.33,39.4668,,0.33,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.28,34,,0.28,percent of total billed charges,"Drugs, Inpatient Only",0.28,34,,0.28,percent of total billed charges,"Drugs, Inpatient Only",0.28,34,,0.28,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.58,70,,0.58,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.28,,,0.28,Other,Drug Cost,0.28,,,0.28,Other,Drug Cost,0.28,,,0.28,Other,Drug Cost,0.28,,,0.28,Other,Drug Cost,0.28,,,0.28,Other,Drug Cost,0.28,,,0.28,Other,Drug Cost,0.62,,,0.62,Other,225% of Medicaid,0.39,,,0.39,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.59,,,0.59,Other,215% Medicaid APG methodology,0.59,,,0.59,Other,215% Medicaid APG methodology,0.34,,,0.34,Other,125% Medicaid APG methodology,0.01,0.62,
HYDROXOCOBALAMIN (CYANOKIT),,,,80002517,CDM,250,RC,50633031011,NDC,both,1,EA,2712.27,1070.45,39.4668,,1070.45,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,922.17,34,,922.17,percent of total billed charges,"Drugs, Inpatient Only",922.17,34,,922.17,percent of total billed charges,"Drugs, Inpatient Only",922.17,34,,922.17,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1898.59,70,,1898.59,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,904.09,,,904.09,Other,Drug Cost,904.09,,,904.09,Other,Drug Cost,904.09,,,904.09,Other,Drug Cost,904.09,,,904.09,Other,Drug Cost,904.09,,,904.09,Other,Drug Cost,904.09,,,904.09,Other,Drug Cost,2034.2,,,2034.2,Other,225% of Medicaid,1265.73,,,1265.73,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,1943.79,,,1943.79,Other,215% Medicaid APG methodology,1943.79,,,1943.79,Other,215% Medicaid APG methodology,1130.11,,,1130.11,Other,125% Medicaid APG methodology,0.01,2034.2,
ASCORBIC ACID 500MG/ML 50ML,,,,80002520,CDM,250,RC,67157010150,NDC,both,1,ML,735.42,290.25,39.4668,,290.25,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,250.04,34,,250.04,percent of total billed charges,"Drugs, Inpatient Only",250.04,34,,250.04,percent of total billed charges,"Drugs, Inpatient Only",250.04,34,,250.04,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,514.79,70,,514.79,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,245.14,,,245.14,Other,Drug Cost,245.14,,,245.14,Other,Drug Cost,245.14,,,245.14,Other,Drug Cost,245.14,,,245.14,Other,Drug Cost,245.14,,,245.14,Other,Drug Cost,245.14,,,245.14,Other,Drug Cost,551.57,,,551.57,Other,225% of Medicaid,343.2,,,343.2,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,527.05,,,527.05,Other,215% Medicaid APG methodology,527.05,,,527.05,Other,215% Medicaid APG methodology,306.43,,,306.43,Other,125% Medicaid APG methodology,0.01,551.57,
APIXABAN 2.5MG TAB,,,,80002522,CDM,250,RC,3089321,NDC,both,60,EA,0.69,0.27,39.4668,,0.27,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.23,34,,0.23,percent of total billed charges,"Drugs, Inpatient Only",0.23,34,,0.23,percent of total billed charges,"Drugs, Inpatient Only",0.23,34,,0.23,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.48,70,,0.48,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.23,,,0.23,Other,Drug Cost,0.23,,,0.23,Other,Drug Cost,0.23,,,0.23,Other,Drug Cost,0.23,,,0.23,Other,Drug Cost,0.23,,,0.23,Other,Drug Cost,0.23,,,0.23,Other,Drug Cost,0.52,,,0.52,Other,225% of Medicaid,0.32,,,0.32,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.49,,,0.49,Other,215% Medicaid APG methodology,0.49,,,0.49,Other,215% Medicaid APG methodology,0.29,,,0.29,Other,125% Medicaid APG methodology,0.01,0.52,
APIXABAN 5MG TAB,,,,80002523,CDM,250,RC,3089421,NDC,both,60,EA,0.23,0.09,39.4668,,0.09,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.08,34,,0.08,percent of total billed charges,"Drugs, Inpatient Only",0.08,34,,0.08,percent of total billed charges,"Drugs, Inpatient Only",0.08,34,,0.08,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.16,70,,0.16,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.08,,,0.08,Other,Drug Cost,0.08,,,0.08,Other,Drug Cost,0.08,,,0.08,Other,Drug Cost,0.08,,,0.08,Other,Drug Cost,0.08,,,0.08,Other,Drug Cost,0.08,,,0.08,Other,Drug Cost,0.17,,,0.17,Other,225% of Medicaid,0.11,,,0.11,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.17,,,0.17,Other,215% Medicaid APG methodology,0.17,,,0.17,Other,215% Medicaid APG methodology,0.1,,,0.1,Other,125% Medicaid APG methodology,0.01,0.17,
CLINIMIX 5/15 1000ML,,,,80002532,CDM,250,RC,338113703,NDC,both,6,ML,41.75,16.48,39.4668,,16.48,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,14.19,34,,14.19,percent of total billed charges,"Drugs, Inpatient Only",14.19,34,,14.19,percent of total billed charges,"Drugs, Inpatient Only",14.19,34,,14.19,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,29.22,70,,29.22,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,13.92,,,13.92,Other,Drug Cost,13.92,,,13.92,Other,Drug Cost,13.92,,,13.92,Other,Drug Cost,13.92,,,13.92,Other,Drug Cost,13.92,,,13.92,Other,Drug Cost,13.92,,,13.92,Other,Drug Cost,31.31,,,31.31,Other,225% of Medicaid,19.48,,,19.48,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,29.92,,,29.92,Other,215% Medicaid APG methodology,29.92,,,29.92,Other,215% Medicaid APG methodology,17.39,,,17.39,Other,125% Medicaid APG methodology,0.01,31.31,
COLLAGENASE OINT 5GM,,,,80002534,CDM,250,RC,50484001030,NDC,both,1,GM,616.29,243.23,39.4668,,243.23,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,209.54,34,,209.54,percent of total billed charges,"Drugs, Inpatient Only",209.54,34,,209.54,percent of total billed charges,"Drugs, Inpatient Only",209.54,34,,209.54,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,431.4,70,,431.4,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,205.43,,,205.43,Other,Drug Cost,205.43,,,205.43,Other,Drug Cost,205.43,,,205.43,Other,Drug Cost,205.43,,,205.43,Other,Drug Cost,205.43,,,205.43,Other,Drug Cost,205.43,,,205.43,Other,Drug Cost,462.22,,,462.22,Other,225% of Medicaid,287.6,,,287.6,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,441.67,,,441.67,Other,215% Medicaid APG methodology,441.67,,,441.67,Other,215% Medicaid APG methodology,256.79,,,256.79,Other,125% Medicaid APG methodology,0.01,462.22,
GENTAMICIN 0.1% OINT 5GM,,,,80002545,CDM,250,RC,45802004611,NDC,both,1,GM,15.42,6.09,39.4668,,6.09,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,5.24,34,,5.24,percent of total billed charges,"Drugs, Inpatient Only",5.24,34,,5.24,percent of total billed charges,"Drugs, Inpatient Only",5.24,34,,5.24,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,10.79,70,,10.79,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,5.14,,,5.14,Other,Drug Cost,5.14,,,5.14,Other,Drug Cost,5.14,,,5.14,Other,Drug Cost,5.14,,,5.14,Other,Drug Cost,5.14,,,5.14,Other,Drug Cost,5.14,,,5.14,Other,Drug Cost,11.57,,,11.57,Other,225% of Medicaid,7.2,,,7.2,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,11.05,,,11.05,Other,215% Medicaid APG methodology,11.05,,,11.05,Other,215% Medicaid APG methodology,6.43,,,6.43,Other,125% Medicaid APG methodology,0.01,11.57,
HEMORRHOIDAL OINT 57GM,,,,80002549,CDM,250,RC,45802018816,NDC,both,1,GM,3.18,1.26,39.4668,,1.26,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1.08,34,,1.08,percent of total billed charges,"Drugs, Inpatient Only",1.08,34,,1.08,percent of total billed charges,"Drugs, Inpatient Only",1.08,34,,1.08,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2.23,70,,2.23,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1.06,,,1.06,Other,Drug Cost,1.06,,,1.06,Other,Drug Cost,1.06,,,1.06,Other,Drug Cost,1.06,,,1.06,Other,Drug Cost,1.06,,,1.06,Other,Drug Cost,1.06,,,1.06,Other,Drug Cost,2.39,,,2.39,Other,225% of Medicaid,1.48,,,1.48,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,2.28,,,2.28,Other,215% Medicaid APG methodology,2.28,,,2.28,Other,215% Medicaid APG methodology,1.33,,,1.33,Other,125% Medicaid APG methodology,0.01,2.39,
LIDOCAINE 4% LARYNGO-O-JET,,,,80002560,CDM,250,RC,76329630005,NDC,both,25,ML,5.11,2.02,39.4668,,2.02,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1.74,34,,1.74,percent of total billed charges,"Drugs, Inpatient Only",1.74,34,,1.74,percent of total billed charges,"Drugs, Inpatient Only",1.74,34,,1.74,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,3.58,70,,3.58,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1.7,,,1.7,Other,Drug Cost,1.7,,,1.7,Other,Drug Cost,1.7,,,1.7,Other,Drug Cost,1.7,,,1.7,Other,Drug Cost,1.7,,,1.7,Other,Drug Cost,1.7,,,1.7,Other,Drug Cost,3.83,,,3.83,Other,225% of Medicaid,2.38,,,2.38,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,3.66,,,3.66,Other,215% Medicaid APG methodology,3.66,,,3.66,Other,215% Medicaid APG methodology,2.13,,,2.13,Other,125% Medicaid APG methodology,0.01,3.83,
MANNITOL 20% 500ML,,,,80002561,CDM,250,RC,338035703,NDC,both,24,ML,14.4,5.68,39.4668,,5.68,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,4.9,34,,4.9,percent of total billed charges,"Drugs, Inpatient Only",4.9,34,,4.9,percent of total billed charges,"Drugs, Inpatient Only",4.9,34,,4.9,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,10.08,70,,10.08,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,4.8,,,4.8,Other,Drug Cost,4.8,,,4.8,Other,Drug Cost,4.8,,,4.8,Other,Drug Cost,4.8,,,4.8,Other,Drug Cost,4.8,,,4.8,Other,Drug Cost,4.8,,,4.8,Other,Drug Cost,10.8,,,10.8,Other,225% of Medicaid,6.72,,,6.72,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,10.32,,,10.32,Other,215% Medicaid APG methodology,10.32,,,10.32,Other,215% Medicaid APG methodology,6,,,6,Other,125% Medicaid APG methodology,0.01,10.8,
MELOXICAM 15MG TAB,,,,80002563,CDM,250,RC,29300012501,NDC,both,100,EA,0.03,0.01,39.4668,,0.01,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.02,70,,0.02,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.03,,,0.03,Other,225% of Medicaid,0.02,,,0.02,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,0.03,
MORPHINE PF 2MG/ML CARP,,,,80002569,CDM,250,RC,409189001,NDC,both,10,ML,2.39,0.94,39.4668,,0.94,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.81,34,,0.81,percent of total billed charges,"Drugs, Inpatient Only",0.81,34,,0.81,percent of total billed charges,"Drugs, Inpatient Only",0.81,34,,0.81,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1.67,70,,1.67,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.8,,,0.8,Other,Drug Cost,0.8,,,0.8,Other,Drug Cost,0.8,,,0.8,Other,Drug Cost,0.8,,,0.8,Other,Drug Cost,0.8,,,0.8,Other,Drug Cost,0.8,,,0.8,Other,Drug Cost,1.79,,,1.79,Other,225% of Medicaid,1.12,,,1.12,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,1.71,,,1.71,Other,215% Medicaid APG methodology,1.71,,,1.71,Other,215% Medicaid APG methodology,1,,,1,Other,125% Medicaid APG methodology,0.01,1.79,
POTASSIUM PHOSPHATE 15MMOL/5ML INJ,,,,80002583,CDM,250,RC,65219005429,NDC,both,25,ML,22.75,8.98,39.4668,,8.98,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,7.73,34,,7.73,percent of total billed charges,"Drugs, Inpatient Only",7.73,34,,7.73,percent of total billed charges,"Drugs, Inpatient Only",7.73,34,,7.73,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,15.92,70,,15.92,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,7.58,,,7.58,Other,Drug Cost,7.58,,,7.58,Other,Drug Cost,7.58,,,7.58,Other,Drug Cost,7.58,,,7.58,Other,Drug Cost,7.58,,,7.58,Other,Drug Cost,7.58,,,7.58,Other,Drug Cost,17.06,,,17.06,Other,225% of Medicaid,10.62,,,10.62,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,16.3,,,16.3,Other,215% Medicaid APG methodology,16.3,,,16.3,Other,215% Medicaid APG methodology,9.48,,,9.48,Other,125% Medicaid APG methodology,0.01,17.06,
QUETIAPINE 50MG TAB,,,,80002584,CDM,250,RC,904663961,NDC,both,10,EA,0.82,0.32,39.4668,,0.32,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.28,34,,0.28,percent of total billed charges,"Drugs, Inpatient Only",0.28,34,,0.28,percent of total billed charges,"Drugs, Inpatient Only",0.28,34,,0.28,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.58,70,,0.58,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.27,,,0.27,Other,Drug Cost,0.27,,,0.27,Other,Drug Cost,0.27,,,0.27,Other,Drug Cost,0.27,,,0.27,Other,Drug Cost,0.27,,,0.27,Other,Drug Cost,0.27,,,0.27,Other,Drug Cost,0.62,,,0.62,Other,225% of Medicaid,0.38,,,0.38,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.59,,,0.59,Other,215% Medicaid APG methodology,0.59,,,0.59,Other,215% Medicaid APG methodology,0.34,,,0.34,Other,125% Medicaid APG methodology,0.01,0.62,
RITONAVIR 100MG TABLET,,,,80002590,CDM,250,RC,65862068730,NDC,both,30,EA,0.94,0.37,39.4668,,0.37,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.32,34,,0.32,percent of total billed charges,"Drugs, Inpatient Only",0.32,34,,0.32,percent of total billed charges,"Drugs, Inpatient Only",0.32,34,,0.32,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.66,70,,0.66,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.31,,,0.31,Other,Drug Cost,0.31,,,0.31,Other,Drug Cost,0.31,,,0.31,Other,Drug Cost,0.31,,,0.31,Other,Drug Cost,0.31,,,0.31,Other,Drug Cost,0.31,,,0.31,Other,Drug Cost,0.71,,,0.71,Other,225% of Medicaid,0.44,,,0.44,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.68,,,0.68,Other,215% Medicaid APG methodology,0.68,,,0.68,Other,215% Medicaid APG methodology,0.39,,,0.39,Other,125% Medicaid APG methodology,0.01,0.71,
VALSARTAN 160MG TAB,,,,80002603,CDM,250,RC,78035934,NDC,both,90,EA,0.03,0.01,39.4668,,0.01,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.02,70,,0.02,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.02,,,0.02,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,0.02,
VERAPAMIL ER 120MG TAB,,,,80002604,CDM,250,RC,68462029201,NDC,both,100,EA,0.21,0.08,39.4668,,0.08,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.07,34,,0.07,percent of total billed charges,"Drugs, Inpatient Only",0.07,34,,0.07,percent of total billed charges,"Drugs, Inpatient Only",0.07,34,,0.07,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.15,70,,0.15,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.07,,,0.07,Other,Drug Cost,0.07,,,0.07,Other,Drug Cost,0.07,,,0.07,Other,Drug Cost,0.07,,,0.07,Other,Drug Cost,0.07,,,0.07,Other,Drug Cost,0.07,,,0.07,Other,Drug Cost,0.16,,,0.16,Other,225% of Medicaid,0.1,,,0.1,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.15,,,0.15,Other,215% Medicaid APG methodology,0.15,,,0.15,Other,215% Medicaid APG methodology,0.09,,,0.09,Other,125% Medicaid APG methodology,0.01,0.16,
TRANEXAMIC ACID 1000MG,,,,80002606,CDM,250,RC,55150018810,NDC,both,10,ML,5.97,2.36,39.4668,,2.36,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2.03,34,,2.03,percent of total billed charges,"Drugs, Inpatient Only",2.03,34,,2.03,percent of total billed charges,"Drugs, Inpatient Only",2.03,34,,2.03,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,4.18,70,,4.18,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1.99,,,1.99,Other,Drug Cost,1.99,,,1.99,Other,Drug Cost,1.99,,,1.99,Other,Drug Cost,1.99,,,1.99,Other,Drug Cost,1.99,,,1.99,Other,Drug Cost,1.99,,,1.99,Other,Drug Cost,4.48,,,4.48,Other,225% of Medicaid,2.79,,,2.79,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,4.28,,,4.28,Other,215% Medicaid APG methodology,4.28,,,4.28,Other,215% Medicaid APG methodology,2.49,,,2.49,Other,125% Medicaid APG methodology,0.01,4.48,
MARAVIROC 300MG TABLET,,,,80002607,CDM,250,RC,49702022418,NDC,both,60,EA,41.72,16.46,39.4668,,16.46,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,14.18,34,,14.18,percent of total billed charges,"Drugs, Inpatient Only",14.18,34,,14.18,percent of total billed charges,"Drugs, Inpatient Only",14.18,34,,14.18,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,29.2,70,,29.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,13.91,,,13.91,Other,Drug Cost,13.91,,,13.91,Other,Drug Cost,13.91,,,13.91,Other,Drug Cost,13.91,,,13.91,Other,Drug Cost,13.91,,,13.91,Other,Drug Cost,13.91,,,13.91,Other,Drug Cost,31.29,,,31.29,Other,225% of Medicaid,19.47,,,19.47,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,29.9,,,29.9,Other,215% Medicaid APG methodology,29.9,,,29.9,Other,215% Medicaid APG methodology,17.38,,,17.38,Other,125% Medicaid APG methodology,0.01,31.29,
METHENAMINE HIPPURATE 1GM TAB,,,,80002614,CDM,250,RC,65862078201,NDC,both,100,EA,0.4,0.16,39.4668,,0.16,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.13,34,,0.13,percent of total billed charges,"Drugs, Inpatient Only",0.13,34,,0.13,percent of total billed charges,"Drugs, Inpatient Only",0.13,34,,0.13,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.28,70,,0.28,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.13,,,0.13,Other,Drug Cost,0.13,,,0.13,Other,Drug Cost,0.13,,,0.13,Other,Drug Cost,0.13,,,0.13,Other,Drug Cost,0.13,,,0.13,Other,Drug Cost,0.13,,,0.13,Other,Drug Cost,0.3,,,0.3,Other,225% of Medicaid,0.19,,,0.19,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.28,,,0.28,Other,215% Medicaid APG methodology,0.28,,,0.28,Other,215% Medicaid APG methodology,0.17,,,0.17,Other,125% Medicaid APG methodology,0.01,0.3,
LEVOCARNITINE 200MG/ML 5ML INJ,,,,80002617,CDM,250,RC,54482014701,NDC,both,5,ML,64.06,25.28,39.4668,,25.28,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,21.78,34,,21.78,percent of total billed charges,"Drugs, Inpatient Only",21.78,34,,21.78,percent of total billed charges,"Drugs, Inpatient Only",21.78,34,,21.78,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,44.84,70,,44.84,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,21.35,,,21.35,Other,Drug Cost,21.35,,,21.35,Other,Drug Cost,21.35,,,21.35,Other,Drug Cost,21.35,,,21.35,Other,Drug Cost,21.35,,,21.35,Other,Drug Cost,21.35,,,21.35,Other,Drug Cost,48.04,,,48.04,Other,225% of Medicaid,29.89,,,29.89,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,45.91,,,45.91,Other,215% Medicaid APG methodology,45.91,,,45.91,Other,215% Medicaid APG methodology,26.69,,,26.69,Other,125% Medicaid APG methodology,0.01,48.04,
INSULIN DRIP,,,,80002633,CDM,250,RC,338012612,NDC,both,12,ML,28.59,11.28,39.4668,,11.28,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,9.72,34,,9.72,percent of total billed charges,"Drugs, Inpatient Only",9.72,34,,9.72,percent of total billed charges,"Drugs, Inpatient Only",9.72,34,,9.72,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,20.01,70,,20.01,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,9.53,,,9.53,Other,Drug Cost,9.53,,,9.53,Other,Drug Cost,9.53,,,9.53,Other,Drug Cost,9.53,,,9.53,Other,Drug Cost,9.53,,,9.53,Other,Drug Cost,9.53,,,9.53,Other,Drug Cost,21.44,,,21.44,Other,225% of Medicaid,13.34,,,13.34,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,20.49,,,20.49,Other,215% Medicaid APG methodology,20.49,,,20.49,Other,215% Medicaid APG methodology,11.91,,,11.91,Other,125% Medicaid APG methodology,0.01,21.44,
RIVAROXABAN 15MG TABLET,,,,80002636,CDM,250,RC,50458057830,NDC,both,30,EA,0.03,0.01,39.4668,,0.01,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.02,70,,0.02,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.02,,,0.02,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,0.02,
RIVAROXABAN 20MG TABLET,,,,80002637,CDM,250,RC,50458057930,NDC,both,30,EA,0.03,0.01,39.4668,,0.01,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.02,70,,0.02,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.02,,,0.02,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,0.02,
DEXTROSE 50% 50ML VIAL,,,,80002644,CDM,250,RC,409664802,NDC,both,25,ML,7.54,2.98,39.4668,,2.98,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2.56,34,,2.56,percent of total billed charges,"Drugs, Inpatient Only",2.56,34,,2.56,percent of total billed charges,"Drugs, Inpatient Only",2.56,34,,2.56,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,5.28,70,,5.28,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2.51,,,2.51,Other,Drug Cost,2.51,,,2.51,Other,Drug Cost,2.51,,,2.51,Other,Drug Cost,2.51,,,2.51,Other,Drug Cost,2.51,,,2.51,Other,Drug Cost,2.51,,,2.51,Other,Drug Cost,5.66,,,5.66,Other,225% of Medicaid,3.52,,,3.52,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,5.41,,,5.41,Other,215% Medicaid APG methodology,5.41,,,5.41,Other,215% Medicaid APG methodology,3.14,,,3.14,Other,125% Medicaid APG methodology,0.01,5.66,
PHENOBARBITAL 32.4MG TABLET,,,,80002651,CDM,250,RC,13517011101,NDC,both,100,EA,0.12,0.05,39.4668,,0.05,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.04,34,,0.04,percent of total billed charges,"Drugs, Inpatient Only",0.04,34,,0.04,percent of total billed charges,"Drugs, Inpatient Only",0.04,34,,0.04,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.09,70,,0.09,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.09,,,0.09,Other,225% of Medicaid,0.06,,,0.06,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.09,,,0.09,Other,215% Medicaid APG methodology,0.09,,,0.09,Other,215% Medicaid APG methodology,0.05,,,0.05,Other,125% Medicaid APG methodology,0.01,0.09,
LINAGLIPTIN 5MG TAB,,,,80002655,CDM,250,RC,597014030,NDC,both,30,EA,0.03,0.01,39.4668,,0.01,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.02,70,,0.02,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.02,,,0.02,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,0.02,
SILVER SULFADIAZINE CREAM 20 GRAM,,,,80002662,CDM,250,RC,67877012420,NDC,both,1,GM,1.83,0.72,39.4668,,0.72,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.62,34,,0.62,percent of total billed charges,"Drugs, Inpatient Only",0.62,34,,0.62,percent of total billed charges,"Drugs, Inpatient Only",0.62,34,,0.62,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1.28,70,,1.28,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.61,,,0.61,Other,Drug Cost,0.61,,,0.61,Other,Drug Cost,0.61,,,0.61,Other,Drug Cost,0.61,,,0.61,Other,Drug Cost,0.61,,,0.61,Other,Drug Cost,0.61,,,0.61,Other,Drug Cost,1.37,,,1.37,Other,225% of Medicaid,0.85,,,0.85,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,1.31,,,1.31,Other,215% Medicaid APG methodology,1.31,,,1.31,Other,215% Medicaid APG methodology,0.76,,,0.76,Other,125% Medicaid APG methodology,0.01,1.37,
PHENOBARBITAL 97.2MG TABLET,,,,80002666,CDM,250,RC,603516821,NDC,both,100,EA,0.21,0.08,39.4668,,0.08,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.07,34,,0.07,percent of total billed charges,"Drugs, Inpatient Only",0.07,34,,0.07,percent of total billed charges,"Drugs, Inpatient Only",0.07,34,,0.07,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.15,70,,0.15,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.07,,,0.07,Other,Drug Cost,0.07,,,0.07,Other,Drug Cost,0.07,,,0.07,Other,Drug Cost,0.07,,,0.07,Other,Drug Cost,0.07,,,0.07,Other,Drug Cost,0.07,,,0.07,Other,Drug Cost,0.16,,,0.16,Other,225% of Medicaid,0.1,,,0.1,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.15,,,0.15,Other,215% Medicaid APG methodology,0.15,,,0.15,Other,215% Medicaid APG methodology,0.09,,,0.09,Other,125% Medicaid APG methodology,0.01,0.16,
MINOCYCLINE 50MG CAP,,,,80002673,CDM,250,RC,591569460,NDC,both,60,EA,0.24,0.09,39.4668,,0.09,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.08,34,,0.08,percent of total billed charges,"Drugs, Inpatient Only",0.08,34,,0.08,percent of total billed charges,"Drugs, Inpatient Only",0.08,34,,0.08,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.17,70,,0.17,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.08,,,0.08,Other,Drug Cost,0.08,,,0.08,Other,Drug Cost,0.08,,,0.08,Other,Drug Cost,0.08,,,0.08,Other,Drug Cost,0.08,,,0.08,Other,Drug Cost,0.08,,,0.08,Other,Drug Cost,0.18,,,0.18,Other,225% of Medicaid,0.11,,,0.11,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.17,,,0.17,Other,215% Medicaid APG methodology,0.17,,,0.17,Other,215% Medicaid APG methodology,0.1,,,0.1,Other,125% Medicaid APG methodology,0.01,0.18,
ATOMOXETINE 40MG TABLET,,,,80002674,CDM,250,RC,68462026830,NDC,both,30,EA,0.86,0.34,39.4668,,0.34,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.29,34,,0.29,percent of total billed charges,"Drugs, Inpatient Only",0.29,34,,0.29,percent of total billed charges,"Drugs, Inpatient Only",0.29,34,,0.29,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.6,70,,0.6,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.29,,,0.29,Other,Drug Cost,0.29,,,0.29,Other,Drug Cost,0.29,,,0.29,Other,Drug Cost,0.29,,,0.29,Other,Drug Cost,0.29,,,0.29,Other,Drug Cost,0.29,,,0.29,Other,Drug Cost,0.64,,,0.64,Other,225% of Medicaid,0.4,,,0.4,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.61,,,0.61,Other,215% Medicaid APG methodology,0.61,,,0.61,Other,215% Medicaid APG methodology,0.36,,,0.36,Other,125% Medicaid APG methodology,0.01,0.64,
EPIVIR 10MG/ML,,,,80002677,CDM,250,RC,57237027424,NDC,both,1,ML,104.1,41.08,39.4668,,41.08,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,35.39,34,,35.39,percent of total billed charges,"Drugs, Inpatient Only",35.39,34,,35.39,percent of total billed charges,"Drugs, Inpatient Only",35.39,34,,35.39,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,72.87,70,,72.87,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,34.7,,,34.7,Other,Drug Cost,34.7,,,34.7,Other,Drug Cost,34.7,,,34.7,Other,Drug Cost,34.7,,,34.7,Other,Drug Cost,34.7,,,34.7,Other,Drug Cost,34.7,,,34.7,Other,Drug Cost,78.08,,,78.08,Other,225% of Medicaid,48.58,,,48.58,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,74.61,,,74.61,Other,215% Medicaid APG methodology,74.61,,,74.61,Other,215% Medicaid APG methodology,43.38,,,43.38,Other,125% Medicaid APG methodology,0.01,78.08,
DARUNAVIR 800MG TABLET,,,,80002680,CDM,250,RC,59676056630,NDC,both,30,EA,62.76,24.77,39.4668,,24.77,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,21.34,34,,21.34,percent of total billed charges,"Drugs, Inpatient Only",21.34,34,,21.34,percent of total billed charges,"Drugs, Inpatient Only",21.34,34,,21.34,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,43.93,70,,43.93,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,20.92,,,20.92,Other,Drug Cost,20.92,,,20.92,Other,Drug Cost,20.92,,,20.92,Other,Drug Cost,20.92,,,20.92,Other,Drug Cost,20.92,,,20.92,Other,Drug Cost,20.92,,,20.92,Other,Drug Cost,47.07,,,47.07,Other,225% of Medicaid,29.29,,,29.29,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,44.98,,,44.98,Other,215% Medicaid APG methodology,44.98,,,44.98,Other,215% Medicaid APG methodology,26.15,,,26.15,Other,125% Medicaid APG methodology,0.01,47.07,
PHENOL EZ SWABS,,,,80002686,CDM,250,RC,884629730,NDC,both,30,EA,15.33,6.05,39.4668,,6.05,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,5.21,34,,5.21,percent of total billed charges,"Drugs, Inpatient Only",5.21,34,,5.21,percent of total billed charges,"Drugs, Inpatient Only",5.21,34,,5.21,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,10.73,70,,10.73,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,5.11,,,5.11,Other,Drug Cost,5.11,,,5.11,Other,Drug Cost,5.11,,,5.11,Other,Drug Cost,5.11,,,5.11,Other,Drug Cost,5.11,,,5.11,Other,Drug Cost,5.11,,,5.11,Other,Drug Cost,11.5,,,11.5,Other,225% of Medicaid,7.15,,,7.15,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,10.99,,,10.99,Other,215% Medicaid APG methodology,10.99,,,10.99,Other,215% Medicaid APG methodology,6.39,,,6.39,Other,125% Medicaid APG methodology,0.01,11.5,
TOLVAPTAN 15MG TABLET,,,,80002688,CDM,250,RC,67877063533,NDC,both,10,EA,58.13,22.94,39.4668,,22.94,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,19.76,34,,19.76,percent of total billed charges,"Drugs, Inpatient Only",19.76,34,,19.76,percent of total billed charges,"Drugs, Inpatient Only",19.76,34,,19.76,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,40.69,70,,40.69,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,19.38,,,19.38,Other,Drug Cost,19.38,,,19.38,Other,Drug Cost,19.38,,,19.38,Other,Drug Cost,19.38,,,19.38,Other,Drug Cost,19.38,,,19.38,Other,Drug Cost,19.38,,,19.38,Other,Drug Cost,43.59,,,43.59,Other,225% of Medicaid,27.13,,,27.13,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,41.66,,,41.66,Other,215% Medicaid APG methodology,41.66,,,41.66,Other,215% Medicaid APG methodology,24.22,,,24.22,Other,125% Medicaid APG methodology,0.01,43.59,
MESALAMINE DR 400 MG CAP,,,,80002689,CDM,250,RC,59762011701,NDC,both,180,EA,2,0.79,39.4668,,0.79,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.68,34,,0.68,percent of total billed charges,"Drugs, Inpatient Only",0.68,34,,0.68,percent of total billed charges,"Drugs, Inpatient Only",0.68,34,,0.68,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1.4,70,,1.4,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.67,,,0.67,Other,Drug Cost,0.67,,,0.67,Other,Drug Cost,0.67,,,0.67,Other,Drug Cost,0.67,,,0.67,Other,Drug Cost,0.67,,,0.67,Other,Drug Cost,0.67,,,0.67,Other,Drug Cost,1.5,,,1.5,Other,225% of Medicaid,0.93,,,0.93,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,1.43,,,1.43,Other,215% Medicaid APG methodology,1.43,,,1.43,Other,215% Medicaid APG methodology,0.83,,,0.83,Other,125% Medicaid APG methodology,0.01,1.5,
OSELTAMIVIR 6MG/ML 60ML SOLN,,,,80002691,CDM,250,RC,4082205,NDC,both,1,ML,246.78,97.4,39.4668,,97.4,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,83.91,34,,83.91,percent of total billed charges,"Drugs, Inpatient Only",83.91,34,,83.91,percent of total billed charges,"Drugs, Inpatient Only",83.91,34,,83.91,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,172.75,70,,172.75,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,82.26,,,82.26,Other,Drug Cost,82.26,,,82.26,Other,Drug Cost,82.26,,,82.26,Other,Drug Cost,82.26,,,82.26,Other,Drug Cost,82.26,,,82.26,Other,Drug Cost,82.26,,,82.26,Other,Drug Cost,185.09,,,185.09,Other,225% of Medicaid,115.16,,,115.16,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,176.86,,,176.86,Other,215% Medicaid APG methodology,176.86,,,176.86,Other,215% Medicaid APG methodology,102.83,,,102.83,Other,125% Medicaid APG methodology,0.01,185.09,
NIMBEX 100MG/100ML,,,,80002692,CDM,250,RC,74438010,NDC,both,10,ML,74.75,29.5,39.4668,,29.5,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,25.41,34,,25.41,percent of total billed charges,"Drugs, Inpatient Only",25.41,34,,25.41,percent of total billed charges,"Drugs, Inpatient Only",25.41,34,,25.41,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,52.32,70,,52.32,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,24.92,,,24.92,Other,Drug Cost,24.92,,,24.92,Other,Drug Cost,24.92,,,24.92,Other,Drug Cost,24.92,,,24.92,Other,Drug Cost,24.92,,,24.92,Other,Drug Cost,24.92,,,24.92,Other,Drug Cost,56.06,,,56.06,Other,225% of Medicaid,34.88,,,34.88,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,53.57,,,53.57,Other,215% Medicaid APG methodology,53.57,,,53.57,Other,215% Medicaid APG methodology,31.15,,,31.15,Other,125% Medicaid APG methodology,0.01,56.06,
DEXMEDETOMIDINE HCL 200MCG/NS 50ML,,,,80002698,CDM,250,RC,409166050,NDC,both,20,ML,17.64,6.96,39.4668,,6.96,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,6,34,,6,percent of total billed charges,"Drugs, Inpatient Only",6,34,,6,percent of total billed charges,"Drugs, Inpatient Only",6,34,,6,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,12.35,70,,12.35,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,5.88,,,5.88,Other,Drug Cost,5.88,,,5.88,Other,Drug Cost,5.88,,,5.88,Other,Drug Cost,5.88,,,5.88,Other,Drug Cost,5.88,,,5.88,Other,Drug Cost,5.88,,,5.88,Other,Drug Cost,13.23,,,13.23,Other,225% of Medicaid,8.23,,,8.23,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,12.65,,,12.65,Other,215% Medicaid APG methodology,12.65,,,12.65,Other,215% Medicaid APG methodology,7.35,,,7.35,Other,125% Medicaid APG methodology,0.01,13.23,
RALTEGRAVIR 100MG CHEW TAB,,,,80002701,CDM,250,RC,6047761,NDC,both,60,EA,9.87,3.9,39.4668,,3.9,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,3.36,34,,3.36,percent of total billed charges,"Drugs, Inpatient Only",3.36,34,,3.36,percent of total billed charges,"Drugs, Inpatient Only",3.36,34,,3.36,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,6.91,70,,6.91,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,3.29,,,3.29,Other,Drug Cost,3.29,,,3.29,Other,Drug Cost,3.29,,,3.29,Other,Drug Cost,3.29,,,3.29,Other,Drug Cost,3.29,,,3.29,Other,Drug Cost,3.29,,,3.29,Other,Drug Cost,7.41,,,7.41,Other,225% of Medicaid,4.61,,,4.61,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,7.08,,,7.08,Other,215% Medicaid APG methodology,7.08,,,7.08,Other,215% Medicaid APG methodology,4.11,,,4.11,Other,125% Medicaid APG methodology,0.01,7.41,
STRONG IODINE 5% 14ML,,,,80002713,CDM,250,RC,48433023015,NDC,both,1,ML,92.04,36.33,39.4668,,36.33,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,31.29,34,,31.29,percent of total billed charges,"Drugs, Inpatient Only",31.29,34,,31.29,percent of total billed charges,"Drugs, Inpatient Only",31.29,34,,31.29,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,64.43,70,,64.43,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,30.68,,,30.68,Other,Drug Cost,30.68,,,30.68,Other,Drug Cost,30.68,,,30.68,Other,Drug Cost,30.68,,,30.68,Other,Drug Cost,30.68,,,30.68,Other,Drug Cost,30.68,,,30.68,Other,Drug Cost,69.03,,,69.03,Other,225% of Medicaid,42.95,,,42.95,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,65.96,,,65.96,Other,215% Medicaid APG methodology,65.96,,,65.96,Other,215% Medicaid APG methodology,38.35,,,38.35,Other,125% Medicaid APG methodology,0.01,69.03,
FLUOCINONIDE 0.05% OINT 15GM,,,,80002715,CDM,250,RC,51672126401,NDC,both,1,GM,4.83,1.91,39.4668,,1.91,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1.64,34,,1.64,percent of total billed charges,"Drugs, Inpatient Only",1.64,34,,1.64,percent of total billed charges,"Drugs, Inpatient Only",1.64,34,,1.64,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,3.38,70,,3.38,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1.61,,,1.61,Other,Drug Cost,1.61,,,1.61,Other,Drug Cost,1.61,,,1.61,Other,Drug Cost,1.61,,,1.61,Other,Drug Cost,1.61,,,1.61,Other,Drug Cost,1.61,,,1.61,Other,Drug Cost,3.62,,,3.62,Other,225% of Medicaid,2.25,,,2.25,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,3.46,,,3.46,Other,215% Medicaid APG methodology,3.46,,,3.46,Other,215% Medicaid APG methodology,2.01,,,2.01,Other,125% Medicaid APG methodology,0.01,3.62,
CLOBETASOL 0.05% OINT 30GM,,,,80002719,CDM,250,RC,51672125902,NDC,both,1,GM,0.42,0.17,39.4668,,0.17,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.14,34,,0.14,percent of total billed charges,"Drugs, Inpatient Only",0.14,34,,0.14,percent of total billed charges,"Drugs, Inpatient Only",0.14,34,,0.14,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.29,70,,0.29,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.14,,,0.14,Other,Drug Cost,0.14,,,0.14,Other,Drug Cost,0.14,,,0.14,Other,Drug Cost,0.14,,,0.14,Other,Drug Cost,0.14,,,0.14,Other,Drug Cost,0.14,,,0.14,Other,Drug Cost,0.32,,,0.32,Other,225% of Medicaid,0.2,,,0.2,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.3,,,0.3,Other,215% Medicaid APG methodology,0.3,,,0.3,Other,215% Medicaid APG methodology,0.18,,,0.18,Other,125% Medicaid APG methodology,0.01,0.32,
ATAZANAVIR 200MG CAPSULE,,,,80002722,CDM,250,RC,3363112,NDC,both,60,EA,36.26,14.31,39.4668,,14.31,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,12.33,34,,12.33,percent of total billed charges,"Drugs, Inpatient Only",12.33,34,,12.33,percent of total billed charges,"Drugs, Inpatient Only",12.33,34,,12.33,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,25.38,70,,25.38,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,12.09,,,12.09,Other,Drug Cost,12.09,,,12.09,Other,Drug Cost,12.09,,,12.09,Other,Drug Cost,12.09,,,12.09,Other,Drug Cost,12.09,,,12.09,Other,Drug Cost,12.09,,,12.09,Other,Drug Cost,27.19,,,27.19,Other,225% of Medicaid,16.92,,,16.92,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,25.98,,,25.98,Other,215% Medicaid APG methodology,25.98,,,25.98,Other,215% Medicaid APG methodology,15.11,,,15.11,Other,125% Medicaid APG methodology,0.01,27.19,
LIDOCAINE 1% 2ML VIAL,,,,80002725,CDM,250,RC,55150016102,NDC,both,10,ML,2.9,1.15,39.4668,,1.15,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.99,34,,0.99,percent of total billed charges,"Drugs, Inpatient Only",0.99,34,,0.99,percent of total billed charges,"Drugs, Inpatient Only",0.99,34,,0.99,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2.03,70,,2.03,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.97,,,0.97,Other,Drug Cost,0.97,,,0.97,Other,Drug Cost,0.97,,,0.97,Other,Drug Cost,0.97,,,0.97,Other,Drug Cost,0.97,,,0.97,Other,Drug Cost,0.97,,,0.97,Other,Drug Cost,2.18,,,2.18,Other,225% of Medicaid,1.36,,,1.36,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,2.08,,,2.08,Other,215% Medicaid APG methodology,2.08,,,2.08,Other,215% Medicaid APG methodology,1.21,,,1.21,Other,125% Medicaid APG methodology,0.01,2.18,
FLUTICASONE-VILANTEROL 100-25MCH INHALER,,,,80002736,CDM,250,RC,173085914,NDC,both,28,EA,3.42,1.35,39.4668,,1.35,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1.16,34,,1.16,percent of total billed charges,"Drugs, Inpatient Only",1.16,34,,1.16,percent of total billed charges,"Drugs, Inpatient Only",1.16,34,,1.16,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2.39,70,,2.39,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1.14,,,1.14,Other,Drug Cost,1.14,,,1.14,Other,Drug Cost,1.14,,,1.14,Other,Drug Cost,1.14,,,1.14,Other,Drug Cost,1.14,,,1.14,Other,Drug Cost,1.14,,,1.14,Other,Drug Cost,2.57,,,2.57,Other,225% of Medicaid,1.6,,,1.6,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,2.45,,,2.45,Other,215% Medicaid APG methodology,2.45,,,2.45,Other,215% Medicaid APG methodology,1.43,,,1.43,Other,125% Medicaid APG methodology,0.01,2.57,
RIFAXIMIN 550MG TABLET,,,,80002744,CDM,250,RC,65649030302,NDC,both,60,EA,31.79,12.55,39.4668,,12.55,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,10.81,34,,10.81,percent of total billed charges,"Drugs, Inpatient Only",10.81,34,,10.81,percent of total billed charges,"Drugs, Inpatient Only",10.81,34,,10.81,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,22.25,70,,22.25,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,10.6,,,10.6,Other,Drug Cost,10.6,,,10.6,Other,Drug Cost,10.6,,,10.6,Other,Drug Cost,10.6,,,10.6,Other,Drug Cost,10.6,,,10.6,Other,Drug Cost,10.6,,,10.6,Other,Drug Cost,23.84,,,23.84,Other,225% of Medicaid,14.84,,,14.84,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,22.78,,,22.78,Other,215% Medicaid APG methodology,22.78,,,22.78,Other,215% Medicaid APG methodology,13.25,,,13.25,Other,125% Medicaid APG methodology,0.01,23.84,
TRUVADA 200MG-300MG TABLET,,,,80002746,CDM,250,RC,42385095330,NDC,both,30,EA,0.63,0.25,39.4668,,0.25,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.21,34,,0.21,percent of total billed charges,"Drugs, Inpatient Only",0.21,34,,0.21,percent of total billed charges,"Drugs, Inpatient Only",0.21,34,,0.21,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.44,70,,0.44,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.21,,,0.21,Other,Drug Cost,0.21,,,0.21,Other,Drug Cost,0.21,,,0.21,Other,Drug Cost,0.21,,,0.21,Other,Drug Cost,0.21,,,0.21,Other,Drug Cost,0.21,,,0.21,Other,Drug Cost,0.47,,,0.47,Other,225% of Medicaid,0.29,,,0.29,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.45,,,0.45,Other,215% Medicaid APG methodology,0.45,,,0.45,Other,215% Medicaid APG methodology,0.26,,,0.26,Other,125% Medicaid APG methodology,0.01,0.47,
RILPIVIRINE 25MG TABLET,,,,80002751,CDM,250,RC,59676027801,NDC,both,30,EA,50.02,19.74,39.4668,,19.74,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,17.01,34,,17.01,percent of total billed charges,"Drugs, Inpatient Only",17.01,34,,17.01,percent of total billed charges,"Drugs, Inpatient Only",17.01,34,,17.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,35.01,70,,35.01,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,16.67,,,16.67,Other,Drug Cost,16.67,,,16.67,Other,Drug Cost,16.67,,,16.67,Other,Drug Cost,16.67,,,16.67,Other,Drug Cost,16.67,,,16.67,Other,Drug Cost,16.67,,,16.67,Other,Drug Cost,37.51,,,37.51,Other,225% of Medicaid,23.34,,,23.34,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,35.85,,,35.85,Other,215% Medicaid APG methodology,35.85,,,35.85,Other,215% Medicaid APG methodology,20.84,,,20.84,Other,125% Medicaid APG methodology,0.01,37.51,
TRANEXAMIC ACID 1000MG/100ML NS,,,,80002762,CDM,250,RC,51754010803,NDC,both,10,ML,20.17,7.96,39.4668,,7.96,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,6.86,34,,6.86,percent of total billed charges,"Drugs, Inpatient Only",6.86,34,,6.86,percent of total billed charges,"Drugs, Inpatient Only",6.86,34,,6.86,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,14.12,70,,14.12,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,6.72,,,6.72,Other,Drug Cost,6.72,,,6.72,Other,Drug Cost,6.72,,,6.72,Other,Drug Cost,6.72,,,6.72,Other,Drug Cost,6.72,,,6.72,Other,Drug Cost,6.72,,,6.72,Other,Drug Cost,15.12,,,15.12,Other,225% of Medicaid,9.41,,,9.41,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,14.45,,,14.45,Other,215% Medicaid APG methodology,14.45,,,14.45,Other,215% Medicaid APG methodology,8.4,,,8.4,Other,125% Medicaid APG methodology,0.01,15.12,
OLANZAPINE 10MG ODT,,,,80002774,CDM,250,RC,33342008407,NDC,both,30,EA,0.12,0.05,39.4668,,0.05,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.04,34,,0.04,percent of total billed charges,"Drugs, Inpatient Only",0.04,34,,0.04,percent of total billed charges,"Drugs, Inpatient Only",0.04,34,,0.04,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.09,70,,0.09,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.09,,,0.09,Other,225% of Medicaid,0.06,,,0.06,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.09,,,0.09,Other,215% Medicaid APG methodology,0.09,,,0.09,Other,215% Medicaid APG methodology,0.05,,,0.05,Other,125% Medicaid APG methodology,0.01,0.09,
LEVONORGESTREL 1.5MG TABLET,,,,80002775,CDM,250,RC,68180085211,NDC,both,1,EA,0.12,0.05,39.4668,,0.05,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.04,34,,0.04,percent of total billed charges,"Drugs, Inpatient Only",0.04,34,,0.04,percent of total billed charges,"Drugs, Inpatient Only",0.04,34,,0.04,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.08,70,,0.08,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.09,,,0.09,Other,225% of Medicaid,0.06,,,0.06,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.09,,,0.09,Other,215% Medicaid APG methodology,0.09,,,0.09,Other,215% Medicaid APG methodology,0.05,,,0.05,Other,125% Medicaid APG methodology,0.01,0.09,
POSACONAZOLE 100MG TABLET,,,,80002790,CDM,250,RC,70748025807,NDC,both,60,EA,5.87,2.32,39.4668,,2.32,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2,34,,2,percent of total billed charges,"Drugs, Inpatient Only",2,34,,2,percent of total billed charges,"Drugs, Inpatient Only",2,34,,2,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,4.11,70,,4.11,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1.96,,,1.96,Other,Drug Cost,1.96,,,1.96,Other,Drug Cost,1.96,,,1.96,Other,Drug Cost,1.96,,,1.96,Other,Drug Cost,1.96,,,1.96,Other,Drug Cost,1.96,,,1.96,Other,Drug Cost,4.4,,,4.4,Other,225% of Medicaid,2.74,,,2.74,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,4.21,,,4.21,Other,215% Medicaid APG methodology,4.21,,,4.21,Other,215% Medicaid APG methodology,2.45,,,2.45,Other,125% Medicaid APG methodology,0.01,4.4,
WOUND SEAL POWDER,,,,80002794,CDM,250,RC,34061000004,NDC,both,4,EA,6.53,2.58,39.4668,,2.58,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2.22,34,,2.22,percent of total billed charges,"Drugs, Inpatient Only",2.22,34,,2.22,percent of total billed charges,"Drugs, Inpatient Only",2.22,34,,2.22,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,4.57,70,,4.57,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2.18,,,2.18,Other,Drug Cost,2.18,,,2.18,Other,Drug Cost,2.18,,,2.18,Other,Drug Cost,2.18,,,2.18,Other,Drug Cost,2.18,,,2.18,Other,Drug Cost,2.18,,,2.18,Other,Drug Cost,4.9,,,4.9,Other,225% of Medicaid,3.05,,,3.05,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,4.68,,,4.68,Other,215% Medicaid APG methodology,4.68,,,4.68,Other,215% Medicaid APG methodology,2.72,,,2.72,Other,125% Medicaid APG methodology,0.01,4.9,
GLYCERIN 35% DRY MOUTH SPRAY,,,,80002796,CDM,250,RC,98669000201,NDC,both,1,ML,15.84,6.25,39.4668,,6.25,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,5.39,34,,5.39,percent of total billed charges,"Drugs, Inpatient Only",5.39,34,,5.39,percent of total billed charges,"Drugs, Inpatient Only",5.39,34,,5.39,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,11.09,70,,11.09,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,5.28,,,5.28,Other,Drug Cost,5.28,,,5.28,Other,Drug Cost,5.28,,,5.28,Other,Drug Cost,5.28,,,5.28,Other,Drug Cost,5.28,,,5.28,Other,Drug Cost,5.28,,,5.28,Other,Drug Cost,11.88,,,11.88,Other,225% of Medicaid,7.39,,,7.39,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,11.35,,,11.35,Other,215% Medicaid APG methodology,11.35,,,11.35,Other,215% Medicaid APG methodology,6.6,,,6.6,Other,125% Medicaid APG methodology,0.01,11.88,
LABETALOL HCL 20MG/4ML INJ,,,,80002799,CDM,250,RC,409233934,NDC,both,10,ML,8.46,3.34,39.4668,,3.34,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2.88,34,,2.88,percent of total billed charges,"Drugs, Inpatient Only",2.88,34,,2.88,percent of total billed charges,"Drugs, Inpatient Only",2.88,34,,2.88,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,5.92,70,,5.92,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2.82,,,2.82,Other,Drug Cost,2.82,,,2.82,Other,Drug Cost,2.82,,,2.82,Other,Drug Cost,2.82,,,2.82,Other,Drug Cost,2.82,,,2.82,Other,Drug Cost,2.82,,,2.82,Other,Drug Cost,6.34,,,6.34,Other,225% of Medicaid,3.95,,,3.95,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,6.06,,,6.06,Other,215% Medicaid APG methodology,6.06,,,6.06,Other,215% Medicaid APG methodology,3.52,,,3.52,Other,125% Medicaid APG methodology,0.01,6.34,
LIDOCAINE 5% ANORECTAL CREAM,,,,80002802,CDM,250,RC,496089230,NDC,both,1,GM,77.82,30.71,39.4668,,30.71,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,26.46,34,,26.46,percent of total billed charges,"Drugs, Inpatient Only",26.46,34,,26.46,percent of total billed charges,"Drugs, Inpatient Only",26.46,34,,26.46,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,54.47,70,,54.47,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,25.94,,,25.94,Other,Drug Cost,25.94,,,25.94,Other,Drug Cost,25.94,,,25.94,Other,Drug Cost,25.94,,,25.94,Other,Drug Cost,25.94,,,25.94,Other,Drug Cost,25.94,,,25.94,Other,Drug Cost,58.37,,,58.37,Other,225% of Medicaid,36.32,,,36.32,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,55.77,,,55.77,Other,215% Medicaid APG methodology,55.77,,,55.77,Other,215% Medicaid APG methodology,32.43,,,32.43,Other,125% Medicaid APG methodology,0.01,58.37,
MEROPENEM 500GM/NS 50ML,,,,80002803,CDM,250,RC,264318311,NDC,both,24,EA,24.57,9.7,39.4668,,9.7,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,8.35,34,,8.35,percent of total billed charges,"Drugs, Inpatient Only",8.35,34,,8.35,percent of total billed charges,"Drugs, Inpatient Only",8.35,34,,8.35,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,17.2,70,,17.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,8.19,,,8.19,Other,Drug Cost,8.19,,,8.19,Other,Drug Cost,8.19,,,8.19,Other,Drug Cost,8.19,,,8.19,Other,Drug Cost,8.19,,,8.19,Other,Drug Cost,8.19,,,8.19,Other,Drug Cost,18.43,,,18.43,Other,225% of Medicaid,11.47,,,11.47,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,17.61,,,17.61,Other,215% Medicaid APG methodology,17.61,,,17.61,Other,215% Medicaid APG methodology,10.24,,,10.24,Other,125% Medicaid APG methodology,0.01,18.43,
VALGANCICLOVIR 450MG TABLET,,,,80002805,CDM,250,RC,904679604,NDC,both,3,EA,160.8,63.46,39.4668,,63.46,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,54.67,34,,54.67,percent of total billed charges,"Drugs, Inpatient Only",54.67,34,,54.67,percent of total billed charges,"Drugs, Inpatient Only",54.67,34,,54.67,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,112.56,70,,112.56,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,53.6,,,53.6,Other,Drug Cost,53.6,,,53.6,Other,Drug Cost,53.6,,,53.6,Other,Drug Cost,53.6,,,53.6,Other,Drug Cost,53.6,,,53.6,Other,Drug Cost,53.6,,,53.6,Other,Drug Cost,120.6,,,120.6,Other,225% of Medicaid,75.04,,,75.04,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,115.24,,,115.24,Other,215% Medicaid APG methodology,115.24,,,115.24,Other,215% Medicaid APG methodology,67,,,67,Other,125% Medicaid APG methodology,0.01,120.6,
TRIAMCINOLONE 0.5% OINT 15GM,,,,80002807,CDM,250,RC,45802004935,NDC,both,1,GM,6.57,2.59,39.4668,,2.59,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2.23,34,,2.23,percent of total billed charges,"Drugs, Inpatient Only",2.23,34,,2.23,percent of total billed charges,"Drugs, Inpatient Only",2.23,34,,2.23,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,4.6,70,,4.6,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2.19,,,2.19,Other,Drug Cost,2.19,,,2.19,Other,Drug Cost,2.19,,,2.19,Other,Drug Cost,2.19,,,2.19,Other,Drug Cost,2.19,,,2.19,Other,Drug Cost,2.19,,,2.19,Other,Drug Cost,4.93,,,4.93,Other,225% of Medicaid,3.07,,,3.07,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,4.71,,,4.71,Other,215% Medicaid APG methodology,4.71,,,4.71,Other,215% Medicaid APG methodology,2.74,,,2.74,Other,125% Medicaid APG methodology,0.01,4.93,
BETAMETHASONE AUGMENTED 0.05% CREAM 15GM,,,,80002808,CDM,250,RC,51672131001,NDC,both,1,GM,3,1.18,39.4668,,1.18,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1.02,34,,1.02,percent of total billed charges,"Drugs, Inpatient Only",1.02,34,,1.02,percent of total billed charges,"Drugs, Inpatient Only",1.02,34,,1.02,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2.1,70,,2.1,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1,,,1,Other,Drug Cost,1,,,1,Other,Drug Cost,1,,,1,Other,Drug Cost,1,,,1,Other,Drug Cost,1,,,1,Other,Drug Cost,1,,,1,Other,Drug Cost,2.25,,,2.25,Other,225% of Medicaid,1.4,,,1.4,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,2.15,,,2.15,Other,215% Medicaid APG methodology,2.15,,,2.15,Other,215% Medicaid APG methodology,1.25,,,1.25,Other,125% Medicaid APG methodology,0.01,2.25,
BETAMETHASONE AUGMENTED 0.05% OINT 15GM,,,,80002809,CDM,250,RC,168026815,NDC,both,1,GM,8.91,3.52,39.4668,,3.52,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,3.03,34,,3.03,percent of total billed charges,"Drugs, Inpatient Only",3.03,34,,3.03,percent of total billed charges,"Drugs, Inpatient Only",3.03,34,,3.03,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,6.24,70,,6.24,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2.97,,,2.97,Other,Drug Cost,2.97,,,2.97,Other,Drug Cost,2.97,,,2.97,Other,Drug Cost,2.97,,,2.97,Other,Drug Cost,2.97,,,2.97,Other,Drug Cost,2.97,,,2.97,Other,Drug Cost,6.68,,,6.68,Other,225% of Medicaid,4.16,,,4.16,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,6.39,,,6.39,Other,215% Medicaid APG methodology,6.39,,,6.39,Other,215% Medicaid APG methodology,3.71,,,3.71,Other,125% Medicaid APG methodology,0.01,6.68,
LANSOPRAZOLE 3MG/ML ORAL SUSP,,,,80002810,CDM,250,RC,65628008003,NDC,both,1,ML,475.59,187.7,39.4668,,187.7,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,161.7,34,,161.7,percent of total billed charges,"Drugs, Inpatient Only",161.7,34,,161.7,percent of total billed charges,"Drugs, Inpatient Only",161.7,34,,161.7,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,332.91,70,,332.91,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,158.53,,,158.53,Other,Drug Cost,158.53,,,158.53,Other,Drug Cost,158.53,,,158.53,Other,Drug Cost,158.53,,,158.53,Other,Drug Cost,158.53,,,158.53,Other,Drug Cost,158.53,,,158.53,Other,Drug Cost,356.69,,,356.69,Other,225% of Medicaid,221.94,,,221.94,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,340.84,,,340.84,Other,215% Medicaid APG methodology,340.84,,,340.84,Other,215% Medicaid APG methodology,198.16,,,198.16,Other,125% Medicaid APG methodology,0.01,356.69,
CLOMIPRAMINE 50MG CAPSULE,,,,80002813,CDM,250,RC,51672401206,NDC,both,30,EA,0.45,0.18,39.4668,,0.18,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.15,34,,0.15,percent of total billed charges,"Drugs, Inpatient Only",0.15,34,,0.15,percent of total billed charges,"Drugs, Inpatient Only",0.15,34,,0.15,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.31,70,,0.31,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.15,,,0.15,Other,Drug Cost,0.15,,,0.15,Other,Drug Cost,0.15,,,0.15,Other,Drug Cost,0.15,,,0.15,Other,Drug Cost,0.15,,,0.15,Other,Drug Cost,0.15,,,0.15,Other,Drug Cost,0.33,,,0.33,Other,225% of Medicaid,0.21,,,0.21,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.32,,,0.32,Other,215% Medicaid APG methodology,0.32,,,0.32,Other,215% Medicaid APG methodology,0.19,,,0.19,Other,125% Medicaid APG methodology,0.01,0.33,
METHADONE ORAL CONCENTRATE 10MG/ML,,,,80002815,CDM,250,RC,66689069430,NDC,both,1,ML,1.29,0.51,39.4668,,0.51,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.44,34,,0.44,percent of total billed charges,"Drugs, Inpatient Only",0.44,34,,0.44,percent of total billed charges,"Drugs, Inpatient Only",0.44,34,,0.44,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.9,70,,0.9,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.43,,,0.43,Other,Drug Cost,0.43,,,0.43,Other,Drug Cost,0.43,,,0.43,Other,Drug Cost,0.43,,,0.43,Other,Drug Cost,0.43,,,0.43,Other,Drug Cost,0.43,,,0.43,Other,Drug Cost,0.97,,,0.97,Other,225% of Medicaid,0.6,,,0.6,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.92,,,0.92,Other,215% Medicaid APG methodology,0.92,,,0.92,Other,215% Medicaid APG methodology,0.54,,,0.54,Other,125% Medicaid APG methodology,0.01,0.97,
MELATONIN 5MG TABLET,,,,80002816,CDM,250,RC,7610015540,NDC,both,200,EA,0.08,0.03,39.4668,,0.03,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.03,34,,0.03,percent of total billed charges,"Drugs, Inpatient Only",0.03,34,,0.03,percent of total billed charges,"Drugs, Inpatient Only",0.03,34,,0.03,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.06,70,,0.06,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.06,,,0.06,Other,225% of Medicaid,0.04,,,0.04,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.06,,,0.06,Other,215% Medicaid APG methodology,0.06,,,0.06,Other,215% Medicaid APG methodology,0.03,,,0.03,Other,125% Medicaid APG methodology,0.01,0.06,
ENTRESTO 24MG/26MG TABLET,,,,80002817,CDM,250,RC,78065920,NDC,both,60,EA,14.15,5.58,39.4668,,5.58,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,4.81,34,,4.81,percent of total billed charges,"Drugs, Inpatient Only",4.81,34,,4.81,percent of total billed charges,"Drugs, Inpatient Only",4.81,34,,4.81,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,9.9,70,,9.9,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,4.72,,,4.72,Other,Drug Cost,4.72,,,4.72,Other,Drug Cost,4.72,,,4.72,Other,Drug Cost,4.72,,,4.72,Other,Drug Cost,4.72,,,4.72,Other,Drug Cost,4.72,,,4.72,Other,Drug Cost,10.61,,,10.61,Other,225% of Medicaid,6.6,,,6.6,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,10.14,,,10.14,Other,215% Medicaid APG methodology,10.14,,,10.14,Other,215% Medicaid APG methodology,5.89,,,5.89,Other,125% Medicaid APG methodology,0.01,10.61,
ENTRESTO 49MG/51MG TABLET,,,,80002818,CDM,250,RC,78077720,NDC,both,60,EA,14.07,5.55,39.4668,,5.55,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,4.78,34,,4.78,percent of total billed charges,"Drugs, Inpatient Only",4.78,34,,4.78,percent of total billed charges,"Drugs, Inpatient Only",4.78,34,,4.78,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,9.85,70,,9.85,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,4.69,,,4.69,Other,Drug Cost,4.69,,,4.69,Other,Drug Cost,4.69,,,4.69,Other,Drug Cost,4.69,,,4.69,Other,Drug Cost,4.69,,,4.69,Other,Drug Cost,4.69,,,4.69,Other,Drug Cost,10.55,,,10.55,Other,225% of Medicaid,6.56,,,6.56,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,10.08,,,10.08,Other,215% Medicaid APG methodology,10.08,,,10.08,Other,215% Medicaid APG methodology,5.86,,,5.86,Other,125% Medicaid APG methodology,0.01,10.55,
ENTRESTO 97MG/103MG TABLET,,,,80002819,CDM,250,RC,78069620,NDC,both,60,EA,14.58,5.75,39.4668,,5.75,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,4.96,34,,4.96,percent of total billed charges,"Drugs, Inpatient Only",4.96,34,,4.96,percent of total billed charges,"Drugs, Inpatient Only",4.96,34,,4.96,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,10.21,70,,10.21,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,4.86,,,4.86,Other,Drug Cost,4.86,,,4.86,Other,Drug Cost,4.86,,,4.86,Other,Drug Cost,4.86,,,4.86,Other,Drug Cost,4.86,,,4.86,Other,Drug Cost,4.86,,,4.86,Other,Drug Cost,10.94,,,10.94,Other,225% of Medicaid,6.8,,,6.8,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,10.45,,,10.45,Other,215% Medicaid APG methodology,10.45,,,10.45,Other,215% Medicaid APG methodology,6.08,,,6.08,Other,125% Medicaid APG methodology,0.01,10.94,
GENVOYA 150MG/150MG/200MG/10MG TAB,,,,80002820,CDM,250,RC,61958190101,NDC,both,30,EA,229.59,90.61,39.4668,,90.61,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,78.06,34,,78.06,percent of total billed charges,"Drugs, Inpatient Only",78.06,34,,78.06,percent of total billed charges,"Drugs, Inpatient Only",78.06,34,,78.06,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,160.71,70,,160.71,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,76.53,,,76.53,Other,Drug Cost,76.53,,,76.53,Other,Drug Cost,76.53,,,76.53,Other,Drug Cost,76.53,,,76.53,Other,Drug Cost,76.53,,,76.53,Other,Drug Cost,76.53,,,76.53,Other,Drug Cost,172.19,,,172.19,Other,225% of Medicaid,107.14,,,107.14,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,164.54,,,164.54,Other,215% Medicaid APG methodology,164.54,,,164.54,Other,215% Medicaid APG methodology,95.66,,,95.66,Other,125% Medicaid APG methodology,0.01,172.19,
AMMONIUM LACTATE 12% LOTION 28GM,,,,80002823,CDM,250,RC,45802041926,NDC,both,1,GM,22.17,8.75,39.4668,,8.75,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,7.54,34,,7.54,percent of total billed charges,"Drugs, Inpatient Only",7.54,34,,7.54,percent of total billed charges,"Drugs, Inpatient Only",7.54,34,,7.54,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,15.52,70,,15.52,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,7.39,,,7.39,Other,Drug Cost,7.39,,,7.39,Other,Drug Cost,7.39,,,7.39,Other,Drug Cost,7.39,,,7.39,Other,Drug Cost,7.39,,,7.39,Other,Drug Cost,7.39,,,7.39,Other,Drug Cost,16.63,,,16.63,Other,225% of Medicaid,10.35,,,10.35,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,15.89,,,15.89,Other,215% Medicaid APG methodology,15.89,,,15.89,Other,215% Medicaid APG methodology,9.24,,,9.24,Other,125% Medicaid APG methodology,0.01,16.63,
BENZOYL PEROXIDE GEL 5%,,,,80002824,CDM,250,RC,536105556,NDC,both,1,GM,3.54,1.4,39.4668,,1.4,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1.2,34,,1.2,percent of total billed charges,"Drugs, Inpatient Only",1.2,34,,1.2,percent of total billed charges,"Drugs, Inpatient Only",1.2,34,,1.2,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2.48,70,,2.48,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1.18,,,1.18,Other,Drug Cost,1.18,,,1.18,Other,Drug Cost,1.18,,,1.18,Other,Drug Cost,1.18,,,1.18,Other,Drug Cost,1.18,,,1.18,Other,Drug Cost,1.18,,,1.18,Other,Drug Cost,2.66,,,2.66,Other,225% of Medicaid,1.65,,,1.65,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,2.54,,,2.54,Other,215% Medicaid APG methodology,2.54,,,2.54,Other,215% Medicaid APG methodology,1.48,,,1.48,Other,125% Medicaid APG methodology,0.01,2.66,
DOLUTEGRAVIR 50MG TAB,,,,80002829,CDM,250,RC,49702022813,NDC,both,30,EA,97.09,38.32,39.4668,,38.32,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,33.01,34,,33.01,percent of total billed charges,"Drugs, Inpatient Only",33.01,34,,33.01,percent of total billed charges,"Drugs, Inpatient Only",33.01,34,,33.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,67.96,70,,67.96,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,32.36,,,32.36,Other,Drug Cost,32.36,,,32.36,Other,Drug Cost,32.36,,,32.36,Other,Drug Cost,32.36,,,32.36,Other,Drug Cost,32.36,,,32.36,Other,Drug Cost,32.36,,,32.36,Other,Drug Cost,72.82,,,72.82,Other,225% of Medicaid,45.31,,,45.31,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,69.58,,,69.58,Other,215% Medicaid APG methodology,69.58,,,69.58,Other,215% Medicaid APG methodology,40.45,,,40.45,Other,125% Medicaid APG methodology,0.01,72.82,
CLOBAZAM 10 MG TABLET,,,,80023637,CDM,250,RC,832058011,NDC,both,100,EA,0.29,0.11,39.4668,,0.11,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.1,34,,0.1,percent of total billed charges,"Drugs, Inpatient Only",0.1,34,,0.1,percent of total billed charges,"Drugs, Inpatient Only",0.1,34,,0.1,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.2,70,,0.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.1,,,0.1,Other,Drug Cost,0.1,,,0.1,Other,Drug Cost,0.1,,,0.1,Other,Drug Cost,0.1,,,0.1,Other,Drug Cost,0.1,,,0.1,Other,Drug Cost,0.1,,,0.1,Other,Drug Cost,0.22,,,0.22,Other,225% of Medicaid,0.13,,,0.13,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.21,,,0.21,Other,215% Medicaid APG methodology,0.21,,,0.21,Other,215% Medicaid APG methodology,0.12,,,0.12,Other,125% Medicaid APG methodology,0.01,0.22,
RASAGILINE MESYLATE 0.5MG TABLET,,,,80023638,CDM,250,RC,93306056,NDC,both,30,EA,0.15,0.06,39.4668,,0.06,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.05,34,,0.05,percent of total billed charges,"Drugs, Inpatient Only",0.05,34,,0.05,percent of total billed charges,"Drugs, Inpatient Only",0.05,34,,0.05,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.11,70,,0.11,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.11,,,0.11,Other,225% of Medicaid,0.07,,,0.07,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.11,,,0.11,Other,215% Medicaid APG methodology,0.11,,,0.11,Other,215% Medicaid APG methodology,0.06,,,0.06,Other,125% Medicaid APG methodology,0.01,0.11,
DESCOVY 200MG TABLET,,,,80023655,CDM,250,RC,61958200201,NDC,both,30,EA,91.48,36.1,39.4668,,36.1,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,31.1,34,,31.1,percent of total billed charges,"Drugs, Inpatient Only",31.1,34,,31.1,percent of total billed charges,"Drugs, Inpatient Only",31.1,34,,31.1,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,64.03,70,,64.03,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,30.49,,,30.49,Other,Drug Cost,30.49,,,30.49,Other,Drug Cost,30.49,,,30.49,Other,Drug Cost,30.49,,,30.49,Other,Drug Cost,30.49,,,30.49,Other,Drug Cost,30.49,,,30.49,Other,Drug Cost,68.61,,,68.61,Other,225% of Medicaid,42.69,,,42.69,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,65.56,,,65.56,Other,215% Medicaid APG methodology,65.56,,,65.56,Other,215% Medicaid APG methodology,38.12,,,38.12,Other,125% Medicaid APG methodology,0.01,68.61,
PREZCOBIX 800-150MG TABLET,,,,80023656,CDM,250,RC,59676057530,NDC,both,30,EA,123.91,48.9,39.4668,,48.9,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,42.13,34,,42.13,percent of total billed charges,"Drugs, Inpatient Only",42.13,34,,42.13,percent of total billed charges,"Drugs, Inpatient Only",42.13,34,,42.13,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,86.73,70,,86.73,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,41.3,,,41.3,Other,Drug Cost,41.3,,,41.3,Other,Drug Cost,41.3,,,41.3,Other,Drug Cost,41.3,,,41.3,Other,Drug Cost,41.3,,,41.3,Other,Drug Cost,41.3,,,41.3,Other,Drug Cost,92.93,,,92.93,Other,225% of Medicaid,57.82,,,57.82,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,88.8,,,88.8,Other,215% Medicaid APG methodology,88.8,,,88.8,Other,215% Medicaid APG methodology,51.63,,,51.63,Other,125% Medicaid APG methodology,0.01,92.93,
SUGAMMADEX 100MG/ML 2ML VIAL,,,,80023659,CDM,250,RC,6542312,NDC,both,10,ML,201.65,79.59,39.4668,,79.59,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,68.56,34,,68.56,percent of total billed charges,"Drugs, Inpatient Only",68.56,34,,68.56,percent of total billed charges,"Drugs, Inpatient Only",68.56,34,,68.56,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,141.16,70,,141.16,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,67.22,,,67.22,Other,Drug Cost,67.22,,,67.22,Other,Drug Cost,67.22,,,67.22,Other,Drug Cost,67.22,,,67.22,Other,Drug Cost,67.22,,,67.22,Other,Drug Cost,67.22,,,67.22,Other,Drug Cost,151.24,,,151.24,Other,225% of Medicaid,94.11,,,94.11,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,144.52,,,144.52,Other,215% Medicaid APG methodology,144.52,,,144.52,Other,215% Medicaid APG methodology,84.02,,,84.02,Other,125% Medicaid APG methodology,0.01,151.24,
MUPIROCIN 2% OINTMENT 1 GM,,,,80023660,CDM,250,RC,50268056815,NDC,both,50,GM,6.6,2.61,39.4668,,2.61,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2.24,34,,2.24,percent of total billed charges,"Drugs, Inpatient Only",2.24,34,,2.24,percent of total billed charges,"Drugs, Inpatient Only",2.24,34,,2.24,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,4.62,70,,4.62,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2.2,,,2.2,Other,Drug Cost,2.2,,,2.2,Other,Drug Cost,2.2,,,2.2,Other,Drug Cost,2.2,,,2.2,Other,Drug Cost,2.2,,,2.2,Other,Drug Cost,2.2,,,2.2,Other,Drug Cost,4.95,,,4.95,Other,225% of Medicaid,3.08,,,3.08,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,4.73,,,4.73,Other,215% Medicaid APG methodology,4.73,,,4.73,Other,215% Medicaid APG methodology,2.75,,,2.75,Other,125% Medicaid APG methodology,0.01,4.95,
CLOTRIMAZOLE 1% CREAM 1.9GM,,,,80023661,CDM,250,RC,51672127506,NDC,both,1,GM,10.71,4.23,39.4668,,4.23,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,3.64,34,,3.64,percent of total billed charges,"Drugs, Inpatient Only",3.64,34,,3.64,percent of total billed charges,"Drugs, Inpatient Only",3.64,34,,3.64,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,7.5,70,,7.5,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,3.57,,,3.57,Other,Drug Cost,3.57,,,3.57,Other,Drug Cost,3.57,,,3.57,Other,Drug Cost,3.57,,,3.57,Other,Drug Cost,3.57,,,3.57,Other,Drug Cost,3.57,,,3.57,Other,Drug Cost,8.03,,,8.03,Other,225% of Medicaid,5,,,5,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,7.68,,,7.68,Other,215% Medicaid APG methodology,7.68,,,7.68,Other,215% Medicaid APG methodology,4.46,,,4.46,Other,125% Medicaid APG methodology,0.01,8.03,
CLOTRIMAZOLE/BETAMETH CREAM 1.9GM,,,,80023662,CDM,250,RC,168025846,NDC,both,1,GM,16.2,6.39,39.4668,,6.39,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,5.51,34,,5.51,percent of total billed charges,"Drugs, Inpatient Only",5.51,34,,5.51,percent of total billed charges,"Drugs, Inpatient Only",5.51,34,,5.51,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,11.34,70,,11.34,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,5.4,,,5.4,Other,Drug Cost,5.4,,,5.4,Other,Drug Cost,5.4,,,5.4,Other,Drug Cost,5.4,,,5.4,Other,Drug Cost,5.4,,,5.4,Other,Drug Cost,5.4,,,5.4,Other,Drug Cost,12.15,,,12.15,Other,225% of Medicaid,7.56,,,7.56,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,11.61,,,11.61,Other,215% Medicaid APG methodology,11.61,,,11.61,Other,215% Medicaid APG methodology,6.75,,,6.75,Other,125% Medicaid APG methodology,0.01,12.15,
GELATIN ABSORBABLE POWDER 1GM,,,,80023678,CDM,250,RC,9043304,NDC,both,6,GM,148.04,58.43,39.4668,,58.43,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,50.33,34,,50.33,percent of total billed charges,"Drugs, Inpatient Only",50.33,34,,50.33,percent of total billed charges,"Drugs, Inpatient Only",50.33,34,,50.33,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,103.63,70,,103.63,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,49.35,,,49.35,Other,Drug Cost,49.35,,,49.35,Other,Drug Cost,49.35,,,49.35,Other,Drug Cost,49.35,,,49.35,Other,Drug Cost,49.35,,,49.35,Other,Drug Cost,49.35,,,49.35,Other,Drug Cost,111.03,,,111.03,Other,225% of Medicaid,69.09,,,69.09,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,106.1,,,106.1,Other,215% Medicaid APG methodology,106.1,,,106.1,Other,215% Medicaid APG methodology,61.68,,,61.68,Other,125% Medicaid APG methodology,0.01,111.03,
FLUTICASONE FUROATE 100MCG INHALATION,,,,80023683,CDM,250,RC,173087414,NDC,both,14,EA,3.39,1.34,39.4668,,1.34,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1.15,34,,1.15,percent of total billed charges,"Drugs, Inpatient Only",1.15,34,,1.15,percent of total billed charges,"Drugs, Inpatient Only",1.15,34,,1.15,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2.37,70,,2.37,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1.13,,,1.13,Other,Drug Cost,1.13,,,1.13,Other,Drug Cost,1.13,,,1.13,Other,Drug Cost,1.13,,,1.13,Other,Drug Cost,1.13,,,1.13,Other,Drug Cost,1.13,,,1.13,Other,Drug Cost,2.54,,,2.54,Other,225% of Medicaid,1.58,,,1.58,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,2.43,,,2.43,Other,215% Medicaid APG methodology,2.43,,,2.43,Other,215% Medicaid APG methodology,1.41,,,1.41,Other,125% Medicaid APG methodology,0.01,2.54,
FLUTICASONE FUROATE 200MCG INHALATION,,,,80023684,CDM,250,RC,173087614,NDC,both,14,EA,4.53,1.79,39.4668,,1.79,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1.54,34,,1.54,percent of total billed charges,"Drugs, Inpatient Only",1.54,34,,1.54,percent of total billed charges,"Drugs, Inpatient Only",1.54,34,,1.54,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,3.17,70,,3.17,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1.51,,,1.51,Other,Drug Cost,1.51,,,1.51,Other,Drug Cost,1.51,,,1.51,Other,Drug Cost,1.51,,,1.51,Other,Drug Cost,1.51,,,1.51,Other,Drug Cost,1.51,,,1.51,Other,Drug Cost,3.4,,,3.4,Other,225% of Medicaid,2.12,,,2.12,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,3.25,,,3.25,Other,215% Medicaid APG methodology,3.25,,,3.25,Other,215% Medicaid APG methodology,1.89,,,1.89,Other,125% Medicaid APG methodology,0.01,3.4,
UMECLIDINIUM 62.5MCG INHALATION,,,,80023685,CDM,250,RC,173087306,NDC,both,7,EA,6.53,2.58,39.4668,,2.58,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2.22,34,,2.22,percent of total billed charges,"Drugs, Inpatient Only",2.22,34,,2.22,percent of total billed charges,"Drugs, Inpatient Only",2.22,34,,2.22,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,4.57,70,,4.57,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2.18,,,2.18,Other,Drug Cost,2.18,,,2.18,Other,Drug Cost,2.18,,,2.18,Other,Drug Cost,2.18,,,2.18,Other,Drug Cost,2.18,,,2.18,Other,Drug Cost,2.18,,,2.18,Other,Drug Cost,4.9,,,4.9,Other,225% of Medicaid,3.05,,,3.05,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,4.68,,,4.68,Other,215% Medicaid APG methodology,4.68,,,4.68,Other,215% Medicaid APG methodology,2.72,,,2.72,Other,125% Medicaid APG methodology,0.01,4.9,
SODIUM CHORIDE 0.45% 250ML,,,,80023686,CDM,250,RC,990798502,NDC,both,24,ML,6.79,2.68,39.4668,,2.68,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2.31,34,,2.31,percent of total billed charges,"Drugs, Inpatient Only",2.31,34,,2.31,percent of total billed charges,"Drugs, Inpatient Only",2.31,34,,2.31,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,4.76,70,,4.76,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2.26,,,2.26,Other,Drug Cost,2.26,,,2.26,Other,Drug Cost,2.26,,,2.26,Other,Drug Cost,2.26,,,2.26,Other,Drug Cost,2.26,,,2.26,Other,Drug Cost,2.26,,,2.26,Other,Drug Cost,5.1,,,5.1,Other,225% of Medicaid,3.17,,,3.17,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,4.87,,,4.87,Other,215% Medicaid APG methodology,4.87,,,4.87,Other,215% Medicaid APG methodology,2.83,,,2.83,Other,125% Medicaid APG methodology,0.01,5.1,
FINASTERIDE SUSP 5MG/10ML,,,,80023688,CDM,250,RC,31722052510,NDC,both,1000,EA,0.1,0.04,39.4668,,0.04,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.03,34,,0.03,percent of total billed charges,"Drugs, Inpatient Only",0.03,34,,0.03,percent of total billed charges,"Drugs, Inpatient Only",0.03,34,,0.03,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.07,70,,0.07,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.08,,,0.08,Other,225% of Medicaid,0.05,,,0.05,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.07,,,0.07,Other,215% Medicaid APG methodology,0.07,,,0.07,Other,215% Medicaid APG methodology,0.04,,,0.04,Other,125% Medicaid APG methodology,0.01,0.08,
FOSFOMYCIN TROMETHAMINE 3 GRAM SACHET,,,,80023690,CDM,250,RC,70700026894,NDC,both,1,EA,85.38,33.7,39.4668,,33.7,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,29.03,34,,29.03,percent of total billed charges,"Drugs, Inpatient Only",29.03,34,,29.03,percent of total billed charges,"Drugs, Inpatient Only",29.03,34,,29.03,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,59.77,70,,59.77,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,28.46,,,28.46,Other,Drug Cost,28.46,,,28.46,Other,Drug Cost,28.46,,,28.46,Other,Drug Cost,28.46,,,28.46,Other,Drug Cost,28.46,,,28.46,Other,Drug Cost,28.46,,,28.46,Other,Drug Cost,64.04,,,64.04,Other,225% of Medicaid,39.84,,,39.84,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,61.19,,,61.19,Other,215% Medicaid APG methodology,61.19,,,61.19,Other,215% Medicaid APG methodology,35.58,,,35.58,Other,125% Medicaid APG methodology,0.01,64.04,
CETIRIZINE 5 MG TAB,,,,80023704,CDM,250,RC,16571040110,NDC,both,100,EA,0.07,0.03,39.4668,,0.03,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.02,34,,0.02,percent of total billed charges,"Drugs, Inpatient Only",0.02,34,,0.02,percent of total billed charges,"Drugs, Inpatient Only",0.02,34,,0.02,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.05,70,,0.05,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.05,,,0.05,Other,225% of Medicaid,0.03,,,0.03,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.05,,,0.05,Other,215% Medicaid APG methodology,0.05,,,0.05,Other,215% Medicaid APG methodology,0.03,,,0.03,Other,125% Medicaid APG methodology,0.01,0.05,
ESCITALOPRAM 5 MG TAB,,,,80023705,CDM,250,RC,456200501,NDC,both,100,EA,0.03,0.01,39.4668,,0.01,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.02,70,,0.02,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.02,,,0.02,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,0.02,
ESTRADIOL 0.5 MG TAB,,,,80023706,CDM,250,RC,555089902,NDC,both,100,EA,0.05,0.02,39.4668,,0.02,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.02,34,,0.02,percent of total billed charges,"Drugs, Inpatient Only",0.02,34,,0.02,percent of total billed charges,"Drugs, Inpatient Only",0.02,34,,0.02,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.04,70,,0.04,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.04,,,0.04,Other,225% of Medicaid,0.02,,,0.02,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.04,,,0.04,Other,215% Medicaid APG methodology,0.04,,,0.04,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,125% Medicaid APG methodology,0.01,0.04,
MIRTAZAPINE 7.5 MG TAB,,,,80023709,CDM,250,RC,57237000730,NDC,both,30,EA,0.32,0.13,39.4668,,0.13,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.11,34,,0.11,percent of total billed charges,"Drugs, Inpatient Only",0.11,34,,0.11,percent of total billed charges,"Drugs, Inpatient Only",0.11,34,,0.11,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.22,70,,0.22,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.11,,,0.11,Other,Drug Cost,0.11,,,0.11,Other,Drug Cost,0.11,,,0.11,Other,Drug Cost,0.11,,,0.11,Other,Drug Cost,0.11,,,0.11,Other,Drug Cost,0.11,,,0.11,Other,Drug Cost,0.24,,,0.24,Other,225% of Medicaid,0.15,,,0.15,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.23,,,0.23,Other,215% Medicaid APG methodology,0.23,,,0.23,Other,215% Medicaid APG methodology,0.13,,,0.13,Other,125% Medicaid APG methodology,0.01,0.24,
TIZANIDINE 2 MG TAB,,,,80023711,CDM,250,RC,57664050289,NDC,both,150,EA,0.02,0.01,39.4668,,0.01,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,70,,0.01,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,0.02,
AMIODARONE 100 MG TABLET,,,,80023714,CDM,250,RC,50268009715,NDC,both,5,EA,70.37,27.77,39.4668,,27.77,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,23.93,34,,23.93,percent of total billed charges,"Drugs, Inpatient Only",23.93,34,,23.93,percent of total billed charges,"Drugs, Inpatient Only",23.93,34,,23.93,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,49.26,70,,49.26,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,23.46,,,23.46,Other,Drug Cost,23.46,,,23.46,Other,Drug Cost,23.46,,,23.46,Other,Drug Cost,23.46,,,23.46,Other,Drug Cost,23.46,,,23.46,Other,Drug Cost,23.46,,,23.46,Other,Drug Cost,52.78,,,52.78,Other,225% of Medicaid,32.84,,,32.84,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,50.43,,,50.43,Other,215% Medicaid APG methodology,50.43,,,50.43,Other,215% Medicaid APG methodology,29.32,,,29.32,Other,125% Medicaid APG methodology,0.01,52.78,
ASCORBIC ACID 250 MG TABLET,,,,80023716,CDM,250,RC,50268086015,NDC,both,5,EA,4.67,1.84,39.4668,,1.84,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1.59,34,,1.59,percent of total billed charges,"Drugs, Inpatient Only",1.59,34,,1.59,percent of total billed charges,"Drugs, Inpatient Only",1.59,34,,1.59,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,3.27,70,,3.27,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1.56,,,1.56,Other,Drug Cost,1.56,,,1.56,Other,Drug Cost,1.56,,,1.56,Other,Drug Cost,1.56,,,1.56,Other,Drug Cost,1.56,,,1.56,Other,Drug Cost,1.56,,,1.56,Other,Drug Cost,3.5,,,3.5,Other,225% of Medicaid,2.18,,,2.18,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,3.35,,,3.35,Other,215% Medicaid APG methodology,3.35,,,3.35,Other,215% Medicaid APG methodology,1.95,,,1.95,Other,125% Medicaid APG methodology,0.01,3.5,
BACLOFEN 5 MG TABLET,,,,80023717,CDM,250,RC,52817031910,NDC,both,100,EA,0.03,0.01,39.4668,,0.01,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.02,70,,0.02,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.02,,,0.02,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,0.02,
CYANOCOBALAMIN 250 MCG TABLET,,,,80023721,CDM,250,RC,50268085315,NDC,both,5,EA,4,1.58,39.4668,,1.58,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1.36,34,,1.36,percent of total billed charges,"Drugs, Inpatient Only",1.36,34,,1.36,percent of total billed charges,"Drugs, Inpatient Only",1.36,34,,1.36,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2.8,70,,2.8,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1.33,,,1.33,Other,Drug Cost,1.33,,,1.33,Other,Drug Cost,1.33,,,1.33,Other,Drug Cost,1.33,,,1.33,Other,Drug Cost,1.33,,,1.33,Other,Drug Cost,1.33,,,1.33,Other,Drug Cost,3,,,3,Other,225% of Medicaid,1.86,,,1.86,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,2.86,,,2.86,Other,215% Medicaid APG methodology,2.86,,,2.86,Other,215% Medicaid APG methodology,1.67,,,1.67,Other,125% Medicaid APG methodology,0.01,3,
FLUVOXAMINE 25 MG TABLET,,,,80023722,CDM,250,RC,60505016401,NDC,both,100,EA,0.15,0.06,39.4668,,0.06,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.05,34,,0.05,percent of total billed charges,"Drugs, Inpatient Only",0.05,34,,0.05,percent of total billed charges,"Drugs, Inpatient Only",0.05,34,,0.05,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.1,70,,0.1,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.11,,,0.11,Other,225% of Medicaid,0.07,,,0.07,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.1,,,0.1,Other,215% Medicaid APG methodology,0.1,,,0.1,Other,215% Medicaid APG methodology,0.06,,,0.06,Other,125% Medicaid APG methodology,0.01,0.11,
NABUMETONE 750 MG TABLET,,,,80023724,CDM,250,RC,69097096607,NDC,both,100,EA,0.18,0.07,39.4668,,0.07,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.06,34,,0.06,percent of total billed charges,"Drugs, Inpatient Only",0.06,34,,0.06,percent of total billed charges,"Drugs, Inpatient Only",0.06,34,,0.06,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.13,70,,0.13,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.06,,,0.06,Other,Drug Cost,0.06,,,0.06,Other,Drug Cost,0.06,,,0.06,Other,Drug Cost,0.06,,,0.06,Other,Drug Cost,0.06,,,0.06,Other,Drug Cost,0.06,,,0.06,Other,Drug Cost,0.14,,,0.14,Other,225% of Medicaid,0.08,,,0.08,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.13,,,0.13,Other,215% Medicaid APG methodology,0.13,,,0.13,Other,215% Medicaid APG methodology,0.08,,,0.08,Other,125% Medicaid APG methodology,0.01,0.14,
PREDNISONE 2.5 MG TABLET,,,,80023727,CDM,250,RC,603533621,NDC,both,100,EA,0.06,0.02,39.4668,,0.02,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.02,34,,0.02,percent of total billed charges,"Drugs, Inpatient Only",0.02,34,,0.02,percent of total billed charges,"Drugs, Inpatient Only",0.02,34,,0.02,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.04,70,,0.04,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.04,,,0.04,Other,225% of Medicaid,0.03,,,0.03,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.04,,,0.04,Other,215% Medicaid APG methodology,0.04,,,0.04,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,125% Medicaid APG methodology,0.01,0.04,
PROPAFENONE 225 MG TABLET,,,,80023728,CDM,250,RC,59651025701,NDC,both,100,EA,0.15,0.06,39.4668,,0.06,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.05,34,,0.05,percent of total billed charges,"Drugs, Inpatient Only",0.05,34,,0.05,percent of total billed charges,"Drugs, Inpatient Only",0.05,34,,0.05,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.1,70,,0.1,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.11,,,0.11,Other,225% of Medicaid,0.07,,,0.07,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.11,,,0.11,Other,215% Medicaid APG methodology,0.11,,,0.11,Other,215% Medicaid APG methodology,0.06,,,0.06,Other,125% Medicaid APG methodology,0.01,0.11,
PHENOBARBITAL 16.2 MG TABLET,,,,80023745,CDM,250,RC,603516521,NDC,both,100,EA,0.11,0.05,39.4668,,0.05,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.04,34,,0.04,percent of total billed charges,"Drugs, Inpatient Only",0.04,34,,0.04,percent of total billed charges,"Drugs, Inpatient Only",0.04,34,,0.04,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.08,70,,0.08,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.09,,,0.09,Other,225% of Medicaid,0.05,,,0.05,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.08,,,0.08,Other,215% Medicaid APG methodology,0.08,,,0.08,Other,215% Medicaid APG methodology,0.05,,,0.05,Other,125% Medicaid APG methodology,0.01,0.09,
CLONAZEPAM 0.25 MG ODT,,,,80023747,CDM,250,RC,49884030702,NDC,both,10,EA,3.23,1.27,39.4668,,1.27,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1.1,34,,1.1,percent of total billed charges,"Drugs, Inpatient Only",1.1,34,,1.1,percent of total billed charges,"Drugs, Inpatient Only",1.1,34,,1.1,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2.26,70,,2.26,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1.08,,,1.08,Other,Drug Cost,1.08,,,1.08,Other,Drug Cost,1.08,,,1.08,Other,Drug Cost,1.08,,,1.08,Other,Drug Cost,1.08,,,1.08,Other,Drug Cost,1.08,,,1.08,Other,Drug Cost,2.42,,,2.42,Other,225% of Medicaid,1.51,,,1.51,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,2.31,,,2.31,Other,215% Medicaid APG methodology,2.31,,,2.31,Other,215% Medicaid APG methodology,1.34,,,1.34,Other,125% Medicaid APG methodology,0.01,2.42,
PRAMIPEXOLE 0.125 MG TABLET,,,,80023752,CDM,250,RC,13668009190,NDC,both,90,EA,0.03,0.01,39.4668,,0.01,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.02,70,,0.02,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.02,,,0.02,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,0.02,
TORSEMIDE 5 MG TABLET,,,,80023753,CDM,250,RC,31722052901,NDC,both,100,EA,0.09,0.03,39.4668,,0.03,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.03,34,,0.03,percent of total billed charges,"Drugs, Inpatient Only",0.03,34,,0.03,percent of total billed charges,"Drugs, Inpatient Only",0.03,34,,0.03,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.06,70,,0.06,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.07,,,0.07,Other,225% of Medicaid,0.04,,,0.04,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.06,,,0.06,Other,215% Medicaid APG methodology,0.06,,,0.06,Other,215% Medicaid APG methodology,0.04,,,0.04,Other,125% Medicaid APG methodology,0.01,0.07,
ANORO ELLIPTA 62.5MCG/25MCG INHALER,,,,80023777,CDM,250,RC,173086906,NDC,both,14,EA,1.95,0.77,39.4668,,0.77,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.66,34,,0.66,percent of total billed charges,"Drugs, Inpatient Only",0.66,34,,0.66,percent of total billed charges,"Drugs, Inpatient Only",0.66,34,,0.66,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1.36,70,,1.36,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.65,,,0.65,Other,Drug Cost,0.65,,,0.65,Other,Drug Cost,0.65,,,0.65,Other,Drug Cost,0.65,,,0.65,Other,Drug Cost,0.65,,,0.65,Other,Drug Cost,0.65,,,0.65,Other,Drug Cost,1.46,,,1.46,Other,225% of Medicaid,0.91,,,0.91,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,1.39,,,1.39,Other,215% Medicaid APG methodology,1.39,,,1.39,Other,215% Medicaid APG methodology,0.81,,,0.81,Other,125% Medicaid APG methodology,0.01,1.46,
SODIUM CHLORIDE 0.9% 2000ML IRRIGATION,,,,80023781,CDM,250,RC,264220150,NDC,both,8,ML,14.34,5.66,39.4668,,5.66,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,4.88,34,,4.88,percent of total billed charges,"Drugs, Inpatient Only",4.88,34,,4.88,percent of total billed charges,"Drugs, Inpatient Only",4.88,34,,4.88,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,10.04,70,,10.04,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,4.78,,,4.78,Other,Drug Cost,4.78,,,4.78,Other,Drug Cost,4.78,,,4.78,Other,Drug Cost,4.78,,,4.78,Other,Drug Cost,4.78,,,4.78,Other,Drug Cost,4.78,,,4.78,Other,Drug Cost,10.76,,,10.76,Other,225% of Medicaid,6.69,,,6.69,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,10.28,,,10.28,Other,215% Medicaid APG methodology,10.28,,,10.28,Other,215% Medicaid APG methodology,5.98,,,5.98,Other,125% Medicaid APG methodology,0.01,10.76,
CEFAZOLIN 3 GM IN 100 ML,,,,80023792,CDM,250,RC,44567070810,NDC,both,10,EA,17.39,6.86,39.4668,,6.86,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,5.91,34,,5.91,percent of total billed charges,"Drugs, Inpatient Only",5.91,34,,5.91,percent of total billed charges,"Drugs, Inpatient Only",5.91,34,,5.91,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,12.17,70,,12.17,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,5.8,,,5.8,Other,Drug Cost,5.8,,,5.8,Other,Drug Cost,5.8,,,5.8,Other,Drug Cost,5.8,,,5.8,Other,Drug Cost,5.8,,,5.8,Other,Drug Cost,5.8,,,5.8,Other,Drug Cost,13.04,,,13.04,Other,225% of Medicaid,8.12,,,8.12,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,12.46,,,12.46,Other,215% Medicaid APG methodology,12.46,,,12.46,Other,215% Medicaid APG methodology,7.25,,,7.25,Other,125% Medicaid APG methodology,0.01,13.04,
BUSPIRONE 7.5 MG TABLET,,,,80023797,CDM,250,RC,64380078706,NDC,both,100,EA,0.08,0.03,39.4668,,0.03,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.03,34,,0.03,percent of total billed charges,"Drugs, Inpatient Only",0.03,34,,0.03,percent of total billed charges,"Drugs, Inpatient Only",0.03,34,,0.03,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.06,70,,0.06,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.06,,,0.06,Other,225% of Medicaid,0.04,,,0.04,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.06,,,0.06,Other,215% Medicaid APG methodology,0.06,,,0.06,Other,215% Medicaid APG methodology,0.03,,,0.03,Other,125% Medicaid APG methodology,0.01,0.06,
ATOMOXETINE HCL 10MG CAPSULE,,,,80023801,CDM,250,RC,68462026530,NDC,both,30,EA,0.42,0.17,39.4668,,0.17,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.14,34,,0.14,percent of total billed charges,"Drugs, Inpatient Only",0.14,34,,0.14,percent of total billed charges,"Drugs, Inpatient Only",0.14,34,,0.14,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.29,70,,0.29,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.14,,,0.14,Other,Drug Cost,0.14,,,0.14,Other,Drug Cost,0.14,,,0.14,Other,Drug Cost,0.14,,,0.14,Other,Drug Cost,0.14,,,0.14,Other,Drug Cost,0.14,,,0.14,Other,Drug Cost,0.31,,,0.31,Other,225% of Medicaid,0.2,,,0.2,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.3,,,0.3,Other,215% Medicaid APG methodology,0.3,,,0.3,Other,215% Medicaid APG methodology,0.17,,,0.17,Other,125% Medicaid APG methodology,0.01,0.31,
SEVELAMER CARBONATE 2.4GM PACKET,,,,80023816,CDM,250,RC,65862093190,NDC,both,90,EA,1.84,0.72,39.4668,,0.72,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.62,34,,0.62,percent of total billed charges,"Drugs, Inpatient Only",0.62,34,,0.62,percent of total billed charges,"Drugs, Inpatient Only",0.62,34,,0.62,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1.29,70,,1.29,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.61,,,0.61,Other,Drug Cost,0.61,,,0.61,Other,Drug Cost,0.61,,,0.61,Other,Drug Cost,0.61,,,0.61,Other,Drug Cost,0.61,,,0.61,Other,Drug Cost,0.61,,,0.61,Other,Drug Cost,1.38,,,1.38,Other,225% of Medicaid,0.86,,,0.86,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,1.32,,,1.32,Other,215% Medicaid APG methodology,1.32,,,1.32,Other,215% Medicaid APG methodology,0.77,,,0.77,Other,125% Medicaid APG methodology,0.01,1.38,
LAMOTRIGINE 150MG TABLET,,,,80023819,CDM,250,RC,51672413204,NDC,both,60,EA,0.08,0.03,39.4668,,0.03,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.03,34,,0.03,percent of total billed charges,"Drugs, Inpatient Only",0.03,34,,0.03,percent of total billed charges,"Drugs, Inpatient Only",0.03,34,,0.03,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.05,70,,0.05,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.06,,,0.06,Other,225% of Medicaid,0.04,,,0.04,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.05,,,0.05,Other,215% Medicaid APG methodology,0.05,,,0.05,Other,215% Medicaid APG methodology,0.03,,,0.03,Other,125% Medicaid APG methodology,0.01,0.06,
LOSARTAN 100 MG TABLET,,,,80023824,CDM,250,RC,31722070290,NDC,both,90,EA,0.06,0.02,39.4668,,0.02,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.02,34,,0.02,percent of total billed charges,"Drugs, Inpatient Only",0.02,34,,0.02,percent of total billed charges,"Drugs, Inpatient Only",0.02,34,,0.02,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.04,70,,0.04,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.05,,,0.05,Other,225% of Medicaid,0.03,,,0.03,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.04,,,0.04,Other,215% Medicaid APG methodology,0.04,,,0.04,Other,215% Medicaid APG methodology,0.03,,,0.03,Other,125% Medicaid APG methodology,0.01,0.05,
ANASTROZOLE 1 MG ORAL SUSP,,,,80023825,CDM,250,RC,51991062010,NDC,both,1000,EA,0.26,0.1,39.4668,,0.1,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.09,34,,0.09,percent of total billed charges,"Drugs, Inpatient Only",0.09,34,,0.09,percent of total billed charges,"Drugs, Inpatient Only",0.09,34,,0.09,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.18,70,,0.18,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.09,,,0.09,Other,Drug Cost,0.09,,,0.09,Other,Drug Cost,0.09,,,0.09,Other,Drug Cost,0.09,,,0.09,Other,Drug Cost,0.09,,,0.09,Other,Drug Cost,0.09,,,0.09,Other,Drug Cost,0.19,,,0.19,Other,225% of Medicaid,0.12,,,0.12,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.18,,,0.18,Other,215% Medicaid APG methodology,0.18,,,0.18,Other,215% Medicaid APG methodology,0.11,,,0.11,Other,125% Medicaid APG methodology,0.01,0.19,
AMPHETAMINE-DEXTROAMPHETAMINE 5 MG TAB,,,,80023829,CDM,250,RC,47781017401,NDC,both,100,EA,0.18,0.07,39.4668,,0.07,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.06,34,,0.06,percent of total billed charges,"Drugs, Inpatient Only",0.06,34,,0.06,percent of total billed charges,"Drugs, Inpatient Only",0.06,34,,0.06,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.13,70,,0.13,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.06,,,0.06,Other,Drug Cost,0.06,,,0.06,Other,Drug Cost,0.06,,,0.06,Other,Drug Cost,0.06,,,0.06,Other,Drug Cost,0.06,,,0.06,Other,Drug Cost,0.06,,,0.06,Other,Drug Cost,0.14,,,0.14,Other,225% of Medicaid,0.09,,,0.09,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.13,,,0.13,Other,215% Medicaid APG methodology,0.13,,,0.13,Other,215% Medicaid APG methodology,0.08,,,0.08,Other,125% Medicaid APG methodology,0.01,0.14,
FLUTICASONE-VILANTEROL 200-25MCG INHALER,,,,80023842,CDM,250,RC,173088214,NDC,both,28,EA,3.41,1.35,39.4668,,1.35,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1.16,34,,1.16,percent of total billed charges,"Drugs, Inpatient Only",1.16,34,,1.16,percent of total billed charges,"Drugs, Inpatient Only",1.16,34,,1.16,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2.39,70,,2.39,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1.14,,,1.14,Other,Drug Cost,1.14,,,1.14,Other,Drug Cost,1.14,,,1.14,Other,Drug Cost,1.14,,,1.14,Other,Drug Cost,1.14,,,1.14,Other,Drug Cost,1.14,,,1.14,Other,Drug Cost,2.56,,,2.56,Other,225% of Medicaid,1.59,,,1.59,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,2.44,,,2.44,Other,215% Medicaid APG methodology,2.44,,,2.44,Other,215% Medicaid APG methodology,1.42,,,1.42,Other,125% Medicaid APG methodology,0.01,2.56,
CARIPRAZINE HCL 3MG CAPSULE,,,,80023862,CDM,250,RC,61874013020,NDC,both,2,EA,731.15,288.56,39.4668,,288.56,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,248.59,34,,248.59,percent of total billed charges,"Drugs, Inpatient Only",248.59,34,,248.59,percent of total billed charges,"Drugs, Inpatient Only",248.59,34,,248.59,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,511.8,70,,511.8,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,243.72,,,243.72,Other,Drug Cost,243.72,,,243.72,Other,Drug Cost,243.72,,,243.72,Other,Drug Cost,243.72,,,243.72,Other,Drug Cost,243.72,,,243.72,Other,Drug Cost,243.72,,,243.72,Other,Drug Cost,548.36,,,548.36,Other,225% of Medicaid,341.2,,,341.2,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,523.99,,,523.99,Other,215% Medicaid APG methodology,523.99,,,523.99,Other,215% Medicaid APG methodology,304.64,,,304.64,Other,125% Medicaid APG methodology,0.01,548.36,
ISOSORBIDE 5 MG TABLET,,,,80023873,CDM,250,RC,50268044715,NDC,both,5,EA,15.98,6.31,39.4668,,6.31,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,5.43,34,,5.43,percent of total billed charges,"Drugs, Inpatient Only",5.43,34,,5.43,percent of total billed charges,"Drugs, Inpatient Only",5.43,34,,5.43,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,11.18,70,,11.18,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,5.33,,,5.33,Other,Drug Cost,5.33,,,5.33,Other,Drug Cost,5.33,,,5.33,Other,Drug Cost,5.33,,,5.33,Other,Drug Cost,5.33,,,5.33,Other,Drug Cost,5.33,,,5.33,Other,Drug Cost,11.98,,,11.98,Other,225% of Medicaid,7.46,,,7.46,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,11.45,,,11.45,Other,215% Medicaid APG methodology,11.45,,,11.45,Other,215% Medicaid APG methodology,6.66,,,6.66,Other,125% Medicaid APG methodology,0.01,11.98,
GLYCOPYRROLATE 1 MG TABLET,,,,80023878,CDM,250,RC,23155060601,NDC,both,100,EA,0.12,0.05,39.4668,,0.05,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.04,34,,0.04,percent of total billed charges,"Drugs, Inpatient Only",0.04,34,,0.04,percent of total billed charges,"Drugs, Inpatient Only",0.04,34,,0.04,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.08,70,,0.08,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.09,,,0.09,Other,225% of Medicaid,0.06,,,0.06,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.09,,,0.09,Other,215% Medicaid APG methodology,0.09,,,0.09,Other,215% Medicaid APG methodology,0.05,,,0.05,Other,125% Medicaid APG methodology,0.01,0.09,
ROFLUMILAST 250MCG TABLET,,,,80023880,CDM,250,RC,310008828,NDC,both,28,EA,11.67,4.6,39.4668,,4.6,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,3.97,34,,3.97,percent of total billed charges,"Drugs, Inpatient Only",3.97,34,,3.97,percent of total billed charges,"Drugs, Inpatient Only",3.97,34,,3.97,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,8.17,70,,8.17,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,3.89,,,3.89,Other,Drug Cost,3.89,,,3.89,Other,Drug Cost,3.89,,,3.89,Other,Drug Cost,3.89,,,3.89,Other,Drug Cost,3.89,,,3.89,Other,Drug Cost,3.89,,,3.89,Other,Drug Cost,8.75,,,8.75,Other,225% of Medicaid,5.44,,,5.44,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,8.36,,,8.36,Other,215% Medicaid APG methodology,8.36,,,8.36,Other,215% Medicaid APG methodology,4.86,,,4.86,Other,125% Medicaid APG methodology,0.01,8.75,
BIKTARVY 50MG-200MG-25MG TABLET,,,,80023891,CDM,250,RC,61958250101,NDC,both,30,EA,257.73,101.72,39.4668,,101.72,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,87.63,34,,87.63,percent of total billed charges,"Drugs, Inpatient Only",87.63,34,,87.63,percent of total billed charges,"Drugs, Inpatient Only",87.63,34,,87.63,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,180.41,70,,180.41,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,85.91,,,85.91,Other,Drug Cost,85.91,,,85.91,Other,Drug Cost,85.91,,,85.91,Other,Drug Cost,85.91,,,85.91,Other,Drug Cost,85.91,,,85.91,Other,Drug Cost,85.91,,,85.91,Other,Drug Cost,193.3,,,193.3,Other,225% of Medicaid,120.27,,,120.27,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,184.7,,,184.7,Other,215% Medicaid APG methodology,184.7,,,184.7,Other,215% Medicaid APG methodology,107.39,,,107.39,Other,125% Medicaid APG methodology,0.01,193.3,
AMOXICILLIN 400MG/5 ML SUSP 5ML,,,,80023898,CDM,250,RC,93416178,NDC,both,1,ML,3.72,1.47,39.4668,,1.47,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1.26,34,,1.26,percent of total billed charges,"Drugs, Inpatient Only",1.26,34,,1.26,percent of total billed charges,"Drugs, Inpatient Only",1.26,34,,1.26,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2.6,70,,2.6,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1.24,,,1.24,Other,Drug Cost,1.24,,,1.24,Other,Drug Cost,1.24,,,1.24,Other,Drug Cost,1.24,,,1.24,Other,Drug Cost,1.24,,,1.24,Other,Drug Cost,1.24,,,1.24,Other,Drug Cost,2.79,,,2.79,Other,225% of Medicaid,1.74,,,1.74,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,2.67,,,2.67,Other,215% Medicaid APG methodology,2.67,,,2.67,Other,215% Medicaid APG methodology,1.55,,,1.55,Other,125% Medicaid APG methodology,0.01,2.79,
TICAGRELOR 60MG TABLET,,,,80023899,CDM,250,RC,186077660,NDC,both,60,EA,4.46,1.76,39.4668,,1.76,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1.52,34,,1.52,percent of total billed charges,"Drugs, Inpatient Only",1.52,34,,1.52,percent of total billed charges,"Drugs, Inpatient Only",1.52,34,,1.52,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,3.12,70,,3.12,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1.49,,,1.49,Other,Drug Cost,1.49,,,1.49,Other,Drug Cost,1.49,,,1.49,Other,Drug Cost,1.49,,,1.49,Other,Drug Cost,1.49,,,1.49,Other,Drug Cost,1.49,,,1.49,Other,Drug Cost,3.34,,,3.34,Other,225% of Medicaid,2.08,,,2.08,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,3.2,,,3.2,Other,215% Medicaid APG methodology,3.2,,,3.2,Other,215% Medicaid APG methodology,1.86,,,1.86,Other,125% Medicaid APG methodology,0.01,3.34,
KETAMINE DRIP 500MG/500ML,,,,80023900,CDM,250,RC,42023011510,NDC,both,10,ML,4.46,1.76,39.4668,,1.76,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1.52,34,,1.52,percent of total billed charges,"Drugs, Inpatient Only",1.52,34,,1.52,percent of total billed charges,"Drugs, Inpatient Only",1.52,34,,1.52,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,3.12,70,,3.12,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1.49,,,1.49,Other,Drug Cost,1.49,,,1.49,Other,Drug Cost,1.49,,,1.49,Other,Drug Cost,1.49,,,1.49,Other,Drug Cost,1.49,,,1.49,Other,Drug Cost,1.49,,,1.49,Other,Drug Cost,3.35,,,3.35,Other,225% of Medicaid,2.08,,,2.08,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,3.2,,,3.2,Other,215% Medicaid APG methodology,3.2,,,3.2,Other,215% Medicaid APG methodology,1.86,,,1.86,Other,125% Medicaid APG methodology,0.01,3.35,
SODIUM ZIRCONIUM CYLOSILICATE 10GM PKT,,,,80023905,CDM,250,RC,310111030,NDC,both,30,EA,37.16,14.67,39.4668,,14.67,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,12.64,34,,12.64,percent of total billed charges,"Drugs, Inpatient Only",12.64,34,,12.64,percent of total billed charges,"Drugs, Inpatient Only",12.64,34,,12.64,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,26.02,70,,26.02,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,12.39,,,12.39,Other,Drug Cost,12.39,,,12.39,Other,Drug Cost,12.39,,,12.39,Other,Drug Cost,12.39,,,12.39,Other,Drug Cost,12.39,,,12.39,Other,Drug Cost,12.39,,,12.39,Other,Drug Cost,27.87,,,27.87,Other,225% of Medicaid,17.34,,,17.34,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,26.63,,,26.63,Other,215% Medicaid APG methodology,26.63,,,26.63,Other,215% Medicaid APG methodology,15.49,,,15.49,Other,125% Medicaid APG methodology,0.01,27.87,
PORACTANT ALFA 80MG/ML 3ML,,,,80023912,CDM,250,RC,10122051003,NDC,both,1,ML,1466.79,578.9,39.4668,,578.9,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,498.71,34,,498.71,percent of total billed charges,"Drugs, Inpatient Only",498.71,34,,498.71,percent of total billed charges,"Drugs, Inpatient Only",498.71,34,,498.71,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1026.75,70,,1026.75,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,488.93,,,488.93,Other,Drug Cost,488.93,,,488.93,Other,Drug Cost,488.93,,,488.93,Other,Drug Cost,488.93,,,488.93,Other,Drug Cost,488.93,,,488.93,Other,Drug Cost,488.93,,,488.93,Other,Drug Cost,1100.09,,,1100.09,Other,225% of Medicaid,684.5,,,684.5,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,1051.2,,,1051.2,Other,215% Medicaid APG methodology,1051.2,,,1051.2,Other,215% Medicaid APG methodology,611.16,,,611.16,Other,125% Medicaid APG methodology,0.01,1100.09,
VANCOMYCIN 1.25G IN 250 ML,,,,80023913,CDM,250,RC,67457082399,NDC,both,10,EA,34.65,13.68,39.4668,,13.68,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,11.78,34,,11.78,percent of total billed charges,"Drugs, Inpatient Only",11.78,34,,11.78,percent of total billed charges,"Drugs, Inpatient Only",11.78,34,,11.78,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,24.26,70,,24.26,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,11.55,,,11.55,Other,Drug Cost,11.55,,,11.55,Other,Drug Cost,11.55,,,11.55,Other,Drug Cost,11.55,,,11.55,Other,Drug Cost,11.55,,,11.55,Other,Drug Cost,11.55,,,11.55,Other,Drug Cost,25.99,,,25.99,Other,225% of Medicaid,16.17,,,16.17,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,24.83,,,24.83,Other,215% Medicaid APG methodology,24.83,,,24.83,Other,215% Medicaid APG methodology,14.44,,,14.44,Other,125% Medicaid APG methodology,0.01,25.99,
VANCOMYCIN 1.5G/250 ML,,,,80023914,CDM,250,RC,67457082499,NDC,both,10,EA,22.97,9.07,39.4668,,9.07,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,7.81,34,,7.81,percent of total billed charges,"Drugs, Inpatient Only",7.81,34,,7.81,percent of total billed charges,"Drugs, Inpatient Only",7.81,34,,7.81,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,16.08,70,,16.08,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,7.66,,,7.66,Other,Drug Cost,7.66,,,7.66,Other,Drug Cost,7.66,,,7.66,Other,Drug Cost,7.66,,,7.66,Other,Drug Cost,7.66,,,7.66,Other,Drug Cost,7.66,,,7.66,Other,Drug Cost,17.23,,,17.23,Other,225% of Medicaid,10.72,,,10.72,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,16.46,,,16.46,Other,215% Medicaid APG methodology,16.46,,,16.46,Other,215% Medicaid APG methodology,9.57,,,9.57,Other,125% Medicaid APG methodology,0.01,17.23,
LIDOCAINE 2% JELLY 20 ML UROJET,,,,80023915,CDM,250,RC,76329301505,NDC,both,25,ML,16.14,6.37,39.4668,,6.37,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,5.49,34,,5.49,percent of total billed charges,"Drugs, Inpatient Only",5.49,34,,5.49,percent of total billed charges,"Drugs, Inpatient Only",5.49,34,,5.49,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,11.3,70,,11.3,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,5.38,,,5.38,Other,Drug Cost,5.38,,,5.38,Other,Drug Cost,5.38,,,5.38,Other,Drug Cost,5.38,,,5.38,Other,Drug Cost,5.38,,,5.38,Other,Drug Cost,5.38,,,5.38,Other,Drug Cost,12.11,,,12.11,Other,225% of Medicaid,7.53,,,7.53,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,11.57,,,11.57,Other,215% Medicaid APG methodology,11.57,,,11.57,Other,215% Medicaid APG methodology,6.73,,,6.73,Other,125% Medicaid APG methodology,0.01,12.11,
NICARDIPINE IN SOD CHLORIDE 40MG/200ML,,,,80023923,CDM,250,RC,43066001610,NDC,both,10,ML,62.07,24.5,39.4668,,24.5,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,21.1,34,,21.1,percent of total billed charges,"Drugs, Inpatient Only",21.1,34,,21.1,percent of total billed charges,"Drugs, Inpatient Only",21.1,34,,21.1,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,43.45,70,,43.45,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,20.69,,,20.69,Other,Drug Cost,20.69,,,20.69,Other,Drug Cost,20.69,,,20.69,Other,Drug Cost,20.69,,,20.69,Other,Drug Cost,20.69,,,20.69,Other,Drug Cost,20.69,,,20.69,Other,Drug Cost,46.55,,,46.55,Other,225% of Medicaid,28.97,,,28.97,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,44.49,,,44.49,Other,215% Medicaid APG methodology,44.49,,,44.49,Other,215% Medicaid APG methodology,25.86,,,25.86,Other,125% Medicaid APG methodology,0.01,46.55,
LEVETIRACETAM 1500MG/100ML IV,,,,80023925,CDM,250,RC,55150024847,NDC,both,10,ML,31.9,12.59,39.4668,,12.59,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,10.85,34,,10.85,percent of total billed charges,"Drugs, Inpatient Only",10.85,34,,10.85,percent of total billed charges,"Drugs, Inpatient Only",10.85,34,,10.85,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,22.33,70,,22.33,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,10.63,,,10.63,Other,Drug Cost,10.63,,,10.63,Other,Drug Cost,10.63,,,10.63,Other,Drug Cost,10.63,,,10.63,Other,Drug Cost,10.63,,,10.63,Other,Drug Cost,10.63,,,10.63,Other,Drug Cost,23.92,,,23.92,Other,225% of Medicaid,14.89,,,14.89,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,22.86,,,22.86,Other,215% Medicaid APG methodology,22.86,,,22.86,Other,215% Medicaid APG methodology,13.29,,,13.29,Other,125% Medicaid APG methodology,0.01,23.92,
THEOPHYLLINE 100MG ER CAPSULE,,,,80023930,CDM,250,RC,52244010010,NDC,both,100,EA,3.53,1.39,39.4668,,1.39,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1.2,34,,1.2,percent of total billed charges,"Drugs, Inpatient Only",1.2,34,,1.2,percent of total billed charges,"Drugs, Inpatient Only",1.2,34,,1.2,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2.47,70,,2.47,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1.18,,,1.18,Other,Drug Cost,1.18,,,1.18,Other,Drug Cost,1.18,,,1.18,Other,Drug Cost,1.18,,,1.18,Other,Drug Cost,1.18,,,1.18,Other,Drug Cost,1.18,,,1.18,Other,Drug Cost,2.65,,,2.65,Other,225% of Medicaid,1.65,,,1.65,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,2.53,,,2.53,Other,215% Medicaid APG methodology,2.53,,,2.53,Other,215% Medicaid APG methodology,1.47,,,1.47,Other,125% Medicaid APG methodology,0.01,2.65,
Dexmedetomidine 400mcg/100mL,,,,80023937,CDM,250,RC,44567060324,NDC,both,24,ML,35.07,13.84,39.4668,,13.84,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,11.92,34,,11.92,percent of total billed charges,"Drugs, Inpatient Only",11.92,34,,11.92,percent of total billed charges,"Drugs, Inpatient Only",11.92,34,,11.92,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,24.55,70,,24.55,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,11.69,,,11.69,Other,Drug Cost,11.69,,,11.69,Other,Drug Cost,11.69,,,11.69,Other,Drug Cost,11.69,,,11.69,Other,Drug Cost,11.69,,,11.69,Other,Drug Cost,11.69,,,11.69,Other,Drug Cost,26.3,,,26.3,Other,225% of Medicaid,16.37,,,16.37,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,25.13,,,25.13,Other,215% Medicaid APG methodology,25.13,,,25.13,Other,215% Medicaid APG methodology,14.61,,,14.61,Other,125% Medicaid APG methodology,0.01,26.3,
SUCCIMER 100MG CAPSULES,,,,80023949,CDM,250,RC,55292020111,NDC,both,100,EA,66.1,26.09,39.4668,,26.09,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,22.48,34,,22.48,percent of total billed charges,"Drugs, Inpatient Only",22.48,34,,22.48,percent of total billed charges,"Drugs, Inpatient Only",22.48,34,,22.48,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,46.27,70,,46.27,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,22.03,,,22.03,Other,Drug Cost,22.03,,,22.03,Other,Drug Cost,22.03,,,22.03,Other,Drug Cost,22.03,,,22.03,Other,Drug Cost,22.03,,,22.03,Other,Drug Cost,22.03,,,22.03,Other,Drug Cost,49.58,,,49.58,Other,225% of Medicaid,30.85,,,30.85,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,47.37,,,47.37,Other,215% Medicaid APG methodology,47.37,,,47.37,Other,215% Medicaid APG methodology,27.54,,,27.54,Other,125% Medicaid APG methodology,0.01,49.58,
RALTEGRAVIR 25MG CHEWABLE TABLET,,,,80023953,CDM,250,RC,6047361,NDC,both,60,EA,2.46,0.97,39.4668,,0.97,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.84,34,,0.84,percent of total billed charges,"Drugs, Inpatient Only",0.84,34,,0.84,percent of total billed charges,"Drugs, Inpatient Only",0.84,34,,0.84,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1.72,70,,1.72,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.82,,,0.82,Other,Drug Cost,0.82,,,0.82,Other,Drug Cost,0.82,,,0.82,Other,Drug Cost,0.82,,,0.82,Other,Drug Cost,0.82,,,0.82,Other,Drug Cost,0.82,,,0.82,Other,Drug Cost,1.85,,,1.85,Other,225% of Medicaid,1.15,,,1.15,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,1.77,,,1.77,Other,215% Medicaid APG methodology,1.77,,,1.77,Other,215% Medicaid APG methodology,1.03,,,1.03,Other,125% Medicaid APG methodology,0.01,1.85,
TENOFOVIR DISOPROXIS FUMARATE 40MG/SCOOP,,,,80023954,CDM,250,RC,61958040301,NDC,both,1,GM,461.43,182.11,39.4668,,182.11,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,156.89,34,,156.89,percent of total billed charges,"Drugs, Inpatient Only",156.89,34,,156.89,percent of total billed charges,"Drugs, Inpatient Only",156.89,34,,156.89,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,323,70,,323,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,153.81,,,153.81,Other,Drug Cost,153.81,,,153.81,Other,Drug Cost,153.81,,,153.81,Other,Drug Cost,153.81,,,153.81,Other,Drug Cost,153.81,,,153.81,Other,Drug Cost,153.81,,,153.81,Other,Drug Cost,346.07,,,346.07,Other,225% of Medicaid,215.33,,,215.33,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,330.69,,,330.69,Other,215% Medicaid APG methodology,330.69,,,330.69,Other,215% Medicaid APG methodology,192.26,,,192.26,Other,125% Medicaid APG methodology,0.01,346.07,
EMTRICITABINE 10MG/ML ORAL SOLN,,,,80023955,CDM,250,RC,61958060201,NDC,both,1,ML,199.5,78.74,39.4668,,78.74,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,67.83,34,,67.83,percent of total billed charges,"Drugs, Inpatient Only",67.83,34,,67.83,percent of total billed charges,"Drugs, Inpatient Only",67.83,34,,67.83,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,139.65,70,,139.65,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,66.5,,,66.5,Other,Drug Cost,66.5,,,66.5,Other,Drug Cost,66.5,,,66.5,Other,Drug Cost,66.5,,,66.5,Other,Drug Cost,66.5,,,66.5,Other,Drug Cost,66.5,,,66.5,Other,Drug Cost,149.63,,,149.63,Other,225% of Medicaid,93.1,,,93.1,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,142.98,,,142.98,Other,215% Medicaid APG methodology,142.98,,,142.98,Other,215% Medicaid APG methodology,83.13,,,83.13,Other,125% Medicaid APG methodology,0.01,149.63,
EPHEDRINE SUOLFATE 50MG/10ML,,,,80023958,CDM,250,RC,14789025010,NDC,both,10,ML,23.1,9.12,39.4668,,9.12,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,7.85,34,,7.85,percent of total billed charges,"Drugs, Inpatient Only",7.85,34,,7.85,percent of total billed charges,"Drugs, Inpatient Only",7.85,34,,7.85,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,16.17,70,,16.17,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,7.7,,,7.7,Other,Drug Cost,7.7,,,7.7,Other,Drug Cost,7.7,,,7.7,Other,Drug Cost,7.7,,,7.7,Other,Drug Cost,7.7,,,7.7,Other,Drug Cost,7.7,,,7.7,Other,Drug Cost,17.33,,,17.33,Other,225% of Medicaid,10.78,,,10.78,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,16.56,,,16.56,Other,215% Medicaid APG methodology,16.56,,,16.56,Other,215% Medicaid APG methodology,9.63,,,9.63,Other,125% Medicaid APG methodology,0.01,17.33,
AMOXICILLIN 875 MG TABLET,,,,80023960,CDM,250,RC,65862001501,NDC,both,100,EA,0.19,0.08,39.4668,,0.08,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.07,34,,0.07,percent of total billed charges,"Drugs, Inpatient Only",0.07,34,,0.07,percent of total billed charges,"Drugs, Inpatient Only",0.07,34,,0.07,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.13,70,,0.13,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.06,,,0.06,Other,Drug Cost,0.06,,,0.06,Other,Drug Cost,0.06,,,0.06,Other,Drug Cost,0.06,,,0.06,Other,Drug Cost,0.06,,,0.06,Other,Drug Cost,0.06,,,0.06,Other,Drug Cost,0.14,,,0.14,Other,225% of Medicaid,0.09,,,0.09,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.14,,,0.14,Other,215% Medicaid APG methodology,0.14,,,0.14,Other,215% Medicaid APG methodology,0.08,,,0.08,Other,125% Medicaid APG methodology,0.01,0.14,
VANCOMYCIN ORAL SOLN 125MG/2.5ML,,,,80023973,CDM,250,RC,62559083055,NDC,both,1,ML,487.08,192.23,39.4668,,192.23,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,165.61,34,,165.61,percent of total billed charges,"Drugs, Inpatient Only",165.61,34,,165.61,percent of total billed charges,"Drugs, Inpatient Only",165.61,34,,165.61,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,340.96,70,,340.96,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,162.36,,,162.36,Other,Drug Cost,162.36,,,162.36,Other,Drug Cost,162.36,,,162.36,Other,Drug Cost,162.36,,,162.36,Other,Drug Cost,162.36,,,162.36,Other,Drug Cost,162.36,,,162.36,Other,Drug Cost,365.31,,,365.31,Other,225% of Medicaid,227.3,,,227.3,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,349.07,,,349.07,Other,215% Medicaid APG methodology,349.07,,,349.07,Other,215% Medicaid APG methodology,202.95,,,202.95,Other,125% Medicaid APG methodology,0.01,365.31,
PRAZOSIN 5MG CAPS,,,,80023984,CDM,250,RC,70377006811,NDC,both,100,EA,0.4,0.16,39.4668,,0.16,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.13,34,,0.13,percent of total billed charges,"Drugs, Inpatient Only",0.13,34,,0.13,percent of total billed charges,"Drugs, Inpatient Only",0.13,34,,0.13,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.28,70,,0.28,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.13,,,0.13,Other,Drug Cost,0.13,,,0.13,Other,Drug Cost,0.13,,,0.13,Other,Drug Cost,0.13,,,0.13,Other,Drug Cost,0.13,,,0.13,Other,Drug Cost,0.13,,,0.13,Other,Drug Cost,0.3,,,0.3,Other,225% of Medicaid,0.18,,,0.18,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.28,,,0.28,Other,215% Medicaid APG methodology,0.28,,,0.28,Other,215% Medicaid APG methodology,0.16,,,0.16,Other,125% Medicaid APG methodology,0.01,0.3,
NOREPINEPHRINE 8MG/250ML,,,,80023990,CDM,250,RC,338010820,NDC,both,20,ML,26.02,10.27,39.4668,,10.27,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,8.85,34,,8.85,percent of total billed charges,"Drugs, Inpatient Only",8.85,34,,8.85,percent of total billed charges,"Drugs, Inpatient Only",8.85,34,,8.85,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,18.21,70,,18.21,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,8.67,,,8.67,Other,Drug Cost,8.67,,,8.67,Other,Drug Cost,8.67,,,8.67,Other,Drug Cost,8.67,,,8.67,Other,Drug Cost,8.67,,,8.67,Other,Drug Cost,8.67,,,8.67,Other,Drug Cost,19.51,,,19.51,Other,225% of Medicaid,12.14,,,12.14,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,18.65,,,18.65,Other,215% Medicaid APG methodology,18.65,,,18.65,Other,215% Medicaid APG methodology,10.84,,,10.84,Other,125% Medicaid APG methodology,0.01,19.51,
BUPIVACAINE 0.75% (7.5MG/ML) 30ML,,,,80024007,CDM,250,RC,55150017230,NDC,both,25,ML,8.26,3.26,39.4668,,3.26,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2.81,34,,2.81,percent of total billed charges,"Drugs, Inpatient Only",2.81,34,,2.81,percent of total billed charges,"Drugs, Inpatient Only",2.81,34,,2.81,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,5.78,70,,5.78,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2.75,,,2.75,Other,Drug Cost,2.75,,,2.75,Other,Drug Cost,2.75,,,2.75,Other,Drug Cost,2.75,,,2.75,Other,Drug Cost,2.75,,,2.75,Other,Drug Cost,2.75,,,2.75,Other,Drug Cost,6.2,,,6.2,Other,225% of Medicaid,3.86,,,3.86,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,5.92,,,5.92,Other,215% Medicaid APG methodology,5.92,,,5.92,Other,215% Medicaid APG methodology,3.44,,,3.44,Other,125% Medicaid APG methodology,0.01,6.2,
DOFETILIDE 125 MCG CAPSULE,,,,80024012,CDM,250,RC,47335006186,NDC,both,60,EA,0.29,0.11,39.4668,,0.11,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.1,34,,0.1,percent of total billed charges,"Drugs, Inpatient Only",0.1,34,,0.1,percent of total billed charges,"Drugs, Inpatient Only",0.1,34,,0.1,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.2,70,,0.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.1,,,0.1,Other,Drug Cost,0.1,,,0.1,Other,Drug Cost,0.1,,,0.1,Other,Drug Cost,0.1,,,0.1,Other,Drug Cost,0.1,,,0.1,Other,Drug Cost,0.1,,,0.1,Other,Drug Cost,0.22,,,0.22,Other,225% of Medicaid,0.14,,,0.14,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.21,,,0.21,Other,215% Medicaid APG methodology,0.21,,,0.21,Other,215% Medicaid APG methodology,0.12,,,0.12,Other,125% Medicaid APG methodology,0.01,0.22,
DOFETILIDE 500 MCG CAPSULE,,,,80024014,CDM,250,RC,72205004160,NDC,both,60,EA,0.38,0.15,39.4668,,0.15,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.13,34,,0.13,percent of total billed charges,"Drugs, Inpatient Only",0.13,34,,0.13,percent of total billed charges,"Drugs, Inpatient Only",0.13,34,,0.13,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.27,70,,0.27,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.13,,,0.13,Other,Drug Cost,0.13,,,0.13,Other,Drug Cost,0.13,,,0.13,Other,Drug Cost,0.13,,,0.13,Other,Drug Cost,0.13,,,0.13,Other,Drug Cost,0.13,,,0.13,Other,Drug Cost,0.29,,,0.29,Other,225% of Medicaid,0.18,,,0.18,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.28,,,0.28,Other,215% Medicaid APG methodology,0.28,,,0.28,Other,215% Medicaid APG methodology,0.16,,,0.16,Other,125% Medicaid APG methodology,0.01,0.29,
EMPAGLIFLOZIN 10 MG TAB,,,,80024021,CDM,250,RC,597015230,NDC,both,30,EA,0.03,0.01,39.4668,,0.01,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,34,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.02,70,,0.02,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.02,,,0.02,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,0.02,
DOXYCYLINE 25MG/5ML ORAL SUSP,,,,80024026,CDM,250,RC,68180065701,NDC,both,1,ML,10.29,4.06,39.4668,,4.06,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,3.5,34,,3.5,percent of total billed charges,"Drugs, Inpatient Only",3.5,34,,3.5,percent of total billed charges,"Drugs, Inpatient Only",3.5,34,,3.5,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,7.2,70,,7.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,3.43,,,3.43,Other,Drug Cost,3.43,,,3.43,Other,Drug Cost,3.43,,,3.43,Other,Drug Cost,3.43,,,3.43,Other,Drug Cost,3.43,,,3.43,Other,Drug Cost,3.43,,,3.43,Other,Drug Cost,7.72,,,7.72,Other,225% of Medicaid,4.8,,,4.8,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,7.37,,,7.37,Other,215% Medicaid APG methodology,7.37,,,7.37,Other,215% Medicaid APG methodology,4.29,,,4.29,Other,125% Medicaid APG methodology,0.01,7.72,
NITROGLYCERIN 25MG / 250ML INJ,,,,80024040,CDM,250,RC,338104702,NDC,both,12,ML,6.96,2.75,39.4668,,2.75,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2.37,34,,2.37,percent of total billed charges,"Drugs, Inpatient Only",2.37,34,,2.37,percent of total billed charges,"Drugs, Inpatient Only",2.37,34,,2.37,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,4.87,70,,4.87,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2.32,,,2.32,Other,Drug Cost,2.32,,,2.32,Other,Drug Cost,2.32,,,2.32,Other,Drug Cost,2.32,,,2.32,Other,Drug Cost,2.32,,,2.32,Other,Drug Cost,2.32,,,2.32,Other,Drug Cost,5.22,,,5.22,Other,225% of Medicaid,3.25,,,3.25,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,4.99,,,4.99,Other,215% Medicaid APG methodology,4.99,,,4.99,Other,215% Medicaid APG methodology,2.9,,,2.9,Other,125% Medicaid APG methodology,0.01,5.22,
LACOSAMIDE 10 MG/ML 5 ML ORAL SOLN,,,,80024043,CDM,250,RC,67877073295,NDC,both,1,ML,14.73,5.81,39.4668,,5.81,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,5.01,34,,5.01,percent of total billed charges,"Drugs, Inpatient Only",5.01,34,,5.01,percent of total billed charges,"Drugs, Inpatient Only",5.01,34,,5.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,10.31,70,,10.31,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,4.91,,,4.91,Other,Drug Cost,4.91,,,4.91,Other,Drug Cost,4.91,,,4.91,Other,Drug Cost,4.91,,,4.91,Other,Drug Cost,4.91,,,4.91,Other,Drug Cost,4.91,,,4.91,Other,Drug Cost,11.05,,,11.05,Other,225% of Medicaid,6.87,,,6.87,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,10.56,,,10.56,Other,215% Medicaid APG methodology,10.56,,,10.56,Other,215% Medicaid APG methodology,6.14,,,6.14,Other,125% Medicaid APG methodology,0.01,11.05,
RISPERIDONE 0.25MG ODT,,,,80024059,CDM,250,RC,49884021255,NDC,both,5,EA,13.88,5.48,39.4668,,5.48,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,4.72,34,,4.72,percent of total billed charges,"Drugs, Inpatient Only",4.72,34,,4.72,percent of total billed charges,"Drugs, Inpatient Only",4.72,34,,4.72,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,9.72,70,,9.72,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,4.63,,,4.63,Other,Drug Cost,4.63,,,4.63,Other,Drug Cost,4.63,,,4.63,Other,Drug Cost,4.63,,,4.63,Other,Drug Cost,4.63,,,4.63,Other,Drug Cost,4.63,,,4.63,Other,Drug Cost,10.41,,,10.41,Other,225% of Medicaid,6.48,,,6.48,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,9.95,,,9.95,Other,215% Medicaid APG methodology,9.95,,,9.95,Other,215% Medicaid APG methodology,5.79,,,5.79,Other,125% Medicaid APG methodology,0.01,10.41,
TRACE ELEMENTS ZN-CU-MN-SE 1ML INJ,,,,80024062,CDM,250,RC,517930525,NDC,both,25,ML,41.35,16.32,39.4668,,16.32,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,14.06,34,,14.06,percent of total billed charges,"Drugs, Inpatient Only",14.06,34,,14.06,percent of total billed charges,"Drugs, Inpatient Only",14.06,34,,14.06,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,28.95,70,,28.95,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,13.78,,,13.78,Other,Drug Cost,13.78,,,13.78,Other,Drug Cost,13.78,,,13.78,Other,Drug Cost,13.78,,,13.78,Other,Drug Cost,13.78,,,13.78,Other,Drug Cost,13.78,,,13.78,Other,Drug Cost,31.01,,,31.01,Other,225% of Medicaid,19.3,,,19.3,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,29.64,,,29.64,Other,215% Medicaid APG methodology,29.64,,,29.64,Other,215% Medicaid APG methodology,17.23,,,17.23,Other,125% Medicaid APG methodology,0.01,31.01,
UREA 15G POWDER,,,,80024064,CDM,250,RC,62530000011,NDC,both,8,GM,12.22,4.82,39.4668,,4.82,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,4.15,34,,4.15,percent of total billed charges,"Drugs, Inpatient Only",4.15,34,,4.15,percent of total billed charges,"Drugs, Inpatient Only",4.15,34,,4.15,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,8.55,70,,8.55,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,4.07,,,4.07,Other,Drug Cost,4.07,,,4.07,Other,Drug Cost,4.07,,,4.07,Other,Drug Cost,4.07,,,4.07,Other,Drug Cost,4.07,,,4.07,Other,Drug Cost,4.07,,,4.07,Other,Drug Cost,9.16,,,9.16,Other,225% of Medicaid,5.7,,,5.7,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,8.76,,,8.76,Other,215% Medicaid APG methodology,8.76,,,8.76,Other,215% Medicaid APG methodology,5.09,,,5.09,Other,125% Medicaid APG methodology,0.01,9.16,
VASOPRESSIN 20 UNITS/100ML,,,,80024068,CDM,250,RC,42023023710,NDC,both,10,ML,141.32,55.77,39.4668,,55.77,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,48.05,34,,48.05,percent of total billed charges,"Drugs, Inpatient Only",48.05,34,,48.05,percent of total billed charges,"Drugs, Inpatient Only",48.05,34,,48.05,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,98.92,70,,98.92,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,47.11,,,47.11,Other,Drug Cost,47.11,,,47.11,Other,Drug Cost,47.11,,,47.11,Other,Drug Cost,47.11,,,47.11,Other,Drug Cost,47.11,,,47.11,Other,Drug Cost,47.11,,,47.11,Other,Drug Cost,105.99,,,105.99,Other,225% of Medicaid,65.95,,,65.95,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,101.28,,,101.28,Other,215% Medicaid APG methodology,101.28,,,101.28,Other,215% Medicaid APG methodology,58.88,,,58.88,Other,125% Medicaid APG methodology,0.01,105.99,
PROPRANOLOL 80 MG TABLET,,,,80024070,CDM,250,RC,603548621,NDC,both,100,EA,0.06,0.02,39.4668,,0.02,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.02,34,,0.02,percent of total billed charges,"Drugs, Inpatient Only",0.02,34,,0.02,percent of total billed charges,"Drugs, Inpatient Only",0.02,34,,0.02,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.04,70,,0.04,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.04,,,0.04,Other,225% of Medicaid,0.03,,,0.03,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.04,,,0.04,Other,215% Medicaid APG methodology,0.04,,,0.04,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,125% Medicaid APG methodology,0.01,0.04,
FERRIC SUBSULFATE(MONSEL'S) 8ML,,,,80024072,CDM,250,RC,48783011208,NDC,both,12,ML,50.54,19.95,39.4668,,19.95,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,17.18,34,,17.18,percent of total billed charges,"Drugs, Inpatient Only",17.18,34,,17.18,percent of total billed charges,"Drugs, Inpatient Only",17.18,34,,17.18,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,35.38,70,,35.38,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,16.85,,,16.85,Other,Drug Cost,16.85,,,16.85,Other,Drug Cost,16.85,,,16.85,Other,Drug Cost,16.85,,,16.85,Other,Drug Cost,16.85,,,16.85,Other,Drug Cost,16.85,,,16.85,Other,Drug Cost,37.91,,,37.91,Other,225% of Medicaid,23.59,,,23.59,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,36.22,,,36.22,Other,215% Medicaid APG methodology,36.22,,,36.22,Other,215% Medicaid APG methodology,21.06,,,21.06,Other,125% Medicaid APG methodology,0.01,37.91,
NAPROXEN 125 MG/5 ML ORAL SUSP,,,,80024088,CDM,250,RC,69238173002,NDC,both,1,ML,110.82,43.74,39.4668,,43.74,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,37.68,34,,37.68,percent of total billed charges,"Drugs, Inpatient Only",37.68,34,,37.68,percent of total billed charges,"Drugs, Inpatient Only",37.68,34,,37.68,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,77.57,70,,77.57,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,36.94,,,36.94,Other,Drug Cost,36.94,,,36.94,Other,Drug Cost,36.94,,,36.94,Other,Drug Cost,36.94,,,36.94,Other,Drug Cost,36.94,,,36.94,Other,Drug Cost,36.94,,,36.94,Other,Drug Cost,83.12,,,83.12,Other,225% of Medicaid,51.72,,,51.72,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,79.42,,,79.42,Other,215% Medicaid APG methodology,79.42,,,79.42,Other,215% Medicaid APG methodology,46.18,,,46.18,Other,125% Medicaid APG methodology,0.01,83.12,
NEVIRAPINE 50MG/5ML SUSPENSION,,,,80024089,CDM,250,RC,65862005724,NDC,both,1,ML,264.63,104.44,39.4668,,104.44,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,89.97,34,,89.97,percent of total billed charges,"Drugs, Inpatient Only",89.97,34,,89.97,percent of total billed charges,"Drugs, Inpatient Only",89.97,34,,89.97,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,185.24,70,,185.24,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,88.21,,,88.21,Other,Drug Cost,88.21,,,88.21,Other,Drug Cost,88.21,,,88.21,Other,Drug Cost,88.21,,,88.21,Other,Drug Cost,88.21,,,88.21,Other,Drug Cost,88.21,,,88.21,Other,Drug Cost,198.47,,,198.47,Other,225% of Medicaid,123.49,,,123.49,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,189.65,,,189.65,Other,215% Medicaid APG methodology,189.65,,,189.65,Other,215% Medicaid APG methodology,110.26,,,110.26,Other,125% Medicaid APG methodology,0.01,198.47,
DOXEPIN 100MG CAPSULE,,,,80024091,CDM,250,RC,904705561,NDC,both,10,EA,42.48,16.77,39.4668,,16.77,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,14.44,34,,14.44,percent of total billed charges,"Drugs, Inpatient Only",14.44,34,,14.44,percent of total billed charges,"Drugs, Inpatient Only",14.44,34,,14.44,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,29.74,70,,29.74,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,14.16,,,14.16,Other,Drug Cost,14.16,,,14.16,Other,Drug Cost,14.16,,,14.16,Other,Drug Cost,14.16,,,14.16,Other,Drug Cost,14.16,,,14.16,Other,Drug Cost,14.16,,,14.16,Other,Drug Cost,31.86,,,31.86,Other,225% of Medicaid,19.83,,,19.83,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,30.45,,,30.45,Other,215% Medicaid APG methodology,30.45,,,30.45,Other,215% Medicaid APG methodology,17.7,,,17.7,Other,125% Medicaid APG methodology,0.01,31.86,
ZONISAMIDE 20 MG/ML SUSP,,,,80024093,CDM,250,RC,52652800101,NDC,both,1,ML,750.18,296.07,39.4668,,296.07,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,255.06,34,,255.06,percent of total billed charges,"Drugs, Inpatient Only",255.06,34,,255.06,percent of total billed charges,"Drugs, Inpatient Only",255.06,34,,255.06,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,525.13,70,,525.13,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,250.06,,,250.06,Other,Drug Cost,250.06,,,250.06,Other,Drug Cost,250.06,,,250.06,Other,Drug Cost,250.06,,,250.06,Other,Drug Cost,250.06,,,250.06,Other,Drug Cost,250.06,,,250.06,Other,Drug Cost,562.64,,,562.64,Other,225% of Medicaid,350.08,,,350.08,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,537.63,,,537.63,Other,215% Medicaid APG methodology,537.63,,,537.63,Other,215% Medicaid APG methodology,312.58,,,312.58,Other,125% Medicaid APG methodology,0.01,562.64,
ABIRATERONE ACETATE 250MG TABLET,,,,80024096,CDM,250,RC,60687045521,NDC,both,3,EA,68.69,27.11,39.4668,,27.11,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,23.35,34,,23.35,percent of total billed charges,"Drugs, Inpatient Only",23.35,34,,23.35,percent of total billed charges,"Drugs, Inpatient Only",23.35,34,,23.35,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,48.08,70,,48.08,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,22.9,,,22.9,Other,Drug Cost,22.9,,,22.9,Other,Drug Cost,22.9,,,22.9,Other,Drug Cost,22.9,,,22.9,Other,Drug Cost,22.9,,,22.9,Other,Drug Cost,22.9,,,22.9,Other,Drug Cost,51.52,,,51.52,Other,225% of Medicaid,32.06,,,32.06,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,49.23,,,49.23,Other,215% Medicaid APG methodology,49.23,,,49.23,Other,215% Medicaid APG methodology,28.62,,,28.62,Other,125% Medicaid APG methodology,0.01,51.52,
SODIUM CHLORIDE 3% INHALATION 4 ML,,,,80024104,CDM,250,RC,76204002260,NDC,both,60,ML,1.67,0.66,39.4668,,0.66,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.57,34,,0.57,percent of total billed charges,"Drugs, Inpatient Only",0.57,34,,0.57,percent of total billed charges,"Drugs, Inpatient Only",0.57,34,,0.57,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1.17,70,,1.17,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.56,,,0.56,Other,Drug Cost,0.56,,,0.56,Other,Drug Cost,0.56,,,0.56,Other,Drug Cost,0.56,,,0.56,Other,Drug Cost,0.56,,,0.56,Other,Drug Cost,0.56,,,0.56,Other,Drug Cost,1.26,,,1.26,Other,225% of Medicaid,0.78,,,0.78,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,1.2,,,1.2,Other,215% Medicaid APG methodology,1.2,,,1.2,Other,215% Medicaid APG methodology,0.7,,,0.7,Other,125% Medicaid APG methodology,0.01,1.26,
CEFADROXIL 500MG CAPSULES,,,,80024108,CDM,250,RC,68180018008,NDC,both,50,EA,0.21,0.08,39.4668,,0.08,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.07,34,,0.07,percent of total billed charges,"Drugs, Inpatient Only",0.07,34,,0.07,percent of total billed charges,"Drugs, Inpatient Only",0.07,34,,0.07,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.15,70,,0.15,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.07,,,0.07,Other,Drug Cost,0.07,,,0.07,Other,Drug Cost,0.07,,,0.07,Other,Drug Cost,0.07,,,0.07,Other,Drug Cost,0.07,,,0.07,Other,Drug Cost,0.07,,,0.07,Other,Drug Cost,0.16,,,0.16,Other,225% of Medicaid,0.1,,,0.1,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.15,,,0.15,Other,215% Medicaid APG methodology,0.15,,,0.15,Other,215% Medicaid APG methodology,0.09,,,0.09,Other,125% Medicaid APG methodology,0.01,0.16,
CEFADROXIL 250MG/5ML SUSP,,,,80024109,CDM,250,RC,57237009701,NDC,both,1,ML,22.65,8.94,39.4668,,8.94,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,7.7,34,,7.7,percent of total billed charges,"Drugs, Inpatient Only",7.7,34,,7.7,percent of total billed charges,"Drugs, Inpatient Only",7.7,34,,7.7,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,15.86,70,,15.86,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,7.55,,,7.55,Other,Drug Cost,7.55,,,7.55,Other,Drug Cost,7.55,,,7.55,Other,Drug Cost,7.55,,,7.55,Other,Drug Cost,7.55,,,7.55,Other,Drug Cost,7.55,,,7.55,Other,Drug Cost,16.99,,,16.99,Other,225% of Medicaid,10.57,,,10.57,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,16.23,,,16.23,Other,215% Medicaid APG methodology,16.23,,,16.23,Other,215% Medicaid APG methodology,9.44,,,9.44,Other,125% Medicaid APG methodology,0.01,16.99,
LEVOTHYROXINE 20MG/ML 5ML,,,,80024110,CDM,250,RC,63323088510,NDC,both,1,ML,85.41,33.71,39.4668,,33.71,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,29.04,34,,29.04,percent of total billed charges,"Drugs, Inpatient Only",29.04,34,,29.04,percent of total billed charges,"Drugs, Inpatient Only",29.04,34,,29.04,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,59.79,70,,59.79,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,28.47,,,28.47,Other,Drug Cost,28.47,,,28.47,Other,Drug Cost,28.47,,,28.47,Other,Drug Cost,28.47,,,28.47,Other,Drug Cost,28.47,,,28.47,Other,Drug Cost,28.47,,,28.47,Other,Drug Cost,64.06,,,64.06,Other,225% of Medicaid,39.86,,,39.86,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,61.21,,,61.21,Other,215% Medicaid APG methodology,61.21,,,61.21,Other,215% Medicaid APG methodology,35.59,,,35.59,Other,125% Medicaid APG methodology,0.01,64.06,
RIVAROXABAN 2.5 MG TABLET,,,,80024117,CDM,250,RC,50458057710,NDC,both,10,EA,0.27,0.11,39.4668,,0.11,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.09,34,,0.09,percent of total billed charges,"Drugs, Inpatient Only",0.09,34,,0.09,percent of total billed charges,"Drugs, Inpatient Only",0.09,34,,0.09,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.19,70,,0.19,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.09,,,0.09,Other,Drug Cost,0.09,,,0.09,Other,Drug Cost,0.09,,,0.09,Other,Drug Cost,0.09,,,0.09,Other,Drug Cost,0.09,,,0.09,Other,Drug Cost,0.09,,,0.09,Other,Drug Cost,0.2,,,0.2,Other,225% of Medicaid,0.13,,,0.13,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.2,,,0.2,Other,215% Medicaid APG methodology,0.2,,,0.2,Other,215% Medicaid APG methodology,0.11,,,0.11,Other,125% Medicaid APG methodology,0.01,0.2,
INDIGOTINDISULFONATE SODIUM 8MG/ML 5ML,,,,80024120,CDM,250,RC,81284031505,NDC,both,5,ML,759.6,299.79,39.4668,,299.79,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,258.26,34,,258.26,percent of total billed charges,"Drugs, Inpatient Only",258.26,34,,258.26,percent of total billed charges,"Drugs, Inpatient Only",258.26,34,,258.26,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,531.72,70,,531.72,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,253.2,,,253.2,Other,Drug Cost,253.2,,,253.2,Other,Drug Cost,253.2,,,253.2,Other,Drug Cost,253.2,,,253.2,Other,Drug Cost,253.2,,,253.2,Other,Drug Cost,253.2,,,253.2,Other,Drug Cost,569.7,,,569.7,Other,225% of Medicaid,354.48,,,354.48,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,544.38,,,544.38,Other,215% Medicaid APG methodology,544.38,,,544.38,Other,215% Medicaid APG methodology,316.5,,,316.5,Other,125% Medicaid APG methodology,0.01,569.7,
BUDESONIDE CR 3MG CAPSULE,,,,80024121,CDM,250,RC,65162077810,NDC,both,100,EA,0.93,0.37,39.4668,,0.37,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.32,34,,0.32,percent of total billed charges,"Drugs, Inpatient Only",0.32,34,,0.32,percent of total billed charges,"Drugs, Inpatient Only",0.32,34,,0.32,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.65,70,,0.65,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.31,,,0.31,Other,Drug Cost,0.31,,,0.31,Other,Drug Cost,0.31,,,0.31,Other,Drug Cost,0.31,,,0.31,Other,Drug Cost,0.31,,,0.31,Other,Drug Cost,0.31,,,0.31,Other,Drug Cost,0.7,,,0.7,Other,225% of Medicaid,0.43,,,0.43,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.67,,,0.67,Other,215% Medicaid APG methodology,0.67,,,0.67,Other,215% Medicaid APG methodology,0.39,,,0.39,Other,125% Medicaid APG methodology,0.01,0.7,
IVABRADINE 5 MG TABLET,,,,80024123,CDM,250,RC,55513080060,NDC,both,60,EA,14,5.52,39.4668,,5.52,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,4.76,34,,4.76,percent of total billed charges,"Drugs, Inpatient Only",4.76,34,,4.76,percent of total billed charges,"Drugs, Inpatient Only",4.76,34,,4.76,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,9.8,70,,9.8,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,4.67,,,4.67,Other,Drug Cost,4.67,,,4.67,Other,Drug Cost,4.67,,,4.67,Other,Drug Cost,4.67,,,4.67,Other,Drug Cost,4.67,,,4.67,Other,Drug Cost,4.67,,,4.67,Other,Drug Cost,10.5,,,10.5,Other,225% of Medicaid,6.53,,,6.53,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,10.03,,,10.03,Other,215% Medicaid APG methodology,10.03,,,10.03,Other,215% Medicaid APG methodology,5.83,,,5.83,Other,125% Medicaid APG methodology,0.01,10.5,
VILAZODONE 40 MG TABLET,,,,80024124,CDM,250,RC,62332023430,NDC,both,30,EA,2.11,0.83,39.4668,,0.83,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.72,34,,0.72,percent of total billed charges,"Drugs, Inpatient Only",0.72,34,,0.72,percent of total billed charges,"Drugs, Inpatient Only",0.72,34,,0.72,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1.47,70,,1.47,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.7,,,0.7,Other,Drug Cost,0.7,,,0.7,Other,Drug Cost,0.7,,,0.7,Other,Drug Cost,0.7,,,0.7,Other,Drug Cost,0.7,,,0.7,Other,Drug Cost,0.7,,,0.7,Other,Drug Cost,1.58,,,1.58,Other,225% of Medicaid,0.98,,,0.98,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,1.51,,,1.51,Other,215% Medicaid APG methodology,1.51,,,1.51,Other,215% Medicaid APG methodology,0.88,,,0.88,Other,125% Medicaid APG methodology,0.01,1.58,
SUMATRIPTAN 20 MG NASAL SPRAY,,,,80024128,CDM,250,RC,66993008269,NDC,both,6,EA,16.02,6.32,39.4668,,6.32,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,5.45,34,,5.45,percent of total billed charges,"Drugs, Inpatient Only",5.45,34,,5.45,percent of total billed charges,"Drugs, Inpatient Only",5.45,34,,5.45,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,11.21,70,,11.21,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,5.34,,,5.34,Other,Drug Cost,5.34,,,5.34,Other,Drug Cost,5.34,,,5.34,Other,Drug Cost,5.34,,,5.34,Other,Drug Cost,5.34,,,5.34,Other,Drug Cost,5.34,,,5.34,Other,Drug Cost,12.01,,,12.01,Other,225% of Medicaid,7.47,,,7.47,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,11.48,,,11.48,Other,215% Medicaid APG methodology,11.48,,,11.48,Other,215% Medicaid APG methodology,6.67,,,6.67,Other,125% Medicaid APG methodology,0.01,12.01,
NS 20 ML FLUSH,,,,80001512,CDM,258,RC,409488820,NDC,both,25,ML,2.94,1.16,39.4668,,1.16,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1,34,,1,percent of total billed charges,"Drugs, Inpatient Only",1,34,,1,percent of total billed charges,"Drugs, Inpatient Only",1,34,,1,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2.05,70,,2.05,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.98,,,0.98,Other,Drug Cost,0.98,,,0.98,Other,Drug Cost,0.98,,,0.98,Other,Drug Cost,0.98,,,0.98,Other,Drug Cost,0.98,,,0.98,Other,Drug Cost,0.98,,,0.98,Other,Drug Cost,2.2,,,2.2,Other,225% of Medicaid,1.37,,,1.37,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,2.1,,,2.1,Other,215% Medicaid APG methodology,2.1,,,2.1,Other,215% Medicaid APG methodology,1.22,,,1.22,Other,125% Medicaid APG methodology,0.01,2.2,
SODIUM CL 0.9% 100ML,,,,80001887,CDM,258,RC,338055318,NDC,both,80,ML,7.66,3.02,39.4668,,3.02,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2.61,34,,2.61,percent of total billed charges,"Drugs, Inpatient Only",2.61,34,,2.61,percent of total billed charges,"Drugs, Inpatient Only",2.61,34,,2.61,percent of total billed charges,"Drugs, Inpatient Only",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,5.36,70,,5.36,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2.55,,,2.55,Other,Drug Cost,2.55,,,2.55,Other,Drug Cost,2.55,,,2.55,Other,Drug Cost,2.55,,,2.55,Other,Drug Cost,2.55,,,2.55,Other,Drug Cost,2.55,,,2.55,Other,Drug Cost,5.75,,,5.75,Other,225% of Medicaid,3.58,,,3.58,Other,140% of Medicaid,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,5.49,,,5.49,Other,215% Medicaid APG methodology,5.49,,,5.49,Other,215% Medicaid APG methodology,3.19,,,3.19,Other,125% Medicaid APG methodology,0.01,5.75,
HYDRATION IV INFUSION INIT 31-60 MINS,96360,CPT,,26096360,CDM,260,RC,,,both,,,466,344.84,,,344.84,Other,150% of Medicare + 9.63% HCRA Surcharge,209.7,45,,209.7,percent of total billed charges,Critical Access Hospital RCC factor,302.9,65,,302.9,percent of total billed charges,All Other,274.94,65,,274.94,percent of total billed charges,All Other,442,,,442,Case Rate,IV Therapy Per Visit,398,,,398,Case Rate,IV Therapy Per Visit,376,,,376,Case Rate,IV Therapy Per Visit,230.67,,,230.67,Other,110% of Medicare,316.88,,,316.88,Other,Non Covered Service,411,,,411,Other,186% of Medicaid,372.8,80,,372.8,percent of total billed charges,All Other,386.78,83,,386.78,percent of total billed charges,All Other,386.78,83,,386.78,percent of total billed charges,All Other,372.8,80,,372.8,percent of total billed charges,All Other,386.78,83,,386.78,percent of total billed charges,All Other,372.8,80,,372.8,percent of total billed charges,All Other,326.2,70,,326.2,percent of total billed charges,All Other,165.64,,,165.64,Other,Non Covered Service,140.39,,,140.39,Fee Schedule,,953,,,953,Case Rate,IV Therapy Per Visit,858,,,858,Case Rate,IV Therapy Per Visit,953,,,953,Case Rate,IV Therapy Per Visit,810,,,810,Case Rate,IV Therapy Per Visit,221.06,,,221.06,Other,100% of Medicaid,221.06,,,221.06,Other,100% of Medicaid,221.06,,,221.06,Other,100% of Medicaid,221.06,,,221.06,Other,100% of Medicaid,497.39,,,497.39,Other,225% of Medicaid,338.22,,,338.22,Other,153% of Medicaid,497.39,,,497.39,Other,225% of Medicaid,309.49,,,309.49,Other,140% of Medicaid,497.39,,,497.39,Other,225% of Medicaid,574.76,,,574.76,Other,260% of Medicaid,716.24,,,716.24,Other,324% of Medicaid,475.28,,,475.28,Other,215% of Medicaid,475.28,,,475.28,Other,215% of Medicaid,276.33,,,276.33,Other,125% of Medicaid,140.39,953,
IV HYDRATION EACH ADDL HOUR,96361,CPT,,26096361,CDM,260,RC,,,both,,,460,340.4,,,340.4,Other,150% of Medicare + 9.63% HCRA Surcharge,207,45,,207,percent of total billed charges,Critical Access Hospital RCC factor,299,65,,299,percent of total billed charges,All Other,271.4,65,,271.4,percent of total billed charges,All Other,442,,,442,Case Rate,IV Therapy Per Visit,398,,,398,Case Rate,IV Therapy Per Visit,376,,,376,Case Rate,IV Therapy Per Visit,227.7,,,227.7,Other,110% of Medicare,312.8,,,312.8,Other,Non Covered Service,1098,,,1098,Other,186% of Medicaid,368,80,,368,percent of total billed charges,All Other,381.8,83,,381.8,percent of total billed charges,All Other,381.8,83,,381.8,percent of total billed charges,All Other,368,80,,368,percent of total billed charges,All Other,381.8,83,,381.8,percent of total billed charges,All Other,368,80,,368,percent of total billed charges,All Other,322,70,,322,percent of total billed charges,All Other,62.32,,,62.32,Other,Non Covered Service,52.82,,,52.82,Fee Schedule,,953,,,953,Case Rate,IV Therapy Per Visit,858,,,858,Case Rate,IV Therapy Per Visit,953,,,953,Case Rate,IV Therapy Per Visit,810,,,810,Case Rate,IV Therapy Per Visit,590.24,,,590.24,Other,100% of Medicaid,590.24,,,590.24,Other,100% of Medicaid,590.24,,,590.24,Other,100% of Medicaid,590.24,,,590.24,Other,100% of Medicaid,1328.05,,,1328.05,Other,225% of Medicaid,903.07,,,903.07,Other,153% of Medicaid,1328.05,,,1328.05,Other,225% of Medicaid,826.34,,,826.34,Other,140% of Medicaid,1328.05,,,1328.05,Other,225% of Medicaid,1534.64,,,1534.64,Other,260% of Medicaid,1912.39,,,1912.39,Other,324% of Medicaid,1269.03,,,1269.03,Other,215% of Medicaid,1269.03,,,1269.03,Other,215% of Medicaid,737.81,,,737.81,Other,125% of Medicaid,52.82,1912.39,
THER/PROPH/DIAG IV INF INIT,96365,CPT,,26096365,CDM,260,RC,,,both,,,713,527.62,,,527.62,Other,150% of Medicare + 9.63% HCRA Surcharge,320.85,45,,320.85,percent of total billed charges,Critical Access Hospital RCC factor,463.45,65,,463.45,percent of total billed charges,All Other,420.67,65,,420.67,percent of total billed charges,All Other,442,,,442,Case Rate,IV Therapy Per Visit,398,,,398,Case Rate,IV Therapy Per Visit,376,,,376,Case Rate,IV Therapy Per Visit,352.94,,,352.94,Other,110% of Medicare,484.84,,,484.84,Other,Non Covered Service,411,,,411,Other,186% of Medicaid,570.4,80,,570.4,percent of total billed charges,All Other,591.79,83,,591.79,percent of total billed charges,All Other,591.79,83,,591.79,percent of total billed charges,All Other,570.4,80,,570.4,percent of total billed charges,All Other,591.79,83,,591.79,percent of total billed charges,All Other,570.4,80,,570.4,percent of total billed charges,All Other,499.1,70,,499.1,percent of total billed charges,All Other,328,,,328,Other,Non Covered Service,278,,,278,Fee Schedule,,953,,,953,Case Rate,IV Therapy Per Visit,858,,,858,Case Rate,IV Therapy Per Visit,953,,,953,Case Rate,IV Therapy Per Visit,810,,,810,Case Rate,IV Therapy Per Visit,221.06,,,221.06,Other,100% of Medicaid,221.06,,,221.06,Other,100% of Medicaid,221.06,,,221.06,Other,100% of Medicaid,221.06,,,221.06,Other,100% of Medicaid,497.39,,,497.39,Other,225% of Medicaid,338.22,,,338.22,Other,153% of Medicaid,497.39,,,497.39,Other,225% of Medicaid,309.49,,,309.49,Other,140% of Medicaid,497.39,,,497.39,Other,225% of Medicaid,574.76,,,574.76,Other,260% of Medicaid,716.24,,,716.24,Other,324% of Medicaid,475.28,,,475.28,Other,215% of Medicaid,475.28,,,475.28,Other,215% of Medicaid,276.33,,,276.33,Other,125% of Medicaid,221.06,953,
IV INFUSION EA ADDITIONAL,96366,CPT,,26096366,CDM,260,RC,,,both,,,460,340.4,,,340.4,Other,150% of Medicare + 9.63% HCRA Surcharge,207,45,,207,percent of total billed charges,Critical Access Hospital RCC factor,299,65,,299,percent of total billed charges,All Other,271.4,65,,271.4,percent of total billed charges,All Other,442,,,442,Case Rate,IV Therapy Per Visit,398,,,398,Case Rate,IV Therapy Per Visit,376,,,376,Case Rate,IV Therapy Per Visit,227.7,,,227.7,Other,110% of Medicare,312.8,,,312.8,Other,Non Covered Service,1098,,,1098,Other,186% of Medicaid,368,80,,368,percent of total billed charges,All Other,381.8,83,,381.8,percent of total billed charges,All Other,381.8,83,,381.8,percent of total billed charges,All Other,368,80,,368,percent of total billed charges,All Other,381.8,83,,381.8,percent of total billed charges,All Other,368,80,,368,percent of total billed charges,All Other,322,70,,322,percent of total billed charges,All Other,101.68,,,101.68,Other,Non Covered Service,86.18,,,86.18,Fee Schedule,,953,,,953,Case Rate,IV Therapy Per Visit,858,,,858,Case Rate,IV Therapy Per Visit,953,,,953,Case Rate,IV Therapy Per Visit,810,,,810,Case Rate,IV Therapy Per Visit,590.24,,,590.24,Other,100% of Medicaid,590.24,,,590.24,Other,100% of Medicaid,590.24,,,590.24,Other,100% of Medicaid,590.24,,,590.24,Other,100% of Medicaid,1328.05,,,1328.05,Other,225% of Medicaid,903.07,,,903.07,Other,153% of Medicaid,1328.05,,,1328.05,Other,225% of Medicaid,826.34,,,826.34,Other,140% of Medicaid,1328.05,,,1328.05,Other,225% of Medicaid,1534.64,,,1534.64,Other,260% of Medicaid,1912.39,,,1912.39,Other,324% of Medicaid,1269.03,,,1269.03,Other,215% of Medicaid,1269.03,,,1269.03,Other,215% of Medicaid,737.81,,,737.81,Other,125% of Medicaid,86.18,1912.39,
TX/PROPH/DG ADDL SEQ IV I,96367,CPT,,26096367,CDM,260,RC,,,both,,,458,338.92,,,338.92,Other,150% of Medicare + 9.63% HCRA Surcharge,206.1,45,,206.1,percent of total billed charges,Critical Access Hospital RCC factor,297.7,65,,297.7,percent of total billed charges,All Other,270.22,65,,270.22,percent of total billed charges,All Other,442,,,442,Case Rate,IV Therapy Per Visit,398,,,398,Case Rate,IV Therapy Per Visit,376,,,376,Case Rate,IV Therapy Per Visit,226.71,,,226.71,Other,110% of Medicare,311.44,,,311.44,Other,Non Covered Service,411,,,411,Other,186% of Medicaid,366.4,80,,366.4,percent of total billed charges,All Other,380.14,83,,380.14,percent of total billed charges,All Other,380.14,83,,380.14,percent of total billed charges,All Other,366.4,80,,366.4,percent of total billed charges,All Other,380.14,83,,380.14,percent of total billed charges,All Other,366.4,80,,366.4,percent of total billed charges,All Other,320.6,70,,320.6,percent of total billed charges,All Other,145.96,,,145.96,Other,Non Covered Service,123.71,,,123.71,Fee Schedule,,953,,,953,Case Rate,IV Therapy Per Visit,858,,,858,Case Rate,IV Therapy Per Visit,953,,,953,Case Rate,IV Therapy Per Visit,810,,,810,Case Rate,IV Therapy Per Visit,221.06,,,221.06,Other,100% of Medicaid,221.06,,,221.06,Other,100% of Medicaid,221.06,,,221.06,Other,100% of Medicaid,221.06,,,221.06,Other,100% of Medicaid,497.39,,,497.39,Other,225% of Medicaid,338.22,,,338.22,Other,153% of Medicaid,497.39,,,497.39,Other,225% of Medicaid,309.49,,,309.49,Other,140% of Medicaid,497.39,,,497.39,Other,225% of Medicaid,574.76,,,574.76,Other,260% of Medicaid,716.24,,,716.24,Other,324% of Medicaid,475.28,,,475.28,Other,215% of Medicaid,475.28,,,475.28,Other,215% of Medicaid,276.33,,,276.33,Other,125% of Medicaid,123.71,953,
THER DIAG CONCURRENT INF,96368,CPT,,26096368,CDM,260,RC,,,both,,,460,340.4,,,340.4,Other,150% of Medicare + 9.63% HCRA Surcharge,207,45,,207,percent of total billed charges,Critical Access Hospital RCC factor,299,65,,299,percent of total billed charges,All Other,271.4,65,,271.4,percent of total billed charges,All Other,442,,,442,Case Rate,IV Therapy Per Visit,398,,,398,Case Rate,IV Therapy Per Visit,376,,,376,Case Rate,IV Therapy Per Visit,227.7,,,227.7,Other,110% of Medicare,312.8,,,312.8,Other,Non Covered Service,411,,,411,Other,186% of Medicaid,368,80,,368,percent of total billed charges,All Other,381.8,83,,381.8,percent of total billed charges,All Other,381.8,83,,381.8,percent of total billed charges,All Other,368,80,,368,percent of total billed charges,All Other,381.8,83,,381.8,percent of total billed charges,All Other,368,80,,368,percent of total billed charges,All Other,322,70,,322,percent of total billed charges,All Other,98.4,,,98.4,Other,Non Covered Service,83.4,,,83.4,Fee Schedule,,953,,,953,Case Rate,IV Therapy Per Visit,858,,,858,Case Rate,IV Therapy Per Visit,953,,,953,Case Rate,IV Therapy Per Visit,810,,,810,Case Rate,IV Therapy Per Visit,221.06,,,221.06,Other,100% of Medicaid,221.06,,,221.06,Other,100% of Medicaid,221.06,,,221.06,Other,100% of Medicaid,221.06,,,221.06,Other,100% of Medicaid,497.39,,,497.39,Other,225% of Medicaid,338.22,,,338.22,Other,153% of Medicaid,497.39,,,497.39,Other,225% of Medicaid,309.49,,,309.49,Other,140% of Medicaid,497.39,,,497.39,Other,225% of Medicaid,574.76,,,574.76,Other,260% of Medicaid,716.24,,,716.24,Other,324% of Medicaid,475.28,,,475.28,Other,215% of Medicaid,475.28,,,475.28,Other,215% of Medicaid,276.33,,,276.33,Other,125% of Medicaid,83.4,953,
THER/PROPH/DIAG INJ SC/IM,96372,CPT,,26096372,CDM,260,RC,,,both,,,460,340.4,,,340.4,Other,150% of Medicare + 9.63% HCRA Surcharge,207,45,,207,percent of total billed charges,Critical Access Hospital RCC factor,299,65,,299,percent of total billed charges,All Other,271.4,65,,271.4,percent of total billed charges,All Other,351.9,76.5,,351.9,percent of total billed charges,All Other,326.6,69,,326.6,percent of total billed charges,All Other,317.4,65,,317.4,percent of total billed charges,All Other,227.7,,,227.7,Other,110% of Medicare,312.8,,,312.8,Other,Non Covered Service,58,,,58,Other,186% of Medicaid,368,80,,368,percent of total billed charges,All Other,381.8,83,,381.8,percent of total billed charges,All Other,381.8,83,,381.8,percent of total billed charges,All Other,368,80,,368,percent of total billed charges,All Other,381.8,83,,381.8,percent of total billed charges,All Other,368,80,,368,percent of total billed charges,All Other,322,70,,322,percent of total billed charges,All Other,68.88,,,68.88,Other,Non Covered Service,58.38,,,58.38,Fee Schedule,,953,,,953,Case Rate,,858,,,858,Case Rate,,953,,,953,Case Rate,,810,,,810,Case Rate,,31.2,,,31.2,Other,100% of Medicaid,31.2,,,31.2,Other,100% of Medicaid,31.2,,,31.2,Other,100% of Medicaid,31.2,,,31.2,Other,100% of Medicaid,70.2,,,70.2,Other,225% of Medicaid,47.74,,,47.74,Other,153% of Medicaid,70.2,,,70.2,Other,225% of Medicaid,43.68,,,43.68,Other,140% of Medicaid,70.2,,,70.2,Other,225% of Medicaid,81.12,,,81.12,Other,260% of Medicaid,101.09,,,101.09,Other,324% of Medicaid,67.08,,,67.08,Other,215% of Medicaid,67.08,,,67.08,Other,215% of Medicaid,39,,,39,Other,125% of Medicaid,31.2,953,
THER/PROPH/DIAG INJ IV PUSH,96374,CPT,,26096374,CDM,260,RC,,,both,,,483,357.42,,,357.42,Other,150% of Medicare + 9.63% HCRA Surcharge,217.35,45,,217.35,percent of total billed charges,Critical Access Hospital RCC factor,313.95,65,,313.95,percent of total billed charges,All Other,284.97,65,,284.97,percent of total billed charges,All Other,369.5,76.5,,369.5,percent of total billed charges,All Other,342.93,69,,342.93,percent of total billed charges,All Other,333.27,65,,333.27,percent of total billed charges,All Other,239.09,,,239.09,Other,110% of Medicare,328.44,,,328.44,Other,Non Covered Service,58,,,58,Other,186% of Medicaid,386.4,80,,386.4,percent of total billed charges,All Other,400.89,83,,400.89,percent of total billed charges,All Other,400.89,83,,400.89,percent of total billed charges,All Other,386.4,80,,386.4,percent of total billed charges,All Other,400.89,83,,400.89,percent of total billed charges,All Other,386.4,80,,386.4,percent of total billed charges,All Other,338.1,70,,338.1,percent of total billed charges,All Other,190.24,,,190.24,Other,Non Covered Service,161.24,,,161.24,Fee Schedule,,953,,,953,Case Rate,,858,,,858,Case Rate,,953,,,953,Case Rate,,810,,,810,Case Rate,,31.2,,,31.2,Other,100% of Medicaid,31.2,,,31.2,Other,100% of Medicaid,31.2,,,31.2,Other,100% of Medicaid,31.2,,,31.2,Other,100% of Medicaid,70.2,,,70.2,Other,225% of Medicaid,47.74,,,47.74,Other,153% of Medicaid,70.2,,,70.2,Other,225% of Medicaid,43.68,,,43.68,Other,140% of Medicaid,70.2,,,70.2,Other,225% of Medicaid,81.12,,,81.12,Other,260% of Medicaid,101.09,,,101.09,Other,324% of Medicaid,67.08,,,67.08,Other,215% of Medicaid,67.08,,,67.08,Other,215% of Medicaid,39,,,39,Other,125% of Medicaid,31.2,953,
NON CHEMO IV PUSH EA ADDL,96375,CPT,,26096375,CDM,260,RC,,,both,,,460,340.4,,,340.4,Other,150% of Medicare + 9.63% HCRA Surcharge,207,45,,207,percent of total billed charges,Critical Access Hospital RCC factor,299,65,,299,percent of total billed charges,All Other,271.4,65,,271.4,percent of total billed charges,All Other,351.9,76.5,,351.9,percent of total billed charges,All Other,326.6,69,,326.6,percent of total billed charges,All Other,317.4,65,,317.4,percent of total billed charges,All Other,227.7,,,227.7,Other,110% of Medicare,312.8,,,312.8,Other,Non Covered Service,58,,,58,Other,186% of Medicaid,368,80,,368,percent of total billed charges,All Other,381.8,83,,381.8,percent of total billed charges,All Other,381.8,83,,381.8,percent of total billed charges,All Other,368,80,,368,percent of total billed charges,All Other,381.8,83,,381.8,percent of total billed charges,All Other,368,80,,368,percent of total billed charges,All Other,322,70,,322,percent of total billed charges,All Other,77.08,,,77.08,Other,Non Covered Service,65.33,,,65.33,Fee Schedule,,953,,,953,Case Rate,,858,,,858,Case Rate,,953,,,953,Case Rate,,810,,,810,Case Rate,,31.2,,,31.2,Other,100% of Medicaid,31.2,,,31.2,Other,100% of Medicaid,31.2,,,31.2,Other,100% of Medicaid,31.2,,,31.2,Other,100% of Medicaid,70.2,,,70.2,Other,225% of Medicaid,47.74,,,47.74,Other,153% of Medicaid,70.2,,,70.2,Other,225% of Medicaid,43.68,,,43.68,Other,140% of Medicaid,70.2,,,70.2,Other,225% of Medicaid,81.12,,,81.12,Other,260% of Medicaid,101.09,,,101.09,Other,324% of Medicaid,67.08,,,67.08,Other,215% of Medicaid,67.08,,,67.08,Other,215% of Medicaid,39,,,39,Other,125% of Medicaid,31.2,953,
TX/PRO/DX INJ SAME DRUG A,96376,CPT,,26096376,CDM,260,RC,,,both,,,460,340.4,,,340.4,Other,150% of Medicare + 9.63% HCRA Surcharge,207,45,,207,percent of total billed charges,Critical Access Hospital RCC factor,299,65,,299,percent of total billed charges,All Other,271.4,65,,271.4,percent of total billed charges,All Other,351.9,76.5,,351.9,percent of total billed charges,All Other,326.6,69,,326.6,percent of total billed charges,All Other,317.4,65,,317.4,percent of total billed charges,All Other,227.7,,,227.7,Other,110% of Medicare,312.8,,,312.8,Other,Non Covered Service,58,,,58,Other,186% of Medicaid,368,80,,368,percent of total billed charges,All Other,381.8,83,,381.8,percent of total billed charges,All Other,381.8,83,,381.8,percent of total billed charges,All Other,368,80,,368,percent of total billed charges,All Other,381.8,83,,381.8,percent of total billed charges,All Other,368,80,,368,percent of total billed charges,All Other,322,70,,322,percent of total billed charges,All Other,299,65,,299,percent of total billed charges,Default if not in Fee Schedule,299,65,,299,percent of total billed charges,Default if not in Fee Schedule,953,,,953,Case Rate,,858,,,858,Case Rate,,953,,,953,Case Rate,,810,,,810,Case Rate,,31.2,,,31.2,Other,100% of Medicaid,31.2,,,31.2,Other,100% of Medicaid,31.2,,,31.2,Other,100% of Medicaid,31.2,,,31.2,Other,100% of Medicaid,70.2,,,70.2,Other,225% of Medicaid,47.74,,,47.74,Other,153% of Medicaid,70.2,,,70.2,Other,225% of Medicaid,43.68,,,43.68,Other,140% of Medicaid,70.2,,,70.2,Other,225% of Medicaid,81.12,,,81.12,Other,260% of Medicaid,101.09,,,101.09,Other,324% of Medicaid,67.08,,,67.08,Other,215% of Medicaid,67.08,,,67.08,Other,215% of Medicaid,39,,,39,Other,125% of Medicaid,31.2,953,
HYDRATION INFUSION IV INIT,96360,CPT,,34096360,CDM,260,RC,,,both,,,466,344.84,,,344.84,Other,150% of Medicare + 9.63% HCRA Surcharge,209.7,45,,209.7,percent of total billed charges,Critical Access Hospital RCC factor,302.9,65,,302.9,percent of total billed charges,All Other,274.94,65,,274.94,percent of total billed charges,All Other,442,,,442,Case Rate,IV Therapy Per Visit,398,,,398,Case Rate,IV Therapy Per Visit,376,,,376,Case Rate,IV Therapy Per Visit,230.67,,,230.67,Other,110% of Medicare,316.88,,,316.88,Other,Non Covered Service,411,,,411,Other,186% of Medicaid,372.8,80,,372.8,percent of total billed charges,All Other,386.78,83,,386.78,percent of total billed charges,All Other,386.78,83,,386.78,percent of total billed charges,All Other,372.8,80,,372.8,percent of total billed charges,All Other,386.78,83,,386.78,percent of total billed charges,All Other,372.8,80,,372.8,percent of total billed charges,All Other,326.2,70,,326.2,percent of total billed charges,All Other,165.64,,,165.64,Other,Non Covered Service,140.39,,,140.39,Fee Schedule,,953,,,953,Case Rate,IV Therapy Per Visit,858,,,858,Case Rate,IV Therapy Per Visit,953,,,953,Case Rate,IV Therapy Per Visit,810,,,810,Case Rate,IV Therapy Per Visit,221.06,,,221.06,Other,100% of Medicaid,221.06,,,221.06,Other,100% of Medicaid,221.06,,,221.06,Other,100% of Medicaid,221.06,,,221.06,Other,100% of Medicaid,497.39,,,497.39,Other,225% of Medicaid,338.22,,,338.22,Other,153% of Medicaid,497.39,,,497.39,Other,225% of Medicaid,309.49,,,309.49,Other,140% of Medicaid,497.39,,,497.39,Other,225% of Medicaid,574.76,,,574.76,Other,260% of Medicaid,716.24,,,716.24,Other,324% of Medicaid,475.28,,,475.28,Other,215% of Medicaid,475.28,,,475.28,Other,215% of Medicaid,276.33,,,276.33,Other,125% of Medicaid,140.39,953,
IV HYDRATION EACH ADDL HOUR,96361,CPT,,34096361,CDM,260,RC,,,both,,,460,340.4,,,340.4,Other,150% of Medicare + 9.63% HCRA Surcharge,207,45,,207,percent of total billed charges,Critical Access Hospital RCC factor,299,65,,299,percent of total billed charges,All Other,271.4,65,,271.4,percent of total billed charges,All Other,442,,,442,Case Rate,IV Therapy Per Visit,398,,,398,Case Rate,IV Therapy Per Visit,376,,,376,Case Rate,IV Therapy Per Visit,227.7,,,227.7,Other,110% of Medicare,312.8,,,312.8,Other,Non Covered Service,1098,,,1098,Other,186% of Medicaid,368,80,,368,percent of total billed charges,All Other,381.8,83,,381.8,percent of total billed charges,All Other,381.8,83,,381.8,percent of total billed charges,All Other,368,80,,368,percent of total billed charges,All Other,381.8,83,,381.8,percent of total billed charges,All Other,368,80,,368,percent of total billed charges,All Other,322,70,,322,percent of total billed charges,All Other,62.32,,,62.32,Other,Non Covered Service,52.82,,,52.82,Fee Schedule,,953,,,953,Case Rate,IV Therapy Per Visit,858,,,858,Case Rate,IV Therapy Per Visit,953,,,953,Case Rate,IV Therapy Per Visit,810,,,810,Case Rate,IV Therapy Per Visit,590.24,,,590.24,Other,100% of Medicaid,590.24,,,590.24,Other,100% of Medicaid,590.24,,,590.24,Other,100% of Medicaid,590.24,,,590.24,Other,100% of Medicaid,1328.05,,,1328.05,Other,225% of Medicaid,903.07,,,903.07,Other,153% of Medicaid,1328.05,,,1328.05,Other,225% of Medicaid,826.34,,,826.34,Other,140% of Medicaid,1328.05,,,1328.05,Other,225% of Medicaid,1534.64,,,1534.64,Other,260% of Medicaid,1912.39,,,1912.39,Other,324% of Medicaid,1269.03,,,1269.03,Other,215% of Medicaid,1269.03,,,1269.03,Other,215% of Medicaid,737.81,,,737.81,Other,125% of Medicaid,52.82,1912.39,
THER/PROPH/DIAG IV INF INIT,96365,CPT,,34096365,CDM,260,RC,,,both,,,713,527.62,,,527.62,Other,150% of Medicare + 9.63% HCRA Surcharge,320.85,45,,320.85,percent of total billed charges,Critical Access Hospital RCC factor,463.45,65,,463.45,percent of total billed charges,All Other,420.67,65,,420.67,percent of total billed charges,All Other,442,,,442,Case Rate,IV Therapy Per Visit,398,,,398,Case Rate,IV Therapy Per Visit,376,,,376,Case Rate,IV Therapy Per Visit,352.94,,,352.94,Other,110% of Medicare,484.84,,,484.84,Other,Non Covered Service,411,,,411,Other,186% of Medicaid,570.4,80,,570.4,percent of total billed charges,All Other,591.79,83,,591.79,percent of total billed charges,All Other,591.79,83,,591.79,percent of total billed charges,All Other,570.4,80,,570.4,percent of total billed charges,All Other,591.79,83,,591.79,percent of total billed charges,All Other,570.4,80,,570.4,percent of total billed charges,All Other,499.1,70,,499.1,percent of total billed charges,All Other,328,,,328,Other,Non Covered Service,278,,,278,Fee Schedule,,953,,,953,Case Rate,IV Therapy Per Visit,858,,,858,Case Rate,IV Therapy Per Visit,953,,,953,Case Rate,IV Therapy Per Visit,810,,,810,Case Rate,IV Therapy Per Visit,221.06,,,221.06,Other,100% of Medicaid,221.06,,,221.06,Other,100% of Medicaid,221.06,,,221.06,Other,100% of Medicaid,221.06,,,221.06,Other,100% of Medicaid,497.39,,,497.39,Other,225% of Medicaid,338.22,,,338.22,Other,153% of Medicaid,497.39,,,497.39,Other,225% of Medicaid,309.49,,,309.49,Other,140% of Medicaid,497.39,,,497.39,Other,225% of Medicaid,574.76,,,574.76,Other,260% of Medicaid,716.24,,,716.24,Other,324% of Medicaid,475.28,,,475.28,Other,215% of Medicaid,475.28,,,475.28,Other,215% of Medicaid,276.33,,,276.33,Other,125% of Medicaid,221.06,953,
THER/PROPH/DIAG IV INF ADDON,96366,CPT,,34096366,CDM,260,RC,,,both,,,460,340.4,,,340.4,Other,150% of Medicare + 9.63% HCRA Surcharge,207,45,,207,percent of total billed charges,Critical Access Hospital RCC factor,299,65,,299,percent of total billed charges,All Other,271.4,65,,271.4,percent of total billed charges,All Other,442,,,442,Case Rate,IV Therapy Per Visit,398,,,398,Case Rate,IV Therapy Per Visit,376,,,376,Case Rate,IV Therapy Per Visit,227.7,,,227.7,Other,110% of Medicare,312.8,,,312.8,Other,Non Covered Service,1098,,,1098,Other,186% of Medicaid,368,80,,368,percent of total billed charges,All Other,381.8,83,,381.8,percent of total billed charges,All Other,381.8,83,,381.8,percent of total billed charges,All Other,368,80,,368,percent of total billed charges,All Other,381.8,83,,381.8,percent of total billed charges,All Other,368,80,,368,percent of total billed charges,All Other,322,70,,322,percent of total billed charges,All Other,101.68,,,101.68,Other,Non Covered Service,86.18,,,86.18,Fee Schedule,,953,,,953,Case Rate,IV Therapy Per Visit,858,,,858,Case Rate,IV Therapy Per Visit,953,,,953,Case Rate,IV Therapy Per Visit,810,,,810,Case Rate,IV Therapy Per Visit,590.24,,,590.24,Other,100% of Medicaid,590.24,,,590.24,Other,100% of Medicaid,590.24,,,590.24,Other,100% of Medicaid,590.24,,,590.24,Other,100% of Medicaid,1328.05,,,1328.05,Other,225% of Medicaid,903.07,,,903.07,Other,153% of Medicaid,1328.05,,,1328.05,Other,225% of Medicaid,826.34,,,826.34,Other,140% of Medicaid,1328.05,,,1328.05,Other,225% of Medicaid,1534.64,,,1534.64,Other,260% of Medicaid,1912.39,,,1912.39,Other,324% of Medicaid,1269.03,,,1269.03,Other,215% of Medicaid,1269.03,,,1269.03,Other,215% of Medicaid,737.81,,,737.81,Other,125% of Medicaid,86.18,1912.39,
TX/PROPH/DG ADDL SEQ IV INF,96367,CPT,,34096367,CDM,260,RC,,,both,,,458,338.92,,,338.92,Other,150% of Medicare + 9.63% HCRA Surcharge,206.1,45,,206.1,percent of total billed charges,Critical Access Hospital RCC factor,297.7,65,,297.7,percent of total billed charges,All Other,270.22,65,,270.22,percent of total billed charges,All Other,442,,,442,Case Rate,IV Therapy Per Visit,398,,,398,Case Rate,IV Therapy Per Visit,376,,,376,Case Rate,IV Therapy Per Visit,226.71,,,226.71,Other,110% of Medicare,311.44,,,311.44,Other,Non Covered Service,411,,,411,Other,186% of Medicaid,366.4,80,,366.4,percent of total billed charges,All Other,380.14,83,,380.14,percent of total billed charges,All Other,380.14,83,,380.14,percent of total billed charges,All Other,366.4,80,,366.4,percent of total billed charges,All Other,380.14,83,,380.14,percent of total billed charges,All Other,366.4,80,,366.4,percent of total billed charges,All Other,320.6,70,,320.6,percent of total billed charges,All Other,145.96,,,145.96,Other,Non Covered Service,123.71,,,123.71,Fee Schedule,,953,,,953,Case Rate,IV Therapy Per Visit,858,,,858,Case Rate,IV Therapy Per Visit,953,,,953,Case Rate,IV Therapy Per Visit,810,,,810,Case Rate,IV Therapy Per Visit,221.06,,,221.06,Other,100% of Medicaid,221.06,,,221.06,Other,100% of Medicaid,221.06,,,221.06,Other,100% of Medicaid,221.06,,,221.06,Other,100% of Medicaid,497.39,,,497.39,Other,225% of Medicaid,338.22,,,338.22,Other,153% of Medicaid,497.39,,,497.39,Other,225% of Medicaid,309.49,,,309.49,Other,140% of Medicaid,497.39,,,497.39,Other,225% of Medicaid,574.76,,,574.76,Other,260% of Medicaid,716.24,,,716.24,Other,324% of Medicaid,475.28,,,475.28,Other,215% of Medicaid,475.28,,,475.28,Other,215% of Medicaid,276.33,,,276.33,Other,125% of Medicaid,123.71,953,
THER DIAG CONCURRENT INF,96368,CPT,,34096368,CDM,260,RC,,,both,,,460,340.4,,,340.4,Other,150% of Medicare + 9.63% HCRA Surcharge,207,45,,207,percent of total billed charges,Critical Access Hospital RCC factor,299,65,,299,percent of total billed charges,All Other,271.4,65,,271.4,percent of total billed charges,All Other,442,,,442,Case Rate,IV Therapy Per Visit,398,,,398,Case Rate,IV Therapy Per Visit,376,,,376,Case Rate,IV Therapy Per Visit,227.7,,,227.7,Other,110% of Medicare,312.8,,,312.8,Other,Non Covered Service,411,,,411,Other,186% of Medicaid,368,80,,368,percent of total billed charges,All Other,381.8,83,,381.8,percent of total billed charges,All Other,381.8,83,,381.8,percent of total billed charges,All Other,368,80,,368,percent of total billed charges,All Other,381.8,83,,381.8,percent of total billed charges,All Other,368,80,,368,percent of total billed charges,All Other,322,70,,322,percent of total billed charges,All Other,98.4,,,98.4,Other,Non Covered Service,83.4,,,83.4,Fee Schedule,,953,,,953,Case Rate,IV Therapy Per Visit,858,,,858,Case Rate,IV Therapy Per Visit,953,,,953,Case Rate,IV Therapy Per Visit,810,,,810,Case Rate,IV Therapy Per Visit,221.06,,,221.06,Other,100% of Medicaid,221.06,,,221.06,Other,100% of Medicaid,221.06,,,221.06,Other,100% of Medicaid,221.06,,,221.06,Other,100% of Medicaid,497.39,,,497.39,Other,225% of Medicaid,338.22,,,338.22,Other,153% of Medicaid,497.39,,,497.39,Other,225% of Medicaid,309.49,,,309.49,Other,140% of Medicaid,497.39,,,497.39,Other,225% of Medicaid,574.76,,,574.76,Other,260% of Medicaid,716.24,,,716.24,Other,324% of Medicaid,475.28,,,475.28,Other,215% of Medicaid,475.28,,,475.28,Other,215% of Medicaid,276.33,,,276.33,Other,125% of Medicaid,83.4,953,
THER/PROPH/DIAG INJ SC/IM,96372,CPT,,34096372,CDM,260,RC,,,both,,,460,340.4,,,340.4,Other,150% of Medicare + 9.63% HCRA Surcharge,207,45,,207,percent of total billed charges,Critical Access Hospital RCC factor,299,65,,299,percent of total billed charges,All Other,271.4,65,,271.4,percent of total billed charges,All Other,351.9,76.5,,351.9,percent of total billed charges,All Other,326.6,69,,326.6,percent of total billed charges,All Other,317.4,65,,317.4,percent of total billed charges,All Other,227.7,,,227.7,Other,110% of Medicare,312.8,,,312.8,Other,Non Covered Service,58,,,58,Other,186% of Medicaid,368,80,,368,percent of total billed charges,All Other,381.8,83,,381.8,percent of total billed charges,All Other,381.8,83,,381.8,percent of total billed charges,All Other,368,80,,368,percent of total billed charges,All Other,381.8,83,,381.8,percent of total billed charges,All Other,368,80,,368,percent of total billed charges,All Other,322,70,,322,percent of total billed charges,All Other,68.88,,,68.88,Other,Non Covered Service,58.38,,,58.38,Fee Schedule,,953,,,953,Case Rate,,858,,,858,Case Rate,,953,,,953,Case Rate,,810,,,810,Case Rate,,31.2,,,31.2,Other,100% of Medicaid,31.2,,,31.2,Other,100% of Medicaid,31.2,,,31.2,Other,100% of Medicaid,31.2,,,31.2,Other,100% of Medicaid,70.2,,,70.2,Other,225% of Medicaid,47.74,,,47.74,Other,153% of Medicaid,70.2,,,70.2,Other,225% of Medicaid,43.68,,,43.68,Other,140% of Medicaid,70.2,,,70.2,Other,225% of Medicaid,81.12,,,81.12,Other,260% of Medicaid,101.09,,,101.09,Other,324% of Medicaid,67.08,,,67.08,Other,215% of Medicaid,67.08,,,67.08,Other,215% of Medicaid,39,,,39,Other,125% of Medicaid,31.2,953,
THER/PROPH/DIAG INJ IV PUSH,96374,CPT,,34096374,CDM,260,RC,,,both,,,466,344.84,,,344.84,Other,150% of Medicare + 9.63% HCRA Surcharge,209.7,45,,209.7,percent of total billed charges,Critical Access Hospital RCC factor,302.9,65,,302.9,percent of total billed charges,All Other,274.94,65,,274.94,percent of total billed charges,All Other,356.49,76.5,,356.49,percent of total billed charges,All Other,330.86,69,,330.86,percent of total billed charges,All Other,321.54,65,,321.54,percent of total billed charges,All Other,230.67,,,230.67,Other,110% of Medicare,316.88,,,316.88,Other,Non Covered Service,58,,,58,Other,186% of Medicaid,372.8,80,,372.8,percent of total billed charges,All Other,386.78,83,,386.78,percent of total billed charges,All Other,386.78,83,,386.78,percent of total billed charges,All Other,372.8,80,,372.8,percent of total billed charges,All Other,386.78,83,,386.78,percent of total billed charges,All Other,372.8,80,,372.8,percent of total billed charges,All Other,326.2,70,,326.2,percent of total billed charges,All Other,190.24,,,190.24,Other,Non Covered Service,161.24,,,161.24,Fee Schedule,,953,,,953,Case Rate,,858,,,858,Case Rate,,953,,,953,Case Rate,,810,,,810,Case Rate,,31.2,,,31.2,Other,100% of Medicaid,31.2,,,31.2,Other,100% of Medicaid,31.2,,,31.2,Other,100% of Medicaid,31.2,,,31.2,Other,100% of Medicaid,70.2,,,70.2,Other,225% of Medicaid,47.74,,,47.74,Other,153% of Medicaid,70.2,,,70.2,Other,225% of Medicaid,43.68,,,43.68,Other,140% of Medicaid,70.2,,,70.2,Other,225% of Medicaid,81.12,,,81.12,Other,260% of Medicaid,101.09,,,101.09,Other,324% of Medicaid,67.08,,,67.08,Other,215% of Medicaid,67.08,,,67.08,Other,215% of Medicaid,39,,,39,Other,125% of Medicaid,31.2,953,
TX/PRO/DX INJ NEW DRUG ADDON,96375,CPT,,34096375,CDM,260,RC,,,both,,,460,340.4,,,340.4,Other,150% of Medicare + 9.63% HCRA Surcharge,207,45,,207,percent of total billed charges,Critical Access Hospital RCC factor,299,65,,299,percent of total billed charges,All Other,271.4,65,,271.4,percent of total billed charges,All Other,351.9,76.5,,351.9,percent of total billed charges,All Other,326.6,69,,326.6,percent of total billed charges,All Other,317.4,65,,317.4,percent of total billed charges,All Other,227.7,,,227.7,Other,110% of Medicare,312.8,,,312.8,Other,Non Covered Service,58,,,58,Other,186% of Medicaid,368,80,,368,percent of total billed charges,All Other,381.8,83,,381.8,percent of total billed charges,All Other,381.8,83,,381.8,percent of total billed charges,All Other,368,80,,368,percent of total billed charges,All Other,381.8,83,,381.8,percent of total billed charges,All Other,368,80,,368,percent of total billed charges,All Other,322,70,,322,percent of total billed charges,All Other,77.08,,,77.08,Other,Non Covered Service,65.33,,,65.33,Fee Schedule,,953,,,953,Case Rate,,858,,,858,Case Rate,,953,,,953,Case Rate,,810,,,810,Case Rate,,31.2,,,31.2,Other,100% of Medicaid,31.2,,,31.2,Other,100% of Medicaid,31.2,,,31.2,Other,100% of Medicaid,31.2,,,31.2,Other,100% of Medicaid,70.2,,,70.2,Other,225% of Medicaid,47.74,,,47.74,Other,153% of Medicaid,70.2,,,70.2,Other,225% of Medicaid,43.68,,,43.68,Other,140% of Medicaid,70.2,,,70.2,Other,225% of Medicaid,81.12,,,81.12,Other,260% of Medicaid,101.09,,,101.09,Other,324% of Medicaid,67.08,,,67.08,Other,215% of Medicaid,67.08,,,67.08,Other,215% of Medicaid,39,,,39,Other,125% of Medicaid,31.2,953,
TX/PRO/DX INJ SAME DRUG ADDON,96376,CPT,,34096376,CDM,260,RC,,,both,,,460,340.4,,,340.4,Other,150% of Medicare + 9.63% HCRA Surcharge,207,45,,207,percent of total billed charges,Critical Access Hospital RCC factor,299,65,,299,percent of total billed charges,All Other,271.4,65,,271.4,percent of total billed charges,All Other,351.9,76.5,,351.9,percent of total billed charges,All Other,326.6,69,,326.6,percent of total billed charges,All Other,317.4,65,,317.4,percent of total billed charges,All Other,227.7,,,227.7,Other,110% of Medicare,312.8,,,312.8,Other,Non Covered Service,58,,,58,Other,186% of Medicaid,368,80,,368,percent of total billed charges,All Other,381.8,83,,381.8,percent of total billed charges,All Other,381.8,83,,381.8,percent of total billed charges,All Other,368,80,,368,percent of total billed charges,All Other,381.8,83,,381.8,percent of total billed charges,All Other,368,80,,368,percent of total billed charges,All Other,322,70,,322,percent of total billed charges,All Other,299,65,,299,percent of total billed charges,Default if not in Fee Schedule,299,65,,299,percent of total billed charges,Default if not in Fee Schedule,953,,,953,Case Rate,,858,,,858,Case Rate,,953,,,953,Case Rate,,810,,,810,Case Rate,,31.2,,,31.2,Other,100% of Medicaid,31.2,,,31.2,Other,100% of Medicaid,31.2,,,31.2,Other,100% of Medicaid,31.2,,,31.2,Other,100% of Medicaid,70.2,,,70.2,Other,225% of Medicaid,47.74,,,47.74,Other,153% of Medicaid,70.2,,,70.2,Other,225% of Medicaid,43.68,,,43.68,Other,140% of Medicaid,70.2,,,70.2,Other,225% of Medicaid,81.12,,,81.12,Other,260% of Medicaid,101.09,,,101.09,Other,324% of Medicaid,67.08,,,67.08,Other,215% of Medicaid,67.08,,,67.08,Other,215% of Medicaid,39,,,39,Other,125% of Medicaid,31.2,953,
IRRIG DRUG DELIVERY DEVICE,96523,CPT,,34096523,CDM,260,RC,,,both,,,243,179.82,,,179.82,Other,150% of Medicare + 9.63% HCRA Surcharge,109.35,45,,109.35,percent of total billed charges,Critical Access Hospital RCC factor,598,,,598,Fee Schedule,,538,,,538,Fee Schedule,,170.12,,,170.12,Fee Schedule,,153.01,,,153.01,Fee Schedule,,144.61,,,144.61,Fee Schedule,,120.29,,,120.29,Other,110% of Medicare,165.24,,,165.24,Other,Non Covered Service,58,,,58,Other,186% of Medicaid,194.4,80,,194.4,percent of total billed charges,All Other,201.69,83,,201.69,percent of total billed charges,All Other,201.69,83,,201.69,percent of total billed charges,All Other,194.4,80,,194.4,percent of total billed charges,All Other,201.69,83,,201.69,percent of total billed charges,All Other,107.2,,,107.2,Fee Schedule,,170.1,70,,170.1,percent of total billed charges,All Other,129.56,,,129.56,Other,Non Covered Service,109.81,,,109.81,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,31.2,,,31.2,Other,100% of Medicaid,31.2,,,31.2,Other,100% of Medicaid,31.2,,,31.2,Other,100% of Medicaid,31.2,,,31.2,Other,100% of Medicaid,70.2,,,70.2,Other,225% of Medicaid,47.74,,,47.74,Other,153% of Medicaid,70.2,,,70.2,Other,225% of Medicaid,43.68,,,43.68,Other,140% of Medicaid,70.2,,,70.2,Other,225% of Medicaid,81.12,,,81.12,Other,260% of Medicaid,101.09,,,101.09,Other,324% of Medicaid,67.08,,,67.08,Other,215% of Medicaid,67.08,,,67.08,Other,215% of Medicaid,39,,,39,Other,125% of Medicaid,0.01,598,
THER/PROPH/DIAG INJ SC/IM,96372,CPT,,36096372,CDM,260,RC,,,both,,,460,340.4,,,340.4,Other,150% of Medicare + 9.63% HCRA Surcharge,207,45,,207,percent of total billed charges,Critical Access Hospital RCC factor,299,65,,299,percent of total billed charges,All Other,271.4,65,,271.4,percent of total billed charges,All Other,351.9,76.5,,351.9,percent of total billed charges,All Other,326.6,69,,326.6,percent of total billed charges,All Other,317.4,65,,317.4,percent of total billed charges,All Other,227.7,,,227.7,Other,110% of Medicare,312.8,,,312.8,Other,Non Covered Service,58,,,58,Other,186% of Medicaid,368,80,,368,percent of total billed charges,All Other,381.8,83,,381.8,percent of total billed charges,All Other,381.8,83,,381.8,percent of total billed charges,All Other,368,80,,368,percent of total billed charges,All Other,381.8,83,,381.8,percent of total billed charges,All Other,368,80,,368,percent of total billed charges,All Other,322,70,,322,percent of total billed charges,All Other,68.88,,,68.88,Other,Non Covered Service,58.38,,,58.38,Fee Schedule,,953,,,953,Case Rate,,858,,,858,Case Rate,,953,,,953,Case Rate,,810,,,810,Case Rate,,31.2,,,31.2,Other,100% of Medicaid,31.2,,,31.2,Other,100% of Medicaid,31.2,,,31.2,Other,100% of Medicaid,31.2,,,31.2,Other,100% of Medicaid,70.2,,,70.2,Other,225% of Medicaid,47.74,,,47.74,Other,153% of Medicaid,70.2,,,70.2,Other,225% of Medicaid,43.68,,,43.68,Other,140% of Medicaid,70.2,,,70.2,Other,225% of Medicaid,81.12,,,81.12,Other,260% of Medicaid,101.09,,,101.09,Other,324% of Medicaid,67.08,,,67.08,Other,215% of Medicaid,67.08,,,67.08,Other,215% of Medicaid,39,,,39,Other,125% of Medicaid,31.2,953,
THER/PROPH/DIAG IV INF INIT,96365,CPT,,44096365,CDM,260,RC,,,both,,,713,527.62,,,527.62,Other,150% of Medicare + 9.63% HCRA Surcharge,320.85,45,,320.85,percent of total billed charges,Critical Access Hospital RCC factor,463.45,65,,463.45,percent of total billed charges,All Other,420.67,65,,420.67,percent of total billed charges,All Other,442,,,442,Case Rate,IV Therapy Per Visit,398,,,398,Case Rate,IV Therapy Per Visit,376,,,376,Case Rate,IV Therapy Per Visit,352.94,,,352.94,Other,110% of Medicare,484.84,,,484.84,Other,Non Covered Service,411,,,411,Other,186% of Medicaid,570.4,80,,570.4,percent of total billed charges,All Other,591.79,83,,591.79,percent of total billed charges,All Other,591.79,83,,591.79,percent of total billed charges,All Other,570.4,80,,570.4,percent of total billed charges,All Other,591.79,83,,591.79,percent of total billed charges,All Other,570.4,80,,570.4,percent of total billed charges,All Other,499.1,70,,499.1,percent of total billed charges,All Other,328,,,328,Other,Non Covered Service,278,,,278,Fee Schedule,,953,,,953,Case Rate,IV Therapy Per Visit,858,,,858,Case Rate,IV Therapy Per Visit,953,,,953,Case Rate,IV Therapy Per Visit,810,,,810,Case Rate,IV Therapy Per Visit,221.06,,,221.06,Other,100% of Medicaid,221.06,,,221.06,Other,100% of Medicaid,221.06,,,221.06,Other,100% of Medicaid,221.06,,,221.06,Other,100% of Medicaid,497.39,,,497.39,Other,225% of Medicaid,338.22,,,338.22,Other,153% of Medicaid,497.39,,,497.39,Other,225% of Medicaid,309.49,,,309.49,Other,140% of Medicaid,497.39,,,497.39,Other,225% of Medicaid,574.76,,,574.76,Other,260% of Medicaid,716.24,,,716.24,Other,324% of Medicaid,475.28,,,475.28,Other,215% of Medicaid,475.28,,,475.28,Other,215% of Medicaid,276.33,,,276.33,Other,125% of Medicaid,221.06,953,
THER/PROPH/DIAG IV INF INIT,96365,CPT,,46096365,CDM,260,RC,,,both,,,713,527.62,,,527.62,Other,150% of Medicare + 9.63% HCRA Surcharge,320.85,45,,320.85,percent of total billed charges,Critical Access Hospital RCC factor,463.45,65,,463.45,percent of total billed charges,All Other,420.67,65,,420.67,percent of total billed charges,All Other,442,,,442,Case Rate,IV Therapy Per Visit,398,,,398,Case Rate,IV Therapy Per Visit,376,,,376,Case Rate,IV Therapy Per Visit,352.94,,,352.94,Other,110% of Medicare,484.84,,,484.84,Other,Non Covered Service,411,,,411,Other,186% of Medicaid,570.4,80,,570.4,percent of total billed charges,All Other,591.79,83,,591.79,percent of total billed charges,All Other,591.79,83,,591.79,percent of total billed charges,All Other,570.4,80,,570.4,percent of total billed charges,All Other,591.79,83,,591.79,percent of total billed charges,All Other,570.4,80,,570.4,percent of total billed charges,All Other,499.1,70,,499.1,percent of total billed charges,All Other,328,,,328,Other,Non Covered Service,278,,,278,Fee Schedule,,953,,,953,Case Rate,IV Therapy Per Visit,858,,,858,Case Rate,IV Therapy Per Visit,953,,,953,Case Rate,IV Therapy Per Visit,810,,,810,Case Rate,IV Therapy Per Visit,221.06,,,221.06,Other,100% of Medicaid,221.06,,,221.06,Other,100% of Medicaid,221.06,,,221.06,Other,100% of Medicaid,221.06,,,221.06,Other,100% of Medicaid,497.39,,,497.39,Other,225% of Medicaid,338.22,,,338.22,Other,153% of Medicaid,497.39,,,497.39,Other,225% of Medicaid,309.49,,,309.49,Other,140% of Medicaid,497.39,,,497.39,Other,225% of Medicaid,574.76,,,574.76,Other,260% of Medicaid,716.24,,,716.24,Other,324% of Medicaid,475.28,,,475.28,Other,215% of Medicaid,475.28,,,475.28,Other,215% of Medicaid,276.33,,,276.33,Other,125% of Medicaid,221.06,953,
HYDRATION IV INFUSION INIT,96360,CPT,,47096360,CDM,260,RC,,,both,,,466,344.84,,,344.84,Other,150% of Medicare + 9.63% HCRA Surcharge,209.7,45,,209.7,percent of total billed charges,Critical Access Hospital RCC factor,302.9,65,,302.9,percent of total billed charges,All Other,274.94,65,,274.94,percent of total billed charges,All Other,442,,,442,Case Rate,IV Therapy Per Visit,398,,,398,Case Rate,IV Therapy Per Visit,376,,,376,Case Rate,IV Therapy Per Visit,230.67,,,230.67,Other,110% of Medicare,316.88,,,316.88,Other,Non Covered Service,411,,,411,Other,186% of Medicaid,372.8,80,,372.8,percent of total billed charges,All Other,386.78,83,,386.78,percent of total billed charges,All Other,386.78,83,,386.78,percent of total billed charges,All Other,372.8,80,,372.8,percent of total billed charges,All Other,386.78,83,,386.78,percent of total billed charges,All Other,372.8,80,,372.8,percent of total billed charges,All Other,326.2,70,,326.2,percent of total billed charges,All Other,165.64,,,165.64,Other,Non Covered Service,140.39,,,140.39,Fee Schedule,,953,,,953,Case Rate,IV Therapy Per Visit,858,,,858,Case Rate,IV Therapy Per Visit,953,,,953,Case Rate,IV Therapy Per Visit,810,,,810,Case Rate,IV Therapy Per Visit,221.06,,,221.06,Other,100% of Medicaid,221.06,,,221.06,Other,100% of Medicaid,221.06,,,221.06,Other,100% of Medicaid,221.06,,,221.06,Other,100% of Medicaid,497.39,,,497.39,Other,225% of Medicaid,338.22,,,338.22,Other,153% of Medicaid,497.39,,,497.39,Other,225% of Medicaid,309.49,,,309.49,Other,140% of Medicaid,497.39,,,497.39,Other,225% of Medicaid,574.76,,,574.76,Other,260% of Medicaid,716.24,,,716.24,Other,324% of Medicaid,475.28,,,475.28,Other,215% of Medicaid,475.28,,,475.28,Other,215% of Medicaid,276.33,,,276.33,Other,125% of Medicaid,140.39,953,
IV HYDRATION EACH ADDL HO,96361,CPT,,47096361,CDM,260,RC,,,both,,,460,340.4,,,340.4,Other,150% of Medicare + 9.63% HCRA Surcharge,207,45,,207,percent of total billed charges,Critical Access Hospital RCC factor,299,65,,299,percent of total billed charges,All Other,271.4,65,,271.4,percent of total billed charges,All Other,442,,,442,Case Rate,IV Therapy Per Visit,398,,,398,Case Rate,IV Therapy Per Visit,376,,,376,Case Rate,IV Therapy Per Visit,227.7,,,227.7,Other,110% of Medicare,312.8,,,312.8,Other,Non Covered Service,1098,,,1098,Other,186% of Medicaid,368,80,,368,percent of total billed charges,All Other,381.8,83,,381.8,percent of total billed charges,All Other,381.8,83,,381.8,percent of total billed charges,All Other,368,80,,368,percent of total billed charges,All Other,381.8,83,,381.8,percent of total billed charges,All Other,368,80,,368,percent of total billed charges,All Other,322,70,,322,percent of total billed charges,All Other,62.32,,,62.32,Other,Non Covered Service,52.82,,,52.82,Fee Schedule,,953,,,953,Case Rate,IV Therapy Per Visit,858,,,858,Case Rate,IV Therapy Per Visit,953,,,953,Case Rate,IV Therapy Per Visit,810,,,810,Case Rate,IV Therapy Per Visit,590.24,,,590.24,Other,100% of Medicaid,590.24,,,590.24,Other,100% of Medicaid,590.24,,,590.24,Other,100% of Medicaid,590.24,,,590.24,Other,100% of Medicaid,1328.05,,,1328.05,Other,225% of Medicaid,903.07,,,903.07,Other,153% of Medicaid,1328.05,,,1328.05,Other,225% of Medicaid,826.34,,,826.34,Other,140% of Medicaid,1328.05,,,1328.05,Other,225% of Medicaid,1534.64,,,1534.64,Other,260% of Medicaid,1912.39,,,1912.39,Other,324% of Medicaid,1269.03,,,1269.03,Other,215% of Medicaid,1269.03,,,1269.03,Other,215% of Medicaid,737.81,,,737.81,Other,125% of Medicaid,52.82,1912.39,
THER/PROPH/DIAG IV INF INIT,96365,CPT,,47096365,CDM,260,RC,,,both,,,713,527.62,,,527.62,Other,150% of Medicare + 9.63% HCRA Surcharge,320.85,45,,320.85,percent of total billed charges,Critical Access Hospital RCC factor,463.45,65,,463.45,percent of total billed charges,All Other,420.67,65,,420.67,percent of total billed charges,All Other,442,,,442,Case Rate,IV Therapy Per Visit,398,,,398,Case Rate,IV Therapy Per Visit,376,,,376,Case Rate,IV Therapy Per Visit,352.94,,,352.94,Other,110% of Medicare,484.84,,,484.84,Other,Non Covered Service,411,,,411,Other,186% of Medicaid,570.4,80,,570.4,percent of total billed charges,All Other,591.79,83,,591.79,percent of total billed charges,All Other,591.79,83,,591.79,percent of total billed charges,All Other,570.4,80,,570.4,percent of total billed charges,All Other,591.79,83,,591.79,percent of total billed charges,All Other,570.4,80,,570.4,percent of total billed charges,All Other,499.1,70,,499.1,percent of total billed charges,All Other,328,,,328,Other,Non Covered Service,278,,,278,Fee Schedule,,953,,,953,Case Rate,IV Therapy Per Visit,858,,,858,Case Rate,IV Therapy Per Visit,953,,,953,Case Rate,IV Therapy Per Visit,810,,,810,Case Rate,IV Therapy Per Visit,221.06,,,221.06,Other,100% of Medicaid,221.06,,,221.06,Other,100% of Medicaid,221.06,,,221.06,Other,100% of Medicaid,221.06,,,221.06,Other,100% of Medicaid,497.39,,,497.39,Other,225% of Medicaid,338.22,,,338.22,Other,153% of Medicaid,497.39,,,497.39,Other,225% of Medicaid,309.49,,,309.49,Other,140% of Medicaid,497.39,,,497.39,Other,225% of Medicaid,574.76,,,574.76,Other,260% of Medicaid,716.24,,,716.24,Other,324% of Medicaid,475.28,,,475.28,Other,215% of Medicaid,475.28,,,475.28,Other,215% of Medicaid,276.33,,,276.33,Other,125% of Medicaid,221.06,953,
THER/PROPH/DIAG INJ SC/IM,96372,CPT,,50096372,CDM,260,RC,,,both,,,460,340.4,,,340.4,Other,150% of Medicare + 9.63% HCRA Surcharge,207,45,,207,percent of total billed charges,Critical Access Hospital RCC factor,299,65,,299,percent of total billed charges,All Other,271.4,65,,271.4,percent of total billed charges,All Other,351.9,76.5,,351.9,percent of total billed charges,All Other,326.6,69,,326.6,percent of total billed charges,All Other,317.4,65,,317.4,percent of total billed charges,All Other,227.7,,,227.7,Other,110% of Medicare,312.8,,,312.8,Other,Non Covered Service,58,,,58,Other,186% of Medicaid,368,80,,368,percent of total billed charges,All Other,381.8,83,,381.8,percent of total billed charges,All Other,381.8,83,,381.8,percent of total billed charges,All Other,368,80,,368,percent of total billed charges,All Other,381.8,83,,381.8,percent of total billed charges,All Other,368,80,,368,percent of total billed charges,All Other,322,70,,322,percent of total billed charges,All Other,68.88,,,68.88,Other,Non Covered Service,58.38,,,58.38,Fee Schedule,,953,,,953,Case Rate,,858,,,858,Case Rate,,953,,,953,Case Rate,,810,,,810,Case Rate,,31.2,,,31.2,Other,100% of Medicaid,31.2,,,31.2,Other,100% of Medicaid,31.2,,,31.2,Other,100% of Medicaid,31.2,,,31.2,Other,100% of Medicaid,70.2,,,70.2,Other,225% of Medicaid,47.74,,,47.74,Other,153% of Medicaid,70.2,,,70.2,Other,225% of Medicaid,43.68,,,43.68,Other,140% of Medicaid,70.2,,,70.2,Other,225% of Medicaid,81.12,,,81.12,Other,260% of Medicaid,101.09,,,101.09,Other,324% of Medicaid,67.08,,,67.08,Other,215% of Medicaid,67.08,,,67.08,Other,215% of Medicaid,39,,,39,Other,125% of Medicaid,31.2,953,
HYDRATION IV INFUSION INIT,96360,CPT,,75096360,CDM,260,RC,,,both,,,466,344.84,,,344.84,Other,150% of Medicare + 9.63% HCRA Surcharge,209.7,45,,209.7,percent of total billed charges,Critical Access Hospital RCC factor,302.9,65,,302.9,percent of total billed charges,All Other,274.94,65,,274.94,percent of total billed charges,All Other,442,,,442,Case Rate,IV Therapy Per Visit,398,,,398,Case Rate,IV Therapy Per Visit,376,,,376,Case Rate,IV Therapy Per Visit,230.67,,,230.67,Other,110% of Medicare,316.88,,,316.88,Other,Non Covered Service,411,,,411,Other,186% of Medicaid,372.8,80,,372.8,percent of total billed charges,All Other,386.78,83,,386.78,percent of total billed charges,All Other,386.78,83,,386.78,percent of total billed charges,All Other,372.8,80,,372.8,percent of total billed charges,All Other,386.78,83,,386.78,percent of total billed charges,All Other,372.8,80,,372.8,percent of total billed charges,All Other,326.2,70,,326.2,percent of total billed charges,All Other,165.64,,,165.64,Other,Non Covered Service,140.39,,,140.39,Fee Schedule,,953,,,953,Case Rate,IV Therapy Per Visit,858,,,858,Case Rate,IV Therapy Per Visit,953,,,953,Case Rate,IV Therapy Per Visit,810,,,810,Case Rate,IV Therapy Per Visit,221.06,,,221.06,Other,100% of Medicaid,221.06,,,221.06,Other,100% of Medicaid,221.06,,,221.06,Other,100% of Medicaid,221.06,,,221.06,Other,100% of Medicaid,497.39,,,497.39,Other,225% of Medicaid,338.22,,,338.22,Other,153% of Medicaid,497.39,,,497.39,Other,225% of Medicaid,309.49,,,309.49,Other,140% of Medicaid,497.39,,,497.39,Other,225% of Medicaid,574.76,,,574.76,Other,260% of Medicaid,716.24,,,716.24,Other,324% of Medicaid,475.28,,,475.28,Other,215% of Medicaid,475.28,,,475.28,Other,215% of Medicaid,276.33,,,276.33,Other,125% of Medicaid,140.39,953,
IV HYDRATION EACH ADDL HO,96361,CPT,,75096361,CDM,260,RC,,,both,,,460,340.4,,,340.4,Other,150% of Medicare + 9.63% HCRA Surcharge,207,45,,207,percent of total billed charges,Critical Access Hospital RCC factor,299,65,,299,percent of total billed charges,All Other,271.4,65,,271.4,percent of total billed charges,All Other,442,,,442,Case Rate,IV Therapy Per Visit,398,,,398,Case Rate,IV Therapy Per Visit,376,,,376,Case Rate,IV Therapy Per Visit,227.7,,,227.7,Other,110% of Medicare,312.8,,,312.8,Other,Non Covered Service,1098,,,1098,Other,186% of Medicaid,368,80,,368,percent of total billed charges,All Other,381.8,83,,381.8,percent of total billed charges,All Other,381.8,83,,381.8,percent of total billed charges,All Other,368,80,,368,percent of total billed charges,All Other,381.8,83,,381.8,percent of total billed charges,All Other,368,80,,368,percent of total billed charges,All Other,322,70,,322,percent of total billed charges,All Other,62.32,,,62.32,Other,Non Covered Service,52.82,,,52.82,Fee Schedule,,953,,,953,Case Rate,IV Therapy Per Visit,858,,,858,Case Rate,IV Therapy Per Visit,953,,,953,Case Rate,IV Therapy Per Visit,810,,,810,Case Rate,IV Therapy Per Visit,590.24,,,590.24,Other,100% of Medicaid,590.24,,,590.24,Other,100% of Medicaid,590.24,,,590.24,Other,100% of Medicaid,590.24,,,590.24,Other,100% of Medicaid,1328.05,,,1328.05,Other,225% of Medicaid,903.07,,,903.07,Other,153% of Medicaid,1328.05,,,1328.05,Other,225% of Medicaid,826.34,,,826.34,Other,140% of Medicaid,1328.05,,,1328.05,Other,225% of Medicaid,1534.64,,,1534.64,Other,260% of Medicaid,1912.39,,,1912.39,Other,324% of Medicaid,1269.03,,,1269.03,Other,215% of Medicaid,1269.03,,,1269.03,Other,215% of Medicaid,737.81,,,737.81,Other,125% of Medicaid,52.82,1912.39,
THER/PROPH/DIAG IV INF INIT,96365,CPT,,75096365,CDM,260,RC,,,both,,,713,527.62,,,527.62,Other,150% of Medicare + 9.63% HCRA Surcharge,320.85,45,,320.85,percent of total billed charges,Critical Access Hospital RCC factor,463.45,65,,463.45,percent of total billed charges,All Other,420.67,65,,420.67,percent of total billed charges,All Other,442,,,442,Case Rate,IV Therapy Per Visit,398,,,398,Case Rate,IV Therapy Per Visit,376,,,376,Case Rate,IV Therapy Per Visit,352.94,,,352.94,Other,110% of Medicare,484.84,,,484.84,Other,Non Covered Service,411,,,411,Other,186% of Medicaid,570.4,80,,570.4,percent of total billed charges,All Other,591.79,83,,591.79,percent of total billed charges,All Other,591.79,83,,591.79,percent of total billed charges,All Other,570.4,80,,570.4,percent of total billed charges,All Other,591.79,83,,591.79,percent of total billed charges,All Other,570.4,80,,570.4,percent of total billed charges,All Other,499.1,70,,499.1,percent of total billed charges,All Other,328,,,328,Other,Non Covered Service,278,,,278,Fee Schedule,,953,,,953,Case Rate,IV Therapy Per Visit,858,,,858,Case Rate,IV Therapy Per Visit,953,,,953,Case Rate,IV Therapy Per Visit,810,,,810,Case Rate,IV Therapy Per Visit,221.06,,,221.06,Other,100% of Medicaid,221.06,,,221.06,Other,100% of Medicaid,221.06,,,221.06,Other,100% of Medicaid,221.06,,,221.06,Other,100% of Medicaid,497.39,,,497.39,Other,225% of Medicaid,338.22,,,338.22,Other,153% of Medicaid,497.39,,,497.39,Other,225% of Medicaid,309.49,,,309.49,Other,140% of Medicaid,497.39,,,497.39,Other,225% of Medicaid,574.76,,,574.76,Other,260% of Medicaid,716.24,,,716.24,Other,324% of Medicaid,475.28,,,475.28,Other,215% of Medicaid,475.28,,,475.28,Other,215% of Medicaid,276.33,,,276.33,Other,125% of Medicaid,221.06,953,
IV INFUSION EA ADDITIONAL,96366,CPT,,75096366,CDM,260,RC,,,both,,,460,340.4,,,340.4,Other,150% of Medicare + 9.63% HCRA Surcharge,207,45,,207,percent of total billed charges,Critical Access Hospital RCC factor,299,65,,299,percent of total billed charges,All Other,271.4,65,,271.4,percent of total billed charges,All Other,442,,,442,Case Rate,IV Therapy Per Visit,398,,,398,Case Rate,IV Therapy Per Visit,376,,,376,Case Rate,IV Therapy Per Visit,227.7,,,227.7,Other,110% of Medicare,312.8,,,312.8,Other,Non Covered Service,1098,,,1098,Other,186% of Medicaid,368,80,,368,percent of total billed charges,All Other,381.8,83,,381.8,percent of total billed charges,All Other,381.8,83,,381.8,percent of total billed charges,All Other,368,80,,368,percent of total billed charges,All Other,381.8,83,,381.8,percent of total billed charges,All Other,368,80,,368,percent of total billed charges,All Other,322,70,,322,percent of total billed charges,All Other,101.68,,,101.68,Other,Non Covered Service,86.18,,,86.18,Fee Schedule,,953,,,953,Case Rate,IV Therapy Per Visit,858,,,858,Case Rate,IV Therapy Per Visit,953,,,953,Case Rate,IV Therapy Per Visit,810,,,810,Case Rate,IV Therapy Per Visit,590.24,,,590.24,Other,100% of Medicaid,590.24,,,590.24,Other,100% of Medicaid,590.24,,,590.24,Other,100% of Medicaid,590.24,,,590.24,Other,100% of Medicaid,1328.05,,,1328.05,Other,225% of Medicaid,903.07,,,903.07,Other,153% of Medicaid,1328.05,,,1328.05,Other,225% of Medicaid,826.34,,,826.34,Other,140% of Medicaid,1328.05,,,1328.05,Other,225% of Medicaid,1534.64,,,1534.64,Other,260% of Medicaid,1912.39,,,1912.39,Other,324% of Medicaid,1269.03,,,1269.03,Other,215% of Medicaid,1269.03,,,1269.03,Other,215% of Medicaid,737.81,,,737.81,Other,125% of Medicaid,86.18,1912.39,
TX/PROPH/DG ADDL SEQ IV I,96367,CPT,,75096367,CDM,260,RC,,,both,,,458,338.92,,,338.92,Other,150% of Medicare + 9.63% HCRA Surcharge,206.1,45,,206.1,percent of total billed charges,Critical Access Hospital RCC factor,297.7,65,,297.7,percent of total billed charges,All Other,270.22,65,,270.22,percent of total billed charges,All Other,442,,,442,Case Rate,IV Therapy Per Visit,398,,,398,Case Rate,IV Therapy Per Visit,376,,,376,Case Rate,IV Therapy Per Visit,226.71,,,226.71,Other,110% of Medicare,311.44,,,311.44,Other,Non Covered Service,411,,,411,Other,186% of Medicaid,366.4,80,,366.4,percent of total billed charges,All Other,380.14,83,,380.14,percent of total billed charges,All Other,380.14,83,,380.14,percent of total billed charges,All Other,366.4,80,,366.4,percent of total billed charges,All Other,380.14,83,,380.14,percent of total billed charges,All Other,366.4,80,,366.4,percent of total billed charges,All Other,320.6,70,,320.6,percent of total billed charges,All Other,145.96,,,145.96,Other,Non Covered Service,123.71,,,123.71,Fee Schedule,,953,,,953,Case Rate,IV Therapy Per Visit,858,,,858,Case Rate,IV Therapy Per Visit,953,,,953,Case Rate,IV Therapy Per Visit,810,,,810,Case Rate,IV Therapy Per Visit,221.06,,,221.06,Other,100% of Medicaid,221.06,,,221.06,Other,100% of Medicaid,221.06,,,221.06,Other,100% of Medicaid,221.06,,,221.06,Other,100% of Medicaid,497.39,,,497.39,Other,225% of Medicaid,338.22,,,338.22,Other,153% of Medicaid,497.39,,,497.39,Other,225% of Medicaid,309.49,,,309.49,Other,140% of Medicaid,497.39,,,497.39,Other,225% of Medicaid,574.76,,,574.76,Other,260% of Medicaid,716.24,,,716.24,Other,324% of Medicaid,475.28,,,475.28,Other,215% of Medicaid,475.28,,,475.28,Other,215% of Medicaid,276.33,,,276.33,Other,125% of Medicaid,123.71,953,
THER DIAG CONCURRENT INF,96368,CPT,,75096368,CDM,260,RC,,,both,,,460,340.4,,,340.4,Other,150% of Medicare + 9.63% HCRA Surcharge,207,45,,207,percent of total billed charges,Critical Access Hospital RCC factor,299,65,,299,percent of total billed charges,All Other,271.4,65,,271.4,percent of total billed charges,All Other,442,,,442,Case Rate,IV Therapy Per Visit,398,,,398,Case Rate,IV Therapy Per Visit,376,,,376,Case Rate,IV Therapy Per Visit,227.7,,,227.7,Other,110% of Medicare,312.8,,,312.8,Other,Non Covered Service,411,,,411,Other,186% of Medicaid,368,80,,368,percent of total billed charges,All Other,381.8,83,,381.8,percent of total billed charges,All Other,381.8,83,,381.8,percent of total billed charges,All Other,368,80,,368,percent of total billed charges,All Other,381.8,83,,381.8,percent of total billed charges,All Other,368,80,,368,percent of total billed charges,All Other,322,70,,322,percent of total billed charges,All Other,98.4,,,98.4,Other,Non Covered Service,83.4,,,83.4,Fee Schedule,,953,,,953,Case Rate,IV Therapy Per Visit,858,,,858,Case Rate,IV Therapy Per Visit,953,,,953,Case Rate,IV Therapy Per Visit,810,,,810,Case Rate,IV Therapy Per Visit,221.06,,,221.06,Other,100% of Medicaid,221.06,,,221.06,Other,100% of Medicaid,221.06,,,221.06,Other,100% of Medicaid,221.06,,,221.06,Other,100% of Medicaid,497.39,,,497.39,Other,225% of Medicaid,338.22,,,338.22,Other,153% of Medicaid,497.39,,,497.39,Other,225% of Medicaid,309.49,,,309.49,Other,140% of Medicaid,497.39,,,497.39,Other,225% of Medicaid,574.76,,,574.76,Other,260% of Medicaid,716.24,,,716.24,Other,324% of Medicaid,475.28,,,475.28,Other,215% of Medicaid,475.28,,,475.28,Other,215% of Medicaid,276.33,,,276.33,Other,125% of Medicaid,83.4,953,
NON CHEMO IM/SC INJECTION,96372,CPT,,75096372,CDM,260,RC,,,both,,,460,340.4,,,340.4,Other,150% of Medicare + 9.63% HCRA Surcharge,207,45,,207,percent of total billed charges,Critical Access Hospital RCC factor,299,65,,299,percent of total billed charges,All Other,271.4,65,,271.4,percent of total billed charges,All Other,351.9,76.5,,351.9,percent of total billed charges,All Other,326.6,69,,326.6,percent of total billed charges,All Other,317.4,65,,317.4,percent of total billed charges,All Other,227.7,,,227.7,Other,110% of Medicare,312.8,,,312.8,Other,Non Covered Service,58,,,58,Other,186% of Medicaid,368,80,,368,percent of total billed charges,All Other,381.8,83,,381.8,percent of total billed charges,All Other,381.8,83,,381.8,percent of total billed charges,All Other,368,80,,368,percent of total billed charges,All Other,381.8,83,,381.8,percent of total billed charges,All Other,368,80,,368,percent of total billed charges,All Other,322,70,,322,percent of total billed charges,All Other,68.88,,,68.88,Other,Non Covered Service,58.38,,,58.38,Fee Schedule,,953,,,953,Case Rate,,858,,,858,Case Rate,,953,,,953,Case Rate,,810,,,810,Case Rate,,31.2,,,31.2,Other,100% of Medicaid,31.2,,,31.2,Other,100% of Medicaid,31.2,,,31.2,Other,100% of Medicaid,31.2,,,31.2,Other,100% of Medicaid,70.2,,,70.2,Other,225% of Medicaid,47.74,,,47.74,Other,153% of Medicaid,70.2,,,70.2,Other,225% of Medicaid,43.68,,,43.68,Other,140% of Medicaid,70.2,,,70.2,Other,225% of Medicaid,81.12,,,81.12,Other,260% of Medicaid,101.09,,,101.09,Other,324% of Medicaid,67.08,,,67.08,Other,215% of Medicaid,67.08,,,67.08,Other,215% of Medicaid,39,,,39,Other,125% of Medicaid,31.2,953,
IV PUSH INITIAL,96374,CPT,,75096374,CDM,260,RC,,,both,,,483,357.42,,,357.42,Other,150% of Medicare + 9.63% HCRA Surcharge,217.35,45,,217.35,percent of total billed charges,Critical Access Hospital RCC factor,313.95,65,,313.95,percent of total billed charges,All Other,284.97,65,,284.97,percent of total billed charges,All Other,369.5,76.5,,369.5,percent of total billed charges,All Other,342.93,69,,342.93,percent of total billed charges,All Other,333.27,65,,333.27,percent of total billed charges,All Other,239.09,,,239.09,Other,110% of Medicare,328.44,,,328.44,Other,Non Covered Service,58,,,58,Other,186% of Medicaid,386.4,80,,386.4,percent of total billed charges,All Other,400.89,83,,400.89,percent of total billed charges,All Other,400.89,83,,400.89,percent of total billed charges,All Other,386.4,80,,386.4,percent of total billed charges,All Other,400.89,83,,400.89,percent of total billed charges,All Other,386.4,80,,386.4,percent of total billed charges,All Other,338.1,70,,338.1,percent of total billed charges,All Other,190.24,,,190.24,Other,Non Covered Service,161.24,,,161.24,Fee Schedule,,953,,,953,Case Rate,,858,,,858,Case Rate,,953,,,953,Case Rate,,810,,,810,Case Rate,,31.2,,,31.2,Other,100% of Medicaid,31.2,,,31.2,Other,100% of Medicaid,31.2,,,31.2,Other,100% of Medicaid,31.2,,,31.2,Other,100% of Medicaid,70.2,,,70.2,Other,225% of Medicaid,47.74,,,47.74,Other,153% of Medicaid,70.2,,,70.2,Other,225% of Medicaid,43.68,,,43.68,Other,140% of Medicaid,70.2,,,70.2,Other,225% of Medicaid,81.12,,,81.12,Other,260% of Medicaid,101.09,,,101.09,Other,324% of Medicaid,67.08,,,67.08,Other,215% of Medicaid,67.08,,,67.08,Other,215% of Medicaid,39,,,39,Other,125% of Medicaid,31.2,953,
NON CHEMO IV PUSH EA ADDL,96375,CPT,,75096375,CDM,260,RC,,,both,,,460,340.4,,,340.4,Other,150% of Medicare + 9.63% HCRA Surcharge,207,45,,207,percent of total billed charges,Critical Access Hospital RCC factor,299,65,,299,percent of total billed charges,All Other,271.4,65,,271.4,percent of total billed charges,All Other,351.9,76.5,,351.9,percent of total billed charges,All Other,326.6,69,,326.6,percent of total billed charges,All Other,317.4,65,,317.4,percent of total billed charges,All Other,227.7,,,227.7,Other,110% of Medicare,312.8,,,312.8,Other,Non Covered Service,58,,,58,Other,186% of Medicaid,368,80,,368,percent of total billed charges,All Other,381.8,83,,381.8,percent of total billed charges,All Other,381.8,83,,381.8,percent of total billed charges,All Other,368,80,,368,percent of total billed charges,All Other,381.8,83,,381.8,percent of total billed charges,All Other,368,80,,368,percent of total billed charges,All Other,322,70,,322,percent of total billed charges,All Other,77.08,,,77.08,Other,Non Covered Service,65.33,,,65.33,Fee Schedule,,953,,,953,Case Rate,,858,,,858,Case Rate,,953,,,953,Case Rate,,810,,,810,Case Rate,,31.2,,,31.2,Other,100% of Medicaid,31.2,,,31.2,Other,100% of Medicaid,31.2,,,31.2,Other,100% of Medicaid,31.2,,,31.2,Other,100% of Medicaid,70.2,,,70.2,Other,225% of Medicaid,47.74,,,47.74,Other,153% of Medicaid,70.2,,,70.2,Other,225% of Medicaid,43.68,,,43.68,Other,140% of Medicaid,70.2,,,70.2,Other,225% of Medicaid,81.12,,,81.12,Other,260% of Medicaid,101.09,,,101.09,Other,324% of Medicaid,67.08,,,67.08,Other,215% of Medicaid,67.08,,,67.08,Other,215% of Medicaid,39,,,39,Other,125% of Medicaid,31.2,953,
TX/PRO/DX INJ SAME DRUG A,96376,CPT,,75096376,CDM,260,RC,,,both,,,460,340.4,,,340.4,Other,150% of Medicare + 9.63% HCRA Surcharge,207,45,,207,percent of total billed charges,Critical Access Hospital RCC factor,299,65,,299,percent of total billed charges,All Other,271.4,65,,271.4,percent of total billed charges,All Other,351.9,76.5,,351.9,percent of total billed charges,All Other,326.6,69,,326.6,percent of total billed charges,All Other,317.4,65,,317.4,percent of total billed charges,All Other,227.7,,,227.7,Other,110% of Medicare,312.8,,,312.8,Other,Non Covered Service,58,,,58,Other,186% of Medicaid,368,80,,368,percent of total billed charges,All Other,381.8,83,,381.8,percent of total billed charges,All Other,381.8,83,,381.8,percent of total billed charges,All Other,368,80,,368,percent of total billed charges,All Other,381.8,83,,381.8,percent of total billed charges,All Other,368,80,,368,percent of total billed charges,All Other,322,70,,322,percent of total billed charges,All Other,299,65,,299,percent of total billed charges,Default if not in Fee Schedule,299,65,,299,percent of total billed charges,Default if not in Fee Schedule,953,,,953,Case Rate,,858,,,858,Case Rate,,953,,,953,Case Rate,,810,,,810,Case Rate,,31.2,,,31.2,Other,100% of Medicaid,31.2,,,31.2,Other,100% of Medicaid,31.2,,,31.2,Other,100% of Medicaid,31.2,,,31.2,Other,100% of Medicaid,70.2,,,70.2,Other,225% of Medicaid,47.74,,,47.74,Other,153% of Medicaid,70.2,,,70.2,Other,225% of Medicaid,43.68,,,43.68,Other,140% of Medicaid,70.2,,,70.2,Other,225% of Medicaid,81.12,,,81.12,Other,260% of Medicaid,101.09,,,101.09,Other,324% of Medicaid,67.08,,,67.08,Other,215% of Medicaid,67.08,,,67.08,Other,215% of Medicaid,39,,,39,Other,125% of Medicaid,31.2,953,
APPLICATION ON-BODY INJECTOR,96377,CPT,,75096377,CDM,260,RC,,,both,,,212,156.88,,,156.88,Other,150% of Medicare + 9.63% HCRA Surcharge,95.4,45,,95.4,percent of total billed charges,Critical Access Hospital RCC factor,137.8,65,,137.8,percent of total billed charges,All Other,125.08,65,,125.08,percent of total billed charges,All Other,17.4,,,17.4,Fee Schedule,,17.4,,,17.4,Fee Schedule,,17.4,,,17.4,Fee Schedule,,104.94,,,104.94,Other,110% of Medicare,144.16,,,144.16,Other,Non Covered Service,58,,,58,Other,186% of Medicaid,169.6,80,,169.6,percent of total billed charges,All Other,175.96,83,,175.96,percent of total billed charges,All Other,175.96,83,,175.96,percent of total billed charges,All Other,169.6,80,,169.6,percent of total billed charges,All Other,175.96,83,,175.96,percent of total billed charges,All Other,169.6,80,,169.6,percent of total billed charges,All Other,148.4,70,,148.4,percent of total billed charges,All Other,91.84,,,91.84,Other,Non Covered Service,77.84,,,77.84,Fee Schedule,,953,,,953,Case Rate,,858,,,858,Case Rate,,953,,,953,Case Rate,,810,,,810,Case Rate,,31.2,,,31.2,Other,100% of Medicaid,31.2,,,31.2,Other,100% of Medicaid,31.2,,,31.2,Other,100% of Medicaid,31.2,,,31.2,Other,100% of Medicaid,70.2,,,70.2,Other,225% of Medicaid,47.74,,,47.74,Other,153% of Medicaid,70.2,,,70.2,Other,225% of Medicaid,43.68,,,43.68,Other,140% of Medicaid,70.2,,,70.2,Other,225% of Medicaid,81.12,,,81.12,Other,260% of Medicaid,101.09,,,101.09,Other,324% of Medicaid,67.08,,,67.08,Other,215% of Medicaid,67.08,,,67.08,Other,215% of Medicaid,39,,,39,Other,125% of Medicaid,17.4,953,
HYDRATION INFUSION IV INIT,96360,CPT,,82096360,CDM,260,RC,,,both,,,466,344.84,,,344.84,Other,150% of Medicare + 9.63% HCRA Surcharge,209.7,45,,209.7,percent of total billed charges,Critical Access Hospital RCC factor,302.9,65,,302.9,percent of total billed charges,All Other,274.94,65,,274.94,percent of total billed charges,All Other,442,,,442,Case Rate,IV Therapy Per Visit,398,,,398,Case Rate,IV Therapy Per Visit,376,,,376,Case Rate,IV Therapy Per Visit,230.67,,,230.67,Other,110% of Medicare,316.88,,,316.88,Other,Non Covered Service,411,,,411,Other,186% of Medicaid,372.8,80,,372.8,percent of total billed charges,All Other,386.78,83,,386.78,percent of total billed charges,All Other,386.78,83,,386.78,percent of total billed charges,All Other,372.8,80,,372.8,percent of total billed charges,All Other,386.78,83,,386.78,percent of total billed charges,All Other,372.8,80,,372.8,percent of total billed charges,All Other,326.2,70,,326.2,percent of total billed charges,All Other,165.64,,,165.64,Other,Non Covered Service,140.39,,,140.39,Fee Schedule,,953,,,953,Case Rate,IV Therapy Per Visit,858,,,858,Case Rate,IV Therapy Per Visit,953,,,953,Case Rate,IV Therapy Per Visit,810,,,810,Case Rate,IV Therapy Per Visit,221.06,,,221.06,Other,100% of Medicaid,221.06,,,221.06,Other,100% of Medicaid,221.06,,,221.06,Other,100% of Medicaid,221.06,,,221.06,Other,100% of Medicaid,497.39,,,497.39,Other,225% of Medicaid,338.22,,,338.22,Other,153% of Medicaid,497.39,,,497.39,Other,225% of Medicaid,309.49,,,309.49,Other,140% of Medicaid,497.39,,,497.39,Other,225% of Medicaid,574.76,,,574.76,Other,260% of Medicaid,716.24,,,716.24,Other,324% of Medicaid,475.28,,,475.28,Other,215% of Medicaid,475.28,,,475.28,Other,215% of Medicaid,276.33,,,276.33,Other,125% of Medicaid,140.39,953,
IV HYDRATION EACH ADD ON,96361,CPT,,82096361,CDM,260,RC,,,both,,,460,340.4,,,340.4,Other,150% of Medicare + 9.63% HCRA Surcharge,207,45,,207,percent of total billed charges,Critical Access Hospital RCC factor,299,65,,299,percent of total billed charges,All Other,271.4,65,,271.4,percent of total billed charges,All Other,442,,,442,Case Rate,IV Therapy Per Visit,398,,,398,Case Rate,IV Therapy Per Visit,376,,,376,Case Rate,IV Therapy Per Visit,227.7,,,227.7,Other,110% of Medicare,312.8,,,312.8,Other,Non Covered Service,1098,,,1098,Other,186% of Medicaid,368,80,,368,percent of total billed charges,All Other,381.8,83,,381.8,percent of total billed charges,All Other,381.8,83,,381.8,percent of total billed charges,All Other,368,80,,368,percent of total billed charges,All Other,381.8,83,,381.8,percent of total billed charges,All Other,368,80,,368,percent of total billed charges,All Other,322,70,,322,percent of total billed charges,All Other,62.32,,,62.32,Other,Non Covered Service,52.82,,,52.82,Fee Schedule,,953,,,953,Case Rate,IV Therapy Per Visit,858,,,858,Case Rate,IV Therapy Per Visit,953,,,953,Case Rate,IV Therapy Per Visit,810,,,810,Case Rate,IV Therapy Per Visit,590.24,,,590.24,Other,100% of Medicaid,590.24,,,590.24,Other,100% of Medicaid,590.24,,,590.24,Other,100% of Medicaid,590.24,,,590.24,Other,100% of Medicaid,1328.05,,,1328.05,Other,225% of Medicaid,903.07,,,903.07,Other,153% of Medicaid,1328.05,,,1328.05,Other,225% of Medicaid,826.34,,,826.34,Other,140% of Medicaid,1328.05,,,1328.05,Other,225% of Medicaid,1534.64,,,1534.64,Other,260% of Medicaid,1912.39,,,1912.39,Other,324% of Medicaid,1269.03,,,1269.03,Other,215% of Medicaid,1269.03,,,1269.03,Other,215% of Medicaid,737.81,,,737.81,Other,125% of Medicaid,52.82,1912.39,
INFUSION THERAPY 1 HOUR,96365,CPT,,82096365,CDM,260,RC,,,both,,,713,527.62,,,527.62,Other,150% of Medicare + 9.63% HCRA Surcharge,320.85,45,,320.85,percent of total billed charges,Critical Access Hospital RCC factor,463.45,65,,463.45,percent of total billed charges,All Other,420.67,65,,420.67,percent of total billed charges,All Other,442,,,442,Case Rate,IV Therapy Per Visit,398,,,398,Case Rate,IV Therapy Per Visit,376,,,376,Case Rate,IV Therapy Per Visit,352.94,,,352.94,Other,110% of Medicare,484.84,,,484.84,Other,Non Covered Service,411,,,411,Other,186% of Medicaid,570.4,80,,570.4,percent of total billed charges,All Other,591.79,83,,591.79,percent of total billed charges,All Other,591.79,83,,591.79,percent of total billed charges,All Other,570.4,80,,570.4,percent of total billed charges,All Other,591.79,83,,591.79,percent of total billed charges,All Other,570.4,80,,570.4,percent of total billed charges,All Other,499.1,70,,499.1,percent of total billed charges,All Other,328,,,328,Other,Non Covered Service,278,,,278,Fee Schedule,,953,,,953,Case Rate,IV Therapy Per Visit,858,,,858,Case Rate,IV Therapy Per Visit,953,,,953,Case Rate,IV Therapy Per Visit,810,,,810,Case Rate,IV Therapy Per Visit,221.06,,,221.06,Other,100% of Medicaid,221.06,,,221.06,Other,100% of Medicaid,221.06,,,221.06,Other,100% of Medicaid,221.06,,,221.06,Other,100% of Medicaid,497.39,,,497.39,Other,225% of Medicaid,338.22,,,338.22,Other,153% of Medicaid,497.39,,,497.39,Other,225% of Medicaid,309.49,,,309.49,Other,140% of Medicaid,497.39,,,497.39,Other,225% of Medicaid,574.76,,,574.76,Other,260% of Medicaid,716.24,,,716.24,Other,324% of Medicaid,475.28,,,475.28,Other,215% of Medicaid,475.28,,,475.28,Other,215% of Medicaid,276.33,,,276.33,Other,125% of Medicaid,221.06,953,
THER/PROPH/DIAG IV INF ADDON,96366,CPT,,82096366,CDM,260,RC,,,both,,,460,340.4,,,340.4,Other,150% of Medicare + 9.63% HCRA Surcharge,207,45,,207,percent of total billed charges,Critical Access Hospital RCC factor,299,65,,299,percent of total billed charges,All Other,271.4,65,,271.4,percent of total billed charges,All Other,442,,,442,Case Rate,IV Therapy Per Visit,398,,,398,Case Rate,IV Therapy Per Visit,376,,,376,Case Rate,IV Therapy Per Visit,227.7,,,227.7,Other,110% of Medicare,312.8,,,312.8,Other,Non Covered Service,1098,,,1098,Other,186% of Medicaid,368,80,,368,percent of total billed charges,All Other,381.8,83,,381.8,percent of total billed charges,All Other,381.8,83,,381.8,percent of total billed charges,All Other,368,80,,368,percent of total billed charges,All Other,381.8,83,,381.8,percent of total billed charges,All Other,368,80,,368,percent of total billed charges,All Other,322,70,,322,percent of total billed charges,All Other,101.68,,,101.68,Other,Non Covered Service,86.18,,,86.18,Fee Schedule,,953,,,953,Case Rate,IV Therapy Per Visit,858,,,858,Case Rate,IV Therapy Per Visit,953,,,953,Case Rate,IV Therapy Per Visit,810,,,810,Case Rate,IV Therapy Per Visit,590.24,,,590.24,Other,100% of Medicaid,590.24,,,590.24,Other,100% of Medicaid,590.24,,,590.24,Other,100% of Medicaid,590.24,,,590.24,Other,100% of Medicaid,1328.05,,,1328.05,Other,225% of Medicaid,903.07,,,903.07,Other,153% of Medicaid,1328.05,,,1328.05,Other,225% of Medicaid,826.34,,,826.34,Other,140% of Medicaid,1328.05,,,1328.05,Other,225% of Medicaid,1534.64,,,1534.64,Other,260% of Medicaid,1912.39,,,1912.39,Other,324% of Medicaid,1269.03,,,1269.03,Other,215% of Medicaid,1269.03,,,1269.03,Other,215% of Medicaid,737.81,,,737.81,Other,125% of Medicaid,86.18,1912.39,
TX/PROPH/DG ADDL SEQ IV INF,96367,CPT,,82096367,CDM,260,RC,,,both,,,458,338.92,,,338.92,Other,150% of Medicare + 9.63% HCRA Surcharge,206.1,45,,206.1,percent of total billed charges,Critical Access Hospital RCC factor,297.7,65,,297.7,percent of total billed charges,All Other,270.22,65,,270.22,percent of total billed charges,All Other,442,,,442,Case Rate,IV Therapy Per Visit,398,,,398,Case Rate,IV Therapy Per Visit,376,,,376,Case Rate,IV Therapy Per Visit,226.71,,,226.71,Other,110% of Medicare,311.44,,,311.44,Other,Non Covered Service,411,,,411,Other,186% of Medicaid,366.4,80,,366.4,percent of total billed charges,All Other,380.14,83,,380.14,percent of total billed charges,All Other,380.14,83,,380.14,percent of total billed charges,All Other,366.4,80,,366.4,percent of total billed charges,All Other,380.14,83,,380.14,percent of total billed charges,All Other,366.4,80,,366.4,percent of total billed charges,All Other,320.6,70,,320.6,percent of total billed charges,All Other,145.96,,,145.96,Other,Non Covered Service,123.71,,,123.71,Fee Schedule,,953,,,953,Case Rate,IV Therapy Per Visit,858,,,858,Case Rate,IV Therapy Per Visit,953,,,953,Case Rate,IV Therapy Per Visit,810,,,810,Case Rate,IV Therapy Per Visit,221.06,,,221.06,Other,100% of Medicaid,221.06,,,221.06,Other,100% of Medicaid,221.06,,,221.06,Other,100% of Medicaid,221.06,,,221.06,Other,100% of Medicaid,497.39,,,497.39,Other,225% of Medicaid,338.22,,,338.22,Other,153% of Medicaid,497.39,,,497.39,Other,225% of Medicaid,309.49,,,309.49,Other,140% of Medicaid,497.39,,,497.39,Other,225% of Medicaid,574.76,,,574.76,Other,260% of Medicaid,716.24,,,716.24,Other,324% of Medicaid,475.28,,,475.28,Other,215% of Medicaid,475.28,,,475.28,Other,215% of Medicaid,276.33,,,276.33,Other,125% of Medicaid,123.71,953,
THER DIAG CONCURRENT INF,96368,CPT,,82096368,CDM,260,RC,,,both,,,460,340.4,,,340.4,Other,150% of Medicare + 9.63% HCRA Surcharge,207,45,,207,percent of total billed charges,Critical Access Hospital RCC factor,299,65,,299,percent of total billed charges,All Other,271.4,65,,271.4,percent of total billed charges,All Other,442,,,442,Case Rate,IV Therapy Per Visit,398,,,398,Case Rate,IV Therapy Per Visit,376,,,376,Case Rate,IV Therapy Per Visit,227.7,,,227.7,Other,110% of Medicare,312.8,,,312.8,Other,Non Covered Service,411,,,411,Other,186% of Medicaid,368,80,,368,percent of total billed charges,All Other,381.8,83,,381.8,percent of total billed charges,All Other,381.8,83,,381.8,percent of total billed charges,All Other,368,80,,368,percent of total billed charges,All Other,381.8,83,,381.8,percent of total billed charges,All Other,368,80,,368,percent of total billed charges,All Other,322,70,,322,percent of total billed charges,All Other,98.4,,,98.4,Other,Non Covered Service,83.4,,,83.4,Fee Schedule,,953,,,953,Case Rate,IV Therapy Per Visit,858,,,858,Case Rate,IV Therapy Per Visit,953,,,953,Case Rate,IV Therapy Per Visit,810,,,810,Case Rate,IV Therapy Per Visit,221.06,,,221.06,Other,100% of Medicaid,221.06,,,221.06,Other,100% of Medicaid,221.06,,,221.06,Other,100% of Medicaid,221.06,,,221.06,Other,100% of Medicaid,497.39,,,497.39,Other,225% of Medicaid,338.22,,,338.22,Other,153% of Medicaid,497.39,,,497.39,Other,225% of Medicaid,309.49,,,309.49,Other,140% of Medicaid,497.39,,,497.39,Other,225% of Medicaid,574.76,,,574.76,Other,260% of Medicaid,716.24,,,716.24,Other,324% of Medicaid,475.28,,,475.28,Other,215% of Medicaid,475.28,,,475.28,Other,215% of Medicaid,276.33,,,276.33,Other,125% of Medicaid,83.4,953,
THER/PROPH/DIAG INJ SC/IM,96372,CPT,,82096372,CDM,260,RC,,,both,,,460,340.4,,,340.4,Other,150% of Medicare + 9.63% HCRA Surcharge,207,45,,207,percent of total billed charges,Critical Access Hospital RCC factor,299,65,,299,percent of total billed charges,All Other,271.4,65,,271.4,percent of total billed charges,All Other,351.9,76.5,,351.9,percent of total billed charges,All Other,326.6,69,,326.6,percent of total billed charges,All Other,317.4,65,,317.4,percent of total billed charges,All Other,227.7,,,227.7,Other,110% of Medicare,312.8,,,312.8,Other,Non Covered Service,58,,,58,Other,186% of Medicaid,368,80,,368,percent of total billed charges,All Other,381.8,83,,381.8,percent of total billed charges,All Other,381.8,83,,381.8,percent of total billed charges,All Other,368,80,,368,percent of total billed charges,All Other,381.8,83,,381.8,percent of total billed charges,All Other,368,80,,368,percent of total billed charges,All Other,322,70,,322,percent of total billed charges,All Other,68.88,,,68.88,Other,Non Covered Service,58.38,,,58.38,Fee Schedule,,953,,,953,Case Rate,,858,,,858,Case Rate,,953,,,953,Case Rate,,810,,,810,Case Rate,,31.2,,,31.2,Other,100% of Medicaid,31.2,,,31.2,Other,100% of Medicaid,31.2,,,31.2,Other,100% of Medicaid,31.2,,,31.2,Other,100% of Medicaid,70.2,,,70.2,Other,225% of Medicaid,47.74,,,47.74,Other,153% of Medicaid,70.2,,,70.2,Other,225% of Medicaid,43.68,,,43.68,Other,140% of Medicaid,70.2,,,70.2,Other,225% of Medicaid,81.12,,,81.12,Other,260% of Medicaid,101.09,,,101.09,Other,324% of Medicaid,67.08,,,67.08,Other,215% of Medicaid,67.08,,,67.08,Other,215% of Medicaid,39,,,39,Other,125% of Medicaid,31.2,953,
IV PUSH INITIAL,96374,CPT,,82096374,CDM,260,RC,,,both,,,483,357.42,,,357.42,Other,150% of Medicare + 9.63% HCRA Surcharge,217.35,45,,217.35,percent of total billed charges,Critical Access Hospital RCC factor,313.95,65,,313.95,percent of total billed charges,All Other,284.97,65,,284.97,percent of total billed charges,All Other,369.5,76.5,,369.5,percent of total billed charges,All Other,342.93,69,,342.93,percent of total billed charges,All Other,333.27,65,,333.27,percent of total billed charges,All Other,239.09,,,239.09,Other,110% of Medicare,328.44,,,328.44,Other,Non Covered Service,58,,,58,Other,186% of Medicaid,386.4,80,,386.4,percent of total billed charges,All Other,400.89,83,,400.89,percent of total billed charges,All Other,400.89,83,,400.89,percent of total billed charges,All Other,386.4,80,,386.4,percent of total billed charges,All Other,400.89,83,,400.89,percent of total billed charges,All Other,386.4,80,,386.4,percent of total billed charges,All Other,338.1,70,,338.1,percent of total billed charges,All Other,190.24,,,190.24,Other,Non Covered Service,161.24,,,161.24,Fee Schedule,,953,,,953,Case Rate,,858,,,858,Case Rate,,953,,,953,Case Rate,,810,,,810,Case Rate,,31.2,,,31.2,Other,100% of Medicaid,31.2,,,31.2,Other,100% of Medicaid,31.2,,,31.2,Other,100% of Medicaid,31.2,,,31.2,Other,100% of Medicaid,70.2,,,70.2,Other,225% of Medicaid,47.74,,,47.74,Other,153% of Medicaid,70.2,,,70.2,Other,225% of Medicaid,43.68,,,43.68,Other,140% of Medicaid,70.2,,,70.2,Other,225% of Medicaid,81.12,,,81.12,Other,260% of Medicaid,101.09,,,101.09,Other,324% of Medicaid,67.08,,,67.08,Other,215% of Medicaid,67.08,,,67.08,Other,215% of Medicaid,39,,,39,Other,125% of Medicaid,31.2,953,
TX/PRO/DX INJ NEW DRUG ADDON,96375,CPT,,82096375,CDM,260,RC,,,both,,,460,340.4,,,340.4,Other,150% of Medicare + 9.63% HCRA Surcharge,207,45,,207,percent of total billed charges,Critical Access Hospital RCC factor,299,65,,299,percent of total billed charges,All Other,271.4,65,,271.4,percent of total billed charges,All Other,351.9,76.5,,351.9,percent of total billed charges,All Other,326.6,69,,326.6,percent of total billed charges,All Other,317.4,65,,317.4,percent of total billed charges,All Other,227.7,,,227.7,Other,110% of Medicare,312.8,,,312.8,Other,Non Covered Service,58,,,58,Other,186% of Medicaid,368,80,,368,percent of total billed charges,All Other,381.8,83,,381.8,percent of total billed charges,All Other,381.8,83,,381.8,percent of total billed charges,All Other,368,80,,368,percent of total billed charges,All Other,381.8,83,,381.8,percent of total billed charges,All Other,368,80,,368,percent of total billed charges,All Other,322,70,,322,percent of total billed charges,All Other,77.08,,,77.08,Other,Non Covered Service,65.33,,,65.33,Fee Schedule,,953,,,953,Case Rate,,858,,,858,Case Rate,,953,,,953,Case Rate,,810,,,810,Case Rate,,31.2,,,31.2,Other,100% of Medicaid,31.2,,,31.2,Other,100% of Medicaid,31.2,,,31.2,Other,100% of Medicaid,31.2,,,31.2,Other,100% of Medicaid,70.2,,,70.2,Other,225% of Medicaid,47.74,,,47.74,Other,153% of Medicaid,70.2,,,70.2,Other,225% of Medicaid,43.68,,,43.68,Other,140% of Medicaid,70.2,,,70.2,Other,225% of Medicaid,81.12,,,81.12,Other,260% of Medicaid,101.09,,,101.09,Other,324% of Medicaid,67.08,,,67.08,Other,215% of Medicaid,67.08,,,67.08,Other,215% of Medicaid,39,,,39,Other,125% of Medicaid,31.2,953,
TX/PRO/DX INJ SAME DRUG ADDON,96376,CPT,,82096376,CDM,260,RC,,,both,,,460,340.4,,,340.4,Other,150% of Medicare + 9.63% HCRA Surcharge,207,45,,207,percent of total billed charges,Critical Access Hospital RCC factor,299,65,,299,percent of total billed charges,All Other,271.4,65,,271.4,percent of total billed charges,All Other,351.9,76.5,,351.9,percent of total billed charges,All Other,326.6,69,,326.6,percent of total billed charges,All Other,317.4,65,,317.4,percent of total billed charges,All Other,227.7,,,227.7,Other,110% of Medicare,312.8,,,312.8,Other,Non Covered Service,58,,,58,Other,186% of Medicaid,368,80,,368,percent of total billed charges,All Other,381.8,83,,381.8,percent of total billed charges,All Other,381.8,83,,381.8,percent of total billed charges,All Other,368,80,,368,percent of total billed charges,All Other,381.8,83,,381.8,percent of total billed charges,All Other,368,80,,368,percent of total billed charges,All Other,322,70,,322,percent of total billed charges,All Other,299,65,,299,percent of total billed charges,Default if not in Fee Schedule,299,65,,299,percent of total billed charges,Default if not in Fee Schedule,953,,,953,Case Rate,,858,,,858,Case Rate,,953,,,953,Case Rate,,810,,,810,Case Rate,,31.2,,,31.2,Other,100% of Medicaid,31.2,,,31.2,Other,100% of Medicaid,31.2,,,31.2,Other,100% of Medicaid,31.2,,,31.2,Other,100% of Medicaid,70.2,,,70.2,Other,225% of Medicaid,47.74,,,47.74,Other,153% of Medicaid,70.2,,,70.2,Other,225% of Medicaid,43.68,,,43.68,Other,140% of Medicaid,70.2,,,70.2,Other,225% of Medicaid,81.12,,,81.12,Other,260% of Medicaid,101.09,,,101.09,Other,324% of Medicaid,67.08,,,67.08,Other,215% of Medicaid,67.08,,,67.08,Other,215% of Medicaid,39,,,39,Other,125% of Medicaid,31.2,953,
EAR MOLD/INSERT (ONE),V5264,HCPCS,,66000115,CDM,270,RC,,,both,,,142.79,105.67,,,105.67,Other,150% of Medicare + 9.63% HCRA Surcharge,64.26,45,,64.26,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,70.69,,,70.69,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,99.95,70,,99.95,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,105.67,
BATTERY FOR HEARING DEVICE,V5266,HCPCS,,66000117,CDM,270,RC,,,both,,,13.08,9.69,,,9.69,Other,150% of Medicare + 9.63% HCRA Surcharge,5.89,45,,5.89,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,6.48,,,6.48,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,9.16,70,,9.16,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,9.69,
HEARING AID DIGIT MON ITE,V5256,HCPCS,,66000130,CDM,270,RC,,,both,,,0.01,0.01,,,0.01,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,45,,0.01,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,70,,0.01,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,0.01,
HEARING AID DIGIT MON BTE,V5257,HCPCS,,66000131,CDM,270,RC,,,both,,,0.01,0.01,,,0.01,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,45,,0.01,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,70,,0.01,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,0.01,
HEARING AID DIGIT BIN ITE,V5260,HCPCS,,66000132,CDM,270,RC,,,both,,,0.01,0.01,,,0.01,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,45,,0.01,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,70,,0.01,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,0.01,
HEARING AID DIGIT BIN BTE,V5261,HCPCS,,66000133,CDM,270,RC,,,both,,,0.01,0.01,,,0.01,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,45,,0.01,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,70,,0.01,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,0.01,
CUSTOM EARPLUGS,V5299,HCPCS,,66000136,CDM,270,RC,,,both,,,0.01,0.01,,,0.01,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,45,,0.01,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,70,,0.01,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,0.01,
HEARING AID CROS BTE,V5181,HCPCS,,66000137,CDM,270,RC,,,both,,,0.01,0.01,,,0.01,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,45,,0.01,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,70,,0.01,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,0.01,
HEARING AID CROS ITE,V5171,HCPCS,,66000138,CDM,270,RC,,,both,,,0.01,0.01,,,0.01,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,45,,0.01,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,70,,0.01,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,0.01,
HEARING AID BICROS BTE,V5221,HCPCS,,66000139,CDM,270,RC,,,both,,,0.01,0.01,,,0.01,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,45,,0.01,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,70,,0.01,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,0.01,
HEARING AID BICROS ITE,V5211,HCPCS,,66000142,CDM,270,RC,,,both,,,0.01,0.01,,,0.01,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,45,,0.01,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,70,,0.01,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,0.01,
HEARING AID MONAURAL ITC,V5172,HCPCS,,66000149,CDM,270,RC,,,both,,,0.01,0.01,,,0.01,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,45,,0.01,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,70,,0.01,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,0.01,
HEARING AID BINAURAL ITE/ITC,V5212,HCPCS,,66000150,CDM,270,RC,,,both,,,0.01,0.01,,,0.01,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,45,,0.01,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,70,,0.01,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,0.01,
HEARING AID BINAURAL ITE/BTE,V5213,HCPCS,,66000151,CDM,270,RC,,,both,,,0.01,0.01,,,0.01,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,45,,0.01,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,70,,0.01,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,0.01,
HEARING AID BINAURAL ITC/ITC,V5214,HCPCS,,66000152,CDM,270,RC,,,both,,,0.01,0.01,,,0.01,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,45,,0.01,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,70,,0.01,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,0.01,
HEARING AID BINAURAL ITC/BTE,V5215,HCPCS,,66000153,CDM,270,RC,,,both,,,0.01,0.01,,,0.01,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,45,,0.01,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,70,,0.01,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,0.01,
ABBOTT 1009660J WIRE TIP,C1769,HCPCS,,79002630,CDM,270,RC,,,both,,,450,333,,,333,Other,150% of Medicare + 9.63% HCRA Surcharge,202.5,45,,202.5,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,222.75,,,222.75,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,315,70,,315,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,333,
ABBOTT 1009660 WIRE STRAIGHT,C1769,HCPCS,,79002631,CDM,270,RC,,,both,,,346,256.04,,,256.04,Other,150% of Medicare + 9.63% HCRA Surcharge,155.7,45,,155.7,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,171.27,,,171.27,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,242.2,70,,242.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,256.04,
ST JUDE 410112 CPS CATHETER,C1893,HCPCS,,79002634,CDM,270,RC,,,both,,,1558,1152.92,,,1152.92,Other,150% of Medicare + 9.63% HCRA Surcharge,701.1,45,,701.1,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,771.21,,,771.21,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1090.6,70,,1090.6,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1152.92,
ABBOTT 12781-01 GRAND SLAM WIRE,C1769,HCPCS,,79002637,CDM,270,RC,,,both,,,300,222,,,222,Other,150% of Medicare + 9.63% HCRA Surcharge,135,45,,135,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,148.5,,,148.5,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,210,70,,210,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,222,
ABBOTT 1005357H GUIDEWIRE,C1769,HCPCS,,79002638,CDM,270,RC,,,both,,,346,256.04,,,256.04,Other,150% of Medicare + 9.63% HCRA Surcharge,155.7,45,,155.7,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,171.27,,,171.27,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,242.2,70,,242.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,256.04,
MEDTRONIC 043325M MARINR CATHETER,C1730,HCPCS,,79002641,CDM,270,RC,,,both,,,1650,1221,,,1221,Other,150% of Medicare + 9.63% HCRA Surcharge,742.5,45,,742.5,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,816.75,,,816.75,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1155,70,,1155,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1221,
PRESSURE PROD CSG/WORLEY-2-09 SHEATH,C1892,HCPCS,,79002643,CDM,270,RC,,,both,,,1350,999,,,999,Other,150% of Medicare + 9.63% HCRA Surcharge,607.5,45,,607.5,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,668.25,,,668.25,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,945,70,,945,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,999,
MEDTRONIC 3037 PATIENT PROGRAMMER,C1787,HCPCS,,79002666,CDM,270,RC,,,both,,,3570,2641.81,,,2641.81,Other,150% of Medicare + 9.63% HCRA Surcharge,1606.5,45,,1606.5,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1767.15,,,1767.15,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2499,70,,2499,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2641.81,
J&J 402-604X SHEATH W/GW 4FRX11CM AVANTI,C1894,HCPCS,,79002710,CDM,270,RC,,,both,,,26,19.24,,,19.24,Other,150% of Medicare + 9.63% HCRA Surcharge,11.7,45,,11.7,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,12.87,,,12.87,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,18.2,70,,18.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,19.24,
J&J 402-605X SHEATH W/GW 5FRX11CM AVANTI,C1894,HCPCS,,79002711,CDM,270,RC,,,both,,,26,19.24,,,19.24,Other,150% of Medicare + 9.63% HCRA Surcharge,11.7,45,,11.7,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,12.87,,,12.87,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,18.2,70,,18.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,19.24,
J&J 402-607X SHEATH W/GW 7FRX11CM AVANTI,C1894,HCPCS,,79002712,CDM,270,RC,,,both,,,29,21.46,,,21.46,Other,150% of Medicare + 9.63% HCRA Surcharge,13.05,45,,13.05,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,14.36,,,14.36,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,20.3,70,,20.3,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,21.46,
BOST SCI 27-136 8FR DRAINAGE CATH,C1729,HCPCS,,79002970,CDM,270,RC,,,both,,,236,174.64,,,174.64,Other,150% of Medicare + 9.63% HCRA Surcharge,106.2,45,,106.2,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,116.82,,,116.82,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,165.2,70,,165.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,174.64,
BOST SCI 27-137 10FR DRAINAGE CATH,C1729,HCPCS,,79002971,CDM,270,RC,,,both,,,236,174.64,,,174.64,Other,150% of Medicare + 9.63% HCRA Surcharge,106.2,45,,106.2,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,116.82,,,116.82,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,165.2,70,,165.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,174.64,
BOST SCI 27-138 12FR DRAINAGE CATH,C1729,HCPCS,,79002972,CDM,270,RC,,,both,,,236,174.64,,,174.64,Other,150% of Medicare + 9.63% HCRA Surcharge,106.2,45,,106.2,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,116.82,,,116.82,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,165.2,70,,165.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,174.64,
BOST SCI 27-139 14FR DRAINAGE CATH,C1729,HCPCS,,79002973,CDM,270,RC,,,both,,,236,174.64,,,174.64,Other,150% of Medicare + 9.63% HCRA Surcharge,106.2,45,,106.2,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,116.82,,,116.82,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,165.2,70,,165.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,174.64,
TERUMO GA3501 .035X180 ADVANTG GLIDEWIRE,C1769,HCPCS,,79005241,CDM,270,RC,,,both,,,630,466.2,,,466.2,Other,150% of Medicare + 9.63% HCRA Surcharge,283.5,45,,283.5,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,311.85,,,311.85,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,441,70,,441,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,466.2,
TERUMO GA3502 .035X260 ADVANTG GLIDEWIRE,C1769,HCPCS,,79005242,CDM,270,RC,,,both,,,690,510.6,,,510.6,Other,150% of Medicare + 9.63% HCRA Surcharge,310.5,45,,310.5,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,341.55,,,341.55,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,483,70,,483,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,510.6,
SO CAP DESIGN W/O JNTS CF,L3671,HCPCS,,79006241,CDM,270,RC,,,both,,,300,222,,,222,Other,150% of Medicare + 9.63% HCRA Surcharge,135,45,,135,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,148.5,,,148.5,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,210,70,,210,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,222,
SO AIRPLANE W/WO JOINT CF,L3674,HCPCS,,79006242,CDM,270,RC,,,both,,,450,333,,,333,Other,150% of Medicare + 9.63% HCRA Surcharge,202.5,45,,202.5,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,222.75,,,222.75,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,315,70,,315,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,333,
EO W/O JOINTS CF,L3702,HCPCS,,79006243,CDM,270,RC,,,both,,,226,167.24,,,167.24,Other,150% of Medicare + 9.63% HCRA Surcharge,101.7,45,,101.7,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,111.87,,,111.87,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,158.2,70,,158.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,167.24,
FOREARM/ARM CUFFS EXT/FLEX A,L3730,HCPCS,,79006244,CDM,270,RC,,,both,,,600,444,,,444,Other,150% of Medicare + 9.63% HCRA Surcharge,270,45,,270,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,297,,,297,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,420,70,,420,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,444,
EWHO RIGID W/O JNTS CF,L3763,HCPCS,,79006245,CDM,270,RC,,,both,,,300,222,,,222,Other,150% of Medicare + 9.63% HCRA Surcharge,135,45,,135,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,148.5,,,148.5,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,210,70,,210,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,222,
EWHO W/JOINT(S) CF,L3764,HCPCS,,79006246,CDM,270,RC,,,both,,,450,333,,,333,Other,150% of Medicare + 9.63% HCRA Surcharge,202.5,45,,202.5,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,222.75,,,222.75,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,315,70,,315,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,333,
EWHFO RIGID W/O JNTS CF,L3765,HCPCS,,79006247,CDM,270,RC,,,both,,,600,444,,,444,Other,150% of Medicare + 9.63% HCRA Surcharge,270,45,,270,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,297,,,297,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,420,70,,420,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,444,
EWHFO W/JOINT(S) CF,L3766,HCPCS,,79006248,CDM,270,RC,,,both,,,600,444,,,444,Other,150% of Medicare + 9.63% HCRA Surcharge,270,45,,270,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,297,,,297,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,420,70,,420,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,444,
WHFO W/JOINT(S) CUSTOM FAB,L3806,HCPCS,,79006249,CDM,270,RC,,,both,,,226,167.24,,,167.24,Other,150% of Medicare + 9.63% HCRA Surcharge,101.7,45,,101.7,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,111.87,,,111.87,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,158.2,70,,158.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,167.24,
WHFO RIGID W/O JOINTS,L3808,HCPCS,,79006250,CDM,270,RC,,,both,,,150,111,,,111,Other,150% of Medicare + 9.63% HCRA Surcharge,67.5,45,,67.5,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,74.25,,,74.25,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,105,70,,105,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,111,
WHO W/NONTORSION JNT(S) CF,L3905,HCPCS,,79006251,CDM,270,RC,,,both,,,450,333,,,333,Other,150% of Medicare + 9.63% HCRA Surcharge,202.5,45,,202.5,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,222.75,,,222.75,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,315,70,,315,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,333,
WHO W/O JOINTS CF,L3906,HCPCS,,79006252,CDM,270,RC,,,both,,,150,111,,,111,Other,150% of Medicare + 9.63% HCRA Surcharge,67.5,45,,67.5,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,74.25,,,74.25,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,105,70,,105,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,111,
HFO W/O JOINTS CF,L3913,HCPCS,,79006253,CDM,270,RC,,,both,,,76,56.24,,,56.24,Other,150% of Medicare + 9.63% HCRA Surcharge,34.2,45,,34.2,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,37.62,,,37.62,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,53.2,70,,53.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,56.24,
HFO W/JOINT(S) CF,L3921,HCPCS,,79006255,CDM,270,RC,,,both,,,120,88.8,,,88.8,Other,150% of Medicare + 9.63% HCRA Surcharge,54,45,,54,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,59.4,,,59.4,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,84,70,,84,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,88.8,
FO W/O JOINTS CF,L3933,HCPCS,,79006256,CDM,270,RC,,,both,,,90,66.6,,,66.6,Other,150% of Medicare + 9.63% HCRA Surcharge,40.5,45,,40.5,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,44.55,,,44.55,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,63,70,,63,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,66.6,
FO NONTORSION JOINT CF,L3935,HCPCS,,79006257,CDM,270,RC,,,both,,,90,66.6,,,66.6,Other,150% of Medicare + 9.63% HCRA Surcharge,40.5,45,,40.5,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,44.55,,,44.55,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,63,70,,63,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,66.6,
SEWHO CAP DESIGN W/O JNTS CF,L3961,HCPCS,,79006258,CDM,270,RC,,,both,,,600,444,,,444,Other,150% of Medicare + 9.63% HCRA Surcharge,270,45,,270,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,297,,,297,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,420,70,,420,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,444,
SEWHO AIRPLANE W/O JNTS CF,L3967,HCPCS,,79006259,CDM,270,RC,,,both,,,600,444,,,444,Other,150% of Medicare + 9.63% HCRA Surcharge,270,45,,270,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,297,,,297,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,420,70,,420,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,444,
SEWHO CAP DESIGN W/JNT(S) CF,L3971,HCPCS,,79006260,CDM,270,RC,,,both,,,600,444,,,444,Other,150% of Medicare + 9.63% HCRA Surcharge,270,45,,270,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,297,,,297,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,420,70,,420,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,444,
SEWHO AIRPLANE W/JNT(S) CF,L3973,HCPCS,,79006261,CDM,270,RC,,,both,,,600,444,,,444,Other,150% of Medicare + 9.63% HCRA Surcharge,270,45,,270,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,297,,,297,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,420,70,,420,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,444,
SEWHFO CAP DESIGN W/O JNT CF,L3975,HCPCS,,79006262,CDM,270,RC,,,both,,,600,444,,,444,Other,150% of Medicare + 9.63% HCRA Surcharge,270,45,,270,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,297,,,297,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,420,70,,420,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,444,
SEWHFO AIRPLANE W/O JNTS CF,L3976,HCPCS,,79006263,CDM,270,RC,,,both,,,600,444,,,444,Other,150% of Medicare + 9.63% HCRA Surcharge,270,45,,270,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,297,,,297,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,420,70,,420,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,444,
SEWHFO CAP DESGN W/JNT(S) CF,L3977,HCPCS,,79006264,CDM,270,RC,,,both,,,600,444,,,444,Other,150% of Medicare + 9.63% HCRA Surcharge,270,45,,270,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,297,,,297,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,420,70,,420,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,444,
SEWHFO AIRPLANE W/JNT(S) CF,L3978,HCPCS,,79006265,CDM,270,RC,,,both,,,600,444,,,444,Other,150% of Medicare + 9.63% HCRA Surcharge,270,45,,270,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,297,,,297,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,420,70,,420,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,444,
UPP EXT FX ORTHOSIS HUMERAL,L3980,HCPCS,,79006266,CDM,270,RC,,,both,,,150,111,,,111,Other,150% of Medicare + 9.63% HCRA Surcharge,67.5,45,,67.5,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,74.25,,,74.25,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,105,70,,105,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,111,
UPPER EXT FX ORTHOSIS RAD/UL,L3982,HCPCS,,79006267,CDM,270,RC,,,both,,,226,167.24,,,167.24,Other,150% of Medicare + 9.63% HCRA Surcharge,101.7,45,,101.7,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,111.87,,,111.87,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,158.2,70,,158.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,167.24,
UPPER EXT FX ORTHOSIS WRIST,L3984,HCPCS,,79006268,CDM,270,RC,,,both,,,150,111,,,111,Other,150% of Medicare + 9.63% HCRA Surcharge,67.5,45,,67.5,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,74.25,,,74.25,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,105,70,,105,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,111,
HAND LAB HFO W/O JOINT PRECST METAGRIP 1,L3923,HCPCS,,79006269,CDM,270,RC,,,both,,,180,133.2,,,133.2,Other,150% of Medicare + 9.63% HCRA Surcharge,81,45,,81,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,89.1,,,89.1,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,126,70,,126,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,133.2,
PATTERSON MED HFO W/O JOINT PRECST,L3923,HCPCS,,79006275,CDM,270,RC,,,both,,,103,76.22,,,76.22,Other,150% of Medicare + 9.63% HCRA Surcharge,46.35,45,,46.35,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,50.99,,,50.99,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,72.1,70,,72.1,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,76.22,
PATTERSON MED FO PIP DIP JNT/SPRNG LMB 1,L3925,HCPCS,,79006287,CDM,270,RC,,,both,,,85,62.9,,,62.9,Other,150% of Medicare + 9.63% HCRA Surcharge,38.25,45,,38.25,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,42.08,,,42.08,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,59.5,70,,59.5,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,62.9,
PATTERSON MED FO PIPDIP JNT/SPRNG CAPNR1,L3925,HCPCS,,79006292,CDM,270,RC,,,both,,,121,89.54,,,89.54,Other,150% of Medicare + 9.63% HCRA Surcharge,54.45,45,,54.45,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,59.9,,,59.9,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,84.7,70,,84.7,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,89.54,
PATTERSON MED FO PIPDIP NO JT SPR OVL8,L3927,HCPCS,,79006295,CDM,270,RC,,,both,,,82,60.68,,,60.68,Other,150% of Medicare + 9.63% HCRA Surcharge,36.9,45,,36.9,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,40.59,,,40.59,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,57.4,70,,57.4,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,60.68,
ARTHREX ABS-4025 JUMPSTART WOUND DRESSIN,A6206,HCPCS,,79012298,CDM,270,RC,,,both,,,48,35.52,,,35.52,Other,150% of Medicare + 9.63% HCRA Surcharge,21.6,45,,21.6,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,23.76,,,23.76,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,33.6,70,,33.6,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,35.52,
MEDTRONIC IAV07006008P 7X60X80CM IN.PACT,C1725,HCPCS,,78013435,CDM,272,RC,,,both,,,4650,3441.01,,,3441.01,Other,150% of Medicare + 9.63% HCRA Surcharge,2092.5,45,,2092.5,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2301.75,,,2301.75,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,3255,70,,3255,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3441.01,
COOK THSF-38-80-AES AMPLATZ COATD XSTIFF,C1769,HCPCS,,79000034,CDM,272,RC,,,both,,,62,45.88,,,45.88,Other,150% of Medicare + 9.63% HCRA Surcharge,27.9,45,,27.9,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,30.69,,,30.69,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,43.4,70,,43.4,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,45.88,
COOK G03224 INTRODCR PLVW-7.0.38-30-VADS,C1894,HCPCS,,79000046,CDM,272,RC,,,both,,,204,150.96,,,150.96,Other,150% of Medicare + 9.63% HCRA Surcharge,91.8,45,,91.8,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,100.98,,,100.98,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,142.8,70,,142.8,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,150.96,
COOK G02994 INTRODUCER SET PEEL-AWAY 8FR,C1894,HCPCS,,79000047,CDM,272,RC,,,both,,,204,150.96,,,150.96,Other,150% of Medicare + 9.63% HCRA Surcharge,91.8,45,,91.8,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,100.98,,,100.98,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,142.8,70,,142.8,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,150.96,
LUNDERQUIST WIREGUIDE TSMG-35-145-7-LES2,C1769,HCPCS,,79000049,CDM,272,RC,,,both,,,214,158.36,,,158.36,Other,150% of Medicare + 9.63% HCRA Surcharge,96.3,45,,96.3,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,105.93,,,105.93,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,149.8,70,,149.8,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,158.36,
TERUMO GR3508 .035X180CM ANGLD GLIDEWIRE,C1769,HCPCS,,79000054,CDM,272,RC,,,both,,,124,91.76,,,91.76,Other,150% of Medicare + 9.63% HCRA Surcharge,55.8,45,,55.8,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,61.38,,,61.38,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,86.8,70,,86.8,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,91.76,
BOST SCI 17-736 SDS BALLOON 10X4X75,C1725,HCPCS,,79000057,CDM,272,RC,,,both,,,612,452.88,,,452.88,Other,150% of Medicare + 9.63% HCRA Surcharge,275.4,45,,275.4,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,302.94,,,302.94,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,428.4,70,,428.4,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,452.88,
BOST SCI 39171-10047 MUSTANG BALLOON,C1725,HCPCS,,79000061,CDM,272,RC,,,both,,,586,433.64,,,433.64,Other,150% of Medicare + 9.63% HCRA Surcharge,263.7,45,,263.7,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,290.07,,,290.07,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,410.2,70,,410.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,433.64,
BARD DR80104 10X4X80 DORADO BALLOON,C1725,HCPCS,,79000064,CDM,272,RC,,,both,,,616,455.84,,,455.84,Other,150% of Medicare + 9.63% HCRA Surcharge,277.2,45,,277.2,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,304.92,,,304.92,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,431.2,70,,431.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,455.84,
COOK G08956 12FR INTRODUCER SHEATH X30CM,C1894,HCPCS,,79000070,CDM,272,RC,,,both,,,214,158.36,,,158.36,Other,150% of Medicare + 9.63% HCRA Surcharge,96.3,45,,96.3,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,105.93,,,105.93,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,149.8,70,,149.8,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,158.36,
COOK G06492 12FR PEEL-AWAY SHEATH,C1894,HCPCS,,79000071,CDM,272,RC,,,both,,,124,91.76,,,91.76,Other,150% of Medicare + 9.63% HCRA Surcharge,55.8,45,,55.8,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,61.38,,,61.38,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,86.8,70,,86.8,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,91.76,
BOST SCI 39171-12047 MUSTANG BALLOON,C1725,HCPCS,,79000073,CDM,272,RC,,,both,,,586,433.64,,,433.64,Other,150% of Medicare + 9.63% HCRA Surcharge,263.7,45,,263.7,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,290.07,,,290.07,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,410.2,70,,410.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,433.64,
BOST SCI 27-182 REG NEPHROSTOMY CATH,C1729,HCPCS,,79000078,CDM,272,RC,,,both,,,236,174.64,,,174.64,Other,150% of Medicare + 9.63% HCRA Surcharge,106.2,45,,106.2,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,116.82,,,116.82,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,165.2,70,,165.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,174.64,
COOK G06496 14FR PEEL-AWAY SHEATH,C1894,HCPCS,,79000079,CDM,272,RC,,,both,,,124,91.76,,,91.76,Other,150% of Medicare + 9.63% HCRA Surcharge,55.8,45,,55.8,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,61.38,,,61.38,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,86.8,70,,86.8,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,91.76,
COOK G08957 14FRX30CM INTRODUCER SHEATH,C1894,HCPCS,,79000080,CDM,272,RC,,,both,,,183,135.42,,,135.42,Other,150% of Medicare + 9.63% HCRA Surcharge,82.35,45,,82.35,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,90.59,,,90.59,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,128.1,70,,128.1,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,135.42,
COOK G09691 16FR INTRODUCER SHEATH 30CM,C1894,HCPCS,,79000082,CDM,272,RC,,,both,,,358,264.92,,,264.92,Other,150% of Medicare + 9.63% HCRA Surcharge,161.1,45,,161.1,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,177.21,,,177.21,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,250.6,70,,250.6,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,264.92,
COOK G11672 18FR INTRODUCER SHEATH 30CM,C1894,HCPCS,,79000083,CDM,272,RC,,,both,,,358,264.92,,,264.92,Other,150% of Medicare + 9.63% HCRA Surcharge,161.1,45,,161.1,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,177.21,,,177.21,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,250.6,70,,250.6,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,264.92,
BOST SCI 39147-25101 STERLING BALLOON,C1725,HCPCS,,79000084,CDM,272,RC,,,both,,,1110,821.4,,,821.4,Other,150% of Medicare + 9.63% HCRA Surcharge,499.5,45,,499.5,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,549.45,,,549.45,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,777,70,,777,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,821.4,
EV3 AB14W025120150 NANOCROSS BALLOON,C1725,HCPCS,,79000085,CDM,272,RC,,,both,,,1041,770.34,,,770.34,Other,150% of Medicare + 9.63% HCRA Surcharge,468.45,45,,468.45,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,515.3,,,515.3,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,728.7,70,,728.7,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,770.34,
BOST SCI 39185-25121 COYOTE BALLOON,C1725,HCPCS,,79000086,CDM,272,RC,,,both,,,1050,777,,,777,Other,150% of Medicare + 9.63% HCRA Surcharge,472.5,45,,472.5,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,519.75,,,519.75,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,735,70,,735,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,777,
BOST SCI 39185-25221 COYOTE BALLOON,C1725,HCPCS,,79000087,CDM,272,RC,,,both,,,1216,899.84,,,899.84,Other,150% of Medicare + 9.63% HCRA Surcharge,547.2,45,,547.2,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,601.92,,,601.92,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,851.2,70,,851.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,899.84,
BOST SCI 39185-25061 COYOTE BALLOON,C1725,HCPCS,,79000088,CDM,272,RC,,,both,,,960,710.4,,,710.4,Other,150% of Medicare + 9.63% HCRA Surcharge,432,45,,432,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,475.2,,,475.2,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,672,70,,672,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,710.4,
COOK G28999 20FRX25CM INTRODUCER SHEATH,C1894,HCPCS,,79000089,CDM,272,RC,,,both,,,1242,919.08,,,919.08,Other,150% of Medicare + 9.63% HCRA Surcharge,558.9,45,,558.9,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,614.79,,,614.79,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,869.4,70,,869.4,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,919.08,
BOST SCI 39147-20101 STERLING MN BALLOON,C1725,HCPCS,,79000091,CDM,272,RC,,,both,,,1110,821.4,,,821.4,Other,150% of Medicare + 9.63% HCRA Surcharge,499.5,45,,499.5,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,549.45,,,549.45,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,777,70,,777,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,821.4,
BOST SCI 39147-20801 STERLING SL BALLOON,C1725,HCPCS,,79000092,CDM,272,RC,,,both,,,1110,821.4,,,821.4,Other,150% of Medicare + 9.63% HCRA Surcharge,499.5,45,,499.5,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,549.45,,,549.45,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,777,70,,777,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,821.4,
BOST SCI 39147-35801 STERLING SL BALLOON,C1725,HCPCS,,79000093,CDM,272,RC,,,both,,,1110,821.4,,,821.4,Other,150% of Medicare + 9.63% HCRA Surcharge,499.5,45,,499.5,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,549.45,,,549.45,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,777,70,,777,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,821.4,
BOST SCI 39171-03034 MUSTANG BALLOON,C1725,HCPCS,,79000094,CDM,272,RC,,,both,,,586,433.64,,,433.64,Other,150% of Medicare + 9.63% HCRA Surcharge,263.7,45,,263.7,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,290.07,,,290.07,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,410.2,70,,410.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,433.64,
BOST SCI 39147-30101 STERLING SL BALLOON,C1725,HCPCS,,79000095,CDM,272,RC,,,both,,,1110,821.4,,,821.4,Other,150% of Medicare + 9.63% HCRA Surcharge,499.5,45,,499.5,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,549.45,,,549.45,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,777,70,,777,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,821.4,
BOST SCI 39185-30101 COYOTE BALLOON,C1725,HCPCS,,79000096,CDM,272,RC,,,both,,,960,710.4,,,710.4,Other,150% of Medicare + 9.63% HCRA Surcharge,432,45,,432,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,475.2,,,475.2,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,672,70,,672,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,710.4,
EV3 AB14W030120150 NANOCROSS BALLOON,C1725,HCPCS,,79000097,CDM,272,RC,,,both,,,720,532.8,,,532.8,Other,150% of Medicare + 9.63% HCRA Surcharge,324,45,,324,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,356.4,,,356.4,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,504,70,,504,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,532.8,
BOST SCI 39185-30151 COYOTE BALLOON,C1725,HCPCS,,79000098,CDM,272,RC,,,both,,,1050,777,,,777,Other,150% of Medicare + 9.63% HCRA Surcharge,472.5,45,,472.5,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,519.75,,,519.75,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,735,70,,735,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,777,
BOST SCI 39185-30061 COYOTE BALLOON,C1725,HCPCS,,79000099,CDM,272,RC,,,both,,,960,710.4,,,710.4,Other,150% of Medicare + 9.63% HCRA Surcharge,432,45,,432,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,475.2,,,475.2,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,672,70,,672,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,710.4,
ANGIODYNAMICS 6508402 MICRO INTRODUCER,C1894,HCPCS,,79000104,CDM,272,RC,,,both,,,593,438.82,,,438.82,Other,150% of Medicare + 9.63% HCRA Surcharge,266.85,45,,266.85,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,293.54,,,293.54,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,415.1,70,,415.1,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,438.82,
ANGIODYNAMICS H965457501 4FRX10CM MINSTK,C1894,HCPCS,,79000105,CDM,272,RC,,,both,,,98,72.52,,,72.52,Other,150% of Medicare + 9.63% HCRA Surcharge,44.1,45,,44.1,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,48.51,,,48.51,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,68.6,70,,68.6,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,72.52,
ANGIODYNAMICS 45-900 4FR MINSTK KIT,C1894,HCPCS,,79000106,CDM,272,RC,,,both,,,58,42.92,,,42.92,Other,150% of Medicare + 9.63% HCRA Surcharge,26.1,45,,26.1,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,28.71,,,28.71,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,40.6,70,,40.6,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,42.92,
BOST SCI 17-556 SDS BALLOONS ULTRATHIN,C1725,HCPCS,,79000109,CDM,272,RC,,,both,,,612,452.88,,,452.88,Other,150% of Medicare + 9.63% HCRA Surcharge,275.4,45,,275.4,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,302.94,,,302.94,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,428.4,70,,428.4,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,452.88,
BOST SCI 39032-40101 STERLING BALLOON,C1725,HCPCS,,79000110,CDM,272,RC,,,both,,,1110,821.4,,,821.4,Other,150% of Medicare + 9.63% HCRA Surcharge,499.5,45,,499.5,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,549.45,,,549.45,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,777,70,,777,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,821.4,
BOST SCI 39147-40101 STERLING BALLOON,C1725,HCPCS,,79000111,CDM,272,RC,,,both,,,1110,821.4,,,821.4,Other,150% of Medicare + 9.63% HCRA Surcharge,499.5,45,,499.5,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,549.45,,,549.45,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,777,70,,777,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,821.4,
BARD DR135410 4X10X135 DORADO BALLOON,C1725,HCPCS,,79000112,CDM,272,RC,,,both,,,646,478.04,,,478.04,Other,150% of Medicare + 9.63% HCRA Surcharge,290.7,45,,290.7,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,319.77,,,319.77,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,452.2,70,,452.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,478.04,
EV3 AB35W04120135 EVERCROSS BALLOON CATH,C1725,HCPCS,,79000113,CDM,272,RC,,,both,,,515,381.1,,,381.1,Other,150% of Medicare + 9.63% HCRA Surcharge,231.75,45,,231.75,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,254.93,,,254.93,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,360.5,70,,360.5,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,381.1,
BOST SCI 39185-40121 COYOTE BALLOON,C1725,HCPCS,,79000114,CDM,272,RC,,,both,,,1050,777,,,777,Other,150% of Medicare + 9.63% HCRA Surcharge,472.5,45,,472.5,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,519.75,,,519.75,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,735,70,,735,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,777,
BOST SCI 39171-04024 MUSTANG BALLOON,C1725,HCPCS,,79000116,CDM,272,RC,,,both,,,586,433.64,,,433.64,Other,150% of Medicare + 9.63% HCRA Surcharge,263.7,45,,263.7,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,290.07,,,290.07,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,410.2,70,,410.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,433.64,
BOST SCI 39171-04034 MUSTANG BALLOON,C1725,HCPCS,,79000117,CDM,272,RC,,,both,,,586,433.64,,,433.64,Other,150% of Medicare + 9.63% HCRA Surcharge,263.7,45,,263.7,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,290.07,,,290.07,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,410.2,70,,410.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,433.64,
BOST SCI 39171-04041 MUSTANG BALLOON,C1725,HCPCS,,79000118,CDM,272,RC,,,both,,,586,433.64,,,433.64,Other,150% of Medicare + 9.63% HCRA Surcharge,263.7,45,,263.7,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,290.07,,,290.07,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,410.2,70,,410.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,433.64,
BARD DR-4044 4X4X40CM DORADO BALLOON,C1725,HCPCS,,79000119,CDM,272,RC,,,both,,,586,433.64,,,433.64,Other,150% of Medicare + 9.63% HCRA Surcharge,263.7,45,,263.7,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,290.07,,,290.07,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,410.2,70,,410.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,433.64,
BOST SCI 39171-04047 MUSTANG BALLOON,C1725,HCPCS,,79000120,CDM,272,RC,,,both,,,586,433.64,,,433.64,Other,150% of Medicare + 9.63% HCRA Surcharge,263.7,45,,263.7,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,290.07,,,290.07,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,410.2,70,,410.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,433.64,
BOST SCI 39185-40061 COYOTE BALLOON,C1725,HCPCS,,79000121,CDM,272,RC,,,both,,,960,710.4,,,710.4,Other,150% of Medicare + 9.63% HCRA Surcharge,432,45,,432,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,475.2,,,475.2,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,672,70,,672,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,710.4,
BOST SCI 39031-40601 STERLING BALLOON,C1725,HCPCS,,79000122,CDM,272,RC,,,both,,,1110,821.4,,,821.4,Other,150% of Medicare + 9.63% HCRA Surcharge,499.5,45,,499.5,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,549.45,,,549.45,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,777,70,,777,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,821.4,
BOST SCI 39147-40801 STERLING BALLOON,C1725,HCPCS,,79000123,CDM,272,RC,,,both,,,1110,821.4,,,821.4,Other,150% of Medicare + 9.63% HCRA Surcharge,499.5,45,,499.5,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,549.45,,,549.45,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,777,70,,777,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,821.4,
BOST SCI 39171-04087 MUSTANG BALLOON,C1725,HCPCS,,79000124,CDM,272,RC,,,both,,,586,433.64,,,433.64,Other,150% of Medicare + 9.63% HCRA Surcharge,263.7,45,,263.7,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,290.07,,,290.07,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,410.2,70,,410.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,433.64,
NAVILYST 45-994 5FR MICROPUNCTURE SET,C1894,HCPCS,,79000132,CDM,272,RC,,,both,,,97,71.78,,,71.78,Other,150% of Medicare + 9.63% HCRA Surcharge,43.65,45,,43.65,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,48.02,,,48.02,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,67.9,70,,67.9,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,71.78,
TERUMO RSB503 5FR PINNACLE SHEATH 25CM,C1894,HCPCS,,79000136,CDM,272,RC,,,both,,,101,74.74,,,74.74,Other,150% of Medicare + 9.63% HCRA Surcharge,45.45,45,,45.45,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,50,,,50,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,70.7,70,,70.7,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,74.74,
TERUMO 5FR R02 SHEATH 10CM,C1894,HCPCS,,79000137,CDM,272,RC,,,both,,,78,57.72,,,57.72,Other,150% of Medicare + 9.63% HCRA Surcharge,35.1,45,,35.1,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,38.61,,,38.61,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,54.6,70,,54.6,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,57.72,
TERUMO RSB501 5FR PINNACLE SHEATH 6CM,C1894,HCPCS,,79000138,CDM,272,RC,,,both,,,73,54.02,,,54.02,Other,150% of Medicare + 9.63% HCRA Surcharge,32.85,45,,32.85,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,36.14,,,36.14,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,51.1,70,,51.1,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,54.02,
BOST SCI 15-721B 5FR SUPER SHEATH 11CM,C1894,HCPCS,,79000140,CDM,272,RC,,,both,,,66,48.84,,,48.84,Other,150% of Medicare + 9.63% HCRA Surcharge,29.7,45,,29.7,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,32.67,,,32.67,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,46.2,70,,46.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,48.84,
NAVILYST 45-990 5FR VAXCEL MIN-STICK KIT,C1894,HCPCS,,79000141,CDM,272,RC,,,both,,,136,100.64,,,100.64,Other,150% of Medicare + 9.63% HCRA Surcharge,61.2,45,,61.2,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,67.32,,,67.32,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,95.2,70,,95.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,100.64,
TERUMO RSB512 5FRX10CM SHEATH INTRODUCER,C1894,HCPCS,,79000142,CDM,272,RC,,,both,,,9,6.66,,,6.66,Other,150% of Medicare + 9.63% HCRA Surcharge,4.05,45,,4.05,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,4.46,,,4.46,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,6.3,70,,6.3,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,6.66,
COOK G06416 INFUSION CATHETER 5FRX65CM,C1887,HCPCS,,79000144,CDM,272,RC,,,both,,,380,281.2,,,281.2,Other,150% of Medicare + 9.63% HCRA Surcharge,171,45,,171,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,188.1,,,188.1,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,266,70,,266,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,281.2,
COOK G06422 INFUSION CATHETER 5FRX100CM,C1887,HCPCS,,79000146,CDM,272,RC,,,both,,,380,281.2,,,281.2,Other,150% of Medicare + 9.63% HCRA Surcharge,171,45,,171,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,188.1,,,188.1,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,266,70,,266,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,281.2,
BOST SCI 17-586 SDS BALLOON ULTRATHIN,C1725,HCPCS,,79000148,CDM,272,RC,,,both,,,612,452.88,,,452.88,Other,150% of Medicare + 9.63% HCRA Surcharge,275.4,45,,275.4,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,302.94,,,302.94,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,428.4,70,,428.4,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,452.88,
BOST SCI 17-596 SDS BALLOON ULTRATHIN,C1725,HCPCS,,79000149,CDM,272,RC,,,both,,,612,452.88,,,452.88,Other,150% of Medicare + 9.63% HCRA Surcharge,275.4,45,,275.4,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,302.94,,,302.94,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,428.4,70,,428.4,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,452.88,
BOST SCI P510012001 POLAR CATH BALLOON,C1725,HCPCS,,79000150,CDM,272,RC,,,both,,,2160,1598.41,,,1598.41,Other,150% of Medicare + 9.63% HCRA Surcharge,972,45,,972,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1069.2,,,1069.2,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1512,70,,1512,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1598.41,
BARD DR135510 5X100X135 DORADO BALLOON,C1725,HCPCS,,79000151,CDM,272,RC,,,both,,,646,478.04,,,478.04,Other,150% of Medicare + 9.63% HCRA Surcharge,290.7,45,,290.7,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,319.77,,,319.77,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,452.2,70,,452.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,478.04,
BOST SCI 39032-50101 STERLING BALLOON,C1725,HCPCS,,79000152,CDM,272,RC,,,both,,,1110,821.4,,,821.4,Other,150% of Medicare + 9.63% HCRA Surcharge,499.5,45,,499.5,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,549.45,,,549.45,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,777,70,,777,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,821.4,
BOST SCI 39171-05101 MUSTANG BALLOON,C1725,HCPCS,,79000153,CDM,272,RC,,,both,,,586,433.64,,,433.64,Other,150% of Medicare + 9.63% HCRA Surcharge,263.7,45,,263.7,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,290.07,,,290.07,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,410.2,70,,410.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,433.64,
EV3 AB35W05120135 EVERCROSS BALLOON,C1725,HCPCS,,79000154,CDM,272,RC,,,both,,,315,233.1,,,233.1,Other,150% of Medicare + 9.63% HCRA Surcharge,141.75,45,,141.75,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,155.93,,,155.93,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,220.5,70,,220.5,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,233.1,
EV3 AB35W05150135 EVERCROSS BALLOON CATH,C1725,HCPCS,,79000155,CDM,272,RC,,,both,,,420,310.8,,,310.8,Other,150% of Medicare + 9.63% HCRA Surcharge,189,45,,189,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,207.9,,,207.9,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,294,70,,294,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,310.8,
BOST SCI 39171-05151 MUSTANG BALLOON,C1725,HCPCS,,79000156,CDM,272,RC,,,both,,,676,500.24,,,500.24,Other,150% of Medicare + 9.63% HCRA Surcharge,304.2,45,,304.2,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,334.62,,,334.62,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,473.2,70,,473.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,500.24,
BOST SCI 39171-05201 MUSTANG BALLOON,C1725,HCPCS,,79000158,CDM,272,RC,,,both,,,676,500.24,,,500.24,Other,150% of Medicare + 9.63% HCRA Surcharge,304.2,45,,304.2,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,334.62,,,334.62,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,473.2,70,,473.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,500.24,
BOST SCI PCB502090 CUTTING BALLOON,C1725,HCPCS,,79000159,CDM,272,RC,,,both,,,2598,1922.53,,,1922.53,Other,150% of Medicare + 9.63% HCRA Surcharge,1169.1,45,,1169.1,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1286.01,,,1286.01,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1818.6,70,,1818.6,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1922.53,
BOST SCI 39171-05047 MUSTANG BALLOON,C1725,HCPCS,,79000160,CDM,272,RC,,,both,,,586,433.64,,,433.64,Other,150% of Medicare + 9.63% HCRA Surcharge,263.7,45,,263.7,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,290.07,,,290.07,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,410.2,70,,410.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,433.64,
BARD DR8054 5X4X80 DORADO BALLOON,C1725,HCPCS,,79000161,CDM,272,RC,,,both,,,616,455.84,,,455.84,Other,150% of Medicare + 9.63% HCRA Surcharge,277.2,45,,277.2,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,304.92,,,304.92,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,431.2,70,,431.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,455.84,
BARD DR13558 5X8X135 DORADO BALLOON,C1725,HCPCS,,79000163,CDM,272,RC,,,both,,,646,478.04,,,478.04,Other,150% of Medicare + 9.63% HCRA Surcharge,290.7,45,,290.7,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,319.77,,,319.77,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,452.2,70,,452.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,478.04,
BOST SCI 39171-05081 MUSTANG BALLOON,C1725,HCPCS,,79000164,CDM,272,RC,,,both,,,586,433.64,,,433.64,Other,150% of Medicare + 9.63% HCRA Surcharge,263.7,45,,263.7,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,290.07,,,290.07,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,410.2,70,,410.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,433.64,
BOST SCI 39171-05087 MUSTANG BALLOON,C1725,HCPCS,,79000165,CDM,272,RC,,,both,,,586,433.64,,,433.64,Other,150% of Medicare + 9.63% HCRA Surcharge,263.7,45,,263.7,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,290.07,,,290.07,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,410.2,70,,410.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,433.64,
MEDTRONIC GN2501 65CMX25MM SNARE,C1773,HCPCS,,79000166,CDM,272,RC,,,both,,,897,663.78,,,663.78,Other,150% of Medicare + 9.63% HCRA Surcharge,403.65,45,,403.65,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,444.02,,,444.02,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,627.9,70,,627.9,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,663.78,
TERUMO RSR14 6FR DESTINATION LIMA,C1894,HCPCS,,79000168,CDM,272,RC,,,both,,,313,231.62,,,231.62,Other,150% of Medicare + 9.63% HCRA Surcharge,140.85,45,,140.85,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,154.94,,,154.94,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,219.1,70,,219.1,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,231.62,
TERUMO RSR13 6FR DESTINATION RDC,C1894,HCPCS,,79000169,CDM,272,RC,,,both,,,319,236.06,,,236.06,Other,150% of Medicare + 9.63% HCRA Surcharge,143.55,45,,143.55,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,157.91,,,157.91,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,223.3,70,,223.3,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,236.06,
TERUMO RSP01 6FR DESTINATION SHEATH 65CM,C1894,HCPCS,,79000170,CDM,272,RC,,,both,,,348,257.52,,,257.52,Other,150% of Medicare + 9.63% HCRA Surcharge,156.6,45,,156.6,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,172.26,,,172.26,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,243.6,70,,243.6,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,257.52,
TERUMO RSC05 6FR DESTINATION SHEATH 90CM,C1894,HCPCS,,79000171,CDM,272,RC,,,both,,,383,283.42,,,283.42,Other,150% of Medicare + 9.63% HCRA Surcharge,172.35,45,,172.35,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,189.59,,,189.59,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,268.1,70,,268.1,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,283.42,
J&J 6FR EXOSEAL CLOSURE DEVICE,C1760,HCPCS,,79000172,CDM,272,RC,,,both,,,570,421.8,,,421.8,Other,150% of Medicare + 9.63% HCRA Surcharge,256.5,45,,256.5,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,282.15,,,282.15,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,399,70,,399,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,421.8,
TERUMO RSB603 6FRX25CM TERUMO SHEATH R/O,C1894,HCPCS,,79000173,CDM,272,RC,,,both,,,100,74,,,74,Other,150% of Medicare + 9.63% HCRA Surcharge,45,45,,45,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,49.5,,,49.5,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,70,70,,70,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,74,
COOK G11638 6FR RAABE SHEATH 55CM,C1894,HCPCS,,79000174,CDM,272,RC,,,both,,,132,97.68,,,97.68,Other,150% of Medicare + 9.63% HCRA Surcharge,59.4,45,,59.4,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,65.34,,,65.34,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,92.4,70,,92.4,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,97.68,
TERUMO RSB601 6FRX6CM TERUMO SHEATH R/O,C1894,HCPCS,,79000175,CDM,272,RC,,,both,,,73,54.02,,,54.02,Other,150% of Medicare + 9.63% HCRA Surcharge,32.85,45,,32.85,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,36.14,,,36.14,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,51.1,70,,51.1,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,54.02,
CORDIS 6FR VISTA BRITE RDC GUIDE CATH,C1887,HCPCS,,79000177,CDM,272,RC,,,both,,,340,251.6,,,251.6,Other,150% of Medicare + 9.63% HCRA Surcharge,153,45,,153,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,168.3,,,168.3,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,238,70,,238,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,251.6,
TERUMO RSB612 6FRX10CM SHEATH,C1894,HCPCS,,79000178,CDM,272,RC,,,both,,,90,66.6,,,66.6,Other,150% of Medicare + 9.63% HCRA Surcharge,40.5,45,,40.5,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,44.55,,,44.55,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,63,70,,63,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,66.6,
TERUMO RSR01 6FRX45CM DESTINATION SHEATH,C1894,HCPCS,,79000179,CDM,272,RC,,,both,,,313,231.62,,,231.62,Other,150% of Medicare + 9.63% HCRA Surcharge,140.85,45,,140.85,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,154.94,,,154.94,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,219.1,70,,219.1,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,231.62,
BOST SCI 17-616 SDS BALLOONS ULTRATHIN,C1725,HCPCS,,79000180,CDM,272,RC,,,both,,,612,452.88,,,452.88,Other,150% of Medicare + 9.63% HCRA Surcharge,275.4,45,,275.4,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,302.94,,,302.94,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,428.4,70,,428.4,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,452.88,
BOST SCI 17-626 SDS BALLOONS ULTRATHIN,C1725,HCPCS,,79000181,CDM,272,RC,,,both,,,612,452.88,,,452.88,Other,150% of Medicare + 9.63% HCRA Surcharge,275.4,45,,275.4,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,302.94,,,302.94,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,428.4,70,,428.4,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,452.88,
BOST SCI P610012001 6X100X120 POLAR CATH,C1725,HCPCS,,79000182,CDM,272,RC,,,both,,,2160,1598.41,,,1598.41,Other,150% of Medicare + 9.63% HCRA Surcharge,972,45,,972,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1069.2,,,1069.2,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1512,70,,1512,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1598.41,
BOST SCI 39171-06101 MUSTANG BALLOON,C1725,HCPCS,,79000183,CDM,272,RC,,,both,,,586,433.64,,,433.64,Other,150% of Medicare + 9.63% HCRA Surcharge,263.7,45,,263.7,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,290.07,,,290.07,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,410.2,70,,410.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,433.64,
BOST SCI 39032-60101 STERLING BALLOON,C1725,HCPCS,,79000184,CDM,272,RC,,,both,,,1110,821.4,,,821.4,Other,150% of Medicare + 9.63% HCRA Surcharge,499.5,45,,499.5,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,549.45,,,549.45,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,777,70,,777,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,821.4,
EV3 AB35W06120135 EVERCROSS BALLOON,C1725,HCPCS,,79000187,CDM,272,RC,,,both,,,515,381.1,,,381.1,Other,150% of Medicare + 9.63% HCRA Surcharge,231.75,45,,231.75,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,254.93,,,254.93,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,360.5,70,,360.5,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,381.1,
EV3 AB35W06150135 EVERCROSS BALLOON,C1725,HCPCS,,79000189,CDM,272,RC,,,both,,,675,499.5,,,499.5,Other,150% of Medicare + 9.63% HCRA Surcharge,303.75,45,,303.75,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,334.13,,,334.13,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,472.5,70,,472.5,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,499.5,
BOST SCI 39171-06151 MUSTANG BALLOON,C1725,HCPCS,,79000190,CDM,272,RC,,,both,,,676,500.24,,,500.24,Other,150% of Medicare + 9.63% HCRA Surcharge,304.2,45,,304.2,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,334.62,,,334.62,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,473.2,70,,473.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,500.24,
BARD DR135620 6X200X135 DORADO BALLOON,C1725,HCPCS,,79000194,CDM,272,RC,,,both,,,826,611.24,,,611.24,Other,150% of Medicare + 9.63% HCRA Surcharge,371.7,45,,371.7,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,408.87,,,408.87,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,578.2,70,,578.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,611.24,
BOST SCI 39171-06047 MUSTANG BALLOON,C1725,HCPCS,,79000199,CDM,272,RC,,,both,,,586,433.64,,,433.64,Other,150% of Medicare + 9.63% HCRA Surcharge,263.7,45,,263.7,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,290.07,,,290.07,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,410.2,70,,410.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,433.64,
BARD DR13568 6X8X135 DORADO BALLOON,C1725,HCPCS,,79000203,CDM,272,RC,,,both,,,646,478.04,,,478.04,Other,150% of Medicare + 9.63% HCRA Surcharge,290.7,45,,290.7,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,319.77,,,319.77,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,452.2,70,,452.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,478.04,
BARD DR-8068 6X8X80 DORADO BALLOON,C1725,HCPCS,,79000204,CDM,272,RC,,,both,,,616,455.84,,,455.84,Other,150% of Medicare + 9.63% HCRA Surcharge,277.2,45,,277.2,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,304.92,,,304.92,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,431.2,70,,431.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,455.84,
TERUMO RSB702 7FRX10CM BRITE TIP SHEATH,C1894,HCPCS,,79000206,CDM,272,RC,,,both,,,78,57.72,,,57.72,Other,150% of Medicare + 9.63% HCRA Surcharge,35.1,45,,35.1,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,38.61,,,38.61,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,54.6,70,,54.6,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,57.72,
TERUMO RSC06 7FR DESTINATION SHEATH 90CM,C1894,HCPCS,,79000207,CDM,272,RC,,,both,,,383,283.42,,,283.42,Other,150% of Medicare + 9.63% HCRA Surcharge,172.35,45,,172.35,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,189.59,,,189.59,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,268.1,70,,268.1,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,283.42,
TERUMO RSB703 7FRX25CM PINNACLE SHEATH,C1894,HCPCS,,79000208,CDM,272,RC,,,both,,,101,74.74,,,74.74,Other,150% of Medicare + 9.63% HCRA Surcharge,45.45,45,,45.45,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,50,,,50,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,70.7,70,,70.7,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,74.74,
COOK G11633 7FR RAABE SHEATH 55CM,C1894,HCPCS,,79000209,CDM,272,RC,,,both,,,132,97.68,,,97.68,Other,150% of Medicare + 9.63% HCRA Surcharge,59.4,45,,59.4,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,65.34,,,65.34,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,92.4,70,,92.4,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,97.68,
J&J 403-7553R 7FR GUIDING CATH,C1887,HCPCS,,79000210,CDM,272,RC,,,both,,,338,250.12,,,250.12,Other,150% of Medicare + 9.63% HCRA Surcharge,152.1,45,,152.1,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,167.31,,,167.31,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,236.6,70,,236.6,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,250.12,
TERUMO RSB701 7FR SHORT BRITE SHEATH,C1894,HCPCS,,79000211,CDM,272,RC,,,both,,,73,54.02,,,54.02,Other,150% of Medicare + 9.63% HCRA Surcharge,32.85,45,,32.85,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,36.14,,,36.14,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,51.1,70,,51.1,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,54.02,
TERUMO RSR04 7FRX45CM DESTINATION SHEATH,C1894,HCPCS,,79000212,CDM,272,RC,,,both,,,313,231.62,,,231.62,Other,150% of Medicare + 9.63% HCRA Surcharge,140.85,45,,140.85,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,154.94,,,154.94,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,219.1,70,,219.1,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,231.62,
BOST SCI 17-646 7X2X75 BALLOON ULTRATHIN,C1725,HCPCS,,79000213,CDM,272,RC,,,both,,,612,452.88,,,452.88,Other,150% of Medicare + 9.63% HCRA Surcharge,275.4,45,,275.4,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,302.94,,,302.94,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,428.4,70,,428.4,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,452.88,
BOST SCI 17-656 7X4X75 BALLOON ULTRATHIN,C1725,HCPCS,,79000214,CDM,272,RC,,,both,,,612,452.88,,,452.88,Other,150% of Medicare + 9.63% HCRA Surcharge,275.4,45,,275.4,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,302.94,,,302.94,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,428.4,70,,428.4,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,452.88,
EV3 AB35W07120135 EVERCROSS BALLOON,C1725,HCPCS,,79000215,CDM,272,RC,,,both,,,316,233.84,,,233.84,Other,150% of Medicare + 9.63% HCRA Surcharge,142.2,45,,142.2,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,156.42,,,156.42,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,221.2,70,,221.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,233.84,
EV3 AB35W07150135 EVERCROSS BALLOON,C1725,HCPCS,,79000217,CDM,272,RC,,,both,,,675,499.5,,,499.5,Other,150% of Medicare + 9.63% HCRA Surcharge,303.75,45,,303.75,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,334.13,,,334.13,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,472.5,70,,472.5,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,499.5,
BOST SCI 39171-07151 MUSTANG BALLOON,C1725,HCPCS,,79000218,CDM,272,RC,,,both,,,676,500.24,,,500.24,Other,150% of Medicare + 9.63% HCRA Surcharge,304.2,45,,304.2,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,334.62,,,334.62,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,473.2,70,,473.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,500.24,
EV3 AB35W07200135 EVERCROSS BALLOON,C1725,HCPCS,,79000221,CDM,272,RC,,,both,,,675,499.5,,,499.5,Other,150% of Medicare + 9.63% HCRA Surcharge,303.75,45,,303.75,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,334.13,,,334.13,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,472.5,70,,472.5,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,499.5,
BOST SCI 39171-07047 MUSTANG BALLOON,C1725,HCPCS,,79000224,CDM,272,RC,,,both,,,586,433.64,,,433.64,Other,150% of Medicare + 9.63% HCRA Surcharge,263.7,45,,263.7,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,290.07,,,290.07,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,410.2,70,,410.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,433.64,
BARD CQ-5074 7X4X50 CONQUEST BALLOON,C1725,HCPCS,,79000225,CDM,272,RC,,,both,,,766,566.84,,,566.84,Other,150% of Medicare + 9.63% HCRA Surcharge,344.7,45,,344.7,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,379.17,,,379.17,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,536.2,70,,536.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,566.84,
BARD CQ-5054 7X4X50 CONQUEST BALLOON,C1725,HCPCS,,79000226,CDM,272,RC,,,both,,,766,566.84,,,566.84,Other,150% of Medicare + 9.63% HCRA Surcharge,344.7,45,,344.7,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,379.17,,,379.17,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,536.2,70,,536.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,566.84,
BOST SCI 27-192 8FR APD KIT NON TEMPTIP,C1729,HCPCS,,79000234,CDM,272,RC,,,both,,,300,222,,,222,Other,150% of Medicare + 9.63% HCRA Surcharge,135,45,,135,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,148.5,,,148.5,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,210,70,,210,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,222,
BOST SCI 19-826 8FR GUIDE CATH MP 90CM,C1887,HCPCS,,79000235,CDM,272,RC,,,both,,,318,235.32,,,235.32,Other,150% of Medicare + 9.63% HCRA Surcharge,143.1,45,,143.1,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,157.41,,,157.41,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,222.6,70,,222.6,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,235.32,
TERUMO 8FR PINNACLE BRITETIP SHEATH 25CM,C1894,HCPCS,,79000236,CDM,272,RC,,,both,,,100,74,,,74,Other,150% of Medicare + 9.63% HCRA Surcharge,45,45,,45,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,49.5,,,49.5,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,70,70,,70,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,74,
TERUMO 8FR 10CM SHEATH,C1894,HCPCS,,79000237,CDM,272,RC,,,both,,,78,57.72,,,57.72,Other,150% of Medicare + 9.63% HCRA Surcharge,35.1,45,,35.1,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,38.61,,,38.61,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,54.6,70,,54.6,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,57.72,
BOST SCI 17-676 SDS BALLOON ULTRATHIN,C1725,HCPCS,,79000239,CDM,272,RC,,,both,,,612,452.88,,,452.88,Other,150% of Medicare + 9.63% HCRA Surcharge,275.4,45,,275.4,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,302.94,,,302.94,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,428.4,70,,428.4,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,452.88,
BOST SCI 17-686 SDS BALLOON ULTRATHIN,C1725,HCPCS,,79000240,CDM,272,RC,,,both,,,612,452.88,,,452.88,Other,150% of Medicare + 9.63% HCRA Surcharge,275.4,45,,275.4,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,302.94,,,302.94,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,428.4,70,,428.4,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,452.88,
BOST SCI 39171-08047 MUSTANG BALLOON,C1725,HCPCS,,79000246,CDM,272,RC,,,both,,,586,433.64,,,433.64,Other,150% of Medicare + 9.63% HCRA Surcharge,263.7,45,,263.7,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,290.07,,,290.07,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,410.2,70,,410.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,433.64,
BARD DR8084 8X4X75 DORADO BALLOON,C1725,HCPCS,,79000247,CDM,272,RC,,,both,,,616,455.84,,,455.84,Other,150% of Medicare + 9.63% HCRA Surcharge,277.2,45,,277.2,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,304.92,,,304.92,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,431.2,70,,431.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,455.84,
BOST SCI 39171-08067 MUSTANG BALLOON,C1725,HCPCS,,79000248,CDM,272,RC,,,both,,,586,433.64,,,433.64,Other,150% of Medicare + 9.63% HCRA Surcharge,263.7,45,,263.7,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,290.07,,,290.07,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,410.2,70,,410.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,433.64,
BARD CQ-7588 8X8X75 CONQUEST BALLOON,C1725,HCPCS,,79000250,CDM,272,RC,,,both,,,660,488.4,,,488.4,Other,150% of Medicare + 9.63% HCRA Surcharge,297,45,,297,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,326.7,,,326.7,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,462,70,,462,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,488.4,
CARDIO MED CME9 9FR INTRODUCER,C1894,HCPCS,,79000253,CDM,272,RC,,,both,,,96,71.04,,,71.04,Other,150% of Medicare + 9.63% HCRA Surcharge,43.2,45,,43.2,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,47.52,,,47.52,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,67.2,70,,67.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,71.04,
TERUMO 9FR R02 PINNACLE SHEATH 6CM,C1894,HCPCS,,79000254,CDM,272,RC,,,both,,,73,54.02,,,54.02,Other,150% of Medicare + 9.63% HCRA Surcharge,32.85,45,,32.85,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,36.14,,,36.14,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,51.1,70,,51.1,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,54.02,
TERUMO 9FR SHEATH 10CM,C1894,HCPCS,,79000255,CDM,272,RC,,,both,,,78,57.72,,,57.72,Other,150% of Medicare + 9.63% HCRA Surcharge,35.1,45,,35.1,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,38.61,,,38.61,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,54.6,70,,54.6,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,57.72,
BOST SCI 17-711 SDS BALLOONS ULTRATHIN,C1725,HCPCS,,79000256,CDM,272,RC,,,both,,,612,452.88,,,452.88,Other,150% of Medicare + 9.63% HCRA Surcharge,275.4,45,,275.4,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,302.94,,,302.94,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,428.4,70,,428.4,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,452.88,
BOST SCI 39171-09047 MUSTANG BALLOON,C1725,HCPCS,,79000257,CDM,272,RC,,,both,,,586,433.64,,,433.64,Other,150% of Medicare + 9.63% HCRA Surcharge,263.7,45,,263.7,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,290.07,,,290.07,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,410.2,70,,410.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,433.64,
BARD DR8094 9X4X80 DORADO BALLOON,C1725,HCPCS,,79000258,CDM,272,RC,,,both,,,616,455.84,,,455.84,Other,150% of Medicare + 9.63% HCRA Surcharge,277.2,45,,277.2,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,304.92,,,304.92,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,431.2,70,,431.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,455.84,
AMPLATZ SUPER STIFF 75CM,C1769,HCPCS,,79000262,CDM,272,RC,,,both,,,94,69.56,,,69.56,Other,150% of Medicare + 9.63% HCRA Surcharge,42.3,45,,42.3,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,46.53,,,46.53,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,65.8,70,,65.8,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,69.56,
BOST SCI 46-524 .035X145CM AMPLATZ WIRE,C1769,HCPCS,,79000263,CDM,272,RC,,,both,,,499,369.26,,,369.26,Other,150% of Medicare + 9.63% HCRA Surcharge,224.55,45,,224.55,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,247.01,,,247.01,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,349.3,70,,349.3,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,369.26,
COOK THSF35180AESBH AMPLATZ WIRE,C1769,HCPCS,,79000264,CDM,272,RC,,,both,,,101,74.74,,,74.74,Other,150% of Medicare + 9.63% HCRA Surcharge,45.45,45,,45.45,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,50,,,50,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,70.7,70,,70.7,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,74.74,
BOST SCI 46-509 AMPLATZ X-CHANGE,C1769,HCPCS,,79000265,CDM,272,RC,,,both,,,773,572.02,,,572.02,Other,150% of Medicare + 9.63% HCRA Surcharge,347.85,45,,347.85,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,382.64,,,382.64,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,541.1,70,,541.1,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,572.02,
ANGIO SEAL,C1760,HCPCS,,79000266,CDM,272,RC,,,both,,,825,610.5,,,610.5,Other,150% of Medicare + 9.63% HCRA Surcharge,371.25,45,,371.25,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,408.38,,,408.38,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,577.5,70,,577.5,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,610.5,
ANGIOSEAL VIP 6FR,C1760,HCPCS,,79000267,CDM,272,RC,,,both,,,711,526.14,,,526.14,Other,150% of Medicare + 9.63% HCRA Surcharge,319.95,45,,319.95,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,351.95,,,351.95,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,497.7,70,,497.7,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,526.14,
BOST SCI PCB03015140F CUTTING BALLOON,C1725,HCPCS,,79000273,CDM,272,RC,,,both,,,2400,1776.01,,,1776.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1080,45,,1080,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1188,,,1188,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1680,70,,1680,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1776.01,
BOST SCI PCB04015140F CUTTING BALLOON,C1725,HCPCS,,79000274,CDM,272,RC,,,both,,,2400,1776.01,,,1776.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1080,45,,1080,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1188,,,1188,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1680,70,,1680,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1776.01,
BARD AT-75124 ATLAS BALLOON 12X4X75,C1725,HCPCS,,79000275,CDM,272,RC,,,both,,,916,677.84,,,677.84,Other,150% of Medicare + 9.63% HCRA Surcharge,412.2,45,,412.2,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,453.42,,,453.42,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,641.2,70,,641.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,677.84,
BARD AT-75144 ATLAS BALLOON 14X4X75,C1725,HCPCS,,79000276,CDM,272,RC,,,both,,,916,677.84,,,677.84,Other,150% of Medicare + 9.63% HCRA Surcharge,412.2,45,,412.2,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,453.42,,,453.42,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,641.2,70,,641.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,677.84,
BARD DR-8064 BALLOON DORADO 6X4X80,C1725,HCPCS,,79000278,CDM,272,RC,,,both,,,616,455.84,,,455.84,Other,150% of Medicare + 9.63% HCRA Surcharge,277.2,45,,277.2,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,304.92,,,304.92,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,431.2,70,,431.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,455.84,
BARD DR8074 BALLOON DORADO 7X4X80,C1725,HCPCS,,79000279,CDM,272,RC,,,both,,,616,455.84,,,455.84,Other,150% of Medicare + 9.63% HCRA Surcharge,277.2,45,,277.2,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,304.92,,,304.92,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,431.2,70,,431.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,455.84,
BOST SCI 39031-70401 BALLOON STERLING,C1725,HCPCS,,79000280,CDM,272,RC,,,both,,,1110,821.4,,,821.4,Other,150% of Medicare + 9.63% HCRA Surcharge,499.5,45,,499.5,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,549.45,,,549.45,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,777,70,,777,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,821.4,
COOK G01431 .035X180 COOK BENTSON WIRE,C1769,HCPCS,,79000281,CDM,272,RC,,,both,,,85,62.9,,,62.9,Other,150% of Medicare + 9.63% HCRA Surcharge,38.25,45,,38.25,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,42.08,,,42.08,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,59.5,70,,59.5,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,62.9,
BOST SCI BENTSON WIRE .035X180CM,C1769,HCPCS,,79000282,CDM,272,RC,,,both,,,47,34.78,,,34.78,Other,150% of Medicare + 9.63% HCRA Surcharge,21.15,45,,21.15,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,23.27,,,23.27,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,32.9,70,,32.9,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,34.78,
BOST SCI 28-260 BILIARY CATH 8FR FLEXIMA,C1729,HCPCS,,79000284,CDM,272,RC,,,both,,,330,244.2,,,244.2,Other,150% of Medicare + 9.63% HCRA Surcharge,148.5,45,,148.5,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,163.35,,,163.35,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,231,70,,231,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,244.2,
BOST SCI 39031-35201 STERLING BALLOON,C1725,HCPCS,,79000288,CDM,272,RC,,,both,,,1110,821.4,,,821.4,Other,150% of Medicare + 9.63% HCRA Surcharge,499.5,45,,499.5,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,549.45,,,549.45,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,777,70,,777,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,821.4,
BOST SCI T30601500 CATH POLAR 3X60X150,C1725,HCPCS,,79000290,CDM,272,RC,,,both,,,2400,1776.01,,,1776.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1080,45,,1080,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1188,,,1188,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1680,70,,1680,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1776.01,
BOST SCI P48012001 CATH POLAR 4X80X120,C1725,HCPCS,,79000291,CDM,272,RC,,,both,,,2266,1676.85,,,1676.85,Other,150% of Medicare + 9.63% HCRA Surcharge,1019.7,45,,1019.7,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1121.67,,,1121.67,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1586.2,70,,1586.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1676.85,
CATHETER 6FR IM VISTA BRITE GUIDE,C1887,HCPCS,,79000294,CDM,272,RC,,,both,,,366,270.84,,,270.84,Other,150% of Medicare + 9.63% HCRA Surcharge,164.7,45,,164.7,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,181.17,,,181.17,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,256.2,70,,256.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,270.84,
J&J G780IMD 7FRX55CM IM GUIDE CATH,C1887,HCPCS,,79000295,CDM,272,RC,,,both,,,539,398.86,,,398.86,Other,150% of Medicare + 9.63% HCRA Surcharge,242.55,45,,242.55,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,266.81,,,266.81,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,377.3,70,,377.3,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,398.86,
J&J 4224020X PTA CATH BALLOON 4MMX2CM,C1725,HCPCS,,79000297,CDM,272,RC,,,both,,,953,705.22,,,705.22,Other,150% of Medicare + 9.63% HCRA Surcharge,428.85,45,,428.85,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,471.74,,,471.74,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,667.1,70,,667.1,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,705.22,
BOST SCI P66012001 POLAR CATH 6X6X120MM,C1725,HCPCS,,79000298,CDM,272,RC,,,both,,,1800,1332,,,1332,Other,150% of Medicare + 9.63% HCRA Surcharge,810,45,,810,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,891,,,891,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1260,70,,1260,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1332,
BOST SCI 28-129 CATHETER DRAINAGE 8FR,C1729,HCPCS,,79000299,CDM,272,RC,,,both,,,300,222,,,222,Other,150% of Medicare + 9.63% HCRA Surcharge,135,45,,135,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,148.5,,,148.5,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,210,70,,210,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,222,
BOST SCI 27-165 CATH FLEXIMA BILIARY 8FR,C1729,HCPCS,,79000300,CDM,272,RC,,,both,,,534,395.16,,,395.16,Other,150% of Medicare + 9.63% HCRA Surcharge,240.3,45,,240.3,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,264.33,,,264.33,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,373.8,70,,373.8,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,395.16,
BOST SCI 28-179 CATH NEPHRO 8FR FLEXIMA,C1729,HCPCS,,79000301,CDM,272,RC,,,both,,,259,191.66,,,191.66,Other,150% of Medicare + 9.63% HCRA Surcharge,116.55,45,,116.55,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,128.21,,,128.21,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,181.3,70,,181.3,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,191.66,
BOST SCI 17-603 CATH SDS BALLOON 5.3FRX5,C1725,HCPCS,,79000302,CDM,272,RC,,,both,,,612,452.88,,,452.88,Other,150% of Medicare + 9.63% HCRA Surcharge,275.4,45,,275.4,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,302.94,,,302.94,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,428.4,70,,428.4,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,452.88,
BOST SCI 17-633 CATH SDS BALLOON 5.3FRX6,C1725,HCPCS,,79000303,CDM,272,RC,,,both,,,612,452.88,,,452.88,Other,150% of Medicare + 9.63% HCRA Surcharge,275.4,45,,275.4,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,302.94,,,302.94,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,428.4,70,,428.4,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,452.88,
J&J 403-7553H 7FRX55CM GUIDE CATHETER,C1887,HCPCS,,79000305,CDM,272,RC,,,both,,,335,247.9,,,247.9,Other,150% of Medicare + 9.63% HCRA Surcharge,150.75,45,,150.75,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,165.83,,,165.83,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,234.5,70,,234.5,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,247.9,
J&J 403-7553A 7FRX55CM IM GUIDE CATHETER,C1887,HCPCS,,79000306,CDM,272,RC,,,both,,,335,247.9,,,247.9,Other,150% of Medicare + 9.63% HCRA Surcharge,150.75,45,,150.75,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,165.83,,,165.83,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,234.5,70,,234.5,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,247.9,
BARD CQ-75104 CONQUEST BALLOON 10X4X75CM,C1725,HCPCS,,79000311,CDM,272,RC,,,both,,,764,565.36,,,565.36,Other,150% of Medicare + 9.63% HCRA Surcharge,343.8,45,,343.8,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,378.18,,,378.18,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,534.8,70,,534.8,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,565.36,
BARD CQ-7564 CONQUEST BALLOON 6X4X75CM,C1725,HCPCS,,79000312,CDM,272,RC,,,both,,,660,488.4,,,488.4,Other,150% of Medicare + 9.63% HCRA Surcharge,297,45,,297,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,326.7,,,326.7,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,462,70,,462,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,488.4,
BARD CQ-7574 CONQUEST 7X4X75CM BALLOON,C1725,HCPCS,,79000313,CDM,272,RC,,,both,,,660,488.4,,,488.4,Other,150% of Medicare + 9.63% HCRA Surcharge,297,45,,297,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,326.7,,,326.7,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,462,70,,462,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,488.4,
BARD CQ-7584 CONQUEST 8X4X75CM BALLOON,C1725,HCPCS,,79000314,CDM,272,RC,,,both,,,660,488.4,,,488.4,Other,150% of Medicare + 9.63% HCRA Surcharge,297,45,,297,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,326.7,,,326.7,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,462,70,,462,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,488.4,
BARD CQ-5062 CONQUEST BALLOON 6X2X50,C1725,HCPCS,,79000315,CDM,272,RC,,,both,,,810,599.4,,,599.4,Other,150% of Medicare + 9.63% HCRA Surcharge,364.5,45,,364.5,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,400.95,,,400.95,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,567,70,,567,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,599.4,
BARD CQ-7568 CONQUEST BALLOON 6X8X75,C1725,HCPCS,,79000316,CDM,272,RC,,,both,,,988,731.12,,,731.12,Other,150% of Medicare + 9.63% HCRA Surcharge,444.6,45,,444.6,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,489.06,,,489.06,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,691.6,70,,691.6,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,731.12,
BARD CQ-7578 CONQUEST BALLOON 7X8X75,C1725,HCPCS,,79000317,CDM,272,RC,,,both,,,930,688.2,,,688.2,Other,150% of Medicare + 9.63% HCRA Surcharge,418.5,45,,418.5,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,460.35,,,460.35,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,651,70,,651,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,688.2,
BARD CQ-5072 CONQUEST BALLOON 7X2X50,C1725,HCPCS,,79000318,CDM,272,RC,,,both,,,660,488.4,,,488.4,Other,150% of Medicare + 9.63% HCRA Surcharge,297,45,,297,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,326.7,,,326.7,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,462,70,,462,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,488.4,
BARD CQ-5084 CONQUEST BALLOON 8X4X50,C1725,HCPCS,,79000319,CDM,272,RC,,,both,,,810,599.4,,,599.4,Other,150% of Medicare + 9.63% HCRA Surcharge,364.5,45,,364.5,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,400.95,,,400.95,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,567,70,,567,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,599.4,
BARD CQ-5064 CONQUEST PTA BALLOON 6X4,C1725,HCPCS,,79000320,CDM,272,RC,,,both,,,766,566.84,,,566.84,Other,150% of Medicare + 9.63% HCRA Surcharge,344.7,45,,344.7,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,379.17,,,379.17,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,536.2,70,,536.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,566.84,
BARD CQ-5083 CONQUEST PTA BALLOON 8X3,C1725,HCPCS,,79000321,CDM,272,RC,,,both,,,810,599.4,,,599.4,Other,150% of Medicare + 9.63% HCRA Surcharge,364.5,45,,364.5,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,400.95,,,400.95,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,567,70,,567,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,599.4,
BOST SCI 46-848 CONTROL WIRE 110CM V18,C1769,HCPCS,,79000322,CDM,272,RC,,,both,,,251,185.74,,,185.74,Other,150% of Medicare + 9.63% HCRA Surcharge,112.95,45,,112.95,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,124.25,,,124.25,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,175.7,70,,175.7,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,185.74,
CSI PRD-SC30-150 CSI ATHERECTOMY DEV 1.5,C1724,HCPCS,,79000326,CDM,272,RC,,,both,,,10186,7537.67,,,7537.67,Other,150% of Medicare + 9.63% HCRA Surcharge,4583.7,45,,4583.7,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,5042.07,,,5042.07,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,7130.2,70,,7130.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,7537.67,
CSI DBE-150 CSI ATHERECTOMY DEVICE 1.5,C1724,HCPCS,,79000327,CDM,272,RC,,,both,,,10186,7537.67,,,7537.67,Other,150% of Medicare + 9.63% HCRA Surcharge,4583.7,45,,4583.7,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,5042.07,,,5042.07,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,7130.2,70,,7130.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,7537.67,
CSI PRD-SC30-200 CSI ATHERECTOMY DEV 2MM,C1724,HCPCS,,79000328,CDM,272,RC,,,both,,,10186,7537.67,,,7537.67,Other,150% of Medicare + 9.63% HCRA Surcharge,4583.7,45,,4583.7,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,5042.07,,,5042.07,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,7130.2,70,,7130.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,7537.67,
BOST SCI PCB5020135 5X2X135 CTNG BALLOON,C1725,HCPCS,,79000329,CDM,272,RC,,,both,,,2400,1776.01,,,1776.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1080,45,,1080,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1188,,,1188,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1680,70,,1680,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1776.01,
BOST SCI PCB702090 7X2X90 CTNG BALLOON,C1725,HCPCS,,79000330,CDM,272,RC,,,both,,,2400,1776.01,,,1776.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1080,45,,1080,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1188,,,1188,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1680,70,,1680,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1776.01,
BOST SCI PCB802090 8X2X90 CTNG BALLOON,C1725,HCPCS,,79000332,CDM,272,RC,,,both,,,2400,1776.01,,,1776.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1080,45,,1080,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1188,,,1188,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1680,70,,1680,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1776.01,
BARD DR8044 DORADO BALLOON 4X4X80,C1725,HCPCS,,79000345,CDM,272,RC,,,both,,,616,455.84,,,455.84,Other,150% of Medicare + 9.63% HCRA Surcharge,277.2,45,,277.2,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,304.92,,,304.92,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,431.2,70,,431.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,455.84,
BARD DR135515 DORADO BALLOON 5X15X135,C1725,HCPCS,,79000346,CDM,272,RC,,,both,,,1110,821.4,,,821.4,Other,150% of Medicare + 9.63% HCRA Surcharge,499.5,45,,499.5,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,549.45,,,549.45,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,777,70,,777,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,821.4,
BARD DR135610 DORADO BALLOON 6X10X135,C1725,HCPCS,,79000347,CDM,272,RC,,,both,,,646,478.04,,,478.04,Other,150% of Medicare + 9.63% HCRA Surcharge,290.7,45,,290.7,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,319.77,,,319.77,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,452.2,70,,452.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,478.04,
BARD DR135615 DORADO BALLOON 6X15C135,C1725,HCPCS,,79000348,CDM,272,RC,,,both,,,1110,821.4,,,821.4,Other,150% of Medicare + 9.63% HCRA Surcharge,499.5,45,,499.5,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,549.45,,,549.45,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,777,70,,777,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,821.4,
EV3 AB35W06200135 EVERCROSS BALLOON,C1725,HCPCS,,79000350,CDM,272,RC,,,both,,,675,499.5,,,499.5,Other,150% of Medicare + 9.63% HCRA Surcharge,303.75,45,,303.75,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,334.13,,,334.13,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,472.5,70,,472.5,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,499.5,
COOK G13287 FILTER RETRIEVAL SET,C1773,HCPCS,,79000359,CDM,272,RC,,,both,,,750,555,,,555,Other,150% of Medicare + 9.63% HCRA Surcharge,337.5,45,,337.5,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,371.25,,,371.25,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,525,70,,525,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,555,
BOST SCI 28-180 FLEXIMA 10FR,C1729,HCPCS,,79000361,CDM,272,RC,,,both,,,259,191.66,,,191.66,Other,150% of Medicare + 9.63% HCRA Surcharge,116.55,45,,116.55,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,128.21,,,128.21,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,181.3,70,,181.3,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,191.66,
BOST SCI 27-180 10FRX25CM NEPHRO CATH,C1729,HCPCS,,79000362,CDM,272,RC,,,both,,,236,174.64,,,174.64,Other,150% of Medicare + 9.63% HCRA Surcharge,106.2,45,,106.2,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,116.82,,,116.82,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,165.2,70,,165.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,174.64,
BOST SCI 27-135 10FRX25CM FLEXIMA,C1729,HCPCS,,79000363,CDM,272,RC,,,both,,,236,174.64,,,174.64,Other,150% of Medicare + 9.63% HCRA Surcharge,106.2,45,,106.2,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,116.82,,,116.82,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,165.2,70,,165.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,174.64,
BOST SCI 27-134 8FRX25CM FLEXIMA,C1729,HCPCS,,79000364,CDM,272,RC,,,both,,,236,174.64,,,174.64,Other,150% of Medicare + 9.63% HCRA Surcharge,106.2,45,,106.2,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,116.82,,,116.82,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,165.2,70,,165.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,174.64,
COOK G44154 FLEXOR CHECK-FLO CATH 6FRX45,C1894,HCPCS,,79000365,CDM,272,RC,,,both,,,151,111.74,,,111.74,Other,150% of Medicare + 9.63% HCRA Surcharge,67.95,45,,67.95,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,74.75,,,74.75,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,105.7,70,,105.7,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,111.74,
STRYKER G11636 FLEXOR SHEATH 70CMX6FR,C1894,HCPCS,,79000366,CDM,272,RC,,,both,,,167,123.58,,,123.58,Other,150% of Medicare + 9.63% HCRA Surcharge,75.15,45,,75.15,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,82.67,,,82.67,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,116.9,70,,116.9,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,123.58,
EDWARDS 12TLW403F FOGARTY 3FR X 40CM,C1757,HCPCS,,79000370,CDM,272,RC,,,both,,,253,187.22,,,187.22,Other,150% of Medicare + 9.63% HCRA Surcharge,113.85,45,,113.85,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,125.24,,,125.24,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,177.1,70,,177.1,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,187.22,
EDWARDS 12TLW803F FOGARTY 3FR X 80CM,C1757,HCPCS,,79000371,CDM,272,RC,,,both,,,253,187.22,,,187.22,Other,150% of Medicare + 9.63% HCRA Surcharge,113.85,45,,113.85,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,125.24,,,125.24,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,177.1,70,,177.1,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,187.22,
EDWARDS 12TLW404F FOGARTY 4FR X 40CM,C1757,HCPCS,,79000372,CDM,272,RC,,,both,,,253,187.22,,,187.22,Other,150% of Medicare + 9.63% HCRA Surcharge,113.85,45,,113.85,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,125.24,,,125.24,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,177.1,70,,177.1,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,187.22,
EDWARDS 12TLW405F35 FOGARTY 5.5FRX40CM,C1757,HCPCS,,79000373,CDM,272,RC,,,both,,,271,200.54,,,200.54,Other,150% of Medicare + 9.63% HCRA Surcharge,121.95,45,,121.95,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,134.15,,,134.15,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,189.7,70,,189.7,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,200.54,
EDWARDS 12TLW805F35 FOGARTY 80CM BALLOON,C1757,HCPCS,,79000374,CDM,272,RC,,,both,,,260,192.4,,,192.4,Other,150% of Medicare + 9.63% HCRA Surcharge,117,45,,117,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,128.7,,,128.7,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,182,70,,182,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,192.4,
J&J MGC3990 FRONTRUNNER CATHETER 90CM,C1887,HCPCS,,79000375,CDM,272,RC,,,both,,,750,555,,,555,Other,150% of Medicare + 9.63% HCRA Surcharge,337.5,45,,337.5,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,371.25,,,371.25,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,525,70,,525,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,555,
J&J FBS3990 FRONTRUNNER XP CTO CATH 90CM,C1887,HCPCS,,79000376,CDM,272,RC,,,both,,,3136,2320.65,,,2320.65,Other,150% of Medicare + 9.63% HCRA Surcharge,1411.2,45,,1411.2,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1552.32,,,1552.32,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2195.2,70,,2195.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2320.65,
TERUMO GS3508 .035X180CM ANGLED GLIDE,C1769,HCPCS,,79000380,CDM,272,RC,,,both,,,145,107.3,,,107.3,Other,150% of Medicare + 9.63% HCRA Surcharge,65.25,45,,65.25,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,71.78,,,71.78,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,101.5,70,,101.5,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,107.3,
TERUMO GR3501 GLIDE WIRE STRAIGHT,C1769,HCPCS,,79000381,CDM,272,RC,,,both,,,460,340.4,,,340.4,Other,150% of Medicare + 9.63% HCRA Surcharge,207,45,,207,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,227.7,,,227.7,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,322,70,,322,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,340.4,
GLIDEWIRE STIFF STRAIGHT .035X180,C1769,HCPCS,,79000385,CDM,272,RC,,,both,,,145,107.3,,,107.3,Other,150% of Medicare + 9.63% HCRA Surcharge,65.25,45,,65.25,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,71.78,,,71.78,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,101.5,70,,101.5,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,107.3,
GOOSE NECK SNAR 15MM LOOP 120CM,C1773,HCPCS,,79000386,CDM,272,RC,,,both,,,810,599.4,,,599.4,Other,150% of Medicare + 9.63% HCRA Surcharge,364.5,45,,364.5,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,400.95,,,400.95,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,567,70,,567,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,599.4,
GOOSENECK SNARE 25MM LOOP 120CM,C1773,HCPCS,,79000387,CDM,272,RC,,,both,,,960,710.4,,,710.4,Other,150% of Medicare + 9.63% HCRA Surcharge,432,45,,432,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,475.2,,,475.2,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,672,70,,672,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,710.4,
COOK G09508 GRAD WIRES,C1769,HCPCS,,79000388,CDM,272,RC,,,both,,,234,173.16,,,173.16,Other,150% of Medicare + 9.63% HCRA Surcharge,105.3,45,,105.3,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,115.83,,,115.83,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,163.8,70,,163.8,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,173.16,
TERUMO GRJ509 GUIDE WIRE,C1769,HCPCS,,79000389,CDM,272,RC,,,both,,,154,113.96,,,113.96,Other,150% of Medicare + 9.63% HCRA Surcharge,69.3,45,,69.3,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,76.23,,,76.23,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,107.8,70,,107.8,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,113.96,
COOK G03290 GUIDEWIRE AMPLATZ XTRA STIFF,C1769,HCPCS,,79000390,CDM,272,RC,,,both,,,108,79.92,,,79.92,Other,150% of Medicare + 9.63% HCRA Surcharge,48.6,45,,48.6,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,53.46,,,53.46,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,75.6,70,,75.6,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,79.92,
COOK G04048 .035X80CM AMPLATZ WIRE COOK,C1769,HCPCS,,79000391,CDM,272,RC,,,both,,,62,45.88,,,45.88,Other,150% of Medicare + 9.63% HCRA Surcharge,27.9,45,,27.9,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,30.69,,,30.69,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,43.4,70,,43.4,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,45.88,
COOK G09956 GUIDEWIRE AMPLATZ STIFF,C1769,HCPCS,,79000392,CDM,272,RC,,,both,,,112,82.88,,,82.88,Other,150% of Medicare + 9.63% HCRA Surcharge,50.4,45,,50.4,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,55.44,,,55.44,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,78.4,70,,78.4,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,82.88,
COOK G03562 .035X260CM AMPLATZ XTRA STFF,C1769,HCPCS,,79000393,CDM,272,RC,,,both,,,77,56.98,,,56.98,Other,150% of Medicare + 9.63% HCRA Surcharge,34.65,45,,34.65,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,38.12,,,38.12,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,53.9,70,,53.9,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,56.98,
BOST SCI 46-852 GUIDEWIRE V-18 .018X200,C1769,HCPCS,,79000394,CDM,272,RC,,,both,,,264,195.36,,,195.36,Other,150% of Medicare + 9.63% HCRA Surcharge,118.8,45,,118.8,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,130.68,,,130.68,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,184.8,70,,184.8,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,195.36,
GUIDEWIRE VASC .018X260 LG TAPER 8CMTIP,C1769,HCPCS,,79000395,CDM,272,RC,,,both,,,275,203.5,,,203.5,Other,150% of Medicare + 9.63% HCRA Surcharge,123.75,45,,123.75,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,136.13,,,136.13,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,192.5,70,,192.5,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,203.5,
GUIDEWIRE XS .014 X 180CM,C1769,HCPCS,,79000396,CDM,272,RC,,,both,,,538,398.12,,,398.12,Other,150% of Medicare + 9.63% HCRA Surcharge,242.1,45,,242.1,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,266.31,,,266.31,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,376.6,70,,376.6,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,398.12,
H20 WIRES .018 X 260CM,C1769,HCPCS,,79000397,CDM,272,RC,,,both,,,150,111,,,111,Other,150% of Medicare + 9.63% HCRA Surcharge,67.5,45,,67.5,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,74.25,,,74.25,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,105,70,,105,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,111,
COOK G02947 INTRODUCER PEEL-AWAY,C1894,HCPCS,,79000400,CDM,272,RC,,,both,,,188,139.12,,,139.12,Other,150% of Medicare + 9.63% HCRA Surcharge,84.6,45,,84.6,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,93.06,,,93.06,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,131.6,70,,131.6,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,139.12,
INTRODUCER SET PEEL-AWAY 8FR,C1894,HCPCS,,79000401,CDM,272,RC,,,both,,,204,150.96,,,150.96,Other,150% of Medicare + 9.63% HCRA Surcharge,91.8,45,,91.8,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,100.98,,,100.98,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,142.8,70,,142.8,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,150.96,
BOST SCI 39-128 JOURNEY WIRE .014X300CM,C1769,HCPCS,,79000404,CDM,272,RC,,,both,,,614,454.36,,,454.36,Other,150% of Medicare + 9.63% HCRA Surcharge,276.3,45,,276.3,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,303.93,,,303.93,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,429.8,70,,429.8,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,454.36,
BOST SCI 19-762 LIMA MACH1 GUIDECATH 7FR,C1887,HCPCS,,79000414,CDM,272,RC,,,both,,,318,235.32,,,235.32,Other,150% of Medicare + 9.63% HCRA Surcharge,143.1,45,,143.1,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,157.41,,,157.41,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,222.6,70,,222.6,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,235.32,
EV3 TH-LS-M TURBOHAWK LS-M,C1714,HCPCS,,79000415,CDM,272,RC,,,both,,,8386,6205.66,,,6205.66,Other,150% of Medicare + 9.63% HCRA Surcharge,3773.7,45,,3773.7,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,4151.07,,,4151.07,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,5870.2,70,,5870.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,6205.66,
COOK G11953 LUNDERQUIST WIRE GUIDE,C1769,HCPCS,,79000416,CDM,272,RC,,,both,,,214,158.36,,,158.36,Other,150% of Medicare + 9.63% HCRA Surcharge,96.3,45,,96.3,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,105.93,,,105.93,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,149.8,70,,149.8,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,158.36,
COOK G31453 LUNDERQUIST X-STIFF .035X260,C1769,HCPCS,,79000417,CDM,272,RC,,,both,,,309,228.66,,,228.66,Other,150% of Medicare + 9.63% HCRA Surcharge,139.05,45,,139.05,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,152.96,,,152.96,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,216.3,70,,216.3,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,228.66,
COOK G46729 LUNDERQUIST X-STIFF .035X180,C1769,HCPCS,,79000418,CDM,272,RC,,,both,,,204,150.96,,,150.96,Other,150% of Medicare + 9.63% HCRA Surcharge,91.8,45,,91.8,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,100.98,,,100.98,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,142.8,70,,142.8,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,150.96,
BOST SCI 46-592 MAGIC TORQUE 3.5X260CM,C1769,HCPCS,,79000419,CDM,272,RC,,,both,,,522,386.28,,,386.28,Other,150% of Medicare + 9.63% HCRA Surcharge,234.9,45,,234.9,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,258.39,,,258.39,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,365.4,70,,365.4,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,386.28,
COOK G05183 MANDRIL WIRE,C1769,HCPCS,,79000420,CDM,272,RC,,,both,,,70,51.8,,,51.8,Other,150% of Medicare + 9.63% HCRA Surcharge,31.5,45,,31.5,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,34.65,,,34.65,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,49,70,,49,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,51.8,
J&J 417-2540S MAXI LD BALLOON CATH 25X4,C1725,HCPCS,,79000421,CDM,272,RC,,,both,,,1576,1166.24,,,1166.24,Other,150% of Medicare + 9.63% HCRA Surcharge,709.2,45,,709.2,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,780.12,,,780.12,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1103.2,70,,1103.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1166.24,
TERUMO RSC07 MPA GUIDE CATH DEST 6FR,C1887,HCPCS,,79000424,CDM,272,RC,,,both,,,383,283.42,,,283.42,Other,150% of Medicare + 9.63% HCRA Surcharge,172.35,45,,172.35,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,189.59,,,189.59,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,268.1,70,,268.1,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,283.42,
BOST SCI H74939171050810 MUSTANG BALLOON,C1725,HCPCS,,79000425,CDM,272,RC,,,both,,,586,433.64,,,433.64,Other,150% of Medicare + 9.63% HCRA Surcharge,263.7,45,,263.7,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,290.07,,,290.07,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,410.2,70,,410.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,433.64,
BOST SCI H74939171080470 MUSTANG BALLOON,C1725,HCPCS,,79000426,CDM,272,RC,,,both,,,586,433.64,,,433.64,Other,150% of Medicare + 9.63% HCRA Surcharge,263.7,45,,263.7,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,290.07,,,290.07,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,410.2,70,,410.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,433.64,
ACCESS MX5021 MYNX CLOSURE DEVICE 5FR,C1760,HCPCS,,79000427,CDM,272,RC,,,both,,,672,497.28,,,497.28,Other,150% of Medicare + 9.63% HCRA Surcharge,302.4,45,,302.4,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,332.64,,,332.64,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,470.4,70,,470.4,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,497.28,
ACCESS MX6721 MYNX CLOSURE DEVICE 6FR,C1760,HCPCS,,79000428,CDM,272,RC,,,both,,,672,497.28,,,497.28,Other,150% of Medicare + 9.63% HCRA Surcharge,302.4,45,,302.4,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,332.64,,,332.64,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,470.4,70,,470.4,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,497.28,
EV3 AB14W035120150 NANOCROSS 3.5X120X150,C1725,HCPCS,,79000429,CDM,272,RC,,,both,,,1041,770.34,,,770.34,Other,150% of Medicare + 9.63% HCRA Surcharge,468.45,45,,468.45,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,515.3,,,515.3,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,728.7,70,,728.7,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,770.34,
BOST SCI 27-181 12FRX25CM NEPHRO CATH,C1729,HCPCS,,79000430,CDM,272,RC,,,both,,,236,174.64,,,174.64,Other,150% of Medicare + 9.63% HCRA Surcharge,106.2,45,,106.2,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,116.82,,,116.82,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,165.2,70,,165.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,174.64,
ACCESS N181804 NITREX WIRE .018X180CM,C1769,HCPCS,,79000434,CDM,272,RC,,,both,,,229,169.46,,,169.46,Other,150% of Medicare + 9.63% HCRA Surcharge,103.05,45,,103.05,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,113.36,,,113.36,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,160.3,70,,160.3,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,169.46,
NITREX WIRE .018X80CM,C1769,HCPCS,,79000435,CDM,272,RC,,,both,,,525,388.5,,,388.5,Other,150% of Medicare + 9.63% HCRA Surcharge,236.25,45,,236.25,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,259.88,,,259.88,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,367.5,70,,367.5,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,388.5,
J&J OTB42120 OUTBACK RE-ENTRY CATH 120CM,C1887,HCPCS,,79000441,CDM,272,RC,,,both,,,6894,5101.58,,,5101.58,Other,150% of Medicare + 9.63% HCRA Surcharge,3102.3,45,,3102.3,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,3412.53,,,3412.53,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,4825.8,70,,4825.8,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5101.58,
NAVILYST 45-989 PEELABLE 4FR MINI-STICK,C1894,HCPCS,,79000443,CDM,272,RC,,,both,,,166,122.84,,,122.84,Other,150% of Medicare + 9.63% HCRA Surcharge,74.7,45,,74.7,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,82.17,,,82.17,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,116.2,70,,116.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,122.84,
TERUMO RSP02 PINNACLE GUIDE SHEATH 7FX65,C1887,HCPCS,,79000447,CDM,272,RC,,,both,,,348,257.52,,,257.52,Other,150% of Medicare + 9.63% HCRA Surcharge,156.6,45,,156.6,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,172.26,,,172.26,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,243.6,70,,243.6,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,257.52,
PLATINUM PLUS .014 300CM,C1769,HCPCS,,79000448,CDM,272,RC,,,both,,,320,236.8,,,236.8,Other,150% of Medicare + 9.63% HCRA Surcharge,144,45,,144,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,158.4,,,158.4,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,224,70,,224,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,236.8,
PLATINUM PLUS .018x180CM,C1769,HCPCS,,79000449,CDM,272,RC,,,both,,,233,172.42,,,172.42,Other,150% of Medicare + 9.63% HCRA Surcharge,104.85,45,,104.85,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,115.34,,,115.34,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,163.1,70,,163.1,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,172.42,
PLATINUM PLUS GUIDE WIRE .014X180CM,C1769,HCPCS,,79000450,CDM,272,RC,,,both,,,310,229.4,,,229.4,Other,150% of Medicare + 9.63% HCRA Surcharge,139.5,45,,139.5,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,153.45,,,153.45,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,217,70,,217,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,229.4,
BOST SCI P58012001 POLAR CATH PERIPHERAL,C1725,HCPCS,,79000453,CDM,272,RC,,,both,,,2160,1598.41,,,1598.41,Other,150% of Medicare + 9.63% HCRA Surcharge,972,45,,972,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1069.2,,,1069.2,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1512,70,,1512,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1598.41,
BOST SCI T3510013501 POLAR CATHETER,C1725,HCPCS,,79000454,CDM,272,RC,,,both,,,2776,2054.25,,,2054.25,Other,150% of Medicare + 9.63% HCRA Surcharge,1249.2,45,,1249.2,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1374.12,,,1374.12,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1943.2,70,,1943.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2054.25,
POLAR CATHETER 4X60X120,C1725,HCPCS,,79000455,CDM,272,RC,,,both,,,1860,1376.4,,,1376.4,Other,150% of Medicare + 9.63% HCRA Surcharge,837,45,,837,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,920.7,,,920.7,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1302,70,,1302,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1376.4,
MEDTRONIC REL46 RELIANT BALLOON,C1725,HCPCS,,79000477,CDM,272,RC,,,both,,,1336,988.64,,,988.64,Other,150% of Medicare + 9.63% HCRA Surcharge,601.2,45,,601.2,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,661.32,,,661.32,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,935.2,70,,935.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,988.64,
COOK G01428 ROSEN WIRE .035X180CM,C1769,HCPCS,,79000480,CDM,272,RC,,,both,,,40,29.6,,,29.6,Other,150% of Medicare + 9.63% HCRA Surcharge,18,45,,18,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,19.8,,,19.8,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,28,70,,28,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,29.6,
J&J 401-855M SHEATH BRITE-TIP 8FR,C1894,HCPCS,,79000493,CDM,272,RC,,,both,,,112,82.88,,,82.88,Other,150% of Medicare + 9.63% HCRA Surcharge,50.4,45,,50.4,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,55.44,,,55.44,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,78.4,70,,78.4,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,82.88,
J&J 401-890M SHEATH BRITE-TIP 8FR,C1894,HCPCS,,79000494,CDM,272,RC,,,both,,,318,235.32,,,235.32,Other,150% of Medicare + 9.63% HCRA Surcharge,143.1,45,,143.1,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,157.41,,,157.41,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,222.6,70,,222.6,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,235.32,
ABBOTT 1005202 SPARTA-CORE WIRE .014X180,C1769,HCPCS,,79000517,CDM,272,RC,,,both,,,300,222,,,222,Other,150% of Medicare + 9.63% HCRA Surcharge,135,45,,135,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,148.5,,,148.5,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,210,70,,210,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,222,
ABBOTT 1005203 SPARTA-CORE WIRE .014X300,C1769,HCPCS,,79000518,CDM,272,RC,,,both,,,360,266.4,,,266.4,Other,150% of Medicare + 9.63% HCRA Surcharge,162,45,,162,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,178.2,,,178.2,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,252,70,,252,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,266.4,
EV3 THS-SS-CL TURBOHAWK SS-CL,C1714,HCPCS,,79000519,CDM,272,RC,,,both,,,10185,7536.93,,,7536.93,Other,150% of Medicare + 9.63% HCRA Surcharge,4583.25,45,,4583.25,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,5041.58,,,5041.58,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,7129.5,70,,7129.5,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,7536.93,
STRYKER 527-914 STABILIZER GUIDEWIRE,C1769,HCPCS,,79000520,CDM,272,RC,,,both,,,420,310.8,,,310.8,Other,150% of Medicare + 9.63% HCRA Surcharge,189,45,,189,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,207.9,,,207.9,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,294,70,,294,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,310.8,
STABILIZER WIRE .014 300CM,C1769,HCPCS,,79000521,CDM,272,RC,,,both,,,2626,1943.25,,,1943.25,Other,150% of Medicare + 9.63% HCRA Surcharge,1181.7,45,,1181.7,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1299.87,,,1299.87,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1838.2,70,,1838.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1943.25,
BOST SCI 39031-30601 STERLING BALLOON,C1725,HCPCS,,79000529,CDM,272,RC,,,both,,,1110,821.4,,,821.4,Other,150% of Medicare + 9.63% HCRA Surcharge,499.5,45,,499.5,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,549.45,,,549.45,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,777,70,,777,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,821.4,
BOST SCI 39031-60401 STERLING BALLOON,C1725,HCPCS,,79000530,CDM,272,RC,,,both,,,1110,821.4,,,821.4,Other,150% of Medicare + 9.63% HCRA Surcharge,499.5,45,,499.5,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,549.45,,,549.45,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,777,70,,777,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,821.4,
BOST SCI 39031-30201 STERLING BALLOON,C1725,HCPCS,,79000531,CDM,272,RC,,,both,,,1110,821.4,,,821.4,Other,150% of Medicare + 9.63% HCRA Surcharge,499.5,45,,499.5,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,549.45,,,549.45,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,777,70,,777,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,821.4,
BOST SCI 39135-35401 STERLING BALLOON,C1725,HCPCS,,79000532,CDM,272,RC,,,both,,,1110,821.4,,,821.4,Other,150% of Medicare + 9.63% HCRA Surcharge,499.5,45,,499.5,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,549.45,,,549.45,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,777,70,,777,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,821.4,
BOST SCI 39031-60201 STERLING BALLOON,C1725,HCPCS,,79000533,CDM,272,RC,,,both,,,1110,821.4,,,821.4,Other,150% of Medicare + 9.63% HCRA Surcharge,499.5,45,,499.5,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,549.45,,,549.45,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,777,70,,777,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,821.4,
BOST SCI 39031-40201 STERLING BALLOON,C1725,HCPCS,,79000534,CDM,272,RC,,,both,,,1110,821.4,,,821.4,Other,150% of Medicare + 9.63% HCRA Surcharge,499.5,45,,499.5,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,549.45,,,549.45,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,777,70,,777,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,821.4,
BOST SCI 39031-40401 STERLING BALLOON,C1725,HCPCS,,79000535,CDM,272,RC,,,both,,,1110,821.4,,,821.4,Other,150% of Medicare + 9.63% HCRA Surcharge,499.5,45,,499.5,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,549.45,,,549.45,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,777,70,,777,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,821.4,
BOST SCI 39031-50201 STERLING BALLOON,C1725,HCPCS,,79000536,CDM,272,RC,,,both,,,1110,821.4,,,821.4,Other,150% of Medicare + 9.63% HCRA Surcharge,499.5,45,,499.5,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,549.45,,,549.45,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,777,70,,777,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,821.4,
BOST SCI 39031-50401 STERLING BALLOON,C1725,HCPCS,,79000537,CDM,272,RC,,,both,,,1110,821.4,,,821.4,Other,150% of Medicare + 9.63% HCRA Surcharge,499.5,45,,499.5,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,549.45,,,549.45,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,777,70,,777,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,821.4,
BOST SCI 39031-70201 STERLING BALLOON,C1725,HCPCS,,79000538,CDM,272,RC,,,both,,,1110,821.4,,,821.4,Other,150% of Medicare + 9.63% HCRA Surcharge,499.5,45,,499.5,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,549.45,,,549.45,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,777,70,,777,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,821.4,
BOST SCI 39135-30401 STERLING BALLOON,C1725,HCPCS,,79000539,CDM,272,RC,,,both,,,1144,846.56,,,846.56,Other,150% of Medicare + 9.63% HCRA Surcharge,514.8,45,,514.8,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,566.28,,,566.28,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,800.8,70,,800.8,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,846.56,
BOST SCI 39147-30801 STERLING BALLOON,C1725,HCPCS,,79000540,CDM,272,RC,,,both,,,1144,846.56,,,846.56,Other,150% of Medicare + 9.63% HCRA Surcharge,514.8,45,,514.8,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,566.28,,,566.28,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,800.8,70,,800.8,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,846.56,
STERLING EX BALLOON 2.5X4X142,C1725,HCPCS,,79000542,CDM,272,RC,,,both,,,1110,821.4,,,821.4,Other,150% of Medicare + 9.63% HCRA Surcharge,499.5,45,,499.5,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,549.45,,,549.45,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,777,70,,777,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,821.4,
BOST SCI 49-297 THRUWAY WIRE .014 300CM,C1769,HCPCS,,79000543,CDM,272,RC,,,both,,,362,267.88,,,267.88,Other,150% of Medicare + 9.63% HCRA Surcharge,162.9,45,,162.9,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,179.19,,,179.19,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,253.4,70,,253.4,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,267.88,
COVIDIEN BVT8-080-30 TRELLIS INF SYS,C1757,HCPCS,,79000549,CDM,272,RC,,,both,,,6286,4651.66,,,4651.66,Other,150% of Medicare + 9.63% HCRA Surcharge,2828.7,45,,2828.7,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,3111.57,,,3111.57,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,4400.2,70,,4400.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4651.66,
EV3 THS-SX-C TURBOHAWK SX-C,C1714,HCPCS,,79000550,CDM,272,RC,,,both,,,10185,7536.93,,,7536.93,Other,150% of Medicare + 9.63% HCRA Surcharge,4583.25,45,,4583.25,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,5041.58,,,5041.58,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,7129.5,70,,7129.5,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,7536.93,
EV3 TH-LX-M TURBOHAWK LX-M,C1714,HCPCS,,79000551,CDM,272,RC,,,both,,,8985,6648.92,,,6648.92,Other,150% of Medicare + 9.63% HCRA Surcharge,4043.25,45,,4043.25,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,4447.58,,,4447.58,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,6289.5,70,,6289.5,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,6648.92,
"CSI VPR-GW-14 VIPER WIRES W/0.014"" TIP",C1769,HCPCS,,79000555,CDM,272,RC,,,both,,,2550,1887.01,,,1887.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1147.5,45,,1147.5,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1262.25,,,1262.25,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1785,70,,1785,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1887.01,
BOST SCI 27-179 NEPHROSTOMY CATH 8FR25CM,C1729,HCPCS,,79000562,CDM,272,RC,,,both,,,236,174.64,,,174.64,Other,150% of Medicare + 9.63% HCRA Surcharge,106.2,45,,106.2,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,116.82,,,116.82,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,165.2,70,,165.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,174.64,
TERUMO GR1806 ANGLD GLIDEWIRE .018X180CM,C1769,HCPCS,,79000563,CDM,272,RC,,,both,,,167,123.58,,,123.58,Other,150% of Medicare + 9.63% HCRA Surcharge,75.15,45,,75.15,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,82.67,,,82.67,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,116.9,70,,116.9,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,123.58,
TERUMO GR1802 STR GLIDEWIRE .018X130CM,C1769,HCPCS,,79000564,CDM,272,RC,,,both,,,167,123.58,,,123.58,Other,150% of Medicare + 9.63% HCRA Surcharge,75.15,45,,75.15,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,82.67,,,82.67,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,116.9,70,,116.9,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,123.58,
BOST SCI 46-125B ANGLED GLIDEWIRE,C1769,HCPCS,,79000565,CDM,272,RC,,,both,,,130,96.2,,,96.2,Other,150% of Medicare + 9.63% HCRA Surcharge,58.5,45,,58.5,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,64.35,,,64.35,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,91,70,,91,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,96.2,
TERUMO GR3509 ANGLED GLIDEWIRE .035X260,C1769,HCPCS,,79000566,CDM,272,RC,,,both,,,138,102.12,,,102.12,Other,150% of Medicare + 9.63% HCRA Surcharge,62.1,45,,62.1,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,68.31,,,68.31,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,96.6,70,,96.6,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,102.12,
TERUMO GS3509 ANGLD GLIDE STIFF .035X260,C1769,HCPCS,,79000567,CDM,272,RC,,,both,,,155,114.7,,,114.7,Other,150% of Medicare + 9.63% HCRA Surcharge,69.75,45,,69.75,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,76.73,,,76.73,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,108.5,70,,108.5,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,114.7,
STRYKER GR3504 STR GLIDEWIRE .035X260CM,C1769,HCPCS,,79000568,CDM,272,RC,,,both,,,190,140.6,,,140.6,Other,150% of Medicare + 9.63% HCRA Surcharge,85.5,45,,85.5,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,94.05,,,94.05,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,133,70,,133,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,140.6,
BOST SCI 46-523 AMPLATZ GUIDE .035X145CM,C1769,HCPCS,,79000569,CDM,272,RC,,,both,,,79,58.46,,,58.46,Other,150% of Medicare + 9.63% HCRA Surcharge,35.55,45,,35.55,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,39.11,,,39.11,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,55.3,70,,55.3,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,58.46,
COOK THSCF351803AES AMPLATZ STIFF G03565,C1769,HCPCS,,79000570,CDM,272,RC,,,both,,,100,74,,,74,Other,150% of Medicare + 9.63% HCRA Surcharge,45,45,,45,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,49.5,,,49.5,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,70,70,,70,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,74,
COOK G08427 WIRE GUIDE COPE MONDIAL 60CM,C1769,HCPCS,,79000571,CDM,272,RC,,,both,,,101,74.74,,,74.74,Other,150% of Medicare + 9.63% HCRA Surcharge,45.45,45,,45.45,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,50,,,50,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,70.7,70,,70.7,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,74.74,
BOST SCI 46-604 WIRE PLATINUM PLUS,C1769,HCPCS,,79000572,CDM,272,RC,,,both,,,233,172.42,,,172.42,Other,150% of Medicare + 9.63% HCRA Surcharge,104.85,45,,104.85,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,115.34,,,115.34,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,163.1,70,,163.1,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,172.42,
STRYKER G07937 WIRE ROADRUNNER .035X180,C1769,HCPCS,,79000573,CDM,272,RC,,,both,,,96,71.04,,,71.04,Other,150% of Medicare + 9.63% HCRA Surcharge,43.2,45,,43.2,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,47.52,,,47.52,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,67.2,70,,67.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,71.04,
BOST SCI 46-854 WIRE V18 CONT .018X300CM,C1769,HCPCS,,79000574,CDM,272,RC,,,both,,,276,204.24,,,204.24,Other,150% of Medicare + 9.63% HCRA Surcharge,124.2,45,,124.2,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,136.62,,,136.62,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,193.2,70,,193.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,204.24,
COOK G03330 AMPLATZ XTRA STIFF .035X180,C1769,HCPCS,,79000575,CDM,272,RC,,,both,,,62,45.88,,,45.88,Other,150% of Medicare + 9.63% HCRA Surcharge,27.9,45,,27.9,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,30.69,,,30.69,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,43.4,70,,43.4,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,45.88,
ANGIODYNAMICS 5500501 NEWTON WIRE 150CM,C1769,HCPCS,,79000576,CDM,272,RC,,,both,,,36,26.64,,,26.64,Other,150% of Medicare + 9.63% HCRA Surcharge,16.2,45,,16.2,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,17.82,,,17.82,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,25.2,70,,25.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,26.64,
ZIP WIRE .035 180CM ANGLED,C1769,HCPCS,,79000577,CDM,272,RC,,,both,,,125,92.5,,,92.5,Other,150% of Medicare + 9.63% HCRA Surcharge,56.25,45,,56.25,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,61.88,,,61.88,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,87.5,70,,87.5,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,92.5,
INTRODUCER PER-Q-CATH 3FR,C1894,HCPCS,,79000596,CDM,272,RC,,,both,,,102,75.48,,,75.48,Other,150% of Medicare + 9.63% HCRA Surcharge,45.9,45,,45.9,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,50.49,,,50.49,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,71.4,70,,71.4,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,75.48,
EDWARDS 120602F FOGARTY CATH EMBOL 2FR,C1757,HCPCS,,79000607,CDM,272,RC,,,both,,,230,170.2,,,170.2,Other,150% of Medicare + 9.63% HCRA Surcharge,103.5,45,,103.5,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,113.85,,,113.85,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,161,70,,161,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,170.2,
EDWARDS 120803F FOGARTY CATH EMBOL 3FR,C1757,HCPCS,,79000608,CDM,272,RC,,,both,,,150,111,,,111,Other,150% of Medicare + 9.63% HCRA Surcharge,67.5,45,,67.5,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,74.25,,,74.25,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,105,70,,105,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,111,
EDWARDS 120804F FOGARTY CATH EMBOL 4FR,C1757,HCPCS,,79000609,CDM,272,RC,,,both,,,150,111,,,111,Other,150% of Medicare + 9.63% HCRA Surcharge,67.5,45,,67.5,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,74.25,,,74.25,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,105,70,,105,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,111,
EDWARDS 120805F FOGARTY CATH EMBOL 5FR,C1757,HCPCS,,79000610,CDM,272,RC,,,both,,,150,111,,,111,Other,150% of Medicare + 9.63% HCRA Surcharge,67.5,45,,67.5,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,74.25,,,74.25,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,105,70,,105,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,111,
EDWARDS 120806F FOGARTY CATH EMBOL 6FR,C1757,HCPCS,,79000611,CDM,272,RC,,,both,,,150,111,,,111,Other,150% of Medicare + 9.63% HCRA Surcharge,67.5,45,,67.5,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,74.25,,,74.25,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,105,70,,105,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,111,
EDWARDS 220804F FOG CATH EMBOL IRRIG 4FR,C1757,HCPCS,,79000612,CDM,272,RC,,,both,,,66,48.84,,,48.84,Other,150% of Medicare + 9.63% HCRA Surcharge,29.7,45,,29.7,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,32.67,,,32.67,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,46.2,70,,46.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,48.84,
EDWARDS 220806F FOG CATH EMBOL IRRIG 6FR,C1757,HCPCS,,79000613,CDM,272,RC,,,both,,,67,49.58,,,49.58,Other,150% of Medicare + 9.63% HCRA Surcharge,30.15,45,,30.15,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,33.17,,,33.17,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,46.9,70,,46.9,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,49.58,
ANGIODYNAMICS HMP-009-08 8FR INTRODUCER,C1894,HCPCS,,79000679,CDM,272,RC,,,both,,,184,136.16,,,136.16,Other,150% of Medicare + 9.63% HCRA Surcharge,82.8,45,,82.8,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,91.08,,,91.08,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,128.8,70,,128.8,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,136.16,
ANGIODYNAMICS HMP-009-09 9FR INTRODUCER,C1894,HCPCS,,79000680,CDM,272,RC,,,both,,,170,125.8,,,125.8,Other,150% of Medicare + 9.63% HCRA Surcharge,76.5,45,,76.5,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,84.15,,,84.15,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,119,70,,119,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,125.8,
ANGIODYNAMICS HMP-009-10 10FR INTRODUCER,C1894,HCPCS,,79000681,CDM,272,RC,,,both,,,184,136.16,,,136.16,Other,150% of Medicare + 9.63% HCRA Surcharge,82.8,45,,82.8,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,91.08,,,91.08,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,128.8,70,,128.8,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,136.16,
ANGIODYNAMICS HMP-009-12 12FR INTRODUCER,C1894,HCPCS,,79000682,CDM,272,RC,,,both,,,179,132.46,,,132.46,Other,150% of Medicare + 9.63% HCRA Surcharge,80.55,45,,80.55,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,88.61,,,88.61,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,125.3,70,,125.3,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,132.46,
BOST SCI 46-517 AMPLATZ SUPER STIFF WIRE,C1769,HCPCS,,79000734,CDM,272,RC,,,both,,,79,58.46,,,58.46,Other,150% of Medicare + 9.63% HCRA Surcharge,35.55,45,,35.55,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,39.11,,,39.11,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,55.3,70,,55.3,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,58.46,
BOST SCI 46-519 AMPLATZ SUPER STIFF WIRE,C1769,HCPCS,,79000735,CDM,272,RC,,,both,,,121,89.54,,,89.54,Other,150% of Medicare + 9.63% HCRA Surcharge,54.45,45,,54.45,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,59.9,,,59.9,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,84.7,70,,84.7,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,89.54,
COOK G03330 AMPLATZ WIRE .035X180CM,C1769,HCPCS,,79000736,CDM,272,RC,,,both,,,62,45.88,,,45.88,Other,150% of Medicare + 9.63% HCRA Surcharge,27.9,45,,27.9,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,30.69,,,30.69,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,43.4,70,,43.4,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,45.88,
EDWARDS 120804F CATHETER EMBOLECTOMY 4FR,C1757,HCPCS,,79000801,CDM,272,RC,,,both,,,154,113.96,,,113.96,Other,150% of Medicare + 9.63% HCRA Surcharge,69.3,45,,69.3,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,76.23,,,76.23,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,107.8,70,,107.8,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,113.96,
EDWARDS 120805F CATHETER EMBOLECTOMY 5FR,C1757,HCPCS,,79000802,CDM,272,RC,,,both,,,154,113.96,,,113.96,Other,150% of Medicare + 9.63% HCRA Surcharge,69.3,45,,69.3,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,76.23,,,76.23,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,107.8,70,,107.8,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,113.96,
EDWARDS 120802F CATHETER EMBOLECTOMY 2FR,C1757,HCPCS,,79000817,CDM,272,RC,,,both,,,234,173.16,,,173.16,Other,150% of Medicare + 9.63% HCRA Surcharge,105.3,45,,105.3,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,115.83,,,115.83,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,163.8,70,,163.8,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,173.16,
EDWARDS 120803F CATHETER EMBOLECTOMY 3FR,C1757,HCPCS,,79000818,CDM,272,RC,,,both,,,154,113.96,,,113.96,Other,150% of Medicare + 9.63% HCRA Surcharge,69.3,45,,69.3,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,76.23,,,76.23,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,107.8,70,,107.8,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,113.96,
EDWARDS 120806F CATHETER EMBOLECTOMY 6FR,C1757,HCPCS,,79000819,CDM,272,RC,,,both,,,154,113.96,,,113.96,Other,150% of Medicare + 9.63% HCRA Surcharge,69.3,45,,69.3,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,76.23,,,76.23,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,107.8,70,,107.8,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,113.96,
BOST SCI 27-179 CATHETER NEPHROSTOMY 8FR,C1729,HCPCS,,79000823,CDM,272,RC,,,both,,,236,174.64,,,174.64,Other,150% of Medicare + 9.63% HCRA Surcharge,106.2,45,,106.2,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,116.82,,,116.82,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,165.2,70,,165.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,174.64,
EDWARDS 220804F-R FOGARTY CATHETER 4FR,C1757,HCPCS,,79000900,CDM,272,RC,,,both,,,67,49.58,,,49.58,Other,150% of Medicare + 9.63% HCRA Surcharge,30.15,45,,30.15,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,33.17,,,33.17,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,46.9,70,,46.9,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,49.58,
EDWARDS 220806F-R FOGARTY CATHETER 6FR,C1757,HCPCS,,79000901,CDM,272,RC,,,both,,,70,51.8,,,51.8,Other,150% of Medicare + 9.63% HCRA Surcharge,31.5,45,,31.5,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,34.65,,,34.65,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,49,70,,49,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,51.8,
EDWARDS 220806FR FOGARTY CATHETER 6FR,C1757,HCPCS,,79000902,CDM,272,RC,,,both,,,71,52.54,,,52.54,Other,150% of Medicare + 9.63% HCRA Surcharge,31.95,45,,31.95,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,35.15,,,35.15,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,49.7,70,,49.7,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,52.54,
EDWARDS 120602F FOGARTY CATH EMBOL 2FR,C1757,HCPCS,,79000903,CDM,272,RC,,,both,,,234,173.16,,,173.16,Other,150% of Medicare + 9.63% HCRA Surcharge,105.3,45,,105.3,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,115.83,,,115.83,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,163.8,70,,163.8,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,173.16,
EDWARDS 2202310F FOGARTY IRRIG CATH 10FR,C1757,HCPCS,,79000905,CDM,272,RC,,,both,,,64,47.36,,,47.36,Other,150% of Medicare + 9.63% HCRA Surcharge,28.8,45,,28.8,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,31.68,,,31.68,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,44.8,70,,44.8,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,47.36,
BOST SCI 46-151 GLIDE WIRE ANGLE,C1769,HCPCS,,79000908,CDM,272,RC,,,both,,,114,84.36,,,84.36,Other,150% of Medicare + 9.63% HCRA Surcharge,51.3,45,,51.3,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,56.43,,,56.43,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,79.8,70,,79.8,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,84.36,
GLIDE WIRES STR TIP 038 X 50CM,C1769,HCPCS,,79000909,CDM,272,RC,,,both,,,164,121.36,,,121.36,Other,150% of Medicare + 9.63% HCRA Surcharge,73.8,45,,73.8,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,81.18,,,81.18,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,114.8,70,,114.8,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,121.36,
BOST SCI 630-201B ZIPWIRE STRAIGHT .025,C1769,HCPCS,,79000910,CDM,272,RC,,,both,,,113,83.62,,,83.62,Other,150% of Medicare + 9.63% HCRA Surcharge,50.85,45,,50.85,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,55.94,,,55.94,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,79.1,70,,79.1,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,83.62,
BOST SCI 630-205B ZIPWIRE STRAIGHT .035,C1769,HCPCS,,79000911,CDM,272,RC,,,both,,,110,81.4,,,81.4,Other,150% of Medicare + 9.63% HCRA Surcharge,49.5,45,,49.5,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,54.45,,,54.45,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,77,70,,77,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,81.4,
BOST SCI 630-208B ZIPWIRE STRAIGHT .038,C1769,HCPCS,,79000912,CDM,272,RC,,,both,,,128,94.72,,,94.72,Other,150% of Medicare + 9.63% HCRA Surcharge,57.6,45,,57.6,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,63.36,,,63.36,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,89.6,70,,89.6,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,94.72,
COOK GR1806RR GLIDEWIRE ANG .018X130CM,C1769,HCPCS,,79000913,CDM,272,RC,,,both,,,64,47.36,,,47.36,Other,150% of Medicare + 9.63% HCRA Surcharge,28.8,45,,28.8,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,31.68,,,31.68,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,44.8,70,,44.8,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,47.36,
GUIDE WIRE 1.2MM,C1769,HCPCS,,79000915,CDM,272,RC,,,both,,,106,78.44,,,78.44,Other,150% of Medicare + 9.63% HCRA Surcharge,47.7,45,,47.7,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,52.47,,,52.47,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,74.2,70,,74.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,78.44,
STRYKER 702459 GUIDE WIRE 1.4X150MM,C1769,HCPCS,,79000916,CDM,272,RC,,,both,,,372,275.28,,,275.28,Other,150% of Medicare + 9.63% HCRA Surcharge,167.4,45,,167.4,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,184.14,,,184.14,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,260.4,70,,260.4,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,275.28,
GUIDE WIRE THREADED 1.1 X 150MM,C1769,HCPCS,,79000918,CDM,272,RC,,,both,,,106,78.44,,,78.44,Other,150% of Medicare + 9.63% HCRA Surcharge,47.7,45,,47.7,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,52.47,,,52.47,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,74.2,70,,74.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,78.44,
BOST SCI 630-103 GUIDEWIRE ANGLED,C1769,HCPCS,,79000921,CDM,272,RC,,,both,,,113,83.62,,,83.62,Other,150% of Medicare + 9.63% HCRA Surcharge,50.85,45,,50.85,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,55.94,,,55.94,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,79.1,70,,79.1,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,83.62,
BOST SCI 630-093 GLIDEWIRE ANGLD TIP 3CM,C1769,HCPCS,,79000923,CDM,272,RC,,,both,,,113,83.62,,,83.62,Other,150% of Medicare + 9.63% HCRA Surcharge,50.85,45,,50.85,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,55.94,,,55.94,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,79.1,70,,79.1,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,83.62,
CARDIO MEDICAL CME6 INTRODUCER 6FR,C1894,HCPCS,,79000957,CDM,272,RC,,,both,,,145,107.3,,,107.3,Other,150% of Medicare + 9.63% HCRA Surcharge,65.25,45,,65.25,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,71.78,,,71.78,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,101.5,70,,101.5,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,107.3,
CARDIO MEDICAL CME7 INTRODUCER 7FR,C1894,HCPCS,,79000958,CDM,272,RC,,,both,,,145,107.3,,,107.3,Other,150% of Medicare + 9.63% HCRA Surcharge,65.25,45,,65.25,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,71.78,,,71.78,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,101.5,70,,101.5,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,107.3,
CARDIO MEDICAL IS-08AS INTRODUCER 8FR,C1894,HCPCS,,79000959,CDM,272,RC,,,both,,,100,74,,,74,Other,150% of Medicare + 9.63% HCRA Surcharge,45,45,,45,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,49.5,,,49.5,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,70,70,,70,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,74,
J&J MCL20 LIGACLIP MULTIPLE CLIP LARGE,C1760,HCPCS,,79001573,CDM,272,RC,,,both,,,189,139.86,,,139.86,Other,150% of Medicare + 9.63% HCRA Surcharge,85.05,45,,85.05,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,93.56,,,93.56,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,132.3,70,,132.3,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,139.86,
J&J MCM20 LIGACLIP MULTIPLE CLIP MEDIUM,C1760,HCPCS,,79001574,CDM,272,RC,,,both,,,164,121.36,,,121.36,Other,150% of Medicare + 9.63% HCRA Surcharge,73.8,45,,73.8,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,81.18,,,81.18,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,114.8,70,,114.8,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,121.36,
SUT EXP MCS20 LIGACLIP MULTIPLE CLIP SM,C1760,HCPCS,,79001575,CDM,272,RC,,,both,,,191,141.34,,,141.34,Other,150% of Medicare + 9.63% HCRA Surcharge,85.95,45,,85.95,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,94.55,,,94.55,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,133.7,70,,133.7,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,141.34,
SUTURE EXPRESS EL21L LIGALOOP SURGITIE,C1760,HCPCS,,79001576,CDM,272,RC,,,both,,,123,91.02,,,91.02,Other,150% of Medicare + 9.63% HCRA Surcharge,55.35,45,,55.35,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,60.89,,,60.89,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,86.1,70,,86.1,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,91.02,
SUT EXP LF4200 LIGASURE IMPACT 18CM,C1760,HCPCS,,79001577,CDM,272,RC,,,both,,,2260,1672.41,,,1672.41,Other,150% of Medicare + 9.63% HCRA Surcharge,1017,45,,1017,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1118.7,,,1118.7,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1582,70,,1582,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1672.41,
SUTURE EXPRESS LS1500 LIGASURE 5MM,C1760,HCPCS,,79001578,CDM,272,RC,,,both,,,1575,1165.5,,,1165.5,Other,150% of Medicare + 9.63% HCRA Surcharge,708.75,45,,708.75,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,779.63,,,779.63,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1102.5,70,,1102.5,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1165.5,
SUT EXP LS1037 LIGASURE ATLAS LAP,C1760,HCPCS,,79001579,CDM,272,RC,,,both,,,1500,1110,,,1110,Other,150% of Medicare + 9.63% HCRA Surcharge,675,45,,675,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,742.5,,,742.5,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1050,70,,1050,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1110,
LIGASURE SHORT HANDLE 20CM SHORT,C1760,HCPCS,,79001580,CDM,272,RC,,,both,,,1457,1078.18,,,1078.18,Other,150% of Medicare + 9.63% HCRA Surcharge,655.65,45,,655.65,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,721.22,,,721.22,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1019.9,70,,1019.9,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1078.18,
ZIMMER 47-2237-38 GUIDE WIRE,C1769,HCPCS,,79002059,CDM,272,RC,,,both,,,510,377.4,,,377.4,Other,150% of Medicare + 9.63% HCRA Surcharge,229.5,45,,229.5,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,252.45,,,252.45,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,357,70,,357,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,377.4,
ARTHREX AR-8941K GUIDE WIRE,C1769,HCPCS,,79002443,CDM,272,RC,,,both,,,49,36.26,,,36.26,Other,150% of Medicare + 9.63% HCRA Surcharge,22.05,45,,22.05,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,24.26,,,24.26,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,34.3,70,,34.3,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,36.26,
ACUMED WS1406ST GUIDE WIRE,C1769,HCPCS,,79002621,CDM,272,RC,,,both,,,46,34.04,,,34.04,Other,150% of Medicare + 9.63% HCRA Surcharge,20.7,45,,20.7,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,22.77,,,22.77,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,32.2,70,,32.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,34.04,
ACUMED WS-2009-ST GUIDE WIRE,C1769,HCPCS,,79002622,CDM,272,RC,,,both,,,70,51.8,,,51.8,Other,150% of Medicare + 9.63% HCRA Surcharge,31.5,45,,31.5,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,34.65,,,34.65,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,49,70,,49,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,51.8,
MEDTRONIC 043325M MARINR EP CATHETER 6FR,C1730,HCPCS,,79002656,CDM,272,RC,,,both,,,1650,1221,,,1221,Other,150% of Medicare + 9.63% HCRA Surcharge,742.5,45,,742.5,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,816.75,,,816.75,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1155,70,,1155,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1221,
GWR419388 HYBRID WIRE,C1769,HCPCS,,79002658,CDM,272,RC,,,both,,,600,444,,,444,Other,150% of Medicare + 9.63% HCRA Surcharge,270,45,,270,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,297,,,297,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,420,70,,420,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,444,
GWR419688 GUIDE WIRE 108CM GLOBAL CE,C1769,HCPCS,,79002659,CDM,272,RC,,,both,,,600,444,,,444,Other,150% of Medicare + 9.63% HCRA Surcharge,270,45,,270,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,297,,,297,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,420,70,,420,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,444,
ST JUDE 610119 ANGIOSEAL 6FR CLOSURE DEV,C1760,HCPCS,,79002691,CDM,272,RC,,,both,,,870,643.8,,,643.8,Other,150% of Medicare + 9.63% HCRA Surcharge,391.5,45,,391.5,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,430.65,,,430.65,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,609,70,,609,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,643.8,
STRYKER 1806-0093S GUIDE WIRE 2.2X800MM,C1769,HCPCS,,79002892,CDM,272,RC,,,both,,,355,262.7,,,262.7,Other,150% of Medicare + 9.63% HCRA Surcharge,159.75,45,,159.75,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,175.73,,,175.73,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,248.5,70,,248.5,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,262.7,
STRYKER 1806-0085S GUIDE WIRE 3X100MM,C1769,HCPCS,,79003022,CDM,272,RC,,,both,,,392,290.08,,,290.08,Other,150% of Medicare + 9.63% HCRA Surcharge,176.4,45,,176.4,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,194.04,,,194.04,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,274.4,70,,274.4,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,290.08,
EV3 THS-SS-C TURBOHAWK SS-C,C1714,HCPCS,,79003031,CDM,272,RC,,,both,,,10185,7536.93,,,7536.93,Other,150% of Medicare + 9.63% HCRA Surcharge,4583.25,45,,4583.25,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,5041.58,,,5041.58,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,7129.5,70,,7129.5,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,7536.93,
EV3 THS-LX-C TURBOHAWK LX-C,C1714,HCPCS,,79003067,CDM,272,RC,,,both,,,8550,6327.02,,,6327.02,Other,150% of Medicare + 9.63% HCRA Surcharge,3847.5,45,,3847.5,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,4232.25,,,4232.25,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,5985,70,,5985,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,6327.02,
EV3 THS-LS-C TURBOHAWK LS-C,C1714,HCPCS,,79003068,CDM,272,RC,,,both,,,8550,6327.02,,,6327.02,Other,150% of Medicare + 9.63% HCRA Surcharge,3847.5,45,,3847.5,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,4232.25,,,4232.25,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,5985,70,,5985,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,6327.02,
PRD-SC30-125S CSI ATHERECTOMY DEV 1.25MM,C1724,HCPCS,,79003069,CDM,272,RC,,,both,,,10186,7537.67,,,7537.67,Other,150% of Medicare + 9.63% HCRA Surcharge,4583.7,45,,4583.7,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,5042.07,,,5042.07,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,7130.2,70,,7130.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,7537.67,
BOST SCI 39031-50601 STERLING BALLOON,C1725,HCPCS,,79003070,CDM,272,RC,,,both,,,1110,821.4,,,821.4,Other,150% of Medicare + 9.63% HCRA Surcharge,499.5,45,,499.5,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,549.45,,,549.45,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,777,70,,777,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,821.4,
BOST SCI 39031-60601 STERLING BALLOON,C1725,HCPCS,,79003071,CDM,272,RC,,,both,,,1110,821.4,,,821.4,Other,150% of Medicare + 9.63% HCRA Surcharge,499.5,45,,499.5,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,549.45,,,549.45,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,777,70,,777,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,821.4,
BOST SCI 39171-03024 MUSTANG BALLOON,C1725,HCPCS,,79003072,CDM,272,RC,,,both,,,586,433.64,,,433.64,Other,150% of Medicare + 9.63% HCRA Surcharge,263.7,45,,263.7,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,290.07,,,290.07,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,410.2,70,,410.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,433.64,
BOST SCI 39171-03024 MUSTANG BALLOON,C1725,HCPCS,,79003073,CDM,272,RC,,,both,,,586,433.64,,,433.64,Other,150% of Medicare + 9.63% HCRA Surcharge,263.7,45,,263.7,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,290.07,,,290.07,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,410.2,70,,410.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,433.64,
BOST SCI 39171-05034 MUSTANG BALLOON,C1725,HCPCS,,79003074,CDM,272,RC,,,both,,,586,433.64,,,433.64,Other,150% of Medicare + 9.63% HCRA Surcharge,263.7,45,,263.7,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,290.07,,,290.07,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,410.2,70,,410.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,433.64,
BOST SCI 39171-05041 MUSTANG BALLOON,C1725,HCPCS,,79003075,CDM,272,RC,,,both,,,586,433.64,,,433.64,Other,150% of Medicare + 9.63% HCRA Surcharge,263.7,45,,263.7,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,290.07,,,290.07,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,410.2,70,,410.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,433.64,
BOST SCI 39171-06087 MUSTANG BALLOON,C1725,HCPCS,,79003076,CDM,272,RC,,,both,,,586,433.64,,,433.64,Other,150% of Medicare + 9.63% HCRA Surcharge,263.7,45,,263.7,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,290.07,,,290.07,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,410.2,70,,410.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,433.64,
BOST SCI 39171-06201 MUSTANG BALLOON,C1725,HCPCS,,79003077,CDM,272,RC,,,both,,,676,500.24,,,500.24,Other,150% of Medicare + 9.63% HCRA Surcharge,304.2,45,,304.2,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,334.62,,,334.62,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,473.2,70,,473.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,500.24,
BOST SCI 39171-07087 MUSTANG BALLOON,C1725,HCPCS,,79003078,CDM,272,RC,,,both,,,586,433.64,,,433.64,Other,150% of Medicare + 9.63% HCRA Surcharge,263.7,45,,263.7,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,290.07,,,290.07,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,410.2,70,,410.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,433.64,
BOST SCI 39171-07101 MUSTANG BALLOON,C1725,HCPCS,,79003079,CDM,272,RC,,,both,,,676,500.24,,,500.24,Other,150% of Medicare + 9.63% HCRA Surcharge,304.2,45,,304.2,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,334.62,,,334.62,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,473.2,70,,473.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,500.24,
BOST SCI 39171-07201 MUSTANG BALLOON,C1725,HCPCS,,79003080,CDM,272,RC,,,both,,,676,500.24,,,500.24,Other,150% of Medicare + 9.63% HCRA Surcharge,304.2,45,,304.2,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,334.62,,,334.62,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,473.2,70,,473.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,500.24,
BOST SCI 39171-08041 MUSTANG BALLOON,C1725,HCPCS,,79003081,CDM,272,RC,,,both,,,585,432.9,,,432.9,Other,150% of Medicare + 9.63% HCRA Surcharge,263.25,45,,263.25,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,289.58,,,289.58,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,409.5,70,,409.5,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,432.9,
BOST SCI 39206-05101 CHARGER BALLOON,C1725,HCPCS,,79003082,CDM,272,RC,,,both,,,496,367.04,,,367.04,Other,150% of Medicare + 9.63% HCRA Surcharge,223.2,45,,223.2,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,245.52,,,245.52,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,347.2,70,,347.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,367.04,
BOST SCI 39206-05201 CHARGER BALLOON,C1725,HCPCS,,79003083,CDM,272,RC,,,both,,,586,433.64,,,433.64,Other,150% of Medicare + 9.63% HCRA Surcharge,263.7,45,,263.7,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,290.07,,,290.07,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,410.2,70,,410.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,433.64,
BOST SCI 39206-06041 CHARGER BALLOON,C1725,HCPCS,,79003084,CDM,272,RC,,,both,,,495,366.3,,,366.3,Other,150% of Medicare + 9.63% HCRA Surcharge,222.75,45,,222.75,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,245.03,,,245.03,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,346.5,70,,346.5,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,366.3,
BOST SCI 39206-06041 CHARGER BALLOON,C1725,HCPCS,,79003085,CDM,272,RC,,,both,,,496,367.04,,,367.04,Other,150% of Medicare + 9.63% HCRA Surcharge,223.2,45,,223.2,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,245.52,,,245.52,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,347.2,70,,347.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,367.04,
BOST SCI 39206-07151 CHARGER BALLOON,C1725,HCPCS,,79003086,CDM,272,RC,,,both,,,586,433.64,,,433.64,Other,150% of Medicare + 9.63% HCRA Surcharge,263.7,45,,263.7,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,290.07,,,290.07,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,410.2,70,,410.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,433.64,
BOST SCI 39185-20061 COYOTE BALLOON,C1725,HCPCS,,79003087,CDM,272,RC,,,both,,,960,710.4,,,710.4,Other,150% of Medicare + 9.63% HCRA Surcharge,432,45,,432,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,475.2,,,475.2,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,672,70,,672,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,710.4,
BOST SCI 39185-20121 COYOTE BALLOON,C1725,HCPCS,,79003088,CDM,272,RC,,,both,,,1050,777,,,777,Other,150% of Medicare + 9.63% HCRA Surcharge,472.5,45,,472.5,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,519.75,,,519.75,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,735,70,,735,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,777,
BOST SCI 39185-20221 COYOTE BALLOON,C1725,HCPCS,,79003089,CDM,272,RC,,,both,,,1216,899.84,,,899.84,Other,150% of Medicare + 9.63% HCRA Surcharge,547.2,45,,547.2,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,601.92,,,601.92,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,851.2,70,,851.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,899.84,
BOST SCI 39135-25401 COYOTE ES BALLOON,C1725,HCPCS,,79003090,CDM,272,RC,,,both,,,1110,821.4,,,821.4,Other,150% of Medicare + 9.63% HCRA Surcharge,499.5,45,,499.5,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,549.45,,,549.45,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,777,70,,777,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,821.4,
BOST SCI 39185-35061 COYOTE BALLOON,C1725,HCPCS,,79003091,CDM,272,RC,,,both,,,960,710.4,,,710.4,Other,150% of Medicare + 9.63% HCRA Surcharge,432,45,,432,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,475.2,,,475.2,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,672,70,,672,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,710.4,
J&J 426-1504X 4FR SLEEK CATH 1.5X40X150,C1725,HCPCS,,79003092,CDM,272,RC,,,both,,,1010,747.4,,,747.4,Other,150% of Medicare + 9.63% HCRA Surcharge,454.5,45,,454.5,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,499.95,,,499.95,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,707,70,,707,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,747.4,
J&J 417-1860S MAXI LD BALLOON CATH 18X6,C1725,HCPCS,,79003093,CDM,272,RC,,,both,,,858,634.92,,,634.92,Other,150% of Medicare + 9.63% HCRA Surcharge,386.1,45,,386.1,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,424.71,,,424.71,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,600.6,70,,600.6,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,634.92,
BOST SCI 17-578 ULTRATHIN SDS BALLOON,C1725,HCPCS,,79003094,CDM,272,RC,,,both,,,480,355.2,,,355.2,Other,150% of Medicare + 9.63% HCRA Surcharge,216,45,,216,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,237.6,,,237.6,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,336,70,,336,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,355.2,
BOST SCI 17-633 ULTRATHIN SDS BALLOON,C1725,HCPCS,,79003095,CDM,272,RC,,,both,,,480,355.2,,,355.2,Other,150% of Medicare + 9.63% HCRA Surcharge,216,45,,216,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,237.6,,,237.6,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,336,70,,336,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,355.2,
BOST SCI 17-668 ULTRATHIN SDS BALLOON,C1725,HCPCS,,79003096,CDM,272,RC,,,both,,,480,355.2,,,355.2,Other,150% of Medicare + 9.63% HCRA Surcharge,216,45,,216,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,237.6,,,237.6,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,336,70,,336,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,355.2,
BOST SCI 17-688 ULTRATHIN SDS BALLOON,C1725,HCPCS,,79003097,CDM,272,RC,,,both,,,480,355.2,,,355.2,Other,150% of Medicare + 9.63% HCRA Surcharge,216,45,,216,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,237.6,,,237.6,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,336,70,,336,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,355.2,
EV3 AB35W03040080 EVERCROSS BALLOON,C1725,HCPCS,,79003098,CDM,272,RC,,,both,,,540,399.6,,,399.6,Other,150% of Medicare + 9.63% HCRA Surcharge,243,45,,243,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,267.3,,,267.3,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,378,70,,378,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,399.6,
EV3 AB35W04020080 EVERCROSS BALLOON,C1725,HCPCS,,79003099,CDM,272,RC,,,both,,,316,233.84,,,233.84,Other,150% of Medicare + 9.63% HCRA Surcharge,142.2,45,,142.2,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,156.42,,,156.42,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,221.2,70,,221.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,233.84,
EV3 AB35W04040135 EVERCROSS BALLOON,C1725,HCPCS,,79003100,CDM,272,RC,,,both,,,316,233.84,,,233.84,Other,150% of Medicare + 9.63% HCRA Surcharge,142.2,45,,142.2,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,156.42,,,156.42,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,221.2,70,,221.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,233.84,
EV3 AB35W04080080 EVERCROSS BALLOON,C1725,HCPCS,,79003101,CDM,272,RC,,,both,,,540,399.6,,,399.6,Other,150% of Medicare + 9.63% HCRA Surcharge,243,45,,243,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,267.3,,,267.3,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,378,70,,378,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,399.6,
EV3 AB35W04100135 EVERCROSS BALLOON,C1725,HCPCS,,79003102,CDM,272,RC,,,both,,,316,233.84,,,233.84,Other,150% of Medicare + 9.63% HCRA Surcharge,142.2,45,,142.2,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,156.42,,,156.42,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,221.2,70,,221.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,233.84,
EV3 AB35W05020080 EVERCROSS BALLOON,C1725,HCPCS,,79003103,CDM,272,RC,,,both,,,316,233.84,,,233.84,Other,150% of Medicare + 9.63% HCRA Surcharge,142.2,45,,142.2,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,156.42,,,156.42,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,221.2,70,,221.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,233.84,
EV3 AB35W05030040 EVERCROSS BALLOON,C1725,HCPCS,,79003104,CDM,272,RC,,,both,,,540,399.6,,,399.6,Other,150% of Medicare + 9.63% HCRA Surcharge,243,45,,243,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,267.3,,,267.3,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,378,70,,378,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,399.6,
EV3 AB35W05040135 EVERCROSS BALLOON,C1725,HCPCS,,79003105,CDM,272,RC,,,both,,,515,381.1,,,381.1,Other,150% of Medicare + 9.63% HCRA Surcharge,231.75,45,,231.75,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,254.93,,,254.93,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,360.5,70,,360.5,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,381.1,
EV3 AB35W05200135 EVERCROSS BALLOON,C1725,HCPCS,,79003106,CDM,272,RC,,,both,,,675,499.5,,,499.5,Other,150% of Medicare + 9.63% HCRA Surcharge,303.75,45,,303.75,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,334.13,,,334.13,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,472.5,70,,472.5,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,499.5,
EV3 AB35W06020040 EVERCROSS BALLOON,C1725,HCPCS,,79003107,CDM,272,RC,,,both,,,316,233.84,,,233.84,Other,150% of Medicare + 9.63% HCRA Surcharge,142.2,45,,142.2,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,156.42,,,156.42,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,221.2,70,,221.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,233.84,
EV3 AB35W06030080 EVERCROSS BALLOON,C1725,HCPCS,,79003108,CDM,272,RC,,,both,,,540,399.6,,,399.6,Other,150% of Medicare + 9.63% HCRA Surcharge,243,45,,243,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,267.3,,,267.3,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,378,70,,378,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,399.6,
EV3 AB35W06040135 EVERCROSS BALLOON,C1725,HCPCS,,79003109,CDM,272,RC,,,both,,,515,381.1,,,381.1,Other,150% of Medicare + 9.63% HCRA Surcharge,231.75,45,,231.75,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,254.93,,,254.93,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,360.5,70,,360.5,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,381.1,
EV3 AB35W06060080 EVERCROSS BALLOON,C1725,HCPCS,,79003110,CDM,272,RC,,,both,,,515,381.1,,,381.1,Other,150% of Medicare + 9.63% HCRA Surcharge,231.75,45,,231.75,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,254.93,,,254.93,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,360.5,70,,360.5,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,381.1,
EV3 AB35W07020080 EVERCROSS BALLOON,C1725,HCPCS,,79003111,CDM,272,RC,,,both,,,316,233.84,,,233.84,Other,150% of Medicare + 9.63% HCRA Surcharge,142.2,45,,142.2,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,156.42,,,156.42,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,221.2,70,,221.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,233.84,
EV3 AB35W07040135 EVERCROSS BALLOON,C1725,HCPCS,,79003112,CDM,272,RC,,,both,,,515,381.1,,,381.1,Other,150% of Medicare + 9.63% HCRA Surcharge,231.75,45,,231.75,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,254.93,,,254.93,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,360.5,70,,360.5,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,381.1,
EV3 AB35W07060080 EVERCROSS BALLOON,C1725,HCPCS,,79003113,CDM,272,RC,,,both,,,515,381.1,,,381.1,Other,150% of Medicare + 9.63% HCRA Surcharge,231.75,45,,231.75,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,254.93,,,254.93,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,360.5,70,,360.5,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,381.1,
EV3 AB35W08040080 EVERCROSS BALLOON,C1725,HCPCS,,79003114,CDM,272,RC,,,both,,,515,381.1,,,381.1,Other,150% of Medicare + 9.63% HCRA Surcharge,231.75,45,,231.75,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,254.93,,,254.93,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,360.5,70,,360.5,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,381.1,
EV3 AB35W09040080 EVERCROSS BALLOON,C1725,HCPCS,,79003115,CDM,272,RC,,,both,,,515,381.1,,,381.1,Other,150% of Medicare + 9.63% HCRA Surcharge,231.75,45,,231.75,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,254.93,,,254.93,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,360.5,70,,360.5,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,381.1,
EV3 AB35W10040080 EVERCROSS BALLOON,C1725,HCPCS,,79003116,CDM,272,RC,,,both,,,515,381.1,,,381.1,Other,150% of Medicare + 9.63% HCRA Surcharge,231.75,45,,231.75,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,254.93,,,254.93,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,360.5,70,,360.5,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,381.1,
BOST SCI T304013501 3X40X135 POLAR CATH,C1725,HCPCS,,79003117,CDM,272,RC,,,both,,,2592,1918.09,,,1918.09,Other,150% of Medicare + 9.63% HCRA Surcharge,1166.4,45,,1166.4,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1283.04,,,1283.04,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1814.4,70,,1814.4,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1918.09,
BOST SCI P56012001 5X60X120 POLAR CATH,C1725,HCPCS,,79003118,CDM,272,RC,,,both,,,2592,1918.09,,,1918.09,Other,150% of Medicare + 9.63% HCRA Surcharge,1166.4,45,,1166.4,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1283.04,,,1283.04,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1814.4,70,,1814.4,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1918.09,
BOST SCI P64012001 6X40X120 POLAR CATH,C1725,HCPCS,,79003119,CDM,272,RC,,,both,,,2592,1918.09,,,1918.09,Other,150% of Medicare + 9.63% HCRA Surcharge,1166.4,45,,1166.4,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1283.04,,,1283.04,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1814.4,70,,1814.4,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1918.09,
BOST SCI PCB7020135 CUTTING BALLOON,C1725,HCPCS,,79003120,CDM,272,RC,,,both,,,2400,1776.01,,,1776.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1080,45,,1080,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1188,,,1188,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1680,70,,1680,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1776.01,
BOST SCI 27-127 8FR FLEXIMA CATHETER SET,C1729,HCPCS,,79003121,CDM,272,RC,,,both,,,292,216.08,,,216.08,Other,150% of Medicare + 9.63% HCRA Surcharge,131.4,45,,131.4,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,144.54,,,144.54,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,204.4,70,,204.4,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,216.08,
BOST SCI 27-260 8FRX35CM FLEXIMA CATH,C1729,HCPCS,,79003122,CDM,272,RC,,,both,,,259,191.66,,,191.66,Other,150% of Medicare + 9.63% HCRA Surcharge,116.55,45,,116.55,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,128.21,,,128.21,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,181.3,70,,181.3,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,191.66,
BOST SCI 27-261 10FRX35CM FLEXIMA CATH,C1729,HCPCS,,79003123,CDM,272,RC,,,both,,,259,191.66,,,191.66,Other,150% of Medicare + 9.63% HCRA Surcharge,116.55,45,,116.55,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,128.21,,,128.21,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,181.3,70,,181.3,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,191.66,
BOST SCI 22-137 8FRX24CM NEPHRRTRL STENT,C1729,HCPCS,,79003124,CDM,272,RC,,,both,,,310,229.4,,,229.4,Other,150% of Medicare + 9.63% HCRA Surcharge,139.5,45,,139.5,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,153.45,,,153.45,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,217,70,,217,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,229.4,
BOST SCI 22-138 8FRX26CM NEPHRRTRL STENT,C1725,HCPCS,,79003125,CDM,272,RC,,,both,,,317,234.58,,,234.58,Other,150% of Medicare + 9.63% HCRA Surcharge,142.65,45,,142.65,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,156.92,,,156.92,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,221.9,70,,221.9,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,234.58,
CSI PAGH18M371 ASTATO 30 GUIDEWIRE,C1729,HCPCS,,79003126,CDM,272,RC,,,both,,,2550,1887.01,,,1887.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1147.5,45,,1147.5,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1262.25,,,1262.25,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1785,70,,1785,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1887.01,
VASCULAR SLNS 4005 5.5 FR EXT CATHETER,C1757,HCPCS,,79003127,CDM,272,RC,,,both,,,886,655.64,,,655.64,Other,150% of Medicare + 9.63% HCRA Surcharge,398.7,45,,398.7,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,438.57,,,438.57,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,620.2,70,,620.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,655.64,
ARGON MED 700009 THROMBECTOMY SYS 65CM,C1757,HCPCS,,79003128,CDM,272,RC,,,both,,,1786,1321.64,,,1321.64,Other,150% of Medicare + 9.63% HCRA Surcharge,803.7,45,,803.7,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,884.07,,,884.07,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1250.2,70,,1250.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1321.64,
ARROW W01801 EMBOLECTOMY CATH 80CM,C1757,HCPCS,,79003129,CDM,272,RC,,,both,,,222,164.28,,,164.28,Other,150% of Medicare + 9.63% HCRA Surcharge,99.9,45,,99.9,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,109.89,,,109.89,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,155.4,70,,155.4,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,164.28,
EXPORTAP MEDTRONIC 6FR ASPIR CATH 140CM,C1757,HCPCS,,79003130,CDM,272,RC,,,both,,,1710,1265.4,,,1265.4,Other,150% of Medicare + 9.63% HCRA Surcharge,769.5,45,,769.5,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,846.45,,,846.45,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1197,70,,1197,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1265.4,
J&J EX500 5FR EXOSEAL CLOSURE DEVICE,C1760,HCPCS,,79003131,CDM,272,RC,,,both,,,5700,4218.01,,,4218.01,Other,150% of Medicare + 9.63% HCRA Surcharge,2565,45,,2565,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2821.5,,,2821.5,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,3990,70,,3990,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4218.01,
BOST SCI 46-152B ANGLED ZIPWIRE .035X180,C1769,HCPCS,,79003132,CDM,272,RC,,,both,,,125,92.5,,,92.5,Other,150% of Medicare + 9.63% HCRA Surcharge,56.25,45,,56.25,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,61.88,,,61.88,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,87.5,70,,87.5,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,92.5,
BOST SCI 39216-73001 V-14 CONTROL WIRE,C1769,HCPCS,,79003133,CDM,272,RC,,,both,,,628,464.72,,,464.72,Other,150% of Medicare + 9.63% HCRA Surcharge,282.6,45,,282.6,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,310.86,,,310.86,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,439.6,70,,439.6,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,464.72,
BOST SCI 49-148 BENTSON WIRE .035X260CM,C1769,HCPCS,,79003134,CDM,272,RC,,,both,,,305,225.7,,,225.7,Other,150% of Medicare + 9.63% HCRA Surcharge,137.25,45,,137.25,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,150.98,,,150.98,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,213.5,70,,213.5,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,225.7,
BOST SCI 50-810 FATHOM-14 .014X200CM,C1769,HCPCS,,79003135,CDM,272,RC,,,both,,,1020,754.8,,,754.8,Other,150% of Medicare + 9.63% HCRA Surcharge,459,45,,459,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,504.9,,,504.9,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,714,70,,714,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,754.8,
BOST SCI 50-910 FATHOM-16 .016X180CM,C1769,HCPCS,,79003136,CDM,272,RC,,,both,,,316,233.84,,,233.84,Other,150% of Medicare + 9.63% HCRA Surcharge,142.2,45,,142.2,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,156.42,,,156.42,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,221.2,70,,221.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,233.84,
BOST SCI 46-740 PLATINUM PLUS .014X180CM,C1769,HCPCS,,79003137,CDM,272,RC,,,both,,,310,229.4,,,229.4,Other,150% of Medicare + 9.63% HCRA Surcharge,139.5,45,,139.5,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,153.45,,,153.45,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,217,70,,217,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,229.4,
BOST SCI 46-712 PLATINUM PLUS .014X300CM,C1769,HCPCS,,79003138,CDM,272,RC,,,both,,,320,236.8,,,236.8,Other,150% of Medicare + 9.63% HCRA Surcharge,144,45,,144,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,158.4,,,158.4,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,224,70,,224,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,236.8,
BOST SCI 46-601 PLATINUM PLUS .018X180CM,C1769,HCPCS,,79003139,CDM,272,RC,,,both,,,233,172.42,,,172.42,Other,150% of Medicare + 9.63% HCRA Surcharge,104.85,45,,104.85,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,115.34,,,115.34,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,163.1,70,,163.1,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,172.42,
BOST SCI 46-602 PLATINUM PLUS .018X260CM,C1769,HCPCS,,79003140,CDM,272,RC,,,both,,,275,203.5,,,203.5,Other,150% of Medicare + 9.63% HCRA Surcharge,123.75,45,,123.75,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,136.13,,,136.13,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,192.5,70,,192.5,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,203.5,
BOST SCI PAGH18M370 TREASURE-12 WIRE,C1769,HCPCS,,79003141,CDM,272,RC,,,both,,,510,377.4,,,377.4,Other,150% of Medicare + 9.63% HCRA Surcharge,229.5,45,,229.5,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,252.45,,,252.45,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,357,70,,357,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,377.4,
J&J 527-914J STABILIZER WIRE .014 180CM,C1769,HCPCS,,79003142,CDM,272,RC,,,both,,,538,398.12,,,398.12,Other,150% of Medicare + 9.63% HCRA Surcharge,242.1,45,,242.1,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,266.31,,,266.31,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,376.6,70,,376.6,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,398.12,
COOK G09957 AMPLATZ ULTRA STIFF WIRE 145,C1769,HCPCS,,79003143,CDM,272,RC,,,both,,,90,66.6,,,66.6,Other,150% of Medicare + 9.63% HCRA Surcharge,40.5,45,,40.5,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,44.55,,,44.55,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,63,70,,63,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,66.6,
COOK G06979 ROADRUNNER PC GUIDE WIRE 145,C1769,HCPCS,,79003144,CDM,272,RC,,,both,,,96,71.04,,,71.04,Other,150% of Medicare + 9.63% HCRA Surcharge,43.2,45,,43.2,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,47.52,,,47.52,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,67.2,70,,67.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,71.04,
COOK G36278 ANGLED HIWIRE .018 X 260CM,C1769,HCPCS,,79003145,CDM,272,RC,,,both,,,162,119.88,,,119.88,Other,150% of Medicare + 9.63% HCRA Surcharge,72.9,45,,72.9,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,80.19,,,80.19,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,113.4,70,,113.4,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,119.88,
COOK G47733 APPROACH PRO LT .014 X 190CM,C1769,HCPCS,,79003146,CDM,272,RC,,,both,,,228,168.72,,,168.72,Other,150% of Medicare + 9.63% HCRA Surcharge,102.6,45,,102.6,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,112.86,,,112.86,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,159.6,70,,159.6,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,168.72,
COOK G47734 APPROACH PRO LT .014 X 300CM,C1769,HCPCS,,79003147,CDM,272,RC,,,both,,,180,133.2,,,133.2,Other,150% of Medicare + 9.63% HCRA Surcharge,81,45,,81,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,89.1,,,89.1,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,126,70,,126,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,133.2,
COOK G01253 ROSEN CURVED GUIDEWIRE 260CM,C1769,HCPCS,,79003148,CDM,272,RC,,,both,,,49,36.26,,,36.26,Other,150% of Medicare + 9.63% HCRA Surcharge,22.05,45,,22.05,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,24.26,,,24.26,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,34.3,70,,34.3,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,36.26,
COOK G52938 APPROACH HYDRO ST .014X190CM,C1769,HCPCS,,79003149,CDM,272,RC,,,both,,,516,381.84,,,381.84,Other,150% of Medicare + 9.63% HCRA Surcharge,232.2,45,,232.2,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,255.42,,,255.42,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,361.2,70,,361.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,381.84,
COOK CMW-14-190 WIRE GUIDE .014 X 190CM,C1769,HCPCS,,79003150,CDM,272,RC,,,both,,,228,168.72,,,168.72,Other,150% of Medicare + 9.63% HCRA Surcharge,102.6,45,,102.6,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,112.86,,,112.86,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,159.6,70,,159.6,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,168.72,
COOK CMW-14-300 WIRE GUIDE .014 X 300CM,C1769,HCPCS,,79003151,CDM,272,RC,,,both,,,180,133.2,,,133.2,Other,150% of Medicare + 9.63% HCRA Surcharge,81,45,,81,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,89.1,,,89.1,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,126,70,,126,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,133.2,
ANGIOTECH 392006020 6FR SNARE SYS12-20MM,C1773,HCPCS,,79003152,CDM,272,RC,,,both,,,1036,766.64,,,766.64,Other,150% of Medicare + 9.63% HCRA Surcharge,466.2,45,,466.2,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,512.82,,,512.82,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,725.2,70,,725.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,766.64,
ANGIOTECH 392006010 6FR SNARE SYS 6-10MM,C1773,HCPCS,,79003153,CDM,272,RC,,,both,,,1155,854.7,,,854.7,Other,150% of Medicare + 9.63% HCRA Surcharge,519.75,45,,519.75,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,571.73,,,571.73,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,808.5,70,,808.5,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,854.7,
COOK G07187 VASC RETVL FORCEPS 3FRX120CM,C1773,HCPCS,,79003154,CDM,272,RC,,,both,,,1836,1358.64,,,1358.64,Other,150% of Medicare + 9.63% HCRA Surcharge,826.2,45,,826.2,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,908.82,,,908.82,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1285.2,70,,1285.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1358.64,
GTRS-200-RB COOK VC FILTER RETRIEVAL SET,C1773,HCPCS,,79003155,CDM,272,RC,,,both,,,750,555,,,555,Other,150% of Medicare + 9.63% HCRA Surcharge,337.5,45,,337.5,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,371.25,,,371.25,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,525,70,,525,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,555,
BOST SCI 18-133 RENEGRADE ANG MICROCATH,C1887,HCPCS,,79003200,CDM,272,RC,,,both,,,1446,1070.04,,,1070.04,Other,150% of Medicare + 9.63% HCRA Surcharge,650.7,45,,650.7,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,715.77,,,715.77,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1012.2,70,,1012.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1070.04,
BOST SCI 18-137 RENEGRADE STR MICROCATH,C1887,HCPCS,,79003201,CDM,272,RC,,,both,,,1446,1070.04,,,1070.04,Other,150% of Medicare + 9.63% HCRA Surcharge,650.7,45,,650.7,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,715.77,,,715.77,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1012.2,70,,1012.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1070.04,
BOST SCI 39239-01813 RUBICON .018X135CM,C1887,HCPCS,,79003202,CDM,272,RC,,,both,,,406,300.44,,,300.44,Other,150% of Medicare + 9.63% HCRA Surcharge,182.7,45,,182.7,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,200.97,,,200.97,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,284.2,70,,284.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,300.44,
BOST SCI 39240-03509 RUBICON .035X90CM,C1887,HCPCS,,79003203,CDM,272,RC,,,both,,,406,300.44,,,300.44,Other,150% of Medicare + 9.63% HCRA Surcharge,182.7,45,,182.7,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,200.97,,,200.97,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,284.2,70,,284.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,300.44,
J&J 670-190-55 GUIDING CATH IM 6FRX55CM,C1887,HCPCS,,79003204,CDM,272,RC,,,both,,,174,128.76,,,128.76,Other,150% of Medicare + 9.63% HCRA Surcharge,78.3,45,,78.3,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,86.13,,,86.13,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,121.8,70,,121.8,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,128.76,
J&J 670-210-55 GUIDING CATH RDC 6FRX55CM,C1887,HCPCS,,79003205,CDM,272,RC,,,both,,,340,251.6,,,251.6,Other,150% of Medicare + 9.63% HCRA Surcharge,153,45,,153,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,168.3,,,168.3,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,238,70,,238,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,251.6,
J&J 670-278-90 GUIDE CATH H-STICK 6FRX90,C1887,HCPCS,,79003206,CDM,272,RC,,,both,,,330,244.2,,,244.2,Other,150% of Medicare + 9.63% HCRA Surcharge,148.5,45,,148.5,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,163.35,,,163.35,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,231,70,,231,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,244.2,
J&J 670-190-90 GUIDING CATH IM 6FRX90CM,C1887,HCPCS,,79003207,CDM,272,RC,,,both,,,336,248.64,,,248.64,Other,150% of Medicare + 9.63% HCRA Surcharge,151.2,45,,151.2,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,166.32,,,166.32,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,235.2,70,,235.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,248.64,
J&J 670-270-90 GUIDING CATH MPA 6FRX90CM,C1887,HCPCS,,79003208,CDM,272,RC,,,both,,,174,128.76,,,128.76,Other,150% of Medicare + 9.63% HCRA Surcharge,78.3,45,,78.3,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,86.13,,,86.13,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,121.8,70,,121.8,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,128.76,
COOK G52546 4FR CXI SUPPORT CATH 90CM,C1887,HCPCS,,79003209,CDM,272,RC,,,both,,,450,333,,,333,Other,150% of Medicare + 9.63% HCRA Surcharge,202.5,45,,202.5,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,222.75,,,222.75,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,315,70,,315,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,333,
EV3 41035-01 INFUSION CATH 4FR X 65CM,C1887,HCPCS,,79003210,CDM,272,RC,,,both,,,346,256.04,,,256.04,Other,150% of Medicare + 9.63% HCRA Surcharge,155.7,45,,155.7,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,171.27,,,171.27,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,242.2,70,,242.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,256.04,
EV3 41042-01 INFUSION CATH 4FR X 135CM,C1887,HCPCS,,79003211,CDM,272,RC,,,both,,,346,256.04,,,256.04,Other,150% of Medicare + 9.63% HCRA Surcharge,155.7,45,,155.7,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,171.27,,,171.27,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,242.2,70,,242.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,256.04,
EV3 SC-035-135 TRAILBLAZER CATH 5FRX135,C1887,HCPCS,,79003212,CDM,272,RC,,,both,,,2626,1943.25,,,1943.25,Other,150% of Medicare + 9.63% HCRA Surcharge,1181.7,45,,1181.7,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1299.87,,,1299.87,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1838.2,70,,1838.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1943.25,
BARD SK15035 .035X150 SEEKER CROSS CATH,C1887,HCPCS,,79003213,CDM,272,RC,,,both,,,480,355.2,,,355.2,Other,150% of Medicare + 9.63% HCRA Surcharge,216,45,,216,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,237.6,,,237.6,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,336,70,,336,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,355.2,
BOST SCI 20-703 ACCUSTICK STR WIRE 21X15,C1894,HCPCS,,79003214,CDM,272,RC,,,both,,,260,192.4,,,192.4,Other,150% of Medicare + 9.63% HCRA Surcharge,117,45,,117,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,128.7,,,128.7,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,182,70,,182,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,192.4,
BOST SCI 20-710 ACCUSTICK JTIP WIRE21X15,C1894,HCPCS,,79003215,CDM,272,RC,,,both,,,233,172.42,,,172.42,Other,150% of Medicare + 9.63% HCRA Surcharge,104.85,45,,104.85,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,115.34,,,115.34,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,163.1,70,,163.1,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,172.42,
J&J 401-755M BRITE TIP SHEATHS 7FRX55CM,C1894,HCPCS,,79003216,CDM,272,RC,,,both,,,112,82.88,,,82.88,Other,150% of Medicare + 9.63% HCRA Surcharge,50.4,45,,50.4,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,55.44,,,55.44,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,78.4,70,,78.4,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,82.88,
J&J 401-823M BRITE TIP SHEATHS 8FRX23CM,C1894,HCPCS,,79003217,CDM,272,RC,,,both,,,100,74,,,74,Other,150% of Medicare + 9.63% HCRA Surcharge,45,45,,45,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,49.5,,,49.5,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,70,70,,70,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,74,
COOK G32233 10FR CHECK-FLO INTRODUCERSET,C1894,HCPCS,,79003218,CDM,272,RC,,,both,,,306,226.44,,,226.44,Other,150% of Medicare + 9.63% HCRA Surcharge,137.7,45,,137.7,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,151.47,,,151.47,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,214.2,70,,214.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,226.44,
COOK G29986 7FR CHECK-FLO INTRODUCER SET,C1894,HCPCS,,79003219,CDM,272,RC,,,both,,,245,181.3,,,181.3,Other,150% of Medicare + 9.63% HCRA Surcharge,110.25,45,,110.25,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,121.28,,,121.28,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,171.5,70,,171.5,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,181.3,
COOK G56233 8FR CHECK-FLO INTRODUCER,C1894,HCPCS,,79003220,CDM,272,RC,,,both,,,192,142.08,,,142.08,Other,150% of Medicare + 9.63% HCRA Surcharge,86.4,45,,86.4,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,95.04,,,95.04,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,134.4,70,,134.4,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,142.08,
COOK G56222 7FR CHECK-FLO INTRODUCER,C1894,HCPCS,,79003221,CDM,272,RC,,,both,,,222,164.28,,,164.28,Other,150% of Medicare + 9.63% HCRA Surcharge,99.9,45,,99.9,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,109.89,,,109.89,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,155.4,70,,155.4,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,164.28,
COOK G56221 6FR CHECK-FLO INTRODUCER,C1894,HCPCS,,79003222,CDM,272,RC,,,both,,,222,164.28,,,164.28,Other,150% of Medicare + 9.63% HCRA Surcharge,99.9,45,,99.9,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,109.89,,,109.89,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,155.4,70,,155.4,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,164.28,
COOK G12831 22FR CHECK-FLO INTRODUCER,C1894,HCPCS,,79003223,CDM,272,RC,,,both,,,1018,753.32,,,753.32,Other,150% of Medicare + 9.63% HCRA Surcharge,458.1,45,,458.1,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,503.91,,,503.91,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,712.6,70,,712.6,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,753.32,
COOK G47944 4FR MICROPUNCT INTRODUCER ST,C1894,HCPCS,,79003224,CDM,272,RC,,,both,,,109,80.66,,,80.66,Other,150% of Medicare + 9.63% HCRA Surcharge,49.05,45,,49.05,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,53.96,,,53.96,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,76.3,70,,76.3,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,80.66,
COOK G48002 4FR STIFF MICROPUNCT INTROD,C1894,HCPCS,,79003225,CDM,272,RC,,,both,,,116,85.84,,,85.84,Other,150% of Medicare + 9.63% HCRA Surcharge,52.2,45,,52.2,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,57.42,,,57.42,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,81.2,70,,81.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,85.84,
COOK G02972 4FR MICROPUNCT PEDAL ACC SET,C1894,HCPCS,,79003226,CDM,272,RC,,,both,,,178,131.72,,,131.72,Other,150% of Medicare + 9.63% HCRA Surcharge,80.1,45,,80.1,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,88.11,,,88.11,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,124.6,70,,124.6,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,131.72,
COOK G03563 5FR NEEDLE SET 15CM,C1894,HCPCS,,79003227,CDM,272,RC,,,both,,,134,99.16,,,99.16,Other,150% of Medicare + 9.63% HCRA Surcharge,60.3,45,,60.3,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,66.33,,,66.33,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,93.8,70,,93.8,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,99.16,
COOK G03388 5FR NEEDLE SET 25CM,C1894,HCPCS,,79003228,CDM,272,RC,,,both,,,134,99.16,,,99.16,Other,150% of Medicare + 9.63% HCRA Surcharge,60.3,45,,60.3,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,66.33,,,66.33,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,93.8,70,,93.8,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,99.16,
TERUMO RSC08 7FR DEST GUIDE SHEATH 90CM,C1894,HCPCS,,79003229,CDM,272,RC,,,both,,,383,283.42,,,283.42,Other,150% of Medicare + 9.63% HCRA Surcharge,172.35,45,,172.35,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,189.59,,,189.59,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,268.1,70,,268.1,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,283.42,
BARD U4150322 ULTRAVERSE BALLOON 3X22,C1725,HCPCS,,79003262,CDM,272,RC,,,both,,,916,677.84,,,677.84,Other,150% of Medicare + 9.63% HCRA Surcharge,412.2,45,,412.2,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,453.42,,,453.42,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,641.2,70,,641.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,677.84,
BARD U813034 ULTRAVERSE BALLOON 3X4,C1725,HCPCS,,79003263,CDM,272,RC,,,both,,,856,633.44,,,633.44,Other,150% of Medicare + 9.63% HCRA Surcharge,385.2,45,,385.2,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,423.72,,,423.72,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,599.2,70,,599.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,633.44,
BARD U8130310 ULTRAVERSE BALLOON 3X10,C1725,HCPCS,,79003264,CDM,272,RC,,,both,,,856,633.44,,,633.44,Other,150% of Medicare + 9.63% HCRA Surcharge,385.2,45,,385.2,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,423.72,,,423.72,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,599.2,70,,599.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,633.44,
ARTHREX AR-8737-01 GUIDE WIRE 1.35MM,C1769,HCPCS,,79003313,CDM,272,RC,,,both,,,49,36.26,,,36.26,Other,150% of Medicare + 9.63% HCRA Surcharge,22.05,45,,22.05,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,24.26,,,24.26,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,34.3,70,,34.3,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,36.26,
ZIMMER 74-2237-37 ZMS GUIDE WIRE 3.0,C1769,HCPCS,,79003417,CDM,272,RC,,,both,,,354,261.96,,,261.96,Other,150% of Medicare + 9.63% HCRA Surcharge,159.3,45,,159.3,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,175.23,,,175.23,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,247.8,70,,247.8,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,261.96,
ARTHREX AR-8737-05 GUIDE WIRE 1.1MM,C1769,HCPCS,,79003615,CDM,272,RC,,,both,,,60,44.4,,,44.4,Other,150% of Medicare + 9.63% HCRA Surcharge,27,45,,27,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,29.7,,,29.7,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,42,70,,42,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,44.4,
GWR419478 GUIDEWIRE 98CM GLOBAL ICE,C1769,HCPCS,,79003626,CDM,272,RC,,,both,,,600,444,,,444,Other,150% of Medicare + 9.63% HCRA Surcharge,270,45,,270,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,297,,,297,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,420,70,,420,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,444,
MEDTRONIC 6250EH02 CATHETER ATTAIN,C1887,HCPCS,,79003627,CDM,272,RC,,,both,,,648,479.52,,,479.52,Other,150% of Medicare + 9.63% HCRA Surcharge,291.6,45,,291.6,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,320.76,,,320.76,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,453.6,70,,453.6,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,479.52,
GORE DSL1828 DRYSEAL SHEATH,C1894,HCPCS,,79003643,CDM,272,RC,,,both,,,1014,750.36,,,750.36,Other,150% of Medicare + 9.63% HCRA Surcharge,456.3,45,,456.3,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,501.93,,,501.93,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,709.8,70,,709.8,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,750.36,
STRYKER 1806-0080S GUIDE WIRE 3X800MM,C1769,HCPCS,,79003726,CDM,272,RC,,,both,,,373,276.02,,,276.02,Other,150% of Medicare + 9.63% HCRA Surcharge,167.85,45,,167.85,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,184.64,,,184.64,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,261.1,70,,261.1,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,276.02,
ARTHREX AR-8737-21 GUIDE WIRE .86MM,C1769,HCPCS,,79003766,CDM,272,RC,,,both,,,65,48.1,,,48.1,Other,150% of Medicare + 9.63% HCRA Surcharge,29.25,45,,29.25,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,32.18,,,32.18,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,45.5,70,,45.5,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,48.1,
ZIMMER 47-2255-008-01 GUIDE WIRE 3X100CM,C1769,HCPCS,,79003774,CDM,272,RC,,,both,,,430,318.2,,,318.2,Other,150% of Medicare + 9.63% HCRA Surcharge,193.5,45,,193.5,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,212.85,,,212.85,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,301,70,,301,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,318.2,
DEPUY 2810-01-100 GUIDE WIRE 3MMX100CM,C1769,HCPCS,,79003913,CDM,272,RC,,,both,,,389,287.86,,,287.86,Other,150% of Medicare + 9.63% HCRA Surcharge,175.05,45,,175.05,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,192.56,,,192.56,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,272.3,70,,272.3,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,287.86,
SYNTHES 900.726 GUIDE WIRE 2.8X450MM,C1769,HCPCS,,79004206,CDM,272,RC,,,both,,,184,136.16,,,136.16,Other,150% of Medicare + 9.63% HCRA Surcharge,82.8,45,,82.8,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,91.08,,,91.08,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,128.8,70,,128.8,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,136.16,
ZIMMER 2228-14 GUIDE WIRE 2.4MM,C1769,HCPCS,,79004820,CDM,272,RC,,,both,,,362,267.88,,,267.88,Other,150% of Medicare + 9.63% HCRA Surcharge,162.9,45,,162.9,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,179.19,,,179.19,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,253.4,70,,253.4,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,267.88,
ZIMMER 47-2255-008-01 GUIDE WIRE 3MM,C1769,HCPCS,,79004842,CDM,272,RC,,,both,,,367,271.58,,,271.58,Other,150% of Medicare + 9.63% HCRA Surcharge,165.15,45,,165.15,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,181.67,,,181.67,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,256.9,70,,256.9,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,271.58,
EV3 ENW-SF-014-300 ENTER GUIDEWIRE STIFF,C1769,HCPCS,,79004846,CDM,272,RC,,,both,,,1080,799.2,,,799.2,Other,150% of Medicare + 9.63% HCRA Surcharge,486,45,,486,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,534.6,,,534.6,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,756,70,,756,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,799.2,
BOST SCI 39206-06201 6X200X135CM BALLOON,C1725,HCPCS,,79004847,CDM,272,RC,,,both,,,586,433.64,,,433.64,Other,150% of Medicare + 9.63% HCRA Surcharge,263.7,45,,263.7,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,290.07,,,290.07,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,410.2,70,,410.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,433.64,
BOST SCI 39206-04087 4X80X75CM BALLOON,C1725,HCPCS,,79004848,CDM,272,RC,,,both,,,496,367.04,,,367.04,Other,150% of Medicare + 9.63% HCRA Surcharge,223.2,45,,223.2,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,245.52,,,245.52,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,347.2,70,,347.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,367.04,
BOST SCI 39206-05087 5X80X75CM BALLOON,C1725,HCPCS,,79004849,CDM,272,RC,,,both,,,496,367.04,,,367.04,Other,150% of Medicare + 9.63% HCRA Surcharge,223.2,45,,223.2,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,245.52,,,245.52,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,347.2,70,,347.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,367.04,
BOST SCI 39206-05151 5X150X135CM BALLOON,C1725,HCPCS,,79004850,CDM,272,RC,,,both,,,586,433.64,,,433.64,Other,150% of Medicare + 9.63% HCRA Surcharge,263.7,45,,263.7,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,290.07,,,290.07,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,410.2,70,,410.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,433.64,
BOST SCI 39206-06087 6X80X75CM BALLOON,C1725,HCPCS,,79004851,CDM,272,RC,,,both,,,496,367.04,,,367.04,Other,150% of Medicare + 9.63% HCRA Surcharge,223.2,45,,223.2,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,245.52,,,245.52,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,347.2,70,,347.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,367.04,
BOST SCI 39206-07101 7X100X135CM BALLOON,C1725,HCPCS,,79004852,CDM,272,RC,,,both,,,496,367.04,,,367.04,Other,150% of Medicare + 9.63% HCRA Surcharge,223.2,45,,223.2,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,245.52,,,245.52,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,347.2,70,,347.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,367.04,
BOST SCI 39206-07201 7X200X135CM BALLOON,C1725,HCPCS,,79004853,CDM,272,RC,,,both,,,586,433.64,,,433.64,Other,150% of Medicare + 9.63% HCRA Surcharge,263.7,45,,263.7,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,290.07,,,290.07,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,410.2,70,,410.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,433.64,
BOST SCI 39206-06151 6X150X135CM BALLOON,C1725,HCPCS,,79004855,CDM,272,RC,,,both,,,586,433.64,,,433.64,Other,150% of Medicare + 9.63% HCRA Surcharge,263.7,45,,263.7,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,290.07,,,290.07,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,410.2,70,,410.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,433.64,
SYNTHES 900.722 GUIDE WIRE 1.25X150MM,C1769,HCPCS,,79004908,CDM,272,RC,,,both,,,59,43.66,,,43.66,Other,150% of Medicare + 9.63% HCRA Surcharge,26.55,45,,26.55,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,29.21,,,29.21,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,41.3,70,,41.3,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,43.66,
BOST SCI 39147-35201 BALLOON 3.5X20X135,C1725,HCPCS,,79004978,CDM,272,RC,,,both,,,1110,821.4,,,821.4,Other,150% of Medicare + 9.63% HCRA Surcharge,499.5,45,,499.5,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,549.45,,,549.45,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,777,70,,777,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,821.4,
STRYKER LF4200 LIGASURE  IMPACT 18CM RR,C1760,HCPCS,,79005058,CDM,272,RC,,,both,,,1298,960.52,,,960.52,Other,150% of Medicare + 9.63% HCRA Surcharge,584.1,45,,584.1,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,642.51,,,642.51,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,908.6,70,,908.6,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,960.52,
J&J 401-655MRR 6FR 55CM BRITE TIP SHEATH,C1894,HCPCS,,79005073,CDM,272,RC,,,both,,,34,25.16,,,25.16,Other,150% of Medicare + 9.63% HCRA Surcharge,15.3,45,,15.3,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,16.83,,,16.83,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,23.8,70,,23.8,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,25.16,
J&J 401-755MRR 7FR 55CM BRITE TIP SHEATH,C1894,HCPCS,,79005074,CDM,272,RC,,,both,,,34,25.16,,,25.16,Other,150% of Medicare + 9.63% HCRA Surcharge,15.3,45,,15.3,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,16.83,,,16.83,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,23.8,70,,23.8,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,25.16,
COOK G11672RR 18FR 30CM CHECK-FLO SHEATH,C1894,HCPCS,,79005075,CDM,272,RC,,,both,,,156,115.44,,,115.44,Other,150% of Medicare + 9.63% HCRA Surcharge,70.2,45,,70.2,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,77.22,,,77.22,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,109.2,70,,109.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,115.44,
SYNTHES 292.68 GUIDE WIRE 2.8X300MM,C1769,HCPCS,,79005117,CDM,272,RC,,,both,,,106,78.44,,,78.44,Other,150% of Medicare + 9.63% HCRA Surcharge,47.7,45,,47.7,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,52.47,,,52.47,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,74.2,70,,74.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,78.44,
EV3 A14BX020040170 RAPIDCROSS BALLOON,C1725,HCPCS,,79005137,CDM,272,RC,,,both,,,1041,770.34,,,770.34,Other,150% of Medicare + 9.63% HCRA Surcharge,468.45,45,,468.45,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,515.3,,,515.3,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,728.7,70,,728.7,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,770.34,
EV3 A14BX020210170 RAPIDCROSS BALLOON,C1725,HCPCS,,79005138,CDM,272,RC,,,both,,,810,599.4,,,599.4,Other,150% of Medicare + 9.63% HCRA Surcharge,364.5,45,,364.5,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,400.95,,,400.95,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,567,70,,567,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,599.4,
EV3 A14BX025210170 RAPIDCROSS BALLOON,C1725,HCPCS,,79005139,CDM,272,RC,,,both,,,1290,954.6,,,954.6,Other,150% of Medicare + 9.63% HCRA Surcharge,580.5,45,,580.5,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,638.55,,,638.55,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,903,70,,903,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,954.6,
EV3 A14BX025120170 RAPIDCROSS BALLOON,C1725,HCPCS,,79005140,CDM,272,RC,,,both,,,720,532.8,,,532.8,Other,150% of Medicare + 9.63% HCRA Surcharge,324,45,,324,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,356.4,,,356.4,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,504,70,,504,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,532.8,
EV3 A14BX030080170 RAPIDCROSS BALLOON,C1725,HCPCS,,79005141,CDM,272,RC,,,both,,,1062,785.88,,,785.88,Other,150% of Medicare + 9.63% HCRA Surcharge,477.9,45,,477.9,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,525.69,,,525.69,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,743.4,70,,743.4,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,785.88,
EV3 A14BX030120170 RAPIDCROSS BALLOON,C1725,HCPCS,,79005142,CDM,272,RC,,,both,,,720,532.8,,,532.8,Other,150% of Medicare + 9.63% HCRA Surcharge,324,45,,324,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,356.4,,,356.4,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,504,70,,504,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,532.8,
EV3 A14BX030210170 RAPIDCROSS BALLOON,C1725,HCPCS,,79005143,CDM,272,RC,,,both,,,810,599.4,,,599.4,Other,150% of Medicare + 9.63% HCRA Surcharge,364.5,45,,364.5,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,400.95,,,400.95,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,567,70,,567,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,599.4,
EV3 A14BX035210170 RAPIDCROSS BALLOON,C1725,HCPCS,,79005144,CDM,272,RC,,,both,,,1290,954.6,,,954.6,Other,150% of Medicare + 9.63% HCRA Surcharge,580.5,45,,580.5,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,638.55,,,638.55,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,903,70,,903,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,954.6,
EV3 A14BX040020170 4X20X170 BALLOON,C1725,HCPCS,,79005145,CDM,272,RC,,,both,,,1062,785.88,,,785.88,Other,150% of Medicare + 9.63% HCRA Surcharge,477.9,45,,477.9,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,525.69,,,525.69,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,743.4,70,,743.4,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,785.88,
EV3 A14BX040080170 4X80X170 BALLOON,C1725,HCPCS,,79005146,CDM,272,RC,,,both,,,1062,785.88,,,785.88,Other,150% of Medicare + 9.63% HCRA Surcharge,477.9,45,,477.9,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,525.69,,,525.69,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,743.4,70,,743.4,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,785.88,
EV3 A14BX040150170 4X150X170 BALLOON,C1725,HCPCS,,79005147,CDM,272,RC,,,both,,,1290,954.6,,,954.6,Other,150% of Medicare + 9.63% HCRA Surcharge,580.5,45,,580.5,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,638.55,,,638.55,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,903,70,,903,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,954.6,
EV3 SPD2-US-050-320 5MM SPIDER FX,C1884,HCPCS,,79005186,CDM,272,RC,,,both,,,3886,2875.65,,,2875.65,Other,150% of Medicare + 9.63% HCRA Surcharge,1748.7,45,,1748.7,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1923.57,,,1923.57,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2720.2,70,,2720.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2875.65,
EV3 SPD2-US-060-320 6MM SPIDER FX,C1884,HCPCS,,79005187,CDM,272,RC,,,both,,,3886,2875.65,,,2875.65,Other,150% of Medicare + 9.63% HCRA Surcharge,1748.7,45,,1748.7,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1923.57,,,1923.57,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2720.2,70,,2720.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2875.65,
BOST SCI PCB602090 CUTTING BALLOON,C1725,HCPCS,,79005239,CDM,272,RC,,,both,,,2400,1776.01,,,1776.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1080,45,,1080,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1188,,,1188,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1680,70,,1680,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1776.01,
EV3 AB18W040150150 POWERCROSS BALLOON,C1725,HCPCS,,79005392,CDM,272,RC,,,both,,,676,500.24,,,500.24,Other,150% of Medicare + 9.63% HCRA Surcharge,304.2,45,,304.2,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,334.62,,,334.62,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,473.2,70,,473.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,500.24,
EV3 AB18W040200150 POWERCROSS BALLOON,C1725,HCPCS,,79005393,CDM,272,RC,,,both,,,676,500.24,,,500.24,Other,150% of Medicare + 9.63% HCRA Surcharge,304.2,45,,304.2,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,334.62,,,334.62,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,473.2,70,,473.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,500.24,
EV3 AB18W050120150 POWERCROSS BALLOON,C1725,HCPCS,,79005394,CDM,272,RC,,,both,,,526,389.24,,,389.24,Other,150% of Medicare + 9.63% HCRA Surcharge,236.7,45,,236.7,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,260.37,,,260.37,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,368.2,70,,368.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,389.24,
EV3 AB18W050150150 POWERCROSS BALLOON,C1725,HCPCS,,79005395,CDM,272,RC,,,both,,,676,500.24,,,500.24,Other,150% of Medicare + 9.63% HCRA Surcharge,304.2,45,,304.2,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,334.62,,,334.62,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,473.2,70,,473.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,500.24,
EV3 AB18W050200150 POWERCROSS BALLOON,C1725,HCPCS,,79005396,CDM,272,RC,,,both,,,676,500.24,,,500.24,Other,150% of Medicare + 9.63% HCRA Surcharge,304.2,45,,304.2,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,334.62,,,334.62,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,473.2,70,,473.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,500.24,
EV3 AB18W060120150 POWERCROSS BALLOON,C1725,HCPCS,,79005397,CDM,272,RC,,,both,,,526,389.24,,,389.24,Other,150% of Medicare + 9.63% HCRA Surcharge,236.7,45,,236.7,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,260.37,,,260.37,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,368.2,70,,368.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,389.24,
EV3 AB18W060150150 POWERCROSS BALLOON,C1725,HCPCS,,79005398,CDM,272,RC,,,both,,,676,500.24,,,500.24,Other,150% of Medicare + 9.63% HCRA Surcharge,304.2,45,,304.2,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,334.62,,,334.62,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,473.2,70,,473.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,500.24,
EV3 AB18W060200150 POWERCROSS BALLOON,C1725,HCPCS,,79005399,CDM,272,RC,,,both,,,676,500.24,,,500.24,Other,150% of Medicare + 9.63% HCRA Surcharge,304.2,45,,304.2,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,334.62,,,334.62,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,473.2,70,,473.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,500.24,
EV3 AB35W04080135 EVERCROSS BALLOON,C1725,HCPCS,,79005400,CDM,272,RC,,,both,,,316,233.84,,,233.84,Other,150% of Medicare + 9.63% HCRA Surcharge,142.2,45,,142.2,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,156.42,,,156.42,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,221.2,70,,221.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,233.84,
EV3 AB35W05060135 EVERCROSS BALLOON,C1725,HCPCS,,79005401,CDM,272,RC,,,both,,,316,233.84,,,233.84,Other,150% of Medicare + 9.63% HCRA Surcharge,142.2,45,,142.2,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,156.42,,,156.42,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,221.2,70,,221.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,233.84,
EV3 AB35W05150135 EVERCROSS BALLOON,C1725,HCPCS,,79005402,CDM,272,RC,,,both,,,420,310.8,,,310.8,Other,150% of Medicare + 9.63% HCRA Surcharge,189,45,,189,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,207.9,,,207.9,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,294,70,,294,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,310.8,
EV3 AB35W06040080 EVERCROSS BALLOON,C1725,HCPCS,,79005403,CDM,272,RC,,,both,,,515,381.1,,,381.1,Other,150% of Medicare + 9.63% HCRA Surcharge,231.75,45,,231.75,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,254.93,,,254.93,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,360.5,70,,360.5,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,381.1,
EV3 AB35W06060135 EVERCROSS BALLOON,C1725,HCPCS,,79005404,CDM,272,RC,,,both,,,316,233.84,,,233.84,Other,150% of Medicare + 9.63% HCRA Surcharge,142.2,45,,142.2,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,156.42,,,156.42,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,221.2,70,,221.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,233.84,
EV3 AB35W06080080 EVERCROSS BALLOON,C1725,HCPCS,,79005405,CDM,272,RC,,,both,,,515,381.1,,,381.1,Other,150% of Medicare + 9.63% HCRA Surcharge,231.75,45,,231.75,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,254.93,,,254.93,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,360.5,70,,360.5,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,381.1,
EV3 AB35W06080135 EVERCROSS BALLOON,C1725,HCPCS,,79005406,CDM,272,RC,,,both,,,515,381.1,,,381.1,Other,150% of Medicare + 9.63% HCRA Surcharge,231.75,45,,231.75,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,254.93,,,254.93,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,360.5,70,,360.5,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,381.1,
EV3 AB35W05080135 EVERCROSS BALLOON,C1725,HCPCS,,79005407,CDM,272,RC,,,both,,,316,233.84,,,233.84,Other,150% of Medicare + 9.63% HCRA Surcharge,142.2,45,,142.2,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,156.42,,,156.42,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,221.2,70,,221.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,233.84,
EV3 AB35W07060135 EVERCROSS BALLOON,C1725,HCPCS,,79005409,CDM,272,RC,,,both,,,316,233.84,,,233.84,Other,150% of Medicare + 9.63% HCRA Surcharge,142.2,45,,142.2,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,156.42,,,156.42,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,221.2,70,,221.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,233.84,
EV3 AB35W07080080 EVERCROSS BALLOON,C1725,HCPCS,,79005410,CDM,272,RC,,,both,,,316,233.84,,,233.84,Other,150% of Medicare + 9.63% HCRA Surcharge,142.2,45,,142.2,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,156.42,,,156.42,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,221.2,70,,221.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,233.84,
EV3 AB35W07080135 EVERCROSS BALLOON,C1725,HCPCS,,79005411,CDM,272,RC,,,both,,,316,233.84,,,233.84,Other,150% of Medicare + 9.63% HCRA Surcharge,142.2,45,,142.2,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,156.42,,,156.42,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,221.2,70,,221.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,233.84,
EV3 AB35W07100135 EVERCROSS BALLOON,C1725,HCPCS,,79005412,CDM,272,RC,,,both,,,316,233.84,,,233.84,Other,150% of Medicare + 9.63% HCRA Surcharge,142.2,45,,142.2,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,156.42,,,156.42,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,221.2,70,,221.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,233.84,
EV3 AB35W08060080 EVERCROSS BALLOON,C1725,HCPCS,,79005413,CDM,272,RC,,,both,,,316,233.84,,,233.84,Other,150% of Medicare + 9.63% HCRA Surcharge,142.2,45,,142.2,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,156.42,,,156.42,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,221.2,70,,221.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,233.84,
EV3 AB35W08080080 EVERCROSS BALLOON,C1725,HCPCS,,79005414,CDM,272,RC,,,both,,,515,381.1,,,381.1,Other,150% of Medicare + 9.63% HCRA Surcharge,231.75,45,,231.75,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,254.93,,,254.93,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,360.5,70,,360.5,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,381.1,
EV3 AB35W09060080 EVERCROSS BALLOON,C1725,HCPCS,,79005415,CDM,272,RC,,,both,,,515,381.1,,,381.1,Other,150% of Medicare + 9.63% HCRA Surcharge,231.75,45,,231.75,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,254.93,,,254.93,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,360.5,70,,360.5,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,381.1,
EV3 AB35W10060080 EVERCROSS BALLOON,C1725,HCPCS,,79005416,CDM,272,RC,,,both,,,316,233.84,,,233.84,Other,150% of Medicare + 9.63% HCRA Surcharge,142.2,45,,142.2,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,156.42,,,156.42,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,221.2,70,,221.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,233.84,
EV3 SPD2-US-040-320 SPIDER FX 4X320/190,C1884,HCPCS,,79005432,CDM,272,RC,,,both,,,3886,2875.65,,,2875.65,Other,150% of Medicare + 9.63% HCRA Surcharge,1748.7,45,,1748.7,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1923.57,,,1923.57,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2720.2,70,,2720.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2875.65,
EV3 SPD2-US-070-320 SPIDER FX 7X320/190,C1884,HCPCS,,79005433,CDM,272,RC,,,both,,,3886,2875.65,,,2875.65,Other,150% of Medicare + 9.63% HCRA Surcharge,1748.7,45,,1748.7,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1923.57,,,1923.57,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2720.2,70,,2720.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2875.65,
COOK G50233 4X10X135 PTA 4 COOK BALLOON,C1725,HCPCS,,79005442,CDM,272,RC,,,both,,,946,700.04,,,700.04,Other,150% of Medicare + 9.63% HCRA Surcharge,425.7,45,,425.7,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,468.27,,,468.27,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,662.2,70,,662.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,700.04,
EV3 AB35W04060135 EVERCROSS BALLOON,C1725,HCPCS,,79005448,CDM,272,RC,,,both,,,316,233.84,,,233.84,Other,150% of Medicare + 9.63% HCRA Surcharge,142.2,45,,142.2,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,156.42,,,156.42,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,221.2,70,,221.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,233.84,
EV3 AB35W06100135 EVERCROSS BALLOON,C1725,HCPCS,,79005449,CDM,272,RC,,,both,,,515,381.1,,,381.1,Other,150% of Medicare + 9.63% HCRA Surcharge,231.75,45,,231.75,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,254.93,,,254.93,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,360.5,70,,360.5,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,381.1,
EV3 AB18W040020090 POWERCROSS BALLOON,C1725,HCPCS,,79005450,CDM,272,RC,,,both,,,526,389.24,,,389.24,Other,150% of Medicare + 9.63% HCRA Surcharge,236.7,45,,236.7,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,260.37,,,260.37,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,368.2,70,,368.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,389.24,
EV3 AB18W050020090 POWERCROSS BALLOON,C1725,HCPCS,,79005451,CDM,272,RC,,,both,,,526,389.24,,,389.24,Other,150% of Medicare + 9.63% HCRA Surcharge,236.7,45,,236.7,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,260.37,,,260.37,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,368.2,70,,368.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,389.24,
EV3 AB18W060020090 POWERCROSS BALLOON,C1725,HCPCS,,79005452,CDM,272,RC,,,both,,,526,389.24,,,389.24,Other,150% of Medicare + 9.63% HCRA Surcharge,236.7,45,,236.7,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,260.37,,,260.37,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,368.2,70,,368.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,389.24,
EV3 AB18W050080150 POWERCROSS BALLOON,C1725,HCPCS,,79005453,CDM,272,RC,,,both,,,526,389.24,,,389.24,Other,150% of Medicare + 9.63% HCRA Surcharge,236.7,45,,236.7,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,260.37,,,260.37,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,368.2,70,,368.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,389.24,
EV3 AB18W060100150 POWERCROSS BALLOON,C1725,HCPCS,,79005454,CDM,272,RC,,,both,,,526,389.24,,,389.24,Other,150% of Medicare + 9.63% HCRA Surcharge,236.7,45,,236.7,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,260.37,,,260.37,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,368.2,70,,368.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,389.24,
EV3 A14BX020060170 RAPIDCROSS BALLOON,C1725,HCPCS,,79005455,CDM,272,RC,,,both,,,1041,770.34,,,770.34,Other,150% of Medicare + 9.63% HCRA Surcharge,468.45,45,,468.45,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,515.3,,,515.3,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,728.7,70,,728.7,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,770.34,
EV3 A14BX020120170 RAPIDCROSS BALLOON,C1725,HCPCS,,79005456,CDM,272,RC,,,both,,,720,532.8,,,532.8,Other,150% of Medicare + 9.63% HCRA Surcharge,324,45,,324,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,356.4,,,356.4,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,504,70,,504,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,532.8,
EV3 A14BX025060170 RAPIDCROSS BALLOON,C1725,HCPCS,,79005457,CDM,272,RC,,,both,,,720,532.8,,,532.8,Other,150% of Medicare + 9.63% HCRA Surcharge,324,45,,324,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,356.4,,,356.4,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,504,70,,504,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,532.8,
EV3 A14BX030060170 RAPIDCROSS BALLOON,C1725,HCPCS,,79005458,CDM,272,RC,,,both,,,1062,785.88,,,785.88,Other,150% of Medicare + 9.63% HCRA Surcharge,477.9,45,,477.9,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,525.69,,,525.69,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,743.4,70,,743.4,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,785.88,
EV3 A14BX035100170 RAPIDCROSS BALLOON,C1725,HCPCS,,79005459,CDM,272,RC,,,both,,,720,532.8,,,532.8,Other,150% of Medicare + 9.63% HCRA Surcharge,324,45,,324,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,356.4,,,356.4,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,504,70,,504,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,532.8,
ZIMMER 2255-25 GUIDE WIRE 2.4MM,C1769,HCPCS,,79005696,CDM,272,RC,,,both,,,160,118.4,,,118.4,Other,150% of Medicare + 9.63% HCRA Surcharge,72,45,,72,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,79.2,,,79.2,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,112,70,,112,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,118.4,
ACUMED WS1106ST GUIDE WIRE .045 ACUMED,C1769,HCPCS,,79005714,CDM,272,RC,,,both,,,46,34.04,,,34.04,Other,150% of Medicare + 9.63% HCRA Surcharge,20.7,45,,20.7,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,22.77,,,22.77,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,32.2,70,,32.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,34.04,
BIOMET 2810-17-006 GUIDE WIRE 2MMX70CM,C1769,HCPCS,,79005755,CDM,272,RC,,,both,,,1080,799.2,,,799.2,Other,150% of Medicare + 9.63% HCRA Surcharge,486,45,,486,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,534.6,,,534.6,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,756,70,,756,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,799.2,
EV3 BVT6 080 30 TRELLIS INF SYS 6FR,C1757,HCPCS,,79005799,CDM,272,RC,,,both,,,6466,4784.86,,,4784.86,Other,150% of Medicare + 9.63% HCRA Surcharge,2909.7,45,,2909.7,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,3200.67,,,3200.67,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,4526.2,70,,4526.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4784.86,
EV3 BVT808015 TRELLIS INFSN 8FRX15X80CM,C1757,HCPCS,,79005821,CDM,272,RC,,,both,,,6286,4651.66,,,4651.66,Other,150% of Medicare + 9.63% HCRA Surcharge,2828.7,45,,2828.7,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,3111.57,,,3111.57,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,4400.2,70,,4400.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4651.66,
EV3 AB18W060080150 POWERCROSS BALLOON,C1725,HCPCS,,79005851,CDM,272,RC,,,both,,,526,389.24,,,389.24,Other,150% of Medicare + 9.63% HCRA Surcharge,236.7,45,,236.7,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,260.37,,,260.37,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,368.2,70,,368.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,389.24,
SYNTHES 03.211.410 COMP GUIDE WIRE 1.6MM,C1769,HCPCS,,79005858,CDM,272,RC,,,both,,,109,80.66,,,80.66,Other,150% of Medicare + 9.63% HCRA Surcharge,49.05,45,,49.05,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,53.96,,,53.96,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,76.3,70,,76.3,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,80.66,
ZIMMER 47-2255-008-00 GUIDE WIRE 2.4MM,C1769,HCPCS,,79005894,CDM,272,RC,,,both,,,367,271.58,,,271.58,Other,150% of Medicare + 9.63% HCRA Surcharge,165.15,45,,165.15,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,181.67,,,181.67,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,256.9,70,,256.9,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,271.58,
ARTHREX AR-8967K GUIDE WIRE .092X8,C1769,HCPCS,,79005993,CDM,272,RC,,,both,,,65,48.1,,,48.1,Other,150% of Medicare + 9.63% HCRA Surcharge,29.25,45,,29.25,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,32.18,,,32.18,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,45.5,70,,45.5,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,48.1,
SYNTHES 292.623 GUIDE WIRE 1.1X150MM,C1769,HCPCS,,79006088,CDM,272,RC,,,both,,,109,80.66,,,80.66,Other,150% of Medicare + 9.63% HCRA Surcharge,49.05,45,,49.05,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,53.96,,,53.96,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,76.3,70,,76.3,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,80.66,
MEDTRONIC GWR419678 ATTAIN GUIDE WIRE,C1769,HCPCS,,79006095,CDM,272,RC,,,both,,,600,444,,,444,Other,150% of Medicare + 9.63% HCRA Surcharge,270,45,,270,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,297,,,297,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,420,70,,420,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,444,
EV3 AB18W040120150 POWERCROSS 4X120X150,C1725,HCPCS,,79006184,CDM,272,RC,,,both,,,526,389.24,,,389.24,Other,150% of Medicare + 9.63% HCRA Surcharge,236.7,45,,236.7,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,260.37,,,260.37,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,368.2,70,,368.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,389.24,
EV3 AB18W030200150 POWERCROSS 3X200X150,C1725,HCPCS,,79006188,CDM,272,RC,,,both,,,676,500.24,,,500.24,Other,150% of Medicare + 9.63% HCRA Surcharge,304.2,45,,304.2,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,334.62,,,334.62,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,473.2,70,,473.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,500.24,
EV3 A14BX020020170 RAPIDCROSS 2X20X170,C1725,HCPCS,,79006189,CDM,272,RC,,,both,,,720,532.8,,,532.8,Other,150% of Medicare + 9.63% HCRA Surcharge,324,45,,324,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,356.4,,,356.4,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,504,70,,504,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,532.8,
EV3 A14BX020080170 RAPIDCROSS 2X80X170,C1725,HCPCS,,79006190,CDM,272,RC,,,both,,,1041,770.34,,,770.34,Other,150% of Medicare + 9.63% HCRA Surcharge,468.45,45,,468.45,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,515.3,,,515.3,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,728.7,70,,728.7,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,770.34,
EV3 A14BX020150170 RAPIDCROSS 2X150X170,C1725,HCPCS,,79006191,CDM,272,RC,,,both,,,810,599.4,,,599.4,Other,150% of Medicare + 9.63% HCRA Surcharge,364.5,45,,364.5,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,400.95,,,400.95,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,567,70,,567,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,599.4,
EV3 A14BX025020170 RAPIDCROSS 2.5X20X170,C1725,HCPCS,,79006192,CDM,272,RC,,,both,,,720,532.8,,,532.8,Other,150% of Medicare + 9.63% HCRA Surcharge,324,45,,324,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,356.4,,,356.4,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,504,70,,504,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,532.8,
EV3 A14BX025040170 RAPIDCROSS 2.5X40X170,C1725,HCPCS,,79006193,CDM,272,RC,,,both,,,720,532.8,,,532.8,Other,150% of Medicare + 9.63% HCRA Surcharge,324,45,,324,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,356.4,,,356.4,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,504,70,,504,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,532.8,
EV3 A14BX025080170 RAPIDCROSS 2.5X80X170,C1725,HCPCS,,79006194,CDM,272,RC,,,both,,,720,532.8,,,532.8,Other,150% of Medicare + 9.63% HCRA Surcharge,324,45,,324,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,356.4,,,356.4,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,504,70,,504,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,532.8,
EV3 A14BX025150170 RAPIDCRSS 2.5X150X170,C1725,HCPCS,,79006195,CDM,272,RC,,,both,,,810,599.4,,,599.4,Other,150% of Medicare + 9.63% HCRA Surcharge,364.5,45,,364.5,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,400.95,,,400.95,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,567,70,,567,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,599.4,
EV3 A14BX030020170 RAPIDCROSS 3X20X170,C1725,HCPCS,,79006196,CDM,272,RC,,,both,,,720,532.8,,,532.8,Other,150% of Medicare + 9.63% HCRA Surcharge,324,45,,324,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,356.4,,,356.4,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,504,70,,504,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,532.8,
EV3 A14BX030040170 RAPIDCROSS 3X40X170,C1725,HCPCS,,79006197,CDM,272,RC,,,both,,,720,532.8,,,532.8,Other,150% of Medicare + 9.63% HCRA Surcharge,324,45,,324,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,356.4,,,356.4,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,504,70,,504,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,532.8,
EV3 A14BX030150170 RAPIDCROSS 3X150X170,C1725,HCPCS,,79006198,CDM,272,RC,,,both,,,1290,954.6,,,954.6,Other,150% of Medicare + 9.63% HCRA Surcharge,580.5,45,,580.5,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,638.55,,,638.55,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,903,70,,903,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,954.6,
EV3 A14BX035020170 RAPIDCROSS 3.5X20X170,C1725,HCPCS,,79006199,CDM,272,RC,,,both,,,720,532.8,,,532.8,Other,150% of Medicare + 9.63% HCRA Surcharge,324,45,,324,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,356.4,,,356.4,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,504,70,,504,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,532.8,
EV3 A14BX035040170 RAPIDCROSS 3.5X40X170,C1725,HCPCS,,79006200,CDM,272,RC,,,both,,,720,532.8,,,532.8,Other,150% of Medicare + 9.63% HCRA Surcharge,324,45,,324,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,356.4,,,356.4,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,504,70,,504,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,532.8,
EV3 A14BX035060170 RAPIDCROSS 3.5X60X170,C1725,HCPCS,,79006201,CDM,272,RC,,,both,,,720,532.8,,,532.8,Other,150% of Medicare + 9.63% HCRA Surcharge,324,45,,324,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,356.4,,,356.4,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,504,70,,504,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,532.8,
EV3 A14BX035080170 RAPIDCROSS 3.5X80X170,C1725,HCPCS,,79006202,CDM,272,RC,,,both,,,720,532.8,,,532.8,Other,150% of Medicare + 9.63% HCRA Surcharge,324,45,,324,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,356.4,,,356.4,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,504,70,,504,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,532.8,
EV3 A14BX035120170 RAPIDCRSS 3.5X120X170,C1725,HCPCS,,79006203,CDM,272,RC,,,both,,,720,532.8,,,532.8,Other,150% of Medicare + 9.63% HCRA Surcharge,324,45,,324,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,356.4,,,356.4,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,504,70,,504,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,532.8,
EV3 A14BX035150170 RAPIDCRSS 3.5X150X170,C1725,HCPCS,,79006204,CDM,272,RC,,,both,,,810,599.4,,,599.4,Other,150% of Medicare + 9.63% HCRA Surcharge,364.5,45,,364.5,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,400.95,,,400.95,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,567,70,,567,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,599.4,
EV3 A14BX040040170 RAPIDCROSS 4X40X170,C1725,HCPCS,,79006205,CDM,272,RC,,,both,,,1062,785.88,,,785.88,Other,150% of Medicare + 9.63% HCRA Surcharge,477.9,45,,477.9,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,525.69,,,525.69,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,743.4,70,,743.4,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,785.88,
EV3 A14BX040060170 RAPIDCROSS 4X60X170,C1725,HCPCS,,79006206,CDM,272,RC,,,both,,,1062,785.88,,,785.88,Other,150% of Medicare + 9.63% HCRA Surcharge,477.9,45,,477.9,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,525.69,,,525.69,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,743.4,70,,743.4,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,785.88,
EV3 A14BX040100170 RAPIDCROSS 4X100X170,C1725,HCPCS,,79006207,CDM,272,RC,,,both,,,1062,785.88,,,785.88,Other,150% of Medicare + 9.63% HCRA Surcharge,477.9,45,,477.9,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,525.69,,,525.69,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,743.4,70,,743.4,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,785.88,
EV3 A14BX040120170 RAPIDCROSS 4X120X170,C1725,HCPCS,,79006208,CDM,272,RC,,,both,,,1062,785.88,,,785.88,Other,150% of Medicare + 9.63% HCRA Surcharge,477.9,45,,477.9,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,525.69,,,525.69,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,743.4,70,,743.4,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,785.88,
EV3 A14BX040210170 RAPIDCROSS 4X210X170,C1725,HCPCS,,79006209,CDM,272,RC,,,both,,,1290,954.6,,,954.6,Other,150% of Medicare + 9.63% HCRA Surcharge,580.5,45,,580.5,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,638.55,,,638.55,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,903,70,,903,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,954.6,
BOST SCI M001145520 BALLOON 16X40X75,C1725,HCPCS,,79006238,CDM,272,RC,,,both,,,780,577.2,,,577.2,Other,150% of Medicare + 9.63% HCRA Surcharge,351,45,,351,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,386.1,,,386.1,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,546,70,,546,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,577.2,
BOST SCI M001145570 BALLOON 18X40X75,C1725,HCPCS,,79006239,CDM,272,RC,,,both,,,780,577.2,,,577.2,Other,150% of Medicare + 9.63% HCRA Surcharge,351,45,,351,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,386.1,,,386.1,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,546,70,,546,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,577.2,
J&J 416-2040S MAXI LD BALLOON 20MMX4CM,C1725,HCPCS,,79006240,CDM,272,RC,,,both,,,858,634.92,,,634.92,Other,150% of Medicare + 9.63% HCRA Surcharge,386.1,45,,386.1,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,424.71,,,424.71,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,600.6,70,,600.6,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,634.92,
ARTHREX AR-8956K-01 GUIDE WIRE 2X200MM,C1769,HCPCS,,79006345,CDM,272,RC,,,both,,,76,56.24,,,56.24,Other,150% of Medicare + 9.63% HCRA Surcharge,34.2,45,,34.2,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,37.62,,,37.62,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,53.2,70,,53.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,56.24,
J&J 436-6015L SAVVY BALLOON 6X150X120,C1725,HCPCS,,79006408,CDM,272,RC,,,both,,,870,643.8,,,643.8,Other,150% of Medicare + 9.63% HCRA Surcharge,391.5,45,,391.5,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,430.65,,,430.65,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,609,70,,609,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,643.8,
J&J 426-3022X SLEEK BALLOON 3X220X150,C1725,HCPCS,,79006409,CDM,272,RC,,,both,,,960,710.4,,,710.4,Other,150% of Medicare + 9.63% HCRA Surcharge,432,45,,432,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,475.2,,,475.2,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,672,70,,672,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,710.4,
ABBOTT 10001782 GUIDE WIRE .014X300CM,C1769,HCPCS,,79006414,CDM,272,RC,,,both,,,276,204.24,,,204.24,Other,150% of Medicare + 9.63% HCRA Surcharge,124.2,45,,124.2,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,136.62,,,136.62,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,193.2,70,,193.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,204.24,
STRYKER 702460 GUIDE WIRE 2X150MM,C1769,HCPCS,,79006440,CDM,272,RC,,,both,,,156,115.44,,,115.44,Other,150% of Medicare + 9.63% HCRA Surcharge,70.2,45,,70.2,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,77.22,,,77.22,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,109.2,70,,109.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,115.44,
BOST SCI 39032-50151 STERLING BALLOON,C1725,HCPCS,,79006456,CDM,272,RC,,,both,,,1186,877.64,,,877.64,Other,150% of Medicare + 9.63% HCRA Surcharge,533.7,45,,533.7,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,587.07,,,587.07,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,830.2,70,,830.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,877.64,
BOST SCI 39032-50211 STERLING BALLOON,C1725,HCPCS,,79006457,CDM,272,RC,,,both,,,1186,877.64,,,877.64,Other,150% of Medicare + 9.63% HCRA Surcharge,533.7,45,,533.7,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,587.07,,,587.07,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,830.2,70,,830.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,877.64,
BOST SCI 39032-60151 STERLING BALLOON,C1725,HCPCS,,79006458,CDM,272,RC,,,both,,,1186,877.64,,,877.64,Other,150% of Medicare + 9.63% HCRA Surcharge,533.7,45,,533.7,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,587.07,,,587.07,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,830.2,70,,830.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,877.64,
BOST SCI 39032-60211 STERLING BALLOON,C1725,HCPCS,,79006459,CDM,272,RC,,,both,,,1186,877.64,,,877.64,Other,150% of Medicare + 9.63% HCRA Surcharge,533.7,45,,533.7,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,587.07,,,587.07,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,830.2,70,,830.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,877.64,
BOST SCI 39032-70151 STERLING BALLOON,C1725,HCPCS,,79006460,CDM,272,RC,,,both,,,1186,877.64,,,877.64,Other,150% of Medicare + 9.63% HCRA Surcharge,533.7,45,,533.7,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,587.07,,,587.07,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,830.2,70,,830.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,877.64,
BOST SCI 39032-70211 STELRING BALLOON,C1725,HCPCS,,79006461,CDM,272,RC,,,both,,,1186,877.64,,,877.64,Other,150% of Medicare + 9.63% HCRA Surcharge,533.7,45,,533.7,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,587.07,,,587.07,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,830.2,70,,830.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,877.64,
COOK G52261 5MMX10CM ADVANCE 35 BALLOON,C1725,HCPCS,,79006466,CDM,272,RC,,,both,,,540,399.6,,,399.6,Other,150% of Medicare + 9.63% HCRA Surcharge,243,45,,243,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,267.3,,,267.3,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,378,70,,378,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,399.6,
COOK G35536 6MMX20CM ADVANCE 35 BALLOON,C1725,HCPCS,,79006468,CDM,272,RC,,,both,,,540,399.6,,,399.6,Other,150% of Medicare + 9.63% HCRA Surcharge,243,45,,243,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,267.3,,,267.3,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,378,70,,378,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,399.6,
BOST SCI 46-300B .035X80CM ZIP WIRE,C1769,HCPCS,,79006469,CDM,272,RC,,,both,,,141,104.34,,,104.34,Other,150% of Medicare + 9.63% HCRA Surcharge,63.45,45,,63.45,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,69.8,,,69.8,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,98.7,70,,98.7,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,104.34,
STRYKER 1806-0090S GUIDE WIRE 3X800MM,C1769,HCPCS,,79006582,CDM,272,RC,,,both,,,311,230.14,,,230.14,Other,150% of Medicare + 9.63% HCRA Surcharge,139.95,45,,139.95,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,153.95,,,153.95,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,217.7,70,,217.7,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,230.14,
MEDTRONIC 6248V-90P ATTAIN CATHETER,C1887,HCPCS,,79006629,CDM,272,RC,,,both,,,910,673.4,,,673.4,Other,150% of Medicare + 9.63% HCRA Surcharge,409.5,45,,409.5,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,450.45,,,450.45,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,637,70,,637,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,673.4,
DEPUY 357.399 3.2MM GUIDE WIRE,C1769,HCPCS,,79006663,CDM,272,RC,,,both,,,146,108.04,,,108.04,Other,150% of Medicare + 9.63% HCRA Surcharge,65.7,45,,65.7,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,72.27,,,72.27,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,102.2,70,,102.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,108.04,
ACUMED 80-1524 TROCAR GUIDE WIRE .035X6,C1769,HCPCS,,79006736,CDM,272,RC,,,both,,,52,38.48,,,38.48,Other,150% of Medicare + 9.63% HCRA Surcharge,23.4,45,,23.4,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,25.74,,,25.74,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,36.4,70,,36.4,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,38.48,
J&J HEALTH 48006015X SABER 6X150 BALLOON,C1725,HCPCS,,79006771,CDM,272,RC,,,both,,,870,643.8,,,643.8,Other,150% of Medicare + 9.63% HCRA Surcharge,391.5,45,,391.5,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,430.65,,,430.65,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,609,70,,609,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,643.8,
J&J HEALTH 48006020X SABER 6X200 BALLOON,C1725,HCPCS,,79006772,CDM,272,RC,,,both,,,870,643.8,,,643.8,Other,150% of Medicare + 9.63% HCRA Surcharge,391.5,45,,391.5,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,430.65,,,430.65,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,609,70,,609,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,643.8,
BOST SCI 7081 MAILMAN .014X182 GUIDEWIRE,C1769,HCPCS,,79006800,CDM,272,RC,,,both,,,420,310.8,,,310.8,Other,150% of Medicare + 9.63% HCRA Surcharge,189,45,,189,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,207.9,,,207.9,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,294,70,,294,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,310.8,
BOST SCI 12130-01 LUGE .014X182 GUIDEWRE,C1769,HCPCS,,79006801,CDM,272,RC,,,both,,,247,182.78,,,182.78,Other,150% of Medicare + 9.63% HCRA Surcharge,111.15,45,,111.15,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,122.27,,,122.27,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,172.9,70,,172.9,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,182.78,
SYNTHES 900.601 GUIDE WIRE 1.6X150MM,C1769,HCPCS,,79006802,CDM,272,RC,,,both,,,98,72.52,,,72.52,Other,150% of Medicare + 9.63% HCRA Surcharge,44.1,45,,44.1,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,48.51,,,48.51,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,68.6,70,,68.6,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,72.52,
BARD AT75164 ATLAS BALLOON 16MMX4CM,C1725,HCPCS,,79006883,CDM,272,RC,,,both,,,1020,754.8,,,754.8,Other,150% of Medicare + 9.63% HCRA Surcharge,459,45,,459,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,504.9,,,504.9,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,714,70,,714,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,754.8,
BARD AT75184 ATLAS BALLOON 18MMX4CM,C1725,HCPCS,,79006884,CDM,272,RC,,,both,,,1020,754.8,,,754.8,Other,150% of Medicare + 9.63% HCRA Surcharge,459,45,,459,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,504.9,,,504.9,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,714,70,,714,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,754.8,
MEDTRONIC CB1812050120OTW BALLOON 5X120,C1725,HCPCS,,79006924,CDM,272,RC,,,both,,,2520,1864.81,,,1864.81,Other,150% of Medicare + 9.63% HCRA Surcharge,1134,45,,1134,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1247.4,,,1247.4,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1764,70,,1764,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1864.81,
J&J 4400704S POWERFLEX BALLOON 7MMX4CM,C1725,HCPCS,,79006925,CDM,272,RC,,,both,,,402,297.48,,,297.48,Other,150% of Medicare + 9.63% HCRA Surcharge,180.9,45,,180.9,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,198.99,,,198.99,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,281.4,70,,281.4,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,297.48,
J&J 4400804S POWERFLEX BALLOON 8MMX4CM,C1725,HCPCS,,79006926,CDM,272,RC,,,both,,,402,297.48,,,297.48,Other,150% of Medicare + 9.63% HCRA Surcharge,180.9,45,,180.9,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,198.99,,,198.99,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,281.4,70,,281.4,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,297.48,
J&J 4400510X POWERFLEX BALLOON 5MMX10CM,C1725,HCPCS,,79006927,CDM,272,RC,,,both,,,402,297.48,,,297.48,Other,150% of Medicare + 9.63% HCRA Surcharge,180.9,45,,180.9,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,198.99,,,198.99,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,281.4,70,,281.4,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,297.48,
J&J 4400515X POWERFLEX BALLOON 5MMX15CM,C1725,HCPCS,,79006928,CDM,272,RC,,,both,,,432,319.68,,,319.68,Other,150% of Medicare + 9.63% HCRA Surcharge,194.4,45,,194.4,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,213.84,,,213.84,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,302.4,70,,302.4,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,319.68,
J&J 4400615X POWERFLEX BALLOON 6MMX15CM,C1725,HCPCS,,79006929,CDM,272,RC,,,both,,,432,319.68,,,319.68,Other,150% of Medicare + 9.63% HCRA Surcharge,194.4,45,,194.4,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,213.84,,,213.84,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,302.4,70,,302.4,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,319.68,
J&J 4400622X POWERFLEX BALLOON 6MMX22CM,C1725,HCPCS,,79006930,CDM,272,RC,,,both,,,432,319.68,,,319.68,Other,150% of Medicare + 9.63% HCRA Surcharge,194.4,45,,194.4,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,213.84,,,213.84,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,302.4,70,,302.4,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,319.68,
EV3 BVT808030 TRELLIS DEVICE 8FRX80X30CM,C1887,HCPCS,,79006931,CDM,272,RC,,,both,,,6285,4650.92,,,4650.92,Other,150% of Medicare + 9.63% HCRA Surcharge,2828.25,45,,2828.25,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,3111.08,,,3111.08,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,4399.5,70,,4399.5,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4650.92,
BARD AT75204 ATLAS BALLOON 20MMX4CM,C1725,HCPCS,,79006932,CDM,272,RC,,,both,,,1126,833.24,,,833.24,Other,150% of Medicare + 9.63% HCRA Surcharge,506.7,45,,506.7,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,557.37,,,557.37,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,788.2,70,,788.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,833.24,
J&J 48003020S SABER 3MMX200MM BALLOON,C1725,HCPCS,,79006955,CDM,272,RC,,,both,,,870,643.8,,,643.8,Other,150% of Medicare + 9.63% HCRA Surcharge,391.5,45,,391.5,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,430.65,,,430.65,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,609,70,,609,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,643.8,
MEDTRONIC CB1812050080OTW BALLOON 5X80,C1725,HCPCS,,79006997,CDM,272,RC,,,both,,,2700,1998.01,,,1998.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1215,45,,1215,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1336.5,,,1336.5,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1890,70,,1890,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1998.01,
"ARTHREX AR-8941-6 GUIDE WIRE 1.6MM 6""",C1769,HCPCS,,79007026,CDM,272,RC,,,both,,,120,88.8,,,88.8,Other,150% of Medicare + 9.63% HCRA Surcharge,54,45,,54,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,59.4,,,59.4,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,84,70,,84,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,88.8,
"ARTHREX AR-8941-7 GUIDE WIRE 1.6MM 7""",C1769,HCPCS,,79007027,CDM,272,RC,,,both,,,120,88.8,,,88.8,Other,150% of Medicare + 9.63% HCRA Surcharge,54,45,,54,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,59.4,,,59.4,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,84,70,,84,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,88.8,
J&J HLTH 48005015X SABER BALLOON 5X150,C1725,HCPCS,,79007058,CDM,272,RC,,,both,,,870,643.8,,,643.8,Other,150% of Medicare + 9.63% HCRA Surcharge,391.5,45,,391.5,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,430.65,,,430.65,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,609,70,,609,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,643.8,
J&J HLTH 48007003X SABER 7X30MM BALLOON,C1725,HCPCS,,79007142,CDM,272,RC,,,both,,,720,532.8,,,532.8,Other,150% of Medicare + 9.63% HCRA Surcharge,324,45,,324,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,356.4,,,356.4,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,504,70,,504,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,532.8,
MERIT MED EN2006020 EN SNARE MULTI 20MM,C1773,HCPCS,,79007178,CDM,272,RC,,,both,,,1080,799.2,,,799.2,Other,150% of Medicare + 9.63% HCRA Surcharge,486,45,,486,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,534.6,,,534.6,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,756,70,,756,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,799.2,
BOST SCI 39031-80201 STERLING BALLOON,C1725,HCPCS,,79007184,CDM,272,RC,,,both,,,1110,821.4,,,821.4,Other,150% of Medicare + 9.63% HCRA Surcharge,499.5,45,,499.5,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,549.45,,,549.45,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,777,70,,777,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,821.4,
J&J 48003015X SABER 3X150MM BALLOON,C1725,HCPCS,,79007257,CDM,272,RC,,,both,,,870,643.8,,,643.8,Other,150% of Medicare + 9.63% HCRA Surcharge,391.5,45,,391.5,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,430.65,,,430.65,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,609,70,,609,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,643.8,
MEDTRONIC CB1413540120OTW  BALLOON 4X120,C1725,HCPCS,,79007272,CDM,272,RC,,,both,,,2520,1864.81,,,1864.81,Other,150% of Medicare + 9.63% HCRA Surcharge,1134,45,,1134,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1247.4,,,1247.4,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1764,70,,1764,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1864.81,
BOST SCI 46-525 180CM AMPLATZ WIRE,C1769,HCPCS,,79007294,CDM,272,RC,,,both,,,125,92.5,,,92.5,Other,150% of Medicare + 9.63% HCRA Surcharge,56.25,45,,56.25,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,61.88,,,61.88,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,87.5,70,,87.5,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,92.5,
COOK G30958 5X200MM ADVANCE 18LP BALLOON,C1725,HCPCS,,79007315,CDM,272,RC,,,both,,,946,700.04,,,700.04,Other,150% of Medicare + 9.63% HCRA Surcharge,425.7,45,,425.7,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,468.27,,,468.27,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,662.2,70,,662.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,700.04,
STRYKER 39031-30201-R 3X20MM BALLOON,C1725,HCPCS,,79007316,CDM,272,RC,,,both,,,450,333,,,333,Other,150% of Medicare + 9.63% HCRA Surcharge,202.5,45,,202.5,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,222.75,,,222.75,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,315,70,,315,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,333,
STRYKER DR13558-R 5X80MM DORADO BALLOON,C1725,HCPCS,,79007317,CDM,272,RC,,,both,,,256,189.44,,,189.44,Other,150% of Medicare + 9.63% HCRA Surcharge,115.2,45,,115.2,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,126.72,,,126.72,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,179.2,70,,179.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,189.44,
STRYKER DR8044-R 4X40MM DORADO BALLOON,C1725,HCPCS,,79007318,CDM,272,RC,,,both,,,228,168.72,,,168.72,Other,150% of Medicare + 9.63% HCRA Surcharge,102.6,45,,102.6,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,112.86,,,112.86,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,159.6,70,,159.6,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,168.72,
STRYKER DR8054-R 5X40MM DORADO BALLOON,C1725,HCPCS,,79007319,CDM,272,RC,,,both,,,228,168.72,,,168.72,Other,150% of Medicare + 9.63% HCRA Surcharge,102.6,45,,102.6,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,112.86,,,112.86,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,159.6,70,,159.6,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,168.72,
STRYKER DR8064-R 6X40MM DORADO BALLOON,C1725,HCPCS,,79007320,CDM,272,RC,,,both,,,228,168.72,,,168.72,Other,150% of Medicare + 9.63% HCRA Surcharge,102.6,45,,102.6,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,112.86,,,112.86,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,159.6,70,,159.6,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,168.72,
STRYKER PCB5020135-R 5X2 CUTTING BALLOON,C1725,HCPCS,,79007321,CDM,272,RC,,,both,,,900,666,,,666,Other,150% of Medicare + 9.63% HCRA Surcharge,405,45,,405,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,445.5,,,445.5,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,630,70,,630,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,666,
STRYKER PCB7020135-R 7X2 CUTTING BALLOON,C1725,HCPCS,,79007322,CDM,272,RC,,,both,,,900,666,,,666,Other,150% of Medicare + 9.63% HCRA Surcharge,405,45,,405,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,445.5,,,445.5,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,630,70,,630,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,666,
DEPUY 900.721 1.25X150MM GUIDE WIRE,C1769,HCPCS,,79007334,CDM,272,RC,,,both,,,55,40.7,,,40.7,Other,150% of Medicare + 9.63% HCRA Surcharge,24.75,45,,24.75,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,27.23,,,27.23,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,38.5,70,,38.5,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,40.7,
BOST SCI 46-564 .038X75CM AMPLATZ WIRE,C1769,HCPCS,,79007338,CDM,272,RC,,,both,,,79,58.46,,,58.46,Other,150% of Medicare + 9.63% HCRA Surcharge,35.55,45,,35.55,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,39.11,,,39.11,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,55.3,70,,55.3,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,58.46,
TERUMO 54-89001 DESTINATION SHEATH 8X90,C1894,HCPCS,,79007350,CDM,272,RC,,,both,,,383,283.42,,,283.42,Other,150% of Medicare + 9.63% HCRA Surcharge,172.35,45,,172.35,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,189.59,,,189.59,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,268.1,70,,268.1,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,283.42,
ARGON MED 700115 7FR X135CM CLEANER 15,C1757,HCPCS,,79007356,CDM,272,RC,,,both,,,2986,2209.65,,,2209.65,Other,150% of Medicare + 9.63% HCRA Surcharge,1343.7,45,,1343.7,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1478.07,,,1478.07,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2090.2,70,,2090.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2209.65,
TERUMO RSB412 4FRX10 SHEATH W/GUIDEWIRE,C1894,HCPCS,,79007374,CDM,272,RC,,,both,,,90,66.6,,,66.6,Other,150% of Medicare + 9.63% HCRA Surcharge,40.5,45,,40.5,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,44.55,,,44.55,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,63,70,,63,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,66.6,
TERUMO RSB712 7FRX10 SHEATH W/GUIDEWIRE,C1894,HCPCS,,79007375,CDM,272,RC,,,both,,,90,66.6,,,66.6,Other,150% of Medicare + 9.63% HCRA Surcharge,40.5,45,,40.5,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,44.55,,,44.55,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,63,70,,63,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,66.6,
BOST SCI 39147-20121 2X120X150 BALLOON,C1725,HCPCS,,79007385,CDM,272,RC,,,both,,,1110,821.4,,,821.4,Other,150% of Medicare + 9.63% HCRA Surcharge,499.5,45,,499.5,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,549.45,,,549.45,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,777,70,,777,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,821.4,
BOST SCI 39147-20151 2X150X150 BALLOON,C1725,HCPCS,,79007386,CDM,272,RC,,,both,,,1110,821.4,,,821.4,Other,150% of Medicare + 9.63% HCRA Surcharge,499.5,45,,499.5,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,549.45,,,549.45,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,777,70,,777,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,821.4,
BOST SCI 39031-20221 2X220X150 BALLOON,C1725,HCPCS,,79007387,CDM,272,RC,,,both,,,1110,821.4,,,821.4,Other,150% of Medicare + 9.63% HCRA Surcharge,499.5,45,,499.5,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,549.45,,,549.45,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,777,70,,777,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,821.4,
BOST SCI 39147-25121 2.5X120X150 BALLOON,C1725,HCPCS,,79007388,CDM,272,RC,,,both,,,1259,931.66,,,931.66,Other,150% of Medicare + 9.63% HCRA Surcharge,566.55,45,,566.55,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,623.21,,,623.21,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,881.3,70,,881.3,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,931.66,
BOST SCI 39147-25151 2.5X150X150 BALLOON,C1725,HCPCS,,79007389,CDM,272,RC,,,both,,,1259,931.66,,,931.66,Other,150% of Medicare + 9.63% HCRA Surcharge,566.55,45,,566.55,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,623.21,,,623.21,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,881.3,70,,881.3,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,931.66,
BOST SCI 39031-25221 2.5X220X150 BALLOON,C1725,HCPCS,,79007390,CDM,272,RC,,,both,,,1110,821.4,,,821.4,Other,150% of Medicare + 9.63% HCRA Surcharge,499.5,45,,499.5,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,549.45,,,549.45,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,777,70,,777,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,821.4,
BOST SCI 39147-30121 3X120X150 BALLOON,C1725,HCPCS,,79007391,CDM,272,RC,,,both,,,1259,931.66,,,931.66,Other,150% of Medicare + 9.63% HCRA Surcharge,566.55,45,,566.55,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,623.21,,,623.21,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,881.3,70,,881.3,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,931.66,
BOST SCI 39147-30151 3X150X150 BALLOON,C1725,HCPCS,,79007392,CDM,272,RC,,,both,,,1259,931.66,,,931.66,Other,150% of Medicare + 9.63% HCRA Surcharge,566.55,45,,566.55,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,623.21,,,623.21,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,881.3,70,,881.3,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,931.66,
BOST SCI 39031-30221 3X220X150 BALLOON,C1725,HCPCS,,79007393,CDM,272,RC,,,both,,,1186,877.64,,,877.64,Other,150% of Medicare + 9.63% HCRA Surcharge,533.7,45,,533.7,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,587.07,,,587.07,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,830.2,70,,830.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,877.64,
BOST SCI 39147-35151 3.5X150X150 BALLOON,C1725,HCPCS,,79007394,CDM,272,RC,,,both,,,1259,931.66,,,931.66,Other,150% of Medicare + 9.63% HCRA Surcharge,566.55,45,,566.55,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,623.21,,,623.21,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,881.3,70,,881.3,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,931.66,
BOST SCI 39031-35221 3.5X220X150 BALLOON,C1725,HCPCS,,79007395,CDM,272,RC,,,both,,,1110,821.4,,,821.4,Other,150% of Medicare + 9.63% HCRA Surcharge,499.5,45,,499.5,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,549.45,,,549.45,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,777,70,,777,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,821.4,
BOST SCI 39147-40121 4X120X150 BALLOON,C1725,HCPCS,,79007396,CDM,272,RC,,,both,,,1259,931.66,,,931.66,Other,150% of Medicare + 9.63% HCRA Surcharge,566.55,45,,566.55,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,623.21,,,623.21,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,881.3,70,,881.3,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,931.66,
BOST SCI 39147-40151 4X150X150 BALLOON,C1725,HCPCS,,79007397,CDM,272,RC,,,both,,,1259,931.66,,,931.66,Other,150% of Medicare + 9.63% HCRA Surcharge,566.55,45,,566.55,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,623.21,,,623.21,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,881.3,70,,881.3,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,931.66,
BOST SCI 39135-15201 1.5X20X143 BALLOON,C1725,HCPCS,,79007398,CDM,272,RC,,,both,,,1144,846.56,,,846.56,Other,150% of Medicare + 9.63% HCRA Surcharge,514.8,45,,514.8,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,566.28,,,566.28,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,800.8,70,,800.8,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,846.56,
BOST SCI 39185-20151 2X150X150 BALLOON,C1725,HCPCS,,79007399,CDM,272,RC,,,both,,,1050,777,,,777,Other,150% of Medicare + 9.63% HCRA Surcharge,472.5,45,,472.5,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,519.75,,,519.75,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,735,70,,735,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,777,
BOST SCI 39185-30221 3X220X150 BALLOON,C1725,HCPCS,,79007400,CDM,272,RC,,,both,,,1216,899.84,,,899.84,Other,150% of Medicare + 9.63% HCRA Surcharge,547.2,45,,547.2,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,601.92,,,601.92,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,851.2,70,,851.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,899.84,
BOST SCI 39185-35101 3.5X100X150 BALLOON,C1725,HCPCS,,79007401,CDM,272,RC,,,both,,,960,710.4,,,710.4,Other,150% of Medicare + 9.63% HCRA Surcharge,432,45,,432,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,475.2,,,475.2,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,672,70,,672,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,710.4,
BOST SCI 39185-35151 3.5X150X150 BALLOON,C1725,HCPCS,,79007402,CDM,272,RC,,,both,,,1050,777,,,777,Other,150% of Medicare + 9.63% HCRA Surcharge,472.5,45,,472.5,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,519.75,,,519.75,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,735,70,,735,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,777,
BOST SCI 39185-35221 3.5X220X150 BALLOON,C1725,HCPCS,,79007403,CDM,272,RC,,,both,,,1216,899.84,,,899.84,Other,150% of Medicare + 9.63% HCRA Surcharge,547.2,45,,547.2,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,601.92,,,601.92,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,851.2,70,,851.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,899.84,
J&J 48002515X SABER 2.5MMX15CM BALLOON,C1725,HCPCS,,79007427,CDM,272,RC,,,both,,,870,643.8,,,643.8,Other,150% of Medicare + 9.63% HCRA Surcharge,391.5,45,,391.5,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,430.65,,,430.65,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,609,70,,609,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,643.8,
J&J 4263004X SLEEK 3MMX40X150CM BALLOON,C1725,HCPCS,,79007428,CDM,272,RC,,,both,,,900,666,,,666,Other,150% of Medicare + 9.63% HCRA Surcharge,405,45,,405,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,445.5,,,445.5,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,630,70,,630,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,666,
COOK G50335 4X40X170CM ADVANCE BALLOON,C1725,HCPCS,,79007430,CDM,272,RC,,,both,,,1237,915.38,,,915.38,Other,150% of Medicare + 9.63% HCRA Surcharge,556.65,45,,556.65,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,612.32,,,612.32,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,865.9,70,,865.9,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,915.38,
COOK G35532 5X200 ADVANCE 35LP BALLOON,C1725,HCPCS,,79007431,CDM,272,RC,,,both,,,540,399.6,,,399.6,Other,150% of Medicare + 9.63% HCRA Surcharge,243,45,,243,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,267.3,,,267.3,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,378,70,,378,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,399.6,
ARTHREX AR-8967KT-12 GUIDE WIRE 2.4X12,C1769,HCPCS,,79007444,CDM,272,RC,,,both,,,90,66.6,,,66.6,Other,150% of Medicare + 9.63% HCRA Surcharge,40.5,45,,40.5,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,44.55,,,44.55,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,63,70,,63,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,66.6,
ARTHREX AR-8005K GUIDE WIRE 1.2MM,C1769,HCPCS,,79007445,CDM,272,RC,,,both,,,66,48.84,,,48.84,Other,150% of Medicare + 9.63% HCRA Surcharge,29.7,45,,29.7,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,32.67,,,32.67,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,46.2,70,,46.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,48.84,
DEPUY 292.656 GUIDE WIRE 2X230MM,C1769,HCPCS,,79007458,CDM,272,RC,,,both,,,75,55.5,,,55.5,Other,150% of Medicare + 9.63% HCRA Surcharge,33.75,45,,33.75,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,37.13,,,37.13,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,52.5,70,,52.5,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,55.5,
J&J HEALTH 48005020X SABER 5X200 BALLOON,C1725,HCPCS,,79007463,CDM,272,RC,,,both,,,870,643.8,,,643.8,Other,150% of Medicare + 9.63% HCRA Surcharge,391.5,45,,391.5,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,430.65,,,430.65,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,609,70,,609,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,643.8,
J&J 48006010X SABER 6MMX100MM BALLOON,C1725,HCPCS,,79007473,CDM,272,RC,,,both,,,720,532.8,,,532.8,Other,150% of Medicare + 9.63% HCRA Surcharge,324,45,,324,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,356.4,,,356.4,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,504,70,,504,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,532.8,
J&J 48004010X SABER 4MMX100MM BALLOON,C1725,HCPCS,,79007474,CDM,272,RC,,,both,,,720,532.8,,,532.8,Other,150% of Medicare + 9.63% HCRA Surcharge,324,45,,324,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,356.4,,,356.4,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,504,70,,504,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,532.8,
ARTHREX AR-8737-40 GUIDE WIRE .86MM,C1769,HCPCS,,79007477,CDM,272,RC,,,both,,,78,57.72,,,57.72,Other,150% of Medicare + 9.63% HCRA Surcharge,35.1,45,,35.1,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,38.61,,,38.61,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,54.6,70,,54.6,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,57.72,
ARTHREX AR-8967K-12 GUIDE WIRE 2.4MM,C1769,HCPCS,,79007536,CDM,272,RC,,,both,,,66,48.84,,,48.84,Other,150% of Medicare + 9.63% HCRA Surcharge,29.7,45,,29.7,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,32.67,,,32.67,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,46.2,70,,46.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,48.84,
BARD CRUS6A CROSSER CATHETER S6 154CM,C1714,HCPCS,,79007564,CDM,272,RC,,,both,,,6600,4884.02,,,4884.02,Other,150% of Medicare + 9.63% HCRA Surcharge,2970,45,,2970,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,3267,,,3267,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,4620,70,,4620,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4884.02,
BARD USH130AT USHER CATH 130CM ANGLED,C1887,HCPCS,,79007565,CDM,272,RC,,,both,,,946,700.04,,,700.04,Other,150% of Medicare + 9.63% HCRA Surcharge,425.7,45,,425.7,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,468.27,,,468.27,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,662.2,70,,662.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,700.04,
BARD CRUOS106 CROSSER CATH 14S 106CM,C1714,HCPCS,,79007567,CDM,272,RC,,,both,,,6600,4884.02,,,4884.02,Other,150% of Medicare + 9.63% HCRA Surcharge,2970,45,,2970,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,3267,,,3267,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,4620,70,,4620,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4884.02,
BARD CRUOS14SA CROSSER CATH 14S 146CM,C1714,HCPCS,,79007568,CDM,272,RC,,,both,,,6600,4884.02,,,4884.02,Other,150% of Medicare + 9.63% HCRA Surcharge,2970,45,,2970,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,3267,,,3267,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,4620,70,,4620,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4884.02,
BARD CRUS6106 CROSSER CATH S6 106CM,C1714,HCPCS,,79007569,CDM,272,RC,,,both,,,6600,4884.02,,,4884.02,Other,150% of Medicare + 9.63% HCRA Surcharge,2970,45,,2970,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,3267,,,3267,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,4620,70,,4620,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4884.02,
BARD USH83AT USHER SUPPORT CATH 83CM,C1887,HCPCS,,79007570,CDM,272,RC,,,both,,,946,700.04,,,700.04,Other,150% of Medicare + 9.63% HCRA Surcharge,425.7,45,,425.7,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,468.27,,,468.27,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,662.2,70,,662.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,700.04,
BARD SD70T SIDEKICK CATH 70CM ANGLED,C1887,HCPCS,,79007571,CDM,272,RC,,,both,,,946,700.04,,,700.04,Other,150% of Medicare + 9.63% HCRA Surcharge,425.7,45,,425.7,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,468.27,,,468.27,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,662.2,70,,662.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,700.04,
BARD SD70AT SIDEKICK CATH 70CM ANG/TAP,C1887,HCPCS,,79007572,CDM,272,RC,,,both,,,946,700.04,,,700.04,Other,150% of Medicare + 9.63% HCRA Surcharge,425.7,45,,425.7,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,468.27,,,468.27,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,662.2,70,,662.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,700.04,
BARD SD110T SIDEKICK CATH 110CM TAPER,C1887,HCPCS,,79007573,CDM,272,RC,,,both,,,946,700.04,,,700.04,Other,150% of Medicare + 9.63% HCRA Surcharge,425.7,45,,425.7,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,468.27,,,468.27,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,662.2,70,,662.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,700.04,
BARD SD110AT SIDEKICK CATH 110CM ANG/TAP,C1887,HCPCS,,79007574,CDM,272,RC,,,both,,,946,700.04,,,700.04,Other,150% of Medicare + 9.63% HCRA Surcharge,425.7,45,,425.7,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,468.27,,,468.27,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,662.2,70,,662.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,700.04,
J&J 48003010S SABER 3X10CMX90CM BALLOON,C1725,HCPCS,,79007604,CDM,272,RC,,,both,,,720,532.8,,,532.8,Other,150% of Medicare + 9.63% HCRA Surcharge,324,45,,324,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,356.4,,,356.4,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,504,70,,504,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,532.8,
MEDTRONIC CB1413535080OTW 3.5X80 BALLOON,C1725,HCPCS,,79007605,CDM,272,RC,,,both,,,2700,1998.01,,,1998.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1215,45,,1215,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1336.5,,,1336.5,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1890,70,,1890,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1998.01,
J&J 426-2508X SLEEK 2.5X80MM BALLOON,C1725,HCPCS,,79007641,CDM,272,RC,,,both,,,900,666,,,666,Other,150% of Medicare + 9.63% HCRA Surcharge,405,45,,405,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,445.5,,,445.5,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,630,70,,630,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,666,
MEDTRONIC CB1415030120OTW 3X120 BALLOON,C1725,HCPCS,,79007650,CDM,272,RC,,,both,,,3000,2220.01,,,2220.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1350,45,,1350,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1485,,,1485,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2100,70,,2100,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2220.01,
ACUMED 80-1525 DOUBLE TROCAR GUIDE WIRE,C1769,HCPCS,,79007657,CDM,272,RC,,,both,,,52,38.48,,,38.48,Other,150% of Medicare + 9.63% HCRA Surcharge,23.4,45,,23.4,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,25.74,,,25.74,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,36.4,70,,36.4,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,38.48,
DEPUY 03.010.025 2.0X240MM GUIDE WIRE,C1769,HCPCS,,79007810,CDM,272,RC,,,both,,,63,46.62,,,46.62,Other,150% of Medicare + 9.63% HCRA Surcharge,28.35,45,,28.35,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,31.19,,,31.19,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,44.1,70,,44.1,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,46.62,
MEDTRONIC ADM04004013P 4X60 ADMIRAL DCB,C2623,HCPCS,,79007827,CDM,272,RC,,,both,,,3990,2952.61,,,2952.61,Other,150% of Medicare + 9.63% HCRA Surcharge,1795.5,45,,1795.5,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1975.05,,,1975.05,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2793,70,,2793,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2952.61,
MEDTRONIC ADM05006013P 5X60 ADMIRAL DCB,C2623,HCPCS,,79007828,CDM,272,RC,,,both,,,3990,2952.61,,,2952.61,Other,150% of Medicare + 9.63% HCRA Surcharge,1795.5,45,,1795.5,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1975.05,,,1975.05,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2793,70,,2793,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2952.61,
MEDTRONIC ADM05008013P 5X80 ADMIRAL DCB,C2623,HCPCS,,79007829,CDM,272,RC,,,both,,,3990,2952.61,,,2952.61,Other,150% of Medicare + 9.63% HCRA Surcharge,1795.5,45,,1795.5,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1975.05,,,1975.05,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2793,70,,2793,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2952.61,
MEDTRONIC ADM06004013P 6X40 ADMIRAL DCB,C2623,HCPCS,,79007830,CDM,272,RC,,,both,,,3990,2952.61,,,2952.61,Other,150% of Medicare + 9.63% HCRA Surcharge,1795.5,45,,1795.5,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1975.05,,,1975.05,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2793,70,,2793,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2952.61,
MEDTRONIC ADM06006013P 6X60 ADMIRAL DCB,C2623,HCPCS,,79007831,CDM,272,RC,,,both,,,3990,2952.61,,,2952.61,Other,150% of Medicare + 9.63% HCRA Surcharge,1795.5,45,,1795.5,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1975.05,,,1975.05,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2793,70,,2793,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2952.61,
MEDTRONIC ADM06008013P 6X80 ADMIRAL DCB,C2623,HCPCS,,79007832,CDM,272,RC,,,both,,,4470,3307.81,,,3307.81,Other,150% of Medicare + 9.63% HCRA Surcharge,2011.5,45,,2011.5,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2212.65,,,2212.65,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,3129,70,,3129,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3307.81,
MEDTRONIC ADM06012013P 6X120 ADMIRAL DCB,C2623,HCPCS,,79007833,CDM,272,RC,,,both,,,4920,3640.81,,,3640.81,Other,150% of Medicare + 9.63% HCRA Surcharge,2214,45,,2214,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2435.4,,,2435.4,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,3444,70,,3444,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3640.81,
MEDTRONIC ADM07004013P 7X40 ADMIRAL DCB,C2623,HCPCS,,79007834,CDM,272,RC,,,both,,,3990,2952.61,,,2952.61,Other,150% of Medicare + 9.63% HCRA Surcharge,1795.5,45,,1795.5,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1975.05,,,1975.05,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2793,70,,2793,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2952.61,
MEDTRONIC ADM07008013P 7X80 ADMIRAL DCB,C2623,HCPCS,,79007835,CDM,272,RC,,,both,,,3990,2952.61,,,2952.61,Other,150% of Medicare + 9.63% HCRA Surcharge,1795.5,45,,1795.5,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1975.05,,,1975.05,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2793,70,,2793,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2952.61,
CH CF1415030080OTW CHOCO 3X80 BALLOON,C1725,HCPCS,,79007857,CDM,272,RC,,,both,,,2370,1753.81,,,1753.81,Other,150% of Medicare + 9.63% HCRA Surcharge,1066.5,45,,1066.5,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1173.15,,,1173.15,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1659,70,,1659,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1753.81,
MEDTRONIC CB1413535040OTW 3.5X40 BALLOON,C1725,HCPCS,,79007858,CDM,272,RC,,,both,,,2430,1798.21,,,1798.21,Other,150% of Medicare + 9.63% HCRA Surcharge,1093.5,45,,1093.5,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1202.85,,,1202.85,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1701,70,,1701,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1798.21,
MEDTRONIC CB1413540040OTW 4X40 BALLOON,C1725,HCPCS,,79007859,CDM,272,RC,,,both,,,2700,1998.01,,,1998.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1215,45,,1215,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1336.5,,,1336.5,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1890,70,,1890,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1998.01,
MEDTRONIC CB1413540080OTW 4X80 BALLOON,C1725,HCPCS,,79007860,CDM,272,RC,,,both,,,2370,1753.81,,,1753.81,Other,150% of Medicare + 9.63% HCRA Surcharge,1066.5,45,,1066.5,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1173.15,,,1173.15,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1659,70,,1659,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1753.81,
MEDTRONIC CB1812050040OTW 5X40 BALLOON,C1725,HCPCS,,79007861,CDM,272,RC,,,both,,,2370,1753.81,,,1753.81,Other,150% of Medicare + 9.63% HCRA Surcharge,1066.5,45,,1066.5,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1173.15,,,1173.15,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1659,70,,1659,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1753.81,
MEDTRONIC CB1812060080OTW 6X80 BALLOON,C1725,HCPCS,,79007862,CDM,272,RC,,,both,,,2370,1753.81,,,1753.81,Other,150% of Medicare + 9.63% HCRA Surcharge,1066.5,45,,1066.5,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1173.15,,,1173.15,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1659,70,,1659,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1753.81,
MEDTRONIC CB1812060120OTW 6X120 BALLOON,C1725,HCPCS,,79007863,CDM,272,RC,,,both,,,2520,1864.81,,,1864.81,Other,150% of Medicare + 9.63% HCRA Surcharge,1134,45,,1134,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1247.4,,,1247.4,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1764,70,,1764,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1864.81,
CARDINAL 426-4004X SLEEK 4X40MM BALLOON,C1725,HCPCS,,79007939,CDM,272,RC,,,both,,,900,666,,,666,Other,150% of Medicare + 9.63% HCRA Surcharge,405,45,,405,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,445.5,,,445.5,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,630,70,,630,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,666,
CARDINAL 426-2022X SLEEK 2X220MM BALLOON,C1725,HCPCS,,79007940,CDM,272,RC,,,both,,,960,710.4,,,710.4,Other,150% of Medicare + 9.63% HCRA Surcharge,432,45,,432,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,475.2,,,475.2,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,672,70,,672,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,710.4,
CARDINAL 426-2522X SLEEK 2.5X220 BALLOON,C1725,HCPCS,,79007959,CDM,272,RC,,,both,,,960,710.4,,,710.4,Other,150% of Medicare + 9.63% HCRA Surcharge,432,45,,432,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,475.2,,,475.2,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,672,70,,672,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,710.4,
BOST SCI 39185-20101 2X100X150 BALLOON,C1725,HCPCS,,79008019,CDM,272,RC,,,both,,,960,710.4,,,710.4,Other,150% of Medicare + 9.63% HCRA Surcharge,432,45,,432,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,475.2,,,475.2,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,672,70,,672,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,710.4,
Medtronic AB35W05040080 5X40X80 BALLOON,C1725,HCPCS,,79008039,CDM,272,RC,,,both,,,316,233.84,,,233.84,Other,150% of Medicare + 9.63% HCRA Surcharge,142.2,45,,142.2,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,156.42,,,156.42,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,221.2,70,,221.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,233.84,
Medtronic AB35W05100135 5100X135 BALLOON,C1725,HCPCS,,79008040,CDM,272,RC,,,both,,,515,381.1,,,381.1,Other,150% of Medicare + 9.63% HCRA Surcharge,231.75,45,,231.75,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,254.93,,,254.93,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,360.5,70,,360.5,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,381.1,
MEDTRONIC ADM05012013P ADMIRAL DCB 5X120,C2623,HCPCS,,79008065,CDM,272,RC,,,both,,,4440,3285.61,,,3285.61,Other,150% of Medicare + 9.63% HCRA Surcharge,1998,45,,1998,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2197.8,,,2197.8,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,3108,70,,3108,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3285.61,
CARDINAL 426-5015X SLEEK 5X150MM BALLOON,C1725,HCPCS,,79008104,CDM,272,RC,,,both,,,960,710.4,,,710.4,Other,150% of Medicare + 9.63% HCRA Surcharge,432,45,,432,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,475.2,,,475.2,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,672,70,,672,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,710.4,
COOK G56888 DUAN PIGTAIL DRAINAGE CATH,C1729,HCPCS,,79008134,CDM,272,RC,,,both,,,166,122.84,,,122.84,Other,150% of Medicare + 9.63% HCRA Surcharge,74.7,45,,74.7,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,82.17,,,82.17,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,116.2,70,,116.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,122.84,
MEDTRONIC CB1413535120OTW 3.5X120 BALLON,C1725,HCPCS,,79008143,CDM,272,RC,,,both,,,2520,1864.81,,,1864.81,Other,150% of Medicare + 9.63% HCRA Surcharge,1134,45,,1134,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1247.4,,,1247.4,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1764,70,,1764,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1864.81,
MEDTRONIC CB14150300400TW 3X40MM BALLOON,C1725,HCPCS,,79008357,CDM,272,RC,,,both,,,2160,1598.41,,,1598.41,Other,150% of Medicare + 9.63% HCRA Surcharge,972,45,,972,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1069.2,,,1069.2,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1512,70,,1512,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1598.41,
MEDTRONIC CB14150300800TW 3X80MM BALLOON,C1725,HCPCS,,79008358,CDM,272,RC,,,both,,,2700,1998.01,,,1998.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1215,45,,1215,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1336.5,,,1336.5,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1890,70,,1890,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1998.01,
MEDTRONIC CB18120600400TW  6X40 BALLOON,C1725,HCPCS,,79008359,CDM,272,RC,,,both,,,2160,1598.41,,,1598.41,Other,150% of Medicare + 9.63% HCRA Surcharge,972,45,,972,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1069.2,,,1069.2,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1512,70,,1512,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1598.41,
CH 4400610X POWERFLEX BALLOON 6MMX10CM,C1725,HCPCS,,79008506,CDM,272,RC,,,both,,,402,297.48,,,297.48,Other,150% of Medicare + 9.63% HCRA Surcharge,180.9,45,,180.9,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,198.99,,,198.99,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,281.4,70,,281.4,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,297.48,
HALYARD 0250-18 G-J TUBE 18FRX45CM,B4087,HCPCS,,79008724,CDM,272,RC,,,both,,,671,496.54,,,496.54,Other,150% of Medicare + 9.63% HCRA Surcharge,301.95,45,,301.95,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,332.15,,,332.15,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,469.7,70,,469.7,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,496.54,
MERIT OSC-5F-17PL 5FRX17CM CENTESIS CATH,C1729,HCPCS,,79008832,CDM,272,RC,,,both,,,120,88.8,,,88.8,Other,150% of Medicare + 9.63% HCRA Surcharge,54,45,,54,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,59.4,,,59.4,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,84,70,,84,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,88.8,
BARD CQF7594 CONQUEST 40 BALLOON 9X4X75,C1725,HCPCS,,79009171,CDM,272,RC,,,both,,,1464,1083.36,,,1083.36,Other,150% of Medicare + 9.63% HCRA Surcharge,658.8,45,,658.8,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,724.68,,,724.68,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1024.8,70,,1024.8,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1083.36,
STRYKER 702463 3.2X300MM GUIDE WIRE,C1769,HCPCS,,79009324,CDM,272,RC,,,both,,,237,175.38,,,175.38,Other,150% of Medicare + 9.63% HCRA Surcharge,106.65,45,,106.65,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,117.32,,,117.32,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,165.9,70,,165.9,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,175.38,
MEDTRONIC A35HPV07080080 7X80X80 BALLOON,C1725,HCPCS,,79009602,CDM,272,RC,,,both,,,617,456.58,,,456.58,Other,150% of Medicare + 9.63% HCRA Surcharge,277.65,45,,277.65,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,305.42,,,305.42,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,431.9,70,,431.9,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,456.58,
MEDTRONIC A35HPV08040080 8X40X80 BALLOON,C1725,HCPCS,,79009603,CDM,272,RC,,,both,,,617,456.58,,,456.58,Other,150% of Medicare + 9.63% HCRA Surcharge,277.65,45,,277.65,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,305.42,,,305.42,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,431.9,70,,431.9,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,456.58,
MEDTRONIC A35HPV08080080 8X80X80 BALLOON,C1725,HCPCS,,79009604,CDM,272,RC,,,both,,,617,456.58,,,456.58,Other,150% of Medicare + 9.63% HCRA Surcharge,277.65,45,,277.65,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,305.42,,,305.42,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,431.9,70,,431.9,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,456.58,
ACUMED 80-1794 DRILL BIT 1.1MM,C1713,HCPCS,,79009755,CDM,272,RC,,,both,,,720,532.8,,,532.8,Other,150% of Medicare + 9.63% HCRA Surcharge,324,45,,324,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,356.4,,,356.4,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,504,70,,504,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,532.8,
COOK G35550 4FR STIFF MICROPUNCTURE,C1894,HCPCS,,79009771,CDM,272,RC,,,both,,,60,44.4,,,44.4,Other,150% of Medicare + 9.63% HCRA Surcharge,27,45,,27,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,29.7,,,29.7,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,42,70,,42,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,44.4,
BIOTRONIK 398493 BIOMONITOR 2-AF,C1764,HCPCS,,79009859,CDM,272,RC,,,both,,,12600,9324.03,,,9324.03,Other,150% of Medicare + 9.63% HCRA Surcharge,5670,45,,5670,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,6237,,,6237,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,8820,70,,8820,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,9324.03,
BOS SCI M0067913500 DISPOSAL URETERSCOPE,C1747,HCPCS,,79010548,CDM,272,RC,,,both,,,4500,3330.01,,,3330.01,Other,150% of Medicare + 9.63% HCRA Surcharge,2025,45,,2025,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2227.5,,,2227.5,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,3150,70,,3150,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3330.01,
WEST COAST CTI-512N-W CLOSURE DEVICE,C1760,HCPCS,,79011002,CDM,272,RC,,,both,,,237,175.38,,,175.38,Other,150% of Medicare + 9.63% HCRA Surcharge,106.65,45,,106.65,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,117.32,,,117.32,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,165.9,70,,165.9,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,175.38,
BIOTRONIK 450218 BIOMONITOR IIIM,C1764,HCPCS,,79011057,CDM,272,RC,,,both,,,12600,9324.03,,,9324.03,Other,150% of Medicare + 9.63% HCRA Surcharge,5670,45,,5670,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,6237,,,6237,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,8820,70,,8820,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,9324.03,
COOK G35551 5FR STIFFENED MICROPUNCTURE,C1894,HCPCS,,79011132,CDM,272,RC,,,both,,,68,50.32,,,50.32,Other,150% of Medicare + 9.63% HCRA Surcharge,30.6,45,,30.6,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,33.66,,,33.66,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,47.6,70,,47.6,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,50.32,
MEDTRONIC IAV12004008P 12X4X80CM BALLOON,C1725,HCPCS,,79011145,CDM,272,RC,,,both,,,4650,3441.01,,,3441.01,Other,150% of Medicare + 9.63% HCRA Surcharge,2092.5,45,,2092.5,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2301.75,,,2301.75,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,3255,70,,3255,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3441.01,
MEDTRONIC IAV10004008P 10X40X80 BALLOON,C1725,HCPCS,,79011156,CDM,272,RC,,,both,,,4650,3441.01,,,3441.01,Other,150% of Medicare + 9.63% HCRA Surcharge,2092.5,45,,2092.5,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2301.75,,,2301.75,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,3255,70,,3255,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3441.01,
MEDTRONIC IAV09008008P 9X80X80 BALLOON,C1725,HCPCS,,79011157,CDM,272,RC,,,both,,,4650,3441.01,,,3441.01,Other,150% of Medicare + 9.63% HCRA Surcharge,2092.5,45,,2092.5,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2301.75,,,2301.75,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,3255,70,,3255,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3441.01,
MEDTRONIC IAV09004008P 9X40X80 BALLOON,C2623,HCPCS,,79011158,CDM,272,RC,,,both,,,4650,3441.01,,,3441.01,Other,150% of Medicare + 9.63% HCRA Surcharge,2092.5,45,,2092.5,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2301.75,,,2301.75,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,3255,70,,3255,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3441.01,
MEDTRONIC IAV08008008P 8X80X80 BALLOON,C1725,HCPCS,,79011159,CDM,272,RC,,,both,,,4650,3441.01,,,3441.01,Other,150% of Medicare + 9.63% HCRA Surcharge,2092.5,45,,2092.5,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2301.75,,,2301.75,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,3255,70,,3255,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3441.01,
MEDTRONIC IAV07004008P 7X40X80 BALLOON,C1725,HCPCS,,79011160,CDM,272,RC,,,both,,,4650,3441.01,,,3441.01,Other,150% of Medicare + 9.63% HCRA Surcharge,2092.5,45,,2092.5,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2301.75,,,2301.75,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,3255,70,,3255,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3441.01,
MEDTRONIC IAV06004008P 6X40X80 BALLOON,C1725,HCPCS,,79011161,CDM,272,RC,,,both,,,4650,3441.01,,,3441.01,Other,150% of Medicare + 9.63% HCRA Surcharge,2092.5,45,,2092.5,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2301.75,,,2301.75,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,3255,70,,3255,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3441.01,
MEDTRONIC EUP1506X BALLOON 1.5X6MM,C1725,HCPCS,,79011336,CDM,272,RC,,,both,,,300,222,,,222,Other,150% of Medicare + 9.63% HCRA Surcharge,135,45,,135,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,148.5,,,148.5,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,210,70,,210,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,222,
MEDTRONIC EUP1510X BALLOON 1.5X10MM,C1725,HCPCS,,79011337,CDM,272,RC,,,both,,,300,222,,,222,Other,150% of Medicare + 9.63% HCRA Surcharge,135,45,,135,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,148.5,,,148.5,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,210,70,,210,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,222,
MEDTRONIC EUP1512X BALLOON 1.5X12MM,C1725,HCPCS,,79011338,CDM,272,RC,,,both,,,300,222,,,222,Other,150% of Medicare + 9.63% HCRA Surcharge,135,45,,135,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,148.5,,,148.5,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,210,70,,210,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,222,
MEDTRONIC EUP1515X BALLOON 1.5X15MM,C1725,HCPCS,,79011339,CDM,272,RC,,,both,,,300,222,,,222,Other,150% of Medicare + 9.63% HCRA Surcharge,135,45,,135,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,148.5,,,148.5,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,210,70,,210,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,222,
MEDTRONIC EUP1520X BALLOON 1.5X20MM,C1725,HCPCS,,79011340,CDM,272,RC,,,both,,,300,222,,,222,Other,150% of Medicare + 9.63% HCRA Surcharge,135,45,,135,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,148.5,,,148.5,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,210,70,,210,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,222,
MEDTRONIC EUP2006X BALLOON 2X6MM,C1725,HCPCS,,79011341,CDM,272,RC,,,both,,,300,222,,,222,Other,150% of Medicare + 9.63% HCRA Surcharge,135,45,,135,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,148.5,,,148.5,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,210,70,,210,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,222,
MEDTRONIC EUP2010X BALLOON 2X10MM,C1725,HCPCS,,79011342,CDM,272,RC,,,both,,,300,222,,,222,Other,150% of Medicare + 9.63% HCRA Surcharge,135,45,,135,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,148.5,,,148.5,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,210,70,,210,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,222,
MEDTRONIC EUP2012X BALLOON 2X12MM,C1725,HCPCS,,79011343,CDM,272,RC,,,both,,,300,222,,,222,Other,150% of Medicare + 9.63% HCRA Surcharge,135,45,,135,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,148.5,,,148.5,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,210,70,,210,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,222,
MEDTRONIC EUP2015X BALLOON 2X15MM,C1725,HCPCS,,79011344,CDM,272,RC,,,both,,,300,222,,,222,Other,150% of Medicare + 9.63% HCRA Surcharge,135,45,,135,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,148.5,,,148.5,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,210,70,,210,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,222,
MEDTRONIC EUP2020X BALLOON 2X20MM,C1725,HCPCS,,79011345,CDM,272,RC,,,both,,,300,222,,,222,Other,150% of Medicare + 9.63% HCRA Surcharge,135,45,,135,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,148.5,,,148.5,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,210,70,,210,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,222,
MEDTRONIC EUP2506X BALLOON 2.5X6MM,C1725,HCPCS,,79011346,CDM,272,RC,,,both,,,300,222,,,222,Other,150% of Medicare + 9.63% HCRA Surcharge,135,45,,135,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,148.5,,,148.5,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,210,70,,210,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,222,
MEDTRONIC EUP2510X BALLOON 2.5X10MM,C1725,HCPCS,,79011347,CDM,272,RC,,,both,,,300,222,,,222,Other,150% of Medicare + 9.63% HCRA Surcharge,135,45,,135,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,148.5,,,148.5,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,210,70,,210,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,222,
MEDTRONIC EUP2512X BALLOON 2.5X12MM,C1725,HCPCS,,79011348,CDM,272,RC,,,both,,,300,222,,,222,Other,150% of Medicare + 9.63% HCRA Surcharge,135,45,,135,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,148.5,,,148.5,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,210,70,,210,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,222,
MEDTRONIC EUP2515X BALLOON 2.5X15MM,C1725,HCPCS,,79011349,CDM,272,RC,,,both,,,300,222,,,222,Other,150% of Medicare + 9.63% HCRA Surcharge,135,45,,135,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,148.5,,,148.5,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,210,70,,210,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,222,
MEDTRONIC EUP2520X BALLOON 2.5X20MM,C1725,HCPCS,,79011351,CDM,272,RC,,,both,,,300,222,,,222,Other,150% of Medicare + 9.63% HCRA Surcharge,135,45,,135,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,148.5,,,148.5,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,210,70,,210,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,222,
MEDTRONIC EUP3006X BALLOON 3X6MM,C1725,HCPCS,,79011352,CDM,272,RC,,,both,,,300,222,,,222,Other,150% of Medicare + 9.63% HCRA Surcharge,135,45,,135,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,148.5,,,148.5,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,210,70,,210,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,222,
MEDTRONIC EUP3010X BALLOON 3X10MM,C1725,HCPCS,,79011353,CDM,272,RC,,,both,,,300,222,,,222,Other,150% of Medicare + 9.63% HCRA Surcharge,135,45,,135,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,148.5,,,148.5,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,210,70,,210,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,222,
MEDTRONIC EUP3012X BALLOON 3X12MM,C1725,HCPCS,,79011354,CDM,272,RC,,,both,,,300,222,,,222,Other,150% of Medicare + 9.63% HCRA Surcharge,135,45,,135,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,148.5,,,148.5,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,210,70,,210,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,222,
MEDTRONIC EUP3015X BALLOON 3X15MM,C1725,HCPCS,,79011355,CDM,272,RC,,,both,,,300,222,,,222,Other,150% of Medicare + 9.63% HCRA Surcharge,135,45,,135,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,148.5,,,148.5,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,210,70,,210,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,222,
MEDTRONIC EUP3506X BALLOON 3.5X6MM,C1725,HCPCS,,79011356,CDM,272,RC,,,both,,,300,222,,,222,Other,150% of Medicare + 9.63% HCRA Surcharge,135,45,,135,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,148.5,,,148.5,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,210,70,,210,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,222,
MEDTRONIC EUP3510X BALLOON 3.5X10MM,C1725,HCPCS,,79011357,CDM,272,RC,,,both,,,300,222,,,222,Other,150% of Medicare + 9.63% HCRA Surcharge,135,45,,135,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,148.5,,,148.5,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,210,70,,210,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,222,
MEDTRONIC EUP3512X BALLOON 3.5X12MM,C1725,HCPCS,,79011358,CDM,272,RC,,,both,,,300,222,,,222,Other,150% of Medicare + 9.63% HCRA Surcharge,135,45,,135,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,148.5,,,148.5,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,210,70,,210,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,222,
MEDTRONIC EUP3515X BALLOON 3.5X15MM,C1725,HCPCS,,79011359,CDM,272,RC,,,both,,,300,222,,,222,Other,150% of Medicare + 9.63% HCRA Surcharge,135,45,,135,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,148.5,,,148.5,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,210,70,,210,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,222,
MEDTRONIC EUP4006X BALLOON 4X6MM,C1725,HCPCS,,79011360,CDM,272,RC,,,both,,,300,222,,,222,Other,150% of Medicare + 9.63% HCRA Surcharge,135,45,,135,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,148.5,,,148.5,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,210,70,,210,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,222,
MEDTRONIC EUP4010X BALLOON 4X10MM,C1725,HCPCS,,79011361,CDM,272,RC,,,both,,,300,222,,,222,Other,150% of Medicare + 9.63% HCRA Surcharge,135,45,,135,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,148.5,,,148.5,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,210,70,,210,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,222,
MEDTRONIC EUP4012X BALLOON 4X12MM,C1725,HCPCS,,79011362,CDM,272,RC,,,both,,,300,222,,,222,Other,150% of Medicare + 9.63% HCRA Surcharge,135,45,,135,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,148.5,,,148.5,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,210,70,,210,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,222,
MEDTRONIC EUP4015X BALLOON 4X15MM,C1725,HCPCS,,79011363,CDM,272,RC,,,both,,,300,222,,,222,Other,150% of Medicare + 9.63% HCRA Surcharge,135,45,,135,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,148.5,,,148.5,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,210,70,,210,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,222,
MEDTRONIC NCEUP2006X BALLOON 2X6MM,C1725,HCPCS,,79011364,CDM,272,RC,,,both,,,300,222,,,222,Other,150% of Medicare + 9.63% HCRA Surcharge,135,45,,135,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,148.5,,,148.5,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,210,70,,210,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,222,
MEDTRONIC NCEUP2008X NC BALLOON 2X8MM,C1725,HCPCS,,79011365,CDM,272,RC,,,both,,,300,222,,,222,Other,150% of Medicare + 9.63% HCRA Surcharge,135,45,,135,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,148.5,,,148.5,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,210,70,,210,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,222,
MEDTRONIC NCEUP2012X NC BALLOON 2X12MM,C1725,HCPCS,,79011366,CDM,272,RC,,,both,,,300,222,,,222,Other,150% of Medicare + 9.63% HCRA Surcharge,135,45,,135,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,148.5,,,148.5,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,210,70,,210,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,222,
MEDTRONIC NCEUP2015X NC BALLOON 2X15MM,C1725,HCPCS,,79011367,CDM,272,RC,,,both,,,300,222,,,222,Other,150% of Medicare + 9.63% HCRA Surcharge,135,45,,135,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,148.5,,,148.5,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,210,70,,210,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,222,
MEDTRONIC NCEUP2020X NC BALLOON 2X20MM,C1725,HCPCS,,79011368,CDM,272,RC,,,both,,,300,222,,,222,Other,150% of Medicare + 9.63% HCRA Surcharge,135,45,,135,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,148.5,,,148.5,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,210,70,,210,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,222,
MEDTRONIC NCEUP22506X NC BALLOON 2.25X6,C1725,HCPCS,,79011369,CDM,272,RC,,,both,,,300,222,,,222,Other,150% of Medicare + 9.63% HCRA Surcharge,135,45,,135,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,148.5,,,148.5,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,210,70,,210,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,222,
MEDTRONIC NCEUP22508X NC BALLOON 2.25X8,C1725,HCPCS,,79011370,CDM,272,RC,,,both,,,300,222,,,222,Other,150% of Medicare + 9.63% HCRA Surcharge,135,45,,135,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,148.5,,,148.5,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,210,70,,210,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,222,
MEDTRONIC NCEUP22512X NC BALLOON 2.25X12,C1725,HCPCS,,79011371,CDM,272,RC,,,both,,,300,222,,,222,Other,150% of Medicare + 9.63% HCRA Surcharge,135,45,,135,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,148.5,,,148.5,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,210,70,,210,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,222,
MEDTRONIC NCEUP22515X NC BALLOON 2.25X15,C1725,HCPCS,,79011372,CDM,272,RC,,,both,,,300,222,,,222,Other,150% of Medicare + 9.63% HCRA Surcharge,135,45,,135,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,148.5,,,148.5,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,210,70,,210,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,222,
MEDTRONIC NCEUP22520X NC BALLOON 2.25X20,C1725,HCPCS,,79011373,CDM,272,RC,,,both,,,300,222,,,222,Other,150% of Medicare + 9.63% HCRA Surcharge,135,45,,135,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,148.5,,,148.5,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,210,70,,210,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,222,
MEDTRONIC NCEUP2506X NC BALLOON 2.5X6MM,C1725,HCPCS,,79011374,CDM,272,RC,,,both,,,300,222,,,222,Other,150% of Medicare + 9.63% HCRA Surcharge,135,45,,135,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,148.5,,,148.5,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,210,70,,210,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,222,
MEDTRONIC NCEUP2508X NC BALLOON 2.5X8MM,C1725,HCPCS,,79011375,CDM,272,RC,,,both,,,300,222,,,222,Other,150% of Medicare + 9.63% HCRA Surcharge,135,45,,135,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,148.5,,,148.5,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,210,70,,210,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,222,
MEDTRONIC NCEUP2512X NC BALLOON 2.5X12MM,C1725,HCPCS,,79011376,CDM,272,RC,,,both,,,300,222,,,222,Other,150% of Medicare + 9.63% HCRA Surcharge,135,45,,135,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,148.5,,,148.5,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,210,70,,210,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,222,
MEDTRONIC NCEUP2515X NC BALLOON 2.5X15MM,C1725,HCPCS,,79011377,CDM,272,RC,,,both,,,300,222,,,222,Other,150% of Medicare + 9.63% HCRA Surcharge,135,45,,135,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,148.5,,,148.5,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,210,70,,210,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,222,
MEDTRONIC NCEUP2520X NC BALLOON 2.5X20MM,C1725,HCPCS,,79011378,CDM,272,RC,,,both,,,300,222,,,222,Other,150% of Medicare + 9.63% HCRA Surcharge,135,45,,135,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,148.5,,,148.5,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,210,70,,210,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,222,
MEDTRONIC NCEUP27506X NC BALLOON 2.75X6,C1725,HCPCS,,79011379,CDM,272,RC,,,both,,,300,222,,,222,Other,150% of Medicare + 9.63% HCRA Surcharge,135,45,,135,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,148.5,,,148.5,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,210,70,,210,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,222,
MEDTRONIC NCEUP27508X NC BALLOON 2.75X8,C1725,HCPCS,,79011380,CDM,272,RC,,,both,,,300,222,,,222,Other,150% of Medicare + 9.63% HCRA Surcharge,135,45,,135,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,148.5,,,148.5,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,210,70,,210,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,222,
MEDTRONIC NCEUP27512X NC BALLOON 2.75X12,C1725,HCPCS,,79011381,CDM,272,RC,,,both,,,300,222,,,222,Other,150% of Medicare + 9.63% HCRA Surcharge,135,45,,135,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,148.5,,,148.5,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,210,70,,210,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,222,
MEDTRONIC NCEUP27515X NC BALLOON 2.75X15,C1725,HCPCS,,79011382,CDM,272,RC,,,both,,,300,222,,,222,Other,150% of Medicare + 9.63% HCRA Surcharge,135,45,,135,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,148.5,,,148.5,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,210,70,,210,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,222,
MEDTRONIC NCEUP27520X NC BALLOON 2.75X20,C1725,HCPCS,,79011383,CDM,272,RC,,,both,,,300,222,,,222,Other,150% of Medicare + 9.63% HCRA Surcharge,135,45,,135,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,148.5,,,148.5,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,210,70,,210,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,222,
MEDTRONIC NCEUP3006X NC BALLOON 3X6MM,C1725,HCPCS,,79011384,CDM,272,RC,,,both,,,300,222,,,222,Other,150% of Medicare + 9.63% HCRA Surcharge,135,45,,135,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,148.5,,,148.5,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,210,70,,210,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,222,
MEDTRONIC NCEUP3008X NC BALLOON 3X8MM,C1725,HCPCS,,79011385,CDM,272,RC,,,both,,,300,222,,,222,Other,150% of Medicare + 9.63% HCRA Surcharge,135,45,,135,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,148.5,,,148.5,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,210,70,,210,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,222,
MEDTRONIC NCEUP3012X NC BALLOON 3X12MM,C1725,HCPCS,,79011386,CDM,272,RC,,,both,,,300,222,,,222,Other,150% of Medicare + 9.63% HCRA Surcharge,135,45,,135,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,148.5,,,148.5,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,210,70,,210,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,222,
MEDTRONIC NCEUP3015X NC BALLOON 3X15MM,C1725,HCPCS,,79011387,CDM,272,RC,,,both,,,300,222,,,222,Other,150% of Medicare + 9.63% HCRA Surcharge,135,45,,135,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,148.5,,,148.5,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,210,70,,210,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,222,
MEDTRONIC NCEUP3020X NC BALLOON 3X20MM,C1725,HCPCS,,79011388,CDM,272,RC,,,both,,,300,222,,,222,Other,150% of Medicare + 9.63% HCRA Surcharge,135,45,,135,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,148.5,,,148.5,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,210,70,,210,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,222,
MEDTRONIC NCEUP32506X NC BALLOON 3.25X6,C1725,HCPCS,,79011389,CDM,272,RC,,,both,,,300,222,,,222,Other,150% of Medicare + 9.63% HCRA Surcharge,135,45,,135,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,148.5,,,148.5,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,210,70,,210,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,222,
MEDTRONIC NCEUP32508X NC BALLOON 3.25X8,C1725,HCPCS,,79011390,CDM,272,RC,,,both,,,300,222,,,222,Other,150% of Medicare + 9.63% HCRA Surcharge,135,45,,135,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,148.5,,,148.5,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,210,70,,210,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,222,
MEDTRONIC NCEUP32512X NC BALLOON 3.25X12,C1725,HCPCS,,79011391,CDM,272,RC,,,both,,,300,222,,,222,Other,150% of Medicare + 9.63% HCRA Surcharge,135,45,,135,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,148.5,,,148.5,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,210,70,,210,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,222,
MEDTRONIC NCEUP32515X NC BALLOON 3.25X15,C1725,HCPCS,,79011392,CDM,272,RC,,,both,,,300,222,,,222,Other,150% of Medicare + 9.63% HCRA Surcharge,135,45,,135,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,148.5,,,148.5,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,210,70,,210,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,222,
MEDTRONIC NCEUP32520X NC BALLOON 3.25X20,C1725,HCPCS,,79011393,CDM,272,RC,,,both,,,300,222,,,222,Other,150% of Medicare + 9.63% HCRA Surcharge,135,45,,135,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,148.5,,,148.5,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,210,70,,210,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,222,
MEDTRONIC NCEUP3506X NC BALLOON 3.5X6MM,C1725,HCPCS,,79011394,CDM,272,RC,,,both,,,300,222,,,222,Other,150% of Medicare + 9.63% HCRA Surcharge,135,45,,135,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,148.5,,,148.5,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,210,70,,210,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,222,
MEDTRONIC NCEUP3508X NC BALLOON 3.5X8MM,C1725,HCPCS,,79011395,CDM,272,RC,,,both,,,300,222,,,222,Other,150% of Medicare + 9.63% HCRA Surcharge,135,45,,135,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,148.5,,,148.5,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,210,70,,210,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,222,
MEDTRONIC NCEUP3512X NC BALLOON 3.5X12MM,C1725,HCPCS,,79011396,CDM,272,RC,,,both,,,300,222,,,222,Other,150% of Medicare + 9.63% HCRA Surcharge,135,45,,135,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,148.5,,,148.5,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,210,70,,210,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,222,
MEDTRONIC NCEUP3515X NC BALLOON 3.5X15MM,C1725,HCPCS,,79011397,CDM,272,RC,,,both,,,300,222,,,222,Other,150% of Medicare + 9.63% HCRA Surcharge,135,45,,135,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,148.5,,,148.5,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,210,70,,210,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,222,
MEDTRONIC NCEUP3520X NC BALLOON 3.5X20MM,C1725,HCPCS,,79011398,CDM,272,RC,,,both,,,300,222,,,222,Other,150% of Medicare + 9.63% HCRA Surcharge,135,45,,135,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,148.5,,,148.5,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,210,70,,210,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,222,
MEDTRONIC NCEUP37506X NC BALLOON 3.75X6,C1725,HCPCS,,79011399,CDM,272,RC,,,both,,,300,222,,,222,Other,150% of Medicare + 9.63% HCRA Surcharge,135,45,,135,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,148.5,,,148.5,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,210,70,,210,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,222,
MEDTRONIC NCEUP37508X NC BALLOON 3.75X8,C1725,HCPCS,,79011400,CDM,272,RC,,,both,,,300,222,,,222,Other,150% of Medicare + 9.63% HCRA Surcharge,135,45,,135,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,148.5,,,148.5,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,210,70,,210,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,222,
MEDTRONIC NCEUP37512X NC BALLOON 3.75X12,C1725,HCPCS,,79011401,CDM,272,RC,,,both,,,300,222,,,222,Other,150% of Medicare + 9.63% HCRA Surcharge,135,45,,135,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,148.5,,,148.5,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,210,70,,210,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,222,
MEDTRONIC NCEUP37515X NC BALLOON 3.75X15,C1725,HCPCS,,79011402,CDM,272,RC,,,both,,,300,222,,,222,Other,150% of Medicare + 9.63% HCRA Surcharge,135,45,,135,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,148.5,,,148.5,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,210,70,,210,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,222,
MEDTRONIC NCEUP37520X NC BALLOON 3.75X20,C1725,HCPCS,,79011403,CDM,272,RC,,,both,,,300,222,,,222,Other,150% of Medicare + 9.63% HCRA Surcharge,135,45,,135,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,148.5,,,148.5,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,210,70,,210,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,222,
MEDTRONIC NCEUP4006X NC BALLOON 4X6MM,C1725,HCPCS,,79011404,CDM,272,RC,,,both,,,300,222,,,222,Other,150% of Medicare + 9.63% HCRA Surcharge,135,45,,135,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,148.5,,,148.5,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,210,70,,210,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,222,
MEDTRONIC NCEUP4008X NC BALLOON 4X8MM,C1725,HCPCS,,79011405,CDM,272,RC,,,both,,,300,222,,,222,Other,150% of Medicare + 9.63% HCRA Surcharge,135,45,,135,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,148.5,,,148.5,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,210,70,,210,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,222,
MEDTRONIC NCEUP4012X NC BALLOON 4X12MM,C1725,HCPCS,,79011406,CDM,272,RC,,,both,,,300,222,,,222,Other,150% of Medicare + 9.63% HCRA Surcharge,135,45,,135,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,148.5,,,148.5,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,210,70,,210,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,222,
MEDTRONIC NCEUP4015X NC BALLOON 4X15MM,C1725,HCPCS,,79011407,CDM,272,RC,,,both,,,300,222,,,222,Other,150% of Medicare + 9.63% HCRA Surcharge,135,45,,135,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,148.5,,,148.5,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,210,70,,210,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,222,
MEDTRONIC NCEUP4020X NC BALLOON 4X20MM,C1725,HCPCS,,79011408,CDM,272,RC,,,both,,,300,222,,,222,Other,150% of Medicare + 9.63% HCRA Surcharge,135,45,,135,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,148.5,,,148.5,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,210,70,,210,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,222,
MEDTRONIC NCEUP4508X NC BALLOON 4.5X8MM,C1725,HCPCS,,79011409,CDM,272,RC,,,both,,,300,222,,,222,Other,150% of Medicare + 9.63% HCRA Surcharge,135,45,,135,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,148.5,,,148.5,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,210,70,,210,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,222,
MEDTRONIC NCEUP4512X NC BALLOON 4.5X12MM,C1725,HCPCS,,79011410,CDM,272,RC,,,both,,,300,222,,,222,Other,150% of Medicare + 9.63% HCRA Surcharge,135,45,,135,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,148.5,,,148.5,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,210,70,,210,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,222,
MEDTRONIC NCEUP4515X NC BALLOON 4.5X15MM,C1725,HCPCS,,79011411,CDM,272,RC,,,both,,,300,222,,,222,Other,150% of Medicare + 9.63% HCRA Surcharge,135,45,,135,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,148.5,,,148.5,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,210,70,,210,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,222,
MEDTRONIC NCEUP5008X NC BALLOON 5X8MM,C1725,HCPCS,,79011412,CDM,272,RC,,,both,,,300,222,,,222,Other,150% of Medicare + 9.63% HCRA Surcharge,135,45,,135,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,148.5,,,148.5,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,210,70,,210,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,222,
MEDTRONIC NCEUP5012X NC BALLOON 5X12MM,C1725,HCPCS,,79011413,CDM,272,RC,,,both,,,300,222,,,222,Other,150% of Medicare + 9.63% HCRA Surcharge,135,45,,135,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,148.5,,,148.5,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,210,70,,210,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,222,
MEDTRONIC NCEUP5015X NC BALLOON 5X15MM,C1725,HCPCS,,79011414,CDM,272,RC,,,both,,,300,222,,,222,Other,150% of Medicare + 9.63% HCRA Surcharge,135,45,,135,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,148.5,,,148.5,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,210,70,,210,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,222,
ABBOTT 1005357H WHISPER MS GUIDEWIRE 190,C1769,HCPCS,,79011415,CDM,272,RC,,,both,,,375,277.5,,,277.5,Other,150% of Medicare + 9.63% HCRA Surcharge,168.75,45,,168.75,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,185.63,,,185.63,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,262.5,70,,262.5,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,277.5,
ABBOTT 1001309 IRON MAN GUIDEWIRE 190CM,C1769,HCPCS,,79011416,CDM,272,RC,,,both,,,375,277.5,,,277.5,Other,150% of Medicare + 9.63% HCRA Surcharge,168.75,45,,168.75,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,185.63,,,185.63,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,262.5,70,,262.5,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,277.5,
ABBOTT 1001780 BMW GUIDEWIRE 190CM,C1769,HCPCS,,79011417,CDM,272,RC,,,both,,,375,277.5,,,277.5,Other,150% of Medicare + 9.63% HCRA Surcharge,168.75,45,,168.75,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,185.63,,,185.63,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,262.5,70,,262.5,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,277.5,
ABBOTT 1001780-HC HYDROCOAT GUIDEWIRE,C1769,HCPCS,,79011418,CDM,272,RC,,,both,,,375,277.5,,,277.5,Other,150% of Medicare + 9.63% HCRA Surcharge,168.75,45,,168.75,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,185.63,,,185.63,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,262.5,70,,262.5,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,277.5,
ABBOTT 1009660 BMW UNIV GUIDEWIRE 190CM,C1769,HCPCS,,79011419,CDM,272,RC,,,both,,,375,277.5,,,277.5,Other,150% of Medicare + 9.63% HCRA Surcharge,168.75,45,,168.75,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,185.63,,,185.63,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,262.5,70,,262.5,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,277.5,
ABBOTT 1009664 BMW UNIV II GUIDEWIRE 190,C1769,HCPCS,,79011420,CDM,272,RC,,,both,,,375,277.5,,,277.5,Other,150% of Medicare + 9.63% HCRA Surcharge,168.75,45,,168.75,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,185.63,,,185.63,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,262.5,70,,262.5,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,277.5,
ASAHI AGH146000 PROWATER PTCA GW 180CM,C1769,HCPCS,,79011421,CDM,272,RC,,,both,,,285,210.9,,,210.9,Other,150% of Medicare + 9.63% HCRA Surcharge,128.25,45,,128.25,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,141.08,,,141.08,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,199.5,70,,199.5,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,210.9,
ASAHI AGP140002 FIELDER XT PTCA GW 190CM,C1769,HCPCS,,79011422,CDM,272,RC,,,both,,,420,310.8,,,310.8,Other,150% of Medicare + 9.63% HCRA Surcharge,189,45,,189,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,207.9,,,207.9,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,294,70,,294,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,310.8,
ASAHI AGP140001 FIELDER FC PTCA GW 180CM,C1769,HCPCS,,79011423,CDM,272,RC,,,both,,,285,210.9,,,210.9,Other,150% of Medicare + 9.63% HCRA Surcharge,128.25,45,,128.25,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,141.08,,,141.08,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,199.5,70,,199.5,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,210.9,
ASAHI AG141000 ASAHI SOFT 180CM,C1769,HCPCS,,79011424,CDM,272,RC,,,both,,,285,210.9,,,210.9,Other,150% of Medicare + 9.63% HCRA Surcharge,128.25,45,,128.25,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,141.08,,,141.08,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,199.5,70,,199.5,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,210.9,
TERUMO 25-1011 NS EXTRA FLOPPY 180CM,C1769,HCPCS,,79011425,CDM,272,RC,,,both,,,300,222,,,222,Other,150% of Medicare + 9.63% HCRA Surcharge,135,45,,135,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,148.5,,,148.5,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,210,70,,210,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,222,
TERUMO 25-3011 NS HYPERCOAT 180CM,C1769,HCPCS,,79011426,CDM,272,RC,,,both,,,390,288.6,,,288.6,Other,150% of Medicare + 9.63% HCRA Surcharge,175.5,45,,175.5,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,193.05,,,193.05,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,273,70,,273,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,288.6,
MEDTRONIC LA6AL10SH GUIDECATH 6FR AL1 SH,C1887,HCPCS,,79011427,CDM,272,RC,,,both,,,120,88.8,,,88.8,Other,150% of Medicare + 9.63% HCRA Surcharge,54,45,,54,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,59.4,,,59.4,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,84,70,,84,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,88.8,
MEDTRONIC LA6AL15 GUIDECATH 6FR AL1.5,C1887,HCPCS,,79011428,CDM,272,RC,,,both,,,120,88.8,,,88.8,Other,150% of Medicare + 9.63% HCRA Surcharge,54,45,,54,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,59.4,,,59.4,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,84,70,,84,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,88.8,
MEDTRONIC LA6AL15SH GUIDECATH 6FR AL1.5,C1887,HCPCS,,79011429,CDM,272,RC,,,both,,,120,88.8,,,88.8,Other,150% of Medicare + 9.63% HCRA Surcharge,54,45,,54,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,59.4,,,59.4,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,84,70,,84,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,88.8,
MEDTRONIC LA6AL20SH GUIDECATH 6FR AL2 SH,C1887,HCPCS,,79011430,CDM,272,RC,,,both,,,120,88.8,,,88.8,Other,150% of Medicare + 9.63% HCRA Surcharge,54,45,,54,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,59.4,,,59.4,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,84,70,,84,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,88.8,
MEDTRONIC LA6AR10SH GUIDECATH 6FR AR1 SH,C1887,HCPCS,,79011431,CDM,272,RC,,,both,,,120,88.8,,,88.8,Other,150% of Medicare + 9.63% HCRA Surcharge,54,45,,54,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,59.4,,,59.4,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,84,70,,84,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,88.8,
MEDTRONIC LA6AR20SH GUIDECATH 6FR AR2 SH,C1887,HCPCS,,79011432,CDM,272,RC,,,both,,,120,88.8,,,88.8,Other,150% of Medicare + 9.63% HCRA Surcharge,54,45,,54,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,59.4,,,59.4,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,84,70,,84,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,88.8,
MEDTRONIC LA6EBU375 GUIDECATH 6FR 3.75,C1887,HCPCS,,79011433,CDM,272,RC,,,both,,,120,88.8,,,88.8,Other,150% of Medicare + 9.63% HCRA Surcharge,54,45,,54,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,59.4,,,59.4,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,84,70,,84,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,88.8,
MEDTRONIC LA6HSISHD GUIDECATH 6FR HS SH,C1887,HCPCS,,79011434,CDM,272,RC,,,both,,,120,88.8,,,88.8,Other,150% of Medicare + 9.63% HCRA Surcharge,54,45,,54,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,59.4,,,59.4,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,84,70,,84,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,88.8,
MEDTRONIC LA6IMASHD GUIDECATH 6FR IM SH,C1887,HCPCS,,79011435,CDM,272,RC,,,both,,,120,88.8,,,88.8,Other,150% of Medicare + 9.63% HCRA Surcharge,54,45,,54,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,59.4,,,59.4,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,84,70,,84,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,88.8,
MEDTRONIC LA6JCL35 GUIDECATH 6FR JCL 3.5,C1887,HCPCS,,79011436,CDM,272,RC,,,both,,,120,88.8,,,88.8,Other,150% of Medicare + 9.63% HCRA Surcharge,54,45,,54,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,59.4,,,59.4,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,84,70,,84,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,88.8,
MEDTRONIC LA6JCL40 GUIDECATH 6FR JCL 4,C1887,HCPCS,,79011437,CDM,272,RC,,,both,,,120,88.8,,,88.8,Other,150% of Medicare + 9.63% HCRA Surcharge,54,45,,54,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,59.4,,,59.4,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,84,70,,84,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,88.8,
MEDTRONIC LA6MB1SH GUIDECATH 6FR SH 100,C1887,HCPCS,,79011438,CDM,272,RC,,,both,,,120,88.8,,,88.8,Other,150% of Medicare + 9.63% HCRA Surcharge,54,45,,54,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,59.4,,,59.4,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,84,70,,84,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,88.8,
MEDTRONIC LA6MB1SHD GUIDECATH 6FR SH 90,C1887,HCPCS,,79011439,CDM,272,RC,,,both,,,120,88.8,,,88.8,Other,150% of Medicare + 9.63% HCRA Surcharge,54,45,,54,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,59.4,,,59.4,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,84,70,,84,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,88.8,
MEDTRONIC LA6MB1 GUIDECATH 6FR MB1,C1887,HCPCS,,79011440,CDM,272,RC,,,both,,,120,88.8,,,88.8,Other,150% of Medicare + 9.63% HCRA Surcharge,54,45,,54,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,59.4,,,59.4,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,84,70,,84,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,88.8,
MEDTRONIC LA6AL10 GUIDECATH 6FR AL1,C1887,HCPCS,,79011441,CDM,272,RC,,,both,,,120,88.8,,,88.8,Other,150% of Medicare + 9.63% HCRA Surcharge,54,45,,54,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,59.4,,,59.4,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,84,70,,84,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,88.8,
MEDTRONIC LA6AL75 GUIDECATH 6FR AL7.5,C1887,HCPCS,,79011442,CDM,272,RC,,,both,,,120,88.8,,,88.8,Other,150% of Medicare + 9.63% HCRA Surcharge,54,45,,54,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,59.4,,,59.4,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,84,70,,84,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,88.8,
MEDTRONIC LA6AR10 GUIDECATH 6FR AR1,C1887,HCPCS,,79011443,CDM,272,RC,,,both,,,120,88.8,,,88.8,Other,150% of Medicare + 9.63% HCRA Surcharge,54,45,,54,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,59.4,,,59.4,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,84,70,,84,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,88.8,
MEDTRONIC LA6AR20 GUIDECATH 6FR AR2,C1887,HCPCS,,79011444,CDM,272,RC,,,both,,,120,88.8,,,88.8,Other,150% of Medicare + 9.63% HCRA Surcharge,54,45,,54,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,59.4,,,59.4,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,84,70,,84,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,88.8,
MEDTRONIC LA6EBU30 GUIDECATH 6FR EBU 3.0,C1887,HCPCS,,79011445,CDM,272,RC,,,both,,,120,88.8,,,88.8,Other,150% of Medicare + 9.63% HCRA Surcharge,54,45,,54,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,59.4,,,59.4,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,84,70,,84,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,88.8,
MEDTRONIC LA6EBU35SH GUIDECATH 6FR 3.5SH,C1887,HCPCS,,79011446,CDM,272,RC,,,both,,,120,88.8,,,88.8,Other,150% of Medicare + 9.63% HCRA Surcharge,54,45,,54,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,59.4,,,59.4,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,84,70,,84,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,88.8,
MEDTRONIC LA6EBU50 GUIDECATH 6FR EBU 5.0,C1887,HCPCS,,79011447,CDM,272,RC,,,both,,,120,88.8,,,88.8,Other,150% of Medicare + 9.63% HCRA Surcharge,54,45,,54,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,59.4,,,59.4,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,84,70,,84,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,88.8,
MEDTRONIC LA6HSI GUIDECATH 6FR HSI,C1887,HCPCS,,79011448,CDM,272,RC,,,both,,,120,88.8,,,88.8,Other,150% of Medicare + 9.63% HCRA Surcharge,54,45,,54,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,59.4,,,59.4,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,84,70,,84,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,88.8,
MEDTRONIC LA6HSISH GUIDECATH 6FR HSI SH,C1887,HCPCS,,79011449,CDM,272,RC,,,both,,,120,88.8,,,88.8,Other,150% of Medicare + 9.63% HCRA Surcharge,54,45,,54,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,59.4,,,59.4,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,84,70,,84,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,88.8,
MEDTRONIC LA6IMAD GUIDECATH 6FR IM,C1887,HCPCS,,79011450,CDM,272,RC,,,both,,,120,88.8,,,88.8,Other,150% of Medicare + 9.63% HCRA Surcharge,54,45,,54,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,59.4,,,59.4,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,84,70,,84,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,88.8,
MEDTRONIC LA6JL35 GUIDECATH 6FR JL 3.5,C1887,HCPCS,,79011451,CDM,272,RC,,,both,,,120,88.8,,,88.8,Other,150% of Medicare + 9.63% HCRA Surcharge,54,45,,54,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,59.4,,,59.4,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,84,70,,84,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,88.8,
MEDTRONIC LA6JL35SH GUIDECATH JL 3.5 SH,C1887,HCPCS,,79011452,CDM,272,RC,,,both,,,120,88.8,,,88.8,Other,150% of Medicare + 9.63% HCRA Surcharge,54,45,,54,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,59.4,,,59.4,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,84,70,,84,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,88.8,
MEDTRONIC LA6JL40SH GUIDECATH JL 4.0 SH,C1887,HCPCS,,79011453,CDM,272,RC,,,both,,,120,88.8,,,88.8,Other,150% of Medicare + 9.63% HCRA Surcharge,54,45,,54,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,59.4,,,59.4,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,84,70,,84,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,88.8,
MEDTRONIC LA6JL50 GUIDECATH 6FR JL 5.0,C1887,HCPCS,,79011454,CDM,272,RC,,,both,,,120,88.8,,,88.8,Other,150% of Medicare + 9.63% HCRA Surcharge,54,45,,54,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,59.4,,,59.4,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,84,70,,84,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,88.8,
MEDTRONIC LA6JR35 GUIDECATH 6FR JR 3.5,C1887,HCPCS,,79011455,CDM,272,RC,,,both,,,120,88.8,,,88.8,Other,150% of Medicare + 9.63% HCRA Surcharge,54,45,,54,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,59.4,,,59.4,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,84,70,,84,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,88.8,
MEDTRONIC LA6JR40SH GUIDECATH JR 4.0 SH,C1887,HCPCS,,79011456,CDM,272,RC,,,both,,,120,88.8,,,88.8,Other,150% of Medicare + 9.63% HCRA Surcharge,54,45,,54,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,59.4,,,59.4,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,84,70,,84,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,88.8,
MEDTRONIC LA6AL20 GUIDECATH 6FR AL2,C1887,HCPCS,,79011457,CDM,272,RC,,,both,,,120,88.8,,,88.8,Other,150% of Medicare + 9.63% HCRA Surcharge,54,45,,54,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,59.4,,,59.4,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,84,70,,84,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,88.8,
MEDTRONIC LA6AL75SH GUIDECATH AL7.5 SH,C1887,HCPCS,,79011458,CDM,272,RC,,,both,,,120,88.8,,,88.8,Other,150% of Medicare + 9.63% HCRA Surcharge,54,45,,54,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,59.4,,,59.4,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,84,70,,84,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,88.8,
MEDTRONIC LA63DRC GUIDECATH 6FR 3DRC,C1887,HCPCS,,79011459,CDM,272,RC,,,both,,,120,88.8,,,88.8,Other,150% of Medicare + 9.63% HCRA Surcharge,54,45,,54,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,59.4,,,59.4,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,84,70,,84,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,88.8,
MEDTRONIC LA6EBU35 GUIDECATH EBU 3.5,C1887,HCPCS,,79011460,CDM,272,RC,,,both,,,120,88.8,,,88.8,Other,150% of Medicare + 9.63% HCRA Surcharge,54,45,,54,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,59.4,,,59.4,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,84,70,,84,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,88.8,
MEDTRONIC LA6EBU40 GUIDECATH 6FR EBU 4.0,C1887,HCPCS,,79011464,CDM,272,RC,,,both,,,120,88.8,,,88.8,Other,150% of Medicare + 9.63% HCRA Surcharge,54,45,,54,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,59.4,,,59.4,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,84,70,,84,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,88.8,
MEDTRONIC LA6JL40 GUIDECATH 6FR JL 4,C1887,HCPCS,,79011465,CDM,272,RC,,,both,,,120,88.8,,,88.8,Other,150% of Medicare + 9.63% HCRA Surcharge,54,45,,54,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,59.4,,,59.4,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,84,70,,84,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,88.8,
MEDTRONIC LA6JR40 GUIDECATH 6FR JR 4,C1887,HCPCS,,79011466,CDM,272,RC,,,both,,,120,88.8,,,88.8,Other,150% of Medicare + 9.63% HCRA Surcharge,54,45,,54,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,59.4,,,59.4,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,84,70,,84,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,88.8,
CARDINAL 67200200 GUIDECATH 6FR JL 3.5,C1887,HCPCS,,79011467,CDM,272,RC,,,both,,,180,133.2,,,133.2,Other,150% of Medicare + 9.63% HCRA Surcharge,81,45,,81,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,89.1,,,89.1,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,126,70,,126,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,133.2,
CARDINAL 67200400 GUIDECATH 6FR JL 4,C1887,HCPCS,,79011468,CDM,272,RC,,,both,,,180,133.2,,,133.2,Other,150% of Medicare + 9.63% HCRA Surcharge,81,45,,81,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,89.1,,,89.1,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,126,70,,126,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,133.2,
CARDINAL 67200800 GUIDECATH 6FR JL 5,C1887,HCPCS,,79011469,CDM,272,RC,,,both,,,180,133.2,,,133.2,Other,150% of Medicare + 9.63% HCRA Surcharge,81,45,,81,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,89.1,,,89.1,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,126,70,,126,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,133.2,
CARDINAL 67208200 GUIDECATH 6FR JR 4,C1887,HCPCS,,79011470,CDM,272,RC,,,both,,,180,133.2,,,133.2,Other,150% of Medicare + 9.63% HCRA Surcharge,81,45,,81,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,89.1,,,89.1,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,126,70,,126,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,133.2,
CARDINAL 67208300 GUIDECATH 6FR JR 4 SH,C1887,HCPCS,,79011471,CDM,272,RC,,,both,,,180,133.2,,,133.2,Other,150% of Medicare + 9.63% HCRA Surcharge,81,45,,81,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,89.1,,,89.1,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,126,70,,126,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,133.2,
CARDINAL 67205200 GUIDECATH 6FR XB 3,C1887,HCPCS,,79011472,CDM,272,RC,,,both,,,180,133.2,,,133.2,Other,150% of Medicare + 9.63% HCRA Surcharge,81,45,,81,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,89.1,,,89.1,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,126,70,,126,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,133.2,
CARDINAL 67205400 GUIDECATH 6FR XB 3.5,C1887,HCPCS,,79011473,CDM,272,RC,,,both,,,180,133.2,,,133.2,Other,150% of Medicare + 9.63% HCRA Surcharge,81,45,,81,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,89.1,,,89.1,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,126,70,,126,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,133.2,
CARDINAL 67205600 GUIDECATH 6FR XB 4,C1887,HCPCS,,79011474,CDM,272,RC,,,both,,,180,133.2,,,133.2,Other,150% of Medicare + 9.63% HCRA Surcharge,81,45,,81,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,89.1,,,89.1,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,126,70,,126,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,133.2,
CARDINAL 67203400 GUIDECATH 6FR AL 0.75,C1887,HCPCS,,79011475,CDM,272,RC,,,both,,,180,133.2,,,133.2,Other,150% of Medicare + 9.63% HCRA Surcharge,81,45,,81,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,89.1,,,89.1,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,126,70,,126,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,133.2,
CARDINAL 67203600 GUIDECATH 6FR AL1,C1887,HCPCS,,79011476,CDM,272,RC,,,both,,,180,133.2,,,133.2,Other,150% of Medicare + 9.63% HCRA Surcharge,81,45,,81,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,89.1,,,89.1,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,126,70,,126,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,133.2,
CARDINAL 67211000 GUIDECATH 6FR AR1,C1887,HCPCS,,79011477,CDM,272,RC,,,both,,,180,133.2,,,133.2,Other,150% of Medicare + 9.63% HCRA Surcharge,81,45,,81,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,89.1,,,89.1,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,126,70,,126,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,133.2,
CARDINAL 67227800 GUIDECATH 6FR H-STICK,C1887,HCPCS,,79011478,CDM,272,RC,,,both,,,180,133.2,,,133.2,Other,150% of Medicare + 9.63% HCRA Surcharge,81,45,,81,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,89.1,,,89.1,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,126,70,,126,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,133.2,
CARDINAL 67227000 GUIDECATH 6FR MPA,C1887,HCPCS,,79011479,CDM,272,RC,,,both,,,180,133.2,,,133.2,Other,150% of Medicare + 9.63% HCRA Surcharge,81,45,,81,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,89.1,,,89.1,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,126,70,,126,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,133.2,
BOSTON SCI H7493918908150 BALLOON 1.5X8,C1725,HCPCS,,79011484,CDM,272,RC,,,both,,,420,310.8,,,310.8,Other,150% of Medicare + 9.63% HCRA Surcharge,189,45,,189,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,207.9,,,207.9,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,294,70,,294,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,310.8,
BOSTON SCI H7493918908200 BALLOON 2X8MM,C1725,HCPCS,,79011485,CDM,272,RC,,,both,,,420,310.8,,,310.8,Other,150% of Medicare + 9.63% HCRA Surcharge,189,45,,189,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,207.9,,,207.9,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,294,70,,294,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,310.8,
BOSTON SCI H7493918908220 BALLOON 2.25X8,C1725,HCPCS,,79011486,CDM,272,RC,,,both,,,420,310.8,,,310.8,Other,150% of Medicare + 9.63% HCRA Surcharge,189,45,,189,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,207.9,,,207.9,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,294,70,,294,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,310.8,
BOSTON SCI H7493918908250 BALLOON 2.5X8,C1725,HCPCS,,79011487,CDM,272,RC,,,both,,,420,310.8,,,310.8,Other,150% of Medicare + 9.63% HCRA Surcharge,189,45,,189,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,207.9,,,207.9,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,294,70,,294,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,310.8,
BOSTON SCI H7493918908270 BALLOON 2.75X8,C1725,HCPCS,,79011488,CDM,272,RC,,,both,,,420,310.8,,,310.8,Other,150% of Medicare + 9.63% HCRA Surcharge,189,45,,189,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,207.9,,,207.9,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,294,70,,294,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,310.8,
BOSTON SCI H7493918908300 BALLOON 3X8MM,C1725,HCPCS,,79011489,CDM,272,RC,,,both,,,420,310.8,,,310.8,Other,150% of Medicare + 9.63% HCRA Surcharge,189,45,,189,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,207.9,,,207.9,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,294,70,,294,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,310.8,
CARDINAL 534524T 5FR JL 6 100CM CATHETER,C1887,HCPCS,,79011490,CDM,272,RC,,,both,,,23,17.02,,,17.02,Other,150% of Medicare + 9.63% HCRA Surcharge,10.35,45,,10.35,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,11.39,,,11.39,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,16.1,70,,16.1,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,17.02,
CARDINAL 534-617T 6FR JL 4.5 100CM CATH,C1887,HCPCS,,79011491,CDM,272,RC,,,both,,,23,17.02,,,17.02,Other,150% of Medicare + 9.63% HCRA Surcharge,10.35,45,,10.35,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,11.39,,,11.39,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,16.1,70,,16.1,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,17.02,
CARDINAL 533-640 6FR MPA1 100CM CATHETER,C1887,HCPCS,,79011492,CDM,272,RC,,,both,,,23,17.02,,,17.02,Other,150% of Medicare + 9.63% HCRA Surcharge,10.35,45,,10.35,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,11.39,,,11.39,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,16.1,70,,16.1,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,17.02,
TERUMO 35-1430 MICRO GUIDE 130CM,C1887,HCPCS,,79011493,CDM,272,RC,,,both,,,1500,1110,,,1110,Other,150% of Medicare + 9.63% HCRA Surcharge,675,45,,675,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,742.5,,,742.5,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1050,70,,1050,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1110,
TERUMO 35-1450 MICRO GUIDE 150CM,C1887,HCPCS,,79011494,CDM,272,RC,,,both,,,1500,1110,,,1110,Other,150% of Medicare + 9.63% HCRA Surcharge,675,45,,675,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,742.5,,,742.5,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1050,70,,1050,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1110,
PHILIPS 89185 PRESSURE WIRE OMNI 185CM,C1769,HCPCS,,79011495,CDM,272,RC,,,both,,,2100,1554.01,,,1554.01,Other,150% of Medicare + 9.63% HCRA Surcharge,945,45,,945,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1039.5,,,1039.5,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1470,70,,1470,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1554.01,
PHILIPS 85900PST EAGLE EYE CATHETER,C1753,HCPCS,,79011496,CDM,272,RC,,,both,,,2175,1609.51,,,1609.51,Other,150% of Medicare + 9.63% HCRA Surcharge,978.75,45,,978.75,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1076.63,,,1076.63,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1522.5,70,,1522.5,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1609.51,
BOSTON SCI H7493918908350 BALLOON 3.5X8,C1725,HCPCS,,79011497,CDM,272,RC,,,both,,,420,310.8,,,310.8,Other,150% of Medicare + 9.63% HCRA Surcharge,189,45,,189,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,207.9,,,207.9,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,294,70,,294,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,310.8,
BOSTON SCI H7493918908400 BALLOON 4X8MM,C1725,HCPCS,,79011498,CDM,272,RC,,,both,,,420,310.8,,,310.8,Other,150% of Medicare + 9.63% HCRA Surcharge,189,45,,189,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,207.9,,,207.9,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,294,70,,294,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,310.8,
BOSTON SCI H7493918908120 BALLOON 1.2X8,C1725,HCPCS,,79011499,CDM,272,RC,,,both,,,420,310.8,,,310.8,Other,150% of Medicare + 9.63% HCRA Surcharge,189,45,,189,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,207.9,,,207.9,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,294,70,,294,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,310.8,
BOSTON SCI H7493918912150 BALLOON 1.5X12,C1725,HCPCS,,79011500,CDM,272,RC,,,both,,,420,310.8,,,310.8,Other,150% of Medicare + 9.63% HCRA Surcharge,189,45,,189,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,207.9,,,207.9,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,294,70,,294,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,310.8,
BOSTON SCI H7493918912200 BALLOON 2X12MM,C1725,HCPCS,,79011501,CDM,272,RC,,,both,,,420,310.8,,,310.8,Other,150% of Medicare + 9.63% HCRA Surcharge,189,45,,189,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,207.9,,,207.9,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,294,70,,294,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,310.8,
BOSTON SC H7493918912220 BALLOON 2.25X12,C1725,HCPCS,,79011502,CDM,272,RC,,,both,,,420,310.8,,,310.8,Other,150% of Medicare + 9.63% HCRA Surcharge,189,45,,189,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,207.9,,,207.9,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,294,70,,294,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,310.8,
BOSTON SCI H7493918912250 BALLOON 2.5X12,C1725,HCPCS,,79011503,CDM,272,RC,,,both,,,420,310.8,,,310.8,Other,150% of Medicare + 9.63% HCRA Surcharge,189,45,,189,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,207.9,,,207.9,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,294,70,,294,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,310.8,
BOSTON SC H7493918912270 BALLOON 2.75X12,C1725,HCPCS,,79011504,CDM,272,RC,,,both,,,420,310.8,,,310.8,Other,150% of Medicare + 9.63% HCRA Surcharge,189,45,,189,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,207.9,,,207.9,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,294,70,,294,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,310.8,
BOSTON SCI H7493918912300 BALLOON 3X12MM,C1725,HCPCS,,79011505,CDM,272,RC,,,both,,,420,310.8,,,310.8,Other,150% of Medicare + 9.63% HCRA Surcharge,189,45,,189,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,207.9,,,207.9,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,294,70,,294,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,310.8,
BOSTON SCI H7493918912350 BALLOON 3.5X12,C1725,HCPCS,,79011506,CDM,272,RC,,,both,,,420,310.8,,,310.8,Other,150% of Medicare + 9.63% HCRA Surcharge,189,45,,189,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,207.9,,,207.9,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,294,70,,294,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,310.8,
BOSTON SCI H7493918912120 BALLOON 1.2X12,C1725,HCPCS,,79011507,CDM,272,RC,,,both,,,420,310.8,,,310.8,Other,150% of Medicare + 9.63% HCRA Surcharge,189,45,,189,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,207.9,,,207.9,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,294,70,,294,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,310.8,
BOSTON SCI H7493918912400 BALLOON 4X12MM,C1725,HCPCS,,79011508,CDM,272,RC,,,both,,,420,310.8,,,310.8,Other,150% of Medicare + 9.63% HCRA Surcharge,189,45,,189,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,207.9,,,207.9,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,294,70,,294,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,310.8,
BOSTON SCI H7493918915200 BALLOON 2X15MM,C1725,HCPCS,,79011509,CDM,272,RC,,,both,,,420,310.8,,,310.8,Other,150% of Medicare + 9.63% HCRA Surcharge,189,45,,189,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,207.9,,,207.9,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,294,70,,294,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,310.8,
BOSTON SC H7493918915220 BALLOON 2.25X15,C1725,HCPCS,,79011510,CDM,272,RC,,,both,,,420,310.8,,,310.8,Other,150% of Medicare + 9.63% HCRA Surcharge,189,45,,189,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,207.9,,,207.9,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,294,70,,294,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,310.8,
BOSTON SCI H7493918915250 BALLOON 2.5X15,C1725,HCPCS,,79011511,CDM,272,RC,,,both,,,420,310.8,,,310.8,Other,150% of Medicare + 9.63% HCRA Surcharge,189,45,,189,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,207.9,,,207.9,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,294,70,,294,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,310.8,
BOSTON SC H7493918915270 BALLOON 2.75X15,C1725,HCPCS,,79011512,CDM,272,RC,,,both,,,420,310.8,,,310.8,Other,150% of Medicare + 9.63% HCRA Surcharge,189,45,,189,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,207.9,,,207.9,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,294,70,,294,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,310.8,
BOSTON SCI H7493918915300 BALLOON 3X15MM,C1725,HCPCS,,79011513,CDM,272,RC,,,both,,,420,310.8,,,310.8,Other,150% of Medicare + 9.63% HCRA Surcharge,189,45,,189,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,207.9,,,207.9,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,294,70,,294,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,310.8,
BOSTON SCI H7493918915350 BALLOON 3.5X15,C1725,HCPCS,,79011514,CDM,272,RC,,,both,,,420,310.8,,,310.8,Other,150% of Medicare + 9.63% HCRA Surcharge,189,45,,189,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,207.9,,,207.9,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,294,70,,294,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,310.8,
BOSTON SCI H7493918915400 BALLOON 4X15MM,C1725,HCPCS,,79011515,CDM,272,RC,,,both,,,420,310.8,,,310.8,Other,150% of Medicare + 9.63% HCRA Surcharge,189,45,,189,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,207.9,,,207.9,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,294,70,,294,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,310.8,
BOSTON SCI H7493918920200 BALLOON 2X20MM,C1725,HCPCS,,79011516,CDM,272,RC,,,both,,,420,310.8,,,310.8,Other,150% of Medicare + 9.63% HCRA Surcharge,189,45,,189,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,207.9,,,207.9,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,294,70,,294,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,310.8,
BOSTON SC H7493918920220 BALLOON 2.25X20,C1725,HCPCS,,79011517,CDM,272,RC,,,both,,,420,310.8,,,310.8,Other,150% of Medicare + 9.63% HCRA Surcharge,189,45,,189,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,207.9,,,207.9,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,294,70,,294,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,310.8,
BOSTON SCI H7493918920250 BALLOON 2.5X20,C1725,HCPCS,,79011518,CDM,272,RC,,,both,,,420,310.8,,,310.8,Other,150% of Medicare + 9.63% HCRA Surcharge,189,45,,189,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,207.9,,,207.9,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,294,70,,294,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,310.8,
BOSTON H7493918920270 BALLOON 2.75X20MM,C1725,HCPCS,,79011519,CDM,272,RC,,,both,,,420,310.8,,,310.8,Other,150% of Medicare + 9.63% HCRA Surcharge,189,45,,189,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,207.9,,,207.9,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,294,70,,294,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,310.8,
BOSTON SCI H7493918920300 BALLOON 3X20MM,C1725,HCPCS,,79011520,CDM,272,RC,,,both,,,420,310.8,,,310.8,Other,150% of Medicare + 9.63% HCRA Surcharge,189,45,,189,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,207.9,,,207.9,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,294,70,,294,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,310.8,
BOSTON SCI H7493918920350 BALLOON 3.5X20,C1725,HCPCS,,79011521,CDM,272,RC,,,both,,,420,310.8,,,310.8,Other,150% of Medicare + 9.63% HCRA Surcharge,189,45,,189,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,207.9,,,207.9,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,294,70,,294,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,310.8,
BOSTON SCI H7493918920400 BALOON 4X20MM,C1725,HCPCS,,79011522,CDM,272,RC,,,both,,,420,310.8,,,310.8,Other,150% of Medicare + 9.63% HCRA Surcharge,189,45,,189,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,207.9,,,207.9,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,294,70,,294,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,310.8,
BOSTON SCI H7493919012150 BALLOON 1.5X12,C1725,HCPCS,,79011523,CDM,272,RC,,,both,,,420,310.8,,,310.8,Other,150% of Medicare + 9.63% HCRA Surcharge,189,45,,189,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,207.9,,,207.9,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,294,70,,294,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,310.8,
BOSTON SCI H7493919012120 BALOON 1.2X12,C1725,HCPCS,,79011524,CDM,272,RC,,,both,,,420,310.8,,,310.8,Other,150% of Medicare + 9.63% HCRA Surcharge,189,45,,189,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,207.9,,,207.9,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,294,70,,294,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,310.8,
BOSTON SCI H7493926706200 BALLOON 2X6MM,C1725,HCPCS,,79011525,CDM,272,RC,,,both,,,420,310.8,,,310.8,Other,150% of Medicare + 9.63% HCRA Surcharge,189,45,,189,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,207.9,,,207.9,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,294,70,,294,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,310.8,
BOSTON SCI H7493926706220 BALLOON 2.25X6,C1725,HCPCS,,79011526,CDM,272,RC,,,both,,,420,310.8,,,310.8,Other,150% of Medicare + 9.63% HCRA Surcharge,189,45,,189,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,207.9,,,207.9,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,294,70,,294,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,310.8,
BOSTON SCI H7493926706250 BALLOON 2.5X6,C1725,HCPCS,,79011527,CDM,272,RC,,,both,,,420,310.8,,,310.8,Other,150% of Medicare + 9.63% HCRA Surcharge,189,45,,189,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,207.9,,,207.9,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,294,70,,294,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,310.8,
BOSTON SCI H7493926706270 BALLOON 2.75X6,C1725,HCPCS,,79011528,CDM,272,RC,,,both,,,420,310.8,,,310.8,Other,150% of Medicare + 9.63% HCRA Surcharge,189,45,,189,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,207.9,,,207.9,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,294,70,,294,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,310.8,
BOSTON SCI H7493926706300 BALLOON 3X6MM,C1725,HCPCS,,79011529,CDM,272,RC,,,both,,,420,310.8,,,310.8,Other,150% of Medicare + 9.63% HCRA Surcharge,189,45,,189,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,207.9,,,207.9,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,294,70,,294,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,310.8,
BOSTON SCI H7493926706320 BALLOON 3.25X6,C1725,HCPCS,,79011530,CDM,272,RC,,,both,,,420,310.8,,,310.8,Other,150% of Medicare + 9.63% HCRA Surcharge,189,45,,189,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,207.9,,,207.9,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,294,70,,294,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,310.8,
BOSTON SCI H7493926706350 BALLOON 3.5X6,C1725,HCPCS,,79011531,CDM,272,RC,,,both,,,420,310.8,,,310.8,Other,150% of Medicare + 9.63% HCRA Surcharge,189,45,,189,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,207.9,,,207.9,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,294,70,,294,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,310.8,
BOSTON SCI H7493926706370 BALLOON 3.75X6,C1725,HCPCS,,79011532,CDM,272,RC,,,both,,,420,310.8,,,310.8,Other,150% of Medicare + 9.63% HCRA Surcharge,189,45,,189,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,207.9,,,207.9,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,294,70,,294,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,310.8,
BOSTON SCI H7493926706400 BALLOON 4X6MM,C1725,HCPCS,,79011533,CDM,272,RC,,,both,,,420,310.8,,,310.8,Other,150% of Medicare + 9.63% HCRA Surcharge,189,45,,189,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,207.9,,,207.9,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,294,70,,294,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,310.8,
BOSTON SCI H7493926706450 BALLOON 4.5X6,C1725,HCPCS,,79011534,CDM,272,RC,,,both,,,420,310.8,,,310.8,Other,150% of Medicare + 9.63% HCRA Surcharge,189,45,,189,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,207.9,,,207.9,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,294,70,,294,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,310.8,
BOSTON SCI H7493926708200 BALLOON 2X8MM,C1725,HCPCS,,79011535,CDM,272,RC,,,both,,,420,310.8,,,310.8,Other,150% of Medicare + 9.63% HCRA Surcharge,189,45,,189,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,207.9,,,207.9,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,294,70,,294,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,310.8,
BOSTON SCI H7493926708220 BALLOON 2.25X8,C1725,HCPCS,,79011536,CDM,272,RC,,,both,,,420,310.8,,,310.8,Other,150% of Medicare + 9.63% HCRA Surcharge,189,45,,189,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,207.9,,,207.9,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,294,70,,294,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,310.8,
BOSTON SCI H7493926708250 BALLOON 2.5X8,C1725,HCPCS,,79011537,CDM,272,RC,,,both,,,420,310.8,,,310.8,Other,150% of Medicare + 9.63% HCRA Surcharge,189,45,,189,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,207.9,,,207.9,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,294,70,,294,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,310.8,
BOSTON SCI H7493926708270 BALLOON 2.75X8,C1725,HCPCS,,79011538,CDM,272,RC,,,both,,,420,310.8,,,310.8,Other,150% of Medicare + 9.63% HCRA Surcharge,189,45,,189,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,207.9,,,207.9,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,294,70,,294,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,310.8,
BOSTON SCI H7493926708300 BALLOON 3X8MM,C1725,HCPCS,,79011539,CDM,272,RC,,,both,,,420,310.8,,,310.8,Other,150% of Medicare + 9.63% HCRA Surcharge,189,45,,189,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,207.9,,,207.9,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,294,70,,294,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,310.8,
BOSTON SCI H7493926708320 BALLOON 3.25X8,C1725,HCPCS,,79011540,CDM,272,RC,,,both,,,420,310.8,,,310.8,Other,150% of Medicare + 9.63% HCRA Surcharge,189,45,,189,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,207.9,,,207.9,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,294,70,,294,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,310.8,
BOSTON SCI H7493926708350 BALLOON 3.5X8,C1725,HCPCS,,79011541,CDM,272,RC,,,both,,,420,310.8,,,310.8,Other,150% of Medicare + 9.63% HCRA Surcharge,189,45,,189,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,207.9,,,207.9,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,294,70,,294,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,310.8,
BOSTON SCI H7493926708370 BALLOON 3.75X8,C1725,HCPCS,,79011542,CDM,272,RC,,,both,,,420,310.8,,,310.8,Other,150% of Medicare + 9.63% HCRA Surcharge,189,45,,189,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,207.9,,,207.9,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,294,70,,294,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,310.8,
BOSTON SCI H7493926708400 BALLOON 4X8MM,C1725,HCPCS,,79011543,CDM,272,RC,,,both,,,420,310.8,,,310.8,Other,150% of Medicare + 9.63% HCRA Surcharge,189,45,,189,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,207.9,,,207.9,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,294,70,,294,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,310.8,
BOSTON SCI H7493926708450 BALLOON 4.5X8,C1725,HCPCS,,79011544,CDM,272,RC,,,both,,,420,310.8,,,310.8,Other,150% of Medicare + 9.63% HCRA Surcharge,189,45,,189,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,207.9,,,207.9,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,294,70,,294,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,310.8,
BOSTON SCI H7493926708500 BALLOON 5X8MM,C1725,HCPCS,,79011545,CDM,272,RC,,,both,,,420,310.8,,,310.8,Other,150% of Medicare + 9.63% HCRA Surcharge,189,45,,189,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,207.9,,,207.9,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,294,70,,294,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,310.8,
BOSTON SCI H7493926708550 BALLOON 5.5X8,C1725,HCPCS,,79011546,CDM,272,RC,,,both,,,420,310.8,,,310.8,Other,150% of Medicare + 9.63% HCRA Surcharge,189,45,,189,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,207.9,,,207.9,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,294,70,,294,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,310.8,
BOSTON SCI H7493926712200 BALLOON 2X12MM,C1725,HCPCS,,79011547,CDM,272,RC,,,both,,,420,310.8,,,310.8,Other,150% of Medicare + 9.63% HCRA Surcharge,189,45,,189,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,207.9,,,207.9,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,294,70,,294,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,310.8,
BOSTON SCI H7493926712220 BALLOON 2.25X1,C1725,HCPCS,,79011548,CDM,272,RC,,,both,,,420,310.8,,,310.8,Other,150% of Medicare + 9.63% HCRA Surcharge,189,45,,189,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,207.9,,,207.9,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,294,70,,294,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,310.8,
BOSTON SCI H7493926712250 BALLOON 2.5X12,C1725,HCPCS,,79011549,CDM,272,RC,,,both,,,420,310.8,,,310.8,Other,150% of Medicare + 9.63% HCRA Surcharge,189,45,,189,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,207.9,,,207.9,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,294,70,,294,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,310.8,
BOSTON SCI H7493926712270 BALLOON 2.75X1,C1725,HCPCS,,79011550,CDM,272,RC,,,both,,,420,310.8,,,310.8,Other,150% of Medicare + 9.63% HCRA Surcharge,189,45,,189,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,207.9,,,207.9,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,294,70,,294,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,310.8,
BOSTON SCI H7493926712300 BALLOON 3X12MM,C1725,HCPCS,,79011551,CDM,272,RC,,,both,,,420,310.8,,,310.8,Other,150% of Medicare + 9.63% HCRA Surcharge,189,45,,189,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,207.9,,,207.9,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,294,70,,294,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,310.8,
BOSTON SC H7493926712320 BALLOON 3.25X12,C1725,HCPCS,,79011552,CDM,272,RC,,,both,,,420,310.8,,,310.8,Other,150% of Medicare + 9.63% HCRA Surcharge,189,45,,189,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,207.9,,,207.9,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,294,70,,294,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,310.8,
BOSTON SCI H7493926712350 BALLOON 3.5X12,C1725,HCPCS,,79011553,CDM,272,RC,,,both,,,420,310.8,,,310.8,Other,150% of Medicare + 9.63% HCRA Surcharge,189,45,,189,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,207.9,,,207.9,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,294,70,,294,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,310.8,
BOSTON SC H7493926712370 BALLOON 3.75X12,C1725,HCPCS,,79011554,CDM,272,RC,,,both,,,420,310.8,,,310.8,Other,150% of Medicare + 9.63% HCRA Surcharge,189,45,,189,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,207.9,,,207.9,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,294,70,,294,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,310.8,
BOSTON SCI H7493926712400 BALLOON 4X12MM,C1725,HCPCS,,79011555,CDM,272,RC,,,both,,,420,310.8,,,310.8,Other,150% of Medicare + 9.63% HCRA Surcharge,189,45,,189,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,207.9,,,207.9,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,294,70,,294,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,310.8,
BOSTON SCI H7493926712450 BALLOON 4.5X12,C1725,HCPCS,,79011556,CDM,272,RC,,,both,,,420,310.8,,,310.8,Other,150% of Medicare + 9.63% HCRA Surcharge,189,45,,189,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,207.9,,,207.9,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,294,70,,294,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,310.8,
BOSTON SCI H7493926712500 BALLOON 5X12MM,C1725,HCPCS,,79011557,CDM,272,RC,,,both,,,420,310.8,,,310.8,Other,150% of Medicare + 9.63% HCRA Surcharge,189,45,,189,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,207.9,,,207.9,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,294,70,,294,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,310.8,
BOSTON SCI H7493926712550 BALLOON 5.5X12,C1725,HCPCS,,79011558,CDM,272,RC,,,both,,,420,310.8,,,310.8,Other,150% of Medicare + 9.63% HCRA Surcharge,189,45,,189,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,207.9,,,207.9,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,294,70,,294,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,310.8,
BOSTON SCI H7493926715200 BALLOON 2X15MM,C1725,HCPCS,,79011559,CDM,272,RC,,,both,,,420,310.8,,,310.8,Other,150% of Medicare + 9.63% HCRA Surcharge,189,45,,189,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,207.9,,,207.9,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,294,70,,294,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,310.8,
BOSTON SC H7493926715220 BALLOON 2.25X15,C1725,HCPCS,,79011560,CDM,272,RC,,,both,,,420,310.8,,,310.8,Other,150% of Medicare + 9.63% HCRA Surcharge,189,45,,189,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,207.9,,,207.9,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,294,70,,294,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,310.8,
BOSTON SCI H7493926715250 BALLOON 2.5X15,C1725,HCPCS,,79011561,CDM,272,RC,,,both,,,420,310.8,,,310.8,Other,150% of Medicare + 9.63% HCRA Surcharge,189,45,,189,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,207.9,,,207.9,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,294,70,,294,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,310.8,
BOSTON SCI H7493926715300 BALLOON 3X15MM,C1725,HCPCS,,79011562,CDM,272,RC,,,both,,,420,310.8,,,310.8,Other,150% of Medicare + 9.63% HCRA Surcharge,189,45,,189,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,207.9,,,207.9,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,294,70,,294,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,310.8,
BOSTON SC H7493926715320 BALLOON 3.25X15,C1725,HCPCS,,79011563,CDM,272,RC,,,both,,,420,310.8,,,310.8,Other,150% of Medicare + 9.63% HCRA Surcharge,189,45,,189,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,207.9,,,207.9,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,294,70,,294,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,310.8,
BOSTON SCI H7493926715350 BALLOON 3.5X15,C1725,HCPCS,,79011564,CDM,272,RC,,,both,,,420,310.8,,,310.8,Other,150% of Medicare + 9.63% HCRA Surcharge,189,45,,189,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,207.9,,,207.9,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,294,70,,294,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,310.8,
BOSTON SC H7493926715370 BALLOON 3.75X15,C1725,HCPCS,,79011565,CDM,272,RC,,,both,,,420,310.8,,,310.8,Other,150% of Medicare + 9.63% HCRA Surcharge,189,45,,189,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,207.9,,,207.9,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,294,70,,294,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,310.8,
BOSTON SCI H7493926715400 BALLOON 4X15MM,C1725,HCPCS,,79011566,CDM,272,RC,,,both,,,420,310.8,,,310.8,Other,150% of Medicare + 9.63% HCRA Surcharge,189,45,,189,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,207.9,,,207.9,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,294,70,,294,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,310.8,
BOSTON SCI H7493926715450 BALLOON 4.5X15,C1725,HCPCS,,79011568,CDM,272,RC,,,both,,,420,310.8,,,310.8,Other,150% of Medicare + 9.63% HCRA Surcharge,189,45,,189,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,207.9,,,207.9,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,294,70,,294,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,310.8,
BOSTON SCI H7493926720200 BALLOON 2X20MM,C1725,HCPCS,,79011569,CDM,272,RC,,,both,,,420,310.8,,,310.8,Other,150% of Medicare + 9.63% HCRA Surcharge,189,45,,189,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,207.9,,,207.9,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,294,70,,294,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,310.8,
BOSTON SC H7493926720220 BALLOON 2.25X20,C1725,HCPCS,,79011570,CDM,272,RC,,,both,,,420,310.8,,,310.8,Other,150% of Medicare + 9.63% HCRA Surcharge,189,45,,189,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,207.9,,,207.9,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,294,70,,294,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,310.8,
BOSTON SCI H7493926720250 BALLOON 2.5X20,C1725,HCPCS,,79011571,CDM,272,RC,,,both,,,420,310.8,,,310.8,Other,150% of Medicare + 9.63% HCRA Surcharge,189,45,,189,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,207.9,,,207.9,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,294,70,,294,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,310.8,
BOSTON SC H7493926720270 BALLOON 2.75X20,C1725,HCPCS,,79011572,CDM,272,RC,,,both,,,420,310.8,,,310.8,Other,150% of Medicare + 9.63% HCRA Surcharge,189,45,,189,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,207.9,,,207.9,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,294,70,,294,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,310.8,
BOSTON SCI H7493926720300 BALLOON 3X20MM,C1725,HCPCS,,79011573,CDM,272,RC,,,both,,,420,310.8,,,310.8,Other,150% of Medicare + 9.63% HCRA Surcharge,189,45,,189,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,207.9,,,207.9,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,294,70,,294,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,310.8,
BOSTON SC H7493926720320 BALLOON 3.25X20,C1725,HCPCS,,79011574,CDM,272,RC,,,both,,,420,310.8,,,310.8,Other,150% of Medicare + 9.63% HCRA Surcharge,189,45,,189,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,207.9,,,207.9,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,294,70,,294,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,310.8,
BOSTON SCI H7493926720350 BALLOON 3.5X20,C1725,HCPCS,,79011575,CDM,272,RC,,,both,,,420,310.8,,,310.8,Other,150% of Medicare + 9.63% HCRA Surcharge,189,45,,189,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,207.9,,,207.9,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,294,70,,294,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,310.8,
BOSTON SC H7493926720370 BALLOON 3.75X20,C1725,HCPCS,,79011576,CDM,272,RC,,,both,,,420,310.8,,,310.8,Other,150% of Medicare + 9.63% HCRA Surcharge,189,45,,189,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,207.9,,,207.9,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,294,70,,294,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,310.8,
BOSTON SCI H7493926720400 BALLOON 4X20MM,C1725,HCPCS,,79011577,CDM,272,RC,,,both,,,420,310.8,,,310.8,Other,150% of Medicare + 9.63% HCRA Surcharge,189,45,,189,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,207.9,,,207.9,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,294,70,,294,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,310.8,
BOSTON SCI H7493926720450 BALLOON 4.5X20,C1725,HCPCS,,79011578,CDM,272,RC,,,both,,,420,310.8,,,310.8,Other,150% of Medicare + 9.63% HCRA Surcharge,189,45,,189,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,207.9,,,207.9,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,294,70,,294,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,310.8,
BOSTON SCI H74939401062500 BALLOON 2.5X6,C1725,HCPCS,,79011579,CDM,272,RC,,,both,,,2850,2109.01,,,2109.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1282.5,45,,1282.5,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1410.75,,,1410.75,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1995,70,,1995,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2109.01,
BOSTON SCI H74939401063000 BALLOON 3X6MM,C1725,HCPCS,,79011580,CDM,272,RC,,,both,,,2850,2109.01,,,2109.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1282.5,45,,1282.5,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1410.75,,,1410.75,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1995,70,,1995,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2109.01,
BOSTON SCI H74939401063500 BALLOON 3.5X6,C1725,HCPCS,,79011581,CDM,272,RC,,,both,,,2850,2109.01,,,2109.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1282.5,45,,1282.5,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1410.75,,,1410.75,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1995,70,,1995,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2109.01,
BOSTON SCI H74939401064000 BALLOON 4X6MM,C1725,HCPCS,,79011582,CDM,272,RC,,,both,,,2850,2109.01,,,2109.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1282.5,45,,1282.5,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1410.75,,,1410.75,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1995,70,,1995,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2109.01,
BOSTON SC H74939401102500 BALLOON 2.5X10,C1725,HCPCS,,79011583,CDM,272,RC,,,both,,,2850,2109.01,,,2109.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1282.5,45,,1282.5,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1410.75,,,1410.75,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1995,70,,1995,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2109.01,
BOSTON SCI H74939401103000 BALLOON 3X10,C1725,HCPCS,,79011584,CDM,272,RC,,,both,,,2850,2109.01,,,2109.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1282.5,45,,1282.5,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1410.75,,,1410.75,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1995,70,,1995,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2109.01,
BOSTON SC H74939401103500 BALLOON 3.5X10,C1725,HCPCS,,79011585,CDM,272,RC,,,both,,,2850,2109.01,,,2109.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1282.5,45,,1282.5,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1410.75,,,1410.75,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1995,70,,1995,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2109.01,
BOSTOB SCI H74939401104000 BALLOON 4X10,C1725,HCPCS,,79011586,CDM,272,RC,,,both,,,2850,2109.01,,,2109.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1282.5,45,,1282.5,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1410.75,,,1410.75,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1995,70,,1995,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2109.01,
TELEFLEX 5571 6FR GUIDELINER 150CM,C1887,HCPCS,,79011587,CDM,272,RC,,,both,,,1275,943.5,,,943.5,Other,150% of Medicare + 9.63% HCRA Surcharge,573.75,45,,573.75,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,631.13,,,631.13,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,892.5,70,,892.5,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,943.5,
TELEFLEX 5572 7FR GUIDELINER 150CM,C1887,HCPCS,,79011588,CDM,272,RC,,,both,,,1275,943.5,,,943.5,Other,150% of Medicare + 9.63% HCRA Surcharge,573.75,45,,573.75,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,631.13,,,631.13,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,892.5,70,,892.5,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,943.5,
BOSTON SCI H74938931032 GUIDEWIRE 185CM,C1769,HCPCS,,79011595,CDM,272,RC,,,both,,,249,184.26,,,184.26,Other,150% of Medicare + 9.63% HCRA Surcharge,112.05,45,,112.05,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,123.26,,,123.26,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,174.3,70,,174.3,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,184.26,
BOSTON SCI H74912161012 GUIDEWIRE 182CM,C1769,HCPCS,,79011596,CDM,272,RC,,,both,,,249,184.26,,,184.26,Other,150% of Medicare + 9.63% HCRA Surcharge,112.05,45,,112.05,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,123.26,,,123.26,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,174.3,70,,174.3,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,184.26,
BOSTON SCI H74912160012 GUIDEWIRE 182CM,C1769,HCPCS,,79011597,CDM,272,RC,,,both,,,249,184.26,,,184.26,Other,150% of Medicare + 9.63% HCRA Surcharge,112.05,45,,112.05,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,123.26,,,123.26,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,174.3,70,,174.3,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,184.26,
BOSTON SCI H74912136012 GUIDEWIRE 182CM,C1769,HCPCS,,79011598,CDM,272,RC,,,both,,,249,184.26,,,184.26,Other,150% of Medicare + 9.63% HCRA Surcharge,112.05,45,,112.05,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,123.26,,,123.26,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,174.3,70,,174.3,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,184.26,
BOSTON SCI H74912120012 GUIDEWIRE 300CM,C1769,HCPCS,,79011599,CDM,272,RC,,,both,,,249,184.26,,,184.26,Other,150% of Medicare + 9.63% HCRA Surcharge,112.05,45,,112.05,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,123.26,,,123.26,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,174.3,70,,174.3,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,184.26,
BOSTON SCI H7491213001M2 GUIDEWIRE 182CM,C1769,HCPCS,,79011600,CDM,272,RC,,,both,,,249,184.26,,,184.26,Other,150% of Medicare + 9.63% HCRA Surcharge,112.05,45,,112.05,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,123.26,,,123.26,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,174.3,70,,174.3,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,184.26,
BOSTON SCI H74912155012 GUIDEWIRE 300CM,C1769,HCPCS,,79011601,CDM,272,RC,,,both,,,249,184.26,,,184.26,Other,150% of Medicare + 9.63% HCRA Surcharge,112.05,45,,112.05,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,123.26,,,123.26,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,174.3,70,,174.3,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,184.26,
ABBOTT 10005359H GUIDEWIRE 300CM,C1769,HCPCS,,79011602,CDM,272,RC,,,both,,,375,277.5,,,277.5,Other,150% of Medicare + 9.63% HCRA Surcharge,168.75,45,,168.75,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,185.63,,,185.63,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,262.5,70,,262.5,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,277.5,
ABBOTT 1011834H GUIDEWIRE 190CM,C1769,HCPCS,,79011603,CDM,272,RC,,,both,,,375,277.5,,,277.5,Other,150% of Medicare + 9.63% HCRA Surcharge,168.75,45,,168.75,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,185.63,,,185.63,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,262.5,70,,262.5,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,277.5,
BOSTON SCI H749201001900 FILTERWIRE 190,C1884,HCPCS,,79011604,CDM,272,RC,,,both,,,4485,3318.91,,,3318.91,Other,150% of Medicare + 9.63% HCRA Surcharge,2018.25,45,,2018.25,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2220.08,,,2220.08,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,3139.5,70,,3139.5,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3318.91,
BOSTON SCI H749201003000 FILTERWIRE 300,C1884,HCPCS,,79011605,CDM,272,RC,,,both,,,4485,3318.91,,,3318.91,Other,150% of Medicare + 9.63% HCRA Surcharge,2018.25,45,,2018.25,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2220.08,,,2220.08,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,3139.5,70,,3139.5,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3318.91,
BOSTON SCI H749390711900 FILTERWIRE 190,C1884,HCPCS,,79011606,CDM,272,RC,,,both,,,4485,3318.91,,,3318.91,Other,150% of Medicare + 9.63% HCRA Surcharge,2018.25,45,,2018.25,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2220.08,,,2220.08,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,3139.5,70,,3139.5,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3318.91,
BOSTON SCI H749390713000 FILTERWIRE 300,C1884,HCPCS,,79011607,CDM,272,RC,,,both,,,4485,3318.91,,,3318.91,Other,150% of Medicare + 9.63% HCRA Surcharge,2018.25,45,,2018.25,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2220.08,,,2220.08,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,3139.5,70,,3139.5,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3318.91,
BOSTON H749501001500 FILTERWIRE SHEATH,C1894,HCPCS,,79011608,CDM,272,RC,,,both,,,240,177.6,,,177.6,Other,150% of Medicare + 9.63% HCRA Surcharge,108,45,,108,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,118.8,,,118.8,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,168,70,,168,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,177.6,
PHILIPS 10185P PRESSURE WIRE 185CM,C1769,HCPCS,,79011609,CDM,272,RC,,,both,,,2025,1498.51,,,1498.51,Other,150% of Medicare + 9.63% HCRA Surcharge,911.25,45,,911.25,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1002.38,,,1002.38,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1417.5,70,,1417.5,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1498.51,
TELEFLEX 5540 6FR CATHETER 145CM,C1887,HCPCS,,79011610,CDM,272,RC,,,both,,,2328,1722.73,,,1722.73,Other,150% of Medicare + 9.63% HCRA Surcharge,1047.6,45,,1047.6,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1152.36,,,1152.36,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1629.6,70,,1629.6,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1722.73,
MEDTRONIC ADM06020013P 6X200MM BALLOON,C2623,HCPCS,,79011611,CDM,272,RC,,,both,,,5835,4317.91,,,4317.91,Other,150% of Medicare + 9.63% HCRA Surcharge,2625.75,45,,2625.75,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2888.33,,,2888.33,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,4084.5,70,,4084.5,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4317.91,
MEDTRONIC LA7AL10 GUIDECATH 7FR AL1,C1887,HCPCS,,79011617,CDM,272,RC,,,both,,,120,88.8,,,88.8,Other,150% of Medicare + 9.63% HCRA Surcharge,54,45,,54,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,59.4,,,59.4,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,84,70,,84,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,88.8,
MEDTRONIC LA7AR10 GUIDECATH 7FR AR1,C1887,HCPCS,,79011618,CDM,272,RC,,,both,,,120,88.8,,,88.8,Other,150% of Medicare + 9.63% HCRA Surcharge,54,45,,54,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,59.4,,,59.4,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,84,70,,84,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,88.8,
MEDTRONIC LA7EBU30 GUIDECATH 7FR EBU 3.0,C1887,HCPCS,,79011619,CDM,272,RC,,,both,,,120,88.8,,,88.8,Other,150% of Medicare + 9.63% HCRA Surcharge,54,45,,54,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,59.4,,,59.4,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,84,70,,84,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,88.8,
MEDTRONIC LA7IMAD GUIDECATH 7FR IM,C1887,HCPCS,,79011620,CDM,272,RC,,,both,,,120,88.8,,,88.8,Other,150% of Medicare + 9.63% HCRA Surcharge,54,45,,54,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,59.4,,,59.4,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,84,70,,84,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,88.8,
MEDTRONIC LA7JL40SH GUIDECATH 7FR JL 4.0,C1887,HCPCS,,79011621,CDM,272,RC,,,both,,,120,88.8,,,88.8,Other,150% of Medicare + 9.63% HCRA Surcharge,54,45,,54,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,59.4,,,59.4,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,84,70,,84,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,88.8,
MEDTRONIC LA7EBU35 GUIDECATH 7FR EBU 3.5,C1887,HCPCS,,79011622,CDM,272,RC,,,both,,,120,88.8,,,88.8,Other,150% of Medicare + 9.63% HCRA Surcharge,54,45,,54,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,59.4,,,59.4,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,84,70,,84,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,88.8,
MEDTRONIC LA7EBU40 GUIDECATH 7FR EBU 4.0,C1887,HCPCS,,79011623,CDM,272,RC,,,both,,,120,88.8,,,88.8,Other,150% of Medicare + 9.63% HCRA Surcharge,54,45,,54,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,59.4,,,59.4,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,84,70,,84,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,88.8,
MEDTRONIC LA7JR40 GUIDECATH 7FR JR 4.0,C1887,HCPCS,,79011624,CDM,272,RC,,,both,,,120,88.8,,,88.8,Other,150% of Medicare + 9.63% HCRA Surcharge,54,45,,54,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,59.4,,,59.4,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,84,70,,84,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,88.8,
MEDTRONIC LA6MP1 GUIDECATH 6FR MP1,C1887,HCPCS,,79011625,CDM,272,RC,,,both,,,120,88.8,,,88.8,Other,150% of Medicare + 9.63% HCRA Surcharge,54,45,,54,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,59.4,,,59.4,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,84,70,,84,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,88.8,
MEDTRONIC LA6HSII GUIDECATH 6FR HS2,C1887,HCPCS,,79011626,CDM,272,RC,,,both,,,120,88.8,,,88.8,Other,150% of Medicare + 9.63% HCRA Surcharge,54,45,,54,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,59.4,,,59.4,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,84,70,,84,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,88.8,
MEDTRONIC LA6JL45SH GUIDECATH 6FR JL 4.5,C1887,HCPCS,,79011627,CDM,272,RC,,,both,,,120,88.8,,,88.8,Other,150% of Medicare + 9.63% HCRA Surcharge,54,45,,54,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,59.4,,,59.4,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,84,70,,84,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,88.8,
MEDTRONIC LA6JL45 GUIDECATH 6FR JL 4.5 S,C1887,HCPCS,,79011628,CDM,272,RC,,,both,,,120,88.8,,,88.8,Other,150% of Medicare + 9.63% HCRA Surcharge,54,45,,54,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,59.4,,,59.4,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,84,70,,84,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,88.8,
MEDTRONIC LA6JR45 GUIDECATH 6FR JR 4.5,C1887,HCPCS,,79011629,CDM,272,RC,,,both,,,120,88.8,,,88.8,Other,150% of Medicare + 9.63% HCRA Surcharge,54,45,,54,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,59.4,,,59.4,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,84,70,,84,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,88.8,
MEDTRONIC LAJR50 GUIDECATH 6FR JR 5,C1887,HCPCS,,79011630,CDM,272,RC,,,both,,,120,88.8,,,88.8,Other,150% of Medicare + 9.63% HCRA Surcharge,54,45,,54,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,59.4,,,59.4,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,84,70,,84,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,88.8,
MEDTRONIC LA6JR50SH GUIDECATH 6FR JR 5 S,C1887,HCPCS,,79011631,CDM,272,RC,,,both,,,120,88.8,,,88.8,Other,150% of Medicare + 9.63% HCRA Surcharge,54,45,,54,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,59.4,,,59.4,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,84,70,,84,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,88.8,
MEDTRONIC LA6EBU45 GUIDECATH 6FR EBU 4.5,C1887,HCPCS,,79011632,CDM,272,RC,,,both,,,120,88.8,,,88.8,Other,150% of Medicare + 9.63% HCRA Surcharge,54,45,,54,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,59.4,,,59.4,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,84,70,,84,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,88.8,
MEDLINE 60110152 RS-LEFT HEART CASE,C1769,HCPCS,,79011702,CDM,272,RC,,,both,,,116,85.84,,,85.84,Other,150% of Medicare + 9.63% HCRA Surcharge,52.2,45,,52.2,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,57.42,,,57.42,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,81.2,70,,81.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,85.84,
EDWARDS 777F8 8FR CCO SWAN-GANZ CATHETER,C1751,HCPCS,,79011737,CDM,272,RC,,,both,,,774,572.76,,,572.76,Other,150% of Medicare + 9.63% HCRA Surcharge,348.3,45,,348.3,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,383.13,,,383.13,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,541.8,70,,541.8,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,572.76,
ABBOTT 22260 DOC GUIDEWIRE EXTENSION,C1769,HCPCS,,79011808,CDM,272,RC,,,both,,,375,277.5,,,277.5,Other,150% of Medicare + 9.63% HCRA Surcharge,168.75,45,,168.75,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,185.63,,,185.63,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,262.5,70,,262.5,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,277.5,
ASAHI-INTECC AG141300 ASAHI SOFT 300CM,C1769,HCPCS,,79011809,CDM,272,RC,,,both,,,285,210.9,,,210.9,Other,150% of Medicare + 9.63% HCRA Surcharge,128.25,45,,128.25,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,141.08,,,141.08,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,199.5,70,,199.5,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,210.9,
CARDINAL 502-521 GUIDEWIRE 0.35X150,C1769,HCPCS,,79011816,CDM,272,RC,,,both,,,28,20.72,,,20.72,Other,150% of Medicare + 9.63% HCRA Surcharge,12.6,45,,12.6,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,13.86,,,13.86,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,19.6,70,,19.6,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,20.72,
CARDINAL 502-455 GUIDEWIRE 0.35X260,C1769,HCPCS,,79011817,CDM,272,RC,,,both,,,30,22.2,,,22.2,Other,150% of Medicare + 9.63% HCRA Surcharge,13.5,45,,13.5,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,14.85,,,14.85,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,21,70,,21,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,22.2,
MEDTRONIC LA6AL30 LAUNCHER GUIDECATH 6FR,C1887,HCPCS,,79011834,CDM,272,RC,,,both,,,120,88.8,,,88.8,Other,150% of Medicare + 9.63% HCRA Surcharge,54,45,,54,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,59.4,,,59.4,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,84,70,,84,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,88.8,
BOST SCI 46-591 MAGIC TORQUE .035X180CM,C1769,HCPCS,,79011840,CDM,272,RC,,,both,,,155,114.7,,,114.7,Other,150% of Medicare + 9.63% HCRA Surcharge,69.75,45,,69.75,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,76.73,,,76.73,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,108.5,70,,108.5,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,114.7,
BOST 3917106067 6X60X75 MUSTANG BALLOON,C1725,HCPCS,,79011862,CDM,272,RC,,,both,,,401,296.74,,,296.74,Other,150% of Medicare + 9.63% HCRA Surcharge,180.45,45,,180.45,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,198.5,,,198.5,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,280.7,70,,280.7,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,296.74,
BOST 3917107067 7X60X75 MUSTANG BALLOON,C1725,HCPCS,,79011863,CDM,272,RC,,,both,,,401,296.74,,,296.74,Other,150% of Medicare + 9.63% HCRA Surcharge,180.45,45,,180.45,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,198.5,,,198.5,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,280.7,70,,280.7,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,296.74,
BOST 3917106041 6X40X135 MUSTANG BALLOON,C1725,HCPCS,,79011864,CDM,272,RC,,,both,,,401,296.74,,,296.74,Other,150% of Medicare + 9.63% HCRA Surcharge,180.45,45,,180.45,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,198.5,,,198.5,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,280.7,70,,280.7,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,296.74,
BOST 3917107041 7X40X135 MUSTANG BALLOON,C1725,HCPCS,,79011865,CDM,272,RC,,,both,,,401,296.74,,,296.74,Other,150% of Medicare + 9.63% HCRA Surcharge,180.45,45,,180.45,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,198.5,,,198.5,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,280.7,70,,280.7,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,296.74,
BOST 3913520401 2X40X150 COYOTE BALLOON,C1725,HCPCS,,79011866,CDM,272,RC,,,both,,,567,419.58,,,419.58,Other,150% of Medicare + 9.63% HCRA Surcharge,255.15,45,,255.15,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,280.67,,,280.67,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,396.9,70,,396.9,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,419.58,
BOST 3918520081 2X80X150 COYOTE BALLOON,C1725,HCPCS,,79011867,CDM,272,RC,,,both,,,567,419.58,,,419.58,Other,150% of Medicare + 9.63% HCRA Surcharge,255.15,45,,255.15,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,280.67,,,280.67,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,396.9,70,,396.9,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,419.58,
BOST 3918525101 2.5X100X150 COY BALLOON,C1725,HCPCS,,79011868,CDM,272,RC,,,both,,,567,419.58,,,419.58,Other,150% of Medicare + 9.63% HCRA Surcharge,255.15,45,,255.15,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,280.67,,,280.67,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,396.9,70,,396.9,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,419.58,
BOST 3913530401 3X40X150 COYOTE BALLOON,C1725,HCPCS,,79011869,CDM,272,RC,,,both,,,567,419.58,,,419.58,Other,150% of Medicare + 9.63% HCRA Surcharge,255.15,45,,255.15,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,280.67,,,280.67,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,396.9,70,,396.9,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,419.58,
BOST 3918530081 3X80X150 COYOTE BALLOON,C1725,HCPCS,,79011870,CDM,272,RC,,,both,,,567,419.58,,,419.58,Other,150% of Medicare + 9.63% HCRA Surcharge,255.15,45,,255.15,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,280.67,,,280.67,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,396.9,70,,396.9,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,419.58,
BOST H74939171070870 7X80X75 MUS BALLOON,C1725,HCPCS,,79011902,CDM,272,RC,,,both,,,401,296.74,,,296.74,Other,150% of Medicare + 9.63% HCRA Surcharge,180.45,45,,180.45,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,198.5,,,198.5,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,280.7,70,,280.7,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,296.74,
MEDTRONIC LA5JL35 GUIDECATH 5FR JL 3.5,C1887,HCPCS,,79011915,CDM,272,RC,,,both,,,120,88.8,,,88.8,Other,150% of Medicare + 9.63% HCRA Surcharge,54,45,,54,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,59.4,,,59.4,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,84,70,,84,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,88.8,
MEDTRONIC LA5JL40 GUIDECATH 5FR JL 4.0,C1887,HCPCS,,79011916,CDM,272,RC,,,both,,,120,88.8,,,88.8,Other,150% of Medicare + 9.63% HCRA Surcharge,54,45,,54,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,59.4,,,59.4,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,84,70,,84,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,88.8,
MEDTRONIC LA5JR40 GUIDECATH 5FR JR 4.0,C1887,HCPCS,,79011917,CDM,272,RC,,,both,,,120,88.8,,,88.8,Other,150% of Medicare + 9.63% HCRA Surcharge,54,45,,54,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,59.4,,,59.4,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,84,70,,84,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,88.8,
MEDTRONIC LA5EBU30 GUIDECATH 5FR EBU 3.0,C1887,HCPCS,,79011918,CDM,272,RC,,,both,,,120,88.8,,,88.8,Other,150% of Medicare + 9.63% HCRA Surcharge,54,45,,54,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,59.4,,,59.4,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,84,70,,84,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,88.8,
MEDTRONIC LA5EBU35 GUIDECATH 5FR EBU 3.5,C1887,HCPCS,,79011919,CDM,272,RC,,,both,,,120,88.8,,,88.8,Other,150% of Medicare + 9.63% HCRA Surcharge,54,45,,54,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,59.4,,,59.4,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,84,70,,84,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,88.8,
MEDTRONIC LA5EBY375 GUIDECATH 5FR 3.75,C1887,HCPCS,,79011920,CDM,272,RC,,,both,,,120,88.8,,,88.8,Other,150% of Medicare + 9.63% HCRA Surcharge,54,45,,54,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,59.4,,,59.4,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,84,70,,84,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,88.8,
MEDTRONIC LA5IMA GUIDECATH 5FR IMA,C1887,HCPCS,,79011921,CDM,272,RC,,,both,,,120,88.8,,,88.8,Other,150% of Medicare + 9.63% HCRA Surcharge,54,45,,54,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,59.4,,,59.4,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,84,70,,84,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,88.8,
GETINGE 0684-00-0254-09 .025X145 GUIDEWI,C1769,HCPCS,,79011922,CDM,272,RC,,,both,,,69,51.06,,,51.06,Other,150% of Medicare + 9.63% HCRA Surcharge,31.05,45,,31.05,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,34.16,,,34.16,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,48.3,70,,48.3,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,51.06,
GETINGE 0684-00-0403-05 7.5FR SHEATH SET,C1893,HCPCS,,79011923,CDM,272,RC,,,both,,,115,85.1,,,85.1,Other,150% of Medicare + 9.63% HCRA Surcharge,51.75,45,,51.75,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,56.93,,,56.93,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,80.5,70,,80.5,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,85.1,
GETINGE 0684-00-0403-10 8FR SHEATH SET,C1893,HCPCS,,79011924,CDM,272,RC,,,both,,,111,82.14,,,82.14,Other,150% of Medicare + 9.63% HCRA Surcharge,49.95,45,,49.95,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,54.95,,,54.95,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,77.7,70,,77.7,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,82.14,
CARDINAL 55800200 GUIDECATH 5FR JL 3.5,C1887,HCPCS,,79011925,CDM,272,RC,,,both,,,180,133.2,,,133.2,Other,150% of Medicare + 9.63% HCRA Surcharge,81,45,,81,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,89.1,,,89.1,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,126,70,,126,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,133.2,
CARDINAL 55800400 GUIDECATH 5FR JL 4.0,C1887,HCPCS,,79011926,CDM,272,RC,,,both,,,180,133.2,,,133.2,Other,150% of Medicare + 9.63% HCRA Surcharge,81,45,,81,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,89.1,,,89.1,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,126,70,,126,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,133.2,
CARDINAL 55808200 GUIDECATH 5FR JR 4.0,C1887,HCPCS,,79011927,CDM,272,RC,,,both,,,180,133.2,,,133.2,Other,150% of Medicare + 9.63% HCRA Surcharge,81,45,,81,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,89.1,,,89.1,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,126,70,,126,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,133.2,
CARDINAL 55819000 GUIDECATH 5FR IM,C1887,HCPCS,,79011928,CDM,272,RC,,,both,,,180,133.2,,,133.2,Other,150% of Medicare + 9.63% HCRA Surcharge,81,45,,81,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,89.1,,,89.1,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,126,70,,126,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,133.2,
CARDINAL 67206600 GUIDECATH 6FR XB LAD 3,C1887,HCPCS,,79011929,CDM,272,RC,,,both,,,180,133.2,,,133.2,Other,150% of Medicare + 9.63% HCRA Surcharge,81,45,,81,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,89.1,,,89.1,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,126,70,,126,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,133.2,
CARDINAL 67206000 GUIDECATH 6FR XB 3.5,C1887,HCPCS,,79011930,CDM,272,RC,,,both,,,180,133.2,,,133.2,Other,150% of Medicare + 9.63% HCRA Surcharge,81,45,,81,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,89.1,,,89.1,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,126,70,,126,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,133.2,
CARDINAL 67206200 GUIDECATH 6FR XB LAD 4,C1887,HCPCS,,79011931,CDM,272,RC,,,both,,,180,133.2,,,133.2,Other,150% of Medicare + 9.63% HCRA Surcharge,81,45,,81,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,89.1,,,89.1,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,126,70,,126,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,133.2,
CARDINAL 67206400 GUIDECATH 6FR XB 4.5,C1887,HCPCS,,79011932,CDM,272,RC,,,both,,,180,133.2,,,133.2,Other,150% of Medicare + 9.63% HCRA Surcharge,81,45,,81,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,89.1,,,89.1,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,126,70,,126,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,133.2,
TERUMO 80-1065 6FR GLIDESHEATH W/NEEDLE,C1893,HCPCS,,79011933,CDM,272,RC,,,both,,,319,236.06,,,236.06,Other,150% of Medicare + 9.63% HCRA Surcharge,143.55,45,,143.55,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,157.91,,,157.91,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,223.3,70,,223.3,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,236.06,
VASCULAR 7262V 4FR STIFF MICROPUNT VASC,C1893,HCPCS,,79011934,CDM,272,RC,,,both,,,129,95.46,,,95.46,Other,150% of Medicare + 9.63% HCRA Surcharge,58.05,45,,58.05,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,63.86,,,63.86,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,90.3,70,,90.3,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,95.46,
ASAHI-INTECC AG141002 PTCA GW 180CM,C1769,HCPCS,,79011965,CDM,272,RC,,,both,,,405,299.7,,,299.7,Other,150% of Medicare + 9.63% HCRA Surcharge,182.25,45,,182.25,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,200.48,,,200.48,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,283.5,70,,283.5,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,299.7,
ABBOTT 12773-03 PERCLOSE PROSTYLE,C1760,HCPCS,,79011968,CDM,272,RC,,,both,,,750,555,,,555,Other,150% of Medicare + 9.63% HCRA Surcharge,337.5,45,,337.5,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,371.25,,,371.25,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,525,70,,525,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,555,
CARDINAL SRD6994 5FR JL 3 100CM CATHETER,C1887,HCPCS,,79011978,CDM,272,RC,,,both,,,23,17.02,,,17.02,Other,150% of Medicare + 9.63% HCRA Surcharge,10.35,45,,10.35,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,11.39,,,11.39,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,16.1,70,,16.1,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,17.02,
CARDINAL 67212600 GUIDECATH 6FR XB RCA,C1887,HCPCS,,79012005,CDM,272,RC,,,both,,,180,133.2,,,133.2,Other,150% of Medicare + 9.63% HCRA Surcharge,81,45,,81,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,89.1,,,89.1,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,126,70,,126,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,133.2,
CARDINAL 67212700 GUIDECATH 6FR XB W/SH,C1887,HCPCS,,79012006,CDM,272,RC,,,both,,,180,133.2,,,133.2,Other,150% of Medicare + 9.63% HCRA Surcharge,81,45,,81,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,89.1,,,89.1,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,126,70,,126,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,133.2,
J&J 03.120.026 DRILL TIP GUIDE WIRE 2.5,C1769,HCPCS,,79012063,CDM,272,RC,,,both,,,141,104.34,,,104.34,Other,150% of Medicare + 9.63% HCRA Surcharge,63.45,45,,63.45,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,69.8,,,69.8,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,98.7,70,,98.7,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,104.34,
J&J 03.010.115 GUIDE WIRE 3.2X290MM,C1769,HCPCS,,79012100,CDM,272,RC,,,both,,,146,108.04,,,108.04,Other,150% of Medicare + 9.63% HCRA Surcharge,65.7,45,,65.7,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,72.27,,,72.27,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,102.2,70,,102.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,108.04,
J&J 292.72 THREADED GUIDE WIRE 1.6X150MM,C1769,HCPCS,,79012104,CDM,272,RC,,,both,,,67,49.58,,,49.58,Other,150% of Medicare + 9.63% HCRA Surcharge,30.15,45,,30.15,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,33.17,,,33.17,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,46.9,70,,46.9,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,49.58,
COOK G24237 BALLOON UTERINE 24FR 54CM,C2628,HCPCS,,79012105,CDM,272,RC,,,both,,,807,597.18,,,597.18,Other,150% of Medicare + 9.63% HCRA Surcharge,363.15,45,,363.15,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,399.47,,,399.47,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,564.9,70,,564.9,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,597.18,
ASAHI AHW14R104S BLUE PCI GUIDEWIRE 190,C1769,HCPCS,,79012140,CDM,272,RC,,,both,,,420,310.8,,,310.8,Other,150% of Medicare + 9.63% HCRA Surcharge,189,45,,189,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,207.9,,,207.9,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,294,70,,294,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,310.8,
BOST SCI 4712 ELECTRODE DELIVERY SYSTEM,C1894,HCPCS,,79012162,CDM,272,RC,,,both,,,2913,2155.63,,,2155.63,Other,150% of Medicare + 9.63% HCRA Surcharge,1310.85,45,,1310.85,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1441.94,,,1441.94,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2039.1,70,,2039.1,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2155.63,
J&J 03.950-001S GRAFT DELIVERY SYSTEM,A4649,HCPCS,,79012224,CDM,272,RC,,,both,,,371,274.54,,,274.54,Other,150% of Medicare + 9.63% HCRA Surcharge,166.95,45,,166.95,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,183.65,,,183.65,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,259.7,70,,259.7,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,274.54,
ASAHI AG141302 GRAND SLAM 300 CM,C1769,HCPCS,,79012287,CDM,272,RC,,,both,,,405,299.7,,,299.7,Other,150% of Medicare + 9.63% HCRA Surcharge,182.25,45,,182.25,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,200.48,,,200.48,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,283.5,70,,283.5,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,299.7,
BOST 39135-20201 COYOTE 2X20X143 BALLOON,C1725,HCPCS,,79012300,CDM,272,RC,,,both,,,567,419.58,,,419.58,Other,150% of Medicare + 9.63% HCRA Surcharge,255.15,45,,255.15,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,280.67,,,280.67,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,396.9,70,,396.9,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,419.58,
BOST 39135-25201 COY 2.5X20X143 BALLOON,C1725,HCPCS,,79012301,CDM,272,RC,,,both,,,567,419.58,,,419.58,Other,150% of Medicare + 9.63% HCRA Surcharge,255.15,45,,255.15,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,280.67,,,280.67,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,396.9,70,,396.9,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,419.58,
BOST 39185-25081 COY 2.5X80X150 BALLOON,C1725,HCPCS,,79012302,CDM,272,RC,,,both,,,567,419.58,,,419.58,Other,150% of Medicare + 9.63% HCRA Surcharge,255.15,45,,255.15,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,280.67,,,280.67,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,396.9,70,,396.9,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,419.58,
BOST 39185-25151 COY 2.5X150X150 BALLOON,C1725,HCPCS,,79012304,CDM,272,RC,,,both,,,567,419.58,,,419.58,Other,150% of Medicare + 9.63% HCRA Surcharge,255.15,45,,255.15,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,280.67,,,280.67,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,396.9,70,,396.9,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,419.58,
BOST 39135-30201 COYOTE 3X20X144 BALLOON,C1725,HCPCS,,79012305,CDM,272,RC,,,both,,,567,419.58,,,419.58,Other,150% of Medicare + 9.63% HCRA Surcharge,255.15,45,,255.15,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,280.67,,,280.67,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,396.9,70,,396.9,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,419.58,
BOST 39185-30121 COY 3X120X150 BALLOON,C1725,HCPCS,,79012306,CDM,272,RC,,,both,,,567,419.58,,,419.58,Other,150% of Medicare + 9.63% HCRA Surcharge,255.15,45,,255.15,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,280.67,,,280.67,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,396.9,70,,396.9,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,419.58,
BOST 39135-35201 COY 3.5X20X144 BALLOON,C1725,HCPCS,,79012307,CDM,272,RC,,,both,,,567,419.58,,,419.58,Other,150% of Medicare + 9.63% HCRA Surcharge,255.15,45,,255.15,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,280.67,,,280.67,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,396.9,70,,396.9,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,419.58,
BOST 39185-35121 COY 3.5X120X150 BALLOON,C1725,HCPCS,,79012308,CDM,272,RC,,,both,,,567,419.58,,,419.58,Other,150% of Medicare + 9.63% HCRA Surcharge,255.15,45,,255.15,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,280.67,,,280.67,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,396.9,70,,396.9,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,419.58,
BOST 39135-40201 COYOTE 4X20X144 BALLOON,C1725,HCPCS,,79012309,CDM,272,RC,,,both,,,567,419.58,,,419.58,Other,150% of Medicare + 9.63% HCRA Surcharge,255.15,45,,255.15,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,280.67,,,280.67,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,396.9,70,,396.9,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,419.58,
BOST 39135-40401 COYOTE 4X40X146 BALLOON,C1725,HCPCS,,79012310,CDM,272,RC,,,both,,,567,419.58,,,419.58,Other,150% of Medicare + 9.63% HCRA Surcharge,255.15,45,,255.15,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,280.67,,,280.67,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,396.9,70,,396.9,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,419.58,
BOST 39185-40081 COYOTE 4X80X150 BALLOON,C1725,HCPCS,,79012311,CDM,272,RC,,,both,,,567,419.58,,,419.58,Other,150% of Medicare + 9.63% HCRA Surcharge,255.15,45,,255.15,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,280.67,,,280.67,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,396.9,70,,396.9,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,419.58,
BOST 39185-40151 COY 4X150X150 BALLOON,C1725,HCPCS,,79012312,CDM,272,RC,,,both,,,567,419.58,,,419.58,Other,150% of Medicare + 9.63% HCRA Surcharge,255.15,45,,255.15,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,280.67,,,280.67,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,396.9,70,,396.9,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,419.58,
BOST 39185-40221 COY 4X220X150 BALLOON,C1725,HCPCS,,79012313,CDM,272,RC,,,both,,,567,419.58,,,419.58,Other,150% of Medicare + 9.63% HCRA Surcharge,255.15,45,,255.15,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,280.67,,,280.67,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,396.9,70,,396.9,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,419.58,
BOST H74939347040470 ATHLETIS 4X40X75CM,C1725,HCPCS,,79012318,CDM,272,RC,,,both,,,525,388.5,,,388.5,Other,150% of Medicare + 9.63% HCRA Surcharge,236.25,45,,236.25,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,259.88,,,259.88,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,367.5,70,,367.5,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,388.5,
BOST H74939347040670 ATHLETIS 4X60X75CM,C1725,HCPCS,,79012319,CDM,272,RC,,,both,,,525,388.5,,,388.5,Other,150% of Medicare + 9.63% HCRA Surcharge,236.25,45,,236.25,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,259.88,,,259.88,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,367.5,70,,367.5,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,388.5,
BOST H74939347040870 ATHLETIS 4X80X75CM,C1725,HCPCS,,79012320,CDM,272,RC,,,both,,,525,388.5,,,388.5,Other,150% of Medicare + 9.63% HCRA Surcharge,236.25,45,,236.25,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,259.88,,,259.88,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,367.5,70,,367.5,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,388.5,
BOST H74939347041070 ATHLETIS 4X100X75CM,C1725,HCPCS,,79012321,CDM,272,RC,,,both,,,525,388.5,,,388.5,Other,150% of Medicare + 9.63% HCRA Surcharge,236.25,45,,236.25,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,259.88,,,259.88,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,367.5,70,,367.5,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,388.5,
BOST H74939347050470 ATHLETIS 5X40X75CM,C1725,HCPCS,,79012322,CDM,272,RC,,,both,,,525,388.5,,,388.5,Other,150% of Medicare + 9.63% HCRA Surcharge,236.25,45,,236.25,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,259.88,,,259.88,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,367.5,70,,367.5,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,388.5,
BOST H74939347050670 ATHLETIS 5X60X75CM,C1725,HCPCS,,79012323,CDM,272,RC,,,both,,,525,388.5,,,388.5,Other,150% of Medicare + 9.63% HCRA Surcharge,236.25,45,,236.25,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,259.88,,,259.88,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,367.5,70,,367.5,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,388.5,
BOST H74939347050870 ATHLETIS 5X80X75CM,C1725,HCPCS,,79012324,CDM,272,RC,,,both,,,525,388.5,,,388.5,Other,150% of Medicare + 9.63% HCRA Surcharge,236.25,45,,236.25,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,259.88,,,259.88,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,367.5,70,,367.5,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,388.5,
BOST H74939374051070 ATHLETIS 5X100X75CM,C1725,HCPCS,,79012325,CDM,272,RC,,,both,,,525,388.5,,,388.5,Other,150% of Medicare + 9.63% HCRA Surcharge,236.25,45,,236.25,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,259.88,,,259.88,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,367.5,70,,367.5,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,388.5,
BOST H74939347060470 ATHLETIS 6X40X75CM,C1725,HCPCS,,79012326,CDM,272,RC,,,both,,,525,388.5,,,388.5,Other,150% of Medicare + 9.63% HCRA Surcharge,236.25,45,,236.25,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,259.88,,,259.88,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,367.5,70,,367.5,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,388.5,
BOST H74939347060670 ATHLETIS 6X60X75CM,C1725,HCPCS,,79012327,CDM,272,RC,,,both,,,525,388.5,,,388.5,Other,150% of Medicare + 9.63% HCRA Surcharge,236.25,45,,236.25,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,259.88,,,259.88,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,367.5,70,,367.5,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,388.5,
BOST H74939347060870 ATHLETIS 6X80X75CM,C1725,HCPCS,,79012328,CDM,272,RC,,,both,,,525,388.5,,,388.5,Other,150% of Medicare + 9.63% HCRA Surcharge,236.25,45,,236.25,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,259.88,,,259.88,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,367.5,70,,367.5,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,388.5,
BOST H74939347061070 ATHLETIS 6X100X75CM,C1725,HCPCS,,79012329,CDM,272,RC,,,both,,,525,388.5,,,388.5,Other,150% of Medicare + 9.63% HCRA Surcharge,236.25,45,,236.25,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,259.88,,,259.88,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,367.5,70,,367.5,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,388.5,
BOST H74939347070470 ATHLETIS 7X40X75CM,C1725,HCPCS,,79012330,CDM,272,RC,,,both,,,525,388.5,,,388.5,Other,150% of Medicare + 9.63% HCRA Surcharge,236.25,45,,236.25,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,259.88,,,259.88,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,367.5,70,,367.5,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,388.5,
BOST H74939347070670 ATHLETIS 7X60X75CM,C1725,HCPCS,,79012331,CDM,272,RC,,,both,,,525,388.5,,,388.5,Other,150% of Medicare + 9.63% HCRA Surcharge,236.25,45,,236.25,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,259.88,,,259.88,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,367.5,70,,367.5,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,388.5,
BOST H74939347070870 ATHLETIS 7X80X75CM,C1725,HCPCS,,79012332,CDM,272,RC,,,both,,,525,388.5,,,388.5,Other,150% of Medicare + 9.63% HCRA Surcharge,236.25,45,,236.25,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,259.88,,,259.88,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,367.5,70,,367.5,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,388.5,
BOST H74939347071070 ATHLETIS 7X100X75CM,C1725,HCPCS,,79012333,CDM,272,RC,,,both,,,525,388.5,,,388.5,Other,150% of Medicare + 9.63% HCRA Surcharge,236.25,45,,236.25,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,259.88,,,259.88,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,367.5,70,,367.5,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,388.5,
BOST H74939347080470 ATHLETIS 8X40X75CM,C1725,HCPCS,,79012334,CDM,272,RC,,,both,,,525,388.5,,,388.5,Other,150% of Medicare + 9.63% HCRA Surcharge,236.25,45,,236.25,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,259.88,,,259.88,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,367.5,70,,367.5,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,388.5,
BOST H74939347080670 ATHLETIS 8X60X75CM,C1725,HCPCS,,79012335,CDM,272,RC,,,both,,,525,388.5,,,388.5,Other,150% of Medicare + 9.63% HCRA Surcharge,236.25,45,,236.25,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,259.88,,,259.88,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,367.5,70,,367.5,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,388.5,
BOST H74939347080870 ATHLETIS 8X80X75CM,C1725,HCPCS,,79012336,CDM,272,RC,,,both,,,525,388.5,,,388.5,Other,150% of Medicare + 9.63% HCRA Surcharge,236.25,45,,236.25,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,259.88,,,259.88,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,367.5,70,,367.5,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,388.5,
BOST H74939347081070 ATHLETIS 8X100X75CM,C1725,HCPCS,,79012337,CDM,272,RC,,,both,,,525,388.5,,,388.5,Other,150% of Medicare + 9.63% HCRA Surcharge,236.25,45,,236.25,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,259.88,,,259.88,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,367.5,70,,367.5,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,388.5,
BOST H74939347090470 ATHLETIS 9X40X75CM,C1725,HCPCS,,79012338,CDM,272,RC,,,both,,,525,388.5,,,388.5,Other,150% of Medicare + 9.63% HCRA Surcharge,236.25,45,,236.25,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,259.88,,,259.88,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,367.5,70,,367.5,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,388.5,
BOST H74939347090870 ATHLETIS 9X80X75CM,C1725,HCPCS,,79012339,CDM,272,RC,,,both,,,525,388.5,,,388.5,Other,150% of Medicare + 9.63% HCRA Surcharge,236.25,45,,236.25,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,259.88,,,259.88,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,367.5,70,,367.5,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,388.5,
BOST H74939347100470 ATHLETIS 10X40X75CM,C1725,HCPCS,,79012340,CDM,272,RC,,,both,,,525,388.5,,,388.5,Other,150% of Medicare + 9.63% HCRA Surcharge,236.25,45,,236.25,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,259.88,,,259.88,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,367.5,70,,367.5,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,388.5,
BOST H74939347100870 ATHLETIS 10X80X75CM,C1725,HCPCS,,79012341,CDM,272,RC,,,both,,,525,388.5,,,388.5,Other,150% of Medicare + 9.63% HCRA Surcharge,236.25,45,,236.25,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,259.88,,,259.88,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,367.5,70,,367.5,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,388.5,
BOST H74939347120470 ATHLETIS 12X40X75CM,C1725,HCPCS,,79012342,CDM,272,RC,,,both,,,525,388.5,,,388.5,Other,150% of Medicare + 9.63% HCRA Surcharge,236.25,45,,236.25,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,259.88,,,259.88,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,367.5,70,,367.5,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,388.5,
BOST H74939347120670 ATHLETIS 12X60X75CM,C1725,HCPCS,,79012343,CDM,272,RC,,,both,,,525,388.5,,,388.5,Other,150% of Medicare + 9.63% HCRA Surcharge,236.25,45,,236.25,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,259.88,,,259.88,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,367.5,70,,367.5,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,388.5,
ABBOTT 1012068-06 .035X260CM GUIDEWIRE,C1769,HCPCS,,79012366,CDM,272,RC,,,both,,,285,210.9,,,210.9,Other,150% of Medicare + 9.63% HCRA Surcharge,128.25,45,,128.25,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,141.08,,,141.08,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,199.5,70,,199.5,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,210.9,
CARDINAL 503-456X STORQ STANDARD,C1769,HCPCS,,79012367,CDM,272,RC,,,both,,,209,154.66,,,154.66,Other,150% of Medicare + 9.63% HCRA Surcharge,94.05,45,,94.05,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,103.46,,,103.46,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,146.3,70,,146.3,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,154.66,
ABBOTT 1012068-04 .035X175CM GUIDEWIRE,C1769,HCPCS,,79012368,CDM,272,RC,,,both,,,255,188.7,,,188.7,Other,150% of Medicare + 9.63% HCRA Surcharge,114.75,45,,114.75,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,126.23,,,126.23,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,178.5,70,,178.5,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,188.7,
ABBOTT 1002703-01 SUPRA CORE 35 0.35X190,C1769,HCPCS,,79012369,CDM,272,RC,,,both,,,240,177.6,,,177.6,Other,150% of Medicare + 9.63% HCRA Surcharge,108,45,,108,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,118.8,,,118.8,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,168,70,,168,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,177.6,
TERUMO RSB801 8FRX6CM TERUMO SHEATH R/O,C1894,HCPCS,,79012371,CDM,272,RC,,,both,,,164,121.36,,,121.36,Other,150% of Medicare + 9.63% HCRA Surcharge,73.8,45,,73.8,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,81.18,,,81.18,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,114.8,70,,114.8,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,121.36,
COOK G56552 CXI .018X150CM SUPPORT CATH,C1725,HCPCS,,79012398,CDM,272,RC,,,both,,,548,405.52,,,405.52,Other,150% of Medicare + 9.63% HCRA Surcharge,246.6,45,,246.6,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,271.26,,,271.26,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,383.6,70,,383.6,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,405.52,
MEDLINE DNYJGWIRE20 GUIDEWIRE .035X260CM,C1769,HCPCS,,79012528,CDM,272,RC,,,both,,,27,19.98,,,19.98,Other,150% of Medicare + 9.63% HCRA Surcharge,12.15,45,,12.15,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,13.37,,,13.37,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,18.9,70,,18.9,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,19.98,
MERIT IQ35F260J3 GUIDEWIRE .035X260CM,C1769,HCPCS,,79012529,CDM,272,RC,,,both,,,28,20.72,,,20.72,Other,150% of Medicare + 9.63% HCRA Surcharge,12.6,45,,12.6,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,13.86,,,13.86,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,19.6,70,,19.6,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,20.72,
MEDTRONIC TELE6F 6FR TELESCOPE 150CM,C1887,HCPCS,,79012539,CDM,272,RC,,,both,,,1200,888,,,888,Other,150% of Medicare + 9.63% HCRA Surcharge,540,45,,540,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,594,,,594,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,840,70,,840,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,888,
MEDTRONIC TELE7F 7FR TELESCOPE 150CM,C1887,HCPCS,,79012540,CDM,272,RC,,,both,,,1200,888,,,888,Other,150% of Medicare + 9.63% HCRA Surcharge,540,45,,540,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,594,,,594,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,840,70,,840,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,888,
MERIT PC101 6FR PERICARDIOCENTESIS CATH,C1729,HCPCS,,79012573,CDM,272,RC,,,both,,,285,210.9,,,210.9,Other,150% of Medicare + 9.63% HCRA Surcharge,128.25,45,,128.25,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,141.08,,,141.08,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,199.5,70,,199.5,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,210.9,
BOST 39147-35121 3.5X120X150 SL BALLOON,C1725,HCPCS,,79012671,CDM,272,RC,,,both,,,435,321.9,,,321.9,Other,150% of Medicare + 9.63% HCRA Surcharge,195.75,45,,195.75,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,215.33,,,215.33,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,304.5,70,,304.5,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,321.9,
BOST H74914902012 MODEL-GRAPHIX INT,C1769,HCPCS,,79012734,CDM,272,RC,,,both,,,249,184.26,,,184.26,Other,150% of Medicare + 9.63% HCRA Surcharge,112.05,45,,112.05,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,123.26,,,123.26,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,174.3,70,,174.3,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,184.26,
MEDTRONIC ADM05015013P 5X150 DC BALLOON,C2623,HCPCS,,79012735,CDM,272,RC,,,both,,,4650,3441.01,,,3441.01,Other,150% of Medicare + 9.63% HCRA Surcharge,2092.5,45,,2092.5,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2301.75,,,2301.75,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,3255,70,,3255,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3441.01,
MEDTRONIC ADM05025013P 5X250 DC BALLOON,C2623,HCPCS,,79012736,CDM,272,RC,,,both,,,6420,4750.82,,,4750.82,Other,150% of Medicare + 9.63% HCRA Surcharge,2889,45,,2889,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,3177.9,,,3177.9,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,4494,70,,4494,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4750.82,
MEDTRONIC ADM06025013P 6X250 DC BALLOON,C2623,HCPCS,,79012737,CDM,272,RC,,,both,,,6420,4750.82,,,4750.82,Other,150% of Medicare + 9.63% HCRA Surcharge,2889,45,,2889,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,3177.9,,,3177.9,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,4494,70,,4494,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4750.82,
LABORIE OPTBDL7003B BALLOON 24FRX5CM,C1726,HCPCS,,79012775,CDM,272,RC,,,both,,,6285,4650.92,,,4650.92,Other,150% of Medicare + 9.63% HCRA Surcharge,2828.25,45,,2828.25,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,3111.08,,,3111.08,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,4399.5,70,,4399.5,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4650.92,
J&J 03.333.001 GUIDEWIRE 1.1MM,C1769,HCPCS,,79012813,CDM,272,RC,,,both,,,182,134.68,,,134.68,Other,150% of Medicare + 9.63% HCRA Surcharge,81.9,45,,81.9,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,90.09,,,90.09,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,127.4,70,,127.4,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,134.68,
MEDTRONIC LA6AL10A CATH LA 6F 110CM AL10,C1887,HCPCS,,79012847,CDM,272,RC,,,both,,,120,88.8,,,88.8,Other,150% of Medicare + 9.63% HCRA Surcharge,54,45,,54,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,59.4,,,59.4,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,84,70,,84,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,88.8,
MEDTRONIC LA6EBU375A CATH 6F 110CM EB375,C1887,HCPCS,,79012848,CDM,272,RC,,,both,,,120,88.8,,,88.8,Other,150% of Medicare + 9.63% HCRA Surcharge,54,45,,54,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,59.4,,,59.4,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,84,70,,84,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,88.8,
MEDTRONIC LA6JL35A CATH 6F 110CM JL35,C1887,HCPCS,,79012849,CDM,272,RC,,,both,,,120,88.8,,,88.8,Other,150% of Medicare + 9.63% HCRA Surcharge,54,45,,54,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,59.4,,,59.4,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,84,70,,84,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,88.8,
MEDTRONIC LA6JL40A CATH 6F 110CM JL40,C1887,HCPCS,,79012850,CDM,272,RC,,,both,,,120,88.8,,,88.8,Other,150% of Medicare + 9.63% HCRA Surcharge,54,45,,54,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,59.4,,,59.4,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,84,70,,84,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,88.8,
MEDTRONIC LA6JR40A CATH 6F 110CM JR40,C1887,HCPCS,,79012851,CDM,272,RC,,,both,,,120,88.8,,,88.8,Other,150% of Medicare + 9.63% HCRA Surcharge,54,45,,54,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,59.4,,,59.4,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,84,70,,84,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,88.8,
COOK G01793 .021X180 CORE WIRE GUIDE,C1769,HCPCS,,79012867,CDM,272,RC,,,both,,,39,28.86,,,28.86,Other,150% of Medicare + 9.63% HCRA Surcharge,17.55,45,,17.55,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,19.31,,,19.31,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,27.3,70,,27.3,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,28.86,
"MERIT 6682 GUIDEWIRE INQWIRE .025"" 150CM",C1769,HCPCS,,79012876,CDM,272,RC,,,both,,,22,16.28,,,16.28,Other,150% of Medicare + 9.63% HCRA Surcharge,9.9,45,,9.9,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,10.89,,,10.89,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,15.4,70,,15.4,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,16.28,
CARDINAL 67005400 3.5 GUIDE CATH VISTABR,C1887,HCPCS,,79012877,CDM,272,RC,,,both,,,180,133.2,,,133.2,Other,150% of Medicare + 9.63% HCRA Surcharge,81,45,,81,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,89.1,,,89.1,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,126,70,,126,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,133.2,
CARDINAL 67027000 MP1 GUIDE CATH VISTABR,C1887,HCPCS,,79012878,CDM,272,RC,,,both,,,180,133.2,,,133.2,Other,150% of Medicare + 9.63% HCRA Surcharge,81,45,,81,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,89.1,,,89.1,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,126,70,,126,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,133.2,
CARDINAL 67027800 GUIDE CATH VISTABRI,C1887,HCPCS,,79012879,CDM,272,RC,,,both,,,180,133.2,,,133.2,Other,150% of Medicare + 9.63% HCRA Surcharge,81,45,,81,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,89.1,,,89.1,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,126,70,,126,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,133.2,
CARDINAL 67019000 IM GUIDE CATH VISTABR,C1887,HCPCS,,79012880,CDM,272,RC,,,both,,,180,133.2,,,133.2,Other,150% of Medicare + 9.63% HCRA Surcharge,81,45,,81,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,89.1,,,89.1,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,126,70,,126,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,133.2,
MEDTRONIC LA6EBU35A CATH LA 6F 110 EB35,C1887,HCPCS,,79012881,CDM,272,RC,,,both,,,120,88.8,,,88.8,Other,150% of Medicare + 9.63% HCRA Surcharge,54,45,,54,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,59.4,,,59.4,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,84,70,,84,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,88.8,
MEDTRONIC LA6AL20A CATH LA 6F 110CM AL20,C1887,HCPCS,,79012882,CDM,272,RC,,,both,,,120,88.8,,,88.8,Other,150% of Medicare + 9.63% HCRA Surcharge,54,45,,54,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,59.4,,,59.4,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,84,70,,84,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,88.8,
MEDTRONIC LA6AL30A CATH LA 6F 110CM AL30,C1887,HCPCS,,79012883,CDM,272,RC,,,both,,,120,88.8,,,88.8,Other,150% of Medicare + 9.63% HCRA Surcharge,54,45,,54,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,59.4,,,59.4,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,84,70,,84,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,88.8,
CARDINAL 67006600 XBLAD 3 GUIDE CATH,C1887,HCPCS,,79012899,CDM,272,RC,,,both,,,180,133.2,,,133.2,Other,150% of Medicare + 9.63% HCRA Surcharge,81,45,,81,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,89.1,,,89.1,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,126,70,,126,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,133.2,
MEDLINE MSG14150 GUIDEWIRE 1.4X150MM,C1769,HCPCS,,79012999,CDM,272,RC,,,both,,,90,66.6,,,66.6,Other,150% of Medicare + 9.63% HCRA Surcharge,40.5,45,,40.5,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,44.55,,,44.55,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,63,70,,63,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,66.6,
BOST H74908641022 JR4 CATHETER FR4 EXPO,C1769,HCPCS,,79013007,CDM,272,RC,,,both,,,29,21.46,,,21.46,Other,150% of Medicare + 9.63% HCRA Surcharge,13.05,45,,13.05,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,14.36,,,14.36,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,20.3,70,,20.3,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,21.46,
WRIGHT CSI-GP09 FUTURA GUIDE PIN 2X229MM,C1769,HCPCS,,79013078,CDM,272,RC,,,both,,,149,110.26,,,110.26,Other,150% of Medicare + 9.63% HCRA Surcharge,67.05,45,,67.05,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,73.76,,,73.76,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,104.3,70,,104.3,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,110.26,
MEDTRONIC IAV08004008P 7X40X80CM BALLOON,C1725,HCPCS,,79013159,CDM,272,RC,,,both,,,4650,3441.01,,,3441.01,Other,150% of Medicare + 9.63% HCRA Surcharge,2092.5,45,,2092.5,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2301.75,,,2301.75,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,3255,70,,3255,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3441.01,
J&J 09.037.010 GUIDEWIRE 3.2X475MM,C1769,HCPCS,,79013160,CDM,272,RC,,,both,,,283,209.42,,,209.42,Other,150% of Medicare + 9.63% HCRA Surcharge,127.35,45,,127.35,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,140.09,,,140.09,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,198.1,70,,198.1,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,209.42,
SHOCKWARE S4IVL2540 2.5MMX40MM S4,C1725,HCPCS,,79013301,CDM,272,RC,,,both,,,8250,6105.02,,,6105.02,Other,150% of Medicare + 9.63% HCRA Surcharge,3712.5,45,,3712.5,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,4083.75,,,4083.75,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,5775,70,,5775,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,6105.02,
SHOCKWARE S4IVL3040 3MMX40MM S4,C1725,HCPCS,,79013302,CDM,272,RC,,,both,,,8250,6105.02,,,6105.02,Other,150% of Medicare + 9.63% HCRA Surcharge,3712.5,45,,3712.5,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,4083.75,,,4083.75,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,5775,70,,5775,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,6105.02,
SHOCKWARE S4IVL3540 3.5MMX40MM S4,C1725,HCPCS,,79013303,CDM,272,RC,,,both,,,8250,6105.02,,,6105.02,Other,150% of Medicare + 9.63% HCRA Surcharge,3712.5,45,,3712.5,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,4083.75,,,4083.75,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,5775,70,,5775,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,6105.02,
SHOCKWARE S4IVL4040 4X40 SHOCKWARE S4,C1725,HCPCS,,79013304,CDM,272,RC,,,both,,,8250,6105.02,,,6105.02,Other,150% of Medicare + 9.63% HCRA Surcharge,3712.5,45,,3712.5,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,4083.75,,,4083.75,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,5775,70,,5775,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,6105.02,
SHOCKWARE M5PIVL3560 3.5MMX60MM M5+,C1725,HCPCS,,79013305,CDM,272,RC,,,both,,,10350,7659.03,,,7659.03,Other,150% of Medicare + 9.63% HCRA Surcharge,4657.5,45,,4657.5,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,5123.25,,,5123.25,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,7245,70,,7245,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,7659.03,
SHOCKWARE M5PIVL4060 4MMX60MM M5+,C1725,HCPCS,,79013306,CDM,272,RC,,,both,,,10350,7659.03,,,7659.03,Other,150% of Medicare + 9.63% HCRA Surcharge,4657.5,45,,4657.5,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,5123.25,,,5123.25,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,7245,70,,7245,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,7659.03,
SHOCKWARE M5PIVL4560 4.5MMX60MM M5+,C1725,HCPCS,,79013307,CDM,272,RC,,,both,,,10350,7659.03,,,7659.03,Other,150% of Medicare + 9.63% HCRA Surcharge,4657.5,45,,4657.5,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,5123.25,,,5123.25,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,7245,70,,7245,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,7659.03,
SHOCKWARE M5PIVL5060 5MMX60MM M5+,C1725,HCPCS,,79013308,CDM,272,RC,,,both,,,10350,7659.03,,,7659.03,Other,150% of Medicare + 9.63% HCRA Surcharge,4657.5,45,,4657.5,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,5123.25,,,5123.25,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,7245,70,,7245,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,7659.03,
SHOCKWARE M5PIVL5560 5.5MMX60MM M5+,C1725,HCPCS,,79013309,CDM,272,RC,,,both,,,10350,7659.03,,,7659.03,Other,150% of Medicare + 9.63% HCRA Surcharge,4657.5,45,,4657.5,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,5123.25,,,5123.25,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,7245,70,,7245,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,7659.03,
SHOCKWARE M5PIVL6060 6MMX60MM M5+,C1725,HCPCS,,79013310,CDM,272,RC,,,both,,,10350,7659.03,,,7659.03,Other,150% of Medicare + 9.63% HCRA Surcharge,4657.5,45,,4657.5,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,5123.25,,,5123.25,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,7245,70,,7245,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,7659.03,
SHOCKWARE M5PIVL6560 6.5MMX60MM M5+,C1725,HCPCS,,79013311,CDM,272,RC,,,both,,,10350,7659.03,,,7659.03,Other,150% of Medicare + 9.63% HCRA Surcharge,4657.5,45,,4657.5,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,5123.25,,,5123.25,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,7245,70,,7245,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,7659.03,
SHOCKWARE M5PIVL7060 7X60 SHOCKWARE M5+,C1725,HCPCS,,79013312,CDM,272,RC,,,both,,,10350,7659.03,,,7659.03,Other,150% of Medicare + 9.63% HCRA Surcharge,4657.5,45,,4657.5,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,5123.25,,,5123.25,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,7245,70,,7245,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,7659.03,
SHOCKWARE M5PIVL8060 8X60 SHOCKWARE M5+,C1725,HCPCS,,79013313,CDM,272,RC,,,both,,,10350,7659.03,,,7659.03,Other,150% of Medicare + 9.63% HCRA Surcharge,4657.5,45,,4657.5,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,5123.25,,,5123.25,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,7245,70,,7245,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,7659.03,
J&J 03.333.000 GUIDEWIRE 0.8MM,C1769,HCPCS,,79013375,CDM,272,RC,,,both,,,164,121.36,,,121.36,Other,150% of Medicare + 9.63% HCRA Surcharge,73.8,45,,73.8,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,81.18,,,81.18,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,114.8,70,,114.8,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,121.36,
J&J 03.333.002 GUIDEWIRE WIRE 1.4X150MM,C1769,HCPCS,,79013493,CDM,272,RC,,,both,,,210,155.4,,,155.4,Other,150% of Medicare + 9.63% HCRA Surcharge,94.5,45,,94.5,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,103.95,,,103.95,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,147,70,,147,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,155.4,
KCI M8278081/5.S SENSATRAC THIN DRESSING,A6550,HCPCS,,79013506,CDM,272,RC,,,both,,,168,124.32,,,124.32,Other,150% of Medicare + 9.63% HCRA Surcharge,75.6,45,,75.6,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,83.16,,,83.16,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,117.6,70,,117.6,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,124.32,
MEDTRONIC IAV06006008P 6X60X80CM BALLOON,C2623,HCPCS,,79013507,CDM,272,RC,,,both,,,4650,3441.01,,,3441.01,Other,150% of Medicare + 9.63% HCRA Surcharge,2092.5,45,,2092.5,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2301.75,,,2301.75,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,3255,70,,3255,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3441.01,
MEDTRONIC ADM05020013P 5X200 BALLOON,C2623,HCPCS,,79013526,CDM,272,RC,,,both,,,5835,4317.91,,,4317.91,Other,150% of Medicare + 9.63% HCRA Surcharge,2625.75,45,,2625.75,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2888.33,,,2888.33,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,4084.5,70,,4084.5,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4317.91,
MERIT IQ35F150J3,C1769,HCPCS,,79013545,CDM,272,RC,,,both,,,21,15.54,,,15.54,Other,150% of Medicare + 9.63% HCRA Surcharge,9.45,45,,9.45,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,10.4,,,10.4,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,14.7,70,,14.7,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,15.54,
TERUMO 25-5211 RUNTHRU AZANAI .014X180CM,C1769,HCPCS,,79013551,CDM,272,RC,,,both,,,334,247.16,,,247.16,Other,150% of Medicare + 9.63% HCRA Surcharge,150.3,45,,150.3,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,165.33,,,165.33,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,233.8,70,,233.8,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,247.16,
TERUMO M3-1430 FINECROSS MICROGUIDE 130,C1887,HCPCS,,79013552,CDM,272,RC,,,both,,,2175,1609.51,,,1609.51,Other,150% of Medicare + 9.63% HCRA Surcharge,978.75,45,,978.75,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1076.63,,,1076.63,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1522.5,70,,1522.5,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1609.51,
MERIT EZ-REG/A RADIAL COMP DEVICE 32CM,C1769,HCPCS,,79013577,CDM,272,RC,,,both,,,105,77.7,,,77.7,Other,150% of Medicare + 9.63% HCRA Surcharge,47.25,45,,47.25,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,51.98,,,51.98,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,73.5,70,,73.5,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,77.7,
MERIT EZ-SML/A RADIAL COMP DEVICE 26CM,C1769,HCPCS,,79013578,CDM,272,RC,,,both,,,105,77.7,,,77.7,Other,150% of Medicare + 9.63% HCRA Surcharge,47.25,45,,47.25,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,51.98,,,51.98,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,73.5,70,,73.5,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,77.7,
TERUMO 25-9092 RUNTHROUGH NS EXT WIRE,C1769,HCPCS,,79013624,CDM,272,RC,,,both,,,318,235.32,,,235.32,Other,150% of Medicare + 9.63% HCRA Surcharge,143.1,45,,143.1,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,157.41,,,157.41,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,222.6,70,,222.6,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,235.32,
COOK G56279 12FRX45CM SHEATH INTRODUCER,C1894,HCPCS,,79013646,CDM,272,RC,,,both,,,191,141.34,,,141.34,Other,150% of Medicare + 9.63% HCRA Surcharge,85.95,45,,85.95,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,94.55,,,94.55,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,133.7,70,,133.7,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,141.34,
COOK G56278 10FRX45CM SHEATH INTRODUCER,C1894,HCPCS,,79013647,CDM,272,RC,,,both,,,191,141.34,,,141.34,Other,150% of Medicare + 9.63% HCRA Surcharge,85.95,45,,85.95,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,94.55,,,94.55,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,133.7,70,,133.7,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,141.34,
BECTON ATG80126 12X6X80CM PTA BALLOON,C1725,HCPCS,,79013652,CDM,272,RC,,,both,,,975,721.5,,,721.5,Other,150% of Medicare + 9.63% HCRA Surcharge,438.75,45,,438.75,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,482.63,,,482.63,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,682.5,70,,682.5,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,721.5,
BECTON ATG80146 14X6X80 PTA BALLOON,C1725,HCPCS,,79013653,CDM,272,RC,,,both,,,975,721.5,,,721.5,Other,150% of Medicare + 9.63% HCRA Surcharge,438.75,45,,438.75,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,482.63,,,482.63,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,682.5,70,,682.5,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,721.5,
BECTON ATG80166 16X6X80CM PTA BALLOON,C1725,HCPCS,,79013654,CDM,272,RC,,,both,,,975,721.5,,,721.5,Other,150% of Medicare + 9.63% HCRA Surcharge,438.75,45,,438.75,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,482.63,,,482.63,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,682.5,70,,682.5,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,721.5,
MEDTRONIC LA7JL40 GUIDECATH 7FR JL 4.0,C1887,HCPCS,,79013655,CDM,272,RC,,,both,,,120,88.8,,,88.8,Other,150% of Medicare + 9.63% HCRA Surcharge,54,45,,54,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,59.4,,,59.4,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,84,70,,84,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,88.8,
SHOCKWAVE L6IVL090030 9MMX30MM L6,C1725,HCPCS,,79013678,CDM,272,RC,,,both,,,10350,7659.03,,,7659.03,Other,150% of Medicare + 9.63% HCRA Surcharge,4657.5,45,,4657.5,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,5123.25,,,5123.25,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,7245,70,,7245,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,7659.03,
TERUMO RSB912 9FR 1OCM SHEATH W/WIRE,C1894,HCPCS,,79013702,CDM,272,RC,,,both,,,181,133.94,,,133.94,Other,150% of Medicare + 9.63% HCRA Surcharge,81.45,45,,81.45,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,89.6,,,89.6,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,126.7,70,,126.7,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,133.94,
PHILIPS IGT 89900 REFINITY ST IVUS CATH,C1753,HCPCS,,79013703,CDM,272,RC,,,both,,,2025,1498.51,,,1498.51,Other,150% of Medicare + 9.63% HCRA Surcharge,911.25,45,,911.25,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1002.38,,,1002.38,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1417.5,70,,1417.5,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1498.51,
PENUMBRA CAT7DKIT INDIGO CATH 7DX50 KIT,C1887,HCPCS,,79013721,CDM,272,RC,,,both,,,8070,5971.82,,,5971.82,Other,150% of Medicare + 9.63% HCRA Surcharge,3631.5,45,,3631.5,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,3994.65,,,3994.65,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,5649,70,,5649,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5971.82,
PENUMBRA CATRXKIT INDIGO CATH RXX140 KIT,C1887,HCPCS,,79013722,CDM,272,RC,,,both,,,5400,3996.01,,,3996.01,Other,150% of Medicare + 9.63% HCRA Surcharge,2430,45,,2430,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2673,,,2673,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,3780,70,,3780,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3996.01,
PENUMBRA LITNGBT7TQ130 BOLT 7 CATH X130,C1887,HCPCS,,79013723,CDM,272,RC,,,both,,,24060,17804.46,,,17804.46,Other,150% of Medicare + 9.63% HCRA Surcharge,10827,45,,10827,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,11909.7,,,11909.7,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,16842,70,,16842,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,17804.46,
MEDTRONIC IPU04006013P 4X60X130 .018 DCB,C2623,HCPCS,,79013731,CDM,272,RC,,,both,,,3750,2775.01,,,2775.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1687.5,45,,1687.5,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1856.25,,,1856.25,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2625,70,,2625,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2775.01,
MEDTRONIC IPU04008013P 4X80X130 .018 DCB,C2623,HCPCS,,79013732,CDM,272,RC,,,both,,,3750,2775.01,,,2775.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1687.5,45,,1687.5,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1856.25,,,1856.25,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2625,70,,2625,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2775.01,
MEDTRONIC IPU04010013P 4X100X130 .018DCB,C2623,HCPCS,,79013733,CDM,272,RC,,,both,,,4200,3108.01,,,3108.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1890,45,,1890,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2079,,,2079,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2940,70,,2940,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3108.01,
MEDTRONIC IPU04012013P 4X120X130 .018DCB,C2623,HCPCS,,79013734,CDM,272,RC,,,both,,,4200,3108.01,,,3108.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1890,45,,1890,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2079,,,2079,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2940,70,,2940,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3108.01,
MEDTRONIC IPU0401013P 4X150X130 .018DCB,C2623,HCPCS,,79013735,CDM,272,RC,,,both,,,4650,3441.01,,,3441.01,Other,150% of Medicare + 9.63% HCRA Surcharge,2092.5,45,,2092.5,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2301.75,,,2301.75,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,3255,70,,3255,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3441.01,
MEDTRONIC IPU05004013P 5X40X130 .018DCB,C2623,HCPCS,,79013736,CDM,272,RC,,,both,,,3750,2775.01,,,2775.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1687.5,45,,1687.5,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1856.25,,,1856.25,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2625,70,,2625,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2775.01,
MEDTRONIC IPU05006013P 5X60X130 .018 DCB,C2623,HCPCS,,79013737,CDM,272,RC,,,both,,,3750,2775.01,,,2775.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1687.5,45,,1687.5,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1856.25,,,1856.25,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2625,70,,2625,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2775.01,
MEDTRONIC IPU05008013P 5X80X130 .018DCB,C2623,HCPCS,,79013738,CDM,272,RC,,,both,,,3750,2775.01,,,2775.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1687.5,45,,1687.5,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1856.25,,,1856.25,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2625,70,,2625,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2775.01,
MEDTRONIC IPU05010013P 5X100X130 .018DCB,C2623,HCPCS,,79013739,CDM,272,RC,,,both,,,4200,3108.01,,,3108.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1890,45,,1890,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2079,,,2079,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2940,70,,2940,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3108.01,
MEDTRONIC IPU05012013P 5X120X130 .018DCB,C2623,HCPCS,,79013740,CDM,272,RC,,,both,,,4200,3108.01,,,3108.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1890,45,,1890,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2079,,,2079,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2940,70,,2940,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3108.01,
MEDTRONIC IPU05012013P 5X150X130 .018DCB,C2623,HCPCS,,79013741,CDM,272,RC,,,both,,,4650,3441.01,,,3441.01,Other,150% of Medicare + 9.63% HCRA Surcharge,2092.5,45,,2092.5,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2301.75,,,2301.75,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,3255,70,,3255,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3441.01,
MEDTRONIC IPU06004013P 6X40X130 .018 DCB,C2623,HCPCS,,79013742,CDM,272,RC,,,both,,,3750,2775.01,,,2775.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1687.5,45,,1687.5,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1856.25,,,1856.25,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2625,70,,2625,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2775.01,
MEDTRONIC IPU06006013P 6X60X130 .018 DCB,C2623,HCPCS,,79013743,CDM,272,RC,,,both,,,3750,2775.01,,,2775.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1687.5,45,,1687.5,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1856.25,,,1856.25,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2625,70,,2625,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2775.01,
MEDTRONIC IPU06008013P 6X80X130 .018 DCB,C2623,HCPCS,,79013744,CDM,272,RC,,,both,,,3750,2775.01,,,2775.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1687.5,45,,1687.5,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1856.25,,,1856.25,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2625,70,,2625,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2775.01,
MEDTRONIC IPU06010013P 6X100X130 .018DCB,C2623,HCPCS,,79013745,CDM,272,RC,,,both,,,4200,3108.01,,,3108.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1890,45,,1890,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2079,,,2079,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2940,70,,2940,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3108.01,
MEDTRONIC IPU06012013P 6X120X130 .018DCB,C2623,HCPCS,,79013746,CDM,272,RC,,,both,,,4200,3108.01,,,3108.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1890,45,,1890,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2079,,,2079,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2940,70,,2940,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3108.01,
MEDTRONIC IPU07006013P 7X60X130 .018 DCB,C2623,HCPCS,,79013747,CDM,272,RC,,,both,,,3750,2775.01,,,2775.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1687.5,45,,1687.5,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1856.25,,,1856.25,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2625,70,,2625,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2775.01,
MEDTRONIC IPU07008013P 7X80X130 .018 DCB,C2623,HCPCS,,79013748,CDM,272,RC,,,both,,,3750,2775.01,,,2775.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1687.5,45,,1687.5,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1856.25,,,1856.25,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2625,70,,2625,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2775.01,
ARTHREX AR-8956K GUIDEWIRE 2.0MM,C1769,HCPCS,,79013779,CDM,272,RC,,,both,,,82,60.68,,,60.68,Other,150% of Medicare + 9.63% HCRA Surcharge,36.9,45,,36.9,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,40.59,,,40.59,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,57.4,70,,57.4,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,60.68,
ARTHREX AR-8750K GUIDEWIRE 1.6MM,C1769,HCPCS,,79013785,CDM,272,RC,,,both,,,49,36.26,,,36.26,Other,150% of Medicare + 9.63% HCRA Surcharge,22.05,45,,22.05,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,24.26,,,24.26,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,34.3,70,,34.3,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,36.26,
MEDTRONIC IPU06015013P .018 INPACT DCB,C2623,HCPCS,,79013836,CDM,272,RC,,,both,,,4650,3441.01,,,3441.01,Other,150% of Medicare + 9.63% HCRA Surcharge,2092.5,45,,2092.5,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2301.75,,,2301.75,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,3255,70,,3255,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3441.01,
MEDTRONIC REACT-71 CATH .071 ID,C1887,HCPCS,,79013866,CDM,272,RC,,,both,,,6285,4650.92,,,4650.92,Other,150% of Medicare + 9.63% HCRA Surcharge,2828.25,45,,2828.25,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,3111.08,,,3111.08,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,4399.5,70,,4399.5,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4650.92,
MEDTRONIC REACT-68 REACT CATH .068 ID,C1887,HCPCS,,79013867,CDM,272,RC,,,both,,,6285,4650.92,,,4650.92,Other,150% of Medicare + 9.63% HCRA Surcharge,2828.25,45,,2828.25,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,3111.08,,,3111.08,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,4399.5,70,,4399.5,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4650.92,
MEDTRONIC SFR4-4-20 SOLITAIRE 4X20-10,C1757,HCPCS,,79013868,CDM,272,RC,,,both,,,17985,13308.94,,,13308.94,Other,150% of Medicare + 9.63% HCRA Surcharge,8093.25,45,,8093.25,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,8902.58,,,8902.58,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,12589.5,70,,12589.5,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,13308.94,
MEDTRONIC SFR4-40-10 SOLITAIRE X 4X40,C1757,HCPCS,,79013869,CDM,272,RC,,,both,,,17985,13308.94,,,13308.94,Other,150% of Medicare + 9.63% HCRA Surcharge,8093.25,45,,8093.25,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,8902.58,,,8902.58,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,12589.5,70,,12589.5,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,13308.94,
MEDTRONIC SFR4-6-40-10 SOLITAIRE X 6X40,C1757,HCPCS,,79013870,CDM,272,RC,,,both,,,17985,13308.94,,,13308.94,Other,150% of Medicare + 9.63% HCRA Surcharge,8093.25,45,,8093.25,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,8902.58,,,8902.58,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,12589.5,70,,12589.5,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,13308.94,
MEDTRONIC SFR4-3-40-40 SOLITAIRE X 3X40,C1757,HCPCS,,79013871,CDM,272,RC,,,both,,,17985,13308.94,,,13308.94,Other,150% of Medicare + 9.63% HCRA Surcharge,8093.25,45,,8093.25,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,8902.58,,,8902.58,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,12589.5,70,,12589.5,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,13308.94,
MEDTRONIC SFR4-3-20-10 SOLITAIRE X 3X20,C1757,HCPCS,,79013872,CDM,272,RC,,,both,,,17985,13308.94,,,13308.94,Other,150% of Medicare + 9.63% HCRA Surcharge,8093.25,45,,8093.25,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,8902.58,,,8902.58,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,12589.5,70,,12589.5,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,13308.94,
MEDTRONIC FG13160-0615-1S MICRO CATHETER,C1887,HCPCS,,79013873,CDM,272,RC,,,both,,,3015,2231.11,,,2231.11,Other,150% of Medicare + 9.63% HCRA Surcharge,1356.75,45,,1356.75,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1492.43,,,1492.43,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2110.5,70,,2110.5,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2231.11,
PENUMBRA RED72KIT RED 72 CATH/TUBING,C1887,HCPCS,,79013875,CDM,272,RC,,,both,,,8250,6105.02,,,6105.02,Other,150% of Medicare + 9.63% HCRA Surcharge,3712.5,45,,3712.5,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,4083.75,,,4083.75,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,5775,70,,5775,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,6105.02,
PENUMBRA RED62SKIT RED 62 CATH/TUBING,C1887,HCPCS,,79013876,CDM,272,RC,,,both,,,8250,6105.02,,,6105.02,Other,150% of Medicare + 9.63% HCRA Surcharge,3712.5,45,,3712.5,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,4083.75,,,4083.75,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,5775,70,,5775,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,6105.02,
PENUMBRA RED43160 RED 43 REPERFUS CATH,C1887,HCPCS,,79013877,CDM,272,RC,,,both,,,7170,5305.82,,,5305.82,Other,150% of Medicare + 9.63% HCRA Surcharge,3226.5,45,,3226.5,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,3549.15,,,3549.15,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,5019,70,,5019,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5305.82,
PENUMBRA RED43138 RED 43 REPERFUS CATH,C1887,HCPCS,,79013878,CDM,272,RC,,,both,,,7170,5305.82,,,5305.82,Other,150% of Medicare + 9.63% HCRA Surcharge,3226.5,45,,3226.5,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,3549.15,,,3549.15,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,5019,70,,5019,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5305.82,
PENUMBRA BMX9690BER125 BMX96 90CM 6F,C1887,HCPCS,,79013881,CDM,272,RC,,,both,,,2685,1986.91,,,1986.91,Other,150% of Medicare + 9.63% HCRA Surcharge,1208.25,45,,1208.25,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1329.08,,,1329.08,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1879.5,70,,1879.5,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1986.91,
PENUMBRA BMX9690SIM125 BMX96 90CM 6F,C1887,HCPCS,,79013882,CDM,272,RC,,,both,,,2685,1986.91,,,1986.91,Other,150% of Medicare + 9.63% HCRA Surcharge,1208.25,45,,1208.25,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1329.08,,,1329.08,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1879.5,70,,1879.5,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1986.91,
PENUMBRA BMX9680BER105 BMX96 80CM 6F,C1887,HCPCS,,79013883,CDM,272,RC,,,both,,,2685,1986.91,,,1986.91,Other,150% of Medicare + 9.63% HCRA Surcharge,1208.25,45,,1208.25,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1329.08,,,1329.08,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1879.5,70,,1879.5,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1986.91,
MEDTRONIC H1-S HAWKONE S,C1714,HCPCS,,79013949,CDM,272,RC,,,both,,,10185,7536.93,,,7536.93,Other,150% of Medicare + 9.63% HCRA Surcharge,4583.25,45,,4583.25,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,5041.58,,,5041.58,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,7129.5,70,,7129.5,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,7536.93,
MEDTRONIC H1-M HAWKONE M,C1714,HCPCS,,79013950,CDM,272,RC,,,both,,,10185,7536.93,,,7536.93,Other,150% of Medicare + 9.63% HCRA Surcharge,4583.25,45,,4583.25,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,5041.58,,,5041.58,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,7129.5,70,,7129.5,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,7536.93,
MERIT BASIXTOUCH IN8802/C INFLATION DEV,C1769,HCPCS,,79013959,CDM,272,RC,,,both,,,172,127.28,,,127.28,Other,150% of Medicare + 9.63% HCRA Surcharge,77.4,45,,77.4,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,85.14,,,85.14,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,120.4,70,,120.4,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,127.28,
BOST H74939185401210 4X120X150CM BALLOON,C1725,HCPCS,,79013973,CDM,272,RC,,,both,,,567,419.58,,,419.58,Other,150% of Medicare + 9.63% HCRA Surcharge,255.15,45,,255.15,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,280.67,,,280.67,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,396.9,70,,396.9,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,419.58,
BOST H74939185202210 2X220X150 BALLOON,C1725,HCPCS,,79013974,CDM,272,RC,,,both,,,567,419.58,,,419.58,Other,150% of Medicare + 9.63% HCRA Surcharge,255.15,45,,255.15,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,280.67,,,280.67,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,396.9,70,,396.9,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,419.58,
TLSO BRACE,L1200,HCPCS,,79000578,CDM,274,RC,,,both,,,2853,2111.23,,,2111.23,Other,150% of Medicare + 9.63% HCRA Surcharge,1283.85,45,,1283.85,percent of total billed charges,Critical Access Hospital RCC factor,970.02,34,,970.02,percent of total billed charges,Implant Device,970.02,34,,970.02,percent of total billed charges,Implant Device,970.02,34,,970.02,percent of total billed charges,Implant Device,970.02,34,,970.02,percent of total billed charges,Implant Device,970.02,34,,970.02,percent of total billed charges,Implant Device,1412.24,,,1412.24,Other,110% of Medicare,998.55,35,,998.55,percent of total billed charges,Implant Device,970.02,34,"Charges > $500, x 34%",970.02,percent of total billed charges,Implant Device,998.55,35,,998.55,percent of total billed charges,Implant Device,998.55,35,,998.55,percent of total billed charges,Implant Device,998.55,35,,998.55,percent of total billed charges,Implant Device,998.55,35,,998.55,percent of total billed charges,Implant Device,998.55,35,,998.55,percent of total billed charges,Implant Device,1141.2,40,,1141.2,percent of total billed charges,Implant Device,1997.1,70,,1997.1,percent of total billed charges,All Other,970.02,34,,970.02,percent of total billed charges,Implant Device,970.02,34,,970.02,percent of total billed charges,Implant Device,998.55,35,,998.55,percent of total billed charges,Implant Device,998.55,35,,998.55,percent of total billed charges,Implant Device,998.55,35,,998.55,percent of total billed charges,Implant Device,998.55,35,,998.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,970.02,34,"If Charge > 2,000, then 34 percent",970.02,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2111.23,
BOST SC-6412-3 PRECISION CHARGE SYS KIT,L8689,HCPCS,,79012703,CDM,274,RC,,,both,,,4200,3108.01,,,3108.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1890,45,,1890,percent of total billed charges,Critical Access Hospital RCC factor,1428,34,,1428,percent of total billed charges,Implant Device,1428,34,,1428,percent of total billed charges,Implant Device,1428,34,,1428,percent of total billed charges,Implant Device,1428,34,,1428,percent of total billed charges,Implant Device,1428,34,,1428,percent of total billed charges,Implant Device,2079,,,2079,Other,110% of Medicare,1470,35,,1470,percent of total billed charges,Implant Device,1428,34,"Charges > $500, x 34%",1428,percent of total billed charges,Implant Device,1470,35,,1470,percent of total billed charges,Implant Device,1470,35,,1470,percent of total billed charges,Implant Device,1470,35,,1470,percent of total billed charges,Implant Device,1470,35,,1470,percent of total billed charges,Implant Device,1470,35,,1470,percent of total billed charges,Implant Device,1680,40,,1680,percent of total billed charges,Implant Device,1470,70,,1470,percent of total billed charges,All Other,1428,34,,1428,percent of total billed charges,Implant Device,1428,34,,1428,percent of total billed charges,Implant Device,1470,35,,1470,percent of total billed charges,Implant Device,1470,35,,1470,percent of total billed charges,Implant Device,1470,35,,1470,percent of total billed charges,Implant Device,1470,35,,1470,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1428,34,"If Charge > 2,000, then 34 percent",1428,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3108.01,
MEDLINE ORT16300M IMMOBILIZ W/ABDUCT MED,L3670,HCPCS,,79013440,CDM,274,RC,,,both,,,51,37.74,,,37.74,Other,150% of Medicare + 9.63% HCRA Surcharge,22.95,45,,22.95,percent of total billed charges,Critical Access Hospital RCC factor,17.34,34,,17.34,percent of total billed charges,Implant Device,17.34,34,,17.34,percent of total billed charges,Implant Device,17.34,34,,17.34,percent of total billed charges,Implant Device,17.34,34,,17.34,percent of total billed charges,Implant Device,17.34,34,,17.34,percent of total billed charges,Implant Device,25.25,,,25.25,Other,110% of Medicare,17.85,35,,17.85,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,17.85,35,,17.85,percent of total billed charges,Implant Device,17.85,35,,17.85,percent of total billed charges,Implant Device,17.85,35,,17.85,percent of total billed charges,Implant Device,17.85,35,,17.85,percent of total billed charges,Implant Device,17.85,35,,17.85,percent of total billed charges,Implant Device,20.4,40,,20.4,percent of total billed charges,Implant Device,17.85,70,,17.85,percent of total billed charges,All Other,17.34,34,,17.34,percent of total billed charges,Implant Device,17.34,34,,17.34,percent of total billed charges,Implant Device,17.85,35,,17.85,percent of total billed charges,Implant Device,17.85,35,,17.85,percent of total billed charges,Implant Device,17.85,35,,17.85,percent of total billed charges,Implant Device,17.85,35,,17.85,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,37.74,
MEDLINE ORT16300L IMMOBILIZ W/ABDUCT LG,L3650,HCPCS,,79013441,CDM,274,RC,,,both,,,51,37.74,,,37.74,Other,150% of Medicare + 9.63% HCRA Surcharge,22.95,45,,22.95,percent of total billed charges,Critical Access Hospital RCC factor,17.34,34,,17.34,percent of total billed charges,Implant Device,17.34,34,,17.34,percent of total billed charges,Implant Device,17.34,34,,17.34,percent of total billed charges,Implant Device,17.34,34,,17.34,percent of total billed charges,Implant Device,17.34,34,,17.34,percent of total billed charges,Implant Device,25.25,,,25.25,Other,110% of Medicare,17.85,35,,17.85,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,17.85,35,,17.85,percent of total billed charges,Implant Device,17.85,35,,17.85,percent of total billed charges,Implant Device,17.85,35,,17.85,percent of total billed charges,Implant Device,17.85,35,,17.85,percent of total billed charges,Implant Device,17.85,35,,17.85,percent of total billed charges,Implant Device,20.4,40,,20.4,percent of total billed charges,Implant Device,17.85,70,,17.85,percent of total billed charges,All Other,17.34,34,,17.34,percent of total billed charges,Implant Device,17.34,34,,17.34,percent of total billed charges,Implant Device,17.85,35,,17.85,percent of total billed charges,Implant Device,17.85,35,,17.85,percent of total billed charges,Implant Device,17.85,35,,17.85,percent of total billed charges,Implant Device,17.85,35,,17.85,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,37.74,
MEDLINE ORT16300XL IMMOBILIZ W/ABDUC XL,L3670,HCPCS,,79013442,CDM,274,RC,,,both,,,51,37.74,,,37.74,Other,150% of Medicare + 9.63% HCRA Surcharge,22.95,45,,22.95,percent of total billed charges,Critical Access Hospital RCC factor,17.34,34,,17.34,percent of total billed charges,Implant Device,17.34,34,,17.34,percent of total billed charges,Implant Device,17.34,34,,17.34,percent of total billed charges,Implant Device,17.34,34,,17.34,percent of total billed charges,Implant Device,17.34,34,,17.34,percent of total billed charges,Implant Device,25.25,,,25.25,Other,110% of Medicare,17.85,35,,17.85,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,17.85,35,,17.85,percent of total billed charges,Implant Device,17.85,35,,17.85,percent of total billed charges,Implant Device,17.85,35,,17.85,percent of total billed charges,Implant Device,17.85,35,,17.85,percent of total billed charges,Implant Device,17.85,35,,17.85,percent of total billed charges,Implant Device,20.4,40,,20.4,percent of total billed charges,Implant Device,17.85,70,,17.85,percent of total billed charges,All Other,17.34,34,,17.34,percent of total billed charges,Implant Device,17.34,34,,17.34,percent of total billed charges,Implant Device,17.85,35,,17.85,percent of total billed charges,Implant Device,17.85,35,,17.85,percent of total billed charges,Implant Device,17.85,35,,17.85,percent of total billed charges,Implant Device,17.85,35,,17.85,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,37.74,
MEDTRONIC RVDR01 PACEMAKER,C1785,HCPCS,,79002604,CDM,275,RC,,,both,,,17214,12738.4,,,12738.4,Other,150% of Medicare + 9.63% HCRA Surcharge,7746.3,45,,7746.3,percent of total billed charges,Critical Access Hospital RCC factor,5852.76,34,,5852.76,percent of total billed charges,Implant Device,5852.76,34,,5852.76,percent of total billed charges,Implant Device,5852.76,34,,5852.76,percent of total billed charges,Implant Device,5852.76,34,,5852.76,percent of total billed charges,Implant Device,5852.76,34,,5852.76,percent of total billed charges,Implant Device,8520.93,,,8520.93,Other,110% of Medicare,6024.9,35,,6024.9,percent of total billed charges,Implant Device,5852.76,34,"Charges > $500, x 34%",5852.76,percent of total billed charges,Implant Device,6024.9,35,,6024.9,percent of total billed charges,Implant Device,6024.9,35,,6024.9,percent of total billed charges,Implant Device,6024.9,35,,6024.9,percent of total billed charges,Implant Device,6024.9,35,,6024.9,percent of total billed charges,Implant Device,6024.9,35,,6024.9,percent of total billed charges,Implant Device,6885.6,40,,6885.6,percent of total billed charges,Implant Device,6024.9,70,,6024.9,percent of total billed charges,All Other,5852.76,34,,5852.76,percent of total billed charges,Implant Device,5852.76,34,,5852.76,percent of total billed charges,Implant Device,6024.9,35,,6024.9,percent of total billed charges,Implant Device,6024.9,35,,6024.9,percent of total billed charges,Implant Device,6024.9,35,,6024.9,percent of total billed charges,Implant Device,6024.9,35,,6024.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,5852.76,34,"If Charge > 2,000, then 34 percent",5852.76,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,12738.4,
MEDTRONIC D314DRG PROTECTA XT,C1721,HCPCS,,79002650,CDM,275,RC,,,both,,,69354,51322.13,,,51322.13,Other,150% of Medicare + 9.63% HCRA Surcharge,31209.3,45,,31209.3,percent of total billed charges,Critical Access Hospital RCC factor,23580.36,34,,23580.36,percent of total billed charges,Implant Device,23580.36,34,,23580.36,percent of total billed charges,Implant Device,23580.36,34,,23580.36,percent of total billed charges,Implant Device,23580.36,34,,23580.36,percent of total billed charges,Implant Device,23580.36,34,,23580.36,percent of total billed charges,Implant Device,34330.23,,,34330.23,Other,110% of Medicare,24273.9,35,,24273.9,percent of total billed charges,Implant Device,23580.36,34,"Charges > $500, x 34%",23580.36,percent of total billed charges,Implant Device,24273.9,35,,24273.9,percent of total billed charges,Implant Device,24273.9,35,,24273.9,percent of total billed charges,Implant Device,24273.9,35,,24273.9,percent of total billed charges,Implant Device,24273.9,35,,24273.9,percent of total billed charges,Implant Device,24273.9,35,,24273.9,percent of total billed charges,Implant Device,27741.6,40,,27741.6,percent of total billed charges,Implant Device,24273.9,70,,24273.9,percent of total billed charges,All Other,23580.36,34,,23580.36,percent of total billed charges,Implant Device,23580.36,34,,23580.36,percent of total billed charges,Implant Device,24273.9,35,,24273.9,percent of total billed charges,Implant Device,24273.9,35,,24273.9,percent of total billed charges,Implant Device,24273.9,35,,24273.9,percent of total billed charges,Implant Device,24273.9,35,,24273.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,23580.36,34,"If Charge > 2,000, then 34 percent",23580.36,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,51322.13,
MEDTRONIC D314DRM PROTECTA XT DR,C1721,HCPCS,,79002651,CDM,275,RC,,,both,,,69354,51322.13,,,51322.13,Other,150% of Medicare + 9.63% HCRA Surcharge,31209.3,45,,31209.3,percent of total billed charges,Critical Access Hospital RCC factor,23580.36,34,,23580.36,percent of total billed charges,Implant Device,23580.36,34,,23580.36,percent of total billed charges,Implant Device,23580.36,34,,23580.36,percent of total billed charges,Implant Device,23580.36,34,,23580.36,percent of total billed charges,Implant Device,23580.36,34,,23580.36,percent of total billed charges,Implant Device,34330.23,,,34330.23,Other,110% of Medicare,24273.9,35,,24273.9,percent of total billed charges,Implant Device,23580.36,34,"Charges > $500, x 34%",23580.36,percent of total billed charges,Implant Device,24273.9,35,,24273.9,percent of total billed charges,Implant Device,24273.9,35,,24273.9,percent of total billed charges,Implant Device,24273.9,35,,24273.9,percent of total billed charges,Implant Device,24273.9,35,,24273.9,percent of total billed charges,Implant Device,24273.9,35,,24273.9,percent of total billed charges,Implant Device,27741.6,40,,27741.6,percent of total billed charges,Implant Device,24273.9,70,,24273.9,percent of total billed charges,All Other,23580.36,34,,23580.36,percent of total billed charges,Implant Device,23580.36,34,,23580.36,percent of total billed charges,Implant Device,24273.9,35,,24273.9,percent of total billed charges,Implant Device,24273.9,35,,24273.9,percent of total billed charges,Implant Device,24273.9,35,,24273.9,percent of total billed charges,Implant Device,24273.9,35,,24273.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,23580.36,34,"If Charge > 2,000, then 34 percent",23580.36,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,51322.13,
MEDTRONIC D334DRG ICD PROTECTA,C1721,HCPCS,,79002652,CDM,275,RC,,,both,,,65430,48418.36,,,48418.36,Other,150% of Medicare + 9.63% HCRA Surcharge,29443.5,45,,29443.5,percent of total billed charges,Critical Access Hospital RCC factor,22246.2,34,,22246.2,percent of total billed charges,Implant Device,22246.2,34,,22246.2,percent of total billed charges,Implant Device,22246.2,34,,22246.2,percent of total billed charges,Implant Device,22246.2,34,,22246.2,percent of total billed charges,Implant Device,22246.2,34,,22246.2,percent of total billed charges,Implant Device,32387.85,,,32387.85,Other,110% of Medicare,22900.5,35,,22900.5,percent of total billed charges,Implant Device,22246.2,34,"Charges > $500, x 34%",22246.2,percent of total billed charges,Implant Device,22900.5,35,,22900.5,percent of total billed charges,Implant Device,22900.5,35,,22900.5,percent of total billed charges,Implant Device,22900.5,35,,22900.5,percent of total billed charges,Implant Device,22900.5,35,,22900.5,percent of total billed charges,Implant Device,22900.5,35,,22900.5,percent of total billed charges,Implant Device,26172,40,,26172,percent of total billed charges,Implant Device,22900.5,70,,22900.5,percent of total billed charges,All Other,22246.2,34,,22246.2,percent of total billed charges,Implant Device,22246.2,34,,22246.2,percent of total billed charges,Implant Device,22900.5,35,,22900.5,percent of total billed charges,Implant Device,22900.5,35,,22900.5,percent of total billed charges,Implant Device,22900.5,35,,22900.5,percent of total billed charges,Implant Device,22900.5,35,,22900.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,22246.2,34,"If Charge > 2,000, then 34 percent",22246.2,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,48418.36,
MEDTRONIC D314VRG PROTECTA XT VR,C1722,HCPCS,,79002653,CDM,275,RC,,,both,,,54012,39969.02,,,39969.02,Other,150% of Medicare + 9.63% HCRA Surcharge,24305.4,45,,24305.4,percent of total billed charges,Critical Access Hospital RCC factor,18364.08,34,,18364.08,percent of total billed charges,Implant Device,18364.08,34,,18364.08,percent of total billed charges,Implant Device,18364.08,34,,18364.08,percent of total billed charges,Implant Device,18364.08,34,,18364.08,percent of total billed charges,Implant Device,18364.08,34,,18364.08,percent of total billed charges,Implant Device,26735.94,,,26735.94,Other,110% of Medicare,18904.2,35,,18904.2,percent of total billed charges,Implant Device,18364.08,34,"Charges > $500, x 34%",18364.08,percent of total billed charges,Implant Device,18904.2,35,,18904.2,percent of total billed charges,Implant Device,18904.2,35,,18904.2,percent of total billed charges,Implant Device,18904.2,35,,18904.2,percent of total billed charges,Implant Device,18904.2,35,,18904.2,percent of total billed charges,Implant Device,18904.2,35,,18904.2,percent of total billed charges,Implant Device,21604.8,40,,21604.8,percent of total billed charges,Implant Device,18904.2,70,,18904.2,percent of total billed charges,All Other,18364.08,34,,18364.08,percent of total billed charges,Implant Device,18364.08,34,,18364.08,percent of total billed charges,Implant Device,18904.2,35,,18904.2,percent of total billed charges,Implant Device,18904.2,35,,18904.2,percent of total billed charges,Implant Device,18904.2,35,,18904.2,percent of total billed charges,Implant Device,18904.2,35,,18904.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,18364.08,34,"If Charge > 2,000, then 34 percent",18364.08,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,39969.02,
MEDTRONIC D314VRM PROTECTA XT VR DR4,C1722,HCPCS,,79002654,CDM,275,RC,,,both,,,56830,42054.34,,,42054.34,Other,150% of Medicare + 9.63% HCRA Surcharge,25573.5,45,,25573.5,percent of total billed charges,Critical Access Hospital RCC factor,19322.2,34,,19322.2,percent of total billed charges,Implant Device,19322.2,34,,19322.2,percent of total billed charges,Implant Device,19322.2,34,,19322.2,percent of total billed charges,Implant Device,19322.2,34,,19322.2,percent of total billed charges,Implant Device,19322.2,34,,19322.2,percent of total billed charges,Implant Device,28130.85,,,28130.85,Other,110% of Medicare,19890.5,35,,19890.5,percent of total billed charges,Implant Device,19322.2,34,"Charges > $500, x 34%",19322.2,percent of total billed charges,Implant Device,19890.5,35,,19890.5,percent of total billed charges,Implant Device,19890.5,35,,19890.5,percent of total billed charges,Implant Device,19890.5,35,,19890.5,percent of total billed charges,Implant Device,19890.5,35,,19890.5,percent of total billed charges,Implant Device,19890.5,35,,19890.5,percent of total billed charges,Implant Device,22732,40,,22732,percent of total billed charges,Implant Device,19890.5,70,,19890.5,percent of total billed charges,All Other,19322.2,34,,19322.2,percent of total billed charges,Implant Device,19322.2,34,,19322.2,percent of total billed charges,Implant Device,19890.5,35,,19890.5,percent of total billed charges,Implant Device,19890.5,35,,19890.5,percent of total billed charges,Implant Device,19890.5,35,,19890.5,percent of total billed charges,Implant Device,19890.5,35,,19890.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,19322.2,34,"If Charge > 2,000, then 34 percent",19322.2,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,42054.34,
MEDTRONIC D334VRG ICD PROTECTA,C1722,HCPCS,,79002655,CDM,275,RC,,,both,,,50956,37707.57,,,37707.57,Other,150% of Medicare + 9.63% HCRA Surcharge,22930.2,45,,22930.2,percent of total billed charges,Critical Access Hospital RCC factor,17325.04,34,,17325.04,percent of total billed charges,Implant Device,17325.04,34,,17325.04,percent of total billed charges,Implant Device,17325.04,34,,17325.04,percent of total billed charges,Implant Device,17325.04,34,,17325.04,percent of total billed charges,Implant Device,17325.04,34,,17325.04,percent of total billed charges,Implant Device,25223.22,,,25223.22,Other,110% of Medicare,17834.6,35,,17834.6,percent of total billed charges,Implant Device,17325.04,34,"Charges > $500, x 34%",17325.04,percent of total billed charges,Implant Device,17834.6,35,,17834.6,percent of total billed charges,Implant Device,17834.6,35,,17834.6,percent of total billed charges,Implant Device,17834.6,35,,17834.6,percent of total billed charges,Implant Device,17834.6,35,,17834.6,percent of total billed charges,Implant Device,17834.6,35,,17834.6,percent of total billed charges,Implant Device,20382.4,40,,20382.4,percent of total billed charges,Implant Device,17834.6,70,,17834.6,percent of total billed charges,All Other,17325.04,34,,17325.04,percent of total billed charges,Implant Device,17325.04,34,,17325.04,percent of total billed charges,Implant Device,17834.6,35,,17834.6,percent of total billed charges,Implant Device,17834.6,35,,17834.6,percent of total billed charges,Implant Device,17834.6,35,,17834.6,percent of total billed charges,Implant Device,17834.6,35,,17834.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,17325.04,34,"If Charge > 2,000, then 34 percent",17325.04,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,37707.57,
RVDR01 REVO MRI DEVICE,C1785,HCPCS,,79002663,CDM,275,RC,,,both,,,16354,12102,,,12102,Other,150% of Medicare + 9.63% HCRA Surcharge,7359.3,45,,7359.3,percent of total billed charges,Critical Access Hospital RCC factor,5560.36,34,,5560.36,percent of total billed charges,Implant Device,5560.36,34,,5560.36,percent of total billed charges,Implant Device,5560.36,34,,5560.36,percent of total billed charges,Implant Device,5560.36,34,,5560.36,percent of total billed charges,Implant Device,5560.36,34,,5560.36,percent of total billed charges,Implant Device,8095.23,,,8095.23,Other,110% of Medicare,5723.9,35,,5723.9,percent of total billed charges,Implant Device,5560.36,34,"Charges > $500, x 34%",5560.36,percent of total billed charges,Implant Device,5723.9,35,,5723.9,percent of total billed charges,Implant Device,5723.9,35,,5723.9,percent of total billed charges,Implant Device,5723.9,35,,5723.9,percent of total billed charges,Implant Device,5723.9,35,,5723.9,percent of total billed charges,Implant Device,5723.9,35,,5723.9,percent of total billed charges,Implant Device,6541.6,40,,6541.6,percent of total billed charges,Implant Device,5723.9,70,,5723.9,percent of total billed charges,All Other,5560.36,34,,5560.36,percent of total billed charges,Implant Device,5560.36,34,,5560.36,percent of total billed charges,Implant Device,5723.9,35,,5723.9,percent of total billed charges,Implant Device,5723.9,35,,5723.9,percent of total billed charges,Implant Device,5723.9,35,,5723.9,percent of total billed charges,Implant Device,5723.9,35,,5723.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,5560.36,34,"If Charge > 2,000, then 34 percent",5560.36,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,12102,
SEDR01 SENSIA DUAL CHAMBER,C1785,HCPCS,,79002664,CDM,275,RC,,,both,,,13572,10043.31,,,10043.31,Other,150% of Medicare + 9.63% HCRA Surcharge,6107.4,45,,6107.4,percent of total billed charges,Critical Access Hospital RCC factor,4614.48,34,,4614.48,percent of total billed charges,Implant Device,4614.48,34,,4614.48,percent of total billed charges,Implant Device,4614.48,34,,4614.48,percent of total billed charges,Implant Device,4614.48,34,,4614.48,percent of total billed charges,Implant Device,4614.48,34,,4614.48,percent of total billed charges,Implant Device,6718.14,,,6718.14,Other,110% of Medicare,4750.2,35,,4750.2,percent of total billed charges,Implant Device,4614.48,34,"Charges > $500, x 34%",4614.48,percent of total billed charges,Implant Device,4750.2,35,,4750.2,percent of total billed charges,Implant Device,4750.2,35,,4750.2,percent of total billed charges,Implant Device,4750.2,35,,4750.2,percent of total billed charges,Implant Device,4750.2,35,,4750.2,percent of total billed charges,Implant Device,4750.2,35,,4750.2,percent of total billed charges,Implant Device,5428.8,40,,5428.8,percent of total billed charges,Implant Device,4750.2,70,,4750.2,percent of total billed charges,All Other,4614.48,34,,4614.48,percent of total billed charges,Implant Device,4614.48,34,,4614.48,percent of total billed charges,Implant Device,4750.2,35,,4750.2,percent of total billed charges,Implant Device,4750.2,35,,4750.2,percent of total billed charges,Implant Device,4750.2,35,,4750.2,percent of total billed charges,Implant Device,4750.2,35,,4750.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,4614.48,34,"If Charge > 2,000, then 34 percent",4614.48,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,10043.31,
SESR01 SENSIA SR SINGLE CHAMBER,C1786,HCPCS,,79002665,CDM,275,RC,,,both,,,11226,8307.27,,,8307.27,Other,150% of Medicare + 9.63% HCRA Surcharge,5051.7,45,,5051.7,percent of total billed charges,Critical Access Hospital RCC factor,3816.84,34,,3816.84,percent of total billed charges,Implant Device,3816.84,34,,3816.84,percent of total billed charges,Implant Device,3816.84,34,,3816.84,percent of total billed charges,Implant Device,3816.84,34,,3816.84,percent of total billed charges,Implant Device,3816.84,34,,3816.84,percent of total billed charges,Implant Device,5556.87,,,5556.87,Other,110% of Medicare,3929.1,35,,3929.1,percent of total billed charges,Implant Device,3816.84,34,"Charges > $500, x 34%",3816.84,percent of total billed charges,Implant Device,3929.1,35,,3929.1,percent of total billed charges,Implant Device,3929.1,35,,3929.1,percent of total billed charges,Implant Device,3929.1,35,,3929.1,percent of total billed charges,Implant Device,3929.1,35,,3929.1,percent of total billed charges,Implant Device,3929.1,35,,3929.1,percent of total billed charges,Implant Device,4490.4,40,,4490.4,percent of total billed charges,Implant Device,3929.1,70,,3929.1,percent of total billed charges,All Other,3816.84,34,,3816.84,percent of total billed charges,Implant Device,3816.84,34,,3816.84,percent of total billed charges,Implant Device,3929.1,35,,3929.1,percent of total billed charges,Implant Device,3929.1,35,,3929.1,percent of total billed charges,Implant Device,3929.1,35,,3929.1,percent of total billed charges,Implant Device,3929.1,35,,3929.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3816.84,34,"If Charge > 2,000, then 34 percent",3816.84,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,8307.27,
MEDTRONIC D314TRG PROTECTA XT CRT,C1882,HCPCS,,79002667,CDM,275,RC,,,both,,,78718,58251.52,,,58251.52,Other,150% of Medicare + 9.63% HCRA Surcharge,35423.1,45,,35423.1,percent of total billed charges,Critical Access Hospital RCC factor,26764.12,34,,26764.12,percent of total billed charges,Implant Device,26764.12,34,,26764.12,percent of total billed charges,Implant Device,26764.12,34,,26764.12,percent of total billed charges,Implant Device,26764.12,34,,26764.12,percent of total billed charges,Implant Device,26764.12,34,,26764.12,percent of total billed charges,Implant Device,38965.41,,,38965.41,Other,110% of Medicare,27551.3,35,,27551.3,percent of total billed charges,Implant Device,26764.12,34,"Charges > $500, x 34%",26764.12,percent of total billed charges,Implant Device,27551.3,35,,27551.3,percent of total billed charges,Implant Device,27551.3,35,,27551.3,percent of total billed charges,Implant Device,27551.3,35,,27551.3,percent of total billed charges,Implant Device,27551.3,35,,27551.3,percent of total billed charges,Implant Device,27551.3,35,,27551.3,percent of total billed charges,Implant Device,31487.2,40,,31487.2,percent of total billed charges,Implant Device,27551.3,70,,27551.3,percent of total billed charges,All Other,26764.12,34,,26764.12,percent of total billed charges,Implant Device,26764.12,34,,26764.12,percent of total billed charges,Implant Device,27551.3,35,,27551.3,percent of total billed charges,Implant Device,27551.3,35,,27551.3,percent of total billed charges,Implant Device,27551.3,35,,27551.3,percent of total billed charges,Implant Device,27551.3,35,,27551.3,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,26764.12,34,"If Charge > 2,000, then 34 percent",26764.12,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,58251.52,
MEDTRONIC D334TRG ICD PROTECTA CRT-D,C1882,HCPCS,,79002668,CDM,275,RC,,,both,,,65794,48687.72,,,48687.72,Other,150% of Medicare + 9.63% HCRA Surcharge,29607.3,45,,29607.3,percent of total billed charges,Critical Access Hospital RCC factor,22369.96,34,,22369.96,percent of total billed charges,Implant Device,22369.96,34,,22369.96,percent of total billed charges,Implant Device,22369.96,34,,22369.96,percent of total billed charges,Implant Device,22369.96,34,,22369.96,percent of total billed charges,Implant Device,22369.96,34,,22369.96,percent of total billed charges,Implant Device,32568.03,,,32568.03,Other,110% of Medicare,23027.9,35,,23027.9,percent of total billed charges,Implant Device,22369.96,34,"Charges > $500, x 34%",22369.96,percent of total billed charges,Implant Device,23027.9,35,,23027.9,percent of total billed charges,Implant Device,23027.9,35,,23027.9,percent of total billed charges,Implant Device,23027.9,35,,23027.9,percent of total billed charges,Implant Device,23027.9,35,,23027.9,percent of total billed charges,Implant Device,23027.9,35,,23027.9,percent of total billed charges,Implant Device,26317.6,40,,26317.6,percent of total billed charges,Implant Device,23027.9,70,,23027.9,percent of total billed charges,All Other,22369.96,34,,22369.96,percent of total billed charges,Implant Device,22369.96,34,,22369.96,percent of total billed charges,Implant Device,23027.9,35,,23027.9,percent of total billed charges,Implant Device,23027.9,35,,23027.9,percent of total billed charges,Implant Device,23027.9,35,,23027.9,percent of total billed charges,Implant Device,23027.9,35,,23027.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,22369.96,34,"If Charge > 2,000, then 34 percent",22369.96,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,48687.72,
ST JUDE CD2231-40 PULSE GENERATOR,C1721,HCPCS,,79002685,CDM,275,RC,,,both,,,52096,38551.17,,,38551.17,Other,150% of Medicare + 9.63% HCRA Surcharge,23443.2,45,,23443.2,percent of total billed charges,Critical Access Hospital RCC factor,17712.64,34,,17712.64,percent of total billed charges,Implant Device,17712.64,34,,17712.64,percent of total billed charges,Implant Device,17712.64,34,,17712.64,percent of total billed charges,Implant Device,17712.64,34,,17712.64,percent of total billed charges,Implant Device,17712.64,34,,17712.64,percent of total billed charges,Implant Device,25787.52,,,25787.52,Other,110% of Medicare,18233.6,35,,18233.6,percent of total billed charges,Implant Device,17712.64,34,"Charges > $500, x 34%",17712.64,percent of total billed charges,Implant Device,18233.6,35,,18233.6,percent of total billed charges,Implant Device,18233.6,35,,18233.6,percent of total billed charges,Implant Device,18233.6,35,,18233.6,percent of total billed charges,Implant Device,18233.6,35,,18233.6,percent of total billed charges,Implant Device,18233.6,35,,18233.6,percent of total billed charges,Implant Device,20838.4,40,,20838.4,percent of total billed charges,Implant Device,18233.6,70,,18233.6,percent of total billed charges,All Other,17712.64,34,,17712.64,percent of total billed charges,Implant Device,17712.64,34,,17712.64,percent of total billed charges,Implant Device,18233.6,35,,18233.6,percent of total billed charges,Implant Device,18233.6,35,,18233.6,percent of total billed charges,Implant Device,18233.6,35,,18233.6,percent of total billed charges,Implant Device,18233.6,35,,18233.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,17712.64,34,"If Charge > 2,000, then 34 percent",17712.64,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,38551.17,
ST JUDE CD2357-40C FORTIFY ASSURA DR,C1721,HCPCS,,79002686,CDM,275,RC,,,both,,,44307,32787.29,,,32787.29,Other,150% of Medicare + 9.63% HCRA Surcharge,19938.15,45,,19938.15,percent of total billed charges,Critical Access Hospital RCC factor,15064.38,34,,15064.38,percent of total billed charges,Implant Device,15064.38,34,,15064.38,percent of total billed charges,Implant Device,15064.38,34,,15064.38,percent of total billed charges,Implant Device,15064.38,34,,15064.38,percent of total billed charges,Implant Device,15064.38,34,,15064.38,percent of total billed charges,Implant Device,21931.97,,,21931.97,Other,110% of Medicare,15507.45,35,,15507.45,percent of total billed charges,Implant Device,15064.38,34,"Charges > $500, x 34%",15064.38,percent of total billed charges,Implant Device,15507.45,35,,15507.45,percent of total billed charges,Implant Device,15507.45,35,,15507.45,percent of total billed charges,Implant Device,15507.45,35,,15507.45,percent of total billed charges,Implant Device,15507.45,35,,15507.45,percent of total billed charges,Implant Device,15507.45,35,,15507.45,percent of total billed charges,Implant Device,17722.8,40,,17722.8,percent of total billed charges,Implant Device,15507.45,70,,15507.45,percent of total billed charges,All Other,15064.38,34,,15064.38,percent of total billed charges,Implant Device,15064.38,34,,15064.38,percent of total billed charges,Implant Device,15507.45,35,,15507.45,percent of total billed charges,Implant Device,15507.45,35,,15507.45,percent of total billed charges,Implant Device,15507.45,35,,15507.45,percent of total billed charges,Implant Device,15507.45,35,,15507.45,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,15064.38,34,"If Charge > 2,000, then 34 percent",15064.38,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,32787.29,
ST JUDE CD2257-40Q FORTIFY ASSURA DR,C1721,HCPCS,,79002687,CDM,275,RC,,,both,,,54586,40393.78,,,40393.78,Other,150% of Medicare + 9.63% HCRA Surcharge,24563.7,45,,24563.7,percent of total billed charges,Critical Access Hospital RCC factor,18559.24,34,,18559.24,percent of total billed charges,Implant Device,18559.24,34,,18559.24,percent of total billed charges,Implant Device,18559.24,34,,18559.24,percent of total billed charges,Implant Device,18559.24,34,,18559.24,percent of total billed charges,Implant Device,18559.24,34,,18559.24,percent of total billed charges,Implant Device,27020.07,,,27020.07,Other,110% of Medicare,19105.1,35,,19105.1,percent of total billed charges,Implant Device,18559.24,34,"Charges > $500, x 34%",18559.24,percent of total billed charges,Implant Device,19105.1,35,,19105.1,percent of total billed charges,Implant Device,19105.1,35,,19105.1,percent of total billed charges,Implant Device,19105.1,35,,19105.1,percent of total billed charges,Implant Device,19105.1,35,,19105.1,percent of total billed charges,Implant Device,19105.1,35,,19105.1,percent of total billed charges,Implant Device,21834.4,40,,21834.4,percent of total billed charges,Implant Device,19105.1,70,,19105.1,percent of total billed charges,All Other,18559.24,34,,18559.24,percent of total billed charges,Implant Device,18559.24,34,,18559.24,percent of total billed charges,Implant Device,19105.1,35,,19105.1,percent of total billed charges,Implant Device,19105.1,35,,19105.1,percent of total billed charges,Implant Device,19105.1,35,,19105.1,percent of total billed charges,Implant Device,19105.1,35,,19105.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,18559.24,34,"If Charge > 2,000, then 34 percent",18559.24,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,40393.78,
ST JUDE CD1231-40Q FORTIFY VR PACEMAKER,C1722,HCPCS,,79002688,CDM,275,RC,,,both,,,51270,37939.93,,,37939.93,Other,150% of Medicare + 9.63% HCRA Surcharge,23071.5,45,,23071.5,percent of total billed charges,Critical Access Hospital RCC factor,17431.8,34,,17431.8,percent of total billed charges,Implant Device,17431.8,34,,17431.8,percent of total billed charges,Implant Device,17431.8,34,,17431.8,percent of total billed charges,Implant Device,17431.8,34,,17431.8,percent of total billed charges,Implant Device,17431.8,34,,17431.8,percent of total billed charges,Implant Device,25378.65,,,25378.65,Other,110% of Medicare,17944.5,35,,17944.5,percent of total billed charges,Implant Device,17431.8,34,"Charges > $500, x 34%",17431.8,percent of total billed charges,Implant Device,17944.5,35,,17944.5,percent of total billed charges,Implant Device,17944.5,35,,17944.5,percent of total billed charges,Implant Device,17944.5,35,,17944.5,percent of total billed charges,Implant Device,17944.5,35,,17944.5,percent of total billed charges,Implant Device,17944.5,35,,17944.5,percent of total billed charges,Implant Device,20508,40,,20508,percent of total billed charges,Implant Device,17944.5,70,,17944.5,percent of total billed charges,All Other,17431.8,34,,17431.8,percent of total billed charges,Implant Device,17431.8,34,,17431.8,percent of total billed charges,Implant Device,17944.5,35,,17944.5,percent of total billed charges,Implant Device,17944.5,35,,17944.5,percent of total billed charges,Implant Device,17944.5,35,,17944.5,percent of total billed charges,Implant Device,17944.5,35,,17944.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,17431.8,34,"If Charge > 2,000, then 34 percent",17431.8,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,37939.93,
ST JUDE CD1257-40 FORTIFYASSURA,C1722,HCPCS,,79002689,CDM,275,RC,,,both,,,44040,32589.71,,,32589.71,Other,150% of Medicare + 9.63% HCRA Surcharge,19818,45,,19818,percent of total billed charges,Critical Access Hospital RCC factor,14973.6,34,,14973.6,percent of total billed charges,Implant Device,14973.6,34,,14973.6,percent of total billed charges,Implant Device,14973.6,34,,14973.6,percent of total billed charges,Implant Device,14973.6,34,,14973.6,percent of total billed charges,Implant Device,14973.6,34,,14973.6,percent of total billed charges,Implant Device,21799.8,,,21799.8,Other,110% of Medicare,15414,35,,15414,percent of total billed charges,Implant Device,14973.6,34,"Charges > $500, x 34%",14973.6,percent of total billed charges,Implant Device,15414,35,,15414,percent of total billed charges,Implant Device,15414,35,,15414,percent of total billed charges,Implant Device,15414,35,,15414,percent of total billed charges,Implant Device,15414,35,,15414,percent of total billed charges,Implant Device,15414,35,,15414,percent of total billed charges,Implant Device,17616,40,,17616,percent of total billed charges,Implant Device,15414,70,,15414,percent of total billed charges,All Other,14973.6,34,,14973.6,percent of total billed charges,Implant Device,14973.6,34,,14973.6,percent of total billed charges,Implant Device,15414,35,,15414,percent of total billed charges,Implant Device,15414,35,,15414,percent of total billed charges,Implant Device,15414,35,,15414,percent of total billed charges,Implant Device,15414,35,,15414,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,14973.6,34,"If Charge > 2,000, then 34 percent",14973.6,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,32589.71,
ST JUDE CD1357-40Q FORTIFY ASSURA,C1722,HCPCS,,79002690,CDM,275,RC,,,both,,,51270,37939.93,,,37939.93,Other,150% of Medicare + 9.63% HCRA Surcharge,23071.5,45,,23071.5,percent of total billed charges,Critical Access Hospital RCC factor,17431.8,34,,17431.8,percent of total billed charges,Implant Device,17431.8,34,,17431.8,percent of total billed charges,Implant Device,17431.8,34,,17431.8,percent of total billed charges,Implant Device,17431.8,34,,17431.8,percent of total billed charges,Implant Device,17431.8,34,,17431.8,percent of total billed charges,Implant Device,25378.65,,,25378.65,Other,110% of Medicare,17944.5,35,,17944.5,percent of total billed charges,Implant Device,17431.8,34,"Charges > $500, x 34%",17431.8,percent of total billed charges,Implant Device,17944.5,35,,17944.5,percent of total billed charges,Implant Device,17944.5,35,,17944.5,percent of total billed charges,Implant Device,17944.5,35,,17944.5,percent of total billed charges,Implant Device,17944.5,35,,17944.5,percent of total billed charges,Implant Device,17944.5,35,,17944.5,percent of total billed charges,Implant Device,20508,40,,20508,percent of total billed charges,Implant Device,17944.5,70,,17944.5,percent of total billed charges,All Other,17431.8,34,,17431.8,percent of total billed charges,Implant Device,17431.8,34,,17431.8,percent of total billed charges,Implant Device,17944.5,35,,17944.5,percent of total billed charges,Implant Device,17944.5,35,,17944.5,percent of total billed charges,Implant Device,17944.5,35,,17944.5,percent of total billed charges,Implant Device,17944.5,35,,17944.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,17431.8,34,"If Charge > 2,000, then 34 percent",17431.8,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,37939.93,
ST JUDE PM2110 ACCENT DR PACEMAKER,C1785,HCPCS,,79002692,CDM,275,RC,,,both,,,15694,11613.6,,,11613.6,Other,150% of Medicare + 9.63% HCRA Surcharge,7062.3,45,,7062.3,percent of total billed charges,Critical Access Hospital RCC factor,5335.96,34,,5335.96,percent of total billed charges,Implant Device,5335.96,34,,5335.96,percent of total billed charges,Implant Device,5335.96,34,,5335.96,percent of total billed charges,Implant Device,5335.96,34,,5335.96,percent of total billed charges,Implant Device,5335.96,34,,5335.96,percent of total billed charges,Implant Device,7768.53,,,7768.53,Other,110% of Medicare,5492.9,35,,5492.9,percent of total billed charges,Implant Device,5335.96,34,"Charges > $500, x 34%",5335.96,percent of total billed charges,Implant Device,5492.9,35,,5492.9,percent of total billed charges,Implant Device,5492.9,35,,5492.9,percent of total billed charges,Implant Device,5492.9,35,,5492.9,percent of total billed charges,Implant Device,5492.9,35,,5492.9,percent of total billed charges,Implant Device,5492.9,35,,5492.9,percent of total billed charges,Implant Device,6277.6,40,,6277.6,percent of total billed charges,Implant Device,5492.9,70,,5492.9,percent of total billed charges,All Other,5335.96,34,,5335.96,percent of total billed charges,Implant Device,5335.96,34,,5335.96,percent of total billed charges,Implant Device,5492.9,35,,5492.9,percent of total billed charges,Implant Device,5492.9,35,,5492.9,percent of total billed charges,Implant Device,5492.9,35,,5492.9,percent of total billed charges,Implant Device,5492.9,35,,5492.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,5335.96,34,"If Charge > 2,000, then 34 percent",5335.96,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,11613.6,
ST JUDE PM2210 ACCENT DR RF PACEMAKER,C1785,HCPCS,,79002693,CDM,275,RC,,,both,,,15694,11613.6,,,11613.6,Other,150% of Medicare + 9.63% HCRA Surcharge,7062.3,45,,7062.3,percent of total billed charges,Critical Access Hospital RCC factor,5335.96,34,,5335.96,percent of total billed charges,Implant Device,5335.96,34,,5335.96,percent of total billed charges,Implant Device,5335.96,34,,5335.96,percent of total billed charges,Implant Device,5335.96,34,,5335.96,percent of total billed charges,Implant Device,5335.96,34,,5335.96,percent of total billed charges,Implant Device,7768.53,,,7768.53,Other,110% of Medicare,5492.9,35,,5492.9,percent of total billed charges,Implant Device,5335.96,34,"Charges > $500, x 34%",5335.96,percent of total billed charges,Implant Device,5492.9,35,,5492.9,percent of total billed charges,Implant Device,5492.9,35,,5492.9,percent of total billed charges,Implant Device,5492.9,35,,5492.9,percent of total billed charges,Implant Device,5492.9,35,,5492.9,percent of total billed charges,Implant Device,5492.9,35,,5492.9,percent of total billed charges,Implant Device,6277.6,40,,6277.6,percent of total billed charges,Implant Device,5492.9,70,,5492.9,percent of total billed charges,All Other,5335.96,34,,5335.96,percent of total billed charges,Implant Device,5335.96,34,,5335.96,percent of total billed charges,Implant Device,5492.9,35,,5492.9,percent of total billed charges,Implant Device,5492.9,35,,5492.9,percent of total billed charges,Implant Device,5492.9,35,,5492.9,percent of total billed charges,Implant Device,5492.9,35,,5492.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,5335.96,34,"If Charge > 2,000, then 34 percent",5335.96,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,11613.6,
ST JUDE PM1210 ACCENT SR RF PACEMAKER,C1786,HCPCS,,79002694,CDM,275,RC,,,both,,,12816,9483.87,,,9483.87,Other,150% of Medicare + 9.63% HCRA Surcharge,5767.2,45,,5767.2,percent of total billed charges,Critical Access Hospital RCC factor,4357.44,34,,4357.44,percent of total billed charges,Implant Device,4357.44,34,,4357.44,percent of total billed charges,Implant Device,4357.44,34,,4357.44,percent of total billed charges,Implant Device,4357.44,34,,4357.44,percent of total billed charges,Implant Device,4357.44,34,,4357.44,percent of total billed charges,Implant Device,6343.92,,,6343.92,Other,110% of Medicare,4485.6,35,,4485.6,percent of total billed charges,Implant Device,4357.44,34,"Charges > $500, x 34%",4357.44,percent of total billed charges,Implant Device,4485.6,35,,4485.6,percent of total billed charges,Implant Device,4485.6,35,,4485.6,percent of total billed charges,Implant Device,4485.6,35,,4485.6,percent of total billed charges,Implant Device,4485.6,35,,4485.6,percent of total billed charges,Implant Device,4485.6,35,,4485.6,percent of total billed charges,Implant Device,5126.4,40,,5126.4,percent of total billed charges,Implant Device,4485.6,70,,4485.6,percent of total billed charges,All Other,4357.44,34,,4357.44,percent of total billed charges,Implant Device,4357.44,34,,4357.44,percent of total billed charges,Implant Device,4485.6,35,,4485.6,percent of total billed charges,Implant Device,4485.6,35,,4485.6,percent of total billed charges,Implant Device,4485.6,35,,4485.6,percent of total billed charges,Implant Device,4485.6,35,,4485.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,4357.44,34,"If Charge > 2,000, then 34 percent",4357.44,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,9483.87,
ST JUDE CD3231-40Q UNIFY PACEMAKER,C1882,HCPCS,,79002695,CDM,275,RC,,,both,,,68962,51032.05,,,51032.05,Other,150% of Medicare + 9.63% HCRA Surcharge,31032.9,45,,31032.9,percent of total billed charges,Critical Access Hospital RCC factor,23447.08,34,,23447.08,percent of total billed charges,Implant Device,23447.08,34,,23447.08,percent of total billed charges,Implant Device,23447.08,34,,23447.08,percent of total billed charges,Implant Device,23447.08,34,,23447.08,percent of total billed charges,Implant Device,23447.08,34,,23447.08,percent of total billed charges,Implant Device,34136.19,,,34136.19,Other,110% of Medicare,24136.7,35,,24136.7,percent of total billed charges,Implant Device,23447.08,34,"Charges > $500, x 34%",23447.08,percent of total billed charges,Implant Device,24136.7,35,,24136.7,percent of total billed charges,Implant Device,24136.7,35,,24136.7,percent of total billed charges,Implant Device,24136.7,35,,24136.7,percent of total billed charges,Implant Device,24136.7,35,,24136.7,percent of total billed charges,Implant Device,24136.7,35,,24136.7,percent of total billed charges,Implant Device,27584.8,40,,27584.8,percent of total billed charges,Implant Device,24136.7,70,,24136.7,percent of total billed charges,All Other,23447.08,34,,23447.08,percent of total billed charges,Implant Device,23447.08,34,,23447.08,percent of total billed charges,Implant Device,24136.7,35,,24136.7,percent of total billed charges,Implant Device,24136.7,35,,24136.7,percent of total billed charges,Implant Device,24136.7,35,,24136.7,percent of total billed charges,Implant Device,24136.7,35,,24136.7,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,23447.08,34,"If Charge > 2,000, then 34 percent",23447.08,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,51032.05,
ST JUDE CD3249-40Q UNIFY QUADRA ICD PACE,C1882,HCPCS,,79002696,CDM,275,RC,,,both,,,78228,57888.92,,,57888.92,Other,150% of Medicare + 9.63% HCRA Surcharge,35202.6,45,,35202.6,percent of total billed charges,Critical Access Hospital RCC factor,26597.52,34,,26597.52,percent of total billed charges,Implant Device,26597.52,34,,26597.52,percent of total billed charges,Implant Device,26597.52,34,,26597.52,percent of total billed charges,Implant Device,26597.52,34,,26597.52,percent of total billed charges,Implant Device,26597.52,34,,26597.52,percent of total billed charges,Implant Device,38722.86,,,38722.86,Other,110% of Medicare,27379.8,35,,27379.8,percent of total billed charges,Implant Device,26597.52,34,"Charges > $500, x 34%",26597.52,percent of total billed charges,Implant Device,27379.8,35,,27379.8,percent of total billed charges,Implant Device,27379.8,35,,27379.8,percent of total billed charges,Implant Device,27379.8,35,,27379.8,percent of total billed charges,Implant Device,27379.8,35,,27379.8,percent of total billed charges,Implant Device,27379.8,35,,27379.8,percent of total billed charges,Implant Device,31291.2,40,,31291.2,percent of total billed charges,Implant Device,27379.8,70,,27379.8,percent of total billed charges,All Other,26597.52,34,,26597.52,percent of total billed charges,Implant Device,26597.52,34,,26597.52,percent of total billed charges,Implant Device,27379.8,35,,27379.8,percent of total billed charges,Implant Device,27379.8,35,,27379.8,percent of total billed charges,Implant Device,27379.8,35,,27379.8,percent of total billed charges,Implant Device,27379.8,35,,27379.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,26597.52,34,"If Charge > 2,000, then 34 percent",26597.52,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,57888.92,
ST JUDE CD3257-40 HV GEN UNIFY ASSURA,C1882,HCPCS,,79002697,CDM,275,RC,,,both,,,68962,51032.05,,,51032.05,Other,150% of Medicare + 9.63% HCRA Surcharge,31032.9,45,,31032.9,percent of total billed charges,Critical Access Hospital RCC factor,23447.08,34,,23447.08,percent of total billed charges,Implant Device,23447.08,34,,23447.08,percent of total billed charges,Implant Device,23447.08,34,,23447.08,percent of total billed charges,Implant Device,23447.08,34,,23447.08,percent of total billed charges,Implant Device,23447.08,34,,23447.08,percent of total billed charges,Implant Device,34136.19,,,34136.19,Other,110% of Medicare,24136.7,35,,24136.7,percent of total billed charges,Implant Device,23447.08,34,"Charges > $500, x 34%",23447.08,percent of total billed charges,Implant Device,24136.7,35,,24136.7,percent of total billed charges,Implant Device,24136.7,35,,24136.7,percent of total billed charges,Implant Device,24136.7,35,,24136.7,percent of total billed charges,Implant Device,24136.7,35,,24136.7,percent of total billed charges,Implant Device,24136.7,35,,24136.7,percent of total billed charges,Implant Device,27584.8,40,,27584.8,percent of total billed charges,Implant Device,24136.7,70,,24136.7,percent of total billed charges,All Other,23447.08,34,,23447.08,percent of total billed charges,Implant Device,23447.08,34,,23447.08,percent of total billed charges,Implant Device,24136.7,35,,24136.7,percent of total billed charges,Implant Device,24136.7,35,,24136.7,percent of total billed charges,Implant Device,24136.7,35,,24136.7,percent of total billed charges,Implant Device,24136.7,35,,24136.7,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,23447.08,34,"If Charge > 2,000, then 34 percent",23447.08,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,51032.05,
ST JUDE 5820 ZEPHYR DR PACEMAKER,C1785,HCPCS,,79002930,CDM,275,RC,,,both,,,12542,9281.11,,,9281.11,Other,150% of Medicare + 9.63% HCRA Surcharge,5643.9,45,,5643.9,percent of total billed charges,Critical Access Hospital RCC factor,4264.28,34,,4264.28,percent of total billed charges,Implant Device,4264.28,34,,4264.28,percent of total billed charges,Implant Device,4264.28,34,,4264.28,percent of total billed charges,Implant Device,4264.28,34,,4264.28,percent of total billed charges,Implant Device,4264.28,34,,4264.28,percent of total billed charges,Implant Device,6208.29,,,6208.29,Other,110% of Medicare,4389.7,35,,4389.7,percent of total billed charges,Implant Device,4264.28,34,"Charges > $500, x 34%",4264.28,percent of total billed charges,Implant Device,4389.7,35,,4389.7,percent of total billed charges,Implant Device,4389.7,35,,4389.7,percent of total billed charges,Implant Device,4389.7,35,,4389.7,percent of total billed charges,Implant Device,4389.7,35,,4389.7,percent of total billed charges,Implant Device,4389.7,35,,4389.7,percent of total billed charges,Implant Device,5016.8,40,,5016.8,percent of total billed charges,Implant Device,4389.7,70,,4389.7,percent of total billed charges,All Other,4264.28,34,,4264.28,percent of total billed charges,Implant Device,4264.28,34,,4264.28,percent of total billed charges,Implant Device,4389.7,35,,4389.7,percent of total billed charges,Implant Device,4389.7,35,,4389.7,percent of total billed charges,Implant Device,4389.7,35,,4389.7,percent of total billed charges,Implant Device,4389.7,35,,4389.7,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,4264.28,34,"If Charge > 2,000, then 34 percent",4264.28,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,9281.11,
BIOTRONIK 372419 LUMAX 740 ICD,C1722,HCPCS,,79003041,CDM,275,RC,,,both,,,49590,36696.72,,,36696.72,Other,150% of Medicare + 9.63% HCRA Surcharge,22315.5,45,,22315.5,percent of total billed charges,Critical Access Hospital RCC factor,16860.6,34,,16860.6,percent of total billed charges,Implant Device,16860.6,34,,16860.6,percent of total billed charges,Implant Device,16860.6,34,,16860.6,percent of total billed charges,Implant Device,16860.6,34,,16860.6,percent of total billed charges,Implant Device,16860.6,34,,16860.6,percent of total billed charges,Implant Device,24547.05,,,24547.05,Other,110% of Medicare,17356.5,35,,17356.5,percent of total billed charges,Implant Device,16860.6,34,"Charges > $500, x 34%",16860.6,percent of total billed charges,Implant Device,17356.5,35,,17356.5,percent of total billed charges,Implant Device,17356.5,35,,17356.5,percent of total billed charges,Implant Device,17356.5,35,,17356.5,percent of total billed charges,Implant Device,17356.5,35,,17356.5,percent of total billed charges,Implant Device,17356.5,35,,17356.5,percent of total billed charges,Implant Device,19836,40,,19836,percent of total billed charges,Implant Device,17356.5,70,,17356.5,percent of total billed charges,All Other,16860.6,34,,16860.6,percent of total billed charges,Implant Device,16860.6,34,,16860.6,percent of total billed charges,Implant Device,17356.5,35,,17356.5,percent of total billed charges,Implant Device,17356.5,35,,17356.5,percent of total billed charges,Implant Device,17356.5,35,,17356.5,percent of total billed charges,Implant Device,17356.5,35,,17356.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,16860.6,34,"If Charge > 2,000, then 34 percent",16860.6,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,36696.72,
BIOTRONIK 397193 LUMAX 740 ICD,C1722,HCPCS,,79003042,CDM,275,RC,,,both,,,53266,39416.97,,,39416.97,Other,150% of Medicare + 9.63% HCRA Surcharge,23969.7,45,,23969.7,percent of total billed charges,Critical Access Hospital RCC factor,18110.44,34,,18110.44,percent of total billed charges,Implant Device,18110.44,34,,18110.44,percent of total billed charges,Implant Device,18110.44,34,,18110.44,percent of total billed charges,Implant Device,18110.44,34,,18110.44,percent of total billed charges,Implant Device,18110.44,34,,18110.44,percent of total billed charges,Implant Device,26366.67,,,26366.67,Other,110% of Medicare,18643.1,35,,18643.1,percent of total billed charges,Implant Device,18110.44,34,"Charges > $500, x 34%",18110.44,percent of total billed charges,Implant Device,18643.1,35,,18643.1,percent of total billed charges,Implant Device,18643.1,35,,18643.1,percent of total billed charges,Implant Device,18643.1,35,,18643.1,percent of total billed charges,Implant Device,18643.1,35,,18643.1,percent of total billed charges,Implant Device,18643.1,35,,18643.1,percent of total billed charges,Implant Device,21306.4,40,,21306.4,percent of total billed charges,Implant Device,18643.1,70,,18643.1,percent of total billed charges,All Other,18110.44,34,,18110.44,percent of total billed charges,Implant Device,18110.44,34,,18110.44,percent of total billed charges,Implant Device,18643.1,35,,18643.1,percent of total billed charges,Implant Device,18643.1,35,,18643.1,percent of total billed charges,Implant Device,18643.1,35,,18643.1,percent of total billed charges,Implant Device,18643.1,35,,18643.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,18110.44,34,"If Charge > 2,000, then 34 percent",18110.44,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,39416.97,
ST JUDE MEDICAL 5620 ZEPHYR SR PACEMAKER,C1786,HCPCS,,79003435,CDM,275,RC,,,both,,,10317,7634.61,,,7634.61,Other,150% of Medicare + 9.63% HCRA Surcharge,4642.65,45,,4642.65,percent of total billed charges,Critical Access Hospital RCC factor,3507.78,34,,3507.78,percent of total billed charges,Implant Device,3507.78,34,,3507.78,percent of total billed charges,Implant Device,3507.78,34,,3507.78,percent of total billed charges,Implant Device,3507.78,34,,3507.78,percent of total billed charges,Implant Device,3507.78,34,,3507.78,percent of total billed charges,Implant Device,5106.92,,,5106.92,Other,110% of Medicare,3610.95,35,,3610.95,percent of total billed charges,Implant Device,3507.78,34,"Charges > $500, x 34%",3507.78,percent of total billed charges,Implant Device,3610.95,35,,3610.95,percent of total billed charges,Implant Device,3610.95,35,,3610.95,percent of total billed charges,Implant Device,3610.95,35,,3610.95,percent of total billed charges,Implant Device,3610.95,35,,3610.95,percent of total billed charges,Implant Device,3610.95,35,,3610.95,percent of total billed charges,Implant Device,4126.8,40,,4126.8,percent of total billed charges,Implant Device,3610.95,70,,3610.95,percent of total billed charges,All Other,3507.78,34,,3507.78,percent of total billed charges,Implant Device,3507.78,34,,3507.78,percent of total billed charges,Implant Device,3610.95,35,,3610.95,percent of total billed charges,Implant Device,3610.95,35,,3610.95,percent of total billed charges,Implant Device,3610.95,35,,3610.95,percent of total billed charges,Implant Device,3610.95,35,,3610.95,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3507.78,34,"If Charge > 2,000, then 34 percent",3507.78,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,7634.61,
ST JUDE PM1110 ACCENT SR PACEMAKER,C1786,HCPCS,,79003479,CDM,275,RC,,,both,,,12816,9483.87,,,9483.87,Other,150% of Medicare + 9.63% HCRA Surcharge,5767.2,45,,5767.2,percent of total billed charges,Critical Access Hospital RCC factor,4357.44,34,,4357.44,percent of total billed charges,Implant Device,4357.44,34,,4357.44,percent of total billed charges,Implant Device,4357.44,34,,4357.44,percent of total billed charges,Implant Device,4357.44,34,,4357.44,percent of total billed charges,Implant Device,4357.44,34,,4357.44,percent of total billed charges,Implant Device,6343.92,,,6343.92,Other,110% of Medicare,4485.6,35,,4485.6,percent of total billed charges,Implant Device,4357.44,34,"Charges > $500, x 34%",4357.44,percent of total billed charges,Implant Device,4485.6,35,,4485.6,percent of total billed charges,Implant Device,4485.6,35,,4485.6,percent of total billed charges,Implant Device,4485.6,35,,4485.6,percent of total billed charges,Implant Device,4485.6,35,,4485.6,percent of total billed charges,Implant Device,4485.6,35,,4485.6,percent of total billed charges,Implant Device,5126.4,40,,5126.4,percent of total billed charges,Implant Device,4485.6,70,,4485.6,percent of total billed charges,All Other,4357.44,34,,4357.44,percent of total billed charges,Implant Device,4357.44,34,,4357.44,percent of total billed charges,Implant Device,4485.6,35,,4485.6,percent of total billed charges,Implant Device,4485.6,35,,4485.6,percent of total billed charges,Implant Device,4485.6,35,,4485.6,percent of total billed charges,Implant Device,4485.6,35,,4485.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,4357.44,34,"If Charge > 2,000, then 34 percent",4357.44,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,9483.87,
MEDTRONIC A2DR01 ADVIS DR MRI SURESCAN,C1785,HCPCS,,79005062,CDM,275,RC,,,both,,,17814,13182.4,,,13182.4,Other,150% of Medicare + 9.63% HCRA Surcharge,8016.3,45,,8016.3,percent of total billed charges,Critical Access Hospital RCC factor,6056.76,34,,6056.76,percent of total billed charges,Implant Device,6056.76,34,,6056.76,percent of total billed charges,Implant Device,6056.76,34,,6056.76,percent of total billed charges,Implant Device,6056.76,34,,6056.76,percent of total billed charges,Implant Device,6056.76,34,,6056.76,percent of total billed charges,Implant Device,8817.93,,,8817.93,Other,110% of Medicare,6234.9,35,,6234.9,percent of total billed charges,Implant Device,6056.76,34,"Charges > $500, x 34%",6056.76,percent of total billed charges,Implant Device,6234.9,35,,6234.9,percent of total billed charges,Implant Device,6234.9,35,,6234.9,percent of total billed charges,Implant Device,6234.9,35,,6234.9,percent of total billed charges,Implant Device,6234.9,35,,6234.9,percent of total billed charges,Implant Device,6234.9,35,,6234.9,percent of total billed charges,Implant Device,7125.6,40,,7125.6,percent of total billed charges,Implant Device,6234.9,70,,6234.9,percent of total billed charges,All Other,6056.76,34,,6056.76,percent of total billed charges,Implant Device,6056.76,34,,6056.76,percent of total billed charges,Implant Device,6234.9,35,,6234.9,percent of total billed charges,Implant Device,6234.9,35,,6234.9,percent of total billed charges,Implant Device,6234.9,35,,6234.9,percent of total billed charges,Implant Device,6234.9,35,,6234.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,6056.76,34,"If Charge > 2,000, then 34 percent",6056.76,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,13182.4,
ST JUDE CD2311-36 ELLIPSE DR ICD,C1721,HCPCS,,79005188,CDM,275,RC,,,both,,,52095,38550.43,,,38550.43,Other,150% of Medicare + 9.63% HCRA Surcharge,23442.75,45,,23442.75,percent of total billed charges,Critical Access Hospital RCC factor,17712.3,34,,17712.3,percent of total billed charges,Implant Device,17712.3,34,,17712.3,percent of total billed charges,Implant Device,17712.3,34,,17712.3,percent of total billed charges,Implant Device,17712.3,34,,17712.3,percent of total billed charges,Implant Device,17712.3,34,,17712.3,percent of total billed charges,Implant Device,25787.03,,,25787.03,Other,110% of Medicare,18233.25,35,,18233.25,percent of total billed charges,Implant Device,17712.3,34,"Charges > $500, x 34%",17712.3,percent of total billed charges,Implant Device,18233.25,35,,18233.25,percent of total billed charges,Implant Device,18233.25,35,,18233.25,percent of total billed charges,Implant Device,18233.25,35,,18233.25,percent of total billed charges,Implant Device,18233.25,35,,18233.25,percent of total billed charges,Implant Device,18233.25,35,,18233.25,percent of total billed charges,Implant Device,20838,40,,20838,percent of total billed charges,Implant Device,18233.25,70,,18233.25,percent of total billed charges,All Other,17712.3,34,,17712.3,percent of total billed charges,Implant Device,17712.3,34,,17712.3,percent of total billed charges,Implant Device,18233.25,35,,18233.25,percent of total billed charges,Implant Device,18233.25,35,,18233.25,percent of total billed charges,Implant Device,18233.25,35,,18233.25,percent of total billed charges,Implant Device,18233.25,35,,18233.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,17712.3,34,"If Charge > 2,000, then 34 percent",17712.3,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,38550.43,
ST JUDE 5626 ZEPHYR SR PACEMAKER,C1786,HCPCS,,79005368,CDM,275,RC,,,both,,,12204,9030.99,,,9030.99,Other,150% of Medicare + 9.63% HCRA Surcharge,5491.8,45,,5491.8,percent of total billed charges,Critical Access Hospital RCC factor,4149.36,34,,4149.36,percent of total billed charges,Implant Device,4149.36,34,,4149.36,percent of total billed charges,Implant Device,4149.36,34,,4149.36,percent of total billed charges,Implant Device,4149.36,34,,4149.36,percent of total billed charges,Implant Device,4149.36,34,,4149.36,percent of total billed charges,Implant Device,6040.98,,,6040.98,Other,110% of Medicare,4271.4,35,,4271.4,percent of total billed charges,Implant Device,4149.36,34,"Charges > $500, x 34%",4149.36,percent of total billed charges,Implant Device,4271.4,35,,4271.4,percent of total billed charges,Implant Device,4271.4,35,,4271.4,percent of total billed charges,Implant Device,4271.4,35,,4271.4,percent of total billed charges,Implant Device,4271.4,35,,4271.4,percent of total billed charges,Implant Device,4271.4,35,,4271.4,percent of total billed charges,Implant Device,4881.6,40,,4881.6,percent of total billed charges,Implant Device,4271.4,70,,4271.4,percent of total billed charges,All Other,4149.36,34,,4149.36,percent of total billed charges,Implant Device,4149.36,34,,4149.36,percent of total billed charges,Implant Device,4271.4,35,,4271.4,percent of total billed charges,Implant Device,4271.4,35,,4271.4,percent of total billed charges,Implant Device,4271.4,35,,4271.4,percent of total billed charges,Implant Device,4271.4,35,,4271.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,4149.36,34,"If Charge > 2,000, then 34 percent",4149.36,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,9030.99,
MEDTRONIC DDBB1D1 EVERA XT DR PACEMAKER,C1721,HCPCS,,79005567,CDM,275,RC,,,both,,,69465,51404.27,,,51404.27,Other,150% of Medicare + 9.63% HCRA Surcharge,31259.25,45,,31259.25,percent of total billed charges,Critical Access Hospital RCC factor,23618.1,34,,23618.1,percent of total billed charges,Implant Device,23618.1,34,,23618.1,percent of total billed charges,Implant Device,23618.1,34,,23618.1,percent of total billed charges,Implant Device,23618.1,34,,23618.1,percent of total billed charges,Implant Device,23618.1,34,,23618.1,percent of total billed charges,Implant Device,34385.18,,,34385.18,Other,110% of Medicare,24312.75,35,,24312.75,percent of total billed charges,Implant Device,23618.1,34,"Charges > $500, x 34%",23618.1,percent of total billed charges,Implant Device,24312.75,35,,24312.75,percent of total billed charges,Implant Device,24312.75,35,,24312.75,percent of total billed charges,Implant Device,24312.75,35,,24312.75,percent of total billed charges,Implant Device,24312.75,35,,24312.75,percent of total billed charges,Implant Device,24312.75,35,,24312.75,percent of total billed charges,Implant Device,27786,40,,27786,percent of total billed charges,Implant Device,24312.75,70,,24312.75,percent of total billed charges,All Other,23618.1,34,,23618.1,percent of total billed charges,Implant Device,23618.1,34,,23618.1,percent of total billed charges,Implant Device,24312.75,35,,24312.75,percent of total billed charges,Implant Device,24312.75,35,,24312.75,percent of total billed charges,Implant Device,24312.75,35,,24312.75,percent of total billed charges,Implant Device,24312.75,35,,24312.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,23618.1,34,"If Charge > 2,000, then 34 percent",23618.1,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,51404.27,
MEDTRONIC ADDR01 ADAPTA DR,C1785,HCPCS,,79005568,CDM,275,RC,,,both,,,15768,11668.36,,,11668.36,Other,150% of Medicare + 9.63% HCRA Surcharge,7095.6,45,,7095.6,percent of total billed charges,Critical Access Hospital RCC factor,5361.12,34,,5361.12,percent of total billed charges,Implant Device,5361.12,34,,5361.12,percent of total billed charges,Implant Device,5361.12,34,,5361.12,percent of total billed charges,Implant Device,5361.12,34,,5361.12,percent of total billed charges,Implant Device,5361.12,34,,5361.12,percent of total billed charges,Implant Device,7805.16,,,7805.16,Other,110% of Medicare,5518.8,35,,5518.8,percent of total billed charges,Implant Device,5361.12,34,"Charges > $500, x 34%",5361.12,percent of total billed charges,Implant Device,5518.8,35,,5518.8,percent of total billed charges,Implant Device,5518.8,35,,5518.8,percent of total billed charges,Implant Device,5518.8,35,,5518.8,percent of total billed charges,Implant Device,5518.8,35,,5518.8,percent of total billed charges,Implant Device,5518.8,35,,5518.8,percent of total billed charges,Implant Device,6307.2,40,,6307.2,percent of total billed charges,Implant Device,5518.8,70,,5518.8,percent of total billed charges,All Other,5361.12,34,,5361.12,percent of total billed charges,Implant Device,5361.12,34,,5361.12,percent of total billed charges,Implant Device,5518.8,35,,5518.8,percent of total billed charges,Implant Device,5518.8,35,,5518.8,percent of total billed charges,Implant Device,5518.8,35,,5518.8,percent of total billed charges,Implant Device,5518.8,35,,5518.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,5361.12,34,"If Charge > 2,000, then 34 percent",5361.12,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,11668.36,
MEDTRONIC DVBB1D1 EVERA XT US ICD,C1722,HCPCS,,79005794,CDM,275,RC,,,both,,,59230,43830.35,,,43830.35,Other,150% of Medicare + 9.63% HCRA Surcharge,26653.5,45,,26653.5,percent of total billed charges,Critical Access Hospital RCC factor,20138.2,34,,20138.2,percent of total billed charges,Implant Device,20138.2,34,,20138.2,percent of total billed charges,Implant Device,20138.2,34,,20138.2,percent of total billed charges,Implant Device,20138.2,34,,20138.2,percent of total billed charges,Implant Device,20138.2,34,,20138.2,percent of total billed charges,Implant Device,29318.85,,,29318.85,Other,110% of Medicare,20730.5,35,,20730.5,percent of total billed charges,Implant Device,20138.2,34,"Charges > $500, x 34%",20138.2,percent of total billed charges,Implant Device,20730.5,35,,20730.5,percent of total billed charges,Implant Device,20730.5,35,,20730.5,percent of total billed charges,Implant Device,20730.5,35,,20730.5,percent of total billed charges,Implant Device,20730.5,35,,20730.5,percent of total billed charges,Implant Device,20730.5,35,,20730.5,percent of total billed charges,Implant Device,23692,40,,23692,percent of total billed charges,Implant Device,20730.5,70,,20730.5,percent of total billed charges,All Other,20138.2,34,,20138.2,percent of total billed charges,Implant Device,20138.2,34,,20138.2,percent of total billed charges,Implant Device,20730.5,35,,20730.5,percent of total billed charges,Implant Device,20730.5,35,,20730.5,percent of total billed charges,Implant Device,20730.5,35,,20730.5,percent of total billed charges,Implant Device,20730.5,35,,20730.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,20138.2,34,"If Charge > 2,000, then 34 percent",20138.2,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,43830.35,
MEDTRONIC DTBA1D1 VIVA XT CRTD,C1882,HCPCS,,79005955,CDM,275,RC,,,both,,,79716,58990.04,,,58990.04,Other,150% of Medicare + 9.63% HCRA Surcharge,35872.2,45,,35872.2,percent of total billed charges,Critical Access Hospital RCC factor,27103.44,34,,27103.44,percent of total billed charges,Implant Device,27103.44,34,,27103.44,percent of total billed charges,Implant Device,27103.44,34,,27103.44,percent of total billed charges,Implant Device,27103.44,34,,27103.44,percent of total billed charges,Implant Device,27103.44,34,,27103.44,percent of total billed charges,Implant Device,39459.42,,,39459.42,Other,110% of Medicare,27900.6,35,,27900.6,percent of total billed charges,Implant Device,27103.44,34,"Charges > $500, x 34%",27103.44,percent of total billed charges,Implant Device,27900.6,35,,27900.6,percent of total billed charges,Implant Device,27900.6,35,,27900.6,percent of total billed charges,Implant Device,27900.6,35,,27900.6,percent of total billed charges,Implant Device,27900.6,35,,27900.6,percent of total billed charges,Implant Device,27900.6,35,,27900.6,percent of total billed charges,Implant Device,31886.4,40,,31886.4,percent of total billed charges,Implant Device,27900.6,70,,27900.6,percent of total billed charges,All Other,27103.44,34,,27103.44,percent of total billed charges,Implant Device,27103.44,34,,27103.44,percent of total billed charges,Implant Device,27900.6,35,,27900.6,percent of total billed charges,Implant Device,27900.6,35,,27900.6,percent of total billed charges,Implant Device,27900.6,35,,27900.6,percent of total billed charges,Implant Device,27900.6,35,,27900.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,27103.44,34,"If Charge > 2,000, then 34 percent",27103.44,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,58990.04,
MEDTRONIC DVBB1D4 EVERA XT ICD-VR,C1722,HCPCS,,79006096,CDM,275,RC,,,both,,,59229,43829.61,,,43829.61,Other,150% of Medicare + 9.63% HCRA Surcharge,26653.05,45,,26653.05,percent of total billed charges,Critical Access Hospital RCC factor,20137.86,34,,20137.86,percent of total billed charges,Implant Device,20137.86,34,,20137.86,percent of total billed charges,Implant Device,20137.86,34,,20137.86,percent of total billed charges,Implant Device,20137.86,34,,20137.86,percent of total billed charges,Implant Device,20137.86,34,,20137.86,percent of total billed charges,Implant Device,29318.36,,,29318.36,Other,110% of Medicare,20730.15,35,,20730.15,percent of total billed charges,Implant Device,20137.86,34,"Charges > $500, x 34%",20137.86,percent of total billed charges,Implant Device,20730.15,35,,20730.15,percent of total billed charges,Implant Device,20730.15,35,,20730.15,percent of total billed charges,Implant Device,20730.15,35,,20730.15,percent of total billed charges,Implant Device,20730.15,35,,20730.15,percent of total billed charges,Implant Device,20730.15,35,,20730.15,percent of total billed charges,Implant Device,23691.6,40,,23691.6,percent of total billed charges,Implant Device,20730.15,70,,20730.15,percent of total billed charges,All Other,20137.86,34,,20137.86,percent of total billed charges,Implant Device,20137.86,34,,20137.86,percent of total billed charges,Implant Device,20730.15,35,,20730.15,percent of total billed charges,Implant Device,20730.15,35,,20730.15,percent of total billed charges,Implant Device,20730.15,35,,20730.15,percent of total billed charges,Implant Device,20730.15,35,,20730.15,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,20137.86,34,"If Charge > 2,000, then 34 percent",20137.86,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,43829.61,
MEDTRONIC DTBA1D4 VIVA XT CRTD (4),C1882,HCPCS,,79006628,CDM,275,RC,,,both,,,79716,58990.04,,,58990.04,Other,150% of Medicare + 9.63% HCRA Surcharge,35872.2,45,,35872.2,percent of total billed charges,Critical Access Hospital RCC factor,27103.44,34,,27103.44,percent of total billed charges,Implant Device,27103.44,34,,27103.44,percent of total billed charges,Implant Device,27103.44,34,,27103.44,percent of total billed charges,Implant Device,27103.44,34,,27103.44,percent of total billed charges,Implant Device,27103.44,34,,27103.44,percent of total billed charges,Implant Device,39459.42,,,39459.42,Other,110% of Medicare,27900.6,35,,27900.6,percent of total billed charges,Implant Device,27103.44,34,"Charges > $500, x 34%",27103.44,percent of total billed charges,Implant Device,27900.6,35,,27900.6,percent of total billed charges,Implant Device,27900.6,35,,27900.6,percent of total billed charges,Implant Device,27900.6,35,,27900.6,percent of total billed charges,Implant Device,27900.6,35,,27900.6,percent of total billed charges,Implant Device,27900.6,35,,27900.6,percent of total billed charges,Implant Device,31886.4,40,,31886.4,percent of total billed charges,Implant Device,27900.6,70,,27900.6,percent of total billed charges,All Other,27103.44,34,,27103.44,percent of total billed charges,Implant Device,27103.44,34,,27103.44,percent of total billed charges,Implant Device,27900.6,35,,27900.6,percent of total billed charges,Implant Device,27900.6,35,,27900.6,percent of total billed charges,Implant Device,27900.6,35,,27900.6,percent of total billed charges,Implant Device,27900.6,35,,27900.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,27103.44,34,"If Charge > 2,000, then 34 percent",27103.44,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,58990.04,
ST JUDE PM2240 ASSURITY PACEMAKER,C1785,HCPCS,,79006723,CDM,275,RC,,,both,,,12300,9102.03,,,9102.03,Other,150% of Medicare + 9.63% HCRA Surcharge,5535,45,,5535,percent of total billed charges,Critical Access Hospital RCC factor,4182,34,,4182,percent of total billed charges,Implant Device,4182,34,,4182,percent of total billed charges,Implant Device,4182,34,,4182,percent of total billed charges,Implant Device,4182,34,,4182,percent of total billed charges,Implant Device,4182,34,,4182,percent of total billed charges,Implant Device,6088.5,,,6088.5,Other,110% of Medicare,4305,35,,4305,percent of total billed charges,Implant Device,4182,34,"Charges > $500, x 34%",4182,percent of total billed charges,Implant Device,4305,35,,4305,percent of total billed charges,Implant Device,4305,35,,4305,percent of total billed charges,Implant Device,4305,35,,4305,percent of total billed charges,Implant Device,4305,35,,4305,percent of total billed charges,Implant Device,4305,35,,4305,percent of total billed charges,Implant Device,4920,40,,4920,percent of total billed charges,Implant Device,4305,70,,4305,percent of total billed charges,All Other,4182,34,,4182,percent of total billed charges,Implant Device,4182,34,,4182,percent of total billed charges,Implant Device,4305,35,,4305,percent of total billed charges,Implant Device,4305,35,,4305,percent of total billed charges,Implant Device,4305,35,,4305,percent of total billed charges,Implant Device,4305,35,,4305,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,4182,34,"If Charge > 2,000, then 34 percent",4182,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,9102.03,
ST JUDE PM1240 ASSURITY PACEMAKER,C1786,HCPCS,,79006724,CDM,275,RC,,,both,,,12962,9591.91,,,9591.91,Other,150% of Medicare + 9.63% HCRA Surcharge,5832.9,45,,5832.9,percent of total billed charges,Critical Access Hospital RCC factor,4407.08,34,,4407.08,percent of total billed charges,Implant Device,4407.08,34,,4407.08,percent of total billed charges,Implant Device,4407.08,34,,4407.08,percent of total billed charges,Implant Device,4407.08,34,,4407.08,percent of total billed charges,Implant Device,4407.08,34,,4407.08,percent of total billed charges,Implant Device,6416.19,,,6416.19,Other,110% of Medicare,4536.7,35,,4536.7,percent of total billed charges,Implant Device,4407.08,34,"Charges > $500, x 34%",4407.08,percent of total billed charges,Implant Device,4536.7,35,,4536.7,percent of total billed charges,Implant Device,4536.7,35,,4536.7,percent of total billed charges,Implant Device,4536.7,35,,4536.7,percent of total billed charges,Implant Device,4536.7,35,,4536.7,percent of total billed charges,Implant Device,4536.7,35,,4536.7,percent of total billed charges,Implant Device,5184.8,40,,5184.8,percent of total billed charges,Implant Device,4536.7,70,,4536.7,percent of total billed charges,All Other,4407.08,34,,4407.08,percent of total billed charges,Implant Device,4407.08,34,,4407.08,percent of total billed charges,Implant Device,4536.7,35,,4536.7,percent of total billed charges,Implant Device,4536.7,35,,4536.7,percent of total billed charges,Implant Device,4536.7,35,,4536.7,percent of total billed charges,Implant Device,4536.7,35,,4536.7,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,4407.08,34,"If Charge > 2,000, then 34 percent",4407.08,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,9591.91,
ST JUDE CD1357-40C FORTIFY ASSURA,C1722,HCPCS,,79007118,CDM,275,RC,,,both,,,48936,36212.76,,,36212.76,Other,150% of Medicare + 9.63% HCRA Surcharge,22021.2,45,,22021.2,percent of total billed charges,Critical Access Hospital RCC factor,16638.24,34,,16638.24,percent of total billed charges,Implant Device,16638.24,34,,16638.24,percent of total billed charges,Implant Device,16638.24,34,,16638.24,percent of total billed charges,Implant Device,16638.24,34,,16638.24,percent of total billed charges,Implant Device,16638.24,34,,16638.24,percent of total billed charges,Implant Device,24223.32,,,24223.32,Other,110% of Medicare,17127.6,35,,17127.6,percent of total billed charges,Implant Device,16638.24,34,"Charges > $500, x 34%",16638.24,percent of total billed charges,Implant Device,17127.6,35,,17127.6,percent of total billed charges,Implant Device,17127.6,35,,17127.6,percent of total billed charges,Implant Device,17127.6,35,,17127.6,percent of total billed charges,Implant Device,17127.6,35,,17127.6,percent of total billed charges,Implant Device,17127.6,35,,17127.6,percent of total billed charges,Implant Device,19574.4,40,,19574.4,percent of total billed charges,Implant Device,17127.6,70,,17127.6,percent of total billed charges,All Other,16638.24,34,,16638.24,percent of total billed charges,Implant Device,16638.24,34,,16638.24,percent of total billed charges,Implant Device,17127.6,35,,17127.6,percent of total billed charges,Implant Device,17127.6,35,,17127.6,percent of total billed charges,Implant Device,17127.6,35,,17127.6,percent of total billed charges,Implant Device,17127.6,35,,17127.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,16638.24,34,"If Charge > 2,000, then 34 percent",16638.24,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,36212.76,
MEDTRONIC DTBA1QQ VIVA QUAD XT CRT-D,C1882,HCPCS,,79007181,CDM,275,RC,,,both,,,79716,58990.04,,,58990.04,Other,150% of Medicare + 9.63% HCRA Surcharge,35872.2,45,,35872.2,percent of total billed charges,Critical Access Hospital RCC factor,27103.44,34,,27103.44,percent of total billed charges,Implant Device,27103.44,34,,27103.44,percent of total billed charges,Implant Device,27103.44,34,,27103.44,percent of total billed charges,Implant Device,27103.44,34,,27103.44,percent of total billed charges,Implant Device,27103.44,34,,27103.44,percent of total billed charges,Implant Device,39459.42,,,39459.42,Other,110% of Medicare,27900.6,35,,27900.6,percent of total billed charges,Implant Device,27103.44,34,"Charges > $500, x 34%",27103.44,percent of total billed charges,Implant Device,27900.6,35,,27900.6,percent of total billed charges,Implant Device,27900.6,35,,27900.6,percent of total billed charges,Implant Device,27900.6,35,,27900.6,percent of total billed charges,Implant Device,27900.6,35,,27900.6,percent of total billed charges,Implant Device,27900.6,35,,27900.6,percent of total billed charges,Implant Device,31886.4,40,,31886.4,percent of total billed charges,Implant Device,27900.6,70,,27900.6,percent of total billed charges,All Other,27103.44,34,,27103.44,percent of total billed charges,Implant Device,27103.44,34,,27103.44,percent of total billed charges,Implant Device,27900.6,35,,27900.6,percent of total billed charges,Implant Device,27900.6,35,,27900.6,percent of total billed charges,Implant Device,27900.6,35,,27900.6,percent of total billed charges,Implant Device,27900.6,35,,27900.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,27103.44,34,"If Charge > 2,000, then 34 percent",27103.44,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,58990.04,
MEDTRONIC DTBB1Q1 VIVA QUAD S CRT-D,C1882,HCPCS,,79007182,CDM,275,RC,,,both,,,77916,57658.03,,,57658.03,Other,150% of Medicare + 9.63% HCRA Surcharge,35062.2,45,,35062.2,percent of total billed charges,Critical Access Hospital RCC factor,26491.44,34,,26491.44,percent of total billed charges,Implant Device,26491.44,34,,26491.44,percent of total billed charges,Implant Device,26491.44,34,,26491.44,percent of total billed charges,Implant Device,26491.44,34,,26491.44,percent of total billed charges,Implant Device,26491.44,34,,26491.44,percent of total billed charges,Implant Device,38568.42,,,38568.42,Other,110% of Medicare,27270.6,35,,27270.6,percent of total billed charges,Implant Device,26491.44,34,"Charges > $500, x 34%",26491.44,percent of total billed charges,Implant Device,27270.6,35,,27270.6,percent of total billed charges,Implant Device,27270.6,35,,27270.6,percent of total billed charges,Implant Device,27270.6,35,,27270.6,percent of total billed charges,Implant Device,27270.6,35,,27270.6,percent of total billed charges,Implant Device,27270.6,35,,27270.6,percent of total billed charges,Implant Device,31166.4,40,,31166.4,percent of total billed charges,Implant Device,27270.6,70,,27270.6,percent of total billed charges,All Other,26491.44,34,,26491.44,percent of total billed charges,Implant Device,26491.44,34,,26491.44,percent of total billed charges,Implant Device,27270.6,35,,27270.6,percent of total billed charges,Implant Device,27270.6,35,,27270.6,percent of total billed charges,Implant Device,27270.6,35,,27270.6,percent of total billed charges,Implant Device,27270.6,35,,27270.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,26491.44,34,"If Charge > 2,000, then 34 percent",26491.44,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,57658.03,
MEDTRONIC DTBB1QQ VIVA QUAD S CRT-D,C1882,HCPCS,,79007183,CDM,275,RC,,,both,,,77916,57658.03,,,57658.03,Other,150% of Medicare + 9.63% HCRA Surcharge,35062.2,45,,35062.2,percent of total billed charges,Critical Access Hospital RCC factor,26491.44,34,,26491.44,percent of total billed charges,Implant Device,26491.44,34,,26491.44,percent of total billed charges,Implant Device,26491.44,34,,26491.44,percent of total billed charges,Implant Device,26491.44,34,,26491.44,percent of total billed charges,Implant Device,26491.44,34,,26491.44,percent of total billed charges,Implant Device,38568.42,,,38568.42,Other,110% of Medicare,27270.6,35,,27270.6,percent of total billed charges,Implant Device,26491.44,34,"Charges > $500, x 34%",26491.44,percent of total billed charges,Implant Device,27270.6,35,,27270.6,percent of total billed charges,Implant Device,27270.6,35,,27270.6,percent of total billed charges,Implant Device,27270.6,35,,27270.6,percent of total billed charges,Implant Device,27270.6,35,,27270.6,percent of total billed charges,Implant Device,27270.6,35,,27270.6,percent of total billed charges,Implant Device,31166.4,40,,31166.4,percent of total billed charges,Implant Device,27270.6,70,,27270.6,percent of total billed charges,All Other,26491.44,34,,26491.44,percent of total billed charges,Implant Device,26491.44,34,,26491.44,percent of total billed charges,Implant Device,27270.6,35,,27270.6,percent of total billed charges,Implant Device,27270.6,35,,27270.6,percent of total billed charges,Implant Device,27270.6,35,,27270.6,percent of total billed charges,Implant Device,27270.6,35,,27270.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,26491.44,34,"If Charge > 2,000, then 34 percent",26491.44,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,57658.03,
ST JUDE CD3357-40C UNIFY ASSURA ICD,C1882,HCPCS,,79007328,CDM,275,RC,,,both,,,57867,42821.72,,,42821.72,Other,150% of Medicare + 9.63% HCRA Surcharge,26040.15,45,,26040.15,percent of total billed charges,Critical Access Hospital RCC factor,19674.78,34,,19674.78,percent of total billed charges,Implant Device,19674.78,34,,19674.78,percent of total billed charges,Implant Device,19674.78,34,,19674.78,percent of total billed charges,Implant Device,19674.78,34,,19674.78,percent of total billed charges,Implant Device,19674.78,34,,19674.78,percent of total billed charges,Implant Device,28644.17,,,28644.17,Other,110% of Medicare,20253.45,35,,20253.45,percent of total billed charges,Implant Device,19674.78,34,"Charges > $500, x 34%",19674.78,percent of total billed charges,Implant Device,20253.45,35,,20253.45,percent of total billed charges,Implant Device,20253.45,35,,20253.45,percent of total billed charges,Implant Device,20253.45,35,,20253.45,percent of total billed charges,Implant Device,20253.45,35,,20253.45,percent of total billed charges,Implant Device,20253.45,35,,20253.45,percent of total billed charges,Implant Device,23146.8,40,,23146.8,percent of total billed charges,Implant Device,20253.45,70,,20253.45,percent of total billed charges,All Other,19674.78,34,,19674.78,percent of total billed charges,Implant Device,19674.78,34,,19674.78,percent of total billed charges,Implant Device,20253.45,35,,20253.45,percent of total billed charges,Implant Device,20253.45,35,,20253.45,percent of total billed charges,Implant Device,20253.45,35,,20253.45,percent of total billed charges,Implant Device,20253.45,35,,20253.45,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,19674.78,34,"If Charge > 2,000, then 34 percent",19674.78,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,42821.72,
MEDTRONIC C4TR01 CRT PACEMAKER CONSULTA,C2621,HCPCS,,79007333,CDM,275,RC,,,both,,,26544,19642.63,,,19642.63,Other,150% of Medicare + 9.63% HCRA Surcharge,11944.8,45,,11944.8,percent of total billed charges,Critical Access Hospital RCC factor,9024.96,34,,9024.96,percent of total billed charges,Implant Device,9024.96,34,,9024.96,percent of total billed charges,Implant Device,9024.96,34,,9024.96,percent of total billed charges,Implant Device,9024.96,34,,9024.96,percent of total billed charges,Implant Device,9024.96,34,,9024.96,percent of total billed charges,Implant Device,13139.28,,,13139.28,Other,110% of Medicare,9290.4,35,,9290.4,percent of total billed charges,Implant Device,9024.96,34,"Charges > $500, x 34%",9024.96,percent of total billed charges,Implant Device,9290.4,35,,9290.4,percent of total billed charges,Implant Device,9290.4,35,,9290.4,percent of total billed charges,Implant Device,9290.4,35,,9290.4,percent of total billed charges,Implant Device,9290.4,35,,9290.4,percent of total billed charges,Implant Device,9290.4,35,,9290.4,percent of total billed charges,Implant Device,10617.6,40,,10617.6,percent of total billed charges,Implant Device,9290.4,70,,9290.4,percent of total billed charges,All Other,9024.96,34,,9024.96,percent of total billed charges,Implant Device,9024.96,34,,9024.96,percent of total billed charges,Implant Device,9290.4,35,,9290.4,percent of total billed charges,Implant Device,9290.4,35,,9290.4,percent of total billed charges,Implant Device,9290.4,35,,9290.4,percent of total billed charges,Implant Device,9290.4,35,,9290.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,9024.96,34,"If Charge > 2,000, then 34 percent",9024.96,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,19642.63,
ST JUDE CD1411-36Q ELLIPSE VR SINGL ICD,C1722,HCPCS,,79007504,CDM,275,RC,,,both,,,44228,32728.83,,,32728.83,Other,150% of Medicare + 9.63% HCRA Surcharge,19902.6,45,,19902.6,percent of total billed charges,Critical Access Hospital RCC factor,15037.52,34,,15037.52,percent of total billed charges,Implant Device,15037.52,34,,15037.52,percent of total billed charges,Implant Device,15037.52,34,,15037.52,percent of total billed charges,Implant Device,15037.52,34,,15037.52,percent of total billed charges,Implant Device,15037.52,34,,15037.52,percent of total billed charges,Implant Device,21892.86,,,21892.86,Other,110% of Medicare,15479.8,35,,15479.8,percent of total billed charges,Implant Device,15037.52,34,"Charges > $500, x 34%",15037.52,percent of total billed charges,Implant Device,15479.8,35,,15479.8,percent of total billed charges,Implant Device,15479.8,35,,15479.8,percent of total billed charges,Implant Device,15479.8,35,,15479.8,percent of total billed charges,Implant Device,15479.8,35,,15479.8,percent of total billed charges,Implant Device,15479.8,35,,15479.8,percent of total billed charges,Implant Device,17691.2,40,,17691.2,percent of total billed charges,Implant Device,15479.8,70,,15479.8,percent of total billed charges,All Other,15037.52,34,,15037.52,percent of total billed charges,Implant Device,15037.52,34,,15037.52,percent of total billed charges,Implant Device,15479.8,35,,15479.8,percent of total billed charges,Implant Device,15479.8,35,,15479.8,percent of total billed charges,Implant Device,15479.8,35,,15479.8,percent of total billed charges,Implant Device,15479.8,35,,15479.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,15037.52,34,"If Charge > 2,000, then 34 percent",15037.52,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,32728.83,
BIOTRONIK 394969 ELUNA 8 DR-T PACEMAKER,C1785,HCPCS,,79007544,CDM,275,RC,,,both,,,18450,13653.05,,,13653.05,Other,150% of Medicare + 9.63% HCRA Surcharge,8302.5,45,,8302.5,percent of total billed charges,Critical Access Hospital RCC factor,6273,34,,6273,percent of total billed charges,Implant Device,6273,34,,6273,percent of total billed charges,Implant Device,6273,34,,6273,percent of total billed charges,Implant Device,6273,34,,6273,percent of total billed charges,Implant Device,6273,34,,6273,percent of total billed charges,Implant Device,9132.75,,,9132.75,Other,110% of Medicare,6457.5,35,,6457.5,percent of total billed charges,Implant Device,6273,34,"Charges > $500, x 34%",6273,percent of total billed charges,Implant Device,6457.5,35,,6457.5,percent of total billed charges,Implant Device,6457.5,35,,6457.5,percent of total billed charges,Implant Device,6457.5,35,,6457.5,percent of total billed charges,Implant Device,6457.5,35,,6457.5,percent of total billed charges,Implant Device,6457.5,35,,6457.5,percent of total billed charges,Implant Device,7380,40,,7380,percent of total billed charges,Implant Device,6457.5,70,,6457.5,percent of total billed charges,All Other,6273,34,,6273,percent of total billed charges,Implant Device,6273,34,,6273,percent of total billed charges,Implant Device,6457.5,35,,6457.5,percent of total billed charges,Implant Device,6457.5,35,,6457.5,percent of total billed charges,Implant Device,6457.5,35,,6457.5,percent of total billed charges,Implant Device,6457.5,35,,6457.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,6273,34,"If Charge > 2,000, then 34 percent",6273,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,13653.05,
ST JUDE CD2357-40C FORTIFY ASSURA DR 40,C1721,HCPCS,,79007701,CDM,275,RC,,,both,,,46444,34368.68,,,34368.68,Other,150% of Medicare + 9.63% HCRA Surcharge,20899.8,45,,20899.8,percent of total billed charges,Critical Access Hospital RCC factor,15790.96,34,,15790.96,percent of total billed charges,Implant Device,15790.96,34,,15790.96,percent of total billed charges,Implant Device,15790.96,34,,15790.96,percent of total billed charges,Implant Device,15790.96,34,,15790.96,percent of total billed charges,Implant Device,15790.96,34,,15790.96,percent of total billed charges,Implant Device,22989.78,,,22989.78,Other,110% of Medicare,16255.4,35,,16255.4,percent of total billed charges,Implant Device,15790.96,34,"Charges > $500, x 34%",15790.96,percent of total billed charges,Implant Device,16255.4,35,,16255.4,percent of total billed charges,Implant Device,16255.4,35,,16255.4,percent of total billed charges,Implant Device,16255.4,35,,16255.4,percent of total billed charges,Implant Device,16255.4,35,,16255.4,percent of total billed charges,Implant Device,16255.4,35,,16255.4,percent of total billed charges,Implant Device,18577.6,40,,18577.6,percent of total billed charges,Implant Device,16255.4,70,,16255.4,percent of total billed charges,All Other,15790.96,34,,15790.96,percent of total billed charges,Implant Device,15790.96,34,,15790.96,percent of total billed charges,Implant Device,16255.4,35,,16255.4,percent of total billed charges,Implant Device,16255.4,35,,16255.4,percent of total billed charges,Implant Device,16255.4,35,,16255.4,percent of total billed charges,Implant Device,16255.4,35,,16255.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,15790.96,34,"If Charge > 2,000, then 34 percent",15790.96,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,34368.68,
ST JUDE CD3357-40Q UNIFY ASSURA,C1882,HCPCS,,79007941,CDM,275,RC,,,both,,,60634,44869.31,,,44869.31,Other,150% of Medicare + 9.63% HCRA Surcharge,27285.3,45,,27285.3,percent of total billed charges,Critical Access Hospital RCC factor,20615.56,34,,20615.56,percent of total billed charges,Implant Device,20615.56,34,,20615.56,percent of total billed charges,Implant Device,20615.56,34,,20615.56,percent of total billed charges,Implant Device,20615.56,34,,20615.56,percent of total billed charges,Implant Device,20615.56,34,,20615.56,percent of total billed charges,Implant Device,30013.83,,,30013.83,Other,110% of Medicare,21221.9,35,,21221.9,percent of total billed charges,Implant Device,20615.56,34,"Charges > $500, x 34%",20615.56,percent of total billed charges,Implant Device,21221.9,35,,21221.9,percent of total billed charges,Implant Device,21221.9,35,,21221.9,percent of total billed charges,Implant Device,21221.9,35,,21221.9,percent of total billed charges,Implant Device,21221.9,35,,21221.9,percent of total billed charges,Implant Device,21221.9,35,,21221.9,percent of total billed charges,Implant Device,24253.6,40,,24253.6,percent of total billed charges,Implant Device,21221.9,70,,21221.9,percent of total billed charges,All Other,20615.56,34,,20615.56,percent of total billed charges,Implant Device,20615.56,34,,20615.56,percent of total billed charges,Implant Device,21221.9,35,,21221.9,percent of total billed charges,Implant Device,21221.9,35,,21221.9,percent of total billed charges,Implant Device,21221.9,35,,21221.9,percent of total billed charges,Implant Device,21221.9,35,,21221.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,20615.56,34,"If Charge > 2,000, then 34 percent",20615.56,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,44869.31,
BIOTRONIK 399436 INVENTRA 7  VR-T  DX,C1722,HCPCS,,79008214,CDM,275,RC,,,both,,,60342,44653.23,,,44653.23,Other,150% of Medicare + 9.63% HCRA Surcharge,27153.9,45,,27153.9,percent of total billed charges,Critical Access Hospital RCC factor,20516.28,34,,20516.28,percent of total billed charges,Implant Device,20516.28,34,,20516.28,percent of total billed charges,Implant Device,20516.28,34,,20516.28,percent of total billed charges,Implant Device,20516.28,34,,20516.28,percent of total billed charges,Implant Device,20516.28,34,,20516.28,percent of total billed charges,Implant Device,29869.29,,,29869.29,Other,110% of Medicare,21119.7,35,,21119.7,percent of total billed charges,Implant Device,20516.28,34,"Charges > $500, x 34%",20516.28,percent of total billed charges,Implant Device,21119.7,35,,21119.7,percent of total billed charges,Implant Device,21119.7,35,,21119.7,percent of total billed charges,Implant Device,21119.7,35,,21119.7,percent of total billed charges,Implant Device,21119.7,35,,21119.7,percent of total billed charges,Implant Device,21119.7,35,,21119.7,percent of total billed charges,Implant Device,24136.8,40,,24136.8,percent of total billed charges,Implant Device,21119.7,70,,21119.7,percent of total billed charges,All Other,20516.28,34,,20516.28,percent of total billed charges,Implant Device,20516.28,34,,20516.28,percent of total billed charges,Implant Device,21119.7,35,,21119.7,percent of total billed charges,Implant Device,21119.7,35,,21119.7,percent of total billed charges,Implant Device,21119.7,35,,21119.7,percent of total billed charges,Implant Device,21119.7,35,,21119.7,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,20516.28,34,"If Charge > 2,000, then 34 percent",20516.28,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,44653.23,
ST JUDE CD2411-36C ELLIPSE DR ICD,C1721,HCPCS,,79008215,CDM,275,RC,,,both,,,45372,33575.39,,,33575.39,Other,150% of Medicare + 9.63% HCRA Surcharge,20417.4,45,,20417.4,percent of total billed charges,Critical Access Hospital RCC factor,15426.48,34,,15426.48,percent of total billed charges,Implant Device,15426.48,34,,15426.48,percent of total billed charges,Implant Device,15426.48,34,,15426.48,percent of total billed charges,Implant Device,15426.48,34,,15426.48,percent of total billed charges,Implant Device,15426.48,34,,15426.48,percent of total billed charges,Implant Device,22459.14,,,22459.14,Other,110% of Medicare,15880.2,35,,15880.2,percent of total billed charges,Implant Device,15426.48,34,"Charges > $500, x 34%",15426.48,percent of total billed charges,Implant Device,15880.2,35,,15880.2,percent of total billed charges,Implant Device,15880.2,35,,15880.2,percent of total billed charges,Implant Device,15880.2,35,,15880.2,percent of total billed charges,Implant Device,15880.2,35,,15880.2,percent of total billed charges,Implant Device,15880.2,35,,15880.2,percent of total billed charges,Implant Device,18148.8,40,,18148.8,percent of total billed charges,Implant Device,15880.2,70,,15880.2,percent of total billed charges,All Other,15426.48,34,,15426.48,percent of total billed charges,Implant Device,15426.48,34,,15426.48,percent of total billed charges,Implant Device,15880.2,35,,15880.2,percent of total billed charges,Implant Device,15880.2,35,,15880.2,percent of total billed charges,Implant Device,15880.2,35,,15880.2,percent of total billed charges,Implant Device,15880.2,35,,15880.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,15426.48,34,"If Charge > 2,000, then 34 percent",15426.48,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,33575.39,
BIOTRONIK 393032 IPERIA  VR-T DX DF-1,C1722,HCPCS,,79008220,CDM,275,RC,,,both,,,58945,43619.45,,,43619.45,Other,150% of Medicare + 9.63% HCRA Surcharge,26525.25,45,,26525.25,percent of total billed charges,Critical Access Hospital RCC factor,20041.3,34,,20041.3,percent of total billed charges,Implant Device,20041.3,34,,20041.3,percent of total billed charges,Implant Device,20041.3,34,,20041.3,percent of total billed charges,Implant Device,20041.3,34,,20041.3,percent of total billed charges,Implant Device,20041.3,34,,20041.3,percent of total billed charges,Implant Device,29177.78,,,29177.78,Other,110% of Medicare,20630.75,35,,20630.75,percent of total billed charges,Implant Device,20041.3,34,"Charges > $500, x 34%",20041.3,percent of total billed charges,Implant Device,20630.75,35,,20630.75,percent of total billed charges,Implant Device,20630.75,35,,20630.75,percent of total billed charges,Implant Device,20630.75,35,,20630.75,percent of total billed charges,Implant Device,20630.75,35,,20630.75,percent of total billed charges,Implant Device,20630.75,35,,20630.75,percent of total billed charges,Implant Device,23578,40,,23578,percent of total billed charges,Implant Device,20630.75,70,,20630.75,percent of total billed charges,All Other,20041.3,34,,20041.3,percent of total billed charges,Implant Device,20041.3,34,,20041.3,percent of total billed charges,Implant Device,20630.75,35,,20630.75,percent of total billed charges,Implant Device,20630.75,35,,20630.75,percent of total billed charges,Implant Device,20630.75,35,,20630.75,percent of total billed charges,Implant Device,20630.75,35,,20630.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,20041.3,34,"If Charge > 2,000, then 34 percent",20041.3,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,43619.45,
MEDTRONIC A3SR01 ADVISA SR MRI,C1786,HCPCS,,79008296,CDM,275,RC,,,both,,,13827,10232.01,,,10232.01,Other,150% of Medicare + 9.63% HCRA Surcharge,6222.15,45,,6222.15,percent of total billed charges,Critical Access Hospital RCC factor,4701.18,34,,4701.18,percent of total billed charges,Implant Device,4701.18,34,,4701.18,percent of total billed charges,Implant Device,4701.18,34,,4701.18,percent of total billed charges,Implant Device,4701.18,34,,4701.18,percent of total billed charges,Implant Device,4701.18,34,,4701.18,percent of total billed charges,Implant Device,6844.37,,,6844.37,Other,110% of Medicare,4839.45,35,,4839.45,percent of total billed charges,Implant Device,4701.18,34,"Charges > $500, x 34%",4701.18,percent of total billed charges,Implant Device,4839.45,35,,4839.45,percent of total billed charges,Implant Device,4839.45,35,,4839.45,percent of total billed charges,Implant Device,4839.45,35,,4839.45,percent of total billed charges,Implant Device,4839.45,35,,4839.45,percent of total billed charges,Implant Device,4839.45,35,,4839.45,percent of total billed charges,Implant Device,5530.8,40,,5530.8,percent of total billed charges,Implant Device,4839.45,70,,4839.45,percent of total billed charges,All Other,4701.18,34,,4701.18,percent of total billed charges,Implant Device,4701.18,34,,4701.18,percent of total billed charges,Implant Device,4839.45,35,,4839.45,percent of total billed charges,Implant Device,4839.45,35,,4839.45,percent of total billed charges,Implant Device,4839.45,35,,4839.45,percent of total billed charges,Implant Device,4839.45,35,,4839.45,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,4701.18,34,"If Charge > 2,000, then 34 percent",4701.18,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,10232.01,
MEDTRONIC VEDR01 VERSA PACEMAKER,C1785,HCPCS,,79008986,CDM,275,RC,,,both,,,10545,7803.33,,,7803.33,Other,150% of Medicare + 9.63% HCRA Surcharge,4745.25,45,,4745.25,percent of total billed charges,Critical Access Hospital RCC factor,3585.3,34,,3585.3,percent of total billed charges,Implant Device,3585.3,34,,3585.3,percent of total billed charges,Implant Device,3585.3,34,,3585.3,percent of total billed charges,Implant Device,3585.3,34,,3585.3,percent of total billed charges,Implant Device,3585.3,34,,3585.3,percent of total billed charges,Implant Device,5219.78,,,5219.78,Other,110% of Medicare,3690.75,35,,3690.75,percent of total billed charges,Implant Device,3585.3,34,"Charges > $500, x 34%",3585.3,percent of total billed charges,Implant Device,3690.75,35,,3690.75,percent of total billed charges,Implant Device,3690.75,35,,3690.75,percent of total billed charges,Implant Device,3690.75,35,,3690.75,percent of total billed charges,Implant Device,3690.75,35,,3690.75,percent of total billed charges,Implant Device,3690.75,35,,3690.75,percent of total billed charges,Implant Device,4218,40,,4218,percent of total billed charges,Implant Device,3690.75,70,,3690.75,percent of total billed charges,All Other,3585.3,34,,3585.3,percent of total billed charges,Implant Device,3585.3,34,,3585.3,percent of total billed charges,Implant Device,3690.75,35,,3690.75,percent of total billed charges,Implant Device,3690.75,35,,3690.75,percent of total billed charges,Implant Device,3690.75,35,,3690.75,percent of total billed charges,Implant Device,3690.75,35,,3690.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3585.3,34,"If Charge > 2,000, then 34 percent",3585.3,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,7803.33,
ST JUDE PM1272 ASSURITY MRI PACEMAKER,C1786,HCPCS,,79009206,CDM,275,RC,,,both,,,14462,10701.92,,,10701.92,Other,150% of Medicare + 9.63% HCRA Surcharge,6507.9,45,,6507.9,percent of total billed charges,Critical Access Hospital RCC factor,4917.08,34,,4917.08,percent of total billed charges,Implant Device,4917.08,34,,4917.08,percent of total billed charges,Implant Device,4917.08,34,,4917.08,percent of total billed charges,Implant Device,4917.08,34,,4917.08,percent of total billed charges,Implant Device,4917.08,34,,4917.08,percent of total billed charges,Implant Device,7158.69,,,7158.69,Other,110% of Medicare,5061.7,35,,5061.7,percent of total billed charges,Implant Device,4917.08,34,"Charges > $500, x 34%",4917.08,percent of total billed charges,Implant Device,5061.7,35,,5061.7,percent of total billed charges,Implant Device,5061.7,35,,5061.7,percent of total billed charges,Implant Device,5061.7,35,,5061.7,percent of total billed charges,Implant Device,5061.7,35,,5061.7,percent of total billed charges,Implant Device,5061.7,35,,5061.7,percent of total billed charges,Implant Device,5784.8,40,,5784.8,percent of total billed charges,Implant Device,5061.7,70,,5061.7,percent of total billed charges,All Other,4917.08,34,,4917.08,percent of total billed charges,Implant Device,4917.08,34,,4917.08,percent of total billed charges,Implant Device,5061.7,35,,5061.7,percent of total billed charges,Implant Device,5061.7,35,,5061.7,percent of total billed charges,Implant Device,5061.7,35,,5061.7,percent of total billed charges,Implant Device,5061.7,35,,5061.7,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,4917.08,34,"If Charge > 2,000, then 34 percent",4917.08,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,10701.92,
ST JUDE PM2272 ASSURITY MRI PACEMAKER,C1786,HCPCS,,79009455,CDM,275,RC,,,both,,,16800,12432.04,,,12432.04,Other,150% of Medicare + 9.63% HCRA Surcharge,7560,45,,7560,percent of total billed charges,Critical Access Hospital RCC factor,5712,34,,5712,percent of total billed charges,Implant Device,5712,34,,5712,percent of total billed charges,Implant Device,5712,34,,5712,percent of total billed charges,Implant Device,5712,34,,5712,percent of total billed charges,Implant Device,5712,34,,5712,percent of total billed charges,Implant Device,8316,,,8316,Other,110% of Medicare,5880,35,,5880,percent of total billed charges,Implant Device,5712,34,"Charges > $500, x 34%",5712,percent of total billed charges,Implant Device,5880,35,,5880,percent of total billed charges,Implant Device,5880,35,,5880,percent of total billed charges,Implant Device,5880,35,,5880,percent of total billed charges,Implant Device,5880,35,,5880,percent of total billed charges,Implant Device,5880,35,,5880,percent of total billed charges,Implant Device,6720,40,,6720,percent of total billed charges,Implant Device,5880,70,,5880,percent of total billed charges,All Other,5712,34,,5712,percent of total billed charges,Implant Device,5712,34,,5712,percent of total billed charges,Implant Device,5880,35,,5880,percent of total billed charges,Implant Device,5880,35,,5880,percent of total billed charges,Implant Device,5880,35,,5880,percent of total billed charges,Implant Device,5880,35,,5880,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,5712,34,"If Charge > 2,000, then 34 percent",5712,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,12432.04,
BIOTRONIK 377177 SOLIA S 53 PACING LEAD,C1898,HCPCS,,79009646,CDM,275,RC,,,both,,,1950,1443,,,1443,Other,150% of Medicare + 9.63% HCRA Surcharge,877.5,45,,877.5,percent of total billed charges,Critical Access Hospital RCC factor,663,34,,663,percent of total billed charges,Implant Device,663,34,,663,percent of total billed charges,Implant Device,663,34,,663,percent of total billed charges,Implant Device,663,34,,663,percent of total billed charges,Implant Device,663,34,,663,percent of total billed charges,Implant Device,965.25,,,965.25,Other,110% of Medicare,682.5,35,,682.5,percent of total billed charges,Implant Device,663,34,"Charges > $500, x 34%",663,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,780,40,,780,percent of total billed charges,Implant Device,682.5,70,,682.5,percent of total billed charges,All Other,663,34,,663,percent of total billed charges,Implant Device,663,34,,663,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1443,
BIOTRONIK 407157 EDORA 8 SR-T PACEMAKER,C1785,HCPCS,,79009647,CDM,275,RC,,,both,,,20456,15137.49,,,15137.49,Other,150% of Medicare + 9.63% HCRA Surcharge,9205.2,45,,9205.2,percent of total billed charges,Critical Access Hospital RCC factor,6955.04,34,,6955.04,percent of total billed charges,Implant Device,6955.04,34,,6955.04,percent of total billed charges,Implant Device,6955.04,34,,6955.04,percent of total billed charges,Implant Device,6955.04,34,,6955.04,percent of total billed charges,Implant Device,6955.04,34,,6955.04,percent of total billed charges,Implant Device,10125.72,,,10125.72,Other,110% of Medicare,7159.6,35,,7159.6,percent of total billed charges,Implant Device,6955.04,34,"Charges > $500, x 34%",6955.04,percent of total billed charges,Implant Device,7159.6,35,,7159.6,percent of total billed charges,Implant Device,7159.6,35,,7159.6,percent of total billed charges,Implant Device,7159.6,35,,7159.6,percent of total billed charges,Implant Device,7159.6,35,,7159.6,percent of total billed charges,Implant Device,7159.6,35,,7159.6,percent of total billed charges,Implant Device,8182.4,40,,8182.4,percent of total billed charges,Implant Device,7159.6,70,,7159.6,percent of total billed charges,All Other,6955.04,34,,6955.04,percent of total billed charges,Implant Device,6955.04,34,,6955.04,percent of total billed charges,Implant Device,7159.6,35,,7159.6,percent of total billed charges,Implant Device,7159.6,35,,7159.6,percent of total billed charges,Implant Device,7159.6,35,,7159.6,percent of total billed charges,Implant Device,7159.6,35,,7159.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,6955.04,34,"If Charge > 2,000, then 34 percent",6955.04,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,15137.49,
BIOTRONIK 407145 EDORA 8 DR-T PACEMAKER,C1785,HCPCS,,79009648,CDM,275,RC,,,both,,,15300,11322.04,,,11322.04,Other,150% of Medicare + 9.63% HCRA Surcharge,6885,45,,6885,percent of total billed charges,Critical Access Hospital RCC factor,5202,34,,5202,percent of total billed charges,Implant Device,5202,34,,5202,percent of total billed charges,Implant Device,5202,34,,5202,percent of total billed charges,Implant Device,5202,34,,5202,percent of total billed charges,Implant Device,5202,34,,5202,percent of total billed charges,Implant Device,7573.5,,,7573.5,Other,110% of Medicare,5355,35,,5355,percent of total billed charges,Implant Device,5202,34,"Charges > $500, x 34%",5202,percent of total billed charges,Implant Device,5355,35,,5355,percent of total billed charges,Implant Device,5355,35,,5355,percent of total billed charges,Implant Device,5355,35,,5355,percent of total billed charges,Implant Device,5355,35,,5355,percent of total billed charges,Implant Device,5355,35,,5355,percent of total billed charges,Implant Device,6120,40,,6120,percent of total billed charges,Implant Device,5355,70,,5355,percent of total billed charges,All Other,5202,34,,5202,percent of total billed charges,Implant Device,5202,34,,5202,percent of total billed charges,Implant Device,5355,35,,5355,percent of total billed charges,Implant Device,5355,35,,5355,percent of total billed charges,Implant Device,5355,35,,5355,percent of total billed charges,Implant Device,5355,35,,5355,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,5202,34,"If Charge > 2,000, then 34 percent",5202,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,11322.04,
MEDTRONIC W1DR01 DR MRI SURESCAN,C1785,HCPCS,,79010746,CDM,275,RC,,,both,,,19614,14514.41,,,14514.41,Other,150% of Medicare + 9.63% HCRA Surcharge,8826.3,45,,8826.3,percent of total billed charges,Critical Access Hospital RCC factor,6668.76,34,,6668.76,percent of total billed charges,Implant Device,6668.76,34,,6668.76,percent of total billed charges,Implant Device,6668.76,34,,6668.76,percent of total billed charges,Implant Device,6668.76,34,,6668.76,percent of total billed charges,Implant Device,6668.76,34,,6668.76,percent of total billed charges,Implant Device,9708.93,,,9708.93,Other,110% of Medicare,6864.9,35,,6864.9,percent of total billed charges,Implant Device,6668.76,34,"Charges > $500, x 34%",6668.76,percent of total billed charges,Implant Device,6864.9,35,,6864.9,percent of total billed charges,Implant Device,6864.9,35,,6864.9,percent of total billed charges,Implant Device,6864.9,35,,6864.9,percent of total billed charges,Implant Device,6864.9,35,,6864.9,percent of total billed charges,Implant Device,6864.9,35,,6864.9,percent of total billed charges,Implant Device,7845.6,40,,7845.6,percent of total billed charges,Implant Device,6864.9,70,,6864.9,percent of total billed charges,All Other,6668.76,34,,6668.76,percent of total billed charges,Implant Device,6668.76,34,,6668.76,percent of total billed charges,Implant Device,6864.9,35,,6864.9,percent of total billed charges,Implant Device,6864.9,35,,6864.9,percent of total billed charges,Implant Device,6864.9,35,,6864.9,percent of total billed charges,Implant Device,6864.9,35,,6864.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,6668.76,34,"If Charge > 2,000, then 34 percent",6668.76,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,14514.41,
BIOTRONIK 377179 SOLIA S 60 LEAD,C1898,HCPCS,,79010765,CDM,275,RC,,,both,,,1950,1443,,,1443,Other,150% of Medicare + 9.63% HCRA Surcharge,877.5,45,,877.5,percent of total billed charges,Critical Access Hospital RCC factor,663,34,,663,percent of total billed charges,Implant Device,663,34,,663,percent of total billed charges,Implant Device,663,34,,663,percent of total billed charges,Implant Device,663,34,,663,percent of total billed charges,Implant Device,663,34,,663,percent of total billed charges,Implant Device,965.25,,,965.25,Other,110% of Medicare,682.5,35,,682.5,percent of total billed charges,Implant Device,663,34,"Charges > $500, x 34%",663,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,780,40,,780,percent of total billed charges,Implant Device,682.5,70,,682.5,percent of total billed charges,All Other,663,34,,663,percent of total billed charges,Implant Device,663,34,,663,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1443,
BOST SCI M365SC12320 PULSE GENERATOR KIT,C1721,HCPCS,,79011850,CDM,275,RC,,,both,,,51000,37740.13,,,37740.13,Other,150% of Medicare + 9.63% HCRA Surcharge,22950,45,,22950,percent of total billed charges,Critical Access Hospital RCC factor,17340,34,,17340,percent of total billed charges,Implant Device,17340,34,,17340,percent of total billed charges,Implant Device,17340,34,,17340,percent of total billed charges,Implant Device,17340,34,,17340,percent of total billed charges,Implant Device,17340,34,,17340,percent of total billed charges,Implant Device,25245,,,25245,Other,110% of Medicare,17850,35,,17850,percent of total billed charges,Implant Device,17340,34,"Charges > $500, x 34%",17340,percent of total billed charges,Implant Device,17850,35,,17850,percent of total billed charges,Implant Device,17850,35,,17850,percent of total billed charges,Implant Device,17850,35,,17850,percent of total billed charges,Implant Device,17850,35,,17850,percent of total billed charges,Implant Device,17850,35,,17850,percent of total billed charges,Implant Device,20400,40,,20400,percent of total billed charges,Implant Device,17850,70,,17850,percent of total billed charges,All Other,17340,34,,17340,percent of total billed charges,Implant Device,17340,34,,17340,percent of total billed charges,Implant Device,17850,35,,17850,percent of total billed charges,Implant Device,17850,35,,17850,percent of total billed charges,Implant Device,17850,35,,17850,percent of total billed charges,Implant Device,17850,35,,17850,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,17340,34,"If Charge > 2,000, then 34 percent",17340,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,37740.13,
MEDTRONIC DVFB1D1 VISIA AF MRI SURESCAN,C1722,HCPCS,,79012139,CDM,275,RC,,,both,,,33000,24420.08,,,24420.08,Other,150% of Medicare + 9.63% HCRA Surcharge,14850,45,,14850,percent of total billed charges,Critical Access Hospital RCC factor,11220,34,,11220,percent of total billed charges,Implant Device,11220,34,,11220,percent of total billed charges,Implant Device,11220,34,,11220,percent of total billed charges,Implant Device,11220,34,,11220,percent of total billed charges,Implant Device,11220,34,,11220,percent of total billed charges,Implant Device,16335,,,16335,Other,110% of Medicare,11550,35,,11550,percent of total billed charges,Implant Device,11220,34,"Charges > $500, x 34%",11220,percent of total billed charges,Implant Device,11550,35,,11550,percent of total billed charges,Implant Device,11550,35,,11550,percent of total billed charges,Implant Device,11550,35,,11550,percent of total billed charges,Implant Device,11550,35,,11550,percent of total billed charges,Implant Device,11550,35,,11550,percent of total billed charges,Implant Device,13200,40,,13200,percent of total billed charges,Implant Device,11550,70,,11550,percent of total billed charges,All Other,11220,34,,11220,percent of total billed charges,Implant Device,11220,34,,11220,percent of total billed charges,Implant Device,11550,35,,11550,percent of total billed charges,Implant Device,11550,35,,11550,percent of total billed charges,Implant Device,11550,35,,11550,percent of total billed charges,Implant Device,11550,35,,11550,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,11220,34,"If Charge > 2,000, then 34 percent",11220,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,24420.08,
BOST SCI A219 EMBLEM MRI S-ICD,C1722,HCPCS,,79012160,CDM,275,RC,,,both,,,99000,73260.25,,,73260.25,Other,150% of Medicare + 9.63% HCRA Surcharge,44550,45,,44550,percent of total billed charges,Critical Access Hospital RCC factor,33660,34,,33660,percent of total billed charges,Implant Device,33660,34,,33660,percent of total billed charges,Implant Device,33660,34,,33660,percent of total billed charges,Implant Device,33660,34,,33660,percent of total billed charges,Implant Device,33660,34,,33660,percent of total billed charges,Implant Device,49005,,,49005,Other,110% of Medicare,34650,35,,34650,percent of total billed charges,Implant Device,33660,34,"Charges > $500, x 34%",33660,percent of total billed charges,Implant Device,34650,35,,34650,percent of total billed charges,Implant Device,34650,35,,34650,percent of total billed charges,Implant Device,34650,35,,34650,percent of total billed charges,Implant Device,34650,35,,34650,percent of total billed charges,Implant Device,34650,35,,34650,percent of total billed charges,Implant Device,39600,40,,39600,percent of total billed charges,Implant Device,34650,70,,34650,percent of total billed charges,All Other,33660,34,,33660,percent of total billed charges,Implant Device,33660,34,,33660,percent of total billed charges,Implant Device,34650,35,,34650,percent of total billed charges,Implant Device,34650,35,,34650,percent of total billed charges,Implant Device,34650,35,,34650,percent of total billed charges,Implant Device,34650,35,,34650,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,33660,34,"If Charge > 2,000, then 34 percent",33660,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,73260.25,
BOST SCI 3501 EMBLEM S-ICD ELECTRODE 45,C1896,HCPCS,,79012161,CDM,275,RC,,,both,,,18000,13320.05,,,13320.05,Other,150% of Medicare + 9.63% HCRA Surcharge,8100,45,,8100,percent of total billed charges,Critical Access Hospital RCC factor,6120,34,,6120,percent of total billed charges,Implant Device,6120,34,,6120,percent of total billed charges,Implant Device,6120,34,,6120,percent of total billed charges,Implant Device,6120,34,,6120,percent of total billed charges,Implant Device,6120,34,,6120,percent of total billed charges,Implant Device,8910,,,8910,Other,110% of Medicare,6300,35,,6300,percent of total billed charges,Implant Device,6120,34,"Charges > $500, x 34%",6120,percent of total billed charges,Implant Device,6300,35,,6300,percent of total billed charges,Implant Device,6300,35,,6300,percent of total billed charges,Implant Device,6300,35,,6300,percent of total billed charges,Implant Device,6300,35,,6300,percent of total billed charges,Implant Device,6300,35,,6300,percent of total billed charges,Implant Device,7200,40,,7200,percent of total billed charges,Implant Device,6300,70,,6300,percent of total billed charges,All Other,6120,34,,6120,percent of total billed charges,Implant Device,6120,34,,6120,percent of total billed charges,Implant Device,6300,35,,6300,percent of total billed charges,Implant Device,6300,35,,6300,percent of total billed charges,Implant Device,6300,35,,6300,percent of total billed charges,Implant Device,6300,35,,6300,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,6120,34,"If Charge > 2,000, then 34 percent",6120,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,13320.05,
BIOTRONIK 429525 ACTICOR 7 VR-T AICD MRI,C1722,HCPCS,,79012235,CDM,275,RC,,,both,,,48177,35651.1,,,35651.1,Other,150% of Medicare + 9.63% HCRA Surcharge,21679.65,45,,21679.65,percent of total billed charges,Critical Access Hospital RCC factor,16380.18,34,,16380.18,percent of total billed charges,Implant Device,16380.18,34,,16380.18,percent of total billed charges,Implant Device,16380.18,34,,16380.18,percent of total billed charges,Implant Device,16380.18,34,,16380.18,percent of total billed charges,Implant Device,16380.18,34,,16380.18,percent of total billed charges,Implant Device,23847.62,,,23847.62,Other,110% of Medicare,16861.95,35,,16861.95,percent of total billed charges,Implant Device,16380.18,34,"Charges > $500, x 34%",16380.18,percent of total billed charges,Implant Device,16861.95,35,,16861.95,percent of total billed charges,Implant Device,16861.95,35,,16861.95,percent of total billed charges,Implant Device,16861.95,35,,16861.95,percent of total billed charges,Implant Device,16861.95,35,,16861.95,percent of total billed charges,Implant Device,16861.95,35,,16861.95,percent of total billed charges,Implant Device,19270.8,40,,19270.8,percent of total billed charges,Implant Device,16861.95,70,,16861.95,percent of total billed charges,All Other,16380.18,34,,16380.18,percent of total billed charges,Implant Device,16380.18,34,,16380.18,percent of total billed charges,Implant Device,16861.95,35,,16861.95,percent of total billed charges,Implant Device,16861.95,35,,16861.95,percent of total billed charges,Implant Device,16861.95,35,,16861.95,percent of total billed charges,Implant Device,16861.95,35,,16861.95,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,16380.18,34,"If Charge > 2,000, then 34 percent",16380.18,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,35651.1,
BIOTRONIK 436909 PLEXA PROMRI S DX 65/15,C1777,HCPCS,,79012236,CDM,275,RC,,,both,,,10800,7992.03,,,7992.03,Other,150% of Medicare + 9.63% HCRA Surcharge,4860,45,,4860,percent of total billed charges,Critical Access Hospital RCC factor,3672,34,,3672,percent of total billed charges,Implant Device,3672,34,,3672,percent of total billed charges,Implant Device,3672,34,,3672,percent of total billed charges,Implant Device,3672,34,,3672,percent of total billed charges,Implant Device,3672,34,,3672,percent of total billed charges,Implant Device,5346,,,5346,Other,110% of Medicare,3780,35,,3780,percent of total billed charges,Implant Device,3672,34,"Charges > $500, x 34%",3672,percent of total billed charges,Implant Device,3780,35,,3780,percent of total billed charges,Implant Device,3780,35,,3780,percent of total billed charges,Implant Device,3780,35,,3780,percent of total billed charges,Implant Device,3780,35,,3780,percent of total billed charges,Implant Device,3780,35,,3780,percent of total billed charges,Implant Device,4320,40,,4320,percent of total billed charges,Implant Device,3780,70,,3780,percent of total billed charges,All Other,3672,34,,3672,percent of total billed charges,Implant Device,3672,34,,3672,percent of total billed charges,Implant Device,3780,35,,3780,percent of total billed charges,Implant Device,3780,35,,3780,percent of total billed charges,Implant Device,3780,35,,3780,percent of total billed charges,Implant Device,3780,35,,3780,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3672,34,"If Charge > 2,000, then 34 percent",3672,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,7992.03,
ABBOTT CDDRA500Q GALLANT DR,C1721,HCPCS,,79012263,CDM,275,RC,,,both,,,54654,40444.1,,,40444.1,Other,150% of Medicare + 9.63% HCRA Surcharge,24594.3,45,,24594.3,percent of total billed charges,Critical Access Hospital RCC factor,18582.36,34,,18582.36,percent of total billed charges,Implant Device,18582.36,34,,18582.36,percent of total billed charges,Implant Device,18582.36,34,,18582.36,percent of total billed charges,Implant Device,18582.36,34,,18582.36,percent of total billed charges,Implant Device,18582.36,34,,18582.36,percent of total billed charges,Implant Device,27053.73,,,27053.73,Other,110% of Medicare,19128.9,35,,19128.9,percent of total billed charges,Implant Device,18582.36,34,"Charges > $500, x 34%",18582.36,percent of total billed charges,Implant Device,19128.9,35,,19128.9,percent of total billed charges,Implant Device,19128.9,35,,19128.9,percent of total billed charges,Implant Device,19128.9,35,,19128.9,percent of total billed charges,Implant Device,19128.9,35,,19128.9,percent of total billed charges,Implant Device,19128.9,35,,19128.9,percent of total billed charges,Implant Device,21861.6,40,,21861.6,percent of total billed charges,Implant Device,19128.9,70,,19128.9,percent of total billed charges,All Other,18582.36,34,,18582.36,percent of total billed charges,Implant Device,18582.36,34,,18582.36,percent of total billed charges,Implant Device,19128.9,35,,19128.9,percent of total billed charges,Implant Device,19128.9,35,,19128.9,percent of total billed charges,Implant Device,19128.9,35,,19128.9,percent of total billed charges,Implant Device,19128.9,35,,19128.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,18582.36,34,"If Charge > 2,000, then 34 percent",18582.36,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,40444.1,
"MEDTRONIC DTMA1D1 CLARIA ,RI CRTD US DF1",C1722,HCPCS,,79012365,CDM,275,RC,,,both,,,57003,42182.36,,,42182.36,Other,150% of Medicare + 9.63% HCRA Surcharge,25651.35,45,,25651.35,percent of total billed charges,Critical Access Hospital RCC factor,19381.02,34,,19381.02,percent of total billed charges,Implant Device,19381.02,34,,19381.02,percent of total billed charges,Implant Device,19381.02,34,,19381.02,percent of total billed charges,Implant Device,19381.02,34,,19381.02,percent of total billed charges,Implant Device,19381.02,34,,19381.02,percent of total billed charges,Implant Device,28216.49,,,28216.49,Other,110% of Medicare,19951.05,35,,19951.05,percent of total billed charges,Implant Device,19381.02,34,"Charges > $500, x 34%",19381.02,percent of total billed charges,Implant Device,19951.05,35,,19951.05,percent of total billed charges,Implant Device,19951.05,35,,19951.05,percent of total billed charges,Implant Device,19951.05,35,,19951.05,percent of total billed charges,Implant Device,19951.05,35,,19951.05,percent of total billed charges,Implant Device,19951.05,35,,19951.05,percent of total billed charges,Implant Device,22801.2,40,,22801.2,percent of total billed charges,Implant Device,19951.05,70,,19951.05,percent of total billed charges,All Other,19381.02,34,,19381.02,percent of total billed charges,Implant Device,19381.02,34,,19381.02,percent of total billed charges,Implant Device,19951.05,35,,19951.05,percent of total billed charges,Implant Device,19951.05,35,,19951.05,percent of total billed charges,Implant Device,19951.05,35,,19951.05,percent of total billed charges,Implant Device,19951.05,35,,19951.05,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,19381.02,34,"If Charge > 2,000, then 34 percent",19381.02,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,42182.36,
BIOTRONIK 429534 RIVACOR 7 DR-T AICD,C1721,HCPCS,,79012416,CDM,275,RC,,,both,,,50028,37020.85,,,37020.85,Other,150% of Medicare + 9.63% HCRA Surcharge,22512.6,45,,22512.6,percent of total billed charges,Critical Access Hospital RCC factor,17009.52,34,,17009.52,percent of total billed charges,Implant Device,17009.52,34,,17009.52,percent of total billed charges,Implant Device,17009.52,34,,17009.52,percent of total billed charges,Implant Device,17009.52,34,,17009.52,percent of total billed charges,Implant Device,17009.52,34,,17009.52,percent of total billed charges,Implant Device,24763.86,,,24763.86,Other,110% of Medicare,17509.8,35,,17509.8,percent of total billed charges,Implant Device,17009.52,34,"Charges > $500, x 34%",17009.52,percent of total billed charges,Implant Device,17509.8,35,,17509.8,percent of total billed charges,Implant Device,17509.8,35,,17509.8,percent of total billed charges,Implant Device,17509.8,35,,17509.8,percent of total billed charges,Implant Device,17509.8,35,,17509.8,percent of total billed charges,Implant Device,17509.8,35,,17509.8,percent of total billed charges,Implant Device,20011.2,40,,20011.2,percent of total billed charges,Implant Device,17509.8,70,,17509.8,percent of total billed charges,All Other,17009.52,34,,17009.52,percent of total billed charges,Implant Device,17009.52,34,,17009.52,percent of total billed charges,Implant Device,17509.8,35,,17509.8,percent of total billed charges,Implant Device,17509.8,35,,17509.8,percent of total billed charges,Implant Device,17509.8,35,,17509.8,percent of total billed charges,Implant Device,17509.8,35,,17509.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,17009.52,34,"If Charge > 2,000, then 34 percent",17009.52,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,37020.85,
BIOTRONIK 402266 PLEXA PROMRI S 65,C1777,HCPCS,,79012419,CDM,275,RC,,,both,,,10800,7992.03,,,7992.03,Other,150% of Medicare + 9.63% HCRA Surcharge,4860,45,,4860,percent of total billed charges,Critical Access Hospital RCC factor,3672,34,,3672,percent of total billed charges,Implant Device,3672,34,,3672,percent of total billed charges,Implant Device,3672,34,,3672,percent of total billed charges,Implant Device,3672,34,,3672,percent of total billed charges,Implant Device,3672,34,,3672,percent of total billed charges,Implant Device,5346,,,5346,Other,110% of Medicare,3780,35,,3780,percent of total billed charges,Implant Device,3672,34,"Charges > $500, x 34%",3672,percent of total billed charges,Implant Device,3780,35,,3780,percent of total billed charges,Implant Device,3780,35,,3780,percent of total billed charges,Implant Device,3780,35,,3780,percent of total billed charges,Implant Device,3780,35,,3780,percent of total billed charges,Implant Device,3780,35,,3780,percent of total billed charges,Implant Device,4320,40,,4320,percent of total billed charges,Implant Device,3780,70,,3780,percent of total billed charges,All Other,3672,34,,3672,percent of total billed charges,Implant Device,3672,34,,3672,percent of total billed charges,Implant Device,3780,35,,3780,percent of total billed charges,Implant Device,3780,35,,3780,percent of total billed charges,Implant Device,3780,35,,3780,percent of total billed charges,Implant Device,3780,35,,3780,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3672,34,"If Charge > 2,000, then 34 percent",3672,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,7992.03,
ABBOTT CDHFA500Q GALLANT HF,C1721,HCPCS,,79012498,CDM,275,RC,,,both,,,80478,59553.92,,,59553.92,Other,150% of Medicare + 9.63% HCRA Surcharge,36215.1,45,,36215.1,percent of total billed charges,Critical Access Hospital RCC factor,27362.52,34,,27362.52,percent of total billed charges,Implant Device,27362.52,34,,27362.52,percent of total billed charges,Implant Device,27362.52,34,,27362.52,percent of total billed charges,Implant Device,27362.52,34,,27362.52,percent of total billed charges,Implant Device,27362.52,34,,27362.52,percent of total billed charges,Implant Device,39836.61,,,39836.61,Other,110% of Medicare,28167.3,35,,28167.3,percent of total billed charges,Implant Device,27362.52,34,"Charges > $500, x 34%",27362.52,percent of total billed charges,Implant Device,28167.3,35,,28167.3,percent of total billed charges,Implant Device,28167.3,35,,28167.3,percent of total billed charges,Implant Device,28167.3,35,,28167.3,percent of total billed charges,Implant Device,28167.3,35,,28167.3,percent of total billed charges,Implant Device,28167.3,35,,28167.3,percent of total billed charges,Implant Device,32191.2,40,,32191.2,percent of total billed charges,Implant Device,28167.3,70,,28167.3,percent of total billed charges,All Other,27362.52,34,,27362.52,percent of total billed charges,Implant Device,27362.52,34,,27362.52,percent of total billed charges,Implant Device,28167.3,35,,28167.3,percent of total billed charges,Implant Device,28167.3,35,,28167.3,percent of total billed charges,Implant Device,28167.3,35,,28167.3,percent of total billed charges,Implant Device,28167.3,35,,28167.3,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,27362.52,34,"If Charge > 2,000, then 34 percent",27362.52,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,59553.92,
ABBOTT CD3369-40Q QUADRA ASSURA,C1882,HCPCS,,79012648,CDM,275,RC,,,both,,,69378,51339.89,,,51339.89,Other,150% of Medicare + 9.63% HCRA Surcharge,31220.1,45,,31220.1,percent of total billed charges,Critical Access Hospital RCC factor,23588.52,34,,23588.52,percent of total billed charges,Implant Device,23588.52,34,,23588.52,percent of total billed charges,Implant Device,23588.52,34,,23588.52,percent of total billed charges,Implant Device,23588.52,34,,23588.52,percent of total billed charges,Implant Device,23588.52,34,,23588.52,percent of total billed charges,Implant Device,34342.11,,,34342.11,Other,110% of Medicare,24282.3,35,,24282.3,percent of total billed charges,Implant Device,23588.52,34,"Charges > $500, x 34%",23588.52,percent of total billed charges,Implant Device,24282.3,35,,24282.3,percent of total billed charges,Implant Device,24282.3,35,,24282.3,percent of total billed charges,Implant Device,24282.3,35,,24282.3,percent of total billed charges,Implant Device,24282.3,35,,24282.3,percent of total billed charges,Implant Device,24282.3,35,,24282.3,percent of total billed charges,Implant Device,27751.2,40,,27751.2,percent of total billed charges,Implant Device,24282.3,70,,24282.3,percent of total billed charges,All Other,23588.52,34,,23588.52,percent of total billed charges,Implant Device,23588.52,34,,23588.52,percent of total billed charges,Implant Device,24282.3,35,,24282.3,percent of total billed charges,Implant Device,24282.3,35,,24282.3,percent of total billed charges,Implant Device,24282.3,35,,24282.3,percent of total billed charges,Implant Device,24282.3,35,,24282.3,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,23588.52,34,"If Charge > 2,000, then 34 percent",23588.52,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,51339.89,
MEDTRONIC RNA015062G AZURE XT SR MRI,C1777,HCPCS,,79012805,CDM,275,RC,,,both,,,11007,8145.21,,,8145.21,Other,150% of Medicare + 9.63% HCRA Surcharge,4953.15,45,,4953.15,percent of total billed charges,Critical Access Hospital RCC factor,3742.38,34,,3742.38,percent of total billed charges,Implant Device,3742.38,34,,3742.38,percent of total billed charges,Implant Device,3742.38,34,,3742.38,percent of total billed charges,Implant Device,3742.38,34,,3742.38,percent of total billed charges,Implant Device,3742.38,34,,3742.38,percent of total billed charges,Implant Device,5448.47,,,5448.47,Other,110% of Medicare,3852.45,35,,3852.45,percent of total billed charges,Implant Device,3742.38,34,"Charges > $500, x 34%",3742.38,percent of total billed charges,Implant Device,3852.45,35,,3852.45,percent of total billed charges,Implant Device,3852.45,35,,3852.45,percent of total billed charges,Implant Device,3852.45,35,,3852.45,percent of total billed charges,Implant Device,3852.45,35,,3852.45,percent of total billed charges,Implant Device,3852.45,35,,3852.45,percent of total billed charges,Implant Device,4402.8,40,,4402.8,percent of total billed charges,Implant Device,3852.45,70,,3852.45,percent of total billed charges,All Other,3742.38,34,,3742.38,percent of total billed charges,Implant Device,3742.38,34,,3742.38,percent of total billed charges,Implant Device,3852.45,35,,3852.45,percent of total billed charges,Implant Device,3852.45,35,,3852.45,percent of total billed charges,Implant Device,3852.45,35,,3852.45,percent of total billed charges,Implant Device,3852.45,35,,3852.45,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3742.38,34,"If Charge > 2,000, then 34 percent",3742.38,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,8145.21,
MEDTRONIC DVPA2D4 XT VR MRI SURESCAN,C1722,HCPCS,,79013837,CDM,275,RC,,,both,,,52332,38725.81,,,38725.81,Other,150% of Medicare + 9.63% HCRA Surcharge,23549.4,45,,23549.4,percent of total billed charges,Critical Access Hospital RCC factor,17792.88,34,,17792.88,percent of total billed charges,Implant Device,17792.88,34,,17792.88,percent of total billed charges,Implant Device,17792.88,34,,17792.88,percent of total billed charges,Implant Device,17792.88,34,,17792.88,percent of total billed charges,Implant Device,17792.88,34,,17792.88,percent of total billed charges,Implant Device,25904.34,,,25904.34,Other,110% of Medicare,18316.2,35,,18316.2,percent of total billed charges,Implant Device,17792.88,34,"Charges > $500, x 34%",17792.88,percent of total billed charges,Implant Device,18316.2,35,,18316.2,percent of total billed charges,Implant Device,18316.2,35,,18316.2,percent of total billed charges,Implant Device,18316.2,35,,18316.2,percent of total billed charges,Implant Device,18316.2,35,,18316.2,percent of total billed charges,Implant Device,18316.2,35,,18316.2,percent of total billed charges,Implant Device,20932.8,40,,20932.8,percent of total billed charges,Implant Device,18316.2,70,,18316.2,percent of total billed charges,All Other,17792.88,34,,17792.88,percent of total billed charges,Implant Device,17792.88,34,,17792.88,percent of total billed charges,Implant Device,18316.2,35,,18316.2,percent of total billed charges,Implant Device,18316.2,35,,18316.2,percent of total billed charges,Implant Device,18316.2,35,,18316.2,percent of total billed charges,Implant Device,18316.2,35,,18316.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,17792.88,34,"If Charge > 2,000, then 34 percent",17792.88,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,38725.81,
BREAST MARKER MAMMOMARK 11G,A4648,HCPCS,,79000016,CDM,278,RC,,,both,,,206,152.44,,,152.44,Other,150% of Medicare + 9.63% HCRA Surcharge,92.7,45,,92.7,percent of total billed charges,Critical Access Hospital RCC factor,70.04,34,,70.04,percent of total billed charges,Implant Device,70.04,34,,70.04,percent of total billed charges,Implant Device,70.04,34,,70.04,percent of total billed charges,Implant Device,70.04,34,,70.04,percent of total billed charges,Implant Device,70.04,34,,70.04,percent of total billed charges,Implant Device,101.97,,,101.97,Other,110% of Medicare,72.1,35,,72.1,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,72.1,35,,72.1,percent of total billed charges,Implant Device,72.1,35,,72.1,percent of total billed charges,Implant Device,72.1,35,,72.1,percent of total billed charges,Implant Device,72.1,35,,72.1,percent of total billed charges,Implant Device,72.1,35,,72.1,percent of total billed charges,Implant Device,82.4,40,,82.4,percent of total billed charges,Implant Device,72.1,70,,72.1,percent of total billed charges,All Other,70.04,34,,70.04,percent of total billed charges,Implant Device,70.04,34,,70.04,percent of total billed charges,Implant Device,72.1,35,,72.1,percent of total billed charges,Implant Device,72.1,35,,72.1,percent of total billed charges,Implant Device,72.1,35,,72.1,percent of total billed charges,Implant Device,72.1,35,,72.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,152.44,
DEVICOR8G MAMMOMARK BREAST MARKER,A4648,HCPCS,,79000019,CDM,278,RC,,,both,,,206,152.44,,,152.44,Other,150% of Medicare + 9.63% HCRA Surcharge,92.7,45,,92.7,percent of total billed charges,Critical Access Hospital RCC factor,70.04,34,,70.04,percent of total billed charges,Implant Device,70.04,34,,70.04,percent of total billed charges,Implant Device,70.04,34,,70.04,percent of total billed charges,Implant Device,70.04,34,,70.04,percent of total billed charges,Implant Device,70.04,34,,70.04,percent of total billed charges,Implant Device,101.97,,,101.97,Other,110% of Medicare,72.1,35,,72.1,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,72.1,35,,72.1,percent of total billed charges,Implant Device,72.1,35,,72.1,percent of total billed charges,Implant Device,72.1,35,,72.1,percent of total billed charges,Implant Device,72.1,35,,72.1,percent of total billed charges,Implant Device,72.1,35,,72.1,percent of total billed charges,Implant Device,82.4,40,,82.4,percent of total billed charges,Implant Device,72.1,70,,72.1,percent of total billed charges,All Other,70.04,34,,70.04,percent of total billed charges,Implant Device,70.04,34,,70.04,percent of total billed charges,Implant Device,72.1,35,,72.1,percent of total billed charges,Implant Device,72.1,35,,72.1,percent of total billed charges,Implant Device,72.1,35,,72.1,percent of total billed charges,Implant Device,72.1,35,,72.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,152.44,
DEVICOR MAM3002 MAMMO MARK 2ND SITE,A4648,HCPCS,,79000021,CDM,278,RC,,,both,,,206,152.44,,,152.44,Other,150% of Medicare + 9.63% HCRA Surcharge,92.7,45,,92.7,percent of total billed charges,Critical Access Hospital RCC factor,70.04,34,,70.04,percent of total billed charges,Implant Device,70.04,34,,70.04,percent of total billed charges,Implant Device,70.04,34,,70.04,percent of total billed charges,Implant Device,70.04,34,,70.04,percent of total billed charges,Implant Device,70.04,34,,70.04,percent of total billed charges,Implant Device,101.97,,,101.97,Other,110% of Medicare,72.1,35,,72.1,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,72.1,35,,72.1,percent of total billed charges,Implant Device,72.1,35,,72.1,percent of total billed charges,Implant Device,72.1,35,,72.1,percent of total billed charges,Implant Device,72.1,35,,72.1,percent of total billed charges,Implant Device,72.1,35,,72.1,percent of total billed charges,Implant Device,82.4,40,,82.4,percent of total billed charges,Implant Device,72.1,70,,72.1,percent of total billed charges,All Other,70.04,34,,70.04,percent of total billed charges,Implant Device,70.04,34,,70.04,percent of total billed charges,Implant Device,72.1,35,,72.1,percent of total billed charges,Implant Device,72.1,35,,72.1,percent of total billed charges,Implant Device,72.1,35,,72.1,percent of total billed charges,Implant Device,72.1,35,,72.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,152.44,
BREAST MARKER MAMMOMARK 11G,A4648,HCPCS,,79000027,CDM,278,RC,,,both,,,227,167.98,,,167.98,Other,150% of Medicare + 9.63% HCRA Surcharge,102.15,45,,102.15,percent of total billed charges,Critical Access Hospital RCC factor,77.18,34,,77.18,percent of total billed charges,Implant Device,77.18,34,,77.18,percent of total billed charges,Implant Device,77.18,34,,77.18,percent of total billed charges,Implant Device,77.18,34,,77.18,percent of total billed charges,Implant Device,77.18,34,,77.18,percent of total billed charges,Implant Device,112.37,,,112.37,Other,110% of Medicare,79.45,35,,79.45,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,79.45,35,,79.45,percent of total billed charges,Implant Device,79.45,35,,79.45,percent of total billed charges,Implant Device,79.45,35,,79.45,percent of total billed charges,Implant Device,79.45,35,,79.45,percent of total billed charges,Implant Device,79.45,35,,79.45,percent of total billed charges,Implant Device,90.8,40,,90.8,percent of total billed charges,Implant Device,79.45,70,,79.45,percent of total billed charges,All Other,77.18,34,,77.18,percent of total billed charges,Implant Device,77.18,34,,77.18,percent of total billed charges,Implant Device,79.45,35,,79.45,percent of total billed charges,Implant Device,79.45,35,,79.45,percent of total billed charges,Implant Device,79.45,35,,79.45,percent of total billed charges,Implant Device,79.45,35,,79.45,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,167.98,
DEVICOR 8G MAMMOMARK BREAST MARKER,A4648,HCPCS,,79000029,CDM,278,RC,,,both,,,230,170.2,,,170.2,Other,150% of Medicare + 9.63% HCRA Surcharge,103.5,45,,103.5,percent of total billed charges,Critical Access Hospital RCC factor,78.2,34,,78.2,percent of total billed charges,Implant Device,78.2,34,,78.2,percent of total billed charges,Implant Device,78.2,34,,78.2,percent of total billed charges,Implant Device,78.2,34,,78.2,percent of total billed charges,Implant Device,78.2,34,,78.2,percent of total billed charges,Implant Device,113.85,,,113.85,Other,110% of Medicare,80.5,35,,80.5,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,80.5,35,,80.5,percent of total billed charges,Implant Device,80.5,35,,80.5,percent of total billed charges,Implant Device,80.5,35,,80.5,percent of total billed charges,Implant Device,80.5,35,,80.5,percent of total billed charges,Implant Device,80.5,35,,80.5,percent of total billed charges,Implant Device,92,40,,92,percent of total billed charges,Implant Device,80.5,70,,80.5,percent of total billed charges,All Other,78.2,34,,78.2,percent of total billed charges,Implant Device,78.2,34,,78.2,percent of total billed charges,Implant Device,80.5,35,,80.5,percent of total billed charges,Implant Device,80.5,35,,80.5,percent of total billed charges,Implant Device,80.5,35,,80.5,percent of total billed charges,Implant Device,80.5,35,,80.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,170.2,
MAMMO MARK 2ND SITE,A4648,HCPCS,,79000030,CDM,278,RC,,,both,,,2263,1674.63,,,1674.63,Other,150% of Medicare + 9.63% HCRA Surcharge,1018.35,45,,1018.35,percent of total billed charges,Critical Access Hospital RCC factor,769.42,34,,769.42,percent of total billed charges,Implant Device,769.42,34,,769.42,percent of total billed charges,Implant Device,769.42,34,,769.42,percent of total billed charges,Implant Device,769.42,34,,769.42,percent of total billed charges,Implant Device,769.42,34,,769.42,percent of total billed charges,Implant Device,1120.19,,,1120.19,Other,110% of Medicare,792.05,35,,792.05,percent of total billed charges,Implant Device,769.42,34,"Charges > $500, x 34%",769.42,percent of total billed charges,Implant Device,792.05,35,,792.05,percent of total billed charges,Implant Device,792.05,35,,792.05,percent of total billed charges,Implant Device,792.05,35,,792.05,percent of total billed charges,Implant Device,792.05,35,,792.05,percent of total billed charges,Implant Device,792.05,35,,792.05,percent of total billed charges,Implant Device,905.2,40,,905.2,percent of total billed charges,Implant Device,792.05,70,,792.05,percent of total billed charges,All Other,769.42,34,,769.42,percent of total billed charges,Implant Device,769.42,34,,769.42,percent of total billed charges,Implant Device,792.05,35,,792.05,percent of total billed charges,Implant Device,792.05,35,,792.05,percent of total billed charges,Implant Device,792.05,35,,792.05,percent of total billed charges,Implant Device,792.05,35,,792.05,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,769.42,34,"If Charge > 2,000, then 34 percent",769.42,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1674.63,
EV3 PXB35-10-27-080 VISI-PRO STENT,C1876,HCPCS,,79000058,CDM,278,RC,,,both,,,3119,2308.07,,,2308.07,Other,150% of Medicare + 9.63% HCRA Surcharge,1403.55,45,,1403.55,percent of total billed charges,Critical Access Hospital RCC factor,1060.46,34,,1060.46,percent of total billed charges,Implant Device,1060.46,34,,1060.46,percent of total billed charges,Implant Device,1060.46,34,,1060.46,percent of total billed charges,Implant Device,1060.46,34,,1060.46,percent of total billed charges,Implant Device,1060.46,34,,1060.46,percent of total billed charges,Implant Device,1543.91,,,1543.91,Other,110% of Medicare,1091.65,35,,1091.65,percent of total billed charges,Implant Device,1060.46,34,"Charges > $500, x 34%",1060.46,percent of total billed charges,Implant Device,1091.65,35,,1091.65,percent of total billed charges,Implant Device,1091.65,35,,1091.65,percent of total billed charges,Implant Device,1091.65,35,,1091.65,percent of total billed charges,Implant Device,1091.65,35,,1091.65,percent of total billed charges,Implant Device,1091.65,35,,1091.65,percent of total billed charges,Implant Device,1247.6,40,,1247.6,percent of total billed charges,Implant Device,1091.65,70,,1091.65,percent of total billed charges,All Other,1060.46,34,,1060.46,percent of total billed charges,Implant Device,1060.46,34,,1060.46,percent of total billed charges,Implant Device,1091.65,35,,1091.65,percent of total billed charges,Implant Device,1091.65,35,,1091.65,percent of total billed charges,Implant Device,1091.65,35,,1091.65,percent of total billed charges,Implant Device,1091.65,35,,1091.65,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1060.46,34,"If Charge > 2,000, then 34 percent",1060.46,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2308.07,
EV3 SERB65-10-40-80 PROTOGE STENT,C1876,HCPCS,,79000062,CDM,278,RC,,,both,,,1950,1443,,,1443,Other,150% of Medicare + 9.63% HCRA Surcharge,877.5,45,,877.5,percent of total billed charges,Critical Access Hospital RCC factor,663,34,,663,percent of total billed charges,Implant Device,663,34,,663,percent of total billed charges,Implant Device,663,34,,663,percent of total billed charges,Implant Device,663,34,,663,percent of total billed charges,Implant Device,663,34,,663,percent of total billed charges,Implant Device,965.25,,,965.25,Other,110% of Medicare,682.5,35,,682.5,percent of total billed charges,Implant Device,663,34,"Charges > $500, x 34%",663,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,780,40,,780,percent of total billed charges,Implant Device,682.5,70,,682.5,percent of total billed charges,All Other,663,34,,663,percent of total billed charges,Implant Device,663,34,,663,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1443,
BARD FTM10040 FLUENCY COVERED STENT,C1875,HCPCS,,79000063,CDM,278,RC,,,both,,,8142,6025.1,,,6025.1,Other,150% of Medicare + 9.63% HCRA Surcharge,3663.9,45,,3663.9,percent of total billed charges,Critical Access Hospital RCC factor,2768.28,34,,2768.28,percent of total billed charges,Implant Device,2768.28,34,,2768.28,percent of total billed charges,Implant Device,2768.28,34,,2768.28,percent of total billed charges,Implant Device,2768.28,34,,2768.28,percent of total billed charges,Implant Device,2768.28,34,,2768.28,percent of total billed charges,Implant Device,4030.29,,,4030.29,Other,110% of Medicare,2849.7,35,,2849.7,percent of total billed charges,Implant Device,2768.28,34,"Charges > $500, x 34%",2768.28,percent of total billed charges,Implant Device,2849.7,35,,2849.7,percent of total billed charges,Implant Device,2849.7,35,,2849.7,percent of total billed charges,Implant Device,2849.7,35,,2849.7,percent of total billed charges,Implant Device,2849.7,35,,2849.7,percent of total billed charges,Implant Device,2849.7,35,,2849.7,percent of total billed charges,Implant Device,3256.8,40,,3256.8,percent of total billed charges,Implant Device,2849.7,70,,2849.7,percent of total billed charges,All Other,2768.28,34,,2768.28,percent of total billed charges,Implant Device,2768.28,34,,2768.28,percent of total billed charges,Implant Device,2849.7,35,,2849.7,percent of total billed charges,Implant Device,2849.7,35,,2849.7,percent of total billed charges,Implant Device,2849.7,35,,2849.7,percent of total billed charges,Implant Device,2849.7,35,,2849.7,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2768.28,34,"If Charge > 2,000, then 34 percent",2768.28,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,6025.1,
EV3 SERB65-10-60-80 PROTOGE STENT,C1876,HCPCS,,79000065,CDM,278,RC,,,both,,,3975,2941.51,,,2941.51,Other,150% of Medicare + 9.63% HCRA Surcharge,1788.75,45,,1788.75,percent of total billed charges,Critical Access Hospital RCC factor,1351.5,34,,1351.5,percent of total billed charges,Implant Device,1351.5,34,,1351.5,percent of total billed charges,Implant Device,1351.5,34,,1351.5,percent of total billed charges,Implant Device,1351.5,34,,1351.5,percent of total billed charges,Implant Device,1351.5,34,,1351.5,percent of total billed charges,Implant Device,1967.63,,,1967.63,Other,110% of Medicare,1391.25,35,,1391.25,percent of total billed charges,Implant Device,1351.5,34,"Charges > $500, x 34%",1351.5,percent of total billed charges,Implant Device,1391.25,35,,1391.25,percent of total billed charges,Implant Device,1391.25,35,,1391.25,percent of total billed charges,Implant Device,1391.25,35,,1391.25,percent of total billed charges,Implant Device,1391.25,35,,1391.25,percent of total billed charges,Implant Device,1391.25,35,,1391.25,percent of total billed charges,Implant Device,1590,40,,1590,percent of total billed charges,Implant Device,1391.25,70,,1391.25,percent of total billed charges,All Other,1351.5,34,,1351.5,percent of total billed charges,Implant Device,1351.5,34,,1351.5,percent of total billed charges,Implant Device,1391.25,35,,1391.25,percent of total billed charges,Implant Device,1391.25,35,,1391.25,percent of total billed charges,Implant Device,1391.25,35,,1391.25,percent of total billed charges,Implant Device,1391.25,35,,1391.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1351.5,34,"If Charge > 2,000, then 34 percent",1351.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2941.51,
BARD 600620 12FR HICKMAN DUAL CV CATH,C1751,HCPCS,,79000069,CDM,278,RC,,,both,,,833,616.42,,,616.42,Other,150% of Medicare + 9.63% HCRA Surcharge,374.85,45,,374.85,percent of total billed charges,Critical Access Hospital RCC factor,283.22,34,,283.22,percent of total billed charges,Implant Device,283.22,34,,283.22,percent of total billed charges,Implant Device,283.22,34,,283.22,percent of total billed charges,Implant Device,283.22,34,,283.22,percent of total billed charges,Implant Device,283.22,34,,283.22,percent of total billed charges,Implant Device,412.34,,,412.34,Other,110% of Medicare,291.55,35,,291.55,percent of total billed charges,Implant Device,283.22,34,"Charges > $500, x 34%",283.22,percent of total billed charges,Implant Device,291.55,35,,291.55,percent of total billed charges,Implant Device,291.55,35,,291.55,percent of total billed charges,Implant Device,291.55,35,,291.55,percent of total billed charges,Implant Device,291.55,35,,291.55,percent of total billed charges,Implant Device,291.55,35,,291.55,percent of total billed charges,Implant Device,333.2,40,,333.2,percent of total billed charges,Implant Device,291.55,70,,291.55,percent of total billed charges,All Other,283.22,34,,283.22,percent of total billed charges,Implant Device,283.22,34,,283.22,percent of total billed charges,Implant Device,291.55,35,,291.55,percent of total billed charges,Implant Device,291.55,35,,291.55,percent of total billed charges,Implant Device,291.55,35,,291.55,percent of total billed charges,Implant Device,291.55,35,,291.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,616.42,
EV3 SERB65-12-40-80 PROTOGE STENT,C1876,HCPCS,,79000074,CDM,278,RC,,,both,,,1950,1443,,,1443,Other,150% of Medicare + 9.63% HCRA Surcharge,877.5,45,,877.5,percent of total billed charges,Critical Access Hospital RCC factor,663,34,,663,percent of total billed charges,Implant Device,663,34,,663,percent of total billed charges,Implant Device,663,34,,663,percent of total billed charges,Implant Device,663,34,,663,percent of total billed charges,Implant Device,663,34,,663,percent of total billed charges,Implant Device,965.25,,,965.25,Other,110% of Medicare,682.5,35,,682.5,percent of total billed charges,Implant Device,663,34,"Charges > $500, x 34%",663,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,780,40,,780,percent of total billed charges,Implant Device,682.5,70,,682.5,percent of total billed charges,All Other,663,34,,663,percent of total billed charges,Implant Device,663,34,,663,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1443,
J&J C12040SB 12X40X80 SMARTSTENT,C1876,HCPCS,,79000075,CDM,278,RC,,,both,,,4607,3409.19,,,3409.19,Other,150% of Medicare + 9.63% HCRA Surcharge,2073.15,45,,2073.15,percent of total billed charges,Critical Access Hospital RCC factor,1566.38,34,,1566.38,percent of total billed charges,Implant Device,1566.38,34,,1566.38,percent of total billed charges,Implant Device,1566.38,34,,1566.38,percent of total billed charges,Implant Device,1566.38,34,,1566.38,percent of total billed charges,Implant Device,1566.38,34,,1566.38,percent of total billed charges,Implant Device,2280.47,,,2280.47,Other,110% of Medicare,1612.45,35,,1612.45,percent of total billed charges,Implant Device,1566.38,34,"Charges > $500, x 34%",1566.38,percent of total billed charges,Implant Device,1612.45,35,,1612.45,percent of total billed charges,Implant Device,1612.45,35,,1612.45,percent of total billed charges,Implant Device,1612.45,35,,1612.45,percent of total billed charges,Implant Device,1612.45,35,,1612.45,percent of total billed charges,Implant Device,1612.45,35,,1612.45,percent of total billed charges,Implant Device,1842.8,40,,1842.8,percent of total billed charges,Implant Device,1612.45,70,,1612.45,percent of total billed charges,All Other,1566.38,34,,1566.38,percent of total billed charges,Implant Device,1566.38,34,,1566.38,percent of total billed charges,Implant Device,1612.45,35,,1612.45,percent of total billed charges,Implant Device,1612.45,35,,1612.45,percent of total billed charges,Implant Device,1612.45,35,,1612.45,percent of total billed charges,Implant Device,1612.45,35,,1612.45,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1566.38,34,"If Charge > 2,000, then 34 percent",1566.38,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3409.19,
J&J C12060SB 12X60X80 SMARTSTENT,C1876,HCPCS,,79000076,CDM,278,RC,,,both,,,2584,1912.17,,,1912.17,Other,150% of Medicare + 9.63% HCRA Surcharge,1162.8,45,,1162.8,percent of total billed charges,Critical Access Hospital RCC factor,878.56,34,,878.56,percent of total billed charges,Implant Device,878.56,34,,878.56,percent of total billed charges,Implant Device,878.56,34,,878.56,percent of total billed charges,Implant Device,878.56,34,,878.56,percent of total billed charges,Implant Device,878.56,34,,878.56,percent of total billed charges,Implant Device,1279.08,,,1279.08,Other,110% of Medicare,904.4,35,,904.4,percent of total billed charges,Implant Device,878.56,34,"Charges > $500, x 34%",878.56,percent of total billed charges,Implant Device,904.4,35,,904.4,percent of total billed charges,Implant Device,904.4,35,,904.4,percent of total billed charges,Implant Device,904.4,35,,904.4,percent of total billed charges,Implant Device,904.4,35,,904.4,percent of total billed charges,Implant Device,904.4,35,,904.4,percent of total billed charges,Implant Device,1033.6,40,,1033.6,percent of total billed charges,Implant Device,904.4,70,,904.4,percent of total billed charges,All Other,878.56,34,,878.56,percent of total billed charges,Implant Device,878.56,34,,878.56,percent of total billed charges,Implant Device,904.4,35,,904.4,percent of total billed charges,Implant Device,904.4,35,,904.4,percent of total billed charges,Implant Device,904.4,35,,904.4,percent of total billed charges,Implant Device,904.4,35,,904.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,878.56,34,"If Charge > 2,000, then 34 percent",878.56,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1912.17,
J&J C14040SB 14X40X80 SMARTSTENT,C1876,HCPCS,,79000081,CDM,278,RC,,,both,,,4607,3409.19,,,3409.19,Other,150% of Medicare + 9.63% HCRA Surcharge,2073.15,45,,2073.15,percent of total billed charges,Critical Access Hospital RCC factor,1566.38,34,,1566.38,percent of total billed charges,Implant Device,1566.38,34,,1566.38,percent of total billed charges,Implant Device,1566.38,34,,1566.38,percent of total billed charges,Implant Device,1566.38,34,,1566.38,percent of total billed charges,Implant Device,1566.38,34,,1566.38,percent of total billed charges,Implant Device,2280.47,,,2280.47,Other,110% of Medicare,1612.45,35,,1612.45,percent of total billed charges,Implant Device,1566.38,34,"Charges > $500, x 34%",1566.38,percent of total billed charges,Implant Device,1612.45,35,,1612.45,percent of total billed charges,Implant Device,1612.45,35,,1612.45,percent of total billed charges,Implant Device,1612.45,35,,1612.45,percent of total billed charges,Implant Device,1612.45,35,,1612.45,percent of total billed charges,Implant Device,1612.45,35,,1612.45,percent of total billed charges,Implant Device,1842.8,40,,1842.8,percent of total billed charges,Implant Device,1612.45,70,,1612.45,percent of total billed charges,All Other,1566.38,34,,1566.38,percent of total billed charges,Implant Device,1566.38,34,,1566.38,percent of total billed charges,Implant Device,1612.45,35,,1612.45,percent of total billed charges,Implant Device,1612.45,35,,1612.45,percent of total billed charges,Implant Device,1612.45,35,,1612.45,percent of total billed charges,Implant Device,1612.45,35,,1612.45,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1566.38,34,"If Charge > 2,000, then 34 percent",1566.38,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3409.19,
NAVILYST 45-714 INJECTABLE PICC LINE 4FR,C1751,HCPCS,,79000107,CDM,278,RC,,,both,,,415,307.1,,,307.1,Other,150% of Medicare + 9.63% HCRA Surcharge,186.75,45,,186.75,percent of total billed charges,Critical Access Hospital RCC factor,141.1,34,,141.1,percent of total billed charges,Implant Device,141.1,34,,141.1,percent of total billed charges,Implant Device,141.1,34,,141.1,percent of total billed charges,Implant Device,141.1,34,,141.1,percent of total billed charges,Implant Device,141.1,34,,141.1,percent of total billed charges,Implant Device,205.43,,,205.43,Other,110% of Medicare,145.25,35,,145.25,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,145.25,35,,145.25,percent of total billed charges,Implant Device,145.25,35,,145.25,percent of total billed charges,Implant Device,145.25,35,,145.25,percent of total billed charges,Implant Device,145.25,35,,145.25,percent of total billed charges,Implant Device,145.25,35,,145.25,percent of total billed charges,Implant Device,166,40,,166,percent of total billed charges,Implant Device,145.25,70,,145.25,percent of total billed charges,All Other,141.1,34,,141.1,percent of total billed charges,Implant Device,141.1,34,,141.1,percent of total billed charges,Implant Device,145.25,35,,145.25,percent of total billed charges,Implant Device,145.25,35,,145.25,percent of total billed charges,Implant Device,145.25,35,,145.25,percent of total billed charges,Implant Device,145.25,35,,145.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,307.1,
NAVILYST 45-7140 XCELA POWER PICC 4FR,C1751,HCPCS,,79000108,CDM,278,RC,,,both,,,400,296,,,296,Other,150% of Medicare + 9.63% HCRA Surcharge,180,45,,180,percent of total billed charges,Critical Access Hospital RCC factor,136,34,,136,percent of total billed charges,Implant Device,136,34,,136,percent of total billed charges,Implant Device,136,34,,136,percent of total billed charges,Implant Device,136,34,,136,percent of total billed charges,Implant Device,136,34,,136,percent of total billed charges,Implant Device,198,,,198,Other,110% of Medicare,140,35,,140,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,140,35,,140,percent of total billed charges,Implant Device,140,35,,140,percent of total billed charges,Implant Device,140,35,,140,percent of total billed charges,Implant Device,140,35,,140,percent of total billed charges,Implant Device,140,35,,140,percent of total billed charges,Implant Device,160,40,,160,percent of total billed charges,Implant Device,140,70,,140,percent of total billed charges,All Other,136,34,,136,percent of total billed charges,Implant Device,136,34,,136,percent of total billed charges,Implant Device,140,35,,140,percent of total billed charges,Implant Device,140,35,,140,percent of total billed charges,Implant Device,140,35,,140,percent of total billed charges,Implant Device,140,35,,140,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,296,
BOST SCI 37911-41515 EXPRESS SD STENT,C1876,HCPCS,,79000115,CDM,278,RC,,,both,,,3600,2664.01,,,2664.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1620,45,,1620,percent of total billed charges,Critical Access Hospital RCC factor,1224,34,,1224,percent of total billed charges,Implant Device,1224,34,,1224,percent of total billed charges,Implant Device,1224,34,,1224,percent of total billed charges,Implant Device,1224,34,,1224,percent of total billed charges,Implant Device,1224,34,,1224,percent of total billed charges,Implant Device,1782,,,1782,Other,110% of Medicare,1260,35,,1260,percent of total billed charges,Implant Device,1224,34,"Charges > $500, x 34%",1224,percent of total billed charges,Implant Device,1260,35,,1260,percent of total billed charges,Implant Device,1260,35,,1260,percent of total billed charges,Implant Device,1260,35,,1260,percent of total billed charges,Implant Device,1260,35,,1260,percent of total billed charges,Implant Device,1260,35,,1260,percent of total billed charges,Implant Device,1440,40,,1440,percent of total billed charges,Implant Device,1260,70,,1260,percent of total billed charges,All Other,1224,34,,1224,percent of total billed charges,Implant Device,1224,34,,1224,percent of total billed charges,Implant Device,1260,35,,1260,percent of total billed charges,Implant Device,1260,35,,1260,percent of total billed charges,Implant Device,1260,35,,1260,percent of total billed charges,Implant Device,1260,35,,1260,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1224,34,"If Charge > 2,000, then 34 percent",1224,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2664.01,
NAVILYST 45-734 INJECTABLE PICC LINE 5FR,C1751,HCPCS,,79000129,CDM,278,RC,,,both,,,457,338.18,,,338.18,Other,150% of Medicare + 9.63% HCRA Surcharge,205.65,45,,205.65,percent of total billed charges,Critical Access Hospital RCC factor,155.38,34,,155.38,percent of total billed charges,Implant Device,155.38,34,,155.38,percent of total billed charges,Implant Device,155.38,34,,155.38,percent of total billed charges,Implant Device,155.38,34,,155.38,percent of total billed charges,Implant Device,155.38,34,,155.38,percent of total billed charges,Implant Device,226.22,,,226.22,Other,110% of Medicare,159.95,35,,159.95,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,159.95,35,,159.95,percent of total billed charges,Implant Device,159.95,35,,159.95,percent of total billed charges,Implant Device,159.95,35,,159.95,percent of total billed charges,Implant Device,159.95,35,,159.95,percent of total billed charges,Implant Device,159.95,35,,159.95,percent of total billed charges,Implant Device,182.8,40,,182.8,percent of total billed charges,Implant Device,159.95,70,,159.95,percent of total billed charges,All Other,155.38,34,,155.38,percent of total billed charges,Implant Device,155.38,34,,155.38,percent of total billed charges,Implant Device,159.95,35,,159.95,percent of total billed charges,Implant Device,159.95,35,,159.95,percent of total billed charges,Implant Device,159.95,35,,159.95,percent of total billed charges,Implant Device,159.95,35,,159.95,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,338.18,
NAVILYST 45-7340 XCELA POWER PICC 5FR,C1751,HCPCS,,79000130,CDM,278,RC,,,both,,,439,324.86,,,324.86,Other,150% of Medicare + 9.63% HCRA Surcharge,197.55,45,,197.55,percent of total billed charges,Critical Access Hospital RCC factor,149.26,34,,149.26,percent of total billed charges,Implant Device,149.26,34,,149.26,percent of total billed charges,Implant Device,149.26,34,,149.26,percent of total billed charges,Implant Device,149.26,34,,149.26,percent of total billed charges,Implant Device,149.26,34,,149.26,percent of total billed charges,Implant Device,217.31,,,217.31,Other,110% of Medicare,153.65,35,,153.65,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,153.65,35,,153.65,percent of total billed charges,Implant Device,153.65,35,,153.65,percent of total billed charges,Implant Device,153.65,35,,153.65,percent of total billed charges,Implant Device,153.65,35,,153.65,percent of total billed charges,Implant Device,153.65,35,,153.65,percent of total billed charges,Implant Device,175.6,40,,175.6,percent of total billed charges,Implant Device,153.65,70,,153.65,percent of total billed charges,All Other,149.26,34,,149.26,percent of total billed charges,Implant Device,149.26,34,,149.26,percent of total billed charges,Implant Device,153.65,35,,153.65,percent of total billed charges,Implant Device,153.65,35,,153.65,percent of total billed charges,Implant Device,153.65,35,,153.65,percent of total billed charges,Implant Device,153.65,35,,153.65,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,324.86,
STRYKER 45-595 5FR PICC LINE CLAMPABLE,C1751,HCPCS,,79000133,CDM,278,RC,,,both,,,290,214.6,,,214.6,Other,150% of Medicare + 9.63% HCRA Surcharge,130.5,45,,130.5,percent of total billed charges,Critical Access Hospital RCC factor,98.6,34,,98.6,percent of total billed charges,Implant Device,98.6,34,,98.6,percent of total billed charges,Implant Device,98.6,34,,98.6,percent of total billed charges,Implant Device,98.6,34,,98.6,percent of total billed charges,Implant Device,98.6,34,,98.6,percent of total billed charges,Implant Device,143.55,,,143.55,Other,110% of Medicare,101.5,35,,101.5,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,101.5,35,,101.5,percent of total billed charges,Implant Device,101.5,35,,101.5,percent of total billed charges,Implant Device,101.5,35,,101.5,percent of total billed charges,Implant Device,101.5,35,,101.5,percent of total billed charges,Implant Device,101.5,35,,101.5,percent of total billed charges,Implant Device,116,40,,116,percent of total billed charges,Implant Device,101.5,70,,101.5,percent of total billed charges,All Other,98.6,34,,98.6,percent of total billed charges,Implant Device,98.6,34,,98.6,percent of total billed charges,Implant Device,101.5,35,,101.5,percent of total billed charges,Implant Device,101.5,35,,101.5,percent of total billed charges,Implant Device,101.5,35,,101.5,percent of total billed charges,Implant Device,101.5,35,,101.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,214.6,
NAVILYST 45-598 5FR PICC LINE CATHETER,C1751,HCPCS,,79000134,CDM,278,RC,,,both,,,365,270.1,,,270.1,Other,150% of Medicare + 9.63% HCRA Surcharge,164.25,45,,164.25,percent of total billed charges,Critical Access Hospital RCC factor,124.1,34,,124.1,percent of total billed charges,Implant Device,124.1,34,,124.1,percent of total billed charges,Implant Device,124.1,34,,124.1,percent of total billed charges,Implant Device,124.1,34,,124.1,percent of total billed charges,Implant Device,124.1,34,,124.1,percent of total billed charges,Implant Device,180.68,,,180.68,Other,110% of Medicare,127.75,35,,127.75,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,127.75,35,,127.75,percent of total billed charges,Implant Device,127.75,35,,127.75,percent of total billed charges,Implant Device,127.75,35,,127.75,percent of total billed charges,Implant Device,127.75,35,,127.75,percent of total billed charges,Implant Device,127.75,35,,127.75,percent of total billed charges,Implant Device,146,40,,146,percent of total billed charges,Implant Device,127.75,70,,127.75,percent of total billed charges,All Other,124.1,34,,124.1,percent of total billed charges,Implant Device,124.1,34,,124.1,percent of total billed charges,Implant Device,127.75,35,,127.75,percent of total billed charges,Implant Device,127.75,35,,127.75,percent of total billed charges,Implant Device,127.75,35,,127.75,percent of total billed charges,Implant Device,127.75,35,,127.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,270.1,
BOST SCI 37912-51915 EXPRESS RENAL STENT,C1876,HCPCS,,79000157,CDM,278,RC,,,both,,,3600,2664.01,,,2664.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1620,45,,1620,percent of total billed charges,Critical Access Hospital RCC factor,1224,34,,1224,percent of total billed charges,Implant Device,1224,34,,1224,percent of total billed charges,Implant Device,1224,34,,1224,percent of total billed charges,Implant Device,1224,34,,1224,percent of total billed charges,Implant Device,1224,34,,1224,percent of total billed charges,Implant Device,1782,,,1782,Other,110% of Medicare,1260,35,,1260,percent of total billed charges,Implant Device,1224,34,"Charges > $500, x 34%",1224,percent of total billed charges,Implant Device,1260,35,,1260,percent of total billed charges,Implant Device,1260,35,,1260,percent of total billed charges,Implant Device,1260,35,,1260,percent of total billed charges,Implant Device,1260,35,,1260,percent of total billed charges,Implant Device,1260,35,,1260,percent of total billed charges,Implant Device,1440,40,,1440,percent of total billed charges,Implant Device,1260,70,,1260,percent of total billed charges,All Other,1224,34,,1224,percent of total billed charges,Implant Device,1224,34,,1224,percent of total billed charges,Implant Device,1260,35,,1260,percent of total billed charges,Implant Device,1260,35,,1260,percent of total billed charges,Implant Device,1260,35,,1260,percent of total billed charges,Implant Device,1260,35,,1260,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1224,34,"If Charge > 2,000, then 34 percent",1224,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2664.01,
EV3 PRB35-05-080-120 EVERFLEX STENT,C1876,HCPCS,,79000162,CDM,278,RC,,,both,,,1950,1443,,,1443,Other,150% of Medicare + 9.63% HCRA Surcharge,877.5,45,,877.5,percent of total billed charges,Critical Access Hospital RCC factor,663,34,,663,percent of total billed charges,Implant Device,663,34,,663,percent of total billed charges,Implant Device,663,34,,663,percent of total billed charges,Implant Device,663,34,,663,percent of total billed charges,Implant Device,663,34,,663,percent of total billed charges,Implant Device,965.25,,,965.25,Other,110% of Medicare,682.5,35,,682.5,percent of total billed charges,Implant Device,663,34,"Charges > $500, x 34%",663,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,780,40,,780,percent of total billed charges,Implant Device,682.5,70,,682.5,percent of total billed charges,All Other,663,34,,663,percent of total billed charges,Implant Device,663,34,,663,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1443,
BOST SCI 27-411 6FR URETERAL STENT SYS,C2617,HCPCS,,79000176,CDM,278,RC,,,both,,,572,423.28,,,423.28,Other,150% of Medicare + 9.63% HCRA Surcharge,257.4,45,,257.4,percent of total billed charges,Critical Access Hospital RCC factor,194.48,34,,194.48,percent of total billed charges,Implant Device,194.48,34,,194.48,percent of total billed charges,Implant Device,194.48,34,,194.48,percent of total billed charges,Implant Device,194.48,34,,194.48,percent of total billed charges,Implant Device,194.48,34,,194.48,percent of total billed charges,Implant Device,283.14,,,283.14,Other,110% of Medicare,200.2,35,,200.2,percent of total billed charges,Implant Device,194.48,34,"Charges > $500, x 34%",194.48,percent of total billed charges,Implant Device,200.2,35,,200.2,percent of total billed charges,Implant Device,200.2,35,,200.2,percent of total billed charges,Implant Device,200.2,35,,200.2,percent of total billed charges,Implant Device,200.2,35,,200.2,percent of total billed charges,Implant Device,200.2,35,,200.2,percent of total billed charges,Implant Device,228.8,40,,228.8,percent of total billed charges,Implant Device,200.2,70,,200.2,percent of total billed charges,All Other,194.48,34,,194.48,percent of total billed charges,Implant Device,194.48,34,,194.48,percent of total billed charges,Implant Device,200.2,35,,200.2,percent of total billed charges,Implant Device,200.2,35,,200.2,percent of total billed charges,Implant Device,200.2,35,,200.2,percent of total billed charges,Implant Device,200.2,35,,200.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,423.28,
J&J C06120MB SMART CONTROL STENT,C1876,HCPCS,,79000185,CDM,278,RC,,,both,,,3300,2442.01,,,2442.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1485,45,,1485,percent of total billed charges,Critical Access Hospital RCC factor,1122,34,,1122,percent of total billed charges,Implant Device,1122,34,,1122,percent of total billed charges,Implant Device,1122,34,,1122,percent of total billed charges,Implant Device,1122,34,,1122,percent of total billed charges,Implant Device,1122,34,,1122,percent of total billed charges,Implant Device,1633.5,,,1633.5,Other,110% of Medicare,1155,35,,1155,percent of total billed charges,Implant Device,1122,34,"Charges > $500, x 34%",1122,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,1320,40,,1320,percent of total billed charges,Implant Device,1155,70,,1155,percent of total billed charges,All Other,1122,34,,1122,percent of total billed charges,Implant Device,1122,34,,1122,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1122,34,"If Charge > 2,000, then 34 percent",1122,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2442.01,
BARD EX061203CS 6X120X130 LIFE STENT,C1876,HCPCS,,79000186,CDM,278,RC,,,both,,,3750,2775.01,,,2775.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1687.5,45,,1687.5,percent of total billed charges,Critical Access Hospital RCC factor,1275,34,,1275,percent of total billed charges,Implant Device,1275,34,,1275,percent of total billed charges,Implant Device,1275,34,,1275,percent of total billed charges,Implant Device,1275,34,,1275,percent of total billed charges,Implant Device,1275,34,,1275,percent of total billed charges,Implant Device,1856.25,,,1856.25,Other,110% of Medicare,1312.5,35,,1312.5,percent of total billed charges,Implant Device,1275,34,"Charges > $500, x 34%",1275,percent of total billed charges,Implant Device,1312.5,35,,1312.5,percent of total billed charges,Implant Device,1312.5,35,,1312.5,percent of total billed charges,Implant Device,1312.5,35,,1312.5,percent of total billed charges,Implant Device,1312.5,35,,1312.5,percent of total billed charges,Implant Device,1312.5,35,,1312.5,percent of total billed charges,Implant Device,1500,40,,1500,percent of total billed charges,Implant Device,1312.5,70,,1312.5,percent of total billed charges,All Other,1275,34,,1275,percent of total billed charges,Implant Device,1275,34,,1275,percent of total billed charges,Implant Device,1312.5,35,,1312.5,percent of total billed charges,Implant Device,1312.5,35,,1312.5,percent of total billed charges,Implant Device,1312.5,35,,1312.5,percent of total billed charges,Implant Device,1312.5,35,,1312.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1275,34,"If Charge > 2,000, then 34 percent",1275,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2775.01,
BARD EX061503CS 6X150X130 LIFESTENT XL,C1876,HCPCS,,79000188,CDM,278,RC,,,both,,,4350,3219.01,,,3219.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1957.5,45,,1957.5,percent of total billed charges,Critical Access Hospital RCC factor,1479,34,,1479,percent of total billed charges,Implant Device,1479,34,,1479,percent of total billed charges,Implant Device,1479,34,,1479,percent of total billed charges,Implant Device,1479,34,,1479,percent of total billed charges,Implant Device,1479,34,,1479,percent of total billed charges,Implant Device,2153.25,,,2153.25,Other,110% of Medicare,1522.5,35,,1522.5,percent of total billed charges,Implant Device,1479,34,"Charges > $500, x 34%",1479,percent of total billed charges,Implant Device,1522.5,35,,1522.5,percent of total billed charges,Implant Device,1522.5,35,,1522.5,percent of total billed charges,Implant Device,1522.5,35,,1522.5,percent of total billed charges,Implant Device,1522.5,35,,1522.5,percent of total billed charges,Implant Device,1522.5,35,,1522.5,percent of total billed charges,Implant Device,1740,40,,1740,percent of total billed charges,Implant Device,1522.5,70,,1522.5,percent of total billed charges,All Other,1479,34,,1479,percent of total billed charges,Implant Device,1479,34,,1479,percent of total billed charges,Implant Device,1522.5,35,,1522.5,percent of total billed charges,Implant Device,1522.5,35,,1522.5,percent of total billed charges,Implant Device,1522.5,35,,1522.5,percent of total billed charges,Implant Device,1522.5,35,,1522.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1479,34,"If Charge > 2,000, then 34 percent",1479,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3219.01,
BARD EX061703CS 6X170X130 LIFESTENT XL,C1876,HCPCS,,79000191,CDM,278,RC,,,both,,,5100,3774.01,,,3774.01,Other,150% of Medicare + 9.63% HCRA Surcharge,2295,45,,2295,percent of total billed charges,Critical Access Hospital RCC factor,1734,34,,1734,percent of total billed charges,Implant Device,1734,34,,1734,percent of total billed charges,Implant Device,1734,34,,1734,percent of total billed charges,Implant Device,1734,34,,1734,percent of total billed charges,Implant Device,1734,34,,1734,percent of total billed charges,Implant Device,2524.5,,,2524.5,Other,110% of Medicare,1785,35,,1785,percent of total billed charges,Implant Device,1734,34,"Charges > $500, x 34%",1734,percent of total billed charges,Implant Device,1785,35,,1785,percent of total billed charges,Implant Device,1785,35,,1785,percent of total billed charges,Implant Device,1785,35,,1785,percent of total billed charges,Implant Device,1785,35,,1785,percent of total billed charges,Implant Device,1785,35,,1785,percent of total billed charges,Implant Device,2040,40,,2040,percent of total billed charges,Implant Device,1785,70,,1785,percent of total billed charges,All Other,1734,34,,1734,percent of total billed charges,Implant Device,1734,34,,1734,percent of total billed charges,Implant Device,1785,35,,1785,percent of total billed charges,Implant Device,1785,35,,1785,percent of total billed charges,Implant Device,1785,35,,1785,percent of total billed charges,Implant Device,1785,35,,1785,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1734,34,"If Charge > 2,000, then 34 percent",1734,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3774.01,
BOST SCI 37912-61815 EXPRESS RENAL STENT,C1876,HCPCS,,79000192,CDM,278,RC,,,both,,,3600,2664.01,,,2664.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1620,45,,1620,percent of total billed charges,Critical Access Hospital RCC factor,1224,34,,1224,percent of total billed charges,Implant Device,1224,34,,1224,percent of total billed charges,Implant Device,1224,34,,1224,percent of total billed charges,Implant Device,1224,34,,1224,percent of total billed charges,Implant Device,1224,34,,1224,percent of total billed charges,Implant Device,1782,,,1782,Other,110% of Medicare,1260,35,,1260,percent of total billed charges,Implant Device,1224,34,"Charges > $500, x 34%",1224,percent of total billed charges,Implant Device,1260,35,,1260,percent of total billed charges,Implant Device,1260,35,,1260,percent of total billed charges,Implant Device,1260,35,,1260,percent of total billed charges,Implant Device,1260,35,,1260,percent of total billed charges,Implant Device,1260,35,,1260,percent of total billed charges,Implant Device,1440,40,,1440,percent of total billed charges,Implant Device,1260,70,,1260,percent of total billed charges,All Other,1224,34,,1224,percent of total billed charges,Implant Device,1224,34,,1224,percent of total billed charges,Implant Device,1260,35,,1260,percent of total billed charges,Implant Device,1260,35,,1260,percent of total billed charges,Implant Device,1260,35,,1260,percent of total billed charges,Implant Device,1260,35,,1260,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1224,34,"If Charge > 2,000, then 34 percent",1224,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2664.01,
BOST SCI 27-412 6X24CM URETERAL STENT,C2617,HCPCS,,79000195,CDM,278,RC,,,both,,,572,423.28,,,423.28,Other,150% of Medicare + 9.63% HCRA Surcharge,257.4,45,,257.4,percent of total billed charges,Critical Access Hospital RCC factor,194.48,34,,194.48,percent of total billed charges,Implant Device,194.48,34,,194.48,percent of total billed charges,Implant Device,194.48,34,,194.48,percent of total billed charges,Implant Device,194.48,34,,194.48,percent of total billed charges,Implant Device,194.48,34,,194.48,percent of total billed charges,Implant Device,283.14,,,283.14,Other,110% of Medicare,200.2,35,,200.2,percent of total billed charges,Implant Device,194.48,34,"Charges > $500, x 34%",194.48,percent of total billed charges,Implant Device,200.2,35,,200.2,percent of total billed charges,Implant Device,200.2,35,,200.2,percent of total billed charges,Implant Device,200.2,35,,200.2,percent of total billed charges,Implant Device,200.2,35,,200.2,percent of total billed charges,Implant Device,200.2,35,,200.2,percent of total billed charges,Implant Device,228.8,40,,228.8,percent of total billed charges,Implant Device,200.2,70,,200.2,percent of total billed charges,All Other,194.48,34,,194.48,percent of total billed charges,Implant Device,194.48,34,,194.48,percent of total billed charges,Implant Device,200.2,35,,200.2,percent of total billed charges,Implant Device,200.2,35,,200.2,percent of total billed charges,Implant Device,200.2,35,,200.2,percent of total billed charges,Implant Device,200.2,35,,200.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,423.28,
BOST SCI 27-413 6X26CM URETERAL STENT,C2617,HCPCS,,79000196,CDM,278,RC,,,both,,,572,423.28,,,423.28,Other,150% of Medicare + 9.63% HCRA Surcharge,257.4,45,,257.4,percent of total billed charges,Critical Access Hospital RCC factor,194.48,34,,194.48,percent of total billed charges,Implant Device,194.48,34,,194.48,percent of total billed charges,Implant Device,194.48,34,,194.48,percent of total billed charges,Implant Device,194.48,34,,194.48,percent of total billed charges,Implant Device,194.48,34,,194.48,percent of total billed charges,Implant Device,283.14,,,283.14,Other,110% of Medicare,200.2,35,,200.2,percent of total billed charges,Implant Device,194.48,34,"Charges > $500, x 34%",194.48,percent of total billed charges,Implant Device,200.2,35,,200.2,percent of total billed charges,Implant Device,200.2,35,,200.2,percent of total billed charges,Implant Device,200.2,35,,200.2,percent of total billed charges,Implant Device,200.2,35,,200.2,percent of total billed charges,Implant Device,200.2,35,,200.2,percent of total billed charges,Implant Device,228.8,40,,228.8,percent of total billed charges,Implant Device,200.2,70,,200.2,percent of total billed charges,All Other,194.48,34,,194.48,percent of total billed charges,Implant Device,194.48,34,,194.48,percent of total billed charges,Implant Device,200.2,35,,200.2,percent of total billed charges,Implant Device,200.2,35,,200.2,percent of total billed charges,Implant Device,200.2,35,,200.2,percent of total billed charges,Implant Device,200.2,35,,200.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,423.28,
BOST SCI 38046-64075 EXPRESS STENT,C1876,HCPCS,,79000197,CDM,278,RC,,,both,,,3851,2849.75,,,2849.75,Other,150% of Medicare + 9.63% HCRA Surcharge,1732.95,45,,1732.95,percent of total billed charges,Critical Access Hospital RCC factor,1309.34,34,,1309.34,percent of total billed charges,Implant Device,1309.34,34,,1309.34,percent of total billed charges,Implant Device,1309.34,34,,1309.34,percent of total billed charges,Implant Device,1309.34,34,,1309.34,percent of total billed charges,Implant Device,1309.34,34,,1309.34,percent of total billed charges,Implant Device,1906.25,,,1906.25,Other,110% of Medicare,1347.85,35,,1347.85,percent of total billed charges,Implant Device,1309.34,34,"Charges > $500, x 34%",1309.34,percent of total billed charges,Implant Device,1347.85,35,,1347.85,percent of total billed charges,Implant Device,1347.85,35,,1347.85,percent of total billed charges,Implant Device,1347.85,35,,1347.85,percent of total billed charges,Implant Device,1347.85,35,,1347.85,percent of total billed charges,Implant Device,1347.85,35,,1347.85,percent of total billed charges,Implant Device,1540.4,40,,1540.4,percent of total billed charges,Implant Device,1347.85,70,,1347.85,percent of total billed charges,All Other,1309.34,34,,1309.34,percent of total billed charges,Implant Device,1309.34,34,,1309.34,percent of total billed charges,Implant Device,1347.85,35,,1347.85,percent of total billed charges,Implant Device,1347.85,35,,1347.85,percent of total billed charges,Implant Device,1347.85,35,,1347.85,percent of total billed charges,Implant Device,1347.85,35,,1347.85,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1309.34,34,"If Charge > 2,000, then 34 percent",1309.34,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2849.75,
EV3 PRB35-06-040-120 EVERFLEX STENT,C1876,HCPCS,,79000198,CDM,278,RC,,,both,,,3975,2941.51,,,2941.51,Other,150% of Medicare + 9.63% HCRA Surcharge,1788.75,45,,1788.75,percent of total billed charges,Critical Access Hospital RCC factor,1351.5,34,,1351.5,percent of total billed charges,Implant Device,1351.5,34,,1351.5,percent of total billed charges,Implant Device,1351.5,34,,1351.5,percent of total billed charges,Implant Device,1351.5,34,,1351.5,percent of total billed charges,Implant Device,1351.5,34,,1351.5,percent of total billed charges,Implant Device,1967.63,,,1967.63,Other,110% of Medicare,1391.25,35,,1391.25,percent of total billed charges,Implant Device,1351.5,34,"Charges > $500, x 34%",1351.5,percent of total billed charges,Implant Device,1391.25,35,,1391.25,percent of total billed charges,Implant Device,1391.25,35,,1391.25,percent of total billed charges,Implant Device,1391.25,35,,1391.25,percent of total billed charges,Implant Device,1391.25,35,,1391.25,percent of total billed charges,Implant Device,1391.25,35,,1391.25,percent of total billed charges,Implant Device,1590,40,,1590,percent of total billed charges,Implant Device,1391.25,70,,1391.25,percent of total billed charges,All Other,1351.5,34,,1351.5,percent of total billed charges,Implant Device,1351.5,34,,1351.5,percent of total billed charges,Implant Device,1391.25,35,,1391.25,percent of total billed charges,Implant Device,1391.25,35,,1391.25,percent of total billed charges,Implant Device,1391.25,35,,1391.25,percent of total billed charges,Implant Device,1391.25,35,,1391.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1351.5,34,"If Charge > 2,000, then 34 percent",1351.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2941.51,
J&J C06040SL 6X40X80 SMARTSTENT,C1876,HCPCS,,79000200,CDM,278,RC,,,both,,,2100,1554.01,,,1554.01,Other,150% of Medicare + 9.63% HCRA Surcharge,945,45,,945,percent of total billed charges,Critical Access Hospital RCC factor,714,34,,714,percent of total billed charges,Implant Device,714,34,,714,percent of total billed charges,Implant Device,714,34,,714,percent of total billed charges,Implant Device,714,34,,714,percent of total billed charges,Implant Device,714,34,,714,percent of total billed charges,Implant Device,1039.5,,,1039.5,Other,110% of Medicare,735,35,,735,percent of total billed charges,Implant Device,714,34,"Charges > $500, x 34%",714,percent of total billed charges,Implant Device,735,35,,735,percent of total billed charges,Implant Device,735,35,,735,percent of total billed charges,Implant Device,735,35,,735,percent of total billed charges,Implant Device,735,35,,735,percent of total billed charges,Implant Device,735,35,,735,percent of total billed charges,Implant Device,840,40,,840,percent of total billed charges,Implant Device,735,70,,735,percent of total billed charges,All Other,714,34,,714,percent of total billed charges,Implant Device,714,34,,714,percent of total billed charges,Implant Device,735,35,,735,percent of total billed charges,Implant Device,735,35,,735,percent of total billed charges,Implant Device,735,35,,735,percent of total billed charges,Implant Device,735,35,,735,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,714,34,"If Charge > 2,000, then 34 percent",714,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1554.01,
BARD EX060603CS 6X60X130 LIFE STENT,C1876,HCPCS,,79000201,CDM,278,RC,,,both,,,3150,2331.01,,,2331.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1417.5,45,,1417.5,percent of total billed charges,Critical Access Hospital RCC factor,1071,34,,1071,percent of total billed charges,Implant Device,1071,34,,1071,percent of total billed charges,Implant Device,1071,34,,1071,percent of total billed charges,Implant Device,1071,34,,1071,percent of total billed charges,Implant Device,1071,34,,1071,percent of total billed charges,Implant Device,1559.25,,,1559.25,Other,110% of Medicare,1102.5,35,,1102.5,percent of total billed charges,Implant Device,1071,34,"Charges > $500, x 34%",1071,percent of total billed charges,Implant Device,1102.5,35,,1102.5,percent of total billed charges,Implant Device,1102.5,35,,1102.5,percent of total billed charges,Implant Device,1102.5,35,,1102.5,percent of total billed charges,Implant Device,1102.5,35,,1102.5,percent of total billed charges,Implant Device,1102.5,35,,1102.5,percent of total billed charges,Implant Device,1260,40,,1260,percent of total billed charges,Implant Device,1102.5,70,,1102.5,percent of total billed charges,All Other,1071,34,,1071,percent of total billed charges,Implant Device,1071,34,,1071,percent of total billed charges,Implant Device,1102.5,35,,1102.5,percent of total billed charges,Implant Device,1102.5,35,,1102.5,percent of total billed charges,Implant Device,1102.5,35,,1102.5,percent of total billed charges,Implant Device,1102.5,35,,1102.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1071,34,"If Charge > 2,000, then 34 percent",1071,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2331.01,
J&J C06060SL 6X60X80 SMARTSTENT,C1876,HCPCS,,79000202,CDM,278,RC,,,both,,,4343,3213.83,,,3213.83,Other,150% of Medicare + 9.63% HCRA Surcharge,1954.35,45,,1954.35,percent of total billed charges,Critical Access Hospital RCC factor,1476.62,34,,1476.62,percent of total billed charges,Implant Device,1476.62,34,,1476.62,percent of total billed charges,Implant Device,1476.62,34,,1476.62,percent of total billed charges,Implant Device,1476.62,34,,1476.62,percent of total billed charges,Implant Device,1476.62,34,,1476.62,percent of total billed charges,Implant Device,2149.79,,,2149.79,Other,110% of Medicare,1520.05,35,,1520.05,percent of total billed charges,Implant Device,1476.62,34,"Charges > $500, x 34%",1476.62,percent of total billed charges,Implant Device,1520.05,35,,1520.05,percent of total billed charges,Implant Device,1520.05,35,,1520.05,percent of total billed charges,Implant Device,1520.05,35,,1520.05,percent of total billed charges,Implant Device,1520.05,35,,1520.05,percent of total billed charges,Implant Device,1520.05,35,,1520.05,percent of total billed charges,Implant Device,1737.2,40,,1737.2,percent of total billed charges,Implant Device,1520.05,70,,1520.05,percent of total billed charges,All Other,1476.62,34,,1476.62,percent of total billed charges,Implant Device,1476.62,34,,1476.62,percent of total billed charges,Implant Device,1520.05,35,,1520.05,percent of total billed charges,Implant Device,1520.05,35,,1520.05,percent of total billed charges,Implant Device,1520.05,35,,1520.05,percent of total billed charges,Implant Device,1520.05,35,,1520.05,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1476.62,34,"If Charge > 2,000, then 34 percent",1476.62,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3213.83,
BARD EX071503CS 7X150X130 LIFE STENT,C1876,HCPCS,,79000216,CDM,278,RC,,,both,,,4350,3219.01,,,3219.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1957.5,45,,1957.5,percent of total billed charges,Critical Access Hospital RCC factor,1479,34,,1479,percent of total billed charges,Implant Device,1479,34,,1479,percent of total billed charges,Implant Device,1479,34,,1479,percent of total billed charges,Implant Device,1479,34,,1479,percent of total billed charges,Implant Device,1479,34,,1479,percent of total billed charges,Implant Device,2153.25,,,2153.25,Other,110% of Medicare,1522.5,35,,1522.5,percent of total billed charges,Implant Device,1479,34,"Charges > $500, x 34%",1479,percent of total billed charges,Implant Device,1522.5,35,,1522.5,percent of total billed charges,Implant Device,1522.5,35,,1522.5,percent of total billed charges,Implant Device,1522.5,35,,1522.5,percent of total billed charges,Implant Device,1522.5,35,,1522.5,percent of total billed charges,Implant Device,1522.5,35,,1522.5,percent of total billed charges,Implant Device,1740,40,,1740,percent of total billed charges,Implant Device,1522.5,70,,1522.5,percent of total billed charges,All Other,1479,34,,1479,percent of total billed charges,Implant Device,1479,34,,1479,percent of total billed charges,Implant Device,1522.5,35,,1522.5,percent of total billed charges,Implant Device,1522.5,35,,1522.5,percent of total billed charges,Implant Device,1522.5,35,,1522.5,percent of total billed charges,Implant Device,1522.5,35,,1522.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1479,34,"If Charge > 2,000, then 34 percent",1479,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3219.01,
BOST SCI 37911-71515 7X15 EXPRESS STENT,C1876,HCPCS,,79000219,CDM,278,RC,,,both,,,3600,2664.01,,,2664.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1620,45,,1620,percent of total billed charges,Critical Access Hospital RCC factor,1224,34,,1224,percent of total billed charges,Implant Device,1224,34,,1224,percent of total billed charges,Implant Device,1224,34,,1224,percent of total billed charges,Implant Device,1224,34,,1224,percent of total billed charges,Implant Device,1224,34,,1224,percent of total billed charges,Implant Device,1782,,,1782,Other,110% of Medicare,1260,35,,1260,percent of total billed charges,Implant Device,1224,34,"Charges > $500, x 34%",1224,percent of total billed charges,Implant Device,1260,35,,1260,percent of total billed charges,Implant Device,1260,35,,1260,percent of total billed charges,Implant Device,1260,35,,1260,percent of total billed charges,Implant Device,1260,35,,1260,percent of total billed charges,Implant Device,1260,35,,1260,percent of total billed charges,Implant Device,1440,40,,1440,percent of total billed charges,Implant Device,1260,70,,1260,percent of total billed charges,All Other,1224,34,,1224,percent of total billed charges,Implant Device,1224,34,,1224,percent of total billed charges,Implant Device,1260,35,,1260,percent of total billed charges,Implant Device,1260,35,,1260,percent of total billed charges,Implant Device,1260,35,,1260,percent of total billed charges,Implant Device,1260,35,,1260,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1224,34,"If Charge > 2,000, then 34 percent",1224,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2664.01,
BARD EX071703CS 7X170X130CM LIFE STENT,C1876,HCPCS,,79000220,CDM,278,RC,,,both,,,5100,3774.01,,,3774.01,Other,150% of Medicare + 9.63% HCRA Surcharge,2295,45,,2295,percent of total billed charges,Critical Access Hospital RCC factor,1734,34,,1734,percent of total billed charges,Implant Device,1734,34,,1734,percent of total billed charges,Implant Device,1734,34,,1734,percent of total billed charges,Implant Device,1734,34,,1734,percent of total billed charges,Implant Device,1734,34,,1734,percent of total billed charges,Implant Device,2524.5,,,2524.5,Other,110% of Medicare,1785,35,,1785,percent of total billed charges,Implant Device,1734,34,"Charges > $500, x 34%",1734,percent of total billed charges,Implant Device,1785,35,,1785,percent of total billed charges,Implant Device,1785,35,,1785,percent of total billed charges,Implant Device,1785,35,,1785,percent of total billed charges,Implant Device,1785,35,,1785,percent of total billed charges,Implant Device,1785,35,,1785,percent of total billed charges,Implant Device,2040,40,,2040,percent of total billed charges,Implant Device,1785,70,,1785,percent of total billed charges,All Other,1734,34,,1734,percent of total billed charges,Implant Device,1734,34,,1734,percent of total billed charges,Implant Device,1785,35,,1785,percent of total billed charges,Implant Device,1785,35,,1785,percent of total billed charges,Implant Device,1785,35,,1785,percent of total billed charges,Implant Device,1785,35,,1785,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1734,34,"If Charge > 2,000, then 34 percent",1734,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3774.01,
J&J C07030ML 7X30X80 SMARTSTENT,C1876,HCPCS,,79000222,CDM,278,RC,,,both,,,4429,3277.47,,,3277.47,Other,150% of Medicare + 9.63% HCRA Surcharge,1993.05,45,,1993.05,percent of total billed charges,Critical Access Hospital RCC factor,1505.86,34,,1505.86,percent of total billed charges,Implant Device,1505.86,34,,1505.86,percent of total billed charges,Implant Device,1505.86,34,,1505.86,percent of total billed charges,Implant Device,1505.86,34,,1505.86,percent of total billed charges,Implant Device,1505.86,34,,1505.86,percent of total billed charges,Implant Device,2192.36,,,2192.36,Other,110% of Medicare,1550.15,35,,1550.15,percent of total billed charges,Implant Device,1505.86,34,"Charges > $500, x 34%",1505.86,percent of total billed charges,Implant Device,1550.15,35,,1550.15,percent of total billed charges,Implant Device,1550.15,35,,1550.15,percent of total billed charges,Implant Device,1550.15,35,,1550.15,percent of total billed charges,Implant Device,1550.15,35,,1550.15,percent of total billed charges,Implant Device,1550.15,35,,1550.15,percent of total billed charges,Implant Device,1771.6,40,,1771.6,percent of total billed charges,Implant Device,1550.15,70,,1550.15,percent of total billed charges,All Other,1505.86,34,,1505.86,percent of total billed charges,Implant Device,1505.86,34,,1505.86,percent of total billed charges,Implant Device,1550.15,35,,1550.15,percent of total billed charges,Implant Device,1550.15,35,,1550.15,percent of total billed charges,Implant Device,1550.15,35,,1550.15,percent of total billed charges,Implant Device,1550.15,35,,1550.15,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1505.86,34,"If Charge > 2,000, then 34 percent",1505.86,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3277.47,
BARD FAF07050 7X50 FLAIR STENT GRAFT,C1768,HCPCS,,79000227,CDM,278,RC,,,both,,,8890,6578.62,,,6578.62,Other,150% of Medicare + 9.63% HCRA Surcharge,4000.5,45,,4000.5,percent of total billed charges,Critical Access Hospital RCC factor,3022.6,34,,3022.6,percent of total billed charges,Implant Device,3022.6,34,,3022.6,percent of total billed charges,Implant Device,3022.6,34,,3022.6,percent of total billed charges,Implant Device,3022.6,34,,3022.6,percent of total billed charges,Implant Device,3022.6,34,,3022.6,percent of total billed charges,Implant Device,4400.55,,,4400.55,Other,110% of Medicare,3111.5,35,,3111.5,percent of total billed charges,Implant Device,3022.6,34,"Charges > $500, x 34%",3022.6,percent of total billed charges,Implant Device,3111.5,35,,3111.5,percent of total billed charges,Implant Device,3111.5,35,,3111.5,percent of total billed charges,Implant Device,3111.5,35,,3111.5,percent of total billed charges,Implant Device,3111.5,35,,3111.5,percent of total billed charges,Implant Device,3111.5,35,,3111.5,percent of total billed charges,Implant Device,3556,40,,3556,percent of total billed charges,Implant Device,3111.5,70,,3111.5,percent of total billed charges,All Other,3022.6,34,,3022.6,percent of total billed charges,Implant Device,3022.6,34,,3022.6,percent of total billed charges,Implant Device,3111.5,35,,3111.5,percent of total billed charges,Implant Device,3111.5,35,,3111.5,percent of total billed charges,Implant Device,3111.5,35,,3111.5,percent of total billed charges,Implant Device,3111.5,35,,3111.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3022.6,34,"If Charge > 2,000, then 34 percent",3022.6,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,6578.62,
J&J C07080ML 7X80 SMARTSTENT,C1876,HCPCS,,79000229,CDM,278,RC,,,both,,,2100,1554.01,,,1554.01,Other,150% of Medicare + 9.63% HCRA Surcharge,945,45,,945,percent of total billed charges,Critical Access Hospital RCC factor,714,34,,714,percent of total billed charges,Implant Device,714,34,,714,percent of total billed charges,Implant Device,714,34,,714,percent of total billed charges,Implant Device,714,34,,714,percent of total billed charges,Implant Device,714,34,,714,percent of total billed charges,Implant Device,1039.5,,,1039.5,Other,110% of Medicare,735,35,,735,percent of total billed charges,Implant Device,714,34,"Charges > $500, x 34%",714,percent of total billed charges,Implant Device,735,35,,735,percent of total billed charges,Implant Device,735,35,,735,percent of total billed charges,Implant Device,735,35,,735,percent of total billed charges,Implant Device,735,35,,735,percent of total billed charges,Implant Device,735,35,,735,percent of total billed charges,Implant Device,840,40,,840,percent of total billed charges,Implant Device,735,70,,735,percent of total billed charges,All Other,714,34,,714,percent of total billed charges,Implant Device,714,34,,714,percent of total billed charges,Implant Device,735,35,,735,percent of total billed charges,Implant Device,735,35,,735,percent of total billed charges,Implant Device,735,35,,735,percent of total billed charges,Implant Device,735,35,,735,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,714,34,"If Charge > 2,000, then 34 percent",714,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1554.01,
BOST SCI 22-136 8FRX22CM STENT SYSTEM,C2617,HCPCS,,79000238,CDM,278,RC,,,both,,,310,229.4,,,229.4,Other,150% of Medicare + 9.63% HCRA Surcharge,139.5,45,,139.5,percent of total billed charges,Critical Access Hospital RCC factor,105.4,34,,105.4,percent of total billed charges,Implant Device,105.4,34,,105.4,percent of total billed charges,Implant Device,105.4,34,,105.4,percent of total billed charges,Implant Device,105.4,34,,105.4,percent of total billed charges,Implant Device,105.4,34,,105.4,percent of total billed charges,Implant Device,153.45,,,153.45,Other,110% of Medicare,108.5,35,,108.5,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,108.5,35,,108.5,percent of total billed charges,Implant Device,108.5,35,,108.5,percent of total billed charges,Implant Device,108.5,35,,108.5,percent of total billed charges,Implant Device,108.5,35,,108.5,percent of total billed charges,Implant Device,108.5,35,,108.5,percent of total billed charges,Implant Device,124,40,,124,percent of total billed charges,Implant Device,108.5,70,,108.5,percent of total billed charges,All Other,105.4,34,,105.4,percent of total billed charges,Implant Device,105.4,34,,105.4,percent of total billed charges,Implant Device,108.5,35,,108.5,percent of total billed charges,Implant Device,108.5,35,,108.5,percent of total billed charges,Implant Device,108.5,35,,108.5,percent of total billed charges,Implant Device,108.5,35,,108.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,229.4,
J&J C08100ML 8X100X125 SMARTSTENT,C1876,HCPCS,,79000241,CDM,278,RC,,,both,,,5587,4134.39,,,4134.39,Other,150% of Medicare + 9.63% HCRA Surcharge,2514.15,45,,2514.15,percent of total billed charges,Critical Access Hospital RCC factor,1899.58,34,,1899.58,percent of total billed charges,Implant Device,1899.58,34,,1899.58,percent of total billed charges,Implant Device,1899.58,34,,1899.58,percent of total billed charges,Implant Device,1899.58,34,,1899.58,percent of total billed charges,Implant Device,1899.58,34,,1899.58,percent of total billed charges,Implant Device,2765.57,,,2765.57,Other,110% of Medicare,1955.45,35,,1955.45,percent of total billed charges,Implant Device,1899.58,34,"Charges > $500, x 34%",1899.58,percent of total billed charges,Implant Device,1955.45,35,,1955.45,percent of total billed charges,Implant Device,1955.45,35,,1955.45,percent of total billed charges,Implant Device,1955.45,35,,1955.45,percent of total billed charges,Implant Device,1955.45,35,,1955.45,percent of total billed charges,Implant Device,1955.45,35,,1955.45,percent of total billed charges,Implant Device,2234.8,40,,2234.8,percent of total billed charges,Implant Device,1955.45,70,,1955.45,percent of total billed charges,All Other,1899.58,34,,1899.58,percent of total billed charges,Implant Device,1899.58,34,,1899.58,percent of total billed charges,Implant Device,1955.45,35,,1955.45,percent of total billed charges,Implant Device,1955.45,35,,1955.45,percent of total billed charges,Implant Device,1955.45,35,,1955.45,percent of total billed charges,Implant Device,1955.45,35,,1955.45,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1899.58,34,"If Charge > 2,000, then 34 percent",1899.58,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4134.39,
EV3 PXB35-08-27-080 8X27X80 VISPRO STENT,C1876,HCPCS,,79000243,CDM,278,RC,,,both,,,1950,1443,,,1443,Other,150% of Medicare + 9.63% HCRA Surcharge,877.5,45,,877.5,percent of total billed charges,Critical Access Hospital RCC factor,663,34,,663,percent of total billed charges,Implant Device,663,34,,663,percent of total billed charges,Implant Device,663,34,,663,percent of total billed charges,Implant Device,663,34,,663,percent of total billed charges,Implant Device,663,34,,663,percent of total billed charges,Implant Device,965.25,,,965.25,Other,110% of Medicare,682.5,35,,682.5,percent of total billed charges,Implant Device,663,34,"Charges > $500, x 34%",663,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,780,40,,780,percent of total billed charges,Implant Device,682.5,70,,682.5,percent of total billed charges,All Other,663,34,,663,percent of total billed charges,Implant Device,663,34,,663,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1443,
J&J C08030SL 8X30X80 SMARTSTENT,C1876,HCPCS,,79000244,CDM,278,RC,,,both,,,4429,3277.47,,,3277.47,Other,150% of Medicare + 9.63% HCRA Surcharge,1993.05,45,,1993.05,percent of total billed charges,Critical Access Hospital RCC factor,1505.86,34,,1505.86,percent of total billed charges,Implant Device,1505.86,34,,1505.86,percent of total billed charges,Implant Device,1505.86,34,,1505.86,percent of total billed charges,Implant Device,1505.86,34,,1505.86,percent of total billed charges,Implant Device,1505.86,34,,1505.86,percent of total billed charges,Implant Device,2192.36,,,2192.36,Other,110% of Medicare,1550.15,35,,1550.15,percent of total billed charges,Implant Device,1505.86,34,"Charges > $500, x 34%",1505.86,percent of total billed charges,Implant Device,1550.15,35,,1550.15,percent of total billed charges,Implant Device,1550.15,35,,1550.15,percent of total billed charges,Implant Device,1550.15,35,,1550.15,percent of total billed charges,Implant Device,1550.15,35,,1550.15,percent of total billed charges,Implant Device,1550.15,35,,1550.15,percent of total billed charges,Implant Device,1771.6,40,,1771.6,percent of total billed charges,Implant Device,1550.15,70,,1550.15,percent of total billed charges,All Other,1505.86,34,,1505.86,percent of total billed charges,Implant Device,1505.86,34,,1505.86,percent of total billed charges,Implant Device,1550.15,35,,1550.15,percent of total billed charges,Implant Device,1550.15,35,,1550.15,percent of total billed charges,Implant Device,1550.15,35,,1550.15,percent of total billed charges,Implant Device,1550.15,35,,1550.15,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1505.86,34,"If Charge > 2,000, then 34 percent",1505.86,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3277.47,
J&J C08040MB SMARTSTENT 8X40X120CM,C1876,HCPCS,,79000245,CDM,278,RC,,,both,,,2027,1499.99,,,1499.99,Other,150% of Medicare + 9.63% HCRA Surcharge,912.15,45,,912.15,percent of total billed charges,Critical Access Hospital RCC factor,689.18,34,,689.18,percent of total billed charges,Implant Device,689.18,34,,689.18,percent of total billed charges,Implant Device,689.18,34,,689.18,percent of total billed charges,Implant Device,689.18,34,,689.18,percent of total billed charges,Implant Device,689.18,34,,689.18,percent of total billed charges,Implant Device,1003.37,,,1003.37,Other,110% of Medicare,709.45,35,,709.45,percent of total billed charges,Implant Device,689.18,34,"Charges > $500, x 34%",689.18,percent of total billed charges,Implant Device,709.45,35,,709.45,percent of total billed charges,Implant Device,709.45,35,,709.45,percent of total billed charges,Implant Device,709.45,35,,709.45,percent of total billed charges,Implant Device,709.45,35,,709.45,percent of total billed charges,Implant Device,709.45,35,,709.45,percent of total billed charges,Implant Device,810.8,40,,810.8,percent of total billed charges,Implant Device,709.45,70,,709.45,percent of total billed charges,All Other,689.18,34,,689.18,percent of total billed charges,Implant Device,689.18,34,,689.18,percent of total billed charges,Implant Device,709.45,35,,709.45,percent of total billed charges,Implant Device,709.45,35,,709.45,percent of total billed charges,Implant Device,709.45,35,,709.45,percent of total billed charges,Implant Device,709.45,35,,709.45,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,689.18,34,"If Charge > 2,000, then 34 percent",689.18,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1499.99,
EV3 PRB35-08-080-080 EVERFLEXT STENT,C1876,HCPCS,,79000249,CDM,278,RC,,,both,,,3975,2941.51,,,2941.51,Other,150% of Medicare + 9.63% HCRA Surcharge,1788.75,45,,1788.75,percent of total billed charges,Critical Access Hospital RCC factor,1351.5,34,,1351.5,percent of total billed charges,Implant Device,1351.5,34,,1351.5,percent of total billed charges,Implant Device,1351.5,34,,1351.5,percent of total billed charges,Implant Device,1351.5,34,,1351.5,percent of total billed charges,Implant Device,1351.5,34,,1351.5,percent of total billed charges,Implant Device,1967.63,,,1967.63,Other,110% of Medicare,1391.25,35,,1391.25,percent of total billed charges,Implant Device,1351.5,34,"Charges > $500, x 34%",1351.5,percent of total billed charges,Implant Device,1391.25,35,,1391.25,percent of total billed charges,Implant Device,1391.25,35,,1391.25,percent of total billed charges,Implant Device,1391.25,35,,1391.25,percent of total billed charges,Implant Device,1391.25,35,,1391.25,percent of total billed charges,Implant Device,1391.25,35,,1391.25,percent of total billed charges,Implant Device,1590,40,,1590,percent of total billed charges,Implant Device,1391.25,70,,1391.25,percent of total billed charges,All Other,1351.5,34,,1351.5,percent of total billed charges,Implant Device,1351.5,34,,1351.5,percent of total billed charges,Implant Device,1391.25,35,,1391.25,percent of total billed charges,Implant Device,1391.25,35,,1391.25,percent of total billed charges,Implant Device,1391.25,35,,1391.25,percent of total billed charges,Implant Device,1391.25,35,,1391.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1351.5,34,"If Charge > 2,000, then 34 percent",1351.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2941.51,
BARD 600604 9FR HICKMAN CATHETER,C1751,HCPCS,,79000252,CDM,278,RC,,,both,,,1297,959.78,,,959.78,Other,150% of Medicare + 9.63% HCRA Surcharge,583.65,45,,583.65,percent of total billed charges,Critical Access Hospital RCC factor,440.98,34,,440.98,percent of total billed charges,Implant Device,440.98,34,,440.98,percent of total billed charges,Implant Device,440.98,34,,440.98,percent of total billed charges,Implant Device,440.98,34,,440.98,percent of total billed charges,Implant Device,440.98,34,,440.98,percent of total billed charges,Implant Device,642.02,,,642.02,Other,110% of Medicare,453.95,35,,453.95,percent of total billed charges,Implant Device,440.98,34,"Charges > $500, x 34%",440.98,percent of total billed charges,Implant Device,453.95,35,,453.95,percent of total billed charges,Implant Device,453.95,35,,453.95,percent of total billed charges,Implant Device,453.95,35,,453.95,percent of total billed charges,Implant Device,453.95,35,,453.95,percent of total billed charges,Implant Device,453.95,35,,453.95,percent of total billed charges,Implant Device,518.8,40,,518.8,percent of total billed charges,Implant Device,453.95,70,,453.95,percent of total billed charges,All Other,440.98,34,,440.98,percent of total billed charges,Implant Device,440.98,34,,440.98,percent of total billed charges,Implant Device,453.95,35,,453.95,percent of total billed charges,Implant Device,453.95,35,,453.95,percent of total billed charges,Implant Device,453.95,35,,453.95,percent of total billed charges,Implant Device,453.95,35,,453.95,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,959.78,
BARD FAS09050 FLAIR STR COVERED STENT,C1875,HCPCS,,79000259,CDM,278,RC,,,both,,,7486,5539.66,,,5539.66,Other,150% of Medicare + 9.63% HCRA Surcharge,3368.7,45,,3368.7,percent of total billed charges,Critical Access Hospital RCC factor,2545.24,34,,2545.24,percent of total billed charges,Implant Device,2545.24,34,,2545.24,percent of total billed charges,Implant Device,2545.24,34,,2545.24,percent of total billed charges,Implant Device,2545.24,34,,2545.24,percent of total billed charges,Implant Device,2545.24,34,,2545.24,percent of total billed charges,Implant Device,3705.57,,,3705.57,Other,110% of Medicare,2620.1,35,,2620.1,percent of total billed charges,Implant Device,2545.24,34,"Charges > $500, x 34%",2545.24,percent of total billed charges,Implant Device,2620.1,35,,2620.1,percent of total billed charges,Implant Device,2620.1,35,,2620.1,percent of total billed charges,Implant Device,2620.1,35,,2620.1,percent of total billed charges,Implant Device,2620.1,35,,2620.1,percent of total billed charges,Implant Device,2620.1,35,,2620.1,percent of total billed charges,Implant Device,2994.4,40,,2994.4,percent of total billed charges,Implant Device,2620.1,70,,2620.1,percent of total billed charges,All Other,2545.24,34,,2545.24,percent of total billed charges,Implant Device,2545.24,34,,2545.24,percent of total billed charges,Implant Device,2620.1,35,,2620.1,percent of total billed charges,Implant Device,2620.1,35,,2620.1,percent of total billed charges,Implant Device,2620.1,35,,2620.1,percent of total billed charges,Implant Device,2620.1,35,,2620.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2545.24,34,"If Charge > 2,000, then 34 percent",2545.24,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5539.66,
EV3 SERB65-09-60-80 PROTOGE GPS STENT,C1876,HCPCS,,79000260,CDM,278,RC,,,both,,,1950,1443,,,1443,Other,150% of Medicare + 9.63% HCRA Surcharge,877.5,45,,877.5,percent of total billed charges,Critical Access Hospital RCC factor,663,34,,663,percent of total billed charges,Implant Device,663,34,,663,percent of total billed charges,Implant Device,663,34,,663,percent of total billed charges,Implant Device,663,34,,663,percent of total billed charges,Implant Device,663,34,,663,percent of total billed charges,Implant Device,965.25,,,965.25,Other,110% of Medicare,682.5,35,,682.5,percent of total billed charges,Implant Device,663,34,"Charges > $500, x 34%",663,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,780,40,,780,percent of total billed charges,Implant Device,682.5,70,,682.5,percent of total billed charges,All Other,663,34,,663,percent of total billed charges,Implant Device,663,34,,663,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1443,
ARROW CS-15272-X CATHETER NEXT STEP 27CM,C1750,HCPCS,,79000292,CDM,278,RC,,,both,,,1002,741.48,,,741.48,Other,150% of Medicare + 9.63% HCRA Surcharge,450.9,45,,450.9,percent of total billed charges,Critical Access Hospital RCC factor,340.68,34,,340.68,percent of total billed charges,Implant Device,340.68,34,,340.68,percent of total billed charges,Implant Device,340.68,34,,340.68,percent of total billed charges,Implant Device,340.68,34,,340.68,percent of total billed charges,Implant Device,340.68,34,,340.68,percent of total billed charges,Implant Device,495.99,,,495.99,Other,110% of Medicare,350.7,35,,350.7,percent of total billed charges,Implant Device,340.68,34,"Charges > $500, x 34%",340.68,percent of total billed charges,Implant Device,350.7,35,,350.7,percent of total billed charges,Implant Device,350.7,35,,350.7,percent of total billed charges,Implant Device,350.7,35,,350.7,percent of total billed charges,Implant Device,350.7,35,,350.7,percent of total billed charges,Implant Device,350.7,35,,350.7,percent of total billed charges,Implant Device,400.8,40,,400.8,percent of total billed charges,Implant Device,350.7,70,,350.7,percent of total billed charges,All Other,340.68,34,,340.68,percent of total billed charges,Implant Device,340.68,34,,340.68,percent of total billed charges,Implant Device,350.7,35,,350.7,percent of total billed charges,Implant Device,350.7,35,,350.7,percent of total billed charges,Implant Device,350.7,35,,350.7,percent of total billed charges,Implant Device,350.7,35,,350.7,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,741.48,
MEDTRONIC C01B CEMENT WITH MIXER,C1713,HCPCS,,79000307,CDM,278,RC,,,both,,,630,466.2,,,466.2,Other,150% of Medicare + 9.63% HCRA Surcharge,283.5,45,,283.5,percent of total billed charges,Critical Access Hospital RCC factor,214.2,34,,214.2,percent of total billed charges,Implant Device,214.2,34,,214.2,percent of total billed charges,Implant Device,214.2,34,,214.2,percent of total billed charges,Implant Device,214.2,34,,214.2,percent of total billed charges,Implant Device,214.2,34,,214.2,percent of total billed charges,Implant Device,311.85,,,311.85,Other,110% of Medicare,220.5,35,,220.5,percent of total billed charges,Implant Device,214.2,34,"Charges > $500, x 34%",214.2,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,252,40,,252,percent of total billed charges,Implant Device,220.5,70,,220.5,percent of total billed charges,All Other,214.2,34,,214.2,percent of total billed charges,Implant Device,214.2,34,,214.2,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,466.2,
ATRIUM 85409 COVERED STENT 9X59X80,C1877,HCPCS,,79000325,CDM,278,RC,,,both,,,8326,6161.26,,,6161.26,Other,150% of Medicare + 9.63% HCRA Surcharge,3746.7,45,,3746.7,percent of total billed charges,Critical Access Hospital RCC factor,2830.84,34,,2830.84,percent of total billed charges,Implant Device,2830.84,34,,2830.84,percent of total billed charges,Implant Device,2830.84,34,,2830.84,percent of total billed charges,Implant Device,2830.84,34,,2830.84,percent of total billed charges,Implant Device,2830.84,34,,2830.84,percent of total billed charges,Implant Device,4121.37,,,4121.37,Other,110% of Medicare,2914.1,35,,2914.1,percent of total billed charges,Implant Device,2830.84,34,"Charges > $500, x 34%",2830.84,percent of total billed charges,Implant Device,2914.1,35,,2914.1,percent of total billed charges,Implant Device,2914.1,35,,2914.1,percent of total billed charges,Implant Device,2914.1,35,,2914.1,percent of total billed charges,Implant Device,2914.1,35,,2914.1,percent of total billed charges,Implant Device,2914.1,35,,2914.1,percent of total billed charges,Implant Device,3330.4,40,,3330.4,percent of total billed charges,Implant Device,2914.1,70,,2914.1,percent of total billed charges,All Other,2830.84,34,,2830.84,percent of total billed charges,Implant Device,2830.84,34,,2830.84,percent of total billed charges,Implant Device,2914.1,35,,2914.1,percent of total billed charges,Implant Device,2914.1,35,,2914.1,percent of total billed charges,Implant Device,2914.1,35,,2914.1,percent of total billed charges,Implant Device,2914.1,35,,2914.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2830.84,34,"If Charge > 2,000, then 34 percent",2830.84,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,6161.26,
EV3 PRB35-08-060-080 EVERFLEX STENT,C1876,HCPCS,,79000351,CDM,278,RC,,,both,,,3975,2941.51,,,2941.51,Other,150% of Medicare + 9.63% HCRA Surcharge,1788.75,45,,1788.75,percent of total billed charges,Critical Access Hospital RCC factor,1351.5,34,,1351.5,percent of total billed charges,Implant Device,1351.5,34,,1351.5,percent of total billed charges,Implant Device,1351.5,34,,1351.5,percent of total billed charges,Implant Device,1351.5,34,,1351.5,percent of total billed charges,Implant Device,1351.5,34,,1351.5,percent of total billed charges,Implant Device,1967.63,,,1967.63,Other,110% of Medicare,1391.25,35,,1391.25,percent of total billed charges,Implant Device,1351.5,34,"Charges > $500, x 34%",1351.5,percent of total billed charges,Implant Device,1391.25,35,,1391.25,percent of total billed charges,Implant Device,1391.25,35,,1391.25,percent of total billed charges,Implant Device,1391.25,35,,1391.25,percent of total billed charges,Implant Device,1391.25,35,,1391.25,percent of total billed charges,Implant Device,1391.25,35,,1391.25,percent of total billed charges,Implant Device,1590,40,,1590,percent of total billed charges,Implant Device,1391.25,70,,1391.25,percent of total billed charges,All Other,1351.5,34,,1351.5,percent of total billed charges,Implant Device,1351.5,34,,1351.5,percent of total billed charges,Implant Device,1391.25,35,,1391.25,percent of total billed charges,Implant Device,1391.25,35,,1391.25,percent of total billed charges,Implant Device,1391.25,35,,1391.25,percent of total billed charges,Implant Device,1391.25,35,,1391.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1351.5,34,"If Charge > 2,000, then 34 percent",1351.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2941.51,
BOST SCI 38046-83075 EXPRESS STENT 8X75,C1876,HCPCS,,79000352,CDM,278,RC,,,both,,,3575,2645.51,,,2645.51,Other,150% of Medicare + 9.63% HCRA Surcharge,1608.75,45,,1608.75,percent of total billed charges,Critical Access Hospital RCC factor,1215.5,34,,1215.5,percent of total billed charges,Implant Device,1215.5,34,,1215.5,percent of total billed charges,Implant Device,1215.5,34,,1215.5,percent of total billed charges,Implant Device,1215.5,34,,1215.5,percent of total billed charges,Implant Device,1215.5,34,,1215.5,percent of total billed charges,Implant Device,1769.63,,,1769.63,Other,110% of Medicare,1251.25,35,,1251.25,percent of total billed charges,Implant Device,1215.5,34,"Charges > $500, x 34%",1215.5,percent of total billed charges,Implant Device,1251.25,35,,1251.25,percent of total billed charges,Implant Device,1251.25,35,,1251.25,percent of total billed charges,Implant Device,1251.25,35,,1251.25,percent of total billed charges,Implant Device,1251.25,35,,1251.25,percent of total billed charges,Implant Device,1251.25,35,,1251.25,percent of total billed charges,Implant Device,1430,40,,1430,percent of total billed charges,Implant Device,1251.25,70,,1251.25,percent of total billed charges,All Other,1215.5,34,,1215.5,percent of total billed charges,Implant Device,1215.5,34,,1215.5,percent of total billed charges,Implant Device,1251.25,35,,1251.25,percent of total billed charges,Implant Device,1251.25,35,,1251.25,percent of total billed charges,Implant Device,1251.25,35,,1251.25,percent of total billed charges,Implant Device,1251.25,35,,1251.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1215.5,34,"If Charge > 2,000, then 34 percent",1215.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2645.51,
BOST SCI 37911-61415 EXPRESS SD STENT,C1876,HCPCS,,79000353,CDM,278,RC,,,both,,,3600,2664.01,,,2664.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1620,45,,1620,percent of total billed charges,Critical Access Hospital RCC factor,1224,34,,1224,percent of total billed charges,Implant Device,1224,34,,1224,percent of total billed charges,Implant Device,1224,34,,1224,percent of total billed charges,Implant Device,1224,34,,1224,percent of total billed charges,Implant Device,1224,34,,1224,percent of total billed charges,Implant Device,1782,,,1782,Other,110% of Medicare,1260,35,,1260,percent of total billed charges,Implant Device,1224,34,"Charges > $500, x 34%",1224,percent of total billed charges,Implant Device,1260,35,,1260,percent of total billed charges,Implant Device,1260,35,,1260,percent of total billed charges,Implant Device,1260,35,,1260,percent of total billed charges,Implant Device,1260,35,,1260,percent of total billed charges,Implant Device,1260,35,,1260,percent of total billed charges,Implant Device,1440,40,,1440,percent of total billed charges,Implant Device,1260,70,,1260,percent of total billed charges,All Other,1224,34,,1224,percent of total billed charges,Implant Device,1224,34,,1224,percent of total billed charges,Implant Device,1260,35,,1260,percent of total billed charges,Implant Device,1260,35,,1260,percent of total billed charges,Implant Device,1260,35,,1260,percent of total billed charges,Implant Device,1260,35,,1260,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1224,34,"If Charge > 2,000, then 34 percent",1224,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2664.01,
BOST SCI 38046-10407 EXPRESS STENT 10X37,C1876,HCPCS,,79000354,CDM,278,RC,,,both,,,3575,2645.51,,,2645.51,Other,150% of Medicare + 9.63% HCRA Surcharge,1608.75,45,,1608.75,percent of total billed charges,Critical Access Hospital RCC factor,1215.5,34,,1215.5,percent of total billed charges,Implant Device,1215.5,34,,1215.5,percent of total billed charges,Implant Device,1215.5,34,,1215.5,percent of total billed charges,Implant Device,1215.5,34,,1215.5,percent of total billed charges,Implant Device,1215.5,34,,1215.5,percent of total billed charges,Implant Device,1769.63,,,1769.63,Other,110% of Medicare,1251.25,35,,1251.25,percent of total billed charges,Implant Device,1215.5,34,"Charges > $500, x 34%",1215.5,percent of total billed charges,Implant Device,1251.25,35,,1251.25,percent of total billed charges,Implant Device,1251.25,35,,1251.25,percent of total billed charges,Implant Device,1251.25,35,,1251.25,percent of total billed charges,Implant Device,1251.25,35,,1251.25,percent of total billed charges,Implant Device,1251.25,35,,1251.25,percent of total billed charges,Implant Device,1430,40,,1430,percent of total billed charges,Implant Device,1251.25,70,,1251.25,percent of total billed charges,All Other,1215.5,34,,1215.5,percent of total billed charges,Implant Device,1215.5,34,,1215.5,percent of total billed charges,Implant Device,1251.25,35,,1251.25,percent of total billed charges,Implant Device,1251.25,35,,1251.25,percent of total billed charges,Implant Device,1251.25,35,,1251.25,percent of total billed charges,Implant Device,1251.25,35,,1251.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1215.5,34,"If Charge > 2,000, then 34 percent",1215.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2645.51,
BOST SCI 38046-84075 EXPRESS STENT 8X75,C1876,HCPCS,,79000355,CDM,278,RC,,,both,,,3575,2645.51,,,2645.51,Other,150% of Medicare + 9.63% HCRA Surcharge,1608.75,45,,1608.75,percent of total billed charges,Critical Access Hospital RCC factor,1215.5,34,,1215.5,percent of total billed charges,Implant Device,1215.5,34,,1215.5,percent of total billed charges,Implant Device,1215.5,34,,1215.5,percent of total billed charges,Implant Device,1215.5,34,,1215.5,percent of total billed charges,Implant Device,1215.5,34,,1215.5,percent of total billed charges,Implant Device,1769.63,,,1769.63,Other,110% of Medicare,1251.25,35,,1251.25,percent of total billed charges,Implant Device,1215.5,34,"Charges > $500, x 34%",1215.5,percent of total billed charges,Implant Device,1251.25,35,,1251.25,percent of total billed charges,Implant Device,1251.25,35,,1251.25,percent of total billed charges,Implant Device,1251.25,35,,1251.25,percent of total billed charges,Implant Device,1251.25,35,,1251.25,percent of total billed charges,Implant Device,1251.25,35,,1251.25,percent of total billed charges,Implant Device,1430,40,,1430,percent of total billed charges,Implant Device,1251.25,70,,1251.25,percent of total billed charges,All Other,1215.5,34,,1215.5,percent of total billed charges,Implant Device,1215.5,34,,1215.5,percent of total billed charges,Implant Device,1251.25,35,,1251.25,percent of total billed charges,Implant Device,1251.25,35,,1251.25,percent of total billed charges,Implant Device,1251.25,35,,1251.25,percent of total billed charges,Implant Device,1251.25,35,,1251.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1215.5,34,"If Charge > 2,000, then 34 percent",1215.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2645.51,
BOST SCI 38046-86075 EXPRESS STENT,C1876,HCPCS,,79000356,CDM,278,RC,,,both,,,4126,3053.25,,,3053.25,Other,150% of Medicare + 9.63% HCRA Surcharge,1856.7,45,,1856.7,percent of total billed charges,Critical Access Hospital RCC factor,1402.84,34,,1402.84,percent of total billed charges,Implant Device,1402.84,34,,1402.84,percent of total billed charges,Implant Device,1402.84,34,,1402.84,percent of total billed charges,Implant Device,1402.84,34,,1402.84,percent of total billed charges,Implant Device,1402.84,34,,1402.84,percent of total billed charges,Implant Device,2042.37,,,2042.37,Other,110% of Medicare,1444.1,35,,1444.1,percent of total billed charges,Implant Device,1402.84,34,"Charges > $500, x 34%",1402.84,percent of total billed charges,Implant Device,1444.1,35,,1444.1,percent of total billed charges,Implant Device,1444.1,35,,1444.1,percent of total billed charges,Implant Device,1444.1,35,,1444.1,percent of total billed charges,Implant Device,1444.1,35,,1444.1,percent of total billed charges,Implant Device,1444.1,35,,1444.1,percent of total billed charges,Implant Device,1650.4,40,,1650.4,percent of total billed charges,Implant Device,1444.1,70,,1444.1,percent of total billed charges,All Other,1402.84,34,,1402.84,percent of total billed charges,Implant Device,1402.84,34,,1402.84,percent of total billed charges,Implant Device,1444.1,35,,1444.1,percent of total billed charges,Implant Device,1444.1,35,,1444.1,percent of total billed charges,Implant Device,1444.1,35,,1444.1,percent of total billed charges,Implant Device,1444.1,35,,1444.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1402.84,34,"If Charge > 2,000, then 34 percent",1402.84,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3053.25,
BOST SCI 550304 FASTTRACKER 325 INF CATH,C1751,HCPCS,,79000357,CDM,278,RC,,,both,,,1390,1028.6,,,1028.6,Other,150% of Medicare + 9.63% HCRA Surcharge,625.5,45,,625.5,percent of total billed charges,Critical Access Hospital RCC factor,472.6,34,,472.6,percent of total billed charges,Implant Device,472.6,34,,472.6,percent of total billed charges,Implant Device,472.6,34,,472.6,percent of total billed charges,Implant Device,472.6,34,,472.6,percent of total billed charges,Implant Device,472.6,34,,472.6,percent of total billed charges,Implant Device,688.05,,,688.05,Other,110% of Medicare,486.5,35,,486.5,percent of total billed charges,Implant Device,472.6,34,"Charges > $500, x 34%",472.6,percent of total billed charges,Implant Device,486.5,35,,486.5,percent of total billed charges,Implant Device,486.5,35,,486.5,percent of total billed charges,Implant Device,486.5,35,,486.5,percent of total billed charges,Implant Device,486.5,35,,486.5,percent of total billed charges,Implant Device,486.5,35,,486.5,percent of total billed charges,Implant Device,556,40,,556,percent of total billed charges,Implant Device,486.5,70,,486.5,percent of total billed charges,All Other,472.6,34,,472.6,percent of total billed charges,Implant Device,472.6,34,,472.6,percent of total billed charges,Implant Device,486.5,35,,486.5,percent of total billed charges,Implant Device,486.5,35,,486.5,percent of total billed charges,Implant Device,486.5,35,,486.5,percent of total billed charges,Implant Device,486.5,35,,486.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1028.6,
BARD RF400F FEMORAL RECOVERY VC FILTER,C1880,HCPCS,,79000358,CDM,278,RC,,,both,,,4336,3208.65,,,3208.65,Other,150% of Medicare + 9.63% HCRA Surcharge,1951.2,45,,1951.2,percent of total billed charges,Critical Access Hospital RCC factor,1474.24,34,,1474.24,percent of total billed charges,Implant Device,1474.24,34,,1474.24,percent of total billed charges,Implant Device,1474.24,34,,1474.24,percent of total billed charges,Implant Device,1474.24,34,,1474.24,percent of total billed charges,Implant Device,1474.24,34,,1474.24,percent of total billed charges,Implant Device,2146.32,,,2146.32,Other,110% of Medicare,1517.6,35,,1517.6,percent of total billed charges,Implant Device,1474.24,34,"Charges > $500, x 34%",1474.24,percent of total billed charges,Implant Device,1517.6,35,,1517.6,percent of total billed charges,Implant Device,1517.6,35,,1517.6,percent of total billed charges,Implant Device,1517.6,35,,1517.6,percent of total billed charges,Implant Device,1517.6,35,,1517.6,percent of total billed charges,Implant Device,1517.6,35,,1517.6,percent of total billed charges,Implant Device,1734.4,40,,1734.4,percent of total billed charges,Implant Device,1517.6,70,,1517.6,percent of total billed charges,All Other,1474.24,34,,1474.24,percent of total billed charges,Implant Device,1474.24,34,,1474.24,percent of total billed charges,Implant Device,1517.6,35,,1517.6,percent of total billed charges,Implant Device,1517.6,35,,1517.6,percent of total billed charges,Implant Device,1517.6,35,,1517.6,percent of total billed charges,Implant Device,1517.6,35,,1517.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1474.24,34,"If Charge > 2,000, then 34 percent",1474.24,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3208.65,
J&J 466-F220A OPTEASE VC FILTER 55CM,C1880,HCPCS,,79000360,CDM,278,RC,,,both,,,4200,3108.01,,,3108.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1890,45,,1890,percent of total billed charges,Critical Access Hospital RCC factor,1428,34,,1428,percent of total billed charges,Implant Device,1428,34,,1428,percent of total billed charges,Implant Device,1428,34,,1428,percent of total billed charges,Implant Device,1428,34,,1428,percent of total billed charges,Implant Device,1428,34,,1428,percent of total billed charges,Implant Device,2079,,,2079,Other,110% of Medicare,1470,35,,1470,percent of total billed charges,Implant Device,1428,34,"Charges > $500, x 34%",1428,percent of total billed charges,Implant Device,1470,35,,1470,percent of total billed charges,Implant Device,1470,35,,1470,percent of total billed charges,Implant Device,1470,35,,1470,percent of total billed charges,Implant Device,1470,35,,1470,percent of total billed charges,Implant Device,1470,35,,1470,percent of total billed charges,Implant Device,1680,40,,1680,percent of total billed charges,Implant Device,1470,70,,1470,percent of total billed charges,All Other,1428,34,,1428,percent of total billed charges,Implant Device,1428,34,,1428,percent of total billed charges,Implant Device,1470,35,,1470,percent of total billed charges,Implant Device,1470,35,,1470,percent of total billed charges,Implant Device,1470,35,,1470,percent of total billed charges,Implant Device,1470,35,,1470,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1428,34,"If Charge > 2,000, then 34 percent",1428,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3108.01,
FLUENCY STENT,C1874,HCPCS,,79000369,CDM,278,RC,,,both,,,6886,5095.66,,,5095.66,Other,150% of Medicare + 9.63% HCRA Surcharge,3098.7,45,,3098.7,percent of total billed charges,Critical Access Hospital RCC factor,2341.24,34,,2341.24,percent of total billed charges,Implant Device,2341.24,34,,2341.24,percent of total billed charges,Implant Device,2341.24,34,,2341.24,percent of total billed charges,Implant Device,2341.24,34,,2341.24,percent of total billed charges,Implant Device,2341.24,34,,2341.24,percent of total billed charges,Implant Device,3408.57,,,3408.57,Other,110% of Medicare,2410.1,35,,2410.1,percent of total billed charges,Implant Device,2341.24,34,"Charges > $500, x 34%",2341.24,percent of total billed charges,Implant Device,2410.1,35,,2410.1,percent of total billed charges,Implant Device,2410.1,35,,2410.1,percent of total billed charges,Implant Device,2410.1,35,,2410.1,percent of total billed charges,Implant Device,2410.1,35,,2410.1,percent of total billed charges,Implant Device,2410.1,35,,2410.1,percent of total billed charges,Implant Device,2754.4,40,,2754.4,percent of total billed charges,Implant Device,2410.1,70,,2410.1,percent of total billed charges,All Other,2341.24,34,,2341.24,percent of total billed charges,Implant Device,2341.24,34,,2341.24,percent of total billed charges,Implant Device,2410.1,35,,2410.1,percent of total billed charges,Implant Device,2410.1,35,,2410.1,percent of total billed charges,Implant Device,2410.1,35,,2410.1,percent of total billed charges,Implant Device,2410.1,35,,2410.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2341.24,34,"If Charge > 2,000, then 34 percent",2341.24,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5095.66,
BOST SCI 22-143 NEPHROURETRAL STENT,C2617,HCPCS,,79000431,CDM,278,RC,,,both,,,310,229.4,,,229.4,Other,150% of Medicare + 9.63% HCRA Surcharge,139.5,45,,139.5,percent of total billed charges,Critical Access Hospital RCC factor,105.4,34,,105.4,percent of total billed charges,Implant Device,105.4,34,,105.4,percent of total billed charges,Implant Device,105.4,34,,105.4,percent of total billed charges,Implant Device,105.4,34,,105.4,percent of total billed charges,Implant Device,105.4,34,,105.4,percent of total billed charges,Implant Device,153.45,,,153.45,Other,110% of Medicare,108.5,35,,108.5,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,108.5,35,,108.5,percent of total billed charges,Implant Device,108.5,35,,108.5,percent of total billed charges,Implant Device,108.5,35,,108.5,percent of total billed charges,Implant Device,108.5,35,,108.5,percent of total billed charges,Implant Device,108.5,35,,108.5,percent of total billed charges,Implant Device,124,40,,124,percent of total billed charges,Implant Device,108.5,70,,108.5,percent of total billed charges,All Other,105.4,34,,105.4,percent of total billed charges,Implant Device,105.4,34,,105.4,percent of total billed charges,Implant Device,108.5,35,,108.5,percent of total billed charges,Implant Device,108.5,35,,108.5,percent of total billed charges,Implant Device,108.5,35,,108.5,percent of total billed charges,Implant Device,108.5,35,,108.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,229.4,
ARROW CS-15192-X NEXTSTEP DIAL CATH 19CM,C1750,HCPCS,,79000432,CDM,278,RC,,,both,,,1002,741.48,,,741.48,Other,150% of Medicare + 9.63% HCRA Surcharge,450.9,45,,450.9,percent of total billed charges,Critical Access Hospital RCC factor,340.68,34,,340.68,percent of total billed charges,Implant Device,340.68,34,,340.68,percent of total billed charges,Implant Device,340.68,34,,340.68,percent of total billed charges,Implant Device,340.68,34,,340.68,percent of total billed charges,Implant Device,340.68,34,,340.68,percent of total billed charges,Implant Device,495.99,,,495.99,Other,110% of Medicare,350.7,35,,350.7,percent of total billed charges,Implant Device,340.68,34,"Charges > $500, x 34%",340.68,percent of total billed charges,Implant Device,350.7,35,,350.7,percent of total billed charges,Implant Device,350.7,35,,350.7,percent of total billed charges,Implant Device,350.7,35,,350.7,percent of total billed charges,Implant Device,350.7,35,,350.7,percent of total billed charges,Implant Device,350.7,35,,350.7,percent of total billed charges,Implant Device,400.8,40,,400.8,percent of total billed charges,Implant Device,350.7,70,,350.7,percent of total billed charges,All Other,340.68,34,,340.68,percent of total billed charges,Implant Device,340.68,34,,340.68,percent of total billed charges,Implant Device,350.7,35,,350.7,percent of total billed charges,Implant Device,350.7,35,,350.7,percent of total billed charges,Implant Device,350.7,35,,350.7,percent of total billed charges,Implant Device,350.7,35,,350.7,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,741.48,
ARROW CS-15232-X NEXTSTEP PERMACATH 23CM,C1750,HCPCS,,79000433,CDM,278,RC,,,both,,,1002,741.48,,,741.48,Other,150% of Medicare + 9.63% HCRA Surcharge,450.9,45,,450.9,percent of total billed charges,Critical Access Hospital RCC factor,340.68,34,,340.68,percent of total billed charges,Implant Device,340.68,34,,340.68,percent of total billed charges,Implant Device,340.68,34,,340.68,percent of total billed charges,Implant Device,340.68,34,,340.68,percent of total billed charges,Implant Device,340.68,34,,340.68,percent of total billed charges,Implant Device,495.99,,,495.99,Other,110% of Medicare,350.7,35,,350.7,percent of total billed charges,Implant Device,340.68,34,"Charges > $500, x 34%",340.68,percent of total billed charges,Implant Device,350.7,35,,350.7,percent of total billed charges,Implant Device,350.7,35,,350.7,percent of total billed charges,Implant Device,350.7,35,,350.7,percent of total billed charges,Implant Device,350.7,35,,350.7,percent of total billed charges,Implant Device,350.7,35,,350.7,percent of total billed charges,Implant Device,400.8,40,,400.8,percent of total billed charges,Implant Device,350.7,70,,350.7,percent of total billed charges,All Other,340.68,34,,340.68,percent of total billed charges,Implant Device,340.68,34,,340.68,percent of total billed charges,Implant Device,350.7,35,,350.7,percent of total billed charges,Implant Device,350.7,35,,350.7,percent of total billed charges,Implant Device,350.7,35,,350.7,percent of total billed charges,Implant Device,350.7,35,,350.7,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,741.48,
ARGON 352506070 OPTION FILTER 70CM,C1880,HCPCS,,79000439,CDM,278,RC,,,both,,,3150,2331.01,,,2331.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1417.5,45,,1417.5,percent of total billed charges,Critical Access Hospital RCC factor,1071,34,,1071,percent of total billed charges,Implant Device,1071,34,,1071,percent of total billed charges,Implant Device,1071,34,,1071,percent of total billed charges,Implant Device,1071,34,,1071,percent of total billed charges,Implant Device,1071,34,,1071,percent of total billed charges,Implant Device,1559.25,,,1559.25,Other,110% of Medicare,1102.5,35,,1102.5,percent of total billed charges,Implant Device,1071,34,"Charges > $500, x 34%",1071,percent of total billed charges,Implant Device,1102.5,35,,1102.5,percent of total billed charges,Implant Device,1102.5,35,,1102.5,percent of total billed charges,Implant Device,1102.5,35,,1102.5,percent of total billed charges,Implant Device,1102.5,35,,1102.5,percent of total billed charges,Implant Device,1102.5,35,,1102.5,percent of total billed charges,Implant Device,1260,40,,1260,percent of total billed charges,Implant Device,1102.5,70,,1102.5,percent of total billed charges,All Other,1071,34,,1071,percent of total billed charges,Implant Device,1071,34,,1071,percent of total billed charges,Implant Device,1102.5,35,,1102.5,percent of total billed charges,Implant Device,1102.5,35,,1102.5,percent of total billed charges,Implant Device,1102.5,35,,1102.5,percent of total billed charges,Implant Device,1102.5,35,,1102.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1071,34,"If Charge > 2,000, then 34 percent",1071,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2331.01,
J&J P5010 PALMZ STENT 10MM X 50MM,C1876,HCPCS,,79000442,CDM,278,RC,,,both,,,4295,3178.31,,,3178.31,Other,150% of Medicare + 9.63% HCRA Surcharge,1932.75,45,,1932.75,percent of total billed charges,Critical Access Hospital RCC factor,1460.3,34,,1460.3,percent of total billed charges,Implant Device,1460.3,34,,1460.3,percent of total billed charges,Implant Device,1460.3,34,,1460.3,percent of total billed charges,Implant Device,1460.3,34,,1460.3,percent of total billed charges,Implant Device,1460.3,34,,1460.3,percent of total billed charges,Implant Device,2126.03,,,2126.03,Other,110% of Medicare,1503.25,35,,1503.25,percent of total billed charges,Implant Device,1460.3,34,"Charges > $500, x 34%",1460.3,percent of total billed charges,Implant Device,1503.25,35,,1503.25,percent of total billed charges,Implant Device,1503.25,35,,1503.25,percent of total billed charges,Implant Device,1503.25,35,,1503.25,percent of total billed charges,Implant Device,1503.25,35,,1503.25,percent of total billed charges,Implant Device,1503.25,35,,1503.25,percent of total billed charges,Implant Device,1718,40,,1718,percent of total billed charges,Implant Device,1503.25,70,,1503.25,percent of total billed charges,All Other,1460.3,34,,1460.3,percent of total billed charges,Implant Device,1460.3,34,,1460.3,percent of total billed charges,Implant Device,1503.25,35,,1503.25,percent of total billed charges,Implant Device,1503.25,35,,1503.25,percent of total billed charges,Implant Device,1503.25,35,,1503.25,percent of total billed charges,Implant Device,1503.25,35,,1503.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1460.3,34,"If Charge > 2,000, then 34 percent",1460.3,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3178.31,
ARROW CS-15282-SPM PERMACATH 23CM,C1750,HCPCS,,79000445,CDM,278,RC,,,both,,,997,737.78,,,737.78,Other,150% of Medicare + 9.63% HCRA Surcharge,448.65,45,,448.65,percent of total billed charges,Critical Access Hospital RCC factor,338.98,34,,338.98,percent of total billed charges,Implant Device,338.98,34,,338.98,percent of total billed charges,Implant Device,338.98,34,,338.98,percent of total billed charges,Implant Device,338.98,34,,338.98,percent of total billed charges,Implant Device,338.98,34,,338.98,percent of total billed charges,Implant Device,493.52,,,493.52,Other,110% of Medicare,348.95,35,,348.95,percent of total billed charges,Implant Device,338.98,34,"Charges > $500, x 34%",338.98,percent of total billed charges,Implant Device,348.95,35,,348.95,percent of total billed charges,Implant Device,348.95,35,,348.95,percent of total billed charges,Implant Device,348.95,35,,348.95,percent of total billed charges,Implant Device,348.95,35,,348.95,percent of total billed charges,Implant Device,348.95,35,,348.95,percent of total billed charges,Implant Device,398.8,40,,398.8,percent of total billed charges,Implant Device,348.95,70,,348.95,percent of total billed charges,All Other,338.98,34,,338.98,percent of total billed charges,Implant Device,338.98,34,,338.98,percent of total billed charges,Implant Device,348.95,35,,348.95,percent of total billed charges,Implant Device,348.95,35,,348.95,percent of total billed charges,Implant Device,348.95,35,,348.95,percent of total billed charges,Implant Device,348.95,35,,348.95,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,737.78,
NAVILYST 45-594 PICC VAXCEL MST KIT 4FR,C1751,HCPCS,,79000446,CDM,278,RC,,,both,,,384,284.16,,,284.16,Other,150% of Medicare + 9.63% HCRA Surcharge,172.8,45,,172.8,percent of total billed charges,Critical Access Hospital RCC factor,130.56,34,,130.56,percent of total billed charges,Implant Device,130.56,34,,130.56,percent of total billed charges,Implant Device,130.56,34,,130.56,percent of total billed charges,Implant Device,130.56,34,,130.56,percent of total billed charges,Implant Device,130.56,34,,130.56,percent of total billed charges,Implant Device,190.08,,,190.08,Other,110% of Medicare,134.4,35,,134.4,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,134.4,35,,134.4,percent of total billed charges,Implant Device,134.4,35,,134.4,percent of total billed charges,Implant Device,134.4,35,,134.4,percent of total billed charges,Implant Device,134.4,35,,134.4,percent of total billed charges,Implant Device,134.4,35,,134.4,percent of total billed charges,Implant Device,153.6,40,,153.6,percent of total billed charges,Implant Device,134.4,70,,134.4,percent of total billed charges,All Other,130.56,34,,130.56,percent of total billed charges,Implant Device,130.56,34,,130.56,percent of total billed charges,Implant Device,134.4,35,,134.4,percent of total billed charges,Implant Device,134.4,35,,134.4,percent of total billed charges,Implant Device,134.4,35,,134.4,percent of total billed charges,Implant Device,134.4,35,,134.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,284.16,
NAVILYST H965451030 POWER PORT 8FR,C1788,HCPCS,,79000456,CDM,278,RC,,,both,,,924,683.76,,,683.76,Other,150% of Medicare + 9.63% HCRA Surcharge,415.8,45,,415.8,percent of total billed charges,Critical Access Hospital RCC factor,314.16,34,,314.16,percent of total billed charges,Implant Device,314.16,34,,314.16,percent of total billed charges,Implant Device,314.16,34,,314.16,percent of total billed charges,Implant Device,314.16,34,,314.16,percent of total billed charges,Implant Device,314.16,34,,314.16,percent of total billed charges,Implant Device,457.38,,,457.38,Other,110% of Medicare,323.4,35,,323.4,percent of total billed charges,Implant Device,314.16,34,"Charges > $500, x 34%",314.16,percent of total billed charges,Implant Device,323.4,35,,323.4,percent of total billed charges,Implant Device,323.4,35,,323.4,percent of total billed charges,Implant Device,323.4,35,,323.4,percent of total billed charges,Implant Device,323.4,35,,323.4,percent of total billed charges,Implant Device,323.4,35,,323.4,percent of total billed charges,Implant Device,369.6,40,,369.6,percent of total billed charges,Implant Device,323.4,70,,323.4,percent of total billed charges,All Other,314.16,34,,314.16,percent of total billed charges,Implant Device,314.16,34,,314.16,percent of total billed charges,Implant Device,323.4,35,,323.4,percent of total billed charges,Implant Device,323.4,35,,323.4,percent of total billed charges,Implant Device,323.4,35,,323.4,percent of total billed charges,Implant Device,323.4,35,,323.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,683.76,
EV3 SERB65-09-40-80 PROTEGE 6FR 9X40X80,C1876,HCPCS,,79000459,CDM,278,RC,,,both,,,1950,1443,,,1443,Other,150% of Medicare + 9.63% HCRA Surcharge,877.5,45,,877.5,percent of total billed charges,Critical Access Hospital RCC factor,663,34,,663,percent of total billed charges,Implant Device,663,34,,663,percent of total billed charges,Implant Device,663,34,,663,percent of total billed charges,Implant Device,663,34,,663,percent of total billed charges,Implant Device,663,34,,663,percent of total billed charges,Implant Device,965.25,,,965.25,Other,110% of Medicare,682.5,35,,682.5,percent of total billed charges,Implant Device,663,34,"Charges > $500, x 34%",663,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,780,40,,780,percent of total billed charges,Implant Device,682.5,70,,682.5,percent of total billed charges,All Other,663,34,,663,percent of total billed charges,Implant Device,663,34,,663,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1443,
EV3 PRB35-06-100-120 PROTEGE EVERFLEX,C1876,HCPCS,,79000460,CDM,278,RC,,,both,,,5070,3751.81,,,3751.81,Other,150% of Medicare + 9.63% HCRA Surcharge,2281.5,45,,2281.5,percent of total billed charges,Critical Access Hospital RCC factor,1723.8,34,,1723.8,percent of total billed charges,Implant Device,1723.8,34,,1723.8,percent of total billed charges,Implant Device,1723.8,34,,1723.8,percent of total billed charges,Implant Device,1723.8,34,,1723.8,percent of total billed charges,Implant Device,1723.8,34,,1723.8,percent of total billed charges,Implant Device,2509.65,,,2509.65,Other,110% of Medicare,1774.5,35,,1774.5,percent of total billed charges,Implant Device,1723.8,34,"Charges > $500, x 34%",1723.8,percent of total billed charges,Implant Device,1774.5,35,,1774.5,percent of total billed charges,Implant Device,1774.5,35,,1774.5,percent of total billed charges,Implant Device,1774.5,35,,1774.5,percent of total billed charges,Implant Device,1774.5,35,,1774.5,percent of total billed charges,Implant Device,1774.5,35,,1774.5,percent of total billed charges,Implant Device,2028,40,,2028,percent of total billed charges,Implant Device,1774.5,70,,1774.5,percent of total billed charges,All Other,1723.8,34,,1723.8,percent of total billed charges,Implant Device,1723.8,34,,1723.8,percent of total billed charges,Implant Device,1774.5,35,,1774.5,percent of total billed charges,Implant Device,1774.5,35,,1774.5,percent of total billed charges,Implant Device,1774.5,35,,1774.5,percent of total billed charges,Implant Device,1774.5,35,,1774.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1723.8,34,"If Charge > 2,000, then 34 percent",1723.8,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3751.81,
EV3 PRB35-06-120-120 PROTEGE EVERFLEX,C1876,HCPCS,,79000461,CDM,278,RC,,,both,,,4950,3663.01,,,3663.01,Other,150% of Medicare + 9.63% HCRA Surcharge,2227.5,45,,2227.5,percent of total billed charges,Critical Access Hospital RCC factor,1683,34,,1683,percent of total billed charges,Implant Device,1683,34,,1683,percent of total billed charges,Implant Device,1683,34,,1683,percent of total billed charges,Implant Device,1683,34,,1683,percent of total billed charges,Implant Device,1683,34,,1683,percent of total billed charges,Implant Device,2450.25,,,2450.25,Other,110% of Medicare,1732.5,35,,1732.5,percent of total billed charges,Implant Device,1683,34,"Charges > $500, x 34%",1683,percent of total billed charges,Implant Device,1732.5,35,,1732.5,percent of total billed charges,Implant Device,1732.5,35,,1732.5,percent of total billed charges,Implant Device,1732.5,35,,1732.5,percent of total billed charges,Implant Device,1732.5,35,,1732.5,percent of total billed charges,Implant Device,1732.5,35,,1732.5,percent of total billed charges,Implant Device,1980,40,,1980,percent of total billed charges,Implant Device,1732.5,70,,1732.5,percent of total billed charges,All Other,1683,34,,1683,percent of total billed charges,Implant Device,1683,34,,1683,percent of total billed charges,Implant Device,1732.5,35,,1732.5,percent of total billed charges,Implant Device,1732.5,35,,1732.5,percent of total billed charges,Implant Device,1732.5,35,,1732.5,percent of total billed charges,Implant Device,1732.5,35,,1732.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1683,34,"If Charge > 2,000, then 34 percent",1683,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3663.01,
EV3 PRB35-06-150-120 PROTEGE EVERFLEX,C1876,HCPCS,,79000462,CDM,278,RC,,,both,,,5400,3996.01,,,3996.01,Other,150% of Medicare + 9.63% HCRA Surcharge,2430,45,,2430,percent of total billed charges,Critical Access Hospital RCC factor,1836,34,,1836,percent of total billed charges,Implant Device,1836,34,,1836,percent of total billed charges,Implant Device,1836,34,,1836,percent of total billed charges,Implant Device,1836,34,,1836,percent of total billed charges,Implant Device,1836,34,,1836,percent of total billed charges,Implant Device,2673,,,2673,Other,110% of Medicare,1890,35,,1890,percent of total billed charges,Implant Device,1836,34,"Charges > $500, x 34%",1836,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,2160,40,,2160,percent of total billed charges,Implant Device,1890,70,,1890,percent of total billed charges,All Other,1836,34,,1836,percent of total billed charges,Implant Device,1836,34,,1836,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1836,34,"If Charge > 2,000, then 34 percent",1836,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3996.01,
EV3 PRB35-06-060-120 PROTEGE EVERFLEX,C1876,HCPCS,,79000463,CDM,278,RC,,,both,,,3975,2941.51,,,2941.51,Other,150% of Medicare + 9.63% HCRA Surcharge,1788.75,45,,1788.75,percent of total billed charges,Critical Access Hospital RCC factor,1351.5,34,,1351.5,percent of total billed charges,Implant Device,1351.5,34,,1351.5,percent of total billed charges,Implant Device,1351.5,34,,1351.5,percent of total billed charges,Implant Device,1351.5,34,,1351.5,percent of total billed charges,Implant Device,1351.5,34,,1351.5,percent of total billed charges,Implant Device,1967.63,,,1967.63,Other,110% of Medicare,1391.25,35,,1391.25,percent of total billed charges,Implant Device,1351.5,34,"Charges > $500, x 34%",1351.5,percent of total billed charges,Implant Device,1391.25,35,,1391.25,percent of total billed charges,Implant Device,1391.25,35,,1391.25,percent of total billed charges,Implant Device,1391.25,35,,1391.25,percent of total billed charges,Implant Device,1391.25,35,,1391.25,percent of total billed charges,Implant Device,1391.25,35,,1391.25,percent of total billed charges,Implant Device,1590,40,,1590,percent of total billed charges,Implant Device,1391.25,70,,1391.25,percent of total billed charges,All Other,1351.5,34,,1351.5,percent of total billed charges,Implant Device,1351.5,34,,1351.5,percent of total billed charges,Implant Device,1391.25,35,,1391.25,percent of total billed charges,Implant Device,1391.25,35,,1391.25,percent of total billed charges,Implant Device,1391.25,35,,1391.25,percent of total billed charges,Implant Device,1391.25,35,,1391.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1351.5,34,"If Charge > 2,000, then 34 percent",1351.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2941.51,
EV3 PRB35-06-080-120 PROTEGE EVERFLEX,C1876,HCPCS,,79000464,CDM,278,RC,,,both,,,1950,1443,,,1443,Other,150% of Medicare + 9.63% HCRA Surcharge,877.5,45,,877.5,percent of total billed charges,Critical Access Hospital RCC factor,663,34,,663,percent of total billed charges,Implant Device,663,34,,663,percent of total billed charges,Implant Device,663,34,,663,percent of total billed charges,Implant Device,663,34,,663,percent of total billed charges,Implant Device,663,34,,663,percent of total billed charges,Implant Device,965.25,,,965.25,Other,110% of Medicare,682.5,35,,682.5,percent of total billed charges,Implant Device,663,34,"Charges > $500, x 34%",663,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,780,40,,780,percent of total billed charges,Implant Device,682.5,70,,682.5,percent of total billed charges,All Other,663,34,,663,percent of total billed charges,Implant Device,663,34,,663,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1443,
EV3 PRB35-07-120-120 PROTEGE EVERFLEX,C1876,HCPCS,,79000465,CDM,278,RC,,,both,,,4950,3663.01,,,3663.01,Other,150% of Medicare + 9.63% HCRA Surcharge,2227.5,45,,2227.5,percent of total billed charges,Critical Access Hospital RCC factor,1683,34,,1683,percent of total billed charges,Implant Device,1683,34,,1683,percent of total billed charges,Implant Device,1683,34,,1683,percent of total billed charges,Implant Device,1683,34,,1683,percent of total billed charges,Implant Device,1683,34,,1683,percent of total billed charges,Implant Device,2450.25,,,2450.25,Other,110% of Medicare,1732.5,35,,1732.5,percent of total billed charges,Implant Device,1683,34,"Charges > $500, x 34%",1683,percent of total billed charges,Implant Device,1732.5,35,,1732.5,percent of total billed charges,Implant Device,1732.5,35,,1732.5,percent of total billed charges,Implant Device,1732.5,35,,1732.5,percent of total billed charges,Implant Device,1732.5,35,,1732.5,percent of total billed charges,Implant Device,1732.5,35,,1732.5,percent of total billed charges,Implant Device,1980,40,,1980,percent of total billed charges,Implant Device,1732.5,70,,1732.5,percent of total billed charges,All Other,1683,34,,1683,percent of total billed charges,Implant Device,1683,34,,1683,percent of total billed charges,Implant Device,1732.5,35,,1732.5,percent of total billed charges,Implant Device,1732.5,35,,1732.5,percent of total billed charges,Implant Device,1732.5,35,,1732.5,percent of total billed charges,Implant Device,1732.5,35,,1732.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1683,34,"If Charge > 2,000, then 34 percent",1683,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3663.01,
EV3 PRB35-07-150-120 PROTEGE EVERFLEX,C1876,HCPCS,,79000466,CDM,278,RC,,,both,,,5400,3996.01,,,3996.01,Other,150% of Medicare + 9.63% HCRA Surcharge,2430,45,,2430,percent of total billed charges,Critical Access Hospital RCC factor,1836,34,,1836,percent of total billed charges,Implant Device,1836,34,,1836,percent of total billed charges,Implant Device,1836,34,,1836,percent of total billed charges,Implant Device,1836,34,,1836,percent of total billed charges,Implant Device,1836,34,,1836,percent of total billed charges,Implant Device,2673,,,2673,Other,110% of Medicare,1890,35,,1890,percent of total billed charges,Implant Device,1836,34,"Charges > $500, x 34%",1836,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,2160,40,,2160,percent of total billed charges,Implant Device,1890,70,,1890,percent of total billed charges,All Other,1836,34,,1836,percent of total billed charges,Implant Device,1836,34,,1836,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1836,34,"If Charge > 2,000, then 34 percent",1836,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3996.01,
EV3 PRB35-07-040-080 PROTEGE EVERFLEX,C1876,HCPCS,,79000467,CDM,278,RC,,,both,,,3975,2941.51,,,2941.51,Other,150% of Medicare + 9.63% HCRA Surcharge,1788.75,45,,1788.75,percent of total billed charges,Critical Access Hospital RCC factor,1351.5,34,,1351.5,percent of total billed charges,Implant Device,1351.5,34,,1351.5,percent of total billed charges,Implant Device,1351.5,34,,1351.5,percent of total billed charges,Implant Device,1351.5,34,,1351.5,percent of total billed charges,Implant Device,1351.5,34,,1351.5,percent of total billed charges,Implant Device,1967.63,,,1967.63,Other,110% of Medicare,1391.25,35,,1391.25,percent of total billed charges,Implant Device,1351.5,34,"Charges > $500, x 34%",1351.5,percent of total billed charges,Implant Device,1391.25,35,,1391.25,percent of total billed charges,Implant Device,1391.25,35,,1391.25,percent of total billed charges,Implant Device,1391.25,35,,1391.25,percent of total billed charges,Implant Device,1391.25,35,,1391.25,percent of total billed charges,Implant Device,1391.25,35,,1391.25,percent of total billed charges,Implant Device,1590,40,,1590,percent of total billed charges,Implant Device,1391.25,70,,1391.25,percent of total billed charges,All Other,1351.5,34,,1351.5,percent of total billed charges,Implant Device,1351.5,34,,1351.5,percent of total billed charges,Implant Device,1391.25,35,,1391.25,percent of total billed charges,Implant Device,1391.25,35,,1391.25,percent of total billed charges,Implant Device,1391.25,35,,1391.25,percent of total billed charges,Implant Device,1391.25,35,,1391.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1351.5,34,"If Charge > 2,000, then 34 percent",1351.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2941.51,
EV3 PRB35-07-060-120 PROTEGE EVERFLEX,C1876,HCPCS,,79000468,CDM,278,RC,,,both,,,1950,1443,,,1443,Other,150% of Medicare + 9.63% HCRA Surcharge,877.5,45,,877.5,percent of total billed charges,Critical Access Hospital RCC factor,663,34,,663,percent of total billed charges,Implant Device,663,34,,663,percent of total billed charges,Implant Device,663,34,,663,percent of total billed charges,Implant Device,663,34,,663,percent of total billed charges,Implant Device,663,34,,663,percent of total billed charges,Implant Device,965.25,,,965.25,Other,110% of Medicare,682.5,35,,682.5,percent of total billed charges,Implant Device,663,34,"Charges > $500, x 34%",663,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,780,40,,780,percent of total billed charges,Implant Device,682.5,70,,682.5,percent of total billed charges,All Other,663,34,,663,percent of total billed charges,Implant Device,663,34,,663,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1443,
EV3 PRB35-07-060-080 PROTEGE EVERFLEX,C1876,HCPCS,,79000469,CDM,278,RC,,,both,,,3975,2941.51,,,2941.51,Other,150% of Medicare + 9.63% HCRA Surcharge,1788.75,45,,1788.75,percent of total billed charges,Critical Access Hospital RCC factor,1351.5,34,,1351.5,percent of total billed charges,Implant Device,1351.5,34,,1351.5,percent of total billed charges,Implant Device,1351.5,34,,1351.5,percent of total billed charges,Implant Device,1351.5,34,,1351.5,percent of total billed charges,Implant Device,1351.5,34,,1351.5,percent of total billed charges,Implant Device,1967.63,,,1967.63,Other,110% of Medicare,1391.25,35,,1391.25,percent of total billed charges,Implant Device,1351.5,34,"Charges > $500, x 34%",1351.5,percent of total billed charges,Implant Device,1391.25,35,,1391.25,percent of total billed charges,Implant Device,1391.25,35,,1391.25,percent of total billed charges,Implant Device,1391.25,35,,1391.25,percent of total billed charges,Implant Device,1391.25,35,,1391.25,percent of total billed charges,Implant Device,1391.25,35,,1391.25,percent of total billed charges,Implant Device,1590,40,,1590,percent of total billed charges,Implant Device,1391.25,70,,1391.25,percent of total billed charges,All Other,1351.5,34,,1351.5,percent of total billed charges,Implant Device,1351.5,34,,1351.5,percent of total billed charges,Implant Device,1391.25,35,,1391.25,percent of total billed charges,Implant Device,1391.25,35,,1391.25,percent of total billed charges,Implant Device,1391.25,35,,1391.25,percent of total billed charges,Implant Device,1391.25,35,,1391.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1351.5,34,"If Charge > 2,000, then 34 percent",1351.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2941.51,
EV3 PRB35-08-030-080 PROTEGE EVERFLEX,C1876,HCPCS,,79000470,CDM,278,RC,,,both,,,1950,1443,,,1443,Other,150% of Medicare + 9.63% HCRA Surcharge,877.5,45,,877.5,percent of total billed charges,Critical Access Hospital RCC factor,663,34,,663,percent of total billed charges,Implant Device,663,34,,663,percent of total billed charges,Implant Device,663,34,,663,percent of total billed charges,Implant Device,663,34,,663,percent of total billed charges,Implant Device,663,34,,663,percent of total billed charges,Implant Device,965.25,,,965.25,Other,110% of Medicare,682.5,35,,682.5,percent of total billed charges,Implant Device,663,34,"Charges > $500, x 34%",663,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,780,40,,780,percent of total billed charges,Implant Device,682.5,70,,682.5,percent of total billed charges,All Other,663,34,,663,percent of total billed charges,Implant Device,663,34,,663,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1443,
EV3 PRB35-08-040-080 PROTEGE EVERFLEX,C1876,HCPCS,,79000471,CDM,278,RC,,,both,,,3975,2941.51,,,2941.51,Other,150% of Medicare + 9.63% HCRA Surcharge,1788.75,45,,1788.75,percent of total billed charges,Critical Access Hospital RCC factor,1351.5,34,,1351.5,percent of total billed charges,Implant Device,1351.5,34,,1351.5,percent of total billed charges,Implant Device,1351.5,34,,1351.5,percent of total billed charges,Implant Device,1351.5,34,,1351.5,percent of total billed charges,Implant Device,1351.5,34,,1351.5,percent of total billed charges,Implant Device,1967.63,,,1967.63,Other,110% of Medicare,1391.25,35,,1391.25,percent of total billed charges,Implant Device,1351.5,34,"Charges > $500, x 34%",1351.5,percent of total billed charges,Implant Device,1391.25,35,,1391.25,percent of total billed charges,Implant Device,1391.25,35,,1391.25,percent of total billed charges,Implant Device,1391.25,35,,1391.25,percent of total billed charges,Implant Device,1391.25,35,,1391.25,percent of total billed charges,Implant Device,1391.25,35,,1391.25,percent of total billed charges,Implant Device,1590,40,,1590,percent of total billed charges,Implant Device,1391.25,70,,1391.25,percent of total billed charges,All Other,1351.5,34,,1351.5,percent of total billed charges,Implant Device,1351.5,34,,1351.5,percent of total billed charges,Implant Device,1391.25,35,,1391.25,percent of total billed charges,Implant Device,1391.25,35,,1391.25,percent of total billed charges,Implant Device,1391.25,35,,1391.25,percent of total billed charges,Implant Device,1391.25,35,,1391.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1351.5,34,"If Charge > 2,000, then 34 percent",1351.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2941.51,
J&J PG2910BPS GENESIS STENT AVIATOR10X29,C1876,HCPCS,,79000481,CDM,278,RC,,,both,,,3506,2594.45,,,2594.45,Other,150% of Medicare + 9.63% HCRA Surcharge,1577.7,45,,1577.7,percent of total billed charges,Critical Access Hospital RCC factor,1192.04,34,,1192.04,percent of total billed charges,Implant Device,1192.04,34,,1192.04,percent of total billed charges,Implant Device,1192.04,34,,1192.04,percent of total billed charges,Implant Device,1192.04,34,,1192.04,percent of total billed charges,Implant Device,1192.04,34,,1192.04,percent of total billed charges,Implant Device,1735.47,,,1735.47,Other,110% of Medicare,1227.1,35,,1227.1,percent of total billed charges,Implant Device,1192.04,34,"Charges > $500, x 34%",1192.04,percent of total billed charges,Implant Device,1227.1,35,,1227.1,percent of total billed charges,Implant Device,1227.1,35,,1227.1,percent of total billed charges,Implant Device,1227.1,35,,1227.1,percent of total billed charges,Implant Device,1227.1,35,,1227.1,percent of total billed charges,Implant Device,1227.1,35,,1227.1,percent of total billed charges,Implant Device,1402.4,40,,1402.4,percent of total billed charges,Implant Device,1227.1,70,,1227.1,percent of total billed charges,All Other,1192.04,34,,1192.04,percent of total billed charges,Implant Device,1192.04,34,,1192.04,percent of total billed charges,Implant Device,1227.1,35,,1227.1,percent of total billed charges,Implant Device,1227.1,35,,1227.1,percent of total billed charges,Implant Device,1227.1,35,,1227.1,percent of total billed charges,Implant Device,1227.1,35,,1227.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1192.04,34,"If Charge > 2,000, then 34 percent",1192.04,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2594.45,
J&J PG2450BAX GENESIS STENT AVIATOR 5X24,C1876,HCPCS,,79000482,CDM,278,RC,,,both,,,3812,2820.89,,,2820.89,Other,150% of Medicare + 9.63% HCRA Surcharge,1715.4,45,,1715.4,percent of total billed charges,Critical Access Hospital RCC factor,1296.08,34,,1296.08,percent of total billed charges,Implant Device,1296.08,34,,1296.08,percent of total billed charges,Implant Device,1296.08,34,,1296.08,percent of total billed charges,Implant Device,1296.08,34,,1296.08,percent of total billed charges,Implant Device,1296.08,34,,1296.08,percent of total billed charges,Implant Device,1886.94,,,1886.94,Other,110% of Medicare,1334.2,35,,1334.2,percent of total billed charges,Implant Device,1296.08,34,"Charges > $500, x 34%",1296.08,percent of total billed charges,Implant Device,1334.2,35,,1334.2,percent of total billed charges,Implant Device,1334.2,35,,1334.2,percent of total billed charges,Implant Device,1334.2,35,,1334.2,percent of total billed charges,Implant Device,1334.2,35,,1334.2,percent of total billed charges,Implant Device,1334.2,35,,1334.2,percent of total billed charges,Implant Device,1524.8,40,,1524.8,percent of total billed charges,Implant Device,1334.2,70,,1334.2,percent of total billed charges,All Other,1296.08,34,,1296.08,percent of total billed charges,Implant Device,1296.08,34,,1296.08,percent of total billed charges,Implant Device,1334.2,35,,1334.2,percent of total billed charges,Implant Device,1334.2,35,,1334.2,percent of total billed charges,Implant Device,1334.2,35,,1334.2,percent of total billed charges,Implant Device,1334.2,35,,1334.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1296.08,34,"If Charge > 2,000, then 34 percent",1296.08,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2820.89,
J&J PG2460BAX GENESIS STENT AVIATOR 6X24,C1876,HCPCS,,79000483,CDM,278,RC,,,both,,,3812,2820.89,,,2820.89,Other,150% of Medicare + 9.63% HCRA Surcharge,1715.4,45,,1715.4,percent of total billed charges,Critical Access Hospital RCC factor,1296.08,34,,1296.08,percent of total billed charges,Implant Device,1296.08,34,,1296.08,percent of total billed charges,Implant Device,1296.08,34,,1296.08,percent of total billed charges,Implant Device,1296.08,34,,1296.08,percent of total billed charges,Implant Device,1296.08,34,,1296.08,percent of total billed charges,Implant Device,1886.94,,,1886.94,Other,110% of Medicare,1334.2,35,,1334.2,percent of total billed charges,Implant Device,1296.08,34,"Charges > $500, x 34%",1296.08,percent of total billed charges,Implant Device,1334.2,35,,1334.2,percent of total billed charges,Implant Device,1334.2,35,,1334.2,percent of total billed charges,Implant Device,1334.2,35,,1334.2,percent of total billed charges,Implant Device,1334.2,35,,1334.2,percent of total billed charges,Implant Device,1334.2,35,,1334.2,percent of total billed charges,Implant Device,1524.8,40,,1524.8,percent of total billed charges,Implant Device,1334.2,70,,1334.2,percent of total billed charges,All Other,1296.08,34,,1296.08,percent of total billed charges,Implant Device,1296.08,34,,1296.08,percent of total billed charges,Implant Device,1334.2,35,,1334.2,percent of total billed charges,Implant Device,1334.2,35,,1334.2,percent of total billed charges,Implant Device,1334.2,35,,1334.2,percent of total billed charges,Implant Device,1334.2,35,,1334.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1296.08,34,"If Charge > 2,000, then 34 percent",1296.08,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2820.89,
J&J PG2960BPS GENESIS STENT AVIATOR 6X29,C1876,HCPCS,,79000484,CDM,278,RC,,,both,,,3506,2594.45,,,2594.45,Other,150% of Medicare + 9.63% HCRA Surcharge,1577.7,45,,1577.7,percent of total billed charges,Critical Access Hospital RCC factor,1192.04,34,,1192.04,percent of total billed charges,Implant Device,1192.04,34,,1192.04,percent of total billed charges,Implant Device,1192.04,34,,1192.04,percent of total billed charges,Implant Device,1192.04,34,,1192.04,percent of total billed charges,Implant Device,1192.04,34,,1192.04,percent of total billed charges,Implant Device,1735.47,,,1735.47,Other,110% of Medicare,1227.1,35,,1227.1,percent of total billed charges,Implant Device,1192.04,34,"Charges > $500, x 34%",1192.04,percent of total billed charges,Implant Device,1227.1,35,,1227.1,percent of total billed charges,Implant Device,1227.1,35,,1227.1,percent of total billed charges,Implant Device,1227.1,35,,1227.1,percent of total billed charges,Implant Device,1227.1,35,,1227.1,percent of total billed charges,Implant Device,1227.1,35,,1227.1,percent of total billed charges,Implant Device,1402.4,40,,1402.4,percent of total billed charges,Implant Device,1227.1,70,,1227.1,percent of total billed charges,All Other,1192.04,34,,1192.04,percent of total billed charges,Implant Device,1192.04,34,,1192.04,percent of total billed charges,Implant Device,1227.1,35,,1227.1,percent of total billed charges,Implant Device,1227.1,35,,1227.1,percent of total billed charges,Implant Device,1227.1,35,,1227.1,percent of total billed charges,Implant Device,1227.1,35,,1227.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1192.04,34,"If Charge > 2,000, then 34 percent",1192.04,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2594.45,
J&J PG1870BAX GENESIS STENT AVIATOR 7X18,C1876,HCPCS,,79000485,CDM,278,RC,,,both,,,3761,2783.15,,,2783.15,Other,150% of Medicare + 9.63% HCRA Surcharge,1692.45,45,,1692.45,percent of total billed charges,Critical Access Hospital RCC factor,1278.74,34,,1278.74,percent of total billed charges,Implant Device,1278.74,34,,1278.74,percent of total billed charges,Implant Device,1278.74,34,,1278.74,percent of total billed charges,Implant Device,1278.74,34,,1278.74,percent of total billed charges,Implant Device,1278.74,34,,1278.74,percent of total billed charges,Implant Device,1861.7,,,1861.7,Other,110% of Medicare,1316.35,35,,1316.35,percent of total billed charges,Implant Device,1278.74,34,"Charges > $500, x 34%",1278.74,percent of total billed charges,Implant Device,1316.35,35,,1316.35,percent of total billed charges,Implant Device,1316.35,35,,1316.35,percent of total billed charges,Implant Device,1316.35,35,,1316.35,percent of total billed charges,Implant Device,1316.35,35,,1316.35,percent of total billed charges,Implant Device,1316.35,35,,1316.35,percent of total billed charges,Implant Device,1504.4,40,,1504.4,percent of total billed charges,Implant Device,1316.35,70,,1316.35,percent of total billed charges,All Other,1278.74,34,,1278.74,percent of total billed charges,Implant Device,1278.74,34,,1278.74,percent of total billed charges,Implant Device,1316.35,35,,1316.35,percent of total billed charges,Implant Device,1316.35,35,,1316.35,percent of total billed charges,Implant Device,1316.35,35,,1316.35,percent of total billed charges,Implant Device,1316.35,35,,1316.35,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1278.74,34,"If Charge > 2,000, then 34 percent",1278.74,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2783.15,
J&J PG2470BAX GENESIS STENT AVIATOR 7X24,C1876,HCPCS,,79000486,CDM,278,RC,,,both,,,3812,2820.89,,,2820.89,Other,150% of Medicare + 9.63% HCRA Surcharge,1715.4,45,,1715.4,percent of total billed charges,Critical Access Hospital RCC factor,1296.08,34,,1296.08,percent of total billed charges,Implant Device,1296.08,34,,1296.08,percent of total billed charges,Implant Device,1296.08,34,,1296.08,percent of total billed charges,Implant Device,1296.08,34,,1296.08,percent of total billed charges,Implant Device,1296.08,34,,1296.08,percent of total billed charges,Implant Device,1886.94,,,1886.94,Other,110% of Medicare,1334.2,35,,1334.2,percent of total billed charges,Implant Device,1296.08,34,"Charges > $500, x 34%",1296.08,percent of total billed charges,Implant Device,1334.2,35,,1334.2,percent of total billed charges,Implant Device,1334.2,35,,1334.2,percent of total billed charges,Implant Device,1334.2,35,,1334.2,percent of total billed charges,Implant Device,1334.2,35,,1334.2,percent of total billed charges,Implant Device,1334.2,35,,1334.2,percent of total billed charges,Implant Device,1524.8,40,,1524.8,percent of total billed charges,Implant Device,1334.2,70,,1334.2,percent of total billed charges,All Other,1296.08,34,,1296.08,percent of total billed charges,Implant Device,1296.08,34,,1296.08,percent of total billed charges,Implant Device,1334.2,35,,1334.2,percent of total billed charges,Implant Device,1334.2,35,,1334.2,percent of total billed charges,Implant Device,1334.2,35,,1334.2,percent of total billed charges,Implant Device,1334.2,35,,1334.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1296.08,34,"If Charge > 2,000, then 34 percent",1296.08,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2820.89,
J&J PG2970BPS GENESIS STENT AVIATOR 7X29,C1876,HCPCS,,79000487,CDM,278,RC,,,both,,,3506,2594.45,,,2594.45,Other,150% of Medicare + 9.63% HCRA Surcharge,1577.7,45,,1577.7,percent of total billed charges,Critical Access Hospital RCC factor,1192.04,34,,1192.04,percent of total billed charges,Implant Device,1192.04,34,,1192.04,percent of total billed charges,Implant Device,1192.04,34,,1192.04,percent of total billed charges,Implant Device,1192.04,34,,1192.04,percent of total billed charges,Implant Device,1192.04,34,,1192.04,percent of total billed charges,Implant Device,1735.47,,,1735.47,Other,110% of Medicare,1227.1,35,,1227.1,percent of total billed charges,Implant Device,1192.04,34,"Charges > $500, x 34%",1192.04,percent of total billed charges,Implant Device,1227.1,35,,1227.1,percent of total billed charges,Implant Device,1227.1,35,,1227.1,percent of total billed charges,Implant Device,1227.1,35,,1227.1,percent of total billed charges,Implant Device,1227.1,35,,1227.1,percent of total billed charges,Implant Device,1227.1,35,,1227.1,percent of total billed charges,Implant Device,1402.4,40,,1402.4,percent of total billed charges,Implant Device,1227.1,70,,1227.1,percent of total billed charges,All Other,1192.04,34,,1192.04,percent of total billed charges,Implant Device,1192.04,34,,1192.04,percent of total billed charges,Implant Device,1227.1,35,,1227.1,percent of total billed charges,Implant Device,1227.1,35,,1227.1,percent of total billed charges,Implant Device,1227.1,35,,1227.1,percent of total billed charges,Implant Device,1227.1,35,,1227.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1192.04,34,"If Charge > 2,000, then 34 percent",1192.04,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2594.45,
J&J PG3970BPS GENESIS STENT AVIATOR 7X39,C1876,HCPCS,,79000488,CDM,278,RC,,,both,,,3557,2632.19,,,2632.19,Other,150% of Medicare + 9.63% HCRA Surcharge,1600.65,45,,1600.65,percent of total billed charges,Critical Access Hospital RCC factor,1209.38,34,,1209.38,percent of total billed charges,Implant Device,1209.38,34,,1209.38,percent of total billed charges,Implant Device,1209.38,34,,1209.38,percent of total billed charges,Implant Device,1209.38,34,,1209.38,percent of total billed charges,Implant Device,1209.38,34,,1209.38,percent of total billed charges,Implant Device,1760.72,,,1760.72,Other,110% of Medicare,1244.95,35,,1244.95,percent of total billed charges,Implant Device,1209.38,34,"Charges > $500, x 34%",1209.38,percent of total billed charges,Implant Device,1244.95,35,,1244.95,percent of total billed charges,Implant Device,1244.95,35,,1244.95,percent of total billed charges,Implant Device,1244.95,35,,1244.95,percent of total billed charges,Implant Device,1244.95,35,,1244.95,percent of total billed charges,Implant Device,1244.95,35,,1244.95,percent of total billed charges,Implant Device,1422.8,40,,1422.8,percent of total billed charges,Implant Device,1244.95,70,,1244.95,percent of total billed charges,All Other,1209.38,34,,1209.38,percent of total billed charges,Implant Device,1209.38,34,,1209.38,percent of total billed charges,Implant Device,1244.95,35,,1244.95,percent of total billed charges,Implant Device,1244.95,35,,1244.95,percent of total billed charges,Implant Device,1244.95,35,,1244.95,percent of total billed charges,Implant Device,1244.95,35,,1244.95,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1209.38,34,"If Charge > 2,000, then 34 percent",1209.38,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2632.19,
J&J PG2980BPS GENESIS STENT AVIATOR 8X29,C1876,HCPCS,,79000489,CDM,278,RC,,,both,,,2643,1955.83,,,1955.83,Other,150% of Medicare + 9.63% HCRA Surcharge,1189.35,45,,1189.35,percent of total billed charges,Critical Access Hospital RCC factor,898.62,34,,898.62,percent of total billed charges,Implant Device,898.62,34,,898.62,percent of total billed charges,Implant Device,898.62,34,,898.62,percent of total billed charges,Implant Device,898.62,34,,898.62,percent of total billed charges,Implant Device,898.62,34,,898.62,percent of total billed charges,Implant Device,1308.29,,,1308.29,Other,110% of Medicare,925.05,35,,925.05,percent of total billed charges,Implant Device,898.62,34,"Charges > $500, x 34%",898.62,percent of total billed charges,Implant Device,925.05,35,,925.05,percent of total billed charges,Implant Device,925.05,35,,925.05,percent of total billed charges,Implant Device,925.05,35,,925.05,percent of total billed charges,Implant Device,925.05,35,,925.05,percent of total billed charges,Implant Device,925.05,35,,925.05,percent of total billed charges,Implant Device,1057.2,40,,1057.2,percent of total billed charges,Implant Device,925.05,70,,925.05,percent of total billed charges,All Other,898.62,34,,898.62,percent of total billed charges,Implant Device,898.62,34,,898.62,percent of total billed charges,Implant Device,925.05,35,,925.05,percent of total billed charges,Implant Device,925.05,35,,925.05,percent of total billed charges,Implant Device,925.05,35,,925.05,percent of total billed charges,Implant Device,925.05,35,,925.05,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,898.62,34,"If Charge > 2,000, then 34 percent",898.62,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1955.83,
J&J PG3980BPS GENESIS STENT AVIATOR 8X39,C1876,HCPCS,,79000490,CDM,278,RC,,,both,,,3557,2632.19,,,2632.19,Other,150% of Medicare + 9.63% HCRA Surcharge,1600.65,45,,1600.65,percent of total billed charges,Critical Access Hospital RCC factor,1209.38,34,,1209.38,percent of total billed charges,Implant Device,1209.38,34,,1209.38,percent of total billed charges,Implant Device,1209.38,34,,1209.38,percent of total billed charges,Implant Device,1209.38,34,,1209.38,percent of total billed charges,Implant Device,1209.38,34,,1209.38,percent of total billed charges,Implant Device,1760.72,,,1760.72,Other,110% of Medicare,1244.95,35,,1244.95,percent of total billed charges,Implant Device,1209.38,34,"Charges > $500, x 34%",1209.38,percent of total billed charges,Implant Device,1244.95,35,,1244.95,percent of total billed charges,Implant Device,1244.95,35,,1244.95,percent of total billed charges,Implant Device,1244.95,35,,1244.95,percent of total billed charges,Implant Device,1244.95,35,,1244.95,percent of total billed charges,Implant Device,1244.95,35,,1244.95,percent of total billed charges,Implant Device,1422.8,40,,1422.8,percent of total billed charges,Implant Device,1244.95,70,,1244.95,percent of total billed charges,All Other,1209.38,34,,1209.38,percent of total billed charges,Implant Device,1209.38,34,,1209.38,percent of total billed charges,Implant Device,1244.95,35,,1244.95,percent of total billed charges,Implant Device,1244.95,35,,1244.95,percent of total billed charges,Implant Device,1244.95,35,,1244.95,percent of total billed charges,Implant Device,1244.95,35,,1244.95,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1209.38,34,"If Charge > 2,000, then 34 percent",1209.38,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2632.19,
J&J PG2990BPS GENESIS STENT AVIATOR 9X29,C1876,HCPCS,,79000491,CDM,278,RC,,,both,,,3430,2538.21,,,2538.21,Other,150% of Medicare + 9.63% HCRA Surcharge,1543.5,45,,1543.5,percent of total billed charges,Critical Access Hospital RCC factor,1166.2,34,,1166.2,percent of total billed charges,Implant Device,1166.2,34,,1166.2,percent of total billed charges,Implant Device,1166.2,34,,1166.2,percent of total billed charges,Implant Device,1166.2,34,,1166.2,percent of total billed charges,Implant Device,1166.2,34,,1166.2,percent of total billed charges,Implant Device,1697.85,,,1697.85,Other,110% of Medicare,1200.5,35,,1200.5,percent of total billed charges,Implant Device,1166.2,34,"Charges > $500, x 34%",1166.2,percent of total billed charges,Implant Device,1200.5,35,,1200.5,percent of total billed charges,Implant Device,1200.5,35,,1200.5,percent of total billed charges,Implant Device,1200.5,35,,1200.5,percent of total billed charges,Implant Device,1200.5,35,,1200.5,percent of total billed charges,Implant Device,1200.5,35,,1200.5,percent of total billed charges,Implant Device,1372,40,,1372,percent of total billed charges,Implant Device,1200.5,70,,1200.5,percent of total billed charges,All Other,1166.2,34,,1166.2,percent of total billed charges,Implant Device,1166.2,34,,1166.2,percent of total billed charges,Implant Device,1200.5,35,,1200.5,percent of total billed charges,Implant Device,1200.5,35,,1200.5,percent of total billed charges,Implant Device,1200.5,35,,1200.5,percent of total billed charges,Implant Device,1200.5,35,,1200.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1166.2,34,"If Charge > 2,000, then 34 percent",1166.2,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2538.21,
J&J C07040ML SMARTSTENT BILIARY 7X40X120,C1876,HCPCS,,79000500,CDM,278,RC,,,both,,,2100,1554.01,,,1554.01,Other,150% of Medicare + 9.63% HCRA Surcharge,945,45,,945,percent of total billed charges,Critical Access Hospital RCC factor,714,34,,714,percent of total billed charges,Implant Device,714,34,,714,percent of total billed charges,Implant Device,714,34,,714,percent of total billed charges,Implant Device,714,34,,714,percent of total billed charges,Implant Device,714,34,,714,percent of total billed charges,Implant Device,1039.5,,,1039.5,Other,110% of Medicare,735,35,,735,percent of total billed charges,Implant Device,714,34,"Charges > $500, x 34%",714,percent of total billed charges,Implant Device,735,35,,735,percent of total billed charges,Implant Device,735,35,,735,percent of total billed charges,Implant Device,735,35,,735,percent of total billed charges,Implant Device,735,35,,735,percent of total billed charges,Implant Device,735,35,,735,percent of total billed charges,Implant Device,840,40,,840,percent of total billed charges,Implant Device,735,70,,735,percent of total billed charges,All Other,714,34,,714,percent of total billed charges,Implant Device,714,34,,714,percent of total billed charges,Implant Device,735,35,,735,percent of total billed charges,Implant Device,735,35,,735,percent of total billed charges,Implant Device,735,35,,735,percent of total billed charges,Implant Device,735,35,,735,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,714,34,"If Charge > 2,000, then 34 percent",714,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1554.01,
J&J C07040SL SMARTSTENT BILIARY 7X40X80,C1876,HCPCS,,79000501,CDM,278,RC,,,both,,,2100,1554.01,,,1554.01,Other,150% of Medicare + 9.63% HCRA Surcharge,945,45,,945,percent of total billed charges,Critical Access Hospital RCC factor,714,34,,714,percent of total billed charges,Implant Device,714,34,,714,percent of total billed charges,Implant Device,714,34,,714,percent of total billed charges,Implant Device,714,34,,714,percent of total billed charges,Implant Device,714,34,,714,percent of total billed charges,Implant Device,1039.5,,,1039.5,Other,110% of Medicare,735,35,,735,percent of total billed charges,Implant Device,714,34,"Charges > $500, x 34%",714,percent of total billed charges,Implant Device,735,35,,735,percent of total billed charges,Implant Device,735,35,,735,percent of total billed charges,Implant Device,735,35,,735,percent of total billed charges,Implant Device,735,35,,735,percent of total billed charges,Implant Device,735,35,,735,percent of total billed charges,Implant Device,840,40,,840,percent of total billed charges,Implant Device,735,70,,735,percent of total billed charges,All Other,714,34,,714,percent of total billed charges,Implant Device,714,34,,714,percent of total billed charges,Implant Device,735,35,,735,percent of total billed charges,Implant Device,735,35,,735,percent of total billed charges,Implant Device,735,35,,735,percent of total billed charges,Implant Device,735,35,,735,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,714,34,"If Charge > 2,000, then 34 percent",714,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1554.01,
J&J C07100ML SMARTSTENT BILI 7X100X120,C1876,HCPCS,,79000502,CDM,278,RC,,,both,,,2027,1499.99,,,1499.99,Other,150% of Medicare + 9.63% HCRA Surcharge,912.15,45,,912.15,percent of total billed charges,Critical Access Hospital RCC factor,689.18,34,,689.18,percent of total billed charges,Implant Device,689.18,34,,689.18,percent of total billed charges,Implant Device,689.18,34,,689.18,percent of total billed charges,Implant Device,689.18,34,,689.18,percent of total billed charges,Implant Device,689.18,34,,689.18,percent of total billed charges,Implant Device,1003.37,,,1003.37,Other,110% of Medicare,709.45,35,,709.45,percent of total billed charges,Implant Device,689.18,34,"Charges > $500, x 34%",689.18,percent of total billed charges,Implant Device,709.45,35,,709.45,percent of total billed charges,Implant Device,709.45,35,,709.45,percent of total billed charges,Implant Device,709.45,35,,709.45,percent of total billed charges,Implant Device,709.45,35,,709.45,percent of total billed charges,Implant Device,709.45,35,,709.45,percent of total billed charges,Implant Device,810.8,40,,810.8,percent of total billed charges,Implant Device,709.45,70,,709.45,percent of total billed charges,All Other,689.18,34,,689.18,percent of total billed charges,Implant Device,689.18,34,,689.18,percent of total billed charges,Implant Device,709.45,35,,709.45,percent of total billed charges,Implant Device,709.45,35,,709.45,percent of total billed charges,Implant Device,709.45,35,,709.45,percent of total billed charges,Implant Device,709.45,35,,709.45,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,689.18,34,"If Charge > 2,000, then 34 percent",689.18,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1499.99,
J&J C10040SL SMARTSTENT BILIARY 10X40X80,C1876,HCPCS,,79000503,CDM,278,RC,,,both,,,4195,3104.31,,,3104.31,Other,150% of Medicare + 9.63% HCRA Surcharge,1887.75,45,,1887.75,percent of total billed charges,Critical Access Hospital RCC factor,1426.3,34,,1426.3,percent of total billed charges,Implant Device,1426.3,34,,1426.3,percent of total billed charges,Implant Device,1426.3,34,,1426.3,percent of total billed charges,Implant Device,1426.3,34,,1426.3,percent of total billed charges,Implant Device,1426.3,34,,1426.3,percent of total billed charges,Implant Device,2076.53,,,2076.53,Other,110% of Medicare,1468.25,35,,1468.25,percent of total billed charges,Implant Device,1426.3,34,"Charges > $500, x 34%",1426.3,percent of total billed charges,Implant Device,1468.25,35,,1468.25,percent of total billed charges,Implant Device,1468.25,35,,1468.25,percent of total billed charges,Implant Device,1468.25,35,,1468.25,percent of total billed charges,Implant Device,1468.25,35,,1468.25,percent of total billed charges,Implant Device,1468.25,35,,1468.25,percent of total billed charges,Implant Device,1678,40,,1678,percent of total billed charges,Implant Device,1468.25,70,,1468.25,percent of total billed charges,All Other,1426.3,34,,1426.3,percent of total billed charges,Implant Device,1426.3,34,,1426.3,percent of total billed charges,Implant Device,1468.25,35,,1468.25,percent of total billed charges,Implant Device,1468.25,35,,1468.25,percent of total billed charges,Implant Device,1468.25,35,,1468.25,percent of total billed charges,Implant Device,1468.25,35,,1468.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1426.3,34,"If Charge > 2,000, then 34 percent",1426.3,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3104.31,
J&J C10060SL SMARTSTENT BILIARY 10X60X80,C1876,HCPCS,,79000504,CDM,278,RC,,,both,,,4195,3104.31,,,3104.31,Other,150% of Medicare + 9.63% HCRA Surcharge,1887.75,45,,1887.75,percent of total billed charges,Critical Access Hospital RCC factor,1426.3,34,,1426.3,percent of total billed charges,Implant Device,1426.3,34,,1426.3,percent of total billed charges,Implant Device,1426.3,34,,1426.3,percent of total billed charges,Implant Device,1426.3,34,,1426.3,percent of total billed charges,Implant Device,1426.3,34,,1426.3,percent of total billed charges,Implant Device,2076.53,,,2076.53,Other,110% of Medicare,1468.25,35,,1468.25,percent of total billed charges,Implant Device,1426.3,34,"Charges > $500, x 34%",1426.3,percent of total billed charges,Implant Device,1468.25,35,,1468.25,percent of total billed charges,Implant Device,1468.25,35,,1468.25,percent of total billed charges,Implant Device,1468.25,35,,1468.25,percent of total billed charges,Implant Device,1468.25,35,,1468.25,percent of total billed charges,Implant Device,1468.25,35,,1468.25,percent of total billed charges,Implant Device,1678,40,,1678,percent of total billed charges,Implant Device,1468.25,70,,1468.25,percent of total billed charges,All Other,1426.3,34,,1426.3,percent of total billed charges,Implant Device,1426.3,34,,1426.3,percent of total billed charges,Implant Device,1468.25,35,,1468.25,percent of total billed charges,Implant Device,1468.25,35,,1468.25,percent of total billed charges,Implant Device,1468.25,35,,1468.25,percent of total billed charges,Implant Device,1468.25,35,,1468.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1426.3,34,"If Charge > 2,000, then 34 percent",1426.3,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3104.31,
J&J C06040ML SMARTSTENT BILIARY 6X40X120,C1876,HCPCS,,79000505,CDM,278,RC,,,both,,,2027,1499.99,,,1499.99,Other,150% of Medicare + 9.63% HCRA Surcharge,912.15,45,,912.15,percent of total billed charges,Critical Access Hospital RCC factor,689.18,34,,689.18,percent of total billed charges,Implant Device,689.18,34,,689.18,percent of total billed charges,Implant Device,689.18,34,,689.18,percent of total billed charges,Implant Device,689.18,34,,689.18,percent of total billed charges,Implant Device,689.18,34,,689.18,percent of total billed charges,Implant Device,1003.37,,,1003.37,Other,110% of Medicare,709.45,35,,709.45,percent of total billed charges,Implant Device,689.18,34,"Charges > $500, x 34%",689.18,percent of total billed charges,Implant Device,709.45,35,,709.45,percent of total billed charges,Implant Device,709.45,35,,709.45,percent of total billed charges,Implant Device,709.45,35,,709.45,percent of total billed charges,Implant Device,709.45,35,,709.45,percent of total billed charges,Implant Device,709.45,35,,709.45,percent of total billed charges,Implant Device,810.8,40,,810.8,percent of total billed charges,Implant Device,709.45,70,,709.45,percent of total billed charges,All Other,689.18,34,,689.18,percent of total billed charges,Implant Device,689.18,34,,689.18,percent of total billed charges,Implant Device,709.45,35,,709.45,percent of total billed charges,Implant Device,709.45,35,,709.45,percent of total billed charges,Implant Device,709.45,35,,709.45,percent of total billed charges,Implant Device,709.45,35,,709.45,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,689.18,34,"If Charge > 2,000, then 34 percent",689.18,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1499.99,
J&J C06060ML SMARTSTENT BILIARY 6X60X120,C1876,HCPCS,,79000506,CDM,278,RC,,,both,,,4195,3104.31,,,3104.31,Other,150% of Medicare + 9.63% HCRA Surcharge,1887.75,45,,1887.75,percent of total billed charges,Critical Access Hospital RCC factor,1426.3,34,,1426.3,percent of total billed charges,Implant Device,1426.3,34,,1426.3,percent of total billed charges,Implant Device,1426.3,34,,1426.3,percent of total billed charges,Implant Device,1426.3,34,,1426.3,percent of total billed charges,Implant Device,1426.3,34,,1426.3,percent of total billed charges,Implant Device,2076.53,,,2076.53,Other,110% of Medicare,1468.25,35,,1468.25,percent of total billed charges,Implant Device,1426.3,34,"Charges > $500, x 34%",1426.3,percent of total billed charges,Implant Device,1468.25,35,,1468.25,percent of total billed charges,Implant Device,1468.25,35,,1468.25,percent of total billed charges,Implant Device,1468.25,35,,1468.25,percent of total billed charges,Implant Device,1468.25,35,,1468.25,percent of total billed charges,Implant Device,1468.25,35,,1468.25,percent of total billed charges,Implant Device,1678,40,,1678,percent of total billed charges,Implant Device,1468.25,70,,1468.25,percent of total billed charges,All Other,1426.3,34,,1426.3,percent of total billed charges,Implant Device,1426.3,34,,1426.3,percent of total billed charges,Implant Device,1468.25,35,,1468.25,percent of total billed charges,Implant Device,1468.25,35,,1468.25,percent of total billed charges,Implant Device,1468.25,35,,1468.25,percent of total billed charges,Implant Device,1468.25,35,,1468.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1426.3,34,"If Charge > 2,000, then 34 percent",1426.3,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3104.31,
J&J C06080ML SMARTSTENT BILIARY 6X80X120,C1876,HCPCS,,79000507,CDM,278,RC,,,both,,,2100,1554.01,,,1554.01,Other,150% of Medicare + 9.63% HCRA Surcharge,945,45,,945,percent of total billed charges,Critical Access Hospital RCC factor,714,34,,714,percent of total billed charges,Implant Device,714,34,,714,percent of total billed charges,Implant Device,714,34,,714,percent of total billed charges,Implant Device,714,34,,714,percent of total billed charges,Implant Device,714,34,,714,percent of total billed charges,Implant Device,1039.5,,,1039.5,Other,110% of Medicare,735,35,,735,percent of total billed charges,Implant Device,714,34,"Charges > $500, x 34%",714,percent of total billed charges,Implant Device,735,35,,735,percent of total billed charges,Implant Device,735,35,,735,percent of total billed charges,Implant Device,735,35,,735,percent of total billed charges,Implant Device,735,35,,735,percent of total billed charges,Implant Device,735,35,,735,percent of total billed charges,Implant Device,840,40,,840,percent of total billed charges,Implant Device,735,70,,735,percent of total billed charges,All Other,714,34,,714,percent of total billed charges,Implant Device,714,34,,714,percent of total billed charges,Implant Device,735,35,,735,percent of total billed charges,Implant Device,735,35,,735,percent of total billed charges,Implant Device,735,35,,735,percent of total billed charges,Implant Device,735,35,,735,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,714,34,"If Charge > 2,000, then 34 percent",714,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1554.01,
J&J C06100ML SMARTSTENT BILARY 6X100X120,C1876,HCPCS,,79000508,CDM,278,RC,,,both,,,5291,3915.35,,,3915.35,Other,150% of Medicare + 9.63% HCRA Surcharge,2380.95,45,,2380.95,percent of total billed charges,Critical Access Hospital RCC factor,1798.94,34,,1798.94,percent of total billed charges,Implant Device,1798.94,34,,1798.94,percent of total billed charges,Implant Device,1798.94,34,,1798.94,percent of total billed charges,Implant Device,1798.94,34,,1798.94,percent of total billed charges,Implant Device,1798.94,34,,1798.94,percent of total billed charges,Implant Device,2619.05,,,2619.05,Other,110% of Medicare,1851.85,35,,1851.85,percent of total billed charges,Implant Device,1798.94,34,"Charges > $500, x 34%",1798.94,percent of total billed charges,Implant Device,1851.85,35,,1851.85,percent of total billed charges,Implant Device,1851.85,35,,1851.85,percent of total billed charges,Implant Device,1851.85,35,,1851.85,percent of total billed charges,Implant Device,1851.85,35,,1851.85,percent of total billed charges,Implant Device,1851.85,35,,1851.85,percent of total billed charges,Implant Device,2116.4,40,,2116.4,percent of total billed charges,Implant Device,1851.85,70,,1851.85,percent of total billed charges,All Other,1798.94,34,,1798.94,percent of total billed charges,Implant Device,1798.94,34,,1798.94,percent of total billed charges,Implant Device,1851.85,35,,1851.85,percent of total billed charges,Implant Device,1851.85,35,,1851.85,percent of total billed charges,Implant Device,1851.85,35,,1851.85,percent of total billed charges,Implant Device,1851.85,35,,1851.85,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1798.94,34,"If Charge > 2,000, then 34 percent",1798.94,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3915.35,
J&J C06150MB SMARTSTENT BILARY 6X150X120,C1876,HCPCS,,79000509,CDM,278,RC,,,both,,,3300,2442.01,,,2442.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1485,45,,1485,percent of total billed charges,Critical Access Hospital RCC factor,1122,34,,1122,percent of total billed charges,Implant Device,1122,34,,1122,percent of total billed charges,Implant Device,1122,34,,1122,percent of total billed charges,Implant Device,1122,34,,1122,percent of total billed charges,Implant Device,1122,34,,1122,percent of total billed charges,Implant Device,1633.5,,,1633.5,Other,110% of Medicare,1155,35,,1155,percent of total billed charges,Implant Device,1122,34,"Charges > $500, x 34%",1122,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,1320,40,,1320,percent of total billed charges,Implant Device,1155,70,,1155,percent of total billed charges,All Other,1122,34,,1122,percent of total billed charges,Implant Device,1122,34,,1122,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1122,34,"If Charge > 2,000, then 34 percent",1122,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2442.01,
J&J C07030SL SMARTSTENT BILIARY 7X30X80,C1876,HCPCS,,79000510,CDM,278,RC,,,both,,,4195,3104.31,,,3104.31,Other,150% of Medicare + 9.63% HCRA Surcharge,1887.75,45,,1887.75,percent of total billed charges,Critical Access Hospital RCC factor,1426.3,34,,1426.3,percent of total billed charges,Implant Device,1426.3,34,,1426.3,percent of total billed charges,Implant Device,1426.3,34,,1426.3,percent of total billed charges,Implant Device,1426.3,34,,1426.3,percent of total billed charges,Implant Device,1426.3,34,,1426.3,percent of total billed charges,Implant Device,2076.53,,,2076.53,Other,110% of Medicare,1468.25,35,,1468.25,percent of total billed charges,Implant Device,1426.3,34,"Charges > $500, x 34%",1426.3,percent of total billed charges,Implant Device,1468.25,35,,1468.25,percent of total billed charges,Implant Device,1468.25,35,,1468.25,percent of total billed charges,Implant Device,1468.25,35,,1468.25,percent of total billed charges,Implant Device,1468.25,35,,1468.25,percent of total billed charges,Implant Device,1468.25,35,,1468.25,percent of total billed charges,Implant Device,1678,40,,1678,percent of total billed charges,Implant Device,1468.25,70,,1468.25,percent of total billed charges,All Other,1426.3,34,,1426.3,percent of total billed charges,Implant Device,1426.3,34,,1426.3,percent of total billed charges,Implant Device,1468.25,35,,1468.25,percent of total billed charges,Implant Device,1468.25,35,,1468.25,percent of total billed charges,Implant Device,1468.25,35,,1468.25,percent of total billed charges,Implant Device,1468.25,35,,1468.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1426.3,34,"If Charge > 2,000, then 34 percent",1426.3,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3104.31,
SMART STENT BILIARY PKG ASSY 7X150X80,C1876,HCPCS,,79000511,CDM,278,RC,,,both,,,3300,2442.01,,,2442.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1485,45,,1485,percent of total billed charges,Critical Access Hospital RCC factor,1122,34,,1122,percent of total billed charges,Implant Device,1122,34,,1122,percent of total billed charges,Implant Device,1122,34,,1122,percent of total billed charges,Implant Device,1122,34,,1122,percent of total billed charges,Implant Device,1122,34,,1122,percent of total billed charges,Implant Device,1633.5,,,1633.5,Other,110% of Medicare,1155,35,,1155,percent of total billed charges,Implant Device,1122,34,"Charges > $500, x 34%",1122,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,1320,40,,1320,percent of total billed charges,Implant Device,1155,70,,1155,percent of total billed charges,All Other,1122,34,,1122,percent of total billed charges,Implant Device,1122,34,,1122,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1122,34,"If Charge > 2,000, then 34 percent",1122,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2442.01,
J&J C08040ML SMARTSTENT BILIARY 8X40X120,C1876,HCPCS,,79000512,CDM,278,RC,,,both,,,2027,1499.99,,,1499.99,Other,150% of Medicare + 9.63% HCRA Surcharge,912.15,45,,912.15,percent of total billed charges,Critical Access Hospital RCC factor,689.18,34,,689.18,percent of total billed charges,Implant Device,689.18,34,,689.18,percent of total billed charges,Implant Device,689.18,34,,689.18,percent of total billed charges,Implant Device,689.18,34,,689.18,percent of total billed charges,Implant Device,689.18,34,,689.18,percent of total billed charges,Implant Device,1003.37,,,1003.37,Other,110% of Medicare,709.45,35,,709.45,percent of total billed charges,Implant Device,689.18,34,"Charges > $500, x 34%",689.18,percent of total billed charges,Implant Device,709.45,35,,709.45,percent of total billed charges,Implant Device,709.45,35,,709.45,percent of total billed charges,Implant Device,709.45,35,,709.45,percent of total billed charges,Implant Device,709.45,35,,709.45,percent of total billed charges,Implant Device,709.45,35,,709.45,percent of total billed charges,Implant Device,810.8,40,,810.8,percent of total billed charges,Implant Device,709.45,70,,709.45,percent of total billed charges,All Other,689.18,34,,689.18,percent of total billed charges,Implant Device,689.18,34,,689.18,percent of total billed charges,Implant Device,709.45,35,,709.45,percent of total billed charges,Implant Device,709.45,35,,709.45,percent of total billed charges,Implant Device,709.45,35,,709.45,percent of total billed charges,Implant Device,709.45,35,,709.45,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,689.18,34,"If Charge > 2,000, then 34 percent",689.18,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1499.99,
J&J C08040SL SMARTSTENT BILIARY 8X40X80,C1876,HCPCS,,79000513,CDM,278,RC,,,both,,,2100,1554.01,,,1554.01,Other,150% of Medicare + 9.63% HCRA Surcharge,945,45,,945,percent of total billed charges,Critical Access Hospital RCC factor,714,34,,714,percent of total billed charges,Implant Device,714,34,,714,percent of total billed charges,Implant Device,714,34,,714,percent of total billed charges,Implant Device,714,34,,714,percent of total billed charges,Implant Device,714,34,,714,percent of total billed charges,Implant Device,1039.5,,,1039.5,Other,110% of Medicare,735,35,,735,percent of total billed charges,Implant Device,714,34,"Charges > $500, x 34%",714,percent of total billed charges,Implant Device,735,35,,735,percent of total billed charges,Implant Device,735,35,,735,percent of total billed charges,Implant Device,735,35,,735,percent of total billed charges,Implant Device,735,35,,735,percent of total billed charges,Implant Device,735,35,,735,percent of total billed charges,Implant Device,840,40,,840,percent of total billed charges,Implant Device,735,70,,735,percent of total billed charges,All Other,714,34,,714,percent of total billed charges,Implant Device,714,34,,714,percent of total billed charges,Implant Device,735,35,,735,percent of total billed charges,Implant Device,735,35,,735,percent of total billed charges,Implant Device,735,35,,735,percent of total billed charges,Implant Device,735,35,,735,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,714,34,"If Charge > 2,000, then 34 percent",714,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1554.01,
J&J C08060SL SMARTSTENT BILIARY 8X60X80,C1876,HCPCS,,79000514,CDM,278,RC,,,both,,,2100,1554.01,,,1554.01,Other,150% of Medicare + 9.63% HCRA Surcharge,945,45,,945,percent of total billed charges,Critical Access Hospital RCC factor,714,34,,714,percent of total billed charges,Implant Device,714,34,,714,percent of total billed charges,Implant Device,714,34,,714,percent of total billed charges,Implant Device,714,34,,714,percent of total billed charges,Implant Device,714,34,,714,percent of total billed charges,Implant Device,1039.5,,,1039.5,Other,110% of Medicare,735,35,,735,percent of total billed charges,Implant Device,714,34,"Charges > $500, x 34%",714,percent of total billed charges,Implant Device,735,35,,735,percent of total billed charges,Implant Device,735,35,,735,percent of total billed charges,Implant Device,735,35,,735,percent of total billed charges,Implant Device,735,35,,735,percent of total billed charges,Implant Device,735,35,,735,percent of total billed charges,Implant Device,840,40,,840,percent of total billed charges,Implant Device,735,70,,735,percent of total billed charges,All Other,714,34,,714,percent of total billed charges,Implant Device,714,34,,714,percent of total billed charges,Implant Device,735,35,,735,percent of total billed charges,Implant Device,735,35,,735,percent of total billed charges,Implant Device,735,35,,735,percent of total billed charges,Implant Device,735,35,,735,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,714,34,"If Charge > 2,000, then 34 percent",714,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1554.01,
J&J C08080SL SMARTSTENT BILIARY 8X80X80,C1876,HCPCS,,79000515,CDM,278,RC,,,both,,,2100,1554.01,,,1554.01,Other,150% of Medicare + 9.63% HCRA Surcharge,945,45,,945,percent of total billed charges,Critical Access Hospital RCC factor,714,34,,714,percent of total billed charges,Implant Device,714,34,,714,percent of total billed charges,Implant Device,714,34,,714,percent of total billed charges,Implant Device,714,34,,714,percent of total billed charges,Implant Device,714,34,,714,percent of total billed charges,Implant Device,1039.5,,,1039.5,Other,110% of Medicare,735,35,,735,percent of total billed charges,Implant Device,714,34,"Charges > $500, x 34%",714,percent of total billed charges,Implant Device,735,35,,735,percent of total billed charges,Implant Device,735,35,,735,percent of total billed charges,Implant Device,735,35,,735,percent of total billed charges,Implant Device,735,35,,735,percent of total billed charges,Implant Device,735,35,,735,percent of total billed charges,Implant Device,840,40,,840,percent of total billed charges,Implant Device,735,70,,735,percent of total billed charges,All Other,714,34,,714,percent of total billed charges,Implant Device,714,34,,714,percent of total billed charges,Implant Device,735,35,,735,percent of total billed charges,Implant Device,735,35,,735,percent of total billed charges,Implant Device,735,35,,735,percent of total billed charges,Implant Device,735,35,,735,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,714,34,"If Charge > 2,000, then 34 percent",714,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1554.01,
J&J C09030SL SMARTSTENT BILIARY 9X30X80,C1876,HCPCS,,79000516,CDM,278,RC,,,both,,,2027,1499.99,,,1499.99,Other,150% of Medicare + 9.63% HCRA Surcharge,912.15,45,,912.15,percent of total billed charges,Critical Access Hospital RCC factor,689.18,34,,689.18,percent of total billed charges,Implant Device,689.18,34,,689.18,percent of total billed charges,Implant Device,689.18,34,,689.18,percent of total billed charges,Implant Device,689.18,34,,689.18,percent of total billed charges,Implant Device,689.18,34,,689.18,percent of total billed charges,Implant Device,1003.37,,,1003.37,Other,110% of Medicare,709.45,35,,709.45,percent of total billed charges,Implant Device,689.18,34,"Charges > $500, x 34%",689.18,percent of total billed charges,Implant Device,709.45,35,,709.45,percent of total billed charges,Implant Device,709.45,35,,709.45,percent of total billed charges,Implant Device,709.45,35,,709.45,percent of total billed charges,Implant Device,709.45,35,,709.45,percent of total billed charges,Implant Device,709.45,35,,709.45,percent of total billed charges,Implant Device,810.8,40,,810.8,percent of total billed charges,Implant Device,709.45,70,,709.45,percent of total billed charges,All Other,689.18,34,,689.18,percent of total billed charges,Implant Device,689.18,34,,689.18,percent of total billed charges,Implant Device,709.45,35,,709.45,percent of total billed charges,Implant Device,709.45,35,,709.45,percent of total billed charges,Implant Device,709.45,35,,709.45,percent of total billed charges,Implant Device,709.45,35,,709.45,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,689.18,34,"If Charge > 2,000, then 34 percent",689.18,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1499.99,
BOST SCI 37911-51515 EXPRESS SD STENT,C1876,HCPCS,,79000522,CDM,278,RC,,,both,,,3600,2664.01,,,2664.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1620,45,,1620,percent of total billed charges,Critical Access Hospital RCC factor,1224,34,,1224,percent of total billed charges,Implant Device,1224,34,,1224,percent of total billed charges,Implant Device,1224,34,,1224,percent of total billed charges,Implant Device,1224,34,,1224,percent of total billed charges,Implant Device,1224,34,,1224,percent of total billed charges,Implant Device,1782,,,1782,Other,110% of Medicare,1260,35,,1260,percent of total billed charges,Implant Device,1224,34,"Charges > $500, x 34%",1224,percent of total billed charges,Implant Device,1260,35,,1260,percent of total billed charges,Implant Device,1260,35,,1260,percent of total billed charges,Implant Device,1260,35,,1260,percent of total billed charges,Implant Device,1260,35,,1260,percent of total billed charges,Implant Device,1260,35,,1260,percent of total billed charges,Implant Device,1440,40,,1440,percent of total billed charges,Implant Device,1260,70,,1260,percent of total billed charges,All Other,1224,34,,1224,percent of total billed charges,Implant Device,1224,34,,1224,percent of total billed charges,Implant Device,1260,35,,1260,percent of total billed charges,Implant Device,1260,35,,1260,percent of total billed charges,Implant Device,1260,35,,1260,percent of total billed charges,Implant Device,1260,35,,1260,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1224,34,"If Charge > 2,000, then 34 percent",1224,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2664.01,
BOST SCI 37912-61890 EXPRESS SD STENT,C1876,HCPCS,,79000523,CDM,278,RC,,,both,,,3600,2664.01,,,2664.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1620,45,,1620,percent of total billed charges,Critical Access Hospital RCC factor,1224,34,,1224,percent of total billed charges,Implant Device,1224,34,,1224,percent of total billed charges,Implant Device,1224,34,,1224,percent of total billed charges,Implant Device,1224,34,,1224,percent of total billed charges,Implant Device,1224,34,,1224,percent of total billed charges,Implant Device,1782,,,1782,Other,110% of Medicare,1260,35,,1260,percent of total billed charges,Implant Device,1224,34,"Charges > $500, x 34%",1224,percent of total billed charges,Implant Device,1260,35,,1260,percent of total billed charges,Implant Device,1260,35,,1260,percent of total billed charges,Implant Device,1260,35,,1260,percent of total billed charges,Implant Device,1260,35,,1260,percent of total billed charges,Implant Device,1260,35,,1260,percent of total billed charges,Implant Device,1440,40,,1440,percent of total billed charges,Implant Device,1260,70,,1260,percent of total billed charges,All Other,1224,34,,1224,percent of total billed charges,Implant Device,1224,34,,1224,percent of total billed charges,Implant Device,1260,35,,1260,percent of total billed charges,Implant Device,1260,35,,1260,percent of total billed charges,Implant Device,1260,35,,1260,percent of total billed charges,Implant Device,1260,35,,1260,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1224,34,"If Charge > 2,000, then 34 percent",1224,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2664.01,
BOST SCI 38046-73075 7X75 EXPRESS STENT,C1876,HCPCS,,79000524,CDM,278,RC,,,both,,,3575,2645.51,,,2645.51,Other,150% of Medicare + 9.63% HCRA Surcharge,1608.75,45,,1608.75,percent of total billed charges,Critical Access Hospital RCC factor,1215.5,34,,1215.5,percent of total billed charges,Implant Device,1215.5,34,,1215.5,percent of total billed charges,Implant Device,1215.5,34,,1215.5,percent of total billed charges,Implant Device,1215.5,34,,1215.5,percent of total billed charges,Implant Device,1215.5,34,,1215.5,percent of total billed charges,Implant Device,1769.63,,,1769.63,Other,110% of Medicare,1251.25,35,,1251.25,percent of total billed charges,Implant Device,1215.5,34,"Charges > $500, x 34%",1215.5,percent of total billed charges,Implant Device,1251.25,35,,1251.25,percent of total billed charges,Implant Device,1251.25,35,,1251.25,percent of total billed charges,Implant Device,1251.25,35,,1251.25,percent of total billed charges,Implant Device,1251.25,35,,1251.25,percent of total billed charges,Implant Device,1251.25,35,,1251.25,percent of total billed charges,Implant Device,1430,40,,1430,percent of total billed charges,Implant Device,1251.25,70,,1251.25,percent of total billed charges,All Other,1215.5,34,,1215.5,percent of total billed charges,Implant Device,1215.5,34,,1215.5,percent of total billed charges,Implant Device,1251.25,35,,1251.25,percent of total billed charges,Implant Device,1251.25,35,,1251.25,percent of total billed charges,Implant Device,1251.25,35,,1251.25,percent of total billed charges,Implant Device,1251.25,35,,1251.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1215.5,34,"If Charge > 2,000, then 34 percent",1215.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2645.51,
BARD FAS08050 STENTGRAFT FLAIR 8X50,C1874,HCPCS,,79000525,CDM,278,RC,,,both,,,7485,5538.92,,,5538.92,Other,150% of Medicare + 9.63% HCRA Surcharge,3368.25,45,,3368.25,percent of total billed charges,Critical Access Hospital RCC factor,2544.9,34,,2544.9,percent of total billed charges,Implant Device,2544.9,34,,2544.9,percent of total billed charges,Implant Device,2544.9,34,,2544.9,percent of total billed charges,Implant Device,2544.9,34,,2544.9,percent of total billed charges,Implant Device,2544.9,34,,2544.9,percent of total billed charges,Implant Device,3705.08,,,3705.08,Other,110% of Medicare,2619.75,35,,2619.75,percent of total billed charges,Implant Device,2544.9,34,"Charges > $500, x 34%",2544.9,percent of total billed charges,Implant Device,2619.75,35,,2619.75,percent of total billed charges,Implant Device,2619.75,35,,2619.75,percent of total billed charges,Implant Device,2619.75,35,,2619.75,percent of total billed charges,Implant Device,2619.75,35,,2619.75,percent of total billed charges,Implant Device,2619.75,35,,2619.75,percent of total billed charges,Implant Device,2994,40,,2994,percent of total billed charges,Implant Device,2619.75,70,,2619.75,percent of total billed charges,All Other,2544.9,34,,2544.9,percent of total billed charges,Implant Device,2544.9,34,,2544.9,percent of total billed charges,Implant Device,2619.75,35,,2619.75,percent of total billed charges,Implant Device,2619.75,35,,2619.75,percent of total billed charges,Implant Device,2619.75,35,,2619.75,percent of total billed charges,Implant Device,2619.75,35,,2619.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2544.9,34,"If Charge > 2,000, then 34 percent",2544.9,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5538.92,
BARD FTL06060 STENTGRAFT FLUENCY 6X60,C1874,HCPCS,,79000526,CDM,278,RC,,,both,,,6585,4872.92,,,4872.92,Other,150% of Medicare + 9.63% HCRA Surcharge,2963.25,45,,2963.25,percent of total billed charges,Critical Access Hospital RCC factor,2238.9,34,,2238.9,percent of total billed charges,Implant Device,2238.9,34,,2238.9,percent of total billed charges,Implant Device,2238.9,34,,2238.9,percent of total billed charges,Implant Device,2238.9,34,,2238.9,percent of total billed charges,Implant Device,2238.9,34,,2238.9,percent of total billed charges,Implant Device,3259.58,,,3259.58,Other,110% of Medicare,2304.75,35,,2304.75,percent of total billed charges,Implant Device,2238.9,34,"Charges > $500, x 34%",2238.9,percent of total billed charges,Implant Device,2304.75,35,,2304.75,percent of total billed charges,Implant Device,2304.75,35,,2304.75,percent of total billed charges,Implant Device,2304.75,35,,2304.75,percent of total billed charges,Implant Device,2304.75,35,,2304.75,percent of total billed charges,Implant Device,2304.75,35,,2304.75,percent of total billed charges,Implant Device,2634,40,,2634,percent of total billed charges,Implant Device,2304.75,70,,2304.75,percent of total billed charges,All Other,2238.9,34,,2238.9,percent of total billed charges,Implant Device,2238.9,34,,2238.9,percent of total billed charges,Implant Device,2304.75,35,,2304.75,percent of total billed charges,Implant Device,2304.75,35,,2304.75,percent of total billed charges,Implant Device,2304.75,35,,2304.75,percent of total billed charges,Implant Device,2304.75,35,,2304.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2238.9,34,"If Charge > 2,000, then 34 percent",2238.9,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4872.92,
BARD FAS08040 STENTGRAFT FLUENCY 8X40,C1874,HCPCS,,79000527,CDM,278,RC,,,both,,,7186,5317.66,,,5317.66,Other,150% of Medicare + 9.63% HCRA Surcharge,3233.7,45,,3233.7,percent of total billed charges,Critical Access Hospital RCC factor,2443.24,34,,2443.24,percent of total billed charges,Implant Device,2443.24,34,,2443.24,percent of total billed charges,Implant Device,2443.24,34,,2443.24,percent of total billed charges,Implant Device,2443.24,34,,2443.24,percent of total billed charges,Implant Device,2443.24,34,,2443.24,percent of total billed charges,Implant Device,3557.07,,,3557.07,Other,110% of Medicare,2515.1,35,,2515.1,percent of total billed charges,Implant Device,2443.24,34,"Charges > $500, x 34%",2443.24,percent of total billed charges,Implant Device,2515.1,35,,2515.1,percent of total billed charges,Implant Device,2515.1,35,,2515.1,percent of total billed charges,Implant Device,2515.1,35,,2515.1,percent of total billed charges,Implant Device,2515.1,35,,2515.1,percent of total billed charges,Implant Device,2515.1,35,,2515.1,percent of total billed charges,Implant Device,2874.4,40,,2874.4,percent of total billed charges,Implant Device,2515.1,70,,2515.1,percent of total billed charges,All Other,2443.24,34,,2443.24,percent of total billed charges,Implant Device,2443.24,34,,2443.24,percent of total billed charges,Implant Device,2515.1,35,,2515.1,percent of total billed charges,Implant Device,2515.1,35,,2515.1,percent of total billed charges,Implant Device,2515.1,35,,2515.1,percent of total billed charges,Implant Device,2515.1,35,,2515.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2443.24,34,"If Charge > 2,000, then 34 percent",2443.24,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5317.66,
BARD FTL08060 STENTGRAFT FLUENCY 8X60,C1874,HCPCS,,79000528,CDM,278,RC,,,both,,,6886,5095.66,,,5095.66,Other,150% of Medicare + 9.63% HCRA Surcharge,3098.7,45,,3098.7,percent of total billed charges,Critical Access Hospital RCC factor,2341.24,34,,2341.24,percent of total billed charges,Implant Device,2341.24,34,,2341.24,percent of total billed charges,Implant Device,2341.24,34,,2341.24,percent of total billed charges,Implant Device,2341.24,34,,2341.24,percent of total billed charges,Implant Device,2341.24,34,,2341.24,percent of total billed charges,Implant Device,3408.57,,,3408.57,Other,110% of Medicare,2410.1,35,,2410.1,percent of total billed charges,Implant Device,2341.24,34,"Charges > $500, x 34%",2341.24,percent of total billed charges,Implant Device,2410.1,35,,2410.1,percent of total billed charges,Implant Device,2410.1,35,,2410.1,percent of total billed charges,Implant Device,2410.1,35,,2410.1,percent of total billed charges,Implant Device,2410.1,35,,2410.1,percent of total billed charges,Implant Device,2410.1,35,,2410.1,percent of total billed charges,Implant Device,2754.4,40,,2754.4,percent of total billed charges,Implant Device,2410.1,70,,2410.1,percent of total billed charges,All Other,2341.24,34,,2341.24,percent of total billed charges,Implant Device,2341.24,34,,2341.24,percent of total billed charges,Implant Device,2410.1,35,,2410.1,percent of total billed charges,Implant Device,2410.1,35,,2410.1,percent of total billed charges,Implant Device,2410.1,35,,2410.1,percent of total billed charges,Implant Device,2410.1,35,,2410.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2341.24,34,"If Charge > 2,000, then 34 percent",2341.24,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5095.66,
J&J 466-P-306BU TRAPEASE FILTER IVC 90CM,C1880,HCPCS,,79000547,CDM,278,RC,,,both,,,4036,2986.65,,,2986.65,Other,150% of Medicare + 9.63% HCRA Surcharge,1816.2,45,,1816.2,percent of total billed charges,Critical Access Hospital RCC factor,1372.24,34,,1372.24,percent of total billed charges,Implant Device,1372.24,34,,1372.24,percent of total billed charges,Implant Device,1372.24,34,,1372.24,percent of total billed charges,Implant Device,1372.24,34,,1372.24,percent of total billed charges,Implant Device,1372.24,34,,1372.24,percent of total billed charges,Implant Device,1997.82,,,1997.82,Other,110% of Medicare,1412.6,35,,1412.6,percent of total billed charges,Implant Device,1372.24,34,"Charges > $500, x 34%",1372.24,percent of total billed charges,Implant Device,1412.6,35,,1412.6,percent of total billed charges,Implant Device,1412.6,35,,1412.6,percent of total billed charges,Implant Device,1412.6,35,,1412.6,percent of total billed charges,Implant Device,1412.6,35,,1412.6,percent of total billed charges,Implant Device,1412.6,35,,1412.6,percent of total billed charges,Implant Device,1614.4,40,,1614.4,percent of total billed charges,Implant Device,1412.6,70,,1412.6,percent of total billed charges,All Other,1372.24,34,,1372.24,percent of total billed charges,Implant Device,1372.24,34,,1372.24,percent of total billed charges,Implant Device,1412.6,35,,1412.6,percent of total billed charges,Implant Device,1412.6,35,,1412.6,percent of total billed charges,Implant Device,1412.6,35,,1412.6,percent of total billed charges,Implant Device,1412.6,35,,1412.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1372.24,34,"If Charge > 2,000, then 34 percent",1372.24,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2986.65,
TRAPEASE FILTER IVC 55CM,C1880,HCPCS,,79000548,CDM,278,RC,,,both,,,2296,1699.05,,,1699.05,Other,150% of Medicare + 9.63% HCRA Surcharge,1033.2,45,,1033.2,percent of total billed charges,Critical Access Hospital RCC factor,780.64,34,,780.64,percent of total billed charges,Implant Device,780.64,34,,780.64,percent of total billed charges,Implant Device,780.64,34,,780.64,percent of total billed charges,Implant Device,780.64,34,,780.64,percent of total billed charges,Implant Device,780.64,34,,780.64,percent of total billed charges,Implant Device,1136.52,,,1136.52,Other,110% of Medicare,803.6,35,,803.6,percent of total billed charges,Implant Device,780.64,34,"Charges > $500, x 34%",780.64,percent of total billed charges,Implant Device,803.6,35,,803.6,percent of total billed charges,Implant Device,803.6,35,,803.6,percent of total billed charges,Implant Device,803.6,35,,803.6,percent of total billed charges,Implant Device,803.6,35,,803.6,percent of total billed charges,Implant Device,803.6,35,,803.6,percent of total billed charges,Implant Device,918.4,40,,918.4,percent of total billed charges,Implant Device,803.6,70,,803.6,percent of total billed charges,All Other,780.64,34,,780.64,percent of total billed charges,Implant Device,780.64,34,,780.64,percent of total billed charges,Implant Device,803.6,35,,803.6,percent of total billed charges,Implant Device,803.6,35,,803.6,percent of total billed charges,Implant Device,803.6,35,,803.6,percent of total billed charges,Implant Device,803.6,35,,803.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,780.64,34,"If Charge > 2,000, then 34 percent",780.64,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1699.05,
STRYKER 27-401 URETERAL STENT US-8-22CM,C2617,HCPCS,,79000552,CDM,278,RC,,,both,,,342,253.08,,,253.08,Other,150% of Medicare + 9.63% HCRA Surcharge,153.9,45,,153.9,percent of total billed charges,Critical Access Hospital RCC factor,116.28,34,,116.28,percent of total billed charges,Implant Device,116.28,34,,116.28,percent of total billed charges,Implant Device,116.28,34,,116.28,percent of total billed charges,Implant Device,116.28,34,,116.28,percent of total billed charges,Implant Device,116.28,34,,116.28,percent of total billed charges,Implant Device,169.29,,,169.29,Other,110% of Medicare,119.7,35,,119.7,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,119.7,35,,119.7,percent of total billed charges,Implant Device,119.7,35,,119.7,percent of total billed charges,Implant Device,119.7,35,,119.7,percent of total billed charges,Implant Device,119.7,35,,119.7,percent of total billed charges,Implant Device,119.7,35,,119.7,percent of total billed charges,Implant Device,136.8,40,,136.8,percent of total billed charges,Implant Device,119.7,70,,119.7,percent of total billed charges,All Other,116.28,34,,116.28,percent of total billed charges,Implant Device,116.28,34,,116.28,percent of total billed charges,Implant Device,119.7,35,,119.7,percent of total billed charges,Implant Device,119.7,35,,119.7,percent of total billed charges,Implant Device,119.7,35,,119.7,percent of total billed charges,Implant Device,119.7,35,,119.7,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,253.08,
STRYKER 27-402 URETERAL STENT US-8-24CM,C2617,HCPCS,,79000553,CDM,278,RC,,,both,,,342,253.08,,,253.08,Other,150% of Medicare + 9.63% HCRA Surcharge,153.9,45,,153.9,percent of total billed charges,Critical Access Hospital RCC factor,116.28,34,,116.28,percent of total billed charges,Implant Device,116.28,34,,116.28,percent of total billed charges,Implant Device,116.28,34,,116.28,percent of total billed charges,Implant Device,116.28,34,,116.28,percent of total billed charges,Implant Device,116.28,34,,116.28,percent of total billed charges,Implant Device,169.29,,,169.29,Other,110% of Medicare,119.7,35,,119.7,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,119.7,35,,119.7,percent of total billed charges,Implant Device,119.7,35,,119.7,percent of total billed charges,Implant Device,119.7,35,,119.7,percent of total billed charges,Implant Device,119.7,35,,119.7,percent of total billed charges,Implant Device,119.7,35,,119.7,percent of total billed charges,Implant Device,136.8,40,,136.8,percent of total billed charges,Implant Device,119.7,70,,119.7,percent of total billed charges,All Other,116.28,34,,116.28,percent of total billed charges,Implant Device,116.28,34,,116.28,percent of total billed charges,Implant Device,119.7,35,,119.7,percent of total billed charges,Implant Device,119.7,35,,119.7,percent of total billed charges,Implant Device,119.7,35,,119.7,percent of total billed charges,Implant Device,119.7,35,,119.7,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,253.08,
GORE VBH050502 VIABHN STENTGRAFT 5X5X120,C1874,HCPCS,,79000554,CDM,278,RC,,,both,,,7140,5283.62,,,5283.62,Other,150% of Medicare + 9.63% HCRA Surcharge,3213,45,,3213,percent of total billed charges,Critical Access Hospital RCC factor,2427.6,34,,2427.6,percent of total billed charges,Implant Device,2427.6,34,,2427.6,percent of total billed charges,Implant Device,2427.6,34,,2427.6,percent of total billed charges,Implant Device,2427.6,34,,2427.6,percent of total billed charges,Implant Device,2427.6,34,,2427.6,percent of total billed charges,Implant Device,3534.3,,,3534.3,Other,110% of Medicare,2499,35,,2499,percent of total billed charges,Implant Device,2427.6,34,"Charges > $500, x 34%",2427.6,percent of total billed charges,Implant Device,2499,35,,2499,percent of total billed charges,Implant Device,2499,35,,2499,percent of total billed charges,Implant Device,2499,35,,2499,percent of total billed charges,Implant Device,2499,35,,2499,percent of total billed charges,Implant Device,2499,35,,2499,percent of total billed charges,Implant Device,2856,40,,2856,percent of total billed charges,Implant Device,2499,70,,2499,percent of total billed charges,All Other,2427.6,34,,2427.6,percent of total billed charges,Implant Device,2427.6,34,,2427.6,percent of total billed charges,Implant Device,2499,35,,2499,percent of total billed charges,Implant Device,2499,35,,2499,percent of total billed charges,Implant Device,2499,35,,2499,percent of total billed charges,Implant Device,2499,35,,2499,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2427.6,34,"If Charge > 2,000, then 34 percent",2427.6,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5283.62,
BARD 600620 CATH BOVIAC HICKMAN 12FR,C1751,HCPCS,,79000594,CDM,278,RC,,,both,,,644,476.56,,,476.56,Other,150% of Medicare + 9.63% HCRA Surcharge,289.8,45,,289.8,percent of total billed charges,Critical Access Hospital RCC factor,218.96,34,,218.96,percent of total billed charges,Implant Device,218.96,34,,218.96,percent of total billed charges,Implant Device,218.96,34,,218.96,percent of total billed charges,Implant Device,218.96,34,,218.96,percent of total billed charges,Implant Device,218.96,34,,218.96,percent of total billed charges,Implant Device,318.78,,,318.78,Other,110% of Medicare,225.4,35,,225.4,percent of total billed charges,Implant Device,218.96,34,"Charges > $500, x 34%",218.96,percent of total billed charges,Implant Device,225.4,35,,225.4,percent of total billed charges,Implant Device,225.4,35,,225.4,percent of total billed charges,Implant Device,225.4,35,,225.4,percent of total billed charges,Implant Device,225.4,35,,225.4,percent of total billed charges,Implant Device,225.4,35,,225.4,percent of total billed charges,Implant Device,257.6,40,,257.6,percent of total billed charges,Implant Device,225.4,70,,225.4,percent of total billed charges,All Other,218.96,34,,218.96,percent of total billed charges,Implant Device,218.96,34,,218.96,percent of total billed charges,Implant Device,225.4,35,,225.4,percent of total billed charges,Implant Device,225.4,35,,225.4,percent of total billed charges,Implant Device,225.4,35,,225.4,percent of total billed charges,Implant Device,225.4,35,,225.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,476.56,
ARROW AK15703SP CATH TRIPLE LUMEN 20CM,C1751,HCPCS,,79000644,CDM,278,RC,,,both,,,103,76.22,,,76.22,Other,150% of Medicare + 9.63% HCRA Surcharge,46.35,45,,46.35,percent of total billed charges,Critical Access Hospital RCC factor,35.02,34,,35.02,percent of total billed charges,Implant Device,35.02,34,,35.02,percent of total billed charges,Implant Device,35.02,34,,35.02,percent of total billed charges,Implant Device,35.02,34,,35.02,percent of total billed charges,Implant Device,35.02,34,,35.02,percent of total billed charges,Implant Device,50.99,,,50.99,Other,110% of Medicare,36.05,35,,36.05,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,36.05,35,,36.05,percent of total billed charges,Implant Device,36.05,35,,36.05,percent of total billed charges,Implant Device,36.05,35,,36.05,percent of total billed charges,Implant Device,36.05,35,,36.05,percent of total billed charges,Implant Device,36.05,35,,36.05,percent of total billed charges,Implant Device,41.2,40,,41.2,percent of total billed charges,Implant Device,36.05,70,,36.05,percent of total billed charges,All Other,35.02,34,,35.02,percent of total billed charges,Implant Device,35.02,34,,35.02,percent of total billed charges,Implant Device,36.05,35,,36.05,percent of total billed charges,Implant Device,36.05,35,,36.05,percent of total billed charges,Implant Device,36.05,35,,36.05,percent of total billed charges,Implant Device,36.05,35,,36.05,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,76.22,
J&J 2205 BLAKE DRAIN 7MM FLUTD EVACUATOR,C1729,HCPCS,,79000707,CDM,278,RC,,,both,,,157,116.18,,,116.18,Other,150% of Medicare + 9.63% HCRA Surcharge,70.65,45,,70.65,percent of total billed charges,Critical Access Hospital RCC factor,53.38,34,,53.38,percent of total billed charges,Implant Device,53.38,34,,53.38,percent of total billed charges,Implant Device,53.38,34,,53.38,percent of total billed charges,Implant Device,53.38,34,,53.38,percent of total billed charges,Implant Device,53.38,34,,53.38,percent of total billed charges,Implant Device,77.72,,,77.72,Other,110% of Medicare,54.95,35,,54.95,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,54.95,35,,54.95,percent of total billed charges,Implant Device,54.95,35,,54.95,percent of total billed charges,Implant Device,54.95,35,,54.95,percent of total billed charges,Implant Device,54.95,35,,54.95,percent of total billed charges,Implant Device,54.95,35,,54.95,percent of total billed charges,Implant Device,62.8,40,,62.8,percent of total billed charges,Implant Device,54.95,70,,54.95,percent of total billed charges,All Other,53.38,34,,53.38,percent of total billed charges,Implant Device,53.38,34,,53.38,percent of total billed charges,Implant Device,54.95,35,,54.95,percent of total billed charges,Implant Device,54.95,35,,54.95,percent of total billed charges,Implant Device,54.95,35,,54.95,percent of total billed charges,Implant Device,54.95,35,,54.95,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,116.18,
ARROW AU-22122-F DIALYSIS CATH STR 16CM,C1752,HCPCS,,79000708,CDM,278,RC,,,both,,,239,176.86,,,176.86,Other,150% of Medicare + 9.63% HCRA Surcharge,107.55,45,,107.55,percent of total billed charges,Critical Access Hospital RCC factor,81.26,34,,81.26,percent of total billed charges,Implant Device,81.26,34,,81.26,percent of total billed charges,Implant Device,81.26,34,,81.26,percent of total billed charges,Implant Device,81.26,34,,81.26,percent of total billed charges,Implant Device,81.26,34,,81.26,percent of total billed charges,Implant Device,118.31,,,118.31,Other,110% of Medicare,83.65,35,,83.65,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,83.65,35,,83.65,percent of total billed charges,Implant Device,83.65,35,,83.65,percent of total billed charges,Implant Device,83.65,35,,83.65,percent of total billed charges,Implant Device,83.65,35,,83.65,percent of total billed charges,Implant Device,83.65,35,,83.65,percent of total billed charges,Implant Device,95.6,40,,95.6,percent of total billed charges,Implant Device,83.65,70,,83.65,percent of total billed charges,All Other,81.26,34,,81.26,percent of total billed charges,Implant Device,81.26,34,,81.26,percent of total billed charges,Implant Device,83.65,35,,83.65,percent of total billed charges,Implant Device,83.65,35,,83.65,percent of total billed charges,Implant Device,83.65,35,,83.65,percent of total billed charges,Implant Device,83.65,35,,83.65,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,176.86,
ARROW AU-25122-F DIALYSIS JUG CATH 20CM,C1752,HCPCS,,79000709,CDM,278,RC,,,both,,,239,176.86,,,176.86,Other,150% of Medicare + 9.63% HCRA Surcharge,107.55,45,,107.55,percent of total billed charges,Critical Access Hospital RCC factor,81.26,34,,81.26,percent of total billed charges,Implant Device,81.26,34,,81.26,percent of total billed charges,Implant Device,81.26,34,,81.26,percent of total billed charges,Implant Device,81.26,34,,81.26,percent of total billed charges,Implant Device,81.26,34,,81.26,percent of total billed charges,Implant Device,118.31,,,118.31,Other,110% of Medicare,83.65,35,,83.65,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,83.65,35,,83.65,percent of total billed charges,Implant Device,83.65,35,,83.65,percent of total billed charges,Implant Device,83.65,35,,83.65,percent of total billed charges,Implant Device,83.65,35,,83.65,percent of total billed charges,Implant Device,83.65,35,,83.65,percent of total billed charges,Implant Device,95.6,40,,95.6,percent of total billed charges,Implant Device,83.65,70,,83.65,percent of total billed charges,All Other,81.26,34,,81.26,percent of total billed charges,Implant Device,81.26,34,,81.26,percent of total billed charges,Implant Device,83.65,35,,83.65,percent of total billed charges,Implant Device,83.65,35,,83.65,percent of total billed charges,Implant Device,83.65,35,,83.65,percent of total billed charges,Implant Device,83.65,35,,83.65,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,176.86,
ARROW CS-15282-VSP CANNON PLUS CATH 15FR,C1750,HCPCS,,79000812,CDM,278,RC,,,both,,,1078,797.72,,,797.72,Other,150% of Medicare + 9.63% HCRA Surcharge,485.1,45,,485.1,percent of total billed charges,Critical Access Hospital RCC factor,366.52,34,,366.52,percent of total billed charges,Implant Device,366.52,34,,366.52,percent of total billed charges,Implant Device,366.52,34,,366.52,percent of total billed charges,Implant Device,366.52,34,,366.52,percent of total billed charges,Implant Device,366.52,34,,366.52,percent of total billed charges,Implant Device,533.61,,,533.61,Other,110% of Medicare,377.3,35,,377.3,percent of total billed charges,Implant Device,366.52,34,"Charges > $500, x 34%",366.52,percent of total billed charges,Implant Device,377.3,35,,377.3,percent of total billed charges,Implant Device,377.3,35,,377.3,percent of total billed charges,Implant Device,377.3,35,,377.3,percent of total billed charges,Implant Device,377.3,35,,377.3,percent of total billed charges,Implant Device,377.3,35,,377.3,percent of total billed charges,Implant Device,431.2,40,,431.2,percent of total billed charges,Implant Device,377.3,70,,377.3,percent of total billed charges,All Other,366.52,34,,366.52,percent of total billed charges,Implant Device,366.52,34,,366.52,percent of total billed charges,Implant Device,377.3,35,,377.3,percent of total billed charges,Implant Device,377.3,35,,377.3,percent of total billed charges,Implant Device,377.3,35,,377.3,percent of total billed charges,Implant Device,377.3,35,,377.3,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,797.72,
ARROW CS-15272-X CATHETER NEXT STEP 27CM,C1750,HCPCS,,79000824,CDM,278,RC,,,both,,,902,667.48,,,667.48,Other,150% of Medicare + 9.63% HCRA Surcharge,405.9,45,,405.9,percent of total billed charges,Critical Access Hospital RCC factor,306.68,34,,306.68,percent of total billed charges,Implant Device,306.68,34,,306.68,percent of total billed charges,Implant Device,306.68,34,,306.68,percent of total billed charges,Implant Device,306.68,34,,306.68,percent of total billed charges,Implant Device,306.68,34,,306.68,percent of total billed charges,Implant Device,446.49,,,446.49,Other,110% of Medicare,315.7,35,,315.7,percent of total billed charges,Implant Device,306.68,34,"Charges > $500, x 34%",306.68,percent of total billed charges,Implant Device,315.7,35,,315.7,percent of total billed charges,Implant Device,315.7,35,,315.7,percent of total billed charges,Implant Device,315.7,35,,315.7,percent of total billed charges,Implant Device,315.7,35,,315.7,percent of total billed charges,Implant Device,315.7,35,,315.7,percent of total billed charges,Implant Device,360.8,40,,360.8,percent of total billed charges,Implant Device,315.7,70,,315.7,percent of total billed charges,All Other,306.68,34,,306.68,percent of total billed charges,Implant Device,306.68,34,,306.68,percent of total billed charges,Implant Device,315.7,35,,315.7,percent of total billed charges,Implant Device,315.7,35,,315.7,percent of total billed charges,Implant Device,315.7,35,,315.7,percent of total billed charges,Implant Device,315.7,35,,315.7,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,667.48,
ARTHREX AR-1530BC SCREW BIOCOMP 3X8MM,C1713,HCPCS,,79000894,CDM,278,RC,,,both,,,1125,832.5,,,832.5,Other,150% of Medicare + 9.63% HCRA Surcharge,506.25,45,,506.25,percent of total billed charges,Critical Access Hospital RCC factor,382.5,34,,382.5,percent of total billed charges,Implant Device,382.5,34,,382.5,percent of total billed charges,Implant Device,382.5,34,,382.5,percent of total billed charges,Implant Device,382.5,34,,382.5,percent of total billed charges,Implant Device,382.5,34,,382.5,percent of total billed charges,Implant Device,556.88,,,556.88,Other,110% of Medicare,393.75,35,,393.75,percent of total billed charges,Implant Device,382.5,34,"Charges > $500, x 34%",382.5,percent of total billed charges,Implant Device,393.75,35,,393.75,percent of total billed charges,Implant Device,393.75,35,,393.75,percent of total billed charges,Implant Device,393.75,35,,393.75,percent of total billed charges,Implant Device,393.75,35,,393.75,percent of total billed charges,Implant Device,393.75,35,,393.75,percent of total billed charges,Implant Device,450,40,,450,percent of total billed charges,Implant Device,393.75,70,,393.75,percent of total billed charges,All Other,382.5,34,,382.5,percent of total billed charges,Implant Device,382.5,34,,382.5,percent of total billed charges,Implant Device,393.75,35,,393.75,percent of total billed charges,Implant Device,393.75,35,,393.75,percent of total billed charges,Implant Device,393.75,35,,393.75,percent of total billed charges,Implant Device,393.75,35,,393.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,832.5,
BARD 600604 HICKMAN CATHETER,C1751,HCPCS,,79000935,CDM,278,RC,,,both,,,833,616.42,,,616.42,Other,150% of Medicare + 9.63% HCRA Surcharge,374.85,45,,374.85,percent of total billed charges,Critical Access Hospital RCC factor,283.22,34,,283.22,percent of total billed charges,Implant Device,283.22,34,,283.22,percent of total billed charges,Implant Device,283.22,34,,283.22,percent of total billed charges,Implant Device,283.22,34,,283.22,percent of total billed charges,Implant Device,283.22,34,,283.22,percent of total billed charges,Implant Device,412.34,,,412.34,Other,110% of Medicare,291.55,35,,291.55,percent of total billed charges,Implant Device,283.22,34,"Charges > $500, x 34%",283.22,percent of total billed charges,Implant Device,291.55,35,,291.55,percent of total billed charges,Implant Device,291.55,35,,291.55,percent of total billed charges,Implant Device,291.55,35,,291.55,percent of total billed charges,Implant Device,291.55,35,,291.55,percent of total billed charges,Implant Device,291.55,35,,291.55,percent of total billed charges,Implant Device,333.2,40,,333.2,percent of total billed charges,Implant Device,291.55,70,,291.55,percent of total billed charges,All Other,283.22,34,,283.22,percent of total billed charges,Implant Device,283.22,34,,283.22,percent of total billed charges,Implant Device,291.55,35,,291.55,percent of total billed charges,Implant Device,291.55,35,,291.55,percent of total billed charges,Implant Device,291.55,35,,291.55,percent of total billed charges,Implant Device,291.55,35,,291.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,616.42,
BARD 600574 HICKMAN CATHETER 7FR,C1751,HCPCS,,79000936,CDM,278,RC,,,both,,,833,616.42,,,616.42,Other,150% of Medicare + 9.63% HCRA Surcharge,374.85,45,,374.85,percent of total billed charges,Critical Access Hospital RCC factor,283.22,34,,283.22,percent of total billed charges,Implant Device,283.22,34,,283.22,percent of total billed charges,Implant Device,283.22,34,,283.22,percent of total billed charges,Implant Device,283.22,34,,283.22,percent of total billed charges,Implant Device,283.22,34,,283.22,percent of total billed charges,Implant Device,412.34,,,412.34,Other,110% of Medicare,291.55,35,,291.55,percent of total billed charges,Implant Device,283.22,34,"Charges > $500, x 34%",283.22,percent of total billed charges,Implant Device,291.55,35,,291.55,percent of total billed charges,Implant Device,291.55,35,,291.55,percent of total billed charges,Implant Device,291.55,35,,291.55,percent of total billed charges,Implant Device,291.55,35,,291.55,percent of total billed charges,Implant Device,291.55,35,,291.55,percent of total billed charges,Implant Device,333.2,40,,333.2,percent of total billed charges,Implant Device,291.55,70,,291.55,percent of total billed charges,All Other,283.22,34,,283.22,percent of total billed charges,Implant Device,283.22,34,,283.22,percent of total billed charges,Implant Device,291.55,35,,291.55,percent of total billed charges,Implant Device,291.55,35,,291.55,percent of total billed charges,Implant Device,291.55,35,,291.55,percent of total billed charges,Implant Device,291.55,35,,291.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,616.42,
BARD 600654 HICKMAN CATH 12.5FR,C1751,HCPCS,,79000937,CDM,278,RC,,,both,,,878,649.72,,,649.72,Other,150% of Medicare + 9.63% HCRA Surcharge,395.1,45,,395.1,percent of total billed charges,Critical Access Hospital RCC factor,298.52,34,,298.52,percent of total billed charges,Implant Device,298.52,34,,298.52,percent of total billed charges,Implant Device,298.52,34,,298.52,percent of total billed charges,Implant Device,298.52,34,,298.52,percent of total billed charges,Implant Device,298.52,34,,298.52,percent of total billed charges,Implant Device,434.61,,,434.61,Other,110% of Medicare,307.3,35,,307.3,percent of total billed charges,Implant Device,298.52,34,"Charges > $500, x 34%",298.52,percent of total billed charges,Implant Device,307.3,35,,307.3,percent of total billed charges,Implant Device,307.3,35,,307.3,percent of total billed charges,Implant Device,307.3,35,,307.3,percent of total billed charges,Implant Device,307.3,35,,307.3,percent of total billed charges,Implant Device,307.3,35,,307.3,percent of total billed charges,Implant Device,351.2,40,,351.2,percent of total billed charges,Implant Device,307.3,70,,307.3,percent of total billed charges,All Other,298.52,34,,298.52,percent of total billed charges,Implant Device,298.52,34,,298.52,percent of total billed charges,Implant Device,307.3,35,,307.3,percent of total billed charges,Implant Device,307.3,35,,307.3,percent of total billed charges,Implant Device,307.3,35,,307.3,percent of total billed charges,Implant Device,307.3,35,,307.3,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,649.72,
MICRO AIRE 1600-1945 K WIRE .045,C1713,HCPCS,,79000962,CDM,278,RC,,,both,,,19,14.06,,,14.06,Other,150% of Medicare + 9.63% HCRA Surcharge,8.55,45,,8.55,percent of total billed charges,Critical Access Hospital RCC factor,6.46,34,,6.46,percent of total billed charges,Implant Device,6.46,34,,6.46,percent of total billed charges,Implant Device,6.46,34,,6.46,percent of total billed charges,Implant Device,6.46,34,,6.46,percent of total billed charges,Implant Device,6.46,34,,6.46,percent of total billed charges,Implant Device,9.41,,,9.41,Other,110% of Medicare,6.65,35,,6.65,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,6.65,35,,6.65,percent of total billed charges,Implant Device,6.65,35,,6.65,percent of total billed charges,Implant Device,6.65,35,,6.65,percent of total billed charges,Implant Device,6.65,35,,6.65,percent of total billed charges,Implant Device,6.65,35,,6.65,percent of total billed charges,Implant Device,7.6,40,,7.6,percent of total billed charges,Implant Device,6.65,70,,6.65,percent of total billed charges,All Other,6.46,34,,6.46,percent of total billed charges,Implant Device,6.46,34,,6.46,percent of total billed charges,Implant Device,6.65,35,,6.65,percent of total billed charges,Implant Device,6.65,35,,6.65,percent of total billed charges,Implant Device,6.65,35,,6.65,percent of total billed charges,Implant Device,6.65,35,,6.65,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,14.06,
ZIMMER 186-03-69 K WIRE .062,C1713,HCPCS,,79000975,CDM,278,RC,,,both,,,18,13.32,,,13.32,Other,150% of Medicare + 9.63% HCRA Surcharge,8.1,45,,8.1,percent of total billed charges,Critical Access Hospital RCC factor,6.12,34,,6.12,percent of total billed charges,Implant Device,6.12,34,,6.12,percent of total billed charges,Implant Device,6.12,34,,6.12,percent of total billed charges,Implant Device,6.12,34,,6.12,percent of total billed charges,Implant Device,6.12,34,,6.12,percent of total billed charges,Implant Device,8.91,,,8.91,Other,110% of Medicare,6.3,35,,6.3,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,6.3,35,,6.3,percent of total billed charges,Implant Device,6.3,35,,6.3,percent of total billed charges,Implant Device,6.3,35,,6.3,percent of total billed charges,Implant Device,6.3,35,,6.3,percent of total billed charges,Implant Device,6.3,35,,6.3,percent of total billed charges,Implant Device,7.2,40,,7.2,percent of total billed charges,Implant Device,6.3,70,,6.3,percent of total billed charges,All Other,6.12,34,,6.12,percent of total billed charges,Implant Device,6.12,34,,6.12,percent of total billed charges,Implant Device,6.3,35,,6.3,percent of total billed charges,Implant Device,6.3,35,,6.3,percent of total billed charges,Implant Device,6.3,35,,6.3,percent of total billed charges,Implant Device,6.3,35,,6.3,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,13.32,
MICRO AIRE 1600-628 K-WIRE 028,C1713,HCPCS,,79000980,CDM,278,RC,,,both,,,19,14.06,,,14.06,Other,150% of Medicare + 9.63% HCRA Surcharge,8.55,45,,8.55,percent of total billed charges,Critical Access Hospital RCC factor,6.46,34,,6.46,percent of total billed charges,Implant Device,6.46,34,,6.46,percent of total billed charges,Implant Device,6.46,34,,6.46,percent of total billed charges,Implant Device,6.46,34,,6.46,percent of total billed charges,Implant Device,6.46,34,,6.46,percent of total billed charges,Implant Device,9.41,,,9.41,Other,110% of Medicare,6.65,35,,6.65,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,6.65,35,,6.65,percent of total billed charges,Implant Device,6.65,35,,6.65,percent of total billed charges,Implant Device,6.65,35,,6.65,percent of total billed charges,Implant Device,6.65,35,,6.65,percent of total billed charges,Implant Device,6.65,35,,6.65,percent of total billed charges,Implant Device,7.6,40,,7.6,percent of total billed charges,Implant Device,6.65,70,,6.65,percent of total billed charges,All Other,6.46,34,,6.46,percent of total billed charges,Implant Device,6.46,34,,6.46,percent of total billed charges,Implant Device,6.65,35,,6.65,percent of total billed charges,Implant Device,6.65,35,,6.65,percent of total billed charges,Implant Device,6.65,35,,6.65,percent of total billed charges,Implant Device,6.65,35,,6.65,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,14.06,
MICRO AIRE 1600-635 K-WIRE 035,C1713,HCPCS,,79000981,CDM,278,RC,,,both,,,19,14.06,,,14.06,Other,150% of Medicare + 9.63% HCRA Surcharge,8.55,45,,8.55,percent of total billed charges,Critical Access Hospital RCC factor,6.46,34,,6.46,percent of total billed charges,Implant Device,6.46,34,,6.46,percent of total billed charges,Implant Device,6.46,34,,6.46,percent of total billed charges,Implant Device,6.46,34,,6.46,percent of total billed charges,Implant Device,6.46,34,,6.46,percent of total billed charges,Implant Device,9.41,,,9.41,Other,110% of Medicare,6.65,35,,6.65,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,6.65,35,,6.65,percent of total billed charges,Implant Device,6.65,35,,6.65,percent of total billed charges,Implant Device,6.65,35,,6.65,percent of total billed charges,Implant Device,6.65,35,,6.65,percent of total billed charges,Implant Device,6.65,35,,6.65,percent of total billed charges,Implant Device,7.6,40,,7.6,percent of total billed charges,Implant Device,6.65,70,,6.65,percent of total billed charges,All Other,6.46,34,,6.46,percent of total billed charges,Implant Device,6.46,34,,6.46,percent of total billed charges,Implant Device,6.65,35,,6.65,percent of total billed charges,Implant Device,6.65,35,,6.65,percent of total billed charges,Implant Device,6.65,35,,6.65,percent of total billed charges,Implant Device,6.65,35,,6.65,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,14.06,
BIOMET 91-5611 2.0X11MM SD IMF SCREW,C1713,HCPCS,,79001186,CDM,278,RC,,,both,,,454,335.96,,,335.96,Other,150% of Medicare + 9.63% HCRA Surcharge,204.3,45,,204.3,percent of total billed charges,Critical Access Hospital RCC factor,154.36,34,,154.36,percent of total billed charges,Implant Device,154.36,34,,154.36,percent of total billed charges,Implant Device,154.36,34,,154.36,percent of total billed charges,Implant Device,154.36,34,,154.36,percent of total billed charges,Implant Device,154.36,34,,154.36,percent of total billed charges,Implant Device,224.73,,,224.73,Other,110% of Medicare,158.9,35,,158.9,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,158.9,35,,158.9,percent of total billed charges,Implant Device,158.9,35,,158.9,percent of total billed charges,Implant Device,158.9,35,,158.9,percent of total billed charges,Implant Device,158.9,35,,158.9,percent of total billed charges,Implant Device,158.9,35,,158.9,percent of total billed charges,Implant Device,181.6,40,,181.6,percent of total billed charges,Implant Device,158.9,70,,158.9,percent of total billed charges,All Other,154.36,34,,154.36,percent of total billed charges,Implant Device,154.36,34,,154.36,percent of total billed charges,Implant Device,158.9,35,,158.9,percent of total billed charges,Implant Device,158.9,35,,158.9,percent of total billed charges,Implant Device,158.9,35,,158.9,percent of total billed charges,Implant Device,158.9,35,,158.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,335.96,
J&J 254506 ABSOLUTE INTER SCREW 9 X 30,C1713,HCPCS,,79001187,CDM,278,RC,,,both,,,436,322.64,,,322.64,Other,150% of Medicare + 9.63% HCRA Surcharge,196.2,45,,196.2,percent of total billed charges,Critical Access Hospital RCC factor,148.24,34,,148.24,percent of total billed charges,Implant Device,148.24,34,,148.24,percent of total billed charges,Implant Device,148.24,34,,148.24,percent of total billed charges,Implant Device,148.24,34,,148.24,percent of total billed charges,Implant Device,148.24,34,,148.24,percent of total billed charges,Implant Device,215.82,,,215.82,Other,110% of Medicare,152.6,35,,152.6,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,152.6,35,,152.6,percent of total billed charges,Implant Device,152.6,35,,152.6,percent of total billed charges,Implant Device,152.6,35,,152.6,percent of total billed charges,Implant Device,152.6,35,,152.6,percent of total billed charges,Implant Device,152.6,35,,152.6,percent of total billed charges,Implant Device,174.4,40,,174.4,percent of total billed charges,Implant Device,152.6,70,,152.6,percent of total billed charges,All Other,148.24,34,,148.24,percent of total billed charges,Implant Device,148.24,34,,148.24,percent of total billed charges,Implant Device,152.6,35,,152.6,percent of total billed charges,Implant Device,152.6,35,,152.6,percent of total billed charges,Implant Device,152.6,35,,152.6,percent of total billed charges,Implant Device,152.6,35,,152.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,322.64,
ARTHREX AR-1588T ACL TIGHTROPE,C1713,HCPCS,,79001188,CDM,278,RC,,,both,,,1180,873.2,,,873.2,Other,150% of Medicare + 9.63% HCRA Surcharge,531,45,,531,percent of total billed charges,Critical Access Hospital RCC factor,401.2,34,,401.2,percent of total billed charges,Implant Device,401.2,34,,401.2,percent of total billed charges,Implant Device,401.2,34,,401.2,percent of total billed charges,Implant Device,401.2,34,,401.2,percent of total billed charges,Implant Device,401.2,34,,401.2,percent of total billed charges,Implant Device,584.1,,,584.1,Other,110% of Medicare,413,35,,413,percent of total billed charges,Implant Device,401.2,34,"Charges > $500, x 34%",401.2,percent of total billed charges,Implant Device,413,35,,413,percent of total billed charges,Implant Device,413,35,,413,percent of total billed charges,Implant Device,413,35,,413,percent of total billed charges,Implant Device,413,35,,413,percent of total billed charges,Implant Device,413,35,,413,percent of total billed charges,Implant Device,472,40,,472,percent of total billed charges,Implant Device,413,70,,413,percent of total billed charges,All Other,401.2,34,,401.2,percent of total billed charges,Implant Device,401.2,34,,401.2,percent of total billed charges,Implant Device,413,35,,413,percent of total billed charges,Implant Device,413,35,,413,percent of total billed charges,Implant Device,413,35,,413,percent of total billed charges,Implant Device,413,35,,413,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,873.2,
ARTHREX AR-1588RT ACL TIGHTROPE KIT,C1713,HCPCS,,79001189,CDM,278,RC,,,both,,,1050,777,,,777,Other,150% of Medicare + 9.63% HCRA Surcharge,472.5,45,,472.5,percent of total billed charges,Critical Access Hospital RCC factor,357,34,,357,percent of total billed charges,Implant Device,357,34,,357,percent of total billed charges,Implant Device,357,34,,357,percent of total billed charges,Implant Device,357,34,,357,percent of total billed charges,Implant Device,357,34,,357,percent of total billed charges,Implant Device,519.75,,,519.75,Other,110% of Medicare,367.5,35,,367.5,percent of total billed charges,Implant Device,357,34,"Charges > $500, x 34%",357,percent of total billed charges,Implant Device,367.5,35,,367.5,percent of total billed charges,Implant Device,367.5,35,,367.5,percent of total billed charges,Implant Device,367.5,35,,367.5,percent of total billed charges,Implant Device,367.5,35,,367.5,percent of total billed charges,Implant Device,367.5,35,,367.5,percent of total billed charges,Implant Device,420,40,,420,percent of total billed charges,Implant Device,367.5,70,,367.5,percent of total billed charges,All Other,357,34,,357,percent of total billed charges,Implant Device,357,34,,357,percent of total billed charges,Implant Device,367.5,35,,367.5,percent of total billed charges,Implant Device,367.5,35,,367.5,percent of total billed charges,Implant Device,367.5,35,,367.5,percent of total billed charges,Implant Device,367.5,35,,367.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,777,
LIFE CELL 102128 ALLODERM 8 X 16CM THICK,Q4116,HCPCS,JC,79001190,CDM,278,RC,,,both,,,14670,10855.84,,,10855.84,Other,150% of Medicare + 9.63% HCRA Surcharge,6601.5,45,,6601.5,percent of total billed charges,Critical Access Hospital RCC factor,4987.8,34,,4987.8,percent of total billed charges,Implant Device,4987.8,34,,4987.8,percent of total billed charges,Implant Device,4987.8,34,,4987.8,percent of total billed charges,Implant Device,4987.8,34,,4987.8,percent of total billed charges,Implant Device,4987.8,34,,4987.8,percent of total billed charges,Implant Device,7261.65,,,7261.65,Other,110% of Medicare,5134.5,35,,5134.5,percent of total billed charges,Implant Device,4987.8,34,"Charges > $500, x 34%",4987.8,percent of total billed charges,Implant Device,5134.5,35,,5134.5,percent of total billed charges,Implant Device,5134.5,35,,5134.5,percent of total billed charges,Implant Device,5134.5,35,,5134.5,percent of total billed charges,Implant Device,5134.5,35,,5134.5,percent of total billed charges,Implant Device,5134.5,35,,5134.5,percent of total billed charges,Implant Device,5868,40,,5868,percent of total billed charges,Implant Device,5134.5,70,,5134.5,percent of total billed charges,All Other,4987.8,34,,4987.8,percent of total billed charges,Implant Device,4987.8,34,,4987.8,percent of total billed charges,Implant Device,5134.5,35,,5134.5,percent of total billed charges,Implant Device,5134.5,35,,5134.5,percent of total billed charges,Implant Device,5134.5,35,,5134.5,percent of total billed charges,Implant Device,5134.5,35,,5134.5,percent of total billed charges,Implant Device,976.07,,,976.07,Other,100% of Medicaid,976.07,,,976.07,Other,100% of Medicaid,976.07,,,976.07,Other,100% of Medicaid,976.07,,,976.07,Other,100% of Medicaid,2196.15,,,2196.15,Other,225% of Medicaid,1493.38,,,1493.38,Other,153% of Medicaid,2196.15,,,2196.15,Other,225% of Medicaid,1366.49,,,1366.49,Other,140% of Medicaid,4987.8,34,"If Charge > 2,000, then 34 percent",4987.8,percent of total billed charges,Implants,2537.77,,,2537.77,Other,260% of Medicaid,3162.45,,,3162.45,Other,324% of Medicaid,2098.54,,,2098.54,Other,215% of Medicaid,2098.54,,,2098.54,Other,215% of Medicaid,1220.08,,,1220.08,Other,125% of Medicaid,976.07,10855.84,
LIFE CELL 102016 ALLODERM 8 X 2CM,Q4116,HCPCS,JC,79001191,CDM,278,RC,,,both,,,18346,13576.09,,,13576.09,Other,150% of Medicare + 9.63% HCRA Surcharge,8255.7,45,,8255.7,percent of total billed charges,Critical Access Hospital RCC factor,6237.64,34,,6237.64,percent of total billed charges,Implant Device,6237.64,34,,6237.64,percent of total billed charges,Implant Device,6237.64,34,,6237.64,percent of total billed charges,Implant Device,6237.64,34,,6237.64,percent of total billed charges,Implant Device,6237.64,34,,6237.64,percent of total billed charges,Implant Device,9081.27,,,9081.27,Other,110% of Medicare,6421.1,35,,6421.1,percent of total billed charges,Implant Device,6237.64,34,"Charges > $500, x 34%",6237.64,percent of total billed charges,Implant Device,6421.1,35,,6421.1,percent of total billed charges,Implant Device,6421.1,35,,6421.1,percent of total billed charges,Implant Device,6421.1,35,,6421.1,percent of total billed charges,Implant Device,6421.1,35,,6421.1,percent of total billed charges,Implant Device,6421.1,35,,6421.1,percent of total billed charges,Implant Device,7338.4,40,,7338.4,percent of total billed charges,Implant Device,6421.1,70,,6421.1,percent of total billed charges,All Other,6237.64,34,,6237.64,percent of total billed charges,Implant Device,6237.64,34,,6237.64,percent of total billed charges,Implant Device,6421.1,35,,6421.1,percent of total billed charges,Implant Device,6421.1,35,,6421.1,percent of total billed charges,Implant Device,6421.1,35,,6421.1,percent of total billed charges,Implant Device,6421.1,35,,6421.1,percent of total billed charges,Implant Device,976.07,,,976.07,Other,100% of Medicaid,976.07,,,976.07,Other,100% of Medicaid,976.07,,,976.07,Other,100% of Medicaid,976.07,,,976.07,Other,100% of Medicaid,2196.15,,,2196.15,Other,225% of Medicaid,1493.38,,,1493.38,Other,153% of Medicaid,2196.15,,,2196.15,Other,225% of Medicaid,1366.49,,,1366.49,Other,140% of Medicaid,6237.64,34,"If Charge > 2,000, then 34 percent",6237.64,percent of total billed charges,Implants,2537.77,,,2537.77,Other,260% of Medicaid,3162.45,,,3162.45,Other,324% of Medicaid,2098.54,,,2098.54,Other,215% of Medicaid,2098.54,,,2098.54,Other,215% of Medicaid,1220.08,,,1220.08,Other,125% of Medicaid,976.07,13576.09,
LIFE CELL 102050 ALLODERM 4 X 12CM,Q4116,HCPCS,JC,79001192,CDM,278,RC,,,both,,,5056,3741.45,,,3741.45,Other,150% of Medicare + 9.63% HCRA Surcharge,2275.2,45,,2275.2,percent of total billed charges,Critical Access Hospital RCC factor,1719.04,34,,1719.04,percent of total billed charges,Implant Device,1719.04,34,,1719.04,percent of total billed charges,Implant Device,1719.04,34,,1719.04,percent of total billed charges,Implant Device,1719.04,34,,1719.04,percent of total billed charges,Implant Device,1719.04,34,,1719.04,percent of total billed charges,Implant Device,2502.72,,,2502.72,Other,110% of Medicare,1769.6,35,,1769.6,percent of total billed charges,Implant Device,1719.04,34,"Charges > $500, x 34%",1719.04,percent of total billed charges,Implant Device,1769.6,35,,1769.6,percent of total billed charges,Implant Device,1769.6,35,,1769.6,percent of total billed charges,Implant Device,1769.6,35,,1769.6,percent of total billed charges,Implant Device,1769.6,35,,1769.6,percent of total billed charges,Implant Device,1769.6,35,,1769.6,percent of total billed charges,Implant Device,2022.4,40,,2022.4,percent of total billed charges,Implant Device,1769.6,70,,1769.6,percent of total billed charges,All Other,1719.04,34,,1719.04,percent of total billed charges,Implant Device,1719.04,34,,1719.04,percent of total billed charges,Implant Device,1769.6,35,,1769.6,percent of total billed charges,Implant Device,1769.6,35,,1769.6,percent of total billed charges,Implant Device,1769.6,35,,1769.6,percent of total billed charges,Implant Device,1769.6,35,,1769.6,percent of total billed charges,Implant Device,976.07,,,976.07,Other,100% of Medicaid,976.07,,,976.07,Other,100% of Medicaid,976.07,,,976.07,Other,100% of Medicaid,976.07,,,976.07,Other,100% of Medicaid,2196.15,,,2196.15,Other,225% of Medicaid,1493.38,,,1493.38,Other,153% of Medicaid,2196.15,,,2196.15,Other,225% of Medicaid,1366.49,,,1366.49,Other,140% of Medicaid,1719.04,34,"If Charge > 2,000, then 34 percent",1719.04,percent of total billed charges,Implants,2537.77,,,2537.77,Other,260% of Medicaid,3162.45,,,3162.45,Other,324% of Medicaid,2098.54,,,2098.54,Other,215% of Medicaid,2098.54,,,2098.54,Other,215% of Medicaid,1220.08,,,1220.08,Other,125% of Medicaid,976.07,3741.45,
STRYKER 54-25384 VOLAR PLATE 56MM RIGHT,C1713,HCPCS,,79001193,CDM,278,RC,,,both,,,3873,2866.03,,,2866.03,Other,150% of Medicare + 9.63% HCRA Surcharge,1742.85,45,,1742.85,percent of total billed charges,Critical Access Hospital RCC factor,1316.82,34,,1316.82,percent of total billed charges,Implant Device,1316.82,34,,1316.82,percent of total billed charges,Implant Device,1316.82,34,,1316.82,percent of total billed charges,Implant Device,1316.82,34,,1316.82,percent of total billed charges,Implant Device,1316.82,34,,1316.82,percent of total billed charges,Implant Device,1917.14,,,1917.14,Other,110% of Medicare,1355.55,35,,1355.55,percent of total billed charges,Implant Device,1316.82,34,"Charges > $500, x 34%",1316.82,percent of total billed charges,Implant Device,1355.55,35,,1355.55,percent of total billed charges,Implant Device,1355.55,35,,1355.55,percent of total billed charges,Implant Device,1355.55,35,,1355.55,percent of total billed charges,Implant Device,1355.55,35,,1355.55,percent of total billed charges,Implant Device,1355.55,35,,1355.55,percent of total billed charges,Implant Device,1549.2,40,,1549.2,percent of total billed charges,Implant Device,1355.55,70,,1355.55,percent of total billed charges,All Other,1316.82,34,,1316.82,percent of total billed charges,Implant Device,1316.82,34,,1316.82,percent of total billed charges,Implant Device,1355.55,35,,1355.55,percent of total billed charges,Implant Device,1355.55,35,,1355.55,percent of total billed charges,Implant Device,1355.55,35,,1355.55,percent of total billed charges,Implant Device,1355.55,35,,1355.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1316.82,34,"If Charge > 2,000, then 34 percent",1316.82,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2866.03,
HEMOSPHERE HERO 1002 ARTERIAL GRAFT COMP,C1750,HCPCS,,79001194,CDM,278,RC,,,both,,,2746,2032.05,,,2032.05,Other,150% of Medicare + 9.63% HCRA Surcharge,1235.7,45,,1235.7,percent of total billed charges,Critical Access Hospital RCC factor,933.64,34,,933.64,percent of total billed charges,Implant Device,933.64,34,,933.64,percent of total billed charges,Implant Device,933.64,34,,933.64,percent of total billed charges,Implant Device,933.64,34,,933.64,percent of total billed charges,Implant Device,933.64,34,,933.64,percent of total billed charges,Implant Device,1359.27,,,1359.27,Other,110% of Medicare,961.1,35,,961.1,percent of total billed charges,Implant Device,933.64,34,"Charges > $500, x 34%",933.64,percent of total billed charges,Implant Device,961.1,35,,961.1,percent of total billed charges,Implant Device,961.1,35,,961.1,percent of total billed charges,Implant Device,961.1,35,,961.1,percent of total billed charges,Implant Device,961.1,35,,961.1,percent of total billed charges,Implant Device,961.1,35,,961.1,percent of total billed charges,Implant Device,1098.4,40,,1098.4,percent of total billed charges,Implant Device,961.1,70,,961.1,percent of total billed charges,All Other,933.64,34,,933.64,percent of total billed charges,Implant Device,933.64,34,,933.64,percent of total billed charges,Implant Device,961.1,35,,961.1,percent of total billed charges,Implant Device,961.1,35,,961.1,percent of total billed charges,Implant Device,961.1,35,,961.1,percent of total billed charges,Implant Device,961.1,35,,961.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,933.64,34,"If Charge > 2,000, then 34 percent",933.64,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2032.05,
ARROW CSD-15282-SP SPLIT CATH 15FRX11,C1750,HCPCS,,79001195,CDM,278,RC,,,both,,,796,589.04,,,589.04,Other,150% of Medicare + 9.63% HCRA Surcharge,358.2,45,,358.2,percent of total billed charges,Critical Access Hospital RCC factor,270.64,34,,270.64,percent of total billed charges,Implant Device,270.64,34,,270.64,percent of total billed charges,Implant Device,270.64,34,,270.64,percent of total billed charges,Implant Device,270.64,34,,270.64,percent of total billed charges,Implant Device,270.64,34,,270.64,percent of total billed charges,Implant Device,394.02,,,394.02,Other,110% of Medicare,278.6,35,,278.6,percent of total billed charges,Implant Device,270.64,34,"Charges > $500, x 34%",270.64,percent of total billed charges,Implant Device,278.6,35,,278.6,percent of total billed charges,Implant Device,278.6,35,,278.6,percent of total billed charges,Implant Device,278.6,35,,278.6,percent of total billed charges,Implant Device,278.6,35,,278.6,percent of total billed charges,Implant Device,278.6,35,,278.6,percent of total billed charges,Implant Device,318.4,40,,318.4,percent of total billed charges,Implant Device,278.6,70,,278.6,percent of total billed charges,All Other,270.64,34,,270.64,percent of total billed charges,Implant Device,270.64,34,,270.64,percent of total billed charges,Implant Device,278.6,35,,278.6,percent of total billed charges,Implant Device,278.6,35,,278.6,percent of total billed charges,Implant Device,278.6,35,,278.6,percent of total billed charges,Implant Device,278.6,35,,278.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,589.04,
ARROW CSD-15242-SP SPLIT CATH 15FRX9.5,C1750,HCPCS,,79001196,CDM,278,RC,,,both,,,750,555,,,555,Other,150% of Medicare + 9.63% HCRA Surcharge,337.5,45,,337.5,percent of total billed charges,Critical Access Hospital RCC factor,255,34,,255,percent of total billed charges,Implant Device,255,34,,255,percent of total billed charges,Implant Device,255,34,,255,percent of total billed charges,Implant Device,255,34,,255,percent of total billed charges,Implant Device,255,34,,255,percent of total billed charges,Implant Device,371.25,,,371.25,Other,110% of Medicare,262.5,35,,262.5,percent of total billed charges,Implant Device,255,34,"Charges > $500, x 34%",255,percent of total billed charges,Implant Device,262.5,35,,262.5,percent of total billed charges,Implant Device,262.5,35,,262.5,percent of total billed charges,Implant Device,262.5,35,,262.5,percent of total billed charges,Implant Device,262.5,35,,262.5,percent of total billed charges,Implant Device,262.5,35,,262.5,percent of total billed charges,Implant Device,300,40,,300,percent of total billed charges,Implant Device,262.5,70,,262.5,percent of total billed charges,All Other,255,34,,255,percent of total billed charges,Implant Device,255,34,,255,percent of total billed charges,Implant Device,262.5,35,,262.5,percent of total billed charges,Implant Device,262.5,35,,262.5,percent of total billed charges,Implant Device,262.5,35,,262.5,percent of total billed charges,Implant Device,262.5,35,,262.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,555,
STRYKER 40-20110E CANN SCREW 2X10/4MM,C1713,HCPCS,,79001197,CDM,278,RC,,,both,,,493,364.82,,,364.82,Other,150% of Medicare + 9.63% HCRA Surcharge,221.85,45,,221.85,percent of total billed charges,Critical Access Hospital RCC factor,167.62,34,,167.62,percent of total billed charges,Implant Device,167.62,34,,167.62,percent of total billed charges,Implant Device,167.62,34,,167.62,percent of total billed charges,Implant Device,167.62,34,,167.62,percent of total billed charges,Implant Device,167.62,34,,167.62,percent of total billed charges,Implant Device,244.04,,,244.04,Other,110% of Medicare,172.55,35,,172.55,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,172.55,35,,172.55,percent of total billed charges,Implant Device,172.55,35,,172.55,percent of total billed charges,Implant Device,172.55,35,,172.55,percent of total billed charges,Implant Device,172.55,35,,172.55,percent of total billed charges,Implant Device,172.55,35,,172.55,percent of total billed charges,Implant Device,197.2,40,,197.2,percent of total billed charges,Implant Device,172.55,70,,172.55,percent of total billed charges,All Other,167.62,34,,167.62,percent of total billed charges,Implant Device,167.62,34,,167.62,percent of total billed charges,Implant Device,172.55,35,,172.55,percent of total billed charges,Implant Device,172.55,35,,172.55,percent of total billed charges,Implant Device,172.55,35,,172.55,percent of total billed charges,Implant Device,172.55,35,,172.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,364.82,
STRYKER 40-20111E CANN SCREW 2X11/5MM,C1713,HCPCS,,79001198,CDM,278,RC,,,both,,,493,364.82,,,364.82,Other,150% of Medicare + 9.63% HCRA Surcharge,221.85,45,,221.85,percent of total billed charges,Critical Access Hospital RCC factor,167.62,34,,167.62,percent of total billed charges,Implant Device,167.62,34,,167.62,percent of total billed charges,Implant Device,167.62,34,,167.62,percent of total billed charges,Implant Device,167.62,34,,167.62,percent of total billed charges,Implant Device,167.62,34,,167.62,percent of total billed charges,Implant Device,244.04,,,244.04,Other,110% of Medicare,172.55,35,,172.55,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,172.55,35,,172.55,percent of total billed charges,Implant Device,172.55,35,,172.55,percent of total billed charges,Implant Device,172.55,35,,172.55,percent of total billed charges,Implant Device,172.55,35,,172.55,percent of total billed charges,Implant Device,172.55,35,,172.55,percent of total billed charges,Implant Device,197.2,40,,197.2,percent of total billed charges,Implant Device,172.55,70,,172.55,percent of total billed charges,All Other,167.62,34,,167.62,percent of total billed charges,Implant Device,167.62,34,,167.62,percent of total billed charges,Implant Device,172.55,35,,172.55,percent of total billed charges,Implant Device,172.55,35,,172.55,percent of total billed charges,Implant Device,172.55,35,,172.55,percent of total billed charges,Implant Device,172.55,35,,172.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,364.82,
STRYKER 40-30112E CANN SCREW 2X12/4MM,C1713,HCPCS,,79001199,CDM,278,RC,,,both,,,859,635.66,,,635.66,Other,150% of Medicare + 9.63% HCRA Surcharge,386.55,45,,386.55,percent of total billed charges,Critical Access Hospital RCC factor,292.06,34,,292.06,percent of total billed charges,Implant Device,292.06,34,,292.06,percent of total billed charges,Implant Device,292.06,34,,292.06,percent of total billed charges,Implant Device,292.06,34,,292.06,percent of total billed charges,Implant Device,292.06,34,,292.06,percent of total billed charges,Implant Device,425.21,,,425.21,Other,110% of Medicare,300.65,35,,300.65,percent of total billed charges,Implant Device,292.06,34,"Charges > $500, x 34%",292.06,percent of total billed charges,Implant Device,300.65,35,,300.65,percent of total billed charges,Implant Device,300.65,35,,300.65,percent of total billed charges,Implant Device,300.65,35,,300.65,percent of total billed charges,Implant Device,300.65,35,,300.65,percent of total billed charges,Implant Device,300.65,35,,300.65,percent of total billed charges,Implant Device,343.6,40,,343.6,percent of total billed charges,Implant Device,300.65,70,,300.65,percent of total billed charges,All Other,292.06,34,,292.06,percent of total billed charges,Implant Device,292.06,34,,292.06,percent of total billed charges,Implant Device,300.65,35,,300.65,percent of total billed charges,Implant Device,300.65,35,,300.65,percent of total billed charges,Implant Device,300.65,35,,300.65,percent of total billed charges,Implant Device,300.65,35,,300.65,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,635.66,
STRYKER 40-20112E CANN SCREW 2X12/5MM,C1713,HCPCS,,79001200,CDM,278,RC,,,both,,,493,364.82,,,364.82,Other,150% of Medicare + 9.63% HCRA Surcharge,221.85,45,,221.85,percent of total billed charges,Critical Access Hospital RCC factor,167.62,34,,167.62,percent of total billed charges,Implant Device,167.62,34,,167.62,percent of total billed charges,Implant Device,167.62,34,,167.62,percent of total billed charges,Implant Device,167.62,34,,167.62,percent of total billed charges,Implant Device,167.62,34,,167.62,percent of total billed charges,Implant Device,244.04,,,244.04,Other,110% of Medicare,172.55,35,,172.55,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,172.55,35,,172.55,percent of total billed charges,Implant Device,172.55,35,,172.55,percent of total billed charges,Implant Device,172.55,35,,172.55,percent of total billed charges,Implant Device,172.55,35,,172.55,percent of total billed charges,Implant Device,172.55,35,,172.55,percent of total billed charges,Implant Device,197.2,40,,197.2,percent of total billed charges,Implant Device,172.55,70,,172.55,percent of total billed charges,All Other,167.62,34,,167.62,percent of total billed charges,Implant Device,167.62,34,,167.62,percent of total billed charges,Implant Device,172.55,35,,172.55,percent of total billed charges,Implant Device,172.55,35,,172.55,percent of total billed charges,Implant Device,172.55,35,,172.55,percent of total billed charges,Implant Device,172.55,35,,172.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,364.82,
STRYKER 40-20113E CANN SCREW 2X13/6MM,C1713,HCPCS,,79001201,CDM,278,RC,,,both,,,583,431.42,,,431.42,Other,150% of Medicare + 9.63% HCRA Surcharge,262.35,45,,262.35,percent of total billed charges,Critical Access Hospital RCC factor,198.22,34,,198.22,percent of total billed charges,Implant Device,198.22,34,,198.22,percent of total billed charges,Implant Device,198.22,34,,198.22,percent of total billed charges,Implant Device,198.22,34,,198.22,percent of total billed charges,Implant Device,198.22,34,,198.22,percent of total billed charges,Implant Device,288.59,,,288.59,Other,110% of Medicare,204.05,35,,204.05,percent of total billed charges,Implant Device,198.22,34,"Charges > $500, x 34%",198.22,percent of total billed charges,Implant Device,204.05,35,,204.05,percent of total billed charges,Implant Device,204.05,35,,204.05,percent of total billed charges,Implant Device,204.05,35,,204.05,percent of total billed charges,Implant Device,204.05,35,,204.05,percent of total billed charges,Implant Device,204.05,35,,204.05,percent of total billed charges,Implant Device,233.2,40,,233.2,percent of total billed charges,Implant Device,204.05,70,,204.05,percent of total billed charges,All Other,198.22,34,,198.22,percent of total billed charges,Implant Device,198.22,34,,198.22,percent of total billed charges,Implant Device,204.05,35,,204.05,percent of total billed charges,Implant Device,204.05,35,,204.05,percent of total billed charges,Implant Device,204.05,35,,204.05,percent of total billed charges,Implant Device,204.05,35,,204.05,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,431.42,
STRYKER 40-30114E CANN SCREW 2X14/4MM,C1713,HCPCS,,79001202,CDM,278,RC,,,both,,,493,364.82,,,364.82,Other,150% of Medicare + 9.63% HCRA Surcharge,221.85,45,,221.85,percent of total billed charges,Critical Access Hospital RCC factor,167.62,34,,167.62,percent of total billed charges,Implant Device,167.62,34,,167.62,percent of total billed charges,Implant Device,167.62,34,,167.62,percent of total billed charges,Implant Device,167.62,34,,167.62,percent of total billed charges,Implant Device,167.62,34,,167.62,percent of total billed charges,Implant Device,244.04,,,244.04,Other,110% of Medicare,172.55,35,,172.55,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,172.55,35,,172.55,percent of total billed charges,Implant Device,172.55,35,,172.55,percent of total billed charges,Implant Device,172.55,35,,172.55,percent of total billed charges,Implant Device,172.55,35,,172.55,percent of total billed charges,Implant Device,172.55,35,,172.55,percent of total billed charges,Implant Device,197.2,40,,197.2,percent of total billed charges,Implant Device,172.55,70,,172.55,percent of total billed charges,All Other,167.62,34,,167.62,percent of total billed charges,Implant Device,167.62,34,,167.62,percent of total billed charges,Implant Device,172.55,35,,172.55,percent of total billed charges,Implant Device,172.55,35,,172.55,percent of total billed charges,Implant Device,172.55,35,,172.55,percent of total billed charges,Implant Device,172.55,35,,172.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,364.82,
STRYKER 40-20114E CANN SCREW 2X14/6MM,C1713,HCPCS,,79001203,CDM,278,RC,,,both,,,455,336.7,,,336.7,Other,150% of Medicare + 9.63% HCRA Surcharge,204.75,45,,204.75,percent of total billed charges,Critical Access Hospital RCC factor,154.7,34,,154.7,percent of total billed charges,Implant Device,154.7,34,,154.7,percent of total billed charges,Implant Device,154.7,34,,154.7,percent of total billed charges,Implant Device,154.7,34,,154.7,percent of total billed charges,Implant Device,154.7,34,,154.7,percent of total billed charges,Implant Device,225.23,,,225.23,Other,110% of Medicare,159.25,35,,159.25,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,159.25,35,,159.25,percent of total billed charges,Implant Device,159.25,35,,159.25,percent of total billed charges,Implant Device,159.25,35,,159.25,percent of total billed charges,Implant Device,159.25,35,,159.25,percent of total billed charges,Implant Device,159.25,35,,159.25,percent of total billed charges,Implant Device,182,40,,182,percent of total billed charges,Implant Device,159.25,70,,159.25,percent of total billed charges,All Other,154.7,34,,154.7,percent of total billed charges,Implant Device,154.7,34,,154.7,percent of total billed charges,Implant Device,159.25,35,,159.25,percent of total billed charges,Implant Device,159.25,35,,159.25,percent of total billed charges,Implant Device,159.25,35,,159.25,percent of total billed charges,Implant Device,159.25,35,,159.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,336.7,
STRYKER 40-20115E CANN SCREW 2X15/6MM,C1713,HCPCS,,79001204,CDM,278,RC,,,both,,,910,673.4,,,673.4,Other,150% of Medicare + 9.63% HCRA Surcharge,409.5,45,,409.5,percent of total billed charges,Critical Access Hospital RCC factor,309.4,34,,309.4,percent of total billed charges,Implant Device,309.4,34,,309.4,percent of total billed charges,Implant Device,309.4,34,,309.4,percent of total billed charges,Implant Device,309.4,34,,309.4,percent of total billed charges,Implant Device,309.4,34,,309.4,percent of total billed charges,Implant Device,450.45,,,450.45,Other,110% of Medicare,318.5,35,,318.5,percent of total billed charges,Implant Device,309.4,34,"Charges > $500, x 34%",309.4,percent of total billed charges,Implant Device,318.5,35,,318.5,percent of total billed charges,Implant Device,318.5,35,,318.5,percent of total billed charges,Implant Device,318.5,35,,318.5,percent of total billed charges,Implant Device,318.5,35,,318.5,percent of total billed charges,Implant Device,318.5,35,,318.5,percent of total billed charges,Implant Device,364,40,,364,percent of total billed charges,Implant Device,318.5,70,,318.5,percent of total billed charges,All Other,309.4,34,,309.4,percent of total billed charges,Implant Device,309.4,34,,309.4,percent of total billed charges,Implant Device,318.5,35,,318.5,percent of total billed charges,Implant Device,318.5,35,,318.5,percent of total billed charges,Implant Device,318.5,35,,318.5,percent of total billed charges,Implant Device,318.5,35,,318.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,673.4,
STRYKER 40-20116S CANN SCREW 2X16/7MM,C1713,HCPCS,,79001205,CDM,278,RC,,,both,,,493,364.82,,,364.82,Other,150% of Medicare + 9.63% HCRA Surcharge,221.85,45,,221.85,percent of total billed charges,Critical Access Hospital RCC factor,167.62,34,,167.62,percent of total billed charges,Implant Device,167.62,34,,167.62,percent of total billed charges,Implant Device,167.62,34,,167.62,percent of total billed charges,Implant Device,167.62,34,,167.62,percent of total billed charges,Implant Device,167.62,34,,167.62,percent of total billed charges,Implant Device,244.04,,,244.04,Other,110% of Medicare,172.55,35,,172.55,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,172.55,35,,172.55,percent of total billed charges,Implant Device,172.55,35,,172.55,percent of total billed charges,Implant Device,172.55,35,,172.55,percent of total billed charges,Implant Device,172.55,35,,172.55,percent of total billed charges,Implant Device,172.55,35,,172.55,percent of total billed charges,Implant Device,197.2,40,,197.2,percent of total billed charges,Implant Device,172.55,70,,172.55,percent of total billed charges,All Other,167.62,34,,167.62,percent of total billed charges,Implant Device,167.62,34,,167.62,percent of total billed charges,Implant Device,172.55,35,,172.55,percent of total billed charges,Implant Device,172.55,35,,172.55,percent of total billed charges,Implant Device,172.55,35,,172.55,percent of total billed charges,Implant Device,172.55,35,,172.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,364.82,
STRYKER 40-20117E CANN SCREW 2X17/5MM,C1713,HCPCS,,79001206,CDM,278,RC,,,both,,,583,431.42,,,431.42,Other,150% of Medicare + 9.63% HCRA Surcharge,262.35,45,,262.35,percent of total billed charges,Critical Access Hospital RCC factor,198.22,34,,198.22,percent of total billed charges,Implant Device,198.22,34,,198.22,percent of total billed charges,Implant Device,198.22,34,,198.22,percent of total billed charges,Implant Device,198.22,34,,198.22,percent of total billed charges,Implant Device,198.22,34,,198.22,percent of total billed charges,Implant Device,288.59,,,288.59,Other,110% of Medicare,204.05,35,,204.05,percent of total billed charges,Implant Device,198.22,34,"Charges > $500, x 34%",198.22,percent of total billed charges,Implant Device,204.05,35,,204.05,percent of total billed charges,Implant Device,204.05,35,,204.05,percent of total billed charges,Implant Device,204.05,35,,204.05,percent of total billed charges,Implant Device,204.05,35,,204.05,percent of total billed charges,Implant Device,204.05,35,,204.05,percent of total billed charges,Implant Device,233.2,40,,233.2,percent of total billed charges,Implant Device,204.05,70,,204.05,percent of total billed charges,All Other,198.22,34,,198.22,percent of total billed charges,Implant Device,198.22,34,,198.22,percent of total billed charges,Implant Device,204.05,35,,204.05,percent of total billed charges,Implant Device,204.05,35,,204.05,percent of total billed charges,Implant Device,204.05,35,,204.05,percent of total billed charges,Implant Device,204.05,35,,204.05,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,431.42,
STRYKER 40-20118E CANN SCREW 2X18/5MM,C1713,HCPCS,,79001207,CDM,278,RC,,,both,,,910,673.4,,,673.4,Other,150% of Medicare + 9.63% HCRA Surcharge,409.5,45,,409.5,percent of total billed charges,Critical Access Hospital RCC factor,309.4,34,,309.4,percent of total billed charges,Implant Device,309.4,34,,309.4,percent of total billed charges,Implant Device,309.4,34,,309.4,percent of total billed charges,Implant Device,309.4,34,,309.4,percent of total billed charges,Implant Device,309.4,34,,309.4,percent of total billed charges,Implant Device,450.45,,,450.45,Other,110% of Medicare,318.5,35,,318.5,percent of total billed charges,Implant Device,309.4,34,"Charges > $500, x 34%",309.4,percent of total billed charges,Implant Device,318.5,35,,318.5,percent of total billed charges,Implant Device,318.5,35,,318.5,percent of total billed charges,Implant Device,318.5,35,,318.5,percent of total billed charges,Implant Device,318.5,35,,318.5,percent of total billed charges,Implant Device,318.5,35,,318.5,percent of total billed charges,Implant Device,364,40,,364,percent of total billed charges,Implant Device,318.5,70,,318.5,percent of total billed charges,All Other,309.4,34,,309.4,percent of total billed charges,Implant Device,309.4,34,,309.4,percent of total billed charges,Implant Device,318.5,35,,318.5,percent of total billed charges,Implant Device,318.5,35,,318.5,percent of total billed charges,Implant Device,318.5,35,,318.5,percent of total billed charges,Implant Device,318.5,35,,318.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,673.4,
STRYKER 40-30118E CANN SCREW 2X18/5MM,C1713,HCPCS,,79001208,CDM,278,RC,,,both,,,646,478.04,,,478.04,Other,150% of Medicare + 9.63% HCRA Surcharge,290.7,45,,290.7,percent of total billed charges,Critical Access Hospital RCC factor,219.64,34,,219.64,percent of total billed charges,Implant Device,219.64,34,,219.64,percent of total billed charges,Implant Device,219.64,34,,219.64,percent of total billed charges,Implant Device,219.64,34,,219.64,percent of total billed charges,Implant Device,219.64,34,,219.64,percent of total billed charges,Implant Device,319.77,,,319.77,Other,110% of Medicare,226.1,35,,226.1,percent of total billed charges,Implant Device,219.64,34,"Charges > $500, x 34%",219.64,percent of total billed charges,Implant Device,226.1,35,,226.1,percent of total billed charges,Implant Device,226.1,35,,226.1,percent of total billed charges,Implant Device,226.1,35,,226.1,percent of total billed charges,Implant Device,226.1,35,,226.1,percent of total billed charges,Implant Device,226.1,35,,226.1,percent of total billed charges,Implant Device,258.4,40,,258.4,percent of total billed charges,Implant Device,226.1,70,,226.1,percent of total billed charges,All Other,219.64,34,,219.64,percent of total billed charges,Implant Device,219.64,34,,219.64,percent of total billed charges,Implant Device,226.1,35,,226.1,percent of total billed charges,Implant Device,226.1,35,,226.1,percent of total billed charges,Implant Device,226.1,35,,226.1,percent of total billed charges,Implant Device,226.1,35,,226.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,478.04,
STRYKER ASNIS MICRO CANN SCREW 2X20/5MM,C1713,HCPCS,,79001209,CDM,278,RC,,,both,,,707,523.18,,,523.18,Other,150% of Medicare + 9.63% HCRA Surcharge,318.15,45,,318.15,percent of total billed charges,Critical Access Hospital RCC factor,240.38,34,,240.38,percent of total billed charges,Implant Device,240.38,34,,240.38,percent of total billed charges,Implant Device,240.38,34,,240.38,percent of total billed charges,Implant Device,240.38,34,,240.38,percent of total billed charges,Implant Device,240.38,34,,240.38,percent of total billed charges,Implant Device,349.97,,,349.97,Other,110% of Medicare,247.45,35,,247.45,percent of total billed charges,Implant Device,240.38,34,"Charges > $500, x 34%",240.38,percent of total billed charges,Implant Device,247.45,35,,247.45,percent of total billed charges,Implant Device,247.45,35,,247.45,percent of total billed charges,Implant Device,247.45,35,,247.45,percent of total billed charges,Implant Device,247.45,35,,247.45,percent of total billed charges,Implant Device,247.45,35,,247.45,percent of total billed charges,Implant Device,282.8,40,,282.8,percent of total billed charges,Implant Device,247.45,70,,247.45,percent of total billed charges,All Other,240.38,34,,240.38,percent of total billed charges,Implant Device,240.38,34,,240.38,percent of total billed charges,Implant Device,247.45,35,,247.45,percent of total billed charges,Implant Device,247.45,35,,247.45,percent of total billed charges,Implant Device,247.45,35,,247.45,percent of total billed charges,Implant Device,247.45,35,,247.45,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,523.18,
STRYKER 40-30120E CANN SCREW 2X20/5MM,C1713,HCPCS,,79001210,CDM,278,RC,,,both,,,910,673.4,,,673.4,Other,150% of Medicare + 9.63% HCRA Surcharge,409.5,45,,409.5,percent of total billed charges,Critical Access Hospital RCC factor,309.4,34,,309.4,percent of total billed charges,Implant Device,309.4,34,,309.4,percent of total billed charges,Implant Device,309.4,34,,309.4,percent of total billed charges,Implant Device,309.4,34,,309.4,percent of total billed charges,Implant Device,309.4,34,,309.4,percent of total billed charges,Implant Device,450.45,,,450.45,Other,110% of Medicare,318.5,35,,318.5,percent of total billed charges,Implant Device,309.4,34,"Charges > $500, x 34%",309.4,percent of total billed charges,Implant Device,318.5,35,,318.5,percent of total billed charges,Implant Device,318.5,35,,318.5,percent of total billed charges,Implant Device,318.5,35,,318.5,percent of total billed charges,Implant Device,318.5,35,,318.5,percent of total billed charges,Implant Device,318.5,35,,318.5,percent of total billed charges,Implant Device,364,40,,364,percent of total billed charges,Implant Device,318.5,70,,318.5,percent of total billed charges,All Other,309.4,34,,309.4,percent of total billed charges,Implant Device,309.4,34,,309.4,percent of total billed charges,Implant Device,318.5,35,,318.5,percent of total billed charges,Implant Device,318.5,35,,318.5,percent of total billed charges,Implant Device,318.5,35,,318.5,percent of total billed charges,Implant Device,318.5,35,,318.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,673.4,
STRYKER 40-20220S CANN SCREW 2X20/9MM,C1713,HCPCS,,79001211,CDM,278,RC,,,both,,,707,523.18,,,523.18,Other,150% of Medicare + 9.63% HCRA Surcharge,318.15,45,,318.15,percent of total billed charges,Critical Access Hospital RCC factor,240.38,34,,240.38,percent of total billed charges,Implant Device,240.38,34,,240.38,percent of total billed charges,Implant Device,240.38,34,,240.38,percent of total billed charges,Implant Device,240.38,34,,240.38,percent of total billed charges,Implant Device,240.38,34,,240.38,percent of total billed charges,Implant Device,349.97,,,349.97,Other,110% of Medicare,247.45,35,,247.45,percent of total billed charges,Implant Device,240.38,34,"Charges > $500, x 34%",240.38,percent of total billed charges,Implant Device,247.45,35,,247.45,percent of total billed charges,Implant Device,247.45,35,,247.45,percent of total billed charges,Implant Device,247.45,35,,247.45,percent of total billed charges,Implant Device,247.45,35,,247.45,percent of total billed charges,Implant Device,247.45,35,,247.45,percent of total billed charges,Implant Device,282.8,40,,282.8,percent of total billed charges,Implant Device,247.45,70,,247.45,percent of total billed charges,All Other,240.38,34,,240.38,percent of total billed charges,Implant Device,240.38,34,,240.38,percent of total billed charges,Implant Device,247.45,35,,247.45,percent of total billed charges,Implant Device,247.45,35,,247.45,percent of total billed charges,Implant Device,247.45,35,,247.45,percent of total billed charges,Implant Device,247.45,35,,247.45,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,523.18,
STRYKER 40-20122E CANN SCREW 2X22/5MM,C1713,HCPCS,,79001212,CDM,278,RC,,,both,,,910,673.4,,,673.4,Other,150% of Medicare + 9.63% HCRA Surcharge,409.5,45,,409.5,percent of total billed charges,Critical Access Hospital RCC factor,309.4,34,,309.4,percent of total billed charges,Implant Device,309.4,34,,309.4,percent of total billed charges,Implant Device,309.4,34,,309.4,percent of total billed charges,Implant Device,309.4,34,,309.4,percent of total billed charges,Implant Device,309.4,34,,309.4,percent of total billed charges,Implant Device,450.45,,,450.45,Other,110% of Medicare,318.5,35,,318.5,percent of total billed charges,Implant Device,309.4,34,"Charges > $500, x 34%",309.4,percent of total billed charges,Implant Device,318.5,35,,318.5,percent of total billed charges,Implant Device,318.5,35,,318.5,percent of total billed charges,Implant Device,318.5,35,,318.5,percent of total billed charges,Implant Device,318.5,35,,318.5,percent of total billed charges,Implant Device,318.5,35,,318.5,percent of total billed charges,Implant Device,364,40,,364,percent of total billed charges,Implant Device,318.5,70,,318.5,percent of total billed charges,All Other,309.4,34,,309.4,percent of total billed charges,Implant Device,309.4,34,,309.4,percent of total billed charges,Implant Device,318.5,35,,318.5,percent of total billed charges,Implant Device,318.5,35,,318.5,percent of total billed charges,Implant Device,318.5,35,,318.5,percent of total billed charges,Implant Device,318.5,35,,318.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,673.4,
STRYKER 40-30122E CANN SCREW 2X22/5MM,C1713,HCPCS,,79001213,CDM,278,RC,,,both,,,646,478.04,,,478.04,Other,150% of Medicare + 9.63% HCRA Surcharge,290.7,45,,290.7,percent of total billed charges,Critical Access Hospital RCC factor,219.64,34,,219.64,percent of total billed charges,Implant Device,219.64,34,,219.64,percent of total billed charges,Implant Device,219.64,34,,219.64,percent of total billed charges,Implant Device,219.64,34,,219.64,percent of total billed charges,Implant Device,219.64,34,,219.64,percent of total billed charges,Implant Device,319.77,,,319.77,Other,110% of Medicare,226.1,35,,226.1,percent of total billed charges,Implant Device,219.64,34,"Charges > $500, x 34%",219.64,percent of total billed charges,Implant Device,226.1,35,,226.1,percent of total billed charges,Implant Device,226.1,35,,226.1,percent of total billed charges,Implant Device,226.1,35,,226.1,percent of total billed charges,Implant Device,226.1,35,,226.1,percent of total billed charges,Implant Device,226.1,35,,226.1,percent of total billed charges,Implant Device,258.4,40,,258.4,percent of total billed charges,Implant Device,226.1,70,,226.1,percent of total billed charges,All Other,219.64,34,,219.64,percent of total billed charges,Implant Device,219.64,34,,219.64,percent of total billed charges,Implant Device,226.1,35,,226.1,percent of total billed charges,Implant Device,226.1,35,,226.1,percent of total billed charges,Implant Device,226.1,35,,226.1,percent of total billed charges,Implant Device,226.1,35,,226.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,478.04,
STRYKER 40-30124E CANN SCREW 2X24/6MM,C1713,HCPCS,,79001214,CDM,278,RC,,,both,,,646,478.04,,,478.04,Other,150% of Medicare + 9.63% HCRA Surcharge,290.7,45,,290.7,percent of total billed charges,Critical Access Hospital RCC factor,219.64,34,,219.64,percent of total billed charges,Implant Device,219.64,34,,219.64,percent of total billed charges,Implant Device,219.64,34,,219.64,percent of total billed charges,Implant Device,219.64,34,,219.64,percent of total billed charges,Implant Device,219.64,34,,219.64,percent of total billed charges,Implant Device,319.77,,,319.77,Other,110% of Medicare,226.1,35,,226.1,percent of total billed charges,Implant Device,219.64,34,"Charges > $500, x 34%",219.64,percent of total billed charges,Implant Device,226.1,35,,226.1,percent of total billed charges,Implant Device,226.1,35,,226.1,percent of total billed charges,Implant Device,226.1,35,,226.1,percent of total billed charges,Implant Device,226.1,35,,226.1,percent of total billed charges,Implant Device,226.1,35,,226.1,percent of total billed charges,Implant Device,258.4,40,,258.4,percent of total billed charges,Implant Device,226.1,70,,226.1,percent of total billed charges,All Other,219.64,34,,219.64,percent of total billed charges,Implant Device,219.64,34,,219.64,percent of total billed charges,Implant Device,226.1,35,,226.1,percent of total billed charges,Implant Device,226.1,35,,226.1,percent of total billed charges,Implant Device,226.1,35,,226.1,percent of total billed charges,Implant Device,226.1,35,,226.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,478.04,
STRYKER 40-30125E CANN SCREW 2 X 25MM,C1713,HCPCS,,79001215,CDM,278,RC,,,both,,,581,429.94,,,429.94,Other,150% of Medicare + 9.63% HCRA Surcharge,261.45,45,,261.45,percent of total billed charges,Critical Access Hospital RCC factor,197.54,34,,197.54,percent of total billed charges,Implant Device,197.54,34,,197.54,percent of total billed charges,Implant Device,197.54,34,,197.54,percent of total billed charges,Implant Device,197.54,34,,197.54,percent of total billed charges,Implant Device,197.54,34,,197.54,percent of total billed charges,Implant Device,287.6,,,287.6,Other,110% of Medicare,203.35,35,,203.35,percent of total billed charges,Implant Device,197.54,34,"Charges > $500, x 34%",197.54,percent of total billed charges,Implant Device,203.35,35,,203.35,percent of total billed charges,Implant Device,203.35,35,,203.35,percent of total billed charges,Implant Device,203.35,35,,203.35,percent of total billed charges,Implant Device,203.35,35,,203.35,percent of total billed charges,Implant Device,203.35,35,,203.35,percent of total billed charges,Implant Device,232.4,40,,232.4,percent of total billed charges,Implant Device,203.35,70,,203.35,percent of total billed charges,All Other,197.54,34,,197.54,percent of total billed charges,Implant Device,197.54,34,,197.54,percent of total billed charges,Implant Device,203.35,35,,203.35,percent of total billed charges,Implant Device,203.35,35,,203.35,percent of total billed charges,Implant Device,203.35,35,,203.35,percent of total billed charges,Implant Device,203.35,35,,203.35,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,429.94,
STRYKER 40-30126E CANN SCREW 2X26/6MM,C1713,HCPCS,,79001216,CDM,278,RC,,,both,,,581,429.94,,,429.94,Other,150% of Medicare + 9.63% HCRA Surcharge,261.45,45,,261.45,percent of total billed charges,Critical Access Hospital RCC factor,197.54,34,,197.54,percent of total billed charges,Implant Device,197.54,34,,197.54,percent of total billed charges,Implant Device,197.54,34,,197.54,percent of total billed charges,Implant Device,197.54,34,,197.54,percent of total billed charges,Implant Device,197.54,34,,197.54,percent of total billed charges,Implant Device,287.6,,,287.6,Other,110% of Medicare,203.35,35,,203.35,percent of total billed charges,Implant Device,197.54,34,"Charges > $500, x 34%",197.54,percent of total billed charges,Implant Device,203.35,35,,203.35,percent of total billed charges,Implant Device,203.35,35,,203.35,percent of total billed charges,Implant Device,203.35,35,,203.35,percent of total billed charges,Implant Device,203.35,35,,203.35,percent of total billed charges,Implant Device,203.35,35,,203.35,percent of total billed charges,Implant Device,232.4,40,,232.4,percent of total billed charges,Implant Device,203.35,70,,203.35,percent of total billed charges,All Other,197.54,34,,197.54,percent of total billed charges,Implant Device,197.54,34,,197.54,percent of total billed charges,Implant Device,203.35,35,,203.35,percent of total billed charges,Implant Device,203.35,35,,203.35,percent of total billed charges,Implant Device,203.35,35,,203.35,percent of total billed charges,Implant Device,203.35,35,,203.35,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,429.94,
STRYKER 40-30128E CANN SCREW 2X28/6MM,C1713,HCPCS,,79001217,CDM,278,RC,,,both,,,596,441.04,,,441.04,Other,150% of Medicare + 9.63% HCRA Surcharge,268.2,45,,268.2,percent of total billed charges,Critical Access Hospital RCC factor,202.64,34,,202.64,percent of total billed charges,Implant Device,202.64,34,,202.64,percent of total billed charges,Implant Device,202.64,34,,202.64,percent of total billed charges,Implant Device,202.64,34,,202.64,percent of total billed charges,Implant Device,202.64,34,,202.64,percent of total billed charges,Implant Device,295.02,,,295.02,Other,110% of Medicare,208.6,35,,208.6,percent of total billed charges,Implant Device,202.64,34,"Charges > $500, x 34%",202.64,percent of total billed charges,Implant Device,208.6,35,,208.6,percent of total billed charges,Implant Device,208.6,35,,208.6,percent of total billed charges,Implant Device,208.6,35,,208.6,percent of total billed charges,Implant Device,208.6,35,,208.6,percent of total billed charges,Implant Device,208.6,35,,208.6,percent of total billed charges,Implant Device,238.4,40,,238.4,percent of total billed charges,Implant Device,208.6,70,,208.6,percent of total billed charges,All Other,202.64,34,,202.64,percent of total billed charges,Implant Device,202.64,34,,202.64,percent of total billed charges,Implant Device,208.6,35,,208.6,percent of total billed charges,Implant Device,208.6,35,,208.6,percent of total billed charges,Implant Device,208.6,35,,208.6,percent of total billed charges,Implant Device,208.6,35,,208.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,441.04,
STRYKER 40-30132E CANN SCREW 2X32/6MM,C1713,HCPCS,,79001218,CDM,278,RC,,,both,,,581,429.94,,,429.94,Other,150% of Medicare + 9.63% HCRA Surcharge,261.45,45,,261.45,percent of total billed charges,Critical Access Hospital RCC factor,197.54,34,,197.54,percent of total billed charges,Implant Device,197.54,34,,197.54,percent of total billed charges,Implant Device,197.54,34,,197.54,percent of total billed charges,Implant Device,197.54,34,,197.54,percent of total billed charges,Implant Device,197.54,34,,197.54,percent of total billed charges,Implant Device,287.6,,,287.6,Other,110% of Medicare,203.35,35,,203.35,percent of total billed charges,Implant Device,197.54,34,"Charges > $500, x 34%",197.54,percent of total billed charges,Implant Device,203.35,35,,203.35,percent of total billed charges,Implant Device,203.35,35,,203.35,percent of total billed charges,Implant Device,203.35,35,,203.35,percent of total billed charges,Implant Device,203.35,35,,203.35,percent of total billed charges,Implant Device,203.35,35,,203.35,percent of total billed charges,Implant Device,232.4,40,,232.4,percent of total billed charges,Implant Device,203.35,70,,203.35,percent of total billed charges,All Other,197.54,34,,197.54,percent of total billed charges,Implant Device,197.54,34,,197.54,percent of total billed charges,Implant Device,203.35,35,,203.35,percent of total billed charges,Implant Device,203.35,35,,203.35,percent of total billed charges,Implant Device,203.35,35,,203.35,percent of total billed charges,Implant Device,203.35,35,,203.35,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,429.94,
STRYKER 40-30134 CANN SCREW 2X34/7MM,C1713,HCPCS,,79001219,CDM,278,RC,,,both,,,596,441.04,,,441.04,Other,150% of Medicare + 9.63% HCRA Surcharge,268.2,45,,268.2,percent of total billed charges,Critical Access Hospital RCC factor,202.64,34,,202.64,percent of total billed charges,Implant Device,202.64,34,,202.64,percent of total billed charges,Implant Device,202.64,34,,202.64,percent of total billed charges,Implant Device,202.64,34,,202.64,percent of total billed charges,Implant Device,202.64,34,,202.64,percent of total billed charges,Implant Device,295.02,,,295.02,Other,110% of Medicare,208.6,35,,208.6,percent of total billed charges,Implant Device,202.64,34,"Charges > $500, x 34%",202.64,percent of total billed charges,Implant Device,208.6,35,,208.6,percent of total billed charges,Implant Device,208.6,35,,208.6,percent of total billed charges,Implant Device,208.6,35,,208.6,percent of total billed charges,Implant Device,208.6,35,,208.6,percent of total billed charges,Implant Device,208.6,35,,208.6,percent of total billed charges,Implant Device,238.4,40,,238.4,percent of total billed charges,Implant Device,208.6,70,,208.6,percent of total billed charges,All Other,202.64,34,,202.64,percent of total billed charges,Implant Device,202.64,34,,202.64,percent of total billed charges,Implant Device,208.6,35,,208.6,percent of total billed charges,Implant Device,208.6,35,,208.6,percent of total billed charges,Implant Device,208.6,35,,208.6,percent of total billed charges,Implant Device,208.6,35,,208.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,441.04,
STRYKER 40-30136S CANN SCREW 2X36/7MM,C1713,HCPCS,,79001220,CDM,278,RC,,,both,,,704,520.96,,,520.96,Other,150% of Medicare + 9.63% HCRA Surcharge,316.8,45,,316.8,percent of total billed charges,Critical Access Hospital RCC factor,239.36,34,,239.36,percent of total billed charges,Implant Device,239.36,34,,239.36,percent of total billed charges,Implant Device,239.36,34,,239.36,percent of total billed charges,Implant Device,239.36,34,,239.36,percent of total billed charges,Implant Device,239.36,34,,239.36,percent of total billed charges,Implant Device,348.48,,,348.48,Other,110% of Medicare,246.4,35,,246.4,percent of total billed charges,Implant Device,239.36,34,"Charges > $500, x 34%",239.36,percent of total billed charges,Implant Device,246.4,35,,246.4,percent of total billed charges,Implant Device,246.4,35,,246.4,percent of total billed charges,Implant Device,246.4,35,,246.4,percent of total billed charges,Implant Device,246.4,35,,246.4,percent of total billed charges,Implant Device,246.4,35,,246.4,percent of total billed charges,Implant Device,281.6,40,,281.6,percent of total billed charges,Implant Device,246.4,70,,246.4,percent of total billed charges,All Other,239.36,34,,239.36,percent of total billed charges,Implant Device,239.36,34,,239.36,percent of total billed charges,Implant Device,246.4,35,,246.4,percent of total billed charges,Implant Device,246.4,35,,246.4,percent of total billed charges,Implant Device,246.4,35,,246.4,percent of total billed charges,Implant Device,246.4,35,,246.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,520.96,
STRYKER 40-30138E CANN SCREW 2X38/8MM,C1713,HCPCS,,79001221,CDM,278,RC,,,both,,,581,429.94,,,429.94,Other,150% of Medicare + 9.63% HCRA Surcharge,261.45,45,,261.45,percent of total billed charges,Critical Access Hospital RCC factor,197.54,34,,197.54,percent of total billed charges,Implant Device,197.54,34,,197.54,percent of total billed charges,Implant Device,197.54,34,,197.54,percent of total billed charges,Implant Device,197.54,34,,197.54,percent of total billed charges,Implant Device,197.54,34,,197.54,percent of total billed charges,Implant Device,287.6,,,287.6,Other,110% of Medicare,203.35,35,,203.35,percent of total billed charges,Implant Device,197.54,34,"Charges > $500, x 34%",197.54,percent of total billed charges,Implant Device,203.35,35,,203.35,percent of total billed charges,Implant Device,203.35,35,,203.35,percent of total billed charges,Implant Device,203.35,35,,203.35,percent of total billed charges,Implant Device,203.35,35,,203.35,percent of total billed charges,Implant Device,203.35,35,,203.35,percent of total billed charges,Implant Device,232.4,40,,232.4,percent of total billed charges,Implant Device,203.35,70,,203.35,percent of total billed charges,All Other,197.54,34,,197.54,percent of total billed charges,Implant Device,197.54,34,,197.54,percent of total billed charges,Implant Device,203.35,35,,203.35,percent of total billed charges,Implant Device,203.35,35,,203.35,percent of total billed charges,Implant Device,203.35,35,,203.35,percent of total billed charges,Implant Device,203.35,35,,203.35,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,429.94,
STRYKER 40-20009E CANN SCREW 2 X 9/4MM,C1713,HCPCS,,79001222,CDM,278,RC,,,both,,,574,424.76,,,424.76,Other,150% of Medicare + 9.63% HCRA Surcharge,258.3,45,,258.3,percent of total billed charges,Critical Access Hospital RCC factor,195.16,34,,195.16,percent of total billed charges,Implant Device,195.16,34,,195.16,percent of total billed charges,Implant Device,195.16,34,,195.16,percent of total billed charges,Implant Device,195.16,34,,195.16,percent of total billed charges,Implant Device,195.16,34,,195.16,percent of total billed charges,Implant Device,284.13,,,284.13,Other,110% of Medicare,200.9,35,,200.9,percent of total billed charges,Implant Device,195.16,34,"Charges > $500, x 34%",195.16,percent of total billed charges,Implant Device,200.9,35,,200.9,percent of total billed charges,Implant Device,200.9,35,,200.9,percent of total billed charges,Implant Device,200.9,35,,200.9,percent of total billed charges,Implant Device,200.9,35,,200.9,percent of total billed charges,Implant Device,200.9,35,,200.9,percent of total billed charges,Implant Device,229.6,40,,229.6,percent of total billed charges,Implant Device,200.9,70,,200.9,percent of total billed charges,All Other,195.16,34,,195.16,percent of total billed charges,Implant Device,195.16,34,,195.16,percent of total billed charges,Implant Device,200.9,35,,200.9,percent of total billed charges,Implant Device,200.9,35,,200.9,percent of total billed charges,Implant Device,200.9,35,,200.9,percent of total billed charges,Implant Device,200.9,35,,200.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,424.76,
GORE SBT1601D BIFURCATED GRAFT 40X168CM,C1768,HCPCS,,79001223,CDM,278,RC,,,both,,,2742,2029.09,,,2029.09,Other,150% of Medicare + 9.63% HCRA Surcharge,1233.9,45,,1233.9,percent of total billed charges,Critical Access Hospital RCC factor,932.28,34,,932.28,percent of total billed charges,Implant Device,932.28,34,,932.28,percent of total billed charges,Implant Device,932.28,34,,932.28,percent of total billed charges,Implant Device,932.28,34,,932.28,percent of total billed charges,Implant Device,932.28,34,,932.28,percent of total billed charges,Implant Device,1357.29,,,1357.29,Other,110% of Medicare,959.7,35,,959.7,percent of total billed charges,Implant Device,932.28,34,"Charges > $500, x 34%",932.28,percent of total billed charges,Implant Device,959.7,35,,959.7,percent of total billed charges,Implant Device,959.7,35,,959.7,percent of total billed charges,Implant Device,959.7,35,,959.7,percent of total billed charges,Implant Device,959.7,35,,959.7,percent of total billed charges,Implant Device,959.7,35,,959.7,percent of total billed charges,Implant Device,1096.8,40,,1096.8,percent of total billed charges,Implant Device,959.7,70,,959.7,percent of total billed charges,All Other,932.28,34,,932.28,percent of total billed charges,Implant Device,932.28,34,,932.28,percent of total billed charges,Implant Device,959.7,35,,959.7,percent of total billed charges,Implant Device,959.7,35,,959.7,percent of total billed charges,Implant Device,959.7,35,,959.7,percent of total billed charges,Implant Device,959.7,35,,959.7,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,932.28,34,"If Charge > 2,000, then 34 percent",932.28,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2029.09,
ARTHREX AR-1923BC BIO COMPOSITE PUSHLOCK,C1713,HCPCS,,79001224,CDM,278,RC,,,both,,,1200,888,,,888,Other,150% of Medicare + 9.63% HCRA Surcharge,540,45,,540,percent of total billed charges,Critical Access Hospital RCC factor,408,34,,408,percent of total billed charges,Implant Device,408,34,,408,percent of total billed charges,Implant Device,408,34,,408,percent of total billed charges,Implant Device,408,34,,408,percent of total billed charges,Implant Device,408,34,,408,percent of total billed charges,Implant Device,594,,,594,Other,110% of Medicare,420,35,,420,percent of total billed charges,Implant Device,408,34,"Charges > $500, x 34%",408,percent of total billed charges,Implant Device,420,35,,420,percent of total billed charges,Implant Device,420,35,,420,percent of total billed charges,Implant Device,420,35,,420,percent of total billed charges,Implant Device,420,35,,420,percent of total billed charges,Implant Device,420,35,,420,percent of total billed charges,Implant Device,480,40,,480,percent of total billed charges,Implant Device,420,70,,420,percent of total billed charges,All Other,408,34,,408,percent of total billed charges,Implant Device,408,34,,408,percent of total billed charges,Implant Device,420,35,,420,percent of total billed charges,Implant Device,420,35,,420,percent of total billed charges,Implant Device,420,35,,420,percent of total billed charges,Implant Device,420,35,,420,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,888,
ARTHREX AR-1927BCFT SUT ANCHOR 5.5MM,C1713,HCPCS,,79001225,CDM,278,RC,,,both,,,1036,766.64,,,766.64,Other,150% of Medicare + 9.63% HCRA Surcharge,466.2,45,,466.2,percent of total billed charges,Critical Access Hospital RCC factor,352.24,34,,352.24,percent of total billed charges,Implant Device,352.24,34,,352.24,percent of total billed charges,Implant Device,352.24,34,,352.24,percent of total billed charges,Implant Device,352.24,34,,352.24,percent of total billed charges,Implant Device,352.24,34,,352.24,percent of total billed charges,Implant Device,512.82,,,512.82,Other,110% of Medicare,362.6,35,,362.6,percent of total billed charges,Implant Device,352.24,34,"Charges > $500, x 34%",352.24,percent of total billed charges,Implant Device,362.6,35,,362.6,percent of total billed charges,Implant Device,362.6,35,,362.6,percent of total billed charges,Implant Device,362.6,35,,362.6,percent of total billed charges,Implant Device,362.6,35,,362.6,percent of total billed charges,Implant Device,362.6,35,,362.6,percent of total billed charges,Implant Device,414.4,40,,414.4,percent of total billed charges,Implant Device,362.6,70,,362.6,percent of total billed charges,All Other,352.24,34,,352.24,percent of total billed charges,Implant Device,352.24,34,,352.24,percent of total billed charges,Implant Device,362.6,35,,362.6,percent of total billed charges,Implant Device,362.6,35,,362.6,percent of total billed charges,Implant Device,362.6,35,,362.6,percent of total billed charges,Implant Device,362.6,35,,362.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,766.64,
ARTHREX AR-1680B BIOTENOD SCREW 8X12,C1713,HCPCS,,79001228,CDM,278,RC,,,both,,,1110,821.4,,,821.4,Other,150% of Medicare + 9.63% HCRA Surcharge,499.5,45,,499.5,percent of total billed charges,Critical Access Hospital RCC factor,377.4,34,,377.4,percent of total billed charges,Implant Device,377.4,34,,377.4,percent of total billed charges,Implant Device,377.4,34,,377.4,percent of total billed charges,Implant Device,377.4,34,,377.4,percent of total billed charges,Implant Device,377.4,34,,377.4,percent of total billed charges,Implant Device,549.45,,,549.45,Other,110% of Medicare,388.5,35,,388.5,percent of total billed charges,Implant Device,377.4,34,"Charges > $500, x 34%",377.4,percent of total billed charges,Implant Device,388.5,35,,388.5,percent of total billed charges,Implant Device,388.5,35,,388.5,percent of total billed charges,Implant Device,388.5,35,,388.5,percent of total billed charges,Implant Device,388.5,35,,388.5,percent of total billed charges,Implant Device,388.5,35,,388.5,percent of total billed charges,Implant Device,444,40,,444,percent of total billed charges,Implant Device,388.5,70,,388.5,percent of total billed charges,All Other,377.4,34,,377.4,percent of total billed charges,Implant Device,377.4,34,,377.4,percent of total billed charges,Implant Device,388.5,35,,388.5,percent of total billed charges,Implant Device,388.5,35,,388.5,percent of total billed charges,Implant Device,388.5,35,,388.5,percent of total billed charges,Implant Device,388.5,35,,388.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,821.4,
ARTHREX AR-1934BCFT SUTURE TACKS 3.0,C1713,HCPCS,,79001229,CDM,278,RC,,,both,,,975,721.5,,,721.5,Other,150% of Medicare + 9.63% HCRA Surcharge,438.75,45,,438.75,percent of total billed charges,Critical Access Hospital RCC factor,331.5,34,,331.5,percent of total billed charges,Implant Device,331.5,34,,331.5,percent of total billed charges,Implant Device,331.5,34,,331.5,percent of total billed charges,Implant Device,331.5,34,,331.5,percent of total billed charges,Implant Device,331.5,34,,331.5,percent of total billed charges,Implant Device,482.63,,,482.63,Other,110% of Medicare,341.25,35,,341.25,percent of total billed charges,Implant Device,331.5,34,"Charges > $500, x 34%",331.5,percent of total billed charges,Implant Device,341.25,35,,341.25,percent of total billed charges,Implant Device,341.25,35,,341.25,percent of total billed charges,Implant Device,341.25,35,,341.25,percent of total billed charges,Implant Device,341.25,35,,341.25,percent of total billed charges,Implant Device,341.25,35,,341.25,percent of total billed charges,Implant Device,390,40,,390,percent of total billed charges,Implant Device,341.25,70,,341.25,percent of total billed charges,All Other,331.5,34,,331.5,percent of total billed charges,Implant Device,331.5,34,,331.5,percent of total billed charges,Implant Device,341.25,35,,341.25,percent of total billed charges,Implant Device,341.25,35,,341.25,percent of total billed charges,Implant Device,341.25,35,,341.25,percent of total billed charges,Implant Device,341.25,35,,341.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,721.5,
ARTHREX AR-1934BCF-24 BIOCOMPOSITE 2.4MM,C1713,HCPCS,,79001230,CDM,278,RC,,,both,,,915,677.1,,,677.1,Other,150% of Medicare + 9.63% HCRA Surcharge,411.75,45,,411.75,percent of total billed charges,Critical Access Hospital RCC factor,311.1,34,,311.1,percent of total billed charges,Implant Device,311.1,34,,311.1,percent of total billed charges,Implant Device,311.1,34,,311.1,percent of total billed charges,Implant Device,311.1,34,,311.1,percent of total billed charges,Implant Device,311.1,34,,311.1,percent of total billed charges,Implant Device,452.93,,,452.93,Other,110% of Medicare,320.25,35,,320.25,percent of total billed charges,Implant Device,311.1,34,"Charges > $500, x 34%",311.1,percent of total billed charges,Implant Device,320.25,35,,320.25,percent of total billed charges,Implant Device,320.25,35,,320.25,percent of total billed charges,Implant Device,320.25,35,,320.25,percent of total billed charges,Implant Device,320.25,35,,320.25,percent of total billed charges,Implant Device,320.25,35,,320.25,percent of total billed charges,Implant Device,366,40,,366,percent of total billed charges,Implant Device,320.25,70,,320.25,percent of total billed charges,All Other,311.1,34,,311.1,percent of total billed charges,Implant Device,311.1,34,,311.1,percent of total billed charges,Implant Device,320.25,35,,320.25,percent of total billed charges,Implant Device,320.25,35,,320.25,percent of total billed charges,Implant Device,320.25,35,,320.25,percent of total billed charges,Implant Device,320.25,35,,320.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,677.1,
ARTHREX AR-1920BNF SUT ANCHOR 5X17.9,C1713,HCPCS,,79001231,CDM,278,RC,,,both,,,810,599.4,,,599.4,Other,150% of Medicare + 9.63% HCRA Surcharge,364.5,45,,364.5,percent of total billed charges,Critical Access Hospital RCC factor,275.4,34,,275.4,percent of total billed charges,Implant Device,275.4,34,,275.4,percent of total billed charges,Implant Device,275.4,34,,275.4,percent of total billed charges,Implant Device,275.4,34,,275.4,percent of total billed charges,Implant Device,275.4,34,,275.4,percent of total billed charges,Implant Device,400.95,,,400.95,Other,110% of Medicare,283.5,35,,283.5,percent of total billed charges,Implant Device,275.4,34,"Charges > $500, x 34%",275.4,percent of total billed charges,Implant Device,283.5,35,,283.5,percent of total billed charges,Implant Device,283.5,35,,283.5,percent of total billed charges,Implant Device,283.5,35,,283.5,percent of total billed charges,Implant Device,283.5,35,,283.5,percent of total billed charges,Implant Device,283.5,35,,283.5,percent of total billed charges,Implant Device,324,40,,324,percent of total billed charges,Implant Device,283.5,70,,283.5,percent of total billed charges,All Other,275.4,34,,275.4,percent of total billed charges,Implant Device,275.4,34,,275.4,percent of total billed charges,Implant Device,283.5,35,,283.5,percent of total billed charges,Implant Device,283.5,35,,283.5,percent of total billed charges,Implant Device,283.5,35,,283.5,percent of total billed charges,Implant Device,283.5,35,,283.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,599.4,
ARTHREX AR-1920BF-37 SUT ANCHOR 3.7X17.9,C1713,HCPCS,,79001232,CDM,278,RC,,,both,,,780,577.2,,,577.2,Other,150% of Medicare + 9.63% HCRA Surcharge,351,45,,351,percent of total billed charges,Critical Access Hospital RCC factor,265.2,34,,265.2,percent of total billed charges,Implant Device,265.2,34,,265.2,percent of total billed charges,Implant Device,265.2,34,,265.2,percent of total billed charges,Implant Device,265.2,34,,265.2,percent of total billed charges,Implant Device,265.2,34,,265.2,percent of total billed charges,Implant Device,386.1,,,386.1,Other,110% of Medicare,273,35,,273,percent of total billed charges,Implant Device,265.2,34,"Charges > $500, x 34%",265.2,percent of total billed charges,Implant Device,273,35,,273,percent of total billed charges,Implant Device,273,35,,273,percent of total billed charges,Implant Device,273,35,,273,percent of total billed charges,Implant Device,273,35,,273,percent of total billed charges,Implant Device,273,35,,273,percent of total billed charges,Implant Device,312,40,,312,percent of total billed charges,Implant Device,273,70,,273,percent of total billed charges,All Other,265.2,34,,265.2,percent of total billed charges,Implant Device,265.2,34,,265.2,percent of total billed charges,Implant Device,273,35,,273,percent of total billed charges,Implant Device,273,35,,273,percent of total billed charges,Implant Device,273,35,,273,percent of total billed charges,Implant Device,273,35,,273,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,577.2,
ARTHREX AR-1925BNF SUT ANCHOR 5X17.9,C1713,HCPCS,,79001233,CDM,278,RC,,,both,,,810,599.4,,,599.4,Other,150% of Medicare + 9.63% HCRA Surcharge,364.5,45,,364.5,percent of total billed charges,Critical Access Hospital RCC factor,275.4,34,,275.4,percent of total billed charges,Implant Device,275.4,34,,275.4,percent of total billed charges,Implant Device,275.4,34,,275.4,percent of total billed charges,Implant Device,275.4,34,,275.4,percent of total billed charges,Implant Device,275.4,34,,275.4,percent of total billed charges,Implant Device,400.95,,,400.95,Other,110% of Medicare,283.5,35,,283.5,percent of total billed charges,Implant Device,275.4,34,"Charges > $500, x 34%",275.4,percent of total billed charges,Implant Device,283.5,35,,283.5,percent of total billed charges,Implant Device,283.5,35,,283.5,percent of total billed charges,Implant Device,283.5,35,,283.5,percent of total billed charges,Implant Device,283.5,35,,283.5,percent of total billed charges,Implant Device,283.5,35,,283.5,percent of total billed charges,Implant Device,324,40,,324,percent of total billed charges,Implant Device,283.5,70,,283.5,percent of total billed charges,All Other,275.4,34,,275.4,percent of total billed charges,Implant Device,275.4,34,,275.4,percent of total billed charges,Implant Device,283.5,35,,283.5,percent of total billed charges,Implant Device,283.5,35,,283.5,percent of total billed charges,Implant Device,283.5,35,,283.5,percent of total billed charges,Implant Device,283.5,35,,283.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,599.4,
ARTHREX AR-1920BFT SUTURE ANCHOR 5X17.9,C1713,HCPCS,,79001234,CDM,278,RC,,,both,,,840,621.6,,,621.6,Other,150% of Medicare + 9.63% HCRA Surcharge,378,45,,378,percent of total billed charges,Critical Access Hospital RCC factor,285.6,34,,285.6,percent of total billed charges,Implant Device,285.6,34,,285.6,percent of total billed charges,Implant Device,285.6,34,,285.6,percent of total billed charges,Implant Device,285.6,34,,285.6,percent of total billed charges,Implant Device,285.6,34,,285.6,percent of total billed charges,Implant Device,415.8,,,415.8,Other,110% of Medicare,294,35,,294,percent of total billed charges,Implant Device,285.6,34,"Charges > $500, x 34%",285.6,percent of total billed charges,Implant Device,294,35,,294,percent of total billed charges,Implant Device,294,35,,294,percent of total billed charges,Implant Device,294,35,,294,percent of total billed charges,Implant Device,294,35,,294,percent of total billed charges,Implant Device,294,35,,294,percent of total billed charges,Implant Device,336,40,,336,percent of total billed charges,Implant Device,294,70,,294,percent of total billed charges,All Other,285.6,34,,285.6,percent of total billed charges,Implant Device,285.6,34,,285.6,percent of total billed charges,Implant Device,294,35,,294,percent of total billed charges,Implant Device,294,35,,294,percent of total billed charges,Implant Device,294,35,,294,percent of total billed charges,Implant Device,294,35,,294,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,621.6,
ARTHREX AR-1927BF-65 SUTURE ANCHOR 6.5,C1713,HCPCS,,79001235,CDM,278,RC,,,both,,,886,655.64,,,655.64,Other,150% of Medicare + 9.63% HCRA Surcharge,398.7,45,,398.7,percent of total billed charges,Critical Access Hospital RCC factor,301.24,34,,301.24,percent of total billed charges,Implant Device,301.24,34,,301.24,percent of total billed charges,Implant Device,301.24,34,,301.24,percent of total billed charges,Implant Device,301.24,34,,301.24,percent of total billed charges,Implant Device,301.24,34,,301.24,percent of total billed charges,Implant Device,438.57,,,438.57,Other,110% of Medicare,310.1,35,,310.1,percent of total billed charges,Implant Device,301.24,34,"Charges > $500, x 34%",301.24,percent of total billed charges,Implant Device,310.1,35,,310.1,percent of total billed charges,Implant Device,310.1,35,,310.1,percent of total billed charges,Implant Device,310.1,35,,310.1,percent of total billed charges,Implant Device,310.1,35,,310.1,percent of total billed charges,Implant Device,310.1,35,,310.1,percent of total billed charges,Implant Device,354.4,40,,354.4,percent of total billed charges,Implant Device,310.1,70,,310.1,percent of total billed charges,All Other,301.24,34,,301.24,percent of total billed charges,Implant Device,301.24,34,,301.24,percent of total billed charges,Implant Device,310.1,35,,310.1,percent of total billed charges,Implant Device,310.1,35,,310.1,percent of total billed charges,Implant Device,310.1,35,,310.1,percent of total billed charges,Implant Device,310.1,35,,310.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,655.64,
J&J 212739 BIOKNOTLSS RC ANCHOR PANACRYL,C1713,HCPCS,,79001236,CDM,278,RC,,,both,,,868,642.32,,,642.32,Other,150% of Medicare + 9.63% HCRA Surcharge,390.6,45,,390.6,percent of total billed charges,Critical Access Hospital RCC factor,295.12,34,,295.12,percent of total billed charges,Implant Device,295.12,34,,295.12,percent of total billed charges,Implant Device,295.12,34,,295.12,percent of total billed charges,Implant Device,295.12,34,,295.12,percent of total billed charges,Implant Device,295.12,34,,295.12,percent of total billed charges,Implant Device,429.66,,,429.66,Other,110% of Medicare,303.8,35,,303.8,percent of total billed charges,Implant Device,295.12,34,"Charges > $500, x 34%",295.12,percent of total billed charges,Implant Device,303.8,35,,303.8,percent of total billed charges,Implant Device,303.8,35,,303.8,percent of total billed charges,Implant Device,303.8,35,,303.8,percent of total billed charges,Implant Device,303.8,35,,303.8,percent of total billed charges,Implant Device,303.8,35,,303.8,percent of total billed charges,Implant Device,347.2,40,,347.2,percent of total billed charges,Implant Device,303.8,70,,303.8,percent of total billed charges,All Other,295.12,34,,295.12,percent of total billed charges,Implant Device,295.12,34,,295.12,percent of total billed charges,Implant Device,303.8,35,,303.8,percent of total billed charges,Implant Device,303.8,35,,303.8,percent of total billed charges,Implant Device,303.8,35,,303.8,percent of total billed charges,Implant Device,303.8,35,,303.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,642.32,
SYNTHES XM106.0816S BIOLOGIC TISSUE 8X16,C1781,HCPCS,,79001237,CDM,278,RC,,,both,,,12567,9299.61,,,9299.61,Other,150% of Medicare + 9.63% HCRA Surcharge,5655.15,45,,5655.15,percent of total billed charges,Critical Access Hospital RCC factor,4272.78,34,,4272.78,percent of total billed charges,Implant Device,4272.78,34,,4272.78,percent of total billed charges,Implant Device,4272.78,34,,4272.78,percent of total billed charges,Implant Device,4272.78,34,,4272.78,percent of total billed charges,Implant Device,4272.78,34,,4272.78,percent of total billed charges,Implant Device,6220.67,,,6220.67,Other,110% of Medicare,4398.45,35,,4398.45,percent of total billed charges,Implant Device,4272.78,34,"Charges > $500, x 34%",4272.78,percent of total billed charges,Implant Device,4398.45,35,,4398.45,percent of total billed charges,Implant Device,4398.45,35,,4398.45,percent of total billed charges,Implant Device,4398.45,35,,4398.45,percent of total billed charges,Implant Device,4398.45,35,,4398.45,percent of total billed charges,Implant Device,4398.45,35,,4398.45,percent of total billed charges,Implant Device,5026.8,40,,5026.8,percent of total billed charges,Implant Device,4398.45,70,,4398.45,percent of total billed charges,All Other,4272.78,34,,4272.78,percent of total billed charges,Implant Device,4272.78,34,,4272.78,percent of total billed charges,Implant Device,4398.45,35,,4398.45,percent of total billed charges,Implant Device,4398.45,35,,4398.45,percent of total billed charges,Implant Device,4398.45,35,,4398.45,percent of total billed charges,Implant Device,4398.45,35,,4398.45,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,4272.78,34,"If Charge > 2,000, then 34 percent",4272.78,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,9299.61,
ARTHREX AR-1934BF BIOSUTURE TACK 3 X 14,C1713,HCPCS,,79001238,CDM,278,RC,,,both,,,148,109.52,,,109.52,Other,150% of Medicare + 9.63% HCRA Surcharge,66.6,45,,66.6,percent of total billed charges,Critical Access Hospital RCC factor,50.32,34,,50.32,percent of total billed charges,Implant Device,50.32,34,,50.32,percent of total billed charges,Implant Device,50.32,34,,50.32,percent of total billed charges,Implant Device,50.32,34,,50.32,percent of total billed charges,Implant Device,50.32,34,,50.32,percent of total billed charges,Implant Device,73.26,,,73.26,Other,110% of Medicare,51.8,35,,51.8,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,51.8,35,,51.8,percent of total billed charges,Implant Device,51.8,35,,51.8,percent of total billed charges,Implant Device,51.8,35,,51.8,percent of total billed charges,Implant Device,51.8,35,,51.8,percent of total billed charges,Implant Device,51.8,35,,51.8,percent of total billed charges,Implant Device,59.2,40,,59.2,percent of total billed charges,Implant Device,51.8,70,,51.8,percent of total billed charges,All Other,50.32,34,,50.32,percent of total billed charges,Implant Device,50.32,34,,50.32,percent of total billed charges,Implant Device,51.8,35,,51.8,percent of total billed charges,Implant Device,51.8,35,,51.8,percent of total billed charges,Implant Device,51.8,35,,51.8,percent of total billed charges,Implant Device,51.8,35,,51.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,109.52,
ARTHREX AR-1530B BIOTENDODESIS SCREW,C1713,HCPCS,,79001239,CDM,278,RC,,,both,,,1006,744.44,,,744.44,Other,150% of Medicare + 9.63% HCRA Surcharge,452.7,45,,452.7,percent of total billed charges,Critical Access Hospital RCC factor,342.04,34,,342.04,percent of total billed charges,Implant Device,342.04,34,,342.04,percent of total billed charges,Implant Device,342.04,34,,342.04,percent of total billed charges,Implant Device,342.04,34,,342.04,percent of total billed charges,Implant Device,342.04,34,,342.04,percent of total billed charges,Implant Device,497.97,,,497.97,Other,110% of Medicare,352.1,35,,352.1,percent of total billed charges,Implant Device,342.04,34,"Charges > $500, x 34%",342.04,percent of total billed charges,Implant Device,352.1,35,,352.1,percent of total billed charges,Implant Device,352.1,35,,352.1,percent of total billed charges,Implant Device,352.1,35,,352.1,percent of total billed charges,Implant Device,352.1,35,,352.1,percent of total billed charges,Implant Device,352.1,35,,352.1,percent of total billed charges,Implant Device,402.4,40,,402.4,percent of total billed charges,Implant Device,352.1,70,,352.1,percent of total billed charges,All Other,342.04,34,,342.04,percent of total billed charges,Implant Device,342.04,34,,342.04,percent of total billed charges,Implant Device,352.1,35,,352.1,percent of total billed charges,Implant Device,352.1,35,,352.1,percent of total billed charges,Implant Device,352.1,35,,352.1,percent of total billed charges,Implant Device,352.1,35,,352.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,744.44,
ARTHREX AR-1570BC BIOTENODESIS 7 X 23,C1713,HCPCS,,79001240,CDM,278,RC,,,both,,,1035,765.9,,,765.9,Other,150% of Medicare + 9.63% HCRA Surcharge,465.75,45,,465.75,percent of total billed charges,Critical Access Hospital RCC factor,351.9,34,,351.9,percent of total billed charges,Implant Device,351.9,34,,351.9,percent of total billed charges,Implant Device,351.9,34,,351.9,percent of total billed charges,Implant Device,351.9,34,,351.9,percent of total billed charges,Implant Device,351.9,34,,351.9,percent of total billed charges,Implant Device,512.33,,,512.33,Other,110% of Medicare,362.25,35,,362.25,percent of total billed charges,Implant Device,351.9,34,"Charges > $500, x 34%",351.9,percent of total billed charges,Implant Device,362.25,35,,362.25,percent of total billed charges,Implant Device,362.25,35,,362.25,percent of total billed charges,Implant Device,362.25,35,,362.25,percent of total billed charges,Implant Device,362.25,35,,362.25,percent of total billed charges,Implant Device,362.25,35,,362.25,percent of total billed charges,Implant Device,414,40,,414,percent of total billed charges,Implant Device,362.25,70,,362.25,percent of total billed charges,All Other,351.9,34,,351.9,percent of total billed charges,Implant Device,351.9,34,,351.9,percent of total billed charges,Implant Device,362.25,35,,362.25,percent of total billed charges,Implant Device,362.25,35,,362.25,percent of total billed charges,Implant Device,362.25,35,,362.25,percent of total billed charges,Implant Device,362.25,35,,362.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,765.9,
ARTHREX AR-1580BC BIOTENODESIS 8 X 23,C1713,HCPCS,,79001241,CDM,278,RC,,,both,,,1036,766.64,,,766.64,Other,150% of Medicare + 9.63% HCRA Surcharge,466.2,45,,466.2,percent of total billed charges,Critical Access Hospital RCC factor,352.24,34,,352.24,percent of total billed charges,Implant Device,352.24,34,,352.24,percent of total billed charges,Implant Device,352.24,34,,352.24,percent of total billed charges,Implant Device,352.24,34,,352.24,percent of total billed charges,Implant Device,352.24,34,,352.24,percent of total billed charges,Implant Device,512.82,,,512.82,Other,110% of Medicare,362.6,35,,362.6,percent of total billed charges,Implant Device,352.24,34,"Charges > $500, x 34%",352.24,percent of total billed charges,Implant Device,362.6,35,,362.6,percent of total billed charges,Implant Device,362.6,35,,362.6,percent of total billed charges,Implant Device,362.6,35,,362.6,percent of total billed charges,Implant Device,362.6,35,,362.6,percent of total billed charges,Implant Device,362.6,35,,362.6,percent of total billed charges,Implant Device,414.4,40,,414.4,percent of total billed charges,Implant Device,362.6,70,,362.6,percent of total billed charges,All Other,352.24,34,,352.24,percent of total billed charges,Implant Device,352.24,34,,352.24,percent of total billed charges,Implant Device,362.6,35,,362.6,percent of total billed charges,Implant Device,362.6,35,,362.6,percent of total billed charges,Implant Device,362.6,35,,362.6,percent of total billed charges,Implant Device,362.6,35,,362.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,766.64,
ARTHREX AR-1547B BIOTENOD SCREW 4.75X15,C1713,HCPCS,,79001243,CDM,278,RC,,,both,,,750,555,,,555,Other,150% of Medicare + 9.63% HCRA Surcharge,337.5,45,,337.5,percent of total billed charges,Critical Access Hospital RCC factor,255,34,,255,percent of total billed charges,Implant Device,255,34,,255,percent of total billed charges,Implant Device,255,34,,255,percent of total billed charges,Implant Device,255,34,,255,percent of total billed charges,Implant Device,255,34,,255,percent of total billed charges,Implant Device,371.25,,,371.25,Other,110% of Medicare,262.5,35,,262.5,percent of total billed charges,Implant Device,255,34,"Charges > $500, x 34%",255,percent of total billed charges,Implant Device,262.5,35,,262.5,percent of total billed charges,Implant Device,262.5,35,,262.5,percent of total billed charges,Implant Device,262.5,35,,262.5,percent of total billed charges,Implant Device,262.5,35,,262.5,percent of total billed charges,Implant Device,262.5,35,,262.5,percent of total billed charges,Implant Device,300,40,,300,percent of total billed charges,Implant Device,262.5,70,,262.5,percent of total billed charges,All Other,255,34,,255,percent of total billed charges,Implant Device,255,34,,255,percent of total billed charges,Implant Device,262.5,35,,262.5,percent of total billed charges,Implant Device,262.5,35,,262.5,percent of total billed charges,Implant Device,262.5,35,,262.5,percent of total billed charges,Implant Device,262.5,35,,262.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,555,
ARTHREX AR-1555B BIOTENOD SCREW 5.5X15,C1713,HCPCS,,79001244,CDM,278,RC,,,both,,,1224,905.76,,,905.76,Other,150% of Medicare + 9.63% HCRA Surcharge,550.8,45,,550.8,percent of total billed charges,Critical Access Hospital RCC factor,416.16,34,,416.16,percent of total billed charges,Implant Device,416.16,34,,416.16,percent of total billed charges,Implant Device,416.16,34,,416.16,percent of total billed charges,Implant Device,416.16,34,,416.16,percent of total billed charges,Implant Device,416.16,34,,416.16,percent of total billed charges,Implant Device,605.88,,,605.88,Other,110% of Medicare,428.4,35,,428.4,percent of total billed charges,Implant Device,416.16,34,"Charges > $500, x 34%",416.16,percent of total billed charges,Implant Device,428.4,35,,428.4,percent of total billed charges,Implant Device,428.4,35,,428.4,percent of total billed charges,Implant Device,428.4,35,,428.4,percent of total billed charges,Implant Device,428.4,35,,428.4,percent of total billed charges,Implant Device,428.4,35,,428.4,percent of total billed charges,Implant Device,489.6,40,,489.6,percent of total billed charges,Implant Device,428.4,70,,428.4,percent of total billed charges,All Other,416.16,34,,416.16,percent of total billed charges,Implant Device,416.16,34,,416.16,percent of total billed charges,Implant Device,428.4,35,,428.4,percent of total billed charges,Implant Device,428.4,35,,428.4,percent of total billed charges,Implant Device,428.4,35,,428.4,percent of total billed charges,Implant Device,428.4,35,,428.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,905.76,
ARTHREX AR-1570B BIOTENOD SCREW 7X23,C1713,HCPCS,,79001245,CDM,278,RC,,,both,,,1110,821.4,,,821.4,Other,150% of Medicare + 9.63% HCRA Surcharge,499.5,45,,499.5,percent of total billed charges,Critical Access Hospital RCC factor,377.4,34,,377.4,percent of total billed charges,Implant Device,377.4,34,,377.4,percent of total billed charges,Implant Device,377.4,34,,377.4,percent of total billed charges,Implant Device,377.4,34,,377.4,percent of total billed charges,Implant Device,377.4,34,,377.4,percent of total billed charges,Implant Device,549.45,,,549.45,Other,110% of Medicare,388.5,35,,388.5,percent of total billed charges,Implant Device,377.4,34,"Charges > $500, x 34%",377.4,percent of total billed charges,Implant Device,388.5,35,,388.5,percent of total billed charges,Implant Device,388.5,35,,388.5,percent of total billed charges,Implant Device,388.5,35,,388.5,percent of total billed charges,Implant Device,388.5,35,,388.5,percent of total billed charges,Implant Device,388.5,35,,388.5,percent of total billed charges,Implant Device,444,40,,444,percent of total billed charges,Implant Device,388.5,70,,388.5,percent of total billed charges,All Other,377.4,34,,377.4,percent of total billed charges,Implant Device,377.4,34,,377.4,percent of total billed charges,Implant Device,388.5,35,,388.5,percent of total billed charges,Implant Device,388.5,35,,388.5,percent of total billed charges,Implant Device,388.5,35,,388.5,percent of total billed charges,Implant Device,388.5,35,,388.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,821.4,
ARTHREX AR-1580B BIOTENOD SCREW 8X23,C1713,HCPCS,,79001246,CDM,278,RC,,,both,,,1110,821.4,,,821.4,Other,150% of Medicare + 9.63% HCRA Surcharge,499.5,45,,499.5,percent of total billed charges,Critical Access Hospital RCC factor,377.4,34,,377.4,percent of total billed charges,Implant Device,377.4,34,,377.4,percent of total billed charges,Implant Device,377.4,34,,377.4,percent of total billed charges,Implant Device,377.4,34,,377.4,percent of total billed charges,Implant Device,377.4,34,,377.4,percent of total billed charges,Implant Device,549.45,,,549.45,Other,110% of Medicare,388.5,35,,388.5,percent of total billed charges,Implant Device,377.4,34,"Charges > $500, x 34%",377.4,percent of total billed charges,Implant Device,388.5,35,,388.5,percent of total billed charges,Implant Device,388.5,35,,388.5,percent of total billed charges,Implant Device,388.5,35,,388.5,percent of total billed charges,Implant Device,388.5,35,,388.5,percent of total billed charges,Implant Device,388.5,35,,388.5,percent of total billed charges,Implant Device,444,40,,444,percent of total billed charges,Implant Device,388.5,70,,388.5,percent of total billed charges,All Other,377.4,34,,377.4,percent of total billed charges,Implant Device,377.4,34,,377.4,percent of total billed charges,Implant Device,388.5,35,,388.5,percent of total billed charges,Implant Device,388.5,35,,388.5,percent of total billed charges,Implant Device,388.5,35,,388.5,percent of total billed charges,Implant Device,388.5,35,,388.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,821.4,
DEPUY 5450-35-500 BONE CEMENT,C1713,HCPCS,,79001247,CDM,278,RC,,,both,,,864,639.36,,,639.36,Other,150% of Medicare + 9.63% HCRA Surcharge,388.8,45,,388.8,percent of total billed charges,Critical Access Hospital RCC factor,293.76,34,,293.76,percent of total billed charges,Implant Device,293.76,34,,293.76,percent of total billed charges,Implant Device,293.76,34,,293.76,percent of total billed charges,Implant Device,293.76,34,,293.76,percent of total billed charges,Implant Device,293.76,34,,293.76,percent of total billed charges,Implant Device,427.68,,,427.68,Other,110% of Medicare,302.4,35,,302.4,percent of total billed charges,Implant Device,293.76,34,"Charges > $500, x 34%",293.76,percent of total billed charges,Implant Device,302.4,35,,302.4,percent of total billed charges,Implant Device,302.4,35,,302.4,percent of total billed charges,Implant Device,302.4,35,,302.4,percent of total billed charges,Implant Device,302.4,35,,302.4,percent of total billed charges,Implant Device,302.4,35,,302.4,percent of total billed charges,Implant Device,345.6,40,,345.6,percent of total billed charges,Implant Device,302.4,70,,302.4,percent of total billed charges,All Other,293.76,34,,293.76,percent of total billed charges,Implant Device,293.76,34,,293.76,percent of total billed charges,Implant Device,302.4,35,,302.4,percent of total billed charges,Implant Device,302.4,35,,302.4,percent of total billed charges,Implant Device,302.4,35,,302.4,percent of total billed charges,Implant Device,302.4,35,,302.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,639.36,
STRYKER 6191-1-001 BONE CEMENT B,C1713,HCPCS,,79001248,CDM,278,RC,,,both,,,346,256.04,,,256.04,Other,150% of Medicare + 9.63% HCRA Surcharge,155.7,45,,155.7,percent of total billed charges,Critical Access Hospital RCC factor,117.64,34,,117.64,percent of total billed charges,Implant Device,117.64,34,,117.64,percent of total billed charges,Implant Device,117.64,34,,117.64,percent of total billed charges,Implant Device,117.64,34,,117.64,percent of total billed charges,Implant Device,117.64,34,,117.64,percent of total billed charges,Implant Device,171.27,,,171.27,Other,110% of Medicare,121.1,35,,121.1,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,121.1,35,,121.1,percent of total billed charges,Implant Device,121.1,35,,121.1,percent of total billed charges,Implant Device,121.1,35,,121.1,percent of total billed charges,Implant Device,121.1,35,,121.1,percent of total billed charges,Implant Device,121.1,35,,121.1,percent of total billed charges,Implant Device,138.4,40,,138.4,percent of total billed charges,Implant Device,121.1,70,,121.1,percent of total billed charges,All Other,117.64,34,,117.64,percent of total billed charges,Implant Device,117.64,34,,117.64,percent of total billed charges,Implant Device,121.1,35,,121.1,percent of total billed charges,Implant Device,121.1,35,,121.1,percent of total billed charges,Implant Device,121.1,35,,121.1,percent of total billed charges,Implant Device,121.1,35,,121.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,256.04,
STRYKER 52-23012E BONE SCREW ST 2.3X12MM,C1713,HCPCS,,79001249,CDM,278,RC,,,both,,,258,190.92,,,190.92,Other,150% of Medicare + 9.63% HCRA Surcharge,116.1,45,,116.1,percent of total billed charges,Critical Access Hospital RCC factor,87.72,34,,87.72,percent of total billed charges,Implant Device,87.72,34,,87.72,percent of total billed charges,Implant Device,87.72,34,,87.72,percent of total billed charges,Implant Device,87.72,34,,87.72,percent of total billed charges,Implant Device,87.72,34,,87.72,percent of total billed charges,Implant Device,127.71,,,127.71,Other,110% of Medicare,90.3,35,,90.3,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,90.3,35,,90.3,percent of total billed charges,Implant Device,90.3,35,,90.3,percent of total billed charges,Implant Device,90.3,35,,90.3,percent of total billed charges,Implant Device,90.3,35,,90.3,percent of total billed charges,Implant Device,90.3,35,,90.3,percent of total billed charges,Implant Device,103.2,40,,103.2,percent of total billed charges,Implant Device,90.3,70,,90.3,percent of total billed charges,All Other,87.72,34,,87.72,percent of total billed charges,Implant Device,87.72,34,,87.72,percent of total billed charges,Implant Device,90.3,35,,90.3,percent of total billed charges,Implant Device,90.3,35,,90.3,percent of total billed charges,Implant Device,90.3,35,,90.3,percent of total billed charges,Implant Device,90.3,35,,90.3,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,190.92,
STRYKER 52-27126E BONE SCREW PT 2.7X26MM,C1713,HCPCS,,79001250,CDM,278,RC,,,both,,,322,238.28,,,238.28,Other,150% of Medicare + 9.63% HCRA Surcharge,144.9,45,,144.9,percent of total billed charges,Critical Access Hospital RCC factor,109.48,34,,109.48,percent of total billed charges,Implant Device,109.48,34,,109.48,percent of total billed charges,Implant Device,109.48,34,,109.48,percent of total billed charges,Implant Device,109.48,34,,109.48,percent of total billed charges,Implant Device,109.48,34,,109.48,percent of total billed charges,Implant Device,159.39,,,159.39,Other,110% of Medicare,112.7,35,,112.7,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,112.7,35,,112.7,percent of total billed charges,Implant Device,112.7,35,,112.7,percent of total billed charges,Implant Device,112.7,35,,112.7,percent of total billed charges,Implant Device,112.7,35,,112.7,percent of total billed charges,Implant Device,112.7,35,,112.7,percent of total billed charges,Implant Device,128.8,40,,128.8,percent of total billed charges,Implant Device,112.7,70,,112.7,percent of total billed charges,All Other,109.48,34,,109.48,percent of total billed charges,Implant Device,109.48,34,,109.48,percent of total billed charges,Implant Device,112.7,35,,112.7,percent of total billed charges,Implant Device,112.7,35,,112.7,percent of total billed charges,Implant Device,112.7,35,,112.7,percent of total billed charges,Implant Device,112.7,35,,112.7,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,238.28,
STRYKER 52-27026E BONE SCREW ST 2.7X26MM,C1713,HCPCS,,79001251,CDM,278,RC,,,both,,,258,190.92,,,190.92,Other,150% of Medicare + 9.63% HCRA Surcharge,116.1,45,,116.1,percent of total billed charges,Critical Access Hospital RCC factor,87.72,34,,87.72,percent of total billed charges,Implant Device,87.72,34,,87.72,percent of total billed charges,Implant Device,87.72,34,,87.72,percent of total billed charges,Implant Device,87.72,34,,87.72,percent of total billed charges,Implant Device,87.72,34,,87.72,percent of total billed charges,Implant Device,127.71,,,127.71,Other,110% of Medicare,90.3,35,,90.3,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,90.3,35,,90.3,percent of total billed charges,Implant Device,90.3,35,,90.3,percent of total billed charges,Implant Device,90.3,35,,90.3,percent of total billed charges,Implant Device,90.3,35,,90.3,percent of total billed charges,Implant Device,90.3,35,,90.3,percent of total billed charges,Implant Device,103.2,40,,103.2,percent of total billed charges,Implant Device,90.3,70,,90.3,percent of total billed charges,All Other,87.72,34,,87.72,percent of total billed charges,Implant Device,87.72,34,,87.72,percent of total billed charges,Implant Device,90.3,35,,90.3,percent of total billed charges,Implant Device,90.3,35,,90.3,percent of total billed charges,Implant Device,90.3,35,,90.3,percent of total billed charges,Implant Device,90.3,35,,90.3,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,190.92,
STRYKER 52-27222E BONE SCREW PT 2.7X22MM,C1713,HCPCS,,79001252,CDM,278,RC,,,both,,,319,236.06,,,236.06,Other,150% of Medicare + 9.63% HCRA Surcharge,143.55,45,,143.55,percent of total billed charges,Critical Access Hospital RCC factor,108.46,34,,108.46,percent of total billed charges,Implant Device,108.46,34,,108.46,percent of total billed charges,Implant Device,108.46,34,,108.46,percent of total billed charges,Implant Device,108.46,34,,108.46,percent of total billed charges,Implant Device,108.46,34,,108.46,percent of total billed charges,Implant Device,157.91,,,157.91,Other,110% of Medicare,111.65,35,,111.65,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,111.65,35,,111.65,percent of total billed charges,Implant Device,111.65,35,,111.65,percent of total billed charges,Implant Device,111.65,35,,111.65,percent of total billed charges,Implant Device,111.65,35,,111.65,percent of total billed charges,Implant Device,111.65,35,,111.65,percent of total billed charges,Implant Device,127.6,40,,127.6,percent of total billed charges,Implant Device,111.65,70,,111.65,percent of total billed charges,All Other,108.46,34,,108.46,percent of total billed charges,Implant Device,108.46,34,,108.46,percent of total billed charges,Implant Device,111.65,35,,111.65,percent of total billed charges,Implant Device,111.65,35,,111.65,percent of total billed charges,Implant Device,111.65,35,,111.65,percent of total billed charges,Implant Device,111.65,35,,111.65,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,236.06,
STRYKER 53-27126E BONE SCREW PT 2.7X26MM,C1713,HCPCS,,79001253,CDM,278,RC,,,both,,,385,284.9,,,284.9,Other,150% of Medicare + 9.63% HCRA Surcharge,173.25,45,,173.25,percent of total billed charges,Critical Access Hospital RCC factor,130.9,34,,130.9,percent of total billed charges,Implant Device,130.9,34,,130.9,percent of total billed charges,Implant Device,130.9,34,,130.9,percent of total billed charges,Implant Device,130.9,34,,130.9,percent of total billed charges,Implant Device,130.9,34,,130.9,percent of total billed charges,Implant Device,190.58,,,190.58,Other,110% of Medicare,134.75,35,,134.75,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,134.75,35,,134.75,percent of total billed charges,Implant Device,134.75,35,,134.75,percent of total billed charges,Implant Device,134.75,35,,134.75,percent of total billed charges,Implant Device,134.75,35,,134.75,percent of total billed charges,Implant Device,134.75,35,,134.75,percent of total billed charges,Implant Device,154,40,,154,percent of total billed charges,Implant Device,134.75,70,,134.75,percent of total billed charges,All Other,130.9,34,,130.9,percent of total billed charges,Implant Device,130.9,34,,130.9,percent of total billed charges,Implant Device,134.75,35,,134.75,percent of total billed charges,Implant Device,134.75,35,,134.75,percent of total billed charges,Implant Device,134.75,35,,134.75,percent of total billed charges,Implant Device,134.75,35,,134.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,284.9,
STRYKER 52-27012E BONE SCREW ST 2.7X12MM,C1713,HCPCS,,79001254,CDM,278,RC,,,both,,,270,199.8,,,199.8,Other,150% of Medicare + 9.63% HCRA Surcharge,121.5,45,,121.5,percent of total billed charges,Critical Access Hospital RCC factor,91.8,34,,91.8,percent of total billed charges,Implant Device,91.8,34,,91.8,percent of total billed charges,Implant Device,91.8,34,,91.8,percent of total billed charges,Implant Device,91.8,34,,91.8,percent of total billed charges,Implant Device,91.8,34,,91.8,percent of total billed charges,Implant Device,133.65,,,133.65,Other,110% of Medicare,94.5,35,,94.5,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,94.5,35,,94.5,percent of total billed charges,Implant Device,94.5,35,,94.5,percent of total billed charges,Implant Device,94.5,35,,94.5,percent of total billed charges,Implant Device,94.5,35,,94.5,percent of total billed charges,Implant Device,94.5,35,,94.5,percent of total billed charges,Implant Device,108,40,,108,percent of total billed charges,Implant Device,94.5,70,,94.5,percent of total billed charges,All Other,91.8,34,,91.8,percent of total billed charges,Implant Device,91.8,34,,91.8,percent of total billed charges,Implant Device,94.5,35,,94.5,percent of total billed charges,Implant Device,94.5,35,,94.5,percent of total billed charges,Implant Device,94.5,35,,94.5,percent of total billed charges,Implant Device,94.5,35,,94.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,199.8,
STRYKER 58-17010E BONE SCREW ST 1.7X10MM,C1713,HCPCS,,79001255,CDM,278,RC,,,both,,,199,147.26,,,147.26,Other,150% of Medicare + 9.63% HCRA Surcharge,89.55,45,,89.55,percent of total billed charges,Critical Access Hospital RCC factor,67.66,34,,67.66,percent of total billed charges,Implant Device,67.66,34,,67.66,percent of total billed charges,Implant Device,67.66,34,,67.66,percent of total billed charges,Implant Device,67.66,34,,67.66,percent of total billed charges,Implant Device,67.66,34,,67.66,percent of total billed charges,Implant Device,98.51,,,98.51,Other,110% of Medicare,69.65,35,,69.65,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,69.65,35,,69.65,percent of total billed charges,Implant Device,69.65,35,,69.65,percent of total billed charges,Implant Device,69.65,35,,69.65,percent of total billed charges,Implant Device,69.65,35,,69.65,percent of total billed charges,Implant Device,69.65,35,,69.65,percent of total billed charges,Implant Device,79.6,40,,79.6,percent of total billed charges,Implant Device,69.65,70,,69.65,percent of total billed charges,All Other,67.66,34,,67.66,percent of total billed charges,Implant Device,67.66,34,,67.66,percent of total billed charges,Implant Device,69.65,35,,69.65,percent of total billed charges,Implant Device,69.65,35,,69.65,percent of total billed charges,Implant Device,69.65,35,,69.65,percent of total billed charges,Implant Device,69.65,35,,69.65,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,147.26,
STRYKER 58-17011E BONE SCREW ST 1.7X11MM,C1713,HCPCS,,79001256,CDM,278,RC,,,both,,,367,271.58,,,271.58,Other,150% of Medicare + 9.63% HCRA Surcharge,165.15,45,,165.15,percent of total billed charges,Critical Access Hospital RCC factor,124.78,34,,124.78,percent of total billed charges,Implant Device,124.78,34,,124.78,percent of total billed charges,Implant Device,124.78,34,,124.78,percent of total billed charges,Implant Device,124.78,34,,124.78,percent of total billed charges,Implant Device,124.78,34,,124.78,percent of total billed charges,Implant Device,181.67,,,181.67,Other,110% of Medicare,128.45,35,,128.45,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,128.45,35,,128.45,percent of total billed charges,Implant Device,128.45,35,,128.45,percent of total billed charges,Implant Device,128.45,35,,128.45,percent of total billed charges,Implant Device,128.45,35,,128.45,percent of total billed charges,Implant Device,128.45,35,,128.45,percent of total billed charges,Implant Device,146.8,40,,146.8,percent of total billed charges,Implant Device,128.45,70,,128.45,percent of total billed charges,All Other,124.78,34,,124.78,percent of total billed charges,Implant Device,124.78,34,,124.78,percent of total billed charges,Implant Device,128.45,35,,128.45,percent of total billed charges,Implant Device,128.45,35,,128.45,percent of total billed charges,Implant Device,128.45,35,,128.45,percent of total billed charges,Implant Device,128.45,35,,128.45,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,271.58,
STRYKER 58-17012E BONE SCREW ST 1.7X12MM,C1713,HCPCS,,79001257,CDM,278,RC,,,both,,,256,189.44,,,189.44,Other,150% of Medicare + 9.63% HCRA Surcharge,115.2,45,,115.2,percent of total billed charges,Critical Access Hospital RCC factor,87.04,34,,87.04,percent of total billed charges,Implant Device,87.04,34,,87.04,percent of total billed charges,Implant Device,87.04,34,,87.04,percent of total billed charges,Implant Device,87.04,34,,87.04,percent of total billed charges,Implant Device,87.04,34,,87.04,percent of total billed charges,Implant Device,126.72,,,126.72,Other,110% of Medicare,89.6,35,,89.6,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,89.6,35,,89.6,percent of total billed charges,Implant Device,89.6,35,,89.6,percent of total billed charges,Implant Device,89.6,35,,89.6,percent of total billed charges,Implant Device,89.6,35,,89.6,percent of total billed charges,Implant Device,89.6,35,,89.6,percent of total billed charges,Implant Device,102.4,40,,102.4,percent of total billed charges,Implant Device,89.6,70,,89.6,percent of total billed charges,All Other,87.04,34,,87.04,percent of total billed charges,Implant Device,87.04,34,,87.04,percent of total billed charges,Implant Device,89.6,35,,89.6,percent of total billed charges,Implant Device,89.6,35,,89.6,percent of total billed charges,Implant Device,89.6,35,,89.6,percent of total billed charges,Implant Device,89.6,35,,89.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,189.44,
STRYKER 58-17014E BONE SCREW ST 1.7X12MM,C1713,HCPCS,,79001258,CDM,278,RC,,,both,,,175,129.5,,,129.5,Other,150% of Medicare + 9.63% HCRA Surcharge,78.75,45,,78.75,percent of total billed charges,Critical Access Hospital RCC factor,59.5,34,,59.5,percent of total billed charges,Implant Device,59.5,34,,59.5,percent of total billed charges,Implant Device,59.5,34,,59.5,percent of total billed charges,Implant Device,59.5,34,,59.5,percent of total billed charges,Implant Device,59.5,34,,59.5,percent of total billed charges,Implant Device,86.63,,,86.63,Other,110% of Medicare,61.25,35,,61.25,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,61.25,35,,61.25,percent of total billed charges,Implant Device,61.25,35,,61.25,percent of total billed charges,Implant Device,61.25,35,,61.25,percent of total billed charges,Implant Device,61.25,35,,61.25,percent of total billed charges,Implant Device,61.25,35,,61.25,percent of total billed charges,Implant Device,70,40,,70,percent of total billed charges,Implant Device,61.25,70,,61.25,percent of total billed charges,All Other,59.5,34,,59.5,percent of total billed charges,Implant Device,59.5,34,,59.5,percent of total billed charges,Implant Device,61.25,35,,61.25,percent of total billed charges,Implant Device,61.25,35,,61.25,percent of total billed charges,Implant Device,61.25,35,,61.25,percent of total billed charges,Implant Device,61.25,35,,61.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,129.5,
STRYKER 58-17016E BONE SCREW ST 1.7X16MM,C1713,HCPCS,,79001259,CDM,278,RC,,,both,,,349,258.26,,,258.26,Other,150% of Medicare + 9.63% HCRA Surcharge,157.05,45,,157.05,percent of total billed charges,Critical Access Hospital RCC factor,118.66,34,,118.66,percent of total billed charges,Implant Device,118.66,34,,118.66,percent of total billed charges,Implant Device,118.66,34,,118.66,percent of total billed charges,Implant Device,118.66,34,,118.66,percent of total billed charges,Implant Device,118.66,34,,118.66,percent of total billed charges,Implant Device,172.76,,,172.76,Other,110% of Medicare,122.15,35,,122.15,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,122.15,35,,122.15,percent of total billed charges,Implant Device,122.15,35,,122.15,percent of total billed charges,Implant Device,122.15,35,,122.15,percent of total billed charges,Implant Device,122.15,35,,122.15,percent of total billed charges,Implant Device,122.15,35,,122.15,percent of total billed charges,Implant Device,139.6,40,,139.6,percent of total billed charges,Implant Device,122.15,70,,122.15,percent of total billed charges,All Other,118.66,34,,118.66,percent of total billed charges,Implant Device,118.66,34,,118.66,percent of total billed charges,Implant Device,122.15,35,,122.15,percent of total billed charges,Implant Device,122.15,35,,122.15,percent of total billed charges,Implant Device,122.15,35,,122.15,percent of total billed charges,Implant Device,122.15,35,,122.15,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,258.26,
STRYKER 58-17018E BONE SCREW ST 1.7X18MM,C1713,HCPCS,,79001260,CDM,278,RC,,,both,,,240,177.6,,,177.6,Other,150% of Medicare + 9.63% HCRA Surcharge,108,45,,108,percent of total billed charges,Critical Access Hospital RCC factor,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,118.8,,,118.8,Other,110% of Medicare,84,35,,84,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,96,40,,96,percent of total billed charges,Implant Device,84,70,,84,percent of total billed charges,All Other,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,177.6,
STRYKER 58-17005E BONE SCREW ST 1.7X5MM,C1713,HCPCS,,79001261,CDM,278,RC,,,both,,,367,271.58,,,271.58,Other,150% of Medicare + 9.63% HCRA Surcharge,165.15,45,,165.15,percent of total billed charges,Critical Access Hospital RCC factor,124.78,34,,124.78,percent of total billed charges,Implant Device,124.78,34,,124.78,percent of total billed charges,Implant Device,124.78,34,,124.78,percent of total billed charges,Implant Device,124.78,34,,124.78,percent of total billed charges,Implant Device,124.78,34,,124.78,percent of total billed charges,Implant Device,181.67,,,181.67,Other,110% of Medicare,128.45,35,,128.45,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,128.45,35,,128.45,percent of total billed charges,Implant Device,128.45,35,,128.45,percent of total billed charges,Implant Device,128.45,35,,128.45,percent of total billed charges,Implant Device,128.45,35,,128.45,percent of total billed charges,Implant Device,128.45,35,,128.45,percent of total billed charges,Implant Device,146.8,40,,146.8,percent of total billed charges,Implant Device,128.45,70,,128.45,percent of total billed charges,All Other,124.78,34,,124.78,percent of total billed charges,Implant Device,124.78,34,,124.78,percent of total billed charges,Implant Device,128.45,35,,128.45,percent of total billed charges,Implant Device,128.45,35,,128.45,percent of total billed charges,Implant Device,128.45,35,,128.45,percent of total billed charges,Implant Device,128.45,35,,128.45,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,271.58,
STRYKER 58-17006E BONE SCREW ST 1.7X6MM,C1713,HCPCS,,79001262,CDM,278,RC,,,both,,,256,189.44,,,189.44,Other,150% of Medicare + 9.63% HCRA Surcharge,115.2,45,,115.2,percent of total billed charges,Critical Access Hospital RCC factor,87.04,34,,87.04,percent of total billed charges,Implant Device,87.04,34,,87.04,percent of total billed charges,Implant Device,87.04,34,,87.04,percent of total billed charges,Implant Device,87.04,34,,87.04,percent of total billed charges,Implant Device,87.04,34,,87.04,percent of total billed charges,Implant Device,126.72,,,126.72,Other,110% of Medicare,89.6,35,,89.6,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,89.6,35,,89.6,percent of total billed charges,Implant Device,89.6,35,,89.6,percent of total billed charges,Implant Device,89.6,35,,89.6,percent of total billed charges,Implant Device,89.6,35,,89.6,percent of total billed charges,Implant Device,89.6,35,,89.6,percent of total billed charges,Implant Device,102.4,40,,102.4,percent of total billed charges,Implant Device,89.6,70,,89.6,percent of total billed charges,All Other,87.04,34,,87.04,percent of total billed charges,Implant Device,87.04,34,,87.04,percent of total billed charges,Implant Device,89.6,35,,89.6,percent of total billed charges,Implant Device,89.6,35,,89.6,percent of total billed charges,Implant Device,89.6,35,,89.6,percent of total billed charges,Implant Device,89.6,35,,89.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,189.44,
STRYKER 58-17008E BONE SCREW ST 1.7X8MM,C1713,HCPCS,,79001263,CDM,278,RC,,,both,,,281,207.94,,,207.94,Other,150% of Medicare + 9.63% HCRA Surcharge,126.45,45,,126.45,percent of total billed charges,Critical Access Hospital RCC factor,95.54,34,,95.54,percent of total billed charges,Implant Device,95.54,34,,95.54,percent of total billed charges,Implant Device,95.54,34,,95.54,percent of total billed charges,Implant Device,95.54,34,,95.54,percent of total billed charges,Implant Device,95.54,34,,95.54,percent of total billed charges,Implant Device,139.1,,,139.1,Other,110% of Medicare,98.35,35,,98.35,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,98.35,35,,98.35,percent of total billed charges,Implant Device,98.35,35,,98.35,percent of total billed charges,Implant Device,98.35,35,,98.35,percent of total billed charges,Implant Device,98.35,35,,98.35,percent of total billed charges,Implant Device,98.35,35,,98.35,percent of total billed charges,Implant Device,112.4,40,,112.4,percent of total billed charges,Implant Device,98.35,70,,98.35,percent of total billed charges,All Other,95.54,34,,95.54,percent of total billed charges,Implant Device,95.54,34,,95.54,percent of total billed charges,Implant Device,98.35,35,,98.35,percent of total billed charges,Implant Device,98.35,35,,98.35,percent of total billed charges,Implant Device,98.35,35,,98.35,percent of total billed charges,Implant Device,98.35,35,,98.35,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,207.94,
STRYKER 58-17009E BONE SCREW ST 1.7X9MM,C1713,HCPCS,,79001264,CDM,278,RC,,,both,,,199,147.26,,,147.26,Other,150% of Medicare + 9.63% HCRA Surcharge,89.55,45,,89.55,percent of total billed charges,Critical Access Hospital RCC factor,67.66,34,,67.66,percent of total billed charges,Implant Device,67.66,34,,67.66,percent of total billed charges,Implant Device,67.66,34,,67.66,percent of total billed charges,Implant Device,67.66,34,,67.66,percent of total billed charges,Implant Device,67.66,34,,67.66,percent of total billed charges,Implant Device,98.51,,,98.51,Other,110% of Medicare,69.65,35,,69.65,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,69.65,35,,69.65,percent of total billed charges,Implant Device,69.65,35,,69.65,percent of total billed charges,Implant Device,69.65,35,,69.65,percent of total billed charges,Implant Device,69.65,35,,69.65,percent of total billed charges,Implant Device,69.65,35,,69.65,percent of total billed charges,Implant Device,79.6,40,,79.6,percent of total billed charges,Implant Device,69.65,70,,69.65,percent of total billed charges,All Other,67.66,34,,67.66,percent of total billed charges,Implant Device,67.66,34,,67.66,percent of total billed charges,Implant Device,69.65,35,,69.65,percent of total billed charges,Implant Device,69.65,35,,69.65,percent of total billed charges,Implant Device,69.65,35,,69.65,percent of total billed charges,Implant Device,69.65,35,,69.65,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,147.26,
STRYKER 58-23010E BONE SCREW ST 2.3X10MM,C1713,HCPCS,,79001265,CDM,278,RC,,,both,,,283,209.42,,,209.42,Other,150% of Medicare + 9.63% HCRA Surcharge,127.35,45,,127.35,percent of total billed charges,Critical Access Hospital RCC factor,96.22,34,,96.22,percent of total billed charges,Implant Device,96.22,34,,96.22,percent of total billed charges,Implant Device,96.22,34,,96.22,percent of total billed charges,Implant Device,96.22,34,,96.22,percent of total billed charges,Implant Device,96.22,34,,96.22,percent of total billed charges,Implant Device,140.09,,,140.09,Other,110% of Medicare,99.05,35,,99.05,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,99.05,35,,99.05,percent of total billed charges,Implant Device,99.05,35,,99.05,percent of total billed charges,Implant Device,99.05,35,,99.05,percent of total billed charges,Implant Device,99.05,35,,99.05,percent of total billed charges,Implant Device,99.05,35,,99.05,percent of total billed charges,Implant Device,113.2,40,,113.2,percent of total billed charges,Implant Device,99.05,70,,99.05,percent of total billed charges,All Other,96.22,34,,96.22,percent of total billed charges,Implant Device,96.22,34,,96.22,percent of total billed charges,Implant Device,99.05,35,,99.05,percent of total billed charges,Implant Device,99.05,35,,99.05,percent of total billed charges,Implant Device,99.05,35,,99.05,percent of total billed charges,Implant Device,99.05,35,,99.05,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,209.42,
STRYKER 58-23011E BONE SCREW ST 2.3X11MM,C1713,HCPCS,,79001266,CDM,278,RC,,,both,,,283,209.42,,,209.42,Other,150% of Medicare + 9.63% HCRA Surcharge,127.35,45,,127.35,percent of total billed charges,Critical Access Hospital RCC factor,96.22,34,,96.22,percent of total billed charges,Implant Device,96.22,34,,96.22,percent of total billed charges,Implant Device,96.22,34,,96.22,percent of total billed charges,Implant Device,96.22,34,,96.22,percent of total billed charges,Implant Device,96.22,34,,96.22,percent of total billed charges,Implant Device,140.09,,,140.09,Other,110% of Medicare,99.05,35,,99.05,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,99.05,35,,99.05,percent of total billed charges,Implant Device,99.05,35,,99.05,percent of total billed charges,Implant Device,99.05,35,,99.05,percent of total billed charges,Implant Device,99.05,35,,99.05,percent of total billed charges,Implant Device,99.05,35,,99.05,percent of total billed charges,Implant Device,113.2,40,,113.2,percent of total billed charges,Implant Device,99.05,70,,99.05,percent of total billed charges,All Other,96.22,34,,96.22,percent of total billed charges,Implant Device,96.22,34,,96.22,percent of total billed charges,Implant Device,99.05,35,,99.05,percent of total billed charges,Implant Device,99.05,35,,99.05,percent of total billed charges,Implant Device,99.05,35,,99.05,percent of total billed charges,Implant Device,99.05,35,,99.05,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,209.42,
STRYKER 58-23012E BONE SCREW ST 2.3X12MM,C1713,HCPCS,,79001267,CDM,278,RC,,,both,,,283,209.42,,,209.42,Other,150% of Medicare + 9.63% HCRA Surcharge,127.35,45,,127.35,percent of total billed charges,Critical Access Hospital RCC factor,96.22,34,,96.22,percent of total billed charges,Implant Device,96.22,34,,96.22,percent of total billed charges,Implant Device,96.22,34,,96.22,percent of total billed charges,Implant Device,96.22,34,,96.22,percent of total billed charges,Implant Device,96.22,34,,96.22,percent of total billed charges,Implant Device,140.09,,,140.09,Other,110% of Medicare,99.05,35,,99.05,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,99.05,35,,99.05,percent of total billed charges,Implant Device,99.05,35,,99.05,percent of total billed charges,Implant Device,99.05,35,,99.05,percent of total billed charges,Implant Device,99.05,35,,99.05,percent of total billed charges,Implant Device,99.05,35,,99.05,percent of total billed charges,Implant Device,113.2,40,,113.2,percent of total billed charges,Implant Device,99.05,70,,99.05,percent of total billed charges,All Other,96.22,34,,96.22,percent of total billed charges,Implant Device,96.22,34,,96.22,percent of total billed charges,Implant Device,99.05,35,,99.05,percent of total billed charges,Implant Device,99.05,35,,99.05,percent of total billed charges,Implant Device,99.05,35,,99.05,percent of total billed charges,Implant Device,99.05,35,,99.05,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,209.42,
STRYKER 58-23013E BONE SCREW ST 2.3X13MM,C1713,HCPCS,,79001268,CDM,278,RC,,,both,,,170,125.8,,,125.8,Other,150% of Medicare + 9.63% HCRA Surcharge,76.5,45,,76.5,percent of total billed charges,Critical Access Hospital RCC factor,57.8,34,,57.8,percent of total billed charges,Implant Device,57.8,34,,57.8,percent of total billed charges,Implant Device,57.8,34,,57.8,percent of total billed charges,Implant Device,57.8,34,,57.8,percent of total billed charges,Implant Device,57.8,34,,57.8,percent of total billed charges,Implant Device,84.15,,,84.15,Other,110% of Medicare,59.5,35,,59.5,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,59.5,35,,59.5,percent of total billed charges,Implant Device,59.5,35,,59.5,percent of total billed charges,Implant Device,59.5,35,,59.5,percent of total billed charges,Implant Device,59.5,35,,59.5,percent of total billed charges,Implant Device,59.5,35,,59.5,percent of total billed charges,Implant Device,68,40,,68,percent of total billed charges,Implant Device,59.5,70,,59.5,percent of total billed charges,All Other,57.8,34,,57.8,percent of total billed charges,Implant Device,57.8,34,,57.8,percent of total billed charges,Implant Device,59.5,35,,59.5,percent of total billed charges,Implant Device,59.5,35,,59.5,percent of total billed charges,Implant Device,59.5,35,,59.5,percent of total billed charges,Implant Device,59.5,35,,59.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,125.8,
STRYKER 58-23014E BONE SCREW ST 2.3X14MM,C1713,HCPCS,,79001269,CDM,278,RC,,,both,,,331,244.94,,,244.94,Other,150% of Medicare + 9.63% HCRA Surcharge,148.95,45,,148.95,percent of total billed charges,Critical Access Hospital RCC factor,112.54,34,,112.54,percent of total billed charges,Implant Device,112.54,34,,112.54,percent of total billed charges,Implant Device,112.54,34,,112.54,percent of total billed charges,Implant Device,112.54,34,,112.54,percent of total billed charges,Implant Device,112.54,34,,112.54,percent of total billed charges,Implant Device,163.85,,,163.85,Other,110% of Medicare,115.85,35,,115.85,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,115.85,35,,115.85,percent of total billed charges,Implant Device,115.85,35,,115.85,percent of total billed charges,Implant Device,115.85,35,,115.85,percent of total billed charges,Implant Device,115.85,35,,115.85,percent of total billed charges,Implant Device,115.85,35,,115.85,percent of total billed charges,Implant Device,132.4,40,,132.4,percent of total billed charges,Implant Device,115.85,70,,115.85,percent of total billed charges,All Other,112.54,34,,112.54,percent of total billed charges,Implant Device,112.54,34,,112.54,percent of total billed charges,Implant Device,115.85,35,,115.85,percent of total billed charges,Implant Device,115.85,35,,115.85,percent of total billed charges,Implant Device,115.85,35,,115.85,percent of total billed charges,Implant Device,115.85,35,,115.85,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,244.94,
STRYKER 58-23015E BONE SCREW ST 2.3X15MM,C1713,HCPCS,,79001270,CDM,278,RC,,,both,,,426,315.24,,,315.24,Other,150% of Medicare + 9.63% HCRA Surcharge,191.7,45,,191.7,percent of total billed charges,Critical Access Hospital RCC factor,144.84,34,,144.84,percent of total billed charges,Implant Device,144.84,34,,144.84,percent of total billed charges,Implant Device,144.84,34,,144.84,percent of total billed charges,Implant Device,144.84,34,,144.84,percent of total billed charges,Implant Device,144.84,34,,144.84,percent of total billed charges,Implant Device,210.87,,,210.87,Other,110% of Medicare,149.1,35,,149.1,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,149.1,35,,149.1,percent of total billed charges,Implant Device,149.1,35,,149.1,percent of total billed charges,Implant Device,149.1,35,,149.1,percent of total billed charges,Implant Device,149.1,35,,149.1,percent of total billed charges,Implant Device,149.1,35,,149.1,percent of total billed charges,Implant Device,170.4,40,,170.4,percent of total billed charges,Implant Device,149.1,70,,149.1,percent of total billed charges,All Other,144.84,34,,144.84,percent of total billed charges,Implant Device,144.84,34,,144.84,percent of total billed charges,Implant Device,149.1,35,,149.1,percent of total billed charges,Implant Device,149.1,35,,149.1,percent of total billed charges,Implant Device,149.1,35,,149.1,percent of total billed charges,Implant Device,149.1,35,,149.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,315.24,
STRYKER 58-23016E BONE SCREW ST 2.3X16MM,C1713,HCPCS,,79001271,CDM,278,RC,,,both,,,265,196.1,,,196.1,Other,150% of Medicare + 9.63% HCRA Surcharge,119.25,45,,119.25,percent of total billed charges,Critical Access Hospital RCC factor,90.1,34,,90.1,percent of total billed charges,Implant Device,90.1,34,,90.1,percent of total billed charges,Implant Device,90.1,34,,90.1,percent of total billed charges,Implant Device,90.1,34,,90.1,percent of total billed charges,Implant Device,90.1,34,,90.1,percent of total billed charges,Implant Device,131.18,,,131.18,Other,110% of Medicare,92.75,35,,92.75,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,92.75,35,,92.75,percent of total billed charges,Implant Device,92.75,35,,92.75,percent of total billed charges,Implant Device,92.75,35,,92.75,percent of total billed charges,Implant Device,92.75,35,,92.75,percent of total billed charges,Implant Device,92.75,35,,92.75,percent of total billed charges,Implant Device,106,40,,106,percent of total billed charges,Implant Device,92.75,70,,92.75,percent of total billed charges,All Other,90.1,34,,90.1,percent of total billed charges,Implant Device,90.1,34,,90.1,percent of total billed charges,Implant Device,92.75,35,,92.75,percent of total billed charges,Implant Device,92.75,35,,92.75,percent of total billed charges,Implant Device,92.75,35,,92.75,percent of total billed charges,Implant Device,92.75,35,,92.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,196.1,
STRYKER 58-23018E BONE SCREW ST 2.3X18MM,C1713,HCPCS,,79001272,CDM,278,RC,,,both,,,426,315.24,,,315.24,Other,150% of Medicare + 9.63% HCRA Surcharge,191.7,45,,191.7,percent of total billed charges,Critical Access Hospital RCC factor,144.84,34,,144.84,percent of total billed charges,Implant Device,144.84,34,,144.84,percent of total billed charges,Implant Device,144.84,34,,144.84,percent of total billed charges,Implant Device,144.84,34,,144.84,percent of total billed charges,Implant Device,144.84,34,,144.84,percent of total billed charges,Implant Device,210.87,,,210.87,Other,110% of Medicare,149.1,35,,149.1,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,149.1,35,,149.1,percent of total billed charges,Implant Device,149.1,35,,149.1,percent of total billed charges,Implant Device,149.1,35,,149.1,percent of total billed charges,Implant Device,149.1,35,,149.1,percent of total billed charges,Implant Device,149.1,35,,149.1,percent of total billed charges,Implant Device,170.4,40,,170.4,percent of total billed charges,Implant Device,149.1,70,,149.1,percent of total billed charges,All Other,144.84,34,,144.84,percent of total billed charges,Implant Device,144.84,34,,144.84,percent of total billed charges,Implant Device,149.1,35,,149.1,percent of total billed charges,Implant Device,149.1,35,,149.1,percent of total billed charges,Implant Device,149.1,35,,149.1,percent of total billed charges,Implant Device,149.1,35,,149.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,315.24,
STRYKER 53-23210E BONE SCREW T7 2.3X10MM,C1713,HCPCS,,79001273,CDM,278,RC,,,both,,,319,236.06,,,236.06,Other,150% of Medicare + 9.63% HCRA Surcharge,143.55,45,,143.55,percent of total billed charges,Critical Access Hospital RCC factor,108.46,34,,108.46,percent of total billed charges,Implant Device,108.46,34,,108.46,percent of total billed charges,Implant Device,108.46,34,,108.46,percent of total billed charges,Implant Device,108.46,34,,108.46,percent of total billed charges,Implant Device,108.46,34,,108.46,percent of total billed charges,Implant Device,157.91,,,157.91,Other,110% of Medicare,111.65,35,,111.65,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,111.65,35,,111.65,percent of total billed charges,Implant Device,111.65,35,,111.65,percent of total billed charges,Implant Device,111.65,35,,111.65,percent of total billed charges,Implant Device,111.65,35,,111.65,percent of total billed charges,Implant Device,111.65,35,,111.65,percent of total billed charges,Implant Device,127.6,40,,127.6,percent of total billed charges,Implant Device,111.65,70,,111.65,percent of total billed charges,All Other,108.46,34,,108.46,percent of total billed charges,Implant Device,108.46,34,,108.46,percent of total billed charges,Implant Device,111.65,35,,111.65,percent of total billed charges,Implant Device,111.65,35,,111.65,percent of total billed charges,Implant Device,111.65,35,,111.65,percent of total billed charges,Implant Device,111.65,35,,111.65,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,236.06,
STRYKER 53-23216E BONE SCREW T7 2.3X16MM,C1713,HCPCS,,79001274,CDM,278,RC,,,both,,,385,284.9,,,284.9,Other,150% of Medicare + 9.63% HCRA Surcharge,173.25,45,,173.25,percent of total billed charges,Critical Access Hospital RCC factor,130.9,34,,130.9,percent of total billed charges,Implant Device,130.9,34,,130.9,percent of total billed charges,Implant Device,130.9,34,,130.9,percent of total billed charges,Implant Device,130.9,34,,130.9,percent of total billed charges,Implant Device,130.9,34,,130.9,percent of total billed charges,Implant Device,190.58,,,190.58,Other,110% of Medicare,134.75,35,,134.75,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,134.75,35,,134.75,percent of total billed charges,Implant Device,134.75,35,,134.75,percent of total billed charges,Implant Device,134.75,35,,134.75,percent of total billed charges,Implant Device,134.75,35,,134.75,percent of total billed charges,Implant Device,134.75,35,,134.75,percent of total billed charges,Implant Device,154,40,,154,percent of total billed charges,Implant Device,134.75,70,,134.75,percent of total billed charges,All Other,130.9,34,,130.9,percent of total billed charges,Implant Device,130.9,34,,130.9,percent of total billed charges,Implant Device,134.75,35,,134.75,percent of total billed charges,Implant Device,134.75,35,,134.75,percent of total billed charges,Implant Device,134.75,35,,134.75,percent of total billed charges,Implant Device,134.75,35,,134.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,284.9,
STRYKER 53-23218E BONE SCREW T7 2.3X20MM,C1713,HCPCS,,79001275,CDM,278,RC,,,both,,,319,236.06,,,236.06,Other,150% of Medicare + 9.63% HCRA Surcharge,143.55,45,,143.55,percent of total billed charges,Critical Access Hospital RCC factor,108.46,34,,108.46,percent of total billed charges,Implant Device,108.46,34,,108.46,percent of total billed charges,Implant Device,108.46,34,,108.46,percent of total billed charges,Implant Device,108.46,34,,108.46,percent of total billed charges,Implant Device,108.46,34,,108.46,percent of total billed charges,Implant Device,157.91,,,157.91,Other,110% of Medicare,111.65,35,,111.65,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,111.65,35,,111.65,percent of total billed charges,Implant Device,111.65,35,,111.65,percent of total billed charges,Implant Device,111.65,35,,111.65,percent of total billed charges,Implant Device,111.65,35,,111.65,percent of total billed charges,Implant Device,111.65,35,,111.65,percent of total billed charges,Implant Device,127.6,40,,127.6,percent of total billed charges,Implant Device,111.65,70,,111.65,percent of total billed charges,All Other,108.46,34,,108.46,percent of total billed charges,Implant Device,108.46,34,,108.46,percent of total billed charges,Implant Device,111.65,35,,111.65,percent of total billed charges,Implant Device,111.65,35,,111.65,percent of total billed charges,Implant Device,111.65,35,,111.65,percent of total billed charges,Implant Device,111.65,35,,111.65,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,236.06,
STRYKER 53-23220E BONE SCREW T7 2.3X20MM,C1713,HCPCS,,79001276,CDM,278,RC,,,both,,,319,236.06,,,236.06,Other,150% of Medicare + 9.63% HCRA Surcharge,143.55,45,,143.55,percent of total billed charges,Critical Access Hospital RCC factor,108.46,34,,108.46,percent of total billed charges,Implant Device,108.46,34,,108.46,percent of total billed charges,Implant Device,108.46,34,,108.46,percent of total billed charges,Implant Device,108.46,34,,108.46,percent of total billed charges,Implant Device,108.46,34,,108.46,percent of total billed charges,Implant Device,157.91,,,157.91,Other,110% of Medicare,111.65,35,,111.65,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,111.65,35,,111.65,percent of total billed charges,Implant Device,111.65,35,,111.65,percent of total billed charges,Implant Device,111.65,35,,111.65,percent of total billed charges,Implant Device,111.65,35,,111.65,percent of total billed charges,Implant Device,111.65,35,,111.65,percent of total billed charges,Implant Device,127.6,40,,127.6,percent of total billed charges,Implant Device,111.65,70,,111.65,percent of total billed charges,All Other,108.46,34,,108.46,percent of total billed charges,Implant Device,108.46,34,,108.46,percent of total billed charges,Implant Device,111.65,35,,111.65,percent of total billed charges,Implant Device,111.65,35,,111.65,percent of total billed charges,Implant Device,111.65,35,,111.65,percent of total billed charges,Implant Device,111.65,35,,111.65,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,236.06,
STRYKER 53-23222E BONE SCREW T7 2.3X22MM,C1713,HCPCS,,79001277,CDM,278,RC,,,both,,,375,277.5,,,277.5,Other,150% of Medicare + 9.63% HCRA Surcharge,168.75,45,,168.75,percent of total billed charges,Critical Access Hospital RCC factor,127.5,34,,127.5,percent of total billed charges,Implant Device,127.5,34,,127.5,percent of total billed charges,Implant Device,127.5,34,,127.5,percent of total billed charges,Implant Device,127.5,34,,127.5,percent of total billed charges,Implant Device,127.5,34,,127.5,percent of total billed charges,Implant Device,185.63,,,185.63,Other,110% of Medicare,131.25,35,,131.25,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,131.25,35,,131.25,percent of total billed charges,Implant Device,131.25,35,,131.25,percent of total billed charges,Implant Device,131.25,35,,131.25,percent of total billed charges,Implant Device,131.25,35,,131.25,percent of total billed charges,Implant Device,131.25,35,,131.25,percent of total billed charges,Implant Device,150,40,,150,percent of total billed charges,Implant Device,131.25,70,,131.25,percent of total billed charges,All Other,127.5,34,,127.5,percent of total billed charges,Implant Device,127.5,34,,127.5,percent of total billed charges,Implant Device,131.25,35,,131.25,percent of total billed charges,Implant Device,131.25,35,,131.25,percent of total billed charges,Implant Device,131.25,35,,131.25,percent of total billed charges,Implant Device,131.25,35,,131.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,277.5,
STRYKER 53-23224E BONE SCREW T7 2.3X24MM,C1713,HCPCS,,79001278,CDM,278,RC,,,both,,,319,236.06,,,236.06,Other,150% of Medicare + 9.63% HCRA Surcharge,143.55,45,,143.55,percent of total billed charges,Critical Access Hospital RCC factor,108.46,34,,108.46,percent of total billed charges,Implant Device,108.46,34,,108.46,percent of total billed charges,Implant Device,108.46,34,,108.46,percent of total billed charges,Implant Device,108.46,34,,108.46,percent of total billed charges,Implant Device,108.46,34,,108.46,percent of total billed charges,Implant Device,157.91,,,157.91,Other,110% of Medicare,111.65,35,,111.65,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,111.65,35,,111.65,percent of total billed charges,Implant Device,111.65,35,,111.65,percent of total billed charges,Implant Device,111.65,35,,111.65,percent of total billed charges,Implant Device,111.65,35,,111.65,percent of total billed charges,Implant Device,111.65,35,,111.65,percent of total billed charges,Implant Device,127.6,40,,127.6,percent of total billed charges,Implant Device,111.65,70,,111.65,percent of total billed charges,All Other,108.46,34,,108.46,percent of total billed charges,Implant Device,108.46,34,,108.46,percent of total billed charges,Implant Device,111.65,35,,111.65,percent of total billed charges,Implant Device,111.65,35,,111.65,percent of total billed charges,Implant Device,111.65,35,,111.65,percent of total billed charges,Implant Device,111.65,35,,111.65,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,236.06,
STRYKER 53-23226E BONE SCREW T7 2.3X26MM,C1713,HCPCS,,79001279,CDM,278,RC,,,both,,,319,236.06,,,236.06,Other,150% of Medicare + 9.63% HCRA Surcharge,143.55,45,,143.55,percent of total billed charges,Critical Access Hospital RCC factor,108.46,34,,108.46,percent of total billed charges,Implant Device,108.46,34,,108.46,percent of total billed charges,Implant Device,108.46,34,,108.46,percent of total billed charges,Implant Device,108.46,34,,108.46,percent of total billed charges,Implant Device,108.46,34,,108.46,percent of total billed charges,Implant Device,157.91,,,157.91,Other,110% of Medicare,111.65,35,,111.65,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,111.65,35,,111.65,percent of total billed charges,Implant Device,111.65,35,,111.65,percent of total billed charges,Implant Device,111.65,35,,111.65,percent of total billed charges,Implant Device,111.65,35,,111.65,percent of total billed charges,Implant Device,111.65,35,,111.65,percent of total billed charges,Implant Device,127.6,40,,127.6,percent of total billed charges,Implant Device,111.65,70,,111.65,percent of total billed charges,All Other,108.46,34,,108.46,percent of total billed charges,Implant Device,108.46,34,,108.46,percent of total billed charges,Implant Device,111.65,35,,111.65,percent of total billed charges,Implant Device,111.65,35,,111.65,percent of total billed charges,Implant Device,111.65,35,,111.65,percent of total billed charges,Implant Device,111.65,35,,111.65,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,236.06,
STRYKER 53-27210E BONE SCREW T7 2.7X10MM,C1713,HCPCS,,79001280,CDM,278,RC,,,both,,,331,244.94,,,244.94,Other,150% of Medicare + 9.63% HCRA Surcharge,148.95,45,,148.95,percent of total billed charges,Critical Access Hospital RCC factor,112.54,34,,112.54,percent of total billed charges,Implant Device,112.54,34,,112.54,percent of total billed charges,Implant Device,112.54,34,,112.54,percent of total billed charges,Implant Device,112.54,34,,112.54,percent of total billed charges,Implant Device,112.54,34,,112.54,percent of total billed charges,Implant Device,163.85,,,163.85,Other,110% of Medicare,115.85,35,,115.85,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,115.85,35,,115.85,percent of total billed charges,Implant Device,115.85,35,,115.85,percent of total billed charges,Implant Device,115.85,35,,115.85,percent of total billed charges,Implant Device,115.85,35,,115.85,percent of total billed charges,Implant Device,115.85,35,,115.85,percent of total billed charges,Implant Device,132.4,40,,132.4,percent of total billed charges,Implant Device,115.85,70,,115.85,percent of total billed charges,All Other,112.54,34,,112.54,percent of total billed charges,Implant Device,112.54,34,,112.54,percent of total billed charges,Implant Device,115.85,35,,115.85,percent of total billed charges,Implant Device,115.85,35,,115.85,percent of total billed charges,Implant Device,115.85,35,,115.85,percent of total billed charges,Implant Device,115.85,35,,115.85,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,244.94,
STRYKER 53-27214E BONE SCREW T7 2.7X14MM,C1713,HCPCS,,79001282,CDM,278,RC,,,both,,,190,140.6,,,140.6,Other,150% of Medicare + 9.63% HCRA Surcharge,85.5,45,,85.5,percent of total billed charges,Critical Access Hospital RCC factor,64.6,34,,64.6,percent of total billed charges,Implant Device,64.6,34,,64.6,percent of total billed charges,Implant Device,64.6,34,,64.6,percent of total billed charges,Implant Device,64.6,34,,64.6,percent of total billed charges,Implant Device,64.6,34,,64.6,percent of total billed charges,Implant Device,94.05,,,94.05,Other,110% of Medicare,66.5,35,,66.5,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,66.5,35,,66.5,percent of total billed charges,Implant Device,66.5,35,,66.5,percent of total billed charges,Implant Device,66.5,35,,66.5,percent of total billed charges,Implant Device,66.5,35,,66.5,percent of total billed charges,Implant Device,66.5,35,,66.5,percent of total billed charges,Implant Device,76,40,,76,percent of total billed charges,Implant Device,66.5,70,,66.5,percent of total billed charges,All Other,64.6,34,,64.6,percent of total billed charges,Implant Device,64.6,34,,64.6,percent of total billed charges,Implant Device,66.5,35,,66.5,percent of total billed charges,Implant Device,66.5,35,,66.5,percent of total billed charges,Implant Device,66.5,35,,66.5,percent of total billed charges,Implant Device,66.5,35,,66.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,140.6,
STRYKER 53-27216E BONE SCREW T7 2.7X16MM,C1713,HCPCS,,79001283,CDM,278,RC,,,both,,,234,173.16,,,173.16,Other,150% of Medicare + 9.63% HCRA Surcharge,105.3,45,,105.3,percent of total billed charges,Critical Access Hospital RCC factor,79.56,34,,79.56,percent of total billed charges,Implant Device,79.56,34,,79.56,percent of total billed charges,Implant Device,79.56,34,,79.56,percent of total billed charges,Implant Device,79.56,34,,79.56,percent of total billed charges,Implant Device,79.56,34,,79.56,percent of total billed charges,Implant Device,115.83,,,115.83,Other,110% of Medicare,81.9,35,,81.9,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,81.9,35,,81.9,percent of total billed charges,Implant Device,81.9,35,,81.9,percent of total billed charges,Implant Device,81.9,35,,81.9,percent of total billed charges,Implant Device,81.9,35,,81.9,percent of total billed charges,Implant Device,81.9,35,,81.9,percent of total billed charges,Implant Device,93.6,40,,93.6,percent of total billed charges,Implant Device,81.9,70,,81.9,percent of total billed charges,All Other,79.56,34,,79.56,percent of total billed charges,Implant Device,79.56,34,,79.56,percent of total billed charges,Implant Device,81.9,35,,81.9,percent of total billed charges,Implant Device,81.9,35,,81.9,percent of total billed charges,Implant Device,81.9,35,,81.9,percent of total billed charges,Implant Device,81.9,35,,81.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,173.16,
STRYKER 53-27220E BONE SCREW T7 2.7X20MM,C1713,HCPCS,,79001284,CDM,278,RC,,,both,,,344,254.56,,,254.56,Other,150% of Medicare + 9.63% HCRA Surcharge,154.8,45,,154.8,percent of total billed charges,Critical Access Hospital RCC factor,116.96,34,,116.96,percent of total billed charges,Implant Device,116.96,34,,116.96,percent of total billed charges,Implant Device,116.96,34,,116.96,percent of total billed charges,Implant Device,116.96,34,,116.96,percent of total billed charges,Implant Device,116.96,34,,116.96,percent of total billed charges,Implant Device,170.28,,,170.28,Other,110% of Medicare,120.4,35,,120.4,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,120.4,35,,120.4,percent of total billed charges,Implant Device,120.4,35,,120.4,percent of total billed charges,Implant Device,120.4,35,,120.4,percent of total billed charges,Implant Device,120.4,35,,120.4,percent of total billed charges,Implant Device,120.4,35,,120.4,percent of total billed charges,Implant Device,137.6,40,,137.6,percent of total billed charges,Implant Device,120.4,70,,120.4,percent of total billed charges,All Other,116.96,34,,116.96,percent of total billed charges,Implant Device,116.96,34,,116.96,percent of total billed charges,Implant Device,120.4,35,,120.4,percent of total billed charges,Implant Device,120.4,35,,120.4,percent of total billed charges,Implant Device,120.4,35,,120.4,percent of total billed charges,Implant Device,120.4,35,,120.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,254.56,
STRYKER 53-27224E BONE SCREW T7 2.7X24MM,C1713,HCPCS,,79001285,CDM,278,RC,,,both,,,319,236.06,,,236.06,Other,150% of Medicare + 9.63% HCRA Surcharge,143.55,45,,143.55,percent of total billed charges,Critical Access Hospital RCC factor,108.46,34,,108.46,percent of total billed charges,Implant Device,108.46,34,,108.46,percent of total billed charges,Implant Device,108.46,34,,108.46,percent of total billed charges,Implant Device,108.46,34,,108.46,percent of total billed charges,Implant Device,108.46,34,,108.46,percent of total billed charges,Implant Device,157.91,,,157.91,Other,110% of Medicare,111.65,35,,111.65,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,111.65,35,,111.65,percent of total billed charges,Implant Device,111.65,35,,111.65,percent of total billed charges,Implant Device,111.65,35,,111.65,percent of total billed charges,Implant Device,111.65,35,,111.65,percent of total billed charges,Implant Device,111.65,35,,111.65,percent of total billed charges,Implant Device,127.6,40,,127.6,percent of total billed charges,Implant Device,111.65,70,,111.65,percent of total billed charges,All Other,108.46,34,,108.46,percent of total billed charges,Implant Device,108.46,34,,108.46,percent of total billed charges,Implant Device,111.65,35,,111.65,percent of total billed charges,Implant Device,111.65,35,,111.65,percent of total billed charges,Implant Device,111.65,35,,111.65,percent of total billed charges,Implant Device,111.65,35,,111.65,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,236.06,
STRYKER 53-27226E BONE SCREW T7 2.7X26MM,C1713,HCPCS,,79001286,CDM,278,RC,,,both,,,234,173.16,,,173.16,Other,150% of Medicare + 9.63% HCRA Surcharge,105.3,45,,105.3,percent of total billed charges,Critical Access Hospital RCC factor,79.56,34,,79.56,percent of total billed charges,Implant Device,79.56,34,,79.56,percent of total billed charges,Implant Device,79.56,34,,79.56,percent of total billed charges,Implant Device,79.56,34,,79.56,percent of total billed charges,Implant Device,79.56,34,,79.56,percent of total billed charges,Implant Device,115.83,,,115.83,Other,110% of Medicare,81.9,35,,81.9,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,81.9,35,,81.9,percent of total billed charges,Implant Device,81.9,35,,81.9,percent of total billed charges,Implant Device,81.9,35,,81.9,percent of total billed charges,Implant Device,81.9,35,,81.9,percent of total billed charges,Implant Device,81.9,35,,81.9,percent of total billed charges,Implant Device,93.6,40,,93.6,percent of total billed charges,Implant Device,81.9,70,,81.9,percent of total billed charges,All Other,79.56,34,,79.56,percent of total billed charges,Implant Device,79.56,34,,79.56,percent of total billed charges,Implant Device,81.9,35,,81.9,percent of total billed charges,Implant Device,81.9,35,,81.9,percent of total billed charges,Implant Device,81.9,35,,81.9,percent of total billed charges,Implant Device,81.9,35,,81.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,173.16,
MENTOR 350-1610 BREAST IMPLANT 125CC,C1789,HCPCS,,79001287,CDM,278,RC,,,both,,,1936,1432.64,,,1432.64,Other,150% of Medicare + 9.63% HCRA Surcharge,871.2,45,,871.2,percent of total billed charges,Critical Access Hospital RCC factor,658.24,34,,658.24,percent of total billed charges,Implant Device,658.24,34,,658.24,percent of total billed charges,Implant Device,658.24,34,,658.24,percent of total billed charges,Implant Device,658.24,34,,658.24,percent of total billed charges,Implant Device,658.24,34,,658.24,percent of total billed charges,Implant Device,958.32,,,958.32,Other,110% of Medicare,677.6,35,,677.6,percent of total billed charges,Implant Device,658.24,34,"Charges > $500, x 34%",658.24,percent of total billed charges,Implant Device,677.6,35,,677.6,percent of total billed charges,Implant Device,677.6,35,,677.6,percent of total billed charges,Implant Device,677.6,35,,677.6,percent of total billed charges,Implant Device,677.6,35,,677.6,percent of total billed charges,Implant Device,677.6,35,,677.6,percent of total billed charges,Implant Device,774.4,40,,774.4,percent of total billed charges,Implant Device,677.6,70,,677.6,percent of total billed charges,All Other,658.24,34,,658.24,percent of total billed charges,Implant Device,658.24,34,,658.24,percent of total billed charges,Implant Device,677.6,35,,677.6,percent of total billed charges,Implant Device,677.6,35,,677.6,percent of total billed charges,Implant Device,677.6,35,,677.6,percent of total billed charges,Implant Device,677.6,35,,677.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1432.64,
MENTOR 350-1615 BREAST IMPLANT 150CC,C1789,HCPCS,,79001288,CDM,278,RC,,,both,,,1936,1432.64,,,1432.64,Other,150% of Medicare + 9.63% HCRA Surcharge,871.2,45,,871.2,percent of total billed charges,Critical Access Hospital RCC factor,658.24,34,,658.24,percent of total billed charges,Implant Device,658.24,34,,658.24,percent of total billed charges,Implant Device,658.24,34,,658.24,percent of total billed charges,Implant Device,658.24,34,,658.24,percent of total billed charges,Implant Device,658.24,34,,658.24,percent of total billed charges,Implant Device,958.32,,,958.32,Other,110% of Medicare,677.6,35,,677.6,percent of total billed charges,Implant Device,658.24,34,"Charges > $500, x 34%",658.24,percent of total billed charges,Implant Device,677.6,35,,677.6,percent of total billed charges,Implant Device,677.6,35,,677.6,percent of total billed charges,Implant Device,677.6,35,,677.6,percent of total billed charges,Implant Device,677.6,35,,677.6,percent of total billed charges,Implant Device,677.6,35,,677.6,percent of total billed charges,Implant Device,774.4,40,,774.4,percent of total billed charges,Implant Device,677.6,70,,677.6,percent of total billed charges,All Other,658.24,34,,658.24,percent of total billed charges,Implant Device,658.24,34,,658.24,percent of total billed charges,Implant Device,677.6,35,,677.6,percent of total billed charges,Implant Device,677.6,35,,677.6,percent of total billed charges,Implant Device,677.6,35,,677.6,percent of total billed charges,Implant Device,677.6,35,,677.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1432.64,
MENTOR 350-1630 BREAST IMPLANT 225CC,C1789,HCPCS,,79001289,CDM,278,RC,,,both,,,1876,1388.24,,,1388.24,Other,150% of Medicare + 9.63% HCRA Surcharge,844.2,45,,844.2,percent of total billed charges,Critical Access Hospital RCC factor,637.84,34,,637.84,percent of total billed charges,Implant Device,637.84,34,,637.84,percent of total billed charges,Implant Device,637.84,34,,637.84,percent of total billed charges,Implant Device,637.84,34,,637.84,percent of total billed charges,Implant Device,637.84,34,,637.84,percent of total billed charges,Implant Device,928.62,,,928.62,Other,110% of Medicare,656.6,35,,656.6,percent of total billed charges,Implant Device,637.84,34,"Charges > $500, x 34%",637.84,percent of total billed charges,Implant Device,656.6,35,,656.6,percent of total billed charges,Implant Device,656.6,35,,656.6,percent of total billed charges,Implant Device,656.6,35,,656.6,percent of total billed charges,Implant Device,656.6,35,,656.6,percent of total billed charges,Implant Device,656.6,35,,656.6,percent of total billed charges,Implant Device,750.4,40,,750.4,percent of total billed charges,Implant Device,656.6,70,,656.6,percent of total billed charges,All Other,637.84,34,,637.84,percent of total billed charges,Implant Device,637.84,34,,637.84,percent of total billed charges,Implant Device,656.6,35,,656.6,percent of total billed charges,Implant Device,656.6,35,,656.6,percent of total billed charges,Implant Device,656.6,35,,656.6,percent of total billed charges,Implant Device,656.6,35,,656.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1388.24,
MENTOR 350-2225 BREAST IMPLANT 225CC,C1789,HCPCS,,79001290,CDM,278,RC,,,both,,,2010,1487.41,,,1487.41,Other,150% of Medicare + 9.63% HCRA Surcharge,904.5,45,,904.5,percent of total billed charges,Critical Access Hospital RCC factor,683.4,34,,683.4,percent of total billed charges,Implant Device,683.4,34,,683.4,percent of total billed charges,Implant Device,683.4,34,,683.4,percent of total billed charges,Implant Device,683.4,34,,683.4,percent of total billed charges,Implant Device,683.4,34,,683.4,percent of total billed charges,Implant Device,994.95,,,994.95,Other,110% of Medicare,703.5,35,,703.5,percent of total billed charges,Implant Device,683.4,34,"Charges > $500, x 34%",683.4,percent of total billed charges,Implant Device,703.5,35,,703.5,percent of total billed charges,Implant Device,703.5,35,,703.5,percent of total billed charges,Implant Device,703.5,35,,703.5,percent of total billed charges,Implant Device,703.5,35,,703.5,percent of total billed charges,Implant Device,703.5,35,,703.5,percent of total billed charges,Implant Device,804,40,,804,percent of total billed charges,Implant Device,703.5,70,,703.5,percent of total billed charges,All Other,683.4,34,,683.4,percent of total billed charges,Implant Device,683.4,34,,683.4,percent of total billed charges,Implant Device,703.5,35,,703.5,percent of total billed charges,Implant Device,703.5,35,,703.5,percent of total billed charges,Implant Device,703.5,35,,703.5,percent of total billed charges,Implant Device,703.5,35,,703.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,683.4,34,"If Charge > 2,000, then 34 percent",683.4,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1487.41,
MENTOR 350-3230 BREAST IMPLANT 230CC,C1789,HCPCS,,79001291,CDM,278,RC,,,both,,,1950,1443,,,1443,Other,150% of Medicare + 9.63% HCRA Surcharge,877.5,45,,877.5,percent of total billed charges,Critical Access Hospital RCC factor,663,34,,663,percent of total billed charges,Implant Device,663,34,,663,percent of total billed charges,Implant Device,663,34,,663,percent of total billed charges,Implant Device,663,34,,663,percent of total billed charges,Implant Device,663,34,,663,percent of total billed charges,Implant Device,965.25,,,965.25,Other,110% of Medicare,682.5,35,,682.5,percent of total billed charges,Implant Device,663,34,"Charges > $500, x 34%",663,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,780,40,,780,percent of total billed charges,Implant Device,682.5,70,,682.5,percent of total billed charges,All Other,663,34,,663,percent of total billed charges,Implant Device,663,34,,663,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1443,
MENTOR 350-2275 BREAST IMPLANT 275CC,C1789,HCPCS,,79001292,CDM,278,RC,,,both,,,2010,1487.41,,,1487.41,Other,150% of Medicare + 9.63% HCRA Surcharge,904.5,45,,904.5,percent of total billed charges,Critical Access Hospital RCC factor,683.4,34,,683.4,percent of total billed charges,Implant Device,683.4,34,,683.4,percent of total billed charges,Implant Device,683.4,34,,683.4,percent of total billed charges,Implant Device,683.4,34,,683.4,percent of total billed charges,Implant Device,683.4,34,,683.4,percent of total billed charges,Implant Device,994.95,,,994.95,Other,110% of Medicare,703.5,35,,703.5,percent of total billed charges,Implant Device,683.4,34,"Charges > $500, x 34%",683.4,percent of total billed charges,Implant Device,703.5,35,,703.5,percent of total billed charges,Implant Device,703.5,35,,703.5,percent of total billed charges,Implant Device,703.5,35,,703.5,percent of total billed charges,Implant Device,703.5,35,,703.5,percent of total billed charges,Implant Device,703.5,35,,703.5,percent of total billed charges,Implant Device,804,40,,804,percent of total billed charges,Implant Device,703.5,70,,703.5,percent of total billed charges,All Other,683.4,34,,683.4,percent of total billed charges,Implant Device,683.4,34,,683.4,percent of total billed charges,Implant Device,703.5,35,,703.5,percent of total billed charges,Implant Device,703.5,35,,703.5,percent of total billed charges,Implant Device,703.5,35,,703.5,percent of total billed charges,Implant Device,703.5,35,,703.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,683.4,34,"If Charge > 2,000, then 34 percent",683.4,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1487.41,
MENTOR 350-3330 BREAST IMPLANT 330CC,C1789,HCPCS,,79001293,CDM,278,RC,,,both,,,1950,1443,,,1443,Other,150% of Medicare + 9.63% HCRA Surcharge,877.5,45,,877.5,percent of total billed charges,Critical Access Hospital RCC factor,663,34,,663,percent of total billed charges,Implant Device,663,34,,663,percent of total billed charges,Implant Device,663,34,,663,percent of total billed charges,Implant Device,663,34,,663,percent of total billed charges,Implant Device,663,34,,663,percent of total billed charges,Implant Device,965.25,,,965.25,Other,110% of Medicare,682.5,35,,682.5,percent of total billed charges,Implant Device,663,34,"Charges > $500, x 34%",663,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,780,40,,780,percent of total billed charges,Implant Device,682.5,70,,682.5,percent of total billed charges,All Other,663,34,,663,percent of total billed charges,Implant Device,663,34,,663,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1443,
MENTOR 354-2512 BREAST IMPLANT 350CC,C1789,HCPCS,,79001294,CDM,278,RC,,,both,,,3676,2720.25,,,2720.25,Other,150% of Medicare + 9.63% HCRA Surcharge,1654.2,45,,1654.2,percent of total billed charges,Critical Access Hospital RCC factor,1249.84,34,,1249.84,percent of total billed charges,Implant Device,1249.84,34,,1249.84,percent of total billed charges,Implant Device,1249.84,34,,1249.84,percent of total billed charges,Implant Device,1249.84,34,,1249.84,percent of total billed charges,Implant Device,1249.84,34,,1249.84,percent of total billed charges,Implant Device,1819.62,,,1819.62,Other,110% of Medicare,1286.6,35,,1286.6,percent of total billed charges,Implant Device,1249.84,34,"Charges > $500, x 34%",1249.84,percent of total billed charges,Implant Device,1286.6,35,,1286.6,percent of total billed charges,Implant Device,1286.6,35,,1286.6,percent of total billed charges,Implant Device,1286.6,35,,1286.6,percent of total billed charges,Implant Device,1286.6,35,,1286.6,percent of total billed charges,Implant Device,1286.6,35,,1286.6,percent of total billed charges,Implant Device,1470.4,40,,1470.4,percent of total billed charges,Implant Device,1286.6,70,,1286.6,percent of total billed charges,All Other,1249.84,34,,1249.84,percent of total billed charges,Implant Device,1249.84,34,,1249.84,percent of total billed charges,Implant Device,1286.6,35,,1286.6,percent of total billed charges,Implant Device,1286.6,35,,1286.6,percent of total billed charges,Implant Device,1286.6,35,,1286.6,percent of total billed charges,Implant Device,1286.6,35,,1286.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1249.84,34,"If Charge > 2,000, then 34 percent",1249.84,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2720.25,
MENTOR 354-6212 BREAST IMPLANT 350CC,C1789,HCPCS,,79001295,CDM,278,RC,,,both,,,4276,3164.25,,,3164.25,Other,150% of Medicare + 9.63% HCRA Surcharge,1924.2,45,,1924.2,percent of total billed charges,Critical Access Hospital RCC factor,1453.84,34,,1453.84,percent of total billed charges,Implant Device,1453.84,34,,1453.84,percent of total billed charges,Implant Device,1453.84,34,,1453.84,percent of total billed charges,Implant Device,1453.84,34,,1453.84,percent of total billed charges,Implant Device,1453.84,34,,1453.84,percent of total billed charges,Implant Device,2116.62,,,2116.62,Other,110% of Medicare,1496.6,35,,1496.6,percent of total billed charges,Implant Device,1453.84,34,"Charges > $500, x 34%",1453.84,percent of total billed charges,Implant Device,1496.6,35,,1496.6,percent of total billed charges,Implant Device,1496.6,35,,1496.6,percent of total billed charges,Implant Device,1496.6,35,,1496.6,percent of total billed charges,Implant Device,1496.6,35,,1496.6,percent of total billed charges,Implant Device,1496.6,35,,1496.6,percent of total billed charges,Implant Device,1710.4,40,,1710.4,percent of total billed charges,Implant Device,1496.6,70,,1496.6,percent of total billed charges,All Other,1453.84,34,,1453.84,percent of total billed charges,Implant Device,1453.84,34,,1453.84,percent of total billed charges,Implant Device,1496.6,35,,1496.6,percent of total billed charges,Implant Device,1496.6,35,,1496.6,percent of total billed charges,Implant Device,1496.6,35,,1496.6,percent of total billed charges,Implant Device,1496.6,35,,1496.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1453.84,34,"If Charge > 2,000, then 34 percent",1453.84,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3164.25,
MENTOR 354-7212 BREAST IMPLANT 350CC,C1789,HCPCS,,79001296,CDM,278,RC,,,both,,,4650,3441.01,,,3441.01,Other,150% of Medicare + 9.63% HCRA Surcharge,2092.5,45,,2092.5,percent of total billed charges,Critical Access Hospital RCC factor,1581,34,,1581,percent of total billed charges,Implant Device,1581,34,,1581,percent of total billed charges,Implant Device,1581,34,,1581,percent of total billed charges,Implant Device,1581,34,,1581,percent of total billed charges,Implant Device,1581,34,,1581,percent of total billed charges,Implant Device,2301.75,,,2301.75,Other,110% of Medicare,1627.5,35,,1627.5,percent of total billed charges,Implant Device,1581,34,"Charges > $500, x 34%",1581,percent of total billed charges,Implant Device,1627.5,35,,1627.5,percent of total billed charges,Implant Device,1627.5,35,,1627.5,percent of total billed charges,Implant Device,1627.5,35,,1627.5,percent of total billed charges,Implant Device,1627.5,35,,1627.5,percent of total billed charges,Implant Device,1627.5,35,,1627.5,percent of total billed charges,Implant Device,1860,40,,1860,percent of total billed charges,Implant Device,1627.5,70,,1627.5,percent of total billed charges,All Other,1581,34,,1581,percent of total billed charges,Implant Device,1581,34,,1581,percent of total billed charges,Implant Device,1627.5,35,,1627.5,percent of total billed charges,Implant Device,1627.5,35,,1627.5,percent of total billed charges,Implant Device,1627.5,35,,1627.5,percent of total billed charges,Implant Device,1627.5,35,,1627.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1581,34,"If Charge > 2,000, then 34 percent",1581,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3441.01,
MENTOR 350-1460 BREAST IMPLANT 375CC,C1789,HCPCS,,79001297,CDM,278,RC,,,both,,,2550,1887.01,,,1887.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1147.5,45,,1147.5,percent of total billed charges,Critical Access Hospital RCC factor,867,34,,867,percent of total billed charges,Implant Device,867,34,,867,percent of total billed charges,Implant Device,867,34,,867,percent of total billed charges,Implant Device,867,34,,867,percent of total billed charges,Implant Device,867,34,,867,percent of total billed charges,Implant Device,1262.25,,,1262.25,Other,110% of Medicare,892.5,35,,892.5,percent of total billed charges,Implant Device,867,34,"Charges > $500, x 34%",867,percent of total billed charges,Implant Device,892.5,35,,892.5,percent of total billed charges,Implant Device,892.5,35,,892.5,percent of total billed charges,Implant Device,892.5,35,,892.5,percent of total billed charges,Implant Device,892.5,35,,892.5,percent of total billed charges,Implant Device,892.5,35,,892.5,percent of total billed charges,Implant Device,1020,40,,1020,percent of total billed charges,Implant Device,892.5,70,,892.5,percent of total billed charges,All Other,867,34,,867,percent of total billed charges,Implant Device,867,34,,867,percent of total billed charges,Implant Device,892.5,35,,892.5,percent of total billed charges,Implant Device,892.5,35,,892.5,percent of total billed charges,Implant Device,892.5,35,,892.5,percent of total billed charges,Implant Device,892.5,35,,892.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,867,34,"If Charge > 2,000, then 34 percent",867,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1887.01,
MENTOR 350-3420 BREAST IMPLANT 420CC,C1789,HCPCS,,79001298,CDM,278,RC,,,both,,,1950,1443,,,1443,Other,150% of Medicare + 9.63% HCRA Surcharge,877.5,45,,877.5,percent of total billed charges,Critical Access Hospital RCC factor,663,34,,663,percent of total billed charges,Implant Device,663,34,,663,percent of total billed charges,Implant Device,663,34,,663,percent of total billed charges,Implant Device,663,34,,663,percent of total billed charges,Implant Device,663,34,,663,percent of total billed charges,Implant Device,965.25,,,965.25,Other,110% of Medicare,682.5,35,,682.5,percent of total billed charges,Implant Device,663,34,"Charges > $500, x 34%",663,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,780,40,,780,percent of total billed charges,Implant Device,682.5,70,,682.5,percent of total billed charges,All Other,663,34,,663,percent of total billed charges,Implant Device,663,34,,663,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1443,
MENTOR 354-2513 BREAST IMPLANT 450CC,C1789,HCPCS,,79001299,CDM,278,RC,,,both,,,3676,2720.25,,,2720.25,Other,150% of Medicare + 9.63% HCRA Surcharge,1654.2,45,,1654.2,percent of total billed charges,Critical Access Hospital RCC factor,1249.84,34,,1249.84,percent of total billed charges,Implant Device,1249.84,34,,1249.84,percent of total billed charges,Implant Device,1249.84,34,,1249.84,percent of total billed charges,Implant Device,1249.84,34,,1249.84,percent of total billed charges,Implant Device,1249.84,34,,1249.84,percent of total billed charges,Implant Device,1819.62,,,1819.62,Other,110% of Medicare,1286.6,35,,1286.6,percent of total billed charges,Implant Device,1249.84,34,"Charges > $500, x 34%",1249.84,percent of total billed charges,Implant Device,1286.6,35,,1286.6,percent of total billed charges,Implant Device,1286.6,35,,1286.6,percent of total billed charges,Implant Device,1286.6,35,,1286.6,percent of total billed charges,Implant Device,1286.6,35,,1286.6,percent of total billed charges,Implant Device,1286.6,35,,1286.6,percent of total billed charges,Implant Device,1470.4,40,,1470.4,percent of total billed charges,Implant Device,1286.6,70,,1286.6,percent of total billed charges,All Other,1249.84,34,,1249.84,percent of total billed charges,Implant Device,1249.84,34,,1249.84,percent of total billed charges,Implant Device,1286.6,35,,1286.6,percent of total billed charges,Implant Device,1286.6,35,,1286.6,percent of total billed charges,Implant Device,1286.6,35,,1286.6,percent of total billed charges,Implant Device,1286.6,35,,1286.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1249.84,34,"If Charge > 2,000, then 34 percent",1249.84,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2720.25,
MENTOR 354-6213 BREAST IMPLANT 450CC,C1789,HCPCS,,79001300,CDM,278,RC,,,both,,,4276,3164.25,,,3164.25,Other,150% of Medicare + 9.63% HCRA Surcharge,1924.2,45,,1924.2,percent of total billed charges,Critical Access Hospital RCC factor,1453.84,34,,1453.84,percent of total billed charges,Implant Device,1453.84,34,,1453.84,percent of total billed charges,Implant Device,1453.84,34,,1453.84,percent of total billed charges,Implant Device,1453.84,34,,1453.84,percent of total billed charges,Implant Device,1453.84,34,,1453.84,percent of total billed charges,Implant Device,2116.62,,,2116.62,Other,110% of Medicare,1496.6,35,,1496.6,percent of total billed charges,Implant Device,1453.84,34,"Charges > $500, x 34%",1453.84,percent of total billed charges,Implant Device,1496.6,35,,1496.6,percent of total billed charges,Implant Device,1496.6,35,,1496.6,percent of total billed charges,Implant Device,1496.6,35,,1496.6,percent of total billed charges,Implant Device,1496.6,35,,1496.6,percent of total billed charges,Implant Device,1496.6,35,,1496.6,percent of total billed charges,Implant Device,1710.4,40,,1710.4,percent of total billed charges,Implant Device,1496.6,70,,1496.6,percent of total billed charges,All Other,1453.84,34,,1453.84,percent of total billed charges,Implant Device,1453.84,34,,1453.84,percent of total billed charges,Implant Device,1496.6,35,,1496.6,percent of total billed charges,Implant Device,1496.6,35,,1496.6,percent of total billed charges,Implant Device,1496.6,35,,1496.6,percent of total billed charges,Implant Device,1496.6,35,,1496.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1453.84,34,"If Charge > 2,000, then 34 percent",1453.84,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3164.25,
MENTOR 354-7213 BREAST IMPLANT 450CC,C1789,HCPCS,,79001301,CDM,278,RC,,,both,,,4650,3441.01,,,3441.01,Other,150% of Medicare + 9.63% HCRA Surcharge,2092.5,45,,2092.5,percent of total billed charges,Critical Access Hospital RCC factor,1581,34,,1581,percent of total billed charges,Implant Device,1581,34,,1581,percent of total billed charges,Implant Device,1581,34,,1581,percent of total billed charges,Implant Device,1581,34,,1581,percent of total billed charges,Implant Device,1581,34,,1581,percent of total billed charges,Implant Device,2301.75,,,2301.75,Other,110% of Medicare,1627.5,35,,1627.5,percent of total billed charges,Implant Device,1581,34,"Charges > $500, x 34%",1581,percent of total billed charges,Implant Device,1627.5,35,,1627.5,percent of total billed charges,Implant Device,1627.5,35,,1627.5,percent of total billed charges,Implant Device,1627.5,35,,1627.5,percent of total billed charges,Implant Device,1627.5,35,,1627.5,percent of total billed charges,Implant Device,1627.5,35,,1627.5,percent of total billed charges,Implant Device,1860,40,,1860,percent of total billed charges,Implant Device,1627.5,70,,1627.5,percent of total billed charges,All Other,1581,34,,1581,percent of total billed charges,Implant Device,1581,34,,1581,percent of total billed charges,Implant Device,1627.5,35,,1627.5,percent of total billed charges,Implant Device,1627.5,35,,1627.5,percent of total billed charges,Implant Device,1627.5,35,,1627.5,percent of total billed charges,Implant Device,1627.5,35,,1627.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1581,34,"If Charge > 2,000, then 34 percent",1581,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3441.01,
MENTOR 354-2514 BREAST IMPLANT 550CC,C1789,HCPCS,,79001302,CDM,278,RC,,,both,,,3676,2720.25,,,2720.25,Other,150% of Medicare + 9.63% HCRA Surcharge,1654.2,45,,1654.2,percent of total billed charges,Critical Access Hospital RCC factor,1249.84,34,,1249.84,percent of total billed charges,Implant Device,1249.84,34,,1249.84,percent of total billed charges,Implant Device,1249.84,34,,1249.84,percent of total billed charges,Implant Device,1249.84,34,,1249.84,percent of total billed charges,Implant Device,1249.84,34,,1249.84,percent of total billed charges,Implant Device,1819.62,,,1819.62,Other,110% of Medicare,1286.6,35,,1286.6,percent of total billed charges,Implant Device,1249.84,34,"Charges > $500, x 34%",1249.84,percent of total billed charges,Implant Device,1286.6,35,,1286.6,percent of total billed charges,Implant Device,1286.6,35,,1286.6,percent of total billed charges,Implant Device,1286.6,35,,1286.6,percent of total billed charges,Implant Device,1286.6,35,,1286.6,percent of total billed charges,Implant Device,1286.6,35,,1286.6,percent of total billed charges,Implant Device,1470.4,40,,1470.4,percent of total billed charges,Implant Device,1286.6,70,,1286.6,percent of total billed charges,All Other,1249.84,34,,1249.84,percent of total billed charges,Implant Device,1249.84,34,,1249.84,percent of total billed charges,Implant Device,1286.6,35,,1286.6,percent of total billed charges,Implant Device,1286.6,35,,1286.6,percent of total billed charges,Implant Device,1286.6,35,,1286.6,percent of total billed charges,Implant Device,1286.6,35,,1286.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1249.84,34,"If Charge > 2,000, then 34 percent",1249.84,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2720.25,
MENTOR 354-6214 BREAST IMPLANT 550CC,C1789,HCPCS,,79001303,CDM,278,RC,,,both,,,4276,3164.25,,,3164.25,Other,150% of Medicare + 9.63% HCRA Surcharge,1924.2,45,,1924.2,percent of total billed charges,Critical Access Hospital RCC factor,1453.84,34,,1453.84,percent of total billed charges,Implant Device,1453.84,34,,1453.84,percent of total billed charges,Implant Device,1453.84,34,,1453.84,percent of total billed charges,Implant Device,1453.84,34,,1453.84,percent of total billed charges,Implant Device,1453.84,34,,1453.84,percent of total billed charges,Implant Device,2116.62,,,2116.62,Other,110% of Medicare,1496.6,35,,1496.6,percent of total billed charges,Implant Device,1453.84,34,"Charges > $500, x 34%",1453.84,percent of total billed charges,Implant Device,1496.6,35,,1496.6,percent of total billed charges,Implant Device,1496.6,35,,1496.6,percent of total billed charges,Implant Device,1496.6,35,,1496.6,percent of total billed charges,Implant Device,1496.6,35,,1496.6,percent of total billed charges,Implant Device,1496.6,35,,1496.6,percent of total billed charges,Implant Device,1710.4,40,,1710.4,percent of total billed charges,Implant Device,1496.6,70,,1496.6,percent of total billed charges,All Other,1453.84,34,,1453.84,percent of total billed charges,Implant Device,1453.84,34,,1453.84,percent of total billed charges,Implant Device,1496.6,35,,1496.6,percent of total billed charges,Implant Device,1496.6,35,,1496.6,percent of total billed charges,Implant Device,1496.6,35,,1496.6,percent of total billed charges,Implant Device,1496.6,35,,1496.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1453.84,34,"If Charge > 2,000, then 34 percent",1453.84,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3164.25,
MENTOR 354-7214 BREAST IMPLANT 550CC,C1789,HCPCS,,79001304,CDM,278,RC,,,both,,,4650,3441.01,,,3441.01,Other,150% of Medicare + 9.63% HCRA Surcharge,2092.5,45,,2092.5,percent of total billed charges,Critical Access Hospital RCC factor,1581,34,,1581,percent of total billed charges,Implant Device,1581,34,,1581,percent of total billed charges,Implant Device,1581,34,,1581,percent of total billed charges,Implant Device,1581,34,,1581,percent of total billed charges,Implant Device,1581,34,,1581,percent of total billed charges,Implant Device,2301.75,,,2301.75,Other,110% of Medicare,1627.5,35,,1627.5,percent of total billed charges,Implant Device,1581,34,"Charges > $500, x 34%",1581,percent of total billed charges,Implant Device,1627.5,35,,1627.5,percent of total billed charges,Implant Device,1627.5,35,,1627.5,percent of total billed charges,Implant Device,1627.5,35,,1627.5,percent of total billed charges,Implant Device,1627.5,35,,1627.5,percent of total billed charges,Implant Device,1627.5,35,,1627.5,percent of total billed charges,Implant Device,1860,40,,1860,percent of total billed charges,Implant Device,1627.5,70,,1627.5,percent of total billed charges,All Other,1581,34,,1581,percent of total billed charges,Implant Device,1581,34,,1581,percent of total billed charges,Implant Device,1627.5,35,,1627.5,percent of total billed charges,Implant Device,1627.5,35,,1627.5,percent of total billed charges,Implant Device,1627.5,35,,1627.5,percent of total billed charges,Implant Device,1627.5,35,,1627.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1581,34,"If Charge > 2,000, then 34 percent",1581,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3441.01,
MENTOR 354-2515 BREAST IMPLANT 650CC,C1789,HCPCS,,79001305,CDM,278,RC,,,both,,,3676,2720.25,,,2720.25,Other,150% of Medicare + 9.63% HCRA Surcharge,1654.2,45,,1654.2,percent of total billed charges,Critical Access Hospital RCC factor,1249.84,34,,1249.84,percent of total billed charges,Implant Device,1249.84,34,,1249.84,percent of total billed charges,Implant Device,1249.84,34,,1249.84,percent of total billed charges,Implant Device,1249.84,34,,1249.84,percent of total billed charges,Implant Device,1249.84,34,,1249.84,percent of total billed charges,Implant Device,1819.62,,,1819.62,Other,110% of Medicare,1286.6,35,,1286.6,percent of total billed charges,Implant Device,1249.84,34,"Charges > $500, x 34%",1249.84,percent of total billed charges,Implant Device,1286.6,35,,1286.6,percent of total billed charges,Implant Device,1286.6,35,,1286.6,percent of total billed charges,Implant Device,1286.6,35,,1286.6,percent of total billed charges,Implant Device,1286.6,35,,1286.6,percent of total billed charges,Implant Device,1286.6,35,,1286.6,percent of total billed charges,Implant Device,1470.4,40,,1470.4,percent of total billed charges,Implant Device,1286.6,70,,1286.6,percent of total billed charges,All Other,1249.84,34,,1249.84,percent of total billed charges,Implant Device,1249.84,34,,1249.84,percent of total billed charges,Implant Device,1286.6,35,,1286.6,percent of total billed charges,Implant Device,1286.6,35,,1286.6,percent of total billed charges,Implant Device,1286.6,35,,1286.6,percent of total billed charges,Implant Device,1286.6,35,,1286.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1249.84,34,"If Charge > 2,000, then 34 percent",1249.84,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2720.25,
MENTOR 354-6215 BREAST IMPLANT 650CC,C1789,HCPCS,,79001306,CDM,278,RC,,,both,,,4276,3164.25,,,3164.25,Other,150% of Medicare + 9.63% HCRA Surcharge,1924.2,45,,1924.2,percent of total billed charges,Critical Access Hospital RCC factor,1453.84,34,,1453.84,percent of total billed charges,Implant Device,1453.84,34,,1453.84,percent of total billed charges,Implant Device,1453.84,34,,1453.84,percent of total billed charges,Implant Device,1453.84,34,,1453.84,percent of total billed charges,Implant Device,1453.84,34,,1453.84,percent of total billed charges,Implant Device,2116.62,,,2116.62,Other,110% of Medicare,1496.6,35,,1496.6,percent of total billed charges,Implant Device,1453.84,34,"Charges > $500, x 34%",1453.84,percent of total billed charges,Implant Device,1496.6,35,,1496.6,percent of total billed charges,Implant Device,1496.6,35,,1496.6,percent of total billed charges,Implant Device,1496.6,35,,1496.6,percent of total billed charges,Implant Device,1496.6,35,,1496.6,percent of total billed charges,Implant Device,1496.6,35,,1496.6,percent of total billed charges,Implant Device,1710.4,40,,1710.4,percent of total billed charges,Implant Device,1496.6,70,,1496.6,percent of total billed charges,All Other,1453.84,34,,1453.84,percent of total billed charges,Implant Device,1453.84,34,,1453.84,percent of total billed charges,Implant Device,1496.6,35,,1496.6,percent of total billed charges,Implant Device,1496.6,35,,1496.6,percent of total billed charges,Implant Device,1496.6,35,,1496.6,percent of total billed charges,Implant Device,1496.6,35,,1496.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1453.84,34,"If Charge > 2,000, then 34 percent",1453.84,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3164.25,
MENTOR 354-7215 BREAST IMPLANT 650CC,C1789,HCPCS,,79001307,CDM,278,RC,,,both,,,4650,3441.01,,,3441.01,Other,150% of Medicare + 9.63% HCRA Surcharge,2092.5,45,,2092.5,percent of total billed charges,Critical Access Hospital RCC factor,1581,34,,1581,percent of total billed charges,Implant Device,1581,34,,1581,percent of total billed charges,Implant Device,1581,34,,1581,percent of total billed charges,Implant Device,1581,34,,1581,percent of total billed charges,Implant Device,1581,34,,1581,percent of total billed charges,Implant Device,2301.75,,,2301.75,Other,110% of Medicare,1627.5,35,,1627.5,percent of total billed charges,Implant Device,1581,34,"Charges > $500, x 34%",1581,percent of total billed charges,Implant Device,1627.5,35,,1627.5,percent of total billed charges,Implant Device,1627.5,35,,1627.5,percent of total billed charges,Implant Device,1627.5,35,,1627.5,percent of total billed charges,Implant Device,1627.5,35,,1627.5,percent of total billed charges,Implant Device,1627.5,35,,1627.5,percent of total billed charges,Implant Device,1860,40,,1860,percent of total billed charges,Implant Device,1627.5,70,,1627.5,percent of total billed charges,All Other,1581,34,,1581,percent of total billed charges,Implant Device,1581,34,,1581,percent of total billed charges,Implant Device,1627.5,35,,1627.5,percent of total billed charges,Implant Device,1627.5,35,,1627.5,percent of total billed charges,Implant Device,1627.5,35,,1627.5,percent of total billed charges,Implant Device,1627.5,35,,1627.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1581,34,"If Charge > 2,000, then 34 percent",1581,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3441.01,
BIOMET 1974503 BURR HOLE PLATE 13MM,C1713,HCPCS,,79001308,CDM,278,RC,,,both,,,574,424.76,,,424.76,Other,150% of Medicare + 9.63% HCRA Surcharge,258.3,45,,258.3,percent of total billed charges,Critical Access Hospital RCC factor,195.16,34,,195.16,percent of total billed charges,Implant Device,195.16,34,,195.16,percent of total billed charges,Implant Device,195.16,34,,195.16,percent of total billed charges,Implant Device,195.16,34,,195.16,percent of total billed charges,Implant Device,195.16,34,,195.16,percent of total billed charges,Implant Device,284.13,,,284.13,Other,110% of Medicare,200.9,35,,200.9,percent of total billed charges,Implant Device,195.16,34,"Charges > $500, x 34%",195.16,percent of total billed charges,Implant Device,200.9,35,,200.9,percent of total billed charges,Implant Device,200.9,35,,200.9,percent of total billed charges,Implant Device,200.9,35,,200.9,percent of total billed charges,Implant Device,200.9,35,,200.9,percent of total billed charges,Implant Device,200.9,35,,200.9,percent of total billed charges,Implant Device,229.6,40,,229.6,percent of total billed charges,Implant Device,200.9,70,,200.9,percent of total billed charges,All Other,195.16,34,,195.16,percent of total billed charges,Implant Device,195.16,34,,195.16,percent of total billed charges,Implant Device,200.9,35,,200.9,percent of total billed charges,Implant Device,200.9,35,,200.9,percent of total billed charges,Implant Device,200.9,35,,200.9,percent of total billed charges,Implant Device,200.9,35,,200.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,424.76,
BIOMET 1975233 BURR HOLE PLATE 18.5MM,C1713,HCPCS,,79001309,CDM,278,RC,,,both,,,960,710.4,,,710.4,Other,150% of Medicare + 9.63% HCRA Surcharge,432,45,,432,percent of total billed charges,Critical Access Hospital RCC factor,326.4,34,,326.4,percent of total billed charges,Implant Device,326.4,34,,326.4,percent of total billed charges,Implant Device,326.4,34,,326.4,percent of total billed charges,Implant Device,326.4,34,,326.4,percent of total billed charges,Implant Device,326.4,34,,326.4,percent of total billed charges,Implant Device,475.2,,,475.2,Other,110% of Medicare,336,35,,336,percent of total billed charges,Implant Device,326.4,34,"Charges > $500, x 34%",326.4,percent of total billed charges,Implant Device,336,35,,336,percent of total billed charges,Implant Device,336,35,,336,percent of total billed charges,Implant Device,336,35,,336,percent of total billed charges,Implant Device,336,35,,336,percent of total billed charges,Implant Device,336,35,,336,percent of total billed charges,Implant Device,384,40,,384,percent of total billed charges,Implant Device,336,70,,336,percent of total billed charges,All Other,326.4,34,,326.4,percent of total billed charges,Implant Device,326.4,34,,326.4,percent of total billed charges,Implant Device,336,35,,336,percent of total billed charges,Implant Device,336,35,,336,percent of total billed charges,Implant Device,336,35,,336,percent of total billed charges,Implant Device,336,35,,336,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,710.4,
BIOMET 45-1405 CANCELLOUS CHIPS 30CC,C1713,HCPCS,,79001310,CDM,278,RC,,,both,,,1278,945.72,,,945.72,Other,150% of Medicare + 9.63% HCRA Surcharge,575.1,45,,575.1,percent of total billed charges,Critical Access Hospital RCC factor,434.52,34,,434.52,percent of total billed charges,Implant Device,434.52,34,,434.52,percent of total billed charges,Implant Device,434.52,34,,434.52,percent of total billed charges,Implant Device,434.52,34,,434.52,percent of total billed charges,Implant Device,434.52,34,,434.52,percent of total billed charges,Implant Device,632.61,,,632.61,Other,110% of Medicare,447.3,35,,447.3,percent of total billed charges,Implant Device,434.52,34,"Charges > $500, x 34%",434.52,percent of total billed charges,Implant Device,447.3,35,,447.3,percent of total billed charges,Implant Device,447.3,35,,447.3,percent of total billed charges,Implant Device,447.3,35,,447.3,percent of total billed charges,Implant Device,447.3,35,,447.3,percent of total billed charges,Implant Device,447.3,35,,447.3,percent of total billed charges,Implant Device,511.2,40,,511.2,percent of total billed charges,Implant Device,447.3,70,,447.3,percent of total billed charges,All Other,434.52,34,,434.52,percent of total billed charges,Implant Device,434.52,34,,434.52,percent of total billed charges,Implant Device,447.3,35,,447.3,percent of total billed charges,Implant Device,447.3,35,,447.3,percent of total billed charges,Implant Device,447.3,35,,447.3,percent of total billed charges,Implant Device,447.3,35,,447.3,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,945.72,
BIOMET SPINE 1595 CANCELLOUS CHIPS 60CC,C1713,HCPCS,,79001311,CDM,278,RC,,,both,,,2196,1625.05,,,1625.05,Other,150% of Medicare + 9.63% HCRA Surcharge,988.2,45,,988.2,percent of total billed charges,Critical Access Hospital RCC factor,746.64,34,,746.64,percent of total billed charges,Implant Device,746.64,34,,746.64,percent of total billed charges,Implant Device,746.64,34,,746.64,percent of total billed charges,Implant Device,746.64,34,,746.64,percent of total billed charges,Implant Device,746.64,34,,746.64,percent of total billed charges,Implant Device,1087.02,,,1087.02,Other,110% of Medicare,768.6,35,,768.6,percent of total billed charges,Implant Device,746.64,34,"Charges > $500, x 34%",746.64,percent of total billed charges,Implant Device,768.6,35,,768.6,percent of total billed charges,Implant Device,768.6,35,,768.6,percent of total billed charges,Implant Device,768.6,35,,768.6,percent of total billed charges,Implant Device,768.6,35,,768.6,percent of total billed charges,Implant Device,768.6,35,,768.6,percent of total billed charges,Implant Device,878.4,40,,878.4,percent of total billed charges,Implant Device,768.6,70,,768.6,percent of total billed charges,All Other,746.64,34,,746.64,percent of total billed charges,Implant Device,746.64,34,,746.64,percent of total billed charges,Implant Device,768.6,35,,768.6,percent of total billed charges,Implant Device,768.6,35,,768.6,percent of total billed charges,Implant Device,768.6,35,,768.6,percent of total billed charges,Implant Device,768.6,35,,768.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,746.64,34,"If Charge > 2,000, then 34 percent",746.64,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1625.05,
BIOMET 45-1597 CANCELLOUS CHIPS 90CC,C1713,HCPCS,,79001312,CDM,278,RC,,,both,,,2280,1687.21,,,1687.21,Other,150% of Medicare + 9.63% HCRA Surcharge,1026,45,,1026,percent of total billed charges,Critical Access Hospital RCC factor,775.2,34,,775.2,percent of total billed charges,Implant Device,775.2,34,,775.2,percent of total billed charges,Implant Device,775.2,34,,775.2,percent of total billed charges,Implant Device,775.2,34,,775.2,percent of total billed charges,Implant Device,775.2,34,,775.2,percent of total billed charges,Implant Device,1128.6,,,1128.6,Other,110% of Medicare,798,35,,798,percent of total billed charges,Implant Device,775.2,34,"Charges > $500, x 34%",775.2,percent of total billed charges,Implant Device,798,35,,798,percent of total billed charges,Implant Device,798,35,,798,percent of total billed charges,Implant Device,798,35,,798,percent of total billed charges,Implant Device,798,35,,798,percent of total billed charges,Implant Device,798,35,,798,percent of total billed charges,Implant Device,912,40,,912,percent of total billed charges,Implant Device,798,70,,798,percent of total billed charges,All Other,775.2,34,,775.2,percent of total billed charges,Implant Device,775.2,34,,775.2,percent of total billed charges,Implant Device,798,35,,798,percent of total billed charges,Implant Device,798,35,,798,percent of total billed charges,Implant Device,798,35,,798,percent of total billed charges,Implant Device,798,35,,798,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,775.2,34,"If Charge > 2,000, then 34 percent",775.2,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1687.21,
BIOMET 8161-40-010 CANC SCREW 4.0X10MM,C1713,HCPCS,,79001313,CDM,278,RC,,,both,,,660,488.4,,,488.4,Other,150% of Medicare + 9.63% HCRA Surcharge,297,45,,297,percent of total billed charges,Critical Access Hospital RCC factor,224.4,34,,224.4,percent of total billed charges,Implant Device,224.4,34,,224.4,percent of total billed charges,Implant Device,224.4,34,,224.4,percent of total billed charges,Implant Device,224.4,34,,224.4,percent of total billed charges,Implant Device,224.4,34,,224.4,percent of total billed charges,Implant Device,326.7,,,326.7,Other,110% of Medicare,231,35,,231,percent of total billed charges,Implant Device,224.4,34,"Charges > $500, x 34%",224.4,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,264,40,,264,percent of total billed charges,Implant Device,231,70,,231,percent of total billed charges,All Other,224.4,34,,224.4,percent of total billed charges,Implant Device,224.4,34,,224.4,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,488.4,
BIOMET 8161-40-012 CANC SCREW 4.0X12MM,C1713,HCPCS,,79001314,CDM,278,RC,,,both,,,660,488.4,,,488.4,Other,150% of Medicare + 9.63% HCRA Surcharge,297,45,,297,percent of total billed charges,Critical Access Hospital RCC factor,224.4,34,,224.4,percent of total billed charges,Implant Device,224.4,34,,224.4,percent of total billed charges,Implant Device,224.4,34,,224.4,percent of total billed charges,Implant Device,224.4,34,,224.4,percent of total billed charges,Implant Device,224.4,34,,224.4,percent of total billed charges,Implant Device,326.7,,,326.7,Other,110% of Medicare,231,35,,231,percent of total billed charges,Implant Device,224.4,34,"Charges > $500, x 34%",224.4,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,264,40,,264,percent of total billed charges,Implant Device,231,70,,231,percent of total billed charges,All Other,224.4,34,,224.4,percent of total billed charges,Implant Device,224.4,34,,224.4,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,488.4,
BIOMET 8161-40-014 CANC SCREW 4.0X14MM,C1713,HCPCS,,79001315,CDM,278,RC,,,both,,,660,488.4,,,488.4,Other,150% of Medicare + 9.63% HCRA Surcharge,297,45,,297,percent of total billed charges,Critical Access Hospital RCC factor,224.4,34,,224.4,percent of total billed charges,Implant Device,224.4,34,,224.4,percent of total billed charges,Implant Device,224.4,34,,224.4,percent of total billed charges,Implant Device,224.4,34,,224.4,percent of total billed charges,Implant Device,224.4,34,,224.4,percent of total billed charges,Implant Device,326.7,,,326.7,Other,110% of Medicare,231,35,,231,percent of total billed charges,Implant Device,224.4,34,"Charges > $500, x 34%",224.4,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,264,40,,264,percent of total billed charges,Implant Device,231,70,,231,percent of total billed charges,All Other,224.4,34,,224.4,percent of total billed charges,Implant Device,224.4,34,,224.4,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,488.4,
BIOMET 8161-40-016 CANC SCREW 4.0X16MM,C1713,HCPCS,,79001316,CDM,278,RC,,,both,,,660,488.4,,,488.4,Other,150% of Medicare + 9.63% HCRA Surcharge,297,45,,297,percent of total billed charges,Critical Access Hospital RCC factor,224.4,34,,224.4,percent of total billed charges,Implant Device,224.4,34,,224.4,percent of total billed charges,Implant Device,224.4,34,,224.4,percent of total billed charges,Implant Device,224.4,34,,224.4,percent of total billed charges,Implant Device,224.4,34,,224.4,percent of total billed charges,Implant Device,326.7,,,326.7,Other,110% of Medicare,231,35,,231,percent of total billed charges,Implant Device,224.4,34,"Charges > $500, x 34%",224.4,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,264,40,,264,percent of total billed charges,Implant Device,231,70,,231,percent of total billed charges,All Other,224.4,34,,224.4,percent of total billed charges,Implant Device,224.4,34,,224.4,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,488.4,
BIOMET 8161-40-018 CANC SCREW 4.0X18MM,C1713,HCPCS,,79001317,CDM,278,RC,,,both,,,660,488.4,,,488.4,Other,150% of Medicare + 9.63% HCRA Surcharge,297,45,,297,percent of total billed charges,Critical Access Hospital RCC factor,224.4,34,,224.4,percent of total billed charges,Implant Device,224.4,34,,224.4,percent of total billed charges,Implant Device,224.4,34,,224.4,percent of total billed charges,Implant Device,224.4,34,,224.4,percent of total billed charges,Implant Device,224.4,34,,224.4,percent of total billed charges,Implant Device,326.7,,,326.7,Other,110% of Medicare,231,35,,231,percent of total billed charges,Implant Device,224.4,34,"Charges > $500, x 34%",224.4,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,264,40,,264,percent of total billed charges,Implant Device,231,70,,231,percent of total billed charges,All Other,224.4,34,,224.4,percent of total billed charges,Implant Device,224.4,34,,224.4,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,488.4,
BIOMET 8161-40-020 CANC SCREW 4.0X20MM,C1713,HCPCS,,79001318,CDM,278,RC,,,both,,,660,488.4,,,488.4,Other,150% of Medicare + 9.63% HCRA Surcharge,297,45,,297,percent of total billed charges,Critical Access Hospital RCC factor,224.4,34,,224.4,percent of total billed charges,Implant Device,224.4,34,,224.4,percent of total billed charges,Implant Device,224.4,34,,224.4,percent of total billed charges,Implant Device,224.4,34,,224.4,percent of total billed charges,Implant Device,224.4,34,,224.4,percent of total billed charges,Implant Device,326.7,,,326.7,Other,110% of Medicare,231,35,,231,percent of total billed charges,Implant Device,224.4,34,"Charges > $500, x 34%",224.4,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,264,40,,264,percent of total billed charges,Implant Device,231,70,,231,percent of total billed charges,All Other,224.4,34,,224.4,percent of total billed charges,Implant Device,224.4,34,,224.4,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,488.4,
BIOMET 8161-40-030 CANC SCREW 4.0X30MM,C1713,HCPCS,,79001319,CDM,278,RC,,,both,,,660,488.4,,,488.4,Other,150% of Medicare + 9.63% HCRA Surcharge,297,45,,297,percent of total billed charges,Critical Access Hospital RCC factor,224.4,34,,224.4,percent of total billed charges,Implant Device,224.4,34,,224.4,percent of total billed charges,Implant Device,224.4,34,,224.4,percent of total billed charges,Implant Device,224.4,34,,224.4,percent of total billed charges,Implant Device,224.4,34,,224.4,percent of total billed charges,Implant Device,326.7,,,326.7,Other,110% of Medicare,231,35,,231,percent of total billed charges,Implant Device,224.4,34,"Charges > $500, x 34%",224.4,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,264,40,,264,percent of total billed charges,Implant Device,231,70,,231,percent of total billed charges,All Other,224.4,34,,224.4,percent of total billed charges,Implant Device,224.4,34,,224.4,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,488.4,
BIOMET 8161-40-034 CANC SCREW 4.0X34MM,C1713,HCPCS,,79001320,CDM,278,RC,,,both,,,660,488.4,,,488.4,Other,150% of Medicare + 9.63% HCRA Surcharge,297,45,,297,percent of total billed charges,Critical Access Hospital RCC factor,224.4,34,,224.4,percent of total billed charges,Implant Device,224.4,34,,224.4,percent of total billed charges,Implant Device,224.4,34,,224.4,percent of total billed charges,Implant Device,224.4,34,,224.4,percent of total billed charges,Implant Device,224.4,34,,224.4,percent of total billed charges,Implant Device,326.7,,,326.7,Other,110% of Medicare,231,35,,231,percent of total billed charges,Implant Device,224.4,34,"Charges > $500, x 34%",224.4,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,264,40,,264,percent of total billed charges,Implant Device,231,70,,231,percent of total billed charges,All Other,224.4,34,,224.4,percent of total billed charges,Implant Device,224.4,34,,224.4,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,488.4,
BIOMET 8161-40-036 CANC SCREW 4.0X36MM,C1713,HCPCS,,79001321,CDM,278,RC,,,both,,,660,488.4,,,488.4,Other,150% of Medicare + 9.63% HCRA Surcharge,297,45,,297,percent of total billed charges,Critical Access Hospital RCC factor,224.4,34,,224.4,percent of total billed charges,Implant Device,224.4,34,,224.4,percent of total billed charges,Implant Device,224.4,34,,224.4,percent of total billed charges,Implant Device,224.4,34,,224.4,percent of total billed charges,Implant Device,224.4,34,,224.4,percent of total billed charges,Implant Device,326.7,,,326.7,Other,110% of Medicare,231,35,,231,percent of total billed charges,Implant Device,224.4,34,"Charges > $500, x 34%",224.4,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,264,40,,264,percent of total billed charges,Implant Device,231,70,,231,percent of total billed charges,All Other,224.4,34,,224.4,percent of total billed charges,Implant Device,224.4,34,,224.4,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,488.4,
BIOMET 8161-40-042 CANC SCREW 4.0X42MM,C1713,HCPCS,,79001322,CDM,278,RC,,,both,,,660,488.4,,,488.4,Other,150% of Medicare + 9.63% HCRA Surcharge,297,45,,297,percent of total billed charges,Critical Access Hospital RCC factor,224.4,34,,224.4,percent of total billed charges,Implant Device,224.4,34,,224.4,percent of total billed charges,Implant Device,224.4,34,,224.4,percent of total billed charges,Implant Device,224.4,34,,224.4,percent of total billed charges,Implant Device,224.4,34,,224.4,percent of total billed charges,Implant Device,326.7,,,326.7,Other,110% of Medicare,231,35,,231,percent of total billed charges,Implant Device,224.4,34,"Charges > $500, x 34%",224.4,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,264,40,,264,percent of total billed charges,Implant Device,231,70,,231,percent of total billed charges,All Other,224.4,34,,224.4,percent of total billed charges,Implant Device,224.4,34,,224.4,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,488.4,
BIOMET 8161-40-044 CANC SCREW 4.0X44MM,C1713,HCPCS,,79001323,CDM,278,RC,,,both,,,660,488.4,,,488.4,Other,150% of Medicare + 9.63% HCRA Surcharge,297,45,,297,percent of total billed charges,Critical Access Hospital RCC factor,224.4,34,,224.4,percent of total billed charges,Implant Device,224.4,34,,224.4,percent of total billed charges,Implant Device,224.4,34,,224.4,percent of total billed charges,Implant Device,224.4,34,,224.4,percent of total billed charges,Implant Device,224.4,34,,224.4,percent of total billed charges,Implant Device,326.7,,,326.7,Other,110% of Medicare,231,35,,231,percent of total billed charges,Implant Device,224.4,34,"Charges > $500, x 34%",224.4,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,264,40,,264,percent of total billed charges,Implant Device,231,70,,231,percent of total billed charges,All Other,224.4,34,,224.4,percent of total billed charges,Implant Device,224.4,34,,224.4,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,488.4,
BIOMET 8161-40-046 CANC SCREW 4.0X46MM,C1713,HCPCS,,79001324,CDM,278,RC,,,both,,,660,488.4,,,488.4,Other,150% of Medicare + 9.63% HCRA Surcharge,297,45,,297,percent of total billed charges,Critical Access Hospital RCC factor,224.4,34,,224.4,percent of total billed charges,Implant Device,224.4,34,,224.4,percent of total billed charges,Implant Device,224.4,34,,224.4,percent of total billed charges,Implant Device,224.4,34,,224.4,percent of total billed charges,Implant Device,224.4,34,,224.4,percent of total billed charges,Implant Device,326.7,,,326.7,Other,110% of Medicare,231,35,,231,percent of total billed charges,Implant Device,224.4,34,"Charges > $500, x 34%",224.4,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,264,40,,264,percent of total billed charges,Implant Device,231,70,,231,percent of total billed charges,All Other,224.4,34,,224.4,percent of total billed charges,Implant Device,224.4,34,,224.4,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,488.4,
BIOMET 8161-40-048 CANC SCREW 4.0X48MM,C1713,HCPCS,,79001325,CDM,278,RC,,,both,,,660,488.4,,,488.4,Other,150% of Medicare + 9.63% HCRA Surcharge,297,45,,297,percent of total billed charges,Critical Access Hospital RCC factor,224.4,34,,224.4,percent of total billed charges,Implant Device,224.4,34,,224.4,percent of total billed charges,Implant Device,224.4,34,,224.4,percent of total billed charges,Implant Device,224.4,34,,224.4,percent of total billed charges,Implant Device,224.4,34,,224.4,percent of total billed charges,Implant Device,326.7,,,326.7,Other,110% of Medicare,231,35,,231,percent of total billed charges,Implant Device,224.4,34,"Charges > $500, x 34%",224.4,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,264,40,,264,percent of total billed charges,Implant Device,231,70,,231,percent of total billed charges,All Other,224.4,34,,224.4,percent of total billed charges,Implant Device,224.4,34,,224.4,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,488.4,
SYNTHES 207.05 CANCELLOUS SCREW 4.0X50MM,C1713,HCPCS,,79001326,CDM,278,RC,,,both,,,61,45.14,,,45.14,Other,150% of Medicare + 9.63% HCRA Surcharge,27.45,45,,27.45,percent of total billed charges,Critical Access Hospital RCC factor,20.74,34,,20.74,percent of total billed charges,Implant Device,20.74,34,,20.74,percent of total billed charges,Implant Device,20.74,34,,20.74,percent of total billed charges,Implant Device,20.74,34,,20.74,percent of total billed charges,Implant Device,20.74,34,,20.74,percent of total billed charges,Implant Device,30.2,,,30.2,Other,110% of Medicare,21.35,35,,21.35,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,21.35,35,,21.35,percent of total billed charges,Implant Device,21.35,35,,21.35,percent of total billed charges,Implant Device,21.35,35,,21.35,percent of total billed charges,Implant Device,21.35,35,,21.35,percent of total billed charges,Implant Device,21.35,35,,21.35,percent of total billed charges,Implant Device,24.4,40,,24.4,percent of total billed charges,Implant Device,21.35,70,,21.35,percent of total billed charges,All Other,20.74,34,,20.74,percent of total billed charges,Implant Device,20.74,34,,20.74,percent of total billed charges,Implant Device,21.35,35,,21.35,percent of total billed charges,Implant Device,21.35,35,,21.35,percent of total billed charges,Implant Device,21.35,35,,21.35,percent of total billed charges,Implant Device,21.35,35,,21.35,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,45.14,
BIOMET 8161-40-050 CANC SCREW 4.0X50MM,C1713,HCPCS,,79001327,CDM,278,RC,,,both,,,660,488.4,,,488.4,Other,150% of Medicare + 9.63% HCRA Surcharge,297,45,,297,percent of total billed charges,Critical Access Hospital RCC factor,224.4,34,,224.4,percent of total billed charges,Implant Device,224.4,34,,224.4,percent of total billed charges,Implant Device,224.4,34,,224.4,percent of total billed charges,Implant Device,224.4,34,,224.4,percent of total billed charges,Implant Device,224.4,34,,224.4,percent of total billed charges,Implant Device,326.7,,,326.7,Other,110% of Medicare,231,35,,231,percent of total billed charges,Implant Device,224.4,34,"Charges > $500, x 34%",224.4,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,264,40,,264,percent of total billed charges,Implant Device,231,70,,231,percent of total billed charges,All Other,224.4,34,,224.4,percent of total billed charges,Implant Device,224.4,34,,224.4,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,488.4,
BIOMET 8161-40-055 CANC SCREW 4.0X55MM,C1713,HCPCS,,79001328,CDM,278,RC,,,both,,,660,488.4,,,488.4,Other,150% of Medicare + 9.63% HCRA Surcharge,297,45,,297,percent of total billed charges,Critical Access Hospital RCC factor,224.4,34,,224.4,percent of total billed charges,Implant Device,224.4,34,,224.4,percent of total billed charges,Implant Device,224.4,34,,224.4,percent of total billed charges,Implant Device,224.4,34,,224.4,percent of total billed charges,Implant Device,224.4,34,,224.4,percent of total billed charges,Implant Device,326.7,,,326.7,Other,110% of Medicare,231,35,,231,percent of total billed charges,Implant Device,224.4,34,"Charges > $500, x 34%",224.4,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,264,40,,264,percent of total billed charges,Implant Device,231,70,,231,percent of total billed charges,All Other,224.4,34,,224.4,percent of total billed charges,Implant Device,224.4,34,,224.4,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,488.4,
BIOMET 8161-40-060 CANC SCREW 4.0X60MM,C1713,HCPCS,,79001329,CDM,278,RC,,,both,,,660,488.4,,,488.4,Other,150% of Medicare + 9.63% HCRA Surcharge,297,45,,297,percent of total billed charges,Critical Access Hospital RCC factor,224.4,34,,224.4,percent of total billed charges,Implant Device,224.4,34,,224.4,percent of total billed charges,Implant Device,224.4,34,,224.4,percent of total billed charges,Implant Device,224.4,34,,224.4,percent of total billed charges,Implant Device,224.4,34,,224.4,percent of total billed charges,Implant Device,326.7,,,326.7,Other,110% of Medicare,231,35,,231,percent of total billed charges,Implant Device,224.4,34,"Charges > $500, x 34%",224.4,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,264,40,,264,percent of total billed charges,Implant Device,231,70,,231,percent of total billed charges,All Other,224.4,34,,224.4,percent of total billed charges,Implant Device,224.4,34,,224.4,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,488.4,
BIOMET 8161-40-075 CANC SCREW 4.0X75MM,C1713,HCPCS,,79001330,CDM,278,RC,,,both,,,660,488.4,,,488.4,Other,150% of Medicare + 9.63% HCRA Surcharge,297,45,,297,percent of total billed charges,Critical Access Hospital RCC factor,224.4,34,,224.4,percent of total billed charges,Implant Device,224.4,34,,224.4,percent of total billed charges,Implant Device,224.4,34,,224.4,percent of total billed charges,Implant Device,224.4,34,,224.4,percent of total billed charges,Implant Device,224.4,34,,224.4,percent of total billed charges,Implant Device,326.7,,,326.7,Other,110% of Medicare,231,35,,231,percent of total billed charges,Implant Device,224.4,34,"Charges > $500, x 34%",224.4,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,264,40,,264,percent of total billed charges,Implant Device,231,70,,231,percent of total billed charges,All Other,224.4,34,,224.4,percent of total billed charges,Implant Device,224.4,34,,224.4,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,488.4,
BIOMET 8161-40-080 CANC SCREW 4.0X80MM,C1713,HCPCS,,79001331,CDM,278,RC,,,both,,,660,488.4,,,488.4,Other,150% of Medicare + 9.63% HCRA Surcharge,297,45,,297,percent of total billed charges,Critical Access Hospital RCC factor,224.4,34,,224.4,percent of total billed charges,Implant Device,224.4,34,,224.4,percent of total billed charges,Implant Device,224.4,34,,224.4,percent of total billed charges,Implant Device,224.4,34,,224.4,percent of total billed charges,Implant Device,224.4,34,,224.4,percent of total billed charges,Implant Device,326.7,,,326.7,Other,110% of Medicare,231,35,,231,percent of total billed charges,Implant Device,224.4,34,"Charges > $500, x 34%",224.4,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,264,40,,264,percent of total billed charges,Implant Device,231,70,,231,percent of total billed charges,All Other,224.4,34,,224.4,percent of total billed charges,Implant Device,224.4,34,,224.4,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,488.4,
BIOMET 8161-40-085 CANC SCREW 4.0X85MM,C1713,HCPCS,,79001332,CDM,278,RC,,,both,,,660,488.4,,,488.4,Other,150% of Medicare + 9.63% HCRA Surcharge,297,45,,297,percent of total billed charges,Critical Access Hospital RCC factor,224.4,34,,224.4,percent of total billed charges,Implant Device,224.4,34,,224.4,percent of total billed charges,Implant Device,224.4,34,,224.4,percent of total billed charges,Implant Device,224.4,34,,224.4,percent of total billed charges,Implant Device,224.4,34,,224.4,percent of total billed charges,Implant Device,326.7,,,326.7,Other,110% of Medicare,231,35,,231,percent of total billed charges,Implant Device,224.4,34,"Charges > $500, x 34%",224.4,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,264,40,,264,percent of total billed charges,Implant Device,231,70,,231,percent of total billed charges,All Other,224.4,34,,224.4,percent of total billed charges,Implant Device,224.4,34,,224.4,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,488.4,
BIOMET 8153-41-038 CANC SCREW 4.0X38MM,C1713,HCPCS,,79001333,CDM,278,RC,,,both,,,240,177.6,,,177.6,Other,150% of Medicare + 9.63% HCRA Surcharge,108,45,,108,percent of total billed charges,Critical Access Hospital RCC factor,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,118.8,,,118.8,Other,110% of Medicare,84,35,,84,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,96,40,,96,percent of total billed charges,Implant Device,84,70,,84,percent of total billed charges,All Other,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,177.6,
BIOMET 8153-41-065 CANC SCREW 4.0X65MM,C1713,HCPCS,,79001334,CDM,278,RC,,,both,,,240,177.6,,,177.6,Other,150% of Medicare + 9.63% HCRA Surcharge,108,45,,108,percent of total billed charges,Critical Access Hospital RCC factor,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,118.8,,,118.8,Other,110% of Medicare,84,35,,84,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,96,40,,96,percent of total billed charges,Implant Device,84,70,,84,percent of total billed charges,All Other,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,177.6,
BIOMET 8153-41-070 CANC SCREW 4.0X70MM,C1713,HCPCS,,79001335,CDM,278,RC,,,both,,,240,177.6,,,177.6,Other,150% of Medicare + 9.63% HCRA Surcharge,108,45,,108,percent of total billed charges,Critical Access Hospital RCC factor,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,118.8,,,118.8,Other,110% of Medicare,84,35,,84,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,96,40,,96,percent of total billed charges,Implant Device,84,70,,84,percent of total billed charges,All Other,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,177.6,
BIOMET 8153-41-010 CANC SCREW 4.1X10MM,C1713,HCPCS,,79001336,CDM,278,RC,,,both,,,240,177.6,,,177.6,Other,150% of Medicare + 9.63% HCRA Surcharge,108,45,,108,percent of total billed charges,Critical Access Hospital RCC factor,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,118.8,,,118.8,Other,110% of Medicare,84,35,,84,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,96,40,,96,percent of total billed charges,Implant Device,84,70,,84,percent of total billed charges,All Other,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,177.6,
BIOMET 8153-41-012 CANC SCREW 4.1X12MM,C1713,HCPCS,,79001337,CDM,278,RC,,,both,,,270,199.8,,,199.8,Other,150% of Medicare + 9.63% HCRA Surcharge,121.5,45,,121.5,percent of total billed charges,Critical Access Hospital RCC factor,91.8,34,,91.8,percent of total billed charges,Implant Device,91.8,34,,91.8,percent of total billed charges,Implant Device,91.8,34,,91.8,percent of total billed charges,Implant Device,91.8,34,,91.8,percent of total billed charges,Implant Device,91.8,34,,91.8,percent of total billed charges,Implant Device,133.65,,,133.65,Other,110% of Medicare,94.5,35,,94.5,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,94.5,35,,94.5,percent of total billed charges,Implant Device,94.5,35,,94.5,percent of total billed charges,Implant Device,94.5,35,,94.5,percent of total billed charges,Implant Device,94.5,35,,94.5,percent of total billed charges,Implant Device,94.5,35,,94.5,percent of total billed charges,Implant Device,108,40,,108,percent of total billed charges,Implant Device,94.5,70,,94.5,percent of total billed charges,All Other,91.8,34,,91.8,percent of total billed charges,Implant Device,91.8,34,,91.8,percent of total billed charges,Implant Device,94.5,35,,94.5,percent of total billed charges,Implant Device,94.5,35,,94.5,percent of total billed charges,Implant Device,94.5,35,,94.5,percent of total billed charges,Implant Device,94.5,35,,94.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,199.8,
BIOMET 8153-41-014 CANC SCREW 4.1X14MM,C1713,HCPCS,,79001338,CDM,278,RC,,,both,,,240,177.6,,,177.6,Other,150% of Medicare + 9.63% HCRA Surcharge,108,45,,108,percent of total billed charges,Critical Access Hospital RCC factor,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,118.8,,,118.8,Other,110% of Medicare,84,35,,84,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,96,40,,96,percent of total billed charges,Implant Device,84,70,,84,percent of total billed charges,All Other,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,177.6,
BIOMET 8153-41-016 CANC SCREW 4.1X16MM,C1713,HCPCS,,79001339,CDM,278,RC,,,both,,,240,177.6,,,177.6,Other,150% of Medicare + 9.63% HCRA Surcharge,108,45,,108,percent of total billed charges,Critical Access Hospital RCC factor,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,118.8,,,118.8,Other,110% of Medicare,84,35,,84,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,96,40,,96,percent of total billed charges,Implant Device,84,70,,84,percent of total billed charges,All Other,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,177.6,
BIOMET 8153-41-018 CANC SCREW 4.1X18MM,C1713,HCPCS,,79001340,CDM,278,RC,,,both,,,240,177.6,,,177.6,Other,150% of Medicare + 9.63% HCRA Surcharge,108,45,,108,percent of total billed charges,Critical Access Hospital RCC factor,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,118.8,,,118.8,Other,110% of Medicare,84,35,,84,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,96,40,,96,percent of total billed charges,Implant Device,84,70,,84,percent of total billed charges,All Other,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,177.6,
BIOMET 8153-41-020 CANC SCREW 4.1X20MM,C1713,HCPCS,,79001341,CDM,278,RC,,,both,,,240,177.6,,,177.6,Other,150% of Medicare + 9.63% HCRA Surcharge,108,45,,108,percent of total billed charges,Critical Access Hospital RCC factor,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,118.8,,,118.8,Other,110% of Medicare,84,35,,84,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,96,40,,96,percent of total billed charges,Implant Device,84,70,,84,percent of total billed charges,All Other,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,177.6,
BIOMET 8153-41-022 CANC SCREW 4.1X38MM,C1713,HCPCS,,79001342,CDM,278,RC,,,both,,,240,177.6,,,177.6,Other,150% of Medicare + 9.63% HCRA Surcharge,108,45,,108,percent of total billed charges,Critical Access Hospital RCC factor,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,118.8,,,118.8,Other,110% of Medicare,84,35,,84,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,96,40,,96,percent of total billed charges,Implant Device,84,70,,84,percent of total billed charges,All Other,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,177.6,
BIOMET 8155-40-014 CANC SCREW 4.0X14MM,C1713,HCPCS,,79001343,CDM,278,RC,,,both,,,240,177.6,,,177.6,Other,150% of Medicare + 9.63% HCRA Surcharge,108,45,,108,percent of total billed charges,Critical Access Hospital RCC factor,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,118.8,,,118.8,Other,110% of Medicare,84,35,,84,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,96,40,,96,percent of total billed charges,Implant Device,84,70,,84,percent of total billed charges,All Other,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,177.6,
BIOMET 8155-40-030 CANC SCREW 4.0X30MM,C1713,HCPCS,,79001344,CDM,278,RC,,,both,,,240,177.6,,,177.6,Other,150% of Medicare + 9.63% HCRA Surcharge,108,45,,108,percent of total billed charges,Critical Access Hospital RCC factor,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,118.8,,,118.8,Other,110% of Medicare,84,35,,84,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,96,40,,96,percent of total billed charges,Implant Device,84,70,,84,percent of total billed charges,All Other,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,177.6,
BIOMET 8155-40-040 CANC SCREW 4.0X40MM,C1713,HCPCS,,79001345,CDM,278,RC,,,both,,,240,177.6,,,177.6,Other,150% of Medicare + 9.63% HCRA Surcharge,108,45,,108,percent of total billed charges,Critical Access Hospital RCC factor,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,118.8,,,118.8,Other,110% of Medicare,84,35,,84,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,96,40,,96,percent of total billed charges,Implant Device,84,70,,84,percent of total billed charges,All Other,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,177.6,
BIOMET 8155-40-045 CANC SCREW 4.0X45MM,C1713,HCPCS,,79001346,CDM,278,RC,,,both,,,240,177.6,,,177.6,Other,150% of Medicare + 9.63% HCRA Surcharge,108,45,,108,percent of total billed charges,Critical Access Hospital RCC factor,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,118.8,,,118.8,Other,110% of Medicare,84,35,,84,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,96,40,,96,percent of total billed charges,Implant Device,84,70,,84,percent of total billed charges,All Other,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,177.6,
BIOMET 8155-40-050 CANC SCREW 4.0X50MM,C1713,HCPCS,,79001347,CDM,278,RC,,,both,,,240,177.6,,,177.6,Other,150% of Medicare + 9.63% HCRA Surcharge,108,45,,108,percent of total billed charges,Critical Access Hospital RCC factor,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,118.8,,,118.8,Other,110% of Medicare,84,35,,84,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,96,40,,96,percent of total billed charges,Implant Device,84,70,,84,percent of total billed charges,All Other,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,177.6,
BIOMET 14196-80 CANN SCREW  6.5X80MM,C1713,HCPCS,,79001349,CDM,278,RC,,,both,,,1290,954.6,,,954.6,Other,150% of Medicare + 9.63% HCRA Surcharge,580.5,45,,580.5,percent of total billed charges,Critical Access Hospital RCC factor,438.6,34,,438.6,percent of total billed charges,Implant Device,438.6,34,,438.6,percent of total billed charges,Implant Device,438.6,34,,438.6,percent of total billed charges,Implant Device,438.6,34,,438.6,percent of total billed charges,Implant Device,438.6,34,,438.6,percent of total billed charges,Implant Device,638.55,,,638.55,Other,110% of Medicare,451.5,35,,451.5,percent of total billed charges,Implant Device,438.6,34,"Charges > $500, x 34%",438.6,percent of total billed charges,Implant Device,451.5,35,,451.5,percent of total billed charges,Implant Device,451.5,35,,451.5,percent of total billed charges,Implant Device,451.5,35,,451.5,percent of total billed charges,Implant Device,451.5,35,,451.5,percent of total billed charges,Implant Device,451.5,35,,451.5,percent of total billed charges,Implant Device,516,40,,516,percent of total billed charges,Implant Device,451.5,70,,451.5,percent of total billed charges,All Other,438.6,34,,438.6,percent of total billed charges,Implant Device,438.6,34,,438.6,percent of total billed charges,Implant Device,451.5,35,,451.5,percent of total billed charges,Implant Device,451.5,35,,451.5,percent of total billed charges,Implant Device,451.5,35,,451.5,percent of total billed charges,Implant Device,451.5,35,,451.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,954.6,
BIOMET 14376-16 CANN SCREW 4.0X16MM,C1713,HCPCS,,79001350,CDM,278,RC,,,both,,,840,621.6,,,621.6,Other,150% of Medicare + 9.63% HCRA Surcharge,378,45,,378,percent of total billed charges,Critical Access Hospital RCC factor,285.6,34,,285.6,percent of total billed charges,Implant Device,285.6,34,,285.6,percent of total billed charges,Implant Device,285.6,34,,285.6,percent of total billed charges,Implant Device,285.6,34,,285.6,percent of total billed charges,Implant Device,285.6,34,,285.6,percent of total billed charges,Implant Device,415.8,,,415.8,Other,110% of Medicare,294,35,,294,percent of total billed charges,Implant Device,285.6,34,"Charges > $500, x 34%",285.6,percent of total billed charges,Implant Device,294,35,,294,percent of total billed charges,Implant Device,294,35,,294,percent of total billed charges,Implant Device,294,35,,294,percent of total billed charges,Implant Device,294,35,,294,percent of total billed charges,Implant Device,294,35,,294,percent of total billed charges,Implant Device,336,40,,336,percent of total billed charges,Implant Device,294,70,,294,percent of total billed charges,All Other,285.6,34,,285.6,percent of total billed charges,Implant Device,285.6,34,,285.6,percent of total billed charges,Implant Device,294,35,,294,percent of total billed charges,Implant Device,294,35,,294,percent of total billed charges,Implant Device,294,35,,294,percent of total billed charges,Implant Device,294,35,,294,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,621.6,
BIOMET 14376-26 CANN SCREW 4.0X26MM,C1713,HCPCS,,79001351,CDM,278,RC,,,both,,,840,621.6,,,621.6,Other,150% of Medicare + 9.63% HCRA Surcharge,378,45,,378,percent of total billed charges,Critical Access Hospital RCC factor,285.6,34,,285.6,percent of total billed charges,Implant Device,285.6,34,,285.6,percent of total billed charges,Implant Device,285.6,34,,285.6,percent of total billed charges,Implant Device,285.6,34,,285.6,percent of total billed charges,Implant Device,285.6,34,,285.6,percent of total billed charges,Implant Device,415.8,,,415.8,Other,110% of Medicare,294,35,,294,percent of total billed charges,Implant Device,285.6,34,"Charges > $500, x 34%",285.6,percent of total billed charges,Implant Device,294,35,,294,percent of total billed charges,Implant Device,294,35,,294,percent of total billed charges,Implant Device,294,35,,294,percent of total billed charges,Implant Device,294,35,,294,percent of total billed charges,Implant Device,294,35,,294,percent of total billed charges,Implant Device,336,40,,336,percent of total billed charges,Implant Device,294,70,,294,percent of total billed charges,All Other,285.6,34,,285.6,percent of total billed charges,Implant Device,285.6,34,,285.6,percent of total billed charges,Implant Device,294,35,,294,percent of total billed charges,Implant Device,294,35,,294,percent of total billed charges,Implant Device,294,35,,294,percent of total billed charges,Implant Device,294,35,,294,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,621.6,
BIOMET 14376-32 CANN SCREW 4.0X32MM,C1713,HCPCS,,79001352,CDM,278,RC,,,both,,,504,372.96,,,372.96,Other,150% of Medicare + 9.63% HCRA Surcharge,226.8,45,,226.8,percent of total billed charges,Critical Access Hospital RCC factor,171.36,34,,171.36,percent of total billed charges,Implant Device,171.36,34,,171.36,percent of total billed charges,Implant Device,171.36,34,,171.36,percent of total billed charges,Implant Device,171.36,34,,171.36,percent of total billed charges,Implant Device,171.36,34,,171.36,percent of total billed charges,Implant Device,249.48,,,249.48,Other,110% of Medicare,176.4,35,,176.4,percent of total billed charges,Implant Device,171.36,34,"Charges > $500, x 34%",171.36,percent of total billed charges,Implant Device,176.4,35,,176.4,percent of total billed charges,Implant Device,176.4,35,,176.4,percent of total billed charges,Implant Device,176.4,35,,176.4,percent of total billed charges,Implant Device,176.4,35,,176.4,percent of total billed charges,Implant Device,176.4,35,,176.4,percent of total billed charges,Implant Device,201.6,40,,201.6,percent of total billed charges,Implant Device,176.4,70,,176.4,percent of total billed charges,All Other,171.36,34,,171.36,percent of total billed charges,Implant Device,171.36,34,,171.36,percent of total billed charges,Implant Device,176.4,35,,176.4,percent of total billed charges,Implant Device,176.4,35,,176.4,percent of total billed charges,Implant Device,176.4,35,,176.4,percent of total billed charges,Implant Device,176.4,35,,176.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,372.96,
BIOMET 14376-36 CANN SCREW 4.0X36MM,C1713,HCPCS,,79001353,CDM,278,RC,,,both,,,504,372.96,,,372.96,Other,150% of Medicare + 9.63% HCRA Surcharge,226.8,45,,226.8,percent of total billed charges,Critical Access Hospital RCC factor,171.36,34,,171.36,percent of total billed charges,Implant Device,171.36,34,,171.36,percent of total billed charges,Implant Device,171.36,34,,171.36,percent of total billed charges,Implant Device,171.36,34,,171.36,percent of total billed charges,Implant Device,171.36,34,,171.36,percent of total billed charges,Implant Device,249.48,,,249.48,Other,110% of Medicare,176.4,35,,176.4,percent of total billed charges,Implant Device,171.36,34,"Charges > $500, x 34%",171.36,percent of total billed charges,Implant Device,176.4,35,,176.4,percent of total billed charges,Implant Device,176.4,35,,176.4,percent of total billed charges,Implant Device,176.4,35,,176.4,percent of total billed charges,Implant Device,176.4,35,,176.4,percent of total billed charges,Implant Device,176.4,35,,176.4,percent of total billed charges,Implant Device,201.6,40,,201.6,percent of total billed charges,Implant Device,176.4,70,,176.4,percent of total billed charges,All Other,171.36,34,,171.36,percent of total billed charges,Implant Device,171.36,34,,171.36,percent of total billed charges,Implant Device,176.4,35,,176.4,percent of total billed charges,Implant Device,176.4,35,,176.4,percent of total billed charges,Implant Device,176.4,35,,176.4,percent of total billed charges,Implant Device,176.4,35,,176.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,372.96,
BIOMET 14376-40 CANN SCREW 4.0X40MM,C1713,HCPCS,,79001354,CDM,278,RC,,,both,,,514,380.36,,,380.36,Other,150% of Medicare + 9.63% HCRA Surcharge,231.3,45,,231.3,percent of total billed charges,Critical Access Hospital RCC factor,174.76,34,,174.76,percent of total billed charges,Implant Device,174.76,34,,174.76,percent of total billed charges,Implant Device,174.76,34,,174.76,percent of total billed charges,Implant Device,174.76,34,,174.76,percent of total billed charges,Implant Device,174.76,34,,174.76,percent of total billed charges,Implant Device,254.43,,,254.43,Other,110% of Medicare,179.9,35,,179.9,percent of total billed charges,Implant Device,174.76,34,"Charges > $500, x 34%",174.76,percent of total billed charges,Implant Device,179.9,35,,179.9,percent of total billed charges,Implant Device,179.9,35,,179.9,percent of total billed charges,Implant Device,179.9,35,,179.9,percent of total billed charges,Implant Device,179.9,35,,179.9,percent of total billed charges,Implant Device,179.9,35,,179.9,percent of total billed charges,Implant Device,205.6,40,,205.6,percent of total billed charges,Implant Device,179.9,70,,179.9,percent of total billed charges,All Other,174.76,34,,174.76,percent of total billed charges,Implant Device,174.76,34,,174.76,percent of total billed charges,Implant Device,179.9,35,,179.9,percent of total billed charges,Implant Device,179.9,35,,179.9,percent of total billed charges,Implant Device,179.9,35,,179.9,percent of total billed charges,Implant Device,179.9,35,,179.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,380.36,
BIOMET 14376-42 CANN SCREW 4.0X42MM,C1713,HCPCS,,79001355,CDM,278,RC,,,both,,,504,372.96,,,372.96,Other,150% of Medicare + 9.63% HCRA Surcharge,226.8,45,,226.8,percent of total billed charges,Critical Access Hospital RCC factor,171.36,34,,171.36,percent of total billed charges,Implant Device,171.36,34,,171.36,percent of total billed charges,Implant Device,171.36,34,,171.36,percent of total billed charges,Implant Device,171.36,34,,171.36,percent of total billed charges,Implant Device,171.36,34,,171.36,percent of total billed charges,Implant Device,249.48,,,249.48,Other,110% of Medicare,176.4,35,,176.4,percent of total billed charges,Implant Device,171.36,34,"Charges > $500, x 34%",171.36,percent of total billed charges,Implant Device,176.4,35,,176.4,percent of total billed charges,Implant Device,176.4,35,,176.4,percent of total billed charges,Implant Device,176.4,35,,176.4,percent of total billed charges,Implant Device,176.4,35,,176.4,percent of total billed charges,Implant Device,176.4,35,,176.4,percent of total billed charges,Implant Device,201.6,40,,201.6,percent of total billed charges,Implant Device,176.4,70,,176.4,percent of total billed charges,All Other,171.36,34,,171.36,percent of total billed charges,Implant Device,171.36,34,,171.36,percent of total billed charges,Implant Device,176.4,35,,176.4,percent of total billed charges,Implant Device,176.4,35,,176.4,percent of total billed charges,Implant Device,176.4,35,,176.4,percent of total billed charges,Implant Device,176.4,35,,176.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,372.96,
BIOMET 14376-44 CANN SCREW 4.0X44MM,C1713,HCPCS,,79001356,CDM,278,RC,,,both,,,870,643.8,,,643.8,Other,150% of Medicare + 9.63% HCRA Surcharge,391.5,45,,391.5,percent of total billed charges,Critical Access Hospital RCC factor,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,430.65,,,430.65,Other,110% of Medicare,304.5,35,,304.5,percent of total billed charges,Implant Device,295.8,34,"Charges > $500, x 34%",295.8,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,348,40,,348,percent of total billed charges,Implant Device,304.5,70,,304.5,percent of total billed charges,All Other,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,643.8,
BIOMET 14376-46 CANN SCREW 4.0X46MM,C1713,HCPCS,,79001357,CDM,278,RC,,,both,,,840,621.6,,,621.6,Other,150% of Medicare + 9.63% HCRA Surcharge,378,45,,378,percent of total billed charges,Critical Access Hospital RCC factor,285.6,34,,285.6,percent of total billed charges,Implant Device,285.6,34,,285.6,percent of total billed charges,Implant Device,285.6,34,,285.6,percent of total billed charges,Implant Device,285.6,34,,285.6,percent of total billed charges,Implant Device,285.6,34,,285.6,percent of total billed charges,Implant Device,415.8,,,415.8,Other,110% of Medicare,294,35,,294,percent of total billed charges,Implant Device,285.6,34,"Charges > $500, x 34%",285.6,percent of total billed charges,Implant Device,294,35,,294,percent of total billed charges,Implant Device,294,35,,294,percent of total billed charges,Implant Device,294,35,,294,percent of total billed charges,Implant Device,294,35,,294,percent of total billed charges,Implant Device,294,35,,294,percent of total billed charges,Implant Device,336,40,,336,percent of total billed charges,Implant Device,294,70,,294,percent of total billed charges,All Other,285.6,34,,285.6,percent of total billed charges,Implant Device,285.6,34,,285.6,percent of total billed charges,Implant Device,294,35,,294,percent of total billed charges,Implant Device,294,35,,294,percent of total billed charges,Implant Device,294,35,,294,percent of total billed charges,Implant Device,294,35,,294,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,621.6,
BIOMET 14376-48 CANN SCREW 4.0X48MM,C1713,HCPCS,,79001358,CDM,278,RC,,,both,,,514,380.36,,,380.36,Other,150% of Medicare + 9.63% HCRA Surcharge,231.3,45,,231.3,percent of total billed charges,Critical Access Hospital RCC factor,174.76,34,,174.76,percent of total billed charges,Implant Device,174.76,34,,174.76,percent of total billed charges,Implant Device,174.76,34,,174.76,percent of total billed charges,Implant Device,174.76,34,,174.76,percent of total billed charges,Implant Device,174.76,34,,174.76,percent of total billed charges,Implant Device,254.43,,,254.43,Other,110% of Medicare,179.9,35,,179.9,percent of total billed charges,Implant Device,174.76,34,"Charges > $500, x 34%",174.76,percent of total billed charges,Implant Device,179.9,35,,179.9,percent of total billed charges,Implant Device,179.9,35,,179.9,percent of total billed charges,Implant Device,179.9,35,,179.9,percent of total billed charges,Implant Device,179.9,35,,179.9,percent of total billed charges,Implant Device,179.9,35,,179.9,percent of total billed charges,Implant Device,205.6,40,,205.6,percent of total billed charges,Implant Device,179.9,70,,179.9,percent of total billed charges,All Other,174.76,34,,174.76,percent of total billed charges,Implant Device,174.76,34,,174.76,percent of total billed charges,Implant Device,179.9,35,,179.9,percent of total billed charges,Implant Device,179.9,35,,179.9,percent of total billed charges,Implant Device,179.9,35,,179.9,percent of total billed charges,Implant Device,179.9,35,,179.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,380.36,
BIOMET 14376-50 CANN SCREW 4.0X50MM,C1713,HCPCS,,79001359,CDM,278,RC,,,both,,,514,380.36,,,380.36,Other,150% of Medicare + 9.63% HCRA Surcharge,231.3,45,,231.3,percent of total billed charges,Critical Access Hospital RCC factor,174.76,34,,174.76,percent of total billed charges,Implant Device,174.76,34,,174.76,percent of total billed charges,Implant Device,174.76,34,,174.76,percent of total billed charges,Implant Device,174.76,34,,174.76,percent of total billed charges,Implant Device,174.76,34,,174.76,percent of total billed charges,Implant Device,254.43,,,254.43,Other,110% of Medicare,179.9,35,,179.9,percent of total billed charges,Implant Device,174.76,34,"Charges > $500, x 34%",174.76,percent of total billed charges,Implant Device,179.9,35,,179.9,percent of total billed charges,Implant Device,179.9,35,,179.9,percent of total billed charges,Implant Device,179.9,35,,179.9,percent of total billed charges,Implant Device,179.9,35,,179.9,percent of total billed charges,Implant Device,179.9,35,,179.9,percent of total billed charges,Implant Device,205.6,40,,205.6,percent of total billed charges,Implant Device,179.9,70,,179.9,percent of total billed charges,All Other,174.76,34,,174.76,percent of total billed charges,Implant Device,174.76,34,,174.76,percent of total billed charges,Implant Device,179.9,35,,179.9,percent of total billed charges,Implant Device,179.9,35,,179.9,percent of total billed charges,Implant Device,179.9,35,,179.9,percent of total billed charges,Implant Device,179.9,35,,179.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,380.36,
BIOMET 14376-55 CANN SCREW 4.0X55MM,C1713,HCPCS,,79001360,CDM,278,RC,,,both,,,840,621.6,,,621.6,Other,150% of Medicare + 9.63% HCRA Surcharge,378,45,,378,percent of total billed charges,Critical Access Hospital RCC factor,285.6,34,,285.6,percent of total billed charges,Implant Device,285.6,34,,285.6,percent of total billed charges,Implant Device,285.6,34,,285.6,percent of total billed charges,Implant Device,285.6,34,,285.6,percent of total billed charges,Implant Device,285.6,34,,285.6,percent of total billed charges,Implant Device,415.8,,,415.8,Other,110% of Medicare,294,35,,294,percent of total billed charges,Implant Device,285.6,34,"Charges > $500, x 34%",285.6,percent of total billed charges,Implant Device,294,35,,294,percent of total billed charges,Implant Device,294,35,,294,percent of total billed charges,Implant Device,294,35,,294,percent of total billed charges,Implant Device,294,35,,294,percent of total billed charges,Implant Device,294,35,,294,percent of total billed charges,Implant Device,336,40,,336,percent of total billed charges,Implant Device,294,70,,294,percent of total billed charges,All Other,285.6,34,,285.6,percent of total billed charges,Implant Device,285.6,34,,285.6,percent of total billed charges,Implant Device,294,35,,294,percent of total billed charges,Implant Device,294,35,,294,percent of total billed charges,Implant Device,294,35,,294,percent of total billed charges,Implant Device,294,35,,294,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,621.6,
BIOMET 14376-60 CANN SCREW 4.0X60MM,C1713,HCPCS,,79001361,CDM,278,RC,,,both,,,840,621.6,,,621.6,Other,150% of Medicare + 9.63% HCRA Surcharge,378,45,,378,percent of total billed charges,Critical Access Hospital RCC factor,285.6,34,,285.6,percent of total billed charges,Implant Device,285.6,34,,285.6,percent of total billed charges,Implant Device,285.6,34,,285.6,percent of total billed charges,Implant Device,285.6,34,,285.6,percent of total billed charges,Implant Device,285.6,34,,285.6,percent of total billed charges,Implant Device,415.8,,,415.8,Other,110% of Medicare,294,35,,294,percent of total billed charges,Implant Device,285.6,34,"Charges > $500, x 34%",285.6,percent of total billed charges,Implant Device,294,35,,294,percent of total billed charges,Implant Device,294,35,,294,percent of total billed charges,Implant Device,294,35,,294,percent of total billed charges,Implant Device,294,35,,294,percent of total billed charges,Implant Device,294,35,,294,percent of total billed charges,Implant Device,336,40,,336,percent of total billed charges,Implant Device,294,70,,294,percent of total billed charges,All Other,285.6,34,,285.6,percent of total billed charges,Implant Device,285.6,34,,285.6,percent of total billed charges,Implant Device,294,35,,294,percent of total billed charges,Implant Device,294,35,,294,percent of total billed charges,Implant Device,294,35,,294,percent of total billed charges,Implant Device,294,35,,294,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,621.6,
BIOMET 14376-65 CANN SCREW 4.0X65MM,C1713,HCPCS,,79001362,CDM,278,RC,,,both,,,840,621.6,,,621.6,Other,150% of Medicare + 9.63% HCRA Surcharge,378,45,,378,percent of total billed charges,Critical Access Hospital RCC factor,285.6,34,,285.6,percent of total billed charges,Implant Device,285.6,34,,285.6,percent of total billed charges,Implant Device,285.6,34,,285.6,percent of total billed charges,Implant Device,285.6,34,,285.6,percent of total billed charges,Implant Device,285.6,34,,285.6,percent of total billed charges,Implant Device,415.8,,,415.8,Other,110% of Medicare,294,35,,294,percent of total billed charges,Implant Device,285.6,34,"Charges > $500, x 34%",285.6,percent of total billed charges,Implant Device,294,35,,294,percent of total billed charges,Implant Device,294,35,,294,percent of total billed charges,Implant Device,294,35,,294,percent of total billed charges,Implant Device,294,35,,294,percent of total billed charges,Implant Device,294,35,,294,percent of total billed charges,Implant Device,336,40,,336,percent of total billed charges,Implant Device,294,70,,294,percent of total billed charges,All Other,285.6,34,,285.6,percent of total billed charges,Implant Device,285.6,34,,285.6,percent of total billed charges,Implant Device,294,35,,294,percent of total billed charges,Implant Device,294,35,,294,percent of total billed charges,Implant Device,294,35,,294,percent of total billed charges,Implant Device,294,35,,294,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,621.6,
BIOMET 14376-70 CANN SCREW 4.0X70MM,C1713,HCPCS,,79001363,CDM,278,RC,,,both,,,840,621.6,,,621.6,Other,150% of Medicare + 9.63% HCRA Surcharge,378,45,,378,percent of total billed charges,Critical Access Hospital RCC factor,285.6,34,,285.6,percent of total billed charges,Implant Device,285.6,34,,285.6,percent of total billed charges,Implant Device,285.6,34,,285.6,percent of total billed charges,Implant Device,285.6,34,,285.6,percent of total billed charges,Implant Device,285.6,34,,285.6,percent of total billed charges,Implant Device,415.8,,,415.8,Other,110% of Medicare,294,35,,294,percent of total billed charges,Implant Device,285.6,34,"Charges > $500, x 34%",285.6,percent of total billed charges,Implant Device,294,35,,294,percent of total billed charges,Implant Device,294,35,,294,percent of total billed charges,Implant Device,294,35,,294,percent of total billed charges,Implant Device,294,35,,294,percent of total billed charges,Implant Device,294,35,,294,percent of total billed charges,Implant Device,336,40,,336,percent of total billed charges,Implant Device,294,70,,294,percent of total billed charges,All Other,285.6,34,,285.6,percent of total billed charges,Implant Device,285.6,34,,285.6,percent of total billed charges,Implant Device,294,35,,294,percent of total billed charges,Implant Device,294,35,,294,percent of total billed charges,Implant Device,294,35,,294,percent of total billed charges,Implant Device,294,35,,294,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,621.6,
BIOMET 14196-70 CANN SCREW 6.5X70MM,C1713,HCPCS,,79001364,CDM,278,RC,,,both,,,1290,954.6,,,954.6,Other,150% of Medicare + 9.63% HCRA Surcharge,580.5,45,,580.5,percent of total billed charges,Critical Access Hospital RCC factor,438.6,34,,438.6,percent of total billed charges,Implant Device,438.6,34,,438.6,percent of total billed charges,Implant Device,438.6,34,,438.6,percent of total billed charges,Implant Device,438.6,34,,438.6,percent of total billed charges,Implant Device,438.6,34,,438.6,percent of total billed charges,Implant Device,638.55,,,638.55,Other,110% of Medicare,451.5,35,,451.5,percent of total billed charges,Implant Device,438.6,34,"Charges > $500, x 34%",438.6,percent of total billed charges,Implant Device,451.5,35,,451.5,percent of total billed charges,Implant Device,451.5,35,,451.5,percent of total billed charges,Implant Device,451.5,35,,451.5,percent of total billed charges,Implant Device,451.5,35,,451.5,percent of total billed charges,Implant Device,451.5,35,,451.5,percent of total billed charges,Implant Device,516,40,,516,percent of total billed charges,Implant Device,451.5,70,,451.5,percent of total billed charges,All Other,438.6,34,,438.6,percent of total billed charges,Implant Device,438.6,34,,438.6,percent of total billed charges,Implant Device,451.5,35,,451.5,percent of total billed charges,Implant Device,451.5,35,,451.5,percent of total billed charges,Implant Device,451.5,35,,451.5,percent of total billed charges,Implant Device,451.5,35,,451.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,954.6,
STRYKER 355028S CANNULATED SCREW 28MM,C1713,HCPCS,,79001365,CDM,278,RC,,,both,,,562,415.88,,,415.88,Other,150% of Medicare + 9.63% HCRA Surcharge,252.9,45,,252.9,percent of total billed charges,Critical Access Hospital RCC factor,191.08,34,,191.08,percent of total billed charges,Implant Device,191.08,34,,191.08,percent of total billed charges,Implant Device,191.08,34,,191.08,percent of total billed charges,Implant Device,191.08,34,,191.08,percent of total billed charges,Implant Device,191.08,34,,191.08,percent of total billed charges,Implant Device,278.19,,,278.19,Other,110% of Medicare,196.7,35,,196.7,percent of total billed charges,Implant Device,191.08,34,"Charges > $500, x 34%",191.08,percent of total billed charges,Implant Device,196.7,35,,196.7,percent of total billed charges,Implant Device,196.7,35,,196.7,percent of total billed charges,Implant Device,196.7,35,,196.7,percent of total billed charges,Implant Device,196.7,35,,196.7,percent of total billed charges,Implant Device,196.7,35,,196.7,percent of total billed charges,Implant Device,224.8,40,,224.8,percent of total billed charges,Implant Device,196.7,70,,196.7,percent of total billed charges,All Other,191.08,34,,191.08,percent of total billed charges,Implant Device,191.08,34,,191.08,percent of total billed charges,Implant Device,196.7,35,,196.7,percent of total billed charges,Implant Device,196.7,35,,196.7,percent of total billed charges,Implant Device,196.7,35,,196.7,percent of total billed charges,Implant Device,196.7,35,,196.7,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,415.88,
STRYKER 325014 CANNULATED SCREW 4.0 X 14,C1713,HCPCS,,79001368,CDM,278,RC,,,both,,,569,421.06,,,421.06,Other,150% of Medicare + 9.63% HCRA Surcharge,256.05,45,,256.05,percent of total billed charges,Critical Access Hospital RCC factor,193.46,34,,193.46,percent of total billed charges,Implant Device,193.46,34,,193.46,percent of total billed charges,Implant Device,193.46,34,,193.46,percent of total billed charges,Implant Device,193.46,34,,193.46,percent of total billed charges,Implant Device,193.46,34,,193.46,percent of total billed charges,Implant Device,281.66,,,281.66,Other,110% of Medicare,199.15,35,,199.15,percent of total billed charges,Implant Device,193.46,34,"Charges > $500, x 34%",193.46,percent of total billed charges,Implant Device,199.15,35,,199.15,percent of total billed charges,Implant Device,199.15,35,,199.15,percent of total billed charges,Implant Device,199.15,35,,199.15,percent of total billed charges,Implant Device,199.15,35,,199.15,percent of total billed charges,Implant Device,199.15,35,,199.15,percent of total billed charges,Implant Device,227.6,40,,227.6,percent of total billed charges,Implant Device,199.15,70,,199.15,percent of total billed charges,All Other,193.46,34,,193.46,percent of total billed charges,Implant Device,193.46,34,,193.46,percent of total billed charges,Implant Device,199.15,35,,199.15,percent of total billed charges,Implant Device,199.15,35,,199.15,percent of total billed charges,Implant Device,199.15,35,,199.15,percent of total billed charges,Implant Device,199.15,35,,199.15,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,421.06,
STRYKER 325024 CANNULATED SCREW 4.0 X 24,C1713,HCPCS,,79001369,CDM,278,RC,,,both,,,569,421.06,,,421.06,Other,150% of Medicare + 9.63% HCRA Surcharge,256.05,45,,256.05,percent of total billed charges,Critical Access Hospital RCC factor,193.46,34,,193.46,percent of total billed charges,Implant Device,193.46,34,,193.46,percent of total billed charges,Implant Device,193.46,34,,193.46,percent of total billed charges,Implant Device,193.46,34,,193.46,percent of total billed charges,Implant Device,193.46,34,,193.46,percent of total billed charges,Implant Device,281.66,,,281.66,Other,110% of Medicare,199.15,35,,199.15,percent of total billed charges,Implant Device,193.46,34,"Charges > $500, x 34%",193.46,percent of total billed charges,Implant Device,199.15,35,,199.15,percent of total billed charges,Implant Device,199.15,35,,199.15,percent of total billed charges,Implant Device,199.15,35,,199.15,percent of total billed charges,Implant Device,199.15,35,,199.15,percent of total billed charges,Implant Device,199.15,35,,199.15,percent of total billed charges,Implant Device,227.6,40,,227.6,percent of total billed charges,Implant Device,199.15,70,,199.15,percent of total billed charges,All Other,193.46,34,,193.46,percent of total billed charges,Implant Device,193.46,34,,193.46,percent of total billed charges,Implant Device,199.15,35,,199.15,percent of total billed charges,Implant Device,199.15,35,,199.15,percent of total billed charges,Implant Device,199.15,35,,199.15,percent of total billed charges,Implant Device,199.15,35,,199.15,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,421.06,
STRYKER 325026 CANNULATED SCREW 4.0 X 26,C1713,HCPCS,,79001370,CDM,278,RC,,,both,,,569,421.06,,,421.06,Other,150% of Medicare + 9.63% HCRA Surcharge,256.05,45,,256.05,percent of total billed charges,Critical Access Hospital RCC factor,193.46,34,,193.46,percent of total billed charges,Implant Device,193.46,34,,193.46,percent of total billed charges,Implant Device,193.46,34,,193.46,percent of total billed charges,Implant Device,193.46,34,,193.46,percent of total billed charges,Implant Device,193.46,34,,193.46,percent of total billed charges,Implant Device,281.66,,,281.66,Other,110% of Medicare,199.15,35,,199.15,percent of total billed charges,Implant Device,193.46,34,"Charges > $500, x 34%",193.46,percent of total billed charges,Implant Device,199.15,35,,199.15,percent of total billed charges,Implant Device,199.15,35,,199.15,percent of total billed charges,Implant Device,199.15,35,,199.15,percent of total billed charges,Implant Device,199.15,35,,199.15,percent of total billed charges,Implant Device,199.15,35,,199.15,percent of total billed charges,Implant Device,227.6,40,,227.6,percent of total billed charges,Implant Device,199.15,70,,199.15,percent of total billed charges,All Other,193.46,34,,193.46,percent of total billed charges,Implant Device,193.46,34,,193.46,percent of total billed charges,Implant Device,199.15,35,,199.15,percent of total billed charges,Implant Device,199.15,35,,199.15,percent of total billed charges,Implant Device,199.15,35,,199.15,percent of total billed charges,Implant Device,199.15,35,,199.15,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,421.06,
STRYKER 325030 CANNULATED SCREW 4.0 X 30,C1713,HCPCS,,79001371,CDM,278,RC,,,both,,,824,609.76,,,609.76,Other,150% of Medicare + 9.63% HCRA Surcharge,370.8,45,,370.8,percent of total billed charges,Critical Access Hospital RCC factor,280.16,34,,280.16,percent of total billed charges,Implant Device,280.16,34,,280.16,percent of total billed charges,Implant Device,280.16,34,,280.16,percent of total billed charges,Implant Device,280.16,34,,280.16,percent of total billed charges,Implant Device,280.16,34,,280.16,percent of total billed charges,Implant Device,407.88,,,407.88,Other,110% of Medicare,288.4,35,,288.4,percent of total billed charges,Implant Device,280.16,34,"Charges > $500, x 34%",280.16,percent of total billed charges,Implant Device,288.4,35,,288.4,percent of total billed charges,Implant Device,288.4,35,,288.4,percent of total billed charges,Implant Device,288.4,35,,288.4,percent of total billed charges,Implant Device,288.4,35,,288.4,percent of total billed charges,Implant Device,288.4,35,,288.4,percent of total billed charges,Implant Device,329.6,40,,329.6,percent of total billed charges,Implant Device,288.4,70,,288.4,percent of total billed charges,All Other,280.16,34,,280.16,percent of total billed charges,Implant Device,280.16,34,,280.16,percent of total billed charges,Implant Device,288.4,35,,288.4,percent of total billed charges,Implant Device,288.4,35,,288.4,percent of total billed charges,Implant Device,288.4,35,,288.4,percent of total billed charges,Implant Device,288.4,35,,288.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,609.76,
SYNTHES 207.63 CANNULATED SCREW 4.0X30MM,C1713,HCPCS,,79001372,CDM,278,RC,,,both,,,856,633.44,,,633.44,Other,150% of Medicare + 9.63% HCRA Surcharge,385.2,45,,385.2,percent of total billed charges,Critical Access Hospital RCC factor,291.04,34,,291.04,percent of total billed charges,Implant Device,291.04,34,,291.04,percent of total billed charges,Implant Device,291.04,34,,291.04,percent of total billed charges,Implant Device,291.04,34,,291.04,percent of total billed charges,Implant Device,291.04,34,,291.04,percent of total billed charges,Implant Device,423.72,,,423.72,Other,110% of Medicare,299.6,35,,299.6,percent of total billed charges,Implant Device,291.04,34,"Charges > $500, x 34%",291.04,percent of total billed charges,Implant Device,299.6,35,,299.6,percent of total billed charges,Implant Device,299.6,35,,299.6,percent of total billed charges,Implant Device,299.6,35,,299.6,percent of total billed charges,Implant Device,299.6,35,,299.6,percent of total billed charges,Implant Device,299.6,35,,299.6,percent of total billed charges,Implant Device,342.4,40,,342.4,percent of total billed charges,Implant Device,299.6,70,,299.6,percent of total billed charges,All Other,291.04,34,,291.04,percent of total billed charges,Implant Device,291.04,34,,291.04,percent of total billed charges,Implant Device,299.6,35,,299.6,percent of total billed charges,Implant Device,299.6,35,,299.6,percent of total billed charges,Implant Device,299.6,35,,299.6,percent of total billed charges,Implant Device,299.6,35,,299.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,633.44,
STRYKER 325032 CANNULATED SCREW 4.0 X 32,C1713,HCPCS,,79001373,CDM,278,RC,,,both,,,562,415.88,,,415.88,Other,150% of Medicare + 9.63% HCRA Surcharge,252.9,45,,252.9,percent of total billed charges,Critical Access Hospital RCC factor,191.08,34,,191.08,percent of total billed charges,Implant Device,191.08,34,,191.08,percent of total billed charges,Implant Device,191.08,34,,191.08,percent of total billed charges,Implant Device,191.08,34,,191.08,percent of total billed charges,Implant Device,191.08,34,,191.08,percent of total billed charges,Implant Device,278.19,,,278.19,Other,110% of Medicare,196.7,35,,196.7,percent of total billed charges,Implant Device,191.08,34,"Charges > $500, x 34%",191.08,percent of total billed charges,Implant Device,196.7,35,,196.7,percent of total billed charges,Implant Device,196.7,35,,196.7,percent of total billed charges,Implant Device,196.7,35,,196.7,percent of total billed charges,Implant Device,196.7,35,,196.7,percent of total billed charges,Implant Device,196.7,35,,196.7,percent of total billed charges,Implant Device,224.8,40,,224.8,percent of total billed charges,Implant Device,196.7,70,,196.7,percent of total billed charges,All Other,191.08,34,,191.08,percent of total billed charges,Implant Device,191.08,34,,191.08,percent of total billed charges,Implant Device,196.7,35,,196.7,percent of total billed charges,Implant Device,196.7,35,,196.7,percent of total billed charges,Implant Device,196.7,35,,196.7,percent of total billed charges,Implant Device,196.7,35,,196.7,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,415.88,
SYNTHES 207.632 CANNULATED SCREW 4X32MM,C1713,HCPCS,,79001374,CDM,278,RC,,,both,,,798,590.52,,,590.52,Other,150% of Medicare + 9.63% HCRA Surcharge,359.1,45,,359.1,percent of total billed charges,Critical Access Hospital RCC factor,271.32,34,,271.32,percent of total billed charges,Implant Device,271.32,34,,271.32,percent of total billed charges,Implant Device,271.32,34,,271.32,percent of total billed charges,Implant Device,271.32,34,,271.32,percent of total billed charges,Implant Device,271.32,34,,271.32,percent of total billed charges,Implant Device,395.01,,,395.01,Other,110% of Medicare,279.3,35,,279.3,percent of total billed charges,Implant Device,271.32,34,"Charges > $500, x 34%",271.32,percent of total billed charges,Implant Device,279.3,35,,279.3,percent of total billed charges,Implant Device,279.3,35,,279.3,percent of total billed charges,Implant Device,279.3,35,,279.3,percent of total billed charges,Implant Device,279.3,35,,279.3,percent of total billed charges,Implant Device,279.3,35,,279.3,percent of total billed charges,Implant Device,319.2,40,,319.2,percent of total billed charges,Implant Device,279.3,70,,279.3,percent of total billed charges,All Other,271.32,34,,271.32,percent of total billed charges,Implant Device,271.32,34,,271.32,percent of total billed charges,Implant Device,279.3,35,,279.3,percent of total billed charges,Implant Device,279.3,35,,279.3,percent of total billed charges,Implant Device,279.3,35,,279.3,percent of total billed charges,Implant Device,279.3,35,,279.3,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,590.52,
STRYKER 325034 CANNULATED SCREW 4.0 X 34,C1713,HCPCS,,79001375,CDM,278,RC,,,both,,,824,609.76,,,609.76,Other,150% of Medicare + 9.63% HCRA Surcharge,370.8,45,,370.8,percent of total billed charges,Critical Access Hospital RCC factor,280.16,34,,280.16,percent of total billed charges,Implant Device,280.16,34,,280.16,percent of total billed charges,Implant Device,280.16,34,,280.16,percent of total billed charges,Implant Device,280.16,34,,280.16,percent of total billed charges,Implant Device,280.16,34,,280.16,percent of total billed charges,Implant Device,407.88,,,407.88,Other,110% of Medicare,288.4,35,,288.4,percent of total billed charges,Implant Device,280.16,34,"Charges > $500, x 34%",280.16,percent of total billed charges,Implant Device,288.4,35,,288.4,percent of total billed charges,Implant Device,288.4,35,,288.4,percent of total billed charges,Implant Device,288.4,35,,288.4,percent of total billed charges,Implant Device,288.4,35,,288.4,percent of total billed charges,Implant Device,288.4,35,,288.4,percent of total billed charges,Implant Device,329.6,40,,329.6,percent of total billed charges,Implant Device,288.4,70,,288.4,percent of total billed charges,All Other,280.16,34,,280.16,percent of total billed charges,Implant Device,280.16,34,,280.16,percent of total billed charges,Implant Device,288.4,35,,288.4,percent of total billed charges,Implant Device,288.4,35,,288.4,percent of total billed charges,Implant Device,288.4,35,,288.4,percent of total billed charges,Implant Device,288.4,35,,288.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,609.76,
STRYKER 325036 CANNULATED SCREW 4.0 X 36,C1713,HCPCS,,79001376,CDM,278,RC,,,both,,,824,609.76,,,609.76,Other,150% of Medicare + 9.63% HCRA Surcharge,370.8,45,,370.8,percent of total billed charges,Critical Access Hospital RCC factor,280.16,34,,280.16,percent of total billed charges,Implant Device,280.16,34,,280.16,percent of total billed charges,Implant Device,280.16,34,,280.16,percent of total billed charges,Implant Device,280.16,34,,280.16,percent of total billed charges,Implant Device,280.16,34,,280.16,percent of total billed charges,Implant Device,407.88,,,407.88,Other,110% of Medicare,288.4,35,,288.4,percent of total billed charges,Implant Device,280.16,34,"Charges > $500, x 34%",280.16,percent of total billed charges,Implant Device,288.4,35,,288.4,percent of total billed charges,Implant Device,288.4,35,,288.4,percent of total billed charges,Implant Device,288.4,35,,288.4,percent of total billed charges,Implant Device,288.4,35,,288.4,percent of total billed charges,Implant Device,288.4,35,,288.4,percent of total billed charges,Implant Device,329.6,40,,329.6,percent of total billed charges,Implant Device,288.4,70,,288.4,percent of total billed charges,All Other,280.16,34,,280.16,percent of total billed charges,Implant Device,280.16,34,,280.16,percent of total billed charges,Implant Device,288.4,35,,288.4,percent of total billed charges,Implant Device,288.4,35,,288.4,percent of total billed charges,Implant Device,288.4,35,,288.4,percent of total billed charges,Implant Device,288.4,35,,288.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,609.76,
SYNTHES 207.64 CANNULATED SCREW 4.0X40MM,C1713,HCPCS,,79001377,CDM,278,RC,,,both,,,815,603.1,,,603.1,Other,150% of Medicare + 9.63% HCRA Surcharge,366.75,45,,366.75,percent of total billed charges,Critical Access Hospital RCC factor,277.1,34,,277.1,percent of total billed charges,Implant Device,277.1,34,,277.1,percent of total billed charges,Implant Device,277.1,34,,277.1,percent of total billed charges,Implant Device,277.1,34,,277.1,percent of total billed charges,Implant Device,277.1,34,,277.1,percent of total billed charges,Implant Device,403.43,,,403.43,Other,110% of Medicare,285.25,35,,285.25,percent of total billed charges,Implant Device,277.1,34,"Charges > $500, x 34%",277.1,percent of total billed charges,Implant Device,285.25,35,,285.25,percent of total billed charges,Implant Device,285.25,35,,285.25,percent of total billed charges,Implant Device,285.25,35,,285.25,percent of total billed charges,Implant Device,285.25,35,,285.25,percent of total billed charges,Implant Device,285.25,35,,285.25,percent of total billed charges,Implant Device,326,40,,326,percent of total billed charges,Implant Device,285.25,70,,285.25,percent of total billed charges,All Other,277.1,34,,277.1,percent of total billed charges,Implant Device,277.1,34,,277.1,percent of total billed charges,Implant Device,285.25,35,,285.25,percent of total billed charges,Implant Device,285.25,35,,285.25,percent of total billed charges,Implant Device,285.25,35,,285.25,percent of total billed charges,Implant Device,285.25,35,,285.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,603.1,
STRYKER 325242 CANNULATED SCREW 4.0 X 42,C1713,HCPCS,,79001378,CDM,278,RC,,,both,,,535,395.9,,,395.9,Other,150% of Medicare + 9.63% HCRA Surcharge,240.75,45,,240.75,percent of total billed charges,Critical Access Hospital RCC factor,181.9,34,,181.9,percent of total billed charges,Implant Device,181.9,34,,181.9,percent of total billed charges,Implant Device,181.9,34,,181.9,percent of total billed charges,Implant Device,181.9,34,,181.9,percent of total billed charges,Implant Device,181.9,34,,181.9,percent of total billed charges,Implant Device,264.83,,,264.83,Other,110% of Medicare,187.25,35,,187.25,percent of total billed charges,Implant Device,181.9,34,"Charges > $500, x 34%",181.9,percent of total billed charges,Implant Device,187.25,35,,187.25,percent of total billed charges,Implant Device,187.25,35,,187.25,percent of total billed charges,Implant Device,187.25,35,,187.25,percent of total billed charges,Implant Device,187.25,35,,187.25,percent of total billed charges,Implant Device,187.25,35,,187.25,percent of total billed charges,Implant Device,214,40,,214,percent of total billed charges,Implant Device,187.25,70,,187.25,percent of total billed charges,All Other,181.9,34,,181.9,percent of total billed charges,Implant Device,181.9,34,,181.9,percent of total billed charges,Implant Device,187.25,35,,187.25,percent of total billed charges,Implant Device,187.25,35,,187.25,percent of total billed charges,Implant Device,187.25,35,,187.25,percent of total billed charges,Implant Device,187.25,35,,187.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,395.9,
STRYKER 325244 CANNULATED SCREW 4.0 X 44,C1713,HCPCS,,79001379,CDM,278,RC,,,both,,,571,422.54,,,422.54,Other,150% of Medicare + 9.63% HCRA Surcharge,256.95,45,,256.95,percent of total billed charges,Critical Access Hospital RCC factor,194.14,34,,194.14,percent of total billed charges,Implant Device,194.14,34,,194.14,percent of total billed charges,Implant Device,194.14,34,,194.14,percent of total billed charges,Implant Device,194.14,34,,194.14,percent of total billed charges,Implant Device,194.14,34,,194.14,percent of total billed charges,Implant Device,282.65,,,282.65,Other,110% of Medicare,199.85,35,,199.85,percent of total billed charges,Implant Device,194.14,34,"Charges > $500, x 34%",194.14,percent of total billed charges,Implant Device,199.85,35,,199.85,percent of total billed charges,Implant Device,199.85,35,,199.85,percent of total billed charges,Implant Device,199.85,35,,199.85,percent of total billed charges,Implant Device,199.85,35,,199.85,percent of total billed charges,Implant Device,199.85,35,,199.85,percent of total billed charges,Implant Device,228.4,40,,228.4,percent of total billed charges,Implant Device,199.85,70,,199.85,percent of total billed charges,All Other,194.14,34,,194.14,percent of total billed charges,Implant Device,194.14,34,,194.14,percent of total billed charges,Implant Device,199.85,35,,199.85,percent of total billed charges,Implant Device,199.85,35,,199.85,percent of total billed charges,Implant Device,199.85,35,,199.85,percent of total billed charges,Implant Device,199.85,35,,199.85,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,422.54,
SYNTHES 207.65 CANNULATED SCREW 4.0X50MM,C1713,HCPCS,,79001380,CDM,278,RC,,,both,,,685,506.9,,,506.9,Other,150% of Medicare + 9.63% HCRA Surcharge,308.25,45,,308.25,percent of total billed charges,Critical Access Hospital RCC factor,232.9,34,,232.9,percent of total billed charges,Implant Device,232.9,34,,232.9,percent of total billed charges,Implant Device,232.9,34,,232.9,percent of total billed charges,Implant Device,232.9,34,,232.9,percent of total billed charges,Implant Device,232.9,34,,232.9,percent of total billed charges,Implant Device,339.08,,,339.08,Other,110% of Medicare,239.75,35,,239.75,percent of total billed charges,Implant Device,232.9,34,"Charges > $500, x 34%",232.9,percent of total billed charges,Implant Device,239.75,35,,239.75,percent of total billed charges,Implant Device,239.75,35,,239.75,percent of total billed charges,Implant Device,239.75,35,,239.75,percent of total billed charges,Implant Device,239.75,35,,239.75,percent of total billed charges,Implant Device,239.75,35,,239.75,percent of total billed charges,Implant Device,274,40,,274,percent of total billed charges,Implant Device,239.75,70,,239.75,percent of total billed charges,All Other,232.9,34,,232.9,percent of total billed charges,Implant Device,232.9,34,,232.9,percent of total billed charges,Implant Device,239.75,35,,239.75,percent of total billed charges,Implant Device,239.75,35,,239.75,percent of total billed charges,Implant Device,239.75,35,,239.75,percent of total billed charges,Implant Device,239.75,35,,239.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,506.9,
STRYKER 355040S CANNULATED SCREW 40MM,C1713,HCPCS,,79001384,CDM,278,RC,,,both,,,575,425.5,,,425.5,Other,150% of Medicare + 9.63% HCRA Surcharge,258.75,45,,258.75,percent of total billed charges,Critical Access Hospital RCC factor,195.5,34,,195.5,percent of total billed charges,Implant Device,195.5,34,,195.5,percent of total billed charges,Implant Device,195.5,34,,195.5,percent of total billed charges,Implant Device,195.5,34,,195.5,percent of total billed charges,Implant Device,195.5,34,,195.5,percent of total billed charges,Implant Device,284.63,,,284.63,Other,110% of Medicare,201.25,35,,201.25,percent of total billed charges,Implant Device,195.5,34,"Charges > $500, x 34%",195.5,percent of total billed charges,Implant Device,201.25,35,,201.25,percent of total billed charges,Implant Device,201.25,35,,201.25,percent of total billed charges,Implant Device,201.25,35,,201.25,percent of total billed charges,Implant Device,201.25,35,,201.25,percent of total billed charges,Implant Device,201.25,35,,201.25,percent of total billed charges,Implant Device,230,40,,230,percent of total billed charges,Implant Device,201.25,70,,201.25,percent of total billed charges,All Other,195.5,34,,195.5,percent of total billed charges,Implant Device,195.5,34,,195.5,percent of total billed charges,Implant Device,201.25,35,,201.25,percent of total billed charges,Implant Device,201.25,35,,201.25,percent of total billed charges,Implant Device,201.25,35,,201.25,percent of total billed charges,Implant Device,201.25,35,,201.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,425.5,
STRYKER 355042S CANNULATED SCREW 42MM,C1713,HCPCS,,79001385,CDM,278,RC,,,both,,,575,425.5,,,425.5,Other,150% of Medicare + 9.63% HCRA Surcharge,258.75,45,,258.75,percent of total billed charges,Critical Access Hospital RCC factor,195.5,34,,195.5,percent of total billed charges,Implant Device,195.5,34,,195.5,percent of total billed charges,Implant Device,195.5,34,,195.5,percent of total billed charges,Implant Device,195.5,34,,195.5,percent of total billed charges,Implant Device,195.5,34,,195.5,percent of total billed charges,Implant Device,284.63,,,284.63,Other,110% of Medicare,201.25,35,,201.25,percent of total billed charges,Implant Device,195.5,34,"Charges > $500, x 34%",195.5,percent of total billed charges,Implant Device,201.25,35,,201.25,percent of total billed charges,Implant Device,201.25,35,,201.25,percent of total billed charges,Implant Device,201.25,35,,201.25,percent of total billed charges,Implant Device,201.25,35,,201.25,percent of total billed charges,Implant Device,201.25,35,,201.25,percent of total billed charges,Implant Device,230,40,,230,percent of total billed charges,Implant Device,201.25,70,,201.25,percent of total billed charges,All Other,195.5,34,,195.5,percent of total billed charges,Implant Device,195.5,34,,195.5,percent of total billed charges,Implant Device,201.25,35,,201.25,percent of total billed charges,Implant Device,201.25,35,,201.25,percent of total billed charges,Implant Device,201.25,35,,201.25,percent of total billed charges,Implant Device,201.25,35,,201.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,425.5,
SYNTHES 208.85 CANNULATED SCREW 7.3X50MM,C1713,HCPCS,,79001386,CDM,278,RC,,,both,,,1042,771.08,,,771.08,Other,150% of Medicare + 9.63% HCRA Surcharge,468.9,45,,468.9,percent of total billed charges,Critical Access Hospital RCC factor,354.28,34,,354.28,percent of total billed charges,Implant Device,354.28,34,,354.28,percent of total billed charges,Implant Device,354.28,34,,354.28,percent of total billed charges,Implant Device,354.28,34,,354.28,percent of total billed charges,Implant Device,354.28,34,,354.28,percent of total billed charges,Implant Device,515.79,,,515.79,Other,110% of Medicare,364.7,35,,364.7,percent of total billed charges,Implant Device,354.28,34,"Charges > $500, x 34%",354.28,percent of total billed charges,Implant Device,364.7,35,,364.7,percent of total billed charges,Implant Device,364.7,35,,364.7,percent of total billed charges,Implant Device,364.7,35,,364.7,percent of total billed charges,Implant Device,364.7,35,,364.7,percent of total billed charges,Implant Device,364.7,35,,364.7,percent of total billed charges,Implant Device,416.8,40,,416.8,percent of total billed charges,Implant Device,364.7,70,,364.7,percent of total billed charges,All Other,354.28,34,,354.28,percent of total billed charges,Implant Device,354.28,34,,354.28,percent of total billed charges,Implant Device,364.7,35,,364.7,percent of total billed charges,Implant Device,364.7,35,,364.7,percent of total billed charges,Implant Device,364.7,35,,364.7,percent of total billed charges,Implant Device,364.7,35,,364.7,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,771.08,
BARD 0123790 COMPOSIX E/X MESH,C1781,HCPCS,,79001387,CDM,278,RC,,,both,,,3426,2535.25,,,2535.25,Other,150% of Medicare + 9.63% HCRA Surcharge,1541.7,45,,1541.7,percent of total billed charges,Critical Access Hospital RCC factor,1164.84,34,,1164.84,percent of total billed charges,Implant Device,1164.84,34,,1164.84,percent of total billed charges,Implant Device,1164.84,34,,1164.84,percent of total billed charges,Implant Device,1164.84,34,,1164.84,percent of total billed charges,Implant Device,1164.84,34,,1164.84,percent of total billed charges,Implant Device,1695.87,,,1695.87,Other,110% of Medicare,1199.1,35,,1199.1,percent of total billed charges,Implant Device,1164.84,34,"Charges > $500, x 34%",1164.84,percent of total billed charges,Implant Device,1199.1,35,,1199.1,percent of total billed charges,Implant Device,1199.1,35,,1199.1,percent of total billed charges,Implant Device,1199.1,35,,1199.1,percent of total billed charges,Implant Device,1199.1,35,,1199.1,percent of total billed charges,Implant Device,1199.1,35,,1199.1,percent of total billed charges,Implant Device,1370.4,40,,1370.4,percent of total billed charges,Implant Device,1199.1,70,,1199.1,percent of total billed charges,All Other,1164.84,34,,1164.84,percent of total billed charges,Implant Device,1164.84,34,,1164.84,percent of total billed charges,Implant Device,1199.1,35,,1199.1,percent of total billed charges,Implant Device,1199.1,35,,1199.1,percent of total billed charges,Implant Device,1199.1,35,,1199.1,percent of total billed charges,Implant Device,1199.1,35,,1199.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1164.84,34,"If Charge > 2,000, then 34 percent",1164.84,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2535.25,
COMPOSIX KUGEL MESH PATCH   CIRCLE,C1781,HCPCS,,79001388,CDM,278,RC,,,both,,,2262,1673.89,,,1673.89,Other,150% of Medicare + 9.63% HCRA Surcharge,1017.9,45,,1017.9,percent of total billed charges,Critical Access Hospital RCC factor,769.08,34,,769.08,percent of total billed charges,Implant Device,769.08,34,,769.08,percent of total billed charges,Implant Device,769.08,34,,769.08,percent of total billed charges,Implant Device,769.08,34,,769.08,percent of total billed charges,Implant Device,769.08,34,,769.08,percent of total billed charges,Implant Device,1119.69,,,1119.69,Other,110% of Medicare,791.7,35,,791.7,percent of total billed charges,Implant Device,769.08,34,"Charges > $500, x 34%",769.08,percent of total billed charges,Implant Device,791.7,35,,791.7,percent of total billed charges,Implant Device,791.7,35,,791.7,percent of total billed charges,Implant Device,791.7,35,,791.7,percent of total billed charges,Implant Device,791.7,35,,791.7,percent of total billed charges,Implant Device,791.7,35,,791.7,percent of total billed charges,Implant Device,904.8,40,,904.8,percent of total billed charges,Implant Device,791.7,70,,791.7,percent of total billed charges,All Other,769.08,34,,769.08,percent of total billed charges,Implant Device,769.08,34,,769.08,percent of total billed charges,Implant Device,791.7,35,,791.7,percent of total billed charges,Implant Device,791.7,35,,791.7,percent of total billed charges,Implant Device,791.7,35,,791.7,percent of total billed charges,Implant Device,791.7,35,,791.7,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,769.08,34,"If Charge > 2,000, then 34 percent",769.08,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1673.89,
COMPOSIX KUGEL MESH XL OVAL 10.8X13.7,C1781,HCPCS,,79001389,CDM,278,RC,,,both,,,3184,2356.17,,,2356.17,Other,150% of Medicare + 9.63% HCRA Surcharge,1432.8,45,,1432.8,percent of total billed charges,Critical Access Hospital RCC factor,1082.56,34,,1082.56,percent of total billed charges,Implant Device,1082.56,34,,1082.56,percent of total billed charges,Implant Device,1082.56,34,,1082.56,percent of total billed charges,Implant Device,1082.56,34,,1082.56,percent of total billed charges,Implant Device,1082.56,34,,1082.56,percent of total billed charges,Implant Device,1576.08,,,1576.08,Other,110% of Medicare,1114.4,35,,1114.4,percent of total billed charges,Implant Device,1082.56,34,"Charges > $500, x 34%",1082.56,percent of total billed charges,Implant Device,1114.4,35,,1114.4,percent of total billed charges,Implant Device,1114.4,35,,1114.4,percent of total billed charges,Implant Device,1114.4,35,,1114.4,percent of total billed charges,Implant Device,1114.4,35,,1114.4,percent of total billed charges,Implant Device,1114.4,35,,1114.4,percent of total billed charges,Implant Device,1273.6,40,,1273.6,percent of total billed charges,Implant Device,1114.4,70,,1114.4,percent of total billed charges,All Other,1082.56,34,,1082.56,percent of total billed charges,Implant Device,1082.56,34,,1082.56,percent of total billed charges,Implant Device,1114.4,35,,1114.4,percent of total billed charges,Implant Device,1114.4,35,,1114.4,percent of total billed charges,Implant Device,1114.4,35,,1114.4,percent of total billed charges,Implant Device,1114.4,35,,1114.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1082.56,34,"If Charge > 2,000, then 34 percent",1082.56,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2356.17,
COMPOSIX KUGEL MESH XL OVAL 7.7 X9.7,C1781,HCPCS,,79001390,CDM,278,RC,,,both,,,2243,1659.83,,,1659.83,Other,150% of Medicare + 9.63% HCRA Surcharge,1009.35,45,,1009.35,percent of total billed charges,Critical Access Hospital RCC factor,762.62,34,,762.62,percent of total billed charges,Implant Device,762.62,34,,762.62,percent of total billed charges,Implant Device,762.62,34,,762.62,percent of total billed charges,Implant Device,762.62,34,,762.62,percent of total billed charges,Implant Device,762.62,34,,762.62,percent of total billed charges,Implant Device,1110.29,,,1110.29,Other,110% of Medicare,785.05,35,,785.05,percent of total billed charges,Implant Device,762.62,34,"Charges > $500, x 34%",762.62,percent of total billed charges,Implant Device,785.05,35,,785.05,percent of total billed charges,Implant Device,785.05,35,,785.05,percent of total billed charges,Implant Device,785.05,35,,785.05,percent of total billed charges,Implant Device,785.05,35,,785.05,percent of total billed charges,Implant Device,785.05,35,,785.05,percent of total billed charges,Implant Device,897.2,40,,897.2,percent of total billed charges,Implant Device,785.05,70,,785.05,percent of total billed charges,All Other,762.62,34,,762.62,percent of total billed charges,Implant Device,762.62,34,,762.62,percent of total billed charges,Implant Device,785.05,35,,785.05,percent of total billed charges,Implant Device,785.05,35,,785.05,percent of total billed charges,Implant Device,785.05,35,,785.05,percent of total billed charges,Implant Device,785.05,35,,785.05,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,762.62,34,"If Charge > 2,000, then 34 percent",762.62,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1659.83,
BARD DAVOL INC. 123460 COMPOSIX MESH,C1781,HCPCS,,79001391,CDM,278,RC,,,both,,,721,533.54,,,533.54,Other,150% of Medicare + 9.63% HCRA Surcharge,324.45,45,,324.45,percent of total billed charges,Critical Access Hospital RCC factor,245.14,34,,245.14,percent of total billed charges,Implant Device,245.14,34,,245.14,percent of total billed charges,Implant Device,245.14,34,,245.14,percent of total billed charges,Implant Device,245.14,34,,245.14,percent of total billed charges,Implant Device,245.14,34,,245.14,percent of total billed charges,Implant Device,356.9,,,356.9,Other,110% of Medicare,252.35,35,,252.35,percent of total billed charges,Implant Device,245.14,34,"Charges > $500, x 34%",245.14,percent of total billed charges,Implant Device,252.35,35,,252.35,percent of total billed charges,Implant Device,252.35,35,,252.35,percent of total billed charges,Implant Device,252.35,35,,252.35,percent of total billed charges,Implant Device,252.35,35,,252.35,percent of total billed charges,Implant Device,252.35,35,,252.35,percent of total billed charges,Implant Device,288.4,40,,288.4,percent of total billed charges,Implant Device,252.35,70,,252.35,percent of total billed charges,All Other,245.14,34,,245.14,percent of total billed charges,Implant Device,245.14,34,,245.14,percent of total billed charges,Implant Device,252.35,35,,252.35,percent of total billed charges,Implant Device,252.35,35,,252.35,percent of total billed charges,Implant Device,252.35,35,,252.35,percent of total billed charges,Implant Device,252.35,35,,252.35,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,533.54,
BARD 651005 CONTIGEN COLLAGEN IMPLANT,C1763,HCPCS,,79001392,CDM,278,RC,,,both,,,1050,777,,,777,Other,150% of Medicare + 9.63% HCRA Surcharge,472.5,45,,472.5,percent of total billed charges,Critical Access Hospital RCC factor,357,34,,357,percent of total billed charges,Implant Device,357,34,,357,percent of total billed charges,Implant Device,357,34,,357,percent of total billed charges,Implant Device,357,34,,357,percent of total billed charges,Implant Device,357,34,,357,percent of total billed charges,Implant Device,519.75,,,519.75,Other,110% of Medicare,367.5,35,,367.5,percent of total billed charges,Implant Device,357,34,"Charges > $500, x 34%",357,percent of total billed charges,Implant Device,367.5,35,,367.5,percent of total billed charges,Implant Device,367.5,35,,367.5,percent of total billed charges,Implant Device,367.5,35,,367.5,percent of total billed charges,Implant Device,367.5,35,,367.5,percent of total billed charges,Implant Device,367.5,35,,367.5,percent of total billed charges,Implant Device,420,40,,420,percent of total billed charges,Implant Device,367.5,70,,367.5,percent of total billed charges,All Other,357,34,,357,percent of total billed charges,Implant Device,357,34,,357,percent of total billed charges,Implant Device,367.5,35,,367.5,percent of total billed charges,Implant Device,367.5,35,,367.5,percent of total billed charges,Implant Device,367.5,35,,367.5,percent of total billed charges,Implant Device,367.5,35,,367.5,percent of total billed charges,Implant Device,976.07,,,976.07,Other,100% of Medicaid,976.07,,,976.07,Other,100% of Medicaid,976.07,,,976.07,Other,100% of Medicaid,976.07,,,976.07,Other,100% of Medicaid,2196.16,,,2196.16,Other,225% of Medicaid,1493.39,,,1493.39,Other,153% of Medicaid,2196.16,,,2196.16,Other,225% of Medicaid,1366.5,,,1366.5,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,2537.78,,,2537.78,Other,260% of Medicaid,3162.47,,,3162.47,Other,324% of Medicaid,2098.55,,,2098.55,Other,215% of Medicaid,2098.55,,,2098.55,Other,215% of Medicaid,1220.09,,,1220.09,Other,125% of Medicaid,0.01,3162.47,
ARTHREX AR-1925SF SUTURE ANCHOR 6.5X15.5,C1713,HCPCS,,79001393,CDM,278,RC,,,both,,,586,433.64,,,433.64,Other,150% of Medicare + 9.63% HCRA Surcharge,263.7,45,,263.7,percent of total billed charges,Critical Access Hospital RCC factor,199.24,34,,199.24,percent of total billed charges,Implant Device,199.24,34,,199.24,percent of total billed charges,Implant Device,199.24,34,,199.24,percent of total billed charges,Implant Device,199.24,34,,199.24,percent of total billed charges,Implant Device,199.24,34,,199.24,percent of total billed charges,Implant Device,290.07,,,290.07,Other,110% of Medicare,205.1,35,,205.1,percent of total billed charges,Implant Device,199.24,34,"Charges > $500, x 34%",199.24,percent of total billed charges,Implant Device,205.1,35,,205.1,percent of total billed charges,Implant Device,205.1,35,,205.1,percent of total billed charges,Implant Device,205.1,35,,205.1,percent of total billed charges,Implant Device,205.1,35,,205.1,percent of total billed charges,Implant Device,205.1,35,,205.1,percent of total billed charges,Implant Device,234.4,40,,234.4,percent of total billed charges,Implant Device,205.1,70,,205.1,percent of total billed charges,All Other,199.24,34,,199.24,percent of total billed charges,Implant Device,199.24,34,,199.24,percent of total billed charges,Implant Device,205.1,35,,205.1,percent of total billed charges,Implant Device,205.1,35,,205.1,percent of total billed charges,Implant Device,205.1,35,,205.1,percent of total billed charges,Implant Device,205.1,35,,205.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,433.64,
SYNTHES 202.012 CORTEX SCREW 2.7 X 12MM,C1713,HCPCS,,79001394,CDM,278,RC,,,both,,,460,340.4,,,340.4,Other,150% of Medicare + 9.63% HCRA Surcharge,207,45,,207,percent of total billed charges,Critical Access Hospital RCC factor,156.4,34,,156.4,percent of total billed charges,Implant Device,156.4,34,,156.4,percent of total billed charges,Implant Device,156.4,34,,156.4,percent of total billed charges,Implant Device,156.4,34,,156.4,percent of total billed charges,Implant Device,156.4,34,,156.4,percent of total billed charges,Implant Device,227.7,,,227.7,Other,110% of Medicare,161,35,,161,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,161,35,,161,percent of total billed charges,Implant Device,161,35,,161,percent of total billed charges,Implant Device,161,35,,161,percent of total billed charges,Implant Device,161,35,,161,percent of total billed charges,Implant Device,161,35,,161,percent of total billed charges,Implant Device,184,40,,184,percent of total billed charges,Implant Device,161,70,,161,percent of total billed charges,All Other,156.4,34,,156.4,percent of total billed charges,Implant Device,156.4,34,,156.4,percent of total billed charges,Implant Device,161,35,,161,percent of total billed charges,Implant Device,161,35,,161,percent of total billed charges,Implant Device,161,35,,161,percent of total billed charges,Implant Device,161,35,,161,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,340.4,
SYNTHES 202.014 CORTEX SCREW 2.7 X 14MM,C1713,HCPCS,,79001395,CDM,278,RC,,,both,,,134,99.16,,,99.16,Other,150% of Medicare + 9.63% HCRA Surcharge,60.3,45,,60.3,percent of total billed charges,Critical Access Hospital RCC factor,45.56,34,,45.56,percent of total billed charges,Implant Device,45.56,34,,45.56,percent of total billed charges,Implant Device,45.56,34,,45.56,percent of total billed charges,Implant Device,45.56,34,,45.56,percent of total billed charges,Implant Device,45.56,34,,45.56,percent of total billed charges,Implant Device,66.33,,,66.33,Other,110% of Medicare,46.9,35,,46.9,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,46.9,35,,46.9,percent of total billed charges,Implant Device,46.9,35,,46.9,percent of total billed charges,Implant Device,46.9,35,,46.9,percent of total billed charges,Implant Device,46.9,35,,46.9,percent of total billed charges,Implant Device,46.9,35,,46.9,percent of total billed charges,Implant Device,53.6,40,,53.6,percent of total billed charges,Implant Device,46.9,70,,46.9,percent of total billed charges,All Other,45.56,34,,45.56,percent of total billed charges,Implant Device,45.56,34,,45.56,percent of total billed charges,Implant Device,46.9,35,,46.9,percent of total billed charges,Implant Device,46.9,35,,46.9,percent of total billed charges,Implant Device,46.9,35,,46.9,percent of total billed charges,Implant Device,46.9,35,,46.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,99.16,
SYNTHES 202.016 CORTEX SCREW 2.7 X 16MM,C1713,HCPCS,,79001396,CDM,278,RC,,,both,,,122,90.28,,,90.28,Other,150% of Medicare + 9.63% HCRA Surcharge,54.9,45,,54.9,percent of total billed charges,Critical Access Hospital RCC factor,41.48,34,,41.48,percent of total billed charges,Implant Device,41.48,34,,41.48,percent of total billed charges,Implant Device,41.48,34,,41.48,percent of total billed charges,Implant Device,41.48,34,,41.48,percent of total billed charges,Implant Device,41.48,34,,41.48,percent of total billed charges,Implant Device,60.39,,,60.39,Other,110% of Medicare,42.7,35,,42.7,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,42.7,35,,42.7,percent of total billed charges,Implant Device,42.7,35,,42.7,percent of total billed charges,Implant Device,42.7,35,,42.7,percent of total billed charges,Implant Device,42.7,35,,42.7,percent of total billed charges,Implant Device,42.7,35,,42.7,percent of total billed charges,Implant Device,48.8,40,,48.8,percent of total billed charges,Implant Device,42.7,70,,42.7,percent of total billed charges,All Other,41.48,34,,41.48,percent of total billed charges,Implant Device,41.48,34,,41.48,percent of total billed charges,Implant Device,42.7,35,,42.7,percent of total billed charges,Implant Device,42.7,35,,42.7,percent of total billed charges,Implant Device,42.7,35,,42.7,percent of total billed charges,Implant Device,42.7,35,,42.7,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,90.28,
SYNTHES 202.018 CORTEX SCREW 2.7 X 18MM,C1713,HCPCS,,79001397,CDM,278,RC,,,both,,,460,340.4,,,340.4,Other,150% of Medicare + 9.63% HCRA Surcharge,207,45,,207,percent of total billed charges,Critical Access Hospital RCC factor,156.4,34,,156.4,percent of total billed charges,Implant Device,156.4,34,,156.4,percent of total billed charges,Implant Device,156.4,34,,156.4,percent of total billed charges,Implant Device,156.4,34,,156.4,percent of total billed charges,Implant Device,156.4,34,,156.4,percent of total billed charges,Implant Device,227.7,,,227.7,Other,110% of Medicare,161,35,,161,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,161,35,,161,percent of total billed charges,Implant Device,161,35,,161,percent of total billed charges,Implant Device,161,35,,161,percent of total billed charges,Implant Device,161,35,,161,percent of total billed charges,Implant Device,161,35,,161,percent of total billed charges,Implant Device,184,40,,184,percent of total billed charges,Implant Device,161,70,,161,percent of total billed charges,All Other,156.4,34,,156.4,percent of total billed charges,Implant Device,156.4,34,,156.4,percent of total billed charges,Implant Device,161,35,,161,percent of total billed charges,Implant Device,161,35,,161,percent of total billed charges,Implant Device,161,35,,161,percent of total billed charges,Implant Device,161,35,,161,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,340.4,
SYNTHES 202.02 CORTEX SCREW 2.7 X 20MM,C1713,HCPCS,,79001398,CDM,278,RC,,,both,,,34,25.16,,,25.16,Other,150% of Medicare + 9.63% HCRA Surcharge,15.3,45,,15.3,percent of total billed charges,Critical Access Hospital RCC factor,11.56,34,,11.56,percent of total billed charges,Implant Device,11.56,34,,11.56,percent of total billed charges,Implant Device,11.56,34,,11.56,percent of total billed charges,Implant Device,11.56,34,,11.56,percent of total billed charges,Implant Device,11.56,34,,11.56,percent of total billed charges,Implant Device,16.83,,,16.83,Other,110% of Medicare,11.9,35,,11.9,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,11.9,35,,11.9,percent of total billed charges,Implant Device,11.9,35,,11.9,percent of total billed charges,Implant Device,11.9,35,,11.9,percent of total billed charges,Implant Device,11.9,35,,11.9,percent of total billed charges,Implant Device,11.9,35,,11.9,percent of total billed charges,Implant Device,13.6,40,,13.6,percent of total billed charges,Implant Device,11.9,70,,11.9,percent of total billed charges,All Other,11.56,34,,11.56,percent of total billed charges,Implant Device,11.56,34,,11.56,percent of total billed charges,Implant Device,11.9,35,,11.9,percent of total billed charges,Implant Device,11.9,35,,11.9,percent of total billed charges,Implant Device,11.9,35,,11.9,percent of total billed charges,Implant Device,11.9,35,,11.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,25.16,
SYNTHES 200.012 CORTEX SCREW 1.5 X 12MM,C1713,HCPCS,,79001399,CDM,278,RC,,,both,,,104,76.96,,,76.96,Other,150% of Medicare + 9.63% HCRA Surcharge,46.8,45,,46.8,percent of total billed charges,Critical Access Hospital RCC factor,35.36,34,,35.36,percent of total billed charges,Implant Device,35.36,34,,35.36,percent of total billed charges,Implant Device,35.36,34,,35.36,percent of total billed charges,Implant Device,35.36,34,,35.36,percent of total billed charges,Implant Device,35.36,34,,35.36,percent of total billed charges,Implant Device,51.48,,,51.48,Other,110% of Medicare,36.4,35,,36.4,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,36.4,35,,36.4,percent of total billed charges,Implant Device,36.4,35,,36.4,percent of total billed charges,Implant Device,36.4,35,,36.4,percent of total billed charges,Implant Device,36.4,35,,36.4,percent of total billed charges,Implant Device,36.4,35,,36.4,percent of total billed charges,Implant Device,41.6,40,,41.6,percent of total billed charges,Implant Device,36.4,70,,36.4,percent of total billed charges,All Other,35.36,34,,35.36,percent of total billed charges,Implant Device,35.36,34,,35.36,percent of total billed charges,Implant Device,36.4,35,,36.4,percent of total billed charges,Implant Device,36.4,35,,36.4,percent of total billed charges,Implant Device,36.4,35,,36.4,percent of total billed charges,Implant Device,36.4,35,,36.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,76.96,
SYNTHES 200.007 CORTEX SCREW 1.5 X 7MM,C1713,HCPCS,,79001400,CDM,278,RC,,,both,,,35,25.9,,,25.9,Other,150% of Medicare + 9.63% HCRA Surcharge,15.75,45,,15.75,percent of total billed charges,Critical Access Hospital RCC factor,11.9,34,,11.9,percent of total billed charges,Implant Device,11.9,34,,11.9,percent of total billed charges,Implant Device,11.9,34,,11.9,percent of total billed charges,Implant Device,11.9,34,,11.9,percent of total billed charges,Implant Device,11.9,34,,11.9,percent of total billed charges,Implant Device,17.33,,,17.33,Other,110% of Medicare,12.25,35,,12.25,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,12.25,35,,12.25,percent of total billed charges,Implant Device,12.25,35,,12.25,percent of total billed charges,Implant Device,12.25,35,,12.25,percent of total billed charges,Implant Device,12.25,35,,12.25,percent of total billed charges,Implant Device,12.25,35,,12.25,percent of total billed charges,Implant Device,14,40,,14,percent of total billed charges,Implant Device,12.25,70,,12.25,percent of total billed charges,All Other,11.9,34,,11.9,percent of total billed charges,Implant Device,11.9,34,,11.9,percent of total billed charges,Implant Device,12.25,35,,12.25,percent of total billed charges,Implant Device,12.25,35,,12.25,percent of total billed charges,Implant Device,12.25,35,,12.25,percent of total billed charges,Implant Device,12.25,35,,12.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,25.9,
SYNTHES 200.008 CORTEX SCREW 1.5 X 8MM,C1713,HCPCS,,79001401,CDM,278,RC,,,both,,,44,32.56,,,32.56,Other,150% of Medicare + 9.63% HCRA Surcharge,19.8,45,,19.8,percent of total billed charges,Critical Access Hospital RCC factor,14.96,34,,14.96,percent of total billed charges,Implant Device,14.96,34,,14.96,percent of total billed charges,Implant Device,14.96,34,,14.96,percent of total billed charges,Implant Device,14.96,34,,14.96,percent of total billed charges,Implant Device,14.96,34,,14.96,percent of total billed charges,Implant Device,21.78,,,21.78,Other,110% of Medicare,15.4,35,,15.4,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,15.4,35,,15.4,percent of total billed charges,Implant Device,15.4,35,,15.4,percent of total billed charges,Implant Device,15.4,35,,15.4,percent of total billed charges,Implant Device,15.4,35,,15.4,percent of total billed charges,Implant Device,15.4,35,,15.4,percent of total billed charges,Implant Device,17.6,40,,17.6,percent of total billed charges,Implant Device,15.4,70,,15.4,percent of total billed charges,All Other,14.96,34,,14.96,percent of total billed charges,Implant Device,14.96,34,,14.96,percent of total billed charges,Implant Device,15.4,35,,15.4,percent of total billed charges,Implant Device,15.4,35,,15.4,percent of total billed charges,Implant Device,15.4,35,,15.4,percent of total billed charges,Implant Device,15.4,35,,15.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,32.56,
SYNTHES 200.009 CORTEX SCREW 1.5 X 9MM,C1713,HCPCS,,79001402,CDM,278,RC,,,both,,,35,25.9,,,25.9,Other,150% of Medicare + 9.63% HCRA Surcharge,15.75,45,,15.75,percent of total billed charges,Critical Access Hospital RCC factor,11.9,34,,11.9,percent of total billed charges,Implant Device,11.9,34,,11.9,percent of total billed charges,Implant Device,11.9,34,,11.9,percent of total billed charges,Implant Device,11.9,34,,11.9,percent of total billed charges,Implant Device,11.9,34,,11.9,percent of total billed charges,Implant Device,17.33,,,17.33,Other,110% of Medicare,12.25,35,,12.25,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,12.25,35,,12.25,percent of total billed charges,Implant Device,12.25,35,,12.25,percent of total billed charges,Implant Device,12.25,35,,12.25,percent of total billed charges,Implant Device,12.25,35,,12.25,percent of total billed charges,Implant Device,12.25,35,,12.25,percent of total billed charges,Implant Device,14,40,,14,percent of total billed charges,Implant Device,12.25,70,,12.25,percent of total billed charges,All Other,11.9,34,,11.9,percent of total billed charges,Implant Device,11.9,34,,11.9,percent of total billed charges,Implant Device,12.25,35,,12.25,percent of total billed charges,Implant Device,12.25,35,,12.25,percent of total billed charges,Implant Device,12.25,35,,12.25,percent of total billed charges,Implant Device,12.25,35,,12.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,25.9,
SYNTHES 201.01 CORTEX SCREW 2.0 X 10MM,C1713,HCPCS,,79001403,CDM,278,RC,,,both,,,122,90.28,,,90.28,Other,150% of Medicare + 9.63% HCRA Surcharge,54.9,45,,54.9,percent of total billed charges,Critical Access Hospital RCC factor,41.48,34,,41.48,percent of total billed charges,Implant Device,41.48,34,,41.48,percent of total billed charges,Implant Device,41.48,34,,41.48,percent of total billed charges,Implant Device,41.48,34,,41.48,percent of total billed charges,Implant Device,41.48,34,,41.48,percent of total billed charges,Implant Device,60.39,,,60.39,Other,110% of Medicare,42.7,35,,42.7,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,42.7,35,,42.7,percent of total billed charges,Implant Device,42.7,35,,42.7,percent of total billed charges,Implant Device,42.7,35,,42.7,percent of total billed charges,Implant Device,42.7,35,,42.7,percent of total billed charges,Implant Device,42.7,35,,42.7,percent of total billed charges,Implant Device,48.8,40,,48.8,percent of total billed charges,Implant Device,42.7,70,,42.7,percent of total billed charges,All Other,41.48,34,,41.48,percent of total billed charges,Implant Device,41.48,34,,41.48,percent of total billed charges,Implant Device,42.7,35,,42.7,percent of total billed charges,Implant Device,42.7,35,,42.7,percent of total billed charges,Implant Device,42.7,35,,42.7,percent of total billed charges,Implant Device,42.7,35,,42.7,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,90.28,
SYNTHES 201.012 CORTEX SCREW 2.0 X 12MM,C1713,HCPCS,,79001404,CDM,278,RC,,,both,,,118,87.32,,,87.32,Other,150% of Medicare + 9.63% HCRA Surcharge,53.1,45,,53.1,percent of total billed charges,Critical Access Hospital RCC factor,40.12,34,,40.12,percent of total billed charges,Implant Device,40.12,34,,40.12,percent of total billed charges,Implant Device,40.12,34,,40.12,percent of total billed charges,Implant Device,40.12,34,,40.12,percent of total billed charges,Implant Device,40.12,34,,40.12,percent of total billed charges,Implant Device,58.41,,,58.41,Other,110% of Medicare,41.3,35,,41.3,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,41.3,35,,41.3,percent of total billed charges,Implant Device,41.3,35,,41.3,percent of total billed charges,Implant Device,41.3,35,,41.3,percent of total billed charges,Implant Device,41.3,35,,41.3,percent of total billed charges,Implant Device,41.3,35,,41.3,percent of total billed charges,Implant Device,47.2,40,,47.2,percent of total billed charges,Implant Device,41.3,70,,41.3,percent of total billed charges,All Other,40.12,34,,40.12,percent of total billed charges,Implant Device,40.12,34,,40.12,percent of total billed charges,Implant Device,41.3,35,,41.3,percent of total billed charges,Implant Device,41.3,35,,41.3,percent of total billed charges,Implant Device,41.3,35,,41.3,percent of total billed charges,Implant Device,41.3,35,,41.3,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,87.32,
SYNTHES 201.014 CORTEX SCREW 2.0 X 14MM,C1713,HCPCS,,79001405,CDM,278,RC,,,both,,,118,87.32,,,87.32,Other,150% of Medicare + 9.63% HCRA Surcharge,53.1,45,,53.1,percent of total billed charges,Critical Access Hospital RCC factor,40.12,34,,40.12,percent of total billed charges,Implant Device,40.12,34,,40.12,percent of total billed charges,Implant Device,40.12,34,,40.12,percent of total billed charges,Implant Device,40.12,34,,40.12,percent of total billed charges,Implant Device,40.12,34,,40.12,percent of total billed charges,Implant Device,58.41,,,58.41,Other,110% of Medicare,41.3,35,,41.3,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,41.3,35,,41.3,percent of total billed charges,Implant Device,41.3,35,,41.3,percent of total billed charges,Implant Device,41.3,35,,41.3,percent of total billed charges,Implant Device,41.3,35,,41.3,percent of total billed charges,Implant Device,41.3,35,,41.3,percent of total billed charges,Implant Device,47.2,40,,47.2,percent of total billed charges,Implant Device,41.3,70,,41.3,percent of total billed charges,All Other,40.12,34,,40.12,percent of total billed charges,Implant Device,40.12,34,,40.12,percent of total billed charges,Implant Device,41.3,35,,41.3,percent of total billed charges,Implant Device,41.3,35,,41.3,percent of total billed charges,Implant Device,41.3,35,,41.3,percent of total billed charges,Implant Device,41.3,35,,41.3,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,87.32,
SYNTHES 201.814 CORTEX SCREW 2X14MM ST,C1713,HCPCS,,79001406,CDM,278,RC,,,both,,,126,93.24,,,93.24,Other,150% of Medicare + 9.63% HCRA Surcharge,56.7,45,,56.7,percent of total billed charges,Critical Access Hospital RCC factor,42.84,34,,42.84,percent of total billed charges,Implant Device,42.84,34,,42.84,percent of total billed charges,Implant Device,42.84,34,,42.84,percent of total billed charges,Implant Device,42.84,34,,42.84,percent of total billed charges,Implant Device,42.84,34,,42.84,percent of total billed charges,Implant Device,62.37,,,62.37,Other,110% of Medicare,44.1,35,,44.1,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,44.1,35,,44.1,percent of total billed charges,Implant Device,44.1,35,,44.1,percent of total billed charges,Implant Device,44.1,35,,44.1,percent of total billed charges,Implant Device,44.1,35,,44.1,percent of total billed charges,Implant Device,44.1,35,,44.1,percent of total billed charges,Implant Device,50.4,40,,50.4,percent of total billed charges,Implant Device,44.1,70,,44.1,percent of total billed charges,All Other,42.84,34,,42.84,percent of total billed charges,Implant Device,42.84,34,,42.84,percent of total billed charges,Implant Device,44.1,35,,44.1,percent of total billed charges,Implant Device,44.1,35,,44.1,percent of total billed charges,Implant Device,44.1,35,,44.1,percent of total billed charges,Implant Device,44.1,35,,44.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,93.24,
SYNTHES 201.016 CORTEX SCREW 2.0 X 16MM,C1713,HCPCS,,79001407,CDM,278,RC,,,both,,,126,93.24,,,93.24,Other,150% of Medicare + 9.63% HCRA Surcharge,56.7,45,,56.7,percent of total billed charges,Critical Access Hospital RCC factor,42.84,34,,42.84,percent of total billed charges,Implant Device,42.84,34,,42.84,percent of total billed charges,Implant Device,42.84,34,,42.84,percent of total billed charges,Implant Device,42.84,34,,42.84,percent of total billed charges,Implant Device,42.84,34,,42.84,percent of total billed charges,Implant Device,62.37,,,62.37,Other,110% of Medicare,44.1,35,,44.1,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,44.1,35,,44.1,percent of total billed charges,Implant Device,44.1,35,,44.1,percent of total billed charges,Implant Device,44.1,35,,44.1,percent of total billed charges,Implant Device,44.1,35,,44.1,percent of total billed charges,Implant Device,44.1,35,,44.1,percent of total billed charges,Implant Device,50.4,40,,50.4,percent of total billed charges,Implant Device,44.1,70,,44.1,percent of total billed charges,All Other,42.84,34,,42.84,percent of total billed charges,Implant Device,42.84,34,,42.84,percent of total billed charges,Implant Device,44.1,35,,44.1,percent of total billed charges,Implant Device,44.1,35,,44.1,percent of total billed charges,Implant Device,44.1,35,,44.1,percent of total billed charges,Implant Device,44.1,35,,44.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,93.24,
SYNTHES 201.018 CORTEX SCREW 2.0 X 18MM,C1713,HCPCS,,79001408,CDM,278,RC,,,both,,,104,76.96,,,76.96,Other,150% of Medicare + 9.63% HCRA Surcharge,46.8,45,,46.8,percent of total billed charges,Critical Access Hospital RCC factor,35.36,34,,35.36,percent of total billed charges,Implant Device,35.36,34,,35.36,percent of total billed charges,Implant Device,35.36,34,,35.36,percent of total billed charges,Implant Device,35.36,34,,35.36,percent of total billed charges,Implant Device,35.36,34,,35.36,percent of total billed charges,Implant Device,51.48,,,51.48,Other,110% of Medicare,36.4,35,,36.4,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,36.4,35,,36.4,percent of total billed charges,Implant Device,36.4,35,,36.4,percent of total billed charges,Implant Device,36.4,35,,36.4,percent of total billed charges,Implant Device,36.4,35,,36.4,percent of total billed charges,Implant Device,36.4,35,,36.4,percent of total billed charges,Implant Device,41.6,40,,41.6,percent of total billed charges,Implant Device,36.4,70,,36.4,percent of total billed charges,All Other,35.36,34,,35.36,percent of total billed charges,Implant Device,35.36,34,,35.36,percent of total billed charges,Implant Device,36.4,35,,36.4,percent of total billed charges,Implant Device,36.4,35,,36.4,percent of total billed charges,Implant Device,36.4,35,,36.4,percent of total billed charges,Implant Device,36.4,35,,36.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,76.96,
SYNTHES 201.006 CORTEX SCREW 2.0 X 6MM,C1713,HCPCS,,79001409,CDM,278,RC,,,both,,,104,76.96,,,76.96,Other,150% of Medicare + 9.63% HCRA Surcharge,46.8,45,,46.8,percent of total billed charges,Critical Access Hospital RCC factor,35.36,34,,35.36,percent of total billed charges,Implant Device,35.36,34,,35.36,percent of total billed charges,Implant Device,35.36,34,,35.36,percent of total billed charges,Implant Device,35.36,34,,35.36,percent of total billed charges,Implant Device,35.36,34,,35.36,percent of total billed charges,Implant Device,51.48,,,51.48,Other,110% of Medicare,36.4,35,,36.4,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,36.4,35,,36.4,percent of total billed charges,Implant Device,36.4,35,,36.4,percent of total billed charges,Implant Device,36.4,35,,36.4,percent of total billed charges,Implant Device,36.4,35,,36.4,percent of total billed charges,Implant Device,36.4,35,,36.4,percent of total billed charges,Implant Device,41.6,40,,41.6,percent of total billed charges,Implant Device,36.4,70,,36.4,percent of total billed charges,All Other,35.36,34,,35.36,percent of total billed charges,Implant Device,35.36,34,,35.36,percent of total billed charges,Implant Device,36.4,35,,36.4,percent of total billed charges,Implant Device,36.4,35,,36.4,percent of total billed charges,Implant Device,36.4,35,,36.4,percent of total billed charges,Implant Device,36.4,35,,36.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,76.96,
SYNTHES 201.008 CORTEX SCREW 2.0 X 8MM,C1713,HCPCS,,79001410,CDM,278,RC,,,both,,,104,76.96,,,76.96,Other,150% of Medicare + 9.63% HCRA Surcharge,46.8,45,,46.8,percent of total billed charges,Critical Access Hospital RCC factor,35.36,34,,35.36,percent of total billed charges,Implant Device,35.36,34,,35.36,percent of total billed charges,Implant Device,35.36,34,,35.36,percent of total billed charges,Implant Device,35.36,34,,35.36,percent of total billed charges,Implant Device,35.36,34,,35.36,percent of total billed charges,Implant Device,51.48,,,51.48,Other,110% of Medicare,36.4,35,,36.4,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,36.4,35,,36.4,percent of total billed charges,Implant Device,36.4,35,,36.4,percent of total billed charges,Implant Device,36.4,35,,36.4,percent of total billed charges,Implant Device,36.4,35,,36.4,percent of total billed charges,Implant Device,36.4,35,,36.4,percent of total billed charges,Implant Device,41.6,40,,41.6,percent of total billed charges,Implant Device,36.4,70,,36.4,percent of total billed charges,All Other,35.36,34,,35.36,percent of total billed charges,Implant Device,35.36,34,,35.36,percent of total billed charges,Implant Device,36.4,35,,36.4,percent of total billed charges,Implant Device,36.4,35,,36.4,percent of total billed charges,Implant Device,36.4,35,,36.4,percent of total billed charges,Implant Device,36.4,35,,36.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,76.96,
SYNTHES 202.814 CORTEX SCREW 2.7 X 14MM,C1713,HCPCS,,79001411,CDM,278,RC,,,both,,,141,104.34,,,104.34,Other,150% of Medicare + 9.63% HCRA Surcharge,63.45,45,,63.45,percent of total billed charges,Critical Access Hospital RCC factor,47.94,34,,47.94,percent of total billed charges,Implant Device,47.94,34,,47.94,percent of total billed charges,Implant Device,47.94,34,,47.94,percent of total billed charges,Implant Device,47.94,34,,47.94,percent of total billed charges,Implant Device,47.94,34,,47.94,percent of total billed charges,Implant Device,69.8,,,69.8,Other,110% of Medicare,49.35,35,,49.35,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,49.35,35,,49.35,percent of total billed charges,Implant Device,49.35,35,,49.35,percent of total billed charges,Implant Device,49.35,35,,49.35,percent of total billed charges,Implant Device,49.35,35,,49.35,percent of total billed charges,Implant Device,49.35,35,,49.35,percent of total billed charges,Implant Device,56.4,40,,56.4,percent of total billed charges,Implant Device,49.35,70,,49.35,percent of total billed charges,All Other,47.94,34,,47.94,percent of total billed charges,Implant Device,47.94,34,,47.94,percent of total billed charges,Implant Device,49.35,35,,49.35,percent of total billed charges,Implant Device,49.35,35,,49.35,percent of total billed charges,Implant Device,49.35,35,,49.35,percent of total billed charges,Implant Device,49.35,35,,49.35,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,104.34,
SYNTHES 202.617 CORTEX SCREW 3.0 X 17MM,C1713,HCPCS,,79001412,CDM,278,RC,,,both,,,712,526.88,,,526.88,Other,150% of Medicare + 9.63% HCRA Surcharge,320.4,45,,320.4,percent of total billed charges,Critical Access Hospital RCC factor,242.08,34,,242.08,percent of total billed charges,Implant Device,242.08,34,,242.08,percent of total billed charges,Implant Device,242.08,34,,242.08,percent of total billed charges,Implant Device,242.08,34,,242.08,percent of total billed charges,Implant Device,242.08,34,,242.08,percent of total billed charges,Implant Device,352.44,,,352.44,Other,110% of Medicare,249.2,35,,249.2,percent of total billed charges,Implant Device,242.08,34,"Charges > $500, x 34%",242.08,percent of total billed charges,Implant Device,249.2,35,,249.2,percent of total billed charges,Implant Device,249.2,35,,249.2,percent of total billed charges,Implant Device,249.2,35,,249.2,percent of total billed charges,Implant Device,249.2,35,,249.2,percent of total billed charges,Implant Device,249.2,35,,249.2,percent of total billed charges,Implant Device,284.8,40,,284.8,percent of total billed charges,Implant Device,249.2,70,,249.2,percent of total billed charges,All Other,242.08,34,,242.08,percent of total billed charges,Implant Device,242.08,34,,242.08,percent of total billed charges,Implant Device,249.2,35,,249.2,percent of total billed charges,Implant Device,249.2,35,,249.2,percent of total billed charges,Implant Device,249.2,35,,249.2,percent of total billed charges,Implant Device,249.2,35,,249.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,526.88,
SYNTHES 202.624 CORTEX SCREW 3.0 X 24MM,C1713,HCPCS,,79001413,CDM,278,RC,,,both,,,712,526.88,,,526.88,Other,150% of Medicare + 9.63% HCRA Surcharge,320.4,45,,320.4,percent of total billed charges,Critical Access Hospital RCC factor,242.08,34,,242.08,percent of total billed charges,Implant Device,242.08,34,,242.08,percent of total billed charges,Implant Device,242.08,34,,242.08,percent of total billed charges,Implant Device,242.08,34,,242.08,percent of total billed charges,Implant Device,242.08,34,,242.08,percent of total billed charges,Implant Device,352.44,,,352.44,Other,110% of Medicare,249.2,35,,249.2,percent of total billed charges,Implant Device,242.08,34,"Charges > $500, x 34%",242.08,percent of total billed charges,Implant Device,249.2,35,,249.2,percent of total billed charges,Implant Device,249.2,35,,249.2,percent of total billed charges,Implant Device,249.2,35,,249.2,percent of total billed charges,Implant Device,249.2,35,,249.2,percent of total billed charges,Implant Device,249.2,35,,249.2,percent of total billed charges,Implant Device,284.8,40,,284.8,percent of total billed charges,Implant Device,249.2,70,,249.2,percent of total billed charges,All Other,242.08,34,,242.08,percent of total billed charges,Implant Device,242.08,34,,242.08,percent of total billed charges,Implant Device,249.2,35,,249.2,percent of total billed charges,Implant Device,249.2,35,,249.2,percent of total billed charges,Implant Device,249.2,35,,249.2,percent of total billed charges,Implant Device,249.2,35,,249.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,526.88,
SYNTHES 202.625 CORTEX SCREW 3.0 X 25MM,C1713,HCPCS,,79001414,CDM,278,RC,,,both,,,712,526.88,,,526.88,Other,150% of Medicare + 9.63% HCRA Surcharge,320.4,45,,320.4,percent of total billed charges,Critical Access Hospital RCC factor,242.08,34,,242.08,percent of total billed charges,Implant Device,242.08,34,,242.08,percent of total billed charges,Implant Device,242.08,34,,242.08,percent of total billed charges,Implant Device,242.08,34,,242.08,percent of total billed charges,Implant Device,242.08,34,,242.08,percent of total billed charges,Implant Device,352.44,,,352.44,Other,110% of Medicare,249.2,35,,249.2,percent of total billed charges,Implant Device,242.08,34,"Charges > $500, x 34%",242.08,percent of total billed charges,Implant Device,249.2,35,,249.2,percent of total billed charges,Implant Device,249.2,35,,249.2,percent of total billed charges,Implant Device,249.2,35,,249.2,percent of total billed charges,Implant Device,249.2,35,,249.2,percent of total billed charges,Implant Device,249.2,35,,249.2,percent of total billed charges,Implant Device,284.8,40,,284.8,percent of total billed charges,Implant Device,249.2,70,,249.2,percent of total billed charges,All Other,242.08,34,,242.08,percent of total billed charges,Implant Device,242.08,34,,242.08,percent of total billed charges,Implant Device,249.2,35,,249.2,percent of total billed charges,Implant Device,249.2,35,,249.2,percent of total billed charges,Implant Device,249.2,35,,249.2,percent of total billed charges,Implant Device,249.2,35,,249.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,526.88,
SYNTHES 204.812 CORTEX SCREW 3.5 X 12MM,C1713,HCPCS,,79001415,CDM,278,RC,,,both,,,57,42.18,,,42.18,Other,150% of Medicare + 9.63% HCRA Surcharge,25.65,45,,25.65,percent of total billed charges,Critical Access Hospital RCC factor,19.38,34,,19.38,percent of total billed charges,Implant Device,19.38,34,,19.38,percent of total billed charges,Implant Device,19.38,34,,19.38,percent of total billed charges,Implant Device,19.38,34,,19.38,percent of total billed charges,Implant Device,19.38,34,,19.38,percent of total billed charges,Implant Device,28.22,,,28.22,Other,110% of Medicare,19.95,35,,19.95,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,19.95,35,,19.95,percent of total billed charges,Implant Device,19.95,35,,19.95,percent of total billed charges,Implant Device,19.95,35,,19.95,percent of total billed charges,Implant Device,19.95,35,,19.95,percent of total billed charges,Implant Device,19.95,35,,19.95,percent of total billed charges,Implant Device,22.8,40,,22.8,percent of total billed charges,Implant Device,19.95,70,,19.95,percent of total billed charges,All Other,19.38,34,,19.38,percent of total billed charges,Implant Device,19.38,34,,19.38,percent of total billed charges,Implant Device,19.95,35,,19.95,percent of total billed charges,Implant Device,19.95,35,,19.95,percent of total billed charges,Implant Device,19.95,35,,19.95,percent of total billed charges,Implant Device,19.95,35,,19.95,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,42.18,
SYNTHES 204.816 CORTEX SCREW 3.5X16MM,C1713,HCPCS,,79001416,CDM,278,RC,,,both,,,57,42.18,,,42.18,Other,150% of Medicare + 9.63% HCRA Surcharge,25.65,45,,25.65,percent of total billed charges,Critical Access Hospital RCC factor,19.38,34,,19.38,percent of total billed charges,Implant Device,19.38,34,,19.38,percent of total billed charges,Implant Device,19.38,34,,19.38,percent of total billed charges,Implant Device,19.38,34,,19.38,percent of total billed charges,Implant Device,19.38,34,,19.38,percent of total billed charges,Implant Device,28.22,,,28.22,Other,110% of Medicare,19.95,35,,19.95,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,19.95,35,,19.95,percent of total billed charges,Implant Device,19.95,35,,19.95,percent of total billed charges,Implant Device,19.95,35,,19.95,percent of total billed charges,Implant Device,19.95,35,,19.95,percent of total billed charges,Implant Device,19.95,35,,19.95,percent of total billed charges,Implant Device,22.8,40,,22.8,percent of total billed charges,Implant Device,19.95,70,,19.95,percent of total billed charges,All Other,19.38,34,,19.38,percent of total billed charges,Implant Device,19.38,34,,19.38,percent of total billed charges,Implant Device,19.95,35,,19.95,percent of total billed charges,Implant Device,19.95,35,,19.95,percent of total billed charges,Implant Device,19.95,35,,19.95,percent of total billed charges,Implant Device,19.95,35,,19.95,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,42.18,
SYNTHES 204.855 CORTEX SCREW 3.5 X 55MM,C1713,HCPCS,,79001417,CDM,278,RC,,,both,,,57,42.18,,,42.18,Other,150% of Medicare + 9.63% HCRA Surcharge,25.65,45,,25.65,percent of total billed charges,Critical Access Hospital RCC factor,19.38,34,,19.38,percent of total billed charges,Implant Device,19.38,34,,19.38,percent of total billed charges,Implant Device,19.38,34,,19.38,percent of total billed charges,Implant Device,19.38,34,,19.38,percent of total billed charges,Implant Device,19.38,34,,19.38,percent of total billed charges,Implant Device,28.22,,,28.22,Other,110% of Medicare,19.95,35,,19.95,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,19.95,35,,19.95,percent of total billed charges,Implant Device,19.95,35,,19.95,percent of total billed charges,Implant Device,19.95,35,,19.95,percent of total billed charges,Implant Device,19.95,35,,19.95,percent of total billed charges,Implant Device,19.95,35,,19.95,percent of total billed charges,Implant Device,22.8,40,,22.8,percent of total billed charges,Implant Device,19.95,70,,19.95,percent of total billed charges,All Other,19.38,34,,19.38,percent of total billed charges,Implant Device,19.38,34,,19.38,percent of total billed charges,Implant Device,19.95,35,,19.95,percent of total billed charges,Implant Device,19.95,35,,19.95,percent of total billed charges,Implant Device,19.95,35,,19.95,percent of total billed charges,Implant Device,19.95,35,,19.95,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,42.18,
ORTHOFIX M316 CORTICAL BONE SCREW,C1713,HCPCS,,79001418,CDM,278,RC,,,both,,,256,189.44,,,189.44,Other,150% of Medicare + 9.63% HCRA Surcharge,115.2,45,,115.2,percent of total billed charges,Critical Access Hospital RCC factor,87.04,34,,87.04,percent of total billed charges,Implant Device,87.04,34,,87.04,percent of total billed charges,Implant Device,87.04,34,,87.04,percent of total billed charges,Implant Device,87.04,34,,87.04,percent of total billed charges,Implant Device,87.04,34,,87.04,percent of total billed charges,Implant Device,126.72,,,126.72,Other,110% of Medicare,89.6,35,,89.6,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,89.6,35,,89.6,percent of total billed charges,Implant Device,89.6,35,,89.6,percent of total billed charges,Implant Device,89.6,35,,89.6,percent of total billed charges,Implant Device,89.6,35,,89.6,percent of total billed charges,Implant Device,89.6,35,,89.6,percent of total billed charges,Implant Device,102.4,40,,102.4,percent of total billed charges,Implant Device,89.6,70,,89.6,percent of total billed charges,All Other,87.04,34,,87.04,percent of total billed charges,Implant Device,87.04,34,,87.04,percent of total billed charges,Implant Device,89.6,35,,89.6,percent of total billed charges,Implant Device,89.6,35,,89.6,percent of total billed charges,Implant Device,89.6,35,,89.6,percent of total billed charges,Implant Device,89.6,35,,89.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,189.44,
BIOMET 8140-27-018 CORT SCREW 2.7X18MM,C1713,HCPCS,,79001419,CDM,278,RC,,,both,,,240,177.6,,,177.6,Other,150% of Medicare + 9.63% HCRA Surcharge,108,45,,108,percent of total billed charges,Critical Access Hospital RCC factor,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,118.8,,,118.8,Other,110% of Medicare,84,35,,84,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,96,40,,96,percent of total billed charges,Implant Device,84,70,,84,percent of total billed charges,All Other,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,177.6,
BIOMET 1312-18-012 CORT SCREW 3.5X12MM,C1713,HCPCS,,79001420,CDM,278,RC,,,both,,,300,222,,,222,Other,150% of Medicare + 9.63% HCRA Surcharge,135,45,,135,percent of total billed charges,Critical Access Hospital RCC factor,102,34,,102,percent of total billed charges,Implant Device,102,34,,102,percent of total billed charges,Implant Device,102,34,,102,percent of total billed charges,Implant Device,102,34,,102,percent of total billed charges,Implant Device,102,34,,102,percent of total billed charges,Implant Device,148.5,,,148.5,Other,110% of Medicare,105,35,,105,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,105,35,,105,percent of total billed charges,Implant Device,105,35,,105,percent of total billed charges,Implant Device,105,35,,105,percent of total billed charges,Implant Device,105,35,,105,percent of total billed charges,Implant Device,105,35,,105,percent of total billed charges,Implant Device,120,40,,120,percent of total billed charges,Implant Device,105,70,,105,percent of total billed charges,All Other,102,34,,102,percent of total billed charges,Implant Device,102,34,,102,percent of total billed charges,Implant Device,105,35,,105,percent of total billed charges,Implant Device,105,35,,105,percent of total billed charges,Implant Device,105,35,,105,percent of total billed charges,Implant Device,105,35,,105,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,222,
BIOMET 1312-18-020 CORT SCREW 3.5X20MM,C1713,HCPCS,,79001421,CDM,278,RC,,,both,,,300,222,,,222,Other,150% of Medicare + 9.63% HCRA Surcharge,135,45,,135,percent of total billed charges,Critical Access Hospital RCC factor,102,34,,102,percent of total billed charges,Implant Device,102,34,,102,percent of total billed charges,Implant Device,102,34,,102,percent of total billed charges,Implant Device,102,34,,102,percent of total billed charges,Implant Device,102,34,,102,percent of total billed charges,Implant Device,148.5,,,148.5,Other,110% of Medicare,105,35,,105,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,105,35,,105,percent of total billed charges,Implant Device,105,35,,105,percent of total billed charges,Implant Device,105,35,,105,percent of total billed charges,Implant Device,105,35,,105,percent of total billed charges,Implant Device,105,35,,105,percent of total billed charges,Implant Device,120,40,,120,percent of total billed charges,Implant Device,105,70,,105,percent of total billed charges,All Other,102,34,,102,percent of total billed charges,Implant Device,102,34,,102,percent of total billed charges,Implant Device,105,35,,105,percent of total billed charges,Implant Device,105,35,,105,percent of total billed charges,Implant Device,105,35,,105,percent of total billed charges,Implant Device,105,35,,105,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,222,
BIOMET 1312-18-022 CORT SCREW 3.5X22MM,C1713,HCPCS,,79001422,CDM,278,RC,,,both,,,300,222,,,222,Other,150% of Medicare + 9.63% HCRA Surcharge,135,45,,135,percent of total billed charges,Critical Access Hospital RCC factor,102,34,,102,percent of total billed charges,Implant Device,102,34,,102,percent of total billed charges,Implant Device,102,34,,102,percent of total billed charges,Implant Device,102,34,,102,percent of total billed charges,Implant Device,102,34,,102,percent of total billed charges,Implant Device,148.5,,,148.5,Other,110% of Medicare,105,35,,105,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,105,35,,105,percent of total billed charges,Implant Device,105,35,,105,percent of total billed charges,Implant Device,105,35,,105,percent of total billed charges,Implant Device,105,35,,105,percent of total billed charges,Implant Device,105,35,,105,percent of total billed charges,Implant Device,120,40,,120,percent of total billed charges,Implant Device,105,70,,105,percent of total billed charges,All Other,102,34,,102,percent of total billed charges,Implant Device,102,34,,102,percent of total billed charges,Implant Device,105,35,,105,percent of total billed charges,Implant Device,105,35,,105,percent of total billed charges,Implant Device,105,35,,105,percent of total billed charges,Implant Device,105,35,,105,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,222,
BIOMET 1312-18-032 CORT SCREW 3.5X32MM,C1713,HCPCS,,79001423,CDM,278,RC,,,both,,,300,222,,,222,Other,150% of Medicare + 9.63% HCRA Surcharge,135,45,,135,percent of total billed charges,Critical Access Hospital RCC factor,102,34,,102,percent of total billed charges,Implant Device,102,34,,102,percent of total billed charges,Implant Device,102,34,,102,percent of total billed charges,Implant Device,102,34,,102,percent of total billed charges,Implant Device,102,34,,102,percent of total billed charges,Implant Device,148.5,,,148.5,Other,110% of Medicare,105,35,,105,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,105,35,,105,percent of total billed charges,Implant Device,105,35,,105,percent of total billed charges,Implant Device,105,35,,105,percent of total billed charges,Implant Device,105,35,,105,percent of total billed charges,Implant Device,105,35,,105,percent of total billed charges,Implant Device,120,40,,120,percent of total billed charges,Implant Device,105,70,,105,percent of total billed charges,All Other,102,34,,102,percent of total billed charges,Implant Device,102,34,,102,percent of total billed charges,Implant Device,105,35,,105,percent of total billed charges,Implant Device,105,35,,105,percent of total billed charges,Implant Device,105,35,,105,percent of total billed charges,Implant Device,105,35,,105,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,222,
BIOMET 1312-18-060 CORT SCREW 3.5X60MM,C1713,HCPCS,,79001424,CDM,278,RC,,,both,,,300,222,,,222,Other,150% of Medicare + 9.63% HCRA Surcharge,135,45,,135,percent of total billed charges,Critical Access Hospital RCC factor,102,34,,102,percent of total billed charges,Implant Device,102,34,,102,percent of total billed charges,Implant Device,102,34,,102,percent of total billed charges,Implant Device,102,34,,102,percent of total billed charges,Implant Device,102,34,,102,percent of total billed charges,Implant Device,148.5,,,148.5,Other,110% of Medicare,105,35,,105,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,105,35,,105,percent of total billed charges,Implant Device,105,35,,105,percent of total billed charges,Implant Device,105,35,,105,percent of total billed charges,Implant Device,105,35,,105,percent of total billed charges,Implant Device,105,35,,105,percent of total billed charges,Implant Device,120,40,,120,percent of total billed charges,Implant Device,105,70,,105,percent of total billed charges,All Other,102,34,,102,percent of total billed charges,Implant Device,102,34,,102,percent of total billed charges,Implant Device,105,35,,105,percent of total billed charges,Implant Device,105,35,,105,percent of total billed charges,Implant Device,105,35,,105,percent of total billed charges,Implant Device,105,35,,105,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,222,
BIOMET 8161-35-010 CORT SCREW 35X10MM,C1713,HCPCS,,79001425,CDM,278,RC,,,both,,,660,488.4,,,488.4,Other,150% of Medicare + 9.63% HCRA Surcharge,297,45,,297,percent of total billed charges,Critical Access Hospital RCC factor,224.4,34,,224.4,percent of total billed charges,Implant Device,224.4,34,,224.4,percent of total billed charges,Implant Device,224.4,34,,224.4,percent of total billed charges,Implant Device,224.4,34,,224.4,percent of total billed charges,Implant Device,224.4,34,,224.4,percent of total billed charges,Implant Device,326.7,,,326.7,Other,110% of Medicare,231,35,,231,percent of total billed charges,Implant Device,224.4,34,"Charges > $500, x 34%",224.4,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,264,40,,264,percent of total billed charges,Implant Device,231,70,,231,percent of total billed charges,All Other,224.4,34,,224.4,percent of total billed charges,Implant Device,224.4,34,,224.4,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,488.4,
BIOMET 8161-35-012 CORT SCREW 35X12MM,C1713,HCPCS,,79001426,CDM,278,RC,,,both,,,660,488.4,,,488.4,Other,150% of Medicare + 9.63% HCRA Surcharge,297,45,,297,percent of total billed charges,Critical Access Hospital RCC factor,224.4,34,,224.4,percent of total billed charges,Implant Device,224.4,34,,224.4,percent of total billed charges,Implant Device,224.4,34,,224.4,percent of total billed charges,Implant Device,224.4,34,,224.4,percent of total billed charges,Implant Device,224.4,34,,224.4,percent of total billed charges,Implant Device,326.7,,,326.7,Other,110% of Medicare,231,35,,231,percent of total billed charges,Implant Device,224.4,34,"Charges > $500, x 34%",224.4,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,264,40,,264,percent of total billed charges,Implant Device,231,70,,231,percent of total billed charges,All Other,224.4,34,,224.4,percent of total billed charges,Implant Device,224.4,34,,224.4,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,488.4,
BIOMET 8161-35-014 CORT SCREW 35X14MM,C1713,HCPCS,,79001427,CDM,278,RC,,,both,,,660,488.4,,,488.4,Other,150% of Medicare + 9.63% HCRA Surcharge,297,45,,297,percent of total billed charges,Critical Access Hospital RCC factor,224.4,34,,224.4,percent of total billed charges,Implant Device,224.4,34,,224.4,percent of total billed charges,Implant Device,224.4,34,,224.4,percent of total billed charges,Implant Device,224.4,34,,224.4,percent of total billed charges,Implant Device,224.4,34,,224.4,percent of total billed charges,Implant Device,326.7,,,326.7,Other,110% of Medicare,231,35,,231,percent of total billed charges,Implant Device,224.4,34,"Charges > $500, x 34%",224.4,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,264,40,,264,percent of total billed charges,Implant Device,231,70,,231,percent of total billed charges,All Other,224.4,34,,224.4,percent of total billed charges,Implant Device,224.4,34,,224.4,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,488.4,
BIOMET 8161-35-018 CORT SCREW 35X18MM,C1713,HCPCS,,79001428,CDM,278,RC,,,both,,,660,488.4,,,488.4,Other,150% of Medicare + 9.63% HCRA Surcharge,297,45,,297,percent of total billed charges,Critical Access Hospital RCC factor,224.4,34,,224.4,percent of total billed charges,Implant Device,224.4,34,,224.4,percent of total billed charges,Implant Device,224.4,34,,224.4,percent of total billed charges,Implant Device,224.4,34,,224.4,percent of total billed charges,Implant Device,224.4,34,,224.4,percent of total billed charges,Implant Device,326.7,,,326.7,Other,110% of Medicare,231,35,,231,percent of total billed charges,Implant Device,224.4,34,"Charges > $500, x 34%",224.4,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,264,40,,264,percent of total billed charges,Implant Device,231,70,,231,percent of total billed charges,All Other,224.4,34,,224.4,percent of total billed charges,Implant Device,224.4,34,,224.4,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,488.4,
BIOMET 8161-35-020 CORT SCREW 3.5X20MM,C1713,HCPCS,,79001429,CDM,278,RC,,,both,,,660,488.4,,,488.4,Other,150% of Medicare + 9.63% HCRA Surcharge,297,45,,297,percent of total billed charges,Critical Access Hospital RCC factor,224.4,34,,224.4,percent of total billed charges,Implant Device,224.4,34,,224.4,percent of total billed charges,Implant Device,224.4,34,,224.4,percent of total billed charges,Implant Device,224.4,34,,224.4,percent of total billed charges,Implant Device,224.4,34,,224.4,percent of total billed charges,Implant Device,326.7,,,326.7,Other,110% of Medicare,231,35,,231,percent of total billed charges,Implant Device,224.4,34,"Charges > $500, x 34%",224.4,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,264,40,,264,percent of total billed charges,Implant Device,231,70,,231,percent of total billed charges,All Other,224.4,34,,224.4,percent of total billed charges,Implant Device,224.4,34,,224.4,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,488.4,
BIOMET 8161-35-052 CORT SCREW 35X52MM,C1713,HCPCS,,79001430,CDM,278,RC,,,both,,,660,488.4,,,488.4,Other,150% of Medicare + 9.63% HCRA Surcharge,297,45,,297,percent of total billed charges,Critical Access Hospital RCC factor,224.4,34,,224.4,percent of total billed charges,Implant Device,224.4,34,,224.4,percent of total billed charges,Implant Device,224.4,34,,224.4,percent of total billed charges,Implant Device,224.4,34,,224.4,percent of total billed charges,Implant Device,224.4,34,,224.4,percent of total billed charges,Implant Device,326.7,,,326.7,Other,110% of Medicare,231,35,,231,percent of total billed charges,Implant Device,224.4,34,"Charges > $500, x 34%",224.4,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,264,40,,264,percent of total billed charges,Implant Device,231,70,,231,percent of total billed charges,All Other,224.4,34,,224.4,percent of total billed charges,Implant Device,224.4,34,,224.4,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,488.4,
BIOMET 8161-35-060 CORT SCREW 35X60MM,C1713,HCPCS,,79001431,CDM,278,RC,,,both,,,660,488.4,,,488.4,Other,150% of Medicare + 9.63% HCRA Surcharge,297,45,,297,percent of total billed charges,Critical Access Hospital RCC factor,224.4,34,,224.4,percent of total billed charges,Implant Device,224.4,34,,224.4,percent of total billed charges,Implant Device,224.4,34,,224.4,percent of total billed charges,Implant Device,224.4,34,,224.4,percent of total billed charges,Implant Device,224.4,34,,224.4,percent of total billed charges,Implant Device,326.7,,,326.7,Other,110% of Medicare,231,35,,231,percent of total billed charges,Implant Device,224.4,34,"Charges > $500, x 34%",224.4,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,264,40,,264,percent of total billed charges,Implant Device,231,70,,231,percent of total billed charges,All Other,224.4,34,,224.4,percent of total billed charges,Implant Device,224.4,34,,224.4,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,488.4,
BIOMET 8161-35-065 CORT SCREW 35X65MM,C1713,HCPCS,,79001432,CDM,278,RC,,,both,,,660,488.4,,,488.4,Other,150% of Medicare + 9.63% HCRA Surcharge,297,45,,297,percent of total billed charges,Critical Access Hospital RCC factor,224.4,34,,224.4,percent of total billed charges,Implant Device,224.4,34,,224.4,percent of total billed charges,Implant Device,224.4,34,,224.4,percent of total billed charges,Implant Device,224.4,34,,224.4,percent of total billed charges,Implant Device,224.4,34,,224.4,percent of total billed charges,Implant Device,326.7,,,326.7,Other,110% of Medicare,231,35,,231,percent of total billed charges,Implant Device,224.4,34,"Charges > $500, x 34%",224.4,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,264,40,,264,percent of total billed charges,Implant Device,231,70,,231,percent of total billed charges,All Other,224.4,34,,224.4,percent of total billed charges,Implant Device,224.4,34,,224.4,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,488.4,
BIOMET 8161-35-070 CORT SCREW 35X70MM,C1713,HCPCS,,79001433,CDM,278,RC,,,both,,,660,488.4,,,488.4,Other,150% of Medicare + 9.63% HCRA Surcharge,297,45,,297,percent of total billed charges,Critical Access Hospital RCC factor,224.4,34,,224.4,percent of total billed charges,Implant Device,224.4,34,,224.4,percent of total billed charges,Implant Device,224.4,34,,224.4,percent of total billed charges,Implant Device,224.4,34,,224.4,percent of total billed charges,Implant Device,224.4,34,,224.4,percent of total billed charges,Implant Device,326.7,,,326.7,Other,110% of Medicare,231,35,,231,percent of total billed charges,Implant Device,224.4,34,"Charges > $500, x 34%",224.4,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,264,40,,264,percent of total billed charges,Implant Device,231,70,,231,percent of total billed charges,All Other,224.4,34,,224.4,percent of total billed charges,Implant Device,224.4,34,,224.4,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,488.4,
BIOMET 8140-27-010 CORT SCREW 2.7X10MM,C1713,HCPCS,,79001434,CDM,278,RC,,,both,,,240,177.6,,,177.6,Other,150% of Medicare + 9.63% HCRA Surcharge,108,45,,108,percent of total billed charges,Critical Access Hospital RCC factor,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,118.8,,,118.8,Other,110% of Medicare,84,35,,84,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,96,40,,96,percent of total billed charges,Implant Device,84,70,,84,percent of total billed charges,All Other,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,177.6,
BIOMET 8140-27-014 CORT SCREW 2.7X14MM,C1713,HCPCS,,79001435,CDM,278,RC,,,both,,,240,177.6,,,177.6,Other,150% of Medicare + 9.63% HCRA Surcharge,108,45,,108,percent of total billed charges,Critical Access Hospital RCC factor,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,118.8,,,118.8,Other,110% of Medicare,84,35,,84,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,96,40,,96,percent of total billed charges,Implant Device,84,70,,84,percent of total billed charges,All Other,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,177.6,
BIOMET 8140-27-016 CORT SCREW 2.7X16MM,C1713,HCPCS,,79001436,CDM,278,RC,,,both,,,240,177.6,,,177.6,Other,150% of Medicare + 9.63% HCRA Surcharge,108,45,,108,percent of total billed charges,Critical Access Hospital RCC factor,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,118.8,,,118.8,Other,110% of Medicare,84,35,,84,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,96,40,,96,percent of total billed charges,Implant Device,84,70,,84,percent of total billed charges,All Other,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,177.6,
BIOMET 8150-37-010 CORT SCREW 3.5X10MM,C1713,HCPCS,,79001437,CDM,278,RC,,,both,,,240,177.6,,,177.6,Other,150% of Medicare + 9.63% HCRA Surcharge,108,45,,108,percent of total billed charges,Critical Access Hospital RCC factor,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,118.8,,,118.8,Other,110% of Medicare,84,35,,84,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,96,40,,96,percent of total billed charges,Implant Device,84,70,,84,percent of total billed charges,All Other,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,177.6,
BIOMET 8150-37-012 CORT SCREW 3.5X12MM,C1713,HCPCS,,79001438,CDM,278,RC,,,both,,,270,199.8,,,199.8,Other,150% of Medicare + 9.63% HCRA Surcharge,121.5,45,,121.5,percent of total billed charges,Critical Access Hospital RCC factor,91.8,34,,91.8,percent of total billed charges,Implant Device,91.8,34,,91.8,percent of total billed charges,Implant Device,91.8,34,,91.8,percent of total billed charges,Implant Device,91.8,34,,91.8,percent of total billed charges,Implant Device,91.8,34,,91.8,percent of total billed charges,Implant Device,133.65,,,133.65,Other,110% of Medicare,94.5,35,,94.5,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,94.5,35,,94.5,percent of total billed charges,Implant Device,94.5,35,,94.5,percent of total billed charges,Implant Device,94.5,35,,94.5,percent of total billed charges,Implant Device,94.5,35,,94.5,percent of total billed charges,Implant Device,94.5,35,,94.5,percent of total billed charges,Implant Device,108,40,,108,percent of total billed charges,Implant Device,94.5,70,,94.5,percent of total billed charges,All Other,91.8,34,,91.8,percent of total billed charges,Implant Device,91.8,34,,91.8,percent of total billed charges,Implant Device,94.5,35,,94.5,percent of total billed charges,Implant Device,94.5,35,,94.5,percent of total billed charges,Implant Device,94.5,35,,94.5,percent of total billed charges,Implant Device,94.5,35,,94.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,199.8,
BIOMET 8150-37-014 CORT SCREW 3.5X14MM,C1713,HCPCS,,79001439,CDM,278,RC,,,both,,,270,199.8,,,199.8,Other,150% of Medicare + 9.63% HCRA Surcharge,121.5,45,,121.5,percent of total billed charges,Critical Access Hospital RCC factor,91.8,34,,91.8,percent of total billed charges,Implant Device,91.8,34,,91.8,percent of total billed charges,Implant Device,91.8,34,,91.8,percent of total billed charges,Implant Device,91.8,34,,91.8,percent of total billed charges,Implant Device,91.8,34,,91.8,percent of total billed charges,Implant Device,133.65,,,133.65,Other,110% of Medicare,94.5,35,,94.5,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,94.5,35,,94.5,percent of total billed charges,Implant Device,94.5,35,,94.5,percent of total billed charges,Implant Device,94.5,35,,94.5,percent of total billed charges,Implant Device,94.5,35,,94.5,percent of total billed charges,Implant Device,94.5,35,,94.5,percent of total billed charges,Implant Device,108,40,,108,percent of total billed charges,Implant Device,94.5,70,,94.5,percent of total billed charges,All Other,91.8,34,,91.8,percent of total billed charges,Implant Device,91.8,34,,91.8,percent of total billed charges,Implant Device,94.5,35,,94.5,percent of total billed charges,Implant Device,94.5,35,,94.5,percent of total billed charges,Implant Device,94.5,35,,94.5,percent of total billed charges,Implant Device,94.5,35,,94.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,199.8,
BIOMET 8150-37-016 CORT SCREW 3.5X16MM,C1713,HCPCS,,79001440,CDM,278,RC,,,both,,,270,199.8,,,199.8,Other,150% of Medicare + 9.63% HCRA Surcharge,121.5,45,,121.5,percent of total billed charges,Critical Access Hospital RCC factor,91.8,34,,91.8,percent of total billed charges,Implant Device,91.8,34,,91.8,percent of total billed charges,Implant Device,91.8,34,,91.8,percent of total billed charges,Implant Device,91.8,34,,91.8,percent of total billed charges,Implant Device,91.8,34,,91.8,percent of total billed charges,Implant Device,133.65,,,133.65,Other,110% of Medicare,94.5,35,,94.5,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,94.5,35,,94.5,percent of total billed charges,Implant Device,94.5,35,,94.5,percent of total billed charges,Implant Device,94.5,35,,94.5,percent of total billed charges,Implant Device,94.5,35,,94.5,percent of total billed charges,Implant Device,94.5,35,,94.5,percent of total billed charges,Implant Device,108,40,,108,percent of total billed charges,Implant Device,94.5,70,,94.5,percent of total billed charges,All Other,91.8,34,,91.8,percent of total billed charges,Implant Device,91.8,34,,91.8,percent of total billed charges,Implant Device,94.5,35,,94.5,percent of total billed charges,Implant Device,94.5,35,,94.5,percent of total billed charges,Implant Device,94.5,35,,94.5,percent of total billed charges,Implant Device,94.5,35,,94.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,199.8,
BIOMET 8150-37-018 CORT SCREW 3.5X18MM,C1713,HCPCS,,79001441,CDM,278,RC,,,both,,,240,177.6,,,177.6,Other,150% of Medicare + 9.63% HCRA Surcharge,108,45,,108,percent of total billed charges,Critical Access Hospital RCC factor,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,118.8,,,118.8,Other,110% of Medicare,84,35,,84,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,96,40,,96,percent of total billed charges,Implant Device,84,70,,84,percent of total billed charges,All Other,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,177.6,
BIOMET 8150-37-020 CORT SCREW 3.5X20MM,C1713,HCPCS,,79001442,CDM,278,RC,,,both,,,240,177.6,,,177.6,Other,150% of Medicare + 9.63% HCRA Surcharge,108,45,,108,percent of total billed charges,Critical Access Hospital RCC factor,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,118.8,,,118.8,Other,110% of Medicare,84,35,,84,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,96,40,,96,percent of total billed charges,Implant Device,84,70,,84,percent of total billed charges,All Other,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,177.6,
BIOMET 8150-37-022 CORT SCREW 3.5X22MM,C1713,HCPCS,,79001443,CDM,278,RC,,,both,,,240,177.6,,,177.6,Other,150% of Medicare + 9.63% HCRA Surcharge,108,45,,108,percent of total billed charges,Critical Access Hospital RCC factor,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,118.8,,,118.8,Other,110% of Medicare,84,35,,84,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,96,40,,96,percent of total billed charges,Implant Device,84,70,,84,percent of total billed charges,All Other,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,177.6,
BIOMET 8150-37-024 CORT SCREW 3.5X24MM,C1713,HCPCS,,79001444,CDM,278,RC,,,both,,,240,177.6,,,177.6,Other,150% of Medicare + 9.63% HCRA Surcharge,108,45,,108,percent of total billed charges,Critical Access Hospital RCC factor,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,118.8,,,118.8,Other,110% of Medicare,84,35,,84,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,96,40,,96,percent of total billed charges,Implant Device,84,70,,84,percent of total billed charges,All Other,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,177.6,
BIOMET 8150-37-026 CORT SCREW 3.5X26MM,C1713,HCPCS,,79001445,CDM,278,RC,,,both,,,240,177.6,,,177.6,Other,150% of Medicare + 9.63% HCRA Surcharge,108,45,,108,percent of total billed charges,Critical Access Hospital RCC factor,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,118.8,,,118.8,Other,110% of Medicare,84,35,,84,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,96,40,,96,percent of total billed charges,Implant Device,84,70,,84,percent of total billed charges,All Other,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,177.6,
BIOMET 8150-37-028 CORT SCREW 3.5X28MM,C1713,HCPCS,,79001446,CDM,278,RC,,,both,,,240,177.6,,,177.6,Other,150% of Medicare + 9.63% HCRA Surcharge,108,45,,108,percent of total billed charges,Critical Access Hospital RCC factor,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,118.8,,,118.8,Other,110% of Medicare,84,35,,84,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,96,40,,96,percent of total billed charges,Implant Device,84,70,,84,percent of total billed charges,All Other,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,177.6,
BIOMET 8150-37-030 CORT SCREW 3.5X30MM,C1713,HCPCS,,79001447,CDM,278,RC,,,both,,,240,177.6,,,177.6,Other,150% of Medicare + 9.63% HCRA Surcharge,108,45,,108,percent of total billed charges,Critical Access Hospital RCC factor,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,118.8,,,118.8,Other,110% of Medicare,84,35,,84,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,96,40,,96,percent of total billed charges,Implant Device,84,70,,84,percent of total billed charges,All Other,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,177.6,
BIOMET 8150-37-032 CORT SCREW 3.5X32MM,C1713,HCPCS,,79001448,CDM,278,RC,,,both,,,240,177.6,,,177.6,Other,150% of Medicare + 9.63% HCRA Surcharge,108,45,,108,percent of total billed charges,Critical Access Hospital RCC factor,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,118.8,,,118.8,Other,110% of Medicare,84,35,,84,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,96,40,,96,percent of total billed charges,Implant Device,84,70,,84,percent of total billed charges,All Other,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,177.6,
BIOMET 8150-37-034 CORT SCREW 3.5X34MM,C1713,HCPCS,,79001449,CDM,278,RC,,,both,,,240,177.6,,,177.6,Other,150% of Medicare + 9.63% HCRA Surcharge,108,45,,108,percent of total billed charges,Critical Access Hospital RCC factor,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,118.8,,,118.8,Other,110% of Medicare,84,35,,84,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,96,40,,96,percent of total billed charges,Implant Device,84,70,,84,percent of total billed charges,All Other,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,177.6,
BIOMET 8150-37-036 CORT SCREW 3.5X36MM,C1713,HCPCS,,79001450,CDM,278,RC,,,both,,,240,177.6,,,177.6,Other,150% of Medicare + 9.63% HCRA Surcharge,108,45,,108,percent of total billed charges,Critical Access Hospital RCC factor,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,118.8,,,118.8,Other,110% of Medicare,84,35,,84,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,96,40,,96,percent of total billed charges,Implant Device,84,70,,84,percent of total billed charges,All Other,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,177.6,
BIOMET 8150-37-040 CORT SCREW 3.5X40MM,C1713,HCPCS,,79001451,CDM,278,RC,,,both,,,240,177.6,,,177.6,Other,150% of Medicare + 9.63% HCRA Surcharge,108,45,,108,percent of total billed charges,Critical Access Hospital RCC factor,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,118.8,,,118.8,Other,110% of Medicare,84,35,,84,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,96,40,,96,percent of total billed charges,Implant Device,84,70,,84,percent of total billed charges,All Other,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,177.6,
BIOMET 8150-37-042 CORT SCREW 3.5X42MM,C1713,HCPCS,,79001452,CDM,278,RC,,,both,,,240,177.6,,,177.6,Other,150% of Medicare + 9.63% HCRA Surcharge,108,45,,108,percent of total billed charges,Critical Access Hospital RCC factor,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,118.8,,,118.8,Other,110% of Medicare,84,35,,84,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,96,40,,96,percent of total billed charges,Implant Device,84,70,,84,percent of total billed charges,All Other,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,177.6,
BIOMET 8150-37-046 CORT SCREW 3.5X46MM,C1713,HCPCS,,79001453,CDM,278,RC,,,both,,,240,177.6,,,177.6,Other,150% of Medicare + 9.63% HCRA Surcharge,108,45,,108,percent of total billed charges,Critical Access Hospital RCC factor,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,118.8,,,118.8,Other,110% of Medicare,84,35,,84,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,96,40,,96,percent of total billed charges,Implant Device,84,70,,84,percent of total billed charges,All Other,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,177.6,
BIOMET 8150-37-048 CORT SCREW 3.5X48MM,C1713,HCPCS,,79001454,CDM,278,RC,,,both,,,240,177.6,,,177.6,Other,150% of Medicare + 9.63% HCRA Surcharge,108,45,,108,percent of total billed charges,Critical Access Hospital RCC factor,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,118.8,,,118.8,Other,110% of Medicare,84,35,,84,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,96,40,,96,percent of total billed charges,Implant Device,84,70,,84,percent of total billed charges,All Other,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,177.6,
BIOMET 8150-37-065 CORT SCREW 3.5X65MM,C1713,HCPCS,,79001455,CDM,278,RC,,,both,,,240,177.6,,,177.6,Other,150% of Medicare + 9.63% HCRA Surcharge,108,45,,108,percent of total billed charges,Critical Access Hospital RCC factor,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,118.8,,,118.8,Other,110% of Medicare,84,35,,84,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,96,40,,96,percent of total billed charges,Implant Device,84,70,,84,percent of total billed charges,All Other,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,177.6,
BIOMET 8150-37-070 CORT SCREW 3.5X70MM,C1713,HCPCS,,79001456,CDM,278,RC,,,both,,,240,177.6,,,177.6,Other,150% of Medicare + 9.63% HCRA Surcharge,108,45,,108,percent of total billed charges,Critical Access Hospital RCC factor,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,118.8,,,118.8,Other,110% of Medicare,84,35,,84,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,96,40,,96,percent of total billed charges,Implant Device,84,70,,84,percent of total billed charges,All Other,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,177.6,
BIOMET CS10000 CORTICAL SCREW 3.5X10MM,C1713,HCPCS,,79001457,CDM,278,RC,,,both,,,420,310.8,,,310.8,Other,150% of Medicare + 9.63% HCRA Surcharge,189,45,,189,percent of total billed charges,Critical Access Hospital RCC factor,142.8,34,,142.8,percent of total billed charges,Implant Device,142.8,34,,142.8,percent of total billed charges,Implant Device,142.8,34,,142.8,percent of total billed charges,Implant Device,142.8,34,,142.8,percent of total billed charges,Implant Device,142.8,34,,142.8,percent of total billed charges,Implant Device,207.9,,,207.9,Other,110% of Medicare,147,35,,147,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,147,35,,147,percent of total billed charges,Implant Device,147,35,,147,percent of total billed charges,Implant Device,147,35,,147,percent of total billed charges,Implant Device,147,35,,147,percent of total billed charges,Implant Device,147,35,,147,percent of total billed charges,Implant Device,168,40,,168,percent of total billed charges,Implant Device,147,70,,147,percent of total billed charges,All Other,142.8,34,,142.8,percent of total billed charges,Implant Device,142.8,34,,142.8,percent of total billed charges,Implant Device,147,35,,147,percent of total billed charges,Implant Device,147,35,,147,percent of total billed charges,Implant Device,147,35,,147,percent of total billed charges,Implant Device,147,35,,147,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,310.8,
BIOMET CS12000 CORTICAL SCREW 3.5X12MM,C1713,HCPCS,,79001458,CDM,278,RC,,,both,,,288,213.12,,,213.12,Other,150% of Medicare + 9.63% HCRA Surcharge,129.6,45,,129.6,percent of total billed charges,Critical Access Hospital RCC factor,97.92,34,,97.92,percent of total billed charges,Implant Device,97.92,34,,97.92,percent of total billed charges,Implant Device,97.92,34,,97.92,percent of total billed charges,Implant Device,97.92,34,,97.92,percent of total billed charges,Implant Device,97.92,34,,97.92,percent of total billed charges,Implant Device,142.56,,,142.56,Other,110% of Medicare,100.8,35,,100.8,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,100.8,35,,100.8,percent of total billed charges,Implant Device,100.8,35,,100.8,percent of total billed charges,Implant Device,100.8,35,,100.8,percent of total billed charges,Implant Device,100.8,35,,100.8,percent of total billed charges,Implant Device,100.8,35,,100.8,percent of total billed charges,Implant Device,115.2,40,,115.2,percent of total billed charges,Implant Device,100.8,70,,100.8,percent of total billed charges,All Other,97.92,34,,97.92,percent of total billed charges,Implant Device,97.92,34,,97.92,percent of total billed charges,Implant Device,100.8,35,,100.8,percent of total billed charges,Implant Device,100.8,35,,100.8,percent of total billed charges,Implant Device,100.8,35,,100.8,percent of total billed charges,Implant Device,100.8,35,,100.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,213.12,
BIOMET CS13000 CORTICAL SCREW 3.5X13MM,C1713,HCPCS,,79001459,CDM,278,RC,,,both,,,420,310.8,,,310.8,Other,150% of Medicare + 9.63% HCRA Surcharge,189,45,,189,percent of total billed charges,Critical Access Hospital RCC factor,142.8,34,,142.8,percent of total billed charges,Implant Device,142.8,34,,142.8,percent of total billed charges,Implant Device,142.8,34,,142.8,percent of total billed charges,Implant Device,142.8,34,,142.8,percent of total billed charges,Implant Device,142.8,34,,142.8,percent of total billed charges,Implant Device,207.9,,,207.9,Other,110% of Medicare,147,35,,147,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,147,35,,147,percent of total billed charges,Implant Device,147,35,,147,percent of total billed charges,Implant Device,147,35,,147,percent of total billed charges,Implant Device,147,35,,147,percent of total billed charges,Implant Device,147,35,,147,percent of total billed charges,Implant Device,168,40,,168,percent of total billed charges,Implant Device,147,70,,147,percent of total billed charges,All Other,142.8,34,,142.8,percent of total billed charges,Implant Device,142.8,34,,142.8,percent of total billed charges,Implant Device,147,35,,147,percent of total billed charges,Implant Device,147,35,,147,percent of total billed charges,Implant Device,147,35,,147,percent of total billed charges,Implant Device,147,35,,147,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,310.8,
BIOMET CS14000 CORTICAL SCREW 3.5X14MM,C1713,HCPCS,,79001460,CDM,278,RC,,,both,,,288,213.12,,,213.12,Other,150% of Medicare + 9.63% HCRA Surcharge,129.6,45,,129.6,percent of total billed charges,Critical Access Hospital RCC factor,97.92,34,,97.92,percent of total billed charges,Implant Device,97.92,34,,97.92,percent of total billed charges,Implant Device,97.92,34,,97.92,percent of total billed charges,Implant Device,97.92,34,,97.92,percent of total billed charges,Implant Device,97.92,34,,97.92,percent of total billed charges,Implant Device,142.56,,,142.56,Other,110% of Medicare,100.8,35,,100.8,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,100.8,35,,100.8,percent of total billed charges,Implant Device,100.8,35,,100.8,percent of total billed charges,Implant Device,100.8,35,,100.8,percent of total billed charges,Implant Device,100.8,35,,100.8,percent of total billed charges,Implant Device,100.8,35,,100.8,percent of total billed charges,Implant Device,115.2,40,,115.2,percent of total billed charges,Implant Device,100.8,70,,100.8,percent of total billed charges,All Other,97.92,34,,97.92,percent of total billed charges,Implant Device,97.92,34,,97.92,percent of total billed charges,Implant Device,100.8,35,,100.8,percent of total billed charges,Implant Device,100.8,35,,100.8,percent of total billed charges,Implant Device,100.8,35,,100.8,percent of total billed charges,Implant Device,100.8,35,,100.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,213.12,
BIOMET CS16000 CORTICAL SCREW 3.5X16MM,C1713,HCPCS,,79001461,CDM,278,RC,,,both,,,288,213.12,,,213.12,Other,150% of Medicare + 9.63% HCRA Surcharge,129.6,45,,129.6,percent of total billed charges,Critical Access Hospital RCC factor,97.92,34,,97.92,percent of total billed charges,Implant Device,97.92,34,,97.92,percent of total billed charges,Implant Device,97.92,34,,97.92,percent of total billed charges,Implant Device,97.92,34,,97.92,percent of total billed charges,Implant Device,97.92,34,,97.92,percent of total billed charges,Implant Device,142.56,,,142.56,Other,110% of Medicare,100.8,35,,100.8,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,100.8,35,,100.8,percent of total billed charges,Implant Device,100.8,35,,100.8,percent of total billed charges,Implant Device,100.8,35,,100.8,percent of total billed charges,Implant Device,100.8,35,,100.8,percent of total billed charges,Implant Device,100.8,35,,100.8,percent of total billed charges,Implant Device,115.2,40,,115.2,percent of total billed charges,Implant Device,100.8,70,,100.8,percent of total billed charges,All Other,97.92,34,,97.92,percent of total billed charges,Implant Device,97.92,34,,97.92,percent of total billed charges,Implant Device,100.8,35,,100.8,percent of total billed charges,Implant Device,100.8,35,,100.8,percent of total billed charges,Implant Device,100.8,35,,100.8,percent of total billed charges,Implant Device,100.8,35,,100.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,213.12,
BIOMET CS18000 CORTICAL SCREW 3.5X18MM,C1713,HCPCS,,79001462,CDM,278,RC,,,both,,,420,310.8,,,310.8,Other,150% of Medicare + 9.63% HCRA Surcharge,189,45,,189,percent of total billed charges,Critical Access Hospital RCC factor,142.8,34,,142.8,percent of total billed charges,Implant Device,142.8,34,,142.8,percent of total billed charges,Implant Device,142.8,34,,142.8,percent of total billed charges,Implant Device,142.8,34,,142.8,percent of total billed charges,Implant Device,142.8,34,,142.8,percent of total billed charges,Implant Device,207.9,,,207.9,Other,110% of Medicare,147,35,,147,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,147,35,,147,percent of total billed charges,Implant Device,147,35,,147,percent of total billed charges,Implant Device,147,35,,147,percent of total billed charges,Implant Device,147,35,,147,percent of total billed charges,Implant Device,147,35,,147,percent of total billed charges,Implant Device,168,40,,168,percent of total billed charges,Implant Device,147,70,,147,percent of total billed charges,All Other,142.8,34,,142.8,percent of total billed charges,Implant Device,142.8,34,,142.8,percent of total billed charges,Implant Device,147,35,,147,percent of total billed charges,Implant Device,147,35,,147,percent of total billed charges,Implant Device,147,35,,147,percent of total billed charges,Implant Device,147,35,,147,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,310.8,
ATRIUM 31526 C-QUR MESH 3 X 6,C1781,HCPCS,,79001465,CDM,278,RC,,,both,,,926,685.24,,,685.24,Other,150% of Medicare + 9.63% HCRA Surcharge,416.7,45,,416.7,percent of total billed charges,Critical Access Hospital RCC factor,314.84,34,,314.84,percent of total billed charges,Implant Device,314.84,34,,314.84,percent of total billed charges,Implant Device,314.84,34,,314.84,percent of total billed charges,Implant Device,314.84,34,,314.84,percent of total billed charges,Implant Device,314.84,34,,314.84,percent of total billed charges,Implant Device,458.37,,,458.37,Other,110% of Medicare,324.1,35,,324.1,percent of total billed charges,Implant Device,314.84,34,"Charges > $500, x 34%",314.84,percent of total billed charges,Implant Device,324.1,35,,324.1,percent of total billed charges,Implant Device,324.1,35,,324.1,percent of total billed charges,Implant Device,324.1,35,,324.1,percent of total billed charges,Implant Device,324.1,35,,324.1,percent of total billed charges,Implant Device,324.1,35,,324.1,percent of total billed charges,Implant Device,370.4,40,,370.4,percent of total billed charges,Implant Device,324.1,70,,324.1,percent of total billed charges,All Other,314.84,34,,314.84,percent of total billed charges,Implant Device,314.84,34,,314.84,percent of total billed charges,Implant Device,324.1,35,,324.1,percent of total billed charges,Implant Device,324.1,35,,324.1,percent of total billed charges,Implant Device,324.1,35,,324.1,percent of total billed charges,Implant Device,324.1,35,,324.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,685.24,
ATRIUM 31543 C-QUR MESH 3.5 X3.5,C1781,HCPCS,,79001466,CDM,278,RC,,,both,,,728,538.72,,,538.72,Other,150% of Medicare + 9.63% HCRA Surcharge,327.6,45,,327.6,percent of total billed charges,Critical Access Hospital RCC factor,247.52,34,,247.52,percent of total billed charges,Implant Device,247.52,34,,247.52,percent of total billed charges,Implant Device,247.52,34,,247.52,percent of total billed charges,Implant Device,247.52,34,,247.52,percent of total billed charges,Implant Device,247.52,34,,247.52,percent of total billed charges,Implant Device,360.36,,,360.36,Other,110% of Medicare,254.8,35,,254.8,percent of total billed charges,Implant Device,247.52,34,"Charges > $500, x 34%",247.52,percent of total billed charges,Implant Device,254.8,35,,254.8,percent of total billed charges,Implant Device,254.8,35,,254.8,percent of total billed charges,Implant Device,254.8,35,,254.8,percent of total billed charges,Implant Device,254.8,35,,254.8,percent of total billed charges,Implant Device,254.8,35,,254.8,percent of total billed charges,Implant Device,291.2,40,,291.2,percent of total billed charges,Implant Device,254.8,70,,254.8,percent of total billed charges,All Other,247.52,34,,247.52,percent of total billed charges,Implant Device,247.52,34,,247.52,percent of total billed charges,Implant Device,254.8,35,,254.8,percent of total billed charges,Implant Device,254.8,35,,254.8,percent of total billed charges,Implant Device,254.8,35,,254.8,percent of total billed charges,Implant Device,254.8,35,,254.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,538.72,
ATRIUM 31527 C-QUR MESH 4.3 X 5.5,C1781,HCPCS,,79001467,CDM,278,RC,,,both,,,960,710.4,,,710.4,Other,150% of Medicare + 9.63% HCRA Surcharge,432,45,,432,percent of total billed charges,Critical Access Hospital RCC factor,326.4,34,,326.4,percent of total billed charges,Implant Device,326.4,34,,326.4,percent of total billed charges,Implant Device,326.4,34,,326.4,percent of total billed charges,Implant Device,326.4,34,,326.4,percent of total billed charges,Implant Device,326.4,34,,326.4,percent of total billed charges,Implant Device,475.2,,,475.2,Other,110% of Medicare,336,35,,336,percent of total billed charges,Implant Device,326.4,34,"Charges > $500, x 34%",326.4,percent of total billed charges,Implant Device,336,35,,336,percent of total billed charges,Implant Device,336,35,,336,percent of total billed charges,Implant Device,336,35,,336,percent of total billed charges,Implant Device,336,35,,336,percent of total billed charges,Implant Device,336,35,,336,percent of total billed charges,Implant Device,384,40,,384,percent of total billed charges,Implant Device,336,70,,336,percent of total billed charges,All Other,326.4,34,,326.4,percent of total billed charges,Implant Device,326.4,34,,326.4,percent of total billed charges,Implant Device,336,35,,336,percent of total billed charges,Implant Device,336,35,,336,percent of total billed charges,Implant Device,336,35,,336,percent of total billed charges,Implant Device,336,35,,336,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,710.4,
ATRIUM 31544 C-QUR MESH 5 X 5,C1781,HCPCS,,79001468,CDM,278,RC,,,both,,,1083,801.42,,,801.42,Other,150% of Medicare + 9.63% HCRA Surcharge,487.35,45,,487.35,percent of total billed charges,Critical Access Hospital RCC factor,368.22,34,,368.22,percent of total billed charges,Implant Device,368.22,34,,368.22,percent of total billed charges,Implant Device,368.22,34,,368.22,percent of total billed charges,Implant Device,368.22,34,,368.22,percent of total billed charges,Implant Device,368.22,34,,368.22,percent of total billed charges,Implant Device,536.09,,,536.09,Other,110% of Medicare,379.05,35,,379.05,percent of total billed charges,Implant Device,368.22,34,"Charges > $500, x 34%",368.22,percent of total billed charges,Implant Device,379.05,35,,379.05,percent of total billed charges,Implant Device,379.05,35,,379.05,percent of total billed charges,Implant Device,379.05,35,,379.05,percent of total billed charges,Implant Device,379.05,35,,379.05,percent of total billed charges,Implant Device,379.05,35,,379.05,percent of total billed charges,Implant Device,433.2,40,,433.2,percent of total billed charges,Implant Device,379.05,70,,379.05,percent of total billed charges,All Other,368.22,34,,368.22,percent of total billed charges,Implant Device,368.22,34,,368.22,percent of total billed charges,Implant Device,379.05,35,,379.05,percent of total billed charges,Implant Device,379.05,35,,379.05,percent of total billed charges,Implant Device,379.05,35,,379.05,percent of total billed charges,Implant Device,379.05,35,,379.05,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,801.42,
ATRIUM 31531 C-QUR MESH 5.4 X 7,C1781,HCPCS,,79001469,CDM,278,RC,,,both,,,1528,1130.72,,,1130.72,Other,150% of Medicare + 9.63% HCRA Surcharge,687.6,45,,687.6,percent of total billed charges,Critical Access Hospital RCC factor,519.52,34,,519.52,percent of total billed charges,Implant Device,519.52,34,,519.52,percent of total billed charges,Implant Device,519.52,34,,519.52,percent of total billed charges,Implant Device,519.52,34,,519.52,percent of total billed charges,Implant Device,519.52,34,,519.52,percent of total billed charges,Implant Device,756.36,,,756.36,Other,110% of Medicare,534.8,35,,534.8,percent of total billed charges,Implant Device,519.52,34,"Charges > $500, x 34%",519.52,percent of total billed charges,Implant Device,534.8,35,,534.8,percent of total billed charges,Implant Device,534.8,35,,534.8,percent of total billed charges,Implant Device,534.8,35,,534.8,percent of total billed charges,Implant Device,534.8,35,,534.8,percent of total billed charges,Implant Device,534.8,35,,534.8,percent of total billed charges,Implant Device,611.2,40,,611.2,percent of total billed charges,Implant Device,534.8,70,,534.8,percent of total billed charges,All Other,519.52,34,,519.52,percent of total billed charges,Implant Device,519.52,34,,519.52,percent of total billed charges,Implant Device,534.8,35,,534.8,percent of total billed charges,Implant Device,534.8,35,,534.8,percent of total billed charges,Implant Device,534.8,35,,534.8,percent of total billed charges,Implant Device,534.8,35,,534.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1130.72,
ATRIUM 31534 C-QUR MESH 6 X 9,C1781,HCPCS,,79001470,CDM,278,RC,,,both,,,2392,1770.09,,,1770.09,Other,150% of Medicare + 9.63% HCRA Surcharge,1076.4,45,,1076.4,percent of total billed charges,Critical Access Hospital RCC factor,813.28,34,,813.28,percent of total billed charges,Implant Device,813.28,34,,813.28,percent of total billed charges,Implant Device,813.28,34,,813.28,percent of total billed charges,Implant Device,813.28,34,,813.28,percent of total billed charges,Implant Device,813.28,34,,813.28,percent of total billed charges,Implant Device,1184.04,,,1184.04,Other,110% of Medicare,837.2,35,,837.2,percent of total billed charges,Implant Device,813.28,34,"Charges > $500, x 34%",813.28,percent of total billed charges,Implant Device,837.2,35,,837.2,percent of total billed charges,Implant Device,837.2,35,,837.2,percent of total billed charges,Implant Device,837.2,35,,837.2,percent of total billed charges,Implant Device,837.2,35,,837.2,percent of total billed charges,Implant Device,837.2,35,,837.2,percent of total billed charges,Implant Device,956.8,40,,956.8,percent of total billed charges,Implant Device,837.2,70,,837.2,percent of total billed charges,All Other,813.28,34,,813.28,percent of total billed charges,Implant Device,813.28,34,,813.28,percent of total billed charges,Implant Device,837.2,35,,837.2,percent of total billed charges,Implant Device,837.2,35,,837.2,percent of total billed charges,Implant Device,837.2,35,,837.2,percent of total billed charges,Implant Device,837.2,35,,837.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,813.28,34,"If Charge > 2,000, then 34 percent",813.28,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1770.09,
ATRIUM 31537 C-QUR MESH 8 X 12,C1781,HCPCS,,79001471,CDM,278,RC,,,both,,,3714,2748.37,,,2748.37,Other,150% of Medicare + 9.63% HCRA Surcharge,1671.3,45,,1671.3,percent of total billed charges,Critical Access Hospital RCC factor,1262.76,34,,1262.76,percent of total billed charges,Implant Device,1262.76,34,,1262.76,percent of total billed charges,Implant Device,1262.76,34,,1262.76,percent of total billed charges,Implant Device,1262.76,34,,1262.76,percent of total billed charges,Implant Device,1262.76,34,,1262.76,percent of total billed charges,Implant Device,1838.43,,,1838.43,Other,110% of Medicare,1299.9,35,,1299.9,percent of total billed charges,Implant Device,1262.76,34,"Charges > $500, x 34%",1262.76,percent of total billed charges,Implant Device,1299.9,35,,1299.9,percent of total billed charges,Implant Device,1299.9,35,,1299.9,percent of total billed charges,Implant Device,1299.9,35,,1299.9,percent of total billed charges,Implant Device,1299.9,35,,1299.9,percent of total billed charges,Implant Device,1299.9,35,,1299.9,percent of total billed charges,Implant Device,1485.6,40,,1485.6,percent of total billed charges,Implant Device,1299.9,70,,1299.9,percent of total billed charges,All Other,1262.76,34,,1262.76,percent of total billed charges,Implant Device,1262.76,34,,1262.76,percent of total billed charges,Implant Device,1299.9,35,,1299.9,percent of total billed charges,Implant Device,1299.9,35,,1299.9,percent of total billed charges,Implant Device,1299.9,35,,1299.9,percent of total billed charges,Implant Device,1299.9,35,,1299.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1262.76,34,"If Charge > 2,000, then 34 percent",1262.76,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2748.37,
ATRIUM 31628 C-QUR TACSHIELD 4 X 6,C1781,HCPCS,,79001472,CDM,278,RC,,,both,,,1382,1022.68,,,1022.68,Other,150% of Medicare + 9.63% HCRA Surcharge,621.9,45,,621.9,percent of total billed charges,Critical Access Hospital RCC factor,469.88,34,,469.88,percent of total billed charges,Implant Device,469.88,34,,469.88,percent of total billed charges,Implant Device,469.88,34,,469.88,percent of total billed charges,Implant Device,469.88,34,,469.88,percent of total billed charges,Implant Device,469.88,34,,469.88,percent of total billed charges,Implant Device,684.09,,,684.09,Other,110% of Medicare,483.7,35,,483.7,percent of total billed charges,Implant Device,469.88,34,"Charges > $500, x 34%",469.88,percent of total billed charges,Implant Device,483.7,35,,483.7,percent of total billed charges,Implant Device,483.7,35,,483.7,percent of total billed charges,Implant Device,483.7,35,,483.7,percent of total billed charges,Implant Device,483.7,35,,483.7,percent of total billed charges,Implant Device,483.7,35,,483.7,percent of total billed charges,Implant Device,552.8,40,,552.8,percent of total billed charges,Implant Device,483.7,70,,483.7,percent of total billed charges,All Other,469.88,34,,469.88,percent of total billed charges,Implant Device,469.88,34,,469.88,percent of total billed charges,Implant Device,483.7,35,,483.7,percent of total billed charges,Implant Device,483.7,35,,483.7,percent of total billed charges,Implant Device,483.7,35,,483.7,percent of total billed charges,Implant Device,483.7,35,,483.7,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1022.68,
ATRIUM 31644 C-QUR TACSHIELD 5 X 5,C1781,HCPCS,,79001473,CDM,278,RC,,,both,,,1382,1022.68,,,1022.68,Other,150% of Medicare + 9.63% HCRA Surcharge,621.9,45,,621.9,percent of total billed charges,Critical Access Hospital RCC factor,469.88,34,,469.88,percent of total billed charges,Implant Device,469.88,34,,469.88,percent of total billed charges,Implant Device,469.88,34,,469.88,percent of total billed charges,Implant Device,469.88,34,,469.88,percent of total billed charges,Implant Device,469.88,34,,469.88,percent of total billed charges,Implant Device,684.09,,,684.09,Other,110% of Medicare,483.7,35,,483.7,percent of total billed charges,Implant Device,469.88,34,"Charges > $500, x 34%",469.88,percent of total billed charges,Implant Device,483.7,35,,483.7,percent of total billed charges,Implant Device,483.7,35,,483.7,percent of total billed charges,Implant Device,483.7,35,,483.7,percent of total billed charges,Implant Device,483.7,35,,483.7,percent of total billed charges,Implant Device,483.7,35,,483.7,percent of total billed charges,Implant Device,552.8,40,,552.8,percent of total billed charges,Implant Device,483.7,70,,483.7,percent of total billed charges,All Other,469.88,34,,469.88,percent of total billed charges,Implant Device,469.88,34,,469.88,percent of total billed charges,Implant Device,483.7,35,,483.7,percent of total billed charges,Implant Device,483.7,35,,483.7,percent of total billed charges,Implant Device,483.7,35,,483.7,percent of total billed charges,Implant Device,483.7,35,,483.7,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1022.68,
ATRIUM 31633 C-QUR TACSHIELD 6 X 8,C1781,HCPCS,,79001474,CDM,278,RC,,,both,,,2434,1801.17,,,1801.17,Other,150% of Medicare + 9.63% HCRA Surcharge,1095.3,45,,1095.3,percent of total billed charges,Critical Access Hospital RCC factor,827.56,34,,827.56,percent of total billed charges,Implant Device,827.56,34,,827.56,percent of total billed charges,Implant Device,827.56,34,,827.56,percent of total billed charges,Implant Device,827.56,34,,827.56,percent of total billed charges,Implant Device,827.56,34,,827.56,percent of total billed charges,Implant Device,1204.83,,,1204.83,Other,110% of Medicare,851.9,35,,851.9,percent of total billed charges,Implant Device,827.56,34,"Charges > $500, x 34%",827.56,percent of total billed charges,Implant Device,851.9,35,,851.9,percent of total billed charges,Implant Device,851.9,35,,851.9,percent of total billed charges,Implant Device,851.9,35,,851.9,percent of total billed charges,Implant Device,851.9,35,,851.9,percent of total billed charges,Implant Device,851.9,35,,851.9,percent of total billed charges,Implant Device,973.6,40,,973.6,percent of total billed charges,Implant Device,851.9,70,,851.9,percent of total billed charges,All Other,827.56,34,,827.56,percent of total billed charges,Implant Device,827.56,34,,827.56,percent of total billed charges,Implant Device,851.9,35,,851.9,percent of total billed charges,Implant Device,851.9,35,,851.9,percent of total billed charges,Implant Device,851.9,35,,851.9,percent of total billed charges,Implant Device,851.9,35,,851.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,827.56,34,"If Charge > 2,000, then 34 percent",827.56,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1801.17,
ATRIUM 31637 C-QUR TACSHIELD 8 X 12,C1781,HCPCS,,79001475,CDM,278,RC,,,both,,,4056,3001.45,,,3001.45,Other,150% of Medicare + 9.63% HCRA Surcharge,1825.2,45,,1825.2,percent of total billed charges,Critical Access Hospital RCC factor,1379.04,34,,1379.04,percent of total billed charges,Implant Device,1379.04,34,,1379.04,percent of total billed charges,Implant Device,1379.04,34,,1379.04,percent of total billed charges,Implant Device,1379.04,34,,1379.04,percent of total billed charges,Implant Device,1379.04,34,,1379.04,percent of total billed charges,Implant Device,2007.72,,,2007.72,Other,110% of Medicare,1419.6,35,,1419.6,percent of total billed charges,Implant Device,1379.04,34,"Charges > $500, x 34%",1379.04,percent of total billed charges,Implant Device,1419.6,35,,1419.6,percent of total billed charges,Implant Device,1419.6,35,,1419.6,percent of total billed charges,Implant Device,1419.6,35,,1419.6,percent of total billed charges,Implant Device,1419.6,35,,1419.6,percent of total billed charges,Implant Device,1419.6,35,,1419.6,percent of total billed charges,Implant Device,1622.4,40,,1622.4,percent of total billed charges,Implant Device,1419.6,70,,1419.6,percent of total billed charges,All Other,1379.04,34,,1379.04,percent of total billed charges,Implant Device,1379.04,34,,1379.04,percent of total billed charges,Implant Device,1419.6,35,,1419.6,percent of total billed charges,Implant Device,1419.6,35,,1419.6,percent of total billed charges,Implant Device,1419.6,35,,1419.6,percent of total billed charges,Implant Device,1419.6,35,,1419.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1379.04,34,"If Charge > 2,000, then 34 percent",1379.04,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3001.45,
ATRIUM 31201 C-QUR V PATCH MED 2.5X2.5,C1781,HCPCS,,79001476,CDM,278,RC,,,both,,,1327,981.98,,,981.98,Other,150% of Medicare + 9.63% HCRA Surcharge,597.15,45,,597.15,percent of total billed charges,Critical Access Hospital RCC factor,451.18,34,,451.18,percent of total billed charges,Implant Device,451.18,34,,451.18,percent of total billed charges,Implant Device,451.18,34,,451.18,percent of total billed charges,Implant Device,451.18,34,,451.18,percent of total billed charges,Implant Device,451.18,34,,451.18,percent of total billed charges,Implant Device,656.87,,,656.87,Other,110% of Medicare,464.45,35,,464.45,percent of total billed charges,Implant Device,451.18,34,"Charges > $500, x 34%",451.18,percent of total billed charges,Implant Device,464.45,35,,464.45,percent of total billed charges,Implant Device,464.45,35,,464.45,percent of total billed charges,Implant Device,464.45,35,,464.45,percent of total billed charges,Implant Device,464.45,35,,464.45,percent of total billed charges,Implant Device,464.45,35,,464.45,percent of total billed charges,Implant Device,530.8,40,,530.8,percent of total billed charges,Implant Device,464.45,70,,464.45,percent of total billed charges,All Other,451.18,34,,451.18,percent of total billed charges,Implant Device,451.18,34,,451.18,percent of total billed charges,Implant Device,464.45,35,,464.45,percent of total billed charges,Implant Device,464.45,35,,464.45,percent of total billed charges,Implant Device,464.45,35,,464.45,percent of total billed charges,Implant Device,464.45,35,,464.45,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,981.98,
ATRIUM 31200 C-QUR V PATCH SMALL 1.7X1.7,C1781,HCPCS,,79001477,CDM,278,RC,,,both,,,1013,749.62,,,749.62,Other,150% of Medicare + 9.63% HCRA Surcharge,455.85,45,,455.85,percent of total billed charges,Critical Access Hospital RCC factor,344.42,34,,344.42,percent of total billed charges,Implant Device,344.42,34,,344.42,percent of total billed charges,Implant Device,344.42,34,,344.42,percent of total billed charges,Implant Device,344.42,34,,344.42,percent of total billed charges,Implant Device,344.42,34,,344.42,percent of total billed charges,Implant Device,501.44,,,501.44,Other,110% of Medicare,354.55,35,,354.55,percent of total billed charges,Implant Device,344.42,34,"Charges > $500, x 34%",344.42,percent of total billed charges,Implant Device,354.55,35,,354.55,percent of total billed charges,Implant Device,354.55,35,,354.55,percent of total billed charges,Implant Device,354.55,35,,354.55,percent of total billed charges,Implant Device,354.55,35,,354.55,percent of total billed charges,Implant Device,354.55,35,,354.55,percent of total billed charges,Implant Device,405.2,40,,405.2,percent of total billed charges,Implant Device,354.55,70,,354.55,percent of total billed charges,All Other,344.42,34,,344.42,percent of total billed charges,Implant Device,344.42,34,,344.42,percent of total billed charges,Implant Device,354.55,35,,354.55,percent of total billed charges,Implant Device,354.55,35,,354.55,percent of total billed charges,Implant Device,354.55,35,,354.55,percent of total billed charges,Implant Device,354.55,35,,354.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,749.62,
ATRIUM 31202 C-QURV PATCH LARGE 3.2X3.2,C1781,HCPCS,,79001478,CDM,278,RC,,,both,,,1667,1233.58,,,1233.58,Other,150% of Medicare + 9.63% HCRA Surcharge,750.15,45,,750.15,percent of total billed charges,Critical Access Hospital RCC factor,566.78,34,,566.78,percent of total billed charges,Implant Device,566.78,34,,566.78,percent of total billed charges,Implant Device,566.78,34,,566.78,percent of total billed charges,Implant Device,566.78,34,,566.78,percent of total billed charges,Implant Device,566.78,34,,566.78,percent of total billed charges,Implant Device,825.17,,,825.17,Other,110% of Medicare,583.45,35,,583.45,percent of total billed charges,Implant Device,566.78,34,"Charges > $500, x 34%",566.78,percent of total billed charges,Implant Device,583.45,35,,583.45,percent of total billed charges,Implant Device,583.45,35,,583.45,percent of total billed charges,Implant Device,583.45,35,,583.45,percent of total billed charges,Implant Device,583.45,35,,583.45,percent of total billed charges,Implant Device,583.45,35,,583.45,percent of total billed charges,Implant Device,666.8,40,,666.8,percent of total billed charges,Implant Device,583.45,70,,583.45,percent of total billed charges,All Other,566.78,34,,566.78,percent of total billed charges,Implant Device,566.78,34,,566.78,percent of total billed charges,Implant Device,583.45,35,,583.45,percent of total billed charges,Implant Device,583.45,35,,583.45,percent of total billed charges,Implant Device,583.45,35,,583.45,percent of total billed charges,Implant Device,583.45,35,,583.45,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1233.58,
BIOMET SPINE DBM001 DBM PUTTY 1CC,C1713,HCPCS,,79001479,CDM,278,RC,,,both,,,627,463.98,,,463.98,Other,150% of Medicare + 9.63% HCRA Surcharge,282.15,45,,282.15,percent of total billed charges,Critical Access Hospital RCC factor,213.18,34,,213.18,percent of total billed charges,Implant Device,213.18,34,,213.18,percent of total billed charges,Implant Device,213.18,34,,213.18,percent of total billed charges,Implant Device,213.18,34,,213.18,percent of total billed charges,Implant Device,213.18,34,,213.18,percent of total billed charges,Implant Device,310.37,,,310.37,Other,110% of Medicare,219.45,35,,219.45,percent of total billed charges,Implant Device,213.18,34,"Charges > $500, x 34%",213.18,percent of total billed charges,Implant Device,219.45,35,,219.45,percent of total billed charges,Implant Device,219.45,35,,219.45,percent of total billed charges,Implant Device,219.45,35,,219.45,percent of total billed charges,Implant Device,219.45,35,,219.45,percent of total billed charges,Implant Device,219.45,35,,219.45,percent of total billed charges,Implant Device,250.8,40,,250.8,percent of total billed charges,Implant Device,219.45,70,,219.45,percent of total billed charges,All Other,213.18,34,,213.18,percent of total billed charges,Implant Device,213.18,34,,213.18,percent of total billed charges,Implant Device,219.45,35,,219.45,percent of total billed charges,Implant Device,219.45,35,,219.45,percent of total billed charges,Implant Device,219.45,35,,219.45,percent of total billed charges,Implant Device,219.45,35,,219.45,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,463.98,
BIOMET SPINE DBM010 DBM PUTTY 10CC,C1713,HCPCS,,79001480,CDM,278,RC,,,both,,,4035,2985.91,,,2985.91,Other,150% of Medicare + 9.63% HCRA Surcharge,1815.75,45,,1815.75,percent of total billed charges,Critical Access Hospital RCC factor,1371.9,34,,1371.9,percent of total billed charges,Implant Device,1371.9,34,,1371.9,percent of total billed charges,Implant Device,1371.9,34,,1371.9,percent of total billed charges,Implant Device,1371.9,34,,1371.9,percent of total billed charges,Implant Device,1371.9,34,,1371.9,percent of total billed charges,Implant Device,1997.33,,,1997.33,Other,110% of Medicare,1412.25,35,,1412.25,percent of total billed charges,Implant Device,1371.9,34,"Charges > $500, x 34%",1371.9,percent of total billed charges,Implant Device,1412.25,35,,1412.25,percent of total billed charges,Implant Device,1412.25,35,,1412.25,percent of total billed charges,Implant Device,1412.25,35,,1412.25,percent of total billed charges,Implant Device,1412.25,35,,1412.25,percent of total billed charges,Implant Device,1412.25,35,,1412.25,percent of total billed charges,Implant Device,1614,40,,1614,percent of total billed charges,Implant Device,1412.25,70,,1412.25,percent of total billed charges,All Other,1371.9,34,,1371.9,percent of total billed charges,Implant Device,1371.9,34,,1371.9,percent of total billed charges,Implant Device,1412.25,35,,1412.25,percent of total billed charges,Implant Device,1412.25,35,,1412.25,percent of total billed charges,Implant Device,1412.25,35,,1412.25,percent of total billed charges,Implant Device,1412.25,35,,1412.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1371.9,34,"If Charge > 2,000, then 34 percent",1371.9,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2985.91,
BIOMET SPINE DBM002 DBM PUTTY 2CC,C1713,HCPCS,,79001481,CDM,278,RC,,,both,,,1050,777,,,777,Other,150% of Medicare + 9.63% HCRA Surcharge,472.5,45,,472.5,percent of total billed charges,Critical Access Hospital RCC factor,357,34,,357,percent of total billed charges,Implant Device,357,34,,357,percent of total billed charges,Implant Device,357,34,,357,percent of total billed charges,Implant Device,357,34,,357,percent of total billed charges,Implant Device,357,34,,357,percent of total billed charges,Implant Device,519.75,,,519.75,Other,110% of Medicare,367.5,35,,367.5,percent of total billed charges,Implant Device,357,34,"Charges > $500, x 34%",357,percent of total billed charges,Implant Device,367.5,35,,367.5,percent of total billed charges,Implant Device,367.5,35,,367.5,percent of total billed charges,Implant Device,367.5,35,,367.5,percent of total billed charges,Implant Device,367.5,35,,367.5,percent of total billed charges,Implant Device,367.5,35,,367.5,percent of total billed charges,Implant Device,420,40,,420,percent of total billed charges,Implant Device,367.5,70,,367.5,percent of total billed charges,All Other,357,34,,357,percent of total billed charges,Implant Device,357,34,,357,percent of total billed charges,Implant Device,367.5,35,,367.5,percent of total billed charges,Implant Device,367.5,35,,367.5,percent of total billed charges,Implant Device,367.5,35,,367.5,percent of total billed charges,Implant Device,367.5,35,,367.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,777,
BIOMET SPINE DBM005 DBM PUTTY 5CC,C1713,HCPCS,,79001482,CDM,278,RC,,,both,,,2304,1704.97,,,1704.97,Other,150% of Medicare + 9.63% HCRA Surcharge,1036.8,45,,1036.8,percent of total billed charges,Critical Access Hospital RCC factor,783.36,34,,783.36,percent of total billed charges,Implant Device,783.36,34,,783.36,percent of total billed charges,Implant Device,783.36,34,,783.36,percent of total billed charges,Implant Device,783.36,34,,783.36,percent of total billed charges,Implant Device,783.36,34,,783.36,percent of total billed charges,Implant Device,1140.48,,,1140.48,Other,110% of Medicare,806.4,35,,806.4,percent of total billed charges,Implant Device,783.36,34,"Charges > $500, x 34%",783.36,percent of total billed charges,Implant Device,806.4,35,,806.4,percent of total billed charges,Implant Device,806.4,35,,806.4,percent of total billed charges,Implant Device,806.4,35,,806.4,percent of total billed charges,Implant Device,806.4,35,,806.4,percent of total billed charges,Implant Device,806.4,35,,806.4,percent of total billed charges,Implant Device,921.6,40,,921.6,percent of total billed charges,Implant Device,806.4,70,,806.4,percent of total billed charges,All Other,783.36,34,,783.36,percent of total billed charges,Implant Device,783.36,34,,783.36,percent of total billed charges,Implant Device,806.4,35,,806.4,percent of total billed charges,Implant Device,806.4,35,,806.4,percent of total billed charges,Implant Device,806.4,35,,806.4,percent of total billed charges,Implant Device,806.4,35,,806.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,783.36,34,"If Charge > 2,000, then 34 percent",783.36,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1704.97,
BIOMET SPINE DBMW05 DBM PUTTY PLUS 5CC,C1713,HCPCS,,79001483,CDM,278,RC,,,both,,,3039,2248.87,,,2248.87,Other,150% of Medicare + 9.63% HCRA Surcharge,1367.55,45,,1367.55,percent of total billed charges,Critical Access Hospital RCC factor,1033.26,34,,1033.26,percent of total billed charges,Implant Device,1033.26,34,,1033.26,percent of total billed charges,Implant Device,1033.26,34,,1033.26,percent of total billed charges,Implant Device,1033.26,34,,1033.26,percent of total billed charges,Implant Device,1033.26,34,,1033.26,percent of total billed charges,Implant Device,1504.31,,,1504.31,Other,110% of Medicare,1063.65,35,,1063.65,percent of total billed charges,Implant Device,1033.26,34,"Charges > $500, x 34%",1033.26,percent of total billed charges,Implant Device,1063.65,35,,1063.65,percent of total billed charges,Implant Device,1063.65,35,,1063.65,percent of total billed charges,Implant Device,1063.65,35,,1063.65,percent of total billed charges,Implant Device,1063.65,35,,1063.65,percent of total billed charges,Implant Device,1063.65,35,,1063.65,percent of total billed charges,Implant Device,1215.6,40,,1215.6,percent of total billed charges,Implant Device,1063.65,70,,1063.65,percent of total billed charges,All Other,1033.26,34,,1033.26,percent of total billed charges,Implant Device,1033.26,34,,1033.26,percent of total billed charges,Implant Device,1063.65,35,,1063.65,percent of total billed charges,Implant Device,1063.65,35,,1063.65,percent of total billed charges,Implant Device,1063.65,35,,1063.65,percent of total billed charges,Implant Device,1063.65,35,,1063.65,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1033.26,34,"If Charge > 2,000, then 34 percent",1033.26,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2248.87,
BIOMET SPINE DBMW10 DBM PUTTY PLUS 10CC,C1713,HCPCS,,79001484,CDM,278,RC,,,both,,,4678,3461.73,,,3461.73,Other,150% of Medicare + 9.63% HCRA Surcharge,2105.1,45,,2105.1,percent of total billed charges,Critical Access Hospital RCC factor,1590.52,34,,1590.52,percent of total billed charges,Implant Device,1590.52,34,,1590.52,percent of total billed charges,Implant Device,1590.52,34,,1590.52,percent of total billed charges,Implant Device,1590.52,34,,1590.52,percent of total billed charges,Implant Device,1590.52,34,,1590.52,percent of total billed charges,Implant Device,2315.61,,,2315.61,Other,110% of Medicare,1637.3,35,,1637.3,percent of total billed charges,Implant Device,1590.52,34,"Charges > $500, x 34%",1590.52,percent of total billed charges,Implant Device,1637.3,35,,1637.3,percent of total billed charges,Implant Device,1637.3,35,,1637.3,percent of total billed charges,Implant Device,1637.3,35,,1637.3,percent of total billed charges,Implant Device,1637.3,35,,1637.3,percent of total billed charges,Implant Device,1637.3,35,,1637.3,percent of total billed charges,Implant Device,1871.2,40,,1871.2,percent of total billed charges,Implant Device,1637.3,70,,1637.3,percent of total billed charges,All Other,1590.52,34,,1590.52,percent of total billed charges,Implant Device,1590.52,34,,1590.52,percent of total billed charges,Implant Device,1637.3,35,,1637.3,percent of total billed charges,Implant Device,1637.3,35,,1637.3,percent of total billed charges,Implant Device,1637.3,35,,1637.3,percent of total billed charges,Implant Device,1637.3,35,,1637.3,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1590.52,34,"If Charge > 2,000, then 34 percent",1590.52,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3461.73,
BIOMET SPINE DBMW20 DBM PUTTY PLUS 20CC,C1713,HCPCS,,79001485,CDM,278,RC,,,both,,,8062,5965.9,,,5965.9,Other,150% of Medicare + 9.63% HCRA Surcharge,3627.9,45,,3627.9,percent of total billed charges,Critical Access Hospital RCC factor,2741.08,34,,2741.08,percent of total billed charges,Implant Device,2741.08,34,,2741.08,percent of total billed charges,Implant Device,2741.08,34,,2741.08,percent of total billed charges,Implant Device,2741.08,34,,2741.08,percent of total billed charges,Implant Device,2741.08,34,,2741.08,percent of total billed charges,Implant Device,3990.69,,,3990.69,Other,110% of Medicare,2821.7,35,,2821.7,percent of total billed charges,Implant Device,2741.08,34,"Charges > $500, x 34%",2741.08,percent of total billed charges,Implant Device,2821.7,35,,2821.7,percent of total billed charges,Implant Device,2821.7,35,,2821.7,percent of total billed charges,Implant Device,2821.7,35,,2821.7,percent of total billed charges,Implant Device,2821.7,35,,2821.7,percent of total billed charges,Implant Device,2821.7,35,,2821.7,percent of total billed charges,Implant Device,3224.8,40,,3224.8,percent of total billed charges,Implant Device,2821.7,70,,2821.7,percent of total billed charges,All Other,2741.08,34,,2741.08,percent of total billed charges,Implant Device,2741.08,34,,2741.08,percent of total billed charges,Implant Device,2821.7,35,,2821.7,percent of total billed charges,Implant Device,2821.7,35,,2821.7,percent of total billed charges,Implant Device,2821.7,35,,2821.7,percent of total billed charges,Implant Device,2821.7,35,,2821.7,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2741.08,34,"If Charge > 2,000, then 34 percent",2741.08,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5965.9,
DESARA SLING SYSTEM,C1771,HCPCS,,79001486,CDM,278,RC,,,both,,,2686,1987.65,,,1987.65,Other,150% of Medicare + 9.63% HCRA Surcharge,1208.7,45,,1208.7,percent of total billed charges,Critical Access Hospital RCC factor,913.24,34,,913.24,percent of total billed charges,Implant Device,913.24,34,,913.24,percent of total billed charges,Implant Device,913.24,34,,913.24,percent of total billed charges,Implant Device,913.24,34,,913.24,percent of total billed charges,Implant Device,913.24,34,,913.24,percent of total billed charges,Implant Device,1329.57,,,1329.57,Other,110% of Medicare,940.1,35,,940.1,percent of total billed charges,Implant Device,913.24,34,"Charges > $500, x 34%",913.24,percent of total billed charges,Implant Device,940.1,35,,940.1,percent of total billed charges,Implant Device,940.1,35,,940.1,percent of total billed charges,Implant Device,940.1,35,,940.1,percent of total billed charges,Implant Device,940.1,35,,940.1,percent of total billed charges,Implant Device,940.1,35,,940.1,percent of total billed charges,Implant Device,1074.4,40,,1074.4,percent of total billed charges,Implant Device,940.1,70,,940.1,percent of total billed charges,All Other,913.24,34,,913.24,percent of total billed charges,Implant Device,913.24,34,,913.24,percent of total billed charges,Implant Device,940.1,35,,940.1,percent of total billed charges,Implant Device,940.1,35,,940.1,percent of total billed charges,Implant Device,940.1,35,,940.1,percent of total billed charges,Implant Device,940.1,35,,940.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,913.24,34,"If Charge > 2,000, then 34 percent",913.24,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1987.65,
CARDIO MEDICAL DG-0209SN DURAGUARD 2X9CM,C1781,HCPCS,,79001487,CDM,278,RC,,,both,,,466,344.84,,,344.84,Other,150% of Medicare + 9.63% HCRA Surcharge,209.7,45,,209.7,percent of total billed charges,Critical Access Hospital RCC factor,158.44,34,,158.44,percent of total billed charges,Implant Device,158.44,34,,158.44,percent of total billed charges,Implant Device,158.44,34,,158.44,percent of total billed charges,Implant Device,158.44,34,,158.44,percent of total billed charges,Implant Device,158.44,34,,158.44,percent of total billed charges,Implant Device,230.67,,,230.67,Other,110% of Medicare,163.1,35,,163.1,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,163.1,35,,163.1,percent of total billed charges,Implant Device,163.1,35,,163.1,percent of total billed charges,Implant Device,163.1,35,,163.1,percent of total billed charges,Implant Device,163.1,35,,163.1,percent of total billed charges,Implant Device,163.1,35,,163.1,percent of total billed charges,Implant Device,186.4,40,,186.4,percent of total billed charges,Implant Device,163.1,70,,163.1,percent of total billed charges,All Other,158.44,34,,158.44,percent of total billed charges,Implant Device,158.44,34,,158.44,percent of total billed charges,Implant Device,163.1,35,,163.1,percent of total billed charges,Implant Device,163.1,35,,163.1,percent of total billed charges,Implant Device,163.1,35,,163.1,percent of total billed charges,Implant Device,163.1,35,,163.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,344.84,
CARDIO MEDICAL DG-0608SN DURAGUARD 6X8CM,C1781,HCPCS,,79001488,CDM,278,RC,,,both,,,826,611.24,,,611.24,Other,150% of Medicare + 9.63% HCRA Surcharge,371.7,45,,371.7,percent of total billed charges,Critical Access Hospital RCC factor,280.84,34,,280.84,percent of total billed charges,Implant Device,280.84,34,,280.84,percent of total billed charges,Implant Device,280.84,34,,280.84,percent of total billed charges,Implant Device,280.84,34,,280.84,percent of total billed charges,Implant Device,280.84,34,,280.84,percent of total billed charges,Implant Device,408.87,,,408.87,Other,110% of Medicare,289.1,35,,289.1,percent of total billed charges,Implant Device,280.84,34,"Charges > $500, x 34%",280.84,percent of total billed charges,Implant Device,289.1,35,,289.1,percent of total billed charges,Implant Device,289.1,35,,289.1,percent of total billed charges,Implant Device,289.1,35,,289.1,percent of total billed charges,Implant Device,289.1,35,,289.1,percent of total billed charges,Implant Device,289.1,35,,289.1,percent of total billed charges,Implant Device,330.4,40,,330.4,percent of total billed charges,Implant Device,289.1,70,,289.1,percent of total billed charges,All Other,280.84,34,,280.84,percent of total billed charges,Implant Device,280.84,34,,280.84,percent of total billed charges,Implant Device,289.1,35,,289.1,percent of total billed charges,Implant Device,289.1,35,,289.1,percent of total billed charges,Implant Device,289.1,35,,289.1,percent of total billed charges,Implant Device,289.1,35,,289.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,611.24,
ZIMMER DVRAX-R DVR PLATE EXT RIGHT,C1713,HCPCS,,79001489,CDM,278,RC,,,both,,,3690,2730.61,,,2730.61,Other,150% of Medicare + 9.63% HCRA Surcharge,1660.5,45,,1660.5,percent of total billed charges,Critical Access Hospital RCC factor,1254.6,34,,1254.6,percent of total billed charges,Implant Device,1254.6,34,,1254.6,percent of total billed charges,Implant Device,1254.6,34,,1254.6,percent of total billed charges,Implant Device,1254.6,34,,1254.6,percent of total billed charges,Implant Device,1254.6,34,,1254.6,percent of total billed charges,Implant Device,1826.55,,,1826.55,Other,110% of Medicare,1291.5,35,,1291.5,percent of total billed charges,Implant Device,1254.6,34,"Charges > $500, x 34%",1254.6,percent of total billed charges,Implant Device,1291.5,35,,1291.5,percent of total billed charges,Implant Device,1291.5,35,,1291.5,percent of total billed charges,Implant Device,1291.5,35,,1291.5,percent of total billed charges,Implant Device,1291.5,35,,1291.5,percent of total billed charges,Implant Device,1291.5,35,,1291.5,percent of total billed charges,Implant Device,1476,40,,1476,percent of total billed charges,Implant Device,1291.5,70,,1291.5,percent of total billed charges,All Other,1254.6,34,,1254.6,percent of total billed charges,Implant Device,1254.6,34,,1254.6,percent of total billed charges,Implant Device,1291.5,35,,1291.5,percent of total billed charges,Implant Device,1291.5,35,,1291.5,percent of total billed charges,Implant Device,1291.5,35,,1291.5,percent of total billed charges,Implant Device,1291.5,35,,1291.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1254.6,34,"If Charge > 2,000, then 34 percent",1254.6,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2730.61,
BIOMET DVRANSL PLATE NARROW SHORT LEFT,C1713,HCPCS,,79001490,CDM,278,RC,,,both,,,3690,2730.61,,,2730.61,Other,150% of Medicare + 9.63% HCRA Surcharge,1660.5,45,,1660.5,percent of total billed charges,Critical Access Hospital RCC factor,1254.6,34,,1254.6,percent of total billed charges,Implant Device,1254.6,34,,1254.6,percent of total billed charges,Implant Device,1254.6,34,,1254.6,percent of total billed charges,Implant Device,1254.6,34,,1254.6,percent of total billed charges,Implant Device,1254.6,34,,1254.6,percent of total billed charges,Implant Device,1826.55,,,1826.55,Other,110% of Medicare,1291.5,35,,1291.5,percent of total billed charges,Implant Device,1254.6,34,"Charges > $500, x 34%",1254.6,percent of total billed charges,Implant Device,1291.5,35,,1291.5,percent of total billed charges,Implant Device,1291.5,35,,1291.5,percent of total billed charges,Implant Device,1291.5,35,,1291.5,percent of total billed charges,Implant Device,1291.5,35,,1291.5,percent of total billed charges,Implant Device,1291.5,35,,1291.5,percent of total billed charges,Implant Device,1476,40,,1476,percent of total billed charges,Implant Device,1291.5,70,,1291.5,percent of total billed charges,All Other,1254.6,34,,1254.6,percent of total billed charges,Implant Device,1254.6,34,,1254.6,percent of total billed charges,Implant Device,1291.5,35,,1291.5,percent of total billed charges,Implant Device,1291.5,35,,1291.5,percent of total billed charges,Implant Device,1291.5,35,,1291.5,percent of total billed charges,Implant Device,1291.5,35,,1291.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1254.6,34,"If Charge > 2,000, then 34 percent",1254.6,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2730.61,
BIOMET DVRASL PLATE SHORT LEFT,C1713,HCPCS,,79001491,CDM,278,RC,,,both,,,2394,1771.57,,,1771.57,Other,150% of Medicare + 9.63% HCRA Surcharge,1077.3,45,,1077.3,percent of total billed charges,Critical Access Hospital RCC factor,813.96,34,,813.96,percent of total billed charges,Implant Device,813.96,34,,813.96,percent of total billed charges,Implant Device,813.96,34,,813.96,percent of total billed charges,Implant Device,813.96,34,,813.96,percent of total billed charges,Implant Device,813.96,34,,813.96,percent of total billed charges,Implant Device,1185.03,,,1185.03,Other,110% of Medicare,837.9,35,,837.9,percent of total billed charges,Implant Device,813.96,34,"Charges > $500, x 34%",813.96,percent of total billed charges,Implant Device,837.9,35,,837.9,percent of total billed charges,Implant Device,837.9,35,,837.9,percent of total billed charges,Implant Device,837.9,35,,837.9,percent of total billed charges,Implant Device,837.9,35,,837.9,percent of total billed charges,Implant Device,837.9,35,,837.9,percent of total billed charges,Implant Device,957.6,40,,957.6,percent of total billed charges,Implant Device,837.9,70,,837.9,percent of total billed charges,All Other,813.96,34,,813.96,percent of total billed charges,Implant Device,813.96,34,,813.96,percent of total billed charges,Implant Device,837.9,35,,837.9,percent of total billed charges,Implant Device,837.9,35,,837.9,percent of total billed charges,Implant Device,837.9,35,,837.9,percent of total billed charges,Implant Device,837.9,35,,837.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,813.96,34,"If Charge > 2,000, then 34 percent",813.96,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1771.57,
BIOMET DVRANS-R PLATE SHORT RIGHT,C1713,HCPCS,,79001492,CDM,278,RC,,,both,,,3690,2730.61,,,2730.61,Other,150% of Medicare + 9.63% HCRA Surcharge,1660.5,45,,1660.5,percent of total billed charges,Critical Access Hospital RCC factor,1254.6,34,,1254.6,percent of total billed charges,Implant Device,1254.6,34,,1254.6,percent of total billed charges,Implant Device,1254.6,34,,1254.6,percent of total billed charges,Implant Device,1254.6,34,,1254.6,percent of total billed charges,Implant Device,1254.6,34,,1254.6,percent of total billed charges,Implant Device,1826.55,,,1826.55,Other,110% of Medicare,1291.5,35,,1291.5,percent of total billed charges,Implant Device,1254.6,34,"Charges > $500, x 34%",1254.6,percent of total billed charges,Implant Device,1291.5,35,,1291.5,percent of total billed charges,Implant Device,1291.5,35,,1291.5,percent of total billed charges,Implant Device,1291.5,35,,1291.5,percent of total billed charges,Implant Device,1291.5,35,,1291.5,percent of total billed charges,Implant Device,1291.5,35,,1291.5,percent of total billed charges,Implant Device,1476,40,,1476,percent of total billed charges,Implant Device,1291.5,70,,1291.5,percent of total billed charges,All Other,1254.6,34,,1254.6,percent of total billed charges,Implant Device,1254.6,34,,1254.6,percent of total billed charges,Implant Device,1291.5,35,,1291.5,percent of total billed charges,Implant Device,1291.5,35,,1291.5,percent of total billed charges,Implant Device,1291.5,35,,1291.5,percent of total billed charges,Implant Device,1291.5,35,,1291.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1254.6,34,"If Charge > 2,000, then 34 percent",1254.6,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2730.61,
BIOMET DVRASR PLATE SHORT RIGHT,C1713,HCPCS,,79001493,CDM,278,RC,,,both,,,3690,2730.61,,,2730.61,Other,150% of Medicare + 9.63% HCRA Surcharge,1660.5,45,,1660.5,percent of total billed charges,Critical Access Hospital RCC factor,1254.6,34,,1254.6,percent of total billed charges,Implant Device,1254.6,34,,1254.6,percent of total billed charges,Implant Device,1254.6,34,,1254.6,percent of total billed charges,Implant Device,1254.6,34,,1254.6,percent of total billed charges,Implant Device,1254.6,34,,1254.6,percent of total billed charges,Implant Device,1826.55,,,1826.55,Other,110% of Medicare,1291.5,35,,1291.5,percent of total billed charges,Implant Device,1254.6,34,"Charges > $500, x 34%",1254.6,percent of total billed charges,Implant Device,1291.5,35,,1291.5,percent of total billed charges,Implant Device,1291.5,35,,1291.5,percent of total billed charges,Implant Device,1291.5,35,,1291.5,percent of total billed charges,Implant Device,1291.5,35,,1291.5,percent of total billed charges,Implant Device,1291.5,35,,1291.5,percent of total billed charges,Implant Device,1476,40,,1476,percent of total billed charges,Implant Device,1291.5,70,,1291.5,percent of total billed charges,All Other,1254.6,34,,1254.6,percent of total billed charges,Implant Device,1254.6,34,,1254.6,percent of total billed charges,Implant Device,1291.5,35,,1291.5,percent of total billed charges,Implant Device,1291.5,35,,1291.5,percent of total billed charges,Implant Device,1291.5,35,,1291.5,percent of total billed charges,Implant Device,1291.5,35,,1291.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1254.6,34,"If Charge > 2,000, then 34 percent",1254.6,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2730.61,
BIOMET DVRAXL PLATE SHORT RIGHT,C1713,HCPCS,,79001494,CDM,278,RC,,,both,,,3690,2730.61,,,2730.61,Other,150% of Medicare + 9.63% HCRA Surcharge,1660.5,45,,1660.5,percent of total billed charges,Critical Access Hospital RCC factor,1254.6,34,,1254.6,percent of total billed charges,Implant Device,1254.6,34,,1254.6,percent of total billed charges,Implant Device,1254.6,34,,1254.6,percent of total billed charges,Implant Device,1254.6,34,,1254.6,percent of total billed charges,Implant Device,1254.6,34,,1254.6,percent of total billed charges,Implant Device,1826.55,,,1826.55,Other,110% of Medicare,1291.5,35,,1291.5,percent of total billed charges,Implant Device,1254.6,34,"Charges > $500, x 34%",1254.6,percent of total billed charges,Implant Device,1291.5,35,,1291.5,percent of total billed charges,Implant Device,1291.5,35,,1291.5,percent of total billed charges,Implant Device,1291.5,35,,1291.5,percent of total billed charges,Implant Device,1291.5,35,,1291.5,percent of total billed charges,Implant Device,1291.5,35,,1291.5,percent of total billed charges,Implant Device,1476,40,,1476,percent of total billed charges,Implant Device,1291.5,70,,1291.5,percent of total billed charges,All Other,1254.6,34,,1254.6,percent of total billed charges,Implant Device,1254.6,34,,1254.6,percent of total billed charges,Implant Device,1291.5,35,,1291.5,percent of total billed charges,Implant Device,1291.5,35,,1291.5,percent of total billed charges,Implant Device,1291.5,35,,1291.5,percent of total billed charges,Implant Device,1291.5,35,,1291.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1254.6,34,"If Charge > 2,000, then 34 percent",1254.6,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2730.61,
BIOMET DVRAL PLATE STD LEFT,C1713,HCPCS,,79001495,CDM,278,RC,,,both,,,3690,2730.61,,,2730.61,Other,150% of Medicare + 9.63% HCRA Surcharge,1660.5,45,,1660.5,percent of total billed charges,Critical Access Hospital RCC factor,1254.6,34,,1254.6,percent of total billed charges,Implant Device,1254.6,34,,1254.6,percent of total billed charges,Implant Device,1254.6,34,,1254.6,percent of total billed charges,Implant Device,1254.6,34,,1254.6,percent of total billed charges,Implant Device,1254.6,34,,1254.6,percent of total billed charges,Implant Device,1826.55,,,1826.55,Other,110% of Medicare,1291.5,35,,1291.5,percent of total billed charges,Implant Device,1254.6,34,"Charges > $500, x 34%",1254.6,percent of total billed charges,Implant Device,1291.5,35,,1291.5,percent of total billed charges,Implant Device,1291.5,35,,1291.5,percent of total billed charges,Implant Device,1291.5,35,,1291.5,percent of total billed charges,Implant Device,1291.5,35,,1291.5,percent of total billed charges,Implant Device,1291.5,35,,1291.5,percent of total billed charges,Implant Device,1476,40,,1476,percent of total billed charges,Implant Device,1291.5,70,,1291.5,percent of total billed charges,All Other,1254.6,34,,1254.6,percent of total billed charges,Implant Device,1254.6,34,,1254.6,percent of total billed charges,Implant Device,1291.5,35,,1291.5,percent of total billed charges,Implant Device,1291.5,35,,1291.5,percent of total billed charges,Implant Device,1291.5,35,,1291.5,percent of total billed charges,Implant Device,1291.5,35,,1291.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1254.6,34,"If Charge > 2,000, then 34 percent",1254.6,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2730.61,
BIOMET DVRAR PLATE STD RIGHT,C1713,HCPCS,,79001496,CDM,278,RC,,,both,,,3690,2730.61,,,2730.61,Other,150% of Medicare + 9.63% HCRA Surcharge,1660.5,45,,1660.5,percent of total billed charges,Critical Access Hospital RCC factor,1254.6,34,,1254.6,percent of total billed charges,Implant Device,1254.6,34,,1254.6,percent of total billed charges,Implant Device,1254.6,34,,1254.6,percent of total billed charges,Implant Device,1254.6,34,,1254.6,percent of total billed charges,Implant Device,1254.6,34,,1254.6,percent of total billed charges,Implant Device,1826.55,,,1826.55,Other,110% of Medicare,1291.5,35,,1291.5,percent of total billed charges,Implant Device,1254.6,34,"Charges > $500, x 34%",1254.6,percent of total billed charges,Implant Device,1291.5,35,,1291.5,percent of total billed charges,Implant Device,1291.5,35,,1291.5,percent of total billed charges,Implant Device,1291.5,35,,1291.5,percent of total billed charges,Implant Device,1291.5,35,,1291.5,percent of total billed charges,Implant Device,1291.5,35,,1291.5,percent of total billed charges,Implant Device,1476,40,,1476,percent of total billed charges,Implant Device,1291.5,70,,1291.5,percent of total billed charges,All Other,1254.6,34,,1254.6,percent of total billed charges,Implant Device,1254.6,34,,1254.6,percent of total billed charges,Implant Device,1291.5,35,,1291.5,percent of total billed charges,Implant Device,1291.5,35,,1291.5,percent of total billed charges,Implant Device,1291.5,35,,1291.5,percent of total billed charges,Implant Device,1291.5,35,,1291.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1254.6,34,"If Charge > 2,000, then 34 percent",1254.6,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2730.61,
AMERICAN MED SYS 720093-01 ELEVATE AAPR,C1781,HCPCS,,79001497,CDM,278,RC,,,both,,,5550,4107.01,,,4107.01,Other,150% of Medicare + 9.63% HCRA Surcharge,2497.5,45,,2497.5,percent of total billed charges,Critical Access Hospital RCC factor,1887,34,,1887,percent of total billed charges,Implant Device,1887,34,,1887,percent of total billed charges,Implant Device,1887,34,,1887,percent of total billed charges,Implant Device,1887,34,,1887,percent of total billed charges,Implant Device,1887,34,,1887,percent of total billed charges,Implant Device,2747.25,,,2747.25,Other,110% of Medicare,1942.5,35,,1942.5,percent of total billed charges,Implant Device,1887,34,"Charges > $500, x 34%",1887,percent of total billed charges,Implant Device,1942.5,35,,1942.5,percent of total billed charges,Implant Device,1942.5,35,,1942.5,percent of total billed charges,Implant Device,1942.5,35,,1942.5,percent of total billed charges,Implant Device,1942.5,35,,1942.5,percent of total billed charges,Implant Device,1942.5,35,,1942.5,percent of total billed charges,Implant Device,2220,40,,2220,percent of total billed charges,Implant Device,1942.5,70,,1942.5,percent of total billed charges,All Other,1887,34,,1887,percent of total billed charges,Implant Device,1887,34,,1887,percent of total billed charges,Implant Device,1942.5,35,,1942.5,percent of total billed charges,Implant Device,1942.5,35,,1942.5,percent of total billed charges,Implant Device,1942.5,35,,1942.5,percent of total billed charges,Implant Device,1942.5,35,,1942.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1887,34,"If Charge > 2,000, then 34 percent",1887,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4107.01,
ELLIK EVACUATOR,C2631,HCPCS,,79001498,CDM,278,RC,,,both,,,594,439.56,,,439.56,Other,150% of Medicare + 9.63% HCRA Surcharge,267.3,45,,267.3,percent of total billed charges,Critical Access Hospital RCC factor,201.96,34,,201.96,percent of total billed charges,Implant Device,201.96,34,,201.96,percent of total billed charges,Implant Device,201.96,34,,201.96,percent of total billed charges,Implant Device,201.96,34,,201.96,percent of total billed charges,Implant Device,201.96,34,,201.96,percent of total billed charges,Implant Device,294.03,,,294.03,Other,110% of Medicare,207.9,35,,207.9,percent of total billed charges,Implant Device,201.96,34,"Charges > $500, x 34%",201.96,percent of total billed charges,Implant Device,207.9,35,,207.9,percent of total billed charges,Implant Device,207.9,35,,207.9,percent of total billed charges,Implant Device,207.9,35,,207.9,percent of total billed charges,Implant Device,207.9,35,,207.9,percent of total billed charges,Implant Device,207.9,35,,207.9,percent of total billed charges,Implant Device,237.6,40,,237.6,percent of total billed charges,Implant Device,207.9,70,,207.9,percent of total billed charges,All Other,201.96,34,,201.96,percent of total billed charges,Implant Device,201.96,34,,201.96,percent of total billed charges,Implant Device,207.9,35,,207.9,percent of total billed charges,Implant Device,207.9,35,,207.9,percent of total billed charges,Implant Device,207.9,35,,207.9,percent of total billed charges,Implant Device,207.9,35,,207.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,439.56,
BARD 0450M ELLIK EVACUATOR SET,C2631,HCPCS,,79001499,CDM,278,RC,,,both,,,348,257.52,,,257.52,Other,150% of Medicare + 9.63% HCRA Surcharge,156.6,45,,156.6,percent of total billed charges,Critical Access Hospital RCC factor,118.32,34,,118.32,percent of total billed charges,Implant Device,118.32,34,,118.32,percent of total billed charges,Implant Device,118.32,34,,118.32,percent of total billed charges,Implant Device,118.32,34,,118.32,percent of total billed charges,Implant Device,118.32,34,,118.32,percent of total billed charges,Implant Device,172.26,,,172.26,Other,110% of Medicare,121.8,35,,121.8,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,121.8,35,,121.8,percent of total billed charges,Implant Device,121.8,35,,121.8,percent of total billed charges,Implant Device,121.8,35,,121.8,percent of total billed charges,Implant Device,121.8,35,,121.8,percent of total billed charges,Implant Device,121.8,35,,121.8,percent of total billed charges,Implant Device,139.2,40,,139.2,percent of total billed charges,Implant Device,121.8,70,,121.8,percent of total billed charges,All Other,118.32,34,,118.32,percent of total billed charges,Implant Device,118.32,34,,118.32,percent of total billed charges,Implant Device,121.8,35,,121.8,percent of total billed charges,Implant Device,121.8,35,,121.8,percent of total billed charges,Implant Device,121.8,35,,121.8,percent of total billed charges,Implant Device,121.8,35,,121.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,257.52,
STRYKER 58-25012E EMERG SCREW 2.5X12MM,C1713,HCPCS,,79001500,CDM,278,RC,,,both,,,423,313.02,,,313.02,Other,150% of Medicare + 9.63% HCRA Surcharge,190.35,45,,190.35,percent of total billed charges,Critical Access Hospital RCC factor,143.82,34,,143.82,percent of total billed charges,Implant Device,143.82,34,,143.82,percent of total billed charges,Implant Device,143.82,34,,143.82,percent of total billed charges,Implant Device,143.82,34,,143.82,percent of total billed charges,Implant Device,143.82,34,,143.82,percent of total billed charges,Implant Device,209.39,,,209.39,Other,110% of Medicare,148.05,35,,148.05,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,148.05,35,,148.05,percent of total billed charges,Implant Device,148.05,35,,148.05,percent of total billed charges,Implant Device,148.05,35,,148.05,percent of total billed charges,Implant Device,148.05,35,,148.05,percent of total billed charges,Implant Device,148.05,35,,148.05,percent of total billed charges,Implant Device,169.2,40,,169.2,percent of total billed charges,Implant Device,148.05,70,,148.05,percent of total billed charges,All Other,143.82,34,,143.82,percent of total billed charges,Implant Device,143.82,34,,143.82,percent of total billed charges,Implant Device,148.05,35,,148.05,percent of total billed charges,Implant Device,148.05,35,,148.05,percent of total billed charges,Implant Device,148.05,35,,148.05,percent of total billed charges,Implant Device,148.05,35,,148.05,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,313.02,
STRYKER 58-19012E EMERG SCREWS 1.9X12MM,C1713,HCPCS,,79001501,CDM,278,RC,,,both,,,349,258.26,,,258.26,Other,150% of Medicare + 9.63% HCRA Surcharge,157.05,45,,157.05,percent of total billed charges,Critical Access Hospital RCC factor,118.66,34,,118.66,percent of total billed charges,Implant Device,118.66,34,,118.66,percent of total billed charges,Implant Device,118.66,34,,118.66,percent of total billed charges,Implant Device,118.66,34,,118.66,percent of total billed charges,Implant Device,118.66,34,,118.66,percent of total billed charges,Implant Device,172.76,,,172.76,Other,110% of Medicare,122.15,35,,122.15,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,122.15,35,,122.15,percent of total billed charges,Implant Device,122.15,35,,122.15,percent of total billed charges,Implant Device,122.15,35,,122.15,percent of total billed charges,Implant Device,122.15,35,,122.15,percent of total billed charges,Implant Device,122.15,35,,122.15,percent of total billed charges,Implant Device,139.6,40,,139.6,percent of total billed charges,Implant Device,122.15,70,,122.15,percent of total billed charges,All Other,118.66,34,,118.66,percent of total billed charges,Implant Device,118.66,34,,118.66,percent of total billed charges,Implant Device,122.15,35,,122.15,percent of total billed charges,Implant Device,122.15,35,,122.15,percent of total billed charges,Implant Device,122.15,35,,122.15,percent of total billed charges,Implant Device,122.15,35,,122.15,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,258.26,
BIOMET 45-0039 FEMORAL HEAD FREEZE DRIED,C1776,HCPCS,,79001502,CDM,278,RC,,,both,,,3174,2348.77,,,2348.77,Other,150% of Medicare + 9.63% HCRA Surcharge,1428.3,45,,1428.3,percent of total billed charges,Critical Access Hospital RCC factor,1079.16,34,,1079.16,percent of total billed charges,Implant Device,1079.16,34,,1079.16,percent of total billed charges,Implant Device,1079.16,34,,1079.16,percent of total billed charges,Implant Device,1079.16,34,,1079.16,percent of total billed charges,Implant Device,1079.16,34,,1079.16,percent of total billed charges,Implant Device,1571.13,,,1571.13,Other,110% of Medicare,1110.9,35,,1110.9,percent of total billed charges,Implant Device,1079.16,34,"Charges > $500, x 34%",1079.16,percent of total billed charges,Implant Device,1110.9,35,,1110.9,percent of total billed charges,Implant Device,1110.9,35,,1110.9,percent of total billed charges,Implant Device,1110.9,35,,1110.9,percent of total billed charges,Implant Device,1110.9,35,,1110.9,percent of total billed charges,Implant Device,1110.9,35,,1110.9,percent of total billed charges,Implant Device,1269.6,40,,1269.6,percent of total billed charges,Implant Device,1110.9,70,,1110.9,percent of total billed charges,All Other,1079.16,34,,1079.16,percent of total billed charges,Implant Device,1079.16,34,,1079.16,percent of total billed charges,Implant Device,1110.9,35,,1110.9,percent of total billed charges,Implant Device,1110.9,35,,1110.9,percent of total billed charges,Implant Device,1110.9,35,,1110.9,percent of total billed charges,Implant Device,1110.9,35,,1110.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1079.16,34,"If Charge > 2,000, then 34 percent",1079.16,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2348.77,
BIOMET 45-0037 FEMORAL PLATE FREEZEDRIED,C1776,HCPCS,,79001503,CDM,278,RC,,,both,,,2169,1605.07,,,1605.07,Other,150% of Medicare + 9.63% HCRA Surcharge,976.05,45,,976.05,percent of total billed charges,Critical Access Hospital RCC factor,737.46,34,,737.46,percent of total billed charges,Implant Device,737.46,34,,737.46,percent of total billed charges,Implant Device,737.46,34,,737.46,percent of total billed charges,Implant Device,737.46,34,,737.46,percent of total billed charges,Implant Device,737.46,34,,737.46,percent of total billed charges,Implant Device,1073.66,,,1073.66,Other,110% of Medicare,759.15,35,,759.15,percent of total billed charges,Implant Device,737.46,34,"Charges > $500, x 34%",737.46,percent of total billed charges,Implant Device,759.15,35,,759.15,percent of total billed charges,Implant Device,759.15,35,,759.15,percent of total billed charges,Implant Device,759.15,35,,759.15,percent of total billed charges,Implant Device,759.15,35,,759.15,percent of total billed charges,Implant Device,759.15,35,,759.15,percent of total billed charges,Implant Device,867.6,40,,867.6,percent of total billed charges,Implant Device,759.15,70,,759.15,percent of total billed charges,All Other,737.46,34,,737.46,percent of total billed charges,Implant Device,737.46,34,,737.46,percent of total billed charges,Implant Device,759.15,35,,759.15,percent of total billed charges,Implant Device,759.15,35,,759.15,percent of total billed charges,Implant Device,759.15,35,,759.15,percent of total billed charges,Implant Device,759.15,35,,759.15,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,737.46,34,"If Charge > 2,000, then 34 percent",737.46,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1605.07,
BIOMET 1991670 GAP PLATE MEDIUM,C1713,HCPCS,,79001504,CDM,278,RC,,,both,,,570,421.8,,,421.8,Other,150% of Medicare + 9.63% HCRA Surcharge,256.5,45,,256.5,percent of total billed charges,Critical Access Hospital RCC factor,193.8,34,,193.8,percent of total billed charges,Implant Device,193.8,34,,193.8,percent of total billed charges,Implant Device,193.8,34,,193.8,percent of total billed charges,Implant Device,193.8,34,,193.8,percent of total billed charges,Implant Device,193.8,34,,193.8,percent of total billed charges,Implant Device,282.15,,,282.15,Other,110% of Medicare,199.5,35,,199.5,percent of total billed charges,Implant Device,193.8,34,"Charges > $500, x 34%",193.8,percent of total billed charges,Implant Device,199.5,35,,199.5,percent of total billed charges,Implant Device,199.5,35,,199.5,percent of total billed charges,Implant Device,199.5,35,,199.5,percent of total billed charges,Implant Device,199.5,35,,199.5,percent of total billed charges,Implant Device,199.5,35,,199.5,percent of total billed charges,Implant Device,228,40,,228,percent of total billed charges,Implant Device,199.5,70,,199.5,percent of total billed charges,All Other,193.8,34,,193.8,percent of total billed charges,Implant Device,193.8,34,,193.8,percent of total billed charges,Implant Device,199.5,35,,199.5,percent of total billed charges,Implant Device,199.5,35,,199.5,percent of total billed charges,Implant Device,199.5,35,,199.5,percent of total billed charges,Implant Device,199.5,35,,199.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,421.8,
BIOMET 1990939 GAP PLATE SMALL,C1713,HCPCS,,79001505,CDM,278,RC,,,both,,,456,337.44,,,337.44,Other,150% of Medicare + 9.63% HCRA Surcharge,205.2,45,,205.2,percent of total billed charges,Critical Access Hospital RCC factor,155.04,34,,155.04,percent of total billed charges,Implant Device,155.04,34,,155.04,percent of total billed charges,Implant Device,155.04,34,,155.04,percent of total billed charges,Implant Device,155.04,34,,155.04,percent of total billed charges,Implant Device,155.04,34,,155.04,percent of total billed charges,Implant Device,225.72,,,225.72,Other,110% of Medicare,159.6,35,,159.6,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,159.6,35,,159.6,percent of total billed charges,Implant Device,159.6,35,,159.6,percent of total billed charges,Implant Device,159.6,35,,159.6,percent of total billed charges,Implant Device,159.6,35,,159.6,percent of total billed charges,Implant Device,159.6,35,,159.6,percent of total billed charges,Implant Device,182.4,40,,182.4,percent of total billed charges,Implant Device,159.6,70,,159.6,percent of total billed charges,All Other,155.04,34,,155.04,percent of total billed charges,Implant Device,155.04,34,,155.04,percent of total billed charges,Implant Device,159.6,35,,159.6,percent of total billed charges,Implant Device,159.6,35,,159.6,percent of total billed charges,Implant Device,159.6,35,,159.6,percent of total billed charges,Implant Device,159.6,35,,159.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,337.44,
GORE HT060040A GRAFT 6X40,C1768,HCPCS,,79001506,CDM,278,RC,,,both,,,3738,2766.13,,,2766.13,Other,150% of Medicare + 9.63% HCRA Surcharge,1682.1,45,,1682.1,percent of total billed charges,Critical Access Hospital RCC factor,1270.92,34,,1270.92,percent of total billed charges,Implant Device,1270.92,34,,1270.92,percent of total billed charges,Implant Device,1270.92,34,,1270.92,percent of total billed charges,Implant Device,1270.92,34,,1270.92,percent of total billed charges,Implant Device,1270.92,34,,1270.92,percent of total billed charges,Implant Device,1850.31,,,1850.31,Other,110% of Medicare,1308.3,35,,1308.3,percent of total billed charges,Implant Device,1270.92,34,"Charges > $500, x 34%",1270.92,percent of total billed charges,Implant Device,1308.3,35,,1308.3,percent of total billed charges,Implant Device,1308.3,35,,1308.3,percent of total billed charges,Implant Device,1308.3,35,,1308.3,percent of total billed charges,Implant Device,1308.3,35,,1308.3,percent of total billed charges,Implant Device,1308.3,35,,1308.3,percent of total billed charges,Implant Device,1495.2,40,,1495.2,percent of total billed charges,Implant Device,1308.3,70,,1308.3,percent of total billed charges,All Other,1270.92,34,,1270.92,percent of total billed charges,Implant Device,1270.92,34,,1270.92,percent of total billed charges,Implant Device,1308.3,35,,1308.3,percent of total billed charges,Implant Device,1308.3,35,,1308.3,percent of total billed charges,Implant Device,1308.3,35,,1308.3,percent of total billed charges,Implant Device,1308.3,35,,1308.3,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1270.92,34,"If Charge > 2,000, then 34 percent",1270.92,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2766.13,
GORE HT060080A GRAFT 6X80,C1768,HCPCS,,79001507,CDM,278,RC,,,both,,,6990,5172.62,,,5172.62,Other,150% of Medicare + 9.63% HCRA Surcharge,3145.5,45,,3145.5,percent of total billed charges,Critical Access Hospital RCC factor,2376.6,34,,2376.6,percent of total billed charges,Implant Device,2376.6,34,,2376.6,percent of total billed charges,Implant Device,2376.6,34,,2376.6,percent of total billed charges,Implant Device,2376.6,34,,2376.6,percent of total billed charges,Implant Device,2376.6,34,,2376.6,percent of total billed charges,Implant Device,3460.05,,,3460.05,Other,110% of Medicare,2446.5,35,,2446.5,percent of total billed charges,Implant Device,2376.6,34,"Charges > $500, x 34%",2376.6,percent of total billed charges,Implant Device,2446.5,35,,2446.5,percent of total billed charges,Implant Device,2446.5,35,,2446.5,percent of total billed charges,Implant Device,2446.5,35,,2446.5,percent of total billed charges,Implant Device,2446.5,35,,2446.5,percent of total billed charges,Implant Device,2446.5,35,,2446.5,percent of total billed charges,Implant Device,2796,40,,2796,percent of total billed charges,Implant Device,2446.5,70,,2446.5,percent of total billed charges,All Other,2376.6,34,,2376.6,percent of total billed charges,Implant Device,2376.6,34,,2376.6,percent of total billed charges,Implant Device,2446.5,35,,2446.5,percent of total billed charges,Implant Device,2446.5,35,,2446.5,percent of total billed charges,Implant Device,2446.5,35,,2446.5,percent of total billed charges,Implant Device,2446.5,35,,2446.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2376.6,34,"If Charge > 2,000, then 34 percent",2376.6,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5172.62,
GORE HT080040A GRAFT 8X40,C1768,HCPCS,,79001508,CDM,278,RC,,,both,,,3636,2690.65,,,2690.65,Other,150% of Medicare + 9.63% HCRA Surcharge,1636.2,45,,1636.2,percent of total billed charges,Critical Access Hospital RCC factor,1236.24,34,,1236.24,percent of total billed charges,Implant Device,1236.24,34,,1236.24,percent of total billed charges,Implant Device,1236.24,34,,1236.24,percent of total billed charges,Implant Device,1236.24,34,,1236.24,percent of total billed charges,Implant Device,1236.24,34,,1236.24,percent of total billed charges,Implant Device,1799.82,,,1799.82,Other,110% of Medicare,1272.6,35,,1272.6,percent of total billed charges,Implant Device,1236.24,34,"Charges > $500, x 34%",1236.24,percent of total billed charges,Implant Device,1272.6,35,,1272.6,percent of total billed charges,Implant Device,1272.6,35,,1272.6,percent of total billed charges,Implant Device,1272.6,35,,1272.6,percent of total billed charges,Implant Device,1272.6,35,,1272.6,percent of total billed charges,Implant Device,1272.6,35,,1272.6,percent of total billed charges,Implant Device,1454.4,40,,1454.4,percent of total billed charges,Implant Device,1272.6,70,,1272.6,percent of total billed charges,All Other,1236.24,34,,1236.24,percent of total billed charges,Implant Device,1236.24,34,,1236.24,percent of total billed charges,Implant Device,1272.6,35,,1272.6,percent of total billed charges,Implant Device,1272.6,35,,1272.6,percent of total billed charges,Implant Device,1272.6,35,,1272.6,percent of total billed charges,Implant Device,1272.6,35,,1272.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1236.24,34,"If Charge > 2,000, then 34 percent",1236.24,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2690.65,
GORE HT080080A GRAFT 8X80,C1768,HCPCS,,79001509,CDM,278,RC,,,both,,,6990,5172.62,,,5172.62,Other,150% of Medicare + 9.63% HCRA Surcharge,3145.5,45,,3145.5,percent of total billed charges,Critical Access Hospital RCC factor,2376.6,34,,2376.6,percent of total billed charges,Implant Device,2376.6,34,,2376.6,percent of total billed charges,Implant Device,2376.6,34,,2376.6,percent of total billed charges,Implant Device,2376.6,34,,2376.6,percent of total billed charges,Implant Device,2376.6,34,,2376.6,percent of total billed charges,Implant Device,3460.05,,,3460.05,Other,110% of Medicare,2446.5,35,,2446.5,percent of total billed charges,Implant Device,2376.6,34,"Charges > $500, x 34%",2376.6,percent of total billed charges,Implant Device,2446.5,35,,2446.5,percent of total billed charges,Implant Device,2446.5,35,,2446.5,percent of total billed charges,Implant Device,2446.5,35,,2446.5,percent of total billed charges,Implant Device,2446.5,35,,2446.5,percent of total billed charges,Implant Device,2446.5,35,,2446.5,percent of total billed charges,Implant Device,2796,40,,2796,percent of total billed charges,Implant Device,2446.5,70,,2446.5,percent of total billed charges,All Other,2376.6,34,,2376.6,percent of total billed charges,Implant Device,2376.6,34,,2376.6,percent of total billed charges,Implant Device,2446.5,35,,2446.5,percent of total billed charges,Implant Device,2446.5,35,,2446.5,percent of total billed charges,Implant Device,2446.5,35,,2446.5,percent of total billed charges,Implant Device,2446.5,35,,2446.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2376.6,34,"If Charge > 2,000, then 34 percent",2376.6,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5172.62,
GORE HT064050A GRAFT RINGED 6X40,C1781,HCPCS,,79001510,CDM,278,RC,,,both,,,5194,3843.57,,,3843.57,Other,150% of Medicare + 9.63% HCRA Surcharge,2337.3,45,,2337.3,percent of total billed charges,Critical Access Hospital RCC factor,1765.96,34,,1765.96,percent of total billed charges,Implant Device,1765.96,34,,1765.96,percent of total billed charges,Implant Device,1765.96,34,,1765.96,percent of total billed charges,Implant Device,1765.96,34,,1765.96,percent of total billed charges,Implant Device,1765.96,34,,1765.96,percent of total billed charges,Implant Device,2571.03,,,2571.03,Other,110% of Medicare,1817.9,35,,1817.9,percent of total billed charges,Implant Device,1765.96,34,"Charges > $500, x 34%",1765.96,percent of total billed charges,Implant Device,1817.9,35,,1817.9,percent of total billed charges,Implant Device,1817.9,35,,1817.9,percent of total billed charges,Implant Device,1817.9,35,,1817.9,percent of total billed charges,Implant Device,1817.9,35,,1817.9,percent of total billed charges,Implant Device,1817.9,35,,1817.9,percent of total billed charges,Implant Device,2077.6,40,,2077.6,percent of total billed charges,Implant Device,1817.9,70,,1817.9,percent of total billed charges,All Other,1765.96,34,,1765.96,percent of total billed charges,Implant Device,1765.96,34,,1765.96,percent of total billed charges,Implant Device,1817.9,35,,1817.9,percent of total billed charges,Implant Device,1817.9,35,,1817.9,percent of total billed charges,Implant Device,1817.9,35,,1817.9,percent of total billed charges,Implant Device,1817.9,35,,1817.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1765.96,34,"If Charge > 2,000, then 34 percent",1765.96,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3843.57,
GORE IRST06080080L GRAFT 6MM X 80CM,C1768,HCPCS,,79001511,CDM,278,RC,,,both,,,4132,3057.69,,,3057.69,Other,150% of Medicare + 9.63% HCRA Surcharge,1859.4,45,,1859.4,percent of total billed charges,Critical Access Hospital RCC factor,1404.88,34,,1404.88,percent of total billed charges,Implant Device,1404.88,34,,1404.88,percent of total billed charges,Implant Device,1404.88,34,,1404.88,percent of total billed charges,Implant Device,1404.88,34,,1404.88,percent of total billed charges,Implant Device,1404.88,34,,1404.88,percent of total billed charges,Implant Device,2045.34,,,2045.34,Other,110% of Medicare,1446.2,35,,1446.2,percent of total billed charges,Implant Device,1404.88,34,"Charges > $500, x 34%",1404.88,percent of total billed charges,Implant Device,1446.2,35,,1446.2,percent of total billed charges,Implant Device,1446.2,35,,1446.2,percent of total billed charges,Implant Device,1446.2,35,,1446.2,percent of total billed charges,Implant Device,1446.2,35,,1446.2,percent of total billed charges,Implant Device,1446.2,35,,1446.2,percent of total billed charges,Implant Device,1652.8,40,,1652.8,percent of total billed charges,Implant Device,1446.2,70,,1446.2,percent of total billed charges,All Other,1404.88,34,,1404.88,percent of total billed charges,Implant Device,1404.88,34,,1404.88,percent of total billed charges,Implant Device,1446.2,35,,1446.2,percent of total billed charges,Implant Device,1446.2,35,,1446.2,percent of total billed charges,Implant Device,1446.2,35,,1446.2,percent of total billed charges,Implant Device,1446.2,35,,1446.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1404.88,34,"If Charge > 2,000, then 34 percent",1404.88,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3057.69,
BARD DFM8006SC GRAFT DISTAFLO 6 X 80,C1768,HCPCS,,79001512,CDM,278,RC,,,both,,,8098,5992.54,,,5992.54,Other,150% of Medicare + 9.63% HCRA Surcharge,3644.1,45,,3644.1,percent of total billed charges,Critical Access Hospital RCC factor,2753.32,34,,2753.32,percent of total billed charges,Implant Device,2753.32,34,,2753.32,percent of total billed charges,Implant Device,2753.32,34,,2753.32,percent of total billed charges,Implant Device,2753.32,34,,2753.32,percent of total billed charges,Implant Device,2753.32,34,,2753.32,percent of total billed charges,Implant Device,4008.51,,,4008.51,Other,110% of Medicare,2834.3,35,,2834.3,percent of total billed charges,Implant Device,2753.32,34,"Charges > $500, x 34%",2753.32,percent of total billed charges,Implant Device,2834.3,35,,2834.3,percent of total billed charges,Implant Device,2834.3,35,,2834.3,percent of total billed charges,Implant Device,2834.3,35,,2834.3,percent of total billed charges,Implant Device,2834.3,35,,2834.3,percent of total billed charges,Implant Device,2834.3,35,,2834.3,percent of total billed charges,Implant Device,3239.2,40,,3239.2,percent of total billed charges,Implant Device,2834.3,70,,2834.3,percent of total billed charges,All Other,2753.32,34,,2753.32,percent of total billed charges,Implant Device,2753.32,34,,2753.32,percent of total billed charges,Implant Device,2834.3,35,,2834.3,percent of total billed charges,Implant Device,2834.3,35,,2834.3,percent of total billed charges,Implant Device,2834.3,35,,2834.3,percent of total billed charges,Implant Device,2834.3,35,,2834.3,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2753.32,34,"If Charge > 2,000, then 34 percent",2753.32,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5992.54,
ATRIUM 25052 GRAFT FLIXENE VASCULAR 6X50,C1768,HCPCS,,79001513,CDM,278,RC,,,both,,,3145,2327.31,,,2327.31,Other,150% of Medicare + 9.63% HCRA Surcharge,1415.25,45,,1415.25,percent of total billed charges,Critical Access Hospital RCC factor,1069.3,34,,1069.3,percent of total billed charges,Implant Device,1069.3,34,,1069.3,percent of total billed charges,Implant Device,1069.3,34,,1069.3,percent of total billed charges,Implant Device,1069.3,34,,1069.3,percent of total billed charges,Implant Device,1069.3,34,,1069.3,percent of total billed charges,Implant Device,1556.78,,,1556.78,Other,110% of Medicare,1100.75,35,,1100.75,percent of total billed charges,Implant Device,1069.3,34,"Charges > $500, x 34%",1069.3,percent of total billed charges,Implant Device,1100.75,35,,1100.75,percent of total billed charges,Implant Device,1100.75,35,,1100.75,percent of total billed charges,Implant Device,1100.75,35,,1100.75,percent of total billed charges,Implant Device,1100.75,35,,1100.75,percent of total billed charges,Implant Device,1100.75,35,,1100.75,percent of total billed charges,Implant Device,1258,40,,1258,percent of total billed charges,Implant Device,1100.75,70,,1100.75,percent of total billed charges,All Other,1069.3,34,,1069.3,percent of total billed charges,Implant Device,1069.3,34,,1069.3,percent of total billed charges,Implant Device,1100.75,35,,1100.75,percent of total billed charges,Implant Device,1100.75,35,,1100.75,percent of total billed charges,Implant Device,1100.75,35,,1100.75,percent of total billed charges,Implant Device,1100.75,35,,1100.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1069.3,34,"If Charge > 2,000, then 34 percent",1069.3,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2327.31,
GORE 0650HYB0905A GRAFT HYBRID LARGE,C1768,HCPCS,,79001514,CDM,278,RC,,,both,,,7350,5439.02,,,5439.02,Other,150% of Medicare + 9.63% HCRA Surcharge,3307.5,45,,3307.5,percent of total billed charges,Critical Access Hospital RCC factor,2499,34,,2499,percent of total billed charges,Implant Device,2499,34,,2499,percent of total billed charges,Implant Device,2499,34,,2499,percent of total billed charges,Implant Device,2499,34,,2499,percent of total billed charges,Implant Device,2499,34,,2499,percent of total billed charges,Implant Device,3638.25,,,3638.25,Other,110% of Medicare,2572.5,35,,2572.5,percent of total billed charges,Implant Device,2499,34,"Charges > $500, x 34%",2499,percent of total billed charges,Implant Device,2572.5,35,,2572.5,percent of total billed charges,Implant Device,2572.5,35,,2572.5,percent of total billed charges,Implant Device,2572.5,35,,2572.5,percent of total billed charges,Implant Device,2572.5,35,,2572.5,percent of total billed charges,Implant Device,2572.5,35,,2572.5,percent of total billed charges,Implant Device,2940,40,,2940,percent of total billed charges,Implant Device,2572.5,70,,2572.5,percent of total billed charges,All Other,2499,34,,2499,percent of total billed charges,Implant Device,2499,34,,2499,percent of total billed charges,Implant Device,2572.5,35,,2572.5,percent of total billed charges,Implant Device,2572.5,35,,2572.5,percent of total billed charges,Implant Device,2572.5,35,,2572.5,percent of total billed charges,Implant Device,2572.5,35,,2572.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2499,34,"If Charge > 2,000, then 34 percent",2499,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5439.02,
GORE 0650HYB0605A GRAFT HYBRID SMALL,C1768,HCPCS,,79001515,CDM,278,RC,,,both,,,7350,5439.02,,,5439.02,Other,150% of Medicare + 9.63% HCRA Surcharge,3307.5,45,,3307.5,percent of total billed charges,Critical Access Hospital RCC factor,2499,34,,2499,percent of total billed charges,Implant Device,2499,34,,2499,percent of total billed charges,Implant Device,2499,34,,2499,percent of total billed charges,Implant Device,2499,34,,2499,percent of total billed charges,Implant Device,2499,34,,2499,percent of total billed charges,Implant Device,3638.25,,,3638.25,Other,110% of Medicare,2572.5,35,,2572.5,percent of total billed charges,Implant Device,2499,34,"Charges > $500, x 34%",2499,percent of total billed charges,Implant Device,2572.5,35,,2572.5,percent of total billed charges,Implant Device,2572.5,35,,2572.5,percent of total billed charges,Implant Device,2572.5,35,,2572.5,percent of total billed charges,Implant Device,2572.5,35,,2572.5,percent of total billed charges,Implant Device,2572.5,35,,2572.5,percent of total billed charges,Implant Device,2940,40,,2940,percent of total billed charges,Implant Device,2572.5,70,,2572.5,percent of total billed charges,All Other,2499,34,,2499,percent of total billed charges,Implant Device,2499,34,,2499,percent of total billed charges,Implant Device,2572.5,35,,2572.5,percent of total billed charges,Implant Device,2572.5,35,,2572.5,percent of total billed charges,Implant Device,2572.5,35,,2572.5,percent of total billed charges,Implant Device,2572.5,35,,2572.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2499,34,"If Charge > 2,000, then 34 percent",2499,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5439.02,
WRIGHT 8600-5X05 GRAFT JACKET,C1762,HCPCS,,79001516,CDM,278,RC,,,both,,,7666,5672.86,,,5672.86,Other,150% of Medicare + 9.63% HCRA Surcharge,3449.7,45,,3449.7,percent of total billed charges,Critical Access Hospital RCC factor,2606.44,34,,2606.44,percent of total billed charges,Implant Device,2606.44,34,,2606.44,percent of total billed charges,Implant Device,2606.44,34,,2606.44,percent of total billed charges,Implant Device,2606.44,34,,2606.44,percent of total billed charges,Implant Device,2606.44,34,,2606.44,percent of total billed charges,Implant Device,3794.67,,,3794.67,Other,110% of Medicare,2683.1,35,,2683.1,percent of total billed charges,Implant Device,2606.44,34,"Charges > $500, x 34%",2606.44,percent of total billed charges,Implant Device,2683.1,35,,2683.1,percent of total billed charges,Implant Device,2683.1,35,,2683.1,percent of total billed charges,Implant Device,2683.1,35,,2683.1,percent of total billed charges,Implant Device,2683.1,35,,2683.1,percent of total billed charges,Implant Device,2683.1,35,,2683.1,percent of total billed charges,Implant Device,3066.4,40,,3066.4,percent of total billed charges,Implant Device,2683.1,70,,2683.1,percent of total billed charges,All Other,2606.44,34,,2606.44,percent of total billed charges,Implant Device,2606.44,34,,2606.44,percent of total billed charges,Implant Device,2683.1,35,,2683.1,percent of total billed charges,Implant Device,2683.1,35,,2683.1,percent of total billed charges,Implant Device,2683.1,35,,2683.1,percent of total billed charges,Implant Device,2683.1,35,,2683.1,percent of total billed charges,Implant Device,976.07,,,976.07,Other,100% of Medicaid,976.07,,,976.07,Other,100% of Medicaid,976.07,,,976.07,Other,100% of Medicaid,976.07,,,976.07,Other,100% of Medicaid,2196.16,,,2196.16,Other,225% of Medicaid,1493.39,,,1493.39,Other,153% of Medicaid,2196.16,,,2196.16,Other,225% of Medicaid,1366.5,,,1366.5,Other,140% of Medicaid,2606.44,34,"If Charge > 2,000, then 34 percent",2606.44,percent of total billed charges,Implants,2537.78,,,2537.78,Other,260% of Medicaid,3162.47,,,3162.47,Other,324% of Medicaid,2098.55,,,2098.55,Other,215% of Medicaid,2098.55,,,2098.55,Other,215% of Medicaid,1220.09,,,1220.09,Other,125% of Medicaid,976.07,5672.86,
GORE RR47010045L GRAFT REMOTE RNG 4.7X45,C1781,HCPCS,,79001517,CDM,278,RC,,,both,,,1932,1429.68,,,1429.68,Other,150% of Medicare + 9.63% HCRA Surcharge,869.4,45,,869.4,percent of total billed charges,Critical Access Hospital RCC factor,656.88,34,,656.88,percent of total billed charges,Implant Device,656.88,34,,656.88,percent of total billed charges,Implant Device,656.88,34,,656.88,percent of total billed charges,Implant Device,656.88,34,,656.88,percent of total billed charges,Implant Device,656.88,34,,656.88,percent of total billed charges,Implant Device,956.34,,,956.34,Other,110% of Medicare,676.2,35,,676.2,percent of total billed charges,Implant Device,656.88,34,"Charges > $500, x 34%",656.88,percent of total billed charges,Implant Device,676.2,35,,676.2,percent of total billed charges,Implant Device,676.2,35,,676.2,percent of total billed charges,Implant Device,676.2,35,,676.2,percent of total billed charges,Implant Device,676.2,35,,676.2,percent of total billed charges,Implant Device,676.2,35,,676.2,percent of total billed charges,Implant Device,772.8,40,,772.8,percent of total billed charges,Implant Device,676.2,70,,676.2,percent of total billed charges,All Other,656.88,34,,656.88,percent of total billed charges,Implant Device,656.88,34,,656.88,percent of total billed charges,Implant Device,676.2,35,,676.2,percent of total billed charges,Implant Device,676.2,35,,676.2,percent of total billed charges,Implant Device,676.2,35,,676.2,percent of total billed charges,Implant Device,676.2,35,,676.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1429.68,
GORE RRT06060080L GRAFT REMOTE RING 6X80,C1781,HCPCS,,79001518,CDM,278,RC,,,both,,,3376,2498.25,,,2498.25,Other,150% of Medicare + 9.63% HCRA Surcharge,1519.2,45,,1519.2,percent of total billed charges,Critical Access Hospital RCC factor,1147.84,34,,1147.84,percent of total billed charges,Implant Device,1147.84,34,,1147.84,percent of total billed charges,Implant Device,1147.84,34,,1147.84,percent of total billed charges,Implant Device,1147.84,34,,1147.84,percent of total billed charges,Implant Device,1147.84,34,,1147.84,percent of total billed charges,Implant Device,1671.12,,,1671.12,Other,110% of Medicare,1181.6,35,,1181.6,percent of total billed charges,Implant Device,1147.84,34,"Charges > $500, x 34%",1147.84,percent of total billed charges,Implant Device,1181.6,35,,1181.6,percent of total billed charges,Implant Device,1181.6,35,,1181.6,percent of total billed charges,Implant Device,1181.6,35,,1181.6,percent of total billed charges,Implant Device,1181.6,35,,1181.6,percent of total billed charges,Implant Device,1181.6,35,,1181.6,percent of total billed charges,Implant Device,1350.4,40,,1350.4,percent of total billed charges,Implant Device,1181.6,70,,1181.6,percent of total billed charges,All Other,1147.84,34,,1147.84,percent of total billed charges,Implant Device,1147.84,34,,1147.84,percent of total billed charges,Implant Device,1181.6,35,,1181.6,percent of total billed charges,Implant Device,1181.6,35,,1181.6,percent of total billed charges,Implant Device,1181.6,35,,1181.6,percent of total billed charges,Implant Device,1181.6,35,,1181.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1147.84,34,"If Charge > 2,000, then 34 percent",1147.84,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2498.25,
GORE RRT08070080L GRAFT REMOTE RING 8X80,C1781,HCPCS,,79001519,CDM,278,RC,,,both,,,3376,2498.25,,,2498.25,Other,150% of Medicare + 9.63% HCRA Surcharge,1519.2,45,,1519.2,percent of total billed charges,Critical Access Hospital RCC factor,1147.84,34,,1147.84,percent of total billed charges,Implant Device,1147.84,34,,1147.84,percent of total billed charges,Implant Device,1147.84,34,,1147.84,percent of total billed charges,Implant Device,1147.84,34,,1147.84,percent of total billed charges,Implant Device,1147.84,34,,1147.84,percent of total billed charges,Implant Device,1671.12,,,1671.12,Other,110% of Medicare,1181.6,35,,1181.6,percent of total billed charges,Implant Device,1147.84,34,"Charges > $500, x 34%",1147.84,percent of total billed charges,Implant Device,1181.6,35,,1181.6,percent of total billed charges,Implant Device,1181.6,35,,1181.6,percent of total billed charges,Implant Device,1181.6,35,,1181.6,percent of total billed charges,Implant Device,1181.6,35,,1181.6,percent of total billed charges,Implant Device,1181.6,35,,1181.6,percent of total billed charges,Implant Device,1350.4,40,,1350.4,percent of total billed charges,Implant Device,1181.6,70,,1181.6,percent of total billed charges,All Other,1147.84,34,,1147.84,percent of total billed charges,Implant Device,1147.84,34,,1147.84,percent of total billed charges,Implant Device,1181.6,35,,1181.6,percent of total billed charges,Implant Device,1181.6,35,,1181.6,percent of total billed charges,Implant Device,1181.6,35,,1181.6,percent of total billed charges,Implant Device,1181.6,35,,1181.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1147.84,34,"If Charge > 2,000, then 34 percent",1147.84,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2498.25,
GORE STO604 GRAFT STRETCH 6X40,C1768,HCPCS,,79001520,CDM,278,RC,,,both,,,1774,1312.76,,,1312.76,Other,150% of Medicare + 9.63% HCRA Surcharge,798.3,45,,798.3,percent of total billed charges,Critical Access Hospital RCC factor,603.16,34,,603.16,percent of total billed charges,Implant Device,603.16,34,,603.16,percent of total billed charges,Implant Device,603.16,34,,603.16,percent of total billed charges,Implant Device,603.16,34,,603.16,percent of total billed charges,Implant Device,603.16,34,,603.16,percent of total billed charges,Implant Device,878.13,,,878.13,Other,110% of Medicare,620.9,35,,620.9,percent of total billed charges,Implant Device,603.16,34,"Charges > $500, x 34%",603.16,percent of total billed charges,Implant Device,620.9,35,,620.9,percent of total billed charges,Implant Device,620.9,35,,620.9,percent of total billed charges,Implant Device,620.9,35,,620.9,percent of total billed charges,Implant Device,620.9,35,,620.9,percent of total billed charges,Implant Device,620.9,35,,620.9,percent of total billed charges,Implant Device,709.6,40,,709.6,percent of total billed charges,Implant Device,620.9,70,,620.9,percent of total billed charges,All Other,603.16,34,,603.16,percent of total billed charges,Implant Device,603.16,34,,603.16,percent of total billed charges,Implant Device,620.9,35,,620.9,percent of total billed charges,Implant Device,620.9,35,,620.9,percent of total billed charges,Implant Device,620.9,35,,620.9,percent of total billed charges,Implant Device,620.9,35,,620.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1312.76,
GORE SRD06005045L GRAFT STRETCH 6X45,C1768,HCPCS,,79001521,CDM,278,RC,,,both,,,2368,1752.33,,,1752.33,Other,150% of Medicare + 9.63% HCRA Surcharge,1065.6,45,,1065.6,percent of total billed charges,Critical Access Hospital RCC factor,805.12,34,,805.12,percent of total billed charges,Implant Device,805.12,34,,805.12,percent of total billed charges,Implant Device,805.12,34,,805.12,percent of total billed charges,Implant Device,805.12,34,,805.12,percent of total billed charges,Implant Device,805.12,34,,805.12,percent of total billed charges,Implant Device,1172.16,,,1172.16,Other,110% of Medicare,828.8,35,,828.8,percent of total billed charges,Implant Device,805.12,34,"Charges > $500, x 34%",805.12,percent of total billed charges,Implant Device,828.8,35,,828.8,percent of total billed charges,Implant Device,828.8,35,,828.8,percent of total billed charges,Implant Device,828.8,35,,828.8,percent of total billed charges,Implant Device,828.8,35,,828.8,percent of total billed charges,Implant Device,828.8,35,,828.8,percent of total billed charges,Implant Device,947.2,40,,947.2,percent of total billed charges,Implant Device,828.8,70,,828.8,percent of total billed charges,All Other,805.12,34,,805.12,percent of total billed charges,Implant Device,805.12,34,,805.12,percent of total billed charges,Implant Device,828.8,35,,828.8,percent of total billed charges,Implant Device,828.8,35,,828.8,percent of total billed charges,Implant Device,828.8,35,,828.8,percent of total billed charges,Implant Device,828.8,35,,828.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,805.12,34,"If Charge > 2,000, then 34 percent",805.12,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1752.33,
GORE V47050L GRAFT TAPERED 47 X 50CM,C1768,HCPCS,,79001522,CDM,278,RC,,,both,,,1672,1237.28,,,1237.28,Other,150% of Medicare + 9.63% HCRA Surcharge,752.4,45,,752.4,percent of total billed charges,Critical Access Hospital RCC factor,568.48,34,,568.48,percent of total billed charges,Implant Device,568.48,34,,568.48,percent of total billed charges,Implant Device,568.48,34,,568.48,percent of total billed charges,Implant Device,568.48,34,,568.48,percent of total billed charges,Implant Device,568.48,34,,568.48,percent of total billed charges,Implant Device,827.64,,,827.64,Other,110% of Medicare,585.2,35,,585.2,percent of total billed charges,Implant Device,568.48,34,"Charges > $500, x 34%",568.48,percent of total billed charges,Implant Device,585.2,35,,585.2,percent of total billed charges,Implant Device,585.2,35,,585.2,percent of total billed charges,Implant Device,585.2,35,,585.2,percent of total billed charges,Implant Device,585.2,35,,585.2,percent of total billed charges,Implant Device,585.2,35,,585.2,percent of total billed charges,Implant Device,668.8,40,,668.8,percent of total billed charges,Implant Device,585.2,70,,585.2,percent of total billed charges,All Other,568.48,34,,568.48,percent of total billed charges,Implant Device,568.48,34,,568.48,percent of total billed charges,Implant Device,585.2,35,,585.2,percent of total billed charges,Implant Device,585.2,35,,585.2,percent of total billed charges,Implant Device,585.2,35,,585.2,percent of total billed charges,Implant Device,585.2,35,,585.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1237.28,
GORE ST0608 GRAFT THIN WALL STRETCH 6X80,C1768,HCPCS,,79001523,CDM,278,RC,,,both,,,3174,2348.77,,,2348.77,Other,150% of Medicare + 9.63% HCRA Surcharge,1428.3,45,,1428.3,percent of total billed charges,Critical Access Hospital RCC factor,1079.16,34,,1079.16,percent of total billed charges,Implant Device,1079.16,34,,1079.16,percent of total billed charges,Implant Device,1079.16,34,,1079.16,percent of total billed charges,Implant Device,1079.16,34,,1079.16,percent of total billed charges,Implant Device,1079.16,34,,1079.16,percent of total billed charges,Implant Device,1571.13,,,1571.13,Other,110% of Medicare,1110.9,35,,1110.9,percent of total billed charges,Implant Device,1079.16,34,"Charges > $500, x 34%",1079.16,percent of total billed charges,Implant Device,1110.9,35,,1110.9,percent of total billed charges,Implant Device,1110.9,35,,1110.9,percent of total billed charges,Implant Device,1110.9,35,,1110.9,percent of total billed charges,Implant Device,1110.9,35,,1110.9,percent of total billed charges,Implant Device,1110.9,35,,1110.9,percent of total billed charges,Implant Device,1269.6,40,,1269.6,percent of total billed charges,Implant Device,1110.9,70,,1110.9,percent of total billed charges,All Other,1079.16,34,,1079.16,percent of total billed charges,Implant Device,1079.16,34,,1079.16,percent of total billed charges,Implant Device,1110.9,35,,1110.9,percent of total billed charges,Implant Device,1110.9,35,,1110.9,percent of total billed charges,Implant Device,1110.9,35,,1110.9,percent of total billed charges,Implant Device,1110.9,35,,1110.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1079.16,34,"If Charge > 2,000, then 34 percent",1079.16,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2348.77,
GORE ST0804 GRAFT THIN WALL STRETCH 8X40,C1768,HCPCS,,79001524,CDM,278,RC,,,both,,,1774,1312.76,,,1312.76,Other,150% of Medicare + 9.63% HCRA Surcharge,798.3,45,,798.3,percent of total billed charges,Critical Access Hospital RCC factor,603.16,34,,603.16,percent of total billed charges,Implant Device,603.16,34,,603.16,percent of total billed charges,Implant Device,603.16,34,,603.16,percent of total billed charges,Implant Device,603.16,34,,603.16,percent of total billed charges,Implant Device,603.16,34,,603.16,percent of total billed charges,Implant Device,878.13,,,878.13,Other,110% of Medicare,620.9,35,,620.9,percent of total billed charges,Implant Device,603.16,34,"Charges > $500, x 34%",603.16,percent of total billed charges,Implant Device,620.9,35,,620.9,percent of total billed charges,Implant Device,620.9,35,,620.9,percent of total billed charges,Implant Device,620.9,35,,620.9,percent of total billed charges,Implant Device,620.9,35,,620.9,percent of total billed charges,Implant Device,620.9,35,,620.9,percent of total billed charges,Implant Device,709.6,40,,709.6,percent of total billed charges,Implant Device,620.9,70,,620.9,percent of total billed charges,All Other,603.16,34,,603.16,percent of total billed charges,Implant Device,603.16,34,,603.16,percent of total billed charges,Implant Device,620.9,35,,620.9,percent of total billed charges,Implant Device,620.9,35,,620.9,percent of total billed charges,Implant Device,620.9,35,,620.9,percent of total billed charges,Implant Device,620.9,35,,620.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1312.76,
GORE ST0808 GRAFT THIN WALL STRETCH 8X80,C1768,HCPCS,,79001525,CDM,278,RC,,,both,,,3318,2455.33,,,2455.33,Other,150% of Medicare + 9.63% HCRA Surcharge,1493.1,45,,1493.1,percent of total billed charges,Critical Access Hospital RCC factor,1128.12,34,,1128.12,percent of total billed charges,Implant Device,1128.12,34,,1128.12,percent of total billed charges,Implant Device,1128.12,34,,1128.12,percent of total billed charges,Implant Device,1128.12,34,,1128.12,percent of total billed charges,Implant Device,1128.12,34,,1128.12,percent of total billed charges,Implant Device,1642.41,,,1642.41,Other,110% of Medicare,1161.3,35,,1161.3,percent of total billed charges,Implant Device,1128.12,34,"Charges > $500, x 34%",1128.12,percent of total billed charges,Implant Device,1161.3,35,,1161.3,percent of total billed charges,Implant Device,1161.3,35,,1161.3,percent of total billed charges,Implant Device,1161.3,35,,1161.3,percent of total billed charges,Implant Device,1161.3,35,,1161.3,percent of total billed charges,Implant Device,1161.3,35,,1161.3,percent of total billed charges,Implant Device,1327.2,40,,1327.2,percent of total billed charges,Implant Device,1161.3,70,,1161.3,percent of total billed charges,All Other,1128.12,34,,1128.12,percent of total billed charges,Implant Device,1128.12,34,,1128.12,percent of total billed charges,Implant Device,1161.3,35,,1161.3,percent of total billed charges,Implant Device,1161.3,35,,1161.3,percent of total billed charges,Implant Device,1161.3,35,,1161.3,percent of total billed charges,Implant Device,1161.3,35,,1161.3,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1128.12,34,"If Charge > 2,000, then 34 percent",1128.12,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2455.33,
GORE VT06080L GRAFT VASC THIN WALL 6MM,C1768,HCPCS,,79001526,CDM,278,RC,,,both,,,2628,1944.73,,,1944.73,Other,150% of Medicare + 9.63% HCRA Surcharge,1182.6,45,,1182.6,percent of total billed charges,Critical Access Hospital RCC factor,893.52,34,,893.52,percent of total billed charges,Implant Device,893.52,34,,893.52,percent of total billed charges,Implant Device,893.52,34,,893.52,percent of total billed charges,Implant Device,893.52,34,,893.52,percent of total billed charges,Implant Device,893.52,34,,893.52,percent of total billed charges,Implant Device,1300.86,,,1300.86,Other,110% of Medicare,919.8,35,,919.8,percent of total billed charges,Implant Device,893.52,34,"Charges > $500, x 34%",893.52,percent of total billed charges,Implant Device,919.8,35,,919.8,percent of total billed charges,Implant Device,919.8,35,,919.8,percent of total billed charges,Implant Device,919.8,35,,919.8,percent of total billed charges,Implant Device,919.8,35,,919.8,percent of total billed charges,Implant Device,919.8,35,,919.8,percent of total billed charges,Implant Device,1051.2,40,,1051.2,percent of total billed charges,Implant Device,919.8,70,,919.8,percent of total billed charges,All Other,893.52,34,,893.52,percent of total billed charges,Implant Device,893.52,34,,893.52,percent of total billed charges,Implant Device,919.8,35,,919.8,percent of total billed charges,Implant Device,919.8,35,,919.8,percent of total billed charges,Implant Device,919.8,35,,919.8,percent of total billed charges,Implant Device,919.8,35,,919.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,893.52,34,"If Charge > 2,000, then 34 percent",893.52,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1944.73,
GORE VT08080L GRAFT VASC THIN WALL 8MM,C1768,HCPCS,,79001527,CDM,278,RC,,,both,,,2352,1740.49,,,1740.49,Other,150% of Medicare + 9.63% HCRA Surcharge,1058.4,45,,1058.4,percent of total billed charges,Critical Access Hospital RCC factor,799.68,34,,799.68,percent of total billed charges,Implant Device,799.68,34,,799.68,percent of total billed charges,Implant Device,799.68,34,,799.68,percent of total billed charges,Implant Device,799.68,34,,799.68,percent of total billed charges,Implant Device,799.68,34,,799.68,percent of total billed charges,Implant Device,1164.24,,,1164.24,Other,110% of Medicare,823.2,35,,823.2,percent of total billed charges,Implant Device,799.68,34,"Charges > $500, x 34%",799.68,percent of total billed charges,Implant Device,823.2,35,,823.2,percent of total billed charges,Implant Device,823.2,35,,823.2,percent of total billed charges,Implant Device,823.2,35,,823.2,percent of total billed charges,Implant Device,823.2,35,,823.2,percent of total billed charges,Implant Device,823.2,35,,823.2,percent of total billed charges,Implant Device,940.8,40,,940.8,percent of total billed charges,Implant Device,823.2,70,,823.2,percent of total billed charges,All Other,799.68,34,,799.68,percent of total billed charges,Implant Device,799.68,34,,799.68,percent of total billed charges,Implant Device,823.2,35,,823.2,percent of total billed charges,Implant Device,823.2,35,,823.2,percent of total billed charges,Implant Device,823.2,35,,823.2,percent of total billed charges,Implant Device,823.2,35,,823.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,799.68,34,"If Charge > 2,000, then 34 percent",799.68,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1740.49,
J&J 82-3111 HAKIM PROGRAMMABLE SHUNT,C1729,HCPCS,,79001528,CDM,278,RC,,,both,,,12942,9577.11,,,9577.11,Other,150% of Medicare + 9.63% HCRA Surcharge,5823.9,45,,5823.9,percent of total billed charges,Critical Access Hospital RCC factor,4400.28,34,,4400.28,percent of total billed charges,Implant Device,4400.28,34,,4400.28,percent of total billed charges,Implant Device,4400.28,34,,4400.28,percent of total billed charges,Implant Device,4400.28,34,,4400.28,percent of total billed charges,Implant Device,4400.28,34,,4400.28,percent of total billed charges,Implant Device,6406.29,,,6406.29,Other,110% of Medicare,4529.7,35,,4529.7,percent of total billed charges,Implant Device,4400.28,34,"Charges > $500, x 34%",4400.28,percent of total billed charges,Implant Device,4529.7,35,,4529.7,percent of total billed charges,Implant Device,4529.7,35,,4529.7,percent of total billed charges,Implant Device,4529.7,35,,4529.7,percent of total billed charges,Implant Device,4529.7,35,,4529.7,percent of total billed charges,Implant Device,4529.7,35,,4529.7,percent of total billed charges,Implant Device,5176.8,40,,5176.8,percent of total billed charges,Implant Device,4529.7,70,,4529.7,percent of total billed charges,All Other,4400.28,34,,4400.28,percent of total billed charges,Implant Device,4400.28,34,,4400.28,percent of total billed charges,Implant Device,4529.7,35,,4529.7,percent of total billed charges,Implant Device,4529.7,35,,4529.7,percent of total billed charges,Implant Device,4529.7,35,,4529.7,percent of total billed charges,Implant Device,4529.7,35,,4529.7,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,4400.28,34,"If Charge > 2,000, then 34 percent",4400.28,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,9577.11,
SGARLATO 70-100-02 HAMMERTOE IMPLANT MED,C1776,HCPCS,,79001529,CDM,278,RC,,,both,,,1200,888,,,888,Other,150% of Medicare + 9.63% HCRA Surcharge,540,45,,540,percent of total billed charges,Critical Access Hospital RCC factor,408,34,,408,percent of total billed charges,Implant Device,408,34,,408,percent of total billed charges,Implant Device,408,34,,408,percent of total billed charges,Implant Device,408,34,,408,percent of total billed charges,Implant Device,408,34,,408,percent of total billed charges,Implant Device,594,,,594,Other,110% of Medicare,420,35,,420,percent of total billed charges,Implant Device,408,34,"Charges > $500, x 34%",408,percent of total billed charges,Implant Device,420,35,,420,percent of total billed charges,Implant Device,420,35,,420,percent of total billed charges,Implant Device,420,35,,420,percent of total billed charges,Implant Device,420,35,,420,percent of total billed charges,Implant Device,420,35,,420,percent of total billed charges,Implant Device,480,40,,480,percent of total billed charges,Implant Device,420,70,,420,percent of total billed charges,All Other,408,34,,408,percent of total billed charges,Implant Device,408,34,,408,percent of total billed charges,Implant Device,420,35,,420,percent of total billed charges,Implant Device,420,35,,420,percent of total billed charges,Implant Device,420,35,,420,percent of total billed charges,Implant Device,420,35,,420,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,888,
SGARLATO 70-100-01 HAMMERTOE IMPLANT SM,C1776,HCPCS,,79001530,CDM,278,RC,,,both,,,1200,888,,,888,Other,150% of Medicare + 9.63% HCRA Surcharge,540,45,,540,percent of total billed charges,Critical Access Hospital RCC factor,408,34,,408,percent of total billed charges,Implant Device,408,34,,408,percent of total billed charges,Implant Device,408,34,,408,percent of total billed charges,Implant Device,408,34,,408,percent of total billed charges,Implant Device,408,34,,408,percent of total billed charges,Implant Device,594,,,594,Other,110% of Medicare,420,35,,420,percent of total billed charges,Implant Device,408,34,"Charges > $500, x 34%",408,percent of total billed charges,Implant Device,420,35,,420,percent of total billed charges,Implant Device,420,35,,420,percent of total billed charges,Implant Device,420,35,,420,percent of total billed charges,Implant Device,420,35,,420,percent of total billed charges,Implant Device,420,35,,420,percent of total billed charges,Implant Device,480,40,,480,percent of total billed charges,Implant Device,420,70,,420,percent of total billed charges,All Other,408,34,,408,percent of total billed charges,Implant Device,408,34,,408,percent of total billed charges,Implant Device,420,35,,420,percent of total billed charges,Implant Device,420,35,,420,percent of total billed charges,Implant Device,420,35,,420,percent of total billed charges,Implant Device,420,35,,420,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,888,
MAQUET 85168 HEMASHIELD GRAFT 16X8MM,C1768,HCPCS,,79001531,CDM,278,RC,,,both,,,2496,1847.05,,,1847.05,Other,150% of Medicare + 9.63% HCRA Surcharge,1123.2,45,,1123.2,percent of total billed charges,Critical Access Hospital RCC factor,848.64,34,,848.64,percent of total billed charges,Implant Device,848.64,34,,848.64,percent of total billed charges,Implant Device,848.64,34,,848.64,percent of total billed charges,Implant Device,848.64,34,,848.64,percent of total billed charges,Implant Device,848.64,34,,848.64,percent of total billed charges,Implant Device,1235.52,,,1235.52,Other,110% of Medicare,873.6,35,,873.6,percent of total billed charges,Implant Device,848.64,34,"Charges > $500, x 34%",848.64,percent of total billed charges,Implant Device,873.6,35,,873.6,percent of total billed charges,Implant Device,873.6,35,,873.6,percent of total billed charges,Implant Device,873.6,35,,873.6,percent of total billed charges,Implant Device,873.6,35,,873.6,percent of total billed charges,Implant Device,873.6,35,,873.6,percent of total billed charges,Implant Device,998.4,40,,998.4,percent of total billed charges,Implant Device,873.6,70,,873.6,percent of total billed charges,All Other,848.64,34,,848.64,percent of total billed charges,Implant Device,848.64,34,,848.64,percent of total billed charges,Implant Device,873.6,35,,873.6,percent of total billed charges,Implant Device,873.6,35,,873.6,percent of total billed charges,Implant Device,873.6,35,,873.6,percent of total billed charges,Implant Device,873.6,35,,873.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,848.64,34,"If Charge > 2,000, then 34 percent",848.64,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1847.05,
MAQUET 85189 HEMASHIELD GRAFT 18X9MM,C1768,HCPCS,,79001532,CDM,278,RC,,,both,,,2600,1924.01,,,1924.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1170,45,,1170,percent of total billed charges,Critical Access Hospital RCC factor,884,34,,884,percent of total billed charges,Implant Device,884,34,,884,percent of total billed charges,Implant Device,884,34,,884,percent of total billed charges,Implant Device,884,34,,884,percent of total billed charges,Implant Device,884,34,,884,percent of total billed charges,Implant Device,1287,,,1287,Other,110% of Medicare,910,35,,910,percent of total billed charges,Implant Device,884,34,"Charges > $500, x 34%",884,percent of total billed charges,Implant Device,910,35,,910,percent of total billed charges,Implant Device,910,35,,910,percent of total billed charges,Implant Device,910,35,,910,percent of total billed charges,Implant Device,910,35,,910,percent of total billed charges,Implant Device,910,35,,910,percent of total billed charges,Implant Device,1040,40,,1040,percent of total billed charges,Implant Device,910,70,,910,percent of total billed charges,All Other,884,34,,884,percent of total billed charges,Implant Device,884,34,,884,percent of total billed charges,Implant Device,910,35,,910,percent of total billed charges,Implant Device,910,35,,910,percent of total billed charges,Implant Device,910,35,,910,percent of total billed charges,Implant Device,910,35,,910,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,884,34,"If Charge > 2,000, then 34 percent",884,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1924.01,
BOST SCI 95410 HEMASHIELD GRAFT 10X30CM,C1768,HCPCS,,79001533,CDM,278,RC,,,both,,,1686,1247.64,,,1247.64,Other,150% of Medicare + 9.63% HCRA Surcharge,758.7,45,,758.7,percent of total billed charges,Critical Access Hospital RCC factor,573.24,34,,573.24,percent of total billed charges,Implant Device,573.24,34,,573.24,percent of total billed charges,Implant Device,573.24,34,,573.24,percent of total billed charges,Implant Device,573.24,34,,573.24,percent of total billed charges,Implant Device,573.24,34,,573.24,percent of total billed charges,Implant Device,834.57,,,834.57,Other,110% of Medicare,590.1,35,,590.1,percent of total billed charges,Implant Device,573.24,34,"Charges > $500, x 34%",573.24,percent of total billed charges,Implant Device,590.1,35,,590.1,percent of total billed charges,Implant Device,590.1,35,,590.1,percent of total billed charges,Implant Device,590.1,35,,590.1,percent of total billed charges,Implant Device,590.1,35,,590.1,percent of total billed charges,Implant Device,590.1,35,,590.1,percent of total billed charges,Implant Device,674.4,40,,674.4,percent of total billed charges,Implant Device,590.1,70,,590.1,percent of total billed charges,All Other,573.24,34,,573.24,percent of total billed charges,Implant Device,573.24,34,,573.24,percent of total billed charges,Implant Device,590.1,35,,590.1,percent of total billed charges,Implant Device,590.1,35,,590.1,percent of total billed charges,Implant Device,590.1,35,,590.1,percent of total billed charges,Implant Device,590.1,35,,590.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1247.64,
BOST SCI 95412 HEMASHIELD GRAFT 12X30CM,C1768,HCPCS,,79001534,CDM,278,RC,,,both,,,1686,1247.64,,,1247.64,Other,150% of Medicare + 9.63% HCRA Surcharge,758.7,45,,758.7,percent of total billed charges,Critical Access Hospital RCC factor,573.24,34,,573.24,percent of total billed charges,Implant Device,573.24,34,,573.24,percent of total billed charges,Implant Device,573.24,34,,573.24,percent of total billed charges,Implant Device,573.24,34,,573.24,percent of total billed charges,Implant Device,573.24,34,,573.24,percent of total billed charges,Implant Device,834.57,,,834.57,Other,110% of Medicare,590.1,35,,590.1,percent of total billed charges,Implant Device,573.24,34,"Charges > $500, x 34%",573.24,percent of total billed charges,Implant Device,590.1,35,,590.1,percent of total billed charges,Implant Device,590.1,35,,590.1,percent of total billed charges,Implant Device,590.1,35,,590.1,percent of total billed charges,Implant Device,590.1,35,,590.1,percent of total billed charges,Implant Device,590.1,35,,590.1,percent of total billed charges,Implant Device,674.4,40,,674.4,percent of total billed charges,Implant Device,590.1,70,,590.1,percent of total billed charges,All Other,573.24,34,,573.24,percent of total billed charges,Implant Device,573.24,34,,573.24,percent of total billed charges,Implant Device,590.1,35,,590.1,percent of total billed charges,Implant Device,590.1,35,,590.1,percent of total billed charges,Implant Device,590.1,35,,590.1,percent of total billed charges,Implant Device,590.1,35,,590.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1247.64,
BOST SCI 95214 HEMASHIELD GRAFT 14X30CM,C1768,HCPCS,,79001535,CDM,278,RC,,,both,,,1746,1292.04,,,1292.04,Other,150% of Medicare + 9.63% HCRA Surcharge,785.7,45,,785.7,percent of total billed charges,Critical Access Hospital RCC factor,593.64,34,,593.64,percent of total billed charges,Implant Device,593.64,34,,593.64,percent of total billed charges,Implant Device,593.64,34,,593.64,percent of total billed charges,Implant Device,593.64,34,,593.64,percent of total billed charges,Implant Device,593.64,34,,593.64,percent of total billed charges,Implant Device,864.27,,,864.27,Other,110% of Medicare,611.1,35,,611.1,percent of total billed charges,Implant Device,593.64,34,"Charges > $500, x 34%",593.64,percent of total billed charges,Implant Device,611.1,35,,611.1,percent of total billed charges,Implant Device,611.1,35,,611.1,percent of total billed charges,Implant Device,611.1,35,,611.1,percent of total billed charges,Implant Device,611.1,35,,611.1,percent of total billed charges,Implant Device,611.1,35,,611.1,percent of total billed charges,Implant Device,698.4,40,,698.4,percent of total billed charges,Implant Device,611.1,70,,611.1,percent of total billed charges,All Other,593.64,34,,593.64,percent of total billed charges,Implant Device,593.64,34,,593.64,percent of total billed charges,Implant Device,611.1,35,,611.1,percent of total billed charges,Implant Device,611.1,35,,611.1,percent of total billed charges,Implant Device,611.1,35,,611.1,percent of total billed charges,Implant Device,611.1,35,,611.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1292.04,
BOST SCI 95216 HEMASHIELD GRAFT 16X30CM,C1768,HCPCS,,79001536,CDM,278,RC,,,both,,,1746,1292.04,,,1292.04,Other,150% of Medicare + 9.63% HCRA Surcharge,785.7,45,,785.7,percent of total billed charges,Critical Access Hospital RCC factor,593.64,34,,593.64,percent of total billed charges,Implant Device,593.64,34,,593.64,percent of total billed charges,Implant Device,593.64,34,,593.64,percent of total billed charges,Implant Device,593.64,34,,593.64,percent of total billed charges,Implant Device,593.64,34,,593.64,percent of total billed charges,Implant Device,864.27,,,864.27,Other,110% of Medicare,611.1,35,,611.1,percent of total billed charges,Implant Device,593.64,34,"Charges > $500, x 34%",593.64,percent of total billed charges,Implant Device,611.1,35,,611.1,percent of total billed charges,Implant Device,611.1,35,,611.1,percent of total billed charges,Implant Device,611.1,35,,611.1,percent of total billed charges,Implant Device,611.1,35,,611.1,percent of total billed charges,Implant Device,611.1,35,,611.1,percent of total billed charges,Implant Device,698.4,40,,698.4,percent of total billed charges,Implant Device,611.1,70,,611.1,percent of total billed charges,All Other,593.64,34,,593.64,percent of total billed charges,Implant Device,593.64,34,,593.64,percent of total billed charges,Implant Device,611.1,35,,611.1,percent of total billed charges,Implant Device,611.1,35,,611.1,percent of total billed charges,Implant Device,611.1,35,,611.1,percent of total billed charges,Implant Device,611.1,35,,611.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1292.04,
BOST SCI 95218 HEMASHIELD GRAFT 18X30CM,C1768,HCPCS,,79001537,CDM,278,RC,,,both,,,1746,1292.04,,,1292.04,Other,150% of Medicare + 9.63% HCRA Surcharge,785.7,45,,785.7,percent of total billed charges,Critical Access Hospital RCC factor,593.64,34,,593.64,percent of total billed charges,Implant Device,593.64,34,,593.64,percent of total billed charges,Implant Device,593.64,34,,593.64,percent of total billed charges,Implant Device,593.64,34,,593.64,percent of total billed charges,Implant Device,593.64,34,,593.64,percent of total billed charges,Implant Device,864.27,,,864.27,Other,110% of Medicare,611.1,35,,611.1,percent of total billed charges,Implant Device,593.64,34,"Charges > $500, x 34%",593.64,percent of total billed charges,Implant Device,611.1,35,,611.1,percent of total billed charges,Implant Device,611.1,35,,611.1,percent of total billed charges,Implant Device,611.1,35,,611.1,percent of total billed charges,Implant Device,611.1,35,,611.1,percent of total billed charges,Implant Device,611.1,35,,611.1,percent of total billed charges,Implant Device,698.4,40,,698.4,percent of total billed charges,Implant Device,611.1,70,,611.1,percent of total billed charges,All Other,593.64,34,,593.64,percent of total billed charges,Implant Device,593.64,34,,593.64,percent of total billed charges,Implant Device,611.1,35,,611.1,percent of total billed charges,Implant Device,611.1,35,,611.1,percent of total billed charges,Implant Device,611.1,35,,611.1,percent of total billed charges,Implant Device,611.1,35,,611.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1292.04,
BOST SCI 95220 HEMASHIELD GRAFT 20X30CM,C1768,HCPCS,,79001538,CDM,278,RC,,,both,,,1746,1292.04,,,1292.04,Other,150% of Medicare + 9.63% HCRA Surcharge,785.7,45,,785.7,percent of total billed charges,Critical Access Hospital RCC factor,593.64,34,,593.64,percent of total billed charges,Implant Device,593.64,34,,593.64,percent of total billed charges,Implant Device,593.64,34,,593.64,percent of total billed charges,Implant Device,593.64,34,,593.64,percent of total billed charges,Implant Device,593.64,34,,593.64,percent of total billed charges,Implant Device,864.27,,,864.27,Other,110% of Medicare,611.1,35,,611.1,percent of total billed charges,Implant Device,593.64,34,"Charges > $500, x 34%",593.64,percent of total billed charges,Implant Device,611.1,35,,611.1,percent of total billed charges,Implant Device,611.1,35,,611.1,percent of total billed charges,Implant Device,611.1,35,,611.1,percent of total billed charges,Implant Device,611.1,35,,611.1,percent of total billed charges,Implant Device,611.1,35,,611.1,percent of total billed charges,Implant Device,698.4,40,,698.4,percent of total billed charges,Implant Device,611.1,70,,611.1,percent of total billed charges,All Other,593.64,34,,593.64,percent of total billed charges,Implant Device,593.64,34,,593.64,percent of total billed charges,Implant Device,611.1,35,,611.1,percent of total billed charges,Implant Device,611.1,35,,611.1,percent of total billed charges,Implant Device,611.1,35,,611.1,percent of total billed charges,Implant Device,611.1,35,,611.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1292.04,
BOST SCI 95222 HEMASHIELD GRAFT 22X30CM,C1768,HCPCS,,79001539,CDM,278,RC,,,both,,,1746,1292.04,,,1292.04,Other,150% of Medicare + 9.63% HCRA Surcharge,785.7,45,,785.7,percent of total billed charges,Critical Access Hospital RCC factor,593.64,34,,593.64,percent of total billed charges,Implant Device,593.64,34,,593.64,percent of total billed charges,Implant Device,593.64,34,,593.64,percent of total billed charges,Implant Device,593.64,34,,593.64,percent of total billed charges,Implant Device,593.64,34,,593.64,percent of total billed charges,Implant Device,864.27,,,864.27,Other,110% of Medicare,611.1,35,,611.1,percent of total billed charges,Implant Device,593.64,34,"Charges > $500, x 34%",593.64,percent of total billed charges,Implant Device,611.1,35,,611.1,percent of total billed charges,Implant Device,611.1,35,,611.1,percent of total billed charges,Implant Device,611.1,35,,611.1,percent of total billed charges,Implant Device,611.1,35,,611.1,percent of total billed charges,Implant Device,611.1,35,,611.1,percent of total billed charges,Implant Device,698.4,40,,698.4,percent of total billed charges,Implant Device,611.1,70,,611.1,percent of total billed charges,All Other,593.64,34,,593.64,percent of total billed charges,Implant Device,593.64,34,,593.64,percent of total billed charges,Implant Device,611.1,35,,611.1,percent of total billed charges,Implant Device,611.1,35,,611.1,percent of total billed charges,Implant Device,611.1,35,,611.1,percent of total billed charges,Implant Device,611.1,35,,611.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1292.04,
BOST SCI 95408 HEMASHIELD GRAFT 8X30CM,C1768,HCPCS,,79001540,CDM,278,RC,,,both,,,1686,1247.64,,,1247.64,Other,150% of Medicare + 9.63% HCRA Surcharge,758.7,45,,758.7,percent of total billed charges,Critical Access Hospital RCC factor,573.24,34,,573.24,percent of total billed charges,Implant Device,573.24,34,,573.24,percent of total billed charges,Implant Device,573.24,34,,573.24,percent of total billed charges,Implant Device,573.24,34,,573.24,percent of total billed charges,Implant Device,573.24,34,,573.24,percent of total billed charges,Implant Device,834.57,,,834.57,Other,110% of Medicare,590.1,35,,590.1,percent of total billed charges,Implant Device,573.24,34,"Charges > $500, x 34%",573.24,percent of total billed charges,Implant Device,590.1,35,,590.1,percent of total billed charges,Implant Device,590.1,35,,590.1,percent of total billed charges,Implant Device,590.1,35,,590.1,percent of total billed charges,Implant Device,590.1,35,,590.1,percent of total billed charges,Implant Device,590.1,35,,590.1,percent of total billed charges,Implant Device,674.4,40,,674.4,percent of total billed charges,Implant Device,590.1,70,,590.1,percent of total billed charges,All Other,573.24,34,,573.24,percent of total billed charges,Implant Device,573.24,34,,573.24,percent of total billed charges,Implant Device,590.1,35,,590.1,percent of total billed charges,Implant Device,590.1,35,,590.1,percent of total billed charges,Implant Device,590.1,35,,590.1,percent of total billed charges,Implant Device,590.1,35,,590.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1247.64,
GORE SBT1401D HEMASHIELD GRAFT 14 X 7CM,C1768,HCPCS,,79001541,CDM,278,RC,,,both,,,2811,2080.15,,,2080.15,Other,150% of Medicare + 9.63% HCRA Surcharge,1264.95,45,,1264.95,percent of total billed charges,Critical Access Hospital RCC factor,955.74,34,,955.74,percent of total billed charges,Implant Device,955.74,34,,955.74,percent of total billed charges,Implant Device,955.74,34,,955.74,percent of total billed charges,Implant Device,955.74,34,,955.74,percent of total billed charges,Implant Device,955.74,34,,955.74,percent of total billed charges,Implant Device,1391.45,,,1391.45,Other,110% of Medicare,983.85,35,,983.85,percent of total billed charges,Implant Device,955.74,34,"Charges > $500, x 34%",955.74,percent of total billed charges,Implant Device,983.85,35,,983.85,percent of total billed charges,Implant Device,983.85,35,,983.85,percent of total billed charges,Implant Device,983.85,35,,983.85,percent of total billed charges,Implant Device,983.85,35,,983.85,percent of total billed charges,Implant Device,983.85,35,,983.85,percent of total billed charges,Implant Device,1124.4,40,,1124.4,percent of total billed charges,Implant Device,983.85,70,,983.85,percent of total billed charges,All Other,955.74,34,,955.74,percent of total billed charges,Implant Device,955.74,34,,955.74,percent of total billed charges,Implant Device,983.85,35,,983.85,percent of total billed charges,Implant Device,983.85,35,,983.85,percent of total billed charges,Implant Device,983.85,35,,983.85,percent of total billed charges,Implant Device,983.85,35,,983.85,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,955.74,34,"If Charge > 2,000, then 34 percent",955.74,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2080.15,
BIOMET 95-6103 HTXDRIVE SCREW SD 1.5X3.5,C1713,HCPCS,,79001542,CDM,278,RC,,,both,,,174,128.76,,,128.76,Other,150% of Medicare + 9.63% HCRA Surcharge,78.3,45,,78.3,percent of total billed charges,Critical Access Hospital RCC factor,59.16,34,,59.16,percent of total billed charges,Implant Device,59.16,34,,59.16,percent of total billed charges,Implant Device,59.16,34,,59.16,percent of total billed charges,Implant Device,59.16,34,,59.16,percent of total billed charges,Implant Device,59.16,34,,59.16,percent of total billed charges,Implant Device,86.13,,,86.13,Other,110% of Medicare,60.9,35,,60.9,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,60.9,35,,60.9,percent of total billed charges,Implant Device,60.9,35,,60.9,percent of total billed charges,Implant Device,60.9,35,,60.9,percent of total billed charges,Implant Device,60.9,35,,60.9,percent of total billed charges,Implant Device,60.9,35,,60.9,percent of total billed charges,Implant Device,69.6,40,,69.6,percent of total billed charges,Implant Device,60.9,70,,60.9,percent of total billed charges,All Other,59.16,34,,59.16,percent of total billed charges,Implant Device,59.16,34,,59.16,percent of total billed charges,Implant Device,60.9,35,,60.9,percent of total billed charges,Implant Device,60.9,35,,60.9,percent of total billed charges,Implant Device,60.9,35,,60.9,percent of total billed charges,Implant Device,60.9,35,,60.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,128.76,
BIOMET 91-6104 HTXDRIVE SCREW SD 1.5X4MM,C1713,HCPCS,,79001543,CDM,278,RC,,,both,,,294,217.56,,,217.56,Other,150% of Medicare + 9.63% HCRA Surcharge,132.3,45,,132.3,percent of total billed charges,Critical Access Hospital RCC factor,99.96,34,,99.96,percent of total billed charges,Implant Device,99.96,34,,99.96,percent of total billed charges,Implant Device,99.96,34,,99.96,percent of total billed charges,Implant Device,99.96,34,,99.96,percent of total billed charges,Implant Device,99.96,34,,99.96,percent of total billed charges,Implant Device,145.53,,,145.53,Other,110% of Medicare,102.9,35,,102.9,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,102.9,35,,102.9,percent of total billed charges,Implant Device,102.9,35,,102.9,percent of total billed charges,Implant Device,102.9,35,,102.9,percent of total billed charges,Implant Device,102.9,35,,102.9,percent of total billed charges,Implant Device,102.9,35,,102.9,percent of total billed charges,Implant Device,117.6,40,,117.6,percent of total billed charges,Implant Device,102.9,70,,102.9,percent of total billed charges,All Other,99.96,34,,99.96,percent of total billed charges,Implant Device,99.96,34,,99.96,percent of total billed charges,Implant Device,102.9,35,,102.9,percent of total billed charges,Implant Device,102.9,35,,102.9,percent of total billed charges,Implant Device,102.9,35,,102.9,percent of total billed charges,Implant Device,102.9,35,,102.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,217.56,
BIOMET 95-6104 HTXDRIVE SCREW SD 1.5X4MM,C1713,HCPCS,,79001544,CDM,278,RC,,,both,,,174,128.76,,,128.76,Other,150% of Medicare + 9.63% HCRA Surcharge,78.3,45,,78.3,percent of total billed charges,Critical Access Hospital RCC factor,59.16,34,,59.16,percent of total billed charges,Implant Device,59.16,34,,59.16,percent of total billed charges,Implant Device,59.16,34,,59.16,percent of total billed charges,Implant Device,59.16,34,,59.16,percent of total billed charges,Implant Device,59.16,34,,59.16,percent of total billed charges,Implant Device,86.13,,,86.13,Other,110% of Medicare,60.9,35,,60.9,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,60.9,35,,60.9,percent of total billed charges,Implant Device,60.9,35,,60.9,percent of total billed charges,Implant Device,60.9,35,,60.9,percent of total billed charges,Implant Device,60.9,35,,60.9,percent of total billed charges,Implant Device,60.9,35,,60.9,percent of total billed charges,Implant Device,69.6,40,,69.6,percent of total billed charges,Implant Device,60.9,70,,60.9,percent of total billed charges,All Other,59.16,34,,59.16,percent of total billed charges,Implant Device,59.16,34,,59.16,percent of total billed charges,Implant Device,60.9,35,,60.9,percent of total billed charges,Implant Device,60.9,35,,60.9,percent of total billed charges,Implant Device,60.9,35,,60.9,percent of total billed charges,Implant Device,60.9,35,,60.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,128.76,
BIOMET 91-6105 HTXDRIVE SCREW SD 1.5X5MM,C1713,HCPCS,,79001545,CDM,278,RC,,,both,,,294,217.56,,,217.56,Other,150% of Medicare + 9.63% HCRA Surcharge,132.3,45,,132.3,percent of total billed charges,Critical Access Hospital RCC factor,99.96,34,,99.96,percent of total billed charges,Implant Device,99.96,34,,99.96,percent of total billed charges,Implant Device,99.96,34,,99.96,percent of total billed charges,Implant Device,99.96,34,,99.96,percent of total billed charges,Implant Device,99.96,34,,99.96,percent of total billed charges,Implant Device,145.53,,,145.53,Other,110% of Medicare,102.9,35,,102.9,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,102.9,35,,102.9,percent of total billed charges,Implant Device,102.9,35,,102.9,percent of total billed charges,Implant Device,102.9,35,,102.9,percent of total billed charges,Implant Device,102.9,35,,102.9,percent of total billed charges,Implant Device,102.9,35,,102.9,percent of total billed charges,Implant Device,117.6,40,,117.6,percent of total billed charges,Implant Device,102.9,70,,102.9,percent of total billed charges,All Other,99.96,34,,99.96,percent of total billed charges,Implant Device,99.96,34,,99.96,percent of total billed charges,Implant Device,102.9,35,,102.9,percent of total billed charges,Implant Device,102.9,35,,102.9,percent of total billed charges,Implant Device,102.9,35,,102.9,percent of total billed charges,Implant Device,102.9,35,,102.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,217.56,
BIOMET 95-6105 HTXDRIVE SCREW SD 1.5X5MM,C1713,HCPCS,,79001546,CDM,278,RC,,,both,,,174,128.76,,,128.76,Other,150% of Medicare + 9.63% HCRA Surcharge,78.3,45,,78.3,percent of total billed charges,Critical Access Hospital RCC factor,59.16,34,,59.16,percent of total billed charges,Implant Device,59.16,34,,59.16,percent of total billed charges,Implant Device,59.16,34,,59.16,percent of total billed charges,Implant Device,59.16,34,,59.16,percent of total billed charges,Implant Device,59.16,34,,59.16,percent of total billed charges,Implant Device,86.13,,,86.13,Other,110% of Medicare,60.9,35,,60.9,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,60.9,35,,60.9,percent of total billed charges,Implant Device,60.9,35,,60.9,percent of total billed charges,Implant Device,60.9,35,,60.9,percent of total billed charges,Implant Device,60.9,35,,60.9,percent of total billed charges,Implant Device,60.9,35,,60.9,percent of total billed charges,Implant Device,69.6,40,,69.6,percent of total billed charges,Implant Device,60.9,70,,60.9,percent of total billed charges,All Other,59.16,34,,59.16,percent of total billed charges,Implant Device,59.16,34,,59.16,percent of total billed charges,Implant Device,60.9,35,,60.9,percent of total billed charges,Implant Device,60.9,35,,60.9,percent of total billed charges,Implant Device,60.9,35,,60.9,percent of total billed charges,Implant Device,60.9,35,,60.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,128.76,
BIOMET 91-6106 HTXDRIVE SCREW SD 1.5X6MM,C1713,HCPCS,,79001547,CDM,278,RC,,,both,,,37,27.38,,,27.38,Other,150% of Medicare + 9.63% HCRA Surcharge,16.65,45,,16.65,percent of total billed charges,Critical Access Hospital RCC factor,12.58,34,,12.58,percent of total billed charges,Implant Device,12.58,34,,12.58,percent of total billed charges,Implant Device,12.58,34,,12.58,percent of total billed charges,Implant Device,12.58,34,,12.58,percent of total billed charges,Implant Device,12.58,34,,12.58,percent of total billed charges,Implant Device,18.32,,,18.32,Other,110% of Medicare,12.95,35,,12.95,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,12.95,35,,12.95,percent of total billed charges,Implant Device,12.95,35,,12.95,percent of total billed charges,Implant Device,12.95,35,,12.95,percent of total billed charges,Implant Device,12.95,35,,12.95,percent of total billed charges,Implant Device,12.95,35,,12.95,percent of total billed charges,Implant Device,14.8,40,,14.8,percent of total billed charges,Implant Device,12.95,70,,12.95,percent of total billed charges,All Other,12.58,34,,12.58,percent of total billed charges,Implant Device,12.58,34,,12.58,percent of total billed charges,Implant Device,12.95,35,,12.95,percent of total billed charges,Implant Device,12.95,35,,12.95,percent of total billed charges,Implant Device,12.95,35,,12.95,percent of total billed charges,Implant Device,12.95,35,,12.95,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,27.38,
BIOMET 91-6107 HTXDRIVE SCREW SD 1.5X7MM,C1713,HCPCS,,79001548,CDM,278,RC,,,both,,,37,27.38,,,27.38,Other,150% of Medicare + 9.63% HCRA Surcharge,16.65,45,,16.65,percent of total billed charges,Critical Access Hospital RCC factor,12.58,34,,12.58,percent of total billed charges,Implant Device,12.58,34,,12.58,percent of total billed charges,Implant Device,12.58,34,,12.58,percent of total billed charges,Implant Device,12.58,34,,12.58,percent of total billed charges,Implant Device,12.58,34,,12.58,percent of total billed charges,Implant Device,18.32,,,18.32,Other,110% of Medicare,12.95,35,,12.95,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,12.95,35,,12.95,percent of total billed charges,Implant Device,12.95,35,,12.95,percent of total billed charges,Implant Device,12.95,35,,12.95,percent of total billed charges,Implant Device,12.95,35,,12.95,percent of total billed charges,Implant Device,12.95,35,,12.95,percent of total billed charges,Implant Device,14.8,40,,14.8,percent of total billed charges,Implant Device,12.95,70,,12.95,percent of total billed charges,All Other,12.58,34,,12.58,percent of total billed charges,Implant Device,12.58,34,,12.58,percent of total billed charges,Implant Device,12.95,35,,12.95,percent of total billed charges,Implant Device,12.95,35,,12.95,percent of total billed charges,Implant Device,12.95,35,,12.95,percent of total billed charges,Implant Device,12.95,35,,12.95,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,27.38,
BIOMET 91-1511 HTXDRIVE SCREW 1.5X11MM,C1713,HCPCS,,79001549,CDM,278,RC,,,both,,,36,26.64,,,26.64,Other,150% of Medicare + 9.63% HCRA Surcharge,16.2,45,,16.2,percent of total billed charges,Critical Access Hospital RCC factor,12.24,34,,12.24,percent of total billed charges,Implant Device,12.24,34,,12.24,percent of total billed charges,Implant Device,12.24,34,,12.24,percent of total billed charges,Implant Device,12.24,34,,12.24,percent of total billed charges,Implant Device,12.24,34,,12.24,percent of total billed charges,Implant Device,17.82,,,17.82,Other,110% of Medicare,12.6,35,,12.6,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,12.6,35,,12.6,percent of total billed charges,Implant Device,12.6,35,,12.6,percent of total billed charges,Implant Device,12.6,35,,12.6,percent of total billed charges,Implant Device,12.6,35,,12.6,percent of total billed charges,Implant Device,12.6,35,,12.6,percent of total billed charges,Implant Device,14.4,40,,14.4,percent of total billed charges,Implant Device,12.6,70,,12.6,percent of total billed charges,All Other,12.24,34,,12.24,percent of total billed charges,Implant Device,12.24,34,,12.24,percent of total billed charges,Implant Device,12.6,35,,12.6,percent of total billed charges,Implant Device,12.6,35,,12.6,percent of total billed charges,Implant Device,12.6,35,,12.6,percent of total billed charges,Implant Device,12.6,35,,12.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,26.64,
BIOMET 91-1507 HTXDRIVE SCREW 1.5X7MM,C1713,HCPCS,,79001550,CDM,278,RC,,,both,,,31,22.94,,,22.94,Other,150% of Medicare + 9.63% HCRA Surcharge,13.95,45,,13.95,percent of total billed charges,Critical Access Hospital RCC factor,10.54,34,,10.54,percent of total billed charges,Implant Device,10.54,34,,10.54,percent of total billed charges,Implant Device,10.54,34,,10.54,percent of total billed charges,Implant Device,10.54,34,,10.54,percent of total billed charges,Implant Device,10.54,34,,10.54,percent of total billed charges,Implant Device,15.35,,,15.35,Other,110% of Medicare,10.85,35,,10.85,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,10.85,35,,10.85,percent of total billed charges,Implant Device,10.85,35,,10.85,percent of total billed charges,Implant Device,10.85,35,,10.85,percent of total billed charges,Implant Device,10.85,35,,10.85,percent of total billed charges,Implant Device,10.85,35,,10.85,percent of total billed charges,Implant Device,12.4,40,,12.4,percent of total billed charges,Implant Device,10.85,70,,10.85,percent of total billed charges,All Other,10.54,34,,10.54,percent of total billed charges,Implant Device,10.54,34,,10.54,percent of total billed charges,Implant Device,10.85,35,,10.85,percent of total billed charges,Implant Device,10.85,35,,10.85,percent of total billed charges,Implant Device,10.85,35,,10.85,percent of total billed charges,Implant Device,10.85,35,,10.85,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,22.94,
BIOMET 91-1509 HTXDRIVE SCREW 1.5X9MM,C1713,HCPCS,,79001551,CDM,278,RC,,,both,,,36,26.64,,,26.64,Other,150% of Medicare + 9.63% HCRA Surcharge,16.2,45,,16.2,percent of total billed charges,Critical Access Hospital RCC factor,12.24,34,,12.24,percent of total billed charges,Implant Device,12.24,34,,12.24,percent of total billed charges,Implant Device,12.24,34,,12.24,percent of total billed charges,Implant Device,12.24,34,,12.24,percent of total billed charges,Implant Device,12.24,34,,12.24,percent of total billed charges,Implant Device,17.82,,,17.82,Other,110% of Medicare,12.6,35,,12.6,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,12.6,35,,12.6,percent of total billed charges,Implant Device,12.6,35,,12.6,percent of total billed charges,Implant Device,12.6,35,,12.6,percent of total billed charges,Implant Device,12.6,35,,12.6,percent of total billed charges,Implant Device,12.6,35,,12.6,percent of total billed charges,Implant Device,14.4,40,,14.4,percent of total billed charges,Implant Device,12.6,70,,12.6,percent of total billed charges,All Other,12.24,34,,12.24,percent of total billed charges,Implant Device,12.24,34,,12.24,percent of total billed charges,Implant Device,12.6,35,,12.6,percent of total billed charges,Implant Device,12.6,35,,12.6,percent of total billed charges,Implant Device,12.6,35,,12.6,percent of total billed charges,Implant Device,12.6,35,,12.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,26.64,
BIOMET 91-1805 HTXDRIVE SCREW 1.8X5MM,C1713,HCPCS,,79001552,CDM,278,RC,,,both,,,294,217.56,,,217.56,Other,150% of Medicare + 9.63% HCRA Surcharge,132.3,45,,132.3,percent of total billed charges,Critical Access Hospital RCC factor,99.96,34,,99.96,percent of total billed charges,Implant Device,99.96,34,,99.96,percent of total billed charges,Implant Device,99.96,34,,99.96,percent of total billed charges,Implant Device,99.96,34,,99.96,percent of total billed charges,Implant Device,99.96,34,,99.96,percent of total billed charges,Implant Device,145.53,,,145.53,Other,110% of Medicare,102.9,35,,102.9,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,102.9,35,,102.9,percent of total billed charges,Implant Device,102.9,35,,102.9,percent of total billed charges,Implant Device,102.9,35,,102.9,percent of total billed charges,Implant Device,102.9,35,,102.9,percent of total billed charges,Implant Device,102.9,35,,102.9,percent of total billed charges,Implant Device,117.6,40,,117.6,percent of total billed charges,Implant Device,102.9,70,,102.9,percent of total billed charges,All Other,99.96,34,,99.96,percent of total billed charges,Implant Device,99.96,34,,99.96,percent of total billed charges,Implant Device,102.9,35,,102.9,percent of total billed charges,Implant Device,102.9,35,,102.9,percent of total billed charges,Implant Device,102.9,35,,102.9,percent of total billed charges,Implant Device,102.9,35,,102.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,217.56,
BIOMET 91-1807 HTXDRIVE SCREW 1.8X7MM,C1713,HCPCS,,79001553,CDM,278,RC,,,both,,,294,217.56,,,217.56,Other,150% of Medicare + 9.63% HCRA Surcharge,132.3,45,,132.3,percent of total billed charges,Critical Access Hospital RCC factor,99.96,34,,99.96,percent of total billed charges,Implant Device,99.96,34,,99.96,percent of total billed charges,Implant Device,99.96,34,,99.96,percent of total billed charges,Implant Device,99.96,34,,99.96,percent of total billed charges,Implant Device,99.96,34,,99.96,percent of total billed charges,Implant Device,145.53,,,145.53,Other,110% of Medicare,102.9,35,,102.9,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,102.9,35,,102.9,percent of total billed charges,Implant Device,102.9,35,,102.9,percent of total billed charges,Implant Device,102.9,35,,102.9,percent of total billed charges,Implant Device,102.9,35,,102.9,percent of total billed charges,Implant Device,102.9,35,,102.9,percent of total billed charges,Implant Device,117.6,40,,117.6,percent of total billed charges,Implant Device,102.9,70,,102.9,percent of total billed charges,All Other,99.96,34,,99.96,percent of total billed charges,Implant Device,99.96,34,,99.96,percent of total billed charges,Implant Device,102.9,35,,102.9,percent of total billed charges,Implant Device,102.9,35,,102.9,percent of total billed charges,Implant Device,102.9,35,,102.9,percent of total billed charges,Implant Device,102.9,35,,102.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,217.56,
BIOMET 95-1803 HT XDRIVE SCREW 1.8X3.5MM,C1713,HCPCS,,79001554,CDM,278,RC,,,both,,,176,130.24,,,130.24,Other,150% of Medicare + 9.63% HCRA Surcharge,79.2,45,,79.2,percent of total billed charges,Critical Access Hospital RCC factor,59.84,34,,59.84,percent of total billed charges,Implant Device,59.84,34,,59.84,percent of total billed charges,Implant Device,59.84,34,,59.84,percent of total billed charges,Implant Device,59.84,34,,59.84,percent of total billed charges,Implant Device,59.84,34,,59.84,percent of total billed charges,Implant Device,87.12,,,87.12,Other,110% of Medicare,61.6,35,,61.6,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,61.6,35,,61.6,percent of total billed charges,Implant Device,61.6,35,,61.6,percent of total billed charges,Implant Device,61.6,35,,61.6,percent of total billed charges,Implant Device,61.6,35,,61.6,percent of total billed charges,Implant Device,61.6,35,,61.6,percent of total billed charges,Implant Device,70.4,40,,70.4,percent of total billed charges,Implant Device,61.6,70,,61.6,percent of total billed charges,All Other,59.84,34,,59.84,percent of total billed charges,Implant Device,59.84,34,,59.84,percent of total billed charges,Implant Device,61.6,35,,61.6,percent of total billed charges,Implant Device,61.6,35,,61.6,percent of total billed charges,Implant Device,61.6,35,,61.6,percent of total billed charges,Implant Device,61.6,35,,61.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,130.24,
BIOMET 95-1805 HT XDRIVE SCREW 1.8X5MM,C1713,HCPCS,,79001555,CDM,278,RC,,,both,,,176,130.24,,,130.24,Other,150% of Medicare + 9.63% HCRA Surcharge,79.2,45,,79.2,percent of total billed charges,Critical Access Hospital RCC factor,59.84,34,,59.84,percent of total billed charges,Implant Device,59.84,34,,59.84,percent of total billed charges,Implant Device,59.84,34,,59.84,percent of total billed charges,Implant Device,59.84,34,,59.84,percent of total billed charges,Implant Device,59.84,34,,59.84,percent of total billed charges,Implant Device,87.12,,,87.12,Other,110% of Medicare,61.6,35,,61.6,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,61.6,35,,61.6,percent of total billed charges,Implant Device,61.6,35,,61.6,percent of total billed charges,Implant Device,61.6,35,,61.6,percent of total billed charges,Implant Device,61.6,35,,61.6,percent of total billed charges,Implant Device,61.6,35,,61.6,percent of total billed charges,Implant Device,70.4,40,,70.4,percent of total billed charges,Implant Device,61.6,70,,61.6,percent of total billed charges,All Other,59.84,34,,59.84,percent of total billed charges,Implant Device,59.84,34,,59.84,percent of total billed charges,Implant Device,61.6,35,,61.6,percent of total billed charges,Implant Device,61.6,35,,61.6,percent of total billed charges,Implant Device,61.6,35,,61.6,percent of total billed charges,Implant Device,61.6,35,,61.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,130.24,
STRYKER 79-43905 HYDROSET - 5CC,C1713,HCPCS,,79001556,CDM,278,RC,,,both,,,4336,3208.65,,,3208.65,Other,150% of Medicare + 9.63% HCRA Surcharge,1951.2,45,,1951.2,percent of total billed charges,Critical Access Hospital RCC factor,1474.24,34,,1474.24,percent of total billed charges,Implant Device,1474.24,34,,1474.24,percent of total billed charges,Implant Device,1474.24,34,,1474.24,percent of total billed charges,Implant Device,1474.24,34,,1474.24,percent of total billed charges,Implant Device,1474.24,34,,1474.24,percent of total billed charges,Implant Device,2146.32,,,2146.32,Other,110% of Medicare,1517.6,35,,1517.6,percent of total billed charges,Implant Device,1474.24,34,"Charges > $500, x 34%",1474.24,percent of total billed charges,Implant Device,1517.6,35,,1517.6,percent of total billed charges,Implant Device,1517.6,35,,1517.6,percent of total billed charges,Implant Device,1517.6,35,,1517.6,percent of total billed charges,Implant Device,1517.6,35,,1517.6,percent of total billed charges,Implant Device,1517.6,35,,1517.6,percent of total billed charges,Implant Device,1734.4,40,,1734.4,percent of total billed charges,Implant Device,1517.6,70,,1517.6,percent of total billed charges,All Other,1474.24,34,,1474.24,percent of total billed charges,Implant Device,1474.24,34,,1474.24,percent of total billed charges,Implant Device,1517.6,35,,1517.6,percent of total billed charges,Implant Device,1517.6,35,,1517.6,percent of total billed charges,Implant Device,1517.6,35,,1517.6,percent of total billed charges,Implant Device,1517.6,35,,1517.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1474.24,34,"If Charge > 2,000, then 34 percent",1474.24,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3208.65,
STRYKER 397010 HYDROSET 10CC,C1713,HCPCS,,79001557,CDM,278,RC,,,both,,,10546,7804.07,,,7804.07,Other,150% of Medicare + 9.63% HCRA Surcharge,4745.7,45,,4745.7,percent of total billed charges,Critical Access Hospital RCC factor,3585.64,34,,3585.64,percent of total billed charges,Implant Device,3585.64,34,,3585.64,percent of total billed charges,Implant Device,3585.64,34,,3585.64,percent of total billed charges,Implant Device,3585.64,34,,3585.64,percent of total billed charges,Implant Device,3585.64,34,,3585.64,percent of total billed charges,Implant Device,5220.27,,,5220.27,Other,110% of Medicare,3691.1,35,,3691.1,percent of total billed charges,Implant Device,3585.64,34,"Charges > $500, x 34%",3585.64,percent of total billed charges,Implant Device,3691.1,35,,3691.1,percent of total billed charges,Implant Device,3691.1,35,,3691.1,percent of total billed charges,Implant Device,3691.1,35,,3691.1,percent of total billed charges,Implant Device,3691.1,35,,3691.1,percent of total billed charges,Implant Device,3691.1,35,,3691.1,percent of total billed charges,Implant Device,4218.4,40,,4218.4,percent of total billed charges,Implant Device,3691.1,70,,3691.1,percent of total billed charges,All Other,3585.64,34,,3585.64,percent of total billed charges,Implant Device,3585.64,34,,3585.64,percent of total billed charges,Implant Device,3691.1,35,,3691.1,percent of total billed charges,Implant Device,3691.1,35,,3691.1,percent of total billed charges,Implant Device,3691.1,35,,3691.1,percent of total billed charges,Implant Device,3691.1,35,,3691.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3585.64,34,"If Charge > 2,000, then 34 percent",3585.64,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,7804.07,
STRYKER 397003 HYDROSET 3CC,C1713,HCPCS,,79001558,CDM,278,RC,,,both,,,3772,2791.29,,,2791.29,Other,150% of Medicare + 9.63% HCRA Surcharge,1697.4,45,,1697.4,percent of total billed charges,Critical Access Hospital RCC factor,1282.48,34,,1282.48,percent of total billed charges,Implant Device,1282.48,34,,1282.48,percent of total billed charges,Implant Device,1282.48,34,,1282.48,percent of total billed charges,Implant Device,1282.48,34,,1282.48,percent of total billed charges,Implant Device,1282.48,34,,1282.48,percent of total billed charges,Implant Device,1867.14,,,1867.14,Other,110% of Medicare,1320.2,35,,1320.2,percent of total billed charges,Implant Device,1282.48,34,"Charges > $500, x 34%",1282.48,percent of total billed charges,Implant Device,1320.2,35,,1320.2,percent of total billed charges,Implant Device,1320.2,35,,1320.2,percent of total billed charges,Implant Device,1320.2,35,,1320.2,percent of total billed charges,Implant Device,1320.2,35,,1320.2,percent of total billed charges,Implant Device,1320.2,35,,1320.2,percent of total billed charges,Implant Device,1508.8,40,,1508.8,percent of total billed charges,Implant Device,1320.2,70,,1320.2,percent of total billed charges,All Other,1282.48,34,,1282.48,percent of total billed charges,Implant Device,1282.48,34,,1282.48,percent of total billed charges,Implant Device,1320.2,35,,1320.2,percent of total billed charges,Implant Device,1320.2,35,,1320.2,percent of total billed charges,Implant Device,1320.2,35,,1320.2,percent of total billed charges,Implant Device,1320.2,35,,1320.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1282.48,34,"If Charge > 2,000, then 34 percent",1282.48,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2791.29,
STRYKER 397005 HYDROSET 5CC,C1713,HCPCS,,79001559,CDM,278,RC,,,both,,,6049,4476.28,,,4476.28,Other,150% of Medicare + 9.63% HCRA Surcharge,2722.05,45,,2722.05,percent of total billed charges,Critical Access Hospital RCC factor,2056.66,34,,2056.66,percent of total billed charges,Implant Device,2056.66,34,,2056.66,percent of total billed charges,Implant Device,2056.66,34,,2056.66,percent of total billed charges,Implant Device,2056.66,34,,2056.66,percent of total billed charges,Implant Device,2056.66,34,,2056.66,percent of total billed charges,Implant Device,2994.26,,,2994.26,Other,110% of Medicare,2117.15,35,,2117.15,percent of total billed charges,Implant Device,2056.66,34,"Charges > $500, x 34%",2056.66,percent of total billed charges,Implant Device,2117.15,35,,2117.15,percent of total billed charges,Implant Device,2117.15,35,,2117.15,percent of total billed charges,Implant Device,2117.15,35,,2117.15,percent of total billed charges,Implant Device,2117.15,35,,2117.15,percent of total billed charges,Implant Device,2117.15,35,,2117.15,percent of total billed charges,Implant Device,2419.6,40,,2419.6,percent of total billed charges,Implant Device,2117.15,70,,2117.15,percent of total billed charges,All Other,2056.66,34,,2056.66,percent of total billed charges,Implant Device,2056.66,34,,2056.66,percent of total billed charges,Implant Device,2117.15,35,,2117.15,percent of total billed charges,Implant Device,2117.15,35,,2117.15,percent of total billed charges,Implant Device,2117.15,35,,2117.15,percent of total billed charges,Implant Device,2117.15,35,,2117.15,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2056.66,34,"If Charge > 2,000, then 34 percent",2056.66,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4476.28,
BIOMET 45-0054 ILIAC CREST WEDGE 19X21,C1762,HCPCS,,79001560,CDM,278,RC,,,both,,,2482,1836.69,,,1836.69,Other,150% of Medicare + 9.63% HCRA Surcharge,1116.9,45,,1116.9,percent of total billed charges,Critical Access Hospital RCC factor,843.88,34,,843.88,percent of total billed charges,Implant Device,843.88,34,,843.88,percent of total billed charges,Implant Device,843.88,34,,843.88,percent of total billed charges,Implant Device,843.88,34,,843.88,percent of total billed charges,Implant Device,843.88,34,,843.88,percent of total billed charges,Implant Device,1228.59,,,1228.59,Other,110% of Medicare,868.7,35,,868.7,percent of total billed charges,Implant Device,843.88,34,"Charges > $500, x 34%",843.88,percent of total billed charges,Implant Device,868.7,35,,868.7,percent of total billed charges,Implant Device,868.7,35,,868.7,percent of total billed charges,Implant Device,868.7,35,,868.7,percent of total billed charges,Implant Device,868.7,35,,868.7,percent of total billed charges,Implant Device,868.7,35,,868.7,percent of total billed charges,Implant Device,992.8,40,,992.8,percent of total billed charges,Implant Device,868.7,70,,868.7,percent of total billed charges,All Other,843.88,34,,843.88,percent of total billed charges,Implant Device,843.88,34,,843.88,percent of total billed charges,Implant Device,868.7,35,,868.7,percent of total billed charges,Implant Device,868.7,35,,868.7,percent of total billed charges,Implant Device,868.7,35,,868.7,percent of total billed charges,Implant Device,868.7,35,,868.7,percent of total billed charges,Implant Device,976.07,,,976.07,Other,100% of Medicaid,976.07,,,976.07,Other,100% of Medicaid,976.07,,,976.07,Other,100% of Medicaid,976.07,,,976.07,Other,100% of Medicaid,2196.16,,,2196.16,Other,225% of Medicaid,1493.39,,,1493.39,Other,153% of Medicaid,2196.16,,,2196.16,Other,225% of Medicaid,1366.5,,,1366.5,Other,140% of Medicaid,843.88,34,"If Charge > 2,000, then 34 percent",843.88,percent of total billed charges,Implants,2537.78,,,2537.78,Other,260% of Medicaid,3162.47,,,3162.47,Other,324% of Medicaid,2098.55,,,2098.55,Other,215% of Medicaid,2098.55,,,2098.55,Other,215% of Medicaid,1220.09,,,1220.09,Other,125% of Medicaid,843.88,3162.47,
CARDIO 6110210075-A INFUSAPORT DUAL LUMN,C1788,HCPCS,,79001561,CDM,278,RC,,,both,,,1176,870.24,,,870.24,Other,150% of Medicare + 9.63% HCRA Surcharge,529.2,45,,529.2,percent of total billed charges,Critical Access Hospital RCC factor,399.84,34,,399.84,percent of total billed charges,Implant Device,399.84,34,,399.84,percent of total billed charges,Implant Device,399.84,34,,399.84,percent of total billed charges,Implant Device,399.84,34,,399.84,percent of total billed charges,Implant Device,399.84,34,,399.84,percent of total billed charges,Implant Device,582.12,,,582.12,Other,110% of Medicare,411.6,35,,411.6,percent of total billed charges,Implant Device,399.84,34,"Charges > $500, x 34%",399.84,percent of total billed charges,Implant Device,411.6,35,,411.6,percent of total billed charges,Implant Device,411.6,35,,411.6,percent of total billed charges,Implant Device,411.6,35,,411.6,percent of total billed charges,Implant Device,411.6,35,,411.6,percent of total billed charges,Implant Device,411.6,35,,411.6,percent of total billed charges,Implant Device,470.4,40,,470.4,percent of total billed charges,Implant Device,411.6,70,,411.6,percent of total billed charges,All Other,399.84,34,,399.84,percent of total billed charges,Implant Device,399.84,34,,399.84,percent of total billed charges,Implant Device,411.6,35,,411.6,percent of total billed charges,Implant Device,411.6,35,,411.6,percent of total billed charges,Implant Device,411.6,35,,411.6,percent of total billed charges,Implant Device,411.6,35,,411.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,870.24,
ARTHREX AR-1370E INTERFERENCE SCREW 7X20,C1713,HCPCS,,79001562,CDM,278,RC,,,both,,,496,367.04,,,367.04,Other,150% of Medicare + 9.63% HCRA Surcharge,223.2,45,,223.2,percent of total billed charges,Critical Access Hospital RCC factor,168.64,34,,168.64,percent of total billed charges,Implant Device,168.64,34,,168.64,percent of total billed charges,Implant Device,168.64,34,,168.64,percent of total billed charges,Implant Device,168.64,34,,168.64,percent of total billed charges,Implant Device,168.64,34,,168.64,percent of total billed charges,Implant Device,245.52,,,245.52,Other,110% of Medicare,173.6,35,,173.6,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,173.6,35,,173.6,percent of total billed charges,Implant Device,173.6,35,,173.6,percent of total billed charges,Implant Device,173.6,35,,173.6,percent of total billed charges,Implant Device,173.6,35,,173.6,percent of total billed charges,Implant Device,173.6,35,,173.6,percent of total billed charges,Implant Device,198.4,40,,198.4,percent of total billed charges,Implant Device,173.6,70,,173.6,percent of total billed charges,All Other,168.64,34,,168.64,percent of total billed charges,Implant Device,168.64,34,,168.64,percent of total billed charges,Implant Device,173.6,35,,173.6,percent of total billed charges,Implant Device,173.6,35,,173.6,percent of total billed charges,Implant Device,173.6,35,,173.6,percent of total billed charges,Implant Device,173.6,35,,173.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,367.04,
S&N 71064701 JET-X MINI DISTAL RADIUS,C1713,HCPCS,,79001564,CDM,278,RC,,,both,,,9002,6661.5,,,6661.5,Other,150% of Medicare + 9.63% HCRA Surcharge,4050.9,45,,4050.9,percent of total billed charges,Critical Access Hospital RCC factor,3060.68,34,,3060.68,percent of total billed charges,Implant Device,3060.68,34,,3060.68,percent of total billed charges,Implant Device,3060.68,34,,3060.68,percent of total billed charges,Implant Device,3060.68,34,,3060.68,percent of total billed charges,Implant Device,3060.68,34,,3060.68,percent of total billed charges,Implant Device,4455.99,,,4455.99,Other,110% of Medicare,3150.7,35,,3150.7,percent of total billed charges,Implant Device,3060.68,34,"Charges > $500, x 34%",3060.68,percent of total billed charges,Implant Device,3150.7,35,,3150.7,percent of total billed charges,Implant Device,3150.7,35,,3150.7,percent of total billed charges,Implant Device,3150.7,35,,3150.7,percent of total billed charges,Implant Device,3150.7,35,,3150.7,percent of total billed charges,Implant Device,3150.7,35,,3150.7,percent of total billed charges,Implant Device,3600.8,40,,3600.8,percent of total billed charges,Implant Device,3150.7,70,,3150.7,percent of total billed charges,All Other,3060.68,34,,3060.68,percent of total billed charges,Implant Device,3060.68,34,,3060.68,percent of total billed charges,Implant Device,3150.7,35,,3150.7,percent of total billed charges,Implant Device,3150.7,35,,3150.7,percent of total billed charges,Implant Device,3150.7,35,,3150.7,percent of total billed charges,Implant Device,3150.7,35,,3150.7,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3060.68,34,"If Charge > 2,000, then 34 percent",3060.68,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,6661.5,
KUGEL HERNIA PATCH 12 X12,C1781,HCPCS,,79001565,CDM,278,RC,,,both,,,504,372.96,,,372.96,Other,150% of Medicare + 9.63% HCRA Surcharge,226.8,45,,226.8,percent of total billed charges,Critical Access Hospital RCC factor,171.36,34,,171.36,percent of total billed charges,Implant Device,171.36,34,,171.36,percent of total billed charges,Implant Device,171.36,34,,171.36,percent of total billed charges,Implant Device,171.36,34,,171.36,percent of total billed charges,Implant Device,171.36,34,,171.36,percent of total billed charges,Implant Device,249.48,,,249.48,Other,110% of Medicare,176.4,35,,176.4,percent of total billed charges,Implant Device,171.36,34,"Charges > $500, x 34%",171.36,percent of total billed charges,Implant Device,176.4,35,,176.4,percent of total billed charges,Implant Device,176.4,35,,176.4,percent of total billed charges,Implant Device,176.4,35,,176.4,percent of total billed charges,Implant Device,176.4,35,,176.4,percent of total billed charges,Implant Device,176.4,35,,176.4,percent of total billed charges,Implant Device,201.6,40,,201.6,percent of total billed charges,Implant Device,176.4,70,,176.4,percent of total billed charges,All Other,171.36,34,,171.36,percent of total billed charges,Implant Device,171.36,34,,171.36,percent of total billed charges,Implant Device,176.4,35,,176.4,percent of total billed charges,Implant Device,176.4,35,,176.4,percent of total billed charges,Implant Device,176.4,35,,176.4,percent of total billed charges,Implant Device,176.4,35,,176.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,372.96,
BARD 10102 KUGEL HERNIA PATCH OVAL 5.5X7,C1781,HCPCS,,79001566,CDM,278,RC,,,both,,,1200,888,,,888,Other,150% of Medicare + 9.63% HCRA Surcharge,540,45,,540,percent of total billed charges,Critical Access Hospital RCC factor,408,34,,408,percent of total billed charges,Implant Device,408,34,,408,percent of total billed charges,Implant Device,408,34,,408,percent of total billed charges,Implant Device,408,34,,408,percent of total billed charges,Implant Device,408,34,,408,percent of total billed charges,Implant Device,594,,,594,Other,110% of Medicare,420,35,,420,percent of total billed charges,Implant Device,408,34,"Charges > $500, x 34%",408,percent of total billed charges,Implant Device,420,35,,420,percent of total billed charges,Implant Device,420,35,,420,percent of total billed charges,Implant Device,420,35,,420,percent of total billed charges,Implant Device,420,35,,420,percent of total billed charges,Implant Device,420,35,,420,percent of total billed charges,Implant Device,480,40,,480,percent of total billed charges,Implant Device,420,70,,420,percent of total billed charges,All Other,408,34,,408,percent of total billed charges,Implant Device,408,34,,408,percent of total billed charges,Implant Device,420,35,,420,percent of total billed charges,Implant Device,420,35,,420,percent of total billed charges,Implant Device,420,35,,420,percent of total billed charges,Implant Device,420,35,,420,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,888,
KUGEL HERNIA PATCH MEDIUM,C1781,HCPCS,,79001567,CDM,278,RC,,,both,,,1063,786.62,,,786.62,Other,150% of Medicare + 9.63% HCRA Surcharge,478.35,45,,478.35,percent of total billed charges,Critical Access Hospital RCC factor,361.42,34,,361.42,percent of total billed charges,Implant Device,361.42,34,,361.42,percent of total billed charges,Implant Device,361.42,34,,361.42,percent of total billed charges,Implant Device,361.42,34,,361.42,percent of total billed charges,Implant Device,361.42,34,,361.42,percent of total billed charges,Implant Device,526.19,,,526.19,Other,110% of Medicare,372.05,35,,372.05,percent of total billed charges,Implant Device,361.42,34,"Charges > $500, x 34%",361.42,percent of total billed charges,Implant Device,372.05,35,,372.05,percent of total billed charges,Implant Device,372.05,35,,372.05,percent of total billed charges,Implant Device,372.05,35,,372.05,percent of total billed charges,Implant Device,372.05,35,,372.05,percent of total billed charges,Implant Device,372.05,35,,372.05,percent of total billed charges,Implant Device,425.2,40,,425.2,percent of total billed charges,Implant Device,372.05,70,,372.05,percent of total billed charges,All Other,361.42,34,,361.42,percent of total billed charges,Implant Device,361.42,34,,361.42,percent of total billed charges,Implant Device,372.05,35,,372.05,percent of total billed charges,Implant Device,372.05,35,,372.05,percent of total billed charges,Implant Device,372.05,35,,372.05,percent of total billed charges,Implant Device,372.05,35,,372.05,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,786.62,
BARD 10103 KUGEL HERNIA PATCH 3X3,C1781,HCPCS,,79001568,CDM,278,RC,,,both,,,964,713.36,,,713.36,Other,150% of Medicare + 9.63% HCRA Surcharge,433.8,45,,433.8,percent of total billed charges,Critical Access Hospital RCC factor,327.76,34,,327.76,percent of total billed charges,Implant Device,327.76,34,,327.76,percent of total billed charges,Implant Device,327.76,34,,327.76,percent of total billed charges,Implant Device,327.76,34,,327.76,percent of total billed charges,Implant Device,327.76,34,,327.76,percent of total billed charges,Implant Device,477.18,,,477.18,Other,110% of Medicare,337.4,35,,337.4,percent of total billed charges,Implant Device,327.76,34,"Charges > $500, x 34%",327.76,percent of total billed charges,Implant Device,337.4,35,,337.4,percent of total billed charges,Implant Device,337.4,35,,337.4,percent of total billed charges,Implant Device,337.4,35,,337.4,percent of total billed charges,Implant Device,337.4,35,,337.4,percent of total billed charges,Implant Device,337.4,35,,337.4,percent of total billed charges,Implant Device,385.6,40,,385.6,percent of total billed charges,Implant Device,337.4,70,,337.4,percent of total billed charges,All Other,327.76,34,,327.76,percent of total billed charges,Implant Device,327.76,34,,327.76,percent of total billed charges,Implant Device,337.4,35,,337.4,percent of total billed charges,Implant Device,337.4,35,,337.4,percent of total billed charges,Implant Device,337.4,35,,337.4,percent of total billed charges,Implant Device,337.4,35,,337.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,713.36,
KUGEL HERNIA PATCH SMALL CIRCLE,C1781,HCPCS,,79001569,CDM,278,RC,,,both,,,680,503.2,,,503.2,Other,150% of Medicare + 9.63% HCRA Surcharge,306,45,,306,percent of total billed charges,Critical Access Hospital RCC factor,231.2,34,,231.2,percent of total billed charges,Implant Device,231.2,34,,231.2,percent of total billed charges,Implant Device,231.2,34,,231.2,percent of total billed charges,Implant Device,231.2,34,,231.2,percent of total billed charges,Implant Device,231.2,34,,231.2,percent of total billed charges,Implant Device,336.6,,,336.6,Other,110% of Medicare,238,35,,238,percent of total billed charges,Implant Device,231.2,34,"Charges > $500, x 34%",231.2,percent of total billed charges,Implant Device,238,35,,238,percent of total billed charges,Implant Device,238,35,,238,percent of total billed charges,Implant Device,238,35,,238,percent of total billed charges,Implant Device,238,35,,238,percent of total billed charges,Implant Device,238,35,,238,percent of total billed charges,Implant Device,272,40,,272,percent of total billed charges,Implant Device,238,70,,238,percent of total billed charges,All Other,231.2,34,,231.2,percent of total billed charges,Implant Device,231.2,34,,231.2,percent of total billed charges,Implant Device,238,35,,238,percent of total billed charges,Implant Device,238,35,,238,percent of total billed charges,Implant Device,238,35,,238,percent of total billed charges,Implant Device,238,35,,238,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,503.2,
KUGEL HERNIA PATCH SMALL OVAL 3 X 5,C1781,HCPCS,,79001570,CDM,278,RC,,,both,,,886,655.64,,,655.64,Other,150% of Medicare + 9.63% HCRA Surcharge,398.7,45,,398.7,percent of total billed charges,Critical Access Hospital RCC factor,301.24,34,,301.24,percent of total billed charges,Implant Device,301.24,34,,301.24,percent of total billed charges,Implant Device,301.24,34,,301.24,percent of total billed charges,Implant Device,301.24,34,,301.24,percent of total billed charges,Implant Device,301.24,34,,301.24,percent of total billed charges,Implant Device,438.57,,,438.57,Other,110% of Medicare,310.1,35,,310.1,percent of total billed charges,Implant Device,301.24,34,"Charges > $500, x 34%",301.24,percent of total billed charges,Implant Device,310.1,35,,310.1,percent of total billed charges,Implant Device,310.1,35,,310.1,percent of total billed charges,Implant Device,310.1,35,,310.1,percent of total billed charges,Implant Device,310.1,35,,310.1,percent of total billed charges,Implant Device,310.1,35,,310.1,percent of total billed charges,Implant Device,354.4,40,,354.4,percent of total billed charges,Implant Device,310.1,70,,310.1,percent of total billed charges,All Other,301.24,34,,301.24,percent of total billed charges,Implant Device,301.24,34,,301.24,percent of total billed charges,Implant Device,310.1,35,,310.1,percent of total billed charges,Implant Device,310.1,35,,310.1,percent of total billed charges,Implant Device,310.1,35,,310.1,percent of total billed charges,Implant Device,310.1,35,,310.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,655.64,
BARD 10101 KUGEL HERNIA PATCH OVAL 3X4.6,C1781,HCPCS,,79001571,CDM,278,RC,,,both,,,791,585.34,,,585.34,Other,150% of Medicare + 9.63% HCRA Surcharge,355.95,45,,355.95,percent of total billed charges,Critical Access Hospital RCC factor,268.94,34,,268.94,percent of total billed charges,Implant Device,268.94,34,,268.94,percent of total billed charges,Implant Device,268.94,34,,268.94,percent of total billed charges,Implant Device,268.94,34,,268.94,percent of total billed charges,Implant Device,268.94,34,,268.94,percent of total billed charges,Implant Device,391.55,,,391.55,Other,110% of Medicare,276.85,35,,276.85,percent of total billed charges,Implant Device,268.94,34,"Charges > $500, x 34%",268.94,percent of total billed charges,Implant Device,276.85,35,,276.85,percent of total billed charges,Implant Device,276.85,35,,276.85,percent of total billed charges,Implant Device,276.85,35,,276.85,percent of total billed charges,Implant Device,276.85,35,,276.85,percent of total billed charges,Implant Device,276.85,35,,276.85,percent of total billed charges,Implant Device,316.4,40,,316.4,percent of total billed charges,Implant Device,276.85,70,,276.85,percent of total billed charges,All Other,268.94,34,,268.94,percent of total billed charges,Implant Device,268.94,34,,268.94,percent of total billed charges,Implant Device,276.85,35,,276.85,percent of total billed charges,Implant Device,276.85,35,,276.85,percent of total billed charges,Implant Device,276.85,35,,276.85,percent of total billed charges,Implant Device,276.85,35,,276.85,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,585.34,
MEDTRONIC 3889-28 LEAD KIT SHORT,C1778,HCPCS,,79001572,CDM,278,RC,,,both,,,10246,7582.07,,,7582.07,Other,150% of Medicare + 9.63% HCRA Surcharge,4610.7,45,,4610.7,percent of total billed charges,Critical Access Hospital RCC factor,3483.64,34,,3483.64,percent of total billed charges,Implant Device,3483.64,34,,3483.64,percent of total billed charges,Implant Device,3483.64,34,,3483.64,percent of total billed charges,Implant Device,3483.64,34,,3483.64,percent of total billed charges,Implant Device,3483.64,34,,3483.64,percent of total billed charges,Implant Device,5071.77,,,5071.77,Other,110% of Medicare,3586.1,35,,3586.1,percent of total billed charges,Implant Device,3483.64,34,"Charges > $500, x 34%",3483.64,percent of total billed charges,Implant Device,3586.1,35,,3586.1,percent of total billed charges,Implant Device,3586.1,35,,3586.1,percent of total billed charges,Implant Device,3586.1,35,,3586.1,percent of total billed charges,Implant Device,3586.1,35,,3586.1,percent of total billed charges,Implant Device,3586.1,35,,3586.1,percent of total billed charges,Implant Device,4098.4,40,,4098.4,percent of total billed charges,Implant Device,3586.1,70,,3586.1,percent of total billed charges,All Other,3483.64,34,,3483.64,percent of total billed charges,Implant Device,3483.64,34,,3483.64,percent of total billed charges,Implant Device,3586.1,35,,3586.1,percent of total billed charges,Implant Device,3586.1,35,,3586.1,percent of total billed charges,Implant Device,3586.1,35,,3586.1,percent of total billed charges,Implant Device,3586.1,35,,3586.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3483.64,34,"If Charge > 2,000, then 34 percent",3483.64,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,7582.07,
BIOMET 8162-04-007 LOCKING PLATE 7 HOLE,C1713,HCPCS,,79001581,CDM,278,RC,,,both,,,1230,910.2,,,910.2,Other,150% of Medicare + 9.63% HCRA Surcharge,553.5,45,,553.5,percent of total billed charges,Critical Access Hospital RCC factor,418.2,34,,418.2,percent of total billed charges,Implant Device,418.2,34,,418.2,percent of total billed charges,Implant Device,418.2,34,,418.2,percent of total billed charges,Implant Device,418.2,34,,418.2,percent of total billed charges,Implant Device,418.2,34,,418.2,percent of total billed charges,Implant Device,608.85,,,608.85,Other,110% of Medicare,430.5,35,,430.5,percent of total billed charges,Implant Device,418.2,34,"Charges > $500, x 34%",418.2,percent of total billed charges,Implant Device,430.5,35,,430.5,percent of total billed charges,Implant Device,430.5,35,,430.5,percent of total billed charges,Implant Device,430.5,35,,430.5,percent of total billed charges,Implant Device,430.5,35,,430.5,percent of total billed charges,Implant Device,430.5,35,,430.5,percent of total billed charges,Implant Device,492,40,,492,percent of total billed charges,Implant Device,430.5,70,,430.5,percent of total billed charges,All Other,418.2,34,,418.2,percent of total billed charges,Implant Device,418.2,34,,418.2,percent of total billed charges,Implant Device,430.5,35,,430.5,percent of total billed charges,Implant Device,430.5,35,,430.5,percent of total billed charges,Implant Device,430.5,35,,430.5,percent of total billed charges,Implant Device,430.5,35,,430.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,910.2,
BIOMET 8162-06-003 LOCKING PLATE 95MM,C1713,HCPCS,,79001582,CDM,278,RC,,,both,,,3390,2508.61,,,2508.61,Other,150% of Medicare + 9.63% HCRA Surcharge,1525.5,45,,1525.5,percent of total billed charges,Critical Access Hospital RCC factor,1152.6,34,,1152.6,percent of total billed charges,Implant Device,1152.6,34,,1152.6,percent of total billed charges,Implant Device,1152.6,34,,1152.6,percent of total billed charges,Implant Device,1152.6,34,,1152.6,percent of total billed charges,Implant Device,1152.6,34,,1152.6,percent of total billed charges,Implant Device,1678.05,,,1678.05,Other,110% of Medicare,1186.5,35,,1186.5,percent of total billed charges,Implant Device,1152.6,34,"Charges > $500, x 34%",1152.6,percent of total billed charges,Implant Device,1186.5,35,,1186.5,percent of total billed charges,Implant Device,1186.5,35,,1186.5,percent of total billed charges,Implant Device,1186.5,35,,1186.5,percent of total billed charges,Implant Device,1186.5,35,,1186.5,percent of total billed charges,Implant Device,1186.5,35,,1186.5,percent of total billed charges,Implant Device,1356,40,,1356,percent of total billed charges,Implant Device,1186.5,70,,1186.5,percent of total billed charges,All Other,1152.6,34,,1152.6,percent of total billed charges,Implant Device,1152.6,34,,1152.6,percent of total billed charges,Implant Device,1186.5,35,,1186.5,percent of total billed charges,Implant Device,1186.5,35,,1186.5,percent of total billed charges,Implant Device,1186.5,35,,1186.5,percent of total billed charges,Implant Device,1186.5,35,,1186.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1152.6,34,"If Charge > 2,000, then 34 percent",1152.6,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2508.61,
BIOMET 8162-10-006 LOCK PLATE TIB 6HOLE,C1713,HCPCS,,79001583,CDM,278,RC,,,both,,,7020,5194.82,,,5194.82,Other,150% of Medicare + 9.63% HCRA Surcharge,3159,45,,3159,percent of total billed charges,Critical Access Hospital RCC factor,2386.8,34,,2386.8,percent of total billed charges,Implant Device,2386.8,34,,2386.8,percent of total billed charges,Implant Device,2386.8,34,,2386.8,percent of total billed charges,Implant Device,2386.8,34,,2386.8,percent of total billed charges,Implant Device,2386.8,34,,2386.8,percent of total billed charges,Implant Device,3474.9,,,3474.9,Other,110% of Medicare,2457,35,,2457,percent of total billed charges,Implant Device,2386.8,34,"Charges > $500, x 34%",2386.8,percent of total billed charges,Implant Device,2457,35,,2457,percent of total billed charges,Implant Device,2457,35,,2457,percent of total billed charges,Implant Device,2457,35,,2457,percent of total billed charges,Implant Device,2457,35,,2457,percent of total billed charges,Implant Device,2457,35,,2457,percent of total billed charges,Implant Device,2808,40,,2808,percent of total billed charges,Implant Device,2457,70,,2457,percent of total billed charges,All Other,2386.8,34,,2386.8,percent of total billed charges,Implant Device,2386.8,34,,2386.8,percent of total billed charges,Implant Device,2457,35,,2457,percent of total billed charges,Implant Device,2457,35,,2457,percent of total billed charges,Implant Device,2457,35,,2457,percent of total billed charges,Implant Device,2457,35,,2457,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2386.8,34,"If Charge > 2,000, then 34 percent",2386.8,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5194.82,
STRYKER 53-23011E LOCKING SCREW 2.3X11MM,C1713,HCPCS,,79001584,CDM,278,RC,,,both,,,296,219.04,,,219.04,Other,150% of Medicare + 9.63% HCRA Surcharge,133.2,45,,133.2,percent of total billed charges,Critical Access Hospital RCC factor,100.64,34,,100.64,percent of total billed charges,Implant Device,100.64,34,,100.64,percent of total billed charges,Implant Device,100.64,34,,100.64,percent of total billed charges,Implant Device,100.64,34,,100.64,percent of total billed charges,Implant Device,100.64,34,,100.64,percent of total billed charges,Implant Device,146.52,,,146.52,Other,110% of Medicare,103.6,35,,103.6,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,103.6,35,,103.6,percent of total billed charges,Implant Device,103.6,35,,103.6,percent of total billed charges,Implant Device,103.6,35,,103.6,percent of total billed charges,Implant Device,103.6,35,,103.6,percent of total billed charges,Implant Device,103.6,35,,103.6,percent of total billed charges,Implant Device,118.4,40,,118.4,percent of total billed charges,Implant Device,103.6,70,,103.6,percent of total billed charges,All Other,100.64,34,,100.64,percent of total billed charges,Implant Device,100.64,34,,100.64,percent of total billed charges,Implant Device,103.6,35,,103.6,percent of total billed charges,Implant Device,103.6,35,,103.6,percent of total billed charges,Implant Device,103.6,35,,103.6,percent of total billed charges,Implant Device,103.6,35,,103.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,219.04,
STRYKER 53-23012E LOCKING SCREW 2.3X12MM,C1713,HCPCS,,79001585,CDM,278,RC,,,both,,,515,381.1,,,381.1,Other,150% of Medicare + 9.63% HCRA Surcharge,231.75,45,,231.75,percent of total billed charges,Critical Access Hospital RCC factor,175.1,34,,175.1,percent of total billed charges,Implant Device,175.1,34,,175.1,percent of total billed charges,Implant Device,175.1,34,,175.1,percent of total billed charges,Implant Device,175.1,34,,175.1,percent of total billed charges,Implant Device,175.1,34,,175.1,percent of total billed charges,Implant Device,254.93,,,254.93,Other,110% of Medicare,180.25,35,,180.25,percent of total billed charges,Implant Device,175.1,34,"Charges > $500, x 34%",175.1,percent of total billed charges,Implant Device,180.25,35,,180.25,percent of total billed charges,Implant Device,180.25,35,,180.25,percent of total billed charges,Implant Device,180.25,35,,180.25,percent of total billed charges,Implant Device,180.25,35,,180.25,percent of total billed charges,Implant Device,180.25,35,,180.25,percent of total billed charges,Implant Device,206,40,,206,percent of total billed charges,Implant Device,180.25,70,,180.25,percent of total billed charges,All Other,175.1,34,,175.1,percent of total billed charges,Implant Device,175.1,34,,175.1,percent of total billed charges,Implant Device,180.25,35,,180.25,percent of total billed charges,Implant Device,180.25,35,,180.25,percent of total billed charges,Implant Device,180.25,35,,180.25,percent of total billed charges,Implant Device,180.25,35,,180.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,381.1,
STRYKER 53-23015E LOCKING SCREW 2.3X15MM,C1713,HCPCS,,79001586,CDM,278,RC,,,both,,,296,219.04,,,219.04,Other,150% of Medicare + 9.63% HCRA Surcharge,133.2,45,,133.2,percent of total billed charges,Critical Access Hospital RCC factor,100.64,34,,100.64,percent of total billed charges,Implant Device,100.64,34,,100.64,percent of total billed charges,Implant Device,100.64,34,,100.64,percent of total billed charges,Implant Device,100.64,34,,100.64,percent of total billed charges,Implant Device,100.64,34,,100.64,percent of total billed charges,Implant Device,146.52,,,146.52,Other,110% of Medicare,103.6,35,,103.6,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,103.6,35,,103.6,percent of total billed charges,Implant Device,103.6,35,,103.6,percent of total billed charges,Implant Device,103.6,35,,103.6,percent of total billed charges,Implant Device,103.6,35,,103.6,percent of total billed charges,Implant Device,103.6,35,,103.6,percent of total billed charges,Implant Device,118.4,40,,118.4,percent of total billed charges,Implant Device,103.6,70,,103.6,percent of total billed charges,All Other,100.64,34,,100.64,percent of total billed charges,Implant Device,100.64,34,,100.64,percent of total billed charges,Implant Device,103.6,35,,103.6,percent of total billed charges,Implant Device,103.6,35,,103.6,percent of total billed charges,Implant Device,103.6,35,,103.6,percent of total billed charges,Implant Device,103.6,35,,103.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,219.04,
STRYKER 53-23016E LOCKING SCREW 2.3X16MM,C1713,HCPCS,,79001587,CDM,278,RC,,,both,,,296,219.04,,,219.04,Other,150% of Medicare + 9.63% HCRA Surcharge,133.2,45,,133.2,percent of total billed charges,Critical Access Hospital RCC factor,100.64,34,,100.64,percent of total billed charges,Implant Device,100.64,34,,100.64,percent of total billed charges,Implant Device,100.64,34,,100.64,percent of total billed charges,Implant Device,100.64,34,,100.64,percent of total billed charges,Implant Device,100.64,34,,100.64,percent of total billed charges,Implant Device,146.52,,,146.52,Other,110% of Medicare,103.6,35,,103.6,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,103.6,35,,103.6,percent of total billed charges,Implant Device,103.6,35,,103.6,percent of total billed charges,Implant Device,103.6,35,,103.6,percent of total billed charges,Implant Device,103.6,35,,103.6,percent of total billed charges,Implant Device,103.6,35,,103.6,percent of total billed charges,Implant Device,118.4,40,,118.4,percent of total billed charges,Implant Device,103.6,70,,103.6,percent of total billed charges,All Other,100.64,34,,100.64,percent of total billed charges,Implant Device,100.64,34,,100.64,percent of total billed charges,Implant Device,103.6,35,,103.6,percent of total billed charges,Implant Device,103.6,35,,103.6,percent of total billed charges,Implant Device,103.6,35,,103.6,percent of total billed charges,Implant Device,103.6,35,,103.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,219.04,
SYNTHES 212.106 LOCKING SCREW 3.5 X 20MM,C1713,HCPCS,,79001588,CDM,278,RC,,,both,,,402,297.48,,,297.48,Other,150% of Medicare + 9.63% HCRA Surcharge,180.9,45,,180.9,percent of total billed charges,Critical Access Hospital RCC factor,136.68,34,,136.68,percent of total billed charges,Implant Device,136.68,34,,136.68,percent of total billed charges,Implant Device,136.68,34,,136.68,percent of total billed charges,Implant Device,136.68,34,,136.68,percent of total billed charges,Implant Device,136.68,34,,136.68,percent of total billed charges,Implant Device,198.99,,,198.99,Other,110% of Medicare,140.7,35,,140.7,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,140.7,35,,140.7,percent of total billed charges,Implant Device,140.7,35,,140.7,percent of total billed charges,Implant Device,140.7,35,,140.7,percent of total billed charges,Implant Device,140.7,35,,140.7,percent of total billed charges,Implant Device,140.7,35,,140.7,percent of total billed charges,Implant Device,160.8,40,,160.8,percent of total billed charges,Implant Device,140.7,70,,140.7,percent of total billed charges,All Other,136.68,34,,136.68,percent of total billed charges,Implant Device,136.68,34,,136.68,percent of total billed charges,Implant Device,140.7,35,,140.7,percent of total billed charges,Implant Device,140.7,35,,140.7,percent of total billed charges,Implant Device,140.7,35,,140.7,percent of total billed charges,Implant Device,140.7,35,,140.7,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,297.48,
SYNTHES 212.11 LOCKING SCREW 3.5 X 28MM,C1713,HCPCS,,79001589,CDM,278,RC,,,both,,,520,384.8,,,384.8,Other,150% of Medicare + 9.63% HCRA Surcharge,234,45,,234,percent of total billed charges,Critical Access Hospital RCC factor,176.8,34,,176.8,percent of total billed charges,Implant Device,176.8,34,,176.8,percent of total billed charges,Implant Device,176.8,34,,176.8,percent of total billed charges,Implant Device,176.8,34,,176.8,percent of total billed charges,Implant Device,176.8,34,,176.8,percent of total billed charges,Implant Device,257.4,,,257.4,Other,110% of Medicare,182,35,,182,percent of total billed charges,Implant Device,176.8,34,"Charges > $500, x 34%",176.8,percent of total billed charges,Implant Device,182,35,,182,percent of total billed charges,Implant Device,182,35,,182,percent of total billed charges,Implant Device,182,35,,182,percent of total billed charges,Implant Device,182,35,,182,percent of total billed charges,Implant Device,182,35,,182,percent of total billed charges,Implant Device,208,40,,208,percent of total billed charges,Implant Device,182,70,,182,percent of total billed charges,All Other,176.8,34,,176.8,percent of total billed charges,Implant Device,176.8,34,,176.8,percent of total billed charges,Implant Device,182,35,,182,percent of total billed charges,Implant Device,182,35,,182,percent of total billed charges,Implant Device,182,35,,182,percent of total billed charges,Implant Device,182,35,,182,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,384.8,
SYNTHES 212.113 LOCKING SCREW 3.5 X 34MM,C1713,HCPCS,,79001593,CDM,278,RC,,,both,,,315,233.1,,,233.1,Other,150% of Medicare + 9.63% HCRA Surcharge,141.75,45,,141.75,percent of total billed charges,Critical Access Hospital RCC factor,107.1,34,,107.1,percent of total billed charges,Implant Device,107.1,34,,107.1,percent of total billed charges,Implant Device,107.1,34,,107.1,percent of total billed charges,Implant Device,107.1,34,,107.1,percent of total billed charges,Implant Device,107.1,34,,107.1,percent of total billed charges,Implant Device,155.93,,,155.93,Other,110% of Medicare,110.25,35,,110.25,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,110.25,35,,110.25,percent of total billed charges,Implant Device,110.25,35,,110.25,percent of total billed charges,Implant Device,110.25,35,,110.25,percent of total billed charges,Implant Device,110.25,35,,110.25,percent of total billed charges,Implant Device,110.25,35,,110.25,percent of total billed charges,Implant Device,126,40,,126,percent of total billed charges,Implant Device,110.25,70,,110.25,percent of total billed charges,All Other,107.1,34,,107.1,percent of total billed charges,Implant Device,107.1,34,,107.1,percent of total billed charges,Implant Device,110.25,35,,110.25,percent of total billed charges,Implant Device,110.25,35,,110.25,percent of total billed charges,Implant Device,110.25,35,,110.25,percent of total billed charges,Implant Device,110.25,35,,110.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,233.1,
SYNTHES 222.588 LOCKING SCREW 4.0 X 42MM,C1713,HCPCS,,79001596,CDM,278,RC,,,both,,,496,367.04,,,367.04,Other,150% of Medicare + 9.63% HCRA Surcharge,223.2,45,,223.2,percent of total billed charges,Critical Access Hospital RCC factor,168.64,34,,168.64,percent of total billed charges,Implant Device,168.64,34,,168.64,percent of total billed charges,Implant Device,168.64,34,,168.64,percent of total billed charges,Implant Device,168.64,34,,168.64,percent of total billed charges,Implant Device,168.64,34,,168.64,percent of total billed charges,Implant Device,245.52,,,245.52,Other,110% of Medicare,173.6,35,,173.6,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,173.6,35,,173.6,percent of total billed charges,Implant Device,173.6,35,,173.6,percent of total billed charges,Implant Device,173.6,35,,173.6,percent of total billed charges,Implant Device,173.6,35,,173.6,percent of total billed charges,Implant Device,173.6,35,,173.6,percent of total billed charges,Implant Device,198.4,40,,198.4,percent of total billed charges,Implant Device,173.6,70,,173.6,percent of total billed charges,All Other,168.64,34,,168.64,percent of total billed charges,Implant Device,168.64,34,,168.64,percent of total billed charges,Implant Device,173.6,35,,173.6,percent of total billed charges,Implant Device,173.6,35,,173.6,percent of total billed charges,Implant Device,173.6,35,,173.6,percent of total billed charges,Implant Device,173.6,35,,173.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,367.04,
SYNTHES 222.59 LOCKING SCREW 4.0 X 50MM,C1713,HCPCS,,79001597,CDM,278,RC,,,both,,,512,378.88,,,378.88,Other,150% of Medicare + 9.63% HCRA Surcharge,230.4,45,,230.4,percent of total billed charges,Critical Access Hospital RCC factor,174.08,34,,174.08,percent of total billed charges,Implant Device,174.08,34,,174.08,percent of total billed charges,Implant Device,174.08,34,,174.08,percent of total billed charges,Implant Device,174.08,34,,174.08,percent of total billed charges,Implant Device,174.08,34,,174.08,percent of total billed charges,Implant Device,253.44,,,253.44,Other,110% of Medicare,179.2,35,,179.2,percent of total billed charges,Implant Device,174.08,34,"Charges > $500, x 34%",174.08,percent of total billed charges,Implant Device,179.2,35,,179.2,percent of total billed charges,Implant Device,179.2,35,,179.2,percent of total billed charges,Implant Device,179.2,35,,179.2,percent of total billed charges,Implant Device,179.2,35,,179.2,percent of total billed charges,Implant Device,179.2,35,,179.2,percent of total billed charges,Implant Device,204.8,40,,204.8,percent of total billed charges,Implant Device,179.2,70,,179.2,percent of total billed charges,All Other,174.08,34,,174.08,percent of total billed charges,Implant Device,174.08,34,,174.08,percent of total billed charges,Implant Device,179.2,35,,179.2,percent of total billed charges,Implant Device,179.2,35,,179.2,percent of total billed charges,Implant Device,179.2,35,,179.2,percent of total billed charges,Implant Device,179.2,35,,179.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,378.88,
SYNTHES 222.591 LOCKING SCREW 4.0 X 54MM,C1713,HCPCS,,79001598,CDM,278,RC,,,both,,,496,367.04,,,367.04,Other,150% of Medicare + 9.63% HCRA Surcharge,223.2,45,,223.2,percent of total billed charges,Critical Access Hospital RCC factor,168.64,34,,168.64,percent of total billed charges,Implant Device,168.64,34,,168.64,percent of total billed charges,Implant Device,168.64,34,,168.64,percent of total billed charges,Implant Device,168.64,34,,168.64,percent of total billed charges,Implant Device,168.64,34,,168.64,percent of total billed charges,Implant Device,245.52,,,245.52,Other,110% of Medicare,173.6,35,,173.6,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,173.6,35,,173.6,percent of total billed charges,Implant Device,173.6,35,,173.6,percent of total billed charges,Implant Device,173.6,35,,173.6,percent of total billed charges,Implant Device,173.6,35,,173.6,percent of total billed charges,Implant Device,173.6,35,,173.6,percent of total billed charges,Implant Device,198.4,40,,198.4,percent of total billed charges,Implant Device,173.6,70,,173.6,percent of total billed charges,All Other,168.64,34,,168.64,percent of total billed charges,Implant Device,168.64,34,,168.64,percent of total billed charges,Implant Device,173.6,35,,173.6,percent of total billed charges,Implant Device,173.6,35,,173.6,percent of total billed charges,Implant Device,173.6,35,,173.6,percent of total billed charges,Implant Device,173.6,35,,173.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,367.04,
STRYKER 53-23610E LOCK SCREW T7 2.3X10MM,C1713,HCPCS,,79001599,CDM,278,RC,,,both,,,385,284.9,,,284.9,Other,150% of Medicare + 9.63% HCRA Surcharge,173.25,45,,173.25,percent of total billed charges,Critical Access Hospital RCC factor,130.9,34,,130.9,percent of total billed charges,Implant Device,130.9,34,,130.9,percent of total billed charges,Implant Device,130.9,34,,130.9,percent of total billed charges,Implant Device,130.9,34,,130.9,percent of total billed charges,Implant Device,130.9,34,,130.9,percent of total billed charges,Implant Device,190.58,,,190.58,Other,110% of Medicare,134.75,35,,134.75,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,134.75,35,,134.75,percent of total billed charges,Implant Device,134.75,35,,134.75,percent of total billed charges,Implant Device,134.75,35,,134.75,percent of total billed charges,Implant Device,134.75,35,,134.75,percent of total billed charges,Implant Device,134.75,35,,134.75,percent of total billed charges,Implant Device,154,40,,154,percent of total billed charges,Implant Device,134.75,70,,134.75,percent of total billed charges,All Other,130.9,34,,130.9,percent of total billed charges,Implant Device,130.9,34,,130.9,percent of total billed charges,Implant Device,134.75,35,,134.75,percent of total billed charges,Implant Device,134.75,35,,134.75,percent of total billed charges,Implant Device,134.75,35,,134.75,percent of total billed charges,Implant Device,134.75,35,,134.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,284.9,
STRYKER 53-23612E LOCK SCREW T7 2.3X12MM,C1713,HCPCS,,79001600,CDM,278,RC,,,both,,,398,294.52,,,294.52,Other,150% of Medicare + 9.63% HCRA Surcharge,179.1,45,,179.1,percent of total billed charges,Critical Access Hospital RCC factor,135.32,34,,135.32,percent of total billed charges,Implant Device,135.32,34,,135.32,percent of total billed charges,Implant Device,135.32,34,,135.32,percent of total billed charges,Implant Device,135.32,34,,135.32,percent of total billed charges,Implant Device,135.32,34,,135.32,percent of total billed charges,Implant Device,197.01,,,197.01,Other,110% of Medicare,139.3,35,,139.3,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,139.3,35,,139.3,percent of total billed charges,Implant Device,139.3,35,,139.3,percent of total billed charges,Implant Device,139.3,35,,139.3,percent of total billed charges,Implant Device,139.3,35,,139.3,percent of total billed charges,Implant Device,139.3,35,,139.3,percent of total billed charges,Implant Device,159.2,40,,159.2,percent of total billed charges,Implant Device,139.3,70,,139.3,percent of total billed charges,All Other,135.32,34,,135.32,percent of total billed charges,Implant Device,135.32,34,,135.32,percent of total billed charges,Implant Device,139.3,35,,139.3,percent of total billed charges,Implant Device,139.3,35,,139.3,percent of total billed charges,Implant Device,139.3,35,,139.3,percent of total billed charges,Implant Device,139.3,35,,139.3,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,294.52,
STRYKER 53-23620E LOCK SCREW T7 2.3X20MM,C1713,HCPCS,,79001601,CDM,278,RC,,,both,,,492,364.08,,,364.08,Other,150% of Medicare + 9.63% HCRA Surcharge,221.4,45,,221.4,percent of total billed charges,Critical Access Hospital RCC factor,167.28,34,,167.28,percent of total billed charges,Implant Device,167.28,34,,167.28,percent of total billed charges,Implant Device,167.28,34,,167.28,percent of total billed charges,Implant Device,167.28,34,,167.28,percent of total billed charges,Implant Device,167.28,34,,167.28,percent of total billed charges,Implant Device,243.54,,,243.54,Other,110% of Medicare,172.2,35,,172.2,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,172.2,35,,172.2,percent of total billed charges,Implant Device,172.2,35,,172.2,percent of total billed charges,Implant Device,172.2,35,,172.2,percent of total billed charges,Implant Device,172.2,35,,172.2,percent of total billed charges,Implant Device,172.2,35,,172.2,percent of total billed charges,Implant Device,196.8,40,,196.8,percent of total billed charges,Implant Device,172.2,70,,172.2,percent of total billed charges,All Other,167.28,34,,167.28,percent of total billed charges,Implant Device,167.28,34,,167.28,percent of total billed charges,Implant Device,172.2,35,,172.2,percent of total billed charges,Implant Device,172.2,35,,172.2,percent of total billed charges,Implant Device,172.2,35,,172.2,percent of total billed charges,Implant Device,172.2,35,,172.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,364.08,
STRYKER 53-23626E LOCK SCREW T7 2.3X26MM,C1713,HCPCS,,79001602,CDM,278,RC,,,both,,,469,347.06,,,347.06,Other,150% of Medicare + 9.63% HCRA Surcharge,211.05,45,,211.05,percent of total billed charges,Critical Access Hospital RCC factor,159.46,34,,159.46,percent of total billed charges,Implant Device,159.46,34,,159.46,percent of total billed charges,Implant Device,159.46,34,,159.46,percent of total billed charges,Implant Device,159.46,34,,159.46,percent of total billed charges,Implant Device,159.46,34,,159.46,percent of total billed charges,Implant Device,232.16,,,232.16,Other,110% of Medicare,164.15,35,,164.15,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,164.15,35,,164.15,percent of total billed charges,Implant Device,164.15,35,,164.15,percent of total billed charges,Implant Device,164.15,35,,164.15,percent of total billed charges,Implant Device,164.15,35,,164.15,percent of total billed charges,Implant Device,164.15,35,,164.15,percent of total billed charges,Implant Device,187.6,40,,187.6,percent of total billed charges,Implant Device,164.15,70,,164.15,percent of total billed charges,All Other,159.46,34,,159.46,percent of total billed charges,Implant Device,159.46,34,,159.46,percent of total billed charges,Implant Device,164.15,35,,164.15,percent of total billed charges,Implant Device,164.15,35,,164.15,percent of total billed charges,Implant Device,164.15,35,,164.15,percent of total billed charges,Implant Device,164.15,35,,164.15,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,347.06,
STRYKER 53-23628E LOCK SCREW T7 2.3X28MM,C1713,HCPCS,,79001603,CDM,278,RC,,,both,,,446,330.04,,,330.04,Other,150% of Medicare + 9.63% HCRA Surcharge,200.7,45,,200.7,percent of total billed charges,Critical Access Hospital RCC factor,151.64,34,,151.64,percent of total billed charges,Implant Device,151.64,34,,151.64,percent of total billed charges,Implant Device,151.64,34,,151.64,percent of total billed charges,Implant Device,151.64,34,,151.64,percent of total billed charges,Implant Device,151.64,34,,151.64,percent of total billed charges,Implant Device,220.77,,,220.77,Other,110% of Medicare,156.1,35,,156.1,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,156.1,35,,156.1,percent of total billed charges,Implant Device,156.1,35,,156.1,percent of total billed charges,Implant Device,156.1,35,,156.1,percent of total billed charges,Implant Device,156.1,35,,156.1,percent of total billed charges,Implant Device,156.1,35,,156.1,percent of total billed charges,Implant Device,178.4,40,,178.4,percent of total billed charges,Implant Device,156.1,70,,156.1,percent of total billed charges,All Other,151.64,34,,151.64,percent of total billed charges,Implant Device,151.64,34,,151.64,percent of total billed charges,Implant Device,156.1,35,,156.1,percent of total billed charges,Implant Device,156.1,35,,156.1,percent of total billed charges,Implant Device,156.1,35,,156.1,percent of total billed charges,Implant Device,156.1,35,,156.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,330.04,
STRYKER 53-27610E LOCK SCREW T7 2.7X10MM,C1713,HCPCS,,79001604,CDM,278,RC,,,both,,,385,284.9,,,284.9,Other,150% of Medicare + 9.63% HCRA Surcharge,173.25,45,,173.25,percent of total billed charges,Critical Access Hospital RCC factor,130.9,34,,130.9,percent of total billed charges,Implant Device,130.9,34,,130.9,percent of total billed charges,Implant Device,130.9,34,,130.9,percent of total billed charges,Implant Device,130.9,34,,130.9,percent of total billed charges,Implant Device,130.9,34,,130.9,percent of total billed charges,Implant Device,190.58,,,190.58,Other,110% of Medicare,134.75,35,,134.75,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,134.75,35,,134.75,percent of total billed charges,Implant Device,134.75,35,,134.75,percent of total billed charges,Implant Device,134.75,35,,134.75,percent of total billed charges,Implant Device,134.75,35,,134.75,percent of total billed charges,Implant Device,134.75,35,,134.75,percent of total billed charges,Implant Device,154,40,,154,percent of total billed charges,Implant Device,134.75,70,,134.75,percent of total billed charges,All Other,130.9,34,,130.9,percent of total billed charges,Implant Device,130.9,34,,130.9,percent of total billed charges,Implant Device,134.75,35,,134.75,percent of total billed charges,Implant Device,134.75,35,,134.75,percent of total billed charges,Implant Device,134.75,35,,134.75,percent of total billed charges,Implant Device,134.75,35,,134.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,284.9,
STRYKER 53-27620E LOCK SCREW T7 2.7X20MM,C1713,HCPCS,,79001605,CDM,278,RC,,,both,,,304,224.96,,,224.96,Other,150% of Medicare + 9.63% HCRA Surcharge,136.8,45,,136.8,percent of total billed charges,Critical Access Hospital RCC factor,103.36,34,,103.36,percent of total billed charges,Implant Device,103.36,34,,103.36,percent of total billed charges,Implant Device,103.36,34,,103.36,percent of total billed charges,Implant Device,103.36,34,,103.36,percent of total billed charges,Implant Device,103.36,34,,103.36,percent of total billed charges,Implant Device,150.48,,,150.48,Other,110% of Medicare,106.4,35,,106.4,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,106.4,35,,106.4,percent of total billed charges,Implant Device,106.4,35,,106.4,percent of total billed charges,Implant Device,106.4,35,,106.4,percent of total billed charges,Implant Device,106.4,35,,106.4,percent of total billed charges,Implant Device,106.4,35,,106.4,percent of total billed charges,Implant Device,121.6,40,,121.6,percent of total billed charges,Implant Device,106.4,70,,106.4,percent of total billed charges,All Other,103.36,34,,103.36,percent of total billed charges,Implant Device,103.36,34,,103.36,percent of total billed charges,Implant Device,106.4,35,,106.4,percent of total billed charges,Implant Device,106.4,35,,106.4,percent of total billed charges,Implant Device,106.4,35,,106.4,percent of total billed charges,Implant Device,106.4,35,,106.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,224.96,
LOCKING SCREW T7 2.7MM 22MM,C1713,HCPCS,,79001606,CDM,278,RC,,,both,,,385,284.9,,,284.9,Other,150% of Medicare + 9.63% HCRA Surcharge,173.25,45,,173.25,percent of total billed charges,Critical Access Hospital RCC factor,130.9,34,,130.9,percent of total billed charges,Implant Device,130.9,34,,130.9,percent of total billed charges,Implant Device,130.9,34,,130.9,percent of total billed charges,Implant Device,130.9,34,,130.9,percent of total billed charges,Implant Device,130.9,34,,130.9,percent of total billed charges,Implant Device,190.58,,,190.58,Other,110% of Medicare,134.75,35,,134.75,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,134.75,35,,134.75,percent of total billed charges,Implant Device,134.75,35,,134.75,percent of total billed charges,Implant Device,134.75,35,,134.75,percent of total billed charges,Implant Device,134.75,35,,134.75,percent of total billed charges,Implant Device,134.75,35,,134.75,percent of total billed charges,Implant Device,154,40,,154,percent of total billed charges,Implant Device,134.75,70,,134.75,percent of total billed charges,All Other,130.9,34,,130.9,percent of total billed charges,Implant Device,130.9,34,,130.9,percent of total billed charges,Implant Device,134.75,35,,134.75,percent of total billed charges,Implant Device,134.75,35,,134.75,percent of total billed charges,Implant Device,134.75,35,,134.75,percent of total billed charges,Implant Device,134.75,35,,134.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,284.9,
STRYKER 53-27624E LOCK SCREW T7 2.7X24MM,C1713,HCPCS,,79001607,CDM,278,RC,,,both,,,492,364.08,,,364.08,Other,150% of Medicare + 9.63% HCRA Surcharge,221.4,45,,221.4,percent of total billed charges,Critical Access Hospital RCC factor,167.28,34,,167.28,percent of total billed charges,Implant Device,167.28,34,,167.28,percent of total billed charges,Implant Device,167.28,34,,167.28,percent of total billed charges,Implant Device,167.28,34,,167.28,percent of total billed charges,Implant Device,167.28,34,,167.28,percent of total billed charges,Implant Device,243.54,,,243.54,Other,110% of Medicare,172.2,35,,172.2,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,172.2,35,,172.2,percent of total billed charges,Implant Device,172.2,35,,172.2,percent of total billed charges,Implant Device,172.2,35,,172.2,percent of total billed charges,Implant Device,172.2,35,,172.2,percent of total billed charges,Implant Device,172.2,35,,172.2,percent of total billed charges,Implant Device,196.8,40,,196.8,percent of total billed charges,Implant Device,172.2,70,,172.2,percent of total billed charges,All Other,167.28,34,,167.28,percent of total billed charges,Implant Device,167.28,34,,167.28,percent of total billed charges,Implant Device,172.2,35,,172.2,percent of total billed charges,Implant Device,172.2,35,,172.2,percent of total billed charges,Implant Device,172.2,35,,172.2,percent of total billed charges,Implant Device,172.2,35,,172.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,364.08,
STRYKER 53-27626E LOCK SCREW T7 2.7X26MM,C1713,HCPCS,,79001608,CDM,278,RC,,,both,,,469,347.06,,,347.06,Other,150% of Medicare + 9.63% HCRA Surcharge,211.05,45,,211.05,percent of total billed charges,Critical Access Hospital RCC factor,159.46,34,,159.46,percent of total billed charges,Implant Device,159.46,34,,159.46,percent of total billed charges,Implant Device,159.46,34,,159.46,percent of total billed charges,Implant Device,159.46,34,,159.46,percent of total billed charges,Implant Device,159.46,34,,159.46,percent of total billed charges,Implant Device,232.16,,,232.16,Other,110% of Medicare,164.15,35,,164.15,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,164.15,35,,164.15,percent of total billed charges,Implant Device,164.15,35,,164.15,percent of total billed charges,Implant Device,164.15,35,,164.15,percent of total billed charges,Implant Device,164.15,35,,164.15,percent of total billed charges,Implant Device,164.15,35,,164.15,percent of total billed charges,Implant Device,187.6,40,,187.6,percent of total billed charges,Implant Device,164.15,70,,164.15,percent of total billed charges,All Other,159.46,34,,159.46,percent of total billed charges,Implant Device,159.46,34,,159.46,percent of total billed charges,Implant Device,164.15,35,,164.15,percent of total billed charges,Implant Device,164.15,35,,164.15,percent of total billed charges,Implant Device,164.15,35,,164.15,percent of total billed charges,Implant Device,164.15,35,,164.15,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,347.06,
STRYKER 52-27618E LOCK SCREW T7 2.7X18MM,C1713,HCPCS,,79001609,CDM,278,RC,,,both,,,316,233.84,,,233.84,Other,150% of Medicare + 9.63% HCRA Surcharge,142.2,45,,142.2,percent of total billed charges,Critical Access Hospital RCC factor,107.44,34,,107.44,percent of total billed charges,Implant Device,107.44,34,,107.44,percent of total billed charges,Implant Device,107.44,34,,107.44,percent of total billed charges,Implant Device,107.44,34,,107.44,percent of total billed charges,Implant Device,107.44,34,,107.44,percent of total billed charges,Implant Device,156.42,,,156.42,Other,110% of Medicare,110.6,35,,110.6,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,110.6,35,,110.6,percent of total billed charges,Implant Device,110.6,35,,110.6,percent of total billed charges,Implant Device,110.6,35,,110.6,percent of total billed charges,Implant Device,110.6,35,,110.6,percent of total billed charges,Implant Device,110.6,35,,110.6,percent of total billed charges,Implant Device,126.4,40,,126.4,percent of total billed charges,Implant Device,110.6,70,,110.6,percent of total billed charges,All Other,107.44,34,,107.44,percent of total billed charges,Implant Device,107.44,34,,107.44,percent of total billed charges,Implant Device,110.6,35,,110.6,percent of total billed charges,Implant Device,110.6,35,,110.6,percent of total billed charges,Implant Device,110.6,35,,110.6,percent of total billed charges,Implant Device,110.6,35,,110.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,233.84,
STRYKER 52-27622E LOCK SCREW T7 2.7X22MM,C1713,HCPCS,,79001610,CDM,278,RC,,,both,,,316,233.84,,,233.84,Other,150% of Medicare + 9.63% HCRA Surcharge,142.2,45,,142.2,percent of total billed charges,Critical Access Hospital RCC factor,107.44,34,,107.44,percent of total billed charges,Implant Device,107.44,34,,107.44,percent of total billed charges,Implant Device,107.44,34,,107.44,percent of total billed charges,Implant Device,107.44,34,,107.44,percent of total billed charges,Implant Device,107.44,34,,107.44,percent of total billed charges,Implant Device,156.42,,,156.42,Other,110% of Medicare,110.6,35,,110.6,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,110.6,35,,110.6,percent of total billed charges,Implant Device,110.6,35,,110.6,percent of total billed charges,Implant Device,110.6,35,,110.6,percent of total billed charges,Implant Device,110.6,35,,110.6,percent of total billed charges,Implant Device,110.6,35,,110.6,percent of total billed charges,Implant Device,126.4,40,,126.4,percent of total billed charges,Implant Device,110.6,70,,110.6,percent of total billed charges,All Other,107.44,34,,107.44,percent of total billed charges,Implant Device,107.44,34,,107.44,percent of total billed charges,Implant Device,110.6,35,,110.6,percent of total billed charges,Implant Device,110.6,35,,110.6,percent of total billed charges,Implant Device,110.6,35,,110.6,percent of total billed charges,Implant Device,110.6,35,,110.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,233.84,
LOCKING SCREW T7 2.7MM X 26MM,C1713,HCPCS,,79001611,CDM,278,RC,,,both,,,316,233.84,,,233.84,Other,150% of Medicare + 9.63% HCRA Surcharge,142.2,45,,142.2,percent of total billed charges,Critical Access Hospital RCC factor,107.44,34,,107.44,percent of total billed charges,Implant Device,107.44,34,,107.44,percent of total billed charges,Implant Device,107.44,34,,107.44,percent of total billed charges,Implant Device,107.44,34,,107.44,percent of total billed charges,Implant Device,107.44,34,,107.44,percent of total billed charges,Implant Device,156.42,,,156.42,Other,110% of Medicare,110.6,35,,110.6,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,110.6,35,,110.6,percent of total billed charges,Implant Device,110.6,35,,110.6,percent of total billed charges,Implant Device,110.6,35,,110.6,percent of total billed charges,Implant Device,110.6,35,,110.6,percent of total billed charges,Implant Device,110.6,35,,110.6,percent of total billed charges,Implant Device,126.4,40,,126.4,percent of total billed charges,Implant Device,110.6,70,,110.6,percent of total billed charges,All Other,107.44,34,,107.44,percent of total billed charges,Implant Device,107.44,34,,107.44,percent of total billed charges,Implant Device,110.6,35,,110.6,percent of total billed charges,Implant Device,110.6,35,,110.6,percent of total billed charges,Implant Device,110.6,35,,110.6,percent of total billed charges,Implant Device,110.6,35,,110.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,233.84,
STRYKER 53-17010E LOCKING SCREW 1.7X10MM,C1713,HCPCS,,79001612,CDM,278,RC,,,both,,,513,379.62,,,379.62,Other,150% of Medicare + 9.63% HCRA Surcharge,230.85,45,,230.85,percent of total billed charges,Critical Access Hospital RCC factor,174.42,34,,174.42,percent of total billed charges,Implant Device,174.42,34,,174.42,percent of total billed charges,Implant Device,174.42,34,,174.42,percent of total billed charges,Implant Device,174.42,34,,174.42,percent of total billed charges,Implant Device,174.42,34,,174.42,percent of total billed charges,Implant Device,253.94,,,253.94,Other,110% of Medicare,179.55,35,,179.55,percent of total billed charges,Implant Device,174.42,34,"Charges > $500, x 34%",174.42,percent of total billed charges,Implant Device,179.55,35,,179.55,percent of total billed charges,Implant Device,179.55,35,,179.55,percent of total billed charges,Implant Device,179.55,35,,179.55,percent of total billed charges,Implant Device,179.55,35,,179.55,percent of total billed charges,Implant Device,179.55,35,,179.55,percent of total billed charges,Implant Device,205.2,40,,205.2,percent of total billed charges,Implant Device,179.55,70,,179.55,percent of total billed charges,All Other,174.42,34,,174.42,percent of total billed charges,Implant Device,174.42,34,,174.42,percent of total billed charges,Implant Device,179.55,35,,179.55,percent of total billed charges,Implant Device,179.55,35,,179.55,percent of total billed charges,Implant Device,179.55,35,,179.55,percent of total billed charges,Implant Device,179.55,35,,179.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,379.62,
STRYKER 53-17012E LOCKING SCREW 1.7X12MM,C1713,HCPCS,,79001613,CDM,278,RC,,,both,,,256,189.44,,,189.44,Other,150% of Medicare + 9.63% HCRA Surcharge,115.2,45,,115.2,percent of total billed charges,Critical Access Hospital RCC factor,87.04,34,,87.04,percent of total billed charges,Implant Device,87.04,34,,87.04,percent of total billed charges,Implant Device,87.04,34,,87.04,percent of total billed charges,Implant Device,87.04,34,,87.04,percent of total billed charges,Implant Device,87.04,34,,87.04,percent of total billed charges,Implant Device,126.72,,,126.72,Other,110% of Medicare,89.6,35,,89.6,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,89.6,35,,89.6,percent of total billed charges,Implant Device,89.6,35,,89.6,percent of total billed charges,Implant Device,89.6,35,,89.6,percent of total billed charges,Implant Device,89.6,35,,89.6,percent of total billed charges,Implant Device,89.6,35,,89.6,percent of total billed charges,Implant Device,102.4,40,,102.4,percent of total billed charges,Implant Device,89.6,70,,89.6,percent of total billed charges,All Other,87.04,34,,87.04,percent of total billed charges,Implant Device,87.04,34,,87.04,percent of total billed charges,Implant Device,89.6,35,,89.6,percent of total billed charges,Implant Device,89.6,35,,89.6,percent of total billed charges,Implant Device,89.6,35,,89.6,percent of total billed charges,Implant Device,89.6,35,,89.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,189.44,
BOST SCI 126-531 MARDIS SOFTSTENT 6X22CM,C2617,HCPCS,,79001614,CDM,278,RC,,,both,,,554,409.96,,,409.96,Other,150% of Medicare + 9.63% HCRA Surcharge,249.3,45,,249.3,percent of total billed charges,Critical Access Hospital RCC factor,188.36,34,,188.36,percent of total billed charges,Implant Device,188.36,34,,188.36,percent of total billed charges,Implant Device,188.36,34,,188.36,percent of total billed charges,Implant Device,188.36,34,,188.36,percent of total billed charges,Implant Device,188.36,34,,188.36,percent of total billed charges,Implant Device,274.23,,,274.23,Other,110% of Medicare,193.9,35,,193.9,percent of total billed charges,Implant Device,188.36,34,"Charges > $500, x 34%",188.36,percent of total billed charges,Implant Device,193.9,35,,193.9,percent of total billed charges,Implant Device,193.9,35,,193.9,percent of total billed charges,Implant Device,193.9,35,,193.9,percent of total billed charges,Implant Device,193.9,35,,193.9,percent of total billed charges,Implant Device,193.9,35,,193.9,percent of total billed charges,Implant Device,221.6,40,,221.6,percent of total billed charges,Implant Device,193.9,70,,193.9,percent of total billed charges,All Other,188.36,34,,188.36,percent of total billed charges,Implant Device,188.36,34,,188.36,percent of total billed charges,Implant Device,193.9,35,,193.9,percent of total billed charges,Implant Device,193.9,35,,193.9,percent of total billed charges,Implant Device,193.9,35,,193.9,percent of total billed charges,Implant Device,193.9,35,,193.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,409.96,
BOST SCI 126-533 MARDIS SOFTSTENT 6X26CM,C2617,HCPCS,,79001615,CDM,278,RC,,,both,,,617,456.58,,,456.58,Other,150% of Medicare + 9.63% HCRA Surcharge,277.65,45,,277.65,percent of total billed charges,Critical Access Hospital RCC factor,209.78,34,,209.78,percent of total billed charges,Implant Device,209.78,34,,209.78,percent of total billed charges,Implant Device,209.78,34,,209.78,percent of total billed charges,Implant Device,209.78,34,,209.78,percent of total billed charges,Implant Device,209.78,34,,209.78,percent of total billed charges,Implant Device,305.42,,,305.42,Other,110% of Medicare,215.95,35,,215.95,percent of total billed charges,Implant Device,209.78,34,"Charges > $500, x 34%",209.78,percent of total billed charges,Implant Device,215.95,35,,215.95,percent of total billed charges,Implant Device,215.95,35,,215.95,percent of total billed charges,Implant Device,215.95,35,,215.95,percent of total billed charges,Implant Device,215.95,35,,215.95,percent of total billed charges,Implant Device,215.95,35,,215.95,percent of total billed charges,Implant Device,246.8,40,,246.8,percent of total billed charges,Implant Device,215.95,70,,215.95,percent of total billed charges,All Other,209.78,34,,209.78,percent of total billed charges,Implant Device,209.78,34,,209.78,percent of total billed charges,Implant Device,215.95,35,,215.95,percent of total billed charges,Implant Device,215.95,35,,215.95,percent of total billed charges,Implant Device,215.95,35,,215.95,percent of total billed charges,Implant Device,215.95,35,,215.95,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,456.58,
BOST SCI 126-534 MARDIS SOFTSTENT 6X28CM,C2617,HCPCS,,79001616,CDM,278,RC,,,both,,,554,409.96,,,409.96,Other,150% of Medicare + 9.63% HCRA Surcharge,249.3,45,,249.3,percent of total billed charges,Critical Access Hospital RCC factor,188.36,34,,188.36,percent of total billed charges,Implant Device,188.36,34,,188.36,percent of total billed charges,Implant Device,188.36,34,,188.36,percent of total billed charges,Implant Device,188.36,34,,188.36,percent of total billed charges,Implant Device,188.36,34,,188.36,percent of total billed charges,Implant Device,274.23,,,274.23,Other,110% of Medicare,193.9,35,,193.9,percent of total billed charges,Implant Device,188.36,34,"Charges > $500, x 34%",188.36,percent of total billed charges,Implant Device,193.9,35,,193.9,percent of total billed charges,Implant Device,193.9,35,,193.9,percent of total billed charges,Implant Device,193.9,35,,193.9,percent of total billed charges,Implant Device,193.9,35,,193.9,percent of total billed charges,Implant Device,193.9,35,,193.9,percent of total billed charges,Implant Device,221.6,40,,221.6,percent of total billed charges,Implant Device,193.9,70,,193.9,percent of total billed charges,All Other,188.36,34,,188.36,percent of total billed charges,Implant Device,188.36,34,,188.36,percent of total billed charges,Implant Device,193.9,35,,193.9,percent of total billed charges,Implant Device,193.9,35,,193.9,percent of total billed charges,Implant Device,193.9,35,,193.9,percent of total billed charges,Implant Device,193.9,35,,193.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,409.96,
BOST SCI 126-532 MARDIS SOFTSTENT 6X24CM,C2617,HCPCS,,79001617,CDM,278,RC,,,both,,,626,463.24,,,463.24,Other,150% of Medicare + 9.63% HCRA Surcharge,281.7,45,,281.7,percent of total billed charges,Critical Access Hospital RCC factor,212.84,34,,212.84,percent of total billed charges,Implant Device,212.84,34,,212.84,percent of total billed charges,Implant Device,212.84,34,,212.84,percent of total billed charges,Implant Device,212.84,34,,212.84,percent of total billed charges,Implant Device,212.84,34,,212.84,percent of total billed charges,Implant Device,309.87,,,309.87,Other,110% of Medicare,219.1,35,,219.1,percent of total billed charges,Implant Device,212.84,34,"Charges > $500, x 34%",212.84,percent of total billed charges,Implant Device,219.1,35,,219.1,percent of total billed charges,Implant Device,219.1,35,,219.1,percent of total billed charges,Implant Device,219.1,35,,219.1,percent of total billed charges,Implant Device,219.1,35,,219.1,percent of total billed charges,Implant Device,219.1,35,,219.1,percent of total billed charges,Implant Device,250.4,40,,250.4,percent of total billed charges,Implant Device,219.1,70,,219.1,percent of total billed charges,All Other,212.84,34,,212.84,percent of total billed charges,Implant Device,212.84,34,,212.84,percent of total billed charges,Implant Device,219.1,35,,219.1,percent of total billed charges,Implant Device,219.1,35,,219.1,percent of total billed charges,Implant Device,219.1,35,,219.1,percent of total billed charges,Implant Device,219.1,35,,219.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,463.24,
BOST SCI 126-553 MARDIS SOFTSTENT 8X26CM,C2617,HCPCS,,79001618,CDM,278,RC,,,both,,,553,409.22,,,409.22,Other,150% of Medicare + 9.63% HCRA Surcharge,248.85,45,,248.85,percent of total billed charges,Critical Access Hospital RCC factor,188.02,34,,188.02,percent of total billed charges,Implant Device,188.02,34,,188.02,percent of total billed charges,Implant Device,188.02,34,,188.02,percent of total billed charges,Implant Device,188.02,34,,188.02,percent of total billed charges,Implant Device,188.02,34,,188.02,percent of total billed charges,Implant Device,273.74,,,273.74,Other,110% of Medicare,193.55,35,,193.55,percent of total billed charges,Implant Device,188.02,34,"Charges > $500, x 34%",188.02,percent of total billed charges,Implant Device,193.55,35,,193.55,percent of total billed charges,Implant Device,193.55,35,,193.55,percent of total billed charges,Implant Device,193.55,35,,193.55,percent of total billed charges,Implant Device,193.55,35,,193.55,percent of total billed charges,Implant Device,193.55,35,,193.55,percent of total billed charges,Implant Device,221.2,40,,221.2,percent of total billed charges,Implant Device,193.55,70,,193.55,percent of total billed charges,All Other,188.02,34,,188.02,percent of total billed charges,Implant Device,188.02,34,,188.02,percent of total billed charges,Implant Device,193.55,35,,193.55,percent of total billed charges,Implant Device,193.55,35,,193.55,percent of total billed charges,Implant Device,193.55,35,,193.55,percent of total billed charges,Implant Device,193.55,35,,193.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,409.22,
ATRIUM 1000204-00 MESH PROLITE POLY 2X4,C1781,HCPCS,,79001619,CDM,278,RC,,,both,,,457,338.18,,,338.18,Other,150% of Medicare + 9.63% HCRA Surcharge,205.65,45,,205.65,percent of total billed charges,Critical Access Hospital RCC factor,155.38,34,,155.38,percent of total billed charges,Implant Device,155.38,34,,155.38,percent of total billed charges,Implant Device,155.38,34,,155.38,percent of total billed charges,Implant Device,155.38,34,,155.38,percent of total billed charges,Implant Device,155.38,34,,155.38,percent of total billed charges,Implant Device,226.22,,,226.22,Other,110% of Medicare,159.95,35,,159.95,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,159.95,35,,159.95,percent of total billed charges,Implant Device,159.95,35,,159.95,percent of total billed charges,Implant Device,159.95,35,,159.95,percent of total billed charges,Implant Device,159.95,35,,159.95,percent of total billed charges,Implant Device,159.95,35,,159.95,percent of total billed charges,Implant Device,182.8,40,,182.8,percent of total billed charges,Implant Device,159.95,70,,159.95,percent of total billed charges,All Other,155.38,34,,155.38,percent of total billed charges,Implant Device,155.38,34,,155.38,percent of total billed charges,Implant Device,159.95,35,,159.95,percent of total billed charges,Implant Device,159.95,35,,159.95,percent of total billed charges,Implant Device,159.95,35,,159.95,percent of total billed charges,Implant Device,159.95,35,,159.95,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,338.18,
J&J 212867 MICRO ANCHOR W/CUTTING,C1713,HCPCS,,79001620,CDM,278,RC,,,both,,,970,717.8,,,717.8,Other,150% of Medicare + 9.63% HCRA Surcharge,436.5,45,,436.5,percent of total billed charges,Critical Access Hospital RCC factor,329.8,34,,329.8,percent of total billed charges,Implant Device,329.8,34,,329.8,percent of total billed charges,Implant Device,329.8,34,,329.8,percent of total billed charges,Implant Device,329.8,34,,329.8,percent of total billed charges,Implant Device,329.8,34,,329.8,percent of total billed charges,Implant Device,480.15,,,480.15,Other,110% of Medicare,339.5,35,,339.5,percent of total billed charges,Implant Device,329.8,34,"Charges > $500, x 34%",329.8,percent of total billed charges,Implant Device,339.5,35,,339.5,percent of total billed charges,Implant Device,339.5,35,,339.5,percent of total billed charges,Implant Device,339.5,35,,339.5,percent of total billed charges,Implant Device,339.5,35,,339.5,percent of total billed charges,Implant Device,339.5,35,,339.5,percent of total billed charges,Implant Device,388,40,,388,percent of total billed charges,Implant Device,339.5,70,,339.5,percent of total billed charges,All Other,329.8,34,,329.8,percent of total billed charges,Implant Device,329.8,34,,329.8,percent of total billed charges,Implant Device,339.5,35,,339.5,percent of total billed charges,Implant Device,339.5,35,,339.5,percent of total billed charges,Implant Device,339.5,35,,339.5,percent of total billed charges,Implant Device,339.5,35,,339.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,717.8,
J&J 212033 MINI QUICK ANCHOR,C1713,HCPCS,,79001621,CDM,278,RC,,,both,,,1068,790.32,,,790.32,Other,150% of Medicare + 9.63% HCRA Surcharge,480.6,45,,480.6,percent of total billed charges,Critical Access Hospital RCC factor,363.12,34,,363.12,percent of total billed charges,Implant Device,363.12,34,,363.12,percent of total billed charges,Implant Device,363.12,34,,363.12,percent of total billed charges,Implant Device,363.12,34,,363.12,percent of total billed charges,Implant Device,363.12,34,,363.12,percent of total billed charges,Implant Device,528.66,,,528.66,Other,110% of Medicare,373.8,35,,373.8,percent of total billed charges,Implant Device,363.12,34,"Charges > $500, x 34%",363.12,percent of total billed charges,Implant Device,373.8,35,,373.8,percent of total billed charges,Implant Device,373.8,35,,373.8,percent of total billed charges,Implant Device,373.8,35,,373.8,percent of total billed charges,Implant Device,373.8,35,,373.8,percent of total billed charges,Implant Device,373.8,35,,373.8,percent of total billed charges,Implant Device,427.2,40,,427.2,percent of total billed charges,Implant Device,373.8,70,,373.8,percent of total billed charges,All Other,363.12,34,,363.12,percent of total billed charges,Implant Device,363.12,34,,363.12,percent of total billed charges,Implant Device,373.8,35,,373.8,percent of total billed charges,Implant Device,373.8,35,,373.8,percent of total billed charges,Implant Device,373.8,35,,373.8,percent of total billed charges,Implant Device,373.8,35,,373.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,790.32,
ZIMMER 400500-38 MOORE HIP 1 1/2 38MM,C1776,HCPCS,,79001622,CDM,278,RC,,,both,,,2987,2210.39,,,2210.39,Other,150% of Medicare + 9.63% HCRA Surcharge,1344.15,45,,1344.15,percent of total billed charges,Critical Access Hospital RCC factor,1015.58,34,,1015.58,percent of total billed charges,Implant Device,1015.58,34,,1015.58,percent of total billed charges,Implant Device,1015.58,34,,1015.58,percent of total billed charges,Implant Device,1015.58,34,,1015.58,percent of total billed charges,Implant Device,1015.58,34,,1015.58,percent of total billed charges,Implant Device,1478.57,,,1478.57,Other,110% of Medicare,1045.45,35,,1045.45,percent of total billed charges,Implant Device,1015.58,34,"Charges > $500, x 34%",1015.58,percent of total billed charges,Implant Device,1045.45,35,,1045.45,percent of total billed charges,Implant Device,1045.45,35,,1045.45,percent of total billed charges,Implant Device,1045.45,35,,1045.45,percent of total billed charges,Implant Device,1045.45,35,,1045.45,percent of total billed charges,Implant Device,1045.45,35,,1045.45,percent of total billed charges,Implant Device,1194.8,40,,1194.8,percent of total billed charges,Implant Device,1045.45,70,,1045.45,percent of total billed charges,All Other,1015.58,34,,1015.58,percent of total billed charges,Implant Device,1015.58,34,,1015.58,percent of total billed charges,Implant Device,1045.45,35,,1045.45,percent of total billed charges,Implant Device,1045.45,35,,1045.45,percent of total billed charges,Implant Device,1045.45,35,,1045.45,percent of total billed charges,Implant Device,1045.45,35,,1045.45,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1015.58,34,"If Charge > 2,000, then 34 percent",1015.58,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2210.39,
ZIMMER 400500-46 MOORE HIP 1 13/16 46MM,C1776,HCPCS,,79001623,CDM,278,RC,,,both,,,2987,2210.39,,,2210.39,Other,150% of Medicare + 9.63% HCRA Surcharge,1344.15,45,,1344.15,percent of total billed charges,Critical Access Hospital RCC factor,1015.58,34,,1015.58,percent of total billed charges,Implant Device,1015.58,34,,1015.58,percent of total billed charges,Implant Device,1015.58,34,,1015.58,percent of total billed charges,Implant Device,1015.58,34,,1015.58,percent of total billed charges,Implant Device,1015.58,34,,1015.58,percent of total billed charges,Implant Device,1478.57,,,1478.57,Other,110% of Medicare,1045.45,35,,1045.45,percent of total billed charges,Implant Device,1015.58,34,"Charges > $500, x 34%",1015.58,percent of total billed charges,Implant Device,1045.45,35,,1045.45,percent of total billed charges,Implant Device,1045.45,35,,1045.45,percent of total billed charges,Implant Device,1045.45,35,,1045.45,percent of total billed charges,Implant Device,1045.45,35,,1045.45,percent of total billed charges,Implant Device,1045.45,35,,1045.45,percent of total billed charges,Implant Device,1194.8,40,,1194.8,percent of total billed charges,Implant Device,1045.45,70,,1045.45,percent of total billed charges,All Other,1015.58,34,,1015.58,percent of total billed charges,Implant Device,1015.58,34,,1015.58,percent of total billed charges,Implant Device,1045.45,35,,1045.45,percent of total billed charges,Implant Device,1045.45,35,,1045.45,percent of total billed charges,Implant Device,1045.45,35,,1045.45,percent of total billed charges,Implant Device,1045.45,35,,1045.45,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1015.58,34,"If Charge > 2,000, then 34 percent",1015.58,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2210.39,
ZIMMER 400500-49 MOORE HIP 1 15/16 49MM,C1776,HCPCS,,79001624,CDM,278,RC,,,both,,,2987,2210.39,,,2210.39,Other,150% of Medicare + 9.63% HCRA Surcharge,1344.15,45,,1344.15,percent of total billed charges,Critical Access Hospital RCC factor,1015.58,34,,1015.58,percent of total billed charges,Implant Device,1015.58,34,,1015.58,percent of total billed charges,Implant Device,1015.58,34,,1015.58,percent of total billed charges,Implant Device,1015.58,34,,1015.58,percent of total billed charges,Implant Device,1015.58,34,,1015.58,percent of total billed charges,Implant Device,1478.57,,,1478.57,Other,110% of Medicare,1045.45,35,,1045.45,percent of total billed charges,Implant Device,1015.58,34,"Charges > $500, x 34%",1015.58,percent of total billed charges,Implant Device,1045.45,35,,1045.45,percent of total billed charges,Implant Device,1045.45,35,,1045.45,percent of total billed charges,Implant Device,1045.45,35,,1045.45,percent of total billed charges,Implant Device,1045.45,35,,1045.45,percent of total billed charges,Implant Device,1045.45,35,,1045.45,percent of total billed charges,Implant Device,1194.8,40,,1194.8,percent of total billed charges,Implant Device,1045.45,70,,1045.45,percent of total billed charges,All Other,1015.58,34,,1015.58,percent of total billed charges,Implant Device,1015.58,34,,1015.58,percent of total billed charges,Implant Device,1045.45,35,,1045.45,percent of total billed charges,Implant Device,1045.45,35,,1045.45,percent of total billed charges,Implant Device,1045.45,35,,1045.45,percent of total billed charges,Implant Device,1045.45,35,,1045.45,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1015.58,34,"If Charge > 2,000, then 34 percent",1015.58,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2210.39,
ZIMMER 400500-42 MOORE HIP 1 21/32 42MM,C1776,HCPCS,,79001625,CDM,278,RC,,,both,,,2987,2210.39,,,2210.39,Other,150% of Medicare + 9.63% HCRA Surcharge,1344.15,45,,1344.15,percent of total billed charges,Critical Access Hospital RCC factor,1015.58,34,,1015.58,percent of total billed charges,Implant Device,1015.58,34,,1015.58,percent of total billed charges,Implant Device,1015.58,34,,1015.58,percent of total billed charges,Implant Device,1015.58,34,,1015.58,percent of total billed charges,Implant Device,1015.58,34,,1015.58,percent of total billed charges,Implant Device,1478.57,,,1478.57,Other,110% of Medicare,1045.45,35,,1045.45,percent of total billed charges,Implant Device,1015.58,34,"Charges > $500, x 34%",1015.58,percent of total billed charges,Implant Device,1045.45,35,,1045.45,percent of total billed charges,Implant Device,1045.45,35,,1045.45,percent of total billed charges,Implant Device,1045.45,35,,1045.45,percent of total billed charges,Implant Device,1045.45,35,,1045.45,percent of total billed charges,Implant Device,1045.45,35,,1045.45,percent of total billed charges,Implant Device,1194.8,40,,1194.8,percent of total billed charges,Implant Device,1045.45,70,,1045.45,percent of total billed charges,All Other,1015.58,34,,1015.58,percent of total billed charges,Implant Device,1015.58,34,,1015.58,percent of total billed charges,Implant Device,1045.45,35,,1045.45,percent of total billed charges,Implant Device,1045.45,35,,1045.45,percent of total billed charges,Implant Device,1045.45,35,,1045.45,percent of total billed charges,Implant Device,1045.45,35,,1045.45,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1015.58,34,"If Charge > 2,000, then 34 percent",1015.58,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2210.39,
ZIMMER 400500-44 MOORE HIP 1 3/4 44MM,C1776,HCPCS,,79001626,CDM,278,RC,,,both,,,3847,2846.79,,,2846.79,Other,150% of Medicare + 9.63% HCRA Surcharge,1731.15,45,,1731.15,percent of total billed charges,Critical Access Hospital RCC factor,1307.98,34,,1307.98,percent of total billed charges,Implant Device,1307.98,34,,1307.98,percent of total billed charges,Implant Device,1307.98,34,,1307.98,percent of total billed charges,Implant Device,1307.98,34,,1307.98,percent of total billed charges,Implant Device,1307.98,34,,1307.98,percent of total billed charges,Implant Device,1904.27,,,1904.27,Other,110% of Medicare,1346.45,35,,1346.45,percent of total billed charges,Implant Device,1307.98,34,"Charges > $500, x 34%",1307.98,percent of total billed charges,Implant Device,1346.45,35,,1346.45,percent of total billed charges,Implant Device,1346.45,35,,1346.45,percent of total billed charges,Implant Device,1346.45,35,,1346.45,percent of total billed charges,Implant Device,1346.45,35,,1346.45,percent of total billed charges,Implant Device,1346.45,35,,1346.45,percent of total billed charges,Implant Device,1538.8,40,,1538.8,percent of total billed charges,Implant Device,1346.45,70,,1346.45,percent of total billed charges,All Other,1307.98,34,,1307.98,percent of total billed charges,Implant Device,1307.98,34,,1307.98,percent of total billed charges,Implant Device,1346.45,35,,1346.45,percent of total billed charges,Implant Device,1346.45,35,,1346.45,percent of total billed charges,Implant Device,1346.45,35,,1346.45,percent of total billed charges,Implant Device,1346.45,35,,1346.45,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1307.98,34,"If Charge > 2,000, then 34 percent",1307.98,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2846.79,
ZIMMER 400500-41 MOORE HIP 1 5/8 41MM,C1776,HCPCS,,79001627,CDM,278,RC,,,both,,,2987,2210.39,,,2210.39,Other,150% of Medicare + 9.63% HCRA Surcharge,1344.15,45,,1344.15,percent of total billed charges,Critical Access Hospital RCC factor,1015.58,34,,1015.58,percent of total billed charges,Implant Device,1015.58,34,,1015.58,percent of total billed charges,Implant Device,1015.58,34,,1015.58,percent of total billed charges,Implant Device,1015.58,34,,1015.58,percent of total billed charges,Implant Device,1015.58,34,,1015.58,percent of total billed charges,Implant Device,1478.57,,,1478.57,Other,110% of Medicare,1045.45,35,,1045.45,percent of total billed charges,Implant Device,1015.58,34,"Charges > $500, x 34%",1015.58,percent of total billed charges,Implant Device,1045.45,35,,1045.45,percent of total billed charges,Implant Device,1045.45,35,,1045.45,percent of total billed charges,Implant Device,1045.45,35,,1045.45,percent of total billed charges,Implant Device,1045.45,35,,1045.45,percent of total billed charges,Implant Device,1045.45,35,,1045.45,percent of total billed charges,Implant Device,1194.8,40,,1194.8,percent of total billed charges,Implant Device,1045.45,70,,1045.45,percent of total billed charges,All Other,1015.58,34,,1015.58,percent of total billed charges,Implant Device,1015.58,34,,1015.58,percent of total billed charges,Implant Device,1045.45,35,,1045.45,percent of total billed charges,Implant Device,1045.45,35,,1045.45,percent of total billed charges,Implant Device,1045.45,35,,1045.45,percent of total billed charges,Implant Device,1045.45,35,,1045.45,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1015.58,34,"If Charge > 2,000, then 34 percent",1015.58,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2210.39,
ZIMMER 400500-48 MOORE HIP 1 7/8 48MM,C1776,HCPCS,,79001628,CDM,278,RC,,,both,,,3790,2804.61,,,2804.61,Other,150% of Medicare + 9.63% HCRA Surcharge,1705.5,45,,1705.5,percent of total billed charges,Critical Access Hospital RCC factor,1288.6,34,,1288.6,percent of total billed charges,Implant Device,1288.6,34,,1288.6,percent of total billed charges,Implant Device,1288.6,34,,1288.6,percent of total billed charges,Implant Device,1288.6,34,,1288.6,percent of total billed charges,Implant Device,1288.6,34,,1288.6,percent of total billed charges,Implant Device,1876.05,,,1876.05,Other,110% of Medicare,1326.5,35,,1326.5,percent of total billed charges,Implant Device,1288.6,34,"Charges > $500, x 34%",1288.6,percent of total billed charges,Implant Device,1326.5,35,,1326.5,percent of total billed charges,Implant Device,1326.5,35,,1326.5,percent of total billed charges,Implant Device,1326.5,35,,1326.5,percent of total billed charges,Implant Device,1326.5,35,,1326.5,percent of total billed charges,Implant Device,1326.5,35,,1326.5,percent of total billed charges,Implant Device,1516,40,,1516,percent of total billed charges,Implant Device,1326.5,70,,1326.5,percent of total billed charges,All Other,1288.6,34,,1288.6,percent of total billed charges,Implant Device,1288.6,34,,1288.6,percent of total billed charges,Implant Device,1326.5,35,,1326.5,percent of total billed charges,Implant Device,1326.5,35,,1326.5,percent of total billed charges,Implant Device,1326.5,35,,1326.5,percent of total billed charges,Implant Device,1326.5,35,,1326.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1288.6,34,"If Charge > 2,000, then 34 percent",1288.6,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2804.61,
ZIMMER 400500-40 MOORE HIP 1 9/16 40MM,C1776,HCPCS,,79001629,CDM,278,RC,,,both,,,2987,2210.39,,,2210.39,Other,150% of Medicare + 9.63% HCRA Surcharge,1344.15,45,,1344.15,percent of total billed charges,Critical Access Hospital RCC factor,1015.58,34,,1015.58,percent of total billed charges,Implant Device,1015.58,34,,1015.58,percent of total billed charges,Implant Device,1015.58,34,,1015.58,percent of total billed charges,Implant Device,1015.58,34,,1015.58,percent of total billed charges,Implant Device,1015.58,34,,1015.58,percent of total billed charges,Implant Device,1478.57,,,1478.57,Other,110% of Medicare,1045.45,35,,1045.45,percent of total billed charges,Implant Device,1015.58,34,"Charges > $500, x 34%",1015.58,percent of total billed charges,Implant Device,1045.45,35,,1045.45,percent of total billed charges,Implant Device,1045.45,35,,1045.45,percent of total billed charges,Implant Device,1045.45,35,,1045.45,percent of total billed charges,Implant Device,1045.45,35,,1045.45,percent of total billed charges,Implant Device,1045.45,35,,1045.45,percent of total billed charges,Implant Device,1194.8,40,,1194.8,percent of total billed charges,Implant Device,1045.45,70,,1045.45,percent of total billed charges,All Other,1015.58,34,,1015.58,percent of total billed charges,Implant Device,1015.58,34,,1015.58,percent of total billed charges,Implant Device,1045.45,35,,1045.45,percent of total billed charges,Implant Device,1045.45,35,,1045.45,percent of total billed charges,Implant Device,1045.45,35,,1045.45,percent of total billed charges,Implant Device,1045.45,35,,1045.45,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1015.58,34,"If Charge > 2,000, then 34 percent",1015.58,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2210.39,
ZIMMER 4005-00-51 MOORE HIP 51MM,C1776,HCPCS,,79001630,CDM,278,RC,,,both,,,3136,2320.65,,,2320.65,Other,150% of Medicare + 9.63% HCRA Surcharge,1411.2,45,,1411.2,percent of total billed charges,Critical Access Hospital RCC factor,1066.24,34,,1066.24,percent of total billed charges,Implant Device,1066.24,34,,1066.24,percent of total billed charges,Implant Device,1066.24,34,,1066.24,percent of total billed charges,Implant Device,1066.24,34,,1066.24,percent of total billed charges,Implant Device,1066.24,34,,1066.24,percent of total billed charges,Implant Device,1552.32,,,1552.32,Other,110% of Medicare,1097.6,35,,1097.6,percent of total billed charges,Implant Device,1066.24,34,"Charges > $500, x 34%",1066.24,percent of total billed charges,Implant Device,1097.6,35,,1097.6,percent of total billed charges,Implant Device,1097.6,35,,1097.6,percent of total billed charges,Implant Device,1097.6,35,,1097.6,percent of total billed charges,Implant Device,1097.6,35,,1097.6,percent of total billed charges,Implant Device,1097.6,35,,1097.6,percent of total billed charges,Implant Device,1254.4,40,,1254.4,percent of total billed charges,Implant Device,1097.6,70,,1097.6,percent of total billed charges,All Other,1066.24,34,,1066.24,percent of total billed charges,Implant Device,1066.24,34,,1066.24,percent of total billed charges,Implant Device,1097.6,35,,1097.6,percent of total billed charges,Implant Device,1097.6,35,,1097.6,percent of total billed charges,Implant Device,1097.6,35,,1097.6,percent of total billed charges,Implant Device,1097.6,35,,1097.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1066.24,34,"If Charge > 2,000, then 34 percent",1066.24,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2320.65,
ZIMMER 4005-00-57 MOORE HIP 57MM,C1776,HCPCS,,79001631,CDM,278,RC,,,both,,,2987,2210.39,,,2210.39,Other,150% of Medicare + 9.63% HCRA Surcharge,1344.15,45,,1344.15,percent of total billed charges,Critical Access Hospital RCC factor,1015.58,34,,1015.58,percent of total billed charges,Implant Device,1015.58,34,,1015.58,percent of total billed charges,Implant Device,1015.58,34,,1015.58,percent of total billed charges,Implant Device,1015.58,34,,1015.58,percent of total billed charges,Implant Device,1015.58,34,,1015.58,percent of total billed charges,Implant Device,1478.57,,,1478.57,Other,110% of Medicare,1045.45,35,,1045.45,percent of total billed charges,Implant Device,1015.58,34,"Charges > $500, x 34%",1015.58,percent of total billed charges,Implant Device,1045.45,35,,1045.45,percent of total billed charges,Implant Device,1045.45,35,,1045.45,percent of total billed charges,Implant Device,1045.45,35,,1045.45,percent of total billed charges,Implant Device,1045.45,35,,1045.45,percent of total billed charges,Implant Device,1045.45,35,,1045.45,percent of total billed charges,Implant Device,1194.8,40,,1194.8,percent of total billed charges,Implant Device,1045.45,70,,1045.45,percent of total billed charges,All Other,1015.58,34,,1015.58,percent of total billed charges,Implant Device,1015.58,34,,1015.58,percent of total billed charges,Implant Device,1045.45,35,,1045.45,percent of total billed charges,Implant Device,1045.45,35,,1045.45,percent of total billed charges,Implant Device,1045.45,35,,1045.45,percent of total billed charges,Implant Device,1045.45,35,,1045.45,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1015.58,34,"If Charge > 2,000, then 34 percent",1015.58,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2210.39,
BIOMET 1312-18-600 OLECRANON PLATE SMALL,C1713,HCPCS,,79001632,CDM,278,RC,,,both,,,4620,3418.81,,,3418.81,Other,150% of Medicare + 9.63% HCRA Surcharge,2079,45,,2079,percent of total billed charges,Critical Access Hospital RCC factor,1570.8,34,,1570.8,percent of total billed charges,Implant Device,1570.8,34,,1570.8,percent of total billed charges,Implant Device,1570.8,34,,1570.8,percent of total billed charges,Implant Device,1570.8,34,,1570.8,percent of total billed charges,Implant Device,1570.8,34,,1570.8,percent of total billed charges,Implant Device,2286.9,,,2286.9,Other,110% of Medicare,1617,35,,1617,percent of total billed charges,Implant Device,1570.8,34,"Charges > $500, x 34%",1570.8,percent of total billed charges,Implant Device,1617,35,,1617,percent of total billed charges,Implant Device,1617,35,,1617,percent of total billed charges,Implant Device,1617,35,,1617,percent of total billed charges,Implant Device,1617,35,,1617,percent of total billed charges,Implant Device,1617,35,,1617,percent of total billed charges,Implant Device,1848,40,,1848,percent of total billed charges,Implant Device,1617,70,,1617,percent of total billed charges,All Other,1570.8,34,,1570.8,percent of total billed charges,Implant Device,1570.8,34,,1570.8,percent of total billed charges,Implant Device,1617,35,,1617,percent of total billed charges,Implant Device,1617,35,,1617,percent of total billed charges,Implant Device,1617,35,,1617,percent of total billed charges,Implant Device,1617,35,,1617,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1570.8,34,"If Charge > 2,000, then 34 percent",1570.8,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3418.81,
DEPUY 84-1052 ORTHOSORB,C1713,HCPCS,,79001633,CDM,278,RC,,,both,,,2940,2175.61,,,2175.61,Other,150% of Medicare + 9.63% HCRA Surcharge,1323,45,,1323,percent of total billed charges,Critical Access Hospital RCC factor,999.6,34,,999.6,percent of total billed charges,Implant Device,999.6,34,,999.6,percent of total billed charges,Implant Device,999.6,34,,999.6,percent of total billed charges,Implant Device,999.6,34,,999.6,percent of total billed charges,Implant Device,999.6,34,,999.6,percent of total billed charges,Implant Device,1455.3,,,1455.3,Other,110% of Medicare,1029,35,,1029,percent of total billed charges,Implant Device,999.6,34,"Charges > $500, x 34%",999.6,percent of total billed charges,Implant Device,1029,35,,1029,percent of total billed charges,Implant Device,1029,35,,1029,percent of total billed charges,Implant Device,1029,35,,1029,percent of total billed charges,Implant Device,1029,35,,1029,percent of total billed charges,Implant Device,1029,35,,1029,percent of total billed charges,Implant Device,1176,40,,1176,percent of total billed charges,Implant Device,1029,70,,1029,percent of total billed charges,All Other,999.6,34,,999.6,percent of total billed charges,Implant Device,999.6,34,,999.6,percent of total billed charges,Implant Device,1029,35,,1029,percent of total billed charges,Implant Device,1029,35,,1029,percent of total billed charges,Implant Device,1029,35,,1029,percent of total billed charges,Implant Device,1029,35,,1029,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,999.6,34,"If Charge > 2,000, then 34 percent",999.6,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2175.61,
DEPUY 84-1070 ORTHOSORB W/KNIFE,C1713,HCPCS,,79001634,CDM,278,RC,,,both,,,870,643.8,,,643.8,Other,150% of Medicare + 9.63% HCRA Surcharge,391.5,45,,391.5,percent of total billed charges,Critical Access Hospital RCC factor,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,430.65,,,430.65,Other,110% of Medicare,304.5,35,,304.5,percent of total billed charges,Implant Device,295.8,34,"Charges > $500, x 34%",295.8,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,348,40,,348,percent of total billed charges,Implant Device,304.5,70,,304.5,percent of total billed charges,All Other,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,643.8,
BIOSTRUCTURES OMCS10 OSTEOMATRX COLLAGEN,C9359,HCPCS,,79001635,CDM,278,RC,,,both,,,4800,3552.01,,,3552.01,Other,150% of Medicare + 9.63% HCRA Surcharge,2160,45,,2160,percent of total billed charges,Critical Access Hospital RCC factor,1632,34,,1632,percent of total billed charges,Implant Device,1632,34,,1632,percent of total billed charges,Implant Device,1632,34,,1632,percent of total billed charges,Implant Device,1632,34,,1632,percent of total billed charges,Implant Device,1632,34,,1632,percent of total billed charges,Implant Device,2376,,,2376,Other,110% of Medicare,1680,35,,1680,percent of total billed charges,Implant Device,1632,34,"Charges > $500, x 34%",1632,percent of total billed charges,Implant Device,1680,35,,1680,percent of total billed charges,Implant Device,1680,35,,1680,percent of total billed charges,Implant Device,1680,35,,1680,percent of total billed charges,Implant Device,1680,35,,1680,percent of total billed charges,Implant Device,1680,35,,1680,percent of total billed charges,Implant Device,1920,40,,1920,percent of total billed charges,Implant Device,1680,70,,1680,percent of total billed charges,All Other,1632,34,,1632,percent of total billed charges,Implant Device,1632,34,,1632,percent of total billed charges,Implant Device,1680,35,,1680,percent of total billed charges,Implant Device,1680,35,,1680,percent of total billed charges,Implant Device,1680,35,,1680,percent of total billed charges,Implant Device,1680,35,,1680,percent of total billed charges,Implant Device,976.07,,,976.07,Other,100% of Medicaid,976.07,,,976.07,Other,100% of Medicaid,976.07,,,976.07,Other,100% of Medicaid,976.07,,,976.07,Other,100% of Medicaid,2196.15,,,2196.15,Other,225% of Medicaid,1493.38,,,1493.38,Other,153% of Medicaid,2196.15,,,2196.15,Other,225% of Medicaid,1366.49,,,1366.49,Other,140% of Medicaid,1632,34,"If Charge > 2,000, then 34 percent",1632,percent of total billed charges,Implants,2537.77,,,2537.77,Other,260% of Medicaid,3162.45,,,3162.45,Other,324% of Medicaid,2098.54,,,2098.54,Other,215% of Medicaid,2098.54,,,2098.54,Other,215% of Medicaid,1220.08,,,1220.08,Other,125% of Medicaid,976.07,3552.01,
ZIMMER 00-1112-140-01 PALACOS R,C1713,HCPCS,,79001636,CDM,278,RC,,,both,,,210,155.4,,,155.4,Other,150% of Medicare + 9.63% HCRA Surcharge,94.5,45,,94.5,percent of total billed charges,Critical Access Hospital RCC factor,71.4,34,,71.4,percent of total billed charges,Implant Device,71.4,34,,71.4,percent of total billed charges,Implant Device,71.4,34,,71.4,percent of total billed charges,Implant Device,71.4,34,,71.4,percent of total billed charges,Implant Device,71.4,34,,71.4,percent of total billed charges,Implant Device,103.95,,,103.95,Other,110% of Medicare,73.5,35,,73.5,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,73.5,35,,73.5,percent of total billed charges,Implant Device,73.5,35,,73.5,percent of total billed charges,Implant Device,73.5,35,,73.5,percent of total billed charges,Implant Device,73.5,35,,73.5,percent of total billed charges,Implant Device,73.5,35,,73.5,percent of total billed charges,Implant Device,84,40,,84,percent of total billed charges,Implant Device,73.5,70,,73.5,percent of total billed charges,All Other,71.4,34,,71.4,percent of total billed charges,Implant Device,71.4,34,,71.4,percent of total billed charges,Implant Device,73.5,35,,73.5,percent of total billed charges,Implant Device,73.5,35,,73.5,percent of total billed charges,Implant Device,73.5,35,,73.5,percent of total billed charges,Implant Device,73.5,35,,73.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,155.4,
ZIMMER 00-1113-140-01 PALACOS R PLUS,C1713,HCPCS,,79001637,CDM,278,RC,,,both,,,825,610.5,,,610.5,Other,150% of Medicare + 9.63% HCRA Surcharge,371.25,45,,371.25,percent of total billed charges,Critical Access Hospital RCC factor,280.5,34,,280.5,percent of total billed charges,Implant Device,280.5,34,,280.5,percent of total billed charges,Implant Device,280.5,34,,280.5,percent of total billed charges,Implant Device,280.5,34,,280.5,percent of total billed charges,Implant Device,280.5,34,,280.5,percent of total billed charges,Implant Device,408.38,,,408.38,Other,110% of Medicare,288.75,35,,288.75,percent of total billed charges,Implant Device,280.5,34,"Charges > $500, x 34%",280.5,percent of total billed charges,Implant Device,288.75,35,,288.75,percent of total billed charges,Implant Device,288.75,35,,288.75,percent of total billed charges,Implant Device,288.75,35,,288.75,percent of total billed charges,Implant Device,288.75,35,,288.75,percent of total billed charges,Implant Device,288.75,35,,288.75,percent of total billed charges,Implant Device,330,40,,330,percent of total billed charges,Implant Device,288.75,70,,288.75,percent of total billed charges,All Other,280.5,34,,280.5,percent of total billed charges,Implant Device,280.5,34,,280.5,percent of total billed charges,Implant Device,288.75,35,,288.75,percent of total billed charges,Implant Device,288.75,35,,288.75,percent of total billed charges,Implant Device,288.75,35,,288.75,percent of total billed charges,Implant Device,288.75,35,,288.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,610.5,
J&J 210725 PANALOK 3.5 ABSORBABLE ANCHOR,C1713,HCPCS,,79001638,CDM,278,RC,,,both,,,1122,830.28,,,830.28,Other,150% of Medicare + 9.63% HCRA Surcharge,504.9,45,,504.9,percent of total billed charges,Critical Access Hospital RCC factor,381.48,34,,381.48,percent of total billed charges,Implant Device,381.48,34,,381.48,percent of total billed charges,Implant Device,381.48,34,,381.48,percent of total billed charges,Implant Device,381.48,34,,381.48,percent of total billed charges,Implant Device,381.48,34,,381.48,percent of total billed charges,Implant Device,555.39,,,555.39,Other,110% of Medicare,392.7,35,,392.7,percent of total billed charges,Implant Device,381.48,34,"Charges > $500, x 34%",381.48,percent of total billed charges,Implant Device,392.7,35,,392.7,percent of total billed charges,Implant Device,392.7,35,,392.7,percent of total billed charges,Implant Device,392.7,35,,392.7,percent of total billed charges,Implant Device,392.7,35,,392.7,percent of total billed charges,Implant Device,392.7,35,,392.7,percent of total billed charges,Implant Device,448.8,40,,448.8,percent of total billed charges,Implant Device,392.7,70,,392.7,percent of total billed charges,All Other,381.48,34,,381.48,percent of total billed charges,Implant Device,381.48,34,,381.48,percent of total billed charges,Implant Device,392.7,35,,392.7,percent of total billed charges,Implant Device,392.7,35,,392.7,percent of total billed charges,Implant Device,392.7,35,,392.7,percent of total billed charges,Implant Device,392.7,35,,392.7,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,830.28,
J&J 212730 PANALOK RC QUICK,C1713,HCPCS,,79001639,CDM,278,RC,,,both,,,1050,777,,,777,Other,150% of Medicare + 9.63% HCRA Surcharge,472.5,45,,472.5,percent of total billed charges,Critical Access Hospital RCC factor,357,34,,357,percent of total billed charges,Implant Device,357,34,,357,percent of total billed charges,Implant Device,357,34,,357,percent of total billed charges,Implant Device,357,34,,357,percent of total billed charges,Implant Device,357,34,,357,percent of total billed charges,Implant Device,519.75,,,519.75,Other,110% of Medicare,367.5,35,,367.5,percent of total billed charges,Implant Device,357,34,"Charges > $500, x 34%",357,percent of total billed charges,Implant Device,367.5,35,,367.5,percent of total billed charges,Implant Device,367.5,35,,367.5,percent of total billed charges,Implant Device,367.5,35,,367.5,percent of total billed charges,Implant Device,367.5,35,,367.5,percent of total billed charges,Implant Device,367.5,35,,367.5,percent of total billed charges,Implant Device,420,40,,420,percent of total billed charges,Implant Device,367.5,70,,367.5,percent of total billed charges,All Other,357,34,,357,percent of total billed charges,Implant Device,357,34,,357,percent of total billed charges,Implant Device,367.5,35,,367.5,percent of total billed charges,Implant Device,367.5,35,,367.5,percent of total billed charges,Implant Device,367.5,35,,367.5,percent of total billed charges,Implant Device,367.5,35,,367.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,777,
ARTHREX AR-1927PSF-45 PEEK 4.5 FTS,C1713,HCPCS,,79001640,CDM,278,RC,,,both,,,856,633.44,,,633.44,Other,150% of Medicare + 9.63% HCRA Surcharge,385.2,45,,385.2,percent of total billed charges,Critical Access Hospital RCC factor,291.04,34,,291.04,percent of total billed charges,Implant Device,291.04,34,,291.04,percent of total billed charges,Implant Device,291.04,34,,291.04,percent of total billed charges,Implant Device,291.04,34,,291.04,percent of total billed charges,Implant Device,291.04,34,,291.04,percent of total billed charges,Implant Device,423.72,,,423.72,Other,110% of Medicare,299.6,35,,299.6,percent of total billed charges,Implant Device,291.04,34,"Charges > $500, x 34%",291.04,percent of total billed charges,Implant Device,299.6,35,,299.6,percent of total billed charges,Implant Device,299.6,35,,299.6,percent of total billed charges,Implant Device,299.6,35,,299.6,percent of total billed charges,Implant Device,299.6,35,,299.6,percent of total billed charges,Implant Device,299.6,35,,299.6,percent of total billed charges,Implant Device,342.4,40,,342.4,percent of total billed charges,Implant Device,299.6,70,,299.6,percent of total billed charges,All Other,291.04,34,,291.04,percent of total billed charges,Implant Device,291.04,34,,291.04,percent of total billed charges,Implant Device,299.6,35,,299.6,percent of total billed charges,Implant Device,299.6,35,,299.6,percent of total billed charges,Implant Device,299.6,35,,299.6,percent of total billed charges,Implant Device,299.6,35,,299.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,633.44,
BIOMET SP12000 PEG SCREW 2.5X12MM,C1713,HCPCS,,79001641,CDM,278,RC,,,both,,,510,377.4,,,377.4,Other,150% of Medicare + 9.63% HCRA Surcharge,229.5,45,,229.5,percent of total billed charges,Critical Access Hospital RCC factor,173.4,34,,173.4,percent of total billed charges,Implant Device,173.4,34,,173.4,percent of total billed charges,Implant Device,173.4,34,,173.4,percent of total billed charges,Implant Device,173.4,34,,173.4,percent of total billed charges,Implant Device,173.4,34,,173.4,percent of total billed charges,Implant Device,252.45,,,252.45,Other,110% of Medicare,178.5,35,,178.5,percent of total billed charges,Implant Device,173.4,34,"Charges > $500, x 34%",173.4,percent of total billed charges,Implant Device,178.5,35,,178.5,percent of total billed charges,Implant Device,178.5,35,,178.5,percent of total billed charges,Implant Device,178.5,35,,178.5,percent of total billed charges,Implant Device,178.5,35,,178.5,percent of total billed charges,Implant Device,178.5,35,,178.5,percent of total billed charges,Implant Device,204,40,,204,percent of total billed charges,Implant Device,178.5,70,,178.5,percent of total billed charges,All Other,173.4,34,,173.4,percent of total billed charges,Implant Device,173.4,34,,173.4,percent of total billed charges,Implant Device,178.5,35,,178.5,percent of total billed charges,Implant Device,178.5,35,,178.5,percent of total billed charges,Implant Device,178.5,35,,178.5,percent of total billed charges,Implant Device,178.5,35,,178.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,377.4,
BIOMET SP14000 PEG SCREW 2.5X14MM,C1713,HCPCS,,79001642,CDM,278,RC,,,both,,,288,213.12,,,213.12,Other,150% of Medicare + 9.63% HCRA Surcharge,129.6,45,,129.6,percent of total billed charges,Critical Access Hospital RCC factor,97.92,34,,97.92,percent of total billed charges,Implant Device,97.92,34,,97.92,percent of total billed charges,Implant Device,97.92,34,,97.92,percent of total billed charges,Implant Device,97.92,34,,97.92,percent of total billed charges,Implant Device,97.92,34,,97.92,percent of total billed charges,Implant Device,142.56,,,142.56,Other,110% of Medicare,100.8,35,,100.8,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,100.8,35,,100.8,percent of total billed charges,Implant Device,100.8,35,,100.8,percent of total billed charges,Implant Device,100.8,35,,100.8,percent of total billed charges,Implant Device,100.8,35,,100.8,percent of total billed charges,Implant Device,100.8,35,,100.8,percent of total billed charges,Implant Device,115.2,40,,115.2,percent of total billed charges,Implant Device,100.8,70,,100.8,percent of total billed charges,All Other,97.92,34,,97.92,percent of total billed charges,Implant Device,97.92,34,,97.92,percent of total billed charges,Implant Device,100.8,35,,100.8,percent of total billed charges,Implant Device,100.8,35,,100.8,percent of total billed charges,Implant Device,100.8,35,,100.8,percent of total billed charges,Implant Device,100.8,35,,100.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,213.12,
BIOMET SP24000 PEG SCREW 2.5X24MM,C1713,HCPCS,,79001643,CDM,278,RC,,,both,,,420,310.8,,,310.8,Other,150% of Medicare + 9.63% HCRA Surcharge,189,45,,189,percent of total billed charges,Critical Access Hospital RCC factor,142.8,34,,142.8,percent of total billed charges,Implant Device,142.8,34,,142.8,percent of total billed charges,Implant Device,142.8,34,,142.8,percent of total billed charges,Implant Device,142.8,34,,142.8,percent of total billed charges,Implant Device,142.8,34,,142.8,percent of total billed charges,Implant Device,207.9,,,207.9,Other,110% of Medicare,147,35,,147,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,147,35,,147,percent of total billed charges,Implant Device,147,35,,147,percent of total billed charges,Implant Device,147,35,,147,percent of total billed charges,Implant Device,147,35,,147,percent of total billed charges,Implant Device,147,35,,147,percent of total billed charges,Implant Device,168,40,,168,percent of total billed charges,Implant Device,147,70,,147,percent of total billed charges,All Other,142.8,34,,142.8,percent of total billed charges,Implant Device,142.8,34,,142.8,percent of total billed charges,Implant Device,147,35,,147,percent of total billed charges,Implant Device,147,35,,147,percent of total billed charges,Implant Device,147,35,,147,percent of total billed charges,Implant Device,147,35,,147,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,310.8,
BIOMET SP28000 PEG SCREW 2.5X28MM,C1713,HCPCS,,79001644,CDM,278,RC,,,both,,,420,310.8,,,310.8,Other,150% of Medicare + 9.63% HCRA Surcharge,189,45,,189,percent of total billed charges,Critical Access Hospital RCC factor,142.8,34,,142.8,percent of total billed charges,Implant Device,142.8,34,,142.8,percent of total billed charges,Implant Device,142.8,34,,142.8,percent of total billed charges,Implant Device,142.8,34,,142.8,percent of total billed charges,Implant Device,142.8,34,,142.8,percent of total billed charges,Implant Device,207.9,,,207.9,Other,110% of Medicare,147,35,,147,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,147,35,,147,percent of total billed charges,Implant Device,147,35,,147,percent of total billed charges,Implant Device,147,35,,147,percent of total billed charges,Implant Device,147,35,,147,percent of total billed charges,Implant Device,147,35,,147,percent of total billed charges,Implant Device,168,40,,168,percent of total billed charges,Implant Device,147,70,,147,percent of total billed charges,All Other,142.8,34,,142.8,percent of total billed charges,Implant Device,142.8,34,,142.8,percent of total billed charges,Implant Device,147,35,,147,percent of total billed charges,Implant Device,147,35,,147,percent of total billed charges,Implant Device,147,35,,147,percent of total billed charges,Implant Device,147,35,,147,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,310.8,
ARROW CS-15282-SPM PERMACATH 23CM,C1750,HCPCS,,79001645,CDM,278,RC,,,both,,,1177,870.98,,,870.98,Other,150% of Medicare + 9.63% HCRA Surcharge,529.65,45,,529.65,percent of total billed charges,Critical Access Hospital RCC factor,400.18,34,,400.18,percent of total billed charges,Implant Device,400.18,34,,400.18,percent of total billed charges,Implant Device,400.18,34,,400.18,percent of total billed charges,Implant Device,400.18,34,,400.18,percent of total billed charges,Implant Device,400.18,34,,400.18,percent of total billed charges,Implant Device,582.62,,,582.62,Other,110% of Medicare,411.95,35,,411.95,percent of total billed charges,Implant Device,400.18,34,"Charges > $500, x 34%",400.18,percent of total billed charges,Implant Device,411.95,35,,411.95,percent of total billed charges,Implant Device,411.95,35,,411.95,percent of total billed charges,Implant Device,411.95,35,,411.95,percent of total billed charges,Implant Device,411.95,35,,411.95,percent of total billed charges,Implant Device,411.95,35,,411.95,percent of total billed charges,Implant Device,470.8,40,,470.8,percent of total billed charges,Implant Device,411.95,70,,411.95,percent of total billed charges,All Other,400.18,34,,400.18,percent of total billed charges,Implant Device,400.18,34,,400.18,percent of total billed charges,Implant Device,411.95,35,,411.95,percent of total billed charges,Implant Device,411.95,35,,411.95,percent of total billed charges,Implant Device,411.95,35,,411.95,percent of total billed charges,Implant Device,411.95,35,,411.95,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,870.98,
ARROW CS-15232-X PERMACATH NEXTSTEP 23CM,C1750,HCPCS,,79001646,CDM,278,RC,,,both,,,902,667.48,,,667.48,Other,150% of Medicare + 9.63% HCRA Surcharge,405.9,45,,405.9,percent of total billed charges,Critical Access Hospital RCC factor,306.68,34,,306.68,percent of total billed charges,Implant Device,306.68,34,,306.68,percent of total billed charges,Implant Device,306.68,34,,306.68,percent of total billed charges,Implant Device,306.68,34,,306.68,percent of total billed charges,Implant Device,306.68,34,,306.68,percent of total billed charges,Implant Device,446.49,,,446.49,Other,110% of Medicare,315.7,35,,315.7,percent of total billed charges,Implant Device,306.68,34,"Charges > $500, x 34%",306.68,percent of total billed charges,Implant Device,315.7,35,,315.7,percent of total billed charges,Implant Device,315.7,35,,315.7,percent of total billed charges,Implant Device,315.7,35,,315.7,percent of total billed charges,Implant Device,315.7,35,,315.7,percent of total billed charges,Implant Device,315.7,35,,315.7,percent of total billed charges,Implant Device,360.8,40,,360.8,percent of total billed charges,Implant Device,315.7,70,,315.7,percent of total billed charges,All Other,306.68,34,,306.68,percent of total billed charges,Implant Device,306.68,34,,306.68,percent of total billed charges,Implant Device,315.7,35,,315.7,percent of total billed charges,Implant Device,315.7,35,,315.7,percent of total billed charges,Implant Device,315.7,35,,315.7,percent of total billed charges,Implant Device,315.7,35,,315.7,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,667.48,
US SURG P101010 PERMACOL COLLAGEN 10X10,C1781,HCPCS,,79001647,CDM,278,RC,,,both,,,6490,4802.62,,,4802.62,Other,150% of Medicare + 9.63% HCRA Surcharge,2920.5,45,,2920.5,percent of total billed charges,Critical Access Hospital RCC factor,2206.6,34,,2206.6,percent of total billed charges,Implant Device,2206.6,34,,2206.6,percent of total billed charges,Implant Device,2206.6,34,,2206.6,percent of total billed charges,Implant Device,2206.6,34,,2206.6,percent of total billed charges,Implant Device,2206.6,34,,2206.6,percent of total billed charges,Implant Device,3212.55,,,3212.55,Other,110% of Medicare,2271.5,35,,2271.5,percent of total billed charges,Implant Device,2206.6,34,"Charges > $500, x 34%",2206.6,percent of total billed charges,Implant Device,2271.5,35,,2271.5,percent of total billed charges,Implant Device,2271.5,35,,2271.5,percent of total billed charges,Implant Device,2271.5,35,,2271.5,percent of total billed charges,Implant Device,2271.5,35,,2271.5,percent of total billed charges,Implant Device,2271.5,35,,2271.5,percent of total billed charges,Implant Device,2596,40,,2596,percent of total billed charges,Implant Device,2271.5,70,,2271.5,percent of total billed charges,All Other,2206.6,34,,2206.6,percent of total billed charges,Implant Device,2206.6,34,,2206.6,percent of total billed charges,Implant Device,2271.5,35,,2271.5,percent of total billed charges,Implant Device,2271.5,35,,2271.5,percent of total billed charges,Implant Device,2271.5,35,,2271.5,percent of total billed charges,Implant Device,2271.5,35,,2271.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2206.6,34,"If Charge > 2,000, then 34 percent",2206.6,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4802.62,
SUTURE EXPRESS 101010 PERMACOL IMPLANT,C1781,HCPCS,,79001648,CDM,278,RC,,,both,,,6667,4933.6,,,4933.6,Other,150% of Medicare + 9.63% HCRA Surcharge,3000.15,45,,3000.15,percent of total billed charges,Critical Access Hospital RCC factor,2266.78,34,,2266.78,percent of total billed charges,Implant Device,2266.78,34,,2266.78,percent of total billed charges,Implant Device,2266.78,34,,2266.78,percent of total billed charges,Implant Device,2266.78,34,,2266.78,percent of total billed charges,Implant Device,2266.78,34,,2266.78,percent of total billed charges,Implant Device,3300.17,,,3300.17,Other,110% of Medicare,2333.45,35,,2333.45,percent of total billed charges,Implant Device,2266.78,34,"Charges > $500, x 34%",2266.78,percent of total billed charges,Implant Device,2333.45,35,,2333.45,percent of total billed charges,Implant Device,2333.45,35,,2333.45,percent of total billed charges,Implant Device,2333.45,35,,2333.45,percent of total billed charges,Implant Device,2333.45,35,,2333.45,percent of total billed charges,Implant Device,2333.45,35,,2333.45,percent of total billed charges,Implant Device,2666.8,40,,2666.8,percent of total billed charges,Implant Device,2333.45,70,,2333.45,percent of total billed charges,All Other,2266.78,34,,2266.78,percent of total billed charges,Implant Device,2266.78,34,,2266.78,percent of total billed charges,Implant Device,2333.45,35,,2333.45,percent of total billed charges,Implant Device,2333.45,35,,2333.45,percent of total billed charges,Implant Device,2333.45,35,,2333.45,percent of total billed charges,Implant Device,2333.45,35,,2333.45,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2266.78,34,"If Charge > 2,000, then 34 percent",2266.78,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4933.6,
BIOMET 14355-7 PLATE  3.5MM 7 HOLE,C1713,HCPCS,,79001649,CDM,278,RC,,,both,,,450,333,,,333,Other,150% of Medicare + 9.63% HCRA Surcharge,202.5,45,,202.5,percent of total billed charges,Critical Access Hospital RCC factor,153,34,,153,percent of total billed charges,Implant Device,153,34,,153,percent of total billed charges,Implant Device,153,34,,153,percent of total billed charges,Implant Device,153,34,,153,percent of total billed charges,Implant Device,153,34,,153,percent of total billed charges,Implant Device,222.75,,,222.75,Other,110% of Medicare,157.5,35,,157.5,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,157.5,35,,157.5,percent of total billed charges,Implant Device,157.5,35,,157.5,percent of total billed charges,Implant Device,157.5,35,,157.5,percent of total billed charges,Implant Device,157.5,35,,157.5,percent of total billed charges,Implant Device,157.5,35,,157.5,percent of total billed charges,Implant Device,180,40,,180,percent of total billed charges,Implant Device,157.5,70,,157.5,percent of total billed charges,All Other,153,34,,153,percent of total billed charges,Implant Device,153,34,,153,percent of total billed charges,Implant Device,157.5,35,,157.5,percent of total billed charges,Implant Device,157.5,35,,157.5,percent of total billed charges,Implant Device,157.5,35,,157.5,percent of total billed charges,Implant Device,157.5,35,,157.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,333,
BIOMET 14355-2 PLATE 3.5MM 2 HOLE,C1713,HCPCS,,79001650,CDM,278,RC,,,both,,,360,266.4,,,266.4,Other,150% of Medicare + 9.63% HCRA Surcharge,162,45,,162,percent of total billed charges,Critical Access Hospital RCC factor,122.4,34,,122.4,percent of total billed charges,Implant Device,122.4,34,,122.4,percent of total billed charges,Implant Device,122.4,34,,122.4,percent of total billed charges,Implant Device,122.4,34,,122.4,percent of total billed charges,Implant Device,122.4,34,,122.4,percent of total billed charges,Implant Device,178.2,,,178.2,Other,110% of Medicare,126,35,,126,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,126,35,,126,percent of total billed charges,Implant Device,126,35,,126,percent of total billed charges,Implant Device,126,35,,126,percent of total billed charges,Implant Device,126,35,,126,percent of total billed charges,Implant Device,126,35,,126,percent of total billed charges,Implant Device,144,40,,144,percent of total billed charges,Implant Device,126,70,,126,percent of total billed charges,All Other,122.4,34,,122.4,percent of total billed charges,Implant Device,122.4,34,,122.4,percent of total billed charges,Implant Device,126,35,,126,percent of total billed charges,Implant Device,126,35,,126,percent of total billed charges,Implant Device,126,35,,126,percent of total billed charges,Implant Device,126,35,,126,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,266.4,
BIOMET 14355-3 PLATE 3.5MM 3 HOLE,C1713,HCPCS,,79001651,CDM,278,RC,,,both,,,360,266.4,,,266.4,Other,150% of Medicare + 9.63% HCRA Surcharge,162,45,,162,percent of total billed charges,Critical Access Hospital RCC factor,122.4,34,,122.4,percent of total billed charges,Implant Device,122.4,34,,122.4,percent of total billed charges,Implant Device,122.4,34,,122.4,percent of total billed charges,Implant Device,122.4,34,,122.4,percent of total billed charges,Implant Device,122.4,34,,122.4,percent of total billed charges,Implant Device,178.2,,,178.2,Other,110% of Medicare,126,35,,126,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,126,35,,126,percent of total billed charges,Implant Device,126,35,,126,percent of total billed charges,Implant Device,126,35,,126,percent of total billed charges,Implant Device,126,35,,126,percent of total billed charges,Implant Device,126,35,,126,percent of total billed charges,Implant Device,144,40,,144,percent of total billed charges,Implant Device,126,70,,126,percent of total billed charges,All Other,122.4,34,,122.4,percent of total billed charges,Implant Device,122.4,34,,122.4,percent of total billed charges,Implant Device,126,35,,126,percent of total billed charges,Implant Device,126,35,,126,percent of total billed charges,Implant Device,126,35,,126,percent of total billed charges,Implant Device,126,35,,126,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,266.4,
BIOMET 14355-5 PLATE 3.5MM 5 HOLE,C1713,HCPCS,,79001652,CDM,278,RC,,,both,,,360,266.4,,,266.4,Other,150% of Medicare + 9.63% HCRA Surcharge,162,45,,162,percent of total billed charges,Critical Access Hospital RCC factor,122.4,34,,122.4,percent of total billed charges,Implant Device,122.4,34,,122.4,percent of total billed charges,Implant Device,122.4,34,,122.4,percent of total billed charges,Implant Device,122.4,34,,122.4,percent of total billed charges,Implant Device,122.4,34,,122.4,percent of total billed charges,Implant Device,178.2,,,178.2,Other,110% of Medicare,126,35,,126,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,126,35,,126,percent of total billed charges,Implant Device,126,35,,126,percent of total billed charges,Implant Device,126,35,,126,percent of total billed charges,Implant Device,126,35,,126,percent of total billed charges,Implant Device,126,35,,126,percent of total billed charges,Implant Device,144,40,,144,percent of total billed charges,Implant Device,126,70,,126,percent of total billed charges,All Other,122.4,34,,122.4,percent of total billed charges,Implant Device,122.4,34,,122.4,percent of total billed charges,Implant Device,126,35,,126,percent of total billed charges,Implant Device,126,35,,126,percent of total billed charges,Implant Device,126,35,,126,percent of total billed charges,Implant Device,126,35,,126,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,266.4,
BIOMET 14355-6 PLATE 3.5MM 6 HOLE,C1713,HCPCS,,79001653,CDM,278,RC,,,both,,,450,333,,,333,Other,150% of Medicare + 9.63% HCRA Surcharge,202.5,45,,202.5,percent of total billed charges,Critical Access Hospital RCC factor,153,34,,153,percent of total billed charges,Implant Device,153,34,,153,percent of total billed charges,Implant Device,153,34,,153,percent of total billed charges,Implant Device,153,34,,153,percent of total billed charges,Implant Device,153,34,,153,percent of total billed charges,Implant Device,222.75,,,222.75,Other,110% of Medicare,157.5,35,,157.5,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,157.5,35,,157.5,percent of total billed charges,Implant Device,157.5,35,,157.5,percent of total billed charges,Implant Device,157.5,35,,157.5,percent of total billed charges,Implant Device,157.5,35,,157.5,percent of total billed charges,Implant Device,157.5,35,,157.5,percent of total billed charges,Implant Device,180,40,,180,percent of total billed charges,Implant Device,157.5,70,,157.5,percent of total billed charges,All Other,153,34,,153,percent of total billed charges,Implant Device,153,34,,153,percent of total billed charges,Implant Device,157.5,35,,157.5,percent of total billed charges,Implant Device,157.5,35,,157.5,percent of total billed charges,Implant Device,157.5,35,,157.5,percent of total billed charges,Implant Device,157.5,35,,157.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,333,
STRYKER 57-05292 PLATE 1.7X4 2 HOLE,C1713,HCPCS,,79001654,CDM,278,RC,,,both,,,1480,1095.2,,,1095.2,Other,150% of Medicare + 9.63% HCRA Surcharge,666,45,,666,percent of total billed charges,Critical Access Hospital RCC factor,503.2,34,,503.2,percent of total billed charges,Implant Device,503.2,34,,503.2,percent of total billed charges,Implant Device,503.2,34,,503.2,percent of total billed charges,Implant Device,503.2,34,,503.2,percent of total billed charges,Implant Device,503.2,34,,503.2,percent of total billed charges,Implant Device,732.6,,,732.6,Other,110% of Medicare,518,35,,518,percent of total billed charges,Implant Device,503.2,34,"Charges > $500, x 34%",503.2,percent of total billed charges,Implant Device,518,35,,518,percent of total billed charges,Implant Device,518,35,,518,percent of total billed charges,Implant Device,518,35,,518,percent of total billed charges,Implant Device,518,35,,518,percent of total billed charges,Implant Device,518,35,,518,percent of total billed charges,Implant Device,592,40,,592,percent of total billed charges,Implant Device,518,70,,518,percent of total billed charges,All Other,503.2,34,,503.2,percent of total billed charges,Implant Device,503.2,34,,503.2,percent of total billed charges,Implant Device,518,35,,518,percent of total billed charges,Implant Device,518,35,,518,percent of total billed charges,Implant Device,518,35,,518,percent of total billed charges,Implant Device,518,35,,518,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1095.2,
STRYKER 57-05270 PLATE 1.7MM 7 HOLE,C1713,HCPCS,,79001655,CDM,278,RC,,,both,,,786,581.64,,,581.64,Other,150% of Medicare + 9.63% HCRA Surcharge,353.7,45,,353.7,percent of total billed charges,Critical Access Hospital RCC factor,267.24,34,,267.24,percent of total billed charges,Implant Device,267.24,34,,267.24,percent of total billed charges,Implant Device,267.24,34,,267.24,percent of total billed charges,Implant Device,267.24,34,,267.24,percent of total billed charges,Implant Device,267.24,34,,267.24,percent of total billed charges,Implant Device,389.07,,,389.07,Other,110% of Medicare,275.1,35,,275.1,percent of total billed charges,Implant Device,267.24,34,"Charges > $500, x 34%",267.24,percent of total billed charges,Implant Device,275.1,35,,275.1,percent of total billed charges,Implant Device,275.1,35,,275.1,percent of total billed charges,Implant Device,275.1,35,,275.1,percent of total billed charges,Implant Device,275.1,35,,275.1,percent of total billed charges,Implant Device,275.1,35,,275.1,percent of total billed charges,Implant Device,314.4,40,,314.4,percent of total billed charges,Implant Device,275.1,70,,275.1,percent of total billed charges,All Other,267.24,34,,267.24,percent of total billed charges,Implant Device,267.24,34,,267.24,percent of total billed charges,Implant Device,275.1,35,,275.1,percent of total billed charges,Implant Device,275.1,35,,275.1,percent of total billed charges,Implant Device,275.1,35,,275.1,percent of total billed charges,Implant Device,275.1,35,,275.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,581.64,
BIOMET 1989478 PLATE 2 HOLE STRAIGHT LG,C1713,HCPCS,,79001656,CDM,278,RC,,,both,,,142,105.08,,,105.08,Other,150% of Medicare + 9.63% HCRA Surcharge,63.9,45,,63.9,percent of total billed charges,Critical Access Hospital RCC factor,48.28,34,,48.28,percent of total billed charges,Implant Device,48.28,34,,48.28,percent of total billed charges,Implant Device,48.28,34,,48.28,percent of total billed charges,Implant Device,48.28,34,,48.28,percent of total billed charges,Implant Device,48.28,34,,48.28,percent of total billed charges,Implant Device,70.29,,,70.29,Other,110% of Medicare,49.7,35,,49.7,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,49.7,35,,49.7,percent of total billed charges,Implant Device,49.7,35,,49.7,percent of total billed charges,Implant Device,49.7,35,,49.7,percent of total billed charges,Implant Device,49.7,35,,49.7,percent of total billed charges,Implant Device,49.7,35,,49.7,percent of total billed charges,Implant Device,56.8,40,,56.8,percent of total billed charges,Implant Device,49.7,70,,49.7,percent of total billed charges,All Other,48.28,34,,48.28,percent of total billed charges,Implant Device,48.28,34,,48.28,percent of total billed charges,Implant Device,49.7,35,,49.7,percent of total billed charges,Implant Device,49.7,35,,49.7,percent of total billed charges,Implant Device,49.7,35,,49.7,percent of total billed charges,Implant Device,49.7,35,,49.7,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,105.08,
BIOMET 1988748 PLATE 2 HOLE STRAIGHT MED,C1713,HCPCS,,79001657,CDM,278,RC,,,both,,,142,105.08,,,105.08,Other,150% of Medicare + 9.63% HCRA Surcharge,63.9,45,,63.9,percent of total billed charges,Critical Access Hospital RCC factor,48.28,34,,48.28,percent of total billed charges,Implant Device,48.28,34,,48.28,percent of total billed charges,Implant Device,48.28,34,,48.28,percent of total billed charges,Implant Device,48.28,34,,48.28,percent of total billed charges,Implant Device,48.28,34,,48.28,percent of total billed charges,Implant Device,70.29,,,70.29,Other,110% of Medicare,49.7,35,,49.7,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,49.7,35,,49.7,percent of total billed charges,Implant Device,49.7,35,,49.7,percent of total billed charges,Implant Device,49.7,35,,49.7,percent of total billed charges,Implant Device,49.7,35,,49.7,percent of total billed charges,Implant Device,49.7,35,,49.7,percent of total billed charges,Implant Device,56.8,40,,56.8,percent of total billed charges,Implant Device,49.7,70,,49.7,percent of total billed charges,All Other,48.28,34,,48.28,percent of total billed charges,Implant Device,48.28,34,,48.28,percent of total billed charges,Implant Device,49.7,35,,49.7,percent of total billed charges,Implant Device,49.7,35,,49.7,percent of total billed charges,Implant Device,49.7,35,,49.7,percent of total billed charges,Implant Device,49.7,35,,49.7,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,105.08,
BIOMET 1912411 PLATE 2X3 MATRIX RECTANGL,C1713,HCPCS,,79001658,CDM,278,RC,,,both,,,574,424.76,,,424.76,Other,150% of Medicare + 9.63% HCRA Surcharge,258.3,45,,258.3,percent of total billed charges,Critical Access Hospital RCC factor,195.16,34,,195.16,percent of total billed charges,Implant Device,195.16,34,,195.16,percent of total billed charges,Implant Device,195.16,34,,195.16,percent of total billed charges,Implant Device,195.16,34,,195.16,percent of total billed charges,Implant Device,195.16,34,,195.16,percent of total billed charges,Implant Device,284.13,,,284.13,Other,110% of Medicare,200.9,35,,200.9,percent of total billed charges,Implant Device,195.16,34,"Charges > $500, x 34%",195.16,percent of total billed charges,Implant Device,200.9,35,,200.9,percent of total billed charges,Implant Device,200.9,35,,200.9,percent of total billed charges,Implant Device,200.9,35,,200.9,percent of total billed charges,Implant Device,200.9,35,,200.9,percent of total billed charges,Implant Device,200.9,35,,200.9,percent of total billed charges,Implant Device,229.6,40,,229.6,percent of total billed charges,Implant Device,200.9,70,,200.9,percent of total billed charges,All Other,195.16,34,,195.16,percent of total billed charges,Implant Device,195.16,34,,195.16,percent of total billed charges,Implant Device,200.9,35,,200.9,percent of total billed charges,Implant Device,200.9,35,,200.9,percent of total billed charges,Implant Device,200.9,35,,200.9,percent of total billed charges,Implant Device,200.9,35,,200.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,424.76,
STRYKER 57-10192 PLATE 2.3X4 2 HOLE,C1713,HCPCS,,79001659,CDM,278,RC,,,both,,,1385,1024.9,,,1024.9,Other,150% of Medicare + 9.63% HCRA Surcharge,623.25,45,,623.25,percent of total billed charges,Critical Access Hospital RCC factor,470.9,34,,470.9,percent of total billed charges,Implant Device,470.9,34,,470.9,percent of total billed charges,Implant Device,470.9,34,,470.9,percent of total billed charges,Implant Device,470.9,34,,470.9,percent of total billed charges,Implant Device,470.9,34,,470.9,percent of total billed charges,Implant Device,685.58,,,685.58,Other,110% of Medicare,484.75,35,,484.75,percent of total billed charges,Implant Device,470.9,34,"Charges > $500, x 34%",470.9,percent of total billed charges,Implant Device,484.75,35,,484.75,percent of total billed charges,Implant Device,484.75,35,,484.75,percent of total billed charges,Implant Device,484.75,35,,484.75,percent of total billed charges,Implant Device,484.75,35,,484.75,percent of total billed charges,Implant Device,484.75,35,,484.75,percent of total billed charges,Implant Device,554,40,,554,percent of total billed charges,Implant Device,484.75,70,,484.75,percent of total billed charges,All Other,470.9,34,,470.9,percent of total billed charges,Implant Device,470.9,34,,470.9,percent of total billed charges,Implant Device,484.75,35,,484.75,percent of total billed charges,Implant Device,484.75,35,,484.75,percent of total billed charges,Implant Device,484.75,35,,484.75,percent of total billed charges,Implant Device,484.75,35,,484.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1024.9,
STRYKER 57-10185 PLATE 2.3MM 5 HOLES,C1713,HCPCS,,79001660,CDM,278,RC,,,both,,,1612,1192.88,,,1192.88,Other,150% of Medicare + 9.63% HCRA Surcharge,725.4,45,,725.4,percent of total billed charges,Critical Access Hospital RCC factor,548.08,34,,548.08,percent of total billed charges,Implant Device,548.08,34,,548.08,percent of total billed charges,Implant Device,548.08,34,,548.08,percent of total billed charges,Implant Device,548.08,34,,548.08,percent of total billed charges,Implant Device,548.08,34,,548.08,percent of total billed charges,Implant Device,797.94,,,797.94,Other,110% of Medicare,564.2,35,,564.2,percent of total billed charges,Implant Device,548.08,34,"Charges > $500, x 34%",548.08,percent of total billed charges,Implant Device,564.2,35,,564.2,percent of total billed charges,Implant Device,564.2,35,,564.2,percent of total billed charges,Implant Device,564.2,35,,564.2,percent of total billed charges,Implant Device,564.2,35,,564.2,percent of total billed charges,Implant Device,564.2,35,,564.2,percent of total billed charges,Implant Device,644.8,40,,644.8,percent of total billed charges,Implant Device,564.2,70,,564.2,percent of total billed charges,All Other,548.08,34,,548.08,percent of total billed charges,Implant Device,548.08,34,,548.08,percent of total billed charges,Implant Device,564.2,35,,564.2,percent of total billed charges,Implant Device,564.2,35,,564.2,percent of total billed charges,Implant Device,564.2,35,,564.2,percent of total billed charges,Implant Device,564.2,35,,564.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1192.88,
STRYKER 57-10121 PLATE 2.3MM LEFT 6 HOLE,C1713,HCPCS,,79001661,CDM,278,RC,,,both,,,775,573.5,,,573.5,Other,150% of Medicare + 9.63% HCRA Surcharge,348.75,45,,348.75,percent of total billed charges,Critical Access Hospital RCC factor,263.5,34,,263.5,percent of total billed charges,Implant Device,263.5,34,,263.5,percent of total billed charges,Implant Device,263.5,34,,263.5,percent of total billed charges,Implant Device,263.5,34,,263.5,percent of total billed charges,Implant Device,263.5,34,,263.5,percent of total billed charges,Implant Device,383.63,,,383.63,Other,110% of Medicare,271.25,35,,271.25,percent of total billed charges,Implant Device,263.5,34,"Charges > $500, x 34%",263.5,percent of total billed charges,Implant Device,271.25,35,,271.25,percent of total billed charges,Implant Device,271.25,35,,271.25,percent of total billed charges,Implant Device,271.25,35,,271.25,percent of total billed charges,Implant Device,271.25,35,,271.25,percent of total billed charges,Implant Device,271.25,35,,271.25,percent of total billed charges,Implant Device,310,40,,310,percent of total billed charges,Implant Device,271.25,70,,271.25,percent of total billed charges,All Other,263.5,34,,263.5,percent of total billed charges,Implant Device,263.5,34,,263.5,percent of total billed charges,Implant Device,271.25,35,,271.25,percent of total billed charges,Implant Device,271.25,35,,271.25,percent of total billed charges,Implant Device,271.25,35,,271.25,percent of total billed charges,Implant Device,271.25,35,,271.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,573.5,
STRYKER 57-10179 PLATE 2.3MM 13 HOLE,C1713,HCPCS,,79001662,CDM,278,RC,,,both,,,913,675.62,,,675.62,Other,150% of Medicare + 9.63% HCRA Surcharge,410.85,45,,410.85,percent of total billed charges,Critical Access Hospital RCC factor,310.42,34,,310.42,percent of total billed charges,Implant Device,310.42,34,,310.42,percent of total billed charges,Implant Device,310.42,34,,310.42,percent of total billed charges,Implant Device,310.42,34,,310.42,percent of total billed charges,Implant Device,310.42,34,,310.42,percent of total billed charges,Implant Device,451.94,,,451.94,Other,110% of Medicare,319.55,35,,319.55,percent of total billed charges,Implant Device,310.42,34,"Charges > $500, x 34%",310.42,percent of total billed charges,Implant Device,319.55,35,,319.55,percent of total billed charges,Implant Device,319.55,35,,319.55,percent of total billed charges,Implant Device,319.55,35,,319.55,percent of total billed charges,Implant Device,319.55,35,,319.55,percent of total billed charges,Implant Device,319.55,35,,319.55,percent of total billed charges,Implant Device,365.2,40,,365.2,percent of total billed charges,Implant Device,319.55,70,,319.55,percent of total billed charges,All Other,310.42,34,,310.42,percent of total billed charges,Implant Device,310.42,34,,310.42,percent of total billed charges,Implant Device,319.55,35,,319.55,percent of total billed charges,Implant Device,319.55,35,,319.55,percent of total billed charges,Implant Device,319.55,35,,319.55,percent of total billed charges,Implant Device,319.55,35,,319.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,675.62,
BIOMET 8162-07-003 PLATE 3 HOLE,C1713,HCPCS,,79001663,CDM,278,RC,,,both,,,1798,1330.52,,,1330.52,Other,150% of Medicare + 9.63% HCRA Surcharge,809.1,45,,809.1,percent of total billed charges,Critical Access Hospital RCC factor,611.32,34,,611.32,percent of total billed charges,Implant Device,611.32,34,,611.32,percent of total billed charges,Implant Device,611.32,34,,611.32,percent of total billed charges,Implant Device,611.32,34,,611.32,percent of total billed charges,Implant Device,611.32,34,,611.32,percent of total billed charges,Implant Device,890.01,,,890.01,Other,110% of Medicare,629.3,35,,629.3,percent of total billed charges,Implant Device,611.32,34,"Charges > $500, x 34%",611.32,percent of total billed charges,Implant Device,629.3,35,,629.3,percent of total billed charges,Implant Device,629.3,35,,629.3,percent of total billed charges,Implant Device,629.3,35,,629.3,percent of total billed charges,Implant Device,629.3,35,,629.3,percent of total billed charges,Implant Device,629.3,35,,629.3,percent of total billed charges,Implant Device,719.2,40,,719.2,percent of total billed charges,Implant Device,629.3,70,,629.3,percent of total billed charges,All Other,611.32,34,,611.32,percent of total billed charges,Implant Device,611.32,34,,611.32,percent of total billed charges,Implant Device,629.3,35,,629.3,percent of total billed charges,Implant Device,629.3,35,,629.3,percent of total billed charges,Implant Device,629.3,35,,629.3,percent of total billed charges,Implant Device,629.3,35,,629.3,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1330.52,
BIOMET 1874426 PLATE 3 X 3 L SHAPED LEFT,C1713,HCPCS,,79001664,CDM,278,RC,,,both,,,534,395.16,,,395.16,Other,150% of Medicare + 9.63% HCRA Surcharge,240.3,45,,240.3,percent of total billed charges,Critical Access Hospital RCC factor,181.56,34,,181.56,percent of total billed charges,Implant Device,181.56,34,,181.56,percent of total billed charges,Implant Device,181.56,34,,181.56,percent of total billed charges,Implant Device,181.56,34,,181.56,percent of total billed charges,Implant Device,181.56,34,,181.56,percent of total billed charges,Implant Device,264.33,,,264.33,Other,110% of Medicare,186.9,35,,186.9,percent of total billed charges,Implant Device,181.56,34,"Charges > $500, x 34%",181.56,percent of total billed charges,Implant Device,186.9,35,,186.9,percent of total billed charges,Implant Device,186.9,35,,186.9,percent of total billed charges,Implant Device,186.9,35,,186.9,percent of total billed charges,Implant Device,186.9,35,,186.9,percent of total billed charges,Implant Device,186.9,35,,186.9,percent of total billed charges,Implant Device,213.6,40,,213.6,percent of total billed charges,Implant Device,186.9,70,,186.9,percent of total billed charges,All Other,181.56,34,,181.56,percent of total billed charges,Implant Device,181.56,34,,181.56,percent of total billed charges,Implant Device,186.9,35,,186.9,percent of total billed charges,Implant Device,186.9,35,,186.9,percent of total billed charges,Implant Device,186.9,35,,186.9,percent of total billed charges,Implant Device,186.9,35,,186.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,395.16,
BIOMET 1895611 PLATE 3X3 T SHAPED REG,C1713,HCPCS,,79001665,CDM,278,RC,,,both,,,480,355.2,,,355.2,Other,150% of Medicare + 9.63% HCRA Surcharge,216,45,,216,percent of total billed charges,Critical Access Hospital RCC factor,163.2,34,,163.2,percent of total billed charges,Implant Device,163.2,34,,163.2,percent of total billed charges,Implant Device,163.2,34,,163.2,percent of total billed charges,Implant Device,163.2,34,,163.2,percent of total billed charges,Implant Device,163.2,34,,163.2,percent of total billed charges,Implant Device,237.6,,,237.6,Other,110% of Medicare,168,35,,168,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,192,40,,192,percent of total billed charges,Implant Device,168,70,,168,percent of total billed charges,All Other,163.2,34,,163.2,percent of total billed charges,Implant Device,163.2,34,,163.2,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,355.2,
BIOMET 1877348 PLATE 4 HOLE STRAIGHT,C1713,HCPCS,,79001666,CDM,278,RC,,,both,,,252,186.48,,,186.48,Other,150% of Medicare + 9.63% HCRA Surcharge,113.4,45,,113.4,percent of total billed charges,Critical Access Hospital RCC factor,85.68,34,,85.68,percent of total billed charges,Implant Device,85.68,34,,85.68,percent of total billed charges,Implant Device,85.68,34,,85.68,percent of total billed charges,Implant Device,85.68,34,,85.68,percent of total billed charges,Implant Device,85.68,34,,85.68,percent of total billed charges,Implant Device,124.74,,,124.74,Other,110% of Medicare,88.2,35,,88.2,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,88.2,35,,88.2,percent of total billed charges,Implant Device,88.2,35,,88.2,percent of total billed charges,Implant Device,88.2,35,,88.2,percent of total billed charges,Implant Device,88.2,35,,88.2,percent of total billed charges,Implant Device,88.2,35,,88.2,percent of total billed charges,Implant Device,100.8,40,,100.8,percent of total billed charges,Implant Device,88.2,70,,88.2,percent of total billed charges,All Other,85.68,34,,85.68,percent of total billed charges,Implant Device,85.68,34,,85.68,percent of total billed charges,Implant Device,88.2,35,,88.2,percent of total billed charges,Implant Device,88.2,35,,88.2,percent of total billed charges,Implant Device,88.2,35,,88.2,percent of total billed charges,Implant Device,88.2,35,,88.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,186.48,
BIOMET 1899993 PLATE 5 HOLE Y LONG,C1713,HCPCS,,79001667,CDM,278,RC,,,both,,,496,367.04,,,367.04,Other,150% of Medicare + 9.63% HCRA Surcharge,223.2,45,,223.2,percent of total billed charges,Critical Access Hospital RCC factor,168.64,34,,168.64,percent of total billed charges,Implant Device,168.64,34,,168.64,percent of total billed charges,Implant Device,168.64,34,,168.64,percent of total billed charges,Implant Device,168.64,34,,168.64,percent of total billed charges,Implant Device,168.64,34,,168.64,percent of total billed charges,Implant Device,245.52,,,245.52,Other,110% of Medicare,173.6,35,,173.6,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,173.6,35,,173.6,percent of total billed charges,Implant Device,173.6,35,,173.6,percent of total billed charges,Implant Device,173.6,35,,173.6,percent of total billed charges,Implant Device,173.6,35,,173.6,percent of total billed charges,Implant Device,173.6,35,,173.6,percent of total billed charges,Implant Device,198.4,40,,198.4,percent of total billed charges,Implant Device,173.6,70,,173.6,percent of total billed charges,All Other,168.64,34,,168.64,percent of total billed charges,Implant Device,168.64,34,,168.64,percent of total billed charges,Implant Device,173.6,35,,173.6,percent of total billed charges,Implant Device,173.6,35,,173.6,percent of total billed charges,Implant Device,173.6,35,,173.6,percent of total billed charges,Implant Device,173.6,35,,173.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,367.04,
SYNTHES 242.16 PLATE 6 HOLE,C1713,HCPCS,,79001668,CDM,278,RC,,,both,,,372,275.28,,,275.28,Other,150% of Medicare + 9.63% HCRA Surcharge,167.4,45,,167.4,percent of total billed charges,Critical Access Hospital RCC factor,126.48,34,,126.48,percent of total billed charges,Implant Device,126.48,34,,126.48,percent of total billed charges,Implant Device,126.48,34,,126.48,percent of total billed charges,Implant Device,126.48,34,,126.48,percent of total billed charges,Implant Device,126.48,34,,126.48,percent of total billed charges,Implant Device,184.14,,,184.14,Other,110% of Medicare,130.2,35,,130.2,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,130.2,35,,130.2,percent of total billed charges,Implant Device,130.2,35,,130.2,percent of total billed charges,Implant Device,130.2,35,,130.2,percent of total billed charges,Implant Device,130.2,35,,130.2,percent of total billed charges,Implant Device,130.2,35,,130.2,percent of total billed charges,Implant Device,148.8,40,,148.8,percent of total billed charges,Implant Device,130.2,70,,130.2,percent of total billed charges,All Other,126.48,34,,126.48,percent of total billed charges,Implant Device,126.48,34,,126.48,percent of total billed charges,Implant Device,130.2,35,,130.2,percent of total billed charges,Implant Device,130.2,35,,130.2,percent of total billed charges,Implant Device,130.2,35,,130.2,percent of total billed charges,Implant Device,130.2,35,,130.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,275.28,
BIOMET 1903645 PLATE 6 HOLE YY LONG,C1713,HCPCS,,79001669,CDM,278,RC,,,both,,,588,435.12,,,435.12,Other,150% of Medicare + 9.63% HCRA Surcharge,264.6,45,,264.6,percent of total billed charges,Critical Access Hospital RCC factor,199.92,34,,199.92,percent of total billed charges,Implant Device,199.92,34,,199.92,percent of total billed charges,Implant Device,199.92,34,,199.92,percent of total billed charges,Implant Device,199.92,34,,199.92,percent of total billed charges,Implant Device,199.92,34,,199.92,percent of total billed charges,Implant Device,291.06,,,291.06,Other,110% of Medicare,205.8,35,,205.8,percent of total billed charges,Implant Device,199.92,34,"Charges > $500, x 34%",199.92,percent of total billed charges,Implant Device,205.8,35,,205.8,percent of total billed charges,Implant Device,205.8,35,,205.8,percent of total billed charges,Implant Device,205.8,35,,205.8,percent of total billed charges,Implant Device,205.8,35,,205.8,percent of total billed charges,Implant Device,205.8,35,,205.8,percent of total billed charges,Implant Device,235.2,40,,235.2,percent of total billed charges,Implant Device,205.8,70,,205.8,percent of total billed charges,All Other,199.92,34,,199.92,percent of total billed charges,Implant Device,199.92,34,,199.92,percent of total billed charges,Implant Device,205.8,35,,205.8,percent of total billed charges,Implant Device,205.8,35,,205.8,percent of total billed charges,Implant Device,205.8,35,,205.8,percent of total billed charges,Implant Device,205.8,35,,205.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,435.12,
SYNTHES 241.361 PLATE 6 HOLE 69MM,C1713,HCPCS,,79001670,CDM,278,RC,,,both,,,702,519.48,,,519.48,Other,150% of Medicare + 9.63% HCRA Surcharge,315.9,45,,315.9,percent of total billed charges,Critical Access Hospital RCC factor,238.68,34,,238.68,percent of total billed charges,Implant Device,238.68,34,,238.68,percent of total billed charges,Implant Device,238.68,34,,238.68,percent of total billed charges,Implant Device,238.68,34,,238.68,percent of total billed charges,Implant Device,238.68,34,,238.68,percent of total billed charges,Implant Device,347.49,,,347.49,Other,110% of Medicare,245.7,35,,245.7,percent of total billed charges,Implant Device,238.68,34,"Charges > $500, x 34%",238.68,percent of total billed charges,Implant Device,245.7,35,,245.7,percent of total billed charges,Implant Device,245.7,35,,245.7,percent of total billed charges,Implant Device,245.7,35,,245.7,percent of total billed charges,Implant Device,245.7,35,,245.7,percent of total billed charges,Implant Device,245.7,35,,245.7,percent of total billed charges,Implant Device,280.8,40,,280.8,percent of total billed charges,Implant Device,245.7,70,,245.7,percent of total billed charges,All Other,238.68,34,,238.68,percent of total billed charges,Implant Device,238.68,34,,238.68,percent of total billed charges,Implant Device,245.7,35,,245.7,percent of total billed charges,Implant Device,245.7,35,,245.7,percent of total billed charges,Implant Device,245.7,35,,245.7,percent of total billed charges,Implant Device,245.7,35,,245.7,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,519.48,
BIOMET 1902915 PLATE 6 HOLE DOUBLE Y REG,C1713,HCPCS,,79001671,CDM,278,RC,,,both,,,570,421.8,,,421.8,Other,150% of Medicare + 9.63% HCRA Surcharge,256.5,45,,256.5,percent of total billed charges,Critical Access Hospital RCC factor,193.8,34,,193.8,percent of total billed charges,Implant Device,193.8,34,,193.8,percent of total billed charges,Implant Device,193.8,34,,193.8,percent of total billed charges,Implant Device,193.8,34,,193.8,percent of total billed charges,Implant Device,193.8,34,,193.8,percent of total billed charges,Implant Device,282.15,,,282.15,Other,110% of Medicare,199.5,35,,199.5,percent of total billed charges,Implant Device,193.8,34,"Charges > $500, x 34%",193.8,percent of total billed charges,Implant Device,199.5,35,,199.5,percent of total billed charges,Implant Device,199.5,35,,199.5,percent of total billed charges,Implant Device,199.5,35,,199.5,percent of total billed charges,Implant Device,199.5,35,,199.5,percent of total billed charges,Implant Device,199.5,35,,199.5,percent of total billed charges,Implant Device,228,40,,228,percent of total billed charges,Implant Device,199.5,70,,199.5,percent of total billed charges,All Other,193.8,34,,193.8,percent of total billed charges,Implant Device,193.8,34,,193.8,percent of total billed charges,Implant Device,199.5,35,,199.5,percent of total billed charges,Implant Device,199.5,35,,199.5,percent of total billed charges,Implant Device,199.5,35,,199.5,percent of total billed charges,Implant Device,199.5,35,,199.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,421.8,
BIOMET 1904376 PLATE 6 HOLE YY X LONG,C1713,HCPCS,,79001672,CDM,278,RC,,,both,,,606,448.44,,,448.44,Other,150% of Medicare + 9.63% HCRA Surcharge,272.7,45,,272.7,percent of total billed charges,Critical Access Hospital RCC factor,206.04,34,,206.04,percent of total billed charges,Implant Device,206.04,34,,206.04,percent of total billed charges,Implant Device,206.04,34,,206.04,percent of total billed charges,Implant Device,206.04,34,,206.04,percent of total billed charges,Implant Device,206.04,34,,206.04,percent of total billed charges,Implant Device,299.97,,,299.97,Other,110% of Medicare,212.1,35,,212.1,percent of total billed charges,Implant Device,206.04,34,"Charges > $500, x 34%",206.04,percent of total billed charges,Implant Device,212.1,35,,212.1,percent of total billed charges,Implant Device,212.1,35,,212.1,percent of total billed charges,Implant Device,212.1,35,,212.1,percent of total billed charges,Implant Device,212.1,35,,212.1,percent of total billed charges,Implant Device,212.1,35,,212.1,percent of total billed charges,Implant Device,242.4,40,,242.4,percent of total billed charges,Implant Device,212.1,70,,212.1,percent of total billed charges,All Other,206.04,34,,206.04,percent of total billed charges,Implant Device,206.04,34,,206.04,percent of total billed charges,Implant Device,212.1,35,,212.1,percent of total billed charges,Implant Device,212.1,35,,212.1,percent of total billed charges,Implant Device,212.1,35,,212.1,percent of total billed charges,Implant Device,212.1,35,,212.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,448.44,
BIOMET 1881001 PLATE 6 HOLE STRAIGHT,C1713,HCPCS,,79001673,CDM,278,RC,,,both,,,537,397.38,,,397.38,Other,150% of Medicare + 9.63% HCRA Surcharge,241.65,45,,241.65,percent of total billed charges,Critical Access Hospital RCC factor,182.58,34,,182.58,percent of total billed charges,Implant Device,182.58,34,,182.58,percent of total billed charges,Implant Device,182.58,34,,182.58,percent of total billed charges,Implant Device,182.58,34,,182.58,percent of total billed charges,Implant Device,182.58,34,,182.58,percent of total billed charges,Implant Device,265.82,,,265.82,Other,110% of Medicare,187.95,35,,187.95,percent of total billed charges,Implant Device,182.58,34,"Charges > $500, x 34%",182.58,percent of total billed charges,Implant Device,187.95,35,,187.95,percent of total billed charges,Implant Device,187.95,35,,187.95,percent of total billed charges,Implant Device,187.95,35,,187.95,percent of total billed charges,Implant Device,187.95,35,,187.95,percent of total billed charges,Implant Device,187.95,35,,187.95,percent of total billed charges,Implant Device,214.8,40,,214.8,percent of total billed charges,Implant Device,187.95,70,,187.95,percent of total billed charges,All Other,182.58,34,,182.58,percent of total billed charges,Implant Device,182.58,34,,182.58,percent of total billed charges,Implant Device,187.95,35,,187.95,percent of total billed charges,Implant Device,187.95,35,,187.95,percent of total billed charges,Implant Device,187.95,35,,187.95,percent of total billed charges,Implant Device,187.95,35,,187.95,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,397.38,
SYNTHES 242.18 PLATE 8 HOLE,C1713,HCPCS,,79001674,CDM,278,RC,,,both,,,382,282.68,,,282.68,Other,150% of Medicare + 9.63% HCRA Surcharge,171.9,45,,171.9,percent of total billed charges,Critical Access Hospital RCC factor,129.88,34,,129.88,percent of total billed charges,Implant Device,129.88,34,,129.88,percent of total billed charges,Implant Device,129.88,34,,129.88,percent of total billed charges,Implant Device,129.88,34,,129.88,percent of total billed charges,Implant Device,129.88,34,,129.88,percent of total billed charges,Implant Device,189.09,,,189.09,Other,110% of Medicare,133.7,35,,133.7,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,133.7,35,,133.7,percent of total billed charges,Implant Device,133.7,35,,133.7,percent of total billed charges,Implant Device,133.7,35,,133.7,percent of total billed charges,Implant Device,133.7,35,,133.7,percent of total billed charges,Implant Device,133.7,35,,133.7,percent of total billed charges,Implant Device,152.8,40,,152.8,percent of total billed charges,Implant Device,133.7,70,,133.7,percent of total billed charges,All Other,129.88,34,,129.88,percent of total billed charges,Implant Device,129.88,34,,129.88,percent of total billed charges,Implant Device,133.7,35,,133.7,percent of total billed charges,Implant Device,133.7,35,,133.7,percent of total billed charges,Implant Device,133.7,35,,133.7,percent of total billed charges,Implant Device,133.7,35,,133.7,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,282.68,
STRYKER 53-05612 PLATE GAP SMALL,C1713,HCPCS,,79001675,CDM,278,RC,,,both,,,851,629.74,,,629.74,Other,150% of Medicare + 9.63% HCRA Surcharge,382.95,45,,382.95,percent of total billed charges,Critical Access Hospital RCC factor,289.34,34,,289.34,percent of total billed charges,Implant Device,289.34,34,,289.34,percent of total billed charges,Implant Device,289.34,34,,289.34,percent of total billed charges,Implant Device,289.34,34,,289.34,percent of total billed charges,Implant Device,289.34,34,,289.34,percent of total billed charges,Implant Device,421.25,,,421.25,Other,110% of Medicare,297.85,35,,297.85,percent of total billed charges,Implant Device,289.34,34,"Charges > $500, x 34%",289.34,percent of total billed charges,Implant Device,297.85,35,,297.85,percent of total billed charges,Implant Device,297.85,35,,297.85,percent of total billed charges,Implant Device,297.85,35,,297.85,percent of total billed charges,Implant Device,297.85,35,,297.85,percent of total billed charges,Implant Device,297.85,35,,297.85,percent of total billed charges,Implant Device,340.4,40,,340.4,percent of total billed charges,Implant Device,297.85,70,,297.85,percent of total billed charges,All Other,289.34,34,,289.34,percent of total billed charges,Implant Device,289.34,34,,289.34,percent of total billed charges,Implant Device,297.85,35,,297.85,percent of total billed charges,Implant Device,297.85,35,,297.85,percent of total billed charges,Implant Device,297.85,35,,297.85,percent of total billed charges,Implant Device,297.85,35,,297.85,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,629.74,
BIOMET 8162-35-009 PLATE LOCK ACP 9 HOLE,C1713,HCPCS,,79001677,CDM,278,RC,,,both,,,1140,843.6,,,843.6,Other,150% of Medicare + 9.63% HCRA Surcharge,513,45,,513,percent of total billed charges,Critical Access Hospital RCC factor,387.6,34,,387.6,percent of total billed charges,Implant Device,387.6,34,,387.6,percent of total billed charges,Implant Device,387.6,34,,387.6,percent of total billed charges,Implant Device,387.6,34,,387.6,percent of total billed charges,Implant Device,387.6,34,,387.6,percent of total billed charges,Implant Device,564.3,,,564.3,Other,110% of Medicare,399,35,,399,percent of total billed charges,Implant Device,387.6,34,"Charges > $500, x 34%",387.6,percent of total billed charges,Implant Device,399,35,,399,percent of total billed charges,Implant Device,399,35,,399,percent of total billed charges,Implant Device,399,35,,399,percent of total billed charges,Implant Device,399,35,,399,percent of total billed charges,Implant Device,399,35,,399,percent of total billed charges,Implant Device,456,40,,456,percent of total billed charges,Implant Device,399,70,,399,percent of total billed charges,All Other,387.6,34,,387.6,percent of total billed charges,Implant Device,387.6,34,,387.6,percent of total billed charges,Implant Device,399,35,,399,percent of total billed charges,Implant Device,399,35,,399,percent of total billed charges,Implant Device,399,35,,399,percent of total billed charges,Implant Device,399,35,,399,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,843.6,
BIOMET 8162-07-004 PLATE RIGHT4 HOLE,C1713,HCPCS,,79001678,CDM,278,RC,,,both,,,3480,2575.21,,,2575.21,Other,150% of Medicare + 9.63% HCRA Surcharge,1566,45,,1566,percent of total billed charges,Critical Access Hospital RCC factor,1183.2,34,,1183.2,percent of total billed charges,Implant Device,1183.2,34,,1183.2,percent of total billed charges,Implant Device,1183.2,34,,1183.2,percent of total billed charges,Implant Device,1183.2,34,,1183.2,percent of total billed charges,Implant Device,1183.2,34,,1183.2,percent of total billed charges,Implant Device,1722.6,,,1722.6,Other,110% of Medicare,1218,35,,1218,percent of total billed charges,Implant Device,1183.2,34,"Charges > $500, x 34%",1183.2,percent of total billed charges,Implant Device,1218,35,,1218,percent of total billed charges,Implant Device,1218,35,,1218,percent of total billed charges,Implant Device,1218,35,,1218,percent of total billed charges,Implant Device,1218,35,,1218,percent of total billed charges,Implant Device,1218,35,,1218,percent of total billed charges,Implant Device,1392,40,,1392,percent of total billed charges,Implant Device,1218,70,,1218,percent of total billed charges,All Other,1183.2,34,,1183.2,percent of total billed charges,Implant Device,1183.2,34,,1183.2,percent of total billed charges,Implant Device,1218,35,,1218,percent of total billed charges,Implant Device,1218,35,,1218,percent of total billed charges,Implant Device,1218,35,,1218,percent of total billed charges,Implant Device,1218,35,,1218,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1183.2,34,"If Charge > 2,000, then 34 percent",1183.2,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2575.21,
BIOMET 1910585 PLATE SQUARE,C1713,HCPCS,,79001679,CDM,278,RC,,,both,,,636,470.64,,,470.64,Other,150% of Medicare + 9.63% HCRA Surcharge,286.2,45,,286.2,percent of total billed charges,Critical Access Hospital RCC factor,216.24,34,,216.24,percent of total billed charges,Implant Device,216.24,34,,216.24,percent of total billed charges,Implant Device,216.24,34,,216.24,percent of total billed charges,Implant Device,216.24,34,,216.24,percent of total billed charges,Implant Device,216.24,34,,216.24,percent of total billed charges,Implant Device,314.82,,,314.82,Other,110% of Medicare,222.6,35,,222.6,percent of total billed charges,Implant Device,216.24,34,"Charges > $500, x 34%",216.24,percent of total billed charges,Implant Device,222.6,35,,222.6,percent of total billed charges,Implant Device,222.6,35,,222.6,percent of total billed charges,Implant Device,222.6,35,,222.6,percent of total billed charges,Implant Device,222.6,35,,222.6,percent of total billed charges,Implant Device,222.6,35,,222.6,percent of total billed charges,Implant Device,254.4,40,,254.4,percent of total billed charges,Implant Device,222.6,70,,222.6,percent of total billed charges,All Other,216.24,34,,216.24,percent of total billed charges,Implant Device,216.24,34,,216.24,percent of total billed charges,Implant Device,222.6,35,,222.6,percent of total billed charges,Implant Device,222.6,35,,222.6,percent of total billed charges,Implant Device,222.6,35,,222.6,percent of total billed charges,Implant Device,222.6,35,,222.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,470.64,
BIOMET 8162-35-703 PLATE TIB LOCK 3 HOLE,C1713,HCPCS,,79001680,CDM,278,RC,,,both,,,6180,4573.22,,,4573.22,Other,150% of Medicare + 9.63% HCRA Surcharge,2781,45,,2781,percent of total billed charges,Critical Access Hospital RCC factor,2101.2,34,,2101.2,percent of total billed charges,Implant Device,2101.2,34,,2101.2,percent of total billed charges,Implant Device,2101.2,34,,2101.2,percent of total billed charges,Implant Device,2101.2,34,,2101.2,percent of total billed charges,Implant Device,2101.2,34,,2101.2,percent of total billed charges,Implant Device,3059.1,,,3059.1,Other,110% of Medicare,2163,35,,2163,percent of total billed charges,Implant Device,2101.2,34,"Charges > $500, x 34%",2101.2,percent of total billed charges,Implant Device,2163,35,,2163,percent of total billed charges,Implant Device,2163,35,,2163,percent of total billed charges,Implant Device,2163,35,,2163,percent of total billed charges,Implant Device,2163,35,,2163,percent of total billed charges,Implant Device,2163,35,,2163,percent of total billed charges,Implant Device,2472,40,,2472,percent of total billed charges,Implant Device,2163,70,,2163,percent of total billed charges,All Other,2101.2,34,,2101.2,percent of total billed charges,Implant Device,2101.2,34,,2101.2,percent of total billed charges,Implant Device,2163,35,,2163,percent of total billed charges,Implant Device,2163,35,,2163,percent of total billed charges,Implant Device,2163,35,,2163,percent of total billed charges,Implant Device,2163,35,,2163,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2101.2,34,"If Charge > 2,000, then 34 percent",2101.2,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4573.22,
STRYKER 53-05608 PLATE-DOUBLE Y 6 HOLE,C1713,HCPCS,,79001681,CDM,278,RC,,,both,,,714,528.36,,,528.36,Other,150% of Medicare + 9.63% HCRA Surcharge,321.3,45,,321.3,percent of total billed charges,Critical Access Hospital RCC factor,242.76,34,,242.76,percent of total billed charges,Implant Device,242.76,34,,242.76,percent of total billed charges,Implant Device,242.76,34,,242.76,percent of total billed charges,Implant Device,242.76,34,,242.76,percent of total billed charges,Implant Device,242.76,34,,242.76,percent of total billed charges,Implant Device,353.43,,,353.43,Other,110% of Medicare,249.9,35,,249.9,percent of total billed charges,Implant Device,242.76,34,"Charges > $500, x 34%",242.76,percent of total billed charges,Implant Device,249.9,35,,249.9,percent of total billed charges,Implant Device,249.9,35,,249.9,percent of total billed charges,Implant Device,249.9,35,,249.9,percent of total billed charges,Implant Device,249.9,35,,249.9,percent of total billed charges,Implant Device,249.9,35,,249.9,percent of total billed charges,Implant Device,285.6,40,,285.6,percent of total billed charges,Implant Device,249.9,70,,249.9,percent of total billed charges,All Other,242.76,34,,242.76,percent of total billed charges,Implant Device,242.76,34,,242.76,percent of total billed charges,Implant Device,249.9,35,,249.9,percent of total billed charges,Implant Device,249.9,35,,249.9,percent of total billed charges,Implant Device,249.9,35,,249.9,percent of total billed charges,Implant Device,249.9,35,,249.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,528.36,
ATRIUM 30902 PLUG LARGE,C1781,HCPCS,,79001682,CDM,278,RC,,,both,,,392,290.08,,,290.08,Other,150% of Medicare + 9.63% HCRA Surcharge,176.4,45,,176.4,percent of total billed charges,Critical Access Hospital RCC factor,133.28,34,,133.28,percent of total billed charges,Implant Device,133.28,34,,133.28,percent of total billed charges,Implant Device,133.28,34,,133.28,percent of total billed charges,Implant Device,133.28,34,,133.28,percent of total billed charges,Implant Device,133.28,34,,133.28,percent of total billed charges,Implant Device,194.04,,,194.04,Other,110% of Medicare,137.2,35,,137.2,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,137.2,35,,137.2,percent of total billed charges,Implant Device,137.2,35,,137.2,percent of total billed charges,Implant Device,137.2,35,,137.2,percent of total billed charges,Implant Device,137.2,35,,137.2,percent of total billed charges,Implant Device,137.2,35,,137.2,percent of total billed charges,Implant Device,156.8,40,,156.8,percent of total billed charges,Implant Device,137.2,70,,137.2,percent of total billed charges,All Other,133.28,34,,133.28,percent of total billed charges,Implant Device,133.28,34,,133.28,percent of total billed charges,Implant Device,137.2,35,,137.2,percent of total billed charges,Implant Device,137.2,35,,137.2,percent of total billed charges,Implant Device,137.2,35,,137.2,percent of total billed charges,Implant Device,137.2,35,,137.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,290.08,
ATRIUM 30901 PLUG MEDIUM,C1781,HCPCS,,79001683,CDM,278,RC,,,both,,,392,290.08,,,290.08,Other,150% of Medicare + 9.63% HCRA Surcharge,176.4,45,,176.4,percent of total billed charges,Critical Access Hospital RCC factor,133.28,34,,133.28,percent of total billed charges,Implant Device,133.28,34,,133.28,percent of total billed charges,Implant Device,133.28,34,,133.28,percent of total billed charges,Implant Device,133.28,34,,133.28,percent of total billed charges,Implant Device,133.28,34,,133.28,percent of total billed charges,Implant Device,194.04,,,194.04,Other,110% of Medicare,137.2,35,,137.2,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,137.2,35,,137.2,percent of total billed charges,Implant Device,137.2,35,,137.2,percent of total billed charges,Implant Device,137.2,35,,137.2,percent of total billed charges,Implant Device,137.2,35,,137.2,percent of total billed charges,Implant Device,137.2,35,,137.2,percent of total billed charges,Implant Device,156.8,40,,156.8,percent of total billed charges,Implant Device,137.2,70,,137.2,percent of total billed charges,All Other,133.28,34,,133.28,percent of total billed charges,Implant Device,133.28,34,,133.28,percent of total billed charges,Implant Device,137.2,35,,137.2,percent of total billed charges,Implant Device,137.2,35,,137.2,percent of total billed charges,Implant Device,137.2,35,,137.2,percent of total billed charges,Implant Device,137.2,35,,137.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,290.08,
ATRIUM 30900 PLUG SMALL,C1781,HCPCS,,79001684,CDM,278,RC,,,both,,,392,290.08,,,290.08,Other,150% of Medicare + 9.63% HCRA Surcharge,176.4,45,,176.4,percent of total billed charges,Critical Access Hospital RCC factor,133.28,34,,133.28,percent of total billed charges,Implant Device,133.28,34,,133.28,percent of total billed charges,Implant Device,133.28,34,,133.28,percent of total billed charges,Implant Device,133.28,34,,133.28,percent of total billed charges,Implant Device,133.28,34,,133.28,percent of total billed charges,Implant Device,194.04,,,194.04,Other,110% of Medicare,137.2,35,,137.2,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,137.2,35,,137.2,percent of total billed charges,Implant Device,137.2,35,,137.2,percent of total billed charges,Implant Device,137.2,35,,137.2,percent of total billed charges,Implant Device,137.2,35,,137.2,percent of total billed charges,Implant Device,137.2,35,,137.2,percent of total billed charges,Implant Device,156.8,40,,156.8,percent of total billed charges,Implant Device,137.2,70,,137.2,percent of total billed charges,All Other,133.28,34,,133.28,percent of total billed charges,Implant Device,133.28,34,,133.28,percent of total billed charges,Implant Device,137.2,35,,137.2,percent of total billed charges,Implant Device,137.2,35,,137.2,percent of total billed charges,Implant Device,137.2,35,,137.2,percent of total billed charges,Implant Device,137.2,35,,137.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,290.08,
BARD 112980 PLUG X LARGE,C1781,HCPCS,,79001685,CDM,278,RC,,,both,,,952,704.48,,,704.48,Other,150% of Medicare + 9.63% HCRA Surcharge,428.4,45,,428.4,percent of total billed charges,Critical Access Hospital RCC factor,323.68,34,,323.68,percent of total billed charges,Implant Device,323.68,34,,323.68,percent of total billed charges,Implant Device,323.68,34,,323.68,percent of total billed charges,Implant Device,323.68,34,,323.68,percent of total billed charges,Implant Device,323.68,34,,323.68,percent of total billed charges,Implant Device,471.24,,,471.24,Other,110% of Medicare,333.2,35,,333.2,percent of total billed charges,Implant Device,323.68,34,"Charges > $500, x 34%",323.68,percent of total billed charges,Implant Device,333.2,35,,333.2,percent of total billed charges,Implant Device,333.2,35,,333.2,percent of total billed charges,Implant Device,333.2,35,,333.2,percent of total billed charges,Implant Device,333.2,35,,333.2,percent of total billed charges,Implant Device,333.2,35,,333.2,percent of total billed charges,Implant Device,380.8,40,,380.8,percent of total billed charges,Implant Device,333.2,70,,333.2,percent of total billed charges,All Other,323.68,34,,323.68,percent of total billed charges,Implant Device,323.68,34,,323.68,percent of total billed charges,Implant Device,333.2,35,,333.2,percent of total billed charges,Implant Device,333.2,35,,333.2,percent of total billed charges,Implant Device,333.2,35,,333.2,percent of total billed charges,Implant Device,333.2,35,,333.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,704.48,
ATRIUM 30909 PLUG MEDIUM,C1781,HCPCS,,79001686,CDM,278,RC,,,both,,,800,592,,,592,Other,150% of Medicare + 9.63% HCRA Surcharge,360,45,,360,percent of total billed charges,Critical Access Hospital RCC factor,272,34,,272,percent of total billed charges,Implant Device,272,34,,272,percent of total billed charges,Implant Device,272,34,,272,percent of total billed charges,Implant Device,272,34,,272,percent of total billed charges,Implant Device,272,34,,272,percent of total billed charges,Implant Device,396,,,396,Other,110% of Medicare,280,35,,280,percent of total billed charges,Implant Device,272,34,"Charges > $500, x 34%",272,percent of total billed charges,Implant Device,280,35,,280,percent of total billed charges,Implant Device,280,35,,280,percent of total billed charges,Implant Device,280,35,,280,percent of total billed charges,Implant Device,280,35,,280,percent of total billed charges,Implant Device,280,35,,280,percent of total billed charges,Implant Device,320,40,,320,percent of total billed charges,Implant Device,280,70,,280,percent of total billed charges,All Other,272,34,,272,percent of total billed charges,Implant Device,272,34,,272,percent of total billed charges,Implant Device,280,35,,280,percent of total billed charges,Implant Device,280,35,,280,percent of total billed charges,Implant Device,280,35,,280,percent of total billed charges,Implant Device,280,35,,280,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,592,
ATRIUM 30903 PLUG XLARGE,C1781,HCPCS,,79001687,CDM,278,RC,,,both,,,428,316.72,,,316.72,Other,150% of Medicare + 9.63% HCRA Surcharge,192.6,45,,192.6,percent of total billed charges,Critical Access Hospital RCC factor,145.52,34,,145.52,percent of total billed charges,Implant Device,145.52,34,,145.52,percent of total billed charges,Implant Device,145.52,34,,145.52,percent of total billed charges,Implant Device,145.52,34,,145.52,percent of total billed charges,Implant Device,145.52,34,,145.52,percent of total billed charges,Implant Device,211.86,,,211.86,Other,110% of Medicare,149.8,35,,149.8,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,149.8,35,,149.8,percent of total billed charges,Implant Device,149.8,35,,149.8,percent of total billed charges,Implant Device,149.8,35,,149.8,percent of total billed charges,Implant Device,149.8,35,,149.8,percent of total billed charges,Implant Device,149.8,35,,149.8,percent of total billed charges,Implant Device,171.2,40,,171.2,percent of total billed charges,Implant Device,149.8,70,,149.8,percent of total billed charges,All Other,145.52,34,,145.52,percent of total billed charges,Implant Device,145.52,34,,145.52,percent of total billed charges,Implant Device,149.8,35,,149.8,percent of total billed charges,Implant Device,149.8,35,,149.8,percent of total billed charges,Implant Device,149.8,35,,149.8,percent of total billed charges,Implant Device,149.8,35,,149.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,316.72,
POLARIS STENT 24FR,C1877,HCPCS,,79001688,CDM,278,RC,,,both,,,431,318.94,,,318.94,Other,150% of Medicare + 9.63% HCRA Surcharge,193.95,45,,193.95,percent of total billed charges,Critical Access Hospital RCC factor,146.54,34,,146.54,percent of total billed charges,Implant Device,146.54,34,,146.54,percent of total billed charges,Implant Device,146.54,34,,146.54,percent of total billed charges,Implant Device,146.54,34,,146.54,percent of total billed charges,Implant Device,146.54,34,,146.54,percent of total billed charges,Implant Device,213.35,,,213.35,Other,110% of Medicare,150.85,35,,150.85,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,150.85,35,,150.85,percent of total billed charges,Implant Device,150.85,35,,150.85,percent of total billed charges,Implant Device,150.85,35,,150.85,percent of total billed charges,Implant Device,150.85,35,,150.85,percent of total billed charges,Implant Device,150.85,35,,150.85,percent of total billed charges,Implant Device,172.4,40,,172.4,percent of total billed charges,Implant Device,150.85,70,,150.85,percent of total billed charges,All Other,146.54,34,,146.54,percent of total billed charges,Implant Device,146.54,34,,146.54,percent of total billed charges,Implant Device,150.85,35,,150.85,percent of total billed charges,Implant Device,150.85,35,,150.85,percent of total billed charges,Implant Device,150.85,35,,150.85,percent of total billed charges,Implant Device,150.85,35,,150.85,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,318.94,
CARDIO 6113651080A PORT-A-CATH TITANIUM,C1788,HCPCS,,79001689,CDM,278,RC,,,both,,,618,457.32,,,457.32,Other,150% of Medicare + 9.63% HCRA Surcharge,278.1,45,,278.1,percent of total billed charges,Critical Access Hospital RCC factor,210.12,34,,210.12,percent of total billed charges,Implant Device,210.12,34,,210.12,percent of total billed charges,Implant Device,210.12,34,,210.12,percent of total billed charges,Implant Device,210.12,34,,210.12,percent of total billed charges,Implant Device,210.12,34,,210.12,percent of total billed charges,Implant Device,305.91,,,305.91,Other,110% of Medicare,216.3,35,,216.3,percent of total billed charges,Implant Device,210.12,34,"Charges > $500, x 34%",210.12,percent of total billed charges,Implant Device,216.3,35,,216.3,percent of total billed charges,Implant Device,216.3,35,,216.3,percent of total billed charges,Implant Device,216.3,35,,216.3,percent of total billed charges,Implant Device,216.3,35,,216.3,percent of total billed charges,Implant Device,216.3,35,,216.3,percent of total billed charges,Implant Device,247.2,40,,247.2,percent of total billed charges,Implant Device,216.3,70,,216.3,percent of total billed charges,All Other,210.12,34,,210.12,percent of total billed charges,Implant Device,210.12,34,,210.12,percent of total billed charges,Implant Device,216.3,35,,216.3,percent of total billed charges,Implant Device,216.3,35,,216.3,percent of total billed charges,Implant Device,216.3,35,,216.3,percent of total billed charges,Implant Device,216.3,35,,216.3,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,457.32,
CARDIO 6164651075-A PORT-A-CATH SILICON,C1788,HCPCS,,79001690,CDM,278,RC,,,both,,,618,457.32,,,457.32,Other,150% of Medicare + 9.63% HCRA Surcharge,278.1,45,,278.1,percent of total billed charges,Critical Access Hospital RCC factor,210.12,34,,210.12,percent of total billed charges,Implant Device,210.12,34,,210.12,percent of total billed charges,Implant Device,210.12,34,,210.12,percent of total billed charges,Implant Device,210.12,34,,210.12,percent of total billed charges,Implant Device,210.12,34,,210.12,percent of total billed charges,Implant Device,305.91,,,305.91,Other,110% of Medicare,216.3,35,,216.3,percent of total billed charges,Implant Device,210.12,34,"Charges > $500, x 34%",210.12,percent of total billed charges,Implant Device,216.3,35,,216.3,percent of total billed charges,Implant Device,216.3,35,,216.3,percent of total billed charges,Implant Device,216.3,35,,216.3,percent of total billed charges,Implant Device,216.3,35,,216.3,percent of total billed charges,Implant Device,216.3,35,,216.3,percent of total billed charges,Implant Device,247.2,40,,247.2,percent of total billed charges,Implant Device,216.3,70,,216.3,percent of total billed charges,All Other,210.12,34,,210.12,percent of total billed charges,Implant Device,210.12,34,,210.12,percent of total billed charges,Implant Device,216.3,35,,216.3,percent of total billed charges,Implant Device,216.3,35,,216.3,percent of total billed charges,Implant Device,216.3,35,,216.3,percent of total billed charges,Implant Device,216.3,35,,216.3,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,457.32,
NAVILYST H965451030 POWER PORT 8FR,C1788,HCPCS,,79001691,CDM,278,RC,,,both,,,924,683.76,,,683.76,Other,150% of Medicare + 9.63% HCRA Surcharge,415.8,45,,415.8,percent of total billed charges,Critical Access Hospital RCC factor,314.16,34,,314.16,percent of total billed charges,Implant Device,314.16,34,,314.16,percent of total billed charges,Implant Device,314.16,34,,314.16,percent of total billed charges,Implant Device,314.16,34,,314.16,percent of total billed charges,Implant Device,314.16,34,,314.16,percent of total billed charges,Implant Device,457.38,,,457.38,Other,110% of Medicare,323.4,35,,323.4,percent of total billed charges,Implant Device,314.16,34,"Charges > $500, x 34%",314.16,percent of total billed charges,Implant Device,323.4,35,,323.4,percent of total billed charges,Implant Device,323.4,35,,323.4,percent of total billed charges,Implant Device,323.4,35,,323.4,percent of total billed charges,Implant Device,323.4,35,,323.4,percent of total billed charges,Implant Device,323.4,35,,323.4,percent of total billed charges,Implant Device,369.6,40,,369.6,percent of total billed charges,Implant Device,323.4,70,,323.4,percent of total billed charges,All Other,314.16,34,,314.16,percent of total billed charges,Implant Device,314.16,34,,314.16,percent of total billed charges,Implant Device,323.4,35,,323.4,percent of total billed charges,Implant Device,323.4,35,,323.4,percent of total billed charges,Implant Device,323.4,35,,323.4,percent of total billed charges,Implant Device,323.4,35,,323.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,683.76,
BARD 1808050 POWERPORT,C1788,HCPCS,,79001692,CDM,278,RC,,,both,,,1498,1108.52,,,1108.52,Other,150% of Medicare + 9.63% HCRA Surcharge,674.1,45,,674.1,percent of total billed charges,Critical Access Hospital RCC factor,509.32,34,,509.32,percent of total billed charges,Implant Device,509.32,34,,509.32,percent of total billed charges,Implant Device,509.32,34,,509.32,percent of total billed charges,Implant Device,509.32,34,,509.32,percent of total billed charges,Implant Device,509.32,34,,509.32,percent of total billed charges,Implant Device,741.51,,,741.51,Other,110% of Medicare,524.3,35,,524.3,percent of total billed charges,Implant Device,509.32,34,"Charges > $500, x 34%",509.32,percent of total billed charges,Implant Device,524.3,35,,524.3,percent of total billed charges,Implant Device,524.3,35,,524.3,percent of total billed charges,Implant Device,524.3,35,,524.3,percent of total billed charges,Implant Device,524.3,35,,524.3,percent of total billed charges,Implant Device,524.3,35,,524.3,percent of total billed charges,Implant Device,599.2,40,,599.2,percent of total billed charges,Implant Device,524.3,70,,524.3,percent of total billed charges,All Other,509.32,34,,509.32,percent of total billed charges,Implant Device,509.32,34,,509.32,percent of total billed charges,Implant Device,524.3,35,,524.3,percent of total billed charges,Implant Device,524.3,35,,524.3,percent of total billed charges,Implant Device,524.3,35,,524.3,percent of total billed charges,Implant Device,524.3,35,,524.3,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1108.52,
BARD 1808560 POWERPORT,C1788,HCPCS,,79001693,CDM,278,RC,,,both,,,1575,1165.5,,,1165.5,Other,150% of Medicare + 9.63% HCRA Surcharge,708.75,45,,708.75,percent of total billed charges,Critical Access Hospital RCC factor,535.5,34,,535.5,percent of total billed charges,Implant Device,535.5,34,,535.5,percent of total billed charges,Implant Device,535.5,34,,535.5,percent of total billed charges,Implant Device,535.5,34,,535.5,percent of total billed charges,Implant Device,535.5,34,,535.5,percent of total billed charges,Implant Device,779.63,,,779.63,Other,110% of Medicare,551.25,35,,551.25,percent of total billed charges,Implant Device,535.5,34,"Charges > $500, x 34%",535.5,percent of total billed charges,Implant Device,551.25,35,,551.25,percent of total billed charges,Implant Device,551.25,35,,551.25,percent of total billed charges,Implant Device,551.25,35,,551.25,percent of total billed charges,Implant Device,551.25,35,,551.25,percent of total billed charges,Implant Device,551.25,35,,551.25,percent of total billed charges,Implant Device,630,40,,630,percent of total billed charges,Implant Device,551.25,70,,551.25,percent of total billed charges,All Other,535.5,34,,535.5,percent of total billed charges,Implant Device,535.5,34,,535.5,percent of total billed charges,Implant Device,551.25,35,,551.25,percent of total billed charges,Implant Device,551.25,35,,551.25,percent of total billed charges,Implant Device,551.25,35,,551.25,percent of total billed charges,Implant Device,551.25,35,,551.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1165.5,
MTF 38100 PUTTY DBX 10CC,C1713,HCPCS,,79001694,CDM,278,RC,,,both,,,3982,2946.69,,,2946.69,Other,150% of Medicare + 9.63% HCRA Surcharge,1791.9,45,,1791.9,percent of total billed charges,Critical Access Hospital RCC factor,1353.88,34,,1353.88,percent of total billed charges,Implant Device,1353.88,34,,1353.88,percent of total billed charges,Implant Device,1353.88,34,,1353.88,percent of total billed charges,Implant Device,1353.88,34,,1353.88,percent of total billed charges,Implant Device,1353.88,34,,1353.88,percent of total billed charges,Implant Device,1971.09,,,1971.09,Other,110% of Medicare,1393.7,35,,1393.7,percent of total billed charges,Implant Device,1353.88,34,"Charges > $500, x 34%",1353.88,percent of total billed charges,Implant Device,1393.7,35,,1393.7,percent of total billed charges,Implant Device,1393.7,35,,1393.7,percent of total billed charges,Implant Device,1393.7,35,,1393.7,percent of total billed charges,Implant Device,1393.7,35,,1393.7,percent of total billed charges,Implant Device,1393.7,35,,1393.7,percent of total billed charges,Implant Device,1592.8,40,,1592.8,percent of total billed charges,Implant Device,1393.7,70,,1393.7,percent of total billed charges,All Other,1353.88,34,,1353.88,percent of total billed charges,Implant Device,1353.88,34,,1353.88,percent of total billed charges,Implant Device,1393.7,35,,1393.7,percent of total billed charges,Implant Device,1393.7,35,,1393.7,percent of total billed charges,Implant Device,1393.7,35,,1393.7,percent of total billed charges,Implant Device,1393.7,35,,1393.7,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1353.88,34,"If Charge > 2,000, then 34 percent",1353.88,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2946.69,
PUTTY DBX 2.5CC,C1713,HCPCS,,79001695,CDM,278,RC,,,both,,,2770,2049.81,,,2049.81,Other,150% of Medicare + 9.63% HCRA Surcharge,1246.5,45,,1246.5,percent of total billed charges,Critical Access Hospital RCC factor,941.8,34,,941.8,percent of total billed charges,Implant Device,941.8,34,,941.8,percent of total billed charges,Implant Device,941.8,34,,941.8,percent of total billed charges,Implant Device,941.8,34,,941.8,percent of total billed charges,Implant Device,941.8,34,,941.8,percent of total billed charges,Implant Device,1371.15,,,1371.15,Other,110% of Medicare,969.5,35,,969.5,percent of total billed charges,Implant Device,941.8,34,"Charges > $500, x 34%",941.8,percent of total billed charges,Implant Device,969.5,35,,969.5,percent of total billed charges,Implant Device,969.5,35,,969.5,percent of total billed charges,Implant Device,969.5,35,,969.5,percent of total billed charges,Implant Device,969.5,35,,969.5,percent of total billed charges,Implant Device,969.5,35,,969.5,percent of total billed charges,Implant Device,1108,40,,1108,percent of total billed charges,Implant Device,969.5,70,,969.5,percent of total billed charges,All Other,941.8,34,,941.8,percent of total billed charges,Implant Device,941.8,34,,941.8,percent of total billed charges,Implant Device,969.5,35,,969.5,percent of total billed charges,Implant Device,969.5,35,,969.5,percent of total billed charges,Implant Device,969.5,35,,969.5,percent of total billed charges,Implant Device,969.5,35,,969.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,941.8,34,"If Charge > 2,000, then 34 percent",941.8,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2049.81,
MTF 38025 PUTTY DBX 2CC,C1713,HCPCS,,79001696,CDM,278,RC,,,both,,,1504,1112.96,,,1112.96,Other,150% of Medicare + 9.63% HCRA Surcharge,676.8,45,,676.8,percent of total billed charges,Critical Access Hospital RCC factor,511.36,34,,511.36,percent of total billed charges,Implant Device,511.36,34,,511.36,percent of total billed charges,Implant Device,511.36,34,,511.36,percent of total billed charges,Implant Device,511.36,34,,511.36,percent of total billed charges,Implant Device,511.36,34,,511.36,percent of total billed charges,Implant Device,744.48,,,744.48,Other,110% of Medicare,526.4,35,,526.4,percent of total billed charges,Implant Device,511.36,34,"Charges > $500, x 34%",511.36,percent of total billed charges,Implant Device,526.4,35,,526.4,percent of total billed charges,Implant Device,526.4,35,,526.4,percent of total billed charges,Implant Device,526.4,35,,526.4,percent of total billed charges,Implant Device,526.4,35,,526.4,percent of total billed charges,Implant Device,526.4,35,,526.4,percent of total billed charges,Implant Device,601.6,40,,601.6,percent of total billed charges,Implant Device,526.4,70,,526.4,percent of total billed charges,All Other,511.36,34,,511.36,percent of total billed charges,Implant Device,511.36,34,,511.36,percent of total billed charges,Implant Device,526.4,35,,526.4,percent of total billed charges,Implant Device,526.4,35,,526.4,percent of total billed charges,Implant Device,526.4,35,,526.4,percent of total billed charges,Implant Device,526.4,35,,526.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1112.96,
MTF 58025 PUTTY DBX MIX 2.5CC,C1713,HCPCS,,79001697,CDM,278,RC,,,both,,,1770,1309.8,,,1309.8,Other,150% of Medicare + 9.63% HCRA Surcharge,796.5,45,,796.5,percent of total billed charges,Critical Access Hospital RCC factor,601.8,34,,601.8,percent of total billed charges,Implant Device,601.8,34,,601.8,percent of total billed charges,Implant Device,601.8,34,,601.8,percent of total billed charges,Implant Device,601.8,34,,601.8,percent of total billed charges,Implant Device,601.8,34,,601.8,percent of total billed charges,Implant Device,876.15,,,876.15,Other,110% of Medicare,619.5,35,,619.5,percent of total billed charges,Implant Device,601.8,34,"Charges > $500, x 34%",601.8,percent of total billed charges,Implant Device,619.5,35,,619.5,percent of total billed charges,Implant Device,619.5,35,,619.5,percent of total billed charges,Implant Device,619.5,35,,619.5,percent of total billed charges,Implant Device,619.5,35,,619.5,percent of total billed charges,Implant Device,619.5,35,,619.5,percent of total billed charges,Implant Device,708,40,,708,percent of total billed charges,Implant Device,619.5,70,,619.5,percent of total billed charges,All Other,601.8,34,,601.8,percent of total billed charges,Implant Device,601.8,34,,601.8,percent of total billed charges,Implant Device,619.5,35,,619.5,percent of total billed charges,Implant Device,619.5,35,,619.5,percent of total billed charges,Implant Device,619.5,35,,619.5,percent of total billed charges,Implant Device,619.5,35,,619.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1309.8,
PUTTY DBX MIX 2.5CC,C1713,HCPCS,,79001698,CDM,278,RC,,,both,,,3434,2541.17,,,2541.17,Other,150% of Medicare + 9.63% HCRA Surcharge,1545.3,45,,1545.3,percent of total billed charges,Critical Access Hospital RCC factor,1167.56,34,,1167.56,percent of total billed charges,Implant Device,1167.56,34,,1167.56,percent of total billed charges,Implant Device,1167.56,34,,1167.56,percent of total billed charges,Implant Device,1167.56,34,,1167.56,percent of total billed charges,Implant Device,1167.56,34,,1167.56,percent of total billed charges,Implant Device,1699.83,,,1699.83,Other,110% of Medicare,1201.9,35,,1201.9,percent of total billed charges,Implant Device,1167.56,34,"Charges > $500, x 34%",1167.56,percent of total billed charges,Implant Device,1201.9,35,,1201.9,percent of total billed charges,Implant Device,1201.9,35,,1201.9,percent of total billed charges,Implant Device,1201.9,35,,1201.9,percent of total billed charges,Implant Device,1201.9,35,,1201.9,percent of total billed charges,Implant Device,1201.9,35,,1201.9,percent of total billed charges,Implant Device,1373.6,40,,1373.6,percent of total billed charges,Implant Device,1201.9,70,,1201.9,percent of total billed charges,All Other,1167.56,34,,1167.56,percent of total billed charges,Implant Device,1167.56,34,,1167.56,percent of total billed charges,Implant Device,1201.9,35,,1201.9,percent of total billed charges,Implant Device,1201.9,35,,1201.9,percent of total billed charges,Implant Device,1201.9,35,,1201.9,percent of total billed charges,Implant Device,1201.9,35,,1201.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1167.56,34,"If Charge > 2,000, then 34 percent",1167.56,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2541.17,
ZIMMER 00-1105-005-01 PUTTY W/CHIPS .5CC,C1713,HCPCS,,79001699,CDM,278,RC,,,both,,,346,256.04,,,256.04,Other,150% of Medicare + 9.63% HCRA Surcharge,155.7,45,,155.7,percent of total billed charges,Critical Access Hospital RCC factor,117.64,34,,117.64,percent of total billed charges,Implant Device,117.64,34,,117.64,percent of total billed charges,Implant Device,117.64,34,,117.64,percent of total billed charges,Implant Device,117.64,34,,117.64,percent of total billed charges,Implant Device,117.64,34,,117.64,percent of total billed charges,Implant Device,171.27,,,171.27,Other,110% of Medicare,121.1,35,,121.1,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,121.1,35,,121.1,percent of total billed charges,Implant Device,121.1,35,,121.1,percent of total billed charges,Implant Device,121.1,35,,121.1,percent of total billed charges,Implant Device,121.1,35,,121.1,percent of total billed charges,Implant Device,121.1,35,,121.1,percent of total billed charges,Implant Device,138.4,40,,138.4,percent of total billed charges,Implant Device,121.1,70,,121.1,percent of total billed charges,All Other,117.64,34,,117.64,percent of total billed charges,Implant Device,117.64,34,,117.64,percent of total billed charges,Implant Device,121.1,35,,121.1,percent of total billed charges,Implant Device,121.1,35,,121.1,percent of total billed charges,Implant Device,121.1,35,,121.1,percent of total billed charges,Implant Device,121.1,35,,121.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,256.04,
ZIMMER 00-1105-010-02 PUTTY W/CHIPS 1CC,C1713,HCPCS,,79001700,CDM,278,RC,,,both,,,1140,843.6,,,843.6,Other,150% of Medicare + 9.63% HCRA Surcharge,513,45,,513,percent of total billed charges,Critical Access Hospital RCC factor,387.6,34,,387.6,percent of total billed charges,Implant Device,387.6,34,,387.6,percent of total billed charges,Implant Device,387.6,34,,387.6,percent of total billed charges,Implant Device,387.6,34,,387.6,percent of total billed charges,Implant Device,387.6,34,,387.6,percent of total billed charges,Implant Device,564.3,,,564.3,Other,110% of Medicare,399,35,,399,percent of total billed charges,Implant Device,387.6,34,"Charges > $500, x 34%",387.6,percent of total billed charges,Implant Device,399,35,,399,percent of total billed charges,Implant Device,399,35,,399,percent of total billed charges,Implant Device,399,35,,399,percent of total billed charges,Implant Device,399,35,,399,percent of total billed charges,Implant Device,399,35,,399,percent of total billed charges,Implant Device,456,40,,456,percent of total billed charges,Implant Device,399,70,,399,percent of total billed charges,All Other,387.6,34,,387.6,percent of total billed charges,Implant Device,387.6,34,,387.6,percent of total billed charges,Implant Device,399,35,,399,percent of total billed charges,Implant Device,399,35,,399,percent of total billed charges,Implant Device,399,35,,399,percent of total billed charges,Implant Device,399,35,,399,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,843.6,
ZIMMER 00-1105-020-02 PUTTY W/CHIPS 2CC,C1713,HCPCS,,79001701,CDM,278,RC,,,both,,,1192,882.08,,,882.08,Other,150% of Medicare + 9.63% HCRA Surcharge,536.4,45,,536.4,percent of total billed charges,Critical Access Hospital RCC factor,405.28,34,,405.28,percent of total billed charges,Implant Device,405.28,34,,405.28,percent of total billed charges,Implant Device,405.28,34,,405.28,percent of total billed charges,Implant Device,405.28,34,,405.28,percent of total billed charges,Implant Device,405.28,34,,405.28,percent of total billed charges,Implant Device,590.04,,,590.04,Other,110% of Medicare,417.2,35,,417.2,percent of total billed charges,Implant Device,405.28,34,"Charges > $500, x 34%",405.28,percent of total billed charges,Implant Device,417.2,35,,417.2,percent of total billed charges,Implant Device,417.2,35,,417.2,percent of total billed charges,Implant Device,417.2,35,,417.2,percent of total billed charges,Implant Device,417.2,35,,417.2,percent of total billed charges,Implant Device,417.2,35,,417.2,percent of total billed charges,Implant Device,476.8,40,,476.8,percent of total billed charges,Implant Device,417.2,70,,417.2,percent of total billed charges,All Other,405.28,34,,405.28,percent of total billed charges,Implant Device,405.28,34,,405.28,percent of total billed charges,Implant Device,417.2,35,,417.2,percent of total billed charges,Implant Device,417.2,35,,417.2,percent of total billed charges,Implant Device,417.2,35,,417.2,percent of total billed charges,Implant Device,417.2,35,,417.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,882.08,
J&J 222983 QUICKANCHOR,C1713,HCPCS,,79001702,CDM,278,RC,,,both,,,1176,870.24,,,870.24,Other,150% of Medicare + 9.63% HCRA Surcharge,529.2,45,,529.2,percent of total billed charges,Critical Access Hospital RCC factor,399.84,34,,399.84,percent of total billed charges,Implant Device,399.84,34,,399.84,percent of total billed charges,Implant Device,399.84,34,,399.84,percent of total billed charges,Implant Device,399.84,34,,399.84,percent of total billed charges,Implant Device,399.84,34,,399.84,percent of total billed charges,Implant Device,582.12,,,582.12,Other,110% of Medicare,411.6,35,,411.6,percent of total billed charges,Implant Device,399.84,34,"Charges > $500, x 34%",399.84,percent of total billed charges,Implant Device,411.6,35,,411.6,percent of total billed charges,Implant Device,411.6,35,,411.6,percent of total billed charges,Implant Device,411.6,35,,411.6,percent of total billed charges,Implant Device,411.6,35,,411.6,percent of total billed charges,Implant Device,411.6,35,,411.6,percent of total billed charges,Implant Device,470.4,40,,470.4,percent of total billed charges,Implant Device,411.6,70,,411.6,percent of total billed charges,All Other,399.84,34,,399.84,percent of total billed charges,Implant Device,399.84,34,,399.84,percent of total billed charges,Implant Device,411.6,35,,411.6,percent of total billed charges,Implant Device,411.6,35,,411.6,percent of total billed charges,Implant Device,411.6,35,,411.6,percent of total billed charges,Implant Device,411.6,35,,411.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,870.24,
GORE RT06050080L RING THINWALL 6 X 80,C1781,HCPCS,,79001703,CDM,278,RC,,,both,,,3262,2413.89,,,2413.89,Other,150% of Medicare + 9.63% HCRA Surcharge,1467.9,45,,1467.9,percent of total billed charges,Critical Access Hospital RCC factor,1109.08,34,,1109.08,percent of total billed charges,Implant Device,1109.08,34,,1109.08,percent of total billed charges,Implant Device,1109.08,34,,1109.08,percent of total billed charges,Implant Device,1109.08,34,,1109.08,percent of total billed charges,Implant Device,1109.08,34,,1109.08,percent of total billed charges,Implant Device,1614.69,,,1614.69,Other,110% of Medicare,1141.7,35,,1141.7,percent of total billed charges,Implant Device,1109.08,34,"Charges > $500, x 34%",1109.08,percent of total billed charges,Implant Device,1141.7,35,,1141.7,percent of total billed charges,Implant Device,1141.7,35,,1141.7,percent of total billed charges,Implant Device,1141.7,35,,1141.7,percent of total billed charges,Implant Device,1141.7,35,,1141.7,percent of total billed charges,Implant Device,1141.7,35,,1141.7,percent of total billed charges,Implant Device,1304.8,40,,1304.8,percent of total billed charges,Implant Device,1141.7,70,,1141.7,percent of total billed charges,All Other,1109.08,34,,1109.08,percent of total billed charges,Implant Device,1109.08,34,,1109.08,percent of total billed charges,Implant Device,1141.7,35,,1141.7,percent of total billed charges,Implant Device,1141.7,35,,1141.7,percent of total billed charges,Implant Device,1141.7,35,,1141.7,percent of total billed charges,Implant Device,1141.7,35,,1141.7,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1109.08,34,"If Charge > 2,000, then 34 percent",1109.08,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2413.89,
BIOMET 21-2109 SCREW 2.0,C1713,HCPCS,,79001704,CDM,278,RC,,,both,,,67,49.58,,,49.58,Other,150% of Medicare + 9.63% HCRA Surcharge,30.15,45,,30.15,percent of total billed charges,Critical Access Hospital RCC factor,22.78,34,,22.78,percent of total billed charges,Implant Device,22.78,34,,22.78,percent of total billed charges,Implant Device,22.78,34,,22.78,percent of total billed charges,Implant Device,22.78,34,,22.78,percent of total billed charges,Implant Device,22.78,34,,22.78,percent of total billed charges,Implant Device,33.17,,,33.17,Other,110% of Medicare,23.45,35,,23.45,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,23.45,35,,23.45,percent of total billed charges,Implant Device,23.45,35,,23.45,percent of total billed charges,Implant Device,23.45,35,,23.45,percent of total billed charges,Implant Device,23.45,35,,23.45,percent of total billed charges,Implant Device,23.45,35,,23.45,percent of total billed charges,Implant Device,26.8,40,,26.8,percent of total billed charges,Implant Device,23.45,70,,23.45,percent of total billed charges,All Other,22.78,34,,22.78,percent of total billed charges,Implant Device,22.78,34,,22.78,percent of total billed charges,Implant Device,23.45,35,,23.45,percent of total billed charges,Implant Device,23.45,35,,23.45,percent of total billed charges,Implant Device,23.45,35,,23.45,percent of total billed charges,Implant Device,23.45,35,,23.45,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,49.58,
BIOMET 20-2107 SCREW 2.0,C1713,HCPCS,,79001705,CDM,278,RC,,,both,,,67,49.58,,,49.58,Other,150% of Medicare + 9.63% HCRA Surcharge,30.15,45,,30.15,percent of total billed charges,Critical Access Hospital RCC factor,22.78,34,,22.78,percent of total billed charges,Implant Device,22.78,34,,22.78,percent of total billed charges,Implant Device,22.78,34,,22.78,percent of total billed charges,Implant Device,22.78,34,,22.78,percent of total billed charges,Implant Device,22.78,34,,22.78,percent of total billed charges,Implant Device,33.17,,,33.17,Other,110% of Medicare,23.45,35,,23.45,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,23.45,35,,23.45,percent of total billed charges,Implant Device,23.45,35,,23.45,percent of total billed charges,Implant Device,23.45,35,,23.45,percent of total billed charges,Implant Device,23.45,35,,23.45,percent of total billed charges,Implant Device,23.45,35,,23.45,percent of total billed charges,Implant Device,26.8,40,,26.8,percent of total billed charges,Implant Device,23.45,70,,23.45,percent of total billed charges,All Other,22.78,34,,22.78,percent of total billed charges,Implant Device,22.78,34,,22.78,percent of total billed charges,Implant Device,23.45,35,,23.45,percent of total billed charges,Implant Device,23.45,35,,23.45,percent of total billed charges,Implant Device,23.45,35,,23.45,percent of total billed charges,Implant Device,23.45,35,,23.45,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,49.58,
BIOMET 20-2111 SCREW 2.0,C1713,HCPCS,,79001706,CDM,278,RC,,,both,,,67,49.58,,,49.58,Other,150% of Medicare + 9.63% HCRA Surcharge,30.15,45,,30.15,percent of total billed charges,Critical Access Hospital RCC factor,22.78,34,,22.78,percent of total billed charges,Implant Device,22.78,34,,22.78,percent of total billed charges,Implant Device,22.78,34,,22.78,percent of total billed charges,Implant Device,22.78,34,,22.78,percent of total billed charges,Implant Device,22.78,34,,22.78,percent of total billed charges,Implant Device,33.17,,,33.17,Other,110% of Medicare,23.45,35,,23.45,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,23.45,35,,23.45,percent of total billed charges,Implant Device,23.45,35,,23.45,percent of total billed charges,Implant Device,23.45,35,,23.45,percent of total billed charges,Implant Device,23.45,35,,23.45,percent of total billed charges,Implant Device,23.45,35,,23.45,percent of total billed charges,Implant Device,26.8,40,,26.8,percent of total billed charges,Implant Device,23.45,70,,23.45,percent of total billed charges,All Other,22.78,34,,22.78,percent of total billed charges,Implant Device,22.78,34,,22.78,percent of total billed charges,Implant Device,23.45,35,,23.45,percent of total billed charges,Implant Device,23.45,35,,23.45,percent of total billed charges,Implant Device,23.45,35,,23.45,percent of total billed charges,Implant Device,23.45,35,,23.45,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,49.58,
BIOMET 20-2307 SCREW 2.3,C1713,HCPCS,,79001707,CDM,278,RC,,,both,,,144,106.56,,,106.56,Other,150% of Medicare + 9.63% HCRA Surcharge,64.8,45,,64.8,percent of total billed charges,Critical Access Hospital RCC factor,48.96,34,,48.96,percent of total billed charges,Implant Device,48.96,34,,48.96,percent of total billed charges,Implant Device,48.96,34,,48.96,percent of total billed charges,Implant Device,48.96,34,,48.96,percent of total billed charges,Implant Device,48.96,34,,48.96,percent of total billed charges,Implant Device,71.28,,,71.28,Other,110% of Medicare,50.4,35,,50.4,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,50.4,35,,50.4,percent of total billed charges,Implant Device,50.4,35,,50.4,percent of total billed charges,Implant Device,50.4,35,,50.4,percent of total billed charges,Implant Device,50.4,35,,50.4,percent of total billed charges,Implant Device,50.4,35,,50.4,percent of total billed charges,Implant Device,57.6,40,,57.6,percent of total billed charges,Implant Device,50.4,70,,50.4,percent of total billed charges,All Other,48.96,34,,48.96,percent of total billed charges,Implant Device,48.96,34,,48.96,percent of total billed charges,Implant Device,50.4,35,,50.4,percent of total billed charges,Implant Device,50.4,35,,50.4,percent of total billed charges,Implant Device,50.4,35,,50.4,percent of total billed charges,Implant Device,50.4,35,,50.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,106.56,
BIOMET 81-2410 SCREW 2.4,C1713,HCPCS,,79001708,CDM,278,RC,,,both,,,52,38.48,,,38.48,Other,150% of Medicare + 9.63% HCRA Surcharge,23.4,45,,23.4,percent of total billed charges,Critical Access Hospital RCC factor,17.68,34,,17.68,percent of total billed charges,Implant Device,17.68,34,,17.68,percent of total billed charges,Implant Device,17.68,34,,17.68,percent of total billed charges,Implant Device,17.68,34,,17.68,percent of total billed charges,Implant Device,17.68,34,,17.68,percent of total billed charges,Implant Device,25.74,,,25.74,Other,110% of Medicare,18.2,35,,18.2,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,18.2,35,,18.2,percent of total billed charges,Implant Device,18.2,35,,18.2,percent of total billed charges,Implant Device,18.2,35,,18.2,percent of total billed charges,Implant Device,18.2,35,,18.2,percent of total billed charges,Implant Device,18.2,35,,18.2,percent of total billed charges,Implant Device,20.8,40,,20.8,percent of total billed charges,Implant Device,18.2,70,,18.2,percent of total billed charges,All Other,17.68,34,,17.68,percent of total billed charges,Implant Device,17.68,34,,17.68,percent of total billed charges,Implant Device,18.2,35,,18.2,percent of total billed charges,Implant Device,18.2,35,,18.2,percent of total billed charges,Implant Device,18.2,35,,18.2,percent of total billed charges,Implant Device,18.2,35,,18.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,38.48,
BIOMET 81-2716 SCREW 2.7,C1713,HCPCS,,79001709,CDM,278,RC,,,both,,,55,40.7,,,40.7,Other,150% of Medicare + 9.63% HCRA Surcharge,24.75,45,,24.75,percent of total billed charges,Critical Access Hospital RCC factor,18.7,34,,18.7,percent of total billed charges,Implant Device,18.7,34,,18.7,percent of total billed charges,Implant Device,18.7,34,,18.7,percent of total billed charges,Implant Device,18.7,34,,18.7,percent of total billed charges,Implant Device,18.7,34,,18.7,percent of total billed charges,Implant Device,27.23,,,27.23,Other,110% of Medicare,19.25,35,,19.25,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,19.25,35,,19.25,percent of total billed charges,Implant Device,19.25,35,,19.25,percent of total billed charges,Implant Device,19.25,35,,19.25,percent of total billed charges,Implant Device,19.25,35,,19.25,percent of total billed charges,Implant Device,19.25,35,,19.25,percent of total billed charges,Implant Device,22,40,,22,percent of total billed charges,Implant Device,19.25,70,,19.25,percent of total billed charges,All Other,18.7,34,,18.7,percent of total billed charges,Implant Device,18.7,34,,18.7,percent of total billed charges,Implant Device,19.25,35,,19.25,percent of total billed charges,Implant Device,19.25,35,,19.25,percent of total billed charges,Implant Device,19.25,35,,19.25,percent of total billed charges,Implant Device,19.25,35,,19.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,40.7,
ARTHREX AR-1390E SCREW 9 X 20,C1713,HCPCS,,79001710,CDM,278,RC,,,both,,,346,256.04,,,256.04,Other,150% of Medicare + 9.63% HCRA Surcharge,155.7,45,,155.7,percent of total billed charges,Critical Access Hospital RCC factor,117.64,34,,117.64,percent of total billed charges,Implant Device,117.64,34,,117.64,percent of total billed charges,Implant Device,117.64,34,,117.64,percent of total billed charges,Implant Device,117.64,34,,117.64,percent of total billed charges,Implant Device,117.64,34,,117.64,percent of total billed charges,Implant Device,171.27,,,171.27,Other,110% of Medicare,121.1,35,,121.1,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,121.1,35,,121.1,percent of total billed charges,Implant Device,121.1,35,,121.1,percent of total billed charges,Implant Device,121.1,35,,121.1,percent of total billed charges,Implant Device,121.1,35,,121.1,percent of total billed charges,Implant Device,121.1,35,,121.1,percent of total billed charges,Implant Device,138.4,40,,138.4,percent of total billed charges,Implant Device,121.1,70,,121.1,percent of total billed charges,All Other,117.64,34,,117.64,percent of total billed charges,Implant Device,117.64,34,,117.64,percent of total billed charges,Implant Device,121.1,35,,121.1,percent of total billed charges,Implant Device,121.1,35,,121.1,percent of total billed charges,Implant Device,121.1,35,,121.1,percent of total billed charges,Implant Device,121.1,35,,121.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,256.04,
BIOMET 63028 SCREW SELF DRILLING 4X14MM,C1713,HCPCS,,79001711,CDM,278,RC,,,both,,,1180,873.2,,,873.2,Other,150% of Medicare + 9.63% HCRA Surcharge,531,45,,531,percent of total billed charges,Critical Access Hospital RCC factor,401.2,34,,401.2,percent of total billed charges,Implant Device,401.2,34,,401.2,percent of total billed charges,Implant Device,401.2,34,,401.2,percent of total billed charges,Implant Device,401.2,34,,401.2,percent of total billed charges,Implant Device,401.2,34,,401.2,percent of total billed charges,Implant Device,584.1,,,584.1,Other,110% of Medicare,413,35,,413,percent of total billed charges,Implant Device,401.2,34,"Charges > $500, x 34%",401.2,percent of total billed charges,Implant Device,413,35,,413,percent of total billed charges,Implant Device,413,35,,413,percent of total billed charges,Implant Device,413,35,,413,percent of total billed charges,Implant Device,413,35,,413,percent of total billed charges,Implant Device,413,35,,413,percent of total billed charges,Implant Device,472,40,,472,percent of total billed charges,Implant Device,413,70,,413,percent of total billed charges,All Other,401.2,34,,401.2,percent of total billed charges,Implant Device,401.2,34,,401.2,percent of total billed charges,Implant Device,413,35,,413,percent of total billed charges,Implant Device,413,35,,413,percent of total billed charges,Implant Device,413,35,,413,percent of total billed charges,Implant Device,413,35,,413,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,873.2,
BIOMET 63030 SCREW SELF DRILLING 4X16MM,C1713,HCPCS,,79001712,CDM,278,RC,,,both,,,1122,830.28,,,830.28,Other,150% of Medicare + 9.63% HCRA Surcharge,504.9,45,,504.9,percent of total billed charges,Critical Access Hospital RCC factor,381.48,34,,381.48,percent of total billed charges,Implant Device,381.48,34,,381.48,percent of total billed charges,Implant Device,381.48,34,,381.48,percent of total billed charges,Implant Device,381.48,34,,381.48,percent of total billed charges,Implant Device,381.48,34,,381.48,percent of total billed charges,Implant Device,555.39,,,555.39,Other,110% of Medicare,392.7,35,,392.7,percent of total billed charges,Implant Device,381.48,34,"Charges > $500, x 34%",381.48,percent of total billed charges,Implant Device,392.7,35,,392.7,percent of total billed charges,Implant Device,392.7,35,,392.7,percent of total billed charges,Implant Device,392.7,35,,392.7,percent of total billed charges,Implant Device,392.7,35,,392.7,percent of total billed charges,Implant Device,392.7,35,,392.7,percent of total billed charges,Implant Device,448.8,40,,448.8,percent of total billed charges,Implant Device,392.7,70,,392.7,percent of total billed charges,All Other,381.48,34,,381.48,percent of total billed charges,Implant Device,381.48,34,,381.48,percent of total billed charges,Implant Device,392.7,35,,392.7,percent of total billed charges,Implant Device,392.7,35,,392.7,percent of total billed charges,Implant Device,392.7,35,,392.7,percent of total billed charges,Implant Device,392.7,35,,392.7,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,830.28,
INTEGRA DHRSL5 SCREW HEAD RING LARGE,C1713,HCPCS,,79001713,CDM,278,RC,,,both,,,408,301.92,,,301.92,Other,150% of Medicare + 9.63% HCRA Surcharge,183.6,45,,183.6,percent of total billed charges,Critical Access Hospital RCC factor,138.72,34,,138.72,percent of total billed charges,Implant Device,138.72,34,,138.72,percent of total billed charges,Implant Device,138.72,34,,138.72,percent of total billed charges,Implant Device,138.72,34,,138.72,percent of total billed charges,Implant Device,138.72,34,,138.72,percent of total billed charges,Implant Device,201.96,,,201.96,Other,110% of Medicare,142.8,35,,142.8,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,142.8,35,,142.8,percent of total billed charges,Implant Device,142.8,35,,142.8,percent of total billed charges,Implant Device,142.8,35,,142.8,percent of total billed charges,Implant Device,142.8,35,,142.8,percent of total billed charges,Implant Device,142.8,35,,142.8,percent of total billed charges,Implant Device,163.2,40,,163.2,percent of total billed charges,Implant Device,142.8,70,,142.8,percent of total billed charges,All Other,138.72,34,,138.72,percent of total billed charges,Implant Device,138.72,34,,138.72,percent of total billed charges,Implant Device,142.8,35,,142.8,percent of total billed charges,Implant Device,142.8,35,,142.8,percent of total billed charges,Implant Device,142.8,35,,142.8,percent of total billed charges,Implant Device,142.8,35,,142.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,301.92,
INTEGRA DHRSS5 SCREWS HEAD RING SMALL,C1713,HCPCS,,79001714,CDM,278,RC,,,both,,,324,239.76,,,239.76,Other,150% of Medicare + 9.63% HCRA Surcharge,145.8,45,,145.8,percent of total billed charges,Critical Access Hospital RCC factor,110.16,34,,110.16,percent of total billed charges,Implant Device,110.16,34,,110.16,percent of total billed charges,Implant Device,110.16,34,,110.16,percent of total billed charges,Implant Device,110.16,34,,110.16,percent of total billed charges,Implant Device,110.16,34,,110.16,percent of total billed charges,Implant Device,160.38,,,160.38,Other,110% of Medicare,113.4,35,,113.4,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,129.6,40,,129.6,percent of total billed charges,Implant Device,113.4,70,,113.4,percent of total billed charges,All Other,110.16,34,,110.16,percent of total billed charges,Implant Device,110.16,34,,110.16,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,239.76,
BIOMET 91-6105X SCREW SD 1.65X5MM,C1713,HCPCS,,79001715,CDM,278,RC,,,both,,,252,186.48,,,186.48,Other,150% of Medicare + 9.63% HCRA Surcharge,113.4,45,,113.4,percent of total billed charges,Critical Access Hospital RCC factor,85.68,34,,85.68,percent of total billed charges,Implant Device,85.68,34,,85.68,percent of total billed charges,Implant Device,85.68,34,,85.68,percent of total billed charges,Implant Device,85.68,34,,85.68,percent of total billed charges,Implant Device,85.68,34,,85.68,percent of total billed charges,Implant Device,124.74,,,124.74,Other,110% of Medicare,88.2,35,,88.2,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,88.2,35,,88.2,percent of total billed charges,Implant Device,88.2,35,,88.2,percent of total billed charges,Implant Device,88.2,35,,88.2,percent of total billed charges,Implant Device,88.2,35,,88.2,percent of total billed charges,Implant Device,88.2,35,,88.2,percent of total billed charges,Implant Device,100.8,40,,100.8,percent of total billed charges,Implant Device,88.2,70,,88.2,percent of total billed charges,All Other,85.68,34,,85.68,percent of total billed charges,Implant Device,85.68,34,,85.68,percent of total billed charges,Implant Device,88.2,35,,88.2,percent of total billed charges,Implant Device,88.2,35,,88.2,percent of total billed charges,Implant Device,88.2,35,,88.2,percent of total billed charges,Implant Device,88.2,35,,88.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,186.48,
BIOMET SPINE 45-5538 SPACER CERVICAL 8MM,C1713,HCPCS,,79001716,CDM,278,RC,,,both,,,3724,2755.77,,,2755.77,Other,150% of Medicare + 9.63% HCRA Surcharge,1675.8,45,,1675.8,percent of total billed charges,Critical Access Hospital RCC factor,1266.16,34,,1266.16,percent of total billed charges,Implant Device,1266.16,34,,1266.16,percent of total billed charges,Implant Device,1266.16,34,,1266.16,percent of total billed charges,Implant Device,1266.16,34,,1266.16,percent of total billed charges,Implant Device,1266.16,34,,1266.16,percent of total billed charges,Implant Device,1843.38,,,1843.38,Other,110% of Medicare,1303.4,35,,1303.4,percent of total billed charges,Implant Device,1266.16,34,"Charges > $500, x 34%",1266.16,percent of total billed charges,Implant Device,1303.4,35,,1303.4,percent of total billed charges,Implant Device,1303.4,35,,1303.4,percent of total billed charges,Implant Device,1303.4,35,,1303.4,percent of total billed charges,Implant Device,1303.4,35,,1303.4,percent of total billed charges,Implant Device,1303.4,35,,1303.4,percent of total billed charges,Implant Device,1489.6,40,,1489.6,percent of total billed charges,Implant Device,1303.4,70,,1303.4,percent of total billed charges,All Other,1266.16,34,,1266.16,percent of total billed charges,Implant Device,1266.16,34,,1266.16,percent of total billed charges,Implant Device,1303.4,35,,1303.4,percent of total billed charges,Implant Device,1303.4,35,,1303.4,percent of total billed charges,Implant Device,1303.4,35,,1303.4,percent of total billed charges,Implant Device,1303.4,35,,1303.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1266.16,34,"If Charge > 2,000, then 34 percent",1266.16,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2755.77,
BIOMET SPINE 45-5539 SPACER CERVICAL 9MM,C1713,HCPCS,,79001717,CDM,278,RC,,,both,,,4170,3085.81,,,3085.81,Other,150% of Medicare + 9.63% HCRA Surcharge,1876.5,45,,1876.5,percent of total billed charges,Critical Access Hospital RCC factor,1417.8,34,,1417.8,percent of total billed charges,Implant Device,1417.8,34,,1417.8,percent of total billed charges,Implant Device,1417.8,34,,1417.8,percent of total billed charges,Implant Device,1417.8,34,,1417.8,percent of total billed charges,Implant Device,1417.8,34,,1417.8,percent of total billed charges,Implant Device,2064.15,,,2064.15,Other,110% of Medicare,1459.5,35,,1459.5,percent of total billed charges,Implant Device,1417.8,34,"Charges > $500, x 34%",1417.8,percent of total billed charges,Implant Device,1459.5,35,,1459.5,percent of total billed charges,Implant Device,1459.5,35,,1459.5,percent of total billed charges,Implant Device,1459.5,35,,1459.5,percent of total billed charges,Implant Device,1459.5,35,,1459.5,percent of total billed charges,Implant Device,1459.5,35,,1459.5,percent of total billed charges,Implant Device,1668,40,,1668,percent of total billed charges,Implant Device,1459.5,70,,1459.5,percent of total billed charges,All Other,1417.8,34,,1417.8,percent of total billed charges,Implant Device,1417.8,34,,1417.8,percent of total billed charges,Implant Device,1459.5,35,,1459.5,percent of total billed charges,Implant Device,1459.5,35,,1459.5,percent of total billed charges,Implant Device,1459.5,35,,1459.5,percent of total billed charges,Implant Device,1459.5,35,,1459.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1417.8,34,"If Charge > 2,000, then 34 percent",1417.8,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3085.81,
SUTURE EXPRESS B3837 STENT 4 X 26,C1875,HCPCS,,79001718,CDM,278,RC,,,both,,,409,302.66,,,302.66,Other,150% of Medicare + 9.63% HCRA Surcharge,184.05,45,,184.05,percent of total billed charges,Critical Access Hospital RCC factor,139.06,34,,139.06,percent of total billed charges,Implant Device,139.06,34,,139.06,percent of total billed charges,Implant Device,139.06,34,,139.06,percent of total billed charges,Implant Device,139.06,34,,139.06,percent of total billed charges,Implant Device,139.06,34,,139.06,percent of total billed charges,Implant Device,202.46,,,202.46,Other,110% of Medicare,143.15,35,,143.15,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,143.15,35,,143.15,percent of total billed charges,Implant Device,143.15,35,,143.15,percent of total billed charges,Implant Device,143.15,35,,143.15,percent of total billed charges,Implant Device,143.15,35,,143.15,percent of total billed charges,Implant Device,143.15,35,,143.15,percent of total billed charges,Implant Device,163.6,40,,163.6,percent of total billed charges,Implant Device,143.15,70,,143.15,percent of total billed charges,All Other,139.06,34,,139.06,percent of total billed charges,Implant Device,139.06,34,,139.06,percent of total billed charges,Implant Device,143.15,35,,143.15,percent of total billed charges,Implant Device,143.15,35,,143.15,percent of total billed charges,Implant Device,143.15,35,,143.15,percent of total billed charges,Implant Device,143.15,35,,143.15,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,302.66,
BOST SCI 192-123 STENT 5 X 26,C1875,HCPCS,,79001719,CDM,278,RC,,,both,,,431,318.94,,,318.94,Other,150% of Medicare + 9.63% HCRA Surcharge,193.95,45,,193.95,percent of total billed charges,Critical Access Hospital RCC factor,146.54,34,,146.54,percent of total billed charges,Implant Device,146.54,34,,146.54,percent of total billed charges,Implant Device,146.54,34,,146.54,percent of total billed charges,Implant Device,146.54,34,,146.54,percent of total billed charges,Implant Device,146.54,34,,146.54,percent of total billed charges,Implant Device,213.35,,,213.35,Other,110% of Medicare,150.85,35,,150.85,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,150.85,35,,150.85,percent of total billed charges,Implant Device,150.85,35,,150.85,percent of total billed charges,Implant Device,150.85,35,,150.85,percent of total billed charges,Implant Device,150.85,35,,150.85,percent of total billed charges,Implant Device,150.85,35,,150.85,percent of total billed charges,Implant Device,172.4,40,,172.4,percent of total billed charges,Implant Device,150.85,70,,150.85,percent of total billed charges,All Other,146.54,34,,146.54,percent of total billed charges,Implant Device,146.54,34,,146.54,percent of total billed charges,Implant Device,150.85,35,,150.85,percent of total billed charges,Implant Device,150.85,35,,150.85,percent of total billed charges,Implant Device,150.85,35,,150.85,percent of total billed charges,Implant Device,150.85,35,,150.85,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,318.94,
BOST SCI 192-124 STENT 5 X 28,C1875,HCPCS,,79001720,CDM,278,RC,,,both,,,431,318.94,,,318.94,Other,150% of Medicare + 9.63% HCRA Surcharge,193.95,45,,193.95,percent of total billed charges,Critical Access Hospital RCC factor,146.54,34,,146.54,percent of total billed charges,Implant Device,146.54,34,,146.54,percent of total billed charges,Implant Device,146.54,34,,146.54,percent of total billed charges,Implant Device,146.54,34,,146.54,percent of total billed charges,Implant Device,146.54,34,,146.54,percent of total billed charges,Implant Device,213.35,,,213.35,Other,110% of Medicare,150.85,35,,150.85,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,150.85,35,,150.85,percent of total billed charges,Implant Device,150.85,35,,150.85,percent of total billed charges,Implant Device,150.85,35,,150.85,percent of total billed charges,Implant Device,150.85,35,,150.85,percent of total billed charges,Implant Device,150.85,35,,150.85,percent of total billed charges,Implant Device,172.4,40,,172.4,percent of total billed charges,Implant Device,150.85,70,,150.85,percent of total billed charges,All Other,146.54,34,,146.54,percent of total billed charges,Implant Device,146.54,34,,146.54,percent of total billed charges,Implant Device,150.85,35,,150.85,percent of total billed charges,Implant Device,150.85,35,,150.85,percent of total billed charges,Implant Device,150.85,35,,150.85,percent of total billed charges,Implant Device,150.85,35,,150.85,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,318.94,
BOST SCI 192-122 STENT 5 X24,C1875,HCPCS,,79001721,CDM,278,RC,,,both,,,431,318.94,,,318.94,Other,150% of Medicare + 9.63% HCRA Surcharge,193.95,45,,193.95,percent of total billed charges,Critical Access Hospital RCC factor,146.54,34,,146.54,percent of total billed charges,Implant Device,146.54,34,,146.54,percent of total billed charges,Implant Device,146.54,34,,146.54,percent of total billed charges,Implant Device,146.54,34,,146.54,percent of total billed charges,Implant Device,146.54,34,,146.54,percent of total billed charges,Implant Device,213.35,,,213.35,Other,110% of Medicare,150.85,35,,150.85,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,150.85,35,,150.85,percent of total billed charges,Implant Device,150.85,35,,150.85,percent of total billed charges,Implant Device,150.85,35,,150.85,percent of total billed charges,Implant Device,150.85,35,,150.85,percent of total billed charges,Implant Device,150.85,35,,150.85,percent of total billed charges,Implant Device,172.4,40,,172.4,percent of total billed charges,Implant Device,150.85,70,,150.85,percent of total billed charges,All Other,146.54,34,,146.54,percent of total billed charges,Implant Device,146.54,34,,146.54,percent of total billed charges,Implant Device,150.85,35,,150.85,percent of total billed charges,Implant Device,150.85,35,,150.85,percent of total billed charges,Implant Device,150.85,35,,150.85,percent of total billed charges,Implant Device,150.85,35,,150.85,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,318.94,
BOST SCI 192-131 STENT 6 X 22 POLARIS,C1875,HCPCS,,79001722,CDM,278,RC,,,both,,,431,318.94,,,318.94,Other,150% of Medicare + 9.63% HCRA Surcharge,193.95,45,,193.95,percent of total billed charges,Critical Access Hospital RCC factor,146.54,34,,146.54,percent of total billed charges,Implant Device,146.54,34,,146.54,percent of total billed charges,Implant Device,146.54,34,,146.54,percent of total billed charges,Implant Device,146.54,34,,146.54,percent of total billed charges,Implant Device,146.54,34,,146.54,percent of total billed charges,Implant Device,213.35,,,213.35,Other,110% of Medicare,150.85,35,,150.85,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,150.85,35,,150.85,percent of total billed charges,Implant Device,150.85,35,,150.85,percent of total billed charges,Implant Device,150.85,35,,150.85,percent of total billed charges,Implant Device,150.85,35,,150.85,percent of total billed charges,Implant Device,150.85,35,,150.85,percent of total billed charges,Implant Device,172.4,40,,172.4,percent of total billed charges,Implant Device,150.85,70,,150.85,percent of total billed charges,All Other,146.54,34,,146.54,percent of total billed charges,Implant Device,146.54,34,,146.54,percent of total billed charges,Implant Device,150.85,35,,150.85,percent of total billed charges,Implant Device,150.85,35,,150.85,percent of total billed charges,Implant Device,150.85,35,,150.85,percent of total billed charges,Implant Device,150.85,35,,150.85,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,318.94,
BOST SCI 192-132 STENT 6 X 24 POLARIS,C1875,HCPCS,,79001723,CDM,278,RC,,,both,,,431,318.94,,,318.94,Other,150% of Medicare + 9.63% HCRA Surcharge,193.95,45,,193.95,percent of total billed charges,Critical Access Hospital RCC factor,146.54,34,,146.54,percent of total billed charges,Implant Device,146.54,34,,146.54,percent of total billed charges,Implant Device,146.54,34,,146.54,percent of total billed charges,Implant Device,146.54,34,,146.54,percent of total billed charges,Implant Device,146.54,34,,146.54,percent of total billed charges,Implant Device,213.35,,,213.35,Other,110% of Medicare,150.85,35,,150.85,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,150.85,35,,150.85,percent of total billed charges,Implant Device,150.85,35,,150.85,percent of total billed charges,Implant Device,150.85,35,,150.85,percent of total billed charges,Implant Device,150.85,35,,150.85,percent of total billed charges,Implant Device,150.85,35,,150.85,percent of total billed charges,Implant Device,172.4,40,,172.4,percent of total billed charges,Implant Device,150.85,70,,150.85,percent of total billed charges,All Other,146.54,34,,146.54,percent of total billed charges,Implant Device,146.54,34,,146.54,percent of total billed charges,Implant Device,150.85,35,,150.85,percent of total billed charges,Implant Device,150.85,35,,150.85,percent of total billed charges,Implant Device,150.85,35,,150.85,percent of total billed charges,Implant Device,150.85,35,,150.85,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,318.94,
BOST SCI 192-133 STENT 6 X 26 POLARIS,C1875,HCPCS,,79001724,CDM,278,RC,,,both,,,431,318.94,,,318.94,Other,150% of Medicare + 9.63% HCRA Surcharge,193.95,45,,193.95,percent of total billed charges,Critical Access Hospital RCC factor,146.54,34,,146.54,percent of total billed charges,Implant Device,146.54,34,,146.54,percent of total billed charges,Implant Device,146.54,34,,146.54,percent of total billed charges,Implant Device,146.54,34,,146.54,percent of total billed charges,Implant Device,146.54,34,,146.54,percent of total billed charges,Implant Device,213.35,,,213.35,Other,110% of Medicare,150.85,35,,150.85,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,150.85,35,,150.85,percent of total billed charges,Implant Device,150.85,35,,150.85,percent of total billed charges,Implant Device,150.85,35,,150.85,percent of total billed charges,Implant Device,150.85,35,,150.85,percent of total billed charges,Implant Device,150.85,35,,150.85,percent of total billed charges,Implant Device,172.4,40,,172.4,percent of total billed charges,Implant Device,150.85,70,,150.85,percent of total billed charges,All Other,146.54,34,,146.54,percent of total billed charges,Implant Device,146.54,34,,146.54,percent of total billed charges,Implant Device,150.85,35,,150.85,percent of total billed charges,Implant Device,150.85,35,,150.85,percent of total billed charges,Implant Device,150.85,35,,150.85,percent of total billed charges,Implant Device,150.85,35,,150.85,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,318.94,
BOST SCI 192-134 STENT 6 X 28 POLARIS,C1875,HCPCS,,79001725,CDM,278,RC,,,both,,,427,315.98,,,315.98,Other,150% of Medicare + 9.63% HCRA Surcharge,192.15,45,,192.15,percent of total billed charges,Critical Access Hospital RCC factor,145.18,34,,145.18,percent of total billed charges,Implant Device,145.18,34,,145.18,percent of total billed charges,Implant Device,145.18,34,,145.18,percent of total billed charges,Implant Device,145.18,34,,145.18,percent of total billed charges,Implant Device,145.18,34,,145.18,percent of total billed charges,Implant Device,211.37,,,211.37,Other,110% of Medicare,149.45,35,,149.45,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,149.45,35,,149.45,percent of total billed charges,Implant Device,149.45,35,,149.45,percent of total billed charges,Implant Device,149.45,35,,149.45,percent of total billed charges,Implant Device,149.45,35,,149.45,percent of total billed charges,Implant Device,149.45,35,,149.45,percent of total billed charges,Implant Device,170.8,40,,170.8,percent of total billed charges,Implant Device,149.45,70,,149.45,percent of total billed charges,All Other,145.18,34,,145.18,percent of total billed charges,Implant Device,145.18,34,,145.18,percent of total billed charges,Implant Device,149.45,35,,149.45,percent of total billed charges,Implant Device,149.45,35,,149.45,percent of total billed charges,Implant Device,149.45,35,,149.45,percent of total billed charges,Implant Device,149.45,35,,149.45,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,315.98,
BOST SCI 192-143 STENT 7 X 26,C1875,HCPCS,,79001726,CDM,278,RC,,,both,,,427,315.98,,,315.98,Other,150% of Medicare + 9.63% HCRA Surcharge,192.15,45,,192.15,percent of total billed charges,Critical Access Hospital RCC factor,145.18,34,,145.18,percent of total billed charges,Implant Device,145.18,34,,145.18,percent of total billed charges,Implant Device,145.18,34,,145.18,percent of total billed charges,Implant Device,145.18,34,,145.18,percent of total billed charges,Implant Device,145.18,34,,145.18,percent of total billed charges,Implant Device,211.37,,,211.37,Other,110% of Medicare,149.45,35,,149.45,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,149.45,35,,149.45,percent of total billed charges,Implant Device,149.45,35,,149.45,percent of total billed charges,Implant Device,149.45,35,,149.45,percent of total billed charges,Implant Device,149.45,35,,149.45,percent of total billed charges,Implant Device,149.45,35,,149.45,percent of total billed charges,Implant Device,170.8,40,,170.8,percent of total billed charges,Implant Device,149.45,70,,149.45,percent of total billed charges,All Other,145.18,34,,145.18,percent of total billed charges,Implant Device,145.18,34,,145.18,percent of total billed charges,Implant Device,149.45,35,,149.45,percent of total billed charges,Implant Device,149.45,35,,149.45,percent of total billed charges,Implant Device,149.45,35,,149.45,percent of total billed charges,Implant Device,149.45,35,,149.45,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,315.98,
BOST SCI 192-151 STENT 8 X 22 POLARIS,C1875,HCPCS,,79001727,CDM,278,RC,,,both,,,431,318.94,,,318.94,Other,150% of Medicare + 9.63% HCRA Surcharge,193.95,45,,193.95,percent of total billed charges,Critical Access Hospital RCC factor,146.54,34,,146.54,percent of total billed charges,Implant Device,146.54,34,,146.54,percent of total billed charges,Implant Device,146.54,34,,146.54,percent of total billed charges,Implant Device,146.54,34,,146.54,percent of total billed charges,Implant Device,146.54,34,,146.54,percent of total billed charges,Implant Device,213.35,,,213.35,Other,110% of Medicare,150.85,35,,150.85,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,150.85,35,,150.85,percent of total billed charges,Implant Device,150.85,35,,150.85,percent of total billed charges,Implant Device,150.85,35,,150.85,percent of total billed charges,Implant Device,150.85,35,,150.85,percent of total billed charges,Implant Device,150.85,35,,150.85,percent of total billed charges,Implant Device,172.4,40,,172.4,percent of total billed charges,Implant Device,150.85,70,,150.85,percent of total billed charges,All Other,146.54,34,,146.54,percent of total billed charges,Implant Device,146.54,34,,146.54,percent of total billed charges,Implant Device,150.85,35,,150.85,percent of total billed charges,Implant Device,150.85,35,,150.85,percent of total billed charges,Implant Device,150.85,35,,150.85,percent of total billed charges,Implant Device,150.85,35,,150.85,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,318.94,
BOST SCI 192-152 STENT 8 X 24 POLARIS,C1875,HCPCS,,79001728,CDM,278,RC,,,both,,,431,318.94,,,318.94,Other,150% of Medicare + 9.63% HCRA Surcharge,193.95,45,,193.95,percent of total billed charges,Critical Access Hospital RCC factor,146.54,34,,146.54,percent of total billed charges,Implant Device,146.54,34,,146.54,percent of total billed charges,Implant Device,146.54,34,,146.54,percent of total billed charges,Implant Device,146.54,34,,146.54,percent of total billed charges,Implant Device,146.54,34,,146.54,percent of total billed charges,Implant Device,213.35,,,213.35,Other,110% of Medicare,150.85,35,,150.85,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,150.85,35,,150.85,percent of total billed charges,Implant Device,150.85,35,,150.85,percent of total billed charges,Implant Device,150.85,35,,150.85,percent of total billed charges,Implant Device,150.85,35,,150.85,percent of total billed charges,Implant Device,150.85,35,,150.85,percent of total billed charges,Implant Device,172.4,40,,172.4,percent of total billed charges,Implant Device,150.85,70,,150.85,percent of total billed charges,All Other,146.54,34,,146.54,percent of total billed charges,Implant Device,146.54,34,,146.54,percent of total billed charges,Implant Device,150.85,35,,150.85,percent of total billed charges,Implant Device,150.85,35,,150.85,percent of total billed charges,Implant Device,150.85,35,,150.85,percent of total billed charges,Implant Device,150.85,35,,150.85,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,318.94,
BOST SCI 192-153 STENT 8 X 26 POLARIS,C1875,HCPCS,,79001729,CDM,278,RC,,,both,,,431,318.94,,,318.94,Other,150% of Medicare + 9.63% HCRA Surcharge,193.95,45,,193.95,percent of total billed charges,Critical Access Hospital RCC factor,146.54,34,,146.54,percent of total billed charges,Implant Device,146.54,34,,146.54,percent of total billed charges,Implant Device,146.54,34,,146.54,percent of total billed charges,Implant Device,146.54,34,,146.54,percent of total billed charges,Implant Device,146.54,34,,146.54,percent of total billed charges,Implant Device,213.35,,,213.35,Other,110% of Medicare,150.85,35,,150.85,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,150.85,35,,150.85,percent of total billed charges,Implant Device,150.85,35,,150.85,percent of total billed charges,Implant Device,150.85,35,,150.85,percent of total billed charges,Implant Device,150.85,35,,150.85,percent of total billed charges,Implant Device,150.85,35,,150.85,percent of total billed charges,Implant Device,172.4,40,,172.4,percent of total billed charges,Implant Device,150.85,70,,150.85,percent of total billed charges,All Other,146.54,34,,146.54,percent of total billed charges,Implant Device,146.54,34,,146.54,percent of total billed charges,Implant Device,150.85,35,,150.85,percent of total billed charges,Implant Device,150.85,35,,150.85,percent of total billed charges,Implant Device,150.85,35,,150.85,percent of total billed charges,Implant Device,150.85,35,,150.85,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,318.94,
SUTURE EXP 175-263 STENT PERCUFLEX 6X26,C1758,HCPCS,,79001730,CDM,278,RC,,,both,,,342,253.08,,,253.08,Other,150% of Medicare + 9.63% HCRA Surcharge,153.9,45,,153.9,percent of total billed charges,Critical Access Hospital RCC factor,116.28,34,,116.28,percent of total billed charges,Implant Device,116.28,34,,116.28,percent of total billed charges,Implant Device,116.28,34,,116.28,percent of total billed charges,Implant Device,116.28,34,,116.28,percent of total billed charges,Implant Device,116.28,34,,116.28,percent of total billed charges,Implant Device,169.29,,,169.29,Other,110% of Medicare,119.7,35,,119.7,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,119.7,35,,119.7,percent of total billed charges,Implant Device,119.7,35,,119.7,percent of total billed charges,Implant Device,119.7,35,,119.7,percent of total billed charges,Implant Device,119.7,35,,119.7,percent of total billed charges,Implant Device,119.7,35,,119.7,percent of total billed charges,Implant Device,136.8,40,,136.8,percent of total billed charges,Implant Device,119.7,70,,119.7,percent of total billed charges,All Other,116.28,34,,116.28,percent of total billed charges,Implant Device,116.28,34,,116.28,percent of total billed charges,Implant Device,119.7,35,,119.7,percent of total billed charges,Implant Device,119.7,35,,119.7,percent of total billed charges,Implant Device,119.7,35,,119.7,percent of total billed charges,Implant Device,119.7,35,,119.7,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,253.08,
JNT RST FDN 80038005 STIMUPLAST PUTTY5CC,C1713,HCPCS,,79001731,CDM,278,RC,,,both,,,2400,1776.01,,,1776.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1080,45,,1080,percent of total billed charges,Critical Access Hospital RCC factor,816,34,,816,percent of total billed charges,Implant Device,816,34,,816,percent of total billed charges,Implant Device,816,34,,816,percent of total billed charges,Implant Device,816,34,,816,percent of total billed charges,Implant Device,816,34,,816,percent of total billed charges,Implant Device,1188,,,1188,Other,110% of Medicare,840,35,,840,percent of total billed charges,Implant Device,816,34,"Charges > $500, x 34%",816,percent of total billed charges,Implant Device,840,35,,840,percent of total billed charges,Implant Device,840,35,,840,percent of total billed charges,Implant Device,840,35,,840,percent of total billed charges,Implant Device,840,35,,840,percent of total billed charges,Implant Device,840,35,,840,percent of total billed charges,Implant Device,960,40,,960,percent of total billed charges,Implant Device,840,70,,840,percent of total billed charges,All Other,816,34,,816,percent of total billed charges,Implant Device,816,34,,816,percent of total billed charges,Implant Device,840,35,,840,percent of total billed charges,Implant Device,840,35,,840,percent of total billed charges,Implant Device,840,35,,840,percent of total billed charges,Implant Device,840,35,,840,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,816,34,"If Charge > 2,000, then 34 percent",816,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1776.01,
GORE SAX01 STRETCH VASCULAR GRAFT RINGED,C1768,HCPCS,,79001732,CDM,278,RC,,,both,,,6690,4950.62,,,4950.62,Other,150% of Medicare + 9.63% HCRA Surcharge,3010.5,45,,3010.5,percent of total billed charges,Critical Access Hospital RCC factor,2274.6,34,,2274.6,percent of total billed charges,Implant Device,2274.6,34,,2274.6,percent of total billed charges,Implant Device,2274.6,34,,2274.6,percent of total billed charges,Implant Device,2274.6,34,,2274.6,percent of total billed charges,Implant Device,2274.6,34,,2274.6,percent of total billed charges,Implant Device,3311.55,,,3311.55,Other,110% of Medicare,2341.5,35,,2341.5,percent of total billed charges,Implant Device,2274.6,34,"Charges > $500, x 34%",2274.6,percent of total billed charges,Implant Device,2341.5,35,,2341.5,percent of total billed charges,Implant Device,2341.5,35,,2341.5,percent of total billed charges,Implant Device,2341.5,35,,2341.5,percent of total billed charges,Implant Device,2341.5,35,,2341.5,percent of total billed charges,Implant Device,2341.5,35,,2341.5,percent of total billed charges,Implant Device,2676,40,,2676,percent of total billed charges,Implant Device,2341.5,70,,2341.5,percent of total billed charges,All Other,2274.6,34,,2274.6,percent of total billed charges,Implant Device,2274.6,34,,2274.6,percent of total billed charges,Implant Device,2341.5,35,,2341.5,percent of total billed charges,Implant Device,2341.5,35,,2341.5,percent of total billed charges,Implant Device,2341.5,35,,2341.5,percent of total billed charges,Implant Device,2341.5,35,,2341.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2274.6,34,"If Charge > 2,000, then 34 percent",2274.6,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4950.62,
SUT EXP SPMM35 SURGIPRO MESH 3 X 5,C1781,HCPCS,,79001733,CDM,278,RC,,,both,,,117,86.58,,,86.58,Other,150% of Medicare + 9.63% HCRA Surcharge,52.65,45,,52.65,percent of total billed charges,Critical Access Hospital RCC factor,39.78,34,,39.78,percent of total billed charges,Implant Device,39.78,34,,39.78,percent of total billed charges,Implant Device,39.78,34,,39.78,percent of total billed charges,Implant Device,39.78,34,,39.78,percent of total billed charges,Implant Device,39.78,34,,39.78,percent of total billed charges,Implant Device,57.92,,,57.92,Other,110% of Medicare,40.95,35,,40.95,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,40.95,35,,40.95,percent of total billed charges,Implant Device,40.95,35,,40.95,percent of total billed charges,Implant Device,40.95,35,,40.95,percent of total billed charges,Implant Device,40.95,35,,40.95,percent of total billed charges,Implant Device,40.95,35,,40.95,percent of total billed charges,Implant Device,46.8,40,,46.8,percent of total billed charges,Implant Device,40.95,70,,40.95,percent of total billed charges,All Other,39.78,34,,39.78,percent of total billed charges,Implant Device,39.78,34,,39.78,percent of total billed charges,Implant Device,40.95,35,,40.95,percent of total billed charges,Implant Device,40.95,35,,40.95,percent of total billed charges,Implant Device,40.95,35,,40.95,percent of total billed charges,Implant Device,40.95,35,,40.95,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,86.58,
SUTURE EXPRESS SPMM66 SURGIPRO MESH 6X6,C1781,HCPCS,,79001734,CDM,278,RC,,,both,,,92,68.08,,,68.08,Other,150% of Medicare + 9.63% HCRA Surcharge,41.4,45,,41.4,percent of total billed charges,Critical Access Hospital RCC factor,31.28,34,,31.28,percent of total billed charges,Implant Device,31.28,34,,31.28,percent of total billed charges,Implant Device,31.28,34,,31.28,percent of total billed charges,Implant Device,31.28,34,,31.28,percent of total billed charges,Implant Device,31.28,34,,31.28,percent of total billed charges,Implant Device,45.54,,,45.54,Other,110% of Medicare,32.2,35,,32.2,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,32.2,35,,32.2,percent of total billed charges,Implant Device,32.2,35,,32.2,percent of total billed charges,Implant Device,32.2,35,,32.2,percent of total billed charges,Implant Device,32.2,35,,32.2,percent of total billed charges,Implant Device,32.2,35,,32.2,percent of total billed charges,Implant Device,36.8,40,,36.8,percent of total billed charges,Implant Device,32.2,70,,32.2,percent of total billed charges,All Other,31.28,34,,31.28,percent of total billed charges,Implant Device,31.28,34,,31.28,percent of total billed charges,Implant Device,32.2,35,,32.2,percent of total billed charges,Implant Device,32.2,35,,32.2,percent of total billed charges,Implant Device,32.2,35,,32.2,percent of total billed charges,Implant Device,32.2,35,,32.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,68.08,
ARTHREX AR-1927BCF-45 SUT ANCHOR 4.5MM,C1713,HCPCS,,79001735,CDM,278,RC,,,both,,,975,721.5,,,721.5,Other,150% of Medicare + 9.63% HCRA Surcharge,438.75,45,,438.75,percent of total billed charges,Critical Access Hospital RCC factor,331.5,34,,331.5,percent of total billed charges,Implant Device,331.5,34,,331.5,percent of total billed charges,Implant Device,331.5,34,,331.5,percent of total billed charges,Implant Device,331.5,34,,331.5,percent of total billed charges,Implant Device,331.5,34,,331.5,percent of total billed charges,Implant Device,482.63,,,482.63,Other,110% of Medicare,341.25,35,,341.25,percent of total billed charges,Implant Device,331.5,34,"Charges > $500, x 34%",331.5,percent of total billed charges,Implant Device,341.25,35,,341.25,percent of total billed charges,Implant Device,341.25,35,,341.25,percent of total billed charges,Implant Device,341.25,35,,341.25,percent of total billed charges,Implant Device,341.25,35,,341.25,percent of total billed charges,Implant Device,341.25,35,,341.25,percent of total billed charges,Implant Device,390,40,,390,percent of total billed charges,Implant Device,341.25,70,,341.25,percent of total billed charges,All Other,331.5,34,,331.5,percent of total billed charges,Implant Device,331.5,34,,331.5,percent of total billed charges,Implant Device,341.25,35,,341.25,percent of total billed charges,Implant Device,341.25,35,,341.25,percent of total billed charges,Implant Device,341.25,35,,341.25,percent of total billed charges,Implant Device,341.25,35,,341.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,721.5,
ARTHREX AR-1927BCFT-65 SUT ANCHOR 4.75,C1713,HCPCS,,79001736,CDM,278,RC,,,both,,,1005,743.7,,,743.7,Other,150% of Medicare + 9.63% HCRA Surcharge,452.25,45,,452.25,percent of total billed charges,Critical Access Hospital RCC factor,341.7,34,,341.7,percent of total billed charges,Implant Device,341.7,34,,341.7,percent of total billed charges,Implant Device,341.7,34,,341.7,percent of total billed charges,Implant Device,341.7,34,,341.7,percent of total billed charges,Implant Device,341.7,34,,341.7,percent of total billed charges,Implant Device,497.48,,,497.48,Other,110% of Medicare,351.75,35,,351.75,percent of total billed charges,Implant Device,341.7,34,"Charges > $500, x 34%",341.7,percent of total billed charges,Implant Device,351.75,35,,351.75,percent of total billed charges,Implant Device,351.75,35,,351.75,percent of total billed charges,Implant Device,351.75,35,,351.75,percent of total billed charges,Implant Device,351.75,35,,351.75,percent of total billed charges,Implant Device,351.75,35,,351.75,percent of total billed charges,Implant Device,402,40,,402,percent of total billed charges,Implant Device,351.75,70,,351.75,percent of total billed charges,All Other,341.7,34,,341.7,percent of total billed charges,Implant Device,341.7,34,,341.7,percent of total billed charges,Implant Device,351.75,35,,351.75,percent of total billed charges,Implant Device,351.75,35,,351.75,percent of total billed charges,Implant Device,351.75,35,,351.75,percent of total billed charges,Implant Device,351.75,35,,351.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,743.7,
ARTHREX AR-1927BNF SUTURE ANCHOR 5.5X15,C1713,HCPCS,,79001737,CDM,278,RC,,,both,,,886,655.64,,,655.64,Other,150% of Medicare + 9.63% HCRA Surcharge,398.7,45,,398.7,percent of total billed charges,Critical Access Hospital RCC factor,301.24,34,,301.24,percent of total billed charges,Implant Device,301.24,34,,301.24,percent of total billed charges,Implant Device,301.24,34,,301.24,percent of total billed charges,Implant Device,301.24,34,,301.24,percent of total billed charges,Implant Device,301.24,34,,301.24,percent of total billed charges,Implant Device,438.57,,,438.57,Other,110% of Medicare,310.1,35,,310.1,percent of total billed charges,Implant Device,301.24,34,"Charges > $500, x 34%",301.24,percent of total billed charges,Implant Device,310.1,35,,310.1,percent of total billed charges,Implant Device,310.1,35,,310.1,percent of total billed charges,Implant Device,310.1,35,,310.1,percent of total billed charges,Implant Device,310.1,35,,310.1,percent of total billed charges,Implant Device,310.1,35,,310.1,percent of total billed charges,Implant Device,354.4,40,,354.4,percent of total billed charges,Implant Device,310.1,70,,310.1,percent of total billed charges,All Other,301.24,34,,301.24,percent of total billed charges,Implant Device,301.24,34,,301.24,percent of total billed charges,Implant Device,310.1,35,,310.1,percent of total billed charges,Implant Device,310.1,35,,310.1,percent of total billed charges,Implant Device,310.1,35,,310.1,percent of total billed charges,Implant Device,310.1,35,,310.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,655.64,
SUTURE ANCHOR SWIVELOCK  4.75 X 19.1,C1713,HCPCS,,79001738,CDM,278,RC,,,both,,,1200,888,,,888,Other,150% of Medicare + 9.63% HCRA Surcharge,540,45,,540,percent of total billed charges,Critical Access Hospital RCC factor,408,34,,408,percent of total billed charges,Implant Device,408,34,,408,percent of total billed charges,Implant Device,408,34,,408,percent of total billed charges,Implant Device,408,34,,408,percent of total billed charges,Implant Device,408,34,,408,percent of total billed charges,Implant Device,594,,,594,Other,110% of Medicare,420,35,,420,percent of total billed charges,Implant Device,408,34,"Charges > $500, x 34%",408,percent of total billed charges,Implant Device,420,35,,420,percent of total billed charges,Implant Device,420,35,,420,percent of total billed charges,Implant Device,420,35,,420,percent of total billed charges,Implant Device,420,35,,420,percent of total billed charges,Implant Device,420,35,,420,percent of total billed charges,Implant Device,480,40,,480,percent of total billed charges,Implant Device,420,70,,420,percent of total billed charges,All Other,408,34,,408,percent of total billed charges,Implant Device,408,34,,408,percent of total billed charges,Implant Device,420,35,,420,percent of total billed charges,Implant Device,420,35,,420,percent of total billed charges,Implant Device,420,35,,420,percent of total billed charges,Implant Device,420,35,,420,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,888,
ARTHREX AR-2323BCC SUT ANCHOR 5.5X19.1,C1713,HCPCS,,79001739,CDM,278,RC,,,both,,,1200,888,,,888,Other,150% of Medicare + 9.63% HCRA Surcharge,540,45,,540,percent of total billed charges,Critical Access Hospital RCC factor,408,34,,408,percent of total billed charges,Implant Device,408,34,,408,percent of total billed charges,Implant Device,408,34,,408,percent of total billed charges,Implant Device,408,34,,408,percent of total billed charges,Implant Device,408,34,,408,percent of total billed charges,Implant Device,594,,,594,Other,110% of Medicare,420,35,,420,percent of total billed charges,Implant Device,408,34,"Charges > $500, x 34%",408,percent of total billed charges,Implant Device,420,35,,420,percent of total billed charges,Implant Device,420,35,,420,percent of total billed charges,Implant Device,420,35,,420,percent of total billed charges,Implant Device,420,35,,420,percent of total billed charges,Implant Device,420,35,,420,percent of total billed charges,Implant Device,480,40,,480,percent of total billed charges,Implant Device,420,70,,420,percent of total billed charges,All Other,408,34,,408,percent of total billed charges,Implant Device,408,34,,408,percent of total billed charges,Implant Device,420,35,,420,percent of total billed charges,Implant Device,420,35,,420,percent of total billed charges,Implant Device,420,35,,420,percent of total billed charges,Implant Device,420,35,,420,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,888,
SOLANA TSF-2718A ALLOGRAFT 2.7X18 ANGLED,C1713,HCPCS,,79001740,CDM,278,RC,,,both,,,3496,2587.05,,,2587.05,Other,150% of Medicare + 9.63% HCRA Surcharge,1573.2,45,,1573.2,percent of total billed charges,Critical Access Hospital RCC factor,1188.64,34,,1188.64,percent of total billed charges,Implant Device,1188.64,34,,1188.64,percent of total billed charges,Implant Device,1188.64,34,,1188.64,percent of total billed charges,Implant Device,1188.64,34,,1188.64,percent of total billed charges,Implant Device,1188.64,34,,1188.64,percent of total billed charges,Implant Device,1730.52,,,1730.52,Other,110% of Medicare,1223.6,35,,1223.6,percent of total billed charges,Implant Device,1188.64,34,"Charges > $500, x 34%",1188.64,percent of total billed charges,Implant Device,1223.6,35,,1223.6,percent of total billed charges,Implant Device,1223.6,35,,1223.6,percent of total billed charges,Implant Device,1223.6,35,,1223.6,percent of total billed charges,Implant Device,1223.6,35,,1223.6,percent of total billed charges,Implant Device,1223.6,35,,1223.6,percent of total billed charges,Implant Device,1398.4,40,,1398.4,percent of total billed charges,Implant Device,1223.6,70,,1223.6,percent of total billed charges,All Other,1188.64,34,,1188.64,percent of total billed charges,Implant Device,1188.64,34,,1188.64,percent of total billed charges,Implant Device,1223.6,35,,1223.6,percent of total billed charges,Implant Device,1223.6,35,,1223.6,percent of total billed charges,Implant Device,1223.6,35,,1223.6,percent of total billed charges,Implant Device,1223.6,35,,1223.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1188.64,34,"If Charge > 2,000, then 34 percent",1188.64,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2587.05,
ARTHREX AR-8921DS TIGHTROPE CANNULATED,C1713,HCPCS,,79001741,CDM,278,RC,,,both,,,1440,1065.6,,,1065.6,Other,150% of Medicare + 9.63% HCRA Surcharge,648,45,,648,percent of total billed charges,Critical Access Hospital RCC factor,489.6,34,,489.6,percent of total billed charges,Implant Device,489.6,34,,489.6,percent of total billed charges,Implant Device,489.6,34,,489.6,percent of total billed charges,Implant Device,489.6,34,,489.6,percent of total billed charges,Implant Device,489.6,34,,489.6,percent of total billed charges,Implant Device,712.8,,,712.8,Other,110% of Medicare,504,35,,504,percent of total billed charges,Implant Device,489.6,34,"Charges > $500, x 34%",489.6,percent of total billed charges,Implant Device,504,35,,504,percent of total billed charges,Implant Device,504,35,,504,percent of total billed charges,Implant Device,504,35,,504,percent of total billed charges,Implant Device,504,35,,504,percent of total billed charges,Implant Device,504,35,,504,percent of total billed charges,Implant Device,576,40,,576,percent of total billed charges,Implant Device,504,70,,504,percent of total billed charges,All Other,489.6,34,,489.6,percent of total billed charges,Implant Device,489.6,34,,489.6,percent of total billed charges,Implant Device,504,35,,504,percent of total billed charges,Implant Device,504,35,,504,percent of total billed charges,Implant Device,504,35,,504,percent of total billed charges,Implant Device,504,35,,504,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1065.6,
ARTHREX AR-8920DS TIGHTROPE REPAIR KIT,C1713,HCPCS,,79001742,CDM,278,RC,,,both,,,2640,1953.61,,,1953.61,Other,150% of Medicare + 9.63% HCRA Surcharge,1188,45,,1188,percent of total billed charges,Critical Access Hospital RCC factor,897.6,34,,897.6,percent of total billed charges,Implant Device,897.6,34,,897.6,percent of total billed charges,Implant Device,897.6,34,,897.6,percent of total billed charges,Implant Device,897.6,34,,897.6,percent of total billed charges,Implant Device,897.6,34,,897.6,percent of total billed charges,Implant Device,1306.8,,,1306.8,Other,110% of Medicare,924,35,,924,percent of total billed charges,Implant Device,897.6,34,"Charges > $500, x 34%",897.6,percent of total billed charges,Implant Device,924,35,,924,percent of total billed charges,Implant Device,924,35,,924,percent of total billed charges,Implant Device,924,35,,924,percent of total billed charges,Implant Device,924,35,,924,percent of total billed charges,Implant Device,924,35,,924,percent of total billed charges,Implant Device,1056,40,,1056,percent of total billed charges,Implant Device,924,70,,924,percent of total billed charges,All Other,897.6,34,,897.6,percent of total billed charges,Implant Device,897.6,34,,897.6,percent of total billed charges,Implant Device,924,35,,924,percent of total billed charges,Implant Device,924,35,,924,percent of total billed charges,Implant Device,924,35,,924,percent of total billed charges,Implant Device,924,35,,924,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,897.6,34,"If Charge > 2,000, then 34 percent",897.6,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1953.61,
ARTHREX AR-8920CDS TIGHTROPE CANN,C1713,HCPCS,,79001743,CDM,278,RC,,,both,,,1576,1166.24,,,1166.24,Other,150% of Medicare + 9.63% HCRA Surcharge,709.2,45,,709.2,percent of total billed charges,Critical Access Hospital RCC factor,535.84,34,,535.84,percent of total billed charges,Implant Device,535.84,34,,535.84,percent of total billed charges,Implant Device,535.84,34,,535.84,percent of total billed charges,Implant Device,535.84,34,,535.84,percent of total billed charges,Implant Device,535.84,34,,535.84,percent of total billed charges,Implant Device,780.12,,,780.12,Other,110% of Medicare,551.6,35,,551.6,percent of total billed charges,Implant Device,535.84,34,"Charges > $500, x 34%",535.84,percent of total billed charges,Implant Device,551.6,35,,551.6,percent of total billed charges,Implant Device,551.6,35,,551.6,percent of total billed charges,Implant Device,551.6,35,,551.6,percent of total billed charges,Implant Device,551.6,35,,551.6,percent of total billed charges,Implant Device,551.6,35,,551.6,percent of total billed charges,Implant Device,630.4,40,,630.4,percent of total billed charges,Implant Device,551.6,70,,551.6,percent of total billed charges,All Other,535.84,34,,535.84,percent of total billed charges,Implant Device,535.84,34,,535.84,percent of total billed charges,Implant Device,551.6,35,,551.6,percent of total billed charges,Implant Device,551.6,35,,551.6,percent of total billed charges,Implant Device,551.6,35,,551.6,percent of total billed charges,Implant Device,551.6,35,,551.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1166.24,
BAXTER 1501236 TISSEEL 2ML FIBRIN,C2615,HCPCS,,79001744,CDM,278,RC,,,both,,,402,297.48,,,297.48,Other,150% of Medicare + 9.63% HCRA Surcharge,180.9,45,,180.9,percent of total billed charges,Critical Access Hospital RCC factor,136.68,34,,136.68,percent of total billed charges,Implant Device,136.68,34,,136.68,percent of total billed charges,Implant Device,136.68,34,,136.68,percent of total billed charges,Implant Device,136.68,34,,136.68,percent of total billed charges,Implant Device,136.68,34,,136.68,percent of total billed charges,Implant Device,198.99,,,198.99,Other,110% of Medicare,140.7,35,,140.7,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,140.7,35,,140.7,percent of total billed charges,Implant Device,140.7,35,,140.7,percent of total billed charges,Implant Device,140.7,35,,140.7,percent of total billed charges,Implant Device,140.7,35,,140.7,percent of total billed charges,Implant Device,140.7,35,,140.7,percent of total billed charges,Implant Device,160.8,40,,160.8,percent of total billed charges,Implant Device,140.7,70,,140.7,percent of total billed charges,All Other,136.68,34,,136.68,percent of total billed charges,Implant Device,136.68,34,,136.68,percent of total billed charges,Implant Device,140.7,35,,140.7,percent of total billed charges,Implant Device,140.7,35,,140.7,percent of total billed charges,Implant Device,140.7,35,,140.7,percent of total billed charges,Implant Device,140.7,35,,140.7,percent of total billed charges,Implant Device,976.07,,,976.07,Other,100% of Medicaid,976.07,,,976.07,Other,100% of Medicaid,976.07,,,976.07,Other,100% of Medicaid,976.07,,,976.07,Other,100% of Medicaid,2196.15,,,2196.15,Other,225% of Medicaid,1493.38,,,1493.38,Other,153% of Medicaid,2196.15,,,2196.15,Other,225% of Medicaid,1366.49,,,1366.49,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,2537.77,,,2537.77,Other,260% of Medicaid,3162.45,,,3162.45,Other,324% of Medicaid,2098.54,,,2098.54,Other,215% of Medicaid,2098.54,,,2098.54,Other,215% of Medicaid,1220.08,,,1220.08,Other,125% of Medicaid,0.01,3162.45,
J&J 3902 EVICEL FIBRIN SEALANT 2ML,C2615,HCPCS,,79001745,CDM,278,RC,,,both,,,997,737.78,,,737.78,Other,150% of Medicare + 9.63% HCRA Surcharge,448.65,45,,448.65,percent of total billed charges,Critical Access Hospital RCC factor,338.98,34,,338.98,percent of total billed charges,Implant Device,338.98,34,,338.98,percent of total billed charges,Implant Device,338.98,34,,338.98,percent of total billed charges,Implant Device,338.98,34,,338.98,percent of total billed charges,Implant Device,338.98,34,,338.98,percent of total billed charges,Implant Device,493.52,,,493.52,Other,110% of Medicare,348.95,35,,348.95,percent of total billed charges,Implant Device,338.98,34,"Charges > $500, x 34%",338.98,percent of total billed charges,Implant Device,348.95,35,,348.95,percent of total billed charges,Implant Device,348.95,35,,348.95,percent of total billed charges,Implant Device,348.95,35,,348.95,percent of total billed charges,Implant Device,348.95,35,,348.95,percent of total billed charges,Implant Device,348.95,35,,348.95,percent of total billed charges,Implant Device,398.8,40,,398.8,percent of total billed charges,Implant Device,348.95,70,,348.95,percent of total billed charges,All Other,338.98,34,,338.98,percent of total billed charges,Implant Device,338.98,34,,338.98,percent of total billed charges,Implant Device,348.95,35,,348.95,percent of total billed charges,Implant Device,348.95,35,,348.95,percent of total billed charges,Implant Device,348.95,35,,348.95,percent of total billed charges,Implant Device,348.95,35,,348.95,percent of total billed charges,Implant Device,976.07,,,976.07,Other,100% of Medicaid,976.07,,,976.07,Other,100% of Medicaid,976.07,,,976.07,Other,100% of Medicaid,976.07,,,976.07,Other,100% of Medicaid,2196.15,,,2196.15,Other,225% of Medicaid,1493.38,,,1493.38,Other,153% of Medicaid,2196.15,,,2196.15,Other,225% of Medicaid,1366.49,,,1366.49,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,2537.77,,,2537.77,Other,260% of Medicaid,3162.45,,,3162.45,Other,324% of Medicaid,2098.54,,,2098.54,Other,215% of Medicaid,2098.54,,,2098.54,Other,215% of Medicaid,1220.08,,,1220.08,Other,125% of Medicaid,0.01,3162.45,
BAXTER 1501237 TISSEEL 4ML FIBRIN,C2615,HCPCS,,79001746,CDM,278,RC,,,both,,,676,500.24,,,500.24,Other,150% of Medicare + 9.63% HCRA Surcharge,304.2,45,,304.2,percent of total billed charges,Critical Access Hospital RCC factor,229.84,34,,229.84,percent of total billed charges,Implant Device,229.84,34,,229.84,percent of total billed charges,Implant Device,229.84,34,,229.84,percent of total billed charges,Implant Device,229.84,34,,229.84,percent of total billed charges,Implant Device,229.84,34,,229.84,percent of total billed charges,Implant Device,334.62,,,334.62,Other,110% of Medicare,236.6,35,,236.6,percent of total billed charges,Implant Device,229.84,34,"Charges > $500, x 34%",229.84,percent of total billed charges,Implant Device,236.6,35,,236.6,percent of total billed charges,Implant Device,236.6,35,,236.6,percent of total billed charges,Implant Device,236.6,35,,236.6,percent of total billed charges,Implant Device,236.6,35,,236.6,percent of total billed charges,Implant Device,236.6,35,,236.6,percent of total billed charges,Implant Device,270.4,40,,270.4,percent of total billed charges,Implant Device,236.6,70,,236.6,percent of total billed charges,All Other,229.84,34,,229.84,percent of total billed charges,Implant Device,229.84,34,,229.84,percent of total billed charges,Implant Device,236.6,35,,236.6,percent of total billed charges,Implant Device,236.6,35,,236.6,percent of total billed charges,Implant Device,236.6,35,,236.6,percent of total billed charges,Implant Device,236.6,35,,236.6,percent of total billed charges,Implant Device,976.07,,,976.07,Other,100% of Medicaid,976.07,,,976.07,Other,100% of Medicaid,976.07,,,976.07,Other,100% of Medicaid,976.07,,,976.07,Other,100% of Medicaid,2196.15,,,2196.15,Other,225% of Medicaid,1493.38,,,1493.38,Other,153% of Medicaid,2196.15,,,2196.15,Other,225% of Medicaid,1366.49,,,1366.49,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,2537.77,,,2537.77,Other,260% of Medicaid,3162.45,,,3162.45,Other,324% of Medicaid,2098.54,,,2098.54,Other,215% of Medicaid,2098.54,,,2098.54,Other,215% of Medicaid,1220.08,,,1220.08,Other,125% of Medicaid,0.01,3162.45,
BAXTER 921030 TISSEEL 5ML KIT,C2615,HCPCS,,79001747,CDM,278,RC,,,both,,,1498,1108.52,,,1108.52,Other,150% of Medicare + 9.63% HCRA Surcharge,674.1,45,,674.1,percent of total billed charges,Critical Access Hospital RCC factor,509.32,34,,509.32,percent of total billed charges,Implant Device,509.32,34,,509.32,percent of total billed charges,Implant Device,509.32,34,,509.32,percent of total billed charges,Implant Device,509.32,34,,509.32,percent of total billed charges,Implant Device,509.32,34,,509.32,percent of total billed charges,Implant Device,741.51,,,741.51,Other,110% of Medicare,524.3,35,,524.3,percent of total billed charges,Implant Device,509.32,34,"Charges > $500, x 34%",509.32,percent of total billed charges,Implant Device,524.3,35,,524.3,percent of total billed charges,Implant Device,524.3,35,,524.3,percent of total billed charges,Implant Device,524.3,35,,524.3,percent of total billed charges,Implant Device,524.3,35,,524.3,percent of total billed charges,Implant Device,524.3,35,,524.3,percent of total billed charges,Implant Device,599.2,40,,599.2,percent of total billed charges,Implant Device,524.3,70,,524.3,percent of total billed charges,All Other,509.32,34,,509.32,percent of total billed charges,Implant Device,509.32,34,,509.32,percent of total billed charges,Implant Device,524.3,35,,524.3,percent of total billed charges,Implant Device,524.3,35,,524.3,percent of total billed charges,Implant Device,524.3,35,,524.3,percent of total billed charges,Implant Device,524.3,35,,524.3,percent of total billed charges,Implant Device,976.07,,,976.07,Other,100% of Medicaid,976.07,,,976.07,Other,100% of Medicaid,976.07,,,976.07,Other,100% of Medicaid,976.07,,,976.07,Other,100% of Medicaid,2196.15,,,2196.15,Other,225% of Medicaid,1493.38,,,1493.38,Other,153% of Medicaid,2196.15,,,2196.15,Other,225% of Medicaid,1366.49,,,1366.49,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,2537.77,,,2537.77,Other,260% of Medicaid,3162.45,,,3162.45,Other,324% of Medicaid,2098.54,,,2098.54,Other,215% of Medicaid,2098.54,,,2098.54,Other,215% of Medicaid,1220.08,,,1220.08,Other,125% of Medicaid,0.01,3162.45,
BAXTER 921028 TISSEEL IML KIT,C2615,HCPCS,,79001748,CDM,278,RC,,,both,,,246,182.04,,,182.04,Other,150% of Medicare + 9.63% HCRA Surcharge,110.7,45,,110.7,percent of total billed charges,Critical Access Hospital RCC factor,83.64,34,,83.64,percent of total billed charges,Implant Device,83.64,34,,83.64,percent of total billed charges,Implant Device,83.64,34,,83.64,percent of total billed charges,Implant Device,83.64,34,,83.64,percent of total billed charges,Implant Device,83.64,34,,83.64,percent of total billed charges,Implant Device,121.77,,,121.77,Other,110% of Medicare,86.1,35,,86.1,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,86.1,35,,86.1,percent of total billed charges,Implant Device,86.1,35,,86.1,percent of total billed charges,Implant Device,86.1,35,,86.1,percent of total billed charges,Implant Device,86.1,35,,86.1,percent of total billed charges,Implant Device,86.1,35,,86.1,percent of total billed charges,Implant Device,98.4,40,,98.4,percent of total billed charges,Implant Device,86.1,70,,86.1,percent of total billed charges,All Other,83.64,34,,83.64,percent of total billed charges,Implant Device,83.64,34,,83.64,percent of total billed charges,Implant Device,86.1,35,,86.1,percent of total billed charges,Implant Device,86.1,35,,86.1,percent of total billed charges,Implant Device,86.1,35,,86.1,percent of total billed charges,Implant Device,86.1,35,,86.1,percent of total billed charges,Implant Device,976.07,,,976.07,Other,100% of Medicaid,976.07,,,976.07,Other,100% of Medicaid,976.07,,,976.07,Other,100% of Medicaid,976.07,,,976.07,Other,100% of Medicaid,2196.15,,,2196.15,Other,225% of Medicaid,1493.38,,,1493.38,Other,153% of Medicaid,2196.15,,,2196.15,Other,225% of Medicaid,1366.49,,,1366.49,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,2537.77,,,2537.77,Other,260% of Medicaid,3162.45,,,3162.45,Other,324% of Medicaid,2098.54,,,2098.54,Other,215% of Medicaid,2098.54,,,2098.54,Other,215% of Medicaid,1220.08,,,1220.08,Other,125% of Medicaid,0.01,3162.45,
SGARLATO LABS 8-100-01 TOE LONGHAMMER,C1776,HCPCS,,79001749,CDM,278,RC,,,both,,,976,722.24,,,722.24,Other,150% of Medicare + 9.63% HCRA Surcharge,439.2,45,,439.2,percent of total billed charges,Critical Access Hospital RCC factor,331.84,34,,331.84,percent of total billed charges,Implant Device,331.84,34,,331.84,percent of total billed charges,Implant Device,331.84,34,,331.84,percent of total billed charges,Implant Device,331.84,34,,331.84,percent of total billed charges,Implant Device,331.84,34,,331.84,percent of total billed charges,Implant Device,483.12,,,483.12,Other,110% of Medicare,341.6,35,,341.6,percent of total billed charges,Implant Device,331.84,34,"Charges > $500, x 34%",331.84,percent of total billed charges,Implant Device,341.6,35,,341.6,percent of total billed charges,Implant Device,341.6,35,,341.6,percent of total billed charges,Implant Device,341.6,35,,341.6,percent of total billed charges,Implant Device,341.6,35,,341.6,percent of total billed charges,Implant Device,341.6,35,,341.6,percent of total billed charges,Implant Device,390.4,40,,390.4,percent of total billed charges,Implant Device,341.6,70,,341.6,percent of total billed charges,All Other,331.84,34,,331.84,percent of total billed charges,Implant Device,331.84,34,,331.84,percent of total billed charges,Implant Device,341.6,35,,341.6,percent of total billed charges,Implant Device,341.6,35,,341.6,percent of total billed charges,Implant Device,341.6,35,,341.6,percent of total billed charges,Implant Device,341.6,35,,341.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,722.24,
J&J 810041A TVT DEVICE W/ABDOMINAL GUIDE,C1771,HCPCS,,79001750,CDM,278,RC,,,both,,,3270,2419.81,,,2419.81,Other,150% of Medicare + 9.63% HCRA Surcharge,1471.5,45,,1471.5,percent of total billed charges,Critical Access Hospital RCC factor,1111.8,34,,1111.8,percent of total billed charges,Implant Device,1111.8,34,,1111.8,percent of total billed charges,Implant Device,1111.8,34,,1111.8,percent of total billed charges,Implant Device,1111.8,34,,1111.8,percent of total billed charges,Implant Device,1111.8,34,,1111.8,percent of total billed charges,Implant Device,1618.65,,,1618.65,Other,110% of Medicare,1144.5,35,,1144.5,percent of total billed charges,Implant Device,1111.8,34,"Charges > $500, x 34%",1111.8,percent of total billed charges,Implant Device,1144.5,35,,1144.5,percent of total billed charges,Implant Device,1144.5,35,,1144.5,percent of total billed charges,Implant Device,1144.5,35,,1144.5,percent of total billed charges,Implant Device,1144.5,35,,1144.5,percent of total billed charges,Implant Device,1144.5,35,,1144.5,percent of total billed charges,Implant Device,1308,40,,1308,percent of total billed charges,Implant Device,1144.5,70,,1144.5,percent of total billed charges,All Other,1111.8,34,,1111.8,percent of total billed charges,Implant Device,1111.8,34,,1111.8,percent of total billed charges,Implant Device,1144.5,35,,1144.5,percent of total billed charges,Implant Device,1144.5,35,,1144.5,percent of total billed charges,Implant Device,1144.5,35,,1144.5,percent of total billed charges,Implant Device,1144.5,35,,1144.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1111.8,34,"If Charge > 2,000, then 34 percent",1111.8,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2419.81,
STRYKER 54-25394 VOLOR PLATE 53MM NARROW,C1713,HCPCS,,79001751,CDM,278,RC,,,both,,,2973,2200.03,,,2200.03,Other,150% of Medicare + 9.63% HCRA Surcharge,1337.85,45,,1337.85,percent of total billed charges,Critical Access Hospital RCC factor,1010.82,34,,1010.82,percent of total billed charges,Implant Device,1010.82,34,,1010.82,percent of total billed charges,Implant Device,1010.82,34,,1010.82,percent of total billed charges,Implant Device,1010.82,34,,1010.82,percent of total billed charges,Implant Device,1010.82,34,,1010.82,percent of total billed charges,Implant Device,1471.64,,,1471.64,Other,110% of Medicare,1040.55,35,,1040.55,percent of total billed charges,Implant Device,1010.82,34,"Charges > $500, x 34%",1010.82,percent of total billed charges,Implant Device,1040.55,35,,1040.55,percent of total billed charges,Implant Device,1040.55,35,,1040.55,percent of total billed charges,Implant Device,1040.55,35,,1040.55,percent of total billed charges,Implant Device,1040.55,35,,1040.55,percent of total billed charges,Implant Device,1040.55,35,,1040.55,percent of total billed charges,Implant Device,1189.2,40,,1189.2,percent of total billed charges,Implant Device,1040.55,70,,1040.55,percent of total billed charges,All Other,1010.82,34,,1010.82,percent of total billed charges,Implant Device,1010.82,34,,1010.82,percent of total billed charges,Implant Device,1040.55,35,,1040.55,percent of total billed charges,Implant Device,1040.55,35,,1040.55,percent of total billed charges,Implant Device,1040.55,35,,1040.55,percent of total billed charges,Implant Device,1040.55,35,,1040.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1010.82,34,"If Charge > 2,000, then 34 percent",1010.82,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2200.03,
STRYKER 54-25398 VOLOR PLATE 73MM WIDE,C1713,HCPCS,,79001752,CDM,278,RC,,,both,,,2269,1679.07,,,1679.07,Other,150% of Medicare + 9.63% HCRA Surcharge,1021.05,45,,1021.05,percent of total billed charges,Critical Access Hospital RCC factor,771.46,34,,771.46,percent of total billed charges,Implant Device,771.46,34,,771.46,percent of total billed charges,Implant Device,771.46,34,,771.46,percent of total billed charges,Implant Device,771.46,34,,771.46,percent of total billed charges,Implant Device,771.46,34,,771.46,percent of total billed charges,Implant Device,1123.16,,,1123.16,Other,110% of Medicare,794.15,35,,794.15,percent of total billed charges,Implant Device,771.46,34,"Charges > $500, x 34%",771.46,percent of total billed charges,Implant Device,794.15,35,,794.15,percent of total billed charges,Implant Device,794.15,35,,794.15,percent of total billed charges,Implant Device,794.15,35,,794.15,percent of total billed charges,Implant Device,794.15,35,,794.15,percent of total billed charges,Implant Device,794.15,35,,794.15,percent of total billed charges,Implant Device,907.6,40,,907.6,percent of total billed charges,Implant Device,794.15,70,,794.15,percent of total billed charges,All Other,771.46,34,,771.46,percent of total billed charges,Implant Device,771.46,34,,771.46,percent of total billed charges,Implant Device,794.15,35,,794.15,percent of total billed charges,Implant Device,794.15,35,,794.15,percent of total billed charges,Implant Device,794.15,35,,794.15,percent of total billed charges,Implant Device,794.15,35,,794.15,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,771.46,34,"If Charge > 2,000, then 34 percent",771.46,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1679.07,
COOK G16996 URETERAL DIVERSION STENT SET,C2617,HCPCS,,79001753,CDM,278,RC,,,both,,,258,190.92,,,190.92,Other,150% of Medicare + 9.63% HCRA Surcharge,116.1,45,,116.1,percent of total billed charges,Critical Access Hospital RCC factor,87.72,34,,87.72,percent of total billed charges,Implant Device,87.72,34,,87.72,percent of total billed charges,Implant Device,87.72,34,,87.72,percent of total billed charges,Implant Device,87.72,34,,87.72,percent of total billed charges,Implant Device,87.72,34,,87.72,percent of total billed charges,Implant Device,127.71,,,127.71,Other,110% of Medicare,90.3,35,,90.3,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,90.3,35,,90.3,percent of total billed charges,Implant Device,90.3,35,,90.3,percent of total billed charges,Implant Device,90.3,35,,90.3,percent of total billed charges,Implant Device,90.3,35,,90.3,percent of total billed charges,Implant Device,90.3,35,,90.3,percent of total billed charges,Implant Device,103.2,40,,103.2,percent of total billed charges,Implant Device,90.3,70,,90.3,percent of total billed charges,All Other,87.72,34,,87.72,percent of total billed charges,Implant Device,87.72,34,,87.72,percent of total billed charges,Implant Device,90.3,35,,90.3,percent of total billed charges,Implant Device,90.3,35,,90.3,percent of total billed charges,Implant Device,90.3,35,,90.3,percent of total billed charges,Implant Device,90.3,35,,90.3,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,190.92,
GORE SA1803 VASCUALR GRAFT 18X30,C1768,HCPCS,,79001754,CDM,278,RC,,,both,,,1659,1227.66,,,1227.66,Other,150% of Medicare + 9.63% HCRA Surcharge,746.55,45,,746.55,percent of total billed charges,Critical Access Hospital RCC factor,564.06,34,,564.06,percent of total billed charges,Implant Device,564.06,34,,564.06,percent of total billed charges,Implant Device,564.06,34,,564.06,percent of total billed charges,Implant Device,564.06,34,,564.06,percent of total billed charges,Implant Device,564.06,34,,564.06,percent of total billed charges,Implant Device,821.21,,,821.21,Other,110% of Medicare,580.65,35,,580.65,percent of total billed charges,Implant Device,564.06,34,"Charges > $500, x 34%",564.06,percent of total billed charges,Implant Device,580.65,35,,580.65,percent of total billed charges,Implant Device,580.65,35,,580.65,percent of total billed charges,Implant Device,580.65,35,,580.65,percent of total billed charges,Implant Device,580.65,35,,580.65,percent of total billed charges,Implant Device,580.65,35,,580.65,percent of total billed charges,Implant Device,663.6,40,,663.6,percent of total billed charges,Implant Device,580.65,70,,580.65,percent of total billed charges,All Other,564.06,34,,564.06,percent of total billed charges,Implant Device,564.06,34,,564.06,percent of total billed charges,Implant Device,580.65,35,,580.65,percent of total billed charges,Implant Device,580.65,35,,580.65,percent of total billed charges,Implant Device,580.65,35,,580.65,percent of total billed charges,Implant Device,580.65,35,,580.65,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1227.66,
GORE S1004 VASCULAR GRAFT 10 X 40,C1768,HCPCS,,79001755,CDM,278,RC,,,both,,,1491,1103.34,,,1103.34,Other,150% of Medicare + 9.63% HCRA Surcharge,670.95,45,,670.95,percent of total billed charges,Critical Access Hospital RCC factor,506.94,34,,506.94,percent of total billed charges,Implant Device,506.94,34,,506.94,percent of total billed charges,Implant Device,506.94,34,,506.94,percent of total billed charges,Implant Device,506.94,34,,506.94,percent of total billed charges,Implant Device,506.94,34,,506.94,percent of total billed charges,Implant Device,738.05,,,738.05,Other,110% of Medicare,521.85,35,,521.85,percent of total billed charges,Implant Device,506.94,34,"Charges > $500, x 34%",506.94,percent of total billed charges,Implant Device,521.85,35,,521.85,percent of total billed charges,Implant Device,521.85,35,,521.85,percent of total billed charges,Implant Device,521.85,35,,521.85,percent of total billed charges,Implant Device,521.85,35,,521.85,percent of total billed charges,Implant Device,521.85,35,,521.85,percent of total billed charges,Implant Device,596.4,40,,596.4,percent of total billed charges,Implant Device,521.85,70,,521.85,percent of total billed charges,All Other,506.94,34,,506.94,percent of total billed charges,Implant Device,506.94,34,,506.94,percent of total billed charges,Implant Device,521.85,35,,521.85,percent of total billed charges,Implant Device,521.85,35,,521.85,percent of total billed charges,Implant Device,521.85,35,,521.85,percent of total billed charges,Implant Device,521.85,35,,521.85,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1103.34,
GORE V06070L VASCULAR GRAFT 6 X 70 ST,C1768,HCPCS,,79001756,CDM,278,RC,,,both,,,1858,1374.92,,,1374.92,Other,150% of Medicare + 9.63% HCRA Surcharge,836.1,45,,836.1,percent of total billed charges,Critical Access Hospital RCC factor,631.72,34,,631.72,percent of total billed charges,Implant Device,631.72,34,,631.72,percent of total billed charges,Implant Device,631.72,34,,631.72,percent of total billed charges,Implant Device,631.72,34,,631.72,percent of total billed charges,Implant Device,631.72,34,,631.72,percent of total billed charges,Implant Device,919.71,,,919.71,Other,110% of Medicare,650.3,35,,650.3,percent of total billed charges,Implant Device,631.72,34,"Charges > $500, x 34%",631.72,percent of total billed charges,Implant Device,650.3,35,,650.3,percent of total billed charges,Implant Device,650.3,35,,650.3,percent of total billed charges,Implant Device,650.3,35,,650.3,percent of total billed charges,Implant Device,650.3,35,,650.3,percent of total billed charges,Implant Device,650.3,35,,650.3,percent of total billed charges,Implant Device,743.2,40,,743.2,percent of total billed charges,Implant Device,650.3,70,,650.3,percent of total billed charges,All Other,631.72,34,,631.72,percent of total billed charges,Implant Device,631.72,34,,631.72,percent of total billed charges,Implant Device,650.3,35,,650.3,percent of total billed charges,Implant Device,650.3,35,,650.3,percent of total billed charges,Implant Device,650.3,35,,650.3,percent of total billed charges,Implant Device,650.3,35,,650.3,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1374.92,
GORE V08070L VASCULAR GRAFT 8 X 70 ST,C1768,HCPCS,,79001757,CDM,278,RC,,,both,,,1858,1374.92,,,1374.92,Other,150% of Medicare + 9.63% HCRA Surcharge,836.1,45,,836.1,percent of total billed charges,Critical Access Hospital RCC factor,631.72,34,,631.72,percent of total billed charges,Implant Device,631.72,34,,631.72,percent of total billed charges,Implant Device,631.72,34,,631.72,percent of total billed charges,Implant Device,631.72,34,,631.72,percent of total billed charges,Implant Device,631.72,34,,631.72,percent of total billed charges,Implant Device,919.71,,,919.71,Other,110% of Medicare,650.3,35,,650.3,percent of total billed charges,Implant Device,631.72,34,"Charges > $500, x 34%",631.72,percent of total billed charges,Implant Device,650.3,35,,650.3,percent of total billed charges,Implant Device,650.3,35,,650.3,percent of total billed charges,Implant Device,650.3,35,,650.3,percent of total billed charges,Implant Device,650.3,35,,650.3,percent of total billed charges,Implant Device,650.3,35,,650.3,percent of total billed charges,Implant Device,743.2,40,,743.2,percent of total billed charges,Implant Device,650.3,70,,650.3,percent of total billed charges,All Other,631.72,34,,631.72,percent of total billed charges,Implant Device,631.72,34,,631.72,percent of total billed charges,Implant Device,650.3,35,,650.3,percent of total billed charges,Implant Device,650.3,35,,650.3,percent of total billed charges,Implant Device,650.3,35,,650.3,percent of total billed charges,Implant Device,650.3,35,,650.3,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1374.92,
GORE V47020L VASCULAR GRAFT TAPER 47,C1768,HCPCS,,79001758,CDM,278,RC,,,both,,,666,492.84,,,492.84,Other,150% of Medicare + 9.63% HCRA Surcharge,299.7,45,,299.7,percent of total billed charges,Critical Access Hospital RCC factor,226.44,34,,226.44,percent of total billed charges,Implant Device,226.44,34,,226.44,percent of total billed charges,Implant Device,226.44,34,,226.44,percent of total billed charges,Implant Device,226.44,34,,226.44,percent of total billed charges,Implant Device,226.44,34,,226.44,percent of total billed charges,Implant Device,329.67,,,329.67,Other,110% of Medicare,233.1,35,,233.1,percent of total billed charges,Implant Device,226.44,34,"Charges > $500, x 34%",226.44,percent of total billed charges,Implant Device,233.1,35,,233.1,percent of total billed charges,Implant Device,233.1,35,,233.1,percent of total billed charges,Implant Device,233.1,35,,233.1,percent of total billed charges,Implant Device,233.1,35,,233.1,percent of total billed charges,Implant Device,233.1,35,,233.1,percent of total billed charges,Implant Device,266.4,40,,266.4,percent of total billed charges,Implant Device,233.1,70,,233.1,percent of total billed charges,All Other,226.44,34,,226.44,percent of total billed charges,Implant Device,226.44,34,,226.44,percent of total billed charges,Implant Device,233.1,35,,233.1,percent of total billed charges,Implant Device,233.1,35,,233.1,percent of total billed charges,Implant Device,233.1,35,,233.1,percent of total billed charges,Implant Device,233.1,35,,233.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,492.84,
HEMOSPHERE HERO 1001 VENOUS OUTFLOW COMP,C1768,HCPCS,,79001759,CDM,278,RC,,,both,,,5850,4329.01,,,4329.01,Other,150% of Medicare + 9.63% HCRA Surcharge,2632.5,45,,2632.5,percent of total billed charges,Critical Access Hospital RCC factor,1989,34,,1989,percent of total billed charges,Implant Device,1989,34,,1989,percent of total billed charges,Implant Device,1989,34,,1989,percent of total billed charges,Implant Device,1989,34,,1989,percent of total billed charges,Implant Device,1989,34,,1989,percent of total billed charges,Implant Device,2895.75,,,2895.75,Other,110% of Medicare,2047.5,35,,2047.5,percent of total billed charges,Implant Device,1989,34,"Charges > $500, x 34%",1989,percent of total billed charges,Implant Device,2047.5,35,,2047.5,percent of total billed charges,Implant Device,2047.5,35,,2047.5,percent of total billed charges,Implant Device,2047.5,35,,2047.5,percent of total billed charges,Implant Device,2047.5,35,,2047.5,percent of total billed charges,Implant Device,2047.5,35,,2047.5,percent of total billed charges,Implant Device,2340,40,,2340,percent of total billed charges,Implant Device,2047.5,70,,2047.5,percent of total billed charges,All Other,1989,34,,1989,percent of total billed charges,Implant Device,1989,34,,1989,percent of total billed charges,Implant Device,2047.5,35,,2047.5,percent of total billed charges,Implant Device,2047.5,35,,2047.5,percent of total billed charges,Implant Device,2047.5,35,,2047.5,percent of total billed charges,Implant Device,2047.5,35,,2047.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1989,34,"If Charge > 2,000, then 34 percent",1989,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4329.01,
SUT EXP VKML VICRYL KNITTED MESH 12X12,C1781,HCPCS,,79001760,CDM,278,RC,,,both,,,3451,2553.75,,,2553.75,Other,150% of Medicare + 9.63% HCRA Surcharge,1552.95,45,,1552.95,percent of total billed charges,Critical Access Hospital RCC factor,1173.34,34,,1173.34,percent of total billed charges,Implant Device,1173.34,34,,1173.34,percent of total billed charges,Implant Device,1173.34,34,,1173.34,percent of total billed charges,Implant Device,1173.34,34,,1173.34,percent of total billed charges,Implant Device,1173.34,34,,1173.34,percent of total billed charges,Implant Device,1708.25,,,1708.25,Other,110% of Medicare,1207.85,35,,1207.85,percent of total billed charges,Implant Device,1173.34,34,"Charges > $500, x 34%",1173.34,percent of total billed charges,Implant Device,1207.85,35,,1207.85,percent of total billed charges,Implant Device,1207.85,35,,1207.85,percent of total billed charges,Implant Device,1207.85,35,,1207.85,percent of total billed charges,Implant Device,1207.85,35,,1207.85,percent of total billed charges,Implant Device,1207.85,35,,1207.85,percent of total billed charges,Implant Device,1380.4,40,,1380.4,percent of total billed charges,Implant Device,1207.85,70,,1207.85,percent of total billed charges,All Other,1173.34,34,,1173.34,percent of total billed charges,Implant Device,1173.34,34,,1173.34,percent of total billed charges,Implant Device,1207.85,35,,1207.85,percent of total billed charges,Implant Device,1207.85,35,,1207.85,percent of total billed charges,Implant Device,1207.85,35,,1207.85,percent of total billed charges,Implant Device,1207.85,35,,1207.85,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1173.34,34,"If Charge > 2,000, then 34 percent",1173.34,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2553.75,
SUTURE EXPRESS VWML VICRYL MESH 12X12,C1781,HCPCS,,79001761,CDM,278,RC,,,both,,,2173,1608.03,,,1608.03,Other,150% of Medicare + 9.63% HCRA Surcharge,977.85,45,,977.85,percent of total billed charges,Critical Access Hospital RCC factor,738.82,34,,738.82,percent of total billed charges,Implant Device,738.82,34,,738.82,percent of total billed charges,Implant Device,738.82,34,,738.82,percent of total billed charges,Implant Device,738.82,34,,738.82,percent of total billed charges,Implant Device,738.82,34,,738.82,percent of total billed charges,Implant Device,1075.64,,,1075.64,Other,110% of Medicare,760.55,35,,760.55,percent of total billed charges,Implant Device,738.82,34,"Charges > $500, x 34%",738.82,percent of total billed charges,Implant Device,760.55,35,,760.55,percent of total billed charges,Implant Device,760.55,35,,760.55,percent of total billed charges,Implant Device,760.55,35,,760.55,percent of total billed charges,Implant Device,760.55,35,,760.55,percent of total billed charges,Implant Device,760.55,35,,760.55,percent of total billed charges,Implant Device,869.2,40,,869.2,percent of total billed charges,Implant Device,760.55,70,,760.55,percent of total billed charges,All Other,738.82,34,,738.82,percent of total billed charges,Implant Device,738.82,34,,738.82,percent of total billed charges,Implant Device,760.55,35,,760.55,percent of total billed charges,Implant Device,760.55,35,,760.55,percent of total billed charges,Implant Device,760.55,35,,760.55,percent of total billed charges,Implant Device,760.55,35,,760.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,738.82,34,"If Charge > 2,000, then 34 percent",738.82,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1608.03,
STRYKER 59-17049E WASHER,C1713,HCPCS,,79001762,CDM,278,RC,,,both,,,102,75.48,,,75.48,Other,150% of Medicare + 9.63% HCRA Surcharge,45.9,45,,45.9,percent of total billed charges,Critical Access Hospital RCC factor,34.68,34,,34.68,percent of total billed charges,Implant Device,34.68,34,,34.68,percent of total billed charges,Implant Device,34.68,34,,34.68,percent of total billed charges,Implant Device,34.68,34,,34.68,percent of total billed charges,Implant Device,34.68,34,,34.68,percent of total billed charges,Implant Device,50.49,,,50.49,Other,110% of Medicare,35.7,35,,35.7,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,35.7,35,,35.7,percent of total billed charges,Implant Device,35.7,35,,35.7,percent of total billed charges,Implant Device,35.7,35,,35.7,percent of total billed charges,Implant Device,35.7,35,,35.7,percent of total billed charges,Implant Device,35.7,35,,35.7,percent of total billed charges,Implant Device,40.8,40,,40.8,percent of total billed charges,Implant Device,35.7,70,,35.7,percent of total billed charges,All Other,34.68,34,,34.68,percent of total billed charges,Implant Device,34.68,34,,34.68,percent of total billed charges,Implant Device,35.7,35,,35.7,percent of total billed charges,Implant Device,35.7,35,,35.7,percent of total billed charges,Implant Device,35.7,35,,35.7,percent of total billed charges,Implant Device,35.7,35,,35.7,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,75.48,
BIOMET 1312-18-000 WASHER 3.5 HEADLESS,C1713,HCPCS,,79001763,CDM,278,RC,,,both,,,300,222,,,222,Other,150% of Medicare + 9.63% HCRA Surcharge,135,45,,135,percent of total billed charges,Critical Access Hospital RCC factor,102,34,,102,percent of total billed charges,Implant Device,102,34,,102,percent of total billed charges,Implant Device,102,34,,102,percent of total billed charges,Implant Device,102,34,,102,percent of total billed charges,Implant Device,102,34,,102,percent of total billed charges,Implant Device,148.5,,,148.5,Other,110% of Medicare,105,35,,105,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,105,35,,105,percent of total billed charges,Implant Device,105,35,,105,percent of total billed charges,Implant Device,105,35,,105,percent of total billed charges,Implant Device,105,35,,105,percent of total billed charges,Implant Device,105,35,,105,percent of total billed charges,Implant Device,120,40,,120,percent of total billed charges,Implant Device,105,70,,105,percent of total billed charges,All Other,102,34,,102,percent of total billed charges,Implant Device,102,34,,102,percent of total billed charges,Implant Device,105,35,,105,percent of total billed charges,Implant Device,105,35,,105,percent of total billed charges,Implant Device,105,35,,105,percent of total billed charges,Implant Device,105,35,,105,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,222,
SYNTHES 219.98 WASHERS 7.0M,C1713,HCPCS,,79001764,CDM,278,RC,,,both,,,88,65.12,,,65.12,Other,150% of Medicare + 9.63% HCRA Surcharge,39.6,45,,39.6,percent of total billed charges,Critical Access Hospital RCC factor,29.92,34,,29.92,percent of total billed charges,Implant Device,29.92,34,,29.92,percent of total billed charges,Implant Device,29.92,34,,29.92,percent of total billed charges,Implant Device,29.92,34,,29.92,percent of total billed charges,Implant Device,29.92,34,,29.92,percent of total billed charges,Implant Device,43.56,,,43.56,Other,110% of Medicare,30.8,35,,30.8,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,30.8,35,,30.8,percent of total billed charges,Implant Device,30.8,35,,30.8,percent of total billed charges,Implant Device,30.8,35,,30.8,percent of total billed charges,Implant Device,30.8,35,,30.8,percent of total billed charges,Implant Device,30.8,35,,30.8,percent of total billed charges,Implant Device,35.2,40,,35.2,percent of total billed charges,Implant Device,30.8,70,,30.8,percent of total billed charges,All Other,29.92,34,,29.92,percent of total billed charges,Implant Device,29.92,34,,29.92,percent of total billed charges,Implant Device,30.8,35,,30.8,percent of total billed charges,Implant Device,30.8,35,,30.8,percent of total billed charges,Implant Device,30.8,35,,30.8,percent of total billed charges,Implant Device,30.8,35,,30.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,65.12,
BIOMET 1.7347 2 HOLE STR PLATE 1.5X16MM,C1713,HCPCS,,79001769,CDM,278,RC,,,both,,,142,105.08,,,105.08,Other,150% of Medicare + 9.63% HCRA Surcharge,63.9,45,,63.9,percent of total billed charges,Critical Access Hospital RCC factor,48.28,34,,48.28,percent of total billed charges,Implant Device,48.28,34,,48.28,percent of total billed charges,Implant Device,48.28,34,,48.28,percent of total billed charges,Implant Device,48.28,34,,48.28,percent of total billed charges,Implant Device,48.28,34,,48.28,percent of total billed charges,Implant Device,70.29,,,70.29,Other,110% of Medicare,49.7,35,,49.7,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,49.7,35,,49.7,percent of total billed charges,Implant Device,49.7,35,,49.7,percent of total billed charges,Implant Device,49.7,35,,49.7,percent of total billed charges,Implant Device,49.7,35,,49.7,percent of total billed charges,Implant Device,49.7,35,,49.7,percent of total billed charges,Implant Device,56.8,40,,56.8,percent of total billed charges,Implant Device,49.7,70,,49.7,percent of total billed charges,All Other,48.28,34,,48.28,percent of total billed charges,Implant Device,48.28,34,,48.28,percent of total billed charges,Implant Device,49.7,35,,49.7,percent of total billed charges,Implant Device,49.7,35,,49.7,percent of total billed charges,Implant Device,49.7,35,,49.7,percent of total billed charges,Implant Device,49.7,35,,49.7,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,105.08,
BIOMET 54 ILIAC CREST WEDGE 19X21,C1713,HCPCS,,79001770,CDM,278,RC,,,both,,,2100,1554.01,,,1554.01,Other,150% of Medicare + 9.63% HCRA Surcharge,945,45,,945,percent of total billed charges,Critical Access Hospital RCC factor,714,34,,714,percent of total billed charges,Implant Device,714,34,,714,percent of total billed charges,Implant Device,714,34,,714,percent of total billed charges,Implant Device,714,34,,714,percent of total billed charges,Implant Device,714,34,,714,percent of total billed charges,Implant Device,1039.5,,,1039.5,Other,110% of Medicare,735,35,,735,percent of total billed charges,Implant Device,714,34,"Charges > $500, x 34%",714,percent of total billed charges,Implant Device,735,35,,735,percent of total billed charges,Implant Device,735,35,,735,percent of total billed charges,Implant Device,735,35,,735,percent of total billed charges,Implant Device,735,35,,735,percent of total billed charges,Implant Device,735,35,,735,percent of total billed charges,Implant Device,840,40,,840,percent of total billed charges,Implant Device,735,70,,735,percent of total billed charges,All Other,714,34,,714,percent of total billed charges,Implant Device,714,34,,714,percent of total billed charges,Implant Device,735,35,,735,percent of total billed charges,Implant Device,735,35,,735,percent of total billed charges,Implant Device,735,35,,735,percent of total billed charges,Implant Device,735,35,,735,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,714,34,"If Charge > 2,000, then 34 percent",714,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1554.01,
SYNTHES 208.407 SCREW,C1713,HCPCS,,79001771,CDM,278,RC,,,both,,,636,470.64,,,470.64,Other,150% of Medicare + 9.63% HCRA Surcharge,286.2,45,,286.2,percent of total billed charges,Critical Access Hospital RCC factor,216.24,34,,216.24,percent of total billed charges,Implant Device,216.24,34,,216.24,percent of total billed charges,Implant Device,216.24,34,,216.24,percent of total billed charges,Implant Device,216.24,34,,216.24,percent of total billed charges,Implant Device,216.24,34,,216.24,percent of total billed charges,Implant Device,314.82,,,314.82,Other,110% of Medicare,222.6,35,,222.6,percent of total billed charges,Implant Device,216.24,34,"Charges > $500, x 34%",216.24,percent of total billed charges,Implant Device,222.6,35,,222.6,percent of total billed charges,Implant Device,222.6,35,,222.6,percent of total billed charges,Implant Device,222.6,35,,222.6,percent of total billed charges,Implant Device,222.6,35,,222.6,percent of total billed charges,Implant Device,222.6,35,,222.6,percent of total billed charges,Implant Device,254.4,40,,254.4,percent of total billed charges,Implant Device,222.6,70,,222.6,percent of total billed charges,All Other,216.24,34,,216.24,percent of total billed charges,Implant Device,216.24,34,,216.24,percent of total billed charges,Implant Device,222.6,35,,222.6,percent of total billed charges,Implant Device,222.6,35,,222.6,percent of total billed charges,Implant Device,222.6,35,,222.6,percent of total billed charges,Implant Device,222.6,35,,222.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,470.64,
SYNTHES 208.415 SCREW,C1713,HCPCS,,79001772,CDM,278,RC,,,both,,,625,462.5,,,462.5,Other,150% of Medicare + 9.63% HCRA Surcharge,281.25,45,,281.25,percent of total billed charges,Critical Access Hospital RCC factor,212.5,34,,212.5,percent of total billed charges,Implant Device,212.5,34,,212.5,percent of total billed charges,Implant Device,212.5,34,,212.5,percent of total billed charges,Implant Device,212.5,34,,212.5,percent of total billed charges,Implant Device,212.5,34,,212.5,percent of total billed charges,Implant Device,309.38,,,309.38,Other,110% of Medicare,218.75,35,,218.75,percent of total billed charges,Implant Device,212.5,34,"Charges > $500, x 34%",212.5,percent of total billed charges,Implant Device,218.75,35,,218.75,percent of total billed charges,Implant Device,218.75,35,,218.75,percent of total billed charges,Implant Device,218.75,35,,218.75,percent of total billed charges,Implant Device,218.75,35,,218.75,percent of total billed charges,Implant Device,218.75,35,,218.75,percent of total billed charges,Implant Device,250,40,,250,percent of total billed charges,Implant Device,218.75,70,,218.75,percent of total billed charges,All Other,212.5,34,,212.5,percent of total billed charges,Implant Device,212.5,34,,212.5,percent of total billed charges,Implant Device,218.75,35,,218.75,percent of total billed charges,Implant Device,218.75,35,,218.75,percent of total billed charges,Implant Device,218.75,35,,218.75,percent of total billed charges,Implant Device,218.75,35,,218.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,462.5,
SYNTHES 208.435 SCREW,C1713,HCPCS,,79001773,CDM,278,RC,,,both,,,636,470.64,,,470.64,Other,150% of Medicare + 9.63% HCRA Surcharge,286.2,45,,286.2,percent of total billed charges,Critical Access Hospital RCC factor,216.24,34,,216.24,percent of total billed charges,Implant Device,216.24,34,,216.24,percent of total billed charges,Implant Device,216.24,34,,216.24,percent of total billed charges,Implant Device,216.24,34,,216.24,percent of total billed charges,Implant Device,216.24,34,,216.24,percent of total billed charges,Implant Device,314.82,,,314.82,Other,110% of Medicare,222.6,35,,222.6,percent of total billed charges,Implant Device,216.24,34,"Charges > $500, x 34%",216.24,percent of total billed charges,Implant Device,222.6,35,,222.6,percent of total billed charges,Implant Device,222.6,35,,222.6,percent of total billed charges,Implant Device,222.6,35,,222.6,percent of total billed charges,Implant Device,222.6,35,,222.6,percent of total billed charges,Implant Device,222.6,35,,222.6,percent of total billed charges,Implant Device,254.4,40,,254.4,percent of total billed charges,Implant Device,222.6,70,,222.6,percent of total billed charges,All Other,216.24,34,,216.24,percent of total billed charges,Implant Device,216.24,34,,216.24,percent of total billed charges,Implant Device,222.6,35,,222.6,percent of total billed charges,Implant Device,222.6,35,,222.6,percent of total billed charges,Implant Device,222.6,35,,222.6,percent of total billed charges,Implant Device,222.6,35,,222.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,470.64,
SYNTHES 208.442 SCREW CANN 6.5X100MM,C1713,HCPCS,,79001774,CDM,278,RC,,,both,,,908,671.92,,,671.92,Other,150% of Medicare + 9.63% HCRA Surcharge,408.6,45,,408.6,percent of total billed charges,Critical Access Hospital RCC factor,308.72,34,,308.72,percent of total billed charges,Implant Device,308.72,34,,308.72,percent of total billed charges,Implant Device,308.72,34,,308.72,percent of total billed charges,Implant Device,308.72,34,,308.72,percent of total billed charges,Implant Device,308.72,34,,308.72,percent of total billed charges,Implant Device,449.46,,,449.46,Other,110% of Medicare,317.8,35,,317.8,percent of total billed charges,Implant Device,308.72,34,"Charges > $500, x 34%",308.72,percent of total billed charges,Implant Device,317.8,35,,317.8,percent of total billed charges,Implant Device,317.8,35,,317.8,percent of total billed charges,Implant Device,317.8,35,,317.8,percent of total billed charges,Implant Device,317.8,35,,317.8,percent of total billed charges,Implant Device,317.8,35,,317.8,percent of total billed charges,Implant Device,363.2,40,,363.2,percent of total billed charges,Implant Device,317.8,70,,317.8,percent of total billed charges,All Other,308.72,34,,308.72,percent of total billed charges,Implant Device,308.72,34,,308.72,percent of total billed charges,Implant Device,317.8,35,,317.8,percent of total billed charges,Implant Device,317.8,35,,317.8,percent of total billed charges,Implant Device,317.8,35,,317.8,percent of total billed charges,Implant Device,317.8,35,,317.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,671.92,
SYNTHES 208.443 SCREW 6.5X105MM,C1713,HCPCS,,79001775,CDM,278,RC,,,both,,,908,671.92,,,671.92,Other,150% of Medicare + 9.63% HCRA Surcharge,408.6,45,,408.6,percent of total billed charges,Critical Access Hospital RCC factor,308.72,34,,308.72,percent of total billed charges,Implant Device,308.72,34,,308.72,percent of total billed charges,Implant Device,308.72,34,,308.72,percent of total billed charges,Implant Device,308.72,34,,308.72,percent of total billed charges,Implant Device,308.72,34,,308.72,percent of total billed charges,Implant Device,449.46,,,449.46,Other,110% of Medicare,317.8,35,,317.8,percent of total billed charges,Implant Device,308.72,34,"Charges > $500, x 34%",308.72,percent of total billed charges,Implant Device,317.8,35,,317.8,percent of total billed charges,Implant Device,317.8,35,,317.8,percent of total billed charges,Implant Device,317.8,35,,317.8,percent of total billed charges,Implant Device,317.8,35,,317.8,percent of total billed charges,Implant Device,317.8,35,,317.8,percent of total billed charges,Implant Device,363.2,40,,363.2,percent of total billed charges,Implant Device,317.8,70,,317.8,percent of total billed charges,All Other,308.72,34,,308.72,percent of total billed charges,Implant Device,308.72,34,,308.72,percent of total billed charges,Implant Device,317.8,35,,317.8,percent of total billed charges,Implant Device,317.8,35,,317.8,percent of total billed charges,Implant Device,317.8,35,,317.8,percent of total billed charges,Implant Device,317.8,35,,317.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,671.92,
BIOMET 1405 CANCELLOUS CRUSHED - 30CC,C1713,HCPCS,,79001778,CDM,278,RC,,,both,,,1521,1125.54,,,1125.54,Other,150% of Medicare + 9.63% HCRA Surcharge,684.45,45,,684.45,percent of total billed charges,Critical Access Hospital RCC factor,517.14,34,,517.14,percent of total billed charges,Implant Device,517.14,34,,517.14,percent of total billed charges,Implant Device,517.14,34,,517.14,percent of total billed charges,Implant Device,517.14,34,,517.14,percent of total billed charges,Implant Device,517.14,34,,517.14,percent of total billed charges,Implant Device,752.9,,,752.9,Other,110% of Medicare,532.35,35,,532.35,percent of total billed charges,Implant Device,517.14,34,"Charges > $500, x 34%",517.14,percent of total billed charges,Implant Device,532.35,35,,532.35,percent of total billed charges,Implant Device,532.35,35,,532.35,percent of total billed charges,Implant Device,532.35,35,,532.35,percent of total billed charges,Implant Device,532.35,35,,532.35,percent of total billed charges,Implant Device,532.35,35,,532.35,percent of total billed charges,Implant Device,608.4,40,,608.4,percent of total billed charges,Implant Device,532.35,70,,532.35,percent of total billed charges,All Other,517.14,34,,517.14,percent of total billed charges,Implant Device,517.14,34,,517.14,percent of total billed charges,Implant Device,532.35,35,,532.35,percent of total billed charges,Implant Device,532.35,35,,532.35,percent of total billed charges,Implant Device,532.35,35,,532.35,percent of total billed charges,Implant Device,532.35,35,,532.35,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1125.54,
UMTB 1482 CANCELLOUS CRUSHED IRRAD 60CC,C1713,HCPCS,,79001779,CDM,278,RC,,,both,,,2196,1625.05,,,1625.05,Other,150% of Medicare + 9.63% HCRA Surcharge,988.2,45,,988.2,percent of total billed charges,Critical Access Hospital RCC factor,746.64,34,,746.64,percent of total billed charges,Implant Device,746.64,34,,746.64,percent of total billed charges,Implant Device,746.64,34,,746.64,percent of total billed charges,Implant Device,746.64,34,,746.64,percent of total billed charges,Implant Device,746.64,34,,746.64,percent of total billed charges,Implant Device,1087.02,,,1087.02,Other,110% of Medicare,768.6,35,,768.6,percent of total billed charges,Implant Device,746.64,34,"Charges > $500, x 34%",746.64,percent of total billed charges,Implant Device,768.6,35,,768.6,percent of total billed charges,Implant Device,768.6,35,,768.6,percent of total billed charges,Implant Device,768.6,35,,768.6,percent of total billed charges,Implant Device,768.6,35,,768.6,percent of total billed charges,Implant Device,768.6,35,,768.6,percent of total billed charges,Implant Device,878.4,40,,878.4,percent of total billed charges,Implant Device,768.6,70,,768.6,percent of total billed charges,All Other,746.64,34,,746.64,percent of total billed charges,Implant Device,746.64,34,,746.64,percent of total billed charges,Implant Device,768.6,35,,768.6,percent of total billed charges,Implant Device,768.6,35,,768.6,percent of total billed charges,Implant Device,768.6,35,,768.6,percent of total billed charges,Implant Device,768.6,35,,768.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,746.64,34,"If Charge > 2,000, then 34 percent",746.64,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1625.05,
BIOMET 29237 LAG SCREW ASSY 90MM,C1713,HCPCS,,79001784,CDM,278,RC,,,both,,,3330,2464.21,,,2464.21,Other,150% of Medicare + 9.63% HCRA Surcharge,1498.5,45,,1498.5,percent of total billed charges,Critical Access Hospital RCC factor,1132.2,34,,1132.2,percent of total billed charges,Implant Device,1132.2,34,,1132.2,percent of total billed charges,Implant Device,1132.2,34,,1132.2,percent of total billed charges,Implant Device,1132.2,34,,1132.2,percent of total billed charges,Implant Device,1132.2,34,,1132.2,percent of total billed charges,Implant Device,1648.35,,,1648.35,Other,110% of Medicare,1165.5,35,,1165.5,percent of total billed charges,Implant Device,1132.2,34,"Charges > $500, x 34%",1132.2,percent of total billed charges,Implant Device,1165.5,35,,1165.5,percent of total billed charges,Implant Device,1165.5,35,,1165.5,percent of total billed charges,Implant Device,1165.5,35,,1165.5,percent of total billed charges,Implant Device,1165.5,35,,1165.5,percent of total billed charges,Implant Device,1165.5,35,,1165.5,percent of total billed charges,Implant Device,1332,40,,1332,percent of total billed charges,Implant Device,1165.5,70,,1165.5,percent of total billed charges,All Other,1132.2,34,,1132.2,percent of total billed charges,Implant Device,1132.2,34,,1132.2,percent of total billed charges,Implant Device,1165.5,35,,1165.5,percent of total billed charges,Implant Device,1165.5,35,,1165.5,percent of total billed charges,Implant Device,1165.5,35,,1165.5,percent of total billed charges,Implant Device,1165.5,35,,1165.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1132.2,34,"If Charge > 2,000, then 34 percent",1132.2,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2464.21,
BIOMET 29241 LAG SCREW ASSY KEYED,C1713,HCPCS,,79001785,CDM,278,RC,,,both,,,2406,1780.45,,,1780.45,Other,150% of Medicare + 9.63% HCRA Surcharge,1082.7,45,,1082.7,percent of total billed charges,Critical Access Hospital RCC factor,818.04,34,,818.04,percent of total billed charges,Implant Device,818.04,34,,818.04,percent of total billed charges,Implant Device,818.04,34,,818.04,percent of total billed charges,Implant Device,818.04,34,,818.04,percent of total billed charges,Implant Device,818.04,34,,818.04,percent of total billed charges,Implant Device,1190.97,,,1190.97,Other,110% of Medicare,842.1,35,,842.1,percent of total billed charges,Implant Device,818.04,34,"Charges > $500, x 34%",818.04,percent of total billed charges,Implant Device,842.1,35,,842.1,percent of total billed charges,Implant Device,842.1,35,,842.1,percent of total billed charges,Implant Device,842.1,35,,842.1,percent of total billed charges,Implant Device,842.1,35,,842.1,percent of total billed charges,Implant Device,842.1,35,,842.1,percent of total billed charges,Implant Device,962.4,40,,962.4,percent of total billed charges,Implant Device,842.1,70,,842.1,percent of total billed charges,All Other,818.04,34,,818.04,percent of total billed charges,Implant Device,818.04,34,,818.04,percent of total billed charges,Implant Device,842.1,35,,842.1,percent of total billed charges,Implant Device,842.1,35,,842.1,percent of total billed charges,Implant Device,842.1,35,,842.1,percent of total billed charges,Implant Device,842.1,35,,842.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,818.04,34,"If Charge > 2,000, then 34 percent",818.04,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1780.45,
BIOMET 29243 LAG SCREW ASSY KEYED 120MM,C1713,HCPCS,,79001786,CDM,278,RC,,,both,,,3330,2464.21,,,2464.21,Other,150% of Medicare + 9.63% HCRA Surcharge,1498.5,45,,1498.5,percent of total billed charges,Critical Access Hospital RCC factor,1132.2,34,,1132.2,percent of total billed charges,Implant Device,1132.2,34,,1132.2,percent of total billed charges,Implant Device,1132.2,34,,1132.2,percent of total billed charges,Implant Device,1132.2,34,,1132.2,percent of total billed charges,Implant Device,1132.2,34,,1132.2,percent of total billed charges,Implant Device,1648.35,,,1648.35,Other,110% of Medicare,1165.5,35,,1165.5,percent of total billed charges,Implant Device,1132.2,34,"Charges > $500, x 34%",1132.2,percent of total billed charges,Implant Device,1165.5,35,,1165.5,percent of total billed charges,Implant Device,1165.5,35,,1165.5,percent of total billed charges,Implant Device,1165.5,35,,1165.5,percent of total billed charges,Implant Device,1165.5,35,,1165.5,percent of total billed charges,Implant Device,1165.5,35,,1165.5,percent of total billed charges,Implant Device,1332,40,,1332,percent of total billed charges,Implant Device,1165.5,70,,1165.5,percent of total billed charges,All Other,1132.2,34,,1132.2,percent of total billed charges,Implant Device,1132.2,34,,1132.2,percent of total billed charges,Implant Device,1165.5,35,,1165.5,percent of total billed charges,Implant Device,1165.5,35,,1165.5,percent of total billed charges,Implant Device,1165.5,35,,1165.5,percent of total billed charges,Implant Device,1165.5,35,,1165.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1132.2,34,"If Charge > 2,000, then 34 percent",1132.2,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2464.21,
BIOMET 29278 LAG SCREW,C1713,HCPCS,,79001787,CDM,278,RC,,,both,,,1738,1286.12,,,1286.12,Other,150% of Medicare + 9.63% HCRA Surcharge,782.1,45,,782.1,percent of total billed charges,Critical Access Hospital RCC factor,590.92,34,,590.92,percent of total billed charges,Implant Device,590.92,34,,590.92,percent of total billed charges,Implant Device,590.92,34,,590.92,percent of total billed charges,Implant Device,590.92,34,,590.92,percent of total billed charges,Implant Device,590.92,34,,590.92,percent of total billed charges,Implant Device,860.31,,,860.31,Other,110% of Medicare,608.3,35,,608.3,percent of total billed charges,Implant Device,590.92,34,"Charges > $500, x 34%",590.92,percent of total billed charges,Implant Device,608.3,35,,608.3,percent of total billed charges,Implant Device,608.3,35,,608.3,percent of total billed charges,Implant Device,608.3,35,,608.3,percent of total billed charges,Implant Device,608.3,35,,608.3,percent of total billed charges,Implant Device,608.3,35,,608.3,percent of total billed charges,Implant Device,695.2,40,,695.2,percent of total billed charges,Implant Device,608.3,70,,608.3,percent of total billed charges,All Other,590.92,34,,590.92,percent of total billed charges,Implant Device,590.92,34,,590.92,percent of total billed charges,Implant Device,608.3,35,,608.3,percent of total billed charges,Implant Device,608.3,35,,608.3,percent of total billed charges,Implant Device,608.3,35,,608.3,percent of total billed charges,Implant Device,608.3,35,,608.3,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1286.12,
ATRIUM 30908 MESH PLUG,C1781,HCPCS,,79001788,CDM,278,RC,,,both,,,370,273.8,,,273.8,Other,150% of Medicare + 9.63% HCRA Surcharge,166.5,45,,166.5,percent of total billed charges,Critical Access Hospital RCC factor,125.8,34,,125.8,percent of total billed charges,Implant Device,125.8,34,,125.8,percent of total billed charges,Implant Device,125.8,34,,125.8,percent of total billed charges,Implant Device,125.8,34,,125.8,percent of total billed charges,Implant Device,125.8,34,,125.8,percent of total billed charges,Implant Device,183.15,,,183.15,Other,110% of Medicare,129.5,35,,129.5,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,129.5,35,,129.5,percent of total billed charges,Implant Device,129.5,35,,129.5,percent of total billed charges,Implant Device,129.5,35,,129.5,percent of total billed charges,Implant Device,129.5,35,,129.5,percent of total billed charges,Implant Device,129.5,35,,129.5,percent of total billed charges,Implant Device,148,40,,148,percent of total billed charges,Implant Device,129.5,70,,129.5,percent of total billed charges,All Other,125.8,34,,125.8,percent of total billed charges,Implant Device,125.8,34,,125.8,percent of total billed charges,Implant Device,129.5,35,,129.5,percent of total billed charges,Implant Device,129.5,35,,129.5,percent of total billed charges,Implant Device,129.5,35,,129.5,percent of total billed charges,Implant Device,129.5,35,,129.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,273.8,
BIOMET 63029 SCREW,C1713,HCPCS,,79001790,CDM,278,RC,,,both,,,1044,772.56,,,772.56,Other,150% of Medicare + 9.63% HCRA Surcharge,469.8,45,,469.8,percent of total billed charges,Critical Access Hospital RCC factor,354.96,34,,354.96,percent of total billed charges,Implant Device,354.96,34,,354.96,percent of total billed charges,Implant Device,354.96,34,,354.96,percent of total billed charges,Implant Device,354.96,34,,354.96,percent of total billed charges,Implant Device,354.96,34,,354.96,percent of total billed charges,Implant Device,516.78,,,516.78,Other,110% of Medicare,365.4,35,,365.4,percent of total billed charges,Implant Device,354.96,34,"Charges > $500, x 34%",354.96,percent of total billed charges,Implant Device,365.4,35,,365.4,percent of total billed charges,Implant Device,365.4,35,,365.4,percent of total billed charges,Implant Device,365.4,35,,365.4,percent of total billed charges,Implant Device,365.4,35,,365.4,percent of total billed charges,Implant Device,365.4,35,,365.4,percent of total billed charges,Implant Device,417.6,40,,417.6,percent of total billed charges,Implant Device,365.4,70,,365.4,percent of total billed charges,All Other,354.96,34,,354.96,percent of total billed charges,Implant Device,354.96,34,,354.96,percent of total billed charges,Implant Device,365.4,35,,365.4,percent of total billed charges,Implant Device,365.4,35,,365.4,percent of total billed charges,Implant Device,365.4,35,,365.4,percent of total billed charges,Implant Device,365.4,35,,365.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,772.56,
BIOMET 113032 MODULAR HEAD,C1776,HCPCS,,79001791,CDM,278,RC,,,both,,,9120,6748.82,,,6748.82,Other,150% of Medicare + 9.63% HCRA Surcharge,4104,45,,4104,percent of total billed charges,Critical Access Hospital RCC factor,3100.8,34,,3100.8,percent of total billed charges,Implant Device,3100.8,34,,3100.8,percent of total billed charges,Implant Device,3100.8,34,,3100.8,percent of total billed charges,Implant Device,3100.8,34,,3100.8,percent of total billed charges,Implant Device,3100.8,34,,3100.8,percent of total billed charges,Implant Device,4514.4,,,4514.4,Other,110% of Medicare,3192,35,,3192,percent of total billed charges,Implant Device,3100.8,34,"Charges > $500, x 34%",3100.8,percent of total billed charges,Implant Device,3192,35,,3192,percent of total billed charges,Implant Device,3192,35,,3192,percent of total billed charges,Implant Device,3192,35,,3192,percent of total billed charges,Implant Device,3192,35,,3192,percent of total billed charges,Implant Device,3192,35,,3192,percent of total billed charges,Implant Device,3648,40,,3648,percent of total billed charges,Implant Device,3192,70,,3192,percent of total billed charges,All Other,3100.8,34,,3100.8,percent of total billed charges,Implant Device,3100.8,34,,3100.8,percent of total billed charges,Implant Device,3192,35,,3192,percent of total billed charges,Implant Device,3192,35,,3192,percent of total billed charges,Implant Device,3192,35,,3192,percent of total billed charges,Implant Device,3192,35,,3192,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3100.8,34,"If Charge > 2,000, then 34 percent",3100.8,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,6748.82,
BIOMET 113652 STEM,C1776,HCPCS,,79001792,CDM,278,RC,,,both,,,18630,13786.25,,,13786.25,Other,150% of Medicare + 9.63% HCRA Surcharge,8383.5,45,,8383.5,percent of total billed charges,Critical Access Hospital RCC factor,6334.2,34,,6334.2,percent of total billed charges,Implant Device,6334.2,34,,6334.2,percent of total billed charges,Implant Device,6334.2,34,,6334.2,percent of total billed charges,Implant Device,6334.2,34,,6334.2,percent of total billed charges,Implant Device,6334.2,34,,6334.2,percent of total billed charges,Implant Device,9221.85,,,9221.85,Other,110% of Medicare,6520.5,35,,6520.5,percent of total billed charges,Implant Device,6334.2,34,"Charges > $500, x 34%",6334.2,percent of total billed charges,Implant Device,6520.5,35,,6520.5,percent of total billed charges,Implant Device,6520.5,35,,6520.5,percent of total billed charges,Implant Device,6520.5,35,,6520.5,percent of total billed charges,Implant Device,6520.5,35,,6520.5,percent of total billed charges,Implant Device,6520.5,35,,6520.5,percent of total billed charges,Implant Device,7452,40,,7452,percent of total billed charges,Implant Device,6520.5,70,,6520.5,percent of total billed charges,All Other,6334.2,34,,6334.2,percent of total billed charges,Implant Device,6334.2,34,,6334.2,percent of total billed charges,Implant Device,6520.5,35,,6520.5,percent of total billed charges,Implant Device,6520.5,35,,6520.5,percent of total billed charges,Implant Device,6520.5,35,,6520.5,percent of total billed charges,Implant Device,6520.5,35,,6520.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,6334.2,34,"If Charge > 2,000, then 34 percent",6334.2,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,13786.25,
BIOMET 113766 HUMERAL HEAD,C1776,HCPCS,,79001793,CDM,278,RC,,,both,,,7080,5239.22,,,5239.22,Other,150% of Medicare + 9.63% HCRA Surcharge,3186,45,,3186,percent of total billed charges,Critical Access Hospital RCC factor,2407.2,34,,2407.2,percent of total billed charges,Implant Device,2407.2,34,,2407.2,percent of total billed charges,Implant Device,2407.2,34,,2407.2,percent of total billed charges,Implant Device,2407.2,34,,2407.2,percent of total billed charges,Implant Device,2407.2,34,,2407.2,percent of total billed charges,Implant Device,3504.6,,,3504.6,Other,110% of Medicare,2478,35,,2478,percent of total billed charges,Implant Device,2407.2,34,"Charges > $500, x 34%",2407.2,percent of total billed charges,Implant Device,2478,35,,2478,percent of total billed charges,Implant Device,2478,35,,2478,percent of total billed charges,Implant Device,2478,35,,2478,percent of total billed charges,Implant Device,2478,35,,2478,percent of total billed charges,Implant Device,2478,35,,2478,percent of total billed charges,Implant Device,2832,40,,2832,percent of total billed charges,Implant Device,2478,70,,2478,percent of total billed charges,All Other,2407.2,34,,2407.2,percent of total billed charges,Implant Device,2407.2,34,,2407.2,percent of total billed charges,Implant Device,2478,35,,2478,percent of total billed charges,Implant Device,2478,35,,2478,percent of total billed charges,Implant Device,2478,35,,2478,percent of total billed charges,Implant Device,2478,35,,2478,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2407.2,34,"If Charge > 2,000, then 34 percent",2407.2,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5239.22,
BIOMET 115310 GLENOSPHERE,C1776,HCPCS,,79001794,CDM,278,RC,,,both,,,7500,5550.02,,,5550.02,Other,150% of Medicare + 9.63% HCRA Surcharge,3375,45,,3375,percent of total billed charges,Critical Access Hospital RCC factor,2550,34,,2550,percent of total billed charges,Implant Device,2550,34,,2550,percent of total billed charges,Implant Device,2550,34,,2550,percent of total billed charges,Implant Device,2550,34,,2550,percent of total billed charges,Implant Device,2550,34,,2550,percent of total billed charges,Implant Device,3712.5,,,3712.5,Other,110% of Medicare,2625,35,,2625,percent of total billed charges,Implant Device,2550,34,"Charges > $500, x 34%",2550,percent of total billed charges,Implant Device,2625,35,,2625,percent of total billed charges,Implant Device,2625,35,,2625,percent of total billed charges,Implant Device,2625,35,,2625,percent of total billed charges,Implant Device,2625,35,,2625,percent of total billed charges,Implant Device,2625,35,,2625,percent of total billed charges,Implant Device,3000,40,,3000,percent of total billed charges,Implant Device,2625,70,,2625,percent of total billed charges,All Other,2550,34,,2550,percent of total billed charges,Implant Device,2550,34,,2550,percent of total billed charges,Implant Device,2625,35,,2625,percent of total billed charges,Implant Device,2625,35,,2625,percent of total billed charges,Implant Device,2625,35,,2625,percent of total billed charges,Implant Device,2625,35,,2625,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2550,34,"If Charge > 2,000, then 34 percent",2550,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5550.02,
BIOMET 115330 GLENOSPHERE,C1776,HCPCS,,79001795,CDM,278,RC,,,both,,,7950,5883.02,,,5883.02,Other,150% of Medicare + 9.63% HCRA Surcharge,3577.5,45,,3577.5,percent of total billed charges,Critical Access Hospital RCC factor,2703,34,,2703,percent of total billed charges,Implant Device,2703,34,,2703,percent of total billed charges,Implant Device,2703,34,,2703,percent of total billed charges,Implant Device,2703,34,,2703,percent of total billed charges,Implant Device,2703,34,,2703,percent of total billed charges,Implant Device,3935.25,,,3935.25,Other,110% of Medicare,2782.5,35,,2782.5,percent of total billed charges,Implant Device,2703,34,"Charges > $500, x 34%",2703,percent of total billed charges,Implant Device,2782.5,35,,2782.5,percent of total billed charges,Implant Device,2782.5,35,,2782.5,percent of total billed charges,Implant Device,2782.5,35,,2782.5,percent of total billed charges,Implant Device,2782.5,35,,2782.5,percent of total billed charges,Implant Device,2782.5,35,,2782.5,percent of total billed charges,Implant Device,3180,40,,3180,percent of total billed charges,Implant Device,2782.5,70,,2782.5,percent of total billed charges,All Other,2703,34,,2703,percent of total billed charges,Implant Device,2703,34,,2703,percent of total billed charges,Implant Device,2782.5,35,,2782.5,percent of total billed charges,Implant Device,2782.5,35,,2782.5,percent of total billed charges,Implant Device,2782.5,35,,2782.5,percent of total billed charges,Implant Device,2782.5,35,,2782.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2703,34,"If Charge > 2,000, then 34 percent",2703,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5883.02,
BIOMET 115340 PLATE,C1713,HCPCS,,79001796,CDM,278,RC,,,both,,,9510,7037.42,,,7037.42,Other,150% of Medicare + 9.63% HCRA Surcharge,4279.5,45,,4279.5,percent of total billed charges,Critical Access Hospital RCC factor,3233.4,34,,3233.4,percent of total billed charges,Implant Device,3233.4,34,,3233.4,percent of total billed charges,Implant Device,3233.4,34,,3233.4,percent of total billed charges,Implant Device,3233.4,34,,3233.4,percent of total billed charges,Implant Device,3233.4,34,,3233.4,percent of total billed charges,Implant Device,4707.45,,,4707.45,Other,110% of Medicare,3328.5,35,,3328.5,percent of total billed charges,Implant Device,3233.4,34,"Charges > $500, x 34%",3233.4,percent of total billed charges,Implant Device,3328.5,35,,3328.5,percent of total billed charges,Implant Device,3328.5,35,,3328.5,percent of total billed charges,Implant Device,3328.5,35,,3328.5,percent of total billed charges,Implant Device,3328.5,35,,3328.5,percent of total billed charges,Implant Device,3328.5,35,,3328.5,percent of total billed charges,Implant Device,3804,40,,3804,percent of total billed charges,Implant Device,3328.5,70,,3328.5,percent of total billed charges,All Other,3233.4,34,,3233.4,percent of total billed charges,Implant Device,3233.4,34,,3233.4,percent of total billed charges,Implant Device,3328.5,35,,3328.5,percent of total billed charges,Implant Device,3328.5,35,,3328.5,percent of total billed charges,Implant Device,3328.5,35,,3328.5,percent of total billed charges,Implant Device,3328.5,35,,3328.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3233.4,34,"If Charge > 2,000, then 34 percent",3233.4,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,7037.42,
BIOMET 115370 STEM,C1776,HCPCS,,79001797,CDM,278,RC,,,both,,,8670,6415.82,,,6415.82,Other,150% of Medicare + 9.63% HCRA Surcharge,3901.5,45,,3901.5,percent of total billed charges,Critical Access Hospital RCC factor,2947.8,34,,2947.8,percent of total billed charges,Implant Device,2947.8,34,,2947.8,percent of total billed charges,Implant Device,2947.8,34,,2947.8,percent of total billed charges,Implant Device,2947.8,34,,2947.8,percent of total billed charges,Implant Device,2947.8,34,,2947.8,percent of total billed charges,Implant Device,4291.65,,,4291.65,Other,110% of Medicare,3034.5,35,,3034.5,percent of total billed charges,Implant Device,2947.8,34,"Charges > $500, x 34%",2947.8,percent of total billed charges,Implant Device,3034.5,35,,3034.5,percent of total billed charges,Implant Device,3034.5,35,,3034.5,percent of total billed charges,Implant Device,3034.5,35,,3034.5,percent of total billed charges,Implant Device,3034.5,35,,3034.5,percent of total billed charges,Implant Device,3034.5,35,,3034.5,percent of total billed charges,Implant Device,3468,40,,3468,percent of total billed charges,Implant Device,3034.5,70,,3034.5,percent of total billed charges,All Other,2947.8,34,,2947.8,percent of total billed charges,Implant Device,2947.8,34,,2947.8,percent of total billed charges,Implant Device,3034.5,35,,3034.5,percent of total billed charges,Implant Device,3034.5,35,,3034.5,percent of total billed charges,Implant Device,3034.5,35,,3034.5,percent of total billed charges,Implant Device,3034.5,35,,3034.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2947.8,34,"If Charge > 2,000, then 34 percent",2947.8,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,6415.82,
BIOMET 115382 SHOULDER,C1776,HCPCS,,79001798,CDM,278,RC,,,both,,,526,389.24,,,389.24,Other,150% of Medicare + 9.63% HCRA Surcharge,236.7,45,,236.7,percent of total billed charges,Critical Access Hospital RCC factor,178.84,34,,178.84,percent of total billed charges,Implant Device,178.84,34,,178.84,percent of total billed charges,Implant Device,178.84,34,,178.84,percent of total billed charges,Implant Device,178.84,34,,178.84,percent of total billed charges,Implant Device,178.84,34,,178.84,percent of total billed charges,Implant Device,260.37,,,260.37,Other,110% of Medicare,184.1,35,,184.1,percent of total billed charges,Implant Device,178.84,34,"Charges > $500, x 34%",178.84,percent of total billed charges,Implant Device,184.1,35,,184.1,percent of total billed charges,Implant Device,184.1,35,,184.1,percent of total billed charges,Implant Device,184.1,35,,184.1,percent of total billed charges,Implant Device,184.1,35,,184.1,percent of total billed charges,Implant Device,184.1,35,,184.1,percent of total billed charges,Implant Device,210.4,40,,210.4,percent of total billed charges,Implant Device,184.1,70,,184.1,percent of total billed charges,All Other,178.84,34,,178.84,percent of total billed charges,Implant Device,178.84,34,,178.84,percent of total billed charges,Implant Device,184.1,35,,184.1,percent of total billed charges,Implant Device,184.1,35,,184.1,percent of total billed charges,Implant Device,184.1,35,,184.1,percent of total billed charges,Implant Device,184.1,35,,184.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,389.24,
BIOMET 139246 TAPER ADAPTER,C1776,HCPCS,,79001799,CDM,278,RC,,,both,,,630,466.2,,,466.2,Other,150% of Medicare + 9.63% HCRA Surcharge,283.5,45,,283.5,percent of total billed charges,Critical Access Hospital RCC factor,214.2,34,,214.2,percent of total billed charges,Implant Device,214.2,34,,214.2,percent of total billed charges,Implant Device,214.2,34,,214.2,percent of total billed charges,Implant Device,214.2,34,,214.2,percent of total billed charges,Implant Device,214.2,34,,214.2,percent of total billed charges,Implant Device,311.85,,,311.85,Other,110% of Medicare,220.5,35,,220.5,percent of total billed charges,Implant Device,214.2,34,"Charges > $500, x 34%",214.2,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,252,40,,252,percent of total billed charges,Implant Device,220.5,70,,220.5,percent of total billed charges,All Other,214.2,34,,214.2,percent of total billed charges,Implant Device,214.2,34,,214.2,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,466.2,
BIOMET 154601 FEMORAL STEM,C1776,HCPCS,,79001800,CDM,278,RC,,,both,,,8544,6322.58,,,6322.58,Other,150% of Medicare + 9.63% HCRA Surcharge,3844.8,45,,3844.8,percent of total billed charges,Critical Access Hospital RCC factor,2904.96,34,,2904.96,percent of total billed charges,Implant Device,2904.96,34,,2904.96,percent of total billed charges,Implant Device,2904.96,34,,2904.96,percent of total billed charges,Implant Device,2904.96,34,,2904.96,percent of total billed charges,Implant Device,2904.96,34,,2904.96,percent of total billed charges,Implant Device,4229.28,,,4229.28,Other,110% of Medicare,2990.4,35,,2990.4,percent of total billed charges,Implant Device,2904.96,34,"Charges > $500, x 34%",2904.96,percent of total billed charges,Implant Device,2990.4,35,,2990.4,percent of total billed charges,Implant Device,2990.4,35,,2990.4,percent of total billed charges,Implant Device,2990.4,35,,2990.4,percent of total billed charges,Implant Device,2990.4,35,,2990.4,percent of total billed charges,Implant Device,2990.4,35,,2990.4,percent of total billed charges,Implant Device,3417.6,40,,3417.6,percent of total billed charges,Implant Device,2990.4,70,,2990.4,percent of total billed charges,All Other,2904.96,34,,2904.96,percent of total billed charges,Implant Device,2904.96,34,,2904.96,percent of total billed charges,Implant Device,2990.4,35,,2990.4,percent of total billed charges,Implant Device,2990.4,35,,2990.4,percent of total billed charges,Implant Device,2990.4,35,,2990.4,percent of total billed charges,Implant Device,2990.4,35,,2990.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2904.96,34,"If Charge > 2,000, then 34 percent",2904.96,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,6322.58,
BIOMET 180501 SCREW,C1776,HCPCS,,79001801,CDM,278,RC,,,both,,,810,599.4,,,599.4,Other,150% of Medicare + 9.63% HCRA Surcharge,364.5,45,,364.5,percent of total billed charges,Critical Access Hospital RCC factor,275.4,34,,275.4,percent of total billed charges,Implant Device,275.4,34,,275.4,percent of total billed charges,Implant Device,275.4,34,,275.4,percent of total billed charges,Implant Device,275.4,34,,275.4,percent of total billed charges,Implant Device,275.4,34,,275.4,percent of total billed charges,Implant Device,400.95,,,400.95,Other,110% of Medicare,283.5,35,,283.5,percent of total billed charges,Implant Device,275.4,34,"Charges > $500, x 34%",275.4,percent of total billed charges,Implant Device,283.5,35,,283.5,percent of total billed charges,Implant Device,283.5,35,,283.5,percent of total billed charges,Implant Device,283.5,35,,283.5,percent of total billed charges,Implant Device,283.5,35,,283.5,percent of total billed charges,Implant Device,283.5,35,,283.5,percent of total billed charges,Implant Device,324,40,,324,percent of total billed charges,Implant Device,283.5,70,,283.5,percent of total billed charges,All Other,275.4,34,,275.4,percent of total billed charges,Implant Device,275.4,34,,275.4,percent of total billed charges,Implant Device,283.5,35,,283.5,percent of total billed charges,Implant Device,283.5,35,,283.5,percent of total billed charges,Implant Device,283.5,35,,283.5,percent of total billed charges,Implant Device,283.5,35,,283.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,599.4,
BIOMET 180507 SCREW,C1776,HCPCS,,79001802,CDM,278,RC,,,both,,,810,599.4,,,599.4,Other,150% of Medicare + 9.63% HCRA Surcharge,364.5,45,,364.5,percent of total billed charges,Critical Access Hospital RCC factor,275.4,34,,275.4,percent of total billed charges,Implant Device,275.4,34,,275.4,percent of total billed charges,Implant Device,275.4,34,,275.4,percent of total billed charges,Implant Device,275.4,34,,275.4,percent of total billed charges,Implant Device,275.4,34,,275.4,percent of total billed charges,Implant Device,400.95,,,400.95,Other,110% of Medicare,283.5,35,,283.5,percent of total billed charges,Implant Device,275.4,34,"Charges > $500, x 34%",275.4,percent of total billed charges,Implant Device,283.5,35,,283.5,percent of total billed charges,Implant Device,283.5,35,,283.5,percent of total billed charges,Implant Device,283.5,35,,283.5,percent of total billed charges,Implant Device,283.5,35,,283.5,percent of total billed charges,Implant Device,283.5,35,,283.5,percent of total billed charges,Implant Device,324,40,,324,percent of total billed charges,Implant Device,283.5,70,,283.5,percent of total billed charges,All Other,275.4,34,,275.4,percent of total billed charges,Implant Device,275.4,34,,275.4,percent of total billed charges,Implant Device,283.5,35,,283.5,percent of total billed charges,Implant Device,283.5,35,,283.5,percent of total billed charges,Implant Device,283.5,35,,283.5,percent of total billed charges,Implant Device,283.5,35,,283.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,599.4,
STRYKER 06-2600 TAPER,C1776,HCPCS,,79001804,CDM,278,RC,,,both,,,3008,2225.93,,,2225.93,Other,150% of Medicare + 9.63% HCRA Surcharge,1353.6,45,,1353.6,percent of total billed charges,Critical Access Hospital RCC factor,1022.72,34,,1022.72,percent of total billed charges,Implant Device,1022.72,34,,1022.72,percent of total billed charges,Implant Device,1022.72,34,,1022.72,percent of total billed charges,Implant Device,1022.72,34,,1022.72,percent of total billed charges,Implant Device,1022.72,34,,1022.72,percent of total billed charges,Implant Device,1488.96,,,1488.96,Other,110% of Medicare,1052.8,35,,1052.8,percent of total billed charges,Implant Device,1022.72,34,"Charges > $500, x 34%",1022.72,percent of total billed charges,Implant Device,1052.8,35,,1052.8,percent of total billed charges,Implant Device,1052.8,35,,1052.8,percent of total billed charges,Implant Device,1052.8,35,,1052.8,percent of total billed charges,Implant Device,1052.8,35,,1052.8,percent of total billed charges,Implant Device,1052.8,35,,1052.8,percent of total billed charges,Implant Device,1203.2,40,,1203.2,percent of total billed charges,Implant Device,1052.8,70,,1052.8,percent of total billed charges,All Other,1022.72,34,,1022.72,percent of total billed charges,Implant Device,1022.72,34,,1022.72,percent of total billed charges,Implant Device,1052.8,35,,1052.8,percent of total billed charges,Implant Device,1052.8,35,,1052.8,percent of total billed charges,Implant Device,1052.8,35,,1052.8,percent of total billed charges,Implant Device,1052.8,35,,1052.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1022.72,34,"If Charge > 2,000, then 34 percent",1022.72,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2225.93,
STRYKER 325040 SCREW,C1713,HCPCS,,79001805,CDM,278,RC,,,both,,,694,513.56,,,513.56,Other,150% of Medicare + 9.63% HCRA Surcharge,312.3,45,,312.3,percent of total billed charges,Critical Access Hospital RCC factor,235.96,34,,235.96,percent of total billed charges,Implant Device,235.96,34,,235.96,percent of total billed charges,Implant Device,235.96,34,,235.96,percent of total billed charges,Implant Device,235.96,34,,235.96,percent of total billed charges,Implant Device,235.96,34,,235.96,percent of total billed charges,Implant Device,343.53,,,343.53,Other,110% of Medicare,242.9,35,,242.9,percent of total billed charges,Implant Device,235.96,34,"Charges > $500, x 34%",235.96,percent of total billed charges,Implant Device,242.9,35,,242.9,percent of total billed charges,Implant Device,242.9,35,,242.9,percent of total billed charges,Implant Device,242.9,35,,242.9,percent of total billed charges,Implant Device,242.9,35,,242.9,percent of total billed charges,Implant Device,242.9,35,,242.9,percent of total billed charges,Implant Device,277.6,40,,277.6,percent of total billed charges,Implant Device,242.9,70,,242.9,percent of total billed charges,All Other,235.96,34,,235.96,percent of total billed charges,Implant Device,235.96,34,,235.96,percent of total billed charges,Implant Device,242.9,35,,242.9,percent of total billed charges,Implant Device,242.9,35,,242.9,percent of total billed charges,Implant Device,242.9,35,,242.9,percent of total billed charges,Implant Device,242.9,35,,242.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,513.56,
STRYKER 325044 CANN SCREW 4X44MM,C1713,HCPCS,,79001806,CDM,278,RC,,,both,,,770,569.8,,,569.8,Other,150% of Medicare + 9.63% HCRA Surcharge,346.5,45,,346.5,percent of total billed charges,Critical Access Hospital RCC factor,261.8,34,,261.8,percent of total billed charges,Implant Device,261.8,34,,261.8,percent of total billed charges,Implant Device,261.8,34,,261.8,percent of total billed charges,Implant Device,261.8,34,,261.8,percent of total billed charges,Implant Device,261.8,34,,261.8,percent of total billed charges,Implant Device,381.15,,,381.15,Other,110% of Medicare,269.5,35,,269.5,percent of total billed charges,Implant Device,261.8,34,"Charges > $500, x 34%",261.8,percent of total billed charges,Implant Device,269.5,35,,269.5,percent of total billed charges,Implant Device,269.5,35,,269.5,percent of total billed charges,Implant Device,269.5,35,,269.5,percent of total billed charges,Implant Device,269.5,35,,269.5,percent of total billed charges,Implant Device,269.5,35,,269.5,percent of total billed charges,Implant Device,308,40,,308,percent of total billed charges,Implant Device,269.5,70,,269.5,percent of total billed charges,All Other,261.8,34,,261.8,percent of total billed charges,Implant Device,261.8,34,,261.8,percent of total billed charges,Implant Device,269.5,35,,269.5,percent of total billed charges,Implant Device,269.5,35,,269.5,percent of total billed charges,Implant Device,269.5,35,,269.5,percent of total billed charges,Implant Device,269.5,35,,269.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,569.8,
STRYKER 370332 SCREW,C1713,HCPCS,,79001807,CDM,278,RC,,,both,,,446,330.04,,,330.04,Other,150% of Medicare + 9.63% HCRA Surcharge,200.7,45,,200.7,percent of total billed charges,Critical Access Hospital RCC factor,151.64,34,,151.64,percent of total billed charges,Implant Device,151.64,34,,151.64,percent of total billed charges,Implant Device,151.64,34,,151.64,percent of total billed charges,Implant Device,151.64,34,,151.64,percent of total billed charges,Implant Device,151.64,34,,151.64,percent of total billed charges,Implant Device,220.77,,,220.77,Other,110% of Medicare,156.1,35,,156.1,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,156.1,35,,156.1,percent of total billed charges,Implant Device,156.1,35,,156.1,percent of total billed charges,Implant Device,156.1,35,,156.1,percent of total billed charges,Implant Device,156.1,35,,156.1,percent of total billed charges,Implant Device,156.1,35,,156.1,percent of total billed charges,Implant Device,178.4,40,,178.4,percent of total billed charges,Implant Device,156.1,70,,156.1,percent of total billed charges,All Other,151.64,34,,151.64,percent of total billed charges,Implant Device,151.64,34,,151.64,percent of total billed charges,Implant Device,156.1,35,,156.1,percent of total billed charges,Implant Device,156.1,35,,156.1,percent of total billed charges,Implant Device,156.1,35,,156.1,percent of total billed charges,Implant Device,156.1,35,,156.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,330.04,
MTF 400047 CANCELLOUS CHIPS 90CC,C1713,HCPCS,,79001808,CDM,278,RC,,,both,,,3912,2894.89,,,2894.89,Other,150% of Medicare + 9.63% HCRA Surcharge,1760.4,45,,1760.4,percent of total billed charges,Critical Access Hospital RCC factor,1330.08,34,,1330.08,percent of total billed charges,Implant Device,1330.08,34,,1330.08,percent of total billed charges,Implant Device,1330.08,34,,1330.08,percent of total billed charges,Implant Device,1330.08,34,,1330.08,percent of total billed charges,Implant Device,1330.08,34,,1330.08,percent of total billed charges,Implant Device,1936.44,,,1936.44,Other,110% of Medicare,1369.2,35,,1369.2,percent of total billed charges,Implant Device,1330.08,34,"Charges > $500, x 34%",1330.08,percent of total billed charges,Implant Device,1369.2,35,,1369.2,percent of total billed charges,Implant Device,1369.2,35,,1369.2,percent of total billed charges,Implant Device,1369.2,35,,1369.2,percent of total billed charges,Implant Device,1369.2,35,,1369.2,percent of total billed charges,Implant Device,1369.2,35,,1369.2,percent of total billed charges,Implant Device,1564.8,40,,1564.8,percent of total billed charges,Implant Device,1369.2,70,,1369.2,percent of total billed charges,All Other,1330.08,34,,1330.08,percent of total billed charges,Implant Device,1330.08,34,,1330.08,percent of total billed charges,Implant Device,1369.2,35,,1369.2,percent of total billed charges,Implant Device,1369.2,35,,1369.2,percent of total billed charges,Implant Device,1369.2,35,,1369.2,percent of total billed charges,Implant Device,1369.2,35,,1369.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1330.08,34,"If Charge > 2,000, then 34 percent",1330.08,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2894.89,
BIOMET 402438 BONE CEMENT,C1713,HCPCS,,79001810,CDM,278,RC,,,both,,,766,566.84,,,566.84,Other,150% of Medicare + 9.63% HCRA Surcharge,344.7,45,,344.7,percent of total billed charges,Critical Access Hospital RCC factor,260.44,34,,260.44,percent of total billed charges,Implant Device,260.44,34,,260.44,percent of total billed charges,Implant Device,260.44,34,,260.44,percent of total billed charges,Implant Device,260.44,34,,260.44,percent of total billed charges,Implant Device,260.44,34,,260.44,percent of total billed charges,Implant Device,379.17,,,379.17,Other,110% of Medicare,268.1,35,,268.1,percent of total billed charges,Implant Device,260.44,34,"Charges > $500, x 34%",260.44,percent of total billed charges,Implant Device,268.1,35,,268.1,percent of total billed charges,Implant Device,268.1,35,,268.1,percent of total billed charges,Implant Device,268.1,35,,268.1,percent of total billed charges,Implant Device,268.1,35,,268.1,percent of total billed charges,Implant Device,268.1,35,,268.1,percent of total billed charges,Implant Device,306.4,40,,306.4,percent of total billed charges,Implant Device,268.1,70,,268.1,percent of total billed charges,All Other,260.44,34,,260.44,percent of total billed charges,Implant Device,260.44,34,,260.44,percent of total billed charges,Implant Device,268.1,35,,268.1,percent of total billed charges,Implant Device,268.1,35,,268.1,percent of total billed charges,Implant Device,268.1,35,,268.1,percent of total billed charges,Implant Device,268.1,35,,268.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,566.84,
BIOMET 402439 BONE CEMENT,C1713,HCPCS,,79001811,CDM,278,RC,,,both,,,1098,812.52,,,812.52,Other,150% of Medicare + 9.63% HCRA Surcharge,494.1,45,,494.1,percent of total billed charges,Critical Access Hospital RCC factor,373.32,34,,373.32,percent of total billed charges,Implant Device,373.32,34,,373.32,percent of total billed charges,Implant Device,373.32,34,,373.32,percent of total billed charges,Implant Device,373.32,34,,373.32,percent of total billed charges,Implant Device,373.32,34,,373.32,percent of total billed charges,Implant Device,543.51,,,543.51,Other,110% of Medicare,384.3,35,,384.3,percent of total billed charges,Implant Device,373.32,34,"Charges > $500, x 34%",373.32,percent of total billed charges,Implant Device,384.3,35,,384.3,percent of total billed charges,Implant Device,384.3,35,,384.3,percent of total billed charges,Implant Device,384.3,35,,384.3,percent of total billed charges,Implant Device,384.3,35,,384.3,percent of total billed charges,Implant Device,384.3,35,,384.3,percent of total billed charges,Implant Device,439.2,40,,439.2,percent of total billed charges,Implant Device,384.3,70,,384.3,percent of total billed charges,All Other,373.32,34,,373.32,percent of total billed charges,Implant Device,373.32,34,,373.32,percent of total billed charges,Implant Device,384.3,35,,384.3,percent of total billed charges,Implant Device,384.3,35,,384.3,percent of total billed charges,Implant Device,384.3,35,,384.3,percent of total billed charges,Implant Device,384.3,35,,384.3,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,812.52,
BIOMET 405800 STEINMAN PIN,C1713,HCPCS,,79001812,CDM,278,RC,,,both,,,660,488.4,,,488.4,Other,150% of Medicare + 9.63% HCRA Surcharge,297,45,,297,percent of total billed charges,Critical Access Hospital RCC factor,224.4,34,,224.4,percent of total billed charges,Implant Device,224.4,34,,224.4,percent of total billed charges,Implant Device,224.4,34,,224.4,percent of total billed charges,Implant Device,224.4,34,,224.4,percent of total billed charges,Implant Device,224.4,34,,224.4,percent of total billed charges,Implant Device,326.7,,,326.7,Other,110% of Medicare,231,35,,231,percent of total billed charges,Implant Device,224.4,34,"Charges > $500, x 34%",224.4,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,264,40,,264,percent of total billed charges,Implant Device,231,70,,231,percent of total billed charges,All Other,224.4,34,,224.4,percent of total billed charges,Implant Device,224.4,34,,224.4,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,488.4,
MTF 410101 ALLOGRAFT 1CC,C1713,HCPCS,,79001814,CDM,278,RC,,,both,,,1740,1287.6,,,1287.6,Other,150% of Medicare + 9.63% HCRA Surcharge,783,45,,783,percent of total billed charges,Critical Access Hospital RCC factor,591.6,34,,591.6,percent of total billed charges,Implant Device,591.6,34,,591.6,percent of total billed charges,Implant Device,591.6,34,,591.6,percent of total billed charges,Implant Device,591.6,34,,591.6,percent of total billed charges,Implant Device,591.6,34,,591.6,percent of total billed charges,Implant Device,861.3,,,861.3,Other,110% of Medicare,609,35,,609,percent of total billed charges,Implant Device,591.6,34,"Charges > $500, x 34%",591.6,percent of total billed charges,Implant Device,609,35,,609,percent of total billed charges,Implant Device,609,35,,609,percent of total billed charges,Implant Device,609,35,,609,percent of total billed charges,Implant Device,609,35,,609,percent of total billed charges,Implant Device,609,35,,609,percent of total billed charges,Implant Device,696,40,,696,percent of total billed charges,Implant Device,609,70,,609,percent of total billed charges,All Other,591.6,34,,591.6,percent of total billed charges,Implant Device,591.6,34,,591.6,percent of total billed charges,Implant Device,609,35,,609,percent of total billed charges,Implant Device,609,35,,609,percent of total billed charges,Implant Device,609,35,,609,percent of total billed charges,Implant Device,609,35,,609,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1287.6,
MTF 410110 ALLOGRAFT 10CC,C1713,HCPCS,,79001815,CDM,278,RC,,,both,,,13096,9691.07,,,9691.07,Other,150% of Medicare + 9.63% HCRA Surcharge,5893.2,45,,5893.2,percent of total billed charges,Critical Access Hospital RCC factor,4452.64,34,,4452.64,percent of total billed charges,Implant Device,4452.64,34,,4452.64,percent of total billed charges,Implant Device,4452.64,34,,4452.64,percent of total billed charges,Implant Device,4452.64,34,,4452.64,percent of total billed charges,Implant Device,4452.64,34,,4452.64,percent of total billed charges,Implant Device,6482.52,,,6482.52,Other,110% of Medicare,4583.6,35,,4583.6,percent of total billed charges,Implant Device,4452.64,34,"Charges > $500, x 34%",4452.64,percent of total billed charges,Implant Device,4583.6,35,,4583.6,percent of total billed charges,Implant Device,4583.6,35,,4583.6,percent of total billed charges,Implant Device,4583.6,35,,4583.6,percent of total billed charges,Implant Device,4583.6,35,,4583.6,percent of total billed charges,Implant Device,4583.6,35,,4583.6,percent of total billed charges,Implant Device,5238.4,40,,5238.4,percent of total billed charges,Implant Device,4583.6,70,,4583.6,percent of total billed charges,All Other,4452.64,34,,4452.64,percent of total billed charges,Implant Device,4452.64,34,,4452.64,percent of total billed charges,Implant Device,4583.6,35,,4583.6,percent of total billed charges,Implant Device,4583.6,35,,4583.6,percent of total billed charges,Implant Device,4583.6,35,,4583.6,percent of total billed charges,Implant Device,4583.6,35,,4583.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,4452.64,34,"If Charge > 2,000, then 34 percent",4452.64,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,9691.07,
BIOMET 431196 STEM,C1776,HCPCS,,79001816,CDM,278,RC,,,both,,,5098,3772.53,,,3772.53,Other,150% of Medicare + 9.63% HCRA Surcharge,2294.1,45,,2294.1,percent of total billed charges,Critical Access Hospital RCC factor,1733.32,34,,1733.32,percent of total billed charges,Implant Device,1733.32,34,,1733.32,percent of total billed charges,Implant Device,1733.32,34,,1733.32,percent of total billed charges,Implant Device,1733.32,34,,1733.32,percent of total billed charges,Implant Device,1733.32,34,,1733.32,percent of total billed charges,Implant Device,2523.51,,,2523.51,Other,110% of Medicare,1784.3,35,,1784.3,percent of total billed charges,Implant Device,1733.32,34,"Charges > $500, x 34%",1733.32,percent of total billed charges,Implant Device,1784.3,35,,1784.3,percent of total billed charges,Implant Device,1784.3,35,,1784.3,percent of total billed charges,Implant Device,1784.3,35,,1784.3,percent of total billed charges,Implant Device,1784.3,35,,1784.3,percent of total billed charges,Implant Device,1784.3,35,,1784.3,percent of total billed charges,Implant Device,2039.2,40,,2039.2,percent of total billed charges,Implant Device,1784.3,70,,1784.3,percent of total billed charges,All Other,1733.32,34,,1733.32,percent of total billed charges,Implant Device,1733.32,34,,1733.32,percent of total billed charges,Implant Device,1784.3,35,,1784.3,percent of total billed charges,Implant Device,1784.3,35,,1784.3,percent of total billed charges,Implant Device,1784.3,35,,1784.3,percent of total billed charges,Implant Device,1784.3,35,,1784.3,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1733.32,34,"If Charge > 2,000, then 34 percent",1733.32,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3772.53,
BIOMET 432160 SPACER MOLD,C1776,HCPCS,,79001817,CDM,278,RC,,,both,,,8490,6282.62,,,6282.62,Other,150% of Medicare + 9.63% HCRA Surcharge,3820.5,45,,3820.5,percent of total billed charges,Critical Access Hospital RCC factor,2886.6,34,,2886.6,percent of total billed charges,Implant Device,2886.6,34,,2886.6,percent of total billed charges,Implant Device,2886.6,34,,2886.6,percent of total billed charges,Implant Device,2886.6,34,,2886.6,percent of total billed charges,Implant Device,2886.6,34,,2886.6,percent of total billed charges,Implant Device,4202.55,,,4202.55,Other,110% of Medicare,2971.5,35,,2971.5,percent of total billed charges,Implant Device,2886.6,34,"Charges > $500, x 34%",2886.6,percent of total billed charges,Implant Device,2971.5,35,,2971.5,percent of total billed charges,Implant Device,2971.5,35,,2971.5,percent of total billed charges,Implant Device,2971.5,35,,2971.5,percent of total billed charges,Implant Device,2971.5,35,,2971.5,percent of total billed charges,Implant Device,2971.5,35,,2971.5,percent of total billed charges,Implant Device,3396,40,,3396,percent of total billed charges,Implant Device,2971.5,70,,2971.5,percent of total billed charges,All Other,2886.6,34,,2886.6,percent of total billed charges,Implant Device,2886.6,34,,2886.6,percent of total billed charges,Implant Device,2971.5,35,,2971.5,percent of total billed charges,Implant Device,2971.5,35,,2971.5,percent of total billed charges,Implant Device,2971.5,35,,2971.5,percent of total billed charges,Implant Device,2971.5,35,,2971.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2886.6,34,"If Charge > 2,000, then 34 percent",2886.6,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,6282.62,
BIOMET 432165 SPACER MOLD,C1776,HCPCS,,79001818,CDM,278,RC,,,both,,,8490,6282.62,,,6282.62,Other,150% of Medicare + 9.63% HCRA Surcharge,3820.5,45,,3820.5,percent of total billed charges,Critical Access Hospital RCC factor,2886.6,34,,2886.6,percent of total billed charges,Implant Device,2886.6,34,,2886.6,percent of total billed charges,Implant Device,2886.6,34,,2886.6,percent of total billed charges,Implant Device,2886.6,34,,2886.6,percent of total billed charges,Implant Device,2886.6,34,,2886.6,percent of total billed charges,Implant Device,4202.55,,,4202.55,Other,110% of Medicare,2971.5,35,,2971.5,percent of total billed charges,Implant Device,2886.6,34,"Charges > $500, x 34%",2886.6,percent of total billed charges,Implant Device,2971.5,35,,2971.5,percent of total billed charges,Implant Device,2971.5,35,,2971.5,percent of total billed charges,Implant Device,2971.5,35,,2971.5,percent of total billed charges,Implant Device,2971.5,35,,2971.5,percent of total billed charges,Implant Device,2971.5,35,,2971.5,percent of total billed charges,Implant Device,3396,40,,3396,percent of total billed charges,Implant Device,2971.5,70,,2971.5,percent of total billed charges,All Other,2886.6,34,,2886.6,percent of total billed charges,Implant Device,2886.6,34,,2886.6,percent of total billed charges,Implant Device,2971.5,35,,2971.5,percent of total billed charges,Implant Device,2971.5,35,,2971.5,percent of total billed charges,Implant Device,2971.5,35,,2971.5,percent of total billed charges,Implant Device,2971.5,35,,2971.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2886.6,34,"If Charge > 2,000, then 34 percent",2886.6,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,6282.62,
BIOMET 433170 SPACER MOLD,C1776,HCPCS,,79001819,CDM,278,RC,,,both,,,4050,2997.01,,,2997.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1822.5,45,,1822.5,percent of total billed charges,Critical Access Hospital RCC factor,1377,34,,1377,percent of total billed charges,Implant Device,1377,34,,1377,percent of total billed charges,Implant Device,1377,34,,1377,percent of total billed charges,Implant Device,1377,34,,1377,percent of total billed charges,Implant Device,1377,34,,1377,percent of total billed charges,Implant Device,2004.75,,,2004.75,Other,110% of Medicare,1417.5,35,,1417.5,percent of total billed charges,Implant Device,1377,34,"Charges > $500, x 34%",1377,percent of total billed charges,Implant Device,1417.5,35,,1417.5,percent of total billed charges,Implant Device,1417.5,35,,1417.5,percent of total billed charges,Implant Device,1417.5,35,,1417.5,percent of total billed charges,Implant Device,1417.5,35,,1417.5,percent of total billed charges,Implant Device,1417.5,35,,1417.5,percent of total billed charges,Implant Device,1620,40,,1620,percent of total billed charges,Implant Device,1417.5,70,,1417.5,percent of total billed charges,All Other,1377,34,,1377,percent of total billed charges,Implant Device,1377,34,,1377,percent of total billed charges,Implant Device,1417.5,35,,1417.5,percent of total billed charges,Implant Device,1417.5,35,,1417.5,percent of total billed charges,Implant Device,1417.5,35,,1417.5,percent of total billed charges,Implant Device,1417.5,35,,1417.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1377,34,"If Charge > 2,000, then 34 percent",1377,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2997.01,
BIOMET 433180 SPACER MOLD,C1776,HCPCS,,79001820,CDM,278,RC,,,both,,,4050,2997.01,,,2997.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1822.5,45,,1822.5,percent of total billed charges,Critical Access Hospital RCC factor,1377,34,,1377,percent of total billed charges,Implant Device,1377,34,,1377,percent of total billed charges,Implant Device,1377,34,,1377,percent of total billed charges,Implant Device,1377,34,,1377,percent of total billed charges,Implant Device,1377,34,,1377,percent of total billed charges,Implant Device,2004.75,,,2004.75,Other,110% of Medicare,1417.5,35,,1417.5,percent of total billed charges,Implant Device,1377,34,"Charges > $500, x 34%",1377,percent of total billed charges,Implant Device,1417.5,35,,1417.5,percent of total billed charges,Implant Device,1417.5,35,,1417.5,percent of total billed charges,Implant Device,1417.5,35,,1417.5,percent of total billed charges,Implant Device,1417.5,35,,1417.5,percent of total billed charges,Implant Device,1417.5,35,,1417.5,percent of total billed charges,Implant Device,1620,40,,1620,percent of total billed charges,Implant Device,1417.5,70,,1417.5,percent of total billed charges,All Other,1377,34,,1377,percent of total billed charges,Implant Device,1377,34,,1377,percent of total billed charges,Implant Device,1417.5,35,,1417.5,percent of total billed charges,Implant Device,1417.5,35,,1417.5,percent of total billed charges,Implant Device,1417.5,35,,1417.5,percent of total billed charges,Implant Device,1417.5,35,,1417.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1377,34,"If Charge > 2,000, then 34 percent",1377,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2997.01,
STRYKER 602670 SCREW,C1713,HCPCS,,79001821,CDM,278,RC,,,both,,,696,515.04,,,515.04,Other,150% of Medicare + 9.63% HCRA Surcharge,313.2,45,,313.2,percent of total billed charges,Critical Access Hospital RCC factor,236.64,34,,236.64,percent of total billed charges,Implant Device,236.64,34,,236.64,percent of total billed charges,Implant Device,236.64,34,,236.64,percent of total billed charges,Implant Device,236.64,34,,236.64,percent of total billed charges,Implant Device,236.64,34,,236.64,percent of total billed charges,Implant Device,344.52,,,344.52,Other,110% of Medicare,243.6,35,,243.6,percent of total billed charges,Implant Device,236.64,34,"Charges > $500, x 34%",236.64,percent of total billed charges,Implant Device,243.6,35,,243.6,percent of total billed charges,Implant Device,243.6,35,,243.6,percent of total billed charges,Implant Device,243.6,35,,243.6,percent of total billed charges,Implant Device,243.6,35,,243.6,percent of total billed charges,Implant Device,243.6,35,,243.6,percent of total billed charges,Implant Device,278.4,40,,278.4,percent of total billed charges,Implant Device,243.6,70,,243.6,percent of total billed charges,All Other,236.64,34,,236.64,percent of total billed charges,Implant Device,236.64,34,,236.64,percent of total billed charges,Implant Device,243.6,35,,243.6,percent of total billed charges,Implant Device,243.6,35,,243.6,percent of total billed charges,Implant Device,243.6,35,,243.6,percent of total billed charges,Implant Device,243.6,35,,243.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,515.04,
STRYKER 602675 SCREW,C1713,HCPCS,,79001822,CDM,278,RC,,,both,,,753,557.22,,,557.22,Other,150% of Medicare + 9.63% HCRA Surcharge,338.85,45,,338.85,percent of total billed charges,Critical Access Hospital RCC factor,256.02,34,,256.02,percent of total billed charges,Implant Device,256.02,34,,256.02,percent of total billed charges,Implant Device,256.02,34,,256.02,percent of total billed charges,Implant Device,256.02,34,,256.02,percent of total billed charges,Implant Device,256.02,34,,256.02,percent of total billed charges,Implant Device,372.74,,,372.74,Other,110% of Medicare,263.55,35,,263.55,percent of total billed charges,Implant Device,256.02,34,"Charges > $500, x 34%",256.02,percent of total billed charges,Implant Device,263.55,35,,263.55,percent of total billed charges,Implant Device,263.55,35,,263.55,percent of total billed charges,Implant Device,263.55,35,,263.55,percent of total billed charges,Implant Device,263.55,35,,263.55,percent of total billed charges,Implant Device,263.55,35,,263.55,percent of total billed charges,Implant Device,301.2,40,,301.2,percent of total billed charges,Implant Device,263.55,70,,263.55,percent of total billed charges,All Other,256.02,34,,256.02,percent of total billed charges,Implant Device,256.02,34,,256.02,percent of total billed charges,Implant Device,263.55,35,,263.55,percent of total billed charges,Implant Device,263.55,35,,263.55,percent of total billed charges,Implant Device,263.55,35,,263.55,percent of total billed charges,Implant Device,263.55,35,,263.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,557.22,
STRYKER 602680 SCREW,C1713,HCPCS,,79001823,CDM,278,RC,,,both,,,753,557.22,,,557.22,Other,150% of Medicare + 9.63% HCRA Surcharge,338.85,45,,338.85,percent of total billed charges,Critical Access Hospital RCC factor,256.02,34,,256.02,percent of total billed charges,Implant Device,256.02,34,,256.02,percent of total billed charges,Implant Device,256.02,34,,256.02,percent of total billed charges,Implant Device,256.02,34,,256.02,percent of total billed charges,Implant Device,256.02,34,,256.02,percent of total billed charges,Implant Device,372.74,,,372.74,Other,110% of Medicare,263.55,35,,263.55,percent of total billed charges,Implant Device,256.02,34,"Charges > $500, x 34%",256.02,percent of total billed charges,Implant Device,263.55,35,,263.55,percent of total billed charges,Implant Device,263.55,35,,263.55,percent of total billed charges,Implant Device,263.55,35,,263.55,percent of total billed charges,Implant Device,263.55,35,,263.55,percent of total billed charges,Implant Device,263.55,35,,263.55,percent of total billed charges,Implant Device,301.2,40,,301.2,percent of total billed charges,Implant Device,263.55,70,,263.55,percent of total billed charges,All Other,256.02,34,,256.02,percent of total billed charges,Implant Device,256.02,34,,256.02,percent of total billed charges,Implant Device,263.55,35,,263.55,percent of total billed charges,Implant Device,263.55,35,,263.55,percent of total billed charges,Implant Device,263.55,35,,263.55,percent of total billed charges,Implant Device,263.55,35,,263.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,557.22,
STRYKER 604642 SCREW,C1713,HCPCS,,79001824,CDM,278,RC,,,both,,,480,355.2,,,355.2,Other,150% of Medicare + 9.63% HCRA Surcharge,216,45,,216,percent of total billed charges,Critical Access Hospital RCC factor,163.2,34,,163.2,percent of total billed charges,Implant Device,163.2,34,,163.2,percent of total billed charges,Implant Device,163.2,34,,163.2,percent of total billed charges,Implant Device,163.2,34,,163.2,percent of total billed charges,Implant Device,163.2,34,,163.2,percent of total billed charges,Implant Device,237.6,,,237.6,Other,110% of Medicare,168,35,,168,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,192,40,,192,percent of total billed charges,Implant Device,168,70,,168,percent of total billed charges,All Other,163.2,34,,163.2,percent of total billed charges,Implant Device,163.2,34,,163.2,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,355.2,
STRYKER 604646 SCREW,C1713,HCPCS,,79001825,CDM,278,RC,,,both,,,612,452.88,,,452.88,Other,150% of Medicare + 9.63% HCRA Surcharge,275.4,45,,275.4,percent of total billed charges,Critical Access Hospital RCC factor,208.08,34,,208.08,percent of total billed charges,Implant Device,208.08,34,,208.08,percent of total billed charges,Implant Device,208.08,34,,208.08,percent of total billed charges,Implant Device,208.08,34,,208.08,percent of total billed charges,Implant Device,208.08,34,,208.08,percent of total billed charges,Implant Device,302.94,,,302.94,Other,110% of Medicare,214.2,35,,214.2,percent of total billed charges,Implant Device,208.08,34,"Charges > $500, x 34%",208.08,percent of total billed charges,Implant Device,214.2,35,,214.2,percent of total billed charges,Implant Device,214.2,35,,214.2,percent of total billed charges,Implant Device,214.2,35,,214.2,percent of total billed charges,Implant Device,214.2,35,,214.2,percent of total billed charges,Implant Device,214.2,35,,214.2,percent of total billed charges,Implant Device,244.8,40,,244.8,percent of total billed charges,Implant Device,214.2,70,,214.2,percent of total billed charges,All Other,208.08,34,,208.08,percent of total billed charges,Implant Device,208.08,34,,208.08,percent of total billed charges,Implant Device,214.2,35,,214.2,percent of total billed charges,Implant Device,214.2,35,,214.2,percent of total billed charges,Implant Device,214.2,35,,214.2,percent of total billed charges,Implant Device,214.2,35,,214.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,452.88,
STRYKER 614620 SCREW 3.5X18MM,C1713,HCPCS,,79001826,CDM,278,RC,,,both,,,755,558.7,,,558.7,Other,150% of Medicare + 9.63% HCRA Surcharge,339.75,45,,339.75,percent of total billed charges,Critical Access Hospital RCC factor,256.7,34,,256.7,percent of total billed charges,Implant Device,256.7,34,,256.7,percent of total billed charges,Implant Device,256.7,34,,256.7,percent of total billed charges,Implant Device,256.7,34,,256.7,percent of total billed charges,Implant Device,256.7,34,,256.7,percent of total billed charges,Implant Device,373.73,,,373.73,Other,110% of Medicare,264.25,35,,264.25,percent of total billed charges,Implant Device,256.7,34,"Charges > $500, x 34%",256.7,percent of total billed charges,Implant Device,264.25,35,,264.25,percent of total billed charges,Implant Device,264.25,35,,264.25,percent of total billed charges,Implant Device,264.25,35,,264.25,percent of total billed charges,Implant Device,264.25,35,,264.25,percent of total billed charges,Implant Device,264.25,35,,264.25,percent of total billed charges,Implant Device,302,40,,302,percent of total billed charges,Implant Device,264.25,70,,264.25,percent of total billed charges,All Other,256.7,34,,256.7,percent of total billed charges,Implant Device,256.7,34,,256.7,percent of total billed charges,Implant Device,264.25,35,,264.25,percent of total billed charges,Implant Device,264.25,35,,264.25,percent of total billed charges,Implant Device,264.25,35,,264.25,percent of total billed charges,Implant Device,264.25,35,,264.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,558.7,
STRYKER 614820 SCREW,C1713,HCPCS,,79001827,CDM,278,RC,,,both,,,331,244.94,,,244.94,Other,150% of Medicare + 9.63% HCRA Surcharge,148.95,45,,148.95,percent of total billed charges,Critical Access Hospital RCC factor,112.54,34,,112.54,percent of total billed charges,Implant Device,112.54,34,,112.54,percent of total billed charges,Implant Device,112.54,34,,112.54,percent of total billed charges,Implant Device,112.54,34,,112.54,percent of total billed charges,Implant Device,112.54,34,,112.54,percent of total billed charges,Implant Device,163.85,,,163.85,Other,110% of Medicare,115.85,35,,115.85,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,115.85,35,,115.85,percent of total billed charges,Implant Device,115.85,35,,115.85,percent of total billed charges,Implant Device,115.85,35,,115.85,percent of total billed charges,Implant Device,115.85,35,,115.85,percent of total billed charges,Implant Device,115.85,35,,115.85,percent of total billed charges,Implant Device,132.4,40,,132.4,percent of total billed charges,Implant Device,115.85,70,,115.85,percent of total billed charges,All Other,112.54,34,,112.54,percent of total billed charges,Implant Device,112.54,34,,112.54,percent of total billed charges,Implant Device,115.85,35,,115.85,percent of total billed charges,Implant Device,115.85,35,,115.85,percent of total billed charges,Implant Device,115.85,35,,115.85,percent of total billed charges,Implant Device,115.85,35,,115.85,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,244.94,
STRYKER 628223 PLATE,C1713,HCPCS,,79001828,CDM,278,RC,,,both,,,3342,2473.09,,,2473.09,Other,150% of Medicare + 9.63% HCRA Surcharge,1503.9,45,,1503.9,percent of total billed charges,Critical Access Hospital RCC factor,1136.28,34,,1136.28,percent of total billed charges,Implant Device,1136.28,34,,1136.28,percent of total billed charges,Implant Device,1136.28,34,,1136.28,percent of total billed charges,Implant Device,1136.28,34,,1136.28,percent of total billed charges,Implant Device,1136.28,34,,1136.28,percent of total billed charges,Implant Device,1654.29,,,1654.29,Other,110% of Medicare,1169.7,35,,1169.7,percent of total billed charges,Implant Device,1136.28,34,"Charges > $500, x 34%",1136.28,percent of total billed charges,Implant Device,1169.7,35,,1169.7,percent of total billed charges,Implant Device,1169.7,35,,1169.7,percent of total billed charges,Implant Device,1169.7,35,,1169.7,percent of total billed charges,Implant Device,1169.7,35,,1169.7,percent of total billed charges,Implant Device,1169.7,35,,1169.7,percent of total billed charges,Implant Device,1336.8,40,,1336.8,percent of total billed charges,Implant Device,1169.7,70,,1169.7,percent of total billed charges,All Other,1136.28,34,,1136.28,percent of total billed charges,Implant Device,1136.28,34,,1136.28,percent of total billed charges,Implant Device,1169.7,35,,1169.7,percent of total billed charges,Implant Device,1169.7,35,,1169.7,percent of total billed charges,Implant Device,1169.7,35,,1169.7,percent of total billed charges,Implant Device,1169.7,35,,1169.7,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1136.28,34,"If Charge > 2,000, then 34 percent",1136.28,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2473.09,
BIOMET 909853 ZIPTIGHT ANKLE,C1713,HCPCS,,79001832,CDM,278,RC,,,both,,,3579,2648.47,,,2648.47,Other,150% of Medicare + 9.63% HCRA Surcharge,1610.55,45,,1610.55,percent of total billed charges,Critical Access Hospital RCC factor,1216.86,34,,1216.86,percent of total billed charges,Implant Device,1216.86,34,,1216.86,percent of total billed charges,Implant Device,1216.86,34,,1216.86,percent of total billed charges,Implant Device,1216.86,34,,1216.86,percent of total billed charges,Implant Device,1216.86,34,,1216.86,percent of total billed charges,Implant Device,1771.61,,,1771.61,Other,110% of Medicare,1252.65,35,,1252.65,percent of total billed charges,Implant Device,1216.86,34,"Charges > $500, x 34%",1216.86,percent of total billed charges,Implant Device,1252.65,35,,1252.65,percent of total billed charges,Implant Device,1252.65,35,,1252.65,percent of total billed charges,Implant Device,1252.65,35,,1252.65,percent of total billed charges,Implant Device,1252.65,35,,1252.65,percent of total billed charges,Implant Device,1252.65,35,,1252.65,percent of total billed charges,Implant Device,1431.6,40,,1431.6,percent of total billed charges,Implant Device,1252.65,70,,1252.65,percent of total billed charges,All Other,1216.86,34,,1216.86,percent of total billed charges,Implant Device,1216.86,34,,1216.86,percent of total billed charges,Implant Device,1252.65,35,,1252.65,percent of total billed charges,Implant Device,1252.65,35,,1252.65,percent of total billed charges,Implant Device,1252.65,35,,1252.65,percent of total billed charges,Implant Device,1252.65,35,,1252.65,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1216.86,34,"If Charge > 2,000, then 34 percent",1216.86,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2648.47,
LIFE CELL 1520128 ALLODERM 8X16,C1781,HCPCS,,79001833,CDM,278,RC,,,both,,,16188,11979.16,,,11979.16,Other,150% of Medicare + 9.63% HCRA Surcharge,7284.6,45,,7284.6,percent of total billed charges,Critical Access Hospital RCC factor,5503.92,34,,5503.92,percent of total billed charges,Implant Device,5503.92,34,,5503.92,percent of total billed charges,Implant Device,5503.92,34,,5503.92,percent of total billed charges,Implant Device,5503.92,34,,5503.92,percent of total billed charges,Implant Device,5503.92,34,,5503.92,percent of total billed charges,Implant Device,8013.06,,,8013.06,Other,110% of Medicare,5665.8,35,,5665.8,percent of total billed charges,Implant Device,5503.92,34,"Charges > $500, x 34%",5503.92,percent of total billed charges,Implant Device,5665.8,35,,5665.8,percent of total billed charges,Implant Device,5665.8,35,,5665.8,percent of total billed charges,Implant Device,5665.8,35,,5665.8,percent of total billed charges,Implant Device,5665.8,35,,5665.8,percent of total billed charges,Implant Device,5665.8,35,,5665.8,percent of total billed charges,Implant Device,6475.2,40,,6475.2,percent of total billed charges,Implant Device,5665.8,70,,5665.8,percent of total billed charges,All Other,5503.92,34,,5503.92,percent of total billed charges,Implant Device,5503.92,34,,5503.92,percent of total billed charges,Implant Device,5665.8,35,,5665.8,percent of total billed charges,Implant Device,5665.8,35,,5665.8,percent of total billed charges,Implant Device,5665.8,35,,5665.8,percent of total billed charges,Implant Device,5665.8,35,,5665.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,5503.92,34,"If Charge > 2,000, then 34 percent",5503.92,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,11979.16,
BARD 1808560 POWERPORT,C1788,HCPCS,,79001834,CDM,278,RC,,,both,,,1636,1210.64,,,1210.64,Other,150% of Medicare + 9.63% HCRA Surcharge,736.2,45,,736.2,percent of total billed charges,Critical Access Hospital RCC factor,556.24,34,,556.24,percent of total billed charges,Implant Device,556.24,34,,556.24,percent of total billed charges,Implant Device,556.24,34,,556.24,percent of total billed charges,Implant Device,556.24,34,,556.24,percent of total billed charges,Implant Device,556.24,34,,556.24,percent of total billed charges,Implant Device,809.82,,,809.82,Other,110% of Medicare,572.6,35,,572.6,percent of total billed charges,Implant Device,556.24,34,"Charges > $500, x 34%",556.24,percent of total billed charges,Implant Device,572.6,35,,572.6,percent of total billed charges,Implant Device,572.6,35,,572.6,percent of total billed charges,Implant Device,572.6,35,,572.6,percent of total billed charges,Implant Device,572.6,35,,572.6,percent of total billed charges,Implant Device,572.6,35,,572.6,percent of total billed charges,Implant Device,654.4,40,,654.4,percent of total billed charges,Implant Device,572.6,70,,572.6,percent of total billed charges,All Other,556.24,34,,556.24,percent of total billed charges,Implant Device,556.24,34,,556.24,percent of total billed charges,Implant Device,572.6,35,,572.6,percent of total billed charges,Implant Device,572.6,35,,572.6,percent of total billed charges,Implant Device,572.6,35,,572.6,percent of total billed charges,Implant Device,572.6,35,,572.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1210.64,
BIOMET 01-7106 PLATE,C1713,HCPCS,,79001835,CDM,278,RC,,,both,,,2472,1829.29,,,1829.29,Other,150% of Medicare + 9.63% HCRA Surcharge,1112.4,45,,1112.4,percent of total billed charges,Critical Access Hospital RCC factor,840.48,34,,840.48,percent of total billed charges,Implant Device,840.48,34,,840.48,percent of total billed charges,Implant Device,840.48,34,,840.48,percent of total billed charges,Implant Device,840.48,34,,840.48,percent of total billed charges,Implant Device,840.48,34,,840.48,percent of total billed charges,Implant Device,1223.64,,,1223.64,Other,110% of Medicare,865.2,35,,865.2,percent of total billed charges,Implant Device,840.48,34,"Charges > $500, x 34%",840.48,percent of total billed charges,Implant Device,865.2,35,,865.2,percent of total billed charges,Implant Device,865.2,35,,865.2,percent of total billed charges,Implant Device,865.2,35,,865.2,percent of total billed charges,Implant Device,865.2,35,,865.2,percent of total billed charges,Implant Device,865.2,35,,865.2,percent of total billed charges,Implant Device,988.8,40,,988.8,percent of total billed charges,Implant Device,865.2,70,,865.2,percent of total billed charges,All Other,840.48,34,,840.48,percent of total billed charges,Implant Device,840.48,34,,840.48,percent of total billed charges,Implant Device,865.2,35,,865.2,percent of total billed charges,Implant Device,865.2,35,,865.2,percent of total billed charges,Implant Device,865.2,35,,865.2,percent of total billed charges,Implant Device,865.2,35,,865.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,840.48,34,"If Charge > 2,000, then 34 percent",840.48,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1829.29,
BIOMET 01-7305 PLATE,C1713,HCPCS,,79001836,CDM,278,RC,,,both,,,960,710.4,,,710.4,Other,150% of Medicare + 9.63% HCRA Surcharge,432,45,,432,percent of total billed charges,Critical Access Hospital RCC factor,326.4,34,,326.4,percent of total billed charges,Implant Device,326.4,34,,326.4,percent of total billed charges,Implant Device,326.4,34,,326.4,percent of total billed charges,Implant Device,326.4,34,,326.4,percent of total billed charges,Implant Device,326.4,34,,326.4,percent of total billed charges,Implant Device,475.2,,,475.2,Other,110% of Medicare,336,35,,336,percent of total billed charges,Implant Device,326.4,34,"Charges > $500, x 34%",326.4,percent of total billed charges,Implant Device,336,35,,336,percent of total billed charges,Implant Device,336,35,,336,percent of total billed charges,Implant Device,336,35,,336,percent of total billed charges,Implant Device,336,35,,336,percent of total billed charges,Implant Device,336,35,,336,percent of total billed charges,Implant Device,384,40,,384,percent of total billed charges,Implant Device,336,70,,336,percent of total billed charges,All Other,326.4,34,,326.4,percent of total billed charges,Implant Device,326.4,34,,326.4,percent of total billed charges,Implant Device,336,35,,336,percent of total billed charges,Implant Device,336,35,,336,percent of total billed charges,Implant Device,336,35,,336,percent of total billed charges,Implant Device,336,35,,336,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,710.4,
BIOMET 01-7309 PLATE,C1713,HCPCS,,79001837,CDM,278,RC,,,both,,,630,466.2,,,466.2,Other,150% of Medicare + 9.63% HCRA Surcharge,283.5,45,,283.5,percent of total billed charges,Critical Access Hospital RCC factor,214.2,34,,214.2,percent of total billed charges,Implant Device,214.2,34,,214.2,percent of total billed charges,Implant Device,214.2,34,,214.2,percent of total billed charges,Implant Device,214.2,34,,214.2,percent of total billed charges,Implant Device,214.2,34,,214.2,percent of total billed charges,Implant Device,311.85,,,311.85,Other,110% of Medicare,220.5,35,,220.5,percent of total billed charges,Implant Device,214.2,34,"Charges > $500, x 34%",214.2,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,252,40,,252,percent of total billed charges,Implant Device,220.5,70,,220.5,percent of total billed charges,All Other,214.2,34,,214.2,percent of total billed charges,Implant Device,214.2,34,,214.2,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,466.2,
MEDTRONIC 7510200 BONE GRAFT,C1713,HCPCS,,79001838,CDM,278,RC,,,both,,,10354,7661.99,,,7661.99,Other,150% of Medicare + 9.63% HCRA Surcharge,4659.3,45,,4659.3,percent of total billed charges,Critical Access Hospital RCC factor,3520.36,34,,3520.36,percent of total billed charges,Implant Device,3520.36,34,,3520.36,percent of total billed charges,Implant Device,3520.36,34,,3520.36,percent of total billed charges,Implant Device,3520.36,34,,3520.36,percent of total billed charges,Implant Device,3520.36,34,,3520.36,percent of total billed charges,Implant Device,5125.23,,,5125.23,Other,110% of Medicare,3623.9,35,,3623.9,percent of total billed charges,Implant Device,3520.36,34,"Charges > $500, x 34%",3520.36,percent of total billed charges,Implant Device,3623.9,35,,3623.9,percent of total billed charges,Implant Device,3623.9,35,,3623.9,percent of total billed charges,Implant Device,3623.9,35,,3623.9,percent of total billed charges,Implant Device,3623.9,35,,3623.9,percent of total billed charges,Implant Device,3623.9,35,,3623.9,percent of total billed charges,Implant Device,4141.6,40,,4141.6,percent of total billed charges,Implant Device,3623.9,70,,3623.9,percent of total billed charges,All Other,3520.36,34,,3520.36,percent of total billed charges,Implant Device,3520.36,34,,3520.36,percent of total billed charges,Implant Device,3623.9,35,,3623.9,percent of total billed charges,Implant Device,3623.9,35,,3623.9,percent of total billed charges,Implant Device,3623.9,35,,3623.9,percent of total billed charges,Implant Device,3623.9,35,,3623.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3520.36,34,"If Charge > 2,000, then 34 percent",3520.36,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,7661.99,
MEDTRONIC 7510400 BONE GRAFT,C1713,HCPCS,,79001839,CDM,278,RC,,,both,,,14680,10863.24,,,10863.24,Other,150% of Medicare + 9.63% HCRA Surcharge,6606,45,,6606,percent of total billed charges,Critical Access Hospital RCC factor,4991.2,34,,4991.2,percent of total billed charges,Implant Device,4991.2,34,,4991.2,percent of total billed charges,Implant Device,4991.2,34,,4991.2,percent of total billed charges,Implant Device,4991.2,34,,4991.2,percent of total billed charges,Implant Device,4991.2,34,,4991.2,percent of total billed charges,Implant Device,7266.6,,,7266.6,Other,110% of Medicare,5138,35,,5138,percent of total billed charges,Implant Device,4991.2,34,"Charges > $500, x 34%",4991.2,percent of total billed charges,Implant Device,5138,35,,5138,percent of total billed charges,Implant Device,5138,35,,5138,percent of total billed charges,Implant Device,5138,35,,5138,percent of total billed charges,Implant Device,5138,35,,5138,percent of total billed charges,Implant Device,5138,35,,5138,percent of total billed charges,Implant Device,5872,40,,5872,percent of total billed charges,Implant Device,5138,70,,5138,percent of total billed charges,All Other,4991.2,34,,4991.2,percent of total billed charges,Implant Device,4991.2,34,,4991.2,percent of total billed charges,Implant Device,5138,35,,5138,percent of total billed charges,Implant Device,5138,35,,5138,percent of total billed charges,Implant Device,5138,35,,5138,percent of total billed charges,Implant Device,5138,35,,5138,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,4991.2,34,"If Charge > 2,000, then 34 percent",4991.2,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,10863.24,
WRIGHT MEDICAL 40130120 PLATE,C1713,HCPCS,,79001840,CDM,278,RC,,,both,,,5370,3973.81,,,3973.81,Other,150% of Medicare + 9.63% HCRA Surcharge,2416.5,45,,2416.5,percent of total billed charges,Critical Access Hospital RCC factor,1825.8,34,,1825.8,percent of total billed charges,Implant Device,1825.8,34,,1825.8,percent of total billed charges,Implant Device,1825.8,34,,1825.8,percent of total billed charges,Implant Device,1825.8,34,,1825.8,percent of total billed charges,Implant Device,1825.8,34,,1825.8,percent of total billed charges,Implant Device,2658.15,,,2658.15,Other,110% of Medicare,1879.5,35,,1879.5,percent of total billed charges,Implant Device,1825.8,34,"Charges > $500, x 34%",1825.8,percent of total billed charges,Implant Device,1879.5,35,,1879.5,percent of total billed charges,Implant Device,1879.5,35,,1879.5,percent of total billed charges,Implant Device,1879.5,35,,1879.5,percent of total billed charges,Implant Device,1879.5,35,,1879.5,percent of total billed charges,Implant Device,1879.5,35,,1879.5,percent of total billed charges,Implant Device,2148,40,,2148,percent of total billed charges,Implant Device,1879.5,70,,1879.5,percent of total billed charges,All Other,1825.8,34,,1825.8,percent of total billed charges,Implant Device,1825.8,34,,1825.8,percent of total billed charges,Implant Device,1879.5,35,,1879.5,percent of total billed charges,Implant Device,1879.5,35,,1879.5,percent of total billed charges,Implant Device,1879.5,35,,1879.5,percent of total billed charges,Implant Device,1879.5,35,,1879.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1825.8,34,"If Charge > 2,000, then 34 percent",1825.8,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3973.81,
WRIGHT MEDICAL 40130125 PLATE,C1713,HCPCS,,79001841,CDM,278,RC,,,both,,,5530,4092.21,,,4092.21,Other,150% of Medicare + 9.63% HCRA Surcharge,2488.5,45,,2488.5,percent of total billed charges,Critical Access Hospital RCC factor,1880.2,34,,1880.2,percent of total billed charges,Implant Device,1880.2,34,,1880.2,percent of total billed charges,Implant Device,1880.2,34,,1880.2,percent of total billed charges,Implant Device,1880.2,34,,1880.2,percent of total billed charges,Implant Device,1880.2,34,,1880.2,percent of total billed charges,Implant Device,2737.35,,,2737.35,Other,110% of Medicare,1935.5,35,,1935.5,percent of total billed charges,Implant Device,1880.2,34,"Charges > $500, x 34%",1880.2,percent of total billed charges,Implant Device,1935.5,35,,1935.5,percent of total billed charges,Implant Device,1935.5,35,,1935.5,percent of total billed charges,Implant Device,1935.5,35,,1935.5,percent of total billed charges,Implant Device,1935.5,35,,1935.5,percent of total billed charges,Implant Device,1935.5,35,,1935.5,percent of total billed charges,Implant Device,2212,40,,2212,percent of total billed charges,Implant Device,1935.5,70,,1935.5,percent of total billed charges,All Other,1880.2,34,,1880.2,percent of total billed charges,Implant Device,1880.2,34,,1880.2,percent of total billed charges,Implant Device,1935.5,35,,1935.5,percent of total billed charges,Implant Device,1935.5,35,,1935.5,percent of total billed charges,Implant Device,1935.5,35,,1935.5,percent of total billed charges,Implant Device,1935.5,35,,1935.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1880.2,34,"If Charge > 2,000, then 34 percent",1880.2,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4092.21,
WRIGHT MEDICAL 40133518 SCREW,C1713,HCPCS,,79001842,CDM,278,RC,,,both,,,822,608.28,,,608.28,Other,150% of Medicare + 9.63% HCRA Surcharge,369.9,45,,369.9,percent of total billed charges,Critical Access Hospital RCC factor,279.48,34,,279.48,percent of total billed charges,Implant Device,279.48,34,,279.48,percent of total billed charges,Implant Device,279.48,34,,279.48,percent of total billed charges,Implant Device,279.48,34,,279.48,percent of total billed charges,Implant Device,279.48,34,,279.48,percent of total billed charges,Implant Device,406.89,,,406.89,Other,110% of Medicare,287.7,35,,287.7,percent of total billed charges,Implant Device,279.48,34,"Charges > $500, x 34%",279.48,percent of total billed charges,Implant Device,287.7,35,,287.7,percent of total billed charges,Implant Device,287.7,35,,287.7,percent of total billed charges,Implant Device,287.7,35,,287.7,percent of total billed charges,Implant Device,287.7,35,,287.7,percent of total billed charges,Implant Device,287.7,35,,287.7,percent of total billed charges,Implant Device,328.8,40,,328.8,percent of total billed charges,Implant Device,287.7,70,,287.7,percent of total billed charges,All Other,279.48,34,,279.48,percent of total billed charges,Implant Device,279.48,34,,279.48,percent of total billed charges,Implant Device,287.7,35,,287.7,percent of total billed charges,Implant Device,287.7,35,,287.7,percent of total billed charges,Implant Device,287.7,35,,287.7,percent of total billed charges,Implant Device,287.7,35,,287.7,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,608.28,
WRIGHT MEDICAL 40133524 SCREW,C1713,HCPCS,,79001843,CDM,278,RC,,,both,,,630,466.2,,,466.2,Other,150% of Medicare + 9.63% HCRA Surcharge,283.5,45,,283.5,percent of total billed charges,Critical Access Hospital RCC factor,214.2,34,,214.2,percent of total billed charges,Implant Device,214.2,34,,214.2,percent of total billed charges,Implant Device,214.2,34,,214.2,percent of total billed charges,Implant Device,214.2,34,,214.2,percent of total billed charges,Implant Device,214.2,34,,214.2,percent of total billed charges,Implant Device,311.85,,,311.85,Other,110% of Medicare,220.5,35,,220.5,percent of total billed charges,Implant Device,214.2,34,"Charges > $500, x 34%",214.2,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,252,40,,252,percent of total billed charges,Implant Device,220.5,70,,220.5,percent of total billed charges,All Other,214.2,34,,214.2,percent of total billed charges,Implant Device,214.2,34,,214.2,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,466.2,
ARGON MED 352508070 VENA CAVA FILTER,C1880,HCPCS,,79001847,CDM,278,RC,,,both,,,3300,2442.01,,,2442.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1485,45,,1485,percent of total billed charges,Critical Access Hospital RCC factor,1122,34,,1122,percent of total billed charges,Implant Device,1122,34,,1122,percent of total billed charges,Implant Device,1122,34,,1122,percent of total billed charges,Implant Device,1122,34,,1122,percent of total billed charges,Implant Device,1122,34,,1122,percent of total billed charges,Implant Device,1633.5,,,1633.5,Other,110% of Medicare,1155,35,,1155,percent of total billed charges,Implant Device,1122,34,"Charges > $500, x 34%",1122,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,1320,40,,1320,percent of total billed charges,Implant Device,1155,70,,1155,percent of total billed charges,All Other,1122,34,,1122,percent of total billed charges,Implant Device,1122,34,,1122,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1122,34,"If Charge > 2,000, then 34 percent",1122,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2442.01,
ZIMMER 00-4835-020-01-REV SCREW,C1713,HCPCS,,79001848,CDM,278,RC,,,both,,,62,45.88,,,45.88,Other,150% of Medicare + 9.63% HCRA Surcharge,27.9,45,,27.9,percent of total billed charges,Critical Access Hospital RCC factor,21.08,34,,21.08,percent of total billed charges,Implant Device,21.08,34,,21.08,percent of total billed charges,Implant Device,21.08,34,,21.08,percent of total billed charges,Implant Device,21.08,34,,21.08,percent of total billed charges,Implant Device,21.08,34,,21.08,percent of total billed charges,Implant Device,30.69,,,30.69,Other,110% of Medicare,21.7,35,,21.7,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,21.7,35,,21.7,percent of total billed charges,Implant Device,21.7,35,,21.7,percent of total billed charges,Implant Device,21.7,35,,21.7,percent of total billed charges,Implant Device,21.7,35,,21.7,percent of total billed charges,Implant Device,21.7,35,,21.7,percent of total billed charges,Implant Device,24.8,40,,24.8,percent of total billed charges,Implant Device,21.7,70,,21.7,percent of total billed charges,All Other,21.08,34,,21.08,percent of total billed charges,Implant Device,21.08,34,,21.08,percent of total billed charges,Implant Device,21.7,35,,21.7,percent of total billed charges,Implant Device,21.7,35,,21.7,percent of total billed charges,Implant Device,21.7,35,,21.7,percent of total billed charges,Implant Device,21.7,35,,21.7,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,45.88,
ZIMMER 00-4835-022-01-REV SCREW,C1713,HCPCS,,79001849,CDM,278,RC,,,both,,,62,45.88,,,45.88,Other,150% of Medicare + 9.63% HCRA Surcharge,27.9,45,,27.9,percent of total billed charges,Critical Access Hospital RCC factor,21.08,34,,21.08,percent of total billed charges,Implant Device,21.08,34,,21.08,percent of total billed charges,Implant Device,21.08,34,,21.08,percent of total billed charges,Implant Device,21.08,34,,21.08,percent of total billed charges,Implant Device,21.08,34,,21.08,percent of total billed charges,Implant Device,30.69,,,30.69,Other,110% of Medicare,21.7,35,,21.7,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,21.7,35,,21.7,percent of total billed charges,Implant Device,21.7,35,,21.7,percent of total billed charges,Implant Device,21.7,35,,21.7,percent of total billed charges,Implant Device,21.7,35,,21.7,percent of total billed charges,Implant Device,21.7,35,,21.7,percent of total billed charges,Implant Device,24.8,40,,24.8,percent of total billed charges,Implant Device,21.7,70,,21.7,percent of total billed charges,All Other,21.08,34,,21.08,percent of total billed charges,Implant Device,21.08,34,,21.08,percent of total billed charges,Implant Device,21.7,35,,21.7,percent of total billed charges,Implant Device,21.7,35,,21.7,percent of total billed charges,Implant Device,21.7,35,,21.7,percent of total billed charges,Implant Device,21.7,35,,21.7,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,45.88,
ZIMMER 00-4835-028-01-REV SCREW,C1713,HCPCS,,79001850,CDM,278,RC,,,both,,,62,45.88,,,45.88,Other,150% of Medicare + 9.63% HCRA Surcharge,27.9,45,,27.9,percent of total billed charges,Critical Access Hospital RCC factor,21.08,34,,21.08,percent of total billed charges,Implant Device,21.08,34,,21.08,percent of total billed charges,Implant Device,21.08,34,,21.08,percent of total billed charges,Implant Device,21.08,34,,21.08,percent of total billed charges,Implant Device,21.08,34,,21.08,percent of total billed charges,Implant Device,30.69,,,30.69,Other,110% of Medicare,21.7,35,,21.7,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,21.7,35,,21.7,percent of total billed charges,Implant Device,21.7,35,,21.7,percent of total billed charges,Implant Device,21.7,35,,21.7,percent of total billed charges,Implant Device,21.7,35,,21.7,percent of total billed charges,Implant Device,21.7,35,,21.7,percent of total billed charges,Implant Device,24.8,40,,24.8,percent of total billed charges,Implant Device,21.7,70,,21.7,percent of total billed charges,All Other,21.08,34,,21.08,percent of total billed charges,Implant Device,21.08,34,,21.08,percent of total billed charges,Implant Device,21.7,35,,21.7,percent of total billed charges,Implant Device,21.7,35,,21.7,percent of total billed charges,Implant Device,21.7,35,,21.7,percent of total billed charges,Implant Device,21.7,35,,21.7,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,45.88,
ZIMMER 00-4835-030-01-REV SCREW,C1713,HCPCS,,79001851,CDM,278,RC,,,both,,,62,45.88,,,45.88,Other,150% of Medicare + 9.63% HCRA Surcharge,27.9,45,,27.9,percent of total billed charges,Critical Access Hospital RCC factor,21.08,34,,21.08,percent of total billed charges,Implant Device,21.08,34,,21.08,percent of total billed charges,Implant Device,21.08,34,,21.08,percent of total billed charges,Implant Device,21.08,34,,21.08,percent of total billed charges,Implant Device,21.08,34,,21.08,percent of total billed charges,Implant Device,30.69,,,30.69,Other,110% of Medicare,21.7,35,,21.7,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,21.7,35,,21.7,percent of total billed charges,Implant Device,21.7,35,,21.7,percent of total billed charges,Implant Device,21.7,35,,21.7,percent of total billed charges,Implant Device,21.7,35,,21.7,percent of total billed charges,Implant Device,21.7,35,,21.7,percent of total billed charges,Implant Device,24.8,40,,24.8,percent of total billed charges,Implant Device,21.7,70,,21.7,percent of total billed charges,All Other,21.08,34,,21.08,percent of total billed charges,Implant Device,21.08,34,,21.08,percent of total billed charges,Implant Device,21.7,35,,21.7,percent of total billed charges,Implant Device,21.7,35,,21.7,percent of total billed charges,Implant Device,21.7,35,,21.7,percent of total billed charges,Implant Device,21.7,35,,21.7,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,45.88,
ZIMMER 00-4835-040-01-REV SCREW,C1713,HCPCS,,79001852,CDM,278,RC,,,both,,,62,45.88,,,45.88,Other,150% of Medicare + 9.63% HCRA Surcharge,27.9,45,,27.9,percent of total billed charges,Critical Access Hospital RCC factor,21.08,34,,21.08,percent of total billed charges,Implant Device,21.08,34,,21.08,percent of total billed charges,Implant Device,21.08,34,,21.08,percent of total billed charges,Implant Device,21.08,34,,21.08,percent of total billed charges,Implant Device,21.08,34,,21.08,percent of total billed charges,Implant Device,30.69,,,30.69,Other,110% of Medicare,21.7,35,,21.7,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,21.7,35,,21.7,percent of total billed charges,Implant Device,21.7,35,,21.7,percent of total billed charges,Implant Device,21.7,35,,21.7,percent of total billed charges,Implant Device,21.7,35,,21.7,percent of total billed charges,Implant Device,21.7,35,,21.7,percent of total billed charges,Implant Device,24.8,40,,24.8,percent of total billed charges,Implant Device,21.7,70,,21.7,percent of total billed charges,All Other,21.08,34,,21.08,percent of total billed charges,Implant Device,21.08,34,,21.08,percent of total billed charges,Implant Device,21.7,35,,21.7,percent of total billed charges,Implant Device,21.7,35,,21.7,percent of total billed charges,Implant Device,21.7,35,,21.7,percent of total billed charges,Implant Device,21.7,35,,21.7,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,45.88,
ZIMMER 00-4835-045-01-REV SCREW,C1713,HCPCS,,79001853,CDM,278,RC,,,both,,,62,45.88,,,45.88,Other,150% of Medicare + 9.63% HCRA Surcharge,27.9,45,,27.9,percent of total billed charges,Critical Access Hospital RCC factor,21.08,34,,21.08,percent of total billed charges,Implant Device,21.08,34,,21.08,percent of total billed charges,Implant Device,21.08,34,,21.08,percent of total billed charges,Implant Device,21.08,34,,21.08,percent of total billed charges,Implant Device,21.08,34,,21.08,percent of total billed charges,Implant Device,30.69,,,30.69,Other,110% of Medicare,21.7,35,,21.7,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,21.7,35,,21.7,percent of total billed charges,Implant Device,21.7,35,,21.7,percent of total billed charges,Implant Device,21.7,35,,21.7,percent of total billed charges,Implant Device,21.7,35,,21.7,percent of total billed charges,Implant Device,21.7,35,,21.7,percent of total billed charges,Implant Device,24.8,40,,24.8,percent of total billed charges,Implant Device,21.7,70,,21.7,percent of total billed charges,All Other,21.08,34,,21.08,percent of total billed charges,Implant Device,21.08,34,,21.08,percent of total billed charges,Implant Device,21.7,35,,21.7,percent of total billed charges,Implant Device,21.7,35,,21.7,percent of total billed charges,Implant Device,21.7,35,,21.7,percent of total billed charges,Implant Device,21.7,35,,21.7,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,45.88,
ZIMMER 00-4835-055-01-REV SCREW,C1713,HCPCS,,79001854,CDM,278,RC,,,both,,,62,45.88,,,45.88,Other,150% of Medicare + 9.63% HCRA Surcharge,27.9,45,,27.9,percent of total billed charges,Critical Access Hospital RCC factor,21.08,34,,21.08,percent of total billed charges,Implant Device,21.08,34,,21.08,percent of total billed charges,Implant Device,21.08,34,,21.08,percent of total billed charges,Implant Device,21.08,34,,21.08,percent of total billed charges,Implant Device,21.08,34,,21.08,percent of total billed charges,Implant Device,30.69,,,30.69,Other,110% of Medicare,21.7,35,,21.7,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,21.7,35,,21.7,percent of total billed charges,Implant Device,21.7,35,,21.7,percent of total billed charges,Implant Device,21.7,35,,21.7,percent of total billed charges,Implant Device,21.7,35,,21.7,percent of total billed charges,Implant Device,21.7,35,,21.7,percent of total billed charges,Implant Device,24.8,40,,24.8,percent of total billed charges,Implant Device,21.7,70,,21.7,percent of total billed charges,All Other,21.08,34,,21.08,percent of total billed charges,Implant Device,21.08,34,,21.08,percent of total billed charges,Implant Device,21.7,35,,21.7,percent of total billed charges,Implant Device,21.7,35,,21.7,percent of total billed charges,Implant Device,21.7,35,,21.7,percent of total billed charges,Implant Device,21.7,35,,21.7,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,45.88,
ZIMMER 00-5001-052-00 BIPOLAR SHELL,C1776,HCPCS,,79001855,CDM,278,RC,,,both,,,960,710.4,,,710.4,Other,150% of Medicare + 9.63% HCRA Surcharge,432,45,,432,percent of total billed charges,Critical Access Hospital RCC factor,326.4,34,,326.4,percent of total billed charges,Implant Device,326.4,34,,326.4,percent of total billed charges,Implant Device,326.4,34,,326.4,percent of total billed charges,Implant Device,326.4,34,,326.4,percent of total billed charges,Implant Device,326.4,34,,326.4,percent of total billed charges,Implant Device,475.2,,,475.2,Other,110% of Medicare,336,35,,336,percent of total billed charges,Implant Device,326.4,34,"Charges > $500, x 34%",326.4,percent of total billed charges,Implant Device,336,35,,336,percent of total billed charges,Implant Device,336,35,,336,percent of total billed charges,Implant Device,336,35,,336,percent of total billed charges,Implant Device,336,35,,336,percent of total billed charges,Implant Device,336,35,,336,percent of total billed charges,Implant Device,384,40,,384,percent of total billed charges,Implant Device,336,70,,336,percent of total billed charges,All Other,326.4,34,,326.4,percent of total billed charges,Implant Device,326.4,34,,326.4,percent of total billed charges,Implant Device,336,35,,336,percent of total billed charges,Implant Device,336,35,,336,percent of total billed charges,Implant Device,336,35,,336,percent of total billed charges,Implant Device,336,35,,336,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,710.4,
ZIMMER 00-5450-013-31-REV TIBIAL CONE,C1776,HCPCS,,79001857,CDM,278,RC,,,both,,,12646,9358.07,,,9358.07,Other,150% of Medicare + 9.63% HCRA Surcharge,5690.7,45,,5690.7,percent of total billed charges,Critical Access Hospital RCC factor,4299.64,34,,4299.64,percent of total billed charges,Implant Device,4299.64,34,,4299.64,percent of total billed charges,Implant Device,4299.64,34,,4299.64,percent of total billed charges,Implant Device,4299.64,34,,4299.64,percent of total billed charges,Implant Device,4299.64,34,,4299.64,percent of total billed charges,Implant Device,6259.77,,,6259.77,Other,110% of Medicare,4426.1,35,,4426.1,percent of total billed charges,Implant Device,4299.64,34,"Charges > $500, x 34%",4299.64,percent of total billed charges,Implant Device,4426.1,35,,4426.1,percent of total billed charges,Implant Device,4426.1,35,,4426.1,percent of total billed charges,Implant Device,4426.1,35,,4426.1,percent of total billed charges,Implant Device,4426.1,35,,4426.1,percent of total billed charges,Implant Device,4426.1,35,,4426.1,percent of total billed charges,Implant Device,5058.4,40,,5058.4,percent of total billed charges,Implant Device,4426.1,70,,4426.1,percent of total billed charges,All Other,4299.64,34,,4299.64,percent of total billed charges,Implant Device,4299.64,34,,4299.64,percent of total billed charges,Implant Device,4426.1,35,,4426.1,percent of total billed charges,Implant Device,4426.1,35,,4426.1,percent of total billed charges,Implant Device,4426.1,35,,4426.1,percent of total billed charges,Implant Device,4426.1,35,,4426.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,4299.64,34,"If Charge > 2,000, then 34 percent",4299.64,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,9358.07,
ZIMMER 00-5606-000-10 TISSUE GRAFT,C1713,HCPCS,,79001858,CDM,278,RC,,,both,,,13200,9768.03,,,9768.03,Other,150% of Medicare + 9.63% HCRA Surcharge,5940,45,,5940,percent of total billed charges,Critical Access Hospital RCC factor,4488,34,,4488,percent of total billed charges,Implant Device,4488,34,,4488,percent of total billed charges,Implant Device,4488,34,,4488,percent of total billed charges,Implant Device,4488,34,,4488,percent of total billed charges,Implant Device,4488,34,,4488,percent of total billed charges,Implant Device,6534,,,6534,Other,110% of Medicare,4620,35,,4620,percent of total billed charges,Implant Device,4488,34,"Charges > $500, x 34%",4488,percent of total billed charges,Implant Device,4620,35,,4620,percent of total billed charges,Implant Device,4620,35,,4620,percent of total billed charges,Implant Device,4620,35,,4620,percent of total billed charges,Implant Device,4620,35,,4620,percent of total billed charges,Implant Device,4620,35,,4620,percent of total billed charges,Implant Device,5280,40,,5280,percent of total billed charges,Implant Device,4620,70,,4620,percent of total billed charges,All Other,4488,34,,4488,percent of total billed charges,Implant Device,4488,34,,4488,percent of total billed charges,Implant Device,4620,35,,4620,percent of total billed charges,Implant Device,4620,35,,4620,percent of total billed charges,Implant Device,4620,35,,4620,percent of total billed charges,Implant Device,4620,35,,4620,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,4488,34,"If Charge > 2,000, then 34 percent",4488,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,9768.03,
ZIMMER 00-5606-000-11 TISSUE GRAFT,C1713,HCPCS,,79001859,CDM,278,RC,,,both,,,13986,10349.67,,,10349.67,Other,150% of Medicare + 9.63% HCRA Surcharge,6293.7,45,,6293.7,percent of total billed charges,Critical Access Hospital RCC factor,4755.24,34,,4755.24,percent of total billed charges,Implant Device,4755.24,34,,4755.24,percent of total billed charges,Implant Device,4755.24,34,,4755.24,percent of total billed charges,Implant Device,4755.24,34,,4755.24,percent of total billed charges,Implant Device,4755.24,34,,4755.24,percent of total billed charges,Implant Device,6923.07,,,6923.07,Other,110% of Medicare,4895.1,35,,4895.1,percent of total billed charges,Implant Device,4755.24,34,"Charges > $500, x 34%",4755.24,percent of total billed charges,Implant Device,4895.1,35,,4895.1,percent of total billed charges,Implant Device,4895.1,35,,4895.1,percent of total billed charges,Implant Device,4895.1,35,,4895.1,percent of total billed charges,Implant Device,4895.1,35,,4895.1,percent of total billed charges,Implant Device,4895.1,35,,4895.1,percent of total billed charges,Implant Device,5594.4,40,,5594.4,percent of total billed charges,Implant Device,4895.1,70,,4895.1,percent of total billed charges,All Other,4755.24,34,,4755.24,percent of total billed charges,Implant Device,4755.24,34,,4755.24,percent of total billed charges,Implant Device,4895.1,35,,4895.1,percent of total billed charges,Implant Device,4895.1,35,,4895.1,percent of total billed charges,Implant Device,4895.1,35,,4895.1,percent of total billed charges,Implant Device,4895.1,35,,4895.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,4755.24,34,"If Charge > 2,000, then 34 percent",4755.24,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,10349.67,
ZIMMER 00-5901-020-00-REV DRILL PIN,C1713,HCPCS,,79001860,CDM,278,RC,,,both,,,1798,1330.52,,,1330.52,Other,150% of Medicare + 9.63% HCRA Surcharge,809.1,45,,809.1,percent of total billed charges,Critical Access Hospital RCC factor,611.32,34,,611.32,percent of total billed charges,Implant Device,611.32,34,,611.32,percent of total billed charges,Implant Device,611.32,34,,611.32,percent of total billed charges,Implant Device,611.32,34,,611.32,percent of total billed charges,Implant Device,611.32,34,,611.32,percent of total billed charges,Implant Device,890.01,,,890.01,Other,110% of Medicare,629.3,35,,629.3,percent of total billed charges,Implant Device,611.32,34,"Charges > $500, x 34%",611.32,percent of total billed charges,Implant Device,629.3,35,,629.3,percent of total billed charges,Implant Device,629.3,35,,629.3,percent of total billed charges,Implant Device,629.3,35,,629.3,percent of total billed charges,Implant Device,629.3,35,,629.3,percent of total billed charges,Implant Device,629.3,35,,629.3,percent of total billed charges,Implant Device,719.2,40,,719.2,percent of total billed charges,Implant Device,629.3,70,,629.3,percent of total billed charges,All Other,611.32,34,,611.32,percent of total billed charges,Implant Device,611.32,34,,611.32,percent of total billed charges,Implant Device,629.3,35,,629.3,percent of total billed charges,Implant Device,629.3,35,,629.3,percent of total billed charges,Implant Device,629.3,35,,629.3,percent of total billed charges,Implant Device,629.3,35,,629.3,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1330.52,
ZIMMER 00-7000-056-20-REV REV SHELL,C1776,HCPCS,,79001861,CDM,278,RC,,,both,,,15450,11433.04,,,11433.04,Other,150% of Medicare + 9.63% HCRA Surcharge,6952.5,45,,6952.5,percent of total billed charges,Critical Access Hospital RCC factor,5253,34,,5253,percent of total billed charges,Implant Device,5253,34,,5253,percent of total billed charges,Implant Device,5253,34,,5253,percent of total billed charges,Implant Device,5253,34,,5253,percent of total billed charges,Implant Device,5253,34,,5253,percent of total billed charges,Implant Device,7647.75,,,7647.75,Other,110% of Medicare,5407.5,35,,5407.5,percent of total billed charges,Implant Device,5253,34,"Charges > $500, x 34%",5253,percent of total billed charges,Implant Device,5407.5,35,,5407.5,percent of total billed charges,Implant Device,5407.5,35,,5407.5,percent of total billed charges,Implant Device,5407.5,35,,5407.5,percent of total billed charges,Implant Device,5407.5,35,,5407.5,percent of total billed charges,Implant Device,5407.5,35,,5407.5,percent of total billed charges,Implant Device,6180,40,,6180,percent of total billed charges,Implant Device,5407.5,70,,5407.5,percent of total billed charges,All Other,5253,34,,5253,percent of total billed charges,Implant Device,5253,34,,5253,percent of total billed charges,Implant Device,5407.5,35,,5407.5,percent of total billed charges,Implant Device,5407.5,35,,5407.5,percent of total billed charges,Implant Device,5407.5,35,,5407.5,percent of total billed charges,Implant Device,5407.5,35,,5407.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,5253,34,"If Charge > 2,000, then 34 percent",5253,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,11433.04,
ZIMMER 00-7123-056-48-REV REV CAGE,C1776,HCPCS,,79001862,CDM,278,RC,,,both,,,14640,10833.64,,,10833.64,Other,150% of Medicare + 9.63% HCRA Surcharge,6588,45,,6588,percent of total billed charges,Critical Access Hospital RCC factor,4977.6,34,,4977.6,percent of total billed charges,Implant Device,4977.6,34,,4977.6,percent of total billed charges,Implant Device,4977.6,34,,4977.6,percent of total billed charges,Implant Device,4977.6,34,,4977.6,percent of total billed charges,Implant Device,4977.6,34,,4977.6,percent of total billed charges,Implant Device,7246.8,,,7246.8,Other,110% of Medicare,5124,35,,5124,percent of total billed charges,Implant Device,4977.6,34,"Charges > $500, x 34%",4977.6,percent of total billed charges,Implant Device,5124,35,,5124,percent of total billed charges,Implant Device,5124,35,,5124,percent of total billed charges,Implant Device,5124,35,,5124,percent of total billed charges,Implant Device,5124,35,,5124,percent of total billed charges,Implant Device,5124,35,,5124,percent of total billed charges,Implant Device,5856,40,,5856,percent of total billed charges,Implant Device,5124,70,,5124,percent of total billed charges,All Other,4977.6,34,,4977.6,percent of total billed charges,Implant Device,4977.6,34,,4977.6,percent of total billed charges,Implant Device,5124,35,,5124,percent of total billed charges,Implant Device,5124,35,,5124,percent of total billed charges,Implant Device,5124,35,,5124,percent of total billed charges,Implant Device,5124,35,,5124,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,4977.6,34,"If Charge > 2,000, then 34 percent",4977.6,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,10833.64,
ZIMMER 00-7133-056-48-REV REV CAGE,C1776,HCPCS,,79001863,CDM,278,RC,,,both,,,1344,994.56,,,994.56,Other,150% of Medicare + 9.63% HCRA Surcharge,604.8,45,,604.8,percent of total billed charges,Critical Access Hospital RCC factor,456.96,34,,456.96,percent of total billed charges,Implant Device,456.96,34,,456.96,percent of total billed charges,Implant Device,456.96,34,,456.96,percent of total billed charges,Implant Device,456.96,34,,456.96,percent of total billed charges,Implant Device,456.96,34,,456.96,percent of total billed charges,Implant Device,665.28,,,665.28,Other,110% of Medicare,470.4,35,,470.4,percent of total billed charges,Implant Device,456.96,34,"Charges > $500, x 34%",456.96,percent of total billed charges,Implant Device,470.4,35,,470.4,percent of total billed charges,Implant Device,470.4,35,,470.4,percent of total billed charges,Implant Device,470.4,35,,470.4,percent of total billed charges,Implant Device,470.4,35,,470.4,percent of total billed charges,Implant Device,470.4,35,,470.4,percent of total billed charges,Implant Device,537.6,40,,537.6,percent of total billed charges,Implant Device,470.4,70,,470.4,percent of total billed charges,All Other,456.96,34,,456.96,percent of total billed charges,Implant Device,456.96,34,,456.96,percent of total billed charges,Implant Device,470.4,35,,470.4,percent of total billed charges,Implant Device,470.4,35,,470.4,percent of total billed charges,Implant Device,470.4,35,,470.4,percent of total billed charges,Implant Device,470.4,35,,470.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,994.56,
ZIMMER 00-7848-024-00-REV MODULAR NECK,C1776,HCPCS,,79001864,CDM,278,RC,,,both,,,2998,2218.53,,,2218.53,Other,150% of Medicare + 9.63% HCRA Surcharge,1349.1,45,,1349.1,percent of total billed charges,Critical Access Hospital RCC factor,1019.32,34,,1019.32,percent of total billed charges,Implant Device,1019.32,34,,1019.32,percent of total billed charges,Implant Device,1019.32,34,,1019.32,percent of total billed charges,Implant Device,1019.32,34,,1019.32,percent of total billed charges,Implant Device,1019.32,34,,1019.32,percent of total billed charges,Implant Device,1484.01,,,1484.01,Other,110% of Medicare,1049.3,35,,1049.3,percent of total billed charges,Implant Device,1019.32,34,"Charges > $500, x 34%",1019.32,percent of total billed charges,Implant Device,1049.3,35,,1049.3,percent of total billed charges,Implant Device,1049.3,35,,1049.3,percent of total billed charges,Implant Device,1049.3,35,,1049.3,percent of total billed charges,Implant Device,1049.3,35,,1049.3,percent of total billed charges,Implant Device,1049.3,35,,1049.3,percent of total billed charges,Implant Device,1199.2,40,,1199.2,percent of total billed charges,Implant Device,1049.3,70,,1049.3,percent of total billed charges,All Other,1019.32,34,,1019.32,percent of total billed charges,Implant Device,1019.32,34,,1019.32,percent of total billed charges,Implant Device,1049.3,35,,1049.3,percent of total billed charges,Implant Device,1049.3,35,,1049.3,percent of total billed charges,Implant Device,1049.3,35,,1049.3,percent of total billed charges,Implant Device,1049.3,35,,1049.3,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1019.32,34,"If Charge > 2,000, then 34 percent",1019.32,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2218.53,
ZIMMER 00-8751-010-36-REV NEUTRAL LINER,C1776,HCPCS,,79001865,CDM,278,RC,,,both,,,4973,3680.03,,,3680.03,Other,150% of Medicare + 9.63% HCRA Surcharge,2237.85,45,,2237.85,percent of total billed charges,Critical Access Hospital RCC factor,1690.82,34,,1690.82,percent of total billed charges,Implant Device,1690.82,34,,1690.82,percent of total billed charges,Implant Device,1690.82,34,,1690.82,percent of total billed charges,Implant Device,1690.82,34,,1690.82,percent of total billed charges,Implant Device,1690.82,34,,1690.82,percent of total billed charges,Implant Device,2461.64,,,2461.64,Other,110% of Medicare,1740.55,35,,1740.55,percent of total billed charges,Implant Device,1690.82,34,"Charges > $500, x 34%",1690.82,percent of total billed charges,Implant Device,1740.55,35,,1740.55,percent of total billed charges,Implant Device,1740.55,35,,1740.55,percent of total billed charges,Implant Device,1740.55,35,,1740.55,percent of total billed charges,Implant Device,1740.55,35,,1740.55,percent of total billed charges,Implant Device,1740.55,35,,1740.55,percent of total billed charges,Implant Device,1989.2,40,,1989.2,percent of total billed charges,Implant Device,1740.55,70,,1740.55,percent of total billed charges,All Other,1690.82,34,,1690.82,percent of total billed charges,Implant Device,1690.82,34,,1690.82,percent of total billed charges,Implant Device,1740.55,35,,1740.55,percent of total billed charges,Implant Device,1740.55,35,,1740.55,percent of total billed charges,Implant Device,1740.55,35,,1740.55,percent of total billed charges,Implant Device,1740.55,35,,1740.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1690.82,34,"If Charge > 2,000, then 34 percent",1690.82,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3680.03,
ZIMMER 00-8751-011-36-REV NEUTRAL LINER,C1776,HCPCS,,79001866,CDM,278,RC,,,both,,,5483,4057.43,,,4057.43,Other,150% of Medicare + 9.63% HCRA Surcharge,2467.35,45,,2467.35,percent of total billed charges,Critical Access Hospital RCC factor,1864.22,34,,1864.22,percent of total billed charges,Implant Device,1864.22,34,,1864.22,percent of total billed charges,Implant Device,1864.22,34,,1864.22,percent of total billed charges,Implant Device,1864.22,34,,1864.22,percent of total billed charges,Implant Device,1864.22,34,,1864.22,percent of total billed charges,Implant Device,2714.09,,,2714.09,Other,110% of Medicare,1919.05,35,,1919.05,percent of total billed charges,Implant Device,1864.22,34,"Charges > $500, x 34%",1864.22,percent of total billed charges,Implant Device,1919.05,35,,1919.05,percent of total billed charges,Implant Device,1919.05,35,,1919.05,percent of total billed charges,Implant Device,1919.05,35,,1919.05,percent of total billed charges,Implant Device,1919.05,35,,1919.05,percent of total billed charges,Implant Device,1919.05,35,,1919.05,percent of total billed charges,Implant Device,2193.2,40,,2193.2,percent of total billed charges,Implant Device,1919.05,70,,1919.05,percent of total billed charges,All Other,1864.22,34,,1864.22,percent of total billed charges,Implant Device,1864.22,34,,1864.22,percent of total billed charges,Implant Device,1919.05,35,,1919.05,percent of total billed charges,Implant Device,1919.05,35,,1919.05,percent of total billed charges,Implant Device,1919.05,35,,1919.05,percent of total billed charges,Implant Device,1919.05,35,,1919.05,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1864.22,34,"If Charge > 2,000, then 34 percent",1864.22,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4057.43,
ZIMMER 00-8751-012-36-REV NEUTRAL LINER,C1776,HCPCS,,79001867,CDM,278,RC,,,both,,,4973,3680.03,,,3680.03,Other,150% of Medicare + 9.63% HCRA Surcharge,2237.85,45,,2237.85,percent of total billed charges,Critical Access Hospital RCC factor,1690.82,34,,1690.82,percent of total billed charges,Implant Device,1690.82,34,,1690.82,percent of total billed charges,Implant Device,1690.82,34,,1690.82,percent of total billed charges,Implant Device,1690.82,34,,1690.82,percent of total billed charges,Implant Device,1690.82,34,,1690.82,percent of total billed charges,Implant Device,2461.64,,,2461.64,Other,110% of Medicare,1740.55,35,,1740.55,percent of total billed charges,Implant Device,1690.82,34,"Charges > $500, x 34%",1690.82,percent of total billed charges,Implant Device,1740.55,35,,1740.55,percent of total billed charges,Implant Device,1740.55,35,,1740.55,percent of total billed charges,Implant Device,1740.55,35,,1740.55,percent of total billed charges,Implant Device,1740.55,35,,1740.55,percent of total billed charges,Implant Device,1740.55,35,,1740.55,percent of total billed charges,Implant Device,1989.2,40,,1989.2,percent of total billed charges,Implant Device,1740.55,70,,1740.55,percent of total billed charges,All Other,1690.82,34,,1690.82,percent of total billed charges,Implant Device,1690.82,34,,1690.82,percent of total billed charges,Implant Device,1740.55,35,,1740.55,percent of total billed charges,Implant Device,1740.55,35,,1740.55,percent of total billed charges,Implant Device,1740.55,35,,1740.55,percent of total billed charges,Implant Device,1740.55,35,,1740.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1690.82,34,"If Charge > 2,000, then 34 percent",1690.82,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3680.03,
ZIMMER 00-8751-01336-REV NEUTRAL LINER,C1776,HCPCS,,79001868,CDM,278,RC,,,both,,,4973,3680.03,,,3680.03,Other,150% of Medicare + 9.63% HCRA Surcharge,2237.85,45,,2237.85,percent of total billed charges,Critical Access Hospital RCC factor,1690.82,34,,1690.82,percent of total billed charges,Implant Device,1690.82,34,,1690.82,percent of total billed charges,Implant Device,1690.82,34,,1690.82,percent of total billed charges,Implant Device,1690.82,34,,1690.82,percent of total billed charges,Implant Device,1690.82,34,,1690.82,percent of total billed charges,Implant Device,2461.64,,,2461.64,Other,110% of Medicare,1740.55,35,,1740.55,percent of total billed charges,Implant Device,1690.82,34,"Charges > $500, x 34%",1690.82,percent of total billed charges,Implant Device,1740.55,35,,1740.55,percent of total billed charges,Implant Device,1740.55,35,,1740.55,percent of total billed charges,Implant Device,1740.55,35,,1740.55,percent of total billed charges,Implant Device,1740.55,35,,1740.55,percent of total billed charges,Implant Device,1740.55,35,,1740.55,percent of total billed charges,Implant Device,1989.2,40,,1989.2,percent of total billed charges,Implant Device,1740.55,70,,1740.55,percent of total billed charges,All Other,1690.82,34,,1690.82,percent of total billed charges,Implant Device,1690.82,34,,1690.82,percent of total billed charges,Implant Device,1740.55,35,,1740.55,percent of total billed charges,Implant Device,1740.55,35,,1740.55,percent of total billed charges,Implant Device,1740.55,35,,1740.55,percent of total billed charges,Implant Device,1740.55,35,,1740.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1690.82,34,"If Charge > 2,000, then 34 percent",1690.82,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3680.03,
ZIMMER 00-8751-013-40-REV NEUTRAL LINER,C1776,HCPCS,,79001869,CDM,278,RC,,,both,,,4973,3680.03,,,3680.03,Other,150% of Medicare + 9.63% HCRA Surcharge,2237.85,45,,2237.85,percent of total billed charges,Critical Access Hospital RCC factor,1690.82,34,,1690.82,percent of total billed charges,Implant Device,1690.82,34,,1690.82,percent of total billed charges,Implant Device,1690.82,34,,1690.82,percent of total billed charges,Implant Device,1690.82,34,,1690.82,percent of total billed charges,Implant Device,1690.82,34,,1690.82,percent of total billed charges,Implant Device,2461.64,,,2461.64,Other,110% of Medicare,1740.55,35,,1740.55,percent of total billed charges,Implant Device,1690.82,34,"Charges > $500, x 34%",1690.82,percent of total billed charges,Implant Device,1740.55,35,,1740.55,percent of total billed charges,Implant Device,1740.55,35,,1740.55,percent of total billed charges,Implant Device,1740.55,35,,1740.55,percent of total billed charges,Implant Device,1740.55,35,,1740.55,percent of total billed charges,Implant Device,1740.55,35,,1740.55,percent of total billed charges,Implant Device,1989.2,40,,1989.2,percent of total billed charges,Implant Device,1740.55,70,,1740.55,percent of total billed charges,All Other,1690.82,34,,1690.82,percent of total billed charges,Implant Device,1690.82,34,,1690.82,percent of total billed charges,Implant Device,1740.55,35,,1740.55,percent of total billed charges,Implant Device,1740.55,35,,1740.55,percent of total billed charges,Implant Device,1740.55,35,,1740.55,percent of total billed charges,Implant Device,1740.55,35,,1740.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1690.82,34,"If Charge > 2,000, then 34 percent",1690.82,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3680.03,
ZIMMER 00-8751-014-40-REV NEUTRAL LINER,C1776,HCPCS,,79001870,CDM,278,RC,,,both,,,4973,3680.03,,,3680.03,Other,150% of Medicare + 9.63% HCRA Surcharge,2237.85,45,,2237.85,percent of total billed charges,Critical Access Hospital RCC factor,1690.82,34,,1690.82,percent of total billed charges,Implant Device,1690.82,34,,1690.82,percent of total billed charges,Implant Device,1690.82,34,,1690.82,percent of total billed charges,Implant Device,1690.82,34,,1690.82,percent of total billed charges,Implant Device,1690.82,34,,1690.82,percent of total billed charges,Implant Device,2461.64,,,2461.64,Other,110% of Medicare,1740.55,35,,1740.55,percent of total billed charges,Implant Device,1690.82,34,"Charges > $500, x 34%",1690.82,percent of total billed charges,Implant Device,1740.55,35,,1740.55,percent of total billed charges,Implant Device,1740.55,35,,1740.55,percent of total billed charges,Implant Device,1740.55,35,,1740.55,percent of total billed charges,Implant Device,1740.55,35,,1740.55,percent of total billed charges,Implant Device,1740.55,35,,1740.55,percent of total billed charges,Implant Device,1989.2,40,,1989.2,percent of total billed charges,Implant Device,1740.55,70,,1740.55,percent of total billed charges,All Other,1690.82,34,,1690.82,percent of total billed charges,Implant Device,1690.82,34,,1690.82,percent of total billed charges,Implant Device,1740.55,35,,1740.55,percent of total billed charges,Implant Device,1740.55,35,,1740.55,percent of total billed charges,Implant Device,1740.55,35,,1740.55,percent of total billed charges,Implant Device,1740.55,35,,1740.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1690.82,34,"If Charge > 2,000, then 34 percent",1690.82,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3680.03,
ZIMMER 00-8751-052-01-REV METAL SHELL,C1776,HCPCS,,79001871,CDM,278,RC,,,both,,,7829,5793.48,,,5793.48,Other,150% of Medicare + 9.63% HCRA Surcharge,3523.05,45,,3523.05,percent of total billed charges,Critical Access Hospital RCC factor,2661.86,34,,2661.86,percent of total billed charges,Implant Device,2661.86,34,,2661.86,percent of total billed charges,Implant Device,2661.86,34,,2661.86,percent of total billed charges,Implant Device,2661.86,34,,2661.86,percent of total billed charges,Implant Device,2661.86,34,,2661.86,percent of total billed charges,Implant Device,3875.36,,,3875.36,Other,110% of Medicare,2740.15,35,,2740.15,percent of total billed charges,Implant Device,2661.86,34,"Charges > $500, x 34%",2661.86,percent of total billed charges,Implant Device,2740.15,35,,2740.15,percent of total billed charges,Implant Device,2740.15,35,,2740.15,percent of total billed charges,Implant Device,2740.15,35,,2740.15,percent of total billed charges,Implant Device,2740.15,35,,2740.15,percent of total billed charges,Implant Device,2740.15,35,,2740.15,percent of total billed charges,Implant Device,3131.6,40,,3131.6,percent of total billed charges,Implant Device,2740.15,70,,2740.15,percent of total billed charges,All Other,2661.86,34,,2661.86,percent of total billed charges,Implant Device,2661.86,34,,2661.86,percent of total billed charges,Implant Device,2740.15,35,,2740.15,percent of total billed charges,Implant Device,2740.15,35,,2740.15,percent of total billed charges,Implant Device,2740.15,35,,2740.15,percent of total billed charges,Implant Device,2740.15,35,,2740.15,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2661.86,34,"If Charge > 2,000, then 34 percent",2661.86,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5793.48,
ZIMMER 00-8752-008-32-REV POLY LINER,C1776,HCPCS,,79001872,CDM,278,RC,,,both,,,4027,2979.99,,,2979.99,Other,150% of Medicare + 9.63% HCRA Surcharge,1812.15,45,,1812.15,percent of total billed charges,Critical Access Hospital RCC factor,1369.18,34,,1369.18,percent of total billed charges,Implant Device,1369.18,34,,1369.18,percent of total billed charges,Implant Device,1369.18,34,,1369.18,percent of total billed charges,Implant Device,1369.18,34,,1369.18,percent of total billed charges,Implant Device,1369.18,34,,1369.18,percent of total billed charges,Implant Device,1993.37,,,1993.37,Other,110% of Medicare,1409.45,35,,1409.45,percent of total billed charges,Implant Device,1369.18,34,"Charges > $500, x 34%",1369.18,percent of total billed charges,Implant Device,1409.45,35,,1409.45,percent of total billed charges,Implant Device,1409.45,35,,1409.45,percent of total billed charges,Implant Device,1409.45,35,,1409.45,percent of total billed charges,Implant Device,1409.45,35,,1409.45,percent of total billed charges,Implant Device,1409.45,35,,1409.45,percent of total billed charges,Implant Device,1610.8,40,,1610.8,percent of total billed charges,Implant Device,1409.45,70,,1409.45,percent of total billed charges,All Other,1369.18,34,,1369.18,percent of total billed charges,Implant Device,1369.18,34,,1369.18,percent of total billed charges,Implant Device,1409.45,35,,1409.45,percent of total billed charges,Implant Device,1409.45,35,,1409.45,percent of total billed charges,Implant Device,1409.45,35,,1409.45,percent of total billed charges,Implant Device,1409.45,35,,1409.45,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1369.18,34,"If Charge > 2,000, then 34 percent",1369.18,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2979.99,
ZIMMER 00-8752-010-36-REV POLY LINER,C1776,HCPCS,,79001873,CDM,278,RC,,,both,,,4973,3680.03,,,3680.03,Other,150% of Medicare + 9.63% HCRA Surcharge,2237.85,45,,2237.85,percent of total billed charges,Critical Access Hospital RCC factor,1690.82,34,,1690.82,percent of total billed charges,Implant Device,1690.82,34,,1690.82,percent of total billed charges,Implant Device,1690.82,34,,1690.82,percent of total billed charges,Implant Device,1690.82,34,,1690.82,percent of total billed charges,Implant Device,1690.82,34,,1690.82,percent of total billed charges,Implant Device,2461.64,,,2461.64,Other,110% of Medicare,1740.55,35,,1740.55,percent of total billed charges,Implant Device,1690.82,34,"Charges > $500, x 34%",1690.82,percent of total billed charges,Implant Device,1740.55,35,,1740.55,percent of total billed charges,Implant Device,1740.55,35,,1740.55,percent of total billed charges,Implant Device,1740.55,35,,1740.55,percent of total billed charges,Implant Device,1740.55,35,,1740.55,percent of total billed charges,Implant Device,1740.55,35,,1740.55,percent of total billed charges,Implant Device,1989.2,40,,1989.2,percent of total billed charges,Implant Device,1740.55,70,,1740.55,percent of total billed charges,All Other,1690.82,34,,1690.82,percent of total billed charges,Implant Device,1690.82,34,,1690.82,percent of total billed charges,Implant Device,1740.55,35,,1740.55,percent of total billed charges,Implant Device,1740.55,35,,1740.55,percent of total billed charges,Implant Device,1740.55,35,,1740.55,percent of total billed charges,Implant Device,1740.55,35,,1740.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1690.82,34,"If Charge > 2,000, then 34 percent",1690.82,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3680.03,
ZIMMER 00-8752-013-36-REV POLY LINER,C1776,HCPCS,,79001874,CDM,278,RC,,,both,,,4973,3680.03,,,3680.03,Other,150% of Medicare + 9.63% HCRA Surcharge,2237.85,45,,2237.85,percent of total billed charges,Critical Access Hospital RCC factor,1690.82,34,,1690.82,percent of total billed charges,Implant Device,1690.82,34,,1690.82,percent of total billed charges,Implant Device,1690.82,34,,1690.82,percent of total billed charges,Implant Device,1690.82,34,,1690.82,percent of total billed charges,Implant Device,1690.82,34,,1690.82,percent of total billed charges,Implant Device,2461.64,,,2461.64,Other,110% of Medicare,1740.55,35,,1740.55,percent of total billed charges,Implant Device,1690.82,34,"Charges > $500, x 34%",1690.82,percent of total billed charges,Implant Device,1740.55,35,,1740.55,percent of total billed charges,Implant Device,1740.55,35,,1740.55,percent of total billed charges,Implant Device,1740.55,35,,1740.55,percent of total billed charges,Implant Device,1740.55,35,,1740.55,percent of total billed charges,Implant Device,1740.55,35,,1740.55,percent of total billed charges,Implant Device,1989.2,40,,1989.2,percent of total billed charges,Implant Device,1740.55,70,,1740.55,percent of total billed charges,All Other,1690.82,34,,1690.82,percent of total billed charges,Implant Device,1690.82,34,,1690.82,percent of total billed charges,Implant Device,1740.55,35,,1740.55,percent of total billed charges,Implant Device,1740.55,35,,1740.55,percent of total billed charges,Implant Device,1740.55,35,,1740.55,percent of total billed charges,Implant Device,1740.55,35,,1740.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1690.82,34,"If Charge > 2,000, then 34 percent",1690.82,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3680.03,
ZIMMER 00-8752-014-36-REV POLY LINER,C1776,HCPCS,,79001875,CDM,278,RC,,,both,,,4972,3679.29,,,3679.29,Other,150% of Medicare + 9.63% HCRA Surcharge,2237.4,45,,2237.4,percent of total billed charges,Critical Access Hospital RCC factor,1690.48,34,,1690.48,percent of total billed charges,Implant Device,1690.48,34,,1690.48,percent of total billed charges,Implant Device,1690.48,34,,1690.48,percent of total billed charges,Implant Device,1690.48,34,,1690.48,percent of total billed charges,Implant Device,1690.48,34,,1690.48,percent of total billed charges,Implant Device,2461.14,,,2461.14,Other,110% of Medicare,1740.2,35,,1740.2,percent of total billed charges,Implant Device,1690.48,34,"Charges > $500, x 34%",1690.48,percent of total billed charges,Implant Device,1740.2,35,,1740.2,percent of total billed charges,Implant Device,1740.2,35,,1740.2,percent of total billed charges,Implant Device,1740.2,35,,1740.2,percent of total billed charges,Implant Device,1740.2,35,,1740.2,percent of total billed charges,Implant Device,1740.2,35,,1740.2,percent of total billed charges,Implant Device,1988.8,40,,1988.8,percent of total billed charges,Implant Device,1740.2,70,,1740.2,percent of total billed charges,All Other,1690.48,34,,1690.48,percent of total billed charges,Implant Device,1690.48,34,,1690.48,percent of total billed charges,Implant Device,1740.2,35,,1740.2,percent of total billed charges,Implant Device,1740.2,35,,1740.2,percent of total billed charges,Implant Device,1740.2,35,,1740.2,percent of total billed charges,Implant Device,1740.2,35,,1740.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1690.48,34,"If Charge > 2,000, then 34 percent",1690.48,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3679.29,
ZIMMER 00-8752-016-36-REV LINER,C1776,HCPCS,,79001876,CDM,278,RC,,,both,,,4973,3680.03,,,3680.03,Other,150% of Medicare + 9.63% HCRA Surcharge,2237.85,45,,2237.85,percent of total billed charges,Critical Access Hospital RCC factor,1690.82,34,,1690.82,percent of total billed charges,Implant Device,1690.82,34,,1690.82,percent of total billed charges,Implant Device,1690.82,34,,1690.82,percent of total billed charges,Implant Device,1690.82,34,,1690.82,percent of total billed charges,Implant Device,1690.82,34,,1690.82,percent of total billed charges,Implant Device,2461.64,,,2461.64,Other,110% of Medicare,1740.55,35,,1740.55,percent of total billed charges,Implant Device,1690.82,34,"Charges > $500, x 34%",1690.82,percent of total billed charges,Implant Device,1740.55,35,,1740.55,percent of total billed charges,Implant Device,1740.55,35,,1740.55,percent of total billed charges,Implant Device,1740.55,35,,1740.55,percent of total billed charges,Implant Device,1740.55,35,,1740.55,percent of total billed charges,Implant Device,1740.55,35,,1740.55,percent of total billed charges,Implant Device,1989.2,40,,1989.2,percent of total billed charges,Implant Device,1740.55,70,,1740.55,percent of total billed charges,All Other,1690.82,34,,1690.82,percent of total billed charges,Implant Device,1690.82,34,,1690.82,percent of total billed charges,Implant Device,1740.55,35,,1740.55,percent of total billed charges,Implant Device,1740.55,35,,1740.55,percent of total billed charges,Implant Device,1740.55,35,,1740.55,percent of total billed charges,Implant Device,1740.55,35,,1740.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1690.82,34,"If Charge > 2,000, then 34 percent",1690.82,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3680.03,
ZIMMER 00-8755-009-32-REV LINER,C1776,HCPCS,,79001877,CDM,278,RC,,,both,,,5483,4057.43,,,4057.43,Other,150% of Medicare + 9.63% HCRA Surcharge,2467.35,45,,2467.35,percent of total billed charges,Critical Access Hospital RCC factor,1864.22,34,,1864.22,percent of total billed charges,Implant Device,1864.22,34,,1864.22,percent of total billed charges,Implant Device,1864.22,34,,1864.22,percent of total billed charges,Implant Device,1864.22,34,,1864.22,percent of total billed charges,Implant Device,1864.22,34,,1864.22,percent of total billed charges,Implant Device,2714.09,,,2714.09,Other,110% of Medicare,1919.05,35,,1919.05,percent of total billed charges,Implant Device,1864.22,34,"Charges > $500, x 34%",1864.22,percent of total billed charges,Implant Device,1919.05,35,,1919.05,percent of total billed charges,Implant Device,1919.05,35,,1919.05,percent of total billed charges,Implant Device,1919.05,35,,1919.05,percent of total billed charges,Implant Device,1919.05,35,,1919.05,percent of total billed charges,Implant Device,1919.05,35,,1919.05,percent of total billed charges,Implant Device,2193.2,40,,2193.2,percent of total billed charges,Implant Device,1919.05,70,,1919.05,percent of total billed charges,All Other,1864.22,34,,1864.22,percent of total billed charges,Implant Device,1864.22,34,,1864.22,percent of total billed charges,Implant Device,1919.05,35,,1919.05,percent of total billed charges,Implant Device,1919.05,35,,1919.05,percent of total billed charges,Implant Device,1919.05,35,,1919.05,percent of total billed charges,Implant Device,1919.05,35,,1919.05,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1864.22,34,"If Charge > 2,000, then 34 percent",1864.22,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4057.43,
ZIMMER 00-8755-010-36-REV LINER,C1776,HCPCS,,79001878,CDM,278,RC,,,both,,,5482,4056.69,,,4056.69,Other,150% of Medicare + 9.63% HCRA Surcharge,2466.9,45,,2466.9,percent of total billed charges,Critical Access Hospital RCC factor,1863.88,34,,1863.88,percent of total billed charges,Implant Device,1863.88,34,,1863.88,percent of total billed charges,Implant Device,1863.88,34,,1863.88,percent of total billed charges,Implant Device,1863.88,34,,1863.88,percent of total billed charges,Implant Device,1863.88,34,,1863.88,percent of total billed charges,Implant Device,2713.59,,,2713.59,Other,110% of Medicare,1918.7,35,,1918.7,percent of total billed charges,Implant Device,1863.88,34,"Charges > $500, x 34%",1863.88,percent of total billed charges,Implant Device,1918.7,35,,1918.7,percent of total billed charges,Implant Device,1918.7,35,,1918.7,percent of total billed charges,Implant Device,1918.7,35,,1918.7,percent of total billed charges,Implant Device,1918.7,35,,1918.7,percent of total billed charges,Implant Device,1918.7,35,,1918.7,percent of total billed charges,Implant Device,2192.8,40,,2192.8,percent of total billed charges,Implant Device,1918.7,70,,1918.7,percent of total billed charges,All Other,1863.88,34,,1863.88,percent of total billed charges,Implant Device,1863.88,34,,1863.88,percent of total billed charges,Implant Device,1918.7,35,,1918.7,percent of total billed charges,Implant Device,1918.7,35,,1918.7,percent of total billed charges,Implant Device,1918.7,35,,1918.7,percent of total billed charges,Implant Device,1918.7,35,,1918.7,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1863.88,34,"If Charge > 2,000, then 34 percent",1863.88,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4056.69,
ZIMMER 00-8755-014-36-REV LINER,C1776,HCPCS,,79001879,CDM,278,RC,,,both,,,4973,3680.03,,,3680.03,Other,150% of Medicare + 9.63% HCRA Surcharge,2237.85,45,,2237.85,percent of total billed charges,Critical Access Hospital RCC factor,1690.82,34,,1690.82,percent of total billed charges,Implant Device,1690.82,34,,1690.82,percent of total billed charges,Implant Device,1690.82,34,,1690.82,percent of total billed charges,Implant Device,1690.82,34,,1690.82,percent of total billed charges,Implant Device,1690.82,34,,1690.82,percent of total billed charges,Implant Device,2461.64,,,2461.64,Other,110% of Medicare,1740.55,35,,1740.55,percent of total billed charges,Implant Device,1690.82,34,"Charges > $500, x 34%",1690.82,percent of total billed charges,Implant Device,1740.55,35,,1740.55,percent of total billed charges,Implant Device,1740.55,35,,1740.55,percent of total billed charges,Implant Device,1740.55,35,,1740.55,percent of total billed charges,Implant Device,1740.55,35,,1740.55,percent of total billed charges,Implant Device,1740.55,35,,1740.55,percent of total billed charges,Implant Device,1989.2,40,,1989.2,percent of total billed charges,Implant Device,1740.55,70,,1740.55,percent of total billed charges,All Other,1690.82,34,,1690.82,percent of total billed charges,Implant Device,1690.82,34,,1690.82,percent of total billed charges,Implant Device,1740.55,35,,1740.55,percent of total billed charges,Implant Device,1740.55,35,,1740.55,percent of total billed charges,Implant Device,1740.55,35,,1740.55,percent of total billed charges,Implant Device,1740.55,35,,1740.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1690.82,34,"If Charge > 2,000, then 34 percent",1690.82,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3680.03,
ZIMMER 00-8755-015-36-REV LINER,C1776,HCPCS,,79001880,CDM,278,RC,,,both,,,4973,3680.03,,,3680.03,Other,150% of Medicare + 9.63% HCRA Surcharge,2237.85,45,,2237.85,percent of total billed charges,Critical Access Hospital RCC factor,1690.82,34,,1690.82,percent of total billed charges,Implant Device,1690.82,34,,1690.82,percent of total billed charges,Implant Device,1690.82,34,,1690.82,percent of total billed charges,Implant Device,1690.82,34,,1690.82,percent of total billed charges,Implant Device,1690.82,34,,1690.82,percent of total billed charges,Implant Device,2461.64,,,2461.64,Other,110% of Medicare,1740.55,35,,1740.55,percent of total billed charges,Implant Device,1690.82,34,"Charges > $500, x 34%",1690.82,percent of total billed charges,Implant Device,1740.55,35,,1740.55,percent of total billed charges,Implant Device,1740.55,35,,1740.55,percent of total billed charges,Implant Device,1740.55,35,,1740.55,percent of total billed charges,Implant Device,1740.55,35,,1740.55,percent of total billed charges,Implant Device,1740.55,35,,1740.55,percent of total billed charges,Implant Device,1989.2,40,,1989.2,percent of total billed charges,Implant Device,1740.55,70,,1740.55,percent of total billed charges,All Other,1690.82,34,,1690.82,percent of total billed charges,Implant Device,1690.82,34,,1690.82,percent of total billed charges,Implant Device,1740.55,35,,1740.55,percent of total billed charges,Implant Device,1740.55,35,,1740.55,percent of total billed charges,Implant Device,1740.55,35,,1740.55,percent of total billed charges,Implant Device,1740.55,35,,1740.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1690.82,34,"If Charge > 2,000, then 34 percent",1690.82,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3680.03,
ZIMMER 00-8757-050-01 SHELL,C1776,HCPCS,,79001881,CDM,278,RC,,,both,,,19566,14478.89,,,14478.89,Other,150% of Medicare + 9.63% HCRA Surcharge,8804.7,45,,8804.7,percent of total billed charges,Critical Access Hospital RCC factor,6652.44,34,,6652.44,percent of total billed charges,Implant Device,6652.44,34,,6652.44,percent of total billed charges,Implant Device,6652.44,34,,6652.44,percent of total billed charges,Implant Device,6652.44,34,,6652.44,percent of total billed charges,Implant Device,6652.44,34,,6652.44,percent of total billed charges,Implant Device,9685.17,,,9685.17,Other,110% of Medicare,6848.1,35,,6848.1,percent of total billed charges,Implant Device,6652.44,34,"Charges > $500, x 34%",6652.44,percent of total billed charges,Implant Device,6848.1,35,,6848.1,percent of total billed charges,Implant Device,6848.1,35,,6848.1,percent of total billed charges,Implant Device,6848.1,35,,6848.1,percent of total billed charges,Implant Device,6848.1,35,,6848.1,percent of total billed charges,Implant Device,6848.1,35,,6848.1,percent of total billed charges,Implant Device,7826.4,40,,7826.4,percent of total billed charges,Implant Device,6848.1,70,,6848.1,percent of total billed charges,All Other,6652.44,34,,6652.44,percent of total billed charges,Implant Device,6652.44,34,,6652.44,percent of total billed charges,Implant Device,6848.1,35,,6848.1,percent of total billed charges,Implant Device,6848.1,35,,6848.1,percent of total billed charges,Implant Device,6848.1,35,,6848.1,percent of total billed charges,Implant Device,6848.1,35,,6848.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,6652.44,34,"If Charge > 2,000, then 34 percent",6652.44,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,14478.89,
ZIMMER 00-8757-050-01-REV SHELL,C1776,HCPCS,,79001882,CDM,278,RC,,,both,,,3450,2553.01,,,2553.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1552.5,45,,1552.5,percent of total billed charges,Critical Access Hospital RCC factor,1173,34,,1173,percent of total billed charges,Implant Device,1173,34,,1173,percent of total billed charges,Implant Device,1173,34,,1173,percent of total billed charges,Implant Device,1173,34,,1173,percent of total billed charges,Implant Device,1173,34,,1173,percent of total billed charges,Implant Device,1707.75,,,1707.75,Other,110% of Medicare,1207.5,35,,1207.5,percent of total billed charges,Implant Device,1173,34,"Charges > $500, x 34%",1173,percent of total billed charges,Implant Device,1207.5,35,,1207.5,percent of total billed charges,Implant Device,1207.5,35,,1207.5,percent of total billed charges,Implant Device,1207.5,35,,1207.5,percent of total billed charges,Implant Device,1207.5,35,,1207.5,percent of total billed charges,Implant Device,1207.5,35,,1207.5,percent of total billed charges,Implant Device,1380,40,,1380,percent of total billed charges,Implant Device,1207.5,70,,1207.5,percent of total billed charges,All Other,1173,34,,1173,percent of total billed charges,Implant Device,1173,34,,1173,percent of total billed charges,Implant Device,1207.5,35,,1207.5,percent of total billed charges,Implant Device,1207.5,35,,1207.5,percent of total billed charges,Implant Device,1207.5,35,,1207.5,percent of total billed charges,Implant Device,1207.5,35,,1207.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1173,34,"If Charge > 2,000, then 34 percent",1173,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2553.01,
ZIMMER 00-8757-052-01 SHELL,C1776,HCPCS,,79001883,CDM,278,RC,,,both,,,4145,3067.31,,,3067.31,Other,150% of Medicare + 9.63% HCRA Surcharge,1865.25,45,,1865.25,percent of total billed charges,Critical Access Hospital RCC factor,1409.3,34,,1409.3,percent of total billed charges,Implant Device,1409.3,34,,1409.3,percent of total billed charges,Implant Device,1409.3,34,,1409.3,percent of total billed charges,Implant Device,1409.3,34,,1409.3,percent of total billed charges,Implant Device,1409.3,34,,1409.3,percent of total billed charges,Implant Device,2051.78,,,2051.78,Other,110% of Medicare,1450.75,35,,1450.75,percent of total billed charges,Implant Device,1409.3,34,"Charges > $500, x 34%",1409.3,percent of total billed charges,Implant Device,1450.75,35,,1450.75,percent of total billed charges,Implant Device,1450.75,35,,1450.75,percent of total billed charges,Implant Device,1450.75,35,,1450.75,percent of total billed charges,Implant Device,1450.75,35,,1450.75,percent of total billed charges,Implant Device,1450.75,35,,1450.75,percent of total billed charges,Implant Device,1658,40,,1658,percent of total billed charges,Implant Device,1450.75,70,,1450.75,percent of total billed charges,All Other,1409.3,34,,1409.3,percent of total billed charges,Implant Device,1409.3,34,,1409.3,percent of total billed charges,Implant Device,1450.75,35,,1450.75,percent of total billed charges,Implant Device,1450.75,35,,1450.75,percent of total billed charges,Implant Device,1450.75,35,,1450.75,percent of total billed charges,Implant Device,1450.75,35,,1450.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1409.3,34,"If Charge > 2,000, then 34 percent",1409.3,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3067.31,
ZIMMER 00-8757-052-01-REV SHELL,C1776,HCPCS,,79001884,CDM,278,RC,,,both,,,7608,5629.94,,,5629.94,Other,150% of Medicare + 9.63% HCRA Surcharge,3423.6,45,,3423.6,percent of total billed charges,Critical Access Hospital RCC factor,2586.72,34,,2586.72,percent of total billed charges,Implant Device,2586.72,34,,2586.72,percent of total billed charges,Implant Device,2586.72,34,,2586.72,percent of total billed charges,Implant Device,2586.72,34,,2586.72,percent of total billed charges,Implant Device,2586.72,34,,2586.72,percent of total billed charges,Implant Device,3765.96,,,3765.96,Other,110% of Medicare,2662.8,35,,2662.8,percent of total billed charges,Implant Device,2586.72,34,"Charges > $500, x 34%",2586.72,percent of total billed charges,Implant Device,2662.8,35,,2662.8,percent of total billed charges,Implant Device,2662.8,35,,2662.8,percent of total billed charges,Implant Device,2662.8,35,,2662.8,percent of total billed charges,Implant Device,2662.8,35,,2662.8,percent of total billed charges,Implant Device,2662.8,35,,2662.8,percent of total billed charges,Implant Device,3043.2,40,,3043.2,percent of total billed charges,Implant Device,2662.8,70,,2662.8,percent of total billed charges,All Other,2586.72,34,,2586.72,percent of total billed charges,Implant Device,2586.72,34,,2586.72,percent of total billed charges,Implant Device,2662.8,35,,2662.8,percent of total billed charges,Implant Device,2662.8,35,,2662.8,percent of total billed charges,Implant Device,2662.8,35,,2662.8,percent of total billed charges,Implant Device,2662.8,35,,2662.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2586.72,34,"If Charge > 2,000, then 34 percent",2586.72,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5629.94,
ZIMMER 00-8757-052-02-REV SHELL,C1776,HCPCS,,79001885,CDM,278,RC,,,both,,,7133,5278.44,,,5278.44,Other,150% of Medicare + 9.63% HCRA Surcharge,3209.85,45,,3209.85,percent of total billed charges,Critical Access Hospital RCC factor,2425.22,34,,2425.22,percent of total billed charges,Implant Device,2425.22,34,,2425.22,percent of total billed charges,Implant Device,2425.22,34,,2425.22,percent of total billed charges,Implant Device,2425.22,34,,2425.22,percent of total billed charges,Implant Device,2425.22,34,,2425.22,percent of total billed charges,Implant Device,3530.84,,,3530.84,Other,110% of Medicare,2496.55,35,,2496.55,percent of total billed charges,Implant Device,2425.22,34,"Charges > $500, x 34%",2425.22,percent of total billed charges,Implant Device,2496.55,35,,2496.55,percent of total billed charges,Implant Device,2496.55,35,,2496.55,percent of total billed charges,Implant Device,2496.55,35,,2496.55,percent of total billed charges,Implant Device,2496.55,35,,2496.55,percent of total billed charges,Implant Device,2496.55,35,,2496.55,percent of total billed charges,Implant Device,2853.2,40,,2853.2,percent of total billed charges,Implant Device,2496.55,70,,2496.55,percent of total billed charges,All Other,2425.22,34,,2425.22,percent of total billed charges,Implant Device,2425.22,34,,2425.22,percent of total billed charges,Implant Device,2496.55,35,,2496.55,percent of total billed charges,Implant Device,2496.55,35,,2496.55,percent of total billed charges,Implant Device,2496.55,35,,2496.55,percent of total billed charges,Implant Device,2496.55,35,,2496.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2425.22,34,"If Charge > 2,000, then 34 percent",2425.22,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5278.44,
ZIMMER 00-8757-054-01-REV SHELL,C1776,HCPCS,,79001886,CDM,278,RC,,,both,,,4145,3067.31,,,3067.31,Other,150% of Medicare + 9.63% HCRA Surcharge,1865.25,45,,1865.25,percent of total billed charges,Critical Access Hospital RCC factor,1409.3,34,,1409.3,percent of total billed charges,Implant Device,1409.3,34,,1409.3,percent of total billed charges,Implant Device,1409.3,34,,1409.3,percent of total billed charges,Implant Device,1409.3,34,,1409.3,percent of total billed charges,Implant Device,1409.3,34,,1409.3,percent of total billed charges,Implant Device,2051.78,,,2051.78,Other,110% of Medicare,1450.75,35,,1450.75,percent of total billed charges,Implant Device,1409.3,34,"Charges > $500, x 34%",1409.3,percent of total billed charges,Implant Device,1450.75,35,,1450.75,percent of total billed charges,Implant Device,1450.75,35,,1450.75,percent of total billed charges,Implant Device,1450.75,35,,1450.75,percent of total billed charges,Implant Device,1450.75,35,,1450.75,percent of total billed charges,Implant Device,1450.75,35,,1450.75,percent of total billed charges,Implant Device,1658,40,,1658,percent of total billed charges,Implant Device,1450.75,70,,1450.75,percent of total billed charges,All Other,1409.3,34,,1409.3,percent of total billed charges,Implant Device,1409.3,34,,1409.3,percent of total billed charges,Implant Device,1450.75,35,,1450.75,percent of total billed charges,Implant Device,1450.75,35,,1450.75,percent of total billed charges,Implant Device,1450.75,35,,1450.75,percent of total billed charges,Implant Device,1450.75,35,,1450.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1409.3,34,"If Charge > 2,000, then 34 percent",1409.3,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3067.31,
ZIMMER 00-8757-058-01-REV SHELL,C1776,HCPCS,,79001887,CDM,278,RC,,,both,,,4145,3067.31,,,3067.31,Other,150% of Medicare + 9.63% HCRA Surcharge,1865.25,45,,1865.25,percent of total billed charges,Critical Access Hospital RCC factor,1409.3,34,,1409.3,percent of total billed charges,Implant Device,1409.3,34,,1409.3,percent of total billed charges,Implant Device,1409.3,34,,1409.3,percent of total billed charges,Implant Device,1409.3,34,,1409.3,percent of total billed charges,Implant Device,1409.3,34,,1409.3,percent of total billed charges,Implant Device,2051.78,,,2051.78,Other,110% of Medicare,1450.75,35,,1450.75,percent of total billed charges,Implant Device,1409.3,34,"Charges > $500, x 34%",1409.3,percent of total billed charges,Implant Device,1450.75,35,,1450.75,percent of total billed charges,Implant Device,1450.75,35,,1450.75,percent of total billed charges,Implant Device,1450.75,35,,1450.75,percent of total billed charges,Implant Device,1450.75,35,,1450.75,percent of total billed charges,Implant Device,1450.75,35,,1450.75,percent of total billed charges,Implant Device,1658,40,,1658,percent of total billed charges,Implant Device,1450.75,70,,1450.75,percent of total billed charges,All Other,1409.3,34,,1409.3,percent of total billed charges,Implant Device,1409.3,34,,1409.3,percent of total billed charges,Implant Device,1450.75,35,,1450.75,percent of total billed charges,Implant Device,1450.75,35,,1450.75,percent of total billed charges,Implant Device,1450.75,35,,1450.75,percent of total billed charges,Implant Device,1450.75,35,,1450.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1409.3,34,"If Charge > 2,000, then 34 percent",1409.3,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3067.31,
ZIMMER 00-8757-060-01-REV SHELL,C1776,HCPCS,,79001888,CDM,278,RC,,,both,,,4145,3067.31,,,3067.31,Other,150% of Medicare + 9.63% HCRA Surcharge,1865.25,45,,1865.25,percent of total billed charges,Critical Access Hospital RCC factor,1409.3,34,,1409.3,percent of total billed charges,Implant Device,1409.3,34,,1409.3,percent of total billed charges,Implant Device,1409.3,34,,1409.3,percent of total billed charges,Implant Device,1409.3,34,,1409.3,percent of total billed charges,Implant Device,1409.3,34,,1409.3,percent of total billed charges,Implant Device,2051.78,,,2051.78,Other,110% of Medicare,1450.75,35,,1450.75,percent of total billed charges,Implant Device,1409.3,34,"Charges > $500, x 34%",1409.3,percent of total billed charges,Implant Device,1450.75,35,,1450.75,percent of total billed charges,Implant Device,1450.75,35,,1450.75,percent of total billed charges,Implant Device,1450.75,35,,1450.75,percent of total billed charges,Implant Device,1450.75,35,,1450.75,percent of total billed charges,Implant Device,1450.75,35,,1450.75,percent of total billed charges,Implant Device,1658,40,,1658,percent of total billed charges,Implant Device,1450.75,70,,1450.75,percent of total billed charges,All Other,1409.3,34,,1409.3,percent of total billed charges,Implant Device,1409.3,34,,1409.3,percent of total billed charges,Implant Device,1450.75,35,,1450.75,percent of total billed charges,Implant Device,1450.75,35,,1450.75,percent of total billed charges,Implant Device,1450.75,35,,1450.75,percent of total billed charges,Implant Device,1450.75,35,,1450.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1409.3,34,"If Charge > 2,000, then 34 percent",1409.3,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3067.31,
ZIMMER 00-8757-062-02-REV SHELL,C1776,HCPCS,,79001889,CDM,278,RC,,,both,,,9203,6810.24,,,6810.24,Other,150% of Medicare + 9.63% HCRA Surcharge,4141.35,45,,4141.35,percent of total billed charges,Critical Access Hospital RCC factor,3129.02,34,,3129.02,percent of total billed charges,Implant Device,3129.02,34,,3129.02,percent of total billed charges,Implant Device,3129.02,34,,3129.02,percent of total billed charges,Implant Device,3129.02,34,,3129.02,percent of total billed charges,Implant Device,3129.02,34,,3129.02,percent of total billed charges,Implant Device,4555.49,,,4555.49,Other,110% of Medicare,3221.05,35,,3221.05,percent of total billed charges,Implant Device,3129.02,34,"Charges > $500, x 34%",3129.02,percent of total billed charges,Implant Device,3221.05,35,,3221.05,percent of total billed charges,Implant Device,3221.05,35,,3221.05,percent of total billed charges,Implant Device,3221.05,35,,3221.05,percent of total billed charges,Implant Device,3221.05,35,,3221.05,percent of total billed charges,Implant Device,3221.05,35,,3221.05,percent of total billed charges,Implant Device,3681.2,40,,3681.2,percent of total billed charges,Implant Device,3221.05,70,,3221.05,percent of total billed charges,All Other,3129.02,34,,3129.02,percent of total billed charges,Implant Device,3129.02,34,,3129.02,percent of total billed charges,Implant Device,3221.05,35,,3221.05,percent of total billed charges,Implant Device,3221.05,35,,3221.05,percent of total billed charges,Implant Device,3221.05,35,,3221.05,percent of total billed charges,Implant Device,3221.05,35,,3221.05,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3129.02,34,"If Charge > 2,000, then 34 percent",3129.02,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,6810.24,
ZIMMER 00-8757-064-02-REV SHELL,C1776,HCPCS,,79001890,CDM,278,RC,,,both,,,9203,6810.24,,,6810.24,Other,150% of Medicare + 9.63% HCRA Surcharge,4141.35,45,,4141.35,percent of total billed charges,Critical Access Hospital RCC factor,3129.02,34,,3129.02,percent of total billed charges,Implant Device,3129.02,34,,3129.02,percent of total billed charges,Implant Device,3129.02,34,,3129.02,percent of total billed charges,Implant Device,3129.02,34,,3129.02,percent of total billed charges,Implant Device,3129.02,34,,3129.02,percent of total billed charges,Implant Device,4555.49,,,4555.49,Other,110% of Medicare,3221.05,35,,3221.05,percent of total billed charges,Implant Device,3129.02,34,"Charges > $500, x 34%",3129.02,percent of total billed charges,Implant Device,3221.05,35,,3221.05,percent of total billed charges,Implant Device,3221.05,35,,3221.05,percent of total billed charges,Implant Device,3221.05,35,,3221.05,percent of total billed charges,Implant Device,3221.05,35,,3221.05,percent of total billed charges,Implant Device,3221.05,35,,3221.05,percent of total billed charges,Implant Device,3681.2,40,,3681.2,percent of total billed charges,Implant Device,3221.05,70,,3221.05,percent of total billed charges,All Other,3129.02,34,,3129.02,percent of total billed charges,Implant Device,3129.02,34,,3129.02,percent of total billed charges,Implant Device,3221.05,35,,3221.05,percent of total billed charges,Implant Device,3221.05,35,,3221.05,percent of total billed charges,Implant Device,3221.05,35,,3221.05,percent of total billed charges,Implant Device,3221.05,35,,3221.05,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3129.02,34,"If Charge > 2,000, then 34 percent",3129.02,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,6810.24,
ZIMMER 00-8775-036-03-REV FEMORAL HEAD,C1776,HCPCS,,79001891,CDM,278,RC,,,both,,,3834,2837.17,,,2837.17,Other,150% of Medicare + 9.63% HCRA Surcharge,1725.3,45,,1725.3,percent of total billed charges,Critical Access Hospital RCC factor,1303.56,34,,1303.56,percent of total billed charges,Implant Device,1303.56,34,,1303.56,percent of total billed charges,Implant Device,1303.56,34,,1303.56,percent of total billed charges,Implant Device,1303.56,34,,1303.56,percent of total billed charges,Implant Device,1303.56,34,,1303.56,percent of total billed charges,Implant Device,1897.83,,,1897.83,Other,110% of Medicare,1341.9,35,,1341.9,percent of total billed charges,Implant Device,1303.56,34,"Charges > $500, x 34%",1303.56,percent of total billed charges,Implant Device,1341.9,35,,1341.9,percent of total billed charges,Implant Device,1341.9,35,,1341.9,percent of total billed charges,Implant Device,1341.9,35,,1341.9,percent of total billed charges,Implant Device,1341.9,35,,1341.9,percent of total billed charges,Implant Device,1341.9,35,,1341.9,percent of total billed charges,Implant Device,1533.6,40,,1533.6,percent of total billed charges,Implant Device,1341.9,70,,1341.9,percent of total billed charges,All Other,1303.56,34,,1303.56,percent of total billed charges,Implant Device,1303.56,34,,1303.56,percent of total billed charges,Implant Device,1341.9,35,,1341.9,percent of total billed charges,Implant Device,1341.9,35,,1341.9,percent of total billed charges,Implant Device,1341.9,35,,1341.9,percent of total billed charges,Implant Device,1341.9,35,,1341.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1303.56,34,"If Charge > 2,000, then 34 percent",1303.56,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2837.17,
ZIMMER 00-8775-036-04-REV TRACH IMPLANT,C1776,HCPCS,,79001892,CDM,278,RC,,,both,,,3834,2837.17,,,2837.17,Other,150% of Medicare + 9.63% HCRA Surcharge,1725.3,45,,1725.3,percent of total billed charges,Critical Access Hospital RCC factor,1303.56,34,,1303.56,percent of total billed charges,Implant Device,1303.56,34,,1303.56,percent of total billed charges,Implant Device,1303.56,34,,1303.56,percent of total billed charges,Implant Device,1303.56,34,,1303.56,percent of total billed charges,Implant Device,1303.56,34,,1303.56,percent of total billed charges,Implant Device,1897.83,,,1897.83,Other,110% of Medicare,1341.9,35,,1341.9,percent of total billed charges,Implant Device,1303.56,34,"Charges > $500, x 34%",1303.56,percent of total billed charges,Implant Device,1341.9,35,,1341.9,percent of total billed charges,Implant Device,1341.9,35,,1341.9,percent of total billed charges,Implant Device,1341.9,35,,1341.9,percent of total billed charges,Implant Device,1341.9,35,,1341.9,percent of total billed charges,Implant Device,1341.9,35,,1341.9,percent of total billed charges,Implant Device,1533.6,40,,1533.6,percent of total billed charges,Implant Device,1341.9,70,,1341.9,percent of total billed charges,All Other,1303.56,34,,1303.56,percent of total billed charges,Implant Device,1303.56,34,,1303.56,percent of total billed charges,Implant Device,1341.9,35,,1341.9,percent of total billed charges,Implant Device,1341.9,35,,1341.9,percent of total billed charges,Implant Device,1341.9,35,,1341.9,percent of total billed charges,Implant Device,1341.9,35,,1341.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1303.56,34,"If Charge > 2,000, then 34 percent",1303.56,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2837.17,
DEPUY 00-8775-040-02-REV FEMORAL HEAD,C1776,HCPCS,,79001893,CDM,278,RC,,,both,,,6526,4829.26,,,4829.26,Other,150% of Medicare + 9.63% HCRA Surcharge,2936.7,45,,2936.7,percent of total billed charges,Critical Access Hospital RCC factor,2218.84,34,,2218.84,percent of total billed charges,Implant Device,2218.84,34,,2218.84,percent of total billed charges,Implant Device,2218.84,34,,2218.84,percent of total billed charges,Implant Device,2218.84,34,,2218.84,percent of total billed charges,Implant Device,2218.84,34,,2218.84,percent of total billed charges,Implant Device,3230.37,,,3230.37,Other,110% of Medicare,2284.1,35,,2284.1,percent of total billed charges,Implant Device,2218.84,34,"Charges > $500, x 34%",2218.84,percent of total billed charges,Implant Device,2284.1,35,,2284.1,percent of total billed charges,Implant Device,2284.1,35,,2284.1,percent of total billed charges,Implant Device,2284.1,35,,2284.1,percent of total billed charges,Implant Device,2284.1,35,,2284.1,percent of total billed charges,Implant Device,2284.1,35,,2284.1,percent of total billed charges,Implant Device,2610.4,40,,2610.4,percent of total billed charges,Implant Device,2284.1,70,,2284.1,percent of total billed charges,All Other,2218.84,34,,2218.84,percent of total billed charges,Implant Device,2218.84,34,,2218.84,percent of total billed charges,Implant Device,2284.1,35,,2284.1,percent of total billed charges,Implant Device,2284.1,35,,2284.1,percent of total billed charges,Implant Device,2284.1,35,,2284.1,percent of total billed charges,Implant Device,2284.1,35,,2284.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2218.84,34,"If Charge > 2,000, then 34 percent",2218.84,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4829.26,
SYNTHES 02.110.152 PLATE,C1713,HCPCS,,79001894,CDM,278,RC,,,both,,,5689,4209.87,,,4209.87,Other,150% of Medicare + 9.63% HCRA Surcharge,2560.05,45,,2560.05,percent of total billed charges,Critical Access Hospital RCC factor,1934.26,34,,1934.26,percent of total billed charges,Implant Device,1934.26,34,,1934.26,percent of total billed charges,Implant Device,1934.26,34,,1934.26,percent of total billed charges,Implant Device,1934.26,34,,1934.26,percent of total billed charges,Implant Device,1934.26,34,,1934.26,percent of total billed charges,Implant Device,2816.06,,,2816.06,Other,110% of Medicare,1991.15,35,,1991.15,percent of total billed charges,Implant Device,1934.26,34,"Charges > $500, x 34%",1934.26,percent of total billed charges,Implant Device,1991.15,35,,1991.15,percent of total billed charges,Implant Device,1991.15,35,,1991.15,percent of total billed charges,Implant Device,1991.15,35,,1991.15,percent of total billed charges,Implant Device,1991.15,35,,1991.15,percent of total billed charges,Implant Device,1991.15,35,,1991.15,percent of total billed charges,Implant Device,2275.6,40,,2275.6,percent of total billed charges,Implant Device,1991.15,70,,1991.15,percent of total billed charges,All Other,1934.26,34,,1934.26,percent of total billed charges,Implant Device,1934.26,34,,1934.26,percent of total billed charges,Implant Device,1991.15,35,,1991.15,percent of total billed charges,Implant Device,1991.15,35,,1991.15,percent of total billed charges,Implant Device,1991.15,35,,1991.15,percent of total billed charges,Implant Device,1991.15,35,,1991.15,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1934.26,34,"If Charge > 2,000, then 34 percent",1934.26,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4209.87,
ZIMMER 02-03150-040 SCREW,C1713,HCPCS,,79001897,CDM,278,RC,,,both,,,523,387.02,,,387.02,Other,150% of Medicare + 9.63% HCRA Surcharge,235.35,45,,235.35,percent of total billed charges,Critical Access Hospital RCC factor,177.82,34,,177.82,percent of total billed charges,Implant Device,177.82,34,,177.82,percent of total billed charges,Implant Device,177.82,34,,177.82,percent of total billed charges,Implant Device,177.82,34,,177.82,percent of total billed charges,Implant Device,177.82,34,,177.82,percent of total billed charges,Implant Device,258.89,,,258.89,Other,110% of Medicare,183.05,35,,183.05,percent of total billed charges,Implant Device,177.82,34,"Charges > $500, x 34%",177.82,percent of total billed charges,Implant Device,183.05,35,,183.05,percent of total billed charges,Implant Device,183.05,35,,183.05,percent of total billed charges,Implant Device,183.05,35,,183.05,percent of total billed charges,Implant Device,183.05,35,,183.05,percent of total billed charges,Implant Device,183.05,35,,183.05,percent of total billed charges,Implant Device,209.2,40,,209.2,percent of total billed charges,Implant Device,183.05,70,,183.05,percent of total billed charges,All Other,177.82,34,,177.82,percent of total billed charges,Implant Device,177.82,34,,177.82,percent of total billed charges,Implant Device,183.05,35,,183.05,percent of total billed charges,Implant Device,183.05,35,,183.05,percent of total billed charges,Implant Device,183.05,35,,183.05,percent of total billed charges,Implant Device,183.05,35,,183.05,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,387.02,
ZIMMER 02-03150-048 SCREW,C1713,HCPCS,,79001898,CDM,278,RC,,,both,,,636,470.64,,,470.64,Other,150% of Medicare + 9.63% HCRA Surcharge,286.2,45,,286.2,percent of total billed charges,Critical Access Hospital RCC factor,216.24,34,,216.24,percent of total billed charges,Implant Device,216.24,34,,216.24,percent of total billed charges,Implant Device,216.24,34,,216.24,percent of total billed charges,Implant Device,216.24,34,,216.24,percent of total billed charges,Implant Device,216.24,34,,216.24,percent of total billed charges,Implant Device,314.82,,,314.82,Other,110% of Medicare,222.6,35,,222.6,percent of total billed charges,Implant Device,216.24,34,"Charges > $500, x 34%",216.24,percent of total billed charges,Implant Device,222.6,35,,222.6,percent of total billed charges,Implant Device,222.6,35,,222.6,percent of total billed charges,Implant Device,222.6,35,,222.6,percent of total billed charges,Implant Device,222.6,35,,222.6,percent of total billed charges,Implant Device,222.6,35,,222.6,percent of total billed charges,Implant Device,254.4,40,,254.4,percent of total billed charges,Implant Device,222.6,70,,222.6,percent of total billed charges,All Other,216.24,34,,216.24,percent of total billed charges,Implant Device,216.24,34,,216.24,percent of total billed charges,Implant Device,222.6,35,,222.6,percent of total billed charges,Implant Device,222.6,35,,222.6,percent of total billed charges,Implant Device,222.6,35,,222.6,percent of total billed charges,Implant Device,222.6,35,,222.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,470.64,
ZIMMER 02-03150-300 SCREW CAP,C1713,HCPCS,,79001899,CDM,278,RC,,,both,,,462,341.88,,,341.88,Other,150% of Medicare + 9.63% HCRA Surcharge,207.9,45,,207.9,percent of total billed charges,Critical Access Hospital RCC factor,157.08,34,,157.08,percent of total billed charges,Implant Device,157.08,34,,157.08,percent of total billed charges,Implant Device,157.08,34,,157.08,percent of total billed charges,Implant Device,157.08,34,,157.08,percent of total billed charges,Implant Device,157.08,34,,157.08,percent of total billed charges,Implant Device,228.69,,,228.69,Other,110% of Medicare,161.7,35,,161.7,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,161.7,35,,161.7,percent of total billed charges,Implant Device,161.7,35,,161.7,percent of total billed charges,Implant Device,161.7,35,,161.7,percent of total billed charges,Implant Device,161.7,35,,161.7,percent of total billed charges,Implant Device,161.7,35,,161.7,percent of total billed charges,Implant Device,184.8,40,,184.8,percent of total billed charges,Implant Device,161.7,70,,161.7,percent of total billed charges,All Other,157.08,34,,157.08,percent of total billed charges,Implant Device,157.08,34,,157.08,percent of total billed charges,Implant Device,161.7,35,,161.7,percent of total billed charges,Implant Device,161.7,35,,161.7,percent of total billed charges,Implant Device,161.7,35,,161.7,percent of total billed charges,Implant Device,161.7,35,,161.7,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,341.88,
ZIMMER 02-03150-310 BLIND CAP,C1713,HCPCS,,79001900,CDM,278,RC,,,both,,,148,109.52,,,109.52,Other,150% of Medicare + 9.63% HCRA Surcharge,66.6,45,,66.6,percent of total billed charges,Critical Access Hospital RCC factor,50.32,34,,50.32,percent of total billed charges,Implant Device,50.32,34,,50.32,percent of total billed charges,Implant Device,50.32,34,,50.32,percent of total billed charges,Implant Device,50.32,34,,50.32,percent of total billed charges,Implant Device,50.32,34,,50.32,percent of total billed charges,Implant Device,73.26,,,73.26,Other,110% of Medicare,51.8,35,,51.8,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,51.8,35,,51.8,percent of total billed charges,Implant Device,51.8,35,,51.8,percent of total billed charges,Implant Device,51.8,35,,51.8,percent of total billed charges,Implant Device,51.8,35,,51.8,percent of total billed charges,Implant Device,51.8,35,,51.8,percent of total billed charges,Implant Device,59.2,40,,59.2,percent of total billed charges,Implant Device,51.8,70,,51.8,percent of total billed charges,All Other,50.32,34,,50.32,percent of total billed charges,Implant Device,50.32,34,,50.32,percent of total billed charges,Implant Device,51.8,35,,51.8,percent of total billed charges,Implant Device,51.8,35,,51.8,percent of total billed charges,Implant Device,51.8,35,,51.8,percent of total billed charges,Implant Device,51.8,35,,51.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,109.52,
ZIMMER 02-03155-036 SCREW,C1713,HCPCS,,79001901,CDM,278,RC,,,both,,,402,297.48,,,297.48,Other,150% of Medicare + 9.63% HCRA Surcharge,180.9,45,,180.9,percent of total billed charges,Critical Access Hospital RCC factor,136.68,34,,136.68,percent of total billed charges,Implant Device,136.68,34,,136.68,percent of total billed charges,Implant Device,136.68,34,,136.68,percent of total billed charges,Implant Device,136.68,34,,136.68,percent of total billed charges,Implant Device,136.68,34,,136.68,percent of total billed charges,Implant Device,198.99,,,198.99,Other,110% of Medicare,140.7,35,,140.7,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,140.7,35,,140.7,percent of total billed charges,Implant Device,140.7,35,,140.7,percent of total billed charges,Implant Device,140.7,35,,140.7,percent of total billed charges,Implant Device,140.7,35,,140.7,percent of total billed charges,Implant Device,140.7,35,,140.7,percent of total billed charges,Implant Device,160.8,40,,160.8,percent of total billed charges,Implant Device,140.7,70,,140.7,percent of total billed charges,All Other,136.68,34,,136.68,percent of total billed charges,Implant Device,136.68,34,,136.68,percent of total billed charges,Implant Device,140.7,35,,140.7,percent of total billed charges,Implant Device,140.7,35,,140.7,percent of total billed charges,Implant Device,140.7,35,,140.7,percent of total billed charges,Implant Device,140.7,35,,140.7,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,297.48,
ZIMMER 02-03155-038 SCREW,C1713,HCPCS,,79001902,CDM,278,RC,,,both,,,402,297.48,,,297.48,Other,150% of Medicare + 9.63% HCRA Surcharge,180.9,45,,180.9,percent of total billed charges,Critical Access Hospital RCC factor,136.68,34,,136.68,percent of total billed charges,Implant Device,136.68,34,,136.68,percent of total billed charges,Implant Device,136.68,34,,136.68,percent of total billed charges,Implant Device,136.68,34,,136.68,percent of total billed charges,Implant Device,136.68,34,,136.68,percent of total billed charges,Implant Device,198.99,,,198.99,Other,110% of Medicare,140.7,35,,140.7,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,140.7,35,,140.7,percent of total billed charges,Implant Device,140.7,35,,140.7,percent of total billed charges,Implant Device,140.7,35,,140.7,percent of total billed charges,Implant Device,140.7,35,,140.7,percent of total billed charges,Implant Device,140.7,35,,140.7,percent of total billed charges,Implant Device,160.8,40,,160.8,percent of total billed charges,Implant Device,140.7,70,,140.7,percent of total billed charges,All Other,136.68,34,,136.68,percent of total billed charges,Implant Device,136.68,34,,136.68,percent of total billed charges,Implant Device,140.7,35,,140.7,percent of total billed charges,Implant Device,140.7,35,,140.7,percent of total billed charges,Implant Device,140.7,35,,140.7,percent of total billed charges,Implant Device,140.7,35,,140.7,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,297.48,
GORE 0650HYB0705A VASCULAR GRAFT,C1768,HCPCS,,79001904,CDM,278,RC,,,both,,,7350,5439.02,,,5439.02,Other,150% of Medicare + 9.63% HCRA Surcharge,3307.5,45,,3307.5,percent of total billed charges,Critical Access Hospital RCC factor,2499,34,,2499,percent of total billed charges,Implant Device,2499,34,,2499,percent of total billed charges,Implant Device,2499,34,,2499,percent of total billed charges,Implant Device,2499,34,,2499,percent of total billed charges,Implant Device,2499,34,,2499,percent of total billed charges,Implant Device,3638.25,,,3638.25,Other,110% of Medicare,2572.5,35,,2572.5,percent of total billed charges,Implant Device,2499,34,"Charges > $500, x 34%",2499,percent of total billed charges,Implant Device,2572.5,35,,2572.5,percent of total billed charges,Implant Device,2572.5,35,,2572.5,percent of total billed charges,Implant Device,2572.5,35,,2572.5,percent of total billed charges,Implant Device,2572.5,35,,2572.5,percent of total billed charges,Implant Device,2572.5,35,,2572.5,percent of total billed charges,Implant Device,2940,40,,2940,percent of total billed charges,Implant Device,2572.5,70,,2572.5,percent of total billed charges,All Other,2499,34,,2499,percent of total billed charges,Implant Device,2499,34,,2499,percent of total billed charges,Implant Device,2572.5,35,,2572.5,percent of total billed charges,Implant Device,2572.5,35,,2572.5,percent of total billed charges,Implant Device,2572.5,35,,2572.5,percent of total billed charges,Implant Device,2572.5,35,,2572.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2499,34,"If Charge > 2,000, then 34 percent",2499,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5439.02,
GORE 0650HYB0805A VASCULAR GRAFT,C1768,HCPCS,,79001905,CDM,278,RC,,,both,,,7350,5439.02,,,5439.02,Other,150% of Medicare + 9.63% HCRA Surcharge,3307.5,45,,3307.5,percent of total billed charges,Critical Access Hospital RCC factor,2499,34,,2499,percent of total billed charges,Implant Device,2499,34,,2499,percent of total billed charges,Implant Device,2499,34,,2499,percent of total billed charges,Implant Device,2499,34,,2499,percent of total billed charges,Implant Device,2499,34,,2499,percent of total billed charges,Implant Device,3638.25,,,3638.25,Other,110% of Medicare,2572.5,35,,2572.5,percent of total billed charges,Implant Device,2499,34,"Charges > $500, x 34%",2499,percent of total billed charges,Implant Device,2572.5,35,,2572.5,percent of total billed charges,Implant Device,2572.5,35,,2572.5,percent of total billed charges,Implant Device,2572.5,35,,2572.5,percent of total billed charges,Implant Device,2572.5,35,,2572.5,percent of total billed charges,Implant Device,2572.5,35,,2572.5,percent of total billed charges,Implant Device,2940,40,,2940,percent of total billed charges,Implant Device,2572.5,70,,2572.5,percent of total billed charges,All Other,2499,34,,2499,percent of total billed charges,Implant Device,2499,34,,2499,percent of total billed charges,Implant Device,2572.5,35,,2572.5,percent of total billed charges,Implant Device,2572.5,35,,2572.5,percent of total billed charges,Implant Device,2572.5,35,,2572.5,percent of total billed charges,Implant Device,2572.5,35,,2572.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2499,34,"If Charge > 2,000, then 34 percent",2499,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5439.02,
DEPUY 1018-36-508-REV FEMORAL HEAD,C1776,HCPCS,,79001906,CDM,278,RC,,,both,,,5471,4048.55,,,4048.55,Other,150% of Medicare + 9.63% HCRA Surcharge,2461.95,45,,2461.95,percent of total billed charges,Critical Access Hospital RCC factor,1860.14,34,,1860.14,percent of total billed charges,Implant Device,1860.14,34,,1860.14,percent of total billed charges,Implant Device,1860.14,34,,1860.14,percent of total billed charges,Implant Device,1860.14,34,,1860.14,percent of total billed charges,Implant Device,1860.14,34,,1860.14,percent of total billed charges,Implant Device,2708.15,,,2708.15,Other,110% of Medicare,1914.85,35,,1914.85,percent of total billed charges,Implant Device,1860.14,34,"Charges > $500, x 34%",1860.14,percent of total billed charges,Implant Device,1914.85,35,,1914.85,percent of total billed charges,Implant Device,1914.85,35,,1914.85,percent of total billed charges,Implant Device,1914.85,35,,1914.85,percent of total billed charges,Implant Device,1914.85,35,,1914.85,percent of total billed charges,Implant Device,1914.85,35,,1914.85,percent of total billed charges,Implant Device,2188.4,40,,2188.4,percent of total billed charges,Implant Device,1914.85,70,,1914.85,percent of total billed charges,All Other,1860.14,34,,1860.14,percent of total billed charges,Implant Device,1860.14,34,,1860.14,percent of total billed charges,Implant Device,1914.85,35,,1914.85,percent of total billed charges,Implant Device,1914.85,35,,1914.85,percent of total billed charges,Implant Device,1914.85,35,,1914.85,percent of total billed charges,Implant Device,1914.85,35,,1914.85,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1860.14,34,"If Charge > 2,000, then 34 percent",1860.14,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4048.55,
ZIMMER 1018-36-511-REV FEMORAL HEAD,C1776,HCPCS,,79001907,CDM,278,RC,,,both,,,4818,3565.33,,,3565.33,Other,150% of Medicare + 9.63% HCRA Surcharge,2168.1,45,,2168.1,percent of total billed charges,Critical Access Hospital RCC factor,1638.12,34,,1638.12,percent of total billed charges,Implant Device,1638.12,34,,1638.12,percent of total billed charges,Implant Device,1638.12,34,,1638.12,percent of total billed charges,Implant Device,1638.12,34,,1638.12,percent of total billed charges,Implant Device,1638.12,34,,1638.12,percent of total billed charges,Implant Device,2384.91,,,2384.91,Other,110% of Medicare,1686.3,35,,1686.3,percent of total billed charges,Implant Device,1638.12,34,"Charges > $500, x 34%",1638.12,percent of total billed charges,Implant Device,1686.3,35,,1686.3,percent of total billed charges,Implant Device,1686.3,35,,1686.3,percent of total billed charges,Implant Device,1686.3,35,,1686.3,percent of total billed charges,Implant Device,1686.3,35,,1686.3,percent of total billed charges,Implant Device,1686.3,35,,1686.3,percent of total billed charges,Implant Device,1927.2,40,,1927.2,percent of total billed charges,Implant Device,1686.3,70,,1686.3,percent of total billed charges,All Other,1638.12,34,,1638.12,percent of total billed charges,Implant Device,1638.12,34,,1638.12,percent of total billed charges,Implant Device,1686.3,35,,1686.3,percent of total billed charges,Implant Device,1686.3,35,,1686.3,percent of total billed charges,Implant Device,1686.3,35,,1686.3,percent of total billed charges,Implant Device,1686.3,35,,1686.3,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1638.12,34,"If Charge > 2,000, then 34 percent",1638.12,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3565.33,
JRF 1020-14 CTS TIBIALIS ANTERIOR TISSUE,C1762,HCPCS,,79001908,CDM,278,RC,,,both,,,5850,4329.01,,,4329.01,Other,150% of Medicare + 9.63% HCRA Surcharge,2632.5,45,,2632.5,percent of total billed charges,Critical Access Hospital RCC factor,1989,34,,1989,percent of total billed charges,Implant Device,1989,34,,1989,percent of total billed charges,Implant Device,1989,34,,1989,percent of total billed charges,Implant Device,1989,34,,1989,percent of total billed charges,Implant Device,1989,34,,1989,percent of total billed charges,Implant Device,2895.75,,,2895.75,Other,110% of Medicare,2047.5,35,,2047.5,percent of total billed charges,Implant Device,1989,34,"Charges > $500, x 34%",1989,percent of total billed charges,Implant Device,2047.5,35,,2047.5,percent of total billed charges,Implant Device,2047.5,35,,2047.5,percent of total billed charges,Implant Device,2047.5,35,,2047.5,percent of total billed charges,Implant Device,2047.5,35,,2047.5,percent of total billed charges,Implant Device,2047.5,35,,2047.5,percent of total billed charges,Implant Device,2340,40,,2340,percent of total billed charges,Implant Device,2047.5,70,,2047.5,percent of total billed charges,All Other,1989,34,,1989,percent of total billed charges,Implant Device,1989,34,,1989,percent of total billed charges,Implant Device,2047.5,35,,2047.5,percent of total billed charges,Implant Device,2047.5,35,,2047.5,percent of total billed charges,Implant Device,2047.5,35,,2047.5,percent of total billed charges,Implant Device,2047.5,35,,2047.5,percent of total billed charges,Implant Device,976.07,,,976.07,Other,100% of Medicaid,976.07,,,976.07,Other,100% of Medicaid,976.07,,,976.07,Other,100% of Medicaid,976.07,,,976.07,Other,100% of Medicaid,2196.16,,,2196.16,Other,225% of Medicaid,1493.39,,,1493.39,Other,153% of Medicaid,2196.16,,,2196.16,Other,225% of Medicaid,1366.5,,,1366.5,Other,140% of Medicaid,1989,34,"If Charge > 2,000, then 34 percent",1989,percent of total billed charges,Implants,2537.78,,,2537.78,Other,260% of Medicaid,3162.47,,,3162.47,Other,324% of Medicaid,2098.55,,,2098.55,Other,215% of Medicaid,2098.55,,,2098.55,Other,215% of Medicaid,1220.09,,,1220.09,Other,125% of Medicaid,976.07,4329.01,
JRF 1025-14-CTS ACHILLES TENDON TISSUE,C1762,HCPCS,,79001909,CDM,278,RC,,,both,,,5850,4329.01,,,4329.01,Other,150% of Medicare + 9.63% HCRA Surcharge,2632.5,45,,2632.5,percent of total billed charges,Critical Access Hospital RCC factor,1989,34,,1989,percent of total billed charges,Implant Device,1989,34,,1989,percent of total billed charges,Implant Device,1989,34,,1989,percent of total billed charges,Implant Device,1989,34,,1989,percent of total billed charges,Implant Device,1989,34,,1989,percent of total billed charges,Implant Device,2895.75,,,2895.75,Other,110% of Medicare,2047.5,35,,2047.5,percent of total billed charges,Implant Device,1989,34,"Charges > $500, x 34%",1989,percent of total billed charges,Implant Device,2047.5,35,,2047.5,percent of total billed charges,Implant Device,2047.5,35,,2047.5,percent of total billed charges,Implant Device,2047.5,35,,2047.5,percent of total billed charges,Implant Device,2047.5,35,,2047.5,percent of total billed charges,Implant Device,2047.5,35,,2047.5,percent of total billed charges,Implant Device,2340,40,,2340,percent of total billed charges,Implant Device,2047.5,70,,2047.5,percent of total billed charges,All Other,1989,34,,1989,percent of total billed charges,Implant Device,1989,34,,1989,percent of total billed charges,Implant Device,2047.5,35,,2047.5,percent of total billed charges,Implant Device,2047.5,35,,2047.5,percent of total billed charges,Implant Device,2047.5,35,,2047.5,percent of total billed charges,Implant Device,2047.5,35,,2047.5,percent of total billed charges,Implant Device,976.07,,,976.07,Other,100% of Medicaid,976.07,,,976.07,Other,100% of Medicaid,976.07,,,976.07,Other,100% of Medicaid,976.07,,,976.07,Other,100% of Medicaid,2196.16,,,2196.16,Other,225% of Medicaid,1493.39,,,1493.39,Other,153% of Medicaid,2196.16,,,2196.16,Other,225% of Medicaid,1366.5,,,1366.5,Other,140% of Medicaid,1989,34,"If Charge > 2,000, then 34 percent",1989,percent of total billed charges,Implants,2537.78,,,2537.78,Other,260% of Medicaid,3162.47,,,3162.47,Other,324% of Medicaid,2098.55,,,2098.55,Other,215% of Medicaid,2098.55,,,2098.55,Other,215% of Medicaid,1220.09,,,1220.09,Other,125% of Medicaid,976.07,4329.01,
BIOMET 11-107018-REV MOD HEAD,C1776,HCPCS,,79001910,CDM,278,RC,,,both,,,7920,5860.82,,,5860.82,Other,150% of Medicare + 9.63% HCRA Surcharge,3564,45,,3564,percent of total billed charges,Critical Access Hospital RCC factor,2692.8,34,,2692.8,percent of total billed charges,Implant Device,2692.8,34,,2692.8,percent of total billed charges,Implant Device,2692.8,34,,2692.8,percent of total billed charges,Implant Device,2692.8,34,,2692.8,percent of total billed charges,Implant Device,2692.8,34,,2692.8,percent of total billed charges,Implant Device,3920.4,,,3920.4,Other,110% of Medicare,2772,35,,2772,percent of total billed charges,Implant Device,2692.8,34,"Charges > $500, x 34%",2692.8,percent of total billed charges,Implant Device,2772,35,,2772,percent of total billed charges,Implant Device,2772,35,,2772,percent of total billed charges,Implant Device,2772,35,,2772,percent of total billed charges,Implant Device,2772,35,,2772,percent of total billed charges,Implant Device,2772,35,,2772,percent of total billed charges,Implant Device,3168,40,,3168,percent of total billed charges,Implant Device,2772,70,,2772,percent of total billed charges,All Other,2692.8,34,,2692.8,percent of total billed charges,Implant Device,2692.8,34,,2692.8,percent of total billed charges,Implant Device,2772,35,,2772,percent of total billed charges,Implant Device,2772,35,,2772,percent of total billed charges,Implant Device,2772,35,,2772,percent of total billed charges,Implant Device,2772,35,,2772,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2692.8,34,"If Charge > 2,000, then 34 percent",2692.8,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5860.82,
BIOMET 11-107019-REV MOD HEAD,C1776,HCPCS,,79001911,CDM,278,RC,,,both,,,4722,3494.29,,,3494.29,Other,150% of Medicare + 9.63% HCRA Surcharge,2124.9,45,,2124.9,percent of total billed charges,Critical Access Hospital RCC factor,1605.48,34,,1605.48,percent of total billed charges,Implant Device,1605.48,34,,1605.48,percent of total billed charges,Implant Device,1605.48,34,,1605.48,percent of total billed charges,Implant Device,1605.48,34,,1605.48,percent of total billed charges,Implant Device,1605.48,34,,1605.48,percent of total billed charges,Implant Device,2337.39,,,2337.39,Other,110% of Medicare,1652.7,35,,1652.7,percent of total billed charges,Implant Device,1605.48,34,"Charges > $500, x 34%",1605.48,percent of total billed charges,Implant Device,1652.7,35,,1652.7,percent of total billed charges,Implant Device,1652.7,35,,1652.7,percent of total billed charges,Implant Device,1652.7,35,,1652.7,percent of total billed charges,Implant Device,1652.7,35,,1652.7,percent of total billed charges,Implant Device,1652.7,35,,1652.7,percent of total billed charges,Implant Device,1888.8,40,,1888.8,percent of total billed charges,Implant Device,1652.7,70,,1652.7,percent of total billed charges,All Other,1605.48,34,,1605.48,percent of total billed charges,Implant Device,1605.48,34,,1605.48,percent of total billed charges,Implant Device,1652.7,35,,1652.7,percent of total billed charges,Implant Device,1652.7,35,,1652.7,percent of total billed charges,Implant Device,1652.7,35,,1652.7,percent of total billed charges,Implant Device,1652.7,35,,1652.7,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1605.48,34,"If Charge > 2,000, then 34 percent",1605.48,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3494.29,
BIOMET 11-107122-REV ACETABULAR CUP,C1776,HCPCS,,79001912,CDM,278,RC,,,both,,,7714,5708.38,,,5708.38,Other,150% of Medicare + 9.63% HCRA Surcharge,3471.3,45,,3471.3,percent of total billed charges,Critical Access Hospital RCC factor,2622.76,34,,2622.76,percent of total billed charges,Implant Device,2622.76,34,,2622.76,percent of total billed charges,Implant Device,2622.76,34,,2622.76,percent of total billed charges,Implant Device,2622.76,34,,2622.76,percent of total billed charges,Implant Device,2622.76,34,,2622.76,percent of total billed charges,Implant Device,3818.43,,,3818.43,Other,110% of Medicare,2699.9,35,,2699.9,percent of total billed charges,Implant Device,2622.76,34,"Charges > $500, x 34%",2622.76,percent of total billed charges,Implant Device,2699.9,35,,2699.9,percent of total billed charges,Implant Device,2699.9,35,,2699.9,percent of total billed charges,Implant Device,2699.9,35,,2699.9,percent of total billed charges,Implant Device,2699.9,35,,2699.9,percent of total billed charges,Implant Device,2699.9,35,,2699.9,percent of total billed charges,Implant Device,3085.6,40,,3085.6,percent of total billed charges,Implant Device,2699.9,70,,2699.9,percent of total billed charges,All Other,2622.76,34,,2622.76,percent of total billed charges,Implant Device,2622.76,34,,2622.76,percent of total billed charges,Implant Device,2699.9,35,,2699.9,percent of total billed charges,Implant Device,2699.9,35,,2699.9,percent of total billed charges,Implant Device,2699.9,35,,2699.9,percent of total billed charges,Implant Device,2699.9,35,,2699.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2622.76,34,"If Charge > 2,000, then 34 percent",2622.76,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5708.38,
BIOMET 11-113556 HUMERAL FRACTURE STEM,C1776,HCPCS,,79001913,CDM,278,RC,,,both,,,19710,14585.45,,,14585.45,Other,150% of Medicare + 9.63% HCRA Surcharge,8869.5,45,,8869.5,percent of total billed charges,Critical Access Hospital RCC factor,6701.4,34,,6701.4,percent of total billed charges,Implant Device,6701.4,34,,6701.4,percent of total billed charges,Implant Device,6701.4,34,,6701.4,percent of total billed charges,Implant Device,6701.4,34,,6701.4,percent of total billed charges,Implant Device,6701.4,34,,6701.4,percent of total billed charges,Implant Device,9756.45,,,9756.45,Other,110% of Medicare,6898.5,35,,6898.5,percent of total billed charges,Implant Device,6701.4,34,"Charges > $500, x 34%",6701.4,percent of total billed charges,Implant Device,6898.5,35,,6898.5,percent of total billed charges,Implant Device,6898.5,35,,6898.5,percent of total billed charges,Implant Device,6898.5,35,,6898.5,percent of total billed charges,Implant Device,6898.5,35,,6898.5,percent of total billed charges,Implant Device,6898.5,35,,6898.5,percent of total billed charges,Implant Device,7884,40,,7884,percent of total billed charges,Implant Device,6898.5,70,,6898.5,percent of total billed charges,All Other,6701.4,34,,6701.4,percent of total billed charges,Implant Device,6701.4,34,,6701.4,percent of total billed charges,Implant Device,6898.5,35,,6898.5,percent of total billed charges,Implant Device,6898.5,35,,6898.5,percent of total billed charges,Implant Device,6898.5,35,,6898.5,percent of total billed charges,Implant Device,6898.5,35,,6898.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,6701.4,34,"If Charge > 2,000, then 34 percent",6701.4,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,14585.45,
BIOMET 11-300920 DISTAL STEM,C1776,HCPCS,,79001914,CDM,278,RC,,,both,,,11059,8183.69,,,8183.69,Other,150% of Medicare + 9.63% HCRA Surcharge,4976.55,45,,4976.55,percent of total billed charges,Critical Access Hospital RCC factor,3760.06,34,,3760.06,percent of total billed charges,Implant Device,3760.06,34,,3760.06,percent of total billed charges,Implant Device,3760.06,34,,3760.06,percent of total billed charges,Implant Device,3760.06,34,,3760.06,percent of total billed charges,Implant Device,3760.06,34,,3760.06,percent of total billed charges,Implant Device,5474.21,,,5474.21,Other,110% of Medicare,3870.65,35,,3870.65,percent of total billed charges,Implant Device,3760.06,34,"Charges > $500, x 34%",3760.06,percent of total billed charges,Implant Device,3870.65,35,,3870.65,percent of total billed charges,Implant Device,3870.65,35,,3870.65,percent of total billed charges,Implant Device,3870.65,35,,3870.65,percent of total billed charges,Implant Device,3870.65,35,,3870.65,percent of total billed charges,Implant Device,3870.65,35,,3870.65,percent of total billed charges,Implant Device,4423.6,40,,4423.6,percent of total billed charges,Implant Device,3870.65,70,,3870.65,percent of total billed charges,All Other,3760.06,34,,3760.06,percent of total billed charges,Implant Device,3760.06,34,,3760.06,percent of total billed charges,Implant Device,3870.65,35,,3870.65,percent of total billed charges,Implant Device,3870.65,35,,3870.65,percent of total billed charges,Implant Device,3870.65,35,,3870.65,percent of total billed charges,Implant Device,3870.65,35,,3870.65,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3760.06,34,"If Charge > 2,000, then 34 percent",3760.06,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,8183.69,
ZIMMER 1179-05-10-REV PLATE,C1713,HCPCS,,79001915,CDM,278,RC,,,both,,,1224,905.76,,,905.76,Other,150% of Medicare + 9.63% HCRA Surcharge,550.8,45,,550.8,percent of total billed charges,Critical Access Hospital RCC factor,416.16,34,,416.16,percent of total billed charges,Implant Device,416.16,34,,416.16,percent of total billed charges,Implant Device,416.16,34,,416.16,percent of total billed charges,Implant Device,416.16,34,,416.16,percent of total billed charges,Implant Device,416.16,34,,416.16,percent of total billed charges,Implant Device,605.88,,,605.88,Other,110% of Medicare,428.4,35,,428.4,percent of total billed charges,Implant Device,416.16,34,"Charges > $500, x 34%",416.16,percent of total billed charges,Implant Device,428.4,35,,428.4,percent of total billed charges,Implant Device,428.4,35,,428.4,percent of total billed charges,Implant Device,428.4,35,,428.4,percent of total billed charges,Implant Device,428.4,35,,428.4,percent of total billed charges,Implant Device,428.4,35,,428.4,percent of total billed charges,Implant Device,489.6,40,,489.6,percent of total billed charges,Implant Device,428.4,70,,428.4,percent of total billed charges,All Other,416.16,34,,416.16,percent of total billed charges,Implant Device,416.16,34,,416.16,percent of total billed charges,Implant Device,428.4,35,,428.4,percent of total billed charges,Implant Device,428.4,35,,428.4,percent of total billed charges,Implant Device,428.4,35,,428.4,percent of total billed charges,Implant Device,428.4,35,,428.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,905.76,
BIOMET 12-139010 ENDO II HEAD,C1776,HCPCS,,79001916,CDM,278,RC,,,both,,,2280,1687.21,,,1687.21,Other,150% of Medicare + 9.63% HCRA Surcharge,1026,45,,1026,percent of total billed charges,Critical Access Hospital RCC factor,775.2,34,,775.2,percent of total billed charges,Implant Device,775.2,34,,775.2,percent of total billed charges,Implant Device,775.2,34,,775.2,percent of total billed charges,Implant Device,775.2,34,,775.2,percent of total billed charges,Implant Device,775.2,34,,775.2,percent of total billed charges,Implant Device,1128.6,,,1128.6,Other,110% of Medicare,798,35,,798,percent of total billed charges,Implant Device,775.2,34,"Charges > $500, x 34%",775.2,percent of total billed charges,Implant Device,798,35,,798,percent of total billed charges,Implant Device,798,35,,798,percent of total billed charges,Implant Device,798,35,,798,percent of total billed charges,Implant Device,798,35,,798,percent of total billed charges,Implant Device,798,35,,798,percent of total billed charges,Implant Device,912,40,,912,percent of total billed charges,Implant Device,798,70,,798,percent of total billed charges,All Other,775.2,34,,775.2,percent of total billed charges,Implant Device,775.2,34,,775.2,percent of total billed charges,Implant Device,798,35,,798,percent of total billed charges,Implant Device,798,35,,798,percent of total billed charges,Implant Device,798,35,,798,percent of total billed charges,Implant Device,798,35,,798,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,775.2,34,"If Charge > 2,000, then 34 percent",775.2,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1687.21,
BIOMET 12-139014 ENDO II HEAD,C1776,HCPCS,,79001917,CDM,278,RC,,,both,,,2280,1687.21,,,1687.21,Other,150% of Medicare + 9.63% HCRA Surcharge,1026,45,,1026,percent of total billed charges,Critical Access Hospital RCC factor,775.2,34,,775.2,percent of total billed charges,Implant Device,775.2,34,,775.2,percent of total billed charges,Implant Device,775.2,34,,775.2,percent of total billed charges,Implant Device,775.2,34,,775.2,percent of total billed charges,Implant Device,775.2,34,,775.2,percent of total billed charges,Implant Device,1128.6,,,1128.6,Other,110% of Medicare,798,35,,798,percent of total billed charges,Implant Device,775.2,34,"Charges > $500, x 34%",775.2,percent of total billed charges,Implant Device,798,35,,798,percent of total billed charges,Implant Device,798,35,,798,percent of total billed charges,Implant Device,798,35,,798,percent of total billed charges,Implant Device,798,35,,798,percent of total billed charges,Implant Device,798,35,,798,percent of total billed charges,Implant Device,912,40,,912,percent of total billed charges,Implant Device,798,70,,798,percent of total billed charges,All Other,775.2,34,,775.2,percent of total billed charges,Implant Device,775.2,34,,775.2,percent of total billed charges,Implant Device,798,35,,798,percent of total billed charges,Implant Device,798,35,,798,percent of total billed charges,Implant Device,798,35,,798,percent of total billed charges,Implant Device,798,35,,798,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,775.2,34,"If Charge > 2,000, then 34 percent",775.2,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1687.21,
DEPUY 12-139022 ENDO II HEAD,C1776,HCPCS,,79001918,CDM,278,RC,,,both,,,1380,1021.2,,,1021.2,Other,150% of Medicare + 9.63% HCRA Surcharge,621,45,,621,percent of total billed charges,Critical Access Hospital RCC factor,469.2,34,,469.2,percent of total billed charges,Implant Device,469.2,34,,469.2,percent of total billed charges,Implant Device,469.2,34,,469.2,percent of total billed charges,Implant Device,469.2,34,,469.2,percent of total billed charges,Implant Device,469.2,34,,469.2,percent of total billed charges,Implant Device,683.1,,,683.1,Other,110% of Medicare,483,35,,483,percent of total billed charges,Implant Device,469.2,34,"Charges > $500, x 34%",469.2,percent of total billed charges,Implant Device,483,35,,483,percent of total billed charges,Implant Device,483,35,,483,percent of total billed charges,Implant Device,483,35,,483,percent of total billed charges,Implant Device,483,35,,483,percent of total billed charges,Implant Device,483,35,,483,percent of total billed charges,Implant Device,552,40,,552,percent of total billed charges,Implant Device,483,70,,483,percent of total billed charges,All Other,469.2,34,,469.2,percent of total billed charges,Implant Device,469.2,34,,469.2,percent of total billed charges,Implant Device,483,35,,483,percent of total billed charges,Implant Device,483,35,,483,percent of total billed charges,Implant Device,483,35,,483,percent of total billed charges,Implant Device,483,35,,483,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1021.2,
BIOMET 12-139024 ENDO II HEAD,C1776,HCPCS,,79001919,CDM,278,RC,,,both,,,2280,1687.21,,,1687.21,Other,150% of Medicare + 9.63% HCRA Surcharge,1026,45,,1026,percent of total billed charges,Critical Access Hospital RCC factor,775.2,34,,775.2,percent of total billed charges,Implant Device,775.2,34,,775.2,percent of total billed charges,Implant Device,775.2,34,,775.2,percent of total billed charges,Implant Device,775.2,34,,775.2,percent of total billed charges,Implant Device,775.2,34,,775.2,percent of total billed charges,Implant Device,1128.6,,,1128.6,Other,110% of Medicare,798,35,,798,percent of total billed charges,Implant Device,775.2,34,"Charges > $500, x 34%",775.2,percent of total billed charges,Implant Device,798,35,,798,percent of total billed charges,Implant Device,798,35,,798,percent of total billed charges,Implant Device,798,35,,798,percent of total billed charges,Implant Device,798,35,,798,percent of total billed charges,Implant Device,798,35,,798,percent of total billed charges,Implant Device,912,40,,912,percent of total billed charges,Implant Device,798,70,,798,percent of total billed charges,All Other,775.2,34,,775.2,percent of total billed charges,Implant Device,775.2,34,,775.2,percent of total billed charges,Implant Device,798,35,,798,percent of total billed charges,Implant Device,798,35,,798,percent of total billed charges,Implant Device,798,35,,798,percent of total billed charges,Implant Device,798,35,,798,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,775.2,34,"If Charge > 2,000, then 34 percent",775.2,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1687.21,
BIOMET 12-139026 ENDO II HEAD,C1776,HCPCS,,79001920,CDM,278,RC,,,both,,,2280,1687.21,,,1687.21,Other,150% of Medicare + 9.63% HCRA Surcharge,1026,45,,1026,percent of total billed charges,Critical Access Hospital RCC factor,775.2,34,,775.2,percent of total billed charges,Implant Device,775.2,34,,775.2,percent of total billed charges,Implant Device,775.2,34,,775.2,percent of total billed charges,Implant Device,775.2,34,,775.2,percent of total billed charges,Implant Device,775.2,34,,775.2,percent of total billed charges,Implant Device,1128.6,,,1128.6,Other,110% of Medicare,798,35,,798,percent of total billed charges,Implant Device,775.2,34,"Charges > $500, x 34%",775.2,percent of total billed charges,Implant Device,798,35,,798,percent of total billed charges,Implant Device,798,35,,798,percent of total billed charges,Implant Device,798,35,,798,percent of total billed charges,Implant Device,798,35,,798,percent of total billed charges,Implant Device,798,35,,798,percent of total billed charges,Implant Device,912,40,,912,percent of total billed charges,Implant Device,798,70,,798,percent of total billed charges,All Other,775.2,34,,775.2,percent of total billed charges,Implant Device,775.2,34,,775.2,percent of total billed charges,Implant Device,798,35,,798,percent of total billed charges,Implant Device,798,35,,798,percent of total billed charges,Implant Device,798,35,,798,percent of total billed charges,Implant Device,798,35,,798,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,775.2,34,"If Charge > 2,000, then 34 percent",775.2,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1687.21,
BIOMET 12-139028 ENDO II HEAD,C1776,HCPCS,,79001921,CDM,278,RC,,,both,,,2280,1687.21,,,1687.21,Other,150% of Medicare + 9.63% HCRA Surcharge,1026,45,,1026,percent of total billed charges,Critical Access Hospital RCC factor,775.2,34,,775.2,percent of total billed charges,Implant Device,775.2,34,,775.2,percent of total billed charges,Implant Device,775.2,34,,775.2,percent of total billed charges,Implant Device,775.2,34,,775.2,percent of total billed charges,Implant Device,775.2,34,,775.2,percent of total billed charges,Implant Device,1128.6,,,1128.6,Other,110% of Medicare,798,35,,798,percent of total billed charges,Implant Device,775.2,34,"Charges > $500, x 34%",775.2,percent of total billed charges,Implant Device,798,35,,798,percent of total billed charges,Implant Device,798,35,,798,percent of total billed charges,Implant Device,798,35,,798,percent of total billed charges,Implant Device,798,35,,798,percent of total billed charges,Implant Device,798,35,,798,percent of total billed charges,Implant Device,912,40,,912,percent of total billed charges,Implant Device,798,70,,798,percent of total billed charges,All Other,775.2,34,,775.2,percent of total billed charges,Implant Device,775.2,34,,775.2,percent of total billed charges,Implant Device,798,35,,798,percent of total billed charges,Implant Device,798,35,,798,percent of total billed charges,Implant Device,798,35,,798,percent of total billed charges,Implant Device,798,35,,798,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,775.2,34,"If Charge > 2,000, then 34 percent",775.2,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1687.21,
BIOMET 12-139030 ENDO II HEAD 53MM,C1776,HCPCS,,79001922,CDM,278,RC,,,both,,,2280,1687.21,,,1687.21,Other,150% of Medicare + 9.63% HCRA Surcharge,1026,45,,1026,percent of total billed charges,Critical Access Hospital RCC factor,775.2,34,,775.2,percent of total billed charges,Implant Device,775.2,34,,775.2,percent of total billed charges,Implant Device,775.2,34,,775.2,percent of total billed charges,Implant Device,775.2,34,,775.2,percent of total billed charges,Implant Device,775.2,34,,775.2,percent of total billed charges,Implant Device,1128.6,,,1128.6,Other,110% of Medicare,798,35,,798,percent of total billed charges,Implant Device,775.2,34,"Charges > $500, x 34%",775.2,percent of total billed charges,Implant Device,798,35,,798,percent of total billed charges,Implant Device,798,35,,798,percent of total billed charges,Implant Device,798,35,,798,percent of total billed charges,Implant Device,798,35,,798,percent of total billed charges,Implant Device,798,35,,798,percent of total billed charges,Implant Device,912,40,,912,percent of total billed charges,Implant Device,798,70,,798,percent of total billed charges,All Other,775.2,34,,775.2,percent of total billed charges,Implant Device,775.2,34,,775.2,percent of total billed charges,Implant Device,798,35,,798,percent of total billed charges,Implant Device,798,35,,798,percent of total billed charges,Implant Device,798,35,,798,percent of total billed charges,Implant Device,798,35,,798,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,775.2,34,"If Charge > 2,000, then 34 percent",775.2,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1687.21,
DEPUY 12-150309 FEMORAL HEAD,C1776,HCPCS,,79001923,CDM,278,RC,,,both,,,15240,11277.64,,,11277.64,Other,150% of Medicare + 9.63% HCRA Surcharge,6858,45,,6858,percent of total billed charges,Critical Access Hospital RCC factor,5181.6,34,,5181.6,percent of total billed charges,Implant Device,5181.6,34,,5181.6,percent of total billed charges,Implant Device,5181.6,34,,5181.6,percent of total billed charges,Implant Device,5181.6,34,,5181.6,percent of total billed charges,Implant Device,5181.6,34,,5181.6,percent of total billed charges,Implant Device,7543.8,,,7543.8,Other,110% of Medicare,5334,35,,5334,percent of total billed charges,Implant Device,5181.6,34,"Charges > $500, x 34%",5181.6,percent of total billed charges,Implant Device,5334,35,,5334,percent of total billed charges,Implant Device,5334,35,,5334,percent of total billed charges,Implant Device,5334,35,,5334,percent of total billed charges,Implant Device,5334,35,,5334,percent of total billed charges,Implant Device,5334,35,,5334,percent of total billed charges,Implant Device,6096,40,,6096,percent of total billed charges,Implant Device,5334,70,,5334,percent of total billed charges,All Other,5181.6,34,,5181.6,percent of total billed charges,Implant Device,5181.6,34,,5181.6,percent of total billed charges,Implant Device,5334,35,,5334,percent of total billed charges,Implant Device,5334,35,,5334,percent of total billed charges,Implant Device,5334,35,,5334,percent of total billed charges,Implant Device,5334,35,,5334,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,5181.6,34,"If Charge > 2,000, then 34 percent",5181.6,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,11277.64,
BIOMET 12-150311 FEMORAL COMPONENT,C1776,HCPCS,,79001924,CDM,278,RC,,,both,,,15240,11277.64,,,11277.64,Other,150% of Medicare + 9.63% HCRA Surcharge,6858,45,,6858,percent of total billed charges,Critical Access Hospital RCC factor,5181.6,34,,5181.6,percent of total billed charges,Implant Device,5181.6,34,,5181.6,percent of total billed charges,Implant Device,5181.6,34,,5181.6,percent of total billed charges,Implant Device,5181.6,34,,5181.6,percent of total billed charges,Implant Device,5181.6,34,,5181.6,percent of total billed charges,Implant Device,7543.8,,,7543.8,Other,110% of Medicare,5334,35,,5334,percent of total billed charges,Implant Device,5181.6,34,"Charges > $500, x 34%",5181.6,percent of total billed charges,Implant Device,5334,35,,5334,percent of total billed charges,Implant Device,5334,35,,5334,percent of total billed charges,Implant Device,5334,35,,5334,percent of total billed charges,Implant Device,5334,35,,5334,percent of total billed charges,Implant Device,5334,35,,5334,percent of total billed charges,Implant Device,6096,40,,6096,percent of total billed charges,Implant Device,5334,70,,5334,percent of total billed charges,All Other,5181.6,34,,5181.6,percent of total billed charges,Implant Device,5181.6,34,,5181.6,percent of total billed charges,Implant Device,5334,35,,5334,percent of total billed charges,Implant Device,5334,35,,5334,percent of total billed charges,Implant Device,5334,35,,5334,percent of total billed charges,Implant Device,5334,35,,5334,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,5181.6,34,"If Charge > 2,000, then 34 percent",5181.6,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,11277.64,
BIOMET 12-151307 FEMORAL COMPONENT,C1776,HCPCS,,79001925,CDM,278,RC,,,both,,,8820,6526.82,,,6526.82,Other,150% of Medicare + 9.63% HCRA Surcharge,3969,45,,3969,percent of total billed charges,Critical Access Hospital RCC factor,2998.8,34,,2998.8,percent of total billed charges,Implant Device,2998.8,34,,2998.8,percent of total billed charges,Implant Device,2998.8,34,,2998.8,percent of total billed charges,Implant Device,2998.8,34,,2998.8,percent of total billed charges,Implant Device,2998.8,34,,2998.8,percent of total billed charges,Implant Device,4365.9,,,4365.9,Other,110% of Medicare,3087,35,,3087,percent of total billed charges,Implant Device,2998.8,34,"Charges > $500, x 34%",2998.8,percent of total billed charges,Implant Device,3087,35,,3087,percent of total billed charges,Implant Device,3087,35,,3087,percent of total billed charges,Implant Device,3087,35,,3087,percent of total billed charges,Implant Device,3087,35,,3087,percent of total billed charges,Implant Device,3087,35,,3087,percent of total billed charges,Implant Device,3528,40,,3528,percent of total billed charges,Implant Device,3087,70,,3087,percent of total billed charges,All Other,2998.8,34,,2998.8,percent of total billed charges,Implant Device,2998.8,34,,2998.8,percent of total billed charges,Implant Device,3087,35,,3087,percent of total billed charges,Implant Device,3087,35,,3087,percent of total billed charges,Implant Device,3087,35,,3087,percent of total billed charges,Implant Device,3087,35,,3087,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2998.8,34,"If Charge > 2,000, then 34 percent",2998.8,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,6526.82,
BIOMET 12-151309 FEMORAL COMP 9X130MM,C1776,HCPCS,,79001926,CDM,278,RC,,,both,,,8820,6526.82,,,6526.82,Other,150% of Medicare + 9.63% HCRA Surcharge,3969,45,,3969,percent of total billed charges,Critical Access Hospital RCC factor,2998.8,34,,2998.8,percent of total billed charges,Implant Device,2998.8,34,,2998.8,percent of total billed charges,Implant Device,2998.8,34,,2998.8,percent of total billed charges,Implant Device,2998.8,34,,2998.8,percent of total billed charges,Implant Device,2998.8,34,,2998.8,percent of total billed charges,Implant Device,4365.9,,,4365.9,Other,110% of Medicare,3087,35,,3087,percent of total billed charges,Implant Device,2998.8,34,"Charges > $500, x 34%",2998.8,percent of total billed charges,Implant Device,3087,35,,3087,percent of total billed charges,Implant Device,3087,35,,3087,percent of total billed charges,Implant Device,3087,35,,3087,percent of total billed charges,Implant Device,3087,35,,3087,percent of total billed charges,Implant Device,3087,35,,3087,percent of total billed charges,Implant Device,3528,40,,3528,percent of total billed charges,Implant Device,3087,70,,3087,percent of total billed charges,All Other,2998.8,34,,2998.8,percent of total billed charges,Implant Device,2998.8,34,,2998.8,percent of total billed charges,Implant Device,3087,35,,3087,percent of total billed charges,Implant Device,3087,35,,3087,percent of total billed charges,Implant Device,3087,35,,3087,percent of total billed charges,Implant Device,3087,35,,3087,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2998.8,34,"If Charge > 2,000, then 34 percent",2998.8,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,6526.82,
BIOMET 12-151313 FEMORAL COMP 13X150MM,C1776,HCPCS,,79001927,CDM,278,RC,,,both,,,8820,6526.82,,,6526.82,Other,150% of Medicare + 9.63% HCRA Surcharge,3969,45,,3969,percent of total billed charges,Critical Access Hospital RCC factor,2998.8,34,,2998.8,percent of total billed charges,Implant Device,2998.8,34,,2998.8,percent of total billed charges,Implant Device,2998.8,34,,2998.8,percent of total billed charges,Implant Device,2998.8,34,,2998.8,percent of total billed charges,Implant Device,2998.8,34,,2998.8,percent of total billed charges,Implant Device,4365.9,,,4365.9,Other,110% of Medicare,3087,35,,3087,percent of total billed charges,Implant Device,2998.8,34,"Charges > $500, x 34%",2998.8,percent of total billed charges,Implant Device,3087,35,,3087,percent of total billed charges,Implant Device,3087,35,,3087,percent of total billed charges,Implant Device,3087,35,,3087,percent of total billed charges,Implant Device,3087,35,,3087,percent of total billed charges,Implant Device,3087,35,,3087,percent of total billed charges,Implant Device,3528,40,,3528,percent of total billed charges,Implant Device,3087,70,,3087,percent of total billed charges,All Other,2998.8,34,,2998.8,percent of total billed charges,Implant Device,2998.8,34,,2998.8,percent of total billed charges,Implant Device,3087,35,,3087,percent of total billed charges,Implant Device,3087,35,,3087,percent of total billed charges,Implant Device,3087,35,,3087,percent of total billed charges,Implant Device,3087,35,,3087,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2998.8,34,"If Charge > 2,000, then 34 percent",2998.8,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,6526.82,
DEPUY 1221-36-158-REV ACETABULAR LINER,C1776,HCPCS,,79001928,CDM,278,RC,,,both,,,5109,3780.67,,,3780.67,Other,150% of Medicare + 9.63% HCRA Surcharge,2299.05,45,,2299.05,percent of total billed charges,Critical Access Hospital RCC factor,1737.06,34,,1737.06,percent of total billed charges,Implant Device,1737.06,34,,1737.06,percent of total billed charges,Implant Device,1737.06,34,,1737.06,percent of total billed charges,Implant Device,1737.06,34,,1737.06,percent of total billed charges,Implant Device,1737.06,34,,1737.06,percent of total billed charges,Implant Device,2528.96,,,2528.96,Other,110% of Medicare,1788.15,35,,1788.15,percent of total billed charges,Implant Device,1737.06,34,"Charges > $500, x 34%",1737.06,percent of total billed charges,Implant Device,1788.15,35,,1788.15,percent of total billed charges,Implant Device,1788.15,35,,1788.15,percent of total billed charges,Implant Device,1788.15,35,,1788.15,percent of total billed charges,Implant Device,1788.15,35,,1788.15,percent of total billed charges,Implant Device,1788.15,35,,1788.15,percent of total billed charges,Implant Device,2043.6,40,,2043.6,percent of total billed charges,Implant Device,1788.15,70,,1788.15,percent of total billed charges,All Other,1737.06,34,,1737.06,percent of total billed charges,Implant Device,1737.06,34,,1737.06,percent of total billed charges,Implant Device,1788.15,35,,1788.15,percent of total billed charges,Implant Device,1788.15,35,,1788.15,percent of total billed charges,Implant Device,1788.15,35,,1788.15,percent of total billed charges,Implant Device,1788.15,35,,1788.15,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1737.06,34,"If Charge > 2,000, then 34 percent",1737.06,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3780.67,
DEPUY 1294-35-125-REV TIBIAL TRAY,C1776,HCPCS,,79001929,CDM,278,RC,,,both,,,19157,14176.23,,,14176.23,Other,150% of Medicare + 9.63% HCRA Surcharge,8620.65,45,,8620.65,percent of total billed charges,Critical Access Hospital RCC factor,6513.38,34,,6513.38,percent of total billed charges,Implant Device,6513.38,34,,6513.38,percent of total billed charges,Implant Device,6513.38,34,,6513.38,percent of total billed charges,Implant Device,6513.38,34,,6513.38,percent of total billed charges,Implant Device,6513.38,34,,6513.38,percent of total billed charges,Implant Device,9482.72,,,9482.72,Other,110% of Medicare,6704.95,35,,6704.95,percent of total billed charges,Implant Device,6513.38,34,"Charges > $500, x 34%",6513.38,percent of total billed charges,Implant Device,6704.95,35,,6704.95,percent of total billed charges,Implant Device,6704.95,35,,6704.95,percent of total billed charges,Implant Device,6704.95,35,,6704.95,percent of total billed charges,Implant Device,6704.95,35,,6704.95,percent of total billed charges,Implant Device,6704.95,35,,6704.95,percent of total billed charges,Implant Device,7662.8,40,,7662.8,percent of total billed charges,Implant Device,6704.95,70,,6704.95,percent of total billed charges,All Other,6513.38,34,,6513.38,percent of total billed charges,Implant Device,6513.38,34,,6513.38,percent of total billed charges,Implant Device,6704.95,35,,6704.95,percent of total billed charges,Implant Device,6704.95,35,,6704.95,percent of total billed charges,Implant Device,6704.95,35,,6704.95,percent of total billed charges,Implant Device,6704.95,35,,6704.95,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,6513.38,34,"If Charge > 2,000, then 34 percent",6513.38,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,14176.23,
DEPUY 1294-35-130-REV TIBIAL TRAY,C1776,HCPCS,,79001930,CDM,278,RC,,,both,,,21319,15776.11,,,15776.11,Other,150% of Medicare + 9.63% HCRA Surcharge,9593.55,45,,9593.55,percent of total billed charges,Critical Access Hospital RCC factor,7248.46,34,,7248.46,percent of total billed charges,Implant Device,7248.46,34,,7248.46,percent of total billed charges,Implant Device,7248.46,34,,7248.46,percent of total billed charges,Implant Device,7248.46,34,,7248.46,percent of total billed charges,Implant Device,7248.46,34,,7248.46,percent of total billed charges,Implant Device,10552.91,,,10552.91,Other,110% of Medicare,7461.65,35,,7461.65,percent of total billed charges,Implant Device,7248.46,34,"Charges > $500, x 34%",7248.46,percent of total billed charges,Implant Device,7461.65,35,,7461.65,percent of total billed charges,Implant Device,7461.65,35,,7461.65,percent of total billed charges,Implant Device,7461.65,35,,7461.65,percent of total billed charges,Implant Device,7461.65,35,,7461.65,percent of total billed charges,Implant Device,7461.65,35,,7461.65,percent of total billed charges,Implant Device,8527.6,40,,8527.6,percent of total billed charges,Implant Device,7461.65,70,,7461.65,percent of total billed charges,All Other,7248.46,34,,7248.46,percent of total billed charges,Implant Device,7248.46,34,,7248.46,percent of total billed charges,Implant Device,7461.65,35,,7461.65,percent of total billed charges,Implant Device,7461.65,35,,7461.65,percent of total billed charges,Implant Device,7461.65,35,,7461.65,percent of total billed charges,Implant Device,7461.65,35,,7461.65,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,7248.46,34,"If Charge > 2,000, then 34 percent",7248.46,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,15776.11,
DEPUY 1294-35-140-REV TIBIAL TRAY,C1776,HCPCS,,79001931,CDM,278,RC,,,both,,,15538,11498.16,,,11498.16,Other,150% of Medicare + 9.63% HCRA Surcharge,6992.1,45,,6992.1,percent of total billed charges,Critical Access Hospital RCC factor,5282.92,34,,5282.92,percent of total billed charges,Implant Device,5282.92,34,,5282.92,percent of total billed charges,Implant Device,5282.92,34,,5282.92,percent of total billed charges,Implant Device,5282.92,34,,5282.92,percent of total billed charges,Implant Device,5282.92,34,,5282.92,percent of total billed charges,Implant Device,7691.31,,,7691.31,Other,110% of Medicare,5438.3,35,,5438.3,percent of total billed charges,Implant Device,5282.92,34,"Charges > $500, x 34%",5282.92,percent of total billed charges,Implant Device,5438.3,35,,5438.3,percent of total billed charges,Implant Device,5438.3,35,,5438.3,percent of total billed charges,Implant Device,5438.3,35,,5438.3,percent of total billed charges,Implant Device,5438.3,35,,5438.3,percent of total billed charges,Implant Device,5438.3,35,,5438.3,percent of total billed charges,Implant Device,6215.2,40,,6215.2,percent of total billed charges,Implant Device,5438.3,70,,5438.3,percent of total billed charges,All Other,5282.92,34,,5282.92,percent of total billed charges,Implant Device,5282.92,34,,5282.92,percent of total billed charges,Implant Device,5438.3,35,,5438.3,percent of total billed charges,Implant Device,5438.3,35,,5438.3,percent of total billed charges,Implant Device,5438.3,35,,5438.3,percent of total billed charges,Implant Device,5438.3,35,,5438.3,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,5282.92,34,"If Charge > 2,000, then 34 percent",5282.92,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,11498.16,
DEPUY 1294-45-120-REV TRAY SLEEVE,C1776,HCPCS,,79001932,CDM,278,RC,,,both,,,9565,7078.12,,,7078.12,Other,150% of Medicare + 9.63% HCRA Surcharge,4304.25,45,,4304.25,percent of total billed charges,Critical Access Hospital RCC factor,3252.1,34,,3252.1,percent of total billed charges,Implant Device,3252.1,34,,3252.1,percent of total billed charges,Implant Device,3252.1,34,,3252.1,percent of total billed charges,Implant Device,3252.1,34,,3252.1,percent of total billed charges,Implant Device,3252.1,34,,3252.1,percent of total billed charges,Implant Device,4734.68,,,4734.68,Other,110% of Medicare,3347.75,35,,3347.75,percent of total billed charges,Implant Device,3252.1,34,"Charges > $500, x 34%",3252.1,percent of total billed charges,Implant Device,3347.75,35,,3347.75,percent of total billed charges,Implant Device,3347.75,35,,3347.75,percent of total billed charges,Implant Device,3347.75,35,,3347.75,percent of total billed charges,Implant Device,3347.75,35,,3347.75,percent of total billed charges,Implant Device,3347.75,35,,3347.75,percent of total billed charges,Implant Device,3826,40,,3826,percent of total billed charges,Implant Device,3347.75,70,,3347.75,percent of total billed charges,All Other,3252.1,34,,3252.1,percent of total billed charges,Implant Device,3252.1,34,,3252.1,percent of total billed charges,Implant Device,3347.75,35,,3347.75,percent of total billed charges,Implant Device,3347.75,35,,3347.75,percent of total billed charges,Implant Device,3347.75,35,,3347.75,percent of total billed charges,Implant Device,3347.75,35,,3347.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3252.1,34,"If Charge > 2,000, then 34 percent",3252.1,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,7078.12,
DEPUY 1294-53-216-REV FEMORAL SLEEVE,C1776,HCPCS,,79001933,CDM,278,RC,,,both,,,9797,7249.8,,,7249.8,Other,150% of Medicare + 9.63% HCRA Surcharge,4408.65,45,,4408.65,percent of total billed charges,Critical Access Hospital RCC factor,3330.98,34,,3330.98,percent of total billed charges,Implant Device,3330.98,34,,3330.98,percent of total billed charges,Implant Device,3330.98,34,,3330.98,percent of total billed charges,Implant Device,3330.98,34,,3330.98,percent of total billed charges,Implant Device,3330.98,34,,3330.98,percent of total billed charges,Implant Device,4849.52,,,4849.52,Other,110% of Medicare,3428.95,35,,3428.95,percent of total billed charges,Implant Device,3330.98,34,"Charges > $500, x 34%",3330.98,percent of total billed charges,Implant Device,3428.95,35,,3428.95,percent of total billed charges,Implant Device,3428.95,35,,3428.95,percent of total billed charges,Implant Device,3428.95,35,,3428.95,percent of total billed charges,Implant Device,3428.95,35,,3428.95,percent of total billed charges,Implant Device,3428.95,35,,3428.95,percent of total billed charges,Implant Device,3918.8,40,,3918.8,percent of total billed charges,Implant Device,3428.95,70,,3428.95,percent of total billed charges,All Other,3330.98,34,,3330.98,percent of total billed charges,Implant Device,3330.98,34,,3330.98,percent of total billed charges,Implant Device,3428.95,35,,3428.95,percent of total billed charges,Implant Device,3428.95,35,,3428.95,percent of total billed charges,Implant Device,3428.95,35,,3428.95,percent of total billed charges,Implant Device,3428.95,35,,3428.95,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3330.98,34,"If Charge > 2,000, then 34 percent",3330.98,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,7249.8,
DEPUY 1294-53-226-REV FEMORAL SLEEVE,C1776,HCPCS,,79001934,CDM,278,RC,,,both,,,10111,7482.17,,,7482.17,Other,150% of Medicare + 9.63% HCRA Surcharge,4549.95,45,,4549.95,percent of total billed charges,Critical Access Hospital RCC factor,3437.74,34,,3437.74,percent of total billed charges,Implant Device,3437.74,34,,3437.74,percent of total billed charges,Implant Device,3437.74,34,,3437.74,percent of total billed charges,Implant Device,3437.74,34,,3437.74,percent of total billed charges,Implant Device,3437.74,34,,3437.74,percent of total billed charges,Implant Device,5004.95,,,5004.95,Other,110% of Medicare,3538.85,35,,3538.85,percent of total billed charges,Implant Device,3437.74,34,"Charges > $500, x 34%",3437.74,percent of total billed charges,Implant Device,3538.85,35,,3538.85,percent of total billed charges,Implant Device,3538.85,35,,3538.85,percent of total billed charges,Implant Device,3538.85,35,,3538.85,percent of total billed charges,Implant Device,3538.85,35,,3538.85,percent of total billed charges,Implant Device,3538.85,35,,3538.85,percent of total billed charges,Implant Device,4044.4,40,,4044.4,percent of total billed charges,Implant Device,3538.85,70,,3538.85,percent of total billed charges,All Other,3437.74,34,,3437.74,percent of total billed charges,Implant Device,3437.74,34,,3437.74,percent of total billed charges,Implant Device,3538.85,35,,3538.85,percent of total billed charges,Implant Device,3538.85,35,,3538.85,percent of total billed charges,Implant Device,3538.85,35,,3538.85,percent of total billed charges,Implant Device,3538.85,35,,3538.85,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3437.74,34,"If Charge > 2,000, then 34 percent",3437.74,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,7482.17,
DEPUY 1294-53-236-REV FEMORAL SLEEVE,C1776,HCPCS,,79001935,CDM,278,RC,,,both,,,9797,7249.8,,,7249.8,Other,150% of Medicare + 9.63% HCRA Surcharge,4408.65,45,,4408.65,percent of total billed charges,Critical Access Hospital RCC factor,3330.98,34,,3330.98,percent of total billed charges,Implant Device,3330.98,34,,3330.98,percent of total billed charges,Implant Device,3330.98,34,,3330.98,percent of total billed charges,Implant Device,3330.98,34,,3330.98,percent of total billed charges,Implant Device,3330.98,34,,3330.98,percent of total billed charges,Implant Device,4849.52,,,4849.52,Other,110% of Medicare,3428.95,35,,3428.95,percent of total billed charges,Implant Device,3330.98,34,"Charges > $500, x 34%",3330.98,percent of total billed charges,Implant Device,3428.95,35,,3428.95,percent of total billed charges,Implant Device,3428.95,35,,3428.95,percent of total billed charges,Implant Device,3428.95,35,,3428.95,percent of total billed charges,Implant Device,3428.95,35,,3428.95,percent of total billed charges,Implant Device,3428.95,35,,3428.95,percent of total billed charges,Implant Device,3918.8,40,,3918.8,percent of total billed charges,Implant Device,3428.95,70,,3428.95,percent of total billed charges,All Other,3330.98,34,,3330.98,percent of total billed charges,Implant Device,3330.98,34,,3330.98,percent of total billed charges,Implant Device,3428.95,35,,3428.95,percent of total billed charges,Implant Device,3428.95,35,,3428.95,percent of total billed charges,Implant Device,3428.95,35,,3428.95,percent of total billed charges,Implant Device,3428.95,35,,3428.95,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3330.98,34,"If Charge > 2,000, then 34 percent",3330.98,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,7249.8,
DEPUY 1294-53-246-REV FEMORAL SLEEVE,C1776,HCPCS,,79001936,CDM,278,RC,,,both,,,11959,8849.69,,,8849.69,Other,150% of Medicare + 9.63% HCRA Surcharge,5381.55,45,,5381.55,percent of total billed charges,Critical Access Hospital RCC factor,4066.06,34,,4066.06,percent of total billed charges,Implant Device,4066.06,34,,4066.06,percent of total billed charges,Implant Device,4066.06,34,,4066.06,percent of total billed charges,Implant Device,4066.06,34,,4066.06,percent of total billed charges,Implant Device,4066.06,34,,4066.06,percent of total billed charges,Implant Device,5919.71,,,5919.71,Other,110% of Medicare,4185.65,35,,4185.65,percent of total billed charges,Implant Device,4066.06,34,"Charges > $500, x 34%",4066.06,percent of total billed charges,Implant Device,4185.65,35,,4185.65,percent of total billed charges,Implant Device,4185.65,35,,4185.65,percent of total billed charges,Implant Device,4185.65,35,,4185.65,percent of total billed charges,Implant Device,4185.65,35,,4185.65,percent of total billed charges,Implant Device,4185.65,35,,4185.65,percent of total billed charges,Implant Device,4783.6,40,,4783.6,percent of total billed charges,Implant Device,4185.65,70,,4185.65,percent of total billed charges,All Other,4066.06,34,,4066.06,percent of total billed charges,Implant Device,4066.06,34,,4066.06,percent of total billed charges,Implant Device,4185.65,35,,4185.65,percent of total billed charges,Implant Device,4185.65,35,,4185.65,percent of total billed charges,Implant Device,4185.65,35,,4185.65,percent of total billed charges,Implant Device,4185.65,35,,4185.65,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,4066.06,34,"If Charge > 2,000, then 34 percent",4066.06,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,8849.69,
DEPUY 1294-54-000-REV TRAY SLEEVE,C1776,HCPCS,,79001937,CDM,278,RC,,,both,,,8813,6521.64,,,6521.64,Other,150% of Medicare + 9.63% HCRA Surcharge,3965.85,45,,3965.85,percent of total billed charges,Critical Access Hospital RCC factor,2996.42,34,,2996.42,percent of total billed charges,Implant Device,2996.42,34,,2996.42,percent of total billed charges,Implant Device,2996.42,34,,2996.42,percent of total billed charges,Implant Device,2996.42,34,,2996.42,percent of total billed charges,Implant Device,2996.42,34,,2996.42,percent of total billed charges,Implant Device,4362.44,,,4362.44,Other,110% of Medicare,3084.55,35,,3084.55,percent of total billed charges,Implant Device,2996.42,34,"Charges > $500, x 34%",2996.42,percent of total billed charges,Implant Device,3084.55,35,,3084.55,percent of total billed charges,Implant Device,3084.55,35,,3084.55,percent of total billed charges,Implant Device,3084.55,35,,3084.55,percent of total billed charges,Implant Device,3084.55,35,,3084.55,percent of total billed charges,Implant Device,3084.55,35,,3084.55,percent of total billed charges,Implant Device,3525.2,40,,3525.2,percent of total billed charges,Implant Device,3084.55,70,,3084.55,percent of total billed charges,All Other,2996.42,34,,2996.42,percent of total billed charges,Implant Device,2996.42,34,,2996.42,percent of total billed charges,Implant Device,3084.55,35,,3084.55,percent of total billed charges,Implant Device,3084.55,35,,3084.55,percent of total billed charges,Implant Device,3084.55,35,,3084.55,percent of total billed charges,Implant Device,3084.55,35,,3084.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2996.42,34,"If Charge > 2,000, then 34 percent",2996.42,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,6521.64,
DEPUY 1294-54-130-REV TRAY SLEEVE,C1776,HCPCS,,79001939,CDM,278,RC,,,both,,,9565,7078.12,,,7078.12,Other,150% of Medicare + 9.63% HCRA Surcharge,4304.25,45,,4304.25,percent of total billed charges,Critical Access Hospital RCC factor,3252.1,34,,3252.1,percent of total billed charges,Implant Device,3252.1,34,,3252.1,percent of total billed charges,Implant Device,3252.1,34,,3252.1,percent of total billed charges,Implant Device,3252.1,34,,3252.1,percent of total billed charges,Implant Device,3252.1,34,,3252.1,percent of total billed charges,Implant Device,4734.68,,,4734.68,Other,110% of Medicare,3347.75,35,,3347.75,percent of total billed charges,Implant Device,3252.1,34,"Charges > $500, x 34%",3252.1,percent of total billed charges,Implant Device,3347.75,35,,3347.75,percent of total billed charges,Implant Device,3347.75,35,,3347.75,percent of total billed charges,Implant Device,3347.75,35,,3347.75,percent of total billed charges,Implant Device,3347.75,35,,3347.75,percent of total billed charges,Implant Device,3347.75,35,,3347.75,percent of total billed charges,Implant Device,3826,40,,3826,percent of total billed charges,Implant Device,3347.75,70,,3347.75,percent of total billed charges,All Other,3252.1,34,,3252.1,percent of total billed charges,Implant Device,3252.1,34,,3252.1,percent of total billed charges,Implant Device,3347.75,35,,3347.75,percent of total billed charges,Implant Device,3347.75,35,,3347.75,percent of total billed charges,Implant Device,3347.75,35,,3347.75,percent of total billed charges,Implant Device,3347.75,35,,3347.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3252.1,34,"If Charge > 2,000, then 34 percent",3252.1,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,7078.12,
DEPUY 1294-56-126-REV WEDGE,C1776,HCPCS,,79001940,CDM,278,RC,,,both,,,6337,4689.4,,,4689.4,Other,150% of Medicare + 9.63% HCRA Surcharge,2851.65,45,,2851.65,percent of total billed charges,Critical Access Hospital RCC factor,2154.58,34,,2154.58,percent of total billed charges,Implant Device,2154.58,34,,2154.58,percent of total billed charges,Implant Device,2154.58,34,,2154.58,percent of total billed charges,Implant Device,2154.58,34,,2154.58,percent of total billed charges,Implant Device,2154.58,34,,2154.58,percent of total billed charges,Implant Device,3136.82,,,3136.82,Other,110% of Medicare,2217.95,35,,2217.95,percent of total billed charges,Implant Device,2154.58,34,"Charges > $500, x 34%",2154.58,percent of total billed charges,Implant Device,2217.95,35,,2217.95,percent of total billed charges,Implant Device,2217.95,35,,2217.95,percent of total billed charges,Implant Device,2217.95,35,,2217.95,percent of total billed charges,Implant Device,2217.95,35,,2217.95,percent of total billed charges,Implant Device,2217.95,35,,2217.95,percent of total billed charges,Implant Device,2534.8,40,,2534.8,percent of total billed charges,Implant Device,2217.95,70,,2217.95,percent of total billed charges,All Other,2154.58,34,,2154.58,percent of total billed charges,Implant Device,2154.58,34,,2154.58,percent of total billed charges,Implant Device,2217.95,35,,2217.95,percent of total billed charges,Implant Device,2217.95,35,,2217.95,percent of total billed charges,Implant Device,2217.95,35,,2217.95,percent of total billed charges,Implant Device,2217.95,35,,2217.95,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2154.58,34,"If Charge > 2,000, then 34 percent",2154.58,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4689.4,
DEPUY 1365-36-210-REV FEMORAL HEAD,C1776,HCPCS,,79001942,CDM,278,RC,,,both,,,4747,3512.79,,,3512.79,Other,150% of Medicare + 9.63% HCRA Surcharge,2136.15,45,,2136.15,percent of total billed charges,Critical Access Hospital RCC factor,1613.98,34,,1613.98,percent of total billed charges,Implant Device,1613.98,34,,1613.98,percent of total billed charges,Implant Device,1613.98,34,,1613.98,percent of total billed charges,Implant Device,1613.98,34,,1613.98,percent of total billed charges,Implant Device,1613.98,34,,1613.98,percent of total billed charges,Implant Device,2349.77,,,2349.77,Other,110% of Medicare,1661.45,35,,1661.45,percent of total billed charges,Implant Device,1613.98,34,"Charges > $500, x 34%",1613.98,percent of total billed charges,Implant Device,1661.45,35,,1661.45,percent of total billed charges,Implant Device,1661.45,35,,1661.45,percent of total billed charges,Implant Device,1661.45,35,,1661.45,percent of total billed charges,Implant Device,1661.45,35,,1661.45,percent of total billed charges,Implant Device,1661.45,35,,1661.45,percent of total billed charges,Implant Device,1898.8,40,,1898.8,percent of total billed charges,Implant Device,1661.45,70,,1661.45,percent of total billed charges,All Other,1613.98,34,,1613.98,percent of total billed charges,Implant Device,1613.98,34,,1613.98,percent of total billed charges,Implant Device,1661.45,35,,1661.45,percent of total billed charges,Implant Device,1661.45,35,,1661.45,percent of total billed charges,Implant Device,1661.45,35,,1661.45,percent of total billed charges,Implant Device,1661.45,35,,1661.45,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1613.98,34,"If Charge > 2,000, then 34 percent",1613.98,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3512.79,
DEPUY 14196-105 SCREW,C1713,HCPCS,,79001944,CDM,278,RC,,,both,,,1290,954.6,,,954.6,Other,150% of Medicare + 9.63% HCRA Surcharge,580.5,45,,580.5,percent of total billed charges,Critical Access Hospital RCC factor,438.6,34,,438.6,percent of total billed charges,Implant Device,438.6,34,,438.6,percent of total billed charges,Implant Device,438.6,34,,438.6,percent of total billed charges,Implant Device,438.6,34,,438.6,percent of total billed charges,Implant Device,438.6,34,,438.6,percent of total billed charges,Implant Device,638.55,,,638.55,Other,110% of Medicare,451.5,35,,451.5,percent of total billed charges,Implant Device,438.6,34,"Charges > $500, x 34%",438.6,percent of total billed charges,Implant Device,451.5,35,,451.5,percent of total billed charges,Implant Device,451.5,35,,451.5,percent of total billed charges,Implant Device,451.5,35,,451.5,percent of total billed charges,Implant Device,451.5,35,,451.5,percent of total billed charges,Implant Device,451.5,35,,451.5,percent of total billed charges,Implant Device,516,40,,516,percent of total billed charges,Implant Device,451.5,70,,451.5,percent of total billed charges,All Other,438.6,34,,438.6,percent of total billed charges,Implant Device,438.6,34,,438.6,percent of total billed charges,Implant Device,451.5,35,,451.5,percent of total billed charges,Implant Device,451.5,35,,451.5,percent of total billed charges,Implant Device,451.5,35,,451.5,percent of total billed charges,Implant Device,451.5,35,,451.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,954.6,
DEPUY 14196-35 SCREW,C1713,HCPCS,,79001945,CDM,278,RC,,,both,,,1290,954.6,,,954.6,Other,150% of Medicare + 9.63% HCRA Surcharge,580.5,45,,580.5,percent of total billed charges,Critical Access Hospital RCC factor,438.6,34,,438.6,percent of total billed charges,Implant Device,438.6,34,,438.6,percent of total billed charges,Implant Device,438.6,34,,438.6,percent of total billed charges,Implant Device,438.6,34,,438.6,percent of total billed charges,Implant Device,438.6,34,,438.6,percent of total billed charges,Implant Device,638.55,,,638.55,Other,110% of Medicare,451.5,35,,451.5,percent of total billed charges,Implant Device,438.6,34,"Charges > $500, x 34%",438.6,percent of total billed charges,Implant Device,451.5,35,,451.5,percent of total billed charges,Implant Device,451.5,35,,451.5,percent of total billed charges,Implant Device,451.5,35,,451.5,percent of total billed charges,Implant Device,451.5,35,,451.5,percent of total billed charges,Implant Device,451.5,35,,451.5,percent of total billed charges,Implant Device,516,40,,516,percent of total billed charges,Implant Device,451.5,70,,451.5,percent of total billed charges,All Other,438.6,34,,438.6,percent of total billed charges,Implant Device,438.6,34,,438.6,percent of total billed charges,Implant Device,451.5,35,,451.5,percent of total billed charges,Implant Device,451.5,35,,451.5,percent of total billed charges,Implant Device,451.5,35,,451.5,percent of total billed charges,Implant Device,451.5,35,,451.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,954.6,
DEPUY 14250-38 SCREW,C1713,HCPCS,,79001946,CDM,278,RC,,,both,,,522,386.28,,,386.28,Other,150% of Medicare + 9.63% HCRA Surcharge,234.9,45,,234.9,percent of total billed charges,Critical Access Hospital RCC factor,177.48,34,,177.48,percent of total billed charges,Implant Device,177.48,34,,177.48,percent of total billed charges,Implant Device,177.48,34,,177.48,percent of total billed charges,Implant Device,177.48,34,,177.48,percent of total billed charges,Implant Device,177.48,34,,177.48,percent of total billed charges,Implant Device,258.39,,,258.39,Other,110% of Medicare,182.7,35,,182.7,percent of total billed charges,Implant Device,177.48,34,"Charges > $500, x 34%",177.48,percent of total billed charges,Implant Device,182.7,35,,182.7,percent of total billed charges,Implant Device,182.7,35,,182.7,percent of total billed charges,Implant Device,182.7,35,,182.7,percent of total billed charges,Implant Device,182.7,35,,182.7,percent of total billed charges,Implant Device,182.7,35,,182.7,percent of total billed charges,Implant Device,208.8,40,,208.8,percent of total billed charges,Implant Device,182.7,70,,182.7,percent of total billed charges,All Other,177.48,34,,177.48,percent of total billed charges,Implant Device,177.48,34,,177.48,percent of total billed charges,Implant Device,182.7,35,,182.7,percent of total billed charges,Implant Device,182.7,35,,182.7,percent of total billed charges,Implant Device,182.7,35,,182.7,percent of total billed charges,Implant Device,182.7,35,,182.7,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,386.28,
DEPUY 14250-42 SCREW,C1713,HCPCS,,79001947,CDM,278,RC,,,both,,,522,386.28,,,386.28,Other,150% of Medicare + 9.63% HCRA Surcharge,234.9,45,,234.9,percent of total billed charges,Critical Access Hospital RCC factor,177.48,34,,177.48,percent of total billed charges,Implant Device,177.48,34,,177.48,percent of total billed charges,Implant Device,177.48,34,,177.48,percent of total billed charges,Implant Device,177.48,34,,177.48,percent of total billed charges,Implant Device,177.48,34,,177.48,percent of total billed charges,Implant Device,258.39,,,258.39,Other,110% of Medicare,182.7,35,,182.7,percent of total billed charges,Implant Device,177.48,34,"Charges > $500, x 34%",177.48,percent of total billed charges,Implant Device,182.7,35,,182.7,percent of total billed charges,Implant Device,182.7,35,,182.7,percent of total billed charges,Implant Device,182.7,35,,182.7,percent of total billed charges,Implant Device,182.7,35,,182.7,percent of total billed charges,Implant Device,182.7,35,,182.7,percent of total billed charges,Implant Device,208.8,40,,208.8,percent of total billed charges,Implant Device,182.7,70,,182.7,percent of total billed charges,All Other,177.48,34,,177.48,percent of total billed charges,Implant Device,177.48,34,,177.48,percent of total billed charges,Implant Device,182.7,35,,182.7,percent of total billed charges,Implant Device,182.7,35,,182.7,percent of total billed charges,Implant Device,182.7,35,,182.7,percent of total billed charges,Implant Device,182.7,35,,182.7,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,386.28,
DEPUY 14250-46 SCREW,C1713,HCPCS,,79001948,CDM,278,RC,,,both,,,810,599.4,,,599.4,Other,150% of Medicare + 9.63% HCRA Surcharge,364.5,45,,364.5,percent of total billed charges,Critical Access Hospital RCC factor,275.4,34,,275.4,percent of total billed charges,Implant Device,275.4,34,,275.4,percent of total billed charges,Implant Device,275.4,34,,275.4,percent of total billed charges,Implant Device,275.4,34,,275.4,percent of total billed charges,Implant Device,275.4,34,,275.4,percent of total billed charges,Implant Device,400.95,,,400.95,Other,110% of Medicare,283.5,35,,283.5,percent of total billed charges,Implant Device,275.4,34,"Charges > $500, x 34%",275.4,percent of total billed charges,Implant Device,283.5,35,,283.5,percent of total billed charges,Implant Device,283.5,35,,283.5,percent of total billed charges,Implant Device,283.5,35,,283.5,percent of total billed charges,Implant Device,283.5,35,,283.5,percent of total billed charges,Implant Device,283.5,35,,283.5,percent of total billed charges,Implant Device,324,40,,324,percent of total billed charges,Implant Device,283.5,70,,283.5,percent of total billed charges,All Other,275.4,34,,275.4,percent of total billed charges,Implant Device,275.4,34,,275.4,percent of total billed charges,Implant Device,283.5,35,,283.5,percent of total billed charges,Implant Device,283.5,35,,283.5,percent of total billed charges,Implant Device,283.5,35,,283.5,percent of total billed charges,Implant Device,283.5,35,,283.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,599.4,
BIOMET 14-405026 SCREW,C1713,HCPCS,,79001949,CDM,278,RC,,,both,,,1020,754.8,,,754.8,Other,150% of Medicare + 9.63% HCRA Surcharge,459,45,,459,percent of total billed charges,Critical Access Hospital RCC factor,346.8,34,,346.8,percent of total billed charges,Implant Device,346.8,34,,346.8,percent of total billed charges,Implant Device,346.8,34,,346.8,percent of total billed charges,Implant Device,346.8,34,,346.8,percent of total billed charges,Implant Device,346.8,34,,346.8,percent of total billed charges,Implant Device,504.9,,,504.9,Other,110% of Medicare,357,35,,357,percent of total billed charges,Implant Device,346.8,34,"Charges > $500, x 34%",346.8,percent of total billed charges,Implant Device,357,35,,357,percent of total billed charges,Implant Device,357,35,,357,percent of total billed charges,Implant Device,357,35,,357,percent of total billed charges,Implant Device,357,35,,357,percent of total billed charges,Implant Device,357,35,,357,percent of total billed charges,Implant Device,408,40,,408,percent of total billed charges,Implant Device,357,70,,357,percent of total billed charges,All Other,346.8,34,,346.8,percent of total billed charges,Implant Device,346.8,34,,346.8,percent of total billed charges,Implant Device,357,35,,357,percent of total billed charges,Implant Device,357,35,,357,percent of total billed charges,Implant Device,357,35,,357,percent of total billed charges,Implant Device,357,35,,357,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,754.8,
BIOMET 14-405030 SCREW,C1713,HCPCS,,79001950,CDM,278,RC,,,both,,,1020,754.8,,,754.8,Other,150% of Medicare + 9.63% HCRA Surcharge,459,45,,459,percent of total billed charges,Critical Access Hospital RCC factor,346.8,34,,346.8,percent of total billed charges,Implant Device,346.8,34,,346.8,percent of total billed charges,Implant Device,346.8,34,,346.8,percent of total billed charges,Implant Device,346.8,34,,346.8,percent of total billed charges,Implant Device,346.8,34,,346.8,percent of total billed charges,Implant Device,504.9,,,504.9,Other,110% of Medicare,357,35,,357,percent of total billed charges,Implant Device,346.8,34,"Charges > $500, x 34%",346.8,percent of total billed charges,Implant Device,357,35,,357,percent of total billed charges,Implant Device,357,35,,357,percent of total billed charges,Implant Device,357,35,,357,percent of total billed charges,Implant Device,357,35,,357,percent of total billed charges,Implant Device,357,35,,357,percent of total billed charges,Implant Device,408,40,,408,percent of total billed charges,Implant Device,357,70,,357,percent of total billed charges,All Other,346.8,34,,346.8,percent of total billed charges,Implant Device,346.8,34,,346.8,percent of total billed charges,Implant Device,357,35,,357,percent of total billed charges,Implant Device,357,35,,357,percent of total billed charges,Implant Device,357,35,,357,percent of total billed charges,Implant Device,357,35,,357,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,754.8,
BIOMET 14-405032 SCREW 5X32MM,C1713,HCPCS,,79001951,CDM,278,RC,,,both,,,1020,754.8,,,754.8,Other,150% of Medicare + 9.63% HCRA Surcharge,459,45,,459,percent of total billed charges,Critical Access Hospital RCC factor,346.8,34,,346.8,percent of total billed charges,Implant Device,346.8,34,,346.8,percent of total billed charges,Implant Device,346.8,34,,346.8,percent of total billed charges,Implant Device,346.8,34,,346.8,percent of total billed charges,Implant Device,346.8,34,,346.8,percent of total billed charges,Implant Device,504.9,,,504.9,Other,110% of Medicare,357,35,,357,percent of total billed charges,Implant Device,346.8,34,"Charges > $500, x 34%",346.8,percent of total billed charges,Implant Device,357,35,,357,percent of total billed charges,Implant Device,357,35,,357,percent of total billed charges,Implant Device,357,35,,357,percent of total billed charges,Implant Device,357,35,,357,percent of total billed charges,Implant Device,357,35,,357,percent of total billed charges,Implant Device,408,40,,408,percent of total billed charges,Implant Device,357,70,,357,percent of total billed charges,All Other,346.8,34,,346.8,percent of total billed charges,Implant Device,346.8,34,,346.8,percent of total billed charges,Implant Device,357,35,,357,percent of total billed charges,Implant Device,357,35,,357,percent of total billed charges,Implant Device,357,35,,357,percent of total billed charges,Implant Device,357,35,,357,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,754.8,
BIOMET 14-405034 SCREW 5X34MM,C1713,HCPCS,,79001952,CDM,278,RC,,,both,,,1020,754.8,,,754.8,Other,150% of Medicare + 9.63% HCRA Surcharge,459,45,,459,percent of total billed charges,Critical Access Hospital RCC factor,346.8,34,,346.8,percent of total billed charges,Implant Device,346.8,34,,346.8,percent of total billed charges,Implant Device,346.8,34,,346.8,percent of total billed charges,Implant Device,346.8,34,,346.8,percent of total billed charges,Implant Device,346.8,34,,346.8,percent of total billed charges,Implant Device,504.9,,,504.9,Other,110% of Medicare,357,35,,357,percent of total billed charges,Implant Device,346.8,34,"Charges > $500, x 34%",346.8,percent of total billed charges,Implant Device,357,35,,357,percent of total billed charges,Implant Device,357,35,,357,percent of total billed charges,Implant Device,357,35,,357,percent of total billed charges,Implant Device,357,35,,357,percent of total billed charges,Implant Device,357,35,,357,percent of total billed charges,Implant Device,408,40,,408,percent of total billed charges,Implant Device,357,70,,357,percent of total billed charges,All Other,346.8,34,,346.8,percent of total billed charges,Implant Device,346.8,34,,346.8,percent of total billed charges,Implant Device,357,35,,357,percent of total billed charges,Implant Device,357,35,,357,percent of total billed charges,Implant Device,357,35,,357,percent of total billed charges,Implant Device,357,35,,357,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,754.8,
BIOMET 14-405036 SCREW 5X36MM,C1713,HCPCS,,79001953,CDM,278,RC,,,both,,,1020,754.8,,,754.8,Other,150% of Medicare + 9.63% HCRA Surcharge,459,45,,459,percent of total billed charges,Critical Access Hospital RCC factor,346.8,34,,346.8,percent of total billed charges,Implant Device,346.8,34,,346.8,percent of total billed charges,Implant Device,346.8,34,,346.8,percent of total billed charges,Implant Device,346.8,34,,346.8,percent of total billed charges,Implant Device,346.8,34,,346.8,percent of total billed charges,Implant Device,504.9,,,504.9,Other,110% of Medicare,357,35,,357,percent of total billed charges,Implant Device,346.8,34,"Charges > $500, x 34%",346.8,percent of total billed charges,Implant Device,357,35,,357,percent of total billed charges,Implant Device,357,35,,357,percent of total billed charges,Implant Device,357,35,,357,percent of total billed charges,Implant Device,357,35,,357,percent of total billed charges,Implant Device,357,35,,357,percent of total billed charges,Implant Device,408,40,,408,percent of total billed charges,Implant Device,357,70,,357,percent of total billed charges,All Other,346.8,34,,346.8,percent of total billed charges,Implant Device,346.8,34,,346.8,percent of total billed charges,Implant Device,357,35,,357,percent of total billed charges,Implant Device,357,35,,357,percent of total billed charges,Implant Device,357,35,,357,percent of total billed charges,Implant Device,357,35,,357,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,754.8,
BIOMET 14-405038 SCREW 5X38MM,C1713,HCPCS,,79001954,CDM,278,RC,,,both,,,1020,754.8,,,754.8,Other,150% of Medicare + 9.63% HCRA Surcharge,459,45,,459,percent of total billed charges,Critical Access Hospital RCC factor,346.8,34,,346.8,percent of total billed charges,Implant Device,346.8,34,,346.8,percent of total billed charges,Implant Device,346.8,34,,346.8,percent of total billed charges,Implant Device,346.8,34,,346.8,percent of total billed charges,Implant Device,346.8,34,,346.8,percent of total billed charges,Implant Device,504.9,,,504.9,Other,110% of Medicare,357,35,,357,percent of total billed charges,Implant Device,346.8,34,"Charges > $500, x 34%",346.8,percent of total billed charges,Implant Device,357,35,,357,percent of total billed charges,Implant Device,357,35,,357,percent of total billed charges,Implant Device,357,35,,357,percent of total billed charges,Implant Device,357,35,,357,percent of total billed charges,Implant Device,357,35,,357,percent of total billed charges,Implant Device,408,40,,408,percent of total billed charges,Implant Device,357,70,,357,percent of total billed charges,All Other,346.8,34,,346.8,percent of total billed charges,Implant Device,346.8,34,,346.8,percent of total billed charges,Implant Device,357,35,,357,percent of total billed charges,Implant Device,357,35,,357,percent of total billed charges,Implant Device,357,35,,357,percent of total billed charges,Implant Device,357,35,,357,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,754.8,
DEPUY 1581-24-115-REV STABILIZED INSERT,C1776,HCPCS,,79001956,CDM,278,RC,,,both,,,4175,3089.51,,,3089.51,Other,150% of Medicare + 9.63% HCRA Surcharge,1878.75,45,,1878.75,percent of total billed charges,Critical Access Hospital RCC factor,1419.5,34,,1419.5,percent of total billed charges,Implant Device,1419.5,34,,1419.5,percent of total billed charges,Implant Device,1419.5,34,,1419.5,percent of total billed charges,Implant Device,1419.5,34,,1419.5,percent of total billed charges,Implant Device,1419.5,34,,1419.5,percent of total billed charges,Implant Device,2066.63,,,2066.63,Other,110% of Medicare,1461.25,35,,1461.25,percent of total billed charges,Implant Device,1419.5,34,"Charges > $500, x 34%",1419.5,percent of total billed charges,Implant Device,1461.25,35,,1461.25,percent of total billed charges,Implant Device,1461.25,35,,1461.25,percent of total billed charges,Implant Device,1461.25,35,,1461.25,percent of total billed charges,Implant Device,1461.25,35,,1461.25,percent of total billed charges,Implant Device,1461.25,35,,1461.25,percent of total billed charges,Implant Device,1670,40,,1670,percent of total billed charges,Implant Device,1461.25,70,,1461.25,percent of total billed charges,All Other,1419.5,34,,1419.5,percent of total billed charges,Implant Device,1419.5,34,,1419.5,percent of total billed charges,Implant Device,1461.25,35,,1461.25,percent of total billed charges,Implant Device,1461.25,35,,1461.25,percent of total billed charges,Implant Device,1461.25,35,,1461.25,percent of total billed charges,Implant Device,1461.25,35,,1461.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1419.5,34,"If Charge > 2,000, then 34 percent",1419.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3089.51,
STRYKER 1822-1037S NAIL,C1713,HCPCS,,79001959,CDM,278,RC,,,both,,,4886,3615.65,,,3615.65,Other,150% of Medicare + 9.63% HCRA Surcharge,2198.7,45,,2198.7,percent of total billed charges,Critical Access Hospital RCC factor,1661.24,34,,1661.24,percent of total billed charges,Implant Device,1661.24,34,,1661.24,percent of total billed charges,Implant Device,1661.24,34,,1661.24,percent of total billed charges,Implant Device,1661.24,34,,1661.24,percent of total billed charges,Implant Device,1661.24,34,,1661.24,percent of total billed charges,Implant Device,2418.57,,,2418.57,Other,110% of Medicare,1710.1,35,,1710.1,percent of total billed charges,Implant Device,1661.24,34,"Charges > $500, x 34%",1661.24,percent of total billed charges,Implant Device,1710.1,35,,1710.1,percent of total billed charges,Implant Device,1710.1,35,,1710.1,percent of total billed charges,Implant Device,1710.1,35,,1710.1,percent of total billed charges,Implant Device,1710.1,35,,1710.1,percent of total billed charges,Implant Device,1710.1,35,,1710.1,percent of total billed charges,Implant Device,1954.4,40,,1954.4,percent of total billed charges,Implant Device,1710.1,70,,1710.1,percent of total billed charges,All Other,1661.24,34,,1661.24,percent of total billed charges,Implant Device,1661.24,34,,1661.24,percent of total billed charges,Implant Device,1710.1,35,,1710.1,percent of total billed charges,Implant Device,1710.1,35,,1710.1,percent of total billed charges,Implant Device,1710.1,35,,1710.1,percent of total billed charges,Implant Device,1710.1,35,,1710.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1661.24,34,"If Charge > 2,000, then 34 percent",1661.24,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3615.65,
STRYKER 1822-1133S NAIL,C1713,HCPCS,,79001960,CDM,278,RC,,,both,,,6416,4747.86,,,4747.86,Other,150% of Medicare + 9.63% HCRA Surcharge,2887.2,45,,2887.2,percent of total billed charges,Critical Access Hospital RCC factor,2181.44,34,,2181.44,percent of total billed charges,Implant Device,2181.44,34,,2181.44,percent of total billed charges,Implant Device,2181.44,34,,2181.44,percent of total billed charges,Implant Device,2181.44,34,,2181.44,percent of total billed charges,Implant Device,2181.44,34,,2181.44,percent of total billed charges,Implant Device,3175.92,,,3175.92,Other,110% of Medicare,2245.6,35,,2245.6,percent of total billed charges,Implant Device,2181.44,34,"Charges > $500, x 34%",2181.44,percent of total billed charges,Implant Device,2245.6,35,,2245.6,percent of total billed charges,Implant Device,2245.6,35,,2245.6,percent of total billed charges,Implant Device,2245.6,35,,2245.6,percent of total billed charges,Implant Device,2245.6,35,,2245.6,percent of total billed charges,Implant Device,2245.6,35,,2245.6,percent of total billed charges,Implant Device,2566.4,40,,2566.4,percent of total billed charges,Implant Device,2245.6,70,,2245.6,percent of total billed charges,All Other,2181.44,34,,2181.44,percent of total billed charges,Implant Device,2181.44,34,,2181.44,percent of total billed charges,Implant Device,2245.6,35,,2245.6,percent of total billed charges,Implant Device,2245.6,35,,2245.6,percent of total billed charges,Implant Device,2245.6,35,,2245.6,percent of total billed charges,Implant Device,2245.6,35,,2245.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2181.44,34,"If Charge > 2,000, then 34 percent",2181.44,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4747.86,
STRYKER 1822-1137S NAIL,C1713,HCPCS,,79001961,CDM,278,RC,,,both,,,5131,3796.95,,,3796.95,Other,150% of Medicare + 9.63% HCRA Surcharge,2308.95,45,,2308.95,percent of total billed charges,Critical Access Hospital RCC factor,1744.54,34,,1744.54,percent of total billed charges,Implant Device,1744.54,34,,1744.54,percent of total billed charges,Implant Device,1744.54,34,,1744.54,percent of total billed charges,Implant Device,1744.54,34,,1744.54,percent of total billed charges,Implant Device,1744.54,34,,1744.54,percent of total billed charges,Implant Device,2539.85,,,2539.85,Other,110% of Medicare,1795.85,35,,1795.85,percent of total billed charges,Implant Device,1744.54,34,"Charges > $500, x 34%",1744.54,percent of total billed charges,Implant Device,1795.85,35,,1795.85,percent of total billed charges,Implant Device,1795.85,35,,1795.85,percent of total billed charges,Implant Device,1795.85,35,,1795.85,percent of total billed charges,Implant Device,1795.85,35,,1795.85,percent of total billed charges,Implant Device,1795.85,35,,1795.85,percent of total billed charges,Implant Device,2052.4,40,,2052.4,percent of total billed charges,Implant Device,1795.85,70,,1795.85,percent of total billed charges,All Other,1744.54,34,,1744.54,percent of total billed charges,Implant Device,1744.54,34,,1744.54,percent of total billed charges,Implant Device,1795.85,35,,1795.85,percent of total billed charges,Implant Device,1795.85,35,,1795.85,percent of total billed charges,Implant Device,1795.85,35,,1795.85,percent of total billed charges,Implant Device,1795.85,35,,1795.85,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1744.54,34,"If Charge > 2,000, then 34 percent",1744.54,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3796.95,
STRYKER 1822-1140S NAIL,C1713,HCPCS,,79001962,CDM,278,RC,,,both,,,5131,3796.95,,,3796.95,Other,150% of Medicare + 9.63% HCRA Surcharge,2308.95,45,,2308.95,percent of total billed charges,Critical Access Hospital RCC factor,1744.54,34,,1744.54,percent of total billed charges,Implant Device,1744.54,34,,1744.54,percent of total billed charges,Implant Device,1744.54,34,,1744.54,percent of total billed charges,Implant Device,1744.54,34,,1744.54,percent of total billed charges,Implant Device,1744.54,34,,1744.54,percent of total billed charges,Implant Device,2539.85,,,2539.85,Other,110% of Medicare,1795.85,35,,1795.85,percent of total billed charges,Implant Device,1744.54,34,"Charges > $500, x 34%",1744.54,percent of total billed charges,Implant Device,1795.85,35,,1795.85,percent of total billed charges,Implant Device,1795.85,35,,1795.85,percent of total billed charges,Implant Device,1795.85,35,,1795.85,percent of total billed charges,Implant Device,1795.85,35,,1795.85,percent of total billed charges,Implant Device,1795.85,35,,1795.85,percent of total billed charges,Implant Device,2052.4,40,,2052.4,percent of total billed charges,Implant Device,1795.85,70,,1795.85,percent of total billed charges,All Other,1744.54,34,,1744.54,percent of total billed charges,Implant Device,1744.54,34,,1744.54,percent of total billed charges,Implant Device,1795.85,35,,1795.85,percent of total billed charges,Implant Device,1795.85,35,,1795.85,percent of total billed charges,Implant Device,1795.85,35,,1795.85,percent of total billed charges,Implant Device,1795.85,35,,1795.85,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1744.54,34,"If Charge > 2,000, then 34 percent",1744.54,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3796.95,
POLARIS 190-131 0 URETERAL STENT,C1758,HCPCS,,79001963,CDM,278,RC,,,both,,,1234,913.16,,,913.16,Other,150% of Medicare + 9.63% HCRA Surcharge,555.3,45,,555.3,percent of total billed charges,Critical Access Hospital RCC factor,419.56,34,,419.56,percent of total billed charges,Implant Device,419.56,34,,419.56,percent of total billed charges,Implant Device,419.56,34,,419.56,percent of total billed charges,Implant Device,419.56,34,,419.56,percent of total billed charges,Implant Device,419.56,34,,419.56,percent of total billed charges,Implant Device,610.83,,,610.83,Other,110% of Medicare,431.9,35,,431.9,percent of total billed charges,Implant Device,419.56,34,"Charges > $500, x 34%",419.56,percent of total billed charges,Implant Device,431.9,35,,431.9,percent of total billed charges,Implant Device,431.9,35,,431.9,percent of total billed charges,Implant Device,431.9,35,,431.9,percent of total billed charges,Implant Device,431.9,35,,431.9,percent of total billed charges,Implant Device,431.9,35,,431.9,percent of total billed charges,Implant Device,493.6,40,,493.6,percent of total billed charges,Implant Device,431.9,70,,431.9,percent of total billed charges,All Other,419.56,34,,419.56,percent of total billed charges,Implant Device,419.56,34,,419.56,percent of total billed charges,Implant Device,431.9,35,,431.9,percent of total billed charges,Implant Device,431.9,35,,431.9,percent of total billed charges,Implant Device,431.9,35,,431.9,percent of total billed charges,Implant Device,431.9,35,,431.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,913.16,
POLARIS 190-134 0 URETERAL STENT,C1758,HCPCS,,79001964,CDM,278,RC,,,both,,,1266,936.84,,,936.84,Other,150% of Medicare + 9.63% HCRA Surcharge,569.7,45,,569.7,percent of total billed charges,Critical Access Hospital RCC factor,430.44,34,,430.44,percent of total billed charges,Implant Device,430.44,34,,430.44,percent of total billed charges,Implant Device,430.44,34,,430.44,percent of total billed charges,Implant Device,430.44,34,,430.44,percent of total billed charges,Implant Device,430.44,34,,430.44,percent of total billed charges,Implant Device,626.67,,,626.67,Other,110% of Medicare,443.1,35,,443.1,percent of total billed charges,Implant Device,430.44,34,"Charges > $500, x 34%",430.44,percent of total billed charges,Implant Device,443.1,35,,443.1,percent of total billed charges,Implant Device,443.1,35,,443.1,percent of total billed charges,Implant Device,443.1,35,,443.1,percent of total billed charges,Implant Device,443.1,35,,443.1,percent of total billed charges,Implant Device,443.1,35,,443.1,percent of total billed charges,Implant Device,506.4,40,,506.4,percent of total billed charges,Implant Device,443.1,70,,443.1,percent of total billed charges,All Other,430.44,34,,430.44,percent of total billed charges,Implant Device,430.44,34,,430.44,percent of total billed charges,Implant Device,443.1,35,,443.1,percent of total billed charges,Implant Device,443.1,35,,443.1,percent of total billed charges,Implant Device,443.1,35,,443.1,percent of total billed charges,Implant Device,443.1,35,,443.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,936.84,
DEPUY 1987-27-112-REV HINGE INSERT,C1776,HCPCS,,79001965,CDM,278,RC,,,both,,,10692,7912.11,,,7912.11,Other,150% of Medicare + 9.63% HCRA Surcharge,4811.4,45,,4811.4,percent of total billed charges,Critical Access Hospital RCC factor,3635.28,34,,3635.28,percent of total billed charges,Implant Device,3635.28,34,,3635.28,percent of total billed charges,Implant Device,3635.28,34,,3635.28,percent of total billed charges,Implant Device,3635.28,34,,3635.28,percent of total billed charges,Implant Device,3635.28,34,,3635.28,percent of total billed charges,Implant Device,5292.54,,,5292.54,Other,110% of Medicare,3742.2,35,,3742.2,percent of total billed charges,Implant Device,3635.28,34,"Charges > $500, x 34%",3635.28,percent of total billed charges,Implant Device,3742.2,35,,3742.2,percent of total billed charges,Implant Device,3742.2,35,,3742.2,percent of total billed charges,Implant Device,3742.2,35,,3742.2,percent of total billed charges,Implant Device,3742.2,35,,3742.2,percent of total billed charges,Implant Device,3742.2,35,,3742.2,percent of total billed charges,Implant Device,4276.8,40,,4276.8,percent of total billed charges,Implant Device,3742.2,70,,3742.2,percent of total billed charges,All Other,3635.28,34,,3635.28,percent of total billed charges,Implant Device,3635.28,34,,3635.28,percent of total billed charges,Implant Device,3742.2,35,,3742.2,percent of total billed charges,Implant Device,3742.2,35,,3742.2,percent of total billed charges,Implant Device,3742.2,35,,3742.2,percent of total billed charges,Implant Device,3742.2,35,,3742.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3635.28,34,"If Charge > 2,000, then 34 percent",3635.28,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,7912.11,
STRYKER 2030-6525-1-REV SCREW,C1713,HCPCS,,79001966,CDM,278,RC,,,both,,,451,333.74,,,333.74,Other,150% of Medicare + 9.63% HCRA Surcharge,202.95,45,,202.95,percent of total billed charges,Critical Access Hospital RCC factor,153.34,34,,153.34,percent of total billed charges,Implant Device,153.34,34,,153.34,percent of total billed charges,Implant Device,153.34,34,,153.34,percent of total billed charges,Implant Device,153.34,34,,153.34,percent of total billed charges,Implant Device,153.34,34,,153.34,percent of total billed charges,Implant Device,223.25,,,223.25,Other,110% of Medicare,157.85,35,,157.85,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,157.85,35,,157.85,percent of total billed charges,Implant Device,157.85,35,,157.85,percent of total billed charges,Implant Device,157.85,35,,157.85,percent of total billed charges,Implant Device,157.85,35,,157.85,percent of total billed charges,Implant Device,157.85,35,,157.85,percent of total billed charges,Implant Device,180.4,40,,180.4,percent of total billed charges,Implant Device,157.85,70,,157.85,percent of total billed charges,All Other,153.34,34,,153.34,percent of total billed charges,Implant Device,153.34,34,,153.34,percent of total billed charges,Implant Device,157.85,35,,157.85,percent of total billed charges,Implant Device,157.85,35,,157.85,percent of total billed charges,Implant Device,157.85,35,,157.85,percent of total billed charges,Implant Device,157.85,35,,157.85,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,333.74,
STRYKER 2030-6535-1-REV SCREW,C1713,HCPCS,,79001967,CDM,278,RC,,,both,,,150,111,,,111,Other,150% of Medicare + 9.63% HCRA Surcharge,67.5,45,,67.5,percent of total billed charges,Critical Access Hospital RCC factor,51,34,,51,percent of total billed charges,Implant Device,51,34,,51,percent of total billed charges,Implant Device,51,34,,51,percent of total billed charges,Implant Device,51,34,,51,percent of total billed charges,Implant Device,51,34,,51,percent of total billed charges,Implant Device,74.25,,,74.25,Other,110% of Medicare,52.5,35,,52.5,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,52.5,35,,52.5,percent of total billed charges,Implant Device,52.5,35,,52.5,percent of total billed charges,Implant Device,52.5,35,,52.5,percent of total billed charges,Implant Device,52.5,35,,52.5,percent of total billed charges,Implant Device,52.5,35,,52.5,percent of total billed charges,Implant Device,60,40,,60,percent of total billed charges,Implant Device,52.5,70,,52.5,percent of total billed charges,All Other,51,34,,51,percent of total billed charges,Implant Device,51,34,,51,percent of total billed charges,Implant Device,52.5,35,,52.5,percent of total billed charges,Implant Device,52.5,35,,52.5,percent of total billed charges,Implant Device,52.5,35,,52.5,percent of total billed charges,Implant Device,52.5,35,,52.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,111,
STRYKER 2102-2102 BONE GRAFT,C1713,HCPCS,,79001970,CDM,278,RC,,,both,,,4116,3045.85,,,3045.85,Other,150% of Medicare + 9.63% HCRA Surcharge,1852.2,45,,1852.2,percent of total billed charges,Critical Access Hospital RCC factor,1399.44,34,,1399.44,percent of total billed charges,Implant Device,1399.44,34,,1399.44,percent of total billed charges,Implant Device,1399.44,34,,1399.44,percent of total billed charges,Implant Device,1399.44,34,,1399.44,percent of total billed charges,Implant Device,1399.44,34,,1399.44,percent of total billed charges,Implant Device,2037.42,,,2037.42,Other,110% of Medicare,1440.6,35,,1440.6,percent of total billed charges,Implant Device,1399.44,34,"Charges > $500, x 34%",1399.44,percent of total billed charges,Implant Device,1440.6,35,,1440.6,percent of total billed charges,Implant Device,1440.6,35,,1440.6,percent of total billed charges,Implant Device,1440.6,35,,1440.6,percent of total billed charges,Implant Device,1440.6,35,,1440.6,percent of total billed charges,Implant Device,1440.6,35,,1440.6,percent of total billed charges,Implant Device,1646.4,40,,1646.4,percent of total billed charges,Implant Device,1440.6,70,,1440.6,percent of total billed charges,All Other,1399.44,34,,1399.44,percent of total billed charges,Implant Device,1399.44,34,,1399.44,percent of total billed charges,Implant Device,1440.6,35,,1440.6,percent of total billed charges,Implant Device,1440.6,35,,1440.6,percent of total billed charges,Implant Device,1440.6,35,,1440.6,percent of total billed charges,Implant Device,1440.6,35,,1440.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1399.44,34,"If Charge > 2,000, then 34 percent",1399.44,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3045.85,
ZIMMER 2102-2105 BONE GRAFT,C1713,HCPCS,,79001971,CDM,278,RC,,,both,,,7722,5714.3,,,5714.3,Other,150% of Medicare + 9.63% HCRA Surcharge,3474.9,45,,3474.9,percent of total billed charges,Critical Access Hospital RCC factor,2625.48,34,,2625.48,percent of total billed charges,Implant Device,2625.48,34,,2625.48,percent of total billed charges,Implant Device,2625.48,34,,2625.48,percent of total billed charges,Implant Device,2625.48,34,,2625.48,percent of total billed charges,Implant Device,2625.48,34,,2625.48,percent of total billed charges,Implant Device,3822.39,,,3822.39,Other,110% of Medicare,2702.7,35,,2702.7,percent of total billed charges,Implant Device,2625.48,34,"Charges > $500, x 34%",2625.48,percent of total billed charges,Implant Device,2702.7,35,,2702.7,percent of total billed charges,Implant Device,2702.7,35,,2702.7,percent of total billed charges,Implant Device,2702.7,35,,2702.7,percent of total billed charges,Implant Device,2702.7,35,,2702.7,percent of total billed charges,Implant Device,2702.7,35,,2702.7,percent of total billed charges,Implant Device,3088.8,40,,3088.8,percent of total billed charges,Implant Device,2702.7,70,,2702.7,percent of total billed charges,All Other,2625.48,34,,2625.48,percent of total billed charges,Implant Device,2625.48,34,,2625.48,percent of total billed charges,Implant Device,2702.7,35,,2702.7,percent of total billed charges,Implant Device,2702.7,35,,2702.7,percent of total billed charges,Implant Device,2702.7,35,,2702.7,percent of total billed charges,Implant Device,2702.7,35,,2702.7,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2625.48,34,"If Charge > 2,000, then 34 percent",2625.48,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5714.3,
PAC 3 21-11-3114 SPINAL PLATE,C1713,HCPCS,,79001973,CDM,278,RC,,,both,,,9000,6660.02,,,6660.02,Other,150% of Medicare + 9.63% HCRA Surcharge,4050,45,,4050,percent of total billed charges,Critical Access Hospital RCC factor,3060,34,,3060,percent of total billed charges,Implant Device,3060,34,,3060,percent of total billed charges,Implant Device,3060,34,,3060,percent of total billed charges,Implant Device,3060,34,,3060,percent of total billed charges,Implant Device,3060,34,,3060,percent of total billed charges,Implant Device,4455,,,4455,Other,110% of Medicare,3150,35,,3150,percent of total billed charges,Implant Device,3060,34,"Charges > $500, x 34%",3060,percent of total billed charges,Implant Device,3150,35,,3150,percent of total billed charges,Implant Device,3150,35,,3150,percent of total billed charges,Implant Device,3150,35,,3150,percent of total billed charges,Implant Device,3150,35,,3150,percent of total billed charges,Implant Device,3150,35,,3150,percent of total billed charges,Implant Device,3600,40,,3600,percent of total billed charges,Implant Device,3150,70,,3150,percent of total billed charges,All Other,3060,34,,3060,percent of total billed charges,Implant Device,3060,34,,3060,percent of total billed charges,Implant Device,3150,35,,3150,percent of total billed charges,Implant Device,3150,35,,3150,percent of total billed charges,Implant Device,3150,35,,3150,percent of total billed charges,Implant Device,3150,35,,3150,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3060,34,"If Charge > 2,000, then 34 percent",3060,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,6660.02,
PAC 3 21-LT-3112 MODULAR NECK,C1713,HCPCS,,79001974,CDM,278,RC,,,both,,,15000,11100.04,,,11100.04,Other,150% of Medicare + 9.63% HCRA Surcharge,6750,45,,6750,percent of total billed charges,Critical Access Hospital RCC factor,5100,34,,5100,percent of total billed charges,Implant Device,5100,34,,5100,percent of total billed charges,Implant Device,5100,34,,5100,percent of total billed charges,Implant Device,5100,34,,5100,percent of total billed charges,Implant Device,5100,34,,5100,percent of total billed charges,Implant Device,7425,,,7425,Other,110% of Medicare,5250,35,,5250,percent of total billed charges,Implant Device,5100,34,"Charges > $500, x 34%",5100,percent of total billed charges,Implant Device,5250,35,,5250,percent of total billed charges,Implant Device,5250,35,,5250,percent of total billed charges,Implant Device,5250,35,,5250,percent of total billed charges,Implant Device,5250,35,,5250,percent of total billed charges,Implant Device,5250,35,,5250,percent of total billed charges,Implant Device,6000,40,,6000,percent of total billed charges,Implant Device,5250,70,,5250,percent of total billed charges,All Other,5100,34,,5100,percent of total billed charges,Implant Device,5100,34,,5100,percent of total billed charges,Implant Device,5250,35,,5250,percent of total billed charges,Implant Device,5250,35,,5250,percent of total billed charges,Implant Device,5250,35,,5250,percent of total billed charges,Implant Device,5250,35,,5250,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,5100,34,"If Charge > 2,000, then 34 percent",5100,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,11100.04,
ZIMMER 2232-02-05-REV GTR PLATE,C1713,HCPCS,,79001975,CDM,278,RC,,,both,,,7720,5712.82,,,5712.82,Other,150% of Medicare + 9.63% HCRA Surcharge,3474,45,,3474,percent of total billed charges,Critical Access Hospital RCC factor,2624.8,34,,2624.8,percent of total billed charges,Implant Device,2624.8,34,,2624.8,percent of total billed charges,Implant Device,2624.8,34,,2624.8,percent of total billed charges,Implant Device,2624.8,34,,2624.8,percent of total billed charges,Implant Device,2624.8,34,,2624.8,percent of total billed charges,Implant Device,3821.4,,,3821.4,Other,110% of Medicare,2702,35,,2702,percent of total billed charges,Implant Device,2624.8,34,"Charges > $500, x 34%",2624.8,percent of total billed charges,Implant Device,2702,35,,2702,percent of total billed charges,Implant Device,2702,35,,2702,percent of total billed charges,Implant Device,2702,35,,2702,percent of total billed charges,Implant Device,2702,35,,2702,percent of total billed charges,Implant Device,2702,35,,2702,percent of total billed charges,Implant Device,3088,40,,3088,percent of total billed charges,Implant Device,2702,70,,2702,percent of total billed charges,All Other,2624.8,34,,2624.8,percent of total billed charges,Implant Device,2624.8,34,,2624.8,percent of total billed charges,Implant Device,2702,35,,2702,percent of total billed charges,Implant Device,2702,35,,2702,percent of total billed charges,Implant Device,2702,35,,2702,percent of total billed charges,Implant Device,2702,35,,2702,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2624.8,34,"If Charge > 2,000, then 34 percent",2624.8,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5712.82,
ZIMMER 2232-02-06-REV GTR PLATE,C1713,HCPCS,,79001976,CDM,278,RC,,,both,,,10568,7820.35,,,7820.35,Other,150% of Medicare + 9.63% HCRA Surcharge,4755.6,45,,4755.6,percent of total billed charges,Critical Access Hospital RCC factor,3593.12,34,,3593.12,percent of total billed charges,Implant Device,3593.12,34,,3593.12,percent of total billed charges,Implant Device,3593.12,34,,3593.12,percent of total billed charges,Implant Device,3593.12,34,,3593.12,percent of total billed charges,Implant Device,3593.12,34,,3593.12,percent of total billed charges,Implant Device,5231.16,,,5231.16,Other,110% of Medicare,3698.8,35,,3698.8,percent of total billed charges,Implant Device,3593.12,34,"Charges > $500, x 34%",3593.12,percent of total billed charges,Implant Device,3698.8,35,,3698.8,percent of total billed charges,Implant Device,3698.8,35,,3698.8,percent of total billed charges,Implant Device,3698.8,35,,3698.8,percent of total billed charges,Implant Device,3698.8,35,,3698.8,percent of total billed charges,Implant Device,3698.8,35,,3698.8,percent of total billed charges,Implant Device,4227.2,40,,4227.2,percent of total billed charges,Implant Device,3698.8,70,,3698.8,percent of total billed charges,All Other,3593.12,34,,3593.12,percent of total billed charges,Implant Device,3593.12,34,,3593.12,percent of total billed charges,Implant Device,3698.8,35,,3698.8,percent of total billed charges,Implant Device,3698.8,35,,3698.8,percent of total billed charges,Implant Device,3698.8,35,,3698.8,percent of total billed charges,Implant Device,3698.8,35,,3698.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3593.12,34,"If Charge > 2,000, then 34 percent",3593.12,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,7820.35,
ZIMMER 2347-17-04 PLATE,C1713,HCPCS,,79001980,CDM,278,RC,,,both,,,1260,932.4,,,932.4,Other,150% of Medicare + 9.63% HCRA Surcharge,567,45,,567,percent of total billed charges,Critical Access Hospital RCC factor,428.4,34,,428.4,percent of total billed charges,Implant Device,428.4,34,,428.4,percent of total billed charges,Implant Device,428.4,34,,428.4,percent of total billed charges,Implant Device,428.4,34,,428.4,percent of total billed charges,Implant Device,428.4,34,,428.4,percent of total billed charges,Implant Device,623.7,,,623.7,Other,110% of Medicare,441,35,,441,percent of total billed charges,Implant Device,428.4,34,"Charges > $500, x 34%",428.4,percent of total billed charges,Implant Device,441,35,,441,percent of total billed charges,Implant Device,441,35,,441,percent of total billed charges,Implant Device,441,35,,441,percent of total billed charges,Implant Device,441,35,,441,percent of total billed charges,Implant Device,441,35,,441,percent of total billed charges,Implant Device,504,40,,504,percent of total billed charges,Implant Device,441,70,,441,percent of total billed charges,All Other,428.4,34,,428.4,percent of total billed charges,Implant Device,428.4,34,,428.4,percent of total billed charges,Implant Device,441,35,,441,percent of total billed charges,Implant Device,441,35,,441,percent of total billed charges,Implant Device,441,35,,441,percent of total billed charges,Implant Device,441,35,,441,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,932.4,
ZIMMER 2357-101-14 PLATE,C1713,HCPCS,,79001981,CDM,278,RC,,,both,,,4872,3605.29,,,3605.29,Other,150% of Medicare + 9.63% HCRA Surcharge,2192.4,45,,2192.4,percent of total billed charges,Critical Access Hospital RCC factor,1656.48,34,,1656.48,percent of total billed charges,Implant Device,1656.48,34,,1656.48,percent of total billed charges,Implant Device,1656.48,34,,1656.48,percent of total billed charges,Implant Device,1656.48,34,,1656.48,percent of total billed charges,Implant Device,1656.48,34,,1656.48,percent of total billed charges,Implant Device,2411.64,,,2411.64,Other,110% of Medicare,1705.2,35,,1705.2,percent of total billed charges,Implant Device,1656.48,34,"Charges > $500, x 34%",1656.48,percent of total billed charges,Implant Device,1705.2,35,,1705.2,percent of total billed charges,Implant Device,1705.2,35,,1705.2,percent of total billed charges,Implant Device,1705.2,35,,1705.2,percent of total billed charges,Implant Device,1705.2,35,,1705.2,percent of total billed charges,Implant Device,1705.2,35,,1705.2,percent of total billed charges,Implant Device,1948.8,40,,1948.8,percent of total billed charges,Implant Device,1705.2,70,,1705.2,percent of total billed charges,All Other,1656.48,34,,1656.48,percent of total billed charges,Implant Device,1656.48,34,,1656.48,percent of total billed charges,Implant Device,1705.2,35,,1705.2,percent of total billed charges,Implant Device,1705.2,35,,1705.2,percent of total billed charges,Implant Device,1705.2,35,,1705.2,percent of total billed charges,Implant Device,1705.2,35,,1705.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1656.48,34,"If Charge > 2,000, then 34 percent",1656.48,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3605.29,
EXACTECH 300-01-07 HUMERAL STEM,C1776,HCPCS,,79001991,CDM,278,RC,,,both,,,4425,3274.51,,,3274.51,Other,150% of Medicare + 9.63% HCRA Surcharge,1991.25,45,,1991.25,percent of total billed charges,Critical Access Hospital RCC factor,1504.5,34,,1504.5,percent of total billed charges,Implant Device,1504.5,34,,1504.5,percent of total billed charges,Implant Device,1504.5,34,,1504.5,percent of total billed charges,Implant Device,1504.5,34,,1504.5,percent of total billed charges,Implant Device,1504.5,34,,1504.5,percent of total billed charges,Implant Device,2190.38,,,2190.38,Other,110% of Medicare,1548.75,35,,1548.75,percent of total billed charges,Implant Device,1504.5,34,"Charges > $500, x 34%",1504.5,percent of total billed charges,Implant Device,1548.75,35,,1548.75,percent of total billed charges,Implant Device,1548.75,35,,1548.75,percent of total billed charges,Implant Device,1548.75,35,,1548.75,percent of total billed charges,Implant Device,1548.75,35,,1548.75,percent of total billed charges,Implant Device,1548.75,35,,1548.75,percent of total billed charges,Implant Device,1770,40,,1770,percent of total billed charges,Implant Device,1548.75,70,,1548.75,percent of total billed charges,All Other,1504.5,34,,1504.5,percent of total billed charges,Implant Device,1504.5,34,,1504.5,percent of total billed charges,Implant Device,1548.75,35,,1548.75,percent of total billed charges,Implant Device,1548.75,35,,1548.75,percent of total billed charges,Implant Device,1548.75,35,,1548.75,percent of total billed charges,Implant Device,1548.75,35,,1548.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1504.5,34,"If Charge > 2,000, then 34 percent",1504.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3274.51,
EXACTECH 300-01-17 HUMERAL STEM,C1776,HCPCS,,79001992,CDM,278,RC,,,both,,,4425,3274.51,,,3274.51,Other,150% of Medicare + 9.63% HCRA Surcharge,1991.25,45,,1991.25,percent of total billed charges,Critical Access Hospital RCC factor,1504.5,34,,1504.5,percent of total billed charges,Implant Device,1504.5,34,,1504.5,percent of total billed charges,Implant Device,1504.5,34,,1504.5,percent of total billed charges,Implant Device,1504.5,34,,1504.5,percent of total billed charges,Implant Device,1504.5,34,,1504.5,percent of total billed charges,Implant Device,2190.38,,,2190.38,Other,110% of Medicare,1548.75,35,,1548.75,percent of total billed charges,Implant Device,1504.5,34,"Charges > $500, x 34%",1504.5,percent of total billed charges,Implant Device,1548.75,35,,1548.75,percent of total billed charges,Implant Device,1548.75,35,,1548.75,percent of total billed charges,Implant Device,1548.75,35,,1548.75,percent of total billed charges,Implant Device,1548.75,35,,1548.75,percent of total billed charges,Implant Device,1548.75,35,,1548.75,percent of total billed charges,Implant Device,1770,40,,1770,percent of total billed charges,Implant Device,1548.75,70,,1548.75,percent of total billed charges,All Other,1504.5,34,,1504.5,percent of total billed charges,Implant Device,1504.5,34,,1504.5,percent of total billed charges,Implant Device,1548.75,35,,1548.75,percent of total billed charges,Implant Device,1548.75,35,,1548.75,percent of total billed charges,Implant Device,1548.75,35,,1548.75,percent of total billed charges,Implant Device,1548.75,35,,1548.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1504.5,34,"If Charge > 2,000, then 34 percent",1504.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3274.51,
EXACTECH 300-10-15 PLATE,C1713,HCPCS,,79001993,CDM,278,RC,,,both,,,1890,1398.6,,,1398.6,Other,150% of Medicare + 9.63% HCRA Surcharge,850.5,45,,850.5,percent of total billed charges,Critical Access Hospital RCC factor,642.6,34,,642.6,percent of total billed charges,Implant Device,642.6,34,,642.6,percent of total billed charges,Implant Device,642.6,34,,642.6,percent of total billed charges,Implant Device,642.6,34,,642.6,percent of total billed charges,Implant Device,642.6,34,,642.6,percent of total billed charges,Implant Device,935.55,,,935.55,Other,110% of Medicare,661.5,35,,661.5,percent of total billed charges,Implant Device,642.6,34,"Charges > $500, x 34%",642.6,percent of total billed charges,Implant Device,661.5,35,,661.5,percent of total billed charges,Implant Device,661.5,35,,661.5,percent of total billed charges,Implant Device,661.5,35,,661.5,percent of total billed charges,Implant Device,661.5,35,,661.5,percent of total billed charges,Implant Device,661.5,35,,661.5,percent of total billed charges,Implant Device,756,40,,756,percent of total billed charges,Implant Device,661.5,70,,661.5,percent of total billed charges,All Other,642.6,34,,642.6,percent of total billed charges,Implant Device,642.6,34,,642.6,percent of total billed charges,Implant Device,661.5,35,,661.5,percent of total billed charges,Implant Device,661.5,35,,661.5,percent of total billed charges,Implant Device,661.5,35,,661.5,percent of total billed charges,Implant Device,661.5,35,,661.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1398.6,
EXACTECH 300-21-00 OMM KIT,C1776,HCPCS,,79001994,CDM,278,RC,,,both,,,1890,1398.6,,,1398.6,Other,150% of Medicare + 9.63% HCRA Surcharge,850.5,45,,850.5,percent of total billed charges,Critical Access Hospital RCC factor,642.6,34,,642.6,percent of total billed charges,Implant Device,642.6,34,,642.6,percent of total billed charges,Implant Device,642.6,34,,642.6,percent of total billed charges,Implant Device,642.6,34,,642.6,percent of total billed charges,Implant Device,642.6,34,,642.6,percent of total billed charges,Implant Device,935.55,,,935.55,Other,110% of Medicare,661.5,35,,661.5,percent of total billed charges,Implant Device,642.6,34,"Charges > $500, x 34%",642.6,percent of total billed charges,Implant Device,661.5,35,,661.5,percent of total billed charges,Implant Device,661.5,35,,661.5,percent of total billed charges,Implant Device,661.5,35,,661.5,percent of total billed charges,Implant Device,661.5,35,,661.5,percent of total billed charges,Implant Device,661.5,35,,661.5,percent of total billed charges,Implant Device,756,40,,756,percent of total billed charges,Implant Device,661.5,70,,661.5,percent of total billed charges,All Other,642.6,34,,642.6,percent of total billed charges,Implant Device,642.6,34,,642.6,percent of total billed charges,Implant Device,661.5,35,,661.5,percent of total billed charges,Implant Device,661.5,35,,661.5,percent of total billed charges,Implant Device,661.5,35,,661.5,percent of total billed charges,Implant Device,661.5,35,,661.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1398.6,
ACUMED 30-0236 SCREW,C1713,HCPCS,,79001995,CDM,278,RC,,,both,,,507,375.18,,,375.18,Other,150% of Medicare + 9.63% HCRA Surcharge,228.15,45,,228.15,percent of total billed charges,Critical Access Hospital RCC factor,172.38,34,,172.38,percent of total billed charges,Implant Device,172.38,34,,172.38,percent of total billed charges,Implant Device,172.38,34,,172.38,percent of total billed charges,Implant Device,172.38,34,,172.38,percent of total billed charges,Implant Device,172.38,34,,172.38,percent of total billed charges,Implant Device,250.97,,,250.97,Other,110% of Medicare,177.45,35,,177.45,percent of total billed charges,Implant Device,172.38,34,"Charges > $500, x 34%",172.38,percent of total billed charges,Implant Device,177.45,35,,177.45,percent of total billed charges,Implant Device,177.45,35,,177.45,percent of total billed charges,Implant Device,177.45,35,,177.45,percent of total billed charges,Implant Device,177.45,35,,177.45,percent of total billed charges,Implant Device,177.45,35,,177.45,percent of total billed charges,Implant Device,202.8,40,,202.8,percent of total billed charges,Implant Device,177.45,70,,177.45,percent of total billed charges,All Other,172.38,34,,172.38,percent of total billed charges,Implant Device,172.38,34,,172.38,percent of total billed charges,Implant Device,177.45,35,,177.45,percent of total billed charges,Implant Device,177.45,35,,177.45,percent of total billed charges,Implant Device,177.45,35,,177.45,percent of total billed charges,Implant Device,177.45,35,,177.45,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,375.18,
ACUMED 30-0238 SCREW,C1713,HCPCS,,79001996,CDM,278,RC,,,both,,,424,313.76,,,313.76,Other,150% of Medicare + 9.63% HCRA Surcharge,190.8,45,,190.8,percent of total billed charges,Critical Access Hospital RCC factor,144.16,34,,144.16,percent of total billed charges,Implant Device,144.16,34,,144.16,percent of total billed charges,Implant Device,144.16,34,,144.16,percent of total billed charges,Implant Device,144.16,34,,144.16,percent of total billed charges,Implant Device,144.16,34,,144.16,percent of total billed charges,Implant Device,209.88,,,209.88,Other,110% of Medicare,148.4,35,,148.4,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,148.4,35,,148.4,percent of total billed charges,Implant Device,148.4,35,,148.4,percent of total billed charges,Implant Device,148.4,35,,148.4,percent of total billed charges,Implant Device,148.4,35,,148.4,percent of total billed charges,Implant Device,148.4,35,,148.4,percent of total billed charges,Implant Device,169.6,40,,169.6,percent of total billed charges,Implant Device,148.4,70,,148.4,percent of total billed charges,All Other,144.16,34,,144.16,percent of total billed charges,Implant Device,144.16,34,,144.16,percent of total billed charges,Implant Device,148.4,35,,148.4,percent of total billed charges,Implant Device,148.4,35,,148.4,percent of total billed charges,Implant Device,148.4,35,,148.4,percent of total billed charges,Implant Device,148.4,35,,148.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,313.76,
ACUMED 30-0248 SCREW 3.5X40,C1713,HCPCS,,79001997,CDM,278,RC,,,both,,,426,315.24,,,315.24,Other,150% of Medicare + 9.63% HCRA Surcharge,191.7,45,,191.7,percent of total billed charges,Critical Access Hospital RCC factor,144.84,34,,144.84,percent of total billed charges,Implant Device,144.84,34,,144.84,percent of total billed charges,Implant Device,144.84,34,,144.84,percent of total billed charges,Implant Device,144.84,34,,144.84,percent of total billed charges,Implant Device,144.84,34,,144.84,percent of total billed charges,Implant Device,210.87,,,210.87,Other,110% of Medicare,149.1,35,,149.1,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,149.1,35,,149.1,percent of total billed charges,Implant Device,149.1,35,,149.1,percent of total billed charges,Implant Device,149.1,35,,149.1,percent of total billed charges,Implant Device,149.1,35,,149.1,percent of total billed charges,Implant Device,149.1,35,,149.1,percent of total billed charges,Implant Device,170.4,40,,170.4,percent of total billed charges,Implant Device,149.1,70,,149.1,percent of total billed charges,All Other,144.84,34,,144.84,percent of total billed charges,Implant Device,144.84,34,,144.84,percent of total billed charges,Implant Device,149.1,35,,149.1,percent of total billed charges,Implant Device,149.1,35,,149.1,percent of total billed charges,Implant Device,149.1,35,,149.1,percent of total billed charges,Implant Device,149.1,35,,149.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,315.24,
ACUMED 30-0249 SCREW,C1713,HCPCS,,79001998,CDM,278,RC,,,both,,,424,313.76,,,313.76,Other,150% of Medicare + 9.63% HCRA Surcharge,190.8,45,,190.8,percent of total billed charges,Critical Access Hospital RCC factor,144.16,34,,144.16,percent of total billed charges,Implant Device,144.16,34,,144.16,percent of total billed charges,Implant Device,144.16,34,,144.16,percent of total billed charges,Implant Device,144.16,34,,144.16,percent of total billed charges,Implant Device,144.16,34,,144.16,percent of total billed charges,Implant Device,209.88,,,209.88,Other,110% of Medicare,148.4,35,,148.4,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,148.4,35,,148.4,percent of total billed charges,Implant Device,148.4,35,,148.4,percent of total billed charges,Implant Device,148.4,35,,148.4,percent of total billed charges,Implant Device,148.4,35,,148.4,percent of total billed charges,Implant Device,148.4,35,,148.4,percent of total billed charges,Implant Device,169.6,40,,169.6,percent of total billed charges,Implant Device,148.4,70,,148.4,percent of total billed charges,All Other,144.16,34,,144.16,percent of total billed charges,Implant Device,144.16,34,,144.16,percent of total billed charges,Implant Device,148.4,35,,148.4,percent of total billed charges,Implant Device,148.4,35,,148.4,percent of total billed charges,Implant Device,148.4,35,,148.4,percent of total billed charges,Implant Device,148.4,35,,148.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,313.76,
ACUMED 30-0259 SCREW,C1713,HCPCS,,79001999,CDM,278,RC,,,both,,,270,199.8,,,199.8,Other,150% of Medicare + 9.63% HCRA Surcharge,121.5,45,,121.5,percent of total billed charges,Critical Access Hospital RCC factor,91.8,34,,91.8,percent of total billed charges,Implant Device,91.8,34,,91.8,percent of total billed charges,Implant Device,91.8,34,,91.8,percent of total billed charges,Implant Device,91.8,34,,91.8,percent of total billed charges,Implant Device,91.8,34,,91.8,percent of total billed charges,Implant Device,133.65,,,133.65,Other,110% of Medicare,94.5,35,,94.5,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,94.5,35,,94.5,percent of total billed charges,Implant Device,94.5,35,,94.5,percent of total billed charges,Implant Device,94.5,35,,94.5,percent of total billed charges,Implant Device,94.5,35,,94.5,percent of total billed charges,Implant Device,94.5,35,,94.5,percent of total billed charges,Implant Device,108,40,,108,percent of total billed charges,Implant Device,94.5,70,,94.5,percent of total billed charges,All Other,91.8,34,,91.8,percent of total billed charges,Implant Device,91.8,34,,91.8,percent of total billed charges,Implant Device,94.5,35,,94.5,percent of total billed charges,Implant Device,94.5,35,,94.5,percent of total billed charges,Implant Device,94.5,35,,94.5,percent of total billed charges,Implant Device,94.5,35,,94.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,199.8,
ACUMED 30-0260 SCREW,C1713,HCPCS,,79002000,CDM,278,RC,,,both,,,270,199.8,,,199.8,Other,150% of Medicare + 9.63% HCRA Surcharge,121.5,45,,121.5,percent of total billed charges,Critical Access Hospital RCC factor,91.8,34,,91.8,percent of total billed charges,Implant Device,91.8,34,,91.8,percent of total billed charges,Implant Device,91.8,34,,91.8,percent of total billed charges,Implant Device,91.8,34,,91.8,percent of total billed charges,Implant Device,91.8,34,,91.8,percent of total billed charges,Implant Device,133.65,,,133.65,Other,110% of Medicare,94.5,35,,94.5,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,94.5,35,,94.5,percent of total billed charges,Implant Device,94.5,35,,94.5,percent of total billed charges,Implant Device,94.5,35,,94.5,percent of total billed charges,Implant Device,94.5,35,,94.5,percent of total billed charges,Implant Device,94.5,35,,94.5,percent of total billed charges,Implant Device,108,40,,108,percent of total billed charges,Implant Device,94.5,70,,94.5,percent of total billed charges,All Other,91.8,34,,91.8,percent of total billed charges,Implant Device,91.8,34,,91.8,percent of total billed charges,Implant Device,94.5,35,,94.5,percent of total billed charges,Implant Device,94.5,35,,94.5,percent of total billed charges,Implant Device,94.5,35,,94.5,percent of total billed charges,Implant Device,94.5,35,,94.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,199.8,
ACUMED 30-0265 SCREW,C1713,HCPCS,,79002001,CDM,278,RC,,,both,,,274,202.76,,,202.76,Other,150% of Medicare + 9.63% HCRA Surcharge,123.3,45,,123.3,percent of total billed charges,Critical Access Hospital RCC factor,93.16,34,,93.16,percent of total billed charges,Implant Device,93.16,34,,93.16,percent of total billed charges,Implant Device,93.16,34,,93.16,percent of total billed charges,Implant Device,93.16,34,,93.16,percent of total billed charges,Implant Device,93.16,34,,93.16,percent of total billed charges,Implant Device,135.63,,,135.63,Other,110% of Medicare,95.9,35,,95.9,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,95.9,35,,95.9,percent of total billed charges,Implant Device,95.9,35,,95.9,percent of total billed charges,Implant Device,95.9,35,,95.9,percent of total billed charges,Implant Device,95.9,35,,95.9,percent of total billed charges,Implant Device,95.9,35,,95.9,percent of total billed charges,Implant Device,109.6,40,,109.6,percent of total billed charges,Implant Device,95.9,70,,95.9,percent of total billed charges,All Other,93.16,34,,93.16,percent of total billed charges,Implant Device,93.16,34,,93.16,percent of total billed charges,Implant Device,95.9,35,,95.9,percent of total billed charges,Implant Device,95.9,35,,95.9,percent of total billed charges,Implant Device,95.9,35,,95.9,percent of total billed charges,Implant Device,95.9,35,,95.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,202.76,
ACUMED 30-0326 SCREW,C1713,HCPCS,,79002002,CDM,278,RC,,,both,,,426,315.24,,,315.24,Other,150% of Medicare + 9.63% HCRA Surcharge,191.7,45,,191.7,percent of total billed charges,Critical Access Hospital RCC factor,144.84,34,,144.84,percent of total billed charges,Implant Device,144.84,34,,144.84,percent of total billed charges,Implant Device,144.84,34,,144.84,percent of total billed charges,Implant Device,144.84,34,,144.84,percent of total billed charges,Implant Device,144.84,34,,144.84,percent of total billed charges,Implant Device,210.87,,,210.87,Other,110% of Medicare,149.1,35,,149.1,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,149.1,35,,149.1,percent of total billed charges,Implant Device,149.1,35,,149.1,percent of total billed charges,Implant Device,149.1,35,,149.1,percent of total billed charges,Implant Device,149.1,35,,149.1,percent of total billed charges,Implant Device,149.1,35,,149.1,percent of total billed charges,Implant Device,170.4,40,,170.4,percent of total billed charges,Implant Device,149.1,70,,149.1,percent of total billed charges,All Other,144.84,34,,144.84,percent of total billed charges,Implant Device,144.84,34,,144.84,percent of total billed charges,Implant Device,149.1,35,,149.1,percent of total billed charges,Implant Device,149.1,35,,149.1,percent of total billed charges,Implant Device,149.1,35,,149.1,percent of total billed charges,Implant Device,149.1,35,,149.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,315.24,
ACUMED 30-0327 SCREW,C1713,HCPCS,,79002003,CDM,278,RC,,,both,,,424,313.76,,,313.76,Other,150% of Medicare + 9.63% HCRA Surcharge,190.8,45,,190.8,percent of total billed charges,Critical Access Hospital RCC factor,144.16,34,,144.16,percent of total billed charges,Implant Device,144.16,34,,144.16,percent of total billed charges,Implant Device,144.16,34,,144.16,percent of total billed charges,Implant Device,144.16,34,,144.16,percent of total billed charges,Implant Device,144.16,34,,144.16,percent of total billed charges,Implant Device,209.88,,,209.88,Other,110% of Medicare,148.4,35,,148.4,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,148.4,35,,148.4,percent of total billed charges,Implant Device,148.4,35,,148.4,percent of total billed charges,Implant Device,148.4,35,,148.4,percent of total billed charges,Implant Device,148.4,35,,148.4,percent of total billed charges,Implant Device,148.4,35,,148.4,percent of total billed charges,Implant Device,169.6,40,,169.6,percent of total billed charges,Implant Device,148.4,70,,148.4,percent of total billed charges,All Other,144.16,34,,144.16,percent of total billed charges,Implant Device,144.16,34,,144.16,percent of total billed charges,Implant Device,148.4,35,,148.4,percent of total billed charges,Implant Device,148.4,35,,148.4,percent of total billed charges,Implant Device,148.4,35,,148.4,percent of total billed charges,Implant Device,148.4,35,,148.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,313.76,
ACUMED 30-0328 SCREW,C1713,HCPCS,,79002004,CDM,278,RC,,,both,,,510,377.4,,,377.4,Other,150% of Medicare + 9.63% HCRA Surcharge,229.5,45,,229.5,percent of total billed charges,Critical Access Hospital RCC factor,173.4,34,,173.4,percent of total billed charges,Implant Device,173.4,34,,173.4,percent of total billed charges,Implant Device,173.4,34,,173.4,percent of total billed charges,Implant Device,173.4,34,,173.4,percent of total billed charges,Implant Device,173.4,34,,173.4,percent of total billed charges,Implant Device,252.45,,,252.45,Other,110% of Medicare,178.5,35,,178.5,percent of total billed charges,Implant Device,173.4,34,"Charges > $500, x 34%",173.4,percent of total billed charges,Implant Device,178.5,35,,178.5,percent of total billed charges,Implant Device,178.5,35,,178.5,percent of total billed charges,Implant Device,178.5,35,,178.5,percent of total billed charges,Implant Device,178.5,35,,178.5,percent of total billed charges,Implant Device,178.5,35,,178.5,percent of total billed charges,Implant Device,204,40,,204,percent of total billed charges,Implant Device,178.5,70,,178.5,percent of total billed charges,All Other,173.4,34,,173.4,percent of total billed charges,Implant Device,173.4,34,,173.4,percent of total billed charges,Implant Device,178.5,35,,178.5,percent of total billed charges,Implant Device,178.5,35,,178.5,percent of total billed charges,Implant Device,178.5,35,,178.5,percent of total billed charges,Implant Device,178.5,35,,178.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,377.4,
ACUMED 30-0348 SCREW 2.7X18,C1713,HCPCS,,79002005,CDM,278,RC,,,both,,,262,193.88,,,193.88,Other,150% of Medicare + 9.63% HCRA Surcharge,117.9,45,,117.9,percent of total billed charges,Critical Access Hospital RCC factor,89.08,34,,89.08,percent of total billed charges,Implant Device,89.08,34,,89.08,percent of total billed charges,Implant Device,89.08,34,,89.08,percent of total billed charges,Implant Device,89.08,34,,89.08,percent of total billed charges,Implant Device,89.08,34,,89.08,percent of total billed charges,Implant Device,129.69,,,129.69,Other,110% of Medicare,91.7,35,,91.7,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,91.7,35,,91.7,percent of total billed charges,Implant Device,91.7,35,,91.7,percent of total billed charges,Implant Device,91.7,35,,91.7,percent of total billed charges,Implant Device,91.7,35,,91.7,percent of total billed charges,Implant Device,91.7,35,,91.7,percent of total billed charges,Implant Device,104.8,40,,104.8,percent of total billed charges,Implant Device,91.7,70,,91.7,percent of total billed charges,All Other,89.08,34,,89.08,percent of total billed charges,Implant Device,89.08,34,,89.08,percent of total billed charges,Implant Device,91.7,35,,91.7,percent of total billed charges,Implant Device,91.7,35,,91.7,percent of total billed charges,Implant Device,91.7,35,,91.7,percent of total billed charges,Implant Device,91.7,35,,91.7,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,193.88,
EXACTECH 304-21-07 FRACTURE STEM,C1776,HCPCS,,79002006,CDM,278,RC,,,both,,,6225,4606.52,,,4606.52,Other,150% of Medicare + 9.63% HCRA Surcharge,2801.25,45,,2801.25,percent of total billed charges,Critical Access Hospital RCC factor,2116.5,34,,2116.5,percent of total billed charges,Implant Device,2116.5,34,,2116.5,percent of total billed charges,Implant Device,2116.5,34,,2116.5,percent of total billed charges,Implant Device,2116.5,34,,2116.5,percent of total billed charges,Implant Device,2116.5,34,,2116.5,percent of total billed charges,Implant Device,3081.38,,,3081.38,Other,110% of Medicare,2178.75,35,,2178.75,percent of total billed charges,Implant Device,2116.5,34,"Charges > $500, x 34%",2116.5,percent of total billed charges,Implant Device,2178.75,35,,2178.75,percent of total billed charges,Implant Device,2178.75,35,,2178.75,percent of total billed charges,Implant Device,2178.75,35,,2178.75,percent of total billed charges,Implant Device,2178.75,35,,2178.75,percent of total billed charges,Implant Device,2178.75,35,,2178.75,percent of total billed charges,Implant Device,2490,40,,2490,percent of total billed charges,Implant Device,2178.75,70,,2178.75,percent of total billed charges,All Other,2116.5,34,,2116.5,percent of total billed charges,Implant Device,2116.5,34,,2116.5,percent of total billed charges,Implant Device,2178.75,35,,2178.75,percent of total billed charges,Implant Device,2178.75,35,,2178.75,percent of total billed charges,Implant Device,2178.75,35,,2178.75,percent of total billed charges,Implant Device,2178.75,35,,2178.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2116.5,34,"If Charge > 2,000, then 34 percent",2116.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4606.52,
EXACTECH 304-22-09 HUMERAL STEM,C1713,HCPCS,,79002007,CDM,278,RC,,,both,,,6225,4606.52,,,4606.52,Other,150% of Medicare + 9.63% HCRA Surcharge,2801.25,45,,2801.25,percent of total billed charges,Critical Access Hospital RCC factor,2116.5,34,,2116.5,percent of total billed charges,Implant Device,2116.5,34,,2116.5,percent of total billed charges,Implant Device,2116.5,34,,2116.5,percent of total billed charges,Implant Device,2116.5,34,,2116.5,percent of total billed charges,Implant Device,2116.5,34,,2116.5,percent of total billed charges,Implant Device,3081.38,,,3081.38,Other,110% of Medicare,2178.75,35,,2178.75,percent of total billed charges,Implant Device,2116.5,34,"Charges > $500, x 34%",2116.5,percent of total billed charges,Implant Device,2178.75,35,,2178.75,percent of total billed charges,Implant Device,2178.75,35,,2178.75,percent of total billed charges,Implant Device,2178.75,35,,2178.75,percent of total billed charges,Implant Device,2178.75,35,,2178.75,percent of total billed charges,Implant Device,2178.75,35,,2178.75,percent of total billed charges,Implant Device,2490,40,,2490,percent of total billed charges,Implant Device,2178.75,70,,2178.75,percent of total billed charges,All Other,2116.5,34,,2116.5,percent of total billed charges,Implant Device,2116.5,34,,2116.5,percent of total billed charges,Implant Device,2178.75,35,,2178.75,percent of total billed charges,Implant Device,2178.75,35,,2178.75,percent of total billed charges,Implant Device,2178.75,35,,2178.75,percent of total billed charges,Implant Device,2178.75,35,,2178.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2116.5,34,"If Charge > 2,000, then 34 percent",2116.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4606.52,
EXACTECH 304-22-11 HUMERAL STEM,C1776,HCPCS,,79002008,CDM,278,RC,,,both,,,6225,4606.52,,,4606.52,Other,150% of Medicare + 9.63% HCRA Surcharge,2801.25,45,,2801.25,percent of total billed charges,Critical Access Hospital RCC factor,2116.5,34,,2116.5,percent of total billed charges,Implant Device,2116.5,34,,2116.5,percent of total billed charges,Implant Device,2116.5,34,,2116.5,percent of total billed charges,Implant Device,2116.5,34,,2116.5,percent of total billed charges,Implant Device,2116.5,34,,2116.5,percent of total billed charges,Implant Device,3081.38,,,3081.38,Other,110% of Medicare,2178.75,35,,2178.75,percent of total billed charges,Implant Device,2116.5,34,"Charges > $500, x 34%",2116.5,percent of total billed charges,Implant Device,2178.75,35,,2178.75,percent of total billed charges,Implant Device,2178.75,35,,2178.75,percent of total billed charges,Implant Device,2178.75,35,,2178.75,percent of total billed charges,Implant Device,2178.75,35,,2178.75,percent of total billed charges,Implant Device,2178.75,35,,2178.75,percent of total billed charges,Implant Device,2490,40,,2490,percent of total billed charges,Implant Device,2178.75,70,,2178.75,percent of total billed charges,All Other,2116.5,34,,2116.5,percent of total billed charges,Implant Device,2116.5,34,,2116.5,percent of total billed charges,Implant Device,2178.75,35,,2178.75,percent of total billed charges,Implant Device,2178.75,35,,2178.75,percent of total billed charges,Implant Device,2178.75,35,,2178.75,percent of total billed charges,Implant Device,2178.75,35,,2178.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2116.5,34,"If Charge > 2,000, then 34 percent",2116.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4606.52,
EXACTECH 306-01-08 HUMERAL STEM,C1776,HCPCS,,79002009,CDM,278,RC,,,both,,,12852,9510.51,,,9510.51,Other,150% of Medicare + 9.63% HCRA Surcharge,5783.4,45,,5783.4,percent of total billed charges,Critical Access Hospital RCC factor,4369.68,34,,4369.68,percent of total billed charges,Implant Device,4369.68,34,,4369.68,percent of total billed charges,Implant Device,4369.68,34,,4369.68,percent of total billed charges,Implant Device,4369.68,34,,4369.68,percent of total billed charges,Implant Device,4369.68,34,,4369.68,percent of total billed charges,Implant Device,6361.74,,,6361.74,Other,110% of Medicare,4498.2,35,,4498.2,percent of total billed charges,Implant Device,4369.68,34,"Charges > $500, x 34%",4369.68,percent of total billed charges,Implant Device,4498.2,35,,4498.2,percent of total billed charges,Implant Device,4498.2,35,,4498.2,percent of total billed charges,Implant Device,4498.2,35,,4498.2,percent of total billed charges,Implant Device,4498.2,35,,4498.2,percent of total billed charges,Implant Device,4498.2,35,,4498.2,percent of total billed charges,Implant Device,5140.8,40,,5140.8,percent of total billed charges,Implant Device,4498.2,70,,4498.2,percent of total billed charges,All Other,4369.68,34,,4369.68,percent of total billed charges,Implant Device,4369.68,34,,4369.68,percent of total billed charges,Implant Device,4498.2,35,,4498.2,percent of total billed charges,Implant Device,4498.2,35,,4498.2,percent of total billed charges,Implant Device,4498.2,35,,4498.2,percent of total billed charges,Implant Device,4498.2,35,,4498.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,4369.68,34,"If Charge > 2,000, then 34 percent",4369.68,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,9510.51,
EXACTECH 310-01-38 HUMERAL HEAD,C1776,HCPCS,,79002010,CDM,278,RC,,,both,,,4968,3676.33,,,3676.33,Other,150% of Medicare + 9.63% HCRA Surcharge,2235.6,45,,2235.6,percent of total billed charges,Critical Access Hospital RCC factor,1689.12,34,,1689.12,percent of total billed charges,Implant Device,1689.12,34,,1689.12,percent of total billed charges,Implant Device,1689.12,34,,1689.12,percent of total billed charges,Implant Device,1689.12,34,,1689.12,percent of total billed charges,Implant Device,1689.12,34,,1689.12,percent of total billed charges,Implant Device,2459.16,,,2459.16,Other,110% of Medicare,1738.8,35,,1738.8,percent of total billed charges,Implant Device,1689.12,34,"Charges > $500, x 34%",1689.12,percent of total billed charges,Implant Device,1738.8,35,,1738.8,percent of total billed charges,Implant Device,1738.8,35,,1738.8,percent of total billed charges,Implant Device,1738.8,35,,1738.8,percent of total billed charges,Implant Device,1738.8,35,,1738.8,percent of total billed charges,Implant Device,1738.8,35,,1738.8,percent of total billed charges,Implant Device,1987.2,40,,1987.2,percent of total billed charges,Implant Device,1738.8,70,,1738.8,percent of total billed charges,All Other,1689.12,34,,1689.12,percent of total billed charges,Implant Device,1689.12,34,,1689.12,percent of total billed charges,Implant Device,1738.8,35,,1738.8,percent of total billed charges,Implant Device,1738.8,35,,1738.8,percent of total billed charges,Implant Device,1738.8,35,,1738.8,percent of total billed charges,Implant Device,1738.8,35,,1738.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1689.12,34,"If Charge > 2,000, then 34 percent",1689.12,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3676.33,
EXACTECH 310-01-50 HUMERAL HEAD,C1776,HCPCS,,79002011,CDM,278,RC,,,both,,,3150,2331.01,,,2331.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1417.5,45,,1417.5,percent of total billed charges,Critical Access Hospital RCC factor,1071,34,,1071,percent of total billed charges,Implant Device,1071,34,,1071,percent of total billed charges,Implant Device,1071,34,,1071,percent of total billed charges,Implant Device,1071,34,,1071,percent of total billed charges,Implant Device,1071,34,,1071,percent of total billed charges,Implant Device,1559.25,,,1559.25,Other,110% of Medicare,1102.5,35,,1102.5,percent of total billed charges,Implant Device,1071,34,"Charges > $500, x 34%",1071,percent of total billed charges,Implant Device,1102.5,35,,1102.5,percent of total billed charges,Implant Device,1102.5,35,,1102.5,percent of total billed charges,Implant Device,1102.5,35,,1102.5,percent of total billed charges,Implant Device,1102.5,35,,1102.5,percent of total billed charges,Implant Device,1102.5,35,,1102.5,percent of total billed charges,Implant Device,1260,40,,1260,percent of total billed charges,Implant Device,1102.5,70,,1102.5,percent of total billed charges,All Other,1071,34,,1071,percent of total billed charges,Implant Device,1071,34,,1071,percent of total billed charges,Implant Device,1102.5,35,,1102.5,percent of total billed charges,Implant Device,1102.5,35,,1102.5,percent of total billed charges,Implant Device,1102.5,35,,1102.5,percent of total billed charges,Implant Device,1102.5,35,,1102.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1071,34,"If Charge > 2,000, then 34 percent",1071,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2331.01,
STRYKER 3125-0170S NAIL KIT,C1713,HCPCS,,79002012,CDM,278,RC,,,both,,,2928,2166.73,,,2166.73,Other,150% of Medicare + 9.63% HCRA Surcharge,1317.6,45,,1317.6,percent of total billed charges,Critical Access Hospital RCC factor,995.52,34,,995.52,percent of total billed charges,Implant Device,995.52,34,,995.52,percent of total billed charges,Implant Device,995.52,34,,995.52,percent of total billed charges,Implant Device,995.52,34,,995.52,percent of total billed charges,Implant Device,995.52,34,,995.52,percent of total billed charges,Implant Device,1449.36,,,1449.36,Other,110% of Medicare,1024.8,35,,1024.8,percent of total billed charges,Implant Device,995.52,34,"Charges > $500, x 34%",995.52,percent of total billed charges,Implant Device,1024.8,35,,1024.8,percent of total billed charges,Implant Device,1024.8,35,,1024.8,percent of total billed charges,Implant Device,1024.8,35,,1024.8,percent of total billed charges,Implant Device,1024.8,35,,1024.8,percent of total billed charges,Implant Device,1024.8,35,,1024.8,percent of total billed charges,Implant Device,1171.2,40,,1171.2,percent of total billed charges,Implant Device,1024.8,70,,1024.8,percent of total billed charges,All Other,995.52,34,,995.52,percent of total billed charges,Implant Device,995.52,34,,995.52,percent of total billed charges,Implant Device,1024.8,35,,1024.8,percent of total billed charges,Implant Device,1024.8,35,,1024.8,percent of total billed charges,Implant Device,1024.8,35,,1024.8,percent of total billed charges,Implant Device,1024.8,35,,1024.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,995.52,34,"If Charge > 2,000, then 34 percent",995.52,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2166.73,
EXACTECH 314-02-34 GLENOID POST,C1776,HCPCS,,79002013,CDM,278,RC,,,both,,,7992,5914.1,,,5914.1,Other,150% of Medicare + 9.63% HCRA Surcharge,3596.4,45,,3596.4,percent of total billed charges,Critical Access Hospital RCC factor,2717.28,34,,2717.28,percent of total billed charges,Implant Device,2717.28,34,,2717.28,percent of total billed charges,Implant Device,2717.28,34,,2717.28,percent of total billed charges,Implant Device,2717.28,34,,2717.28,percent of total billed charges,Implant Device,2717.28,34,,2717.28,percent of total billed charges,Implant Device,3956.04,,,3956.04,Other,110% of Medicare,2797.2,35,,2797.2,percent of total billed charges,Implant Device,2717.28,34,"Charges > $500, x 34%",2717.28,percent of total billed charges,Implant Device,2797.2,35,,2797.2,percent of total billed charges,Implant Device,2797.2,35,,2797.2,percent of total billed charges,Implant Device,2797.2,35,,2797.2,percent of total billed charges,Implant Device,2797.2,35,,2797.2,percent of total billed charges,Implant Device,2797.2,35,,2797.2,percent of total billed charges,Implant Device,3196.8,40,,3196.8,percent of total billed charges,Implant Device,2797.2,70,,2797.2,percent of total billed charges,All Other,2717.28,34,,2717.28,percent of total billed charges,Implant Device,2717.28,34,,2717.28,percent of total billed charges,Implant Device,2797.2,35,,2797.2,percent of total billed charges,Implant Device,2797.2,35,,2797.2,percent of total billed charges,Implant Device,2797.2,35,,2797.2,percent of total billed charges,Implant Device,2797.2,35,,2797.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2717.28,34,"If Charge > 2,000, then 34 percent",2717.28,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5914.1,
EXACTECH 320-01-42 GLENOSPHERE,C1776,HCPCS,,79002014,CDM,278,RC,,,both,,,4050,2997.01,,,2997.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1822.5,45,,1822.5,percent of total billed charges,Critical Access Hospital RCC factor,1377,34,,1377,percent of total billed charges,Implant Device,1377,34,,1377,percent of total billed charges,Implant Device,1377,34,,1377,percent of total billed charges,Implant Device,1377,34,,1377,percent of total billed charges,Implant Device,1377,34,,1377,percent of total billed charges,Implant Device,2004.75,,,2004.75,Other,110% of Medicare,1417.5,35,,1417.5,percent of total billed charges,Implant Device,1377,34,"Charges > $500, x 34%",1377,percent of total billed charges,Implant Device,1417.5,35,,1417.5,percent of total billed charges,Implant Device,1417.5,35,,1417.5,percent of total billed charges,Implant Device,1417.5,35,,1417.5,percent of total billed charges,Implant Device,1417.5,35,,1417.5,percent of total billed charges,Implant Device,1417.5,35,,1417.5,percent of total billed charges,Implant Device,1620,40,,1620,percent of total billed charges,Implant Device,1417.5,70,,1417.5,percent of total billed charges,All Other,1377,34,,1377,percent of total billed charges,Implant Device,1377,34,,1377,percent of total billed charges,Implant Device,1417.5,35,,1417.5,percent of total billed charges,Implant Device,1417.5,35,,1417.5,percent of total billed charges,Implant Device,1417.5,35,,1417.5,percent of total billed charges,Implant Device,1417.5,35,,1417.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1377,34,"If Charge > 2,000, then 34 percent",1377,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2997.01,
EXACTECH 320-02-42 GLENOSPHERE,C1776,HCPCS,,79002015,CDM,278,RC,,,both,,,10020,7414.83,,,7414.83,Other,150% of Medicare + 9.63% HCRA Surcharge,4509,45,,4509,percent of total billed charges,Critical Access Hospital RCC factor,3406.8,34,,3406.8,percent of total billed charges,Implant Device,3406.8,34,,3406.8,percent of total billed charges,Implant Device,3406.8,34,,3406.8,percent of total billed charges,Implant Device,3406.8,34,,3406.8,percent of total billed charges,Implant Device,3406.8,34,,3406.8,percent of total billed charges,Implant Device,4959.9,,,4959.9,Other,110% of Medicare,3507,35,,3507,percent of total billed charges,Implant Device,3406.8,34,"Charges > $500, x 34%",3406.8,percent of total billed charges,Implant Device,3507,35,,3507,percent of total billed charges,Implant Device,3507,35,,3507,percent of total billed charges,Implant Device,3507,35,,3507,percent of total billed charges,Implant Device,3507,35,,3507,percent of total billed charges,Implant Device,3507,35,,3507,percent of total billed charges,Implant Device,4008,40,,4008,percent of total billed charges,Implant Device,3507,70,,3507,percent of total billed charges,All Other,3406.8,34,,3406.8,percent of total billed charges,Implant Device,3406.8,34,,3406.8,percent of total billed charges,Implant Device,3507,35,,3507,percent of total billed charges,Implant Device,3507,35,,3507,percent of total billed charges,Implant Device,3507,35,,3507,percent of total billed charges,Implant Device,3507,35,,3507,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3406.8,34,"If Charge > 2,000, then 34 percent",3406.8,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,7414.83,
EXACTECH 320-15-02 GLENOID PLATE,C1776,HCPCS,,79002016,CDM,278,RC,,,both,,,5925,4384.51,,,4384.51,Other,150% of Medicare + 9.63% HCRA Surcharge,2666.25,45,,2666.25,percent of total billed charges,Critical Access Hospital RCC factor,2014.5,34,,2014.5,percent of total billed charges,Implant Device,2014.5,34,,2014.5,percent of total billed charges,Implant Device,2014.5,34,,2014.5,percent of total billed charges,Implant Device,2014.5,34,,2014.5,percent of total billed charges,Implant Device,2014.5,34,,2014.5,percent of total billed charges,Implant Device,2932.88,,,2932.88,Other,110% of Medicare,2073.75,35,,2073.75,percent of total billed charges,Implant Device,2014.5,34,"Charges > $500, x 34%",2014.5,percent of total billed charges,Implant Device,2073.75,35,,2073.75,percent of total billed charges,Implant Device,2073.75,35,,2073.75,percent of total billed charges,Implant Device,2073.75,35,,2073.75,percent of total billed charges,Implant Device,2073.75,35,,2073.75,percent of total billed charges,Implant Device,2073.75,35,,2073.75,percent of total billed charges,Implant Device,2370,40,,2370,percent of total billed charges,Implant Device,2073.75,70,,2073.75,percent of total billed charges,All Other,2014.5,34,,2014.5,percent of total billed charges,Implant Device,2014.5,34,,2014.5,percent of total billed charges,Implant Device,2073.75,35,,2073.75,percent of total billed charges,Implant Device,2073.75,35,,2073.75,percent of total billed charges,Implant Device,2073.75,35,,2073.75,percent of total billed charges,Implant Device,2073.75,35,,2073.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2014.5,34,"If Charge > 2,000, then 34 percent",2014.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4384.51,
EXACTECH 320-42-00 HUMERAL LINER,C1776,HCPCS,,79002017,CDM,278,RC,,,both,,,2325,1720.51,,,1720.51,Other,150% of Medicare + 9.63% HCRA Surcharge,1046.25,45,,1046.25,percent of total billed charges,Critical Access Hospital RCC factor,790.5,34,,790.5,percent of total billed charges,Implant Device,790.5,34,,790.5,percent of total billed charges,Implant Device,790.5,34,,790.5,percent of total billed charges,Implant Device,790.5,34,,790.5,percent of total billed charges,Implant Device,790.5,34,,790.5,percent of total billed charges,Implant Device,1150.88,,,1150.88,Other,110% of Medicare,813.75,35,,813.75,percent of total billed charges,Implant Device,790.5,34,"Charges > $500, x 34%",790.5,percent of total billed charges,Implant Device,813.75,35,,813.75,percent of total billed charges,Implant Device,813.75,35,,813.75,percent of total billed charges,Implant Device,813.75,35,,813.75,percent of total billed charges,Implant Device,813.75,35,,813.75,percent of total billed charges,Implant Device,813.75,35,,813.75,percent of total billed charges,Implant Device,930,40,,930,percent of total billed charges,Implant Device,813.75,70,,813.75,percent of total billed charges,All Other,790.5,34,,790.5,percent of total billed charges,Implant Device,790.5,34,,790.5,percent of total billed charges,Implant Device,813.75,35,,813.75,percent of total billed charges,Implant Device,813.75,35,,813.75,percent of total billed charges,Implant Device,813.75,35,,813.75,percent of total billed charges,Implant Device,813.75,35,,813.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,790.5,34,"If Charge > 2,000, then 34 percent",790.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1720.51,
EXACTECH 320-42-03 HUMERAL LINER,C1776,HCPCS,,79002018,CDM,278,RC,,,both,,,2325,1720.51,,,1720.51,Other,150% of Medicare + 9.63% HCRA Surcharge,1046.25,45,,1046.25,percent of total billed charges,Critical Access Hospital RCC factor,790.5,34,,790.5,percent of total billed charges,Implant Device,790.5,34,,790.5,percent of total billed charges,Implant Device,790.5,34,,790.5,percent of total billed charges,Implant Device,790.5,34,,790.5,percent of total billed charges,Implant Device,790.5,34,,790.5,percent of total billed charges,Implant Device,1150.88,,,1150.88,Other,110% of Medicare,813.75,35,,813.75,percent of total billed charges,Implant Device,790.5,34,"Charges > $500, x 34%",790.5,percent of total billed charges,Implant Device,813.75,35,,813.75,percent of total billed charges,Implant Device,813.75,35,,813.75,percent of total billed charges,Implant Device,813.75,35,,813.75,percent of total billed charges,Implant Device,813.75,35,,813.75,percent of total billed charges,Implant Device,813.75,35,,813.75,percent of total billed charges,Implant Device,930,40,,930,percent of total billed charges,Implant Device,813.75,70,,813.75,percent of total billed charges,All Other,790.5,34,,790.5,percent of total billed charges,Implant Device,790.5,34,,790.5,percent of total billed charges,Implant Device,813.75,35,,813.75,percent of total billed charges,Implant Device,813.75,35,,813.75,percent of total billed charges,Implant Device,813.75,35,,813.75,percent of total billed charges,Implant Device,813.75,35,,813.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,790.5,34,"If Charge > 2,000, then 34 percent",790.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1720.51,
ZIMMER 32-7828-85-01-REV LINER,C1776,HCPCS,,79002020,CDM,278,RC,,,both,,,5287,3912.39,,,3912.39,Other,150% of Medicare + 9.63% HCRA Surcharge,2379.15,45,,2379.15,percent of total billed charges,Critical Access Hospital RCC factor,1797.58,34,,1797.58,percent of total billed charges,Implant Device,1797.58,34,,1797.58,percent of total billed charges,Implant Device,1797.58,34,,1797.58,percent of total billed charges,Implant Device,1797.58,34,,1797.58,percent of total billed charges,Implant Device,1797.58,34,,1797.58,percent of total billed charges,Implant Device,2617.07,,,2617.07,Other,110% of Medicare,1850.45,35,,1850.45,percent of total billed charges,Implant Device,1797.58,34,"Charges > $500, x 34%",1797.58,percent of total billed charges,Implant Device,1850.45,35,,1850.45,percent of total billed charges,Implant Device,1850.45,35,,1850.45,percent of total billed charges,Implant Device,1850.45,35,,1850.45,percent of total billed charges,Implant Device,1850.45,35,,1850.45,percent of total billed charges,Implant Device,1850.45,35,,1850.45,percent of total billed charges,Implant Device,2114.8,40,,2114.8,percent of total billed charges,Implant Device,1850.45,70,,1850.45,percent of total billed charges,All Other,1797.58,34,,1797.58,percent of total billed charges,Implant Device,1797.58,34,,1797.58,percent of total billed charges,Implant Device,1850.45,35,,1850.45,percent of total billed charges,Implant Device,1850.45,35,,1850.45,percent of total billed charges,Implant Device,1850.45,35,,1850.45,percent of total billed charges,Implant Device,1850.45,35,,1850.45,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1797.58,34,"If Charge > 2,000, then 34 percent",1797.58,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3912.39,
MENTOR 350-1645 BREAST IMPLANT,C1789,HCPCS,,79002021,CDM,278,RC,,,both,,,1876,1388.24,,,1388.24,Other,150% of Medicare + 9.63% HCRA Surcharge,844.2,45,,844.2,percent of total billed charges,Critical Access Hospital RCC factor,637.84,34,,637.84,percent of total billed charges,Implant Device,637.84,34,,637.84,percent of total billed charges,Implant Device,637.84,34,,637.84,percent of total billed charges,Implant Device,637.84,34,,637.84,percent of total billed charges,Implant Device,637.84,34,,637.84,percent of total billed charges,Implant Device,928.62,,,928.62,Other,110% of Medicare,656.6,35,,656.6,percent of total billed charges,Implant Device,637.84,34,"Charges > $500, x 34%",637.84,percent of total billed charges,Implant Device,656.6,35,,656.6,percent of total billed charges,Implant Device,656.6,35,,656.6,percent of total billed charges,Implant Device,656.6,35,,656.6,percent of total billed charges,Implant Device,656.6,35,,656.6,percent of total billed charges,Implant Device,656.6,35,,656.6,percent of total billed charges,Implant Device,750.4,40,,750.4,percent of total billed charges,Implant Device,656.6,70,,656.6,percent of total billed charges,All Other,637.84,34,,637.84,percent of total billed charges,Implant Device,637.84,34,,637.84,percent of total billed charges,Implant Device,656.6,35,,656.6,percent of total billed charges,Implant Device,656.6,35,,656.6,percent of total billed charges,Implant Device,656.6,35,,656.6,percent of total billed charges,Implant Device,656.6,35,,656.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1388.24,
MENTOR 350-2300 BREAST IMPLANT 300CC,C1789,HCPCS,,79002022,CDM,278,RC,,,both,,,2010,1487.41,,,1487.41,Other,150% of Medicare + 9.63% HCRA Surcharge,904.5,45,,904.5,percent of total billed charges,Critical Access Hospital RCC factor,683.4,34,,683.4,percent of total billed charges,Implant Device,683.4,34,,683.4,percent of total billed charges,Implant Device,683.4,34,,683.4,percent of total billed charges,Implant Device,683.4,34,,683.4,percent of total billed charges,Implant Device,683.4,34,,683.4,percent of total billed charges,Implant Device,994.95,,,994.95,Other,110% of Medicare,703.5,35,,703.5,percent of total billed charges,Implant Device,683.4,34,"Charges > $500, x 34%",683.4,percent of total billed charges,Implant Device,703.5,35,,703.5,percent of total billed charges,Implant Device,703.5,35,,703.5,percent of total billed charges,Implant Device,703.5,35,,703.5,percent of total billed charges,Implant Device,703.5,35,,703.5,percent of total billed charges,Implant Device,703.5,35,,703.5,percent of total billed charges,Implant Device,804,40,,804,percent of total billed charges,Implant Device,703.5,70,,703.5,percent of total billed charges,All Other,683.4,34,,683.4,percent of total billed charges,Implant Device,683.4,34,,683.4,percent of total billed charges,Implant Device,703.5,35,,703.5,percent of total billed charges,Implant Device,703.5,35,,703.5,percent of total billed charges,Implant Device,703.5,35,,703.5,percent of total billed charges,Implant Device,703.5,35,,703.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,683.4,34,"If Charge > 2,000, then 34 percent",683.4,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1487.41,
MENTOR 350-2500 BREAST IMPLANT,C1789,HCPCS,,79002023,CDM,278,RC,,,both,,,2010,1487.41,,,1487.41,Other,150% of Medicare + 9.63% HCRA Surcharge,904.5,45,,904.5,percent of total billed charges,Critical Access Hospital RCC factor,683.4,34,,683.4,percent of total billed charges,Implant Device,683.4,34,,683.4,percent of total billed charges,Implant Device,683.4,34,,683.4,percent of total billed charges,Implant Device,683.4,34,,683.4,percent of total billed charges,Implant Device,683.4,34,,683.4,percent of total billed charges,Implant Device,994.95,,,994.95,Other,110% of Medicare,703.5,35,,703.5,percent of total billed charges,Implant Device,683.4,34,"Charges > $500, x 34%",683.4,percent of total billed charges,Implant Device,703.5,35,,703.5,percent of total billed charges,Implant Device,703.5,35,,703.5,percent of total billed charges,Implant Device,703.5,35,,703.5,percent of total billed charges,Implant Device,703.5,35,,703.5,percent of total billed charges,Implant Device,703.5,35,,703.5,percent of total billed charges,Implant Device,804,40,,804,percent of total billed charges,Implant Device,703.5,70,,703.5,percent of total billed charges,All Other,683.4,34,,683.4,percent of total billed charges,Implant Device,683.4,34,,683.4,percent of total billed charges,Implant Device,703.5,35,,703.5,percent of total billed charges,Implant Device,703.5,35,,703.5,percent of total billed charges,Implant Device,703.5,35,,703.5,percent of total billed charges,Implant Device,703.5,35,,703.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,683.4,34,"If Charge > 2,000, then 34 percent",683.4,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1487.41,
MENTOR 350-2600 BREAST IMPLANT,C1789,HCPCS,,79002024,CDM,278,RC,,,both,,,1950,1443,,,1443,Other,150% of Medicare + 9.63% HCRA Surcharge,877.5,45,,877.5,percent of total billed charges,Critical Access Hospital RCC factor,663,34,,663,percent of total billed charges,Implant Device,663,34,,663,percent of total billed charges,Implant Device,663,34,,663,percent of total billed charges,Implant Device,663,34,,663,percent of total billed charges,Implant Device,663,34,,663,percent of total billed charges,Implant Device,965.25,,,965.25,Other,110% of Medicare,682.5,35,,682.5,percent of total billed charges,Implant Device,663,34,"Charges > $500, x 34%",663,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,780,40,,780,percent of total billed charges,Implant Device,682.5,70,,682.5,percent of total billed charges,All Other,663,34,,663,percent of total billed charges,Implant Device,663,34,,663,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1443,
MENTOR 350-3250 BREAST IMPLANT,C1789,HCPCS,,79002025,CDM,278,RC,,,both,,,1950,1443,,,1443,Other,150% of Medicare + 9.63% HCRA Surcharge,877.5,45,,877.5,percent of total billed charges,Critical Access Hospital RCC factor,663,34,,663,percent of total billed charges,Implant Device,663,34,,663,percent of total billed charges,Implant Device,663,34,,663,percent of total billed charges,Implant Device,663,34,,663,percent of total billed charges,Implant Device,663,34,,663,percent of total billed charges,Implant Device,965.25,,,965.25,Other,110% of Medicare,682.5,35,,682.5,percent of total billed charges,Implant Device,663,34,"Charges > $500, x 34%",663,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,780,40,,780,percent of total billed charges,Implant Device,682.5,70,,682.5,percent of total billed charges,All Other,663,34,,663,percent of total billed charges,Implant Device,663,34,,663,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1443,
MENTOR 350-7004BC BREAST IMPLANT,C1789,HCPCS,,79002026,CDM,278,RC,,,both,,,2850,2109.01,,,2109.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1282.5,45,,1282.5,percent of total billed charges,Critical Access Hospital RCC factor,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,1410.75,,,1410.75,Other,110% of Medicare,997.5,35,,997.5,percent of total billed charges,Implant Device,969,34,"Charges > $500, x 34%",969,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,1140,40,,1140,percent of total billed charges,Implant Device,997.5,70,,997.5,percent of total billed charges,All Other,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,969,34,"If Charge > 2,000, then 34 percent",969,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2109.01,
MENTOR 354-6216 TISSUE EXPANDER,C1789,HCPCS,,79002027,CDM,278,RC,,,both,,,4276,3164.25,,,3164.25,Other,150% of Medicare + 9.63% HCRA Surcharge,1924.2,45,,1924.2,percent of total billed charges,Critical Access Hospital RCC factor,1453.84,34,,1453.84,percent of total billed charges,Implant Device,1453.84,34,,1453.84,percent of total billed charges,Implant Device,1453.84,34,,1453.84,percent of total billed charges,Implant Device,1453.84,34,,1453.84,percent of total billed charges,Implant Device,1453.84,34,,1453.84,percent of total billed charges,Implant Device,2116.62,,,2116.62,Other,110% of Medicare,1496.6,35,,1496.6,percent of total billed charges,Implant Device,1453.84,34,"Charges > $500, x 34%",1453.84,percent of total billed charges,Implant Device,1496.6,35,,1496.6,percent of total billed charges,Implant Device,1496.6,35,,1496.6,percent of total billed charges,Implant Device,1496.6,35,,1496.6,percent of total billed charges,Implant Device,1496.6,35,,1496.6,percent of total billed charges,Implant Device,1496.6,35,,1496.6,percent of total billed charges,Implant Device,1710.4,40,,1710.4,percent of total billed charges,Implant Device,1496.6,70,,1496.6,percent of total billed charges,All Other,1453.84,34,,1453.84,percent of total billed charges,Implant Device,1453.84,34,,1453.84,percent of total billed charges,Implant Device,1496.6,35,,1496.6,percent of total billed charges,Implant Device,1496.6,35,,1496.6,percent of total billed charges,Implant Device,1496.6,35,,1496.6,percent of total billed charges,Implant Device,1496.6,35,,1496.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1453.84,34,"If Charge > 2,000, then 34 percent",1453.84,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3164.25,
ZIMMER 3704-0-510-REV CABLE SLEEVE,C1713,HCPCS,,79002028,CDM,278,RC,,,both,,,1536,1136.64,,,1136.64,Other,150% of Medicare + 9.63% HCRA Surcharge,691.2,45,,691.2,percent of total billed charges,Critical Access Hospital RCC factor,522.24,34,,522.24,percent of total billed charges,Implant Device,522.24,34,,522.24,percent of total billed charges,Implant Device,522.24,34,,522.24,percent of total billed charges,Implant Device,522.24,34,,522.24,percent of total billed charges,Implant Device,522.24,34,,522.24,percent of total billed charges,Implant Device,760.32,,,760.32,Other,110% of Medicare,537.6,35,,537.6,percent of total billed charges,Implant Device,522.24,34,"Charges > $500, x 34%",522.24,percent of total billed charges,Implant Device,537.6,35,,537.6,percent of total billed charges,Implant Device,537.6,35,,537.6,percent of total billed charges,Implant Device,537.6,35,,537.6,percent of total billed charges,Implant Device,537.6,35,,537.6,percent of total billed charges,Implant Device,537.6,35,,537.6,percent of total billed charges,Implant Device,614.4,40,,614.4,percent of total billed charges,Implant Device,537.6,70,,537.6,percent of total billed charges,All Other,522.24,34,,522.24,percent of total billed charges,Implant Device,522.24,34,,522.24,percent of total billed charges,Implant Device,537.6,35,,537.6,percent of total billed charges,Implant Device,537.6,35,,537.6,percent of total billed charges,Implant Device,537.6,35,,537.6,percent of total billed charges,Implant Device,537.6,35,,537.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1136.64,
STRYKER 40-20116E SCREW,C1713,HCPCS,,79002034,CDM,278,RC,,,both,,,859,635.66,,,635.66,Other,150% of Medicare + 9.63% HCRA Surcharge,386.55,45,,386.55,percent of total billed charges,Critical Access Hospital RCC factor,292.06,34,,292.06,percent of total billed charges,Implant Device,292.06,34,,292.06,percent of total billed charges,Implant Device,292.06,34,,292.06,percent of total billed charges,Implant Device,292.06,34,,292.06,percent of total billed charges,Implant Device,292.06,34,,292.06,percent of total billed charges,Implant Device,425.21,,,425.21,Other,110% of Medicare,300.65,35,,300.65,percent of total billed charges,Implant Device,292.06,34,"Charges > $500, x 34%",292.06,percent of total billed charges,Implant Device,300.65,35,,300.65,percent of total billed charges,Implant Device,300.65,35,,300.65,percent of total billed charges,Implant Device,300.65,35,,300.65,percent of total billed charges,Implant Device,300.65,35,,300.65,percent of total billed charges,Implant Device,300.65,35,,300.65,percent of total billed charges,Implant Device,343.6,40,,343.6,percent of total billed charges,Implant Device,300.65,70,,300.65,percent of total billed charges,All Other,292.06,34,,292.06,percent of total billed charges,Implant Device,292.06,34,,292.06,percent of total billed charges,Implant Device,300.65,35,,300.65,percent of total billed charges,Implant Device,300.65,35,,300.65,percent of total billed charges,Implant Device,300.65,35,,300.65,percent of total billed charges,Implant Device,300.65,35,,300.65,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,635.66,
STRYKER 40-20903 FIBULA 77MM 3 HOLE,C1776,HCPCS,,79002035,CDM,278,RC,,,both,,,1867,1381.58,,,1381.58,Other,150% of Medicare + 9.63% HCRA Surcharge,840.15,45,,840.15,percent of total billed charges,Critical Access Hospital RCC factor,634.78,34,,634.78,percent of total billed charges,Implant Device,634.78,34,,634.78,percent of total billed charges,Implant Device,634.78,34,,634.78,percent of total billed charges,Implant Device,634.78,34,,634.78,percent of total billed charges,Implant Device,634.78,34,,634.78,percent of total billed charges,Implant Device,924.17,,,924.17,Other,110% of Medicare,653.45,35,,653.45,percent of total billed charges,Implant Device,634.78,34,"Charges > $500, x 34%",634.78,percent of total billed charges,Implant Device,653.45,35,,653.45,percent of total billed charges,Implant Device,653.45,35,,653.45,percent of total billed charges,Implant Device,653.45,35,,653.45,percent of total billed charges,Implant Device,653.45,35,,653.45,percent of total billed charges,Implant Device,653.45,35,,653.45,percent of total billed charges,Implant Device,746.8,40,,746.8,percent of total billed charges,Implant Device,653.45,70,,653.45,percent of total billed charges,All Other,634.78,34,,634.78,percent of total billed charges,Implant Device,634.78,34,,634.78,percent of total billed charges,Implant Device,653.45,35,,653.45,percent of total billed charges,Implant Device,653.45,35,,653.45,percent of total billed charges,Implant Device,653.45,35,,653.45,percent of total billed charges,Implant Device,653.45,35,,653.45,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1381.58,
STRYKER 40-30114 MICRO CANN SCREW 3X14MM,C1713,HCPCS,,79002036,CDM,278,RC,,,both,,,859,635.66,,,635.66,Other,150% of Medicare + 9.63% HCRA Surcharge,386.55,45,,386.55,percent of total billed charges,Critical Access Hospital RCC factor,292.06,34,,292.06,percent of total billed charges,Implant Device,292.06,34,,292.06,percent of total billed charges,Implant Device,292.06,34,,292.06,percent of total billed charges,Implant Device,292.06,34,,292.06,percent of total billed charges,Implant Device,292.06,34,,292.06,percent of total billed charges,Implant Device,425.21,,,425.21,Other,110% of Medicare,300.65,35,,300.65,percent of total billed charges,Implant Device,292.06,34,"Charges > $500, x 34%",292.06,percent of total billed charges,Implant Device,300.65,35,,300.65,percent of total billed charges,Implant Device,300.65,35,,300.65,percent of total billed charges,Implant Device,300.65,35,,300.65,percent of total billed charges,Implant Device,300.65,35,,300.65,percent of total billed charges,Implant Device,300.65,35,,300.65,percent of total billed charges,Implant Device,343.6,40,,343.6,percent of total billed charges,Implant Device,300.65,70,,300.65,percent of total billed charges,All Other,292.06,34,,292.06,percent of total billed charges,Implant Device,292.06,34,,292.06,percent of total billed charges,Implant Device,300.65,35,,300.65,percent of total billed charges,Implant Device,300.65,35,,300.65,percent of total billed charges,Implant Device,300.65,35,,300.65,percent of total billed charges,Implant Device,300.65,35,,300.65,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,635.66,
STRYKER 40-30120 SCREW,C1713,HCPCS,,79002038,CDM,278,RC,,,both,,,964,713.36,,,713.36,Other,150% of Medicare + 9.63% HCRA Surcharge,433.8,45,,433.8,percent of total billed charges,Critical Access Hospital RCC factor,327.76,34,,327.76,percent of total billed charges,Implant Device,327.76,34,,327.76,percent of total billed charges,Implant Device,327.76,34,,327.76,percent of total billed charges,Implant Device,327.76,34,,327.76,percent of total billed charges,Implant Device,327.76,34,,327.76,percent of total billed charges,Implant Device,477.18,,,477.18,Other,110% of Medicare,337.4,35,,337.4,percent of total billed charges,Implant Device,327.76,34,"Charges > $500, x 34%",327.76,percent of total billed charges,Implant Device,337.4,35,,337.4,percent of total billed charges,Implant Device,337.4,35,,337.4,percent of total billed charges,Implant Device,337.4,35,,337.4,percent of total billed charges,Implant Device,337.4,35,,337.4,percent of total billed charges,Implant Device,337.4,35,,337.4,percent of total billed charges,Implant Device,385.6,40,,385.6,percent of total billed charges,Implant Device,337.4,70,,337.4,percent of total billed charges,All Other,327.76,34,,327.76,percent of total billed charges,Implant Device,327.76,34,,327.76,percent of total billed charges,Implant Device,337.4,35,,337.4,percent of total billed charges,Implant Device,337.4,35,,337.4,percent of total billed charges,Implant Device,337.4,35,,337.4,percent of total billed charges,Implant Device,337.4,35,,337.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,713.36,
STRYKER 40-30130 SCREW,C1713,HCPCS,,79002039,CDM,278,RC,,,both,,,859,635.66,,,635.66,Other,150% of Medicare + 9.63% HCRA Surcharge,386.55,45,,386.55,percent of total billed charges,Critical Access Hospital RCC factor,292.06,34,,292.06,percent of total billed charges,Implant Device,292.06,34,,292.06,percent of total billed charges,Implant Device,292.06,34,,292.06,percent of total billed charges,Implant Device,292.06,34,,292.06,percent of total billed charges,Implant Device,292.06,34,,292.06,percent of total billed charges,Implant Device,425.21,,,425.21,Other,110% of Medicare,300.65,35,,300.65,percent of total billed charges,Implant Device,292.06,34,"Charges > $500, x 34%",292.06,percent of total billed charges,Implant Device,300.65,35,,300.65,percent of total billed charges,Implant Device,300.65,35,,300.65,percent of total billed charges,Implant Device,300.65,35,,300.65,percent of total billed charges,Implant Device,300.65,35,,300.65,percent of total billed charges,Implant Device,300.65,35,,300.65,percent of total billed charges,Implant Device,343.6,40,,343.6,percent of total billed charges,Implant Device,300.65,70,,300.65,percent of total billed charges,All Other,292.06,34,,292.06,percent of total billed charges,Implant Device,292.06,34,,292.06,percent of total billed charges,Implant Device,300.65,35,,300.65,percent of total billed charges,Implant Device,300.65,35,,300.65,percent of total billed charges,Implant Device,300.65,35,,300.65,percent of total billed charges,Implant Device,300.65,35,,300.65,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,635.66,
STRYKER 40-30134E SCREW,C1713,HCPCS,,79002040,CDM,278,RC,,,both,,,493,364.82,,,364.82,Other,150% of Medicare + 9.63% HCRA Surcharge,221.85,45,,221.85,percent of total billed charges,Critical Access Hospital RCC factor,167.62,34,,167.62,percent of total billed charges,Implant Device,167.62,34,,167.62,percent of total billed charges,Implant Device,167.62,34,,167.62,percent of total billed charges,Implant Device,167.62,34,,167.62,percent of total billed charges,Implant Device,167.62,34,,167.62,percent of total billed charges,Implant Device,244.04,,,244.04,Other,110% of Medicare,172.55,35,,172.55,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,172.55,35,,172.55,percent of total billed charges,Implant Device,172.55,35,,172.55,percent of total billed charges,Implant Device,172.55,35,,172.55,percent of total billed charges,Implant Device,172.55,35,,172.55,percent of total billed charges,Implant Device,172.55,35,,172.55,percent of total billed charges,Implant Device,197.2,40,,197.2,percent of total billed charges,Implant Device,172.55,70,,172.55,percent of total billed charges,All Other,167.62,34,,167.62,percent of total billed charges,Implant Device,167.62,34,,167.62,percent of total billed charges,Implant Device,172.55,35,,172.55,percent of total billed charges,Implant Device,172.55,35,,172.55,percent of total billed charges,Implant Device,172.55,35,,172.55,percent of total billed charges,Implant Device,172.55,35,,172.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,364.82,
STRYKER 40-30136 SCREW 3X36X7MM,C1713,HCPCS,,79002041,CDM,278,RC,,,both,,,750,555,,,555,Other,150% of Medicare + 9.63% HCRA Surcharge,337.5,45,,337.5,percent of total billed charges,Critical Access Hospital RCC factor,255,34,,255,percent of total billed charges,Implant Device,255,34,,255,percent of total billed charges,Implant Device,255,34,,255,percent of total billed charges,Implant Device,255,34,,255,percent of total billed charges,Implant Device,255,34,,255,percent of total billed charges,Implant Device,371.25,,,371.25,Other,110% of Medicare,262.5,35,,262.5,percent of total billed charges,Implant Device,255,34,"Charges > $500, x 34%",255,percent of total billed charges,Implant Device,262.5,35,,262.5,percent of total billed charges,Implant Device,262.5,35,,262.5,percent of total billed charges,Implant Device,262.5,35,,262.5,percent of total billed charges,Implant Device,262.5,35,,262.5,percent of total billed charges,Implant Device,262.5,35,,262.5,percent of total billed charges,Implant Device,300,40,,300,percent of total billed charges,Implant Device,262.5,70,,262.5,percent of total billed charges,All Other,255,34,,255,percent of total billed charges,Implant Device,255,34,,255,percent of total billed charges,Implant Device,262.5,35,,262.5,percent of total billed charges,Implant Device,262.5,35,,262.5,percent of total billed charges,Implant Device,262.5,35,,262.5,percent of total billed charges,Implant Device,262.5,35,,262.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,555,
STRYKER 40-30215 SCREW,C1713,HCPCS,,79002042,CDM,278,RC,,,both,,,566,418.84,,,418.84,Other,150% of Medicare + 9.63% HCRA Surcharge,254.7,45,,254.7,percent of total billed charges,Critical Access Hospital RCC factor,192.44,34,,192.44,percent of total billed charges,Implant Device,192.44,34,,192.44,percent of total billed charges,Implant Device,192.44,34,,192.44,percent of total billed charges,Implant Device,192.44,34,,192.44,percent of total billed charges,Implant Device,192.44,34,,192.44,percent of total billed charges,Implant Device,280.17,,,280.17,Other,110% of Medicare,198.1,35,,198.1,percent of total billed charges,Implant Device,192.44,34,"Charges > $500, x 34%",192.44,percent of total billed charges,Implant Device,198.1,35,,198.1,percent of total billed charges,Implant Device,198.1,35,,198.1,percent of total billed charges,Implant Device,198.1,35,,198.1,percent of total billed charges,Implant Device,198.1,35,,198.1,percent of total billed charges,Implant Device,198.1,35,,198.1,percent of total billed charges,Implant Device,226.4,40,,226.4,percent of total billed charges,Implant Device,198.1,70,,198.1,percent of total billed charges,All Other,192.44,34,,192.44,percent of total billed charges,Implant Device,192.44,34,,192.44,percent of total billed charges,Implant Device,198.1,35,,198.1,percent of total billed charges,Implant Device,198.1,35,,198.1,percent of total billed charges,Implant Device,198.1,35,,198.1,percent of total billed charges,Implant Device,198.1,35,,198.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,418.84,
STRYKER 40-35024 SCREW 3.5X24MM,C1713,HCPCS,,79002043,CDM,278,RC,,,both,,,192,142.08,,,142.08,Other,150% of Medicare + 9.63% HCRA Surcharge,86.4,45,,86.4,percent of total billed charges,Critical Access Hospital RCC factor,65.28,34,,65.28,percent of total billed charges,Implant Device,65.28,34,,65.28,percent of total billed charges,Implant Device,65.28,34,,65.28,percent of total billed charges,Implant Device,65.28,34,,65.28,percent of total billed charges,Implant Device,65.28,34,,65.28,percent of total billed charges,Implant Device,95.04,,,95.04,Other,110% of Medicare,67.2,35,,67.2,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,67.2,35,,67.2,percent of total billed charges,Implant Device,67.2,35,,67.2,percent of total billed charges,Implant Device,67.2,35,,67.2,percent of total billed charges,Implant Device,67.2,35,,67.2,percent of total billed charges,Implant Device,67.2,35,,67.2,percent of total billed charges,Implant Device,76.8,40,,76.8,percent of total billed charges,Implant Device,67.2,70,,67.2,percent of total billed charges,All Other,65.28,34,,65.28,percent of total billed charges,Implant Device,65.28,34,,65.28,percent of total billed charges,Implant Device,67.2,35,,67.2,percent of total billed charges,Implant Device,67.2,35,,67.2,percent of total billed charges,Implant Device,67.2,35,,67.2,percent of total billed charges,Implant Device,67.2,35,,67.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,142.08,
STRYKER 40-35028 SCREW,C1713,HCPCS,,79002044,CDM,278,RC,,,both,,,163,120.62,,,120.62,Other,150% of Medicare + 9.63% HCRA Surcharge,73.35,45,,73.35,percent of total billed charges,Critical Access Hospital RCC factor,55.42,34,,55.42,percent of total billed charges,Implant Device,55.42,34,,55.42,percent of total billed charges,Implant Device,55.42,34,,55.42,percent of total billed charges,Implant Device,55.42,34,,55.42,percent of total billed charges,Implant Device,55.42,34,,55.42,percent of total billed charges,Implant Device,80.69,,,80.69,Other,110% of Medicare,57.05,35,,57.05,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,57.05,35,,57.05,percent of total billed charges,Implant Device,57.05,35,,57.05,percent of total billed charges,Implant Device,57.05,35,,57.05,percent of total billed charges,Implant Device,57.05,35,,57.05,percent of total billed charges,Implant Device,57.05,35,,57.05,percent of total billed charges,Implant Device,65.2,40,,65.2,percent of total billed charges,Implant Device,57.05,70,,57.05,percent of total billed charges,All Other,55.42,34,,55.42,percent of total billed charges,Implant Device,55.42,34,,55.42,percent of total billed charges,Implant Device,57.05,35,,57.05,percent of total billed charges,Implant Device,57.05,35,,57.05,percent of total billed charges,Implant Device,57.05,35,,57.05,percent of total billed charges,Implant Device,57.05,35,,57.05,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,120.62,
STRYKER 40-35618 SCREW,C1713,HCPCS,,79002045,CDM,278,RC,,,both,,,379,280.46,,,280.46,Other,150% of Medicare + 9.63% HCRA Surcharge,170.55,45,,170.55,percent of total billed charges,Critical Access Hospital RCC factor,128.86,34,,128.86,percent of total billed charges,Implant Device,128.86,34,,128.86,percent of total billed charges,Implant Device,128.86,34,,128.86,percent of total billed charges,Implant Device,128.86,34,,128.86,percent of total billed charges,Implant Device,128.86,34,,128.86,percent of total billed charges,Implant Device,187.61,,,187.61,Other,110% of Medicare,132.65,35,,132.65,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,132.65,35,,132.65,percent of total billed charges,Implant Device,132.65,35,,132.65,percent of total billed charges,Implant Device,132.65,35,,132.65,percent of total billed charges,Implant Device,132.65,35,,132.65,percent of total billed charges,Implant Device,132.65,35,,132.65,percent of total billed charges,Implant Device,151.6,40,,151.6,percent of total billed charges,Implant Device,132.65,70,,132.65,percent of total billed charges,All Other,128.86,34,,128.86,percent of total billed charges,Implant Device,128.86,34,,128.86,percent of total billed charges,Implant Device,132.65,35,,132.65,percent of total billed charges,Implant Device,132.65,35,,132.65,percent of total billed charges,Implant Device,132.65,35,,132.65,percent of total billed charges,Implant Device,132.65,35,,132.65,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,280.46,
STRYKER 40-35624 SCREW,C1713,HCPCS,,79002046,CDM,278,RC,,,both,,,474,350.76,,,350.76,Other,150% of Medicare + 9.63% HCRA Surcharge,213.3,45,,213.3,percent of total billed charges,Critical Access Hospital RCC factor,161.16,34,,161.16,percent of total billed charges,Implant Device,161.16,34,,161.16,percent of total billed charges,Implant Device,161.16,34,,161.16,percent of total billed charges,Implant Device,161.16,34,,161.16,percent of total billed charges,Implant Device,161.16,34,,161.16,percent of total billed charges,Implant Device,234.63,,,234.63,Other,110% of Medicare,165.9,35,,165.9,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,165.9,35,,165.9,percent of total billed charges,Implant Device,165.9,35,,165.9,percent of total billed charges,Implant Device,165.9,35,,165.9,percent of total billed charges,Implant Device,165.9,35,,165.9,percent of total billed charges,Implant Device,165.9,35,,165.9,percent of total billed charges,Implant Device,189.6,40,,189.6,percent of total billed charges,Implant Device,165.9,70,,165.9,percent of total billed charges,All Other,161.16,34,,161.16,percent of total billed charges,Implant Device,161.16,34,,161.16,percent of total billed charges,Implant Device,165.9,35,,165.9,percent of total billed charges,Implant Device,165.9,35,,165.9,percent of total billed charges,Implant Device,165.9,35,,165.9,percent of total billed charges,Implant Device,165.9,35,,165.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,350.76,
STRYKER 40-35628 SCREW,C1713,HCPCS,,79002047,CDM,278,RC,,,both,,,809,598.66,,,598.66,Other,150% of Medicare + 9.63% HCRA Surcharge,364.05,45,,364.05,percent of total billed charges,Critical Access Hospital RCC factor,275.06,34,,275.06,percent of total billed charges,Implant Device,275.06,34,,275.06,percent of total billed charges,Implant Device,275.06,34,,275.06,percent of total billed charges,Implant Device,275.06,34,,275.06,percent of total billed charges,Implant Device,275.06,34,,275.06,percent of total billed charges,Implant Device,400.46,,,400.46,Other,110% of Medicare,283.15,35,,283.15,percent of total billed charges,Implant Device,275.06,34,"Charges > $500, x 34%",275.06,percent of total billed charges,Implant Device,283.15,35,,283.15,percent of total billed charges,Implant Device,283.15,35,,283.15,percent of total billed charges,Implant Device,283.15,35,,283.15,percent of total billed charges,Implant Device,283.15,35,,283.15,percent of total billed charges,Implant Device,283.15,35,,283.15,percent of total billed charges,Implant Device,323.6,40,,323.6,percent of total billed charges,Implant Device,283.15,70,,283.15,percent of total billed charges,All Other,275.06,34,,275.06,percent of total billed charges,Implant Device,275.06,34,,275.06,percent of total billed charges,Implant Device,283.15,35,,283.15,percent of total billed charges,Implant Device,283.15,35,,283.15,percent of total billed charges,Implant Device,283.15,35,,283.15,percent of total billed charges,Implant Device,283.15,35,,283.15,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,598.66,
STRYKER 40-35630 SCREW,C1713,HCPCS,,79002048,CDM,278,RC,,,both,,,732,541.68,,,541.68,Other,150% of Medicare + 9.63% HCRA Surcharge,329.4,45,,329.4,percent of total billed charges,Critical Access Hospital RCC factor,248.88,34,,248.88,percent of total billed charges,Implant Device,248.88,34,,248.88,percent of total billed charges,Implant Device,248.88,34,,248.88,percent of total billed charges,Implant Device,248.88,34,,248.88,percent of total billed charges,Implant Device,248.88,34,,248.88,percent of total billed charges,Implant Device,362.34,,,362.34,Other,110% of Medicare,256.2,35,,256.2,percent of total billed charges,Implant Device,248.88,34,"Charges > $500, x 34%",248.88,percent of total billed charges,Implant Device,256.2,35,,256.2,percent of total billed charges,Implant Device,256.2,35,,256.2,percent of total billed charges,Implant Device,256.2,35,,256.2,percent of total billed charges,Implant Device,256.2,35,,256.2,percent of total billed charges,Implant Device,256.2,35,,256.2,percent of total billed charges,Implant Device,292.8,40,,292.8,percent of total billed charges,Implant Device,256.2,70,,256.2,percent of total billed charges,All Other,248.88,34,,248.88,percent of total billed charges,Implant Device,248.88,34,,248.88,percent of total billed charges,Implant Device,256.2,35,,256.2,percent of total billed charges,Implant Device,256.2,35,,256.2,percent of total billed charges,Implant Device,256.2,35,,256.2,percent of total billed charges,Implant Device,256.2,35,,256.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,541.68,
WRIGHT MEDICAL 426-0020 TOE IMPLANT,C1713,HCPCS,,79002050,CDM,278,RC,,,both,,,3510,2597.41,,,2597.41,Other,150% of Medicare + 9.63% HCRA Surcharge,1579.5,45,,1579.5,percent of total billed charges,Critical Access Hospital RCC factor,1193.4,34,,1193.4,percent of total billed charges,Implant Device,1193.4,34,,1193.4,percent of total billed charges,Implant Device,1193.4,34,,1193.4,percent of total billed charges,Implant Device,1193.4,34,,1193.4,percent of total billed charges,Implant Device,1193.4,34,,1193.4,percent of total billed charges,Implant Device,1737.45,,,1737.45,Other,110% of Medicare,1228.5,35,,1228.5,percent of total billed charges,Implant Device,1193.4,34,"Charges > $500, x 34%",1193.4,percent of total billed charges,Implant Device,1228.5,35,,1228.5,percent of total billed charges,Implant Device,1228.5,35,,1228.5,percent of total billed charges,Implant Device,1228.5,35,,1228.5,percent of total billed charges,Implant Device,1228.5,35,,1228.5,percent of total billed charges,Implant Device,1228.5,35,,1228.5,percent of total billed charges,Implant Device,1404,40,,1404,percent of total billed charges,Implant Device,1228.5,70,,1228.5,percent of total billed charges,All Other,1193.4,34,,1193.4,percent of total billed charges,Implant Device,1193.4,34,,1193.4,percent of total billed charges,Implant Device,1228.5,35,,1228.5,percent of total billed charges,Implant Device,1228.5,35,,1228.5,percent of total billed charges,Implant Device,1228.5,35,,1228.5,percent of total billed charges,Implant Device,1228.5,35,,1228.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1193.4,34,"If Charge > 2,000, then 34 percent",1193.4,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2597.41,
BIOMET 431196-REV SPACER STEM,C1776,HCPCS,,79002051,CDM,278,RC,,,both,,,6570,4861.82,,,4861.82,Other,150% of Medicare + 9.63% HCRA Surcharge,2956.5,45,,2956.5,percent of total billed charges,Critical Access Hospital RCC factor,2233.8,34,,2233.8,percent of total billed charges,Implant Device,2233.8,34,,2233.8,percent of total billed charges,Implant Device,2233.8,34,,2233.8,percent of total billed charges,Implant Device,2233.8,34,,2233.8,percent of total billed charges,Implant Device,2233.8,34,,2233.8,percent of total billed charges,Implant Device,3252.15,,,3252.15,Other,110% of Medicare,2299.5,35,,2299.5,percent of total billed charges,Implant Device,2233.8,34,"Charges > $500, x 34%",2233.8,percent of total billed charges,Implant Device,2299.5,35,,2299.5,percent of total billed charges,Implant Device,2299.5,35,,2299.5,percent of total billed charges,Implant Device,2299.5,35,,2299.5,percent of total billed charges,Implant Device,2299.5,35,,2299.5,percent of total billed charges,Implant Device,2299.5,35,,2299.5,percent of total billed charges,Implant Device,2628,40,,2628,percent of total billed charges,Implant Device,2299.5,70,,2299.5,percent of total billed charges,All Other,2233.8,34,,2233.8,percent of total billed charges,Implant Device,2233.8,34,,2233.8,percent of total billed charges,Implant Device,2299.5,35,,2299.5,percent of total billed charges,Implant Device,2299.5,35,,2299.5,percent of total billed charges,Implant Device,2299.5,35,,2299.5,percent of total billed charges,Implant Device,2299.5,35,,2299.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2233.8,34,"If Charge > 2,000, then 34 percent",2233.8,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4861.82,
BIOMET 431197-REV SPACER STEM,C1776,HCPCS,,79002052,CDM,278,RC,,,both,,,6570,4861.82,,,4861.82,Other,150% of Medicare + 9.63% HCRA Surcharge,2956.5,45,,2956.5,percent of total billed charges,Critical Access Hospital RCC factor,2233.8,34,,2233.8,percent of total billed charges,Implant Device,2233.8,34,,2233.8,percent of total billed charges,Implant Device,2233.8,34,,2233.8,percent of total billed charges,Implant Device,2233.8,34,,2233.8,percent of total billed charges,Implant Device,2233.8,34,,2233.8,percent of total billed charges,Implant Device,3252.15,,,3252.15,Other,110% of Medicare,2299.5,35,,2299.5,percent of total billed charges,Implant Device,2233.8,34,"Charges > $500, x 34%",2233.8,percent of total billed charges,Implant Device,2299.5,35,,2299.5,percent of total billed charges,Implant Device,2299.5,35,,2299.5,percent of total billed charges,Implant Device,2299.5,35,,2299.5,percent of total billed charges,Implant Device,2299.5,35,,2299.5,percent of total billed charges,Implant Device,2299.5,35,,2299.5,percent of total billed charges,Implant Device,2628,40,,2628,percent of total billed charges,Implant Device,2299.5,70,,2299.5,percent of total billed charges,All Other,2233.8,34,,2233.8,percent of total billed charges,Implant Device,2233.8,34,,2233.8,percent of total billed charges,Implant Device,2299.5,35,,2299.5,percent of total billed charges,Implant Device,2299.5,35,,2299.5,percent of total billed charges,Implant Device,2299.5,35,,2299.5,percent of total billed charges,Implant Device,2299.5,35,,2299.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2233.8,34,"If Charge > 2,000, then 34 percent",2233.8,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4861.82,
BIOMET 45-3009 BONE GRAFT,C1713,HCPCS,,79002054,CDM,278,RC,,,both,,,5400,3996.01,,,3996.01,Other,150% of Medicare + 9.63% HCRA Surcharge,2430,45,,2430,percent of total billed charges,Critical Access Hospital RCC factor,1836,34,,1836,percent of total billed charges,Implant Device,1836,34,,1836,percent of total billed charges,Implant Device,1836,34,,1836,percent of total billed charges,Implant Device,1836,34,,1836,percent of total billed charges,Implant Device,1836,34,,1836,percent of total billed charges,Implant Device,2673,,,2673,Other,110% of Medicare,1890,35,,1890,percent of total billed charges,Implant Device,1836,34,"Charges > $500, x 34%",1836,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,2160,40,,2160,percent of total billed charges,Implant Device,1890,70,,1890,percent of total billed charges,All Other,1836,34,,1836,percent of total billed charges,Implant Device,1836,34,,1836,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1836,34,"If Charge > 2,000, then 34 percent",1836,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3996.01,
BIOMET 45-5556 ALLOGRAFT,C1713,HCPCS,,79002055,CDM,278,RC,,,both,,,4594,3399.57,,,3399.57,Other,150% of Medicare + 9.63% HCRA Surcharge,2067.3,45,,2067.3,percent of total billed charges,Critical Access Hospital RCC factor,1561.96,34,,1561.96,percent of total billed charges,Implant Device,1561.96,34,,1561.96,percent of total billed charges,Implant Device,1561.96,34,,1561.96,percent of total billed charges,Implant Device,1561.96,34,,1561.96,percent of total billed charges,Implant Device,1561.96,34,,1561.96,percent of total billed charges,Implant Device,2274.03,,,2274.03,Other,110% of Medicare,1607.9,35,,1607.9,percent of total billed charges,Implant Device,1561.96,34,"Charges > $500, x 34%",1561.96,percent of total billed charges,Implant Device,1607.9,35,,1607.9,percent of total billed charges,Implant Device,1607.9,35,,1607.9,percent of total billed charges,Implant Device,1607.9,35,,1607.9,percent of total billed charges,Implant Device,1607.9,35,,1607.9,percent of total billed charges,Implant Device,1607.9,35,,1607.9,percent of total billed charges,Implant Device,1837.6,40,,1837.6,percent of total billed charges,Implant Device,1607.9,70,,1607.9,percent of total billed charges,All Other,1561.96,34,,1561.96,percent of total billed charges,Implant Device,1561.96,34,,1561.96,percent of total billed charges,Implant Device,1607.9,35,,1607.9,percent of total billed charges,Implant Device,1607.9,35,,1607.9,percent of total billed charges,Implant Device,1607.9,35,,1607.9,percent of total billed charges,Implant Device,1607.9,35,,1607.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1561.96,34,"If Charge > 2,000, then 34 percent",1561.96,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3399.57,
BIOMET 45-5557 ALLOGRAFT,C1713,HCPCS,,79002056,CDM,278,RC,,,both,,,4594,3399.57,,,3399.57,Other,150% of Medicare + 9.63% HCRA Surcharge,2067.3,45,,2067.3,percent of total billed charges,Critical Access Hospital RCC factor,1561.96,34,,1561.96,percent of total billed charges,Implant Device,1561.96,34,,1561.96,percent of total billed charges,Implant Device,1561.96,34,,1561.96,percent of total billed charges,Implant Device,1561.96,34,,1561.96,percent of total billed charges,Implant Device,1561.96,34,,1561.96,percent of total billed charges,Implant Device,2274.03,,,2274.03,Other,110% of Medicare,1607.9,35,,1607.9,percent of total billed charges,Implant Device,1561.96,34,"Charges > $500, x 34%",1561.96,percent of total billed charges,Implant Device,1607.9,35,,1607.9,percent of total billed charges,Implant Device,1607.9,35,,1607.9,percent of total billed charges,Implant Device,1607.9,35,,1607.9,percent of total billed charges,Implant Device,1607.9,35,,1607.9,percent of total billed charges,Implant Device,1607.9,35,,1607.9,percent of total billed charges,Implant Device,1837.6,40,,1837.6,percent of total billed charges,Implant Device,1607.9,70,,1607.9,percent of total billed charges,All Other,1561.96,34,,1561.96,percent of total billed charges,Implant Device,1561.96,34,,1561.96,percent of total billed charges,Implant Device,1607.9,35,,1607.9,percent of total billed charges,Implant Device,1607.9,35,,1607.9,percent of total billed charges,Implant Device,1607.9,35,,1607.9,percent of total billed charges,Implant Device,1607.9,35,,1607.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1561.96,34,"If Charge > 2,000, then 34 percent",1561.96,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3399.57,
BIOMET 45-5558 ALLOGRAFT,C1713,HCPCS,,79002057,CDM,278,RC,,,both,,,4594,3399.57,,,3399.57,Other,150% of Medicare + 9.63% HCRA Surcharge,2067.3,45,,2067.3,percent of total billed charges,Critical Access Hospital RCC factor,1561.96,34,,1561.96,percent of total billed charges,Implant Device,1561.96,34,,1561.96,percent of total billed charges,Implant Device,1561.96,34,,1561.96,percent of total billed charges,Implant Device,1561.96,34,,1561.96,percent of total billed charges,Implant Device,1561.96,34,,1561.96,percent of total billed charges,Implant Device,2274.03,,,2274.03,Other,110% of Medicare,1607.9,35,,1607.9,percent of total billed charges,Implant Device,1561.96,34,"Charges > $500, x 34%",1561.96,percent of total billed charges,Implant Device,1607.9,35,,1607.9,percent of total billed charges,Implant Device,1607.9,35,,1607.9,percent of total billed charges,Implant Device,1607.9,35,,1607.9,percent of total billed charges,Implant Device,1607.9,35,,1607.9,percent of total billed charges,Implant Device,1607.9,35,,1607.9,percent of total billed charges,Implant Device,1837.6,40,,1837.6,percent of total billed charges,Implant Device,1607.9,70,,1607.9,percent of total billed charges,All Other,1561.96,34,,1561.96,percent of total billed charges,Implant Device,1561.96,34,,1561.96,percent of total billed charges,Implant Device,1607.9,35,,1607.9,percent of total billed charges,Implant Device,1607.9,35,,1607.9,percent of total billed charges,Implant Device,1607.9,35,,1607.9,percent of total billed charges,Implant Device,1607.9,35,,1607.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1561.96,34,"If Charge > 2,000, then 34 percent",1561.96,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3399.57,
ZIMMER 47-2484-027-50 SCREW,C1713,HCPCS,,79002060,CDM,278,RC,,,both,,,667,493.58,,,493.58,Other,150% of Medicare + 9.63% HCRA Surcharge,300.15,45,,300.15,percent of total billed charges,Critical Access Hospital RCC factor,226.78,34,,226.78,percent of total billed charges,Implant Device,226.78,34,,226.78,percent of total billed charges,Implant Device,226.78,34,,226.78,percent of total billed charges,Implant Device,226.78,34,,226.78,percent of total billed charges,Implant Device,226.78,34,,226.78,percent of total billed charges,Implant Device,330.17,,,330.17,Other,110% of Medicare,233.45,35,,233.45,percent of total billed charges,Implant Device,226.78,34,"Charges > $500, x 34%",226.78,percent of total billed charges,Implant Device,233.45,35,,233.45,percent of total billed charges,Implant Device,233.45,35,,233.45,percent of total billed charges,Implant Device,233.45,35,,233.45,percent of total billed charges,Implant Device,233.45,35,,233.45,percent of total billed charges,Implant Device,233.45,35,,233.45,percent of total billed charges,Implant Device,266.8,40,,266.8,percent of total billed charges,Implant Device,233.45,70,,233.45,percent of total billed charges,All Other,226.78,34,,226.78,percent of total billed charges,Implant Device,226.78,34,,226.78,percent of total billed charges,Implant Device,233.45,35,,233.45,percent of total billed charges,Implant Device,233.45,35,,233.45,percent of total billed charges,Implant Device,233.45,35,,233.45,percent of total billed charges,Implant Device,233.45,35,,233.45,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,493.58,
ZIMMER 47-2484-032-50 SCREW,C1713,HCPCS,,79002061,CDM,278,RC,,,both,,,665,492.1,,,492.1,Other,150% of Medicare + 9.63% HCRA Surcharge,299.25,45,,299.25,percent of total billed charges,Critical Access Hospital RCC factor,226.1,34,,226.1,percent of total billed charges,Implant Device,226.1,34,,226.1,percent of total billed charges,Implant Device,226.1,34,,226.1,percent of total billed charges,Implant Device,226.1,34,,226.1,percent of total billed charges,Implant Device,226.1,34,,226.1,percent of total billed charges,Implant Device,329.18,,,329.18,Other,110% of Medicare,232.75,35,,232.75,percent of total billed charges,Implant Device,226.1,34,"Charges > $500, x 34%",226.1,percent of total billed charges,Implant Device,232.75,35,,232.75,percent of total billed charges,Implant Device,232.75,35,,232.75,percent of total billed charges,Implant Device,232.75,35,,232.75,percent of total billed charges,Implant Device,232.75,35,,232.75,percent of total billed charges,Implant Device,232.75,35,,232.75,percent of total billed charges,Implant Device,266,40,,266,percent of total billed charges,Implant Device,232.75,70,,232.75,percent of total billed charges,All Other,226.1,34,,226.1,percent of total billed charges,Implant Device,226.1,34,,226.1,percent of total billed charges,Implant Device,232.75,35,,232.75,percent of total billed charges,Implant Device,232.75,35,,232.75,percent of total billed charges,Implant Device,232.75,35,,232.75,percent of total billed charges,Implant Device,232.75,35,,232.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,492.1,
ZIMMER 47-2484-042-50 SCREW,C1713,HCPCS,,79002062,CDM,278,RC,,,both,,,665,492.1,,,492.1,Other,150% of Medicare + 9.63% HCRA Surcharge,299.25,45,,299.25,percent of total billed charges,Critical Access Hospital RCC factor,226.1,34,,226.1,percent of total billed charges,Implant Device,226.1,34,,226.1,percent of total billed charges,Implant Device,226.1,34,,226.1,percent of total billed charges,Implant Device,226.1,34,,226.1,percent of total billed charges,Implant Device,226.1,34,,226.1,percent of total billed charges,Implant Device,329.18,,,329.18,Other,110% of Medicare,232.75,35,,232.75,percent of total billed charges,Implant Device,226.1,34,"Charges > $500, x 34%",226.1,percent of total billed charges,Implant Device,232.75,35,,232.75,percent of total billed charges,Implant Device,232.75,35,,232.75,percent of total billed charges,Implant Device,232.75,35,,232.75,percent of total billed charges,Implant Device,232.75,35,,232.75,percent of total billed charges,Implant Device,232.75,35,,232.75,percent of total billed charges,Implant Device,266,40,,266,percent of total billed charges,Implant Device,232.75,70,,232.75,percent of total billed charges,All Other,226.1,34,,226.1,percent of total billed charges,Implant Device,226.1,34,,226.1,percent of total billed charges,Implant Device,232.75,35,,232.75,percent of total billed charges,Implant Device,232.75,35,,232.75,percent of total billed charges,Implant Device,232.75,35,,232.75,percent of total billed charges,Implant Device,232.75,35,,232.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,492.1,
ZIMMER 47-2485-080-10 SCREW,C1713,HCPCS,,79002063,CDM,278,RC,,,both,,,1990,1472.6,,,1472.6,Other,150% of Medicare + 9.63% HCRA Surcharge,895.5,45,,895.5,percent of total billed charges,Critical Access Hospital RCC factor,676.6,34,,676.6,percent of total billed charges,Implant Device,676.6,34,,676.6,percent of total billed charges,Implant Device,676.6,34,,676.6,percent of total billed charges,Implant Device,676.6,34,,676.6,percent of total billed charges,Implant Device,676.6,34,,676.6,percent of total billed charges,Implant Device,985.05,,,985.05,Other,110% of Medicare,696.5,35,,696.5,percent of total billed charges,Implant Device,676.6,34,"Charges > $500, x 34%",676.6,percent of total billed charges,Implant Device,696.5,35,,696.5,percent of total billed charges,Implant Device,696.5,35,,696.5,percent of total billed charges,Implant Device,696.5,35,,696.5,percent of total billed charges,Implant Device,696.5,35,,696.5,percent of total billed charges,Implant Device,696.5,35,,696.5,percent of total billed charges,Implant Device,796,40,,796,percent of total billed charges,Implant Device,696.5,70,,696.5,percent of total billed charges,All Other,676.6,34,,676.6,percent of total billed charges,Implant Device,676.6,34,,676.6,percent of total billed charges,Implant Device,696.5,35,,696.5,percent of total billed charges,Implant Device,696.5,35,,696.5,percent of total billed charges,Implant Device,696.5,35,,696.5,percent of total billed charges,Implant Device,696.5,35,,696.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1472.6,
ZIMMER 47-2485-095-10 SCREW 10.5X95MM,C1713,HCPCS,,79002064,CDM,278,RC,,,both,,,1685,1246.9,,,1246.9,Other,150% of Medicare + 9.63% HCRA Surcharge,758.25,45,,758.25,percent of total billed charges,Critical Access Hospital RCC factor,572.9,34,,572.9,percent of total billed charges,Implant Device,572.9,34,,572.9,percent of total billed charges,Implant Device,572.9,34,,572.9,percent of total billed charges,Implant Device,572.9,34,,572.9,percent of total billed charges,Implant Device,572.9,34,,572.9,percent of total billed charges,Implant Device,834.08,,,834.08,Other,110% of Medicare,589.75,35,,589.75,percent of total billed charges,Implant Device,572.9,34,"Charges > $500, x 34%",572.9,percent of total billed charges,Implant Device,589.75,35,,589.75,percent of total billed charges,Implant Device,589.75,35,,589.75,percent of total billed charges,Implant Device,589.75,35,,589.75,percent of total billed charges,Implant Device,589.75,35,,589.75,percent of total billed charges,Implant Device,589.75,35,,589.75,percent of total billed charges,Implant Device,674,40,,674,percent of total billed charges,Implant Device,589.75,70,,589.75,percent of total billed charges,All Other,572.9,34,,572.9,percent of total billed charges,Implant Device,572.9,34,,572.9,percent of total billed charges,Implant Device,589.75,35,,589.75,percent of total billed charges,Implant Device,589.75,35,,589.75,percent of total billed charges,Implant Device,589.75,35,,589.75,percent of total billed charges,Implant Device,589.75,35,,589.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1246.9,
ZIMMER 47-2485-100-10 SCREW,C1713,HCPCS,,79002065,CDM,278,RC,,,both,,,1872,1385.28,,,1385.28,Other,150% of Medicare + 9.63% HCRA Surcharge,842.4,45,,842.4,percent of total billed charges,Critical Access Hospital RCC factor,636.48,34,,636.48,percent of total billed charges,Implant Device,636.48,34,,636.48,percent of total billed charges,Implant Device,636.48,34,,636.48,percent of total billed charges,Implant Device,636.48,34,,636.48,percent of total billed charges,Implant Device,636.48,34,,636.48,percent of total billed charges,Implant Device,926.64,,,926.64,Other,110% of Medicare,655.2,35,,655.2,percent of total billed charges,Implant Device,636.48,34,"Charges > $500, x 34%",636.48,percent of total billed charges,Implant Device,655.2,35,,655.2,percent of total billed charges,Implant Device,655.2,35,,655.2,percent of total billed charges,Implant Device,655.2,35,,655.2,percent of total billed charges,Implant Device,655.2,35,,655.2,percent of total billed charges,Implant Device,655.2,35,,655.2,percent of total billed charges,Implant Device,748.8,40,,748.8,percent of total billed charges,Implant Device,655.2,70,,655.2,percent of total billed charges,All Other,636.48,34,,636.48,percent of total billed charges,Implant Device,636.48,34,,636.48,percent of total billed charges,Implant Device,655.2,35,,655.2,percent of total billed charges,Implant Device,655.2,35,,655.2,percent of total billed charges,Implant Device,655.2,35,,655.2,percent of total billed charges,Implant Device,655.2,35,,655.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1385.28,
ZIMMER 47-2485-105-10 SCREW,C1713,HCPCS,,79002066,CDM,278,RC,,,both,,,1872,1385.28,,,1385.28,Other,150% of Medicare + 9.63% HCRA Surcharge,842.4,45,,842.4,percent of total billed charges,Critical Access Hospital RCC factor,636.48,34,,636.48,percent of total billed charges,Implant Device,636.48,34,,636.48,percent of total billed charges,Implant Device,636.48,34,,636.48,percent of total billed charges,Implant Device,636.48,34,,636.48,percent of total billed charges,Implant Device,636.48,34,,636.48,percent of total billed charges,Implant Device,926.64,,,926.64,Other,110% of Medicare,655.2,35,,655.2,percent of total billed charges,Implant Device,636.48,34,"Charges > $500, x 34%",636.48,percent of total billed charges,Implant Device,655.2,35,,655.2,percent of total billed charges,Implant Device,655.2,35,,655.2,percent of total billed charges,Implant Device,655.2,35,,655.2,percent of total billed charges,Implant Device,655.2,35,,655.2,percent of total billed charges,Implant Device,655.2,35,,655.2,percent of total billed charges,Implant Device,748.8,40,,748.8,percent of total billed charges,Implant Device,655.2,70,,655.2,percent of total billed charges,All Other,636.48,34,,636.48,percent of total billed charges,Implant Device,636.48,34,,636.48,percent of total billed charges,Implant Device,655.2,35,,655.2,percent of total billed charges,Implant Device,655.2,35,,655.2,percent of total billed charges,Implant Device,655.2,35,,655.2,percent of total billed charges,Implant Device,655.2,35,,655.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1385.28,
ZIMMER 47-2485-110-10 NAIL SYSTEM,C1713,HCPCS,,79002067,CDM,278,RC,,,both,,,1873,1386.02,,,1386.02,Other,150% of Medicare + 9.63% HCRA Surcharge,842.85,45,,842.85,percent of total billed charges,Critical Access Hospital RCC factor,636.82,34,,636.82,percent of total billed charges,Implant Device,636.82,34,,636.82,percent of total billed charges,Implant Device,636.82,34,,636.82,percent of total billed charges,Implant Device,636.82,34,,636.82,percent of total billed charges,Implant Device,636.82,34,,636.82,percent of total billed charges,Implant Device,927.14,,,927.14,Other,110% of Medicare,655.55,35,,655.55,percent of total billed charges,Implant Device,636.82,34,"Charges > $500, x 34%",636.82,percent of total billed charges,Implant Device,655.55,35,,655.55,percent of total billed charges,Implant Device,655.55,35,,655.55,percent of total billed charges,Implant Device,655.55,35,,655.55,percent of total billed charges,Implant Device,655.55,35,,655.55,percent of total billed charges,Implant Device,655.55,35,,655.55,percent of total billed charges,Implant Device,749.2,40,,749.2,percent of total billed charges,Implant Device,655.55,70,,655.55,percent of total billed charges,All Other,636.82,34,,636.82,percent of total billed charges,Implant Device,636.82,34,,636.82,percent of total billed charges,Implant Device,655.55,35,,655.55,percent of total billed charges,Implant Device,655.55,35,,655.55,percent of total billed charges,Implant Device,655.55,35,,655.55,percent of total billed charges,Implant Device,655.55,35,,655.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1386.02,
ZIMMER 47-2493-000-00 NAIL SYSTEM,C1713,HCPCS,,79002068,CDM,278,RC,,,both,,,432,319.68,,,319.68,Other,150% of Medicare + 9.63% HCRA Surcharge,194.4,45,,194.4,percent of total billed charges,Critical Access Hospital RCC factor,146.88,34,,146.88,percent of total billed charges,Implant Device,146.88,34,,146.88,percent of total billed charges,Implant Device,146.88,34,,146.88,percent of total billed charges,Implant Device,146.88,34,,146.88,percent of total billed charges,Implant Device,146.88,34,,146.88,percent of total billed charges,Implant Device,213.84,,,213.84,Other,110% of Medicare,151.2,35,,151.2,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,151.2,35,,151.2,percent of total billed charges,Implant Device,151.2,35,,151.2,percent of total billed charges,Implant Device,151.2,35,,151.2,percent of total billed charges,Implant Device,151.2,35,,151.2,percent of total billed charges,Implant Device,151.2,35,,151.2,percent of total billed charges,Implant Device,172.8,40,,172.8,percent of total billed charges,Implant Device,151.2,70,,151.2,percent of total billed charges,All Other,146.88,34,,146.88,percent of total billed charges,Implant Device,146.88,34,,146.88,percent of total billed charges,Implant Device,151.2,35,,151.2,percent of total billed charges,Implant Device,151.2,35,,151.2,percent of total billed charges,Implant Device,151.2,35,,151.2,percent of total billed charges,Implant Device,151.2,35,,151.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,319.68,
ZIMMER 47-2493-210-10 NAIL SYSTEM,C1713,HCPCS,,79002069,CDM,278,RC,,,both,,,5160,3818.41,,,3818.41,Other,150% of Medicare + 9.63% HCRA Surcharge,2322,45,,2322,percent of total billed charges,Critical Access Hospital RCC factor,1754.4,34,,1754.4,percent of total billed charges,Implant Device,1754.4,34,,1754.4,percent of total billed charges,Implant Device,1754.4,34,,1754.4,percent of total billed charges,Implant Device,1754.4,34,,1754.4,percent of total billed charges,Implant Device,1754.4,34,,1754.4,percent of total billed charges,Implant Device,2554.2,,,2554.2,Other,110% of Medicare,1806,35,,1806,percent of total billed charges,Implant Device,1754.4,34,"Charges > $500, x 34%",1754.4,percent of total billed charges,Implant Device,1806,35,,1806,percent of total billed charges,Implant Device,1806,35,,1806,percent of total billed charges,Implant Device,1806,35,,1806,percent of total billed charges,Implant Device,1806,35,,1806,percent of total billed charges,Implant Device,1806,35,,1806,percent of total billed charges,Implant Device,2064,40,,2064,percent of total billed charges,Implant Device,1806,70,,1806,percent of total billed charges,All Other,1754.4,34,,1754.4,percent of total billed charges,Implant Device,1754.4,34,,1754.4,percent of total billed charges,Implant Device,1806,35,,1806,percent of total billed charges,Implant Device,1806,35,,1806,percent of total billed charges,Implant Device,1806,35,,1806,percent of total billed charges,Implant Device,1806,35,,1806,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1754.4,34,"If Charge > 2,000, then 34 percent",1754.4,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3818.41,
ZIMMER 47-2493-210-11 NAIL SYSTEM,C1713,HCPCS,,79002070,CDM,278,RC,,,both,,,4644,3436.57,,,3436.57,Other,150% of Medicare + 9.63% HCRA Surcharge,2089.8,45,,2089.8,percent of total billed charges,Critical Access Hospital RCC factor,1578.96,34,,1578.96,percent of total billed charges,Implant Device,1578.96,34,,1578.96,percent of total billed charges,Implant Device,1578.96,34,,1578.96,percent of total billed charges,Implant Device,1578.96,34,,1578.96,percent of total billed charges,Implant Device,1578.96,34,,1578.96,percent of total billed charges,Implant Device,2298.78,,,2298.78,Other,110% of Medicare,1625.4,35,,1625.4,percent of total billed charges,Implant Device,1578.96,34,"Charges > $500, x 34%",1578.96,percent of total billed charges,Implant Device,1625.4,35,,1625.4,percent of total billed charges,Implant Device,1625.4,35,,1625.4,percent of total billed charges,Implant Device,1625.4,35,,1625.4,percent of total billed charges,Implant Device,1625.4,35,,1625.4,percent of total billed charges,Implant Device,1625.4,35,,1625.4,percent of total billed charges,Implant Device,1857.6,40,,1857.6,percent of total billed charges,Implant Device,1625.4,70,,1625.4,percent of total billed charges,All Other,1578.96,34,,1578.96,percent of total billed charges,Implant Device,1578.96,34,,1578.96,percent of total billed charges,Implant Device,1625.4,35,,1625.4,percent of total billed charges,Implant Device,1625.4,35,,1625.4,percent of total billed charges,Implant Device,1625.4,35,,1625.4,percent of total billed charges,Implant Device,1625.4,35,,1625.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1578.96,34,"If Charge > 2,000, then 34 percent",1578.96,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3436.57,
ZIMMER 47-2493-211-13 NAIL CPM 13X21.5,C1713,HCPCS,,79002071,CDM,278,RC,,,both,,,5170,3825.81,,,3825.81,Other,150% of Medicare + 9.63% HCRA Surcharge,2326.5,45,,2326.5,percent of total billed charges,Critical Access Hospital RCC factor,1757.8,34,,1757.8,percent of total billed charges,Implant Device,1757.8,34,,1757.8,percent of total billed charges,Implant Device,1757.8,34,,1757.8,percent of total billed charges,Implant Device,1757.8,34,,1757.8,percent of total billed charges,Implant Device,1757.8,34,,1757.8,percent of total billed charges,Implant Device,2559.15,,,2559.15,Other,110% of Medicare,1809.5,35,,1809.5,percent of total billed charges,Implant Device,1757.8,34,"Charges > $500, x 34%",1757.8,percent of total billed charges,Implant Device,1809.5,35,,1809.5,percent of total billed charges,Implant Device,1809.5,35,,1809.5,percent of total billed charges,Implant Device,1809.5,35,,1809.5,percent of total billed charges,Implant Device,1809.5,35,,1809.5,percent of total billed charges,Implant Device,1809.5,35,,1809.5,percent of total billed charges,Implant Device,2068,40,,2068,percent of total billed charges,Implant Device,1809.5,70,,1809.5,percent of total billed charges,All Other,1757.8,34,,1757.8,percent of total billed charges,Implant Device,1757.8,34,,1757.8,percent of total billed charges,Implant Device,1809.5,35,,1809.5,percent of total billed charges,Implant Device,1809.5,35,,1809.5,percent of total billed charges,Implant Device,1809.5,35,,1809.5,percent of total billed charges,Implant Device,1809.5,35,,1809.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1757.8,34,"If Charge > 2,000, then 34 percent",1757.8,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3825.81,
ZIMMER 47-2493-212-11 NAIL CPM,C1713,HCPCS,,79002072,CDM,278,RC,,,both,,,5106,3778.45,,,3778.45,Other,150% of Medicare + 9.63% HCRA Surcharge,2297.7,45,,2297.7,percent of total billed charges,Critical Access Hospital RCC factor,1736.04,34,,1736.04,percent of total billed charges,Implant Device,1736.04,34,,1736.04,percent of total billed charges,Implant Device,1736.04,34,,1736.04,percent of total billed charges,Implant Device,1736.04,34,,1736.04,percent of total billed charges,Implant Device,1736.04,34,,1736.04,percent of total billed charges,Implant Device,2527.47,,,2527.47,Other,110% of Medicare,1787.1,35,,1787.1,percent of total billed charges,Implant Device,1736.04,34,"Charges > $500, x 34%",1736.04,percent of total billed charges,Implant Device,1787.1,35,,1787.1,percent of total billed charges,Implant Device,1787.1,35,,1787.1,percent of total billed charges,Implant Device,1787.1,35,,1787.1,percent of total billed charges,Implant Device,1787.1,35,,1787.1,percent of total billed charges,Implant Device,1787.1,35,,1787.1,percent of total billed charges,Implant Device,2042.4,40,,2042.4,percent of total billed charges,Implant Device,1787.1,70,,1787.1,percent of total billed charges,All Other,1736.04,34,,1736.04,percent of total billed charges,Implant Device,1736.04,34,,1736.04,percent of total billed charges,Implant Device,1787.1,35,,1787.1,percent of total billed charges,Implant Device,1787.1,35,,1787.1,percent of total billed charges,Implant Device,1787.1,35,,1787.1,percent of total billed charges,Implant Device,1787.1,35,,1787.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1736.04,34,"If Charge > 2,000, then 34 percent",1736.04,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3778.45,
ZIMMER 47-2493-213-11 NAIL CPM,C1713,HCPCS,,79002073,CDM,278,RC,,,both,,,5170,3825.81,,,3825.81,Other,150% of Medicare + 9.63% HCRA Surcharge,2326.5,45,,2326.5,percent of total billed charges,Critical Access Hospital RCC factor,1757.8,34,,1757.8,percent of total billed charges,Implant Device,1757.8,34,,1757.8,percent of total billed charges,Implant Device,1757.8,34,,1757.8,percent of total billed charges,Implant Device,1757.8,34,,1757.8,percent of total billed charges,Implant Device,1757.8,34,,1757.8,percent of total billed charges,Implant Device,2559.15,,,2559.15,Other,110% of Medicare,1809.5,35,,1809.5,percent of total billed charges,Implant Device,1757.8,34,"Charges > $500, x 34%",1757.8,percent of total billed charges,Implant Device,1809.5,35,,1809.5,percent of total billed charges,Implant Device,1809.5,35,,1809.5,percent of total billed charges,Implant Device,1809.5,35,,1809.5,percent of total billed charges,Implant Device,1809.5,35,,1809.5,percent of total billed charges,Implant Device,1809.5,35,,1809.5,percent of total billed charges,Implant Device,2068,40,,2068,percent of total billed charges,Implant Device,1809.5,70,,1809.5,percent of total billed charges,All Other,1757.8,34,,1757.8,percent of total billed charges,Implant Device,1757.8,34,,1757.8,percent of total billed charges,Implant Device,1809.5,35,,1809.5,percent of total billed charges,Implant Device,1809.5,35,,1809.5,percent of total billed charges,Implant Device,1809.5,35,,1809.5,percent of total billed charges,Implant Device,1809.5,35,,1809.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1757.8,34,"If Charge > 2,000, then 34 percent",1757.8,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3825.81,
ZIMMER 4811-110-40 SCREW,C1713,HCPCS,,79002079,CDM,278,RC,,,both,,,378,279.72,,,279.72,Other,150% of Medicare + 9.63% HCRA Surcharge,170.1,45,,170.1,percent of total billed charges,Critical Access Hospital RCC factor,128.52,34,,128.52,percent of total billed charges,Implant Device,128.52,34,,128.52,percent of total billed charges,Implant Device,128.52,34,,128.52,percent of total billed charges,Implant Device,128.52,34,,128.52,percent of total billed charges,Implant Device,128.52,34,,128.52,percent of total billed charges,Implant Device,187.11,,,187.11,Other,110% of Medicare,132.3,35,,132.3,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,132.3,35,,132.3,percent of total billed charges,Implant Device,132.3,35,,132.3,percent of total billed charges,Implant Device,132.3,35,,132.3,percent of total billed charges,Implant Device,132.3,35,,132.3,percent of total billed charges,Implant Device,132.3,35,,132.3,percent of total billed charges,Implant Device,151.2,40,,151.2,percent of total billed charges,Implant Device,132.3,70,,132.3,percent of total billed charges,All Other,128.52,34,,128.52,percent of total billed charges,Implant Device,128.52,34,,128.52,percent of total billed charges,Implant Device,132.3,35,,132.3,percent of total billed charges,Implant Device,132.3,35,,132.3,percent of total billed charges,Implant Device,132.3,35,,132.3,percent of total billed charges,Implant Device,132.3,35,,132.3,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,279.72,
ZIMMER 4828-012-02 SCREW,C1713,HCPCS,,79002080,CDM,278,RC,,,both,,,345,255.3,,,255.3,Other,150% of Medicare + 9.63% HCRA Surcharge,155.25,45,,155.25,percent of total billed charges,Critical Access Hospital RCC factor,117.3,34,,117.3,percent of total billed charges,Implant Device,117.3,34,,117.3,percent of total billed charges,Implant Device,117.3,34,,117.3,percent of total billed charges,Implant Device,117.3,34,,117.3,percent of total billed charges,Implant Device,117.3,34,,117.3,percent of total billed charges,Implant Device,170.78,,,170.78,Other,110% of Medicare,120.75,35,,120.75,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,120.75,35,,120.75,percent of total billed charges,Implant Device,120.75,35,,120.75,percent of total billed charges,Implant Device,120.75,35,,120.75,percent of total billed charges,Implant Device,120.75,35,,120.75,percent of total billed charges,Implant Device,120.75,35,,120.75,percent of total billed charges,Implant Device,138,40,,138,percent of total billed charges,Implant Device,120.75,70,,120.75,percent of total billed charges,All Other,117.3,34,,117.3,percent of total billed charges,Implant Device,117.3,34,,117.3,percent of total billed charges,Implant Device,120.75,35,,120.75,percent of total billed charges,Implant Device,120.75,35,,120.75,percent of total billed charges,Implant Device,120.75,35,,120.75,percent of total billed charges,Implant Device,120.75,35,,120.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,255.3,
ZIMMER 4828-014-02 SCREW,C1713,HCPCS,,79002081,CDM,278,RC,,,both,,,335,247.9,,,247.9,Other,150% of Medicare + 9.63% HCRA Surcharge,150.75,45,,150.75,percent of total billed charges,Critical Access Hospital RCC factor,113.9,34,,113.9,percent of total billed charges,Implant Device,113.9,34,,113.9,percent of total billed charges,Implant Device,113.9,34,,113.9,percent of total billed charges,Implant Device,113.9,34,,113.9,percent of total billed charges,Implant Device,113.9,34,,113.9,percent of total billed charges,Implant Device,165.83,,,165.83,Other,110% of Medicare,117.25,35,,117.25,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,117.25,35,,117.25,percent of total billed charges,Implant Device,117.25,35,,117.25,percent of total billed charges,Implant Device,117.25,35,,117.25,percent of total billed charges,Implant Device,117.25,35,,117.25,percent of total billed charges,Implant Device,117.25,35,,117.25,percent of total billed charges,Implant Device,134,40,,134,percent of total billed charges,Implant Device,117.25,70,,117.25,percent of total billed charges,All Other,113.9,34,,113.9,percent of total billed charges,Implant Device,113.9,34,,113.9,percent of total billed charges,Implant Device,117.25,35,,117.25,percent of total billed charges,Implant Device,117.25,35,,117.25,percent of total billed charges,Implant Device,117.25,35,,117.25,percent of total billed charges,Implant Device,117.25,35,,117.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,247.9,
ZIMMER 4828-016-02 SCREW,C1713,HCPCS,,79002082,CDM,278,RC,,,both,,,335,247.9,,,247.9,Other,150% of Medicare + 9.63% HCRA Surcharge,150.75,45,,150.75,percent of total billed charges,Critical Access Hospital RCC factor,113.9,34,,113.9,percent of total billed charges,Implant Device,113.9,34,,113.9,percent of total billed charges,Implant Device,113.9,34,,113.9,percent of total billed charges,Implant Device,113.9,34,,113.9,percent of total billed charges,Implant Device,113.9,34,,113.9,percent of total billed charges,Implant Device,165.83,,,165.83,Other,110% of Medicare,117.25,35,,117.25,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,117.25,35,,117.25,percent of total billed charges,Implant Device,117.25,35,,117.25,percent of total billed charges,Implant Device,117.25,35,,117.25,percent of total billed charges,Implant Device,117.25,35,,117.25,percent of total billed charges,Implant Device,117.25,35,,117.25,percent of total billed charges,Implant Device,134,40,,134,percent of total billed charges,Implant Device,117.25,70,,117.25,percent of total billed charges,All Other,113.9,34,,113.9,percent of total billed charges,Implant Device,113.9,34,,113.9,percent of total billed charges,Implant Device,117.25,35,,117.25,percent of total billed charges,Implant Device,117.25,35,,117.25,percent of total billed charges,Implant Device,117.25,35,,117.25,percent of total billed charges,Implant Device,117.25,35,,117.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,247.9,
ZIMMER 4828-018-02 SCREW,C1713,HCPCS,,79002083,CDM,278,RC,,,both,,,335,247.9,,,247.9,Other,150% of Medicare + 9.63% HCRA Surcharge,150.75,45,,150.75,percent of total billed charges,Critical Access Hospital RCC factor,113.9,34,,113.9,percent of total billed charges,Implant Device,113.9,34,,113.9,percent of total billed charges,Implant Device,113.9,34,,113.9,percent of total billed charges,Implant Device,113.9,34,,113.9,percent of total billed charges,Implant Device,113.9,34,,113.9,percent of total billed charges,Implant Device,165.83,,,165.83,Other,110% of Medicare,117.25,35,,117.25,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,117.25,35,,117.25,percent of total billed charges,Implant Device,117.25,35,,117.25,percent of total billed charges,Implant Device,117.25,35,,117.25,percent of total billed charges,Implant Device,117.25,35,,117.25,percent of total billed charges,Implant Device,117.25,35,,117.25,percent of total billed charges,Implant Device,134,40,,134,percent of total billed charges,Implant Device,117.25,70,,117.25,percent of total billed charges,All Other,113.9,34,,113.9,percent of total billed charges,Implant Device,113.9,34,,113.9,percent of total billed charges,Implant Device,117.25,35,,117.25,percent of total billed charges,Implant Device,117.25,35,,117.25,percent of total billed charges,Implant Device,117.25,35,,117.25,percent of total billed charges,Implant Device,117.25,35,,117.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,247.9,
ZIMMER 4828-020-02 SCREW,C1713,HCPCS,,79002084,CDM,278,RC,,,both,,,345,255.3,,,255.3,Other,150% of Medicare + 9.63% HCRA Surcharge,155.25,45,,155.25,percent of total billed charges,Critical Access Hospital RCC factor,117.3,34,,117.3,percent of total billed charges,Implant Device,117.3,34,,117.3,percent of total billed charges,Implant Device,117.3,34,,117.3,percent of total billed charges,Implant Device,117.3,34,,117.3,percent of total billed charges,Implant Device,117.3,34,,117.3,percent of total billed charges,Implant Device,170.78,,,170.78,Other,110% of Medicare,120.75,35,,120.75,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,120.75,35,,120.75,percent of total billed charges,Implant Device,120.75,35,,120.75,percent of total billed charges,Implant Device,120.75,35,,120.75,percent of total billed charges,Implant Device,120.75,35,,120.75,percent of total billed charges,Implant Device,120.75,35,,120.75,percent of total billed charges,Implant Device,138,40,,138,percent of total billed charges,Implant Device,120.75,70,,120.75,percent of total billed charges,All Other,117.3,34,,117.3,percent of total billed charges,Implant Device,117.3,34,,117.3,percent of total billed charges,Implant Device,120.75,35,,120.75,percent of total billed charges,Implant Device,120.75,35,,120.75,percent of total billed charges,Implant Device,120.75,35,,120.75,percent of total billed charges,Implant Device,120.75,35,,120.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,255.3,
ZIMMER 4835-014-01 SCREW,C1713,HCPCS,,79002085,CDM,278,RC,,,both,,,601,444.74,,,444.74,Other,150% of Medicare + 9.63% HCRA Surcharge,270.45,45,,270.45,percent of total billed charges,Critical Access Hospital RCC factor,204.34,34,,204.34,percent of total billed charges,Implant Device,204.34,34,,204.34,percent of total billed charges,Implant Device,204.34,34,,204.34,percent of total billed charges,Implant Device,204.34,34,,204.34,percent of total billed charges,Implant Device,204.34,34,,204.34,percent of total billed charges,Implant Device,297.5,,,297.5,Other,110% of Medicare,210.35,35,,210.35,percent of total billed charges,Implant Device,204.34,34,"Charges > $500, x 34%",204.34,percent of total billed charges,Implant Device,210.35,35,,210.35,percent of total billed charges,Implant Device,210.35,35,,210.35,percent of total billed charges,Implant Device,210.35,35,,210.35,percent of total billed charges,Implant Device,210.35,35,,210.35,percent of total billed charges,Implant Device,210.35,35,,210.35,percent of total billed charges,Implant Device,240.4,40,,240.4,percent of total billed charges,Implant Device,210.35,70,,210.35,percent of total billed charges,All Other,204.34,34,,204.34,percent of total billed charges,Implant Device,204.34,34,,204.34,percent of total billed charges,Implant Device,210.35,35,,210.35,percent of total billed charges,Implant Device,210.35,35,,210.35,percent of total billed charges,Implant Device,210.35,35,,210.35,percent of total billed charges,Implant Device,210.35,35,,210.35,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,444.74,
ZIMMER 4840-022-00 SCREW,C1713,HCPCS,,79002086,CDM,278,RC,,,both,,,84,62.16,,,62.16,Other,150% of Medicare + 9.63% HCRA Surcharge,37.8,45,,37.8,percent of total billed charges,Critical Access Hospital RCC factor,28.56,34,,28.56,percent of total billed charges,Implant Device,28.56,34,,28.56,percent of total billed charges,Implant Device,28.56,34,,28.56,percent of total billed charges,Implant Device,28.56,34,,28.56,percent of total billed charges,Implant Device,28.56,34,,28.56,percent of total billed charges,Implant Device,41.58,,,41.58,Other,110% of Medicare,29.4,35,,29.4,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,29.4,35,,29.4,percent of total billed charges,Implant Device,29.4,35,,29.4,percent of total billed charges,Implant Device,29.4,35,,29.4,percent of total billed charges,Implant Device,29.4,35,,29.4,percent of total billed charges,Implant Device,29.4,35,,29.4,percent of total billed charges,Implant Device,33.6,40,,33.6,percent of total billed charges,Implant Device,29.4,70,,29.4,percent of total billed charges,All Other,28.56,34,,28.56,percent of total billed charges,Implant Device,28.56,34,,28.56,percent of total billed charges,Implant Device,29.4,35,,29.4,percent of total billed charges,Implant Device,29.4,35,,29.4,percent of total billed charges,Implant Device,29.4,35,,29.4,percent of total billed charges,Implant Device,29.4,35,,29.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,62.16,
ZIMMER 4840-030-01 SCREW,C1713,HCPCS,,79002087,CDM,278,RC,,,both,,,84,62.16,,,62.16,Other,150% of Medicare + 9.63% HCRA Surcharge,37.8,45,,37.8,percent of total billed charges,Critical Access Hospital RCC factor,28.56,34,,28.56,percent of total billed charges,Implant Device,28.56,34,,28.56,percent of total billed charges,Implant Device,28.56,34,,28.56,percent of total billed charges,Implant Device,28.56,34,,28.56,percent of total billed charges,Implant Device,28.56,34,,28.56,percent of total billed charges,Implant Device,41.58,,,41.58,Other,110% of Medicare,29.4,35,,29.4,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,29.4,35,,29.4,percent of total billed charges,Implant Device,29.4,35,,29.4,percent of total billed charges,Implant Device,29.4,35,,29.4,percent of total billed charges,Implant Device,29.4,35,,29.4,percent of total billed charges,Implant Device,29.4,35,,29.4,percent of total billed charges,Implant Device,33.6,40,,33.6,percent of total billed charges,Implant Device,29.4,70,,29.4,percent of total billed charges,All Other,28.56,34,,28.56,percent of total billed charges,Implant Device,28.56,34,,28.56,percent of total billed charges,Implant Device,29.4,35,,29.4,percent of total billed charges,Implant Device,29.4,35,,29.4,percent of total billed charges,Implant Device,29.4,35,,29.4,percent of total billed charges,Implant Device,29.4,35,,29.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,62.16,
ZIMMER 4840-045-00 SCREW,C1713,HCPCS,,79002088,CDM,278,RC,,,both,,,84,62.16,,,62.16,Other,150% of Medicare + 9.63% HCRA Surcharge,37.8,45,,37.8,percent of total billed charges,Critical Access Hospital RCC factor,28.56,34,,28.56,percent of total billed charges,Implant Device,28.56,34,,28.56,percent of total billed charges,Implant Device,28.56,34,,28.56,percent of total billed charges,Implant Device,28.56,34,,28.56,percent of total billed charges,Implant Device,28.56,34,,28.56,percent of total billed charges,Implant Device,41.58,,,41.58,Other,110% of Medicare,29.4,35,,29.4,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,29.4,35,,29.4,percent of total billed charges,Implant Device,29.4,35,,29.4,percent of total billed charges,Implant Device,29.4,35,,29.4,percent of total billed charges,Implant Device,29.4,35,,29.4,percent of total billed charges,Implant Device,29.4,35,,29.4,percent of total billed charges,Implant Device,33.6,40,,33.6,percent of total billed charges,Implant Device,29.4,70,,29.4,percent of total billed charges,All Other,28.56,34,,28.56,percent of total billed charges,Implant Device,28.56,34,,28.56,percent of total billed charges,Implant Device,29.4,35,,29.4,percent of total billed charges,Implant Device,29.4,35,,29.4,percent of total billed charges,Implant Device,29.4,35,,29.4,percent of total billed charges,Implant Device,29.4,35,,29.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,62.16,
ZIMMER 4936-006-03 PLATE,C1713,HCPCS,,79002090,CDM,278,RC,,,both,,,466,344.84,,,344.84,Other,150% of Medicare + 9.63% HCRA Surcharge,209.7,45,,209.7,percent of total billed charges,Critical Access Hospital RCC factor,158.44,34,,158.44,percent of total billed charges,Implant Device,158.44,34,,158.44,percent of total billed charges,Implant Device,158.44,34,,158.44,percent of total billed charges,Implant Device,158.44,34,,158.44,percent of total billed charges,Implant Device,158.44,34,,158.44,percent of total billed charges,Implant Device,230.67,,,230.67,Other,110% of Medicare,163.1,35,,163.1,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,163.1,35,,163.1,percent of total billed charges,Implant Device,163.1,35,,163.1,percent of total billed charges,Implant Device,163.1,35,,163.1,percent of total billed charges,Implant Device,163.1,35,,163.1,percent of total billed charges,Implant Device,163.1,35,,163.1,percent of total billed charges,Implant Device,186.4,40,,186.4,percent of total billed charges,Implant Device,163.1,70,,163.1,percent of total billed charges,All Other,158.44,34,,158.44,percent of total billed charges,Implant Device,158.44,34,,158.44,percent of total billed charges,Implant Device,163.1,35,,163.1,percent of total billed charges,Implant Device,163.1,35,,163.1,percent of total billed charges,Implant Device,163.1,35,,163.1,percent of total billed charges,Implant Device,163.1,35,,163.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,344.84,
STRYKER ORTHO 500-03-54E BACK SHELL,C1776,HCPCS,,79002091,CDM,278,RC,,,both,,,5185,3836.91,,,3836.91,Other,150% of Medicare + 9.63% HCRA Surcharge,2333.25,45,,2333.25,percent of total billed charges,Critical Access Hospital RCC factor,1762.9,34,,1762.9,percent of total billed charges,Implant Device,1762.9,34,,1762.9,percent of total billed charges,Implant Device,1762.9,34,,1762.9,percent of total billed charges,Implant Device,1762.9,34,,1762.9,percent of total billed charges,Implant Device,1762.9,34,,1762.9,percent of total billed charges,Implant Device,2566.58,,,2566.58,Other,110% of Medicare,1814.75,35,,1814.75,percent of total billed charges,Implant Device,1762.9,34,"Charges > $500, x 34%",1762.9,percent of total billed charges,Implant Device,1814.75,35,,1814.75,percent of total billed charges,Implant Device,1814.75,35,,1814.75,percent of total billed charges,Implant Device,1814.75,35,,1814.75,percent of total billed charges,Implant Device,1814.75,35,,1814.75,percent of total billed charges,Implant Device,1814.75,35,,1814.75,percent of total billed charges,Implant Device,2074,40,,2074,percent of total billed charges,Implant Device,1814.75,70,,1814.75,percent of total billed charges,All Other,1762.9,34,,1762.9,percent of total billed charges,Implant Device,1762.9,34,,1762.9,percent of total billed charges,Implant Device,1814.75,35,,1814.75,percent of total billed charges,Implant Device,1814.75,35,,1814.75,percent of total billed charges,Implant Device,1814.75,35,,1814.75,percent of total billed charges,Implant Device,1814.75,35,,1814.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1762.9,34,"If Charge > 2,000, then 34 percent",1762.9,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3836.91,
STRYKER 502-03-52D-REV SHELL,C1776,HCPCS,,79002092,CDM,278,RC,,,both,,,9823,7269.04,,,7269.04,Other,150% of Medicare + 9.63% HCRA Surcharge,4420.35,45,,4420.35,percent of total billed charges,Critical Access Hospital RCC factor,3339.82,34,,3339.82,percent of total billed charges,Implant Device,3339.82,34,,3339.82,percent of total billed charges,Implant Device,3339.82,34,,3339.82,percent of total billed charges,Implant Device,3339.82,34,,3339.82,percent of total billed charges,Implant Device,3339.82,34,,3339.82,percent of total billed charges,Implant Device,4862.39,,,4862.39,Other,110% of Medicare,3438.05,35,,3438.05,percent of total billed charges,Implant Device,3339.82,34,"Charges > $500, x 34%",3339.82,percent of total billed charges,Implant Device,3438.05,35,,3438.05,percent of total billed charges,Implant Device,3438.05,35,,3438.05,percent of total billed charges,Implant Device,3438.05,35,,3438.05,percent of total billed charges,Implant Device,3438.05,35,,3438.05,percent of total billed charges,Implant Device,3438.05,35,,3438.05,percent of total billed charges,Implant Device,3929.2,40,,3929.2,percent of total billed charges,Implant Device,3438.05,70,,3438.05,percent of total billed charges,All Other,3339.82,34,,3339.82,percent of total billed charges,Implant Device,3339.82,34,,3339.82,percent of total billed charges,Implant Device,3438.05,35,,3438.05,percent of total billed charges,Implant Device,3438.05,35,,3438.05,percent of total billed charges,Implant Device,3438.05,35,,3438.05,percent of total billed charges,Implant Device,3438.05,35,,3438.05,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3339.82,34,"If Charge > 2,000, then 34 percent",3339.82,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,7269.04,
STRYKER 5029-8-200 ROD,C1776,HCPCS,,79002093,CDM,278,RC,,,both,,,217,160.58,,,160.58,Other,150% of Medicare + 9.63% HCRA Surcharge,97.65,45,,97.65,percent of total billed charges,Critical Access Hospital RCC factor,73.78,34,,73.78,percent of total billed charges,Implant Device,73.78,34,,73.78,percent of total billed charges,Implant Device,73.78,34,,73.78,percent of total billed charges,Implant Device,73.78,34,,73.78,percent of total billed charges,Implant Device,73.78,34,,73.78,percent of total billed charges,Implant Device,107.42,,,107.42,Other,110% of Medicare,75.95,35,,75.95,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,75.95,35,,75.95,percent of total billed charges,Implant Device,75.95,35,,75.95,percent of total billed charges,Implant Device,75.95,35,,75.95,percent of total billed charges,Implant Device,75.95,35,,75.95,percent of total billed charges,Implant Device,75.95,35,,75.95,percent of total billed charges,Implant Device,86.8,40,,86.8,percent of total billed charges,Implant Device,75.95,70,,75.95,percent of total billed charges,All Other,73.78,34,,73.78,percent of total billed charges,Implant Device,73.78,34,,73.78,percent of total billed charges,Implant Device,75.95,35,,75.95,percent of total billed charges,Implant Device,75.95,35,,75.95,percent of total billed charges,Implant Device,75.95,35,,75.95,percent of total billed charges,Implant Device,75.95,35,,75.95,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,160.58,
MEDTRONIC 5086-MRI45 BRADYCARDIA LEAD,C1898,HCPCS,,79002094,CDM,278,RC,,,both,,,2940,2175.61,,,2175.61,Other,150% of Medicare + 9.63% HCRA Surcharge,1323,45,,1323,percent of total billed charges,Critical Access Hospital RCC factor,999.6,34,,999.6,percent of total billed charges,Implant Device,999.6,34,,999.6,percent of total billed charges,Implant Device,999.6,34,,999.6,percent of total billed charges,Implant Device,999.6,34,,999.6,percent of total billed charges,Implant Device,999.6,34,,999.6,percent of total billed charges,Implant Device,1455.3,,,1455.3,Other,110% of Medicare,1029,35,,1029,percent of total billed charges,Implant Device,999.6,34,"Charges > $500, x 34%",999.6,percent of total billed charges,Implant Device,1029,35,,1029,percent of total billed charges,Implant Device,1029,35,,1029,percent of total billed charges,Implant Device,1029,35,,1029,percent of total billed charges,Implant Device,1029,35,,1029,percent of total billed charges,Implant Device,1029,35,,1029,percent of total billed charges,Implant Device,1176,40,,1176,percent of total billed charges,Implant Device,1029,70,,1029,percent of total billed charges,All Other,999.6,34,,999.6,percent of total billed charges,Implant Device,999.6,34,,999.6,percent of total billed charges,Implant Device,1029,35,,1029,percent of total billed charges,Implant Device,1029,35,,1029,percent of total billed charges,Implant Device,1029,35,,1029,percent of total billed charges,Implant Device,1029,35,,1029,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,999.6,34,"If Charge > 2,000, then 34 percent",999.6,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2175.61,
MEDTRONIC 5086-MRI52 BRADYCARDIA LEAD,C1898,HCPCS,,79002095,CDM,278,RC,,,both,,,2940,2175.61,,,2175.61,Other,150% of Medicare + 9.63% HCRA Surcharge,1323,45,,1323,percent of total billed charges,Critical Access Hospital RCC factor,999.6,34,,999.6,percent of total billed charges,Implant Device,999.6,34,,999.6,percent of total billed charges,Implant Device,999.6,34,,999.6,percent of total billed charges,Implant Device,999.6,34,,999.6,percent of total billed charges,Implant Device,999.6,34,,999.6,percent of total billed charges,Implant Device,1455.3,,,1455.3,Other,110% of Medicare,1029,35,,1029,percent of total billed charges,Implant Device,999.6,34,"Charges > $500, x 34%",999.6,percent of total billed charges,Implant Device,1029,35,,1029,percent of total billed charges,Implant Device,1029,35,,1029,percent of total billed charges,Implant Device,1029,35,,1029,percent of total billed charges,Implant Device,1029,35,,1029,percent of total billed charges,Implant Device,1029,35,,1029,percent of total billed charges,Implant Device,1176,40,,1176,percent of total billed charges,Implant Device,1029,70,,1029,percent of total billed charges,All Other,999.6,34,,999.6,percent of total billed charges,Implant Device,999.6,34,,999.6,percent of total billed charges,Implant Device,1029,35,,1029,percent of total billed charges,Implant Device,1029,35,,1029,percent of total billed charges,Implant Device,1029,35,,1029,percent of total billed charges,Implant Device,1029,35,,1029,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,999.6,34,"If Charge > 2,000, then 34 percent",999.6,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2175.61,
MEDTRONIC 5086-MRI58 BRADYCARDIA LEAD,C1898,HCPCS,,79002096,CDM,278,RC,,,both,,,2940,2175.61,,,2175.61,Other,150% of Medicare + 9.63% HCRA Surcharge,1323,45,,1323,percent of total billed charges,Critical Access Hospital RCC factor,999.6,34,,999.6,percent of total billed charges,Implant Device,999.6,34,,999.6,percent of total billed charges,Implant Device,999.6,34,,999.6,percent of total billed charges,Implant Device,999.6,34,,999.6,percent of total billed charges,Implant Device,999.6,34,,999.6,percent of total billed charges,Implant Device,1455.3,,,1455.3,Other,110% of Medicare,1029,35,,1029,percent of total billed charges,Implant Device,999.6,34,"Charges > $500, x 34%",999.6,percent of total billed charges,Implant Device,1029,35,,1029,percent of total billed charges,Implant Device,1029,35,,1029,percent of total billed charges,Implant Device,1029,35,,1029,percent of total billed charges,Implant Device,1029,35,,1029,percent of total billed charges,Implant Device,1029,35,,1029,percent of total billed charges,Implant Device,1176,40,,1176,percent of total billed charges,Implant Device,1029,70,,1029,percent of total billed charges,All Other,999.6,34,,999.6,percent of total billed charges,Implant Device,999.6,34,,999.6,percent of total billed charges,Implant Device,1029,35,,1029,percent of total billed charges,Implant Device,1029,35,,1029,percent of total billed charges,Implant Device,1029,35,,1029,percent of total billed charges,Implant Device,1029,35,,1029,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,999.6,34,"If Charge > 2,000, then 34 percent",999.6,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2175.61,
CAREFUSION 50-9000B PLEURX CATHETER KIT,C1729,HCPCS,,79002097,CDM,278,RC,,,both,,,1650,1221,,,1221,Other,150% of Medicare + 9.63% HCRA Surcharge,742.5,45,,742.5,percent of total billed charges,Critical Access Hospital RCC factor,561,34,,561,percent of total billed charges,Implant Device,561,34,,561,percent of total billed charges,Implant Device,561,34,,561,percent of total billed charges,Implant Device,561,34,,561,percent of total billed charges,Implant Device,561,34,,561,percent of total billed charges,Implant Device,816.75,,,816.75,Other,110% of Medicare,577.5,35,,577.5,percent of total billed charges,Implant Device,561,34,"Charges > $500, x 34%",561,percent of total billed charges,Implant Device,577.5,35,,577.5,percent of total billed charges,Implant Device,577.5,35,,577.5,percent of total billed charges,Implant Device,577.5,35,,577.5,percent of total billed charges,Implant Device,577.5,35,,577.5,percent of total billed charges,Implant Device,577.5,35,,577.5,percent of total billed charges,Implant Device,660,40,,660,percent of total billed charges,Implant Device,577.5,70,,577.5,percent of total billed charges,All Other,561,34,,561,percent of total billed charges,Implant Device,561,34,,561,percent of total billed charges,Implant Device,577.5,35,,577.5,percent of total billed charges,Implant Device,577.5,35,,577.5,percent of total billed charges,Implant Device,577.5,35,,577.5,percent of total billed charges,Implant Device,577.5,35,,577.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1221,
DEPUY 52-3293-REV FEMORAL STEM,C1776,HCPCS,,79002098,CDM,278,RC,,,both,,,8245,6101.32,,,6101.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3710.25,45,,3710.25,percent of total billed charges,Critical Access Hospital RCC factor,2803.3,34,,2803.3,percent of total billed charges,Implant Device,2803.3,34,,2803.3,percent of total billed charges,Implant Device,2803.3,34,,2803.3,percent of total billed charges,Implant Device,2803.3,34,,2803.3,percent of total billed charges,Implant Device,2803.3,34,,2803.3,percent of total billed charges,Implant Device,4081.28,,,4081.28,Other,110% of Medicare,2885.75,35,,2885.75,percent of total billed charges,Implant Device,2803.3,34,"Charges > $500, x 34%",2803.3,percent of total billed charges,Implant Device,2885.75,35,,2885.75,percent of total billed charges,Implant Device,2885.75,35,,2885.75,percent of total billed charges,Implant Device,2885.75,35,,2885.75,percent of total billed charges,Implant Device,2885.75,35,,2885.75,percent of total billed charges,Implant Device,2885.75,35,,2885.75,percent of total billed charges,Implant Device,3298,40,,3298,percent of total billed charges,Implant Device,2885.75,70,,2885.75,percent of total billed charges,All Other,2803.3,34,,2803.3,percent of total billed charges,Implant Device,2803.3,34,,2803.3,percent of total billed charges,Implant Device,2885.75,35,,2885.75,percent of total billed charges,Implant Device,2885.75,35,,2885.75,percent of total billed charges,Implant Device,2885.75,35,,2885.75,percent of total billed charges,Implant Device,2885.75,35,,2885.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2803.3,34,"If Charge > 2,000, then 34 percent",2803.3,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,6101.32,
STRYKER 53-17008E SCREW,C1713,HCPCS,,79002099,CDM,278,RC,,,both,,,241,178.34,,,178.34,Other,150% of Medicare + 9.63% HCRA Surcharge,108.45,45,,108.45,percent of total billed charges,Critical Access Hospital RCC factor,81.94,34,,81.94,percent of total billed charges,Implant Device,81.94,34,,81.94,percent of total billed charges,Implant Device,81.94,34,,81.94,percent of total billed charges,Implant Device,81.94,34,,81.94,percent of total billed charges,Implant Device,81.94,34,,81.94,percent of total billed charges,Implant Device,119.3,,,119.3,Other,110% of Medicare,84.35,35,,84.35,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,84.35,35,,84.35,percent of total billed charges,Implant Device,84.35,35,,84.35,percent of total billed charges,Implant Device,84.35,35,,84.35,percent of total billed charges,Implant Device,84.35,35,,84.35,percent of total billed charges,Implant Device,84.35,35,,84.35,percent of total billed charges,Implant Device,96.4,40,,96.4,percent of total billed charges,Implant Device,84.35,70,,84.35,percent of total billed charges,All Other,81.94,34,,81.94,percent of total billed charges,Implant Device,81.94,34,,81.94,percent of total billed charges,Implant Device,84.35,35,,84.35,percent of total billed charges,Implant Device,84.35,35,,84.35,percent of total billed charges,Implant Device,84.35,35,,84.35,percent of total billed charges,Implant Device,84.35,35,,84.35,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,178.34,
STRYKER 53-17011E SCREW,C1713,HCPCS,,79002100,CDM,278,RC,,,both,,,306,226.44,,,226.44,Other,150% of Medicare + 9.63% HCRA Surcharge,137.7,45,,137.7,percent of total billed charges,Critical Access Hospital RCC factor,104.04,34,,104.04,percent of total billed charges,Implant Device,104.04,34,,104.04,percent of total billed charges,Implant Device,104.04,34,,104.04,percent of total billed charges,Implant Device,104.04,34,,104.04,percent of total billed charges,Implant Device,104.04,34,,104.04,percent of total billed charges,Implant Device,151.47,,,151.47,Other,110% of Medicare,107.1,35,,107.1,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,107.1,35,,107.1,percent of total billed charges,Implant Device,107.1,35,,107.1,percent of total billed charges,Implant Device,107.1,35,,107.1,percent of total billed charges,Implant Device,107.1,35,,107.1,percent of total billed charges,Implant Device,107.1,35,,107.1,percent of total billed charges,Implant Device,122.4,40,,122.4,percent of total billed charges,Implant Device,107.1,70,,107.1,percent of total billed charges,All Other,104.04,34,,104.04,percent of total billed charges,Implant Device,104.04,34,,104.04,percent of total billed charges,Implant Device,107.1,35,,107.1,percent of total billed charges,Implant Device,107.1,35,,107.1,percent of total billed charges,Implant Device,107.1,35,,107.1,percent of total billed charges,Implant Device,107.1,35,,107.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,226.44,
STRYKER 53-17013E SCREW,C1713,HCPCS,,79002101,CDM,278,RC,,,both,,,306,226.44,,,226.44,Other,150% of Medicare + 9.63% HCRA Surcharge,137.7,45,,137.7,percent of total billed charges,Critical Access Hospital RCC factor,104.04,34,,104.04,percent of total billed charges,Implant Device,104.04,34,,104.04,percent of total billed charges,Implant Device,104.04,34,,104.04,percent of total billed charges,Implant Device,104.04,34,,104.04,percent of total billed charges,Implant Device,104.04,34,,104.04,percent of total billed charges,Implant Device,151.47,,,151.47,Other,110% of Medicare,107.1,35,,107.1,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,107.1,35,,107.1,percent of total billed charges,Implant Device,107.1,35,,107.1,percent of total billed charges,Implant Device,107.1,35,,107.1,percent of total billed charges,Implant Device,107.1,35,,107.1,percent of total billed charges,Implant Device,107.1,35,,107.1,percent of total billed charges,Implant Device,122.4,40,,122.4,percent of total billed charges,Implant Device,107.1,70,,107.1,percent of total billed charges,All Other,104.04,34,,104.04,percent of total billed charges,Implant Device,104.04,34,,104.04,percent of total billed charges,Implant Device,107.1,35,,107.1,percent of total billed charges,Implant Device,107.1,35,,107.1,percent of total billed charges,Implant Device,107.1,35,,107.1,percent of total billed charges,Implant Device,107.1,35,,107.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,226.44,
STRYKER 53-23614E SCREW 2.3X14MM,C1713,HCPCS,,79002102,CDM,278,RC,,,both,,,492,364.08,,,364.08,Other,150% of Medicare + 9.63% HCRA Surcharge,221.4,45,,221.4,percent of total billed charges,Critical Access Hospital RCC factor,167.28,34,,167.28,percent of total billed charges,Implant Device,167.28,34,,167.28,percent of total billed charges,Implant Device,167.28,34,,167.28,percent of total billed charges,Implant Device,167.28,34,,167.28,percent of total billed charges,Implant Device,167.28,34,,167.28,percent of total billed charges,Implant Device,243.54,,,243.54,Other,110% of Medicare,172.2,35,,172.2,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,172.2,35,,172.2,percent of total billed charges,Implant Device,172.2,35,,172.2,percent of total billed charges,Implant Device,172.2,35,,172.2,percent of total billed charges,Implant Device,172.2,35,,172.2,percent of total billed charges,Implant Device,172.2,35,,172.2,percent of total billed charges,Implant Device,196.8,40,,196.8,percent of total billed charges,Implant Device,172.2,70,,172.2,percent of total billed charges,All Other,167.28,34,,167.28,percent of total billed charges,Implant Device,167.28,34,,167.28,percent of total billed charges,Implant Device,172.2,35,,172.2,percent of total billed charges,Implant Device,172.2,35,,172.2,percent of total billed charges,Implant Device,172.2,35,,172.2,percent of total billed charges,Implant Device,172.2,35,,172.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,364.08,
STRYKER 53-23618E SCREW,C1713,HCPCS,,79002103,CDM,278,RC,,,both,,,398,294.52,,,294.52,Other,150% of Medicare + 9.63% HCRA Surcharge,179.1,45,,179.1,percent of total billed charges,Critical Access Hospital RCC factor,135.32,34,,135.32,percent of total billed charges,Implant Device,135.32,34,,135.32,percent of total billed charges,Implant Device,135.32,34,,135.32,percent of total billed charges,Implant Device,135.32,34,,135.32,percent of total billed charges,Implant Device,135.32,34,,135.32,percent of total billed charges,Implant Device,197.01,,,197.01,Other,110% of Medicare,139.3,35,,139.3,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,139.3,35,,139.3,percent of total billed charges,Implant Device,139.3,35,,139.3,percent of total billed charges,Implant Device,139.3,35,,139.3,percent of total billed charges,Implant Device,139.3,35,,139.3,percent of total billed charges,Implant Device,139.3,35,,139.3,percent of total billed charges,Implant Device,159.2,40,,159.2,percent of total billed charges,Implant Device,139.3,70,,139.3,percent of total billed charges,All Other,135.32,34,,135.32,percent of total billed charges,Implant Device,135.32,34,,135.32,percent of total billed charges,Implant Device,139.3,35,,139.3,percent of total billed charges,Implant Device,139.3,35,,139.3,percent of total billed charges,Implant Device,139.3,35,,139.3,percent of total billed charges,Implant Device,139.3,35,,139.3,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,294.52,
STRYKER 53-27612E SCREW,C1713,HCPCS,,79002104,CDM,278,RC,,,both,,,492,364.08,,,364.08,Other,150% of Medicare + 9.63% HCRA Surcharge,221.4,45,,221.4,percent of total billed charges,Critical Access Hospital RCC factor,167.28,34,,167.28,percent of total billed charges,Implant Device,167.28,34,,167.28,percent of total billed charges,Implant Device,167.28,34,,167.28,percent of total billed charges,Implant Device,167.28,34,,167.28,percent of total billed charges,Implant Device,167.28,34,,167.28,percent of total billed charges,Implant Device,243.54,,,243.54,Other,110% of Medicare,172.2,35,,172.2,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,172.2,35,,172.2,percent of total billed charges,Implant Device,172.2,35,,172.2,percent of total billed charges,Implant Device,172.2,35,,172.2,percent of total billed charges,Implant Device,172.2,35,,172.2,percent of total billed charges,Implant Device,172.2,35,,172.2,percent of total billed charges,Implant Device,196.8,40,,196.8,percent of total billed charges,Implant Device,172.2,70,,172.2,percent of total billed charges,All Other,167.28,34,,167.28,percent of total billed charges,Implant Device,167.28,34,,167.28,percent of total billed charges,Implant Device,172.2,35,,172.2,percent of total billed charges,Implant Device,172.2,35,,172.2,percent of total billed charges,Implant Device,172.2,35,,172.2,percent of total billed charges,Implant Device,172.2,35,,172.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,364.08,
DEPUY 55-0524-REV PROXIMAL SLEEVE,C1776,HCPCS,,79002105,CDM,278,RC,,,both,,,3000,2220.01,,,2220.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1350,45,,1350,percent of total billed charges,Critical Access Hospital RCC factor,1020,34,,1020,percent of total billed charges,Implant Device,1020,34,,1020,percent of total billed charges,Implant Device,1020,34,,1020,percent of total billed charges,Implant Device,1020,34,,1020,percent of total billed charges,Implant Device,1020,34,,1020,percent of total billed charges,Implant Device,1485,,,1485,Other,110% of Medicare,1050,35,,1050,percent of total billed charges,Implant Device,1020,34,"Charges > $500, x 34%",1020,percent of total billed charges,Implant Device,1050,35,,1050,percent of total billed charges,Implant Device,1050,35,,1050,percent of total billed charges,Implant Device,1050,35,,1050,percent of total billed charges,Implant Device,1050,35,,1050,percent of total billed charges,Implant Device,1050,35,,1050,percent of total billed charges,Implant Device,1200,40,,1200,percent of total billed charges,Implant Device,1050,70,,1050,percent of total billed charges,All Other,1020,34,,1020,percent of total billed charges,Implant Device,1020,34,,1020,percent of total billed charges,Implant Device,1050,35,,1050,percent of total billed charges,Implant Device,1050,35,,1050,percent of total billed charges,Implant Device,1050,35,,1050,percent of total billed charges,Implant Device,1050,35,,1050,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1020,34,"If Charge > 2,000, then 34 percent",1020,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2220.01,
ZIMMER 5791-41-UNI SCREW,C1713,HCPCS,,79002106,CDM,278,RC,,,both,,,244,180.56,,,180.56,Other,150% of Medicare + 9.63% HCRA Surcharge,109.8,45,,109.8,percent of total billed charges,Critical Access Hospital RCC factor,82.96,34,,82.96,percent of total billed charges,Implant Device,82.96,34,,82.96,percent of total billed charges,Implant Device,82.96,34,,82.96,percent of total billed charges,Implant Device,82.96,34,,82.96,percent of total billed charges,Implant Device,82.96,34,,82.96,percent of total billed charges,Implant Device,120.78,,,120.78,Other,110% of Medicare,85.4,35,,85.4,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,85.4,35,,85.4,percent of total billed charges,Implant Device,85.4,35,,85.4,percent of total billed charges,Implant Device,85.4,35,,85.4,percent of total billed charges,Implant Device,85.4,35,,85.4,percent of total billed charges,Implant Device,85.4,35,,85.4,percent of total billed charges,Implant Device,97.6,40,,97.6,percent of total billed charges,Implant Device,85.4,70,,85.4,percent of total billed charges,All Other,82.96,34,,82.96,percent of total billed charges,Implant Device,82.96,34,,82.96,percent of total billed charges,Implant Device,85.4,35,,85.4,percent of total billed charges,Implant Device,85.4,35,,85.4,percent of total billed charges,Implant Device,85.4,35,,85.4,percent of total billed charges,Implant Device,85.4,35,,85.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,180.56,
ZIMMER 5791-44-UNI SCREW,C1713,HCPCS,,79002107,CDM,278,RC,,,both,,,274,202.76,,,202.76,Other,150% of Medicare + 9.63% HCRA Surcharge,123.3,45,,123.3,percent of total billed charges,Critical Access Hospital RCC factor,93.16,34,,93.16,percent of total billed charges,Implant Device,93.16,34,,93.16,percent of total billed charges,Implant Device,93.16,34,,93.16,percent of total billed charges,Implant Device,93.16,34,,93.16,percent of total billed charges,Implant Device,93.16,34,,93.16,percent of total billed charges,Implant Device,135.63,,,135.63,Other,110% of Medicare,95.9,35,,95.9,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,95.9,35,,95.9,percent of total billed charges,Implant Device,95.9,35,,95.9,percent of total billed charges,Implant Device,95.9,35,,95.9,percent of total billed charges,Implant Device,95.9,35,,95.9,percent of total billed charges,Implant Device,95.9,35,,95.9,percent of total billed charges,Implant Device,109.6,40,,109.6,percent of total billed charges,Implant Device,95.9,70,,95.9,percent of total billed charges,All Other,93.16,34,,93.16,percent of total billed charges,Implant Device,93.16,34,,93.16,percent of total billed charges,Implant Device,95.9,35,,95.9,percent of total billed charges,Implant Device,95.9,35,,95.9,percent of total billed charges,Implant Device,95.9,35,,95.9,percent of total billed charges,Implant Device,95.9,35,,95.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,202.76,
STRYKER FOOT & ANKLE 58-17007E SCREW,C1713,HCPCS,,79002108,CDM,278,RC,,,both,,,256,189.44,,,189.44,Other,150% of Medicare + 9.63% HCRA Surcharge,115.2,45,,115.2,percent of total billed charges,Critical Access Hospital RCC factor,87.04,34,,87.04,percent of total billed charges,Implant Device,87.04,34,,87.04,percent of total billed charges,Implant Device,87.04,34,,87.04,percent of total billed charges,Implant Device,87.04,34,,87.04,percent of total billed charges,Implant Device,87.04,34,,87.04,percent of total billed charges,Implant Device,126.72,,,126.72,Other,110% of Medicare,89.6,35,,89.6,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,89.6,35,,89.6,percent of total billed charges,Implant Device,89.6,35,,89.6,percent of total billed charges,Implant Device,89.6,35,,89.6,percent of total billed charges,Implant Device,89.6,35,,89.6,percent of total billed charges,Implant Device,89.6,35,,89.6,percent of total billed charges,Implant Device,102.4,40,,102.4,percent of total billed charges,Implant Device,89.6,70,,89.6,percent of total billed charges,All Other,87.04,34,,87.04,percent of total billed charges,Implant Device,87.04,34,,87.04,percent of total billed charges,Implant Device,89.6,35,,89.6,percent of total billed charges,Implant Device,89.6,35,,89.6,percent of total billed charges,Implant Device,89.6,35,,89.6,percent of total billed charges,Implant Device,89.6,35,,89.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,189.44,
STRYKER 58-17013E SCREW,C1713,HCPCS,,79002109,CDM,278,RC,,,both,,,175,129.5,,,129.5,Other,150% of Medicare + 9.63% HCRA Surcharge,78.75,45,,78.75,percent of total billed charges,Critical Access Hospital RCC factor,59.5,34,,59.5,percent of total billed charges,Implant Device,59.5,34,,59.5,percent of total billed charges,Implant Device,59.5,34,,59.5,percent of total billed charges,Implant Device,59.5,34,,59.5,percent of total billed charges,Implant Device,59.5,34,,59.5,percent of total billed charges,Implant Device,86.63,,,86.63,Other,110% of Medicare,61.25,35,,61.25,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,61.25,35,,61.25,percent of total billed charges,Implant Device,61.25,35,,61.25,percent of total billed charges,Implant Device,61.25,35,,61.25,percent of total billed charges,Implant Device,61.25,35,,61.25,percent of total billed charges,Implant Device,61.25,35,,61.25,percent of total billed charges,Implant Device,70,40,,70,percent of total billed charges,Implant Device,61.25,70,,61.25,percent of total billed charges,All Other,59.5,34,,59.5,percent of total billed charges,Implant Device,59.5,34,,59.5,percent of total billed charges,Implant Device,61.25,35,,61.25,percent of total billed charges,Implant Device,61.25,35,,61.25,percent of total billed charges,Implant Device,61.25,35,,61.25,percent of total billed charges,Implant Device,61.25,35,,61.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,129.5,
ZIMMER 5842-03-02-UNI TIBIAL COMPONENT,C1776,HCPCS,,79002111,CDM,278,RC,,,both,,,6346,4696.06,,,4696.06,Other,150% of Medicare + 9.63% HCRA Surcharge,2855.7,45,,2855.7,percent of total billed charges,Critical Access Hospital RCC factor,2157.64,34,,2157.64,percent of total billed charges,Implant Device,2157.64,34,,2157.64,percent of total billed charges,Implant Device,2157.64,34,,2157.64,percent of total billed charges,Implant Device,2157.64,34,,2157.64,percent of total billed charges,Implant Device,2157.64,34,,2157.64,percent of total billed charges,Implant Device,3141.27,,,3141.27,Other,110% of Medicare,2221.1,35,,2221.1,percent of total billed charges,Implant Device,2157.64,34,"Charges > $500, x 34%",2157.64,percent of total billed charges,Implant Device,2221.1,35,,2221.1,percent of total billed charges,Implant Device,2221.1,35,,2221.1,percent of total billed charges,Implant Device,2221.1,35,,2221.1,percent of total billed charges,Implant Device,2221.1,35,,2221.1,percent of total billed charges,Implant Device,2221.1,35,,2221.1,percent of total billed charges,Implant Device,2538.4,40,,2538.4,percent of total billed charges,Implant Device,2221.1,70,,2221.1,percent of total billed charges,All Other,2157.64,34,,2157.64,percent of total billed charges,Implant Device,2157.64,34,,2157.64,percent of total billed charges,Implant Device,2221.1,35,,2221.1,percent of total billed charges,Implant Device,2221.1,35,,2221.1,percent of total billed charges,Implant Device,2221.1,35,,2221.1,percent of total billed charges,Implant Device,2221.1,35,,2221.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2157.64,34,"If Charge > 2,000, then 34 percent",2157.64,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4696.06,
ZIMMER 5842-05-01-UNI TIBIAL COMPONENT,C1776,HCPCS,,79002112,CDM,278,RC,,,both,,,6346,4696.06,,,4696.06,Other,150% of Medicare + 9.63% HCRA Surcharge,2855.7,45,,2855.7,percent of total billed charges,Critical Access Hospital RCC factor,2157.64,34,,2157.64,percent of total billed charges,Implant Device,2157.64,34,,2157.64,percent of total billed charges,Implant Device,2157.64,34,,2157.64,percent of total billed charges,Implant Device,2157.64,34,,2157.64,percent of total billed charges,Implant Device,2157.64,34,,2157.64,percent of total billed charges,Implant Device,3141.27,,,3141.27,Other,110% of Medicare,2221.1,35,,2221.1,percent of total billed charges,Implant Device,2157.64,34,"Charges > $500, x 34%",2157.64,percent of total billed charges,Implant Device,2221.1,35,,2221.1,percent of total billed charges,Implant Device,2221.1,35,,2221.1,percent of total billed charges,Implant Device,2221.1,35,,2221.1,percent of total billed charges,Implant Device,2221.1,35,,2221.1,percent of total billed charges,Implant Device,2221.1,35,,2221.1,percent of total billed charges,Implant Device,2538.4,40,,2538.4,percent of total billed charges,Implant Device,2221.1,70,,2221.1,percent of total billed charges,All Other,2157.64,34,,2157.64,percent of total billed charges,Implant Device,2157.64,34,,2157.64,percent of total billed charges,Implant Device,2221.1,35,,2221.1,percent of total billed charges,Implant Device,2221.1,35,,2221.1,percent of total billed charges,Implant Device,2221.1,35,,2221.1,percent of total billed charges,Implant Device,2221.1,35,,2221.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2157.64,34,"If Charge > 2,000, then 34 percent",2157.64,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4696.06,
ZIMMER 5842-05-02-UNI TIBIAL COMPONENT,C1776,HCPCS,,79002113,CDM,278,RC,,,both,,,6346,4696.06,,,4696.06,Other,150% of Medicare + 9.63% HCRA Surcharge,2855.7,45,,2855.7,percent of total billed charges,Critical Access Hospital RCC factor,2157.64,34,,2157.64,percent of total billed charges,Implant Device,2157.64,34,,2157.64,percent of total billed charges,Implant Device,2157.64,34,,2157.64,percent of total billed charges,Implant Device,2157.64,34,,2157.64,percent of total billed charges,Implant Device,2157.64,34,,2157.64,percent of total billed charges,Implant Device,3141.27,,,3141.27,Other,110% of Medicare,2221.1,35,,2221.1,percent of total billed charges,Implant Device,2157.64,34,"Charges > $500, x 34%",2157.64,percent of total billed charges,Implant Device,2221.1,35,,2221.1,percent of total billed charges,Implant Device,2221.1,35,,2221.1,percent of total billed charges,Implant Device,2221.1,35,,2221.1,percent of total billed charges,Implant Device,2221.1,35,,2221.1,percent of total billed charges,Implant Device,2221.1,35,,2221.1,percent of total billed charges,Implant Device,2538.4,40,,2538.4,percent of total billed charges,Implant Device,2221.1,70,,2221.1,percent of total billed charges,All Other,2157.64,34,,2157.64,percent of total billed charges,Implant Device,2157.64,34,,2157.64,percent of total billed charges,Implant Device,2221.1,35,,2221.1,percent of total billed charges,Implant Device,2221.1,35,,2221.1,percent of total billed charges,Implant Device,2221.1,35,,2221.1,percent of total billed charges,Implant Device,2221.1,35,,2221.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2157.64,34,"If Charge > 2,000, then 34 percent",2157.64,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4696.06,
ZIMMER 5842-14-02-UNI FEMORAL COMPONENT,C1776,HCPCS,,79002114,CDM,278,RC,,,both,,,10486,7759.67,,,7759.67,Other,150% of Medicare + 9.63% HCRA Surcharge,4718.7,45,,4718.7,percent of total billed charges,Critical Access Hospital RCC factor,3565.24,34,,3565.24,percent of total billed charges,Implant Device,3565.24,34,,3565.24,percent of total billed charges,Implant Device,3565.24,34,,3565.24,percent of total billed charges,Implant Device,3565.24,34,,3565.24,percent of total billed charges,Implant Device,3565.24,34,,3565.24,percent of total billed charges,Implant Device,5190.57,,,5190.57,Other,110% of Medicare,3670.1,35,,3670.1,percent of total billed charges,Implant Device,3565.24,34,"Charges > $500, x 34%",3565.24,percent of total billed charges,Implant Device,3670.1,35,,3670.1,percent of total billed charges,Implant Device,3670.1,35,,3670.1,percent of total billed charges,Implant Device,3670.1,35,,3670.1,percent of total billed charges,Implant Device,3670.1,35,,3670.1,percent of total billed charges,Implant Device,3670.1,35,,3670.1,percent of total billed charges,Implant Device,4194.4,40,,4194.4,percent of total billed charges,Implant Device,3670.1,70,,3670.1,percent of total billed charges,All Other,3565.24,34,,3565.24,percent of total billed charges,Implant Device,3565.24,34,,3565.24,percent of total billed charges,Implant Device,3670.1,35,,3670.1,percent of total billed charges,Implant Device,3670.1,35,,3670.1,percent of total billed charges,Implant Device,3670.1,35,,3670.1,percent of total billed charges,Implant Device,3670.1,35,,3670.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3565.24,34,"If Charge > 2,000, then 34 percent",3565.24,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,7759.67,
ZIMMER 5842-15-01-UNI FEMORAL COMPONENT,C1776,HCPCS,,79002115,CDM,278,RC,,,both,,,10486,7759.67,,,7759.67,Other,150% of Medicare + 9.63% HCRA Surcharge,4718.7,45,,4718.7,percent of total billed charges,Critical Access Hospital RCC factor,3565.24,34,,3565.24,percent of total billed charges,Implant Device,3565.24,34,,3565.24,percent of total billed charges,Implant Device,3565.24,34,,3565.24,percent of total billed charges,Implant Device,3565.24,34,,3565.24,percent of total billed charges,Implant Device,3565.24,34,,3565.24,percent of total billed charges,Implant Device,5190.57,,,5190.57,Other,110% of Medicare,3670.1,35,,3670.1,percent of total billed charges,Implant Device,3565.24,34,"Charges > $500, x 34%",3565.24,percent of total billed charges,Implant Device,3670.1,35,,3670.1,percent of total billed charges,Implant Device,3670.1,35,,3670.1,percent of total billed charges,Implant Device,3670.1,35,,3670.1,percent of total billed charges,Implant Device,3670.1,35,,3670.1,percent of total billed charges,Implant Device,3670.1,35,,3670.1,percent of total billed charges,Implant Device,4194.4,40,,4194.4,percent of total billed charges,Implant Device,3670.1,70,,3670.1,percent of total billed charges,All Other,3565.24,34,,3565.24,percent of total billed charges,Implant Device,3565.24,34,,3565.24,percent of total billed charges,Implant Device,3670.1,35,,3670.1,percent of total billed charges,Implant Device,3670.1,35,,3670.1,percent of total billed charges,Implant Device,3670.1,35,,3670.1,percent of total billed charges,Implant Device,3670.1,35,,3670.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3565.24,34,"If Charge > 2,000, then 34 percent",3565.24,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,7759.67,
ZIMMER 5842-15-02-UNI FEMORAL COMPONENT,C1776,HCPCS,,79002116,CDM,278,RC,,,both,,,10486,7759.67,,,7759.67,Other,150% of Medicare + 9.63% HCRA Surcharge,4718.7,45,,4718.7,percent of total billed charges,Critical Access Hospital RCC factor,3565.24,34,,3565.24,percent of total billed charges,Implant Device,3565.24,34,,3565.24,percent of total billed charges,Implant Device,3565.24,34,,3565.24,percent of total billed charges,Implant Device,3565.24,34,,3565.24,percent of total billed charges,Implant Device,3565.24,34,,3565.24,percent of total billed charges,Implant Device,5190.57,,,5190.57,Other,110% of Medicare,3670.1,35,,3670.1,percent of total billed charges,Implant Device,3565.24,34,"Charges > $500, x 34%",3565.24,percent of total billed charges,Implant Device,3670.1,35,,3670.1,percent of total billed charges,Implant Device,3670.1,35,,3670.1,percent of total billed charges,Implant Device,3670.1,35,,3670.1,percent of total billed charges,Implant Device,3670.1,35,,3670.1,percent of total billed charges,Implant Device,3670.1,35,,3670.1,percent of total billed charges,Implant Device,4194.4,40,,4194.4,percent of total billed charges,Implant Device,3670.1,70,,3670.1,percent of total billed charges,All Other,3565.24,34,,3565.24,percent of total billed charges,Implant Device,3565.24,34,,3565.24,percent of total billed charges,Implant Device,3670.1,35,,3670.1,percent of total billed charges,Implant Device,3670.1,35,,3670.1,percent of total billed charges,Implant Device,3670.1,35,,3670.1,percent of total billed charges,Implant Device,3670.1,35,,3670.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3565.24,34,"If Charge > 2,000, then 34 percent",3565.24,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,7759.67,
ZIMMER 5842-23-08-UNI ARTICULAR SURFACE,C1776,HCPCS,,79002117,CDM,278,RC,,,both,,,2677,1980.99,,,1980.99,Other,150% of Medicare + 9.63% HCRA Surcharge,1204.65,45,,1204.65,percent of total billed charges,Critical Access Hospital RCC factor,910.18,34,,910.18,percent of total billed charges,Implant Device,910.18,34,,910.18,percent of total billed charges,Implant Device,910.18,34,,910.18,percent of total billed charges,Implant Device,910.18,34,,910.18,percent of total billed charges,Implant Device,910.18,34,,910.18,percent of total billed charges,Implant Device,1325.12,,,1325.12,Other,110% of Medicare,936.95,35,,936.95,percent of total billed charges,Implant Device,910.18,34,"Charges > $500, x 34%",910.18,percent of total billed charges,Implant Device,936.95,35,,936.95,percent of total billed charges,Implant Device,936.95,35,,936.95,percent of total billed charges,Implant Device,936.95,35,,936.95,percent of total billed charges,Implant Device,936.95,35,,936.95,percent of total billed charges,Implant Device,936.95,35,,936.95,percent of total billed charges,Implant Device,1070.8,40,,1070.8,percent of total billed charges,Implant Device,936.95,70,,936.95,percent of total billed charges,All Other,910.18,34,,910.18,percent of total billed charges,Implant Device,910.18,34,,910.18,percent of total billed charges,Implant Device,936.95,35,,936.95,percent of total billed charges,Implant Device,936.95,35,,936.95,percent of total billed charges,Implant Device,936.95,35,,936.95,percent of total billed charges,Implant Device,936.95,35,,936.95,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,910.18,34,"If Charge > 2,000, then 34 percent",910.18,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1980.99,
ZIMMER 5842-25-09-UNI ARTICULAR SURFACE,C1776,HCPCS,,79002118,CDM,278,RC,,,both,,,2677,1980.99,,,1980.99,Other,150% of Medicare + 9.63% HCRA Surcharge,1204.65,45,,1204.65,percent of total billed charges,Critical Access Hospital RCC factor,910.18,34,,910.18,percent of total billed charges,Implant Device,910.18,34,,910.18,percent of total billed charges,Implant Device,910.18,34,,910.18,percent of total billed charges,Implant Device,910.18,34,,910.18,percent of total billed charges,Implant Device,910.18,34,,910.18,percent of total billed charges,Implant Device,1325.12,,,1325.12,Other,110% of Medicare,936.95,35,,936.95,percent of total billed charges,Implant Device,910.18,34,"Charges > $500, x 34%",910.18,percent of total billed charges,Implant Device,936.95,35,,936.95,percent of total billed charges,Implant Device,936.95,35,,936.95,percent of total billed charges,Implant Device,936.95,35,,936.95,percent of total billed charges,Implant Device,936.95,35,,936.95,percent of total billed charges,Implant Device,936.95,35,,936.95,percent of total billed charges,Implant Device,1070.8,40,,1070.8,percent of total billed charges,Implant Device,936.95,70,,936.95,percent of total billed charges,All Other,910.18,34,,910.18,percent of total billed charges,Implant Device,910.18,34,,910.18,percent of total billed charges,Implant Device,936.95,35,,936.95,percent of total billed charges,Implant Device,936.95,35,,936.95,percent of total billed charges,Implant Device,936.95,35,,936.95,percent of total billed charges,Implant Device,936.95,35,,936.95,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,910.18,34,"If Charge > 2,000, then 34 percent",910.18,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1980.99,
ZIMMER 5842-25-10-UNI ARTICULAR SURFACE,C1776,HCPCS,,79002119,CDM,278,RC,,,both,,,2677,1980.99,,,1980.99,Other,150% of Medicare + 9.63% HCRA Surcharge,1204.65,45,,1204.65,percent of total billed charges,Critical Access Hospital RCC factor,910.18,34,,910.18,percent of total billed charges,Implant Device,910.18,34,,910.18,percent of total billed charges,Implant Device,910.18,34,,910.18,percent of total billed charges,Implant Device,910.18,34,,910.18,percent of total billed charges,Implant Device,910.18,34,,910.18,percent of total billed charges,Implant Device,1325.12,,,1325.12,Other,110% of Medicare,936.95,35,,936.95,percent of total billed charges,Implant Device,910.18,34,"Charges > $500, x 34%",910.18,percent of total billed charges,Implant Device,936.95,35,,936.95,percent of total billed charges,Implant Device,936.95,35,,936.95,percent of total billed charges,Implant Device,936.95,35,,936.95,percent of total billed charges,Implant Device,936.95,35,,936.95,percent of total billed charges,Implant Device,936.95,35,,936.95,percent of total billed charges,Implant Device,1070.8,40,,1070.8,percent of total billed charges,Implant Device,936.95,70,,936.95,percent of total billed charges,All Other,910.18,34,,910.18,percent of total billed charges,Implant Device,910.18,34,,910.18,percent of total billed charges,Implant Device,936.95,35,,936.95,percent of total billed charges,Implant Device,936.95,35,,936.95,percent of total billed charges,Implant Device,936.95,35,,936.95,percent of total billed charges,Implant Device,936.95,35,,936.95,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,910.18,34,"If Charge > 2,000, then 34 percent",910.18,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1980.99,
ZIMMER 5842-52-01-UNI ARTICULAR SURFACE,C1776,HCPCS,,79002120,CDM,278,RC,,,both,,,420,310.8,,,310.8,Other,150% of Medicare + 9.63% HCRA Surcharge,189,45,,189,percent of total billed charges,Critical Access Hospital RCC factor,142.8,34,,142.8,percent of total billed charges,Implant Device,142.8,34,,142.8,percent of total billed charges,Implant Device,142.8,34,,142.8,percent of total billed charges,Implant Device,142.8,34,,142.8,percent of total billed charges,Implant Device,142.8,34,,142.8,percent of total billed charges,Implant Device,207.9,,,207.9,Other,110% of Medicare,147,35,,147,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,147,35,,147,percent of total billed charges,Implant Device,147,35,,147,percent of total billed charges,Implant Device,147,35,,147,percent of total billed charges,Implant Device,147,35,,147,percent of total billed charges,Implant Device,147,35,,147,percent of total billed charges,Implant Device,168,40,,168,percent of total billed charges,Implant Device,147,70,,147,percent of total billed charges,All Other,142.8,34,,142.8,percent of total billed charges,Implant Device,142.8,34,,142.8,percent of total billed charges,Implant Device,147,35,,147,percent of total billed charges,Implant Device,147,35,,147,percent of total billed charges,Implant Device,147,35,,147,percent of total billed charges,Implant Device,147,35,,147,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,310.8,
ZIMMER 5880-04-REV TIBIAL COMPONENT,C1776,HCPCS,,79002121,CDM,278,RC,,,both,,,13631,10086.97,,,10086.97,Other,150% of Medicare + 9.63% HCRA Surcharge,6133.95,45,,6133.95,percent of total billed charges,Critical Access Hospital RCC factor,4634.54,34,,4634.54,percent of total billed charges,Implant Device,4634.54,34,,4634.54,percent of total billed charges,Implant Device,4634.54,34,,4634.54,percent of total billed charges,Implant Device,4634.54,34,,4634.54,percent of total billed charges,Implant Device,4634.54,34,,4634.54,percent of total billed charges,Implant Device,6747.35,,,6747.35,Other,110% of Medicare,4770.85,35,,4770.85,percent of total billed charges,Implant Device,4634.54,34,"Charges > $500, x 34%",4634.54,percent of total billed charges,Implant Device,4770.85,35,,4770.85,percent of total billed charges,Implant Device,4770.85,35,,4770.85,percent of total billed charges,Implant Device,4770.85,35,,4770.85,percent of total billed charges,Implant Device,4770.85,35,,4770.85,percent of total billed charges,Implant Device,4770.85,35,,4770.85,percent of total billed charges,Implant Device,5452.4,40,,5452.4,percent of total billed charges,Implant Device,4770.85,70,,4770.85,percent of total billed charges,All Other,4634.54,34,,4634.54,percent of total billed charges,Implant Device,4634.54,34,,4634.54,percent of total billed charges,Implant Device,4770.85,35,,4770.85,percent of total billed charges,Implant Device,4770.85,35,,4770.85,percent of total billed charges,Implant Device,4770.85,35,,4770.85,percent of total billed charges,Implant Device,4770.85,35,,4770.85,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,4634.54,34,"If Charge > 2,000, then 34 percent",4634.54,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,10086.97,
ZIMMER 5880-06-REV TIBIAL COMPONENT,C1776,HCPCS,,79002122,CDM,278,RC,,,both,,,13023,9637.05,,,9637.05,Other,150% of Medicare + 9.63% HCRA Surcharge,5860.35,45,,5860.35,percent of total billed charges,Critical Access Hospital RCC factor,4427.82,34,,4427.82,percent of total billed charges,Implant Device,4427.82,34,,4427.82,percent of total billed charges,Implant Device,4427.82,34,,4427.82,percent of total billed charges,Implant Device,4427.82,34,,4427.82,percent of total billed charges,Implant Device,4427.82,34,,4427.82,percent of total billed charges,Implant Device,6446.39,,,6446.39,Other,110% of Medicare,4558.05,35,,4558.05,percent of total billed charges,Implant Device,4427.82,34,"Charges > $500, x 34%",4427.82,percent of total billed charges,Implant Device,4558.05,35,,4558.05,percent of total billed charges,Implant Device,4558.05,35,,4558.05,percent of total billed charges,Implant Device,4558.05,35,,4558.05,percent of total billed charges,Implant Device,4558.05,35,,4558.05,percent of total billed charges,Implant Device,4558.05,35,,4558.05,percent of total billed charges,Implant Device,5209.2,40,,5209.2,percent of total billed charges,Implant Device,4558.05,70,,4558.05,percent of total billed charges,All Other,4427.82,34,,4427.82,percent of total billed charges,Implant Device,4427.82,34,,4427.82,percent of total billed charges,Implant Device,4558.05,35,,4558.05,percent of total billed charges,Implant Device,4558.05,35,,4558.05,percent of total billed charges,Implant Device,4558.05,35,,4558.05,percent of total billed charges,Implant Device,4558.05,35,,4558.05,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,4427.82,34,"If Charge > 2,000, then 34 percent",4427.82,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,9637.05,
ZIMMER 5880-15-02-REV FEMORAL COMPONENT,C1776,HCPCS,,79002123,CDM,278,RC,,,both,,,25560,18914.46,,,18914.46,Other,150% of Medicare + 9.63% HCRA Surcharge,11502,45,,11502,percent of total billed charges,Critical Access Hospital RCC factor,8690.4,34,,8690.4,percent of total billed charges,Implant Device,8690.4,34,,8690.4,percent of total billed charges,Implant Device,8690.4,34,,8690.4,percent of total billed charges,Implant Device,8690.4,34,,8690.4,percent of total billed charges,Implant Device,8690.4,34,,8690.4,percent of total billed charges,Implant Device,12652.2,,,12652.2,Other,110% of Medicare,8946,35,,8946,percent of total billed charges,Implant Device,8690.4,34,"Charges > $500, x 34%",8690.4,percent of total billed charges,Implant Device,8946,35,,8946,percent of total billed charges,Implant Device,8946,35,,8946,percent of total billed charges,Implant Device,8946,35,,8946,percent of total billed charges,Implant Device,8946,35,,8946,percent of total billed charges,Implant Device,8946,35,,8946,percent of total billed charges,Implant Device,10224,40,,10224,percent of total billed charges,Implant Device,8946,70,,8946,percent of total billed charges,All Other,8690.4,34,,8690.4,percent of total billed charges,Implant Device,8690.4,34,,8690.4,percent of total billed charges,Implant Device,8946,35,,8946,percent of total billed charges,Implant Device,8946,35,,8946,percent of total billed charges,Implant Device,8946,35,,8946,percent of total billed charges,Implant Device,8946,35,,8946,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,8690.4,34,"If Charge > 2,000, then 34 percent",8690.4,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,18914.46,
ZIMMER 5880-16-01-REV FEMORAL COMPONENT,C1776,HCPCS,,79002124,CDM,278,RC,,,both,,,25560,18914.46,,,18914.46,Other,150% of Medicare + 9.63% HCRA Surcharge,11502,45,,11502,percent of total billed charges,Critical Access Hospital RCC factor,8690.4,34,,8690.4,percent of total billed charges,Implant Device,8690.4,34,,8690.4,percent of total billed charges,Implant Device,8690.4,34,,8690.4,percent of total billed charges,Implant Device,8690.4,34,,8690.4,percent of total billed charges,Implant Device,8690.4,34,,8690.4,percent of total billed charges,Implant Device,12652.2,,,12652.2,Other,110% of Medicare,8946,35,,8946,percent of total billed charges,Implant Device,8690.4,34,"Charges > $500, x 34%",8690.4,percent of total billed charges,Implant Device,8946,35,,8946,percent of total billed charges,Implant Device,8946,35,,8946,percent of total billed charges,Implant Device,8946,35,,8946,percent of total billed charges,Implant Device,8946,35,,8946,percent of total billed charges,Implant Device,8946,35,,8946,percent of total billed charges,Implant Device,10224,40,,10224,percent of total billed charges,Implant Device,8946,70,,8946,percent of total billed charges,All Other,8690.4,34,,8690.4,percent of total billed charges,Implant Device,8690.4,34,,8690.4,percent of total billed charges,Implant Device,8946,35,,8946,percent of total billed charges,Implant Device,8946,35,,8946,percent of total billed charges,Implant Device,8946,35,,8946,percent of total billed charges,Implant Device,8946,35,,8946,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,8690.4,34,"If Charge > 2,000, then 34 percent",8690.4,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,18914.46,
ZIMMER 5880-50-14-REV ARTICULAR SURFACE,C1776,HCPCS,,79002125,CDM,278,RC,,,both,,,5603,4146.23,,,4146.23,Other,150% of Medicare + 9.63% HCRA Surcharge,2521.35,45,,2521.35,percent of total billed charges,Critical Access Hospital RCC factor,1905.02,34,,1905.02,percent of total billed charges,Implant Device,1905.02,34,,1905.02,percent of total billed charges,Implant Device,1905.02,34,,1905.02,percent of total billed charges,Implant Device,1905.02,34,,1905.02,percent of total billed charges,Implant Device,1905.02,34,,1905.02,percent of total billed charges,Implant Device,2773.49,,,2773.49,Other,110% of Medicare,1961.05,35,,1961.05,percent of total billed charges,Implant Device,1905.02,34,"Charges > $500, x 34%",1905.02,percent of total billed charges,Implant Device,1961.05,35,,1961.05,percent of total billed charges,Implant Device,1961.05,35,,1961.05,percent of total billed charges,Implant Device,1961.05,35,,1961.05,percent of total billed charges,Implant Device,1961.05,35,,1961.05,percent of total billed charges,Implant Device,1961.05,35,,1961.05,percent of total billed charges,Implant Device,2241.2,40,,2241.2,percent of total billed charges,Implant Device,1961.05,70,,1961.05,percent of total billed charges,All Other,1905.02,34,,1905.02,percent of total billed charges,Implant Device,1905.02,34,,1905.02,percent of total billed charges,Implant Device,1961.05,35,,1961.05,percent of total billed charges,Implant Device,1961.05,35,,1961.05,percent of total billed charges,Implant Device,1961.05,35,,1961.05,percent of total billed charges,Implant Device,1961.05,35,,1961.05,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1905.02,34,"If Charge > 2,000, then 34 percent",1905.02,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4146.23,
ZIMMER 5880-60-12-REV ARTICULAR SURFACE,C1776,HCPCS,,79002126,CDM,278,RC,,,both,,,7128,5274.74,,,5274.74,Other,150% of Medicare + 9.63% HCRA Surcharge,3207.6,45,,3207.6,percent of total billed charges,Critical Access Hospital RCC factor,2423.52,34,,2423.52,percent of total billed charges,Implant Device,2423.52,34,,2423.52,percent of total billed charges,Implant Device,2423.52,34,,2423.52,percent of total billed charges,Implant Device,2423.52,34,,2423.52,percent of total billed charges,Implant Device,2423.52,34,,2423.52,percent of total billed charges,Implant Device,3528.36,,,3528.36,Other,110% of Medicare,2494.8,35,,2494.8,percent of total billed charges,Implant Device,2423.52,34,"Charges > $500, x 34%",2423.52,percent of total billed charges,Implant Device,2494.8,35,,2494.8,percent of total billed charges,Implant Device,2494.8,35,,2494.8,percent of total billed charges,Implant Device,2494.8,35,,2494.8,percent of total billed charges,Implant Device,2494.8,35,,2494.8,percent of total billed charges,Implant Device,2494.8,35,,2494.8,percent of total billed charges,Implant Device,2851.2,40,,2851.2,percent of total billed charges,Implant Device,2494.8,70,,2494.8,percent of total billed charges,All Other,2423.52,34,,2423.52,percent of total billed charges,Implant Device,2423.52,34,,2423.52,percent of total billed charges,Implant Device,2494.8,35,,2494.8,percent of total billed charges,Implant Device,2494.8,35,,2494.8,percent of total billed charges,Implant Device,2494.8,35,,2494.8,percent of total billed charges,Implant Device,2494.8,35,,2494.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2423.52,34,"If Charge > 2,000, then 34 percent",2423.52,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5274.74,
ZIMMER 5952-30-10 ARTICULAR SURFACE,C1776,HCPCS,,79002127,CDM,278,RC,,,both,,,2496,1847.05,,,1847.05,Other,150% of Medicare + 9.63% HCRA Surcharge,1123.2,45,,1123.2,percent of total billed charges,Critical Access Hospital RCC factor,848.64,34,,848.64,percent of total billed charges,Implant Device,848.64,34,,848.64,percent of total billed charges,Implant Device,848.64,34,,848.64,percent of total billed charges,Implant Device,848.64,34,,848.64,percent of total billed charges,Implant Device,848.64,34,,848.64,percent of total billed charges,Implant Device,1235.52,,,1235.52,Other,110% of Medicare,873.6,35,,873.6,percent of total billed charges,Implant Device,848.64,34,"Charges > $500, x 34%",848.64,percent of total billed charges,Implant Device,873.6,35,,873.6,percent of total billed charges,Implant Device,873.6,35,,873.6,percent of total billed charges,Implant Device,873.6,35,,873.6,percent of total billed charges,Implant Device,873.6,35,,873.6,percent of total billed charges,Implant Device,873.6,35,,873.6,percent of total billed charges,Implant Device,998.4,40,,998.4,percent of total billed charges,Implant Device,873.6,70,,873.6,percent of total billed charges,All Other,848.64,34,,848.64,percent of total billed charges,Implant Device,848.64,34,,848.64,percent of total billed charges,Implant Device,873.6,35,,873.6,percent of total billed charges,Implant Device,873.6,35,,873.6,percent of total billed charges,Implant Device,873.6,35,,873.6,percent of total billed charges,Implant Device,873.6,35,,873.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,848.64,34,"If Charge > 2,000, then 34 percent",848.64,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1847.05,
ZIMMER 5952-30-14 ARTICULAR SURFACE,C1776,HCPCS,,79002128,CDM,278,RC,,,both,,,2496,1847.05,,,1847.05,Other,150% of Medicare + 9.63% HCRA Surcharge,1123.2,45,,1123.2,percent of total billed charges,Critical Access Hospital RCC factor,848.64,34,,848.64,percent of total billed charges,Implant Device,848.64,34,,848.64,percent of total billed charges,Implant Device,848.64,34,,848.64,percent of total billed charges,Implant Device,848.64,34,,848.64,percent of total billed charges,Implant Device,848.64,34,,848.64,percent of total billed charges,Implant Device,1235.52,,,1235.52,Other,110% of Medicare,873.6,35,,873.6,percent of total billed charges,Implant Device,848.64,34,"Charges > $500, x 34%",848.64,percent of total billed charges,Implant Device,873.6,35,,873.6,percent of total billed charges,Implant Device,873.6,35,,873.6,percent of total billed charges,Implant Device,873.6,35,,873.6,percent of total billed charges,Implant Device,873.6,35,,873.6,percent of total billed charges,Implant Device,873.6,35,,873.6,percent of total billed charges,Implant Device,998.4,40,,998.4,percent of total billed charges,Implant Device,873.6,70,,873.6,percent of total billed charges,All Other,848.64,34,,848.64,percent of total billed charges,Implant Device,848.64,34,,848.64,percent of total billed charges,Implant Device,873.6,35,,873.6,percent of total billed charges,Implant Device,873.6,35,,873.6,percent of total billed charges,Implant Device,873.6,35,,873.6,percent of total billed charges,Implant Device,873.6,35,,873.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,848.64,34,"If Charge > 2,000, then 34 percent",848.64,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1847.05,
ZIMMER 5952-30-14-REV ARTICULAR SURFACE,C1776,HCPCS,,79002129,CDM,278,RC,,,both,,,5107,3779.19,,,3779.19,Other,150% of Medicare + 9.63% HCRA Surcharge,2298.15,45,,2298.15,percent of total billed charges,Critical Access Hospital RCC factor,1736.38,34,,1736.38,percent of total billed charges,Implant Device,1736.38,34,,1736.38,percent of total billed charges,Implant Device,1736.38,34,,1736.38,percent of total billed charges,Implant Device,1736.38,34,,1736.38,percent of total billed charges,Implant Device,1736.38,34,,1736.38,percent of total billed charges,Implant Device,2527.97,,,2527.97,Other,110% of Medicare,1787.45,35,,1787.45,percent of total billed charges,Implant Device,1736.38,34,"Charges > $500, x 34%",1736.38,percent of total billed charges,Implant Device,1787.45,35,,1787.45,percent of total billed charges,Implant Device,1787.45,35,,1787.45,percent of total billed charges,Implant Device,1787.45,35,,1787.45,percent of total billed charges,Implant Device,1787.45,35,,1787.45,percent of total billed charges,Implant Device,1787.45,35,,1787.45,percent of total billed charges,Implant Device,2042.8,40,,2042.8,percent of total billed charges,Implant Device,1787.45,70,,1787.45,percent of total billed charges,All Other,1736.38,34,,1736.38,percent of total billed charges,Implant Device,1736.38,34,,1736.38,percent of total billed charges,Implant Device,1787.45,35,,1787.45,percent of total billed charges,Implant Device,1787.45,35,,1787.45,percent of total billed charges,Implant Device,1787.45,35,,1787.45,percent of total billed charges,Implant Device,1787.45,35,,1787.45,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1736.38,34,"If Charge > 2,000, then 34 percent",1736.38,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3779.19,
ZIMMER 5952-50-12 ARTICULAR SURFACE,C1776,HCPCS,,79002130,CDM,278,RC,,,both,,,2496,1847.05,,,1847.05,Other,150% of Medicare + 9.63% HCRA Surcharge,1123.2,45,,1123.2,percent of total billed charges,Critical Access Hospital RCC factor,848.64,34,,848.64,percent of total billed charges,Implant Device,848.64,34,,848.64,percent of total billed charges,Implant Device,848.64,34,,848.64,percent of total billed charges,Implant Device,848.64,34,,848.64,percent of total billed charges,Implant Device,848.64,34,,848.64,percent of total billed charges,Implant Device,1235.52,,,1235.52,Other,110% of Medicare,873.6,35,,873.6,percent of total billed charges,Implant Device,848.64,34,"Charges > $500, x 34%",848.64,percent of total billed charges,Implant Device,873.6,35,,873.6,percent of total billed charges,Implant Device,873.6,35,,873.6,percent of total billed charges,Implant Device,873.6,35,,873.6,percent of total billed charges,Implant Device,873.6,35,,873.6,percent of total billed charges,Implant Device,873.6,35,,873.6,percent of total billed charges,Implant Device,998.4,40,,998.4,percent of total billed charges,Implant Device,873.6,70,,873.6,percent of total billed charges,All Other,848.64,34,,848.64,percent of total billed charges,Implant Device,848.64,34,,848.64,percent of total billed charges,Implant Device,873.6,35,,873.6,percent of total billed charges,Implant Device,873.6,35,,873.6,percent of total billed charges,Implant Device,873.6,35,,873.6,percent of total billed charges,Implant Device,873.6,35,,873.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,848.64,34,"If Charge > 2,000, then 34 percent",848.64,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1847.05,
ZIMMER 5952-50-14 ARTICULAR SURFACE,C1776,HCPCS,,79002131,CDM,278,RC,,,both,,,2496,1847.05,,,1847.05,Other,150% of Medicare + 9.63% HCRA Surcharge,1123.2,45,,1123.2,percent of total billed charges,Critical Access Hospital RCC factor,848.64,34,,848.64,percent of total billed charges,Implant Device,848.64,34,,848.64,percent of total billed charges,Implant Device,848.64,34,,848.64,percent of total billed charges,Implant Device,848.64,34,,848.64,percent of total billed charges,Implant Device,848.64,34,,848.64,percent of total billed charges,Implant Device,1235.52,,,1235.52,Other,110% of Medicare,873.6,35,,873.6,percent of total billed charges,Implant Device,848.64,34,"Charges > $500, x 34%",848.64,percent of total billed charges,Implant Device,873.6,35,,873.6,percent of total billed charges,Implant Device,873.6,35,,873.6,percent of total billed charges,Implant Device,873.6,35,,873.6,percent of total billed charges,Implant Device,873.6,35,,873.6,percent of total billed charges,Implant Device,873.6,35,,873.6,percent of total billed charges,Implant Device,998.4,40,,998.4,percent of total billed charges,Implant Device,873.6,70,,873.6,percent of total billed charges,All Other,848.64,34,,848.64,percent of total billed charges,Implant Device,848.64,34,,848.64,percent of total billed charges,Implant Device,873.6,35,,873.6,percent of total billed charges,Implant Device,873.6,35,,873.6,percent of total billed charges,Implant Device,873.6,35,,873.6,percent of total billed charges,Implant Device,873.6,35,,873.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,848.64,34,"If Charge > 2,000, then 34 percent",848.64,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1847.05,
ZIMMER 5952-50-14-REV ARTICULAR SURFACE,C1776,HCPCS,,79002132,CDM,278,RC,,,both,,,3406,2520.45,,,2520.45,Other,150% of Medicare + 9.63% HCRA Surcharge,1532.7,45,,1532.7,percent of total billed charges,Critical Access Hospital RCC factor,1158.04,34,,1158.04,percent of total billed charges,Implant Device,1158.04,34,,1158.04,percent of total billed charges,Implant Device,1158.04,34,,1158.04,percent of total billed charges,Implant Device,1158.04,34,,1158.04,percent of total billed charges,Implant Device,1158.04,34,,1158.04,percent of total billed charges,Implant Device,1685.97,,,1685.97,Other,110% of Medicare,1192.1,35,,1192.1,percent of total billed charges,Implant Device,1158.04,34,"Charges > $500, x 34%",1158.04,percent of total billed charges,Implant Device,1192.1,35,,1192.1,percent of total billed charges,Implant Device,1192.1,35,,1192.1,percent of total billed charges,Implant Device,1192.1,35,,1192.1,percent of total billed charges,Implant Device,1192.1,35,,1192.1,percent of total billed charges,Implant Device,1192.1,35,,1192.1,percent of total billed charges,Implant Device,1362.4,40,,1362.4,percent of total billed charges,Implant Device,1192.1,70,,1192.1,percent of total billed charges,All Other,1158.04,34,,1158.04,percent of total billed charges,Implant Device,1158.04,34,,1158.04,percent of total billed charges,Implant Device,1192.1,35,,1192.1,percent of total billed charges,Implant Device,1192.1,35,,1192.1,percent of total billed charges,Implant Device,1192.1,35,,1192.1,percent of total billed charges,Implant Device,1192.1,35,,1192.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1158.04,34,"If Charge > 2,000, then 34 percent",1158.04,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2520.45,
ZIMMER 5962-32-17-REV ARTICULAR SURFACE,C1776,HCPCS,,79002133,CDM,278,RC,,,both,,,6292,4656.1,,,4656.1,Other,150% of Medicare + 9.63% HCRA Surcharge,2831.4,45,,2831.4,percent of total billed charges,Critical Access Hospital RCC factor,2139.28,34,,2139.28,percent of total billed charges,Implant Device,2139.28,34,,2139.28,percent of total billed charges,Implant Device,2139.28,34,,2139.28,percent of total billed charges,Implant Device,2139.28,34,,2139.28,percent of total billed charges,Implant Device,2139.28,34,,2139.28,percent of total billed charges,Implant Device,3114.54,,,3114.54,Other,110% of Medicare,2202.2,35,,2202.2,percent of total billed charges,Implant Device,2139.28,34,"Charges > $500, x 34%",2139.28,percent of total billed charges,Implant Device,2202.2,35,,2202.2,percent of total billed charges,Implant Device,2202.2,35,,2202.2,percent of total billed charges,Implant Device,2202.2,35,,2202.2,percent of total billed charges,Implant Device,2202.2,35,,2202.2,percent of total billed charges,Implant Device,2202.2,35,,2202.2,percent of total billed charges,Implant Device,2516.8,40,,2516.8,percent of total billed charges,Implant Device,2202.2,70,,2202.2,percent of total billed charges,All Other,2139.28,34,,2139.28,percent of total billed charges,Implant Device,2139.28,34,,2139.28,percent of total billed charges,Implant Device,2202.2,35,,2202.2,percent of total billed charges,Implant Device,2202.2,35,,2202.2,percent of total billed charges,Implant Device,2202.2,35,,2202.2,percent of total billed charges,Implant Device,2202.2,35,,2202.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2139.28,34,"If Charge > 2,000, then 34 percent",2139.28,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4656.1,
ZIMMER 5972-65-29-REV ALL POLY PATELLA,C1776,HCPCS,,79002134,CDM,278,RC,,,both,,,2881,2131.95,,,2131.95,Other,150% of Medicare + 9.63% HCRA Surcharge,1296.45,45,,1296.45,percent of total billed charges,Critical Access Hospital RCC factor,979.54,34,,979.54,percent of total billed charges,Implant Device,979.54,34,,979.54,percent of total billed charges,Implant Device,979.54,34,,979.54,percent of total billed charges,Implant Device,979.54,34,,979.54,percent of total billed charges,Implant Device,979.54,34,,979.54,percent of total billed charges,Implant Device,1426.1,,,1426.1,Other,110% of Medicare,1008.35,35,,1008.35,percent of total billed charges,Implant Device,979.54,34,"Charges > $500, x 34%",979.54,percent of total billed charges,Implant Device,1008.35,35,,1008.35,percent of total billed charges,Implant Device,1008.35,35,,1008.35,percent of total billed charges,Implant Device,1008.35,35,,1008.35,percent of total billed charges,Implant Device,1008.35,35,,1008.35,percent of total billed charges,Implant Device,1008.35,35,,1008.35,percent of total billed charges,Implant Device,1152.4,40,,1152.4,percent of total billed charges,Implant Device,1008.35,70,,1008.35,percent of total billed charges,All Other,979.54,34,,979.54,percent of total billed charges,Implant Device,979.54,34,,979.54,percent of total billed charges,Implant Device,1008.35,35,,1008.35,percent of total billed charges,Implant Device,1008.35,35,,1008.35,percent of total billed charges,Implant Device,1008.35,35,,1008.35,percent of total billed charges,Implant Device,1008.35,35,,1008.35,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,979.54,34,"If Charge > 2,000, then 34 percent",979.54,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2131.95,
ZIMMER 5976-30-14-REV ARTICULAR SURFACE,C1776,HCPCS,,79002135,CDM,278,RC,,,both,,,2250,1665.01,,,1665.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1012.5,45,,1012.5,percent of total billed charges,Critical Access Hospital RCC factor,765,34,,765,percent of total billed charges,Implant Device,765,34,,765,percent of total billed charges,Implant Device,765,34,,765,percent of total billed charges,Implant Device,765,34,,765,percent of total billed charges,Implant Device,765,34,,765,percent of total billed charges,Implant Device,1113.75,,,1113.75,Other,110% of Medicare,787.5,35,,787.5,percent of total billed charges,Implant Device,765,34,"Charges > $500, x 34%",765,percent of total billed charges,Implant Device,787.5,35,,787.5,percent of total billed charges,Implant Device,787.5,35,,787.5,percent of total billed charges,Implant Device,787.5,35,,787.5,percent of total billed charges,Implant Device,787.5,35,,787.5,percent of total billed charges,Implant Device,787.5,35,,787.5,percent of total billed charges,Implant Device,900,40,,900,percent of total billed charges,Implant Device,787.5,70,,787.5,percent of total billed charges,All Other,765,34,,765,percent of total billed charges,Implant Device,765,34,,765,percent of total billed charges,Implant Device,787.5,35,,787.5,percent of total billed charges,Implant Device,787.5,35,,787.5,percent of total billed charges,Implant Device,787.5,35,,787.5,percent of total billed charges,Implant Device,787.5,35,,787.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,765,34,"If Charge > 2,000, then 34 percent",765,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1665.01,
ZIMMER 5976-30-17-REV ARTICULAR SURFACE,C1776,HCPCS,,79002136,CDM,278,RC,,,both,,,3826,2831.25,,,2831.25,Other,150% of Medicare + 9.63% HCRA Surcharge,1721.7,45,,1721.7,percent of total billed charges,Critical Access Hospital RCC factor,1300.84,34,,1300.84,percent of total billed charges,Implant Device,1300.84,34,,1300.84,percent of total billed charges,Implant Device,1300.84,34,,1300.84,percent of total billed charges,Implant Device,1300.84,34,,1300.84,percent of total billed charges,Implant Device,1300.84,34,,1300.84,percent of total billed charges,Implant Device,1893.87,,,1893.87,Other,110% of Medicare,1339.1,35,,1339.1,percent of total billed charges,Implant Device,1300.84,34,"Charges > $500, x 34%",1300.84,percent of total billed charges,Implant Device,1339.1,35,,1339.1,percent of total billed charges,Implant Device,1339.1,35,,1339.1,percent of total billed charges,Implant Device,1339.1,35,,1339.1,percent of total billed charges,Implant Device,1339.1,35,,1339.1,percent of total billed charges,Implant Device,1339.1,35,,1339.1,percent of total billed charges,Implant Device,1530.4,40,,1530.4,percent of total billed charges,Implant Device,1339.1,70,,1339.1,percent of total billed charges,All Other,1300.84,34,,1300.84,percent of total billed charges,Implant Device,1300.84,34,,1300.84,percent of total billed charges,Implant Device,1339.1,35,,1339.1,percent of total billed charges,Implant Device,1339.1,35,,1339.1,percent of total billed charges,Implant Device,1339.1,35,,1339.1,percent of total billed charges,Implant Device,1339.1,35,,1339.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1300.84,34,"If Charge > 2,000, then 34 percent",1300.84,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2831.25,
ZIMMER 5976-40-12-REV ARTICULAR SURFACE,C1776,HCPCS,,79002137,CDM,278,RC,,,both,,,1920,1420.8,,,1420.8,Other,150% of Medicare + 9.63% HCRA Surcharge,864,45,,864,percent of total billed charges,Critical Access Hospital RCC factor,652.8,34,,652.8,percent of total billed charges,Implant Device,652.8,34,,652.8,percent of total billed charges,Implant Device,652.8,34,,652.8,percent of total billed charges,Implant Device,652.8,34,,652.8,percent of total billed charges,Implant Device,652.8,34,,652.8,percent of total billed charges,Implant Device,950.4,,,950.4,Other,110% of Medicare,672,35,,672,percent of total billed charges,Implant Device,652.8,34,"Charges > $500, x 34%",652.8,percent of total billed charges,Implant Device,672,35,,672,percent of total billed charges,Implant Device,672,35,,672,percent of total billed charges,Implant Device,672,35,,672,percent of total billed charges,Implant Device,672,35,,672,percent of total billed charges,Implant Device,672,35,,672,percent of total billed charges,Implant Device,768,40,,768,percent of total billed charges,Implant Device,672,70,,672,percent of total billed charges,All Other,652.8,34,,652.8,percent of total billed charges,Implant Device,652.8,34,,652.8,percent of total billed charges,Implant Device,672,35,,672,percent of total billed charges,Implant Device,672,35,,672,percent of total billed charges,Implant Device,672,35,,672,percent of total billed charges,Implant Device,672,35,,672,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1420.8,
ZIMMER 5980-37-01-REV TIBIAL COMPONENT,C1776,HCPCS,,79002138,CDM,278,RC,,,both,,,6616,4895.86,,,4895.86,Other,150% of Medicare + 9.63% HCRA Surcharge,2977.2,45,,2977.2,percent of total billed charges,Critical Access Hospital RCC factor,2249.44,34,,2249.44,percent of total billed charges,Implant Device,2249.44,34,,2249.44,percent of total billed charges,Implant Device,2249.44,34,,2249.44,percent of total billed charges,Implant Device,2249.44,34,,2249.44,percent of total billed charges,Implant Device,2249.44,34,,2249.44,percent of total billed charges,Implant Device,3274.92,,,3274.92,Other,110% of Medicare,2315.6,35,,2315.6,percent of total billed charges,Implant Device,2249.44,34,"Charges > $500, x 34%",2249.44,percent of total billed charges,Implant Device,2315.6,35,,2315.6,percent of total billed charges,Implant Device,2315.6,35,,2315.6,percent of total billed charges,Implant Device,2315.6,35,,2315.6,percent of total billed charges,Implant Device,2315.6,35,,2315.6,percent of total billed charges,Implant Device,2315.6,35,,2315.6,percent of total billed charges,Implant Device,2646.4,40,,2646.4,percent of total billed charges,Implant Device,2315.6,70,,2315.6,percent of total billed charges,All Other,2249.44,34,,2249.44,percent of total billed charges,Implant Device,2249.44,34,,2249.44,percent of total billed charges,Implant Device,2315.6,35,,2315.6,percent of total billed charges,Implant Device,2315.6,35,,2315.6,percent of total billed charges,Implant Device,2315.6,35,,2315.6,percent of total billed charges,Implant Device,2315.6,35,,2315.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2249.44,34,"If Charge > 2,000, then 34 percent",2249.44,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4895.86,
ZIMMER 5980-37-02-REV TIBIAL COMPONENT,C1776,HCPCS,,79002139,CDM,278,RC,,,both,,,2304,1704.97,,,1704.97,Other,150% of Medicare + 9.63% HCRA Surcharge,1036.8,45,,1036.8,percent of total billed charges,Critical Access Hospital RCC factor,783.36,34,,783.36,percent of total billed charges,Implant Device,783.36,34,,783.36,percent of total billed charges,Implant Device,783.36,34,,783.36,percent of total billed charges,Implant Device,783.36,34,,783.36,percent of total billed charges,Implant Device,783.36,34,,783.36,percent of total billed charges,Implant Device,1140.48,,,1140.48,Other,110% of Medicare,806.4,35,,806.4,percent of total billed charges,Implant Device,783.36,34,"Charges > $500, x 34%",783.36,percent of total billed charges,Implant Device,806.4,35,,806.4,percent of total billed charges,Implant Device,806.4,35,,806.4,percent of total billed charges,Implant Device,806.4,35,,806.4,percent of total billed charges,Implant Device,806.4,35,,806.4,percent of total billed charges,Implant Device,806.4,35,,806.4,percent of total billed charges,Implant Device,921.6,40,,921.6,percent of total billed charges,Implant Device,806.4,70,,806.4,percent of total billed charges,All Other,783.36,34,,783.36,percent of total billed charges,Implant Device,783.36,34,,783.36,percent of total billed charges,Implant Device,806.4,35,,806.4,percent of total billed charges,Implant Device,806.4,35,,806.4,percent of total billed charges,Implant Device,806.4,35,,806.4,percent of total billed charges,Implant Device,806.4,35,,806.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,783.36,34,"If Charge > 2,000, then 34 percent",783.36,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1704.97,
ZIMMER 5980-47-01-REV TIBIAL COMPONENT,C1776,HCPCS,,79002140,CDM,278,RC,,,both,,,2304,1704.97,,,1704.97,Other,150% of Medicare + 9.63% HCRA Surcharge,1036.8,45,,1036.8,percent of total billed charges,Critical Access Hospital RCC factor,783.36,34,,783.36,percent of total billed charges,Implant Device,783.36,34,,783.36,percent of total billed charges,Implant Device,783.36,34,,783.36,percent of total billed charges,Implant Device,783.36,34,,783.36,percent of total billed charges,Implant Device,783.36,34,,783.36,percent of total billed charges,Implant Device,1140.48,,,1140.48,Other,110% of Medicare,806.4,35,,806.4,percent of total billed charges,Implant Device,783.36,34,"Charges > $500, x 34%",783.36,percent of total billed charges,Implant Device,806.4,35,,806.4,percent of total billed charges,Implant Device,806.4,35,,806.4,percent of total billed charges,Implant Device,806.4,35,,806.4,percent of total billed charges,Implant Device,806.4,35,,806.4,percent of total billed charges,Implant Device,806.4,35,,806.4,percent of total billed charges,Implant Device,921.6,40,,921.6,percent of total billed charges,Implant Device,806.4,70,,806.4,percent of total billed charges,All Other,783.36,34,,783.36,percent of total billed charges,Implant Device,783.36,34,,783.36,percent of total billed charges,Implant Device,806.4,35,,806.4,percent of total billed charges,Implant Device,806.4,35,,806.4,percent of total billed charges,Implant Device,806.4,35,,806.4,percent of total billed charges,Implant Device,806.4,35,,806.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,783.36,34,"If Charge > 2,000, then 34 percent",783.36,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1704.97,
ZIMMER 5980-57-01-REV TIBIAL COMPONENT,C1776,HCPCS,,79002141,CDM,278,RC,,,both,,,2304,1704.97,,,1704.97,Other,150% of Medicare + 9.63% HCRA Surcharge,1036.8,45,,1036.8,percent of total billed charges,Critical Access Hospital RCC factor,783.36,34,,783.36,percent of total billed charges,Implant Device,783.36,34,,783.36,percent of total billed charges,Implant Device,783.36,34,,783.36,percent of total billed charges,Implant Device,783.36,34,,783.36,percent of total billed charges,Implant Device,783.36,34,,783.36,percent of total billed charges,Implant Device,1140.48,,,1140.48,Other,110% of Medicare,806.4,35,,806.4,percent of total billed charges,Implant Device,783.36,34,"Charges > $500, x 34%",783.36,percent of total billed charges,Implant Device,806.4,35,,806.4,percent of total billed charges,Implant Device,806.4,35,,806.4,percent of total billed charges,Implant Device,806.4,35,,806.4,percent of total billed charges,Implant Device,806.4,35,,806.4,percent of total billed charges,Implant Device,806.4,35,,806.4,percent of total billed charges,Implant Device,921.6,40,,921.6,percent of total billed charges,Implant Device,806.4,70,,806.4,percent of total billed charges,All Other,783.36,34,,783.36,percent of total billed charges,Implant Device,783.36,34,,783.36,percent of total billed charges,Implant Device,806.4,35,,806.4,percent of total billed charges,Implant Device,806.4,35,,806.4,percent of total billed charges,Implant Device,806.4,35,,806.4,percent of total billed charges,Implant Device,806.4,35,,806.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,783.36,34,"If Charge > 2,000, then 34 percent",783.36,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1704.97,
ZIMMER 5988-03-REV TIBIAL COMPONENT,C1776,HCPCS,,79002142,CDM,278,RC,,,both,,,8416,6227.86,,,6227.86,Other,150% of Medicare + 9.63% HCRA Surcharge,3787.2,45,,3787.2,percent of total billed charges,Critical Access Hospital RCC factor,2861.44,34,,2861.44,percent of total billed charges,Implant Device,2861.44,34,,2861.44,percent of total billed charges,Implant Device,2861.44,34,,2861.44,percent of total billed charges,Implant Device,2861.44,34,,2861.44,percent of total billed charges,Implant Device,2861.44,34,,2861.44,percent of total billed charges,Implant Device,4165.92,,,4165.92,Other,110% of Medicare,2945.6,35,,2945.6,percent of total billed charges,Implant Device,2861.44,34,"Charges > $500, x 34%",2861.44,percent of total billed charges,Implant Device,2945.6,35,,2945.6,percent of total billed charges,Implant Device,2945.6,35,,2945.6,percent of total billed charges,Implant Device,2945.6,35,,2945.6,percent of total billed charges,Implant Device,2945.6,35,,2945.6,percent of total billed charges,Implant Device,2945.6,35,,2945.6,percent of total billed charges,Implant Device,3366.4,40,,3366.4,percent of total billed charges,Implant Device,2945.6,70,,2945.6,percent of total billed charges,All Other,2861.44,34,,2861.44,percent of total billed charges,Implant Device,2861.44,34,,2861.44,percent of total billed charges,Implant Device,2945.6,35,,2945.6,percent of total billed charges,Implant Device,2945.6,35,,2945.6,percent of total billed charges,Implant Device,2945.6,35,,2945.6,percent of total billed charges,Implant Device,2945.6,35,,2945.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2861.44,34,"If Charge > 2,000, then 34 percent",2861.44,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,6227.86,
ZIMMER 5988-04-REV TIBIAL COMPONENT,C1776,HCPCS,,79002143,CDM,278,RC,,,both,,,7740,5727.62,,,5727.62,Other,150% of Medicare + 9.63% HCRA Surcharge,3483,45,,3483,percent of total billed charges,Critical Access Hospital RCC factor,2631.6,34,,2631.6,percent of total billed charges,Implant Device,2631.6,34,,2631.6,percent of total billed charges,Implant Device,2631.6,34,,2631.6,percent of total billed charges,Implant Device,2631.6,34,,2631.6,percent of total billed charges,Implant Device,2631.6,34,,2631.6,percent of total billed charges,Implant Device,3831.3,,,3831.3,Other,110% of Medicare,2709,35,,2709,percent of total billed charges,Implant Device,2631.6,34,"Charges > $500, x 34%",2631.6,percent of total billed charges,Implant Device,2709,35,,2709,percent of total billed charges,Implant Device,2709,35,,2709,percent of total billed charges,Implant Device,2709,35,,2709,percent of total billed charges,Implant Device,2709,35,,2709,percent of total billed charges,Implant Device,2709,35,,2709,percent of total billed charges,Implant Device,3096,40,,3096,percent of total billed charges,Implant Device,2709,70,,2709,percent of total billed charges,All Other,2631.6,34,,2631.6,percent of total billed charges,Implant Device,2631.6,34,,2631.6,percent of total billed charges,Implant Device,2709,35,,2709,percent of total billed charges,Implant Device,2709,35,,2709,percent of total billed charges,Implant Device,2709,35,,2709,percent of total billed charges,Implant Device,2709,35,,2709,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2631.6,34,"If Charge > 2,000, then 34 percent",2631.6,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5727.62,
ZIMMER 5988-05-10-REV TIBIAL COMPONENT,C1776,HCPCS,,79002144,CDM,278,RC,,,both,,,3968,2936.33,,,2936.33,Other,150% of Medicare + 9.63% HCRA Surcharge,1785.6,45,,1785.6,percent of total billed charges,Critical Access Hospital RCC factor,1349.12,34,,1349.12,percent of total billed charges,Implant Device,1349.12,34,,1349.12,percent of total billed charges,Implant Device,1349.12,34,,1349.12,percent of total billed charges,Implant Device,1349.12,34,,1349.12,percent of total billed charges,Implant Device,1349.12,34,,1349.12,percent of total billed charges,Implant Device,1964.16,,,1964.16,Other,110% of Medicare,1388.8,35,,1388.8,percent of total billed charges,Implant Device,1349.12,34,"Charges > $500, x 34%",1349.12,percent of total billed charges,Implant Device,1388.8,35,,1388.8,percent of total billed charges,Implant Device,1388.8,35,,1388.8,percent of total billed charges,Implant Device,1388.8,35,,1388.8,percent of total billed charges,Implant Device,1388.8,35,,1388.8,percent of total billed charges,Implant Device,1388.8,35,,1388.8,percent of total billed charges,Implant Device,1587.2,40,,1587.2,percent of total billed charges,Implant Device,1388.8,70,,1388.8,percent of total billed charges,All Other,1349.12,34,,1349.12,percent of total billed charges,Implant Device,1349.12,34,,1349.12,percent of total billed charges,Implant Device,1388.8,35,,1388.8,percent of total billed charges,Implant Device,1388.8,35,,1388.8,percent of total billed charges,Implant Device,1388.8,35,,1388.8,percent of total billed charges,Implant Device,1388.8,35,,1388.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1349.12,34,"If Charge > 2,000, then 34 percent",1349.12,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2936.33,
ZIMMER 5988-10-12-REV STEM EXTENSION,C1776,HCPCS,,79002145,CDM,278,RC,,,both,,,3756,2779.45,,,2779.45,Other,150% of Medicare + 9.63% HCRA Surcharge,1690.2,45,,1690.2,percent of total billed charges,Critical Access Hospital RCC factor,1277.04,34,,1277.04,percent of total billed charges,Implant Device,1277.04,34,,1277.04,percent of total billed charges,Implant Device,1277.04,34,,1277.04,percent of total billed charges,Implant Device,1277.04,34,,1277.04,percent of total billed charges,Implant Device,1277.04,34,,1277.04,percent of total billed charges,Implant Device,1859.22,,,1859.22,Other,110% of Medicare,1314.6,35,,1314.6,percent of total billed charges,Implant Device,1277.04,34,"Charges > $500, x 34%",1277.04,percent of total billed charges,Implant Device,1314.6,35,,1314.6,percent of total billed charges,Implant Device,1314.6,35,,1314.6,percent of total billed charges,Implant Device,1314.6,35,,1314.6,percent of total billed charges,Implant Device,1314.6,35,,1314.6,percent of total billed charges,Implant Device,1314.6,35,,1314.6,percent of total billed charges,Implant Device,1502.4,40,,1502.4,percent of total billed charges,Implant Device,1314.6,70,,1314.6,percent of total billed charges,All Other,1277.04,34,,1277.04,percent of total billed charges,Implant Device,1277.04,34,,1277.04,percent of total billed charges,Implant Device,1314.6,35,,1314.6,percent of total billed charges,Implant Device,1314.6,35,,1314.6,percent of total billed charges,Implant Device,1314.6,35,,1314.6,percent of total billed charges,Implant Device,1314.6,35,,1314.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1277.04,34,"If Charge > 2,000, then 34 percent",1277.04,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2779.45,
ZIMMER 5988-10-13-REV STEM EXTENSION,C1776,HCPCS,,79002146,CDM,278,RC,,,both,,,3325,2460.51,,,2460.51,Other,150% of Medicare + 9.63% HCRA Surcharge,1496.25,45,,1496.25,percent of total billed charges,Critical Access Hospital RCC factor,1130.5,34,,1130.5,percent of total billed charges,Implant Device,1130.5,34,,1130.5,percent of total billed charges,Implant Device,1130.5,34,,1130.5,percent of total billed charges,Implant Device,1130.5,34,,1130.5,percent of total billed charges,Implant Device,1130.5,34,,1130.5,percent of total billed charges,Implant Device,1645.88,,,1645.88,Other,110% of Medicare,1163.75,35,,1163.75,percent of total billed charges,Implant Device,1130.5,34,"Charges > $500, x 34%",1130.5,percent of total billed charges,Implant Device,1163.75,35,,1163.75,percent of total billed charges,Implant Device,1163.75,35,,1163.75,percent of total billed charges,Implant Device,1163.75,35,,1163.75,percent of total billed charges,Implant Device,1163.75,35,,1163.75,percent of total billed charges,Implant Device,1163.75,35,,1163.75,percent of total billed charges,Implant Device,1330,40,,1330,percent of total billed charges,Implant Device,1163.75,70,,1163.75,percent of total billed charges,All Other,1130.5,34,,1130.5,percent of total billed charges,Implant Device,1130.5,34,,1130.5,percent of total billed charges,Implant Device,1163.75,35,,1163.75,percent of total billed charges,Implant Device,1163.75,35,,1163.75,percent of total billed charges,Implant Device,1163.75,35,,1163.75,percent of total billed charges,Implant Device,1163.75,35,,1163.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1130.5,34,"If Charge > 2,000, then 34 percent",1130.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2460.51,
ZIMMER 5988-10-14-REV STEM EXTENSION,C1776,HCPCS,,79002147,CDM,278,RC,,,both,,,3325,2460.51,,,2460.51,Other,150% of Medicare + 9.63% HCRA Surcharge,1496.25,45,,1496.25,percent of total billed charges,Critical Access Hospital RCC factor,1130.5,34,,1130.5,percent of total billed charges,Implant Device,1130.5,34,,1130.5,percent of total billed charges,Implant Device,1130.5,34,,1130.5,percent of total billed charges,Implant Device,1130.5,34,,1130.5,percent of total billed charges,Implant Device,1130.5,34,,1130.5,percent of total billed charges,Implant Device,1645.88,,,1645.88,Other,110% of Medicare,1163.75,35,,1163.75,percent of total billed charges,Implant Device,1130.5,34,"Charges > $500, x 34%",1130.5,percent of total billed charges,Implant Device,1163.75,35,,1163.75,percent of total billed charges,Implant Device,1163.75,35,,1163.75,percent of total billed charges,Implant Device,1163.75,35,,1163.75,percent of total billed charges,Implant Device,1163.75,35,,1163.75,percent of total billed charges,Implant Device,1163.75,35,,1163.75,percent of total billed charges,Implant Device,1330,40,,1330,percent of total billed charges,Implant Device,1163.75,70,,1163.75,percent of total billed charges,All Other,1130.5,34,,1130.5,percent of total billed charges,Implant Device,1130.5,34,,1130.5,percent of total billed charges,Implant Device,1163.75,35,,1163.75,percent of total billed charges,Implant Device,1163.75,35,,1163.75,percent of total billed charges,Implant Device,1163.75,35,,1163.75,percent of total billed charges,Implant Device,1163.75,35,,1163.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1130.5,34,"If Charge > 2,000, then 34 percent",1130.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2460.51,
ZIMMER 5988-10-15-REV STEM EXTENSION,C1776,HCPCS,,79002148,CDM,278,RC,,,both,,,2970,2197.81,,,2197.81,Other,150% of Medicare + 9.63% HCRA Surcharge,1336.5,45,,1336.5,percent of total billed charges,Critical Access Hospital RCC factor,1009.8,34,,1009.8,percent of total billed charges,Implant Device,1009.8,34,,1009.8,percent of total billed charges,Implant Device,1009.8,34,,1009.8,percent of total billed charges,Implant Device,1009.8,34,,1009.8,percent of total billed charges,Implant Device,1009.8,34,,1009.8,percent of total billed charges,Implant Device,1470.15,,,1470.15,Other,110% of Medicare,1039.5,35,,1039.5,percent of total billed charges,Implant Device,1009.8,34,"Charges > $500, x 34%",1009.8,percent of total billed charges,Implant Device,1039.5,35,,1039.5,percent of total billed charges,Implant Device,1039.5,35,,1039.5,percent of total billed charges,Implant Device,1039.5,35,,1039.5,percent of total billed charges,Implant Device,1039.5,35,,1039.5,percent of total billed charges,Implant Device,1039.5,35,,1039.5,percent of total billed charges,Implant Device,1188,40,,1188,percent of total billed charges,Implant Device,1039.5,70,,1039.5,percent of total billed charges,All Other,1009.8,34,,1009.8,percent of total billed charges,Implant Device,1009.8,34,,1009.8,percent of total billed charges,Implant Device,1039.5,35,,1039.5,percent of total billed charges,Implant Device,1039.5,35,,1039.5,percent of total billed charges,Implant Device,1039.5,35,,1039.5,percent of total billed charges,Implant Device,1039.5,35,,1039.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1009.8,34,"If Charge > 2,000, then 34 percent",1009.8,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2197.81,
ZIMMER 5988-10-16-REV STEM EXTENSION,C1776,HCPCS,,79002149,CDM,278,RC,,,both,,,3325,2460.51,,,2460.51,Other,150% of Medicare + 9.63% HCRA Surcharge,1496.25,45,,1496.25,percent of total billed charges,Critical Access Hospital RCC factor,1130.5,34,,1130.5,percent of total billed charges,Implant Device,1130.5,34,,1130.5,percent of total billed charges,Implant Device,1130.5,34,,1130.5,percent of total billed charges,Implant Device,1130.5,34,,1130.5,percent of total billed charges,Implant Device,1130.5,34,,1130.5,percent of total billed charges,Implant Device,1645.88,,,1645.88,Other,110% of Medicare,1163.75,35,,1163.75,percent of total billed charges,Implant Device,1130.5,34,"Charges > $500, x 34%",1130.5,percent of total billed charges,Implant Device,1163.75,35,,1163.75,percent of total billed charges,Implant Device,1163.75,35,,1163.75,percent of total billed charges,Implant Device,1163.75,35,,1163.75,percent of total billed charges,Implant Device,1163.75,35,,1163.75,percent of total billed charges,Implant Device,1163.75,35,,1163.75,percent of total billed charges,Implant Device,1330,40,,1330,percent of total billed charges,Implant Device,1163.75,70,,1163.75,percent of total billed charges,All Other,1130.5,34,,1130.5,percent of total billed charges,Implant Device,1130.5,34,,1130.5,percent of total billed charges,Implant Device,1163.75,35,,1163.75,percent of total billed charges,Implant Device,1163.75,35,,1163.75,percent of total billed charges,Implant Device,1163.75,35,,1163.75,percent of total billed charges,Implant Device,1163.75,35,,1163.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1130.5,34,"If Charge > 2,000, then 34 percent",1130.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2460.51,
ZIMMER 5988-10-18-REV STEM EXTENSION,C1776,HCPCS,,79002150,CDM,278,RC,,,both,,,3758,2780.93,,,2780.93,Other,150% of Medicare + 9.63% HCRA Surcharge,1691.1,45,,1691.1,percent of total billed charges,Critical Access Hospital RCC factor,1277.72,34,,1277.72,percent of total billed charges,Implant Device,1277.72,34,,1277.72,percent of total billed charges,Implant Device,1277.72,34,,1277.72,percent of total billed charges,Implant Device,1277.72,34,,1277.72,percent of total billed charges,Implant Device,1277.72,34,,1277.72,percent of total billed charges,Implant Device,1860.21,,,1860.21,Other,110% of Medicare,1315.3,35,,1315.3,percent of total billed charges,Implant Device,1277.72,34,"Charges > $500, x 34%",1277.72,percent of total billed charges,Implant Device,1315.3,35,,1315.3,percent of total billed charges,Implant Device,1315.3,35,,1315.3,percent of total billed charges,Implant Device,1315.3,35,,1315.3,percent of total billed charges,Implant Device,1315.3,35,,1315.3,percent of total billed charges,Implant Device,1315.3,35,,1315.3,percent of total billed charges,Implant Device,1503.2,40,,1503.2,percent of total billed charges,Implant Device,1315.3,70,,1315.3,percent of total billed charges,All Other,1277.72,34,,1277.72,percent of total billed charges,Implant Device,1277.72,34,,1277.72,percent of total billed charges,Implant Device,1315.3,35,,1315.3,percent of total billed charges,Implant Device,1315.3,35,,1315.3,percent of total billed charges,Implant Device,1315.3,35,,1315.3,percent of total billed charges,Implant Device,1315.3,35,,1315.3,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1277.72,34,"If Charge > 2,000, then 34 percent",1277.72,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2780.93,
ZIMMER 5988-10-20-REV STEM EXTENSION,C1776,HCPCS,,79002151,CDM,278,RC,,,both,,,3325,2460.51,,,2460.51,Other,150% of Medicare + 9.63% HCRA Surcharge,1496.25,45,,1496.25,percent of total billed charges,Critical Access Hospital RCC factor,1130.5,34,,1130.5,percent of total billed charges,Implant Device,1130.5,34,,1130.5,percent of total billed charges,Implant Device,1130.5,34,,1130.5,percent of total billed charges,Implant Device,1130.5,34,,1130.5,percent of total billed charges,Implant Device,1130.5,34,,1130.5,percent of total billed charges,Implant Device,1645.88,,,1645.88,Other,110% of Medicare,1163.75,35,,1163.75,percent of total billed charges,Implant Device,1130.5,34,"Charges > $500, x 34%",1130.5,percent of total billed charges,Implant Device,1163.75,35,,1163.75,percent of total billed charges,Implant Device,1163.75,35,,1163.75,percent of total billed charges,Implant Device,1163.75,35,,1163.75,percent of total billed charges,Implant Device,1163.75,35,,1163.75,percent of total billed charges,Implant Device,1163.75,35,,1163.75,percent of total billed charges,Implant Device,1330,40,,1330,percent of total billed charges,Implant Device,1163.75,70,,1163.75,percent of total billed charges,All Other,1130.5,34,,1130.5,percent of total billed charges,Implant Device,1130.5,34,,1130.5,percent of total billed charges,Implant Device,1163.75,35,,1163.75,percent of total billed charges,Implant Device,1163.75,35,,1163.75,percent of total billed charges,Implant Device,1163.75,35,,1163.75,percent of total billed charges,Implant Device,1163.75,35,,1163.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1130.5,34,"If Charge > 2,000, then 34 percent",1130.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2460.51,
ZIMMER 5988-11-12-REV STEM EXTENSION,C1776,HCPCS,,79002152,CDM,278,RC,,,both,,,3325,2460.51,,,2460.51,Other,150% of Medicare + 9.63% HCRA Surcharge,1496.25,45,,1496.25,percent of total billed charges,Critical Access Hospital RCC factor,1130.5,34,,1130.5,percent of total billed charges,Implant Device,1130.5,34,,1130.5,percent of total billed charges,Implant Device,1130.5,34,,1130.5,percent of total billed charges,Implant Device,1130.5,34,,1130.5,percent of total billed charges,Implant Device,1130.5,34,,1130.5,percent of total billed charges,Implant Device,1645.88,,,1645.88,Other,110% of Medicare,1163.75,35,,1163.75,percent of total billed charges,Implant Device,1130.5,34,"Charges > $500, x 34%",1130.5,percent of total billed charges,Implant Device,1163.75,35,,1163.75,percent of total billed charges,Implant Device,1163.75,35,,1163.75,percent of total billed charges,Implant Device,1163.75,35,,1163.75,percent of total billed charges,Implant Device,1163.75,35,,1163.75,percent of total billed charges,Implant Device,1163.75,35,,1163.75,percent of total billed charges,Implant Device,1330,40,,1330,percent of total billed charges,Implant Device,1163.75,70,,1163.75,percent of total billed charges,All Other,1130.5,34,,1130.5,percent of total billed charges,Implant Device,1130.5,34,,1130.5,percent of total billed charges,Implant Device,1163.75,35,,1163.75,percent of total billed charges,Implant Device,1163.75,35,,1163.75,percent of total billed charges,Implant Device,1163.75,35,,1163.75,percent of total billed charges,Implant Device,1163.75,35,,1163.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1130.5,34,"If Charge > 2,000, then 34 percent",1130.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2460.51,
ZIMMER 5988-11-14-REV STEM EXTENSION,C1776,HCPCS,,79002153,CDM,278,RC,,,both,,,3324,2459.77,,,2459.77,Other,150% of Medicare + 9.63% HCRA Surcharge,1495.8,45,,1495.8,percent of total billed charges,Critical Access Hospital RCC factor,1130.16,34,,1130.16,percent of total billed charges,Implant Device,1130.16,34,,1130.16,percent of total billed charges,Implant Device,1130.16,34,,1130.16,percent of total billed charges,Implant Device,1130.16,34,,1130.16,percent of total billed charges,Implant Device,1130.16,34,,1130.16,percent of total billed charges,Implant Device,1645.38,,,1645.38,Other,110% of Medicare,1163.4,35,,1163.4,percent of total billed charges,Implant Device,1130.16,34,"Charges > $500, x 34%",1130.16,percent of total billed charges,Implant Device,1163.4,35,,1163.4,percent of total billed charges,Implant Device,1163.4,35,,1163.4,percent of total billed charges,Implant Device,1163.4,35,,1163.4,percent of total billed charges,Implant Device,1163.4,35,,1163.4,percent of total billed charges,Implant Device,1163.4,35,,1163.4,percent of total billed charges,Implant Device,1329.6,40,,1329.6,percent of total billed charges,Implant Device,1163.4,70,,1163.4,percent of total billed charges,All Other,1130.16,34,,1130.16,percent of total billed charges,Implant Device,1130.16,34,,1130.16,percent of total billed charges,Implant Device,1163.4,35,,1163.4,percent of total billed charges,Implant Device,1163.4,35,,1163.4,percent of total billed charges,Implant Device,1163.4,35,,1163.4,percent of total billed charges,Implant Device,1163.4,35,,1163.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1130.16,34,"If Charge > 2,000, then 34 percent",1130.16,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2459.77,
ZIMMER 5988-11-15-REV STEM EXTENSION,C1776,HCPCS,,79002154,CDM,278,RC,,,both,,,3758,2780.93,,,2780.93,Other,150% of Medicare + 9.63% HCRA Surcharge,1691.1,45,,1691.1,percent of total billed charges,Critical Access Hospital RCC factor,1277.72,34,,1277.72,percent of total billed charges,Implant Device,1277.72,34,,1277.72,percent of total billed charges,Implant Device,1277.72,34,,1277.72,percent of total billed charges,Implant Device,1277.72,34,,1277.72,percent of total billed charges,Implant Device,1277.72,34,,1277.72,percent of total billed charges,Implant Device,1860.21,,,1860.21,Other,110% of Medicare,1315.3,35,,1315.3,percent of total billed charges,Implant Device,1277.72,34,"Charges > $500, x 34%",1277.72,percent of total billed charges,Implant Device,1315.3,35,,1315.3,percent of total billed charges,Implant Device,1315.3,35,,1315.3,percent of total billed charges,Implant Device,1315.3,35,,1315.3,percent of total billed charges,Implant Device,1315.3,35,,1315.3,percent of total billed charges,Implant Device,1315.3,35,,1315.3,percent of total billed charges,Implant Device,1503.2,40,,1503.2,percent of total billed charges,Implant Device,1315.3,70,,1315.3,percent of total billed charges,All Other,1277.72,34,,1277.72,percent of total billed charges,Implant Device,1277.72,34,,1277.72,percent of total billed charges,Implant Device,1315.3,35,,1315.3,percent of total billed charges,Implant Device,1315.3,35,,1315.3,percent of total billed charges,Implant Device,1315.3,35,,1315.3,percent of total billed charges,Implant Device,1315.3,35,,1315.3,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1277.72,34,"If Charge > 2,000, then 34 percent",1277.72,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2780.93,
ZIMMER 5988-12-15-REV STEM EXTENSION,C1776,HCPCS,,79002155,CDM,278,RC,,,both,,,3324,2459.77,,,2459.77,Other,150% of Medicare + 9.63% HCRA Surcharge,1495.8,45,,1495.8,percent of total billed charges,Critical Access Hospital RCC factor,1130.16,34,,1130.16,percent of total billed charges,Implant Device,1130.16,34,,1130.16,percent of total billed charges,Implant Device,1130.16,34,,1130.16,percent of total billed charges,Implant Device,1130.16,34,,1130.16,percent of total billed charges,Implant Device,1130.16,34,,1130.16,percent of total billed charges,Implant Device,1645.38,,,1645.38,Other,110% of Medicare,1163.4,35,,1163.4,percent of total billed charges,Implant Device,1130.16,34,"Charges > $500, x 34%",1130.16,percent of total billed charges,Implant Device,1163.4,35,,1163.4,percent of total billed charges,Implant Device,1163.4,35,,1163.4,percent of total billed charges,Implant Device,1163.4,35,,1163.4,percent of total billed charges,Implant Device,1163.4,35,,1163.4,percent of total billed charges,Implant Device,1163.4,35,,1163.4,percent of total billed charges,Implant Device,1329.6,40,,1329.6,percent of total billed charges,Implant Device,1163.4,70,,1163.4,percent of total billed charges,All Other,1130.16,34,,1130.16,percent of total billed charges,Implant Device,1130.16,34,,1130.16,percent of total billed charges,Implant Device,1163.4,35,,1163.4,percent of total billed charges,Implant Device,1163.4,35,,1163.4,percent of total billed charges,Implant Device,1163.4,35,,1163.4,percent of total billed charges,Implant Device,1163.4,35,,1163.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1130.16,34,"If Charge > 2,000, then 34 percent",1130.16,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2459.77,
ZIMMER 5990-33-10-REV FEMORAL AUGMENT,C1776,HCPCS,,79002156,CDM,278,RC,,,both,,,3240,2397.61,,,2397.61,Other,150% of Medicare + 9.63% HCRA Surcharge,1458,45,,1458,percent of total billed charges,Critical Access Hospital RCC factor,1101.6,34,,1101.6,percent of total billed charges,Implant Device,1101.6,34,,1101.6,percent of total billed charges,Implant Device,1101.6,34,,1101.6,percent of total billed charges,Implant Device,1101.6,34,,1101.6,percent of total billed charges,Implant Device,1101.6,34,,1101.6,percent of total billed charges,Implant Device,1603.8,,,1603.8,Other,110% of Medicare,1134,35,,1134,percent of total billed charges,Implant Device,1101.6,34,"Charges > $500, x 34%",1101.6,percent of total billed charges,Implant Device,1134,35,,1134,percent of total billed charges,Implant Device,1134,35,,1134,percent of total billed charges,Implant Device,1134,35,,1134,percent of total billed charges,Implant Device,1134,35,,1134,percent of total billed charges,Implant Device,1134,35,,1134,percent of total billed charges,Implant Device,1296,40,,1296,percent of total billed charges,Implant Device,1134,70,,1134,percent of total billed charges,All Other,1101.6,34,,1101.6,percent of total billed charges,Implant Device,1101.6,34,,1101.6,percent of total billed charges,Implant Device,1134,35,,1134,percent of total billed charges,Implant Device,1134,35,,1134,percent of total billed charges,Implant Device,1134,35,,1134,percent of total billed charges,Implant Device,1134,35,,1134,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1101.6,34,"If Charge > 2,000, then 34 percent",1101.6,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2397.61,
ZIMMER 5990-34-10-REV FEMORAL AUGMENT,C1776,HCPCS,,79002157,CDM,278,RC,,,both,,,2993,2214.83,,,2214.83,Other,150% of Medicare + 9.63% HCRA Surcharge,1346.85,45,,1346.85,percent of total billed charges,Critical Access Hospital RCC factor,1017.62,34,,1017.62,percent of total billed charges,Implant Device,1017.62,34,,1017.62,percent of total billed charges,Implant Device,1017.62,34,,1017.62,percent of total billed charges,Implant Device,1017.62,34,,1017.62,percent of total billed charges,Implant Device,1017.62,34,,1017.62,percent of total billed charges,Implant Device,1481.54,,,1481.54,Other,110% of Medicare,1047.55,35,,1047.55,percent of total billed charges,Implant Device,1017.62,34,"Charges > $500, x 34%",1017.62,percent of total billed charges,Implant Device,1047.55,35,,1047.55,percent of total billed charges,Implant Device,1047.55,35,,1047.55,percent of total billed charges,Implant Device,1047.55,35,,1047.55,percent of total billed charges,Implant Device,1047.55,35,,1047.55,percent of total billed charges,Implant Device,1047.55,35,,1047.55,percent of total billed charges,Implant Device,1197.2,40,,1197.2,percent of total billed charges,Implant Device,1047.55,70,,1047.55,percent of total billed charges,All Other,1017.62,34,,1017.62,percent of total billed charges,Implant Device,1017.62,34,,1017.62,percent of total billed charges,Implant Device,1047.55,35,,1047.55,percent of total billed charges,Implant Device,1047.55,35,,1047.55,percent of total billed charges,Implant Device,1047.55,35,,1047.55,percent of total billed charges,Implant Device,1047.55,35,,1047.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1017.62,34,"If Charge > 2,000, then 34 percent",1017.62,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2214.83,
ZIMMER 5990-34-21-REV FEMORAL AUGMENT,C1776,HCPCS,,79002158,CDM,278,RC,,,both,,,3520,2604.81,,,2604.81,Other,150% of Medicare + 9.63% HCRA Surcharge,1584,45,,1584,percent of total billed charges,Critical Access Hospital RCC factor,1196.8,34,,1196.8,percent of total billed charges,Implant Device,1196.8,34,,1196.8,percent of total billed charges,Implant Device,1196.8,34,,1196.8,percent of total billed charges,Implant Device,1196.8,34,,1196.8,percent of total billed charges,Implant Device,1196.8,34,,1196.8,percent of total billed charges,Implant Device,1742.4,,,1742.4,Other,110% of Medicare,1232,35,,1232,percent of total billed charges,Implant Device,1196.8,34,"Charges > $500, x 34%",1196.8,percent of total billed charges,Implant Device,1232,35,,1232,percent of total billed charges,Implant Device,1232,35,,1232,percent of total billed charges,Implant Device,1232,35,,1232,percent of total billed charges,Implant Device,1232,35,,1232,percent of total billed charges,Implant Device,1232,35,,1232,percent of total billed charges,Implant Device,1408,40,,1408,percent of total billed charges,Implant Device,1232,70,,1232,percent of total billed charges,All Other,1196.8,34,,1196.8,percent of total billed charges,Implant Device,1196.8,34,,1196.8,percent of total billed charges,Implant Device,1232,35,,1232,percent of total billed charges,Implant Device,1232,35,,1232,percent of total billed charges,Implant Device,1232,35,,1232,percent of total billed charges,Implant Device,1232,35,,1232,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1196.8,34,"If Charge > 2,000, then 34 percent",1196.8,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2604.81,
ZIMMER 5994-13-92-REV FEMORAL COMPONENT,C1776,HCPCS,,79002159,CDM,278,RC,,,both,,,20430,15118.25,,,15118.25,Other,150% of Medicare + 9.63% HCRA Surcharge,9193.5,45,,9193.5,percent of total billed charges,Critical Access Hospital RCC factor,6946.2,34,,6946.2,percent of total billed charges,Implant Device,6946.2,34,,6946.2,percent of total billed charges,Implant Device,6946.2,34,,6946.2,percent of total billed charges,Implant Device,6946.2,34,,6946.2,percent of total billed charges,Implant Device,6946.2,34,,6946.2,percent of total billed charges,Implant Device,10112.85,,,10112.85,Other,110% of Medicare,7150.5,35,,7150.5,percent of total billed charges,Implant Device,6946.2,34,"Charges > $500, x 34%",6946.2,percent of total billed charges,Implant Device,7150.5,35,,7150.5,percent of total billed charges,Implant Device,7150.5,35,,7150.5,percent of total billed charges,Implant Device,7150.5,35,,7150.5,percent of total billed charges,Implant Device,7150.5,35,,7150.5,percent of total billed charges,Implant Device,7150.5,35,,7150.5,percent of total billed charges,Implant Device,8172,40,,8172,percent of total billed charges,Implant Device,7150.5,70,,7150.5,percent of total billed charges,All Other,6946.2,34,,6946.2,percent of total billed charges,Implant Device,6946.2,34,,6946.2,percent of total billed charges,Implant Device,7150.5,35,,7150.5,percent of total billed charges,Implant Device,7150.5,35,,7150.5,percent of total billed charges,Implant Device,7150.5,35,,7150.5,percent of total billed charges,Implant Device,7150.5,35,,7150.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,6946.2,34,"If Charge > 2,000, then 34 percent",6946.2,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,15118.25,
ZIMMER 5994-14-91-REV FEMORAL COMPONENT,C1776,HCPCS,,79002160,CDM,278,RC,,,both,,,17989,13311.9,,,13311.9,Other,150% of Medicare + 9.63% HCRA Surcharge,8095.05,45,,8095.05,percent of total billed charges,Critical Access Hospital RCC factor,6116.26,34,,6116.26,percent of total billed charges,Implant Device,6116.26,34,,6116.26,percent of total billed charges,Implant Device,6116.26,34,,6116.26,percent of total billed charges,Implant Device,6116.26,34,,6116.26,percent of total billed charges,Implant Device,6116.26,34,,6116.26,percent of total billed charges,Implant Device,8904.56,,,8904.56,Other,110% of Medicare,6296.15,35,,6296.15,percent of total billed charges,Implant Device,6116.26,34,"Charges > $500, x 34%",6116.26,percent of total billed charges,Implant Device,6296.15,35,,6296.15,percent of total billed charges,Implant Device,6296.15,35,,6296.15,percent of total billed charges,Implant Device,6296.15,35,,6296.15,percent of total billed charges,Implant Device,6296.15,35,,6296.15,percent of total billed charges,Implant Device,6296.15,35,,6296.15,percent of total billed charges,Implant Device,7195.6,40,,7195.6,percent of total billed charges,Implant Device,6296.15,70,,6296.15,percent of total billed charges,All Other,6116.26,34,,6116.26,percent of total billed charges,Implant Device,6116.26,34,,6116.26,percent of total billed charges,Implant Device,6296.15,35,,6296.15,percent of total billed charges,Implant Device,6296.15,35,,6296.15,percent of total billed charges,Implant Device,6296.15,35,,6296.15,percent of total billed charges,Implant Device,6296.15,35,,6296.15,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,6116.26,34,"If Charge > 2,000, then 34 percent",6116.26,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,13311.9,
ZIMMER 5994-14-92-REV FEMORAL COMPONENT,C1776,HCPCS,,79002161,CDM,278,RC,,,both,,,20430,15118.25,,,15118.25,Other,150% of Medicare + 9.63% HCRA Surcharge,9193.5,45,,9193.5,percent of total billed charges,Critical Access Hospital RCC factor,6946.2,34,,6946.2,percent of total billed charges,Implant Device,6946.2,34,,6946.2,percent of total billed charges,Implant Device,6946.2,34,,6946.2,percent of total billed charges,Implant Device,6946.2,34,,6946.2,percent of total billed charges,Implant Device,6946.2,34,,6946.2,percent of total billed charges,Implant Device,10112.85,,,10112.85,Other,110% of Medicare,7150.5,35,,7150.5,percent of total billed charges,Implant Device,6946.2,34,"Charges > $500, x 34%",6946.2,percent of total billed charges,Implant Device,7150.5,35,,7150.5,percent of total billed charges,Implant Device,7150.5,35,,7150.5,percent of total billed charges,Implant Device,7150.5,35,,7150.5,percent of total billed charges,Implant Device,7150.5,35,,7150.5,percent of total billed charges,Implant Device,7150.5,35,,7150.5,percent of total billed charges,Implant Device,8172,40,,8172,percent of total billed charges,Implant Device,7150.5,70,,7150.5,percent of total billed charges,All Other,6946.2,34,,6946.2,percent of total billed charges,Implant Device,6946.2,34,,6946.2,percent of total billed charges,Implant Device,7150.5,35,,7150.5,percent of total billed charges,Implant Device,7150.5,35,,7150.5,percent of total billed charges,Implant Device,7150.5,35,,7150.5,percent of total billed charges,Implant Device,7150.5,35,,7150.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,6946.2,34,"If Charge > 2,000, then 34 percent",6946.2,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,15118.25,
ZIMMER 5994-15-91-REV FEMORAL COMPONENT,C1776,HCPCS,,79002162,CDM,278,RC,,,both,,,17989,13311.9,,,13311.9,Other,150% of Medicare + 9.63% HCRA Surcharge,8095.05,45,,8095.05,percent of total billed charges,Critical Access Hospital RCC factor,6116.26,34,,6116.26,percent of total billed charges,Implant Device,6116.26,34,,6116.26,percent of total billed charges,Implant Device,6116.26,34,,6116.26,percent of total billed charges,Implant Device,6116.26,34,,6116.26,percent of total billed charges,Implant Device,6116.26,34,,6116.26,percent of total billed charges,Implant Device,8904.56,,,8904.56,Other,110% of Medicare,6296.15,35,,6296.15,percent of total billed charges,Implant Device,6116.26,34,"Charges > $500, x 34%",6116.26,percent of total billed charges,Implant Device,6296.15,35,,6296.15,percent of total billed charges,Implant Device,6296.15,35,,6296.15,percent of total billed charges,Implant Device,6296.15,35,,6296.15,percent of total billed charges,Implant Device,6296.15,35,,6296.15,percent of total billed charges,Implant Device,6296.15,35,,6296.15,percent of total billed charges,Implant Device,7195.6,40,,7195.6,percent of total billed charges,Implant Device,6296.15,70,,6296.15,percent of total billed charges,All Other,6116.26,34,,6116.26,percent of total billed charges,Implant Device,6116.26,34,,6116.26,percent of total billed charges,Implant Device,6296.15,35,,6296.15,percent of total billed charges,Implant Device,6296.15,35,,6296.15,percent of total billed charges,Implant Device,6296.15,35,,6296.15,percent of total billed charges,Implant Device,6296.15,35,,6296.15,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,6116.26,34,"If Charge > 2,000, then 34 percent",6116.26,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,13311.9,
ZIMMER 5994-15-92-REV FEMORAL COMPONENT,C1776,HCPCS,,79002163,CDM,278,RC,,,both,,,18586,13753.69,,,13753.69,Other,150% of Medicare + 9.63% HCRA Surcharge,8363.7,45,,8363.7,percent of total billed charges,Critical Access Hospital RCC factor,6319.24,34,,6319.24,percent of total billed charges,Implant Device,6319.24,34,,6319.24,percent of total billed charges,Implant Device,6319.24,34,,6319.24,percent of total billed charges,Implant Device,6319.24,34,,6319.24,percent of total billed charges,Implant Device,6319.24,34,,6319.24,percent of total billed charges,Implant Device,9200.07,,,9200.07,Other,110% of Medicare,6505.1,35,,6505.1,percent of total billed charges,Implant Device,6319.24,34,"Charges > $500, x 34%",6319.24,percent of total billed charges,Implant Device,6505.1,35,,6505.1,percent of total billed charges,Implant Device,6505.1,35,,6505.1,percent of total billed charges,Implant Device,6505.1,35,,6505.1,percent of total billed charges,Implant Device,6505.1,35,,6505.1,percent of total billed charges,Implant Device,6505.1,35,,6505.1,percent of total billed charges,Implant Device,7434.4,40,,7434.4,percent of total billed charges,Implant Device,6505.1,70,,6505.1,percent of total billed charges,All Other,6319.24,34,,6319.24,percent of total billed charges,Implant Device,6319.24,34,,6319.24,percent of total billed charges,Implant Device,6505.1,35,,6505.1,percent of total billed charges,Implant Device,6505.1,35,,6505.1,percent of total billed charges,Implant Device,6505.1,35,,6505.1,percent of total billed charges,Implant Device,6505.1,35,,6505.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,6319.24,34,"If Charge > 2,000, then 34 percent",6319.24,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,13753.69,
ZIMMER 5994-17-92-REV FEMORAL COMPONENT,C1776,HCPCS,,79002164,CDM,278,RC,,,both,,,17989,13311.9,,,13311.9,Other,150% of Medicare + 9.63% HCRA Surcharge,8095.05,45,,8095.05,percent of total billed charges,Critical Access Hospital RCC factor,6116.26,34,,6116.26,percent of total billed charges,Implant Device,6116.26,34,,6116.26,percent of total billed charges,Implant Device,6116.26,34,,6116.26,percent of total billed charges,Implant Device,6116.26,34,,6116.26,percent of total billed charges,Implant Device,6116.26,34,,6116.26,percent of total billed charges,Implant Device,8904.56,,,8904.56,Other,110% of Medicare,6296.15,35,,6296.15,percent of total billed charges,Implant Device,6116.26,34,"Charges > $500, x 34%",6116.26,percent of total billed charges,Implant Device,6296.15,35,,6296.15,percent of total billed charges,Implant Device,6296.15,35,,6296.15,percent of total billed charges,Implant Device,6296.15,35,,6296.15,percent of total billed charges,Implant Device,6296.15,35,,6296.15,percent of total billed charges,Implant Device,6296.15,35,,6296.15,percent of total billed charges,Implant Device,7195.6,40,,7195.6,percent of total billed charges,Implant Device,6296.15,70,,6296.15,percent of total billed charges,All Other,6116.26,34,,6116.26,percent of total billed charges,Implant Device,6116.26,34,,6116.26,percent of total billed charges,Implant Device,6296.15,35,,6296.15,percent of total billed charges,Implant Device,6296.15,35,,6296.15,percent of total billed charges,Implant Device,6296.15,35,,6296.15,percent of total billed charges,Implant Device,6296.15,35,,6296.15,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,6116.26,34,"If Charge > 2,000, then 34 percent",6116.26,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,13311.9,
ZIMMER 5994-30-12-REV ARTICULAR SURFACE,C1776,HCPCS,,79002165,CDM,278,RC,,,both,,,6257,4630.2,,,4630.2,Other,150% of Medicare + 9.63% HCRA Surcharge,2815.65,45,,2815.65,percent of total billed charges,Critical Access Hospital RCC factor,2127.38,34,,2127.38,percent of total billed charges,Implant Device,2127.38,34,,2127.38,percent of total billed charges,Implant Device,2127.38,34,,2127.38,percent of total billed charges,Implant Device,2127.38,34,,2127.38,percent of total billed charges,Implant Device,2127.38,34,,2127.38,percent of total billed charges,Implant Device,3097.22,,,3097.22,Other,110% of Medicare,2189.95,35,,2189.95,percent of total billed charges,Implant Device,2127.38,34,"Charges > $500, x 34%",2127.38,percent of total billed charges,Implant Device,2189.95,35,,2189.95,percent of total billed charges,Implant Device,2189.95,35,,2189.95,percent of total billed charges,Implant Device,2189.95,35,,2189.95,percent of total billed charges,Implant Device,2189.95,35,,2189.95,percent of total billed charges,Implant Device,2189.95,35,,2189.95,percent of total billed charges,Implant Device,2502.8,40,,2502.8,percent of total billed charges,Implant Device,2189.95,70,,2189.95,percent of total billed charges,All Other,2127.38,34,,2127.38,percent of total billed charges,Implant Device,2127.38,34,,2127.38,percent of total billed charges,Implant Device,2189.95,35,,2189.95,percent of total billed charges,Implant Device,2189.95,35,,2189.95,percent of total billed charges,Implant Device,2189.95,35,,2189.95,percent of total billed charges,Implant Device,2189.95,35,,2189.95,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2127.38,34,"If Charge > 2,000, then 34 percent",2127.38,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4630.2,
ZIMMER 5994-30-17-REV ARTICULAR SURFACE,C1776,HCPCS,,79002166,CDM,278,RC,,,both,,,6773,5012.04,,,5012.04,Other,150% of Medicare + 9.63% HCRA Surcharge,3047.85,45,,3047.85,percent of total billed charges,Critical Access Hospital RCC factor,2302.82,34,,2302.82,percent of total billed charges,Implant Device,2302.82,34,,2302.82,percent of total billed charges,Implant Device,2302.82,34,,2302.82,percent of total billed charges,Implant Device,2302.82,34,,2302.82,percent of total billed charges,Implant Device,2302.82,34,,2302.82,percent of total billed charges,Implant Device,3352.64,,,3352.64,Other,110% of Medicare,2370.55,35,,2370.55,percent of total billed charges,Implant Device,2302.82,34,"Charges > $500, x 34%",2302.82,percent of total billed charges,Implant Device,2370.55,35,,2370.55,percent of total billed charges,Implant Device,2370.55,35,,2370.55,percent of total billed charges,Implant Device,2370.55,35,,2370.55,percent of total billed charges,Implant Device,2370.55,35,,2370.55,percent of total billed charges,Implant Device,2370.55,35,,2370.55,percent of total billed charges,Implant Device,2709.2,40,,2709.2,percent of total billed charges,Implant Device,2370.55,70,,2370.55,percent of total billed charges,All Other,2302.82,34,,2302.82,percent of total billed charges,Implant Device,2302.82,34,,2302.82,percent of total billed charges,Implant Device,2370.55,35,,2370.55,percent of total billed charges,Implant Device,2370.55,35,,2370.55,percent of total billed charges,Implant Device,2370.55,35,,2370.55,percent of total billed charges,Implant Device,2370.55,35,,2370.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2302.82,34,"If Charge > 2,000, then 34 percent",2302.82,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5012.04,
ZIMMER 5994-40-014-REV ARTICULAR SURFACE,C1776,HCPCS,,79002167,CDM,278,RC,,,both,,,6257,4630.2,,,4630.2,Other,150% of Medicare + 9.63% HCRA Surcharge,2815.65,45,,2815.65,percent of total billed charges,Critical Access Hospital RCC factor,2127.38,34,,2127.38,percent of total billed charges,Implant Device,2127.38,34,,2127.38,percent of total billed charges,Implant Device,2127.38,34,,2127.38,percent of total billed charges,Implant Device,2127.38,34,,2127.38,percent of total billed charges,Implant Device,2127.38,34,,2127.38,percent of total billed charges,Implant Device,3097.22,,,3097.22,Other,110% of Medicare,2189.95,35,,2189.95,percent of total billed charges,Implant Device,2127.38,34,"Charges > $500, x 34%",2127.38,percent of total billed charges,Implant Device,2189.95,35,,2189.95,percent of total billed charges,Implant Device,2189.95,35,,2189.95,percent of total billed charges,Implant Device,2189.95,35,,2189.95,percent of total billed charges,Implant Device,2189.95,35,,2189.95,percent of total billed charges,Implant Device,2189.95,35,,2189.95,percent of total billed charges,Implant Device,2502.8,40,,2502.8,percent of total billed charges,Implant Device,2189.95,70,,2189.95,percent of total billed charges,All Other,2127.38,34,,2127.38,percent of total billed charges,Implant Device,2127.38,34,,2127.38,percent of total billed charges,Implant Device,2189.95,35,,2189.95,percent of total billed charges,Implant Device,2189.95,35,,2189.95,percent of total billed charges,Implant Device,2189.95,35,,2189.95,percent of total billed charges,Implant Device,2189.95,35,,2189.95,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2127.38,34,"If Charge > 2,000, then 34 percent",2127.38,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4630.2,
ZIMMER 5994-50-17-REV ARTICULAR SURFACE,C1776,HCPCS,,79002168,CDM,278,RC,,,both,,,6257,4630.2,,,4630.2,Other,150% of Medicare + 9.63% HCRA Surcharge,2815.65,45,,2815.65,percent of total billed charges,Critical Access Hospital RCC factor,2127.38,34,,2127.38,percent of total billed charges,Implant Device,2127.38,34,,2127.38,percent of total billed charges,Implant Device,2127.38,34,,2127.38,percent of total billed charges,Implant Device,2127.38,34,,2127.38,percent of total billed charges,Implant Device,2127.38,34,,2127.38,percent of total billed charges,Implant Device,3097.22,,,3097.22,Other,110% of Medicare,2189.95,35,,2189.95,percent of total billed charges,Implant Device,2127.38,34,"Charges > $500, x 34%",2127.38,percent of total billed charges,Implant Device,2189.95,35,,2189.95,percent of total billed charges,Implant Device,2189.95,35,,2189.95,percent of total billed charges,Implant Device,2189.95,35,,2189.95,percent of total billed charges,Implant Device,2189.95,35,,2189.95,percent of total billed charges,Implant Device,2189.95,35,,2189.95,percent of total billed charges,Implant Device,2502.8,40,,2502.8,percent of total billed charges,Implant Device,2189.95,70,,2189.95,percent of total billed charges,All Other,2127.38,34,,2127.38,percent of total billed charges,Implant Device,2127.38,34,,2127.38,percent of total billed charges,Implant Device,2189.95,35,,2189.95,percent of total billed charges,Implant Device,2189.95,35,,2189.95,percent of total billed charges,Implant Device,2189.95,35,,2189.95,percent of total billed charges,Implant Device,2189.95,35,,2189.95,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2127.38,34,"If Charge > 2,000, then 34 percent",2127.38,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4630.2,
ZIMMER 5994-51-14-REV ARTICULAR SURFACE,C1776,HCPCS,,79002169,CDM,278,RC,,,both,,,6773,5012.04,,,5012.04,Other,150% of Medicare + 9.63% HCRA Surcharge,3047.85,45,,3047.85,percent of total billed charges,Critical Access Hospital RCC factor,2302.82,34,,2302.82,percent of total billed charges,Implant Device,2302.82,34,,2302.82,percent of total billed charges,Implant Device,2302.82,34,,2302.82,percent of total billed charges,Implant Device,2302.82,34,,2302.82,percent of total billed charges,Implant Device,2302.82,34,,2302.82,percent of total billed charges,Implant Device,3352.64,,,3352.64,Other,110% of Medicare,2370.55,35,,2370.55,percent of total billed charges,Implant Device,2302.82,34,"Charges > $500, x 34%",2302.82,percent of total billed charges,Implant Device,2370.55,35,,2370.55,percent of total billed charges,Implant Device,2370.55,35,,2370.55,percent of total billed charges,Implant Device,2370.55,35,,2370.55,percent of total billed charges,Implant Device,2370.55,35,,2370.55,percent of total billed charges,Implant Device,2370.55,35,,2370.55,percent of total billed charges,Implant Device,2709.2,40,,2709.2,percent of total billed charges,Implant Device,2370.55,70,,2370.55,percent of total billed charges,All Other,2302.82,34,,2302.82,percent of total billed charges,Implant Device,2302.82,34,,2302.82,percent of total billed charges,Implant Device,2370.55,35,,2370.55,percent of total billed charges,Implant Device,2370.55,35,,2370.55,percent of total billed charges,Implant Device,2370.55,35,,2370.55,percent of total billed charges,Implant Device,2370.55,35,,2370.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2302.82,34,"If Charge > 2,000, then 34 percent",2302.82,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5012.04,
STRYKER FOOT & ANKLE 604628S SCREW,C1713,HCPCS,,79002170,CDM,278,RC,,,both,,,882,652.68,,,652.68,Other,150% of Medicare + 9.63% HCRA Surcharge,396.9,45,,396.9,percent of total billed charges,Critical Access Hospital RCC factor,299.88,34,,299.88,percent of total billed charges,Implant Device,299.88,34,,299.88,percent of total billed charges,Implant Device,299.88,34,,299.88,percent of total billed charges,Implant Device,299.88,34,,299.88,percent of total billed charges,Implant Device,299.88,34,,299.88,percent of total billed charges,Implant Device,436.59,,,436.59,Other,110% of Medicare,308.7,35,,308.7,percent of total billed charges,Implant Device,299.88,34,"Charges > $500, x 34%",299.88,percent of total billed charges,Implant Device,308.7,35,,308.7,percent of total billed charges,Implant Device,308.7,35,,308.7,percent of total billed charges,Implant Device,308.7,35,,308.7,percent of total billed charges,Implant Device,308.7,35,,308.7,percent of total billed charges,Implant Device,308.7,35,,308.7,percent of total billed charges,Implant Device,352.8,40,,352.8,percent of total billed charges,Implant Device,308.7,70,,308.7,percent of total billed charges,All Other,299.88,34,,299.88,percent of total billed charges,Implant Device,299.88,34,,299.88,percent of total billed charges,Implant Device,308.7,35,,308.7,percent of total billed charges,Implant Device,308.7,35,,308.7,percent of total billed charges,Implant Device,308.7,35,,308.7,percent of total billed charges,Implant Device,308.7,35,,308.7,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,652.68,
STRYKER 604632S SCREW,C1713,HCPCS,,79002171,CDM,278,RC,,,both,,,446,330.04,,,330.04,Other,150% of Medicare + 9.63% HCRA Surcharge,200.7,45,,200.7,percent of total billed charges,Critical Access Hospital RCC factor,151.64,34,,151.64,percent of total billed charges,Implant Device,151.64,34,,151.64,percent of total billed charges,Implant Device,151.64,34,,151.64,percent of total billed charges,Implant Device,151.64,34,,151.64,percent of total billed charges,Implant Device,151.64,34,,151.64,percent of total billed charges,Implant Device,220.77,,,220.77,Other,110% of Medicare,156.1,35,,156.1,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,156.1,35,,156.1,percent of total billed charges,Implant Device,156.1,35,,156.1,percent of total billed charges,Implant Device,156.1,35,,156.1,percent of total billed charges,Implant Device,156.1,35,,156.1,percent of total billed charges,Implant Device,156.1,35,,156.1,percent of total billed charges,Implant Device,178.4,40,,178.4,percent of total billed charges,Implant Device,156.1,70,,156.1,percent of total billed charges,All Other,151.64,34,,151.64,percent of total billed charges,Implant Device,151.64,34,,151.64,percent of total billed charges,Implant Device,156.1,35,,156.1,percent of total billed charges,Implant Device,156.1,35,,156.1,percent of total billed charges,Implant Device,156.1,35,,156.1,percent of total billed charges,Implant Device,156.1,35,,156.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,330.04,
ZIMMER 604634S SCREW,C1713,HCPCS,,79002172,CDM,278,RC,,,both,,,446,330.04,,,330.04,Other,150% of Medicare + 9.63% HCRA Surcharge,200.7,45,,200.7,percent of total billed charges,Critical Access Hospital RCC factor,151.64,34,,151.64,percent of total billed charges,Implant Device,151.64,34,,151.64,percent of total billed charges,Implant Device,151.64,34,,151.64,percent of total billed charges,Implant Device,151.64,34,,151.64,percent of total billed charges,Implant Device,151.64,34,,151.64,percent of total billed charges,Implant Device,220.77,,,220.77,Other,110% of Medicare,156.1,35,,156.1,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,156.1,35,,156.1,percent of total billed charges,Implant Device,156.1,35,,156.1,percent of total billed charges,Implant Device,156.1,35,,156.1,percent of total billed charges,Implant Device,156.1,35,,156.1,percent of total billed charges,Implant Device,156.1,35,,156.1,percent of total billed charges,Implant Device,178.4,40,,178.4,percent of total billed charges,Implant Device,156.1,70,,156.1,percent of total billed charges,All Other,151.64,34,,151.64,percent of total billed charges,Implant Device,151.64,34,,151.64,percent of total billed charges,Implant Device,156.1,35,,156.1,percent of total billed charges,Implant Device,156.1,35,,156.1,percent of total billed charges,Implant Device,156.1,35,,156.1,percent of total billed charges,Implant Device,156.1,35,,156.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,330.04,
STRYKER 604636S SCREW,C1713,HCPCS,,79002173,CDM,278,RC,,,both,,,882,652.68,,,652.68,Other,150% of Medicare + 9.63% HCRA Surcharge,396.9,45,,396.9,percent of total billed charges,Critical Access Hospital RCC factor,299.88,34,,299.88,percent of total billed charges,Implant Device,299.88,34,,299.88,percent of total billed charges,Implant Device,299.88,34,,299.88,percent of total billed charges,Implant Device,299.88,34,,299.88,percent of total billed charges,Implant Device,299.88,34,,299.88,percent of total billed charges,Implant Device,436.59,,,436.59,Other,110% of Medicare,308.7,35,,308.7,percent of total billed charges,Implant Device,299.88,34,"Charges > $500, x 34%",299.88,percent of total billed charges,Implant Device,308.7,35,,308.7,percent of total billed charges,Implant Device,308.7,35,,308.7,percent of total billed charges,Implant Device,308.7,35,,308.7,percent of total billed charges,Implant Device,308.7,35,,308.7,percent of total billed charges,Implant Device,308.7,35,,308.7,percent of total billed charges,Implant Device,352.8,40,,352.8,percent of total billed charges,Implant Device,308.7,70,,308.7,percent of total billed charges,All Other,299.88,34,,299.88,percent of total billed charges,Implant Device,299.88,34,,299.88,percent of total billed charges,Implant Device,308.7,35,,308.7,percent of total billed charges,Implant Device,308.7,35,,308.7,percent of total billed charges,Implant Device,308.7,35,,308.7,percent of total billed charges,Implant Device,308.7,35,,308.7,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,652.68,
STRYKER 604640S SCREW,C1713,HCPCS,,79002174,CDM,278,RC,,,both,,,480,355.2,,,355.2,Other,150% of Medicare + 9.63% HCRA Surcharge,216,45,,216,percent of total billed charges,Critical Access Hospital RCC factor,163.2,34,,163.2,percent of total billed charges,Implant Device,163.2,34,,163.2,percent of total billed charges,Implant Device,163.2,34,,163.2,percent of total billed charges,Implant Device,163.2,34,,163.2,percent of total billed charges,Implant Device,163.2,34,,163.2,percent of total billed charges,Implant Device,237.6,,,237.6,Other,110% of Medicare,168,35,,168,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,192,40,,192,percent of total billed charges,Implant Device,168,70,,168,percent of total billed charges,All Other,163.2,34,,163.2,percent of total billed charges,Implant Device,163.2,34,,163.2,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,355.2,
STRYKER 6097-0530 FEMORAL STEM,C1776,HCPCS,,79002175,CDM,278,RC,,,both,,,12044,8912.59,,,8912.59,Other,150% of Medicare + 9.63% HCRA Surcharge,5419.8,45,,5419.8,percent of total billed charges,Critical Access Hospital RCC factor,4094.96,34,,4094.96,percent of total billed charges,Implant Device,4094.96,34,,4094.96,percent of total billed charges,Implant Device,4094.96,34,,4094.96,percent of total billed charges,Implant Device,4094.96,34,,4094.96,percent of total billed charges,Implant Device,4094.96,34,,4094.96,percent of total billed charges,Implant Device,5961.78,,,5961.78,Other,110% of Medicare,4215.4,35,,4215.4,percent of total billed charges,Implant Device,4094.96,34,"Charges > $500, x 34%",4094.96,percent of total billed charges,Implant Device,4215.4,35,,4215.4,percent of total billed charges,Implant Device,4215.4,35,,4215.4,percent of total billed charges,Implant Device,4215.4,35,,4215.4,percent of total billed charges,Implant Device,4215.4,35,,4215.4,percent of total billed charges,Implant Device,4215.4,35,,4215.4,percent of total billed charges,Implant Device,4817.6,40,,4817.6,percent of total billed charges,Implant Device,4215.4,70,,4215.4,percent of total billed charges,All Other,4094.96,34,,4094.96,percent of total billed charges,Implant Device,4094.96,34,,4094.96,percent of total billed charges,Implant Device,4215.4,35,,4215.4,percent of total billed charges,Implant Device,4215.4,35,,4215.4,percent of total billed charges,Implant Device,4215.4,35,,4215.4,percent of total billed charges,Implant Device,4215.4,35,,4215.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,4094.96,34,"If Charge > 2,000, then 34 percent",4094.96,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,8912.59,
STRYKER 6097-0630 FEMORAL STEM,C1776,HCPCS,,79002176,CDM,278,RC,,,both,,,5797,4289.79,,,4289.79,Other,150% of Medicare + 9.63% HCRA Surcharge,2608.65,45,,2608.65,percent of total billed charges,Critical Access Hospital RCC factor,1970.98,34,,1970.98,percent of total billed charges,Implant Device,1970.98,34,,1970.98,percent of total billed charges,Implant Device,1970.98,34,,1970.98,percent of total billed charges,Implant Device,1970.98,34,,1970.98,percent of total billed charges,Implant Device,1970.98,34,,1970.98,percent of total billed charges,Implant Device,2869.52,,,2869.52,Other,110% of Medicare,2028.95,35,,2028.95,percent of total billed charges,Implant Device,1970.98,34,"Charges > $500, x 34%",1970.98,percent of total billed charges,Implant Device,2028.95,35,,2028.95,percent of total billed charges,Implant Device,2028.95,35,,2028.95,percent of total billed charges,Implant Device,2028.95,35,,2028.95,percent of total billed charges,Implant Device,2028.95,35,,2028.95,percent of total billed charges,Implant Device,2028.95,35,,2028.95,percent of total billed charges,Implant Device,2318.8,40,,2318.8,percent of total billed charges,Implant Device,2028.95,70,,2028.95,percent of total billed charges,All Other,1970.98,34,,1970.98,percent of total billed charges,Implant Device,1970.98,34,,1970.98,percent of total billed charges,Implant Device,2028.95,35,,2028.95,percent of total billed charges,Implant Device,2028.95,35,,2028.95,percent of total billed charges,Implant Device,2028.95,35,,2028.95,percent of total billed charges,Implant Device,2028.95,35,,2028.95,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1970.98,34,"If Charge > 2,000, then 34 percent",1970.98,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4289.79,
STRYKER 6097-0735 FEMORAL STEM,C1776,HCPCS,,79002177,CDM,278,RC,,,both,,,11810,8739.43,,,8739.43,Other,150% of Medicare + 9.63% HCRA Surcharge,5314.5,45,,5314.5,percent of total billed charges,Critical Access Hospital RCC factor,4015.4,34,,4015.4,percent of total billed charges,Implant Device,4015.4,34,,4015.4,percent of total billed charges,Implant Device,4015.4,34,,4015.4,percent of total billed charges,Implant Device,4015.4,34,,4015.4,percent of total billed charges,Implant Device,4015.4,34,,4015.4,percent of total billed charges,Implant Device,5845.95,,,5845.95,Other,110% of Medicare,4133.5,35,,4133.5,percent of total billed charges,Implant Device,4015.4,34,"Charges > $500, x 34%",4015.4,percent of total billed charges,Implant Device,4133.5,35,,4133.5,percent of total billed charges,Implant Device,4133.5,35,,4133.5,percent of total billed charges,Implant Device,4133.5,35,,4133.5,percent of total billed charges,Implant Device,4133.5,35,,4133.5,percent of total billed charges,Implant Device,4133.5,35,,4133.5,percent of total billed charges,Implant Device,4724,40,,4724,percent of total billed charges,Implant Device,4133.5,70,,4133.5,percent of total billed charges,All Other,4015.4,34,,4015.4,percent of total billed charges,Implant Device,4015.4,34,,4015.4,percent of total billed charges,Implant Device,4133.5,35,,4133.5,percent of total billed charges,Implant Device,4133.5,35,,4133.5,percent of total billed charges,Implant Device,4133.5,35,,4133.5,percent of total billed charges,Implant Device,4133.5,35,,4133.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,4015.4,34,"If Charge > 2,000, then 34 percent",4015.4,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,8739.43,
STRYKER 6098-0425 FEMORAL STEM,C1776,HCPCS,,79002178,CDM,278,RC,,,both,,,13114,9704.39,,,9704.39,Other,150% of Medicare + 9.63% HCRA Surcharge,5901.3,45,,5901.3,percent of total billed charges,Critical Access Hospital RCC factor,4458.76,34,,4458.76,percent of total billed charges,Implant Device,4458.76,34,,4458.76,percent of total billed charges,Implant Device,4458.76,34,,4458.76,percent of total billed charges,Implant Device,4458.76,34,,4458.76,percent of total billed charges,Implant Device,4458.76,34,,4458.76,percent of total billed charges,Implant Device,6491.43,,,6491.43,Other,110% of Medicare,4589.9,35,,4589.9,percent of total billed charges,Implant Device,4458.76,34,"Charges > $500, x 34%",4458.76,percent of total billed charges,Implant Device,4589.9,35,,4589.9,percent of total billed charges,Implant Device,4589.9,35,,4589.9,percent of total billed charges,Implant Device,4589.9,35,,4589.9,percent of total billed charges,Implant Device,4589.9,35,,4589.9,percent of total billed charges,Implant Device,4589.9,35,,4589.9,percent of total billed charges,Implant Device,5245.6,40,,5245.6,percent of total billed charges,Implant Device,4589.9,70,,4589.9,percent of total billed charges,All Other,4458.76,34,,4458.76,percent of total billed charges,Implant Device,4458.76,34,,4458.76,percent of total billed charges,Implant Device,4589.9,35,,4589.9,percent of total billed charges,Implant Device,4589.9,35,,4589.9,percent of total billed charges,Implant Device,4589.9,35,,4589.9,percent of total billed charges,Implant Device,4589.9,35,,4589.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,4458.76,34,"If Charge > 2,000, then 34 percent",4458.76,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,9704.39,
STRYKER 6098-0530 FEMORAL STEM,C1776,HCPCS,,79002179,CDM,278,RC,,,both,,,11809,8738.69,,,8738.69,Other,150% of Medicare + 9.63% HCRA Surcharge,5314.05,45,,5314.05,percent of total billed charges,Critical Access Hospital RCC factor,4015.06,34,,4015.06,percent of total billed charges,Implant Device,4015.06,34,,4015.06,percent of total billed charges,Implant Device,4015.06,34,,4015.06,percent of total billed charges,Implant Device,4015.06,34,,4015.06,percent of total billed charges,Implant Device,4015.06,34,,4015.06,percent of total billed charges,Implant Device,5845.46,,,5845.46,Other,110% of Medicare,4133.15,35,,4133.15,percent of total billed charges,Implant Device,4015.06,34,"Charges > $500, x 34%",4015.06,percent of total billed charges,Implant Device,4133.15,35,,4133.15,percent of total billed charges,Implant Device,4133.15,35,,4133.15,percent of total billed charges,Implant Device,4133.15,35,,4133.15,percent of total billed charges,Implant Device,4133.15,35,,4133.15,percent of total billed charges,Implant Device,4133.15,35,,4133.15,percent of total billed charges,Implant Device,4723.6,40,,4723.6,percent of total billed charges,Implant Device,4133.15,70,,4133.15,percent of total billed charges,All Other,4015.06,34,,4015.06,percent of total billed charges,Implant Device,4015.06,34,,4015.06,percent of total billed charges,Implant Device,4133.15,35,,4133.15,percent of total billed charges,Implant Device,4133.15,35,,4133.15,percent of total billed charges,Implant Device,4133.15,35,,4133.15,percent of total billed charges,Implant Device,4133.15,35,,4133.15,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,4015.06,34,"If Charge > 2,000, then 34 percent",4015.06,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,8738.69,
STRYKER 6098-0735 FEMORAL STEM,C1776,HCPCS,,79002180,CDM,278,RC,,,both,,,12044,8912.59,,,8912.59,Other,150% of Medicare + 9.63% HCRA Surcharge,5419.8,45,,5419.8,percent of total billed charges,Critical Access Hospital RCC factor,4094.96,34,,4094.96,percent of total billed charges,Implant Device,4094.96,34,,4094.96,percent of total billed charges,Implant Device,4094.96,34,,4094.96,percent of total billed charges,Implant Device,4094.96,34,,4094.96,percent of total billed charges,Implant Device,4094.96,34,,4094.96,percent of total billed charges,Implant Device,5961.78,,,5961.78,Other,110% of Medicare,4215.4,35,,4215.4,percent of total billed charges,Implant Device,4094.96,34,"Charges > $500, x 34%",4094.96,percent of total billed charges,Implant Device,4215.4,35,,4215.4,percent of total billed charges,Implant Device,4215.4,35,,4215.4,percent of total billed charges,Implant Device,4215.4,35,,4215.4,percent of total billed charges,Implant Device,4215.4,35,,4215.4,percent of total billed charges,Implant Device,4215.4,35,,4215.4,percent of total billed charges,Implant Device,4817.6,40,,4817.6,percent of total billed charges,Implant Device,4215.4,70,,4215.4,percent of total billed charges,All Other,4094.96,34,,4094.96,percent of total billed charges,Implant Device,4094.96,34,,4094.96,percent of total billed charges,Implant Device,4215.4,35,,4215.4,percent of total billed charges,Implant Device,4215.4,35,,4215.4,percent of total billed charges,Implant Device,4215.4,35,,4215.4,percent of total billed charges,Implant Device,4215.4,35,,4215.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,4094.96,34,"If Charge > 2,000, then 34 percent",4094.96,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,8912.59,
EXACTECH 616-01-05 ALLOGRAFT PASTE,C1713,HCPCS,,79002182,CDM,278,RC,,,both,,,1618,1197.32,,,1197.32,Other,150% of Medicare + 9.63% HCRA Surcharge,728.1,45,,728.1,percent of total billed charges,Critical Access Hospital RCC factor,550.12,34,,550.12,percent of total billed charges,Implant Device,550.12,34,,550.12,percent of total billed charges,Implant Device,550.12,34,,550.12,percent of total billed charges,Implant Device,550.12,34,,550.12,percent of total billed charges,Implant Device,550.12,34,,550.12,percent of total billed charges,Implant Device,800.91,,,800.91,Other,110% of Medicare,566.3,35,,566.3,percent of total billed charges,Implant Device,550.12,34,"Charges > $500, x 34%",550.12,percent of total billed charges,Implant Device,566.3,35,,566.3,percent of total billed charges,Implant Device,566.3,35,,566.3,percent of total billed charges,Implant Device,566.3,35,,566.3,percent of total billed charges,Implant Device,566.3,35,,566.3,percent of total billed charges,Implant Device,566.3,35,,566.3,percent of total billed charges,Implant Device,647.2,40,,647.2,percent of total billed charges,Implant Device,566.3,70,,566.3,percent of total billed charges,All Other,550.12,34,,550.12,percent of total billed charges,Implant Device,550.12,34,,550.12,percent of total billed charges,Implant Device,566.3,35,,566.3,percent of total billed charges,Implant Device,566.3,35,,566.3,percent of total billed charges,Implant Device,566.3,35,,566.3,percent of total billed charges,Implant Device,566.3,35,,566.3,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1197.32,
PAC 3 62004-05 CURVED ROD,C1776,HCPCS,,79002183,CDM,278,RC,,,both,,,600,444,,,444,Other,150% of Medicare + 9.63% HCRA Surcharge,270,45,,270,percent of total billed charges,Critical Access Hospital RCC factor,204,34,,204,percent of total billed charges,Implant Device,204,34,,204,percent of total billed charges,Implant Device,204,34,,204,percent of total billed charges,Implant Device,204,34,,204,percent of total billed charges,Implant Device,204,34,,204,percent of total billed charges,Implant Device,297,,,297,Other,110% of Medicare,210,35,,210,percent of total billed charges,Implant Device,204,34,"Charges > $500, x 34%",204,percent of total billed charges,Implant Device,210,35,,210,percent of total billed charges,Implant Device,210,35,,210,percent of total billed charges,Implant Device,210,35,,210,percent of total billed charges,Implant Device,210,35,,210,percent of total billed charges,Implant Device,210,35,,210,percent of total billed charges,Implant Device,240,40,,240,percent of total billed charges,Implant Device,210,70,,210,percent of total billed charges,All Other,204,34,,204,percent of total billed charges,Implant Device,204,34,,204,percent of total billed charges,Implant Device,210,35,,210,percent of total billed charges,Implant Device,210,35,,210,percent of total billed charges,Implant Device,210,35,,210,percent of total billed charges,Implant Device,210,35,,210,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,444,
PAC 3 62004-06 CURVED ROD,C1776,HCPCS,,79002184,CDM,278,RC,,,both,,,600,444,,,444,Other,150% of Medicare + 9.63% HCRA Surcharge,270,45,,270,percent of total billed charges,Critical Access Hospital RCC factor,204,34,,204,percent of total billed charges,Implant Device,204,34,,204,percent of total billed charges,Implant Device,204,34,,204,percent of total billed charges,Implant Device,204,34,,204,percent of total billed charges,Implant Device,204,34,,204,percent of total billed charges,Implant Device,297,,,297,Other,110% of Medicare,210,35,,210,percent of total billed charges,Implant Device,204,34,"Charges > $500, x 34%",204,percent of total billed charges,Implant Device,210,35,,210,percent of total billed charges,Implant Device,210,35,,210,percent of total billed charges,Implant Device,210,35,,210,percent of total billed charges,Implant Device,210,35,,210,percent of total billed charges,Implant Device,210,35,,210,percent of total billed charges,Implant Device,240,40,,240,percent of total billed charges,Implant Device,210,70,,210,percent of total billed charges,All Other,204,34,,204,percent of total billed charges,Implant Device,204,34,,204,percent of total billed charges,Implant Device,210,35,,210,percent of total billed charges,Implant Device,210,35,,210,percent of total billed charges,Implant Device,210,35,,210,percent of total billed charges,Implant Device,210,35,,210,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,444,
PAC 3 62004-08 CURVED ROD,C1776,HCPCS,,79002185,CDM,278,RC,,,both,,,600,444,,,444,Other,150% of Medicare + 9.63% HCRA Surcharge,270,45,,270,percent of total billed charges,Critical Access Hospital RCC factor,204,34,,204,percent of total billed charges,Implant Device,204,34,,204,percent of total billed charges,Implant Device,204,34,,204,percent of total billed charges,Implant Device,204,34,,204,percent of total billed charges,Implant Device,204,34,,204,percent of total billed charges,Implant Device,297,,,297,Other,110% of Medicare,210,35,,210,percent of total billed charges,Implant Device,204,34,"Charges > $500, x 34%",204,percent of total billed charges,Implant Device,210,35,,210,percent of total billed charges,Implant Device,210,35,,210,percent of total billed charges,Implant Device,210,35,,210,percent of total billed charges,Implant Device,210,35,,210,percent of total billed charges,Implant Device,210,35,,210,percent of total billed charges,Implant Device,240,40,,240,percent of total billed charges,Implant Device,210,70,,210,percent of total billed charges,All Other,204,34,,204,percent of total billed charges,Implant Device,204,34,,204,percent of total billed charges,Implant Device,210,35,,210,percent of total billed charges,Implant Device,210,35,,210,percent of total billed charges,Implant Device,210,35,,210,percent of total billed charges,Implant Device,210,35,,210,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,444,
PAC 3 62004-13 CURVED ROD,C1776,HCPCS,,79002186,CDM,278,RC,,,both,,,676,500.24,,,500.24,Other,150% of Medicare + 9.63% HCRA Surcharge,304.2,45,,304.2,percent of total billed charges,Critical Access Hospital RCC factor,229.84,34,,229.84,percent of total billed charges,Implant Device,229.84,34,,229.84,percent of total billed charges,Implant Device,229.84,34,,229.84,percent of total billed charges,Implant Device,229.84,34,,229.84,percent of total billed charges,Implant Device,229.84,34,,229.84,percent of total billed charges,Implant Device,334.62,,,334.62,Other,110% of Medicare,236.6,35,,236.6,percent of total billed charges,Implant Device,229.84,34,"Charges > $500, x 34%",229.84,percent of total billed charges,Implant Device,236.6,35,,236.6,percent of total billed charges,Implant Device,236.6,35,,236.6,percent of total billed charges,Implant Device,236.6,35,,236.6,percent of total billed charges,Implant Device,236.6,35,,236.6,percent of total billed charges,Implant Device,236.6,35,,236.6,percent of total billed charges,Implant Device,270.4,40,,270.4,percent of total billed charges,Implant Device,236.6,70,,236.6,percent of total billed charges,All Other,229.84,34,,229.84,percent of total billed charges,Implant Device,229.84,34,,229.84,percent of total billed charges,Implant Device,236.6,35,,236.6,percent of total billed charges,Implant Device,236.6,35,,236.6,percent of total billed charges,Implant Device,236.6,35,,236.6,percent of total billed charges,Implant Device,236.6,35,,236.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,500.24,
PAC 3 62055-40 SCREW,C1713,HCPCS,,79002187,CDM,278,RC,,,both,,,2694,1993.57,,,1993.57,Other,150% of Medicare + 9.63% HCRA Surcharge,1212.3,45,,1212.3,percent of total billed charges,Critical Access Hospital RCC factor,915.96,34,,915.96,percent of total billed charges,Implant Device,915.96,34,,915.96,percent of total billed charges,Implant Device,915.96,34,,915.96,percent of total billed charges,Implant Device,915.96,34,,915.96,percent of total billed charges,Implant Device,915.96,34,,915.96,percent of total billed charges,Implant Device,1333.53,,,1333.53,Other,110% of Medicare,942.9,35,,942.9,percent of total billed charges,Implant Device,915.96,34,"Charges > $500, x 34%",915.96,percent of total billed charges,Implant Device,942.9,35,,942.9,percent of total billed charges,Implant Device,942.9,35,,942.9,percent of total billed charges,Implant Device,942.9,35,,942.9,percent of total billed charges,Implant Device,942.9,35,,942.9,percent of total billed charges,Implant Device,942.9,35,,942.9,percent of total billed charges,Implant Device,1077.6,40,,1077.6,percent of total billed charges,Implant Device,942.9,70,,942.9,percent of total billed charges,All Other,915.96,34,,915.96,percent of total billed charges,Implant Device,915.96,34,,915.96,percent of total billed charges,Implant Device,942.9,35,,942.9,percent of total billed charges,Implant Device,942.9,35,,942.9,percent of total billed charges,Implant Device,942.9,35,,942.9,percent of total billed charges,Implant Device,942.9,35,,942.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,915.96,34,"If Charge > 2,000, then 34 percent",915.96,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1993.57,
PAC 3 62055-45 SCREW,C1713,HCPCS,,79002188,CDM,278,RC,,,both,,,2550,1887.01,,,1887.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1147.5,45,,1147.5,percent of total billed charges,Critical Access Hospital RCC factor,867,34,,867,percent of total billed charges,Implant Device,867,34,,867,percent of total billed charges,Implant Device,867,34,,867,percent of total billed charges,Implant Device,867,34,,867,percent of total billed charges,Implant Device,867,34,,867,percent of total billed charges,Implant Device,1262.25,,,1262.25,Other,110% of Medicare,892.5,35,,892.5,percent of total billed charges,Implant Device,867,34,"Charges > $500, x 34%",867,percent of total billed charges,Implant Device,892.5,35,,892.5,percent of total billed charges,Implant Device,892.5,35,,892.5,percent of total billed charges,Implant Device,892.5,35,,892.5,percent of total billed charges,Implant Device,892.5,35,,892.5,percent of total billed charges,Implant Device,892.5,35,,892.5,percent of total billed charges,Implant Device,1020,40,,1020,percent of total billed charges,Implant Device,892.5,70,,892.5,percent of total billed charges,All Other,867,34,,867,percent of total billed charges,Implant Device,867,34,,867,percent of total billed charges,Implant Device,892.5,35,,892.5,percent of total billed charges,Implant Device,892.5,35,,892.5,percent of total billed charges,Implant Device,892.5,35,,892.5,percent of total billed charges,Implant Device,892.5,35,,892.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,867,34,"If Charge > 2,000, then 34 percent",867,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1887.01,
PAC 3 62055-50 SCREW,C1713,HCPCS,,79002189,CDM,278,RC,,,both,,,2550,1887.01,,,1887.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1147.5,45,,1147.5,percent of total billed charges,Critical Access Hospital RCC factor,867,34,,867,percent of total billed charges,Implant Device,867,34,,867,percent of total billed charges,Implant Device,867,34,,867,percent of total billed charges,Implant Device,867,34,,867,percent of total billed charges,Implant Device,867,34,,867,percent of total billed charges,Implant Device,1262.25,,,1262.25,Other,110% of Medicare,892.5,35,,892.5,percent of total billed charges,Implant Device,867,34,"Charges > $500, x 34%",867,percent of total billed charges,Implant Device,892.5,35,,892.5,percent of total billed charges,Implant Device,892.5,35,,892.5,percent of total billed charges,Implant Device,892.5,35,,892.5,percent of total billed charges,Implant Device,892.5,35,,892.5,percent of total billed charges,Implant Device,892.5,35,,892.5,percent of total billed charges,Implant Device,1020,40,,1020,percent of total billed charges,Implant Device,892.5,70,,892.5,percent of total billed charges,All Other,867,34,,867,percent of total billed charges,Implant Device,867,34,,867,percent of total billed charges,Implant Device,892.5,35,,892.5,percent of total billed charges,Implant Device,892.5,35,,892.5,percent of total billed charges,Implant Device,892.5,35,,892.5,percent of total billed charges,Implant Device,892.5,35,,892.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,867,34,"If Charge > 2,000, then 34 percent",867,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1887.01,
PAC 3 62065-35 SCREW,C1713,HCPCS,,79002190,CDM,278,RC,,,both,,,2550,1887.01,,,1887.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1147.5,45,,1147.5,percent of total billed charges,Critical Access Hospital RCC factor,867,34,,867,percent of total billed charges,Implant Device,867,34,,867,percent of total billed charges,Implant Device,867,34,,867,percent of total billed charges,Implant Device,867,34,,867,percent of total billed charges,Implant Device,867,34,,867,percent of total billed charges,Implant Device,1262.25,,,1262.25,Other,110% of Medicare,892.5,35,,892.5,percent of total billed charges,Implant Device,867,34,"Charges > $500, x 34%",867,percent of total billed charges,Implant Device,892.5,35,,892.5,percent of total billed charges,Implant Device,892.5,35,,892.5,percent of total billed charges,Implant Device,892.5,35,,892.5,percent of total billed charges,Implant Device,892.5,35,,892.5,percent of total billed charges,Implant Device,892.5,35,,892.5,percent of total billed charges,Implant Device,1020,40,,1020,percent of total billed charges,Implant Device,892.5,70,,892.5,percent of total billed charges,All Other,867,34,,867,percent of total billed charges,Implant Device,867,34,,867,percent of total billed charges,Implant Device,892.5,35,,892.5,percent of total billed charges,Implant Device,892.5,35,,892.5,percent of total billed charges,Implant Device,892.5,35,,892.5,percent of total billed charges,Implant Device,892.5,35,,892.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,867,34,"If Charge > 2,000, then 34 percent",867,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1887.01,
PAC 3 62065-45 SCREW,C1713,HCPCS,,79002191,CDM,278,RC,,,both,,,2550,1887.01,,,1887.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1147.5,45,,1147.5,percent of total billed charges,Critical Access Hospital RCC factor,867,34,,867,percent of total billed charges,Implant Device,867,34,,867,percent of total billed charges,Implant Device,867,34,,867,percent of total billed charges,Implant Device,867,34,,867,percent of total billed charges,Implant Device,867,34,,867,percent of total billed charges,Implant Device,1262.25,,,1262.25,Other,110% of Medicare,892.5,35,,892.5,percent of total billed charges,Implant Device,867,34,"Charges > $500, x 34%",867,percent of total billed charges,Implant Device,892.5,35,,892.5,percent of total billed charges,Implant Device,892.5,35,,892.5,percent of total billed charges,Implant Device,892.5,35,,892.5,percent of total billed charges,Implant Device,892.5,35,,892.5,percent of total billed charges,Implant Device,892.5,35,,892.5,percent of total billed charges,Implant Device,1020,40,,1020,percent of total billed charges,Implant Device,892.5,70,,892.5,percent of total billed charges,All Other,867,34,,867,percent of total billed charges,Implant Device,867,34,,867,percent of total billed charges,Implant Device,892.5,35,,892.5,percent of total billed charges,Implant Device,892.5,35,,892.5,percent of total billed charges,Implant Device,892.5,35,,892.5,percent of total billed charges,Implant Device,892.5,35,,892.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,867,34,"If Charge > 2,000, then 34 percent",867,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1887.01,
PAC 3 62065-50 SCREW,C1713,HCPCS,,79002192,CDM,278,RC,,,both,,,2550,1887.01,,,1887.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1147.5,45,,1147.5,percent of total billed charges,Critical Access Hospital RCC factor,867,34,,867,percent of total billed charges,Implant Device,867,34,,867,percent of total billed charges,Implant Device,867,34,,867,percent of total billed charges,Implant Device,867,34,,867,percent of total billed charges,Implant Device,867,34,,867,percent of total billed charges,Implant Device,1262.25,,,1262.25,Other,110% of Medicare,892.5,35,,892.5,percent of total billed charges,Implant Device,867,34,"Charges > $500, x 34%",867,percent of total billed charges,Implant Device,892.5,35,,892.5,percent of total billed charges,Implant Device,892.5,35,,892.5,percent of total billed charges,Implant Device,892.5,35,,892.5,percent of total billed charges,Implant Device,892.5,35,,892.5,percent of total billed charges,Implant Device,892.5,35,,892.5,percent of total billed charges,Implant Device,1020,40,,1020,percent of total billed charges,Implant Device,892.5,70,,892.5,percent of total billed charges,All Other,867,34,,867,percent of total billed charges,Implant Device,867,34,,867,percent of total billed charges,Implant Device,892.5,35,,892.5,percent of total billed charges,Implant Device,892.5,35,,892.5,percent of total billed charges,Implant Device,892.5,35,,892.5,percent of total billed charges,Implant Device,892.5,35,,892.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,867,34,"If Charge > 2,000, then 34 percent",867,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1887.01,
PAC 3 62065-55 SCREW,C1713,HCPCS,,79002193,CDM,278,RC,,,both,,,2550,1887.01,,,1887.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1147.5,45,,1147.5,percent of total billed charges,Critical Access Hospital RCC factor,867,34,,867,percent of total billed charges,Implant Device,867,34,,867,percent of total billed charges,Implant Device,867,34,,867,percent of total billed charges,Implant Device,867,34,,867,percent of total billed charges,Implant Device,867,34,,867,percent of total billed charges,Implant Device,1262.25,,,1262.25,Other,110% of Medicare,892.5,35,,892.5,percent of total billed charges,Implant Device,867,34,"Charges > $500, x 34%",867,percent of total billed charges,Implant Device,892.5,35,,892.5,percent of total billed charges,Implant Device,892.5,35,,892.5,percent of total billed charges,Implant Device,892.5,35,,892.5,percent of total billed charges,Implant Device,892.5,35,,892.5,percent of total billed charges,Implant Device,892.5,35,,892.5,percent of total billed charges,Implant Device,1020,40,,1020,percent of total billed charges,Implant Device,892.5,70,,892.5,percent of total billed charges,All Other,867,34,,867,percent of total billed charges,Implant Device,867,34,,867,percent of total billed charges,Implant Device,892.5,35,,892.5,percent of total billed charges,Implant Device,892.5,35,,892.5,percent of total billed charges,Implant Device,892.5,35,,892.5,percent of total billed charges,Implant Device,892.5,35,,892.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,867,34,"If Charge > 2,000, then 34 percent",867,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1887.01,
PAC 3 62075-35 SCREW,C1713,HCPCS,,79002194,CDM,278,RC,,,both,,,2550,1887.01,,,1887.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1147.5,45,,1147.5,percent of total billed charges,Critical Access Hospital RCC factor,867,34,,867,percent of total billed charges,Implant Device,867,34,,867,percent of total billed charges,Implant Device,867,34,,867,percent of total billed charges,Implant Device,867,34,,867,percent of total billed charges,Implant Device,867,34,,867,percent of total billed charges,Implant Device,1262.25,,,1262.25,Other,110% of Medicare,892.5,35,,892.5,percent of total billed charges,Implant Device,867,34,"Charges > $500, x 34%",867,percent of total billed charges,Implant Device,892.5,35,,892.5,percent of total billed charges,Implant Device,892.5,35,,892.5,percent of total billed charges,Implant Device,892.5,35,,892.5,percent of total billed charges,Implant Device,892.5,35,,892.5,percent of total billed charges,Implant Device,892.5,35,,892.5,percent of total billed charges,Implant Device,1020,40,,1020,percent of total billed charges,Implant Device,892.5,70,,892.5,percent of total billed charges,All Other,867,34,,867,percent of total billed charges,Implant Device,867,34,,867,percent of total billed charges,Implant Device,892.5,35,,892.5,percent of total billed charges,Implant Device,892.5,35,,892.5,percent of total billed charges,Implant Device,892.5,35,,892.5,percent of total billed charges,Implant Device,892.5,35,,892.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,867,34,"If Charge > 2,000, then 34 percent",867,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1887.01,
PAC 3 62075-40 SCREW,C1713,HCPCS,,79002195,CDM,278,RC,,,both,,,2550,1887.01,,,1887.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1147.5,45,,1147.5,percent of total billed charges,Critical Access Hospital RCC factor,867,34,,867,percent of total billed charges,Implant Device,867,34,,867,percent of total billed charges,Implant Device,867,34,,867,percent of total billed charges,Implant Device,867,34,,867,percent of total billed charges,Implant Device,867,34,,867,percent of total billed charges,Implant Device,1262.25,,,1262.25,Other,110% of Medicare,892.5,35,,892.5,percent of total billed charges,Implant Device,867,34,"Charges > $500, x 34%",867,percent of total billed charges,Implant Device,892.5,35,,892.5,percent of total billed charges,Implant Device,892.5,35,,892.5,percent of total billed charges,Implant Device,892.5,35,,892.5,percent of total billed charges,Implant Device,892.5,35,,892.5,percent of total billed charges,Implant Device,892.5,35,,892.5,percent of total billed charges,Implant Device,1020,40,,1020,percent of total billed charges,Implant Device,892.5,70,,892.5,percent of total billed charges,All Other,867,34,,867,percent of total billed charges,Implant Device,867,34,,867,percent of total billed charges,Implant Device,892.5,35,,892.5,percent of total billed charges,Implant Device,892.5,35,,892.5,percent of total billed charges,Implant Device,892.5,35,,892.5,percent of total billed charges,Implant Device,892.5,35,,892.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,867,34,"If Charge > 2,000, then 34 percent",867,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1887.01,
STRYKER 623-00-36D-REV INSERT,C1776,HCPCS,,79002196,CDM,278,RC,,,both,,,2503,1852.23,,,1852.23,Other,150% of Medicare + 9.63% HCRA Surcharge,1126.35,45,,1126.35,percent of total billed charges,Critical Access Hospital RCC factor,851.02,34,,851.02,percent of total billed charges,Implant Device,851.02,34,,851.02,percent of total billed charges,Implant Device,851.02,34,,851.02,percent of total billed charges,Implant Device,851.02,34,,851.02,percent of total billed charges,Implant Device,851.02,34,,851.02,percent of total billed charges,Implant Device,1238.99,,,1238.99,Other,110% of Medicare,876.05,35,,876.05,percent of total billed charges,Implant Device,851.02,34,"Charges > $500, x 34%",851.02,percent of total billed charges,Implant Device,876.05,35,,876.05,percent of total billed charges,Implant Device,876.05,35,,876.05,percent of total billed charges,Implant Device,876.05,35,,876.05,percent of total billed charges,Implant Device,876.05,35,,876.05,percent of total billed charges,Implant Device,876.05,35,,876.05,percent of total billed charges,Implant Device,1001.2,40,,1001.2,percent of total billed charges,Implant Device,876.05,70,,876.05,percent of total billed charges,All Other,851.02,34,,851.02,percent of total billed charges,Implant Device,851.02,34,,851.02,percent of total billed charges,Implant Device,876.05,35,,876.05,percent of total billed charges,Implant Device,876.05,35,,876.05,percent of total billed charges,Implant Device,876.05,35,,876.05,percent of total billed charges,Implant Device,876.05,35,,876.05,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,851.02,34,"If Charge > 2,000, then 34 percent",851.02,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1852.23,
STRYKER 623-00-40E INSERT,C1776,HCPCS,,79002197,CDM,278,RC,,,both,,,3300,2442.01,,,2442.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1485,45,,1485,percent of total billed charges,Critical Access Hospital RCC factor,1122,34,,1122,percent of total billed charges,Implant Device,1122,34,,1122,percent of total billed charges,Implant Device,1122,34,,1122,percent of total billed charges,Implant Device,1122,34,,1122,percent of total billed charges,Implant Device,1122,34,,1122,percent of total billed charges,Implant Device,1633.5,,,1633.5,Other,110% of Medicare,1155,35,,1155,percent of total billed charges,Implant Device,1122,34,"Charges > $500, x 34%",1122,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,1320,40,,1320,percent of total billed charges,Implant Device,1155,70,,1155,percent of total billed charges,All Other,1122,34,,1122,percent of total billed charges,Implant Device,1122,34,,1122,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1122,34,"If Charge > 2,000, then 34 percent",1122,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2442.01,
DEPUY 62-3421-REV KNEE SYSTEM,C1776,HCPCS,,79002198,CDM,278,RC,,,both,,,21192,15682.13,,,15682.13,Other,150% of Medicare + 9.63% HCRA Surcharge,9536.4,45,,9536.4,percent of total billed charges,Critical Access Hospital RCC factor,7205.28,34,,7205.28,percent of total billed charges,Implant Device,7205.28,34,,7205.28,percent of total billed charges,Implant Device,7205.28,34,,7205.28,percent of total billed charges,Implant Device,7205.28,34,,7205.28,percent of total billed charges,Implant Device,7205.28,34,,7205.28,percent of total billed charges,Implant Device,10490.04,,,10490.04,Other,110% of Medicare,7417.2,35,,7417.2,percent of total billed charges,Implant Device,7205.28,34,"Charges > $500, x 34%",7205.28,percent of total billed charges,Implant Device,7417.2,35,,7417.2,percent of total billed charges,Implant Device,7417.2,35,,7417.2,percent of total billed charges,Implant Device,7417.2,35,,7417.2,percent of total billed charges,Implant Device,7417.2,35,,7417.2,percent of total billed charges,Implant Device,7417.2,35,,7417.2,percent of total billed charges,Implant Device,8476.8,40,,8476.8,percent of total billed charges,Implant Device,7417.2,70,,7417.2,percent of total billed charges,All Other,7205.28,34,,7205.28,percent of total billed charges,Implant Device,7205.28,34,,7205.28,percent of total billed charges,Implant Device,7417.2,35,,7417.2,percent of total billed charges,Implant Device,7417.2,35,,7417.2,percent of total billed charges,Implant Device,7417.2,35,,7417.2,percent of total billed charges,Implant Device,7417.2,35,,7417.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,7205.28,34,"If Charge > 2,000, then 34 percent",7205.28,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,15682.13,
DEPUY 62-3805-REV FEMORAL AUGMENT,C1776,HCPCS,,79002199,CDM,278,RC,,,both,,,2653,1963.23,,,1963.23,Other,150% of Medicare + 9.63% HCRA Surcharge,1193.85,45,,1193.85,percent of total billed charges,Critical Access Hospital RCC factor,902.02,34,,902.02,percent of total billed charges,Implant Device,902.02,34,,902.02,percent of total billed charges,Implant Device,902.02,34,,902.02,percent of total billed charges,Implant Device,902.02,34,,902.02,percent of total billed charges,Implant Device,902.02,34,,902.02,percent of total billed charges,Implant Device,1313.24,,,1313.24,Other,110% of Medicare,928.55,35,,928.55,percent of total billed charges,Implant Device,902.02,34,"Charges > $500, x 34%",902.02,percent of total billed charges,Implant Device,928.55,35,,928.55,percent of total billed charges,Implant Device,928.55,35,,928.55,percent of total billed charges,Implant Device,928.55,35,,928.55,percent of total billed charges,Implant Device,928.55,35,,928.55,percent of total billed charges,Implant Device,928.55,35,,928.55,percent of total billed charges,Implant Device,1061.2,40,,1061.2,percent of total billed charges,Implant Device,928.55,70,,928.55,percent of total billed charges,All Other,902.02,34,,902.02,percent of total billed charges,Implant Device,902.02,34,,902.02,percent of total billed charges,Implant Device,928.55,35,,928.55,percent of total billed charges,Implant Device,928.55,35,,928.55,percent of total billed charges,Implant Device,928.55,35,,928.55,percent of total billed charges,Implant Device,928.55,35,,928.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,902.02,34,"If Charge > 2,000, then 34 percent",902.02,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1963.23,
DEPUY 62-3810-REV FEMORAL AUGMENT,C1776,HCPCS,,79002200,CDM,278,RC,,,both,,,2653,1963.23,,,1963.23,Other,150% of Medicare + 9.63% HCRA Surcharge,1193.85,45,,1193.85,percent of total billed charges,Critical Access Hospital RCC factor,902.02,34,,902.02,percent of total billed charges,Implant Device,902.02,34,,902.02,percent of total billed charges,Implant Device,902.02,34,,902.02,percent of total billed charges,Implant Device,902.02,34,,902.02,percent of total billed charges,Implant Device,902.02,34,,902.02,percent of total billed charges,Implant Device,1313.24,,,1313.24,Other,110% of Medicare,928.55,35,,928.55,percent of total billed charges,Implant Device,902.02,34,"Charges > $500, x 34%",902.02,percent of total billed charges,Implant Device,928.55,35,,928.55,percent of total billed charges,Implant Device,928.55,35,,928.55,percent of total billed charges,Implant Device,928.55,35,,928.55,percent of total billed charges,Implant Device,928.55,35,,928.55,percent of total billed charges,Implant Device,928.55,35,,928.55,percent of total billed charges,Implant Device,1061.2,40,,1061.2,percent of total billed charges,Implant Device,928.55,70,,928.55,percent of total billed charges,All Other,902.02,34,,902.02,percent of total billed charges,Implant Device,902.02,34,,902.02,percent of total billed charges,Implant Device,928.55,35,,928.55,percent of total billed charges,Implant Device,928.55,35,,928.55,percent of total billed charges,Implant Device,928.55,35,,928.55,percent of total billed charges,Implant Device,928.55,35,,928.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,902.02,34,"If Charge > 2,000, then 34 percent",902.02,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1963.23,
ZIMMER 6250-65-20-REV SCREW,C1713,HCPCS,,79002202,CDM,278,RC,,,both,,,427,315.98,,,315.98,Other,150% of Medicare + 9.63% HCRA Surcharge,192.15,45,,192.15,percent of total billed charges,Critical Access Hospital RCC factor,145.18,34,,145.18,percent of total billed charges,Implant Device,145.18,34,,145.18,percent of total billed charges,Implant Device,145.18,34,,145.18,percent of total billed charges,Implant Device,145.18,34,,145.18,percent of total billed charges,Implant Device,145.18,34,,145.18,percent of total billed charges,Implant Device,211.37,,,211.37,Other,110% of Medicare,149.45,35,,149.45,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,149.45,35,,149.45,percent of total billed charges,Implant Device,149.45,35,,149.45,percent of total billed charges,Implant Device,149.45,35,,149.45,percent of total billed charges,Implant Device,149.45,35,,149.45,percent of total billed charges,Implant Device,149.45,35,,149.45,percent of total billed charges,Implant Device,170.8,40,,170.8,percent of total billed charges,Implant Device,149.45,70,,149.45,percent of total billed charges,All Other,145.18,34,,145.18,percent of total billed charges,Implant Device,145.18,34,,145.18,percent of total billed charges,Implant Device,149.45,35,,149.45,percent of total billed charges,Implant Device,149.45,35,,149.45,percent of total billed charges,Implant Device,149.45,35,,149.45,percent of total billed charges,Implant Device,149.45,35,,149.45,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,315.98,
ZIMMER 6250-65-25-REV SCREW,C1713,HCPCS,,79002203,CDM,278,RC,,,both,,,96,71.04,,,71.04,Other,150% of Medicare + 9.63% HCRA Surcharge,43.2,45,,43.2,percent of total billed charges,Critical Access Hospital RCC factor,32.64,34,,32.64,percent of total billed charges,Implant Device,32.64,34,,32.64,percent of total billed charges,Implant Device,32.64,34,,32.64,percent of total billed charges,Implant Device,32.64,34,,32.64,percent of total billed charges,Implant Device,32.64,34,,32.64,percent of total billed charges,Implant Device,47.52,,,47.52,Other,110% of Medicare,33.6,35,,33.6,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,33.6,35,,33.6,percent of total billed charges,Implant Device,33.6,35,,33.6,percent of total billed charges,Implant Device,33.6,35,,33.6,percent of total billed charges,Implant Device,33.6,35,,33.6,percent of total billed charges,Implant Device,33.6,35,,33.6,percent of total billed charges,Implant Device,38.4,40,,38.4,percent of total billed charges,Implant Device,33.6,70,,33.6,percent of total billed charges,All Other,32.64,34,,32.64,percent of total billed charges,Implant Device,32.64,34,,32.64,percent of total billed charges,Implant Device,33.6,35,,33.6,percent of total billed charges,Implant Device,33.6,35,,33.6,percent of total billed charges,Implant Device,33.6,35,,33.6,percent of total billed charges,Implant Device,33.6,35,,33.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,71.04,
ZIMMER 6250-65-30-REV SCREW,C1713,HCPCS,,79002204,CDM,278,RC,,,both,,,243,179.82,,,179.82,Other,150% of Medicare + 9.63% HCRA Surcharge,109.35,45,,109.35,percent of total billed charges,Critical Access Hospital RCC factor,82.62,34,,82.62,percent of total billed charges,Implant Device,82.62,34,,82.62,percent of total billed charges,Implant Device,82.62,34,,82.62,percent of total billed charges,Implant Device,82.62,34,,82.62,percent of total billed charges,Implant Device,82.62,34,,82.62,percent of total billed charges,Implant Device,120.29,,,120.29,Other,110% of Medicare,85.05,35,,85.05,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,85.05,35,,85.05,percent of total billed charges,Implant Device,85.05,35,,85.05,percent of total billed charges,Implant Device,85.05,35,,85.05,percent of total billed charges,Implant Device,85.05,35,,85.05,percent of total billed charges,Implant Device,85.05,35,,85.05,percent of total billed charges,Implant Device,97.2,40,,97.2,percent of total billed charges,Implant Device,85.05,70,,85.05,percent of total billed charges,All Other,82.62,34,,82.62,percent of total billed charges,Implant Device,82.62,34,,82.62,percent of total billed charges,Implant Device,85.05,35,,85.05,percent of total billed charges,Implant Device,85.05,35,,85.05,percent of total billed charges,Implant Device,85.05,35,,85.05,percent of total billed charges,Implant Device,85.05,35,,85.05,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,179.82,
ZIMMER 6250-65-35-REV SCREW,C1713,HCPCS,,79002205,CDM,278,RC,,,both,,,96,71.04,,,71.04,Other,150% of Medicare + 9.63% HCRA Surcharge,43.2,45,,43.2,percent of total billed charges,Critical Access Hospital RCC factor,32.64,34,,32.64,percent of total billed charges,Implant Device,32.64,34,,32.64,percent of total billed charges,Implant Device,32.64,34,,32.64,percent of total billed charges,Implant Device,32.64,34,,32.64,percent of total billed charges,Implant Device,32.64,34,,32.64,percent of total billed charges,Implant Device,47.52,,,47.52,Other,110% of Medicare,33.6,35,,33.6,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,33.6,35,,33.6,percent of total billed charges,Implant Device,33.6,35,,33.6,percent of total billed charges,Implant Device,33.6,35,,33.6,percent of total billed charges,Implant Device,33.6,35,,33.6,percent of total billed charges,Implant Device,33.6,35,,33.6,percent of total billed charges,Implant Device,38.4,40,,38.4,percent of total billed charges,Implant Device,33.6,70,,33.6,percent of total billed charges,All Other,32.64,34,,32.64,percent of total billed charges,Implant Device,32.64,34,,32.64,percent of total billed charges,Implant Device,33.6,35,,33.6,percent of total billed charges,Implant Device,33.6,35,,33.6,percent of total billed charges,Implant Device,33.6,35,,33.6,percent of total billed charges,Implant Device,33.6,35,,33.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,71.04,
ZIMMER 6250-65-40-REV SCREW,C1713,HCPCS,,79002206,CDM,278,RC,,,both,,,243,179.82,,,179.82,Other,150% of Medicare + 9.63% HCRA Surcharge,109.35,45,,109.35,percent of total billed charges,Critical Access Hospital RCC factor,82.62,34,,82.62,percent of total billed charges,Implant Device,82.62,34,,82.62,percent of total billed charges,Implant Device,82.62,34,,82.62,percent of total billed charges,Implant Device,82.62,34,,82.62,percent of total billed charges,Implant Device,82.62,34,,82.62,percent of total billed charges,Implant Device,120.29,,,120.29,Other,110% of Medicare,85.05,35,,85.05,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,85.05,35,,85.05,percent of total billed charges,Implant Device,85.05,35,,85.05,percent of total billed charges,Implant Device,85.05,35,,85.05,percent of total billed charges,Implant Device,85.05,35,,85.05,percent of total billed charges,Implant Device,85.05,35,,85.05,percent of total billed charges,Implant Device,97.2,40,,97.2,percent of total billed charges,Implant Device,85.05,70,,85.05,percent of total billed charges,All Other,82.62,34,,82.62,percent of total billed charges,Implant Device,82.62,34,,82.62,percent of total billed charges,Implant Device,85.05,35,,85.05,percent of total billed charges,Implant Device,85.05,35,,85.05,percent of total billed charges,Implant Device,85.05,35,,85.05,percent of total billed charges,Implant Device,85.05,35,,85.05,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,179.82,
ZIMMER 6250-65-50-REV SCREW,C1713,HCPCS,,79002207,CDM,278,RC,,,both,,,427,315.98,,,315.98,Other,150% of Medicare + 9.63% HCRA Surcharge,192.15,45,,192.15,percent of total billed charges,Critical Access Hospital RCC factor,145.18,34,,145.18,percent of total billed charges,Implant Device,145.18,34,,145.18,percent of total billed charges,Implant Device,145.18,34,,145.18,percent of total billed charges,Implant Device,145.18,34,,145.18,percent of total billed charges,Implant Device,145.18,34,,145.18,percent of total billed charges,Implant Device,211.37,,,211.37,Other,110% of Medicare,149.45,35,,149.45,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,149.45,35,,149.45,percent of total billed charges,Implant Device,149.45,35,,149.45,percent of total billed charges,Implant Device,149.45,35,,149.45,percent of total billed charges,Implant Device,149.45,35,,149.45,percent of total billed charges,Implant Device,149.45,35,,149.45,percent of total billed charges,Implant Device,170.8,40,,170.8,percent of total billed charges,Implant Device,149.45,70,,149.45,percent of total billed charges,All Other,145.18,34,,145.18,percent of total billed charges,Implant Device,145.18,34,,145.18,percent of total billed charges,Implant Device,149.45,35,,149.45,percent of total billed charges,Implant Device,149.45,35,,149.45,percent of total billed charges,Implant Device,149.45,35,,149.45,percent of total billed charges,Implant Device,149.45,35,,149.45,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,315.98,
STRYKER 6259-8-100 STEM CENTRALIZER,C1776,HCPCS,,79002208,CDM,278,RC,,,both,,,497,367.78,,,367.78,Other,150% of Medicare + 9.63% HCRA Surcharge,223.65,45,,223.65,percent of total billed charges,Critical Access Hospital RCC factor,168.98,34,,168.98,percent of total billed charges,Implant Device,168.98,34,,168.98,percent of total billed charges,Implant Device,168.98,34,,168.98,percent of total billed charges,Implant Device,168.98,34,,168.98,percent of total billed charges,Implant Device,168.98,34,,168.98,percent of total billed charges,Implant Device,246.02,,,246.02,Other,110% of Medicare,173.95,35,,173.95,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,173.95,35,,173.95,percent of total billed charges,Implant Device,173.95,35,,173.95,percent of total billed charges,Implant Device,173.95,35,,173.95,percent of total billed charges,Implant Device,173.95,35,,173.95,percent of total billed charges,Implant Device,173.95,35,,173.95,percent of total billed charges,Implant Device,198.8,40,,198.8,percent of total billed charges,Implant Device,173.95,70,,173.95,percent of total billed charges,All Other,168.98,34,,168.98,percent of total billed charges,Implant Device,168.98,34,,168.98,percent of total billed charges,Implant Device,173.95,35,,173.95,percent of total billed charges,Implant Device,173.95,35,,173.95,percent of total billed charges,Implant Device,173.95,35,,173.95,percent of total billed charges,Implant Device,173.95,35,,173.95,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,367.78,
STRYKER 6259-8-110 STEM CENTRALIZER,C1776,HCPCS,,79002209,CDM,278,RC,,,both,,,486,359.64,,,359.64,Other,150% of Medicare + 9.63% HCRA Surcharge,218.7,45,,218.7,percent of total billed charges,Critical Access Hospital RCC factor,165.24,34,,165.24,percent of total billed charges,Implant Device,165.24,34,,165.24,percent of total billed charges,Implant Device,165.24,34,,165.24,percent of total billed charges,Implant Device,165.24,34,,165.24,percent of total billed charges,Implant Device,165.24,34,,165.24,percent of total billed charges,Implant Device,240.57,,,240.57,Other,110% of Medicare,170.1,35,,170.1,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,170.1,35,,170.1,percent of total billed charges,Implant Device,170.1,35,,170.1,percent of total billed charges,Implant Device,170.1,35,,170.1,percent of total billed charges,Implant Device,170.1,35,,170.1,percent of total billed charges,Implant Device,170.1,35,,170.1,percent of total billed charges,Implant Device,194.4,40,,194.4,percent of total billed charges,Implant Device,170.1,70,,170.1,percent of total billed charges,All Other,165.24,34,,165.24,percent of total billed charges,Implant Device,165.24,34,,165.24,percent of total billed charges,Implant Device,170.1,35,,170.1,percent of total billed charges,Implant Device,170.1,35,,170.1,percent of total billed charges,Implant Device,170.1,35,,170.1,percent of total billed charges,Implant Device,170.1,35,,170.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,359.64,
STRYKER 626-00-42E LINER,C1776,HCPCS,,79002210,CDM,278,RC,,,both,,,3893,2880.83,,,2880.83,Other,150% of Medicare + 9.63% HCRA Surcharge,1751.85,45,,1751.85,percent of total billed charges,Critical Access Hospital RCC factor,1323.62,34,,1323.62,percent of total billed charges,Implant Device,1323.62,34,,1323.62,percent of total billed charges,Implant Device,1323.62,34,,1323.62,percent of total billed charges,Implant Device,1323.62,34,,1323.62,percent of total billed charges,Implant Device,1323.62,34,,1323.62,percent of total billed charges,Implant Device,1927.04,,,1927.04,Other,110% of Medicare,1362.55,35,,1362.55,percent of total billed charges,Implant Device,1323.62,34,"Charges > $500, x 34%",1323.62,percent of total billed charges,Implant Device,1362.55,35,,1362.55,percent of total billed charges,Implant Device,1362.55,35,,1362.55,percent of total billed charges,Implant Device,1362.55,35,,1362.55,percent of total billed charges,Implant Device,1362.55,35,,1362.55,percent of total billed charges,Implant Device,1362.55,35,,1362.55,percent of total billed charges,Implant Device,1557.2,40,,1557.2,percent of total billed charges,Implant Device,1362.55,70,,1362.55,percent of total billed charges,All Other,1323.62,34,,1323.62,percent of total billed charges,Implant Device,1323.62,34,,1323.62,percent of total billed charges,Implant Device,1362.55,35,,1362.55,percent of total billed charges,Implant Device,1362.55,35,,1362.55,percent of total billed charges,Implant Device,1362.55,35,,1362.55,percent of total billed charges,Implant Device,1362.55,35,,1362.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1323.62,34,"If Charge > 2,000, then 34 percent",1323.62,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2880.83,
STRYKER 6260-9-032-REV FEMORAL HEAD,C1776,HCPCS,,79002211,CDM,278,RC,,,both,,,3067,2269.59,,,2269.59,Other,150% of Medicare + 9.63% HCRA Surcharge,1380.15,45,,1380.15,percent of total billed charges,Critical Access Hospital RCC factor,1042.78,34,,1042.78,percent of total billed charges,Implant Device,1042.78,34,,1042.78,percent of total billed charges,Implant Device,1042.78,34,,1042.78,percent of total billed charges,Implant Device,1042.78,34,,1042.78,percent of total billed charges,Implant Device,1042.78,34,,1042.78,percent of total billed charges,Implant Device,1518.17,,,1518.17,Other,110% of Medicare,1073.45,35,,1073.45,percent of total billed charges,Implant Device,1042.78,34,"Charges > $500, x 34%",1042.78,percent of total billed charges,Implant Device,1073.45,35,,1073.45,percent of total billed charges,Implant Device,1073.45,35,,1073.45,percent of total billed charges,Implant Device,1073.45,35,,1073.45,percent of total billed charges,Implant Device,1073.45,35,,1073.45,percent of total billed charges,Implant Device,1073.45,35,,1073.45,percent of total billed charges,Implant Device,1226.8,40,,1226.8,percent of total billed charges,Implant Device,1073.45,70,,1073.45,percent of total billed charges,All Other,1042.78,34,,1042.78,percent of total billed charges,Implant Device,1042.78,34,,1042.78,percent of total billed charges,Implant Device,1073.45,35,,1073.45,percent of total billed charges,Implant Device,1073.45,35,,1073.45,percent of total billed charges,Implant Device,1073.45,35,,1073.45,percent of total billed charges,Implant Device,1073.45,35,,1073.45,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1042.78,34,"If Charge > 2,000, then 34 percent",1042.78,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2269.59,
STRYKER 6260-9-036-REV FEMORAL HEAD,C1776,HCPCS,,79002212,CDM,278,RC,,,both,,,5832,4315.69,,,4315.69,Other,150% of Medicare + 9.63% HCRA Surcharge,2624.4,45,,2624.4,percent of total billed charges,Critical Access Hospital RCC factor,1982.88,34,,1982.88,percent of total billed charges,Implant Device,1982.88,34,,1982.88,percent of total billed charges,Implant Device,1982.88,34,,1982.88,percent of total billed charges,Implant Device,1982.88,34,,1982.88,percent of total billed charges,Implant Device,1982.88,34,,1982.88,percent of total billed charges,Implant Device,2886.84,,,2886.84,Other,110% of Medicare,2041.2,35,,2041.2,percent of total billed charges,Implant Device,1982.88,34,"Charges > $500, x 34%",1982.88,percent of total billed charges,Implant Device,2041.2,35,,2041.2,percent of total billed charges,Implant Device,2041.2,35,,2041.2,percent of total billed charges,Implant Device,2041.2,35,,2041.2,percent of total billed charges,Implant Device,2041.2,35,,2041.2,percent of total billed charges,Implant Device,2041.2,35,,2041.2,percent of total billed charges,Implant Device,2332.8,40,,2332.8,percent of total billed charges,Implant Device,2041.2,70,,2041.2,percent of total billed charges,All Other,1982.88,34,,1982.88,percent of total billed charges,Implant Device,1982.88,34,,1982.88,percent of total billed charges,Implant Device,2041.2,35,,2041.2,percent of total billed charges,Implant Device,2041.2,35,,2041.2,percent of total billed charges,Implant Device,2041.2,35,,2041.2,percent of total billed charges,Implant Device,2041.2,35,,2041.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1982.88,34,"If Charge > 2,000, then 34 percent",1982.88,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4315.69,
STRYKER 6260-9-132-REV FEMORAL HEAD,C1776,HCPCS,,79002213,CDM,278,RC,,,both,,,3067,2269.59,,,2269.59,Other,150% of Medicare + 9.63% HCRA Surcharge,1380.15,45,,1380.15,percent of total billed charges,Critical Access Hospital RCC factor,1042.78,34,,1042.78,percent of total billed charges,Implant Device,1042.78,34,,1042.78,percent of total billed charges,Implant Device,1042.78,34,,1042.78,percent of total billed charges,Implant Device,1042.78,34,,1042.78,percent of total billed charges,Implant Device,1042.78,34,,1042.78,percent of total billed charges,Implant Device,1518.17,,,1518.17,Other,110% of Medicare,1073.45,35,,1073.45,percent of total billed charges,Implant Device,1042.78,34,"Charges > $500, x 34%",1042.78,percent of total billed charges,Implant Device,1073.45,35,,1073.45,percent of total billed charges,Implant Device,1073.45,35,,1073.45,percent of total billed charges,Implant Device,1073.45,35,,1073.45,percent of total billed charges,Implant Device,1073.45,35,,1073.45,percent of total billed charges,Implant Device,1073.45,35,,1073.45,percent of total billed charges,Implant Device,1226.8,40,,1226.8,percent of total billed charges,Implant Device,1073.45,70,,1073.45,percent of total billed charges,All Other,1042.78,34,,1042.78,percent of total billed charges,Implant Device,1042.78,34,,1042.78,percent of total billed charges,Implant Device,1073.45,35,,1073.45,percent of total billed charges,Implant Device,1073.45,35,,1073.45,percent of total billed charges,Implant Device,1073.45,35,,1073.45,percent of total billed charges,Implant Device,1073.45,35,,1073.45,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1042.78,34,"If Charge > 2,000, then 34 percent",1042.78,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2269.59,
STRYKER 6260-9-1440-REV FEMORAL HEAD,C1776,HCPCS,,79002214,CDM,278,RC,,,both,,,5832,4315.69,,,4315.69,Other,150% of Medicare + 9.63% HCRA Surcharge,2624.4,45,,2624.4,percent of total billed charges,Critical Access Hospital RCC factor,1982.88,34,,1982.88,percent of total billed charges,Implant Device,1982.88,34,,1982.88,percent of total billed charges,Implant Device,1982.88,34,,1982.88,percent of total billed charges,Implant Device,1982.88,34,,1982.88,percent of total billed charges,Implant Device,1982.88,34,,1982.88,percent of total billed charges,Implant Device,2886.84,,,2886.84,Other,110% of Medicare,2041.2,35,,2041.2,percent of total billed charges,Implant Device,1982.88,34,"Charges > $500, x 34%",1982.88,percent of total billed charges,Implant Device,2041.2,35,,2041.2,percent of total billed charges,Implant Device,2041.2,35,,2041.2,percent of total billed charges,Implant Device,2041.2,35,,2041.2,percent of total billed charges,Implant Device,2041.2,35,,2041.2,percent of total billed charges,Implant Device,2041.2,35,,2041.2,percent of total billed charges,Implant Device,2332.8,40,,2332.8,percent of total billed charges,Implant Device,2041.2,70,,2041.2,percent of total billed charges,All Other,1982.88,34,,1982.88,percent of total billed charges,Implant Device,1982.88,34,,1982.88,percent of total billed charges,Implant Device,2041.2,35,,2041.2,percent of total billed charges,Implant Device,2041.2,35,,2041.2,percent of total billed charges,Implant Device,2041.2,35,,2041.2,percent of total billed charges,Implant Device,2041.2,35,,2041.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1982.88,34,"If Charge > 2,000, then 34 percent",1982.88,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4315.69,
STRYKER 6260-9-228-REV FEMORAL HEAD,C1776,HCPCS,,79002215,CDM,278,RC,,,both,,,3067,2269.59,,,2269.59,Other,150% of Medicare + 9.63% HCRA Surcharge,1380.15,45,,1380.15,percent of total billed charges,Critical Access Hospital RCC factor,1042.78,34,,1042.78,percent of total billed charges,Implant Device,1042.78,34,,1042.78,percent of total billed charges,Implant Device,1042.78,34,,1042.78,percent of total billed charges,Implant Device,1042.78,34,,1042.78,percent of total billed charges,Implant Device,1042.78,34,,1042.78,percent of total billed charges,Implant Device,1518.17,,,1518.17,Other,110% of Medicare,1073.45,35,,1073.45,percent of total billed charges,Implant Device,1042.78,34,"Charges > $500, x 34%",1042.78,percent of total billed charges,Implant Device,1073.45,35,,1073.45,percent of total billed charges,Implant Device,1073.45,35,,1073.45,percent of total billed charges,Implant Device,1073.45,35,,1073.45,percent of total billed charges,Implant Device,1073.45,35,,1073.45,percent of total billed charges,Implant Device,1073.45,35,,1073.45,percent of total billed charges,Implant Device,1226.8,40,,1226.8,percent of total billed charges,Implant Device,1073.45,70,,1073.45,percent of total billed charges,All Other,1042.78,34,,1042.78,percent of total billed charges,Implant Device,1042.78,34,,1042.78,percent of total billed charges,Implant Device,1073.45,35,,1073.45,percent of total billed charges,Implant Device,1073.45,35,,1073.45,percent of total billed charges,Implant Device,1073.45,35,,1073.45,percent of total billed charges,Implant Device,1073.45,35,,1073.45,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1042.78,34,"If Charge > 2,000, then 34 percent",1042.78,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2269.59,
STRYKER 6260-9-236-REV FEMORAL HEAD,C1776,HCPCS,,79002216,CDM,278,RC,,,both,,,5832,4315.69,,,4315.69,Other,150% of Medicare + 9.63% HCRA Surcharge,2624.4,45,,2624.4,percent of total billed charges,Critical Access Hospital RCC factor,1982.88,34,,1982.88,percent of total billed charges,Implant Device,1982.88,34,,1982.88,percent of total billed charges,Implant Device,1982.88,34,,1982.88,percent of total billed charges,Implant Device,1982.88,34,,1982.88,percent of total billed charges,Implant Device,1982.88,34,,1982.88,percent of total billed charges,Implant Device,2886.84,,,2886.84,Other,110% of Medicare,2041.2,35,,2041.2,percent of total billed charges,Implant Device,1982.88,34,"Charges > $500, x 34%",1982.88,percent of total billed charges,Implant Device,2041.2,35,,2041.2,percent of total billed charges,Implant Device,2041.2,35,,2041.2,percent of total billed charges,Implant Device,2041.2,35,,2041.2,percent of total billed charges,Implant Device,2041.2,35,,2041.2,percent of total billed charges,Implant Device,2041.2,35,,2041.2,percent of total billed charges,Implant Device,2332.8,40,,2332.8,percent of total billed charges,Implant Device,2041.2,70,,2041.2,percent of total billed charges,All Other,1982.88,34,,1982.88,percent of total billed charges,Implant Device,1982.88,34,,1982.88,percent of total billed charges,Implant Device,2041.2,35,,2041.2,percent of total billed charges,Implant Device,2041.2,35,,2041.2,percent of total billed charges,Implant Device,2041.2,35,,2041.2,percent of total billed charges,Implant Device,2041.2,35,,2041.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1982.88,34,"If Charge > 2,000, then 34 percent",1982.88,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4315.69,
STRYKER 6260-9-326-REV FEMORAL HEAD,C1776,HCPCS,,79002217,CDM,278,RC,,,both,,,1391,1029.34,,,1029.34,Other,150% of Medicare + 9.63% HCRA Surcharge,625.95,45,,625.95,percent of total billed charges,Critical Access Hospital RCC factor,472.94,34,,472.94,percent of total billed charges,Implant Device,472.94,34,,472.94,percent of total billed charges,Implant Device,472.94,34,,472.94,percent of total billed charges,Implant Device,472.94,34,,472.94,percent of total billed charges,Implant Device,472.94,34,,472.94,percent of total billed charges,Implant Device,688.55,,,688.55,Other,110% of Medicare,486.85,35,,486.85,percent of total billed charges,Implant Device,472.94,34,"Charges > $500, x 34%",472.94,percent of total billed charges,Implant Device,486.85,35,,486.85,percent of total billed charges,Implant Device,486.85,35,,486.85,percent of total billed charges,Implant Device,486.85,35,,486.85,percent of total billed charges,Implant Device,486.85,35,,486.85,percent of total billed charges,Implant Device,486.85,35,,486.85,percent of total billed charges,Implant Device,556.4,40,,556.4,percent of total billed charges,Implant Device,486.85,70,,486.85,percent of total billed charges,All Other,472.94,34,,472.94,percent of total billed charges,Implant Device,472.94,34,,472.94,percent of total billed charges,Implant Device,486.85,35,,486.85,percent of total billed charges,Implant Device,486.85,35,,486.85,percent of total billed charges,Implant Device,486.85,35,,486.85,percent of total billed charges,Implant Device,486.85,35,,486.85,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1029.34,
ZIMMER 6260-9-332-REV FEMORAL HEAD,C1776,HCPCS,,79002218,CDM,278,RC,,,both,,,3067,2269.59,,,2269.59,Other,150% of Medicare + 9.63% HCRA Surcharge,1380.15,45,,1380.15,percent of total billed charges,Critical Access Hospital RCC factor,1042.78,34,,1042.78,percent of total billed charges,Implant Device,1042.78,34,,1042.78,percent of total billed charges,Implant Device,1042.78,34,,1042.78,percent of total billed charges,Implant Device,1042.78,34,,1042.78,percent of total billed charges,Implant Device,1042.78,34,,1042.78,percent of total billed charges,Implant Device,1518.17,,,1518.17,Other,110% of Medicare,1073.45,35,,1073.45,percent of total billed charges,Implant Device,1042.78,34,"Charges > $500, x 34%",1042.78,percent of total billed charges,Implant Device,1073.45,35,,1073.45,percent of total billed charges,Implant Device,1073.45,35,,1073.45,percent of total billed charges,Implant Device,1073.45,35,,1073.45,percent of total billed charges,Implant Device,1073.45,35,,1073.45,percent of total billed charges,Implant Device,1073.45,35,,1073.45,percent of total billed charges,Implant Device,1226.8,40,,1226.8,percent of total billed charges,Implant Device,1073.45,70,,1073.45,percent of total billed charges,All Other,1042.78,34,,1042.78,percent of total billed charges,Implant Device,1042.78,34,,1042.78,percent of total billed charges,Implant Device,1073.45,35,,1073.45,percent of total billed charges,Implant Device,1073.45,35,,1073.45,percent of total billed charges,Implant Device,1073.45,35,,1073.45,percent of total billed charges,Implant Device,1073.45,35,,1073.45,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1042.78,34,"If Charge > 2,000, then 34 percent",1042.78,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2269.59,
STRYKER 6260-9-336-REV FEMORAL HEAD,C1776,HCPCS,,79002219,CDM,278,RC,,,both,,,6232,4611.7,,,4611.7,Other,150% of Medicare + 9.63% HCRA Surcharge,2804.4,45,,2804.4,percent of total billed charges,Critical Access Hospital RCC factor,2118.88,34,,2118.88,percent of total billed charges,Implant Device,2118.88,34,,2118.88,percent of total billed charges,Implant Device,2118.88,34,,2118.88,percent of total billed charges,Implant Device,2118.88,34,,2118.88,percent of total billed charges,Implant Device,2118.88,34,,2118.88,percent of total billed charges,Implant Device,3084.84,,,3084.84,Other,110% of Medicare,2181.2,35,,2181.2,percent of total billed charges,Implant Device,2118.88,34,"Charges > $500, x 34%",2118.88,percent of total billed charges,Implant Device,2181.2,35,,2181.2,percent of total billed charges,Implant Device,2181.2,35,,2181.2,percent of total billed charges,Implant Device,2181.2,35,,2181.2,percent of total billed charges,Implant Device,2181.2,35,,2181.2,percent of total billed charges,Implant Device,2181.2,35,,2181.2,percent of total billed charges,Implant Device,2492.8,40,,2492.8,percent of total billed charges,Implant Device,2181.2,70,,2181.2,percent of total billed charges,All Other,2118.88,34,,2118.88,percent of total billed charges,Implant Device,2118.88,34,,2118.88,percent of total billed charges,Implant Device,2181.2,35,,2181.2,percent of total billed charges,Implant Device,2181.2,35,,2181.2,percent of total billed charges,Implant Device,2181.2,35,,2181.2,percent of total billed charges,Implant Device,2181.2,35,,2181.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2118.88,34,"If Charge > 2,000, then 34 percent",2118.88,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4611.7,
HOWMEDICA 6265-2-000 STEM,C1776,HCPCS,,79002220,CDM,278,RC,,,both,,,5797,4289.79,,,4289.79,Other,150% of Medicare + 9.63% HCRA Surcharge,2608.65,45,,2608.65,percent of total billed charges,Critical Access Hospital RCC factor,1970.98,34,,1970.98,percent of total billed charges,Implant Device,1970.98,34,,1970.98,percent of total billed charges,Implant Device,1970.98,34,,1970.98,percent of total billed charges,Implant Device,1970.98,34,,1970.98,percent of total billed charges,Implant Device,1970.98,34,,1970.98,percent of total billed charges,Implant Device,2869.52,,,2869.52,Other,110% of Medicare,2028.95,35,,2028.95,percent of total billed charges,Implant Device,1970.98,34,"Charges > $500, x 34%",1970.98,percent of total billed charges,Implant Device,2028.95,35,,2028.95,percent of total billed charges,Implant Device,2028.95,35,,2028.95,percent of total billed charges,Implant Device,2028.95,35,,2028.95,percent of total billed charges,Implant Device,2028.95,35,,2028.95,percent of total billed charges,Implant Device,2028.95,35,,2028.95,percent of total billed charges,Implant Device,2318.8,40,,2318.8,percent of total billed charges,Implant Device,2028.95,70,,2028.95,percent of total billed charges,All Other,1970.98,34,,1970.98,percent of total billed charges,Implant Device,1970.98,34,,1970.98,percent of total billed charges,Implant Device,2028.95,35,,2028.95,percent of total billed charges,Implant Device,2028.95,35,,2028.95,percent of total billed charges,Implant Device,2028.95,35,,2028.95,percent of total billed charges,Implant Device,2028.95,35,,2028.95,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1970.98,34,"If Charge > 2,000, then 34 percent",1970.98,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4289.79,
STRYKER 6276-1-021-REV MODULAR HIP,C1776,HCPCS,,79002221,CDM,278,RC,,,both,,,11948,8841.55,,,8841.55,Other,150% of Medicare + 9.63% HCRA Surcharge,5376.6,45,,5376.6,percent of total billed charges,Critical Access Hospital RCC factor,4062.32,34,,4062.32,percent of total billed charges,Implant Device,4062.32,34,,4062.32,percent of total billed charges,Implant Device,4062.32,34,,4062.32,percent of total billed charges,Implant Device,4062.32,34,,4062.32,percent of total billed charges,Implant Device,4062.32,34,,4062.32,percent of total billed charges,Implant Device,5914.26,,,5914.26,Other,110% of Medicare,4181.8,35,,4181.8,percent of total billed charges,Implant Device,4062.32,34,"Charges > $500, x 34%",4062.32,percent of total billed charges,Implant Device,4181.8,35,,4181.8,percent of total billed charges,Implant Device,4181.8,35,,4181.8,percent of total billed charges,Implant Device,4181.8,35,,4181.8,percent of total billed charges,Implant Device,4181.8,35,,4181.8,percent of total billed charges,Implant Device,4181.8,35,,4181.8,percent of total billed charges,Implant Device,4779.2,40,,4779.2,percent of total billed charges,Implant Device,4181.8,70,,4181.8,percent of total billed charges,All Other,4062.32,34,,4062.32,percent of total billed charges,Implant Device,4062.32,34,,4062.32,percent of total billed charges,Implant Device,4181.8,35,,4181.8,percent of total billed charges,Implant Device,4181.8,35,,4181.8,percent of total billed charges,Implant Device,4181.8,35,,4181.8,percent of total billed charges,Implant Device,4181.8,35,,4181.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,4062.32,34,"If Charge > 2,000, then 34 percent",4062.32,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,8841.55,
STRYKER 6276-1-023-REV MODULAR HIP,C1776,HCPCS,,79002222,CDM,278,RC,,,both,,,11948,8841.55,,,8841.55,Other,150% of Medicare + 9.63% HCRA Surcharge,5376.6,45,,5376.6,percent of total billed charges,Critical Access Hospital RCC factor,4062.32,34,,4062.32,percent of total billed charges,Implant Device,4062.32,34,,4062.32,percent of total billed charges,Implant Device,4062.32,34,,4062.32,percent of total billed charges,Implant Device,4062.32,34,,4062.32,percent of total billed charges,Implant Device,4062.32,34,,4062.32,percent of total billed charges,Implant Device,5914.26,,,5914.26,Other,110% of Medicare,4181.8,35,,4181.8,percent of total billed charges,Implant Device,4062.32,34,"Charges > $500, x 34%",4062.32,percent of total billed charges,Implant Device,4181.8,35,,4181.8,percent of total billed charges,Implant Device,4181.8,35,,4181.8,percent of total billed charges,Implant Device,4181.8,35,,4181.8,percent of total billed charges,Implant Device,4181.8,35,,4181.8,percent of total billed charges,Implant Device,4181.8,35,,4181.8,percent of total billed charges,Implant Device,4779.2,40,,4779.2,percent of total billed charges,Implant Device,4181.8,70,,4181.8,percent of total billed charges,All Other,4062.32,34,,4062.32,percent of total billed charges,Implant Device,4062.32,34,,4062.32,percent of total billed charges,Implant Device,4181.8,35,,4181.8,percent of total billed charges,Implant Device,4181.8,35,,4181.8,percent of total billed charges,Implant Device,4181.8,35,,4181.8,percent of total billed charges,Implant Device,4181.8,35,,4181.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,4062.32,34,"If Charge > 2,000, then 34 percent",4062.32,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,8841.55,
STRYKER 6276-1-025-REV MODULAR HIP,C1776,HCPCS,,79002223,CDM,278,RC,,,both,,,19494,14425.61,,,14425.61,Other,150% of Medicare + 9.63% HCRA Surcharge,8772.3,45,,8772.3,percent of total billed charges,Critical Access Hospital RCC factor,6627.96,34,,6627.96,percent of total billed charges,Implant Device,6627.96,34,,6627.96,percent of total billed charges,Implant Device,6627.96,34,,6627.96,percent of total billed charges,Implant Device,6627.96,34,,6627.96,percent of total billed charges,Implant Device,6627.96,34,,6627.96,percent of total billed charges,Implant Device,9649.53,,,9649.53,Other,110% of Medicare,6822.9,35,,6822.9,percent of total billed charges,Implant Device,6627.96,34,"Charges > $500, x 34%",6627.96,percent of total billed charges,Implant Device,6822.9,35,,6822.9,percent of total billed charges,Implant Device,6822.9,35,,6822.9,percent of total billed charges,Implant Device,6822.9,35,,6822.9,percent of total billed charges,Implant Device,6822.9,35,,6822.9,percent of total billed charges,Implant Device,6822.9,35,,6822.9,percent of total billed charges,Implant Device,7797.6,40,,7797.6,percent of total billed charges,Implant Device,6822.9,70,,6822.9,percent of total billed charges,All Other,6627.96,34,,6627.96,percent of total billed charges,Implant Device,6627.96,34,,6627.96,percent of total billed charges,Implant Device,6822.9,35,,6822.9,percent of total billed charges,Implant Device,6822.9,35,,6822.9,percent of total billed charges,Implant Device,6822.9,35,,6822.9,percent of total billed charges,Implant Device,6822.9,35,,6822.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,6627.96,34,"If Charge > 2,000, then 34 percent",6627.96,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,14425.61,
STRYKER 6276-1-121-REV MODULAR HIP,C1776,HCPCS,,79002224,CDM,278,RC,,,both,,,21084,15602.21,,,15602.21,Other,150% of Medicare + 9.63% HCRA Surcharge,9487.8,45,,9487.8,percent of total billed charges,Critical Access Hospital RCC factor,7168.56,34,,7168.56,percent of total billed charges,Implant Device,7168.56,34,,7168.56,percent of total billed charges,Implant Device,7168.56,34,,7168.56,percent of total billed charges,Implant Device,7168.56,34,,7168.56,percent of total billed charges,Implant Device,7168.56,34,,7168.56,percent of total billed charges,Implant Device,10436.58,,,10436.58,Other,110% of Medicare,7379.4,35,,7379.4,percent of total billed charges,Implant Device,7168.56,34,"Charges > $500, x 34%",7168.56,percent of total billed charges,Implant Device,7379.4,35,,7379.4,percent of total billed charges,Implant Device,7379.4,35,,7379.4,percent of total billed charges,Implant Device,7379.4,35,,7379.4,percent of total billed charges,Implant Device,7379.4,35,,7379.4,percent of total billed charges,Implant Device,7379.4,35,,7379.4,percent of total billed charges,Implant Device,8433.6,40,,8433.6,percent of total billed charges,Implant Device,7379.4,70,,7379.4,percent of total billed charges,All Other,7168.56,34,,7168.56,percent of total billed charges,Implant Device,7168.56,34,,7168.56,percent of total billed charges,Implant Device,7379.4,35,,7379.4,percent of total billed charges,Implant Device,7379.4,35,,7379.4,percent of total billed charges,Implant Device,7379.4,35,,7379.4,percent of total billed charges,Implant Device,7379.4,35,,7379.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,7168.56,34,"If Charge > 2,000, then 34 percent",7168.56,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,15602.21,
STRYKER 6276-1-123-REV MODULAR HIP,C1776,HCPCS,,79002225,CDM,278,RC,,,both,,,19076,14116.29,,,14116.29,Other,150% of Medicare + 9.63% HCRA Surcharge,8584.2,45,,8584.2,percent of total billed charges,Critical Access Hospital RCC factor,6485.84,34,,6485.84,percent of total billed charges,Implant Device,6485.84,34,,6485.84,percent of total billed charges,Implant Device,6485.84,34,,6485.84,percent of total billed charges,Implant Device,6485.84,34,,6485.84,percent of total billed charges,Implant Device,6485.84,34,,6485.84,percent of total billed charges,Implant Device,9442.62,,,9442.62,Other,110% of Medicare,6676.6,35,,6676.6,percent of total billed charges,Implant Device,6485.84,34,"Charges > $500, x 34%",6485.84,percent of total billed charges,Implant Device,6676.6,35,,6676.6,percent of total billed charges,Implant Device,6676.6,35,,6676.6,percent of total billed charges,Implant Device,6676.6,35,,6676.6,percent of total billed charges,Implant Device,6676.6,35,,6676.6,percent of total billed charges,Implant Device,6676.6,35,,6676.6,percent of total billed charges,Implant Device,7630.4,40,,7630.4,percent of total billed charges,Implant Device,6676.6,70,,6676.6,percent of total billed charges,All Other,6485.84,34,,6485.84,percent of total billed charges,Implant Device,6485.84,34,,6485.84,percent of total billed charges,Implant Device,6676.6,35,,6676.6,percent of total billed charges,Implant Device,6676.6,35,,6676.6,percent of total billed charges,Implant Device,6676.6,35,,6676.6,percent of total billed charges,Implant Device,6676.6,35,,6676.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,6485.84,34,"If Charge > 2,000, then 34 percent",6485.84,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,14116.29,
STRYKER 6276-1-221-REV MODULAR HIP,C1776,HCPCS,,79002226,CDM,278,RC,,,both,,,17088,12645.16,,,12645.16,Other,150% of Medicare + 9.63% HCRA Surcharge,7689.6,45,,7689.6,percent of total billed charges,Critical Access Hospital RCC factor,5809.92,34,,5809.92,percent of total billed charges,Implant Device,5809.92,34,,5809.92,percent of total billed charges,Implant Device,5809.92,34,,5809.92,percent of total billed charges,Implant Device,5809.92,34,,5809.92,percent of total billed charges,Implant Device,5809.92,34,,5809.92,percent of total billed charges,Implant Device,8458.56,,,8458.56,Other,110% of Medicare,5980.8,35,,5980.8,percent of total billed charges,Implant Device,5809.92,34,"Charges > $500, x 34%",5809.92,percent of total billed charges,Implant Device,5980.8,35,,5980.8,percent of total billed charges,Implant Device,5980.8,35,,5980.8,percent of total billed charges,Implant Device,5980.8,35,,5980.8,percent of total billed charges,Implant Device,5980.8,35,,5980.8,percent of total billed charges,Implant Device,5980.8,35,,5980.8,percent of total billed charges,Implant Device,6835.2,40,,6835.2,percent of total billed charges,Implant Device,5980.8,70,,5980.8,percent of total billed charges,All Other,5809.92,34,,5809.92,percent of total billed charges,Implant Device,5809.92,34,,5809.92,percent of total billed charges,Implant Device,5980.8,35,,5980.8,percent of total billed charges,Implant Device,5980.8,35,,5980.8,percent of total billed charges,Implant Device,5980.8,35,,5980.8,percent of total billed charges,Implant Device,5980.8,35,,5980.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,5809.92,34,"If Charge > 2,000, then 34 percent",5809.92,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,12645.16,
STRYKER 6276-1-225-REV MODULAR HIPO,C1776,HCPCS,,79002227,CDM,278,RC,,,both,,,17088,12645.16,,,12645.16,Other,150% of Medicare + 9.63% HCRA Surcharge,7689.6,45,,7689.6,percent of total billed charges,Critical Access Hospital RCC factor,5809.92,34,,5809.92,percent of total billed charges,Implant Device,5809.92,34,,5809.92,percent of total billed charges,Implant Device,5809.92,34,,5809.92,percent of total billed charges,Implant Device,5809.92,34,,5809.92,percent of total billed charges,Implant Device,5809.92,34,,5809.92,percent of total billed charges,Implant Device,8458.56,,,8458.56,Other,110% of Medicare,5980.8,35,,5980.8,percent of total billed charges,Implant Device,5809.92,34,"Charges > $500, x 34%",5809.92,percent of total billed charges,Implant Device,5980.8,35,,5980.8,percent of total billed charges,Implant Device,5980.8,35,,5980.8,percent of total billed charges,Implant Device,5980.8,35,,5980.8,percent of total billed charges,Implant Device,5980.8,35,,5980.8,percent of total billed charges,Implant Device,5980.8,35,,5980.8,percent of total billed charges,Implant Device,6835.2,40,,6835.2,percent of total billed charges,Implant Device,5980.8,70,,5980.8,percent of total billed charges,All Other,5809.92,34,,5809.92,percent of total billed charges,Implant Device,5809.92,34,,5809.92,percent of total billed charges,Implant Device,5980.8,35,,5980.8,percent of total billed charges,Implant Device,5980.8,35,,5980.8,percent of total billed charges,Implant Device,5980.8,35,,5980.8,percent of total billed charges,Implant Device,5980.8,35,,5980.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,5809.92,34,"If Charge > 2,000, then 34 percent",5809.92,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,12645.16,
STRYKER 6276-7-016-REV MODULAR HIP,C1776,HCPCS,,79002228,CDM,278,RC,,,both,,,9112,6742.9,,,6742.9,Other,150% of Medicare + 9.63% HCRA Surcharge,4100.4,45,,4100.4,percent of total billed charges,Critical Access Hospital RCC factor,3098.08,34,,3098.08,percent of total billed charges,Implant Device,3098.08,34,,3098.08,percent of total billed charges,Implant Device,3098.08,34,,3098.08,percent of total billed charges,Implant Device,3098.08,34,,3098.08,percent of total billed charges,Implant Device,3098.08,34,,3098.08,percent of total billed charges,Implant Device,4510.44,,,4510.44,Other,110% of Medicare,3189.2,35,,3189.2,percent of total billed charges,Implant Device,3098.08,34,"Charges > $500, x 34%",3098.08,percent of total billed charges,Implant Device,3189.2,35,,3189.2,percent of total billed charges,Implant Device,3189.2,35,,3189.2,percent of total billed charges,Implant Device,3189.2,35,,3189.2,percent of total billed charges,Implant Device,3189.2,35,,3189.2,percent of total billed charges,Implant Device,3189.2,35,,3189.2,percent of total billed charges,Implant Device,3644.8,40,,3644.8,percent of total billed charges,Implant Device,3189.2,70,,3189.2,percent of total billed charges,All Other,3098.08,34,,3098.08,percent of total billed charges,Implant Device,3098.08,34,,3098.08,percent of total billed charges,Implant Device,3189.2,35,,3189.2,percent of total billed charges,Implant Device,3189.2,35,,3189.2,percent of total billed charges,Implant Device,3189.2,35,,3189.2,percent of total billed charges,Implant Device,3189.2,35,,3189.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3098.08,34,"If Charge > 2,000, then 34 percent",3098.08,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,6742.9,
STRYKER 6276-7-020-REV MODULAR HIP,C1776,HCPCS,,79002229,CDM,278,RC,,,both,,,12245,9061.33,,,9061.33,Other,150% of Medicare + 9.63% HCRA Surcharge,5510.25,45,,5510.25,percent of total billed charges,Critical Access Hospital RCC factor,4163.3,34,,4163.3,percent of total billed charges,Implant Device,4163.3,34,,4163.3,percent of total billed charges,Implant Device,4163.3,34,,4163.3,percent of total billed charges,Implant Device,4163.3,34,,4163.3,percent of total billed charges,Implant Device,4163.3,34,,4163.3,percent of total billed charges,Implant Device,6061.28,,,6061.28,Other,110% of Medicare,4285.75,35,,4285.75,percent of total billed charges,Implant Device,4163.3,34,"Charges > $500, x 34%",4163.3,percent of total billed charges,Implant Device,4285.75,35,,4285.75,percent of total billed charges,Implant Device,4285.75,35,,4285.75,percent of total billed charges,Implant Device,4285.75,35,,4285.75,percent of total billed charges,Implant Device,4285.75,35,,4285.75,percent of total billed charges,Implant Device,4285.75,35,,4285.75,percent of total billed charges,Implant Device,4898,40,,4898,percent of total billed charges,Implant Device,4285.75,70,,4285.75,percent of total billed charges,All Other,4163.3,34,,4163.3,percent of total billed charges,Implant Device,4163.3,34,,4163.3,percent of total billed charges,Implant Device,4285.75,35,,4285.75,percent of total billed charges,Implant Device,4285.75,35,,4285.75,percent of total billed charges,Implant Device,4285.75,35,,4285.75,percent of total billed charges,Implant Device,4285.75,35,,4285.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,4163.3,34,"If Charge > 2,000, then 34 percent",4163.3,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,9061.33,
STRYKER 6276-7-114-REV MODULAR HIP,C1776,HCPCS,,79002230,CDM,278,RC,,,both,,,12966,9594.87,,,9594.87,Other,150% of Medicare + 9.63% HCRA Surcharge,5834.7,45,,5834.7,percent of total billed charges,Critical Access Hospital RCC factor,4408.44,34,,4408.44,percent of total billed charges,Implant Device,4408.44,34,,4408.44,percent of total billed charges,Implant Device,4408.44,34,,4408.44,percent of total billed charges,Implant Device,4408.44,34,,4408.44,percent of total billed charges,Implant Device,4408.44,34,,4408.44,percent of total billed charges,Implant Device,6418.17,,,6418.17,Other,110% of Medicare,4538.1,35,,4538.1,percent of total billed charges,Implant Device,4408.44,34,"Charges > $500, x 34%",4408.44,percent of total billed charges,Implant Device,4538.1,35,,4538.1,percent of total billed charges,Implant Device,4538.1,35,,4538.1,percent of total billed charges,Implant Device,4538.1,35,,4538.1,percent of total billed charges,Implant Device,4538.1,35,,4538.1,percent of total billed charges,Implant Device,4538.1,35,,4538.1,percent of total billed charges,Implant Device,5186.4,40,,5186.4,percent of total billed charges,Implant Device,4538.1,70,,4538.1,percent of total billed charges,All Other,4408.44,34,,4408.44,percent of total billed charges,Implant Device,4408.44,34,,4408.44,percent of total billed charges,Implant Device,4538.1,35,,4538.1,percent of total billed charges,Implant Device,4538.1,35,,4538.1,percent of total billed charges,Implant Device,4538.1,35,,4538.1,percent of total billed charges,Implant Device,4538.1,35,,4538.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,4408.44,34,"If Charge > 2,000, then 34 percent",4408.44,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,9594.87,
STRYKER 6276-7-115-REV MODULAR HIP,C1776,HCPCS,,79002231,CDM,278,RC,,,both,,,13484,9978.19,,,9978.19,Other,150% of Medicare + 9.63% HCRA Surcharge,6067.8,45,,6067.8,percent of total billed charges,Critical Access Hospital RCC factor,4584.56,34,,4584.56,percent of total billed charges,Implant Device,4584.56,34,,4584.56,percent of total billed charges,Implant Device,4584.56,34,,4584.56,percent of total billed charges,Implant Device,4584.56,34,,4584.56,percent of total billed charges,Implant Device,4584.56,34,,4584.56,percent of total billed charges,Implant Device,6674.58,,,6674.58,Other,110% of Medicare,4719.4,35,,4719.4,percent of total billed charges,Implant Device,4584.56,34,"Charges > $500, x 34%",4584.56,percent of total billed charges,Implant Device,4719.4,35,,4719.4,percent of total billed charges,Implant Device,4719.4,35,,4719.4,percent of total billed charges,Implant Device,4719.4,35,,4719.4,percent of total billed charges,Implant Device,4719.4,35,,4719.4,percent of total billed charges,Implant Device,4719.4,35,,4719.4,percent of total billed charges,Implant Device,5393.6,40,,5393.6,percent of total billed charges,Implant Device,4719.4,70,,4719.4,percent of total billed charges,All Other,4584.56,34,,4584.56,percent of total billed charges,Implant Device,4584.56,34,,4584.56,percent of total billed charges,Implant Device,4719.4,35,,4719.4,percent of total billed charges,Implant Device,4719.4,35,,4719.4,percent of total billed charges,Implant Device,4719.4,35,,4719.4,percent of total billed charges,Implant Device,4719.4,35,,4719.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,4584.56,34,"If Charge > 2,000, then 34 percent",4584.56,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,9978.19,
STRYKER 6276-7-116-REV MODULAR HIP,C1776,HCPCS,,79002232,CDM,278,RC,,,both,,,12964,9593.39,,,9593.39,Other,150% of Medicare + 9.63% HCRA Surcharge,5833.8,45,,5833.8,percent of total billed charges,Critical Access Hospital RCC factor,4407.76,34,,4407.76,percent of total billed charges,Implant Device,4407.76,34,,4407.76,percent of total billed charges,Implant Device,4407.76,34,,4407.76,percent of total billed charges,Implant Device,4407.76,34,,4407.76,percent of total billed charges,Implant Device,4407.76,34,,4407.76,percent of total billed charges,Implant Device,6417.18,,,6417.18,Other,110% of Medicare,4537.4,35,,4537.4,percent of total billed charges,Implant Device,4407.76,34,"Charges > $500, x 34%",4407.76,percent of total billed charges,Implant Device,4537.4,35,,4537.4,percent of total billed charges,Implant Device,4537.4,35,,4537.4,percent of total billed charges,Implant Device,4537.4,35,,4537.4,percent of total billed charges,Implant Device,4537.4,35,,4537.4,percent of total billed charges,Implant Device,4537.4,35,,4537.4,percent of total billed charges,Implant Device,5185.6,40,,5185.6,percent of total billed charges,Implant Device,4537.4,70,,4537.4,percent of total billed charges,All Other,4407.76,34,,4407.76,percent of total billed charges,Implant Device,4407.76,34,,4407.76,percent of total billed charges,Implant Device,4537.4,35,,4537.4,percent of total billed charges,Implant Device,4537.4,35,,4537.4,percent of total billed charges,Implant Device,4537.4,35,,4537.4,percent of total billed charges,Implant Device,4537.4,35,,4537.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,4407.76,34,"If Charge > 2,000, then 34 percent",4407.76,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,9593.39,
STRYKER 6276-7-117-REV MODULAR HIP,C1776,HCPCS,,79002233,CDM,278,RC,,,both,,,12966,9594.87,,,9594.87,Other,150% of Medicare + 9.63% HCRA Surcharge,5834.7,45,,5834.7,percent of total billed charges,Critical Access Hospital RCC factor,4408.44,34,,4408.44,percent of total billed charges,Implant Device,4408.44,34,,4408.44,percent of total billed charges,Implant Device,4408.44,34,,4408.44,percent of total billed charges,Implant Device,4408.44,34,,4408.44,percent of total billed charges,Implant Device,4408.44,34,,4408.44,percent of total billed charges,Implant Device,6418.17,,,6418.17,Other,110% of Medicare,4538.1,35,,4538.1,percent of total billed charges,Implant Device,4408.44,34,"Charges > $500, x 34%",4408.44,percent of total billed charges,Implant Device,4538.1,35,,4538.1,percent of total billed charges,Implant Device,4538.1,35,,4538.1,percent of total billed charges,Implant Device,4538.1,35,,4538.1,percent of total billed charges,Implant Device,4538.1,35,,4538.1,percent of total billed charges,Implant Device,4538.1,35,,4538.1,percent of total billed charges,Implant Device,5186.4,40,,5186.4,percent of total billed charges,Implant Device,4538.1,70,,4538.1,percent of total billed charges,All Other,4408.44,34,,4408.44,percent of total billed charges,Implant Device,4408.44,34,,4408.44,percent of total billed charges,Implant Device,4538.1,35,,4538.1,percent of total billed charges,Implant Device,4538.1,35,,4538.1,percent of total billed charges,Implant Device,4538.1,35,,4538.1,percent of total billed charges,Implant Device,4538.1,35,,4538.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,4408.44,34,"If Charge > 2,000, then 34 percent",4408.44,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,9594.87,
STRYKER 6276-7-118-REV MODULAR HIP,C1776,HCPCS,,79002234,CDM,278,RC,,,both,,,12964,9593.39,,,9593.39,Other,150% of Medicare + 9.63% HCRA Surcharge,5833.8,45,,5833.8,percent of total billed charges,Critical Access Hospital RCC factor,4407.76,34,,4407.76,percent of total billed charges,Implant Device,4407.76,34,,4407.76,percent of total billed charges,Implant Device,4407.76,34,,4407.76,percent of total billed charges,Implant Device,4407.76,34,,4407.76,percent of total billed charges,Implant Device,4407.76,34,,4407.76,percent of total billed charges,Implant Device,6417.18,,,6417.18,Other,110% of Medicare,4537.4,35,,4537.4,percent of total billed charges,Implant Device,4407.76,34,"Charges > $500, x 34%",4407.76,percent of total billed charges,Implant Device,4537.4,35,,4537.4,percent of total billed charges,Implant Device,4537.4,35,,4537.4,percent of total billed charges,Implant Device,4537.4,35,,4537.4,percent of total billed charges,Implant Device,4537.4,35,,4537.4,percent of total billed charges,Implant Device,4537.4,35,,4537.4,percent of total billed charges,Implant Device,5185.6,40,,5185.6,percent of total billed charges,Implant Device,4537.4,70,,4537.4,percent of total billed charges,All Other,4407.76,34,,4407.76,percent of total billed charges,Implant Device,4407.76,34,,4407.76,percent of total billed charges,Implant Device,4537.4,35,,4537.4,percent of total billed charges,Implant Device,4537.4,35,,4537.4,percent of total billed charges,Implant Device,4537.4,35,,4537.4,percent of total billed charges,Implant Device,4537.4,35,,4537.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,4407.76,34,"If Charge > 2,000, then 34 percent",4407.76,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,9593.39,
STRYKER 6276-7-120-REV MODULAR HIP,C1776,HCPCS,,79002235,CDM,278,RC,,,both,,,9648,7139.54,,,7139.54,Other,150% of Medicare + 9.63% HCRA Surcharge,4341.6,45,,4341.6,percent of total billed charges,Critical Access Hospital RCC factor,3280.32,34,,3280.32,percent of total billed charges,Implant Device,3280.32,34,,3280.32,percent of total billed charges,Implant Device,3280.32,34,,3280.32,percent of total billed charges,Implant Device,3280.32,34,,3280.32,percent of total billed charges,Implant Device,3280.32,34,,3280.32,percent of total billed charges,Implant Device,4775.76,,,4775.76,Other,110% of Medicare,3376.8,35,,3376.8,percent of total billed charges,Implant Device,3280.32,34,"Charges > $500, x 34%",3280.32,percent of total billed charges,Implant Device,3376.8,35,,3376.8,percent of total billed charges,Implant Device,3376.8,35,,3376.8,percent of total billed charges,Implant Device,3376.8,35,,3376.8,percent of total billed charges,Implant Device,3376.8,35,,3376.8,percent of total billed charges,Implant Device,3376.8,35,,3376.8,percent of total billed charges,Implant Device,3859.2,40,,3859.2,percent of total billed charges,Implant Device,3376.8,70,,3376.8,percent of total billed charges,All Other,3280.32,34,,3280.32,percent of total billed charges,Implant Device,3280.32,34,,3280.32,percent of total billed charges,Implant Device,3376.8,35,,3376.8,percent of total billed charges,Implant Device,3376.8,35,,3376.8,percent of total billed charges,Implant Device,3376.8,35,,3376.8,percent of total billed charges,Implant Device,3376.8,35,,3376.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3280.32,34,"If Charge > 2,000, then 34 percent",3280.32,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,7139.54,
STRYKER 6276-7-218-REV DISTAL STEM,C1776,HCPCS,,79002236,CDM,278,RC,,,both,,,13684,10126.19,,,10126.19,Other,150% of Medicare + 9.63% HCRA Surcharge,6157.8,45,,6157.8,percent of total billed charges,Critical Access Hospital RCC factor,4652.56,34,,4652.56,percent of total billed charges,Implant Device,4652.56,34,,4652.56,percent of total billed charges,Implant Device,4652.56,34,,4652.56,percent of total billed charges,Implant Device,4652.56,34,,4652.56,percent of total billed charges,Implant Device,4652.56,34,,4652.56,percent of total billed charges,Implant Device,6773.58,,,6773.58,Other,110% of Medicare,4789.4,35,,4789.4,percent of total billed charges,Implant Device,4652.56,34,"Charges > $500, x 34%",4652.56,percent of total billed charges,Implant Device,4789.4,35,,4789.4,percent of total billed charges,Implant Device,4789.4,35,,4789.4,percent of total billed charges,Implant Device,4789.4,35,,4789.4,percent of total billed charges,Implant Device,4789.4,35,,4789.4,percent of total billed charges,Implant Device,4789.4,35,,4789.4,percent of total billed charges,Implant Device,5473.6,40,,5473.6,percent of total billed charges,Implant Device,4789.4,70,,4789.4,percent of total billed charges,All Other,4652.56,34,,4652.56,percent of total billed charges,Implant Device,4652.56,34,,4652.56,percent of total billed charges,Implant Device,4789.4,35,,4789.4,percent of total billed charges,Implant Device,4789.4,35,,4789.4,percent of total billed charges,Implant Device,4789.4,35,,4789.4,percent of total billed charges,Implant Device,4789.4,35,,4789.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,4652.56,34,"If Charge > 2,000, then 34 percent",4652.56,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,10126.19,
STRYKER 6276-7-323-REV MODULAR HIP SYS,C1776,HCPCS,,79002237,CDM,278,RC,,,both,,,14405,10659.74,,,10659.74,Other,150% of Medicare + 9.63% HCRA Surcharge,6482.25,45,,6482.25,percent of total billed charges,Critical Access Hospital RCC factor,4897.7,34,,4897.7,percent of total billed charges,Implant Device,4897.7,34,,4897.7,percent of total billed charges,Implant Device,4897.7,34,,4897.7,percent of total billed charges,Implant Device,4897.7,34,,4897.7,percent of total billed charges,Implant Device,4897.7,34,,4897.7,percent of total billed charges,Implant Device,7130.48,,,7130.48,Other,110% of Medicare,5041.75,35,,5041.75,percent of total billed charges,Implant Device,4897.7,34,"Charges > $500, x 34%",4897.7,percent of total billed charges,Implant Device,5041.75,35,,5041.75,percent of total billed charges,Implant Device,5041.75,35,,5041.75,percent of total billed charges,Implant Device,5041.75,35,,5041.75,percent of total billed charges,Implant Device,5041.75,35,,5041.75,percent of total billed charges,Implant Device,5041.75,35,,5041.75,percent of total billed charges,Implant Device,5762,40,,5762,percent of total billed charges,Implant Device,5041.75,70,,5041.75,percent of total billed charges,All Other,4897.7,34,,4897.7,percent of total billed charges,Implant Device,4897.7,34,,4897.7,percent of total billed charges,Implant Device,5041.75,35,,5041.75,percent of total billed charges,Implant Device,5041.75,35,,5041.75,percent of total billed charges,Implant Device,5041.75,35,,5041.75,percent of total billed charges,Implant Device,5041.75,35,,5041.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,4897.7,34,"If Charge > 2,000, then 34 percent",4897.7,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,10659.74,
STRYKER ORTHO 6495-9-001 TISSUEMEND,C1781,HCPCS,,79002238,CDM,278,RC,,,both,,,6900,5106.02,,,5106.02,Other,150% of Medicare + 9.63% HCRA Surcharge,3105,45,,3105,percent of total billed charges,Critical Access Hospital RCC factor,2346,34,,2346,percent of total billed charges,Implant Device,2346,34,,2346,percent of total billed charges,Implant Device,2346,34,,2346,percent of total billed charges,Implant Device,2346,34,,2346,percent of total billed charges,Implant Device,2346,34,,2346,percent of total billed charges,Implant Device,3415.5,,,3415.5,Other,110% of Medicare,2415,35,,2415,percent of total billed charges,Implant Device,2346,34,"Charges > $500, x 34%",2346,percent of total billed charges,Implant Device,2415,35,,2415,percent of total billed charges,Implant Device,2415,35,,2415,percent of total billed charges,Implant Device,2415,35,,2415,percent of total billed charges,Implant Device,2415,35,,2415,percent of total billed charges,Implant Device,2415,35,,2415,percent of total billed charges,Implant Device,2760,40,,2760,percent of total billed charges,Implant Device,2415,70,,2415,percent of total billed charges,All Other,2346,34,,2346,percent of total billed charges,Implant Device,2346,34,,2346,percent of total billed charges,Implant Device,2415,35,,2415,percent of total billed charges,Implant Device,2415,35,,2415,percent of total billed charges,Implant Device,2415,35,,2415,percent of total billed charges,Implant Device,2415,35,,2415,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2346,34,"If Charge > 2,000, then 34 percent",2346,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5106.02,
STRYKER 6495-9-004 TISSUEMEND,C1781,HCPCS,,79002239,CDM,278,RC,,,both,,,8972,6639.3,,,6639.3,Other,150% of Medicare + 9.63% HCRA Surcharge,4037.4,45,,4037.4,percent of total billed charges,Critical Access Hospital RCC factor,3050.48,34,,3050.48,percent of total billed charges,Implant Device,3050.48,34,,3050.48,percent of total billed charges,Implant Device,3050.48,34,,3050.48,percent of total billed charges,Implant Device,3050.48,34,,3050.48,percent of total billed charges,Implant Device,3050.48,34,,3050.48,percent of total billed charges,Implant Device,4441.14,,,4441.14,Other,110% of Medicare,3140.2,35,,3140.2,percent of total billed charges,Implant Device,3050.48,34,"Charges > $500, x 34%",3050.48,percent of total billed charges,Implant Device,3140.2,35,,3140.2,percent of total billed charges,Implant Device,3140.2,35,,3140.2,percent of total billed charges,Implant Device,3140.2,35,,3140.2,percent of total billed charges,Implant Device,3140.2,35,,3140.2,percent of total billed charges,Implant Device,3140.2,35,,3140.2,percent of total billed charges,Implant Device,3588.8,40,,3588.8,percent of total billed charges,Implant Device,3140.2,70,,3140.2,percent of total billed charges,All Other,3050.48,34,,3050.48,percent of total billed charges,Implant Device,3050.48,34,,3050.48,percent of total billed charges,Implant Device,3140.2,35,,3140.2,percent of total billed charges,Implant Device,3140.2,35,,3140.2,percent of total billed charges,Implant Device,3140.2,35,,3140.2,percent of total billed charges,Implant Device,3140.2,35,,3140.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3050.48,34,"If Charge > 2,000, then 34 percent",3050.48,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,6639.3,
STRYKER 6570-0-036-REV FEMORAL HEAD,C1776,HCPCS,,79002240,CDM,278,RC,,,both,,,6914,5116.38,,,5116.38,Other,150% of Medicare + 9.63% HCRA Surcharge,3111.3,45,,3111.3,percent of total billed charges,Critical Access Hospital RCC factor,2350.76,34,,2350.76,percent of total billed charges,Implant Device,2350.76,34,,2350.76,percent of total billed charges,Implant Device,2350.76,34,,2350.76,percent of total billed charges,Implant Device,2350.76,34,,2350.76,percent of total billed charges,Implant Device,2350.76,34,,2350.76,percent of total billed charges,Implant Device,3422.43,,,3422.43,Other,110% of Medicare,2419.9,35,,2419.9,percent of total billed charges,Implant Device,2350.76,34,"Charges > $500, x 34%",2350.76,percent of total billed charges,Implant Device,2419.9,35,,2419.9,percent of total billed charges,Implant Device,2419.9,35,,2419.9,percent of total billed charges,Implant Device,2419.9,35,,2419.9,percent of total billed charges,Implant Device,2419.9,35,,2419.9,percent of total billed charges,Implant Device,2419.9,35,,2419.9,percent of total billed charges,Implant Device,2765.6,40,,2765.6,percent of total billed charges,Implant Device,2419.9,70,,2419.9,percent of total billed charges,All Other,2350.76,34,,2350.76,percent of total billed charges,Implant Device,2350.76,34,,2350.76,percent of total billed charges,Implant Device,2419.9,35,,2419.9,percent of total billed charges,Implant Device,2419.9,35,,2419.9,percent of total billed charges,Implant Device,2419.9,35,,2419.9,percent of total billed charges,Implant Device,2419.9,35,,2419.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2350.76,34,"If Charge > 2,000, then 34 percent",2350.76,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5116.38,
STRYKER 6570-0-536-REV FEMORAL HEAD,C1776,HCPCS,,79002241,CDM,278,RC,,,both,,,2503,1852.23,,,1852.23,Other,150% of Medicare + 9.63% HCRA Surcharge,1126.35,45,,1126.35,percent of total billed charges,Critical Access Hospital RCC factor,851.02,34,,851.02,percent of total billed charges,Implant Device,851.02,34,,851.02,percent of total billed charges,Implant Device,851.02,34,,851.02,percent of total billed charges,Implant Device,851.02,34,,851.02,percent of total billed charges,Implant Device,851.02,34,,851.02,percent of total billed charges,Implant Device,1238.99,,,1238.99,Other,110% of Medicare,876.05,35,,876.05,percent of total billed charges,Implant Device,851.02,34,"Charges > $500, x 34%",851.02,percent of total billed charges,Implant Device,876.05,35,,876.05,percent of total billed charges,Implant Device,876.05,35,,876.05,percent of total billed charges,Implant Device,876.05,35,,876.05,percent of total billed charges,Implant Device,876.05,35,,876.05,percent of total billed charges,Implant Device,876.05,35,,876.05,percent of total billed charges,Implant Device,1001.2,40,,1001.2,percent of total billed charges,Implant Device,876.05,70,,876.05,percent of total billed charges,All Other,851.02,34,,851.02,percent of total billed charges,Implant Device,851.02,34,,851.02,percent of total billed charges,Implant Device,876.05,35,,876.05,percent of total billed charges,Implant Device,876.05,35,,876.05,percent of total billed charges,Implant Device,876.05,35,,876.05,percent of total billed charges,Implant Device,876.05,35,,876.05,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,851.02,34,"If Charge > 2,000, then 34 percent",851.02,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1852.23,
STRYKER 6570-0-736-REV FEMORAL HEAD,C1776,HCPCS,,79002242,CDM,278,RC,,,both,,,2503,1852.23,,,1852.23,Other,150% of Medicare + 9.63% HCRA Surcharge,1126.35,45,,1126.35,percent of total billed charges,Critical Access Hospital RCC factor,851.02,34,,851.02,percent of total billed charges,Implant Device,851.02,34,,851.02,percent of total billed charges,Implant Device,851.02,34,,851.02,percent of total billed charges,Implant Device,851.02,34,,851.02,percent of total billed charges,Implant Device,851.02,34,,851.02,percent of total billed charges,Implant Device,1238.99,,,1238.99,Other,110% of Medicare,876.05,35,,876.05,percent of total billed charges,Implant Device,851.02,34,"Charges > $500, x 34%",851.02,percent of total billed charges,Implant Device,876.05,35,,876.05,percent of total billed charges,Implant Device,876.05,35,,876.05,percent of total billed charges,Implant Device,876.05,35,,876.05,percent of total billed charges,Implant Device,876.05,35,,876.05,percent of total billed charges,Implant Device,876.05,35,,876.05,percent of total billed charges,Implant Device,1001.2,40,,1001.2,percent of total billed charges,Implant Device,876.05,70,,876.05,percent of total billed charges,All Other,851.02,34,,851.02,percent of total billed charges,Implant Device,851.02,34,,851.02,percent of total billed charges,Implant Device,876.05,35,,876.05,percent of total billed charges,Implant Device,876.05,35,,876.05,percent of total billed charges,Implant Device,876.05,35,,876.05,percent of total billed charges,Implant Device,876.05,35,,876.05,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,851.02,34,"If Charge > 2,000, then 34 percent",851.02,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1852.23,
ZIMMER 6624-65-25-REV SCREW,C1713,HCPCS,,79002243,CDM,278,RC,,,both,,,616,455.84,,,455.84,Other,150% of Medicare + 9.63% HCRA Surcharge,277.2,45,,277.2,percent of total billed charges,Critical Access Hospital RCC factor,209.44,34,,209.44,percent of total billed charges,Implant Device,209.44,34,,209.44,percent of total billed charges,Implant Device,209.44,34,,209.44,percent of total billed charges,Implant Device,209.44,34,,209.44,percent of total billed charges,Implant Device,209.44,34,,209.44,percent of total billed charges,Implant Device,304.92,,,304.92,Other,110% of Medicare,215.6,35,,215.6,percent of total billed charges,Implant Device,209.44,34,"Charges > $500, x 34%",209.44,percent of total billed charges,Implant Device,215.6,35,,215.6,percent of total billed charges,Implant Device,215.6,35,,215.6,percent of total billed charges,Implant Device,215.6,35,,215.6,percent of total billed charges,Implant Device,215.6,35,,215.6,percent of total billed charges,Implant Device,215.6,35,,215.6,percent of total billed charges,Implant Device,246.4,40,,246.4,percent of total billed charges,Implant Device,215.6,70,,215.6,percent of total billed charges,All Other,209.44,34,,209.44,percent of total billed charges,Implant Device,209.44,34,,209.44,percent of total billed charges,Implant Device,215.6,35,,215.6,percent of total billed charges,Implant Device,215.6,35,,215.6,percent of total billed charges,Implant Device,215.6,35,,215.6,percent of total billed charges,Implant Device,215.6,35,,215.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,455.84,
ZIMMER 6624-65-35-REV SCREW,C1713,HCPCS,,79002244,CDM,278,RC,,,both,,,616,455.84,,,455.84,Other,150% of Medicare + 9.63% HCRA Surcharge,277.2,45,,277.2,percent of total billed charges,Critical Access Hospital RCC factor,209.44,34,,209.44,percent of total billed charges,Implant Device,209.44,34,,209.44,percent of total billed charges,Implant Device,209.44,34,,209.44,percent of total billed charges,Implant Device,209.44,34,,209.44,percent of total billed charges,Implant Device,209.44,34,,209.44,percent of total billed charges,Implant Device,304.92,,,304.92,Other,110% of Medicare,215.6,35,,215.6,percent of total billed charges,Implant Device,209.44,34,"Charges > $500, x 34%",209.44,percent of total billed charges,Implant Device,215.6,35,,215.6,percent of total billed charges,Implant Device,215.6,35,,215.6,percent of total billed charges,Implant Device,215.6,35,,215.6,percent of total billed charges,Implant Device,215.6,35,,215.6,percent of total billed charges,Implant Device,215.6,35,,215.6,percent of total billed charges,Implant Device,246.4,40,,246.4,percent of total billed charges,Implant Device,215.6,70,,215.6,percent of total billed charges,All Other,209.44,34,,209.44,percent of total billed charges,Implant Device,209.44,34,,209.44,percent of total billed charges,Implant Device,215.6,35,,215.6,percent of total billed charges,Implant Device,215.6,35,,215.6,percent of total billed charges,Implant Device,215.6,35,,215.6,percent of total billed charges,Implant Device,215.6,35,,215.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,455.84,
ZIMMER 6624-65-40-REV SCREW,C1713,HCPCS,,79002245,CDM,278,RC,,,both,,,450,333,,,333,Other,150% of Medicare + 9.63% HCRA Surcharge,202.5,45,,202.5,percent of total billed charges,Critical Access Hospital RCC factor,153,34,,153,percent of total billed charges,Implant Device,153,34,,153,percent of total billed charges,Implant Device,153,34,,153,percent of total billed charges,Implant Device,153,34,,153,percent of total billed charges,Implant Device,153,34,,153,percent of total billed charges,Implant Device,222.75,,,222.75,Other,110% of Medicare,157.5,35,,157.5,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,157.5,35,,157.5,percent of total billed charges,Implant Device,157.5,35,,157.5,percent of total billed charges,Implant Device,157.5,35,,157.5,percent of total billed charges,Implant Device,157.5,35,,157.5,percent of total billed charges,Implant Device,157.5,35,,157.5,percent of total billed charges,Implant Device,180,40,,180,percent of total billed charges,Implant Device,157.5,70,,157.5,percent of total billed charges,All Other,153,34,,153,percent of total billed charges,Implant Device,153,34,,153,percent of total billed charges,Implant Device,157.5,35,,157.5,percent of total billed charges,Implant Device,157.5,35,,157.5,percent of total billed charges,Implant Device,157.5,35,,157.5,percent of total billed charges,Implant Device,157.5,35,,157.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,333,
STRYKER 6704-0-510 CABLE & SLEEVE 2MM,C1713,HCPCS,,79002246,CDM,278,RC,,,both,,,1588,1175.12,,,1175.12,Other,150% of Medicare + 9.63% HCRA Surcharge,714.6,45,,714.6,percent of total billed charges,Critical Access Hospital RCC factor,539.92,34,,539.92,percent of total billed charges,Implant Device,539.92,34,,539.92,percent of total billed charges,Implant Device,539.92,34,,539.92,percent of total billed charges,Implant Device,539.92,34,,539.92,percent of total billed charges,Implant Device,539.92,34,,539.92,percent of total billed charges,Implant Device,786.06,,,786.06,Other,110% of Medicare,555.8,35,,555.8,percent of total billed charges,Implant Device,539.92,34,"Charges > $500, x 34%",539.92,percent of total billed charges,Implant Device,555.8,35,,555.8,percent of total billed charges,Implant Device,555.8,35,,555.8,percent of total billed charges,Implant Device,555.8,35,,555.8,percent of total billed charges,Implant Device,555.8,35,,555.8,percent of total billed charges,Implant Device,555.8,35,,555.8,percent of total billed charges,Implant Device,635.2,40,,635.2,percent of total billed charges,Implant Device,555.8,70,,555.8,percent of total billed charges,All Other,539.92,34,,539.92,percent of total billed charges,Implant Device,539.92,34,,539.92,percent of total billed charges,Implant Device,555.8,35,,555.8,percent of total billed charges,Implant Device,555.8,35,,555.8,percent of total billed charges,Implant Device,555.8,35,,555.8,percent of total billed charges,Implant Device,555.8,35,,555.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1175.12,
STRYKER 6704-0-520 CABLE & SLEEVE,C1713,HCPCS,,79002247,CDM,278,RC,,,both,,,1536,1136.64,,,1136.64,Other,150% of Medicare + 9.63% HCRA Surcharge,691.2,45,,691.2,percent of total billed charges,Critical Access Hospital RCC factor,522.24,34,,522.24,percent of total billed charges,Implant Device,522.24,34,,522.24,percent of total billed charges,Implant Device,522.24,34,,522.24,percent of total billed charges,Implant Device,522.24,34,,522.24,percent of total billed charges,Implant Device,522.24,34,,522.24,percent of total billed charges,Implant Device,760.32,,,760.32,Other,110% of Medicare,537.6,35,,537.6,percent of total billed charges,Implant Device,522.24,34,"Charges > $500, x 34%",522.24,percent of total billed charges,Implant Device,537.6,35,,537.6,percent of total billed charges,Implant Device,537.6,35,,537.6,percent of total billed charges,Implant Device,537.6,35,,537.6,percent of total billed charges,Implant Device,537.6,35,,537.6,percent of total billed charges,Implant Device,537.6,35,,537.6,percent of total billed charges,Implant Device,614.4,40,,614.4,percent of total billed charges,Implant Device,537.6,70,,537.6,percent of total billed charges,All Other,522.24,34,,522.24,percent of total billed charges,Implant Device,522.24,34,,522.24,percent of total billed charges,Implant Device,537.6,35,,537.6,percent of total billed charges,Implant Device,537.6,35,,537.6,percent of total billed charges,Implant Device,537.6,35,,537.6,percent of total billed charges,Implant Device,537.6,35,,537.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1136.64,
STRYKER 6704-0-520-REV CABLE & SLEEVE,C1713,HCPCS,,79002248,CDM,278,RC,,,both,,,963,712.62,,,712.62,Other,150% of Medicare + 9.63% HCRA Surcharge,433.35,45,,433.35,percent of total billed charges,Critical Access Hospital RCC factor,327.42,34,,327.42,percent of total billed charges,Implant Device,327.42,34,,327.42,percent of total billed charges,Implant Device,327.42,34,,327.42,percent of total billed charges,Implant Device,327.42,34,,327.42,percent of total billed charges,Implant Device,327.42,34,,327.42,percent of total billed charges,Implant Device,476.69,,,476.69,Other,110% of Medicare,337.05,35,,337.05,percent of total billed charges,Implant Device,327.42,34,"Charges > $500, x 34%",327.42,percent of total billed charges,Implant Device,337.05,35,,337.05,percent of total billed charges,Implant Device,337.05,35,,337.05,percent of total billed charges,Implant Device,337.05,35,,337.05,percent of total billed charges,Implant Device,337.05,35,,337.05,percent of total billed charges,Implant Device,337.05,35,,337.05,percent of total billed charges,Implant Device,385.2,40,,385.2,percent of total billed charges,Implant Device,337.05,70,,337.05,percent of total billed charges,All Other,327.42,34,,327.42,percent of total billed charges,Implant Device,327.42,34,,327.42,percent of total billed charges,Implant Device,337.05,35,,337.05,percent of total billed charges,Implant Device,337.05,35,,337.05,percent of total billed charges,Implant Device,337.05,35,,337.05,percent of total billed charges,Implant Device,337.05,35,,337.05,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,712.62,
STRYKER 6704-3-082-REV PLATE,C1713,HCPCS,,79002249,CDM,278,RC,,,both,,,4320,3196.81,,,3196.81,Other,150% of Medicare + 9.63% HCRA Surcharge,1944,45,,1944,percent of total billed charges,Critical Access Hospital RCC factor,1468.8,34,,1468.8,percent of total billed charges,Implant Device,1468.8,34,,1468.8,percent of total billed charges,Implant Device,1468.8,34,,1468.8,percent of total billed charges,Implant Device,1468.8,34,,1468.8,percent of total billed charges,Implant Device,1468.8,34,,1468.8,percent of total billed charges,Implant Device,2138.4,,,2138.4,Other,110% of Medicare,1512,35,,1512,percent of total billed charges,Implant Device,1468.8,34,"Charges > $500, x 34%",1468.8,percent of total billed charges,Implant Device,1512,35,,1512,percent of total billed charges,Implant Device,1512,35,,1512,percent of total billed charges,Implant Device,1512,35,,1512,percent of total billed charges,Implant Device,1512,35,,1512,percent of total billed charges,Implant Device,1512,35,,1512,percent of total billed charges,Implant Device,1728,40,,1728,percent of total billed charges,Implant Device,1512,70,,1512,percent of total billed charges,All Other,1468.8,34,,1468.8,percent of total billed charges,Implant Device,1468.8,34,,1468.8,percent of total billed charges,Implant Device,1512,35,,1512,percent of total billed charges,Implant Device,1512,35,,1512,percent of total billed charges,Implant Device,1512,35,,1512,percent of total billed charges,Implant Device,1512,35,,1512,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1468.8,34,"If Charge > 2,000, then 34 percent",1468.8,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3196.81,
ZIMMER 6704-3-083-REV PLATE,C1713,HCPCS,,79002250,CDM,278,RC,,,both,,,8688,6429.14,,,6429.14,Other,150% of Medicare + 9.63% HCRA Surcharge,3909.6,45,,3909.6,percent of total billed charges,Critical Access Hospital RCC factor,2953.92,34,,2953.92,percent of total billed charges,Implant Device,2953.92,34,,2953.92,percent of total billed charges,Implant Device,2953.92,34,,2953.92,percent of total billed charges,Implant Device,2953.92,34,,2953.92,percent of total billed charges,Implant Device,2953.92,34,,2953.92,percent of total billed charges,Implant Device,4300.56,,,4300.56,Other,110% of Medicare,3040.8,35,,3040.8,percent of total billed charges,Implant Device,2953.92,34,"Charges > $500, x 34%",2953.92,percent of total billed charges,Implant Device,3040.8,35,,3040.8,percent of total billed charges,Implant Device,3040.8,35,,3040.8,percent of total billed charges,Implant Device,3040.8,35,,3040.8,percent of total billed charges,Implant Device,3040.8,35,,3040.8,percent of total billed charges,Implant Device,3040.8,35,,3040.8,percent of total billed charges,Implant Device,3475.2,40,,3475.2,percent of total billed charges,Implant Device,3040.8,70,,3040.8,percent of total billed charges,All Other,2953.92,34,,2953.92,percent of total billed charges,Implant Device,2953.92,34,,2953.92,percent of total billed charges,Implant Device,3040.8,35,,3040.8,percent of total billed charges,Implant Device,3040.8,35,,3040.8,percent of total billed charges,Implant Device,3040.8,35,,3040.8,percent of total billed charges,Implant Device,3040.8,35,,3040.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2953.92,34,"If Charge > 2,000, then 34 percent",2953.92,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,6429.14,
ACUMED 70-0060 PLATE,C1713,HCPCS,,79002251,CDM,278,RC,,,both,,,2446,1810.05,,,1810.05,Other,150% of Medicare + 9.63% HCRA Surcharge,1100.7,45,,1100.7,percent of total billed charges,Critical Access Hospital RCC factor,831.64,34,,831.64,percent of total billed charges,Implant Device,831.64,34,,831.64,percent of total billed charges,Implant Device,831.64,34,,831.64,percent of total billed charges,Implant Device,831.64,34,,831.64,percent of total billed charges,Implant Device,831.64,34,,831.64,percent of total billed charges,Implant Device,1210.77,,,1210.77,Other,110% of Medicare,856.1,35,,856.1,percent of total billed charges,Implant Device,831.64,34,"Charges > $500, x 34%",831.64,percent of total billed charges,Implant Device,856.1,35,,856.1,percent of total billed charges,Implant Device,856.1,35,,856.1,percent of total billed charges,Implant Device,856.1,35,,856.1,percent of total billed charges,Implant Device,856.1,35,,856.1,percent of total billed charges,Implant Device,856.1,35,,856.1,percent of total billed charges,Implant Device,978.4,40,,978.4,percent of total billed charges,Implant Device,856.1,70,,856.1,percent of total billed charges,All Other,831.64,34,,831.64,percent of total billed charges,Implant Device,831.64,34,,831.64,percent of total billed charges,Implant Device,856.1,35,,856.1,percent of total billed charges,Implant Device,856.1,35,,856.1,percent of total billed charges,Implant Device,856.1,35,,856.1,percent of total billed charges,Implant Device,856.1,35,,856.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,831.64,34,"If Charge > 2,000, then 34 percent",831.64,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1810.05,
ACUMED 70-0067 PLATE,C1713,HCPCS,,79002252,CDM,278,RC,,,both,,,2734,2023.17,,,2023.17,Other,150% of Medicare + 9.63% HCRA Surcharge,1230.3,45,,1230.3,percent of total billed charges,Critical Access Hospital RCC factor,929.56,34,,929.56,percent of total billed charges,Implant Device,929.56,34,,929.56,percent of total billed charges,Implant Device,929.56,34,,929.56,percent of total billed charges,Implant Device,929.56,34,,929.56,percent of total billed charges,Implant Device,929.56,34,,929.56,percent of total billed charges,Implant Device,1353.33,,,1353.33,Other,110% of Medicare,956.9,35,,956.9,percent of total billed charges,Implant Device,929.56,34,"Charges > $500, x 34%",929.56,percent of total billed charges,Implant Device,956.9,35,,956.9,percent of total billed charges,Implant Device,956.9,35,,956.9,percent of total billed charges,Implant Device,956.9,35,,956.9,percent of total billed charges,Implant Device,956.9,35,,956.9,percent of total billed charges,Implant Device,956.9,35,,956.9,percent of total billed charges,Implant Device,1093.6,40,,1093.6,percent of total billed charges,Implant Device,956.9,70,,956.9,percent of total billed charges,All Other,929.56,34,,929.56,percent of total billed charges,Implant Device,929.56,34,,929.56,percent of total billed charges,Implant Device,956.9,35,,956.9,percent of total billed charges,Implant Device,956.9,35,,956.9,percent of total billed charges,Implant Device,956.9,35,,956.9,percent of total billed charges,Implant Device,956.9,35,,956.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,929.56,34,"If Charge > 2,000, then 34 percent",929.56,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2023.17,
ACUMED 70-0070 PLATE,C1713,HCPCS,,79002253,CDM,278,RC,,,both,,,2734,2023.17,,,2023.17,Other,150% of Medicare + 9.63% HCRA Surcharge,1230.3,45,,1230.3,percent of total billed charges,Critical Access Hospital RCC factor,929.56,34,,929.56,percent of total billed charges,Implant Device,929.56,34,,929.56,percent of total billed charges,Implant Device,929.56,34,,929.56,percent of total billed charges,Implant Device,929.56,34,,929.56,percent of total billed charges,Implant Device,929.56,34,,929.56,percent of total billed charges,Implant Device,1353.33,,,1353.33,Other,110% of Medicare,956.9,35,,956.9,percent of total billed charges,Implant Device,929.56,34,"Charges > $500, x 34%",929.56,percent of total billed charges,Implant Device,956.9,35,,956.9,percent of total billed charges,Implant Device,956.9,35,,956.9,percent of total billed charges,Implant Device,956.9,35,,956.9,percent of total billed charges,Implant Device,956.9,35,,956.9,percent of total billed charges,Implant Device,956.9,35,,956.9,percent of total billed charges,Implant Device,1093.6,40,,1093.6,percent of total billed charges,Implant Device,956.9,70,,956.9,percent of total billed charges,All Other,929.56,34,,929.56,percent of total billed charges,Implant Device,929.56,34,,929.56,percent of total billed charges,Implant Device,956.9,35,,956.9,percent of total billed charges,Implant Device,956.9,35,,956.9,percent of total billed charges,Implant Device,956.9,35,,956.9,percent of total billed charges,Implant Device,956.9,35,,956.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,929.56,34,"If Charge > 2,000, then 34 percent",929.56,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2023.17,
ACUMED 70-0071 PLATE,C1713,HCPCS,,79002254,CDM,278,RC,,,both,,,2446,1810.05,,,1810.05,Other,150% of Medicare + 9.63% HCRA Surcharge,1100.7,45,,1100.7,percent of total billed charges,Critical Access Hospital RCC factor,831.64,34,,831.64,percent of total billed charges,Implant Device,831.64,34,,831.64,percent of total billed charges,Implant Device,831.64,34,,831.64,percent of total billed charges,Implant Device,831.64,34,,831.64,percent of total billed charges,Implant Device,831.64,34,,831.64,percent of total billed charges,Implant Device,1210.77,,,1210.77,Other,110% of Medicare,856.1,35,,856.1,percent of total billed charges,Implant Device,831.64,34,"Charges > $500, x 34%",831.64,percent of total billed charges,Implant Device,856.1,35,,856.1,percent of total billed charges,Implant Device,856.1,35,,856.1,percent of total billed charges,Implant Device,856.1,35,,856.1,percent of total billed charges,Implant Device,856.1,35,,856.1,percent of total billed charges,Implant Device,856.1,35,,856.1,percent of total billed charges,Implant Device,978.4,40,,978.4,percent of total billed charges,Implant Device,856.1,70,,856.1,percent of total billed charges,All Other,831.64,34,,831.64,percent of total billed charges,Implant Device,831.64,34,,831.64,percent of total billed charges,Implant Device,856.1,35,,856.1,percent of total billed charges,Implant Device,856.1,35,,856.1,percent of total billed charges,Implant Device,856.1,35,,856.1,percent of total billed charges,Implant Device,856.1,35,,856.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,831.64,34,"If Charge > 2,000, then 34 percent",831.64,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1810.05,
ACUMED 70-0112 PLATE,C1713,HCPCS,,79002255,CDM,278,RC,,,both,,,3366,2490.85,,,2490.85,Other,150% of Medicare + 9.63% HCRA Surcharge,1514.7,45,,1514.7,percent of total billed charges,Critical Access Hospital RCC factor,1144.44,34,,1144.44,percent of total billed charges,Implant Device,1144.44,34,,1144.44,percent of total billed charges,Implant Device,1144.44,34,,1144.44,percent of total billed charges,Implant Device,1144.44,34,,1144.44,percent of total billed charges,Implant Device,1144.44,34,,1144.44,percent of total billed charges,Implant Device,1666.17,,,1666.17,Other,110% of Medicare,1178.1,35,,1178.1,percent of total billed charges,Implant Device,1144.44,34,"Charges > $500, x 34%",1144.44,percent of total billed charges,Implant Device,1178.1,35,,1178.1,percent of total billed charges,Implant Device,1178.1,35,,1178.1,percent of total billed charges,Implant Device,1178.1,35,,1178.1,percent of total billed charges,Implant Device,1178.1,35,,1178.1,percent of total billed charges,Implant Device,1178.1,35,,1178.1,percent of total billed charges,Implant Device,1346.4,40,,1346.4,percent of total billed charges,Implant Device,1178.1,70,,1178.1,percent of total billed charges,All Other,1144.44,34,,1144.44,percent of total billed charges,Implant Device,1144.44,34,,1144.44,percent of total billed charges,Implant Device,1178.1,35,,1178.1,percent of total billed charges,Implant Device,1178.1,35,,1178.1,percent of total billed charges,Implant Device,1178.1,35,,1178.1,percent of total billed charges,Implant Device,1178.1,35,,1178.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1144.44,34,"If Charge > 2,000, then 34 percent",1144.44,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2490.85,
ACUMED 70-0295 PLATE,C1713,HCPCS,,79002256,CDM,278,RC,,,both,,,4467,3305.59,,,3305.59,Other,150% of Medicare + 9.63% HCRA Surcharge,2010.15,45,,2010.15,percent of total billed charges,Critical Access Hospital RCC factor,1518.78,34,,1518.78,percent of total billed charges,Implant Device,1518.78,34,,1518.78,percent of total billed charges,Implant Device,1518.78,34,,1518.78,percent of total billed charges,Implant Device,1518.78,34,,1518.78,percent of total billed charges,Implant Device,1518.78,34,,1518.78,percent of total billed charges,Implant Device,2211.17,,,2211.17,Other,110% of Medicare,1563.45,35,,1563.45,percent of total billed charges,Implant Device,1518.78,34,"Charges > $500, x 34%",1518.78,percent of total billed charges,Implant Device,1563.45,35,,1563.45,percent of total billed charges,Implant Device,1563.45,35,,1563.45,percent of total billed charges,Implant Device,1563.45,35,,1563.45,percent of total billed charges,Implant Device,1563.45,35,,1563.45,percent of total billed charges,Implant Device,1563.45,35,,1563.45,percent of total billed charges,Implant Device,1786.8,40,,1786.8,percent of total billed charges,Implant Device,1563.45,70,,1563.45,percent of total billed charges,All Other,1518.78,34,,1518.78,percent of total billed charges,Implant Device,1518.78,34,,1518.78,percent of total billed charges,Implant Device,1563.45,35,,1563.45,percent of total billed charges,Implant Device,1563.45,35,,1563.45,percent of total billed charges,Implant Device,1563.45,35,,1563.45,percent of total billed charges,Implant Device,1563.45,35,,1563.45,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1518.78,34,"If Charge > 2,000, then 34 percent",1518.78,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3305.59,
ACUMED 70-0297 PLATE,C1713,HCPCS,,79002257,CDM,278,RC,,,both,,,3498,2588.53,,,2588.53,Other,150% of Medicare + 9.63% HCRA Surcharge,1574.1,45,,1574.1,percent of total billed charges,Critical Access Hospital RCC factor,1189.32,34,,1189.32,percent of total billed charges,Implant Device,1189.32,34,,1189.32,percent of total billed charges,Implant Device,1189.32,34,,1189.32,percent of total billed charges,Implant Device,1189.32,34,,1189.32,percent of total billed charges,Implant Device,1189.32,34,,1189.32,percent of total billed charges,Implant Device,1731.51,,,1731.51,Other,110% of Medicare,1224.3,35,,1224.3,percent of total billed charges,Implant Device,1189.32,34,"Charges > $500, x 34%",1189.32,percent of total billed charges,Implant Device,1224.3,35,,1224.3,percent of total billed charges,Implant Device,1224.3,35,,1224.3,percent of total billed charges,Implant Device,1224.3,35,,1224.3,percent of total billed charges,Implant Device,1224.3,35,,1224.3,percent of total billed charges,Implant Device,1224.3,35,,1224.3,percent of total billed charges,Implant Device,1399.2,40,,1399.2,percent of total billed charges,Implant Device,1224.3,70,,1224.3,percent of total billed charges,All Other,1189.32,34,,1189.32,percent of total billed charges,Implant Device,1189.32,34,,1189.32,percent of total billed charges,Implant Device,1224.3,35,,1224.3,percent of total billed charges,Implant Device,1224.3,35,,1224.3,percent of total billed charges,Implant Device,1224.3,35,,1224.3,percent of total billed charges,Implant Device,1224.3,35,,1224.3,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1189.32,34,"If Charge > 2,000, then 34 percent",1189.32,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2588.53,
ACUMED 70-0298 PLATE,C1713,HCPCS,,79002258,CDM,278,RC,,,both,,,3498,2588.53,,,2588.53,Other,150% of Medicare + 9.63% HCRA Surcharge,1574.1,45,,1574.1,percent of total billed charges,Critical Access Hospital RCC factor,1189.32,34,,1189.32,percent of total billed charges,Implant Device,1189.32,34,,1189.32,percent of total billed charges,Implant Device,1189.32,34,,1189.32,percent of total billed charges,Implant Device,1189.32,34,,1189.32,percent of total billed charges,Implant Device,1189.32,34,,1189.32,percent of total billed charges,Implant Device,1731.51,,,1731.51,Other,110% of Medicare,1224.3,35,,1224.3,percent of total billed charges,Implant Device,1189.32,34,"Charges > $500, x 34%",1189.32,percent of total billed charges,Implant Device,1224.3,35,,1224.3,percent of total billed charges,Implant Device,1224.3,35,,1224.3,percent of total billed charges,Implant Device,1224.3,35,,1224.3,percent of total billed charges,Implant Device,1224.3,35,,1224.3,percent of total billed charges,Implant Device,1224.3,35,,1224.3,percent of total billed charges,Implant Device,1399.2,40,,1399.2,percent of total billed charges,Implant Device,1224.3,70,,1224.3,percent of total billed charges,All Other,1189.32,34,,1189.32,percent of total billed charges,Implant Device,1189.32,34,,1189.32,percent of total billed charges,Implant Device,1224.3,35,,1224.3,percent of total billed charges,Implant Device,1224.3,35,,1224.3,percent of total billed charges,Implant Device,1224.3,35,,1224.3,percent of total billed charges,Implant Device,1224.3,35,,1224.3,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1189.32,34,"If Charge > 2,000, then 34 percent",1189.32,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2588.53,
ACUMED 70-0299 PLATE,C1713,HCPCS,,79002259,CDM,278,RC,,,both,,,3498,2588.53,,,2588.53,Other,150% of Medicare + 9.63% HCRA Surcharge,1574.1,45,,1574.1,percent of total billed charges,Critical Access Hospital RCC factor,1189.32,34,,1189.32,percent of total billed charges,Implant Device,1189.32,34,,1189.32,percent of total billed charges,Implant Device,1189.32,34,,1189.32,percent of total billed charges,Implant Device,1189.32,34,,1189.32,percent of total billed charges,Implant Device,1189.32,34,,1189.32,percent of total billed charges,Implant Device,1731.51,,,1731.51,Other,110% of Medicare,1224.3,35,,1224.3,percent of total billed charges,Implant Device,1189.32,34,"Charges > $500, x 34%",1189.32,percent of total billed charges,Implant Device,1224.3,35,,1224.3,percent of total billed charges,Implant Device,1224.3,35,,1224.3,percent of total billed charges,Implant Device,1224.3,35,,1224.3,percent of total billed charges,Implant Device,1224.3,35,,1224.3,percent of total billed charges,Implant Device,1224.3,35,,1224.3,percent of total billed charges,Implant Device,1399.2,40,,1399.2,percent of total billed charges,Implant Device,1224.3,70,,1224.3,percent of total billed charges,All Other,1189.32,34,,1189.32,percent of total billed charges,Implant Device,1189.32,34,,1189.32,percent of total billed charges,Implant Device,1224.3,35,,1224.3,percent of total billed charges,Implant Device,1224.3,35,,1224.3,percent of total billed charges,Implant Device,1224.3,35,,1224.3,percent of total billed charges,Implant Device,1224.3,35,,1224.3,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1189.32,34,"If Charge > 2,000, then 34 percent",1189.32,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2588.53,
ACUMED 70-0301 PLATE,C1713,HCPCS,,79002260,CDM,278,RC,,,both,,,3498,2588.53,,,2588.53,Other,150% of Medicare + 9.63% HCRA Surcharge,1574.1,45,,1574.1,percent of total billed charges,Critical Access Hospital RCC factor,1189.32,34,,1189.32,percent of total billed charges,Implant Device,1189.32,34,,1189.32,percent of total billed charges,Implant Device,1189.32,34,,1189.32,percent of total billed charges,Implant Device,1189.32,34,,1189.32,percent of total billed charges,Implant Device,1189.32,34,,1189.32,percent of total billed charges,Implant Device,1731.51,,,1731.51,Other,110% of Medicare,1224.3,35,,1224.3,percent of total billed charges,Implant Device,1189.32,34,"Charges > $500, x 34%",1189.32,percent of total billed charges,Implant Device,1224.3,35,,1224.3,percent of total billed charges,Implant Device,1224.3,35,,1224.3,percent of total billed charges,Implant Device,1224.3,35,,1224.3,percent of total billed charges,Implant Device,1224.3,35,,1224.3,percent of total billed charges,Implant Device,1224.3,35,,1224.3,percent of total billed charges,Implant Device,1399.2,40,,1399.2,percent of total billed charges,Implant Device,1224.3,70,,1224.3,percent of total billed charges,All Other,1189.32,34,,1189.32,percent of total billed charges,Implant Device,1189.32,34,,1189.32,percent of total billed charges,Implant Device,1224.3,35,,1224.3,percent of total billed charges,Implant Device,1224.3,35,,1224.3,percent of total billed charges,Implant Device,1224.3,35,,1224.3,percent of total billed charges,Implant Device,1224.3,35,,1224.3,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1189.32,34,"If Charge > 2,000, then 34 percent",1189.32,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2588.53,
ACUMED 70-0304 PLATE,C1713,HCPCS,,79002261,CDM,278,RC,,,both,,,3300,2442.01,,,2442.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1485,45,,1485,percent of total billed charges,Critical Access Hospital RCC factor,1122,34,,1122,percent of total billed charges,Implant Device,1122,34,,1122,percent of total billed charges,Implant Device,1122,34,,1122,percent of total billed charges,Implant Device,1122,34,,1122,percent of total billed charges,Implant Device,1122,34,,1122,percent of total billed charges,Implant Device,1633.5,,,1633.5,Other,110% of Medicare,1155,35,,1155,percent of total billed charges,Implant Device,1122,34,"Charges > $500, x 34%",1122,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,1320,40,,1320,percent of total billed charges,Implant Device,1155,70,,1155,percent of total billed charges,All Other,1122,34,,1122,percent of total billed charges,Implant Device,1122,34,,1122,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1122,34,"If Charge > 2,000, then 34 percent",1122,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2442.01,
ACUMED 70-0357-PLATE,C1713,HCPCS,,79002262,CDM,278,RC,,,both,,,3801,2812.75,,,2812.75,Other,150% of Medicare + 9.63% HCRA Surcharge,1710.45,45,,1710.45,percent of total billed charges,Critical Access Hospital RCC factor,1292.34,34,,1292.34,percent of total billed charges,Implant Device,1292.34,34,,1292.34,percent of total billed charges,Implant Device,1292.34,34,,1292.34,percent of total billed charges,Implant Device,1292.34,34,,1292.34,percent of total billed charges,Implant Device,1292.34,34,,1292.34,percent of total billed charges,Implant Device,1881.5,,,1881.5,Other,110% of Medicare,1330.35,35,,1330.35,percent of total billed charges,Implant Device,1292.34,34,"Charges > $500, x 34%",1292.34,percent of total billed charges,Implant Device,1330.35,35,,1330.35,percent of total billed charges,Implant Device,1330.35,35,,1330.35,percent of total billed charges,Implant Device,1330.35,35,,1330.35,percent of total billed charges,Implant Device,1330.35,35,,1330.35,percent of total billed charges,Implant Device,1330.35,35,,1330.35,percent of total billed charges,Implant Device,1520.4,40,,1520.4,percent of total billed charges,Implant Device,1330.35,70,,1330.35,percent of total billed charges,All Other,1292.34,34,,1292.34,percent of total billed charges,Implant Device,1292.34,34,,1292.34,percent of total billed charges,Implant Device,1330.35,35,,1330.35,percent of total billed charges,Implant Device,1330.35,35,,1330.35,percent of total billed charges,Implant Device,1330.35,35,,1330.35,percent of total billed charges,Implant Device,1330.35,35,,1330.35,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1292.34,34,"If Charge > 2,000, then 34 percent",1292.34,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2812.75,
ZIMMER 7110-48-28-REV TRABECULAR SHELL,C1776,HCPCS,,79002263,CDM,278,RC,,,both,,,7620,5638.82,,,5638.82,Other,150% of Medicare + 9.63% HCRA Surcharge,3429,45,,3429,percent of total billed charges,Critical Access Hospital RCC factor,2590.8,34,,2590.8,percent of total billed charges,Implant Device,2590.8,34,,2590.8,percent of total billed charges,Implant Device,2590.8,34,,2590.8,percent of total billed charges,Implant Device,2590.8,34,,2590.8,percent of total billed charges,Implant Device,2590.8,34,,2590.8,percent of total billed charges,Implant Device,3771.9,,,3771.9,Other,110% of Medicare,2667,35,,2667,percent of total billed charges,Implant Device,2590.8,34,"Charges > $500, x 34%",2590.8,percent of total billed charges,Implant Device,2667,35,,2667,percent of total billed charges,Implant Device,2667,35,,2667,percent of total billed charges,Implant Device,2667,35,,2667,percent of total billed charges,Implant Device,2667,35,,2667,percent of total billed charges,Implant Device,2667,35,,2667,percent of total billed charges,Implant Device,3048,40,,3048,percent of total billed charges,Implant Device,2667,70,,2667,percent of total billed charges,All Other,2590.8,34,,2590.8,percent of total billed charges,Implant Device,2590.8,34,,2590.8,percent of total billed charges,Implant Device,2667,35,,2667,percent of total billed charges,Implant Device,2667,35,,2667,percent of total billed charges,Implant Device,2667,35,,2667,percent of total billed charges,Implant Device,2667,35,,2667,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2590.8,34,"If Charge > 2,000, then 34 percent",2590.8,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5638.82,
S&N 71303604-REV FEMORAL HEAD,C1776,HCPCS,,79002264,CDM,278,RC,,,both,,,2573,1904.03,,,1904.03,Other,150% of Medicare + 9.63% HCRA Surcharge,1157.85,45,,1157.85,percent of total billed charges,Critical Access Hospital RCC factor,874.82,34,,874.82,percent of total billed charges,Implant Device,874.82,34,,874.82,percent of total billed charges,Implant Device,874.82,34,,874.82,percent of total billed charges,Implant Device,874.82,34,,874.82,percent of total billed charges,Implant Device,874.82,34,,874.82,percent of total billed charges,Implant Device,1273.64,,,1273.64,Other,110% of Medicare,900.55,35,,900.55,percent of total billed charges,Implant Device,874.82,34,"Charges > $500, x 34%",874.82,percent of total billed charges,Implant Device,900.55,35,,900.55,percent of total billed charges,Implant Device,900.55,35,,900.55,percent of total billed charges,Implant Device,900.55,35,,900.55,percent of total billed charges,Implant Device,900.55,35,,900.55,percent of total billed charges,Implant Device,900.55,35,,900.55,percent of total billed charges,Implant Device,1029.2,40,,1029.2,percent of total billed charges,Implant Device,900.55,70,,900.55,percent of total billed charges,All Other,874.82,34,,874.82,percent of total billed charges,Implant Device,874.82,34,,874.82,percent of total billed charges,Implant Device,900.55,35,,900.55,percent of total billed charges,Implant Device,900.55,35,,900.55,percent of total billed charges,Implant Device,900.55,35,,900.55,percent of total billed charges,Implant Device,900.55,35,,900.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,874.82,34,"If Charge > 2,000, then 34 percent",874.82,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1904.03,
S&N 71306613-REV FEMORAL COMP,C1776,HCPCS,,79002265,CDM,278,RC,,,both,,,8988,6651.14,,,6651.14,Other,150% of Medicare + 9.63% HCRA Surcharge,4044.6,45,,4044.6,percent of total billed charges,Critical Access Hospital RCC factor,3055.92,34,,3055.92,percent of total billed charges,Implant Device,3055.92,34,,3055.92,percent of total billed charges,Implant Device,3055.92,34,,3055.92,percent of total billed charges,Implant Device,3055.92,34,,3055.92,percent of total billed charges,Implant Device,3055.92,34,,3055.92,percent of total billed charges,Implant Device,4449.06,,,4449.06,Other,110% of Medicare,3145.8,35,,3145.8,percent of total billed charges,Implant Device,3055.92,34,"Charges > $500, x 34%",3055.92,percent of total billed charges,Implant Device,3145.8,35,,3145.8,percent of total billed charges,Implant Device,3145.8,35,,3145.8,percent of total billed charges,Implant Device,3145.8,35,,3145.8,percent of total billed charges,Implant Device,3145.8,35,,3145.8,percent of total billed charges,Implant Device,3145.8,35,,3145.8,percent of total billed charges,Implant Device,3595.2,40,,3595.2,percent of total billed charges,Implant Device,3145.8,70,,3145.8,percent of total billed charges,All Other,3055.92,34,,3055.92,percent of total billed charges,Implant Device,3055.92,34,,3055.92,percent of total billed charges,Implant Device,3145.8,35,,3145.8,percent of total billed charges,Implant Device,3145.8,35,,3145.8,percent of total billed charges,Implant Device,3145.8,35,,3145.8,percent of total billed charges,Implant Device,3145.8,35,,3145.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3055.92,34,"If Charge > 2,000, then 34 percent",3055.92,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,6651.14,
S&N 7133345-REV ADCET LINER,C1776,HCPCS,,79002266,CDM,278,RC,,,both,,,3852,2850.49,,,2850.49,Other,150% of Medicare + 9.63% HCRA Surcharge,1733.4,45,,1733.4,percent of total billed charges,Critical Access Hospital RCC factor,1309.68,34,,1309.68,percent of total billed charges,Implant Device,1309.68,34,,1309.68,percent of total billed charges,Implant Device,1309.68,34,,1309.68,percent of total billed charges,Implant Device,1309.68,34,,1309.68,percent of total billed charges,Implant Device,1309.68,34,,1309.68,percent of total billed charges,Implant Device,1906.74,,,1906.74,Other,110% of Medicare,1348.2,35,,1348.2,percent of total billed charges,Implant Device,1309.68,34,"Charges > $500, x 34%",1309.68,percent of total billed charges,Implant Device,1348.2,35,,1348.2,percent of total billed charges,Implant Device,1348.2,35,,1348.2,percent of total billed charges,Implant Device,1348.2,35,,1348.2,percent of total billed charges,Implant Device,1348.2,35,,1348.2,percent of total billed charges,Implant Device,1348.2,35,,1348.2,percent of total billed charges,Implant Device,1540.8,40,,1540.8,percent of total billed charges,Implant Device,1348.2,70,,1348.2,percent of total billed charges,All Other,1309.68,34,,1309.68,percent of total billed charges,Implant Device,1309.68,34,,1309.68,percent of total billed charges,Implant Device,1348.2,35,,1348.2,percent of total billed charges,Implant Device,1348.2,35,,1348.2,percent of total billed charges,Implant Device,1348.2,35,,1348.2,percent of total billed charges,Implant Device,1348.2,35,,1348.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1309.68,34,"If Charge > 2,000, then 34 percent",1309.68,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2850.49,
S&N 71420504-REV ART INSERT,C1776,HCPCS,,79002267,CDM,278,RC,,,both,,,2962,2191.89,,,2191.89,Other,150% of Medicare + 9.63% HCRA Surcharge,1332.9,45,,1332.9,percent of total billed charges,Critical Access Hospital RCC factor,1007.08,34,,1007.08,percent of total billed charges,Implant Device,1007.08,34,,1007.08,percent of total billed charges,Implant Device,1007.08,34,,1007.08,percent of total billed charges,Implant Device,1007.08,34,,1007.08,percent of total billed charges,Implant Device,1007.08,34,,1007.08,percent of total billed charges,Implant Device,1466.19,,,1466.19,Other,110% of Medicare,1036.7,35,,1036.7,percent of total billed charges,Implant Device,1007.08,34,"Charges > $500, x 34%",1007.08,percent of total billed charges,Implant Device,1036.7,35,,1036.7,percent of total billed charges,Implant Device,1036.7,35,,1036.7,percent of total billed charges,Implant Device,1036.7,35,,1036.7,percent of total billed charges,Implant Device,1036.7,35,,1036.7,percent of total billed charges,Implant Device,1036.7,35,,1036.7,percent of total billed charges,Implant Device,1184.8,40,,1184.8,percent of total billed charges,Implant Device,1036.7,70,,1036.7,percent of total billed charges,All Other,1007.08,34,,1007.08,percent of total billed charges,Implant Device,1007.08,34,,1007.08,percent of total billed charges,Implant Device,1036.7,35,,1036.7,percent of total billed charges,Implant Device,1036.7,35,,1036.7,percent of total billed charges,Implant Device,1036.7,35,,1036.7,percent of total billed charges,Implant Device,1036.7,35,,1036.7,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1007.08,34,"If Charge > 2,000, then 34 percent",1007.08,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2191.89,
S&N 71420551-REV ART INSERT,C1776,HCPCS,,79002268,CDM,278,RC,,,both,,,8700,6438.02,,,6438.02,Other,150% of Medicare + 9.63% HCRA Surcharge,3915,45,,3915,percent of total billed charges,Critical Access Hospital RCC factor,2958,34,,2958,percent of total billed charges,Implant Device,2958,34,,2958,percent of total billed charges,Implant Device,2958,34,,2958,percent of total billed charges,Implant Device,2958,34,,2958,percent of total billed charges,Implant Device,2958,34,,2958,percent of total billed charges,Implant Device,4306.5,,,4306.5,Other,110% of Medicare,3045,35,,3045,percent of total billed charges,Implant Device,2958,34,"Charges > $500, x 34%",2958,percent of total billed charges,Implant Device,3045,35,,3045,percent of total billed charges,Implant Device,3045,35,,3045,percent of total billed charges,Implant Device,3045,35,,3045,percent of total billed charges,Implant Device,3045,35,,3045,percent of total billed charges,Implant Device,3045,35,,3045,percent of total billed charges,Implant Device,3480,40,,3480,percent of total billed charges,Implant Device,3045,70,,3045,percent of total billed charges,All Other,2958,34,,2958,percent of total billed charges,Implant Device,2958,34,,2958,percent of total billed charges,Implant Device,3045,35,,3045,percent of total billed charges,Implant Device,3045,35,,3045,percent of total billed charges,Implant Device,3045,35,,3045,percent of total billed charges,Implant Device,3045,35,,3045,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2958,34,"If Charge > 2,000, then 34 percent",2958,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,6438.02,
S&N 71420554-REV ART INSERT,C1776,HCPCS,,79002269,CDM,278,RC,,,both,,,8700,6438.02,,,6438.02,Other,150% of Medicare + 9.63% HCRA Surcharge,3915,45,,3915,percent of total billed charges,Critical Access Hospital RCC factor,2958,34,,2958,percent of total billed charges,Implant Device,2958,34,,2958,percent of total billed charges,Implant Device,2958,34,,2958,percent of total billed charges,Implant Device,2958,34,,2958,percent of total billed charges,Implant Device,2958,34,,2958,percent of total billed charges,Implant Device,4306.5,,,4306.5,Other,110% of Medicare,3045,35,,3045,percent of total billed charges,Implant Device,2958,34,"Charges > $500, x 34%",2958,percent of total billed charges,Implant Device,3045,35,,3045,percent of total billed charges,Implant Device,3045,35,,3045,percent of total billed charges,Implant Device,3045,35,,3045,percent of total billed charges,Implant Device,3045,35,,3045,percent of total billed charges,Implant Device,3045,35,,3045,percent of total billed charges,Implant Device,3480,40,,3480,percent of total billed charges,Implant Device,3045,70,,3045,percent of total billed charges,All Other,2958,34,,2958,percent of total billed charges,Implant Device,2958,34,,2958,percent of total billed charges,Implant Device,3045,35,,3045,percent of total billed charges,Implant Device,3045,35,,3045,percent of total billed charges,Implant Device,3045,35,,3045,percent of total billed charges,Implant Device,3045,35,,3045,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2958,34,"If Charge > 2,000, then 34 percent",2958,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,6438.02,
S&N 71420574-REV PATELLA COMP,C1776,HCPCS,,79002270,CDM,278,RC,,,both,,,1815,1343.1,,,1343.1,Other,150% of Medicare + 9.63% HCRA Surcharge,816.75,45,,816.75,percent of total billed charges,Critical Access Hospital RCC factor,617.1,34,,617.1,percent of total billed charges,Implant Device,617.1,34,,617.1,percent of total billed charges,Implant Device,617.1,34,,617.1,percent of total billed charges,Implant Device,617.1,34,,617.1,percent of total billed charges,Implant Device,617.1,34,,617.1,percent of total billed charges,Implant Device,898.43,,,898.43,Other,110% of Medicare,635.25,35,,635.25,percent of total billed charges,Implant Device,617.1,34,"Charges > $500, x 34%",617.1,percent of total billed charges,Implant Device,635.25,35,,635.25,percent of total billed charges,Implant Device,635.25,35,,635.25,percent of total billed charges,Implant Device,635.25,35,,635.25,percent of total billed charges,Implant Device,635.25,35,,635.25,percent of total billed charges,Implant Device,635.25,35,,635.25,percent of total billed charges,Implant Device,726,40,,726,percent of total billed charges,Implant Device,635.25,70,,635.25,percent of total billed charges,All Other,617.1,34,,617.1,percent of total billed charges,Implant Device,617.1,34,,617.1,percent of total billed charges,Implant Device,635.25,35,,635.25,percent of total billed charges,Implant Device,635.25,35,,635.25,percent of total billed charges,Implant Device,635.25,35,,635.25,percent of total billed charges,Implant Device,635.25,35,,635.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1343.1,
S&N 71420576-REV PATELLA COMP,C1776,HCPCS,,79002271,CDM,278,RC,,,both,,,1816,1343.84,,,1343.84,Other,150% of Medicare + 9.63% HCRA Surcharge,817.2,45,,817.2,percent of total billed charges,Critical Access Hospital RCC factor,617.44,34,,617.44,percent of total billed charges,Implant Device,617.44,34,,617.44,percent of total billed charges,Implant Device,617.44,34,,617.44,percent of total billed charges,Implant Device,617.44,34,,617.44,percent of total billed charges,Implant Device,617.44,34,,617.44,percent of total billed charges,Implant Device,898.92,,,898.92,Other,110% of Medicare,635.6,35,,635.6,percent of total billed charges,Implant Device,617.44,34,"Charges > $500, x 34%",617.44,percent of total billed charges,Implant Device,635.6,35,,635.6,percent of total billed charges,Implant Device,635.6,35,,635.6,percent of total billed charges,Implant Device,635.6,35,,635.6,percent of total billed charges,Implant Device,635.6,35,,635.6,percent of total billed charges,Implant Device,635.6,35,,635.6,percent of total billed charges,Implant Device,726.4,40,,726.4,percent of total billed charges,Implant Device,635.6,70,,635.6,percent of total billed charges,All Other,617.44,34,,617.44,percent of total billed charges,Implant Device,617.44,34,,617.44,percent of total billed charges,Implant Device,635.6,35,,635.6,percent of total billed charges,Implant Device,635.6,35,,635.6,percent of total billed charges,Implant Device,635.6,35,,635.6,percent of total billed charges,Implant Device,635.6,35,,635.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1343.84,
S&N 71420580-REV PATELLA COMP,C1776,HCPCS,,79002272,CDM,278,RC,,,both,,,1816,1343.84,,,1343.84,Other,150% of Medicare + 9.63% HCRA Surcharge,817.2,45,,817.2,percent of total billed charges,Critical Access Hospital RCC factor,617.44,34,,617.44,percent of total billed charges,Implant Device,617.44,34,,617.44,percent of total billed charges,Implant Device,617.44,34,,617.44,percent of total billed charges,Implant Device,617.44,34,,617.44,percent of total billed charges,Implant Device,617.44,34,,617.44,percent of total billed charges,Implant Device,898.92,,,898.92,Other,110% of Medicare,635.6,35,,635.6,percent of total billed charges,Implant Device,617.44,34,"Charges > $500, x 34%",617.44,percent of total billed charges,Implant Device,635.6,35,,635.6,percent of total billed charges,Implant Device,635.6,35,,635.6,percent of total billed charges,Implant Device,635.6,35,,635.6,percent of total billed charges,Implant Device,635.6,35,,635.6,percent of total billed charges,Implant Device,635.6,35,,635.6,percent of total billed charges,Implant Device,726.4,40,,726.4,percent of total billed charges,Implant Device,635.6,70,,635.6,percent of total billed charges,All Other,617.44,34,,617.44,percent of total billed charges,Implant Device,617.44,34,,617.44,percent of total billed charges,Implant Device,635.6,35,,635.6,percent of total billed charges,Implant Device,635.6,35,,635.6,percent of total billed charges,Implant Device,635.6,35,,635.6,percent of total billed charges,Implant Device,635.6,35,,635.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1343.84,
S&N 71420792-REV ART INSERT,C1776,HCPCS,,79002273,CDM,278,RC,,,both,,,3457,2558.19,,,2558.19,Other,150% of Medicare + 9.63% HCRA Surcharge,1555.65,45,,1555.65,percent of total billed charges,Critical Access Hospital RCC factor,1175.38,34,,1175.38,percent of total billed charges,Implant Device,1175.38,34,,1175.38,percent of total billed charges,Implant Device,1175.38,34,,1175.38,percent of total billed charges,Implant Device,1175.38,34,,1175.38,percent of total billed charges,Implant Device,1175.38,34,,1175.38,percent of total billed charges,Implant Device,1711.22,,,1711.22,Other,110% of Medicare,1209.95,35,,1209.95,percent of total billed charges,Implant Device,1175.38,34,"Charges > $500, x 34%",1175.38,percent of total billed charges,Implant Device,1209.95,35,,1209.95,percent of total billed charges,Implant Device,1209.95,35,,1209.95,percent of total billed charges,Implant Device,1209.95,35,,1209.95,percent of total billed charges,Implant Device,1209.95,35,,1209.95,percent of total billed charges,Implant Device,1209.95,35,,1209.95,percent of total billed charges,Implant Device,1382.8,40,,1382.8,percent of total billed charges,Implant Device,1209.95,70,,1209.95,percent of total billed charges,All Other,1175.38,34,,1175.38,percent of total billed charges,Implant Device,1175.38,34,,1175.38,percent of total billed charges,Implant Device,1209.95,35,,1209.95,percent of total billed charges,Implant Device,1209.95,35,,1209.95,percent of total billed charges,Implant Device,1209.95,35,,1209.95,percent of total billed charges,Implant Device,1209.95,35,,1209.95,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1175.38,34,"If Charge > 2,000, then 34 percent",1175.38,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2558.19,
S&N 71421168-REV FEMORAL COMP,C1776,HCPCS,,79002274,CDM,278,RC,,,both,,,27360,20246.47,,,20246.47,Other,150% of Medicare + 9.63% HCRA Surcharge,12312,45,,12312,percent of total billed charges,Critical Access Hospital RCC factor,9302.4,34,,9302.4,percent of total billed charges,Implant Device,9302.4,34,,9302.4,percent of total billed charges,Implant Device,9302.4,34,,9302.4,percent of total billed charges,Implant Device,9302.4,34,,9302.4,percent of total billed charges,Implant Device,9302.4,34,,9302.4,percent of total billed charges,Implant Device,13543.2,,,13543.2,Other,110% of Medicare,9576,35,,9576,percent of total billed charges,Implant Device,9302.4,34,"Charges > $500, x 34%",9302.4,percent of total billed charges,Implant Device,9576,35,,9576,percent of total billed charges,Implant Device,9576,35,,9576,percent of total billed charges,Implant Device,9576,35,,9576,percent of total billed charges,Implant Device,9576,35,,9576,percent of total billed charges,Implant Device,9576,35,,9576,percent of total billed charges,Implant Device,10944,40,,10944,percent of total billed charges,Implant Device,9576,70,,9576,percent of total billed charges,All Other,9302.4,34,,9302.4,percent of total billed charges,Implant Device,9302.4,34,,9302.4,percent of total billed charges,Implant Device,9576,35,,9576,percent of total billed charges,Implant Device,9576,35,,9576,percent of total billed charges,Implant Device,9576,35,,9576,percent of total billed charges,Implant Device,9576,35,,9576,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,9302.4,34,"If Charge > 2,000, then 34 percent",9302.4,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,20246.47,
S&N 71421324-REV STEM,C1776,HCPCS,,79002275,CDM,278,RC,,,both,,,5746,4252.05,,,4252.05,Other,150% of Medicare + 9.63% HCRA Surcharge,2585.7,45,,2585.7,percent of total billed charges,Critical Access Hospital RCC factor,1953.64,34,,1953.64,percent of total billed charges,Implant Device,1953.64,34,,1953.64,percent of total billed charges,Implant Device,1953.64,34,,1953.64,percent of total billed charges,Implant Device,1953.64,34,,1953.64,percent of total billed charges,Implant Device,1953.64,34,,1953.64,percent of total billed charges,Implant Device,2844.27,,,2844.27,Other,110% of Medicare,2011.1,35,,2011.1,percent of total billed charges,Implant Device,1953.64,34,"Charges > $500, x 34%",1953.64,percent of total billed charges,Implant Device,2011.1,35,,2011.1,percent of total billed charges,Implant Device,2011.1,35,,2011.1,percent of total billed charges,Implant Device,2011.1,35,,2011.1,percent of total billed charges,Implant Device,2011.1,35,,2011.1,percent of total billed charges,Implant Device,2011.1,35,,2011.1,percent of total billed charges,Implant Device,2298.4,40,,2298.4,percent of total billed charges,Implant Device,2011.1,70,,2011.1,percent of total billed charges,All Other,1953.64,34,,1953.64,percent of total billed charges,Implant Device,1953.64,34,,1953.64,percent of total billed charges,Implant Device,2011.1,35,,2011.1,percent of total billed charges,Implant Device,2011.1,35,,2011.1,percent of total billed charges,Implant Device,2011.1,35,,2011.1,percent of total billed charges,Implant Device,2011.1,35,,2011.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1953.64,34,"If Charge > 2,000, then 34 percent",1953.64,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4252.05,
S&N 71421674-REV FEM WEDGE,C1776,HCPCS,,79002276,CDM,278,RC,,,both,,,5130,3796.21,,,3796.21,Other,150% of Medicare + 9.63% HCRA Surcharge,2308.5,45,,2308.5,percent of total billed charges,Critical Access Hospital RCC factor,1744.2,34,,1744.2,percent of total billed charges,Implant Device,1744.2,34,,1744.2,percent of total billed charges,Implant Device,1744.2,34,,1744.2,percent of total billed charges,Implant Device,1744.2,34,,1744.2,percent of total billed charges,Implant Device,1744.2,34,,1744.2,percent of total billed charges,Implant Device,2539.35,,,2539.35,Other,110% of Medicare,1795.5,35,,1795.5,percent of total billed charges,Implant Device,1744.2,34,"Charges > $500, x 34%",1744.2,percent of total billed charges,Implant Device,1795.5,35,,1795.5,percent of total billed charges,Implant Device,1795.5,35,,1795.5,percent of total billed charges,Implant Device,1795.5,35,,1795.5,percent of total billed charges,Implant Device,1795.5,35,,1795.5,percent of total billed charges,Implant Device,1795.5,35,,1795.5,percent of total billed charges,Implant Device,2052,40,,2052,percent of total billed charges,Implant Device,1795.5,70,,1795.5,percent of total billed charges,All Other,1744.2,34,,1744.2,percent of total billed charges,Implant Device,1744.2,34,,1744.2,percent of total billed charges,Implant Device,1795.5,35,,1795.5,percent of total billed charges,Implant Device,1795.5,35,,1795.5,percent of total billed charges,Implant Device,1795.5,35,,1795.5,percent of total billed charges,Implant Device,1795.5,35,,1795.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1744.2,34,"If Charge > 2,000, then 34 percent",1744.2,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3796.21,
S&N 71421771-REV FEM WEDGE,C1776,HCPCS,,79002277,CDM,278,RC,,,both,,,11520,8524.83,,,8524.83,Other,150% of Medicare + 9.63% HCRA Surcharge,5184,45,,5184,percent of total billed charges,Critical Access Hospital RCC factor,3916.8,34,,3916.8,percent of total billed charges,Implant Device,3916.8,34,,3916.8,percent of total billed charges,Implant Device,3916.8,34,,3916.8,percent of total billed charges,Implant Device,3916.8,34,,3916.8,percent of total billed charges,Implant Device,3916.8,34,,3916.8,percent of total billed charges,Implant Device,5702.4,,,5702.4,Other,110% of Medicare,4032,35,,4032,percent of total billed charges,Implant Device,3916.8,34,"Charges > $500, x 34%",3916.8,percent of total billed charges,Implant Device,4032,35,,4032,percent of total billed charges,Implant Device,4032,35,,4032,percent of total billed charges,Implant Device,4032,35,,4032,percent of total billed charges,Implant Device,4032,35,,4032,percent of total billed charges,Implant Device,4032,35,,4032,percent of total billed charges,Implant Device,4608,40,,4608,percent of total billed charges,Implant Device,4032,70,,4032,percent of total billed charges,All Other,3916.8,34,,3916.8,percent of total billed charges,Implant Device,3916.8,34,,3916.8,percent of total billed charges,Implant Device,4032,35,,4032,percent of total billed charges,Implant Device,4032,35,,4032,percent of total billed charges,Implant Device,4032,35,,4032,percent of total billed charges,Implant Device,4032,35,,4032,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3916.8,34,"If Charge > 2,000, then 34 percent",3916.8,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,8524.83,
S&N 71424007-REV BASEPLATE,C1776,HCPCS,,79002278,CDM,278,RC,,,both,,,11970,8857.83,,,8857.83,Other,150% of Medicare + 9.63% HCRA Surcharge,5386.5,45,,5386.5,percent of total billed charges,Critical Access Hospital RCC factor,4069.8,34,,4069.8,percent of total billed charges,Implant Device,4069.8,34,,4069.8,percent of total billed charges,Implant Device,4069.8,34,,4069.8,percent of total billed charges,Implant Device,4069.8,34,,4069.8,percent of total billed charges,Implant Device,4069.8,34,,4069.8,percent of total billed charges,Implant Device,5925.15,,,5925.15,Other,110% of Medicare,4189.5,35,,4189.5,percent of total billed charges,Implant Device,4069.8,34,"Charges > $500, x 34%",4069.8,percent of total billed charges,Implant Device,4189.5,35,,4189.5,percent of total billed charges,Implant Device,4189.5,35,,4189.5,percent of total billed charges,Implant Device,4189.5,35,,4189.5,percent of total billed charges,Implant Device,4189.5,35,,4189.5,percent of total billed charges,Implant Device,4189.5,35,,4189.5,percent of total billed charges,Implant Device,4788,40,,4788,percent of total billed charges,Implant Device,4189.5,70,,4189.5,percent of total billed charges,All Other,4069.8,34,,4069.8,percent of total billed charges,Implant Device,4069.8,34,,4069.8,percent of total billed charges,Implant Device,4189.5,35,,4189.5,percent of total billed charges,Implant Device,4189.5,35,,4189.5,percent of total billed charges,Implant Device,4189.5,35,,4189.5,percent of total billed charges,Implant Device,4189.5,35,,4189.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,4069.8,34,"If Charge > 2,000, then 34 percent",4069.8,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,8857.83,
S&N 71424015-REV BASEPLATE,C1776,HCPCS,,79002279,CDM,278,RC,,,both,,,11970,8857.83,,,8857.83,Other,150% of Medicare + 9.63% HCRA Surcharge,5386.5,45,,5386.5,percent of total billed charges,Critical Access Hospital RCC factor,4069.8,34,,4069.8,percent of total billed charges,Implant Device,4069.8,34,,4069.8,percent of total billed charges,Implant Device,4069.8,34,,4069.8,percent of total billed charges,Implant Device,4069.8,34,,4069.8,percent of total billed charges,Implant Device,4069.8,34,,4069.8,percent of total billed charges,Implant Device,5925.15,,,5925.15,Other,110% of Medicare,4189.5,35,,4189.5,percent of total billed charges,Implant Device,4069.8,34,"Charges > $500, x 34%",4069.8,percent of total billed charges,Implant Device,4189.5,35,,4189.5,percent of total billed charges,Implant Device,4189.5,35,,4189.5,percent of total billed charges,Implant Device,4189.5,35,,4189.5,percent of total billed charges,Implant Device,4189.5,35,,4189.5,percent of total billed charges,Implant Device,4189.5,35,,4189.5,percent of total billed charges,Implant Device,4788,40,,4788,percent of total billed charges,Implant Device,4189.5,70,,4189.5,percent of total billed charges,All Other,4069.8,34,,4069.8,percent of total billed charges,Implant Device,4069.8,34,,4069.8,percent of total billed charges,Implant Device,4189.5,35,,4189.5,percent of total billed charges,Implant Device,4189.5,35,,4189.5,percent of total billed charges,Implant Device,4189.5,35,,4189.5,percent of total billed charges,Implant Device,4189.5,35,,4189.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,4069.8,34,"If Charge > 2,000, then 34 percent",4069.8,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,8857.83,
S&N 71424027-REV STEM,C1776,HCPCS,,79002280,CDM,278,RC,,,both,,,5520,4084.81,,,4084.81,Other,150% of Medicare + 9.63% HCRA Surcharge,2484,45,,2484,percent of total billed charges,Critical Access Hospital RCC factor,1876.8,34,,1876.8,percent of total billed charges,Implant Device,1876.8,34,,1876.8,percent of total billed charges,Implant Device,1876.8,34,,1876.8,percent of total billed charges,Implant Device,1876.8,34,,1876.8,percent of total billed charges,Implant Device,1876.8,34,,1876.8,percent of total billed charges,Implant Device,2732.4,,,2732.4,Other,110% of Medicare,1932,35,,1932,percent of total billed charges,Implant Device,1876.8,34,"Charges > $500, x 34%",1876.8,percent of total billed charges,Implant Device,1932,35,,1932,percent of total billed charges,Implant Device,1932,35,,1932,percent of total billed charges,Implant Device,1932,35,,1932,percent of total billed charges,Implant Device,1932,35,,1932,percent of total billed charges,Implant Device,1932,35,,1932,percent of total billed charges,Implant Device,2208,40,,2208,percent of total billed charges,Implant Device,1932,70,,1932,percent of total billed charges,All Other,1876.8,34,,1876.8,percent of total billed charges,Implant Device,1876.8,34,,1876.8,percent of total billed charges,Implant Device,1932,35,,1932,percent of total billed charges,Implant Device,1932,35,,1932,percent of total billed charges,Implant Device,1932,35,,1932,percent of total billed charges,Implant Device,1932,35,,1932,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1876.8,34,"If Charge > 2,000, then 34 percent",1876.8,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4084.81,
S&N 71424051-REV STEM,C1776,HCPCS,,79002281,CDM,278,RC,,,both,,,4734,3503.17,,,3503.17,Other,150% of Medicare + 9.63% HCRA Surcharge,2130.3,45,,2130.3,percent of total billed charges,Critical Access Hospital RCC factor,1609.56,34,,1609.56,percent of total billed charges,Implant Device,1609.56,34,,1609.56,percent of total billed charges,Implant Device,1609.56,34,,1609.56,percent of total billed charges,Implant Device,1609.56,34,,1609.56,percent of total billed charges,Implant Device,1609.56,34,,1609.56,percent of total billed charges,Implant Device,2343.33,,,2343.33,Other,110% of Medicare,1656.9,35,,1656.9,percent of total billed charges,Implant Device,1609.56,34,"Charges > $500, x 34%",1609.56,percent of total billed charges,Implant Device,1656.9,35,,1656.9,percent of total billed charges,Implant Device,1656.9,35,,1656.9,percent of total billed charges,Implant Device,1656.9,35,,1656.9,percent of total billed charges,Implant Device,1656.9,35,,1656.9,percent of total billed charges,Implant Device,1656.9,35,,1656.9,percent of total billed charges,Implant Device,1893.6,40,,1893.6,percent of total billed charges,Implant Device,1656.9,70,,1656.9,percent of total billed charges,All Other,1609.56,34,,1609.56,percent of total billed charges,Implant Device,1609.56,34,,1609.56,percent of total billed charges,Implant Device,1656.9,35,,1656.9,percent of total billed charges,Implant Device,1656.9,35,,1656.9,percent of total billed charges,Implant Device,1656.9,35,,1656.9,percent of total billed charges,Implant Device,1656.9,35,,1656.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1609.56,34,"If Charge > 2,000, then 34 percent",1609.56,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3503.17,
S&N 71424206-REV STEM,C1776,HCPCS,,79002282,CDM,278,RC,,,both,,,5760,4262.41,,,4262.41,Other,150% of Medicare + 9.63% HCRA Surcharge,2592,45,,2592,percent of total billed charges,Critical Access Hospital RCC factor,1958.4,34,,1958.4,percent of total billed charges,Implant Device,1958.4,34,,1958.4,percent of total billed charges,Implant Device,1958.4,34,,1958.4,percent of total billed charges,Implant Device,1958.4,34,,1958.4,percent of total billed charges,Implant Device,1958.4,34,,1958.4,percent of total billed charges,Implant Device,2851.2,,,2851.2,Other,110% of Medicare,2016,35,,2016,percent of total billed charges,Implant Device,1958.4,34,"Charges > $500, x 34%",1958.4,percent of total billed charges,Implant Device,2016,35,,2016,percent of total billed charges,Implant Device,2016,35,,2016,percent of total billed charges,Implant Device,2016,35,,2016,percent of total billed charges,Implant Device,2016,35,,2016,percent of total billed charges,Implant Device,2016,35,,2016,percent of total billed charges,Implant Device,2304,40,,2304,percent of total billed charges,Implant Device,2016,70,,2016,percent of total billed charges,All Other,1958.4,34,,1958.4,percent of total billed charges,Implant Device,1958.4,34,,1958.4,percent of total billed charges,Implant Device,2016,35,,2016,percent of total billed charges,Implant Device,2016,35,,2016,percent of total billed charges,Implant Device,2016,35,,2016,percent of total billed charges,Implant Device,2016,35,,2016,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1958.4,34,"If Charge > 2,000, then 34 percent",1958.4,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4262.41,
S&N 71424210-REV STEM,C1776,HCPCS,,79002283,CDM,278,RC,,,both,,,5760,4262.41,,,4262.41,Other,150% of Medicare + 9.63% HCRA Surcharge,2592,45,,2592,percent of total billed charges,Critical Access Hospital RCC factor,1958.4,34,,1958.4,percent of total billed charges,Implant Device,1958.4,34,,1958.4,percent of total billed charges,Implant Device,1958.4,34,,1958.4,percent of total billed charges,Implant Device,1958.4,34,,1958.4,percent of total billed charges,Implant Device,1958.4,34,,1958.4,percent of total billed charges,Implant Device,2851.2,,,2851.2,Other,110% of Medicare,2016,35,,2016,percent of total billed charges,Implant Device,1958.4,34,"Charges > $500, x 34%",1958.4,percent of total billed charges,Implant Device,2016,35,,2016,percent of total billed charges,Implant Device,2016,35,,2016,percent of total billed charges,Implant Device,2016,35,,2016,percent of total billed charges,Implant Device,2016,35,,2016,percent of total billed charges,Implant Device,2016,35,,2016,percent of total billed charges,Implant Device,2304,40,,2304,percent of total billed charges,Implant Device,2016,70,,2016,percent of total billed charges,All Other,1958.4,34,,1958.4,percent of total billed charges,Implant Device,1958.4,34,,1958.4,percent of total billed charges,Implant Device,2016,35,,2016,percent of total billed charges,Implant Device,2016,35,,2016,percent of total billed charges,Implant Device,2016,35,,2016,percent of total billed charges,Implant Device,2016,35,,2016,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1958.4,34,"If Charge > 2,000, then 34 percent",1958.4,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4262.41,
S&N 74022217-REV BASEPLATE,C1776,HCPCS,,79002284,CDM,278,RC,,,both,,,9000,6660.02,,,6660.02,Other,150% of Medicare + 9.63% HCRA Surcharge,4050,45,,4050,percent of total billed charges,Critical Access Hospital RCC factor,3060,34,,3060,percent of total billed charges,Implant Device,3060,34,,3060,percent of total billed charges,Implant Device,3060,34,,3060,percent of total billed charges,Implant Device,3060,34,,3060,percent of total billed charges,Implant Device,3060,34,,3060,percent of total billed charges,Implant Device,4455,,,4455,Other,110% of Medicare,3150,35,,3150,percent of total billed charges,Implant Device,3060,34,"Charges > $500, x 34%",3060,percent of total billed charges,Implant Device,3150,35,,3150,percent of total billed charges,Implant Device,3150,35,,3150,percent of total billed charges,Implant Device,3150,35,,3150,percent of total billed charges,Implant Device,3150,35,,3150,percent of total billed charges,Implant Device,3150,35,,3150,percent of total billed charges,Implant Device,3600,40,,3600,percent of total billed charges,Implant Device,3150,70,,3150,percent of total billed charges,All Other,3060,34,,3060,percent of total billed charges,Implant Device,3060,34,,3060,percent of total billed charges,Implant Device,3150,35,,3150,percent of total billed charges,Implant Device,3150,35,,3150,percent of total billed charges,Implant Device,3150,35,,3150,percent of total billed charges,Implant Device,3150,35,,3150,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3060,34,"If Charge > 2,000, then 34 percent",3060,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,6660.02,
S&N 74023274-REV ART INSERT,C1776,HCPCS,,79002285,CDM,278,RC,,,both,,,7500,5550.02,,,5550.02,Other,150% of Medicare + 9.63% HCRA Surcharge,3375,45,,3375,percent of total billed charges,Critical Access Hospital RCC factor,2550,34,,2550,percent of total billed charges,Implant Device,2550,34,,2550,percent of total billed charges,Implant Device,2550,34,,2550,percent of total billed charges,Implant Device,2550,34,,2550,percent of total billed charges,Implant Device,2550,34,,2550,percent of total billed charges,Implant Device,3712.5,,,3712.5,Other,110% of Medicare,2625,35,,2625,percent of total billed charges,Implant Device,2550,34,"Charges > $500, x 34%",2550,percent of total billed charges,Implant Device,2625,35,,2625,percent of total billed charges,Implant Device,2625,35,,2625,percent of total billed charges,Implant Device,2625,35,,2625,percent of total billed charges,Implant Device,2625,35,,2625,percent of total billed charges,Implant Device,2625,35,,2625,percent of total billed charges,Implant Device,3000,40,,3000,percent of total billed charges,Implant Device,2625,70,,2625,percent of total billed charges,All Other,2550,34,,2550,percent of total billed charges,Implant Device,2550,34,,2550,percent of total billed charges,Implant Device,2625,35,,2625,percent of total billed charges,Implant Device,2625,35,,2625,percent of total billed charges,Implant Device,2625,35,,2625,percent of total billed charges,Implant Device,2625,35,,2625,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2550,34,"If Charge > 2,000, then 34 percent",2550,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5550.02,
S&N 74023285-REV ART INSERT,C1776,HCPCS,,79002286,CDM,278,RC,,,both,,,7200,5328.02,,,5328.02,Other,150% of Medicare + 9.63% HCRA Surcharge,3240,45,,3240,percent of total billed charges,Critical Access Hospital RCC factor,2448,34,,2448,percent of total billed charges,Implant Device,2448,34,,2448,percent of total billed charges,Implant Device,2448,34,,2448,percent of total billed charges,Implant Device,2448,34,,2448,percent of total billed charges,Implant Device,2448,34,,2448,percent of total billed charges,Implant Device,3564,,,3564,Other,110% of Medicare,2520,35,,2520,percent of total billed charges,Implant Device,2448,34,"Charges > $500, x 34%",2448,percent of total billed charges,Implant Device,2520,35,,2520,percent of total billed charges,Implant Device,2520,35,,2520,percent of total billed charges,Implant Device,2520,35,,2520,percent of total billed charges,Implant Device,2520,35,,2520,percent of total billed charges,Implant Device,2520,35,,2520,percent of total billed charges,Implant Device,2880,40,,2880,percent of total billed charges,Implant Device,2520,70,,2520,percent of total billed charges,All Other,2448,34,,2448,percent of total billed charges,Implant Device,2448,34,,2448,percent of total billed charges,Implant Device,2520,35,,2520,percent of total billed charges,Implant Device,2520,35,,2520,percent of total billed charges,Implant Device,2520,35,,2520,percent of total billed charges,Implant Device,2520,35,,2520,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2448,34,"If Charge > 2,000, then 34 percent",2448,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5328.02,
ZIMMER 7818-46-REV FEMORAL HEAD,C1776,HCPCS,,79002287,CDM,278,RC,,,both,,,1759,1301.66,,,1301.66,Other,150% of Medicare + 9.63% HCRA Surcharge,791.55,45,,791.55,percent of total billed charges,Critical Access Hospital RCC factor,598.06,34,,598.06,percent of total billed charges,Implant Device,598.06,34,,598.06,percent of total billed charges,Implant Device,598.06,34,,598.06,percent of total billed charges,Implant Device,598.06,34,,598.06,percent of total billed charges,Implant Device,598.06,34,,598.06,percent of total billed charges,Implant Device,870.71,,,870.71,Other,110% of Medicare,615.65,35,,615.65,percent of total billed charges,Implant Device,598.06,34,"Charges > $500, x 34%",598.06,percent of total billed charges,Implant Device,615.65,35,,615.65,percent of total billed charges,Implant Device,615.65,35,,615.65,percent of total billed charges,Implant Device,615.65,35,,615.65,percent of total billed charges,Implant Device,615.65,35,,615.65,percent of total billed charges,Implant Device,615.65,35,,615.65,percent of total billed charges,Implant Device,703.6,40,,703.6,percent of total billed charges,Implant Device,615.65,70,,615.65,percent of total billed charges,All Other,598.06,34,,598.06,percent of total billed charges,Implant Device,598.06,34,,598.06,percent of total billed charges,Implant Device,615.65,35,,615.65,percent of total billed charges,Implant Device,615.65,35,,615.65,percent of total billed charges,Implant Device,615.65,35,,615.65,percent of total billed charges,Implant Device,615.65,35,,615.65,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1301.66,
ZIMMER 7818-47-REV FEMORAL HEAD,C1776,HCPCS,,79002288,CDM,278,RC,,,both,,,1620,1198.8,,,1198.8,Other,150% of Medicare + 9.63% HCRA Surcharge,729,45,,729,percent of total billed charges,Critical Access Hospital RCC factor,550.8,34,,550.8,percent of total billed charges,Implant Device,550.8,34,,550.8,percent of total billed charges,Implant Device,550.8,34,,550.8,percent of total billed charges,Implant Device,550.8,34,,550.8,percent of total billed charges,Implant Device,550.8,34,,550.8,percent of total billed charges,Implant Device,801.9,,,801.9,Other,110% of Medicare,567,35,,567,percent of total billed charges,Implant Device,550.8,34,"Charges > $500, x 34%",550.8,percent of total billed charges,Implant Device,567,35,,567,percent of total billed charges,Implant Device,567,35,,567,percent of total billed charges,Implant Device,567,35,,567,percent of total billed charges,Implant Device,567,35,,567,percent of total billed charges,Implant Device,567,35,,567,percent of total billed charges,Implant Device,648,40,,648,percent of total billed charges,Implant Device,567,70,,567,percent of total billed charges,All Other,550.8,34,,550.8,percent of total billed charges,Implant Device,550.8,34,,550.8,percent of total billed charges,Implant Device,567,35,,567,percent of total billed charges,Implant Device,567,35,,567,percent of total billed charges,Implant Device,567,35,,567,percent of total billed charges,Implant Device,567,35,,567,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1198.8,
ZIMMER 7818-99-01 REV FEMORAL HEAD,C1776,HCPCS,,79002289,CDM,278,RC,,,both,,,460,340.4,,,340.4,Other,150% of Medicare + 9.63% HCRA Surcharge,207,45,,207,percent of total billed charges,Critical Access Hospital RCC factor,156.4,34,,156.4,percent of total billed charges,Implant Device,156.4,34,,156.4,percent of total billed charges,Implant Device,156.4,34,,156.4,percent of total billed charges,Implant Device,156.4,34,,156.4,percent of total billed charges,Implant Device,156.4,34,,156.4,percent of total billed charges,Implant Device,227.7,,,227.7,Other,110% of Medicare,161,35,,161,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,161,35,,161,percent of total billed charges,Implant Device,161,35,,161,percent of total billed charges,Implant Device,161,35,,161,percent of total billed charges,Implant Device,161,35,,161,percent of total billed charges,Implant Device,161,35,,161,percent of total billed charges,Implant Device,184,40,,184,percent of total billed charges,Implant Device,161,70,,161,percent of total billed charges,All Other,156.4,34,,156.4,percent of total billed charges,Implant Device,156.4,34,,156.4,percent of total billed charges,Implant Device,161,35,,161,percent of total billed charges,Implant Device,161,35,,161,percent of total billed charges,Implant Device,161,35,,161,percent of total billed charges,Implant Device,161,35,,161,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,340.4,
ZIMMER 7818-99-02 REV FEM HEAD ADAPTOR,C1776,HCPCS,,79002290,CDM,278,RC,,,both,,,427,315.98,,,315.98,Other,150% of Medicare + 9.63% HCRA Surcharge,192.15,45,,192.15,percent of total billed charges,Critical Access Hospital RCC factor,145.18,34,,145.18,percent of total billed charges,Implant Device,145.18,34,,145.18,percent of total billed charges,Implant Device,145.18,34,,145.18,percent of total billed charges,Implant Device,145.18,34,,145.18,percent of total billed charges,Implant Device,145.18,34,,145.18,percent of total billed charges,Implant Device,211.37,,,211.37,Other,110% of Medicare,149.45,35,,149.45,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,149.45,35,,149.45,percent of total billed charges,Implant Device,149.45,35,,149.45,percent of total billed charges,Implant Device,149.45,35,,149.45,percent of total billed charges,Implant Device,149.45,35,,149.45,percent of total billed charges,Implant Device,149.45,35,,149.45,percent of total billed charges,Implant Device,170.8,40,,170.8,percent of total billed charges,Implant Device,149.45,70,,149.45,percent of total billed charges,All Other,145.18,34,,145.18,percent of total billed charges,Implant Device,145.18,34,,145.18,percent of total billed charges,Implant Device,149.45,35,,149.45,percent of total billed charges,Implant Device,149.45,35,,149.45,percent of total billed charges,Implant Device,149.45,35,,149.45,percent of total billed charges,Implant Device,149.45,35,,149.45,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,315.98,
ZIMMER 7843-14-06-REV FEMORAL STEM,C1776,HCPCS,,79002291,CDM,278,RC,,,both,,,17374,12856.8,,,12856.8,Other,150% of Medicare + 9.63% HCRA Surcharge,7818.3,45,,7818.3,percent of total billed charges,Critical Access Hospital RCC factor,5907.16,34,,5907.16,percent of total billed charges,Implant Device,5907.16,34,,5907.16,percent of total billed charges,Implant Device,5907.16,34,,5907.16,percent of total billed charges,Implant Device,5907.16,34,,5907.16,percent of total billed charges,Implant Device,5907.16,34,,5907.16,percent of total billed charges,Implant Device,8600.13,,,8600.13,Other,110% of Medicare,6080.9,35,,6080.9,percent of total billed charges,Implant Device,5907.16,34,"Charges > $500, x 34%",5907.16,percent of total billed charges,Implant Device,6080.9,35,,6080.9,percent of total billed charges,Implant Device,6080.9,35,,6080.9,percent of total billed charges,Implant Device,6080.9,35,,6080.9,percent of total billed charges,Implant Device,6080.9,35,,6080.9,percent of total billed charges,Implant Device,6080.9,35,,6080.9,percent of total billed charges,Implant Device,6949.6,40,,6949.6,percent of total billed charges,Implant Device,6080.9,70,,6080.9,percent of total billed charges,All Other,5907.16,34,,5907.16,percent of total billed charges,Implant Device,5907.16,34,,5907.16,percent of total billed charges,Implant Device,6080.9,35,,6080.9,percent of total billed charges,Implant Device,6080.9,35,,6080.9,percent of total billed charges,Implant Device,6080.9,35,,6080.9,percent of total billed charges,Implant Device,6080.9,35,,6080.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,5907.16,34,"If Charge > 2,000, then 34 percent",5907.16,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,12856.8,
ZIMMER 7843-14-36-REV FEMORAL HEAD,C1776,HCPCS,,79002292,CDM,278,RC,,,both,,,18648,13799.57,,,13799.57,Other,150% of Medicare + 9.63% HCRA Surcharge,8391.6,45,,8391.6,percent of total billed charges,Critical Access Hospital RCC factor,6340.32,34,,6340.32,percent of total billed charges,Implant Device,6340.32,34,,6340.32,percent of total billed charges,Implant Device,6340.32,34,,6340.32,percent of total billed charges,Implant Device,6340.32,34,,6340.32,percent of total billed charges,Implant Device,6340.32,34,,6340.32,percent of total billed charges,Implant Device,9230.76,,,9230.76,Other,110% of Medicare,6526.8,35,,6526.8,percent of total billed charges,Implant Device,6340.32,34,"Charges > $500, x 34%",6340.32,percent of total billed charges,Implant Device,6526.8,35,,6526.8,percent of total billed charges,Implant Device,6526.8,35,,6526.8,percent of total billed charges,Implant Device,6526.8,35,,6526.8,percent of total billed charges,Implant Device,6526.8,35,,6526.8,percent of total billed charges,Implant Device,6526.8,35,,6526.8,percent of total billed charges,Implant Device,7459.2,40,,7459.2,percent of total billed charges,Implant Device,6526.8,70,,6526.8,percent of total billed charges,All Other,6340.32,34,,6340.32,percent of total billed charges,Implant Device,6340.32,34,,6340.32,percent of total billed charges,Implant Device,6526.8,35,,6526.8,percent of total billed charges,Implant Device,6526.8,35,,6526.8,percent of total billed charges,Implant Device,6526.8,35,,6526.8,percent of total billed charges,Implant Device,6526.8,35,,6526.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,6340.32,34,"If Charge > 2,000, then 34 percent",6340.32,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,13799.57,
ZIMMER 7843-15-18-REV FEMORAL STEM,C1776,HCPCS,,79002293,CDM,278,RC,,,both,,,22968,16996.38,,,16996.38,Other,150% of Medicare + 9.63% HCRA Surcharge,10335.6,45,,10335.6,percent of total billed charges,Critical Access Hospital RCC factor,7809.12,34,,7809.12,percent of total billed charges,Implant Device,7809.12,34,,7809.12,percent of total billed charges,Implant Device,7809.12,34,,7809.12,percent of total billed charges,Implant Device,7809.12,34,,7809.12,percent of total billed charges,Implant Device,7809.12,34,,7809.12,percent of total billed charges,Implant Device,11369.16,,,11369.16,Other,110% of Medicare,8038.8,35,,8038.8,percent of total billed charges,Implant Device,7809.12,34,"Charges > $500, x 34%",7809.12,percent of total billed charges,Implant Device,8038.8,35,,8038.8,percent of total billed charges,Implant Device,8038.8,35,,8038.8,percent of total billed charges,Implant Device,8038.8,35,,8038.8,percent of total billed charges,Implant Device,8038.8,35,,8038.8,percent of total billed charges,Implant Device,8038.8,35,,8038.8,percent of total billed charges,Implant Device,9187.2,40,,9187.2,percent of total billed charges,Implant Device,8038.8,70,,8038.8,percent of total billed charges,All Other,7809.12,34,,7809.12,percent of total billed charges,Implant Device,7809.12,34,,7809.12,percent of total billed charges,Implant Device,8038.8,35,,8038.8,percent of total billed charges,Implant Device,8038.8,35,,8038.8,percent of total billed charges,Implant Device,8038.8,35,,8038.8,percent of total billed charges,Implant Device,8038.8,35,,8038.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,7809.12,34,"If Charge > 2,000, then 34 percent",7809.12,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,16996.38,
ZIMMER 7850-12-REV FEMORAL STEM,C1776,HCPCS,,79002294,CDM,278,RC,,,both,,,11730,8680.23,,,8680.23,Other,150% of Medicare + 9.63% HCRA Surcharge,5278.5,45,,5278.5,percent of total billed charges,Critical Access Hospital RCC factor,3988.2,34,,3988.2,percent of total billed charges,Implant Device,3988.2,34,,3988.2,percent of total billed charges,Implant Device,3988.2,34,,3988.2,percent of total billed charges,Implant Device,3988.2,34,,3988.2,percent of total billed charges,Implant Device,3988.2,34,,3988.2,percent of total billed charges,Implant Device,5806.35,,,5806.35,Other,110% of Medicare,4105.5,35,,4105.5,percent of total billed charges,Implant Device,3988.2,34,"Charges > $500, x 34%",3988.2,percent of total billed charges,Implant Device,4105.5,35,,4105.5,percent of total billed charges,Implant Device,4105.5,35,,4105.5,percent of total billed charges,Implant Device,4105.5,35,,4105.5,percent of total billed charges,Implant Device,4105.5,35,,4105.5,percent of total billed charges,Implant Device,4105.5,35,,4105.5,percent of total billed charges,Implant Device,4692,40,,4692,percent of total billed charges,Implant Device,4105.5,70,,4105.5,percent of total billed charges,All Other,3988.2,34,,3988.2,percent of total billed charges,Implant Device,3988.2,34,,3988.2,percent of total billed charges,Implant Device,4105.5,35,,4105.5,percent of total billed charges,Implant Device,4105.5,35,,4105.5,percent of total billed charges,Implant Device,4105.5,35,,4105.5,percent of total billed charges,Implant Device,4105.5,35,,4105.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3988.2,34,"If Charge > 2,000, then 34 percent",3988.2,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,8680.23,
ZIMMER 7850-15-REV FEMORAL STEM,C1776,HCPCS,,79002295,CDM,278,RC,,,both,,,8532,6313.7,,,6313.7,Other,150% of Medicare + 9.63% HCRA Surcharge,3839.4,45,,3839.4,percent of total billed charges,Critical Access Hospital RCC factor,2900.88,34,,2900.88,percent of total billed charges,Implant Device,2900.88,34,,2900.88,percent of total billed charges,Implant Device,2900.88,34,,2900.88,percent of total billed charges,Implant Device,2900.88,34,,2900.88,percent of total billed charges,Implant Device,2900.88,34,,2900.88,percent of total billed charges,Implant Device,4223.34,,,4223.34,Other,110% of Medicare,2986.2,35,,2986.2,percent of total billed charges,Implant Device,2900.88,34,"Charges > $500, x 34%",2900.88,percent of total billed charges,Implant Device,2986.2,35,,2986.2,percent of total billed charges,Implant Device,2986.2,35,,2986.2,percent of total billed charges,Implant Device,2986.2,35,,2986.2,percent of total billed charges,Implant Device,2986.2,35,,2986.2,percent of total billed charges,Implant Device,2986.2,35,,2986.2,percent of total billed charges,Implant Device,3412.8,40,,3412.8,percent of total billed charges,Implant Device,2986.2,70,,2986.2,percent of total billed charges,All Other,2900.88,34,,2900.88,percent of total billed charges,Implant Device,2900.88,34,,2900.88,percent of total billed charges,Implant Device,2986.2,35,,2986.2,percent of total billed charges,Implant Device,2986.2,35,,2986.2,percent of total billed charges,Implant Device,2986.2,35,,2986.2,percent of total billed charges,Implant Device,2986.2,35,,2986.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2900.88,34,"If Charge > 2,000, then 34 percent",2900.88,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,6313.7,
ZIMMER 7859-12-REV DISTAL CENTRALIZER,C1776,HCPCS,,79002296,CDM,278,RC,,,both,,,383,283.42,,,283.42,Other,150% of Medicare + 9.63% HCRA Surcharge,172.35,45,,172.35,percent of total billed charges,Critical Access Hospital RCC factor,130.22,34,,130.22,percent of total billed charges,Implant Device,130.22,34,,130.22,percent of total billed charges,Implant Device,130.22,34,,130.22,percent of total billed charges,Implant Device,130.22,34,,130.22,percent of total billed charges,Implant Device,130.22,34,,130.22,percent of total billed charges,Implant Device,189.59,,,189.59,Other,110% of Medicare,134.05,35,,134.05,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,134.05,35,,134.05,percent of total billed charges,Implant Device,134.05,35,,134.05,percent of total billed charges,Implant Device,134.05,35,,134.05,percent of total billed charges,Implant Device,134.05,35,,134.05,percent of total billed charges,Implant Device,134.05,35,,134.05,percent of total billed charges,Implant Device,153.2,40,,153.2,percent of total billed charges,Implant Device,134.05,70,,134.05,percent of total billed charges,All Other,130.22,34,,130.22,percent of total billed charges,Implant Device,130.22,34,,130.22,percent of total billed charges,Implant Device,134.05,35,,134.05,percent of total billed charges,Implant Device,134.05,35,,134.05,percent of total billed charges,Implant Device,134.05,35,,134.05,percent of total billed charges,Implant Device,134.05,35,,134.05,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,283.42,
ZIMMER 7859-14-REV DISTAL CENTRALIZER,C1776,HCPCS,,79002297,CDM,278,RC,,,both,,,360,266.4,,,266.4,Other,150% of Medicare + 9.63% HCRA Surcharge,162,45,,162,percent of total billed charges,Critical Access Hospital RCC factor,122.4,34,,122.4,percent of total billed charges,Implant Device,122.4,34,,122.4,percent of total billed charges,Implant Device,122.4,34,,122.4,percent of total billed charges,Implant Device,122.4,34,,122.4,percent of total billed charges,Implant Device,122.4,34,,122.4,percent of total billed charges,Implant Device,178.2,,,178.2,Other,110% of Medicare,126,35,,126,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,126,35,,126,percent of total billed charges,Implant Device,126,35,,126,percent of total billed charges,Implant Device,126,35,,126,percent of total billed charges,Implant Device,126,35,,126,percent of total billed charges,Implant Device,126,35,,126,percent of total billed charges,Implant Device,144,40,,144,percent of total billed charges,Implant Device,126,70,,126,percent of total billed charges,All Other,122.4,34,,122.4,percent of total billed charges,Implant Device,122.4,34,,122.4,percent of total billed charges,Implant Device,126,35,,126,percent of total billed charges,Implant Device,126,35,,126,percent of total billed charges,Implant Device,126,35,,126,percent of total billed charges,Implant Device,126,35,,126,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,266.4,
ZIMMER 7871-15-61-REV FEMORAL STEM,C1776,HCPCS,,79002298,CDM,278,RC,,,both,,,17550,12987.04,,,12987.04,Other,150% of Medicare + 9.63% HCRA Surcharge,7897.5,45,,7897.5,percent of total billed charges,Critical Access Hospital RCC factor,5967,34,,5967,percent of total billed charges,Implant Device,5967,34,,5967,percent of total billed charges,Implant Device,5967,34,,5967,percent of total billed charges,Implant Device,5967,34,,5967,percent of total billed charges,Implant Device,5967,34,,5967,percent of total billed charges,Implant Device,8687.25,,,8687.25,Other,110% of Medicare,6142.5,35,,6142.5,percent of total billed charges,Implant Device,5967,34,"Charges > $500, x 34%",5967,percent of total billed charges,Implant Device,6142.5,35,,6142.5,percent of total billed charges,Implant Device,6142.5,35,,6142.5,percent of total billed charges,Implant Device,6142.5,35,,6142.5,percent of total billed charges,Implant Device,6142.5,35,,6142.5,percent of total billed charges,Implant Device,6142.5,35,,6142.5,percent of total billed charges,Implant Device,7020,40,,7020,percent of total billed charges,Implant Device,6142.5,70,,6142.5,percent of total billed charges,All Other,5967,34,,5967,percent of total billed charges,Implant Device,5967,34,,5967,percent of total billed charges,Implant Device,6142.5,35,,6142.5,percent of total billed charges,Implant Device,6142.5,35,,6142.5,percent of total billed charges,Implant Device,6142.5,35,,6142.5,percent of total billed charges,Implant Device,6142.5,35,,6142.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,5967,34,"If Charge > 2,000, then 34 percent",5967,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,12987.04,
ZIMMER 8018-32-02-REV FEMORAL HEAD,C1776,HCPCS,,79002300,CDM,278,RC,,,both,,,2034,1505.17,,,1505.17,Other,150% of Medicare + 9.63% HCRA Surcharge,915.3,45,,915.3,percent of total billed charges,Critical Access Hospital RCC factor,691.56,34,,691.56,percent of total billed charges,Implant Device,691.56,34,,691.56,percent of total billed charges,Implant Device,691.56,34,,691.56,percent of total billed charges,Implant Device,691.56,34,,691.56,percent of total billed charges,Implant Device,691.56,34,,691.56,percent of total billed charges,Implant Device,1006.83,,,1006.83,Other,110% of Medicare,711.9,35,,711.9,percent of total billed charges,Implant Device,691.56,34,"Charges > $500, x 34%",691.56,percent of total billed charges,Implant Device,711.9,35,,711.9,percent of total billed charges,Implant Device,711.9,35,,711.9,percent of total billed charges,Implant Device,711.9,35,,711.9,percent of total billed charges,Implant Device,711.9,35,,711.9,percent of total billed charges,Implant Device,711.9,35,,711.9,percent of total billed charges,Implant Device,813.6,40,,813.6,percent of total billed charges,Implant Device,711.9,70,,711.9,percent of total billed charges,All Other,691.56,34,,691.56,percent of total billed charges,Implant Device,691.56,34,,691.56,percent of total billed charges,Implant Device,711.9,35,,711.9,percent of total billed charges,Implant Device,711.9,35,,711.9,percent of total billed charges,Implant Device,711.9,35,,711.9,percent of total billed charges,Implant Device,711.9,35,,711.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,691.56,34,"If Charge > 2,000, then 34 percent",691.56,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1505.17,
ZIMMER 8018-32-03-REV FEMORAL HEAD,C1776,HCPCS,,79002301,CDM,278,RC,,,both,,,2729,2019.47,,,2019.47,Other,150% of Medicare + 9.63% HCRA Surcharge,1228.05,45,,1228.05,percent of total billed charges,Critical Access Hospital RCC factor,927.86,34,,927.86,percent of total billed charges,Implant Device,927.86,34,,927.86,percent of total billed charges,Implant Device,927.86,34,,927.86,percent of total billed charges,Implant Device,927.86,34,,927.86,percent of total billed charges,Implant Device,927.86,34,,927.86,percent of total billed charges,Implant Device,1350.86,,,1350.86,Other,110% of Medicare,955.15,35,,955.15,percent of total billed charges,Implant Device,927.86,34,"Charges > $500, x 34%",927.86,percent of total billed charges,Implant Device,955.15,35,,955.15,percent of total billed charges,Implant Device,955.15,35,,955.15,percent of total billed charges,Implant Device,955.15,35,,955.15,percent of total billed charges,Implant Device,955.15,35,,955.15,percent of total billed charges,Implant Device,955.15,35,,955.15,percent of total billed charges,Implant Device,1091.6,40,,1091.6,percent of total billed charges,Implant Device,955.15,70,,955.15,percent of total billed charges,All Other,927.86,34,,927.86,percent of total billed charges,Implant Device,927.86,34,,927.86,percent of total billed charges,Implant Device,955.15,35,,955.15,percent of total billed charges,Implant Device,955.15,35,,955.15,percent of total billed charges,Implant Device,955.15,35,,955.15,percent of total billed charges,Implant Device,955.15,35,,955.15,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,927.86,34,"If Charge > 2,000, then 34 percent",927.86,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2019.47,
ZIMMER 8018-36-01-REV FEMORAL HEAD,C1776,HCPCS,,79002302,CDM,278,RC,,,both,,,3150,2331.01,,,2331.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1417.5,45,,1417.5,percent of total billed charges,Critical Access Hospital RCC factor,1071,34,,1071,percent of total billed charges,Implant Device,1071,34,,1071,percent of total billed charges,Implant Device,1071,34,,1071,percent of total billed charges,Implant Device,1071,34,,1071,percent of total billed charges,Implant Device,1071,34,,1071,percent of total billed charges,Implant Device,1559.25,,,1559.25,Other,110% of Medicare,1102.5,35,,1102.5,percent of total billed charges,Implant Device,1071,34,"Charges > $500, x 34%",1071,percent of total billed charges,Implant Device,1102.5,35,,1102.5,percent of total billed charges,Implant Device,1102.5,35,,1102.5,percent of total billed charges,Implant Device,1102.5,35,,1102.5,percent of total billed charges,Implant Device,1102.5,35,,1102.5,percent of total billed charges,Implant Device,1102.5,35,,1102.5,percent of total billed charges,Implant Device,1260,40,,1260,percent of total billed charges,Implant Device,1102.5,70,,1102.5,percent of total billed charges,All Other,1071,34,,1071,percent of total billed charges,Implant Device,1071,34,,1071,percent of total billed charges,Implant Device,1102.5,35,,1102.5,percent of total billed charges,Implant Device,1102.5,35,,1102.5,percent of total billed charges,Implant Device,1102.5,35,,1102.5,percent of total billed charges,Implant Device,1102.5,35,,1102.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1071,34,"If Charge > 2,000, then 34 percent",1071,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2331.01,
ZIMMER 8018-36-02-REV FEMORAL HEAD,C1776,HCPCS,,79002303,CDM,278,RC,,,both,,,3391,2509.35,,,2509.35,Other,150% of Medicare + 9.63% HCRA Surcharge,1525.95,45,,1525.95,percent of total billed charges,Critical Access Hospital RCC factor,1152.94,34,,1152.94,percent of total billed charges,Implant Device,1152.94,34,,1152.94,percent of total billed charges,Implant Device,1152.94,34,,1152.94,percent of total billed charges,Implant Device,1152.94,34,,1152.94,percent of total billed charges,Implant Device,1152.94,34,,1152.94,percent of total billed charges,Implant Device,1678.55,,,1678.55,Other,110% of Medicare,1186.85,35,,1186.85,percent of total billed charges,Implant Device,1152.94,34,"Charges > $500, x 34%",1152.94,percent of total billed charges,Implant Device,1186.85,35,,1186.85,percent of total billed charges,Implant Device,1186.85,35,,1186.85,percent of total billed charges,Implant Device,1186.85,35,,1186.85,percent of total billed charges,Implant Device,1186.85,35,,1186.85,percent of total billed charges,Implant Device,1186.85,35,,1186.85,percent of total billed charges,Implant Device,1356.4,40,,1356.4,percent of total billed charges,Implant Device,1186.85,70,,1186.85,percent of total billed charges,All Other,1152.94,34,,1152.94,percent of total billed charges,Implant Device,1152.94,34,,1152.94,percent of total billed charges,Implant Device,1186.85,35,,1186.85,percent of total billed charges,Implant Device,1186.85,35,,1186.85,percent of total billed charges,Implant Device,1186.85,35,,1186.85,percent of total billed charges,Implant Device,1186.85,35,,1186.85,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1152.94,34,"If Charge > 2,000, then 34 percent",1152.94,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2509.35,
ZIMMER 8018-36-04-REV FEMORAL HEAD,C1776,HCPCS,,79002304,CDM,278,RC,,,both,,,3391,2509.35,,,2509.35,Other,150% of Medicare + 9.63% HCRA Surcharge,1525.95,45,,1525.95,percent of total billed charges,Critical Access Hospital RCC factor,1152.94,34,,1152.94,percent of total billed charges,Implant Device,1152.94,34,,1152.94,percent of total billed charges,Implant Device,1152.94,34,,1152.94,percent of total billed charges,Implant Device,1152.94,34,,1152.94,percent of total billed charges,Implant Device,1152.94,34,,1152.94,percent of total billed charges,Implant Device,1678.55,,,1678.55,Other,110% of Medicare,1186.85,35,,1186.85,percent of total billed charges,Implant Device,1152.94,34,"Charges > $500, x 34%",1152.94,percent of total billed charges,Implant Device,1186.85,35,,1186.85,percent of total billed charges,Implant Device,1186.85,35,,1186.85,percent of total billed charges,Implant Device,1186.85,35,,1186.85,percent of total billed charges,Implant Device,1186.85,35,,1186.85,percent of total billed charges,Implant Device,1186.85,35,,1186.85,percent of total billed charges,Implant Device,1356.4,40,,1356.4,percent of total billed charges,Implant Device,1186.85,70,,1186.85,percent of total billed charges,All Other,1152.94,34,,1152.94,percent of total billed charges,Implant Device,1152.94,34,,1152.94,percent of total billed charges,Implant Device,1186.85,35,,1186.85,percent of total billed charges,Implant Device,1186.85,35,,1186.85,percent of total billed charges,Implant Device,1186.85,35,,1186.85,percent of total billed charges,Implant Device,1186.85,35,,1186.85,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1152.94,34,"If Charge > 2,000, then 34 percent",1152.94,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2509.35,
BIOMET 8155-40-022 SCREW,C1713,HCPCS,,79002305,CDM,278,RC,,,both,,,240,177.6,,,177.6,Other,150% of Medicare + 9.63% HCRA Surcharge,108,45,,108,percent of total billed charges,Critical Access Hospital RCC factor,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,118.8,,,118.8,Other,110% of Medicare,84,35,,84,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,96,40,,96,percent of total billed charges,Implant Device,84,70,,84,percent of total billed charges,All Other,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,177.6,
BIOMET 8155-40-028 SCREW,C1713,HCPCS,,79002306,CDM,278,RC,,,both,,,240,177.6,,,177.6,Other,150% of Medicare + 9.63% HCRA Surcharge,108,45,,108,percent of total billed charges,Critical Access Hospital RCC factor,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,118.8,,,118.8,Other,110% of Medicare,84,35,,84,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,96,40,,96,percent of total billed charges,Implant Device,84,70,,84,percent of total billed charges,All Other,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,177.6,
ARTHROSURFACE 8156-0032-W TAPER POST,C1776,HCPCS,,79002307,CDM,278,RC,,,both,,,2478,1833.73,,,1833.73,Other,150% of Medicare + 9.63% HCRA Surcharge,1115.1,45,,1115.1,percent of total billed charges,Critical Access Hospital RCC factor,842.52,34,,842.52,percent of total billed charges,Implant Device,842.52,34,,842.52,percent of total billed charges,Implant Device,842.52,34,,842.52,percent of total billed charges,Implant Device,842.52,34,,842.52,percent of total billed charges,Implant Device,842.52,34,,842.52,percent of total billed charges,Implant Device,1226.61,,,1226.61,Other,110% of Medicare,867.3,35,,867.3,percent of total billed charges,Implant Device,842.52,34,"Charges > $500, x 34%",842.52,percent of total billed charges,Implant Device,867.3,35,,867.3,percent of total billed charges,Implant Device,867.3,35,,867.3,percent of total billed charges,Implant Device,867.3,35,,867.3,percent of total billed charges,Implant Device,867.3,35,,867.3,percent of total billed charges,Implant Device,867.3,35,,867.3,percent of total billed charges,Implant Device,991.2,40,,991.2,percent of total billed charges,Implant Device,867.3,70,,867.3,percent of total billed charges,All Other,842.52,34,,842.52,percent of total billed charges,Implant Device,842.52,34,,842.52,percent of total billed charges,Implant Device,867.3,35,,867.3,percent of total billed charges,Implant Device,867.3,35,,867.3,percent of total billed charges,Implant Device,867.3,35,,867.3,percent of total billed charges,Implant Device,867.3,35,,867.3,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,842.52,34,"If Charge > 2,000, then 34 percent",842.52,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1833.73,
DEPUY 8157-45-022 SCREW,C1713,HCPCS,,79002308,CDM,278,RC,,,both,,,210,155.4,,,155.4,Other,150% of Medicare + 9.63% HCRA Surcharge,94.5,45,,94.5,percent of total billed charges,Critical Access Hospital RCC factor,71.4,34,,71.4,percent of total billed charges,Implant Device,71.4,34,,71.4,percent of total billed charges,Implant Device,71.4,34,,71.4,percent of total billed charges,Implant Device,71.4,34,,71.4,percent of total billed charges,Implant Device,71.4,34,,71.4,percent of total billed charges,Implant Device,103.95,,,103.95,Other,110% of Medicare,73.5,35,,73.5,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,73.5,35,,73.5,percent of total billed charges,Implant Device,73.5,35,,73.5,percent of total billed charges,Implant Device,73.5,35,,73.5,percent of total billed charges,Implant Device,73.5,35,,73.5,percent of total billed charges,Implant Device,73.5,35,,73.5,percent of total billed charges,Implant Device,84,40,,84,percent of total billed charges,Implant Device,73.5,70,,73.5,percent of total billed charges,All Other,71.4,34,,71.4,percent of total billed charges,Implant Device,71.4,34,,71.4,percent of total billed charges,Implant Device,73.5,35,,73.5,percent of total billed charges,Implant Device,73.5,35,,73.5,percent of total billed charges,Implant Device,73.5,35,,73.5,percent of total billed charges,Implant Device,73.5,35,,73.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,155.4,
DEPUY 8157-45-024 SCREW,C1713,HCPCS,,79002309,CDM,278,RC,,,both,,,210,155.4,,,155.4,Other,150% of Medicare + 9.63% HCRA Surcharge,94.5,45,,94.5,percent of total billed charges,Critical Access Hospital RCC factor,71.4,34,,71.4,percent of total billed charges,Implant Device,71.4,34,,71.4,percent of total billed charges,Implant Device,71.4,34,,71.4,percent of total billed charges,Implant Device,71.4,34,,71.4,percent of total billed charges,Implant Device,71.4,34,,71.4,percent of total billed charges,Implant Device,103.95,,,103.95,Other,110% of Medicare,73.5,35,,73.5,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,73.5,35,,73.5,percent of total billed charges,Implant Device,73.5,35,,73.5,percent of total billed charges,Implant Device,73.5,35,,73.5,percent of total billed charges,Implant Device,73.5,35,,73.5,percent of total billed charges,Implant Device,73.5,35,,73.5,percent of total billed charges,Implant Device,84,40,,84,percent of total billed charges,Implant Device,73.5,70,,73.5,percent of total billed charges,All Other,71.4,34,,71.4,percent of total billed charges,Implant Device,71.4,34,,71.4,percent of total billed charges,Implant Device,73.5,35,,73.5,percent of total billed charges,Implant Device,73.5,35,,73.5,percent of total billed charges,Implant Device,73.5,35,,73.5,percent of total billed charges,Implant Device,73.5,35,,73.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,155.4,
BIOMET 8161-35-034 SCREW,C1713,HCPCS,,79002310,CDM,278,RC,,,both,,,432,319.68,,,319.68,Other,150% of Medicare + 9.63% HCRA Surcharge,194.4,45,,194.4,percent of total billed charges,Critical Access Hospital RCC factor,146.88,34,,146.88,percent of total billed charges,Implant Device,146.88,34,,146.88,percent of total billed charges,Implant Device,146.88,34,,146.88,percent of total billed charges,Implant Device,146.88,34,,146.88,percent of total billed charges,Implant Device,146.88,34,,146.88,percent of total billed charges,Implant Device,213.84,,,213.84,Other,110% of Medicare,151.2,35,,151.2,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,151.2,35,,151.2,percent of total billed charges,Implant Device,151.2,35,,151.2,percent of total billed charges,Implant Device,151.2,35,,151.2,percent of total billed charges,Implant Device,151.2,35,,151.2,percent of total billed charges,Implant Device,151.2,35,,151.2,percent of total billed charges,Implant Device,172.8,40,,172.8,percent of total billed charges,Implant Device,151.2,70,,151.2,percent of total billed charges,All Other,146.88,34,,146.88,percent of total billed charges,Implant Device,146.88,34,,146.88,percent of total billed charges,Implant Device,151.2,35,,151.2,percent of total billed charges,Implant Device,151.2,35,,151.2,percent of total billed charges,Implant Device,151.2,35,,151.2,percent of total billed charges,Implant Device,151.2,35,,151.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,319.68,
BIOMET 8161-35-036 SCREW,C1713,HCPCS,,79002311,CDM,278,RC,,,both,,,432,319.68,,,319.68,Other,150% of Medicare + 9.63% HCRA Surcharge,194.4,45,,194.4,percent of total billed charges,Critical Access Hospital RCC factor,146.88,34,,146.88,percent of total billed charges,Implant Device,146.88,34,,146.88,percent of total billed charges,Implant Device,146.88,34,,146.88,percent of total billed charges,Implant Device,146.88,34,,146.88,percent of total billed charges,Implant Device,146.88,34,,146.88,percent of total billed charges,Implant Device,213.84,,,213.84,Other,110% of Medicare,151.2,35,,151.2,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,151.2,35,,151.2,percent of total billed charges,Implant Device,151.2,35,,151.2,percent of total billed charges,Implant Device,151.2,35,,151.2,percent of total billed charges,Implant Device,151.2,35,,151.2,percent of total billed charges,Implant Device,151.2,35,,151.2,percent of total billed charges,Implant Device,172.8,40,,172.8,percent of total billed charges,Implant Device,151.2,70,,151.2,percent of total billed charges,All Other,146.88,34,,146.88,percent of total billed charges,Implant Device,146.88,34,,146.88,percent of total billed charges,Implant Device,151.2,35,,151.2,percent of total billed charges,Implant Device,151.2,35,,151.2,percent of total billed charges,Implant Device,151.2,35,,151.2,percent of total billed charges,Implant Device,151.2,35,,151.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,319.68,
DEPUY 8161-35-080 SCREW,C1713,HCPCS,,79002312,CDM,278,RC,,,both,,,364,269.36,,,269.36,Other,150% of Medicare + 9.63% HCRA Surcharge,163.8,45,,163.8,percent of total billed charges,Critical Access Hospital RCC factor,123.76,34,,123.76,percent of total billed charges,Implant Device,123.76,34,,123.76,percent of total billed charges,Implant Device,123.76,34,,123.76,percent of total billed charges,Implant Device,123.76,34,,123.76,percent of total billed charges,Implant Device,123.76,34,,123.76,percent of total billed charges,Implant Device,180.18,,,180.18,Other,110% of Medicare,127.4,35,,127.4,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,127.4,35,,127.4,percent of total billed charges,Implant Device,127.4,35,,127.4,percent of total billed charges,Implant Device,127.4,35,,127.4,percent of total billed charges,Implant Device,127.4,35,,127.4,percent of total billed charges,Implant Device,127.4,35,,127.4,percent of total billed charges,Implant Device,145.6,40,,145.6,percent of total billed charges,Implant Device,127.4,70,,127.4,percent of total billed charges,All Other,123.76,34,,123.76,percent of total billed charges,Implant Device,123.76,34,,123.76,percent of total billed charges,Implant Device,127.4,35,,127.4,percent of total billed charges,Implant Device,127.4,35,,127.4,percent of total billed charges,Implant Device,127.4,35,,127.4,percent of total billed charges,Implant Device,127.4,35,,127.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,269.36,
DEPUY 8161-35-085 SCREW,C1713,HCPCS,,79002313,CDM,278,RC,,,both,,,364,269.36,,,269.36,Other,150% of Medicare + 9.63% HCRA Surcharge,163.8,45,,163.8,percent of total billed charges,Critical Access Hospital RCC factor,123.76,34,,123.76,percent of total billed charges,Implant Device,123.76,34,,123.76,percent of total billed charges,Implant Device,123.76,34,,123.76,percent of total billed charges,Implant Device,123.76,34,,123.76,percent of total billed charges,Implant Device,123.76,34,,123.76,percent of total billed charges,Implant Device,180.18,,,180.18,Other,110% of Medicare,127.4,35,,127.4,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,127.4,35,,127.4,percent of total billed charges,Implant Device,127.4,35,,127.4,percent of total billed charges,Implant Device,127.4,35,,127.4,percent of total billed charges,Implant Device,127.4,35,,127.4,percent of total billed charges,Implant Device,127.4,35,,127.4,percent of total billed charges,Implant Device,145.6,40,,145.6,percent of total billed charges,Implant Device,127.4,70,,127.4,percent of total billed charges,All Other,123.76,34,,123.76,percent of total billed charges,Implant Device,123.76,34,,123.76,percent of total billed charges,Implant Device,127.4,35,,127.4,percent of total billed charges,Implant Device,127.4,35,,127.4,percent of total billed charges,Implant Device,127.4,35,,127.4,percent of total billed charges,Implant Device,127.4,35,,127.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,269.36,
DEPUY 8161-35-095 SCREW,C1713,HCPCS,,79002314,CDM,278,RC,,,both,,,660,488.4,,,488.4,Other,150% of Medicare + 9.63% HCRA Surcharge,297,45,,297,percent of total billed charges,Critical Access Hospital RCC factor,224.4,34,,224.4,percent of total billed charges,Implant Device,224.4,34,,224.4,percent of total billed charges,Implant Device,224.4,34,,224.4,percent of total billed charges,Implant Device,224.4,34,,224.4,percent of total billed charges,Implant Device,224.4,34,,224.4,percent of total billed charges,Implant Device,326.7,,,326.7,Other,110% of Medicare,231,35,,231,percent of total billed charges,Implant Device,224.4,34,"Charges > $500, x 34%",224.4,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,264,40,,264,percent of total billed charges,Implant Device,231,70,,231,percent of total billed charges,All Other,224.4,34,,224.4,percent of total billed charges,Implant Device,224.4,34,,224.4,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,488.4,
DEPUY 8161-40-038 SCREW,C1713,HCPCS,,79002315,CDM,278,RC,,,both,,,660,488.4,,,488.4,Other,150% of Medicare + 9.63% HCRA Surcharge,297,45,,297,percent of total billed charges,Critical Access Hospital RCC factor,224.4,34,,224.4,percent of total billed charges,Implant Device,224.4,34,,224.4,percent of total billed charges,Implant Device,224.4,34,,224.4,percent of total billed charges,Implant Device,224.4,34,,224.4,percent of total billed charges,Implant Device,224.4,34,,224.4,percent of total billed charges,Implant Device,326.7,,,326.7,Other,110% of Medicare,231,35,,231,percent of total billed charges,Implant Device,224.4,34,"Charges > $500, x 34%",224.4,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,264,40,,264,percent of total billed charges,Implant Device,231,70,,231,percent of total billed charges,All Other,224.4,34,,224.4,percent of total billed charges,Implant Device,224.4,34,,224.4,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,488.4,
DEPUY 8162-07-006 PLATE,C1713,HCPCS,,79002316,CDM,278,RC,,,both,,,4020,2974.81,,,2974.81,Other,150% of Medicare + 9.63% HCRA Surcharge,1809,45,,1809,percent of total billed charges,Critical Access Hospital RCC factor,1366.8,34,,1366.8,percent of total billed charges,Implant Device,1366.8,34,,1366.8,percent of total billed charges,Implant Device,1366.8,34,,1366.8,percent of total billed charges,Implant Device,1366.8,34,,1366.8,percent of total billed charges,Implant Device,1366.8,34,,1366.8,percent of total billed charges,Implant Device,1989.9,,,1989.9,Other,110% of Medicare,1407,35,,1407,percent of total billed charges,Implant Device,1366.8,34,"Charges > $500, x 34%",1366.8,percent of total billed charges,Implant Device,1407,35,,1407,percent of total billed charges,Implant Device,1407,35,,1407,percent of total billed charges,Implant Device,1407,35,,1407,percent of total billed charges,Implant Device,1407,35,,1407,percent of total billed charges,Implant Device,1407,35,,1407,percent of total billed charges,Implant Device,1608,40,,1608,percent of total billed charges,Implant Device,1407,70,,1407,percent of total billed charges,All Other,1366.8,34,,1366.8,percent of total billed charges,Implant Device,1366.8,34,,1366.8,percent of total billed charges,Implant Device,1407,35,,1407,percent of total billed charges,Implant Device,1407,35,,1407,percent of total billed charges,Implant Device,1407,35,,1407,percent of total billed charges,Implant Device,1407,35,,1407,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1366.8,34,"If Charge > 2,000, then 34 percent",1366.8,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2974.81,
BIOMET 8162-35-005 PLATE,C1713,HCPCS,,79002317,CDM,278,RC,,,both,,,1020,754.8,,,754.8,Other,150% of Medicare + 9.63% HCRA Surcharge,459,45,,459,percent of total billed charges,Critical Access Hospital RCC factor,346.8,34,,346.8,percent of total billed charges,Implant Device,346.8,34,,346.8,percent of total billed charges,Implant Device,346.8,34,,346.8,percent of total billed charges,Implant Device,346.8,34,,346.8,percent of total billed charges,Implant Device,346.8,34,,346.8,percent of total billed charges,Implant Device,504.9,,,504.9,Other,110% of Medicare,357,35,,357,percent of total billed charges,Implant Device,346.8,34,"Charges > $500, x 34%",346.8,percent of total billed charges,Implant Device,357,35,,357,percent of total billed charges,Implant Device,357,35,,357,percent of total billed charges,Implant Device,357,35,,357,percent of total billed charges,Implant Device,357,35,,357,percent of total billed charges,Implant Device,357,35,,357,percent of total billed charges,Implant Device,408,40,,408,percent of total billed charges,Implant Device,357,70,,357,percent of total billed charges,All Other,346.8,34,,346.8,percent of total billed charges,Implant Device,346.8,34,,346.8,percent of total billed charges,Implant Device,357,35,,357,percent of total billed charges,Implant Device,357,35,,357,percent of total billed charges,Implant Device,357,35,,357,percent of total billed charges,Implant Device,357,35,,357,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,754.8,
DEPUY 8162-45-007 PLATE,C1713,HCPCS,,79002318,CDM,278,RC,,,both,,,1290,954.6,,,954.6,Other,150% of Medicare + 9.63% HCRA Surcharge,580.5,45,,580.5,percent of total billed charges,Critical Access Hospital RCC factor,438.6,34,,438.6,percent of total billed charges,Implant Device,438.6,34,,438.6,percent of total billed charges,Implant Device,438.6,34,,438.6,percent of total billed charges,Implant Device,438.6,34,,438.6,percent of total billed charges,Implant Device,438.6,34,,438.6,percent of total billed charges,Implant Device,638.55,,,638.55,Other,110% of Medicare,451.5,35,,451.5,percent of total billed charges,Implant Device,438.6,34,"Charges > $500, x 34%",438.6,percent of total billed charges,Implant Device,451.5,35,,451.5,percent of total billed charges,Implant Device,451.5,35,,451.5,percent of total billed charges,Implant Device,451.5,35,,451.5,percent of total billed charges,Implant Device,451.5,35,,451.5,percent of total billed charges,Implant Device,451.5,35,,451.5,percent of total billed charges,Implant Device,516,40,,516,percent of total billed charges,Implant Device,451.5,70,,451.5,percent of total billed charges,All Other,438.6,34,,438.6,percent of total billed charges,Implant Device,438.6,34,,438.6,percent of total billed charges,Implant Device,451.5,35,,451.5,percent of total billed charges,Implant Device,451.5,35,,451.5,percent of total billed charges,Implant Device,451.5,35,,451.5,percent of total billed charges,Implant Device,451.5,35,,451.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,954.6,
DEPUY 86-7410-REV STEM,C1776,HCPCS,,79002321,CDM,278,RC,,,both,,,6144,4546.58,,,4546.58,Other,150% of Medicare + 9.63% HCRA Surcharge,2764.8,45,,2764.8,percent of total billed charges,Critical Access Hospital RCC factor,2088.96,34,,2088.96,percent of total billed charges,Implant Device,2088.96,34,,2088.96,percent of total billed charges,Implant Device,2088.96,34,,2088.96,percent of total billed charges,Implant Device,2088.96,34,,2088.96,percent of total billed charges,Implant Device,2088.96,34,,2088.96,percent of total billed charges,Implant Device,3041.28,,,3041.28,Other,110% of Medicare,2150.4,35,,2150.4,percent of total billed charges,Implant Device,2088.96,34,"Charges > $500, x 34%",2088.96,percent of total billed charges,Implant Device,2150.4,35,,2150.4,percent of total billed charges,Implant Device,2150.4,35,,2150.4,percent of total billed charges,Implant Device,2150.4,35,,2150.4,percent of total billed charges,Implant Device,2150.4,35,,2150.4,percent of total billed charges,Implant Device,2150.4,35,,2150.4,percent of total billed charges,Implant Device,2457.6,40,,2457.6,percent of total billed charges,Implant Device,2150.4,70,,2150.4,percent of total billed charges,All Other,2088.96,34,,2088.96,percent of total billed charges,Implant Device,2088.96,34,,2088.96,percent of total billed charges,Implant Device,2150.4,35,,2150.4,percent of total billed charges,Implant Device,2150.4,35,,2150.4,percent of total billed charges,Implant Device,2150.4,35,,2150.4,percent of total billed charges,Implant Device,2150.4,35,,2150.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2088.96,34,"If Charge > 2,000, then 34 percent",2088.96,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4546.58,
DEPUY 86-7414-REV STEM,C1776,HCPCS,,79002322,CDM,278,RC,,,both,,,4886,3615.65,,,3615.65,Other,150% of Medicare + 9.63% HCRA Surcharge,2198.7,45,,2198.7,percent of total billed charges,Critical Access Hospital RCC factor,1661.24,34,,1661.24,percent of total billed charges,Implant Device,1661.24,34,,1661.24,percent of total billed charges,Implant Device,1661.24,34,,1661.24,percent of total billed charges,Implant Device,1661.24,34,,1661.24,percent of total billed charges,Implant Device,1661.24,34,,1661.24,percent of total billed charges,Implant Device,2418.57,,,2418.57,Other,110% of Medicare,1710.1,35,,1710.1,percent of total billed charges,Implant Device,1661.24,34,"Charges > $500, x 34%",1661.24,percent of total billed charges,Implant Device,1710.1,35,,1710.1,percent of total billed charges,Implant Device,1710.1,35,,1710.1,percent of total billed charges,Implant Device,1710.1,35,,1710.1,percent of total billed charges,Implant Device,1710.1,35,,1710.1,percent of total billed charges,Implant Device,1710.1,35,,1710.1,percent of total billed charges,Implant Device,1954.4,40,,1954.4,percent of total billed charges,Implant Device,1710.1,70,,1710.1,percent of total billed charges,All Other,1661.24,34,,1661.24,percent of total billed charges,Implant Device,1661.24,34,,1661.24,percent of total billed charges,Implant Device,1710.1,35,,1710.1,percent of total billed charges,Implant Device,1710.1,35,,1710.1,percent of total billed charges,Implant Device,1710.1,35,,1710.1,percent of total billed charges,Implant Device,1710.1,35,,1710.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1661.24,34,"If Charge > 2,000, then 34 percent",1661.24,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3615.65,
DEPUY 86-7416-REV STEM,C1776,HCPCS,,79002323,CDM,278,RC,,,both,,,4886,3615.65,,,3615.65,Other,150% of Medicare + 9.63% HCRA Surcharge,2198.7,45,,2198.7,percent of total billed charges,Critical Access Hospital RCC factor,1661.24,34,,1661.24,percent of total billed charges,Implant Device,1661.24,34,,1661.24,percent of total billed charges,Implant Device,1661.24,34,,1661.24,percent of total billed charges,Implant Device,1661.24,34,,1661.24,percent of total billed charges,Implant Device,1661.24,34,,1661.24,percent of total billed charges,Implant Device,2418.57,,,2418.57,Other,110% of Medicare,1710.1,35,,1710.1,percent of total billed charges,Implant Device,1661.24,34,"Charges > $500, x 34%",1661.24,percent of total billed charges,Implant Device,1710.1,35,,1710.1,percent of total billed charges,Implant Device,1710.1,35,,1710.1,percent of total billed charges,Implant Device,1710.1,35,,1710.1,percent of total billed charges,Implant Device,1710.1,35,,1710.1,percent of total billed charges,Implant Device,1710.1,35,,1710.1,percent of total billed charges,Implant Device,1954.4,40,,1954.4,percent of total billed charges,Implant Device,1710.1,70,,1710.1,percent of total billed charges,All Other,1661.24,34,,1661.24,percent of total billed charges,Implant Device,1661.24,34,,1661.24,percent of total billed charges,Implant Device,1710.1,35,,1710.1,percent of total billed charges,Implant Device,1710.1,35,,1710.1,percent of total billed charges,Implant Device,1710.1,35,,1710.1,percent of total billed charges,Implant Device,1710.1,35,,1710.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1661.24,34,"If Charge > 2,000, then 34 percent",1661.24,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3615.65,
DEPUY 86-7418-REV STEM,C1776,HCPCS,,79002324,CDM,278,RC,,,both,,,5042,3731.09,,,3731.09,Other,150% of Medicare + 9.63% HCRA Surcharge,2268.9,45,,2268.9,percent of total billed charges,Critical Access Hospital RCC factor,1714.28,34,,1714.28,percent of total billed charges,Implant Device,1714.28,34,,1714.28,percent of total billed charges,Implant Device,1714.28,34,,1714.28,percent of total billed charges,Implant Device,1714.28,34,,1714.28,percent of total billed charges,Implant Device,1714.28,34,,1714.28,percent of total billed charges,Implant Device,2495.79,,,2495.79,Other,110% of Medicare,1764.7,35,,1764.7,percent of total billed charges,Implant Device,1714.28,34,"Charges > $500, x 34%",1714.28,percent of total billed charges,Implant Device,1764.7,35,,1764.7,percent of total billed charges,Implant Device,1764.7,35,,1764.7,percent of total billed charges,Implant Device,1764.7,35,,1764.7,percent of total billed charges,Implant Device,1764.7,35,,1764.7,percent of total billed charges,Implant Device,1764.7,35,,1764.7,percent of total billed charges,Implant Device,2016.8,40,,2016.8,percent of total billed charges,Implant Device,1764.7,70,,1764.7,percent of total billed charges,All Other,1714.28,34,,1714.28,percent of total billed charges,Implant Device,1714.28,34,,1714.28,percent of total billed charges,Implant Device,1764.7,35,,1764.7,percent of total billed charges,Implant Device,1764.7,35,,1764.7,percent of total billed charges,Implant Device,1764.7,35,,1764.7,percent of total billed charges,Implant Device,1764.7,35,,1764.7,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1714.28,34,"If Charge > 2,000, then 34 percent",1714.28,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3731.09,
DEPUY 86-7419-REV STEM,C1776,HCPCS,,79002325,CDM,278,RC,,,both,,,4886,3615.65,,,3615.65,Other,150% of Medicare + 9.63% HCRA Surcharge,2198.7,45,,2198.7,percent of total billed charges,Critical Access Hospital RCC factor,1661.24,34,,1661.24,percent of total billed charges,Implant Device,1661.24,34,,1661.24,percent of total billed charges,Implant Device,1661.24,34,,1661.24,percent of total billed charges,Implant Device,1661.24,34,,1661.24,percent of total billed charges,Implant Device,1661.24,34,,1661.24,percent of total billed charges,Implant Device,2418.57,,,2418.57,Other,110% of Medicare,1710.1,35,,1710.1,percent of total billed charges,Implant Device,1661.24,34,"Charges > $500, x 34%",1661.24,percent of total billed charges,Implant Device,1710.1,35,,1710.1,percent of total billed charges,Implant Device,1710.1,35,,1710.1,percent of total billed charges,Implant Device,1710.1,35,,1710.1,percent of total billed charges,Implant Device,1710.1,35,,1710.1,percent of total billed charges,Implant Device,1710.1,35,,1710.1,percent of total billed charges,Implant Device,1954.4,40,,1954.4,percent of total billed charges,Implant Device,1710.1,70,,1710.1,percent of total billed charges,All Other,1661.24,34,,1661.24,percent of total billed charges,Implant Device,1661.24,34,,1661.24,percent of total billed charges,Implant Device,1710.1,35,,1710.1,percent of total billed charges,Implant Device,1710.1,35,,1710.1,percent of total billed charges,Implant Device,1710.1,35,,1710.1,percent of total billed charges,Implant Device,1710.1,35,,1710.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1661.24,34,"If Charge > 2,000, then 34 percent",1661.24,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3615.65,
DEPUY 86-7428-REV STEM,C1776,HCPCS,,79002326,CDM,278,RC,,,both,,,4886,3615.65,,,3615.65,Other,150% of Medicare + 9.63% HCRA Surcharge,2198.7,45,,2198.7,percent of total billed charges,Critical Access Hospital RCC factor,1661.24,34,,1661.24,percent of total billed charges,Implant Device,1661.24,34,,1661.24,percent of total billed charges,Implant Device,1661.24,34,,1661.24,percent of total billed charges,Implant Device,1661.24,34,,1661.24,percent of total billed charges,Implant Device,1661.24,34,,1661.24,percent of total billed charges,Implant Device,2418.57,,,2418.57,Other,110% of Medicare,1710.1,35,,1710.1,percent of total billed charges,Implant Device,1661.24,34,"Charges > $500, x 34%",1661.24,percent of total billed charges,Implant Device,1710.1,35,,1710.1,percent of total billed charges,Implant Device,1710.1,35,,1710.1,percent of total billed charges,Implant Device,1710.1,35,,1710.1,percent of total billed charges,Implant Device,1710.1,35,,1710.1,percent of total billed charges,Implant Device,1710.1,35,,1710.1,percent of total billed charges,Implant Device,1954.4,40,,1954.4,percent of total billed charges,Implant Device,1710.1,70,,1710.1,percent of total billed charges,All Other,1661.24,34,,1661.24,percent of total billed charges,Implant Device,1661.24,34,,1661.24,percent of total billed charges,Implant Device,1710.1,35,,1710.1,percent of total billed charges,Implant Device,1710.1,35,,1710.1,percent of total billed charges,Implant Device,1710.1,35,,1710.1,percent of total billed charges,Implant Device,1710.1,35,,1710.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1661.24,34,"If Charge > 2,000, then 34 percent",1661.24,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3615.65,
DEPUY 86-7430-REV STEM,C1776,HCPCS,,79002327,CDM,278,RC,,,both,,,6144,4546.58,,,4546.58,Other,150% of Medicare + 9.63% HCRA Surcharge,2764.8,45,,2764.8,percent of total billed charges,Critical Access Hospital RCC factor,2088.96,34,,2088.96,percent of total billed charges,Implant Device,2088.96,34,,2088.96,percent of total billed charges,Implant Device,2088.96,34,,2088.96,percent of total billed charges,Implant Device,2088.96,34,,2088.96,percent of total billed charges,Implant Device,2088.96,34,,2088.96,percent of total billed charges,Implant Device,3041.28,,,3041.28,Other,110% of Medicare,2150.4,35,,2150.4,percent of total billed charges,Implant Device,2088.96,34,"Charges > $500, x 34%",2088.96,percent of total billed charges,Implant Device,2150.4,35,,2150.4,percent of total billed charges,Implant Device,2150.4,35,,2150.4,percent of total billed charges,Implant Device,2150.4,35,,2150.4,percent of total billed charges,Implant Device,2150.4,35,,2150.4,percent of total billed charges,Implant Device,2150.4,35,,2150.4,percent of total billed charges,Implant Device,2457.6,40,,2457.6,percent of total billed charges,Implant Device,2150.4,70,,2150.4,percent of total billed charges,All Other,2088.96,34,,2088.96,percent of total billed charges,Implant Device,2088.96,34,,2088.96,percent of total billed charges,Implant Device,2150.4,35,,2150.4,percent of total billed charges,Implant Device,2150.4,35,,2150.4,percent of total billed charges,Implant Device,2150.4,35,,2150.4,percent of total billed charges,Implant Device,2150.4,35,,2150.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2088.96,34,"If Charge > 2,000, then 34 percent",2088.96,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4546.58,
DEPUY 86-7432-REV STEM,C1776,HCPCS,,79002328,CDM,278,RC,,,both,,,5472,4049.29,,,4049.29,Other,150% of Medicare + 9.63% HCRA Surcharge,2462.4,45,,2462.4,percent of total billed charges,Critical Access Hospital RCC factor,1860.48,34,,1860.48,percent of total billed charges,Implant Device,1860.48,34,,1860.48,percent of total billed charges,Implant Device,1860.48,34,,1860.48,percent of total billed charges,Implant Device,1860.48,34,,1860.48,percent of total billed charges,Implant Device,1860.48,34,,1860.48,percent of total billed charges,Implant Device,2708.64,,,2708.64,Other,110% of Medicare,1915.2,35,,1915.2,percent of total billed charges,Implant Device,1860.48,34,"Charges > $500, x 34%",1860.48,percent of total billed charges,Implant Device,1915.2,35,,1915.2,percent of total billed charges,Implant Device,1915.2,35,,1915.2,percent of total billed charges,Implant Device,1915.2,35,,1915.2,percent of total billed charges,Implant Device,1915.2,35,,1915.2,percent of total billed charges,Implant Device,1915.2,35,,1915.2,percent of total billed charges,Implant Device,2188.8,40,,2188.8,percent of total billed charges,Implant Device,1915.2,70,,1915.2,percent of total billed charges,All Other,1860.48,34,,1860.48,percent of total billed charges,Implant Device,1860.48,34,,1860.48,percent of total billed charges,Implant Device,1915.2,35,,1915.2,percent of total billed charges,Implant Device,1915.2,35,,1915.2,percent of total billed charges,Implant Device,1915.2,35,,1915.2,percent of total billed charges,Implant Device,1915.2,35,,1915.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1860.48,34,"If Charge > 2,000, then 34 percent",1860.48,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4049.29,
ARTHROSURFACE 8H02-5652-W ART COMPONENT,C1776,HCPCS,,79002329,CDM,278,RC,,,both,,,17436,12902.68,,,12902.68,Other,150% of Medicare + 9.63% HCRA Surcharge,7846.2,45,,7846.2,percent of total billed charges,Critical Access Hospital RCC factor,5928.24,34,,5928.24,percent of total billed charges,Implant Device,5928.24,34,,5928.24,percent of total billed charges,Implant Device,5928.24,34,,5928.24,percent of total billed charges,Implant Device,5928.24,34,,5928.24,percent of total billed charges,Implant Device,5928.24,34,,5928.24,percent of total billed charges,Implant Device,8630.82,,,8630.82,Other,110% of Medicare,6102.6,35,,6102.6,percent of total billed charges,Implant Device,5928.24,34,"Charges > $500, x 34%",5928.24,percent of total billed charges,Implant Device,6102.6,35,,6102.6,percent of total billed charges,Implant Device,6102.6,35,,6102.6,percent of total billed charges,Implant Device,6102.6,35,,6102.6,percent of total billed charges,Implant Device,6102.6,35,,6102.6,percent of total billed charges,Implant Device,6102.6,35,,6102.6,percent of total billed charges,Implant Device,6974.4,40,,6974.4,percent of total billed charges,Implant Device,6102.6,70,,6102.6,percent of total billed charges,All Other,5928.24,34,,5928.24,percent of total billed charges,Implant Device,5928.24,34,,5928.24,percent of total billed charges,Implant Device,6102.6,35,,6102.6,percent of total billed charges,Implant Device,6102.6,35,,6102.6,percent of total billed charges,Implant Device,6102.6,35,,6102.6,percent of total billed charges,Implant Device,6102.6,35,,6102.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,5928.24,34,"If Charge > 2,000, then 34 percent",5928.24,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,12902.68,
ZIMMER 9026-29-358-REV FEMORAL HEAD,C1776,HCPCS,,79002330,CDM,278,RC,,,both,,,2497,1847.79,,,1847.79,Other,150% of Medicare + 9.63% HCRA Surcharge,1123.65,45,,1123.65,percent of total billed charges,Critical Access Hospital RCC factor,848.98,34,,848.98,percent of total billed charges,Implant Device,848.98,34,,848.98,percent of total billed charges,Implant Device,848.98,34,,848.98,percent of total billed charges,Implant Device,848.98,34,,848.98,percent of total billed charges,Implant Device,848.98,34,,848.98,percent of total billed charges,Implant Device,1236.02,,,1236.02,Other,110% of Medicare,873.95,35,,873.95,percent of total billed charges,Implant Device,848.98,34,"Charges > $500, x 34%",848.98,percent of total billed charges,Implant Device,873.95,35,,873.95,percent of total billed charges,Implant Device,873.95,35,,873.95,percent of total billed charges,Implant Device,873.95,35,,873.95,percent of total billed charges,Implant Device,873.95,35,,873.95,percent of total billed charges,Implant Device,873.95,35,,873.95,percent of total billed charges,Implant Device,998.8,40,,998.8,percent of total billed charges,Implant Device,873.95,70,,873.95,percent of total billed charges,All Other,848.98,34,,848.98,percent of total billed charges,Implant Device,848.98,34,,848.98,percent of total billed charges,Implant Device,873.95,35,,873.95,percent of total billed charges,Implant Device,873.95,35,,873.95,percent of total billed charges,Implant Device,873.95,35,,873.95,percent of total billed charges,Implant Device,873.95,35,,873.95,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,848.98,34,"If Charge > 2,000, then 34 percent",848.98,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1847.79,
ZIMMER 90-5952-40-17 REV ART SURFACE,C1776,HCPCS,,79002331,CDM,278,RC,,,both,,,5107,3779.19,,,3779.19,Other,150% of Medicare + 9.63% HCRA Surcharge,2298.15,45,,2298.15,percent of total billed charges,Critical Access Hospital RCC factor,1736.38,34,,1736.38,percent of total billed charges,Implant Device,1736.38,34,,1736.38,percent of total billed charges,Implant Device,1736.38,34,,1736.38,percent of total billed charges,Implant Device,1736.38,34,,1736.38,percent of total billed charges,Implant Device,1736.38,34,,1736.38,percent of total billed charges,Implant Device,2527.97,,,2527.97,Other,110% of Medicare,1787.45,35,,1787.45,percent of total billed charges,Implant Device,1736.38,34,"Charges > $500, x 34%",1736.38,percent of total billed charges,Implant Device,1787.45,35,,1787.45,percent of total billed charges,Implant Device,1787.45,35,,1787.45,percent of total billed charges,Implant Device,1787.45,35,,1787.45,percent of total billed charges,Implant Device,1787.45,35,,1787.45,percent of total billed charges,Implant Device,1787.45,35,,1787.45,percent of total billed charges,Implant Device,2042.8,40,,2042.8,percent of total billed charges,Implant Device,1787.45,70,,1787.45,percent of total billed charges,All Other,1736.38,34,,1736.38,percent of total billed charges,Implant Device,1736.38,34,,1736.38,percent of total billed charges,Implant Device,1787.45,35,,1787.45,percent of total billed charges,Implant Device,1787.45,35,,1787.45,percent of total billed charges,Implant Device,1787.45,35,,1787.45,percent of total billed charges,Implant Device,1787.45,35,,1787.45,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1736.38,34,"If Charge > 2,000, then 34 percent",1736.38,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3779.19,
DEPUY 96-0003-REV FEMORAL COMPONENT,C1776,HCPCS,,79002333,CDM,278,RC,,,both,,,7104,5256.98,,,5256.98,Other,150% of Medicare + 9.63% HCRA Surcharge,3196.8,45,,3196.8,percent of total billed charges,Critical Access Hospital RCC factor,2415.36,34,,2415.36,percent of total billed charges,Implant Device,2415.36,34,,2415.36,percent of total billed charges,Implant Device,2415.36,34,,2415.36,percent of total billed charges,Implant Device,2415.36,34,,2415.36,percent of total billed charges,Implant Device,2415.36,34,,2415.36,percent of total billed charges,Implant Device,3516.48,,,3516.48,Other,110% of Medicare,2486.4,35,,2486.4,percent of total billed charges,Implant Device,2415.36,34,"Charges > $500, x 34%",2415.36,percent of total billed charges,Implant Device,2486.4,35,,2486.4,percent of total billed charges,Implant Device,2486.4,35,,2486.4,percent of total billed charges,Implant Device,2486.4,35,,2486.4,percent of total billed charges,Implant Device,2486.4,35,,2486.4,percent of total billed charges,Implant Device,2486.4,35,,2486.4,percent of total billed charges,Implant Device,2841.6,40,,2841.6,percent of total billed charges,Implant Device,2486.4,70,,2486.4,percent of total billed charges,All Other,2415.36,34,,2415.36,percent of total billed charges,Implant Device,2415.36,34,,2415.36,percent of total billed charges,Implant Device,2486.4,35,,2486.4,percent of total billed charges,Implant Device,2486.4,35,,2486.4,percent of total billed charges,Implant Device,2486.4,35,,2486.4,percent of total billed charges,Implant Device,2486.4,35,,2486.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2415.36,34,"If Charge > 2,000, then 34 percent",2415.36,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5256.98,
DEPUY 96-0082-REV FEMORAL COMPONENT,C1776,HCPCS,,79002334,CDM,278,RC,,,both,,,19650,14541.05,,,14541.05,Other,150% of Medicare + 9.63% HCRA Surcharge,8842.5,45,,8842.5,percent of total billed charges,Critical Access Hospital RCC factor,6681,34,,6681,percent of total billed charges,Implant Device,6681,34,,6681,percent of total billed charges,Implant Device,6681,34,,6681,percent of total billed charges,Implant Device,6681,34,,6681,percent of total billed charges,Implant Device,6681,34,,6681,percent of total billed charges,Implant Device,9726.75,,,9726.75,Other,110% of Medicare,6877.5,35,,6877.5,percent of total billed charges,Implant Device,6681,34,"Charges > $500, x 34%",6681,percent of total billed charges,Implant Device,6877.5,35,,6877.5,percent of total billed charges,Implant Device,6877.5,35,,6877.5,percent of total billed charges,Implant Device,6877.5,35,,6877.5,percent of total billed charges,Implant Device,6877.5,35,,6877.5,percent of total billed charges,Implant Device,6877.5,35,,6877.5,percent of total billed charges,Implant Device,7860,40,,7860,percent of total billed charges,Implant Device,6877.5,70,,6877.5,percent of total billed charges,All Other,6681,34,,6681,percent of total billed charges,Implant Device,6681,34,,6681,percent of total billed charges,Implant Device,6877.5,35,,6877.5,percent of total billed charges,Implant Device,6877.5,35,,6877.5,percent of total billed charges,Implant Device,6877.5,35,,6877.5,percent of total billed charges,Implant Device,6877.5,35,,6877.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,6681,34,"If Charge > 2,000, then 34 percent",6681,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,14541.05,
DEPUY 96-0084-REV FEMORAL COMPONENT,C1776,HCPCS,,79002335,CDM,278,RC,,,both,,,19650,14541.05,,,14541.05,Other,150% of Medicare + 9.63% HCRA Surcharge,8842.5,45,,8842.5,percent of total billed charges,Critical Access Hospital RCC factor,6681,34,,6681,percent of total billed charges,Implant Device,6681,34,,6681,percent of total billed charges,Implant Device,6681,34,,6681,percent of total billed charges,Implant Device,6681,34,,6681,percent of total billed charges,Implant Device,6681,34,,6681,percent of total billed charges,Implant Device,9726.75,,,9726.75,Other,110% of Medicare,6877.5,35,,6877.5,percent of total billed charges,Implant Device,6681,34,"Charges > $500, x 34%",6681,percent of total billed charges,Implant Device,6877.5,35,,6877.5,percent of total billed charges,Implant Device,6877.5,35,,6877.5,percent of total billed charges,Implant Device,6877.5,35,,6877.5,percent of total billed charges,Implant Device,6877.5,35,,6877.5,percent of total billed charges,Implant Device,6877.5,35,,6877.5,percent of total billed charges,Implant Device,7860,40,,7860,percent of total billed charges,Implant Device,6877.5,70,,6877.5,percent of total billed charges,All Other,6681,34,,6681,percent of total billed charges,Implant Device,6681,34,,6681,percent of total billed charges,Implant Device,6877.5,35,,6877.5,percent of total billed charges,Implant Device,6877.5,35,,6877.5,percent of total billed charges,Implant Device,6877.5,35,,6877.5,percent of total billed charges,Implant Device,6877.5,35,,6877.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,6681,34,"If Charge > 2,000, then 34 percent",6681,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,14541.05,
DEPUY 96-0089-REV FEMORAL COMPONENT,C1776,HCPCS,,79002336,CDM,278,RC,,,both,,,21616,15995.89,,,15995.89,Other,150% of Medicare + 9.63% HCRA Surcharge,9727.2,45,,9727.2,percent of total billed charges,Critical Access Hospital RCC factor,7349.44,34,,7349.44,percent of total billed charges,Implant Device,7349.44,34,,7349.44,percent of total billed charges,Implant Device,7349.44,34,,7349.44,percent of total billed charges,Implant Device,7349.44,34,,7349.44,percent of total billed charges,Implant Device,7349.44,34,,7349.44,percent of total billed charges,Implant Device,10699.92,,,10699.92,Other,110% of Medicare,7565.6,35,,7565.6,percent of total billed charges,Implant Device,7349.44,34,"Charges > $500, x 34%",7349.44,percent of total billed charges,Implant Device,7565.6,35,,7565.6,percent of total billed charges,Implant Device,7565.6,35,,7565.6,percent of total billed charges,Implant Device,7565.6,35,,7565.6,percent of total billed charges,Implant Device,7565.6,35,,7565.6,percent of total billed charges,Implant Device,7565.6,35,,7565.6,percent of total billed charges,Implant Device,8646.4,40,,8646.4,percent of total billed charges,Implant Device,7565.6,70,,7565.6,percent of total billed charges,All Other,7349.44,34,,7349.44,percent of total billed charges,Implant Device,7349.44,34,,7349.44,percent of total billed charges,Implant Device,7565.6,35,,7565.6,percent of total billed charges,Implant Device,7565.6,35,,7565.6,percent of total billed charges,Implant Device,7565.6,35,,7565.6,percent of total billed charges,Implant Device,7565.6,35,,7565.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,7349.44,34,"If Charge > 2,000, then 34 percent",7349.44,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,15995.89,
DEPUY 96-0090-REV FEMORAL COMPONENT,C1776,HCPCS,,79002337,CDM,278,RC,,,both,,,20279,15006.51,,,15006.51,Other,150% of Medicare + 9.63% HCRA Surcharge,9125.55,45,,9125.55,percent of total billed charges,Critical Access Hospital RCC factor,6894.86,34,,6894.86,percent of total billed charges,Implant Device,6894.86,34,,6894.86,percent of total billed charges,Implant Device,6894.86,34,,6894.86,percent of total billed charges,Implant Device,6894.86,34,,6894.86,percent of total billed charges,Implant Device,6894.86,34,,6894.86,percent of total billed charges,Implant Device,10038.11,,,10038.11,Other,110% of Medicare,7097.65,35,,7097.65,percent of total billed charges,Implant Device,6894.86,34,"Charges > $500, x 34%",6894.86,percent of total billed charges,Implant Device,7097.65,35,,7097.65,percent of total billed charges,Implant Device,7097.65,35,,7097.65,percent of total billed charges,Implant Device,7097.65,35,,7097.65,percent of total billed charges,Implant Device,7097.65,35,,7097.65,percent of total billed charges,Implant Device,7097.65,35,,7097.65,percent of total billed charges,Implant Device,8111.6,40,,8111.6,percent of total billed charges,Implant Device,7097.65,70,,7097.65,percent of total billed charges,All Other,6894.86,34,,6894.86,percent of total billed charges,Implant Device,6894.86,34,,6894.86,percent of total billed charges,Implant Device,7097.65,35,,7097.65,percent of total billed charges,Implant Device,7097.65,35,,7097.65,percent of total billed charges,Implant Device,7097.65,35,,7097.65,percent of total billed charges,Implant Device,7097.65,35,,7097.65,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,6894.86,34,"If Charge > 2,000, then 34 percent",6894.86,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,15006.51,
DEPUY 96-0101-REV PATELLA,C1776,HCPCS,,79002338,CDM,278,RC,,,both,,,2024,1497.77,,,1497.77,Other,150% of Medicare + 9.63% HCRA Surcharge,910.8,45,,910.8,percent of total billed charges,Critical Access Hospital RCC factor,688.16,34,,688.16,percent of total billed charges,Implant Device,688.16,34,,688.16,percent of total billed charges,Implant Device,688.16,34,,688.16,percent of total billed charges,Implant Device,688.16,34,,688.16,percent of total billed charges,Implant Device,688.16,34,,688.16,percent of total billed charges,Implant Device,1001.88,,,1001.88,Other,110% of Medicare,708.4,35,,708.4,percent of total billed charges,Implant Device,688.16,34,"Charges > $500, x 34%",688.16,percent of total billed charges,Implant Device,708.4,35,,708.4,percent of total billed charges,Implant Device,708.4,35,,708.4,percent of total billed charges,Implant Device,708.4,35,,708.4,percent of total billed charges,Implant Device,708.4,35,,708.4,percent of total billed charges,Implant Device,708.4,35,,708.4,percent of total billed charges,Implant Device,809.6,40,,809.6,percent of total billed charges,Implant Device,708.4,70,,708.4,percent of total billed charges,All Other,688.16,34,,688.16,percent of total billed charges,Implant Device,688.16,34,,688.16,percent of total billed charges,Implant Device,708.4,35,,708.4,percent of total billed charges,Implant Device,708.4,35,,708.4,percent of total billed charges,Implant Device,708.4,35,,708.4,percent of total billed charges,Implant Device,708.4,35,,708.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,688.16,34,"If Charge > 2,000, then 34 percent",688.16,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1497.77,
DEPUY 96-0781-REV FEMORAL COMPONENT,C1776,HCPCS,,79002339,CDM,278,RC,,,both,,,8558,6332.94,,,6332.94,Other,150% of Medicare + 9.63% HCRA Surcharge,3851.1,45,,3851.1,percent of total billed charges,Critical Access Hospital RCC factor,2909.72,34,,2909.72,percent of total billed charges,Implant Device,2909.72,34,,2909.72,percent of total billed charges,Implant Device,2909.72,34,,2909.72,percent of total billed charges,Implant Device,2909.72,34,,2909.72,percent of total billed charges,Implant Device,2909.72,34,,2909.72,percent of total billed charges,Implant Device,4236.21,,,4236.21,Other,110% of Medicare,2995.3,35,,2995.3,percent of total billed charges,Implant Device,2909.72,34,"Charges > $500, x 34%",2909.72,percent of total billed charges,Implant Device,2995.3,35,,2995.3,percent of total billed charges,Implant Device,2995.3,35,,2995.3,percent of total billed charges,Implant Device,2995.3,35,,2995.3,percent of total billed charges,Implant Device,2995.3,35,,2995.3,percent of total billed charges,Implant Device,2995.3,35,,2995.3,percent of total billed charges,Implant Device,3423.2,40,,3423.2,percent of total billed charges,Implant Device,2995.3,70,,2995.3,percent of total billed charges,All Other,2909.72,34,,2909.72,percent of total billed charges,Implant Device,2909.72,34,,2909.72,percent of total billed charges,Implant Device,2995.3,35,,2995.3,percent of total billed charges,Implant Device,2995.3,35,,2995.3,percent of total billed charges,Implant Device,2995.3,35,,2995.3,percent of total billed charges,Implant Device,2995.3,35,,2995.3,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2909.72,34,"If Charge > 2,000, then 34 percent",2909.72,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,6332.94,
DEPUY 96-0783-REV FEMORAL ADAPTER,C1776,HCPCS,,79002340,CDM,278,RC,,,both,,,1088,805.12,,,805.12,Other,150% of Medicare + 9.63% HCRA Surcharge,489.6,45,,489.6,percent of total billed charges,Critical Access Hospital RCC factor,369.92,34,,369.92,percent of total billed charges,Implant Device,369.92,34,,369.92,percent of total billed charges,Implant Device,369.92,34,,369.92,percent of total billed charges,Implant Device,369.92,34,,369.92,percent of total billed charges,Implant Device,369.92,34,,369.92,percent of total billed charges,Implant Device,538.56,,,538.56,Other,110% of Medicare,380.8,35,,380.8,percent of total billed charges,Implant Device,369.92,34,"Charges > $500, x 34%",369.92,percent of total billed charges,Implant Device,380.8,35,,380.8,percent of total billed charges,Implant Device,380.8,35,,380.8,percent of total billed charges,Implant Device,380.8,35,,380.8,percent of total billed charges,Implant Device,380.8,35,,380.8,percent of total billed charges,Implant Device,380.8,35,,380.8,percent of total billed charges,Implant Device,435.2,40,,435.2,percent of total billed charges,Implant Device,380.8,70,,380.8,percent of total billed charges,All Other,369.92,34,,369.92,percent of total billed charges,Implant Device,369.92,34,,369.92,percent of total billed charges,Implant Device,380.8,35,,380.8,percent of total billed charges,Implant Device,380.8,35,,380.8,percent of total billed charges,Implant Device,380.8,35,,380.8,percent of total billed charges,Implant Device,380.8,35,,380.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,805.12,
DEPUY 96-0784-REV FEMORAL ADAPTER,C1776,HCPCS,,79002341,CDM,278,RC,,,both,,,1200,888,,,888,Other,150% of Medicare + 9.63% HCRA Surcharge,540,45,,540,percent of total billed charges,Critical Access Hospital RCC factor,408,34,,408,percent of total billed charges,Implant Device,408,34,,408,percent of total billed charges,Implant Device,408,34,,408,percent of total billed charges,Implant Device,408,34,,408,percent of total billed charges,Implant Device,408,34,,408,percent of total billed charges,Implant Device,594,,,594,Other,110% of Medicare,420,35,,420,percent of total billed charges,Implant Device,408,34,"Charges > $500, x 34%",408,percent of total billed charges,Implant Device,420,35,,420,percent of total billed charges,Implant Device,420,35,,420,percent of total billed charges,Implant Device,420,35,,420,percent of total billed charges,Implant Device,420,35,,420,percent of total billed charges,Implant Device,420,35,,420,percent of total billed charges,Implant Device,480,40,,480,percent of total billed charges,Implant Device,420,70,,420,percent of total billed charges,All Other,408,34,,408,percent of total billed charges,Implant Device,408,34,,408,percent of total billed charges,Implant Device,420,35,,420,percent of total billed charges,Implant Device,420,35,,420,percent of total billed charges,Implant Device,420,35,,420,percent of total billed charges,Implant Device,420,35,,420,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,888,
DEPUY 96-0862-REV DISTAL AUGMENT,C1776,HCPCS,,79002342,CDM,278,RC,,,both,,,3371,2494.55,,,2494.55,Other,150% of Medicare + 9.63% HCRA Surcharge,1516.95,45,,1516.95,percent of total billed charges,Critical Access Hospital RCC factor,1146.14,34,,1146.14,percent of total billed charges,Implant Device,1146.14,34,,1146.14,percent of total billed charges,Implant Device,1146.14,34,,1146.14,percent of total billed charges,Implant Device,1146.14,34,,1146.14,percent of total billed charges,Implant Device,1146.14,34,,1146.14,percent of total billed charges,Implant Device,1668.65,,,1668.65,Other,110% of Medicare,1179.85,35,,1179.85,percent of total billed charges,Implant Device,1146.14,34,"Charges > $500, x 34%",1146.14,percent of total billed charges,Implant Device,1179.85,35,,1179.85,percent of total billed charges,Implant Device,1179.85,35,,1179.85,percent of total billed charges,Implant Device,1179.85,35,,1179.85,percent of total billed charges,Implant Device,1179.85,35,,1179.85,percent of total billed charges,Implant Device,1179.85,35,,1179.85,percent of total billed charges,Implant Device,1348.4,40,,1348.4,percent of total billed charges,Implant Device,1179.85,70,,1179.85,percent of total billed charges,All Other,1146.14,34,,1146.14,percent of total billed charges,Implant Device,1146.14,34,,1146.14,percent of total billed charges,Implant Device,1179.85,35,,1179.85,percent of total billed charges,Implant Device,1179.85,35,,1179.85,percent of total billed charges,Implant Device,1179.85,35,,1179.85,percent of total billed charges,Implant Device,1179.85,35,,1179.85,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1146.14,34,"If Charge > 2,000, then 34 percent",1146.14,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2494.55,
DEPUY 96-0868-REV POST AUGMENT,C1776,HCPCS,,79002343,CDM,278,RC,,,both,,,3371,2494.55,,,2494.55,Other,150% of Medicare + 9.63% HCRA Surcharge,1516.95,45,,1516.95,percent of total billed charges,Critical Access Hospital RCC factor,1146.14,34,,1146.14,percent of total billed charges,Implant Device,1146.14,34,,1146.14,percent of total billed charges,Implant Device,1146.14,34,,1146.14,percent of total billed charges,Implant Device,1146.14,34,,1146.14,percent of total billed charges,Implant Device,1146.14,34,,1146.14,percent of total billed charges,Implant Device,1668.65,,,1668.65,Other,110% of Medicare,1179.85,35,,1179.85,percent of total billed charges,Implant Device,1146.14,34,"Charges > $500, x 34%",1146.14,percent of total billed charges,Implant Device,1179.85,35,,1179.85,percent of total billed charges,Implant Device,1179.85,35,,1179.85,percent of total billed charges,Implant Device,1179.85,35,,1179.85,percent of total billed charges,Implant Device,1179.85,35,,1179.85,percent of total billed charges,Implant Device,1179.85,35,,1179.85,percent of total billed charges,Implant Device,1348.4,40,,1348.4,percent of total billed charges,Implant Device,1179.85,70,,1179.85,percent of total billed charges,All Other,1146.14,34,,1146.14,percent of total billed charges,Implant Device,1146.14,34,,1146.14,percent of total billed charges,Implant Device,1179.85,35,,1179.85,percent of total billed charges,Implant Device,1179.85,35,,1179.85,percent of total billed charges,Implant Device,1179.85,35,,1179.85,percent of total billed charges,Implant Device,1179.85,35,,1179.85,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1146.14,34,"If Charge > 2,000, then 34 percent",1146.14,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2494.55,
DEPUY 96-0869-REV DISTAL AUGMENT,C1776,HCPCS,,79002344,CDM,278,RC,,,both,,,3371,2494.55,,,2494.55,Other,150% of Medicare + 9.63% HCRA Surcharge,1516.95,45,,1516.95,percent of total billed charges,Critical Access Hospital RCC factor,1146.14,34,,1146.14,percent of total billed charges,Implant Device,1146.14,34,,1146.14,percent of total billed charges,Implant Device,1146.14,34,,1146.14,percent of total billed charges,Implant Device,1146.14,34,,1146.14,percent of total billed charges,Implant Device,1146.14,34,,1146.14,percent of total billed charges,Implant Device,1668.65,,,1668.65,Other,110% of Medicare,1179.85,35,,1179.85,percent of total billed charges,Implant Device,1146.14,34,"Charges > $500, x 34%",1146.14,percent of total billed charges,Implant Device,1179.85,35,,1179.85,percent of total billed charges,Implant Device,1179.85,35,,1179.85,percent of total billed charges,Implant Device,1179.85,35,,1179.85,percent of total billed charges,Implant Device,1179.85,35,,1179.85,percent of total billed charges,Implant Device,1179.85,35,,1179.85,percent of total billed charges,Implant Device,1348.4,40,,1348.4,percent of total billed charges,Implant Device,1179.85,70,,1179.85,percent of total billed charges,All Other,1146.14,34,,1146.14,percent of total billed charges,Implant Device,1146.14,34,,1146.14,percent of total billed charges,Implant Device,1179.85,35,,1179.85,percent of total billed charges,Implant Device,1179.85,35,,1179.85,percent of total billed charges,Implant Device,1179.85,35,,1179.85,percent of total billed charges,Implant Device,1179.85,35,,1179.85,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1146.14,34,"If Charge > 2,000, then 34 percent",1146.14,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2494.55,
DEPUY 96-0883-REV DISTAL AUGMENT,C1776,HCPCS,,79002345,CDM,278,RC,,,both,,,3708,2743.93,,,2743.93,Other,150% of Medicare + 9.63% HCRA Surcharge,1668.6,45,,1668.6,percent of total billed charges,Critical Access Hospital RCC factor,1260.72,34,,1260.72,percent of total billed charges,Implant Device,1260.72,34,,1260.72,percent of total billed charges,Implant Device,1260.72,34,,1260.72,percent of total billed charges,Implant Device,1260.72,34,,1260.72,percent of total billed charges,Implant Device,1260.72,34,,1260.72,percent of total billed charges,Implant Device,1835.46,,,1835.46,Other,110% of Medicare,1297.8,35,,1297.8,percent of total billed charges,Implant Device,1260.72,34,"Charges > $500, x 34%",1260.72,percent of total billed charges,Implant Device,1297.8,35,,1297.8,percent of total billed charges,Implant Device,1297.8,35,,1297.8,percent of total billed charges,Implant Device,1297.8,35,,1297.8,percent of total billed charges,Implant Device,1297.8,35,,1297.8,percent of total billed charges,Implant Device,1297.8,35,,1297.8,percent of total billed charges,Implant Device,1483.2,40,,1483.2,percent of total billed charges,Implant Device,1297.8,70,,1297.8,percent of total billed charges,All Other,1260.72,34,,1260.72,percent of total billed charges,Implant Device,1260.72,34,,1260.72,percent of total billed charges,Implant Device,1297.8,35,,1297.8,percent of total billed charges,Implant Device,1297.8,35,,1297.8,percent of total billed charges,Implant Device,1297.8,35,,1297.8,percent of total billed charges,Implant Device,1297.8,35,,1297.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1260.72,34,"If Charge > 2,000, then 34 percent",1260.72,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2743.93,
DEPUY 96-0886-REV POST AUGMENT,C1776,HCPCS,,79002346,CDM,278,RC,,,both,,,3929,2907.47,,,2907.47,Other,150% of Medicare + 9.63% HCRA Surcharge,1768.05,45,,1768.05,percent of total billed charges,Critical Access Hospital RCC factor,1335.86,34,,1335.86,percent of total billed charges,Implant Device,1335.86,34,,1335.86,percent of total billed charges,Implant Device,1335.86,34,,1335.86,percent of total billed charges,Implant Device,1335.86,34,,1335.86,percent of total billed charges,Implant Device,1335.86,34,,1335.86,percent of total billed charges,Implant Device,1944.86,,,1944.86,Other,110% of Medicare,1375.15,35,,1375.15,percent of total billed charges,Implant Device,1335.86,34,"Charges > $500, x 34%",1335.86,percent of total billed charges,Implant Device,1375.15,35,,1375.15,percent of total billed charges,Implant Device,1375.15,35,,1375.15,percent of total billed charges,Implant Device,1375.15,35,,1375.15,percent of total billed charges,Implant Device,1375.15,35,,1375.15,percent of total billed charges,Implant Device,1375.15,35,,1375.15,percent of total billed charges,Implant Device,1571.6,40,,1571.6,percent of total billed charges,Implant Device,1375.15,70,,1375.15,percent of total billed charges,All Other,1335.86,34,,1335.86,percent of total billed charges,Implant Device,1335.86,34,,1335.86,percent of total billed charges,Implant Device,1375.15,35,,1375.15,percent of total billed charges,Implant Device,1375.15,35,,1375.15,percent of total billed charges,Implant Device,1375.15,35,,1375.15,percent of total billed charges,Implant Device,1375.15,35,,1375.15,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1335.86,34,"If Charge > 2,000, then 34 percent",1335.86,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2907.47,
DEPUY 96-0890-REV DISTAL AUGMENT,C1776,HCPCS,,79002347,CDM,278,RC,,,both,,,3708,2743.93,,,2743.93,Other,150% of Medicare + 9.63% HCRA Surcharge,1668.6,45,,1668.6,percent of total billed charges,Critical Access Hospital RCC factor,1260.72,34,,1260.72,percent of total billed charges,Implant Device,1260.72,34,,1260.72,percent of total billed charges,Implant Device,1260.72,34,,1260.72,percent of total billed charges,Implant Device,1260.72,34,,1260.72,percent of total billed charges,Implant Device,1260.72,34,,1260.72,percent of total billed charges,Implant Device,1835.46,,,1835.46,Other,110% of Medicare,1297.8,35,,1297.8,percent of total billed charges,Implant Device,1260.72,34,"Charges > $500, x 34%",1260.72,percent of total billed charges,Implant Device,1297.8,35,,1297.8,percent of total billed charges,Implant Device,1297.8,35,,1297.8,percent of total billed charges,Implant Device,1297.8,35,,1297.8,percent of total billed charges,Implant Device,1297.8,35,,1297.8,percent of total billed charges,Implant Device,1297.8,35,,1297.8,percent of total billed charges,Implant Device,1483.2,40,,1483.2,percent of total billed charges,Implant Device,1297.8,70,,1297.8,percent of total billed charges,All Other,1260.72,34,,1260.72,percent of total billed charges,Implant Device,1260.72,34,,1260.72,percent of total billed charges,Implant Device,1297.8,35,,1297.8,percent of total billed charges,Implant Device,1297.8,35,,1297.8,percent of total billed charges,Implant Device,1297.8,35,,1297.8,percent of total billed charges,Implant Device,1297.8,35,,1297.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1260.72,34,"If Charge > 2,000, then 34 percent",1260.72,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2743.93,
DEPUY 96-0900-REV DISTAL AUGMENT,C1776,HCPCS,,79002348,CDM,278,RC,,,both,,,3708,2743.93,,,2743.93,Other,150% of Medicare + 9.63% HCRA Surcharge,1668.6,45,,1668.6,percent of total billed charges,Critical Access Hospital RCC factor,1260.72,34,,1260.72,percent of total billed charges,Implant Device,1260.72,34,,1260.72,percent of total billed charges,Implant Device,1260.72,34,,1260.72,percent of total billed charges,Implant Device,1260.72,34,,1260.72,percent of total billed charges,Implant Device,1260.72,34,,1260.72,percent of total billed charges,Implant Device,1835.46,,,1835.46,Other,110% of Medicare,1297.8,35,,1297.8,percent of total billed charges,Implant Device,1260.72,34,"Charges > $500, x 34%",1260.72,percent of total billed charges,Implant Device,1297.8,35,,1297.8,percent of total billed charges,Implant Device,1297.8,35,,1297.8,percent of total billed charges,Implant Device,1297.8,35,,1297.8,percent of total billed charges,Implant Device,1297.8,35,,1297.8,percent of total billed charges,Implant Device,1297.8,35,,1297.8,percent of total billed charges,Implant Device,1483.2,40,,1483.2,percent of total billed charges,Implant Device,1297.8,70,,1297.8,percent of total billed charges,All Other,1260.72,34,,1260.72,percent of total billed charges,Implant Device,1260.72,34,,1260.72,percent of total billed charges,Implant Device,1297.8,35,,1297.8,percent of total billed charges,Implant Device,1297.8,35,,1297.8,percent of total billed charges,Implant Device,1297.8,35,,1297.8,percent of total billed charges,Implant Device,1297.8,35,,1297.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1260.72,34,"If Charge > 2,000, then 34 percent",1260.72,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2743.93,
DEPUY 96-0903-REV DISTAL AUGMENT,C1776,HCPCS,,79002349,CDM,278,RC,,,both,,,3479,2574.47,,,2574.47,Other,150% of Medicare + 9.63% HCRA Surcharge,1565.55,45,,1565.55,percent of total billed charges,Critical Access Hospital RCC factor,1182.86,34,,1182.86,percent of total billed charges,Implant Device,1182.86,34,,1182.86,percent of total billed charges,Implant Device,1182.86,34,,1182.86,percent of total billed charges,Implant Device,1182.86,34,,1182.86,percent of total billed charges,Implant Device,1182.86,34,,1182.86,percent of total billed charges,Implant Device,1722.11,,,1722.11,Other,110% of Medicare,1217.65,35,,1217.65,percent of total billed charges,Implant Device,1182.86,34,"Charges > $500, x 34%",1182.86,percent of total billed charges,Implant Device,1217.65,35,,1217.65,percent of total billed charges,Implant Device,1217.65,35,,1217.65,percent of total billed charges,Implant Device,1217.65,35,,1217.65,percent of total billed charges,Implant Device,1217.65,35,,1217.65,percent of total billed charges,Implant Device,1217.65,35,,1217.65,percent of total billed charges,Implant Device,1391.6,40,,1391.6,percent of total billed charges,Implant Device,1217.65,70,,1217.65,percent of total billed charges,All Other,1182.86,34,,1182.86,percent of total billed charges,Implant Device,1182.86,34,,1182.86,percent of total billed charges,Implant Device,1217.65,35,,1217.65,percent of total billed charges,Implant Device,1217.65,35,,1217.65,percent of total billed charges,Implant Device,1217.65,35,,1217.65,percent of total billed charges,Implant Device,1217.65,35,,1217.65,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1182.86,34,"If Charge > 2,000, then 34 percent",1182.86,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2574.47,
DEPUY 96-0906-REV AUGMENTATION COMBO,C1776,HCPCS,,79002350,CDM,278,RC,,,both,,,3479,2574.47,,,2574.47,Other,150% of Medicare + 9.63% HCRA Surcharge,1565.55,45,,1565.55,percent of total billed charges,Critical Access Hospital RCC factor,1182.86,34,,1182.86,percent of total billed charges,Implant Device,1182.86,34,,1182.86,percent of total billed charges,Implant Device,1182.86,34,,1182.86,percent of total billed charges,Implant Device,1182.86,34,,1182.86,percent of total billed charges,Implant Device,1182.86,34,,1182.86,percent of total billed charges,Implant Device,1722.11,,,1722.11,Other,110% of Medicare,1217.65,35,,1217.65,percent of total billed charges,Implant Device,1182.86,34,"Charges > $500, x 34%",1182.86,percent of total billed charges,Implant Device,1217.65,35,,1217.65,percent of total billed charges,Implant Device,1217.65,35,,1217.65,percent of total billed charges,Implant Device,1217.65,35,,1217.65,percent of total billed charges,Implant Device,1217.65,35,,1217.65,percent of total billed charges,Implant Device,1217.65,35,,1217.65,percent of total billed charges,Implant Device,1391.6,40,,1391.6,percent of total billed charges,Implant Device,1217.65,70,,1217.65,percent of total billed charges,All Other,1182.86,34,,1182.86,percent of total billed charges,Implant Device,1182.86,34,,1182.86,percent of total billed charges,Implant Device,1217.65,35,,1217.65,percent of total billed charges,Implant Device,1217.65,35,,1217.65,percent of total billed charges,Implant Device,1217.65,35,,1217.65,percent of total billed charges,Implant Device,1217.65,35,,1217.65,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1182.86,34,"If Charge > 2,000, then 34 percent",1182.86,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2574.47,
DEPUY 96-0910-REV DISTAL AUGMENT,C1776,HCPCS,,79002351,CDM,278,RC,,,both,,,3479,2574.47,,,2574.47,Other,150% of Medicare + 9.63% HCRA Surcharge,1565.55,45,,1565.55,percent of total billed charges,Critical Access Hospital RCC factor,1182.86,34,,1182.86,percent of total billed charges,Implant Device,1182.86,34,,1182.86,percent of total billed charges,Implant Device,1182.86,34,,1182.86,percent of total billed charges,Implant Device,1182.86,34,,1182.86,percent of total billed charges,Implant Device,1182.86,34,,1182.86,percent of total billed charges,Implant Device,1722.11,,,1722.11,Other,110% of Medicare,1217.65,35,,1217.65,percent of total billed charges,Implant Device,1182.86,34,"Charges > $500, x 34%",1182.86,percent of total billed charges,Implant Device,1217.65,35,,1217.65,percent of total billed charges,Implant Device,1217.65,35,,1217.65,percent of total billed charges,Implant Device,1217.65,35,,1217.65,percent of total billed charges,Implant Device,1217.65,35,,1217.65,percent of total billed charges,Implant Device,1217.65,35,,1217.65,percent of total billed charges,Implant Device,1391.6,40,,1391.6,percent of total billed charges,Implant Device,1217.65,70,,1217.65,percent of total billed charges,All Other,1182.86,34,,1182.86,percent of total billed charges,Implant Device,1182.86,34,,1182.86,percent of total billed charges,Implant Device,1217.65,35,,1217.65,percent of total billed charges,Implant Device,1217.65,35,,1217.65,percent of total billed charges,Implant Device,1217.65,35,,1217.65,percent of total billed charges,Implant Device,1217.65,35,,1217.65,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1182.86,34,"If Charge > 2,000, then 34 percent",1182.86,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2574.47,
DEPUY 96-2031-REV TIBIAL INSERT,C1776,HCPCS,,79002352,CDM,278,RC,,,both,,,3514,2600.37,,,2600.37,Other,150% of Medicare + 9.63% HCRA Surcharge,1581.3,45,,1581.3,percent of total billed charges,Critical Access Hospital RCC factor,1194.76,34,,1194.76,percent of total billed charges,Implant Device,1194.76,34,,1194.76,percent of total billed charges,Implant Device,1194.76,34,,1194.76,percent of total billed charges,Implant Device,1194.76,34,,1194.76,percent of total billed charges,Implant Device,1194.76,34,,1194.76,percent of total billed charges,Implant Device,1739.43,,,1739.43,Other,110% of Medicare,1229.9,35,,1229.9,percent of total billed charges,Implant Device,1194.76,34,"Charges > $500, x 34%",1194.76,percent of total billed charges,Implant Device,1229.9,35,,1229.9,percent of total billed charges,Implant Device,1229.9,35,,1229.9,percent of total billed charges,Implant Device,1229.9,35,,1229.9,percent of total billed charges,Implant Device,1229.9,35,,1229.9,percent of total billed charges,Implant Device,1229.9,35,,1229.9,percent of total billed charges,Implant Device,1405.6,40,,1405.6,percent of total billed charges,Implant Device,1229.9,70,,1229.9,percent of total billed charges,All Other,1194.76,34,,1194.76,percent of total billed charges,Implant Device,1194.76,34,,1194.76,percent of total billed charges,Implant Device,1229.9,35,,1229.9,percent of total billed charges,Implant Device,1229.9,35,,1229.9,percent of total billed charges,Implant Device,1229.9,35,,1229.9,percent of total billed charges,Implant Device,1229.9,35,,1229.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1194.76,34,"If Charge > 2,000, then 34 percent",1194.76,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2600.37,
DEPUY 96-2123-REV TIBIAL INSERT,C1776,HCPCS,,79002353,CDM,278,RC,,,both,,,3775,2793.51,,,2793.51,Other,150% of Medicare + 9.63% HCRA Surcharge,1698.75,45,,1698.75,percent of total billed charges,Critical Access Hospital RCC factor,1283.5,34,,1283.5,percent of total billed charges,Implant Device,1283.5,34,,1283.5,percent of total billed charges,Implant Device,1283.5,34,,1283.5,percent of total billed charges,Implant Device,1283.5,34,,1283.5,percent of total billed charges,Implant Device,1283.5,34,,1283.5,percent of total billed charges,Implant Device,1868.63,,,1868.63,Other,110% of Medicare,1321.25,35,,1321.25,percent of total billed charges,Implant Device,1283.5,34,"Charges > $500, x 34%",1283.5,percent of total billed charges,Implant Device,1321.25,35,,1321.25,percent of total billed charges,Implant Device,1321.25,35,,1321.25,percent of total billed charges,Implant Device,1321.25,35,,1321.25,percent of total billed charges,Implant Device,1321.25,35,,1321.25,percent of total billed charges,Implant Device,1321.25,35,,1321.25,percent of total billed charges,Implant Device,1510,40,,1510,percent of total billed charges,Implant Device,1321.25,70,,1321.25,percent of total billed charges,All Other,1283.5,34,,1283.5,percent of total billed charges,Implant Device,1283.5,34,,1283.5,percent of total billed charges,Implant Device,1321.25,35,,1321.25,percent of total billed charges,Implant Device,1321.25,35,,1321.25,percent of total billed charges,Implant Device,1321.25,35,,1321.25,percent of total billed charges,Implant Device,1321.25,35,,1321.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1283.5,34,"If Charge > 2,000, then 34 percent",1283.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2793.51,
DEPUY 96-2355-REV TIBIAL INSERT,C1776,HCPCS,,79002354,CDM,278,RC,,,both,,,9342,6913.1,,,6913.1,Other,150% of Medicare + 9.63% HCRA Surcharge,4203.9,45,,4203.9,percent of total billed charges,Critical Access Hospital RCC factor,3176.28,34,,3176.28,percent of total billed charges,Implant Device,3176.28,34,,3176.28,percent of total billed charges,Implant Device,3176.28,34,,3176.28,percent of total billed charges,Implant Device,3176.28,34,,3176.28,percent of total billed charges,Implant Device,3176.28,34,,3176.28,percent of total billed charges,Implant Device,4624.29,,,4624.29,Other,110% of Medicare,3269.7,35,,3269.7,percent of total billed charges,Implant Device,3176.28,34,"Charges > $500, x 34%",3176.28,percent of total billed charges,Implant Device,3269.7,35,,3269.7,percent of total billed charges,Implant Device,3269.7,35,,3269.7,percent of total billed charges,Implant Device,3269.7,35,,3269.7,percent of total billed charges,Implant Device,3269.7,35,,3269.7,percent of total billed charges,Implant Device,3269.7,35,,3269.7,percent of total billed charges,Implant Device,3736.8,40,,3736.8,percent of total billed charges,Implant Device,3269.7,70,,3269.7,percent of total billed charges,All Other,3176.28,34,,3176.28,percent of total billed charges,Implant Device,3176.28,34,,3176.28,percent of total billed charges,Implant Device,3269.7,35,,3269.7,percent of total billed charges,Implant Device,3269.7,35,,3269.7,percent of total billed charges,Implant Device,3269.7,35,,3269.7,percent of total billed charges,Implant Device,3269.7,35,,3269.7,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3176.28,34,"If Charge > 2,000, then 34 percent",3176.28,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,6913.1,
DEPUY 96-2361-REV INSERT,C1776,HCPCS,,79002355,CDM,278,RC,,,both,,,9342,6913.1,,,6913.1,Other,150% of Medicare + 9.63% HCRA Surcharge,4203.9,45,,4203.9,percent of total billed charges,Critical Access Hospital RCC factor,3176.28,34,,3176.28,percent of total billed charges,Implant Device,3176.28,34,,3176.28,percent of total billed charges,Implant Device,3176.28,34,,3176.28,percent of total billed charges,Implant Device,3176.28,34,,3176.28,percent of total billed charges,Implant Device,3176.28,34,,3176.28,percent of total billed charges,Implant Device,4624.29,,,4624.29,Other,110% of Medicare,3269.7,35,,3269.7,percent of total billed charges,Implant Device,3176.28,34,"Charges > $500, x 34%",3176.28,percent of total billed charges,Implant Device,3269.7,35,,3269.7,percent of total billed charges,Implant Device,3269.7,35,,3269.7,percent of total billed charges,Implant Device,3269.7,35,,3269.7,percent of total billed charges,Implant Device,3269.7,35,,3269.7,percent of total billed charges,Implant Device,3269.7,35,,3269.7,percent of total billed charges,Implant Device,3736.8,40,,3736.8,percent of total billed charges,Implant Device,3269.7,70,,3269.7,percent of total billed charges,All Other,3176.28,34,,3176.28,percent of total billed charges,Implant Device,3176.28,34,,3176.28,percent of total billed charges,Implant Device,3269.7,35,,3269.7,percent of total billed charges,Implant Device,3269.7,35,,3269.7,percent of total billed charges,Implant Device,3269.7,35,,3269.7,percent of total billed charges,Implant Device,3269.7,35,,3269.7,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3176.28,34,"If Charge > 2,000, then 34 percent",3176.28,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,6913.1,
DEPUY 96-2362-REV INSERT,C1776,HCPCS,,79002356,CDM,278,RC,,,both,,,8341,6172.36,,,6172.36,Other,150% of Medicare + 9.63% HCRA Surcharge,3753.45,45,,3753.45,percent of total billed charges,Critical Access Hospital RCC factor,2835.94,34,,2835.94,percent of total billed charges,Implant Device,2835.94,34,,2835.94,percent of total billed charges,Implant Device,2835.94,34,,2835.94,percent of total billed charges,Implant Device,2835.94,34,,2835.94,percent of total billed charges,Implant Device,2835.94,34,,2835.94,percent of total billed charges,Implant Device,4128.8,,,4128.8,Other,110% of Medicare,2919.35,35,,2919.35,percent of total billed charges,Implant Device,2835.94,34,"Charges > $500, x 34%",2835.94,percent of total billed charges,Implant Device,2919.35,35,,2919.35,percent of total billed charges,Implant Device,2919.35,35,,2919.35,percent of total billed charges,Implant Device,2919.35,35,,2919.35,percent of total billed charges,Implant Device,2919.35,35,,2919.35,percent of total billed charges,Implant Device,2919.35,35,,2919.35,percent of total billed charges,Implant Device,3336.4,40,,3336.4,percent of total billed charges,Implant Device,2919.35,70,,2919.35,percent of total billed charges,All Other,2835.94,34,,2835.94,percent of total billed charges,Implant Device,2835.94,34,,2835.94,percent of total billed charges,Implant Device,2919.35,35,,2919.35,percent of total billed charges,Implant Device,2919.35,35,,2919.35,percent of total billed charges,Implant Device,2919.35,35,,2919.35,percent of total billed charges,Implant Device,2919.35,35,,2919.35,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2835.94,34,"If Charge > 2,000, then 34 percent",2835.94,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,6172.36,
ZIMMER 9943-16-35-REV FEMORAL BODY,C1776,HCPCS,,79002357,CDM,278,RC,,,both,,,14407,10661.22,,,10661.22,Other,150% of Medicare + 9.63% HCRA Surcharge,6483.15,45,,6483.15,percent of total billed charges,Critical Access Hospital RCC factor,4898.38,34,,4898.38,percent of total billed charges,Implant Device,4898.38,34,,4898.38,percent of total billed charges,Implant Device,4898.38,34,,4898.38,percent of total billed charges,Implant Device,4898.38,34,,4898.38,percent of total billed charges,Implant Device,4898.38,34,,4898.38,percent of total billed charges,Implant Device,7131.47,,,7131.47,Other,110% of Medicare,5042.45,35,,5042.45,percent of total billed charges,Implant Device,4898.38,34,"Charges > $500, x 34%",4898.38,percent of total billed charges,Implant Device,5042.45,35,,5042.45,percent of total billed charges,Implant Device,5042.45,35,,5042.45,percent of total billed charges,Implant Device,5042.45,35,,5042.45,percent of total billed charges,Implant Device,5042.45,35,,5042.45,percent of total billed charges,Implant Device,5042.45,35,,5042.45,percent of total billed charges,Implant Device,5762.8,40,,5762.8,percent of total billed charges,Implant Device,5042.45,70,,5042.45,percent of total billed charges,All Other,4898.38,34,,4898.38,percent of total billed charges,Implant Device,4898.38,34,,4898.38,percent of total billed charges,Implant Device,5042.45,35,,5042.45,percent of total billed charges,Implant Device,5042.45,35,,5042.45,percent of total billed charges,Implant Device,5042.45,35,,5042.45,percent of total billed charges,Implant Device,5042.45,35,,5042.45,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,4898.38,34,"If Charge > 2,000, then 34 percent",4898.38,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,10661.22,
ZIMMER 9982-16-18-REV FEMORAL HEAD,C1776,HCPCS,,79002358,CDM,278,RC,,,both,,,10966,8114.87,,,8114.87,Other,150% of Medicare + 9.63% HCRA Surcharge,4934.7,45,,4934.7,percent of total billed charges,Critical Access Hospital RCC factor,3728.44,34,,3728.44,percent of total billed charges,Implant Device,3728.44,34,,3728.44,percent of total billed charges,Implant Device,3728.44,34,,3728.44,percent of total billed charges,Implant Device,3728.44,34,,3728.44,percent of total billed charges,Implant Device,3728.44,34,,3728.44,percent of total billed charges,Implant Device,5428.17,,,5428.17,Other,110% of Medicare,3838.1,35,,3838.1,percent of total billed charges,Implant Device,3728.44,34,"Charges > $500, x 34%",3728.44,percent of total billed charges,Implant Device,3838.1,35,,3838.1,percent of total billed charges,Implant Device,3838.1,35,,3838.1,percent of total billed charges,Implant Device,3838.1,35,,3838.1,percent of total billed charges,Implant Device,3838.1,35,,3838.1,percent of total billed charges,Implant Device,3838.1,35,,3838.1,percent of total billed charges,Implant Device,4386.4,40,,4386.4,percent of total billed charges,Implant Device,3838.1,70,,3838.1,percent of total billed charges,All Other,3728.44,34,,3728.44,percent of total billed charges,Implant Device,3728.44,34,,3728.44,percent of total billed charges,Implant Device,3838.1,35,,3838.1,percent of total billed charges,Implant Device,3838.1,35,,3838.1,percent of total billed charges,Implant Device,3838.1,35,,3838.1,percent of total billed charges,Implant Device,3838.1,35,,3838.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3728.44,34,"If Charge > 2,000, then 34 percent",3728.44,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,8114.87,
ZIMMER 9982-19-13-REV FEMORAL STEM,C1776,HCPCS,,79002359,CDM,278,RC,,,both,,,9588,7095.14,,,7095.14,Other,150% of Medicare + 9.63% HCRA Surcharge,4314.6,45,,4314.6,percent of total billed charges,Critical Access Hospital RCC factor,3259.92,34,,3259.92,percent of total billed charges,Implant Device,3259.92,34,,3259.92,percent of total billed charges,Implant Device,3259.92,34,,3259.92,percent of total billed charges,Implant Device,3259.92,34,,3259.92,percent of total billed charges,Implant Device,3259.92,34,,3259.92,percent of total billed charges,Implant Device,4746.06,,,4746.06,Other,110% of Medicare,3355.8,35,,3355.8,percent of total billed charges,Implant Device,3259.92,34,"Charges > $500, x 34%",3259.92,percent of total billed charges,Implant Device,3355.8,35,,3355.8,percent of total billed charges,Implant Device,3355.8,35,,3355.8,percent of total billed charges,Implant Device,3355.8,35,,3355.8,percent of total billed charges,Implant Device,3355.8,35,,3355.8,percent of total billed charges,Implant Device,3355.8,35,,3355.8,percent of total billed charges,Implant Device,3835.2,40,,3835.2,percent of total billed charges,Implant Device,3355.8,70,,3355.8,percent of total billed charges,All Other,3259.92,34,,3259.92,percent of total billed charges,Implant Device,3259.92,34,,3259.92,percent of total billed charges,Implant Device,3355.8,35,,3355.8,percent of total billed charges,Implant Device,3355.8,35,,3355.8,percent of total billed charges,Implant Device,3355.8,35,,3355.8,percent of total billed charges,Implant Device,3355.8,35,,3355.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3259.92,34,"If Charge > 2,000, then 34 percent",3259.92,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,7095.14,
ZIMMER 9996-17-45-REV FEMORAL BODY,C1776,HCPCS,,79002360,CDM,278,RC,,,both,,,14407,10661.22,,,10661.22,Other,150% of Medicare + 9.63% HCRA Surcharge,6483.15,45,,6483.15,percent of total billed charges,Critical Access Hospital RCC factor,4898.38,34,,4898.38,percent of total billed charges,Implant Device,4898.38,34,,4898.38,percent of total billed charges,Implant Device,4898.38,34,,4898.38,percent of total billed charges,Implant Device,4898.38,34,,4898.38,percent of total billed charges,Implant Device,4898.38,34,,4898.38,percent of total billed charges,Implant Device,7131.47,,,7131.47,Other,110% of Medicare,5042.45,35,,5042.45,percent of total billed charges,Implant Device,4898.38,34,"Charges > $500, x 34%",4898.38,percent of total billed charges,Implant Device,5042.45,35,,5042.45,percent of total billed charges,Implant Device,5042.45,35,,5042.45,percent of total billed charges,Implant Device,5042.45,35,,5042.45,percent of total billed charges,Implant Device,5042.45,35,,5042.45,percent of total billed charges,Implant Device,5042.45,35,,5042.45,percent of total billed charges,Implant Device,5762.8,40,,5762.8,percent of total billed charges,Implant Device,5042.45,70,,5042.45,percent of total billed charges,All Other,4898.38,34,,4898.38,percent of total billed charges,Implant Device,4898.38,34,,4898.38,percent of total billed charges,Implant Device,5042.45,35,,5042.45,percent of total billed charges,Implant Device,5042.45,35,,5042.45,percent of total billed charges,Implant Device,5042.45,35,,5042.45,percent of total billed charges,Implant Device,5042.45,35,,5042.45,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,4898.38,34,"If Charge > 2,000, then 34 percent",4898.38,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,10661.22,
ARTHROSURFACE 9M52-1535-W ART COMPONENT,L8641,HCPCS,,79002361,CDM,278,RC,,,both,,,7384,5464.18,,,5464.18,Other,150% of Medicare + 9.63% HCRA Surcharge,3322.8,45,,3322.8,percent of total billed charges,Critical Access Hospital RCC factor,2510.56,34,,2510.56,percent of total billed charges,Implant Device,2510.56,34,,2510.56,percent of total billed charges,Implant Device,2510.56,34,,2510.56,percent of total billed charges,Implant Device,2510.56,34,,2510.56,percent of total billed charges,Implant Device,2510.56,34,,2510.56,percent of total billed charges,Implant Device,3655.08,,,3655.08,Other,110% of Medicare,2584.4,35,,2584.4,percent of total billed charges,Implant Device,2510.56,34,"Charges > $500, x 34%",2510.56,percent of total billed charges,Implant Device,2584.4,35,,2584.4,percent of total billed charges,Implant Device,2584.4,35,,2584.4,percent of total billed charges,Implant Device,2584.4,35,,2584.4,percent of total billed charges,Implant Device,2584.4,35,,2584.4,percent of total billed charges,Implant Device,2584.4,35,,2584.4,percent of total billed charges,Implant Device,2953.6,40,,2953.6,percent of total billed charges,Implant Device,2584.4,70,,2584.4,percent of total billed charges,All Other,2510.56,34,,2510.56,percent of total billed charges,Implant Device,2510.56,34,,2510.56,percent of total billed charges,Implant Device,2584.4,35,,2584.4,percent of total billed charges,Implant Device,2584.4,35,,2584.4,percent of total billed charges,Implant Device,2584.4,35,,2584.4,percent of total billed charges,Implant Device,2584.4,35,,2584.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2510.56,34,"If Charge > 2,000, then 34 percent",2510.56,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5464.18,
ARTHREX AR-1008 LIGAMENT STAPLE,C1713,HCPCS,,79002363,CDM,278,RC,,,both,,,340,251.6,,,251.6,Other,150% of Medicare + 9.63% HCRA Surcharge,153,45,,153,percent of total billed charges,Critical Access Hospital RCC factor,115.6,34,,115.6,percent of total billed charges,Implant Device,115.6,34,,115.6,percent of total billed charges,Implant Device,115.6,34,,115.6,percent of total billed charges,Implant Device,115.6,34,,115.6,percent of total billed charges,Implant Device,115.6,34,,115.6,percent of total billed charges,Implant Device,168.3,,,168.3,Other,110% of Medicare,119,35,,119,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,119,35,,119,percent of total billed charges,Implant Device,119,35,,119,percent of total billed charges,Implant Device,119,35,,119,percent of total billed charges,Implant Device,119,35,,119,percent of total billed charges,Implant Device,119,35,,119,percent of total billed charges,Implant Device,136,40,,136,percent of total billed charges,Implant Device,119,70,,119,percent of total billed charges,All Other,115.6,34,,115.6,percent of total billed charges,Implant Device,115.6,34,,115.6,percent of total billed charges,Implant Device,119,35,,119,percent of total billed charges,Implant Device,119,35,,119,percent of total billed charges,Implant Device,119,35,,119,percent of total billed charges,Implant Device,119,35,,119,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,251.6,
ARTHREX AR-1310T-05.0 PLATE,C1776,HCPCS,,79002368,CDM,278,RC,,,both,,,2686,1987.65,,,1987.65,Other,150% of Medicare + 9.63% HCRA Surcharge,1208.7,45,,1208.7,percent of total billed charges,Critical Access Hospital RCC factor,913.24,34,,913.24,percent of total billed charges,Implant Device,913.24,34,,913.24,percent of total billed charges,Implant Device,913.24,34,,913.24,percent of total billed charges,Implant Device,913.24,34,,913.24,percent of total billed charges,Implant Device,913.24,34,,913.24,percent of total billed charges,Implant Device,1329.57,,,1329.57,Other,110% of Medicare,940.1,35,,940.1,percent of total billed charges,Implant Device,913.24,34,"Charges > $500, x 34%",913.24,percent of total billed charges,Implant Device,940.1,35,,940.1,percent of total billed charges,Implant Device,940.1,35,,940.1,percent of total billed charges,Implant Device,940.1,35,,940.1,percent of total billed charges,Implant Device,940.1,35,,940.1,percent of total billed charges,Implant Device,940.1,35,,940.1,percent of total billed charges,Implant Device,1074.4,40,,1074.4,percent of total billed charges,Implant Device,940.1,70,,940.1,percent of total billed charges,All Other,913.24,34,,913.24,percent of total billed charges,Implant Device,913.24,34,,913.24,percent of total billed charges,Implant Device,940.1,35,,940.1,percent of total billed charges,Implant Device,940.1,35,,940.1,percent of total billed charges,Implant Device,940.1,35,,940.1,percent of total billed charges,Implant Device,940.1,35,,940.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,913.24,34,"If Charge > 2,000, then 34 percent",913.24,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1987.65,
ARTHREX AR-1320BNF SUTURE TAK,C1713,HCPCS,,79002369,CDM,278,RC,,,both,,,1050,777,,,777,Other,150% of Medicare + 9.63% HCRA Surcharge,472.5,45,,472.5,percent of total billed charges,Critical Access Hospital RCC factor,357,34,,357,percent of total billed charges,Implant Device,357,34,,357,percent of total billed charges,Implant Device,357,34,,357,percent of total billed charges,Implant Device,357,34,,357,percent of total billed charges,Implant Device,357,34,,357,percent of total billed charges,Implant Device,519.75,,,519.75,Other,110% of Medicare,367.5,35,,367.5,percent of total billed charges,Implant Device,357,34,"Charges > $500, x 34%",357,percent of total billed charges,Implant Device,367.5,35,,367.5,percent of total billed charges,Implant Device,367.5,35,,367.5,percent of total billed charges,Implant Device,367.5,35,,367.5,percent of total billed charges,Implant Device,367.5,35,,367.5,percent of total billed charges,Implant Device,367.5,35,,367.5,percent of total billed charges,Implant Device,420,40,,420,percent of total billed charges,Implant Device,367.5,70,,367.5,percent of total billed charges,All Other,357,34,,357,percent of total billed charges,Implant Device,357,34,,357,percent of total billed charges,Implant Device,367.5,35,,367.5,percent of total billed charges,Implant Device,367.5,35,,367.5,percent of total billed charges,Implant Device,367.5,35,,367.5,percent of total billed charges,Implant Device,367.5,35,,367.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,777,
ARTHREX AR-13226T THREADED BBTAK,C1713,HCPCS,,79002372,CDM,278,RC,,,both,,,277,204.98,,,204.98,Other,150% of Medicare + 9.63% HCRA Surcharge,124.65,45,,124.65,percent of total billed charges,Critical Access Hospital RCC factor,94.18,34,,94.18,percent of total billed charges,Implant Device,94.18,34,,94.18,percent of total billed charges,Implant Device,94.18,34,,94.18,percent of total billed charges,Implant Device,94.18,34,,94.18,percent of total billed charges,Implant Device,94.18,34,,94.18,percent of total billed charges,Implant Device,137.12,,,137.12,Other,110% of Medicare,96.95,35,,96.95,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,96.95,35,,96.95,percent of total billed charges,Implant Device,96.95,35,,96.95,percent of total billed charges,Implant Device,96.95,35,,96.95,percent of total billed charges,Implant Device,96.95,35,,96.95,percent of total billed charges,Implant Device,96.95,35,,96.95,percent of total billed charges,Implant Device,110.8,40,,110.8,percent of total billed charges,Implant Device,96.95,70,,96.95,percent of total billed charges,All Other,94.18,34,,94.18,percent of total billed charges,Implant Device,94.18,34,,94.18,percent of total billed charges,Implant Device,96.95,35,,96.95,percent of total billed charges,Implant Device,96.95,35,,96.95,percent of total billed charges,Implant Device,96.95,35,,96.95,percent of total billed charges,Implant Device,96.95,35,,96.95,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,204.98,
ARTHREX AR-13280-40 SCREW,C1713,HCPCS,,79002373,CDM,278,RC,,,both,,,256,189.44,,,189.44,Other,150% of Medicare + 9.63% HCRA Surcharge,115.2,45,,115.2,percent of total billed charges,Critical Access Hospital RCC factor,87.04,34,,87.04,percent of total billed charges,Implant Device,87.04,34,,87.04,percent of total billed charges,Implant Device,87.04,34,,87.04,percent of total billed charges,Implant Device,87.04,34,,87.04,percent of total billed charges,Implant Device,87.04,34,,87.04,percent of total billed charges,Implant Device,126.72,,,126.72,Other,110% of Medicare,89.6,35,,89.6,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,89.6,35,,89.6,percent of total billed charges,Implant Device,89.6,35,,89.6,percent of total billed charges,Implant Device,89.6,35,,89.6,percent of total billed charges,Implant Device,89.6,35,,89.6,percent of total billed charges,Implant Device,89.6,35,,89.6,percent of total billed charges,Implant Device,102.4,40,,102.4,percent of total billed charges,Implant Device,89.6,70,,89.6,percent of total billed charges,All Other,87.04,34,,87.04,percent of total billed charges,Implant Device,87.04,34,,87.04,percent of total billed charges,Implant Device,89.6,35,,89.6,percent of total billed charges,Implant Device,89.6,35,,89.6,percent of total billed charges,Implant Device,89.6,35,,89.6,percent of total billed charges,Implant Device,89.6,35,,89.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,189.44,
ARTHREX AR-13280-70 SCREW,C1713,HCPCS,,79002374,CDM,278,RC,,,both,,,256,189.44,,,189.44,Other,150% of Medicare + 9.63% HCRA Surcharge,115.2,45,,115.2,percent of total billed charges,Critical Access Hospital RCC factor,87.04,34,,87.04,percent of total billed charges,Implant Device,87.04,34,,87.04,percent of total billed charges,Implant Device,87.04,34,,87.04,percent of total billed charges,Implant Device,87.04,34,,87.04,percent of total billed charges,Implant Device,87.04,34,,87.04,percent of total billed charges,Implant Device,126.72,,,126.72,Other,110% of Medicare,89.6,35,,89.6,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,89.6,35,,89.6,percent of total billed charges,Implant Device,89.6,35,,89.6,percent of total billed charges,Implant Device,89.6,35,,89.6,percent of total billed charges,Implant Device,89.6,35,,89.6,percent of total billed charges,Implant Device,89.6,35,,89.6,percent of total billed charges,Implant Device,102.4,40,,102.4,percent of total billed charges,Implant Device,89.6,70,,89.6,percent of total billed charges,All Other,87.04,34,,87.04,percent of total billed charges,Implant Device,87.04,34,,87.04,percent of total billed charges,Implant Device,89.6,35,,89.6,percent of total billed charges,Implant Device,89.6,35,,89.6,percent of total billed charges,Implant Device,89.6,35,,89.6,percent of total billed charges,Implant Device,89.6,35,,89.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,189.44,
ARTHREX AR-13370-1 BONE WEDGE,C1713,HCPCS,,79002375,CDM,278,RC,,,both,,,2400,1776.01,,,1776.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1080,45,,1080,percent of total billed charges,Critical Access Hospital RCC factor,816,34,,816,percent of total billed charges,Implant Device,816,34,,816,percent of total billed charges,Implant Device,816,34,,816,percent of total billed charges,Implant Device,816,34,,816,percent of total billed charges,Implant Device,816,34,,816,percent of total billed charges,Implant Device,1188,,,1188,Other,110% of Medicare,840,35,,840,percent of total billed charges,Implant Device,816,34,"Charges > $500, x 34%",816,percent of total billed charges,Implant Device,840,35,,840,percent of total billed charges,Implant Device,840,35,,840,percent of total billed charges,Implant Device,840,35,,840,percent of total billed charges,Implant Device,840,35,,840,percent of total billed charges,Implant Device,840,35,,840,percent of total billed charges,Implant Device,960,40,,960,percent of total billed charges,Implant Device,840,70,,840,percent of total billed charges,All Other,816,34,,816,percent of total billed charges,Implant Device,816,34,,816,percent of total billed charges,Implant Device,840,35,,840,percent of total billed charges,Implant Device,840,35,,840,percent of total billed charges,Implant Device,840,35,,840,percent of total billed charges,Implant Device,840,35,,840,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,816,34,"If Charge > 2,000, then 34 percent",816,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1776.01,
ARTHREX AR-13370-2 BONE WEDGE,C1713,HCPCS,,79002376,CDM,278,RC,,,both,,,2124,1571.77,,,1571.77,Other,150% of Medicare + 9.63% HCRA Surcharge,955.8,45,,955.8,percent of total billed charges,Critical Access Hospital RCC factor,722.16,34,,722.16,percent of total billed charges,Implant Device,722.16,34,,722.16,percent of total billed charges,Implant Device,722.16,34,,722.16,percent of total billed charges,Implant Device,722.16,34,,722.16,percent of total billed charges,Implant Device,722.16,34,,722.16,percent of total billed charges,Implant Device,1051.38,,,1051.38,Other,110% of Medicare,743.4,35,,743.4,percent of total billed charges,Implant Device,722.16,34,"Charges > $500, x 34%",722.16,percent of total billed charges,Implant Device,743.4,35,,743.4,percent of total billed charges,Implant Device,743.4,35,,743.4,percent of total billed charges,Implant Device,743.4,35,,743.4,percent of total billed charges,Implant Device,743.4,35,,743.4,percent of total billed charges,Implant Device,743.4,35,,743.4,percent of total billed charges,Implant Device,849.6,40,,849.6,percent of total billed charges,Implant Device,743.4,70,,743.4,percent of total billed charges,All Other,722.16,34,,722.16,percent of total billed charges,Implant Device,722.16,34,,722.16,percent of total billed charges,Implant Device,743.4,35,,743.4,percent of total billed charges,Implant Device,743.4,35,,743.4,percent of total billed charges,Implant Device,743.4,35,,743.4,percent of total billed charges,Implant Device,743.4,35,,743.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,722.16,34,"If Charge > 2,000, then 34 percent",722.16,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1571.77,
ARTHREX AR-13372-2 BONE VOID FILLER,C1713,HCPCS,,79002377,CDM,278,RC,,,both,,,1074,794.76,,,794.76,Other,150% of Medicare + 9.63% HCRA Surcharge,483.3,45,,483.3,percent of total billed charges,Critical Access Hospital RCC factor,365.16,34,,365.16,percent of total billed charges,Implant Device,365.16,34,,365.16,percent of total billed charges,Implant Device,365.16,34,,365.16,percent of total billed charges,Implant Device,365.16,34,,365.16,percent of total billed charges,Implant Device,365.16,34,,365.16,percent of total billed charges,Implant Device,531.63,,,531.63,Other,110% of Medicare,375.9,35,,375.9,percent of total billed charges,Implant Device,365.16,34,"Charges > $500, x 34%",365.16,percent of total billed charges,Implant Device,375.9,35,,375.9,percent of total billed charges,Implant Device,375.9,35,,375.9,percent of total billed charges,Implant Device,375.9,35,,375.9,percent of total billed charges,Implant Device,375.9,35,,375.9,percent of total billed charges,Implant Device,375.9,35,,375.9,percent of total billed charges,Implant Device,429.6,40,,429.6,percent of total billed charges,Implant Device,375.9,70,,375.9,percent of total billed charges,All Other,365.16,34,,365.16,percent of total billed charges,Implant Device,365.16,34,,365.16,percent of total billed charges,Implant Device,375.9,35,,375.9,percent of total billed charges,Implant Device,375.9,35,,375.9,percent of total billed charges,Implant Device,375.9,35,,375.9,percent of total billed charges,Implant Device,375.9,35,,375.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,794.76,
ARTHREX AR-13380-34 SCREW,C1713,HCPCS,,79002378,CDM,278,RC,,,both,,,256,189.44,,,189.44,Other,150% of Medicare + 9.63% HCRA Surcharge,115.2,45,,115.2,percent of total billed charges,Critical Access Hospital RCC factor,87.04,34,,87.04,percent of total billed charges,Implant Device,87.04,34,,87.04,percent of total billed charges,Implant Device,87.04,34,,87.04,percent of total billed charges,Implant Device,87.04,34,,87.04,percent of total billed charges,Implant Device,87.04,34,,87.04,percent of total billed charges,Implant Device,126.72,,,126.72,Other,110% of Medicare,89.6,35,,89.6,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,89.6,35,,89.6,percent of total billed charges,Implant Device,89.6,35,,89.6,percent of total billed charges,Implant Device,89.6,35,,89.6,percent of total billed charges,Implant Device,89.6,35,,89.6,percent of total billed charges,Implant Device,89.6,35,,89.6,percent of total billed charges,Implant Device,102.4,40,,102.4,percent of total billed charges,Implant Device,89.6,70,,89.6,percent of total billed charges,All Other,87.04,34,,87.04,percent of total billed charges,Implant Device,87.04,34,,87.04,percent of total billed charges,Implant Device,89.6,35,,89.6,percent of total billed charges,Implant Device,89.6,35,,89.6,percent of total billed charges,Implant Device,89.6,35,,89.6,percent of total billed charges,Implant Device,89.6,35,,89.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,189.44,
ARTHREX AR-13380-38 SCREW,C1713,HCPCS,,79002379,CDM,278,RC,,,both,,,256,189.44,,,189.44,Other,150% of Medicare + 9.63% HCRA Surcharge,115.2,45,,115.2,percent of total billed charges,Critical Access Hospital RCC factor,87.04,34,,87.04,percent of total billed charges,Implant Device,87.04,34,,87.04,percent of total billed charges,Implant Device,87.04,34,,87.04,percent of total billed charges,Implant Device,87.04,34,,87.04,percent of total billed charges,Implant Device,87.04,34,,87.04,percent of total billed charges,Implant Device,126.72,,,126.72,Other,110% of Medicare,89.6,35,,89.6,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,89.6,35,,89.6,percent of total billed charges,Implant Device,89.6,35,,89.6,percent of total billed charges,Implant Device,89.6,35,,89.6,percent of total billed charges,Implant Device,89.6,35,,89.6,percent of total billed charges,Implant Device,89.6,35,,89.6,percent of total billed charges,Implant Device,102.4,40,,102.4,percent of total billed charges,Implant Device,89.6,70,,89.6,percent of total billed charges,All Other,87.04,34,,87.04,percent of total billed charges,Implant Device,87.04,34,,87.04,percent of total billed charges,Implant Device,89.6,35,,89.6,percent of total billed charges,Implant Device,89.6,35,,89.6,percent of total billed charges,Implant Device,89.6,35,,89.6,percent of total billed charges,Implant Device,89.6,35,,89.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,189.44,
ARTHREX AR-13401-28 ANCHOR,C1713,HCPCS,,79002380,CDM,278,RC,,,both,,,1074,794.76,,,794.76,Other,150% of Medicare + 9.63% HCRA Surcharge,483.3,45,,483.3,percent of total billed charges,Critical Access Hospital RCC factor,365.16,34,,365.16,percent of total billed charges,Implant Device,365.16,34,,365.16,percent of total billed charges,Implant Device,365.16,34,,365.16,percent of total billed charges,Implant Device,365.16,34,,365.16,percent of total billed charges,Implant Device,365.16,34,,365.16,percent of total billed charges,Implant Device,531.63,,,531.63,Other,110% of Medicare,375.9,35,,375.9,percent of total billed charges,Implant Device,365.16,34,"Charges > $500, x 34%",365.16,percent of total billed charges,Implant Device,375.9,35,,375.9,percent of total billed charges,Implant Device,375.9,35,,375.9,percent of total billed charges,Implant Device,375.9,35,,375.9,percent of total billed charges,Implant Device,375.9,35,,375.9,percent of total billed charges,Implant Device,375.9,35,,375.9,percent of total billed charges,Implant Device,429.6,40,,429.6,percent of total billed charges,Implant Device,375.9,70,,375.9,percent of total billed charges,All Other,365.16,34,,365.16,percent of total billed charges,Implant Device,365.16,34,,365.16,percent of total billed charges,Implant Device,375.9,35,,375.9,percent of total billed charges,Implant Device,375.9,35,,375.9,percent of total billed charges,Implant Device,375.9,35,,375.9,percent of total billed charges,Implant Device,375.9,35,,375.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,794.76,
ARTHREX AR-13401-30 ANCHOR,C1713,HCPCS,,79002381,CDM,278,RC,,,both,,,1074,794.76,,,794.76,Other,150% of Medicare + 9.63% HCRA Surcharge,483.3,45,,483.3,percent of total billed charges,Critical Access Hospital RCC factor,365.16,34,,365.16,percent of total billed charges,Implant Device,365.16,34,,365.16,percent of total billed charges,Implant Device,365.16,34,,365.16,percent of total billed charges,Implant Device,365.16,34,,365.16,percent of total billed charges,Implant Device,365.16,34,,365.16,percent of total billed charges,Implant Device,531.63,,,531.63,Other,110% of Medicare,375.9,35,,375.9,percent of total billed charges,Implant Device,365.16,34,"Charges > $500, x 34%",365.16,percent of total billed charges,Implant Device,375.9,35,,375.9,percent of total billed charges,Implant Device,375.9,35,,375.9,percent of total billed charges,Implant Device,375.9,35,,375.9,percent of total billed charges,Implant Device,375.9,35,,375.9,percent of total billed charges,Implant Device,375.9,35,,375.9,percent of total billed charges,Implant Device,429.6,40,,429.6,percent of total billed charges,Implant Device,375.9,70,,375.9,percent of total billed charges,All Other,365.16,34,,365.16,percent of total billed charges,Implant Device,365.16,34,,365.16,percent of total billed charges,Implant Device,375.9,35,,375.9,percent of total billed charges,Implant Device,375.9,35,,375.9,percent of total billed charges,Implant Device,375.9,35,,375.9,percent of total billed charges,Implant Device,375.9,35,,375.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,794.76,
ARTHREX AR-13402-36 ANCHOR,C1713,HCPCS,,79002382,CDM,278,RC,,,both,,,1074,794.76,,,794.76,Other,150% of Medicare + 9.63% HCRA Surcharge,483.3,45,,483.3,percent of total billed charges,Critical Access Hospital RCC factor,365.16,34,,365.16,percent of total billed charges,Implant Device,365.16,34,,365.16,percent of total billed charges,Implant Device,365.16,34,,365.16,percent of total billed charges,Implant Device,365.16,34,,365.16,percent of total billed charges,Implant Device,365.16,34,,365.16,percent of total billed charges,Implant Device,531.63,,,531.63,Other,110% of Medicare,375.9,35,,375.9,percent of total billed charges,Implant Device,365.16,34,"Charges > $500, x 34%",365.16,percent of total billed charges,Implant Device,375.9,35,,375.9,percent of total billed charges,Implant Device,375.9,35,,375.9,percent of total billed charges,Implant Device,375.9,35,,375.9,percent of total billed charges,Implant Device,375.9,35,,375.9,percent of total billed charges,Implant Device,375.9,35,,375.9,percent of total billed charges,Implant Device,429.6,40,,429.6,percent of total billed charges,Implant Device,375.9,70,,375.9,percent of total billed charges,All Other,365.16,34,,365.16,percent of total billed charges,Implant Device,365.16,34,,365.16,percent of total billed charges,Implant Device,375.9,35,,375.9,percent of total billed charges,Implant Device,375.9,35,,375.9,percent of total billed charges,Implant Device,375.9,35,,375.9,percent of total billed charges,Implant Device,375.9,35,,375.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,794.76,
ARTHREX AR-13402-48 ANCHOR,C1713,HCPCS,,79002383,CDM,278,RC,,,both,,,1074,794.76,,,794.76,Other,150% of Medicare + 9.63% HCRA Surcharge,483.3,45,,483.3,percent of total billed charges,Critical Access Hospital RCC factor,365.16,34,,365.16,percent of total billed charges,Implant Device,365.16,34,,365.16,percent of total billed charges,Implant Device,365.16,34,,365.16,percent of total billed charges,Implant Device,365.16,34,,365.16,percent of total billed charges,Implant Device,365.16,34,,365.16,percent of total billed charges,Implant Device,531.63,,,531.63,Other,110% of Medicare,375.9,35,,375.9,percent of total billed charges,Implant Device,365.16,34,"Charges > $500, x 34%",365.16,percent of total billed charges,Implant Device,375.9,35,,375.9,percent of total billed charges,Implant Device,375.9,35,,375.9,percent of total billed charges,Implant Device,375.9,35,,375.9,percent of total billed charges,Implant Device,375.9,35,,375.9,percent of total billed charges,Implant Device,375.9,35,,375.9,percent of total billed charges,Implant Device,429.6,40,,429.6,percent of total billed charges,Implant Device,375.9,70,,375.9,percent of total billed charges,All Other,365.16,34,,365.16,percent of total billed charges,Implant Device,365.16,34,,365.16,percent of total billed charges,Implant Device,375.9,35,,375.9,percent of total billed charges,Implant Device,375.9,35,,375.9,percent of total billed charges,Implant Device,375.9,35,,375.9,percent of total billed charges,Implant Device,375.9,35,,375.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,794.76,
ARTHREX AR-1349L SPIKED WASHER,C1713,HCPCS,,79002384,CDM,278,RC,,,both,,,430,318.2,,,318.2,Other,150% of Medicare + 9.63% HCRA Surcharge,193.5,45,,193.5,percent of total billed charges,Critical Access Hospital RCC factor,146.2,34,,146.2,percent of total billed charges,Implant Device,146.2,34,,146.2,percent of total billed charges,Implant Device,146.2,34,,146.2,percent of total billed charges,Implant Device,146.2,34,,146.2,percent of total billed charges,Implant Device,146.2,34,,146.2,percent of total billed charges,Implant Device,212.85,,,212.85,Other,110% of Medicare,150.5,35,,150.5,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,150.5,35,,150.5,percent of total billed charges,Implant Device,150.5,35,,150.5,percent of total billed charges,Implant Device,150.5,35,,150.5,percent of total billed charges,Implant Device,150.5,35,,150.5,percent of total billed charges,Implant Device,150.5,35,,150.5,percent of total billed charges,Implant Device,172,40,,172,percent of total billed charges,Implant Device,150.5,70,,150.5,percent of total billed charges,All Other,146.2,34,,146.2,percent of total billed charges,Implant Device,146.2,34,,146.2,percent of total billed charges,Implant Device,150.5,35,,150.5,percent of total billed charges,Implant Device,150.5,35,,150.5,percent of total billed charges,Implant Device,150.5,35,,150.5,percent of total billed charges,Implant Device,150.5,35,,150.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,318.2,
ARTHREX AR-14003 PLATE,C1713,HCPCS,,79002385,CDM,278,RC,,,both,,,6408,4741.94,,,4741.94,Other,150% of Medicare + 9.63% HCRA Surcharge,2883.6,45,,2883.6,percent of total billed charges,Critical Access Hospital RCC factor,2178.72,34,,2178.72,percent of total billed charges,Implant Device,2178.72,34,,2178.72,percent of total billed charges,Implant Device,2178.72,34,,2178.72,percent of total billed charges,Implant Device,2178.72,34,,2178.72,percent of total billed charges,Implant Device,2178.72,34,,2178.72,percent of total billed charges,Implant Device,3171.96,,,3171.96,Other,110% of Medicare,2242.8,35,,2242.8,percent of total billed charges,Implant Device,2178.72,34,"Charges > $500, x 34%",2178.72,percent of total billed charges,Implant Device,2242.8,35,,2242.8,percent of total billed charges,Implant Device,2242.8,35,,2242.8,percent of total billed charges,Implant Device,2242.8,35,,2242.8,percent of total billed charges,Implant Device,2242.8,35,,2242.8,percent of total billed charges,Implant Device,2242.8,35,,2242.8,percent of total billed charges,Implant Device,2563.2,40,,2563.2,percent of total billed charges,Implant Device,2242.8,70,,2242.8,percent of total billed charges,All Other,2178.72,34,,2178.72,percent of total billed charges,Implant Device,2178.72,34,,2178.72,percent of total billed charges,Implant Device,2242.8,35,,2242.8,percent of total billed charges,Implant Device,2242.8,35,,2242.8,percent of total billed charges,Implant Device,2242.8,35,,2242.8,percent of total billed charges,Implant Device,2242.8,35,,2242.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2178.72,34,"If Charge > 2,000, then 34 percent",2178.72,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4741.94,
ARTHREX AR-1403TC SCREW,C1713,HCPCS,,79002386,CDM,278,RC,,,both,,,966,714.84,,,714.84,Other,150% of Medicare + 9.63% HCRA Surcharge,434.7,45,,434.7,percent of total billed charges,Critical Access Hospital RCC factor,328.44,34,,328.44,percent of total billed charges,Implant Device,328.44,34,,328.44,percent of total billed charges,Implant Device,328.44,34,,328.44,percent of total billed charges,Implant Device,328.44,34,,328.44,percent of total billed charges,Implant Device,328.44,34,,328.44,percent of total billed charges,Implant Device,478.17,,,478.17,Other,110% of Medicare,338.1,35,,338.1,percent of total billed charges,Implant Device,328.44,34,"Charges > $500, x 34%",328.44,percent of total billed charges,Implant Device,338.1,35,,338.1,percent of total billed charges,Implant Device,338.1,35,,338.1,percent of total billed charges,Implant Device,338.1,35,,338.1,percent of total billed charges,Implant Device,338.1,35,,338.1,percent of total billed charges,Implant Device,338.1,35,,338.1,percent of total billed charges,Implant Device,386.4,40,,386.4,percent of total billed charges,Implant Device,338.1,70,,338.1,percent of total billed charges,All Other,328.44,34,,328.44,percent of total billed charges,Implant Device,328.44,34,,328.44,percent of total billed charges,Implant Device,338.1,35,,338.1,percent of total billed charges,Implant Device,338.1,35,,338.1,percent of total billed charges,Implant Device,338.1,35,,338.1,percent of total billed charges,Implant Device,338.1,35,,338.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,714.84,
ARTHREX AR-14120 SCREW,C1713,HCPCS,,79002388,CDM,278,RC,,,both,,,480,355.2,,,355.2,Other,150% of Medicare + 9.63% HCRA Surcharge,216,45,,216,percent of total billed charges,Critical Access Hospital RCC factor,163.2,34,,163.2,percent of total billed charges,Implant Device,163.2,34,,163.2,percent of total billed charges,Implant Device,163.2,34,,163.2,percent of total billed charges,Implant Device,163.2,34,,163.2,percent of total billed charges,Implant Device,163.2,34,,163.2,percent of total billed charges,Implant Device,237.6,,,237.6,Other,110% of Medicare,168,35,,168,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,192,40,,192,percent of total billed charges,Implant Device,168,70,,168,percent of total billed charges,All Other,163.2,34,,163.2,percent of total billed charges,Implant Device,163.2,34,,163.2,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,355.2,
ARTHREX AR-14122 SCREW,C1713,HCPCS,,79002389,CDM,278,RC,,,both,,,336,248.64,,,248.64,Other,150% of Medicare + 9.63% HCRA Surcharge,151.2,45,,151.2,percent of total billed charges,Critical Access Hospital RCC factor,114.24,34,,114.24,percent of total billed charges,Implant Device,114.24,34,,114.24,percent of total billed charges,Implant Device,114.24,34,,114.24,percent of total billed charges,Implant Device,114.24,34,,114.24,percent of total billed charges,Implant Device,114.24,34,,114.24,percent of total billed charges,Implant Device,166.32,,,166.32,Other,110% of Medicare,117.6,35,,117.6,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,117.6,35,,117.6,percent of total billed charges,Implant Device,117.6,35,,117.6,percent of total billed charges,Implant Device,117.6,35,,117.6,percent of total billed charges,Implant Device,117.6,35,,117.6,percent of total billed charges,Implant Device,117.6,35,,117.6,percent of total billed charges,Implant Device,134.4,40,,134.4,percent of total billed charges,Implant Device,117.6,70,,117.6,percent of total billed charges,All Other,114.24,34,,114.24,percent of total billed charges,Implant Device,114.24,34,,114.24,percent of total billed charges,Implant Device,117.6,35,,117.6,percent of total billed charges,Implant Device,117.6,35,,117.6,percent of total billed charges,Implant Device,117.6,35,,117.6,percent of total billed charges,Implant Device,117.6,35,,117.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,248.64,
ARTHREX AR-14122NL SCREW,C1713,HCPCS,,79002390,CDM,278,RC,,,both,,,136,100.64,,,100.64,Other,150% of Medicare + 9.63% HCRA Surcharge,61.2,45,,61.2,percent of total billed charges,Critical Access Hospital RCC factor,46.24,34,,46.24,percent of total billed charges,Implant Device,46.24,34,,46.24,percent of total billed charges,Implant Device,46.24,34,,46.24,percent of total billed charges,Implant Device,46.24,34,,46.24,percent of total billed charges,Implant Device,46.24,34,,46.24,percent of total billed charges,Implant Device,67.32,,,67.32,Other,110% of Medicare,47.6,35,,47.6,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,47.6,35,,47.6,percent of total billed charges,Implant Device,47.6,35,,47.6,percent of total billed charges,Implant Device,47.6,35,,47.6,percent of total billed charges,Implant Device,47.6,35,,47.6,percent of total billed charges,Implant Device,47.6,35,,47.6,percent of total billed charges,Implant Device,54.4,40,,54.4,percent of total billed charges,Implant Device,47.6,70,,47.6,percent of total billed charges,All Other,46.24,34,,46.24,percent of total billed charges,Implant Device,46.24,34,,46.24,percent of total billed charges,Implant Device,47.6,35,,47.6,percent of total billed charges,Implant Device,47.6,35,,47.6,percent of total billed charges,Implant Device,47.6,35,,47.6,percent of total billed charges,Implant Device,47.6,35,,47.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,100.64,
ARTHREX AR-14224 SCREW,C1713,HCPCS,,79002391,CDM,278,RC,,,both,,,480,355.2,,,355.2,Other,150% of Medicare + 9.63% HCRA Surcharge,216,45,,216,percent of total billed charges,Critical Access Hospital RCC factor,163.2,34,,163.2,percent of total billed charges,Implant Device,163.2,34,,163.2,percent of total billed charges,Implant Device,163.2,34,,163.2,percent of total billed charges,Implant Device,163.2,34,,163.2,percent of total billed charges,Implant Device,163.2,34,,163.2,percent of total billed charges,Implant Device,237.6,,,237.6,Other,110% of Medicare,168,35,,168,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,192,40,,192,percent of total billed charges,Implant Device,168,70,,168,percent of total billed charges,All Other,163.2,34,,163.2,percent of total billed charges,Implant Device,163.2,34,,163.2,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,355.2,
ARTHREX AR-14238 SCREW,C1713,HCPCS,,79002392,CDM,278,RC,,,both,,,336,248.64,,,248.64,Other,150% of Medicare + 9.63% HCRA Surcharge,151.2,45,,151.2,percent of total billed charges,Critical Access Hospital RCC factor,114.24,34,,114.24,percent of total billed charges,Implant Device,114.24,34,,114.24,percent of total billed charges,Implant Device,114.24,34,,114.24,percent of total billed charges,Implant Device,114.24,34,,114.24,percent of total billed charges,Implant Device,114.24,34,,114.24,percent of total billed charges,Implant Device,166.32,,,166.32,Other,110% of Medicare,117.6,35,,117.6,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,117.6,35,,117.6,percent of total billed charges,Implant Device,117.6,35,,117.6,percent of total billed charges,Implant Device,117.6,35,,117.6,percent of total billed charges,Implant Device,117.6,35,,117.6,percent of total billed charges,Implant Device,117.6,35,,117.6,percent of total billed charges,Implant Device,134.4,40,,134.4,percent of total billed charges,Implant Device,117.6,70,,117.6,percent of total billed charges,All Other,114.24,34,,114.24,percent of total billed charges,Implant Device,114.24,34,,114.24,percent of total billed charges,Implant Device,117.6,35,,117.6,percent of total billed charges,Implant Device,117.6,35,,117.6,percent of total billed charges,Implant Device,117.6,35,,117.6,percent of total billed charges,Implant Device,117.6,35,,117.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,248.64,
ARTHREX AR-14240 SCREW,C1713,HCPCS,,79002393,CDM,278,RC,,,both,,,336,248.64,,,248.64,Other,150% of Medicare + 9.63% HCRA Surcharge,151.2,45,,151.2,percent of total billed charges,Critical Access Hospital RCC factor,114.24,34,,114.24,percent of total billed charges,Implant Device,114.24,34,,114.24,percent of total billed charges,Implant Device,114.24,34,,114.24,percent of total billed charges,Implant Device,114.24,34,,114.24,percent of total billed charges,Implant Device,114.24,34,,114.24,percent of total billed charges,Implant Device,166.32,,,166.32,Other,110% of Medicare,117.6,35,,117.6,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,117.6,35,,117.6,percent of total billed charges,Implant Device,117.6,35,,117.6,percent of total billed charges,Implant Device,117.6,35,,117.6,percent of total billed charges,Implant Device,117.6,35,,117.6,percent of total billed charges,Implant Device,117.6,35,,117.6,percent of total billed charges,Implant Device,134.4,40,,134.4,percent of total billed charges,Implant Device,117.6,70,,117.6,percent of total billed charges,All Other,114.24,34,,114.24,percent of total billed charges,Implant Device,114.24,34,,114.24,percent of total billed charges,Implant Device,117.6,35,,117.6,percent of total billed charges,Implant Device,117.6,35,,117.6,percent of total billed charges,Implant Device,117.6,35,,117.6,percent of total billed charges,Implant Device,117.6,35,,117.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,248.64,
ARTHREX AR-14242 SCREW,C1713,HCPCS,,79002394,CDM,278,RC,,,both,,,336,248.64,,,248.64,Other,150% of Medicare + 9.63% HCRA Surcharge,151.2,45,,151.2,percent of total billed charges,Critical Access Hospital RCC factor,114.24,34,,114.24,percent of total billed charges,Implant Device,114.24,34,,114.24,percent of total billed charges,Implant Device,114.24,34,,114.24,percent of total billed charges,Implant Device,114.24,34,,114.24,percent of total billed charges,Implant Device,114.24,34,,114.24,percent of total billed charges,Implant Device,166.32,,,166.32,Other,110% of Medicare,117.6,35,,117.6,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,117.6,35,,117.6,percent of total billed charges,Implant Device,117.6,35,,117.6,percent of total billed charges,Implant Device,117.6,35,,117.6,percent of total billed charges,Implant Device,117.6,35,,117.6,percent of total billed charges,Implant Device,117.6,35,,117.6,percent of total billed charges,Implant Device,134.4,40,,134.4,percent of total billed charges,Implant Device,117.6,70,,117.6,percent of total billed charges,All Other,114.24,34,,114.24,percent of total billed charges,Implant Device,114.24,34,,114.24,percent of total billed charges,Implant Device,117.6,35,,117.6,percent of total billed charges,Implant Device,117.6,35,,117.6,percent of total billed charges,Implant Device,117.6,35,,117.6,percent of total billed charges,Implant Device,117.6,35,,117.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,248.64,
ARTHREX AR-1540BC SCREW,C1713,HCPCS,,79002395,CDM,278,RC,,,both,,,1036,766.64,,,766.64,Other,150% of Medicare + 9.63% HCRA Surcharge,466.2,45,,466.2,percent of total billed charges,Critical Access Hospital RCC factor,352.24,34,,352.24,percent of total billed charges,Implant Device,352.24,34,,352.24,percent of total billed charges,Implant Device,352.24,34,,352.24,percent of total billed charges,Implant Device,352.24,34,,352.24,percent of total billed charges,Implant Device,352.24,34,,352.24,percent of total billed charges,Implant Device,512.82,,,512.82,Other,110% of Medicare,362.6,35,,362.6,percent of total billed charges,Implant Device,352.24,34,"Charges > $500, x 34%",352.24,percent of total billed charges,Implant Device,362.6,35,,362.6,percent of total billed charges,Implant Device,362.6,35,,362.6,percent of total billed charges,Implant Device,362.6,35,,362.6,percent of total billed charges,Implant Device,362.6,35,,362.6,percent of total billed charges,Implant Device,362.6,35,,362.6,percent of total billed charges,Implant Device,414.4,40,,414.4,percent of total billed charges,Implant Device,362.6,70,,362.6,percent of total billed charges,All Other,352.24,34,,352.24,percent of total billed charges,Implant Device,352.24,34,,352.24,percent of total billed charges,Implant Device,362.6,35,,362.6,percent of total billed charges,Implant Device,362.6,35,,362.6,percent of total billed charges,Implant Device,362.6,35,,362.6,percent of total billed charges,Implant Device,362.6,35,,362.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,766.64,
ARTHREX AR-1586RB-08 SCREW,C1713,HCPCS,,79002396,CDM,278,RC,,,both,,,834,617.16,,,617.16,Other,150% of Medicare + 9.63% HCRA Surcharge,375.3,45,,375.3,percent of total billed charges,Critical Access Hospital RCC factor,283.56,34,,283.56,percent of total billed charges,Implant Device,283.56,34,,283.56,percent of total billed charges,Implant Device,283.56,34,,283.56,percent of total billed charges,Implant Device,283.56,34,,283.56,percent of total billed charges,Implant Device,283.56,34,,283.56,percent of total billed charges,Implant Device,412.83,,,412.83,Other,110% of Medicare,291.9,35,,291.9,percent of total billed charges,Implant Device,283.56,34,"Charges > $500, x 34%",283.56,percent of total billed charges,Implant Device,291.9,35,,291.9,percent of total billed charges,Implant Device,291.9,35,,291.9,percent of total billed charges,Implant Device,291.9,35,,291.9,percent of total billed charges,Implant Device,291.9,35,,291.9,percent of total billed charges,Implant Device,291.9,35,,291.9,percent of total billed charges,Implant Device,333.6,40,,333.6,percent of total billed charges,Implant Device,291.9,70,,291.9,percent of total billed charges,All Other,283.56,34,,283.56,percent of total billed charges,Implant Device,283.56,34,,283.56,percent of total billed charges,Implant Device,291.9,35,,291.9,percent of total billed charges,Implant Device,291.9,35,,291.9,percent of total billed charges,Implant Device,291.9,35,,291.9,percent of total billed charges,Implant Device,291.9,35,,291.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,617.16,
ARTHREX AR-1923BCH SUTURE ANCHOR,C1713,HCPCS,,79002398,CDM,278,RC,,,both,,,1200,888,,,888,Other,150% of Medicare + 9.63% HCRA Surcharge,540,45,,540,percent of total billed charges,Critical Access Hospital RCC factor,408,34,,408,percent of total billed charges,Implant Device,408,34,,408,percent of total billed charges,Implant Device,408,34,,408,percent of total billed charges,Implant Device,408,34,,408,percent of total billed charges,Implant Device,408,34,,408,percent of total billed charges,Implant Device,594,,,594,Other,110% of Medicare,420,35,,420,percent of total billed charges,Implant Device,408,34,"Charges > $500, x 34%",408,percent of total billed charges,Implant Device,420,35,,420,percent of total billed charges,Implant Device,420,35,,420,percent of total billed charges,Implant Device,420,35,,420,percent of total billed charges,Implant Device,420,35,,420,percent of total billed charges,Implant Device,420,35,,420,percent of total billed charges,Implant Device,480,40,,480,percent of total billed charges,Implant Device,420,70,,420,percent of total billed charges,All Other,408,34,,408,percent of total billed charges,Implant Device,408,34,,408,percent of total billed charges,Implant Device,420,35,,420,percent of total billed charges,Implant Device,420,35,,420,percent of total billed charges,Implant Device,420,35,,420,percent of total billed charges,Implant Device,420,35,,420,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,888,
ARTHREX AR-1927BCF-65 SUTURE ANCHOR,C1713,HCPCS,,79002399,CDM,278,RC,,,both,,,1006,744.44,,,744.44,Other,150% of Medicare + 9.63% HCRA Surcharge,452.7,45,,452.7,percent of total billed charges,Critical Access Hospital RCC factor,342.04,34,,342.04,percent of total billed charges,Implant Device,342.04,34,,342.04,percent of total billed charges,Implant Device,342.04,34,,342.04,percent of total billed charges,Implant Device,342.04,34,,342.04,percent of total billed charges,Implant Device,342.04,34,,342.04,percent of total billed charges,Implant Device,497.97,,,497.97,Other,110% of Medicare,352.1,35,,352.1,percent of total billed charges,Implant Device,342.04,34,"Charges > $500, x 34%",342.04,percent of total billed charges,Implant Device,352.1,35,,352.1,percent of total billed charges,Implant Device,352.1,35,,352.1,percent of total billed charges,Implant Device,352.1,35,,352.1,percent of total billed charges,Implant Device,352.1,35,,352.1,percent of total billed charges,Implant Device,352.1,35,,352.1,percent of total billed charges,Implant Device,402.4,40,,402.4,percent of total billed charges,Implant Device,352.1,70,,352.1,percent of total billed charges,All Other,342.04,34,,342.04,percent of total billed charges,Implant Device,342.04,34,,342.04,percent of total billed charges,Implant Device,352.1,35,,352.1,percent of total billed charges,Implant Device,352.1,35,,352.1,percent of total billed charges,Implant Device,352.1,35,,352.1,percent of total billed charges,Implant Device,352.1,35,,352.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,744.44,
ARTHREX AR-1934BCF-24 SUTURE ANCHOR,C1713,HCPCS,,79002400,CDM,278,RC,,,both,,,916,677.84,,,677.84,Other,150% of Medicare + 9.63% HCRA Surcharge,412.2,45,,412.2,percent of total billed charges,Critical Access Hospital RCC factor,311.44,34,,311.44,percent of total billed charges,Implant Device,311.44,34,,311.44,percent of total billed charges,Implant Device,311.44,34,,311.44,percent of total billed charges,Implant Device,311.44,34,,311.44,percent of total billed charges,Implant Device,311.44,34,,311.44,percent of total billed charges,Implant Device,453.42,,,453.42,Other,110% of Medicare,320.6,35,,320.6,percent of total billed charges,Implant Device,311.44,34,"Charges > $500, x 34%",311.44,percent of total billed charges,Implant Device,320.6,35,,320.6,percent of total billed charges,Implant Device,320.6,35,,320.6,percent of total billed charges,Implant Device,320.6,35,,320.6,percent of total billed charges,Implant Device,320.6,35,,320.6,percent of total billed charges,Implant Device,320.6,35,,320.6,percent of total billed charges,Implant Device,366.4,40,,366.4,percent of total billed charges,Implant Device,320.6,70,,320.6,percent of total billed charges,All Other,311.44,34,,311.44,percent of total billed charges,Implant Device,311.44,34,,311.44,percent of total billed charges,Implant Device,320.6,35,,320.6,percent of total billed charges,Implant Device,320.6,35,,320.6,percent of total billed charges,Implant Device,320.6,35,,320.6,percent of total billed charges,Implant Device,320.6,35,,320.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,677.84,
ARTHREX AR-2258 AC GRAFTROPE,C1713,HCPCS,,79002401,CDM,278,RC,,,both,,,2086,1543.65,,,1543.65,Other,150% of Medicare + 9.63% HCRA Surcharge,938.7,45,,938.7,percent of total billed charges,Critical Access Hospital RCC factor,709.24,34,,709.24,percent of total billed charges,Implant Device,709.24,34,,709.24,percent of total billed charges,Implant Device,709.24,34,,709.24,percent of total billed charges,Implant Device,709.24,34,,709.24,percent of total billed charges,Implant Device,709.24,34,,709.24,percent of total billed charges,Implant Device,1032.57,,,1032.57,Other,110% of Medicare,730.1,35,,730.1,percent of total billed charges,Implant Device,709.24,34,"Charges > $500, x 34%",709.24,percent of total billed charges,Implant Device,730.1,35,,730.1,percent of total billed charges,Implant Device,730.1,35,,730.1,percent of total billed charges,Implant Device,730.1,35,,730.1,percent of total billed charges,Implant Device,730.1,35,,730.1,percent of total billed charges,Implant Device,730.1,35,,730.1,percent of total billed charges,Implant Device,834.4,40,,834.4,percent of total billed charges,Implant Device,730.1,70,,730.1,percent of total billed charges,All Other,709.24,34,,709.24,percent of total billed charges,Implant Device,709.24,34,,709.24,percent of total billed charges,Implant Device,730.1,35,,730.1,percent of total billed charges,Implant Device,730.1,35,,730.1,percent of total billed charges,Implant Device,730.1,35,,730.1,percent of total billed charges,Implant Device,730.1,35,,730.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,709.24,34,"If Charge > 2,000, then 34 percent",709.24,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1543.65,
ARTHREX AR-5025B-22 SCREW,C1713,HCPCS,,79002404,CDM,278,RC,,,both,,,1500,1110,,,1110,Other,150% of Medicare + 9.63% HCRA Surcharge,675,45,,675,percent of total billed charges,Critical Access Hospital RCC factor,510,34,,510,percent of total billed charges,Implant Device,510,34,,510,percent of total billed charges,Implant Device,510,34,,510,percent of total billed charges,Implant Device,510,34,,510,percent of total billed charges,Implant Device,510,34,,510,percent of total billed charges,Implant Device,742.5,,,742.5,Other,110% of Medicare,525,35,,525,percent of total billed charges,Implant Device,510,34,"Charges > $500, x 34%",510,percent of total billed charges,Implant Device,525,35,,525,percent of total billed charges,Implant Device,525,35,,525,percent of total billed charges,Implant Device,525,35,,525,percent of total billed charges,Implant Device,525,35,,525,percent of total billed charges,Implant Device,525,35,,525,percent of total billed charges,Implant Device,600,40,,600,percent of total billed charges,Implant Device,525,70,,525,percent of total billed charges,All Other,510,34,,510,percent of total billed charges,Implant Device,510,34,,510,percent of total billed charges,Implant Device,525,35,,525,percent of total billed charges,Implant Device,525,35,,525,percent of total billed charges,Implant Device,525,35,,525,percent of total billed charges,Implant Device,525,35,,525,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1110,
ARTHREX AR-5026B-16 SCREW,C1713,HCPCS,,79002407,CDM,278,RC,,,both,,,1650,1221,,,1221,Other,150% of Medicare + 9.63% HCRA Surcharge,742.5,45,,742.5,percent of total billed charges,Critical Access Hospital RCC factor,561,34,,561,percent of total billed charges,Implant Device,561,34,,561,percent of total billed charges,Implant Device,561,34,,561,percent of total billed charges,Implant Device,561,34,,561,percent of total billed charges,Implant Device,561,34,,561,percent of total billed charges,Implant Device,816.75,,,816.75,Other,110% of Medicare,577.5,35,,577.5,percent of total billed charges,Implant Device,561,34,"Charges > $500, x 34%",561,percent of total billed charges,Implant Device,577.5,35,,577.5,percent of total billed charges,Implant Device,577.5,35,,577.5,percent of total billed charges,Implant Device,577.5,35,,577.5,percent of total billed charges,Implant Device,577.5,35,,577.5,percent of total billed charges,Implant Device,577.5,35,,577.5,percent of total billed charges,Implant Device,660,40,,660,percent of total billed charges,Implant Device,577.5,70,,577.5,percent of total billed charges,All Other,561,34,,561,percent of total billed charges,Implant Device,561,34,,561,percent of total billed charges,Implant Device,577.5,35,,577.5,percent of total billed charges,Implant Device,577.5,35,,577.5,percent of total billed charges,Implant Device,577.5,35,,577.5,percent of total billed charges,Implant Device,577.5,35,,577.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1221,
ARTHREX AR-5026B-18 SCREW,C1713,HCPCS,,79002408,CDM,278,RC,,,both,,,1650,1221,,,1221,Other,150% of Medicare + 9.63% HCRA Surcharge,742.5,45,,742.5,percent of total billed charges,Critical Access Hospital RCC factor,561,34,,561,percent of total billed charges,Implant Device,561,34,,561,percent of total billed charges,Implant Device,561,34,,561,percent of total billed charges,Implant Device,561,34,,561,percent of total billed charges,Implant Device,561,34,,561,percent of total billed charges,Implant Device,816.75,,,816.75,Other,110% of Medicare,577.5,35,,577.5,percent of total billed charges,Implant Device,561,34,"Charges > $500, x 34%",561,percent of total billed charges,Implant Device,577.5,35,,577.5,percent of total billed charges,Implant Device,577.5,35,,577.5,percent of total billed charges,Implant Device,577.5,35,,577.5,percent of total billed charges,Implant Device,577.5,35,,577.5,percent of total billed charges,Implant Device,577.5,35,,577.5,percent of total billed charges,Implant Device,660,40,,660,percent of total billed charges,Implant Device,577.5,70,,577.5,percent of total billed charges,All Other,561,34,,561,percent of total billed charges,Implant Device,561,34,,561,percent of total billed charges,Implant Device,577.5,35,,577.5,percent of total billed charges,Implant Device,577.5,35,,577.5,percent of total billed charges,Implant Device,577.5,35,,577.5,percent of total billed charges,Implant Device,577.5,35,,577.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1221,
ARTHREX AR-5028C-09 SCREW,C1713,HCPCS,,79002409,CDM,278,RC,,,both,,,705,521.7,,,521.7,Other,150% of Medicare + 9.63% HCRA Surcharge,317.25,45,,317.25,percent of total billed charges,Critical Access Hospital RCC factor,239.7,34,,239.7,percent of total billed charges,Implant Device,239.7,34,,239.7,percent of total billed charges,Implant Device,239.7,34,,239.7,percent of total billed charges,Implant Device,239.7,34,,239.7,percent of total billed charges,Implant Device,239.7,34,,239.7,percent of total billed charges,Implant Device,348.98,,,348.98,Other,110% of Medicare,246.75,35,,246.75,percent of total billed charges,Implant Device,239.7,34,"Charges > $500, x 34%",239.7,percent of total billed charges,Implant Device,246.75,35,,246.75,percent of total billed charges,Implant Device,246.75,35,,246.75,percent of total billed charges,Implant Device,246.75,35,,246.75,percent of total billed charges,Implant Device,246.75,35,,246.75,percent of total billed charges,Implant Device,246.75,35,,246.75,percent of total billed charges,Implant Device,282,40,,282,percent of total billed charges,Implant Device,246.75,70,,246.75,percent of total billed charges,All Other,239.7,34,,239.7,percent of total billed charges,Implant Device,239.7,34,,239.7,percent of total billed charges,Implant Device,246.75,35,,246.75,percent of total billed charges,Implant Device,246.75,35,,246.75,percent of total billed charges,Implant Device,246.75,35,,246.75,percent of total billed charges,Implant Device,246.75,35,,246.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,521.7,
ARTHREX AR-5028C-10 SCREW,C1713,HCPCS,,79002410,CDM,278,RC,,,both,,,705,521.7,,,521.7,Other,150% of Medicare + 9.63% HCRA Surcharge,317.25,45,,317.25,percent of total billed charges,Critical Access Hospital RCC factor,239.7,34,,239.7,percent of total billed charges,Implant Device,239.7,34,,239.7,percent of total billed charges,Implant Device,239.7,34,,239.7,percent of total billed charges,Implant Device,239.7,34,,239.7,percent of total billed charges,Implant Device,239.7,34,,239.7,percent of total billed charges,Implant Device,348.98,,,348.98,Other,110% of Medicare,246.75,35,,246.75,percent of total billed charges,Implant Device,239.7,34,"Charges > $500, x 34%",239.7,percent of total billed charges,Implant Device,246.75,35,,246.75,percent of total billed charges,Implant Device,246.75,35,,246.75,percent of total billed charges,Implant Device,246.75,35,,246.75,percent of total billed charges,Implant Device,246.75,35,,246.75,percent of total billed charges,Implant Device,246.75,35,,246.75,percent of total billed charges,Implant Device,282,40,,282,percent of total billed charges,Implant Device,246.75,70,,246.75,percent of total billed charges,All Other,239.7,34,,239.7,percent of total billed charges,Implant Device,239.7,34,,239.7,percent of total billed charges,Implant Device,246.75,35,,246.75,percent of total billed charges,Implant Device,246.75,35,,246.75,percent of total billed charges,Implant Device,246.75,35,,246.75,percent of total billed charges,Implant Device,246.75,35,,246.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,521.7,
ARTHREX AR-5035TC-10 SCREW,C1713,HCPCS,,79002411,CDM,278,RC,,,both,,,705,521.7,,,521.7,Other,150% of Medicare + 9.63% HCRA Surcharge,317.25,45,,317.25,percent of total billed charges,Critical Access Hospital RCC factor,239.7,34,,239.7,percent of total billed charges,Implant Device,239.7,34,,239.7,percent of total billed charges,Implant Device,239.7,34,,239.7,percent of total billed charges,Implant Device,239.7,34,,239.7,percent of total billed charges,Implant Device,239.7,34,,239.7,percent of total billed charges,Implant Device,348.98,,,348.98,Other,110% of Medicare,246.75,35,,246.75,percent of total billed charges,Implant Device,239.7,34,"Charges > $500, x 34%",239.7,percent of total billed charges,Implant Device,246.75,35,,246.75,percent of total billed charges,Implant Device,246.75,35,,246.75,percent of total billed charges,Implant Device,246.75,35,,246.75,percent of total billed charges,Implant Device,246.75,35,,246.75,percent of total billed charges,Implant Device,246.75,35,,246.75,percent of total billed charges,Implant Device,282,40,,282,percent of total billed charges,Implant Device,246.75,70,,246.75,percent of total billed charges,All Other,239.7,34,,239.7,percent of total billed charges,Implant Device,239.7,34,,239.7,percent of total billed charges,Implant Device,246.75,35,,246.75,percent of total billed charges,Implant Device,246.75,35,,246.75,percent of total billed charges,Implant Device,246.75,35,,246.75,percent of total billed charges,Implant Device,246.75,35,,246.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,521.7,
ARTHREX AR-5080AB SCREW,C1713,HCPCS,,79002412,CDM,278,RC,,,both,,,610,451.4,,,451.4,Other,150% of Medicare + 9.63% HCRA Surcharge,274.5,45,,274.5,percent of total billed charges,Critical Access Hospital RCC factor,207.4,34,,207.4,percent of total billed charges,Implant Device,207.4,34,,207.4,percent of total billed charges,Implant Device,207.4,34,,207.4,percent of total billed charges,Implant Device,207.4,34,,207.4,percent of total billed charges,Implant Device,207.4,34,,207.4,percent of total billed charges,Implant Device,301.95,,,301.95,Other,110% of Medicare,213.5,35,,213.5,percent of total billed charges,Implant Device,207.4,34,"Charges > $500, x 34%",207.4,percent of total billed charges,Implant Device,213.5,35,,213.5,percent of total billed charges,Implant Device,213.5,35,,213.5,percent of total billed charges,Implant Device,213.5,35,,213.5,percent of total billed charges,Implant Device,213.5,35,,213.5,percent of total billed charges,Implant Device,213.5,35,,213.5,percent of total billed charges,Implant Device,244,40,,244,percent of total billed charges,Implant Device,213.5,70,,213.5,percent of total billed charges,All Other,207.4,34,,207.4,percent of total billed charges,Implant Device,207.4,34,,207.4,percent of total billed charges,Implant Device,213.5,35,,213.5,percent of total billed charges,Implant Device,213.5,35,,213.5,percent of total billed charges,Implant Device,213.5,35,,213.5,percent of total billed charges,Implant Device,213.5,35,,213.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,451.4,
ARTHREX AR-5100-09 GRAFTBOLT,C1713,HCPCS,,79002413,CDM,278,RC,,,both,,,1696,1255.04,,,1255.04,Other,150% of Medicare + 9.63% HCRA Surcharge,763.2,45,,763.2,percent of total billed charges,Critical Access Hospital RCC factor,576.64,34,,576.64,percent of total billed charges,Implant Device,576.64,34,,576.64,percent of total billed charges,Implant Device,576.64,34,,576.64,percent of total billed charges,Implant Device,576.64,34,,576.64,percent of total billed charges,Implant Device,576.64,34,,576.64,percent of total billed charges,Implant Device,839.52,,,839.52,Other,110% of Medicare,593.6,35,,593.6,percent of total billed charges,Implant Device,576.64,34,"Charges > $500, x 34%",576.64,percent of total billed charges,Implant Device,593.6,35,,593.6,percent of total billed charges,Implant Device,593.6,35,,593.6,percent of total billed charges,Implant Device,593.6,35,,593.6,percent of total billed charges,Implant Device,593.6,35,,593.6,percent of total billed charges,Implant Device,593.6,35,,593.6,percent of total billed charges,Implant Device,678.4,40,,678.4,percent of total billed charges,Implant Device,593.6,70,,593.6,percent of total billed charges,All Other,576.64,34,,576.64,percent of total billed charges,Implant Device,576.64,34,,576.64,percent of total billed charges,Implant Device,593.6,35,,593.6,percent of total billed charges,Implant Device,593.6,35,,593.6,percent of total billed charges,Implant Device,593.6,35,,593.6,percent of total billed charges,Implant Device,593.6,35,,593.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1255.04,
ARTHREX AR-8720-12PT SCREW,C1713,HCPCS,,79002415,CDM,278,RC,,,both,,,420,310.8,,,310.8,Other,150% of Medicare + 9.63% HCRA Surcharge,189,45,,189,percent of total billed charges,Critical Access Hospital RCC factor,142.8,34,,142.8,percent of total billed charges,Implant Device,142.8,34,,142.8,percent of total billed charges,Implant Device,142.8,34,,142.8,percent of total billed charges,Implant Device,142.8,34,,142.8,percent of total billed charges,Implant Device,142.8,34,,142.8,percent of total billed charges,Implant Device,207.9,,,207.9,Other,110% of Medicare,147,35,,147,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,147,35,,147,percent of total billed charges,Implant Device,147,35,,147,percent of total billed charges,Implant Device,147,35,,147,percent of total billed charges,Implant Device,147,35,,147,percent of total billed charges,Implant Device,147,35,,147,percent of total billed charges,Implant Device,168,40,,168,percent of total billed charges,Implant Device,147,70,,147,percent of total billed charges,All Other,142.8,34,,142.8,percent of total billed charges,Implant Device,142.8,34,,142.8,percent of total billed charges,Implant Device,147,35,,147,percent of total billed charges,Implant Device,147,35,,147,percent of total billed charges,Implant Device,147,35,,147,percent of total billed charges,Implant Device,147,35,,147,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,310.8,
ARTHREX AR-8835-12 SCREW,C1713,HCPCS,,79002416,CDM,278,RC,,,both,,,105,77.7,,,77.7,Other,150% of Medicare + 9.63% HCRA Surcharge,47.25,45,,47.25,percent of total billed charges,Critical Access Hospital RCC factor,35.7,34,,35.7,percent of total billed charges,Implant Device,35.7,34,,35.7,percent of total billed charges,Implant Device,35.7,34,,35.7,percent of total billed charges,Implant Device,35.7,34,,35.7,percent of total billed charges,Implant Device,35.7,34,,35.7,percent of total billed charges,Implant Device,51.98,,,51.98,Other,110% of Medicare,36.75,35,,36.75,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,36.75,35,,36.75,percent of total billed charges,Implant Device,36.75,35,,36.75,percent of total billed charges,Implant Device,36.75,35,,36.75,percent of total billed charges,Implant Device,36.75,35,,36.75,percent of total billed charges,Implant Device,36.75,35,,36.75,percent of total billed charges,Implant Device,42,40,,42,percent of total billed charges,Implant Device,36.75,70,,36.75,percent of total billed charges,All Other,35.7,34,,35.7,percent of total billed charges,Implant Device,35.7,34,,35.7,percent of total billed charges,Implant Device,36.75,35,,36.75,percent of total billed charges,Implant Device,36.75,35,,36.75,percent of total billed charges,Implant Device,36.75,35,,36.75,percent of total billed charges,Implant Device,36.75,35,,36.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,77.7,
ARTHREX AR-8835-14 SCREW,C1713,HCPCS,,79002417,CDM,278,RC,,,both,,,106,78.44,,,78.44,Other,150% of Medicare + 9.63% HCRA Surcharge,47.7,45,,47.7,percent of total billed charges,Critical Access Hospital RCC factor,36.04,34,,36.04,percent of total billed charges,Implant Device,36.04,34,,36.04,percent of total billed charges,Implant Device,36.04,34,,36.04,percent of total billed charges,Implant Device,36.04,34,,36.04,percent of total billed charges,Implant Device,36.04,34,,36.04,percent of total billed charges,Implant Device,52.47,,,52.47,Other,110% of Medicare,37.1,35,,37.1,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,37.1,35,,37.1,percent of total billed charges,Implant Device,37.1,35,,37.1,percent of total billed charges,Implant Device,37.1,35,,37.1,percent of total billed charges,Implant Device,37.1,35,,37.1,percent of total billed charges,Implant Device,37.1,35,,37.1,percent of total billed charges,Implant Device,42.4,40,,42.4,percent of total billed charges,Implant Device,37.1,70,,37.1,percent of total billed charges,All Other,36.04,34,,36.04,percent of total billed charges,Implant Device,36.04,34,,36.04,percent of total billed charges,Implant Device,37.1,35,,37.1,percent of total billed charges,Implant Device,37.1,35,,37.1,percent of total billed charges,Implant Device,37.1,35,,37.1,percent of total billed charges,Implant Device,37.1,35,,37.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,78.44,
ARTHREX AR-8835-18 SCREW,C1713,HCPCS,,79002418,CDM,278,RC,,,both,,,105,77.7,,,77.7,Other,150% of Medicare + 9.63% HCRA Surcharge,47.25,45,,47.25,percent of total billed charges,Critical Access Hospital RCC factor,35.7,34,,35.7,percent of total billed charges,Implant Device,35.7,34,,35.7,percent of total billed charges,Implant Device,35.7,34,,35.7,percent of total billed charges,Implant Device,35.7,34,,35.7,percent of total billed charges,Implant Device,35.7,34,,35.7,percent of total billed charges,Implant Device,51.98,,,51.98,Other,110% of Medicare,36.75,35,,36.75,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,36.75,35,,36.75,percent of total billed charges,Implant Device,36.75,35,,36.75,percent of total billed charges,Implant Device,36.75,35,,36.75,percent of total billed charges,Implant Device,36.75,35,,36.75,percent of total billed charges,Implant Device,36.75,35,,36.75,percent of total billed charges,Implant Device,42,40,,42,percent of total billed charges,Implant Device,36.75,70,,36.75,percent of total billed charges,All Other,35.7,34,,35.7,percent of total billed charges,Implant Device,35.7,34,,35.7,percent of total billed charges,Implant Device,36.75,35,,36.75,percent of total billed charges,Implant Device,36.75,35,,36.75,percent of total billed charges,Implant Device,36.75,35,,36.75,percent of total billed charges,Implant Device,36.75,35,,36.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,77.7,
ARTHREX AR-8835-24 SCREW,C1713,HCPCS,,79002419,CDM,278,RC,,,both,,,106,78.44,,,78.44,Other,150% of Medicare + 9.63% HCRA Surcharge,47.7,45,,47.7,percent of total billed charges,Critical Access Hospital RCC factor,36.04,34,,36.04,percent of total billed charges,Implant Device,36.04,34,,36.04,percent of total billed charges,Implant Device,36.04,34,,36.04,percent of total billed charges,Implant Device,36.04,34,,36.04,percent of total billed charges,Implant Device,36.04,34,,36.04,percent of total billed charges,Implant Device,52.47,,,52.47,Other,110% of Medicare,37.1,35,,37.1,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,37.1,35,,37.1,percent of total billed charges,Implant Device,37.1,35,,37.1,percent of total billed charges,Implant Device,37.1,35,,37.1,percent of total billed charges,Implant Device,37.1,35,,37.1,percent of total billed charges,Implant Device,37.1,35,,37.1,percent of total billed charges,Implant Device,42.4,40,,42.4,percent of total billed charges,Implant Device,37.1,70,,37.1,percent of total billed charges,All Other,36.04,34,,36.04,percent of total billed charges,Implant Device,36.04,34,,36.04,percent of total billed charges,Implant Device,37.1,35,,37.1,percent of total billed charges,Implant Device,37.1,35,,37.1,percent of total billed charges,Implant Device,37.1,35,,37.1,percent of total billed charges,Implant Device,37.1,35,,37.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,78.44,
ARTHREX AR-8840C-42 SCREW,C1713,HCPCS,,79002420,CDM,278,RC,,,both,,,495,366.3,,,366.3,Other,150% of Medicare + 9.63% HCRA Surcharge,222.75,45,,222.75,percent of total billed charges,Critical Access Hospital RCC factor,168.3,34,,168.3,percent of total billed charges,Implant Device,168.3,34,,168.3,percent of total billed charges,Implant Device,168.3,34,,168.3,percent of total billed charges,Implant Device,168.3,34,,168.3,percent of total billed charges,Implant Device,168.3,34,,168.3,percent of total billed charges,Implant Device,245.03,,,245.03,Other,110% of Medicare,173.25,35,,173.25,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,173.25,35,,173.25,percent of total billed charges,Implant Device,173.25,35,,173.25,percent of total billed charges,Implant Device,173.25,35,,173.25,percent of total billed charges,Implant Device,173.25,35,,173.25,percent of total billed charges,Implant Device,173.25,35,,173.25,percent of total billed charges,Implant Device,198,40,,198,percent of total billed charges,Implant Device,173.25,70,,173.25,percent of total billed charges,All Other,168.3,34,,168.3,percent of total billed charges,Implant Device,168.3,34,,168.3,percent of total billed charges,Implant Device,173.25,35,,173.25,percent of total billed charges,Implant Device,173.25,35,,173.25,percent of total billed charges,Implant Device,173.25,35,,173.25,percent of total billed charges,Implant Device,173.25,35,,173.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,366.3,
ARTHREX AR-8840C-46 SCREW,C1713,HCPCS,,79002421,CDM,278,RC,,,both,,,496,367.04,,,367.04,Other,150% of Medicare + 9.63% HCRA Surcharge,223.2,45,,223.2,percent of total billed charges,Critical Access Hospital RCC factor,168.64,34,,168.64,percent of total billed charges,Implant Device,168.64,34,,168.64,percent of total billed charges,Implant Device,168.64,34,,168.64,percent of total billed charges,Implant Device,168.64,34,,168.64,percent of total billed charges,Implant Device,168.64,34,,168.64,percent of total billed charges,Implant Device,245.52,,,245.52,Other,110% of Medicare,173.6,35,,173.6,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,173.6,35,,173.6,percent of total billed charges,Implant Device,173.6,35,,173.6,percent of total billed charges,Implant Device,173.6,35,,173.6,percent of total billed charges,Implant Device,173.6,35,,173.6,percent of total billed charges,Implant Device,173.6,35,,173.6,percent of total billed charges,Implant Device,198.4,40,,198.4,percent of total billed charges,Implant Device,173.6,70,,173.6,percent of total billed charges,All Other,168.64,34,,168.64,percent of total billed charges,Implant Device,168.64,34,,168.64,percent of total billed charges,Implant Device,173.6,35,,173.6,percent of total billed charges,Implant Device,173.6,35,,173.6,percent of total billed charges,Implant Device,173.6,35,,173.6,percent of total billed charges,Implant Device,173.6,35,,173.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,367.04,
ARTHREX AR-8928BC-CP ACH SPEEDBRIDGE,C1713,HCPCS,,79002422,CDM,278,RC,,,both,,,7116,5265.86,,,5265.86,Other,150% of Medicare + 9.63% HCRA Surcharge,3202.2,45,,3202.2,percent of total billed charges,Critical Access Hospital RCC factor,2419.44,34,,2419.44,percent of total billed charges,Implant Device,2419.44,34,,2419.44,percent of total billed charges,Implant Device,2419.44,34,,2419.44,percent of total billed charges,Implant Device,2419.44,34,,2419.44,percent of total billed charges,Implant Device,2419.44,34,,2419.44,percent of total billed charges,Implant Device,3522.42,,,3522.42,Other,110% of Medicare,2490.6,35,,2490.6,percent of total billed charges,Implant Device,2419.44,34,"Charges > $500, x 34%",2419.44,percent of total billed charges,Implant Device,2490.6,35,,2490.6,percent of total billed charges,Implant Device,2490.6,35,,2490.6,percent of total billed charges,Implant Device,2490.6,35,,2490.6,percent of total billed charges,Implant Device,2490.6,35,,2490.6,percent of total billed charges,Implant Device,2490.6,35,,2490.6,percent of total billed charges,Implant Device,2846.4,40,,2846.4,percent of total billed charges,Implant Device,2490.6,70,,2490.6,percent of total billed charges,All Other,2419.44,34,,2419.44,percent of total billed charges,Implant Device,2419.44,34,,2419.44,percent of total billed charges,Implant Device,2490.6,35,,2490.6,percent of total billed charges,Implant Device,2490.6,35,,2490.6,percent of total billed charges,Implant Device,2490.6,35,,2490.6,percent of total billed charges,Implant Device,2490.6,35,,2490.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2419.44,34,"If Charge > 2,000, then 34 percent",2419.44,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5265.86,
ARTHREX AR-8933-10 SCREW,C1713,HCPCS,,79002423,CDM,278,RC,,,both,,,474,350.76,,,350.76,Other,150% of Medicare + 9.63% HCRA Surcharge,213.3,45,,213.3,percent of total billed charges,Critical Access Hospital RCC factor,161.16,34,,161.16,percent of total billed charges,Implant Device,161.16,34,,161.16,percent of total billed charges,Implant Device,161.16,34,,161.16,percent of total billed charges,Implant Device,161.16,34,,161.16,percent of total billed charges,Implant Device,161.16,34,,161.16,percent of total billed charges,Implant Device,234.63,,,234.63,Other,110% of Medicare,165.9,35,,165.9,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,165.9,35,,165.9,percent of total billed charges,Implant Device,165.9,35,,165.9,percent of total billed charges,Implant Device,165.9,35,,165.9,percent of total billed charges,Implant Device,165.9,35,,165.9,percent of total billed charges,Implant Device,165.9,35,,165.9,percent of total billed charges,Implant Device,189.6,40,,189.6,percent of total billed charges,Implant Device,165.9,70,,165.9,percent of total billed charges,All Other,161.16,34,,161.16,percent of total billed charges,Implant Device,161.16,34,,161.16,percent of total billed charges,Implant Device,165.9,35,,165.9,percent of total billed charges,Implant Device,165.9,35,,165.9,percent of total billed charges,Implant Device,165.9,35,,165.9,percent of total billed charges,Implant Device,165.9,35,,165.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,350.76,
ARTHREX AR-8933-12 SCREEW,C1713,HCPCS,,79002424,CDM,278,RC,,,both,,,474,350.76,,,350.76,Other,150% of Medicare + 9.63% HCRA Surcharge,213.3,45,,213.3,percent of total billed charges,Critical Access Hospital RCC factor,161.16,34,,161.16,percent of total billed charges,Implant Device,161.16,34,,161.16,percent of total billed charges,Implant Device,161.16,34,,161.16,percent of total billed charges,Implant Device,161.16,34,,161.16,percent of total billed charges,Implant Device,161.16,34,,161.16,percent of total billed charges,Implant Device,234.63,,,234.63,Other,110% of Medicare,165.9,35,,165.9,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,165.9,35,,165.9,percent of total billed charges,Implant Device,165.9,35,,165.9,percent of total billed charges,Implant Device,165.9,35,,165.9,percent of total billed charges,Implant Device,165.9,35,,165.9,percent of total billed charges,Implant Device,165.9,35,,165.9,percent of total billed charges,Implant Device,189.6,40,,189.6,percent of total billed charges,Implant Device,165.9,70,,165.9,percent of total billed charges,All Other,161.16,34,,161.16,percent of total billed charges,Implant Device,161.16,34,,161.16,percent of total billed charges,Implant Device,165.9,35,,165.9,percent of total billed charges,Implant Device,165.9,35,,165.9,percent of total billed charges,Implant Device,165.9,35,,165.9,percent of total billed charges,Implant Device,165.9,35,,165.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,350.76,
ARTHREX AR-8933-14 SCREW,C1713,HCPCS,,79002425,CDM,278,RC,,,both,,,330,244.2,,,244.2,Other,150% of Medicare + 9.63% HCRA Surcharge,148.5,45,,148.5,percent of total billed charges,Critical Access Hospital RCC factor,112.2,34,,112.2,percent of total billed charges,Implant Device,112.2,34,,112.2,percent of total billed charges,Implant Device,112.2,34,,112.2,percent of total billed charges,Implant Device,112.2,34,,112.2,percent of total billed charges,Implant Device,112.2,34,,112.2,percent of total billed charges,Implant Device,163.35,,,163.35,Other,110% of Medicare,115.5,35,,115.5,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,132,40,,132,percent of total billed charges,Implant Device,115.5,70,,115.5,percent of total billed charges,All Other,112.2,34,,112.2,percent of total billed charges,Implant Device,112.2,34,,112.2,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,244.2,
ARTHREX AR-8933-16 SCREW,C1713,HCPCS,,79002426,CDM,278,RC,,,both,,,474,350.76,,,350.76,Other,150% of Medicare + 9.63% HCRA Surcharge,213.3,45,,213.3,percent of total billed charges,Critical Access Hospital RCC factor,161.16,34,,161.16,percent of total billed charges,Implant Device,161.16,34,,161.16,percent of total billed charges,Implant Device,161.16,34,,161.16,percent of total billed charges,Implant Device,161.16,34,,161.16,percent of total billed charges,Implant Device,161.16,34,,161.16,percent of total billed charges,Implant Device,234.63,,,234.63,Other,110% of Medicare,165.9,35,,165.9,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,165.9,35,,165.9,percent of total billed charges,Implant Device,165.9,35,,165.9,percent of total billed charges,Implant Device,165.9,35,,165.9,percent of total billed charges,Implant Device,165.9,35,,165.9,percent of total billed charges,Implant Device,165.9,35,,165.9,percent of total billed charges,Implant Device,189.6,40,,189.6,percent of total billed charges,Implant Device,165.9,70,,165.9,percent of total billed charges,All Other,161.16,34,,161.16,percent of total billed charges,Implant Device,161.16,34,,161.16,percent of total billed charges,Implant Device,165.9,35,,165.9,percent of total billed charges,Implant Device,165.9,35,,165.9,percent of total billed charges,Implant Device,165.9,35,,165.9,percent of total billed charges,Implant Device,165.9,35,,165.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,350.76,
ARTHREX AR-8933-18 SCREW,C1713,HCPCS,,79002427,CDM,278,RC,,,both,,,330,244.2,,,244.2,Other,150% of Medicare + 9.63% HCRA Surcharge,148.5,45,,148.5,percent of total billed charges,Critical Access Hospital RCC factor,112.2,34,,112.2,percent of total billed charges,Implant Device,112.2,34,,112.2,percent of total billed charges,Implant Device,112.2,34,,112.2,percent of total billed charges,Implant Device,112.2,34,,112.2,percent of total billed charges,Implant Device,112.2,34,,112.2,percent of total billed charges,Implant Device,163.35,,,163.35,Other,110% of Medicare,115.5,35,,115.5,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,132,40,,132,percent of total billed charges,Implant Device,115.5,70,,115.5,percent of total billed charges,All Other,112.2,34,,112.2,percent of total billed charges,Implant Device,112.2,34,,112.2,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,244.2,
ARTHREX AR-8933-20 SCREW,C1713,HCPCS,,79002428,CDM,278,RC,,,both,,,359,265.66,,,265.66,Other,150% of Medicare + 9.63% HCRA Surcharge,161.55,45,,161.55,percent of total billed charges,Critical Access Hospital RCC factor,122.06,34,,122.06,percent of total billed charges,Implant Device,122.06,34,,122.06,percent of total billed charges,Implant Device,122.06,34,,122.06,percent of total billed charges,Implant Device,122.06,34,,122.06,percent of total billed charges,Implant Device,122.06,34,,122.06,percent of total billed charges,Implant Device,177.71,,,177.71,Other,110% of Medicare,125.65,35,,125.65,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,125.65,35,,125.65,percent of total billed charges,Implant Device,125.65,35,,125.65,percent of total billed charges,Implant Device,125.65,35,,125.65,percent of total billed charges,Implant Device,125.65,35,,125.65,percent of total billed charges,Implant Device,125.65,35,,125.65,percent of total billed charges,Implant Device,143.6,40,,143.6,percent of total billed charges,Implant Device,125.65,70,,125.65,percent of total billed charges,All Other,122.06,34,,122.06,percent of total billed charges,Implant Device,122.06,34,,122.06,percent of total billed charges,Implant Device,125.65,35,,125.65,percent of total billed charges,Implant Device,125.65,35,,125.65,percent of total billed charges,Implant Device,125.65,35,,125.65,percent of total billed charges,Implant Device,125.65,35,,125.65,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,265.66,
ARTHREX AR-8933-22PT SCREW,C1713,HCPCS,,79002429,CDM,278,RC,,,both,,,330,244.2,,,244.2,Other,150% of Medicare + 9.63% HCRA Surcharge,148.5,45,,148.5,percent of total billed charges,Critical Access Hospital RCC factor,112.2,34,,112.2,percent of total billed charges,Implant Device,112.2,34,,112.2,percent of total billed charges,Implant Device,112.2,34,,112.2,percent of total billed charges,Implant Device,112.2,34,,112.2,percent of total billed charges,Implant Device,112.2,34,,112.2,percent of total billed charges,Implant Device,163.35,,,163.35,Other,110% of Medicare,115.5,35,,115.5,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,132,40,,132,percent of total billed charges,Implant Device,115.5,70,,115.5,percent of total billed charges,All Other,112.2,34,,112.2,percent of total billed charges,Implant Device,112.2,34,,112.2,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,244.2,
ARTHREX AR-8933-26PT SCREW,C1713,HCPCS,,79002430,CDM,278,RC,,,both,,,316,233.84,,,233.84,Other,150% of Medicare + 9.63% HCRA Surcharge,142.2,45,,142.2,percent of total billed charges,Critical Access Hospital RCC factor,107.44,34,,107.44,percent of total billed charges,Implant Device,107.44,34,,107.44,percent of total billed charges,Implant Device,107.44,34,,107.44,percent of total billed charges,Implant Device,107.44,34,,107.44,percent of total billed charges,Implant Device,107.44,34,,107.44,percent of total billed charges,Implant Device,156.42,,,156.42,Other,110% of Medicare,110.6,35,,110.6,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,110.6,35,,110.6,percent of total billed charges,Implant Device,110.6,35,,110.6,percent of total billed charges,Implant Device,110.6,35,,110.6,percent of total billed charges,Implant Device,110.6,35,,110.6,percent of total billed charges,Implant Device,110.6,35,,110.6,percent of total billed charges,Implant Device,126.4,40,,126.4,percent of total billed charges,Implant Device,110.6,70,,110.6,percent of total billed charges,All Other,107.44,34,,107.44,percent of total billed charges,Implant Device,107.44,34,,107.44,percent of total billed charges,Implant Device,110.6,35,,110.6,percent of total billed charges,Implant Device,110.6,35,,110.6,percent of total billed charges,Implant Device,110.6,35,,110.6,percent of total billed charges,Implant Device,110.6,35,,110.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,233.84,
ARTHREX AR-8933-28PT SCREW,C1713,HCPCS,,79002431,CDM,278,RC,,,both,,,316,233.84,,,233.84,Other,150% of Medicare + 9.63% HCRA Surcharge,142.2,45,,142.2,percent of total billed charges,Critical Access Hospital RCC factor,107.44,34,,107.44,percent of total billed charges,Implant Device,107.44,34,,107.44,percent of total billed charges,Implant Device,107.44,34,,107.44,percent of total billed charges,Implant Device,107.44,34,,107.44,percent of total billed charges,Implant Device,107.44,34,,107.44,percent of total billed charges,Implant Device,156.42,,,156.42,Other,110% of Medicare,110.6,35,,110.6,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,110.6,35,,110.6,percent of total billed charges,Implant Device,110.6,35,,110.6,percent of total billed charges,Implant Device,110.6,35,,110.6,percent of total billed charges,Implant Device,110.6,35,,110.6,percent of total billed charges,Implant Device,110.6,35,,110.6,percent of total billed charges,Implant Device,126.4,40,,126.4,percent of total billed charges,Implant Device,110.6,70,,110.6,percent of total billed charges,All Other,107.44,34,,107.44,percent of total billed charges,Implant Device,107.44,34,,107.44,percent of total billed charges,Implant Device,110.6,35,,110.6,percent of total billed charges,Implant Device,110.6,35,,110.6,percent of total billed charges,Implant Device,110.6,35,,110.6,percent of total billed charges,Implant Device,110.6,35,,110.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,233.84,
ARTHREX AR-8933L-10 SCREW,C1713,HCPCS,,79002433,CDM,278,RC,,,both,,,474,350.76,,,350.76,Other,150% of Medicare + 9.63% HCRA Surcharge,213.3,45,,213.3,percent of total billed charges,Critical Access Hospital RCC factor,161.16,34,,161.16,percent of total billed charges,Implant Device,161.16,34,,161.16,percent of total billed charges,Implant Device,161.16,34,,161.16,percent of total billed charges,Implant Device,161.16,34,,161.16,percent of total billed charges,Implant Device,161.16,34,,161.16,percent of total billed charges,Implant Device,234.63,,,234.63,Other,110% of Medicare,165.9,35,,165.9,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,165.9,35,,165.9,percent of total billed charges,Implant Device,165.9,35,,165.9,percent of total billed charges,Implant Device,165.9,35,,165.9,percent of total billed charges,Implant Device,165.9,35,,165.9,percent of total billed charges,Implant Device,165.9,35,,165.9,percent of total billed charges,Implant Device,189.6,40,,189.6,percent of total billed charges,Implant Device,165.9,70,,165.9,percent of total billed charges,All Other,161.16,34,,161.16,percent of total billed charges,Implant Device,161.16,34,,161.16,percent of total billed charges,Implant Device,165.9,35,,165.9,percent of total billed charges,Implant Device,165.9,35,,165.9,percent of total billed charges,Implant Device,165.9,35,,165.9,percent of total billed charges,Implant Device,165.9,35,,165.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,350.76,
ARTHREX AR-8933L-12 SCREW,C1713,HCPCS,,79002434,CDM,278,RC,,,both,,,474,350.76,,,350.76,Other,150% of Medicare + 9.63% HCRA Surcharge,213.3,45,,213.3,percent of total billed charges,Critical Access Hospital RCC factor,161.16,34,,161.16,percent of total billed charges,Implant Device,161.16,34,,161.16,percent of total billed charges,Implant Device,161.16,34,,161.16,percent of total billed charges,Implant Device,161.16,34,,161.16,percent of total billed charges,Implant Device,161.16,34,,161.16,percent of total billed charges,Implant Device,234.63,,,234.63,Other,110% of Medicare,165.9,35,,165.9,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,165.9,35,,165.9,percent of total billed charges,Implant Device,165.9,35,,165.9,percent of total billed charges,Implant Device,165.9,35,,165.9,percent of total billed charges,Implant Device,165.9,35,,165.9,percent of total billed charges,Implant Device,165.9,35,,165.9,percent of total billed charges,Implant Device,189.6,40,,189.6,percent of total billed charges,Implant Device,165.9,70,,165.9,percent of total billed charges,All Other,161.16,34,,161.16,percent of total billed charges,Implant Device,161.16,34,,161.16,percent of total billed charges,Implant Device,165.9,35,,165.9,percent of total billed charges,Implant Device,165.9,35,,165.9,percent of total billed charges,Implant Device,165.9,35,,165.9,percent of total billed charges,Implant Device,165.9,35,,165.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,350.76,
ARTHREX AR-8933L-14 SCREW,C1713,HCPCS,,79002435,CDM,278,RC,,,both,,,330,244.2,,,244.2,Other,150% of Medicare + 9.63% HCRA Surcharge,148.5,45,,148.5,percent of total billed charges,Critical Access Hospital RCC factor,112.2,34,,112.2,percent of total billed charges,Implant Device,112.2,34,,112.2,percent of total billed charges,Implant Device,112.2,34,,112.2,percent of total billed charges,Implant Device,112.2,34,,112.2,percent of total billed charges,Implant Device,112.2,34,,112.2,percent of total billed charges,Implant Device,163.35,,,163.35,Other,110% of Medicare,115.5,35,,115.5,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,132,40,,132,percent of total billed charges,Implant Device,115.5,70,,115.5,percent of total billed charges,All Other,112.2,34,,112.2,percent of total billed charges,Implant Device,112.2,34,,112.2,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,244.2,
ARTHREX AR-8933L-16 SCREW,C1713,HCPCS,,79002436,CDM,278,RC,,,both,,,474,350.76,,,350.76,Other,150% of Medicare + 9.63% HCRA Surcharge,213.3,45,,213.3,percent of total billed charges,Critical Access Hospital RCC factor,161.16,34,,161.16,percent of total billed charges,Implant Device,161.16,34,,161.16,percent of total billed charges,Implant Device,161.16,34,,161.16,percent of total billed charges,Implant Device,161.16,34,,161.16,percent of total billed charges,Implant Device,161.16,34,,161.16,percent of total billed charges,Implant Device,234.63,,,234.63,Other,110% of Medicare,165.9,35,,165.9,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,165.9,35,,165.9,percent of total billed charges,Implant Device,165.9,35,,165.9,percent of total billed charges,Implant Device,165.9,35,,165.9,percent of total billed charges,Implant Device,165.9,35,,165.9,percent of total billed charges,Implant Device,165.9,35,,165.9,percent of total billed charges,Implant Device,189.6,40,,189.6,percent of total billed charges,Implant Device,165.9,70,,165.9,percent of total billed charges,All Other,161.16,34,,161.16,percent of total billed charges,Implant Device,161.16,34,,161.16,percent of total billed charges,Implant Device,165.9,35,,165.9,percent of total billed charges,Implant Device,165.9,35,,165.9,percent of total billed charges,Implant Device,165.9,35,,165.9,percent of total billed charges,Implant Device,165.9,35,,165.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,350.76,
ARTHREX AR-8933L-18 SCREW,C1713,HCPCS,,79002437,CDM,278,RC,,,both,,,474,350.76,,,350.76,Other,150% of Medicare + 9.63% HCRA Surcharge,213.3,45,,213.3,percent of total billed charges,Critical Access Hospital RCC factor,161.16,34,,161.16,percent of total billed charges,Implant Device,161.16,34,,161.16,percent of total billed charges,Implant Device,161.16,34,,161.16,percent of total billed charges,Implant Device,161.16,34,,161.16,percent of total billed charges,Implant Device,161.16,34,,161.16,percent of total billed charges,Implant Device,234.63,,,234.63,Other,110% of Medicare,165.9,35,,165.9,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,165.9,35,,165.9,percent of total billed charges,Implant Device,165.9,35,,165.9,percent of total billed charges,Implant Device,165.9,35,,165.9,percent of total billed charges,Implant Device,165.9,35,,165.9,percent of total billed charges,Implant Device,165.9,35,,165.9,percent of total billed charges,Implant Device,189.6,40,,189.6,percent of total billed charges,Implant Device,165.9,70,,165.9,percent of total billed charges,All Other,161.16,34,,161.16,percent of total billed charges,Implant Device,161.16,34,,161.16,percent of total billed charges,Implant Device,165.9,35,,165.9,percent of total billed charges,Implant Device,165.9,35,,165.9,percent of total billed charges,Implant Device,165.9,35,,165.9,percent of total billed charges,Implant Device,165.9,35,,165.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,350.76,
ARTHREX AR-8935L-20 SCREW,C1713,HCPCS,,79002440,CDM,278,RC,,,both,,,645,477.3,,,477.3,Other,150% of Medicare + 9.63% HCRA Surcharge,290.25,45,,290.25,percent of total billed charges,Critical Access Hospital RCC factor,219.3,34,,219.3,percent of total billed charges,Implant Device,219.3,34,,219.3,percent of total billed charges,Implant Device,219.3,34,,219.3,percent of total billed charges,Implant Device,219.3,34,,219.3,percent of total billed charges,Implant Device,219.3,34,,219.3,percent of total billed charges,Implant Device,319.28,,,319.28,Other,110% of Medicare,225.75,35,,225.75,percent of total billed charges,Implant Device,219.3,34,"Charges > $500, x 34%",219.3,percent of total billed charges,Implant Device,225.75,35,,225.75,percent of total billed charges,Implant Device,225.75,35,,225.75,percent of total billed charges,Implant Device,225.75,35,,225.75,percent of total billed charges,Implant Device,225.75,35,,225.75,percent of total billed charges,Implant Device,225.75,35,,225.75,percent of total billed charges,Implant Device,258,40,,258,percent of total billed charges,Implant Device,225.75,70,,225.75,percent of total billed charges,All Other,219.3,34,,219.3,percent of total billed charges,Implant Device,219.3,34,,219.3,percent of total billed charges,Implant Device,225.75,35,,225.75,percent of total billed charges,Implant Device,225.75,35,,225.75,percent of total billed charges,Implant Device,225.75,35,,225.75,percent of total billed charges,Implant Device,225.75,35,,225.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,477.3,
ARTHREX AR-8935L-24 SCREW,C1713,HCPCS,,79002441,CDM,278,RC,,,both,,,256,189.44,,,189.44,Other,150% of Medicare + 9.63% HCRA Surcharge,115.2,45,,115.2,percent of total billed charges,Critical Access Hospital RCC factor,87.04,34,,87.04,percent of total billed charges,Implant Device,87.04,34,,87.04,percent of total billed charges,Implant Device,87.04,34,,87.04,percent of total billed charges,Implant Device,87.04,34,,87.04,percent of total billed charges,Implant Device,87.04,34,,87.04,percent of total billed charges,Implant Device,126.72,,,126.72,Other,110% of Medicare,89.6,35,,89.6,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,89.6,35,,89.6,percent of total billed charges,Implant Device,89.6,35,,89.6,percent of total billed charges,Implant Device,89.6,35,,89.6,percent of total billed charges,Implant Device,89.6,35,,89.6,percent of total billed charges,Implant Device,89.6,35,,89.6,percent of total billed charges,Implant Device,102.4,40,,102.4,percent of total billed charges,Implant Device,89.6,70,,89.6,percent of total billed charges,All Other,87.04,34,,87.04,percent of total billed charges,Implant Device,87.04,34,,87.04,percent of total billed charges,Implant Device,89.6,35,,89.6,percent of total billed charges,Implant Device,89.6,35,,89.6,percent of total billed charges,Implant Device,89.6,35,,89.6,percent of total billed charges,Implant Device,89.6,35,,89.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,189.44,
ARTHREX AR-8941 PLATE,C1713,HCPCS,,79002442,CDM,278,RC,,,both,,,2574,1904.77,,,1904.77,Other,150% of Medicare + 9.63% HCRA Surcharge,1158.3,45,,1158.3,percent of total billed charges,Critical Access Hospital RCC factor,875.16,34,,875.16,percent of total billed charges,Implant Device,875.16,34,,875.16,percent of total billed charges,Implant Device,875.16,34,,875.16,percent of total billed charges,Implant Device,875.16,34,,875.16,percent of total billed charges,Implant Device,875.16,34,,875.16,percent of total billed charges,Implant Device,1274.13,,,1274.13,Other,110% of Medicare,900.9,35,,900.9,percent of total billed charges,Implant Device,875.16,34,"Charges > $500, x 34%",875.16,percent of total billed charges,Implant Device,900.9,35,,900.9,percent of total billed charges,Implant Device,900.9,35,,900.9,percent of total billed charges,Implant Device,900.9,35,,900.9,percent of total billed charges,Implant Device,900.9,35,,900.9,percent of total billed charges,Implant Device,900.9,35,,900.9,percent of total billed charges,Implant Device,1029.6,40,,1029.6,percent of total billed charges,Implant Device,900.9,70,,900.9,percent of total billed charges,All Other,875.16,34,,875.16,percent of total billed charges,Implant Device,875.16,34,,875.16,percent of total billed charges,Implant Device,900.9,35,,900.9,percent of total billed charges,Implant Device,900.9,35,,900.9,percent of total billed charges,Implant Device,900.9,35,,900.9,percent of total billed charges,Implant Device,900.9,35,,900.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,875.16,34,"If Charge > 2,000, then 34 percent",875.16,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1904.77,
ARTHREX AR-8942L-M PLATE,C1713,HCPCS,,79002444,CDM,278,RC,,,both,,,2574,1904.77,,,1904.77,Other,150% of Medicare + 9.63% HCRA Surcharge,1158.3,45,,1158.3,percent of total billed charges,Critical Access Hospital RCC factor,875.16,34,,875.16,percent of total billed charges,Implant Device,875.16,34,,875.16,percent of total billed charges,Implant Device,875.16,34,,875.16,percent of total billed charges,Implant Device,875.16,34,,875.16,percent of total billed charges,Implant Device,875.16,34,,875.16,percent of total billed charges,Implant Device,1274.13,,,1274.13,Other,110% of Medicare,900.9,35,,900.9,percent of total billed charges,Implant Device,875.16,34,"Charges > $500, x 34%",875.16,percent of total billed charges,Implant Device,900.9,35,,900.9,percent of total billed charges,Implant Device,900.9,35,,900.9,percent of total billed charges,Implant Device,900.9,35,,900.9,percent of total billed charges,Implant Device,900.9,35,,900.9,percent of total billed charges,Implant Device,900.9,35,,900.9,percent of total billed charges,Implant Device,1029.6,40,,1029.6,percent of total billed charges,Implant Device,900.9,70,,900.9,percent of total billed charges,All Other,875.16,34,,875.16,percent of total billed charges,Implant Device,875.16,34,,875.16,percent of total billed charges,Implant Device,900.9,35,,900.9,percent of total billed charges,Implant Device,900.9,35,,900.9,percent of total billed charges,Implant Device,900.9,35,,900.9,percent of total billed charges,Implant Device,900.9,35,,900.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,875.16,34,"If Charge > 2,000, then 34 percent",875.16,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1904.77,
ARTHREX AR-8944CL-P PLATE,C1713,HCPCS,,79002447,CDM,278,RC,,,both,,,2400,1776.01,,,1776.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1080,45,,1080,percent of total billed charges,Critical Access Hospital RCC factor,816,34,,816,percent of total billed charges,Implant Device,816,34,,816,percent of total billed charges,Implant Device,816,34,,816,percent of total billed charges,Implant Device,816,34,,816,percent of total billed charges,Implant Device,816,34,,816,percent of total billed charges,Implant Device,1188,,,1188,Other,110% of Medicare,840,35,,840,percent of total billed charges,Implant Device,816,34,"Charges > $500, x 34%",816,percent of total billed charges,Implant Device,840,35,,840,percent of total billed charges,Implant Device,840,35,,840,percent of total billed charges,Implant Device,840,35,,840,percent of total billed charges,Implant Device,840,35,,840,percent of total billed charges,Implant Device,840,35,,840,percent of total billed charges,Implant Device,960,40,,960,percent of total billed charges,Implant Device,840,70,,840,percent of total billed charges,All Other,816,34,,816,percent of total billed charges,Implant Device,816,34,,816,percent of total billed charges,Implant Device,840,35,,840,percent of total billed charges,Implant Device,840,35,,840,percent of total billed charges,Implant Device,840,35,,840,percent of total billed charges,Implant Device,840,35,,840,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,816,34,"If Charge > 2,000, then 34 percent",816,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1776.01,
ARTHREX AR-8944CR-5 PLATE,C1713,HCPCS,,79002448,CDM,278,RC,,,both,,,2400,1776.01,,,1776.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1080,45,,1080,percent of total billed charges,Critical Access Hospital RCC factor,816,34,,816,percent of total billed charges,Implant Device,816,34,,816,percent of total billed charges,Implant Device,816,34,,816,percent of total billed charges,Implant Device,816,34,,816,percent of total billed charges,Implant Device,816,34,,816,percent of total billed charges,Implant Device,1188,,,1188,Other,110% of Medicare,840,35,,840,percent of total billed charges,Implant Device,816,34,"Charges > $500, x 34%",816,percent of total billed charges,Implant Device,840,35,,840,percent of total billed charges,Implant Device,840,35,,840,percent of total billed charges,Implant Device,840,35,,840,percent of total billed charges,Implant Device,840,35,,840,percent of total billed charges,Implant Device,840,35,,840,percent of total billed charges,Implant Device,960,40,,960,percent of total billed charges,Implant Device,840,70,,840,percent of total billed charges,All Other,816,34,,816,percent of total billed charges,Implant Device,816,34,,816,percent of total billed charges,Implant Device,840,35,,840,percent of total billed charges,Implant Device,840,35,,840,percent of total billed charges,Implant Device,840,35,,840,percent of total billed charges,Implant Device,840,35,,840,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,816,34,"If Charge > 2,000, then 34 percent",816,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1776.01,
ARTHREX AR-8944CR-L PLATE,C1713,HCPCS,,79002449,CDM,278,RC,,,both,,,2400,1776.01,,,1776.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1080,45,,1080,percent of total billed charges,Critical Access Hospital RCC factor,816,34,,816,percent of total billed charges,Implant Device,816,34,,816,percent of total billed charges,Implant Device,816,34,,816,percent of total billed charges,Implant Device,816,34,,816,percent of total billed charges,Implant Device,816,34,,816,percent of total billed charges,Implant Device,1188,,,1188,Other,110% of Medicare,840,35,,840,percent of total billed charges,Implant Device,816,34,"Charges > $500, x 34%",816,percent of total billed charges,Implant Device,840,35,,840,percent of total billed charges,Implant Device,840,35,,840,percent of total billed charges,Implant Device,840,35,,840,percent of total billed charges,Implant Device,840,35,,840,percent of total billed charges,Implant Device,840,35,,840,percent of total billed charges,Implant Device,960,40,,960,percent of total billed charges,Implant Device,840,70,,840,percent of total billed charges,All Other,816,34,,816,percent of total billed charges,Implant Device,816,34,,816,percent of total billed charges,Implant Device,840,35,,840,percent of total billed charges,Implant Device,840,35,,840,percent of total billed charges,Implant Device,840,35,,840,percent of total billed charges,Implant Device,840,35,,840,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,816,34,"If Charge > 2,000, then 34 percent",816,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1776.01,
ARTHREX AR-8944CR-P PLATE,C1713,HCPCS,,79002450,CDM,278,RC,,,both,,,3430,2538.21,,,2538.21,Other,150% of Medicare + 9.63% HCRA Surcharge,1543.5,45,,1543.5,percent of total billed charges,Critical Access Hospital RCC factor,1166.2,34,,1166.2,percent of total billed charges,Implant Device,1166.2,34,,1166.2,percent of total billed charges,Implant Device,1166.2,34,,1166.2,percent of total billed charges,Implant Device,1166.2,34,,1166.2,percent of total billed charges,Implant Device,1166.2,34,,1166.2,percent of total billed charges,Implant Device,1697.85,,,1697.85,Other,110% of Medicare,1200.5,35,,1200.5,percent of total billed charges,Implant Device,1166.2,34,"Charges > $500, x 34%",1166.2,percent of total billed charges,Implant Device,1200.5,35,,1200.5,percent of total billed charges,Implant Device,1200.5,35,,1200.5,percent of total billed charges,Implant Device,1200.5,35,,1200.5,percent of total billed charges,Implant Device,1200.5,35,,1200.5,percent of total billed charges,Implant Device,1200.5,35,,1200.5,percent of total billed charges,Implant Device,1372,40,,1372,percent of total billed charges,Implant Device,1200.5,70,,1200.5,percent of total billed charges,All Other,1166.2,34,,1166.2,percent of total billed charges,Implant Device,1166.2,34,,1166.2,percent of total billed charges,Implant Device,1200.5,35,,1200.5,percent of total billed charges,Implant Device,1200.5,35,,1200.5,percent of total billed charges,Implant Device,1200.5,35,,1200.5,percent of total billed charges,Implant Device,1200.5,35,,1200.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1166.2,34,"If Charge > 2,000, then 34 percent",1166.2,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2538.21,
ARTHREX AR-8944CR-S PLATE,C1713,HCPCS,,79002451,CDM,278,RC,,,both,,,2400,1776.01,,,1776.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1080,45,,1080,percent of total billed charges,Critical Access Hospital RCC factor,816,34,,816,percent of total billed charges,Implant Device,816,34,,816,percent of total billed charges,Implant Device,816,34,,816,percent of total billed charges,Implant Device,816,34,,816,percent of total billed charges,Implant Device,816,34,,816,percent of total billed charges,Implant Device,1188,,,1188,Other,110% of Medicare,840,35,,840,percent of total billed charges,Implant Device,816,34,"Charges > $500, x 34%",816,percent of total billed charges,Implant Device,840,35,,840,percent of total billed charges,Implant Device,840,35,,840,percent of total billed charges,Implant Device,840,35,,840,percent of total billed charges,Implant Device,840,35,,840,percent of total billed charges,Implant Device,840,35,,840,percent of total billed charges,Implant Device,960,40,,960,percent of total billed charges,Implant Device,840,70,,840,percent of total billed charges,All Other,816,34,,816,percent of total billed charges,Implant Device,816,34,,816,percent of total billed charges,Implant Device,840,35,,840,percent of total billed charges,Implant Device,840,35,,840,percent of total billed charges,Implant Device,840,35,,840,percent of total billed charges,Implant Device,840,35,,840,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,816,34,"If Charge > 2,000, then 34 percent",816,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1776.01,
ARTHREX AR-8945-40FT SCREW,C1713,HCPCS,,79002461,CDM,278,RC,,,both,,,646,478.04,,,478.04,Other,150% of Medicare + 9.63% HCRA Surcharge,290.7,45,,290.7,percent of total billed charges,Critical Access Hospital RCC factor,219.64,34,,219.64,percent of total billed charges,Implant Device,219.64,34,,219.64,percent of total billed charges,Implant Device,219.64,34,,219.64,percent of total billed charges,Implant Device,219.64,34,,219.64,percent of total billed charges,Implant Device,219.64,34,,219.64,percent of total billed charges,Implant Device,319.77,,,319.77,Other,110% of Medicare,226.1,35,,226.1,percent of total billed charges,Implant Device,219.64,34,"Charges > $500, x 34%",219.64,percent of total billed charges,Implant Device,226.1,35,,226.1,percent of total billed charges,Implant Device,226.1,35,,226.1,percent of total billed charges,Implant Device,226.1,35,,226.1,percent of total billed charges,Implant Device,226.1,35,,226.1,percent of total billed charges,Implant Device,226.1,35,,226.1,percent of total billed charges,Implant Device,258.4,40,,258.4,percent of total billed charges,Implant Device,226.1,70,,226.1,percent of total billed charges,All Other,219.64,34,,219.64,percent of total billed charges,Implant Device,219.64,34,,219.64,percent of total billed charges,Implant Device,226.1,35,,226.1,percent of total billed charges,Implant Device,226.1,35,,226.1,percent of total billed charges,Implant Device,226.1,35,,226.1,percent of total billed charges,Implant Device,226.1,35,,226.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,478.04,
ARTHREX AR-8945-50FT SCREW,C1713,HCPCS,,79002462,CDM,278,RC,,,both,,,646,478.04,,,478.04,Other,150% of Medicare + 9.63% HCRA Surcharge,290.7,45,,290.7,percent of total billed charges,Critical Access Hospital RCC factor,219.64,34,,219.64,percent of total billed charges,Implant Device,219.64,34,,219.64,percent of total billed charges,Implant Device,219.64,34,,219.64,percent of total billed charges,Implant Device,219.64,34,,219.64,percent of total billed charges,Implant Device,219.64,34,,219.64,percent of total billed charges,Implant Device,319.77,,,319.77,Other,110% of Medicare,226.1,35,,226.1,percent of total billed charges,Implant Device,219.64,34,"Charges > $500, x 34%",219.64,percent of total billed charges,Implant Device,226.1,35,,226.1,percent of total billed charges,Implant Device,226.1,35,,226.1,percent of total billed charges,Implant Device,226.1,35,,226.1,percent of total billed charges,Implant Device,226.1,35,,226.1,percent of total billed charges,Implant Device,226.1,35,,226.1,percent of total billed charges,Implant Device,258.4,40,,258.4,percent of total billed charges,Implant Device,226.1,70,,226.1,percent of total billed charges,All Other,219.64,34,,219.64,percent of total billed charges,Implant Device,219.64,34,,219.64,percent of total billed charges,Implant Device,226.1,35,,226.1,percent of total billed charges,Implant Device,226.1,35,,226.1,percent of total billed charges,Implant Device,226.1,35,,226.1,percent of total billed charges,Implant Device,226.1,35,,226.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,478.04,
ARTHREX AR-8967-2885 SCREW,C1713,HCPCS,,79002464,CDM,278,RC,,,both,,,750,555,,,555,Other,150% of Medicare + 9.63% HCRA Surcharge,337.5,45,,337.5,percent of total billed charges,Critical Access Hospital RCC factor,255,34,,255,percent of total billed charges,Implant Device,255,34,,255,percent of total billed charges,Implant Device,255,34,,255,percent of total billed charges,Implant Device,255,34,,255,percent of total billed charges,Implant Device,255,34,,255,percent of total billed charges,Implant Device,371.25,,,371.25,Other,110% of Medicare,262.5,35,,262.5,percent of total billed charges,Implant Device,255,34,"Charges > $500, x 34%",255,percent of total billed charges,Implant Device,262.5,35,,262.5,percent of total billed charges,Implant Device,262.5,35,,262.5,percent of total billed charges,Implant Device,262.5,35,,262.5,percent of total billed charges,Implant Device,262.5,35,,262.5,percent of total billed charges,Implant Device,262.5,35,,262.5,percent of total billed charges,Implant Device,300,40,,300,percent of total billed charges,Implant Device,262.5,70,,262.5,percent of total billed charges,All Other,255,34,,255,percent of total billed charges,Implant Device,255,34,,255,percent of total billed charges,Implant Device,262.5,35,,262.5,percent of total billed charges,Implant Device,262.5,35,,262.5,percent of total billed charges,Implant Device,262.5,35,,262.5,percent of total billed charges,Implant Device,262.5,35,,262.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,555,
ACUMED AT2-M22 SCREW,C1713,HCPCS,,79002467,CDM,278,RC,,,both,,,1570,1161.8,,,1161.8,Other,150% of Medicare + 9.63% HCRA Surcharge,706.5,45,,706.5,percent of total billed charges,Critical Access Hospital RCC factor,533.8,34,,533.8,percent of total billed charges,Implant Device,533.8,34,,533.8,percent of total billed charges,Implant Device,533.8,34,,533.8,percent of total billed charges,Implant Device,533.8,34,,533.8,percent of total billed charges,Implant Device,533.8,34,,533.8,percent of total billed charges,Implant Device,777.15,,,777.15,Other,110% of Medicare,549.5,35,,549.5,percent of total billed charges,Implant Device,533.8,34,"Charges > $500, x 34%",533.8,percent of total billed charges,Implant Device,549.5,35,,549.5,percent of total billed charges,Implant Device,549.5,35,,549.5,percent of total billed charges,Implant Device,549.5,35,,549.5,percent of total billed charges,Implant Device,549.5,35,,549.5,percent of total billed charges,Implant Device,549.5,35,,549.5,percent of total billed charges,Implant Device,628,40,,628,percent of total billed charges,Implant Device,549.5,70,,549.5,percent of total billed charges,All Other,533.8,34,,533.8,percent of total billed charges,Implant Device,533.8,34,,533.8,percent of total billed charges,Implant Device,549.5,35,,549.5,percent of total billed charges,Implant Device,549.5,35,,549.5,percent of total billed charges,Implant Device,549.5,35,,549.5,percent of total billed charges,Implant Device,549.5,35,,549.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1161.8,
ACUMED AT2-M24 SCREW,C1713,HCPCS,,79002468,CDM,278,RC,,,both,,,1570,1161.8,,,1161.8,Other,150% of Medicare + 9.63% HCRA Surcharge,706.5,45,,706.5,percent of total billed charges,Critical Access Hospital RCC factor,533.8,34,,533.8,percent of total billed charges,Implant Device,533.8,34,,533.8,percent of total billed charges,Implant Device,533.8,34,,533.8,percent of total billed charges,Implant Device,533.8,34,,533.8,percent of total billed charges,Implant Device,533.8,34,,533.8,percent of total billed charges,Implant Device,777.15,,,777.15,Other,110% of Medicare,549.5,35,,549.5,percent of total billed charges,Implant Device,533.8,34,"Charges > $500, x 34%",533.8,percent of total billed charges,Implant Device,549.5,35,,549.5,percent of total billed charges,Implant Device,549.5,35,,549.5,percent of total billed charges,Implant Device,549.5,35,,549.5,percent of total billed charges,Implant Device,549.5,35,,549.5,percent of total billed charges,Implant Device,549.5,35,,549.5,percent of total billed charges,Implant Device,628,40,,628,percent of total billed charges,Implant Device,549.5,70,,549.5,percent of total billed charges,All Other,533.8,34,,533.8,percent of total billed charges,Implant Device,533.8,34,,533.8,percent of total billed charges,Implant Device,549.5,35,,549.5,percent of total billed charges,Implant Device,549.5,35,,549.5,percent of total billed charges,Implant Device,549.5,35,,549.5,percent of total billed charges,Implant Device,549.5,35,,549.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1161.8,
ACUMED AT2-M26 SCREW,C1713,HCPCS,,79002469,CDM,278,RC,,,both,,,1584,1172.16,,,1172.16,Other,150% of Medicare + 9.63% HCRA Surcharge,712.8,45,,712.8,percent of total billed charges,Critical Access Hospital RCC factor,538.56,34,,538.56,percent of total billed charges,Implant Device,538.56,34,,538.56,percent of total billed charges,Implant Device,538.56,34,,538.56,percent of total billed charges,Implant Device,538.56,34,,538.56,percent of total billed charges,Implant Device,538.56,34,,538.56,percent of total billed charges,Implant Device,784.08,,,784.08,Other,110% of Medicare,554.4,35,,554.4,percent of total billed charges,Implant Device,538.56,34,"Charges > $500, x 34%",538.56,percent of total billed charges,Implant Device,554.4,35,,554.4,percent of total billed charges,Implant Device,554.4,35,,554.4,percent of total billed charges,Implant Device,554.4,35,,554.4,percent of total billed charges,Implant Device,554.4,35,,554.4,percent of total billed charges,Implant Device,554.4,35,,554.4,percent of total billed charges,Implant Device,633.6,40,,633.6,percent of total billed charges,Implant Device,554.4,70,,554.4,percent of total billed charges,All Other,538.56,34,,538.56,percent of total billed charges,Implant Device,538.56,34,,538.56,percent of total billed charges,Implant Device,554.4,35,,554.4,percent of total billed charges,Implant Device,554.4,35,,554.4,percent of total billed charges,Implant Device,554.4,35,,554.4,percent of total billed charges,Implant Device,554.4,35,,554.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1172.16,
ACUMED AT2-S22 SCREW,C1713,HCPCS,,79002471,CDM,278,RC,,,both,,,1570,1161.8,,,1161.8,Other,150% of Medicare + 9.63% HCRA Surcharge,706.5,45,,706.5,percent of total billed charges,Critical Access Hospital RCC factor,533.8,34,,533.8,percent of total billed charges,Implant Device,533.8,34,,533.8,percent of total billed charges,Implant Device,533.8,34,,533.8,percent of total billed charges,Implant Device,533.8,34,,533.8,percent of total billed charges,Implant Device,533.8,34,,533.8,percent of total billed charges,Implant Device,777.15,,,777.15,Other,110% of Medicare,549.5,35,,549.5,percent of total billed charges,Implant Device,533.8,34,"Charges > $500, x 34%",533.8,percent of total billed charges,Implant Device,549.5,35,,549.5,percent of total billed charges,Implant Device,549.5,35,,549.5,percent of total billed charges,Implant Device,549.5,35,,549.5,percent of total billed charges,Implant Device,549.5,35,,549.5,percent of total billed charges,Implant Device,549.5,35,,549.5,percent of total billed charges,Implant Device,628,40,,628,percent of total billed charges,Implant Device,549.5,70,,549.5,percent of total billed charges,All Other,533.8,34,,533.8,percent of total billed charges,Implant Device,533.8,34,,533.8,percent of total billed charges,Implant Device,549.5,35,,549.5,percent of total billed charges,Implant Device,549.5,35,,549.5,percent of total billed charges,Implant Device,549.5,35,,549.5,percent of total billed charges,Implant Device,549.5,35,,549.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1161.8,
CALDERA MEDICAL CAL-DSO1A SLING SYSTEM,C1781,HCPCS,,79002472,CDM,278,RC,,,both,,,2686,1987.65,,,1987.65,Other,150% of Medicare + 9.63% HCRA Surcharge,1208.7,45,,1208.7,percent of total billed charges,Critical Access Hospital RCC factor,913.24,34,,913.24,percent of total billed charges,Implant Device,913.24,34,,913.24,percent of total billed charges,Implant Device,913.24,34,,913.24,percent of total billed charges,Implant Device,913.24,34,,913.24,percent of total billed charges,Implant Device,913.24,34,,913.24,percent of total billed charges,Implant Device,1329.57,,,1329.57,Other,110% of Medicare,940.1,35,,940.1,percent of total billed charges,Implant Device,913.24,34,"Charges > $500, x 34%",913.24,percent of total billed charges,Implant Device,940.1,35,,940.1,percent of total billed charges,Implant Device,940.1,35,,940.1,percent of total billed charges,Implant Device,940.1,35,,940.1,percent of total billed charges,Implant Device,940.1,35,,940.1,percent of total billed charges,Implant Device,940.1,35,,940.1,percent of total billed charges,Implant Device,1074.4,40,,1074.4,percent of total billed charges,Implant Device,940.1,70,,940.1,percent of total billed charges,All Other,913.24,34,,913.24,percent of total billed charges,Implant Device,913.24,34,,913.24,percent of total billed charges,Implant Device,940.1,35,,940.1,percent of total billed charges,Implant Device,940.1,35,,940.1,percent of total billed charges,Implant Device,940.1,35,,940.1,percent of total billed charges,Implant Device,940.1,35,,940.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,913.24,34,"If Charge > 2,000, then 34 percent",913.24,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1987.65,
CAYENNE CM-3009C TIBIAL PEEK IMPLANT,C1776,HCPCS,,79002474,CDM,278,RC,,,both,,,1426,1055.24,,,1055.24,Other,150% of Medicare + 9.63% HCRA Surcharge,641.7,45,,641.7,percent of total billed charges,Critical Access Hospital RCC factor,484.84,34,,484.84,percent of total billed charges,Implant Device,484.84,34,,484.84,percent of total billed charges,Implant Device,484.84,34,,484.84,percent of total billed charges,Implant Device,484.84,34,,484.84,percent of total billed charges,Implant Device,484.84,34,,484.84,percent of total billed charges,Implant Device,705.87,,,705.87,Other,110% of Medicare,499.1,35,,499.1,percent of total billed charges,Implant Device,484.84,34,"Charges > $500, x 34%",484.84,percent of total billed charges,Implant Device,499.1,35,,499.1,percent of total billed charges,Implant Device,499.1,35,,499.1,percent of total billed charges,Implant Device,499.1,35,,499.1,percent of total billed charges,Implant Device,499.1,35,,499.1,percent of total billed charges,Implant Device,499.1,35,,499.1,percent of total billed charges,Implant Device,570.4,40,,570.4,percent of total billed charges,Implant Device,499.1,70,,499.1,percent of total billed charges,All Other,484.84,34,,484.84,percent of total billed charges,Implant Device,484.84,34,,484.84,percent of total billed charges,Implant Device,499.1,35,,499.1,percent of total billed charges,Implant Device,499.1,35,,499.1,percent of total billed charges,Implant Device,499.1,35,,499.1,percent of total billed charges,Implant Device,499.1,35,,499.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1055.24,
CAYENNE CM-3010C TIBIAL PEEK IMPLANT,C1776,HCPCS,,79002475,CDM,278,RC,,,both,,,1426,1055.24,,,1055.24,Other,150% of Medicare + 9.63% HCRA Surcharge,641.7,45,,641.7,percent of total billed charges,Critical Access Hospital RCC factor,484.84,34,,484.84,percent of total billed charges,Implant Device,484.84,34,,484.84,percent of total billed charges,Implant Device,484.84,34,,484.84,percent of total billed charges,Implant Device,484.84,34,,484.84,percent of total billed charges,Implant Device,484.84,34,,484.84,percent of total billed charges,Implant Device,705.87,,,705.87,Other,110% of Medicare,499.1,35,,499.1,percent of total billed charges,Implant Device,484.84,34,"Charges > $500, x 34%",484.84,percent of total billed charges,Implant Device,499.1,35,,499.1,percent of total billed charges,Implant Device,499.1,35,,499.1,percent of total billed charges,Implant Device,499.1,35,,499.1,percent of total billed charges,Implant Device,499.1,35,,499.1,percent of total billed charges,Implant Device,499.1,35,,499.1,percent of total billed charges,Implant Device,570.4,40,,570.4,percent of total billed charges,Implant Device,499.1,70,,499.1,percent of total billed charges,All Other,484.84,34,,484.84,percent of total billed charges,Implant Device,484.84,34,,484.84,percent of total billed charges,Implant Device,499.1,35,,499.1,percent of total billed charges,Implant Device,499.1,35,,499.1,percent of total billed charges,Implant Device,499.1,35,,499.1,percent of total billed charges,Implant Device,499.1,35,,499.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1055.24,
STRYKER CNW12025 NEUROMEND,C9361,HCPCS,,79002476,CDM,278,RC,,,both,,,4570,3381.81,,,3381.81,Other,150% of Medicare + 9.63% HCRA Surcharge,2056.5,45,,2056.5,percent of total billed charges,Critical Access Hospital RCC factor,1553.8,34,,1553.8,percent of total billed charges,Implant Device,1553.8,34,,1553.8,percent of total billed charges,Implant Device,1553.8,34,,1553.8,percent of total billed charges,Implant Device,1553.8,34,,1553.8,percent of total billed charges,Implant Device,1553.8,34,,1553.8,percent of total billed charges,Implant Device,2262.15,,,2262.15,Other,110% of Medicare,1599.5,35,,1599.5,percent of total billed charges,Implant Device,1553.8,34,"Charges > $500, x 34%",1553.8,percent of total billed charges,Implant Device,1599.5,35,,1599.5,percent of total billed charges,Implant Device,1599.5,35,,1599.5,percent of total billed charges,Implant Device,1599.5,35,,1599.5,percent of total billed charges,Implant Device,1599.5,35,,1599.5,percent of total billed charges,Implant Device,1599.5,35,,1599.5,percent of total billed charges,Implant Device,1828,40,,1828,percent of total billed charges,Implant Device,1599.5,70,,1599.5,percent of total billed charges,All Other,1553.8,34,,1553.8,percent of total billed charges,Implant Device,1553.8,34,,1553.8,percent of total billed charges,Implant Device,1599.5,35,,1599.5,percent of total billed charges,Implant Device,1599.5,35,,1599.5,percent of total billed charges,Implant Device,1599.5,35,,1599.5,percent of total billed charges,Implant Device,1599.5,35,,1599.5,percent of total billed charges,Implant Device,976.07,,,976.07,Other,100% of Medicaid,976.07,,,976.07,Other,100% of Medicaid,976.07,,,976.07,Other,100% of Medicaid,976.07,,,976.07,Other,100% of Medicaid,2196.15,,,2196.15,Other,225% of Medicaid,1493.38,,,1493.38,Other,153% of Medicaid,2196.15,,,2196.15,Other,225% of Medicaid,1366.49,,,1366.49,Other,140% of Medicaid,1553.8,34,"If Charge > 2,000, then 34 percent",1553.8,percent of total billed charges,Implants,2537.77,,,2537.77,Other,260% of Medicaid,3162.45,,,3162.45,Other,324% of Medicaid,2098.54,,,2098.54,Other,215% of Medicaid,2098.54,,,2098.54,Other,215% of Medicaid,1220.08,,,1220.08,Other,125% of Medicaid,976.07,3381.81,
ACUMED CO-2716 SCREW,C1713,HCPCS,,79002477,CDM,278,RC,,,both,,,226,167.24,,,167.24,Other,150% of Medicare + 9.63% HCRA Surcharge,101.7,45,,101.7,percent of total billed charges,Critical Access Hospital RCC factor,76.84,34,,76.84,percent of total billed charges,Implant Device,76.84,34,,76.84,percent of total billed charges,Implant Device,76.84,34,,76.84,percent of total billed charges,Implant Device,76.84,34,,76.84,percent of total billed charges,Implant Device,76.84,34,,76.84,percent of total billed charges,Implant Device,111.87,,,111.87,Other,110% of Medicare,79.1,35,,79.1,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,79.1,35,,79.1,percent of total billed charges,Implant Device,79.1,35,,79.1,percent of total billed charges,Implant Device,79.1,35,,79.1,percent of total billed charges,Implant Device,79.1,35,,79.1,percent of total billed charges,Implant Device,79.1,35,,79.1,percent of total billed charges,Implant Device,90.4,40,,90.4,percent of total billed charges,Implant Device,79.1,70,,79.1,percent of total billed charges,All Other,76.84,34,,76.84,percent of total billed charges,Implant Device,76.84,34,,76.84,percent of total billed charges,Implant Device,79.1,35,,79.1,percent of total billed charges,Implant Device,79.1,35,,79.1,percent of total billed charges,Implant Device,79.1,35,,79.1,percent of total billed charges,Implant Device,79.1,35,,79.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,167.24,
ACUMED CO-2718 SCREW,C1713,HCPCS,,79002478,CDM,278,RC,,,both,,,234,173.16,,,173.16,Other,150% of Medicare + 9.63% HCRA Surcharge,105.3,45,,105.3,percent of total billed charges,Critical Access Hospital RCC factor,79.56,34,,79.56,percent of total billed charges,Implant Device,79.56,34,,79.56,percent of total billed charges,Implant Device,79.56,34,,79.56,percent of total billed charges,Implant Device,79.56,34,,79.56,percent of total billed charges,Implant Device,79.56,34,,79.56,percent of total billed charges,Implant Device,115.83,,,115.83,Other,110% of Medicare,81.9,35,,81.9,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,81.9,35,,81.9,percent of total billed charges,Implant Device,81.9,35,,81.9,percent of total billed charges,Implant Device,81.9,35,,81.9,percent of total billed charges,Implant Device,81.9,35,,81.9,percent of total billed charges,Implant Device,81.9,35,,81.9,percent of total billed charges,Implant Device,93.6,40,,93.6,percent of total billed charges,Implant Device,81.9,70,,81.9,percent of total billed charges,All Other,79.56,34,,79.56,percent of total billed charges,Implant Device,79.56,34,,79.56,percent of total billed charges,Implant Device,81.9,35,,81.9,percent of total billed charges,Implant Device,81.9,35,,81.9,percent of total billed charges,Implant Device,81.9,35,,81.9,percent of total billed charges,Implant Device,81.9,35,,81.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,173.16,
ACUMED CO-2720 SCREW,C1713,HCPCS,,79002479,CDM,278,RC,,,both,,,234,173.16,,,173.16,Other,150% of Medicare + 9.63% HCRA Surcharge,105.3,45,,105.3,percent of total billed charges,Critical Access Hospital RCC factor,79.56,34,,79.56,percent of total billed charges,Implant Device,79.56,34,,79.56,percent of total billed charges,Implant Device,79.56,34,,79.56,percent of total billed charges,Implant Device,79.56,34,,79.56,percent of total billed charges,Implant Device,79.56,34,,79.56,percent of total billed charges,Implant Device,115.83,,,115.83,Other,110% of Medicare,81.9,35,,81.9,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,81.9,35,,81.9,percent of total billed charges,Implant Device,81.9,35,,81.9,percent of total billed charges,Implant Device,81.9,35,,81.9,percent of total billed charges,Implant Device,81.9,35,,81.9,percent of total billed charges,Implant Device,81.9,35,,81.9,percent of total billed charges,Implant Device,93.6,40,,93.6,percent of total billed charges,Implant Device,81.9,70,,81.9,percent of total billed charges,All Other,79.56,34,,79.56,percent of total billed charges,Implant Device,79.56,34,,79.56,percent of total billed charges,Implant Device,81.9,35,,81.9,percent of total billed charges,Implant Device,81.9,35,,81.9,percent of total billed charges,Implant Device,81.9,35,,81.9,percent of total billed charges,Implant Device,81.9,35,,81.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,173.16,
ACUMED CO-2724 SCREW,C1713,HCPCS,,79002480,CDM,278,RC,,,both,,,226,167.24,,,167.24,Other,150% of Medicare + 9.63% HCRA Surcharge,101.7,45,,101.7,percent of total billed charges,Critical Access Hospital RCC factor,76.84,34,,76.84,percent of total billed charges,Implant Device,76.84,34,,76.84,percent of total billed charges,Implant Device,76.84,34,,76.84,percent of total billed charges,Implant Device,76.84,34,,76.84,percent of total billed charges,Implant Device,76.84,34,,76.84,percent of total billed charges,Implant Device,111.87,,,111.87,Other,110% of Medicare,79.1,35,,79.1,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,79.1,35,,79.1,percent of total billed charges,Implant Device,79.1,35,,79.1,percent of total billed charges,Implant Device,79.1,35,,79.1,percent of total billed charges,Implant Device,79.1,35,,79.1,percent of total billed charges,Implant Device,79.1,35,,79.1,percent of total billed charges,Implant Device,90.4,40,,90.4,percent of total billed charges,Implant Device,79.1,70,,79.1,percent of total billed charges,All Other,76.84,34,,76.84,percent of total billed charges,Implant Device,76.84,34,,76.84,percent of total billed charges,Implant Device,79.1,35,,79.1,percent of total billed charges,Implant Device,79.1,35,,79.1,percent of total billed charges,Implant Device,79.1,35,,79.1,percent of total billed charges,Implant Device,79.1,35,,79.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,167.24,
ACUMED CO-3080 SCREW,C1713,HCPCS,,79002481,CDM,278,RC,,,both,,,226,167.24,,,167.24,Other,150% of Medicare + 9.63% HCRA Surcharge,101.7,45,,101.7,percent of total billed charges,Critical Access Hospital RCC factor,76.84,34,,76.84,percent of total billed charges,Implant Device,76.84,34,,76.84,percent of total billed charges,Implant Device,76.84,34,,76.84,percent of total billed charges,Implant Device,76.84,34,,76.84,percent of total billed charges,Implant Device,76.84,34,,76.84,percent of total billed charges,Implant Device,111.87,,,111.87,Other,110% of Medicare,79.1,35,,79.1,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,79.1,35,,79.1,percent of total billed charges,Implant Device,79.1,35,,79.1,percent of total billed charges,Implant Device,79.1,35,,79.1,percent of total billed charges,Implant Device,79.1,35,,79.1,percent of total billed charges,Implant Device,79.1,35,,79.1,percent of total billed charges,Implant Device,90.4,40,,90.4,percent of total billed charges,Implant Device,79.1,70,,79.1,percent of total billed charges,All Other,76.84,34,,76.84,percent of total billed charges,Implant Device,76.84,34,,76.84,percent of total billed charges,Implant Device,79.1,35,,79.1,percent of total billed charges,Implant Device,79.1,35,,79.1,percent of total billed charges,Implant Device,79.1,35,,79.1,percent of total billed charges,Implant Device,79.1,35,,79.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,167.24,
ACUMED CO-3100 SCREW,C1713,HCPCS,,79002482,CDM,278,RC,,,both,,,232,171.68,,,171.68,Other,150% of Medicare + 9.63% HCRA Surcharge,104.4,45,,104.4,percent of total billed charges,Critical Access Hospital RCC factor,78.88,34,,78.88,percent of total billed charges,Implant Device,78.88,34,,78.88,percent of total billed charges,Implant Device,78.88,34,,78.88,percent of total billed charges,Implant Device,78.88,34,,78.88,percent of total billed charges,Implant Device,78.88,34,,78.88,percent of total billed charges,Implant Device,114.84,,,114.84,Other,110% of Medicare,81.2,35,,81.2,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,81.2,35,,81.2,percent of total billed charges,Implant Device,81.2,35,,81.2,percent of total billed charges,Implant Device,81.2,35,,81.2,percent of total billed charges,Implant Device,81.2,35,,81.2,percent of total billed charges,Implant Device,81.2,35,,81.2,percent of total billed charges,Implant Device,92.8,40,,92.8,percent of total billed charges,Implant Device,81.2,70,,81.2,percent of total billed charges,All Other,78.88,34,,78.88,percent of total billed charges,Implant Device,78.88,34,,78.88,percent of total billed charges,Implant Device,81.2,35,,81.2,percent of total billed charges,Implant Device,81.2,35,,81.2,percent of total billed charges,Implant Device,81.2,35,,81.2,percent of total billed charges,Implant Device,81.2,35,,81.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,171.68,
ACUMED CO-3140 SCREW,C1713,HCPCS,,79002483,CDM,278,RC,,,both,,,234,173.16,,,173.16,Other,150% of Medicare + 9.63% HCRA Surcharge,105.3,45,,105.3,percent of total billed charges,Critical Access Hospital RCC factor,79.56,34,,79.56,percent of total billed charges,Implant Device,79.56,34,,79.56,percent of total billed charges,Implant Device,79.56,34,,79.56,percent of total billed charges,Implant Device,79.56,34,,79.56,percent of total billed charges,Implant Device,79.56,34,,79.56,percent of total billed charges,Implant Device,115.83,,,115.83,Other,110% of Medicare,81.9,35,,81.9,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,81.9,35,,81.9,percent of total billed charges,Implant Device,81.9,35,,81.9,percent of total billed charges,Implant Device,81.9,35,,81.9,percent of total billed charges,Implant Device,81.9,35,,81.9,percent of total billed charges,Implant Device,81.9,35,,81.9,percent of total billed charges,Implant Device,93.6,40,,93.6,percent of total billed charges,Implant Device,81.9,70,,81.9,percent of total billed charges,All Other,79.56,34,,79.56,percent of total billed charges,Implant Device,79.56,34,,79.56,percent of total billed charges,Implant Device,81.9,35,,81.9,percent of total billed charges,Implant Device,81.9,35,,81.9,percent of total billed charges,Implant Device,81.9,35,,81.9,percent of total billed charges,Implant Device,81.9,35,,81.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,173.16,
ACUMED CO-3160 SCREW,C1713,HCPCS,,79002484,CDM,278,RC,,,both,,,234,173.16,,,173.16,Other,150% of Medicare + 9.63% HCRA Surcharge,105.3,45,,105.3,percent of total billed charges,Critical Access Hospital RCC factor,79.56,34,,79.56,percent of total billed charges,Implant Device,79.56,34,,79.56,percent of total billed charges,Implant Device,79.56,34,,79.56,percent of total billed charges,Implant Device,79.56,34,,79.56,percent of total billed charges,Implant Device,79.56,34,,79.56,percent of total billed charges,Implant Device,115.83,,,115.83,Other,110% of Medicare,81.9,35,,81.9,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,81.9,35,,81.9,percent of total billed charges,Implant Device,81.9,35,,81.9,percent of total billed charges,Implant Device,81.9,35,,81.9,percent of total billed charges,Implant Device,81.9,35,,81.9,percent of total billed charges,Implant Device,81.9,35,,81.9,percent of total billed charges,Implant Device,93.6,40,,93.6,percent of total billed charges,Implant Device,81.9,70,,81.9,percent of total billed charges,All Other,79.56,34,,79.56,percent of total billed charges,Implant Device,79.56,34,,79.56,percent of total billed charges,Implant Device,81.9,35,,81.9,percent of total billed charges,Implant Device,81.9,35,,81.9,percent of total billed charges,Implant Device,81.9,35,,81.9,percent of total billed charges,Implant Device,81.9,35,,81.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,173.16,
ACUMED CO-3200 SCREW,C1713,HCPCS,,79002485,CDM,278,RC,,,both,,,234,173.16,,,173.16,Other,150% of Medicare + 9.63% HCRA Surcharge,105.3,45,,105.3,percent of total billed charges,Critical Access Hospital RCC factor,79.56,34,,79.56,percent of total billed charges,Implant Device,79.56,34,,79.56,percent of total billed charges,Implant Device,79.56,34,,79.56,percent of total billed charges,Implant Device,79.56,34,,79.56,percent of total billed charges,Implant Device,79.56,34,,79.56,percent of total billed charges,Implant Device,115.83,,,115.83,Other,110% of Medicare,81.9,35,,81.9,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,81.9,35,,81.9,percent of total billed charges,Implant Device,81.9,35,,81.9,percent of total billed charges,Implant Device,81.9,35,,81.9,percent of total billed charges,Implant Device,81.9,35,,81.9,percent of total billed charges,Implant Device,81.9,35,,81.9,percent of total billed charges,Implant Device,93.6,40,,93.6,percent of total billed charges,Implant Device,81.9,70,,81.9,percent of total billed charges,All Other,79.56,34,,79.56,percent of total billed charges,Implant Device,79.56,34,,79.56,percent of total billed charges,Implant Device,81.9,35,,81.9,percent of total billed charges,Implant Device,81.9,35,,81.9,percent of total billed charges,Implant Device,81.9,35,,81.9,percent of total billed charges,Implant Device,81.9,35,,81.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,173.16,
ACUMED CO-3220 SCREW,C1713,HCPCS,,79002486,CDM,278,RC,,,both,,,234,173.16,,,173.16,Other,150% of Medicare + 9.63% HCRA Surcharge,105.3,45,,105.3,percent of total billed charges,Critical Access Hospital RCC factor,79.56,34,,79.56,percent of total billed charges,Implant Device,79.56,34,,79.56,percent of total billed charges,Implant Device,79.56,34,,79.56,percent of total billed charges,Implant Device,79.56,34,,79.56,percent of total billed charges,Implant Device,79.56,34,,79.56,percent of total billed charges,Implant Device,115.83,,,115.83,Other,110% of Medicare,81.9,35,,81.9,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,81.9,35,,81.9,percent of total billed charges,Implant Device,81.9,35,,81.9,percent of total billed charges,Implant Device,81.9,35,,81.9,percent of total billed charges,Implant Device,81.9,35,,81.9,percent of total billed charges,Implant Device,81.9,35,,81.9,percent of total billed charges,Implant Device,93.6,40,,93.6,percent of total billed charges,Implant Device,81.9,70,,81.9,percent of total billed charges,All Other,79.56,34,,79.56,percent of total billed charges,Implant Device,79.56,34,,79.56,percent of total billed charges,Implant Device,81.9,35,,81.9,percent of total billed charges,Implant Device,81.9,35,,81.9,percent of total billed charges,Implant Device,81.9,35,,81.9,percent of total billed charges,Implant Device,81.9,35,,81.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,173.16,
ACUMED CO-3260 SCREW,C1713,HCPCS,,79002487,CDM,278,RC,,,both,,,232,171.68,,,171.68,Other,150% of Medicare + 9.63% HCRA Surcharge,104.4,45,,104.4,percent of total billed charges,Critical Access Hospital RCC factor,78.88,34,,78.88,percent of total billed charges,Implant Device,78.88,34,,78.88,percent of total billed charges,Implant Device,78.88,34,,78.88,percent of total billed charges,Implant Device,78.88,34,,78.88,percent of total billed charges,Implant Device,78.88,34,,78.88,percent of total billed charges,Implant Device,114.84,,,114.84,Other,110% of Medicare,81.2,35,,81.2,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,81.2,35,,81.2,percent of total billed charges,Implant Device,81.2,35,,81.2,percent of total billed charges,Implant Device,81.2,35,,81.2,percent of total billed charges,Implant Device,81.2,35,,81.2,percent of total billed charges,Implant Device,81.2,35,,81.2,percent of total billed charges,Implant Device,92.8,40,,92.8,percent of total billed charges,Implant Device,81.2,70,,81.2,percent of total billed charges,All Other,78.88,34,,78.88,percent of total billed charges,Implant Device,78.88,34,,78.88,percent of total billed charges,Implant Device,81.2,35,,81.2,percent of total billed charges,Implant Device,81.2,35,,81.2,percent of total billed charges,Implant Device,81.2,35,,81.2,percent of total billed charges,Implant Device,81.2,35,,81.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,171.68,
ACUMED COL-3140 SCREW,C1713,HCPCS,,79002488,CDM,278,RC,,,both,,,382,282.68,,,282.68,Other,150% of Medicare + 9.63% HCRA Surcharge,171.9,45,,171.9,percent of total billed charges,Critical Access Hospital RCC factor,129.88,34,,129.88,percent of total billed charges,Implant Device,129.88,34,,129.88,percent of total billed charges,Implant Device,129.88,34,,129.88,percent of total billed charges,Implant Device,129.88,34,,129.88,percent of total billed charges,Implant Device,129.88,34,,129.88,percent of total billed charges,Implant Device,189.09,,,189.09,Other,110% of Medicare,133.7,35,,133.7,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,133.7,35,,133.7,percent of total billed charges,Implant Device,133.7,35,,133.7,percent of total billed charges,Implant Device,133.7,35,,133.7,percent of total billed charges,Implant Device,133.7,35,,133.7,percent of total billed charges,Implant Device,133.7,35,,133.7,percent of total billed charges,Implant Device,152.8,40,,152.8,percent of total billed charges,Implant Device,133.7,70,,133.7,percent of total billed charges,All Other,129.88,34,,129.88,percent of total billed charges,Implant Device,129.88,34,,129.88,percent of total billed charges,Implant Device,133.7,35,,133.7,percent of total billed charges,Implant Device,133.7,35,,133.7,percent of total billed charges,Implant Device,133.7,35,,133.7,percent of total billed charges,Implant Device,133.7,35,,133.7,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,282.68,
ACUMED COL-3160 SCREW,C1713,HCPCS,,79002489,CDM,278,RC,,,both,,,382,282.68,,,282.68,Other,150% of Medicare + 9.63% HCRA Surcharge,171.9,45,,171.9,percent of total billed charges,Critical Access Hospital RCC factor,129.88,34,,129.88,percent of total billed charges,Implant Device,129.88,34,,129.88,percent of total billed charges,Implant Device,129.88,34,,129.88,percent of total billed charges,Implant Device,129.88,34,,129.88,percent of total billed charges,Implant Device,129.88,34,,129.88,percent of total billed charges,Implant Device,189.09,,,189.09,Other,110% of Medicare,133.7,35,,133.7,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,133.7,35,,133.7,percent of total billed charges,Implant Device,133.7,35,,133.7,percent of total billed charges,Implant Device,133.7,35,,133.7,percent of total billed charges,Implant Device,133.7,35,,133.7,percent of total billed charges,Implant Device,133.7,35,,133.7,percent of total billed charges,Implant Device,152.8,40,,152.8,percent of total billed charges,Implant Device,133.7,70,,133.7,percent of total billed charges,All Other,129.88,34,,129.88,percent of total billed charges,Implant Device,129.88,34,,129.88,percent of total billed charges,Implant Device,133.7,35,,133.7,percent of total billed charges,Implant Device,133.7,35,,133.7,percent of total billed charges,Implant Device,133.7,35,,133.7,percent of total billed charges,Implant Device,133.7,35,,133.7,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,282.68,
BIOMET DBMW02 DBM PUTTY,C1713,HCPCS,,79002490,CDM,278,RC,,,both,,,1746,1292.04,,,1292.04,Other,150% of Medicare + 9.63% HCRA Surcharge,785.7,45,,785.7,percent of total billed charges,Critical Access Hospital RCC factor,593.64,34,,593.64,percent of total billed charges,Implant Device,593.64,34,,593.64,percent of total billed charges,Implant Device,593.64,34,,593.64,percent of total billed charges,Implant Device,593.64,34,,593.64,percent of total billed charges,Implant Device,593.64,34,,593.64,percent of total billed charges,Implant Device,864.27,,,864.27,Other,110% of Medicare,611.1,35,,611.1,percent of total billed charges,Implant Device,593.64,34,"Charges > $500, x 34%",593.64,percent of total billed charges,Implant Device,611.1,35,,611.1,percent of total billed charges,Implant Device,611.1,35,,611.1,percent of total billed charges,Implant Device,611.1,35,,611.1,percent of total billed charges,Implant Device,611.1,35,,611.1,percent of total billed charges,Implant Device,611.1,35,,611.1,percent of total billed charges,Implant Device,698.4,40,,698.4,percent of total billed charges,Implant Device,611.1,70,,611.1,percent of total billed charges,All Other,593.64,34,,593.64,percent of total billed charges,Implant Device,593.64,34,,593.64,percent of total billed charges,Implant Device,611.1,35,,611.1,percent of total billed charges,Implant Device,611.1,35,,611.1,percent of total billed charges,Implant Device,611.1,35,,611.1,percent of total billed charges,Implant Device,611.1,35,,611.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1292.04,
WRIGHT MEDICAL DC2820016 SCREW,C1713,HCPCS,,79002491,CDM,278,RC,,,both,,,654,483.96,,,483.96,Other,150% of Medicare + 9.63% HCRA Surcharge,294.3,45,,294.3,percent of total billed charges,Critical Access Hospital RCC factor,222.36,34,,222.36,percent of total billed charges,Implant Device,222.36,34,,222.36,percent of total billed charges,Implant Device,222.36,34,,222.36,percent of total billed charges,Implant Device,222.36,34,,222.36,percent of total billed charges,Implant Device,222.36,34,,222.36,percent of total billed charges,Implant Device,323.73,,,323.73,Other,110% of Medicare,228.9,35,,228.9,percent of total billed charges,Implant Device,222.36,34,"Charges > $500, x 34%",222.36,percent of total billed charges,Implant Device,228.9,35,,228.9,percent of total billed charges,Implant Device,228.9,35,,228.9,percent of total billed charges,Implant Device,228.9,35,,228.9,percent of total billed charges,Implant Device,228.9,35,,228.9,percent of total billed charges,Implant Device,228.9,35,,228.9,percent of total billed charges,Implant Device,261.6,40,,261.6,percent of total billed charges,Implant Device,228.9,70,,228.9,percent of total billed charges,All Other,222.36,34,,222.36,percent of total billed charges,Implant Device,222.36,34,,222.36,percent of total billed charges,Implant Device,228.9,35,,228.9,percent of total billed charges,Implant Device,228.9,35,,228.9,percent of total billed charges,Implant Device,228.9,35,,228.9,percent of total billed charges,Implant Device,228.9,35,,228.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,483.96,
WRIGHT MEDICAL DC2820018 SCREW,C1713,HCPCS,,79002492,CDM,278,RC,,,both,,,322,238.28,,,238.28,Other,150% of Medicare + 9.63% HCRA Surcharge,144.9,45,,144.9,percent of total billed charges,Critical Access Hospital RCC factor,109.48,34,,109.48,percent of total billed charges,Implant Device,109.48,34,,109.48,percent of total billed charges,Implant Device,109.48,34,,109.48,percent of total billed charges,Implant Device,109.48,34,,109.48,percent of total billed charges,Implant Device,109.48,34,,109.48,percent of total billed charges,Implant Device,159.39,,,159.39,Other,110% of Medicare,112.7,35,,112.7,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,112.7,35,,112.7,percent of total billed charges,Implant Device,112.7,35,,112.7,percent of total billed charges,Implant Device,112.7,35,,112.7,percent of total billed charges,Implant Device,112.7,35,,112.7,percent of total billed charges,Implant Device,112.7,35,,112.7,percent of total billed charges,Implant Device,128.8,40,,128.8,percent of total billed charges,Implant Device,112.7,70,,112.7,percent of total billed charges,All Other,109.48,34,,109.48,percent of total billed charges,Implant Device,109.48,34,,109.48,percent of total billed charges,Implant Device,112.7,35,,112.7,percent of total billed charges,Implant Device,112.7,35,,112.7,percent of total billed charges,Implant Device,112.7,35,,112.7,percent of total billed charges,Implant Device,112.7,35,,112.7,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,238.28,
WRIGHT MEDICAL DC2820022 SCREW,C1713,HCPCS,,79002493,CDM,278,RC,,,both,,,322,238.28,,,238.28,Other,150% of Medicare + 9.63% HCRA Surcharge,144.9,45,,144.9,percent of total billed charges,Critical Access Hospital RCC factor,109.48,34,,109.48,percent of total billed charges,Implant Device,109.48,34,,109.48,percent of total billed charges,Implant Device,109.48,34,,109.48,percent of total billed charges,Implant Device,109.48,34,,109.48,percent of total billed charges,Implant Device,109.48,34,,109.48,percent of total billed charges,Implant Device,159.39,,,159.39,Other,110% of Medicare,112.7,35,,112.7,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,112.7,35,,112.7,percent of total billed charges,Implant Device,112.7,35,,112.7,percent of total billed charges,Implant Device,112.7,35,,112.7,percent of total billed charges,Implant Device,112.7,35,,112.7,percent of total billed charges,Implant Device,112.7,35,,112.7,percent of total billed charges,Implant Device,128.8,40,,128.8,percent of total billed charges,Implant Device,112.7,70,,112.7,percent of total billed charges,All Other,109.48,34,,109.48,percent of total billed charges,Implant Device,109.48,34,,109.48,percent of total billed charges,Implant Device,112.7,35,,112.7,percent of total billed charges,Implant Device,112.7,35,,112.7,percent of total billed charges,Implant Device,112.7,35,,112.7,percent of total billed charges,Implant Device,112.7,35,,112.7,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,238.28,
WRIGHT MEDICAL DC2820030 SCREW,C1713,HCPCS,,79002494,CDM,278,RC,,,both,,,316,233.84,,,233.84,Other,150% of Medicare + 9.63% HCRA Surcharge,142.2,45,,142.2,percent of total billed charges,Critical Access Hospital RCC factor,107.44,34,,107.44,percent of total billed charges,Implant Device,107.44,34,,107.44,percent of total billed charges,Implant Device,107.44,34,,107.44,percent of total billed charges,Implant Device,107.44,34,,107.44,percent of total billed charges,Implant Device,107.44,34,,107.44,percent of total billed charges,Implant Device,156.42,,,156.42,Other,110% of Medicare,110.6,35,,110.6,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,110.6,35,,110.6,percent of total billed charges,Implant Device,110.6,35,,110.6,percent of total billed charges,Implant Device,110.6,35,,110.6,percent of total billed charges,Implant Device,110.6,35,,110.6,percent of total billed charges,Implant Device,110.6,35,,110.6,percent of total billed charges,Implant Device,126.4,40,,126.4,percent of total billed charges,Implant Device,110.6,70,,110.6,percent of total billed charges,All Other,107.44,34,,107.44,percent of total billed charges,Implant Device,107.44,34,,107.44,percent of total billed charges,Implant Device,110.6,35,,110.6,percent of total billed charges,Implant Device,110.6,35,,110.6,percent of total billed charges,Implant Device,110.6,35,,110.6,percent of total billed charges,Implant Device,110.6,35,,110.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,233.84,
WRIGHT MEDICAL DC2820118 SCREW,C1713,HCPCS,,79002495,CDM,278,RC,,,both,,,322,238.28,,,238.28,Other,150% of Medicare + 9.63% HCRA Surcharge,144.9,45,,144.9,percent of total billed charges,Critical Access Hospital RCC factor,109.48,34,,109.48,percent of total billed charges,Implant Device,109.48,34,,109.48,percent of total billed charges,Implant Device,109.48,34,,109.48,percent of total billed charges,Implant Device,109.48,34,,109.48,percent of total billed charges,Implant Device,109.48,34,,109.48,percent of total billed charges,Implant Device,159.39,,,159.39,Other,110% of Medicare,112.7,35,,112.7,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,112.7,35,,112.7,percent of total billed charges,Implant Device,112.7,35,,112.7,percent of total billed charges,Implant Device,112.7,35,,112.7,percent of total billed charges,Implant Device,112.7,35,,112.7,percent of total billed charges,Implant Device,112.7,35,,112.7,percent of total billed charges,Implant Device,128.8,40,,128.8,percent of total billed charges,Implant Device,112.7,70,,112.7,percent of total billed charges,All Other,109.48,34,,109.48,percent of total billed charges,Implant Device,109.48,34,,109.48,percent of total billed charges,Implant Device,112.7,35,,112.7,percent of total billed charges,Implant Device,112.7,35,,112.7,percent of total billed charges,Implant Device,112.7,35,,112.7,percent of total billed charges,Implant Device,112.7,35,,112.7,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,238.28,
WRIGHT MEDICAL DC2820122 SCREW,C1713,HCPCS,,79002496,CDM,278,RC,,,both,,,654,483.96,,,483.96,Other,150% of Medicare + 9.63% HCRA Surcharge,294.3,45,,294.3,percent of total billed charges,Critical Access Hospital RCC factor,222.36,34,,222.36,percent of total billed charges,Implant Device,222.36,34,,222.36,percent of total billed charges,Implant Device,222.36,34,,222.36,percent of total billed charges,Implant Device,222.36,34,,222.36,percent of total billed charges,Implant Device,222.36,34,,222.36,percent of total billed charges,Implant Device,323.73,,,323.73,Other,110% of Medicare,228.9,35,,228.9,percent of total billed charges,Implant Device,222.36,34,"Charges > $500, x 34%",222.36,percent of total billed charges,Implant Device,228.9,35,,228.9,percent of total billed charges,Implant Device,228.9,35,,228.9,percent of total billed charges,Implant Device,228.9,35,,228.9,percent of total billed charges,Implant Device,228.9,35,,228.9,percent of total billed charges,Implant Device,228.9,35,,228.9,percent of total billed charges,Implant Device,261.6,40,,261.6,percent of total billed charges,Implant Device,228.9,70,,228.9,percent of total billed charges,All Other,222.36,34,,222.36,percent of total billed charges,Implant Device,222.36,34,,222.36,percent of total billed charges,Implant Device,228.9,35,,228.9,percent of total billed charges,Implant Device,228.9,35,,228.9,percent of total billed charges,Implant Device,228.9,35,,228.9,percent of total billed charges,Implant Device,228.9,35,,228.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,483.96,
WRIGHT MEDICAL DC2820126 SCREW,C1713,HCPCS,,79002497,CDM,278,RC,,,both,,,322,238.28,,,238.28,Other,150% of Medicare + 9.63% HCRA Surcharge,144.9,45,,144.9,percent of total billed charges,Critical Access Hospital RCC factor,109.48,34,,109.48,percent of total billed charges,Implant Device,109.48,34,,109.48,percent of total billed charges,Implant Device,109.48,34,,109.48,percent of total billed charges,Implant Device,109.48,34,,109.48,percent of total billed charges,Implant Device,109.48,34,,109.48,percent of total billed charges,Implant Device,159.39,,,159.39,Other,110% of Medicare,112.7,35,,112.7,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,112.7,35,,112.7,percent of total billed charges,Implant Device,112.7,35,,112.7,percent of total billed charges,Implant Device,112.7,35,,112.7,percent of total billed charges,Implant Device,112.7,35,,112.7,percent of total billed charges,Implant Device,112.7,35,,112.7,percent of total billed charges,Implant Device,128.8,40,,128.8,percent of total billed charges,Implant Device,112.7,70,,112.7,percent of total billed charges,All Other,109.48,34,,109.48,percent of total billed charges,Implant Device,109.48,34,,109.48,percent of total billed charges,Implant Device,112.7,35,,112.7,percent of total billed charges,Implant Device,112.7,35,,112.7,percent of total billed charges,Implant Device,112.7,35,,112.7,percent of total billed charges,Implant Device,112.7,35,,112.7,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,238.28,
BIOMET DVRANR PLATE,C1713,HCPCS,,79002501,CDM,278,RC,,,both,,,2394,1771.57,,,1771.57,Other,150% of Medicare + 9.63% HCRA Surcharge,1077.3,45,,1077.3,percent of total billed charges,Critical Access Hospital RCC factor,813.96,34,,813.96,percent of total billed charges,Implant Device,813.96,34,,813.96,percent of total billed charges,Implant Device,813.96,34,,813.96,percent of total billed charges,Implant Device,813.96,34,,813.96,percent of total billed charges,Implant Device,813.96,34,,813.96,percent of total billed charges,Implant Device,1185.03,,,1185.03,Other,110% of Medicare,837.9,35,,837.9,percent of total billed charges,Implant Device,813.96,34,"Charges > $500, x 34%",813.96,percent of total billed charges,Implant Device,837.9,35,,837.9,percent of total billed charges,Implant Device,837.9,35,,837.9,percent of total billed charges,Implant Device,837.9,35,,837.9,percent of total billed charges,Implant Device,837.9,35,,837.9,percent of total billed charges,Implant Device,837.9,35,,837.9,percent of total billed charges,Implant Device,957.6,40,,957.6,percent of total billed charges,Implant Device,837.9,70,,837.9,percent of total billed charges,All Other,813.96,34,,813.96,percent of total billed charges,Implant Device,813.96,34,,813.96,percent of total billed charges,Implant Device,837.9,35,,837.9,percent of total billed charges,Implant Device,837.9,35,,837.9,percent of total billed charges,Implant Device,837.9,35,,837.9,percent of total billed charges,Implant Device,837.9,35,,837.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,813.96,34,"If Charge > 2,000, then 34 percent",813.96,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1771.57,
MEDTRONIC ENBF2513C124E STENT,C1876,HCPCS,,79002505,CDM,278,RC,,,both,,,29926,22145.31,,,22145.31,Other,150% of Medicare + 9.63% HCRA Surcharge,13466.7,45,,13466.7,percent of total billed charges,Critical Access Hospital RCC factor,10174.84,34,,10174.84,percent of total billed charges,Implant Device,10174.84,34,,10174.84,percent of total billed charges,Implant Device,10174.84,34,,10174.84,percent of total billed charges,Implant Device,10174.84,34,,10174.84,percent of total billed charges,Implant Device,10174.84,34,,10174.84,percent of total billed charges,Implant Device,14813.37,,,14813.37,Other,110% of Medicare,10474.1,35,,10474.1,percent of total billed charges,Implant Device,10174.84,34,"Charges > $500, x 34%",10174.84,percent of total billed charges,Implant Device,10474.1,35,,10474.1,percent of total billed charges,Implant Device,10474.1,35,,10474.1,percent of total billed charges,Implant Device,10474.1,35,,10474.1,percent of total billed charges,Implant Device,10474.1,35,,10474.1,percent of total billed charges,Implant Device,10474.1,35,,10474.1,percent of total billed charges,Implant Device,11970.4,40,,11970.4,percent of total billed charges,Implant Device,10474.1,70,,10474.1,percent of total billed charges,All Other,10174.84,34,,10174.84,percent of total billed charges,Implant Device,10174.84,34,,10174.84,percent of total billed charges,Implant Device,10474.1,35,,10474.1,percent of total billed charges,Implant Device,10474.1,35,,10474.1,percent of total billed charges,Implant Device,10474.1,35,,10474.1,percent of total billed charges,Implant Device,10474.1,35,,10474.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,10174.84,34,"If Charge > 2,000, then 34 percent",10174.84,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,22145.31,
MEDTRONIC ENBF2816C124E STENT,C1876,HCPCS,,79002506,CDM,278,RC,,,both,,,29926,22145.31,,,22145.31,Other,150% of Medicare + 9.63% HCRA Surcharge,13466.7,45,,13466.7,percent of total billed charges,Critical Access Hospital RCC factor,10174.84,34,,10174.84,percent of total billed charges,Implant Device,10174.84,34,,10174.84,percent of total billed charges,Implant Device,10174.84,34,,10174.84,percent of total billed charges,Implant Device,10174.84,34,,10174.84,percent of total billed charges,Implant Device,10174.84,34,,10174.84,percent of total billed charges,Implant Device,14813.37,,,14813.37,Other,110% of Medicare,10474.1,35,,10474.1,percent of total billed charges,Implant Device,10174.84,34,"Charges > $500, x 34%",10174.84,percent of total billed charges,Implant Device,10474.1,35,,10474.1,percent of total billed charges,Implant Device,10474.1,35,,10474.1,percent of total billed charges,Implant Device,10474.1,35,,10474.1,percent of total billed charges,Implant Device,10474.1,35,,10474.1,percent of total billed charges,Implant Device,10474.1,35,,10474.1,percent of total billed charges,Implant Device,11970.4,40,,11970.4,percent of total billed charges,Implant Device,10474.1,70,,10474.1,percent of total billed charges,All Other,10174.84,34,,10174.84,percent of total billed charges,Implant Device,10174.84,34,,10174.84,percent of total billed charges,Implant Device,10474.1,35,,10474.1,percent of total billed charges,Implant Device,10474.1,35,,10474.1,percent of total billed charges,Implant Device,10474.1,35,,10474.1,percent of total billed charges,Implant Device,10474.1,35,,10474.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,10174.84,34,"If Charge > 2,000, then 34 percent",10174.84,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,22145.31,
MEDTRONIC ENBF2816C166E STENT,C1876,HCPCS,,79002507,CDM,278,RC,,,both,,,29926,22145.31,,,22145.31,Other,150% of Medicare + 9.63% HCRA Surcharge,13466.7,45,,13466.7,percent of total billed charges,Critical Access Hospital RCC factor,10174.84,34,,10174.84,percent of total billed charges,Implant Device,10174.84,34,,10174.84,percent of total billed charges,Implant Device,10174.84,34,,10174.84,percent of total billed charges,Implant Device,10174.84,34,,10174.84,percent of total billed charges,Implant Device,10174.84,34,,10174.84,percent of total billed charges,Implant Device,14813.37,,,14813.37,Other,110% of Medicare,10474.1,35,,10474.1,percent of total billed charges,Implant Device,10174.84,34,"Charges > $500, x 34%",10174.84,percent of total billed charges,Implant Device,10474.1,35,,10474.1,percent of total billed charges,Implant Device,10474.1,35,,10474.1,percent of total billed charges,Implant Device,10474.1,35,,10474.1,percent of total billed charges,Implant Device,10474.1,35,,10474.1,percent of total billed charges,Implant Device,10474.1,35,,10474.1,percent of total billed charges,Implant Device,11970.4,40,,11970.4,percent of total billed charges,Implant Device,10474.1,70,,10474.1,percent of total billed charges,All Other,10174.84,34,,10174.84,percent of total billed charges,Implant Device,10174.84,34,,10174.84,percent of total billed charges,Implant Device,10474.1,35,,10474.1,percent of total billed charges,Implant Device,10474.1,35,,10474.1,percent of total billed charges,Implant Device,10474.1,35,,10474.1,percent of total billed charges,Implant Device,10474.1,35,,10474.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,10174.84,34,"If Charge > 2,000, then 34 percent",10174.84,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,22145.31,
MEDTRONIC ENBF3216C145E STENT,C1876,HCPCS,,79002508,CDM,278,RC,,,both,,,29926,22145.31,,,22145.31,Other,150% of Medicare + 9.63% HCRA Surcharge,13466.7,45,,13466.7,percent of total billed charges,Critical Access Hospital RCC factor,10174.84,34,,10174.84,percent of total billed charges,Implant Device,10174.84,34,,10174.84,percent of total billed charges,Implant Device,10174.84,34,,10174.84,percent of total billed charges,Implant Device,10174.84,34,,10174.84,percent of total billed charges,Implant Device,10174.84,34,,10174.84,percent of total billed charges,Implant Device,14813.37,,,14813.37,Other,110% of Medicare,10474.1,35,,10474.1,percent of total billed charges,Implant Device,10174.84,34,"Charges > $500, x 34%",10174.84,percent of total billed charges,Implant Device,10474.1,35,,10474.1,percent of total billed charges,Implant Device,10474.1,35,,10474.1,percent of total billed charges,Implant Device,10474.1,35,,10474.1,percent of total billed charges,Implant Device,10474.1,35,,10474.1,percent of total billed charges,Implant Device,10474.1,35,,10474.1,percent of total billed charges,Implant Device,11970.4,40,,11970.4,percent of total billed charges,Implant Device,10474.1,70,,10474.1,percent of total billed charges,All Other,10174.84,34,,10174.84,percent of total billed charges,Implant Device,10174.84,34,,10174.84,percent of total billed charges,Implant Device,10474.1,35,,10474.1,percent of total billed charges,Implant Device,10474.1,35,,10474.1,percent of total billed charges,Implant Device,10474.1,35,,10474.1,percent of total billed charges,Implant Device,10474.1,35,,10474.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,10174.84,34,"If Charge > 2,000, then 34 percent",10174.84,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,22145.31,
MEDTRONIC ENBF3616C145E STENT,C1876,HCPCS,,79002509,CDM,278,RC,,,both,,,29926,22145.31,,,22145.31,Other,150% of Medicare + 9.63% HCRA Surcharge,13466.7,45,,13466.7,percent of total billed charges,Critical Access Hospital RCC factor,10174.84,34,,10174.84,percent of total billed charges,Implant Device,10174.84,34,,10174.84,percent of total billed charges,Implant Device,10174.84,34,,10174.84,percent of total billed charges,Implant Device,10174.84,34,,10174.84,percent of total billed charges,Implant Device,10174.84,34,,10174.84,percent of total billed charges,Implant Device,14813.37,,,14813.37,Other,110% of Medicare,10474.1,35,,10474.1,percent of total billed charges,Implant Device,10174.84,34,"Charges > $500, x 34%",10174.84,percent of total billed charges,Implant Device,10474.1,35,,10474.1,percent of total billed charges,Implant Device,10474.1,35,,10474.1,percent of total billed charges,Implant Device,10474.1,35,,10474.1,percent of total billed charges,Implant Device,10474.1,35,,10474.1,percent of total billed charges,Implant Device,10474.1,35,,10474.1,percent of total billed charges,Implant Device,11970.4,40,,11970.4,percent of total billed charges,Implant Device,10474.1,70,,10474.1,percent of total billed charges,All Other,10174.84,34,,10174.84,percent of total billed charges,Implant Device,10174.84,34,,10174.84,percent of total billed charges,Implant Device,10474.1,35,,10474.1,percent of total billed charges,Implant Device,10474.1,35,,10474.1,percent of total billed charges,Implant Device,10474.1,35,,10474.1,percent of total billed charges,Implant Device,10474.1,35,,10474.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,10174.84,34,"If Charge > 2,000, then 34 percent",10174.84,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,22145.31,
MEDTRONIC ENEW2424C832E STENT,C1876,HCPCS,,79002510,CDM,278,RC,,,both,,,14776,10934.28,,,10934.28,Other,150% of Medicare + 9.63% HCRA Surcharge,6649.2,45,,6649.2,percent of total billed charges,Critical Access Hospital RCC factor,5023.84,34,,5023.84,percent of total billed charges,Implant Device,5023.84,34,,5023.84,percent of total billed charges,Implant Device,5023.84,34,,5023.84,percent of total billed charges,Implant Device,5023.84,34,,5023.84,percent of total billed charges,Implant Device,5023.84,34,,5023.84,percent of total billed charges,Implant Device,7314.12,,,7314.12,Other,110% of Medicare,5171.6,35,,5171.6,percent of total billed charges,Implant Device,5023.84,34,"Charges > $500, x 34%",5023.84,percent of total billed charges,Implant Device,5171.6,35,,5171.6,percent of total billed charges,Implant Device,5171.6,35,,5171.6,percent of total billed charges,Implant Device,5171.6,35,,5171.6,percent of total billed charges,Implant Device,5171.6,35,,5171.6,percent of total billed charges,Implant Device,5171.6,35,,5171.6,percent of total billed charges,Implant Device,5910.4,40,,5910.4,percent of total billed charges,Implant Device,5171.6,70,,5171.6,percent of total billed charges,All Other,5023.84,34,,5023.84,percent of total billed charges,Implant Device,5023.84,34,,5023.84,percent of total billed charges,Implant Device,5171.6,35,,5171.6,percent of total billed charges,Implant Device,5171.6,35,,5171.6,percent of total billed charges,Implant Device,5171.6,35,,5171.6,percent of total billed charges,Implant Device,5171.6,35,,5171.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,5023.84,34,"If Charge > 2,000, then 34 percent",5023.84,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,10934.28,
MEDTRONIC ENLW1610C124E STENT,C1876,HCPCS,,79002511,CDM,278,RC,,,both,,,14926,11045.28,,,11045.28,Other,150% of Medicare + 9.63% HCRA Surcharge,6716.7,45,,6716.7,percent of total billed charges,Critical Access Hospital RCC factor,5074.84,34,,5074.84,percent of total billed charges,Implant Device,5074.84,34,,5074.84,percent of total billed charges,Implant Device,5074.84,34,,5074.84,percent of total billed charges,Implant Device,5074.84,34,,5074.84,percent of total billed charges,Implant Device,5074.84,34,,5074.84,percent of total billed charges,Implant Device,7388.37,,,7388.37,Other,110% of Medicare,5224.1,35,,5224.1,percent of total billed charges,Implant Device,5074.84,34,"Charges > $500, x 34%",5074.84,percent of total billed charges,Implant Device,5224.1,35,,5224.1,percent of total billed charges,Implant Device,5224.1,35,,5224.1,percent of total billed charges,Implant Device,5224.1,35,,5224.1,percent of total billed charges,Implant Device,5224.1,35,,5224.1,percent of total billed charges,Implant Device,5224.1,35,,5224.1,percent of total billed charges,Implant Device,5970.4,40,,5970.4,percent of total billed charges,Implant Device,5224.1,70,,5224.1,percent of total billed charges,All Other,5074.84,34,,5074.84,percent of total billed charges,Implant Device,5074.84,34,,5074.84,percent of total billed charges,Implant Device,5224.1,35,,5224.1,percent of total billed charges,Implant Device,5224.1,35,,5224.1,percent of total billed charges,Implant Device,5224.1,35,,5224.1,percent of total billed charges,Implant Device,5224.1,35,,5224.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,5074.84,34,"If Charge > 2,000, then 34 percent",5074.84,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,11045.28,
MEDTRONIC ENLW1613C124E STENT,C1876,HCPCS,,79002512,CDM,278,RC,,,both,,,14926,11045.28,,,11045.28,Other,150% of Medicare + 9.63% HCRA Surcharge,6716.7,45,,6716.7,percent of total billed charges,Critical Access Hospital RCC factor,5074.84,34,,5074.84,percent of total billed charges,Implant Device,5074.84,34,,5074.84,percent of total billed charges,Implant Device,5074.84,34,,5074.84,percent of total billed charges,Implant Device,5074.84,34,,5074.84,percent of total billed charges,Implant Device,5074.84,34,,5074.84,percent of total billed charges,Implant Device,7388.37,,,7388.37,Other,110% of Medicare,5224.1,35,,5224.1,percent of total billed charges,Implant Device,5074.84,34,"Charges > $500, x 34%",5074.84,percent of total billed charges,Implant Device,5224.1,35,,5224.1,percent of total billed charges,Implant Device,5224.1,35,,5224.1,percent of total billed charges,Implant Device,5224.1,35,,5224.1,percent of total billed charges,Implant Device,5224.1,35,,5224.1,percent of total billed charges,Implant Device,5224.1,35,,5224.1,percent of total billed charges,Implant Device,5970.4,40,,5970.4,percent of total billed charges,Implant Device,5224.1,70,,5224.1,percent of total billed charges,All Other,5074.84,34,,5074.84,percent of total billed charges,Implant Device,5074.84,34,,5074.84,percent of total billed charges,Implant Device,5224.1,35,,5224.1,percent of total billed charges,Implant Device,5224.1,35,,5224.1,percent of total billed charges,Implant Device,5224.1,35,,5224.1,percent of total billed charges,Implant Device,5224.1,35,,5224.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,5074.84,34,"If Charge > 2,000, then 34 percent",5074.84,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,11045.28,
MEDTRONIC ENLW1616C124E STENT,C1876,HCPCS,,79002513,CDM,278,RC,,,both,,,14776,10934.28,,,10934.28,Other,150% of Medicare + 9.63% HCRA Surcharge,6649.2,45,,6649.2,percent of total billed charges,Critical Access Hospital RCC factor,5023.84,34,,5023.84,percent of total billed charges,Implant Device,5023.84,34,,5023.84,percent of total billed charges,Implant Device,5023.84,34,,5023.84,percent of total billed charges,Implant Device,5023.84,34,,5023.84,percent of total billed charges,Implant Device,5023.84,34,,5023.84,percent of total billed charges,Implant Device,7314.12,,,7314.12,Other,110% of Medicare,5171.6,35,,5171.6,percent of total billed charges,Implant Device,5023.84,34,"Charges > $500, x 34%",5023.84,percent of total billed charges,Implant Device,5171.6,35,,5171.6,percent of total billed charges,Implant Device,5171.6,35,,5171.6,percent of total billed charges,Implant Device,5171.6,35,,5171.6,percent of total billed charges,Implant Device,5171.6,35,,5171.6,percent of total billed charges,Implant Device,5171.6,35,,5171.6,percent of total billed charges,Implant Device,5910.4,40,,5910.4,percent of total billed charges,Implant Device,5171.6,70,,5171.6,percent of total billed charges,All Other,5023.84,34,,5023.84,percent of total billed charges,Implant Device,5023.84,34,,5023.84,percent of total billed charges,Implant Device,5171.6,35,,5171.6,percent of total billed charges,Implant Device,5171.6,35,,5171.6,percent of total billed charges,Implant Device,5171.6,35,,5171.6,percent of total billed charges,Implant Device,5171.6,35,,5171.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,5023.84,34,"If Charge > 2,000, then 34 percent",5023.84,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,10934.28,
MEDTRONIC ENLW1616C82E STENT,C1876,HCPCS,,79002514,CDM,278,RC,,,both,,,13426,9935.27,,,9935.27,Other,150% of Medicare + 9.63% HCRA Surcharge,6041.7,45,,6041.7,percent of total billed charges,Critical Access Hospital RCC factor,4564.84,34,,4564.84,percent of total billed charges,Implant Device,4564.84,34,,4564.84,percent of total billed charges,Implant Device,4564.84,34,,4564.84,percent of total billed charges,Implant Device,4564.84,34,,4564.84,percent of total billed charges,Implant Device,4564.84,34,,4564.84,percent of total billed charges,Implant Device,6645.87,,,6645.87,Other,110% of Medicare,4699.1,35,,4699.1,percent of total billed charges,Implant Device,4564.84,34,"Charges > $500, x 34%",4564.84,percent of total billed charges,Implant Device,4699.1,35,,4699.1,percent of total billed charges,Implant Device,4699.1,35,,4699.1,percent of total billed charges,Implant Device,4699.1,35,,4699.1,percent of total billed charges,Implant Device,4699.1,35,,4699.1,percent of total billed charges,Implant Device,4699.1,35,,4699.1,percent of total billed charges,Implant Device,5370.4,40,,5370.4,percent of total billed charges,Implant Device,4699.1,70,,4699.1,percent of total billed charges,All Other,4564.84,34,,4564.84,percent of total billed charges,Implant Device,4564.84,34,,4564.84,percent of total billed charges,Implant Device,4699.1,35,,4699.1,percent of total billed charges,Implant Device,4699.1,35,,4699.1,percent of total billed charges,Implant Device,4699.1,35,,4699.1,percent of total billed charges,Implant Device,4699.1,35,,4699.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,4564.84,34,"If Charge > 2,000, then 34 percent",4564.84,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,9935.27,
MEDTRONIC ENLW1620C93E STENT,C1876,HCPCS,,79002515,CDM,278,RC,,,both,,,14776,10934.28,,,10934.28,Other,150% of Medicare + 9.63% HCRA Surcharge,6649.2,45,,6649.2,percent of total billed charges,Critical Access Hospital RCC factor,5023.84,34,,5023.84,percent of total billed charges,Implant Device,5023.84,34,,5023.84,percent of total billed charges,Implant Device,5023.84,34,,5023.84,percent of total billed charges,Implant Device,5023.84,34,,5023.84,percent of total billed charges,Implant Device,5023.84,34,,5023.84,percent of total billed charges,Implant Device,7314.12,,,7314.12,Other,110% of Medicare,5171.6,35,,5171.6,percent of total billed charges,Implant Device,5023.84,34,"Charges > $500, x 34%",5023.84,percent of total billed charges,Implant Device,5171.6,35,,5171.6,percent of total billed charges,Implant Device,5171.6,35,,5171.6,percent of total billed charges,Implant Device,5171.6,35,,5171.6,percent of total billed charges,Implant Device,5171.6,35,,5171.6,percent of total billed charges,Implant Device,5171.6,35,,5171.6,percent of total billed charges,Implant Device,5910.4,40,,5910.4,percent of total billed charges,Implant Device,5171.6,70,,5171.6,percent of total billed charges,All Other,5023.84,34,,5023.84,percent of total billed charges,Implant Device,5023.84,34,,5023.84,percent of total billed charges,Implant Device,5171.6,35,,5171.6,percent of total billed charges,Implant Device,5171.6,35,,5171.6,percent of total billed charges,Implant Device,5171.6,35,,5171.6,percent of total billed charges,Implant Device,5171.6,35,,5171.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,5023.84,34,"If Charge > 2,000, then 34 percent",5023.84,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,10934.28,
MEDTRONIC ENLW1624C82E STENT,C1876,HCPCS,,79002516,CDM,278,RC,,,both,,,14550,10767.04,,,10767.04,Other,150% of Medicare + 9.63% HCRA Surcharge,6547.5,45,,6547.5,percent of total billed charges,Critical Access Hospital RCC factor,4947,34,,4947,percent of total billed charges,Implant Device,4947,34,,4947,percent of total billed charges,Implant Device,4947,34,,4947,percent of total billed charges,Implant Device,4947,34,,4947,percent of total billed charges,Implant Device,4947,34,,4947,percent of total billed charges,Implant Device,7202.25,,,7202.25,Other,110% of Medicare,5092.5,35,,5092.5,percent of total billed charges,Implant Device,4947,34,"Charges > $500, x 34%",4947,percent of total billed charges,Implant Device,5092.5,35,,5092.5,percent of total billed charges,Implant Device,5092.5,35,,5092.5,percent of total billed charges,Implant Device,5092.5,35,,5092.5,percent of total billed charges,Implant Device,5092.5,35,,5092.5,percent of total billed charges,Implant Device,5092.5,35,,5092.5,percent of total billed charges,Implant Device,5820,40,,5820,percent of total billed charges,Implant Device,5092.5,70,,5092.5,percent of total billed charges,All Other,4947,34,,4947,percent of total billed charges,Implant Device,4947,34,,4947,percent of total billed charges,Implant Device,5092.5,35,,5092.5,percent of total billed charges,Implant Device,5092.5,35,,5092.5,percent of total billed charges,Implant Device,5092.5,35,,5092.5,percent of total billed charges,Implant Device,5092.5,35,,5092.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,4947,34,"If Charge > 2,000, then 34 percent",4947,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,10767.04,
MEDTRONIC ENLW1624C93E STENT,C1876,HCPCS,,79002517,CDM,278,RC,,,both,,,14776,10934.28,,,10934.28,Other,150% of Medicare + 9.63% HCRA Surcharge,6649.2,45,,6649.2,percent of total billed charges,Critical Access Hospital RCC factor,5023.84,34,,5023.84,percent of total billed charges,Implant Device,5023.84,34,,5023.84,percent of total billed charges,Implant Device,5023.84,34,,5023.84,percent of total billed charges,Implant Device,5023.84,34,,5023.84,percent of total billed charges,Implant Device,5023.84,34,,5023.84,percent of total billed charges,Implant Device,7314.12,,,7314.12,Other,110% of Medicare,5171.6,35,,5171.6,percent of total billed charges,Implant Device,5023.84,34,"Charges > $500, x 34%",5023.84,percent of total billed charges,Implant Device,5171.6,35,,5171.6,percent of total billed charges,Implant Device,5171.6,35,,5171.6,percent of total billed charges,Implant Device,5171.6,35,,5171.6,percent of total billed charges,Implant Device,5171.6,35,,5171.6,percent of total billed charges,Implant Device,5171.6,35,,5171.6,percent of total billed charges,Implant Device,5910.4,40,,5910.4,percent of total billed charges,Implant Device,5171.6,70,,5171.6,percent of total billed charges,All Other,5023.84,34,,5023.84,percent of total billed charges,Implant Device,5023.84,34,,5023.84,percent of total billed charges,Implant Device,5171.6,35,,5171.6,percent of total billed charges,Implant Device,5171.6,35,,5171.6,percent of total billed charges,Implant Device,5171.6,35,,5171.6,percent of total billed charges,Implant Device,5171.6,35,,5171.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,5023.84,34,"If Charge > 2,000, then 34 percent",5023.84,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,10934.28,
MEDTRONIC ETLW1610C124E STENT,C1876,HCPCS,,79002518,CDM,278,RC,,,both,,,14926,11045.28,,,11045.28,Other,150% of Medicare + 9.63% HCRA Surcharge,6716.7,45,,6716.7,percent of total billed charges,Critical Access Hospital RCC factor,5074.84,34,,5074.84,percent of total billed charges,Implant Device,5074.84,34,,5074.84,percent of total billed charges,Implant Device,5074.84,34,,5074.84,percent of total billed charges,Implant Device,5074.84,34,,5074.84,percent of total billed charges,Implant Device,5074.84,34,,5074.84,percent of total billed charges,Implant Device,7388.37,,,7388.37,Other,110% of Medicare,5224.1,35,,5224.1,percent of total billed charges,Implant Device,5074.84,34,"Charges > $500, x 34%",5074.84,percent of total billed charges,Implant Device,5224.1,35,,5224.1,percent of total billed charges,Implant Device,5224.1,35,,5224.1,percent of total billed charges,Implant Device,5224.1,35,,5224.1,percent of total billed charges,Implant Device,5224.1,35,,5224.1,percent of total billed charges,Implant Device,5224.1,35,,5224.1,percent of total billed charges,Implant Device,5970.4,40,,5970.4,percent of total billed charges,Implant Device,5224.1,70,,5224.1,percent of total billed charges,All Other,5074.84,34,,5074.84,percent of total billed charges,Implant Device,5074.84,34,,5074.84,percent of total billed charges,Implant Device,5224.1,35,,5224.1,percent of total billed charges,Implant Device,5224.1,35,,5224.1,percent of total billed charges,Implant Device,5224.1,35,,5224.1,percent of total billed charges,Implant Device,5224.1,35,,5224.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,5074.84,34,"If Charge > 2,000, then 34 percent",5074.84,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,11045.28,
MEDTRONIC ETLW1624C124E STENT,C1876,HCPCS,,79002519,CDM,278,RC,,,both,,,14926,11045.28,,,11045.28,Other,150% of Medicare + 9.63% HCRA Surcharge,6716.7,45,,6716.7,percent of total billed charges,Critical Access Hospital RCC factor,5074.84,34,,5074.84,percent of total billed charges,Implant Device,5074.84,34,,5074.84,percent of total billed charges,Implant Device,5074.84,34,,5074.84,percent of total billed charges,Implant Device,5074.84,34,,5074.84,percent of total billed charges,Implant Device,5074.84,34,,5074.84,percent of total billed charges,Implant Device,7388.37,,,7388.37,Other,110% of Medicare,5224.1,35,,5224.1,percent of total billed charges,Implant Device,5074.84,34,"Charges > $500, x 34%",5074.84,percent of total billed charges,Implant Device,5224.1,35,,5224.1,percent of total billed charges,Implant Device,5224.1,35,,5224.1,percent of total billed charges,Implant Device,5224.1,35,,5224.1,percent of total billed charges,Implant Device,5224.1,35,,5224.1,percent of total billed charges,Implant Device,5224.1,35,,5224.1,percent of total billed charges,Implant Device,5970.4,40,,5970.4,percent of total billed charges,Implant Device,5224.1,70,,5224.1,percent of total billed charges,All Other,5074.84,34,,5074.84,percent of total billed charges,Implant Device,5074.84,34,,5074.84,percent of total billed charges,Implant Device,5224.1,35,,5224.1,percent of total billed charges,Implant Device,5224.1,35,,5224.1,percent of total billed charges,Implant Device,5224.1,35,,5224.1,percent of total billed charges,Implant Device,5224.1,35,,5224.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,5074.84,34,"If Charge > 2,000, then 34 percent",5074.84,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,11045.28,
MEDTRONIC ETLW1624C156E STENT,C1876,HCPCS,,79002520,CDM,278,RC,,,both,,,14926,11045.28,,,11045.28,Other,150% of Medicare + 9.63% HCRA Surcharge,6716.7,45,,6716.7,percent of total billed charges,Critical Access Hospital RCC factor,5074.84,34,,5074.84,percent of total billed charges,Implant Device,5074.84,34,,5074.84,percent of total billed charges,Implant Device,5074.84,34,,5074.84,percent of total billed charges,Implant Device,5074.84,34,,5074.84,percent of total billed charges,Implant Device,5074.84,34,,5074.84,percent of total billed charges,Implant Device,7388.37,,,7388.37,Other,110% of Medicare,5224.1,35,,5224.1,percent of total billed charges,Implant Device,5074.84,34,"Charges > $500, x 34%",5074.84,percent of total billed charges,Implant Device,5224.1,35,,5224.1,percent of total billed charges,Implant Device,5224.1,35,,5224.1,percent of total billed charges,Implant Device,5224.1,35,,5224.1,percent of total billed charges,Implant Device,5224.1,35,,5224.1,percent of total billed charges,Implant Device,5224.1,35,,5224.1,percent of total billed charges,Implant Device,5970.4,40,,5970.4,percent of total billed charges,Implant Device,5224.1,70,,5224.1,percent of total billed charges,All Other,5074.84,34,,5074.84,percent of total billed charges,Implant Device,5074.84,34,,5074.84,percent of total billed charges,Implant Device,5224.1,35,,5224.1,percent of total billed charges,Implant Device,5224.1,35,,5224.1,percent of total billed charges,Implant Device,5224.1,35,,5224.1,percent of total billed charges,Implant Device,5224.1,35,,5224.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,5074.84,34,"If Charge > 2,000, then 34 percent",5074.84,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,11045.28,
J&J FTL10060 STENT,C1874,HCPCS,,79002521,CDM,278,RC,,,both,,,8142,6025.1,,,6025.1,Other,150% of Medicare + 9.63% HCRA Surcharge,3663.9,45,,3663.9,percent of total billed charges,Critical Access Hospital RCC factor,2768.28,34,,2768.28,percent of total billed charges,Implant Device,2768.28,34,,2768.28,percent of total billed charges,Implant Device,2768.28,34,,2768.28,percent of total billed charges,Implant Device,2768.28,34,,2768.28,percent of total billed charges,Implant Device,2768.28,34,,2768.28,percent of total billed charges,Implant Device,4030.29,,,4030.29,Other,110% of Medicare,2849.7,35,,2849.7,percent of total billed charges,Implant Device,2768.28,34,"Charges > $500, x 34%",2768.28,percent of total billed charges,Implant Device,2849.7,35,,2849.7,percent of total billed charges,Implant Device,2849.7,35,,2849.7,percent of total billed charges,Implant Device,2849.7,35,,2849.7,percent of total billed charges,Implant Device,2849.7,35,,2849.7,percent of total billed charges,Implant Device,2849.7,35,,2849.7,percent of total billed charges,Implant Device,3256.8,40,,3256.8,percent of total billed charges,Implant Device,2849.7,70,,2849.7,percent of total billed charges,All Other,2768.28,34,,2768.28,percent of total billed charges,Implant Device,2768.28,34,,2768.28,percent of total billed charges,Implant Device,2849.7,35,,2849.7,percent of total billed charges,Implant Device,2849.7,35,,2849.7,percent of total billed charges,Implant Device,2849.7,35,,2849.7,percent of total billed charges,Implant Device,2849.7,35,,2849.7,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2768.28,34,"If Charge > 2,000, then 34 percent",2768.28,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,6025.1,
COOK G53703 MEDICAL STENT,C1874,HCPCS,,79002522,CDM,278,RC,,,both,,,264,195.36,,,195.36,Other,150% of Medicare + 9.63% HCRA Surcharge,118.8,45,,118.8,percent of total billed charges,Critical Access Hospital RCC factor,89.76,34,,89.76,percent of total billed charges,Implant Device,89.76,34,,89.76,percent of total billed charges,Implant Device,89.76,34,,89.76,percent of total billed charges,Implant Device,89.76,34,,89.76,percent of total billed charges,Implant Device,89.76,34,,89.76,percent of total billed charges,Implant Device,130.68,,,130.68,Other,110% of Medicare,92.4,35,,92.4,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,92.4,35,,92.4,percent of total billed charges,Implant Device,92.4,35,,92.4,percent of total billed charges,Implant Device,92.4,35,,92.4,percent of total billed charges,Implant Device,92.4,35,,92.4,percent of total billed charges,Implant Device,92.4,35,,92.4,percent of total billed charges,Implant Device,105.6,40,,105.6,percent of total billed charges,Implant Device,92.4,70,,92.4,percent of total billed charges,All Other,89.76,34,,89.76,percent of total billed charges,Implant Device,89.76,34,,89.76,percent of total billed charges,Implant Device,92.4,35,,92.4,percent of total billed charges,Implant Device,92.4,35,,92.4,percent of total billed charges,Implant Device,92.4,35,,92.4,percent of total billed charges,Implant Device,92.4,35,,92.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,195.36,
ORTHOFIX M315 SCREW,C1713,HCPCS,,79002525,CDM,278,RC,,,both,,,300,222,,,222,Other,150% of Medicare + 9.63% HCRA Surcharge,135,45,,135,percent of total billed charges,Critical Access Hospital RCC factor,102,34,,102,percent of total billed charges,Implant Device,102,34,,102,percent of total billed charges,Implant Device,102,34,,102,percent of total billed charges,Implant Device,102,34,,102,percent of total billed charges,Implant Device,102,34,,102,percent of total billed charges,Implant Device,148.5,,,148.5,Other,110% of Medicare,105,35,,105,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,105,35,,105,percent of total billed charges,Implant Device,105,35,,105,percent of total billed charges,Implant Device,105,35,,105,percent of total billed charges,Implant Device,105,35,,105,percent of total billed charges,Implant Device,105,35,,105,percent of total billed charges,Implant Device,120,40,,120,percent of total billed charges,Implant Device,105,70,,105,percent of total billed charges,All Other,102,34,,102,percent of total billed charges,Implant Device,102,34,,102,percent of total billed charges,Implant Device,105,35,,105,percent of total billed charges,Implant Device,105,35,,105,percent of total billed charges,Implant Device,105,35,,105,percent of total billed charges,Implant Device,105,35,,105,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,222,
SOLANA MD103 METATARSAL IMPLANT,C1776,HCPCS,,79002527,CDM,278,RC,,,both,,,9886,7315.66,,,7315.66,Other,150% of Medicare + 9.63% HCRA Surcharge,4448.7,45,,4448.7,percent of total billed charges,Critical Access Hospital RCC factor,3361.24,34,,3361.24,percent of total billed charges,Implant Device,3361.24,34,,3361.24,percent of total billed charges,Implant Device,3361.24,34,,3361.24,percent of total billed charges,Implant Device,3361.24,34,,3361.24,percent of total billed charges,Implant Device,3361.24,34,,3361.24,percent of total billed charges,Implant Device,4893.57,,,4893.57,Other,110% of Medicare,3460.1,35,,3460.1,percent of total billed charges,Implant Device,3361.24,34,"Charges > $500, x 34%",3361.24,percent of total billed charges,Implant Device,3460.1,35,,3460.1,percent of total billed charges,Implant Device,3460.1,35,,3460.1,percent of total billed charges,Implant Device,3460.1,35,,3460.1,percent of total billed charges,Implant Device,3460.1,35,,3460.1,percent of total billed charges,Implant Device,3460.1,35,,3460.1,percent of total billed charges,Implant Device,3954.4,40,,3954.4,percent of total billed charges,Implant Device,3460.1,70,,3460.1,percent of total billed charges,All Other,3361.24,34,,3361.24,percent of total billed charges,Implant Device,3361.24,34,,3361.24,percent of total billed charges,Implant Device,3460.1,35,,3460.1,percent of total billed charges,Implant Device,3460.1,35,,3460.1,percent of total billed charges,Implant Device,3460.1,35,,3460.1,percent of total billed charges,Implant Device,3460.1,35,,3460.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3361.24,34,"If Charge > 2,000, then 34 percent",3361.24,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,7315.66,
ORTHOHELIX MFT-002-PMLKG PLATE,C1713,HCPCS,,79002530,CDM,278,RC,,,both,,,3624,2681.77,,,2681.77,Other,150% of Medicare + 9.63% HCRA Surcharge,1630.8,45,,1630.8,percent of total billed charges,Critical Access Hospital RCC factor,1232.16,34,,1232.16,percent of total billed charges,Implant Device,1232.16,34,,1232.16,percent of total billed charges,Implant Device,1232.16,34,,1232.16,percent of total billed charges,Implant Device,1232.16,34,,1232.16,percent of total billed charges,Implant Device,1232.16,34,,1232.16,percent of total billed charges,Implant Device,1793.88,,,1793.88,Other,110% of Medicare,1268.4,35,,1268.4,percent of total billed charges,Implant Device,1232.16,34,"Charges > $500, x 34%",1232.16,percent of total billed charges,Implant Device,1268.4,35,,1268.4,percent of total billed charges,Implant Device,1268.4,35,,1268.4,percent of total billed charges,Implant Device,1268.4,35,,1268.4,percent of total billed charges,Implant Device,1268.4,35,,1268.4,percent of total billed charges,Implant Device,1268.4,35,,1268.4,percent of total billed charges,Implant Device,1449.6,40,,1449.6,percent of total billed charges,Implant Device,1268.4,70,,1268.4,percent of total billed charges,All Other,1232.16,34,,1232.16,percent of total billed charges,Implant Device,1232.16,34,,1232.16,percent of total billed charges,Implant Device,1268.4,35,,1268.4,percent of total billed charges,Implant Device,1268.4,35,,1268.4,percent of total billed charges,Implant Device,1268.4,35,,1268.4,percent of total billed charges,Implant Device,1268.4,35,,1268.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1232.16,34,"If Charge > 2,000, then 34 percent",1232.16,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2681.77,
ORTHOHELIX MFT-002-PMX PLATE,C1713,HCPCS,,79002531,CDM,278,RC,,,both,,,3624,2681.77,,,2681.77,Other,150% of Medicare + 9.63% HCRA Surcharge,1630.8,45,,1630.8,percent of total billed charges,Critical Access Hospital RCC factor,1232.16,34,,1232.16,percent of total billed charges,Implant Device,1232.16,34,,1232.16,percent of total billed charges,Implant Device,1232.16,34,,1232.16,percent of total billed charges,Implant Device,1232.16,34,,1232.16,percent of total billed charges,Implant Device,1232.16,34,,1232.16,percent of total billed charges,Implant Device,1793.88,,,1793.88,Other,110% of Medicare,1268.4,35,,1268.4,percent of total billed charges,Implant Device,1232.16,34,"Charges > $500, x 34%",1232.16,percent of total billed charges,Implant Device,1268.4,35,,1268.4,percent of total billed charges,Implant Device,1268.4,35,,1268.4,percent of total billed charges,Implant Device,1268.4,35,,1268.4,percent of total billed charges,Implant Device,1268.4,35,,1268.4,percent of total billed charges,Implant Device,1268.4,35,,1268.4,percent of total billed charges,Implant Device,1449.6,40,,1449.6,percent of total billed charges,Implant Device,1268.4,70,,1268.4,percent of total billed charges,All Other,1232.16,34,,1232.16,percent of total billed charges,Implant Device,1232.16,34,,1232.16,percent of total billed charges,Implant Device,1268.4,35,,1268.4,percent of total billed charges,Implant Device,1268.4,35,,1268.4,percent of total billed charges,Implant Device,1268.4,35,,1268.4,percent of total billed charges,Implant Device,1268.4,35,,1268.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1232.16,34,"If Charge > 2,000, then 34 percent",1232.16,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2681.77,
ORTHOHELIX MFT-011-40-30 SCREW,C1713,HCPCS,,79002532,CDM,278,RC,,,both,,,546,404.04,,,404.04,Other,150% of Medicare + 9.63% HCRA Surcharge,245.7,45,,245.7,percent of total billed charges,Critical Access Hospital RCC factor,185.64,34,,185.64,percent of total billed charges,Implant Device,185.64,34,,185.64,percent of total billed charges,Implant Device,185.64,34,,185.64,percent of total billed charges,Implant Device,185.64,34,,185.64,percent of total billed charges,Implant Device,185.64,34,,185.64,percent of total billed charges,Implant Device,270.27,,,270.27,Other,110% of Medicare,191.1,35,,191.1,percent of total billed charges,Implant Device,185.64,34,"Charges > $500, x 34%",185.64,percent of total billed charges,Implant Device,191.1,35,,191.1,percent of total billed charges,Implant Device,191.1,35,,191.1,percent of total billed charges,Implant Device,191.1,35,,191.1,percent of total billed charges,Implant Device,191.1,35,,191.1,percent of total billed charges,Implant Device,191.1,35,,191.1,percent of total billed charges,Implant Device,218.4,40,,218.4,percent of total billed charges,Implant Device,191.1,70,,191.1,percent of total billed charges,All Other,185.64,34,,185.64,percent of total billed charges,Implant Device,185.64,34,,185.64,percent of total billed charges,Implant Device,191.1,35,,191.1,percent of total billed charges,Implant Device,191.1,35,,191.1,percent of total billed charges,Implant Device,191.1,35,,191.1,percent of total billed charges,Implant Device,191.1,35,,191.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,404.04,
ORTHOHELIX MFT-021-35-14 SCREEW,C1713,HCPCS,,79002533,CDM,278,RC,,,both,,,546,404.04,,,404.04,Other,150% of Medicare + 9.63% HCRA Surcharge,245.7,45,,245.7,percent of total billed charges,Critical Access Hospital RCC factor,185.64,34,,185.64,percent of total billed charges,Implant Device,185.64,34,,185.64,percent of total billed charges,Implant Device,185.64,34,,185.64,percent of total billed charges,Implant Device,185.64,34,,185.64,percent of total billed charges,Implant Device,185.64,34,,185.64,percent of total billed charges,Implant Device,270.27,,,270.27,Other,110% of Medicare,191.1,35,,191.1,percent of total billed charges,Implant Device,185.64,34,"Charges > $500, x 34%",185.64,percent of total billed charges,Implant Device,191.1,35,,191.1,percent of total billed charges,Implant Device,191.1,35,,191.1,percent of total billed charges,Implant Device,191.1,35,,191.1,percent of total billed charges,Implant Device,191.1,35,,191.1,percent of total billed charges,Implant Device,191.1,35,,191.1,percent of total billed charges,Implant Device,218.4,40,,218.4,percent of total billed charges,Implant Device,191.1,70,,191.1,percent of total billed charges,All Other,185.64,34,,185.64,percent of total billed charges,Implant Device,185.64,34,,185.64,percent of total billed charges,Implant Device,191.1,35,,191.1,percent of total billed charges,Implant Device,191.1,35,,191.1,percent of total billed charges,Implant Device,191.1,35,,191.1,percent of total billed charges,Implant Device,191.1,35,,191.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,404.04,
ORTHOHELIX MFT-021-35-18 SCREW,C1713,HCPCS,,79002534,CDM,278,RC,,,both,,,546,404.04,,,404.04,Other,150% of Medicare + 9.63% HCRA Surcharge,245.7,45,,245.7,percent of total billed charges,Critical Access Hospital RCC factor,185.64,34,,185.64,percent of total billed charges,Implant Device,185.64,34,,185.64,percent of total billed charges,Implant Device,185.64,34,,185.64,percent of total billed charges,Implant Device,185.64,34,,185.64,percent of total billed charges,Implant Device,185.64,34,,185.64,percent of total billed charges,Implant Device,270.27,,,270.27,Other,110% of Medicare,191.1,35,,191.1,percent of total billed charges,Implant Device,185.64,34,"Charges > $500, x 34%",185.64,percent of total billed charges,Implant Device,191.1,35,,191.1,percent of total billed charges,Implant Device,191.1,35,,191.1,percent of total billed charges,Implant Device,191.1,35,,191.1,percent of total billed charges,Implant Device,191.1,35,,191.1,percent of total billed charges,Implant Device,191.1,35,,191.1,percent of total billed charges,Implant Device,218.4,40,,218.4,percent of total billed charges,Implant Device,191.1,70,,191.1,percent of total billed charges,All Other,185.64,34,,185.64,percent of total billed charges,Implant Device,185.64,34,,185.64,percent of total billed charges,Implant Device,191.1,35,,191.1,percent of total billed charges,Implant Device,191.1,35,,191.1,percent of total billed charges,Implant Device,191.1,35,,191.1,percent of total billed charges,Implant Device,191.1,35,,191.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,404.04,
ORTHOHELIX MFT-021-35-30 SCREW,C1713,HCPCS,,79002535,CDM,278,RC,,,both,,,546,404.04,,,404.04,Other,150% of Medicare + 9.63% HCRA Surcharge,245.7,45,,245.7,percent of total billed charges,Critical Access Hospital RCC factor,185.64,34,,185.64,percent of total billed charges,Implant Device,185.64,34,,185.64,percent of total billed charges,Implant Device,185.64,34,,185.64,percent of total billed charges,Implant Device,185.64,34,,185.64,percent of total billed charges,Implant Device,185.64,34,,185.64,percent of total billed charges,Implant Device,270.27,,,270.27,Other,110% of Medicare,191.1,35,,191.1,percent of total billed charges,Implant Device,185.64,34,"Charges > $500, x 34%",185.64,percent of total billed charges,Implant Device,191.1,35,,191.1,percent of total billed charges,Implant Device,191.1,35,,191.1,percent of total billed charges,Implant Device,191.1,35,,191.1,percent of total billed charges,Implant Device,191.1,35,,191.1,percent of total billed charges,Implant Device,191.1,35,,191.1,percent of total billed charges,Implant Device,218.4,40,,218.4,percent of total billed charges,Implant Device,191.1,70,,191.1,percent of total billed charges,All Other,185.64,34,,185.64,percent of total billed charges,Implant Device,185.64,34,,185.64,percent of total billed charges,Implant Device,191.1,35,,191.1,percent of total billed charges,Implant Device,191.1,35,,191.1,percent of total billed charges,Implant Device,191.1,35,,191.1,percent of total billed charges,Implant Device,191.1,35,,191.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,404.04,
ORTHOHELIX MFT-021-35-325 SCREW,C1713,HCPCS,,79002536,CDM,278,RC,,,both,,,546,404.04,,,404.04,Other,150% of Medicare + 9.63% HCRA Surcharge,245.7,45,,245.7,percent of total billed charges,Critical Access Hospital RCC factor,185.64,34,,185.64,percent of total billed charges,Implant Device,185.64,34,,185.64,percent of total billed charges,Implant Device,185.64,34,,185.64,percent of total billed charges,Implant Device,185.64,34,,185.64,percent of total billed charges,Implant Device,185.64,34,,185.64,percent of total billed charges,Implant Device,270.27,,,270.27,Other,110% of Medicare,191.1,35,,191.1,percent of total billed charges,Implant Device,185.64,34,"Charges > $500, x 34%",185.64,percent of total billed charges,Implant Device,191.1,35,,191.1,percent of total billed charges,Implant Device,191.1,35,,191.1,percent of total billed charges,Implant Device,191.1,35,,191.1,percent of total billed charges,Implant Device,191.1,35,,191.1,percent of total billed charges,Implant Device,191.1,35,,191.1,percent of total billed charges,Implant Device,218.4,40,,218.4,percent of total billed charges,Implant Device,191.1,70,,191.1,percent of total billed charges,All Other,185.64,34,,185.64,percent of total billed charges,Implant Device,185.64,34,,185.64,percent of total billed charges,Implant Device,191.1,35,,191.1,percent of total billed charges,Implant Device,191.1,35,,191.1,percent of total billed charges,Implant Device,191.1,35,,191.1,percent of total billed charges,Implant Device,191.1,35,,191.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,404.04,
MPQ-2.5 UROPLASTY MACROPLASTIQUE IMPLANT,L8606,HCPCS,,79002542,CDM,278,RC,,,both,,,1486,1099.64,,,1099.64,Other,150% of Medicare + 9.63% HCRA Surcharge,668.7,45,,668.7,percent of total billed charges,Critical Access Hospital RCC factor,505.24,34,,505.24,percent of total billed charges,Implant Device,505.24,34,,505.24,percent of total billed charges,Implant Device,505.24,34,,505.24,percent of total billed charges,Implant Device,505.24,34,,505.24,percent of total billed charges,Implant Device,505.24,34,,505.24,percent of total billed charges,Implant Device,735.57,,,735.57,Other,110% of Medicare,520.1,35,,520.1,percent of total billed charges,Implant Device,505.24,34,"Charges > $500, x 34%",505.24,percent of total billed charges,Implant Device,520.1,35,,520.1,percent of total billed charges,Implant Device,520.1,35,,520.1,percent of total billed charges,Implant Device,520.1,35,,520.1,percent of total billed charges,Implant Device,520.1,35,,520.1,percent of total billed charges,Implant Device,520.1,35,,520.1,percent of total billed charges,Implant Device,594.4,40,,594.4,percent of total billed charges,Implant Device,520.1,70,,520.1,percent of total billed charges,All Other,505.24,34,,505.24,percent of total billed charges,Implant Device,505.24,34,,505.24,percent of total billed charges,Implant Device,520.1,35,,520.1,percent of total billed charges,Implant Device,520.1,35,,520.1,percent of total billed charges,Implant Device,520.1,35,,520.1,percent of total billed charges,Implant Device,520.1,35,,520.1,percent of total billed charges,Implant Device,976.07,,,976.07,Other,100% of Medicaid,976.07,,,976.07,Other,100% of Medicaid,976.07,,,976.07,Other,100% of Medicaid,976.07,,,976.07,Other,100% of Medicaid,2196.15,,,2196.15,Other,225% of Medicaid,1493.38,,,1493.38,Other,153% of Medicaid,2196.15,,,2196.15,Other,225% of Medicaid,1366.49,,,1366.49,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,2537.77,,,2537.77,Other,260% of Medicaid,3162.45,,,3162.45,Other,324% of Medicaid,2098.54,,,2098.54,Other,215% of Medicaid,2098.54,,,2098.54,Other,215% of Medicaid,1220.08,,,1220.08,Other,125% of Medicaid,0.01,3162.45,
ORTHOHELIX MDS-010-40-285 SCREW,C1713,HCPCS,,79002544,CDM,278,RC,,,both,,,646,478.04,,,478.04,Other,150% of Medicare + 9.63% HCRA Surcharge,290.7,45,,290.7,percent of total billed charges,Critical Access Hospital RCC factor,219.64,34,,219.64,percent of total billed charges,Implant Device,219.64,34,,219.64,percent of total billed charges,Implant Device,219.64,34,,219.64,percent of total billed charges,Implant Device,219.64,34,,219.64,percent of total billed charges,Implant Device,219.64,34,,219.64,percent of total billed charges,Implant Device,319.77,,,319.77,Other,110% of Medicare,226.1,35,,226.1,percent of total billed charges,Implant Device,219.64,34,"Charges > $500, x 34%",219.64,percent of total billed charges,Implant Device,226.1,35,,226.1,percent of total billed charges,Implant Device,226.1,35,,226.1,percent of total billed charges,Implant Device,226.1,35,,226.1,percent of total billed charges,Implant Device,226.1,35,,226.1,percent of total billed charges,Implant Device,226.1,35,,226.1,percent of total billed charges,Implant Device,258.4,40,,258.4,percent of total billed charges,Implant Device,226.1,70,,226.1,percent of total billed charges,All Other,219.64,34,,219.64,percent of total billed charges,Implant Device,219.64,34,,219.64,percent of total billed charges,Implant Device,226.1,35,,226.1,percent of total billed charges,Implant Device,226.1,35,,226.1,percent of total billed charges,Implant Device,226.1,35,,226.1,percent of total billed charges,Implant Device,226.1,35,,226.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,478.04,
ORTHOHELIX MSD-010-40-3255 SCREW,C1713,HCPCS,,79002545,CDM,278,RC,,,both,,,646,478.04,,,478.04,Other,150% of Medicare + 9.63% HCRA Surcharge,290.7,45,,290.7,percent of total billed charges,Critical Access Hospital RCC factor,219.64,34,,219.64,percent of total billed charges,Implant Device,219.64,34,,219.64,percent of total billed charges,Implant Device,219.64,34,,219.64,percent of total billed charges,Implant Device,219.64,34,,219.64,percent of total billed charges,Implant Device,219.64,34,,219.64,percent of total billed charges,Implant Device,319.77,,,319.77,Other,110% of Medicare,226.1,35,,226.1,percent of total billed charges,Implant Device,219.64,34,"Charges > $500, x 34%",219.64,percent of total billed charges,Implant Device,226.1,35,,226.1,percent of total billed charges,Implant Device,226.1,35,,226.1,percent of total billed charges,Implant Device,226.1,35,,226.1,percent of total billed charges,Implant Device,226.1,35,,226.1,percent of total billed charges,Implant Device,226.1,35,,226.1,percent of total billed charges,Implant Device,258.4,40,,258.4,percent of total billed charges,Implant Device,226.1,70,,226.1,percent of total billed charges,All Other,219.64,34,,219.64,percent of total billed charges,Implant Device,219.64,34,,219.64,percent of total billed charges,Implant Device,226.1,35,,226.1,percent of total billed charges,Implant Device,226.1,35,,226.1,percent of total billed charges,Implant Device,226.1,35,,226.1,percent of total billed charges,Implant Device,226.1,35,,226.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,478.04,
ORTHOHELIX MXM-011-24-08 SCREW,C1713,HCPCS,,79002550,CDM,278,RC,,,both,,,330,244.2,,,244.2,Other,150% of Medicare + 9.63% HCRA Surcharge,148.5,45,,148.5,percent of total billed charges,Critical Access Hospital RCC factor,112.2,34,,112.2,percent of total billed charges,Implant Device,112.2,34,,112.2,percent of total billed charges,Implant Device,112.2,34,,112.2,percent of total billed charges,Implant Device,112.2,34,,112.2,percent of total billed charges,Implant Device,112.2,34,,112.2,percent of total billed charges,Implant Device,163.35,,,163.35,Other,110% of Medicare,115.5,35,,115.5,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,132,40,,132,percent of total billed charges,Implant Device,115.5,70,,115.5,percent of total billed charges,All Other,112.2,34,,112.2,percent of total billed charges,Implant Device,112.2,34,,112.2,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,244.2,
ORTHOHELIX MXM-011-24-14 SCREW,C1713,HCPCS,,79002551,CDM,278,RC,,,both,,,330,244.2,,,244.2,Other,150% of Medicare + 9.63% HCRA Surcharge,148.5,45,,148.5,percent of total billed charges,Critical Access Hospital RCC factor,112.2,34,,112.2,percent of total billed charges,Implant Device,112.2,34,,112.2,percent of total billed charges,Implant Device,112.2,34,,112.2,percent of total billed charges,Implant Device,112.2,34,,112.2,percent of total billed charges,Implant Device,112.2,34,,112.2,percent of total billed charges,Implant Device,163.35,,,163.35,Other,110% of Medicare,115.5,35,,115.5,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,132,40,,132,percent of total billed charges,Implant Device,115.5,70,,115.5,percent of total billed charges,All Other,112.2,34,,112.2,percent of total billed charges,Implant Device,112.2,34,,112.2,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,244.2,
ORTHOHELIX MXM-011-24-16 SCREW,C1713,HCPCS,,79002552,CDM,278,RC,,,both,,,330,244.2,,,244.2,Other,150% of Medicare + 9.63% HCRA Surcharge,148.5,45,,148.5,percent of total billed charges,Critical Access Hospital RCC factor,112.2,34,,112.2,percent of total billed charges,Implant Device,112.2,34,,112.2,percent of total billed charges,Implant Device,112.2,34,,112.2,percent of total billed charges,Implant Device,112.2,34,,112.2,percent of total billed charges,Implant Device,112.2,34,,112.2,percent of total billed charges,Implant Device,163.35,,,163.35,Other,110% of Medicare,115.5,35,,115.5,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,132,40,,132,percent of total billed charges,Implant Device,115.5,70,,115.5,percent of total billed charges,All Other,112.2,34,,112.2,percent of total billed charges,Implant Device,112.2,34,,112.2,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,244.2,
ORTHOHELIX MXM-011-27-12 SCREW,C1713,HCPCS,,79002553,CDM,278,RC,,,both,,,330,244.2,,,244.2,Other,150% of Medicare + 9.63% HCRA Surcharge,148.5,45,,148.5,percent of total billed charges,Critical Access Hospital RCC factor,112.2,34,,112.2,percent of total billed charges,Implant Device,112.2,34,,112.2,percent of total billed charges,Implant Device,112.2,34,,112.2,percent of total billed charges,Implant Device,112.2,34,,112.2,percent of total billed charges,Implant Device,112.2,34,,112.2,percent of total billed charges,Implant Device,163.35,,,163.35,Other,110% of Medicare,115.5,35,,115.5,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,132,40,,132,percent of total billed charges,Implant Device,115.5,70,,115.5,percent of total billed charges,All Other,112.2,34,,112.2,percent of total billed charges,Implant Device,112.2,34,,112.2,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,244.2,
ORTHOHELIX MXM-021-24-08 SCREW,C1713,HCPCS,,79002554,CDM,278,RC,,,both,,,330,244.2,,,244.2,Other,150% of Medicare + 9.63% HCRA Surcharge,148.5,45,,148.5,percent of total billed charges,Critical Access Hospital RCC factor,112.2,34,,112.2,percent of total billed charges,Implant Device,112.2,34,,112.2,percent of total billed charges,Implant Device,112.2,34,,112.2,percent of total billed charges,Implant Device,112.2,34,,112.2,percent of total billed charges,Implant Device,112.2,34,,112.2,percent of total billed charges,Implant Device,163.35,,,163.35,Other,110% of Medicare,115.5,35,,115.5,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,132,40,,132,percent of total billed charges,Implant Device,115.5,70,,115.5,percent of total billed charges,All Other,112.2,34,,112.2,percent of total billed charges,Implant Device,112.2,34,,112.2,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,244.2,
ORTHOHELIX MXM-021-24-10 SCREW,C1713,HCPCS,,79002555,CDM,278,RC,,,both,,,330,244.2,,,244.2,Other,150% of Medicare + 9.63% HCRA Surcharge,148.5,45,,148.5,percent of total billed charges,Critical Access Hospital RCC factor,112.2,34,,112.2,percent of total billed charges,Implant Device,112.2,34,,112.2,percent of total billed charges,Implant Device,112.2,34,,112.2,percent of total billed charges,Implant Device,112.2,34,,112.2,percent of total billed charges,Implant Device,112.2,34,,112.2,percent of total billed charges,Implant Device,163.35,,,163.35,Other,110% of Medicare,115.5,35,,115.5,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,132,40,,132,percent of total billed charges,Implant Device,115.5,70,,115.5,percent of total billed charges,All Other,112.2,34,,112.2,percent of total billed charges,Implant Device,112.2,34,,112.2,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,244.2,
ORTHOHELIX MXM-021-24-14 SCREW,C1713,HCPCS,,79002556,CDM,278,RC,,,both,,,330,244.2,,,244.2,Other,150% of Medicare + 9.63% HCRA Surcharge,148.5,45,,148.5,percent of total billed charges,Critical Access Hospital RCC factor,112.2,34,,112.2,percent of total billed charges,Implant Device,112.2,34,,112.2,percent of total billed charges,Implant Device,112.2,34,,112.2,percent of total billed charges,Implant Device,112.2,34,,112.2,percent of total billed charges,Implant Device,112.2,34,,112.2,percent of total billed charges,Implant Device,163.35,,,163.35,Other,110% of Medicare,115.5,35,,115.5,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,132,40,,132,percent of total billed charges,Implant Device,115.5,70,,115.5,percent of total billed charges,All Other,112.2,34,,112.2,percent of total billed charges,Implant Device,112.2,34,,112.2,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,244.2,
ORTHOHELIX MXM-021-27-14 SCREW,C1713,HCPCS,,79002557,CDM,278,RC,,,both,,,330,244.2,,,244.2,Other,150% of Medicare + 9.63% HCRA Surcharge,148.5,45,,148.5,percent of total billed charges,Critical Access Hospital RCC factor,112.2,34,,112.2,percent of total billed charges,Implant Device,112.2,34,,112.2,percent of total billed charges,Implant Device,112.2,34,,112.2,percent of total billed charges,Implant Device,112.2,34,,112.2,percent of total billed charges,Implant Device,112.2,34,,112.2,percent of total billed charges,Implant Device,163.35,,,163.35,Other,110% of Medicare,115.5,35,,115.5,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,132,40,,132,percent of total billed charges,Implant Device,115.5,70,,115.5,percent of total billed charges,All Other,112.2,34,,112.2,percent of total billed charges,Implant Device,112.2,34,,112.2,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,244.2,
PAC 3 N60000101 X-SPINE PLATE,C1713,HCPCS,,79002561,CDM,278,RC,,,both,,,2250,1665.01,,,1665.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1012.5,45,,1012.5,percent of total billed charges,Critical Access Hospital RCC factor,765,34,,765,percent of total billed charges,Implant Device,765,34,,765,percent of total billed charges,Implant Device,765,34,,765,percent of total billed charges,Implant Device,765,34,,765,percent of total billed charges,Implant Device,765,34,,765,percent of total billed charges,Implant Device,1113.75,,,1113.75,Other,110% of Medicare,787.5,35,,787.5,percent of total billed charges,Implant Device,765,34,"Charges > $500, x 34%",765,percent of total billed charges,Implant Device,787.5,35,,787.5,percent of total billed charges,Implant Device,787.5,35,,787.5,percent of total billed charges,Implant Device,787.5,35,,787.5,percent of total billed charges,Implant Device,787.5,35,,787.5,percent of total billed charges,Implant Device,787.5,35,,787.5,percent of total billed charges,Implant Device,900,40,,900,percent of total billed charges,Implant Device,787.5,70,,787.5,percent of total billed charges,All Other,765,34,,765,percent of total billed charges,Implant Device,765,34,,765,percent of total billed charges,Implant Device,787.5,35,,787.5,percent of total billed charges,Implant Device,787.5,35,,787.5,percent of total billed charges,Implant Device,787.5,35,,787.5,percent of total billed charges,Implant Device,787.5,35,,787.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,765,34,"If Charge > 2,000, then 34 percent",765,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1665.01,
PAC 3 N60000103 X-SPINE PLATE,C1713,HCPCS,,79002562,CDM,278,RC,,,both,,,2280,1687.21,,,1687.21,Other,150% of Medicare + 9.63% HCRA Surcharge,1026,45,,1026,percent of total billed charges,Critical Access Hospital RCC factor,775.2,34,,775.2,percent of total billed charges,Implant Device,775.2,34,,775.2,percent of total billed charges,Implant Device,775.2,34,,775.2,percent of total billed charges,Implant Device,775.2,34,,775.2,percent of total billed charges,Implant Device,775.2,34,,775.2,percent of total billed charges,Implant Device,1128.6,,,1128.6,Other,110% of Medicare,798,35,,798,percent of total billed charges,Implant Device,775.2,34,"Charges > $500, x 34%",775.2,percent of total billed charges,Implant Device,798,35,,798,percent of total billed charges,Implant Device,798,35,,798,percent of total billed charges,Implant Device,798,35,,798,percent of total billed charges,Implant Device,798,35,,798,percent of total billed charges,Implant Device,798,35,,798,percent of total billed charges,Implant Device,912,40,,912,percent of total billed charges,Implant Device,798,70,,798,percent of total billed charges,All Other,775.2,34,,775.2,percent of total billed charges,Implant Device,775.2,34,,775.2,percent of total billed charges,Implant Device,798,35,,798,percent of total billed charges,Implant Device,798,35,,798,percent of total billed charges,Implant Device,798,35,,798,percent of total billed charges,Implant Device,798,35,,798,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,775.2,34,"If Charge > 2,000, then 34 percent",775.2,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1687.21,
PAC 3 N60000109 X-SPINE PLATE,C1713,HCPCS,,79002563,CDM,278,RC,,,both,,,2700,1998.01,,,1998.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1215,45,,1215,percent of total billed charges,Critical Access Hospital RCC factor,918,34,,918,percent of total billed charges,Implant Device,918,34,,918,percent of total billed charges,Implant Device,918,34,,918,percent of total billed charges,Implant Device,918,34,,918,percent of total billed charges,Implant Device,918,34,,918,percent of total billed charges,Implant Device,1336.5,,,1336.5,Other,110% of Medicare,945,35,,945,percent of total billed charges,Implant Device,918,34,"Charges > $500, x 34%",918,percent of total billed charges,Implant Device,945,35,,945,percent of total billed charges,Implant Device,945,35,,945,percent of total billed charges,Implant Device,945,35,,945,percent of total billed charges,Implant Device,945,35,,945,percent of total billed charges,Implant Device,945,35,,945,percent of total billed charges,Implant Device,1080,40,,1080,percent of total billed charges,Implant Device,945,70,,945,percent of total billed charges,All Other,918,34,,918,percent of total billed charges,Implant Device,918,34,,918,percent of total billed charges,Implant Device,945,35,,945,percent of total billed charges,Implant Device,945,35,,945,percent of total billed charges,Implant Device,945,35,,945,percent of total billed charges,Implant Device,945,35,,945,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,918,34,"If Charge > 2,000, then 34 percent",918,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1998.01,
PAC 3 N60000110 X-SPINE PLATE,C1713,HCPCS,,79002564,CDM,278,RC,,,both,,,2700,1998.01,,,1998.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1215,45,,1215,percent of total billed charges,Critical Access Hospital RCC factor,918,34,,918,percent of total billed charges,Implant Device,918,34,,918,percent of total billed charges,Implant Device,918,34,,918,percent of total billed charges,Implant Device,918,34,,918,percent of total billed charges,Implant Device,918,34,,918,percent of total billed charges,Implant Device,1336.5,,,1336.5,Other,110% of Medicare,945,35,,945,percent of total billed charges,Implant Device,918,34,"Charges > $500, x 34%",918,percent of total billed charges,Implant Device,945,35,,945,percent of total billed charges,Implant Device,945,35,,945,percent of total billed charges,Implant Device,945,35,,945,percent of total billed charges,Implant Device,945,35,,945,percent of total billed charges,Implant Device,945,35,,945,percent of total billed charges,Implant Device,1080,40,,1080,percent of total billed charges,Implant Device,945,70,,945,percent of total billed charges,All Other,918,34,,918,percent of total billed charges,Implant Device,918,34,,918,percent of total billed charges,Implant Device,945,35,,945,percent of total billed charges,Implant Device,945,35,,945,percent of total billed charges,Implant Device,945,35,,945,percent of total billed charges,Implant Device,945,35,,945,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,918,34,"If Charge > 2,000, then 34 percent",918,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1998.01,
PAC 3 N60000111 X-SPINE PLATE,C1713,HCPCS,,79002565,CDM,278,RC,,,both,,,2700,1998.01,,,1998.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1215,45,,1215,percent of total billed charges,Critical Access Hospital RCC factor,918,34,,918,percent of total billed charges,Implant Device,918,34,,918,percent of total billed charges,Implant Device,918,34,,918,percent of total billed charges,Implant Device,918,34,,918,percent of total billed charges,Implant Device,918,34,,918,percent of total billed charges,Implant Device,1336.5,,,1336.5,Other,110% of Medicare,945,35,,945,percent of total billed charges,Implant Device,918,34,"Charges > $500, x 34%",918,percent of total billed charges,Implant Device,945,35,,945,percent of total billed charges,Implant Device,945,35,,945,percent of total billed charges,Implant Device,945,35,,945,percent of total billed charges,Implant Device,945,35,,945,percent of total billed charges,Implant Device,945,35,,945,percent of total billed charges,Implant Device,1080,40,,1080,percent of total billed charges,Implant Device,945,70,,945,percent of total billed charges,All Other,918,34,,918,percent of total billed charges,Implant Device,918,34,,918,percent of total billed charges,Implant Device,945,35,,945,percent of total billed charges,Implant Device,945,35,,945,percent of total billed charges,Implant Device,945,35,,945,percent of total billed charges,Implant Device,945,35,,945,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,918,34,"If Charge > 2,000, then 34 percent",918,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1998.01,
PAC 3 N60000115 X-SPINE PLATE,C1713,HCPCS,,79002566,CDM,278,RC,,,both,,,3136,2320.65,,,2320.65,Other,150% of Medicare + 9.63% HCRA Surcharge,1411.2,45,,1411.2,percent of total billed charges,Critical Access Hospital RCC factor,1066.24,34,,1066.24,percent of total billed charges,Implant Device,1066.24,34,,1066.24,percent of total billed charges,Implant Device,1066.24,34,,1066.24,percent of total billed charges,Implant Device,1066.24,34,,1066.24,percent of total billed charges,Implant Device,1066.24,34,,1066.24,percent of total billed charges,Implant Device,1552.32,,,1552.32,Other,110% of Medicare,1097.6,35,,1097.6,percent of total billed charges,Implant Device,1066.24,34,"Charges > $500, x 34%",1066.24,percent of total billed charges,Implant Device,1097.6,35,,1097.6,percent of total billed charges,Implant Device,1097.6,35,,1097.6,percent of total billed charges,Implant Device,1097.6,35,,1097.6,percent of total billed charges,Implant Device,1097.6,35,,1097.6,percent of total billed charges,Implant Device,1097.6,35,,1097.6,percent of total billed charges,Implant Device,1254.4,40,,1254.4,percent of total billed charges,Implant Device,1097.6,70,,1097.6,percent of total billed charges,All Other,1066.24,34,,1066.24,percent of total billed charges,Implant Device,1066.24,34,,1066.24,percent of total billed charges,Implant Device,1097.6,35,,1097.6,percent of total billed charges,Implant Device,1097.6,35,,1097.6,percent of total billed charges,Implant Device,1097.6,35,,1097.6,percent of total billed charges,Implant Device,1097.6,35,,1097.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1066.24,34,"If Charge > 2,000, then 34 percent",1066.24,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2320.65,
PAC 3 N60000116 X-SPINE PLATE,C1713,HCPCS,,79002567,CDM,278,RC,,,both,,,3136,2320.65,,,2320.65,Other,150% of Medicare + 9.63% HCRA Surcharge,1411.2,45,,1411.2,percent of total billed charges,Critical Access Hospital RCC factor,1066.24,34,,1066.24,percent of total billed charges,Implant Device,1066.24,34,,1066.24,percent of total billed charges,Implant Device,1066.24,34,,1066.24,percent of total billed charges,Implant Device,1066.24,34,,1066.24,percent of total billed charges,Implant Device,1066.24,34,,1066.24,percent of total billed charges,Implant Device,1552.32,,,1552.32,Other,110% of Medicare,1097.6,35,,1097.6,percent of total billed charges,Implant Device,1066.24,34,"Charges > $500, x 34%",1066.24,percent of total billed charges,Implant Device,1097.6,35,,1097.6,percent of total billed charges,Implant Device,1097.6,35,,1097.6,percent of total billed charges,Implant Device,1097.6,35,,1097.6,percent of total billed charges,Implant Device,1097.6,35,,1097.6,percent of total billed charges,Implant Device,1097.6,35,,1097.6,percent of total billed charges,Implant Device,1254.4,40,,1254.4,percent of total billed charges,Implant Device,1097.6,70,,1097.6,percent of total billed charges,All Other,1066.24,34,,1066.24,percent of total billed charges,Implant Device,1066.24,34,,1066.24,percent of total billed charges,Implant Device,1097.6,35,,1097.6,percent of total billed charges,Implant Device,1097.6,35,,1097.6,percent of total billed charges,Implant Device,1097.6,35,,1097.6,percent of total billed charges,Implant Device,1097.6,35,,1097.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1066.24,34,"If Charge > 2,000, then 34 percent",1066.24,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2320.65,
N60000117,C1713,HCPCS,,79002568,CDM,278,RC,,,both,,,3136,2320.65,,,2320.65,Other,150% of Medicare + 9.63% HCRA Surcharge,1411.2,45,,1411.2,percent of total billed charges,Critical Access Hospital RCC factor,1066.24,34,,1066.24,percent of total billed charges,Implant Device,1066.24,34,,1066.24,percent of total billed charges,Implant Device,1066.24,34,,1066.24,percent of total billed charges,Implant Device,1066.24,34,,1066.24,percent of total billed charges,Implant Device,1066.24,34,,1066.24,percent of total billed charges,Implant Device,1552.32,,,1552.32,Other,110% of Medicare,1097.6,35,,1097.6,percent of total billed charges,Implant Device,1066.24,34,"Charges > $500, x 34%",1066.24,percent of total billed charges,Implant Device,1097.6,35,,1097.6,percent of total billed charges,Implant Device,1097.6,35,,1097.6,percent of total billed charges,Implant Device,1097.6,35,,1097.6,percent of total billed charges,Implant Device,1097.6,35,,1097.6,percent of total billed charges,Implant Device,1097.6,35,,1097.6,percent of total billed charges,Implant Device,1254.4,40,,1254.4,percent of total billed charges,Implant Device,1097.6,70,,1097.6,percent of total billed charges,All Other,1066.24,34,,1066.24,percent of total billed charges,Implant Device,1066.24,34,,1066.24,percent of total billed charges,Implant Device,1097.6,35,,1097.6,percent of total billed charges,Implant Device,1097.6,35,,1097.6,percent of total billed charges,Implant Device,1097.6,35,,1097.6,percent of total billed charges,Implant Device,1097.6,35,,1097.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1066.24,34,"If Charge > 2,000, then 34 percent",1066.24,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2320.65,
PAC 3 N60000118 X-SPINE PLATE,C1713,HCPCS,,79002569,CDM,278,RC,,,both,,,3136,2320.65,,,2320.65,Other,150% of Medicare + 9.63% HCRA Surcharge,1411.2,45,,1411.2,percent of total billed charges,Critical Access Hospital RCC factor,1066.24,34,,1066.24,percent of total billed charges,Implant Device,1066.24,34,,1066.24,percent of total billed charges,Implant Device,1066.24,34,,1066.24,percent of total billed charges,Implant Device,1066.24,34,,1066.24,percent of total billed charges,Implant Device,1066.24,34,,1066.24,percent of total billed charges,Implant Device,1552.32,,,1552.32,Other,110% of Medicare,1097.6,35,,1097.6,percent of total billed charges,Implant Device,1066.24,34,"Charges > $500, x 34%",1066.24,percent of total billed charges,Implant Device,1097.6,35,,1097.6,percent of total billed charges,Implant Device,1097.6,35,,1097.6,percent of total billed charges,Implant Device,1097.6,35,,1097.6,percent of total billed charges,Implant Device,1097.6,35,,1097.6,percent of total billed charges,Implant Device,1097.6,35,,1097.6,percent of total billed charges,Implant Device,1254.4,40,,1254.4,percent of total billed charges,Implant Device,1097.6,70,,1097.6,percent of total billed charges,All Other,1066.24,34,,1066.24,percent of total billed charges,Implant Device,1066.24,34,,1066.24,percent of total billed charges,Implant Device,1097.6,35,,1097.6,percent of total billed charges,Implant Device,1097.6,35,,1097.6,percent of total billed charges,Implant Device,1097.6,35,,1097.6,percent of total billed charges,Implant Device,1097.6,35,,1097.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1066.24,34,"If Charge > 2,000, then 34 percent",1066.24,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2320.65,
PAC 3 N60000119 X-SPINE PLATE,C1713,HCPCS,,79002570,CDM,278,RC,,,both,,,3136,2320.65,,,2320.65,Other,150% of Medicare + 9.63% HCRA Surcharge,1411.2,45,,1411.2,percent of total billed charges,Critical Access Hospital RCC factor,1066.24,34,,1066.24,percent of total billed charges,Implant Device,1066.24,34,,1066.24,percent of total billed charges,Implant Device,1066.24,34,,1066.24,percent of total billed charges,Implant Device,1066.24,34,,1066.24,percent of total billed charges,Implant Device,1066.24,34,,1066.24,percent of total billed charges,Implant Device,1552.32,,,1552.32,Other,110% of Medicare,1097.6,35,,1097.6,percent of total billed charges,Implant Device,1066.24,34,"Charges > $500, x 34%",1066.24,percent of total billed charges,Implant Device,1097.6,35,,1097.6,percent of total billed charges,Implant Device,1097.6,35,,1097.6,percent of total billed charges,Implant Device,1097.6,35,,1097.6,percent of total billed charges,Implant Device,1097.6,35,,1097.6,percent of total billed charges,Implant Device,1097.6,35,,1097.6,percent of total billed charges,Implant Device,1254.4,40,,1254.4,percent of total billed charges,Implant Device,1097.6,70,,1097.6,percent of total billed charges,All Other,1066.24,34,,1066.24,percent of total billed charges,Implant Device,1066.24,34,,1066.24,percent of total billed charges,Implant Device,1097.6,35,,1097.6,percent of total billed charges,Implant Device,1097.6,35,,1097.6,percent of total billed charges,Implant Device,1097.6,35,,1097.6,percent of total billed charges,Implant Device,1097.6,35,,1097.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1066.24,34,"If Charge > 2,000, then 34 percent",1066.24,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2320.65,
PAC 3 N60000135 X-SPINE SCREW,C1713,HCPCS,,79002571,CDM,278,RC,,,both,,,706,522.44,,,522.44,Other,150% of Medicare + 9.63% HCRA Surcharge,317.7,45,,317.7,percent of total billed charges,Critical Access Hospital RCC factor,240.04,34,,240.04,percent of total billed charges,Implant Device,240.04,34,,240.04,percent of total billed charges,Implant Device,240.04,34,,240.04,percent of total billed charges,Implant Device,240.04,34,,240.04,percent of total billed charges,Implant Device,240.04,34,,240.04,percent of total billed charges,Implant Device,349.47,,,349.47,Other,110% of Medicare,247.1,35,,247.1,percent of total billed charges,Implant Device,240.04,34,"Charges > $500, x 34%",240.04,percent of total billed charges,Implant Device,247.1,35,,247.1,percent of total billed charges,Implant Device,247.1,35,,247.1,percent of total billed charges,Implant Device,247.1,35,,247.1,percent of total billed charges,Implant Device,247.1,35,,247.1,percent of total billed charges,Implant Device,247.1,35,,247.1,percent of total billed charges,Implant Device,282.4,40,,282.4,percent of total billed charges,Implant Device,247.1,70,,247.1,percent of total billed charges,All Other,240.04,34,,240.04,percent of total billed charges,Implant Device,240.04,34,,240.04,percent of total billed charges,Implant Device,247.1,35,,247.1,percent of total billed charges,Implant Device,247.1,35,,247.1,percent of total billed charges,Implant Device,247.1,35,,247.1,percent of total billed charges,Implant Device,247.1,35,,247.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,522.44,
PAC 3 N60000136 X-SPINE SCREW,C1713,HCPCS,,79002572,CDM,278,RC,,,both,,,706,522.44,,,522.44,Other,150% of Medicare + 9.63% HCRA Surcharge,317.7,45,,317.7,percent of total billed charges,Critical Access Hospital RCC factor,240.04,34,,240.04,percent of total billed charges,Implant Device,240.04,34,,240.04,percent of total billed charges,Implant Device,240.04,34,,240.04,percent of total billed charges,Implant Device,240.04,34,,240.04,percent of total billed charges,Implant Device,240.04,34,,240.04,percent of total billed charges,Implant Device,349.47,,,349.47,Other,110% of Medicare,247.1,35,,247.1,percent of total billed charges,Implant Device,240.04,34,"Charges > $500, x 34%",240.04,percent of total billed charges,Implant Device,247.1,35,,247.1,percent of total billed charges,Implant Device,247.1,35,,247.1,percent of total billed charges,Implant Device,247.1,35,,247.1,percent of total billed charges,Implant Device,247.1,35,,247.1,percent of total billed charges,Implant Device,247.1,35,,247.1,percent of total billed charges,Implant Device,282.4,40,,282.4,percent of total billed charges,Implant Device,247.1,70,,247.1,percent of total billed charges,All Other,240.04,34,,240.04,percent of total billed charges,Implant Device,240.04,34,,240.04,percent of total billed charges,Implant Device,247.1,35,,247.1,percent of total billed charges,Implant Device,247.1,35,,247.1,percent of total billed charges,Implant Device,247.1,35,,247.1,percent of total billed charges,Implant Device,247.1,35,,247.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,522.44,
PAC 3 N60000141 X-SPINE SCREW,C1713,HCPCS,,79002573,CDM,278,RC,,,both,,,706,522.44,,,522.44,Other,150% of Medicare + 9.63% HCRA Surcharge,317.7,45,,317.7,percent of total billed charges,Critical Access Hospital RCC factor,240.04,34,,240.04,percent of total billed charges,Implant Device,240.04,34,,240.04,percent of total billed charges,Implant Device,240.04,34,,240.04,percent of total billed charges,Implant Device,240.04,34,,240.04,percent of total billed charges,Implant Device,240.04,34,,240.04,percent of total billed charges,Implant Device,349.47,,,349.47,Other,110% of Medicare,247.1,35,,247.1,percent of total billed charges,Implant Device,240.04,34,"Charges > $500, x 34%",240.04,percent of total billed charges,Implant Device,247.1,35,,247.1,percent of total billed charges,Implant Device,247.1,35,,247.1,percent of total billed charges,Implant Device,247.1,35,,247.1,percent of total billed charges,Implant Device,247.1,35,,247.1,percent of total billed charges,Implant Device,247.1,35,,247.1,percent of total billed charges,Implant Device,282.4,40,,282.4,percent of total billed charges,Implant Device,247.1,70,,247.1,percent of total billed charges,All Other,240.04,34,,240.04,percent of total billed charges,Implant Device,240.04,34,,240.04,percent of total billed charges,Implant Device,247.1,35,,247.1,percent of total billed charges,Implant Device,247.1,35,,247.1,percent of total billed charges,Implant Device,247.1,35,,247.1,percent of total billed charges,Implant Device,247.1,35,,247.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,522.44,
SOLANA SURGICAL NBAT1134078 ALLOGRAFT,C1713,HCPCS,,79002574,CDM,278,RC,,,both,,,3886,2875.65,,,2875.65,Other,150% of Medicare + 9.63% HCRA Surcharge,1748.7,45,,1748.7,percent of total billed charges,Critical Access Hospital RCC factor,1321.24,34,,1321.24,percent of total billed charges,Implant Device,1321.24,34,,1321.24,percent of total billed charges,Implant Device,1321.24,34,,1321.24,percent of total billed charges,Implant Device,1321.24,34,,1321.24,percent of total billed charges,Implant Device,1321.24,34,,1321.24,percent of total billed charges,Implant Device,1923.57,,,1923.57,Other,110% of Medicare,1360.1,35,,1360.1,percent of total billed charges,Implant Device,1321.24,34,"Charges > $500, x 34%",1321.24,percent of total billed charges,Implant Device,1360.1,35,,1360.1,percent of total billed charges,Implant Device,1360.1,35,,1360.1,percent of total billed charges,Implant Device,1360.1,35,,1360.1,percent of total billed charges,Implant Device,1360.1,35,,1360.1,percent of total billed charges,Implant Device,1360.1,35,,1360.1,percent of total billed charges,Implant Device,1554.4,40,,1554.4,percent of total billed charges,Implant Device,1360.1,70,,1360.1,percent of total billed charges,All Other,1321.24,34,,1321.24,percent of total billed charges,Implant Device,1321.24,34,,1321.24,percent of total billed charges,Implant Device,1360.1,35,,1360.1,percent of total billed charges,Implant Device,1360.1,35,,1360.1,percent of total billed charges,Implant Device,1360.1,35,,1360.1,percent of total billed charges,Implant Device,1360.1,35,,1360.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1321.24,34,"If Charge > 2,000, then 34 percent",1321.24,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2875.65,
STRYKER NLS-301600P MODULAR NECK,C1776,HCPCS,,79002576,CDM,278,RC,,,both,,,2009,1486.67,,,1486.67,Other,150% of Medicare + 9.63% HCRA Surcharge,904.05,45,,904.05,percent of total billed charges,Critical Access Hospital RCC factor,683.06,34,,683.06,percent of total billed charges,Implant Device,683.06,34,,683.06,percent of total billed charges,Implant Device,683.06,34,,683.06,percent of total billed charges,Implant Device,683.06,34,,683.06,percent of total billed charges,Implant Device,683.06,34,,683.06,percent of total billed charges,Implant Device,994.46,,,994.46,Other,110% of Medicare,703.15,35,,703.15,percent of total billed charges,Implant Device,683.06,34,"Charges > $500, x 34%",683.06,percent of total billed charges,Implant Device,703.15,35,,703.15,percent of total billed charges,Implant Device,703.15,35,,703.15,percent of total billed charges,Implant Device,703.15,35,,703.15,percent of total billed charges,Implant Device,703.15,35,,703.15,percent of total billed charges,Implant Device,703.15,35,,703.15,percent of total billed charges,Implant Device,803.6,40,,803.6,percent of total billed charges,Implant Device,703.15,70,,703.15,percent of total billed charges,All Other,683.06,34,,683.06,percent of total billed charges,Implant Device,683.06,34,,683.06,percent of total billed charges,Implant Device,703.15,35,,703.15,percent of total billed charges,Implant Device,703.15,35,,703.15,percent of total billed charges,Implant Device,703.15,35,,703.15,percent of total billed charges,Implant Device,703.15,35,,703.15,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,683.06,34,"If Charge > 2,000, then 34 percent",683.06,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1486.67,
SOLANA PHG-02C ALLOGRAFT CRUSH,C1713,HCPCS,,79002577,CDM,278,RC,,,both,,,3348,2477.53,,,2477.53,Other,150% of Medicare + 9.63% HCRA Surcharge,1506.6,45,,1506.6,percent of total billed charges,Critical Access Hospital RCC factor,1138.32,34,,1138.32,percent of total billed charges,Implant Device,1138.32,34,,1138.32,percent of total billed charges,Implant Device,1138.32,34,,1138.32,percent of total billed charges,Implant Device,1138.32,34,,1138.32,percent of total billed charges,Implant Device,1138.32,34,,1138.32,percent of total billed charges,Implant Device,1657.26,,,1657.26,Other,110% of Medicare,1171.8,35,,1171.8,percent of total billed charges,Implant Device,1138.32,34,"Charges > $500, x 34%",1138.32,percent of total billed charges,Implant Device,1171.8,35,,1171.8,percent of total billed charges,Implant Device,1171.8,35,,1171.8,percent of total billed charges,Implant Device,1171.8,35,,1171.8,percent of total billed charges,Implant Device,1171.8,35,,1171.8,percent of total billed charges,Implant Device,1171.8,35,,1171.8,percent of total billed charges,Implant Device,1339.2,40,,1339.2,percent of total billed charges,Implant Device,1171.8,70,,1171.8,percent of total billed charges,All Other,1138.32,34,,1138.32,percent of total billed charges,Implant Device,1138.32,34,,1138.32,percent of total billed charges,Implant Device,1171.8,35,,1171.8,percent of total billed charges,Implant Device,1171.8,35,,1171.8,percent of total billed charges,Implant Device,1171.8,35,,1171.8,percent of total billed charges,Implant Device,1171.8,35,,1171.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1138.32,34,"If Charge > 2,000, then 34 percent",1138.32,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2477.53,
SOLANA PHG-02P ALLOGRAFT PUTTY,C1713,HCPCS,,79002578,CDM,278,RC,,,both,,,2497,1847.79,,,1847.79,Other,150% of Medicare + 9.63% HCRA Surcharge,1123.65,45,,1123.65,percent of total billed charges,Critical Access Hospital RCC factor,848.98,34,,848.98,percent of total billed charges,Implant Device,848.98,34,,848.98,percent of total billed charges,Implant Device,848.98,34,,848.98,percent of total billed charges,Implant Device,848.98,34,,848.98,percent of total billed charges,Implant Device,848.98,34,,848.98,percent of total billed charges,Implant Device,1236.02,,,1236.02,Other,110% of Medicare,873.95,35,,873.95,percent of total billed charges,Implant Device,848.98,34,"Charges > $500, x 34%",848.98,percent of total billed charges,Implant Device,873.95,35,,873.95,percent of total billed charges,Implant Device,873.95,35,,873.95,percent of total billed charges,Implant Device,873.95,35,,873.95,percent of total billed charges,Implant Device,873.95,35,,873.95,percent of total billed charges,Implant Device,873.95,35,,873.95,percent of total billed charges,Implant Device,998.8,40,,998.8,percent of total billed charges,Implant Device,873.95,70,,873.95,percent of total billed charges,All Other,848.98,34,,848.98,percent of total billed charges,Implant Device,848.98,34,,848.98,percent of total billed charges,Implant Device,873.95,35,,873.95,percent of total billed charges,Implant Device,873.95,35,,873.95,percent of total billed charges,Implant Device,873.95,35,,873.95,percent of total billed charges,Implant Device,873.95,35,,873.95,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,848.98,34,"If Charge > 2,000, then 34 percent",848.98,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1847.79,
SOLANA PHG-10C ALLOGRAFT CRUSH,C1713,HCPCS,,79002579,CDM,278,RC,,,both,,,8506,6294.46,,,6294.46,Other,150% of Medicare + 9.63% HCRA Surcharge,3827.7,45,,3827.7,percent of total billed charges,Critical Access Hospital RCC factor,2892.04,34,,2892.04,percent of total billed charges,Implant Device,2892.04,34,,2892.04,percent of total billed charges,Implant Device,2892.04,34,,2892.04,percent of total billed charges,Implant Device,2892.04,34,,2892.04,percent of total billed charges,Implant Device,2892.04,34,,2892.04,percent of total billed charges,Implant Device,4210.47,,,4210.47,Other,110% of Medicare,2977.1,35,,2977.1,percent of total billed charges,Implant Device,2892.04,34,"Charges > $500, x 34%",2892.04,percent of total billed charges,Implant Device,2977.1,35,,2977.1,percent of total billed charges,Implant Device,2977.1,35,,2977.1,percent of total billed charges,Implant Device,2977.1,35,,2977.1,percent of total billed charges,Implant Device,2977.1,35,,2977.1,percent of total billed charges,Implant Device,2977.1,35,,2977.1,percent of total billed charges,Implant Device,3402.4,40,,3402.4,percent of total billed charges,Implant Device,2977.1,70,,2977.1,percent of total billed charges,All Other,2892.04,34,,2892.04,percent of total billed charges,Implant Device,2892.04,34,,2892.04,percent of total billed charges,Implant Device,2977.1,35,,2977.1,percent of total billed charges,Implant Device,2977.1,35,,2977.1,percent of total billed charges,Implant Device,2977.1,35,,2977.1,percent of total billed charges,Implant Device,2977.1,35,,2977.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2892.04,34,"If Charge > 2,000, then 34 percent",2892.04,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,6294.46,
GORE PXA280300 STENT,C1874,HCPCS,,79002580,CDM,278,RC,,,both,,,9300,6882.02,,,6882.02,Other,150% of Medicare + 9.63% HCRA Surcharge,4185,45,,4185,percent of total billed charges,Critical Access Hospital RCC factor,3162,34,,3162,percent of total billed charges,Implant Device,3162,34,,3162,percent of total billed charges,Implant Device,3162,34,,3162,percent of total billed charges,Implant Device,3162,34,,3162,percent of total billed charges,Implant Device,3162,34,,3162,percent of total billed charges,Implant Device,4603.5,,,4603.5,Other,110% of Medicare,3255,35,,3255,percent of total billed charges,Implant Device,3162,34,"Charges > $500, x 34%",3162,percent of total billed charges,Implant Device,3255,35,,3255,percent of total billed charges,Implant Device,3255,35,,3255,percent of total billed charges,Implant Device,3255,35,,3255,percent of total billed charges,Implant Device,3255,35,,3255,percent of total billed charges,Implant Device,3255,35,,3255,percent of total billed charges,Implant Device,3720,40,,3720,percent of total billed charges,Implant Device,3255,70,,3255,percent of total billed charges,All Other,3162,34,,3162,percent of total billed charges,Implant Device,3162,34,,3162,percent of total billed charges,Implant Device,3255,35,,3255,percent of total billed charges,Implant Device,3255,35,,3255,percent of total billed charges,Implant Device,3255,35,,3255,percent of total billed charges,Implant Device,3255,35,,3255,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3162,34,"If Charge > 2,000, then 34 percent",3162,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,6882.02,
GORE PXC121400 STENT,C1874,HCPCS,,79002581,CDM,278,RC,,,both,,,12300,9102.03,,,9102.03,Other,150% of Medicare + 9.63% HCRA Surcharge,5535,45,,5535,percent of total billed charges,Critical Access Hospital RCC factor,4182,34,,4182,percent of total billed charges,Implant Device,4182,34,,4182,percent of total billed charges,Implant Device,4182,34,,4182,percent of total billed charges,Implant Device,4182,34,,4182,percent of total billed charges,Implant Device,4182,34,,4182,percent of total billed charges,Implant Device,6088.5,,,6088.5,Other,110% of Medicare,4305,35,,4305,percent of total billed charges,Implant Device,4182,34,"Charges > $500, x 34%",4182,percent of total billed charges,Implant Device,4305,35,,4305,percent of total billed charges,Implant Device,4305,35,,4305,percent of total billed charges,Implant Device,4305,35,,4305,percent of total billed charges,Implant Device,4305,35,,4305,percent of total billed charges,Implant Device,4305,35,,4305,percent of total billed charges,Implant Device,4920,40,,4920,percent of total billed charges,Implant Device,4305,70,,4305,percent of total billed charges,All Other,4182,34,,4182,percent of total billed charges,Implant Device,4182,34,,4182,percent of total billed charges,Implant Device,4305,35,,4305,percent of total billed charges,Implant Device,4305,35,,4305,percent of total billed charges,Implant Device,4305,35,,4305,percent of total billed charges,Implant Device,4305,35,,4305,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,4182,34,"If Charge > 2,000, then 34 percent",4182,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,9102.03,
GORE PXC141000 STENT,C1874,HCPCS,,79002582,CDM,278,RC,,,both,,,13530,10012.23,,,10012.23,Other,150% of Medicare + 9.63% HCRA Surcharge,6088.5,45,,6088.5,percent of total billed charges,Critical Access Hospital RCC factor,4600.2,34,,4600.2,percent of total billed charges,Implant Device,4600.2,34,,4600.2,percent of total billed charges,Implant Device,4600.2,34,,4600.2,percent of total billed charges,Implant Device,4600.2,34,,4600.2,percent of total billed charges,Implant Device,4600.2,34,,4600.2,percent of total billed charges,Implant Device,6697.35,,,6697.35,Other,110% of Medicare,4735.5,35,,4735.5,percent of total billed charges,Implant Device,4600.2,34,"Charges > $500, x 34%",4600.2,percent of total billed charges,Implant Device,4735.5,35,,4735.5,percent of total billed charges,Implant Device,4735.5,35,,4735.5,percent of total billed charges,Implant Device,4735.5,35,,4735.5,percent of total billed charges,Implant Device,4735.5,35,,4735.5,percent of total billed charges,Implant Device,4735.5,35,,4735.5,percent of total billed charges,Implant Device,5412,40,,5412,percent of total billed charges,Implant Device,4735.5,70,,4735.5,percent of total billed charges,All Other,4600.2,34,,4600.2,percent of total billed charges,Implant Device,4600.2,34,,4600.2,percent of total billed charges,Implant Device,4735.5,35,,4735.5,percent of total billed charges,Implant Device,4735.5,35,,4735.5,percent of total billed charges,Implant Device,4735.5,35,,4735.5,percent of total billed charges,Implant Device,4735.5,35,,4735.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,4600.2,34,"If Charge > 2,000, then 34 percent",4600.2,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,10012.23,
GORE PXC141200 STENT,C1874,HCPCS,,79002583,CDM,278,RC,,,both,,,13200,9768.03,,,9768.03,Other,150% of Medicare + 9.63% HCRA Surcharge,5940,45,,5940,percent of total billed charges,Critical Access Hospital RCC factor,4488,34,,4488,percent of total billed charges,Implant Device,4488,34,,4488,percent of total billed charges,Implant Device,4488,34,,4488,percent of total billed charges,Implant Device,4488,34,,4488,percent of total billed charges,Implant Device,4488,34,,4488,percent of total billed charges,Implant Device,6534,,,6534,Other,110% of Medicare,4620,35,,4620,percent of total billed charges,Implant Device,4488,34,"Charges > $500, x 34%",4488,percent of total billed charges,Implant Device,4620,35,,4620,percent of total billed charges,Implant Device,4620,35,,4620,percent of total billed charges,Implant Device,4620,35,,4620,percent of total billed charges,Implant Device,4620,35,,4620,percent of total billed charges,Implant Device,4620,35,,4620,percent of total billed charges,Implant Device,5280,40,,5280,percent of total billed charges,Implant Device,4620,70,,4620,percent of total billed charges,All Other,4488,34,,4488,percent of total billed charges,Implant Device,4488,34,,4488,percent of total billed charges,Implant Device,4620,35,,4620,percent of total billed charges,Implant Device,4620,35,,4620,percent of total billed charges,Implant Device,4620,35,,4620,percent of total billed charges,Implant Device,4620,35,,4620,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,4488,34,"If Charge > 2,000, then 34 percent",4488,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,9768.03,
GORE PXC161000 STENT,C1874,HCPCS,,79002584,CDM,278,RC,,,both,,,12300,9102.03,,,9102.03,Other,150% of Medicare + 9.63% HCRA Surcharge,5535,45,,5535,percent of total billed charges,Critical Access Hospital RCC factor,4182,34,,4182,percent of total billed charges,Implant Device,4182,34,,4182,percent of total billed charges,Implant Device,4182,34,,4182,percent of total billed charges,Implant Device,4182,34,,4182,percent of total billed charges,Implant Device,4182,34,,4182,percent of total billed charges,Implant Device,6088.5,,,6088.5,Other,110% of Medicare,4305,35,,4305,percent of total billed charges,Implant Device,4182,34,"Charges > $500, x 34%",4182,percent of total billed charges,Implant Device,4305,35,,4305,percent of total billed charges,Implant Device,4305,35,,4305,percent of total billed charges,Implant Device,4305,35,,4305,percent of total billed charges,Implant Device,4305,35,,4305,percent of total billed charges,Implant Device,4305,35,,4305,percent of total billed charges,Implant Device,4920,40,,4920,percent of total billed charges,Implant Device,4305,70,,4305,percent of total billed charges,All Other,4182,34,,4182,percent of total billed charges,Implant Device,4182,34,,4182,percent of total billed charges,Implant Device,4305,35,,4305,percent of total billed charges,Implant Device,4305,35,,4305,percent of total billed charges,Implant Device,4305,35,,4305,percent of total billed charges,Implant Device,4305,35,,4305,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,4182,34,"If Charge > 2,000, then 34 percent",4182,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,9102.03,
GORE PXC181000 STENT,C1874,HCPCS,,79002585,CDM,278,RC,,,both,,,12300,9102.03,,,9102.03,Other,150% of Medicare + 9.63% HCRA Surcharge,5535,45,,5535,percent of total billed charges,Critical Access Hospital RCC factor,4182,34,,4182,percent of total billed charges,Implant Device,4182,34,,4182,percent of total billed charges,Implant Device,4182,34,,4182,percent of total billed charges,Implant Device,4182,34,,4182,percent of total billed charges,Implant Device,4182,34,,4182,percent of total billed charges,Implant Device,6088.5,,,6088.5,Other,110% of Medicare,4305,35,,4305,percent of total billed charges,Implant Device,4182,34,"Charges > $500, x 34%",4182,percent of total billed charges,Implant Device,4305,35,,4305,percent of total billed charges,Implant Device,4305,35,,4305,percent of total billed charges,Implant Device,4305,35,,4305,percent of total billed charges,Implant Device,4305,35,,4305,percent of total billed charges,Implant Device,4305,35,,4305,percent of total billed charges,Implant Device,4920,40,,4920,percent of total billed charges,Implant Device,4305,70,,4305,percent of total billed charges,All Other,4182,34,,4182,percent of total billed charges,Implant Device,4182,34,,4182,percent of total billed charges,Implant Device,4305,35,,4305,percent of total billed charges,Implant Device,4305,35,,4305,percent of total billed charges,Implant Device,4305,35,,4305,percent of total billed charges,Implant Device,4305,35,,4305,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,4182,34,"If Charge > 2,000, then 34 percent",4182,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,9102.03,
GORE PXC201000 STENT,C1874,HCPCS,,79002586,CDM,278,RC,,,both,,,11940,8835.63,,,8835.63,Other,150% of Medicare + 9.63% HCRA Surcharge,5373,45,,5373,percent of total billed charges,Critical Access Hospital RCC factor,4059.6,34,,4059.6,percent of total billed charges,Implant Device,4059.6,34,,4059.6,percent of total billed charges,Implant Device,4059.6,34,,4059.6,percent of total billed charges,Implant Device,4059.6,34,,4059.6,percent of total billed charges,Implant Device,4059.6,34,,4059.6,percent of total billed charges,Implant Device,5910.3,,,5910.3,Other,110% of Medicare,4179,35,,4179,percent of total billed charges,Implant Device,4059.6,34,"Charges > $500, x 34%",4059.6,percent of total billed charges,Implant Device,4179,35,,4179,percent of total billed charges,Implant Device,4179,35,,4179,percent of total billed charges,Implant Device,4179,35,,4179,percent of total billed charges,Implant Device,4179,35,,4179,percent of total billed charges,Implant Device,4179,35,,4179,percent of total billed charges,Implant Device,4776,40,,4776,percent of total billed charges,Implant Device,4179,70,,4179,percent of total billed charges,All Other,4059.6,34,,4059.6,percent of total billed charges,Implant Device,4059.6,34,,4059.6,percent of total billed charges,Implant Device,4179,35,,4179,percent of total billed charges,Implant Device,4179,35,,4179,percent of total billed charges,Implant Device,4179,35,,4179,percent of total billed charges,Implant Device,4179,35,,4179,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,4059.6,34,"If Charge > 2,000, then 34 percent",4059.6,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,8835.63,
GORE PXC201400 STENT,C1874,HCPCS,,79002587,CDM,278,RC,,,both,,,12300,9102.03,,,9102.03,Other,150% of Medicare + 9.63% HCRA Surcharge,5535,45,,5535,percent of total billed charges,Critical Access Hospital RCC factor,4182,34,,4182,percent of total billed charges,Implant Device,4182,34,,4182,percent of total billed charges,Implant Device,4182,34,,4182,percent of total billed charges,Implant Device,4182,34,,4182,percent of total billed charges,Implant Device,4182,34,,4182,percent of total billed charges,Implant Device,6088.5,,,6088.5,Other,110% of Medicare,4305,35,,4305,percent of total billed charges,Implant Device,4182,34,"Charges > $500, x 34%",4182,percent of total billed charges,Implant Device,4305,35,,4305,percent of total billed charges,Implant Device,4305,35,,4305,percent of total billed charges,Implant Device,4305,35,,4305,percent of total billed charges,Implant Device,4305,35,,4305,percent of total billed charges,Implant Device,4305,35,,4305,percent of total billed charges,Implant Device,4920,40,,4920,percent of total billed charges,Implant Device,4305,70,,4305,percent of total billed charges,All Other,4182,34,,4182,percent of total billed charges,Implant Device,4182,34,,4182,percent of total billed charges,Implant Device,4305,35,,4305,percent of total billed charges,Implant Device,4305,35,,4305,percent of total billed charges,Implant Device,4305,35,,4305,percent of total billed charges,Implant Device,4305,35,,4305,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,4182,34,"If Charge > 2,000, then 34 percent",4182,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,9102.03,
GORE PXC231000 STENT,C1874,HCPCS,,79002588,CDM,278,RC,,,both,,,12300,9102.03,,,9102.03,Other,150% of Medicare + 9.63% HCRA Surcharge,5535,45,,5535,percent of total billed charges,Critical Access Hospital RCC factor,4182,34,,4182,percent of total billed charges,Implant Device,4182,34,,4182,percent of total billed charges,Implant Device,4182,34,,4182,percent of total billed charges,Implant Device,4182,34,,4182,percent of total billed charges,Implant Device,4182,34,,4182,percent of total billed charges,Implant Device,6088.5,,,6088.5,Other,110% of Medicare,4305,35,,4305,percent of total billed charges,Implant Device,4182,34,"Charges > $500, x 34%",4182,percent of total billed charges,Implant Device,4305,35,,4305,percent of total billed charges,Implant Device,4305,35,,4305,percent of total billed charges,Implant Device,4305,35,,4305,percent of total billed charges,Implant Device,4305,35,,4305,percent of total billed charges,Implant Device,4305,35,,4305,percent of total billed charges,Implant Device,4920,40,,4920,percent of total billed charges,Implant Device,4305,70,,4305,percent of total billed charges,All Other,4182,34,,4182,percent of total billed charges,Implant Device,4182,34,,4182,percent of total billed charges,Implant Device,4305,35,,4305,percent of total billed charges,Implant Device,4305,35,,4305,percent of total billed charges,Implant Device,4305,35,,4305,percent of total billed charges,Implant Device,4305,35,,4305,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,4182,34,"If Charge > 2,000, then 34 percent",4182,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,9102.03,
GORE PXC231200 STENT,C1874,HCPCS,,79002589,CDM,278,RC,,,both,,,12300,9102.03,,,9102.03,Other,150% of Medicare + 9.63% HCRA Surcharge,5535,45,,5535,percent of total billed charges,Critical Access Hospital RCC factor,4182,34,,4182,percent of total billed charges,Implant Device,4182,34,,4182,percent of total billed charges,Implant Device,4182,34,,4182,percent of total billed charges,Implant Device,4182,34,,4182,percent of total billed charges,Implant Device,4182,34,,4182,percent of total billed charges,Implant Device,6088.5,,,6088.5,Other,110% of Medicare,4305,35,,4305,percent of total billed charges,Implant Device,4182,34,"Charges > $500, x 34%",4182,percent of total billed charges,Implant Device,4305,35,,4305,percent of total billed charges,Implant Device,4305,35,,4305,percent of total billed charges,Implant Device,4305,35,,4305,percent of total billed charges,Implant Device,4305,35,,4305,percent of total billed charges,Implant Device,4305,35,,4305,percent of total billed charges,Implant Device,4920,40,,4920,percent of total billed charges,Implant Device,4305,70,,4305,percent of total billed charges,All Other,4182,34,,4182,percent of total billed charges,Implant Device,4182,34,,4182,percent of total billed charges,Implant Device,4305,35,,4305,percent of total billed charges,Implant Device,4305,35,,4305,percent of total billed charges,Implant Device,4305,35,,4305,percent of total billed charges,Implant Device,4305,35,,4305,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,4182,34,"If Charge > 2,000, then 34 percent",4182,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,9102.03,
GORE PXC271200 STENT,C1874,HCPCS,,79002590,CDM,278,RC,,,both,,,12300,9102.03,,,9102.03,Other,150% of Medicare + 9.63% HCRA Surcharge,5535,45,,5535,percent of total billed charges,Critical Access Hospital RCC factor,4182,34,,4182,percent of total billed charges,Implant Device,4182,34,,4182,percent of total billed charges,Implant Device,4182,34,,4182,percent of total billed charges,Implant Device,4182,34,,4182,percent of total billed charges,Implant Device,4182,34,,4182,percent of total billed charges,Implant Device,6088.5,,,6088.5,Other,110% of Medicare,4305,35,,4305,percent of total billed charges,Implant Device,4182,34,"Charges > $500, x 34%",4182,percent of total billed charges,Implant Device,4305,35,,4305,percent of total billed charges,Implant Device,4305,35,,4305,percent of total billed charges,Implant Device,4305,35,,4305,percent of total billed charges,Implant Device,4305,35,,4305,percent of total billed charges,Implant Device,4305,35,,4305,percent of total billed charges,Implant Device,4920,40,,4920,percent of total billed charges,Implant Device,4305,70,,4305,percent of total billed charges,All Other,4182,34,,4182,percent of total billed charges,Implant Device,4182,34,,4182,percent of total billed charges,Implant Device,4305,35,,4305,percent of total billed charges,Implant Device,4305,35,,4305,percent of total billed charges,Implant Device,4305,35,,4305,percent of total billed charges,Implant Device,4305,35,,4305,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,4182,34,"If Charge > 2,000, then 34 percent",4182,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,9102.03,
GORE PXL161207 STENT,C1874,HCPCS,,79002591,CDM,278,RC,,,both,,,8626,6383.26,,,6383.26,Other,150% of Medicare + 9.63% HCRA Surcharge,3881.7,45,,3881.7,percent of total billed charges,Critical Access Hospital RCC factor,2932.84,34,,2932.84,percent of total billed charges,Implant Device,2932.84,34,,2932.84,percent of total billed charges,Implant Device,2932.84,34,,2932.84,percent of total billed charges,Implant Device,2932.84,34,,2932.84,percent of total billed charges,Implant Device,2932.84,34,,2932.84,percent of total billed charges,Implant Device,4269.87,,,4269.87,Other,110% of Medicare,3019.1,35,,3019.1,percent of total billed charges,Implant Device,2932.84,34,"Charges > $500, x 34%",2932.84,percent of total billed charges,Implant Device,3019.1,35,,3019.1,percent of total billed charges,Implant Device,3019.1,35,,3019.1,percent of total billed charges,Implant Device,3019.1,35,,3019.1,percent of total billed charges,Implant Device,3019.1,35,,3019.1,percent of total billed charges,Implant Device,3019.1,35,,3019.1,percent of total billed charges,Implant Device,3450.4,40,,3450.4,percent of total billed charges,Implant Device,3019.1,70,,3019.1,percent of total billed charges,All Other,2932.84,34,,2932.84,percent of total billed charges,Implant Device,2932.84,34,,2932.84,percent of total billed charges,Implant Device,3019.1,35,,3019.1,percent of total billed charges,Implant Device,3019.1,35,,3019.1,percent of total billed charges,Implant Device,3019.1,35,,3019.1,percent of total billed charges,Implant Device,3019.1,35,,3019.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2932.84,34,"If Charge > 2,000, then 34 percent",2932.84,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,6383.26,
GORE RMT231412 STENT,C1874,HCPCS,,79002595,CDM,278,RC,,,both,,,29986,22189.71,,,22189.71,Other,150% of Medicare + 9.63% HCRA Surcharge,13493.7,45,,13493.7,percent of total billed charges,Critical Access Hospital RCC factor,10195.24,34,,10195.24,percent of total billed charges,Implant Device,10195.24,34,,10195.24,percent of total billed charges,Implant Device,10195.24,34,,10195.24,percent of total billed charges,Implant Device,10195.24,34,,10195.24,percent of total billed charges,Implant Device,10195.24,34,,10195.24,percent of total billed charges,Implant Device,14843.07,,,14843.07,Other,110% of Medicare,10495.1,35,,10495.1,percent of total billed charges,Implant Device,10195.24,34,"Charges > $500, x 34%",10195.24,percent of total billed charges,Implant Device,10495.1,35,,10495.1,percent of total billed charges,Implant Device,10495.1,35,,10495.1,percent of total billed charges,Implant Device,10495.1,35,,10495.1,percent of total billed charges,Implant Device,10495.1,35,,10495.1,percent of total billed charges,Implant Device,10495.1,35,,10495.1,percent of total billed charges,Implant Device,11994.4,40,,11994.4,percent of total billed charges,Implant Device,10495.1,70,,10495.1,percent of total billed charges,All Other,10195.24,34,,10195.24,percent of total billed charges,Implant Device,10195.24,34,,10195.24,percent of total billed charges,Implant Device,10495.1,35,,10495.1,percent of total billed charges,Implant Device,10495.1,35,,10495.1,percent of total billed charges,Implant Device,10495.1,35,,10495.1,percent of total billed charges,Implant Device,10495.1,35,,10495.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,10195.24,34,"If Charge > 2,000, then 34 percent",10195.24,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,22189.71,
GORE RMT231416 STENT,C1874,HCPCS,,79002596,CDM,278,RC,,,both,,,31500,23310.08,,,23310.08,Other,150% of Medicare + 9.63% HCRA Surcharge,14175,45,,14175,percent of total billed charges,Critical Access Hospital RCC factor,10710,34,,10710,percent of total billed charges,Implant Device,10710,34,,10710,percent of total billed charges,Implant Device,10710,34,,10710,percent of total billed charges,Implant Device,10710,34,,10710,percent of total billed charges,Implant Device,10710,34,,10710,percent of total billed charges,Implant Device,15592.5,,,15592.5,Other,110% of Medicare,11025,35,,11025,percent of total billed charges,Implant Device,10710,34,"Charges > $500, x 34%",10710,percent of total billed charges,Implant Device,11025,35,,11025,percent of total billed charges,Implant Device,11025,35,,11025,percent of total billed charges,Implant Device,11025,35,,11025,percent of total billed charges,Implant Device,11025,35,,11025,percent of total billed charges,Implant Device,11025,35,,11025,percent of total billed charges,Implant Device,12600,40,,12600,percent of total billed charges,Implant Device,11025,70,,11025,percent of total billed charges,All Other,10710,34,,10710,percent of total billed charges,Implant Device,10710,34,,10710,percent of total billed charges,Implant Device,11025,35,,11025,percent of total billed charges,Implant Device,11025,35,,11025,percent of total billed charges,Implant Device,11025,35,,11025,percent of total billed charges,Implant Device,11025,35,,11025,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,10710,34,"If Charge > 2,000, then 34 percent",10710,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,23310.08,
GORE RMT261218 STENT,C1874,HCPCS,,79002597,CDM,278,RC,,,both,,,29986,22189.71,,,22189.71,Other,150% of Medicare + 9.63% HCRA Surcharge,13493.7,45,,13493.7,percent of total billed charges,Critical Access Hospital RCC factor,10195.24,34,,10195.24,percent of total billed charges,Implant Device,10195.24,34,,10195.24,percent of total billed charges,Implant Device,10195.24,34,,10195.24,percent of total billed charges,Implant Device,10195.24,34,,10195.24,percent of total billed charges,Implant Device,10195.24,34,,10195.24,percent of total billed charges,Implant Device,14843.07,,,14843.07,Other,110% of Medicare,10495.1,35,,10495.1,percent of total billed charges,Implant Device,10195.24,34,"Charges > $500, x 34%",10195.24,percent of total billed charges,Implant Device,10495.1,35,,10495.1,percent of total billed charges,Implant Device,10495.1,35,,10495.1,percent of total billed charges,Implant Device,10495.1,35,,10495.1,percent of total billed charges,Implant Device,10495.1,35,,10495.1,percent of total billed charges,Implant Device,10495.1,35,,10495.1,percent of total billed charges,Implant Device,11994.4,40,,11994.4,percent of total billed charges,Implant Device,10495.1,70,,10495.1,percent of total billed charges,All Other,10195.24,34,,10195.24,percent of total billed charges,Implant Device,10195.24,34,,10195.24,percent of total billed charges,Implant Device,10495.1,35,,10495.1,percent of total billed charges,Implant Device,10495.1,35,,10495.1,percent of total billed charges,Implant Device,10495.1,35,,10495.1,percent of total billed charges,Implant Device,10495.1,35,,10495.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,10195.24,34,"If Charge > 2,000, then 34 percent",10195.24,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,22189.71,
GORE RMT261412 STENT,C1874,HCPCS,,79002598,CDM,278,RC,,,both,,,30736,22744.72,,,22744.72,Other,150% of Medicare + 9.63% HCRA Surcharge,13831.2,45,,13831.2,percent of total billed charges,Critical Access Hospital RCC factor,10450.24,34,,10450.24,percent of total billed charges,Implant Device,10450.24,34,,10450.24,percent of total billed charges,Implant Device,10450.24,34,,10450.24,percent of total billed charges,Implant Device,10450.24,34,,10450.24,percent of total billed charges,Implant Device,10450.24,34,,10450.24,percent of total billed charges,Implant Device,15214.32,,,15214.32,Other,110% of Medicare,10757.6,35,,10757.6,percent of total billed charges,Implant Device,10450.24,34,"Charges > $500, x 34%",10450.24,percent of total billed charges,Implant Device,10757.6,35,,10757.6,percent of total billed charges,Implant Device,10757.6,35,,10757.6,percent of total billed charges,Implant Device,10757.6,35,,10757.6,percent of total billed charges,Implant Device,10757.6,35,,10757.6,percent of total billed charges,Implant Device,10757.6,35,,10757.6,percent of total billed charges,Implant Device,12294.4,40,,12294.4,percent of total billed charges,Implant Device,10757.6,70,,10757.6,percent of total billed charges,All Other,10450.24,34,,10450.24,percent of total billed charges,Implant Device,10450.24,34,,10450.24,percent of total billed charges,Implant Device,10757.6,35,,10757.6,percent of total billed charges,Implant Device,10757.6,35,,10757.6,percent of total billed charges,Implant Device,10757.6,35,,10757.6,percent of total billed charges,Implant Device,10757.6,35,,10757.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,10450.24,34,"If Charge > 2,000, then 34 percent",10450.24,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,22744.72,
GORE RMT261414 STENT,C1874,HCPCS,,79002599,CDM,278,RC,,,both,,,31500,23310.08,,,23310.08,Other,150% of Medicare + 9.63% HCRA Surcharge,14175,45,,14175,percent of total billed charges,Critical Access Hospital RCC factor,10710,34,,10710,percent of total billed charges,Implant Device,10710,34,,10710,percent of total billed charges,Implant Device,10710,34,,10710,percent of total billed charges,Implant Device,10710,34,,10710,percent of total billed charges,Implant Device,10710,34,,10710,percent of total billed charges,Implant Device,15592.5,,,15592.5,Other,110% of Medicare,11025,35,,11025,percent of total billed charges,Implant Device,10710,34,"Charges > $500, x 34%",10710,percent of total billed charges,Implant Device,11025,35,,11025,percent of total billed charges,Implant Device,11025,35,,11025,percent of total billed charges,Implant Device,11025,35,,11025,percent of total billed charges,Implant Device,11025,35,,11025,percent of total billed charges,Implant Device,11025,35,,11025,percent of total billed charges,Implant Device,12600,40,,12600,percent of total billed charges,Implant Device,11025,70,,11025,percent of total billed charges,All Other,10710,34,,10710,percent of total billed charges,Implant Device,10710,34,,10710,percent of total billed charges,Implant Device,11025,35,,11025,percent of total billed charges,Implant Device,11025,35,,11025,percent of total billed charges,Implant Device,11025,35,,11025,percent of total billed charges,Implant Device,11025,35,,11025,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,10710,34,"If Charge > 2,000, then 34 percent",10710,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,23310.08,
GORE RMT281412 STENT,C1874,HCPCS,,79002600,CDM,278,RC,,,both,,,31500,23310.08,,,23310.08,Other,150% of Medicare + 9.63% HCRA Surcharge,14175,45,,14175,percent of total billed charges,Critical Access Hospital RCC factor,10710,34,,10710,percent of total billed charges,Implant Device,10710,34,,10710,percent of total billed charges,Implant Device,10710,34,,10710,percent of total billed charges,Implant Device,10710,34,,10710,percent of total billed charges,Implant Device,10710,34,,10710,percent of total billed charges,Implant Device,15592.5,,,15592.5,Other,110% of Medicare,11025,35,,11025,percent of total billed charges,Implant Device,10710,34,"Charges > $500, x 34%",10710,percent of total billed charges,Implant Device,11025,35,,11025,percent of total billed charges,Implant Device,11025,35,,11025,percent of total billed charges,Implant Device,11025,35,,11025,percent of total billed charges,Implant Device,11025,35,,11025,percent of total billed charges,Implant Device,11025,35,,11025,percent of total billed charges,Implant Device,12600,40,,12600,percent of total billed charges,Implant Device,11025,70,,11025,percent of total billed charges,All Other,10710,34,,10710,percent of total billed charges,Implant Device,10710,34,,10710,percent of total billed charges,Implant Device,11025,35,,11025,percent of total billed charges,Implant Device,11025,35,,11025,percent of total billed charges,Implant Device,11025,35,,11025,percent of total billed charges,Implant Device,11025,35,,11025,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,10710,34,"If Charge > 2,000, then 34 percent",10710,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,23310.08,
GORE RMT281414 STENT,C1874,HCPCS,,79002601,CDM,278,RC,,,both,,,32250,23865.08,,,23865.08,Other,150% of Medicare + 9.63% HCRA Surcharge,14512.5,45,,14512.5,percent of total billed charges,Critical Access Hospital RCC factor,10965,34,,10965,percent of total billed charges,Implant Device,10965,34,,10965,percent of total billed charges,Implant Device,10965,34,,10965,percent of total billed charges,Implant Device,10965,34,,10965,percent of total billed charges,Implant Device,10965,34,,10965,percent of total billed charges,Implant Device,15963.75,,,15963.75,Other,110% of Medicare,11287.5,35,,11287.5,percent of total billed charges,Implant Device,10965,34,"Charges > $500, x 34%",10965,percent of total billed charges,Implant Device,11287.5,35,,11287.5,percent of total billed charges,Implant Device,11287.5,35,,11287.5,percent of total billed charges,Implant Device,11287.5,35,,11287.5,percent of total billed charges,Implant Device,11287.5,35,,11287.5,percent of total billed charges,Implant Device,11287.5,35,,11287.5,percent of total billed charges,Implant Device,12900,40,,12900,percent of total billed charges,Implant Device,11287.5,70,,11287.5,percent of total billed charges,All Other,10965,34,,10965,percent of total billed charges,Implant Device,10965,34,,10965,percent of total billed charges,Implant Device,11287.5,35,,11287.5,percent of total billed charges,Implant Device,11287.5,35,,11287.5,percent of total billed charges,Implant Device,11287.5,35,,11287.5,percent of total billed charges,Implant Device,11287.5,35,,11287.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,10965,34,"If Charge > 2,000, then 34 percent",10965,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,23865.08,
GORE RMT311413 STENT,C1874,HCPCS,,79002602,CDM,278,RC,,,both,,,29986,22189.71,,,22189.71,Other,150% of Medicare + 9.63% HCRA Surcharge,13493.7,45,,13493.7,percent of total billed charges,Critical Access Hospital RCC factor,10195.24,34,,10195.24,percent of total billed charges,Implant Device,10195.24,34,,10195.24,percent of total billed charges,Implant Device,10195.24,34,,10195.24,percent of total billed charges,Implant Device,10195.24,34,,10195.24,percent of total billed charges,Implant Device,10195.24,34,,10195.24,percent of total billed charges,Implant Device,14843.07,,,14843.07,Other,110% of Medicare,10495.1,35,,10495.1,percent of total billed charges,Implant Device,10195.24,34,"Charges > $500, x 34%",10195.24,percent of total billed charges,Implant Device,10495.1,35,,10495.1,percent of total billed charges,Implant Device,10495.1,35,,10495.1,percent of total billed charges,Implant Device,10495.1,35,,10495.1,percent of total billed charges,Implant Device,10495.1,35,,10495.1,percent of total billed charges,Implant Device,10495.1,35,,10495.1,percent of total billed charges,Implant Device,11994.4,40,,11994.4,percent of total billed charges,Implant Device,10495.1,70,,10495.1,percent of total billed charges,All Other,10195.24,34,,10195.24,percent of total billed charges,Implant Device,10195.24,34,,10195.24,percent of total billed charges,Implant Device,10495.1,35,,10495.1,percent of total billed charges,Implant Device,10495.1,35,,10495.1,percent of total billed charges,Implant Device,10495.1,35,,10495.1,percent of total billed charges,Implant Device,10495.1,35,,10495.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,10195.24,34,"If Charge > 2,000, then 34 percent",10195.24,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,22189.71,
GORE RMT311417 STENT,C1874,HCPCS,,79002603,CDM,278,RC,,,both,,,29986,22189.71,,,22189.71,Other,150% of Medicare + 9.63% HCRA Surcharge,13493.7,45,,13493.7,percent of total billed charges,Critical Access Hospital RCC factor,10195.24,34,,10195.24,percent of total billed charges,Implant Device,10195.24,34,,10195.24,percent of total billed charges,Implant Device,10195.24,34,,10195.24,percent of total billed charges,Implant Device,10195.24,34,,10195.24,percent of total billed charges,Implant Device,10195.24,34,,10195.24,percent of total billed charges,Implant Device,14843.07,,,14843.07,Other,110% of Medicare,10495.1,35,,10495.1,percent of total billed charges,Implant Device,10195.24,34,"Charges > $500, x 34%",10195.24,percent of total billed charges,Implant Device,10495.1,35,,10495.1,percent of total billed charges,Implant Device,10495.1,35,,10495.1,percent of total billed charges,Implant Device,10495.1,35,,10495.1,percent of total billed charges,Implant Device,10495.1,35,,10495.1,percent of total billed charges,Implant Device,10495.1,35,,10495.1,percent of total billed charges,Implant Device,11994.4,40,,11994.4,percent of total billed charges,Implant Device,10495.1,70,,10495.1,percent of total billed charges,All Other,10195.24,34,,10195.24,percent of total billed charges,Implant Device,10195.24,34,,10195.24,percent of total billed charges,Implant Device,10495.1,35,,10495.1,percent of total billed charges,Implant Device,10495.1,35,,10495.1,percent of total billed charges,Implant Device,10495.1,35,,10495.1,percent of total billed charges,Implant Device,10495.1,35,,10495.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,10195.24,34,"If Charge > 2,000, then 34 percent",10195.24,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,22189.71,
WRIGHT MEDICAL SCN403232 SCREW,C1713,HCPCS,,79002605,CDM,278,RC,,,both,,,952,704.48,,,704.48,Other,150% of Medicare + 9.63% HCRA Surcharge,428.4,45,,428.4,percent of total billed charges,Critical Access Hospital RCC factor,323.68,34,,323.68,percent of total billed charges,Implant Device,323.68,34,,323.68,percent of total billed charges,Implant Device,323.68,34,,323.68,percent of total billed charges,Implant Device,323.68,34,,323.68,percent of total billed charges,Implant Device,323.68,34,,323.68,percent of total billed charges,Implant Device,471.24,,,471.24,Other,110% of Medicare,333.2,35,,333.2,percent of total billed charges,Implant Device,323.68,34,"Charges > $500, x 34%",323.68,percent of total billed charges,Implant Device,333.2,35,,333.2,percent of total billed charges,Implant Device,333.2,35,,333.2,percent of total billed charges,Implant Device,333.2,35,,333.2,percent of total billed charges,Implant Device,333.2,35,,333.2,percent of total billed charges,Implant Device,333.2,35,,333.2,percent of total billed charges,Implant Device,380.8,40,,380.8,percent of total billed charges,Implant Device,333.2,70,,333.2,percent of total billed charges,All Other,323.68,34,,323.68,percent of total billed charges,Implant Device,323.68,34,,323.68,percent of total billed charges,Implant Device,333.2,35,,333.2,percent of total billed charges,Implant Device,333.2,35,,333.2,percent of total billed charges,Implant Device,333.2,35,,333.2,percent of total billed charges,Implant Device,333.2,35,,333.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,704.48,
BIOMET 63027 SCREW,C1713,HCPCS,,79002608,CDM,278,RC,,,both,,,1044,772.56,,,772.56,Other,150% of Medicare + 9.63% HCRA Surcharge,469.8,45,,469.8,percent of total billed charges,Critical Access Hospital RCC factor,354.96,34,,354.96,percent of total billed charges,Implant Device,354.96,34,,354.96,percent of total billed charges,Implant Device,354.96,34,,354.96,percent of total billed charges,Implant Device,354.96,34,,354.96,percent of total billed charges,Implant Device,354.96,34,,354.96,percent of total billed charges,Implant Device,516.78,,,516.78,Other,110% of Medicare,365.4,35,,365.4,percent of total billed charges,Implant Device,354.96,34,"Charges > $500, x 34%",354.96,percent of total billed charges,Implant Device,365.4,35,,365.4,percent of total billed charges,Implant Device,365.4,35,,365.4,percent of total billed charges,Implant Device,365.4,35,,365.4,percent of total billed charges,Implant Device,365.4,35,,365.4,percent of total billed charges,Implant Device,365.4,35,,365.4,percent of total billed charges,Implant Device,417.6,40,,417.6,percent of total billed charges,Implant Device,365.4,70,,365.4,percent of total billed charges,All Other,354.96,34,,354.96,percent of total billed charges,Implant Device,354.96,34,,354.96,percent of total billed charges,Implant Device,365.4,35,,365.4,percent of total billed charges,Implant Device,365.4,35,,365.4,percent of total billed charges,Implant Device,365.4,35,,365.4,percent of total billed charges,Implant Device,365.4,35,,365.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,772.56,
SOLANO SFT-2011 SCREW,C1713,HCPCS,,79002611,CDM,278,RC,,,both,,,1380,1021.2,,,1021.2,Other,150% of Medicare + 9.63% HCRA Surcharge,621,45,,621,percent of total billed charges,Critical Access Hospital RCC factor,469.2,34,,469.2,percent of total billed charges,Implant Device,469.2,34,,469.2,percent of total billed charges,Implant Device,469.2,34,,469.2,percent of total billed charges,Implant Device,469.2,34,,469.2,percent of total billed charges,Implant Device,469.2,34,,469.2,percent of total billed charges,Implant Device,683.1,,,683.1,Other,110% of Medicare,483,35,,483,percent of total billed charges,Implant Device,469.2,34,"Charges > $500, x 34%",469.2,percent of total billed charges,Implant Device,483,35,,483,percent of total billed charges,Implant Device,483,35,,483,percent of total billed charges,Implant Device,483,35,,483,percent of total billed charges,Implant Device,483,35,,483,percent of total billed charges,Implant Device,483,35,,483,percent of total billed charges,Implant Device,552,40,,552,percent of total billed charges,Implant Device,483,70,,483,percent of total billed charges,All Other,469.2,34,,469.2,percent of total billed charges,Implant Device,469.2,34,,469.2,percent of total billed charges,Implant Device,483,35,,483,percent of total billed charges,Implant Device,483,35,,483,percent of total billed charges,Implant Device,483,35,,483,percent of total billed charges,Implant Device,483,35,,483,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1021.2,
ARTHREX TFF-2718 ALLOGRAFT,C1713,HCPCS,,79002614,CDM,278,RC,,,both,,,3557,2632.19,,,2632.19,Other,150% of Medicare + 9.63% HCRA Surcharge,1600.65,45,,1600.65,percent of total billed charges,Critical Access Hospital RCC factor,1209.38,34,,1209.38,percent of total billed charges,Implant Device,1209.38,34,,1209.38,percent of total billed charges,Implant Device,1209.38,34,,1209.38,percent of total billed charges,Implant Device,1209.38,34,,1209.38,percent of total billed charges,Implant Device,1209.38,34,,1209.38,percent of total billed charges,Implant Device,1760.72,,,1760.72,Other,110% of Medicare,1244.95,35,,1244.95,percent of total billed charges,Implant Device,1209.38,34,"Charges > $500, x 34%",1209.38,percent of total billed charges,Implant Device,1244.95,35,,1244.95,percent of total billed charges,Implant Device,1244.95,35,,1244.95,percent of total billed charges,Implant Device,1244.95,35,,1244.95,percent of total billed charges,Implant Device,1244.95,35,,1244.95,percent of total billed charges,Implant Device,1244.95,35,,1244.95,percent of total billed charges,Implant Device,1422.8,40,,1422.8,percent of total billed charges,Implant Device,1244.95,70,,1244.95,percent of total billed charges,All Other,1209.38,34,,1209.38,percent of total billed charges,Implant Device,1209.38,34,,1209.38,percent of total billed charges,Implant Device,1244.95,35,,1244.95,percent of total billed charges,Implant Device,1244.95,35,,1244.95,percent of total billed charges,Implant Device,1244.95,35,,1244.95,percent of total billed charges,Implant Device,1244.95,35,,1244.95,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1209.38,34,"If Charge > 2,000, then 34 percent",1209.38,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2632.19,
ARTHREX TFF-2718A ALLOGRAFT,C1713,HCPCS,,79002615,CDM,278,RC,,,both,,,3556,2631.45,,,2631.45,Other,150% of Medicare + 9.63% HCRA Surcharge,1600.2,45,,1600.2,percent of total billed charges,Critical Access Hospital RCC factor,1209.04,34,,1209.04,percent of total billed charges,Implant Device,1209.04,34,,1209.04,percent of total billed charges,Implant Device,1209.04,34,,1209.04,percent of total billed charges,Implant Device,1209.04,34,,1209.04,percent of total billed charges,Implant Device,1209.04,34,,1209.04,percent of total billed charges,Implant Device,1760.22,,,1760.22,Other,110% of Medicare,1244.6,35,,1244.6,percent of total billed charges,Implant Device,1209.04,34,"Charges > $500, x 34%",1209.04,percent of total billed charges,Implant Device,1244.6,35,,1244.6,percent of total billed charges,Implant Device,1244.6,35,,1244.6,percent of total billed charges,Implant Device,1244.6,35,,1244.6,percent of total billed charges,Implant Device,1244.6,35,,1244.6,percent of total billed charges,Implant Device,1244.6,35,,1244.6,percent of total billed charges,Implant Device,1422.4,40,,1422.4,percent of total billed charges,Implant Device,1244.6,70,,1244.6,percent of total billed charges,All Other,1209.04,34,,1209.04,percent of total billed charges,Implant Device,1209.04,34,,1209.04,percent of total billed charges,Implant Device,1244.6,35,,1244.6,percent of total billed charges,Implant Device,1244.6,35,,1244.6,percent of total billed charges,Implant Device,1244.6,35,,1244.6,percent of total billed charges,Implant Device,1244.6,35,,1244.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1209.04,34,"If Charge > 2,000, then 34 percent",1209.04,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2631.45,
SOLANA TSS-05CC SPONGE FILLER,C1713,HCPCS,,79002617,CDM,278,RC,,,both,,,3847,2846.79,,,2846.79,Other,150% of Medicare + 9.63% HCRA Surcharge,1731.15,45,,1731.15,percent of total billed charges,Critical Access Hospital RCC factor,1307.98,34,,1307.98,percent of total billed charges,Implant Device,1307.98,34,,1307.98,percent of total billed charges,Implant Device,1307.98,34,,1307.98,percent of total billed charges,Implant Device,1307.98,34,,1307.98,percent of total billed charges,Implant Device,1307.98,34,,1307.98,percent of total billed charges,Implant Device,1904.27,,,1904.27,Other,110% of Medicare,1346.45,35,,1346.45,percent of total billed charges,Implant Device,1307.98,34,"Charges > $500, x 34%",1307.98,percent of total billed charges,Implant Device,1346.45,35,,1346.45,percent of total billed charges,Implant Device,1346.45,35,,1346.45,percent of total billed charges,Implant Device,1346.45,35,,1346.45,percent of total billed charges,Implant Device,1346.45,35,,1346.45,percent of total billed charges,Implant Device,1346.45,35,,1346.45,percent of total billed charges,Implant Device,1538.8,40,,1538.8,percent of total billed charges,Implant Device,1346.45,70,,1346.45,percent of total billed charges,All Other,1307.98,34,,1307.98,percent of total billed charges,Implant Device,1307.98,34,,1307.98,percent of total billed charges,Implant Device,1346.45,35,,1346.45,percent of total billed charges,Implant Device,1346.45,35,,1346.45,percent of total billed charges,Implant Device,1346.45,35,,1346.45,percent of total billed charges,Implant Device,1346.45,35,,1346.45,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1307.98,34,"If Charge > 2,000, then 34 percent",1307.98,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2846.79,
STRYKER UH1-41-26 HEAD,C1776,HCPCS,,79002618,CDM,278,RC,,,both,,,1391,1029.34,,,1029.34,Other,150% of Medicare + 9.63% HCRA Surcharge,625.95,45,,625.95,percent of total billed charges,Critical Access Hospital RCC factor,472.94,34,,472.94,percent of total billed charges,Implant Device,472.94,34,,472.94,percent of total billed charges,Implant Device,472.94,34,,472.94,percent of total billed charges,Implant Device,472.94,34,,472.94,percent of total billed charges,Implant Device,472.94,34,,472.94,percent of total billed charges,Implant Device,688.55,,,688.55,Other,110% of Medicare,486.85,35,,486.85,percent of total billed charges,Implant Device,472.94,34,"Charges > $500, x 34%",472.94,percent of total billed charges,Implant Device,486.85,35,,486.85,percent of total billed charges,Implant Device,486.85,35,,486.85,percent of total billed charges,Implant Device,486.85,35,,486.85,percent of total billed charges,Implant Device,486.85,35,,486.85,percent of total billed charges,Implant Device,486.85,35,,486.85,percent of total billed charges,Implant Device,556.4,40,,556.4,percent of total billed charges,Implant Device,486.85,70,,486.85,percent of total billed charges,All Other,472.94,34,,472.94,percent of total billed charges,Implant Device,472.94,34,,472.94,percent of total billed charges,Implant Device,486.85,35,,486.85,percent of total billed charges,Implant Device,486.85,35,,486.85,percent of total billed charges,Implant Device,486.85,35,,486.85,percent of total billed charges,Implant Device,486.85,35,,486.85,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1029.34,
STRYKER UH1-46-26-REV HEAD,C1776,HCPCS,,79002619,CDM,278,RC,,,both,,,1391,1029.34,,,1029.34,Other,150% of Medicare + 9.63% HCRA Surcharge,625.95,45,,625.95,percent of total billed charges,Critical Access Hospital RCC factor,472.94,34,,472.94,percent of total billed charges,Implant Device,472.94,34,,472.94,percent of total billed charges,Implant Device,472.94,34,,472.94,percent of total billed charges,Implant Device,472.94,34,,472.94,percent of total billed charges,Implant Device,472.94,34,,472.94,percent of total billed charges,Implant Device,688.55,,,688.55,Other,110% of Medicare,486.85,35,,486.85,percent of total billed charges,Implant Device,472.94,34,"Charges > $500, x 34%",472.94,percent of total billed charges,Implant Device,486.85,35,,486.85,percent of total billed charges,Implant Device,486.85,35,,486.85,percent of total billed charges,Implant Device,486.85,35,,486.85,percent of total billed charges,Implant Device,486.85,35,,486.85,percent of total billed charges,Implant Device,486.85,35,,486.85,percent of total billed charges,Implant Device,556.4,40,,556.4,percent of total billed charges,Implant Device,486.85,70,,486.85,percent of total billed charges,All Other,472.94,34,,472.94,percent of total billed charges,Implant Device,472.94,34,,472.94,percent of total billed charges,Implant Device,486.85,35,,486.85,percent of total billed charges,Implant Device,486.85,35,,486.85,percent of total billed charges,Implant Device,486.85,35,,486.85,percent of total billed charges,Implant Device,486.85,35,,486.85,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1029.34,
STRYKER UH1-47-26 HEAD,C1776,HCPCS,,79002620,CDM,278,RC,,,both,,,1391,1029.34,,,1029.34,Other,150% of Medicare + 9.63% HCRA Surcharge,625.95,45,,625.95,percent of total billed charges,Critical Access Hospital RCC factor,472.94,34,,472.94,percent of total billed charges,Implant Device,472.94,34,,472.94,percent of total billed charges,Implant Device,472.94,34,,472.94,percent of total billed charges,Implant Device,472.94,34,,472.94,percent of total billed charges,Implant Device,472.94,34,,472.94,percent of total billed charges,Implant Device,688.55,,,688.55,Other,110% of Medicare,486.85,35,,486.85,percent of total billed charges,Implant Device,472.94,34,"Charges > $500, x 34%",472.94,percent of total billed charges,Implant Device,486.85,35,,486.85,percent of total billed charges,Implant Device,486.85,35,,486.85,percent of total billed charges,Implant Device,486.85,35,,486.85,percent of total billed charges,Implant Device,486.85,35,,486.85,percent of total billed charges,Implant Device,486.85,35,,486.85,percent of total billed charges,Implant Device,556.4,40,,556.4,percent of total billed charges,Implant Device,486.85,70,,486.85,percent of total billed charges,All Other,472.94,34,,472.94,percent of total billed charges,Implant Device,472.94,34,,472.94,percent of total billed charges,Implant Device,486.85,35,,486.85,percent of total billed charges,Implant Device,486.85,35,,486.85,percent of total billed charges,Implant Device,486.85,35,,486.85,percent of total billed charges,Implant Device,486.85,35,,486.85,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1029.34,
BIOMET XL-115363 HUMERAL BEARING,C1776,HCPCS,,79002628,CDM,278,RC,,,both,,,5100,3774.01,,,3774.01,Other,150% of Medicare + 9.63% HCRA Surcharge,2295,45,,2295,percent of total billed charges,Critical Access Hospital RCC factor,1734,34,,1734,percent of total billed charges,Implant Device,1734,34,,1734,percent of total billed charges,Implant Device,1734,34,,1734,percent of total billed charges,Implant Device,1734,34,,1734,percent of total billed charges,Implant Device,1734,34,,1734,percent of total billed charges,Implant Device,2524.5,,,2524.5,Other,110% of Medicare,1785,35,,1785,percent of total billed charges,Implant Device,1734,34,"Charges > $500, x 34%",1734,percent of total billed charges,Implant Device,1785,35,,1785,percent of total billed charges,Implant Device,1785,35,,1785,percent of total billed charges,Implant Device,1785,35,,1785,percent of total billed charges,Implant Device,1785,35,,1785,percent of total billed charges,Implant Device,1785,35,,1785,percent of total billed charges,Implant Device,2040,40,,2040,percent of total billed charges,Implant Device,1785,70,,1785,percent of total billed charges,All Other,1734,34,,1734,percent of total billed charges,Implant Device,1734,34,,1734,percent of total billed charges,Implant Device,1785,35,,1785,percent of total billed charges,Implant Device,1785,35,,1785,percent of total billed charges,Implant Device,1785,35,,1785,percent of total billed charges,Implant Device,1785,35,,1785,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1734,34,"If Charge > 2,000, then 34 percent",1734,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3774.01,
BIOMET XL-115364 HUMERAL BEARING,C1776,HCPCS,,79002629,CDM,278,RC,,,both,,,5100,3774.01,,,3774.01,Other,150% of Medicare + 9.63% HCRA Surcharge,2295,45,,2295,percent of total billed charges,Critical Access Hospital RCC factor,1734,34,,1734,percent of total billed charges,Implant Device,1734,34,,1734,percent of total billed charges,Implant Device,1734,34,,1734,percent of total billed charges,Implant Device,1734,34,,1734,percent of total billed charges,Implant Device,1734,34,,1734,percent of total billed charges,Implant Device,2524.5,,,2524.5,Other,110% of Medicare,1785,35,,1785,percent of total billed charges,Implant Device,1734,34,"Charges > $500, x 34%",1734,percent of total billed charges,Implant Device,1785,35,,1785,percent of total billed charges,Implant Device,1785,35,,1785,percent of total billed charges,Implant Device,1785,35,,1785,percent of total billed charges,Implant Device,1785,35,,1785,percent of total billed charges,Implant Device,1785,35,,1785,percent of total billed charges,Implant Device,2040,40,,2040,percent of total billed charges,Implant Device,1785,70,,1785,percent of total billed charges,All Other,1734,34,,1734,percent of total billed charges,Implant Device,1734,34,,1734,percent of total billed charges,Implant Device,1785,35,,1785,percent of total billed charges,Implant Device,1785,35,,1785,percent of total billed charges,Implant Device,1785,35,,1785,percent of total billed charges,Implant Device,1785,35,,1785,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1734,34,"If Charge > 2,000, then 34 percent",1734,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3774.01,
TOTAL HIP HIGH CAP,C1776,HCPCS,,79002646,CDM,278,RC,,,both,,,21000,15540.05,,,15540.05,Other,150% of Medicare + 9.63% HCRA Surcharge,9450,45,,9450,percent of total billed charges,Critical Access Hospital RCC factor,7140,34,,7140,percent of total billed charges,Implant Device,7140,34,,7140,percent of total billed charges,Implant Device,7140,34,,7140,percent of total billed charges,Implant Device,7140,34,,7140,percent of total billed charges,Implant Device,7140,34,,7140,percent of total billed charges,Implant Device,10395,,,10395,Other,110% of Medicare,7350,35,,7350,percent of total billed charges,Implant Device,7140,34,"Charges > $500, x 34%",7140,percent of total billed charges,Implant Device,7350,35,,7350,percent of total billed charges,Implant Device,7350,35,,7350,percent of total billed charges,Implant Device,7350,35,,7350,percent of total billed charges,Implant Device,7350,35,,7350,percent of total billed charges,Implant Device,7350,35,,7350,percent of total billed charges,Implant Device,8400,40,,8400,percent of total billed charges,Implant Device,7350,70,,7350,percent of total billed charges,All Other,7140,34,,7140,percent of total billed charges,Implant Device,7140,34,,7140,percent of total billed charges,Implant Device,7350,35,,7350,percent of total billed charges,Implant Device,7350,35,,7350,percent of total billed charges,Implant Device,7350,35,,7350,percent of total billed charges,Implant Device,7350,35,,7350,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,7140,34,"If Charge > 2,000, then 34 percent",7140,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,15540.05,
TOTAL HIP LOW CAP,C1776,HCPCS,,79002647,CDM,278,RC,,,both,,,19200,14208.05,,,14208.05,Other,150% of Medicare + 9.63% HCRA Surcharge,8640,45,,8640,percent of total billed charges,Critical Access Hospital RCC factor,6528,34,,6528,percent of total billed charges,Implant Device,6528,34,,6528,percent of total billed charges,Implant Device,6528,34,,6528,percent of total billed charges,Implant Device,6528,34,,6528,percent of total billed charges,Implant Device,6528,34,,6528,percent of total billed charges,Implant Device,9504,,,9504,Other,110% of Medicare,6720,35,,6720,percent of total billed charges,Implant Device,6528,34,"Charges > $500, x 34%",6528,percent of total billed charges,Implant Device,6720,35,,6720,percent of total billed charges,Implant Device,6720,35,,6720,percent of total billed charges,Implant Device,6720,35,,6720,percent of total billed charges,Implant Device,6720,35,,6720,percent of total billed charges,Implant Device,6720,35,,6720,percent of total billed charges,Implant Device,7680,40,,7680,percent of total billed charges,Implant Device,6720,70,,6720,percent of total billed charges,All Other,6528,34,,6528,percent of total billed charges,Implant Device,6528,34,,6528,percent of total billed charges,Implant Device,6720,35,,6720,percent of total billed charges,Implant Device,6720,35,,6720,percent of total billed charges,Implant Device,6720,35,,6720,percent of total billed charges,Implant Device,6720,35,,6720,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,6528,34,"If Charge > 2,000, then 34 percent",6528,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,14208.05,
TOTAL KNEE HIGH CAP,C1776,HCPCS,,79002648,CDM,278,RC,,,both,,,19200,14208.05,,,14208.05,Other,150% of Medicare + 9.63% HCRA Surcharge,8640,45,,8640,percent of total billed charges,Critical Access Hospital RCC factor,6528,34,,6528,percent of total billed charges,Implant Device,6528,34,,6528,percent of total billed charges,Implant Device,6528,34,,6528,percent of total billed charges,Implant Device,6528,34,,6528,percent of total billed charges,Implant Device,6528,34,,6528,percent of total billed charges,Implant Device,9504,,,9504,Other,110% of Medicare,6720,35,,6720,percent of total billed charges,Implant Device,6528,34,"Charges > $500, x 34%",6528,percent of total billed charges,Implant Device,6720,35,,6720,percent of total billed charges,Implant Device,6720,35,,6720,percent of total billed charges,Implant Device,6720,35,,6720,percent of total billed charges,Implant Device,6720,35,,6720,percent of total billed charges,Implant Device,6720,35,,6720,percent of total billed charges,Implant Device,7680,40,,7680,percent of total billed charges,Implant Device,6720,70,,6720,percent of total billed charges,All Other,6528,34,,6528,percent of total billed charges,Implant Device,6528,34,,6528,percent of total billed charges,Implant Device,6720,35,,6720,percent of total billed charges,Implant Device,6720,35,,6720,percent of total billed charges,Implant Device,6720,35,,6720,percent of total billed charges,Implant Device,6720,35,,6720,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,6528,34,"If Charge > 2,000, then 34 percent",6528,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,14208.05,
TOTAL KNEE LOW CAP,C1776,HCPCS,,79002649,CDM,278,RC,,,both,,,15900,11766.04,,,11766.04,Other,150% of Medicare + 9.63% HCRA Surcharge,7155,45,,7155,percent of total billed charges,Critical Access Hospital RCC factor,5406,34,,5406,percent of total billed charges,Implant Device,5406,34,,5406,percent of total billed charges,Implant Device,5406,34,,5406,percent of total billed charges,Implant Device,5406,34,,5406,percent of total billed charges,Implant Device,5406,34,,5406,percent of total billed charges,Implant Device,7870.5,,,7870.5,Other,110% of Medicare,5565,35,,5565,percent of total billed charges,Implant Device,5406,34,"Charges > $500, x 34%",5406,percent of total billed charges,Implant Device,5565,35,,5565,percent of total billed charges,Implant Device,5565,35,,5565,percent of total billed charges,Implant Device,5565,35,,5565,percent of total billed charges,Implant Device,5565,35,,5565,percent of total billed charges,Implant Device,5565,35,,5565,percent of total billed charges,Implant Device,6360,40,,6360,percent of total billed charges,Implant Device,5565,70,,5565,percent of total billed charges,All Other,5406,34,,5406,percent of total billed charges,Implant Device,5406,34,,5406,percent of total billed charges,Implant Device,5565,35,,5565,percent of total billed charges,Implant Device,5565,35,,5565,percent of total billed charges,Implant Device,5565,35,,5565,percent of total billed charges,Implant Device,5565,35,,5565,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,5406,34,"If Charge > 2,000, then 34 percent",5406,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,11766.04,
MEDTRONIC 3058 INTERSTIM,C1767,HCPCS,,79002657,CDM,278,RC,,,both,,,33675,24919.58,,,24919.58,Other,150% of Medicare + 9.63% HCRA Surcharge,15153.75,45,,15153.75,percent of total billed charges,Critical Access Hospital RCC factor,11449.5,34,,11449.5,percent of total billed charges,Implant Device,11449.5,34,,11449.5,percent of total billed charges,Implant Device,11449.5,34,,11449.5,percent of total billed charges,Implant Device,11449.5,34,,11449.5,percent of total billed charges,Implant Device,11449.5,34,,11449.5,percent of total billed charges,Implant Device,16669.13,,,16669.13,Other,110% of Medicare,11786.25,35,,11786.25,percent of total billed charges,Implant Device,11449.5,34,"Charges > $500, x 34%",11449.5,percent of total billed charges,Implant Device,11786.25,35,,11786.25,percent of total billed charges,Implant Device,11786.25,35,,11786.25,percent of total billed charges,Implant Device,11786.25,35,,11786.25,percent of total billed charges,Implant Device,11786.25,35,,11786.25,percent of total billed charges,Implant Device,11786.25,35,,11786.25,percent of total billed charges,Implant Device,13470,40,,13470,percent of total billed charges,Implant Device,11786.25,70,,11786.25,percent of total billed charges,All Other,11449.5,34,,11449.5,percent of total billed charges,Implant Device,11449.5,34,,11449.5,percent of total billed charges,Implant Device,11786.25,35,,11786.25,percent of total billed charges,Implant Device,11786.25,35,,11786.25,percent of total billed charges,Implant Device,11786.25,35,,11786.25,percent of total billed charges,Implant Device,11786.25,35,,11786.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,11449.5,34,"If Charge > 2,000, then 34 percent",11449.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,24919.58,
MEDTRONIC 30571SC INTERSTIM TEMP LEAD,C1778,HCPCS,,79002660,CDM,278,RC,,,both,,,346,256.04,,,256.04,Other,150% of Medicare + 9.63% HCRA Surcharge,155.7,45,,155.7,percent of total billed charges,Critical Access Hospital RCC factor,117.64,34,,117.64,percent of total billed charges,Implant Device,117.64,34,,117.64,percent of total billed charges,Implant Device,117.64,34,,117.64,percent of total billed charges,Implant Device,117.64,34,,117.64,percent of total billed charges,Implant Device,117.64,34,,117.64,percent of total billed charges,Implant Device,171.27,,,171.27,Other,110% of Medicare,121.1,35,,121.1,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,121.1,35,,121.1,percent of total billed charges,Implant Device,121.1,35,,121.1,percent of total billed charges,Implant Device,121.1,35,,121.1,percent of total billed charges,Implant Device,121.1,35,,121.1,percent of total billed charges,Implant Device,121.1,35,,121.1,percent of total billed charges,Implant Device,138.4,40,,138.4,percent of total billed charges,Implant Device,121.1,70,,121.1,percent of total billed charges,All Other,117.64,34,,117.64,percent of total billed charges,Implant Device,117.64,34,,117.64,percent of total billed charges,Implant Device,121.1,35,,121.1,percent of total billed charges,Implant Device,121.1,35,,121.1,percent of total billed charges,Implant Device,121.1,35,,121.1,percent of total billed charges,Implant Device,121.1,35,,121.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,256.04,
MEDTRONIC 3550-18 INTRODUCER LEAD KIT,C1778,HCPCS,,79002661,CDM,278,RC,,,both,,,840,621.6,,,621.6,Other,150% of Medicare + 9.63% HCRA Surcharge,378,45,,378,percent of total billed charges,Critical Access Hospital RCC factor,285.6,34,,285.6,percent of total billed charges,Implant Device,285.6,34,,285.6,percent of total billed charges,Implant Device,285.6,34,,285.6,percent of total billed charges,Implant Device,285.6,34,,285.6,percent of total billed charges,Implant Device,285.6,34,,285.6,percent of total billed charges,Implant Device,415.8,,,415.8,Other,110% of Medicare,294,35,,294,percent of total billed charges,Implant Device,285.6,34,"Charges > $500, x 34%",285.6,percent of total billed charges,Implant Device,294,35,,294,percent of total billed charges,Implant Device,294,35,,294,percent of total billed charges,Implant Device,294,35,,294,percent of total billed charges,Implant Device,294,35,,294,percent of total billed charges,Implant Device,294,35,,294,percent of total billed charges,Implant Device,336,40,,336,percent of total billed charges,Implant Device,294,70,,294,percent of total billed charges,All Other,285.6,34,,285.6,percent of total billed charges,Implant Device,285.6,34,,285.6,percent of total billed charges,Implant Device,294,35,,294,percent of total billed charges,Implant Device,294,35,,294,percent of total billed charges,Implant Device,294,35,,294,percent of total billed charges,Implant Device,294,35,,294,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,621.6,
MEDTRONIC 3889-28 LEAD KIT,C1778,HCPCS,,79002662,CDM,278,RC,,,both,,,9856,7293.46,,,7293.46,Other,150% of Medicare + 9.63% HCRA Surcharge,4435.2,45,,4435.2,percent of total billed charges,Critical Access Hospital RCC factor,3351.04,34,,3351.04,percent of total billed charges,Implant Device,3351.04,34,,3351.04,percent of total billed charges,Implant Device,3351.04,34,,3351.04,percent of total billed charges,Implant Device,3351.04,34,,3351.04,percent of total billed charges,Implant Device,3351.04,34,,3351.04,percent of total billed charges,Implant Device,4878.72,,,4878.72,Other,110% of Medicare,3449.6,35,,3449.6,percent of total billed charges,Implant Device,3351.04,34,"Charges > $500, x 34%",3351.04,percent of total billed charges,Implant Device,3449.6,35,,3449.6,percent of total billed charges,Implant Device,3449.6,35,,3449.6,percent of total billed charges,Implant Device,3449.6,35,,3449.6,percent of total billed charges,Implant Device,3449.6,35,,3449.6,percent of total billed charges,Implant Device,3449.6,35,,3449.6,percent of total billed charges,Implant Device,3942.4,40,,3942.4,percent of total billed charges,Implant Device,3449.6,70,,3449.6,percent of total billed charges,All Other,3351.04,34,,3351.04,percent of total billed charges,Implant Device,3351.04,34,,3351.04,percent of total billed charges,Implant Device,3449.6,35,,3449.6,percent of total billed charges,Implant Device,3449.6,35,,3449.6,percent of total billed charges,Implant Device,3449.6,35,,3449.6,percent of total billed charges,Implant Device,3449.6,35,,3449.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3351.04,34,"If Charge > 2,000, then 34 percent",3351.04,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,7293.46,
MEDTRONIC 6935 SERIES SPRINT LEADS,C1895,HCPCS,,79002669,CDM,278,RC,,,both,,,16563,12256.66,,,12256.66,Other,150% of Medicare + 9.63% HCRA Surcharge,7453.35,45,,7453.35,percent of total billed charges,Critical Access Hospital RCC factor,5631.42,34,,5631.42,percent of total billed charges,Implant Device,5631.42,34,,5631.42,percent of total billed charges,Implant Device,5631.42,34,,5631.42,percent of total billed charges,Implant Device,5631.42,34,,5631.42,percent of total billed charges,Implant Device,5631.42,34,,5631.42,percent of total billed charges,Implant Device,8198.69,,,8198.69,Other,110% of Medicare,5797.05,35,,5797.05,percent of total billed charges,Implant Device,5631.42,34,"Charges > $500, x 34%",5631.42,percent of total billed charges,Implant Device,5797.05,35,,5797.05,percent of total billed charges,Implant Device,5797.05,35,,5797.05,percent of total billed charges,Implant Device,5797.05,35,,5797.05,percent of total billed charges,Implant Device,5797.05,35,,5797.05,percent of total billed charges,Implant Device,5797.05,35,,5797.05,percent of total billed charges,Implant Device,6625.2,40,,6625.2,percent of total billed charges,Implant Device,5797.05,70,,5797.05,percent of total billed charges,All Other,5631.42,34,,5631.42,percent of total billed charges,Implant Device,5631.42,34,,5631.42,percent of total billed charges,Implant Device,5797.05,35,,5797.05,percent of total billed charges,Implant Device,5797.05,35,,5797.05,percent of total billed charges,Implant Device,5797.05,35,,5797.05,percent of total billed charges,Implant Device,5797.05,35,,5797.05,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,5631.42,34,"If Charge > 2,000, then 34 percent",5631.42,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,12256.66,
MEDTRONIC 6947 SERIES SPRINT LEADS,C1895,HCPCS,,79002670,CDM,278,RC,,,both,,,16018,11853.36,,,11853.36,Other,150% of Medicare + 9.63% HCRA Surcharge,7208.1,45,,7208.1,percent of total billed charges,Critical Access Hospital RCC factor,5446.12,34,,5446.12,percent of total billed charges,Implant Device,5446.12,34,,5446.12,percent of total billed charges,Implant Device,5446.12,34,,5446.12,percent of total billed charges,Implant Device,5446.12,34,,5446.12,percent of total billed charges,Implant Device,5446.12,34,,5446.12,percent of total billed charges,Implant Device,7928.91,,,7928.91,Other,110% of Medicare,5606.3,35,,5606.3,percent of total billed charges,Implant Device,5446.12,34,"Charges > $500, x 34%",5446.12,percent of total billed charges,Implant Device,5606.3,35,,5606.3,percent of total billed charges,Implant Device,5606.3,35,,5606.3,percent of total billed charges,Implant Device,5606.3,35,,5606.3,percent of total billed charges,Implant Device,5606.3,35,,5606.3,percent of total billed charges,Implant Device,5606.3,35,,5606.3,percent of total billed charges,Implant Device,6407.2,40,,6407.2,percent of total billed charges,Implant Device,5606.3,70,,5606.3,percent of total billed charges,All Other,5446.12,34,,5446.12,percent of total billed charges,Implant Device,5446.12,34,,5446.12,percent of total billed charges,Implant Device,5606.3,35,,5606.3,percent of total billed charges,Implant Device,5606.3,35,,5606.3,percent of total billed charges,Implant Device,5606.3,35,,5606.3,percent of total billed charges,Implant Device,5606.3,35,,5606.3,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,5446.12,34,"If Charge > 2,000, then 34 percent",5446.12,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,11853.36,
MEDTRONIC 3065USC INTERSTIM TEST KIT,C1897,HCPCS,,79002671,CDM,278,RC,,,both,,,916,677.84,,,677.84,Other,150% of Medicare + 9.63% HCRA Surcharge,412.2,45,,412.2,percent of total billed charges,Critical Access Hospital RCC factor,311.44,34,,311.44,percent of total billed charges,Implant Device,311.44,34,,311.44,percent of total billed charges,Implant Device,311.44,34,,311.44,percent of total billed charges,Implant Device,311.44,34,,311.44,percent of total billed charges,Implant Device,311.44,34,,311.44,percent of total billed charges,Implant Device,453.42,,,453.42,Other,110% of Medicare,320.6,35,,320.6,percent of total billed charges,Implant Device,311.44,34,"Charges > $500, x 34%",311.44,percent of total billed charges,Implant Device,320.6,35,,320.6,percent of total billed charges,Implant Device,320.6,35,,320.6,percent of total billed charges,Implant Device,320.6,35,,320.6,percent of total billed charges,Implant Device,320.6,35,,320.6,percent of total billed charges,Implant Device,320.6,35,,320.6,percent of total billed charges,Implant Device,366.4,40,,366.4,percent of total billed charges,Implant Device,320.6,70,,320.6,percent of total billed charges,All Other,311.44,34,,311.44,percent of total billed charges,Implant Device,311.44,34,,311.44,percent of total billed charges,Implant Device,320.6,35,,320.6,percent of total billed charges,Implant Device,320.6,35,,320.6,percent of total billed charges,Implant Device,320.6,35,,320.6,percent of total billed charges,Implant Device,320.6,35,,320.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,677.84,
MEDTRONIC 4076 5076 SERIES CAPSURE LEADS,C1898,HCPCS,,79002672,CDM,278,RC,,,both,,,1489,1101.86,,,1101.86,Other,150% of Medicare + 9.63% HCRA Surcharge,670.05,45,,670.05,percent of total billed charges,Critical Access Hospital RCC factor,506.26,34,,506.26,percent of total billed charges,Implant Device,506.26,34,,506.26,percent of total billed charges,Implant Device,506.26,34,,506.26,percent of total billed charges,Implant Device,506.26,34,,506.26,percent of total billed charges,Implant Device,506.26,34,,506.26,percent of total billed charges,Implant Device,737.06,,,737.06,Other,110% of Medicare,521.15,35,,521.15,percent of total billed charges,Implant Device,506.26,34,"Charges > $500, x 34%",506.26,percent of total billed charges,Implant Device,521.15,35,,521.15,percent of total billed charges,Implant Device,521.15,35,,521.15,percent of total billed charges,Implant Device,521.15,35,,521.15,percent of total billed charges,Implant Device,521.15,35,,521.15,percent of total billed charges,Implant Device,521.15,35,,521.15,percent of total billed charges,Implant Device,595.6,40,,595.6,percent of total billed charges,Implant Device,521.15,70,,521.15,percent of total billed charges,All Other,506.26,34,,506.26,percent of total billed charges,Implant Device,506.26,34,,506.26,percent of total billed charges,Implant Device,521.15,35,,521.15,percent of total billed charges,Implant Device,521.15,35,,521.15,percent of total billed charges,Implant Device,521.15,35,,521.15,percent of total billed charges,Implant Device,521.15,35,,521.15,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1101.86,
MEDTRONIC 5086MRI SRS CAPSURE FIX LEAD,C1898,HCPCS,,79002673,CDM,278,RC,,,both,,,2808,2077.93,,,2077.93,Other,150% of Medicare + 9.63% HCRA Surcharge,1263.6,45,,1263.6,percent of total billed charges,Critical Access Hospital RCC factor,954.72,34,,954.72,percent of total billed charges,Implant Device,954.72,34,,954.72,percent of total billed charges,Implant Device,954.72,34,,954.72,percent of total billed charges,Implant Device,954.72,34,,954.72,percent of total billed charges,Implant Device,954.72,34,,954.72,percent of total billed charges,Implant Device,1389.96,,,1389.96,Other,110% of Medicare,982.8,35,,982.8,percent of total billed charges,Implant Device,954.72,34,"Charges > $500, x 34%",954.72,percent of total billed charges,Implant Device,982.8,35,,982.8,percent of total billed charges,Implant Device,982.8,35,,982.8,percent of total billed charges,Implant Device,982.8,35,,982.8,percent of total billed charges,Implant Device,982.8,35,,982.8,percent of total billed charges,Implant Device,982.8,35,,982.8,percent of total billed charges,Implant Device,1123.2,40,,1123.2,percent of total billed charges,Implant Device,982.8,70,,982.8,percent of total billed charges,All Other,954.72,34,,954.72,percent of total billed charges,Implant Device,954.72,34,,954.72,percent of total billed charges,Implant Device,982.8,35,,982.8,percent of total billed charges,Implant Device,982.8,35,,982.8,percent of total billed charges,Implant Device,982.8,35,,982.8,percent of total billed charges,Implant Device,982.8,35,,982.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,954.72,34,"If Charge > 2,000, then 34 percent",954.72,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2077.93,
MEDTRONIC 5086MRI 52 LEAD CAPSURE FIX,C1898,HCPCS,,79002674,CDM,278,RC,,,both,,,2940,2175.61,,,2175.61,Other,150% of Medicare + 9.63% HCRA Surcharge,1323,45,,1323,percent of total billed charges,Critical Access Hospital RCC factor,999.6,34,,999.6,percent of total billed charges,Implant Device,999.6,34,,999.6,percent of total billed charges,Implant Device,999.6,34,,999.6,percent of total billed charges,Implant Device,999.6,34,,999.6,percent of total billed charges,Implant Device,999.6,34,,999.6,percent of total billed charges,Implant Device,1455.3,,,1455.3,Other,110% of Medicare,1029,35,,1029,percent of total billed charges,Implant Device,999.6,34,"Charges > $500, x 34%",999.6,percent of total billed charges,Implant Device,1029,35,,1029,percent of total billed charges,Implant Device,1029,35,,1029,percent of total billed charges,Implant Device,1029,35,,1029,percent of total billed charges,Implant Device,1029,35,,1029,percent of total billed charges,Implant Device,1029,35,,1029,percent of total billed charges,Implant Device,1176,40,,1176,percent of total billed charges,Implant Device,1029,70,,1029,percent of total billed charges,All Other,999.6,34,,999.6,percent of total billed charges,Implant Device,999.6,34,,999.6,percent of total billed charges,Implant Device,1029,35,,1029,percent of total billed charges,Implant Device,1029,35,,1029,percent of total billed charges,Implant Device,1029,35,,1029,percent of total billed charges,Implant Device,1029,35,,1029,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,999.6,34,"If Charge > 2,000, then 34 percent",999.6,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2175.61,
MEDTRONIC 5086MRI 58 LEAD CAPSURE FIX,C1898,HCPCS,,79002675,CDM,278,RC,,,both,,,2940,2175.61,,,2175.61,Other,150% of Medicare + 9.63% HCRA Surcharge,1323,45,,1323,percent of total billed charges,Critical Access Hospital RCC factor,999.6,34,,999.6,percent of total billed charges,Implant Device,999.6,34,,999.6,percent of total billed charges,Implant Device,999.6,34,,999.6,percent of total billed charges,Implant Device,999.6,34,,999.6,percent of total billed charges,Implant Device,999.6,34,,999.6,percent of total billed charges,Implant Device,1455.3,,,1455.3,Other,110% of Medicare,1029,35,,1029,percent of total billed charges,Implant Device,999.6,34,"Charges > $500, x 34%",999.6,percent of total billed charges,Implant Device,1029,35,,1029,percent of total billed charges,Implant Device,1029,35,,1029,percent of total billed charges,Implant Device,1029,35,,1029,percent of total billed charges,Implant Device,1029,35,,1029,percent of total billed charges,Implant Device,1029,35,,1029,percent of total billed charges,Implant Device,1176,40,,1176,percent of total billed charges,Implant Device,1029,70,,1029,percent of total billed charges,All Other,999.6,34,,999.6,percent of total billed charges,Implant Device,999.6,34,,999.6,percent of total billed charges,Implant Device,1029,35,,1029,percent of total billed charges,Implant Device,1029,35,,1029,percent of total billed charges,Implant Device,1029,35,,1029,percent of total billed charges,Implant Device,1029,35,,1029,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,999.6,34,"If Charge > 2,000, then 34 percent",999.6,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2175.61,
MEDTRONIC 4194-78 LEAD PACE TRANSV,C1900,HCPCS,,79002676,CDM,278,RC,,,both,,,5626,4163.25,,,4163.25,Other,150% of Medicare + 9.63% HCRA Surcharge,2531.7,45,,2531.7,percent of total billed charges,Critical Access Hospital RCC factor,1912.84,34,,1912.84,percent of total billed charges,Implant Device,1912.84,34,,1912.84,percent of total billed charges,Implant Device,1912.84,34,,1912.84,percent of total billed charges,Implant Device,1912.84,34,,1912.84,percent of total billed charges,Implant Device,1912.84,34,,1912.84,percent of total billed charges,Implant Device,2784.87,,,2784.87,Other,110% of Medicare,1969.1,35,,1969.1,percent of total billed charges,Implant Device,1912.84,34,"Charges > $500, x 34%",1912.84,percent of total billed charges,Implant Device,1969.1,35,,1969.1,percent of total billed charges,Implant Device,1969.1,35,,1969.1,percent of total billed charges,Implant Device,1969.1,35,,1969.1,percent of total billed charges,Implant Device,1969.1,35,,1969.1,percent of total billed charges,Implant Device,1969.1,35,,1969.1,percent of total billed charges,Implant Device,2250.4,40,,2250.4,percent of total billed charges,Implant Device,1969.1,70,,1969.1,percent of total billed charges,All Other,1912.84,34,,1912.84,percent of total billed charges,Implant Device,1912.84,34,,1912.84,percent of total billed charges,Implant Device,1969.1,35,,1969.1,percent of total billed charges,Implant Device,1969.1,35,,1969.1,percent of total billed charges,Implant Device,1969.1,35,,1969.1,percent of total billed charges,Implant Device,1969.1,35,,1969.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1912.84,34,"If Charge > 2,000, then 34 percent",1912.84,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4163.25,
MEDTRONIC 419478 LEAD PACE TRANSV,C1900,HCPCS,,79002677,CDM,278,RC,,,both,,,6120,4528.82,,,4528.82,Other,150% of Medicare + 9.63% HCRA Surcharge,2754,45,,2754,percent of total billed charges,Critical Access Hospital RCC factor,2080.8,34,,2080.8,percent of total billed charges,Implant Device,2080.8,34,,2080.8,percent of total billed charges,Implant Device,2080.8,34,,2080.8,percent of total billed charges,Implant Device,2080.8,34,,2080.8,percent of total billed charges,Implant Device,2080.8,34,,2080.8,percent of total billed charges,Implant Device,3029.4,,,3029.4,Other,110% of Medicare,2142,35,,2142,percent of total billed charges,Implant Device,2080.8,34,"Charges > $500, x 34%",2080.8,percent of total billed charges,Implant Device,2142,35,,2142,percent of total billed charges,Implant Device,2142,35,,2142,percent of total billed charges,Implant Device,2142,35,,2142,percent of total billed charges,Implant Device,2142,35,,2142,percent of total billed charges,Implant Device,2142,35,,2142,percent of total billed charges,Implant Device,2448,40,,2448,percent of total billed charges,Implant Device,2142,70,,2142,percent of total billed charges,All Other,2080.8,34,,2080.8,percent of total billed charges,Implant Device,2080.8,34,,2080.8,percent of total billed charges,Implant Device,2142,35,,2142,percent of total billed charges,Implant Device,2142,35,,2142,percent of total billed charges,Implant Device,2142,35,,2142,percent of total billed charges,Implant Device,2142,35,,2142,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2080.8,34,"If Charge > 2,000, then 34 percent",2080.8,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4528.82,
MEDTRONIC 4196 ATTAIN ABILITY LEAD,C1900,HCPCS,,79002678,CDM,278,RC,,,both,,,7590,5616.62,,,5616.62,Other,150% of Medicare + 9.63% HCRA Surcharge,3415.5,45,,3415.5,percent of total billed charges,Critical Access Hospital RCC factor,2580.6,34,,2580.6,percent of total billed charges,Implant Device,2580.6,34,,2580.6,percent of total billed charges,Implant Device,2580.6,34,,2580.6,percent of total billed charges,Implant Device,2580.6,34,,2580.6,percent of total billed charges,Implant Device,2580.6,34,,2580.6,percent of total billed charges,Implant Device,3757.05,,,3757.05,Other,110% of Medicare,2656.5,35,,2656.5,percent of total billed charges,Implant Device,2580.6,34,"Charges > $500, x 34%",2580.6,percent of total billed charges,Implant Device,2656.5,35,,2656.5,percent of total billed charges,Implant Device,2656.5,35,,2656.5,percent of total billed charges,Implant Device,2656.5,35,,2656.5,percent of total billed charges,Implant Device,2656.5,35,,2656.5,percent of total billed charges,Implant Device,2656.5,35,,2656.5,percent of total billed charges,Implant Device,3036,40,,3036,percent of total billed charges,Implant Device,2656.5,70,,2656.5,percent of total billed charges,All Other,2580.6,34,,2580.6,percent of total billed charges,Implant Device,2580.6,34,,2580.6,percent of total billed charges,Implant Device,2656.5,35,,2656.5,percent of total billed charges,Implant Device,2656.5,35,,2656.5,percent of total billed charges,Implant Device,2656.5,35,,2656.5,percent of total billed charges,Implant Device,2656.5,35,,2656.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2580.6,34,"If Charge > 2,000, then 34 percent",2580.6,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5616.62,
ST JUDE 7120Q/58 DURATA  SJ4-ACTIVE,C1895,HCPCS,,79002698,CDM,278,RC,,,both,,,14164,10481.4,,,10481.4,Other,150% of Medicare + 9.63% HCRA Surcharge,6373.8,45,,6373.8,percent of total billed charges,Critical Access Hospital RCC factor,4815.76,34,,4815.76,percent of total billed charges,Implant Device,4815.76,34,,4815.76,percent of total billed charges,Implant Device,4815.76,34,,4815.76,percent of total billed charges,Implant Device,4815.76,34,,4815.76,percent of total billed charges,Implant Device,4815.76,34,,4815.76,percent of total billed charges,Implant Device,7011.18,,,7011.18,Other,110% of Medicare,4957.4,35,,4957.4,percent of total billed charges,Implant Device,4815.76,34,"Charges > $500, x 34%",4815.76,percent of total billed charges,Implant Device,4957.4,35,,4957.4,percent of total billed charges,Implant Device,4957.4,35,,4957.4,percent of total billed charges,Implant Device,4957.4,35,,4957.4,percent of total billed charges,Implant Device,4957.4,35,,4957.4,percent of total billed charges,Implant Device,4957.4,35,,4957.4,percent of total billed charges,Implant Device,5665.6,40,,5665.6,percent of total billed charges,Implant Device,4957.4,70,,4957.4,percent of total billed charges,All Other,4815.76,34,,4815.76,percent of total billed charges,Implant Device,4815.76,34,,4815.76,percent of total billed charges,Implant Device,4957.4,35,,4957.4,percent of total billed charges,Implant Device,4957.4,35,,4957.4,percent of total billed charges,Implant Device,4957.4,35,,4957.4,percent of total billed charges,Implant Device,4957.4,35,,4957.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,4815.76,34,"If Charge > 2,000, then 34 percent",4815.76,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,10481.4,
ST JUDE 7120Q/65 DURATA LEAD,C1895,HCPCS,,79002699,CDM,278,RC,,,both,,,11471,8488.57,,,8488.57,Other,150% of Medicare + 9.63% HCRA Surcharge,5161.95,45,,5161.95,percent of total billed charges,Critical Access Hospital RCC factor,3900.14,34,,3900.14,percent of total billed charges,Implant Device,3900.14,34,,3900.14,percent of total billed charges,Implant Device,3900.14,34,,3900.14,percent of total billed charges,Implant Device,3900.14,34,,3900.14,percent of total billed charges,Implant Device,3900.14,34,,3900.14,percent of total billed charges,Implant Device,5678.15,,,5678.15,Other,110% of Medicare,4014.85,35,,4014.85,percent of total billed charges,Implant Device,3900.14,34,"Charges > $500, x 34%",3900.14,percent of total billed charges,Implant Device,4014.85,35,,4014.85,percent of total billed charges,Implant Device,4014.85,35,,4014.85,percent of total billed charges,Implant Device,4014.85,35,,4014.85,percent of total billed charges,Implant Device,4014.85,35,,4014.85,percent of total billed charges,Implant Device,4014.85,35,,4014.85,percent of total billed charges,Implant Device,4588.4,40,,4588.4,percent of total billed charges,Implant Device,4014.85,70,,4014.85,percent of total billed charges,All Other,3900.14,34,,3900.14,percent of total billed charges,Implant Device,3900.14,34,,3900.14,percent of total billed charges,Implant Device,4014.85,35,,4014.85,percent of total billed charges,Implant Device,4014.85,35,,4014.85,percent of total billed charges,Implant Device,4014.85,35,,4014.85,percent of total billed charges,Implant Device,4014.85,35,,4014.85,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3900.14,34,"If Charge > 2,000, then 34 percent",3900.14,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,8488.57,
ST JUDE 1888TC/46 TENDRIL ST OPTIM 46 CM,C1898,HCPCS,,79002700,CDM,278,RC,,,both,,,1650,1221,,,1221,Other,150% of Medicare + 9.63% HCRA Surcharge,742.5,45,,742.5,percent of total billed charges,Critical Access Hospital RCC factor,561,34,,561,percent of total billed charges,Implant Device,561,34,,561,percent of total billed charges,Implant Device,561,34,,561,percent of total billed charges,Implant Device,561,34,,561,percent of total billed charges,Implant Device,561,34,,561,percent of total billed charges,Implant Device,816.75,,,816.75,Other,110% of Medicare,577.5,35,,577.5,percent of total billed charges,Implant Device,561,34,"Charges > $500, x 34%",561,percent of total billed charges,Implant Device,577.5,35,,577.5,percent of total billed charges,Implant Device,577.5,35,,577.5,percent of total billed charges,Implant Device,577.5,35,,577.5,percent of total billed charges,Implant Device,577.5,35,,577.5,percent of total billed charges,Implant Device,577.5,35,,577.5,percent of total billed charges,Implant Device,660,40,,660,percent of total billed charges,Implant Device,577.5,70,,577.5,percent of total billed charges,All Other,561,34,,561,percent of total billed charges,Implant Device,561,34,,561,percent of total billed charges,Implant Device,577.5,35,,577.5,percent of total billed charges,Implant Device,577.5,35,,577.5,percent of total billed charges,Implant Device,577.5,35,,577.5,percent of total billed charges,Implant Device,577.5,35,,577.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1221,
ST JUDE 1888TC/52 TENDRIL ST OPTIM 52 CM,C1898,HCPCS,,79002701,CDM,278,RC,,,both,,,1650,1221,,,1221,Other,150% of Medicare + 9.63% HCRA Surcharge,742.5,45,,742.5,percent of total billed charges,Critical Access Hospital RCC factor,561,34,,561,percent of total billed charges,Implant Device,561,34,,561,percent of total billed charges,Implant Device,561,34,,561,percent of total billed charges,Implant Device,561,34,,561,percent of total billed charges,Implant Device,561,34,,561,percent of total billed charges,Implant Device,816.75,,,816.75,Other,110% of Medicare,577.5,35,,577.5,percent of total billed charges,Implant Device,561,34,"Charges > $500, x 34%",561,percent of total billed charges,Implant Device,577.5,35,,577.5,percent of total billed charges,Implant Device,577.5,35,,577.5,percent of total billed charges,Implant Device,577.5,35,,577.5,percent of total billed charges,Implant Device,577.5,35,,577.5,percent of total billed charges,Implant Device,577.5,35,,577.5,percent of total billed charges,Implant Device,660,40,,660,percent of total billed charges,Implant Device,577.5,70,,577.5,percent of total billed charges,All Other,561,34,,561,percent of total billed charges,Implant Device,561,34,,561,percent of total billed charges,Implant Device,577.5,35,,577.5,percent of total billed charges,Implant Device,577.5,35,,577.5,percent of total billed charges,Implant Device,577.5,35,,577.5,percent of total billed charges,Implant Device,577.5,35,,577.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1221,
ST JUDE 1888TC/58 TENDRIL ST OPTIM 58 CM,C1898,HCPCS,,79002702,CDM,278,RC,,,both,,,1650,1221,,,1221,Other,150% of Medicare + 9.63% HCRA Surcharge,742.5,45,,742.5,percent of total billed charges,Critical Access Hospital RCC factor,561,34,,561,percent of total billed charges,Implant Device,561,34,,561,percent of total billed charges,Implant Device,561,34,,561,percent of total billed charges,Implant Device,561,34,,561,percent of total billed charges,Implant Device,561,34,,561,percent of total billed charges,Implant Device,816.75,,,816.75,Other,110% of Medicare,577.5,35,,577.5,percent of total billed charges,Implant Device,561,34,"Charges > $500, x 34%",561,percent of total billed charges,Implant Device,577.5,35,,577.5,percent of total billed charges,Implant Device,577.5,35,,577.5,percent of total billed charges,Implant Device,577.5,35,,577.5,percent of total billed charges,Implant Device,577.5,35,,577.5,percent of total billed charges,Implant Device,577.5,35,,577.5,percent of total billed charges,Implant Device,660,40,,660,percent of total billed charges,Implant Device,577.5,70,,577.5,percent of total billed charges,All Other,561,34,,561,percent of total billed charges,Implant Device,561,34,,561,percent of total billed charges,Implant Device,577.5,35,,577.5,percent of total billed charges,Implant Device,577.5,35,,577.5,percent of total billed charges,Implant Device,577.5,35,,577.5,percent of total billed charges,Implant Device,577.5,35,,577.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1221,
ST JUDE 1999/52 OPTISENSE LEAD,C1898,HCPCS,,79002703,CDM,278,RC,,,both,,,2262,1673.89,,,1673.89,Other,150% of Medicare + 9.63% HCRA Surcharge,1017.9,45,,1017.9,percent of total billed charges,Critical Access Hospital RCC factor,769.08,34,,769.08,percent of total billed charges,Implant Device,769.08,34,,769.08,percent of total billed charges,Implant Device,769.08,34,,769.08,percent of total billed charges,Implant Device,769.08,34,,769.08,percent of total billed charges,Implant Device,769.08,34,,769.08,percent of total billed charges,Implant Device,1119.69,,,1119.69,Other,110% of Medicare,791.7,35,,791.7,percent of total billed charges,Implant Device,769.08,34,"Charges > $500, x 34%",769.08,percent of total billed charges,Implant Device,791.7,35,,791.7,percent of total billed charges,Implant Device,791.7,35,,791.7,percent of total billed charges,Implant Device,791.7,35,,791.7,percent of total billed charges,Implant Device,791.7,35,,791.7,percent of total billed charges,Implant Device,791.7,35,,791.7,percent of total billed charges,Implant Device,904.8,40,,904.8,percent of total billed charges,Implant Device,791.7,70,,791.7,percent of total billed charges,All Other,769.08,34,,769.08,percent of total billed charges,Implant Device,769.08,34,,769.08,percent of total billed charges,Implant Device,791.7,35,,791.7,percent of total billed charges,Implant Device,791.7,35,,791.7,percent of total billed charges,Implant Device,791.7,35,,791.7,percent of total billed charges,Implant Device,791.7,35,,791.7,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,769.08,34,"If Charge > 2,000, then 34 percent",769.08,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1673.89,
NAVILYST H965451270 POWERPORT PLASTIC,C1788,HCPCS,,79002708,CDM,278,RC,,,both,,,924,683.76,,,683.76,Other,150% of Medicare + 9.63% HCRA Surcharge,415.8,45,,415.8,percent of total billed charges,Critical Access Hospital RCC factor,314.16,34,,314.16,percent of total billed charges,Implant Device,314.16,34,,314.16,percent of total billed charges,Implant Device,314.16,34,,314.16,percent of total billed charges,Implant Device,314.16,34,,314.16,percent of total billed charges,Implant Device,314.16,34,,314.16,percent of total billed charges,Implant Device,457.38,,,457.38,Other,110% of Medicare,323.4,35,,323.4,percent of total billed charges,Implant Device,314.16,34,"Charges > $500, x 34%",314.16,percent of total billed charges,Implant Device,323.4,35,,323.4,percent of total billed charges,Implant Device,323.4,35,,323.4,percent of total billed charges,Implant Device,323.4,35,,323.4,percent of total billed charges,Implant Device,323.4,35,,323.4,percent of total billed charges,Implant Device,323.4,35,,323.4,percent of total billed charges,Implant Device,369.6,40,,369.6,percent of total billed charges,Implant Device,323.4,70,,323.4,percent of total billed charges,All Other,314.16,34,,314.16,percent of total billed charges,Implant Device,314.16,34,,314.16,percent of total billed charges,Implant Device,323.4,35,,323.4,percent of total billed charges,Implant Device,323.4,35,,323.4,percent of total billed charges,Implant Device,323.4,35,,323.4,percent of total billed charges,Implant Device,323.4,35,,323.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,683.76,
SYWEST 231030G MAMMOLOCK NEEDLE 20GAX3CM,A4648,HCPCS,,79002709,CDM,278,RC,,,both,,,99,73.26,,,73.26,Other,150% of Medicare + 9.63% HCRA Surcharge,44.55,45,,44.55,percent of total billed charges,Critical Access Hospital RCC factor,33.66,34,,33.66,percent of total billed charges,Implant Device,33.66,34,,33.66,percent of total billed charges,Implant Device,33.66,34,,33.66,percent of total billed charges,Implant Device,33.66,34,,33.66,percent of total billed charges,Implant Device,33.66,34,,33.66,percent of total billed charges,Implant Device,49.01,,,49.01,Other,110% of Medicare,34.65,35,,34.65,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,34.65,35,,34.65,percent of total billed charges,Implant Device,34.65,35,,34.65,percent of total billed charges,Implant Device,34.65,35,,34.65,percent of total billed charges,Implant Device,34.65,35,,34.65,percent of total billed charges,Implant Device,34.65,35,,34.65,percent of total billed charges,Implant Device,39.6,40,,39.6,percent of total billed charges,Implant Device,34.65,70,,34.65,percent of total billed charges,All Other,33.66,34,,33.66,percent of total billed charges,Implant Device,33.66,34,,33.66,percent of total billed charges,Implant Device,34.65,35,,34.65,percent of total billed charges,Implant Device,34.65,35,,34.65,percent of total billed charges,Implant Device,34.65,35,,34.65,percent of total billed charges,Implant Device,34.65,35,,34.65,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,73.26,
STRYKER HEMIARTHROPLASTY HIP,C1776,HCPCS,,79002802,CDM,278,RC,,,both,,,13209,9774.69,,,9774.69,Other,150% of Medicare + 9.63% HCRA Surcharge,5944.05,45,,5944.05,percent of total billed charges,Critical Access Hospital RCC factor,4491.06,34,,4491.06,percent of total billed charges,Implant Device,4491.06,34,,4491.06,percent of total billed charges,Implant Device,4491.06,34,,4491.06,percent of total billed charges,Implant Device,4491.06,34,,4491.06,percent of total billed charges,Implant Device,4491.06,34,,4491.06,percent of total billed charges,Implant Device,6538.46,,,6538.46,Other,110% of Medicare,4623.15,35,,4623.15,percent of total billed charges,Implant Device,4491.06,34,"Charges > $500, x 34%",4491.06,percent of total billed charges,Implant Device,4623.15,35,,4623.15,percent of total billed charges,Implant Device,4623.15,35,,4623.15,percent of total billed charges,Implant Device,4623.15,35,,4623.15,percent of total billed charges,Implant Device,4623.15,35,,4623.15,percent of total billed charges,Implant Device,4623.15,35,,4623.15,percent of total billed charges,Implant Device,5283.6,40,,5283.6,percent of total billed charges,Implant Device,4623.15,70,,4623.15,percent of total billed charges,All Other,4491.06,34,,4491.06,percent of total billed charges,Implant Device,4491.06,34,,4491.06,percent of total billed charges,Implant Device,4623.15,35,,4623.15,percent of total billed charges,Implant Device,4623.15,35,,4623.15,percent of total billed charges,Implant Device,4623.15,35,,4623.15,percent of total billed charges,Implant Device,4623.15,35,,4623.15,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,4491.06,34,"If Charge > 2,000, then 34 percent",4491.06,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,9774.69,
STRYKER ORTHO 3125-1180S NAIL 11X180MM,C1713,HCPCS,,79002804,CDM,278,RC,,,both,,,5274,3902.77,,,3902.77,Other,150% of Medicare + 9.63% HCRA Surcharge,2373.3,45,,2373.3,percent of total billed charges,Critical Access Hospital RCC factor,1793.16,34,,1793.16,percent of total billed charges,Implant Device,1793.16,34,,1793.16,percent of total billed charges,Implant Device,1793.16,34,,1793.16,percent of total billed charges,Implant Device,1793.16,34,,1793.16,percent of total billed charges,Implant Device,1793.16,34,,1793.16,percent of total billed charges,Implant Device,2610.63,,,2610.63,Other,110% of Medicare,1845.9,35,,1845.9,percent of total billed charges,Implant Device,1793.16,34,"Charges > $500, x 34%",1793.16,percent of total billed charges,Implant Device,1845.9,35,,1845.9,percent of total billed charges,Implant Device,1845.9,35,,1845.9,percent of total billed charges,Implant Device,1845.9,35,,1845.9,percent of total billed charges,Implant Device,1845.9,35,,1845.9,percent of total billed charges,Implant Device,1845.9,35,,1845.9,percent of total billed charges,Implant Device,2109.6,40,,2109.6,percent of total billed charges,Implant Device,1845.9,70,,1845.9,percent of total billed charges,All Other,1793.16,34,,1793.16,percent of total billed charges,Implant Device,1793.16,34,,1793.16,percent of total billed charges,Implant Device,1845.9,35,,1845.9,percent of total billed charges,Implant Device,1845.9,35,,1845.9,percent of total billed charges,Implant Device,1845.9,35,,1845.9,percent of total billed charges,Implant Device,1845.9,35,,1845.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1793.16,34,"If Charge > 2,000, then 34 percent",1793.16,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3902.77,
STRYKER ORTHO 3060-0100S SCREW 10.5X100M,C1713,HCPCS,,79002807,CDM,278,RC,,,both,,,1230,910.2,,,910.2,Other,150% of Medicare + 9.63% HCRA Surcharge,553.5,45,,553.5,percent of total billed charges,Critical Access Hospital RCC factor,418.2,34,,418.2,percent of total billed charges,Implant Device,418.2,34,,418.2,percent of total billed charges,Implant Device,418.2,34,,418.2,percent of total billed charges,Implant Device,418.2,34,,418.2,percent of total billed charges,Implant Device,418.2,34,,418.2,percent of total billed charges,Implant Device,608.85,,,608.85,Other,110% of Medicare,430.5,35,,430.5,percent of total billed charges,Implant Device,418.2,34,"Charges > $500, x 34%",418.2,percent of total billed charges,Implant Device,430.5,35,,430.5,percent of total billed charges,Implant Device,430.5,35,,430.5,percent of total billed charges,Implant Device,430.5,35,,430.5,percent of total billed charges,Implant Device,430.5,35,,430.5,percent of total billed charges,Implant Device,430.5,35,,430.5,percent of total billed charges,Implant Device,492,40,,492,percent of total billed charges,Implant Device,430.5,70,,430.5,percent of total billed charges,All Other,418.2,34,,418.2,percent of total billed charges,Implant Device,418.2,34,,418.2,percent of total billed charges,Implant Device,430.5,35,,430.5,percent of total billed charges,Implant Device,430.5,35,,430.5,percent of total billed charges,Implant Device,430.5,35,,430.5,percent of total billed charges,Implant Device,430.5,35,,430.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,910.2,
STRYKER ORTHO 1896-5032S SCREW 5X32/5MM,C1713,HCPCS,,79002808,CDM,278,RC,,,both,,,355,262.7,,,262.7,Other,150% of Medicare + 9.63% HCRA Surcharge,159.75,45,,159.75,percent of total billed charges,Critical Access Hospital RCC factor,120.7,34,,120.7,percent of total billed charges,Implant Device,120.7,34,,120.7,percent of total billed charges,Implant Device,120.7,34,,120.7,percent of total billed charges,Implant Device,120.7,34,,120.7,percent of total billed charges,Implant Device,120.7,34,,120.7,percent of total billed charges,Implant Device,175.73,,,175.73,Other,110% of Medicare,124.25,35,,124.25,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,124.25,35,,124.25,percent of total billed charges,Implant Device,124.25,35,,124.25,percent of total billed charges,Implant Device,124.25,35,,124.25,percent of total billed charges,Implant Device,124.25,35,,124.25,percent of total billed charges,Implant Device,124.25,35,,124.25,percent of total billed charges,Implant Device,142,40,,142,percent of total billed charges,Implant Device,124.25,70,,124.25,percent of total billed charges,All Other,120.7,34,,120.7,percent of total billed charges,Implant Device,120.7,34,,120.7,percent of total billed charges,Implant Device,124.25,35,,124.25,percent of total billed charges,Implant Device,124.25,35,,124.25,percent of total billed charges,Implant Device,124.25,35,,124.25,percent of total billed charges,Implant Device,124.25,35,,124.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,262.7,
ZIMMER 00-5980-037-01-REV PLATE SZ3,C1713,HCPCS,,79002813,CDM,278,RC,,,both,,,2304,1704.97,,,1704.97,Other,150% of Medicare + 9.63% HCRA Surcharge,1036.8,45,,1036.8,percent of total billed charges,Critical Access Hospital RCC factor,783.36,34,,783.36,percent of total billed charges,Implant Device,783.36,34,,783.36,percent of total billed charges,Implant Device,783.36,34,,783.36,percent of total billed charges,Implant Device,783.36,34,,783.36,percent of total billed charges,Implant Device,783.36,34,,783.36,percent of total billed charges,Implant Device,1140.48,,,1140.48,Other,110% of Medicare,806.4,35,,806.4,percent of total billed charges,Implant Device,783.36,34,"Charges > $500, x 34%",783.36,percent of total billed charges,Implant Device,806.4,35,,806.4,percent of total billed charges,Implant Device,806.4,35,,806.4,percent of total billed charges,Implant Device,806.4,35,,806.4,percent of total billed charges,Implant Device,806.4,35,,806.4,percent of total billed charges,Implant Device,806.4,35,,806.4,percent of total billed charges,Implant Device,921.6,40,,921.6,percent of total billed charges,Implant Device,806.4,70,,806.4,percent of total billed charges,All Other,783.36,34,,783.36,percent of total billed charges,Implant Device,783.36,34,,783.36,percent of total billed charges,Implant Device,806.4,35,,806.4,percent of total billed charges,Implant Device,806.4,35,,806.4,percent of total billed charges,Implant Device,806.4,35,,806.4,percent of total billed charges,Implant Device,806.4,35,,806.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,783.36,34,"If Charge > 2,000, then 34 percent",783.36,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1704.97,
ZIMMER 00-5988-011-13-REV STEM,C1776,HCPCS,,79002814,CDM,278,RC,,,both,,,2970,2197.81,,,2197.81,Other,150% of Medicare + 9.63% HCRA Surcharge,1336.5,45,,1336.5,percent of total billed charges,Critical Access Hospital RCC factor,1009.8,34,,1009.8,percent of total billed charges,Implant Device,1009.8,34,,1009.8,percent of total billed charges,Implant Device,1009.8,34,,1009.8,percent of total billed charges,Implant Device,1009.8,34,,1009.8,percent of total billed charges,Implant Device,1009.8,34,,1009.8,percent of total billed charges,Implant Device,1470.15,,,1470.15,Other,110% of Medicare,1039.5,35,,1039.5,percent of total billed charges,Implant Device,1009.8,34,"Charges > $500, x 34%",1009.8,percent of total billed charges,Implant Device,1039.5,35,,1039.5,percent of total billed charges,Implant Device,1039.5,35,,1039.5,percent of total billed charges,Implant Device,1039.5,35,,1039.5,percent of total billed charges,Implant Device,1039.5,35,,1039.5,percent of total billed charges,Implant Device,1039.5,35,,1039.5,percent of total billed charges,Implant Device,1188,40,,1188,percent of total billed charges,Implant Device,1039.5,70,,1039.5,percent of total billed charges,All Other,1009.8,34,,1009.8,percent of total billed charges,Implant Device,1009.8,34,,1009.8,percent of total billed charges,Implant Device,1039.5,35,,1039.5,percent of total billed charges,Implant Device,1039.5,35,,1039.5,percent of total billed charges,Implant Device,1039.5,35,,1039.5,percent of total billed charges,Implant Device,1039.5,35,,1039.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1009.8,34,"If Charge > 2,000, then 34 percent",1009.8,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2197.81,
ZIMMER 00-5990-0136-01-REV AUGMENT BLOCK,C1776,HCPCS,,79002815,CDM,278,RC,,,both,,,3240,2397.61,,,2397.61,Other,150% of Medicare + 9.63% HCRA Surcharge,1458,45,,1458,percent of total billed charges,Critical Access Hospital RCC factor,1101.6,34,,1101.6,percent of total billed charges,Implant Device,1101.6,34,,1101.6,percent of total billed charges,Implant Device,1101.6,34,,1101.6,percent of total billed charges,Implant Device,1101.6,34,,1101.6,percent of total billed charges,Implant Device,1101.6,34,,1101.6,percent of total billed charges,Implant Device,1603.8,,,1603.8,Other,110% of Medicare,1134,35,,1134,percent of total billed charges,Implant Device,1101.6,34,"Charges > $500, x 34%",1101.6,percent of total billed charges,Implant Device,1134,35,,1134,percent of total billed charges,Implant Device,1134,35,,1134,percent of total billed charges,Implant Device,1134,35,,1134,percent of total billed charges,Implant Device,1134,35,,1134,percent of total billed charges,Implant Device,1134,35,,1134,percent of total billed charges,Implant Device,1296,40,,1296,percent of total billed charges,Implant Device,1134,70,,1134,percent of total billed charges,All Other,1101.6,34,,1101.6,percent of total billed charges,Implant Device,1101.6,34,,1101.6,percent of total billed charges,Implant Device,1134,35,,1134,percent of total billed charges,Implant Device,1134,35,,1134,percent of total billed charges,Implant Device,1134,35,,1134,percent of total billed charges,Implant Device,1134,35,,1134,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1101.6,34,"If Charge > 2,000, then 34 percent",1101.6,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2397.61,
ZIMMER 00-5990-036-20-REV AUGMENT BLOCK,C1776,HCPCS,,79002816,CDM,278,RC,,,both,,,2963,2192.63,,,2192.63,Other,150% of Medicare + 9.63% HCRA Surcharge,1333.35,45,,1333.35,percent of total billed charges,Critical Access Hospital RCC factor,1007.42,34,,1007.42,percent of total billed charges,Implant Device,1007.42,34,,1007.42,percent of total billed charges,Implant Device,1007.42,34,,1007.42,percent of total billed charges,Implant Device,1007.42,34,,1007.42,percent of total billed charges,Implant Device,1007.42,34,,1007.42,percent of total billed charges,Implant Device,1466.69,,,1466.69,Other,110% of Medicare,1037.05,35,,1037.05,percent of total billed charges,Implant Device,1007.42,34,"Charges > $500, x 34%",1007.42,percent of total billed charges,Implant Device,1037.05,35,,1037.05,percent of total billed charges,Implant Device,1037.05,35,,1037.05,percent of total billed charges,Implant Device,1037.05,35,,1037.05,percent of total billed charges,Implant Device,1037.05,35,,1037.05,percent of total billed charges,Implant Device,1037.05,35,,1037.05,percent of total billed charges,Implant Device,1185.2,40,,1185.2,percent of total billed charges,Implant Device,1037.05,70,,1037.05,percent of total billed charges,All Other,1007.42,34,,1007.42,percent of total billed charges,Implant Device,1007.42,34,,1007.42,percent of total billed charges,Implant Device,1037.05,35,,1037.05,percent of total billed charges,Implant Device,1037.05,35,,1037.05,percent of total billed charges,Implant Device,1037.05,35,,1037.05,percent of total billed charges,Implant Device,1037.05,35,,1037.05,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1007.42,34,"If Charge > 2,000, then 34 percent",1007.42,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2192.63,
ZIMMER 00-5994-016-92-REV FEM COMPONENT,C1776,HCPCS,,79002817,CDM,278,RC,,,both,,,17989,13311.9,,,13311.9,Other,150% of Medicare + 9.63% HCRA Surcharge,8095.05,45,,8095.05,percent of total billed charges,Critical Access Hospital RCC factor,6116.26,34,,6116.26,percent of total billed charges,Implant Device,6116.26,34,,6116.26,percent of total billed charges,Implant Device,6116.26,34,,6116.26,percent of total billed charges,Implant Device,6116.26,34,,6116.26,percent of total billed charges,Implant Device,6116.26,34,,6116.26,percent of total billed charges,Implant Device,8904.56,,,8904.56,Other,110% of Medicare,6296.15,35,,6296.15,percent of total billed charges,Implant Device,6116.26,34,"Charges > $500, x 34%",6116.26,percent of total billed charges,Implant Device,6296.15,35,,6296.15,percent of total billed charges,Implant Device,6296.15,35,,6296.15,percent of total billed charges,Implant Device,6296.15,35,,6296.15,percent of total billed charges,Implant Device,6296.15,35,,6296.15,percent of total billed charges,Implant Device,6296.15,35,,6296.15,percent of total billed charges,Implant Device,7195.6,40,,7195.6,percent of total billed charges,Implant Device,6296.15,70,,6296.15,percent of total billed charges,All Other,6116.26,34,,6116.26,percent of total billed charges,Implant Device,6116.26,34,,6116.26,percent of total billed charges,Implant Device,6296.15,35,,6296.15,percent of total billed charges,Implant Device,6296.15,35,,6296.15,percent of total billed charges,Implant Device,6296.15,35,,6296.15,percent of total billed charges,Implant Device,6296.15,35,,6296.15,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,6116.26,34,"If Charge > 2,000, then 34 percent",6116.26,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,13311.9,
ZIMMER 00-5994-032-14-REV ARTICULAR SURF,C1776,HCPCS,,79002818,CDM,278,RC,,,both,,,6465,4784.12,,,4784.12,Other,150% of Medicare + 9.63% HCRA Surcharge,2909.25,45,,2909.25,percent of total billed charges,Critical Access Hospital RCC factor,2198.1,34,,2198.1,percent of total billed charges,Implant Device,2198.1,34,,2198.1,percent of total billed charges,Implant Device,2198.1,34,,2198.1,percent of total billed charges,Implant Device,2198.1,34,,2198.1,percent of total billed charges,Implant Device,2198.1,34,,2198.1,percent of total billed charges,Implant Device,3200.18,,,3200.18,Other,110% of Medicare,2262.75,35,,2262.75,percent of total billed charges,Implant Device,2198.1,34,"Charges > $500, x 34%",2198.1,percent of total billed charges,Implant Device,2262.75,35,,2262.75,percent of total billed charges,Implant Device,2262.75,35,,2262.75,percent of total billed charges,Implant Device,2262.75,35,,2262.75,percent of total billed charges,Implant Device,2262.75,35,,2262.75,percent of total billed charges,Implant Device,2262.75,35,,2262.75,percent of total billed charges,Implant Device,2586,40,,2586,percent of total billed charges,Implant Device,2262.75,70,,2262.75,percent of total billed charges,All Other,2198.1,34,,2198.1,percent of total billed charges,Implant Device,2198.1,34,,2198.1,percent of total billed charges,Implant Device,2262.75,35,,2262.75,percent of total billed charges,Implant Device,2262.75,35,,2262.75,percent of total billed charges,Implant Device,2262.75,35,,2262.75,percent of total billed charges,Implant Device,2262.75,35,,2262.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2198.1,34,"If Charge > 2,000, then 34 percent",2198.1,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4784.12,
ZIMMER 00-5901-020-00-REV DRILL PIN,C1713,HCPCS,,79002819,CDM,278,RC,,,both,,,257,190.18,,,190.18,Other,150% of Medicare + 9.63% HCRA Surcharge,115.65,45,,115.65,percent of total billed charges,Critical Access Hospital RCC factor,87.38,34,,87.38,percent of total billed charges,Implant Device,87.38,34,,87.38,percent of total billed charges,Implant Device,87.38,34,,87.38,percent of total billed charges,Implant Device,87.38,34,,87.38,percent of total billed charges,Implant Device,87.38,34,,87.38,percent of total billed charges,Implant Device,127.22,,,127.22,Other,110% of Medicare,89.95,35,,89.95,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,89.95,35,,89.95,percent of total billed charges,Implant Device,89.95,35,,89.95,percent of total billed charges,Implant Device,89.95,35,,89.95,percent of total billed charges,Implant Device,89.95,35,,89.95,percent of total billed charges,Implant Device,89.95,35,,89.95,percent of total billed charges,Implant Device,102.8,40,,102.8,percent of total billed charges,Implant Device,89.95,70,,89.95,percent of total billed charges,All Other,87.38,34,,87.38,percent of total billed charges,Implant Device,87.38,34,,87.38,percent of total billed charges,Implant Device,89.95,35,,89.95,percent of total billed charges,Implant Device,89.95,35,,89.95,percent of total billed charges,Implant Device,89.95,35,,89.95,percent of total billed charges,Implant Device,89.95,35,,89.95,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,190.18,
ARTHREX AR-1360C BIOCOMP SCREW 6X23MM,C1713,HCPCS,,79002820,CDM,278,RC,,,both,,,966,714.84,,,714.84,Other,150% of Medicare + 9.63% HCRA Surcharge,434.7,45,,434.7,percent of total billed charges,Critical Access Hospital RCC factor,328.44,34,,328.44,percent of total billed charges,Implant Device,328.44,34,,328.44,percent of total billed charges,Implant Device,328.44,34,,328.44,percent of total billed charges,Implant Device,328.44,34,,328.44,percent of total billed charges,Implant Device,328.44,34,,328.44,percent of total billed charges,Implant Device,478.17,,,478.17,Other,110% of Medicare,338.1,35,,338.1,percent of total billed charges,Implant Device,328.44,34,"Charges > $500, x 34%",328.44,percent of total billed charges,Implant Device,338.1,35,,338.1,percent of total billed charges,Implant Device,338.1,35,,338.1,percent of total billed charges,Implant Device,338.1,35,,338.1,percent of total billed charges,Implant Device,338.1,35,,338.1,percent of total billed charges,Implant Device,338.1,35,,338.1,percent of total billed charges,Implant Device,386.4,40,,386.4,percent of total billed charges,Implant Device,338.1,70,,338.1,percent of total billed charges,All Other,328.44,34,,328.44,percent of total billed charges,Implant Device,328.44,34,,328.44,percent of total billed charges,Implant Device,338.1,35,,338.1,percent of total billed charges,Implant Device,338.1,35,,338.1,percent of total billed charges,Implant Device,338.1,35,,338.1,percent of total billed charges,Implant Device,338.1,35,,338.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,714.84,
STRYKER ORTHO R5351-4510 HUMERAL COMP,C1776,HCPCS,,79002821,CDM,278,RC,,,both,,,14089,10425.9,,,10425.9,Other,150% of Medicare + 9.63% HCRA Surcharge,6340.05,45,,6340.05,percent of total billed charges,Critical Access Hospital RCC factor,4790.26,34,,4790.26,percent of total billed charges,Implant Device,4790.26,34,,4790.26,percent of total billed charges,Implant Device,4790.26,34,,4790.26,percent of total billed charges,Implant Device,4790.26,34,,4790.26,percent of total billed charges,Implant Device,4790.26,34,,4790.26,percent of total billed charges,Implant Device,6974.06,,,6974.06,Other,110% of Medicare,4931.15,35,,4931.15,percent of total billed charges,Implant Device,4790.26,34,"Charges > $500, x 34%",4790.26,percent of total billed charges,Implant Device,4931.15,35,,4931.15,percent of total billed charges,Implant Device,4931.15,35,,4931.15,percent of total billed charges,Implant Device,4931.15,35,,4931.15,percent of total billed charges,Implant Device,4931.15,35,,4931.15,percent of total billed charges,Implant Device,4931.15,35,,4931.15,percent of total billed charges,Implant Device,5635.6,40,,5635.6,percent of total billed charges,Implant Device,4931.15,70,,4931.15,percent of total billed charges,All Other,4790.26,34,,4790.26,percent of total billed charges,Implant Device,4790.26,34,,4790.26,percent of total billed charges,Implant Device,4931.15,35,,4931.15,percent of total billed charges,Implant Device,4931.15,35,,4931.15,percent of total billed charges,Implant Device,4931.15,35,,4931.15,percent of total billed charges,Implant Device,4931.15,35,,4931.15,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,4790.26,34,"If Charge > 2,000, then 34 percent",4790.26,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,10425.9,
STRYKER ORTHO R5350-5024 SHLDR HUM HEAD,C1776,HCPCS,,79002822,CDM,278,RC,,,both,,,7018,5193.34,,,5193.34,Other,150% of Medicare + 9.63% HCRA Surcharge,3158.1,45,,3158.1,percent of total billed charges,Critical Access Hospital RCC factor,2386.12,34,,2386.12,percent of total billed charges,Implant Device,2386.12,34,,2386.12,percent of total billed charges,Implant Device,2386.12,34,,2386.12,percent of total billed charges,Implant Device,2386.12,34,,2386.12,percent of total billed charges,Implant Device,2386.12,34,,2386.12,percent of total billed charges,Implant Device,3473.91,,,3473.91,Other,110% of Medicare,2456.3,35,,2456.3,percent of total billed charges,Implant Device,2386.12,34,"Charges > $500, x 34%",2386.12,percent of total billed charges,Implant Device,2456.3,35,,2456.3,percent of total billed charges,Implant Device,2456.3,35,,2456.3,percent of total billed charges,Implant Device,2456.3,35,,2456.3,percent of total billed charges,Implant Device,2456.3,35,,2456.3,percent of total billed charges,Implant Device,2456.3,35,,2456.3,percent of total billed charges,Implant Device,2807.2,40,,2807.2,percent of total billed charges,Implant Device,2456.3,70,,2456.3,percent of total billed charges,All Other,2386.12,34,,2386.12,percent of total billed charges,Implant Device,2386.12,34,,2386.12,percent of total billed charges,Implant Device,2456.3,35,,2456.3,percent of total billed charges,Implant Device,2456.3,35,,2456.3,percent of total billed charges,Implant Device,2456.3,35,,2456.3,percent of total billed charges,Implant Device,2456.3,35,,2456.3,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2386.12,34,"If Charge > 2,000, then 34 percent",2386.12,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5193.34,
SOLANA SURGICAL TFF-2718A TENFUSE 2.7X18,C1713,HCPCS,,79002825,CDM,278,RC,,,both,,,3557,2632.19,,,2632.19,Other,150% of Medicare + 9.63% HCRA Surcharge,1600.65,45,,1600.65,percent of total billed charges,Critical Access Hospital RCC factor,1209.38,34,,1209.38,percent of total billed charges,Implant Device,1209.38,34,,1209.38,percent of total billed charges,Implant Device,1209.38,34,,1209.38,percent of total billed charges,Implant Device,1209.38,34,,1209.38,percent of total billed charges,Implant Device,1209.38,34,,1209.38,percent of total billed charges,Implant Device,1760.72,,,1760.72,Other,110% of Medicare,1244.95,35,,1244.95,percent of total billed charges,Implant Device,1209.38,34,"Charges > $500, x 34%",1209.38,percent of total billed charges,Implant Device,1244.95,35,,1244.95,percent of total billed charges,Implant Device,1244.95,35,,1244.95,percent of total billed charges,Implant Device,1244.95,35,,1244.95,percent of total billed charges,Implant Device,1244.95,35,,1244.95,percent of total billed charges,Implant Device,1244.95,35,,1244.95,percent of total billed charges,Implant Device,1422.8,40,,1422.8,percent of total billed charges,Implant Device,1244.95,70,,1244.95,percent of total billed charges,All Other,1209.38,34,,1209.38,percent of total billed charges,Implant Device,1209.38,34,,1209.38,percent of total billed charges,Implant Device,1244.95,35,,1244.95,percent of total billed charges,Implant Device,1244.95,35,,1244.95,percent of total billed charges,Implant Device,1244.95,35,,1244.95,percent of total billed charges,Implant Device,1244.95,35,,1244.95,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1209.38,34,"If Charge > 2,000, then 34 percent",1209.38,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2632.19,
SOLANA SURGICAL SFT-2012 SCREW 12MM,C1713,HCPCS,,79002826,CDM,278,RC,,,both,,,1161,859.14,,,859.14,Other,150% of Medicare + 9.63% HCRA Surcharge,522.45,45,,522.45,percent of total billed charges,Critical Access Hospital RCC factor,394.74,34,,394.74,percent of total billed charges,Implant Device,394.74,34,,394.74,percent of total billed charges,Implant Device,394.74,34,,394.74,percent of total billed charges,Implant Device,394.74,34,,394.74,percent of total billed charges,Implant Device,394.74,34,,394.74,percent of total billed charges,Implant Device,574.7,,,574.7,Other,110% of Medicare,406.35,35,,406.35,percent of total billed charges,Implant Device,394.74,34,"Charges > $500, x 34%",394.74,percent of total billed charges,Implant Device,406.35,35,,406.35,percent of total billed charges,Implant Device,406.35,35,,406.35,percent of total billed charges,Implant Device,406.35,35,,406.35,percent of total billed charges,Implant Device,406.35,35,,406.35,percent of total billed charges,Implant Device,406.35,35,,406.35,percent of total billed charges,Implant Device,464.4,40,,464.4,percent of total billed charges,Implant Device,406.35,70,,406.35,percent of total billed charges,All Other,394.74,34,,394.74,percent of total billed charges,Implant Device,394.74,34,,394.74,percent of total billed charges,Implant Device,406.35,35,,406.35,percent of total billed charges,Implant Device,406.35,35,,406.35,percent of total billed charges,Implant Device,406.35,35,,406.35,percent of total billed charges,Implant Device,406.35,35,,406.35,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,859.14,
SOLANA SURGICAL SFT-1003 PIN 1.1X100MM,C1713,HCPCS,,79002827,CDM,278,RC,,,both,,,203,150.22,,,150.22,Other,150% of Medicare + 9.63% HCRA Surcharge,91.35,45,,91.35,percent of total billed charges,Critical Access Hospital RCC factor,69.02,34,,69.02,percent of total billed charges,Implant Device,69.02,34,,69.02,percent of total billed charges,Implant Device,69.02,34,,69.02,percent of total billed charges,Implant Device,69.02,34,,69.02,percent of total billed charges,Implant Device,69.02,34,,69.02,percent of total billed charges,Implant Device,100.49,,,100.49,Other,110% of Medicare,71.05,35,,71.05,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,71.05,35,,71.05,percent of total billed charges,Implant Device,71.05,35,,71.05,percent of total billed charges,Implant Device,71.05,35,,71.05,percent of total billed charges,Implant Device,71.05,35,,71.05,percent of total billed charges,Implant Device,71.05,35,,71.05,percent of total billed charges,Implant Device,81.2,40,,81.2,percent of total billed charges,Implant Device,71.05,70,,71.05,percent of total billed charges,All Other,69.02,34,,69.02,percent of total billed charges,Implant Device,69.02,34,,69.02,percent of total billed charges,Implant Device,71.05,35,,71.05,percent of total billed charges,Implant Device,71.05,35,,71.05,percent of total billed charges,Implant Device,71.05,35,,71.05,percent of total billed charges,Implant Device,71.05,35,,71.05,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,150.22,
LIFE NET VG2C-T46P CERVICAL BONE GRAFT,C1713,HCPCS,,79002828,CDM,278,RC,,,both,,,3516,2601.85,,,2601.85,Other,150% of Medicare + 9.63% HCRA Surcharge,1582.2,45,,1582.2,percent of total billed charges,Critical Access Hospital RCC factor,1195.44,34,,1195.44,percent of total billed charges,Implant Device,1195.44,34,,1195.44,percent of total billed charges,Implant Device,1195.44,34,,1195.44,percent of total billed charges,Implant Device,1195.44,34,,1195.44,percent of total billed charges,Implant Device,1195.44,34,,1195.44,percent of total billed charges,Implant Device,1740.42,,,1740.42,Other,110% of Medicare,1230.6,35,,1230.6,percent of total billed charges,Implant Device,1195.44,34,"Charges > $500, x 34%",1195.44,percent of total billed charges,Implant Device,1230.6,35,,1230.6,percent of total billed charges,Implant Device,1230.6,35,,1230.6,percent of total billed charges,Implant Device,1230.6,35,,1230.6,percent of total billed charges,Implant Device,1230.6,35,,1230.6,percent of total billed charges,Implant Device,1230.6,35,,1230.6,percent of total billed charges,Implant Device,1406.4,40,,1406.4,percent of total billed charges,Implant Device,1230.6,70,,1230.6,percent of total billed charges,All Other,1195.44,34,,1195.44,percent of total billed charges,Implant Device,1195.44,34,,1195.44,percent of total billed charges,Implant Device,1230.6,35,,1230.6,percent of total billed charges,Implant Device,1230.6,35,,1230.6,percent of total billed charges,Implant Device,1230.6,35,,1230.6,percent of total billed charges,Implant Device,1230.6,35,,1230.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1195.44,34,"If Charge > 2,000, then 34 percent",1195.44,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2601.85,
ARTHREX AR-1547BC TENOD SCREW 4.75X15MM,C1713,HCPCS,,79002829,CDM,278,RC,,,both,,,1036,766.64,,,766.64,Other,150% of Medicare + 9.63% HCRA Surcharge,466.2,45,,466.2,percent of total billed charges,Critical Access Hospital RCC factor,352.24,34,,352.24,percent of total billed charges,Implant Device,352.24,34,,352.24,percent of total billed charges,Implant Device,352.24,34,,352.24,percent of total billed charges,Implant Device,352.24,34,,352.24,percent of total billed charges,Implant Device,352.24,34,,352.24,percent of total billed charges,Implant Device,512.82,,,512.82,Other,110% of Medicare,362.6,35,,362.6,percent of total billed charges,Implant Device,352.24,34,"Charges > $500, x 34%",352.24,percent of total billed charges,Implant Device,362.6,35,,362.6,percent of total billed charges,Implant Device,362.6,35,,362.6,percent of total billed charges,Implant Device,362.6,35,,362.6,percent of total billed charges,Implant Device,362.6,35,,362.6,percent of total billed charges,Implant Device,362.6,35,,362.6,percent of total billed charges,Implant Device,414.4,40,,414.4,percent of total billed charges,Implant Device,362.6,70,,362.6,percent of total billed charges,All Other,352.24,34,,352.24,percent of total billed charges,Implant Device,352.24,34,,352.24,percent of total billed charges,Implant Device,362.6,35,,362.6,percent of total billed charges,Implant Device,362.6,35,,362.6,percent of total billed charges,Implant Device,362.6,35,,362.6,percent of total billed charges,Implant Device,362.6,35,,362.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,766.64,
ZIMMER 00-5938-040-48 HEADED SCREW,C1713,HCPCS,,79002830,CDM,278,RC,,,both,,,348,257.52,,,257.52,Other,150% of Medicare + 9.63% HCRA Surcharge,156.6,45,,156.6,percent of total billed charges,Critical Access Hospital RCC factor,118.32,34,,118.32,percent of total billed charges,Implant Device,118.32,34,,118.32,percent of total billed charges,Implant Device,118.32,34,,118.32,percent of total billed charges,Implant Device,118.32,34,,118.32,percent of total billed charges,Implant Device,118.32,34,,118.32,percent of total billed charges,Implant Device,172.26,,,172.26,Other,110% of Medicare,121.8,35,,121.8,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,121.8,35,,121.8,percent of total billed charges,Implant Device,121.8,35,,121.8,percent of total billed charges,Implant Device,121.8,35,,121.8,percent of total billed charges,Implant Device,121.8,35,,121.8,percent of total billed charges,Implant Device,121.8,35,,121.8,percent of total billed charges,Implant Device,139.2,40,,139.2,percent of total billed charges,Implant Device,121.8,70,,121.8,percent of total billed charges,All Other,118.32,34,,118.32,percent of total billed charges,Implant Device,118.32,34,,118.32,percent of total billed charges,Implant Device,121.8,35,,121.8,percent of total billed charges,Implant Device,121.8,35,,121.8,percent of total billed charges,Implant Device,121.8,35,,121.8,percent of total billed charges,Implant Device,121.8,35,,121.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,257.52,
ARTHREX AR-8944CL-S STD LT MTP PLATE,C1713,HCPCS,,79002831,CDM,278,RC,,,both,,,2909,2152.67,,,2152.67,Other,150% of Medicare + 9.63% HCRA Surcharge,1309.05,45,,1309.05,percent of total billed charges,Critical Access Hospital RCC factor,989.06,34,,989.06,percent of total billed charges,Implant Device,989.06,34,,989.06,percent of total billed charges,Implant Device,989.06,34,,989.06,percent of total billed charges,Implant Device,989.06,34,,989.06,percent of total billed charges,Implant Device,989.06,34,,989.06,percent of total billed charges,Implant Device,1439.96,,,1439.96,Other,110% of Medicare,1018.15,35,,1018.15,percent of total billed charges,Implant Device,989.06,34,"Charges > $500, x 34%",989.06,percent of total billed charges,Implant Device,1018.15,35,,1018.15,percent of total billed charges,Implant Device,1018.15,35,,1018.15,percent of total billed charges,Implant Device,1018.15,35,,1018.15,percent of total billed charges,Implant Device,1018.15,35,,1018.15,percent of total billed charges,Implant Device,1018.15,35,,1018.15,percent of total billed charges,Implant Device,1163.6,40,,1163.6,percent of total billed charges,Implant Device,1018.15,70,,1018.15,percent of total billed charges,All Other,989.06,34,,989.06,percent of total billed charges,Implant Device,989.06,34,,989.06,percent of total billed charges,Implant Device,1018.15,35,,1018.15,percent of total billed charges,Implant Device,1018.15,35,,1018.15,percent of total billed charges,Implant Device,1018.15,35,,1018.15,percent of total billed charges,Implant Device,1018.15,35,,1018.15,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,989.06,34,"If Charge > 2,000, then 34 percent",989.06,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2152.67,
ARTHREX AR-8933-32PT CANN SCREW 3.0X32MM,C1713,HCPCS,,79002832,CDM,278,RC,,,both,,,316,233.84,,,233.84,Other,150% of Medicare + 9.63% HCRA Surcharge,142.2,45,,142.2,percent of total billed charges,Critical Access Hospital RCC factor,107.44,34,,107.44,percent of total billed charges,Implant Device,107.44,34,,107.44,percent of total billed charges,Implant Device,107.44,34,,107.44,percent of total billed charges,Implant Device,107.44,34,,107.44,percent of total billed charges,Implant Device,107.44,34,,107.44,percent of total billed charges,Implant Device,156.42,,,156.42,Other,110% of Medicare,110.6,35,,110.6,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,110.6,35,,110.6,percent of total billed charges,Implant Device,110.6,35,,110.6,percent of total billed charges,Implant Device,110.6,35,,110.6,percent of total billed charges,Implant Device,110.6,35,,110.6,percent of total billed charges,Implant Device,110.6,35,,110.6,percent of total billed charges,Implant Device,126.4,40,,126.4,percent of total billed charges,Implant Device,110.6,70,,110.6,percent of total billed charges,All Other,107.44,34,,107.44,percent of total billed charges,Implant Device,107.44,34,,107.44,percent of total billed charges,Implant Device,110.6,35,,110.6,percent of total billed charges,Implant Device,110.6,35,,110.6,percent of total billed charges,Implant Device,110.6,35,,110.6,percent of total billed charges,Implant Device,110.6,35,,110.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,233.84,
ARTHREX AR-8933-34PT CANN SCREW 3.0X34MM,C1713,HCPCS,,79002833,CDM,278,RC,,,both,,,316,233.84,,,233.84,Other,150% of Medicare + 9.63% HCRA Surcharge,142.2,45,,142.2,percent of total billed charges,Critical Access Hospital RCC factor,107.44,34,,107.44,percent of total billed charges,Implant Device,107.44,34,,107.44,percent of total billed charges,Implant Device,107.44,34,,107.44,percent of total billed charges,Implant Device,107.44,34,,107.44,percent of total billed charges,Implant Device,107.44,34,,107.44,percent of total billed charges,Implant Device,156.42,,,156.42,Other,110% of Medicare,110.6,35,,110.6,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,110.6,35,,110.6,percent of total billed charges,Implant Device,110.6,35,,110.6,percent of total billed charges,Implant Device,110.6,35,,110.6,percent of total billed charges,Implant Device,110.6,35,,110.6,percent of total billed charges,Implant Device,110.6,35,,110.6,percent of total billed charges,Implant Device,126.4,40,,126.4,percent of total billed charges,Implant Device,110.6,70,,110.6,percent of total billed charges,All Other,107.44,34,,107.44,percent of total billed charges,Implant Device,107.44,34,,107.44,percent of total billed charges,Implant Device,110.6,35,,110.6,percent of total billed charges,Implant Device,110.6,35,,110.6,percent of total billed charges,Implant Device,110.6,35,,110.6,percent of total billed charges,Implant Device,110.6,35,,110.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,233.84,
ARTHREX AR-8933-36PT CANN SCREW 3.0X36MM,C1713,HCPCS,,79002834,CDM,278,RC,,,both,,,316,233.84,,,233.84,Other,150% of Medicare + 9.63% HCRA Surcharge,142.2,45,,142.2,percent of total billed charges,Critical Access Hospital RCC factor,107.44,34,,107.44,percent of total billed charges,Implant Device,107.44,34,,107.44,percent of total billed charges,Implant Device,107.44,34,,107.44,percent of total billed charges,Implant Device,107.44,34,,107.44,percent of total billed charges,Implant Device,107.44,34,,107.44,percent of total billed charges,Implant Device,156.42,,,156.42,Other,110% of Medicare,110.6,35,,110.6,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,110.6,35,,110.6,percent of total billed charges,Implant Device,110.6,35,,110.6,percent of total billed charges,Implant Device,110.6,35,,110.6,percent of total billed charges,Implant Device,110.6,35,,110.6,percent of total billed charges,Implant Device,110.6,35,,110.6,percent of total billed charges,Implant Device,126.4,40,,126.4,percent of total billed charges,Implant Device,110.6,70,,110.6,percent of total billed charges,All Other,107.44,34,,107.44,percent of total billed charges,Implant Device,107.44,34,,107.44,percent of total billed charges,Implant Device,110.6,35,,110.6,percent of total billed charges,Implant Device,110.6,35,,110.6,percent of total billed charges,Implant Device,110.6,35,,110.6,percent of total billed charges,Implant Device,110.6,35,,110.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,233.84,
ARTHREX AR-8933-16 SCREW 3.0X16MM,C1713,HCPCS,,79002835,CDM,278,RC,,,both,,,330,244.2,,,244.2,Other,150% of Medicare + 9.63% HCRA Surcharge,148.5,45,,148.5,percent of total billed charges,Critical Access Hospital RCC factor,112.2,34,,112.2,percent of total billed charges,Implant Device,112.2,34,,112.2,percent of total billed charges,Implant Device,112.2,34,,112.2,percent of total billed charges,Implant Device,112.2,34,,112.2,percent of total billed charges,Implant Device,112.2,34,,112.2,percent of total billed charges,Implant Device,163.35,,,163.35,Other,110% of Medicare,115.5,35,,115.5,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,132,40,,132,percent of total billed charges,Implant Device,115.5,70,,115.5,percent of total billed charges,All Other,112.2,34,,112.2,percent of total billed charges,Implant Device,112.2,34,,112.2,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,244.2,
BIOMET 14285 BONE SCREW 5MM,C1713,HCPCS,,79002836,CDM,278,RC,,,both,,,900,666,,,666,Other,150% of Medicare + 9.63% HCRA Surcharge,405,45,,405,percent of total billed charges,Critical Access Hospital RCC factor,306,34,,306,percent of total billed charges,Implant Device,306,34,,306,percent of total billed charges,Implant Device,306,34,,306,percent of total billed charges,Implant Device,306,34,,306,percent of total billed charges,Implant Device,306,34,,306,percent of total billed charges,Implant Device,445.5,,,445.5,Other,110% of Medicare,315,35,,315,percent of total billed charges,Implant Device,306,34,"Charges > $500, x 34%",306,percent of total billed charges,Implant Device,315,35,,315,percent of total billed charges,Implant Device,315,35,,315,percent of total billed charges,Implant Device,315,35,,315,percent of total billed charges,Implant Device,315,35,,315,percent of total billed charges,Implant Device,315,35,,315,percent of total billed charges,Implant Device,360,40,,360,percent of total billed charges,Implant Device,315,70,,315,percent of total billed charges,All Other,306,34,,306,percent of total billed charges,Implant Device,306,34,,306,percent of total billed charges,Implant Device,315,35,,315,percent of total billed charges,Implant Device,315,35,,315,percent of total billed charges,Implant Device,315,35,,315,percent of total billed charges,Implant Device,315,35,,315,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,666,
BIOMET SD50-15050 BONE SCREW 5MM,C1713,HCPCS,,79002837,CDM,278,RC,,,both,,,720,532.8,,,532.8,Other,150% of Medicare + 9.63% HCRA Surcharge,324,45,,324,percent of total billed charges,Critical Access Hospital RCC factor,244.8,34,,244.8,percent of total billed charges,Implant Device,244.8,34,,244.8,percent of total billed charges,Implant Device,244.8,34,,244.8,percent of total billed charges,Implant Device,244.8,34,,244.8,percent of total billed charges,Implant Device,244.8,34,,244.8,percent of total billed charges,Implant Device,356.4,,,356.4,Other,110% of Medicare,252,35,,252,percent of total billed charges,Implant Device,244.8,34,"Charges > $500, x 34%",244.8,percent of total billed charges,Implant Device,252,35,,252,percent of total billed charges,Implant Device,252,35,,252,percent of total billed charges,Implant Device,252,35,,252,percent of total billed charges,Implant Device,252,35,,252,percent of total billed charges,Implant Device,252,35,,252,percent of total billed charges,Implant Device,288,40,,288,percent of total billed charges,Implant Device,252,70,,252,percent of total billed charges,All Other,244.8,34,,244.8,percent of total billed charges,Implant Device,244.8,34,,244.8,percent of total billed charges,Implant Device,252,35,,252,percent of total billed charges,Implant Device,252,35,,252,percent of total billed charges,Implant Device,252,35,,252,percent of total billed charges,Implant Device,252,35,,252,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,532.8,
BIOMET 14180 CARBON RODS 350 MM,C1713,HCPCS,,79002838,CDM,278,RC,,,both,,,1020,754.8,,,754.8,Other,150% of Medicare + 9.63% HCRA Surcharge,459,45,,459,percent of total billed charges,Critical Access Hospital RCC factor,346.8,34,,346.8,percent of total billed charges,Implant Device,346.8,34,,346.8,percent of total billed charges,Implant Device,346.8,34,,346.8,percent of total billed charges,Implant Device,346.8,34,,346.8,percent of total billed charges,Implant Device,346.8,34,,346.8,percent of total billed charges,Implant Device,504.9,,,504.9,Other,110% of Medicare,357,35,,357,percent of total billed charges,Implant Device,346.8,34,"Charges > $500, x 34%",346.8,percent of total billed charges,Implant Device,357,35,,357,percent of total billed charges,Implant Device,357,35,,357,percent of total billed charges,Implant Device,357,35,,357,percent of total billed charges,Implant Device,357,35,,357,percent of total billed charges,Implant Device,357,35,,357,percent of total billed charges,Implant Device,408,40,,408,percent of total billed charges,Implant Device,357,70,,357,percent of total billed charges,All Other,346.8,34,,346.8,percent of total billed charges,Implant Device,346.8,34,,346.8,percent of total billed charges,Implant Device,357,35,,357,percent of total billed charges,Implant Device,357,35,,357,percent of total billed charges,Implant Device,357,35,,357,percent of total billed charges,Implant Device,357,35,,357,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,754.8,
BIOMET 14600 CLAMP BAR TO BAR,C1713,HCPCS,,79002840,CDM,278,RC,,,both,,,3120,2308.81,,,2308.81,Other,150% of Medicare + 9.63% HCRA Surcharge,1404,45,,1404,percent of total billed charges,Critical Access Hospital RCC factor,1060.8,34,,1060.8,percent of total billed charges,Implant Device,1060.8,34,,1060.8,percent of total billed charges,Implant Device,1060.8,34,,1060.8,percent of total billed charges,Implant Device,1060.8,34,,1060.8,percent of total billed charges,Implant Device,1060.8,34,,1060.8,percent of total billed charges,Implant Device,1544.4,,,1544.4,Other,110% of Medicare,1092,35,,1092,percent of total billed charges,Implant Device,1060.8,34,"Charges > $500, x 34%",1060.8,percent of total billed charges,Implant Device,1092,35,,1092,percent of total billed charges,Implant Device,1092,35,,1092,percent of total billed charges,Implant Device,1092,35,,1092,percent of total billed charges,Implant Device,1092,35,,1092,percent of total billed charges,Implant Device,1092,35,,1092,percent of total billed charges,Implant Device,1248,40,,1248,percent of total billed charges,Implant Device,1092,70,,1092,percent of total billed charges,All Other,1060.8,34,,1060.8,percent of total billed charges,Implant Device,1060.8,34,,1060.8,percent of total billed charges,Implant Device,1092,35,,1092,percent of total billed charges,Implant Device,1092,35,,1092,percent of total billed charges,Implant Device,1092,35,,1092,percent of total billed charges,Implant Device,1092,35,,1092,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1060.8,34,"If Charge > 2,000, then 34 percent",1060.8,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2308.81,
BIOMET 14060 CLAMP 3 HOLE,C1713,HCPCS,,79002841,CDM,278,RC,,,both,,,2730,2020.21,,,2020.21,Other,150% of Medicare + 9.63% HCRA Surcharge,1228.5,45,,1228.5,percent of total billed charges,Critical Access Hospital RCC factor,928.2,34,,928.2,percent of total billed charges,Implant Device,928.2,34,,928.2,percent of total billed charges,Implant Device,928.2,34,,928.2,percent of total billed charges,Implant Device,928.2,34,,928.2,percent of total billed charges,Implant Device,928.2,34,,928.2,percent of total billed charges,Implant Device,1351.35,,,1351.35,Other,110% of Medicare,955.5,35,,955.5,percent of total billed charges,Implant Device,928.2,34,"Charges > $500, x 34%",928.2,percent of total billed charges,Implant Device,955.5,35,,955.5,percent of total billed charges,Implant Device,955.5,35,,955.5,percent of total billed charges,Implant Device,955.5,35,,955.5,percent of total billed charges,Implant Device,955.5,35,,955.5,percent of total billed charges,Implant Device,955.5,35,,955.5,percent of total billed charges,Implant Device,1092,40,,1092,percent of total billed charges,Implant Device,955.5,70,,955.5,percent of total billed charges,All Other,928.2,34,,928.2,percent of total billed charges,Implant Device,928.2,34,,928.2,percent of total billed charges,Implant Device,955.5,35,,955.5,percent of total billed charges,Implant Device,955.5,35,,955.5,percent of total billed charges,Implant Device,955.5,35,,955.5,percent of total billed charges,Implant Device,955.5,35,,955.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,928.2,34,"If Charge > 2,000, then 34 percent",928.2,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2020.21,
BIOMET 14-400065 POST 3/5,C1713,HCPCS,,79002842,CDM,278,RC,,,both,,,1110,821.4,,,821.4,Other,150% of Medicare + 9.63% HCRA Surcharge,499.5,45,,499.5,percent of total billed charges,Critical Access Hospital RCC factor,377.4,34,,377.4,percent of total billed charges,Implant Device,377.4,34,,377.4,percent of total billed charges,Implant Device,377.4,34,,377.4,percent of total billed charges,Implant Device,377.4,34,,377.4,percent of total billed charges,Implant Device,377.4,34,,377.4,percent of total billed charges,Implant Device,549.45,,,549.45,Other,110% of Medicare,388.5,35,,388.5,percent of total billed charges,Implant Device,377.4,34,"Charges > $500, x 34%",377.4,percent of total billed charges,Implant Device,388.5,35,,388.5,percent of total billed charges,Implant Device,388.5,35,,388.5,percent of total billed charges,Implant Device,388.5,35,,388.5,percent of total billed charges,Implant Device,388.5,35,,388.5,percent of total billed charges,Implant Device,388.5,35,,388.5,percent of total billed charges,Implant Device,444,40,,444,percent of total billed charges,Implant Device,388.5,70,,388.5,percent of total billed charges,All Other,377.4,34,,377.4,percent of total billed charges,Implant Device,377.4,34,,377.4,percent of total billed charges,Implant Device,388.5,35,,388.5,percent of total billed charges,Implant Device,388.5,35,,388.5,percent of total billed charges,Implant Device,388.5,35,,388.5,percent of total billed charges,Implant Device,388.5,35,,388.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,821.4,
MENTOR 350-2200 BREAST IMPLANT,C1789,HCPCS,,79002846,CDM,278,RC,,,both,,,2010,1487.41,,,1487.41,Other,150% of Medicare + 9.63% HCRA Surcharge,904.5,45,,904.5,percent of total billed charges,Critical Access Hospital RCC factor,683.4,34,,683.4,percent of total billed charges,Implant Device,683.4,34,,683.4,percent of total billed charges,Implant Device,683.4,34,,683.4,percent of total billed charges,Implant Device,683.4,34,,683.4,percent of total billed charges,Implant Device,683.4,34,,683.4,percent of total billed charges,Implant Device,994.95,,,994.95,Other,110% of Medicare,703.5,35,,703.5,percent of total billed charges,Implant Device,683.4,34,"Charges > $500, x 34%",683.4,percent of total billed charges,Implant Device,703.5,35,,703.5,percent of total billed charges,Implant Device,703.5,35,,703.5,percent of total billed charges,Implant Device,703.5,35,,703.5,percent of total billed charges,Implant Device,703.5,35,,703.5,percent of total billed charges,Implant Device,703.5,35,,703.5,percent of total billed charges,Implant Device,804,40,,804,percent of total billed charges,Implant Device,703.5,70,,703.5,percent of total billed charges,All Other,683.4,34,,683.4,percent of total billed charges,Implant Device,683.4,34,,683.4,percent of total billed charges,Implant Device,703.5,35,,703.5,percent of total billed charges,Implant Device,703.5,35,,703.5,percent of total billed charges,Implant Device,703.5,35,,703.5,percent of total billed charges,Implant Device,703.5,35,,703.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,683.4,34,"If Charge > 2,000, then 34 percent",683.4,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1487.41,
ARTHREX AR-1934-BCF-24-2 SUTURE TAK,C1713,HCPCS,,79002847,CDM,278,RC,,,both,,,960,710.4,,,710.4,Other,150% of Medicare + 9.63% HCRA Surcharge,432,45,,432,percent of total billed charges,Critical Access Hospital RCC factor,326.4,34,,326.4,percent of total billed charges,Implant Device,326.4,34,,326.4,percent of total billed charges,Implant Device,326.4,34,,326.4,percent of total billed charges,Implant Device,326.4,34,,326.4,percent of total billed charges,Implant Device,326.4,34,,326.4,percent of total billed charges,Implant Device,475.2,,,475.2,Other,110% of Medicare,336,35,,336,percent of total billed charges,Implant Device,326.4,34,"Charges > $500, x 34%",326.4,percent of total billed charges,Implant Device,336,35,,336,percent of total billed charges,Implant Device,336,35,,336,percent of total billed charges,Implant Device,336,35,,336,percent of total billed charges,Implant Device,336,35,,336,percent of total billed charges,Implant Device,336,35,,336,percent of total billed charges,Implant Device,384,40,,384,percent of total billed charges,Implant Device,336,70,,336,percent of total billed charges,All Other,326.4,34,,326.4,percent of total billed charges,Implant Device,326.4,34,,326.4,percent of total billed charges,Implant Device,336,35,,336,percent of total billed charges,Implant Device,336,35,,336,percent of total billed charges,Implant Device,336,35,,336,percent of total billed charges,Implant Device,336,35,,336,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,710.4,
ZIMMER 00-5988-010-12-REV STR STEM EXT,C1776,HCPCS,,79002849,CDM,278,RC,,,both,,,3325,2460.51,,,2460.51,Other,150% of Medicare + 9.63% HCRA Surcharge,1496.25,45,,1496.25,percent of total billed charges,Critical Access Hospital RCC factor,1130.5,34,,1130.5,percent of total billed charges,Implant Device,1130.5,34,,1130.5,percent of total billed charges,Implant Device,1130.5,34,,1130.5,percent of total billed charges,Implant Device,1130.5,34,,1130.5,percent of total billed charges,Implant Device,1130.5,34,,1130.5,percent of total billed charges,Implant Device,1645.88,,,1645.88,Other,110% of Medicare,1163.75,35,,1163.75,percent of total billed charges,Implant Device,1130.5,34,"Charges > $500, x 34%",1130.5,percent of total billed charges,Implant Device,1163.75,35,,1163.75,percent of total billed charges,Implant Device,1163.75,35,,1163.75,percent of total billed charges,Implant Device,1163.75,35,,1163.75,percent of total billed charges,Implant Device,1163.75,35,,1163.75,percent of total billed charges,Implant Device,1163.75,35,,1163.75,percent of total billed charges,Implant Device,1330,40,,1330,percent of total billed charges,Implant Device,1163.75,70,,1163.75,percent of total billed charges,All Other,1130.5,34,,1130.5,percent of total billed charges,Implant Device,1130.5,34,,1130.5,percent of total billed charges,Implant Device,1163.75,35,,1163.75,percent of total billed charges,Implant Device,1163.75,35,,1163.75,percent of total billed charges,Implant Device,1163.75,35,,1163.75,percent of total billed charges,Implant Device,1163.75,35,,1163.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1130.5,34,"If Charge > 2,000, then 34 percent",1130.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2460.51,
ZIMMER 00-5983-040-48-REV HEADED SCREW,C1713,HCPCS,,79002850,CDM,278,RC,,,both,,,237,175.38,,,175.38,Other,150% of Medicare + 9.63% HCRA Surcharge,106.65,45,,106.65,percent of total billed charges,Critical Access Hospital RCC factor,80.58,34,,80.58,percent of total billed charges,Implant Device,80.58,34,,80.58,percent of total billed charges,Implant Device,80.58,34,,80.58,percent of total billed charges,Implant Device,80.58,34,,80.58,percent of total billed charges,Implant Device,80.58,34,,80.58,percent of total billed charges,Implant Device,117.32,,,117.32,Other,110% of Medicare,82.95,35,,82.95,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,82.95,35,,82.95,percent of total billed charges,Implant Device,82.95,35,,82.95,percent of total billed charges,Implant Device,82.95,35,,82.95,percent of total billed charges,Implant Device,82.95,35,,82.95,percent of total billed charges,Implant Device,82.95,35,,82.95,percent of total billed charges,Implant Device,94.8,40,,94.8,percent of total billed charges,Implant Device,82.95,70,,82.95,percent of total billed charges,All Other,80.58,34,,80.58,percent of total billed charges,Implant Device,80.58,34,,80.58,percent of total billed charges,Implant Device,82.95,35,,82.95,percent of total billed charges,Implant Device,82.95,35,,82.95,percent of total billed charges,Implant Device,82.95,35,,82.95,percent of total billed charges,Implant Device,82.95,35,,82.95,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,175.38,
BIOMET 45-5537 LORDOTIC CERVICAL SPACER,C1713,HCPCS,,79002851,CDM,278,RC,,,both,,,3724,2755.77,,,2755.77,Other,150% of Medicare + 9.63% HCRA Surcharge,1675.8,45,,1675.8,percent of total billed charges,Critical Access Hospital RCC factor,1266.16,34,,1266.16,percent of total billed charges,Implant Device,1266.16,34,,1266.16,percent of total billed charges,Implant Device,1266.16,34,,1266.16,percent of total billed charges,Implant Device,1266.16,34,,1266.16,percent of total billed charges,Implant Device,1266.16,34,,1266.16,percent of total billed charges,Implant Device,1843.38,,,1843.38,Other,110% of Medicare,1303.4,35,,1303.4,percent of total billed charges,Implant Device,1266.16,34,"Charges > $500, x 34%",1266.16,percent of total billed charges,Implant Device,1303.4,35,,1303.4,percent of total billed charges,Implant Device,1303.4,35,,1303.4,percent of total billed charges,Implant Device,1303.4,35,,1303.4,percent of total billed charges,Implant Device,1303.4,35,,1303.4,percent of total billed charges,Implant Device,1303.4,35,,1303.4,percent of total billed charges,Implant Device,1489.6,40,,1489.6,percent of total billed charges,Implant Device,1303.4,70,,1303.4,percent of total billed charges,All Other,1266.16,34,,1266.16,percent of total billed charges,Implant Device,1266.16,34,,1266.16,percent of total billed charges,Implant Device,1303.4,35,,1303.4,percent of total billed charges,Implant Device,1303.4,35,,1303.4,percent of total billed charges,Implant Device,1303.4,35,,1303.4,percent of total billed charges,Implant Device,1303.4,35,,1303.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1266.16,34,"If Charge > 2,000, then 34 percent",1266.16,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2755.77,
BIOMET 14-522234 SLEEVE PLATE 34MM,C1713,HCPCS,,79002852,CDM,278,RC,,,both,,,6761,5003.16,,,5003.16,Other,150% of Medicare + 9.63% HCRA Surcharge,3042.45,45,,3042.45,percent of total billed charges,Critical Access Hospital RCC factor,2298.74,34,,2298.74,percent of total billed charges,Implant Device,2298.74,34,,2298.74,percent of total billed charges,Implant Device,2298.74,34,,2298.74,percent of total billed charges,Implant Device,2298.74,34,,2298.74,percent of total billed charges,Implant Device,2298.74,34,,2298.74,percent of total billed charges,Implant Device,3346.7,,,3346.7,Other,110% of Medicare,2366.35,35,,2366.35,percent of total billed charges,Implant Device,2298.74,34,"Charges > $500, x 34%",2298.74,percent of total billed charges,Implant Device,2366.35,35,,2366.35,percent of total billed charges,Implant Device,2366.35,35,,2366.35,percent of total billed charges,Implant Device,2366.35,35,,2366.35,percent of total billed charges,Implant Device,2366.35,35,,2366.35,percent of total billed charges,Implant Device,2366.35,35,,2366.35,percent of total billed charges,Implant Device,2704.4,40,,2704.4,percent of total billed charges,Implant Device,2366.35,70,,2366.35,percent of total billed charges,All Other,2298.74,34,,2298.74,percent of total billed charges,Implant Device,2298.74,34,,2298.74,percent of total billed charges,Implant Device,2366.35,35,,2366.35,percent of total billed charges,Implant Device,2366.35,35,,2366.35,percent of total billed charges,Implant Device,2366.35,35,,2366.35,percent of total billed charges,Implant Device,2366.35,35,,2366.35,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2298.74,34,"If Charge > 2,000, then 34 percent",2298.74,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5003.16,
BIOMET 14-521614 VARIABLE SCREW,C1713,HCPCS,,79002853,CDM,278,RC,,,both,,,1369,1013.06,,,1013.06,Other,150% of Medicare + 9.63% HCRA Surcharge,616.05,45,,616.05,percent of total billed charges,Critical Access Hospital RCC factor,465.46,34,,465.46,percent of total billed charges,Implant Device,465.46,34,,465.46,percent of total billed charges,Implant Device,465.46,34,,465.46,percent of total billed charges,Implant Device,465.46,34,,465.46,percent of total billed charges,Implant Device,465.46,34,,465.46,percent of total billed charges,Implant Device,677.66,,,677.66,Other,110% of Medicare,479.15,35,,479.15,percent of total billed charges,Implant Device,465.46,34,"Charges > $500, x 34%",465.46,percent of total billed charges,Implant Device,479.15,35,,479.15,percent of total billed charges,Implant Device,479.15,35,,479.15,percent of total billed charges,Implant Device,479.15,35,,479.15,percent of total billed charges,Implant Device,479.15,35,,479.15,percent of total billed charges,Implant Device,479.15,35,,479.15,percent of total billed charges,Implant Device,547.6,40,,547.6,percent of total billed charges,Implant Device,479.15,70,,479.15,percent of total billed charges,All Other,465.46,34,,465.46,percent of total billed charges,Implant Device,465.46,34,,465.46,percent of total billed charges,Implant Device,479.15,35,,479.15,percent of total billed charges,Implant Device,479.15,35,,479.15,percent of total billed charges,Implant Device,479.15,35,,479.15,percent of total billed charges,Implant Device,479.15,35,,479.15,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1013.06,
BIOMET 14-521612 VARIABLE SCREW 4X12MM,C1713,HCPCS,,79002854,CDM,278,RC,,,both,,,1369,1013.06,,,1013.06,Other,150% of Medicare + 9.63% HCRA Surcharge,616.05,45,,616.05,percent of total billed charges,Critical Access Hospital RCC factor,465.46,34,,465.46,percent of total billed charges,Implant Device,465.46,34,,465.46,percent of total billed charges,Implant Device,465.46,34,,465.46,percent of total billed charges,Implant Device,465.46,34,,465.46,percent of total billed charges,Implant Device,465.46,34,,465.46,percent of total billed charges,Implant Device,677.66,,,677.66,Other,110% of Medicare,479.15,35,,479.15,percent of total billed charges,Implant Device,465.46,34,"Charges > $500, x 34%",465.46,percent of total billed charges,Implant Device,479.15,35,,479.15,percent of total billed charges,Implant Device,479.15,35,,479.15,percent of total billed charges,Implant Device,479.15,35,,479.15,percent of total billed charges,Implant Device,479.15,35,,479.15,percent of total billed charges,Implant Device,479.15,35,,479.15,percent of total billed charges,Implant Device,547.6,40,,547.6,percent of total billed charges,Implant Device,479.15,70,,479.15,percent of total billed charges,All Other,465.46,34,,465.46,percent of total billed charges,Implant Device,465.46,34,,465.46,percent of total billed charges,Implant Device,479.15,35,,479.15,percent of total billed charges,Implant Device,479.15,35,,479.15,percent of total billed charges,Implant Device,479.15,35,,479.15,percent of total billed charges,Implant Device,479.15,35,,479.15,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1013.06,
STRYKER 1830-0001S COMP SCREW 6X13.5MM,C1713,HCPCS,,79002883,CDM,278,RC,,,both,,,668,494.32,,,494.32,Other,150% of Medicare + 9.63% HCRA Surcharge,300.6,45,,300.6,percent of total billed charges,Critical Access Hospital RCC factor,227.12,34,,227.12,percent of total billed charges,Implant Device,227.12,34,,227.12,percent of total billed charges,Implant Device,227.12,34,,227.12,percent of total billed charges,Implant Device,227.12,34,,227.12,percent of total billed charges,Implant Device,227.12,34,,227.12,percent of total billed charges,Implant Device,330.66,,,330.66,Other,110% of Medicare,233.8,35,,233.8,percent of total billed charges,Implant Device,227.12,34,"Charges > $500, x 34%",227.12,percent of total billed charges,Implant Device,233.8,35,,233.8,percent of total billed charges,Implant Device,233.8,35,,233.8,percent of total billed charges,Implant Device,233.8,35,,233.8,percent of total billed charges,Implant Device,233.8,35,,233.8,percent of total billed charges,Implant Device,233.8,35,,233.8,percent of total billed charges,Implant Device,267.2,40,,267.2,percent of total billed charges,Implant Device,233.8,70,,233.8,percent of total billed charges,All Other,227.12,34,,227.12,percent of total billed charges,Implant Device,227.12,34,,227.12,percent of total billed charges,Implant Device,233.8,35,,233.8,percent of total billed charges,Implant Device,233.8,35,,233.8,percent of total billed charges,Implant Device,233.8,35,,233.8,percent of total billed charges,Implant Device,233.8,35,,233.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,494.32,
STRYKER 1896-4026S LOCKING SCREW 4X26MM,C1713,HCPCS,,79002884,CDM,278,RC,,,both,,,447,330.78,,,330.78,Other,150% of Medicare + 9.63% HCRA Surcharge,201.15,45,,201.15,percent of total billed charges,Critical Access Hospital RCC factor,151.98,34,,151.98,percent of total billed charges,Implant Device,151.98,34,,151.98,percent of total billed charges,Implant Device,151.98,34,,151.98,percent of total billed charges,Implant Device,151.98,34,,151.98,percent of total billed charges,Implant Device,151.98,34,,151.98,percent of total billed charges,Implant Device,221.27,,,221.27,Other,110% of Medicare,156.45,35,,156.45,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,156.45,35,,156.45,percent of total billed charges,Implant Device,156.45,35,,156.45,percent of total billed charges,Implant Device,156.45,35,,156.45,percent of total billed charges,Implant Device,156.45,35,,156.45,percent of total billed charges,Implant Device,156.45,35,,156.45,percent of total billed charges,Implant Device,178.8,40,,178.8,percent of total billed charges,Implant Device,156.45,70,,156.45,percent of total billed charges,All Other,151.98,34,,151.98,percent of total billed charges,Implant Device,151.98,34,,151.98,percent of total billed charges,Implant Device,156.45,35,,156.45,percent of total billed charges,Implant Device,156.45,35,,156.45,percent of total billed charges,Implant Device,156.45,35,,156.45,percent of total billed charges,Implant Device,156.45,35,,156.45,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,330.78,
STRYKER 1891-4032S LOCKING SCREW 4X32MM,C1713,HCPCS,,79002885,CDM,278,RC,,,both,,,668,494.32,,,494.32,Other,150% of Medicare + 9.63% HCRA Surcharge,300.6,45,,300.6,percent of total billed charges,Critical Access Hospital RCC factor,227.12,34,,227.12,percent of total billed charges,Implant Device,227.12,34,,227.12,percent of total billed charges,Implant Device,227.12,34,,227.12,percent of total billed charges,Implant Device,227.12,34,,227.12,percent of total billed charges,Implant Device,227.12,34,,227.12,percent of total billed charges,Implant Device,330.66,,,330.66,Other,110% of Medicare,233.8,35,,233.8,percent of total billed charges,Implant Device,227.12,34,"Charges > $500, x 34%",227.12,percent of total billed charges,Implant Device,233.8,35,,233.8,percent of total billed charges,Implant Device,233.8,35,,233.8,percent of total billed charges,Implant Device,233.8,35,,233.8,percent of total billed charges,Implant Device,233.8,35,,233.8,percent of total billed charges,Implant Device,233.8,35,,233.8,percent of total billed charges,Implant Device,267.2,40,,267.2,percent of total billed charges,Implant Device,233.8,70,,233.8,percent of total billed charges,All Other,227.12,34,,227.12,percent of total billed charges,Implant Device,227.12,34,,227.12,percent of total billed charges,Implant Device,233.8,35,,233.8,percent of total billed charges,Implant Device,233.8,35,,233.8,percent of total billed charges,Implant Device,233.8,35,,233.8,percent of total billed charges,Implant Device,233.8,35,,233.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,494.32,
STRYKER ST0-16P SMART TOE,C1776,HCPCS,,79002911,CDM,278,RC,,,both,,,3582,2650.69,,,2650.69,Other,150% of Medicare + 9.63% HCRA Surcharge,1611.9,45,,1611.9,percent of total billed charges,Critical Access Hospital RCC factor,1217.88,34,,1217.88,percent of total billed charges,Implant Device,1217.88,34,,1217.88,percent of total billed charges,Implant Device,1217.88,34,,1217.88,percent of total billed charges,Implant Device,1217.88,34,,1217.88,percent of total billed charges,Implant Device,1217.88,34,,1217.88,percent of total billed charges,Implant Device,1773.09,,,1773.09,Other,110% of Medicare,1253.7,35,,1253.7,percent of total billed charges,Implant Device,1217.88,34,"Charges > $500, x 34%",1217.88,percent of total billed charges,Implant Device,1253.7,35,,1253.7,percent of total billed charges,Implant Device,1253.7,35,,1253.7,percent of total billed charges,Implant Device,1253.7,35,,1253.7,percent of total billed charges,Implant Device,1253.7,35,,1253.7,percent of total billed charges,Implant Device,1253.7,35,,1253.7,percent of total billed charges,Implant Device,1432.8,40,,1432.8,percent of total billed charges,Implant Device,1253.7,70,,1253.7,percent of total billed charges,All Other,1217.88,34,,1217.88,percent of total billed charges,Implant Device,1217.88,34,,1217.88,percent of total billed charges,Implant Device,1253.7,35,,1253.7,percent of total billed charges,Implant Device,1253.7,35,,1253.7,percent of total billed charges,Implant Device,1253.7,35,,1253.7,percent of total billed charges,Implant Device,1253.7,35,,1253.7,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1217.88,34,"If Charge > 2,000, then 34 percent",1217.88,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2650.69,
STRYKER ST0A-16P SMART TOE,C1776,HCPCS,,79002912,CDM,278,RC,,,both,,,3582,2650.69,,,2650.69,Other,150% of Medicare + 9.63% HCRA Surcharge,1611.9,45,,1611.9,percent of total billed charges,Critical Access Hospital RCC factor,1217.88,34,,1217.88,percent of total billed charges,Implant Device,1217.88,34,,1217.88,percent of total billed charges,Implant Device,1217.88,34,,1217.88,percent of total billed charges,Implant Device,1217.88,34,,1217.88,percent of total billed charges,Implant Device,1217.88,34,,1217.88,percent of total billed charges,Implant Device,1773.09,,,1773.09,Other,110% of Medicare,1253.7,35,,1253.7,percent of total billed charges,Implant Device,1217.88,34,"Charges > $500, x 34%",1217.88,percent of total billed charges,Implant Device,1253.7,35,,1253.7,percent of total billed charges,Implant Device,1253.7,35,,1253.7,percent of total billed charges,Implant Device,1253.7,35,,1253.7,percent of total billed charges,Implant Device,1253.7,35,,1253.7,percent of total billed charges,Implant Device,1253.7,35,,1253.7,percent of total billed charges,Implant Device,1432.8,40,,1432.8,percent of total billed charges,Implant Device,1253.7,70,,1253.7,percent of total billed charges,All Other,1217.88,34,,1217.88,percent of total billed charges,Implant Device,1217.88,34,,1217.88,percent of total billed charges,Implant Device,1253.7,35,,1253.7,percent of total billed charges,Implant Device,1253.7,35,,1253.7,percent of total billed charges,Implant Device,1253.7,35,,1253.7,percent of total billed charges,Implant Device,1253.7,35,,1253.7,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1217.88,34,"If Charge > 2,000, then 34 percent",1217.88,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2650.69,
MEDTRONIC 3350-18 INTRODUCER LEAD KIT,C1897,HCPCS,,79002913,CDM,278,RC,,,both,,,840,621.6,,,621.6,Other,150% of Medicare + 9.63% HCRA Surcharge,378,45,,378,percent of total billed charges,Critical Access Hospital RCC factor,285.6,34,,285.6,percent of total billed charges,Implant Device,285.6,34,,285.6,percent of total billed charges,Implant Device,285.6,34,,285.6,percent of total billed charges,Implant Device,285.6,34,,285.6,percent of total billed charges,Implant Device,285.6,34,,285.6,percent of total billed charges,Implant Device,415.8,,,415.8,Other,110% of Medicare,294,35,,294,percent of total billed charges,Implant Device,285.6,34,"Charges > $500, x 34%",285.6,percent of total billed charges,Implant Device,294,35,,294,percent of total billed charges,Implant Device,294,35,,294,percent of total billed charges,Implant Device,294,35,,294,percent of total billed charges,Implant Device,294,35,,294,percent of total billed charges,Implant Device,294,35,,294,percent of total billed charges,Implant Device,336,40,,336,percent of total billed charges,Implant Device,294,70,,294,percent of total billed charges,All Other,285.6,34,,285.6,percent of total billed charges,Implant Device,285.6,34,,285.6,percent of total billed charges,Implant Device,294,35,,294,percent of total billed charges,Implant Device,294,35,,294,percent of total billed charges,Implant Device,294,35,,294,percent of total billed charges,Implant Device,294,35,,294,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,621.6,
ARTHREX AR-8926T TITANIUM TIGHTROPE,C1713,HCPCS,,79002915,CDM,278,RC,,,both,,,2640,1953.61,,,1953.61,Other,150% of Medicare + 9.63% HCRA Surcharge,1188,45,,1188,percent of total billed charges,Critical Access Hospital RCC factor,897.6,34,,897.6,percent of total billed charges,Implant Device,897.6,34,,897.6,percent of total billed charges,Implant Device,897.6,34,,897.6,percent of total billed charges,Implant Device,897.6,34,,897.6,percent of total billed charges,Implant Device,897.6,34,,897.6,percent of total billed charges,Implant Device,1306.8,,,1306.8,Other,110% of Medicare,924,35,,924,percent of total billed charges,Implant Device,897.6,34,"Charges > $500, x 34%",897.6,percent of total billed charges,Implant Device,924,35,,924,percent of total billed charges,Implant Device,924,35,,924,percent of total billed charges,Implant Device,924,35,,924,percent of total billed charges,Implant Device,924,35,,924,percent of total billed charges,Implant Device,924,35,,924,percent of total billed charges,Implant Device,1056,40,,1056,percent of total billed charges,Implant Device,924,70,,924,percent of total billed charges,All Other,897.6,34,,897.6,percent of total billed charges,Implant Device,897.6,34,,897.6,percent of total billed charges,Implant Device,924,35,,924,percent of total billed charges,Implant Device,924,35,,924,percent of total billed charges,Implant Device,924,35,,924,percent of total billed charges,Implant Device,924,35,,924,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,897.6,34,"If Charge > 2,000, then 34 percent",897.6,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1953.61,
SOLANA SFT-2013 SOLAFIX SCREW 2.0X13MM,C1713,HCPCS,,79002916,CDM,278,RC,,,both,,,3496,2587.05,,,2587.05,Other,150% of Medicare + 9.63% HCRA Surcharge,1573.2,45,,1573.2,percent of total billed charges,Critical Access Hospital RCC factor,1188.64,34,,1188.64,percent of total billed charges,Implant Device,1188.64,34,,1188.64,percent of total billed charges,Implant Device,1188.64,34,,1188.64,percent of total billed charges,Implant Device,1188.64,34,,1188.64,percent of total billed charges,Implant Device,1188.64,34,,1188.64,percent of total billed charges,Implant Device,1730.52,,,1730.52,Other,110% of Medicare,1223.6,35,,1223.6,percent of total billed charges,Implant Device,1188.64,34,"Charges > $500, x 34%",1188.64,percent of total billed charges,Implant Device,1223.6,35,,1223.6,percent of total billed charges,Implant Device,1223.6,35,,1223.6,percent of total billed charges,Implant Device,1223.6,35,,1223.6,percent of total billed charges,Implant Device,1223.6,35,,1223.6,percent of total billed charges,Implant Device,1223.6,35,,1223.6,percent of total billed charges,Implant Device,1398.4,40,,1398.4,percent of total billed charges,Implant Device,1223.6,70,,1223.6,percent of total billed charges,All Other,1188.64,34,,1188.64,percent of total billed charges,Implant Device,1188.64,34,,1188.64,percent of total billed charges,Implant Device,1223.6,35,,1223.6,percent of total billed charges,Implant Device,1223.6,35,,1223.6,percent of total billed charges,Implant Device,1223.6,35,,1223.6,percent of total billed charges,Implant Device,1223.6,35,,1223.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1188.64,34,"If Charge > 2,000, then 34 percent",1188.64,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2587.05,
ARTHREX AR-1580BC SCREW 8X23MM,C1713,HCPCS,,79002917,CDM,278,RC,,,both,,,1035,765.9,,,765.9,Other,150% of Medicare + 9.63% HCRA Surcharge,465.75,45,,465.75,percent of total billed charges,Critical Access Hospital RCC factor,351.9,34,,351.9,percent of total billed charges,Implant Device,351.9,34,,351.9,percent of total billed charges,Implant Device,351.9,34,,351.9,percent of total billed charges,Implant Device,351.9,34,,351.9,percent of total billed charges,Implant Device,351.9,34,,351.9,percent of total billed charges,Implant Device,512.33,,,512.33,Other,110% of Medicare,362.25,35,,362.25,percent of total billed charges,Implant Device,351.9,34,"Charges > $500, x 34%",351.9,percent of total billed charges,Implant Device,362.25,35,,362.25,percent of total billed charges,Implant Device,362.25,35,,362.25,percent of total billed charges,Implant Device,362.25,35,,362.25,percent of total billed charges,Implant Device,362.25,35,,362.25,percent of total billed charges,Implant Device,362.25,35,,362.25,percent of total billed charges,Implant Device,414,40,,414,percent of total billed charges,Implant Device,362.25,70,,362.25,percent of total billed charges,All Other,351.9,34,,351.9,percent of total billed charges,Implant Device,351.9,34,,351.9,percent of total billed charges,Implant Device,362.25,35,,362.25,percent of total billed charges,Implant Device,362.25,35,,362.25,percent of total billed charges,Implant Device,362.25,35,,362.25,percent of total billed charges,Implant Device,362.25,35,,362.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,765.9,
ALAMO TISSUE AT292FF BONE TENDON BONE,C1713,HCPCS,,79002918,CDM,278,RC,,,both,,,7500,5550.02,,,5550.02,Other,150% of Medicare + 9.63% HCRA Surcharge,3375,45,,3375,percent of total billed charges,Critical Access Hospital RCC factor,2550,34,,2550,percent of total billed charges,Implant Device,2550,34,,2550,percent of total billed charges,Implant Device,2550,34,,2550,percent of total billed charges,Implant Device,2550,34,,2550,percent of total billed charges,Implant Device,2550,34,,2550,percent of total billed charges,Implant Device,3712.5,,,3712.5,Other,110% of Medicare,2625,35,,2625,percent of total billed charges,Implant Device,2550,34,"Charges > $500, x 34%",2550,percent of total billed charges,Implant Device,2625,35,,2625,percent of total billed charges,Implant Device,2625,35,,2625,percent of total billed charges,Implant Device,2625,35,,2625,percent of total billed charges,Implant Device,2625,35,,2625,percent of total billed charges,Implant Device,2625,35,,2625,percent of total billed charges,Implant Device,3000,40,,3000,percent of total billed charges,Implant Device,2625,70,,2625,percent of total billed charges,All Other,2550,34,,2550,percent of total billed charges,Implant Device,2550,34,,2550,percent of total billed charges,Implant Device,2625,35,,2625,percent of total billed charges,Implant Device,2625,35,,2625,percent of total billed charges,Implant Device,2625,35,,2625,percent of total billed charges,Implant Device,2625,35,,2625,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2550,34,"If Charge > 2,000, then 34 percent",2550,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5550.02,
ARTHREX AR-8952MS-05 PLATE STRT 5 HOLE,C1713,HCPCS,,79002919,CDM,278,RC,,,both,,,2086,1543.65,,,1543.65,Other,150% of Medicare + 9.63% HCRA Surcharge,938.7,45,,938.7,percent of total billed charges,Critical Access Hospital RCC factor,709.24,34,,709.24,percent of total billed charges,Implant Device,709.24,34,,709.24,percent of total billed charges,Implant Device,709.24,34,,709.24,percent of total billed charges,Implant Device,709.24,34,,709.24,percent of total billed charges,Implant Device,709.24,34,,709.24,percent of total billed charges,Implant Device,1032.57,,,1032.57,Other,110% of Medicare,730.1,35,,730.1,percent of total billed charges,Implant Device,709.24,34,"Charges > $500, x 34%",709.24,percent of total billed charges,Implant Device,730.1,35,,730.1,percent of total billed charges,Implant Device,730.1,35,,730.1,percent of total billed charges,Implant Device,730.1,35,,730.1,percent of total billed charges,Implant Device,730.1,35,,730.1,percent of total billed charges,Implant Device,730.1,35,,730.1,percent of total billed charges,Implant Device,834.4,40,,834.4,percent of total billed charges,Implant Device,730.1,70,,730.1,percent of total billed charges,All Other,709.24,34,,709.24,percent of total billed charges,Implant Device,709.24,34,,709.24,percent of total billed charges,Implant Device,730.1,35,,730.1,percent of total billed charges,Implant Device,730.1,35,,730.1,percent of total billed charges,Implant Device,730.1,35,,730.1,percent of total billed charges,Implant Device,730.1,35,,730.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,709.24,34,"If Charge > 2,000, then 34 percent",709.24,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1543.65,
ARTHREX AR-8724-18 SCREW 2.4X18MM,C1713,HCPCS,,79002920,CDM,278,RC,,,both,,,474,350.76,,,350.76,Other,150% of Medicare + 9.63% HCRA Surcharge,213.3,45,,213.3,percent of total billed charges,Critical Access Hospital RCC factor,161.16,34,,161.16,percent of total billed charges,Implant Device,161.16,34,,161.16,percent of total billed charges,Implant Device,161.16,34,,161.16,percent of total billed charges,Implant Device,161.16,34,,161.16,percent of total billed charges,Implant Device,161.16,34,,161.16,percent of total billed charges,Implant Device,234.63,,,234.63,Other,110% of Medicare,165.9,35,,165.9,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,165.9,35,,165.9,percent of total billed charges,Implant Device,165.9,35,,165.9,percent of total billed charges,Implant Device,165.9,35,,165.9,percent of total billed charges,Implant Device,165.9,35,,165.9,percent of total billed charges,Implant Device,165.9,35,,165.9,percent of total billed charges,Implant Device,189.6,40,,189.6,percent of total billed charges,Implant Device,165.9,70,,165.9,percent of total billed charges,All Other,161.16,34,,161.16,percent of total billed charges,Implant Device,161.16,34,,161.16,percent of total billed charges,Implant Device,165.9,35,,165.9,percent of total billed charges,Implant Device,165.9,35,,165.9,percent of total billed charges,Implant Device,165.9,35,,165.9,percent of total billed charges,Implant Device,165.9,35,,165.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,350.76,
ARTHREX AR-8724-20 SCREW 2.4X20MM,C1713,HCPCS,,79002921,CDM,278,RC,,,both,,,474,350.76,,,350.76,Other,150% of Medicare + 9.63% HCRA Surcharge,213.3,45,,213.3,percent of total billed charges,Critical Access Hospital RCC factor,161.16,34,,161.16,percent of total billed charges,Implant Device,161.16,34,,161.16,percent of total billed charges,Implant Device,161.16,34,,161.16,percent of total billed charges,Implant Device,161.16,34,,161.16,percent of total billed charges,Implant Device,161.16,34,,161.16,percent of total billed charges,Implant Device,234.63,,,234.63,Other,110% of Medicare,165.9,35,,165.9,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,165.9,35,,165.9,percent of total billed charges,Implant Device,165.9,35,,165.9,percent of total billed charges,Implant Device,165.9,35,,165.9,percent of total billed charges,Implant Device,165.9,35,,165.9,percent of total billed charges,Implant Device,165.9,35,,165.9,percent of total billed charges,Implant Device,189.6,40,,189.6,percent of total billed charges,Implant Device,165.9,70,,165.9,percent of total billed charges,All Other,161.16,34,,161.16,percent of total billed charges,Implant Device,161.16,34,,161.16,percent of total billed charges,Implant Device,165.9,35,,165.9,percent of total billed charges,Implant Device,165.9,35,,165.9,percent of total billed charges,Implant Device,165.9,35,,165.9,percent of total billed charges,Implant Device,165.9,35,,165.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,350.76,
ARTHREX AR-8924-22 SCREW 2.4X22MM,C1713,HCPCS,,79002922,CDM,278,RC,,,both,,,330,244.2,,,244.2,Other,150% of Medicare + 9.63% HCRA Surcharge,148.5,45,,148.5,percent of total billed charges,Critical Access Hospital RCC factor,112.2,34,,112.2,percent of total billed charges,Implant Device,112.2,34,,112.2,percent of total billed charges,Implant Device,112.2,34,,112.2,percent of total billed charges,Implant Device,112.2,34,,112.2,percent of total billed charges,Implant Device,112.2,34,,112.2,percent of total billed charges,Implant Device,163.35,,,163.35,Other,110% of Medicare,115.5,35,,115.5,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,132,40,,132,percent of total billed charges,Implant Device,115.5,70,,115.5,percent of total billed charges,All Other,112.2,34,,112.2,percent of total billed charges,Implant Device,112.2,34,,112.2,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,244.2,
ZIMMER 00-5952-050-14-REV ART SURF 14MM,C1776,HCPCS,,79002924,CDM,278,RC,,,both,,,5107,3779.19,,,3779.19,Other,150% of Medicare + 9.63% HCRA Surcharge,2298.15,45,,2298.15,percent of total billed charges,Critical Access Hospital RCC factor,1736.38,34,,1736.38,percent of total billed charges,Implant Device,1736.38,34,,1736.38,percent of total billed charges,Implant Device,1736.38,34,,1736.38,percent of total billed charges,Implant Device,1736.38,34,,1736.38,percent of total billed charges,Implant Device,1736.38,34,,1736.38,percent of total billed charges,Implant Device,2527.97,,,2527.97,Other,110% of Medicare,1787.45,35,,1787.45,percent of total billed charges,Implant Device,1736.38,34,"Charges > $500, x 34%",1736.38,percent of total billed charges,Implant Device,1787.45,35,,1787.45,percent of total billed charges,Implant Device,1787.45,35,,1787.45,percent of total billed charges,Implant Device,1787.45,35,,1787.45,percent of total billed charges,Implant Device,1787.45,35,,1787.45,percent of total billed charges,Implant Device,1787.45,35,,1787.45,percent of total billed charges,Implant Device,2042.8,40,,2042.8,percent of total billed charges,Implant Device,1787.45,70,,1787.45,percent of total billed charges,All Other,1736.38,34,,1736.38,percent of total billed charges,Implant Device,1736.38,34,,1736.38,percent of total billed charges,Implant Device,1787.45,35,,1787.45,percent of total billed charges,Implant Device,1787.45,35,,1787.45,percent of total billed charges,Implant Device,1787.45,35,,1787.45,percent of total billed charges,Implant Device,1787.45,35,,1787.45,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1736.38,34,"If Charge > 2,000, then 34 percent",1736.38,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3779.19,
ARTHREX AR-1380BC BIOCOMP SCREW 8X23MM,C1713,HCPCS,,79002935,CDM,278,RC,,,both,,,705,521.7,,,521.7,Other,150% of Medicare + 9.63% HCRA Surcharge,317.25,45,,317.25,percent of total billed charges,Critical Access Hospital RCC factor,239.7,34,,239.7,percent of total billed charges,Implant Device,239.7,34,,239.7,percent of total billed charges,Implant Device,239.7,34,,239.7,percent of total billed charges,Implant Device,239.7,34,,239.7,percent of total billed charges,Implant Device,239.7,34,,239.7,percent of total billed charges,Implant Device,348.98,,,348.98,Other,110% of Medicare,246.75,35,,246.75,percent of total billed charges,Implant Device,239.7,34,"Charges > $500, x 34%",239.7,percent of total billed charges,Implant Device,246.75,35,,246.75,percent of total billed charges,Implant Device,246.75,35,,246.75,percent of total billed charges,Implant Device,246.75,35,,246.75,percent of total billed charges,Implant Device,246.75,35,,246.75,percent of total billed charges,Implant Device,246.75,35,,246.75,percent of total billed charges,Implant Device,282,40,,282,percent of total billed charges,Implant Device,246.75,70,,246.75,percent of total billed charges,All Other,239.7,34,,239.7,percent of total billed charges,Implant Device,239.7,34,,239.7,percent of total billed charges,Implant Device,246.75,35,,246.75,percent of total billed charges,Implant Device,246.75,35,,246.75,percent of total billed charges,Implant Device,246.75,35,,246.75,percent of total billed charges,Implant Device,246.75,35,,246.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,521.7,
STRYKER 6197-9-010 CEMENT W/TOBRAMYCIN,C1713,HCPCS,,79002944,CDM,278,RC,,,both,,,786,581.64,,,581.64,Other,150% of Medicare + 9.63% HCRA Surcharge,353.7,45,,353.7,percent of total billed charges,Critical Access Hospital RCC factor,267.24,34,,267.24,percent of total billed charges,Implant Device,267.24,34,,267.24,percent of total billed charges,Implant Device,267.24,34,,267.24,percent of total billed charges,Implant Device,267.24,34,,267.24,percent of total billed charges,Implant Device,267.24,34,,267.24,percent of total billed charges,Implant Device,389.07,,,389.07,Other,110% of Medicare,275.1,35,,275.1,percent of total billed charges,Implant Device,267.24,34,"Charges > $500, x 34%",267.24,percent of total billed charges,Implant Device,275.1,35,,275.1,percent of total billed charges,Implant Device,275.1,35,,275.1,percent of total billed charges,Implant Device,275.1,35,,275.1,percent of total billed charges,Implant Device,275.1,35,,275.1,percent of total billed charges,Implant Device,275.1,35,,275.1,percent of total billed charges,Implant Device,314.4,40,,314.4,percent of total billed charges,Implant Device,275.1,70,,275.1,percent of total billed charges,All Other,267.24,34,,267.24,percent of total billed charges,Implant Device,267.24,34,,267.24,percent of total billed charges,Implant Device,275.1,35,,275.1,percent of total billed charges,Implant Device,275.1,35,,275.1,percent of total billed charges,Implant Device,275.1,35,,275.1,percent of total billed charges,Implant Device,275.1,35,,275.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,581.64,
SYNTHES 201.810 2.0 CORTEX SCREW 10MM,C1713,HCPCS,,79002958,CDM,278,RC,,,both,,,83,61.42,,,61.42,Other,150% of Medicare + 9.63% HCRA Surcharge,37.35,45,,37.35,percent of total billed charges,Critical Access Hospital RCC factor,28.22,34,,28.22,percent of total billed charges,Implant Device,28.22,34,,28.22,percent of total billed charges,Implant Device,28.22,34,,28.22,percent of total billed charges,Implant Device,28.22,34,,28.22,percent of total billed charges,Implant Device,28.22,34,,28.22,percent of total billed charges,Implant Device,41.09,,,41.09,Other,110% of Medicare,29.05,35,,29.05,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,29.05,35,,29.05,percent of total billed charges,Implant Device,29.05,35,,29.05,percent of total billed charges,Implant Device,29.05,35,,29.05,percent of total billed charges,Implant Device,29.05,35,,29.05,percent of total billed charges,Implant Device,29.05,35,,29.05,percent of total billed charges,Implant Device,33.2,40,,33.2,percent of total billed charges,Implant Device,29.05,70,,29.05,percent of total billed charges,All Other,28.22,34,,28.22,percent of total billed charges,Implant Device,28.22,34,,28.22,percent of total billed charges,Implant Device,29.05,35,,29.05,percent of total billed charges,Implant Device,29.05,35,,29.05,percent of total billed charges,Implant Device,29.05,35,,29.05,percent of total billed charges,Implant Device,29.05,35,,29.05,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,61.42,
SYNTHES 201.812 2.0 CORTEX SCREW 12MM,C1713,HCPCS,,79002959,CDM,278,RC,,,both,,,83,61.42,,,61.42,Other,150% of Medicare + 9.63% HCRA Surcharge,37.35,45,,37.35,percent of total billed charges,Critical Access Hospital RCC factor,28.22,34,,28.22,percent of total billed charges,Implant Device,28.22,34,,28.22,percent of total billed charges,Implant Device,28.22,34,,28.22,percent of total billed charges,Implant Device,28.22,34,,28.22,percent of total billed charges,Implant Device,28.22,34,,28.22,percent of total billed charges,Implant Device,41.09,,,41.09,Other,110% of Medicare,29.05,35,,29.05,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,29.05,35,,29.05,percent of total billed charges,Implant Device,29.05,35,,29.05,percent of total billed charges,Implant Device,29.05,35,,29.05,percent of total billed charges,Implant Device,29.05,35,,29.05,percent of total billed charges,Implant Device,29.05,35,,29.05,percent of total billed charges,Implant Device,33.2,40,,33.2,percent of total billed charges,Implant Device,29.05,70,,29.05,percent of total billed charges,All Other,28.22,34,,28.22,percent of total billed charges,Implant Device,28.22,34,,28.22,percent of total billed charges,Implant Device,29.05,35,,29.05,percent of total billed charges,Implant Device,29.05,35,,29.05,percent of total billed charges,Implant Device,29.05,35,,29.05,percent of total billed charges,Implant Device,29.05,35,,29.05,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,61.42,
SYNTHES 201.814 2.0 CORTEX SCREW 14MM,C1713,HCPCS,,79002960,CDM,278,RC,,,both,,,83,61.42,,,61.42,Other,150% of Medicare + 9.63% HCRA Surcharge,37.35,45,,37.35,percent of total billed charges,Critical Access Hospital RCC factor,28.22,34,,28.22,percent of total billed charges,Implant Device,28.22,34,,28.22,percent of total billed charges,Implant Device,28.22,34,,28.22,percent of total billed charges,Implant Device,28.22,34,,28.22,percent of total billed charges,Implant Device,28.22,34,,28.22,percent of total billed charges,Implant Device,41.09,,,41.09,Other,110% of Medicare,29.05,35,,29.05,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,29.05,35,,29.05,percent of total billed charges,Implant Device,29.05,35,,29.05,percent of total billed charges,Implant Device,29.05,35,,29.05,percent of total billed charges,Implant Device,29.05,35,,29.05,percent of total billed charges,Implant Device,29.05,35,,29.05,percent of total billed charges,Implant Device,33.2,40,,33.2,percent of total billed charges,Implant Device,29.05,70,,29.05,percent of total billed charges,All Other,28.22,34,,28.22,percent of total billed charges,Implant Device,28.22,34,,28.22,percent of total billed charges,Implant Device,29.05,35,,29.05,percent of total billed charges,Implant Device,29.05,35,,29.05,percent of total billed charges,Implant Device,29.05,35,,29.05,percent of total billed charges,Implant Device,29.05,35,,29.05,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,61.42,
ARTHREX AR-1555BC TENODESIS SCREW 5.5X15,C1713,HCPCS,,79002976,CDM,278,RC,,,both,,,1036,766.64,,,766.64,Other,150% of Medicare + 9.63% HCRA Surcharge,466.2,45,,466.2,percent of total billed charges,Critical Access Hospital RCC factor,352.24,34,,352.24,percent of total billed charges,Implant Device,352.24,34,,352.24,percent of total billed charges,Implant Device,352.24,34,,352.24,percent of total billed charges,Implant Device,352.24,34,,352.24,percent of total billed charges,Implant Device,352.24,34,,352.24,percent of total billed charges,Implant Device,512.82,,,512.82,Other,110% of Medicare,362.6,35,,362.6,percent of total billed charges,Implant Device,352.24,34,"Charges > $500, x 34%",352.24,percent of total billed charges,Implant Device,362.6,35,,362.6,percent of total billed charges,Implant Device,362.6,35,,362.6,percent of total billed charges,Implant Device,362.6,35,,362.6,percent of total billed charges,Implant Device,362.6,35,,362.6,percent of total billed charges,Implant Device,362.6,35,,362.6,percent of total billed charges,Implant Device,414.4,40,,414.4,percent of total billed charges,Implant Device,362.6,70,,362.6,percent of total billed charges,All Other,352.24,34,,352.24,percent of total billed charges,Implant Device,352.24,34,,352.24,percent of total billed charges,Implant Device,362.6,35,,362.6,percent of total billed charges,Implant Device,362.6,35,,362.6,percent of total billed charges,Implant Device,362.6,35,,362.6,percent of total billed charges,Implant Device,362.6,35,,362.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,766.64,
ARTHREX AR-2656DL CLAVICLE LOCKING PLATE,C1713,HCPCS,,79002978,CDM,278,RC,,,both,,,1650,1221,,,1221,Other,150% of Medicare + 9.63% HCRA Surcharge,742.5,45,,742.5,percent of total billed charges,Critical Access Hospital RCC factor,561,34,,561,percent of total billed charges,Implant Device,561,34,,561,percent of total billed charges,Implant Device,561,34,,561,percent of total billed charges,Implant Device,561,34,,561,percent of total billed charges,Implant Device,561,34,,561,percent of total billed charges,Implant Device,816.75,,,816.75,Other,110% of Medicare,577.5,35,,577.5,percent of total billed charges,Implant Device,561,34,"Charges > $500, x 34%",561,percent of total billed charges,Implant Device,577.5,35,,577.5,percent of total billed charges,Implant Device,577.5,35,,577.5,percent of total billed charges,Implant Device,577.5,35,,577.5,percent of total billed charges,Implant Device,577.5,35,,577.5,percent of total billed charges,Implant Device,577.5,35,,577.5,percent of total billed charges,Implant Device,660,40,,660,percent of total billed charges,Implant Device,577.5,70,,577.5,percent of total billed charges,All Other,561,34,,561,percent of total billed charges,Implant Device,561,34,,561,percent of total billed charges,Implant Device,577.5,35,,577.5,percent of total billed charges,Implant Device,577.5,35,,577.5,percent of total billed charges,Implant Device,577.5,35,,577.5,percent of total billed charges,Implant Device,577.5,35,,577.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1221,
ARTHREX AR-8827L-18 LOCKING SCREW 2.7X18,C1713,HCPCS,,79002979,CDM,278,RC,,,both,,,345,255.3,,,255.3,Other,150% of Medicare + 9.63% HCRA Surcharge,155.25,45,,155.25,percent of total billed charges,Critical Access Hospital RCC factor,117.3,34,,117.3,percent of total billed charges,Implant Device,117.3,34,,117.3,percent of total billed charges,Implant Device,117.3,34,,117.3,percent of total billed charges,Implant Device,117.3,34,,117.3,percent of total billed charges,Implant Device,117.3,34,,117.3,percent of total billed charges,Implant Device,170.78,,,170.78,Other,110% of Medicare,120.75,35,,120.75,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,120.75,35,,120.75,percent of total billed charges,Implant Device,120.75,35,,120.75,percent of total billed charges,Implant Device,120.75,35,,120.75,percent of total billed charges,Implant Device,120.75,35,,120.75,percent of total billed charges,Implant Device,120.75,35,,120.75,percent of total billed charges,Implant Device,138,40,,138,percent of total billed charges,Implant Device,120.75,70,,120.75,percent of total billed charges,All Other,117.3,34,,117.3,percent of total billed charges,Implant Device,117.3,34,,117.3,percent of total billed charges,Implant Device,120.75,35,,120.75,percent of total billed charges,Implant Device,120.75,35,,120.75,percent of total billed charges,Implant Device,120.75,35,,120.75,percent of total billed charges,Implant Device,120.75,35,,120.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,255.3,
ARTHREX AR-8827L-20 LOCKING SCREW 2.7X20,C1713,HCPCS,,79002980,CDM,278,RC,,,both,,,495,366.3,,,366.3,Other,150% of Medicare + 9.63% HCRA Surcharge,222.75,45,,222.75,percent of total billed charges,Critical Access Hospital RCC factor,168.3,34,,168.3,percent of total billed charges,Implant Device,168.3,34,,168.3,percent of total billed charges,Implant Device,168.3,34,,168.3,percent of total billed charges,Implant Device,168.3,34,,168.3,percent of total billed charges,Implant Device,168.3,34,,168.3,percent of total billed charges,Implant Device,245.03,,,245.03,Other,110% of Medicare,173.25,35,,173.25,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,173.25,35,,173.25,percent of total billed charges,Implant Device,173.25,35,,173.25,percent of total billed charges,Implant Device,173.25,35,,173.25,percent of total billed charges,Implant Device,173.25,35,,173.25,percent of total billed charges,Implant Device,173.25,35,,173.25,percent of total billed charges,Implant Device,198,40,,198,percent of total billed charges,Implant Device,173.25,70,,173.25,percent of total billed charges,All Other,168.3,34,,168.3,percent of total billed charges,Implant Device,168.3,34,,168.3,percent of total billed charges,Implant Device,173.25,35,,173.25,percent of total billed charges,Implant Device,173.25,35,,173.25,percent of total billed charges,Implant Device,173.25,35,,173.25,percent of total billed charges,Implant Device,173.25,35,,173.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,366.3,
ARTHREX AR-8835L-14 LOCKING SCREW 3.5X14,C1713,HCPCS,,79002981,CDM,278,RC,,,both,,,495,366.3,,,366.3,Other,150% of Medicare + 9.63% HCRA Surcharge,222.75,45,,222.75,percent of total billed charges,Critical Access Hospital RCC factor,168.3,34,,168.3,percent of total billed charges,Implant Device,168.3,34,,168.3,percent of total billed charges,Implant Device,168.3,34,,168.3,percent of total billed charges,Implant Device,168.3,34,,168.3,percent of total billed charges,Implant Device,168.3,34,,168.3,percent of total billed charges,Implant Device,245.03,,,245.03,Other,110% of Medicare,173.25,35,,173.25,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,173.25,35,,173.25,percent of total billed charges,Implant Device,173.25,35,,173.25,percent of total billed charges,Implant Device,173.25,35,,173.25,percent of total billed charges,Implant Device,173.25,35,,173.25,percent of total billed charges,Implant Device,173.25,35,,173.25,percent of total billed charges,Implant Device,198,40,,198,percent of total billed charges,Implant Device,173.25,70,,173.25,percent of total billed charges,All Other,168.3,34,,168.3,percent of total billed charges,Implant Device,168.3,34,,168.3,percent of total billed charges,Implant Device,173.25,35,,173.25,percent of total billed charges,Implant Device,173.25,35,,173.25,percent of total billed charges,Implant Device,173.25,35,,173.25,percent of total billed charges,Implant Device,173.25,35,,173.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,366.3,
ARTHREX AR-8835-12 SCREW 2.5X12MM,C1713,HCPCS,,79002982,CDM,278,RC,,,both,,,106,78.44,,,78.44,Other,150% of Medicare + 9.63% HCRA Surcharge,47.7,45,,47.7,percent of total billed charges,Critical Access Hospital RCC factor,36.04,34,,36.04,percent of total billed charges,Implant Device,36.04,34,,36.04,percent of total billed charges,Implant Device,36.04,34,,36.04,percent of total billed charges,Implant Device,36.04,34,,36.04,percent of total billed charges,Implant Device,36.04,34,,36.04,percent of total billed charges,Implant Device,52.47,,,52.47,Other,110% of Medicare,37.1,35,,37.1,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,37.1,35,,37.1,percent of total billed charges,Implant Device,37.1,35,,37.1,percent of total billed charges,Implant Device,37.1,35,,37.1,percent of total billed charges,Implant Device,37.1,35,,37.1,percent of total billed charges,Implant Device,37.1,35,,37.1,percent of total billed charges,Implant Device,42.4,40,,42.4,percent of total billed charges,Implant Device,37.1,70,,37.1,percent of total billed charges,All Other,36.04,34,,36.04,percent of total billed charges,Implant Device,36.04,34,,36.04,percent of total billed charges,Implant Device,37.1,35,,37.1,percent of total billed charges,Implant Device,37.1,35,,37.1,percent of total billed charges,Implant Device,37.1,35,,37.1,percent of total billed charges,Implant Device,37.1,35,,37.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,78.44,
ARTHREX AR-8835-14 SCREW 3.5X14MM,C1713,HCPCS,,79002983,CDM,278,RC,,,both,,,150,111,,,111,Other,150% of Medicare + 9.63% HCRA Surcharge,67.5,45,,67.5,percent of total billed charges,Critical Access Hospital RCC factor,51,34,,51,percent of total billed charges,Implant Device,51,34,,51,percent of total billed charges,Implant Device,51,34,,51,percent of total billed charges,Implant Device,51,34,,51,percent of total billed charges,Implant Device,51,34,,51,percent of total billed charges,Implant Device,74.25,,,74.25,Other,110% of Medicare,52.5,35,,52.5,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,52.5,35,,52.5,percent of total billed charges,Implant Device,52.5,35,,52.5,percent of total billed charges,Implant Device,52.5,35,,52.5,percent of total billed charges,Implant Device,52.5,35,,52.5,percent of total billed charges,Implant Device,52.5,35,,52.5,percent of total billed charges,Implant Device,60,40,,60,percent of total billed charges,Implant Device,52.5,70,,52.5,percent of total billed charges,All Other,51,34,,51,percent of total billed charges,Implant Device,51,34,,51,percent of total billed charges,Implant Device,52.5,35,,52.5,percent of total billed charges,Implant Device,52.5,35,,52.5,percent of total billed charges,Implant Device,52.5,35,,52.5,percent of total billed charges,Implant Device,52.5,35,,52.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,111,
ARTHREX AR-8830-18 SCREW 3X18MM,C1713,HCPCS,,79002984,CDM,278,RC,,,both,,,150,111,,,111,Other,150% of Medicare + 9.63% HCRA Surcharge,67.5,45,,67.5,percent of total billed charges,Critical Access Hospital RCC factor,51,34,,51,percent of total billed charges,Implant Device,51,34,,51,percent of total billed charges,Implant Device,51,34,,51,percent of total billed charges,Implant Device,51,34,,51,percent of total billed charges,Implant Device,51,34,,51,percent of total billed charges,Implant Device,74.25,,,74.25,Other,110% of Medicare,52.5,35,,52.5,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,52.5,35,,52.5,percent of total billed charges,Implant Device,52.5,35,,52.5,percent of total billed charges,Implant Device,52.5,35,,52.5,percent of total billed charges,Implant Device,52.5,35,,52.5,percent of total billed charges,Implant Device,52.5,35,,52.5,percent of total billed charges,Implant Device,60,40,,60,percent of total billed charges,Implant Device,52.5,70,,52.5,percent of total billed charges,All Other,51,34,,51,percent of total billed charges,Implant Device,51,34,,51,percent of total billed charges,Implant Device,52.5,35,,52.5,percent of total billed charges,Implant Device,52.5,35,,52.5,percent of total billed charges,Implant Device,52.5,35,,52.5,percent of total billed charges,Implant Device,52.5,35,,52.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,111,
S&N 71322052 SHELL 28X52MM,C1776,HCPCS,,79002986,CDM,278,RC,,,both,,,5596,4141.05,,,4141.05,Other,150% of Medicare + 9.63% HCRA Surcharge,2518.2,45,,2518.2,percent of total billed charges,Critical Access Hospital RCC factor,1902.64,34,,1902.64,percent of total billed charges,Implant Device,1902.64,34,,1902.64,percent of total billed charges,Implant Device,1902.64,34,,1902.64,percent of total billed charges,Implant Device,1902.64,34,,1902.64,percent of total billed charges,Implant Device,1902.64,34,,1902.64,percent of total billed charges,Implant Device,2770.02,,,2770.02,Other,110% of Medicare,1958.6,35,,1958.6,percent of total billed charges,Implant Device,1902.64,34,"Charges > $500, x 34%",1902.64,percent of total billed charges,Implant Device,1958.6,35,,1958.6,percent of total billed charges,Implant Device,1958.6,35,,1958.6,percent of total billed charges,Implant Device,1958.6,35,,1958.6,percent of total billed charges,Implant Device,1958.6,35,,1958.6,percent of total billed charges,Implant Device,1958.6,35,,1958.6,percent of total billed charges,Implant Device,2238.4,40,,2238.4,percent of total billed charges,Implant Device,1958.6,70,,1958.6,percent of total billed charges,All Other,1902.64,34,,1902.64,percent of total billed charges,Implant Device,1902.64,34,,1902.64,percent of total billed charges,Implant Device,1958.6,35,,1958.6,percent of total billed charges,Implant Device,1958.6,35,,1958.6,percent of total billed charges,Implant Device,1958.6,35,,1958.6,percent of total billed charges,Implant Device,1958.6,35,,1958.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1902.64,34,"If Charge > 2,000, then 34 percent",1902.64,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4141.05,
S&N 71313209 CENTRALIZER 9MM,C1776,HCPCS,,79002987,CDM,278,RC,,,both,,,281,207.94,,,207.94,Other,150% of Medicare + 9.63% HCRA Surcharge,126.45,45,,126.45,percent of total billed charges,Critical Access Hospital RCC factor,95.54,34,,95.54,percent of total billed charges,Implant Device,95.54,34,,95.54,percent of total billed charges,Implant Device,95.54,34,,95.54,percent of total billed charges,Implant Device,95.54,34,,95.54,percent of total billed charges,Implant Device,95.54,34,,95.54,percent of total billed charges,Implant Device,139.1,,,139.1,Other,110% of Medicare,98.35,35,,98.35,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,98.35,35,,98.35,percent of total billed charges,Implant Device,98.35,35,,98.35,percent of total billed charges,Implant Device,98.35,35,,98.35,percent of total billed charges,Implant Device,98.35,35,,98.35,percent of total billed charges,Implant Device,98.35,35,,98.35,percent of total billed charges,Implant Device,112.4,40,,112.4,percent of total billed charges,Implant Device,98.35,70,,98.35,percent of total billed charges,All Other,95.54,34,,95.54,percent of total billed charges,Implant Device,95.54,34,,95.54,percent of total billed charges,Implant Device,98.35,35,,98.35,percent of total billed charges,Implant Device,98.35,35,,98.35,percent of total billed charges,Implant Device,98.35,35,,98.35,percent of total billed charges,Implant Device,98.35,35,,98.35,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,207.94,
S&N 71312112 FEM COMP 12/14,C1776,HCPCS,,79002988,CDM,278,RC,,,both,,,8550,6327.02,,,6327.02,Other,150% of Medicare + 9.63% HCRA Surcharge,3847.5,45,,3847.5,percent of total billed charges,Critical Access Hospital RCC factor,2907,34,,2907,percent of total billed charges,Implant Device,2907,34,,2907,percent of total billed charges,Implant Device,2907,34,,2907,percent of total billed charges,Implant Device,2907,34,,2907,percent of total billed charges,Implant Device,2907,34,,2907,percent of total billed charges,Implant Device,4232.25,,,4232.25,Other,110% of Medicare,2992.5,35,,2992.5,percent of total billed charges,Implant Device,2907,34,"Charges > $500, x 34%",2907,percent of total billed charges,Implant Device,2992.5,35,,2992.5,percent of total billed charges,Implant Device,2992.5,35,,2992.5,percent of total billed charges,Implant Device,2992.5,35,,2992.5,percent of total billed charges,Implant Device,2992.5,35,,2992.5,percent of total billed charges,Implant Device,2992.5,35,,2992.5,percent of total billed charges,Implant Device,3420,40,,3420,percent of total billed charges,Implant Device,2992.5,70,,2992.5,percent of total billed charges,All Other,2907,34,,2907,percent of total billed charges,Implant Device,2907,34,,2907,percent of total billed charges,Implant Device,2992.5,35,,2992.5,percent of total billed charges,Implant Device,2992.5,35,,2992.5,percent of total billed charges,Implant Device,2992.5,35,,2992.5,percent of total billed charges,Implant Device,2992.5,35,,2992.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2907,34,"If Charge > 2,000, then 34 percent",2907,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,6327.02,
S&N 71302804 FEMORAL HEAD 12/14,C1776,HCPCS,,79002989,CDM,278,RC,,,both,,,1920,1420.8,,,1420.8,Other,150% of Medicare + 9.63% HCRA Surcharge,864,45,,864,percent of total billed charges,Critical Access Hospital RCC factor,652.8,34,,652.8,percent of total billed charges,Implant Device,652.8,34,,652.8,percent of total billed charges,Implant Device,652.8,34,,652.8,percent of total billed charges,Implant Device,652.8,34,,652.8,percent of total billed charges,Implant Device,652.8,34,,652.8,percent of total billed charges,Implant Device,950.4,,,950.4,Other,110% of Medicare,672,35,,672,percent of total billed charges,Implant Device,652.8,34,"Charges > $500, x 34%",652.8,percent of total billed charges,Implant Device,672,35,,672,percent of total billed charges,Implant Device,672,35,,672,percent of total billed charges,Implant Device,672,35,,672,percent of total billed charges,Implant Device,672,35,,672,percent of total billed charges,Implant Device,672,35,,672,percent of total billed charges,Implant Device,768,40,,768,percent of total billed charges,Implant Device,672,70,,672,percent of total billed charges,All Other,652.8,34,,652.8,percent of total billed charges,Implant Device,652.8,34,,652.8,percent of total billed charges,Implant Device,672,35,,672,percent of total billed charges,Implant Device,672,35,,672,percent of total billed charges,Implant Device,672,35,,672,percent of total billed charges,Implant Device,672,35,,672,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1420.8,
STRYKER 1830-0001S COM SCREW 6X13.5MM,C1713,HCPCS,,79002994,CDM,278,RC,,,both,,,668,494.32,,,494.32,Other,150% of Medicare + 9.63% HCRA Surcharge,300.6,45,,300.6,percent of total billed charges,Critical Access Hospital RCC factor,227.12,34,,227.12,percent of total billed charges,Implant Device,227.12,34,,227.12,percent of total billed charges,Implant Device,227.12,34,,227.12,percent of total billed charges,Implant Device,227.12,34,,227.12,percent of total billed charges,Implant Device,227.12,34,,227.12,percent of total billed charges,Implant Device,330.66,,,330.66,Other,110% of Medicare,233.8,35,,233.8,percent of total billed charges,Implant Device,227.12,34,"Charges > $500, x 34%",227.12,percent of total billed charges,Implant Device,233.8,35,,233.8,percent of total billed charges,Implant Device,233.8,35,,233.8,percent of total billed charges,Implant Device,233.8,35,,233.8,percent of total billed charges,Implant Device,233.8,35,,233.8,percent of total billed charges,Implant Device,233.8,35,,233.8,percent of total billed charges,Implant Device,267.2,40,,267.2,percent of total billed charges,Implant Device,233.8,70,,233.8,percent of total billed charges,All Other,227.12,34,,227.12,percent of total billed charges,Implant Device,227.12,34,,227.12,percent of total billed charges,Implant Device,233.8,35,,233.8,percent of total billed charges,Implant Device,233.8,35,,233.8,percent of total billed charges,Implant Device,233.8,35,,233.8,percent of total billed charges,Implant Device,233.8,35,,233.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,494.32,
STRYKER 1830-0925S HUMERAL NAIL 9X250MM,C1713,HCPCS,,79002995,CDM,278,RC,,,both,,,3489,2581.87,,,2581.87,Other,150% of Medicare + 9.63% HCRA Surcharge,1570.05,45,,1570.05,percent of total billed charges,Critical Access Hospital RCC factor,1186.26,34,,1186.26,percent of total billed charges,Implant Device,1186.26,34,,1186.26,percent of total billed charges,Implant Device,1186.26,34,,1186.26,percent of total billed charges,Implant Device,1186.26,34,,1186.26,percent of total billed charges,Implant Device,1186.26,34,,1186.26,percent of total billed charges,Implant Device,1727.06,,,1727.06,Other,110% of Medicare,1221.15,35,,1221.15,percent of total billed charges,Implant Device,1186.26,34,"Charges > $500, x 34%",1186.26,percent of total billed charges,Implant Device,1221.15,35,,1221.15,percent of total billed charges,Implant Device,1221.15,35,,1221.15,percent of total billed charges,Implant Device,1221.15,35,,1221.15,percent of total billed charges,Implant Device,1221.15,35,,1221.15,percent of total billed charges,Implant Device,1221.15,35,,1221.15,percent of total billed charges,Implant Device,1395.6,40,,1395.6,percent of total billed charges,Implant Device,1221.15,70,,1221.15,percent of total billed charges,All Other,1186.26,34,,1186.26,percent of total billed charges,Implant Device,1186.26,34,,1186.26,percent of total billed charges,Implant Device,1221.15,35,,1221.15,percent of total billed charges,Implant Device,1221.15,35,,1221.15,percent of total billed charges,Implant Device,1221.15,35,,1221.15,percent of total billed charges,Implant Device,1221.15,35,,1221.15,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1186.26,34,"If Charge > 2,000, then 34 percent",1186.26,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2581.87,
ATLAS SPINE 1106-09-0000 LOCKING COLLAR,C1713,HCPCS,,79003000,CDM,278,RC,,,both,,,540,399.6,,,399.6,Other,150% of Medicare + 9.63% HCRA Surcharge,243,45,,243,percent of total billed charges,Critical Access Hospital RCC factor,183.6,34,,183.6,percent of total billed charges,Implant Device,183.6,34,,183.6,percent of total billed charges,Implant Device,183.6,34,,183.6,percent of total billed charges,Implant Device,183.6,34,,183.6,percent of total billed charges,Implant Device,183.6,34,,183.6,percent of total billed charges,Implant Device,267.3,,,267.3,Other,110% of Medicare,189,35,,189,percent of total billed charges,Implant Device,183.6,34,"Charges > $500, x 34%",183.6,percent of total billed charges,Implant Device,189,35,,189,percent of total billed charges,Implant Device,189,35,,189,percent of total billed charges,Implant Device,189,35,,189,percent of total billed charges,Implant Device,189,35,,189,percent of total billed charges,Implant Device,189,35,,189,percent of total billed charges,Implant Device,216,40,,216,percent of total billed charges,Implant Device,189,70,,189,percent of total billed charges,All Other,183.6,34,,183.6,percent of total billed charges,Implant Device,183.6,34,,183.6,percent of total billed charges,Implant Device,189,35,,189,percent of total billed charges,Implant Device,189,35,,189,percent of total billed charges,Implant Device,189,35,,189,percent of total billed charges,Implant Device,189,35,,189,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,399.6,
ATLAS SPINE 1106-05-0000 REDUCTION HEAD,C1713,HCPCS,,79003001,CDM,278,RC,,,both,,,2468,1826.33,,,1826.33,Other,150% of Medicare + 9.63% HCRA Surcharge,1110.6,45,,1110.6,percent of total billed charges,Critical Access Hospital RCC factor,839.12,34,,839.12,percent of total billed charges,Implant Device,839.12,34,,839.12,percent of total billed charges,Implant Device,839.12,34,,839.12,percent of total billed charges,Implant Device,839.12,34,,839.12,percent of total billed charges,Implant Device,839.12,34,,839.12,percent of total billed charges,Implant Device,1221.66,,,1221.66,Other,110% of Medicare,863.8,35,,863.8,percent of total billed charges,Implant Device,839.12,34,"Charges > $500, x 34%",839.12,percent of total billed charges,Implant Device,863.8,35,,863.8,percent of total billed charges,Implant Device,863.8,35,,863.8,percent of total billed charges,Implant Device,863.8,35,,863.8,percent of total billed charges,Implant Device,863.8,35,,863.8,percent of total billed charges,Implant Device,863.8,35,,863.8,percent of total billed charges,Implant Device,987.2,40,,987.2,percent of total billed charges,Implant Device,863.8,70,,863.8,percent of total billed charges,All Other,839.12,34,,839.12,percent of total billed charges,Implant Device,839.12,34,,839.12,percent of total billed charges,Implant Device,863.8,35,,863.8,percent of total billed charges,Implant Device,863.8,35,,863.8,percent of total billed charges,Implant Device,863.8,35,,863.8,percent of total billed charges,Implant Device,863.8,35,,863.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,839.12,34,"If Charge > 2,000, then 34 percent",839.12,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1826.33,
ATLAS SPINE 1106-01-6550 SCREW 6.5X50MM,C1713,HCPCS,,79003002,CDM,278,RC,,,both,,,630,466.2,,,466.2,Other,150% of Medicare + 9.63% HCRA Surcharge,283.5,45,,283.5,percent of total billed charges,Critical Access Hospital RCC factor,214.2,34,,214.2,percent of total billed charges,Implant Device,214.2,34,,214.2,percent of total billed charges,Implant Device,214.2,34,,214.2,percent of total billed charges,Implant Device,214.2,34,,214.2,percent of total billed charges,Implant Device,214.2,34,,214.2,percent of total billed charges,Implant Device,311.85,,,311.85,Other,110% of Medicare,220.5,35,,220.5,percent of total billed charges,Implant Device,214.2,34,"Charges > $500, x 34%",214.2,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,252,40,,252,percent of total billed charges,Implant Device,220.5,70,,220.5,percent of total billed charges,All Other,214.2,34,,214.2,percent of total billed charges,Implant Device,214.2,34,,214.2,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,466.2,
ATLAS SPINE 1106-01-6555 SCREW 6.5X55MM,C1713,HCPCS,,79003003,CDM,278,RC,,,both,,,630,466.2,,,466.2,Other,150% of Medicare + 9.63% HCRA Surcharge,283.5,45,,283.5,percent of total billed charges,Critical Access Hospital RCC factor,214.2,34,,214.2,percent of total billed charges,Implant Device,214.2,34,,214.2,percent of total billed charges,Implant Device,214.2,34,,214.2,percent of total billed charges,Implant Device,214.2,34,,214.2,percent of total billed charges,Implant Device,214.2,34,,214.2,percent of total billed charges,Implant Device,311.85,,,311.85,Other,110% of Medicare,220.5,35,,220.5,percent of total billed charges,Implant Device,214.2,34,"Charges > $500, x 34%",214.2,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,252,40,,252,percent of total billed charges,Implant Device,220.5,70,,220.5,percent of total billed charges,All Other,214.2,34,,214.2,percent of total billed charges,Implant Device,214.2,34,,214.2,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,466.2,
ATLAS SPINE 1100-03-0085 CONTOURED ROD,C1713,HCPCS,,79003004,CDM,278,RC,,,both,,,600,444,,,444,Other,150% of Medicare + 9.63% HCRA Surcharge,270,45,,270,percent of total billed charges,Critical Access Hospital RCC factor,204,34,,204,percent of total billed charges,Implant Device,204,34,,204,percent of total billed charges,Implant Device,204,34,,204,percent of total billed charges,Implant Device,204,34,,204,percent of total billed charges,Implant Device,204,34,,204,percent of total billed charges,Implant Device,297,,,297,Other,110% of Medicare,210,35,,210,percent of total billed charges,Implant Device,204,34,"Charges > $500, x 34%",204,percent of total billed charges,Implant Device,210,35,,210,percent of total billed charges,Implant Device,210,35,,210,percent of total billed charges,Implant Device,210,35,,210,percent of total billed charges,Implant Device,210,35,,210,percent of total billed charges,Implant Device,210,35,,210,percent of total billed charges,Implant Device,240,40,,240,percent of total billed charges,Implant Device,210,70,,210,percent of total billed charges,All Other,204,34,,204,percent of total billed charges,Implant Device,204,34,,204,percent of total billed charges,Implant Device,210,35,,210,percent of total billed charges,Implant Device,210,35,,210,percent of total billed charges,Implant Device,210,35,,210,percent of total billed charges,Implant Device,210,35,,210,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,444,
ATLAS SPINE 1106-01-7540 SCREW 7.5X40MM,C1713,HCPCS,,79003005,CDM,278,RC,,,both,,,1050,777,,,777,Other,150% of Medicare + 9.63% HCRA Surcharge,472.5,45,,472.5,percent of total billed charges,Critical Access Hospital RCC factor,357,34,,357,percent of total billed charges,Implant Device,357,34,,357,percent of total billed charges,Implant Device,357,34,,357,percent of total billed charges,Implant Device,357,34,,357,percent of total billed charges,Implant Device,357,34,,357,percent of total billed charges,Implant Device,519.75,,,519.75,Other,110% of Medicare,367.5,35,,367.5,percent of total billed charges,Implant Device,357,34,"Charges > $500, x 34%",357,percent of total billed charges,Implant Device,367.5,35,,367.5,percent of total billed charges,Implant Device,367.5,35,,367.5,percent of total billed charges,Implant Device,367.5,35,,367.5,percent of total billed charges,Implant Device,367.5,35,,367.5,percent of total billed charges,Implant Device,367.5,35,,367.5,percent of total billed charges,Implant Device,420,40,,420,percent of total billed charges,Implant Device,367.5,70,,367.5,percent of total billed charges,All Other,357,34,,357,percent of total billed charges,Implant Device,357,34,,357,percent of total billed charges,Implant Device,367.5,35,,367.5,percent of total billed charges,Implant Device,367.5,35,,367.5,percent of total billed charges,Implant Device,367.5,35,,367.5,percent of total billed charges,Implant Device,367.5,35,,367.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,777,
ATLAS SPINE 1100-05-6066 CROSS CONNECTOR,C1713,HCPCS,,79003006,CDM,278,RC,,,both,,,3570,2641.81,,,2641.81,Other,150% of Medicare + 9.63% HCRA Surcharge,1606.5,45,,1606.5,percent of total billed charges,Critical Access Hospital RCC factor,1213.8,34,,1213.8,percent of total billed charges,Implant Device,1213.8,34,,1213.8,percent of total billed charges,Implant Device,1213.8,34,,1213.8,percent of total billed charges,Implant Device,1213.8,34,,1213.8,percent of total billed charges,Implant Device,1213.8,34,,1213.8,percent of total billed charges,Implant Device,1767.15,,,1767.15,Other,110% of Medicare,1249.5,35,,1249.5,percent of total billed charges,Implant Device,1213.8,34,"Charges > $500, x 34%",1213.8,percent of total billed charges,Implant Device,1249.5,35,,1249.5,percent of total billed charges,Implant Device,1249.5,35,,1249.5,percent of total billed charges,Implant Device,1249.5,35,,1249.5,percent of total billed charges,Implant Device,1249.5,35,,1249.5,percent of total billed charges,Implant Device,1249.5,35,,1249.5,percent of total billed charges,Implant Device,1428,40,,1428,percent of total billed charges,Implant Device,1249.5,70,,1249.5,percent of total billed charges,All Other,1213.8,34,,1213.8,percent of total billed charges,Implant Device,1213.8,34,,1213.8,percent of total billed charges,Implant Device,1249.5,35,,1249.5,percent of total billed charges,Implant Device,1249.5,35,,1249.5,percent of total billed charges,Implant Device,1249.5,35,,1249.5,percent of total billed charges,Implant Device,1249.5,35,,1249.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1213.8,34,"If Charge > 2,000, then 34 percent",1213.8,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2641.81,
ATLAS SPINE 1100-03-0070 CONTOURED ROD,C1713,HCPCS,,79003007,CDM,278,RC,,,both,,,840,621.6,,,621.6,Other,150% of Medicare + 9.63% HCRA Surcharge,378,45,,378,percent of total billed charges,Critical Access Hospital RCC factor,285.6,34,,285.6,percent of total billed charges,Implant Device,285.6,34,,285.6,percent of total billed charges,Implant Device,285.6,34,,285.6,percent of total billed charges,Implant Device,285.6,34,,285.6,percent of total billed charges,Implant Device,285.6,34,,285.6,percent of total billed charges,Implant Device,415.8,,,415.8,Other,110% of Medicare,294,35,,294,percent of total billed charges,Implant Device,285.6,34,"Charges > $500, x 34%",285.6,percent of total billed charges,Implant Device,294,35,,294,percent of total billed charges,Implant Device,294,35,,294,percent of total billed charges,Implant Device,294,35,,294,percent of total billed charges,Implant Device,294,35,,294,percent of total billed charges,Implant Device,294,35,,294,percent of total billed charges,Implant Device,336,40,,336,percent of total billed charges,Implant Device,294,70,,294,percent of total billed charges,All Other,285.6,34,,285.6,percent of total billed charges,Implant Device,285.6,34,,285.6,percent of total billed charges,Implant Device,294,35,,294,percent of total billed charges,Implant Device,294,35,,294,percent of total billed charges,Implant Device,294,35,,294,percent of total billed charges,Implant Device,294,35,,294,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,621.6,
ATLAS SPINE 1100-05-6672 CROSS CONNECTOR,C1713,HCPCS,,79003008,CDM,278,RC,,,both,,,3570,2641.81,,,2641.81,Other,150% of Medicare + 9.63% HCRA Surcharge,1606.5,45,,1606.5,percent of total billed charges,Critical Access Hospital RCC factor,1213.8,34,,1213.8,percent of total billed charges,Implant Device,1213.8,34,,1213.8,percent of total billed charges,Implant Device,1213.8,34,,1213.8,percent of total billed charges,Implant Device,1213.8,34,,1213.8,percent of total billed charges,Implant Device,1213.8,34,,1213.8,percent of total billed charges,Implant Device,1767.15,,,1767.15,Other,110% of Medicare,1249.5,35,,1249.5,percent of total billed charges,Implant Device,1213.8,34,"Charges > $500, x 34%",1213.8,percent of total billed charges,Implant Device,1249.5,35,,1249.5,percent of total billed charges,Implant Device,1249.5,35,,1249.5,percent of total billed charges,Implant Device,1249.5,35,,1249.5,percent of total billed charges,Implant Device,1249.5,35,,1249.5,percent of total billed charges,Implant Device,1249.5,35,,1249.5,percent of total billed charges,Implant Device,1428,40,,1428,percent of total billed charges,Implant Device,1249.5,70,,1249.5,percent of total billed charges,All Other,1213.8,34,,1213.8,percent of total billed charges,Implant Device,1213.8,34,,1213.8,percent of total billed charges,Implant Device,1249.5,35,,1249.5,percent of total billed charges,Implant Device,1249.5,35,,1249.5,percent of total billed charges,Implant Device,1249.5,35,,1249.5,percent of total billed charges,Implant Device,1249.5,35,,1249.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1213.8,34,"If Charge > 2,000, then 34 percent",1213.8,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2641.81,
ATLAS SPINE 1100-05-5460 CROSS CONNECTOR,C1713,HCPCS,,79003009,CDM,278,RC,,,both,,,3570,2641.81,,,2641.81,Other,150% of Medicare + 9.63% HCRA Surcharge,1606.5,45,,1606.5,percent of total billed charges,Critical Access Hospital RCC factor,1213.8,34,,1213.8,percent of total billed charges,Implant Device,1213.8,34,,1213.8,percent of total billed charges,Implant Device,1213.8,34,,1213.8,percent of total billed charges,Implant Device,1213.8,34,,1213.8,percent of total billed charges,Implant Device,1213.8,34,,1213.8,percent of total billed charges,Implant Device,1767.15,,,1767.15,Other,110% of Medicare,1249.5,35,,1249.5,percent of total billed charges,Implant Device,1213.8,34,"Charges > $500, x 34%",1213.8,percent of total billed charges,Implant Device,1249.5,35,,1249.5,percent of total billed charges,Implant Device,1249.5,35,,1249.5,percent of total billed charges,Implant Device,1249.5,35,,1249.5,percent of total billed charges,Implant Device,1249.5,35,,1249.5,percent of total billed charges,Implant Device,1249.5,35,,1249.5,percent of total billed charges,Implant Device,1428,40,,1428,percent of total billed charges,Implant Device,1249.5,70,,1249.5,percent of total billed charges,All Other,1213.8,34,,1213.8,percent of total billed charges,Implant Device,1213.8,34,,1213.8,percent of total billed charges,Implant Device,1249.5,35,,1249.5,percent of total billed charges,Implant Device,1249.5,35,,1249.5,percent of total billed charges,Implant Device,1249.5,35,,1249.5,percent of total billed charges,Implant Device,1249.5,35,,1249.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1213.8,34,"If Charge > 2,000, then 34 percent",1213.8,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2641.81,
STRYKER 1830-0924S T2 HUMERUS SYSTEM,C1713,HCPCS,,79003013,CDM,278,RC,,,both,,,7061,5225.16,,,5225.16,Other,150% of Medicare + 9.63% HCRA Surcharge,3177.45,45,,3177.45,percent of total billed charges,Critical Access Hospital RCC factor,2400.74,34,,2400.74,percent of total billed charges,Implant Device,2400.74,34,,2400.74,percent of total billed charges,Implant Device,2400.74,34,,2400.74,percent of total billed charges,Implant Device,2400.74,34,,2400.74,percent of total billed charges,Implant Device,2400.74,34,,2400.74,percent of total billed charges,Implant Device,3495.2,,,3495.2,Other,110% of Medicare,2471.35,35,,2471.35,percent of total billed charges,Implant Device,2400.74,34,"Charges > $500, x 34%",2400.74,percent of total billed charges,Implant Device,2471.35,35,,2471.35,percent of total billed charges,Implant Device,2471.35,35,,2471.35,percent of total billed charges,Implant Device,2471.35,35,,2471.35,percent of total billed charges,Implant Device,2471.35,35,,2471.35,percent of total billed charges,Implant Device,2471.35,35,,2471.35,percent of total billed charges,Implant Device,2824.4,40,,2824.4,percent of total billed charges,Implant Device,2471.35,70,,2471.35,percent of total billed charges,All Other,2400.74,34,,2400.74,percent of total billed charges,Implant Device,2400.74,34,,2400.74,percent of total billed charges,Implant Device,2471.35,35,,2471.35,percent of total billed charges,Implant Device,2471.35,35,,2471.35,percent of total billed charges,Implant Device,2471.35,35,,2471.35,percent of total billed charges,Implant Device,2471.35,35,,2471.35,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2400.74,34,"If Charge > 2,000, then 34 percent",2400.74,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5225.16,
STRYKER 1896-4040S LOCKING SCREW 4X40MM,C1713,HCPCS,,79003014,CDM,278,RC,,,both,,,836,618.64,,,618.64,Other,150% of Medicare + 9.63% HCRA Surcharge,376.2,45,,376.2,percent of total billed charges,Critical Access Hospital RCC factor,284.24,34,,284.24,percent of total billed charges,Implant Device,284.24,34,,284.24,percent of total billed charges,Implant Device,284.24,34,,284.24,percent of total billed charges,Implant Device,284.24,34,,284.24,percent of total billed charges,Implant Device,284.24,34,,284.24,percent of total billed charges,Implant Device,413.82,,,413.82,Other,110% of Medicare,292.6,35,,292.6,percent of total billed charges,Implant Device,284.24,34,"Charges > $500, x 34%",284.24,percent of total billed charges,Implant Device,292.6,35,,292.6,percent of total billed charges,Implant Device,292.6,35,,292.6,percent of total billed charges,Implant Device,292.6,35,,292.6,percent of total billed charges,Implant Device,292.6,35,,292.6,percent of total billed charges,Implant Device,292.6,35,,292.6,percent of total billed charges,Implant Device,334.4,40,,334.4,percent of total billed charges,Implant Device,292.6,70,,292.6,percent of total billed charges,All Other,284.24,34,,284.24,percent of total billed charges,Implant Device,284.24,34,,284.24,percent of total billed charges,Implant Device,292.6,35,,292.6,percent of total billed charges,Implant Device,292.6,35,,292.6,percent of total billed charges,Implant Device,292.6,35,,292.6,percent of total billed charges,Implant Device,292.6,35,,292.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,618.64,
STRYKER 1896-5035S SCREW LOCKING FT 5X35,C1713,HCPCS,,79003023,CDM,278,RC,,,both,,,355,262.7,,,262.7,Other,150% of Medicare + 9.63% HCRA Surcharge,159.75,45,,159.75,percent of total billed charges,Critical Access Hospital RCC factor,120.7,34,,120.7,percent of total billed charges,Implant Device,120.7,34,,120.7,percent of total billed charges,Implant Device,120.7,34,,120.7,percent of total billed charges,Implant Device,120.7,34,,120.7,percent of total billed charges,Implant Device,120.7,34,,120.7,percent of total billed charges,Implant Device,175.73,,,175.73,Other,110% of Medicare,124.25,35,,124.25,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,124.25,35,,124.25,percent of total billed charges,Implant Device,124.25,35,,124.25,percent of total billed charges,Implant Device,124.25,35,,124.25,percent of total billed charges,Implant Device,124.25,35,,124.25,percent of total billed charges,Implant Device,124.25,35,,124.25,percent of total billed charges,Implant Device,142,40,,142,percent of total billed charges,Implant Device,124.25,70,,124.25,percent of total billed charges,All Other,120.7,34,,120.7,percent of total billed charges,Implant Device,120.7,34,,120.7,percent of total billed charges,Implant Device,124.25,35,,124.25,percent of total billed charges,Implant Device,124.25,35,,124.25,percent of total billed charges,Implant Device,124.25,35,,124.25,percent of total billed charges,Implant Device,124.25,35,,124.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,262.7,
STRYKER 3060-0110S SCREW LAG TI 10.5X110,C1713,HCPCS,,79003024,CDM,278,RC,,,both,,,1230,910.2,,,910.2,Other,150% of Medicare + 9.63% HCRA Surcharge,553.5,45,,553.5,percent of total billed charges,Critical Access Hospital RCC factor,418.2,34,,418.2,percent of total billed charges,Implant Device,418.2,34,,418.2,percent of total billed charges,Implant Device,418.2,34,,418.2,percent of total billed charges,Implant Device,418.2,34,,418.2,percent of total billed charges,Implant Device,418.2,34,,418.2,percent of total billed charges,Implant Device,608.85,,,608.85,Other,110% of Medicare,430.5,35,,430.5,percent of total billed charges,Implant Device,418.2,34,"Charges > $500, x 34%",418.2,percent of total billed charges,Implant Device,430.5,35,,430.5,percent of total billed charges,Implant Device,430.5,35,,430.5,percent of total billed charges,Implant Device,430.5,35,,430.5,percent of total billed charges,Implant Device,430.5,35,,430.5,percent of total billed charges,Implant Device,430.5,35,,430.5,percent of total billed charges,Implant Device,492,40,,492,percent of total billed charges,Implant Device,430.5,70,,430.5,percent of total billed charges,All Other,418.2,34,,418.2,percent of total billed charges,Implant Device,418.2,34,,418.2,percent of total billed charges,Implant Device,430.5,35,,430.5,percent of total billed charges,Implant Device,430.5,35,,430.5,percent of total billed charges,Implant Device,430.5,35,,430.5,percent of total billed charges,Implant Device,430.5,35,,430.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,910.2,
STRYKER 3125-1180S NAIL KIT 11X180X125,C1713,HCPCS,,79003025,CDM,278,RC,,,both,,,2928,2166.73,,,2166.73,Other,150% of Medicare + 9.63% HCRA Surcharge,1317.6,45,,1317.6,percent of total billed charges,Critical Access Hospital RCC factor,995.52,34,,995.52,percent of total billed charges,Implant Device,995.52,34,,995.52,percent of total billed charges,Implant Device,995.52,34,,995.52,percent of total billed charges,Implant Device,995.52,34,,995.52,percent of total billed charges,Implant Device,995.52,34,,995.52,percent of total billed charges,Implant Device,1449.36,,,1449.36,Other,110% of Medicare,1024.8,35,,1024.8,percent of total billed charges,Implant Device,995.52,34,"Charges > $500, x 34%",995.52,percent of total billed charges,Implant Device,1024.8,35,,1024.8,percent of total billed charges,Implant Device,1024.8,35,,1024.8,percent of total billed charges,Implant Device,1024.8,35,,1024.8,percent of total billed charges,Implant Device,1024.8,35,,1024.8,percent of total billed charges,Implant Device,1024.8,35,,1024.8,percent of total billed charges,Implant Device,1171.2,40,,1171.2,percent of total billed charges,Implant Device,1024.8,70,,1024.8,percent of total billed charges,All Other,995.52,34,,995.52,percent of total billed charges,Implant Device,995.52,34,,995.52,percent of total billed charges,Implant Device,1024.8,35,,1024.8,percent of total billed charges,Implant Device,1024.8,35,,1024.8,percent of total billed charges,Implant Device,1024.8,35,,1024.8,percent of total billed charges,Implant Device,1024.8,35,,1024.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,995.52,34,"If Charge > 2,000, then 34 percent",995.52,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2166.73,
ARTHREX ALFEX101 ARTHROFLEX 4X7CM,C1713,HCPCS,,79003026,CDM,278,RC,,,both,,,7517,5562.6,,,5562.6,Other,150% of Medicare + 9.63% HCRA Surcharge,3382.65,45,,3382.65,percent of total billed charges,Critical Access Hospital RCC factor,2555.78,34,,2555.78,percent of total billed charges,Implant Device,2555.78,34,,2555.78,percent of total billed charges,Implant Device,2555.78,34,,2555.78,percent of total billed charges,Implant Device,2555.78,34,,2555.78,percent of total billed charges,Implant Device,2555.78,34,,2555.78,percent of total billed charges,Implant Device,3720.92,,,3720.92,Other,110% of Medicare,2630.95,35,,2630.95,percent of total billed charges,Implant Device,2555.78,34,"Charges > $500, x 34%",2555.78,percent of total billed charges,Implant Device,2630.95,35,,2630.95,percent of total billed charges,Implant Device,2630.95,35,,2630.95,percent of total billed charges,Implant Device,2630.95,35,,2630.95,percent of total billed charges,Implant Device,2630.95,35,,2630.95,percent of total billed charges,Implant Device,2630.95,35,,2630.95,percent of total billed charges,Implant Device,3006.8,40,,3006.8,percent of total billed charges,Implant Device,2630.95,70,,2630.95,percent of total billed charges,All Other,2555.78,34,,2555.78,percent of total billed charges,Implant Device,2555.78,34,,2555.78,percent of total billed charges,Implant Device,2630.95,35,,2630.95,percent of total billed charges,Implant Device,2630.95,35,,2630.95,percent of total billed charges,Implant Device,2630.95,35,,2630.95,percent of total billed charges,Implant Device,2630.95,35,,2630.95,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2555.78,34,"If Charge > 2,000, then 34 percent",2555.78,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5562.6,
MENTOR 350-1660 BREAST IMPLANT,C1789,HCPCS,,79003027,CDM,278,RC,,,both,,,1936,1432.64,,,1432.64,Other,150% of Medicare + 9.63% HCRA Surcharge,871.2,45,,871.2,percent of total billed charges,Critical Access Hospital RCC factor,658.24,34,,658.24,percent of total billed charges,Implant Device,658.24,34,,658.24,percent of total billed charges,Implant Device,658.24,34,,658.24,percent of total billed charges,Implant Device,658.24,34,,658.24,percent of total billed charges,Implant Device,658.24,34,,658.24,percent of total billed charges,Implant Device,958.32,,,958.32,Other,110% of Medicare,677.6,35,,677.6,percent of total billed charges,Implant Device,658.24,34,"Charges > $500, x 34%",658.24,percent of total billed charges,Implant Device,677.6,35,,677.6,percent of total billed charges,Implant Device,677.6,35,,677.6,percent of total billed charges,Implant Device,677.6,35,,677.6,percent of total billed charges,Implant Device,677.6,35,,677.6,percent of total billed charges,Implant Device,677.6,35,,677.6,percent of total billed charges,Implant Device,774.4,40,,774.4,percent of total billed charges,Implant Device,677.6,70,,677.6,percent of total billed charges,All Other,658.24,34,,658.24,percent of total billed charges,Implant Device,658.24,34,,658.24,percent of total billed charges,Implant Device,677.6,35,,677.6,percent of total billed charges,Implant Device,677.6,35,,677.6,percent of total billed charges,Implant Device,677.6,35,,677.6,percent of total billed charges,Implant Device,677.6,35,,677.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1432.64,
EV3 PRB35-06-200-120 EVERFLEX STENT,C1876,HCPCS,,79003029,CDM,278,RC,,,both,,,9687,7168.4,,,7168.4,Other,150% of Medicare + 9.63% HCRA Surcharge,4359.15,45,,4359.15,percent of total billed charges,Critical Access Hospital RCC factor,3293.58,34,,3293.58,percent of total billed charges,Implant Device,3293.58,34,,3293.58,percent of total billed charges,Implant Device,3293.58,34,,3293.58,percent of total billed charges,Implant Device,3293.58,34,,3293.58,percent of total billed charges,Implant Device,3293.58,34,,3293.58,percent of total billed charges,Implant Device,4795.07,,,4795.07,Other,110% of Medicare,3390.45,35,,3390.45,percent of total billed charges,Implant Device,3293.58,34,"Charges > $500, x 34%",3293.58,percent of total billed charges,Implant Device,3390.45,35,,3390.45,percent of total billed charges,Implant Device,3390.45,35,,3390.45,percent of total billed charges,Implant Device,3390.45,35,,3390.45,percent of total billed charges,Implant Device,3390.45,35,,3390.45,percent of total billed charges,Implant Device,3390.45,35,,3390.45,percent of total billed charges,Implant Device,3874.8,40,,3874.8,percent of total billed charges,Implant Device,3390.45,70,,3390.45,percent of total billed charges,All Other,3293.58,34,,3293.58,percent of total billed charges,Implant Device,3293.58,34,,3293.58,percent of total billed charges,Implant Device,3390.45,35,,3390.45,percent of total billed charges,Implant Device,3390.45,35,,3390.45,percent of total billed charges,Implant Device,3390.45,35,,3390.45,percent of total billed charges,Implant Device,3390.45,35,,3390.45,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3293.58,34,"If Charge > 2,000, then 34 percent",3293.58,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,7168.4,
EV3 PRB35-07-200-120 EVERFLEX STENT,C1876,HCPCS,,79003030,CDM,278,RC,,,both,,,9687,7168.4,,,7168.4,Other,150% of Medicare + 9.63% HCRA Surcharge,4359.15,45,,4359.15,percent of total billed charges,Critical Access Hospital RCC factor,3293.58,34,,3293.58,percent of total billed charges,Implant Device,3293.58,34,,3293.58,percent of total billed charges,Implant Device,3293.58,34,,3293.58,percent of total billed charges,Implant Device,3293.58,34,,3293.58,percent of total billed charges,Implant Device,3293.58,34,,3293.58,percent of total billed charges,Implant Device,4795.07,,,4795.07,Other,110% of Medicare,3390.45,35,,3390.45,percent of total billed charges,Implant Device,3293.58,34,"Charges > $500, x 34%",3293.58,percent of total billed charges,Implant Device,3390.45,35,,3390.45,percent of total billed charges,Implant Device,3390.45,35,,3390.45,percent of total billed charges,Implant Device,3390.45,35,,3390.45,percent of total billed charges,Implant Device,3390.45,35,,3390.45,percent of total billed charges,Implant Device,3390.45,35,,3390.45,percent of total billed charges,Implant Device,3874.8,40,,3874.8,percent of total billed charges,Implant Device,3390.45,70,,3390.45,percent of total billed charges,All Other,3293.58,34,,3293.58,percent of total billed charges,Implant Device,3293.58,34,,3293.58,percent of total billed charges,Implant Device,3390.45,35,,3390.45,percent of total billed charges,Implant Device,3390.45,35,,3390.45,percent of total billed charges,Implant Device,3390.45,35,,3390.45,percent of total billed charges,Implant Device,3390.45,35,,3390.45,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3293.58,34,"If Charge > 2,000, then 34 percent",3293.58,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,7168.4,
ZIMMER 6624-65-360-REV BONE SCREW,C1713,HCPCS,,79003034,CDM,278,RC,,,both,,,450,333,,,333,Other,150% of Medicare + 9.63% HCRA Surcharge,202.5,45,,202.5,percent of total billed charges,Critical Access Hospital RCC factor,153,34,,153,percent of total billed charges,Implant Device,153,34,,153,percent of total billed charges,Implant Device,153,34,,153,percent of total billed charges,Implant Device,153,34,,153,percent of total billed charges,Implant Device,153,34,,153,percent of total billed charges,Implant Device,222.75,,,222.75,Other,110% of Medicare,157.5,35,,157.5,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,157.5,35,,157.5,percent of total billed charges,Implant Device,157.5,35,,157.5,percent of total billed charges,Implant Device,157.5,35,,157.5,percent of total billed charges,Implant Device,157.5,35,,157.5,percent of total billed charges,Implant Device,157.5,35,,157.5,percent of total billed charges,Implant Device,180,40,,180,percent of total billed charges,Implant Device,157.5,70,,157.5,percent of total billed charges,All Other,153,34,,153,percent of total billed charges,Implant Device,153,34,,153,percent of total billed charges,Implant Device,157.5,35,,157.5,percent of total billed charges,Implant Device,157.5,35,,157.5,percent of total billed charges,Implant Device,157.5,35,,157.5,percent of total billed charges,Implant Device,157.5,35,,157.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,333,
ZIMMER 00-8757-056-02-REV SHELL,C1776,HCPCS,,79003035,CDM,278,RC,,,both,,,9203,6810.24,,,6810.24,Other,150% of Medicare + 9.63% HCRA Surcharge,4141.35,45,,4141.35,percent of total billed charges,Critical Access Hospital RCC factor,3129.02,34,,3129.02,percent of total billed charges,Implant Device,3129.02,34,,3129.02,percent of total billed charges,Implant Device,3129.02,34,,3129.02,percent of total billed charges,Implant Device,3129.02,34,,3129.02,percent of total billed charges,Implant Device,3129.02,34,,3129.02,percent of total billed charges,Implant Device,4555.49,,,4555.49,Other,110% of Medicare,3221.05,35,,3221.05,percent of total billed charges,Implant Device,3129.02,34,"Charges > $500, x 34%",3129.02,percent of total billed charges,Implant Device,3221.05,35,,3221.05,percent of total billed charges,Implant Device,3221.05,35,,3221.05,percent of total billed charges,Implant Device,3221.05,35,,3221.05,percent of total billed charges,Implant Device,3221.05,35,,3221.05,percent of total billed charges,Implant Device,3221.05,35,,3221.05,percent of total billed charges,Implant Device,3681.2,40,,3681.2,percent of total billed charges,Implant Device,3221.05,70,,3221.05,percent of total billed charges,All Other,3129.02,34,,3129.02,percent of total billed charges,Implant Device,3129.02,34,,3129.02,percent of total billed charges,Implant Device,3221.05,35,,3221.05,percent of total billed charges,Implant Device,3221.05,35,,3221.05,percent of total billed charges,Implant Device,3221.05,35,,3221.05,percent of total billed charges,Implant Device,3221.05,35,,3221.05,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3129.02,34,"If Charge > 2,000, then 34 percent",3129.02,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,6810.24,
ZIMMER 00-4894-05-20-REV ACETAB AUGMENT,C1776,HCPCS,,79003036,CDM,278,RC,,,both,,,8370,6193.82,,,6193.82,Other,150% of Medicare + 9.63% HCRA Surcharge,3766.5,45,,3766.5,percent of total billed charges,Critical Access Hospital RCC factor,2845.8,34,,2845.8,percent of total billed charges,Implant Device,2845.8,34,,2845.8,percent of total billed charges,Implant Device,2845.8,34,,2845.8,percent of total billed charges,Implant Device,2845.8,34,,2845.8,percent of total billed charges,Implant Device,2845.8,34,,2845.8,percent of total billed charges,Implant Device,4143.15,,,4143.15,Other,110% of Medicare,2929.5,35,,2929.5,percent of total billed charges,Implant Device,2845.8,34,"Charges > $500, x 34%",2845.8,percent of total billed charges,Implant Device,2929.5,35,,2929.5,percent of total billed charges,Implant Device,2929.5,35,,2929.5,percent of total billed charges,Implant Device,2929.5,35,,2929.5,percent of total billed charges,Implant Device,2929.5,35,,2929.5,percent of total billed charges,Implant Device,2929.5,35,,2929.5,percent of total billed charges,Implant Device,3348,40,,3348,percent of total billed charges,Implant Device,2929.5,70,,2929.5,percent of total billed charges,All Other,2845.8,34,,2845.8,percent of total billed charges,Implant Device,2845.8,34,,2845.8,percent of total billed charges,Implant Device,2929.5,35,,2929.5,percent of total billed charges,Implant Device,2929.5,35,,2929.5,percent of total billed charges,Implant Device,2929.5,35,,2929.5,percent of total billed charges,Implant Device,2929.5,35,,2929.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2845.8,34,"If Charge > 2,000, then 34 percent",2845.8,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,6193.82,
ZIMMER 00-8752-012-36-REV LINER,C1776,HCPCS,,79003037,CDM,278,RC,,,both,,,4973,3680.03,,,3680.03,Other,150% of Medicare + 9.63% HCRA Surcharge,2237.85,45,,2237.85,percent of total billed charges,Critical Access Hospital RCC factor,1690.82,34,,1690.82,percent of total billed charges,Implant Device,1690.82,34,,1690.82,percent of total billed charges,Implant Device,1690.82,34,,1690.82,percent of total billed charges,Implant Device,1690.82,34,,1690.82,percent of total billed charges,Implant Device,1690.82,34,,1690.82,percent of total billed charges,Implant Device,2461.64,,,2461.64,Other,110% of Medicare,1740.55,35,,1740.55,percent of total billed charges,Implant Device,1690.82,34,"Charges > $500, x 34%",1690.82,percent of total billed charges,Implant Device,1740.55,35,,1740.55,percent of total billed charges,Implant Device,1740.55,35,,1740.55,percent of total billed charges,Implant Device,1740.55,35,,1740.55,percent of total billed charges,Implant Device,1740.55,35,,1740.55,percent of total billed charges,Implant Device,1740.55,35,,1740.55,percent of total billed charges,Implant Device,1989.2,40,,1989.2,percent of total billed charges,Implant Device,1740.55,70,,1740.55,percent of total billed charges,All Other,1690.82,34,,1690.82,percent of total billed charges,Implant Device,1690.82,34,,1690.82,percent of total billed charges,Implant Device,1740.55,35,,1740.55,percent of total billed charges,Implant Device,1740.55,35,,1740.55,percent of total billed charges,Implant Device,1740.55,35,,1740.55,percent of total billed charges,Implant Device,1740.55,35,,1740.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1690.82,34,"If Charge > 2,000, then 34 percent",1690.82,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3680.03,
STRYKER 6570-0-136-REV FEMORAL HEAD,C1776,HCPCS,,79003039,CDM,278,RC,,,both,,,2503,1852.23,,,1852.23,Other,150% of Medicare + 9.63% HCRA Surcharge,1126.35,45,,1126.35,percent of total billed charges,Critical Access Hospital RCC factor,851.02,34,,851.02,percent of total billed charges,Implant Device,851.02,34,,851.02,percent of total billed charges,Implant Device,851.02,34,,851.02,percent of total billed charges,Implant Device,851.02,34,,851.02,percent of total billed charges,Implant Device,851.02,34,,851.02,percent of total billed charges,Implant Device,1238.99,,,1238.99,Other,110% of Medicare,876.05,35,,876.05,percent of total billed charges,Implant Device,851.02,34,"Charges > $500, x 34%",851.02,percent of total billed charges,Implant Device,876.05,35,,876.05,percent of total billed charges,Implant Device,876.05,35,,876.05,percent of total billed charges,Implant Device,876.05,35,,876.05,percent of total billed charges,Implant Device,876.05,35,,876.05,percent of total billed charges,Implant Device,876.05,35,,876.05,percent of total billed charges,Implant Device,1001.2,40,,1001.2,percent of total billed charges,Implant Device,876.05,70,,876.05,percent of total billed charges,All Other,851.02,34,,851.02,percent of total billed charges,Implant Device,851.02,34,,851.02,percent of total billed charges,Implant Device,876.05,35,,876.05,percent of total billed charges,Implant Device,876.05,35,,876.05,percent of total billed charges,Implant Device,876.05,35,,876.05,percent of total billed charges,Implant Device,876.05,35,,876.05,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,851.02,34,"If Charge > 2,000, then 34 percent",851.02,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1852.23,
STRYKER 6570-0-236-REV FEMORAL HEAD,C1776,HCPCS,,79003040,CDM,278,RC,,,both,,,2503,1852.23,,,1852.23,Other,150% of Medicare + 9.63% HCRA Surcharge,1126.35,45,,1126.35,percent of total billed charges,Critical Access Hospital RCC factor,851.02,34,,851.02,percent of total billed charges,Implant Device,851.02,34,,851.02,percent of total billed charges,Implant Device,851.02,34,,851.02,percent of total billed charges,Implant Device,851.02,34,,851.02,percent of total billed charges,Implant Device,851.02,34,,851.02,percent of total billed charges,Implant Device,1238.99,,,1238.99,Other,110% of Medicare,876.05,35,,876.05,percent of total billed charges,Implant Device,851.02,34,"Charges > $500, x 34%",851.02,percent of total billed charges,Implant Device,876.05,35,,876.05,percent of total billed charges,Implant Device,876.05,35,,876.05,percent of total billed charges,Implant Device,876.05,35,,876.05,percent of total billed charges,Implant Device,876.05,35,,876.05,percent of total billed charges,Implant Device,876.05,35,,876.05,percent of total billed charges,Implant Device,1001.2,40,,1001.2,percent of total billed charges,Implant Device,876.05,70,,876.05,percent of total billed charges,All Other,851.02,34,,851.02,percent of total billed charges,Implant Device,851.02,34,,851.02,percent of total billed charges,Implant Device,876.05,35,,876.05,percent of total billed charges,Implant Device,876.05,35,,876.05,percent of total billed charges,Implant Device,876.05,35,,876.05,percent of total billed charges,Implant Device,876.05,35,,876.05,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,851.02,34,"If Charge > 2,000, then 34 percent",851.02,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1852.23,
BIOTRONIK 365500 LINOX LEAD 65/15,C1895,HCPCS,,79003043,CDM,278,RC,,,both,,,12600,9324.03,,,9324.03,Other,150% of Medicare + 9.63% HCRA Surcharge,5670,45,,5670,percent of total billed charges,Critical Access Hospital RCC factor,4284,34,,4284,percent of total billed charges,Implant Device,4284,34,,4284,percent of total billed charges,Implant Device,4284,34,,4284,percent of total billed charges,Implant Device,4284,34,,4284,percent of total billed charges,Implant Device,4284,34,,4284,percent of total billed charges,Implant Device,6237,,,6237,Other,110% of Medicare,4410,35,,4410,percent of total billed charges,Implant Device,4284,34,"Charges > $500, x 34%",4284,percent of total billed charges,Implant Device,4410,35,,4410,percent of total billed charges,Implant Device,4410,35,,4410,percent of total billed charges,Implant Device,4410,35,,4410,percent of total billed charges,Implant Device,4410,35,,4410,percent of total billed charges,Implant Device,4410,35,,4410,percent of total billed charges,Implant Device,5040,40,,5040,percent of total billed charges,Implant Device,4410,70,,4410,percent of total billed charges,All Other,4284,34,,4284,percent of total billed charges,Implant Device,4284,34,,4284,percent of total billed charges,Implant Device,4410,35,,4410,percent of total billed charges,Implant Device,4410,35,,4410,percent of total billed charges,Implant Device,4410,35,,4410,percent of total billed charges,Implant Device,4410,35,,4410,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,4284,34,"If Charge > 2,000, then 34 percent",4284,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,9324.03,
BIOTRONIK 365501 LINOX LEAD 65/17,C1895,HCPCS,,79003044,CDM,278,RC,,,both,,,12702,9399.51,,,9399.51,Other,150% of Medicare + 9.63% HCRA Surcharge,5715.9,45,,5715.9,percent of total billed charges,Critical Access Hospital RCC factor,4318.68,34,,4318.68,percent of total billed charges,Implant Device,4318.68,34,,4318.68,percent of total billed charges,Implant Device,4318.68,34,,4318.68,percent of total billed charges,Implant Device,4318.68,34,,4318.68,percent of total billed charges,Implant Device,4318.68,34,,4318.68,percent of total billed charges,Implant Device,6287.49,,,6287.49,Other,110% of Medicare,4445.7,35,,4445.7,percent of total billed charges,Implant Device,4318.68,34,"Charges > $500, x 34%",4318.68,percent of total billed charges,Implant Device,4445.7,35,,4445.7,percent of total billed charges,Implant Device,4445.7,35,,4445.7,percent of total billed charges,Implant Device,4445.7,35,,4445.7,percent of total billed charges,Implant Device,4445.7,35,,4445.7,percent of total billed charges,Implant Device,4445.7,35,,4445.7,percent of total billed charges,Implant Device,5080.8,40,,5080.8,percent of total billed charges,Implant Device,4445.7,70,,4445.7,percent of total billed charges,All Other,4318.68,34,,4318.68,percent of total billed charges,Implant Device,4318.68,34,,4318.68,percent of total billed charges,Implant Device,4445.7,35,,4445.7,percent of total billed charges,Implant Device,4445.7,35,,4445.7,percent of total billed charges,Implant Device,4445.7,35,,4445.7,percent of total billed charges,Implant Device,4445.7,35,,4445.7,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,4318.68,34,"If Charge > 2,000, then 34 percent",4318.68,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,9399.51,
EXACTECH 320-15-01 GLENOID PLATE,C1776,HCPCS,,79003047,CDM,278,RC,,,both,,,5374,3976.77,,,3976.77,Other,150% of Medicare + 9.63% HCRA Surcharge,2418.3,45,,2418.3,percent of total billed charges,Critical Access Hospital RCC factor,1827.16,34,,1827.16,percent of total billed charges,Implant Device,1827.16,34,,1827.16,percent of total billed charges,Implant Device,1827.16,34,,1827.16,percent of total billed charges,Implant Device,1827.16,34,,1827.16,percent of total billed charges,Implant Device,1827.16,34,,1827.16,percent of total billed charges,Implant Device,2660.13,,,2660.13,Other,110% of Medicare,1880.9,35,,1880.9,percent of total billed charges,Implant Device,1827.16,34,"Charges > $500, x 34%",1827.16,percent of total billed charges,Implant Device,1880.9,35,,1880.9,percent of total billed charges,Implant Device,1880.9,35,,1880.9,percent of total billed charges,Implant Device,1880.9,35,,1880.9,percent of total billed charges,Implant Device,1880.9,35,,1880.9,percent of total billed charges,Implant Device,1880.9,35,,1880.9,percent of total billed charges,Implant Device,2149.6,40,,2149.6,percent of total billed charges,Implant Device,1880.9,70,,1880.9,percent of total billed charges,All Other,1827.16,34,,1827.16,percent of total billed charges,Implant Device,1827.16,34,,1827.16,percent of total billed charges,Implant Device,1880.9,35,,1880.9,percent of total billed charges,Implant Device,1880.9,35,,1880.9,percent of total billed charges,Implant Device,1880.9,35,,1880.9,percent of total billed charges,Implant Device,1880.9,35,,1880.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1827.16,34,"If Charge > 2,000, then 34 percent",1827.16,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3976.77,
EXACTECH 320-20-334 COMPRESSION SCREW 34,C1713,HCPCS,,79003048,CDM,278,RC,,,both,,,406,300.44,,,300.44,Other,150% of Medicare + 9.63% HCRA Surcharge,182.7,45,,182.7,percent of total billed charges,Critical Access Hospital RCC factor,138.04,34,,138.04,percent of total billed charges,Implant Device,138.04,34,,138.04,percent of total billed charges,Implant Device,138.04,34,,138.04,percent of total billed charges,Implant Device,138.04,34,,138.04,percent of total billed charges,Implant Device,138.04,34,,138.04,percent of total billed charges,Implant Device,200.97,,,200.97,Other,110% of Medicare,142.1,35,,142.1,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,142.1,35,,142.1,percent of total billed charges,Implant Device,142.1,35,,142.1,percent of total billed charges,Implant Device,142.1,35,,142.1,percent of total billed charges,Implant Device,142.1,35,,142.1,percent of total billed charges,Implant Device,142.1,35,,142.1,percent of total billed charges,Implant Device,162.4,40,,162.4,percent of total billed charges,Implant Device,142.1,70,,142.1,percent of total billed charges,All Other,138.04,34,,138.04,percent of total billed charges,Implant Device,138.04,34,,138.04,percent of total billed charges,Implant Device,142.1,35,,142.1,percent of total billed charges,Implant Device,142.1,35,,142.1,percent of total billed charges,Implant Device,142.1,35,,142.1,percent of total billed charges,Implant Device,142.1,35,,142.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,300.44,
EXACTECH 320-20-30 COMPRESSION SCREW 30,C1713,HCPCS,,79003049,CDM,278,RC,,,both,,,406,300.44,,,300.44,Other,150% of Medicare + 9.63% HCRA Surcharge,182.7,45,,182.7,percent of total billed charges,Critical Access Hospital RCC factor,138.04,34,,138.04,percent of total billed charges,Implant Device,138.04,34,,138.04,percent of total billed charges,Implant Device,138.04,34,,138.04,percent of total billed charges,Implant Device,138.04,34,,138.04,percent of total billed charges,Implant Device,138.04,34,,138.04,percent of total billed charges,Implant Device,200.97,,,200.97,Other,110% of Medicare,142.1,35,,142.1,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,142.1,35,,142.1,percent of total billed charges,Implant Device,142.1,35,,142.1,percent of total billed charges,Implant Device,142.1,35,,142.1,percent of total billed charges,Implant Device,142.1,35,,142.1,percent of total billed charges,Implant Device,142.1,35,,142.1,percent of total billed charges,Implant Device,162.4,40,,162.4,percent of total billed charges,Implant Device,142.1,70,,142.1,percent of total billed charges,All Other,138.04,34,,138.04,percent of total billed charges,Implant Device,138.04,34,,138.04,percent of total billed charges,Implant Device,142.1,35,,142.1,percent of total billed charges,Implant Device,142.1,35,,142.1,percent of total billed charges,Implant Device,142.1,35,,142.1,percent of total billed charges,Implant Device,142.1,35,,142.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,300.44,
EXACTECH 320-20-18 COMPRESSION SCREW 18,C1713,HCPCS,,79003050,CDM,278,RC,,,both,,,300,222,,,222,Other,150% of Medicare + 9.63% HCRA Surcharge,135,45,,135,percent of total billed charges,Critical Access Hospital RCC factor,102,34,,102,percent of total billed charges,Implant Device,102,34,,102,percent of total billed charges,Implant Device,102,34,,102,percent of total billed charges,Implant Device,102,34,,102,percent of total billed charges,Implant Device,102,34,,102,percent of total billed charges,Implant Device,148.5,,,148.5,Other,110% of Medicare,105,35,,105,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,105,35,,105,percent of total billed charges,Implant Device,105,35,,105,percent of total billed charges,Implant Device,105,35,,105,percent of total billed charges,Implant Device,105,35,,105,percent of total billed charges,Implant Device,105,35,,105,percent of total billed charges,Implant Device,120,40,,120,percent of total billed charges,Implant Device,105,70,,105,percent of total billed charges,All Other,102,34,,102,percent of total billed charges,Implant Device,102,34,,102,percent of total billed charges,Implant Device,105,35,,105,percent of total billed charges,Implant Device,105,35,,105,percent of total billed charges,Implant Device,105,35,,105,percent of total billed charges,Implant Device,105,35,,105,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,222,
EXACTECH 320-20-26 COMPRESSION SCREW 26,C1713,HCPCS,,79003051,CDM,278,RC,,,both,,,406,300.44,,,300.44,Other,150% of Medicare + 9.63% HCRA Surcharge,182.7,45,,182.7,percent of total billed charges,Critical Access Hospital RCC factor,138.04,34,,138.04,percent of total billed charges,Implant Device,138.04,34,,138.04,percent of total billed charges,Implant Device,138.04,34,,138.04,percent of total billed charges,Implant Device,138.04,34,,138.04,percent of total billed charges,Implant Device,138.04,34,,138.04,percent of total billed charges,Implant Device,200.97,,,200.97,Other,110% of Medicare,142.1,35,,142.1,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,142.1,35,,142.1,percent of total billed charges,Implant Device,142.1,35,,142.1,percent of total billed charges,Implant Device,142.1,35,,142.1,percent of total billed charges,Implant Device,142.1,35,,142.1,percent of total billed charges,Implant Device,142.1,35,,142.1,percent of total billed charges,Implant Device,162.4,40,,162.4,percent of total billed charges,Implant Device,142.1,70,,142.1,percent of total billed charges,All Other,138.04,34,,138.04,percent of total billed charges,Implant Device,138.04,34,,138.04,percent of total billed charges,Implant Device,142.1,35,,142.1,percent of total billed charges,Implant Device,142.1,35,,142.1,percent of total billed charges,Implant Device,142.1,35,,142.1,percent of total billed charges,Implant Device,142.1,35,,142.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,300.44,
EXACTECH 320-15-05 GLENOSPHERE LOCK SCRW,C1713,HCPCS,,79003052,CDM,278,RC,,,both,,,406,300.44,,,300.44,Other,150% of Medicare + 9.63% HCRA Surcharge,182.7,45,,182.7,percent of total billed charges,Critical Access Hospital RCC factor,138.04,34,,138.04,percent of total billed charges,Implant Device,138.04,34,,138.04,percent of total billed charges,Implant Device,138.04,34,,138.04,percent of total billed charges,Implant Device,138.04,34,,138.04,percent of total billed charges,Implant Device,138.04,34,,138.04,percent of total billed charges,Implant Device,200.97,,,200.97,Other,110% of Medicare,142.1,35,,142.1,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,142.1,35,,142.1,percent of total billed charges,Implant Device,142.1,35,,142.1,percent of total billed charges,Implant Device,142.1,35,,142.1,percent of total billed charges,Implant Device,142.1,35,,142.1,percent of total billed charges,Implant Device,142.1,35,,142.1,percent of total billed charges,Implant Device,162.4,40,,162.4,percent of total billed charges,Implant Device,142.1,70,,142.1,percent of total billed charges,All Other,138.04,34,,138.04,percent of total billed charges,Implant Device,138.04,34,,138.04,percent of total billed charges,Implant Device,142.1,35,,142.1,percent of total billed charges,Implant Device,142.1,35,,142.1,percent of total billed charges,Implant Device,142.1,35,,142.1,percent of total billed charges,Implant Device,142.1,35,,142.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,300.44,
EXACTECH 320-01-38 GLENOSPHERE 38MM,C1776,HCPCS,,79003053,CDM,278,RC,,,both,,,4050,2997.01,,,2997.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1822.5,45,,1822.5,percent of total billed charges,Critical Access Hospital RCC factor,1377,34,,1377,percent of total billed charges,Implant Device,1377,34,,1377,percent of total billed charges,Implant Device,1377,34,,1377,percent of total billed charges,Implant Device,1377,34,,1377,percent of total billed charges,Implant Device,1377,34,,1377,percent of total billed charges,Implant Device,2004.75,,,2004.75,Other,110% of Medicare,1417.5,35,,1417.5,percent of total billed charges,Implant Device,1377,34,"Charges > $500, x 34%",1377,percent of total billed charges,Implant Device,1417.5,35,,1417.5,percent of total billed charges,Implant Device,1417.5,35,,1417.5,percent of total billed charges,Implant Device,1417.5,35,,1417.5,percent of total billed charges,Implant Device,1417.5,35,,1417.5,percent of total billed charges,Implant Device,1417.5,35,,1417.5,percent of total billed charges,Implant Device,1620,40,,1620,percent of total billed charges,Implant Device,1417.5,70,,1417.5,percent of total billed charges,All Other,1377,34,,1377,percent of total billed charges,Implant Device,1377,34,,1377,percent of total billed charges,Implant Device,1417.5,35,,1417.5,percent of total billed charges,Implant Device,1417.5,35,,1417.5,percent of total billed charges,Implant Device,1417.5,35,,1417.5,percent of total billed charges,Implant Device,1417.5,35,,1417.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1377,34,"If Charge > 2,000, then 34 percent",1377,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2997.01,
EXACTECH 300-01-09 HUMERAL STEM 9MM,C1776,HCPCS,,79003054,CDM,278,RC,,,both,,,4425,3274.51,,,3274.51,Other,150% of Medicare + 9.63% HCRA Surcharge,1991.25,45,,1991.25,percent of total billed charges,Critical Access Hospital RCC factor,1504.5,34,,1504.5,percent of total billed charges,Implant Device,1504.5,34,,1504.5,percent of total billed charges,Implant Device,1504.5,34,,1504.5,percent of total billed charges,Implant Device,1504.5,34,,1504.5,percent of total billed charges,Implant Device,1504.5,34,,1504.5,percent of total billed charges,Implant Device,2190.38,,,2190.38,Other,110% of Medicare,1548.75,35,,1548.75,percent of total billed charges,Implant Device,1504.5,34,"Charges > $500, x 34%",1504.5,percent of total billed charges,Implant Device,1548.75,35,,1548.75,percent of total billed charges,Implant Device,1548.75,35,,1548.75,percent of total billed charges,Implant Device,1548.75,35,,1548.75,percent of total billed charges,Implant Device,1548.75,35,,1548.75,percent of total billed charges,Implant Device,1548.75,35,,1548.75,percent of total billed charges,Implant Device,1770,40,,1770,percent of total billed charges,Implant Device,1548.75,70,,1548.75,percent of total billed charges,All Other,1504.5,34,,1504.5,percent of total billed charges,Implant Device,1504.5,34,,1504.5,percent of total billed charges,Implant Device,1548.75,35,,1548.75,percent of total billed charges,Implant Device,1548.75,35,,1548.75,percent of total billed charges,Implant Device,1548.75,35,,1548.75,percent of total billed charges,Implant Device,1548.75,35,,1548.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1504.5,34,"If Charge > 2,000, then 34 percent",1504.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3274.51,
EXACTECH 320-20-00 REV TORQUE SCREW KIT,C1713,HCPCS,,79003055,CDM,278,RC,,,both,,,1404,1038.96,,,1038.96,Other,150% of Medicare + 9.63% HCRA Surcharge,631.8,45,,631.8,percent of total billed charges,Critical Access Hospital RCC factor,477.36,34,,477.36,percent of total billed charges,Implant Device,477.36,34,,477.36,percent of total billed charges,Implant Device,477.36,34,,477.36,percent of total billed charges,Implant Device,477.36,34,,477.36,percent of total billed charges,Implant Device,477.36,34,,477.36,percent of total billed charges,Implant Device,694.98,,,694.98,Other,110% of Medicare,491.4,35,,491.4,percent of total billed charges,Implant Device,477.36,34,"Charges > $500, x 34%",477.36,percent of total billed charges,Implant Device,491.4,35,,491.4,percent of total billed charges,Implant Device,491.4,35,,491.4,percent of total billed charges,Implant Device,491.4,35,,491.4,percent of total billed charges,Implant Device,491.4,35,,491.4,percent of total billed charges,Implant Device,491.4,35,,491.4,percent of total billed charges,Implant Device,561.6,40,,561.6,percent of total billed charges,Implant Device,491.4,70,,491.4,percent of total billed charges,All Other,477.36,34,,477.36,percent of total billed charges,Implant Device,477.36,34,,477.36,percent of total billed charges,Implant Device,491.4,35,,491.4,percent of total billed charges,Implant Device,491.4,35,,491.4,percent of total billed charges,Implant Device,491.4,35,,491.4,percent of total billed charges,Implant Device,491.4,35,,491.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1038.96,
EXACTECH 320-10-00 HUMERAL ADAPTOR TRAY,C1776,HCPCS,,79003056,CDM,278,RC,,,both,,,4950,3663.01,,,3663.01,Other,150% of Medicare + 9.63% HCRA Surcharge,2227.5,45,,2227.5,percent of total billed charges,Critical Access Hospital RCC factor,1683,34,,1683,percent of total billed charges,Implant Device,1683,34,,1683,percent of total billed charges,Implant Device,1683,34,,1683,percent of total billed charges,Implant Device,1683,34,,1683,percent of total billed charges,Implant Device,1683,34,,1683,percent of total billed charges,Implant Device,2450.25,,,2450.25,Other,110% of Medicare,1732.5,35,,1732.5,percent of total billed charges,Implant Device,1683,34,"Charges > $500, x 34%",1683,percent of total billed charges,Implant Device,1732.5,35,,1732.5,percent of total billed charges,Implant Device,1732.5,35,,1732.5,percent of total billed charges,Implant Device,1732.5,35,,1732.5,percent of total billed charges,Implant Device,1732.5,35,,1732.5,percent of total billed charges,Implant Device,1732.5,35,,1732.5,percent of total billed charges,Implant Device,1980,40,,1980,percent of total billed charges,Implant Device,1732.5,70,,1732.5,percent of total billed charges,All Other,1683,34,,1683,percent of total billed charges,Implant Device,1683,34,,1683,percent of total billed charges,Implant Device,1732.5,35,,1732.5,percent of total billed charges,Implant Device,1732.5,35,,1732.5,percent of total billed charges,Implant Device,1732.5,35,,1732.5,percent of total billed charges,Implant Device,1732.5,35,,1732.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1683,34,"If Charge > 2,000, then 34 percent",1683,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3663.01,
EXACTECH 320-38-00 HUMERAL LINER 38 +0MM,C1776,HCPCS,,79003057,CDM,278,RC,,,both,,,2836,2098.65,,,2098.65,Other,150% of Medicare + 9.63% HCRA Surcharge,1276.2,45,,1276.2,percent of total billed charges,Critical Access Hospital RCC factor,964.24,34,,964.24,percent of total billed charges,Implant Device,964.24,34,,964.24,percent of total billed charges,Implant Device,964.24,34,,964.24,percent of total billed charges,Implant Device,964.24,34,,964.24,percent of total billed charges,Implant Device,964.24,34,,964.24,percent of total billed charges,Implant Device,1403.82,,,1403.82,Other,110% of Medicare,992.6,35,,992.6,percent of total billed charges,Implant Device,964.24,34,"Charges > $500, x 34%",964.24,percent of total billed charges,Implant Device,992.6,35,,992.6,percent of total billed charges,Implant Device,992.6,35,,992.6,percent of total billed charges,Implant Device,992.6,35,,992.6,percent of total billed charges,Implant Device,992.6,35,,992.6,percent of total billed charges,Implant Device,992.6,35,,992.6,percent of total billed charges,Implant Device,1134.4,40,,1134.4,percent of total billed charges,Implant Device,992.6,70,,992.6,percent of total billed charges,All Other,964.24,34,,964.24,percent of total billed charges,Implant Device,964.24,34,,964.24,percent of total billed charges,Implant Device,992.6,35,,992.6,percent of total billed charges,Implant Device,992.6,35,,992.6,percent of total billed charges,Implant Device,992.6,35,,992.6,percent of total billed charges,Implant Device,992.6,35,,992.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,964.24,34,"If Charge > 2,000, then 34 percent",964.24,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2098.65,
ARTHREX AR-2324BCM SWIVELOCK 4.75X24.5,C1713,HCPCS,,79003058,CDM,278,RC,,,both,,,1716,1269.84,,,1269.84,Other,150% of Medicare + 9.63% HCRA Surcharge,772.2,45,,772.2,percent of total billed charges,Critical Access Hospital RCC factor,583.44,34,,583.44,percent of total billed charges,Implant Device,583.44,34,,583.44,percent of total billed charges,Implant Device,583.44,34,,583.44,percent of total billed charges,Implant Device,583.44,34,,583.44,percent of total billed charges,Implant Device,583.44,34,,583.44,percent of total billed charges,Implant Device,849.42,,,849.42,Other,110% of Medicare,600.6,35,,600.6,percent of total billed charges,Implant Device,583.44,34,"Charges > $500, x 34%",583.44,percent of total billed charges,Implant Device,600.6,35,,600.6,percent of total billed charges,Implant Device,600.6,35,,600.6,percent of total billed charges,Implant Device,600.6,35,,600.6,percent of total billed charges,Implant Device,600.6,35,,600.6,percent of total billed charges,Implant Device,600.6,35,,600.6,percent of total billed charges,Implant Device,686.4,40,,686.4,percent of total billed charges,Implant Device,600.6,70,,600.6,percent of total billed charges,All Other,583.44,34,,583.44,percent of total billed charges,Implant Device,583.44,34,,583.44,percent of total billed charges,Implant Device,600.6,35,,600.6,percent of total billed charges,Implant Device,600.6,35,,600.6,percent of total billed charges,Implant Device,600.6,35,,600.6,percent of total billed charges,Implant Device,600.6,35,,600.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1269.84,
ARTHREX AR-7000-28 CANN SCREW 3.75X28MM,C1713,HCPCS,,79003059,CDM,278,RC,,,both,,,858,634.92,,,634.92,Other,150% of Medicare + 9.63% HCRA Surcharge,386.1,45,,386.1,percent of total billed charges,Critical Access Hospital RCC factor,291.72,34,,291.72,percent of total billed charges,Implant Device,291.72,34,,291.72,percent of total billed charges,Implant Device,291.72,34,,291.72,percent of total billed charges,Implant Device,291.72,34,,291.72,percent of total billed charges,Implant Device,291.72,34,,291.72,percent of total billed charges,Implant Device,424.71,,,424.71,Other,110% of Medicare,300.3,35,,300.3,percent of total billed charges,Implant Device,291.72,34,"Charges > $500, x 34%",291.72,percent of total billed charges,Implant Device,300.3,35,,300.3,percent of total billed charges,Implant Device,300.3,35,,300.3,percent of total billed charges,Implant Device,300.3,35,,300.3,percent of total billed charges,Implant Device,300.3,35,,300.3,percent of total billed charges,Implant Device,300.3,35,,300.3,percent of total billed charges,Implant Device,343.2,40,,343.2,percent of total billed charges,Implant Device,300.3,70,,300.3,percent of total billed charges,All Other,291.72,34,,291.72,percent of total billed charges,Implant Device,291.72,34,,291.72,percent of total billed charges,Implant Device,300.3,35,,300.3,percent of total billed charges,Implant Device,300.3,35,,300.3,percent of total billed charges,Implant Device,300.3,35,,300.3,percent of total billed charges,Implant Device,300.3,35,,300.3,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,634.92,
ARTHREX AR-7000-32 CANN SCREW 3.75X32MM,C1713,HCPCS,,79003060,CDM,278,RC,,,both,,,858,634.92,,,634.92,Other,150% of Medicare + 9.63% HCRA Surcharge,386.1,45,,386.1,percent of total billed charges,Critical Access Hospital RCC factor,291.72,34,,291.72,percent of total billed charges,Implant Device,291.72,34,,291.72,percent of total billed charges,Implant Device,291.72,34,,291.72,percent of total billed charges,Implant Device,291.72,34,,291.72,percent of total billed charges,Implant Device,291.72,34,,291.72,percent of total billed charges,Implant Device,424.71,,,424.71,Other,110% of Medicare,300.3,35,,300.3,percent of total billed charges,Implant Device,291.72,34,"Charges > $500, x 34%",291.72,percent of total billed charges,Implant Device,300.3,35,,300.3,percent of total billed charges,Implant Device,300.3,35,,300.3,percent of total billed charges,Implant Device,300.3,35,,300.3,percent of total billed charges,Implant Device,300.3,35,,300.3,percent of total billed charges,Implant Device,300.3,35,,300.3,percent of total billed charges,Implant Device,343.2,40,,343.2,percent of total billed charges,Implant Device,300.3,70,,300.3,percent of total billed charges,All Other,291.72,34,,291.72,percent of total billed charges,Implant Device,291.72,34,,291.72,percent of total billed charges,Implant Device,300.3,35,,300.3,percent of total billed charges,Implant Device,300.3,35,,300.3,percent of total billed charges,Implant Device,300.3,35,,300.3,percent of total billed charges,Implant Device,300.3,35,,300.3,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,634.92,
ARTHREX AR-7000-34 CANN SCREW 3.75X34MM,C1713,HCPCS,,79003061,CDM,278,RC,,,both,,,858,634.92,,,634.92,Other,150% of Medicare + 9.63% HCRA Surcharge,386.1,45,,386.1,percent of total billed charges,Critical Access Hospital RCC factor,291.72,34,,291.72,percent of total billed charges,Implant Device,291.72,34,,291.72,percent of total billed charges,Implant Device,291.72,34,,291.72,percent of total billed charges,Implant Device,291.72,34,,291.72,percent of total billed charges,Implant Device,291.72,34,,291.72,percent of total billed charges,Implant Device,424.71,,,424.71,Other,110% of Medicare,300.3,35,,300.3,percent of total billed charges,Implant Device,291.72,34,"Charges > $500, x 34%",291.72,percent of total billed charges,Implant Device,300.3,35,,300.3,percent of total billed charges,Implant Device,300.3,35,,300.3,percent of total billed charges,Implant Device,300.3,35,,300.3,percent of total billed charges,Implant Device,300.3,35,,300.3,percent of total billed charges,Implant Device,300.3,35,,300.3,percent of total billed charges,Implant Device,343.2,40,,343.2,percent of total billed charges,Implant Device,300.3,70,,300.3,percent of total billed charges,All Other,291.72,34,,291.72,percent of total billed charges,Implant Device,291.72,34,,291.72,percent of total billed charges,Implant Device,300.3,35,,300.3,percent of total billed charges,Implant Device,300.3,35,,300.3,percent of total billed charges,Implant Device,300.3,35,,300.3,percent of total billed charges,Implant Device,300.3,35,,300.3,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,634.92,
ALAMO TISSUE AR652FF TIBIALIS TENDON,C1713,HCPCS,,79003065,CDM,278,RC,,,both,,,5700,4218.01,,,4218.01,Other,150% of Medicare + 9.63% HCRA Surcharge,2565,45,,2565,percent of total billed charges,Critical Access Hospital RCC factor,1938,34,,1938,percent of total billed charges,Implant Device,1938,34,,1938,percent of total billed charges,Implant Device,1938,34,,1938,percent of total billed charges,Implant Device,1938,34,,1938,percent of total billed charges,Implant Device,1938,34,,1938,percent of total billed charges,Implant Device,2821.5,,,2821.5,Other,110% of Medicare,1995,35,,1995,percent of total billed charges,Implant Device,1938,34,"Charges > $500, x 34%",1938,percent of total billed charges,Implant Device,1995,35,,1995,percent of total billed charges,Implant Device,1995,35,,1995,percent of total billed charges,Implant Device,1995,35,,1995,percent of total billed charges,Implant Device,1995,35,,1995,percent of total billed charges,Implant Device,1995,35,,1995,percent of total billed charges,Implant Device,2280,40,,2280,percent of total billed charges,Implant Device,1995,70,,1995,percent of total billed charges,All Other,1938,34,,1938,percent of total billed charges,Implant Device,1938,34,,1938,percent of total billed charges,Implant Device,1995,35,,1995,percent of total billed charges,Implant Device,1995,35,,1995,percent of total billed charges,Implant Device,1995,35,,1995,percent of total billed charges,Implant Device,1995,35,,1995,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1938,34,"If Charge > 2,000, then 34 percent",1938,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4218.01,
STRYKER 6495-9-001 TISSUE MEND 5X6,C1713,HCPCS,,79003066,CDM,278,RC,,,both,,,9137,6761.4,,,6761.4,Other,150% of Medicare + 9.63% HCRA Surcharge,4111.65,45,,4111.65,percent of total billed charges,Critical Access Hospital RCC factor,3106.58,34,,3106.58,percent of total billed charges,Implant Device,3106.58,34,,3106.58,percent of total billed charges,Implant Device,3106.58,34,,3106.58,percent of total billed charges,Implant Device,3106.58,34,,3106.58,percent of total billed charges,Implant Device,3106.58,34,,3106.58,percent of total billed charges,Implant Device,4522.82,,,4522.82,Other,110% of Medicare,3197.95,35,,3197.95,percent of total billed charges,Implant Device,3106.58,34,"Charges > $500, x 34%",3106.58,percent of total billed charges,Implant Device,3197.95,35,,3197.95,percent of total billed charges,Implant Device,3197.95,35,,3197.95,percent of total billed charges,Implant Device,3197.95,35,,3197.95,percent of total billed charges,Implant Device,3197.95,35,,3197.95,percent of total billed charges,Implant Device,3197.95,35,,3197.95,percent of total billed charges,Implant Device,3654.8,40,,3654.8,percent of total billed charges,Implant Device,3197.95,70,,3197.95,percent of total billed charges,All Other,3106.58,34,,3106.58,percent of total billed charges,Implant Device,3106.58,34,,3106.58,percent of total billed charges,Implant Device,3197.95,35,,3197.95,percent of total billed charges,Implant Device,3197.95,35,,3197.95,percent of total billed charges,Implant Device,3197.95,35,,3197.95,percent of total billed charges,Implant Device,3197.95,35,,3197.95,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3106.58,34,"If Charge > 2,000, then 34 percent",3106.58,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,6761.4,
BARD FAS07050 7X50 STRT FLAIR STENT GRAF,C1874,HCPCS,,79003156,CDM,278,RC,,,both,,,7936,5872.66,,,5872.66,Other,150% of Medicare + 9.63% HCRA Surcharge,3571.2,45,,3571.2,percent of total billed charges,Critical Access Hospital RCC factor,2698.24,34,,2698.24,percent of total billed charges,Implant Device,2698.24,34,,2698.24,percent of total billed charges,Implant Device,2698.24,34,,2698.24,percent of total billed charges,Implant Device,2698.24,34,,2698.24,percent of total billed charges,Implant Device,2698.24,34,,2698.24,percent of total billed charges,Implant Device,3928.32,,,3928.32,Other,110% of Medicare,2777.6,35,,2777.6,percent of total billed charges,Implant Device,2698.24,34,"Charges > $500, x 34%",2698.24,percent of total billed charges,Implant Device,2777.6,35,,2777.6,percent of total billed charges,Implant Device,2777.6,35,,2777.6,percent of total billed charges,Implant Device,2777.6,35,,2777.6,percent of total billed charges,Implant Device,2777.6,35,,2777.6,percent of total billed charges,Implant Device,2777.6,35,,2777.6,percent of total billed charges,Implant Device,3174.4,40,,3174.4,percent of total billed charges,Implant Device,2777.6,70,,2777.6,percent of total billed charges,All Other,2698.24,34,,2698.24,percent of total billed charges,Implant Device,2698.24,34,,2698.24,percent of total billed charges,Implant Device,2777.6,35,,2777.6,percent of total billed charges,Implant Device,2777.6,35,,2777.6,percent of total billed charges,Implant Device,2777.6,35,,2777.6,percent of total billed charges,Implant Device,2777.6,35,,2777.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2698.24,34,"If Charge > 2,000, then 34 percent",2698.24,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5872.66,
ATRIUM 85453 COVERED STENT 6X22X120,C1874,HCPCS,,79003157,CDM,278,RC,,,both,,,7546,5584.06,,,5584.06,Other,150% of Medicare + 9.63% HCRA Surcharge,3395.7,45,,3395.7,percent of total billed charges,Critical Access Hospital RCC factor,2565.64,34,,2565.64,percent of total billed charges,Implant Device,2565.64,34,,2565.64,percent of total billed charges,Implant Device,2565.64,34,,2565.64,percent of total billed charges,Implant Device,2565.64,34,,2565.64,percent of total billed charges,Implant Device,2565.64,34,,2565.64,percent of total billed charges,Implant Device,3735.27,,,3735.27,Other,110% of Medicare,2641.1,35,,2641.1,percent of total billed charges,Implant Device,2565.64,34,"Charges > $500, x 34%",2565.64,percent of total billed charges,Implant Device,2641.1,35,,2641.1,percent of total billed charges,Implant Device,2641.1,35,,2641.1,percent of total billed charges,Implant Device,2641.1,35,,2641.1,percent of total billed charges,Implant Device,2641.1,35,,2641.1,percent of total billed charges,Implant Device,2641.1,35,,2641.1,percent of total billed charges,Implant Device,3018.4,40,,3018.4,percent of total billed charges,Implant Device,2641.1,70,,2641.1,percent of total billed charges,All Other,2565.64,34,,2565.64,percent of total billed charges,Implant Device,2565.64,34,,2565.64,percent of total billed charges,Implant Device,2641.1,35,,2641.1,percent of total billed charges,Implant Device,2641.1,35,,2641.1,percent of total billed charges,Implant Device,2641.1,35,,2641.1,percent of total billed charges,Implant Device,2641.1,35,,2641.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2565.64,34,"If Charge > 2,000, then 34 percent",2565.64,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5584.06,
ATRIUM 85413 COVERED STENT 6X59X120,C1874,HCPCS,,79003158,CDM,278,RC,,,both,,,8326,6161.26,,,6161.26,Other,150% of Medicare + 9.63% HCRA Surcharge,3746.7,45,,3746.7,percent of total billed charges,Critical Access Hospital RCC factor,2830.84,34,,2830.84,percent of total billed charges,Implant Device,2830.84,34,,2830.84,percent of total billed charges,Implant Device,2830.84,34,,2830.84,percent of total billed charges,Implant Device,2830.84,34,,2830.84,percent of total billed charges,Implant Device,2830.84,34,,2830.84,percent of total billed charges,Implant Device,4121.37,,,4121.37,Other,110% of Medicare,2914.1,35,,2914.1,percent of total billed charges,Implant Device,2830.84,34,"Charges > $500, x 34%",2830.84,percent of total billed charges,Implant Device,2914.1,35,,2914.1,percent of total billed charges,Implant Device,2914.1,35,,2914.1,percent of total billed charges,Implant Device,2914.1,35,,2914.1,percent of total billed charges,Implant Device,2914.1,35,,2914.1,percent of total billed charges,Implant Device,2914.1,35,,2914.1,percent of total billed charges,Implant Device,3330.4,40,,3330.4,percent of total billed charges,Implant Device,2914.1,70,,2914.1,percent of total billed charges,All Other,2830.84,34,,2830.84,percent of total billed charges,Implant Device,2830.84,34,,2830.84,percent of total billed charges,Implant Device,2914.1,35,,2914.1,percent of total billed charges,Implant Device,2914.1,35,,2914.1,percent of total billed charges,Implant Device,2914.1,35,,2914.1,percent of total billed charges,Implant Device,2914.1,35,,2914.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2830.84,34,"If Charge > 2,000, then 34 percent",2830.84,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,6161.26,
GORE VBJ070502 VIABAHN STENT  7X5X120,C1874,HCPCS,,79003160,CDM,278,RC,,,both,,,9586,7093.66,,,7093.66,Other,150% of Medicare + 9.63% HCRA Surcharge,4313.7,45,,4313.7,percent of total billed charges,Critical Access Hospital RCC factor,3259.24,34,,3259.24,percent of total billed charges,Implant Device,3259.24,34,,3259.24,percent of total billed charges,Implant Device,3259.24,34,,3259.24,percent of total billed charges,Implant Device,3259.24,34,,3259.24,percent of total billed charges,Implant Device,3259.24,34,,3259.24,percent of total billed charges,Implant Device,4745.07,,,4745.07,Other,110% of Medicare,3355.1,35,,3355.1,percent of total billed charges,Implant Device,3259.24,34,"Charges > $500, x 34%",3259.24,percent of total billed charges,Implant Device,3355.1,35,,3355.1,percent of total billed charges,Implant Device,3355.1,35,,3355.1,percent of total billed charges,Implant Device,3355.1,35,,3355.1,percent of total billed charges,Implant Device,3355.1,35,,3355.1,percent of total billed charges,Implant Device,3355.1,35,,3355.1,percent of total billed charges,Implant Device,3834.4,40,,3834.4,percent of total billed charges,Implant Device,3355.1,70,,3355.1,percent of total billed charges,All Other,3259.24,34,,3259.24,percent of total billed charges,Implant Device,3259.24,34,,3259.24,percent of total billed charges,Implant Device,3355.1,35,,3355.1,percent of total billed charges,Implant Device,3355.1,35,,3355.1,percent of total billed charges,Implant Device,3355.1,35,,3355.1,percent of total billed charges,Implant Device,3355.1,35,,3355.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3259.24,34,"If Charge > 2,000, then 34 percent",3259.24,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,7093.66,
BOST SCI 38046-74075 7X37X75 XPRSS STENT,C1876,HCPCS,,79003162,CDM,278,RC,,,both,,,3575,2645.51,,,2645.51,Other,150% of Medicare + 9.63% HCRA Surcharge,1608.75,45,,1608.75,percent of total billed charges,Critical Access Hospital RCC factor,1215.5,34,,1215.5,percent of total billed charges,Implant Device,1215.5,34,,1215.5,percent of total billed charges,Implant Device,1215.5,34,,1215.5,percent of total billed charges,Implant Device,1215.5,34,,1215.5,percent of total billed charges,Implant Device,1215.5,34,,1215.5,percent of total billed charges,Implant Device,1769.63,,,1769.63,Other,110% of Medicare,1251.25,35,,1251.25,percent of total billed charges,Implant Device,1215.5,34,"Charges > $500, x 34%",1215.5,percent of total billed charges,Implant Device,1251.25,35,,1251.25,percent of total billed charges,Implant Device,1251.25,35,,1251.25,percent of total billed charges,Implant Device,1251.25,35,,1251.25,percent of total billed charges,Implant Device,1251.25,35,,1251.25,percent of total billed charges,Implant Device,1251.25,35,,1251.25,percent of total billed charges,Implant Device,1430,40,,1430,percent of total billed charges,Implant Device,1251.25,70,,1251.25,percent of total billed charges,All Other,1215.5,34,,1215.5,percent of total billed charges,Implant Device,1215.5,34,,1215.5,percent of total billed charges,Implant Device,1251.25,35,,1251.25,percent of total billed charges,Implant Device,1251.25,35,,1251.25,percent of total billed charges,Implant Device,1251.25,35,,1251.25,percent of total billed charges,Implant Device,1251.25,35,,1251.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1215.5,34,"If Charge > 2,000, then 34 percent",1215.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2645.51,
BOST SCI 38046-76075 7X57X75 XPRSS STENT,C1876,HCPCS,,79003163,CDM,278,RC,,,both,,,3575,2645.51,,,2645.51,Other,150% of Medicare + 9.63% HCRA Surcharge,1608.75,45,,1608.75,percent of total billed charges,Critical Access Hospital RCC factor,1215.5,34,,1215.5,percent of total billed charges,Implant Device,1215.5,34,,1215.5,percent of total billed charges,Implant Device,1215.5,34,,1215.5,percent of total billed charges,Implant Device,1215.5,34,,1215.5,percent of total billed charges,Implant Device,1215.5,34,,1215.5,percent of total billed charges,Implant Device,1769.63,,,1769.63,Other,110% of Medicare,1251.25,35,,1251.25,percent of total billed charges,Implant Device,1215.5,34,"Charges > $500, x 34%",1215.5,percent of total billed charges,Implant Device,1251.25,35,,1251.25,percent of total billed charges,Implant Device,1251.25,35,,1251.25,percent of total billed charges,Implant Device,1251.25,35,,1251.25,percent of total billed charges,Implant Device,1251.25,35,,1251.25,percent of total billed charges,Implant Device,1251.25,35,,1251.25,percent of total billed charges,Implant Device,1430,40,,1430,percent of total billed charges,Implant Device,1251.25,70,,1251.25,percent of total billed charges,All Other,1215.5,34,,1215.5,percent of total billed charges,Implant Device,1215.5,34,,1215.5,percent of total billed charges,Implant Device,1251.25,35,,1251.25,percent of total billed charges,Implant Device,1251.25,35,,1251.25,percent of total billed charges,Implant Device,1251.25,35,,1251.25,percent of total billed charges,Implant Device,1251.25,35,,1251.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1215.5,34,"If Charge > 2,000, then 34 percent",1215.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2645.51,
BOST SCI 38046-94075 9X37X75 XPRSS STENT,C1876,HCPCS,,79003164,CDM,278,RC,,,both,,,3575,2645.51,,,2645.51,Other,150% of Medicare + 9.63% HCRA Surcharge,1608.75,45,,1608.75,percent of total billed charges,Critical Access Hospital RCC factor,1215.5,34,,1215.5,percent of total billed charges,Implant Device,1215.5,34,,1215.5,percent of total billed charges,Implant Device,1215.5,34,,1215.5,percent of total billed charges,Implant Device,1215.5,34,,1215.5,percent of total billed charges,Implant Device,1215.5,34,,1215.5,percent of total billed charges,Implant Device,1769.63,,,1769.63,Other,110% of Medicare,1251.25,35,,1251.25,percent of total billed charges,Implant Device,1215.5,34,"Charges > $500, x 34%",1215.5,percent of total billed charges,Implant Device,1251.25,35,,1251.25,percent of total billed charges,Implant Device,1251.25,35,,1251.25,percent of total billed charges,Implant Device,1251.25,35,,1251.25,percent of total billed charges,Implant Device,1251.25,35,,1251.25,percent of total billed charges,Implant Device,1251.25,35,,1251.25,percent of total billed charges,Implant Device,1430,40,,1430,percent of total billed charges,Implant Device,1251.25,70,,1251.25,percent of total billed charges,All Other,1215.5,34,,1215.5,percent of total billed charges,Implant Device,1215.5,34,,1215.5,percent of total billed charges,Implant Device,1251.25,35,,1251.25,percent of total billed charges,Implant Device,1251.25,35,,1251.25,percent of total billed charges,Implant Device,1251.25,35,,1251.25,percent of total billed charges,Implant Device,1251.25,35,,1251.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1215.5,34,"If Charge > 2,000, then 34 percent",1215.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2645.51,
BOST SCI 40312 14X60X75 WALLSTENT,C1876,HCPCS,,79003165,CDM,278,RC,,,both,,,3192,2362.09,,,2362.09,Other,150% of Medicare + 9.63% HCRA Surcharge,1436.4,45,,1436.4,percent of total billed charges,Critical Access Hospital RCC factor,1085.28,34,,1085.28,percent of total billed charges,Implant Device,1085.28,34,,1085.28,percent of total billed charges,Implant Device,1085.28,34,,1085.28,percent of total billed charges,Implant Device,1085.28,34,,1085.28,percent of total billed charges,Implant Device,1085.28,34,,1085.28,percent of total billed charges,Implant Device,1580.04,,,1580.04,Other,110% of Medicare,1117.2,35,,1117.2,percent of total billed charges,Implant Device,1085.28,34,"Charges > $500, x 34%",1085.28,percent of total billed charges,Implant Device,1117.2,35,,1117.2,percent of total billed charges,Implant Device,1117.2,35,,1117.2,percent of total billed charges,Implant Device,1117.2,35,,1117.2,percent of total billed charges,Implant Device,1117.2,35,,1117.2,percent of total billed charges,Implant Device,1117.2,35,,1117.2,percent of total billed charges,Implant Device,1276.8,40,,1276.8,percent of total billed charges,Implant Device,1117.2,70,,1117.2,percent of total billed charges,All Other,1085.28,34,,1085.28,percent of total billed charges,Implant Device,1085.28,34,,1085.28,percent of total billed charges,Implant Device,1117.2,35,,1117.2,percent of total billed charges,Implant Device,1117.2,35,,1117.2,percent of total billed charges,Implant Device,1117.2,35,,1117.2,percent of total billed charges,Implant Device,1117.2,35,,1117.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1085.28,34,"If Charge > 2,000, then 34 percent",1085.28,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2362.09,
BOST SCI 40313 14X90X75 WALLSTENT,C1876,HCPCS,,79003166,CDM,278,RC,,,both,,,3229,2389.47,,,2389.47,Other,150% of Medicare + 9.63% HCRA Surcharge,1453.05,45,,1453.05,percent of total billed charges,Critical Access Hospital RCC factor,1097.86,34,,1097.86,percent of total billed charges,Implant Device,1097.86,34,,1097.86,percent of total billed charges,Implant Device,1097.86,34,,1097.86,percent of total billed charges,Implant Device,1097.86,34,,1097.86,percent of total billed charges,Implant Device,1097.86,34,,1097.86,percent of total billed charges,Implant Device,1598.36,,,1598.36,Other,110% of Medicare,1130.15,35,,1130.15,percent of total billed charges,Implant Device,1097.86,34,"Charges > $500, x 34%",1097.86,percent of total billed charges,Implant Device,1130.15,35,,1130.15,percent of total billed charges,Implant Device,1130.15,35,,1130.15,percent of total billed charges,Implant Device,1130.15,35,,1130.15,percent of total billed charges,Implant Device,1130.15,35,,1130.15,percent of total billed charges,Implant Device,1130.15,35,,1130.15,percent of total billed charges,Implant Device,1291.6,40,,1291.6,percent of total billed charges,Implant Device,1130.15,70,,1130.15,percent of total billed charges,All Other,1097.86,34,,1097.86,percent of total billed charges,Implant Device,1097.86,34,,1097.86,percent of total billed charges,Implant Device,1130.15,35,,1130.15,percent of total billed charges,Implant Device,1130.15,35,,1130.15,percent of total billed charges,Implant Device,1130.15,35,,1130.15,percent of total billed charges,Implant Device,1130.15,35,,1130.15,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1097.86,34,"If Charge > 2,000, then 34 percent",1097.86,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2389.47,
BOST SCI 40331 16X40X75 WALLSTENT,C1876,HCPCS,,79003167,CDM,278,RC,,,both,,,3192,2362.09,,,2362.09,Other,150% of Medicare + 9.63% HCRA Surcharge,1436.4,45,,1436.4,percent of total billed charges,Critical Access Hospital RCC factor,1085.28,34,,1085.28,percent of total billed charges,Implant Device,1085.28,34,,1085.28,percent of total billed charges,Implant Device,1085.28,34,,1085.28,percent of total billed charges,Implant Device,1085.28,34,,1085.28,percent of total billed charges,Implant Device,1085.28,34,,1085.28,percent of total billed charges,Implant Device,1580.04,,,1580.04,Other,110% of Medicare,1117.2,35,,1117.2,percent of total billed charges,Implant Device,1085.28,34,"Charges > $500, x 34%",1085.28,percent of total billed charges,Implant Device,1117.2,35,,1117.2,percent of total billed charges,Implant Device,1117.2,35,,1117.2,percent of total billed charges,Implant Device,1117.2,35,,1117.2,percent of total billed charges,Implant Device,1117.2,35,,1117.2,percent of total billed charges,Implant Device,1117.2,35,,1117.2,percent of total billed charges,Implant Device,1276.8,40,,1276.8,percent of total billed charges,Implant Device,1117.2,70,,1117.2,percent of total billed charges,All Other,1085.28,34,,1085.28,percent of total billed charges,Implant Device,1085.28,34,,1085.28,percent of total billed charges,Implant Device,1117.2,35,,1117.2,percent of total billed charges,Implant Device,1117.2,35,,1117.2,percent of total billed charges,Implant Device,1117.2,35,,1117.2,percent of total billed charges,Implant Device,1117.2,35,,1117.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1085.28,34,"If Charge > 2,000, then 34 percent",1085.28,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2362.09,
BOST SCI 40332 16X60X75 WALLSTENT,C1876,HCPCS,,79003168,CDM,278,RC,,,both,,,3192,2362.09,,,2362.09,Other,150% of Medicare + 9.63% HCRA Surcharge,1436.4,45,,1436.4,percent of total billed charges,Critical Access Hospital RCC factor,1085.28,34,,1085.28,percent of total billed charges,Implant Device,1085.28,34,,1085.28,percent of total billed charges,Implant Device,1085.28,34,,1085.28,percent of total billed charges,Implant Device,1085.28,34,,1085.28,percent of total billed charges,Implant Device,1085.28,34,,1085.28,percent of total billed charges,Implant Device,1580.04,,,1580.04,Other,110% of Medicare,1117.2,35,,1117.2,percent of total billed charges,Implant Device,1085.28,34,"Charges > $500, x 34%",1085.28,percent of total billed charges,Implant Device,1117.2,35,,1117.2,percent of total billed charges,Implant Device,1117.2,35,,1117.2,percent of total billed charges,Implant Device,1117.2,35,,1117.2,percent of total billed charges,Implant Device,1117.2,35,,1117.2,percent of total billed charges,Implant Device,1117.2,35,,1117.2,percent of total billed charges,Implant Device,1276.8,40,,1276.8,percent of total billed charges,Implant Device,1117.2,70,,1117.2,percent of total billed charges,All Other,1085.28,34,,1085.28,percent of total billed charges,Implant Device,1085.28,34,,1085.28,percent of total billed charges,Implant Device,1117.2,35,,1117.2,percent of total billed charges,Implant Device,1117.2,35,,1117.2,percent of total billed charges,Implant Device,1117.2,35,,1117.2,percent of total billed charges,Implant Device,1117.2,35,,1117.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1085.28,34,"If Charge > 2,000, then 34 percent",1085.28,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2362.09,
BOST SCI 40333 16X90X75 WALLSTENT,C1876,HCPCS,,79003169,CDM,278,RC,,,both,,,5417,4008.59,,,4008.59,Other,150% of Medicare + 9.63% HCRA Surcharge,2437.65,45,,2437.65,percent of total billed charges,Critical Access Hospital RCC factor,1841.78,34,,1841.78,percent of total billed charges,Implant Device,1841.78,34,,1841.78,percent of total billed charges,Implant Device,1841.78,34,,1841.78,percent of total billed charges,Implant Device,1841.78,34,,1841.78,percent of total billed charges,Implant Device,1841.78,34,,1841.78,percent of total billed charges,Implant Device,2681.42,,,2681.42,Other,110% of Medicare,1895.95,35,,1895.95,percent of total billed charges,Implant Device,1841.78,34,"Charges > $500, x 34%",1841.78,percent of total billed charges,Implant Device,1895.95,35,,1895.95,percent of total billed charges,Implant Device,1895.95,35,,1895.95,percent of total billed charges,Implant Device,1895.95,35,,1895.95,percent of total billed charges,Implant Device,1895.95,35,,1895.95,percent of total billed charges,Implant Device,1895.95,35,,1895.95,percent of total billed charges,Implant Device,2166.8,40,,2166.8,percent of total billed charges,Implant Device,1895.95,70,,1895.95,percent of total billed charges,All Other,1841.78,34,,1841.78,percent of total billed charges,Implant Device,1841.78,34,,1841.78,percent of total billed charges,Implant Device,1895.95,35,,1895.95,percent of total billed charges,Implant Device,1895.95,35,,1895.95,percent of total billed charges,Implant Device,1895.95,35,,1895.95,percent of total billed charges,Implant Device,1895.95,35,,1895.95,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1841.78,34,"If Charge > 2,000, then 34 percent",1841.78,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4008.59,
BOST SCI 40411 18X40X75 WALLSTENT,C1876,HCPCS,,79003170,CDM,278,RC,,,both,,,3548,2625.53,,,2625.53,Other,150% of Medicare + 9.63% HCRA Surcharge,1596.6,45,,1596.6,percent of total billed charges,Critical Access Hospital RCC factor,1206.32,34,,1206.32,percent of total billed charges,Implant Device,1206.32,34,,1206.32,percent of total billed charges,Implant Device,1206.32,34,,1206.32,percent of total billed charges,Implant Device,1206.32,34,,1206.32,percent of total billed charges,Implant Device,1206.32,34,,1206.32,percent of total billed charges,Implant Device,1756.26,,,1756.26,Other,110% of Medicare,1241.8,35,,1241.8,percent of total billed charges,Implant Device,1206.32,34,"Charges > $500, x 34%",1206.32,percent of total billed charges,Implant Device,1241.8,35,,1241.8,percent of total billed charges,Implant Device,1241.8,35,,1241.8,percent of total billed charges,Implant Device,1241.8,35,,1241.8,percent of total billed charges,Implant Device,1241.8,35,,1241.8,percent of total billed charges,Implant Device,1241.8,35,,1241.8,percent of total billed charges,Implant Device,1419.2,40,,1419.2,percent of total billed charges,Implant Device,1241.8,70,,1241.8,percent of total billed charges,All Other,1206.32,34,,1206.32,percent of total billed charges,Implant Device,1206.32,34,,1206.32,percent of total billed charges,Implant Device,1241.8,35,,1241.8,percent of total billed charges,Implant Device,1241.8,35,,1241.8,percent of total billed charges,Implant Device,1241.8,35,,1241.8,percent of total billed charges,Implant Device,1241.8,35,,1241.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1206.32,34,"If Charge > 2,000, then 34 percent",1206.32,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2625.53,
J&J C06030SL 6X30X80 SMART STENT,C1876,HCPCS,,79003171,CDM,278,RC,,,both,,,2027,1499.99,,,1499.99,Other,150% of Medicare + 9.63% HCRA Surcharge,912.15,45,,912.15,percent of total billed charges,Critical Access Hospital RCC factor,689.18,34,,689.18,percent of total billed charges,Implant Device,689.18,34,,689.18,percent of total billed charges,Implant Device,689.18,34,,689.18,percent of total billed charges,Implant Device,689.18,34,,689.18,percent of total billed charges,Implant Device,689.18,34,,689.18,percent of total billed charges,Implant Device,1003.37,,,1003.37,Other,110% of Medicare,709.45,35,,709.45,percent of total billed charges,Implant Device,689.18,34,"Charges > $500, x 34%",689.18,percent of total billed charges,Implant Device,709.45,35,,709.45,percent of total billed charges,Implant Device,709.45,35,,709.45,percent of total billed charges,Implant Device,709.45,35,,709.45,percent of total billed charges,Implant Device,709.45,35,,709.45,percent of total billed charges,Implant Device,709.45,35,,709.45,percent of total billed charges,Implant Device,810.8,40,,810.8,percent of total billed charges,Implant Device,709.45,70,,709.45,percent of total billed charges,All Other,689.18,34,,689.18,percent of total billed charges,Implant Device,689.18,34,,689.18,percent of total billed charges,Implant Device,709.45,35,,709.45,percent of total billed charges,Implant Device,709.45,35,,709.45,percent of total billed charges,Implant Device,709.45,35,,709.45,percent of total billed charges,Implant Device,709.45,35,,709.45,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,689.18,34,"If Charge > 2,000, then 34 percent",689.18,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1499.99,
J&J C07060SL 7X60X80 SMART STENT,C1876,HCPCS,,79003172,CDM,278,RC,,,both,,,2100,1554.01,,,1554.01,Other,150% of Medicare + 9.63% HCRA Surcharge,945,45,,945,percent of total billed charges,Critical Access Hospital RCC factor,714,34,,714,percent of total billed charges,Implant Device,714,34,,714,percent of total billed charges,Implant Device,714,34,,714,percent of total billed charges,Implant Device,714,34,,714,percent of total billed charges,Implant Device,714,34,,714,percent of total billed charges,Implant Device,1039.5,,,1039.5,Other,110% of Medicare,735,35,,735,percent of total billed charges,Implant Device,714,34,"Charges > $500, x 34%",714,percent of total billed charges,Implant Device,735,35,,735,percent of total billed charges,Implant Device,735,35,,735,percent of total billed charges,Implant Device,735,35,,735,percent of total billed charges,Implant Device,735,35,,735,percent of total billed charges,Implant Device,735,35,,735,percent of total billed charges,Implant Device,840,40,,840,percent of total billed charges,Implant Device,735,70,,735,percent of total billed charges,All Other,714,34,,714,percent of total billed charges,Implant Device,714,34,,714,percent of total billed charges,Implant Device,735,35,,735,percent of total billed charges,Implant Device,735,35,,735,percent of total billed charges,Implant Device,735,35,,735,percent of total billed charges,Implant Device,735,35,,735,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,714,34,"If Charge > 2,000, then 34 percent",714,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1554.01,
J&J C08030ML 8X30X120 SMART STENT,C1876,HCPCS,,79003173,CDM,278,RC,,,both,,,2027,1499.99,,,1499.99,Other,150% of Medicare + 9.63% HCRA Surcharge,912.15,45,,912.15,percent of total billed charges,Critical Access Hospital RCC factor,689.18,34,,689.18,percent of total billed charges,Implant Device,689.18,34,,689.18,percent of total billed charges,Implant Device,689.18,34,,689.18,percent of total billed charges,Implant Device,689.18,34,,689.18,percent of total billed charges,Implant Device,689.18,34,,689.18,percent of total billed charges,Implant Device,1003.37,,,1003.37,Other,110% of Medicare,709.45,35,,709.45,percent of total billed charges,Implant Device,689.18,34,"Charges > $500, x 34%",689.18,percent of total billed charges,Implant Device,709.45,35,,709.45,percent of total billed charges,Implant Device,709.45,35,,709.45,percent of total billed charges,Implant Device,709.45,35,,709.45,percent of total billed charges,Implant Device,709.45,35,,709.45,percent of total billed charges,Implant Device,709.45,35,,709.45,percent of total billed charges,Implant Device,810.8,40,,810.8,percent of total billed charges,Implant Device,709.45,70,,709.45,percent of total billed charges,All Other,689.18,34,,689.18,percent of total billed charges,Implant Device,689.18,34,,689.18,percent of total billed charges,Implant Device,709.45,35,,709.45,percent of total billed charges,Implant Device,709.45,35,,709.45,percent of total billed charges,Implant Device,709.45,35,,709.45,percent of total billed charges,Implant Device,709.45,35,,709.45,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,689.18,34,"If Charge > 2,000, then 34 percent",689.18,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1499.99,
J&J C09040SL 9X40X80 SMART STENT,C1876,HCPCS,,79003174,CDM,278,RC,,,both,,,2100,1554.01,,,1554.01,Other,150% of Medicare + 9.63% HCRA Surcharge,945,45,,945,percent of total billed charges,Critical Access Hospital RCC factor,714,34,,714,percent of total billed charges,Implant Device,714,34,,714,percent of total billed charges,Implant Device,714,34,,714,percent of total billed charges,Implant Device,714,34,,714,percent of total billed charges,Implant Device,714,34,,714,percent of total billed charges,Implant Device,1039.5,,,1039.5,Other,110% of Medicare,735,35,,735,percent of total billed charges,Implant Device,714,34,"Charges > $500, x 34%",714,percent of total billed charges,Implant Device,735,35,,735,percent of total billed charges,Implant Device,735,35,,735,percent of total billed charges,Implant Device,735,35,,735,percent of total billed charges,Implant Device,735,35,,735,percent of total billed charges,Implant Device,735,35,,735,percent of total billed charges,Implant Device,840,40,,840,percent of total billed charges,Implant Device,735,70,,735,percent of total billed charges,All Other,714,34,,714,percent of total billed charges,Implant Device,714,34,,714,percent of total billed charges,Implant Device,735,35,,735,percent of total billed charges,Implant Device,735,35,,735,percent of total billed charges,Implant Device,735,35,,735,percent of total billed charges,Implant Device,735,35,,735,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,714,34,"If Charge > 2,000, then 34 percent",714,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1554.01,
BARD ZMB08060 8X60X80 E-LUMINEXX STENT,C1876,HCPCS,,79003175,CDM,278,RC,,,both,,,3000,2220.01,,,2220.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1350,45,,1350,percent of total billed charges,Critical Access Hospital RCC factor,1020,34,,1020,percent of total billed charges,Implant Device,1020,34,,1020,percent of total billed charges,Implant Device,1020,34,,1020,percent of total billed charges,Implant Device,1020,34,,1020,percent of total billed charges,Implant Device,1020,34,,1020,percent of total billed charges,Implant Device,1485,,,1485,Other,110% of Medicare,1050,35,,1050,percent of total billed charges,Implant Device,1020,34,"Charges > $500, x 34%",1020,percent of total billed charges,Implant Device,1050,35,,1050,percent of total billed charges,Implant Device,1050,35,,1050,percent of total billed charges,Implant Device,1050,35,,1050,percent of total billed charges,Implant Device,1050,35,,1050,percent of total billed charges,Implant Device,1050,35,,1050,percent of total billed charges,Implant Device,1200,40,,1200,percent of total billed charges,Implant Device,1050,70,,1050,percent of total billed charges,All Other,1020,34,,1020,percent of total billed charges,Implant Device,1020,34,,1020,percent of total billed charges,Implant Device,1050,35,,1050,percent of total billed charges,Implant Device,1050,35,,1050,percent of total billed charges,Implant Device,1050,35,,1050,percent of total billed charges,Implant Device,1050,35,,1050,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1020,34,"If Charge > 2,000, then 34 percent",1020,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2220.01,
BARD ZMB10060 10X60X80 E-LUMINEXX STENT,C1876,HCPCS,,79003176,CDM,278,RC,,,both,,,3000,2220.01,,,2220.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1350,45,,1350,percent of total billed charges,Critical Access Hospital RCC factor,1020,34,,1020,percent of total billed charges,Implant Device,1020,34,,1020,percent of total billed charges,Implant Device,1020,34,,1020,percent of total billed charges,Implant Device,1020,34,,1020,percent of total billed charges,Implant Device,1020,34,,1020,percent of total billed charges,Implant Device,1485,,,1485,Other,110% of Medicare,1050,35,,1050,percent of total billed charges,Implant Device,1020,34,"Charges > $500, x 34%",1020,percent of total billed charges,Implant Device,1050,35,,1050,percent of total billed charges,Implant Device,1050,35,,1050,percent of total billed charges,Implant Device,1050,35,,1050,percent of total billed charges,Implant Device,1050,35,,1050,percent of total billed charges,Implant Device,1050,35,,1050,percent of total billed charges,Implant Device,1200,40,,1200,percent of total billed charges,Implant Device,1050,70,,1050,percent of total billed charges,All Other,1020,34,,1020,percent of total billed charges,Implant Device,1020,34,,1020,percent of total billed charges,Implant Device,1050,35,,1050,percent of total billed charges,Implant Device,1050,35,,1050,percent of total billed charges,Implant Device,1050,35,,1050,percent of total billed charges,Implant Device,1050,35,,1050,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1020,34,"If Charge > 2,000, then 34 percent",1020,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2220.01,
BARD EX060403CS 6X40X130 LIFESTENT,C1876,HCPCS,,79003177,CDM,278,RC,,,both,,,2850,2109.01,,,2109.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1282.5,45,,1282.5,percent of total billed charges,Critical Access Hospital RCC factor,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,1410.75,,,1410.75,Other,110% of Medicare,997.5,35,,997.5,percent of total billed charges,Implant Device,969,34,"Charges > $500, x 34%",969,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,1140,40,,1140,percent of total billed charges,Implant Device,997.5,70,,997.5,percent of total billed charges,All Other,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,969,34,"If Charge > 2,000, then 34 percent",969,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2109.01,
BARD EX060803CS 6X80X130 LIFESTENT,C1876,HCPCS,,79003178,CDM,278,RC,,,both,,,2850,2109.01,,,2109.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1282.5,45,,1282.5,percent of total billed charges,Critical Access Hospital RCC factor,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,1410.75,,,1410.75,Other,110% of Medicare,997.5,35,,997.5,percent of total billed charges,Implant Device,969,34,"Charges > $500, x 34%",969,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,1140,40,,1140,percent of total billed charges,Implant Device,997.5,70,,997.5,percent of total billed charges,All Other,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,969,34,"If Charge > 2,000, then 34 percent",969,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2109.01,
BARD EX061003CS 6X100X130 LIFESTENT,C1876,HCPCS,,79003179,CDM,278,RC,,,both,,,3150,2331.01,,,2331.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1417.5,45,,1417.5,percent of total billed charges,Critical Access Hospital RCC factor,1071,34,,1071,percent of total billed charges,Implant Device,1071,34,,1071,percent of total billed charges,Implant Device,1071,34,,1071,percent of total billed charges,Implant Device,1071,34,,1071,percent of total billed charges,Implant Device,1071,34,,1071,percent of total billed charges,Implant Device,1559.25,,,1559.25,Other,110% of Medicare,1102.5,35,,1102.5,percent of total billed charges,Implant Device,1071,34,"Charges > $500, x 34%",1071,percent of total billed charges,Implant Device,1102.5,35,,1102.5,percent of total billed charges,Implant Device,1102.5,35,,1102.5,percent of total billed charges,Implant Device,1102.5,35,,1102.5,percent of total billed charges,Implant Device,1102.5,35,,1102.5,percent of total billed charges,Implant Device,1102.5,35,,1102.5,percent of total billed charges,Implant Device,1260,40,,1260,percent of total billed charges,Implant Device,1102.5,70,,1102.5,percent of total billed charges,All Other,1071,34,,1071,percent of total billed charges,Implant Device,1071,34,,1071,percent of total billed charges,Implant Device,1102.5,35,,1102.5,percent of total billed charges,Implant Device,1102.5,35,,1102.5,percent of total billed charges,Implant Device,1102.5,35,,1102.5,percent of total billed charges,Implant Device,1102.5,35,,1102.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1071,34,"If Charge > 2,000, then 34 percent",1071,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2331.01,
BARD EX062003CL 6X200X135 LIFESTENT SOLO,C1876,HCPCS,,79003180,CDM,278,RC,,,both,,,5850,4329.01,,,4329.01,Other,150% of Medicare + 9.63% HCRA Surcharge,2632.5,45,,2632.5,percent of total billed charges,Critical Access Hospital RCC factor,1989,34,,1989,percent of total billed charges,Implant Device,1989,34,,1989,percent of total billed charges,Implant Device,1989,34,,1989,percent of total billed charges,Implant Device,1989,34,,1989,percent of total billed charges,Implant Device,1989,34,,1989,percent of total billed charges,Implant Device,2895.75,,,2895.75,Other,110% of Medicare,2047.5,35,,2047.5,percent of total billed charges,Implant Device,1989,34,"Charges > $500, x 34%",1989,percent of total billed charges,Implant Device,2047.5,35,,2047.5,percent of total billed charges,Implant Device,2047.5,35,,2047.5,percent of total billed charges,Implant Device,2047.5,35,,2047.5,percent of total billed charges,Implant Device,2047.5,35,,2047.5,percent of total billed charges,Implant Device,2047.5,35,,2047.5,percent of total billed charges,Implant Device,2340,40,,2340,percent of total billed charges,Implant Device,2047.5,70,,2047.5,percent of total billed charges,All Other,1989,34,,1989,percent of total billed charges,Implant Device,1989,34,,1989,percent of total billed charges,Implant Device,2047.5,35,,2047.5,percent of total billed charges,Implant Device,2047.5,35,,2047.5,percent of total billed charges,Implant Device,2047.5,35,,2047.5,percent of total billed charges,Implant Device,2047.5,35,,2047.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1989,34,"If Charge > 2,000, then 34 percent",1989,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4329.01,
BARD EX070403CS 7X40X130 LIFESTENT,C1876,HCPCS,,79003181,CDM,278,RC,,,both,,,2850,2109.01,,,2109.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1282.5,45,,1282.5,percent of total billed charges,Critical Access Hospital RCC factor,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,1410.75,,,1410.75,Other,110% of Medicare,997.5,35,,997.5,percent of total billed charges,Implant Device,969,34,"Charges > $500, x 34%",969,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,1140,40,,1140,percent of total billed charges,Implant Device,997.5,70,,997.5,percent of total billed charges,All Other,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,969,34,"If Charge > 2,000, then 34 percent",969,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2109.01,
BARD EX070803CS 7X80X130 LIFESTENT,C1876,HCPCS,,79003182,CDM,278,RC,,,both,,,2850,2109.01,,,2109.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1282.5,45,,1282.5,percent of total billed charges,Critical Access Hospital RCC factor,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,1410.75,,,1410.75,Other,110% of Medicare,997.5,35,,997.5,percent of total billed charges,Implant Device,969,34,"Charges > $500, x 34%",969,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,1140,40,,1140,percent of total billed charges,Implant Device,997.5,70,,997.5,percent of total billed charges,All Other,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,969,34,"If Charge > 2,000, then 34 percent",969,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2109.01,
BARD EX071003CS 7X100X130 LIFESTENT,C1876,HCPCS,,79003183,CDM,278,RC,,,both,,,3150,2331.01,,,2331.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1417.5,45,,1417.5,percent of total billed charges,Critical Access Hospital RCC factor,1071,34,,1071,percent of total billed charges,Implant Device,1071,34,,1071,percent of total billed charges,Implant Device,1071,34,,1071,percent of total billed charges,Implant Device,1071,34,,1071,percent of total billed charges,Implant Device,1071,34,,1071,percent of total billed charges,Implant Device,1559.25,,,1559.25,Other,110% of Medicare,1102.5,35,,1102.5,percent of total billed charges,Implant Device,1071,34,"Charges > $500, x 34%",1071,percent of total billed charges,Implant Device,1102.5,35,,1102.5,percent of total billed charges,Implant Device,1102.5,35,,1102.5,percent of total billed charges,Implant Device,1102.5,35,,1102.5,percent of total billed charges,Implant Device,1102.5,35,,1102.5,percent of total billed charges,Implant Device,1102.5,35,,1102.5,percent of total billed charges,Implant Device,1260,40,,1260,percent of total billed charges,Implant Device,1102.5,70,,1102.5,percent of total billed charges,All Other,1071,34,,1071,percent of total billed charges,Implant Device,1071,34,,1071,percent of total billed charges,Implant Device,1102.5,35,,1102.5,percent of total billed charges,Implant Device,1102.5,35,,1102.5,percent of total billed charges,Implant Device,1102.5,35,,1102.5,percent of total billed charges,Implant Device,1102.5,35,,1102.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1071,34,"If Charge > 2,000, then 34 percent",1071,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2331.01,
BARD EX071203CS 7X120X130 LIFESTENT,C1876,HCPCS,,79003184,CDM,278,RC,,,both,,,3150,2331.01,,,2331.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1417.5,45,,1417.5,percent of total billed charges,Critical Access Hospital RCC factor,1071,34,,1071,percent of total billed charges,Implant Device,1071,34,,1071,percent of total billed charges,Implant Device,1071,34,,1071,percent of total billed charges,Implant Device,1071,34,,1071,percent of total billed charges,Implant Device,1071,34,,1071,percent of total billed charges,Implant Device,1559.25,,,1559.25,Other,110% of Medicare,1102.5,35,,1102.5,percent of total billed charges,Implant Device,1071,34,"Charges > $500, x 34%",1071,percent of total billed charges,Implant Device,1102.5,35,,1102.5,percent of total billed charges,Implant Device,1102.5,35,,1102.5,percent of total billed charges,Implant Device,1102.5,35,,1102.5,percent of total billed charges,Implant Device,1102.5,35,,1102.5,percent of total billed charges,Implant Device,1102.5,35,,1102.5,percent of total billed charges,Implant Device,1260,40,,1260,percent of total billed charges,Implant Device,1102.5,70,,1102.5,percent of total billed charges,All Other,1071,34,,1071,percent of total billed charges,Implant Device,1071,34,,1071,percent of total billed charges,Implant Device,1102.5,35,,1102.5,percent of total billed charges,Implant Device,1102.5,35,,1102.5,percent of total billed charges,Implant Device,1102.5,35,,1102.5,percent of total billed charges,Implant Device,1102.5,35,,1102.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1071,34,"If Charge > 2,000, then 34 percent",1071,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2331.01,
BARD EX072003CL 7X200X135 LIFESTENT SOLO,C1876,HCPCS,,79003185,CDM,278,RC,,,both,,,5850,4329.01,,,4329.01,Other,150% of Medicare + 9.63% HCRA Surcharge,2632.5,45,,2632.5,percent of total billed charges,Critical Access Hospital RCC factor,1989,34,,1989,percent of total billed charges,Implant Device,1989,34,,1989,percent of total billed charges,Implant Device,1989,34,,1989,percent of total billed charges,Implant Device,1989,34,,1989,percent of total billed charges,Implant Device,1989,34,,1989,percent of total billed charges,Implant Device,2895.75,,,2895.75,Other,110% of Medicare,2047.5,35,,2047.5,percent of total billed charges,Implant Device,1989,34,"Charges > $500, x 34%",1989,percent of total billed charges,Implant Device,2047.5,35,,2047.5,percent of total billed charges,Implant Device,2047.5,35,,2047.5,percent of total billed charges,Implant Device,2047.5,35,,2047.5,percent of total billed charges,Implant Device,2047.5,35,,2047.5,percent of total billed charges,Implant Device,2047.5,35,,2047.5,percent of total billed charges,Implant Device,2340,40,,2340,percent of total billed charges,Implant Device,2047.5,70,,2047.5,percent of total billed charges,All Other,1989,34,,1989,percent of total billed charges,Implant Device,1989,34,,1989,percent of total billed charges,Implant Device,2047.5,35,,2047.5,percent of total billed charges,Implant Device,2047.5,35,,2047.5,percent of total billed charges,Implant Device,2047.5,35,,2047.5,percent of total billed charges,Implant Device,2047.5,35,,2047.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1989,34,"If Charge > 2,000, then 34 percent",1989,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4329.01,
EV3 PRB35-05-060-120 EVERFLEX STENT,C1876,HCPCS,,79003186,CDM,278,RC,,,both,,,3000,2220.01,,,2220.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1350,45,,1350,percent of total billed charges,Critical Access Hospital RCC factor,1020,34,,1020,percent of total billed charges,Implant Device,1020,34,,1020,percent of total billed charges,Implant Device,1020,34,,1020,percent of total billed charges,Implant Device,1020,34,,1020,percent of total billed charges,Implant Device,1020,34,,1020,percent of total billed charges,Implant Device,1485,,,1485,Other,110% of Medicare,1050,35,,1050,percent of total billed charges,Implant Device,1020,34,"Charges > $500, x 34%",1020,percent of total billed charges,Implant Device,1050,35,,1050,percent of total billed charges,Implant Device,1050,35,,1050,percent of total billed charges,Implant Device,1050,35,,1050,percent of total billed charges,Implant Device,1050,35,,1050,percent of total billed charges,Implant Device,1050,35,,1050,percent of total billed charges,Implant Device,1200,40,,1200,percent of total billed charges,Implant Device,1050,70,,1050,percent of total billed charges,All Other,1020,34,,1020,percent of total billed charges,Implant Device,1020,34,,1020,percent of total billed charges,Implant Device,1050,35,,1050,percent of total billed charges,Implant Device,1050,35,,1050,percent of total billed charges,Implant Device,1050,35,,1050,percent of total billed charges,Implant Device,1050,35,,1050,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1020,34,"If Charge > 2,000, then 34 percent",1020,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2220.01,
EV3 PRB35-05-100-120 EVERFLEX STENT,C1876,HCPCS,,79003187,CDM,278,RC,,,both,,,2326,1721.25,,,1721.25,Other,150% of Medicare + 9.63% HCRA Surcharge,1046.7,45,,1046.7,percent of total billed charges,Critical Access Hospital RCC factor,790.84,34,,790.84,percent of total billed charges,Implant Device,790.84,34,,790.84,percent of total billed charges,Implant Device,790.84,34,,790.84,percent of total billed charges,Implant Device,790.84,34,,790.84,percent of total billed charges,Implant Device,790.84,34,,790.84,percent of total billed charges,Implant Device,1151.37,,,1151.37,Other,110% of Medicare,814.1,35,,814.1,percent of total billed charges,Implant Device,790.84,34,"Charges > $500, x 34%",790.84,percent of total billed charges,Implant Device,814.1,35,,814.1,percent of total billed charges,Implant Device,814.1,35,,814.1,percent of total billed charges,Implant Device,814.1,35,,814.1,percent of total billed charges,Implant Device,814.1,35,,814.1,percent of total billed charges,Implant Device,814.1,35,,814.1,percent of total billed charges,Implant Device,930.4,40,,930.4,percent of total billed charges,Implant Device,814.1,70,,814.1,percent of total billed charges,All Other,790.84,34,,790.84,percent of total billed charges,Implant Device,790.84,34,,790.84,percent of total billed charges,Implant Device,814.1,35,,814.1,percent of total billed charges,Implant Device,814.1,35,,814.1,percent of total billed charges,Implant Device,814.1,35,,814.1,percent of total billed charges,Implant Device,814.1,35,,814.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,790.84,34,"If Charge > 2,000, then 34 percent",790.84,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1721.25,
EV3 PRB35-06-020-120 EVERFLEX STENT,C1876,HCPCS,,79003188,CDM,278,RC,,,both,,,1950,1443,,,1443,Other,150% of Medicare + 9.63% HCRA Surcharge,877.5,45,,877.5,percent of total billed charges,Critical Access Hospital RCC factor,663,34,,663,percent of total billed charges,Implant Device,663,34,,663,percent of total billed charges,Implant Device,663,34,,663,percent of total billed charges,Implant Device,663,34,,663,percent of total billed charges,Implant Device,663,34,,663,percent of total billed charges,Implant Device,965.25,,,965.25,Other,110% of Medicare,682.5,35,,682.5,percent of total billed charges,Implant Device,663,34,"Charges > $500, x 34%",663,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,780,40,,780,percent of total billed charges,Implant Device,682.5,70,,682.5,percent of total billed charges,All Other,663,34,,663,percent of total billed charges,Implant Device,663,34,,663,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1443,
EV3 PRB35-06-080-080 EVERFLEX STENT,C1876,HCPCS,,79003189,CDM,278,RC,,,both,,,1950,1443,,,1443,Other,150% of Medicare + 9.63% HCRA Surcharge,877.5,45,,877.5,percent of total billed charges,Critical Access Hospital RCC factor,663,34,,663,percent of total billed charges,Implant Device,663,34,,663,percent of total billed charges,Implant Device,663,34,,663,percent of total billed charges,Implant Device,663,34,,663,percent of total billed charges,Implant Device,663,34,,663,percent of total billed charges,Implant Device,965.25,,,965.25,Other,110% of Medicare,682.5,35,,682.5,percent of total billed charges,Implant Device,663,34,"Charges > $500, x 34%",663,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,780,40,,780,percent of total billed charges,Implant Device,682.5,70,,682.5,percent of total billed charges,All Other,663,34,,663,percent of total billed charges,Implant Device,663,34,,663,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1443,
EV3 PRB35-07-080-080 EVERFLEX STENT,C1876,HCPCS,,79003190,CDM,278,RC,,,both,,,1950,1443,,,1443,Other,150% of Medicare + 9.63% HCRA Surcharge,877.5,45,,877.5,percent of total billed charges,Critical Access Hospital RCC factor,663,34,,663,percent of total billed charges,Implant Device,663,34,,663,percent of total billed charges,Implant Device,663,34,,663,percent of total billed charges,Implant Device,663,34,,663,percent of total billed charges,Implant Device,663,34,,663,percent of total billed charges,Implant Device,965.25,,,965.25,Other,110% of Medicare,682.5,35,,682.5,percent of total billed charges,Implant Device,663,34,"Charges > $500, x 34%",663,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,780,40,,780,percent of total billed charges,Implant Device,682.5,70,,682.5,percent of total billed charges,All Other,663,34,,663,percent of total billed charges,Implant Device,663,34,,663,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1443,
EV3 PRB35-07-100-120 EVERFLEX STENT,C1876,HCPCS,,79003191,CDM,278,RC,,,both,,,5070,3751.81,,,3751.81,Other,150% of Medicare + 9.63% HCRA Surcharge,2281.5,45,,2281.5,percent of total billed charges,Critical Access Hospital RCC factor,1723.8,34,,1723.8,percent of total billed charges,Implant Device,1723.8,34,,1723.8,percent of total billed charges,Implant Device,1723.8,34,,1723.8,percent of total billed charges,Implant Device,1723.8,34,,1723.8,percent of total billed charges,Implant Device,1723.8,34,,1723.8,percent of total billed charges,Implant Device,2509.65,,,2509.65,Other,110% of Medicare,1774.5,35,,1774.5,percent of total billed charges,Implant Device,1723.8,34,"Charges > $500, x 34%",1723.8,percent of total billed charges,Implant Device,1774.5,35,,1774.5,percent of total billed charges,Implant Device,1774.5,35,,1774.5,percent of total billed charges,Implant Device,1774.5,35,,1774.5,percent of total billed charges,Implant Device,1774.5,35,,1774.5,percent of total billed charges,Implant Device,1774.5,35,,1774.5,percent of total billed charges,Implant Device,2028,40,,2028,percent of total billed charges,Implant Device,1774.5,70,,1774.5,percent of total billed charges,All Other,1723.8,34,,1723.8,percent of total billed charges,Implant Device,1723.8,34,,1723.8,percent of total billed charges,Implant Device,1774.5,35,,1774.5,percent of total billed charges,Implant Device,1774.5,35,,1774.5,percent of total billed charges,Implant Device,1774.5,35,,1774.5,percent of total billed charges,Implant Device,1774.5,35,,1774.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1723.8,34,"If Charge > 2,000, then 34 percent",1723.8,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3751.81,
EV3 PRB35-08-100-080 EVERFLEX STENT,C1876,HCPCS,,79003192,CDM,278,RC,,,both,,,5070,3751.81,,,3751.81,Other,150% of Medicare + 9.63% HCRA Surcharge,2281.5,45,,2281.5,percent of total billed charges,Critical Access Hospital RCC factor,1723.8,34,,1723.8,percent of total billed charges,Implant Device,1723.8,34,,1723.8,percent of total billed charges,Implant Device,1723.8,34,,1723.8,percent of total billed charges,Implant Device,1723.8,34,,1723.8,percent of total billed charges,Implant Device,1723.8,34,,1723.8,percent of total billed charges,Implant Device,2509.65,,,2509.65,Other,110% of Medicare,1774.5,35,,1774.5,percent of total billed charges,Implant Device,1723.8,34,"Charges > $500, x 34%",1723.8,percent of total billed charges,Implant Device,1774.5,35,,1774.5,percent of total billed charges,Implant Device,1774.5,35,,1774.5,percent of total billed charges,Implant Device,1774.5,35,,1774.5,percent of total billed charges,Implant Device,1774.5,35,,1774.5,percent of total billed charges,Implant Device,1774.5,35,,1774.5,percent of total billed charges,Implant Device,2028,40,,2028,percent of total billed charges,Implant Device,1774.5,70,,1774.5,percent of total billed charges,All Other,1723.8,34,,1723.8,percent of total billed charges,Implant Device,1723.8,34,,1723.8,percent of total billed charges,Implant Device,1774.5,35,,1774.5,percent of total billed charges,Implant Device,1774.5,35,,1774.5,percent of total billed charges,Implant Device,1774.5,35,,1774.5,percent of total billed charges,Implant Device,1774.5,35,,1774.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1723.8,34,"If Charge > 2,000, then 34 percent",1723.8,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3751.81,
EV3 PXB35-07-27-080 VISIPRO STENT,C1876,HCPCS,,79003193,CDM,278,RC,,,both,,,3119,2308.07,,,2308.07,Other,150% of Medicare + 9.63% HCRA Surcharge,1403.55,45,,1403.55,percent of total billed charges,Critical Access Hospital RCC factor,1060.46,34,,1060.46,percent of total billed charges,Implant Device,1060.46,34,,1060.46,percent of total billed charges,Implant Device,1060.46,34,,1060.46,percent of total billed charges,Implant Device,1060.46,34,,1060.46,percent of total billed charges,Implant Device,1060.46,34,,1060.46,percent of total billed charges,Implant Device,1543.91,,,1543.91,Other,110% of Medicare,1091.65,35,,1091.65,percent of total billed charges,Implant Device,1060.46,34,"Charges > $500, x 34%",1060.46,percent of total billed charges,Implant Device,1091.65,35,,1091.65,percent of total billed charges,Implant Device,1091.65,35,,1091.65,percent of total billed charges,Implant Device,1091.65,35,,1091.65,percent of total billed charges,Implant Device,1091.65,35,,1091.65,percent of total billed charges,Implant Device,1091.65,35,,1091.65,percent of total billed charges,Implant Device,1247.6,40,,1247.6,percent of total billed charges,Implant Device,1091.65,70,,1091.65,percent of total billed charges,All Other,1060.46,34,,1060.46,percent of total billed charges,Implant Device,1060.46,34,,1060.46,percent of total billed charges,Implant Device,1091.65,35,,1091.65,percent of total billed charges,Implant Device,1091.65,35,,1091.65,percent of total billed charges,Implant Device,1091.65,35,,1091.65,percent of total billed charges,Implant Device,1091.65,35,,1091.65,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1060.46,34,"If Charge > 2,000, then 34 percent",1060.46,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2308.07,
EV3 PXB35-07-57-080 VISIPRO STENT,C1876,HCPCS,,79003194,CDM,278,RC,,,both,,,1950,1443,,,1443,Other,150% of Medicare + 9.63% HCRA Surcharge,877.5,45,,877.5,percent of total billed charges,Critical Access Hospital RCC factor,663,34,,663,percent of total billed charges,Implant Device,663,34,,663,percent of total billed charges,Implant Device,663,34,,663,percent of total billed charges,Implant Device,663,34,,663,percent of total billed charges,Implant Device,663,34,,663,percent of total billed charges,Implant Device,965.25,,,965.25,Other,110% of Medicare,682.5,35,,682.5,percent of total billed charges,Implant Device,663,34,"Charges > $500, x 34%",663,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,780,40,,780,percent of total billed charges,Implant Device,682.5,70,,682.5,percent of total billed charges,All Other,663,34,,663,percent of total billed charges,Implant Device,663,34,,663,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1443,
EV3 PXB35-09-27-080 VISIPRO STENT,C1876,HCPCS,,79003195,CDM,278,RC,,,both,,,3119,2308.07,,,2308.07,Other,150% of Medicare + 9.63% HCRA Surcharge,1403.55,45,,1403.55,percent of total billed charges,Critical Access Hospital RCC factor,1060.46,34,,1060.46,percent of total billed charges,Implant Device,1060.46,34,,1060.46,percent of total billed charges,Implant Device,1060.46,34,,1060.46,percent of total billed charges,Implant Device,1060.46,34,,1060.46,percent of total billed charges,Implant Device,1060.46,34,,1060.46,percent of total billed charges,Implant Device,1543.91,,,1543.91,Other,110% of Medicare,1091.65,35,,1091.65,percent of total billed charges,Implant Device,1060.46,34,"Charges > $500, x 34%",1060.46,percent of total billed charges,Implant Device,1091.65,35,,1091.65,percent of total billed charges,Implant Device,1091.65,35,,1091.65,percent of total billed charges,Implant Device,1091.65,35,,1091.65,percent of total billed charges,Implant Device,1091.65,35,,1091.65,percent of total billed charges,Implant Device,1091.65,35,,1091.65,percent of total billed charges,Implant Device,1247.6,40,,1247.6,percent of total billed charges,Implant Device,1091.65,70,,1091.65,percent of total billed charges,All Other,1060.46,34,,1060.46,percent of total billed charges,Implant Device,1060.46,34,,1060.46,percent of total billed charges,Implant Device,1091.65,35,,1091.65,percent of total billed charges,Implant Device,1091.65,35,,1091.65,percent of total billed charges,Implant Device,1091.65,35,,1091.65,percent of total billed charges,Implant Device,1091.65,35,,1091.65,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1060.46,34,"If Charge > 2,000, then 34 percent",1060.46,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2308.07,
EV3 PXB35-09-37-080 VISIPRO STENT,C1876,HCPCS,,79003196,CDM,278,RC,,,both,,,1950,1443,,,1443,Other,150% of Medicare + 9.63% HCRA Surcharge,877.5,45,,877.5,percent of total billed charges,Critical Access Hospital RCC factor,663,34,,663,percent of total billed charges,Implant Device,663,34,,663,percent of total billed charges,Implant Device,663,34,,663,percent of total billed charges,Implant Device,663,34,,663,percent of total billed charges,Implant Device,663,34,,663,percent of total billed charges,Implant Device,965.25,,,965.25,Other,110% of Medicare,682.5,35,,682.5,percent of total billed charges,Implant Device,663,34,"Charges > $500, x 34%",663,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,780,40,,780,percent of total billed charges,Implant Device,682.5,70,,682.5,percent of total billed charges,All Other,663,34,,663,percent of total billed charges,Implant Device,663,34,,663,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1443,
EV3 PXB35-10-37-080 VISIPRO STENT,C1876,HCPCS,,79003197,CDM,278,RC,,,both,,,3119,2308.07,,,2308.07,Other,150% of Medicare + 9.63% HCRA Surcharge,1403.55,45,,1403.55,percent of total billed charges,Critical Access Hospital RCC factor,1060.46,34,,1060.46,percent of total billed charges,Implant Device,1060.46,34,,1060.46,percent of total billed charges,Implant Device,1060.46,34,,1060.46,percent of total billed charges,Implant Device,1060.46,34,,1060.46,percent of total billed charges,Implant Device,1060.46,34,,1060.46,percent of total billed charges,Implant Device,1543.91,,,1543.91,Other,110% of Medicare,1091.65,35,,1091.65,percent of total billed charges,Implant Device,1060.46,34,"Charges > $500, x 34%",1060.46,percent of total billed charges,Implant Device,1091.65,35,,1091.65,percent of total billed charges,Implant Device,1091.65,35,,1091.65,percent of total billed charges,Implant Device,1091.65,35,,1091.65,percent of total billed charges,Implant Device,1091.65,35,,1091.65,percent of total billed charges,Implant Device,1091.65,35,,1091.65,percent of total billed charges,Implant Device,1247.6,40,,1247.6,percent of total billed charges,Implant Device,1091.65,70,,1091.65,percent of total billed charges,All Other,1060.46,34,,1060.46,percent of total billed charges,Implant Device,1060.46,34,,1060.46,percent of total billed charges,Implant Device,1091.65,35,,1091.65,percent of total billed charges,Implant Device,1091.65,35,,1091.65,percent of total billed charges,Implant Device,1091.65,35,,1091.65,percent of total billed charges,Implant Device,1091.65,35,,1091.65,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1060.46,34,"If Charge > 2,000, then 34 percent",1060.46,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2308.07,
EV3 SERB65-12-60-80 PROTEGE STENT,C1876,HCPCS,,79003198,CDM,278,RC,,,both,,,1950,1443,,,1443,Other,150% of Medicare + 9.63% HCRA Surcharge,877.5,45,,877.5,percent of total billed charges,Critical Access Hospital RCC factor,663,34,,663,percent of total billed charges,Implant Device,663,34,,663,percent of total billed charges,Implant Device,663,34,,663,percent of total billed charges,Implant Device,663,34,,663,percent of total billed charges,Implant Device,663,34,,663,percent of total billed charges,Implant Device,965.25,,,965.25,Other,110% of Medicare,682.5,35,,682.5,percent of total billed charges,Implant Device,663,34,"Charges > $500, x 34%",663,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,780,40,,780,percent of total billed charges,Implant Device,682.5,70,,682.5,percent of total billed charges,All Other,663,34,,663,percent of total billed charges,Implant Device,663,34,,663,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1443,
EV3 SERB65-14-40-80 PROTOGE STENT,C1876,HCPCS,,79003199,CDM,278,RC,,,both,,,1950,1443,,,1443,Other,150% of Medicare + 9.63% HCRA Surcharge,877.5,45,,877.5,percent of total billed charges,Critical Access Hospital RCC factor,663,34,,663,percent of total billed charges,Implant Device,663,34,,663,percent of total billed charges,Implant Device,663,34,,663,percent of total billed charges,Implant Device,663,34,,663,percent of total billed charges,Implant Device,663,34,,663,percent of total billed charges,Implant Device,965.25,,,965.25,Other,110% of Medicare,682.5,35,,682.5,percent of total billed charges,Implant Device,663,34,"Charges > $500, x 34%",663,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,780,40,,780,percent of total billed charges,Implant Device,682.5,70,,682.5,percent of total billed charges,All Other,663,34,,663,percent of total billed charges,Implant Device,663,34,,663,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1443,
IGTCFS-65-1-FEM-CELECT COOK VENACAVAFILT,C1880,HCPCS,,79003243,CDM,278,RC,,,both,,,4260,3152.41,,,3152.41,Other,150% of Medicare + 9.63% HCRA Surcharge,1917,45,,1917,percent of total billed charges,Critical Access Hospital RCC factor,1448.4,34,,1448.4,percent of total billed charges,Implant Device,1448.4,34,,1448.4,percent of total billed charges,Implant Device,1448.4,34,,1448.4,percent of total billed charges,Implant Device,1448.4,34,,1448.4,percent of total billed charges,Implant Device,1448.4,34,,1448.4,percent of total billed charges,Implant Device,2108.7,,,2108.7,Other,110% of Medicare,1491,35,,1491,percent of total billed charges,Implant Device,1448.4,34,"Charges > $500, x 34%",1448.4,percent of total billed charges,Implant Device,1491,35,,1491,percent of total billed charges,Implant Device,1491,35,,1491,percent of total billed charges,Implant Device,1491,35,,1491,percent of total billed charges,Implant Device,1491,35,,1491,percent of total billed charges,Implant Device,1491,35,,1491,percent of total billed charges,Implant Device,1704,40,,1704,percent of total billed charges,Implant Device,1491,70,,1491,percent of total billed charges,All Other,1448.4,34,,1448.4,percent of total billed charges,Implant Device,1448.4,34,,1448.4,percent of total billed charges,Implant Device,1491,35,,1491,percent of total billed charges,Implant Device,1491,35,,1491,percent of total billed charges,Implant Device,1491,35,,1491,percent of total billed charges,Implant Device,1491,35,,1491,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1448.4,34,"If Charge > 2,000, then 34 percent",1448.4,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3152.41,
STRYKER 53-23214E BONE SCREW T7 2.3X14MM,C1713,HCPCS,,79003265,CDM,278,RC,,,both,,,344,254.56,,,254.56,Other,150% of Medicare + 9.63% HCRA Surcharge,154.8,45,,154.8,percent of total billed charges,Critical Access Hospital RCC factor,116.96,34,,116.96,percent of total billed charges,Implant Device,116.96,34,,116.96,percent of total billed charges,Implant Device,116.96,34,,116.96,percent of total billed charges,Implant Device,116.96,34,,116.96,percent of total billed charges,Implant Device,116.96,34,,116.96,percent of total billed charges,Implant Device,170.28,,,170.28,Other,110% of Medicare,120.4,35,,120.4,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,120.4,35,,120.4,percent of total billed charges,Implant Device,120.4,35,,120.4,percent of total billed charges,Implant Device,120.4,35,,120.4,percent of total billed charges,Implant Device,120.4,35,,120.4,percent of total billed charges,Implant Device,120.4,35,,120.4,percent of total billed charges,Implant Device,137.6,40,,137.6,percent of total billed charges,Implant Device,120.4,70,,120.4,percent of total billed charges,All Other,116.96,34,,116.96,percent of total billed charges,Implant Device,116.96,34,,116.96,percent of total billed charges,Implant Device,120.4,35,,120.4,percent of total billed charges,Implant Device,120.4,35,,120.4,percent of total billed charges,Implant Device,120.4,35,,120.4,percent of total billed charges,Implant Device,120.4,35,,120.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,254.56,
ARTHREX AR-8730-30PT CANN SCREW 3.0X30MM,C1713,HCPCS,,79003270,CDM,278,RC,,,both,,,450,333,,,333,Other,150% of Medicare + 9.63% HCRA Surcharge,202.5,45,,202.5,percent of total billed charges,Critical Access Hospital RCC factor,153,34,,153,percent of total billed charges,Implant Device,153,34,,153,percent of total billed charges,Implant Device,153,34,,153,percent of total billed charges,Implant Device,153,34,,153,percent of total billed charges,Implant Device,153,34,,153,percent of total billed charges,Implant Device,222.75,,,222.75,Other,110% of Medicare,157.5,35,,157.5,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,157.5,35,,157.5,percent of total billed charges,Implant Device,157.5,35,,157.5,percent of total billed charges,Implant Device,157.5,35,,157.5,percent of total billed charges,Implant Device,157.5,35,,157.5,percent of total billed charges,Implant Device,157.5,35,,157.5,percent of total billed charges,Implant Device,180,40,,180,percent of total billed charges,Implant Device,157.5,70,,157.5,percent of total billed charges,All Other,153,34,,153,percent of total billed charges,Implant Device,153,34,,153,percent of total billed charges,Implant Device,157.5,35,,157.5,percent of total billed charges,Implant Device,157.5,35,,157.5,percent of total billed charges,Implant Device,157.5,35,,157.5,percent of total billed charges,Implant Device,157.5,35,,157.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,333,
ARTHREX AR-8724-26PT CANN SCREW 2.4X26MM,C1713,HCPCS,,79003271,CDM,278,RC,,,both,,,330,244.2,,,244.2,Other,150% of Medicare + 9.63% HCRA Surcharge,148.5,45,,148.5,percent of total billed charges,Critical Access Hospital RCC factor,112.2,34,,112.2,percent of total billed charges,Implant Device,112.2,34,,112.2,percent of total billed charges,Implant Device,112.2,34,,112.2,percent of total billed charges,Implant Device,112.2,34,,112.2,percent of total billed charges,Implant Device,112.2,34,,112.2,percent of total billed charges,Implant Device,163.35,,,163.35,Other,110% of Medicare,115.5,35,,115.5,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,132,40,,132,percent of total billed charges,Implant Device,115.5,70,,115.5,percent of total billed charges,All Other,112.2,34,,112.2,percent of total billed charges,Implant Device,112.2,34,,112.2,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,244.2,
ARTHREX AR-13226 BB TAK,C1713,HCPCS,,79003272,CDM,278,RC,,,both,,,163,120.62,,,120.62,Other,150% of Medicare + 9.63% HCRA Surcharge,73.35,45,,73.35,percent of total billed charges,Critical Access Hospital RCC factor,55.42,34,,55.42,percent of total billed charges,Implant Device,55.42,34,,55.42,percent of total billed charges,Implant Device,55.42,34,,55.42,percent of total billed charges,Implant Device,55.42,34,,55.42,percent of total billed charges,Implant Device,55.42,34,,55.42,percent of total billed charges,Implant Device,80.69,,,80.69,Other,110% of Medicare,57.05,35,,57.05,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,57.05,35,,57.05,percent of total billed charges,Implant Device,57.05,35,,57.05,percent of total billed charges,Implant Device,57.05,35,,57.05,percent of total billed charges,Implant Device,57.05,35,,57.05,percent of total billed charges,Implant Device,57.05,35,,57.05,percent of total billed charges,Implant Device,65.2,40,,65.2,percent of total billed charges,Implant Device,57.05,70,,57.05,percent of total billed charges,All Other,55.42,34,,55.42,percent of total billed charges,Implant Device,55.42,34,,55.42,percent of total billed charges,Implant Device,57.05,35,,57.05,percent of total billed charges,Implant Device,57.05,35,,57.05,percent of total billed charges,Implant Device,57.05,35,,57.05,percent of total billed charges,Implant Device,57.05,35,,57.05,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,120.62,
ARTHREX AR-8941 LAPIDUS PLATE,C1713,HCPCS,,79003273,CDM,278,RC,,,both,,,1800,1332,,,1332,Other,150% of Medicare + 9.63% HCRA Surcharge,810,45,,810,percent of total billed charges,Critical Access Hospital RCC factor,612,34,,612,percent of total billed charges,Implant Device,612,34,,612,percent of total billed charges,Implant Device,612,34,,612,percent of total billed charges,Implant Device,612,34,,612,percent of total billed charges,Implant Device,612,34,,612,percent of total billed charges,Implant Device,891,,,891,Other,110% of Medicare,630,35,,630,percent of total billed charges,Implant Device,612,34,"Charges > $500, x 34%",612,percent of total billed charges,Implant Device,630,35,,630,percent of total billed charges,Implant Device,630,35,,630,percent of total billed charges,Implant Device,630,35,,630,percent of total billed charges,Implant Device,630,35,,630,percent of total billed charges,Implant Device,630,35,,630,percent of total billed charges,Implant Device,720,40,,720,percent of total billed charges,Implant Device,630,70,,630,percent of total billed charges,All Other,612,34,,612,percent of total billed charges,Implant Device,612,34,,612,percent of total billed charges,Implant Device,630,35,,630,percent of total billed charges,Implant Device,630,35,,630,percent of total billed charges,Implant Device,630,35,,630,percent of total billed charges,Implant Device,630,35,,630,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1332,
STRYKER 40-35020 BONE SCREW 3.5X20MM,C1713,HCPCS,,79003283,CDM,278,RC,,,both,,,192,142.08,,,142.08,Other,150% of Medicare + 9.63% HCRA Surcharge,86.4,45,,86.4,percent of total billed charges,Critical Access Hospital RCC factor,65.28,34,,65.28,percent of total billed charges,Implant Device,65.28,34,,65.28,percent of total billed charges,Implant Device,65.28,34,,65.28,percent of total billed charges,Implant Device,65.28,34,,65.28,percent of total billed charges,Implant Device,65.28,34,,65.28,percent of total billed charges,Implant Device,95.04,,,95.04,Other,110% of Medicare,67.2,35,,67.2,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,67.2,35,,67.2,percent of total billed charges,Implant Device,67.2,35,,67.2,percent of total billed charges,Implant Device,67.2,35,,67.2,percent of total billed charges,Implant Device,67.2,35,,67.2,percent of total billed charges,Implant Device,67.2,35,,67.2,percent of total billed charges,Implant Device,76.8,40,,76.8,percent of total billed charges,Implant Device,67.2,70,,67.2,percent of total billed charges,All Other,65.28,34,,65.28,percent of total billed charges,Implant Device,65.28,34,,65.28,percent of total billed charges,Implant Device,67.2,35,,67.2,percent of total billed charges,Implant Device,67.2,35,,67.2,percent of total billed charges,Implant Device,67.2,35,,67.2,percent of total billed charges,Implant Device,67.2,35,,67.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,142.08,
STRYKER 40-35018 BONE SCREW 3.5X18MM,C1713,HCPCS,,79003284,CDM,278,RC,,,both,,,232,171.68,,,171.68,Other,150% of Medicare + 9.63% HCRA Surcharge,104.4,45,,104.4,percent of total billed charges,Critical Access Hospital RCC factor,78.88,34,,78.88,percent of total billed charges,Implant Device,78.88,34,,78.88,percent of total billed charges,Implant Device,78.88,34,,78.88,percent of total billed charges,Implant Device,78.88,34,,78.88,percent of total billed charges,Implant Device,78.88,34,,78.88,percent of total billed charges,Implant Device,114.84,,,114.84,Other,110% of Medicare,81.2,35,,81.2,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,81.2,35,,81.2,percent of total billed charges,Implant Device,81.2,35,,81.2,percent of total billed charges,Implant Device,81.2,35,,81.2,percent of total billed charges,Implant Device,81.2,35,,81.2,percent of total billed charges,Implant Device,81.2,35,,81.2,percent of total billed charges,Implant Device,92.8,40,,92.8,percent of total billed charges,Implant Device,81.2,70,,81.2,percent of total billed charges,All Other,78.88,34,,78.88,percent of total billed charges,Implant Device,78.88,34,,78.88,percent of total billed charges,Implant Device,81.2,35,,81.2,percent of total billed charges,Implant Device,81.2,35,,81.2,percent of total billed charges,Implant Device,81.2,35,,81.2,percent of total billed charges,Implant Device,81.2,35,,81.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,171.68,
STRYKER 40-35012 BONE SCREW 3.5X12MM,C1713,HCPCS,,79003285,CDM,278,RC,,,both,,,192,142.08,,,142.08,Other,150% of Medicare + 9.63% HCRA Surcharge,86.4,45,,86.4,percent of total billed charges,Critical Access Hospital RCC factor,65.28,34,,65.28,percent of total billed charges,Implant Device,65.28,34,,65.28,percent of total billed charges,Implant Device,65.28,34,,65.28,percent of total billed charges,Implant Device,65.28,34,,65.28,percent of total billed charges,Implant Device,65.28,34,,65.28,percent of total billed charges,Implant Device,95.04,,,95.04,Other,110% of Medicare,67.2,35,,67.2,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,67.2,35,,67.2,percent of total billed charges,Implant Device,67.2,35,,67.2,percent of total billed charges,Implant Device,67.2,35,,67.2,percent of total billed charges,Implant Device,67.2,35,,67.2,percent of total billed charges,Implant Device,67.2,35,,67.2,percent of total billed charges,Implant Device,76.8,40,,76.8,percent of total billed charges,Implant Device,67.2,70,,67.2,percent of total billed charges,All Other,65.28,34,,65.28,percent of total billed charges,Implant Device,65.28,34,,65.28,percent of total billed charges,Implant Device,67.2,35,,67.2,percent of total billed charges,Implant Device,67.2,35,,67.2,percent of total billed charges,Implant Device,67.2,35,,67.2,percent of total billed charges,Implant Device,67.2,35,,67.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,142.08,
STRYKER 40-35014 LOCKING SCREW 3.5X14MM,C1713,HCPCS,,79003286,CDM,278,RC,,,both,,,192,142.08,,,142.08,Other,150% of Medicare + 9.63% HCRA Surcharge,86.4,45,,86.4,percent of total billed charges,Critical Access Hospital RCC factor,65.28,34,,65.28,percent of total billed charges,Implant Device,65.28,34,,65.28,percent of total billed charges,Implant Device,65.28,34,,65.28,percent of total billed charges,Implant Device,65.28,34,,65.28,percent of total billed charges,Implant Device,65.28,34,,65.28,percent of total billed charges,Implant Device,95.04,,,95.04,Other,110% of Medicare,67.2,35,,67.2,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,67.2,35,,67.2,percent of total billed charges,Implant Device,67.2,35,,67.2,percent of total billed charges,Implant Device,67.2,35,,67.2,percent of total billed charges,Implant Device,67.2,35,,67.2,percent of total billed charges,Implant Device,67.2,35,,67.2,percent of total billed charges,Implant Device,76.8,40,,76.8,percent of total billed charges,Implant Device,67.2,70,,67.2,percent of total billed charges,All Other,65.28,34,,65.28,percent of total billed charges,Implant Device,65.28,34,,65.28,percent of total billed charges,Implant Device,67.2,35,,67.2,percent of total billed charges,Implant Device,67.2,35,,67.2,percent of total billed charges,Implant Device,67.2,35,,67.2,percent of total billed charges,Implant Device,67.2,35,,67.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,142.08,
STRYKER 40-35612 LOCKING SCREW 3.5X12MM,C1713,HCPCS,,79003287,CDM,278,RC,,,both,,,379,280.46,,,280.46,Other,150% of Medicare + 9.63% HCRA Surcharge,170.55,45,,170.55,percent of total billed charges,Critical Access Hospital RCC factor,128.86,34,,128.86,percent of total billed charges,Implant Device,128.86,34,,128.86,percent of total billed charges,Implant Device,128.86,34,,128.86,percent of total billed charges,Implant Device,128.86,34,,128.86,percent of total billed charges,Implant Device,128.86,34,,128.86,percent of total billed charges,Implant Device,187.61,,,187.61,Other,110% of Medicare,132.65,35,,132.65,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,132.65,35,,132.65,percent of total billed charges,Implant Device,132.65,35,,132.65,percent of total billed charges,Implant Device,132.65,35,,132.65,percent of total billed charges,Implant Device,132.65,35,,132.65,percent of total billed charges,Implant Device,132.65,35,,132.65,percent of total billed charges,Implant Device,151.6,40,,151.6,percent of total billed charges,Implant Device,132.65,70,,132.65,percent of total billed charges,All Other,128.86,34,,128.86,percent of total billed charges,Implant Device,128.86,34,,128.86,percent of total billed charges,Implant Device,132.65,35,,132.65,percent of total billed charges,Implant Device,132.65,35,,132.65,percent of total billed charges,Implant Device,132.65,35,,132.65,percent of total billed charges,Implant Device,132.65,35,,132.65,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,280.46,
STRYKER 604650 CANNULATED SCREW 4X50,C1713,HCPCS,,79003289,CDM,278,RC,,,both,,,480,355.2,,,355.2,Other,150% of Medicare + 9.63% HCRA Surcharge,216,45,,216,percent of total billed charges,Critical Access Hospital RCC factor,163.2,34,,163.2,percent of total billed charges,Implant Device,163.2,34,,163.2,percent of total billed charges,Implant Device,163.2,34,,163.2,percent of total billed charges,Implant Device,163.2,34,,163.2,percent of total billed charges,Implant Device,163.2,34,,163.2,percent of total billed charges,Implant Device,237.6,,,237.6,Other,110% of Medicare,168,35,,168,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,192,40,,192,percent of total billed charges,Implant Device,168,70,,168,percent of total billed charges,All Other,163.2,34,,163.2,percent of total billed charges,Implant Device,163.2,34,,163.2,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,355.2,
STRYKER 40-20906 FIBULA PLATE 6 HOLE,C1713,HCPCS,,79003290,CDM,278,RC,,,both,,,1781,1317.94,,,1317.94,Other,150% of Medicare + 9.63% HCRA Surcharge,801.45,45,,801.45,percent of total billed charges,Critical Access Hospital RCC factor,605.54,34,,605.54,percent of total billed charges,Implant Device,605.54,34,,605.54,percent of total billed charges,Implant Device,605.54,34,,605.54,percent of total billed charges,Implant Device,605.54,34,,605.54,percent of total billed charges,Implant Device,605.54,34,,605.54,percent of total billed charges,Implant Device,881.6,,,881.6,Other,110% of Medicare,623.35,35,,623.35,percent of total billed charges,Implant Device,605.54,34,"Charges > $500, x 34%",605.54,percent of total billed charges,Implant Device,623.35,35,,623.35,percent of total billed charges,Implant Device,623.35,35,,623.35,percent of total billed charges,Implant Device,623.35,35,,623.35,percent of total billed charges,Implant Device,623.35,35,,623.35,percent of total billed charges,Implant Device,623.35,35,,623.35,percent of total billed charges,Implant Device,712.4,40,,712.4,percent of total billed charges,Implant Device,623.35,70,,623.35,percent of total billed charges,All Other,605.54,34,,605.54,percent of total billed charges,Implant Device,605.54,34,,605.54,percent of total billed charges,Implant Device,623.35,35,,623.35,percent of total billed charges,Implant Device,623.35,35,,623.35,percent of total billed charges,Implant Device,623.35,35,,623.35,percent of total billed charges,Implant Device,623.35,35,,623.35,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1317.94,
STRYKER 40-20905 FIBULA PLATE 5 HOLE,C1713,HCPCS,,79003291,CDM,278,RC,,,both,,,1867,1381.58,,,1381.58,Other,150% of Medicare + 9.63% HCRA Surcharge,840.15,45,,840.15,percent of total billed charges,Critical Access Hospital RCC factor,634.78,34,,634.78,percent of total billed charges,Implant Device,634.78,34,,634.78,percent of total billed charges,Implant Device,634.78,34,,634.78,percent of total billed charges,Implant Device,634.78,34,,634.78,percent of total billed charges,Implant Device,634.78,34,,634.78,percent of total billed charges,Implant Device,924.17,,,924.17,Other,110% of Medicare,653.45,35,,653.45,percent of total billed charges,Implant Device,634.78,34,"Charges > $500, x 34%",634.78,percent of total billed charges,Implant Device,653.45,35,,653.45,percent of total billed charges,Implant Device,653.45,35,,653.45,percent of total billed charges,Implant Device,653.45,35,,653.45,percent of total billed charges,Implant Device,653.45,35,,653.45,percent of total billed charges,Implant Device,653.45,35,,653.45,percent of total billed charges,Implant Device,746.8,40,,746.8,percent of total billed charges,Implant Device,653.45,70,,653.45,percent of total billed charges,All Other,634.78,34,,634.78,percent of total billed charges,Implant Device,634.78,34,,634.78,percent of total billed charges,Implant Device,653.45,35,,653.45,percent of total billed charges,Implant Device,653.45,35,,653.45,percent of total billed charges,Implant Device,653.45,35,,653.45,percent of total billed charges,Implant Device,653.45,35,,653.45,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1381.58,
STRYKER 40-35022 BONE SCREW,C1713,HCPCS,,79003292,CDM,278,RC,,,both,,,192,142.08,,,142.08,Other,150% of Medicare + 9.63% HCRA Surcharge,86.4,45,,86.4,percent of total billed charges,Critical Access Hospital RCC factor,65.28,34,,65.28,percent of total billed charges,Implant Device,65.28,34,,65.28,percent of total billed charges,Implant Device,65.28,34,,65.28,percent of total billed charges,Implant Device,65.28,34,,65.28,percent of total billed charges,Implant Device,65.28,34,,65.28,percent of total billed charges,Implant Device,95.04,,,95.04,Other,110% of Medicare,67.2,35,,67.2,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,67.2,35,,67.2,percent of total billed charges,Implant Device,67.2,35,,67.2,percent of total billed charges,Implant Device,67.2,35,,67.2,percent of total billed charges,Implant Device,67.2,35,,67.2,percent of total billed charges,Implant Device,67.2,35,,67.2,percent of total billed charges,Implant Device,76.8,40,,76.8,percent of total billed charges,Implant Device,67.2,70,,67.2,percent of total billed charges,All Other,65.28,34,,65.28,percent of total billed charges,Implant Device,65.28,34,,65.28,percent of total billed charges,Implant Device,67.2,35,,67.2,percent of total billed charges,Implant Device,67.2,35,,67.2,percent of total billed charges,Implant Device,67.2,35,,67.2,percent of total billed charges,Implant Device,67.2,35,,67.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,142.08,
STRYKER 619905 WASHER 4.0,C1713,HCPCS,,79003293,CDM,278,RC,,,both,,,80,59.2,,,59.2,Other,150% of Medicare + 9.63% HCRA Surcharge,36,45,,36,percent of total billed charges,Critical Access Hospital RCC factor,27.2,34,,27.2,percent of total billed charges,Implant Device,27.2,34,,27.2,percent of total billed charges,Implant Device,27.2,34,,27.2,percent of total billed charges,Implant Device,27.2,34,,27.2,percent of total billed charges,Implant Device,27.2,34,,27.2,percent of total billed charges,Implant Device,39.6,,,39.6,Other,110% of Medicare,28,35,,28,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,28,35,,28,percent of total billed charges,Implant Device,28,35,,28,percent of total billed charges,Implant Device,28,35,,28,percent of total billed charges,Implant Device,28,35,,28,percent of total billed charges,Implant Device,28,35,,28,percent of total billed charges,Implant Device,32,40,,32,percent of total billed charges,Implant Device,28,70,,28,percent of total billed charges,All Other,27.2,34,,27.2,percent of total billed charges,Implant Device,27.2,34,,27.2,percent of total billed charges,Implant Device,28,35,,28,percent of total billed charges,Implant Device,28,35,,28,percent of total billed charges,Implant Device,28,35,,28,percent of total billed charges,Implant Device,28,35,,28,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,59.2,
STRYKER 40-35612 LOCKING SCREW 3.5X12MM,C1713,HCPCS,,79003294,CDM,278,RC,,,both,,,523,387.02,,,387.02,Other,150% of Medicare + 9.63% HCRA Surcharge,235.35,45,,235.35,percent of total billed charges,Critical Access Hospital RCC factor,177.82,34,,177.82,percent of total billed charges,Implant Device,177.82,34,,177.82,percent of total billed charges,Implant Device,177.82,34,,177.82,percent of total billed charges,Implant Device,177.82,34,,177.82,percent of total billed charges,Implant Device,177.82,34,,177.82,percent of total billed charges,Implant Device,258.89,,,258.89,Other,110% of Medicare,183.05,35,,183.05,percent of total billed charges,Implant Device,177.82,34,"Charges > $500, x 34%",177.82,percent of total billed charges,Implant Device,183.05,35,,183.05,percent of total billed charges,Implant Device,183.05,35,,183.05,percent of total billed charges,Implant Device,183.05,35,,183.05,percent of total billed charges,Implant Device,183.05,35,,183.05,percent of total billed charges,Implant Device,183.05,35,,183.05,percent of total billed charges,Implant Device,209.2,40,,209.2,percent of total billed charges,Implant Device,183.05,70,,183.05,percent of total billed charges,All Other,177.82,34,,177.82,percent of total billed charges,Implant Device,177.82,34,,177.82,percent of total billed charges,Implant Device,183.05,35,,183.05,percent of total billed charges,Implant Device,183.05,35,,183.05,percent of total billed charges,Implant Device,183.05,35,,183.05,percent of total billed charges,Implant Device,183.05,35,,183.05,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,387.02,
STRYKER 40-35614 LOCKING SCREW 3.5X14MM,C1713,HCPCS,,79003295,CDM,278,RC,,,both,,,379,280.46,,,280.46,Other,150% of Medicare + 9.63% HCRA Surcharge,170.55,45,,170.55,percent of total billed charges,Critical Access Hospital RCC factor,128.86,34,,128.86,percent of total billed charges,Implant Device,128.86,34,,128.86,percent of total billed charges,Implant Device,128.86,34,,128.86,percent of total billed charges,Implant Device,128.86,34,,128.86,percent of total billed charges,Implant Device,128.86,34,,128.86,percent of total billed charges,Implant Device,187.61,,,187.61,Other,110% of Medicare,132.65,35,,132.65,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,132.65,35,,132.65,percent of total billed charges,Implant Device,132.65,35,,132.65,percent of total billed charges,Implant Device,132.65,35,,132.65,percent of total billed charges,Implant Device,132.65,35,,132.65,percent of total billed charges,Implant Device,132.65,35,,132.65,percent of total billed charges,Implant Device,151.6,40,,151.6,percent of total billed charges,Implant Device,132.65,70,,132.65,percent of total billed charges,All Other,128.86,34,,128.86,percent of total billed charges,Implant Device,128.86,34,,128.86,percent of total billed charges,Implant Device,132.65,35,,132.65,percent of total billed charges,Implant Device,132.65,35,,132.65,percent of total billed charges,Implant Device,132.65,35,,132.65,percent of total billed charges,Implant Device,132.65,35,,132.65,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,280.46,
STRYKER 40-35616 LOCKING SCREW 3.5X16MM,C1713,HCPCS,,79003296,CDM,278,RC,,,both,,,379,280.46,,,280.46,Other,150% of Medicare + 9.63% HCRA Surcharge,170.55,45,,170.55,percent of total billed charges,Critical Access Hospital RCC factor,128.86,34,,128.86,percent of total billed charges,Implant Device,128.86,34,,128.86,percent of total billed charges,Implant Device,128.86,34,,128.86,percent of total billed charges,Implant Device,128.86,34,,128.86,percent of total billed charges,Implant Device,128.86,34,,128.86,percent of total billed charges,Implant Device,187.61,,,187.61,Other,110% of Medicare,132.65,35,,132.65,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,132.65,35,,132.65,percent of total billed charges,Implant Device,132.65,35,,132.65,percent of total billed charges,Implant Device,132.65,35,,132.65,percent of total billed charges,Implant Device,132.65,35,,132.65,percent of total billed charges,Implant Device,132.65,35,,132.65,percent of total billed charges,Implant Device,151.6,40,,151.6,percent of total billed charges,Implant Device,132.65,70,,132.65,percent of total billed charges,All Other,128.86,34,,128.86,percent of total billed charges,Implant Device,128.86,34,,128.86,percent of total billed charges,Implant Device,132.65,35,,132.65,percent of total billed charges,Implant Device,132.65,35,,132.65,percent of total billed charges,Implant Device,132.65,35,,132.65,percent of total billed charges,Implant Device,132.65,35,,132.65,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,280.46,
ZIMMER 00-5791-041-UNI HEADED SCREW 48MM,C1713,HCPCS,,79003297,CDM,278,RC,,,both,,,244,180.56,,,180.56,Other,150% of Medicare + 9.63% HCRA Surcharge,109.8,45,,109.8,percent of total billed charges,Critical Access Hospital RCC factor,82.96,34,,82.96,percent of total billed charges,Implant Device,82.96,34,,82.96,percent of total billed charges,Implant Device,82.96,34,,82.96,percent of total billed charges,Implant Device,82.96,34,,82.96,percent of total billed charges,Implant Device,82.96,34,,82.96,percent of total billed charges,Implant Device,120.78,,,120.78,Other,110% of Medicare,85.4,35,,85.4,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,85.4,35,,85.4,percent of total billed charges,Implant Device,85.4,35,,85.4,percent of total billed charges,Implant Device,85.4,35,,85.4,percent of total billed charges,Implant Device,85.4,35,,85.4,percent of total billed charges,Implant Device,85.4,35,,85.4,percent of total billed charges,Implant Device,97.6,40,,97.6,percent of total billed charges,Implant Device,85.4,70,,85.4,percent of total billed charges,All Other,82.96,34,,82.96,percent of total billed charges,Implant Device,82.96,34,,82.96,percent of total billed charges,Implant Device,85.4,35,,85.4,percent of total billed charges,Implant Device,85.4,35,,85.4,percent of total billed charges,Implant Device,85.4,35,,85.4,percent of total billed charges,Implant Device,85.4,35,,85.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,180.56,
ZIMMER 00-5791-044-UNI HEADED SCREW 33MM,C1713,HCPCS,,79003298,CDM,278,RC,,,both,,,274,202.76,,,202.76,Other,150% of Medicare + 9.63% HCRA Surcharge,123.3,45,,123.3,percent of total billed charges,Critical Access Hospital RCC factor,93.16,34,,93.16,percent of total billed charges,Implant Device,93.16,34,,93.16,percent of total billed charges,Implant Device,93.16,34,,93.16,percent of total billed charges,Implant Device,93.16,34,,93.16,percent of total billed charges,Implant Device,93.16,34,,93.16,percent of total billed charges,Implant Device,135.63,,,135.63,Other,110% of Medicare,95.9,35,,95.9,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,95.9,35,,95.9,percent of total billed charges,Implant Device,95.9,35,,95.9,percent of total billed charges,Implant Device,95.9,35,,95.9,percent of total billed charges,Implant Device,95.9,35,,95.9,percent of total billed charges,Implant Device,95.9,35,,95.9,percent of total billed charges,Implant Device,109.6,40,,109.6,percent of total billed charges,Implant Device,95.9,70,,95.9,percent of total billed charges,All Other,93.16,34,,93.16,percent of total billed charges,Implant Device,93.16,34,,93.16,percent of total billed charges,Implant Device,95.9,35,,95.9,percent of total billed charges,Implant Device,95.9,35,,95.9,percent of total billed charges,Implant Device,95.9,35,,95.9,percent of total billed charges,Implant Device,95.9,35,,95.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,202.76,
ZIMMER 00-5842-004-01-UNI TIBIAL COMP S4,C1776,HCPCS,,79003299,CDM,278,RC,,,both,,,6346,4696.06,,,4696.06,Other,150% of Medicare + 9.63% HCRA Surcharge,2855.7,45,,2855.7,percent of total billed charges,Critical Access Hospital RCC factor,2157.64,34,,2157.64,percent of total billed charges,Implant Device,2157.64,34,,2157.64,percent of total billed charges,Implant Device,2157.64,34,,2157.64,percent of total billed charges,Implant Device,2157.64,34,,2157.64,percent of total billed charges,Implant Device,2157.64,34,,2157.64,percent of total billed charges,Implant Device,3141.27,,,3141.27,Other,110% of Medicare,2221.1,35,,2221.1,percent of total billed charges,Implant Device,2157.64,34,"Charges > $500, x 34%",2157.64,percent of total billed charges,Implant Device,2221.1,35,,2221.1,percent of total billed charges,Implant Device,2221.1,35,,2221.1,percent of total billed charges,Implant Device,2221.1,35,,2221.1,percent of total billed charges,Implant Device,2221.1,35,,2221.1,percent of total billed charges,Implant Device,2221.1,35,,2221.1,percent of total billed charges,Implant Device,2538.4,40,,2538.4,percent of total billed charges,Implant Device,2221.1,70,,2221.1,percent of total billed charges,All Other,2157.64,34,,2157.64,percent of total billed charges,Implant Device,2157.64,34,,2157.64,percent of total billed charges,Implant Device,2221.1,35,,2221.1,percent of total billed charges,Implant Device,2221.1,35,,2221.1,percent of total billed charges,Implant Device,2221.1,35,,2221.1,percent of total billed charges,Implant Device,2221.1,35,,2221.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2157.64,34,"If Charge > 2,000, then 34 percent",2157.64,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4696.06,
ZIMMER 00-5842-015-01-UNI FEM COMP SZ E,C1776,HCPCS,,79003300,CDM,278,RC,,,both,,,10486,7759.67,,,7759.67,Other,150% of Medicare + 9.63% HCRA Surcharge,4718.7,45,,4718.7,percent of total billed charges,Critical Access Hospital RCC factor,3565.24,34,,3565.24,percent of total billed charges,Implant Device,3565.24,34,,3565.24,percent of total billed charges,Implant Device,3565.24,34,,3565.24,percent of total billed charges,Implant Device,3565.24,34,,3565.24,percent of total billed charges,Implant Device,3565.24,34,,3565.24,percent of total billed charges,Implant Device,5190.57,,,5190.57,Other,110% of Medicare,3670.1,35,,3670.1,percent of total billed charges,Implant Device,3565.24,34,"Charges > $500, x 34%",3565.24,percent of total billed charges,Implant Device,3670.1,35,,3670.1,percent of total billed charges,Implant Device,3670.1,35,,3670.1,percent of total billed charges,Implant Device,3670.1,35,,3670.1,percent of total billed charges,Implant Device,3670.1,35,,3670.1,percent of total billed charges,Implant Device,3670.1,35,,3670.1,percent of total billed charges,Implant Device,4194.4,40,,4194.4,percent of total billed charges,Implant Device,3670.1,70,,3670.1,percent of total billed charges,All Other,3565.24,34,,3565.24,percent of total billed charges,Implant Device,3565.24,34,,3565.24,percent of total billed charges,Implant Device,3670.1,35,,3670.1,percent of total billed charges,Implant Device,3670.1,35,,3670.1,percent of total billed charges,Implant Device,3670.1,35,,3670.1,percent of total billed charges,Implant Device,3670.1,35,,3670.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3565.24,34,"If Charge > 2,000, then 34 percent",3565.24,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,7759.67,
ZIMMER 00-5842-024-11-UNI ART SURF SZ 4,C1776,HCPCS,,79003301,CDM,278,RC,,,both,,,2677,1980.99,,,1980.99,Other,150% of Medicare + 9.63% HCRA Surcharge,1204.65,45,,1204.65,percent of total billed charges,Critical Access Hospital RCC factor,910.18,34,,910.18,percent of total billed charges,Implant Device,910.18,34,,910.18,percent of total billed charges,Implant Device,910.18,34,,910.18,percent of total billed charges,Implant Device,910.18,34,,910.18,percent of total billed charges,Implant Device,910.18,34,,910.18,percent of total billed charges,Implant Device,1325.12,,,1325.12,Other,110% of Medicare,936.95,35,,936.95,percent of total billed charges,Implant Device,910.18,34,"Charges > $500, x 34%",910.18,percent of total billed charges,Implant Device,936.95,35,,936.95,percent of total billed charges,Implant Device,936.95,35,,936.95,percent of total billed charges,Implant Device,936.95,35,,936.95,percent of total billed charges,Implant Device,936.95,35,,936.95,percent of total billed charges,Implant Device,936.95,35,,936.95,percent of total billed charges,Implant Device,1070.8,40,,1070.8,percent of total billed charges,Implant Device,936.95,70,,936.95,percent of total billed charges,All Other,910.18,34,,910.18,percent of total billed charges,Implant Device,910.18,34,,910.18,percent of total billed charges,Implant Device,936.95,35,,936.95,percent of total billed charges,Implant Device,936.95,35,,936.95,percent of total billed charges,Implant Device,936.95,35,,936.95,percent of total billed charges,Implant Device,936.95,35,,936.95,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,910.18,34,"If Charge > 2,000, then 34 percent",910.18,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1980.99,
BIOMET 14-520510 LORDOTIC SPACR 10X14X12,C1713,HCPCS,,79003303,CDM,278,RC,,,both,,,15120,11188.84,,,11188.84,Other,150% of Medicare + 9.63% HCRA Surcharge,6804,45,,6804,percent of total billed charges,Critical Access Hospital RCC factor,5140.8,34,,5140.8,percent of total billed charges,Implant Device,5140.8,34,,5140.8,percent of total billed charges,Implant Device,5140.8,34,,5140.8,percent of total billed charges,Implant Device,5140.8,34,,5140.8,percent of total billed charges,Implant Device,5140.8,34,,5140.8,percent of total billed charges,Implant Device,7484.4,,,7484.4,Other,110% of Medicare,5292,35,,5292,percent of total billed charges,Implant Device,5140.8,34,"Charges > $500, x 34%",5140.8,percent of total billed charges,Implant Device,5292,35,,5292,percent of total billed charges,Implant Device,5292,35,,5292,percent of total billed charges,Implant Device,5292,35,,5292,percent of total billed charges,Implant Device,5292,35,,5292,percent of total billed charges,Implant Device,5292,35,,5292,percent of total billed charges,Implant Device,6048,40,,6048,percent of total billed charges,Implant Device,5292,70,,5292,percent of total billed charges,All Other,5140.8,34,,5140.8,percent of total billed charges,Implant Device,5140.8,34,,5140.8,percent of total billed charges,Implant Device,5292,35,,5292,percent of total billed charges,Implant Device,5292,35,,5292,percent of total billed charges,Implant Device,5292,35,,5292,percent of total billed charges,Implant Device,5292,35,,5292,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,5140.8,34,"If Charge > 2,000, then 34 percent",5140.8,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,11188.84,
BIOMET 14-531712 SCREW 3.5X12MM,C1713,HCPCS,,79003304,CDM,278,RC,,,both,,,1080,799.2,,,799.2,Other,150% of Medicare + 9.63% HCRA Surcharge,486,45,,486,percent of total billed charges,Critical Access Hospital RCC factor,367.2,34,,367.2,percent of total billed charges,Implant Device,367.2,34,,367.2,percent of total billed charges,Implant Device,367.2,34,,367.2,percent of total billed charges,Implant Device,367.2,34,,367.2,percent of total billed charges,Implant Device,367.2,34,,367.2,percent of total billed charges,Implant Device,534.6,,,534.6,Other,110% of Medicare,378,35,,378,percent of total billed charges,Implant Device,367.2,34,"Charges > $500, x 34%",367.2,percent of total billed charges,Implant Device,378,35,,378,percent of total billed charges,Implant Device,378,35,,378,percent of total billed charges,Implant Device,378,35,,378,percent of total billed charges,Implant Device,378,35,,378,percent of total billed charges,Implant Device,378,35,,378,percent of total billed charges,Implant Device,432,40,,432,percent of total billed charges,Implant Device,378,70,,378,percent of total billed charges,All Other,367.2,34,,367.2,percent of total billed charges,Implant Device,367.2,34,,367.2,percent of total billed charges,Implant Device,378,35,,378,percent of total billed charges,Implant Device,378,35,,378,percent of total billed charges,Implant Device,378,35,,378,percent of total billed charges,Implant Device,378,35,,378,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,799.2,
ARTHREX AR-8935L-14 LOCKING SCREW 3.5X14,C1713,HCPCS,,79003310,CDM,278,RC,,,both,,,488,361.12,,,361.12,Other,150% of Medicare + 9.63% HCRA Surcharge,219.6,45,,219.6,percent of total billed charges,Critical Access Hospital RCC factor,165.92,34,,165.92,percent of total billed charges,Implant Device,165.92,34,,165.92,percent of total billed charges,Implant Device,165.92,34,,165.92,percent of total billed charges,Implant Device,165.92,34,,165.92,percent of total billed charges,Implant Device,165.92,34,,165.92,percent of total billed charges,Implant Device,241.56,,,241.56,Other,110% of Medicare,170.8,35,,170.8,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,170.8,35,,170.8,percent of total billed charges,Implant Device,170.8,35,,170.8,percent of total billed charges,Implant Device,170.8,35,,170.8,percent of total billed charges,Implant Device,170.8,35,,170.8,percent of total billed charges,Implant Device,170.8,35,,170.8,percent of total billed charges,Implant Device,195.2,40,,195.2,percent of total billed charges,Implant Device,170.8,70,,170.8,percent of total billed charges,All Other,165.92,34,,165.92,percent of total billed charges,Implant Device,165.92,34,,165.92,percent of total billed charges,Implant Device,170.8,35,,170.8,percent of total billed charges,Implant Device,170.8,35,,170.8,percent of total billed charges,Implant Device,170.8,35,,170.8,percent of total billed charges,Implant Device,170.8,35,,170.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,361.12,
ARTHREX AR-8935-18 SCREW 3.5X18MM,C1713,HCPCS,,79003311,CDM,278,RC,,,both,,,258,190.92,,,190.92,Other,150% of Medicare + 9.63% HCRA Surcharge,116.1,45,,116.1,percent of total billed charges,Critical Access Hospital RCC factor,87.72,34,,87.72,percent of total billed charges,Implant Device,87.72,34,,87.72,percent of total billed charges,Implant Device,87.72,34,,87.72,percent of total billed charges,Implant Device,87.72,34,,87.72,percent of total billed charges,Implant Device,87.72,34,,87.72,percent of total billed charges,Implant Device,127.71,,,127.71,Other,110% of Medicare,90.3,35,,90.3,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,90.3,35,,90.3,percent of total billed charges,Implant Device,90.3,35,,90.3,percent of total billed charges,Implant Device,90.3,35,,90.3,percent of total billed charges,Implant Device,90.3,35,,90.3,percent of total billed charges,Implant Device,90.3,35,,90.3,percent of total billed charges,Implant Device,103.2,40,,103.2,percent of total billed charges,Implant Device,90.3,70,,90.3,percent of total billed charges,All Other,87.72,34,,87.72,percent of total billed charges,Implant Device,87.72,34,,87.72,percent of total billed charges,Implant Device,90.3,35,,90.3,percent of total billed charges,Implant Device,90.3,35,,90.3,percent of total billed charges,Implant Device,90.3,35,,90.3,percent of total billed charges,Implant Device,90.3,35,,90.3,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,190.92,
ARTHREX AR-8740-36PTS CANN SCREW 4.0X36,C1713,HCPCS,,79003312,CDM,278,RC,,,both,,,536,396.64,,,396.64,Other,150% of Medicare + 9.63% HCRA Surcharge,241.2,45,,241.2,percent of total billed charges,Critical Access Hospital RCC factor,182.24,34,,182.24,percent of total billed charges,Implant Device,182.24,34,,182.24,percent of total billed charges,Implant Device,182.24,34,,182.24,percent of total billed charges,Implant Device,182.24,34,,182.24,percent of total billed charges,Implant Device,182.24,34,,182.24,percent of total billed charges,Implant Device,265.32,,,265.32,Other,110% of Medicare,187.6,35,,187.6,percent of total billed charges,Implant Device,182.24,34,"Charges > $500, x 34%",182.24,percent of total billed charges,Implant Device,187.6,35,,187.6,percent of total billed charges,Implant Device,187.6,35,,187.6,percent of total billed charges,Implant Device,187.6,35,,187.6,percent of total billed charges,Implant Device,187.6,35,,187.6,percent of total billed charges,Implant Device,187.6,35,,187.6,percent of total billed charges,Implant Device,214.4,40,,214.4,percent of total billed charges,Implant Device,187.6,70,,187.6,percent of total billed charges,All Other,182.24,34,,182.24,percent of total billed charges,Implant Device,182.24,34,,182.24,percent of total billed charges,Implant Device,187.6,35,,187.6,percent of total billed charges,Implant Device,187.6,35,,187.6,percent of total billed charges,Implant Device,187.6,35,,187.6,percent of total billed charges,Implant Device,187.6,35,,187.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,396.64,
STRYKER 0194-2250S FLEX NAIL 2.25X300MM,C1713,HCPCS,,79003314,CDM,278,RC,,,both,,,1124,831.76,,,831.76,Other,150% of Medicare + 9.63% HCRA Surcharge,505.8,45,,505.8,percent of total billed charges,Critical Access Hospital RCC factor,382.16,34,,382.16,percent of total billed charges,Implant Device,382.16,34,,382.16,percent of total billed charges,Implant Device,382.16,34,,382.16,percent of total billed charges,Implant Device,382.16,34,,382.16,percent of total billed charges,Implant Device,382.16,34,,382.16,percent of total billed charges,Implant Device,556.38,,,556.38,Other,110% of Medicare,393.4,35,,393.4,percent of total billed charges,Implant Device,382.16,34,"Charges > $500, x 34%",382.16,percent of total billed charges,Implant Device,393.4,35,,393.4,percent of total billed charges,Implant Device,393.4,35,,393.4,percent of total billed charges,Implant Device,393.4,35,,393.4,percent of total billed charges,Implant Device,393.4,35,,393.4,percent of total billed charges,Implant Device,393.4,35,,393.4,percent of total billed charges,Implant Device,449.6,40,,449.6,percent of total billed charges,Implant Device,393.4,70,,393.4,percent of total billed charges,All Other,382.16,34,,382.16,percent of total billed charges,Implant Device,382.16,34,,382.16,percent of total billed charges,Implant Device,393.4,35,,393.4,percent of total billed charges,Implant Device,393.4,35,,393.4,percent of total billed charges,Implant Device,393.4,35,,393.4,percent of total billed charges,Implant Device,393.4,35,,393.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,831.76,
STRYKER 0194-2500S FLEX NAIL 2.5X450MM,C1713,HCPCS,,79003315,CDM,278,RC,,,both,,,966,714.84,,,714.84,Other,150% of Medicare + 9.63% HCRA Surcharge,434.7,45,,434.7,percent of total billed charges,Critical Access Hospital RCC factor,328.44,34,,328.44,percent of total billed charges,Implant Device,328.44,34,,328.44,percent of total billed charges,Implant Device,328.44,34,,328.44,percent of total billed charges,Implant Device,328.44,34,,328.44,percent of total billed charges,Implant Device,328.44,34,,328.44,percent of total billed charges,Implant Device,478.17,,,478.17,Other,110% of Medicare,338.1,35,,338.1,percent of total billed charges,Implant Device,328.44,34,"Charges > $500, x 34%",328.44,percent of total billed charges,Implant Device,338.1,35,,338.1,percent of total billed charges,Implant Device,338.1,35,,338.1,percent of total billed charges,Implant Device,338.1,35,,338.1,percent of total billed charges,Implant Device,338.1,35,,338.1,percent of total billed charges,Implant Device,338.1,35,,338.1,percent of total billed charges,Implant Device,386.4,40,,386.4,percent of total billed charges,Implant Device,338.1,70,,338.1,percent of total billed charges,All Other,328.44,34,,328.44,percent of total billed charges,Implant Device,328.44,34,,328.44,percent of total billed charges,Implant Device,338.1,35,,338.1,percent of total billed charges,Implant Device,338.1,35,,338.1,percent of total billed charges,Implant Device,338.1,35,,338.1,percent of total billed charges,Implant Device,338.1,35,,338.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,714.84,
STRYKER 3325-0360S NAIL KIT R2.0 TI LT,C1713,HCPCS,,79003316,CDM,278,RC,,,both,,,5021,3715.55,,,3715.55,Other,150% of Medicare + 9.63% HCRA Surcharge,2259.45,45,,2259.45,percent of total billed charges,Critical Access Hospital RCC factor,1707.14,34,,1707.14,percent of total billed charges,Implant Device,1707.14,34,,1707.14,percent of total billed charges,Implant Device,1707.14,34,,1707.14,percent of total billed charges,Implant Device,1707.14,34,,1707.14,percent of total billed charges,Implant Device,1707.14,34,,1707.14,percent of total billed charges,Implant Device,2485.4,,,2485.4,Other,110% of Medicare,1757.35,35,,1757.35,percent of total billed charges,Implant Device,1707.14,34,"Charges > $500, x 34%",1707.14,percent of total billed charges,Implant Device,1757.35,35,,1757.35,percent of total billed charges,Implant Device,1757.35,35,,1757.35,percent of total billed charges,Implant Device,1757.35,35,,1757.35,percent of total billed charges,Implant Device,1757.35,35,,1757.35,percent of total billed charges,Implant Device,1757.35,35,,1757.35,percent of total billed charges,Implant Device,2008.4,40,,2008.4,percent of total billed charges,Implant Device,1757.35,70,,1757.35,percent of total billed charges,All Other,1707.14,34,,1707.14,percent of total billed charges,Implant Device,1707.14,34,,1707.14,percent of total billed charges,Implant Device,1757.35,35,,1757.35,percent of total billed charges,Implant Device,1757.35,35,,1757.35,percent of total billed charges,Implant Device,1757.35,35,,1757.35,percent of total billed charges,Implant Device,1757.35,35,,1757.35,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1707.14,34,"If Charge > 2,000, then 34 percent",1707.14,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3715.55,
STRYKER 3060-0090S LAG SCREW 5X90MM,C1713,HCPCS,,79003317,CDM,278,RC,,,both,,,1230,910.2,,,910.2,Other,150% of Medicare + 9.63% HCRA Surcharge,553.5,45,,553.5,percent of total billed charges,Critical Access Hospital RCC factor,418.2,34,,418.2,percent of total billed charges,Implant Device,418.2,34,,418.2,percent of total billed charges,Implant Device,418.2,34,,418.2,percent of total billed charges,Implant Device,418.2,34,,418.2,percent of total billed charges,Implant Device,418.2,34,,418.2,percent of total billed charges,Implant Device,608.85,,,608.85,Other,110% of Medicare,430.5,35,,430.5,percent of total billed charges,Implant Device,418.2,34,"Charges > $500, x 34%",418.2,percent of total billed charges,Implant Device,430.5,35,,430.5,percent of total billed charges,Implant Device,430.5,35,,430.5,percent of total billed charges,Implant Device,430.5,35,,430.5,percent of total billed charges,Implant Device,430.5,35,,430.5,percent of total billed charges,Implant Device,430.5,35,,430.5,percent of total billed charges,Implant Device,492,40,,492,percent of total billed charges,Implant Device,430.5,70,,430.5,percent of total billed charges,All Other,418.2,34,,418.2,percent of total billed charges,Implant Device,418.2,34,,418.2,percent of total billed charges,Implant Device,430.5,35,,430.5,percent of total billed charges,Implant Device,430.5,35,,430.5,percent of total billed charges,Implant Device,430.5,35,,430.5,percent of total billed charges,Implant Device,430.5,35,,430.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,910.2,
STRYKER 1896-5040S LOCK SCREW 5X40MM FT,C1713,HCPCS,,79003318,CDM,278,RC,,,both,,,355,262.7,,,262.7,Other,150% of Medicare + 9.63% HCRA Surcharge,159.75,45,,159.75,percent of total billed charges,Critical Access Hospital RCC factor,120.7,34,,120.7,percent of total billed charges,Implant Device,120.7,34,,120.7,percent of total billed charges,Implant Device,120.7,34,,120.7,percent of total billed charges,Implant Device,120.7,34,,120.7,percent of total billed charges,Implant Device,120.7,34,,120.7,percent of total billed charges,Implant Device,175.73,,,175.73,Other,110% of Medicare,124.25,35,,124.25,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,124.25,35,,124.25,percent of total billed charges,Implant Device,124.25,35,,124.25,percent of total billed charges,Implant Device,124.25,35,,124.25,percent of total billed charges,Implant Device,124.25,35,,124.25,percent of total billed charges,Implant Device,124.25,35,,124.25,percent of total billed charges,Implant Device,142,40,,142,percent of total billed charges,Implant Device,124.25,70,,124.25,percent of total billed charges,All Other,120.7,34,,120.7,percent of total billed charges,Implant Device,120.7,34,,120.7,percent of total billed charges,Implant Device,124.25,35,,124.25,percent of total billed charges,Implant Device,124.25,35,,124.25,percent of total billed charges,Implant Device,124.25,35,,124.25,percent of total billed charges,Implant Device,124.25,35,,124.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,262.7,
STRYKER 437324 TIBIA PLATE 4 HOLE RIGHT,C1713,HCPCS,,79003323,CDM,278,RC,,,both,,,5111,3782.15,,,3782.15,Other,150% of Medicare + 9.63% HCRA Surcharge,2299.95,45,,2299.95,percent of total billed charges,Critical Access Hospital RCC factor,1737.74,34,,1737.74,percent of total billed charges,Implant Device,1737.74,34,,1737.74,percent of total billed charges,Implant Device,1737.74,34,,1737.74,percent of total billed charges,Implant Device,1737.74,34,,1737.74,percent of total billed charges,Implant Device,1737.74,34,,1737.74,percent of total billed charges,Implant Device,2529.95,,,2529.95,Other,110% of Medicare,1788.85,35,,1788.85,percent of total billed charges,Implant Device,1737.74,34,"Charges > $500, x 34%",1737.74,percent of total billed charges,Implant Device,1788.85,35,,1788.85,percent of total billed charges,Implant Device,1788.85,35,,1788.85,percent of total billed charges,Implant Device,1788.85,35,,1788.85,percent of total billed charges,Implant Device,1788.85,35,,1788.85,percent of total billed charges,Implant Device,1788.85,35,,1788.85,percent of total billed charges,Implant Device,2044.4,40,,2044.4,percent of total billed charges,Implant Device,1788.85,70,,1788.85,percent of total billed charges,All Other,1737.74,34,,1737.74,percent of total billed charges,Implant Device,1737.74,34,,1737.74,percent of total billed charges,Implant Device,1788.85,35,,1788.85,percent of total billed charges,Implant Device,1788.85,35,,1788.85,percent of total billed charges,Implant Device,1788.85,35,,1788.85,percent of total billed charges,Implant Device,1788.85,35,,1788.85,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1737.74,34,"If Charge > 2,000, then 34 percent",1737.74,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3782.15,
STRYKER 427036S RECON LOCK PLATE 6 HOLE,C1713,HCPCS,,79003324,CDM,278,RC,,,both,,,1721,1273.54,,,1273.54,Other,150% of Medicare + 9.63% HCRA Surcharge,774.45,45,,774.45,percent of total billed charges,Critical Access Hospital RCC factor,585.14,34,,585.14,percent of total billed charges,Implant Device,585.14,34,,585.14,percent of total billed charges,Implant Device,585.14,34,,585.14,percent of total billed charges,Implant Device,585.14,34,,585.14,percent of total billed charges,Implant Device,585.14,34,,585.14,percent of total billed charges,Implant Device,851.9,,,851.9,Other,110% of Medicare,602.35,35,,602.35,percent of total billed charges,Implant Device,585.14,34,"Charges > $500, x 34%",585.14,percent of total billed charges,Implant Device,602.35,35,,602.35,percent of total billed charges,Implant Device,602.35,35,,602.35,percent of total billed charges,Implant Device,602.35,35,,602.35,percent of total billed charges,Implant Device,602.35,35,,602.35,percent of total billed charges,Implant Device,602.35,35,,602.35,percent of total billed charges,Implant Device,688.4,40,,688.4,percent of total billed charges,Implant Device,602.35,70,,602.35,percent of total billed charges,All Other,585.14,34,,585.14,percent of total billed charges,Implant Device,585.14,34,,585.14,percent of total billed charges,Implant Device,602.35,35,,602.35,percent of total billed charges,Implant Device,602.35,35,,602.35,percent of total billed charges,Implant Device,602.35,35,,602.35,percent of total billed charges,Implant Device,602.35,35,,602.35,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1273.54,
STRYKER 371534 LOCKING SCREW 4.0X34MM,C1713,HCPCS,,79003325,CDM,278,RC,,,both,,,569,421.06,,,421.06,Other,150% of Medicare + 9.63% HCRA Surcharge,256.05,45,,256.05,percent of total billed charges,Critical Access Hospital RCC factor,193.46,34,,193.46,percent of total billed charges,Implant Device,193.46,34,,193.46,percent of total billed charges,Implant Device,193.46,34,,193.46,percent of total billed charges,Implant Device,193.46,34,,193.46,percent of total billed charges,Implant Device,193.46,34,,193.46,percent of total billed charges,Implant Device,281.66,,,281.66,Other,110% of Medicare,199.15,35,,199.15,percent of total billed charges,Implant Device,193.46,34,"Charges > $500, x 34%",193.46,percent of total billed charges,Implant Device,199.15,35,,199.15,percent of total billed charges,Implant Device,199.15,35,,199.15,percent of total billed charges,Implant Device,199.15,35,,199.15,percent of total billed charges,Implant Device,199.15,35,,199.15,percent of total billed charges,Implant Device,199.15,35,,199.15,percent of total billed charges,Implant Device,227.6,40,,227.6,percent of total billed charges,Implant Device,199.15,70,,199.15,percent of total billed charges,All Other,193.46,34,,193.46,percent of total billed charges,Implant Device,193.46,34,,193.46,percent of total billed charges,Implant Device,199.15,35,,199.15,percent of total billed charges,Implant Device,199.15,35,,199.15,percent of total billed charges,Implant Device,199.15,35,,199.15,percent of total billed charges,Implant Device,199.15,35,,199.15,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,421.06,
STRYKER 371540 LOCKING SCREW 4.0X40MM,C1713,HCPCS,,79003326,CDM,278,RC,,,both,,,569,421.06,,,421.06,Other,150% of Medicare + 9.63% HCRA Surcharge,256.05,45,,256.05,percent of total billed charges,Critical Access Hospital RCC factor,193.46,34,,193.46,percent of total billed charges,Implant Device,193.46,34,,193.46,percent of total billed charges,Implant Device,193.46,34,,193.46,percent of total billed charges,Implant Device,193.46,34,,193.46,percent of total billed charges,Implant Device,193.46,34,,193.46,percent of total billed charges,Implant Device,281.66,,,281.66,Other,110% of Medicare,199.15,35,,199.15,percent of total billed charges,Implant Device,193.46,34,"Charges > $500, x 34%",193.46,percent of total billed charges,Implant Device,199.15,35,,199.15,percent of total billed charges,Implant Device,199.15,35,,199.15,percent of total billed charges,Implant Device,199.15,35,,199.15,percent of total billed charges,Implant Device,199.15,35,,199.15,percent of total billed charges,Implant Device,199.15,35,,199.15,percent of total billed charges,Implant Device,227.6,40,,227.6,percent of total billed charges,Implant Device,199.15,70,,199.15,percent of total billed charges,All Other,193.46,34,,193.46,percent of total billed charges,Implant Device,193.46,34,,193.46,percent of total billed charges,Implant Device,199.15,35,,199.15,percent of total billed charges,Implant Device,199.15,35,,199.15,percent of total billed charges,Implant Device,199.15,35,,199.15,percent of total billed charges,Implant Device,199.15,35,,199.15,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,421.06,
STRYKER 371560 LOCKING SCREW 4.0X60MM,C1713,HCPCS,,79003327,CDM,278,RC,,,both,,,569,421.06,,,421.06,Other,150% of Medicare + 9.63% HCRA Surcharge,256.05,45,,256.05,percent of total billed charges,Critical Access Hospital RCC factor,193.46,34,,193.46,percent of total billed charges,Implant Device,193.46,34,,193.46,percent of total billed charges,Implant Device,193.46,34,,193.46,percent of total billed charges,Implant Device,193.46,34,,193.46,percent of total billed charges,Implant Device,193.46,34,,193.46,percent of total billed charges,Implant Device,281.66,,,281.66,Other,110% of Medicare,199.15,35,,199.15,percent of total billed charges,Implant Device,193.46,34,"Charges > $500, x 34%",193.46,percent of total billed charges,Implant Device,199.15,35,,199.15,percent of total billed charges,Implant Device,199.15,35,,199.15,percent of total billed charges,Implant Device,199.15,35,,199.15,percent of total billed charges,Implant Device,199.15,35,,199.15,percent of total billed charges,Implant Device,199.15,35,,199.15,percent of total billed charges,Implant Device,227.6,40,,227.6,percent of total billed charges,Implant Device,199.15,70,,199.15,percent of total billed charges,All Other,193.46,34,,193.46,percent of total billed charges,Implant Device,193.46,34,,193.46,percent of total billed charges,Implant Device,199.15,35,,199.15,percent of total billed charges,Implant Device,199.15,35,,199.15,percent of total billed charges,Implant Device,199.15,35,,199.15,percent of total billed charges,Implant Device,199.15,35,,199.15,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,421.06,
STRYKER 338650 CORTICAL SCREW 3.5X50MM,C1713,HCPCS,,79003331,CDM,278,RC,,,both,,,69,51.06,,,51.06,Other,150% of Medicare + 9.63% HCRA Surcharge,31.05,45,,31.05,percent of total billed charges,Critical Access Hospital RCC factor,23.46,34,,23.46,percent of total billed charges,Implant Device,23.46,34,,23.46,percent of total billed charges,Implant Device,23.46,34,,23.46,percent of total billed charges,Implant Device,23.46,34,,23.46,percent of total billed charges,Implant Device,23.46,34,,23.46,percent of total billed charges,Implant Device,34.16,,,34.16,Other,110% of Medicare,24.15,35,,24.15,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,24.15,35,,24.15,percent of total billed charges,Implant Device,24.15,35,,24.15,percent of total billed charges,Implant Device,24.15,35,,24.15,percent of total billed charges,Implant Device,24.15,35,,24.15,percent of total billed charges,Implant Device,24.15,35,,24.15,percent of total billed charges,Implant Device,27.6,40,,27.6,percent of total billed charges,Implant Device,24.15,70,,24.15,percent of total billed charges,All Other,23.46,34,,23.46,percent of total billed charges,Implant Device,23.46,34,,23.46,percent of total billed charges,Implant Device,24.15,35,,24.15,percent of total billed charges,Implant Device,24.15,35,,24.15,percent of total billed charges,Implant Device,24.15,35,,24.15,percent of total billed charges,Implant Device,24.15,35,,24.15,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,51.06,
STRYKER 345450 CANC SCREW FT 4.0X50MM,C1713,HCPCS,,79003332,CDM,278,RC,,,both,,,89,65.86,,,65.86,Other,150% of Medicare + 9.63% HCRA Surcharge,40.05,45,,40.05,percent of total billed charges,Critical Access Hospital RCC factor,30.26,34,,30.26,percent of total billed charges,Implant Device,30.26,34,,30.26,percent of total billed charges,Implant Device,30.26,34,,30.26,percent of total billed charges,Implant Device,30.26,34,,30.26,percent of total billed charges,Implant Device,30.26,34,,30.26,percent of total billed charges,Implant Device,44.06,,,44.06,Other,110% of Medicare,31.15,35,,31.15,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,31.15,35,,31.15,percent of total billed charges,Implant Device,31.15,35,,31.15,percent of total billed charges,Implant Device,31.15,35,,31.15,percent of total billed charges,Implant Device,31.15,35,,31.15,percent of total billed charges,Implant Device,31.15,35,,31.15,percent of total billed charges,Implant Device,35.6,40,,35.6,percent of total billed charges,Implant Device,31.15,70,,31.15,percent of total billed charges,All Other,30.26,34,,30.26,percent of total billed charges,Implant Device,30.26,34,,30.26,percent of total billed charges,Implant Device,31.15,35,,31.15,percent of total billed charges,Implant Device,31.15,35,,31.15,percent of total billed charges,Implant Device,31.15,35,,31.15,percent of total billed charges,Implant Device,31.15,35,,31.15,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,65.86,
STRYKER 345460 CANC SCREW FT 4.0X60MM,C1713,HCPCS,,79003333,CDM,278,RC,,,both,,,89,65.86,,,65.86,Other,150% of Medicare + 9.63% HCRA Surcharge,40.05,45,,40.05,percent of total billed charges,Critical Access Hospital RCC factor,30.26,34,,30.26,percent of total billed charges,Implant Device,30.26,34,,30.26,percent of total billed charges,Implant Device,30.26,34,,30.26,percent of total billed charges,Implant Device,30.26,34,,30.26,percent of total billed charges,Implant Device,30.26,34,,30.26,percent of total billed charges,Implant Device,44.06,,,44.06,Other,110% of Medicare,31.15,35,,31.15,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,31.15,35,,31.15,percent of total billed charges,Implant Device,31.15,35,,31.15,percent of total billed charges,Implant Device,31.15,35,,31.15,percent of total billed charges,Implant Device,31.15,35,,31.15,percent of total billed charges,Implant Device,31.15,35,,31.15,percent of total billed charges,Implant Device,35.6,40,,35.6,percent of total billed charges,Implant Device,31.15,70,,31.15,percent of total billed charges,All Other,30.26,34,,30.26,percent of total billed charges,Implant Device,30.26,34,,30.26,percent of total billed charges,Implant Device,31.15,35,,31.15,percent of total billed charges,Implant Device,31.15,35,,31.15,percent of total billed charges,Implant Device,31.15,35,,31.15,percent of total billed charges,Implant Device,31.15,35,,31.15,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,65.86,
STRYKER 370002 LOCKING INSERT 4.0,C1713,HCPCS,,79003334,CDM,278,RC,,,both,,,209,154.66,,,154.66,Other,150% of Medicare + 9.63% HCRA Surcharge,94.05,45,,94.05,percent of total billed charges,Critical Access Hospital RCC factor,71.06,34,,71.06,percent of total billed charges,Implant Device,71.06,34,,71.06,percent of total billed charges,Implant Device,71.06,34,,71.06,percent of total billed charges,Implant Device,71.06,34,,71.06,percent of total billed charges,Implant Device,71.06,34,,71.06,percent of total billed charges,Implant Device,103.46,,,103.46,Other,110% of Medicare,73.15,35,,73.15,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,73.15,35,,73.15,percent of total billed charges,Implant Device,73.15,35,,73.15,percent of total billed charges,Implant Device,73.15,35,,73.15,percent of total billed charges,Implant Device,73.15,35,,73.15,percent of total billed charges,Implant Device,73.15,35,,73.15,percent of total billed charges,Implant Device,83.6,40,,83.6,percent of total billed charges,Implant Device,73.15,70,,73.15,percent of total billed charges,All Other,71.06,34,,71.06,percent of total billed charges,Implant Device,71.06,34,,71.06,percent of total billed charges,Implant Device,73.15,35,,73.15,percent of total billed charges,Implant Device,73.15,35,,73.15,percent of total billed charges,Implant Device,73.15,35,,73.15,percent of total billed charges,Implant Device,73.15,35,,73.15,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,154.66,
PIONEER SURGI 83-00-08 BACFUSE STD 8MM,C1713,HCPCS,,79003340,CDM,278,RC,,,both,,,24900,18426.06,,,18426.06,Other,150% of Medicare + 9.63% HCRA Surcharge,11205,45,,11205,percent of total billed charges,Critical Access Hospital RCC factor,8466,34,,8466,percent of total billed charges,Implant Device,8466,34,,8466,percent of total billed charges,Implant Device,8466,34,,8466,percent of total billed charges,Implant Device,8466,34,,8466,percent of total billed charges,Implant Device,8466,34,,8466,percent of total billed charges,Implant Device,12325.5,,,12325.5,Other,110% of Medicare,8715,35,,8715,percent of total billed charges,Implant Device,8466,34,"Charges > $500, x 34%",8466,percent of total billed charges,Implant Device,8715,35,,8715,percent of total billed charges,Implant Device,8715,35,,8715,percent of total billed charges,Implant Device,8715,35,,8715,percent of total billed charges,Implant Device,8715,35,,8715,percent of total billed charges,Implant Device,8715,35,,8715,percent of total billed charges,Implant Device,9960,40,,9960,percent of total billed charges,Implant Device,8715,70,,8715,percent of total billed charges,All Other,8466,34,,8466,percent of total billed charges,Implant Device,8466,34,,8466,percent of total billed charges,Implant Device,8715,35,,8715,percent of total billed charges,Implant Device,8715,35,,8715,percent of total billed charges,Implant Device,8715,35,,8715,percent of total billed charges,Implant Device,8715,35,,8715,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,8466,34,"If Charge > 2,000, then 34 percent",8466,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,18426.06,
STRYKER 371528 LOCKING SCREW 4.0X28MM,C1713,HCPCS,,79003341,CDM,278,RC,,,both,,,569,421.06,,,421.06,Other,150% of Medicare + 9.63% HCRA Surcharge,256.05,45,,256.05,percent of total billed charges,Critical Access Hospital RCC factor,193.46,34,,193.46,percent of total billed charges,Implant Device,193.46,34,,193.46,percent of total billed charges,Implant Device,193.46,34,,193.46,percent of total billed charges,Implant Device,193.46,34,,193.46,percent of total billed charges,Implant Device,193.46,34,,193.46,percent of total billed charges,Implant Device,281.66,,,281.66,Other,110% of Medicare,199.15,35,,199.15,percent of total billed charges,Implant Device,193.46,34,"Charges > $500, x 34%",193.46,percent of total billed charges,Implant Device,199.15,35,,199.15,percent of total billed charges,Implant Device,199.15,35,,199.15,percent of total billed charges,Implant Device,199.15,35,,199.15,percent of total billed charges,Implant Device,199.15,35,,199.15,percent of total billed charges,Implant Device,199.15,35,,199.15,percent of total billed charges,Implant Device,227.6,40,,227.6,percent of total billed charges,Implant Device,199.15,70,,199.15,percent of total billed charges,All Other,193.46,34,,193.46,percent of total billed charges,Implant Device,193.46,34,,193.46,percent of total billed charges,Implant Device,199.15,35,,199.15,percent of total billed charges,Implant Device,199.15,35,,199.15,percent of total billed charges,Implant Device,199.15,35,,199.15,percent of total billed charges,Implant Device,199.15,35,,199.15,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,421.06,
STRYKER 3715505 LOCKING SCREW 4.0X55MM,C1713,HCPCS,,79003342,CDM,278,RC,,,both,,,492,364.08,,,364.08,Other,150% of Medicare + 9.63% HCRA Surcharge,221.4,45,,221.4,percent of total billed charges,Critical Access Hospital RCC factor,167.28,34,,167.28,percent of total billed charges,Implant Device,167.28,34,,167.28,percent of total billed charges,Implant Device,167.28,34,,167.28,percent of total billed charges,Implant Device,167.28,34,,167.28,percent of total billed charges,Implant Device,167.28,34,,167.28,percent of total billed charges,Implant Device,243.54,,,243.54,Other,110% of Medicare,172.2,35,,172.2,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,172.2,35,,172.2,percent of total billed charges,Implant Device,172.2,35,,172.2,percent of total billed charges,Implant Device,172.2,35,,172.2,percent of total billed charges,Implant Device,172.2,35,,172.2,percent of total billed charges,Implant Device,172.2,35,,172.2,percent of total billed charges,Implant Device,196.8,40,,196.8,percent of total billed charges,Implant Device,172.2,70,,172.2,percent of total billed charges,All Other,167.28,34,,167.28,percent of total billed charges,Implant Device,167.28,34,,167.28,percent of total billed charges,Implant Device,172.2,35,,172.2,percent of total billed charges,Implant Device,172.2,35,,172.2,percent of total billed charges,Implant Device,172.2,35,,172.2,percent of total billed charges,Implant Device,172.2,35,,172.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,364.08,
STRYKER 371530 LOCKING SCREW 4.0X30MM,C1713,HCPCS,,79003343,CDM,278,RC,,,both,,,569,421.06,,,421.06,Other,150% of Medicare + 9.63% HCRA Surcharge,256.05,45,,256.05,percent of total billed charges,Critical Access Hospital RCC factor,193.46,34,,193.46,percent of total billed charges,Implant Device,193.46,34,,193.46,percent of total billed charges,Implant Device,193.46,34,,193.46,percent of total billed charges,Implant Device,193.46,34,,193.46,percent of total billed charges,Implant Device,193.46,34,,193.46,percent of total billed charges,Implant Device,281.66,,,281.66,Other,110% of Medicare,199.15,35,,199.15,percent of total billed charges,Implant Device,193.46,34,"Charges > $500, x 34%",193.46,percent of total billed charges,Implant Device,199.15,35,,199.15,percent of total billed charges,Implant Device,199.15,35,,199.15,percent of total billed charges,Implant Device,199.15,35,,199.15,percent of total billed charges,Implant Device,199.15,35,,199.15,percent of total billed charges,Implant Device,199.15,35,,199.15,percent of total billed charges,Implant Device,227.6,40,,227.6,percent of total billed charges,Implant Device,199.15,70,,199.15,percent of total billed charges,All Other,193.46,34,,193.46,percent of total billed charges,Implant Device,193.46,34,,193.46,percent of total billed charges,Implant Device,199.15,35,,199.15,percent of total billed charges,Implant Device,199.15,35,,199.15,percent of total billed charges,Implant Device,199.15,35,,199.15,percent of total billed charges,Implant Device,199.15,35,,199.15,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,421.06,
STRYKER 371532 LOCKING SCREW 4.0X32MM,C1713,HCPCS,,79003344,CDM,278,RC,,,both,,,569,421.06,,,421.06,Other,150% of Medicare + 9.63% HCRA Surcharge,256.05,45,,256.05,percent of total billed charges,Critical Access Hospital RCC factor,193.46,34,,193.46,percent of total billed charges,Implant Device,193.46,34,,193.46,percent of total billed charges,Implant Device,193.46,34,,193.46,percent of total billed charges,Implant Device,193.46,34,,193.46,percent of total billed charges,Implant Device,193.46,34,,193.46,percent of total billed charges,Implant Device,281.66,,,281.66,Other,110% of Medicare,199.15,35,,199.15,percent of total billed charges,Implant Device,193.46,34,"Charges > $500, x 34%",193.46,percent of total billed charges,Implant Device,199.15,35,,199.15,percent of total billed charges,Implant Device,199.15,35,,199.15,percent of total billed charges,Implant Device,199.15,35,,199.15,percent of total billed charges,Implant Device,199.15,35,,199.15,percent of total billed charges,Implant Device,199.15,35,,199.15,percent of total billed charges,Implant Device,227.6,40,,227.6,percent of total billed charges,Implant Device,199.15,70,,199.15,percent of total billed charges,All Other,193.46,34,,193.46,percent of total billed charges,Implant Device,193.46,34,,193.46,percent of total billed charges,Implant Device,199.15,35,,199.15,percent of total billed charges,Implant Device,199.15,35,,199.15,percent of total billed charges,Implant Device,199.15,35,,199.15,percent of total billed charges,Implant Device,199.15,35,,199.15,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,421.06,
STRYKER 371536 LOCKING SCREW 4.0X36MM,C1713,HCPCS,,79003345,CDM,278,RC,,,both,,,541,400.34,,,400.34,Other,150% of Medicare + 9.63% HCRA Surcharge,243.45,45,,243.45,percent of total billed charges,Critical Access Hospital RCC factor,183.94,34,,183.94,percent of total billed charges,Implant Device,183.94,34,,183.94,percent of total billed charges,Implant Device,183.94,34,,183.94,percent of total billed charges,Implant Device,183.94,34,,183.94,percent of total billed charges,Implant Device,183.94,34,,183.94,percent of total billed charges,Implant Device,267.8,,,267.8,Other,110% of Medicare,189.35,35,,189.35,percent of total billed charges,Implant Device,183.94,34,"Charges > $500, x 34%",183.94,percent of total billed charges,Implant Device,189.35,35,,189.35,percent of total billed charges,Implant Device,189.35,35,,189.35,percent of total billed charges,Implant Device,189.35,35,,189.35,percent of total billed charges,Implant Device,189.35,35,,189.35,percent of total billed charges,Implant Device,189.35,35,,189.35,percent of total billed charges,Implant Device,216.4,40,,216.4,percent of total billed charges,Implant Device,189.35,70,,189.35,percent of total billed charges,All Other,183.94,34,,183.94,percent of total billed charges,Implant Device,183.94,34,,183.94,percent of total billed charges,Implant Device,189.35,35,,189.35,percent of total billed charges,Implant Device,189.35,35,,189.35,percent of total billed charges,Implant Device,189.35,35,,189.35,percent of total billed charges,Implant Device,189.35,35,,189.35,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,400.34,
STRYKER 371542 LOCKING SCREW 4.0X42MM,C1713,HCPCS,,79003346,CDM,278,RC,,,both,,,569,421.06,,,421.06,Other,150% of Medicare + 9.63% HCRA Surcharge,256.05,45,,256.05,percent of total billed charges,Critical Access Hospital RCC factor,193.46,34,,193.46,percent of total billed charges,Implant Device,193.46,34,,193.46,percent of total billed charges,Implant Device,193.46,34,,193.46,percent of total billed charges,Implant Device,193.46,34,,193.46,percent of total billed charges,Implant Device,193.46,34,,193.46,percent of total billed charges,Implant Device,281.66,,,281.66,Other,110% of Medicare,199.15,35,,199.15,percent of total billed charges,Implant Device,193.46,34,"Charges > $500, x 34%",193.46,percent of total billed charges,Implant Device,199.15,35,,199.15,percent of total billed charges,Implant Device,199.15,35,,199.15,percent of total billed charges,Implant Device,199.15,35,,199.15,percent of total billed charges,Implant Device,199.15,35,,199.15,percent of total billed charges,Implant Device,199.15,35,,199.15,percent of total billed charges,Implant Device,227.6,40,,227.6,percent of total billed charges,Implant Device,199.15,70,,199.15,percent of total billed charges,All Other,193.46,34,,193.46,percent of total billed charges,Implant Device,193.46,34,,193.46,percent of total billed charges,Implant Device,199.15,35,,199.15,percent of total billed charges,Implant Device,199.15,35,,199.15,percent of total billed charges,Implant Device,199.15,35,,199.15,percent of total billed charges,Implant Device,199.15,35,,199.15,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,421.06,
ZIMMER 5988-11-16-REV STEM EXT 16X155MM,C1776,HCPCS,,79003347,CDM,278,RC,,,both,,,2970,2197.81,,,2197.81,Other,150% of Medicare + 9.63% HCRA Surcharge,1336.5,45,,1336.5,percent of total billed charges,Critical Access Hospital RCC factor,1009.8,34,,1009.8,percent of total billed charges,Implant Device,1009.8,34,,1009.8,percent of total billed charges,Implant Device,1009.8,34,,1009.8,percent of total billed charges,Implant Device,1009.8,34,,1009.8,percent of total billed charges,Implant Device,1009.8,34,,1009.8,percent of total billed charges,Implant Device,1470.15,,,1470.15,Other,110% of Medicare,1039.5,35,,1039.5,percent of total billed charges,Implant Device,1009.8,34,"Charges > $500, x 34%",1009.8,percent of total billed charges,Implant Device,1039.5,35,,1039.5,percent of total billed charges,Implant Device,1039.5,35,,1039.5,percent of total billed charges,Implant Device,1039.5,35,,1039.5,percent of total billed charges,Implant Device,1039.5,35,,1039.5,percent of total billed charges,Implant Device,1039.5,35,,1039.5,percent of total billed charges,Implant Device,1188,40,,1188,percent of total billed charges,Implant Device,1039.5,70,,1039.5,percent of total billed charges,All Other,1009.8,34,,1009.8,percent of total billed charges,Implant Device,1009.8,34,,1009.8,percent of total billed charges,Implant Device,1039.5,35,,1039.5,percent of total billed charges,Implant Device,1039.5,35,,1039.5,percent of total billed charges,Implant Device,1039.5,35,,1039.5,percent of total billed charges,Implant Device,1039.5,35,,1039.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1009.8,34,"If Charge > 2,000, then 34 percent",1009.8,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2197.81,
ZIMMER 00-5450-013-46-REV TRAB TIB CONE,C1776,HCPCS,,79003348,CDM,278,RC,,,both,,,13113,9703.65,,,9703.65,Other,150% of Medicare + 9.63% HCRA Surcharge,5900.85,45,,5900.85,percent of total billed charges,Critical Access Hospital RCC factor,4458.42,34,,4458.42,percent of total billed charges,Implant Device,4458.42,34,,4458.42,percent of total billed charges,Implant Device,4458.42,34,,4458.42,percent of total billed charges,Implant Device,4458.42,34,,4458.42,percent of total billed charges,Implant Device,4458.42,34,,4458.42,percent of total billed charges,Implant Device,6490.94,,,6490.94,Other,110% of Medicare,4589.55,35,,4589.55,percent of total billed charges,Implant Device,4458.42,34,"Charges > $500, x 34%",4458.42,percent of total billed charges,Implant Device,4589.55,35,,4589.55,percent of total billed charges,Implant Device,4589.55,35,,4589.55,percent of total billed charges,Implant Device,4589.55,35,,4589.55,percent of total billed charges,Implant Device,4589.55,35,,4589.55,percent of total billed charges,Implant Device,4589.55,35,,4589.55,percent of total billed charges,Implant Device,5245.2,40,,5245.2,percent of total billed charges,Implant Device,4589.55,70,,4589.55,percent of total billed charges,All Other,4458.42,34,,4458.42,percent of total billed charges,Implant Device,4458.42,34,,4458.42,percent of total billed charges,Implant Device,4589.55,35,,4589.55,percent of total billed charges,Implant Device,4589.55,35,,4589.55,percent of total billed charges,Implant Device,4589.55,35,,4589.55,percent of total billed charges,Implant Device,4589.55,35,,4589.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,4458.42,34,"If Charge > 2,000, then 34 percent",4458.42,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,9703.65,
ZIMMER 5980-47-02-REV NEXGEN TIBIAL COMP,C1776,HCPCS,,79003350,CDM,278,RC,,,both,,,6616,4895.86,,,4895.86,Other,150% of Medicare + 9.63% HCRA Surcharge,2977.2,45,,2977.2,percent of total billed charges,Critical Access Hospital RCC factor,2249.44,34,,2249.44,percent of total billed charges,Implant Device,2249.44,34,,2249.44,percent of total billed charges,Implant Device,2249.44,34,,2249.44,percent of total billed charges,Implant Device,2249.44,34,,2249.44,percent of total billed charges,Implant Device,2249.44,34,,2249.44,percent of total billed charges,Implant Device,3274.92,,,3274.92,Other,110% of Medicare,2315.6,35,,2315.6,percent of total billed charges,Implant Device,2249.44,34,"Charges > $500, x 34%",2249.44,percent of total billed charges,Implant Device,2315.6,35,,2315.6,percent of total billed charges,Implant Device,2315.6,35,,2315.6,percent of total billed charges,Implant Device,2315.6,35,,2315.6,percent of total billed charges,Implant Device,2315.6,35,,2315.6,percent of total billed charges,Implant Device,2315.6,35,,2315.6,percent of total billed charges,Implant Device,2646.4,40,,2646.4,percent of total billed charges,Implant Device,2315.6,70,,2315.6,percent of total billed charges,All Other,2249.44,34,,2249.44,percent of total billed charges,Implant Device,2249.44,34,,2249.44,percent of total billed charges,Implant Device,2315.6,35,,2315.6,percent of total billed charges,Implant Device,2315.6,35,,2315.6,percent of total billed charges,Implant Device,2315.6,35,,2315.6,percent of total billed charges,Implant Device,2315.6,35,,2315.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2249.44,34,"If Charge > 2,000, then 34 percent",2249.44,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4895.86,
ZIMMER 90-5952-40-17-REV NEXGEN ART SURF,C1776,HCPCS,,79003351,CDM,278,RC,,,both,,,5107,3779.19,,,3779.19,Other,150% of Medicare + 9.63% HCRA Surcharge,2298.15,45,,2298.15,percent of total billed charges,Critical Access Hospital RCC factor,1736.38,34,,1736.38,percent of total billed charges,Implant Device,1736.38,34,,1736.38,percent of total billed charges,Implant Device,1736.38,34,,1736.38,percent of total billed charges,Implant Device,1736.38,34,,1736.38,percent of total billed charges,Implant Device,1736.38,34,,1736.38,percent of total billed charges,Implant Device,2527.97,,,2527.97,Other,110% of Medicare,1787.45,35,,1787.45,percent of total billed charges,Implant Device,1736.38,34,"Charges > $500, x 34%",1736.38,percent of total billed charges,Implant Device,1787.45,35,,1787.45,percent of total billed charges,Implant Device,1787.45,35,,1787.45,percent of total billed charges,Implant Device,1787.45,35,,1787.45,percent of total billed charges,Implant Device,1787.45,35,,1787.45,percent of total billed charges,Implant Device,1787.45,35,,1787.45,percent of total billed charges,Implant Device,2042.8,40,,2042.8,percent of total billed charges,Implant Device,1787.45,70,,1787.45,percent of total billed charges,All Other,1736.38,34,,1736.38,percent of total billed charges,Implant Device,1736.38,34,,1736.38,percent of total billed charges,Implant Device,1787.45,35,,1787.45,percent of total billed charges,Implant Device,1787.45,35,,1787.45,percent of total billed charges,Implant Device,1787.45,35,,1787.45,percent of total billed charges,Implant Device,1787.45,35,,1787.45,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1736.38,34,"If Charge > 2,000, then 34 percent",1736.38,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3779.19,
EXACTECH 320-20-34 COMPRESSION SCRW 34MM,C1713,HCPCS,,79003360,CDM,278,RC,,,both,,,300,222,,,222,Other,150% of Medicare + 9.63% HCRA Surcharge,135,45,,135,percent of total billed charges,Critical Access Hospital RCC factor,102,34,,102,percent of total billed charges,Implant Device,102,34,,102,percent of total billed charges,Implant Device,102,34,,102,percent of total billed charges,Implant Device,102,34,,102,percent of total billed charges,Implant Device,102,34,,102,percent of total billed charges,Implant Device,148.5,,,148.5,Other,110% of Medicare,105,35,,105,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,105,35,,105,percent of total billed charges,Implant Device,105,35,,105,percent of total billed charges,Implant Device,105,35,,105,percent of total billed charges,Implant Device,105,35,,105,percent of total billed charges,Implant Device,105,35,,105,percent of total billed charges,Implant Device,120,40,,120,percent of total billed charges,Implant Device,105,70,,105,percent of total billed charges,All Other,102,34,,102,percent of total billed charges,Implant Device,102,34,,102,percent of total billed charges,Implant Device,105,35,,105,percent of total billed charges,Implant Device,105,35,,105,percent of total billed charges,Implant Device,105,35,,105,percent of total billed charges,Implant Device,105,35,,105,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,222,
EXACTECH 320-20-22 COMPRESSION SCRW 22MM,C1713,HCPCS,,79003361,CDM,278,RC,,,both,,,300,222,,,222,Other,150% of Medicare + 9.63% HCRA Surcharge,135,45,,135,percent of total billed charges,Critical Access Hospital RCC factor,102,34,,102,percent of total billed charges,Implant Device,102,34,,102,percent of total billed charges,Implant Device,102,34,,102,percent of total billed charges,Implant Device,102,34,,102,percent of total billed charges,Implant Device,102,34,,102,percent of total billed charges,Implant Device,148.5,,,148.5,Other,110% of Medicare,105,35,,105,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,105,35,,105,percent of total billed charges,Implant Device,105,35,,105,percent of total billed charges,Implant Device,105,35,,105,percent of total billed charges,Implant Device,105,35,,105,percent of total billed charges,Implant Device,105,35,,105,percent of total billed charges,Implant Device,120,40,,120,percent of total billed charges,Implant Device,105,70,,105,percent of total billed charges,All Other,102,34,,102,percent of total billed charges,Implant Device,102,34,,102,percent of total billed charges,Implant Device,105,35,,105,percent of total billed charges,Implant Device,105,35,,105,percent of total billed charges,Implant Device,105,35,,105,percent of total billed charges,Implant Device,105,35,,105,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,222,
EXACTECH 300-01-11 HUMERAL STEM 11MM,C1776,HCPCS,,79003362,CDM,278,RC,,,both,,,4425,3274.51,,,3274.51,Other,150% of Medicare + 9.63% HCRA Surcharge,1991.25,45,,1991.25,percent of total billed charges,Critical Access Hospital RCC factor,1504.5,34,,1504.5,percent of total billed charges,Implant Device,1504.5,34,,1504.5,percent of total billed charges,Implant Device,1504.5,34,,1504.5,percent of total billed charges,Implant Device,1504.5,34,,1504.5,percent of total billed charges,Implant Device,1504.5,34,,1504.5,percent of total billed charges,Implant Device,2190.38,,,2190.38,Other,110% of Medicare,1548.75,35,,1548.75,percent of total billed charges,Implant Device,1504.5,34,"Charges > $500, x 34%",1504.5,percent of total billed charges,Implant Device,1548.75,35,,1548.75,percent of total billed charges,Implant Device,1548.75,35,,1548.75,percent of total billed charges,Implant Device,1548.75,35,,1548.75,percent of total billed charges,Implant Device,1548.75,35,,1548.75,percent of total billed charges,Implant Device,1548.75,35,,1548.75,percent of total billed charges,Implant Device,1770,40,,1770,percent of total billed charges,Implant Device,1548.75,70,,1548.75,percent of total billed charges,All Other,1504.5,34,,1504.5,percent of total billed charges,Implant Device,1504.5,34,,1504.5,percent of total billed charges,Implant Device,1548.75,35,,1548.75,percent of total billed charges,Implant Device,1548.75,35,,1548.75,percent of total billed charges,Implant Device,1548.75,35,,1548.75,percent of total billed charges,Implant Device,1548.75,35,,1548.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1504.5,34,"If Charge > 2,000, then 34 percent",1504.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3274.51,
EXACTECH 340-02-01 EQUINOX FX PLATE 80MM,C1713,HCPCS,,79003363,CDM,278,RC,,,both,,,4644,3436.57,,,3436.57,Other,150% of Medicare + 9.63% HCRA Surcharge,2089.8,45,,2089.8,percent of total billed charges,Critical Access Hospital RCC factor,1578.96,34,,1578.96,percent of total billed charges,Implant Device,1578.96,34,,1578.96,percent of total billed charges,Implant Device,1578.96,34,,1578.96,percent of total billed charges,Implant Device,1578.96,34,,1578.96,percent of total billed charges,Implant Device,1578.96,34,,1578.96,percent of total billed charges,Implant Device,2298.78,,,2298.78,Other,110% of Medicare,1625.4,35,,1625.4,percent of total billed charges,Implant Device,1578.96,34,"Charges > $500, x 34%",1578.96,percent of total billed charges,Implant Device,1625.4,35,,1625.4,percent of total billed charges,Implant Device,1625.4,35,,1625.4,percent of total billed charges,Implant Device,1625.4,35,,1625.4,percent of total billed charges,Implant Device,1625.4,35,,1625.4,percent of total billed charges,Implant Device,1625.4,35,,1625.4,percent of total billed charges,Implant Device,1857.6,40,,1857.6,percent of total billed charges,Implant Device,1625.4,70,,1625.4,percent of total billed charges,All Other,1578.96,34,,1578.96,percent of total billed charges,Implant Device,1578.96,34,,1578.96,percent of total billed charges,Implant Device,1625.4,35,,1625.4,percent of total billed charges,Implant Device,1625.4,35,,1625.4,percent of total billed charges,Implant Device,1625.4,35,,1625.4,percent of total billed charges,Implant Device,1625.4,35,,1625.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1578.96,34,"If Charge > 2,000, then 34 percent",1578.96,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3436.57,
EXACTECH 340-65-35 CANC LCK SCREW 6.5X35,C1713,HCPCS,,79003364,CDM,278,RC,,,both,,,581,429.94,,,429.94,Other,150% of Medicare + 9.63% HCRA Surcharge,261.45,45,,261.45,percent of total billed charges,Critical Access Hospital RCC factor,197.54,34,,197.54,percent of total billed charges,Implant Device,197.54,34,,197.54,percent of total billed charges,Implant Device,197.54,34,,197.54,percent of total billed charges,Implant Device,197.54,34,,197.54,percent of total billed charges,Implant Device,197.54,34,,197.54,percent of total billed charges,Implant Device,287.6,,,287.6,Other,110% of Medicare,203.35,35,,203.35,percent of total billed charges,Implant Device,197.54,34,"Charges > $500, x 34%",197.54,percent of total billed charges,Implant Device,203.35,35,,203.35,percent of total billed charges,Implant Device,203.35,35,,203.35,percent of total billed charges,Implant Device,203.35,35,,203.35,percent of total billed charges,Implant Device,203.35,35,,203.35,percent of total billed charges,Implant Device,203.35,35,,203.35,percent of total billed charges,Implant Device,232.4,40,,232.4,percent of total billed charges,Implant Device,203.35,70,,203.35,percent of total billed charges,All Other,197.54,34,,197.54,percent of total billed charges,Implant Device,197.54,34,,197.54,percent of total billed charges,Implant Device,203.35,35,,203.35,percent of total billed charges,Implant Device,203.35,35,,203.35,percent of total billed charges,Implant Device,203.35,35,,203.35,percent of total billed charges,Implant Device,203.35,35,,203.35,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,429.94,
EXACTECH 340-38-20 CANC LCK SCREW 3.8X20,C1713,HCPCS,,79003365,CDM,278,RC,,,both,,,406,300.44,,,300.44,Other,150% of Medicare + 9.63% HCRA Surcharge,182.7,45,,182.7,percent of total billed charges,Critical Access Hospital RCC factor,138.04,34,,138.04,percent of total billed charges,Implant Device,138.04,34,,138.04,percent of total billed charges,Implant Device,138.04,34,,138.04,percent of total billed charges,Implant Device,138.04,34,,138.04,percent of total billed charges,Implant Device,138.04,34,,138.04,percent of total billed charges,Implant Device,200.97,,,200.97,Other,110% of Medicare,142.1,35,,142.1,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,142.1,35,,142.1,percent of total billed charges,Implant Device,142.1,35,,142.1,percent of total billed charges,Implant Device,142.1,35,,142.1,percent of total billed charges,Implant Device,142.1,35,,142.1,percent of total billed charges,Implant Device,142.1,35,,142.1,percent of total billed charges,Implant Device,162.4,40,,162.4,percent of total billed charges,Implant Device,142.1,70,,142.1,percent of total billed charges,All Other,138.04,34,,138.04,percent of total billed charges,Implant Device,138.04,34,,138.04,percent of total billed charges,Implant Device,142.1,35,,142.1,percent of total billed charges,Implant Device,142.1,35,,142.1,percent of total billed charges,Implant Device,142.1,35,,142.1,percent of total billed charges,Implant Device,142.1,35,,142.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,300.44,
EXACTECH 340-38-23 CANC LCK SCREW 3.8X23,C1713,HCPCS,,79003366,CDM,278,RC,,,both,,,499,369.26,,,369.26,Other,150% of Medicare + 9.63% HCRA Surcharge,224.55,45,,224.55,percent of total billed charges,Critical Access Hospital RCC factor,169.66,34,,169.66,percent of total billed charges,Implant Device,169.66,34,,169.66,percent of total billed charges,Implant Device,169.66,34,,169.66,percent of total billed charges,Implant Device,169.66,34,,169.66,percent of total billed charges,Implant Device,169.66,34,,169.66,percent of total billed charges,Implant Device,247.01,,,247.01,Other,110% of Medicare,174.65,35,,174.65,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,174.65,35,,174.65,percent of total billed charges,Implant Device,174.65,35,,174.65,percent of total billed charges,Implant Device,174.65,35,,174.65,percent of total billed charges,Implant Device,174.65,35,,174.65,percent of total billed charges,Implant Device,174.65,35,,174.65,percent of total billed charges,Implant Device,199.6,40,,199.6,percent of total billed charges,Implant Device,174.65,70,,174.65,percent of total billed charges,All Other,169.66,34,,169.66,percent of total billed charges,Implant Device,169.66,34,,169.66,percent of total billed charges,Implant Device,174.65,35,,174.65,percent of total billed charges,Implant Device,174.65,35,,174.65,percent of total billed charges,Implant Device,174.65,35,,174.65,percent of total billed charges,Implant Device,174.65,35,,174.65,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,369.26,
EXACTECH 340-38-26 CANC LCK SCREW 3.8X26,C1713,HCPCS,,79003367,CDM,278,RC,,,both,,,499,369.26,,,369.26,Other,150% of Medicare + 9.63% HCRA Surcharge,224.55,45,,224.55,percent of total billed charges,Critical Access Hospital RCC factor,169.66,34,,169.66,percent of total billed charges,Implant Device,169.66,34,,169.66,percent of total billed charges,Implant Device,169.66,34,,169.66,percent of total billed charges,Implant Device,169.66,34,,169.66,percent of total billed charges,Implant Device,169.66,34,,169.66,percent of total billed charges,Implant Device,247.01,,,247.01,Other,110% of Medicare,174.65,35,,174.65,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,174.65,35,,174.65,percent of total billed charges,Implant Device,174.65,35,,174.65,percent of total billed charges,Implant Device,174.65,35,,174.65,percent of total billed charges,Implant Device,174.65,35,,174.65,percent of total billed charges,Implant Device,174.65,35,,174.65,percent of total billed charges,Implant Device,199.6,40,,199.6,percent of total billed charges,Implant Device,174.65,70,,174.65,percent of total billed charges,All Other,169.66,34,,169.66,percent of total billed charges,Implant Device,169.66,34,,169.66,percent of total billed charges,Implant Device,174.65,35,,174.65,percent of total billed charges,Implant Device,174.65,35,,174.65,percent of total billed charges,Implant Device,174.65,35,,174.65,percent of total billed charges,Implant Device,174.65,35,,174.65,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,369.26,
EXACTECH 340-38-32 CANC LCK SCREW 3.8X32,C1713,HCPCS,,79003368,CDM,278,RC,,,both,,,499,369.26,,,369.26,Other,150% of Medicare + 9.63% HCRA Surcharge,224.55,45,,224.55,percent of total billed charges,Critical Access Hospital RCC factor,169.66,34,,169.66,percent of total billed charges,Implant Device,169.66,34,,169.66,percent of total billed charges,Implant Device,169.66,34,,169.66,percent of total billed charges,Implant Device,169.66,34,,169.66,percent of total billed charges,Implant Device,169.66,34,,169.66,percent of total billed charges,Implant Device,247.01,,,247.01,Other,110% of Medicare,174.65,35,,174.65,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,174.65,35,,174.65,percent of total billed charges,Implant Device,174.65,35,,174.65,percent of total billed charges,Implant Device,174.65,35,,174.65,percent of total billed charges,Implant Device,174.65,35,,174.65,percent of total billed charges,Implant Device,174.65,35,,174.65,percent of total billed charges,Implant Device,199.6,40,,199.6,percent of total billed charges,Implant Device,174.65,70,,174.65,percent of total billed charges,All Other,169.66,34,,169.66,percent of total billed charges,Implant Device,169.66,34,,169.66,percent of total billed charges,Implant Device,174.65,35,,174.65,percent of total billed charges,Implant Device,174.65,35,,174.65,percent of total billed charges,Implant Device,174.65,35,,174.65,percent of total billed charges,Implant Device,174.65,35,,174.65,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,369.26,
EXACTECH 340-38-35 CANC LCK SCREW 3.8X35,C1713,HCPCS,,79003369,CDM,278,RC,,,both,,,499,369.26,,,369.26,Other,150% of Medicare + 9.63% HCRA Surcharge,224.55,45,,224.55,percent of total billed charges,Critical Access Hospital RCC factor,169.66,34,,169.66,percent of total billed charges,Implant Device,169.66,34,,169.66,percent of total billed charges,Implant Device,169.66,34,,169.66,percent of total billed charges,Implant Device,169.66,34,,169.66,percent of total billed charges,Implant Device,169.66,34,,169.66,percent of total billed charges,Implant Device,247.01,,,247.01,Other,110% of Medicare,174.65,35,,174.65,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,174.65,35,,174.65,percent of total billed charges,Implant Device,174.65,35,,174.65,percent of total billed charges,Implant Device,174.65,35,,174.65,percent of total billed charges,Implant Device,174.65,35,,174.65,percent of total billed charges,Implant Device,174.65,35,,174.65,percent of total billed charges,Implant Device,199.6,40,,199.6,percent of total billed charges,Implant Device,174.65,70,,174.65,percent of total billed charges,All Other,169.66,34,,169.66,percent of total billed charges,Implant Device,169.66,34,,169.66,percent of total billed charges,Implant Device,174.65,35,,174.65,percent of total billed charges,Implant Device,174.65,35,,174.65,percent of total billed charges,Implant Device,174.65,35,,174.65,percent of total billed charges,Implant Device,174.65,35,,174.65,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,369.26,
EXACTECH 340-38-38 CANC LCK SCREW 3.8X38,C1713,HCPCS,,79003370,CDM,278,RC,,,both,,,499,369.26,,,369.26,Other,150% of Medicare + 9.63% HCRA Surcharge,224.55,45,,224.55,percent of total billed charges,Critical Access Hospital RCC factor,169.66,34,,169.66,percent of total billed charges,Implant Device,169.66,34,,169.66,percent of total billed charges,Implant Device,169.66,34,,169.66,percent of total billed charges,Implant Device,169.66,34,,169.66,percent of total billed charges,Implant Device,169.66,34,,169.66,percent of total billed charges,Implant Device,247.01,,,247.01,Other,110% of Medicare,174.65,35,,174.65,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,174.65,35,,174.65,percent of total billed charges,Implant Device,174.65,35,,174.65,percent of total billed charges,Implant Device,174.65,35,,174.65,percent of total billed charges,Implant Device,174.65,35,,174.65,percent of total billed charges,Implant Device,174.65,35,,174.65,percent of total billed charges,Implant Device,199.6,40,,199.6,percent of total billed charges,Implant Device,174.65,70,,174.65,percent of total billed charges,All Other,169.66,34,,169.66,percent of total billed charges,Implant Device,169.66,34,,169.66,percent of total billed charges,Implant Device,174.65,35,,174.65,percent of total billed charges,Implant Device,174.65,35,,174.65,percent of total billed charges,Implant Device,174.65,35,,174.65,percent of total billed charges,Implant Device,174.65,35,,174.65,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,369.26,
EXACTECH 340-40-23 CORT LCK SCREW 3.8X23,C1713,HCPCS,,79003371,CDM,278,RC,,,both,,,499,369.26,,,369.26,Other,150% of Medicare + 9.63% HCRA Surcharge,224.55,45,,224.55,percent of total billed charges,Critical Access Hospital RCC factor,169.66,34,,169.66,percent of total billed charges,Implant Device,169.66,34,,169.66,percent of total billed charges,Implant Device,169.66,34,,169.66,percent of total billed charges,Implant Device,169.66,34,,169.66,percent of total billed charges,Implant Device,169.66,34,,169.66,percent of total billed charges,Implant Device,247.01,,,247.01,Other,110% of Medicare,174.65,35,,174.65,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,174.65,35,,174.65,percent of total billed charges,Implant Device,174.65,35,,174.65,percent of total billed charges,Implant Device,174.65,35,,174.65,percent of total billed charges,Implant Device,174.65,35,,174.65,percent of total billed charges,Implant Device,174.65,35,,174.65,percent of total billed charges,Implant Device,199.6,40,,199.6,percent of total billed charges,Implant Device,174.65,70,,174.65,percent of total billed charges,All Other,169.66,34,,169.66,percent of total billed charges,Implant Device,169.66,34,,169.66,percent of total billed charges,Implant Device,174.65,35,,174.65,percent of total billed charges,Implant Device,174.65,35,,174.65,percent of total billed charges,Implant Device,174.65,35,,174.65,percent of total billed charges,Implant Device,174.65,35,,174.65,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,369.26,
EXACTECH 340-40-26 CORT LCK SCREW 3.8X26,C1713,HCPCS,,79003372,CDM,278,RC,,,both,,,499,369.26,,,369.26,Other,150% of Medicare + 9.63% HCRA Surcharge,224.55,45,,224.55,percent of total billed charges,Critical Access Hospital RCC factor,169.66,34,,169.66,percent of total billed charges,Implant Device,169.66,34,,169.66,percent of total billed charges,Implant Device,169.66,34,,169.66,percent of total billed charges,Implant Device,169.66,34,,169.66,percent of total billed charges,Implant Device,169.66,34,,169.66,percent of total billed charges,Implant Device,247.01,,,247.01,Other,110% of Medicare,174.65,35,,174.65,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,174.65,35,,174.65,percent of total billed charges,Implant Device,174.65,35,,174.65,percent of total billed charges,Implant Device,174.65,35,,174.65,percent of total billed charges,Implant Device,174.65,35,,174.65,percent of total billed charges,Implant Device,174.65,35,,174.65,percent of total billed charges,Implant Device,199.6,40,,199.6,percent of total billed charges,Implant Device,174.65,70,,174.65,percent of total billed charges,All Other,169.66,34,,169.66,percent of total billed charges,Implant Device,169.66,34,,169.66,percent of total billed charges,Implant Device,174.65,35,,174.65,percent of total billed charges,Implant Device,174.65,35,,174.65,percent of total billed charges,Implant Device,174.65,35,,174.65,percent of total billed charges,Implant Device,174.65,35,,174.65,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,369.26,
EXACTECH 340-41-23 CORT CMP SCREW 3.8X23,C1713,HCPCS,,79003373,CDM,278,RC,,,both,,,499,369.26,,,369.26,Other,150% of Medicare + 9.63% HCRA Surcharge,224.55,45,,224.55,percent of total billed charges,Critical Access Hospital RCC factor,169.66,34,,169.66,percent of total billed charges,Implant Device,169.66,34,,169.66,percent of total billed charges,Implant Device,169.66,34,,169.66,percent of total billed charges,Implant Device,169.66,34,,169.66,percent of total billed charges,Implant Device,169.66,34,,169.66,percent of total billed charges,Implant Device,247.01,,,247.01,Other,110% of Medicare,174.65,35,,174.65,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,174.65,35,,174.65,percent of total billed charges,Implant Device,174.65,35,,174.65,percent of total billed charges,Implant Device,174.65,35,,174.65,percent of total billed charges,Implant Device,174.65,35,,174.65,percent of total billed charges,Implant Device,174.65,35,,174.65,percent of total billed charges,Implant Device,199.6,40,,199.6,percent of total billed charges,Implant Device,174.65,70,,174.65,percent of total billed charges,All Other,169.66,34,,169.66,percent of total billed charges,Implant Device,169.66,34,,169.66,percent of total billed charges,Implant Device,174.65,35,,174.65,percent of total billed charges,Implant Device,174.65,35,,174.65,percent of total billed charges,Implant Device,174.65,35,,174.65,percent of total billed charges,Implant Device,174.65,35,,174.65,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,369.26,
EXACTECH 340-41-26 CORT CMP SCREW 3.8X26,C1713,HCPCS,,79003374,CDM,278,RC,,,both,,,499,369.26,,,369.26,Other,150% of Medicare + 9.63% HCRA Surcharge,224.55,45,,224.55,percent of total billed charges,Critical Access Hospital RCC factor,169.66,34,,169.66,percent of total billed charges,Implant Device,169.66,34,,169.66,percent of total billed charges,Implant Device,169.66,34,,169.66,percent of total billed charges,Implant Device,169.66,34,,169.66,percent of total billed charges,Implant Device,169.66,34,,169.66,percent of total billed charges,Implant Device,247.01,,,247.01,Other,110% of Medicare,174.65,35,,174.65,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,174.65,35,,174.65,percent of total billed charges,Implant Device,174.65,35,,174.65,percent of total billed charges,Implant Device,174.65,35,,174.65,percent of total billed charges,Implant Device,174.65,35,,174.65,percent of total billed charges,Implant Device,174.65,35,,174.65,percent of total billed charges,Implant Device,199.6,40,,199.6,percent of total billed charges,Implant Device,174.65,70,,174.65,percent of total billed charges,All Other,169.66,34,,169.66,percent of total billed charges,Implant Device,169.66,34,,169.66,percent of total billed charges,Implant Device,174.65,35,,174.65,percent of total billed charges,Implant Device,174.65,35,,174.65,percent of total billed charges,Implant Device,174.65,35,,174.65,percent of total billed charges,Implant Device,174.65,35,,174.65,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,369.26,
EXACTECH 320-10-05 HUMERAL ADAPTOR +5MM,C1776,HCPCS,,79003392,CDM,278,RC,,,both,,,6480,4795.22,,,4795.22,Other,150% of Medicare + 9.63% HCRA Surcharge,2916,45,,2916,percent of total billed charges,Critical Access Hospital RCC factor,2203.2,34,,2203.2,percent of total billed charges,Implant Device,2203.2,34,,2203.2,percent of total billed charges,Implant Device,2203.2,34,,2203.2,percent of total billed charges,Implant Device,2203.2,34,,2203.2,percent of total billed charges,Implant Device,2203.2,34,,2203.2,percent of total billed charges,Implant Device,3207.6,,,3207.6,Other,110% of Medicare,2268,35,,2268,percent of total billed charges,Implant Device,2203.2,34,"Charges > $500, x 34%",2203.2,percent of total billed charges,Implant Device,2268,35,,2268,percent of total billed charges,Implant Device,2268,35,,2268,percent of total billed charges,Implant Device,2268,35,,2268,percent of total billed charges,Implant Device,2268,35,,2268,percent of total billed charges,Implant Device,2268,35,,2268,percent of total billed charges,Implant Device,2592,40,,2592,percent of total billed charges,Implant Device,2268,70,,2268,percent of total billed charges,All Other,2203.2,34,,2203.2,percent of total billed charges,Implant Device,2203.2,34,,2203.2,percent of total billed charges,Implant Device,2268,35,,2268,percent of total billed charges,Implant Device,2268,35,,2268,percent of total billed charges,Implant Device,2268,35,,2268,percent of total billed charges,Implant Device,2268,35,,2268,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2203.2,34,"If Charge > 2,000, then 34 percent",2203.2,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4795.22,
EXACTECH 320-380-00 HUMERAL LINER 38MM+0,C1776,HCPCS,,79003393,CDM,278,RC,,,both,,,2836,2098.65,,,2098.65,Other,150% of Medicare + 9.63% HCRA Surcharge,1276.2,45,,1276.2,percent of total billed charges,Critical Access Hospital RCC factor,964.24,34,,964.24,percent of total billed charges,Implant Device,964.24,34,,964.24,percent of total billed charges,Implant Device,964.24,34,,964.24,percent of total billed charges,Implant Device,964.24,34,,964.24,percent of total billed charges,Implant Device,964.24,34,,964.24,percent of total billed charges,Implant Device,1403.82,,,1403.82,Other,110% of Medicare,992.6,35,,992.6,percent of total billed charges,Implant Device,964.24,34,"Charges > $500, x 34%",964.24,percent of total billed charges,Implant Device,992.6,35,,992.6,percent of total billed charges,Implant Device,992.6,35,,992.6,percent of total billed charges,Implant Device,992.6,35,,992.6,percent of total billed charges,Implant Device,992.6,35,,992.6,percent of total billed charges,Implant Device,992.6,35,,992.6,percent of total billed charges,Implant Device,1134.4,40,,1134.4,percent of total billed charges,Implant Device,992.6,70,,992.6,percent of total billed charges,All Other,964.24,34,,964.24,percent of total billed charges,Implant Device,964.24,34,,964.24,percent of total billed charges,Implant Device,992.6,35,,992.6,percent of total billed charges,Implant Device,992.6,35,,992.6,percent of total billed charges,Implant Device,992.6,35,,992.6,percent of total billed charges,Implant Device,992.6,35,,992.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,964.24,34,"If Charge > 2,000, then 34 percent",964.24,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2098.65,
STABL BIOLGCS ATAM1236-008-005 ALLOGRAFT,C1713,HCPCS,,79003404,CDM,278,RC,,,both,,,5310,3929.41,,,3929.41,Other,150% of Medicare + 9.63% HCRA Surcharge,2389.5,45,,2389.5,percent of total billed charges,Critical Access Hospital RCC factor,1805.4,34,,1805.4,percent of total billed charges,Implant Device,1805.4,34,,1805.4,percent of total billed charges,Implant Device,1805.4,34,,1805.4,percent of total billed charges,Implant Device,1805.4,34,,1805.4,percent of total billed charges,Implant Device,1805.4,34,,1805.4,percent of total billed charges,Implant Device,2628.45,,,2628.45,Other,110% of Medicare,1858.5,35,,1858.5,percent of total billed charges,Implant Device,1805.4,34,"Charges > $500, x 34%",1805.4,percent of total billed charges,Implant Device,1858.5,35,,1858.5,percent of total billed charges,Implant Device,1858.5,35,,1858.5,percent of total billed charges,Implant Device,1858.5,35,,1858.5,percent of total billed charges,Implant Device,1858.5,35,,1858.5,percent of total billed charges,Implant Device,1858.5,35,,1858.5,percent of total billed charges,Implant Device,2124,40,,2124,percent of total billed charges,Implant Device,1858.5,70,,1858.5,percent of total billed charges,All Other,1805.4,34,,1805.4,percent of total billed charges,Implant Device,1805.4,34,,1805.4,percent of total billed charges,Implant Device,1858.5,35,,1858.5,percent of total billed charges,Implant Device,1858.5,35,,1858.5,percent of total billed charges,Implant Device,1858.5,35,,1858.5,percent of total billed charges,Implant Device,1858.5,35,,1858.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1805.4,34,"If Charge > 2,000, then 34 percent",1805.4,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3929.41,
ARTHREX AR-8827L-14 LOCK SCREW 2.7X14MM,C1713,HCPCS,,79003405,CDM,278,RC,,,both,,,495,366.3,,,366.3,Other,150% of Medicare + 9.63% HCRA Surcharge,222.75,45,,222.75,percent of total billed charges,Critical Access Hospital RCC factor,168.3,34,,168.3,percent of total billed charges,Implant Device,168.3,34,,168.3,percent of total billed charges,Implant Device,168.3,34,,168.3,percent of total billed charges,Implant Device,168.3,34,,168.3,percent of total billed charges,Implant Device,168.3,34,,168.3,percent of total billed charges,Implant Device,245.03,,,245.03,Other,110% of Medicare,173.25,35,,173.25,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,173.25,35,,173.25,percent of total billed charges,Implant Device,173.25,35,,173.25,percent of total billed charges,Implant Device,173.25,35,,173.25,percent of total billed charges,Implant Device,173.25,35,,173.25,percent of total billed charges,Implant Device,173.25,35,,173.25,percent of total billed charges,Implant Device,198,40,,198,percent of total billed charges,Implant Device,173.25,70,,173.25,percent of total billed charges,All Other,168.3,34,,168.3,percent of total billed charges,Implant Device,168.3,34,,168.3,percent of total billed charges,Implant Device,173.25,35,,173.25,percent of total billed charges,Implant Device,173.25,35,,173.25,percent of total billed charges,Implant Device,173.25,35,,173.25,percent of total billed charges,Implant Device,173.25,35,,173.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,366.3,
ARTHREX AR-8827L-12 LOCK SCREW 2.7X12MM,C1713,HCPCS,,79003406,CDM,278,RC,,,both,,,346,256.04,,,256.04,Other,150% of Medicare + 9.63% HCRA Surcharge,155.7,45,,155.7,percent of total billed charges,Critical Access Hospital RCC factor,117.64,34,,117.64,percent of total billed charges,Implant Device,117.64,34,,117.64,percent of total billed charges,Implant Device,117.64,34,,117.64,percent of total billed charges,Implant Device,117.64,34,,117.64,percent of total billed charges,Implant Device,117.64,34,,117.64,percent of total billed charges,Implant Device,171.27,,,171.27,Other,110% of Medicare,121.1,35,,121.1,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,121.1,35,,121.1,percent of total billed charges,Implant Device,121.1,35,,121.1,percent of total billed charges,Implant Device,121.1,35,,121.1,percent of total billed charges,Implant Device,121.1,35,,121.1,percent of total billed charges,Implant Device,121.1,35,,121.1,percent of total billed charges,Implant Device,138.4,40,,138.4,percent of total billed charges,Implant Device,121.1,70,,121.1,percent of total billed charges,All Other,117.64,34,,117.64,percent of total billed charges,Implant Device,117.64,34,,117.64,percent of total billed charges,Implant Device,121.1,35,,121.1,percent of total billed charges,Implant Device,121.1,35,,121.1,percent of total billed charges,Implant Device,121.1,35,,121.1,percent of total billed charges,Implant Device,121.1,35,,121.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,256.04,
ARTHREX AR-8835-16 NON LOCK SCREW 3.5X16,C1713,HCPCS,,79003407,CDM,278,RC,,,both,,,106,78.44,,,78.44,Other,150% of Medicare + 9.63% HCRA Surcharge,47.7,45,,47.7,percent of total billed charges,Critical Access Hospital RCC factor,36.04,34,,36.04,percent of total billed charges,Implant Device,36.04,34,,36.04,percent of total billed charges,Implant Device,36.04,34,,36.04,percent of total billed charges,Implant Device,36.04,34,,36.04,percent of total billed charges,Implant Device,36.04,34,,36.04,percent of total billed charges,Implant Device,52.47,,,52.47,Other,110% of Medicare,37.1,35,,37.1,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,37.1,35,,37.1,percent of total billed charges,Implant Device,37.1,35,,37.1,percent of total billed charges,Implant Device,37.1,35,,37.1,percent of total billed charges,Implant Device,37.1,35,,37.1,percent of total billed charges,Implant Device,37.1,35,,37.1,percent of total billed charges,Implant Device,42.4,40,,42.4,percent of total billed charges,Implant Device,37.1,70,,37.1,percent of total billed charges,All Other,36.04,34,,36.04,percent of total billed charges,Implant Device,36.04,34,,36.04,percent of total billed charges,Implant Device,37.1,35,,37.1,percent of total billed charges,Implant Device,37.1,35,,37.1,percent of total billed charges,Implant Device,37.1,35,,37.1,percent of total billed charges,Implant Device,37.1,35,,37.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,78.44,
ARTHREX AR-8830-16 CANCNONLOCK SCRW 3X16,C1713,HCPCS,,79003408,CDM,278,RC,,,both,,,106,78.44,,,78.44,Other,150% of Medicare + 9.63% HCRA Surcharge,47.7,45,,47.7,percent of total billed charges,Critical Access Hospital RCC factor,36.04,34,,36.04,percent of total billed charges,Implant Device,36.04,34,,36.04,percent of total billed charges,Implant Device,36.04,34,,36.04,percent of total billed charges,Implant Device,36.04,34,,36.04,percent of total billed charges,Implant Device,36.04,34,,36.04,percent of total billed charges,Implant Device,52.47,,,52.47,Other,110% of Medicare,37.1,35,,37.1,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,37.1,35,,37.1,percent of total billed charges,Implant Device,37.1,35,,37.1,percent of total billed charges,Implant Device,37.1,35,,37.1,percent of total billed charges,Implant Device,37.1,35,,37.1,percent of total billed charges,Implant Device,37.1,35,,37.1,percent of total billed charges,Implant Device,42.4,40,,42.4,percent of total billed charges,Implant Device,37.1,70,,37.1,percent of total billed charges,All Other,36.04,34,,36.04,percent of total billed charges,Implant Device,36.04,34,,36.04,percent of total billed charges,Implant Device,37.1,35,,37.1,percent of total billed charges,Implant Device,37.1,35,,37.1,percent of total billed charges,Implant Device,37.1,35,,37.1,percent of total billed charges,Implant Device,37.1,35,,37.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,78.44,
EXACTECH 320-10-05 HUMERAL ADAPTOR +5MM,C1776,HCPCS,,79003410,CDM,278,RC,,,both,,,4950,3663.01,,,3663.01,Other,150% of Medicare + 9.63% HCRA Surcharge,2227.5,45,,2227.5,percent of total billed charges,Critical Access Hospital RCC factor,1683,34,,1683,percent of total billed charges,Implant Device,1683,34,,1683,percent of total billed charges,Implant Device,1683,34,,1683,percent of total billed charges,Implant Device,1683,34,,1683,percent of total billed charges,Implant Device,1683,34,,1683,percent of total billed charges,Implant Device,2450.25,,,2450.25,Other,110% of Medicare,1732.5,35,,1732.5,percent of total billed charges,Implant Device,1683,34,"Charges > $500, x 34%",1683,percent of total billed charges,Implant Device,1732.5,35,,1732.5,percent of total billed charges,Implant Device,1732.5,35,,1732.5,percent of total billed charges,Implant Device,1732.5,35,,1732.5,percent of total billed charges,Implant Device,1732.5,35,,1732.5,percent of total billed charges,Implant Device,1732.5,35,,1732.5,percent of total billed charges,Implant Device,1980,40,,1980,percent of total billed charges,Implant Device,1732.5,70,,1732.5,percent of total billed charges,All Other,1683,34,,1683,percent of total billed charges,Implant Device,1683,34,,1683,percent of total billed charges,Implant Device,1732.5,35,,1732.5,percent of total billed charges,Implant Device,1732.5,35,,1732.5,percent of total billed charges,Implant Device,1732.5,35,,1732.5,percent of total billed charges,Implant Device,1732.5,35,,1732.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1683,34,"If Charge > 2,000, then 34 percent",1683,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3663.01,
STRYKER 3060-0085S LAG SCREW 10.5X85MM,C1713,HCPCS,,79003415,CDM,278,RC,,,both,,,1230,910.2,,,910.2,Other,150% of Medicare + 9.63% HCRA Surcharge,553.5,45,,553.5,percent of total billed charges,Critical Access Hospital RCC factor,418.2,34,,418.2,percent of total billed charges,Implant Device,418.2,34,,418.2,percent of total billed charges,Implant Device,418.2,34,,418.2,percent of total billed charges,Implant Device,418.2,34,,418.2,percent of total billed charges,Implant Device,418.2,34,,418.2,percent of total billed charges,Implant Device,608.85,,,608.85,Other,110% of Medicare,430.5,35,,430.5,percent of total billed charges,Implant Device,418.2,34,"Charges > $500, x 34%",418.2,percent of total billed charges,Implant Device,430.5,35,,430.5,percent of total billed charges,Implant Device,430.5,35,,430.5,percent of total billed charges,Implant Device,430.5,35,,430.5,percent of total billed charges,Implant Device,430.5,35,,430.5,percent of total billed charges,Implant Device,430.5,35,,430.5,percent of total billed charges,Implant Device,492,40,,492,percent of total billed charges,Implant Device,430.5,70,,430.5,percent of total billed charges,All Other,418.2,34,,418.2,percent of total billed charges,Implant Device,418.2,34,,418.2,percent of total billed charges,Implant Device,430.5,35,,430.5,percent of total billed charges,Implant Device,430.5,35,,430.5,percent of total billed charges,Implant Device,430.5,35,,430.5,percent of total billed charges,Implant Device,430.5,35,,430.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,910.2,
SUTURE EXPRESS SPM-148 SURGIPRO MESH,C1781,HCPCS,,79003418,CDM,278,RC,,,both,,,397,293.78,,,293.78,Other,150% of Medicare + 9.63% HCRA Surcharge,178.65,45,,178.65,percent of total billed charges,Critical Access Hospital RCC factor,134.98,34,,134.98,percent of total billed charges,Implant Device,134.98,34,,134.98,percent of total billed charges,Implant Device,134.98,34,,134.98,percent of total billed charges,Implant Device,134.98,34,,134.98,percent of total billed charges,Implant Device,134.98,34,,134.98,percent of total billed charges,Implant Device,196.52,,,196.52,Other,110% of Medicare,138.95,35,,138.95,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,138.95,35,,138.95,percent of total billed charges,Implant Device,138.95,35,,138.95,percent of total billed charges,Implant Device,138.95,35,,138.95,percent of total billed charges,Implant Device,138.95,35,,138.95,percent of total billed charges,Implant Device,138.95,35,,138.95,percent of total billed charges,Implant Device,158.8,40,,158.8,percent of total billed charges,Implant Device,138.95,70,,138.95,percent of total billed charges,All Other,134.98,34,,134.98,percent of total billed charges,Implant Device,134.98,34,,134.98,percent of total billed charges,Implant Device,138.95,35,,138.95,percent of total billed charges,Implant Device,138.95,35,,138.95,percent of total billed charges,Implant Device,138.95,35,,138.95,percent of total billed charges,Implant Device,138.95,35,,138.95,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,293.78,
STRYKER 437103 PLATE 3 HOLE,C1713,HCPCS,,79003419,CDM,278,RC,,,both,,,5483,4057.43,,,4057.43,Other,150% of Medicare + 9.63% HCRA Surcharge,2467.35,45,,2467.35,percent of total billed charges,Critical Access Hospital RCC factor,1864.22,34,,1864.22,percent of total billed charges,Implant Device,1864.22,34,,1864.22,percent of total billed charges,Implant Device,1864.22,34,,1864.22,percent of total billed charges,Implant Device,1864.22,34,,1864.22,percent of total billed charges,Implant Device,1864.22,34,,1864.22,percent of total billed charges,Implant Device,2714.09,,,2714.09,Other,110% of Medicare,1919.05,35,,1919.05,percent of total billed charges,Implant Device,1864.22,34,"Charges > $500, x 34%",1864.22,percent of total billed charges,Implant Device,1919.05,35,,1919.05,percent of total billed charges,Implant Device,1919.05,35,,1919.05,percent of total billed charges,Implant Device,1919.05,35,,1919.05,percent of total billed charges,Implant Device,1919.05,35,,1919.05,percent of total billed charges,Implant Device,1919.05,35,,1919.05,percent of total billed charges,Implant Device,2193.2,40,,2193.2,percent of total billed charges,Implant Device,1919.05,70,,1919.05,percent of total billed charges,All Other,1864.22,34,,1864.22,percent of total billed charges,Implant Device,1864.22,34,,1864.22,percent of total billed charges,Implant Device,1919.05,35,,1919.05,percent of total billed charges,Implant Device,1919.05,35,,1919.05,percent of total billed charges,Implant Device,1919.05,35,,1919.05,percent of total billed charges,Implant Device,1919.05,35,,1919.05,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1864.22,34,"If Charge > 2,000, then 34 percent",1864.22,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4057.43,
STRYKER 345434 CANCELLOUS SCREW 4.0X34MM,C1713,HCPCS,,79003421,CDM,278,RC,,,both,,,89,65.86,,,65.86,Other,150% of Medicare + 9.63% HCRA Surcharge,40.05,45,,40.05,percent of total billed charges,Critical Access Hospital RCC factor,30.26,34,,30.26,percent of total billed charges,Implant Device,30.26,34,,30.26,percent of total billed charges,Implant Device,30.26,34,,30.26,percent of total billed charges,Implant Device,30.26,34,,30.26,percent of total billed charges,Implant Device,30.26,34,,30.26,percent of total billed charges,Implant Device,44.06,,,44.06,Other,110% of Medicare,31.15,35,,31.15,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,31.15,35,,31.15,percent of total billed charges,Implant Device,31.15,35,,31.15,percent of total billed charges,Implant Device,31.15,35,,31.15,percent of total billed charges,Implant Device,31.15,35,,31.15,percent of total billed charges,Implant Device,31.15,35,,31.15,percent of total billed charges,Implant Device,35.6,40,,35.6,percent of total billed charges,Implant Device,31.15,70,,31.15,percent of total billed charges,All Other,30.26,34,,30.26,percent of total billed charges,Implant Device,30.26,34,,30.26,percent of total billed charges,Implant Device,31.15,35,,31.15,percent of total billed charges,Implant Device,31.15,35,,31.15,percent of total billed charges,Implant Device,31.15,35,,31.15,percent of total billed charges,Implant Device,31.15,35,,31.15,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,65.86,
STRYKER 371550 LOCKING SCREW 4.0X50MM,C1713,HCPCS,,79003422,CDM,278,RC,,,both,,,569,421.06,,,421.06,Other,150% of Medicare + 9.63% HCRA Surcharge,256.05,45,,256.05,percent of total billed charges,Critical Access Hospital RCC factor,193.46,34,,193.46,percent of total billed charges,Implant Device,193.46,34,,193.46,percent of total billed charges,Implant Device,193.46,34,,193.46,percent of total billed charges,Implant Device,193.46,34,,193.46,percent of total billed charges,Implant Device,193.46,34,,193.46,percent of total billed charges,Implant Device,281.66,,,281.66,Other,110% of Medicare,199.15,35,,199.15,percent of total billed charges,Implant Device,193.46,34,"Charges > $500, x 34%",193.46,percent of total billed charges,Implant Device,199.15,35,,199.15,percent of total billed charges,Implant Device,199.15,35,,199.15,percent of total billed charges,Implant Device,199.15,35,,199.15,percent of total billed charges,Implant Device,199.15,35,,199.15,percent of total billed charges,Implant Device,199.15,35,,199.15,percent of total billed charges,Implant Device,227.6,40,,227.6,percent of total billed charges,Implant Device,199.15,70,,199.15,percent of total billed charges,All Other,193.46,34,,193.46,percent of total billed charges,Implant Device,193.46,34,,193.46,percent of total billed charges,Implant Device,199.15,35,,199.15,percent of total billed charges,Implant Device,199.15,35,,199.15,percent of total billed charges,Implant Device,199.15,35,,199.15,percent of total billed charges,Implant Device,199.15,35,,199.15,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,421.06,
STRYKER 338634 CORTICAL SCREW 3.5X34MM,C1713,HCPCS,,79003423,CDM,278,RC,,,both,,,120,88.8,,,88.8,Other,150% of Medicare + 9.63% HCRA Surcharge,54,45,,54,percent of total billed charges,Critical Access Hospital RCC factor,40.8,34,,40.8,percent of total billed charges,Implant Device,40.8,34,,40.8,percent of total billed charges,Implant Device,40.8,34,,40.8,percent of total billed charges,Implant Device,40.8,34,,40.8,percent of total billed charges,Implant Device,40.8,34,,40.8,percent of total billed charges,Implant Device,59.4,,,59.4,Other,110% of Medicare,42,35,,42,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,42,35,,42,percent of total billed charges,Implant Device,42,35,,42,percent of total billed charges,Implant Device,42,35,,42,percent of total billed charges,Implant Device,42,35,,42,percent of total billed charges,Implant Device,42,35,,42,percent of total billed charges,Implant Device,48,40,,48,percent of total billed charges,Implant Device,42,70,,42,percent of total billed charges,All Other,40.8,34,,40.8,percent of total billed charges,Implant Device,40.8,34,,40.8,percent of total billed charges,Implant Device,42,35,,42,percent of total billed charges,Implant Device,42,35,,42,percent of total billed charges,Implant Device,42,35,,42,percent of total billed charges,Implant Device,42,35,,42,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,88.8,
STRYKER 338638 CORTICAL SCREW 3.5X38MM,C1713,HCPCS,,79003424,CDM,278,RC,,,both,,,120,88.8,,,88.8,Other,150% of Medicare + 9.63% HCRA Surcharge,54,45,,54,percent of total billed charges,Critical Access Hospital RCC factor,40.8,34,,40.8,percent of total billed charges,Implant Device,40.8,34,,40.8,percent of total billed charges,Implant Device,40.8,34,,40.8,percent of total billed charges,Implant Device,40.8,34,,40.8,percent of total billed charges,Implant Device,40.8,34,,40.8,percent of total billed charges,Implant Device,59.4,,,59.4,Other,110% of Medicare,42,35,,42,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,42,35,,42,percent of total billed charges,Implant Device,42,35,,42,percent of total billed charges,Implant Device,42,35,,42,percent of total billed charges,Implant Device,42,35,,42,percent of total billed charges,Implant Device,42,35,,42,percent of total billed charges,Implant Device,48,40,,48,percent of total billed charges,Implant Device,42,70,,42,percent of total billed charges,All Other,40.8,34,,40.8,percent of total billed charges,Implant Device,40.8,34,,40.8,percent of total billed charges,Implant Device,42,35,,42,percent of total billed charges,Implant Device,42,35,,42,percent of total billed charges,Implant Device,42,35,,42,percent of total billed charges,Implant Device,42,35,,42,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,88.8,
STRYKER 1830-0928S HUMERAL NAIL 9X280MM,C1713,HCPCS,,79003427,CDM,278,RC,,,both,,,5483,4057.43,,,4057.43,Other,150% of Medicare + 9.63% HCRA Surcharge,2467.35,45,,2467.35,percent of total billed charges,Critical Access Hospital RCC factor,1864.22,34,,1864.22,percent of total billed charges,Implant Device,1864.22,34,,1864.22,percent of total billed charges,Implant Device,1864.22,34,,1864.22,percent of total billed charges,Implant Device,1864.22,34,,1864.22,percent of total billed charges,Implant Device,1864.22,34,,1864.22,percent of total billed charges,Implant Device,2714.09,,,2714.09,Other,110% of Medicare,1919.05,35,,1919.05,percent of total billed charges,Implant Device,1864.22,34,"Charges > $500, x 34%",1864.22,percent of total billed charges,Implant Device,1919.05,35,,1919.05,percent of total billed charges,Implant Device,1919.05,35,,1919.05,percent of total billed charges,Implant Device,1919.05,35,,1919.05,percent of total billed charges,Implant Device,1919.05,35,,1919.05,percent of total billed charges,Implant Device,1919.05,35,,1919.05,percent of total billed charges,Implant Device,2193.2,40,,2193.2,percent of total billed charges,Implant Device,1919.05,70,,1919.05,percent of total billed charges,All Other,1864.22,34,,1864.22,percent of total billed charges,Implant Device,1864.22,34,,1864.22,percent of total billed charges,Implant Device,1919.05,35,,1919.05,percent of total billed charges,Implant Device,1919.05,35,,1919.05,percent of total billed charges,Implant Device,1919.05,35,,1919.05,percent of total billed charges,Implant Device,1919.05,35,,1919.05,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1864.22,34,"If Charge > 2,000, then 34 percent",1864.22,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4057.43,
STRYKER 1896-4055S LOCKING SCREW FT 4X55,C1713,HCPCS,,79003428,CDM,278,RC,,,both,,,836,618.64,,,618.64,Other,150% of Medicare + 9.63% HCRA Surcharge,376.2,45,,376.2,percent of total billed charges,Critical Access Hospital RCC factor,284.24,34,,284.24,percent of total billed charges,Implant Device,284.24,34,,284.24,percent of total billed charges,Implant Device,284.24,34,,284.24,percent of total billed charges,Implant Device,284.24,34,,284.24,percent of total billed charges,Implant Device,284.24,34,,284.24,percent of total billed charges,Implant Device,413.82,,,413.82,Other,110% of Medicare,292.6,35,,292.6,percent of total billed charges,Implant Device,284.24,34,"Charges > $500, x 34%",284.24,percent of total billed charges,Implant Device,292.6,35,,292.6,percent of total billed charges,Implant Device,292.6,35,,292.6,percent of total billed charges,Implant Device,292.6,35,,292.6,percent of total billed charges,Implant Device,292.6,35,,292.6,percent of total billed charges,Implant Device,292.6,35,,292.6,percent of total billed charges,Implant Device,334.4,40,,334.4,percent of total billed charges,Implant Device,292.6,70,,292.6,percent of total billed charges,All Other,284.24,34,,284.24,percent of total billed charges,Implant Device,284.24,34,,284.24,percent of total billed charges,Implant Device,292.6,35,,292.6,percent of total billed charges,Implant Device,292.6,35,,292.6,percent of total billed charges,Implant Device,292.6,35,,292.6,percent of total billed charges,Implant Device,292.6,35,,292.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,618.64,
STRYKER 1896-4028S LOCKING SCREW FT 4X28,C1713,HCPCS,,79003429,CDM,278,RC,,,both,,,447,330.78,,,330.78,Other,150% of Medicare + 9.63% HCRA Surcharge,201.15,45,,201.15,percent of total billed charges,Critical Access Hospital RCC factor,151.98,34,,151.98,percent of total billed charges,Implant Device,151.98,34,,151.98,percent of total billed charges,Implant Device,151.98,34,,151.98,percent of total billed charges,Implant Device,151.98,34,,151.98,percent of total billed charges,Implant Device,151.98,34,,151.98,percent of total billed charges,Implant Device,221.27,,,221.27,Other,110% of Medicare,156.45,35,,156.45,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,156.45,35,,156.45,percent of total billed charges,Implant Device,156.45,35,,156.45,percent of total billed charges,Implant Device,156.45,35,,156.45,percent of total billed charges,Implant Device,156.45,35,,156.45,percent of total billed charges,Implant Device,156.45,35,,156.45,percent of total billed charges,Implant Device,178.8,40,,178.8,percent of total billed charges,Implant Device,156.45,70,,156.45,percent of total billed charges,All Other,151.98,34,,151.98,percent of total billed charges,Implant Device,151.98,34,,151.98,percent of total billed charges,Implant Device,156.45,35,,156.45,percent of total billed charges,Implant Device,156.45,35,,156.45,percent of total billed charges,Implant Device,156.45,35,,156.45,percent of total billed charges,Implant Device,156.45,35,,156.45,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,330.78,
RTI BIOLOGICS 606-01-05 ALLOGRAFT PASTE,C1713,HCPCS,,79003434,CDM,278,RC,,,both,,,4494,3325.57,,,3325.57,Other,150% of Medicare + 9.63% HCRA Surcharge,2022.3,45,,2022.3,percent of total billed charges,Critical Access Hospital RCC factor,1527.96,34,,1527.96,percent of total billed charges,Implant Device,1527.96,34,,1527.96,percent of total billed charges,Implant Device,1527.96,34,,1527.96,percent of total billed charges,Implant Device,1527.96,34,,1527.96,percent of total billed charges,Implant Device,1527.96,34,,1527.96,percent of total billed charges,Implant Device,2224.53,,,2224.53,Other,110% of Medicare,1572.9,35,,1572.9,percent of total billed charges,Implant Device,1527.96,34,"Charges > $500, x 34%",1527.96,percent of total billed charges,Implant Device,1572.9,35,,1572.9,percent of total billed charges,Implant Device,1572.9,35,,1572.9,percent of total billed charges,Implant Device,1572.9,35,,1572.9,percent of total billed charges,Implant Device,1572.9,35,,1572.9,percent of total billed charges,Implant Device,1572.9,35,,1572.9,percent of total billed charges,Implant Device,1797.6,40,,1797.6,percent of total billed charges,Implant Device,1572.9,70,,1572.9,percent of total billed charges,All Other,1527.96,34,,1527.96,percent of total billed charges,Implant Device,1527.96,34,,1527.96,percent of total billed charges,Implant Device,1572.9,35,,1572.9,percent of total billed charges,Implant Device,1572.9,35,,1572.9,percent of total billed charges,Implant Device,1572.9,35,,1572.9,percent of total billed charges,Implant Device,1572.9,35,,1572.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1527.96,34,"If Charge > 2,000, then 34 percent",1527.96,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3325.57,
ZIMMER 47-2493-211-10 FEM NAIL 10.5X100,C1713,HCPCS,,79003437,CDM,278,RC,,,both,,,5170,3825.81,,,3825.81,Other,150% of Medicare + 9.63% HCRA Surcharge,2326.5,45,,2326.5,percent of total billed charges,Critical Access Hospital RCC factor,1757.8,34,,1757.8,percent of total billed charges,Implant Device,1757.8,34,,1757.8,percent of total billed charges,Implant Device,1757.8,34,,1757.8,percent of total billed charges,Implant Device,1757.8,34,,1757.8,percent of total billed charges,Implant Device,1757.8,34,,1757.8,percent of total billed charges,Implant Device,2559.15,,,2559.15,Other,110% of Medicare,1809.5,35,,1809.5,percent of total billed charges,Implant Device,1757.8,34,"Charges > $500, x 34%",1757.8,percent of total billed charges,Implant Device,1809.5,35,,1809.5,percent of total billed charges,Implant Device,1809.5,35,,1809.5,percent of total billed charges,Implant Device,1809.5,35,,1809.5,percent of total billed charges,Implant Device,1809.5,35,,1809.5,percent of total billed charges,Implant Device,1809.5,35,,1809.5,percent of total billed charges,Implant Device,2068,40,,2068,percent of total billed charges,Implant Device,1809.5,70,,1809.5,percent of total billed charges,All Other,1757.8,34,,1757.8,percent of total billed charges,Implant Device,1757.8,34,,1757.8,percent of total billed charges,Implant Device,1809.5,35,,1809.5,percent of total billed charges,Implant Device,1809.5,35,,1809.5,percent of total billed charges,Implant Device,1809.5,35,,1809.5,percent of total billed charges,Implant Device,1809.5,35,,1809.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1757.8,34,"If Charge > 2,000, then 34 percent",1757.8,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3825.81,
ZIMMER 1147-85-75 7.5MM CANN SCREW 16X85,C1713,HCPCS,,79003439,CDM,278,RC,,,both,,,738,546.12,,,546.12,Other,150% of Medicare + 9.63% HCRA Surcharge,332.1,45,,332.1,percent of total billed charges,Critical Access Hospital RCC factor,250.92,34,,250.92,percent of total billed charges,Implant Device,250.92,34,,250.92,percent of total billed charges,Implant Device,250.92,34,,250.92,percent of total billed charges,Implant Device,250.92,34,,250.92,percent of total billed charges,Implant Device,250.92,34,,250.92,percent of total billed charges,Implant Device,365.31,,,365.31,Other,110% of Medicare,258.3,35,,258.3,percent of total billed charges,Implant Device,250.92,34,"Charges > $500, x 34%",250.92,percent of total billed charges,Implant Device,258.3,35,,258.3,percent of total billed charges,Implant Device,258.3,35,,258.3,percent of total billed charges,Implant Device,258.3,35,,258.3,percent of total billed charges,Implant Device,258.3,35,,258.3,percent of total billed charges,Implant Device,258.3,35,,258.3,percent of total billed charges,Implant Device,295.2,40,,295.2,percent of total billed charges,Implant Device,258.3,70,,258.3,percent of total billed charges,All Other,250.92,34,,250.92,percent of total billed charges,Implant Device,250.92,34,,250.92,percent of total billed charges,Implant Device,258.3,35,,258.3,percent of total billed charges,Implant Device,258.3,35,,258.3,percent of total billed charges,Implant Device,258.3,35,,258.3,percent of total billed charges,Implant Device,258.3,35,,258.3,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,546.12,
ZIMMER 1147-90-75 7.5MM CANN SCREW 16X90,C1713,HCPCS,,79003440,CDM,278,RC,,,both,,,738,546.12,,,546.12,Other,150% of Medicare + 9.63% HCRA Surcharge,332.1,45,,332.1,percent of total billed charges,Critical Access Hospital RCC factor,250.92,34,,250.92,percent of total billed charges,Implant Device,250.92,34,,250.92,percent of total billed charges,Implant Device,250.92,34,,250.92,percent of total billed charges,Implant Device,250.92,34,,250.92,percent of total billed charges,Implant Device,250.92,34,,250.92,percent of total billed charges,Implant Device,365.31,,,365.31,Other,110% of Medicare,258.3,35,,258.3,percent of total billed charges,Implant Device,250.92,34,"Charges > $500, x 34%",250.92,percent of total billed charges,Implant Device,258.3,35,,258.3,percent of total billed charges,Implant Device,258.3,35,,258.3,percent of total billed charges,Implant Device,258.3,35,,258.3,percent of total billed charges,Implant Device,258.3,35,,258.3,percent of total billed charges,Implant Device,258.3,35,,258.3,percent of total billed charges,Implant Device,295.2,40,,295.2,percent of total billed charges,Implant Device,258.3,70,,258.3,percent of total billed charges,All Other,250.92,34,,250.92,percent of total billed charges,Implant Device,250.92,34,,250.92,percent of total billed charges,Implant Device,258.3,35,,258.3,percent of total billed charges,Implant Device,258.3,35,,258.3,percent of total billed charges,Implant Device,258.3,35,,258.3,percent of total billed charges,Implant Device,258.3,35,,258.3,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,546.12,
ZIMMER 1147-90-76 7.5MM CANN SCREW 32X90,C1713,HCPCS,,79003441,CDM,278,RC,,,both,,,738,546.12,,,546.12,Other,150% of Medicare + 9.63% HCRA Surcharge,332.1,45,,332.1,percent of total billed charges,Critical Access Hospital RCC factor,250.92,34,,250.92,percent of total billed charges,Implant Device,250.92,34,,250.92,percent of total billed charges,Implant Device,250.92,34,,250.92,percent of total billed charges,Implant Device,250.92,34,,250.92,percent of total billed charges,Implant Device,250.92,34,,250.92,percent of total billed charges,Implant Device,365.31,,,365.31,Other,110% of Medicare,258.3,35,,258.3,percent of total billed charges,Implant Device,250.92,34,"Charges > $500, x 34%",250.92,percent of total billed charges,Implant Device,258.3,35,,258.3,percent of total billed charges,Implant Device,258.3,35,,258.3,percent of total billed charges,Implant Device,258.3,35,,258.3,percent of total billed charges,Implant Device,258.3,35,,258.3,percent of total billed charges,Implant Device,258.3,35,,258.3,percent of total billed charges,Implant Device,295.2,40,,295.2,percent of total billed charges,Implant Device,258.3,70,,258.3,percent of total billed charges,All Other,250.92,34,,250.92,percent of total billed charges,Implant Device,250.92,34,,250.92,percent of total billed charges,Implant Device,258.3,35,,258.3,percent of total billed charges,Implant Device,258.3,35,,258.3,percent of total billed charges,Implant Device,258.3,35,,258.3,percent of total billed charges,Implant Device,258.3,35,,258.3,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,546.12,
STRYKER 53-23616E LOCKING SCREW 2.3X16MM,C1713,HCPCS,,79003445,CDM,278,RC,,,both,,,492,364.08,,,364.08,Other,150% of Medicare + 9.63% HCRA Surcharge,221.4,45,,221.4,percent of total billed charges,Critical Access Hospital RCC factor,167.28,34,,167.28,percent of total billed charges,Implant Device,167.28,34,,167.28,percent of total billed charges,Implant Device,167.28,34,,167.28,percent of total billed charges,Implant Device,167.28,34,,167.28,percent of total billed charges,Implant Device,167.28,34,,167.28,percent of total billed charges,Implant Device,243.54,,,243.54,Other,110% of Medicare,172.2,35,,172.2,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,172.2,35,,172.2,percent of total billed charges,Implant Device,172.2,35,,172.2,percent of total billed charges,Implant Device,172.2,35,,172.2,percent of total billed charges,Implant Device,172.2,35,,172.2,percent of total billed charges,Implant Device,172.2,35,,172.2,percent of total billed charges,Implant Device,196.8,40,,196.8,percent of total billed charges,Implant Device,172.2,70,,172.2,percent of total billed charges,All Other,167.28,34,,167.28,percent of total billed charges,Implant Device,167.28,34,,167.28,percent of total billed charges,Implant Device,172.2,35,,172.2,percent of total billed charges,Implant Device,172.2,35,,172.2,percent of total billed charges,Implant Device,172.2,35,,172.2,percent of total billed charges,Implant Device,172.2,35,,172.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,364.08,
STRYKER 53-27614E LOCKING SCREW 2.7X14MM,C1713,HCPCS,,79003446,CDM,278,RC,,,both,,,253,187.22,,,187.22,Other,150% of Medicare + 9.63% HCRA Surcharge,113.85,45,,113.85,percent of total billed charges,Critical Access Hospital RCC factor,86.02,34,,86.02,percent of total billed charges,Implant Device,86.02,34,,86.02,percent of total billed charges,Implant Device,86.02,34,,86.02,percent of total billed charges,Implant Device,86.02,34,,86.02,percent of total billed charges,Implant Device,86.02,34,,86.02,percent of total billed charges,Implant Device,125.24,,,125.24,Other,110% of Medicare,88.55,35,,88.55,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,88.55,35,,88.55,percent of total billed charges,Implant Device,88.55,35,,88.55,percent of total billed charges,Implant Device,88.55,35,,88.55,percent of total billed charges,Implant Device,88.55,35,,88.55,percent of total billed charges,Implant Device,88.55,35,,88.55,percent of total billed charges,Implant Device,101.2,40,,101.2,percent of total billed charges,Implant Device,88.55,70,,88.55,percent of total billed charges,All Other,86.02,34,,86.02,percent of total billed charges,Implant Device,86.02,34,,86.02,percent of total billed charges,Implant Device,88.55,35,,88.55,percent of total billed charges,Implant Device,88.55,35,,88.55,percent of total billed charges,Implant Device,88.55,35,,88.55,percent of total billed charges,Implant Device,88.55,35,,88.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,187.22,
ZIMMER 00-4936-007-07 PLATE 7 HOLE,C1713,HCPCS,,79003449,CDM,278,RC,,,both,,,886,655.64,,,655.64,Other,150% of Medicare + 9.63% HCRA Surcharge,398.7,45,,398.7,percent of total billed charges,Critical Access Hospital RCC factor,301.24,34,,301.24,percent of total billed charges,Implant Device,301.24,34,,301.24,percent of total billed charges,Implant Device,301.24,34,,301.24,percent of total billed charges,Implant Device,301.24,34,,301.24,percent of total billed charges,Implant Device,301.24,34,,301.24,percent of total billed charges,Implant Device,438.57,,,438.57,Other,110% of Medicare,310.1,35,,310.1,percent of total billed charges,Implant Device,301.24,34,"Charges > $500, x 34%",301.24,percent of total billed charges,Implant Device,310.1,35,,310.1,percent of total billed charges,Implant Device,310.1,35,,310.1,percent of total billed charges,Implant Device,310.1,35,,310.1,percent of total billed charges,Implant Device,310.1,35,,310.1,percent of total billed charges,Implant Device,310.1,35,,310.1,percent of total billed charges,Implant Device,354.4,40,,354.4,percent of total billed charges,Implant Device,310.1,70,,310.1,percent of total billed charges,All Other,301.24,34,,301.24,percent of total billed charges,Implant Device,301.24,34,,301.24,percent of total billed charges,Implant Device,310.1,35,,310.1,percent of total billed charges,Implant Device,310.1,35,,310.1,percent of total billed charges,Implant Device,310.1,35,,310.1,percent of total billed charges,Implant Device,310.1,35,,310.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,655.64,
ZIMMER 5842-13-01-UNI FEM COMP SZC-UNI,C1776,HCPCS,,79003450,CDM,278,RC,,,both,,,10486,7759.67,,,7759.67,Other,150% of Medicare + 9.63% HCRA Surcharge,4718.7,45,,4718.7,percent of total billed charges,Critical Access Hospital RCC factor,3565.24,34,,3565.24,percent of total billed charges,Implant Device,3565.24,34,,3565.24,percent of total billed charges,Implant Device,3565.24,34,,3565.24,percent of total billed charges,Implant Device,3565.24,34,,3565.24,percent of total billed charges,Implant Device,3565.24,34,,3565.24,percent of total billed charges,Implant Device,5190.57,,,5190.57,Other,110% of Medicare,3670.1,35,,3670.1,percent of total billed charges,Implant Device,3565.24,34,"Charges > $500, x 34%",3565.24,percent of total billed charges,Implant Device,3670.1,35,,3670.1,percent of total billed charges,Implant Device,3670.1,35,,3670.1,percent of total billed charges,Implant Device,3670.1,35,,3670.1,percent of total billed charges,Implant Device,3670.1,35,,3670.1,percent of total billed charges,Implant Device,3670.1,35,,3670.1,percent of total billed charges,Implant Device,4194.4,40,,4194.4,percent of total billed charges,Implant Device,3670.1,70,,3670.1,percent of total billed charges,All Other,3565.24,34,,3565.24,percent of total billed charges,Implant Device,3565.24,34,,3565.24,percent of total billed charges,Implant Device,3670.1,35,,3670.1,percent of total billed charges,Implant Device,3670.1,35,,3670.1,percent of total billed charges,Implant Device,3670.1,35,,3670.1,percent of total billed charges,Implant Device,3670.1,35,,3670.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3565.24,34,"If Charge > 2,000, then 34 percent",3565.24,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,7759.67,
ZIMMER 5842-02-01-UNI TIB COMP SZ 2-UNI,C1776,HCPCS,,79003451,CDM,278,RC,,,both,,,6346,4696.06,,,4696.06,Other,150% of Medicare + 9.63% HCRA Surcharge,2855.7,45,,2855.7,percent of total billed charges,Critical Access Hospital RCC factor,2157.64,34,,2157.64,percent of total billed charges,Implant Device,2157.64,34,,2157.64,percent of total billed charges,Implant Device,2157.64,34,,2157.64,percent of total billed charges,Implant Device,2157.64,34,,2157.64,percent of total billed charges,Implant Device,2157.64,34,,2157.64,percent of total billed charges,Implant Device,3141.27,,,3141.27,Other,110% of Medicare,2221.1,35,,2221.1,percent of total billed charges,Implant Device,2157.64,34,"Charges > $500, x 34%",2157.64,percent of total billed charges,Implant Device,2221.1,35,,2221.1,percent of total billed charges,Implant Device,2221.1,35,,2221.1,percent of total billed charges,Implant Device,2221.1,35,,2221.1,percent of total billed charges,Implant Device,2221.1,35,,2221.1,percent of total billed charges,Implant Device,2221.1,35,,2221.1,percent of total billed charges,Implant Device,2538.4,40,,2538.4,percent of total billed charges,Implant Device,2221.1,70,,2221.1,percent of total billed charges,All Other,2157.64,34,,2157.64,percent of total billed charges,Implant Device,2157.64,34,,2157.64,percent of total billed charges,Implant Device,2221.1,35,,2221.1,percent of total billed charges,Implant Device,2221.1,35,,2221.1,percent of total billed charges,Implant Device,2221.1,35,,2221.1,percent of total billed charges,Implant Device,2221.1,35,,2221.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2157.64,34,"If Charge > 2,000, then 34 percent",2157.64,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4696.06,
ZIMMER 5842-22-12-UNI ART SURF FEM SZA-G,C1776,HCPCS,,79003452,CDM,278,RC,,,both,,,2677,1980.99,,,1980.99,Other,150% of Medicare + 9.63% HCRA Surcharge,1204.65,45,,1204.65,percent of total billed charges,Critical Access Hospital RCC factor,910.18,34,,910.18,percent of total billed charges,Implant Device,910.18,34,,910.18,percent of total billed charges,Implant Device,910.18,34,,910.18,percent of total billed charges,Implant Device,910.18,34,,910.18,percent of total billed charges,Implant Device,910.18,34,,910.18,percent of total billed charges,Implant Device,1325.12,,,1325.12,Other,110% of Medicare,936.95,35,,936.95,percent of total billed charges,Implant Device,910.18,34,"Charges > $500, x 34%",910.18,percent of total billed charges,Implant Device,936.95,35,,936.95,percent of total billed charges,Implant Device,936.95,35,,936.95,percent of total billed charges,Implant Device,936.95,35,,936.95,percent of total billed charges,Implant Device,936.95,35,,936.95,percent of total billed charges,Implant Device,936.95,35,,936.95,percent of total billed charges,Implant Device,1070.8,40,,1070.8,percent of total billed charges,Implant Device,936.95,70,,936.95,percent of total billed charges,All Other,910.18,34,,910.18,percent of total billed charges,Implant Device,910.18,34,,910.18,percent of total billed charges,Implant Device,936.95,35,,936.95,percent of total billed charges,Implant Device,936.95,35,,936.95,percent of total billed charges,Implant Device,936.95,35,,936.95,percent of total billed charges,Implant Device,936.95,35,,936.95,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,910.18,34,"If Charge > 2,000, then 34 percent",910.18,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1980.99,
ARTHREX AR-8943BR-06 FIB LCK PLATE 6 HOL,C1713,HCPCS,,79003453,CDM,278,RC,,,both,,,2176,1610.25,,,1610.25,Other,150% of Medicare + 9.63% HCRA Surcharge,979.2,45,,979.2,percent of total billed charges,Critical Access Hospital RCC factor,739.84,34,,739.84,percent of total billed charges,Implant Device,739.84,34,,739.84,percent of total billed charges,Implant Device,739.84,34,,739.84,percent of total billed charges,Implant Device,739.84,34,,739.84,percent of total billed charges,Implant Device,739.84,34,,739.84,percent of total billed charges,Implant Device,1077.12,,,1077.12,Other,110% of Medicare,761.6,35,,761.6,percent of total billed charges,Implant Device,739.84,34,"Charges > $500, x 34%",739.84,percent of total billed charges,Implant Device,761.6,35,,761.6,percent of total billed charges,Implant Device,761.6,35,,761.6,percent of total billed charges,Implant Device,761.6,35,,761.6,percent of total billed charges,Implant Device,761.6,35,,761.6,percent of total billed charges,Implant Device,761.6,35,,761.6,percent of total billed charges,Implant Device,870.4,40,,870.4,percent of total billed charges,Implant Device,761.6,70,,761.6,percent of total billed charges,All Other,739.84,34,,739.84,percent of total billed charges,Implant Device,739.84,34,,739.84,percent of total billed charges,Implant Device,761.6,35,,761.6,percent of total billed charges,Implant Device,761.6,35,,761.6,percent of total billed charges,Implant Device,761.6,35,,761.6,percent of total billed charges,Implant Device,761.6,35,,761.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,739.84,34,"If Charge > 2,000, then 34 percent",739.84,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1610.25,
ARTHREX AR-8835-22 SCREW 3.5X22MM,C1713,HCPCS,,79003454,CDM,278,RC,,,both,,,150,111,,,111,Other,150% of Medicare + 9.63% HCRA Surcharge,67.5,45,,67.5,percent of total billed charges,Critical Access Hospital RCC factor,51,34,,51,percent of total billed charges,Implant Device,51,34,,51,percent of total billed charges,Implant Device,51,34,,51,percent of total billed charges,Implant Device,51,34,,51,percent of total billed charges,Implant Device,51,34,,51,percent of total billed charges,Implant Device,74.25,,,74.25,Other,110% of Medicare,52.5,35,,52.5,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,52.5,35,,52.5,percent of total billed charges,Implant Device,52.5,35,,52.5,percent of total billed charges,Implant Device,52.5,35,,52.5,percent of total billed charges,Implant Device,52.5,35,,52.5,percent of total billed charges,Implant Device,52.5,35,,52.5,percent of total billed charges,Implant Device,60,40,,60,percent of total billed charges,Implant Device,52.5,70,,52.5,percent of total billed charges,All Other,51,34,,51,percent of total billed charges,Implant Device,51,34,,51,percent of total billed charges,Implant Device,52.5,35,,52.5,percent of total billed charges,Implant Device,52.5,35,,52.5,percent of total billed charges,Implant Device,52.5,35,,52.5,percent of total billed charges,Implant Device,52.5,35,,52.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,111,
ARTHREX AR-8835-26 SCREW 3.5X26MM,C1713,HCPCS,,79003455,CDM,278,RC,,,both,,,106,78.44,,,78.44,Other,150% of Medicare + 9.63% HCRA Surcharge,47.7,45,,47.7,percent of total billed charges,Critical Access Hospital RCC factor,36.04,34,,36.04,percent of total billed charges,Implant Device,36.04,34,,36.04,percent of total billed charges,Implant Device,36.04,34,,36.04,percent of total billed charges,Implant Device,36.04,34,,36.04,percent of total billed charges,Implant Device,36.04,34,,36.04,percent of total billed charges,Implant Device,52.47,,,52.47,Other,110% of Medicare,37.1,35,,37.1,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,37.1,35,,37.1,percent of total billed charges,Implant Device,37.1,35,,37.1,percent of total billed charges,Implant Device,37.1,35,,37.1,percent of total billed charges,Implant Device,37.1,35,,37.1,percent of total billed charges,Implant Device,37.1,35,,37.1,percent of total billed charges,Implant Device,42.4,40,,42.4,percent of total billed charges,Implant Device,37.1,70,,37.1,percent of total billed charges,All Other,36.04,34,,36.04,percent of total billed charges,Implant Device,36.04,34,,36.04,percent of total billed charges,Implant Device,37.1,35,,37.1,percent of total billed charges,Implant Device,37.1,35,,37.1,percent of total billed charges,Implant Device,37.1,35,,37.1,percent of total billed charges,Implant Device,37.1,35,,37.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,78.44,
ZIMMER 00-2490-047-32 3.2MM PIN 508MM,C1713,HCPCS,,79003458,CDM,278,RC,,,both,,,389,287.86,,,287.86,Other,150% of Medicare + 9.63% HCRA Surcharge,175.05,45,,175.05,percent of total billed charges,Critical Access Hospital RCC factor,132.26,34,,132.26,percent of total billed charges,Implant Device,132.26,34,,132.26,percent of total billed charges,Implant Device,132.26,34,,132.26,percent of total billed charges,Implant Device,132.26,34,,132.26,percent of total billed charges,Implant Device,132.26,34,,132.26,percent of total billed charges,Implant Device,192.56,,,192.56,Other,110% of Medicare,136.15,35,,136.15,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,136.15,35,,136.15,percent of total billed charges,Implant Device,136.15,35,,136.15,percent of total billed charges,Implant Device,136.15,35,,136.15,percent of total billed charges,Implant Device,136.15,35,,136.15,percent of total billed charges,Implant Device,136.15,35,,136.15,percent of total billed charges,Implant Device,155.6,40,,155.6,percent of total billed charges,Implant Device,136.15,70,,136.15,percent of total billed charges,All Other,132.26,34,,132.26,percent of total billed charges,Implant Device,132.26,34,,132.26,percent of total billed charges,Implant Device,136.15,35,,136.15,percent of total billed charges,Implant Device,136.15,35,,136.15,percent of total billed charges,Implant Device,136.15,35,,136.15,percent of total billed charges,Implant Device,136.15,35,,136.15,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,287.86,
ARTHREX AR-8935L-16 LOCK SCREW 3.5X16MM,C1713,HCPCS,,79003463,CDM,278,RC,,,both,,,180,133.2,,,133.2,Other,150% of Medicare + 9.63% HCRA Surcharge,81,45,,81,percent of total billed charges,Critical Access Hospital RCC factor,61.2,34,,61.2,percent of total billed charges,Implant Device,61.2,34,,61.2,percent of total billed charges,Implant Device,61.2,34,,61.2,percent of total billed charges,Implant Device,61.2,34,,61.2,percent of total billed charges,Implant Device,61.2,34,,61.2,percent of total billed charges,Implant Device,89.1,,,89.1,Other,110% of Medicare,63,35,,63,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,63,35,,63,percent of total billed charges,Implant Device,63,35,,63,percent of total billed charges,Implant Device,63,35,,63,percent of total billed charges,Implant Device,63,35,,63,percent of total billed charges,Implant Device,63,35,,63,percent of total billed charges,Implant Device,72,40,,72,percent of total billed charges,Implant Device,63,70,,63,percent of total billed charges,All Other,61.2,34,,61.2,percent of total billed charges,Implant Device,61.2,34,,61.2,percent of total billed charges,Implant Device,63,35,,63,percent of total billed charges,Implant Device,63,35,,63,percent of total billed charges,Implant Device,63,35,,63,percent of total billed charges,Implant Device,63,35,,63,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,133.2,
STRYKER 40-35026 NON-LOCK SCREW 3.5X26MM,C1713,HCPCS,,79003464,CDM,278,RC,,,both,,,192,142.08,,,142.08,Other,150% of Medicare + 9.63% HCRA Surcharge,86.4,45,,86.4,percent of total billed charges,Critical Access Hospital RCC factor,65.28,34,,65.28,percent of total billed charges,Implant Device,65.28,34,,65.28,percent of total billed charges,Implant Device,65.28,34,,65.28,percent of total billed charges,Implant Device,65.28,34,,65.28,percent of total billed charges,Implant Device,65.28,34,,65.28,percent of total billed charges,Implant Device,95.04,,,95.04,Other,110% of Medicare,67.2,35,,67.2,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,67.2,35,,67.2,percent of total billed charges,Implant Device,67.2,35,,67.2,percent of total billed charges,Implant Device,67.2,35,,67.2,percent of total billed charges,Implant Device,67.2,35,,67.2,percent of total billed charges,Implant Device,67.2,35,,67.2,percent of total billed charges,Implant Device,76.8,40,,76.8,percent of total billed charges,Implant Device,67.2,70,,67.2,percent of total billed charges,All Other,65.28,34,,65.28,percent of total billed charges,Implant Device,65.28,34,,65.28,percent of total billed charges,Implant Device,67.2,35,,67.2,percent of total billed charges,Implant Device,67.2,35,,67.2,percent of total billed charges,Implant Device,67.2,35,,67.2,percent of total billed charges,Implant Device,67.2,35,,67.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,142.08,
EXACTECH 340-01-01 FRACTURE PLATE 80MM,C1713,HCPCS,,79003466,CDM,278,RC,,,both,,,4644,3436.57,,,3436.57,Other,150% of Medicare + 9.63% HCRA Surcharge,2089.8,45,,2089.8,percent of total billed charges,Critical Access Hospital RCC factor,1578.96,34,,1578.96,percent of total billed charges,Implant Device,1578.96,34,,1578.96,percent of total billed charges,Implant Device,1578.96,34,,1578.96,percent of total billed charges,Implant Device,1578.96,34,,1578.96,percent of total billed charges,Implant Device,1578.96,34,,1578.96,percent of total billed charges,Implant Device,2298.78,,,2298.78,Other,110% of Medicare,1625.4,35,,1625.4,percent of total billed charges,Implant Device,1578.96,34,"Charges > $500, x 34%",1578.96,percent of total billed charges,Implant Device,1625.4,35,,1625.4,percent of total billed charges,Implant Device,1625.4,35,,1625.4,percent of total billed charges,Implant Device,1625.4,35,,1625.4,percent of total billed charges,Implant Device,1625.4,35,,1625.4,percent of total billed charges,Implant Device,1625.4,35,,1625.4,percent of total billed charges,Implant Device,1857.6,40,,1857.6,percent of total billed charges,Implant Device,1625.4,70,,1625.4,percent of total billed charges,All Other,1578.96,34,,1578.96,percent of total billed charges,Implant Device,1578.96,34,,1578.96,percent of total billed charges,Implant Device,1625.4,35,,1625.4,percent of total billed charges,Implant Device,1625.4,35,,1625.4,percent of total billed charges,Implant Device,1625.4,35,,1625.4,percent of total billed charges,Implant Device,1625.4,35,,1625.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1578.96,34,"If Charge > 2,000, then 34 percent",1578.96,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3436.57,
EXACTECH 340-65-41 CANC SCREW 6.5X41MM,C1713,HCPCS,,79003467,CDM,278,RC,,,both,,,581,429.94,,,429.94,Other,150% of Medicare + 9.63% HCRA Surcharge,261.45,45,,261.45,percent of total billed charges,Critical Access Hospital RCC factor,197.54,34,,197.54,percent of total billed charges,Implant Device,197.54,34,,197.54,percent of total billed charges,Implant Device,197.54,34,,197.54,percent of total billed charges,Implant Device,197.54,34,,197.54,percent of total billed charges,Implant Device,197.54,34,,197.54,percent of total billed charges,Implant Device,287.6,,,287.6,Other,110% of Medicare,203.35,35,,203.35,percent of total billed charges,Implant Device,197.54,34,"Charges > $500, x 34%",197.54,percent of total billed charges,Implant Device,203.35,35,,203.35,percent of total billed charges,Implant Device,203.35,35,,203.35,percent of total billed charges,Implant Device,203.35,35,,203.35,percent of total billed charges,Implant Device,203.35,35,,203.35,percent of total billed charges,Implant Device,203.35,35,,203.35,percent of total billed charges,Implant Device,232.4,40,,232.4,percent of total billed charges,Implant Device,203.35,70,,203.35,percent of total billed charges,All Other,197.54,34,,197.54,percent of total billed charges,Implant Device,197.54,34,,197.54,percent of total billed charges,Implant Device,203.35,35,,203.35,percent of total billed charges,Implant Device,203.35,35,,203.35,percent of total billed charges,Implant Device,203.35,35,,203.35,percent of total billed charges,Implant Device,203.35,35,,203.35,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,429.94,
EXACTECH 340-38-29 CANC SCREW 3.8X29MM,C1713,HCPCS,,79003468,CDM,278,RC,,,both,,,499,369.26,,,369.26,Other,150% of Medicare + 9.63% HCRA Surcharge,224.55,45,,224.55,percent of total billed charges,Critical Access Hospital RCC factor,169.66,34,,169.66,percent of total billed charges,Implant Device,169.66,34,,169.66,percent of total billed charges,Implant Device,169.66,34,,169.66,percent of total billed charges,Implant Device,169.66,34,,169.66,percent of total billed charges,Implant Device,169.66,34,,169.66,percent of total billed charges,Implant Device,247.01,,,247.01,Other,110% of Medicare,174.65,35,,174.65,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,174.65,35,,174.65,percent of total billed charges,Implant Device,174.65,35,,174.65,percent of total billed charges,Implant Device,174.65,35,,174.65,percent of total billed charges,Implant Device,174.65,35,,174.65,percent of total billed charges,Implant Device,174.65,35,,174.65,percent of total billed charges,Implant Device,199.6,40,,199.6,percent of total billed charges,Implant Device,174.65,70,,174.65,percent of total billed charges,All Other,169.66,34,,169.66,percent of total billed charges,Implant Device,169.66,34,,169.66,percent of total billed charges,Implant Device,174.65,35,,174.65,percent of total billed charges,Implant Device,174.65,35,,174.65,percent of total billed charges,Implant Device,174.65,35,,174.65,percent of total billed charges,Implant Device,174.65,35,,174.65,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,369.26,
EXACTECH 340-40-20 CORTICAL SCREW 3.8X20,C1713,HCPCS,,79003469,CDM,278,RC,,,both,,,499,369.26,,,369.26,Other,150% of Medicare + 9.63% HCRA Surcharge,224.55,45,,224.55,percent of total billed charges,Critical Access Hospital RCC factor,169.66,34,,169.66,percent of total billed charges,Implant Device,169.66,34,,169.66,percent of total billed charges,Implant Device,169.66,34,,169.66,percent of total billed charges,Implant Device,169.66,34,,169.66,percent of total billed charges,Implant Device,169.66,34,,169.66,percent of total billed charges,Implant Device,247.01,,,247.01,Other,110% of Medicare,174.65,35,,174.65,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,174.65,35,,174.65,percent of total billed charges,Implant Device,174.65,35,,174.65,percent of total billed charges,Implant Device,174.65,35,,174.65,percent of total billed charges,Implant Device,174.65,35,,174.65,percent of total billed charges,Implant Device,174.65,35,,174.65,percent of total billed charges,Implant Device,199.6,40,,199.6,percent of total billed charges,Implant Device,174.65,70,,174.65,percent of total billed charges,All Other,169.66,34,,169.66,percent of total billed charges,Implant Device,169.66,34,,169.66,percent of total billed charges,Implant Device,174.65,35,,174.65,percent of total billed charges,Implant Device,174.65,35,,174.65,percent of total billed charges,Implant Device,174.65,35,,174.65,percent of total billed charges,Implant Device,174.65,35,,174.65,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,369.26,
ARTHREX AR-1670BC BIOCOMP SCREW 7X10MM,C1713,HCPCS,,79003470,CDM,278,RC,,,both,,,1350,999,,,999,Other,150% of Medicare + 9.63% HCRA Surcharge,607.5,45,,607.5,percent of total billed charges,Critical Access Hospital RCC factor,459,34,,459,percent of total billed charges,Implant Device,459,34,,459,percent of total billed charges,Implant Device,459,34,,459,percent of total billed charges,Implant Device,459,34,,459,percent of total billed charges,Implant Device,459,34,,459,percent of total billed charges,Implant Device,668.25,,,668.25,Other,110% of Medicare,472.5,35,,472.5,percent of total billed charges,Implant Device,459,34,"Charges > $500, x 34%",459,percent of total billed charges,Implant Device,472.5,35,,472.5,percent of total billed charges,Implant Device,472.5,35,,472.5,percent of total billed charges,Implant Device,472.5,35,,472.5,percent of total billed charges,Implant Device,472.5,35,,472.5,percent of total billed charges,Implant Device,472.5,35,,472.5,percent of total billed charges,Implant Device,540,40,,540,percent of total billed charges,Implant Device,472.5,70,,472.5,percent of total billed charges,All Other,459,34,,459,percent of total billed charges,Implant Device,459,34,,459,percent of total billed charges,Implant Device,472.5,35,,472.5,percent of total billed charges,Implant Device,472.5,35,,472.5,percent of total billed charges,Implant Device,472.5,35,,472.5,percent of total billed charges,Implant Device,472.5,35,,472.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,999,
ARTHREX AR-1680BC BIOCOMP SCREW 8X12MM,C1713,HCPCS,,79003471,CDM,278,RC,,,both,,,1350,999,,,999,Other,150% of Medicare + 9.63% HCRA Surcharge,607.5,45,,607.5,percent of total billed charges,Critical Access Hospital RCC factor,459,34,,459,percent of total billed charges,Implant Device,459,34,,459,percent of total billed charges,Implant Device,459,34,,459,percent of total billed charges,Implant Device,459,34,,459,percent of total billed charges,Implant Device,459,34,,459,percent of total billed charges,Implant Device,668.25,,,668.25,Other,110% of Medicare,472.5,35,,472.5,percent of total billed charges,Implant Device,459,34,"Charges > $500, x 34%",459,percent of total billed charges,Implant Device,472.5,35,,472.5,percent of total billed charges,Implant Device,472.5,35,,472.5,percent of total billed charges,Implant Device,472.5,35,,472.5,percent of total billed charges,Implant Device,472.5,35,,472.5,percent of total billed charges,Implant Device,472.5,35,,472.5,percent of total billed charges,Implant Device,540,40,,540,percent of total billed charges,Implant Device,472.5,70,,472.5,percent of total billed charges,All Other,459,34,,459,percent of total billed charges,Implant Device,459,34,,459,percent of total billed charges,Implant Device,472.5,35,,472.5,percent of total billed charges,Implant Device,472.5,35,,472.5,percent of total billed charges,Implant Device,472.5,35,,472.5,percent of total billed charges,Implant Device,472.5,35,,472.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,999,
INTL BIOLOGICS 905 TENOD GRAFT 9.5X170MM,C1713,HCPCS,,79003472,CDM,278,RC,,,both,,,5325,3940.51,,,3940.51,Other,150% of Medicare + 9.63% HCRA Surcharge,2396.25,45,,2396.25,percent of total billed charges,Critical Access Hospital RCC factor,1810.5,34,,1810.5,percent of total billed charges,Implant Device,1810.5,34,,1810.5,percent of total billed charges,Implant Device,1810.5,34,,1810.5,percent of total billed charges,Implant Device,1810.5,34,,1810.5,percent of total billed charges,Implant Device,1810.5,34,,1810.5,percent of total billed charges,Implant Device,2635.88,,,2635.88,Other,110% of Medicare,1863.75,35,,1863.75,percent of total billed charges,Implant Device,1810.5,34,"Charges > $500, x 34%",1810.5,percent of total billed charges,Implant Device,1863.75,35,,1863.75,percent of total billed charges,Implant Device,1863.75,35,,1863.75,percent of total billed charges,Implant Device,1863.75,35,,1863.75,percent of total billed charges,Implant Device,1863.75,35,,1863.75,percent of total billed charges,Implant Device,1863.75,35,,1863.75,percent of total billed charges,Implant Device,2130,40,,2130,percent of total billed charges,Implant Device,1863.75,70,,1863.75,percent of total billed charges,All Other,1810.5,34,,1810.5,percent of total billed charges,Implant Device,1810.5,34,,1810.5,percent of total billed charges,Implant Device,1863.75,35,,1863.75,percent of total billed charges,Implant Device,1863.75,35,,1863.75,percent of total billed charges,Implant Device,1863.75,35,,1863.75,percent of total billed charges,Implant Device,1863.75,35,,1863.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1810.5,34,"If Charge > 2,000, then 34 percent",1810.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3940.51,
SYNTHES 223.551 PLATE 3.5MM LCP 5H 72MM,C1713,HCPCS,,79003477,CDM,278,RC,,,both,,,1049,776.26,,,776.26,Other,150% of Medicare + 9.63% HCRA Surcharge,472.05,45,,472.05,percent of total billed charges,Critical Access Hospital RCC factor,356.66,34,,356.66,percent of total billed charges,Implant Device,356.66,34,,356.66,percent of total billed charges,Implant Device,356.66,34,,356.66,percent of total billed charges,Implant Device,356.66,34,,356.66,percent of total billed charges,Implant Device,356.66,34,,356.66,percent of total billed charges,Implant Device,519.26,,,519.26,Other,110% of Medicare,367.15,35,,367.15,percent of total billed charges,Implant Device,356.66,34,"Charges > $500, x 34%",356.66,percent of total billed charges,Implant Device,367.15,35,,367.15,percent of total billed charges,Implant Device,367.15,35,,367.15,percent of total billed charges,Implant Device,367.15,35,,367.15,percent of total billed charges,Implant Device,367.15,35,,367.15,percent of total billed charges,Implant Device,367.15,35,,367.15,percent of total billed charges,Implant Device,419.6,40,,419.6,percent of total billed charges,Implant Device,367.15,70,,367.15,percent of total billed charges,All Other,356.66,34,,356.66,percent of total billed charges,Implant Device,356.66,34,,356.66,percent of total billed charges,Implant Device,367.15,35,,367.15,percent of total billed charges,Implant Device,367.15,35,,367.15,percent of total billed charges,Implant Device,367.15,35,,367.15,percent of total billed charges,Implant Device,367.15,35,,367.15,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,776.26,
SYNTHES 204.814 SCREW 3.5MM CORTEX 14MM,C1713,HCPCS,,79003478,CDM,278,RC,,,both,,,59,43.66,,,43.66,Other,150% of Medicare + 9.63% HCRA Surcharge,26.55,45,,26.55,percent of total billed charges,Critical Access Hospital RCC factor,20.06,34,,20.06,percent of total billed charges,Implant Device,20.06,34,,20.06,percent of total billed charges,Implant Device,20.06,34,,20.06,percent of total billed charges,Implant Device,20.06,34,,20.06,percent of total billed charges,Implant Device,20.06,34,,20.06,percent of total billed charges,Implant Device,29.21,,,29.21,Other,110% of Medicare,20.65,35,,20.65,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,20.65,35,,20.65,percent of total billed charges,Implant Device,20.65,35,,20.65,percent of total billed charges,Implant Device,20.65,35,,20.65,percent of total billed charges,Implant Device,20.65,35,,20.65,percent of total billed charges,Implant Device,20.65,35,,20.65,percent of total billed charges,Implant Device,23.6,40,,23.6,percent of total billed charges,Implant Device,20.65,70,,20.65,percent of total billed charges,All Other,20.06,34,,20.06,percent of total billed charges,Implant Device,20.06,34,,20.06,percent of total billed charges,Implant Device,20.65,35,,20.65,percent of total billed charges,Implant Device,20.65,35,,20.65,percent of total billed charges,Implant Device,20.65,35,,20.65,percent of total billed charges,Implant Device,20.65,35,,20.65,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,43.66,
EXACTECH 320-15-04 GLENOID PLATE 8DEG,C1776,HCPCS,,79003485,CDM,278,RC,,,both,,,5925,4384.51,,,4384.51,Other,150% of Medicare + 9.63% HCRA Surcharge,2666.25,45,,2666.25,percent of total billed charges,Critical Access Hospital RCC factor,2014.5,34,,2014.5,percent of total billed charges,Implant Device,2014.5,34,,2014.5,percent of total billed charges,Implant Device,2014.5,34,,2014.5,percent of total billed charges,Implant Device,2014.5,34,,2014.5,percent of total billed charges,Implant Device,2014.5,34,,2014.5,percent of total billed charges,Implant Device,2932.88,,,2932.88,Other,110% of Medicare,2073.75,35,,2073.75,percent of total billed charges,Implant Device,2014.5,34,"Charges > $500, x 34%",2014.5,percent of total billed charges,Implant Device,2073.75,35,,2073.75,percent of total billed charges,Implant Device,2073.75,35,,2073.75,percent of total billed charges,Implant Device,2073.75,35,,2073.75,percent of total billed charges,Implant Device,2073.75,35,,2073.75,percent of total billed charges,Implant Device,2073.75,35,,2073.75,percent of total billed charges,Implant Device,2370,40,,2370,percent of total billed charges,Implant Device,2073.75,70,,2073.75,percent of total billed charges,All Other,2014.5,34,,2014.5,percent of total billed charges,Implant Device,2014.5,34,,2014.5,percent of total billed charges,Implant Device,2073.75,35,,2073.75,percent of total billed charges,Implant Device,2073.75,35,,2073.75,percent of total billed charges,Implant Device,2073.75,35,,2073.75,percent of total billed charges,Implant Device,2073.75,35,,2073.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2014.5,34,"If Charge > 2,000, then 34 percent",2014.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4384.51,
EXACTECH 320-15-01 GLENOID PLATE,C1776,HCPCS,,79003487,CDM,278,RC,,,both,,,4350,3219.01,,,3219.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1957.5,45,,1957.5,percent of total billed charges,Critical Access Hospital RCC factor,1479,34,,1479,percent of total billed charges,Implant Device,1479,34,,1479,percent of total billed charges,Implant Device,1479,34,,1479,percent of total billed charges,Implant Device,1479,34,,1479,percent of total billed charges,Implant Device,1479,34,,1479,percent of total billed charges,Implant Device,2153.25,,,2153.25,Other,110% of Medicare,1522.5,35,,1522.5,percent of total billed charges,Implant Device,1479,34,"Charges > $500, x 34%",1479,percent of total billed charges,Implant Device,1522.5,35,,1522.5,percent of total billed charges,Implant Device,1522.5,35,,1522.5,percent of total billed charges,Implant Device,1522.5,35,,1522.5,percent of total billed charges,Implant Device,1522.5,35,,1522.5,percent of total billed charges,Implant Device,1522.5,35,,1522.5,percent of total billed charges,Implant Device,1740,40,,1740,percent of total billed charges,Implant Device,1522.5,70,,1522.5,percent of total billed charges,All Other,1479,34,,1479,percent of total billed charges,Implant Device,1479,34,,1479,percent of total billed charges,Implant Device,1522.5,35,,1522.5,percent of total billed charges,Implant Device,1522.5,35,,1522.5,percent of total billed charges,Implant Device,1522.5,35,,1522.5,percent of total billed charges,Implant Device,1522.5,35,,1522.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1479,34,"If Charge > 2,000, then 34 percent",1479,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3219.01,
EXACTECH 320-20-26 COMPRESSN SCREW 26MM,C1713,HCPCS,,79003488,CDM,278,RC,,,both,,,300,222,,,222,Other,150% of Medicare + 9.63% HCRA Surcharge,135,45,,135,percent of total billed charges,Critical Access Hospital RCC factor,102,34,,102,percent of total billed charges,Implant Device,102,34,,102,percent of total billed charges,Implant Device,102,34,,102,percent of total billed charges,Implant Device,102,34,,102,percent of total billed charges,Implant Device,102,34,,102,percent of total billed charges,Implant Device,148.5,,,148.5,Other,110% of Medicare,105,35,,105,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,105,35,,105,percent of total billed charges,Implant Device,105,35,,105,percent of total billed charges,Implant Device,105,35,,105,percent of total billed charges,Implant Device,105,35,,105,percent of total billed charges,Implant Device,105,35,,105,percent of total billed charges,Implant Device,120,40,,120,percent of total billed charges,Implant Device,105,70,,105,percent of total billed charges,All Other,102,34,,102,percent of total billed charges,Implant Device,102,34,,102,percent of total billed charges,Implant Device,105,35,,105,percent of total billed charges,Implant Device,105,35,,105,percent of total billed charges,Implant Device,105,35,,105,percent of total billed charges,Implant Device,105,35,,105,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,222,
EXACTECH 320-20-30 COMPRESSN SCREW 30MM,C1713,HCPCS,,79003489,CDM,278,RC,,,both,,,300,222,,,222,Other,150% of Medicare + 9.63% HCRA Surcharge,135,45,,135,percent of total billed charges,Critical Access Hospital RCC factor,102,34,,102,percent of total billed charges,Implant Device,102,34,,102,percent of total billed charges,Implant Device,102,34,,102,percent of total billed charges,Implant Device,102,34,,102,percent of total billed charges,Implant Device,102,34,,102,percent of total billed charges,Implant Device,148.5,,,148.5,Other,110% of Medicare,105,35,,105,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,105,35,,105,percent of total billed charges,Implant Device,105,35,,105,percent of total billed charges,Implant Device,105,35,,105,percent of total billed charges,Implant Device,105,35,,105,percent of total billed charges,Implant Device,105,35,,105,percent of total billed charges,Implant Device,120,40,,120,percent of total billed charges,Implant Device,105,70,,105,percent of total billed charges,All Other,102,34,,102,percent of total billed charges,Implant Device,102,34,,102,percent of total billed charges,Implant Device,105,35,,105,percent of total billed charges,Implant Device,105,35,,105,percent of total billed charges,Implant Device,105,35,,105,percent of total billed charges,Implant Device,105,35,,105,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,222,
EXACTECH 304-22-13 FRACTURE STEM 12.5MM,C1776,HCPCS,,79003490,CDM,278,RC,,,both,,,6225,4606.52,,,4606.52,Other,150% of Medicare + 9.63% HCRA Surcharge,2801.25,45,,2801.25,percent of total billed charges,Critical Access Hospital RCC factor,2116.5,34,,2116.5,percent of total billed charges,Implant Device,2116.5,34,,2116.5,percent of total billed charges,Implant Device,2116.5,34,,2116.5,percent of total billed charges,Implant Device,2116.5,34,,2116.5,percent of total billed charges,Implant Device,2116.5,34,,2116.5,percent of total billed charges,Implant Device,3081.38,,,3081.38,Other,110% of Medicare,2178.75,35,,2178.75,percent of total billed charges,Implant Device,2116.5,34,"Charges > $500, x 34%",2116.5,percent of total billed charges,Implant Device,2178.75,35,,2178.75,percent of total billed charges,Implant Device,2178.75,35,,2178.75,percent of total billed charges,Implant Device,2178.75,35,,2178.75,percent of total billed charges,Implant Device,2178.75,35,,2178.75,percent of total billed charges,Implant Device,2178.75,35,,2178.75,percent of total billed charges,Implant Device,2490,40,,2490,percent of total billed charges,Implant Device,2178.75,70,,2178.75,percent of total billed charges,All Other,2116.5,34,,2116.5,percent of total billed charges,Implant Device,2116.5,34,,2116.5,percent of total billed charges,Implant Device,2178.75,35,,2178.75,percent of total billed charges,Implant Device,2178.75,35,,2178.75,percent of total billed charges,Implant Device,2178.75,35,,2178.75,percent of total billed charges,Implant Device,2178.75,35,,2178.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2116.5,34,"If Charge > 2,000, then 34 percent",2116.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4606.52,
EXACTECH 320-15-05 GLENOSPHRE LOCK SCREW,C1713,HCPCS,,79003491,CDM,278,RC,,,both,,,300,222,,,222,Other,150% of Medicare + 9.63% HCRA Surcharge,135,45,,135,percent of total billed charges,Critical Access Hospital RCC factor,102,34,,102,percent of total billed charges,Implant Device,102,34,,102,percent of total billed charges,Implant Device,102,34,,102,percent of total billed charges,Implant Device,102,34,,102,percent of total billed charges,Implant Device,102,34,,102,percent of total billed charges,Implant Device,148.5,,,148.5,Other,110% of Medicare,105,35,,105,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,105,35,,105,percent of total billed charges,Implant Device,105,35,,105,percent of total billed charges,Implant Device,105,35,,105,percent of total billed charges,Implant Device,105,35,,105,percent of total billed charges,Implant Device,105,35,,105,percent of total billed charges,Implant Device,120,40,,120,percent of total billed charges,Implant Device,105,70,,105,percent of total billed charges,All Other,102,34,,102,percent of total billed charges,Implant Device,102,34,,102,percent of total billed charges,Implant Device,105,35,,105,percent of total billed charges,Implant Device,105,35,,105,percent of total billed charges,Implant Device,105,35,,105,percent of total billed charges,Implant Device,105,35,,105,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,222,
EXACTECH 320-20-00 REV TORQUE SCREW KIT,C1713,HCPCS,,79003492,CDM,278,RC,,,both,,,675,499.5,,,499.5,Other,150% of Medicare + 9.63% HCRA Surcharge,303.75,45,,303.75,percent of total billed charges,Critical Access Hospital RCC factor,229.5,34,,229.5,percent of total billed charges,Implant Device,229.5,34,,229.5,percent of total billed charges,Implant Device,229.5,34,,229.5,percent of total billed charges,Implant Device,229.5,34,,229.5,percent of total billed charges,Implant Device,229.5,34,,229.5,percent of total billed charges,Implant Device,334.13,,,334.13,Other,110% of Medicare,236.25,35,,236.25,percent of total billed charges,Implant Device,229.5,34,"Charges > $500, x 34%",229.5,percent of total billed charges,Implant Device,236.25,35,,236.25,percent of total billed charges,Implant Device,236.25,35,,236.25,percent of total billed charges,Implant Device,236.25,35,,236.25,percent of total billed charges,Implant Device,236.25,35,,236.25,percent of total billed charges,Implant Device,236.25,35,,236.25,percent of total billed charges,Implant Device,270,40,,270,percent of total billed charges,Implant Device,236.25,70,,236.25,percent of total billed charges,All Other,229.5,34,,229.5,percent of total billed charges,Implant Device,229.5,34,,229.5,percent of total billed charges,Implant Device,236.25,35,,236.25,percent of total billed charges,Implant Device,236.25,35,,236.25,percent of total billed charges,Implant Device,236.25,35,,236.25,percent of total billed charges,Implant Device,236.25,35,,236.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,499.5,
EXACTECH 320-10-00 HUM ADAPTOR TRAY +0MM,C1776,HCPCS,,79003493,CDM,278,RC,,,both,,,6480,4795.22,,,4795.22,Other,150% of Medicare + 9.63% HCRA Surcharge,2916,45,,2916,percent of total billed charges,Critical Access Hospital RCC factor,2203.2,34,,2203.2,percent of total billed charges,Implant Device,2203.2,34,,2203.2,percent of total billed charges,Implant Device,2203.2,34,,2203.2,percent of total billed charges,Implant Device,2203.2,34,,2203.2,percent of total billed charges,Implant Device,2203.2,34,,2203.2,percent of total billed charges,Implant Device,3207.6,,,3207.6,Other,110% of Medicare,2268,35,,2268,percent of total billed charges,Implant Device,2203.2,34,"Charges > $500, x 34%",2203.2,percent of total billed charges,Implant Device,2268,35,,2268,percent of total billed charges,Implant Device,2268,35,,2268,percent of total billed charges,Implant Device,2268,35,,2268,percent of total billed charges,Implant Device,2268,35,,2268,percent of total billed charges,Implant Device,2268,35,,2268,percent of total billed charges,Implant Device,2592,40,,2592,percent of total billed charges,Implant Device,2268,70,,2268,percent of total billed charges,All Other,2203.2,34,,2203.2,percent of total billed charges,Implant Device,2203.2,34,,2203.2,percent of total billed charges,Implant Device,2268,35,,2268,percent of total billed charges,Implant Device,2268,35,,2268,percent of total billed charges,Implant Device,2268,35,,2268,percent of total billed charges,Implant Device,2268,35,,2268,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2203.2,34,"If Charge > 2,000, then 34 percent",2203.2,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4795.22,
ARTHREX AR-8967-2875 CANN SCREW 6.7X75MM,C1713,HCPCS,,79003494,CDM,278,RC,,,both,,,660,488.4,,,488.4,Other,150% of Medicare + 9.63% HCRA Surcharge,297,45,,297,percent of total billed charges,Critical Access Hospital RCC factor,224.4,34,,224.4,percent of total billed charges,Implant Device,224.4,34,,224.4,percent of total billed charges,Implant Device,224.4,34,,224.4,percent of total billed charges,Implant Device,224.4,34,,224.4,percent of total billed charges,Implant Device,224.4,34,,224.4,percent of total billed charges,Implant Device,326.7,,,326.7,Other,110% of Medicare,231,35,,231,percent of total billed charges,Implant Device,224.4,34,"Charges > $500, x 34%",224.4,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,264,40,,264,percent of total billed charges,Implant Device,231,70,,231,percent of total billed charges,All Other,224.4,34,,224.4,percent of total billed charges,Implant Device,224.4,34,,224.4,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,488.4,
ARTHREX AR-8945-55PT CANN SCREW 4.5X55MM,C1713,HCPCS,,79003495,CDM,278,RC,,,both,,,750,555,,,555,Other,150% of Medicare + 9.63% HCRA Surcharge,337.5,45,,337.5,percent of total billed charges,Critical Access Hospital RCC factor,255,34,,255,percent of total billed charges,Implant Device,255,34,,255,percent of total billed charges,Implant Device,255,34,,255,percent of total billed charges,Implant Device,255,34,,255,percent of total billed charges,Implant Device,255,34,,255,percent of total billed charges,Implant Device,371.25,,,371.25,Other,110% of Medicare,262.5,35,,262.5,percent of total billed charges,Implant Device,255,34,"Charges > $500, x 34%",255,percent of total billed charges,Implant Device,262.5,35,,262.5,percent of total billed charges,Implant Device,262.5,35,,262.5,percent of total billed charges,Implant Device,262.5,35,,262.5,percent of total billed charges,Implant Device,262.5,35,,262.5,percent of total billed charges,Implant Device,262.5,35,,262.5,percent of total billed charges,Implant Device,300,40,,300,percent of total billed charges,Implant Device,262.5,70,,262.5,percent of total billed charges,All Other,255,34,,255,percent of total billed charges,Implant Device,255,34,,255,percent of total billed charges,Implant Device,262.5,35,,262.5,percent of total billed charges,Implant Device,262.5,35,,262.5,percent of total billed charges,Implant Device,262.5,35,,262.5,percent of total billed charges,Implant Device,262.5,35,,262.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,555,
ARTHREX AR-8952XM X-PLATE MEDIUM,C1713,HCPCS,,79003496,CDM,278,RC,,,both,,,3429,2537.47,,,2537.47,Other,150% of Medicare + 9.63% HCRA Surcharge,1543.05,45,,1543.05,percent of total billed charges,Critical Access Hospital RCC factor,1165.86,34,,1165.86,percent of total billed charges,Implant Device,1165.86,34,,1165.86,percent of total billed charges,Implant Device,1165.86,34,,1165.86,percent of total billed charges,Implant Device,1165.86,34,,1165.86,percent of total billed charges,Implant Device,1165.86,34,,1165.86,percent of total billed charges,Implant Device,1697.36,,,1697.36,Other,110% of Medicare,1200.15,35,,1200.15,percent of total billed charges,Implant Device,1165.86,34,"Charges > $500, x 34%",1165.86,percent of total billed charges,Implant Device,1200.15,35,,1200.15,percent of total billed charges,Implant Device,1200.15,35,,1200.15,percent of total billed charges,Implant Device,1200.15,35,,1200.15,percent of total billed charges,Implant Device,1200.15,35,,1200.15,percent of total billed charges,Implant Device,1200.15,35,,1200.15,percent of total billed charges,Implant Device,1371.6,40,,1371.6,percent of total billed charges,Implant Device,1200.15,70,,1200.15,percent of total billed charges,All Other,1165.86,34,,1165.86,percent of total billed charges,Implant Device,1165.86,34,,1165.86,percent of total billed charges,Implant Device,1200.15,35,,1200.15,percent of total billed charges,Implant Device,1200.15,35,,1200.15,percent of total billed charges,Implant Device,1200.15,35,,1200.15,percent of total billed charges,Implant Device,1200.15,35,,1200.15,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1165.86,34,"If Charge > 2,000, then 34 percent",1165.86,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2537.47,
ARTHREX AR-8740-38PTS CANN SCREW 4X38M,C1713,HCPCS,,79003497,CDM,278,RC,,,both,,,825,610.5,,,610.5,Other,150% of Medicare + 9.63% HCRA Surcharge,371.25,45,,371.25,percent of total billed charges,Critical Access Hospital RCC factor,280.5,34,,280.5,percent of total billed charges,Implant Device,280.5,34,,280.5,percent of total billed charges,Implant Device,280.5,34,,280.5,percent of total billed charges,Implant Device,280.5,34,,280.5,percent of total billed charges,Implant Device,280.5,34,,280.5,percent of total billed charges,Implant Device,408.38,,,408.38,Other,110% of Medicare,288.75,35,,288.75,percent of total billed charges,Implant Device,280.5,34,"Charges > $500, x 34%",280.5,percent of total billed charges,Implant Device,288.75,35,,288.75,percent of total billed charges,Implant Device,288.75,35,,288.75,percent of total billed charges,Implant Device,288.75,35,,288.75,percent of total billed charges,Implant Device,288.75,35,,288.75,percent of total billed charges,Implant Device,288.75,35,,288.75,percent of total billed charges,Implant Device,330,40,,330,percent of total billed charges,Implant Device,288.75,70,,288.75,percent of total billed charges,All Other,280.5,34,,280.5,percent of total billed charges,Implant Device,280.5,34,,280.5,percent of total billed charges,Implant Device,288.75,35,,288.75,percent of total billed charges,Implant Device,288.75,35,,288.75,percent of total billed charges,Implant Device,288.75,35,,288.75,percent of total billed charges,Implant Device,288.75,35,,288.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,610.5,
SOLANA TSS-2020S ALLOGRAFT TENSIX 2X2X.5,C1713,HCPCS,,79003499,CDM,278,RC,,,both,,,6467,4785.6,,,4785.6,Other,150% of Medicare + 9.63% HCRA Surcharge,2910.15,45,,2910.15,percent of total billed charges,Critical Access Hospital RCC factor,2198.78,34,,2198.78,percent of total billed charges,Implant Device,2198.78,34,,2198.78,percent of total billed charges,Implant Device,2198.78,34,,2198.78,percent of total billed charges,Implant Device,2198.78,34,,2198.78,percent of total billed charges,Implant Device,2198.78,34,,2198.78,percent of total billed charges,Implant Device,3201.17,,,3201.17,Other,110% of Medicare,2263.45,35,,2263.45,percent of total billed charges,Implant Device,2198.78,34,"Charges > $500, x 34%",2198.78,percent of total billed charges,Implant Device,2263.45,35,,2263.45,percent of total billed charges,Implant Device,2263.45,35,,2263.45,percent of total billed charges,Implant Device,2263.45,35,,2263.45,percent of total billed charges,Implant Device,2263.45,35,,2263.45,percent of total billed charges,Implant Device,2263.45,35,,2263.45,percent of total billed charges,Implant Device,2586.8,40,,2586.8,percent of total billed charges,Implant Device,2263.45,70,,2263.45,percent of total billed charges,All Other,2198.78,34,,2198.78,percent of total billed charges,Implant Device,2198.78,34,,2198.78,percent of total billed charges,Implant Device,2263.45,35,,2263.45,percent of total billed charges,Implant Device,2263.45,35,,2263.45,percent of total billed charges,Implant Device,2263.45,35,,2263.45,percent of total billed charges,Implant Device,2263.45,35,,2263.45,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2198.78,34,"If Charge > 2,000, then 34 percent",2198.78,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4785.6,
SOLANA TSS-1515 ALLOGRAFT 1.5X1.5X1.5,C1713,HCPCS,,79003500,CDM,278,RC,,,both,,,5467,4045.59,,,4045.59,Other,150% of Medicare + 9.63% HCRA Surcharge,2460.15,45,,2460.15,percent of total billed charges,Critical Access Hospital RCC factor,1858.78,34,,1858.78,percent of total billed charges,Implant Device,1858.78,34,,1858.78,percent of total billed charges,Implant Device,1858.78,34,,1858.78,percent of total billed charges,Implant Device,1858.78,34,,1858.78,percent of total billed charges,Implant Device,1858.78,34,,1858.78,percent of total billed charges,Implant Device,2706.17,,,2706.17,Other,110% of Medicare,1913.45,35,,1913.45,percent of total billed charges,Implant Device,1858.78,34,"Charges > $500, x 34%",1858.78,percent of total billed charges,Implant Device,1913.45,35,,1913.45,percent of total billed charges,Implant Device,1913.45,35,,1913.45,percent of total billed charges,Implant Device,1913.45,35,,1913.45,percent of total billed charges,Implant Device,1913.45,35,,1913.45,percent of total billed charges,Implant Device,1913.45,35,,1913.45,percent of total billed charges,Implant Device,2186.8,40,,2186.8,percent of total billed charges,Implant Device,1913.45,70,,1913.45,percent of total billed charges,All Other,1858.78,34,,1858.78,percent of total billed charges,Implant Device,1858.78,34,,1858.78,percent of total billed charges,Implant Device,1913.45,35,,1913.45,percent of total billed charges,Implant Device,1913.45,35,,1913.45,percent of total billed charges,Implant Device,1913.45,35,,1913.45,percent of total billed charges,Implant Device,1913.45,35,,1913.45,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1858.78,34,"If Charge > 2,000, then 34 percent",1858.78,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4045.59,
PARAGON 28 P28-05-001 CALCANEUS PLATE,C1713,HCPCS,,79003501,CDM,278,RC,,,both,,,4590,3396.61,,,3396.61,Other,150% of Medicare + 9.63% HCRA Surcharge,2065.5,45,,2065.5,percent of total billed charges,Critical Access Hospital RCC factor,1560.6,34,,1560.6,percent of total billed charges,Implant Device,1560.6,34,,1560.6,percent of total billed charges,Implant Device,1560.6,34,,1560.6,percent of total billed charges,Implant Device,1560.6,34,,1560.6,percent of total billed charges,Implant Device,1560.6,34,,1560.6,percent of total billed charges,Implant Device,2272.05,,,2272.05,Other,110% of Medicare,1606.5,35,,1606.5,percent of total billed charges,Implant Device,1560.6,34,"Charges > $500, x 34%",1560.6,percent of total billed charges,Implant Device,1606.5,35,,1606.5,percent of total billed charges,Implant Device,1606.5,35,,1606.5,percent of total billed charges,Implant Device,1606.5,35,,1606.5,percent of total billed charges,Implant Device,1606.5,35,,1606.5,percent of total billed charges,Implant Device,1606.5,35,,1606.5,percent of total billed charges,Implant Device,1836,40,,1836,percent of total billed charges,Implant Device,1606.5,70,,1606.5,percent of total billed charges,All Other,1560.6,34,,1560.6,percent of total billed charges,Implant Device,1560.6,34,,1560.6,percent of total billed charges,Implant Device,1606.5,35,,1606.5,percent of total billed charges,Implant Device,1606.5,35,,1606.5,percent of total billed charges,Implant Device,1606.5,35,,1606.5,percent of total billed charges,Implant Device,1606.5,35,,1606.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1560.6,34,"If Charge > 2,000, then 34 percent",1560.6,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3396.61,
PARAGON 28 P28-20-028 SCREW 3.5X28MM,C1713,HCPCS,,79003502,CDM,278,RC,,,both,,,532,393.68,,,393.68,Other,150% of Medicare + 9.63% HCRA Surcharge,239.4,45,,239.4,percent of total billed charges,Critical Access Hospital RCC factor,180.88,34,,180.88,percent of total billed charges,Implant Device,180.88,34,,180.88,percent of total billed charges,Implant Device,180.88,34,,180.88,percent of total billed charges,Implant Device,180.88,34,,180.88,percent of total billed charges,Implant Device,180.88,34,,180.88,percent of total billed charges,Implant Device,263.34,,,263.34,Other,110% of Medicare,186.2,35,,186.2,percent of total billed charges,Implant Device,180.88,34,"Charges > $500, x 34%",180.88,percent of total billed charges,Implant Device,186.2,35,,186.2,percent of total billed charges,Implant Device,186.2,35,,186.2,percent of total billed charges,Implant Device,186.2,35,,186.2,percent of total billed charges,Implant Device,186.2,35,,186.2,percent of total billed charges,Implant Device,186.2,35,,186.2,percent of total billed charges,Implant Device,212.8,40,,212.8,percent of total billed charges,Implant Device,186.2,70,,186.2,percent of total billed charges,All Other,180.88,34,,180.88,percent of total billed charges,Implant Device,180.88,34,,180.88,percent of total billed charges,Implant Device,186.2,35,,186.2,percent of total billed charges,Implant Device,186.2,35,,186.2,percent of total billed charges,Implant Device,186.2,35,,186.2,percent of total billed charges,Implant Device,186.2,35,,186.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,393.68,
PARAGON 28 P28-20-030 SCREW 3.5X30MM,C1713,HCPCS,,79003503,CDM,278,RC,,,both,,,586,433.64,,,433.64,Other,150% of Medicare + 9.63% HCRA Surcharge,263.7,45,,263.7,percent of total billed charges,Critical Access Hospital RCC factor,199.24,34,,199.24,percent of total billed charges,Implant Device,199.24,34,,199.24,percent of total billed charges,Implant Device,199.24,34,,199.24,percent of total billed charges,Implant Device,199.24,34,,199.24,percent of total billed charges,Implant Device,199.24,34,,199.24,percent of total billed charges,Implant Device,290.07,,,290.07,Other,110% of Medicare,205.1,35,,205.1,percent of total billed charges,Implant Device,199.24,34,"Charges > $500, x 34%",199.24,percent of total billed charges,Implant Device,205.1,35,,205.1,percent of total billed charges,Implant Device,205.1,35,,205.1,percent of total billed charges,Implant Device,205.1,35,,205.1,percent of total billed charges,Implant Device,205.1,35,,205.1,percent of total billed charges,Implant Device,205.1,35,,205.1,percent of total billed charges,Implant Device,234.4,40,,234.4,percent of total billed charges,Implant Device,205.1,70,,205.1,percent of total billed charges,All Other,199.24,34,,199.24,percent of total billed charges,Implant Device,199.24,34,,199.24,percent of total billed charges,Implant Device,205.1,35,,205.1,percent of total billed charges,Implant Device,205.1,35,,205.1,percent of total billed charges,Implant Device,205.1,35,,205.1,percent of total billed charges,Implant Device,205.1,35,,205.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,433.64,
PARAGON 28 P28-20-035 SCREW 3.5X35MM,C1713,HCPCS,,79003504,CDM,278,RC,,,both,,,532,393.68,,,393.68,Other,150% of Medicare + 9.63% HCRA Surcharge,239.4,45,,239.4,percent of total billed charges,Critical Access Hospital RCC factor,180.88,34,,180.88,percent of total billed charges,Implant Device,180.88,34,,180.88,percent of total billed charges,Implant Device,180.88,34,,180.88,percent of total billed charges,Implant Device,180.88,34,,180.88,percent of total billed charges,Implant Device,180.88,34,,180.88,percent of total billed charges,Implant Device,263.34,,,263.34,Other,110% of Medicare,186.2,35,,186.2,percent of total billed charges,Implant Device,180.88,34,"Charges > $500, x 34%",180.88,percent of total billed charges,Implant Device,186.2,35,,186.2,percent of total billed charges,Implant Device,186.2,35,,186.2,percent of total billed charges,Implant Device,186.2,35,,186.2,percent of total billed charges,Implant Device,186.2,35,,186.2,percent of total billed charges,Implant Device,186.2,35,,186.2,percent of total billed charges,Implant Device,212.8,40,,212.8,percent of total billed charges,Implant Device,186.2,70,,186.2,percent of total billed charges,All Other,180.88,34,,180.88,percent of total billed charges,Implant Device,180.88,34,,180.88,percent of total billed charges,Implant Device,186.2,35,,186.2,percent of total billed charges,Implant Device,186.2,35,,186.2,percent of total billed charges,Implant Device,186.2,35,,186.2,percent of total billed charges,Implant Device,186.2,35,,186.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,393.68,
PARAGON 28 P28-20-128 SCREW STD 3.5X28MM,C1713,HCPCS,,79003505,CDM,278,RC,,,both,,,360,266.4,,,266.4,Other,150% of Medicare + 9.63% HCRA Surcharge,162,45,,162,percent of total billed charges,Critical Access Hospital RCC factor,122.4,34,,122.4,percent of total billed charges,Implant Device,122.4,34,,122.4,percent of total billed charges,Implant Device,122.4,34,,122.4,percent of total billed charges,Implant Device,122.4,34,,122.4,percent of total billed charges,Implant Device,122.4,34,,122.4,percent of total billed charges,Implant Device,178.2,,,178.2,Other,110% of Medicare,126,35,,126,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,126,35,,126,percent of total billed charges,Implant Device,126,35,,126,percent of total billed charges,Implant Device,126,35,,126,percent of total billed charges,Implant Device,126,35,,126,percent of total billed charges,Implant Device,126,35,,126,percent of total billed charges,Implant Device,144,40,,144,percent of total billed charges,Implant Device,126,70,,126,percent of total billed charges,All Other,122.4,34,,122.4,percent of total billed charges,Implant Device,122.4,34,,122.4,percent of total billed charges,Implant Device,126,35,,126,percent of total billed charges,Implant Device,126,35,,126,percent of total billed charges,Implant Device,126,35,,126,percent of total billed charges,Implant Device,126,35,,126,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,266.4,
BIOMET 12-150307 FEMORAL HIP 7X120MM,C1776,HCPCS,,79003507,CDM,278,RC,,,both,,,8352,6180.5,,,6180.5,Other,150% of Medicare + 9.63% HCRA Surcharge,3758.4,45,,3758.4,percent of total billed charges,Critical Access Hospital RCC factor,2839.68,34,,2839.68,percent of total billed charges,Implant Device,2839.68,34,,2839.68,percent of total billed charges,Implant Device,2839.68,34,,2839.68,percent of total billed charges,Implant Device,2839.68,34,,2839.68,percent of total billed charges,Implant Device,2839.68,34,,2839.68,percent of total billed charges,Implant Device,4134.24,,,4134.24,Other,110% of Medicare,2923.2,35,,2923.2,percent of total billed charges,Implant Device,2839.68,34,"Charges > $500, x 34%",2839.68,percent of total billed charges,Implant Device,2923.2,35,,2923.2,percent of total billed charges,Implant Device,2923.2,35,,2923.2,percent of total billed charges,Implant Device,2923.2,35,,2923.2,percent of total billed charges,Implant Device,2923.2,35,,2923.2,percent of total billed charges,Implant Device,2923.2,35,,2923.2,percent of total billed charges,Implant Device,3340.8,40,,3340.8,percent of total billed charges,Implant Device,2923.2,70,,2923.2,percent of total billed charges,All Other,2839.68,34,,2839.68,percent of total billed charges,Implant Device,2839.68,34,,2839.68,percent of total billed charges,Implant Device,2923.2,35,,2923.2,percent of total billed charges,Implant Device,2923.2,35,,2923.2,percent of total billed charges,Implant Device,2923.2,35,,2923.2,percent of total billed charges,Implant Device,2923.2,35,,2923.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2839.68,34,"If Charge > 2,000, then 34 percent",2839.68,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,6180.5,
SYNTHES 223.551 LCP PLATE 3.5X72MM,C1713,HCPCS,,79003508,CDM,278,RC,,,both,,,1049,776.26,,,776.26,Other,150% of Medicare + 9.63% HCRA Surcharge,472.05,45,,472.05,percent of total billed charges,Critical Access Hospital RCC factor,356.66,34,,356.66,percent of total billed charges,Implant Device,356.66,34,,356.66,percent of total billed charges,Implant Device,356.66,34,,356.66,percent of total billed charges,Implant Device,356.66,34,,356.66,percent of total billed charges,Implant Device,356.66,34,,356.66,percent of total billed charges,Implant Device,519.26,,,519.26,Other,110% of Medicare,367.15,35,,367.15,percent of total billed charges,Implant Device,356.66,34,"Charges > $500, x 34%",356.66,percent of total billed charges,Implant Device,367.15,35,,367.15,percent of total billed charges,Implant Device,367.15,35,,367.15,percent of total billed charges,Implant Device,367.15,35,,367.15,percent of total billed charges,Implant Device,367.15,35,,367.15,percent of total billed charges,Implant Device,367.15,35,,367.15,percent of total billed charges,Implant Device,419.6,40,,419.6,percent of total billed charges,Implant Device,367.15,70,,367.15,percent of total billed charges,All Other,356.66,34,,356.66,percent of total billed charges,Implant Device,356.66,34,,356.66,percent of total billed charges,Implant Device,367.15,35,,367.15,percent of total billed charges,Implant Device,367.15,35,,367.15,percent of total billed charges,Implant Device,367.15,35,,367.15,percent of total billed charges,Implant Device,367.15,35,,367.15,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,776.26,
SYNTHES 202.816 CORTEX ST SCREW 2.7X16MM,C1713,HCPCS,,79003509,CDM,278,RC,,,both,,,85,62.9,,,62.9,Other,150% of Medicare + 9.63% HCRA Surcharge,38.25,45,,38.25,percent of total billed charges,Critical Access Hospital RCC factor,28.9,34,,28.9,percent of total billed charges,Implant Device,28.9,34,,28.9,percent of total billed charges,Implant Device,28.9,34,,28.9,percent of total billed charges,Implant Device,28.9,34,,28.9,percent of total billed charges,Implant Device,28.9,34,,28.9,percent of total billed charges,Implant Device,42.08,,,42.08,Other,110% of Medicare,29.75,35,,29.75,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,29.75,35,,29.75,percent of total billed charges,Implant Device,29.75,35,,29.75,percent of total billed charges,Implant Device,29.75,35,,29.75,percent of total billed charges,Implant Device,29.75,35,,29.75,percent of total billed charges,Implant Device,29.75,35,,29.75,percent of total billed charges,Implant Device,34,40,,34,percent of total billed charges,Implant Device,29.75,70,,29.75,percent of total billed charges,All Other,28.9,34,,28.9,percent of total billed charges,Implant Device,28.9,34,,28.9,percent of total billed charges,Implant Device,29.75,35,,29.75,percent of total billed charges,Implant Device,29.75,35,,29.75,percent of total billed charges,Implant Device,29.75,35,,29.75,percent of total billed charges,Implant Device,29.75,35,,29.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,62.9,
SYNTHES 202.818 CORTEX ST SCREW 2.7X18MM,C1713,HCPCS,,79003510,CDM,278,RC,,,both,,,85,62.9,,,62.9,Other,150% of Medicare + 9.63% HCRA Surcharge,38.25,45,,38.25,percent of total billed charges,Critical Access Hospital RCC factor,28.9,34,,28.9,percent of total billed charges,Implant Device,28.9,34,,28.9,percent of total billed charges,Implant Device,28.9,34,,28.9,percent of total billed charges,Implant Device,28.9,34,,28.9,percent of total billed charges,Implant Device,28.9,34,,28.9,percent of total billed charges,Implant Device,42.08,,,42.08,Other,110% of Medicare,29.75,35,,29.75,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,29.75,35,,29.75,percent of total billed charges,Implant Device,29.75,35,,29.75,percent of total billed charges,Implant Device,29.75,35,,29.75,percent of total billed charges,Implant Device,29.75,35,,29.75,percent of total billed charges,Implant Device,29.75,35,,29.75,percent of total billed charges,Implant Device,34,40,,34,percent of total billed charges,Implant Device,29.75,70,,29.75,percent of total billed charges,All Other,28.9,34,,28.9,percent of total billed charges,Implant Device,28.9,34,,28.9,percent of total billed charges,Implant Device,29.75,35,,29.75,percent of total billed charges,Implant Device,29.75,35,,29.75,percent of total billed charges,Implant Device,29.75,35,,29.75,percent of total billed charges,Implant Device,29.75,35,,29.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,62.9,
BIOMET 010000589 GLENOSPHERE 25MM,C1776,HCPCS,,79003512,CDM,278,RC,,,both,,,9630,7126.22,,,7126.22,Other,150% of Medicare + 9.63% HCRA Surcharge,4333.5,45,,4333.5,percent of total billed charges,Critical Access Hospital RCC factor,3274.2,34,,3274.2,percent of total billed charges,Implant Device,3274.2,34,,3274.2,percent of total billed charges,Implant Device,3274.2,34,,3274.2,percent of total billed charges,Implant Device,3274.2,34,,3274.2,percent of total billed charges,Implant Device,3274.2,34,,3274.2,percent of total billed charges,Implant Device,4766.85,,,4766.85,Other,110% of Medicare,3370.5,35,,3370.5,percent of total billed charges,Implant Device,3274.2,34,"Charges > $500, x 34%",3274.2,percent of total billed charges,Implant Device,3370.5,35,,3370.5,percent of total billed charges,Implant Device,3370.5,35,,3370.5,percent of total billed charges,Implant Device,3370.5,35,,3370.5,percent of total billed charges,Implant Device,3370.5,35,,3370.5,percent of total billed charges,Implant Device,3370.5,35,,3370.5,percent of total billed charges,Implant Device,3852,40,,3852,percent of total billed charges,Implant Device,3370.5,70,,3370.5,percent of total billed charges,All Other,3274.2,34,,3274.2,percent of total billed charges,Implant Device,3274.2,34,,3274.2,percent of total billed charges,Implant Device,3370.5,35,,3370.5,percent of total billed charges,Implant Device,3370.5,35,,3370.5,percent of total billed charges,Implant Device,3370.5,35,,3370.5,percent of total billed charges,Implant Device,3370.5,35,,3370.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3274.2,34,"If Charge > 2,000, then 34 percent",3274.2,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,7126.22,
BIOMET 180500 LOCKING SCREW 4.75X15MM,C1713,HCPCS,,79003513,CDM,278,RC,,,both,,,570,421.8,,,421.8,Other,150% of Medicare + 9.63% HCRA Surcharge,256.5,45,,256.5,percent of total billed charges,Critical Access Hospital RCC factor,193.8,34,,193.8,percent of total billed charges,Implant Device,193.8,34,,193.8,percent of total billed charges,Implant Device,193.8,34,,193.8,percent of total billed charges,Implant Device,193.8,34,,193.8,percent of total billed charges,Implant Device,193.8,34,,193.8,percent of total billed charges,Implant Device,282.15,,,282.15,Other,110% of Medicare,199.5,35,,199.5,percent of total billed charges,Implant Device,193.8,34,"Charges > $500, x 34%",193.8,percent of total billed charges,Implant Device,199.5,35,,199.5,percent of total billed charges,Implant Device,199.5,35,,199.5,percent of total billed charges,Implant Device,199.5,35,,199.5,percent of total billed charges,Implant Device,199.5,35,,199.5,percent of total billed charges,Implant Device,199.5,35,,199.5,percent of total billed charges,Implant Device,228,40,,228,percent of total billed charges,Implant Device,199.5,70,,199.5,percent of total billed charges,All Other,193.8,34,,193.8,percent of total billed charges,Implant Device,193.8,34,,193.8,percent of total billed charges,Implant Device,199.5,35,,199.5,percent of total billed charges,Implant Device,199.5,35,,199.5,percent of total billed charges,Implant Device,199.5,35,,199.5,percent of total billed charges,Implant Device,199.5,35,,199.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,421.8,
BIOMET 113654 SHLDR STEM STD LEN 14X122,C1776,HCPCS,,79003514,CDM,278,RC,,,both,,,18630,13786.25,,,13786.25,Other,150% of Medicare + 9.63% HCRA Surcharge,8383.5,45,,8383.5,percent of total billed charges,Critical Access Hospital RCC factor,6334.2,34,,6334.2,percent of total billed charges,Implant Device,6334.2,34,,6334.2,percent of total billed charges,Implant Device,6334.2,34,,6334.2,percent of total billed charges,Implant Device,6334.2,34,,6334.2,percent of total billed charges,Implant Device,6334.2,34,,6334.2,percent of total billed charges,Implant Device,9221.85,,,9221.85,Other,110% of Medicare,6520.5,35,,6520.5,percent of total billed charges,Implant Device,6334.2,34,"Charges > $500, x 34%",6334.2,percent of total billed charges,Implant Device,6520.5,35,,6520.5,percent of total billed charges,Implant Device,6520.5,35,,6520.5,percent of total billed charges,Implant Device,6520.5,35,,6520.5,percent of total billed charges,Implant Device,6520.5,35,,6520.5,percent of total billed charges,Implant Device,6520.5,35,,6520.5,percent of total billed charges,Implant Device,7452,40,,7452,percent of total billed charges,Implant Device,6520.5,70,,6520.5,percent of total billed charges,All Other,6334.2,34,,6334.2,percent of total billed charges,Implant Device,6334.2,34,,6334.2,percent of total billed charges,Implant Device,6520.5,35,,6520.5,percent of total billed charges,Implant Device,6520.5,35,,6520.5,percent of total billed charges,Implant Device,6520.5,35,,6520.5,percent of total billed charges,Implant Device,6520.5,35,,6520.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,6334.2,34,"If Charge > 2,000, then 34 percent",6334.2,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,13786.25,
EV3 SERB65-14-60-80 PROTEGE STENT,C1876,HCPCS,,79003515,CDM,278,RC,,,both,,,4650,3441.01,,,3441.01,Other,150% of Medicare + 9.63% HCRA Surcharge,2092.5,45,,2092.5,percent of total billed charges,Critical Access Hospital RCC factor,1581,34,,1581,percent of total billed charges,Implant Device,1581,34,,1581,percent of total billed charges,Implant Device,1581,34,,1581,percent of total billed charges,Implant Device,1581,34,,1581,percent of total billed charges,Implant Device,1581,34,,1581,percent of total billed charges,Implant Device,2301.75,,,2301.75,Other,110% of Medicare,1627.5,35,,1627.5,percent of total billed charges,Implant Device,1581,34,"Charges > $500, x 34%",1581,percent of total billed charges,Implant Device,1627.5,35,,1627.5,percent of total billed charges,Implant Device,1627.5,35,,1627.5,percent of total billed charges,Implant Device,1627.5,35,,1627.5,percent of total billed charges,Implant Device,1627.5,35,,1627.5,percent of total billed charges,Implant Device,1627.5,35,,1627.5,percent of total billed charges,Implant Device,1860,40,,1860,percent of total billed charges,Implant Device,1627.5,70,,1627.5,percent of total billed charges,All Other,1581,34,,1581,percent of total billed charges,Implant Device,1581,34,,1581,percent of total billed charges,Implant Device,1627.5,35,,1627.5,percent of total billed charges,Implant Device,1627.5,35,,1627.5,percent of total billed charges,Implant Device,1627.5,35,,1627.5,percent of total billed charges,Implant Device,1627.5,35,,1627.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1581,34,"If Charge > 2,000, then 34 percent",1581,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3441.01,
SYNTHES 404.014 3.5 TITANIUM SCREW 14MM,C1713,HCPCS,,79003516,CDM,278,RC,,,both,,,53,39.22,,,39.22,Other,150% of Medicare + 9.63% HCRA Surcharge,23.85,45,,23.85,percent of total billed charges,Critical Access Hospital RCC factor,18.02,34,,18.02,percent of total billed charges,Implant Device,18.02,34,,18.02,percent of total billed charges,Implant Device,18.02,34,,18.02,percent of total billed charges,Implant Device,18.02,34,,18.02,percent of total billed charges,Implant Device,18.02,34,,18.02,percent of total billed charges,Implant Device,26.24,,,26.24,Other,110% of Medicare,18.55,35,,18.55,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,18.55,35,,18.55,percent of total billed charges,Implant Device,18.55,35,,18.55,percent of total billed charges,Implant Device,18.55,35,,18.55,percent of total billed charges,Implant Device,18.55,35,,18.55,percent of total billed charges,Implant Device,18.55,35,,18.55,percent of total billed charges,Implant Device,21.2,40,,21.2,percent of total billed charges,Implant Device,18.55,70,,18.55,percent of total billed charges,All Other,18.02,34,,18.02,percent of total billed charges,Implant Device,18.02,34,,18.02,percent of total billed charges,Implant Device,18.55,35,,18.55,percent of total billed charges,Implant Device,18.55,35,,18.55,percent of total billed charges,Implant Device,18.55,35,,18.55,percent of total billed charges,Implant Device,18.55,35,,18.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,39.22,
SYNTHES 404.016 3.5 TITANIUM SCREW 16MM,C1713,HCPCS,,79003517,CDM,278,RC,,,both,,,53,39.22,,,39.22,Other,150% of Medicare + 9.63% HCRA Surcharge,23.85,45,,23.85,percent of total billed charges,Critical Access Hospital RCC factor,18.02,34,,18.02,percent of total billed charges,Implant Device,18.02,34,,18.02,percent of total billed charges,Implant Device,18.02,34,,18.02,percent of total billed charges,Implant Device,18.02,34,,18.02,percent of total billed charges,Implant Device,18.02,34,,18.02,percent of total billed charges,Implant Device,26.24,,,26.24,Other,110% of Medicare,18.55,35,,18.55,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,18.55,35,,18.55,percent of total billed charges,Implant Device,18.55,35,,18.55,percent of total billed charges,Implant Device,18.55,35,,18.55,percent of total billed charges,Implant Device,18.55,35,,18.55,percent of total billed charges,Implant Device,18.55,35,,18.55,percent of total billed charges,Implant Device,21.2,40,,21.2,percent of total billed charges,Implant Device,18.55,70,,18.55,percent of total billed charges,All Other,18.02,34,,18.02,percent of total billed charges,Implant Device,18.02,34,,18.02,percent of total billed charges,Implant Device,18.55,35,,18.55,percent of total billed charges,Implant Device,18.55,35,,18.55,percent of total billed charges,Implant Device,18.55,35,,18.55,percent of total billed charges,Implant Device,18.55,35,,18.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,39.22,
SYNTHES 404.018 3.5 TITANIUM SCREW 18MM,C1713,HCPCS,,79003518,CDM,278,RC,,,both,,,53,39.22,,,39.22,Other,150% of Medicare + 9.63% HCRA Surcharge,23.85,45,,23.85,percent of total billed charges,Critical Access Hospital RCC factor,18.02,34,,18.02,percent of total billed charges,Implant Device,18.02,34,,18.02,percent of total billed charges,Implant Device,18.02,34,,18.02,percent of total billed charges,Implant Device,18.02,34,,18.02,percent of total billed charges,Implant Device,18.02,34,,18.02,percent of total billed charges,Implant Device,26.24,,,26.24,Other,110% of Medicare,18.55,35,,18.55,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,18.55,35,,18.55,percent of total billed charges,Implant Device,18.55,35,,18.55,percent of total billed charges,Implant Device,18.55,35,,18.55,percent of total billed charges,Implant Device,18.55,35,,18.55,percent of total billed charges,Implant Device,18.55,35,,18.55,percent of total billed charges,Implant Device,21.2,40,,21.2,percent of total billed charges,Implant Device,18.55,70,,18.55,percent of total billed charges,All Other,18.02,34,,18.02,percent of total billed charges,Implant Device,18.02,34,,18.02,percent of total billed charges,Implant Device,18.55,35,,18.55,percent of total billed charges,Implant Device,18.55,35,,18.55,percent of total billed charges,Implant Device,18.55,35,,18.55,percent of total billed charges,Implant Device,18.55,35,,18.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,39.22,
SYNTHES 404.020 3.5 TITANIUM SCREW 20MM,C1713,HCPCS,,79003519,CDM,278,RC,,,both,,,53,39.22,,,39.22,Other,150% of Medicare + 9.63% HCRA Surcharge,23.85,45,,23.85,percent of total billed charges,Critical Access Hospital RCC factor,18.02,34,,18.02,percent of total billed charges,Implant Device,18.02,34,,18.02,percent of total billed charges,Implant Device,18.02,34,,18.02,percent of total billed charges,Implant Device,18.02,34,,18.02,percent of total billed charges,Implant Device,18.02,34,,18.02,percent of total billed charges,Implant Device,26.24,,,26.24,Other,110% of Medicare,18.55,35,,18.55,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,18.55,35,,18.55,percent of total billed charges,Implant Device,18.55,35,,18.55,percent of total billed charges,Implant Device,18.55,35,,18.55,percent of total billed charges,Implant Device,18.55,35,,18.55,percent of total billed charges,Implant Device,18.55,35,,18.55,percent of total billed charges,Implant Device,21.2,40,,21.2,percent of total billed charges,Implant Device,18.55,70,,18.55,percent of total billed charges,All Other,18.02,34,,18.02,percent of total billed charges,Implant Device,18.02,34,,18.02,percent of total billed charges,Implant Device,18.55,35,,18.55,percent of total billed charges,Implant Device,18.55,35,,18.55,percent of total billed charges,Implant Device,18.55,35,,18.55,percent of total billed charges,Implant Device,18.55,35,,18.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,39.22,
SYNTHES 423.57 LC-DCP PLATE 3.5MM 7 HOLE,C1713,HCPCS,,79003520,CDM,278,RC,,,both,,,550,407,,,407,Other,150% of Medicare + 9.63% HCRA Surcharge,247.5,45,,247.5,percent of total billed charges,Critical Access Hospital RCC factor,187,34,,187,percent of total billed charges,Implant Device,187,34,,187,percent of total billed charges,Implant Device,187,34,,187,percent of total billed charges,Implant Device,187,34,,187,percent of total billed charges,Implant Device,187,34,,187,percent of total billed charges,Implant Device,272.25,,,272.25,Other,110% of Medicare,192.5,35,,192.5,percent of total billed charges,Implant Device,187,34,"Charges > $500, x 34%",187,percent of total billed charges,Implant Device,192.5,35,,192.5,percent of total billed charges,Implant Device,192.5,35,,192.5,percent of total billed charges,Implant Device,192.5,35,,192.5,percent of total billed charges,Implant Device,192.5,35,,192.5,percent of total billed charges,Implant Device,192.5,35,,192.5,percent of total billed charges,Implant Device,220,40,,220,percent of total billed charges,Implant Device,192.5,70,,192.5,percent of total billed charges,All Other,187,34,,187,percent of total billed charges,Implant Device,187,34,,187,percent of total billed charges,Implant Device,192.5,35,,192.5,percent of total billed charges,Implant Device,192.5,35,,192.5,percent of total billed charges,Implant Device,192.5,35,,192.5,percent of total billed charges,Implant Device,192.5,35,,192.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,407,
SYNTHES 441.36 6 HOLE PLATE COLLAR,C1713,HCPCS,,79003521,CDM,278,RC,,,both,,,244,180.56,,,180.56,Other,150% of Medicare + 9.63% HCRA Surcharge,109.8,45,,109.8,percent of total billed charges,Critical Access Hospital RCC factor,82.96,34,,82.96,percent of total billed charges,Implant Device,82.96,34,,82.96,percent of total billed charges,Implant Device,82.96,34,,82.96,percent of total billed charges,Implant Device,82.96,34,,82.96,percent of total billed charges,Implant Device,82.96,34,,82.96,percent of total billed charges,Implant Device,120.78,,,120.78,Other,110% of Medicare,85.4,35,,85.4,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,85.4,35,,85.4,percent of total billed charges,Implant Device,85.4,35,,85.4,percent of total billed charges,Implant Device,85.4,35,,85.4,percent of total billed charges,Implant Device,85.4,35,,85.4,percent of total billed charges,Implant Device,85.4,35,,85.4,percent of total billed charges,Implant Device,97.6,40,,97.6,percent of total billed charges,Implant Device,85.4,70,,85.4,percent of total billed charges,All Other,82.96,34,,82.96,percent of total billed charges,Implant Device,82.96,34,,82.96,percent of total billed charges,Implant Device,85.4,35,,85.4,percent of total billed charges,Implant Device,85.4,35,,85.4,percent of total billed charges,Implant Device,85.4,35,,85.4,percent of total billed charges,Implant Device,85.4,35,,85.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,180.56,
SYNTHES 204.814 SCREW 3.5X14MM,C1713,HCPCS,,79003523,CDM,278,RC,,,both,,,59,43.66,,,43.66,Other,150% of Medicare + 9.63% HCRA Surcharge,26.55,45,,26.55,percent of total billed charges,Critical Access Hospital RCC factor,20.06,34,,20.06,percent of total billed charges,Implant Device,20.06,34,,20.06,percent of total billed charges,Implant Device,20.06,34,,20.06,percent of total billed charges,Implant Device,20.06,34,,20.06,percent of total billed charges,Implant Device,20.06,34,,20.06,percent of total billed charges,Implant Device,29.21,,,29.21,Other,110% of Medicare,20.65,35,,20.65,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,20.65,35,,20.65,percent of total billed charges,Implant Device,20.65,35,,20.65,percent of total billed charges,Implant Device,20.65,35,,20.65,percent of total billed charges,Implant Device,20.65,35,,20.65,percent of total billed charges,Implant Device,20.65,35,,20.65,percent of total billed charges,Implant Device,23.6,40,,23.6,percent of total billed charges,Implant Device,20.65,70,,20.65,percent of total billed charges,All Other,20.06,34,,20.06,percent of total billed charges,Implant Device,20.06,34,,20.06,percent of total billed charges,Implant Device,20.65,35,,20.65,percent of total billed charges,Implant Device,20.65,35,,20.65,percent of total billed charges,Implant Device,20.65,35,,20.65,percent of total billed charges,Implant Device,20.65,35,,20.65,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,43.66,
SYNTHES 208.845 SCREW 2.7X50MM,C1713,HCPCS,,79003524,CDM,278,RC,,,both,,,1080,799.2,,,799.2,Other,150% of Medicare + 9.63% HCRA Surcharge,486,45,,486,percent of total billed charges,Critical Access Hospital RCC factor,367.2,34,,367.2,percent of total billed charges,Implant Device,367.2,34,,367.2,percent of total billed charges,Implant Device,367.2,34,,367.2,percent of total billed charges,Implant Device,367.2,34,,367.2,percent of total billed charges,Implant Device,367.2,34,,367.2,percent of total billed charges,Implant Device,534.6,,,534.6,Other,110% of Medicare,378,35,,378,percent of total billed charges,Implant Device,367.2,34,"Charges > $500, x 34%",367.2,percent of total billed charges,Implant Device,378,35,,378,percent of total billed charges,Implant Device,378,35,,378,percent of total billed charges,Implant Device,378,35,,378,percent of total billed charges,Implant Device,378,35,,378,percent of total billed charges,Implant Device,378,35,,378,percent of total billed charges,Implant Device,432,40,,432,percent of total billed charges,Implant Device,378,70,,378,percent of total billed charges,All Other,367.2,34,,367.2,percent of total billed charges,Implant Device,367.2,34,,367.2,percent of total billed charges,Implant Device,378,35,,378,percent of total billed charges,Implant Device,378,35,,378,percent of total billed charges,Implant Device,378,35,,378,percent of total billed charges,Implant Device,378,35,,378,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,799.2,
STRYKER 629284 DISTAL MEDIAL HUM PLATE,C1713,HCPCS,,79003527,CDM,278,RC,,,both,,,3697,2735.79,,,2735.79,Other,150% of Medicare + 9.63% HCRA Surcharge,1663.65,45,,1663.65,percent of total billed charges,Critical Access Hospital RCC factor,1256.98,34,,1256.98,percent of total billed charges,Implant Device,1256.98,34,,1256.98,percent of total billed charges,Implant Device,1256.98,34,,1256.98,percent of total billed charges,Implant Device,1256.98,34,,1256.98,percent of total billed charges,Implant Device,1256.98,34,,1256.98,percent of total billed charges,Implant Device,1830.02,,,1830.02,Other,110% of Medicare,1293.95,35,,1293.95,percent of total billed charges,Implant Device,1256.98,34,"Charges > $500, x 34%",1256.98,percent of total billed charges,Implant Device,1293.95,35,,1293.95,percent of total billed charges,Implant Device,1293.95,35,,1293.95,percent of total billed charges,Implant Device,1293.95,35,,1293.95,percent of total billed charges,Implant Device,1293.95,35,,1293.95,percent of total billed charges,Implant Device,1293.95,35,,1293.95,percent of total billed charges,Implant Device,1478.8,40,,1478.8,percent of total billed charges,Implant Device,1293.95,70,,1293.95,percent of total billed charges,All Other,1256.98,34,,1256.98,percent of total billed charges,Implant Device,1256.98,34,,1256.98,percent of total billed charges,Implant Device,1293.95,35,,1293.95,percent of total billed charges,Implant Device,1293.95,35,,1293.95,percent of total billed charges,Implant Device,1293.95,35,,1293.95,percent of total billed charges,Implant Device,1293.95,35,,1293.95,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1256.98,34,"If Charge > 2,000, then 34 percent",1256.98,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2735.79,
STRYKER 629264 DISTAL POST LAT PLATE R,C1713,HCPCS,,79003528,CDM,278,RC,,,both,,,3697,2735.79,,,2735.79,Other,150% of Medicare + 9.63% HCRA Surcharge,1663.65,45,,1663.65,percent of total billed charges,Critical Access Hospital RCC factor,1256.98,34,,1256.98,percent of total billed charges,Implant Device,1256.98,34,,1256.98,percent of total billed charges,Implant Device,1256.98,34,,1256.98,percent of total billed charges,Implant Device,1256.98,34,,1256.98,percent of total billed charges,Implant Device,1256.98,34,,1256.98,percent of total billed charges,Implant Device,1830.02,,,1830.02,Other,110% of Medicare,1293.95,35,,1293.95,percent of total billed charges,Implant Device,1256.98,34,"Charges > $500, x 34%",1256.98,percent of total billed charges,Implant Device,1293.95,35,,1293.95,percent of total billed charges,Implant Device,1293.95,35,,1293.95,percent of total billed charges,Implant Device,1293.95,35,,1293.95,percent of total billed charges,Implant Device,1293.95,35,,1293.95,percent of total billed charges,Implant Device,1293.95,35,,1293.95,percent of total billed charges,Implant Device,1478.8,40,,1478.8,percent of total billed charges,Implant Device,1293.95,70,,1293.95,percent of total billed charges,All Other,1256.98,34,,1256.98,percent of total billed charges,Implant Device,1256.98,34,,1256.98,percent of total billed charges,Implant Device,1293.95,35,,1293.95,percent of total billed charges,Implant Device,1293.95,35,,1293.95,percent of total billed charges,Implant Device,1293.95,35,,1293.95,percent of total billed charges,Implant Device,1293.95,35,,1293.95,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1256.98,34,"If Charge > 2,000, then 34 percent",1256.98,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2735.79,
STRYKER 629364 4 HOLE R PLATE OLECRANON,C1713,HCPCS,,79003529,CDM,278,RC,,,both,,,2804,2074.97,,,2074.97,Other,150% of Medicare + 9.63% HCRA Surcharge,1261.8,45,,1261.8,percent of total billed charges,Critical Access Hospital RCC factor,953.36,34,,953.36,percent of total billed charges,Implant Device,953.36,34,,953.36,percent of total billed charges,Implant Device,953.36,34,,953.36,percent of total billed charges,Implant Device,953.36,34,,953.36,percent of total billed charges,Implant Device,953.36,34,,953.36,percent of total billed charges,Implant Device,1387.98,,,1387.98,Other,110% of Medicare,981.4,35,,981.4,percent of total billed charges,Implant Device,953.36,34,"Charges > $500, x 34%",953.36,percent of total billed charges,Implant Device,981.4,35,,981.4,percent of total billed charges,Implant Device,981.4,35,,981.4,percent of total billed charges,Implant Device,981.4,35,,981.4,percent of total billed charges,Implant Device,981.4,35,,981.4,percent of total billed charges,Implant Device,981.4,35,,981.4,percent of total billed charges,Implant Device,1121.6,40,,1121.6,percent of total billed charges,Implant Device,981.4,70,,981.4,percent of total billed charges,All Other,953.36,34,,953.36,percent of total billed charges,Implant Device,953.36,34,,953.36,percent of total billed charges,Implant Device,981.4,35,,981.4,percent of total billed charges,Implant Device,981.4,35,,981.4,percent of total billed charges,Implant Device,981.4,35,,981.4,percent of total billed charges,Implant Device,981.4,35,,981.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,953.36,34,"If Charge > 2,000, then 34 percent",953.36,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2074.97,
STRYKER 614608 LOCKING SCREW 3.5X8MM,C1713,HCPCS,,79003530,CDM,278,RC,,,both,,,574,424.76,,,424.76,Other,150% of Medicare + 9.63% HCRA Surcharge,258.3,45,,258.3,percent of total billed charges,Critical Access Hospital RCC factor,195.16,34,,195.16,percent of total billed charges,Implant Device,195.16,34,,195.16,percent of total billed charges,Implant Device,195.16,34,,195.16,percent of total billed charges,Implant Device,195.16,34,,195.16,percent of total billed charges,Implant Device,195.16,34,,195.16,percent of total billed charges,Implant Device,284.13,,,284.13,Other,110% of Medicare,200.9,35,,200.9,percent of total billed charges,Implant Device,195.16,34,"Charges > $500, x 34%",195.16,percent of total billed charges,Implant Device,200.9,35,,200.9,percent of total billed charges,Implant Device,200.9,35,,200.9,percent of total billed charges,Implant Device,200.9,35,,200.9,percent of total billed charges,Implant Device,200.9,35,,200.9,percent of total billed charges,Implant Device,200.9,35,,200.9,percent of total billed charges,Implant Device,229.6,40,,229.6,percent of total billed charges,Implant Device,200.9,70,,200.9,percent of total billed charges,All Other,195.16,34,,195.16,percent of total billed charges,Implant Device,195.16,34,,195.16,percent of total billed charges,Implant Device,200.9,35,,200.9,percent of total billed charges,Implant Device,200.9,35,,200.9,percent of total billed charges,Implant Device,200.9,35,,200.9,percent of total billed charges,Implant Device,200.9,35,,200.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,424.76,
STRYKER 614610 LOCKING SCREW 3.5X10MM,C1713,HCPCS,,79003531,CDM,278,RC,,,both,,,1451,1073.74,,,1073.74,Other,150% of Medicare + 9.63% HCRA Surcharge,652.95,45,,652.95,percent of total billed charges,Critical Access Hospital RCC factor,493.34,34,,493.34,percent of total billed charges,Implant Device,493.34,34,,493.34,percent of total billed charges,Implant Device,493.34,34,,493.34,percent of total billed charges,Implant Device,493.34,34,,493.34,percent of total billed charges,Implant Device,493.34,34,,493.34,percent of total billed charges,Implant Device,718.25,,,718.25,Other,110% of Medicare,507.85,35,,507.85,percent of total billed charges,Implant Device,493.34,34,"Charges > $500, x 34%",493.34,percent of total billed charges,Implant Device,507.85,35,,507.85,percent of total billed charges,Implant Device,507.85,35,,507.85,percent of total billed charges,Implant Device,507.85,35,,507.85,percent of total billed charges,Implant Device,507.85,35,,507.85,percent of total billed charges,Implant Device,507.85,35,,507.85,percent of total billed charges,Implant Device,580.4,40,,580.4,percent of total billed charges,Implant Device,507.85,70,,507.85,percent of total billed charges,All Other,493.34,34,,493.34,percent of total billed charges,Implant Device,493.34,34,,493.34,percent of total billed charges,Implant Device,507.85,35,,507.85,percent of total billed charges,Implant Device,507.85,35,,507.85,percent of total billed charges,Implant Device,507.85,35,,507.85,percent of total billed charges,Implant Device,507.85,35,,507.85,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1073.74,
STRYKER 614612 LOCKING SCREW 3.5X12MM,C1713,HCPCS,,79003532,CDM,278,RC,,,both,,,727,537.98,,,537.98,Other,150% of Medicare + 9.63% HCRA Surcharge,327.15,45,,327.15,percent of total billed charges,Critical Access Hospital RCC factor,247.18,34,,247.18,percent of total billed charges,Implant Device,247.18,34,,247.18,percent of total billed charges,Implant Device,247.18,34,,247.18,percent of total billed charges,Implant Device,247.18,34,,247.18,percent of total billed charges,Implant Device,247.18,34,,247.18,percent of total billed charges,Implant Device,359.87,,,359.87,Other,110% of Medicare,254.45,35,,254.45,percent of total billed charges,Implant Device,247.18,34,"Charges > $500, x 34%",247.18,percent of total billed charges,Implant Device,254.45,35,,254.45,percent of total billed charges,Implant Device,254.45,35,,254.45,percent of total billed charges,Implant Device,254.45,35,,254.45,percent of total billed charges,Implant Device,254.45,35,,254.45,percent of total billed charges,Implant Device,254.45,35,,254.45,percent of total billed charges,Implant Device,290.8,40,,290.8,percent of total billed charges,Implant Device,254.45,70,,254.45,percent of total billed charges,All Other,247.18,34,,247.18,percent of total billed charges,Implant Device,247.18,34,,247.18,percent of total billed charges,Implant Device,254.45,35,,254.45,percent of total billed charges,Implant Device,254.45,35,,254.45,percent of total billed charges,Implant Device,254.45,35,,254.45,percent of total billed charges,Implant Device,254.45,35,,254.45,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,537.98,
STRYKER 614616 LOCKING SCREW 3.5X16MM,C1713,HCPCS,,79003533,CDM,278,RC,,,both,,,755,558.7,,,558.7,Other,150% of Medicare + 9.63% HCRA Surcharge,339.75,45,,339.75,percent of total billed charges,Critical Access Hospital RCC factor,256.7,34,,256.7,percent of total billed charges,Implant Device,256.7,34,,256.7,percent of total billed charges,Implant Device,256.7,34,,256.7,percent of total billed charges,Implant Device,256.7,34,,256.7,percent of total billed charges,Implant Device,256.7,34,,256.7,percent of total billed charges,Implant Device,373.73,,,373.73,Other,110% of Medicare,264.25,35,,264.25,percent of total billed charges,Implant Device,256.7,34,"Charges > $500, x 34%",256.7,percent of total billed charges,Implant Device,264.25,35,,264.25,percent of total billed charges,Implant Device,264.25,35,,264.25,percent of total billed charges,Implant Device,264.25,35,,264.25,percent of total billed charges,Implant Device,264.25,35,,264.25,percent of total billed charges,Implant Device,264.25,35,,264.25,percent of total billed charges,Implant Device,302,40,,302,percent of total billed charges,Implant Device,264.25,70,,264.25,percent of total billed charges,All Other,256.7,34,,256.7,percent of total billed charges,Implant Device,256.7,34,,256.7,percent of total billed charges,Implant Device,264.25,35,,264.25,percent of total billed charges,Implant Device,264.25,35,,264.25,percent of total billed charges,Implant Device,264.25,35,,264.25,percent of total billed charges,Implant Device,264.25,35,,264.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,558.7,
STRYKER 614618 LOCKING SCREW 3.5X18MM,C1713,HCPCS,,79003534,CDM,278,RC,,,both,,,755,558.7,,,558.7,Other,150% of Medicare + 9.63% HCRA Surcharge,339.75,45,,339.75,percent of total billed charges,Critical Access Hospital RCC factor,256.7,34,,256.7,percent of total billed charges,Implant Device,256.7,34,,256.7,percent of total billed charges,Implant Device,256.7,34,,256.7,percent of total billed charges,Implant Device,256.7,34,,256.7,percent of total billed charges,Implant Device,256.7,34,,256.7,percent of total billed charges,Implant Device,373.73,,,373.73,Other,110% of Medicare,264.25,35,,264.25,percent of total billed charges,Implant Device,256.7,34,"Charges > $500, x 34%",256.7,percent of total billed charges,Implant Device,264.25,35,,264.25,percent of total billed charges,Implant Device,264.25,35,,264.25,percent of total billed charges,Implant Device,264.25,35,,264.25,percent of total billed charges,Implant Device,264.25,35,,264.25,percent of total billed charges,Implant Device,264.25,35,,264.25,percent of total billed charges,Implant Device,302,40,,302,percent of total billed charges,Implant Device,264.25,70,,264.25,percent of total billed charges,All Other,256.7,34,,256.7,percent of total billed charges,Implant Device,256.7,34,,256.7,percent of total billed charges,Implant Device,264.25,35,,264.25,percent of total billed charges,Implant Device,264.25,35,,264.25,percent of total billed charges,Implant Device,264.25,35,,264.25,percent of total billed charges,Implant Device,264.25,35,,264.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,558.7,
STRYKER 614622 LOCKING SCREW 3.5X22MM,C1713,HCPCS,,79003535,CDM,278,RC,,,both,,,727,537.98,,,537.98,Other,150% of Medicare + 9.63% HCRA Surcharge,327.15,45,,327.15,percent of total billed charges,Critical Access Hospital RCC factor,247.18,34,,247.18,percent of total billed charges,Implant Device,247.18,34,,247.18,percent of total billed charges,Implant Device,247.18,34,,247.18,percent of total billed charges,Implant Device,247.18,34,,247.18,percent of total billed charges,Implant Device,247.18,34,,247.18,percent of total billed charges,Implant Device,359.87,,,359.87,Other,110% of Medicare,254.45,35,,254.45,percent of total billed charges,Implant Device,247.18,34,"Charges > $500, x 34%",247.18,percent of total billed charges,Implant Device,254.45,35,,254.45,percent of total billed charges,Implant Device,254.45,35,,254.45,percent of total billed charges,Implant Device,254.45,35,,254.45,percent of total billed charges,Implant Device,254.45,35,,254.45,percent of total billed charges,Implant Device,254.45,35,,254.45,percent of total billed charges,Implant Device,290.8,40,,290.8,percent of total billed charges,Implant Device,254.45,70,,254.45,percent of total billed charges,All Other,247.18,34,,247.18,percent of total billed charges,Implant Device,247.18,34,,247.18,percent of total billed charges,Implant Device,254.45,35,,254.45,percent of total billed charges,Implant Device,254.45,35,,254.45,percent of total billed charges,Implant Device,254.45,35,,254.45,percent of total billed charges,Implant Device,254.45,35,,254.45,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,537.98,
STRYKER 614624 LOCKING SCREW 3.5X24MM,C1713,HCPCS,,79003536,CDM,278,RC,,,both,,,666,492.84,,,492.84,Other,150% of Medicare + 9.63% HCRA Surcharge,299.7,45,,299.7,percent of total billed charges,Critical Access Hospital RCC factor,226.44,34,,226.44,percent of total billed charges,Implant Device,226.44,34,,226.44,percent of total billed charges,Implant Device,226.44,34,,226.44,percent of total billed charges,Implant Device,226.44,34,,226.44,percent of total billed charges,Implant Device,226.44,34,,226.44,percent of total billed charges,Implant Device,329.67,,,329.67,Other,110% of Medicare,233.1,35,,233.1,percent of total billed charges,Implant Device,226.44,34,"Charges > $500, x 34%",226.44,percent of total billed charges,Implant Device,233.1,35,,233.1,percent of total billed charges,Implant Device,233.1,35,,233.1,percent of total billed charges,Implant Device,233.1,35,,233.1,percent of total billed charges,Implant Device,233.1,35,,233.1,percent of total billed charges,Implant Device,233.1,35,,233.1,percent of total billed charges,Implant Device,266.4,40,,266.4,percent of total billed charges,Implant Device,233.1,70,,233.1,percent of total billed charges,All Other,226.44,34,,226.44,percent of total billed charges,Implant Device,226.44,34,,226.44,percent of total billed charges,Implant Device,233.1,35,,233.1,percent of total billed charges,Implant Device,233.1,35,,233.1,percent of total billed charges,Implant Device,233.1,35,,233.1,percent of total billed charges,Implant Device,233.1,35,,233.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,492.84,
STRYKER 614640 LOCKING SCREW 3.5X40MM,C1713,HCPCS,,79003537,CDM,278,RC,,,both,,,293,216.82,,,216.82,Other,150% of Medicare + 9.63% HCRA Surcharge,131.85,45,,131.85,percent of total billed charges,Critical Access Hospital RCC factor,99.62,34,,99.62,percent of total billed charges,Implant Device,99.62,34,,99.62,percent of total billed charges,Implant Device,99.62,34,,99.62,percent of total billed charges,Implant Device,99.62,34,,99.62,percent of total billed charges,Implant Device,99.62,34,,99.62,percent of total billed charges,Implant Device,145.04,,,145.04,Other,110% of Medicare,102.55,35,,102.55,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,102.55,35,,102.55,percent of total billed charges,Implant Device,102.55,35,,102.55,percent of total billed charges,Implant Device,102.55,35,,102.55,percent of total billed charges,Implant Device,102.55,35,,102.55,percent of total billed charges,Implant Device,102.55,35,,102.55,percent of total billed charges,Implant Device,117.2,40,,117.2,percent of total billed charges,Implant Device,102.55,70,,102.55,percent of total billed charges,All Other,99.62,34,,99.62,percent of total billed charges,Implant Device,99.62,34,,99.62,percent of total billed charges,Implant Device,102.55,35,,102.55,percent of total billed charges,Implant Device,102.55,35,,102.55,percent of total billed charges,Implant Device,102.55,35,,102.55,percent of total billed charges,Implant Device,102.55,35,,102.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,216.82,
STRYKER 614670 LOCKING SCREW 3.5X70MM,C1713,HCPCS,,79003538,CDM,278,RC,,,both,,,653,483.22,,,483.22,Other,150% of Medicare + 9.63% HCRA Surcharge,293.85,45,,293.85,percent of total billed charges,Critical Access Hospital RCC factor,222.02,34,,222.02,percent of total billed charges,Implant Device,222.02,34,,222.02,percent of total billed charges,Implant Device,222.02,34,,222.02,percent of total billed charges,Implant Device,222.02,34,,222.02,percent of total billed charges,Implant Device,222.02,34,,222.02,percent of total billed charges,Implant Device,323.24,,,323.24,Other,110% of Medicare,228.55,35,,228.55,percent of total billed charges,Implant Device,222.02,34,"Charges > $500, x 34%",222.02,percent of total billed charges,Implant Device,228.55,35,,228.55,percent of total billed charges,Implant Device,228.55,35,,228.55,percent of total billed charges,Implant Device,228.55,35,,228.55,percent of total billed charges,Implant Device,228.55,35,,228.55,percent of total billed charges,Implant Device,228.55,35,,228.55,percent of total billed charges,Implant Device,261.2,40,,261.2,percent of total billed charges,Implant Device,228.55,70,,228.55,percent of total billed charges,All Other,222.02,34,,222.02,percent of total billed charges,Implant Device,222.02,34,,222.02,percent of total billed charges,Implant Device,228.55,35,,228.55,percent of total billed charges,Implant Device,228.55,35,,228.55,percent of total billed charges,Implant Device,228.55,35,,228.55,percent of total billed charges,Implant Device,228.55,35,,228.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,483.22,
STRYKER 614812 NON LOCK SCREW 3.5X17MM,C1713,HCPCS,,79003539,CDM,278,RC,,,both,,,374,276.76,,,276.76,Other,150% of Medicare + 9.63% HCRA Surcharge,168.3,45,,168.3,percent of total billed charges,Critical Access Hospital RCC factor,127.16,34,,127.16,percent of total billed charges,Implant Device,127.16,34,,127.16,percent of total billed charges,Implant Device,127.16,34,,127.16,percent of total billed charges,Implant Device,127.16,34,,127.16,percent of total billed charges,Implant Device,127.16,34,,127.16,percent of total billed charges,Implant Device,185.13,,,185.13,Other,110% of Medicare,130.9,35,,130.9,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,130.9,35,,130.9,percent of total billed charges,Implant Device,130.9,35,,130.9,percent of total billed charges,Implant Device,130.9,35,,130.9,percent of total billed charges,Implant Device,130.9,35,,130.9,percent of total billed charges,Implant Device,130.9,35,,130.9,percent of total billed charges,Implant Device,149.6,40,,149.6,percent of total billed charges,Implant Device,130.9,70,,130.9,percent of total billed charges,All Other,127.16,34,,127.16,percent of total billed charges,Implant Device,127.16,34,,127.16,percent of total billed charges,Implant Device,130.9,35,,130.9,percent of total billed charges,Implant Device,130.9,35,,130.9,percent of total billed charges,Implant Device,130.9,35,,130.9,percent of total billed charges,Implant Device,130.9,35,,130.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,276.76,
STRYKER 614818 NON LOCK SCREW 3.5X18MM,C1713,HCPCS,,79003540,CDM,278,RC,,,both,,,727,537.98,,,537.98,Other,150% of Medicare + 9.63% HCRA Surcharge,327.15,45,,327.15,percent of total billed charges,Critical Access Hospital RCC factor,247.18,34,,247.18,percent of total billed charges,Implant Device,247.18,34,,247.18,percent of total billed charges,Implant Device,247.18,34,,247.18,percent of total billed charges,Implant Device,247.18,34,,247.18,percent of total billed charges,Implant Device,247.18,34,,247.18,percent of total billed charges,Implant Device,359.87,,,359.87,Other,110% of Medicare,254.45,35,,254.45,percent of total billed charges,Implant Device,247.18,34,"Charges > $500, x 34%",247.18,percent of total billed charges,Implant Device,254.45,35,,254.45,percent of total billed charges,Implant Device,254.45,35,,254.45,percent of total billed charges,Implant Device,254.45,35,,254.45,percent of total billed charges,Implant Device,254.45,35,,254.45,percent of total billed charges,Implant Device,254.45,35,,254.45,percent of total billed charges,Implant Device,290.8,40,,290.8,percent of total billed charges,Implant Device,254.45,70,,254.45,percent of total billed charges,All Other,247.18,34,,247.18,percent of total billed charges,Implant Device,247.18,34,,247.18,percent of total billed charges,Implant Device,254.45,35,,254.45,percent of total billed charges,Implant Device,254.45,35,,254.45,percent of total billed charges,Implant Device,254.45,35,,254.45,percent of total billed charges,Implant Device,254.45,35,,254.45,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,537.98,
STRYKER 614822 NON LOCK SCREW 3.5X22MM,C1713,HCPCS,,79003541,CDM,278,RC,,,both,,,375,277.5,,,277.5,Other,150% of Medicare + 9.63% HCRA Surcharge,168.75,45,,168.75,percent of total billed charges,Critical Access Hospital RCC factor,127.5,34,,127.5,percent of total billed charges,Implant Device,127.5,34,,127.5,percent of total billed charges,Implant Device,127.5,34,,127.5,percent of total billed charges,Implant Device,127.5,34,,127.5,percent of total billed charges,Implant Device,127.5,34,,127.5,percent of total billed charges,Implant Device,185.63,,,185.63,Other,110% of Medicare,131.25,35,,131.25,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,131.25,35,,131.25,percent of total billed charges,Implant Device,131.25,35,,131.25,percent of total billed charges,Implant Device,131.25,35,,131.25,percent of total billed charges,Implant Device,131.25,35,,131.25,percent of total billed charges,Implant Device,131.25,35,,131.25,percent of total billed charges,Implant Device,150,40,,150,percent of total billed charges,Implant Device,131.25,70,,131.25,percent of total billed charges,All Other,127.5,34,,127.5,percent of total billed charges,Implant Device,127.5,34,,127.5,percent of total billed charges,Implant Device,131.25,35,,131.25,percent of total billed charges,Implant Device,131.25,35,,131.25,percent of total billed charges,Implant Device,131.25,35,,131.25,percent of total billed charges,Implant Device,131.25,35,,131.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,277.5,
STRYKER 614828 NON LOCK SCREW 3.5X28MM,C1713,HCPCS,,79003542,CDM,278,RC,,,both,,,293,216.82,,,216.82,Other,150% of Medicare + 9.63% HCRA Surcharge,131.85,45,,131.85,percent of total billed charges,Critical Access Hospital RCC factor,99.62,34,,99.62,percent of total billed charges,Implant Device,99.62,34,,99.62,percent of total billed charges,Implant Device,99.62,34,,99.62,percent of total billed charges,Implant Device,99.62,34,,99.62,percent of total billed charges,Implant Device,99.62,34,,99.62,percent of total billed charges,Implant Device,145.04,,,145.04,Other,110% of Medicare,102.55,35,,102.55,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,102.55,35,,102.55,percent of total billed charges,Implant Device,102.55,35,,102.55,percent of total billed charges,Implant Device,102.55,35,,102.55,percent of total billed charges,Implant Device,102.55,35,,102.55,percent of total billed charges,Implant Device,102.55,35,,102.55,percent of total billed charges,Implant Device,117.2,40,,117.2,percent of total billed charges,Implant Device,102.55,70,,102.55,percent of total billed charges,All Other,99.62,34,,99.62,percent of total billed charges,Implant Device,99.62,34,,99.62,percent of total billed charges,Implant Device,102.55,35,,102.55,percent of total billed charges,Implant Device,102.55,35,,102.55,percent of total billed charges,Implant Device,102.55,35,,102.55,percent of total billed charges,Implant Device,102.55,35,,102.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,216.82,
STRYKER 614850 NON LOCK SCREW 3.5X50MM,C1713,HCPCS,,79003543,CDM,278,RC,,,both,,,319,236.06,,,236.06,Other,150% of Medicare + 9.63% HCRA Surcharge,143.55,45,,143.55,percent of total billed charges,Critical Access Hospital RCC factor,108.46,34,,108.46,percent of total billed charges,Implant Device,108.46,34,,108.46,percent of total billed charges,Implant Device,108.46,34,,108.46,percent of total billed charges,Implant Device,108.46,34,,108.46,percent of total billed charges,Implant Device,108.46,34,,108.46,percent of total billed charges,Implant Device,157.91,,,157.91,Other,110% of Medicare,111.65,35,,111.65,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,111.65,35,,111.65,percent of total billed charges,Implant Device,111.65,35,,111.65,percent of total billed charges,Implant Device,111.65,35,,111.65,percent of total billed charges,Implant Device,111.65,35,,111.65,percent of total billed charges,Implant Device,111.65,35,,111.65,percent of total billed charges,Implant Device,127.6,40,,127.6,percent of total billed charges,Implant Device,111.65,70,,111.65,percent of total billed charges,All Other,108.46,34,,108.46,percent of total billed charges,Implant Device,108.46,34,,108.46,percent of total billed charges,Implant Device,111.65,35,,111.65,percent of total billed charges,Implant Device,111.65,35,,111.65,percent of total billed charges,Implant Device,111.65,35,,111.65,percent of total billed charges,Implant Device,111.65,35,,111.65,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,236.06,
STRYKER 2102-2202 VITOSS BB TRAUMA 2.5CC,C1713,HCPCS,,79003544,CDM,278,RC,,,both,,,4977,3682.99,,,3682.99,Other,150% of Medicare + 9.63% HCRA Surcharge,2239.65,45,,2239.65,percent of total billed charges,Critical Access Hospital RCC factor,1692.18,34,,1692.18,percent of total billed charges,Implant Device,1692.18,34,,1692.18,percent of total billed charges,Implant Device,1692.18,34,,1692.18,percent of total billed charges,Implant Device,1692.18,34,,1692.18,percent of total billed charges,Implant Device,1692.18,34,,1692.18,percent of total billed charges,Implant Device,2463.62,,,2463.62,Other,110% of Medicare,1741.95,35,,1741.95,percent of total billed charges,Implant Device,1692.18,34,"Charges > $500, x 34%",1692.18,percent of total billed charges,Implant Device,1741.95,35,,1741.95,percent of total billed charges,Implant Device,1741.95,35,,1741.95,percent of total billed charges,Implant Device,1741.95,35,,1741.95,percent of total billed charges,Implant Device,1741.95,35,,1741.95,percent of total billed charges,Implant Device,1741.95,35,,1741.95,percent of total billed charges,Implant Device,1990.8,40,,1990.8,percent of total billed charges,Implant Device,1741.95,70,,1741.95,percent of total billed charges,All Other,1692.18,34,,1692.18,percent of total billed charges,Implant Device,1692.18,34,,1692.18,percent of total billed charges,Implant Device,1741.95,35,,1741.95,percent of total billed charges,Implant Device,1741.95,35,,1741.95,percent of total billed charges,Implant Device,1741.95,35,,1741.95,percent of total billed charges,Implant Device,1741.95,35,,1741.95,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1692.18,34,"If Charge > 2,000, then 34 percent",1692.18,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3682.99,
ZIMMER 2232-04-18-REV CBL RDY COCR ASSY,C1713,HCPCS,,79003554,CDM,278,RC,,,both,,,2222,1644.29,,,1644.29,Other,150% of Medicare + 9.63% HCRA Surcharge,999.9,45,,999.9,percent of total billed charges,Critical Access Hospital RCC factor,755.48,34,,755.48,percent of total billed charges,Implant Device,755.48,34,,755.48,percent of total billed charges,Implant Device,755.48,34,,755.48,percent of total billed charges,Implant Device,755.48,34,,755.48,percent of total billed charges,Implant Device,755.48,34,,755.48,percent of total billed charges,Implant Device,1099.89,,,1099.89,Other,110% of Medicare,777.7,35,,777.7,percent of total billed charges,Implant Device,755.48,34,"Charges > $500, x 34%",755.48,percent of total billed charges,Implant Device,777.7,35,,777.7,percent of total billed charges,Implant Device,777.7,35,,777.7,percent of total billed charges,Implant Device,777.7,35,,777.7,percent of total billed charges,Implant Device,777.7,35,,777.7,percent of total billed charges,Implant Device,777.7,35,,777.7,percent of total billed charges,Implant Device,888.8,40,,888.8,percent of total billed charges,Implant Device,777.7,70,,777.7,percent of total billed charges,All Other,755.48,34,,755.48,percent of total billed charges,Implant Device,755.48,34,,755.48,percent of total billed charges,Implant Device,777.7,35,,777.7,percent of total billed charges,Implant Device,777.7,35,,777.7,percent of total billed charges,Implant Device,777.7,35,,777.7,percent of total billed charges,Implant Device,777.7,35,,777.7,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,755.48,34,"If Charge > 2,000, then 34 percent",755.48,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1644.29,
BIOMET 115-382 COMPRSNSV REV SHLDR 6.5MM,C1776,HCPCS,,79003555,CDM,278,RC,,,both,,,780,577.2,,,577.2,Other,150% of Medicare + 9.63% HCRA Surcharge,351,45,,351,percent of total billed charges,Critical Access Hospital RCC factor,265.2,34,,265.2,percent of total billed charges,Implant Device,265.2,34,,265.2,percent of total billed charges,Implant Device,265.2,34,,265.2,percent of total billed charges,Implant Device,265.2,34,,265.2,percent of total billed charges,Implant Device,265.2,34,,265.2,percent of total billed charges,Implant Device,386.1,,,386.1,Other,110% of Medicare,273,35,,273,percent of total billed charges,Implant Device,265.2,34,"Charges > $500, x 34%",265.2,percent of total billed charges,Implant Device,273,35,,273,percent of total billed charges,Implant Device,273,35,,273,percent of total billed charges,Implant Device,273,35,,273,percent of total billed charges,Implant Device,273,35,,273,percent of total billed charges,Implant Device,273,35,,273,percent of total billed charges,Implant Device,312,40,,312,percent of total billed charges,Implant Device,273,70,,273,percent of total billed charges,All Other,265.2,34,,265.2,percent of total billed charges,Implant Device,265.2,34,,265.2,percent of total billed charges,Implant Device,273,35,,273,percent of total billed charges,Implant Device,273,35,,273,percent of total billed charges,Implant Device,273,35,,273,percent of total billed charges,Implant Device,273,35,,273,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,577.2,
BIOMET 180502 FIXED LOCK SCREW 4.75X25MM,C1713,HCPCS,,79003556,CDM,278,RC,,,both,,,810,599.4,,,599.4,Other,150% of Medicare + 9.63% HCRA Surcharge,364.5,45,,364.5,percent of total billed charges,Critical Access Hospital RCC factor,275.4,34,,275.4,percent of total billed charges,Implant Device,275.4,34,,275.4,percent of total billed charges,Implant Device,275.4,34,,275.4,percent of total billed charges,Implant Device,275.4,34,,275.4,percent of total billed charges,Implant Device,275.4,34,,275.4,percent of total billed charges,Implant Device,400.95,,,400.95,Other,110% of Medicare,283.5,35,,283.5,percent of total billed charges,Implant Device,275.4,34,"Charges > $500, x 34%",275.4,percent of total billed charges,Implant Device,283.5,35,,283.5,percent of total billed charges,Implant Device,283.5,35,,283.5,percent of total billed charges,Implant Device,283.5,35,,283.5,percent of total billed charges,Implant Device,283.5,35,,283.5,percent of total billed charges,Implant Device,283.5,35,,283.5,percent of total billed charges,Implant Device,324,40,,324,percent of total billed charges,Implant Device,283.5,70,,283.5,percent of total billed charges,All Other,275.4,34,,275.4,percent of total billed charges,Implant Device,275.4,34,,275.4,percent of total billed charges,Implant Device,283.5,35,,283.5,percent of total billed charges,Implant Device,283.5,35,,283.5,percent of total billed charges,Implant Device,283.5,35,,283.5,percent of total billed charges,Implant Device,283.5,35,,283.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,599.4,
ARTHREX AR-1934BCF-24-2 SUTURETAK 2.4,C1713,HCPCS,,79003557,CDM,278,RC,,,both,,,960,710.4,,,710.4,Other,150% of Medicare + 9.63% HCRA Surcharge,432,45,,432,percent of total billed charges,Critical Access Hospital RCC factor,326.4,34,,326.4,percent of total billed charges,Implant Device,326.4,34,,326.4,percent of total billed charges,Implant Device,326.4,34,,326.4,percent of total billed charges,Implant Device,326.4,34,,326.4,percent of total billed charges,Implant Device,326.4,34,,326.4,percent of total billed charges,Implant Device,475.2,,,475.2,Other,110% of Medicare,336,35,,336,percent of total billed charges,Implant Device,326.4,34,"Charges > $500, x 34%",326.4,percent of total billed charges,Implant Device,336,35,,336,percent of total billed charges,Implant Device,336,35,,336,percent of total billed charges,Implant Device,336,35,,336,percent of total billed charges,Implant Device,336,35,,336,percent of total billed charges,Implant Device,336,35,,336,percent of total billed charges,Implant Device,384,40,,384,percent of total billed charges,Implant Device,336,70,,336,percent of total billed charges,All Other,326.4,34,,326.4,percent of total billed charges,Implant Device,326.4,34,,326.4,percent of total billed charges,Implant Device,336,35,,336,percent of total billed charges,Implant Device,336,35,,336,percent of total billed charges,Implant Device,336,35,,336,percent of total billed charges,Implant Device,336,35,,336,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,710.4,
PARAGON 28 P28-20-130 SCREW STD 3.5X30,C1713,HCPCS,,79003558,CDM,278,RC,,,both,,,360,266.4,,,266.4,Other,150% of Medicare + 9.63% HCRA Surcharge,162,45,,162,percent of total billed charges,Critical Access Hospital RCC factor,122.4,34,,122.4,percent of total billed charges,Implant Device,122.4,34,,122.4,percent of total billed charges,Implant Device,122.4,34,,122.4,percent of total billed charges,Implant Device,122.4,34,,122.4,percent of total billed charges,Implant Device,122.4,34,,122.4,percent of total billed charges,Implant Device,178.2,,,178.2,Other,110% of Medicare,126,35,,126,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,126,35,,126,percent of total billed charges,Implant Device,126,35,,126,percent of total billed charges,Implant Device,126,35,,126,percent of total billed charges,Implant Device,126,35,,126,percent of total billed charges,Implant Device,126,35,,126,percent of total billed charges,Implant Device,144,40,,144,percent of total billed charges,Implant Device,126,70,,126,percent of total billed charges,All Other,122.4,34,,122.4,percent of total billed charges,Implant Device,122.4,34,,122.4,percent of total billed charges,Implant Device,126,35,,126,percent of total billed charges,Implant Device,126,35,,126,percent of total billed charges,Implant Device,126,35,,126,percent of total billed charges,Implant Device,126,35,,126,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,266.4,
INTL BIOLOGICS 907 ANT TIB TENDON 7X290,C1713,HCPCS,,79003560,CDM,278,RC,,,both,,,5325,3940.51,,,3940.51,Other,150% of Medicare + 9.63% HCRA Surcharge,2396.25,45,,2396.25,percent of total billed charges,Critical Access Hospital RCC factor,1810.5,34,,1810.5,percent of total billed charges,Implant Device,1810.5,34,,1810.5,percent of total billed charges,Implant Device,1810.5,34,,1810.5,percent of total billed charges,Implant Device,1810.5,34,,1810.5,percent of total billed charges,Implant Device,1810.5,34,,1810.5,percent of total billed charges,Implant Device,2635.88,,,2635.88,Other,110% of Medicare,1863.75,35,,1863.75,percent of total billed charges,Implant Device,1810.5,34,"Charges > $500, x 34%",1810.5,percent of total billed charges,Implant Device,1863.75,35,,1863.75,percent of total billed charges,Implant Device,1863.75,35,,1863.75,percent of total billed charges,Implant Device,1863.75,35,,1863.75,percent of total billed charges,Implant Device,1863.75,35,,1863.75,percent of total billed charges,Implant Device,1863.75,35,,1863.75,percent of total billed charges,Implant Device,2130,40,,2130,percent of total billed charges,Implant Device,1863.75,70,,1863.75,percent of total billed charges,All Other,1810.5,34,,1810.5,percent of total billed charges,Implant Device,1810.5,34,,1810.5,percent of total billed charges,Implant Device,1863.75,35,,1863.75,percent of total billed charges,Implant Device,1863.75,35,,1863.75,percent of total billed charges,Implant Device,1863.75,35,,1863.75,percent of total billed charges,Implant Device,1863.75,35,,1863.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1810.5,34,"If Charge > 2,000, then 34 percent",1810.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3940.51,
STRYKER 5023-5-120 APEX PINS 4X120MM,C1713,HCPCS,,79003563,CDM,278,RC,,,both,,,503,372.22,,,372.22,Other,150% of Medicare + 9.63% HCRA Surcharge,226.35,45,,226.35,percent of total billed charges,Critical Access Hospital RCC factor,171.02,34,,171.02,percent of total billed charges,Implant Device,171.02,34,,171.02,percent of total billed charges,Implant Device,171.02,34,,171.02,percent of total billed charges,Implant Device,171.02,34,,171.02,percent of total billed charges,Implant Device,171.02,34,,171.02,percent of total billed charges,Implant Device,248.99,,,248.99,Other,110% of Medicare,176.05,35,,176.05,percent of total billed charges,Implant Device,171.02,34,"Charges > $500, x 34%",171.02,percent of total billed charges,Implant Device,176.05,35,,176.05,percent of total billed charges,Implant Device,176.05,35,,176.05,percent of total billed charges,Implant Device,176.05,35,,176.05,percent of total billed charges,Implant Device,176.05,35,,176.05,percent of total billed charges,Implant Device,176.05,35,,176.05,percent of total billed charges,Implant Device,201.2,40,,201.2,percent of total billed charges,Implant Device,176.05,70,,176.05,percent of total billed charges,All Other,171.02,34,,171.02,percent of total billed charges,Implant Device,171.02,34,,171.02,percent of total billed charges,Implant Device,176.05,35,,176.05,percent of total billed charges,Implant Device,176.05,35,,176.05,percent of total billed charges,Implant Device,176.05,35,,176.05,percent of total billed charges,Implant Device,176.05,35,,176.05,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,372.22,
BIOMET 11-165218 ACETABULAR CUP 28X47MM,C1776,HCPCS,,79003567,CDM,278,RC,,,both,,,6540,4839.62,,,4839.62,Other,150% of Medicare + 9.63% HCRA Surcharge,2943,45,,2943,percent of total billed charges,Critical Access Hospital RCC factor,2223.6,34,,2223.6,percent of total billed charges,Implant Device,2223.6,34,,2223.6,percent of total billed charges,Implant Device,2223.6,34,,2223.6,percent of total billed charges,Implant Device,2223.6,34,,2223.6,percent of total billed charges,Implant Device,2223.6,34,,2223.6,percent of total billed charges,Implant Device,3237.3,,,3237.3,Other,110% of Medicare,2289,35,,2289,percent of total billed charges,Implant Device,2223.6,34,"Charges > $500, x 34%",2223.6,percent of total billed charges,Implant Device,2289,35,,2289,percent of total billed charges,Implant Device,2289,35,,2289,percent of total billed charges,Implant Device,2289,35,,2289,percent of total billed charges,Implant Device,2289,35,,2289,percent of total billed charges,Implant Device,2289,35,,2289,percent of total billed charges,Implant Device,2616,40,,2616,percent of total billed charges,Implant Device,2289,70,,2289,percent of total billed charges,All Other,2223.6,34,,2223.6,percent of total billed charges,Implant Device,2223.6,34,,2223.6,percent of total billed charges,Implant Device,2289,35,,2289,percent of total billed charges,Implant Device,2289,35,,2289,percent of total billed charges,Implant Device,2289,35,,2289,percent of total billed charges,Implant Device,2289,35,,2289,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2223.6,34,"If Charge > 2,000, then 34 percent",2223.6,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4839.62,
BIOMET 163662 MOD HEAD COMP 28X6MM,C1776,HCPCS,,79003568,CDM,278,RC,,,both,,,4830,3574.21,,,3574.21,Other,150% of Medicare + 9.63% HCRA Surcharge,2173.5,45,,2173.5,percent of total billed charges,Critical Access Hospital RCC factor,1642.2,34,,1642.2,percent of total billed charges,Implant Device,1642.2,34,,1642.2,percent of total billed charges,Implant Device,1642.2,34,,1642.2,percent of total billed charges,Implant Device,1642.2,34,,1642.2,percent of total billed charges,Implant Device,1642.2,34,,1642.2,percent of total billed charges,Implant Device,2390.85,,,2390.85,Other,110% of Medicare,1690.5,35,,1690.5,percent of total billed charges,Implant Device,1642.2,34,"Charges > $500, x 34%",1642.2,percent of total billed charges,Implant Device,1690.5,35,,1690.5,percent of total billed charges,Implant Device,1690.5,35,,1690.5,percent of total billed charges,Implant Device,1690.5,35,,1690.5,percent of total billed charges,Implant Device,1690.5,35,,1690.5,percent of total billed charges,Implant Device,1690.5,35,,1690.5,percent of total billed charges,Implant Device,1932,40,,1932,percent of total billed charges,Implant Device,1690.5,70,,1690.5,percent of total billed charges,All Other,1642.2,34,,1642.2,percent of total billed charges,Implant Device,1642.2,34,,1642.2,percent of total billed charges,Implant Device,1690.5,35,,1690.5,percent of total billed charges,Implant Device,1690.5,35,,1690.5,percent of total billed charges,Implant Device,1690.5,35,,1690.5,percent of total billed charges,Implant Device,1690.5,35,,1690.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1642.2,34,"If Charge > 2,000, then 34 percent",1642.2,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3574.21,
BIOMET 402283 BONE CEMENT W/GENTAMICIN,C1713,HCPCS,,79003571,CDM,278,RC,,,both,,,1098,812.52,,,812.52,Other,150% of Medicare + 9.63% HCRA Surcharge,494.1,45,,494.1,percent of total billed charges,Critical Access Hospital RCC factor,373.32,34,,373.32,percent of total billed charges,Implant Device,373.32,34,,373.32,percent of total billed charges,Implant Device,373.32,34,,373.32,percent of total billed charges,Implant Device,373.32,34,,373.32,percent of total billed charges,Implant Device,373.32,34,,373.32,percent of total billed charges,Implant Device,543.51,,,543.51,Other,110% of Medicare,384.3,35,,384.3,percent of total billed charges,Implant Device,373.32,34,"Charges > $500, x 34%",373.32,percent of total billed charges,Implant Device,384.3,35,,384.3,percent of total billed charges,Implant Device,384.3,35,,384.3,percent of total billed charges,Implant Device,384.3,35,,384.3,percent of total billed charges,Implant Device,384.3,35,,384.3,percent of total billed charges,Implant Device,384.3,35,,384.3,percent of total billed charges,Implant Device,439.2,40,,439.2,percent of total billed charges,Implant Device,384.3,70,,384.3,percent of total billed charges,All Other,373.32,34,,373.32,percent of total billed charges,Implant Device,373.32,34,,373.32,percent of total billed charges,Implant Device,384.3,35,,384.3,percent of total billed charges,Implant Device,384.3,35,,384.3,percent of total billed charges,Implant Device,384.3,35,,384.3,percent of total billed charges,Implant Device,384.3,35,,384.3,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,812.52,
ACUMED 70-0383 OLECRANON PLATE 3 HOLE,C1713,HCPCS,,79003572,CDM,278,RC,,,both,,,3300,2442.01,,,2442.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1485,45,,1485,percent of total billed charges,Critical Access Hospital RCC factor,1122,34,,1122,percent of total billed charges,Implant Device,1122,34,,1122,percent of total billed charges,Implant Device,1122,34,,1122,percent of total billed charges,Implant Device,1122,34,,1122,percent of total billed charges,Implant Device,1122,34,,1122,percent of total billed charges,Implant Device,1633.5,,,1633.5,Other,110% of Medicare,1155,35,,1155,percent of total billed charges,Implant Device,1122,34,"Charges > $500, x 34%",1122,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,1320,40,,1320,percent of total billed charges,Implant Device,1155,70,,1155,percent of total billed charges,All Other,1122,34,,1122,percent of total billed charges,Implant Device,1122,34,,1122,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1122,34,"If Charge > 2,000, then 34 percent",1122,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2442.01,
ACUMED 30-0262 NON LOCK SCREW 3.5X22MM,C1713,HCPCS,,79003575,CDM,278,RC,,,both,,,315,233.1,,,233.1,Other,150% of Medicare + 9.63% HCRA Surcharge,141.75,45,,141.75,percent of total billed charges,Critical Access Hospital RCC factor,107.1,34,,107.1,percent of total billed charges,Implant Device,107.1,34,,107.1,percent of total billed charges,Implant Device,107.1,34,,107.1,percent of total billed charges,Implant Device,107.1,34,,107.1,percent of total billed charges,Implant Device,107.1,34,,107.1,percent of total billed charges,Implant Device,155.93,,,155.93,Other,110% of Medicare,110.25,35,,110.25,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,110.25,35,,110.25,percent of total billed charges,Implant Device,110.25,35,,110.25,percent of total billed charges,Implant Device,110.25,35,,110.25,percent of total billed charges,Implant Device,110.25,35,,110.25,percent of total billed charges,Implant Device,110.25,35,,110.25,percent of total billed charges,Implant Device,126,40,,126,percent of total billed charges,Implant Device,110.25,70,,110.25,percent of total billed charges,All Other,107.1,34,,107.1,percent of total billed charges,Implant Device,107.1,34,,107.1,percent of total billed charges,Implant Device,110.25,35,,110.25,percent of total billed charges,Implant Device,110.25,35,,110.25,percent of total billed charges,Implant Device,110.25,35,,110.25,percent of total billed charges,Implant Device,110.25,35,,110.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,233.1,
ACUMED 30-0330 LOCKING SCREW 2.7X20MM,C1713,HCPCS,,79003576,CDM,278,RC,,,both,,,450,333,,,333,Other,150% of Medicare + 9.63% HCRA Surcharge,202.5,45,,202.5,percent of total billed charges,Critical Access Hospital RCC factor,153,34,,153,percent of total billed charges,Implant Device,153,34,,153,percent of total billed charges,Implant Device,153,34,,153,percent of total billed charges,Implant Device,153,34,,153,percent of total billed charges,Implant Device,153,34,,153,percent of total billed charges,Implant Device,222.75,,,222.75,Other,110% of Medicare,157.5,35,,157.5,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,157.5,35,,157.5,percent of total billed charges,Implant Device,157.5,35,,157.5,percent of total billed charges,Implant Device,157.5,35,,157.5,percent of total billed charges,Implant Device,157.5,35,,157.5,percent of total billed charges,Implant Device,157.5,35,,157.5,percent of total billed charges,Implant Device,180,40,,180,percent of total billed charges,Implant Device,157.5,70,,157.5,percent of total billed charges,All Other,153,34,,153,percent of total billed charges,Implant Device,153,34,,153,percent of total billed charges,Implant Device,157.5,35,,157.5,percent of total billed charges,Implant Device,157.5,35,,157.5,percent of total billed charges,Implant Device,157.5,35,,157.5,percent of total billed charges,Implant Device,157.5,35,,157.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,333,
ACUMED 30-0331 LOCKING SCREW 2.7X22MM,C1713,HCPCS,,79003577,CDM,278,RC,,,both,,,424,313.76,,,313.76,Other,150% of Medicare + 9.63% HCRA Surcharge,190.8,45,,190.8,percent of total billed charges,Critical Access Hospital RCC factor,144.16,34,,144.16,percent of total billed charges,Implant Device,144.16,34,,144.16,percent of total billed charges,Implant Device,144.16,34,,144.16,percent of total billed charges,Implant Device,144.16,34,,144.16,percent of total billed charges,Implant Device,144.16,34,,144.16,percent of total billed charges,Implant Device,209.88,,,209.88,Other,110% of Medicare,148.4,35,,148.4,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,148.4,35,,148.4,percent of total billed charges,Implant Device,148.4,35,,148.4,percent of total billed charges,Implant Device,148.4,35,,148.4,percent of total billed charges,Implant Device,148.4,35,,148.4,percent of total billed charges,Implant Device,148.4,35,,148.4,percent of total billed charges,Implant Device,169.6,40,,169.6,percent of total billed charges,Implant Device,148.4,70,,148.4,percent of total billed charges,All Other,144.16,34,,144.16,percent of total billed charges,Implant Device,144.16,34,,144.16,percent of total billed charges,Implant Device,148.4,35,,148.4,percent of total billed charges,Implant Device,148.4,35,,148.4,percent of total billed charges,Implant Device,148.4,35,,148.4,percent of total billed charges,Implant Device,148.4,35,,148.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,313.76,
ACUMED 30-0241 LOCKING SCREW 3.5X26MM,C1713,HCPCS,,79003578,CDM,278,RC,,,both,,,450,333,,,333,Other,150% of Medicare + 9.63% HCRA Surcharge,202.5,45,,202.5,percent of total billed charges,Critical Access Hospital RCC factor,153,34,,153,percent of total billed charges,Implant Device,153,34,,153,percent of total billed charges,Implant Device,153,34,,153,percent of total billed charges,Implant Device,153,34,,153,percent of total billed charges,Implant Device,153,34,,153,percent of total billed charges,Implant Device,222.75,,,222.75,Other,110% of Medicare,157.5,35,,157.5,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,157.5,35,,157.5,percent of total billed charges,Implant Device,157.5,35,,157.5,percent of total billed charges,Implant Device,157.5,35,,157.5,percent of total billed charges,Implant Device,157.5,35,,157.5,percent of total billed charges,Implant Device,157.5,35,,157.5,percent of total billed charges,Implant Device,180,40,,180,percent of total billed charges,Implant Device,157.5,70,,157.5,percent of total billed charges,All Other,153,34,,153,percent of total billed charges,Implant Device,153,34,,153,percent of total billed charges,Implant Device,157.5,35,,157.5,percent of total billed charges,Implant Device,157.5,35,,157.5,percent of total billed charges,Implant Device,157.5,35,,157.5,percent of total billed charges,Implant Device,157.5,35,,157.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,333,
ACUMED 30-0239 LOCKING SC REW 3.5X22MM,C1713,HCPCS,,79003579,CDM,278,RC,,,both,,,426,315.24,,,315.24,Other,150% of Medicare + 9.63% HCRA Surcharge,191.7,45,,191.7,percent of total billed charges,Critical Access Hospital RCC factor,144.84,34,,144.84,percent of total billed charges,Implant Device,144.84,34,,144.84,percent of total billed charges,Implant Device,144.84,34,,144.84,percent of total billed charges,Implant Device,144.84,34,,144.84,percent of total billed charges,Implant Device,144.84,34,,144.84,percent of total billed charges,Implant Device,210.87,,,210.87,Other,110% of Medicare,149.1,35,,149.1,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,149.1,35,,149.1,percent of total billed charges,Implant Device,149.1,35,,149.1,percent of total billed charges,Implant Device,149.1,35,,149.1,percent of total billed charges,Implant Device,149.1,35,,149.1,percent of total billed charges,Implant Device,149.1,35,,149.1,percent of total billed charges,Implant Device,170.4,40,,170.4,percent of total billed charges,Implant Device,149.1,70,,149.1,percent of total billed charges,All Other,144.84,34,,144.84,percent of total billed charges,Implant Device,144.84,34,,144.84,percent of total billed charges,Implant Device,149.1,35,,149.1,percent of total billed charges,Implant Device,149.1,35,,149.1,percent of total billed charges,Implant Device,149.1,35,,149.1,percent of total billed charges,Implant Device,149.1,35,,149.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,315.24,
ACUMED 70-0296 CLAVICLE PLATE 6 HOLE,C1713,HCPCS,,79003580,CDM,278,RC,,,both,,,3366,2490.85,,,2490.85,Other,150% of Medicare + 9.63% HCRA Surcharge,1514.7,45,,1514.7,percent of total billed charges,Critical Access Hospital RCC factor,1144.44,34,,1144.44,percent of total billed charges,Implant Device,1144.44,34,,1144.44,percent of total billed charges,Implant Device,1144.44,34,,1144.44,percent of total billed charges,Implant Device,1144.44,34,,1144.44,percent of total billed charges,Implant Device,1144.44,34,,1144.44,percent of total billed charges,Implant Device,1666.17,,,1666.17,Other,110% of Medicare,1178.1,35,,1178.1,percent of total billed charges,Implant Device,1144.44,34,"Charges > $500, x 34%",1144.44,percent of total billed charges,Implant Device,1178.1,35,,1178.1,percent of total billed charges,Implant Device,1178.1,35,,1178.1,percent of total billed charges,Implant Device,1178.1,35,,1178.1,percent of total billed charges,Implant Device,1178.1,35,,1178.1,percent of total billed charges,Implant Device,1178.1,35,,1178.1,percent of total billed charges,Implant Device,1346.4,40,,1346.4,percent of total billed charges,Implant Device,1178.1,70,,1178.1,percent of total billed charges,All Other,1144.44,34,,1144.44,percent of total billed charges,Implant Device,1144.44,34,,1144.44,percent of total billed charges,Implant Device,1178.1,35,,1178.1,percent of total billed charges,Implant Device,1178.1,35,,1178.1,percent of total billed charges,Implant Device,1178.1,35,,1178.1,percent of total billed charges,Implant Device,1178.1,35,,1178.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1144.44,34,"If Charge > 2,000, then 34 percent",1144.44,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2490.85,
ACUMED CO-3180 NON LOCK SCREW 3.5X18MM,C1713,HCPCS,,79003581,CDM,278,RC,,,both,,,234,173.16,,,173.16,Other,150% of Medicare + 9.63% HCRA Surcharge,105.3,45,,105.3,percent of total billed charges,Critical Access Hospital RCC factor,79.56,34,,79.56,percent of total billed charges,Implant Device,79.56,34,,79.56,percent of total billed charges,Implant Device,79.56,34,,79.56,percent of total billed charges,Implant Device,79.56,34,,79.56,percent of total billed charges,Implant Device,79.56,34,,79.56,percent of total billed charges,Implant Device,115.83,,,115.83,Other,110% of Medicare,81.9,35,,81.9,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,81.9,35,,81.9,percent of total billed charges,Implant Device,81.9,35,,81.9,percent of total billed charges,Implant Device,81.9,35,,81.9,percent of total billed charges,Implant Device,81.9,35,,81.9,percent of total billed charges,Implant Device,81.9,35,,81.9,percent of total billed charges,Implant Device,93.6,40,,93.6,percent of total billed charges,Implant Device,81.9,70,,81.9,percent of total billed charges,All Other,79.56,34,,79.56,percent of total billed charges,Implant Device,79.56,34,,79.56,percent of total billed charges,Implant Device,81.9,35,,81.9,percent of total billed charges,Implant Device,81.9,35,,81.9,percent of total billed charges,Implant Device,81.9,35,,81.9,percent of total billed charges,Implant Device,81.9,35,,81.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,173.16,
ACUMED CO-3120 NON LOCK SCREW 3.5X12MM,C1713,HCPCS,,79003582,CDM,278,RC,,,both,,,232,171.68,,,171.68,Other,150% of Medicare + 9.63% HCRA Surcharge,104.4,45,,104.4,percent of total billed charges,Critical Access Hospital RCC factor,78.88,34,,78.88,percent of total billed charges,Implant Device,78.88,34,,78.88,percent of total billed charges,Implant Device,78.88,34,,78.88,percent of total billed charges,Implant Device,78.88,34,,78.88,percent of total billed charges,Implant Device,78.88,34,,78.88,percent of total billed charges,Implant Device,114.84,,,114.84,Other,110% of Medicare,81.2,35,,81.2,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,81.2,35,,81.2,percent of total billed charges,Implant Device,81.2,35,,81.2,percent of total billed charges,Implant Device,81.2,35,,81.2,percent of total billed charges,Implant Device,81.2,35,,81.2,percent of total billed charges,Implant Device,81.2,35,,81.2,percent of total billed charges,Implant Device,92.8,40,,92.8,percent of total billed charges,Implant Device,81.2,70,,81.2,percent of total billed charges,All Other,78.88,34,,78.88,percent of total billed charges,Implant Device,78.88,34,,78.88,percent of total billed charges,Implant Device,81.2,35,,81.2,percent of total billed charges,Implant Device,81.2,35,,81.2,percent of total billed charges,Implant Device,81.2,35,,81.2,percent of total billed charges,Implant Device,81.2,35,,81.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,171.68,
ACUMED COL-3100 LOCKING SCREW 3.5X10MM,C1713,HCPCS,,79003584,CDM,278,RC,,,both,,,382,282.68,,,282.68,Other,150% of Medicare + 9.63% HCRA Surcharge,171.9,45,,171.9,percent of total billed charges,Critical Access Hospital RCC factor,129.88,34,,129.88,percent of total billed charges,Implant Device,129.88,34,,129.88,percent of total billed charges,Implant Device,129.88,34,,129.88,percent of total billed charges,Implant Device,129.88,34,,129.88,percent of total billed charges,Implant Device,129.88,34,,129.88,percent of total billed charges,Implant Device,189.09,,,189.09,Other,110% of Medicare,133.7,35,,133.7,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,133.7,35,,133.7,percent of total billed charges,Implant Device,133.7,35,,133.7,percent of total billed charges,Implant Device,133.7,35,,133.7,percent of total billed charges,Implant Device,133.7,35,,133.7,percent of total billed charges,Implant Device,133.7,35,,133.7,percent of total billed charges,Implant Device,152.8,40,,152.8,percent of total billed charges,Implant Device,133.7,70,,133.7,percent of total billed charges,All Other,129.88,34,,129.88,percent of total billed charges,Implant Device,129.88,34,,129.88,percent of total billed charges,Implant Device,133.7,35,,133.7,percent of total billed charges,Implant Device,133.7,35,,133.7,percent of total billed charges,Implant Device,133.7,35,,133.7,percent of total billed charges,Implant Device,133.7,35,,133.7,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,282.68,
ARTHREX AR-893-40PT PART THRD SCREW 3X40,C1713,HCPCS,,79003586,CDM,278,RC,,,both,,,316,233.84,,,233.84,Other,150% of Medicare + 9.63% HCRA Surcharge,142.2,45,,142.2,percent of total billed charges,Critical Access Hospital RCC factor,107.44,34,,107.44,percent of total billed charges,Implant Device,107.44,34,,107.44,percent of total billed charges,Implant Device,107.44,34,,107.44,percent of total billed charges,Implant Device,107.44,34,,107.44,percent of total billed charges,Implant Device,107.44,34,,107.44,percent of total billed charges,Implant Device,156.42,,,156.42,Other,110% of Medicare,110.6,35,,110.6,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,110.6,35,,110.6,percent of total billed charges,Implant Device,110.6,35,,110.6,percent of total billed charges,Implant Device,110.6,35,,110.6,percent of total billed charges,Implant Device,110.6,35,,110.6,percent of total billed charges,Implant Device,110.6,35,,110.6,percent of total billed charges,Implant Device,126.4,40,,126.4,percent of total billed charges,Implant Device,110.6,70,,110.6,percent of total billed charges,All Other,107.44,34,,107.44,percent of total billed charges,Implant Device,107.44,34,,107.44,percent of total billed charges,Implant Device,110.6,35,,110.6,percent of total billed charges,Implant Device,110.6,35,,110.6,percent of total billed charges,Implant Device,110.6,35,,110.6,percent of total billed charges,Implant Device,110.6,35,,110.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,233.84,
STABL BIOLOGICS 908 POST TIB ALLOGRAFT,C1713,HCPCS,,79003587,CDM,278,RC,,,both,,,5326,3941.25,,,3941.25,Other,150% of Medicare + 9.63% HCRA Surcharge,2396.7,45,,2396.7,percent of total billed charges,Critical Access Hospital RCC factor,1810.84,34,,1810.84,percent of total billed charges,Implant Device,1810.84,34,,1810.84,percent of total billed charges,Implant Device,1810.84,34,,1810.84,percent of total billed charges,Implant Device,1810.84,34,,1810.84,percent of total billed charges,Implant Device,1810.84,34,,1810.84,percent of total billed charges,Implant Device,2636.37,,,2636.37,Other,110% of Medicare,1864.1,35,,1864.1,percent of total billed charges,Implant Device,1810.84,34,"Charges > $500, x 34%",1810.84,percent of total billed charges,Implant Device,1864.1,35,,1864.1,percent of total billed charges,Implant Device,1864.1,35,,1864.1,percent of total billed charges,Implant Device,1864.1,35,,1864.1,percent of total billed charges,Implant Device,1864.1,35,,1864.1,percent of total billed charges,Implant Device,1864.1,35,,1864.1,percent of total billed charges,Implant Device,2130.4,40,,2130.4,percent of total billed charges,Implant Device,1864.1,70,,1864.1,percent of total billed charges,All Other,1810.84,34,,1810.84,percent of total billed charges,Implant Device,1810.84,34,,1810.84,percent of total billed charges,Implant Device,1864.1,35,,1864.1,percent of total billed charges,Implant Device,1864.1,35,,1864.1,percent of total billed charges,Implant Device,1864.1,35,,1864.1,percent of total billed charges,Implant Device,1864.1,35,,1864.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1810.84,34,"If Charge > 2,000, then 34 percent",1810.84,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3941.25,
EXACTECH 314-02-02 PEGGED GLENOID SMALL,C1776,HCPCS,,79003588,CDM,278,RC,,,both,,,4333,3206.43,,,3206.43,Other,150% of Medicare + 9.63% HCRA Surcharge,1949.85,45,,1949.85,percent of total billed charges,Critical Access Hospital RCC factor,1473.22,34,,1473.22,percent of total billed charges,Implant Device,1473.22,34,,1473.22,percent of total billed charges,Implant Device,1473.22,34,,1473.22,percent of total billed charges,Implant Device,1473.22,34,,1473.22,percent of total billed charges,Implant Device,1473.22,34,,1473.22,percent of total billed charges,Implant Device,2144.84,,,2144.84,Other,110% of Medicare,1516.55,35,,1516.55,percent of total billed charges,Implant Device,1473.22,34,"Charges > $500, x 34%",1473.22,percent of total billed charges,Implant Device,1516.55,35,,1516.55,percent of total billed charges,Implant Device,1516.55,35,,1516.55,percent of total billed charges,Implant Device,1516.55,35,,1516.55,percent of total billed charges,Implant Device,1516.55,35,,1516.55,percent of total billed charges,Implant Device,1516.55,35,,1516.55,percent of total billed charges,Implant Device,1733.2,40,,1733.2,percent of total billed charges,Implant Device,1516.55,70,,1516.55,percent of total billed charges,All Other,1473.22,34,,1473.22,percent of total billed charges,Implant Device,1473.22,34,,1473.22,percent of total billed charges,Implant Device,1516.55,35,,1516.55,percent of total billed charges,Implant Device,1516.55,35,,1516.55,percent of total billed charges,Implant Device,1516.55,35,,1516.55,percent of total billed charges,Implant Device,1516.55,35,,1516.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1473.22,34,"If Charge > 2,000, then 34 percent",1473.22,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3206.43,
EXACTECH 300-10-45 REPLICATOR PLATE 4.5,C1713,HCPCS,,79003589,CDM,278,RC,,,both,,,1890,1398.6,,,1398.6,Other,150% of Medicare + 9.63% HCRA Surcharge,850.5,45,,850.5,percent of total billed charges,Critical Access Hospital RCC factor,642.6,34,,642.6,percent of total billed charges,Implant Device,642.6,34,,642.6,percent of total billed charges,Implant Device,642.6,34,,642.6,percent of total billed charges,Implant Device,642.6,34,,642.6,percent of total billed charges,Implant Device,642.6,34,,642.6,percent of total billed charges,Implant Device,935.55,,,935.55,Other,110% of Medicare,661.5,35,,661.5,percent of total billed charges,Implant Device,642.6,34,"Charges > $500, x 34%",642.6,percent of total billed charges,Implant Device,661.5,35,,661.5,percent of total billed charges,Implant Device,661.5,35,,661.5,percent of total billed charges,Implant Device,661.5,35,,661.5,percent of total billed charges,Implant Device,661.5,35,,661.5,percent of total billed charges,Implant Device,661.5,35,,661.5,percent of total billed charges,Implant Device,756,40,,756,percent of total billed charges,Implant Device,661.5,70,,661.5,percent of total billed charges,All Other,642.6,34,,642.6,percent of total billed charges,Implant Device,642.6,34,,642.6,percent of total billed charges,Implant Device,661.5,35,,661.5,percent of total billed charges,Implant Device,661.5,35,,661.5,percent of total billed charges,Implant Device,661.5,35,,661.5,percent of total billed charges,Implant Device,661.5,35,,661.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1398.6,
EXACTECH 300-20-02 TORQUE SCREW KIT,C1713,HCPCS,,79003590,CDM,278,RC,,,both,,,675,499.5,,,499.5,Other,150% of Medicare + 9.63% HCRA Surcharge,303.75,45,,303.75,percent of total billed charges,Critical Access Hospital RCC factor,229.5,34,,229.5,percent of total billed charges,Implant Device,229.5,34,,229.5,percent of total billed charges,Implant Device,229.5,34,,229.5,percent of total billed charges,Implant Device,229.5,34,,229.5,percent of total billed charges,Implant Device,229.5,34,,229.5,percent of total billed charges,Implant Device,334.13,,,334.13,Other,110% of Medicare,236.25,35,,236.25,percent of total billed charges,Implant Device,229.5,34,"Charges > $500, x 34%",229.5,percent of total billed charges,Implant Device,236.25,35,,236.25,percent of total billed charges,Implant Device,236.25,35,,236.25,percent of total billed charges,Implant Device,236.25,35,,236.25,percent of total billed charges,Implant Device,236.25,35,,236.25,percent of total billed charges,Implant Device,236.25,35,,236.25,percent of total billed charges,Implant Device,270,40,,270,percent of total billed charges,Implant Device,236.25,70,,236.25,percent of total billed charges,All Other,229.5,34,,229.5,percent of total billed charges,Implant Device,229.5,34,,229.5,percent of total billed charges,Implant Device,236.25,35,,236.25,percent of total billed charges,Implant Device,236.25,35,,236.25,percent of total billed charges,Implant Device,236.25,35,,236.25,percent of total billed charges,Implant Device,236.25,35,,236.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,499.5,
EXACTECH 310-01-44 HUMERAL HEAD 44 SHORT,C1776,HCPCS,,79003591,CDM,278,RC,,,both,,,3150,2331.01,,,2331.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1417.5,45,,1417.5,percent of total billed charges,Critical Access Hospital RCC factor,1071,34,,1071,percent of total billed charges,Implant Device,1071,34,,1071,percent of total billed charges,Implant Device,1071,34,,1071,percent of total billed charges,Implant Device,1071,34,,1071,percent of total billed charges,Implant Device,1071,34,,1071,percent of total billed charges,Implant Device,1559.25,,,1559.25,Other,110% of Medicare,1102.5,35,,1102.5,percent of total billed charges,Implant Device,1071,34,"Charges > $500, x 34%",1071,percent of total billed charges,Implant Device,1102.5,35,,1102.5,percent of total billed charges,Implant Device,1102.5,35,,1102.5,percent of total billed charges,Implant Device,1102.5,35,,1102.5,percent of total billed charges,Implant Device,1102.5,35,,1102.5,percent of total billed charges,Implant Device,1102.5,35,,1102.5,percent of total billed charges,Implant Device,1260,40,,1260,percent of total billed charges,Implant Device,1102.5,70,,1102.5,percent of total billed charges,All Other,1071,34,,1071,percent of total billed charges,Implant Device,1071,34,,1071,percent of total billed charges,Implant Device,1102.5,35,,1102.5,percent of total billed charges,Implant Device,1102.5,35,,1102.5,percent of total billed charges,Implant Device,1102.5,35,,1102.5,percent of total billed charges,Implant Device,1102.5,35,,1102.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1071,34,"If Charge > 2,000, then 34 percent",1071,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2331.01,
ACUMED 70-0306 OLECRANON PLATE 7 HOLE LT,C1713,HCPCS,,79003592,CDM,278,RC,,,both,,,3744,2770.57,,,2770.57,Other,150% of Medicare + 9.63% HCRA Surcharge,1684.8,45,,1684.8,percent of total billed charges,Critical Access Hospital RCC factor,1272.96,34,,1272.96,percent of total billed charges,Implant Device,1272.96,34,,1272.96,percent of total billed charges,Implant Device,1272.96,34,,1272.96,percent of total billed charges,Implant Device,1272.96,34,,1272.96,percent of total billed charges,Implant Device,1272.96,34,,1272.96,percent of total billed charges,Implant Device,1853.28,,,1853.28,Other,110% of Medicare,1310.4,35,,1310.4,percent of total billed charges,Implant Device,1272.96,34,"Charges > $500, x 34%",1272.96,percent of total billed charges,Implant Device,1310.4,35,,1310.4,percent of total billed charges,Implant Device,1310.4,35,,1310.4,percent of total billed charges,Implant Device,1310.4,35,,1310.4,percent of total billed charges,Implant Device,1310.4,35,,1310.4,percent of total billed charges,Implant Device,1310.4,35,,1310.4,percent of total billed charges,Implant Device,1497.6,40,,1497.6,percent of total billed charges,Implant Device,1310.4,70,,1310.4,percent of total billed charges,All Other,1272.96,34,,1272.96,percent of total billed charges,Implant Device,1272.96,34,,1272.96,percent of total billed charges,Implant Device,1310.4,35,,1310.4,percent of total billed charges,Implant Device,1310.4,35,,1310.4,percent of total billed charges,Implant Device,1310.4,35,,1310.4,percent of total billed charges,Implant Device,1310.4,35,,1310.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1272.96,34,"If Charge > 2,000, then 34 percent",1272.96,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2770.57,
ACUMED CON2326 NON LOCK SCREW 3.5X14MM,C1713,HCPCS,,79003593,CDM,278,RC,,,both,,,312,230.88,,,230.88,Other,150% of Medicare + 9.63% HCRA Surcharge,140.4,45,,140.4,percent of total billed charges,Critical Access Hospital RCC factor,106.08,34,,106.08,percent of total billed charges,Implant Device,106.08,34,,106.08,percent of total billed charges,Implant Device,106.08,34,,106.08,percent of total billed charges,Implant Device,106.08,34,,106.08,percent of total billed charges,Implant Device,106.08,34,,106.08,percent of total billed charges,Implant Device,154.44,,,154.44,Other,110% of Medicare,109.2,35,,109.2,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,109.2,35,,109.2,percent of total billed charges,Implant Device,109.2,35,,109.2,percent of total billed charges,Implant Device,109.2,35,,109.2,percent of total billed charges,Implant Device,109.2,35,,109.2,percent of total billed charges,Implant Device,109.2,35,,109.2,percent of total billed charges,Implant Device,124.8,40,,124.8,percent of total billed charges,Implant Device,109.2,70,,109.2,percent of total billed charges,All Other,106.08,34,,106.08,percent of total billed charges,Implant Device,106.08,34,,106.08,percent of total billed charges,Implant Device,109.2,35,,109.2,percent of total billed charges,Implant Device,109.2,35,,109.2,percent of total billed charges,Implant Device,109.2,35,,109.2,percent of total billed charges,Implant Device,109.2,35,,109.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,230.88,
ACUMED 30-0258 LOCKING SCREW 2.7X18MM,C1713,HCPCS,,79003594,CDM,278,RC,,,both,,,408,301.92,,,301.92,Other,150% of Medicare + 9.63% HCRA Surcharge,183.6,45,,183.6,percent of total billed charges,Critical Access Hospital RCC factor,138.72,34,,138.72,percent of total billed charges,Implant Device,138.72,34,,138.72,percent of total billed charges,Implant Device,138.72,34,,138.72,percent of total billed charges,Implant Device,138.72,34,,138.72,percent of total billed charges,Implant Device,138.72,34,,138.72,percent of total billed charges,Implant Device,201.96,,,201.96,Other,110% of Medicare,142.8,35,,142.8,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,142.8,35,,142.8,percent of total billed charges,Implant Device,142.8,35,,142.8,percent of total billed charges,Implant Device,142.8,35,,142.8,percent of total billed charges,Implant Device,142.8,35,,142.8,percent of total billed charges,Implant Device,142.8,35,,142.8,percent of total billed charges,Implant Device,163.2,40,,163.2,percent of total billed charges,Implant Device,142.8,70,,142.8,percent of total billed charges,All Other,138.72,34,,138.72,percent of total billed charges,Implant Device,138.72,34,,138.72,percent of total billed charges,Implant Device,142.8,35,,142.8,percent of total billed charges,Implant Device,142.8,35,,142.8,percent of total billed charges,Implant Device,142.8,35,,142.8,percent of total billed charges,Implant Device,142.8,35,,142.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,301.92,
ACUMED 30-0329 LOCKING SCREW 2.7X18MM,C1713,HCPCS,,79003595,CDM,278,RC,,,both,,,510,377.4,,,377.4,Other,150% of Medicare + 9.63% HCRA Surcharge,229.5,45,,229.5,percent of total billed charges,Critical Access Hospital RCC factor,173.4,34,,173.4,percent of total billed charges,Implant Device,173.4,34,,173.4,percent of total billed charges,Implant Device,173.4,34,,173.4,percent of total billed charges,Implant Device,173.4,34,,173.4,percent of total billed charges,Implant Device,173.4,34,,173.4,percent of total billed charges,Implant Device,252.45,,,252.45,Other,110% of Medicare,178.5,35,,178.5,percent of total billed charges,Implant Device,173.4,34,"Charges > $500, x 34%",173.4,percent of total billed charges,Implant Device,178.5,35,,178.5,percent of total billed charges,Implant Device,178.5,35,,178.5,percent of total billed charges,Implant Device,178.5,35,,178.5,percent of total billed charges,Implant Device,178.5,35,,178.5,percent of total billed charges,Implant Device,178.5,35,,178.5,percent of total billed charges,Implant Device,204,40,,204,percent of total billed charges,Implant Device,178.5,70,,178.5,percent of total billed charges,All Other,173.4,34,,173.4,percent of total billed charges,Implant Device,173.4,34,,173.4,percent of total billed charges,Implant Device,178.5,35,,178.5,percent of total billed charges,Implant Device,178.5,35,,178.5,percent of total billed charges,Implant Device,178.5,35,,178.5,percent of total billed charges,Implant Device,178.5,35,,178.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,377.4,
ACUMED 30-0262 NON LOCK SCREW 3.5X22MM,C1713,HCPCS,,79003596,CDM,278,RC,,,both,,,274,202.76,,,202.76,Other,150% of Medicare + 9.63% HCRA Surcharge,123.3,45,,123.3,percent of total billed charges,Critical Access Hospital RCC factor,93.16,34,,93.16,percent of total billed charges,Implant Device,93.16,34,,93.16,percent of total billed charges,Implant Device,93.16,34,,93.16,percent of total billed charges,Implant Device,93.16,34,,93.16,percent of total billed charges,Implant Device,93.16,34,,93.16,percent of total billed charges,Implant Device,135.63,,,135.63,Other,110% of Medicare,95.9,35,,95.9,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,95.9,35,,95.9,percent of total billed charges,Implant Device,95.9,35,,95.9,percent of total billed charges,Implant Device,95.9,35,,95.9,percent of total billed charges,Implant Device,95.9,35,,95.9,percent of total billed charges,Implant Device,95.9,35,,95.9,percent of total billed charges,Implant Device,109.6,40,,109.6,percent of total billed charges,Implant Device,95.9,70,,95.9,percent of total billed charges,All Other,93.16,34,,93.16,percent of total billed charges,Implant Device,93.16,34,,93.16,percent of total billed charges,Implant Device,95.9,35,,95.9,percent of total billed charges,Implant Device,95.9,35,,95.9,percent of total billed charges,Implant Device,95.9,35,,95.9,percent of total billed charges,Implant Device,95.9,35,,95.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,202.76,
ACUMED 30-0257 NON LOCK SCREW 3.5X12MM,C1713,HCPCS,,79003597,CDM,278,RC,,,both,,,270,199.8,,,199.8,Other,150% of Medicare + 9.63% HCRA Surcharge,121.5,45,,121.5,percent of total billed charges,Critical Access Hospital RCC factor,91.8,34,,91.8,percent of total billed charges,Implant Device,91.8,34,,91.8,percent of total billed charges,Implant Device,91.8,34,,91.8,percent of total billed charges,Implant Device,91.8,34,,91.8,percent of total billed charges,Implant Device,91.8,34,,91.8,percent of total billed charges,Implant Device,133.65,,,133.65,Other,110% of Medicare,94.5,35,,94.5,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,94.5,35,,94.5,percent of total billed charges,Implant Device,94.5,35,,94.5,percent of total billed charges,Implant Device,94.5,35,,94.5,percent of total billed charges,Implant Device,94.5,35,,94.5,percent of total billed charges,Implant Device,94.5,35,,94.5,percent of total billed charges,Implant Device,108,40,,108,percent of total billed charges,Implant Device,94.5,70,,94.5,percent of total billed charges,All Other,91.8,34,,91.8,percent of total billed charges,Implant Device,91.8,34,,91.8,percent of total billed charges,Implant Device,94.5,35,,94.5,percent of total billed charges,Implant Device,94.5,35,,94.5,percent of total billed charges,Implant Device,94.5,35,,94.5,percent of total billed charges,Implant Device,94.5,35,,94.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,199.8,
ACUMED 30-0243 LOCKING SCREW 3.5 X 30MM,C1713,HCPCS,,79003598,CDM,278,RC,,,both,,,424,313.76,,,313.76,Other,150% of Medicare + 9.63% HCRA Surcharge,190.8,45,,190.8,percent of total billed charges,Critical Access Hospital RCC factor,144.16,34,,144.16,percent of total billed charges,Implant Device,144.16,34,,144.16,percent of total billed charges,Implant Device,144.16,34,,144.16,percent of total billed charges,Implant Device,144.16,34,,144.16,percent of total billed charges,Implant Device,144.16,34,,144.16,percent of total billed charges,Implant Device,209.88,,,209.88,Other,110% of Medicare,148.4,35,,148.4,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,148.4,35,,148.4,percent of total billed charges,Implant Device,148.4,35,,148.4,percent of total billed charges,Implant Device,148.4,35,,148.4,percent of total billed charges,Implant Device,148.4,35,,148.4,percent of total billed charges,Implant Device,148.4,35,,148.4,percent of total billed charges,Implant Device,169.6,40,,169.6,percent of total billed charges,Implant Device,148.4,70,,148.4,percent of total billed charges,All Other,144.16,34,,144.16,percent of total billed charges,Implant Device,144.16,34,,144.16,percent of total billed charges,Implant Device,148.4,35,,148.4,percent of total billed charges,Implant Device,148.4,35,,148.4,percent of total billed charges,Implant Device,148.4,35,,148.4,percent of total billed charges,Implant Device,148.4,35,,148.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,313.76,
ACUMED AT2-C18-S MICRO SCREW 18MM,C1713,HCPCS,,79003601,CDM,278,RC,,,both,,,1570,1161.8,,,1161.8,Other,150% of Medicare + 9.63% HCRA Surcharge,706.5,45,,706.5,percent of total billed charges,Critical Access Hospital RCC factor,533.8,34,,533.8,percent of total billed charges,Implant Device,533.8,34,,533.8,percent of total billed charges,Implant Device,533.8,34,,533.8,percent of total billed charges,Implant Device,533.8,34,,533.8,percent of total billed charges,Implant Device,533.8,34,,533.8,percent of total billed charges,Implant Device,777.15,,,777.15,Other,110% of Medicare,549.5,35,,549.5,percent of total billed charges,Implant Device,533.8,34,"Charges > $500, x 34%",533.8,percent of total billed charges,Implant Device,549.5,35,,549.5,percent of total billed charges,Implant Device,549.5,35,,549.5,percent of total billed charges,Implant Device,549.5,35,,549.5,percent of total billed charges,Implant Device,549.5,35,,549.5,percent of total billed charges,Implant Device,549.5,35,,549.5,percent of total billed charges,Implant Device,628,40,,628,percent of total billed charges,Implant Device,549.5,70,,549.5,percent of total billed charges,All Other,533.8,34,,533.8,percent of total billed charges,Implant Device,533.8,34,,533.8,percent of total billed charges,Implant Device,549.5,35,,549.5,percent of total billed charges,Implant Device,549.5,35,,549.5,percent of total billed charges,Implant Device,549.5,35,,549.5,percent of total billed charges,Implant Device,549.5,35,,549.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1161.8,
ACUMED AT2-C16-S MICRO SCREW 16MM,C1713,HCPCS,,79003602,CDM,278,RC,,,both,,,1584,1172.16,,,1172.16,Other,150% of Medicare + 9.63% HCRA Surcharge,712.8,45,,712.8,percent of total billed charges,Critical Access Hospital RCC factor,538.56,34,,538.56,percent of total billed charges,Implant Device,538.56,34,,538.56,percent of total billed charges,Implant Device,538.56,34,,538.56,percent of total billed charges,Implant Device,538.56,34,,538.56,percent of total billed charges,Implant Device,538.56,34,,538.56,percent of total billed charges,Implant Device,784.08,,,784.08,Other,110% of Medicare,554.4,35,,554.4,percent of total billed charges,Implant Device,538.56,34,"Charges > $500, x 34%",538.56,percent of total billed charges,Implant Device,554.4,35,,554.4,percent of total billed charges,Implant Device,554.4,35,,554.4,percent of total billed charges,Implant Device,554.4,35,,554.4,percent of total billed charges,Implant Device,554.4,35,,554.4,percent of total billed charges,Implant Device,554.4,35,,554.4,percent of total billed charges,Implant Device,633.6,40,,633.6,percent of total billed charges,Implant Device,554.4,70,,554.4,percent of total billed charges,All Other,538.56,34,,538.56,percent of total billed charges,Implant Device,538.56,34,,538.56,percent of total billed charges,Implant Device,554.4,35,,554.4,percent of total billed charges,Implant Device,554.4,35,,554.4,percent of total billed charges,Implant Device,554.4,35,,554.4,percent of total billed charges,Implant Device,554.4,35,,554.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1172.16,
STRYKER 5038-5-060 APEX PIN 3X60MM,C1713,HCPCS,,79003610,CDM,278,RC,,,both,,,148,109.52,,,109.52,Other,150% of Medicare + 9.63% HCRA Surcharge,66.6,45,,66.6,percent of total billed charges,Critical Access Hospital RCC factor,50.32,34,,50.32,percent of total billed charges,Implant Device,50.32,34,,50.32,percent of total billed charges,Implant Device,50.32,34,,50.32,percent of total billed charges,Implant Device,50.32,34,,50.32,percent of total billed charges,Implant Device,50.32,34,,50.32,percent of total billed charges,Implant Device,73.26,,,73.26,Other,110% of Medicare,51.8,35,,51.8,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,51.8,35,,51.8,percent of total billed charges,Implant Device,51.8,35,,51.8,percent of total billed charges,Implant Device,51.8,35,,51.8,percent of total billed charges,Implant Device,51.8,35,,51.8,percent of total billed charges,Implant Device,51.8,35,,51.8,percent of total billed charges,Implant Device,59.2,40,,59.2,percent of total billed charges,Implant Device,51.8,70,,51.8,percent of total billed charges,All Other,50.32,34,,50.32,percent of total billed charges,Implant Device,50.32,34,,50.32,percent of total billed charges,Implant Device,51.8,35,,51.8,percent of total billed charges,Implant Device,51.8,35,,51.8,percent of total billed charges,Implant Device,51.8,35,,51.8,percent of total billed charges,Implant Device,51.8,35,,51.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,109.52,
STRYKER 5038-5-080 APEX PIN 3X80MM,C1713,HCPCS,,79003611,CDM,278,RC,,,both,,,148,109.52,,,109.52,Other,150% of Medicare + 9.63% HCRA Surcharge,66.6,45,,66.6,percent of total billed charges,Critical Access Hospital RCC factor,50.32,34,,50.32,percent of total billed charges,Implant Device,50.32,34,,50.32,percent of total billed charges,Implant Device,50.32,34,,50.32,percent of total billed charges,Implant Device,50.32,34,,50.32,percent of total billed charges,Implant Device,50.32,34,,50.32,percent of total billed charges,Implant Device,73.26,,,73.26,Other,110% of Medicare,51.8,35,,51.8,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,51.8,35,,51.8,percent of total billed charges,Implant Device,51.8,35,,51.8,percent of total billed charges,Implant Device,51.8,35,,51.8,percent of total billed charges,Implant Device,51.8,35,,51.8,percent of total billed charges,Implant Device,51.8,35,,51.8,percent of total billed charges,Implant Device,59.2,40,,59.2,percent of total billed charges,Implant Device,51.8,70,,51.8,percent of total billed charges,All Other,50.32,34,,50.32,percent of total billed charges,Implant Device,50.32,34,,50.32,percent of total billed charges,Implant Device,51.8,35,,51.8,percent of total billed charges,Implant Device,51.8,35,,51.8,percent of total billed charges,Implant Device,51.8,35,,51.8,percent of total billed charges,Implant Device,51.8,35,,51.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,109.52,
ARTRHEX AR-8740-34PTS CANN SCREW 4X34MM,C1713,HCPCS,,79003612,CDM,278,RC,,,both,,,708,523.92,,,523.92,Other,150% of Medicare + 9.63% HCRA Surcharge,318.6,45,,318.6,percent of total billed charges,Critical Access Hospital RCC factor,240.72,34,,240.72,percent of total billed charges,Implant Device,240.72,34,,240.72,percent of total billed charges,Implant Device,240.72,34,,240.72,percent of total billed charges,Implant Device,240.72,34,,240.72,percent of total billed charges,Implant Device,240.72,34,,240.72,percent of total billed charges,Implant Device,350.46,,,350.46,Other,110% of Medicare,247.8,35,,247.8,percent of total billed charges,Implant Device,240.72,34,"Charges > $500, x 34%",240.72,percent of total billed charges,Implant Device,247.8,35,,247.8,percent of total billed charges,Implant Device,247.8,35,,247.8,percent of total billed charges,Implant Device,247.8,35,,247.8,percent of total billed charges,Implant Device,247.8,35,,247.8,percent of total billed charges,Implant Device,247.8,35,,247.8,percent of total billed charges,Implant Device,283.2,40,,283.2,percent of total billed charges,Implant Device,247.8,70,,247.8,percent of total billed charges,All Other,240.72,34,,240.72,percent of total billed charges,Implant Device,240.72,34,,240.72,percent of total billed charges,Implant Device,247.8,35,,247.8,percent of total billed charges,Implant Device,247.8,35,,247.8,percent of total billed charges,Implant Device,247.8,35,,247.8,percent of total billed charges,Implant Device,247.8,35,,247.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,523.92,
ARTHREX AR-8740-44PTS CANN SCREW 4X44MM,C1713,HCPCS,,79003613,CDM,278,RC,,,both,,,536,396.64,,,396.64,Other,150% of Medicare + 9.63% HCRA Surcharge,241.2,45,,241.2,percent of total billed charges,Critical Access Hospital RCC factor,182.24,34,,182.24,percent of total billed charges,Implant Device,182.24,34,,182.24,percent of total billed charges,Implant Device,182.24,34,,182.24,percent of total billed charges,Implant Device,182.24,34,,182.24,percent of total billed charges,Implant Device,182.24,34,,182.24,percent of total billed charges,Implant Device,265.32,,,265.32,Other,110% of Medicare,187.6,35,,187.6,percent of total billed charges,Implant Device,182.24,34,"Charges > $500, x 34%",182.24,percent of total billed charges,Implant Device,187.6,35,,187.6,percent of total billed charges,Implant Device,187.6,35,,187.6,percent of total billed charges,Implant Device,187.6,35,,187.6,percent of total billed charges,Implant Device,187.6,35,,187.6,percent of total billed charges,Implant Device,187.6,35,,187.6,percent of total billed charges,Implant Device,214.4,40,,214.4,percent of total billed charges,Implant Device,187.6,70,,187.6,percent of total billed charges,All Other,182.24,34,,182.24,percent of total billed charges,Implant Device,182.24,34,,182.24,percent of total billed charges,Implant Device,187.6,35,,187.6,percent of total billed charges,Implant Device,187.6,35,,187.6,percent of total billed charges,Implant Device,187.6,35,,187.6,percent of total billed charges,Implant Device,187.6,35,,187.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,396.64,
ARTRHEX AR-8730-14PT CANN SCREW 3X14MM,C1713,HCPCS,,79003614,CDM,278,RC,,,both,,,488,361.12,,,361.12,Other,150% of Medicare + 9.63% HCRA Surcharge,219.6,45,,219.6,percent of total billed charges,Critical Access Hospital RCC factor,165.92,34,,165.92,percent of total billed charges,Implant Device,165.92,34,,165.92,percent of total billed charges,Implant Device,165.92,34,,165.92,percent of total billed charges,Implant Device,165.92,34,,165.92,percent of total billed charges,Implant Device,165.92,34,,165.92,percent of total billed charges,Implant Device,241.56,,,241.56,Other,110% of Medicare,170.8,35,,170.8,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,170.8,35,,170.8,percent of total billed charges,Implant Device,170.8,35,,170.8,percent of total billed charges,Implant Device,170.8,35,,170.8,percent of total billed charges,Implant Device,170.8,35,,170.8,percent of total billed charges,Implant Device,170.8,35,,170.8,percent of total billed charges,Implant Device,195.2,40,,195.2,percent of total billed charges,Implant Device,170.8,70,,170.8,percent of total billed charges,All Other,165.92,34,,165.92,percent of total billed charges,Implant Device,165.92,34,,165.92,percent of total billed charges,Implant Device,170.8,35,,170.8,percent of total billed charges,Implant Device,170.8,35,,170.8,percent of total billed charges,Implant Device,170.8,35,,170.8,percent of total billed charges,Implant Device,170.8,35,,170.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,361.12,
ZIMMER 5952-21-14 CR HIGHLY CROSSLINKED,C1776,HCPCS,,79003616,CDM,278,RC,,,both,,,3496,2587.05,,,2587.05,Other,150% of Medicare + 9.63% HCRA Surcharge,1573.2,45,,1573.2,percent of total billed charges,Critical Access Hospital RCC factor,1188.64,34,,1188.64,percent of total billed charges,Implant Device,1188.64,34,,1188.64,percent of total billed charges,Implant Device,1188.64,34,,1188.64,percent of total billed charges,Implant Device,1188.64,34,,1188.64,percent of total billed charges,Implant Device,1188.64,34,,1188.64,percent of total billed charges,Implant Device,1730.52,,,1730.52,Other,110% of Medicare,1223.6,35,,1223.6,percent of total billed charges,Implant Device,1188.64,34,"Charges > $500, x 34%",1188.64,percent of total billed charges,Implant Device,1223.6,35,,1223.6,percent of total billed charges,Implant Device,1223.6,35,,1223.6,percent of total billed charges,Implant Device,1223.6,35,,1223.6,percent of total billed charges,Implant Device,1223.6,35,,1223.6,percent of total billed charges,Implant Device,1223.6,35,,1223.6,percent of total billed charges,Implant Device,1398.4,40,,1398.4,percent of total billed charges,Implant Device,1223.6,70,,1223.6,percent of total billed charges,All Other,1188.64,34,,1188.64,percent of total billed charges,Implant Device,1188.64,34,,1188.64,percent of total billed charges,Implant Device,1223.6,35,,1223.6,percent of total billed charges,Implant Device,1223.6,35,,1223.6,percent of total billed charges,Implant Device,1223.6,35,,1223.6,percent of total billed charges,Implant Device,1223.6,35,,1223.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1188.64,34,"If Charge > 2,000, then 34 percent",1188.64,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2587.05,
ARTHREX AR-8933-40PT PT SCREW 3.0X40MM,C1713,HCPCS,,79003617,CDM,278,RC,,,both,,,316,233.84,,,233.84,Other,150% of Medicare + 9.63% HCRA Surcharge,142.2,45,,142.2,percent of total billed charges,Critical Access Hospital RCC factor,107.44,34,,107.44,percent of total billed charges,Implant Device,107.44,34,,107.44,percent of total billed charges,Implant Device,107.44,34,,107.44,percent of total billed charges,Implant Device,107.44,34,,107.44,percent of total billed charges,Implant Device,107.44,34,,107.44,percent of total billed charges,Implant Device,156.42,,,156.42,Other,110% of Medicare,110.6,35,,110.6,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,110.6,35,,110.6,percent of total billed charges,Implant Device,110.6,35,,110.6,percent of total billed charges,Implant Device,110.6,35,,110.6,percent of total billed charges,Implant Device,110.6,35,,110.6,percent of total billed charges,Implant Device,110.6,35,,110.6,percent of total billed charges,Implant Device,126.4,40,,126.4,percent of total billed charges,Implant Device,110.6,70,,110.6,percent of total billed charges,All Other,107.44,34,,107.44,percent of total billed charges,Implant Device,107.44,34,,107.44,percent of total billed charges,Implant Device,110.6,35,,110.6,percent of total billed charges,Implant Device,110.6,35,,110.6,percent of total billed charges,Implant Device,110.6,35,,110.6,percent of total billed charges,Implant Device,110.6,35,,110.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,233.84,
BIOMET 14-520508 SOLI-C SPACER 8X14X12,C1713,HCPCS,,79003618,CDM,278,RC,,,both,,,15120,11188.84,,,11188.84,Other,150% of Medicare + 9.63% HCRA Surcharge,6804,45,,6804,percent of total billed charges,Critical Access Hospital RCC factor,5140.8,34,,5140.8,percent of total billed charges,Implant Device,5140.8,34,,5140.8,percent of total billed charges,Implant Device,5140.8,34,,5140.8,percent of total billed charges,Implant Device,5140.8,34,,5140.8,percent of total billed charges,Implant Device,5140.8,34,,5140.8,percent of total billed charges,Implant Device,7484.4,,,7484.4,Other,110% of Medicare,5292,35,,5292,percent of total billed charges,Implant Device,5140.8,34,"Charges > $500, x 34%",5140.8,percent of total billed charges,Implant Device,5292,35,,5292,percent of total billed charges,Implant Device,5292,35,,5292,percent of total billed charges,Implant Device,5292,35,,5292,percent of total billed charges,Implant Device,5292,35,,5292,percent of total billed charges,Implant Device,5292,35,,5292,percent of total billed charges,Implant Device,6048,40,,6048,percent of total billed charges,Implant Device,5292,70,,5292,percent of total billed charges,All Other,5140.8,34,,5140.8,percent of total billed charges,Implant Device,5140.8,34,,5140.8,percent of total billed charges,Implant Device,5292,35,,5292,percent of total billed charges,Implant Device,5292,35,,5292,percent of total billed charges,Implant Device,5292,35,,5292,percent of total billed charges,Implant Device,5292,35,,5292,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,5140.8,34,"If Charge > 2,000, then 34 percent",5140.8,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,11188.84,
STRYKER 3060-0080S LAG SCREW 10.5X80MM,C1713,HCPCS,,79003623,CDM,278,RC,,,both,,,2012,1488.89,,,1488.89,Other,150% of Medicare + 9.63% HCRA Surcharge,905.4,45,,905.4,percent of total billed charges,Critical Access Hospital RCC factor,684.08,34,,684.08,percent of total billed charges,Implant Device,684.08,34,,684.08,percent of total billed charges,Implant Device,684.08,34,,684.08,percent of total billed charges,Implant Device,684.08,34,,684.08,percent of total billed charges,Implant Device,684.08,34,,684.08,percent of total billed charges,Implant Device,995.94,,,995.94,Other,110% of Medicare,704.2,35,,704.2,percent of total billed charges,Implant Device,684.08,34,"Charges > $500, x 34%",684.08,percent of total billed charges,Implant Device,704.2,35,,704.2,percent of total billed charges,Implant Device,704.2,35,,704.2,percent of total billed charges,Implant Device,704.2,35,,704.2,percent of total billed charges,Implant Device,704.2,35,,704.2,percent of total billed charges,Implant Device,704.2,35,,704.2,percent of total billed charges,Implant Device,804.8,40,,804.8,percent of total billed charges,Implant Device,704.2,70,,704.2,percent of total billed charges,All Other,684.08,34,,684.08,percent of total billed charges,Implant Device,684.08,34,,684.08,percent of total billed charges,Implant Device,704.2,35,,704.2,percent of total billed charges,Implant Device,704.2,35,,704.2,percent of total billed charges,Implant Device,704.2,35,,704.2,percent of total billed charges,Implant Device,704.2,35,,704.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,684.08,34,"If Charge > 2,000, then 34 percent",684.08,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1488.89,
MEDTRONIC LNQ22 ICM LINQ II,C1764,HCPCS,,79003624,CDM,278,RC,,,both,,,14535,10755.94,,,10755.94,Other,150% of Medicare + 9.63% HCRA Surcharge,6540.75,45,,6540.75,percent of total billed charges,Critical Access Hospital RCC factor,4941.9,34,,4941.9,percent of total billed charges,Implant Device,4941.9,34,,4941.9,percent of total billed charges,Implant Device,4941.9,34,,4941.9,percent of total billed charges,Implant Device,4941.9,34,,4941.9,percent of total billed charges,Implant Device,4941.9,34,,4941.9,percent of total billed charges,Implant Device,7194.83,,,7194.83,Other,110% of Medicare,5087.25,35,,5087.25,percent of total billed charges,Implant Device,4941.9,34,"Charges > $500, x 34%",4941.9,percent of total billed charges,Implant Device,5087.25,35,,5087.25,percent of total billed charges,Implant Device,5087.25,35,,5087.25,percent of total billed charges,Implant Device,5087.25,35,,5087.25,percent of total billed charges,Implant Device,5087.25,35,,5087.25,percent of total billed charges,Implant Device,5087.25,35,,5087.25,percent of total billed charges,Implant Device,5814,40,,5814,percent of total billed charges,Implant Device,5087.25,70,,5087.25,percent of total billed charges,All Other,4941.9,34,,4941.9,percent of total billed charges,Implant Device,4941.9,34,,4941.9,percent of total billed charges,Implant Device,5087.25,35,,5087.25,percent of total billed charges,Implant Device,5087.25,35,,5087.25,percent of total billed charges,Implant Device,5087.25,35,,5087.25,percent of total billed charges,Implant Device,5087.25,35,,5087.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,4941.9,34,"If Charge > 2,000, then 34 percent",4941.9,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,10755.94,
MEDTRONIC 6935M SERIES QUATRO SEC S LEAD,C1777,HCPCS,,79003625,CDM,278,RC,,,both,,,16564,12257.4,,,12257.4,Other,150% of Medicare + 9.63% HCRA Surcharge,7453.8,45,,7453.8,percent of total billed charges,Critical Access Hospital RCC factor,5631.76,34,,5631.76,percent of total billed charges,Implant Device,5631.76,34,,5631.76,percent of total billed charges,Implant Device,5631.76,34,,5631.76,percent of total billed charges,Implant Device,5631.76,34,,5631.76,percent of total billed charges,Implant Device,5631.76,34,,5631.76,percent of total billed charges,Implant Device,8199.18,,,8199.18,Other,110% of Medicare,5797.4,35,,5797.4,percent of total billed charges,Implant Device,5631.76,34,"Charges > $500, x 34%",5631.76,percent of total billed charges,Implant Device,5797.4,35,,5797.4,percent of total billed charges,Implant Device,5797.4,35,,5797.4,percent of total billed charges,Implant Device,5797.4,35,,5797.4,percent of total billed charges,Implant Device,5797.4,35,,5797.4,percent of total billed charges,Implant Device,5797.4,35,,5797.4,percent of total billed charges,Implant Device,6625.6,40,,6625.6,percent of total billed charges,Implant Device,5797.4,70,,5797.4,percent of total billed charges,All Other,5631.76,34,,5631.76,percent of total billed charges,Implant Device,5631.76,34,,5631.76,percent of total billed charges,Implant Device,5797.4,35,,5797.4,percent of total billed charges,Implant Device,5797.4,35,,5797.4,percent of total billed charges,Implant Device,5797.4,35,,5797.4,percent of total billed charges,Implant Device,5797.4,35,,5797.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,5631.76,34,"If Charge > 2,000, then 34 percent",5631.76,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,12257.4,
MEDTRONIC D314TRM PROTECTA XT CRT-D,C1882,HCPCS,,79003628,CDM,278,RC,,,both,,,78718,58251.52,,,58251.52,Other,150% of Medicare + 9.63% HCRA Surcharge,35423.1,45,,35423.1,percent of total billed charges,Critical Access Hospital RCC factor,26764.12,34,,26764.12,percent of total billed charges,Implant Device,26764.12,34,,26764.12,percent of total billed charges,Implant Device,26764.12,34,,26764.12,percent of total billed charges,Implant Device,26764.12,34,,26764.12,percent of total billed charges,Implant Device,26764.12,34,,26764.12,percent of total billed charges,Implant Device,38965.41,,,38965.41,Other,110% of Medicare,27551.3,35,,27551.3,percent of total billed charges,Implant Device,26764.12,34,"Charges > $500, x 34%",26764.12,percent of total billed charges,Implant Device,27551.3,35,,27551.3,percent of total billed charges,Implant Device,27551.3,35,,27551.3,percent of total billed charges,Implant Device,27551.3,35,,27551.3,percent of total billed charges,Implant Device,27551.3,35,,27551.3,percent of total billed charges,Implant Device,27551.3,35,,27551.3,percent of total billed charges,Implant Device,31487.2,40,,31487.2,percent of total billed charges,Implant Device,27551.3,70,,27551.3,percent of total billed charges,All Other,26764.12,34,,26764.12,percent of total billed charges,Implant Device,26764.12,34,,26764.12,percent of total billed charges,Implant Device,27551.3,35,,27551.3,percent of total billed charges,Implant Device,27551.3,35,,27551.3,percent of total billed charges,Implant Device,27551.3,35,,27551.3,percent of total billed charges,Implant Device,27551.3,35,,27551.3,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,26764.12,34,"If Charge > 2,000, then 34 percent",26764.12,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,58251.52,
STRYKER 628006 CLAVICLE PLATE 6 HOLE,C1713,HCPCS,,79003631,CDM,278,RC,,,both,,,4050,2997.01,,,2997.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1822.5,45,,1822.5,percent of total billed charges,Critical Access Hospital RCC factor,1377,34,,1377,percent of total billed charges,Implant Device,1377,34,,1377,percent of total billed charges,Implant Device,1377,34,,1377,percent of total billed charges,Implant Device,1377,34,,1377,percent of total billed charges,Implant Device,1377,34,,1377,percent of total billed charges,Implant Device,2004.75,,,2004.75,Other,110% of Medicare,1417.5,35,,1417.5,percent of total billed charges,Implant Device,1377,34,"Charges > $500, x 34%",1377,percent of total billed charges,Implant Device,1417.5,35,,1417.5,percent of total billed charges,Implant Device,1417.5,35,,1417.5,percent of total billed charges,Implant Device,1417.5,35,,1417.5,percent of total billed charges,Implant Device,1417.5,35,,1417.5,percent of total billed charges,Implant Device,1417.5,35,,1417.5,percent of total billed charges,Implant Device,1620,40,,1620,percent of total billed charges,Implant Device,1417.5,70,,1417.5,percent of total billed charges,All Other,1377,34,,1377,percent of total billed charges,Implant Device,1377,34,,1377,percent of total billed charges,Implant Device,1417.5,35,,1417.5,percent of total billed charges,Implant Device,1417.5,35,,1417.5,percent of total billed charges,Implant Device,1417.5,35,,1417.5,percent of total billed charges,Implant Device,1417.5,35,,1417.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1377,34,"If Charge > 2,000, then 34 percent",1377,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2997.01,
STRYKER 614614 LOCKING SCREW 3.5X14MM,C1713,HCPCS,,79003632,CDM,278,RC,,,both,,,727,537.98,,,537.98,Other,150% of Medicare + 9.63% HCRA Surcharge,327.15,45,,327.15,percent of total billed charges,Critical Access Hospital RCC factor,247.18,34,,247.18,percent of total billed charges,Implant Device,247.18,34,,247.18,percent of total billed charges,Implant Device,247.18,34,,247.18,percent of total billed charges,Implant Device,247.18,34,,247.18,percent of total billed charges,Implant Device,247.18,34,,247.18,percent of total billed charges,Implant Device,359.87,,,359.87,Other,110% of Medicare,254.45,35,,254.45,percent of total billed charges,Implant Device,247.18,34,"Charges > $500, x 34%",247.18,percent of total billed charges,Implant Device,254.45,35,,254.45,percent of total billed charges,Implant Device,254.45,35,,254.45,percent of total billed charges,Implant Device,254.45,35,,254.45,percent of total billed charges,Implant Device,254.45,35,,254.45,percent of total billed charges,Implant Device,254.45,35,,254.45,percent of total billed charges,Implant Device,290.8,40,,290.8,percent of total billed charges,Implant Device,254.45,70,,254.45,percent of total billed charges,All Other,247.18,34,,247.18,percent of total billed charges,Implant Device,247.18,34,,247.18,percent of total billed charges,Implant Device,254.45,35,,254.45,percent of total billed charges,Implant Device,254.45,35,,254.45,percent of total billed charges,Implant Device,254.45,35,,254.45,percent of total billed charges,Implant Device,254.45,35,,254.45,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,537.98,
STRYKER 614814 NON LOCKING SCREW 3.5X14,C1713,HCPCS,,79003633,CDM,278,RC,,,both,,,374,276.76,,,276.76,Other,150% of Medicare + 9.63% HCRA Surcharge,168.3,45,,168.3,percent of total billed charges,Critical Access Hospital RCC factor,127.16,34,,127.16,percent of total billed charges,Implant Device,127.16,34,,127.16,percent of total billed charges,Implant Device,127.16,34,,127.16,percent of total billed charges,Implant Device,127.16,34,,127.16,percent of total billed charges,Implant Device,127.16,34,,127.16,percent of total billed charges,Implant Device,185.13,,,185.13,Other,110% of Medicare,130.9,35,,130.9,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,130.9,35,,130.9,percent of total billed charges,Implant Device,130.9,35,,130.9,percent of total billed charges,Implant Device,130.9,35,,130.9,percent of total billed charges,Implant Device,130.9,35,,130.9,percent of total billed charges,Implant Device,130.9,35,,130.9,percent of total billed charges,Implant Device,149.6,40,,149.6,percent of total billed charges,Implant Device,130.9,70,,130.9,percent of total billed charges,All Other,127.16,34,,127.16,percent of total billed charges,Implant Device,127.16,34,,127.16,percent of total billed charges,Implant Device,130.9,35,,130.9,percent of total billed charges,Implant Device,130.9,35,,130.9,percent of total billed charges,Implant Device,130.9,35,,130.9,percent of total billed charges,Implant Device,130.9,35,,130.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,276.76,
STRYKER 40-30110 3.0X10MM ASNIS SCREW,C1713,HCPCS,,79003634,CDM,278,RC,,,both,,,707,523.18,,,523.18,Other,150% of Medicare + 9.63% HCRA Surcharge,318.15,45,,318.15,percent of total billed charges,Critical Access Hospital RCC factor,240.38,34,,240.38,percent of total billed charges,Implant Device,240.38,34,,240.38,percent of total billed charges,Implant Device,240.38,34,,240.38,percent of total billed charges,Implant Device,240.38,34,,240.38,percent of total billed charges,Implant Device,240.38,34,,240.38,percent of total billed charges,Implant Device,349.97,,,349.97,Other,110% of Medicare,247.45,35,,247.45,percent of total billed charges,Implant Device,240.38,34,"Charges > $500, x 34%",240.38,percent of total billed charges,Implant Device,247.45,35,,247.45,percent of total billed charges,Implant Device,247.45,35,,247.45,percent of total billed charges,Implant Device,247.45,35,,247.45,percent of total billed charges,Implant Device,247.45,35,,247.45,percent of total billed charges,Implant Device,247.45,35,,247.45,percent of total billed charges,Implant Device,282.8,40,,282.8,percent of total billed charges,Implant Device,247.45,70,,247.45,percent of total billed charges,All Other,240.38,34,,240.38,percent of total billed charges,Implant Device,240.38,34,,240.38,percent of total billed charges,Implant Device,247.45,35,,247.45,percent of total billed charges,Implant Device,247.45,35,,247.45,percent of total billed charges,Implant Device,247.45,35,,247.45,percent of total billed charges,Implant Device,247.45,35,,247.45,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,523.18,
WRIGHT MEDICAL 4260030 FLEX HINGE SIZE 3,C1776,HCPCS,,79003638,CDM,278,RC,,,both,,,3634,2689.17,,,2689.17,Other,150% of Medicare + 9.63% HCRA Surcharge,1635.3,45,,1635.3,percent of total billed charges,Critical Access Hospital RCC factor,1235.56,34,,1235.56,percent of total billed charges,Implant Device,1235.56,34,,1235.56,percent of total billed charges,Implant Device,1235.56,34,,1235.56,percent of total billed charges,Implant Device,1235.56,34,,1235.56,percent of total billed charges,Implant Device,1235.56,34,,1235.56,percent of total billed charges,Implant Device,1798.83,,,1798.83,Other,110% of Medicare,1271.9,35,,1271.9,percent of total billed charges,Implant Device,1235.56,34,"Charges > $500, x 34%",1235.56,percent of total billed charges,Implant Device,1271.9,35,,1271.9,percent of total billed charges,Implant Device,1271.9,35,,1271.9,percent of total billed charges,Implant Device,1271.9,35,,1271.9,percent of total billed charges,Implant Device,1271.9,35,,1271.9,percent of total billed charges,Implant Device,1271.9,35,,1271.9,percent of total billed charges,Implant Device,1453.6,40,,1453.6,percent of total billed charges,Implant Device,1271.9,70,,1271.9,percent of total billed charges,All Other,1235.56,34,,1235.56,percent of total billed charges,Implant Device,1235.56,34,,1235.56,percent of total billed charges,Implant Device,1271.9,35,,1271.9,percent of total billed charges,Implant Device,1271.9,35,,1271.9,percent of total billed charges,Implant Device,1271.9,35,,1271.9,percent of total billed charges,Implant Device,1271.9,35,,1271.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1235.56,34,"If Charge > 2,000, then 34 percent",1235.56,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2689.17,
SYNTHES 208.870 CANNULATED SCREW 7.3X10,C1713,HCPCS,,79003639,CDM,278,RC,,,both,,,1080,799.2,,,799.2,Other,150% of Medicare + 9.63% HCRA Surcharge,486,45,,486,percent of total billed charges,Critical Access Hospital RCC factor,367.2,34,,367.2,percent of total billed charges,Implant Device,367.2,34,,367.2,percent of total billed charges,Implant Device,367.2,34,,367.2,percent of total billed charges,Implant Device,367.2,34,,367.2,percent of total billed charges,Implant Device,367.2,34,,367.2,percent of total billed charges,Implant Device,534.6,,,534.6,Other,110% of Medicare,378,35,,378,percent of total billed charges,Implant Device,367.2,34,"Charges > $500, x 34%",367.2,percent of total billed charges,Implant Device,378,35,,378,percent of total billed charges,Implant Device,378,35,,378,percent of total billed charges,Implant Device,378,35,,378,percent of total billed charges,Implant Device,378,35,,378,percent of total billed charges,Implant Device,378,35,,378,percent of total billed charges,Implant Device,432,40,,432,percent of total billed charges,Implant Device,378,70,,378,percent of total billed charges,All Other,367.2,34,,367.2,percent of total billed charges,Implant Device,367.2,34,,367.2,percent of total billed charges,Implant Device,378,35,,378,percent of total billed charges,Implant Device,378,35,,378,percent of total billed charges,Implant Device,378,35,,378,percent of total billed charges,Implant Device,378,35,,378,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,799.2,
ZIMMER 5001-044-28 BIPOLAR LINER 44-46MM,C1776,HCPCS,,79003640,CDM,278,RC,,,both,,,789,583.86,,,583.86,Other,150% of Medicare + 9.63% HCRA Surcharge,355.05,45,,355.05,percent of total billed charges,Critical Access Hospital RCC factor,268.26,34,,268.26,percent of total billed charges,Implant Device,268.26,34,,268.26,percent of total billed charges,Implant Device,268.26,34,,268.26,percent of total billed charges,Implant Device,268.26,34,,268.26,percent of total billed charges,Implant Device,268.26,34,,268.26,percent of total billed charges,Implant Device,390.56,,,390.56,Other,110% of Medicare,276.15,35,,276.15,percent of total billed charges,Implant Device,268.26,34,"Charges > $500, x 34%",268.26,percent of total billed charges,Implant Device,276.15,35,,276.15,percent of total billed charges,Implant Device,276.15,35,,276.15,percent of total billed charges,Implant Device,276.15,35,,276.15,percent of total billed charges,Implant Device,276.15,35,,276.15,percent of total billed charges,Implant Device,276.15,35,,276.15,percent of total billed charges,Implant Device,315.6,40,,315.6,percent of total billed charges,Implant Device,276.15,70,,276.15,percent of total billed charges,All Other,268.26,34,,268.26,percent of total billed charges,Implant Device,268.26,34,,268.26,percent of total billed charges,Implant Device,276.15,35,,276.15,percent of total billed charges,Implant Device,276.15,35,,276.15,percent of total billed charges,Implant Device,276.15,35,,276.15,percent of total billed charges,Implant Device,276.15,35,,276.15,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,583.86,
ZIMMER 7711-007-00 M/L TAPER 7.5 STD,C1776,HCPCS,,79003641,CDM,278,RC,,,both,,,6912,5114.9,,,5114.9,Other,150% of Medicare + 9.63% HCRA Surcharge,3110.4,45,,3110.4,percent of total billed charges,Critical Access Hospital RCC factor,2350.08,34,,2350.08,percent of total billed charges,Implant Device,2350.08,34,,2350.08,percent of total billed charges,Implant Device,2350.08,34,,2350.08,percent of total billed charges,Implant Device,2350.08,34,,2350.08,percent of total billed charges,Implant Device,2350.08,34,,2350.08,percent of total billed charges,Implant Device,3421.44,,,3421.44,Other,110% of Medicare,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2350.08,34,"Charges > $500, x 34%",2350.08,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2764.8,40,,2764.8,percent of total billed charges,Implant Device,2419.2,70,,2419.2,percent of total billed charges,All Other,2350.08,34,,2350.08,percent of total billed charges,Implant Device,2350.08,34,,2350.08,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2350.08,34,"If Charge > 2,000, then 34 percent",2350.08,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5114.9,
GORE PLA360400 EXCLUDER ENDOPROSTHETIC,C1874,HCPCS,,79003642,CDM,278,RC,,,both,,,8850,6549.02,,,6549.02,Other,150% of Medicare + 9.63% HCRA Surcharge,3982.5,45,,3982.5,percent of total billed charges,Critical Access Hospital RCC factor,3009,34,,3009,percent of total billed charges,Implant Device,3009,34,,3009,percent of total billed charges,Implant Device,3009,34,,3009,percent of total billed charges,Implant Device,3009,34,,3009,percent of total billed charges,Implant Device,3009,34,,3009,percent of total billed charges,Implant Device,4380.75,,,4380.75,Other,110% of Medicare,3097.5,35,,3097.5,percent of total billed charges,Implant Device,3009,34,"Charges > $500, x 34%",3009,percent of total billed charges,Implant Device,3097.5,35,,3097.5,percent of total billed charges,Implant Device,3097.5,35,,3097.5,percent of total billed charges,Implant Device,3097.5,35,,3097.5,percent of total billed charges,Implant Device,3097.5,35,,3097.5,percent of total billed charges,Implant Device,3097.5,35,,3097.5,percent of total billed charges,Implant Device,3540,40,,3540,percent of total billed charges,Implant Device,3097.5,70,,3097.5,percent of total billed charges,All Other,3009,34,,3009,percent of total billed charges,Implant Device,3009,34,,3009,percent of total billed charges,Implant Device,3097.5,35,,3097.5,percent of total billed charges,Implant Device,3097.5,35,,3097.5,percent of total billed charges,Implant Device,3097.5,35,,3097.5,percent of total billed charges,Implant Device,3097.5,35,,3097.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3009,34,"If Charge > 2,000, then 34 percent",3009,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,6549.02,
SOLANA PHG-05C TENSIX ALLOFRAFT 5CC,C1713,HCPCS,,79003645,CDM,278,RC,,,both,,,4788,3543.13,,,3543.13,Other,150% of Medicare + 9.63% HCRA Surcharge,2154.6,45,,2154.6,percent of total billed charges,Critical Access Hospital RCC factor,1627.92,34,,1627.92,percent of total billed charges,Implant Device,1627.92,34,,1627.92,percent of total billed charges,Implant Device,1627.92,34,,1627.92,percent of total billed charges,Implant Device,1627.92,34,,1627.92,percent of total billed charges,Implant Device,1627.92,34,,1627.92,percent of total billed charges,Implant Device,2370.06,,,2370.06,Other,110% of Medicare,1675.8,35,,1675.8,percent of total billed charges,Implant Device,1627.92,34,"Charges > $500, x 34%",1627.92,percent of total billed charges,Implant Device,1675.8,35,,1675.8,percent of total billed charges,Implant Device,1675.8,35,,1675.8,percent of total billed charges,Implant Device,1675.8,35,,1675.8,percent of total billed charges,Implant Device,1675.8,35,,1675.8,percent of total billed charges,Implant Device,1675.8,35,,1675.8,percent of total billed charges,Implant Device,1915.2,40,,1915.2,percent of total billed charges,Implant Device,1675.8,70,,1675.8,percent of total billed charges,All Other,1627.92,34,,1627.92,percent of total billed charges,Implant Device,1627.92,34,,1627.92,percent of total billed charges,Implant Device,1675.8,35,,1675.8,percent of total billed charges,Implant Device,1675.8,35,,1675.8,percent of total billed charges,Implant Device,1675.8,35,,1675.8,percent of total billed charges,Implant Device,1675.8,35,,1675.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1627.92,34,"If Charge > 2,000, then 34 percent",1627.92,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3543.13,
WRIGHT 4700002 FINGER JOINT IMPLANT SZ 2,C1776,HCPCS,,79003646,CDM,278,RC,,,both,,,6756,4999.46,,,4999.46,Other,150% of Medicare + 9.63% HCRA Surcharge,3040.2,45,,3040.2,percent of total billed charges,Critical Access Hospital RCC factor,2297.04,34,,2297.04,percent of total billed charges,Implant Device,2297.04,34,,2297.04,percent of total billed charges,Implant Device,2297.04,34,,2297.04,percent of total billed charges,Implant Device,2297.04,34,,2297.04,percent of total billed charges,Implant Device,2297.04,34,,2297.04,percent of total billed charges,Implant Device,3344.22,,,3344.22,Other,110% of Medicare,2364.6,35,,2364.6,percent of total billed charges,Implant Device,2297.04,34,"Charges > $500, x 34%",2297.04,percent of total billed charges,Implant Device,2364.6,35,,2364.6,percent of total billed charges,Implant Device,2364.6,35,,2364.6,percent of total billed charges,Implant Device,2364.6,35,,2364.6,percent of total billed charges,Implant Device,2364.6,35,,2364.6,percent of total billed charges,Implant Device,2364.6,35,,2364.6,percent of total billed charges,Implant Device,2702.4,40,,2702.4,percent of total billed charges,Implant Device,2364.6,70,,2364.6,percent of total billed charges,All Other,2297.04,34,,2297.04,percent of total billed charges,Implant Device,2297.04,34,,2297.04,percent of total billed charges,Implant Device,2364.6,35,,2364.6,percent of total billed charges,Implant Device,2364.6,35,,2364.6,percent of total billed charges,Implant Device,2364.6,35,,2364.6,percent of total billed charges,Implant Device,2364.6,35,,2364.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2297.04,34,"If Charge > 2,000, then 34 percent",2297.04,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4999.46,
WRIGHT G4700004 FINGER JOINT IMPLNT SZ 4,C1776,HCPCS,,79003647,CDM,278,RC,,,both,,,6756,4999.46,,,4999.46,Other,150% of Medicare + 9.63% HCRA Surcharge,3040.2,45,,3040.2,percent of total billed charges,Critical Access Hospital RCC factor,2297.04,34,,2297.04,percent of total billed charges,Implant Device,2297.04,34,,2297.04,percent of total billed charges,Implant Device,2297.04,34,,2297.04,percent of total billed charges,Implant Device,2297.04,34,,2297.04,percent of total billed charges,Implant Device,2297.04,34,,2297.04,percent of total billed charges,Implant Device,3344.22,,,3344.22,Other,110% of Medicare,2364.6,35,,2364.6,percent of total billed charges,Implant Device,2297.04,34,"Charges > $500, x 34%",2297.04,percent of total billed charges,Implant Device,2364.6,35,,2364.6,percent of total billed charges,Implant Device,2364.6,35,,2364.6,percent of total billed charges,Implant Device,2364.6,35,,2364.6,percent of total billed charges,Implant Device,2364.6,35,,2364.6,percent of total billed charges,Implant Device,2364.6,35,,2364.6,percent of total billed charges,Implant Device,2702.4,40,,2702.4,percent of total billed charges,Implant Device,2364.6,70,,2364.6,percent of total billed charges,All Other,2297.04,34,,2297.04,percent of total billed charges,Implant Device,2297.04,34,,2297.04,percent of total billed charges,Implant Device,2364.6,35,,2364.6,percent of total billed charges,Implant Device,2364.6,35,,2364.6,percent of total billed charges,Implant Device,2364.6,35,,2364.6,percent of total billed charges,Implant Device,2364.6,35,,2364.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2297.04,34,"If Charge > 2,000, then 34 percent",2297.04,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4999.46,
SYNTHES 208.875 CANN SCREW 7.3X75MM,C1713,HCPCS,,79003649,CDM,278,RC,,,both,,,742,549.08,,,549.08,Other,150% of Medicare + 9.63% HCRA Surcharge,333.9,45,,333.9,percent of total billed charges,Critical Access Hospital RCC factor,252.28,34,,252.28,percent of total billed charges,Implant Device,252.28,34,,252.28,percent of total billed charges,Implant Device,252.28,34,,252.28,percent of total billed charges,Implant Device,252.28,34,,252.28,percent of total billed charges,Implant Device,252.28,34,,252.28,percent of total billed charges,Implant Device,367.29,,,367.29,Other,110% of Medicare,259.7,35,,259.7,percent of total billed charges,Implant Device,252.28,34,"Charges > $500, x 34%",252.28,percent of total billed charges,Implant Device,259.7,35,,259.7,percent of total billed charges,Implant Device,259.7,35,,259.7,percent of total billed charges,Implant Device,259.7,35,,259.7,percent of total billed charges,Implant Device,259.7,35,,259.7,percent of total billed charges,Implant Device,259.7,35,,259.7,percent of total billed charges,Implant Device,296.8,40,,296.8,percent of total billed charges,Implant Device,259.7,70,,259.7,percent of total billed charges,All Other,252.28,34,,252.28,percent of total billed charges,Implant Device,252.28,34,,252.28,percent of total billed charges,Implant Device,259.7,35,,259.7,percent of total billed charges,Implant Device,259.7,35,,259.7,percent of total billed charges,Implant Device,259.7,35,,259.7,percent of total billed charges,Implant Device,259.7,35,,259.7,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,549.08,
EXACTECH 320-38-03 HUMERAL LINER 38X25MM,C1776,HCPCS,,79003650,CDM,278,RC,,,both,,,2325,1720.51,,,1720.51,Other,150% of Medicare + 9.63% HCRA Surcharge,1046.25,45,,1046.25,percent of total billed charges,Critical Access Hospital RCC factor,790.5,34,,790.5,percent of total billed charges,Implant Device,790.5,34,,790.5,percent of total billed charges,Implant Device,790.5,34,,790.5,percent of total billed charges,Implant Device,790.5,34,,790.5,percent of total billed charges,Implant Device,790.5,34,,790.5,percent of total billed charges,Implant Device,1150.88,,,1150.88,Other,110% of Medicare,813.75,35,,813.75,percent of total billed charges,Implant Device,790.5,34,"Charges > $500, x 34%",790.5,percent of total billed charges,Implant Device,813.75,35,,813.75,percent of total billed charges,Implant Device,813.75,35,,813.75,percent of total billed charges,Implant Device,813.75,35,,813.75,percent of total billed charges,Implant Device,813.75,35,,813.75,percent of total billed charges,Implant Device,813.75,35,,813.75,percent of total billed charges,Implant Device,930,40,,930,percent of total billed charges,Implant Device,813.75,70,,813.75,percent of total billed charges,All Other,790.5,34,,790.5,percent of total billed charges,Implant Device,790.5,34,,790.5,percent of total billed charges,Implant Device,813.75,35,,813.75,percent of total billed charges,Implant Device,813.75,35,,813.75,percent of total billed charges,Implant Device,813.75,35,,813.75,percent of total billed charges,Implant Device,813.75,35,,813.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,790.5,34,"If Charge > 2,000, then 34 percent",790.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1720.51,
BIOMET EP-183440 TIBIAL BEARING 18X71/75,C1776,HCPCS,,79003651,CDM,278,RC,,,both,,,12510,9257.43,,,9257.43,Other,150% of Medicare + 9.63% HCRA Surcharge,5629.5,45,,5629.5,percent of total billed charges,Critical Access Hospital RCC factor,4253.4,34,,4253.4,percent of total billed charges,Implant Device,4253.4,34,,4253.4,percent of total billed charges,Implant Device,4253.4,34,,4253.4,percent of total billed charges,Implant Device,4253.4,34,,4253.4,percent of total billed charges,Implant Device,4253.4,34,,4253.4,percent of total billed charges,Implant Device,6192.45,,,6192.45,Other,110% of Medicare,4378.5,35,,4378.5,percent of total billed charges,Implant Device,4253.4,34,"Charges > $500, x 34%",4253.4,percent of total billed charges,Implant Device,4378.5,35,,4378.5,percent of total billed charges,Implant Device,4378.5,35,,4378.5,percent of total billed charges,Implant Device,4378.5,35,,4378.5,percent of total billed charges,Implant Device,4378.5,35,,4378.5,percent of total billed charges,Implant Device,4378.5,35,,4378.5,percent of total billed charges,Implant Device,5004,40,,5004,percent of total billed charges,Implant Device,4378.5,70,,4378.5,percent of total billed charges,All Other,4253.4,34,,4253.4,percent of total billed charges,Implant Device,4253.4,34,,4253.4,percent of total billed charges,Implant Device,4378.5,35,,4378.5,percent of total billed charges,Implant Device,4378.5,35,,4378.5,percent of total billed charges,Implant Device,4378.5,35,,4378.5,percent of total billed charges,Implant Device,4378.5,35,,4378.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,4253.4,34,"If Charge > 2,000, then 34 percent",4253.4,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,9257.43,
BIOMET 141205 MODULAR TIBIAL LOCK BAR,C1776,HCPCS,,79003652,CDM,278,RC,,,both,,,384,284.16,,,284.16,Other,150% of Medicare + 9.63% HCRA Surcharge,172.8,45,,172.8,percent of total billed charges,Critical Access Hospital RCC factor,130.56,34,,130.56,percent of total billed charges,Implant Device,130.56,34,,130.56,percent of total billed charges,Implant Device,130.56,34,,130.56,percent of total billed charges,Implant Device,130.56,34,,130.56,percent of total billed charges,Implant Device,130.56,34,,130.56,percent of total billed charges,Implant Device,190.08,,,190.08,Other,110% of Medicare,134.4,35,,134.4,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,134.4,35,,134.4,percent of total billed charges,Implant Device,134.4,35,,134.4,percent of total billed charges,Implant Device,134.4,35,,134.4,percent of total billed charges,Implant Device,134.4,35,,134.4,percent of total billed charges,Implant Device,134.4,35,,134.4,percent of total billed charges,Implant Device,153.6,40,,153.6,percent of total billed charges,Implant Device,134.4,70,,134.4,percent of total billed charges,All Other,130.56,34,,130.56,percent of total billed charges,Implant Device,130.56,34,,130.56,percent of total billed charges,Implant Device,134.4,35,,134.4,percent of total billed charges,Implant Device,134.4,35,,134.4,percent of total billed charges,Implant Device,134.4,35,,134.4,percent of total billed charges,Implant Device,134.4,35,,134.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,284.16,
ARTHREX AR-8720-14PT CANN SCREW 2X14MM,C1713,HCPCS,,79003653,CDM,278,RC,,,both,,,420,310.8,,,310.8,Other,150% of Medicare + 9.63% HCRA Surcharge,189,45,,189,percent of total billed charges,Critical Access Hospital RCC factor,142.8,34,,142.8,percent of total billed charges,Implant Device,142.8,34,,142.8,percent of total billed charges,Implant Device,142.8,34,,142.8,percent of total billed charges,Implant Device,142.8,34,,142.8,percent of total billed charges,Implant Device,142.8,34,,142.8,percent of total billed charges,Implant Device,207.9,,,207.9,Other,110% of Medicare,147,35,,147,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,147,35,,147,percent of total billed charges,Implant Device,147,35,,147,percent of total billed charges,Implant Device,147,35,,147,percent of total billed charges,Implant Device,147,35,,147,percent of total billed charges,Implant Device,147,35,,147,percent of total billed charges,Implant Device,168,40,,168,percent of total billed charges,Implant Device,147,70,,147,percent of total billed charges,All Other,142.8,34,,142.8,percent of total billed charges,Implant Device,142.8,34,,142.8,percent of total billed charges,Implant Device,147,35,,147,percent of total billed charges,Implant Device,147,35,,147,percent of total billed charges,Implant Device,147,35,,147,percent of total billed charges,Implant Device,147,35,,147,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,310.8,
ARTHREX AR-8724-18PT CANN SCREW 2.4X18MM,C1713,HCPCS,,79003654,CDM,278,RC,,,both,,,376,278.24,,,278.24,Other,150% of Medicare + 9.63% HCRA Surcharge,169.2,45,,169.2,percent of total billed charges,Critical Access Hospital RCC factor,127.84,34,,127.84,percent of total billed charges,Implant Device,127.84,34,,127.84,percent of total billed charges,Implant Device,127.84,34,,127.84,percent of total billed charges,Implant Device,127.84,34,,127.84,percent of total billed charges,Implant Device,127.84,34,,127.84,percent of total billed charges,Implant Device,186.12,,,186.12,Other,110% of Medicare,131.6,35,,131.6,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,131.6,35,,131.6,percent of total billed charges,Implant Device,131.6,35,,131.6,percent of total billed charges,Implant Device,131.6,35,,131.6,percent of total billed charges,Implant Device,131.6,35,,131.6,percent of total billed charges,Implant Device,131.6,35,,131.6,percent of total billed charges,Implant Device,150.4,40,,150.4,percent of total billed charges,Implant Device,131.6,70,,131.6,percent of total billed charges,All Other,127.84,34,,127.84,percent of total billed charges,Implant Device,127.84,34,,127.84,percent of total billed charges,Implant Device,131.6,35,,131.6,percent of total billed charges,Implant Device,131.6,35,,131.6,percent of total billed charges,Implant Device,131.6,35,,131.6,percent of total billed charges,Implant Device,131.6,35,,131.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,278.24,
ZIMMER 5001-46 BIPOLAR CUP SHELL 46MM OD,C1776,HCPCS,,79003656,CDM,278,RC,,,both,,,2026,1499.25,,,1499.25,Other,150% of Medicare + 9.63% HCRA Surcharge,911.7,45,,911.7,percent of total billed charges,Critical Access Hospital RCC factor,688.84,34,,688.84,percent of total billed charges,Implant Device,688.84,34,,688.84,percent of total billed charges,Implant Device,688.84,34,,688.84,percent of total billed charges,Implant Device,688.84,34,,688.84,percent of total billed charges,Implant Device,688.84,34,,688.84,percent of total billed charges,Implant Device,1002.87,,,1002.87,Other,110% of Medicare,709.1,35,,709.1,percent of total billed charges,Implant Device,688.84,34,"Charges > $500, x 34%",688.84,percent of total billed charges,Implant Device,709.1,35,,709.1,percent of total billed charges,Implant Device,709.1,35,,709.1,percent of total billed charges,Implant Device,709.1,35,,709.1,percent of total billed charges,Implant Device,709.1,35,,709.1,percent of total billed charges,Implant Device,709.1,35,,709.1,percent of total billed charges,Implant Device,810.4,40,,810.4,percent of total billed charges,Implant Device,709.1,70,,709.1,percent of total billed charges,All Other,688.84,34,,688.84,percent of total billed charges,Implant Device,688.84,34,,688.84,percent of total billed charges,Implant Device,709.1,35,,709.1,percent of total billed charges,Implant Device,709.1,35,,709.1,percent of total billed charges,Implant Device,709.1,35,,709.1,percent of total billed charges,Implant Device,709.1,35,,709.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,688.84,34,"If Charge > 2,000, then 34 percent",688.84,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1499.25,
ZIMMER 8018-28-02 VERSYS FEMRL HEAD 26MM,C1776,HCPCS,,79003657,CDM,278,RC,,,both,,,2543,1881.83,,,1881.83,Other,150% of Medicare + 9.63% HCRA Surcharge,1144.35,45,,1144.35,percent of total billed charges,Critical Access Hospital RCC factor,864.62,34,,864.62,percent of total billed charges,Implant Device,864.62,34,,864.62,percent of total billed charges,Implant Device,864.62,34,,864.62,percent of total billed charges,Implant Device,864.62,34,,864.62,percent of total billed charges,Implant Device,864.62,34,,864.62,percent of total billed charges,Implant Device,1258.79,,,1258.79,Other,110% of Medicare,890.05,35,,890.05,percent of total billed charges,Implant Device,864.62,34,"Charges > $500, x 34%",864.62,percent of total billed charges,Implant Device,890.05,35,,890.05,percent of total billed charges,Implant Device,890.05,35,,890.05,percent of total billed charges,Implant Device,890.05,35,,890.05,percent of total billed charges,Implant Device,890.05,35,,890.05,percent of total billed charges,Implant Device,890.05,35,,890.05,percent of total billed charges,Implant Device,1017.2,40,,1017.2,percent of total billed charges,Implant Device,890.05,70,,890.05,percent of total billed charges,All Other,864.62,34,,864.62,percent of total billed charges,Implant Device,864.62,34,,864.62,percent of total billed charges,Implant Device,890.05,35,,890.05,percent of total billed charges,Implant Device,890.05,35,,890.05,percent of total billed charges,Implant Device,890.05,35,,890.05,percent of total billed charges,Implant Device,890.05,35,,890.05,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,864.62,34,"If Charge > 2,000, then 34 percent",864.62,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1881.83,
BIOMET 28821 TROCHANTERIC NAIL 11X17CM,C1713,HCPCS,,79003658,CDM,278,RC,,,both,,,7950,5883.02,,,5883.02,Other,150% of Medicare + 9.63% HCRA Surcharge,3577.5,45,,3577.5,percent of total billed charges,Critical Access Hospital RCC factor,2703,34,,2703,percent of total billed charges,Implant Device,2703,34,,2703,percent of total billed charges,Implant Device,2703,34,,2703,percent of total billed charges,Implant Device,2703,34,,2703,percent of total billed charges,Implant Device,2703,34,,2703,percent of total billed charges,Implant Device,3935.25,,,3935.25,Other,110% of Medicare,2782.5,35,,2782.5,percent of total billed charges,Implant Device,2703,34,"Charges > $500, x 34%",2703,percent of total billed charges,Implant Device,2782.5,35,,2782.5,percent of total billed charges,Implant Device,2782.5,35,,2782.5,percent of total billed charges,Implant Device,2782.5,35,,2782.5,percent of total billed charges,Implant Device,2782.5,35,,2782.5,percent of total billed charges,Implant Device,2782.5,35,,2782.5,percent of total billed charges,Implant Device,3180,40,,3180,percent of total billed charges,Implant Device,2782.5,70,,2782.5,percent of total billed charges,All Other,2703,34,,2703,percent of total billed charges,Implant Device,2703,34,,2703,percent of total billed charges,Implant Device,2782.5,35,,2782.5,percent of total billed charges,Implant Device,2782.5,35,,2782.5,percent of total billed charges,Implant Device,2782.5,35,,2782.5,percent of total billed charges,Implant Device,2782.5,35,,2782.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2703,34,"If Charge > 2,000, then 34 percent",2703,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5883.02,
ZIMMER 6250-65-60 BONE SCREW 6.5X60MM,C1713,HCPCS,,79003663,CDM,278,RC,,,both,,,96,71.04,,,71.04,Other,150% of Medicare + 9.63% HCRA Surcharge,43.2,45,,43.2,percent of total billed charges,Critical Access Hospital RCC factor,32.64,34,,32.64,percent of total billed charges,Implant Device,32.64,34,,32.64,percent of total billed charges,Implant Device,32.64,34,,32.64,percent of total billed charges,Implant Device,32.64,34,,32.64,percent of total billed charges,Implant Device,32.64,34,,32.64,percent of total billed charges,Implant Device,47.52,,,47.52,Other,110% of Medicare,33.6,35,,33.6,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,33.6,35,,33.6,percent of total billed charges,Implant Device,33.6,35,,33.6,percent of total billed charges,Implant Device,33.6,35,,33.6,percent of total billed charges,Implant Device,33.6,35,,33.6,percent of total billed charges,Implant Device,33.6,35,,33.6,percent of total billed charges,Implant Device,38.4,40,,38.4,percent of total billed charges,Implant Device,33.6,70,,33.6,percent of total billed charges,All Other,32.64,34,,32.64,percent of total billed charges,Implant Device,32.64,34,,32.64,percent of total billed charges,Implant Device,33.6,35,,33.6,percent of total billed charges,Implant Device,33.6,35,,33.6,percent of total billed charges,Implant Device,33.6,35,,33.6,percent of total billed charges,Implant Device,33.6,35,,33.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,71.04,
ARTHROSURFACE 8H02-5450-W ART COMP 54X50,C1776,HCPCS,,79003664,CDM,278,RC,,,both,,,16764,12405.4,,,12405.4,Other,150% of Medicare + 9.63% HCRA Surcharge,7543.8,45,,7543.8,percent of total billed charges,Critical Access Hospital RCC factor,5699.76,34,,5699.76,percent of total billed charges,Implant Device,5699.76,34,,5699.76,percent of total billed charges,Implant Device,5699.76,34,,5699.76,percent of total billed charges,Implant Device,5699.76,34,,5699.76,percent of total billed charges,Implant Device,5699.76,34,,5699.76,percent of total billed charges,Implant Device,8298.18,,,8298.18,Other,110% of Medicare,5867.4,35,,5867.4,percent of total billed charges,Implant Device,5699.76,34,"Charges > $500, x 34%",5699.76,percent of total billed charges,Implant Device,5867.4,35,,5867.4,percent of total billed charges,Implant Device,5867.4,35,,5867.4,percent of total billed charges,Implant Device,5867.4,35,,5867.4,percent of total billed charges,Implant Device,5867.4,35,,5867.4,percent of total billed charges,Implant Device,5867.4,35,,5867.4,percent of total billed charges,Implant Device,6705.6,40,,6705.6,percent of total billed charges,Implant Device,5867.4,70,,5867.4,percent of total billed charges,All Other,5699.76,34,,5699.76,percent of total billed charges,Implant Device,5699.76,34,,5699.76,percent of total billed charges,Implant Device,5867.4,35,,5867.4,percent of total billed charges,Implant Device,5867.4,35,,5867.4,percent of total billed charges,Implant Device,5867.4,35,,5867.4,percent of total billed charges,Implant Device,5867.4,35,,5867.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,5699.76,34,"If Charge > 2,000, then 34 percent",5699.76,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,12405.4,
COOK MEDICAL GPSO-5-3 STENT 5FRX3CM,C2617,HCPCS,,79003665,CDM,278,RC,,,both,,,180,133.2,,,133.2,Other,150% of Medicare + 9.63% HCRA Surcharge,81,45,,81,percent of total billed charges,Critical Access Hospital RCC factor,61.2,34,,61.2,percent of total billed charges,Implant Device,61.2,34,,61.2,percent of total billed charges,Implant Device,61.2,34,,61.2,percent of total billed charges,Implant Device,61.2,34,,61.2,percent of total billed charges,Implant Device,61.2,34,,61.2,percent of total billed charges,Implant Device,89.1,,,89.1,Other,110% of Medicare,63,35,,63,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,63,35,,63,percent of total billed charges,Implant Device,63,35,,63,percent of total billed charges,Implant Device,63,35,,63,percent of total billed charges,Implant Device,63,35,,63,percent of total billed charges,Implant Device,63,35,,63,percent of total billed charges,Implant Device,72,40,,72,percent of total billed charges,Implant Device,63,70,,63,percent of total billed charges,All Other,61.2,34,,61.2,percent of total billed charges,Implant Device,61.2,34,,61.2,percent of total billed charges,Implant Device,63,35,,63,percent of total billed charges,Implant Device,63,35,,63,percent of total billed charges,Implant Device,63,35,,63,percent of total billed charges,Implant Device,63,35,,63,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,133.2,
STRYKER 40-30118 MICRO SCREW 3X18/5MM,C1713,HCPCS,,79003668,CDM,278,RC,,,both,,,493,364.82,,,364.82,Other,150% of Medicare + 9.63% HCRA Surcharge,221.85,45,,221.85,percent of total billed charges,Critical Access Hospital RCC factor,167.62,34,,167.62,percent of total billed charges,Implant Device,167.62,34,,167.62,percent of total billed charges,Implant Device,167.62,34,,167.62,percent of total billed charges,Implant Device,167.62,34,,167.62,percent of total billed charges,Implant Device,167.62,34,,167.62,percent of total billed charges,Implant Device,244.04,,,244.04,Other,110% of Medicare,172.55,35,,172.55,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,172.55,35,,172.55,percent of total billed charges,Implant Device,172.55,35,,172.55,percent of total billed charges,Implant Device,172.55,35,,172.55,percent of total billed charges,Implant Device,172.55,35,,172.55,percent of total billed charges,Implant Device,172.55,35,,172.55,percent of total billed charges,Implant Device,197.2,40,,197.2,percent of total billed charges,Implant Device,172.55,70,,172.55,percent of total billed charges,All Other,167.62,34,,167.62,percent of total billed charges,Implant Device,167.62,34,,167.62,percent of total billed charges,Implant Device,172.55,35,,172.55,percent of total billed charges,Implant Device,172.55,35,,172.55,percent of total billed charges,Implant Device,172.55,35,,172.55,percent of total billed charges,Implant Device,172.55,35,,172.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,364.82,
COOK US-600 SOFTEX STENT MULTI LENGTH,C2617,HCPCS,,79003679,CDM,278,RC,,,both,,,264,195.36,,,195.36,Other,150% of Medicare + 9.63% HCRA Surcharge,118.8,45,,118.8,percent of total billed charges,Critical Access Hospital RCC factor,89.76,34,,89.76,percent of total billed charges,Implant Device,89.76,34,,89.76,percent of total billed charges,Implant Device,89.76,34,,89.76,percent of total billed charges,Implant Device,89.76,34,,89.76,percent of total billed charges,Implant Device,89.76,34,,89.76,percent of total billed charges,Implant Device,130.68,,,130.68,Other,110% of Medicare,92.4,35,,92.4,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,92.4,35,,92.4,percent of total billed charges,Implant Device,92.4,35,,92.4,percent of total billed charges,Implant Device,92.4,35,,92.4,percent of total billed charges,Implant Device,92.4,35,,92.4,percent of total billed charges,Implant Device,92.4,35,,92.4,percent of total billed charges,Implant Device,105.6,40,,105.6,percent of total billed charges,Implant Device,92.4,70,,92.4,percent of total billed charges,All Other,89.76,34,,89.76,percent of total billed charges,Implant Device,89.76,34,,89.76,percent of total billed charges,Implant Device,92.4,35,,92.4,percent of total billed charges,Implant Device,92.4,35,,92.4,percent of total billed charges,Implant Device,92.4,35,,92.4,percent of total billed charges,Implant Device,92.4,35,,92.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,195.36,
ZIMMER 00-8757-052-02-RV TRAB SHELL 52MM,C1776,HCPCS,,79003681,CDM,278,RC,,,both,,,3450,2553.01,,,2553.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1552.5,45,,1552.5,percent of total billed charges,Critical Access Hospital RCC factor,1173,34,,1173,percent of total billed charges,Implant Device,1173,34,,1173,percent of total billed charges,Implant Device,1173,34,,1173,percent of total billed charges,Implant Device,1173,34,,1173,percent of total billed charges,Implant Device,1173,34,,1173,percent of total billed charges,Implant Device,1707.75,,,1707.75,Other,110% of Medicare,1207.5,35,,1207.5,percent of total billed charges,Implant Device,1173,34,"Charges > $500, x 34%",1173,percent of total billed charges,Implant Device,1207.5,35,,1207.5,percent of total billed charges,Implant Device,1207.5,35,,1207.5,percent of total billed charges,Implant Device,1207.5,35,,1207.5,percent of total billed charges,Implant Device,1207.5,35,,1207.5,percent of total billed charges,Implant Device,1207.5,35,,1207.5,percent of total billed charges,Implant Device,1380,40,,1380,percent of total billed charges,Implant Device,1207.5,70,,1207.5,percent of total billed charges,All Other,1173,34,,1173,percent of total billed charges,Implant Device,1173,34,,1173,percent of total billed charges,Implant Device,1207.5,35,,1207.5,percent of total billed charges,Implant Device,1207.5,35,,1207.5,percent of total billed charges,Implant Device,1207.5,35,,1207.5,percent of total billed charges,Implant Device,1207.5,35,,1207.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1173,34,"If Charge > 2,000, then 34 percent",1173,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2553.01,
ZIMMER 00-8752-010-36-RV POLY LINR SZ 11,C1776,HCPCS,,79003682,CDM,278,RC,,,both,,,4973,3680.03,,,3680.03,Other,150% of Medicare + 9.63% HCRA Surcharge,2237.85,45,,2237.85,percent of total billed charges,Critical Access Hospital RCC factor,1690.82,34,,1690.82,percent of total billed charges,Implant Device,1690.82,34,,1690.82,percent of total billed charges,Implant Device,1690.82,34,,1690.82,percent of total billed charges,Implant Device,1690.82,34,,1690.82,percent of total billed charges,Implant Device,1690.82,34,,1690.82,percent of total billed charges,Implant Device,2461.64,,,2461.64,Other,110% of Medicare,1740.55,35,,1740.55,percent of total billed charges,Implant Device,1690.82,34,"Charges > $500, x 34%",1690.82,percent of total billed charges,Implant Device,1740.55,35,,1740.55,percent of total billed charges,Implant Device,1740.55,35,,1740.55,percent of total billed charges,Implant Device,1740.55,35,,1740.55,percent of total billed charges,Implant Device,1740.55,35,,1740.55,percent of total billed charges,Implant Device,1740.55,35,,1740.55,percent of total billed charges,Implant Device,1989.2,40,,1989.2,percent of total billed charges,Implant Device,1740.55,70,,1740.55,percent of total billed charges,All Other,1690.82,34,,1690.82,percent of total billed charges,Implant Device,1690.82,34,,1690.82,percent of total billed charges,Implant Device,1740.55,35,,1740.55,percent of total billed charges,Implant Device,1740.55,35,,1740.55,percent of total billed charges,Implant Device,1740.55,35,,1740.55,percent of total billed charges,Implant Device,1740.55,35,,1740.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1690.82,34,"If Charge > 2,000, then 34 percent",1690.82,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3680.03,
ZIMMER 00-8775-036-01-REV FEM HEAD,C1776,HCPCS,,79003683,CDM,278,RC,,,both,,,3834,2837.17,,,2837.17,Other,150% of Medicare + 9.63% HCRA Surcharge,1725.3,45,,1725.3,percent of total billed charges,Critical Access Hospital RCC factor,1303.56,34,,1303.56,percent of total billed charges,Implant Device,1303.56,34,,1303.56,percent of total billed charges,Implant Device,1303.56,34,,1303.56,percent of total billed charges,Implant Device,1303.56,34,,1303.56,percent of total billed charges,Implant Device,1303.56,34,,1303.56,percent of total billed charges,Implant Device,1897.83,,,1897.83,Other,110% of Medicare,1341.9,35,,1341.9,percent of total billed charges,Implant Device,1303.56,34,"Charges > $500, x 34%",1303.56,percent of total billed charges,Implant Device,1341.9,35,,1341.9,percent of total billed charges,Implant Device,1341.9,35,,1341.9,percent of total billed charges,Implant Device,1341.9,35,,1341.9,percent of total billed charges,Implant Device,1341.9,35,,1341.9,percent of total billed charges,Implant Device,1341.9,35,,1341.9,percent of total billed charges,Implant Device,1533.6,40,,1533.6,percent of total billed charges,Implant Device,1341.9,70,,1341.9,percent of total billed charges,All Other,1303.56,34,,1303.56,percent of total billed charges,Implant Device,1303.56,34,,1303.56,percent of total billed charges,Implant Device,1341.9,35,,1341.9,percent of total billed charges,Implant Device,1341.9,35,,1341.9,percent of total billed charges,Implant Device,1341.9,35,,1341.9,percent of total billed charges,Implant Device,1341.9,35,,1341.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1303.56,34,"If Charge > 2,000, then 34 percent",1303.56,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2837.17,
SGARLATO LABS 80-100-01 HAMMERTOE IMP-LG,C1776,HCPCS,,79003685,CDM,278,RC,,,both,,,1200,888,,,888,Other,150% of Medicare + 9.63% HCRA Surcharge,540,45,,540,percent of total billed charges,Critical Access Hospital RCC factor,408,34,,408,percent of total billed charges,Implant Device,408,34,,408,percent of total billed charges,Implant Device,408,34,,408,percent of total billed charges,Implant Device,408,34,,408,percent of total billed charges,Implant Device,408,34,,408,percent of total billed charges,Implant Device,594,,,594,Other,110% of Medicare,420,35,,420,percent of total billed charges,Implant Device,408,34,"Charges > $500, x 34%",408,percent of total billed charges,Implant Device,420,35,,420,percent of total billed charges,Implant Device,420,35,,420,percent of total billed charges,Implant Device,420,35,,420,percent of total billed charges,Implant Device,420,35,,420,percent of total billed charges,Implant Device,420,35,,420,percent of total billed charges,Implant Device,480,40,,480,percent of total billed charges,Implant Device,420,70,,420,percent of total billed charges,All Other,408,34,,408,percent of total billed charges,Implant Device,408,34,,408,percent of total billed charges,Implant Device,420,35,,420,percent of total billed charges,Implant Device,420,35,,420,percent of total billed charges,Implant Device,420,35,,420,percent of total billed charges,Implant Device,420,35,,420,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,888,
SYNTHES 208.440 CANNULATD SCREW 3.2X90MM,C1713,HCPCS,,79003686,CDM,278,RC,,,both,,,908,671.92,,,671.92,Other,150% of Medicare + 9.63% HCRA Surcharge,408.6,45,,408.6,percent of total billed charges,Critical Access Hospital RCC factor,308.72,34,,308.72,percent of total billed charges,Implant Device,308.72,34,,308.72,percent of total billed charges,Implant Device,308.72,34,,308.72,percent of total billed charges,Implant Device,308.72,34,,308.72,percent of total billed charges,Implant Device,308.72,34,,308.72,percent of total billed charges,Implant Device,449.46,,,449.46,Other,110% of Medicare,317.8,35,,317.8,percent of total billed charges,Implant Device,308.72,34,"Charges > $500, x 34%",308.72,percent of total billed charges,Implant Device,317.8,35,,317.8,percent of total billed charges,Implant Device,317.8,35,,317.8,percent of total billed charges,Implant Device,317.8,35,,317.8,percent of total billed charges,Implant Device,317.8,35,,317.8,percent of total billed charges,Implant Device,317.8,35,,317.8,percent of total billed charges,Implant Device,363.2,40,,363.2,percent of total billed charges,Implant Device,317.8,70,,317.8,percent of total billed charges,All Other,308.72,34,,308.72,percent of total billed charges,Implant Device,308.72,34,,308.72,percent of total billed charges,Implant Device,317.8,35,,317.8,percent of total billed charges,Implant Device,317.8,35,,317.8,percent of total billed charges,Implant Device,317.8,35,,317.8,percent of total billed charges,Implant Device,317.8,35,,317.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,671.92,
SYNTHES 208.441 CANNULATD SCREW 3.2X95MM,C1713,HCPCS,,79003687,CDM,278,RC,,,both,,,908,671.92,,,671.92,Other,150% of Medicare + 9.63% HCRA Surcharge,408.6,45,,408.6,percent of total billed charges,Critical Access Hospital RCC factor,308.72,34,,308.72,percent of total billed charges,Implant Device,308.72,34,,308.72,percent of total billed charges,Implant Device,308.72,34,,308.72,percent of total billed charges,Implant Device,308.72,34,,308.72,percent of total billed charges,Implant Device,308.72,34,,308.72,percent of total billed charges,Implant Device,449.46,,,449.46,Other,110% of Medicare,317.8,35,,317.8,percent of total billed charges,Implant Device,308.72,34,"Charges > $500, x 34%",308.72,percent of total billed charges,Implant Device,317.8,35,,317.8,percent of total billed charges,Implant Device,317.8,35,,317.8,percent of total billed charges,Implant Device,317.8,35,,317.8,percent of total billed charges,Implant Device,317.8,35,,317.8,percent of total billed charges,Implant Device,317.8,35,,317.8,percent of total billed charges,Implant Device,363.2,40,,363.2,percent of total billed charges,Implant Device,317.8,70,,317.8,percent of total billed charges,All Other,308.72,34,,308.72,percent of total billed charges,Implant Device,308.72,34,,308.72,percent of total billed charges,Implant Device,317.8,35,,317.8,percent of total billed charges,Implant Device,317.8,35,,317.8,percent of total billed charges,Implant Device,317.8,35,,317.8,percent of total billed charges,Implant Device,317.8,35,,317.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,671.92,
ARTHREX AR-5035TC-12 BIOCOMP SCREW 12X35,C1713,HCPCS,,79003691,CDM,278,RC,,,both,,,966,714.84,,,714.84,Other,150% of Medicare + 9.63% HCRA Surcharge,434.7,45,,434.7,percent of total billed charges,Critical Access Hospital RCC factor,328.44,34,,328.44,percent of total billed charges,Implant Device,328.44,34,,328.44,percent of total billed charges,Implant Device,328.44,34,,328.44,percent of total billed charges,Implant Device,328.44,34,,328.44,percent of total billed charges,Implant Device,328.44,34,,328.44,percent of total billed charges,Implant Device,478.17,,,478.17,Other,110% of Medicare,338.1,35,,338.1,percent of total billed charges,Implant Device,328.44,34,"Charges > $500, x 34%",328.44,percent of total billed charges,Implant Device,338.1,35,,338.1,percent of total billed charges,Implant Device,338.1,35,,338.1,percent of total billed charges,Implant Device,338.1,35,,338.1,percent of total billed charges,Implant Device,338.1,35,,338.1,percent of total billed charges,Implant Device,338.1,35,,338.1,percent of total billed charges,Implant Device,386.4,40,,386.4,percent of total billed charges,Implant Device,338.1,70,,338.1,percent of total billed charges,All Other,328.44,34,,328.44,percent of total billed charges,Implant Device,328.44,34,,328.44,percent of total billed charges,Implant Device,338.1,35,,338.1,percent of total billed charges,Implant Device,338.1,35,,338.1,percent of total billed charges,Implant Device,338.1,35,,338.1,percent of total billed charges,Implant Device,338.1,35,,338.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,714.84,
SYNTHES XM106.1625S TISSUE MATRX 16X25CM,C1713,HCPCS,,79003692,CDM,278,RC,,,both,,,36810,27239.49,,,27239.49,Other,150% of Medicare + 9.63% HCRA Surcharge,16564.5,45,,16564.5,percent of total billed charges,Critical Access Hospital RCC factor,12515.4,34,,12515.4,percent of total billed charges,Implant Device,12515.4,34,,12515.4,percent of total billed charges,Implant Device,12515.4,34,,12515.4,percent of total billed charges,Implant Device,12515.4,34,,12515.4,percent of total billed charges,Implant Device,12515.4,34,,12515.4,percent of total billed charges,Implant Device,18220.95,,,18220.95,Other,110% of Medicare,12883.5,35,,12883.5,percent of total billed charges,Implant Device,12515.4,34,"Charges > $500, x 34%",12515.4,percent of total billed charges,Implant Device,12883.5,35,,12883.5,percent of total billed charges,Implant Device,12883.5,35,,12883.5,percent of total billed charges,Implant Device,12883.5,35,,12883.5,percent of total billed charges,Implant Device,12883.5,35,,12883.5,percent of total billed charges,Implant Device,12883.5,35,,12883.5,percent of total billed charges,Implant Device,14724,40,,14724,percent of total billed charges,Implant Device,12883.5,70,,12883.5,percent of total billed charges,All Other,12515.4,34,,12515.4,percent of total billed charges,Implant Device,12515.4,34,,12515.4,percent of total billed charges,Implant Device,12883.5,35,,12883.5,percent of total billed charges,Implant Device,12883.5,35,,12883.5,percent of total billed charges,Implant Device,12883.5,35,,12883.5,percent of total billed charges,Implant Device,12883.5,35,,12883.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,12515.4,34,"If Charge > 2,000, then 34 percent",12515.4,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,27239.49,
ZIMMER 00-2359-014-35 SCREW 3.5X14MM,C1713,HCPCS,,79003696,CDM,278,RC,,,both,,,306,226.44,,,226.44,Other,150% of Medicare + 9.63% HCRA Surcharge,137.7,45,,137.7,percent of total billed charges,Critical Access Hospital RCC factor,104.04,34,,104.04,percent of total billed charges,Implant Device,104.04,34,,104.04,percent of total billed charges,Implant Device,104.04,34,,104.04,percent of total billed charges,Implant Device,104.04,34,,104.04,percent of total billed charges,Implant Device,104.04,34,,104.04,percent of total billed charges,Implant Device,151.47,,,151.47,Other,110% of Medicare,107.1,35,,107.1,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,107.1,35,,107.1,percent of total billed charges,Implant Device,107.1,35,,107.1,percent of total billed charges,Implant Device,107.1,35,,107.1,percent of total billed charges,Implant Device,107.1,35,,107.1,percent of total billed charges,Implant Device,107.1,35,,107.1,percent of total billed charges,Implant Device,122.4,40,,122.4,percent of total billed charges,Implant Device,107.1,70,,107.1,percent of total billed charges,All Other,104.04,34,,104.04,percent of total billed charges,Implant Device,104.04,34,,104.04,percent of total billed charges,Implant Device,107.1,35,,107.1,percent of total billed charges,Implant Device,107.1,35,,107.1,percent of total billed charges,Implant Device,107.1,35,,107.1,percent of total billed charges,Implant Device,107.1,35,,107.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,226.44,
ZIMMER 00-2359-016-35 SCREW 3.5X16MM,C1713,HCPCS,,79003697,CDM,278,RC,,,both,,,310,229.4,,,229.4,Other,150% of Medicare + 9.63% HCRA Surcharge,139.5,45,,139.5,percent of total billed charges,Critical Access Hospital RCC factor,105.4,34,,105.4,percent of total billed charges,Implant Device,105.4,34,,105.4,percent of total billed charges,Implant Device,105.4,34,,105.4,percent of total billed charges,Implant Device,105.4,34,,105.4,percent of total billed charges,Implant Device,105.4,34,,105.4,percent of total billed charges,Implant Device,153.45,,,153.45,Other,110% of Medicare,108.5,35,,108.5,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,108.5,35,,108.5,percent of total billed charges,Implant Device,108.5,35,,108.5,percent of total billed charges,Implant Device,108.5,35,,108.5,percent of total billed charges,Implant Device,108.5,35,,108.5,percent of total billed charges,Implant Device,108.5,35,,108.5,percent of total billed charges,Implant Device,124,40,,124,percent of total billed charges,Implant Device,108.5,70,,108.5,percent of total billed charges,All Other,105.4,34,,105.4,percent of total billed charges,Implant Device,105.4,34,,105.4,percent of total billed charges,Implant Device,108.5,35,,108.5,percent of total billed charges,Implant Device,108.5,35,,108.5,percent of total billed charges,Implant Device,108.5,35,,108.5,percent of total billed charges,Implant Device,108.5,35,,108.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,229.4,
ZIMMER 00-4835-014-01 CORT SCREW 3.4X14,C1713,HCPCS,,79003701,CDM,278,RC,,,both,,,72,53.28,,,53.28,Other,150% of Medicare + 9.63% HCRA Surcharge,32.4,45,,32.4,percent of total billed charges,Critical Access Hospital RCC factor,24.48,34,,24.48,percent of total billed charges,Implant Device,24.48,34,,24.48,percent of total billed charges,Implant Device,24.48,34,,24.48,percent of total billed charges,Implant Device,24.48,34,,24.48,percent of total billed charges,Implant Device,24.48,34,,24.48,percent of total billed charges,Implant Device,35.64,,,35.64,Other,110% of Medicare,25.2,35,,25.2,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,25.2,35,,25.2,percent of total billed charges,Implant Device,25.2,35,,25.2,percent of total billed charges,Implant Device,25.2,35,,25.2,percent of total billed charges,Implant Device,25.2,35,,25.2,percent of total billed charges,Implant Device,25.2,35,,25.2,percent of total billed charges,Implant Device,28.8,40,,28.8,percent of total billed charges,Implant Device,25.2,70,,25.2,percent of total billed charges,All Other,24.48,34,,24.48,percent of total billed charges,Implant Device,24.48,34,,24.48,percent of total billed charges,Implant Device,25.2,35,,25.2,percent of total billed charges,Implant Device,25.2,35,,25.2,percent of total billed charges,Implant Device,25.2,35,,25.2,percent of total billed charges,Implant Device,25.2,35,,25.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,53.28,
ZIMMER 00-4835-016-01 CORT SCREW 3.5X16,C1713,HCPCS,,79003702,CDM,278,RC,,,both,,,72,53.28,,,53.28,Other,150% of Medicare + 9.63% HCRA Surcharge,32.4,45,,32.4,percent of total billed charges,Critical Access Hospital RCC factor,24.48,34,,24.48,percent of total billed charges,Implant Device,24.48,34,,24.48,percent of total billed charges,Implant Device,24.48,34,,24.48,percent of total billed charges,Implant Device,24.48,34,,24.48,percent of total billed charges,Implant Device,24.48,34,,24.48,percent of total billed charges,Implant Device,35.64,,,35.64,Other,110% of Medicare,25.2,35,,25.2,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,25.2,35,,25.2,percent of total billed charges,Implant Device,25.2,35,,25.2,percent of total billed charges,Implant Device,25.2,35,,25.2,percent of total billed charges,Implant Device,25.2,35,,25.2,percent of total billed charges,Implant Device,25.2,35,,25.2,percent of total billed charges,Implant Device,28.8,40,,28.8,percent of total billed charges,Implant Device,25.2,70,,25.2,percent of total billed charges,All Other,24.48,34,,24.48,percent of total billed charges,Implant Device,24.48,34,,24.48,percent of total billed charges,Implant Device,25.2,35,,25.2,percent of total billed charges,Implant Device,25.2,35,,25.2,percent of total billed charges,Implant Device,25.2,35,,25.2,percent of total billed charges,Implant Device,25.2,35,,25.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,53.28,
ZIMMER 00-4835-018-01 CORT SCREW 3.5X18,C1713,HCPCS,,79003703,CDM,278,RC,,,both,,,72,53.28,,,53.28,Other,150% of Medicare + 9.63% HCRA Surcharge,32.4,45,,32.4,percent of total billed charges,Critical Access Hospital RCC factor,24.48,34,,24.48,percent of total billed charges,Implant Device,24.48,34,,24.48,percent of total billed charges,Implant Device,24.48,34,,24.48,percent of total billed charges,Implant Device,24.48,34,,24.48,percent of total billed charges,Implant Device,24.48,34,,24.48,percent of total billed charges,Implant Device,35.64,,,35.64,Other,110% of Medicare,25.2,35,,25.2,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,25.2,35,,25.2,percent of total billed charges,Implant Device,25.2,35,,25.2,percent of total billed charges,Implant Device,25.2,35,,25.2,percent of total billed charges,Implant Device,25.2,35,,25.2,percent of total billed charges,Implant Device,25.2,35,,25.2,percent of total billed charges,Implant Device,28.8,40,,28.8,percent of total billed charges,Implant Device,25.2,70,,25.2,percent of total billed charges,All Other,24.48,34,,24.48,percent of total billed charges,Implant Device,24.48,34,,24.48,percent of total billed charges,Implant Device,25.2,35,,25.2,percent of total billed charges,Implant Device,25.2,35,,25.2,percent of total billed charges,Implant Device,25.2,35,,25.2,percent of total billed charges,Implant Device,25.2,35,,25.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,53.28,
STRYKER 6191-1-010 SIMPLEX BONE CEMENT,C1713,HCPCS,,79003711,CDM,278,RC,,,both,,,314,232.36,,,232.36,Other,150% of Medicare + 9.63% HCRA Surcharge,141.3,45,,141.3,percent of total billed charges,Critical Access Hospital RCC factor,106.76,34,,106.76,percent of total billed charges,Implant Device,106.76,34,,106.76,percent of total billed charges,Implant Device,106.76,34,,106.76,percent of total billed charges,Implant Device,106.76,34,,106.76,percent of total billed charges,Implant Device,106.76,34,,106.76,percent of total billed charges,Implant Device,155.43,,,155.43,Other,110% of Medicare,109.9,35,,109.9,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,109.9,35,,109.9,percent of total billed charges,Implant Device,109.9,35,,109.9,percent of total billed charges,Implant Device,109.9,35,,109.9,percent of total billed charges,Implant Device,109.9,35,,109.9,percent of total billed charges,Implant Device,109.9,35,,109.9,percent of total billed charges,Implant Device,125.6,40,,125.6,percent of total billed charges,Implant Device,109.9,70,,109.9,percent of total billed charges,All Other,106.76,34,,106.76,percent of total billed charges,Implant Device,106.76,34,,106.76,percent of total billed charges,Implant Device,109.9,35,,109.9,percent of total billed charges,Implant Device,109.9,35,,109.9,percent of total billed charges,Implant Device,109.9,35,,109.9,percent of total billed charges,Implant Device,109.9,35,,109.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,232.36,
COOK G49668 PANCREATIC STENT 5FRX30,C2617,HCPCS,,79003713,CDM,278,RC,,,both,,,291,215.34,,,215.34,Other,150% of Medicare + 9.63% HCRA Surcharge,130.95,45,,130.95,percent of total billed charges,Critical Access Hospital RCC factor,98.94,34,,98.94,percent of total billed charges,Implant Device,98.94,34,,98.94,percent of total billed charges,Implant Device,98.94,34,,98.94,percent of total billed charges,Implant Device,98.94,34,,98.94,percent of total billed charges,Implant Device,98.94,34,,98.94,percent of total billed charges,Implant Device,144.05,,,144.05,Other,110% of Medicare,101.85,35,,101.85,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,101.85,35,,101.85,percent of total billed charges,Implant Device,101.85,35,,101.85,percent of total billed charges,Implant Device,101.85,35,,101.85,percent of total billed charges,Implant Device,101.85,35,,101.85,percent of total billed charges,Implant Device,101.85,35,,101.85,percent of total billed charges,Implant Device,116.4,40,,116.4,percent of total billed charges,Implant Device,101.85,70,,101.85,percent of total billed charges,All Other,98.94,34,,98.94,percent of total billed charges,Implant Device,98.94,34,,98.94,percent of total billed charges,Implant Device,101.85,35,,101.85,percent of total billed charges,Implant Device,101.85,35,,101.85,percent of total billed charges,Implant Device,101.85,35,,101.85,percent of total billed charges,Implant Device,101.85,35,,101.85,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,215.34,
BARD FTL10060 FLUENCY STENT GRAFT 10X60,C1874,HCPCS,,79003716,CDM,278,RC,,,both,,,10917,8078.61,,,8078.61,Other,150% of Medicare + 9.63% HCRA Surcharge,4912.65,45,,4912.65,percent of total billed charges,Critical Access Hospital RCC factor,3711.78,34,,3711.78,percent of total billed charges,Implant Device,3711.78,34,,3711.78,percent of total billed charges,Implant Device,3711.78,34,,3711.78,percent of total billed charges,Implant Device,3711.78,34,,3711.78,percent of total billed charges,Implant Device,3711.78,34,,3711.78,percent of total billed charges,Implant Device,5403.92,,,5403.92,Other,110% of Medicare,3820.95,35,,3820.95,percent of total billed charges,Implant Device,3711.78,34,"Charges > $500, x 34%",3711.78,percent of total billed charges,Implant Device,3820.95,35,,3820.95,percent of total billed charges,Implant Device,3820.95,35,,3820.95,percent of total billed charges,Implant Device,3820.95,35,,3820.95,percent of total billed charges,Implant Device,3820.95,35,,3820.95,percent of total billed charges,Implant Device,3820.95,35,,3820.95,percent of total billed charges,Implant Device,4366.8,40,,4366.8,percent of total billed charges,Implant Device,3820.95,70,,3820.95,percent of total billed charges,All Other,3711.78,34,,3711.78,percent of total billed charges,Implant Device,3711.78,34,,3711.78,percent of total billed charges,Implant Device,3820.95,35,,3820.95,percent of total billed charges,Implant Device,3820.95,35,,3820.95,percent of total billed charges,Implant Device,3820.95,35,,3820.95,percent of total billed charges,Implant Device,3820.95,35,,3820.95,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3711.78,34,"If Charge > 2,000, then 34 percent",3711.78,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,8078.61,
ZIMMER 5960-99 NEXGEN TAPER STEM PLUG,C1776,HCPCS,,79003717,CDM,278,RC,,,both,,,2476,1832.25,,,1832.25,Other,150% of Medicare + 9.63% HCRA Surcharge,1114.2,45,,1114.2,percent of total billed charges,Critical Access Hospital RCC factor,841.84,34,,841.84,percent of total billed charges,Implant Device,841.84,34,,841.84,percent of total billed charges,Implant Device,841.84,34,,841.84,percent of total billed charges,Implant Device,841.84,34,,841.84,percent of total billed charges,Implant Device,841.84,34,,841.84,percent of total billed charges,Implant Device,1225.62,,,1225.62,Other,110% of Medicare,866.6,35,,866.6,percent of total billed charges,Implant Device,841.84,34,"Charges > $500, x 34%",841.84,percent of total billed charges,Implant Device,866.6,35,,866.6,percent of total billed charges,Implant Device,866.6,35,,866.6,percent of total billed charges,Implant Device,866.6,35,,866.6,percent of total billed charges,Implant Device,866.6,35,,866.6,percent of total billed charges,Implant Device,866.6,35,,866.6,percent of total billed charges,Implant Device,990.4,40,,990.4,percent of total billed charges,Implant Device,866.6,70,,866.6,percent of total billed charges,All Other,841.84,34,,841.84,percent of total billed charges,Implant Device,841.84,34,,841.84,percent of total billed charges,Implant Device,866.6,35,,866.6,percent of total billed charges,Implant Device,866.6,35,,866.6,percent of total billed charges,Implant Device,866.6,35,,866.6,percent of total billed charges,Implant Device,866.6,35,,866.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,841.84,34,"If Charge > 2,000, then 34 percent",841.84,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1832.25,
ZIMMER 00-8751-010-36 POLY LINER 36MM,C1776,HCPCS,,79003718,CDM,278,RC,,,both,,,4973,3680.03,,,3680.03,Other,150% of Medicare + 9.63% HCRA Surcharge,2237.85,45,,2237.85,percent of total billed charges,Critical Access Hospital RCC factor,1690.82,34,,1690.82,percent of total billed charges,Implant Device,1690.82,34,,1690.82,percent of total billed charges,Implant Device,1690.82,34,,1690.82,percent of total billed charges,Implant Device,1690.82,34,,1690.82,percent of total billed charges,Implant Device,1690.82,34,,1690.82,percent of total billed charges,Implant Device,2461.64,,,2461.64,Other,110% of Medicare,1740.55,35,,1740.55,percent of total billed charges,Implant Device,1690.82,34,"Charges > $500, x 34%",1690.82,percent of total billed charges,Implant Device,1740.55,35,,1740.55,percent of total billed charges,Implant Device,1740.55,35,,1740.55,percent of total billed charges,Implant Device,1740.55,35,,1740.55,percent of total billed charges,Implant Device,1740.55,35,,1740.55,percent of total billed charges,Implant Device,1740.55,35,,1740.55,percent of total billed charges,Implant Device,1989.2,40,,1989.2,percent of total billed charges,Implant Device,1740.55,70,,1740.55,percent of total billed charges,All Other,1690.82,34,,1690.82,percent of total billed charges,Implant Device,1690.82,34,,1690.82,percent of total billed charges,Implant Device,1740.55,35,,1740.55,percent of total billed charges,Implant Device,1740.55,35,,1740.55,percent of total billed charges,Implant Device,1740.55,35,,1740.55,percent of total billed charges,Implant Device,1740.55,35,,1740.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1690.82,34,"If Charge > 2,000, then 34 percent",1690.82,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3680.03,
STRYKER 6260-9-126 FEMORAL HEAD 26X+0MM,C1776,HCPCS,,79003719,CDM,278,RC,,,both,,,1391,1029.34,,,1029.34,Other,150% of Medicare + 9.63% HCRA Surcharge,625.95,45,,625.95,percent of total billed charges,Critical Access Hospital RCC factor,472.94,34,,472.94,percent of total billed charges,Implant Device,472.94,34,,472.94,percent of total billed charges,Implant Device,472.94,34,,472.94,percent of total billed charges,Implant Device,472.94,34,,472.94,percent of total billed charges,Implant Device,472.94,34,,472.94,percent of total billed charges,Implant Device,688.55,,,688.55,Other,110% of Medicare,486.85,35,,486.85,percent of total billed charges,Implant Device,472.94,34,"Charges > $500, x 34%",472.94,percent of total billed charges,Implant Device,486.85,35,,486.85,percent of total billed charges,Implant Device,486.85,35,,486.85,percent of total billed charges,Implant Device,486.85,35,,486.85,percent of total billed charges,Implant Device,486.85,35,,486.85,percent of total billed charges,Implant Device,486.85,35,,486.85,percent of total billed charges,Implant Device,556.4,40,,556.4,percent of total billed charges,Implant Device,486.85,70,,486.85,percent of total billed charges,All Other,472.94,34,,472.94,percent of total billed charges,Implant Device,472.94,34,,472.94,percent of total billed charges,Implant Device,486.85,35,,486.85,percent of total billed charges,Implant Device,486.85,35,,486.85,percent of total billed charges,Implant Device,486.85,35,,486.85,percent of total billed charges,Implant Device,486.85,35,,486.85,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1029.34,
STRYKER 6495-1-102 FEMORAL COMP LT,C1776,HCPCS,,79003720,CDM,278,RC,,,both,,,20749,15354.31,,,15354.31,Other,150% of Medicare + 9.63% HCRA Surcharge,9337.05,45,,9337.05,percent of total billed charges,Critical Access Hospital RCC factor,7054.66,34,,7054.66,percent of total billed charges,Implant Device,7054.66,34,,7054.66,percent of total billed charges,Implant Device,7054.66,34,,7054.66,percent of total billed charges,Implant Device,7054.66,34,,7054.66,percent of total billed charges,Implant Device,7054.66,34,,7054.66,percent of total billed charges,Implant Device,10270.76,,,10270.76,Other,110% of Medicare,7262.15,35,,7262.15,percent of total billed charges,Implant Device,7054.66,34,"Charges > $500, x 34%",7054.66,percent of total billed charges,Implant Device,7262.15,35,,7262.15,percent of total billed charges,Implant Device,7262.15,35,,7262.15,percent of total billed charges,Implant Device,7262.15,35,,7262.15,percent of total billed charges,Implant Device,7262.15,35,,7262.15,percent of total billed charges,Implant Device,7262.15,35,,7262.15,percent of total billed charges,Implant Device,8299.6,40,,8299.6,percent of total billed charges,Implant Device,7262.15,70,,7262.15,percent of total billed charges,All Other,7054.66,34,,7054.66,percent of total billed charges,Implant Device,7054.66,34,,7054.66,percent of total billed charges,Implant Device,7262.15,35,,7262.15,percent of total billed charges,Implant Device,7262.15,35,,7262.15,percent of total billed charges,Implant Device,7262.15,35,,7262.15,percent of total billed charges,Implant Device,7262.15,35,,7262.15,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,7054.66,34,"If Charge > 2,000, then 34 percent",7054.66,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,15354.31,
STRYKER 6495-6-080 GMRS EXT PIECE 80MM,C1776,HCPCS,,79003721,CDM,278,RC,,,both,,,11686,8647.67,,,8647.67,Other,150% of Medicare + 9.63% HCRA Surcharge,5258.7,45,,5258.7,percent of total billed charges,Critical Access Hospital RCC factor,3973.24,34,,3973.24,percent of total billed charges,Implant Device,3973.24,34,,3973.24,percent of total billed charges,Implant Device,3973.24,34,,3973.24,percent of total billed charges,Implant Device,3973.24,34,,3973.24,percent of total billed charges,Implant Device,3973.24,34,,3973.24,percent of total billed charges,Implant Device,5784.57,,,5784.57,Other,110% of Medicare,4090.1,35,,4090.1,percent of total billed charges,Implant Device,3973.24,34,"Charges > $500, x 34%",3973.24,percent of total billed charges,Implant Device,4090.1,35,,4090.1,percent of total billed charges,Implant Device,4090.1,35,,4090.1,percent of total billed charges,Implant Device,4090.1,35,,4090.1,percent of total billed charges,Implant Device,4090.1,35,,4090.1,percent of total billed charges,Implant Device,4090.1,35,,4090.1,percent of total billed charges,Implant Device,4674.4,40,,4674.4,percent of total billed charges,Implant Device,4090.1,70,,4090.1,percent of total billed charges,All Other,3973.24,34,,3973.24,percent of total billed charges,Implant Device,3973.24,34,,3973.24,percent of total billed charges,Implant Device,4090.1,35,,4090.1,percent of total billed charges,Implant Device,4090.1,35,,4090.1,percent of total billed charges,Implant Device,4090.1,35,,4090.1,percent of total billed charges,Implant Device,4090.1,35,,4090.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3973.24,34,"If Charge > 2,000, then 34 percent",3973.24,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,8647.67,
STRYKER UH1-55-26 UNIVERSAL HEAD 55X26MM,C1776,HCPCS,,79003722,CDM,278,RC,,,both,,,1391,1029.34,,,1029.34,Other,150% of Medicare + 9.63% HCRA Surcharge,625.95,45,,625.95,percent of total billed charges,Critical Access Hospital RCC factor,472.94,34,,472.94,percent of total billed charges,Implant Device,472.94,34,,472.94,percent of total billed charges,Implant Device,472.94,34,,472.94,percent of total billed charges,Implant Device,472.94,34,,472.94,percent of total billed charges,Implant Device,472.94,34,,472.94,percent of total billed charges,Implant Device,688.55,,,688.55,Other,110% of Medicare,486.85,35,,486.85,percent of total billed charges,Implant Device,472.94,34,"Charges > $500, x 34%",472.94,percent of total billed charges,Implant Device,486.85,35,,486.85,percent of total billed charges,Implant Device,486.85,35,,486.85,percent of total billed charges,Implant Device,486.85,35,,486.85,percent of total billed charges,Implant Device,486.85,35,,486.85,percent of total billed charges,Implant Device,486.85,35,,486.85,percent of total billed charges,Implant Device,556.4,40,,556.4,percent of total billed charges,Implant Device,486.85,70,,486.85,percent of total billed charges,All Other,472.94,34,,472.94,percent of total billed charges,Implant Device,472.94,34,,472.94,percent of total billed charges,Implant Device,486.85,35,,486.85,percent of total billed charges,Implant Device,486.85,35,,486.85,percent of total billed charges,Implant Device,486.85,35,,486.85,percent of total billed charges,Implant Device,486.85,35,,486.85,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1029.34,
STRYKER 6495-6-030 GMRS EXT PIECE 30MM,C1776,HCPCS,,79003723,CDM,278,RC,,,both,,,7856,5813.46,,,5813.46,Other,150% of Medicare + 9.63% HCRA Surcharge,3535.2,45,,3535.2,percent of total billed charges,Critical Access Hospital RCC factor,2671.04,34,,2671.04,percent of total billed charges,Implant Device,2671.04,34,,2671.04,percent of total billed charges,Implant Device,2671.04,34,,2671.04,percent of total billed charges,Implant Device,2671.04,34,,2671.04,percent of total billed charges,Implant Device,2671.04,34,,2671.04,percent of total billed charges,Implant Device,3888.72,,,3888.72,Other,110% of Medicare,2749.6,35,,2749.6,percent of total billed charges,Implant Device,2671.04,34,"Charges > $500, x 34%",2671.04,percent of total billed charges,Implant Device,2749.6,35,,2749.6,percent of total billed charges,Implant Device,2749.6,35,,2749.6,percent of total billed charges,Implant Device,2749.6,35,,2749.6,percent of total billed charges,Implant Device,2749.6,35,,2749.6,percent of total billed charges,Implant Device,2749.6,35,,2749.6,percent of total billed charges,Implant Device,3142.4,40,,3142.4,percent of total billed charges,Implant Device,2749.6,70,,2749.6,percent of total billed charges,All Other,2671.04,34,,2671.04,percent of total billed charges,Implant Device,2671.04,34,,2671.04,percent of total billed charges,Implant Device,2749.6,35,,2749.6,percent of total billed charges,Implant Device,2749.6,35,,2749.6,percent of total billed charges,Implant Device,2749.6,35,,2749.6,percent of total billed charges,Implant Device,2749.6,35,,2749.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2671.04,34,"If Charge > 2,000, then 34 percent",2671.04,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5813.46,
STRYKER 8485-3-113 STRAIGHT STEM 13X127,C1776,HCPCS,,79003724,CDM,278,RC,,,both,,,10792,7986.11,,,7986.11,Other,150% of Medicare + 9.63% HCRA Surcharge,4856.4,45,,4856.4,percent of total billed charges,Critical Access Hospital RCC factor,3669.28,34,,3669.28,percent of total billed charges,Implant Device,3669.28,34,,3669.28,percent of total billed charges,Implant Device,3669.28,34,,3669.28,percent of total billed charges,Implant Device,3669.28,34,,3669.28,percent of total billed charges,Implant Device,3669.28,34,,3669.28,percent of total billed charges,Implant Device,5342.04,,,5342.04,Other,110% of Medicare,3777.2,35,,3777.2,percent of total billed charges,Implant Device,3669.28,34,"Charges > $500, x 34%",3669.28,percent of total billed charges,Implant Device,3777.2,35,,3777.2,percent of total billed charges,Implant Device,3777.2,35,,3777.2,percent of total billed charges,Implant Device,3777.2,35,,3777.2,percent of total billed charges,Implant Device,3777.2,35,,3777.2,percent of total billed charges,Implant Device,3777.2,35,,3777.2,percent of total billed charges,Implant Device,4316.8,40,,4316.8,percent of total billed charges,Implant Device,3777.2,70,,3777.2,percent of total billed charges,All Other,3669.28,34,,3669.28,percent of total billed charges,Implant Device,3669.28,34,,3669.28,percent of total billed charges,Implant Device,3777.2,35,,3777.2,percent of total billed charges,Implant Device,3777.2,35,,3777.2,percent of total billed charges,Implant Device,3777.2,35,,3777.2,percent of total billed charges,Implant Device,3777.2,35,,3777.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3669.28,34,"If Charge > 2,000, then 34 percent",3669.28,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,7986.11,
STRYKER 6704-3-090 TROCH GRIP CABLES LG,C1713,HCPCS,,79003725,CDM,278,RC,,,both,,,5203,3850.23,,,3850.23,Other,150% of Medicare + 9.63% HCRA Surcharge,2341.35,45,,2341.35,percent of total billed charges,Critical Access Hospital RCC factor,1769.02,34,,1769.02,percent of total billed charges,Implant Device,1769.02,34,,1769.02,percent of total billed charges,Implant Device,1769.02,34,,1769.02,percent of total billed charges,Implant Device,1769.02,34,,1769.02,percent of total billed charges,Implant Device,1769.02,34,,1769.02,percent of total billed charges,Implant Device,2575.49,,,2575.49,Other,110% of Medicare,1821.05,35,,1821.05,percent of total billed charges,Implant Device,1769.02,34,"Charges > $500, x 34%",1769.02,percent of total billed charges,Implant Device,1821.05,35,,1821.05,percent of total billed charges,Implant Device,1821.05,35,,1821.05,percent of total billed charges,Implant Device,1821.05,35,,1821.05,percent of total billed charges,Implant Device,1821.05,35,,1821.05,percent of total billed charges,Implant Device,1821.05,35,,1821.05,percent of total billed charges,Implant Device,2081.2,40,,2081.2,percent of total billed charges,Implant Device,1821.05,70,,1821.05,percent of total billed charges,All Other,1769.02,34,,1769.02,percent of total billed charges,Implant Device,1769.02,34,,1769.02,percent of total billed charges,Implant Device,1821.05,35,,1821.05,percent of total billed charges,Implant Device,1821.05,35,,1821.05,percent of total billed charges,Implant Device,1821.05,35,,1821.05,percent of total billed charges,Implant Device,1821.05,35,,1821.05,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1769.02,34,"If Charge > 2,000, then 34 percent",1769.02,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3850.23,
ARTHREX AR-1400C BIOCOMP SCREW 6X23MM,C1713,HCPCS,,79003727,CDM,278,RC,,,both,,,966,714.84,,,714.84,Other,150% of Medicare + 9.63% HCRA Surcharge,434.7,45,,434.7,percent of total billed charges,Critical Access Hospital RCC factor,328.44,34,,328.44,percent of total billed charges,Implant Device,328.44,34,,328.44,percent of total billed charges,Implant Device,328.44,34,,328.44,percent of total billed charges,Implant Device,328.44,34,,328.44,percent of total billed charges,Implant Device,328.44,34,,328.44,percent of total billed charges,Implant Device,478.17,,,478.17,Other,110% of Medicare,338.1,35,,338.1,percent of total billed charges,Implant Device,328.44,34,"Charges > $500, x 34%",328.44,percent of total billed charges,Implant Device,338.1,35,,338.1,percent of total billed charges,Implant Device,338.1,35,,338.1,percent of total billed charges,Implant Device,338.1,35,,338.1,percent of total billed charges,Implant Device,338.1,35,,338.1,percent of total billed charges,Implant Device,338.1,35,,338.1,percent of total billed charges,Implant Device,386.4,40,,386.4,percent of total billed charges,Implant Device,338.1,70,,338.1,percent of total billed charges,All Other,328.44,34,,328.44,percent of total billed charges,Implant Device,328.44,34,,328.44,percent of total billed charges,Implant Device,338.1,35,,338.1,percent of total billed charges,Implant Device,338.1,35,,338.1,percent of total billed charges,Implant Device,338.1,35,,338.1,percent of total billed charges,Implant Device,338.1,35,,338.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,714.84,
ACUMED 70-0294 CLAVICLE PLATE 4 HOLE,C1713,HCPCS,,79003731,CDM,278,RC,,,both,,,2940,2175.61,,,2175.61,Other,150% of Medicare + 9.63% HCRA Surcharge,1323,45,,1323,percent of total billed charges,Critical Access Hospital RCC factor,999.6,34,,999.6,percent of total billed charges,Implant Device,999.6,34,,999.6,percent of total billed charges,Implant Device,999.6,34,,999.6,percent of total billed charges,Implant Device,999.6,34,,999.6,percent of total billed charges,Implant Device,999.6,34,,999.6,percent of total billed charges,Implant Device,1455.3,,,1455.3,Other,110% of Medicare,1029,35,,1029,percent of total billed charges,Implant Device,999.6,34,"Charges > $500, x 34%",999.6,percent of total billed charges,Implant Device,1029,35,,1029,percent of total billed charges,Implant Device,1029,35,,1029,percent of total billed charges,Implant Device,1029,35,,1029,percent of total billed charges,Implant Device,1029,35,,1029,percent of total billed charges,Implant Device,1029,35,,1029,percent of total billed charges,Implant Device,1176,40,,1176,percent of total billed charges,Implant Device,1029,70,,1029,percent of total billed charges,All Other,999.6,34,,999.6,percent of total billed charges,Implant Device,999.6,34,,999.6,percent of total billed charges,Implant Device,1029,35,,1029,percent of total billed charges,Implant Device,1029,35,,1029,percent of total billed charges,Implant Device,1029,35,,1029,percent of total billed charges,Implant Device,1029,35,,1029,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,999.6,34,"If Charge > 2,000, then 34 percent",999.6,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2175.61,
ACUMED CO-2326 THRED LOCK SCREW 2.3X26MM,C1713,HCPCS,,79003732,CDM,278,RC,,,both,,,312,230.88,,,230.88,Other,150% of Medicare + 9.63% HCRA Surcharge,140.4,45,,140.4,percent of total billed charges,Critical Access Hospital RCC factor,106.08,34,,106.08,percent of total billed charges,Implant Device,106.08,34,,106.08,percent of total billed charges,Implant Device,106.08,34,,106.08,percent of total billed charges,Implant Device,106.08,34,,106.08,percent of total billed charges,Implant Device,106.08,34,,106.08,percent of total billed charges,Implant Device,154.44,,,154.44,Other,110% of Medicare,109.2,35,,109.2,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,109.2,35,,109.2,percent of total billed charges,Implant Device,109.2,35,,109.2,percent of total billed charges,Implant Device,109.2,35,,109.2,percent of total billed charges,Implant Device,109.2,35,,109.2,percent of total billed charges,Implant Device,109.2,35,,109.2,percent of total billed charges,Implant Device,124.8,40,,124.8,percent of total billed charges,Implant Device,109.2,70,,109.2,percent of total billed charges,All Other,106.08,34,,106.08,percent of total billed charges,Implant Device,106.08,34,,106.08,percent of total billed charges,Implant Device,109.2,35,,109.2,percent of total billed charges,Implant Device,109.2,35,,109.2,percent of total billed charges,Implant Device,109.2,35,,109.2,percent of total billed charges,Implant Device,109.2,35,,109.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,230.88,
ACUMED AT2-M165 ACUTAK 2 SCREW 16MM,C1713,HCPCS,,79003733,CDM,278,RC,,,both,,,1374,1016.76,,,1016.76,Other,150% of Medicare + 9.63% HCRA Surcharge,618.3,45,,618.3,percent of total billed charges,Critical Access Hospital RCC factor,467.16,34,,467.16,percent of total billed charges,Implant Device,467.16,34,,467.16,percent of total billed charges,Implant Device,467.16,34,,467.16,percent of total billed charges,Implant Device,467.16,34,,467.16,percent of total billed charges,Implant Device,467.16,34,,467.16,percent of total billed charges,Implant Device,680.13,,,680.13,Other,110% of Medicare,480.9,35,,480.9,percent of total billed charges,Implant Device,467.16,34,"Charges > $500, x 34%",467.16,percent of total billed charges,Implant Device,480.9,35,,480.9,percent of total billed charges,Implant Device,480.9,35,,480.9,percent of total billed charges,Implant Device,480.9,35,,480.9,percent of total billed charges,Implant Device,480.9,35,,480.9,percent of total billed charges,Implant Device,480.9,35,,480.9,percent of total billed charges,Implant Device,549.6,40,,549.6,percent of total billed charges,Implant Device,480.9,70,,480.9,percent of total billed charges,All Other,467.16,34,,467.16,percent of total billed charges,Implant Device,467.16,34,,467.16,percent of total billed charges,Implant Device,480.9,35,,480.9,percent of total billed charges,Implant Device,480.9,35,,480.9,percent of total billed charges,Implant Device,480.9,35,,480.9,percent of total billed charges,Implant Device,480.9,35,,480.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1016.76,
ACUMED TR-H240R-S RADIAL HD RIGHT 24MM,C1776,HCPCS,,79003734,CDM,278,RC,,,both,,,8176,6050.26,,,6050.26,Other,150% of Medicare + 9.63% HCRA Surcharge,3679.2,45,,3679.2,percent of total billed charges,Critical Access Hospital RCC factor,2779.84,34,,2779.84,percent of total billed charges,Implant Device,2779.84,34,,2779.84,percent of total billed charges,Implant Device,2779.84,34,,2779.84,percent of total billed charges,Implant Device,2779.84,34,,2779.84,percent of total billed charges,Implant Device,2779.84,34,,2779.84,percent of total billed charges,Implant Device,4047.12,,,4047.12,Other,110% of Medicare,2861.6,35,,2861.6,percent of total billed charges,Implant Device,2779.84,34,"Charges > $500, x 34%",2779.84,percent of total billed charges,Implant Device,2861.6,35,,2861.6,percent of total billed charges,Implant Device,2861.6,35,,2861.6,percent of total billed charges,Implant Device,2861.6,35,,2861.6,percent of total billed charges,Implant Device,2861.6,35,,2861.6,percent of total billed charges,Implant Device,2861.6,35,,2861.6,percent of total billed charges,Implant Device,3270.4,40,,3270.4,percent of total billed charges,Implant Device,2861.6,70,,2861.6,percent of total billed charges,All Other,2779.84,34,,2779.84,percent of total billed charges,Implant Device,2779.84,34,,2779.84,percent of total billed charges,Implant Device,2861.6,35,,2861.6,percent of total billed charges,Implant Device,2861.6,35,,2861.6,percent of total billed charges,Implant Device,2861.6,35,,2861.6,percent of total billed charges,Implant Device,2861.6,35,,2861.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2779.84,34,"If Charge > 2,000, then 34 percent",2779.84,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,6050.26,
ACUMED COL-2712 2.7X12MM LOCKING SCREW,C1713,HCPCS,,79003735,CDM,278,RC,,,both,,,328,242.72,,,242.72,Other,150% of Medicare + 9.63% HCRA Surcharge,147.6,45,,147.6,percent of total billed charges,Critical Access Hospital RCC factor,111.52,34,,111.52,percent of total billed charges,Implant Device,111.52,34,,111.52,percent of total billed charges,Implant Device,111.52,34,,111.52,percent of total billed charges,Implant Device,111.52,34,,111.52,percent of total billed charges,Implant Device,111.52,34,,111.52,percent of total billed charges,Implant Device,162.36,,,162.36,Other,110% of Medicare,114.8,35,,114.8,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,114.8,35,,114.8,percent of total billed charges,Implant Device,114.8,35,,114.8,percent of total billed charges,Implant Device,114.8,35,,114.8,percent of total billed charges,Implant Device,114.8,35,,114.8,percent of total billed charges,Implant Device,114.8,35,,114.8,percent of total billed charges,Implant Device,131.2,40,,131.2,percent of total billed charges,Implant Device,114.8,70,,114.8,percent of total billed charges,All Other,111.52,34,,111.52,percent of total billed charges,Implant Device,111.52,34,,111.52,percent of total billed charges,Implant Device,114.8,35,,114.8,percent of total billed charges,Implant Device,114.8,35,,114.8,percent of total billed charges,Implant Device,114.8,35,,114.8,percent of total billed charges,Implant Device,114.8,35,,114.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,242.72,
ACUMED COL-3030 3.5X8MM LOCKING SCREW,C1713,HCPCS,,79003736,CDM,278,RC,,,both,,,328,242.72,,,242.72,Other,150% of Medicare + 9.63% HCRA Surcharge,147.6,45,,147.6,percent of total billed charges,Critical Access Hospital RCC factor,111.52,34,,111.52,percent of total billed charges,Implant Device,111.52,34,,111.52,percent of total billed charges,Implant Device,111.52,34,,111.52,percent of total billed charges,Implant Device,111.52,34,,111.52,percent of total billed charges,Implant Device,111.52,34,,111.52,percent of total billed charges,Implant Device,162.36,,,162.36,Other,110% of Medicare,114.8,35,,114.8,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,114.8,35,,114.8,percent of total billed charges,Implant Device,114.8,35,,114.8,percent of total billed charges,Implant Device,114.8,35,,114.8,percent of total billed charges,Implant Device,114.8,35,,114.8,percent of total billed charges,Implant Device,114.8,35,,114.8,percent of total billed charges,Implant Device,131.2,40,,131.2,percent of total billed charges,Implant Device,114.8,70,,114.8,percent of total billed charges,All Other,111.52,34,,111.52,percent of total billed charges,Implant Device,111.52,34,,111.52,percent of total billed charges,Implant Device,114.8,35,,114.8,percent of total billed charges,Implant Device,114.8,35,,114.8,percent of total billed charges,Implant Device,114.8,35,,114.8,percent of total billed charges,Implant Device,114.8,35,,114.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,242.72,
ACUMED TR-S0800-S STEM 8.0X0MM,C1776,HCPCS,,79003737,CDM,278,RC,,,both,,,6951,5143.76,,,5143.76,Other,150% of Medicare + 9.63% HCRA Surcharge,3127.95,45,,3127.95,percent of total billed charges,Critical Access Hospital RCC factor,2363.34,34,,2363.34,percent of total billed charges,Implant Device,2363.34,34,,2363.34,percent of total billed charges,Implant Device,2363.34,34,,2363.34,percent of total billed charges,Implant Device,2363.34,34,,2363.34,percent of total billed charges,Implant Device,2363.34,34,,2363.34,percent of total billed charges,Implant Device,3440.75,,,3440.75,Other,110% of Medicare,2432.85,35,,2432.85,percent of total billed charges,Implant Device,2363.34,34,"Charges > $500, x 34%",2363.34,percent of total billed charges,Implant Device,2432.85,35,,2432.85,percent of total billed charges,Implant Device,2432.85,35,,2432.85,percent of total billed charges,Implant Device,2432.85,35,,2432.85,percent of total billed charges,Implant Device,2432.85,35,,2432.85,percent of total billed charges,Implant Device,2432.85,35,,2432.85,percent of total billed charges,Implant Device,2780.4,40,,2780.4,percent of total billed charges,Implant Device,2432.85,70,,2432.85,percent of total billed charges,All Other,2363.34,34,,2363.34,percent of total billed charges,Implant Device,2363.34,34,,2363.34,percent of total billed charges,Implant Device,2432.85,35,,2432.85,percent of total billed charges,Implant Device,2432.85,35,,2432.85,percent of total billed charges,Implant Device,2432.85,35,,2432.85,percent of total billed charges,Implant Device,2432.85,35,,2432.85,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2363.34,34,"If Charge > 2,000, then 34 percent",2363.34,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5143.76,
ACUMED AT2-M22-S ACUTRAK II BONE SCREW,C1713,HCPCS,,79003738,CDM,278,RC,,,both,,,1374,1016.76,,,1016.76,Other,150% of Medicare + 9.63% HCRA Surcharge,618.3,45,,618.3,percent of total billed charges,Critical Access Hospital RCC factor,467.16,34,,467.16,percent of total billed charges,Implant Device,467.16,34,,467.16,percent of total billed charges,Implant Device,467.16,34,,467.16,percent of total billed charges,Implant Device,467.16,34,,467.16,percent of total billed charges,Implant Device,467.16,34,,467.16,percent of total billed charges,Implant Device,680.13,,,680.13,Other,110% of Medicare,480.9,35,,480.9,percent of total billed charges,Implant Device,467.16,34,"Charges > $500, x 34%",467.16,percent of total billed charges,Implant Device,480.9,35,,480.9,percent of total billed charges,Implant Device,480.9,35,,480.9,percent of total billed charges,Implant Device,480.9,35,,480.9,percent of total billed charges,Implant Device,480.9,35,,480.9,percent of total billed charges,Implant Device,480.9,35,,480.9,percent of total billed charges,Implant Device,549.6,40,,549.6,percent of total billed charges,Implant Device,480.9,70,,480.9,percent of total billed charges,All Other,467.16,34,,467.16,percent of total billed charges,Implant Device,467.16,34,,467.16,percent of total billed charges,Implant Device,480.9,35,,480.9,percent of total billed charges,Implant Device,480.9,35,,480.9,percent of total billed charges,Implant Device,480.9,35,,480.9,percent of total billed charges,Implant Device,480.9,35,,480.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1016.76,
ACUMED AT2-M30-S ACUTAK 2 SCREW 30MM,C1713,HCPCS,,79003739,CDM,278,RC,,,both,,,1374,1016.76,,,1016.76,Other,150% of Medicare + 9.63% HCRA Surcharge,618.3,45,,618.3,percent of total billed charges,Critical Access Hospital RCC factor,467.16,34,,467.16,percent of total billed charges,Implant Device,467.16,34,,467.16,percent of total billed charges,Implant Device,467.16,34,,467.16,percent of total billed charges,Implant Device,467.16,34,,467.16,percent of total billed charges,Implant Device,467.16,34,,467.16,percent of total billed charges,Implant Device,680.13,,,680.13,Other,110% of Medicare,480.9,35,,480.9,percent of total billed charges,Implant Device,467.16,34,"Charges > $500, x 34%",467.16,percent of total billed charges,Implant Device,480.9,35,,480.9,percent of total billed charges,Implant Device,480.9,35,,480.9,percent of total billed charges,Implant Device,480.9,35,,480.9,percent of total billed charges,Implant Device,480.9,35,,480.9,percent of total billed charges,Implant Device,480.9,35,,480.9,percent of total billed charges,Implant Device,549.6,40,,549.6,percent of total billed charges,Implant Device,480.9,70,,480.9,percent of total billed charges,All Other,467.16,34,,467.16,percent of total billed charges,Implant Device,467.16,34,,467.16,percent of total billed charges,Implant Device,480.9,35,,480.9,percent of total billed charges,Implant Device,480.9,35,,480.9,percent of total billed charges,Implant Device,480.9,35,,480.9,percent of total billed charges,Implant Device,480.9,35,,480.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1016.76,
ACUMED AT2-M30 ACUTRAK MINI SCREW 30MM,C1713,HCPCS,,79003740,CDM,278,RC,,,both,,,1570,1161.8,,,1161.8,Other,150% of Medicare + 9.63% HCRA Surcharge,706.5,45,,706.5,percent of total billed charges,Critical Access Hospital RCC factor,533.8,34,,533.8,percent of total billed charges,Implant Device,533.8,34,,533.8,percent of total billed charges,Implant Device,533.8,34,,533.8,percent of total billed charges,Implant Device,533.8,34,,533.8,percent of total billed charges,Implant Device,533.8,34,,533.8,percent of total billed charges,Implant Device,777.15,,,777.15,Other,110% of Medicare,549.5,35,,549.5,percent of total billed charges,Implant Device,533.8,34,"Charges > $500, x 34%",533.8,percent of total billed charges,Implant Device,549.5,35,,549.5,percent of total billed charges,Implant Device,549.5,35,,549.5,percent of total billed charges,Implant Device,549.5,35,,549.5,percent of total billed charges,Implant Device,549.5,35,,549.5,percent of total billed charges,Implant Device,549.5,35,,549.5,percent of total billed charges,Implant Device,628,40,,628,percent of total billed charges,Implant Device,549.5,70,,549.5,percent of total billed charges,All Other,533.8,34,,533.8,percent of total billed charges,Implant Device,533.8,34,,533.8,percent of total billed charges,Implant Device,549.5,35,,549.5,percent of total billed charges,Implant Device,549.5,35,,549.5,percent of total billed charges,Implant Device,549.5,35,,549.5,percent of total billed charges,Implant Device,549.5,35,,549.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1161.8,
ACUMED 70-0305 7 HOLE OLECRANON PATE R,C1713,HCPCS,,79003741,CDM,278,RC,,,both,,,3430,2538.21,,,2538.21,Other,150% of Medicare + 9.63% HCRA Surcharge,1543.5,45,,1543.5,percent of total billed charges,Critical Access Hospital RCC factor,1166.2,34,,1166.2,percent of total billed charges,Implant Device,1166.2,34,,1166.2,percent of total billed charges,Implant Device,1166.2,34,,1166.2,percent of total billed charges,Implant Device,1166.2,34,,1166.2,percent of total billed charges,Implant Device,1166.2,34,,1166.2,percent of total billed charges,Implant Device,1697.85,,,1697.85,Other,110% of Medicare,1200.5,35,,1200.5,percent of total billed charges,Implant Device,1166.2,34,"Charges > $500, x 34%",1166.2,percent of total billed charges,Implant Device,1200.5,35,,1200.5,percent of total billed charges,Implant Device,1200.5,35,,1200.5,percent of total billed charges,Implant Device,1200.5,35,,1200.5,percent of total billed charges,Implant Device,1200.5,35,,1200.5,percent of total billed charges,Implant Device,1200.5,35,,1200.5,percent of total billed charges,Implant Device,1372,40,,1372,percent of total billed charges,Implant Device,1200.5,70,,1200.5,percent of total billed charges,All Other,1166.2,34,,1166.2,percent of total billed charges,Implant Device,1166.2,34,,1166.2,percent of total billed charges,Implant Device,1200.5,35,,1200.5,percent of total billed charges,Implant Device,1200.5,35,,1200.5,percent of total billed charges,Implant Device,1200.5,35,,1200.5,percent of total billed charges,Implant Device,1200.5,35,,1200.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1166.2,34,"If Charge > 2,000, then 34 percent",1166.2,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2538.21,
ACUMED CO-2714 CORTICAL SCREW 2.7X14,C1713,HCPCS,,79003742,CDM,278,RC,,,both,,,234,173.16,,,173.16,Other,150% of Medicare + 9.63% HCRA Surcharge,105.3,45,,105.3,percent of total billed charges,Critical Access Hospital RCC factor,79.56,34,,79.56,percent of total billed charges,Implant Device,79.56,34,,79.56,percent of total billed charges,Implant Device,79.56,34,,79.56,percent of total billed charges,Implant Device,79.56,34,,79.56,percent of total billed charges,Implant Device,79.56,34,,79.56,percent of total billed charges,Implant Device,115.83,,,115.83,Other,110% of Medicare,81.9,35,,81.9,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,81.9,35,,81.9,percent of total billed charges,Implant Device,81.9,35,,81.9,percent of total billed charges,Implant Device,81.9,35,,81.9,percent of total billed charges,Implant Device,81.9,35,,81.9,percent of total billed charges,Implant Device,81.9,35,,81.9,percent of total billed charges,Implant Device,93.6,40,,93.6,percent of total billed charges,Implant Device,81.9,70,,81.9,percent of total billed charges,All Other,79.56,34,,79.56,percent of total billed charges,Implant Device,79.56,34,,79.56,percent of total billed charges,Implant Device,81.9,35,,81.9,percent of total billed charges,Implant Device,81.9,35,,81.9,percent of total billed charges,Implant Device,81.9,35,,81.9,percent of total billed charges,Implant Device,81.9,35,,81.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,173.16,
ACUMED CO-T2322 LOCKING SCREW 2.3X22MM,C1713,HCPCS,,79003743,CDM,278,RC,,,both,,,324,239.76,,,239.76,Other,150% of Medicare + 9.63% HCRA Surcharge,145.8,45,,145.8,percent of total billed charges,Critical Access Hospital RCC factor,110.16,34,,110.16,percent of total billed charges,Implant Device,110.16,34,,110.16,percent of total billed charges,Implant Device,110.16,34,,110.16,percent of total billed charges,Implant Device,110.16,34,,110.16,percent of total billed charges,Implant Device,110.16,34,,110.16,percent of total billed charges,Implant Device,160.38,,,160.38,Other,110% of Medicare,113.4,35,,113.4,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,129.6,40,,129.6,percent of total billed charges,Implant Device,113.4,70,,113.4,percent of total billed charges,All Other,110.16,34,,110.16,percent of total billed charges,Implant Device,110.16,34,,110.16,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,239.76,
ACUMED AT2-M18-S BONE SCREW 18.0MM,C1713,HCPCS,,79003744,CDM,278,RC,,,both,,,1374,1016.76,,,1016.76,Other,150% of Medicare + 9.63% HCRA Surcharge,618.3,45,,618.3,percent of total billed charges,Critical Access Hospital RCC factor,467.16,34,,467.16,percent of total billed charges,Implant Device,467.16,34,,467.16,percent of total billed charges,Implant Device,467.16,34,,467.16,percent of total billed charges,Implant Device,467.16,34,,467.16,percent of total billed charges,Implant Device,467.16,34,,467.16,percent of total billed charges,Implant Device,680.13,,,680.13,Other,110% of Medicare,480.9,35,,480.9,percent of total billed charges,Implant Device,467.16,34,"Charges > $500, x 34%",467.16,percent of total billed charges,Implant Device,480.9,35,,480.9,percent of total billed charges,Implant Device,480.9,35,,480.9,percent of total billed charges,Implant Device,480.9,35,,480.9,percent of total billed charges,Implant Device,480.9,35,,480.9,percent of total billed charges,Implant Device,480.9,35,,480.9,percent of total billed charges,Implant Device,549.6,40,,549.6,percent of total billed charges,Implant Device,480.9,70,,480.9,percent of total billed charges,All Other,467.16,34,,467.16,percent of total billed charges,Implant Device,467.16,34,,467.16,percent of total billed charges,Implant Device,480.9,35,,480.9,percent of total billed charges,Implant Device,480.9,35,,480.9,percent of total billed charges,Implant Device,480.9,35,,480.9,percent of total billed charges,Implant Device,480.9,35,,480.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1016.76,
ACUMED TR-H200R-S RADIAL HEAD 20MM RT,C1776,HCPCS,,79003745,CDM,278,RC,,,both,,,8176,6050.26,,,6050.26,Other,150% of Medicare + 9.63% HCRA Surcharge,3679.2,45,,3679.2,percent of total billed charges,Critical Access Hospital RCC factor,2779.84,34,,2779.84,percent of total billed charges,Implant Device,2779.84,34,,2779.84,percent of total billed charges,Implant Device,2779.84,34,,2779.84,percent of total billed charges,Implant Device,2779.84,34,,2779.84,percent of total billed charges,Implant Device,2779.84,34,,2779.84,percent of total billed charges,Implant Device,4047.12,,,4047.12,Other,110% of Medicare,2861.6,35,,2861.6,percent of total billed charges,Implant Device,2779.84,34,"Charges > $500, x 34%",2779.84,percent of total billed charges,Implant Device,2861.6,35,,2861.6,percent of total billed charges,Implant Device,2861.6,35,,2861.6,percent of total billed charges,Implant Device,2861.6,35,,2861.6,percent of total billed charges,Implant Device,2861.6,35,,2861.6,percent of total billed charges,Implant Device,2861.6,35,,2861.6,percent of total billed charges,Implant Device,3270.4,40,,3270.4,percent of total billed charges,Implant Device,2861.6,70,,2861.6,percent of total billed charges,All Other,2779.84,34,,2779.84,percent of total billed charges,Implant Device,2779.84,34,,2779.84,percent of total billed charges,Implant Device,2861.6,35,,2861.6,percent of total billed charges,Implant Device,2861.6,35,,2861.6,percent of total billed charges,Implant Device,2861.6,35,,2861.6,percent of total billed charges,Implant Device,2861.6,35,,2861.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2779.84,34,"If Charge > 2,000, then 34 percent",2779.84,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,6050.26,
ARGON 352506070 OPTION VENA CAVA FILTER,C1880,HCPCS,,79003747,CDM,278,RC,,,both,,,5086,3763.65,,,3763.65,Other,150% of Medicare + 9.63% HCRA Surcharge,2288.7,45,,2288.7,percent of total billed charges,Critical Access Hospital RCC factor,1729.24,34,,1729.24,percent of total billed charges,Implant Device,1729.24,34,,1729.24,percent of total billed charges,Implant Device,1729.24,34,,1729.24,percent of total billed charges,Implant Device,1729.24,34,,1729.24,percent of total billed charges,Implant Device,1729.24,34,,1729.24,percent of total billed charges,Implant Device,2517.57,,,2517.57,Other,110% of Medicare,1780.1,35,,1780.1,percent of total billed charges,Implant Device,1729.24,34,"Charges > $500, x 34%",1729.24,percent of total billed charges,Implant Device,1780.1,35,,1780.1,percent of total billed charges,Implant Device,1780.1,35,,1780.1,percent of total billed charges,Implant Device,1780.1,35,,1780.1,percent of total billed charges,Implant Device,1780.1,35,,1780.1,percent of total billed charges,Implant Device,1780.1,35,,1780.1,percent of total billed charges,Implant Device,2034.4,40,,2034.4,percent of total billed charges,Implant Device,1780.1,70,,1780.1,percent of total billed charges,All Other,1729.24,34,,1729.24,percent of total billed charges,Implant Device,1729.24,34,,1729.24,percent of total billed charges,Implant Device,1780.1,35,,1780.1,percent of total billed charges,Implant Device,1780.1,35,,1780.1,percent of total billed charges,Implant Device,1780.1,35,,1780.1,percent of total billed charges,Implant Device,1780.1,35,,1780.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1729.24,34,"If Charge > 2,000, then 34 percent",1729.24,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3763.65,
ARTHREX AR-8949CL-S MTP PLATE STD LT,C1713,HCPCS,,79003752,CDM,278,RC,,,both,,,3430,2538.21,,,2538.21,Other,150% of Medicare + 9.63% HCRA Surcharge,1543.5,45,,1543.5,percent of total billed charges,Critical Access Hospital RCC factor,1166.2,34,,1166.2,percent of total billed charges,Implant Device,1166.2,34,,1166.2,percent of total billed charges,Implant Device,1166.2,34,,1166.2,percent of total billed charges,Implant Device,1166.2,34,,1166.2,percent of total billed charges,Implant Device,1166.2,34,,1166.2,percent of total billed charges,Implant Device,1697.85,,,1697.85,Other,110% of Medicare,1200.5,35,,1200.5,percent of total billed charges,Implant Device,1166.2,34,"Charges > $500, x 34%",1166.2,percent of total billed charges,Implant Device,1200.5,35,,1200.5,percent of total billed charges,Implant Device,1200.5,35,,1200.5,percent of total billed charges,Implant Device,1200.5,35,,1200.5,percent of total billed charges,Implant Device,1200.5,35,,1200.5,percent of total billed charges,Implant Device,1200.5,35,,1200.5,percent of total billed charges,Implant Device,1372,40,,1372,percent of total billed charges,Implant Device,1200.5,70,,1200.5,percent of total billed charges,All Other,1166.2,34,,1166.2,percent of total billed charges,Implant Device,1166.2,34,,1166.2,percent of total billed charges,Implant Device,1200.5,35,,1200.5,percent of total billed charges,Implant Device,1200.5,35,,1200.5,percent of total billed charges,Implant Device,1200.5,35,,1200.5,percent of total billed charges,Implant Device,1200.5,35,,1200.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1166.2,34,"If Charge > 2,000, then 34 percent",1166.2,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2538.21,
ARTHREX AR-1655PS TENODESIS SCREW 5.5X8,C1713,HCPCS,,79003753,CDM,278,RC,,,both,,,1224,905.76,,,905.76,Other,150% of Medicare + 9.63% HCRA Surcharge,550.8,45,,550.8,percent of total billed charges,Critical Access Hospital RCC factor,416.16,34,,416.16,percent of total billed charges,Implant Device,416.16,34,,416.16,percent of total billed charges,Implant Device,416.16,34,,416.16,percent of total billed charges,Implant Device,416.16,34,,416.16,percent of total billed charges,Implant Device,416.16,34,,416.16,percent of total billed charges,Implant Device,605.88,,,605.88,Other,110% of Medicare,428.4,35,,428.4,percent of total billed charges,Implant Device,416.16,34,"Charges > $500, x 34%",416.16,percent of total billed charges,Implant Device,428.4,35,,428.4,percent of total billed charges,Implant Device,428.4,35,,428.4,percent of total billed charges,Implant Device,428.4,35,,428.4,percent of total billed charges,Implant Device,428.4,35,,428.4,percent of total billed charges,Implant Device,428.4,35,,428.4,percent of total billed charges,Implant Device,489.6,40,,489.6,percent of total billed charges,Implant Device,428.4,70,,428.4,percent of total billed charges,All Other,416.16,34,,416.16,percent of total billed charges,Implant Device,416.16,34,,416.16,percent of total billed charges,Implant Device,428.4,35,,428.4,percent of total billed charges,Implant Device,428.4,35,,428.4,percent of total billed charges,Implant Device,428.4,35,,428.4,percent of total billed charges,Implant Device,428.4,35,,428.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,905.76,
ARTHREX AR-8935L-18 LOCKING SCREW 3.5X18,C1713,HCPCS,,79003756,CDM,278,RC,,,both,,,645,477.3,,,477.3,Other,150% of Medicare + 9.63% HCRA Surcharge,290.25,45,,290.25,percent of total billed charges,Critical Access Hospital RCC factor,219.3,34,,219.3,percent of total billed charges,Implant Device,219.3,34,,219.3,percent of total billed charges,Implant Device,219.3,34,,219.3,percent of total billed charges,Implant Device,219.3,34,,219.3,percent of total billed charges,Implant Device,219.3,34,,219.3,percent of total billed charges,Implant Device,319.28,,,319.28,Other,110% of Medicare,225.75,35,,225.75,percent of total billed charges,Implant Device,219.3,34,"Charges > $500, x 34%",219.3,percent of total billed charges,Implant Device,225.75,35,,225.75,percent of total billed charges,Implant Device,225.75,35,,225.75,percent of total billed charges,Implant Device,225.75,35,,225.75,percent of total billed charges,Implant Device,225.75,35,,225.75,percent of total billed charges,Implant Device,225.75,35,,225.75,percent of total billed charges,Implant Device,258,40,,258,percent of total billed charges,Implant Device,225.75,70,,225.75,percent of total billed charges,All Other,219.3,34,,219.3,percent of total billed charges,Implant Device,219.3,34,,219.3,percent of total billed charges,Implant Device,225.75,35,,225.75,percent of total billed charges,Implant Device,225.75,35,,225.75,percent of total billed charges,Implant Device,225.75,35,,225.75,percent of total billed charges,Implant Device,225.75,35,,225.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,477.3,
ARTHREX AR-8943T-08 PLATE 8 HOLE,C1713,HCPCS,,79003757,CDM,278,RC,,,both,,,1138,842.12,,,842.12,Other,150% of Medicare + 9.63% HCRA Surcharge,512.1,45,,512.1,percent of total billed charges,Critical Access Hospital RCC factor,386.92,34,,386.92,percent of total billed charges,Implant Device,386.92,34,,386.92,percent of total billed charges,Implant Device,386.92,34,,386.92,percent of total billed charges,Implant Device,386.92,34,,386.92,percent of total billed charges,Implant Device,386.92,34,,386.92,percent of total billed charges,Implant Device,563.31,,,563.31,Other,110% of Medicare,398.3,35,,398.3,percent of total billed charges,Implant Device,386.92,34,"Charges > $500, x 34%",386.92,percent of total billed charges,Implant Device,398.3,35,,398.3,percent of total billed charges,Implant Device,398.3,35,,398.3,percent of total billed charges,Implant Device,398.3,35,,398.3,percent of total billed charges,Implant Device,398.3,35,,398.3,percent of total billed charges,Implant Device,398.3,35,,398.3,percent of total billed charges,Implant Device,455.2,40,,455.2,percent of total billed charges,Implant Device,398.3,70,,398.3,percent of total billed charges,All Other,386.92,34,,386.92,percent of total billed charges,Implant Device,386.92,34,,386.92,percent of total billed charges,Implant Device,398.3,35,,398.3,percent of total billed charges,Implant Device,398.3,35,,398.3,percent of total billed charges,Implant Device,398.3,35,,398.3,percent of total billed charges,Implant Device,398.3,35,,398.3,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,842.12,
ARTHREX AR-8928BC-CP ACHILLES SPEEDBRIDG,C1713,HCPCS,,79003765,CDM,278,RC,,,both,,,5220,3862.81,,,3862.81,Other,150% of Medicare + 9.63% HCRA Surcharge,2349,45,,2349,percent of total billed charges,Critical Access Hospital RCC factor,1774.8,34,,1774.8,percent of total billed charges,Implant Device,1774.8,34,,1774.8,percent of total billed charges,Implant Device,1774.8,34,,1774.8,percent of total billed charges,Implant Device,1774.8,34,,1774.8,percent of total billed charges,Implant Device,1774.8,34,,1774.8,percent of total billed charges,Implant Device,2583.9,,,2583.9,Other,110% of Medicare,1827,35,,1827,percent of total billed charges,Implant Device,1774.8,34,"Charges > $500, x 34%",1774.8,percent of total billed charges,Implant Device,1827,35,,1827,percent of total billed charges,Implant Device,1827,35,,1827,percent of total billed charges,Implant Device,1827,35,,1827,percent of total billed charges,Implant Device,1827,35,,1827,percent of total billed charges,Implant Device,1827,35,,1827,percent of total billed charges,Implant Device,2088,40,,2088,percent of total billed charges,Implant Device,1827,70,,1827,percent of total billed charges,All Other,1774.8,34,,1774.8,percent of total billed charges,Implant Device,1774.8,34,,1774.8,percent of total billed charges,Implant Device,1827,35,,1827,percent of total billed charges,Implant Device,1827,35,,1827,percent of total billed charges,Implant Device,1827,35,,1827,percent of total billed charges,Implant Device,1827,35,,1827,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1774.8,34,"If Charge > 2,000, then 34 percent",1774.8,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3862.81,
ARTHREX 8945-40FT SCREW 4.5X40FT,C1713,HCPCS,,79003768,CDM,278,RC,,,both,,,646,478.04,,,478.04,Other,150% of Medicare + 9.63% HCRA Surcharge,290.7,45,,290.7,percent of total billed charges,Critical Access Hospital RCC factor,219.64,34,,219.64,percent of total billed charges,Implant Device,219.64,34,,219.64,percent of total billed charges,Implant Device,219.64,34,,219.64,percent of total billed charges,Implant Device,219.64,34,,219.64,percent of total billed charges,Implant Device,219.64,34,,219.64,percent of total billed charges,Implant Device,319.77,,,319.77,Other,110% of Medicare,226.1,35,,226.1,percent of total billed charges,Implant Device,219.64,34,"Charges > $500, x 34%",219.64,percent of total billed charges,Implant Device,226.1,35,,226.1,percent of total billed charges,Implant Device,226.1,35,,226.1,percent of total billed charges,Implant Device,226.1,35,,226.1,percent of total billed charges,Implant Device,226.1,35,,226.1,percent of total billed charges,Implant Device,226.1,35,,226.1,percent of total billed charges,Implant Device,258.4,40,,258.4,percent of total billed charges,Implant Device,226.1,70,,226.1,percent of total billed charges,All Other,219.64,34,,219.64,percent of total billed charges,Implant Device,219.64,34,,219.64,percent of total billed charges,Implant Device,226.1,35,,226.1,percent of total billed charges,Implant Device,226.1,35,,226.1,percent of total billed charges,Implant Device,226.1,35,,226.1,percent of total billed charges,Implant Device,226.1,35,,226.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,478.04,
ARTHREX AR-8945-45PT CANN SCREW 4-5X45MM,C1713,HCPCS,,79003769,CDM,278,RC,,,both,,,750,555,,,555,Other,150% of Medicare + 9.63% HCRA Surcharge,337.5,45,,337.5,percent of total billed charges,Critical Access Hospital RCC factor,255,34,,255,percent of total billed charges,Implant Device,255,34,,255,percent of total billed charges,Implant Device,255,34,,255,percent of total billed charges,Implant Device,255,34,,255,percent of total billed charges,Implant Device,255,34,,255,percent of total billed charges,Implant Device,371.25,,,371.25,Other,110% of Medicare,262.5,35,,262.5,percent of total billed charges,Implant Device,255,34,"Charges > $500, x 34%",255,percent of total billed charges,Implant Device,262.5,35,,262.5,percent of total billed charges,Implant Device,262.5,35,,262.5,percent of total billed charges,Implant Device,262.5,35,,262.5,percent of total billed charges,Implant Device,262.5,35,,262.5,percent of total billed charges,Implant Device,262.5,35,,262.5,percent of total billed charges,Implant Device,300,40,,300,percent of total billed charges,Implant Device,262.5,70,,262.5,percent of total billed charges,All Other,255,34,,255,percent of total billed charges,Implant Device,255,34,,255,percent of total billed charges,Implant Device,262.5,35,,262.5,percent of total billed charges,Implant Device,262.5,35,,262.5,percent of total billed charges,Implant Device,262.5,35,,262.5,percent of total billed charges,Implant Device,262.5,35,,262.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,555,
ARTHREX AR-8935-20 CORT SCREW 3.5X20MM,C1713,HCPCS,,79003770,CDM,278,RC,,,both,,,258,190.92,,,190.92,Other,150% of Medicare + 9.63% HCRA Surcharge,116.1,45,,116.1,percent of total billed charges,Critical Access Hospital RCC factor,87.72,34,,87.72,percent of total billed charges,Implant Device,87.72,34,,87.72,percent of total billed charges,Implant Device,87.72,34,,87.72,percent of total billed charges,Implant Device,87.72,34,,87.72,percent of total billed charges,Implant Device,87.72,34,,87.72,percent of total billed charges,Implant Device,127.71,,,127.71,Other,110% of Medicare,90.3,35,,90.3,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,90.3,35,,90.3,percent of total billed charges,Implant Device,90.3,35,,90.3,percent of total billed charges,Implant Device,90.3,35,,90.3,percent of total billed charges,Implant Device,90.3,35,,90.3,percent of total billed charges,Implant Device,90.3,35,,90.3,percent of total billed charges,Implant Device,103.2,40,,103.2,percent of total billed charges,Implant Device,90.3,70,,90.3,percent of total billed charges,All Other,87.72,34,,87.72,percent of total billed charges,Implant Device,87.72,34,,87.72,percent of total billed charges,Implant Device,90.3,35,,90.3,percent of total billed charges,Implant Device,90.3,35,,90.3,percent of total billed charges,Implant Device,90.3,35,,90.3,percent of total billed charges,Implant Device,90.3,35,,90.3,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,190.92,
ARTHREX AR-13380-28 CORT SCREW 4.5X28MM,C1713,HCPCS,,79003772,CDM,278,RC,,,both,,,256,189.44,,,189.44,Other,150% of Medicare + 9.63% HCRA Surcharge,115.2,45,,115.2,percent of total billed charges,Critical Access Hospital RCC factor,87.04,34,,87.04,percent of total billed charges,Implant Device,87.04,34,,87.04,percent of total billed charges,Implant Device,87.04,34,,87.04,percent of total billed charges,Implant Device,87.04,34,,87.04,percent of total billed charges,Implant Device,87.04,34,,87.04,percent of total billed charges,Implant Device,126.72,,,126.72,Other,110% of Medicare,89.6,35,,89.6,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,89.6,35,,89.6,percent of total billed charges,Implant Device,89.6,35,,89.6,percent of total billed charges,Implant Device,89.6,35,,89.6,percent of total billed charges,Implant Device,89.6,35,,89.6,percent of total billed charges,Implant Device,89.6,35,,89.6,percent of total billed charges,Implant Device,102.4,40,,102.4,percent of total billed charges,Implant Device,89.6,70,,89.6,percent of total billed charges,All Other,87.04,34,,87.04,percent of total billed charges,Implant Device,87.04,34,,87.04,percent of total billed charges,Implant Device,89.6,35,,89.6,percent of total billed charges,Implant Device,89.6,35,,89.6,percent of total billed charges,Implant Device,89.6,35,,89.6,percent of total billed charges,Implant Device,89.6,35,,89.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,189.44,
ARTHREX AR-1380C BIOCOMP SCREW 8X23MM,C1713,HCPCS,,79003773,CDM,278,RC,,,both,,,705,521.7,,,521.7,Other,150% of Medicare + 9.63% HCRA Surcharge,317.25,45,,317.25,percent of total billed charges,Critical Access Hospital RCC factor,239.7,34,,239.7,percent of total billed charges,Implant Device,239.7,34,,239.7,percent of total billed charges,Implant Device,239.7,34,,239.7,percent of total billed charges,Implant Device,239.7,34,,239.7,percent of total billed charges,Implant Device,239.7,34,,239.7,percent of total billed charges,Implant Device,348.98,,,348.98,Other,110% of Medicare,246.75,35,,246.75,percent of total billed charges,Implant Device,239.7,34,"Charges > $500, x 34%",239.7,percent of total billed charges,Implant Device,246.75,35,,246.75,percent of total billed charges,Implant Device,246.75,35,,246.75,percent of total billed charges,Implant Device,246.75,35,,246.75,percent of total billed charges,Implant Device,246.75,35,,246.75,percent of total billed charges,Implant Device,246.75,35,,246.75,percent of total billed charges,Implant Device,282,40,,282,percent of total billed charges,Implant Device,246.75,70,,246.75,percent of total billed charges,All Other,239.7,34,,239.7,percent of total billed charges,Implant Device,239.7,34,,239.7,percent of total billed charges,Implant Device,246.75,35,,246.75,percent of total billed charges,Implant Device,246.75,35,,246.75,percent of total billed charges,Implant Device,246.75,35,,246.75,percent of total billed charges,Implant Device,246.75,35,,246.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,521.7,
ARTHREX 8945-50FT ARTHREX 4.5X50FT SCREW,C1713,HCPCS,,79003775,CDM,278,RC,,,both,,,646,478.04,,,478.04,Other,150% of Medicare + 9.63% HCRA Surcharge,290.7,45,,290.7,percent of total billed charges,Critical Access Hospital RCC factor,219.64,34,,219.64,percent of total billed charges,Implant Device,219.64,34,,219.64,percent of total billed charges,Implant Device,219.64,34,,219.64,percent of total billed charges,Implant Device,219.64,34,,219.64,percent of total billed charges,Implant Device,219.64,34,,219.64,percent of total billed charges,Implant Device,319.77,,,319.77,Other,110% of Medicare,226.1,35,,226.1,percent of total billed charges,Implant Device,219.64,34,"Charges > $500, x 34%",219.64,percent of total billed charges,Implant Device,226.1,35,,226.1,percent of total billed charges,Implant Device,226.1,35,,226.1,percent of total billed charges,Implant Device,226.1,35,,226.1,percent of total billed charges,Implant Device,226.1,35,,226.1,percent of total billed charges,Implant Device,226.1,35,,226.1,percent of total billed charges,Implant Device,258.4,40,,258.4,percent of total billed charges,Implant Device,226.1,70,,226.1,percent of total billed charges,All Other,219.64,34,,219.64,percent of total billed charges,Implant Device,219.64,34,,219.64,percent of total billed charges,Implant Device,226.1,35,,226.1,percent of total billed charges,Implant Device,226.1,35,,226.1,percent of total billed charges,Implant Device,226.1,35,,226.1,percent of total billed charges,Implant Device,226.1,35,,226.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,478.04,
ARTHREX AR-5028C-08 BIOCOMP SCREW 8X28,C1713,HCPCS,,79003776,CDM,278,RC,,,both,,,705,521.7,,,521.7,Other,150% of Medicare + 9.63% HCRA Surcharge,317.25,45,,317.25,percent of total billed charges,Critical Access Hospital RCC factor,239.7,34,,239.7,percent of total billed charges,Implant Device,239.7,34,,239.7,percent of total billed charges,Implant Device,239.7,34,,239.7,percent of total billed charges,Implant Device,239.7,34,,239.7,percent of total billed charges,Implant Device,239.7,34,,239.7,percent of total billed charges,Implant Device,348.98,,,348.98,Other,110% of Medicare,246.75,35,,246.75,percent of total billed charges,Implant Device,239.7,34,"Charges > $500, x 34%",239.7,percent of total billed charges,Implant Device,246.75,35,,246.75,percent of total billed charges,Implant Device,246.75,35,,246.75,percent of total billed charges,Implant Device,246.75,35,,246.75,percent of total billed charges,Implant Device,246.75,35,,246.75,percent of total billed charges,Implant Device,246.75,35,,246.75,percent of total billed charges,Implant Device,282,40,,282,percent of total billed charges,Implant Device,246.75,70,,246.75,percent of total billed charges,All Other,239.7,34,,239.7,percent of total billed charges,Implant Device,239.7,34,,239.7,percent of total billed charges,Implant Device,246.75,35,,246.75,percent of total billed charges,Implant Device,246.75,35,,246.75,percent of total billed charges,Implant Device,246.75,35,,246.75,percent of total billed charges,Implant Device,246.75,35,,246.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,521.7,
ARTHREX AR-5035P-10 DELTA PK INTER SCREW,C1713,HCPCS,,79003778,CDM,278,RC,,,both,,,1074,794.76,,,794.76,Other,150% of Medicare + 9.63% HCRA Surcharge,483.3,45,,483.3,percent of total billed charges,Critical Access Hospital RCC factor,365.16,34,,365.16,percent of total billed charges,Implant Device,365.16,34,,365.16,percent of total billed charges,Implant Device,365.16,34,,365.16,percent of total billed charges,Implant Device,365.16,34,,365.16,percent of total billed charges,Implant Device,365.16,34,,365.16,percent of total billed charges,Implant Device,531.63,,,531.63,Other,110% of Medicare,375.9,35,,375.9,percent of total billed charges,Implant Device,365.16,34,"Charges > $500, x 34%",365.16,percent of total billed charges,Implant Device,375.9,35,,375.9,percent of total billed charges,Implant Device,375.9,35,,375.9,percent of total billed charges,Implant Device,375.9,35,,375.9,percent of total billed charges,Implant Device,375.9,35,,375.9,percent of total billed charges,Implant Device,375.9,35,,375.9,percent of total billed charges,Implant Device,429.6,40,,429.6,percent of total billed charges,Implant Device,375.9,70,,375.9,percent of total billed charges,All Other,365.16,34,,365.16,percent of total billed charges,Implant Device,365.16,34,,365.16,percent of total billed charges,Implant Device,375.9,35,,375.9,percent of total billed charges,Implant Device,375.9,35,,375.9,percent of total billed charges,Implant Device,375.9,35,,375.9,percent of total billed charges,Implant Device,375.9,35,,375.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,794.76,
ARTHREX AR-2521 2.8 THREADED PIN,C1713,HCPCS,,79003779,CDM,278,RC,,,both,,,258,190.92,,,190.92,Other,150% of Medicare + 9.63% HCRA Surcharge,116.1,45,,116.1,percent of total billed charges,Critical Access Hospital RCC factor,87.72,34,,87.72,percent of total billed charges,Implant Device,87.72,34,,87.72,percent of total billed charges,Implant Device,87.72,34,,87.72,percent of total billed charges,Implant Device,87.72,34,,87.72,percent of total billed charges,Implant Device,87.72,34,,87.72,percent of total billed charges,Implant Device,127.71,,,127.71,Other,110% of Medicare,90.3,35,,90.3,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,90.3,35,,90.3,percent of total billed charges,Implant Device,90.3,35,,90.3,percent of total billed charges,Implant Device,90.3,35,,90.3,percent of total billed charges,Implant Device,90.3,35,,90.3,percent of total billed charges,Implant Device,90.3,35,,90.3,percent of total billed charges,Implant Device,103.2,40,,103.2,percent of total billed charges,Implant Device,90.3,70,,90.3,percent of total billed charges,All Other,87.72,34,,87.72,percent of total billed charges,Implant Device,87.72,34,,87.72,percent of total billed charges,Implant Device,90.3,35,,90.3,percent of total billed charges,Implant Device,90.3,35,,90.3,percent of total billed charges,Implant Device,90.3,35,,90.3,percent of total billed charges,Implant Device,90.3,35,,90.3,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,190.92,
ARTHREX AR-8935-22 CORT SCREW 3.5X22MM,C1713,HCPCS,,79003781,CDM,278,RC,,,both,,,258,190.92,,,190.92,Other,150% of Medicare + 9.63% HCRA Surcharge,116.1,45,,116.1,percent of total billed charges,Critical Access Hospital RCC factor,87.72,34,,87.72,percent of total billed charges,Implant Device,87.72,34,,87.72,percent of total billed charges,Implant Device,87.72,34,,87.72,percent of total billed charges,Implant Device,87.72,34,,87.72,percent of total billed charges,Implant Device,87.72,34,,87.72,percent of total billed charges,Implant Device,127.71,,,127.71,Other,110% of Medicare,90.3,35,,90.3,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,90.3,35,,90.3,percent of total billed charges,Implant Device,90.3,35,,90.3,percent of total billed charges,Implant Device,90.3,35,,90.3,percent of total billed charges,Implant Device,90.3,35,,90.3,percent of total billed charges,Implant Device,90.3,35,,90.3,percent of total billed charges,Implant Device,103.2,40,,103.2,percent of total billed charges,Implant Device,90.3,70,,90.3,percent of total billed charges,All Other,87.72,34,,87.72,percent of total billed charges,Implant Device,87.72,34,,87.72,percent of total billed charges,Implant Device,90.3,35,,90.3,percent of total billed charges,Implant Device,90.3,35,,90.3,percent of total billed charges,Implant Device,90.3,35,,90.3,percent of total billed charges,Implant Device,90.3,35,,90.3,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,190.92,
ARTHROSURFACE 9122-1015-W ART COMP 1X1.5,C1776,HCPCS,,79003782,CDM,278,RC,,,both,,,6612,4892.9,,,4892.9,Other,150% of Medicare + 9.63% HCRA Surcharge,2975.4,45,,2975.4,percent of total billed charges,Critical Access Hospital RCC factor,2248.08,34,,2248.08,percent of total billed charges,Implant Device,2248.08,34,,2248.08,percent of total billed charges,Implant Device,2248.08,34,,2248.08,percent of total billed charges,Implant Device,2248.08,34,,2248.08,percent of total billed charges,Implant Device,2248.08,34,,2248.08,percent of total billed charges,Implant Device,3272.94,,,3272.94,Other,110% of Medicare,2314.2,35,,2314.2,percent of total billed charges,Implant Device,2248.08,34,"Charges > $500, x 34%",2248.08,percent of total billed charges,Implant Device,2314.2,35,,2314.2,percent of total billed charges,Implant Device,2314.2,35,,2314.2,percent of total billed charges,Implant Device,2314.2,35,,2314.2,percent of total billed charges,Implant Device,2314.2,35,,2314.2,percent of total billed charges,Implant Device,2314.2,35,,2314.2,percent of total billed charges,Implant Device,2644.8,40,,2644.8,percent of total billed charges,Implant Device,2314.2,70,,2314.2,percent of total billed charges,All Other,2248.08,34,,2248.08,percent of total billed charges,Implant Device,2248.08,34,,2248.08,percent of total billed charges,Implant Device,2314.2,35,,2314.2,percent of total billed charges,Implant Device,2314.2,35,,2314.2,percent of total billed charges,Implant Device,2314.2,35,,2314.2,percent of total billed charges,Implant Device,2314.2,35,,2314.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2248.08,34,"If Charge > 2,000, then 34 percent",2248.08,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4892.9,
ATRIUM 31506 CQUR MESH ROUND 13X13CM,C1781,HCPCS,,79003784,CDM,278,RC,,,both,,,1025,758.5,,,758.5,Other,150% of Medicare + 9.63% HCRA Surcharge,461.25,45,,461.25,percent of total billed charges,Critical Access Hospital RCC factor,348.5,34,,348.5,percent of total billed charges,Implant Device,348.5,34,,348.5,percent of total billed charges,Implant Device,348.5,34,,348.5,percent of total billed charges,Implant Device,348.5,34,,348.5,percent of total billed charges,Implant Device,348.5,34,,348.5,percent of total billed charges,Implant Device,507.38,,,507.38,Other,110% of Medicare,358.75,35,,358.75,percent of total billed charges,Implant Device,348.5,34,"Charges > $500, x 34%",348.5,percent of total billed charges,Implant Device,358.75,35,,358.75,percent of total billed charges,Implant Device,358.75,35,,358.75,percent of total billed charges,Implant Device,358.75,35,,358.75,percent of total billed charges,Implant Device,358.75,35,,358.75,percent of total billed charges,Implant Device,358.75,35,,358.75,percent of total billed charges,Implant Device,410,40,,410,percent of total billed charges,Implant Device,358.75,70,,358.75,percent of total billed charges,All Other,348.5,34,,348.5,percent of total billed charges,Implant Device,348.5,34,,348.5,percent of total billed charges,Implant Device,358.75,35,,358.75,percent of total billed charges,Implant Device,358.75,35,,358.75,percent of total billed charges,Implant Device,358.75,35,,358.75,percent of total billed charges,Implant Device,358.75,35,,358.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,758.5,
ATRIUM 31505 CQUR MESH ROUND 9X9CM,C1781,HCPCS,,79003785,CDM,278,RC,,,both,,,740,547.6,,,547.6,Other,150% of Medicare + 9.63% HCRA Surcharge,333,45,,333,percent of total billed charges,Critical Access Hospital RCC factor,251.6,34,,251.6,percent of total billed charges,Implant Device,251.6,34,,251.6,percent of total billed charges,Implant Device,251.6,34,,251.6,percent of total billed charges,Implant Device,251.6,34,,251.6,percent of total billed charges,Implant Device,251.6,34,,251.6,percent of total billed charges,Implant Device,366.3,,,366.3,Other,110% of Medicare,259,35,,259,percent of total billed charges,Implant Device,251.6,34,"Charges > $500, x 34%",251.6,percent of total billed charges,Implant Device,259,35,,259,percent of total billed charges,Implant Device,259,35,,259,percent of total billed charges,Implant Device,259,35,,259,percent of total billed charges,Implant Device,259,35,,259,percent of total billed charges,Implant Device,259,35,,259,percent of total billed charges,Implant Device,296,40,,296,percent of total billed charges,Implant Device,259,70,,259,percent of total billed charges,All Other,251.6,34,,251.6,percent of total billed charges,Implant Device,251.6,34,,251.6,percent of total billed charges,Implant Device,259,35,,259,percent of total billed charges,Implant Device,259,35,,259,percent of total billed charges,Implant Device,259,35,,259,percent of total billed charges,Implant Device,259,35,,259,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,547.6,
ATRIUM 31507 CQUR MESH ROUND 15X15CM,C1781,HCPCS,,79003786,CDM,278,RC,,,both,,,1420,1050.8,,,1050.8,Other,150% of Medicare + 9.63% HCRA Surcharge,639,45,,639,percent of total billed charges,Critical Access Hospital RCC factor,482.8,34,,482.8,percent of total billed charges,Implant Device,482.8,34,,482.8,percent of total billed charges,Implant Device,482.8,34,,482.8,percent of total billed charges,Implant Device,482.8,34,,482.8,percent of total billed charges,Implant Device,482.8,34,,482.8,percent of total billed charges,Implant Device,702.9,,,702.9,Other,110% of Medicare,497,35,,497,percent of total billed charges,Implant Device,482.8,34,"Charges > $500, x 34%",482.8,percent of total billed charges,Implant Device,497,35,,497,percent of total billed charges,Implant Device,497,35,,497,percent of total billed charges,Implant Device,497,35,,497,percent of total billed charges,Implant Device,497,35,,497,percent of total billed charges,Implant Device,497,35,,497,percent of total billed charges,Implant Device,568,40,,568,percent of total billed charges,Implant Device,497,70,,497,percent of total billed charges,All Other,482.8,34,,482.8,percent of total billed charges,Implant Device,482.8,34,,482.8,percent of total billed charges,Implant Device,497,35,,497,percent of total billed charges,Implant Device,497,35,,497,percent of total billed charges,Implant Device,497,35,,497,percent of total billed charges,Implant Device,497,35,,497,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1050.8,
BIOMED 430-9109 BME BOSS 9X7X7 1.2MM,C1713,HCPCS,,79003787,CDM,278,RC,,,both,,,2386,1765.65,,,1765.65,Other,150% of Medicare + 9.63% HCRA Surcharge,1073.7,45,,1073.7,percent of total billed charges,Critical Access Hospital RCC factor,811.24,34,,811.24,percent of total billed charges,Implant Device,811.24,34,,811.24,percent of total billed charges,Implant Device,811.24,34,,811.24,percent of total billed charges,Implant Device,811.24,34,,811.24,percent of total billed charges,Implant Device,811.24,34,,811.24,percent of total billed charges,Implant Device,1181.07,,,1181.07,Other,110% of Medicare,835.1,35,,835.1,percent of total billed charges,Implant Device,811.24,34,"Charges > $500, x 34%",811.24,percent of total billed charges,Implant Device,835.1,35,,835.1,percent of total billed charges,Implant Device,835.1,35,,835.1,percent of total billed charges,Implant Device,835.1,35,,835.1,percent of total billed charges,Implant Device,835.1,35,,835.1,percent of total billed charges,Implant Device,835.1,35,,835.1,percent of total billed charges,Implant Device,954.4,40,,954.4,percent of total billed charges,Implant Device,835.1,70,,835.1,percent of total billed charges,All Other,811.24,34,,811.24,percent of total billed charges,Implant Device,811.24,34,,811.24,percent of total billed charges,Implant Device,835.1,35,,835.1,percent of total billed charges,Implant Device,835.1,35,,835.1,percent of total billed charges,Implant Device,835.1,35,,835.1,percent of total billed charges,Implant Device,835.1,35,,835.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,811.24,34,"If Charge > 2,000, then 34 percent",811.24,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1765.65,
BIOMET 162656 DISTAL CENTRALIZER 9MM,C1713,HCPCS,,79003788,CDM,278,RC,,,both,,,960,710.4,,,710.4,Other,150% of Medicare + 9.63% HCRA Surcharge,432,45,,432,percent of total billed charges,Critical Access Hospital RCC factor,326.4,34,,326.4,percent of total billed charges,Implant Device,326.4,34,,326.4,percent of total billed charges,Implant Device,326.4,34,,326.4,percent of total billed charges,Implant Device,326.4,34,,326.4,percent of total billed charges,Implant Device,326.4,34,,326.4,percent of total billed charges,Implant Device,475.2,,,475.2,Other,110% of Medicare,336,35,,336,percent of total billed charges,Implant Device,326.4,34,"Charges > $500, x 34%",326.4,percent of total billed charges,Implant Device,336,35,,336,percent of total billed charges,Implant Device,336,35,,336,percent of total billed charges,Implant Device,336,35,,336,percent of total billed charges,Implant Device,336,35,,336,percent of total billed charges,Implant Device,336,35,,336,percent of total billed charges,Implant Device,384,40,,384,percent of total billed charges,Implant Device,336,70,,336,percent of total billed charges,All Other,326.4,34,,326.4,percent of total billed charges,Implant Device,326.4,34,,326.4,percent of total billed charges,Implant Device,336,35,,336,percent of total billed charges,Implant Device,336,35,,336,percent of total billed charges,Implant Device,336,35,,336,percent of total billed charges,Implant Device,336,35,,336,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,710.4,
BIOMET 154722 TIBIAL IMPLANT SIZE C LEFT,C1776,HCPCS,,79003789,CDM,278,RC,,,both,,,11070,8191.83,,,8191.83,Other,150% of Medicare + 9.63% HCRA Surcharge,4981.5,45,,4981.5,percent of total billed charges,Critical Access Hospital RCC factor,3763.8,34,,3763.8,percent of total billed charges,Implant Device,3763.8,34,,3763.8,percent of total billed charges,Implant Device,3763.8,34,,3763.8,percent of total billed charges,Implant Device,3763.8,34,,3763.8,percent of total billed charges,Implant Device,3763.8,34,,3763.8,percent of total billed charges,Implant Device,5479.65,,,5479.65,Other,110% of Medicare,3874.5,35,,3874.5,percent of total billed charges,Implant Device,3763.8,34,"Charges > $500, x 34%",3763.8,percent of total billed charges,Implant Device,3874.5,35,,3874.5,percent of total billed charges,Implant Device,3874.5,35,,3874.5,percent of total billed charges,Implant Device,3874.5,35,,3874.5,percent of total billed charges,Implant Device,3874.5,35,,3874.5,percent of total billed charges,Implant Device,3874.5,35,,3874.5,percent of total billed charges,Implant Device,4428,40,,4428,percent of total billed charges,Implant Device,3874.5,70,,3874.5,percent of total billed charges,All Other,3763.8,34,,3763.8,percent of total billed charges,Implant Device,3763.8,34,,3763.8,percent of total billed charges,Implant Device,3874.5,35,,3874.5,percent of total billed charges,Implant Device,3874.5,35,,3874.5,percent of total billed charges,Implant Device,3874.5,35,,3874.5,percent of total billed charges,Implant Device,3874.5,35,,3874.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3763.8,34,"If Charge > 2,000, then 34 percent",3763.8,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,8191.83,
BIOMET 26885 NON LOCK SCREW 4.5X85MM,C1713,HCPCS,,79003790,CDM,278,RC,,,both,,,330,244.2,,,244.2,Other,150% of Medicare + 9.63% HCRA Surcharge,148.5,45,,148.5,percent of total billed charges,Critical Access Hospital RCC factor,112.2,34,,112.2,percent of total billed charges,Implant Device,112.2,34,,112.2,percent of total billed charges,Implant Device,112.2,34,,112.2,percent of total billed charges,Implant Device,112.2,34,,112.2,percent of total billed charges,Implant Device,112.2,34,,112.2,percent of total billed charges,Implant Device,163.35,,,163.35,Other,110% of Medicare,115.5,35,,115.5,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,132,40,,132,percent of total billed charges,Implant Device,115.5,70,,115.5,percent of total billed charges,All Other,112.2,34,,112.2,percent of total billed charges,Implant Device,112.2,34,,112.2,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,244.2,
BIIOMET 26860 NON LOCK SCREW 4.5X60MM,C1713,HCPCS,,79003791,CDM,278,RC,,,both,,,330,244.2,,,244.2,Other,150% of Medicare + 9.63% HCRA Surcharge,148.5,45,,148.5,percent of total billed charges,Critical Access Hospital RCC factor,112.2,34,,112.2,percent of total billed charges,Implant Device,112.2,34,,112.2,percent of total billed charges,Implant Device,112.2,34,,112.2,percent of total billed charges,Implant Device,112.2,34,,112.2,percent of total billed charges,Implant Device,112.2,34,,112.2,percent of total billed charges,Implant Device,163.35,,,163.35,Other,110% of Medicare,115.5,35,,115.5,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,132,40,,132,percent of total billed charges,Implant Device,115.5,70,,115.5,percent of total billed charges,All Other,112.2,34,,112.2,percent of total billed charges,Implant Device,112.2,34,,112.2,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,244.2,
BIOMET 180-503 FIXED LOCK SCREW 4.75X30,C1713,HCPCS,,79003792,CDM,278,RC,,,both,,,810,599.4,,,599.4,Other,150% of Medicare + 9.63% HCRA Surcharge,364.5,45,,364.5,percent of total billed charges,Critical Access Hospital RCC factor,275.4,34,,275.4,percent of total billed charges,Implant Device,275.4,34,,275.4,percent of total billed charges,Implant Device,275.4,34,,275.4,percent of total billed charges,Implant Device,275.4,34,,275.4,percent of total billed charges,Implant Device,275.4,34,,275.4,percent of total billed charges,Implant Device,400.95,,,400.95,Other,110% of Medicare,283.5,35,,283.5,percent of total billed charges,Implant Device,275.4,34,"Charges > $500, x 34%",275.4,percent of total billed charges,Implant Device,283.5,35,,283.5,percent of total billed charges,Implant Device,283.5,35,,283.5,percent of total billed charges,Implant Device,283.5,35,,283.5,percent of total billed charges,Implant Device,283.5,35,,283.5,percent of total billed charges,Implant Device,283.5,35,,283.5,percent of total billed charges,Implant Device,324,40,,324,percent of total billed charges,Implant Device,283.5,70,,283.5,percent of total billed charges,All Other,275.4,34,,275.4,percent of total billed charges,Implant Device,275.4,34,,275.4,percent of total billed charges,Implant Device,283.5,35,,283.5,percent of total billed charges,Implant Device,283.5,35,,283.5,percent of total billed charges,Implant Device,283.5,35,,283.5,percent of total billed charges,Implant Device,283.5,35,,283.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,599.4,
BIOMET 948213 REWRITE PIN 2.4X40MM,C1713,HCPCS,,79003793,CDM,278,RC,,,both,,,1230,910.2,,,910.2,Other,150% of Medicare + 9.63% HCRA Surcharge,553.5,45,,553.5,percent of total billed charges,Critical Access Hospital RCC factor,418.2,34,,418.2,percent of total billed charges,Implant Device,418.2,34,,418.2,percent of total billed charges,Implant Device,418.2,34,,418.2,percent of total billed charges,Implant Device,418.2,34,,418.2,percent of total billed charges,Implant Device,418.2,34,,418.2,percent of total billed charges,Implant Device,608.85,,,608.85,Other,110% of Medicare,430.5,35,,430.5,percent of total billed charges,Implant Device,418.2,34,"Charges > $500, x 34%",418.2,percent of total billed charges,Implant Device,430.5,35,,430.5,percent of total billed charges,Implant Device,430.5,35,,430.5,percent of total billed charges,Implant Device,430.5,35,,430.5,percent of total billed charges,Implant Device,430.5,35,,430.5,percent of total billed charges,Implant Device,430.5,35,,430.5,percent of total billed charges,Implant Device,492,40,,492,percent of total billed charges,Implant Device,430.5,70,,430.5,percent of total billed charges,All Other,418.2,34,,418.2,percent of total billed charges,Implant Device,418.2,34,,418.2,percent of total billed charges,Implant Device,430.5,35,,430.5,percent of total billed charges,Implant Device,430.5,35,,430.5,percent of total billed charges,Implant Device,430.5,35,,430.5,percent of total billed charges,Implant Device,430.5,35,,430.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,910.2,
BIOMET 26880 NON LOCK SCREW 4.5X80MM,C1713,HCPCS,,79003794,CDM,278,RC,,,both,,,330,244.2,,,244.2,Other,150% of Medicare + 9.63% HCRA Surcharge,148.5,45,,148.5,percent of total billed charges,Critical Access Hospital RCC factor,112.2,34,,112.2,percent of total billed charges,Implant Device,112.2,34,,112.2,percent of total billed charges,Implant Device,112.2,34,,112.2,percent of total billed charges,Implant Device,112.2,34,,112.2,percent of total billed charges,Implant Device,112.2,34,,112.2,percent of total billed charges,Implant Device,163.35,,,163.35,Other,110% of Medicare,115.5,35,,115.5,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,132,40,,132,percent of total billed charges,Implant Device,115.5,70,,115.5,percent of total billed charges,All Other,112.2,34,,112.2,percent of total billed charges,Implant Device,112.2,34,,112.2,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,244.2,
BIOMET 26128 TIBIA PLATE LEFT LAT PROX,C1776,HCPCS,,79003796,CDM,278,RC,,,both,,,6930,5128.22,,,5128.22,Other,150% of Medicare + 9.63% HCRA Surcharge,3118.5,45,,3118.5,percent of total billed charges,Critical Access Hospital RCC factor,2356.2,34,,2356.2,percent of total billed charges,Implant Device,2356.2,34,,2356.2,percent of total billed charges,Implant Device,2356.2,34,,2356.2,percent of total billed charges,Implant Device,2356.2,34,,2356.2,percent of total billed charges,Implant Device,2356.2,34,,2356.2,percent of total billed charges,Implant Device,3430.35,,,3430.35,Other,110% of Medicare,2425.5,35,,2425.5,percent of total billed charges,Implant Device,2356.2,34,"Charges > $500, x 34%",2356.2,percent of total billed charges,Implant Device,2425.5,35,,2425.5,percent of total billed charges,Implant Device,2425.5,35,,2425.5,percent of total billed charges,Implant Device,2425.5,35,,2425.5,percent of total billed charges,Implant Device,2425.5,35,,2425.5,percent of total billed charges,Implant Device,2425.5,35,,2425.5,percent of total billed charges,Implant Device,2772,40,,2772,percent of total billed charges,Implant Device,2425.5,70,,2425.5,percent of total billed charges,All Other,2356.2,34,,2356.2,percent of total billed charges,Implant Device,2356.2,34,,2356.2,percent of total billed charges,Implant Device,2425.5,35,,2425.5,percent of total billed charges,Implant Device,2425.5,35,,2425.5,percent of total billed charges,Implant Device,2425.5,35,,2425.5,percent of total billed charges,Implant Device,2425.5,35,,2425.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2356.2,34,"If Charge > 2,000, then 34 percent",2356.2,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5128.22,
BIOMET 29277 LAG SCREW 90MM,C1713,HCPCS,,79003797,CDM,278,RC,,,both,,,2670,1975.81,,,1975.81,Other,150% of Medicare + 9.63% HCRA Surcharge,1201.5,45,,1201.5,percent of total billed charges,Critical Access Hospital RCC factor,907.8,34,,907.8,percent of total billed charges,Implant Device,907.8,34,,907.8,percent of total billed charges,Implant Device,907.8,34,,907.8,percent of total billed charges,Implant Device,907.8,34,,907.8,percent of total billed charges,Implant Device,907.8,34,,907.8,percent of total billed charges,Implant Device,1321.65,,,1321.65,Other,110% of Medicare,934.5,35,,934.5,percent of total billed charges,Implant Device,907.8,34,"Charges > $500, x 34%",907.8,percent of total billed charges,Implant Device,934.5,35,,934.5,percent of total billed charges,Implant Device,934.5,35,,934.5,percent of total billed charges,Implant Device,934.5,35,,934.5,percent of total billed charges,Implant Device,934.5,35,,934.5,percent of total billed charges,Implant Device,934.5,35,,934.5,percent of total billed charges,Implant Device,1068,40,,1068,percent of total billed charges,Implant Device,934.5,70,,934.5,percent of total billed charges,All Other,907.8,34,,907.8,percent of total billed charges,Implant Device,907.8,34,,907.8,percent of total billed charges,Implant Device,934.5,35,,934.5,percent of total billed charges,Implant Device,934.5,35,,934.5,percent of total billed charges,Implant Device,934.5,35,,934.5,percent of total billed charges,Implant Device,934.5,35,,934.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,907.8,34,"If Charge > 2,000, then 34 percent",907.8,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1975.81,
BIOMET 406669 STEINMANN PIN 1/2X2/5,C1713,HCPCS,,79003798,CDM,278,RC,,,both,,,1110,821.4,,,821.4,Other,150% of Medicare + 9.63% HCRA Surcharge,499.5,45,,499.5,percent of total billed charges,Critical Access Hospital RCC factor,377.4,34,,377.4,percent of total billed charges,Implant Device,377.4,34,,377.4,percent of total billed charges,Implant Device,377.4,34,,377.4,percent of total billed charges,Implant Device,377.4,34,,377.4,percent of total billed charges,Implant Device,377.4,34,,377.4,percent of total billed charges,Implant Device,549.45,,,549.45,Other,110% of Medicare,388.5,35,,388.5,percent of total billed charges,Implant Device,377.4,34,"Charges > $500, x 34%",377.4,percent of total billed charges,Implant Device,388.5,35,,388.5,percent of total billed charges,Implant Device,388.5,35,,388.5,percent of total billed charges,Implant Device,388.5,35,,388.5,percent of total billed charges,Implant Device,388.5,35,,388.5,percent of total billed charges,Implant Device,388.5,35,,388.5,percent of total billed charges,Implant Device,444,40,,444,percent of total billed charges,Implant Device,388.5,70,,388.5,percent of total billed charges,All Other,377.4,34,,377.4,percent of total billed charges,Implant Device,377.4,34,,377.4,percent of total billed charges,Implant Device,388.5,35,,388.5,percent of total billed charges,Implant Device,388.5,35,,388.5,percent of total billed charges,Implant Device,388.5,35,,388.5,percent of total billed charges,Implant Device,388.5,35,,388.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,821.4,
BIOMET 11-107128 ACETAB CUP W LINR 62X36,C1776,HCPCS,,79003799,CDM,278,RC,,,both,,,12900,9546.03,,,9546.03,Other,150% of Medicare + 9.63% HCRA Surcharge,5805,45,,5805,percent of total billed charges,Critical Access Hospital RCC factor,4386,34,,4386,percent of total billed charges,Implant Device,4386,34,,4386,percent of total billed charges,Implant Device,4386,34,,4386,percent of total billed charges,Implant Device,4386,34,,4386,percent of total billed charges,Implant Device,4386,34,,4386,percent of total billed charges,Implant Device,6385.5,,,6385.5,Other,110% of Medicare,4515,35,,4515,percent of total billed charges,Implant Device,4386,34,"Charges > $500, x 34%",4386,percent of total billed charges,Implant Device,4515,35,,4515,percent of total billed charges,Implant Device,4515,35,,4515,percent of total billed charges,Implant Device,4515,35,,4515,percent of total billed charges,Implant Device,4515,35,,4515,percent of total billed charges,Implant Device,4515,35,,4515,percent of total billed charges,Implant Device,5160,40,,5160,percent of total billed charges,Implant Device,4515,70,,4515,percent of total billed charges,All Other,4386,34,,4386,percent of total billed charges,Implant Device,4386,34,,4386,percent of total billed charges,Implant Device,4515,35,,4515,percent of total billed charges,Implant Device,4515,35,,4515,percent of total billed charges,Implant Device,4515,35,,4515,percent of total billed charges,Implant Device,4515,35,,4515,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,4386,34,"If Charge > 2,000, then 34 percent",4386,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,9546.03,
BIOMET 11-107019 MODULAR HEAD 36X3MM,C1776,HCPCS,,79003801,CDM,278,RC,,,both,,,7920,5860.82,,,5860.82,Other,150% of Medicare + 9.63% HCRA Surcharge,3564,45,,3564,percent of total billed charges,Critical Access Hospital RCC factor,2692.8,34,,2692.8,percent of total billed charges,Implant Device,2692.8,34,,2692.8,percent of total billed charges,Implant Device,2692.8,34,,2692.8,percent of total billed charges,Implant Device,2692.8,34,,2692.8,percent of total billed charges,Implant Device,2692.8,34,,2692.8,percent of total billed charges,Implant Device,3920.4,,,3920.4,Other,110% of Medicare,2772,35,,2772,percent of total billed charges,Implant Device,2692.8,34,"Charges > $500, x 34%",2692.8,percent of total billed charges,Implant Device,2772,35,,2772,percent of total billed charges,Implant Device,2772,35,,2772,percent of total billed charges,Implant Device,2772,35,,2772,percent of total billed charges,Implant Device,2772,35,,2772,percent of total billed charges,Implant Device,2772,35,,2772,percent of total billed charges,Implant Device,3168,40,,3168,percent of total billed charges,Implant Device,2772,70,,2772,percent of total billed charges,All Other,2692.8,34,,2692.8,percent of total billed charges,Implant Device,2692.8,34,,2692.8,percent of total billed charges,Implant Device,2772,35,,2772,percent of total billed charges,Implant Device,2772,35,,2772,percent of total billed charges,Implant Device,2772,35,,2772,percent of total billed charges,Implant Device,2772,35,,2772,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2692.8,34,"If Charge > 2,000, then 34 percent",2692.8,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5860.82,
BIOMET 26875 NON LOCK SCREW 4.5X75MM,C1713,HCPCS,,79003802,CDM,278,RC,,,both,,,330,244.2,,,244.2,Other,150% of Medicare + 9.63% HCRA Surcharge,148.5,45,,148.5,percent of total billed charges,Critical Access Hospital RCC factor,112.2,34,,112.2,percent of total billed charges,Implant Device,112.2,34,,112.2,percent of total billed charges,Implant Device,112.2,34,,112.2,percent of total billed charges,Implant Device,112.2,34,,112.2,percent of total billed charges,Implant Device,112.2,34,,112.2,percent of total billed charges,Implant Device,163.35,,,163.35,Other,110% of Medicare,115.5,35,,115.5,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,132,40,,132,percent of total billed charges,Implant Device,115.5,70,,115.5,percent of total billed charges,All Other,112.2,34,,112.2,percent of total billed charges,Implant Device,112.2,34,,112.2,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,244.2,
BIOMET 11-107122 ACETAB CUP 50X36MM,C1776,HCPCS,,79003803,CDM,278,RC,,,both,,,12900,9546.03,,,9546.03,Other,150% of Medicare + 9.63% HCRA Surcharge,5805,45,,5805,percent of total billed charges,Critical Access Hospital RCC factor,4386,34,,4386,percent of total billed charges,Implant Device,4386,34,,4386,percent of total billed charges,Implant Device,4386,34,,4386,percent of total billed charges,Implant Device,4386,34,,4386,percent of total billed charges,Implant Device,4386,34,,4386,percent of total billed charges,Implant Device,6385.5,,,6385.5,Other,110% of Medicare,4515,35,,4515,percent of total billed charges,Implant Device,4386,34,"Charges > $500, x 34%",4386,percent of total billed charges,Implant Device,4515,35,,4515,percent of total billed charges,Implant Device,4515,35,,4515,percent of total billed charges,Implant Device,4515,35,,4515,percent of total billed charges,Implant Device,4515,35,,4515,percent of total billed charges,Implant Device,4515,35,,4515,percent of total billed charges,Implant Device,5160,40,,5160,percent of total billed charges,Implant Device,4515,70,,4515,percent of total billed charges,All Other,4386,34,,4386,percent of total billed charges,Implant Device,4386,34,,4386,percent of total billed charges,Implant Device,4515,35,,4515,percent of total billed charges,Implant Device,4515,35,,4515,percent of total billed charges,Implant Device,4515,35,,4515,percent of total billed charges,Implant Device,4515,35,,4515,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,4386,34,"If Charge > 2,000, then 34 percent",4386,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,9546.03,
BIOMET 2000-1005 LUMBAR PLUG,C1713,HCPCS,,79003804,CDM,278,RC,,,both,,,750,555,,,555,Other,150% of Medicare + 9.63% HCRA Surcharge,337.5,45,,337.5,percent of total billed charges,Critical Access Hospital RCC factor,255,34,,255,percent of total billed charges,Implant Device,255,34,,255,percent of total billed charges,Implant Device,255,34,,255,percent of total billed charges,Implant Device,255,34,,255,percent of total billed charges,Implant Device,255,34,,255,percent of total billed charges,Implant Device,371.25,,,371.25,Other,110% of Medicare,262.5,35,,262.5,percent of total billed charges,Implant Device,255,34,"Charges > $500, x 34%",255,percent of total billed charges,Implant Device,262.5,35,,262.5,percent of total billed charges,Implant Device,262.5,35,,262.5,percent of total billed charges,Implant Device,262.5,35,,262.5,percent of total billed charges,Implant Device,262.5,35,,262.5,percent of total billed charges,Implant Device,262.5,35,,262.5,percent of total billed charges,Implant Device,300,40,,300,percent of total billed charges,Implant Device,262.5,70,,262.5,percent of total billed charges,All Other,255,34,,255,percent of total billed charges,Implant Device,255,34,,255,percent of total billed charges,Implant Device,262.5,35,,262.5,percent of total billed charges,Implant Device,262.5,35,,262.5,percent of total billed charges,Implant Device,262.5,35,,262.5,percent of total billed charges,Implant Device,262.5,35,,262.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,555,
BIOMET 163660 HEAD COMPONET 28X6MM,C1776,HCPCS,,79003805,CDM,278,RC,,,both,,,1152,852.48,,,852.48,Other,150% of Medicare + 9.63% HCRA Surcharge,518.4,45,,518.4,percent of total billed charges,Critical Access Hospital RCC factor,391.68,34,,391.68,percent of total billed charges,Implant Device,391.68,34,,391.68,percent of total billed charges,Implant Device,391.68,34,,391.68,percent of total billed charges,Implant Device,391.68,34,,391.68,percent of total billed charges,Implant Device,391.68,34,,391.68,percent of total billed charges,Implant Device,570.24,,,570.24,Other,110% of Medicare,403.2,35,,403.2,percent of total billed charges,Implant Device,391.68,34,"Charges > $500, x 34%",391.68,percent of total billed charges,Implant Device,403.2,35,,403.2,percent of total billed charges,Implant Device,403.2,35,,403.2,percent of total billed charges,Implant Device,403.2,35,,403.2,percent of total billed charges,Implant Device,403.2,35,,403.2,percent of total billed charges,Implant Device,403.2,35,,403.2,percent of total billed charges,Implant Device,460.8,40,,460.8,percent of total billed charges,Implant Device,403.2,70,,403.2,percent of total billed charges,All Other,391.68,34,,391.68,percent of total billed charges,Implant Device,391.68,34,,391.68,percent of total billed charges,Implant Device,403.2,35,,403.2,percent of total billed charges,Implant Device,403.2,35,,403.2,percent of total billed charges,Implant Device,403.2,35,,403.2,percent of total billed charges,Implant Device,403.2,35,,403.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,852.48,
BIOMET 1200 FF SEMI TENODESIS-IRR,C1713,HCPCS,,79003806,CDM,278,RC,,,both,,,5170,3825.81,,,3825.81,Other,150% of Medicare + 9.63% HCRA Surcharge,2326.5,45,,2326.5,percent of total billed charges,Critical Access Hospital RCC factor,1757.8,34,,1757.8,percent of total billed charges,Implant Device,1757.8,34,,1757.8,percent of total billed charges,Implant Device,1757.8,34,,1757.8,percent of total billed charges,Implant Device,1757.8,34,,1757.8,percent of total billed charges,Implant Device,1757.8,34,,1757.8,percent of total billed charges,Implant Device,2559.15,,,2559.15,Other,110% of Medicare,1809.5,35,,1809.5,percent of total billed charges,Implant Device,1757.8,34,"Charges > $500, x 34%",1757.8,percent of total billed charges,Implant Device,1809.5,35,,1809.5,percent of total billed charges,Implant Device,1809.5,35,,1809.5,percent of total billed charges,Implant Device,1809.5,35,,1809.5,percent of total billed charges,Implant Device,1809.5,35,,1809.5,percent of total billed charges,Implant Device,1809.5,35,,1809.5,percent of total billed charges,Implant Device,2068,40,,2068,percent of total billed charges,Implant Device,1809.5,70,,1809.5,percent of total billed charges,All Other,1757.8,34,,1757.8,percent of total billed charges,Implant Device,1757.8,34,,1757.8,percent of total billed charges,Implant Device,1809.5,35,,1809.5,percent of total billed charges,Implant Device,1809.5,35,,1809.5,percent of total billed charges,Implant Device,1809.5,35,,1809.5,percent of total billed charges,Implant Device,1809.5,35,,1809.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1757.8,34,"If Charge > 2,000, then 34 percent",1757.8,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3825.81,
BIOMET 103202 MOD TAPER LOCK FEM 7.5X135,C1776,HCPCS,,79003807,CDM,278,RC,,,both,,,25920,19180.86,,,19180.86,Other,150% of Medicare + 9.63% HCRA Surcharge,11664,45,,11664,percent of total billed charges,Critical Access Hospital RCC factor,8812.8,34,,8812.8,percent of total billed charges,Implant Device,8812.8,34,,8812.8,percent of total billed charges,Implant Device,8812.8,34,,8812.8,percent of total billed charges,Implant Device,8812.8,34,,8812.8,percent of total billed charges,Implant Device,8812.8,34,,8812.8,percent of total billed charges,Implant Device,12830.4,,,12830.4,Other,110% of Medicare,9072,35,,9072,percent of total billed charges,Implant Device,8812.8,34,"Charges > $500, x 34%",8812.8,percent of total billed charges,Implant Device,9072,35,,9072,percent of total billed charges,Implant Device,9072,35,,9072,percent of total billed charges,Implant Device,9072,35,,9072,percent of total billed charges,Implant Device,9072,35,,9072,percent of total billed charges,Implant Device,9072,35,,9072,percent of total billed charges,Implant Device,10368,40,,10368,percent of total billed charges,Implant Device,9072,70,,9072,percent of total billed charges,All Other,8812.8,34,,8812.8,percent of total billed charges,Implant Device,8812.8,34,,8812.8,percent of total billed charges,Implant Device,9072,35,,9072,percent of total billed charges,Implant Device,9072,35,,9072,percent of total billed charges,Implant Device,9072,35,,9072,percent of total billed charges,Implant Device,9072,35,,9072,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,8812.8,34,"If Charge > 2,000, then 34 percent",8812.8,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,19180.86,
BIOMET 211-242 MODULAR STEM 8X150MM,C1776,HCPCS,,79003808,CDM,278,RC,,,both,,,18834,13937.21,,,13937.21,Other,150% of Medicare + 9.63% HCRA Surcharge,8475.3,45,,8475.3,percent of total billed charges,Critical Access Hospital RCC factor,6403.56,34,,6403.56,percent of total billed charges,Implant Device,6403.56,34,,6403.56,percent of total billed charges,Implant Device,6403.56,34,,6403.56,percent of total billed charges,Implant Device,6403.56,34,,6403.56,percent of total billed charges,Implant Device,6403.56,34,,6403.56,percent of total billed charges,Implant Device,9322.83,,,9322.83,Other,110% of Medicare,6591.9,35,,6591.9,percent of total billed charges,Implant Device,6403.56,34,"Charges > $500, x 34%",6403.56,percent of total billed charges,Implant Device,6591.9,35,,6591.9,percent of total billed charges,Implant Device,6591.9,35,,6591.9,percent of total billed charges,Implant Device,6591.9,35,,6591.9,percent of total billed charges,Implant Device,6591.9,35,,6591.9,percent of total billed charges,Implant Device,6591.9,35,,6591.9,percent of total billed charges,Implant Device,7533.6,40,,7533.6,percent of total billed charges,Implant Device,6591.9,70,,6591.9,percent of total billed charges,All Other,6403.56,34,,6403.56,percent of total billed charges,Implant Device,6403.56,34,,6403.56,percent of total billed charges,Implant Device,6591.9,35,,6591.9,percent of total billed charges,Implant Device,6591.9,35,,6591.9,percent of total billed charges,Implant Device,6591.9,35,,6591.9,percent of total billed charges,Implant Device,6591.9,35,,6591.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,6403.56,34,"If Charge > 2,000, then 34 percent",6403.56,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,13937.21,
BIOMET 115383 CENTRAL SCREW 6.5X35MM,C1713,HCPCS,,79003809,CDM,278,RC,,,both,,,780,577.2,,,577.2,Other,150% of Medicare + 9.63% HCRA Surcharge,351,45,,351,percent of total billed charges,Critical Access Hospital RCC factor,265.2,34,,265.2,percent of total billed charges,Implant Device,265.2,34,,265.2,percent of total billed charges,Implant Device,265.2,34,,265.2,percent of total billed charges,Implant Device,265.2,34,,265.2,percent of total billed charges,Implant Device,265.2,34,,265.2,percent of total billed charges,Implant Device,386.1,,,386.1,Other,110% of Medicare,273,35,,273,percent of total billed charges,Implant Device,265.2,34,"Charges > $500, x 34%",265.2,percent of total billed charges,Implant Device,273,35,,273,percent of total billed charges,Implant Device,273,35,,273,percent of total billed charges,Implant Device,273,35,,273,percent of total billed charges,Implant Device,273,35,,273,percent of total billed charges,Implant Device,273,35,,273,percent of total billed charges,Implant Device,312,40,,312,percent of total billed charges,Implant Device,273,70,,273,percent of total billed charges,All Other,265.2,34,,265.2,percent of total billed charges,Implant Device,265.2,34,,265.2,percent of total billed charges,Implant Device,273,35,,273,percent of total billed charges,Implant Device,273,35,,273,percent of total billed charges,Implant Device,273,35,,273,percent of total billed charges,Implant Device,273,35,,273,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,577.2,
BIOMET 91-61035 HT X-DRIVE SCREW 1.5X3.5,C1713,HCPCS,,79003810,CDM,278,RC,,,both,,,174,128.76,,,128.76,Other,150% of Medicare + 9.63% HCRA Surcharge,78.3,45,,78.3,percent of total billed charges,Critical Access Hospital RCC factor,59.16,34,,59.16,percent of total billed charges,Implant Device,59.16,34,,59.16,percent of total billed charges,Implant Device,59.16,34,,59.16,percent of total billed charges,Implant Device,59.16,34,,59.16,percent of total billed charges,Implant Device,59.16,34,,59.16,percent of total billed charges,Implant Device,86.13,,,86.13,Other,110% of Medicare,60.9,35,,60.9,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,60.9,35,,60.9,percent of total billed charges,Implant Device,60.9,35,,60.9,percent of total billed charges,Implant Device,60.9,35,,60.9,percent of total billed charges,Implant Device,60.9,35,,60.9,percent of total billed charges,Implant Device,60.9,35,,60.9,percent of total billed charges,Implant Device,69.6,40,,69.6,percent of total billed charges,Implant Device,60.9,70,,60.9,percent of total billed charges,All Other,59.16,34,,59.16,percent of total billed charges,Implant Device,59.16,34,,59.16,percent of total billed charges,Implant Device,60.9,35,,60.9,percent of total billed charges,Implant Device,60.9,35,,60.9,percent of total billed charges,Implant Device,60.9,35,,60.9,percent of total billed charges,Implant Device,60.9,35,,60.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,128.76,
BIOMET 11-107017 MOD HEAD 36X3MM TAPER,C1776,HCPCS,,79003811,CDM,278,RC,,,both,,,7920,5860.82,,,5860.82,Other,150% of Medicare + 9.63% HCRA Surcharge,3564,45,,3564,percent of total billed charges,Critical Access Hospital RCC factor,2692.8,34,,2692.8,percent of total billed charges,Implant Device,2692.8,34,,2692.8,percent of total billed charges,Implant Device,2692.8,34,,2692.8,percent of total billed charges,Implant Device,2692.8,34,,2692.8,percent of total billed charges,Implant Device,2692.8,34,,2692.8,percent of total billed charges,Implant Device,3920.4,,,3920.4,Other,110% of Medicare,2772,35,,2772,percent of total billed charges,Implant Device,2692.8,34,"Charges > $500, x 34%",2692.8,percent of total billed charges,Implant Device,2772,35,,2772,percent of total billed charges,Implant Device,2772,35,,2772,percent of total billed charges,Implant Device,2772,35,,2772,percent of total billed charges,Implant Device,2772,35,,2772,percent of total billed charges,Implant Device,2772,35,,2772,percent of total billed charges,Implant Device,3168,40,,3168,percent of total billed charges,Implant Device,2772,70,,2772,percent of total billed charges,All Other,2692.8,34,,2692.8,percent of total billed charges,Implant Device,2692.8,34,,2692.8,percent of total billed charges,Implant Device,2772,35,,2772,percent of total billed charges,Implant Device,2772,35,,2772,percent of total billed charges,Implant Device,2772,35,,2772,percent of total billed charges,Implant Device,2772,35,,2772,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2692.8,34,"If Charge > 2,000, then 34 percent",2692.8,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5860.82,
BIOMET 211242 COMPRHNSV SEG STEM 8X150MM,C1776,HCPCS,,79003812,CDM,278,RC,,,both,,,18180,13453.25,,,13453.25,Other,150% of Medicare + 9.63% HCRA Surcharge,8181,45,,8181,percent of total billed charges,Critical Access Hospital RCC factor,6181.2,34,,6181.2,percent of total billed charges,Implant Device,6181.2,34,,6181.2,percent of total billed charges,Implant Device,6181.2,34,,6181.2,percent of total billed charges,Implant Device,6181.2,34,,6181.2,percent of total billed charges,Implant Device,6181.2,34,,6181.2,percent of total billed charges,Implant Device,8999.1,,,8999.1,Other,110% of Medicare,6363,35,,6363,percent of total billed charges,Implant Device,6181.2,34,"Charges > $500, x 34%",6181.2,percent of total billed charges,Implant Device,6363,35,,6363,percent of total billed charges,Implant Device,6363,35,,6363,percent of total billed charges,Implant Device,6363,35,,6363,percent of total billed charges,Implant Device,6363,35,,6363,percent of total billed charges,Implant Device,6363,35,,6363,percent of total billed charges,Implant Device,7272,40,,7272,percent of total billed charges,Implant Device,6363,70,,6363,percent of total billed charges,All Other,6181.2,34,,6181.2,percent of total billed charges,Implant Device,6181.2,34,,6181.2,percent of total billed charges,Implant Device,6363,35,,6363,percent of total billed charges,Implant Device,6363,35,,6363,percent of total billed charges,Implant Device,6363,35,,6363,percent of total billed charges,Implant Device,6363,35,,6363,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,6181.2,34,"If Charge > 2,000, then 34 percent",6181.2,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,13453.25,
BIOMET 2000-5145 CURVED ROD 45MM,C1776,HCPCS,,79003814,CDM,278,RC,,,both,,,1200,888,,,888,Other,150% of Medicare + 9.63% HCRA Surcharge,540,45,,540,percent of total billed charges,Critical Access Hospital RCC factor,408,34,,408,percent of total billed charges,Implant Device,408,34,,408,percent of total billed charges,Implant Device,408,34,,408,percent of total billed charges,Implant Device,408,34,,408,percent of total billed charges,Implant Device,408,34,,408,percent of total billed charges,Implant Device,594,,,594,Other,110% of Medicare,420,35,,420,percent of total billed charges,Implant Device,408,34,"Charges > $500, x 34%",408,percent of total billed charges,Implant Device,420,35,,420,percent of total billed charges,Implant Device,420,35,,420,percent of total billed charges,Implant Device,420,35,,420,percent of total billed charges,Implant Device,420,35,,420,percent of total billed charges,Implant Device,420,35,,420,percent of total billed charges,Implant Device,480,40,,480,percent of total billed charges,Implant Device,420,70,,420,percent of total billed charges,All Other,408,34,,408,percent of total billed charges,Implant Device,408,34,,408,percent of total billed charges,Implant Device,420,35,,420,percent of total billed charges,Implant Device,420,35,,420,percent of total billed charges,Implant Device,420,35,,420,percent of total billed charges,Implant Device,420,35,,420,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,888,
BIOMET 113022 VERSA-DIAL SHOULDER SYS,C1776,HCPCS,,79003815,CDM,278,RC,,,both,,,9120,6748.82,,,6748.82,Other,150% of Medicare + 9.63% HCRA Surcharge,4104,45,,4104,percent of total billed charges,Critical Access Hospital RCC factor,3100.8,34,,3100.8,percent of total billed charges,Implant Device,3100.8,34,,3100.8,percent of total billed charges,Implant Device,3100.8,34,,3100.8,percent of total billed charges,Implant Device,3100.8,34,,3100.8,percent of total billed charges,Implant Device,3100.8,34,,3100.8,percent of total billed charges,Implant Device,4514.4,,,4514.4,Other,110% of Medicare,3192,35,,3192,percent of total billed charges,Implant Device,3100.8,34,"Charges > $500, x 34%",3100.8,percent of total billed charges,Implant Device,3192,35,,3192,percent of total billed charges,Implant Device,3192,35,,3192,percent of total billed charges,Implant Device,3192,35,,3192,percent of total billed charges,Implant Device,3192,35,,3192,percent of total billed charges,Implant Device,3192,35,,3192,percent of total billed charges,Implant Device,3648,40,,3648,percent of total billed charges,Implant Device,3192,70,,3192,percent of total billed charges,All Other,3100.8,34,,3100.8,percent of total billed charges,Implant Device,3100.8,34,,3100.8,percent of total billed charges,Implant Device,3192,35,,3192,percent of total billed charges,Implant Device,3192,35,,3192,percent of total billed charges,Implant Device,3192,35,,3192,percent of total billed charges,Implant Device,3192,35,,3192,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3100.8,34,"If Charge > 2,000, then 34 percent",3100.8,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,6748.82,
BIOMET 26480 CANNULATED SCREW 5.5X80MM,C1713,HCPCS,,79003816,CDM,278,RC,,,both,,,420,310.8,,,310.8,Other,150% of Medicare + 9.63% HCRA Surcharge,189,45,,189,percent of total billed charges,Critical Access Hospital RCC factor,142.8,34,,142.8,percent of total billed charges,Implant Device,142.8,34,,142.8,percent of total billed charges,Implant Device,142.8,34,,142.8,percent of total billed charges,Implant Device,142.8,34,,142.8,percent of total billed charges,Implant Device,142.8,34,,142.8,percent of total billed charges,Implant Device,207.9,,,207.9,Other,110% of Medicare,147,35,,147,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,147,35,,147,percent of total billed charges,Implant Device,147,35,,147,percent of total billed charges,Implant Device,147,35,,147,percent of total billed charges,Implant Device,147,35,,147,percent of total billed charges,Implant Device,147,35,,147,percent of total billed charges,Implant Device,168,40,,168,percent of total billed charges,Implant Device,147,70,,147,percent of total billed charges,All Other,142.8,34,,142.8,percent of total billed charges,Implant Device,142.8,34,,142.8,percent of total billed charges,Implant Device,147,35,,147,percent of total billed charges,Implant Device,147,35,,147,percent of total billed charges,Implant Device,147,35,,147,percent of total billed charges,Implant Device,147,35,,147,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,310.8,
BIOMET 28811 TROCHANT NAIL SHORT 11X22CM,C1713,HCPCS,,79003818,CDM,278,RC,,,both,,,7950,5883.02,,,5883.02,Other,150% of Medicare + 9.63% HCRA Surcharge,3577.5,45,,3577.5,percent of total billed charges,Critical Access Hospital RCC factor,2703,34,,2703,percent of total billed charges,Implant Device,2703,34,,2703,percent of total billed charges,Implant Device,2703,34,,2703,percent of total billed charges,Implant Device,2703,34,,2703,percent of total billed charges,Implant Device,2703,34,,2703,percent of total billed charges,Implant Device,3935.25,,,3935.25,Other,110% of Medicare,2782.5,35,,2782.5,percent of total billed charges,Implant Device,2703,34,"Charges > $500, x 34%",2703,percent of total billed charges,Implant Device,2782.5,35,,2782.5,percent of total billed charges,Implant Device,2782.5,35,,2782.5,percent of total billed charges,Implant Device,2782.5,35,,2782.5,percent of total billed charges,Implant Device,2782.5,35,,2782.5,percent of total billed charges,Implant Device,2782.5,35,,2782.5,percent of total billed charges,Implant Device,3180,40,,3180,percent of total billed charges,Implant Device,2782.5,70,,2782.5,percent of total billed charges,All Other,2703,34,,2703,percent of total billed charges,Implant Device,2703,34,,2703,percent of total billed charges,Implant Device,2782.5,35,,2782.5,percent of total billed charges,Implant Device,2782.5,35,,2782.5,percent of total billed charges,Implant Device,2782.5,35,,2782.5,percent of total billed charges,Implant Device,2782.5,35,,2782.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2703,34,"If Charge > 2,000, then 34 percent",2703,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5883.02,
BIOMET 26852 NON LOCK SCREW 4.5X52MM,C1713,HCPCS,,79003819,CDM,278,RC,,,both,,,330,244.2,,,244.2,Other,150% of Medicare + 9.63% HCRA Surcharge,148.5,45,,148.5,percent of total billed charges,Critical Access Hospital RCC factor,112.2,34,,112.2,percent of total billed charges,Implant Device,112.2,34,,112.2,percent of total billed charges,Implant Device,112.2,34,,112.2,percent of total billed charges,Implant Device,112.2,34,,112.2,percent of total billed charges,Implant Device,112.2,34,,112.2,percent of total billed charges,Implant Device,163.35,,,163.35,Other,110% of Medicare,115.5,35,,115.5,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,132,40,,132,percent of total billed charges,Implant Device,115.5,70,,115.5,percent of total billed charges,All Other,112.2,34,,112.2,percent of total billed charges,Implant Device,112.2,34,,112.2,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,244.2,
BIOMET 8135-0032-W HEMICAP 13.5MM TAPER,C1713,HCPCS,,79003820,CDM,278,RC,,,both,,,1956,1447.44,,,1447.44,Other,150% of Medicare + 9.63% HCRA Surcharge,880.2,45,,880.2,percent of total billed charges,Critical Access Hospital RCC factor,665.04,34,,665.04,percent of total billed charges,Implant Device,665.04,34,,665.04,percent of total billed charges,Implant Device,665.04,34,,665.04,percent of total billed charges,Implant Device,665.04,34,,665.04,percent of total billed charges,Implant Device,665.04,34,,665.04,percent of total billed charges,Implant Device,968.22,,,968.22,Other,110% of Medicare,684.6,35,,684.6,percent of total billed charges,Implant Device,665.04,34,"Charges > $500, x 34%",665.04,percent of total billed charges,Implant Device,684.6,35,,684.6,percent of total billed charges,Implant Device,684.6,35,,684.6,percent of total billed charges,Implant Device,684.6,35,,684.6,percent of total billed charges,Implant Device,684.6,35,,684.6,percent of total billed charges,Implant Device,684.6,35,,684.6,percent of total billed charges,Implant Device,782.4,40,,782.4,percent of total billed charges,Implant Device,684.6,70,,684.6,percent of total billed charges,All Other,665.04,34,,665.04,percent of total billed charges,Implant Device,665.04,34,,665.04,percent of total billed charges,Implant Device,684.6,35,,684.6,percent of total billed charges,Implant Device,684.6,35,,684.6,percent of total billed charges,Implant Device,684.6,35,,684.6,percent of total billed charges,Implant Device,684.6,35,,684.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1447.44,
BIOMET 28-334 TROCH NAIL RT 11MM/34CM,C1713,HCPCS,,79003821,CDM,278,RC,,,both,,,11040,8169.63,,,8169.63,Other,150% of Medicare + 9.63% HCRA Surcharge,4968,45,,4968,percent of total billed charges,Critical Access Hospital RCC factor,3753.6,34,,3753.6,percent of total billed charges,Implant Device,3753.6,34,,3753.6,percent of total billed charges,Implant Device,3753.6,34,,3753.6,percent of total billed charges,Implant Device,3753.6,34,,3753.6,percent of total billed charges,Implant Device,3753.6,34,,3753.6,percent of total billed charges,Implant Device,5464.8,,,5464.8,Other,110% of Medicare,3864,35,,3864,percent of total billed charges,Implant Device,3753.6,34,"Charges > $500, x 34%",3753.6,percent of total billed charges,Implant Device,3864,35,,3864,percent of total billed charges,Implant Device,3864,35,,3864,percent of total billed charges,Implant Device,3864,35,,3864,percent of total billed charges,Implant Device,3864,35,,3864,percent of total billed charges,Implant Device,3864,35,,3864,percent of total billed charges,Implant Device,4416,40,,4416,percent of total billed charges,Implant Device,3864,70,,3864,percent of total billed charges,All Other,3753.6,34,,3753.6,percent of total billed charges,Implant Device,3753.6,34,,3753.6,percent of total billed charges,Implant Device,3864,35,,3864,percent of total billed charges,Implant Device,3864,35,,3864,percent of total billed charges,Implant Device,3864,35,,3864,percent of total billed charges,Implant Device,3864,35,,3864,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3753.6,34,"If Charge > 2,000, then 34 percent",3753.6,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,8169.63,
BIOMET 2000-2450 MULTIAXIAL SCREW 6.5X50,C1713,HCPCS,,79003822,CDM,278,RC,,,both,,,2820,2086.81,,,2086.81,Other,150% of Medicare + 9.63% HCRA Surcharge,1269,45,,1269,percent of total billed charges,Critical Access Hospital RCC factor,958.8,34,,958.8,percent of total billed charges,Implant Device,958.8,34,,958.8,percent of total billed charges,Implant Device,958.8,34,,958.8,percent of total billed charges,Implant Device,958.8,34,,958.8,percent of total billed charges,Implant Device,958.8,34,,958.8,percent of total billed charges,Implant Device,1395.9,,,1395.9,Other,110% of Medicare,987,35,,987,percent of total billed charges,Implant Device,958.8,34,"Charges > $500, x 34%",958.8,percent of total billed charges,Implant Device,987,35,,987,percent of total billed charges,Implant Device,987,35,,987,percent of total billed charges,Implant Device,987,35,,987,percent of total billed charges,Implant Device,987,35,,987,percent of total billed charges,Implant Device,987,35,,987,percent of total billed charges,Implant Device,1128,40,,1128,percent of total billed charges,Implant Device,987,70,,987,percent of total billed charges,All Other,958.8,34,,958.8,percent of total billed charges,Implant Device,958.8,34,,958.8,percent of total billed charges,Implant Device,987,35,,987,percent of total billed charges,Implant Device,987,35,,987,percent of total billed charges,Implant Device,987,35,,987,percent of total billed charges,Implant Device,987,35,,987,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,958.8,34,"If Charge > 2,000, then 34 percent",958.8,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2086.81,
BIOMET 1198 FF ANTERIOR TIBIALIS TENDON,C1713,HCPCS,,79003823,CDM,278,RC,,,both,,,6606,4888.46,,,4888.46,Other,150% of Medicare + 9.63% HCRA Surcharge,2972.7,45,,2972.7,percent of total billed charges,Critical Access Hospital RCC factor,2246.04,34,,2246.04,percent of total billed charges,Implant Device,2246.04,34,,2246.04,percent of total billed charges,Implant Device,2246.04,34,,2246.04,percent of total billed charges,Implant Device,2246.04,34,,2246.04,percent of total billed charges,Implant Device,2246.04,34,,2246.04,percent of total billed charges,Implant Device,3269.97,,,3269.97,Other,110% of Medicare,2312.1,35,,2312.1,percent of total billed charges,Implant Device,2246.04,34,"Charges > $500, x 34%",2246.04,percent of total billed charges,Implant Device,2312.1,35,,2312.1,percent of total billed charges,Implant Device,2312.1,35,,2312.1,percent of total billed charges,Implant Device,2312.1,35,,2312.1,percent of total billed charges,Implant Device,2312.1,35,,2312.1,percent of total billed charges,Implant Device,2312.1,35,,2312.1,percent of total billed charges,Implant Device,2642.4,40,,2642.4,percent of total billed charges,Implant Device,2312.1,70,,2312.1,percent of total billed charges,All Other,2246.04,34,,2246.04,percent of total billed charges,Implant Device,2246.04,34,,2246.04,percent of total billed charges,Implant Device,2312.1,35,,2312.1,percent of total billed charges,Implant Device,2312.1,35,,2312.1,percent of total billed charges,Implant Device,2312.1,35,,2312.1,percent of total billed charges,Implant Device,2312.1,35,,2312.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2246.04,34,"If Charge > 2,000, then 34 percent",2246.04,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4888.46,
BIOMET 28232 TROCH NAIL LONG 11MM/32CM,C1713,HCPCS,,79003824,CDM,278,RC,,,both,,,11040,8169.63,,,8169.63,Other,150% of Medicare + 9.63% HCRA Surcharge,4968,45,,4968,percent of total billed charges,Critical Access Hospital RCC factor,3753.6,34,,3753.6,percent of total billed charges,Implant Device,3753.6,34,,3753.6,percent of total billed charges,Implant Device,3753.6,34,,3753.6,percent of total billed charges,Implant Device,3753.6,34,,3753.6,percent of total billed charges,Implant Device,3753.6,34,,3753.6,percent of total billed charges,Implant Device,5464.8,,,5464.8,Other,110% of Medicare,3864,35,,3864,percent of total billed charges,Implant Device,3753.6,34,"Charges > $500, x 34%",3753.6,percent of total billed charges,Implant Device,3864,35,,3864,percent of total billed charges,Implant Device,3864,35,,3864,percent of total billed charges,Implant Device,3864,35,,3864,percent of total billed charges,Implant Device,3864,35,,3864,percent of total billed charges,Implant Device,3864,35,,3864,percent of total billed charges,Implant Device,4416,40,,4416,percent of total billed charges,Implant Device,3864,70,,3864,percent of total billed charges,All Other,3753.6,34,,3753.6,percent of total billed charges,Implant Device,3753.6,34,,3753.6,percent of total billed charges,Implant Device,3864,35,,3864,percent of total billed charges,Implant Device,3864,35,,3864,percent of total billed charges,Implant Device,3864,35,,3864,percent of total billed charges,Implant Device,3864,35,,3864,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3753.6,34,"If Charge > 2,000, then 34 percent",3753.6,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,8169.63,
BIOMET 162657 DISTAL CENTRALIZER 11MM,C1776,HCPCS,,79003825,CDM,278,RC,,,both,,,960,710.4,,,710.4,Other,150% of Medicare + 9.63% HCRA Surcharge,432,45,,432,percent of total billed charges,Critical Access Hospital RCC factor,326.4,34,,326.4,percent of total billed charges,Implant Device,326.4,34,,326.4,percent of total billed charges,Implant Device,326.4,34,,326.4,percent of total billed charges,Implant Device,326.4,34,,326.4,percent of total billed charges,Implant Device,326.4,34,,326.4,percent of total billed charges,Implant Device,475.2,,,475.2,Other,110% of Medicare,336,35,,336,percent of total billed charges,Implant Device,326.4,34,"Charges > $500, x 34%",326.4,percent of total billed charges,Implant Device,336,35,,336,percent of total billed charges,Implant Device,336,35,,336,percent of total billed charges,Implant Device,336,35,,336,percent of total billed charges,Implant Device,336,35,,336,percent of total billed charges,Implant Device,336,35,,336,percent of total billed charges,Implant Device,384,40,,384,percent of total billed charges,Implant Device,336,70,,336,percent of total billed charges,All Other,326.4,34,,326.4,percent of total billed charges,Implant Device,326.4,34,,326.4,percent of total billed charges,Implant Device,336,35,,336,percent of total billed charges,Implant Device,336,35,,336,percent of total billed charges,Implant Device,336,35,,336,percent of total billed charges,Implant Device,336,35,,336,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,710.4,
BIOMET 154602 FEMORAL IMPLANT LARGE,C1776,HCPCS,,79003826,CDM,278,RC,,,both,,,21360,15806.45,,,15806.45,Other,150% of Medicare + 9.63% HCRA Surcharge,9612,45,,9612,percent of total billed charges,Critical Access Hospital RCC factor,7262.4,34,,7262.4,percent of total billed charges,Implant Device,7262.4,34,,7262.4,percent of total billed charges,Implant Device,7262.4,34,,7262.4,percent of total billed charges,Implant Device,7262.4,34,,7262.4,percent of total billed charges,Implant Device,7262.4,34,,7262.4,percent of total billed charges,Implant Device,10573.2,,,10573.2,Other,110% of Medicare,7476,35,,7476,percent of total billed charges,Implant Device,7262.4,34,"Charges > $500, x 34%",7262.4,percent of total billed charges,Implant Device,7476,35,,7476,percent of total billed charges,Implant Device,7476,35,,7476,percent of total billed charges,Implant Device,7476,35,,7476,percent of total billed charges,Implant Device,7476,35,,7476,percent of total billed charges,Implant Device,7476,35,,7476,percent of total billed charges,Implant Device,8544,40,,8544,percent of total billed charges,Implant Device,7476,70,,7476,percent of total billed charges,All Other,7262.4,34,,7262.4,percent of total billed charges,Implant Device,7262.4,34,,7262.4,percent of total billed charges,Implant Device,7476,35,,7476,percent of total billed charges,Implant Device,7476,35,,7476,percent of total billed charges,Implant Device,7476,35,,7476,percent of total billed charges,Implant Device,7476,35,,7476,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,7262.4,34,"If Charge > 2,000, then 34 percent",7262.4,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,15806.45,
BIOMET 159575 MENISCAL BEARING MED RT3MM,C1776,HCPCS,,79003827,CDM,278,RC,,,both,,,5190,3840.61,,,3840.61,Other,150% of Medicare + 9.63% HCRA Surcharge,2335.5,45,,2335.5,percent of total billed charges,Critical Access Hospital RCC factor,1764.6,34,,1764.6,percent of total billed charges,Implant Device,1764.6,34,,1764.6,percent of total billed charges,Implant Device,1764.6,34,,1764.6,percent of total billed charges,Implant Device,1764.6,34,,1764.6,percent of total billed charges,Implant Device,1764.6,34,,1764.6,percent of total billed charges,Implant Device,2569.05,,,2569.05,Other,110% of Medicare,1816.5,35,,1816.5,percent of total billed charges,Implant Device,1764.6,34,"Charges > $500, x 34%",1764.6,percent of total billed charges,Implant Device,1816.5,35,,1816.5,percent of total billed charges,Implant Device,1816.5,35,,1816.5,percent of total billed charges,Implant Device,1816.5,35,,1816.5,percent of total billed charges,Implant Device,1816.5,35,,1816.5,percent of total billed charges,Implant Device,1816.5,35,,1816.5,percent of total billed charges,Implant Device,2076,40,,2076,percent of total billed charges,Implant Device,1816.5,70,,1816.5,percent of total billed charges,All Other,1764.6,34,,1764.6,percent of total billed charges,Implant Device,1764.6,34,,1764.6,percent of total billed charges,Implant Device,1816.5,35,,1816.5,percent of total billed charges,Implant Device,1816.5,35,,1816.5,percent of total billed charges,Implant Device,1816.5,35,,1816.5,percent of total billed charges,Implant Device,1816.5,35,,1816.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1764.6,34,"If Charge > 2,000, then 34 percent",1764.6,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3840.61,
BIOMET 29238 LAG SCREW ASSY 95MM,C1713,HCPCS,,79003828,CDM,278,RC,,,both,,,3330,2464.21,,,2464.21,Other,150% of Medicare + 9.63% HCRA Surcharge,1498.5,45,,1498.5,percent of total billed charges,Critical Access Hospital RCC factor,1132.2,34,,1132.2,percent of total billed charges,Implant Device,1132.2,34,,1132.2,percent of total billed charges,Implant Device,1132.2,34,,1132.2,percent of total billed charges,Implant Device,1132.2,34,,1132.2,percent of total billed charges,Implant Device,1132.2,34,,1132.2,percent of total billed charges,Implant Device,1648.35,,,1648.35,Other,110% of Medicare,1165.5,35,,1165.5,percent of total billed charges,Implant Device,1132.2,34,"Charges > $500, x 34%",1132.2,percent of total billed charges,Implant Device,1165.5,35,,1165.5,percent of total billed charges,Implant Device,1165.5,35,,1165.5,percent of total billed charges,Implant Device,1165.5,35,,1165.5,percent of total billed charges,Implant Device,1165.5,35,,1165.5,percent of total billed charges,Implant Device,1165.5,35,,1165.5,percent of total billed charges,Implant Device,1332,40,,1332,percent of total billed charges,Implant Device,1165.5,70,,1165.5,percent of total billed charges,All Other,1132.2,34,,1132.2,percent of total billed charges,Implant Device,1132.2,34,,1132.2,percent of total billed charges,Implant Device,1165.5,35,,1165.5,percent of total billed charges,Implant Device,1165.5,35,,1165.5,percent of total billed charges,Implant Device,1165.5,35,,1165.5,percent of total billed charges,Implant Device,1165.5,35,,1165.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1132.2,34,"If Charge > 2,000, then 34 percent",1132.2,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2464.21,
BIOMET 113952 HYBRIDD GLENOID BASE 4MM,C1776,HCPCS,,79003829,CDM,278,RC,,,both,,,7800,5772.02,,,5772.02,Other,150% of Medicare + 9.63% HCRA Surcharge,3510,45,,3510,percent of total billed charges,Critical Access Hospital RCC factor,2652,34,,2652,percent of total billed charges,Implant Device,2652,34,,2652,percent of total billed charges,Implant Device,2652,34,,2652,percent of total billed charges,Implant Device,2652,34,,2652,percent of total billed charges,Implant Device,2652,34,,2652,percent of total billed charges,Implant Device,3861,,,3861,Other,110% of Medicare,2730,35,,2730,percent of total billed charges,Implant Device,2652,34,"Charges > $500, x 34%",2652,percent of total billed charges,Implant Device,2730,35,,2730,percent of total billed charges,Implant Device,2730,35,,2730,percent of total billed charges,Implant Device,2730,35,,2730,percent of total billed charges,Implant Device,2730,35,,2730,percent of total billed charges,Implant Device,2730,35,,2730,percent of total billed charges,Implant Device,3120,40,,3120,percent of total billed charges,Implant Device,2730,70,,2730,percent of total billed charges,All Other,2652,34,,2652,percent of total billed charges,Implant Device,2652,34,,2652,percent of total billed charges,Implant Device,2730,35,,2730,percent of total billed charges,Implant Device,2730,35,,2730,percent of total billed charges,Implant Device,2730,35,,2730,percent of total billed charges,Implant Device,2730,35,,2730,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2652,34,"If Charge > 2,000, then 34 percent",2652,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5772.02,
BIOMET 1199 POST TIBIALIS TENDON GRAFT,C1713,HCPCS,,79003831,CDM,278,RC,,,both,,,6606,4888.46,,,4888.46,Other,150% of Medicare + 9.63% HCRA Surcharge,2972.7,45,,2972.7,percent of total billed charges,Critical Access Hospital RCC factor,2246.04,34,,2246.04,percent of total billed charges,Implant Device,2246.04,34,,2246.04,percent of total billed charges,Implant Device,2246.04,34,,2246.04,percent of total billed charges,Implant Device,2246.04,34,,2246.04,percent of total billed charges,Implant Device,2246.04,34,,2246.04,percent of total billed charges,Implant Device,3269.97,,,3269.97,Other,110% of Medicare,2312.1,35,,2312.1,percent of total billed charges,Implant Device,2246.04,34,"Charges > $500, x 34%",2246.04,percent of total billed charges,Implant Device,2312.1,35,,2312.1,percent of total billed charges,Implant Device,2312.1,35,,2312.1,percent of total billed charges,Implant Device,2312.1,35,,2312.1,percent of total billed charges,Implant Device,2312.1,35,,2312.1,percent of total billed charges,Implant Device,2312.1,35,,2312.1,percent of total billed charges,Implant Device,2642.4,40,,2642.4,percent of total billed charges,Implant Device,2312.1,70,,2312.1,percent of total billed charges,All Other,2246.04,34,,2246.04,percent of total billed charges,Implant Device,2246.04,34,,2246.04,percent of total billed charges,Implant Device,2312.1,35,,2312.1,percent of total billed charges,Implant Device,2312.1,35,,2312.1,percent of total billed charges,Implant Device,2312.1,35,,2312.1,percent of total billed charges,Implant Device,2312.1,35,,2312.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2246.04,34,"If Charge > 2,000, then 34 percent",2246.04,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4888.46,
BIOMET 11-114644 HUMERAL HEAD SIZE 4,C1776,HCPCS,,79003834,CDM,278,RC,,,both,,,21990,16272.65,,,16272.65,Other,150% of Medicare + 9.63% HCRA Surcharge,9895.5,45,,9895.5,percent of total billed charges,Critical Access Hospital RCC factor,7476.6,34,,7476.6,percent of total billed charges,Implant Device,7476.6,34,,7476.6,percent of total billed charges,Implant Device,7476.6,34,,7476.6,percent of total billed charges,Implant Device,7476.6,34,,7476.6,percent of total billed charges,Implant Device,7476.6,34,,7476.6,percent of total billed charges,Implant Device,10885.05,,,10885.05,Other,110% of Medicare,7696.5,35,,7696.5,percent of total billed charges,Implant Device,7476.6,34,"Charges > $500, x 34%",7476.6,percent of total billed charges,Implant Device,7696.5,35,,7696.5,percent of total billed charges,Implant Device,7696.5,35,,7696.5,percent of total billed charges,Implant Device,7696.5,35,,7696.5,percent of total billed charges,Implant Device,7696.5,35,,7696.5,percent of total billed charges,Implant Device,7696.5,35,,7696.5,percent of total billed charges,Implant Device,8796,40,,8796,percent of total billed charges,Implant Device,7696.5,70,,7696.5,percent of total billed charges,All Other,7476.6,34,,7476.6,percent of total billed charges,Implant Device,7476.6,34,,7476.6,percent of total billed charges,Implant Device,7696.5,35,,7696.5,percent of total billed charges,Implant Device,7696.5,35,,7696.5,percent of total billed charges,Implant Device,7696.5,35,,7696.5,percent of total billed charges,Implant Device,7696.5,35,,7696.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,7476.6,34,"If Charge > 2,000, then 34 percent",7476.6,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,16272.65,
BIOMET 11-165214 ACETABULAR CUP 28X45MM,C1776,HCPCS,,79003835,CDM,278,RC,,,both,,,6540,4839.62,,,4839.62,Other,150% of Medicare + 9.63% HCRA Surcharge,2943,45,,2943,percent of total billed charges,Critical Access Hospital RCC factor,2223.6,34,,2223.6,percent of total billed charges,Implant Device,2223.6,34,,2223.6,percent of total billed charges,Implant Device,2223.6,34,,2223.6,percent of total billed charges,Implant Device,2223.6,34,,2223.6,percent of total billed charges,Implant Device,2223.6,34,,2223.6,percent of total billed charges,Implant Device,3237.3,,,3237.3,Other,110% of Medicare,2289,35,,2289,percent of total billed charges,Implant Device,2223.6,34,"Charges > $500, x 34%",2223.6,percent of total billed charges,Implant Device,2289,35,,2289,percent of total billed charges,Implant Device,2289,35,,2289,percent of total billed charges,Implant Device,2289,35,,2289,percent of total billed charges,Implant Device,2289,35,,2289,percent of total billed charges,Implant Device,2289,35,,2289,percent of total billed charges,Implant Device,2616,40,,2616,percent of total billed charges,Implant Device,2289,70,,2289,percent of total billed charges,All Other,2223.6,34,,2223.6,percent of total billed charges,Implant Device,2223.6,34,,2223.6,percent of total billed charges,Implant Device,2289,35,,2289,percent of total billed charges,Implant Device,2289,35,,2289,percent of total billed charges,Implant Device,2289,35,,2289,percent of total billed charges,Implant Device,2289,35,,2289,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2223.6,34,"If Charge > 2,000, then 34 percent",2223.6,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4839.62,
ARTHREX AR-1530PS TENODESIS SCREW 3.8MM,C1713,HCPCS,,79003838,CDM,278,RC,,,both,,,1566,1158.84,,,1158.84,Other,150% of Medicare + 9.63% HCRA Surcharge,704.7,45,,704.7,percent of total billed charges,Critical Access Hospital RCC factor,532.44,34,,532.44,percent of total billed charges,Implant Device,532.44,34,,532.44,percent of total billed charges,Implant Device,532.44,34,,532.44,percent of total billed charges,Implant Device,532.44,34,,532.44,percent of total billed charges,Implant Device,532.44,34,,532.44,percent of total billed charges,Implant Device,775.17,,,775.17,Other,110% of Medicare,548.1,35,,548.1,percent of total billed charges,Implant Device,532.44,34,"Charges > $500, x 34%",532.44,percent of total billed charges,Implant Device,548.1,35,,548.1,percent of total billed charges,Implant Device,548.1,35,,548.1,percent of total billed charges,Implant Device,548.1,35,,548.1,percent of total billed charges,Implant Device,548.1,35,,548.1,percent of total billed charges,Implant Device,548.1,35,,548.1,percent of total billed charges,Implant Device,626.4,40,,626.4,percent of total billed charges,Implant Device,548.1,70,,548.1,percent of total billed charges,All Other,532.44,34,,532.44,percent of total billed charges,Implant Device,532.44,34,,532.44,percent of total billed charges,Implant Device,548.1,35,,548.1,percent of total billed charges,Implant Device,548.1,35,,548.1,percent of total billed charges,Implant Device,548.1,35,,548.1,percent of total billed charges,Implant Device,548.1,35,,548.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1158.84,
SYNTHES 207.636 CANN SCREW ST SS,C1713,HCPCS,,79003840,CDM,278,RC,,,both,,,685,506.9,,,506.9,Other,150% of Medicare + 9.63% HCRA Surcharge,308.25,45,,308.25,percent of total billed charges,Critical Access Hospital RCC factor,232.9,34,,232.9,percent of total billed charges,Implant Device,232.9,34,,232.9,percent of total billed charges,Implant Device,232.9,34,,232.9,percent of total billed charges,Implant Device,232.9,34,,232.9,percent of total billed charges,Implant Device,232.9,34,,232.9,percent of total billed charges,Implant Device,339.08,,,339.08,Other,110% of Medicare,239.75,35,,239.75,percent of total billed charges,Implant Device,232.9,34,"Charges > $500, x 34%",232.9,percent of total billed charges,Implant Device,239.75,35,,239.75,percent of total billed charges,Implant Device,239.75,35,,239.75,percent of total billed charges,Implant Device,239.75,35,,239.75,percent of total billed charges,Implant Device,239.75,35,,239.75,percent of total billed charges,Implant Device,239.75,35,,239.75,percent of total billed charges,Implant Device,274,40,,274,percent of total billed charges,Implant Device,239.75,70,,239.75,percent of total billed charges,All Other,232.9,34,,232.9,percent of total billed charges,Implant Device,232.9,34,,232.9,percent of total billed charges,Implant Device,239.75,35,,239.75,percent of total billed charges,Implant Device,239.75,35,,239.75,percent of total billed charges,Implant Device,239.75,35,,239.75,percent of total billed charges,Implant Device,239.75,35,,239.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,506.9,
SYNTHES 207.634 CANN SCREW ST SS,C1713,HCPCS,,79003841,CDM,278,RC,,,both,,,761,563.14,,,563.14,Other,150% of Medicare + 9.63% HCRA Surcharge,342.45,45,,342.45,percent of total billed charges,Critical Access Hospital RCC factor,258.74,34,,258.74,percent of total billed charges,Implant Device,258.74,34,,258.74,percent of total billed charges,Implant Device,258.74,34,,258.74,percent of total billed charges,Implant Device,258.74,34,,258.74,percent of total billed charges,Implant Device,258.74,34,,258.74,percent of total billed charges,Implant Device,376.7,,,376.7,Other,110% of Medicare,266.35,35,,266.35,percent of total billed charges,Implant Device,258.74,34,"Charges > $500, x 34%",258.74,percent of total billed charges,Implant Device,266.35,35,,266.35,percent of total billed charges,Implant Device,266.35,35,,266.35,percent of total billed charges,Implant Device,266.35,35,,266.35,percent of total billed charges,Implant Device,266.35,35,,266.35,percent of total billed charges,Implant Device,266.35,35,,266.35,percent of total billed charges,Implant Device,304.4,40,,304.4,percent of total billed charges,Implant Device,266.35,70,,266.35,percent of total billed charges,All Other,258.74,34,,258.74,percent of total billed charges,Implant Device,258.74,34,,258.74,percent of total billed charges,Implant Device,266.35,35,,266.35,percent of total billed charges,Implant Device,266.35,35,,266.35,percent of total billed charges,Implant Device,266.35,35,,266.35,percent of total billed charges,Implant Device,266.35,35,,266.35,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,563.14,
SYNTHES 208.441 CANN SCREW 6.5X32MM,C1713,HCPCS,,79003843,CDM,278,RC,,,both,,,908,671.92,,,671.92,Other,150% of Medicare + 9.63% HCRA Surcharge,408.6,45,,408.6,percent of total billed charges,Critical Access Hospital RCC factor,308.72,34,,308.72,percent of total billed charges,Implant Device,308.72,34,,308.72,percent of total billed charges,Implant Device,308.72,34,,308.72,percent of total billed charges,Implant Device,308.72,34,,308.72,percent of total billed charges,Implant Device,308.72,34,,308.72,percent of total billed charges,Implant Device,449.46,,,449.46,Other,110% of Medicare,317.8,35,,317.8,percent of total billed charges,Implant Device,308.72,34,"Charges > $500, x 34%",308.72,percent of total billed charges,Implant Device,317.8,35,,317.8,percent of total billed charges,Implant Device,317.8,35,,317.8,percent of total billed charges,Implant Device,317.8,35,,317.8,percent of total billed charges,Implant Device,317.8,35,,317.8,percent of total billed charges,Implant Device,317.8,35,,317.8,percent of total billed charges,Implant Device,363.2,40,,363.2,percent of total billed charges,Implant Device,317.8,70,,317.8,percent of total billed charges,All Other,308.72,34,,308.72,percent of total billed charges,Implant Device,308.72,34,,308.72,percent of total billed charges,Implant Device,317.8,35,,317.8,percent of total billed charges,Implant Device,317.8,35,,317.8,percent of total billed charges,Implant Device,317.8,35,,317.8,percent of total billed charges,Implant Device,317.8,35,,317.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,671.92,
STRYKER 1830-0823S HUMERAL NAIL 8X230MM,C1713,HCPCS,,79003852,CDM,278,RC,,,both,,,5483,4057.43,,,4057.43,Other,150% of Medicare + 9.63% HCRA Surcharge,2467.35,45,,2467.35,percent of total billed charges,Critical Access Hospital RCC factor,1864.22,34,,1864.22,percent of total billed charges,Implant Device,1864.22,34,,1864.22,percent of total billed charges,Implant Device,1864.22,34,,1864.22,percent of total billed charges,Implant Device,1864.22,34,,1864.22,percent of total billed charges,Implant Device,1864.22,34,,1864.22,percent of total billed charges,Implant Device,2714.09,,,2714.09,Other,110% of Medicare,1919.05,35,,1919.05,percent of total billed charges,Implant Device,1864.22,34,"Charges > $500, x 34%",1864.22,percent of total billed charges,Implant Device,1919.05,35,,1919.05,percent of total billed charges,Implant Device,1919.05,35,,1919.05,percent of total billed charges,Implant Device,1919.05,35,,1919.05,percent of total billed charges,Implant Device,1919.05,35,,1919.05,percent of total billed charges,Implant Device,1919.05,35,,1919.05,percent of total billed charges,Implant Device,2193.2,40,,2193.2,percent of total billed charges,Implant Device,1919.05,70,,1919.05,percent of total billed charges,All Other,1864.22,34,,1864.22,percent of total billed charges,Implant Device,1864.22,34,,1864.22,percent of total billed charges,Implant Device,1919.05,35,,1919.05,percent of total billed charges,Implant Device,1919.05,35,,1919.05,percent of total billed charges,Implant Device,1919.05,35,,1919.05,percent of total billed charges,Implant Device,1919.05,35,,1919.05,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1864.22,34,"If Charge > 2,000, then 34 percent",1864.22,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4057.43,
STRYKER 1896-4036S LOCKING SCREW 4X36MM,C1713,HCPCS,,79003853,CDM,278,RC,,,both,,,905,669.7,,,669.7,Other,150% of Medicare + 9.63% HCRA Surcharge,407.25,45,,407.25,percent of total billed charges,Critical Access Hospital RCC factor,307.7,34,,307.7,percent of total billed charges,Implant Device,307.7,34,,307.7,percent of total billed charges,Implant Device,307.7,34,,307.7,percent of total billed charges,Implant Device,307.7,34,,307.7,percent of total billed charges,Implant Device,307.7,34,,307.7,percent of total billed charges,Implant Device,447.98,,,447.98,Other,110% of Medicare,316.75,35,,316.75,percent of total billed charges,Implant Device,307.7,34,"Charges > $500, x 34%",307.7,percent of total billed charges,Implant Device,316.75,35,,316.75,percent of total billed charges,Implant Device,316.75,35,,316.75,percent of total billed charges,Implant Device,316.75,35,,316.75,percent of total billed charges,Implant Device,316.75,35,,316.75,percent of total billed charges,Implant Device,316.75,35,,316.75,percent of total billed charges,Implant Device,362,40,,362,percent of total billed charges,Implant Device,316.75,70,,316.75,percent of total billed charges,All Other,307.7,34,,307.7,percent of total billed charges,Implant Device,307.7,34,,307.7,percent of total billed charges,Implant Device,316.75,35,,316.75,percent of total billed charges,Implant Device,316.75,35,,316.75,percent of total billed charges,Implant Device,316.75,35,,316.75,percent of total billed charges,Implant Device,316.75,35,,316.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,669.7,
STRYKER 1896-4024S LOCKING SCREW 4X24MM,C1713,HCPCS,,79003854,CDM,278,RC,,,both,,,701,518.74,,,518.74,Other,150% of Medicare + 9.63% HCRA Surcharge,315.45,45,,315.45,percent of total billed charges,Critical Access Hospital RCC factor,238.34,34,,238.34,percent of total billed charges,Implant Device,238.34,34,,238.34,percent of total billed charges,Implant Device,238.34,34,,238.34,percent of total billed charges,Implant Device,238.34,34,,238.34,percent of total billed charges,Implant Device,238.34,34,,238.34,percent of total billed charges,Implant Device,347,,,347,Other,110% of Medicare,245.35,35,,245.35,percent of total billed charges,Implant Device,238.34,34,"Charges > $500, x 34%",238.34,percent of total billed charges,Implant Device,245.35,35,,245.35,percent of total billed charges,Implant Device,245.35,35,,245.35,percent of total billed charges,Implant Device,245.35,35,,245.35,percent of total billed charges,Implant Device,245.35,35,,245.35,percent of total billed charges,Implant Device,245.35,35,,245.35,percent of total billed charges,Implant Device,280.4,40,,280.4,percent of total billed charges,Implant Device,245.35,70,,245.35,percent of total billed charges,All Other,238.34,34,,238.34,percent of total billed charges,Implant Device,238.34,34,,238.34,percent of total billed charges,Implant Device,245.35,35,,245.35,percent of total billed charges,Implant Device,245.35,35,,245.35,percent of total billed charges,Implant Device,245.35,35,,245.35,percent of total billed charges,Implant Device,245.35,35,,245.35,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,518.74,
EXACTECH 300-01-13 HUMERAL STEM 13MM,C1776,HCPCS,,79003855,CDM,278,RC,,,both,,,4425,3274.51,,,3274.51,Other,150% of Medicare + 9.63% HCRA Surcharge,1991.25,45,,1991.25,percent of total billed charges,Critical Access Hospital RCC factor,1504.5,34,,1504.5,percent of total billed charges,Implant Device,1504.5,34,,1504.5,percent of total billed charges,Implant Device,1504.5,34,,1504.5,percent of total billed charges,Implant Device,1504.5,34,,1504.5,percent of total billed charges,Implant Device,1504.5,34,,1504.5,percent of total billed charges,Implant Device,2190.38,,,2190.38,Other,110% of Medicare,1548.75,35,,1548.75,percent of total billed charges,Implant Device,1504.5,34,"Charges > $500, x 34%",1504.5,percent of total billed charges,Implant Device,1548.75,35,,1548.75,percent of total billed charges,Implant Device,1548.75,35,,1548.75,percent of total billed charges,Implant Device,1548.75,35,,1548.75,percent of total billed charges,Implant Device,1548.75,35,,1548.75,percent of total billed charges,Implant Device,1548.75,35,,1548.75,percent of total billed charges,Implant Device,1770,40,,1770,percent of total billed charges,Implant Device,1548.75,70,,1548.75,percent of total billed charges,All Other,1504.5,34,,1504.5,percent of total billed charges,Implant Device,1504.5,34,,1504.5,percent of total billed charges,Implant Device,1548.75,35,,1548.75,percent of total billed charges,Implant Device,1548.75,35,,1548.75,percent of total billed charges,Implant Device,1548.75,35,,1548.75,percent of total billed charges,Implant Device,1548.75,35,,1548.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1504.5,34,"If Charge > 2,000, then 34 percent",1504.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3274.51,
EXACTECH 314-02-13 GLENOID CEMENTED MED,C1776,HCPCS,,79003856,CDM,278,RC,,,both,,,4333,3206.43,,,3206.43,Other,150% of Medicare + 9.63% HCRA Surcharge,1949.85,45,,1949.85,percent of total billed charges,Critical Access Hospital RCC factor,1473.22,34,,1473.22,percent of total billed charges,Implant Device,1473.22,34,,1473.22,percent of total billed charges,Implant Device,1473.22,34,,1473.22,percent of total billed charges,Implant Device,1473.22,34,,1473.22,percent of total billed charges,Implant Device,1473.22,34,,1473.22,percent of total billed charges,Implant Device,2144.84,,,2144.84,Other,110% of Medicare,1516.55,35,,1516.55,percent of total billed charges,Implant Device,1473.22,34,"Charges > $500, x 34%",1473.22,percent of total billed charges,Implant Device,1516.55,35,,1516.55,percent of total billed charges,Implant Device,1516.55,35,,1516.55,percent of total billed charges,Implant Device,1516.55,35,,1516.55,percent of total billed charges,Implant Device,1516.55,35,,1516.55,percent of total billed charges,Implant Device,1516.55,35,,1516.55,percent of total billed charges,Implant Device,1733.2,40,,1733.2,percent of total billed charges,Implant Device,1516.55,70,,1516.55,percent of total billed charges,All Other,1473.22,34,,1473.22,percent of total billed charges,Implant Device,1473.22,34,,1473.22,percent of total billed charges,Implant Device,1516.55,35,,1516.55,percent of total billed charges,Implant Device,1516.55,35,,1516.55,percent of total billed charges,Implant Device,1516.55,35,,1516.55,percent of total billed charges,Implant Device,1516.55,35,,1516.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1473.22,34,"If Charge > 2,000, then 34 percent",1473.22,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3206.43,
EXACTECH 310-01-47 HUMERAL HEAD 47X18MM,C1776,HCPCS,,79003857,CDM,278,RC,,,both,,,3150,2331.01,,,2331.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1417.5,45,,1417.5,percent of total billed charges,Critical Access Hospital RCC factor,1071,34,,1071,percent of total billed charges,Implant Device,1071,34,,1071,percent of total billed charges,Implant Device,1071,34,,1071,percent of total billed charges,Implant Device,1071,34,,1071,percent of total billed charges,Implant Device,1071,34,,1071,percent of total billed charges,Implant Device,1559.25,,,1559.25,Other,110% of Medicare,1102.5,35,,1102.5,percent of total billed charges,Implant Device,1071,34,"Charges > $500, x 34%",1071,percent of total billed charges,Implant Device,1102.5,35,,1102.5,percent of total billed charges,Implant Device,1102.5,35,,1102.5,percent of total billed charges,Implant Device,1102.5,35,,1102.5,percent of total billed charges,Implant Device,1102.5,35,,1102.5,percent of total billed charges,Implant Device,1102.5,35,,1102.5,percent of total billed charges,Implant Device,1260,40,,1260,percent of total billed charges,Implant Device,1102.5,70,,1102.5,percent of total billed charges,All Other,1071,34,,1071,percent of total billed charges,Implant Device,1071,34,,1071,percent of total billed charges,Implant Device,1102.5,35,,1102.5,percent of total billed charges,Implant Device,1102.5,35,,1102.5,percent of total billed charges,Implant Device,1102.5,35,,1102.5,percent of total billed charges,Implant Device,1102.5,35,,1102.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1071,34,"If Charge > 2,000, then 34 percent",1071,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2331.01,
ARTHREX AR-1322BCNF SUTURE TAK 2.4X8.5,C1713,HCPCS,,79003858,CDM,278,RC,,,both,,,1308,967.92,,,967.92,Other,150% of Medicare + 9.63% HCRA Surcharge,588.6,45,,588.6,percent of total billed charges,Critical Access Hospital RCC factor,444.72,34,,444.72,percent of total billed charges,Implant Device,444.72,34,,444.72,percent of total billed charges,Implant Device,444.72,34,,444.72,percent of total billed charges,Implant Device,444.72,34,,444.72,percent of total billed charges,Implant Device,444.72,34,,444.72,percent of total billed charges,Implant Device,647.46,,,647.46,Other,110% of Medicare,457.8,35,,457.8,percent of total billed charges,Implant Device,444.72,34,"Charges > $500, x 34%",444.72,percent of total billed charges,Implant Device,457.8,35,,457.8,percent of total billed charges,Implant Device,457.8,35,,457.8,percent of total billed charges,Implant Device,457.8,35,,457.8,percent of total billed charges,Implant Device,457.8,35,,457.8,percent of total billed charges,Implant Device,457.8,35,,457.8,percent of total billed charges,Implant Device,523.2,40,,523.2,percent of total billed charges,Implant Device,457.8,70,,457.8,percent of total billed charges,All Other,444.72,34,,444.72,percent of total billed charges,Implant Device,444.72,34,,444.72,percent of total billed charges,Implant Device,457.8,35,,457.8,percent of total billed charges,Implant Device,457.8,35,,457.8,percent of total billed charges,Implant Device,457.8,35,,457.8,percent of total billed charges,Implant Device,457.8,35,,457.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,967.92,
ARTHREX AR-8825B MINI PUSHLOCK 2.5X8MM,C1713,HCPCS,,79003859,CDM,278,RC,,,both,,,1545,1143.3,,,1143.3,Other,150% of Medicare + 9.63% HCRA Surcharge,695.25,45,,695.25,percent of total billed charges,Critical Access Hospital RCC factor,525.3,34,,525.3,percent of total billed charges,Implant Device,525.3,34,,525.3,percent of total billed charges,Implant Device,525.3,34,,525.3,percent of total billed charges,Implant Device,525.3,34,,525.3,percent of total billed charges,Implant Device,525.3,34,,525.3,percent of total billed charges,Implant Device,764.78,,,764.78,Other,110% of Medicare,540.75,35,,540.75,percent of total billed charges,Implant Device,525.3,34,"Charges > $500, x 34%",525.3,percent of total billed charges,Implant Device,540.75,35,,540.75,percent of total billed charges,Implant Device,540.75,35,,540.75,percent of total billed charges,Implant Device,540.75,35,,540.75,percent of total billed charges,Implant Device,540.75,35,,540.75,percent of total billed charges,Implant Device,540.75,35,,540.75,percent of total billed charges,Implant Device,618,40,,618,percent of total billed charges,Implant Device,540.75,70,,540.75,percent of total billed charges,All Other,525.3,34,,525.3,percent of total billed charges,Implant Device,525.3,34,,525.3,percent of total billed charges,Implant Device,540.75,35,,540.75,percent of total billed charges,Implant Device,540.75,35,,540.75,percent of total billed charges,Implant Device,540.75,35,,540.75,percent of total billed charges,Implant Device,540.75,35,,540.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1143.3,
ARTHREX AR-5028C-11 INTER SCREW 11X28MM,C1713,HCPCS,,79003862,CDM,278,RC,,,both,,,1008,745.92,,,745.92,Other,150% of Medicare + 9.63% HCRA Surcharge,453.6,45,,453.6,percent of total billed charges,Critical Access Hospital RCC factor,342.72,34,,342.72,percent of total billed charges,Implant Device,342.72,34,,342.72,percent of total billed charges,Implant Device,342.72,34,,342.72,percent of total billed charges,Implant Device,342.72,34,,342.72,percent of total billed charges,Implant Device,342.72,34,,342.72,percent of total billed charges,Implant Device,498.96,,,498.96,Other,110% of Medicare,352.8,35,,352.8,percent of total billed charges,Implant Device,342.72,34,"Charges > $500, x 34%",342.72,percent of total billed charges,Implant Device,352.8,35,,352.8,percent of total billed charges,Implant Device,352.8,35,,352.8,percent of total billed charges,Implant Device,352.8,35,,352.8,percent of total billed charges,Implant Device,352.8,35,,352.8,percent of total billed charges,Implant Device,352.8,35,,352.8,percent of total billed charges,Implant Device,403.2,40,,403.2,percent of total billed charges,Implant Device,352.8,70,,352.8,percent of total billed charges,All Other,342.72,34,,342.72,percent of total billed charges,Implant Device,342.72,34,,342.72,percent of total billed charges,Implant Device,352.8,35,,352.8,percent of total billed charges,Implant Device,352.8,35,,352.8,percent of total billed charges,Implant Device,352.8,35,,352.8,percent of total billed charges,Implant Device,352.8,35,,352.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,745.92,
BIOMET 2000-2535 MULTIAXIAL SCREW 7.5X35,C1713,HCPCS,,79003864,CDM,278,RC,,,both,,,2820,2086.81,,,2086.81,Other,150% of Medicare + 9.63% HCRA Surcharge,1269,45,,1269,percent of total billed charges,Critical Access Hospital RCC factor,958.8,34,,958.8,percent of total billed charges,Implant Device,958.8,34,,958.8,percent of total billed charges,Implant Device,958.8,34,,958.8,percent of total billed charges,Implant Device,958.8,34,,958.8,percent of total billed charges,Implant Device,958.8,34,,958.8,percent of total billed charges,Implant Device,1395.9,,,1395.9,Other,110% of Medicare,987,35,,987,percent of total billed charges,Implant Device,958.8,34,"Charges > $500, x 34%",958.8,percent of total billed charges,Implant Device,987,35,,987,percent of total billed charges,Implant Device,987,35,,987,percent of total billed charges,Implant Device,987,35,,987,percent of total billed charges,Implant Device,987,35,,987,percent of total billed charges,Implant Device,987,35,,987,percent of total billed charges,Implant Device,1128,40,,1128,percent of total billed charges,Implant Device,987,70,,987,percent of total billed charges,All Other,958.8,34,,958.8,percent of total billed charges,Implant Device,958.8,34,,958.8,percent of total billed charges,Implant Device,987,35,,987,percent of total billed charges,Implant Device,987,35,,987,percent of total billed charges,Implant Device,987,35,,987,percent of total billed charges,Implant Device,987,35,,987,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,958.8,34,"If Charge > 2,000, then 34 percent",958.8,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2086.81,
BIOMET 29279 LAG SCREW 100MM,C1713,HCPCS,,79003866,CDM,278,RC,,,both,,,2670,1975.81,,,1975.81,Other,150% of Medicare + 9.63% HCRA Surcharge,1201.5,45,,1201.5,percent of total billed charges,Critical Access Hospital RCC factor,907.8,34,,907.8,percent of total billed charges,Implant Device,907.8,34,,907.8,percent of total billed charges,Implant Device,907.8,34,,907.8,percent of total billed charges,Implant Device,907.8,34,,907.8,percent of total billed charges,Implant Device,907.8,34,,907.8,percent of total billed charges,Implant Device,1321.65,,,1321.65,Other,110% of Medicare,934.5,35,,934.5,percent of total billed charges,Implant Device,907.8,34,"Charges > $500, x 34%",907.8,percent of total billed charges,Implant Device,934.5,35,,934.5,percent of total billed charges,Implant Device,934.5,35,,934.5,percent of total billed charges,Implant Device,934.5,35,,934.5,percent of total billed charges,Implant Device,934.5,35,,934.5,percent of total billed charges,Implant Device,934.5,35,,934.5,percent of total billed charges,Implant Device,1068,40,,1068,percent of total billed charges,Implant Device,934.5,70,,934.5,percent of total billed charges,All Other,907.8,34,,907.8,percent of total billed charges,Implant Device,907.8,34,,907.8,percent of total billed charges,Implant Device,934.5,35,,934.5,percent of total billed charges,Implant Device,934.5,35,,934.5,percent of total billed charges,Implant Device,934.5,35,,934.5,percent of total billed charges,Implant Device,934.5,35,,934.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,907.8,34,"If Charge > 2,000, then 34 percent",907.8,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1975.81,
BIOMET 8352-7070-W HEMICAP 35MM ART COMP,C1776,HCPCS,,79003867,CDM,278,RC,,,both,,,13824,10229.79,,,10229.79,Other,150% of Medicare + 9.63% HCRA Surcharge,6220.8,45,,6220.8,percent of total billed charges,Critical Access Hospital RCC factor,4700.16,34,,4700.16,percent of total billed charges,Implant Device,4700.16,34,,4700.16,percent of total billed charges,Implant Device,4700.16,34,,4700.16,percent of total billed charges,Implant Device,4700.16,34,,4700.16,percent of total billed charges,Implant Device,4700.16,34,,4700.16,percent of total billed charges,Implant Device,6842.88,,,6842.88,Other,110% of Medicare,4838.4,35,,4838.4,percent of total billed charges,Implant Device,4700.16,34,"Charges > $500, x 34%",4700.16,percent of total billed charges,Implant Device,4838.4,35,,4838.4,percent of total billed charges,Implant Device,4838.4,35,,4838.4,percent of total billed charges,Implant Device,4838.4,35,,4838.4,percent of total billed charges,Implant Device,4838.4,35,,4838.4,percent of total billed charges,Implant Device,4838.4,35,,4838.4,percent of total billed charges,Implant Device,5529.6,40,,5529.6,percent of total billed charges,Implant Device,4838.4,70,,4838.4,percent of total billed charges,All Other,4700.16,34,,4700.16,percent of total billed charges,Implant Device,4700.16,34,,4700.16,percent of total billed charges,Implant Device,4838.4,35,,4838.4,percent of total billed charges,Implant Device,4838.4,35,,4838.4,percent of total billed charges,Implant Device,4838.4,35,,4838.4,percent of total billed charges,Implant Device,4838.4,35,,4838.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,4700.16,34,"If Charge > 2,000, then 34 percent",4700.16,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,10229.79,
BIOMET O1-7306 BURR HOLE PLATE 13MM,C1713,HCPCS,,79003868,CDM,278,RC,,,both,,,540,399.6,,,399.6,Other,150% of Medicare + 9.63% HCRA Surcharge,243,45,,243,percent of total billed charges,Critical Access Hospital RCC factor,183.6,34,,183.6,percent of total billed charges,Implant Device,183.6,34,,183.6,percent of total billed charges,Implant Device,183.6,34,,183.6,percent of total billed charges,Implant Device,183.6,34,,183.6,percent of total billed charges,Implant Device,183.6,34,,183.6,percent of total billed charges,Implant Device,267.3,,,267.3,Other,110% of Medicare,189,35,,189,percent of total billed charges,Implant Device,183.6,34,"Charges > $500, x 34%",183.6,percent of total billed charges,Implant Device,189,35,,189,percent of total billed charges,Implant Device,189,35,,189,percent of total billed charges,Implant Device,189,35,,189,percent of total billed charges,Implant Device,189,35,,189,percent of total billed charges,Implant Device,189,35,,189,percent of total billed charges,Implant Device,216,40,,216,percent of total billed charges,Implant Device,189,70,,189,percent of total billed charges,All Other,183.6,34,,183.6,percent of total billed charges,Implant Device,183.6,34,,183.6,percent of total billed charges,Implant Device,189,35,,189,percent of total billed charges,Implant Device,189,35,,189,percent of total billed charges,Implant Device,189,35,,189,percent of total billed charges,Implant Device,189,35,,189,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,399.6,
BIOMET 159560 MENISCAL BEARING LG LT 9MM,C1776,HCPCS,,79003869,CDM,278,RC,,,both,,,5190,3840.61,,,3840.61,Other,150% of Medicare + 9.63% HCRA Surcharge,2335.5,45,,2335.5,percent of total billed charges,Critical Access Hospital RCC factor,1764.6,34,,1764.6,percent of total billed charges,Implant Device,1764.6,34,,1764.6,percent of total billed charges,Implant Device,1764.6,34,,1764.6,percent of total billed charges,Implant Device,1764.6,34,,1764.6,percent of total billed charges,Implant Device,1764.6,34,,1764.6,percent of total billed charges,Implant Device,2569.05,,,2569.05,Other,110% of Medicare,1816.5,35,,1816.5,percent of total billed charges,Implant Device,1764.6,34,"Charges > $500, x 34%",1764.6,percent of total billed charges,Implant Device,1816.5,35,,1816.5,percent of total billed charges,Implant Device,1816.5,35,,1816.5,percent of total billed charges,Implant Device,1816.5,35,,1816.5,percent of total billed charges,Implant Device,1816.5,35,,1816.5,percent of total billed charges,Implant Device,1816.5,35,,1816.5,percent of total billed charges,Implant Device,2076,40,,2076,percent of total billed charges,Implant Device,1816.5,70,,1816.5,percent of total billed charges,All Other,1764.6,34,,1764.6,percent of total billed charges,Implant Device,1764.6,34,,1764.6,percent of total billed charges,Implant Device,1816.5,35,,1816.5,percent of total billed charges,Implant Device,1816.5,35,,1816.5,percent of total billed charges,Implant Device,1816.5,35,,1816.5,percent of total billed charges,Implant Device,1816.5,35,,1816.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1764.6,34,"If Charge > 2,000, then 34 percent",1764.6,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3840.61,
BIOMET 29-278 LAG SCREW 95MM,C1713,HCPCS,,79003870,CDM,278,RC,,,both,,,1738,1286.12,,,1286.12,Other,150% of Medicare + 9.63% HCRA Surcharge,782.1,45,,782.1,percent of total billed charges,Critical Access Hospital RCC factor,590.92,34,,590.92,percent of total billed charges,Implant Device,590.92,34,,590.92,percent of total billed charges,Implant Device,590.92,34,,590.92,percent of total billed charges,Implant Device,590.92,34,,590.92,percent of total billed charges,Implant Device,590.92,34,,590.92,percent of total billed charges,Implant Device,860.31,,,860.31,Other,110% of Medicare,608.3,35,,608.3,percent of total billed charges,Implant Device,590.92,34,"Charges > $500, x 34%",590.92,percent of total billed charges,Implant Device,608.3,35,,608.3,percent of total billed charges,Implant Device,608.3,35,,608.3,percent of total billed charges,Implant Device,608.3,35,,608.3,percent of total billed charges,Implant Device,608.3,35,,608.3,percent of total billed charges,Implant Device,608.3,35,,608.3,percent of total billed charges,Implant Device,695.2,40,,695.2,percent of total billed charges,Implant Device,608.3,70,,608.3,percent of total billed charges,All Other,590.92,34,,590.92,percent of total billed charges,Implant Device,590.92,34,,590.92,percent of total billed charges,Implant Device,608.3,35,,608.3,percent of total billed charges,Implant Device,608.3,35,,608.3,percent of total billed charges,Implant Device,608.3,35,,608.3,percent of total billed charges,Implant Device,608.3,35,,608.3,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1286.12,
BIOMET 162659 CENTRALIZER DISTAL 15MM,C1776,HCPCS,,79003871,CDM,278,RC,,,both,,,960,710.4,,,710.4,Other,150% of Medicare + 9.63% HCRA Surcharge,432,45,,432,percent of total billed charges,Critical Access Hospital RCC factor,326.4,34,,326.4,percent of total billed charges,Implant Device,326.4,34,,326.4,percent of total billed charges,Implant Device,326.4,34,,326.4,percent of total billed charges,Implant Device,326.4,34,,326.4,percent of total billed charges,Implant Device,326.4,34,,326.4,percent of total billed charges,Implant Device,475.2,,,475.2,Other,110% of Medicare,336,35,,336,percent of total billed charges,Implant Device,326.4,34,"Charges > $500, x 34%",326.4,percent of total billed charges,Implant Device,336,35,,336,percent of total billed charges,Implant Device,336,35,,336,percent of total billed charges,Implant Device,336,35,,336,percent of total billed charges,Implant Device,336,35,,336,percent of total billed charges,Implant Device,336,35,,336,percent of total billed charges,Implant Device,384,40,,384,percent of total billed charges,Implant Device,336,70,,336,percent of total billed charges,All Other,326.4,34,,326.4,percent of total billed charges,Implant Device,326.4,34,,326.4,percent of total billed charges,Implant Device,336,35,,336,percent of total billed charges,Implant Device,336,35,,336,percent of total billed charges,Implant Device,336,35,,336,percent of total billed charges,Implant Device,336,35,,336,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,710.4,
BIOMET 948208 REUNITE PIN 2X40MM,C1713,HCPCS,,79003872,CDM,278,RC,,,both,,,834,617.16,,,617.16,Other,150% of Medicare + 9.63% HCRA Surcharge,375.3,45,,375.3,percent of total billed charges,Critical Access Hospital RCC factor,283.56,34,,283.56,percent of total billed charges,Implant Device,283.56,34,,283.56,percent of total billed charges,Implant Device,283.56,34,,283.56,percent of total billed charges,Implant Device,283.56,34,,283.56,percent of total billed charges,Implant Device,283.56,34,,283.56,percent of total billed charges,Implant Device,412.83,,,412.83,Other,110% of Medicare,291.9,35,,291.9,percent of total billed charges,Implant Device,283.56,34,"Charges > $500, x 34%",283.56,percent of total billed charges,Implant Device,291.9,35,,291.9,percent of total billed charges,Implant Device,291.9,35,,291.9,percent of total billed charges,Implant Device,291.9,35,,291.9,percent of total billed charges,Implant Device,291.9,35,,291.9,percent of total billed charges,Implant Device,291.9,35,,291.9,percent of total billed charges,Implant Device,333.6,40,,333.6,percent of total billed charges,Implant Device,291.9,70,,291.9,percent of total billed charges,All Other,283.56,34,,283.56,percent of total billed charges,Implant Device,283.56,34,,283.56,percent of total billed charges,Implant Device,291.9,35,,291.9,percent of total billed charges,Implant Device,291.9,35,,291.9,percent of total billed charges,Implant Device,291.9,35,,291.9,percent of total billed charges,Implant Device,291.9,35,,291.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,617.16,
BOST SCI 65-02 WALLFELX DUODENAL 22X90MM,C1876,HCPCS,,79003875,CDM,278,RC,,,both,,,7786,5761.66,,,5761.66,Other,150% of Medicare + 9.63% HCRA Surcharge,3503.7,45,,3503.7,percent of total billed charges,Critical Access Hospital RCC factor,2647.24,34,,2647.24,percent of total billed charges,Implant Device,2647.24,34,,2647.24,percent of total billed charges,Implant Device,2647.24,34,,2647.24,percent of total billed charges,Implant Device,2647.24,34,,2647.24,percent of total billed charges,Implant Device,2647.24,34,,2647.24,percent of total billed charges,Implant Device,3854.07,,,3854.07,Other,110% of Medicare,2725.1,35,,2725.1,percent of total billed charges,Implant Device,2647.24,34,"Charges > $500, x 34%",2647.24,percent of total billed charges,Implant Device,2725.1,35,,2725.1,percent of total billed charges,Implant Device,2725.1,35,,2725.1,percent of total billed charges,Implant Device,2725.1,35,,2725.1,percent of total billed charges,Implant Device,2725.1,35,,2725.1,percent of total billed charges,Implant Device,2725.1,35,,2725.1,percent of total billed charges,Implant Device,3114.4,40,,3114.4,percent of total billed charges,Implant Device,2725.1,70,,2725.1,percent of total billed charges,All Other,2647.24,34,,2647.24,percent of total billed charges,Implant Device,2647.24,34,,2647.24,percent of total billed charges,Implant Device,2725.1,35,,2725.1,percent of total billed charges,Implant Device,2725.1,35,,2725.1,percent of total billed charges,Implant Device,2725.1,35,,2725.1,percent of total billed charges,Implant Device,2725.1,35,,2725.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2647.24,34,"If Charge > 2,000, then 34 percent",2647.24,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5761.66,
BARD OO10105 HERNIA PATCH OVAL 11X14CM,C1781,HCPCS,,79003876,CDM,278,RC,,,both,,,1063,786.62,,,786.62,Other,150% of Medicare + 9.63% HCRA Surcharge,478.35,45,,478.35,percent of total billed charges,Critical Access Hospital RCC factor,361.42,34,,361.42,percent of total billed charges,Implant Device,361.42,34,,361.42,percent of total billed charges,Implant Device,361.42,34,,361.42,percent of total billed charges,Implant Device,361.42,34,,361.42,percent of total billed charges,Implant Device,361.42,34,,361.42,percent of total billed charges,Implant Device,526.19,,,526.19,Other,110% of Medicare,372.05,35,,372.05,percent of total billed charges,Implant Device,361.42,34,"Charges > $500, x 34%",361.42,percent of total billed charges,Implant Device,372.05,35,,372.05,percent of total billed charges,Implant Device,372.05,35,,372.05,percent of total billed charges,Implant Device,372.05,35,,372.05,percent of total billed charges,Implant Device,372.05,35,,372.05,percent of total billed charges,Implant Device,372.05,35,,372.05,percent of total billed charges,Implant Device,425.2,40,,425.2,percent of total billed charges,Implant Device,372.05,70,,372.05,percent of total billed charges,All Other,361.42,34,,361.42,percent of total billed charges,Implant Device,361.42,34,,361.42,percent of total billed charges,Implant Device,372.05,35,,372.05,percent of total billed charges,Implant Device,372.05,35,,372.05,percent of total billed charges,Implant Device,372.05,35,,372.05,percent of total billed charges,Implant Device,372.05,35,,372.05,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,786.62,
DEPUY 8153-04-080 POLY LOCK SCREW 4X80MM,C1713,HCPCS,,79003883,CDM,278,RC,,,both,,,630,466.2,,,466.2,Other,150% of Medicare + 9.63% HCRA Surcharge,283.5,45,,283.5,percent of total billed charges,Critical Access Hospital RCC factor,214.2,34,,214.2,percent of total billed charges,Implant Device,214.2,34,,214.2,percent of total billed charges,Implant Device,214.2,34,,214.2,percent of total billed charges,Implant Device,214.2,34,,214.2,percent of total billed charges,Implant Device,214.2,34,,214.2,percent of total billed charges,Implant Device,311.85,,,311.85,Other,110% of Medicare,220.5,35,,220.5,percent of total billed charges,Implant Device,214.2,34,"Charges > $500, x 34%",214.2,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,252,40,,252,percent of total billed charges,Implant Device,220.5,70,,220.5,percent of total billed charges,All Other,214.2,34,,214.2,percent of total billed charges,Implant Device,214.2,34,,214.2,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,466.2,
DEPUY 1570-11-090 FEM STEM 12/14 TAPER,C1776,HCPCS,,79003884,CDM,278,RC,,,both,,,10469,7747.09,,,7747.09,Other,150% of Medicare + 9.63% HCRA Surcharge,4711.05,45,,4711.05,percent of total billed charges,Critical Access Hospital RCC factor,3559.46,34,,3559.46,percent of total billed charges,Implant Device,3559.46,34,,3559.46,percent of total billed charges,Implant Device,3559.46,34,,3559.46,percent of total billed charges,Implant Device,3559.46,34,,3559.46,percent of total billed charges,Implant Device,3559.46,34,,3559.46,percent of total billed charges,Implant Device,5182.16,,,5182.16,Other,110% of Medicare,3664.15,35,,3664.15,percent of total billed charges,Implant Device,3559.46,34,"Charges > $500, x 34%",3559.46,percent of total billed charges,Implant Device,3664.15,35,,3664.15,percent of total billed charges,Implant Device,3664.15,35,,3664.15,percent of total billed charges,Implant Device,3664.15,35,,3664.15,percent of total billed charges,Implant Device,3664.15,35,,3664.15,percent of total billed charges,Implant Device,3664.15,35,,3664.15,percent of total billed charges,Implant Device,4187.6,40,,4187.6,percent of total billed charges,Implant Device,3664.15,70,,3664.15,percent of total billed charges,All Other,3559.46,34,,3559.46,percent of total billed charges,Implant Device,3559.46,34,,3559.46,percent of total billed charges,Implant Device,3664.15,35,,3664.15,percent of total billed charges,Implant Device,3664.15,35,,3664.15,percent of total billed charges,Implant Device,3664.15,35,,3664.15,percent of total billed charges,Implant Device,3664.15,35,,3664.15,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3559.46,34,"If Charge > 2,000, then 34 percent",3559.46,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,7747.09,
DEPUY 1570-06-150 BASIC CEMENTED SZ8,C1776,HCPCS,,79003885,CDM,278,RC,,,both,,,4692,3472.09,,,3472.09,Other,150% of Medicare + 9.63% HCRA Surcharge,2111.4,45,,2111.4,percent of total billed charges,Critical Access Hospital RCC factor,1595.28,34,,1595.28,percent of total billed charges,Implant Device,1595.28,34,,1595.28,percent of total billed charges,Implant Device,1595.28,34,,1595.28,percent of total billed charges,Implant Device,1595.28,34,,1595.28,percent of total billed charges,Implant Device,1595.28,34,,1595.28,percent of total billed charges,Implant Device,2322.54,,,2322.54,Other,110% of Medicare,1642.2,35,,1642.2,percent of total billed charges,Implant Device,1595.28,34,"Charges > $500, x 34%",1595.28,percent of total billed charges,Implant Device,1642.2,35,,1642.2,percent of total billed charges,Implant Device,1642.2,35,,1642.2,percent of total billed charges,Implant Device,1642.2,35,,1642.2,percent of total billed charges,Implant Device,1642.2,35,,1642.2,percent of total billed charges,Implant Device,1642.2,35,,1642.2,percent of total billed charges,Implant Device,1876.8,40,,1876.8,percent of total billed charges,Implant Device,1642.2,70,,1642.2,percent of total billed charges,All Other,1595.28,34,,1595.28,percent of total billed charges,Implant Device,1595.28,34,,1595.28,percent of total billed charges,Implant Device,1642.2,35,,1642.2,percent of total billed charges,Implant Device,1642.2,35,,1642.2,percent of total billed charges,Implant Device,1642.2,35,,1642.2,percent of total billed charges,Implant Device,1642.2,35,,1642.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1595.28,34,"If Charge > 2,000, then 34 percent",1595.28,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3472.09,
DEPUY 8153-04-065 POLY SCREW 4X65MM,C1713,HCPCS,,79003886,CDM,278,RC,,,both,,,630,466.2,,,466.2,Other,150% of Medicare + 9.63% HCRA Surcharge,283.5,45,,283.5,percent of total billed charges,Critical Access Hospital RCC factor,214.2,34,,214.2,percent of total billed charges,Implant Device,214.2,34,,214.2,percent of total billed charges,Implant Device,214.2,34,,214.2,percent of total billed charges,Implant Device,214.2,34,,214.2,percent of total billed charges,Implant Device,214.2,34,,214.2,percent of total billed charges,Implant Device,311.85,,,311.85,Other,110% of Medicare,220.5,35,,220.5,percent of total billed charges,Implant Device,214.2,34,"Charges > $500, x 34%",214.2,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,252,40,,252,percent of total billed charges,Implant Device,220.5,70,,220.5,percent of total billed charges,All Other,214.2,34,,214.2,percent of total billed charges,Implant Device,214.2,34,,214.2,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,466.2,
DEPUY 14196-40 CANN SCREW 6.5X40M,C1713,HCPCS,,79003887,CDM,278,RC,,,both,,,1290,954.6,,,954.6,Other,150% of Medicare + 9.63% HCRA Surcharge,580.5,45,,580.5,percent of total billed charges,Critical Access Hospital RCC factor,438.6,34,,438.6,percent of total billed charges,Implant Device,438.6,34,,438.6,percent of total billed charges,Implant Device,438.6,34,,438.6,percent of total billed charges,Implant Device,438.6,34,,438.6,percent of total billed charges,Implant Device,438.6,34,,438.6,percent of total billed charges,Implant Device,638.55,,,638.55,Other,110% of Medicare,451.5,35,,451.5,percent of total billed charges,Implant Device,438.6,34,"Charges > $500, x 34%",438.6,percent of total billed charges,Implant Device,451.5,35,,451.5,percent of total billed charges,Implant Device,451.5,35,,451.5,percent of total billed charges,Implant Device,451.5,35,,451.5,percent of total billed charges,Implant Device,451.5,35,,451.5,percent of total billed charges,Implant Device,451.5,35,,451.5,percent of total billed charges,Implant Device,516,40,,516,percent of total billed charges,Implant Device,451.5,70,,451.5,percent of total billed charges,All Other,438.6,34,,438.6,percent of total billed charges,Implant Device,438.6,34,,438.6,percent of total billed charges,Implant Device,451.5,35,,451.5,percent of total billed charges,Implant Device,451.5,35,,451.5,percent of total billed charges,Implant Device,451.5,35,,451.5,percent of total billed charges,Implant Device,451.5,35,,451.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,954.6,
DEPUY 8150-45-530 CORT LOCK SCREW 4X30MM,C1713,HCPCS,,79003888,CDM,278,RC,,,both,,,630,466.2,,,466.2,Other,150% of Medicare + 9.63% HCRA Surcharge,283.5,45,,283.5,percent of total billed charges,Critical Access Hospital RCC factor,214.2,34,,214.2,percent of total billed charges,Implant Device,214.2,34,,214.2,percent of total billed charges,Implant Device,214.2,34,,214.2,percent of total billed charges,Implant Device,214.2,34,,214.2,percent of total billed charges,Implant Device,214.2,34,,214.2,percent of total billed charges,Implant Device,311.85,,,311.85,Other,110% of Medicare,220.5,35,,220.5,percent of total billed charges,Implant Device,214.2,34,"Charges > $500, x 34%",214.2,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,252,40,,252,percent of total billed charges,Implant Device,220.5,70,,220.5,percent of total billed charges,All Other,214.2,34,,214.2,percent of total billed charges,Implant Device,214.2,34,,214.2,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,466.2,
DEPUY 8153-55-050 POLY LOCK SCREW 55X50,C1713,HCPCS,,79003889,CDM,278,RC,,,both,,,630,466.2,,,466.2,Other,150% of Medicare + 9.63% HCRA Surcharge,283.5,45,,283.5,percent of total billed charges,Critical Access Hospital RCC factor,214.2,34,,214.2,percent of total billed charges,Implant Device,214.2,34,,214.2,percent of total billed charges,Implant Device,214.2,34,,214.2,percent of total billed charges,Implant Device,214.2,34,,214.2,percent of total billed charges,Implant Device,214.2,34,,214.2,percent of total billed charges,Implant Device,311.85,,,311.85,Other,110% of Medicare,220.5,35,,220.5,percent of total billed charges,Implant Device,214.2,34,"Charges > $500, x 34%",214.2,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,252,40,,252,percent of total billed charges,Implant Device,220.5,70,,220.5,percent of total billed charges,All Other,214.2,34,,214.2,percent of total billed charges,Implant Device,214.2,34,,214.2,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,466.2,
DEPUY 1570-01-120 FEM STEM 12/14 TAPER,C1776,HCPCS,,79003890,CDM,278,RC,,,both,,,11846,8766.07,,,8766.07,Other,150% of Medicare + 9.63% HCRA Surcharge,5330.7,45,,5330.7,percent of total billed charges,Critical Access Hospital RCC factor,4027.64,34,,4027.64,percent of total billed charges,Implant Device,4027.64,34,,4027.64,percent of total billed charges,Implant Device,4027.64,34,,4027.64,percent of total billed charges,Implant Device,4027.64,34,,4027.64,percent of total billed charges,Implant Device,4027.64,34,,4027.64,percent of total billed charges,Implant Device,5863.77,,,5863.77,Other,110% of Medicare,4146.1,35,,4146.1,percent of total billed charges,Implant Device,4027.64,34,"Charges > $500, x 34%",4027.64,percent of total billed charges,Implant Device,4146.1,35,,4146.1,percent of total billed charges,Implant Device,4146.1,35,,4146.1,percent of total billed charges,Implant Device,4146.1,35,,4146.1,percent of total billed charges,Implant Device,4146.1,35,,4146.1,percent of total billed charges,Implant Device,4146.1,35,,4146.1,percent of total billed charges,Implant Device,4738.4,40,,4738.4,percent of total billed charges,Implant Device,4146.1,70,,4146.1,percent of total billed charges,All Other,4027.64,34,,4027.64,percent of total billed charges,Implant Device,4027.64,34,,4027.64,percent of total billed charges,Implant Device,4146.1,35,,4146.1,percent of total billed charges,Implant Device,4146.1,35,,4146.1,percent of total billed charges,Implant Device,4146.1,35,,4146.1,percent of total billed charges,Implant Device,4146.1,35,,4146.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,4027.64,34,"If Charge > 2,000, then 34 percent",4027.64,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,8766.07,
DEPUY NL28 90 DEG LOCK SCREW 3.8X28MM,C1713,HCPCS,,79003891,CDM,278,RC,,,both,,,378,279.72,,,279.72,Other,150% of Medicare + 9.63% HCRA Surcharge,170.1,45,,170.1,percent of total billed charges,Critical Access Hospital RCC factor,128.52,34,,128.52,percent of total billed charges,Implant Device,128.52,34,,128.52,percent of total billed charges,Implant Device,128.52,34,,128.52,percent of total billed charges,Implant Device,128.52,34,,128.52,percent of total billed charges,Implant Device,128.52,34,,128.52,percent of total billed charges,Implant Device,187.11,,,187.11,Other,110% of Medicare,132.3,35,,132.3,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,132.3,35,,132.3,percent of total billed charges,Implant Device,132.3,35,,132.3,percent of total billed charges,Implant Device,132.3,35,,132.3,percent of total billed charges,Implant Device,132.3,35,,132.3,percent of total billed charges,Implant Device,132.3,35,,132.3,percent of total billed charges,Implant Device,151.2,40,,151.2,percent of total billed charges,Implant Device,132.3,70,,132.3,percent of total billed charges,All Other,128.52,34,,128.52,percent of total billed charges,Implant Device,128.52,34,,128.52,percent of total billed charges,Implant Device,132.3,35,,132.3,percent of total billed charges,Implant Device,132.3,35,,132.3,percent of total billed charges,Implant Device,132.3,35,,132.3,percent of total billed charges,Implant Device,132.3,35,,132.3,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,279.72,
DEPUY 8157-45-028 CORT BONE SCREW 4.5X28,C1713,HCPCS,,79003892,CDM,278,RC,,,both,,,210,155.4,,,155.4,Other,150% of Medicare + 9.63% HCRA Surcharge,94.5,45,,94.5,percent of total billed charges,Critical Access Hospital RCC factor,71.4,34,,71.4,percent of total billed charges,Implant Device,71.4,34,,71.4,percent of total billed charges,Implant Device,71.4,34,,71.4,percent of total billed charges,Implant Device,71.4,34,,71.4,percent of total billed charges,Implant Device,71.4,34,,71.4,percent of total billed charges,Implant Device,103.95,,,103.95,Other,110% of Medicare,73.5,35,,73.5,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,73.5,35,,73.5,percent of total billed charges,Implant Device,73.5,35,,73.5,percent of total billed charges,Implant Device,73.5,35,,73.5,percent of total billed charges,Implant Device,73.5,35,,73.5,percent of total billed charges,Implant Device,73.5,35,,73.5,percent of total billed charges,Implant Device,84,40,,84,percent of total billed charges,Implant Device,73.5,70,,73.5,percent of total billed charges,All Other,71.4,34,,71.4,percent of total billed charges,Implant Device,71.4,34,,71.4,percent of total billed charges,Implant Device,73.5,35,,73.5,percent of total billed charges,Implant Device,73.5,35,,73.5,percent of total billed charges,Implant Device,73.5,35,,73.5,percent of total billed charges,Implant Device,73.5,35,,73.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,155.4,
DEPUY 1570-01-110 FEM STEM 12/14 TAPER,C1776,HCPCS,,79003893,CDM,278,RC,,,both,,,11846,8766.07,,,8766.07,Other,150% of Medicare + 9.63% HCRA Surcharge,5330.7,45,,5330.7,percent of total billed charges,Critical Access Hospital RCC factor,4027.64,34,,4027.64,percent of total billed charges,Implant Device,4027.64,34,,4027.64,percent of total billed charges,Implant Device,4027.64,34,,4027.64,percent of total billed charges,Implant Device,4027.64,34,,4027.64,percent of total billed charges,Implant Device,4027.64,34,,4027.64,percent of total billed charges,Implant Device,5863.77,,,5863.77,Other,110% of Medicare,4146.1,35,,4146.1,percent of total billed charges,Implant Device,4027.64,34,"Charges > $500, x 34%",4027.64,percent of total billed charges,Implant Device,4146.1,35,,4146.1,percent of total billed charges,Implant Device,4146.1,35,,4146.1,percent of total billed charges,Implant Device,4146.1,35,,4146.1,percent of total billed charges,Implant Device,4146.1,35,,4146.1,percent of total billed charges,Implant Device,4146.1,35,,4146.1,percent of total billed charges,Implant Device,4738.4,40,,4738.4,percent of total billed charges,Implant Device,4146.1,70,,4146.1,percent of total billed charges,All Other,4027.64,34,,4027.64,percent of total billed charges,Implant Device,4027.64,34,,4027.64,percent of total billed charges,Implant Device,4146.1,35,,4146.1,percent of total billed charges,Implant Device,4146.1,35,,4146.1,percent of total billed charges,Implant Device,4146.1,35,,4146.1,percent of total billed charges,Implant Device,4146.1,35,,4146.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,4027.64,34,"If Charge > 2,000, then 34 percent",4027.64,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,8766.07,
DEPUY STPT35 PEG THREADED 4X34MM,C1713,HCPCS,,79003894,CDM,278,RC,,,both,,,378,279.72,,,279.72,Other,150% of Medicare + 9.63% HCRA Surcharge,170.1,45,,170.1,percent of total billed charges,Critical Access Hospital RCC factor,128.52,34,,128.52,percent of total billed charges,Implant Device,128.52,34,,128.52,percent of total billed charges,Implant Device,128.52,34,,128.52,percent of total billed charges,Implant Device,128.52,34,,128.52,percent of total billed charges,Implant Device,128.52,34,,128.52,percent of total billed charges,Implant Device,187.11,,,187.11,Other,110% of Medicare,132.3,35,,132.3,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,132.3,35,,132.3,percent of total billed charges,Implant Device,132.3,35,,132.3,percent of total billed charges,Implant Device,132.3,35,,132.3,percent of total billed charges,Implant Device,132.3,35,,132.3,percent of total billed charges,Implant Device,132.3,35,,132.3,percent of total billed charges,Implant Device,151.2,40,,151.2,percent of total billed charges,Implant Device,132.3,70,,132.3,percent of total billed charges,All Other,128.52,34,,128.52,percent of total billed charges,Implant Device,128.52,34,,128.52,percent of total billed charges,Implant Device,132.3,35,,132.3,percent of total billed charges,Implant Device,132.3,35,,132.3,percent of total billed charges,Implant Device,132.3,35,,132.3,percent of total billed charges,Implant Device,132.3,35,,132.3,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,279.72,
DEPUY 8153-04-060 LOCKING SCREW 4X60MM,C1713,HCPCS,,79003895,CDM,278,RC,,,both,,,630,466.2,,,466.2,Other,150% of Medicare + 9.63% HCRA Surcharge,283.5,45,,283.5,percent of total billed charges,Critical Access Hospital RCC factor,214.2,34,,214.2,percent of total billed charges,Implant Device,214.2,34,,214.2,percent of total billed charges,Implant Device,214.2,34,,214.2,percent of total billed charges,Implant Device,214.2,34,,214.2,percent of total billed charges,Implant Device,214.2,34,,214.2,percent of total billed charges,Implant Device,311.85,,,311.85,Other,110% of Medicare,220.5,35,,220.5,percent of total billed charges,Implant Device,214.2,34,"Charges > $500, x 34%",214.2,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,252,40,,252,percent of total billed charges,Implant Device,220.5,70,,220.5,percent of total billed charges,All Other,214.2,34,,214.2,percent of total billed charges,Implant Device,214.2,34,,214.2,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,466.2,
DEPUY 8157-45-040 LOCKING SCREW 4.5X40MM,C1713,HCPCS,,79003896,CDM,278,RC,,,both,,,210,155.4,,,155.4,Other,150% of Medicare + 9.63% HCRA Surcharge,94.5,45,,94.5,percent of total billed charges,Critical Access Hospital RCC factor,71.4,34,,71.4,percent of total billed charges,Implant Device,71.4,34,,71.4,percent of total billed charges,Implant Device,71.4,34,,71.4,percent of total billed charges,Implant Device,71.4,34,,71.4,percent of total billed charges,Implant Device,71.4,34,,71.4,percent of total billed charges,Implant Device,103.95,,,103.95,Other,110% of Medicare,73.5,35,,73.5,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,73.5,35,,73.5,percent of total billed charges,Implant Device,73.5,35,,73.5,percent of total billed charges,Implant Device,73.5,35,,73.5,percent of total billed charges,Implant Device,73.5,35,,73.5,percent of total billed charges,Implant Device,73.5,35,,73.5,percent of total billed charges,Implant Device,84,40,,84,percent of total billed charges,Implant Device,73.5,70,,73.5,percent of total billed charges,All Other,71.4,34,,71.4,percent of total billed charges,Implant Device,71.4,34,,71.4,percent of total billed charges,Implant Device,73.5,35,,73.5,percent of total billed charges,Implant Device,73.5,35,,73.5,percent of total billed charges,Implant Device,73.5,35,,73.5,percent of total billed charges,Implant Device,73.5,35,,73.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,155.4,
DEPUY 1987-25-414 STEM STR CMTD 14X125,C1776,HCPCS,,79003897,CDM,278,RC,,,both,,,11555,8550.73,,,8550.73,Other,150% of Medicare + 9.63% HCRA Surcharge,5199.75,45,,5199.75,percent of total billed charges,Critical Access Hospital RCC factor,3928.7,34,,3928.7,percent of total billed charges,Implant Device,3928.7,34,,3928.7,percent of total billed charges,Implant Device,3928.7,34,,3928.7,percent of total billed charges,Implant Device,3928.7,34,,3928.7,percent of total billed charges,Implant Device,3928.7,34,,3928.7,percent of total billed charges,Implant Device,5719.73,,,5719.73,Other,110% of Medicare,4044.25,35,,4044.25,percent of total billed charges,Implant Device,3928.7,34,"Charges > $500, x 34%",3928.7,percent of total billed charges,Implant Device,4044.25,35,,4044.25,percent of total billed charges,Implant Device,4044.25,35,,4044.25,percent of total billed charges,Implant Device,4044.25,35,,4044.25,percent of total billed charges,Implant Device,4044.25,35,,4044.25,percent of total billed charges,Implant Device,4044.25,35,,4044.25,percent of total billed charges,Implant Device,4622,40,,4622,percent of total billed charges,Implant Device,4044.25,70,,4044.25,percent of total billed charges,All Other,3928.7,34,,3928.7,percent of total billed charges,Implant Device,3928.7,34,,3928.7,percent of total billed charges,Implant Device,4044.25,35,,4044.25,percent of total billed charges,Implant Device,4044.25,35,,4044.25,percent of total billed charges,Implant Device,4044.25,35,,4044.25,percent of total billed charges,Implant Device,4044.25,35,,4044.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3928.7,34,"If Charge > 2,000, then 34 percent",3928.7,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,8550.73,
DEPUY 1570-01-135 FEM STEM TAPRD SZ 7,C1776,HCPCS,,79003898,CDM,278,RC,,,both,,,11846,8766.07,,,8766.07,Other,150% of Medicare + 9.63% HCRA Surcharge,5330.7,45,,5330.7,percent of total billed charges,Critical Access Hospital RCC factor,4027.64,34,,4027.64,percent of total billed charges,Implant Device,4027.64,34,,4027.64,percent of total billed charges,Implant Device,4027.64,34,,4027.64,percent of total billed charges,Implant Device,4027.64,34,,4027.64,percent of total billed charges,Implant Device,4027.64,34,,4027.64,percent of total billed charges,Implant Device,5863.77,,,5863.77,Other,110% of Medicare,4146.1,35,,4146.1,percent of total billed charges,Implant Device,4027.64,34,"Charges > $500, x 34%",4027.64,percent of total billed charges,Implant Device,4146.1,35,,4146.1,percent of total billed charges,Implant Device,4146.1,35,,4146.1,percent of total billed charges,Implant Device,4146.1,35,,4146.1,percent of total billed charges,Implant Device,4146.1,35,,4146.1,percent of total billed charges,Implant Device,4146.1,35,,4146.1,percent of total billed charges,Implant Device,4738.4,40,,4738.4,percent of total billed charges,Implant Device,4146.1,70,,4146.1,percent of total billed charges,All Other,4027.64,34,,4027.64,percent of total billed charges,Implant Device,4027.64,34,,4027.64,percent of total billed charges,Implant Device,4146.1,35,,4146.1,percent of total billed charges,Implant Device,4146.1,35,,4146.1,percent of total billed charges,Implant Device,4146.1,35,,4146.1,percent of total billed charges,Implant Device,4146.1,35,,4146.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,4027.64,34,"If Charge > 2,000, then 34 percent",4027.64,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,8766.07,
DEPUY 1376-47-000 STEM CENTRALIZR 9.25MM,C1776,HCPCS,,79003900,CDM,278,RC,,,both,,,524,387.76,,,387.76,Other,150% of Medicare + 9.63% HCRA Surcharge,235.8,45,,235.8,percent of total billed charges,Critical Access Hospital RCC factor,178.16,34,,178.16,percent of total billed charges,Implant Device,178.16,34,,178.16,percent of total billed charges,Implant Device,178.16,34,,178.16,percent of total billed charges,Implant Device,178.16,34,,178.16,percent of total billed charges,Implant Device,178.16,34,,178.16,percent of total billed charges,Implant Device,259.38,,,259.38,Other,110% of Medicare,183.4,35,,183.4,percent of total billed charges,Implant Device,178.16,34,"Charges > $500, x 34%",178.16,percent of total billed charges,Implant Device,183.4,35,,183.4,percent of total billed charges,Implant Device,183.4,35,,183.4,percent of total billed charges,Implant Device,183.4,35,,183.4,percent of total billed charges,Implant Device,183.4,35,,183.4,percent of total billed charges,Implant Device,183.4,35,,183.4,percent of total billed charges,Implant Device,209.6,40,,209.6,percent of total billed charges,Implant Device,183.4,70,,183.4,percent of total billed charges,All Other,178.16,34,,178.16,percent of total billed charges,Implant Device,178.16,34,,178.16,percent of total billed charges,Implant Device,183.4,35,,183.4,percent of total billed charges,Implant Device,183.4,35,,183.4,percent of total billed charges,Implant Device,183.4,35,,183.4,percent of total billed charges,Implant Device,183.4,35,,183.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,387.76,
DEPUY 1365-36-310 FEMORAL HEAD +1.5 36MM,C1776,HCPCS,,79003901,CDM,278,RC,,,both,,,2636,1950.65,,,1950.65,Other,150% of Medicare + 9.63% HCRA Surcharge,1186.2,45,,1186.2,percent of total billed charges,Critical Access Hospital RCC factor,896.24,34,,896.24,percent of total billed charges,Implant Device,896.24,34,,896.24,percent of total billed charges,Implant Device,896.24,34,,896.24,percent of total billed charges,Implant Device,896.24,34,,896.24,percent of total billed charges,Implant Device,896.24,34,,896.24,percent of total billed charges,Implant Device,1304.82,,,1304.82,Other,110% of Medicare,922.6,35,,922.6,percent of total billed charges,Implant Device,896.24,34,"Charges > $500, x 34%",896.24,percent of total billed charges,Implant Device,922.6,35,,922.6,percent of total billed charges,Implant Device,922.6,35,,922.6,percent of total billed charges,Implant Device,922.6,35,,922.6,percent of total billed charges,Implant Device,922.6,35,,922.6,percent of total billed charges,Implant Device,922.6,35,,922.6,percent of total billed charges,Implant Device,1054.4,40,,1054.4,percent of total billed charges,Implant Device,922.6,70,,922.6,percent of total billed charges,All Other,896.24,34,,896.24,percent of total billed charges,Implant Device,896.24,34,,896.24,percent of total billed charges,Implant Device,922.6,35,,922.6,percent of total billed charges,Implant Device,922.6,35,,922.6,percent of total billed charges,Implant Device,922.6,35,,922.6,percent of total billed charges,Implant Device,922.6,35,,922.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,896.24,34,"If Charge > 2,000, then 34 percent",896.24,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1950.65,
DEPUY 222233 ORTHOCORD 5.5MM,C1713,HCPCS,,79003902,CDM,278,RC,,,both,,,1218,901.32,,,901.32,Other,150% of Medicare + 9.63% HCRA Surcharge,548.1,45,,548.1,percent of total billed charges,Critical Access Hospital RCC factor,414.12,34,,414.12,percent of total billed charges,Implant Device,414.12,34,,414.12,percent of total billed charges,Implant Device,414.12,34,,414.12,percent of total billed charges,Implant Device,414.12,34,,414.12,percent of total billed charges,Implant Device,414.12,34,,414.12,percent of total billed charges,Implant Device,602.91,,,602.91,Other,110% of Medicare,426.3,35,,426.3,percent of total billed charges,Implant Device,414.12,34,"Charges > $500, x 34%",414.12,percent of total billed charges,Implant Device,426.3,35,,426.3,percent of total billed charges,Implant Device,426.3,35,,426.3,percent of total billed charges,Implant Device,426.3,35,,426.3,percent of total billed charges,Implant Device,426.3,35,,426.3,percent of total billed charges,Implant Device,426.3,35,,426.3,percent of total billed charges,Implant Device,487.2,40,,487.2,percent of total billed charges,Implant Device,426.3,70,,426.3,percent of total billed charges,All Other,414.12,34,,414.12,percent of total billed charges,Implant Device,414.12,34,,414.12,percent of total billed charges,Implant Device,426.3,35,,426.3,percent of total billed charges,Implant Device,426.3,35,,426.3,percent of total billed charges,Implant Device,426.3,35,,426.3,percent of total billed charges,Implant Device,426.3,35,,426.3,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,901.32,
DEPUY 8141-23-009 PLATE 9 HOLE L 122MM,C1713,HCPCS,,79003903,CDM,278,RC,,,both,,,870,643.8,,,643.8,Other,150% of Medicare + 9.63% HCRA Surcharge,391.5,45,,391.5,percent of total billed charges,Critical Access Hospital RCC factor,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,430.65,,,430.65,Other,110% of Medicare,304.5,35,,304.5,percent of total billed charges,Implant Device,295.8,34,"Charges > $500, x 34%",295.8,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,348,40,,348,percent of total billed charges,Implant Device,304.5,70,,304.5,percent of total billed charges,All Other,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,643.8,
DEPUY 1365-14-000 FEM HEAD 12/14 CONE,C1776,HCPCS,,79003905,CDM,278,RC,,,both,,,1710,1265.4,,,1265.4,Other,150% of Medicare + 9.63% HCRA Surcharge,769.5,45,,769.5,percent of total billed charges,Critical Access Hospital RCC factor,581.4,34,,581.4,percent of total billed charges,Implant Device,581.4,34,,581.4,percent of total billed charges,Implant Device,581.4,34,,581.4,percent of total billed charges,Implant Device,581.4,34,,581.4,percent of total billed charges,Implant Device,581.4,34,,581.4,percent of total billed charges,Implant Device,846.45,,,846.45,Other,110% of Medicare,598.5,35,,598.5,percent of total billed charges,Implant Device,581.4,34,"Charges > $500, x 34%",581.4,percent of total billed charges,Implant Device,598.5,35,,598.5,percent of total billed charges,Implant Device,598.5,35,,598.5,percent of total billed charges,Implant Device,598.5,35,,598.5,percent of total billed charges,Implant Device,598.5,35,,598.5,percent of total billed charges,Implant Device,598.5,35,,598.5,percent of total billed charges,Implant Device,684,40,,684,percent of total billed charges,Implant Device,598.5,70,,598.5,percent of total billed charges,All Other,581.4,34,,581.4,percent of total billed charges,Implant Device,581.4,34,,581.4,percent of total billed charges,Implant Device,598.5,35,,598.5,percent of total billed charges,Implant Device,598.5,35,,598.5,percent of total billed charges,Implant Device,598.5,35,,598.5,percent of total billed charges,Implant Device,598.5,35,,598.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1265.4,
DEPUY SBFS062 SMALL BONE FIXATION 1.6MM,C1713,HCPCS,,79003907,CDM,278,RC,,,both,,,1148,849.52,,,849.52,Other,150% of Medicare + 9.63% HCRA Surcharge,516.6,45,,516.6,percent of total billed charges,Critical Access Hospital RCC factor,390.32,34,,390.32,percent of total billed charges,Implant Device,390.32,34,,390.32,percent of total billed charges,Implant Device,390.32,34,,390.32,percent of total billed charges,Implant Device,390.32,34,,390.32,percent of total billed charges,Implant Device,390.32,34,,390.32,percent of total billed charges,Implant Device,568.26,,,568.26,Other,110% of Medicare,401.8,35,,401.8,percent of total billed charges,Implant Device,390.32,34,"Charges > $500, x 34%",390.32,percent of total billed charges,Implant Device,401.8,35,,401.8,percent of total billed charges,Implant Device,401.8,35,,401.8,percent of total billed charges,Implant Device,401.8,35,,401.8,percent of total billed charges,Implant Device,401.8,35,,401.8,percent of total billed charges,Implant Device,401.8,35,,401.8,percent of total billed charges,Implant Device,459.2,40,,459.2,percent of total billed charges,Implant Device,401.8,70,,401.8,percent of total billed charges,All Other,390.32,34,,390.32,percent of total billed charges,Implant Device,390.32,34,,390.32,percent of total billed charges,Implant Device,401.8,35,,401.8,percent of total billed charges,Implant Device,401.8,35,,401.8,percent of total billed charges,Implant Device,401.8,35,,401.8,percent of total billed charges,Implant Device,401.8,35,,401.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,849.52,
DEPUY 8153-41-030 CAN SCREW 4X30MM,C1713,HCPCS,,79003908,CDM,278,RC,,,both,,,240,177.6,,,177.6,Other,150% of Medicare + 9.63% HCRA Surcharge,108,45,,108,percent of total billed charges,Critical Access Hospital RCC factor,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,118.8,,,118.8,Other,110% of Medicare,84,35,,84,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,96,40,,96,percent of total billed charges,Implant Device,84,70,,84,percent of total billed charges,All Other,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,177.6,
DEPUY 1987-14-111 DIST FEM COMP SZ XSM,C1776,HCPCS,,79003909,CDM,278,RC,,,both,,,32693,24192.9,,,24192.9,Other,150% of Medicare + 9.63% HCRA Surcharge,14711.85,45,,14711.85,percent of total billed charges,Critical Access Hospital RCC factor,11115.62,34,,11115.62,percent of total billed charges,Implant Device,11115.62,34,,11115.62,percent of total billed charges,Implant Device,11115.62,34,,11115.62,percent of total billed charges,Implant Device,11115.62,34,,11115.62,percent of total billed charges,Implant Device,11115.62,34,,11115.62,percent of total billed charges,Implant Device,16183.04,,,16183.04,Other,110% of Medicare,11442.55,35,,11442.55,percent of total billed charges,Implant Device,11115.62,34,"Charges > $500, x 34%",11115.62,percent of total billed charges,Implant Device,11442.55,35,,11442.55,percent of total billed charges,Implant Device,11442.55,35,,11442.55,percent of total billed charges,Implant Device,11442.55,35,,11442.55,percent of total billed charges,Implant Device,11442.55,35,,11442.55,percent of total billed charges,Implant Device,11442.55,35,,11442.55,percent of total billed charges,Implant Device,13077.2,40,,13077.2,percent of total billed charges,Implant Device,11442.55,70,,11442.55,percent of total billed charges,All Other,11115.62,34,,11115.62,percent of total billed charges,Implant Device,11115.62,34,,11115.62,percent of total billed charges,Implant Device,11442.55,35,,11442.55,percent of total billed charges,Implant Device,11442.55,35,,11442.55,percent of total billed charges,Implant Device,11442.55,35,,11442.55,percent of total billed charges,Implant Device,11442.55,35,,11442.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,11115.62,34,"If Charge > 2,000, then 34 percent",11115.62,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,24192.9,
DEPUY 8155-40-065 CANC LAG SCREW 4X65MM,C1713,HCPCS,,79003910,CDM,278,RC,,,both,,,240,177.6,,,177.6,Other,150% of Medicare + 9.63% HCRA Surcharge,108,45,,108,percent of total billed charges,Critical Access Hospital RCC factor,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,118.8,,,118.8,Other,110% of Medicare,84,35,,84,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,96,40,,96,percent of total billed charges,Implant Device,84,70,,84,percent of total billed charges,All Other,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,177.6,
DEPUY 222207 SUTURE ANCHOR W/ORTHOCORD,C1713,HCPCS,,79003911,CDM,278,RC,,,both,,,2334,1727.17,,,1727.17,Other,150% of Medicare + 9.63% HCRA Surcharge,1050.3,45,,1050.3,percent of total billed charges,Critical Access Hospital RCC factor,793.56,34,,793.56,percent of total billed charges,Implant Device,793.56,34,,793.56,percent of total billed charges,Implant Device,793.56,34,,793.56,percent of total billed charges,Implant Device,793.56,34,,793.56,percent of total billed charges,Implant Device,793.56,34,,793.56,percent of total billed charges,Implant Device,1155.33,,,1155.33,Other,110% of Medicare,816.9,35,,816.9,percent of total billed charges,Implant Device,793.56,34,"Charges > $500, x 34%",793.56,percent of total billed charges,Implant Device,816.9,35,,816.9,percent of total billed charges,Implant Device,816.9,35,,816.9,percent of total billed charges,Implant Device,816.9,35,,816.9,percent of total billed charges,Implant Device,816.9,35,,816.9,percent of total billed charges,Implant Device,816.9,35,,816.9,percent of total billed charges,Implant Device,933.6,40,,933.6,percent of total billed charges,Implant Device,816.9,70,,816.9,percent of total billed charges,All Other,793.56,34,,793.56,percent of total billed charges,Implant Device,793.56,34,,793.56,percent of total billed charges,Implant Device,816.9,35,,816.9,percent of total billed charges,Implant Device,816.9,35,,816.9,percent of total billed charges,Implant Device,816.9,35,,816.9,percent of total billed charges,Implant Device,816.9,35,,816.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,793.56,34,"If Charge > 2,000, then 34 percent",793.56,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1727.17,
DEPUY 1570-01-165 FEM STEM 12/14 TAPER,C1776,HCPCS,,79003912,CDM,278,RC,,,both,,,10992,8134.11,,,8134.11,Other,150% of Medicare + 9.63% HCRA Surcharge,4946.4,45,,4946.4,percent of total billed charges,Critical Access Hospital RCC factor,3737.28,34,,3737.28,percent of total billed charges,Implant Device,3737.28,34,,3737.28,percent of total billed charges,Implant Device,3737.28,34,,3737.28,percent of total billed charges,Implant Device,3737.28,34,,3737.28,percent of total billed charges,Implant Device,3737.28,34,,3737.28,percent of total billed charges,Implant Device,5441.04,,,5441.04,Other,110% of Medicare,3847.2,35,,3847.2,percent of total billed charges,Implant Device,3737.28,34,"Charges > $500, x 34%",3737.28,percent of total billed charges,Implant Device,3847.2,35,,3847.2,percent of total billed charges,Implant Device,3847.2,35,,3847.2,percent of total billed charges,Implant Device,3847.2,35,,3847.2,percent of total billed charges,Implant Device,3847.2,35,,3847.2,percent of total billed charges,Implant Device,3847.2,35,,3847.2,percent of total billed charges,Implant Device,4396.8,40,,4396.8,percent of total billed charges,Implant Device,3847.2,70,,3847.2,percent of total billed charges,All Other,3737.28,34,,3737.28,percent of total billed charges,Implant Device,3737.28,34,,3737.28,percent of total billed charges,Implant Device,3847.2,35,,3847.2,percent of total billed charges,Implant Device,3847.2,35,,3847.2,percent of total billed charges,Implant Device,3847.2,35,,3847.2,percent of total billed charges,Implant Device,3847.2,35,,3847.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3737.28,34,"If Charge > 2,000, then 34 percent",3737.28,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,8134.11,
DEPUY 1365-36-710-REV FEM HEAD 36MM,C1776,HCPCS,,79003914,CDM,278,RC,,,both,,,9349,6918.28,,,6918.28,Other,150% of Medicare + 9.63% HCRA Surcharge,4207.05,45,,4207.05,percent of total billed charges,Critical Access Hospital RCC factor,3178.66,34,,3178.66,percent of total billed charges,Implant Device,3178.66,34,,3178.66,percent of total billed charges,Implant Device,3178.66,34,,3178.66,percent of total billed charges,Implant Device,3178.66,34,,3178.66,percent of total billed charges,Implant Device,3178.66,34,,3178.66,percent of total billed charges,Implant Device,4627.76,,,4627.76,Other,110% of Medicare,3272.15,35,,3272.15,percent of total billed charges,Implant Device,3178.66,34,"Charges > $500, x 34%",3178.66,percent of total billed charges,Implant Device,3272.15,35,,3272.15,percent of total billed charges,Implant Device,3272.15,35,,3272.15,percent of total billed charges,Implant Device,3272.15,35,,3272.15,percent of total billed charges,Implant Device,3272.15,35,,3272.15,percent of total billed charges,Implant Device,3272.15,35,,3272.15,percent of total billed charges,Implant Device,3739.6,40,,3739.6,percent of total billed charges,Implant Device,3272.15,70,,3272.15,percent of total billed charges,All Other,3178.66,34,,3178.66,percent of total billed charges,Implant Device,3178.66,34,,3178.66,percent of total billed charges,Implant Device,3272.15,35,,3272.15,percent of total billed charges,Implant Device,3272.15,35,,3272.15,percent of total billed charges,Implant Device,3272.15,35,,3272.15,percent of total billed charges,Implant Device,3272.15,35,,3272.15,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3178.66,34,"If Charge > 2,000, then 34 percent",3178.66,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,6918.28,
DEPUY 8141-32-011 TIBIAL PLATE 11 HOLE,C1713,HCPCS,,79003915,CDM,278,RC,,,both,,,7320,5416.82,,,5416.82,Other,150% of Medicare + 9.63% HCRA Surcharge,3294,45,,3294,percent of total billed charges,Critical Access Hospital RCC factor,2488.8,34,,2488.8,percent of total billed charges,Implant Device,2488.8,34,,2488.8,percent of total billed charges,Implant Device,2488.8,34,,2488.8,percent of total billed charges,Implant Device,2488.8,34,,2488.8,percent of total billed charges,Implant Device,2488.8,34,,2488.8,percent of total billed charges,Implant Device,3623.4,,,3623.4,Other,110% of Medicare,2562,35,,2562,percent of total billed charges,Implant Device,2488.8,34,"Charges > $500, x 34%",2488.8,percent of total billed charges,Implant Device,2562,35,,2562,percent of total billed charges,Implant Device,2562,35,,2562,percent of total billed charges,Implant Device,2562,35,,2562,percent of total billed charges,Implant Device,2562,35,,2562,percent of total billed charges,Implant Device,2562,35,,2562,percent of total billed charges,Implant Device,2928,40,,2928,percent of total billed charges,Implant Device,2562,70,,2562,percent of total billed charges,All Other,2488.8,34,,2488.8,percent of total billed charges,Implant Device,2488.8,34,,2488.8,percent of total billed charges,Implant Device,2562,35,,2562,percent of total billed charges,Implant Device,2562,35,,2562,percent of total billed charges,Implant Device,2562,35,,2562,percent of total billed charges,Implant Device,2562,35,,2562,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2488.8,34,"If Charge > 2,000, then 34 percent",2488.8,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5416.82,
DEPUY 1987-14-105 FEM COMP XS RIGHT,C1776,HCPCS,,79003916,CDM,278,RC,,,both,,,26440,19565.67,,,19565.67,Other,150% of Medicare + 9.63% HCRA Surcharge,11898,45,,11898,percent of total billed charges,Critical Access Hospital RCC factor,8989.6,34,,8989.6,percent of total billed charges,Implant Device,8989.6,34,,8989.6,percent of total billed charges,Implant Device,8989.6,34,,8989.6,percent of total billed charges,Implant Device,8989.6,34,,8989.6,percent of total billed charges,Implant Device,8989.6,34,,8989.6,percent of total billed charges,Implant Device,13087.8,,,13087.8,Other,110% of Medicare,9254,35,,9254,percent of total billed charges,Implant Device,8989.6,34,"Charges > $500, x 34%",8989.6,percent of total billed charges,Implant Device,9254,35,,9254,percent of total billed charges,Implant Device,9254,35,,9254,percent of total billed charges,Implant Device,9254,35,,9254,percent of total billed charges,Implant Device,9254,35,,9254,percent of total billed charges,Implant Device,9254,35,,9254,percent of total billed charges,Implant Device,10576,40,,10576,percent of total billed charges,Implant Device,9254,70,,9254,percent of total billed charges,All Other,8989.6,34,,8989.6,percent of total billed charges,Implant Device,8989.6,34,,8989.6,percent of total billed charges,Implant Device,9254,35,,9254,percent of total billed charges,Implant Device,9254,35,,9254,percent of total billed charges,Implant Device,9254,35,,9254,percent of total billed charges,Implant Device,9254,35,,9254,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,8989.6,34,"If Charge > 2,000, then 34 percent",8989.6,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,19565.67,
DEPUY 8162-35-006 LOCK PLATE 6HOLE 3.5MM,C1713,HCPCS,,79003917,CDM,278,RC,,,both,,,1020,754.8,,,754.8,Other,150% of Medicare + 9.63% HCRA Surcharge,459,45,,459,percent of total billed charges,Critical Access Hospital RCC factor,346.8,34,,346.8,percent of total billed charges,Implant Device,346.8,34,,346.8,percent of total billed charges,Implant Device,346.8,34,,346.8,percent of total billed charges,Implant Device,346.8,34,,346.8,percent of total billed charges,Implant Device,346.8,34,,346.8,percent of total billed charges,Implant Device,504.9,,,504.9,Other,110% of Medicare,357,35,,357,percent of total billed charges,Implant Device,346.8,34,"Charges > $500, x 34%",346.8,percent of total billed charges,Implant Device,357,35,,357,percent of total billed charges,Implant Device,357,35,,357,percent of total billed charges,Implant Device,357,35,,357,percent of total billed charges,Implant Device,357,35,,357,percent of total billed charges,Implant Device,357,35,,357,percent of total billed charges,Implant Device,408,40,,408,percent of total billed charges,Implant Device,357,70,,357,percent of total billed charges,All Other,346.8,34,,346.8,percent of total billed charges,Implant Device,346.8,34,,346.8,percent of total billed charges,Implant Device,357,35,,357,percent of total billed charges,Implant Device,357,35,,357,percent of total billed charges,Implant Device,357,35,,357,percent of total billed charges,Implant Device,357,35,,357,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,754.8,
DEPUY 8157.45-038 LOCKING SCREW 4.5X38MM,C1713,HCPCS,,79003918,CDM,278,RC,,,both,,,210,155.4,,,155.4,Other,150% of Medicare + 9.63% HCRA Surcharge,94.5,45,,94.5,percent of total billed charges,Critical Access Hospital RCC factor,71.4,34,,71.4,percent of total billed charges,Implant Device,71.4,34,,71.4,percent of total billed charges,Implant Device,71.4,34,,71.4,percent of total billed charges,Implant Device,71.4,34,,71.4,percent of total billed charges,Implant Device,71.4,34,,71.4,percent of total billed charges,Implant Device,103.95,,,103.95,Other,110% of Medicare,73.5,35,,73.5,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,73.5,35,,73.5,percent of total billed charges,Implant Device,73.5,35,,73.5,percent of total billed charges,Implant Device,73.5,35,,73.5,percent of total billed charges,Implant Device,73.5,35,,73.5,percent of total billed charges,Implant Device,73.5,35,,73.5,percent of total billed charges,Implant Device,84,40,,84,percent of total billed charges,Implant Device,73.5,70,,73.5,percent of total billed charges,All Other,71.4,34,,71.4,percent of total billed charges,Implant Device,71.4,34,,71.4,percent of total billed charges,Implant Device,73.5,35,,73.5,percent of total billed charges,Implant Device,73.5,35,,73.5,percent of total billed charges,Implant Device,73.5,35,,73.5,percent of total billed charges,Implant Device,73.5,35,,73.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,155.4,
DEPUY 1363-51-000 FRACTURE HEAD HIP 51MM,C1776,HCPCS,,79003919,CDM,278,RC,,,both,,,894,661.56,,,661.56,Other,150% of Medicare + 9.63% HCRA Surcharge,402.3,45,,402.3,percent of total billed charges,Critical Access Hospital RCC factor,303.96,34,,303.96,percent of total billed charges,Implant Device,303.96,34,,303.96,percent of total billed charges,Implant Device,303.96,34,,303.96,percent of total billed charges,Implant Device,303.96,34,,303.96,percent of total billed charges,Implant Device,303.96,34,,303.96,percent of total billed charges,Implant Device,442.53,,,442.53,Other,110% of Medicare,312.9,35,,312.9,percent of total billed charges,Implant Device,303.96,34,"Charges > $500, x 34%",303.96,percent of total billed charges,Implant Device,312.9,35,,312.9,percent of total billed charges,Implant Device,312.9,35,,312.9,percent of total billed charges,Implant Device,312.9,35,,312.9,percent of total billed charges,Implant Device,312.9,35,,312.9,percent of total billed charges,Implant Device,312.9,35,,312.9,percent of total billed charges,Implant Device,357.6,40,,357.6,percent of total billed charges,Implant Device,312.9,70,,312.9,percent of total billed charges,All Other,303.96,34,,303.96,percent of total billed charges,Implant Device,303.96,34,,303.96,percent of total billed charges,Implant Device,312.9,35,,312.9,percent of total billed charges,Implant Device,312.9,35,,312.9,percent of total billed charges,Implant Device,312.9,35,,312.9,percent of total billed charges,Implant Device,312.9,35,,312.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,661.56,
DEPUY SBFN062 BONE FIXATION NAIL 1.6MM,C1713,HCPCS,,79003920,CDM,278,RC,,,both,,,776,574.24,,,574.24,Other,150% of Medicare + 9.63% HCRA Surcharge,349.2,45,,349.2,percent of total billed charges,Critical Access Hospital RCC factor,263.84,34,,263.84,percent of total billed charges,Implant Device,263.84,34,,263.84,percent of total billed charges,Implant Device,263.84,34,,263.84,percent of total billed charges,Implant Device,263.84,34,,263.84,percent of total billed charges,Implant Device,263.84,34,,263.84,percent of total billed charges,Implant Device,384.12,,,384.12,Other,110% of Medicare,271.6,35,,271.6,percent of total billed charges,Implant Device,263.84,34,"Charges > $500, x 34%",263.84,percent of total billed charges,Implant Device,271.6,35,,271.6,percent of total billed charges,Implant Device,271.6,35,,271.6,percent of total billed charges,Implant Device,271.6,35,,271.6,percent of total billed charges,Implant Device,271.6,35,,271.6,percent of total billed charges,Implant Device,271.6,35,,271.6,percent of total billed charges,Implant Device,310.4,40,,310.4,percent of total billed charges,Implant Device,271.6,70,,271.6,percent of total billed charges,All Other,263.84,34,,263.84,percent of total billed charges,Implant Device,263.84,34,,263.84,percent of total billed charges,Implant Device,271.6,35,,271.6,percent of total billed charges,Implant Device,271.6,35,,271.6,percent of total billed charges,Implant Device,271.6,35,,271.6,percent of total billed charges,Implant Device,271.6,35,,271.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,574.24,
DEPUY 8161-40-065 CANC LOCK SCREW 4X65MM,C1713,HCPCS,,79003921,CDM,278,RC,,,both,,,660,488.4,,,488.4,Other,150% of Medicare + 9.63% HCRA Surcharge,297,45,,297,percent of total billed charges,Critical Access Hospital RCC factor,224.4,34,,224.4,percent of total billed charges,Implant Device,224.4,34,,224.4,percent of total billed charges,Implant Device,224.4,34,,224.4,percent of total billed charges,Implant Device,224.4,34,,224.4,percent of total billed charges,Implant Device,224.4,34,,224.4,percent of total billed charges,Implant Device,326.7,,,326.7,Other,110% of Medicare,231,35,,231,percent of total billed charges,Implant Device,224.4,34,"Charges > $500, x 34%",224.4,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,264,40,,264,percent of total billed charges,Implant Device,231,70,,231,percent of total billed charges,All Other,224.4,34,,224.4,percent of total billed charges,Implant Device,224.4,34,,224.4,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,488.4,
DEPUY 1987-07-045 LPS SEGMENTAL COMP 45M,C1776,HCPCS,,79003922,CDM,278,RC,,,both,,,6266,4636.86,,,4636.86,Other,150% of Medicare + 9.63% HCRA Surcharge,2819.7,45,,2819.7,percent of total billed charges,Critical Access Hospital RCC factor,2130.44,34,,2130.44,percent of total billed charges,Implant Device,2130.44,34,,2130.44,percent of total billed charges,Implant Device,2130.44,34,,2130.44,percent of total billed charges,Implant Device,2130.44,34,,2130.44,percent of total billed charges,Implant Device,2130.44,34,,2130.44,percent of total billed charges,Implant Device,3101.67,,,3101.67,Other,110% of Medicare,2193.1,35,,2193.1,percent of total billed charges,Implant Device,2130.44,34,"Charges > $500, x 34%",2130.44,percent of total billed charges,Implant Device,2193.1,35,,2193.1,percent of total billed charges,Implant Device,2193.1,35,,2193.1,percent of total billed charges,Implant Device,2193.1,35,,2193.1,percent of total billed charges,Implant Device,2193.1,35,,2193.1,percent of total billed charges,Implant Device,2193.1,35,,2193.1,percent of total billed charges,Implant Device,2506.4,40,,2506.4,percent of total billed charges,Implant Device,2193.1,70,,2193.1,percent of total billed charges,All Other,2130.44,34,,2130.44,percent of total billed charges,Implant Device,2130.44,34,,2130.44,percent of total billed charges,Implant Device,2193.1,35,,2193.1,percent of total billed charges,Implant Device,2193.1,35,,2193.1,percent of total billed charges,Implant Device,2193.1,35,,2193.1,percent of total billed charges,Implant Device,2193.1,35,,2193.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2130.44,34,"If Charge > 2,000, then 34 percent",2130.44,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4636.86,
DEPUY 8141-32-005 POLYAX TIB PLATE 5HOLE,C1776,HCPCS,,79003923,CDM,278,RC,,,both,,,7320,5416.82,,,5416.82,Other,150% of Medicare + 9.63% HCRA Surcharge,3294,45,,3294,percent of total billed charges,Critical Access Hospital RCC factor,2488.8,34,,2488.8,percent of total billed charges,Implant Device,2488.8,34,,2488.8,percent of total billed charges,Implant Device,2488.8,34,,2488.8,percent of total billed charges,Implant Device,2488.8,34,,2488.8,percent of total billed charges,Implant Device,2488.8,34,,2488.8,percent of total billed charges,Implant Device,3623.4,,,3623.4,Other,110% of Medicare,2562,35,,2562,percent of total billed charges,Implant Device,2488.8,34,"Charges > $500, x 34%",2488.8,percent of total billed charges,Implant Device,2562,35,,2562,percent of total billed charges,Implant Device,2562,35,,2562,percent of total billed charges,Implant Device,2562,35,,2562,percent of total billed charges,Implant Device,2562,35,,2562,percent of total billed charges,Implant Device,2562,35,,2562,percent of total billed charges,Implant Device,2928,40,,2928,percent of total billed charges,Implant Device,2562,70,,2562,percent of total billed charges,All Other,2488.8,34,,2488.8,percent of total billed charges,Implant Device,2488.8,34,,2488.8,percent of total billed charges,Implant Device,2562,35,,2562,percent of total billed charges,Implant Device,2562,35,,2562,percent of total billed charges,Implant Device,2562,35,,2562,percent of total billed charges,Implant Device,2562,35,,2562,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2488.8,34,"If Charge > 2,000, then 34 percent",2488.8,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5416.82,
DEPUY 1217-32-052 ACETABLR SHELL 52MM,C1776,HCPCS,,79003924,CDM,278,RC,,,both,,,3420,2530.81,,,2530.81,Other,150% of Medicare + 9.63% HCRA Surcharge,1539,45,,1539,percent of total billed charges,Critical Access Hospital RCC factor,1162.8,34,,1162.8,percent of total billed charges,Implant Device,1162.8,34,,1162.8,percent of total billed charges,Implant Device,1162.8,34,,1162.8,percent of total billed charges,Implant Device,1162.8,34,,1162.8,percent of total billed charges,Implant Device,1162.8,34,,1162.8,percent of total billed charges,Implant Device,1692.9,,,1692.9,Other,110% of Medicare,1197,35,,1197,percent of total billed charges,Implant Device,1162.8,34,"Charges > $500, x 34%",1162.8,percent of total billed charges,Implant Device,1197,35,,1197,percent of total billed charges,Implant Device,1197,35,,1197,percent of total billed charges,Implant Device,1197,35,,1197,percent of total billed charges,Implant Device,1197,35,,1197,percent of total billed charges,Implant Device,1197,35,,1197,percent of total billed charges,Implant Device,1368,40,,1368,percent of total billed charges,Implant Device,1197,70,,1197,percent of total billed charges,All Other,1162.8,34,,1162.8,percent of total billed charges,Implant Device,1162.8,34,,1162.8,percent of total billed charges,Implant Device,1197,35,,1197,percent of total billed charges,Implant Device,1197,35,,1197,percent of total billed charges,Implant Device,1197,35,,1197,percent of total billed charges,Implant Device,1197,35,,1197,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1162.8,34,"If Charge > 2,000, then 34 percent",1162.8,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2530.81,
DEPUY 8141-16-003 META PLATE LG 3HOLE,C1713,HCPCS,,79003925,CDM,278,RC,,,both,,,1590,1176.6,,,1176.6,Other,150% of Medicare + 9.63% HCRA Surcharge,715.5,45,,715.5,percent of total billed charges,Critical Access Hospital RCC factor,540.6,34,,540.6,percent of total billed charges,Implant Device,540.6,34,,540.6,percent of total billed charges,Implant Device,540.6,34,,540.6,percent of total billed charges,Implant Device,540.6,34,,540.6,percent of total billed charges,Implant Device,540.6,34,,540.6,percent of total billed charges,Implant Device,787.05,,,787.05,Other,110% of Medicare,556.5,35,,556.5,percent of total billed charges,Implant Device,540.6,34,"Charges > $500, x 34%",540.6,percent of total billed charges,Implant Device,556.5,35,,556.5,percent of total billed charges,Implant Device,556.5,35,,556.5,percent of total billed charges,Implant Device,556.5,35,,556.5,percent of total billed charges,Implant Device,556.5,35,,556.5,percent of total billed charges,Implant Device,556.5,35,,556.5,percent of total billed charges,Implant Device,636,40,,636,percent of total billed charges,Implant Device,556.5,70,,556.5,percent of total billed charges,All Other,540.6,34,,540.6,percent of total billed charges,Implant Device,540.6,34,,540.6,percent of total billed charges,Implant Device,556.5,35,,556.5,percent of total billed charges,Implant Device,556.5,35,,556.5,percent of total billed charges,Implant Device,556.5,35,,556.5,percent of total billed charges,Implant Device,556.5,35,,556.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1176.6,
DEPUY 8145-10-090 LAG SCREW 10.5X90MM,C1713,HCPCS,,79003926,CDM,278,RC,,,both,,,1786,1321.64,,,1321.64,Other,150% of Medicare + 9.63% HCRA Surcharge,803.7,45,,803.7,percent of total billed charges,Critical Access Hospital RCC factor,607.24,34,,607.24,percent of total billed charges,Implant Device,607.24,34,,607.24,percent of total billed charges,Implant Device,607.24,34,,607.24,percent of total billed charges,Implant Device,607.24,34,,607.24,percent of total billed charges,Implant Device,607.24,34,,607.24,percent of total billed charges,Implant Device,884.07,,,884.07,Other,110% of Medicare,625.1,35,,625.1,percent of total billed charges,Implant Device,607.24,34,"Charges > $500, x 34%",607.24,percent of total billed charges,Implant Device,625.1,35,,625.1,percent of total billed charges,Implant Device,625.1,35,,625.1,percent of total billed charges,Implant Device,625.1,35,,625.1,percent of total billed charges,Implant Device,625.1,35,,625.1,percent of total billed charges,Implant Device,625.1,35,,625.1,percent of total billed charges,Implant Device,714.4,40,,714.4,percent of total billed charges,Implant Device,625.1,70,,625.1,percent of total billed charges,All Other,607.24,34,,607.24,percent of total billed charges,Implant Device,607.24,34,,607.24,percent of total billed charges,Implant Device,625.1,35,,625.1,percent of total billed charges,Implant Device,625.1,35,,625.1,percent of total billed charges,Implant Device,625.1,35,,625.1,percent of total billed charges,Implant Device,625.1,35,,625.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1321.64,
DEPUY 8150-45-526 LOCK SCREW 4.5X26MM,C1713,HCPCS,,79003927,CDM,278,RC,,,both,,,630,466.2,,,466.2,Other,150% of Medicare + 9.63% HCRA Surcharge,283.5,45,,283.5,percent of total billed charges,Critical Access Hospital RCC factor,214.2,34,,214.2,percent of total billed charges,Implant Device,214.2,34,,214.2,percent of total billed charges,Implant Device,214.2,34,,214.2,percent of total billed charges,Implant Device,214.2,34,,214.2,percent of total billed charges,Implant Device,214.2,34,,214.2,percent of total billed charges,Implant Device,311.85,,,311.85,Other,110% of Medicare,220.5,35,,220.5,percent of total billed charges,Implant Device,214.2,34,"Charges > $500, x 34%",214.2,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,252,40,,252,percent of total billed charges,Implant Device,220.5,70,,220.5,percent of total billed charges,All Other,214.2,34,,214.2,percent of total billed charges,Implant Device,214.2,34,,214.2,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,466.2,
DEPUY 8153-55-060 LOCKING SCREW 5.5X60MM,C1713,HCPCS,,79003928,CDM,278,RC,,,both,,,630,466.2,,,466.2,Other,150% of Medicare + 9.63% HCRA Surcharge,283.5,45,,283.5,percent of total billed charges,Critical Access Hospital RCC factor,214.2,34,,214.2,percent of total billed charges,Implant Device,214.2,34,,214.2,percent of total billed charges,Implant Device,214.2,34,,214.2,percent of total billed charges,Implant Device,214.2,34,,214.2,percent of total billed charges,Implant Device,214.2,34,,214.2,percent of total billed charges,Implant Device,311.85,,,311.85,Other,110% of Medicare,220.5,35,,220.5,percent of total billed charges,Implant Device,214.2,34,"Charges > $500, x 34%",214.2,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,252,40,,252,percent of total billed charges,Implant Device,220.5,70,,220.5,percent of total billed charges,All Other,214.2,34,,214.2,percent of total billed charges,Implant Device,214.2,34,,214.2,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,466.2,
DEPUY 14196-55 CANN SCREW 6.5X55MM,C1713,HCPCS,,79003929,CDM,278,RC,,,both,,,1290,954.6,,,954.6,Other,150% of Medicare + 9.63% HCRA Surcharge,580.5,45,,580.5,percent of total billed charges,Critical Access Hospital RCC factor,438.6,34,,438.6,percent of total billed charges,Implant Device,438.6,34,,438.6,percent of total billed charges,Implant Device,438.6,34,,438.6,percent of total billed charges,Implant Device,438.6,34,,438.6,percent of total billed charges,Implant Device,438.6,34,,438.6,percent of total billed charges,Implant Device,638.55,,,638.55,Other,110% of Medicare,451.5,35,,451.5,percent of total billed charges,Implant Device,438.6,34,"Charges > $500, x 34%",438.6,percent of total billed charges,Implant Device,451.5,35,,451.5,percent of total billed charges,Implant Device,451.5,35,,451.5,percent of total billed charges,Implant Device,451.5,35,,451.5,percent of total billed charges,Implant Device,451.5,35,,451.5,percent of total billed charges,Implant Device,451.5,35,,451.5,percent of total billed charges,Implant Device,516,40,,516,percent of total billed charges,Implant Device,451.5,70,,451.5,percent of total billed charges,All Other,438.6,34,,438.6,percent of total billed charges,Implant Device,438.6,34,,438.6,percent of total billed charges,Implant Device,451.5,35,,451.5,percent of total billed charges,Implant Device,451.5,35,,451.5,percent of total billed charges,Implant Device,451.5,35,,451.5,percent of total billed charges,Implant Device,451.5,35,,451.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,954.6,
DEPUY 8143-13-180 HIP FX NAIL 13X180MM,C1713,HCPCS,,79003930,CDM,278,RC,,,both,,,4464,3303.37,,,3303.37,Other,150% of Medicare + 9.63% HCRA Surcharge,2008.8,45,,2008.8,percent of total billed charges,Critical Access Hospital RCC factor,1517.76,34,,1517.76,percent of total billed charges,Implant Device,1517.76,34,,1517.76,percent of total billed charges,Implant Device,1517.76,34,,1517.76,percent of total billed charges,Implant Device,1517.76,34,,1517.76,percent of total billed charges,Implant Device,1517.76,34,,1517.76,percent of total billed charges,Implant Device,2209.68,,,2209.68,Other,110% of Medicare,1562.4,35,,1562.4,percent of total billed charges,Implant Device,1517.76,34,"Charges > $500, x 34%",1517.76,percent of total billed charges,Implant Device,1562.4,35,,1562.4,percent of total billed charges,Implant Device,1562.4,35,,1562.4,percent of total billed charges,Implant Device,1562.4,35,,1562.4,percent of total billed charges,Implant Device,1562.4,35,,1562.4,percent of total billed charges,Implant Device,1562.4,35,,1562.4,percent of total billed charges,Implant Device,1785.6,40,,1785.6,percent of total billed charges,Implant Device,1562.4,70,,1562.4,percent of total billed charges,All Other,1517.76,34,,1517.76,percent of total billed charges,Implant Device,1517.76,34,,1517.76,percent of total billed charges,Implant Device,1562.4,35,,1562.4,percent of total billed charges,Implant Device,1562.4,35,,1562.4,percent of total billed charges,Implant Device,1562.4,35,,1562.4,percent of total billed charges,Implant Device,1562.4,35,,1562.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1517.76,34,"If Charge > 2,000, then 34 percent",1517.76,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3303.37,
DEPUY 8145-13-180 HIP FX NAIL 13X180MM,C1713,HCPCS,,79003931,CDM,278,RC,,,both,,,8040,5949.62,,,5949.62,Other,150% of Medicare + 9.63% HCRA Surcharge,3618,45,,3618,percent of total billed charges,Critical Access Hospital RCC factor,2733.6,34,,2733.6,percent of total billed charges,Implant Device,2733.6,34,,2733.6,percent of total billed charges,Implant Device,2733.6,34,,2733.6,percent of total billed charges,Implant Device,2733.6,34,,2733.6,percent of total billed charges,Implant Device,2733.6,34,,2733.6,percent of total billed charges,Implant Device,3979.8,,,3979.8,Other,110% of Medicare,2814,35,,2814,percent of total billed charges,Implant Device,2733.6,34,"Charges > $500, x 34%",2733.6,percent of total billed charges,Implant Device,2814,35,,2814,percent of total billed charges,Implant Device,2814,35,,2814,percent of total billed charges,Implant Device,2814,35,,2814,percent of total billed charges,Implant Device,2814,35,,2814,percent of total billed charges,Implant Device,2814,35,,2814,percent of total billed charges,Implant Device,3216,40,,3216,percent of total billed charges,Implant Device,2814,70,,2814,percent of total billed charges,All Other,2733.6,34,,2733.6,percent of total billed charges,Implant Device,2733.6,34,,2733.6,percent of total billed charges,Implant Device,2814,35,,2814,percent of total billed charges,Implant Device,2814,35,,2814,percent of total billed charges,Implant Device,2814,35,,2814,percent of total billed charges,Implant Device,2814,35,,2814,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2733.6,34,"If Charge > 2,000, then 34 percent",2733.6,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5949.62,
DEPUY 8153-04-085 PLOY LOCK SCREW 4X85MM,C1713,HCPCS,,79003932,CDM,278,RC,,,both,,,630,466.2,,,466.2,Other,150% of Medicare + 9.63% HCRA Surcharge,283.5,45,,283.5,percent of total billed charges,Critical Access Hospital RCC factor,214.2,34,,214.2,percent of total billed charges,Implant Device,214.2,34,,214.2,percent of total billed charges,Implant Device,214.2,34,,214.2,percent of total billed charges,Implant Device,214.2,34,,214.2,percent of total billed charges,Implant Device,214.2,34,,214.2,percent of total billed charges,Implant Device,311.85,,,311.85,Other,110% of Medicare,220.5,35,,220.5,percent of total billed charges,Implant Device,214.2,34,"Charges > $500, x 34%",214.2,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,252,40,,252,percent of total billed charges,Implant Device,220.5,70,,220.5,percent of total billed charges,All Other,214.2,34,,214.2,percent of total billed charges,Implant Device,214.2,34,,214.2,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,466.2,
DEPUY SP20000 PEG SCREW 2.5X20MM,C1713,HCPCS,,79003933,CDM,278,RC,,,both,,,288,213.12,,,213.12,Other,150% of Medicare + 9.63% HCRA Surcharge,129.6,45,,129.6,percent of total billed charges,Critical Access Hospital RCC factor,97.92,34,,97.92,percent of total billed charges,Implant Device,97.92,34,,97.92,percent of total billed charges,Implant Device,97.92,34,,97.92,percent of total billed charges,Implant Device,97.92,34,,97.92,percent of total billed charges,Implant Device,97.92,34,,97.92,percent of total billed charges,Implant Device,142.56,,,142.56,Other,110% of Medicare,100.8,35,,100.8,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,100.8,35,,100.8,percent of total billed charges,Implant Device,100.8,35,,100.8,percent of total billed charges,Implant Device,100.8,35,,100.8,percent of total billed charges,Implant Device,100.8,35,,100.8,percent of total billed charges,Implant Device,100.8,35,,100.8,percent of total billed charges,Implant Device,115.2,40,,115.2,percent of total billed charges,Implant Device,100.8,70,,100.8,percent of total billed charges,All Other,97.92,34,,97.92,percent of total billed charges,Implant Device,97.92,34,,97.92,percent of total billed charges,Implant Device,100.8,35,,100.8,percent of total billed charges,Implant Device,100.8,35,,100.8,percent of total billed charges,Implant Device,100.8,35,,100.8,percent of total billed charges,Implant Device,100.8,35,,100.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,213.12,
DEPUY 1987-07-125 SEGMENTED COMP 125MM,C1713,HCPCS,,79003934,CDM,278,RC,,,both,,,5497,4067.79,,,4067.79,Other,150% of Medicare + 9.63% HCRA Surcharge,2473.65,45,,2473.65,percent of total billed charges,Critical Access Hospital RCC factor,1868.98,34,,1868.98,percent of total billed charges,Implant Device,1868.98,34,,1868.98,percent of total billed charges,Implant Device,1868.98,34,,1868.98,percent of total billed charges,Implant Device,1868.98,34,,1868.98,percent of total billed charges,Implant Device,1868.98,34,,1868.98,percent of total billed charges,Implant Device,2721.02,,,2721.02,Other,110% of Medicare,1923.95,35,,1923.95,percent of total billed charges,Implant Device,1868.98,34,"Charges > $500, x 34%",1868.98,percent of total billed charges,Implant Device,1923.95,35,,1923.95,percent of total billed charges,Implant Device,1923.95,35,,1923.95,percent of total billed charges,Implant Device,1923.95,35,,1923.95,percent of total billed charges,Implant Device,1923.95,35,,1923.95,percent of total billed charges,Implant Device,1923.95,35,,1923.95,percent of total billed charges,Implant Device,2198.8,40,,2198.8,percent of total billed charges,Implant Device,1923.95,70,,1923.95,percent of total billed charges,All Other,1868.98,34,,1868.98,percent of total billed charges,Implant Device,1868.98,34,,1868.98,percent of total billed charges,Implant Device,1923.95,35,,1923.95,percent of total billed charges,Implant Device,1923.95,35,,1923.95,percent of total billed charges,Implant Device,1923.95,35,,1923.95,percent of total billed charges,Implant Device,1923.95,35,,1923.95,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1868.98,34,"If Charge > 2,000, then 34 percent",1868.98,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4067.79,
DEPUY 8153-41-050 CANN SCREW FT 4MM,C1713,HCPCS,,79003935,CDM,278,RC,,,both,,,240,177.6,,,177.6,Other,150% of Medicare + 9.63% HCRA Surcharge,108,45,,108,percent of total billed charges,Critical Access Hospital RCC factor,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,118.8,,,118.8,Other,110% of Medicare,84,35,,84,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,96,40,,96,percent of total billed charges,Implant Device,84,70,,84,percent of total billed charges,All Other,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,177.6,
DEPUY 8161-40-070 CANC LOCK SCREW 4X70MM,C1713,HCPCS,,79003936,CDM,278,RC,,,both,,,660,488.4,,,488.4,Other,150% of Medicare + 9.63% HCRA Surcharge,297,45,,297,percent of total billed charges,Critical Access Hospital RCC factor,224.4,34,,224.4,percent of total billed charges,Implant Device,224.4,34,,224.4,percent of total billed charges,Implant Device,224.4,34,,224.4,percent of total billed charges,Implant Device,224.4,34,,224.4,percent of total billed charges,Implant Device,224.4,34,,224.4,percent of total billed charges,Implant Device,326.7,,,326.7,Other,110% of Medicare,231,35,,231,percent of total billed charges,Implant Device,224.4,34,"Charges > $500, x 34%",224.4,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,264,40,,264,percent of total billed charges,Implant Device,231,70,,231,percent of total billed charges,All Other,224.4,34,,224.4,percent of total billed charges,Implant Device,224.4,34,,224.4,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,488.4,
DEPUY 1987-25-112 CEMENTED STEM 12X100MM,C1776,HCPCS,,79003937,CDM,278,RC,,,both,,,11197,8285.81,,,8285.81,Other,150% of Medicare + 9.63% HCRA Surcharge,5038.65,45,,5038.65,percent of total billed charges,Critical Access Hospital RCC factor,3806.98,34,,3806.98,percent of total billed charges,Implant Device,3806.98,34,,3806.98,percent of total billed charges,Implant Device,3806.98,34,,3806.98,percent of total billed charges,Implant Device,3806.98,34,,3806.98,percent of total billed charges,Implant Device,3806.98,34,,3806.98,percent of total billed charges,Implant Device,5542.52,,,5542.52,Other,110% of Medicare,3918.95,35,,3918.95,percent of total billed charges,Implant Device,3806.98,34,"Charges > $500, x 34%",3806.98,percent of total billed charges,Implant Device,3918.95,35,,3918.95,percent of total billed charges,Implant Device,3918.95,35,,3918.95,percent of total billed charges,Implant Device,3918.95,35,,3918.95,percent of total billed charges,Implant Device,3918.95,35,,3918.95,percent of total billed charges,Implant Device,3918.95,35,,3918.95,percent of total billed charges,Implant Device,4478.8,40,,4478.8,percent of total billed charges,Implant Device,3918.95,70,,3918.95,percent of total billed charges,All Other,3806.98,34,,3806.98,percent of total billed charges,Implant Device,3806.98,34,,3806.98,percent of total billed charges,Implant Device,3918.95,35,,3918.95,percent of total billed charges,Implant Device,3918.95,35,,3918.95,percent of total billed charges,Implant Device,3918.95,35,,3918.95,percent of total billed charges,Implant Device,3918.95,35,,3918.95,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3806.98,34,"If Charge > 2,000, then 34 percent",3806.98,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,8285.81,
DEPUY 8154-55-090 NONLOCK SCREW 5.5X90MM,C1713,HCPCS,,79003938,CDM,278,RC,,,both,,,360,266.4,,,266.4,Other,150% of Medicare + 9.63% HCRA Surcharge,162,45,,162,percent of total billed charges,Critical Access Hospital RCC factor,122.4,34,,122.4,percent of total billed charges,Implant Device,122.4,34,,122.4,percent of total billed charges,Implant Device,122.4,34,,122.4,percent of total billed charges,Implant Device,122.4,34,,122.4,percent of total billed charges,Implant Device,122.4,34,,122.4,percent of total billed charges,Implant Device,178.2,,,178.2,Other,110% of Medicare,126,35,,126,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,126,35,,126,percent of total billed charges,Implant Device,126,35,,126,percent of total billed charges,Implant Device,126,35,,126,percent of total billed charges,Implant Device,126,35,,126,percent of total billed charges,Implant Device,126,35,,126,percent of total billed charges,Implant Device,144,40,,144,percent of total billed charges,Implant Device,126,70,,126,percent of total billed charges,All Other,122.4,34,,122.4,percent of total billed charges,Implant Device,122.4,34,,122.4,percent of total billed charges,Implant Device,126,35,,126,percent of total billed charges,Implant Device,126,35,,126,percent of total billed charges,Implant Device,126,35,,126,percent of total billed charges,Implant Device,126,35,,126,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,266.4,
DEPUY 1570-06-090 SUMMIT BASIC CEM SZ 3,C1776,HCPCS,,79003939,CDM,278,RC,,,both,,,5575,4125.51,,,4125.51,Other,150% of Medicare + 9.63% HCRA Surcharge,2508.75,45,,2508.75,percent of total billed charges,Critical Access Hospital RCC factor,1895.5,34,,1895.5,percent of total billed charges,Implant Device,1895.5,34,,1895.5,percent of total billed charges,Implant Device,1895.5,34,,1895.5,percent of total billed charges,Implant Device,1895.5,34,,1895.5,percent of total billed charges,Implant Device,1895.5,34,,1895.5,percent of total billed charges,Implant Device,2759.63,,,2759.63,Other,110% of Medicare,1951.25,35,,1951.25,percent of total billed charges,Implant Device,1895.5,34,"Charges > $500, x 34%",1895.5,percent of total billed charges,Implant Device,1951.25,35,,1951.25,percent of total billed charges,Implant Device,1951.25,35,,1951.25,percent of total billed charges,Implant Device,1951.25,35,,1951.25,percent of total billed charges,Implant Device,1951.25,35,,1951.25,percent of total billed charges,Implant Device,1951.25,35,,1951.25,percent of total billed charges,Implant Device,2230,40,,2230,percent of total billed charges,Implant Device,1951.25,70,,1951.25,percent of total billed charges,All Other,1895.5,34,,1895.5,percent of total billed charges,Implant Device,1895.5,34,,1895.5,percent of total billed charges,Implant Device,1951.25,35,,1951.25,percent of total billed charges,Implant Device,1951.25,35,,1951.25,percent of total billed charges,Implant Device,1951.25,35,,1951.25,percent of total billed charges,Implant Device,1951.25,35,,1951.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1895.5,34,"If Charge > 2,000, then 34 percent",1895.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4125.51,
DEPUY 1035-50-000 BIPOLAR SELF CNT 28X50,C1776,HCPCS,,79003940,CDM,278,RC,,,both,,,1733,1282.42,,,1282.42,Other,150% of Medicare + 9.63% HCRA Surcharge,779.85,45,,779.85,percent of total billed charges,Critical Access Hospital RCC factor,589.22,34,,589.22,percent of total billed charges,Implant Device,589.22,34,,589.22,percent of total billed charges,Implant Device,589.22,34,,589.22,percent of total billed charges,Implant Device,589.22,34,,589.22,percent of total billed charges,Implant Device,589.22,34,,589.22,percent of total billed charges,Implant Device,857.84,,,857.84,Other,110% of Medicare,606.55,35,,606.55,percent of total billed charges,Implant Device,589.22,34,"Charges > $500, x 34%",589.22,percent of total billed charges,Implant Device,606.55,35,,606.55,percent of total billed charges,Implant Device,606.55,35,,606.55,percent of total billed charges,Implant Device,606.55,35,,606.55,percent of total billed charges,Implant Device,606.55,35,,606.55,percent of total billed charges,Implant Device,606.55,35,,606.55,percent of total billed charges,Implant Device,693.2,40,,693.2,percent of total billed charges,Implant Device,606.55,70,,606.55,percent of total billed charges,All Other,589.22,34,,589.22,percent of total billed charges,Implant Device,589.22,34,,589.22,percent of total billed charges,Implant Device,606.55,35,,606.55,percent of total billed charges,Implant Device,606.55,35,,606.55,percent of total billed charges,Implant Device,606.55,35,,606.55,percent of total billed charges,Implant Device,606.55,35,,606.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1282.42,
DEPUY 1035-45-000 HEAD BIPOLAR 28X45MM,C1776,HCPCS,,79003941,CDM,278,RC,,,both,,,4030,2982.21,,,2982.21,Other,150% of Medicare + 9.63% HCRA Surcharge,1813.5,45,,1813.5,percent of total billed charges,Critical Access Hospital RCC factor,1370.2,34,,1370.2,percent of total billed charges,Implant Device,1370.2,34,,1370.2,percent of total billed charges,Implant Device,1370.2,34,,1370.2,percent of total billed charges,Implant Device,1370.2,34,,1370.2,percent of total billed charges,Implant Device,1370.2,34,,1370.2,percent of total billed charges,Implant Device,1994.85,,,1994.85,Other,110% of Medicare,1410.5,35,,1410.5,percent of total billed charges,Implant Device,1370.2,34,"Charges > $500, x 34%",1370.2,percent of total billed charges,Implant Device,1410.5,35,,1410.5,percent of total billed charges,Implant Device,1410.5,35,,1410.5,percent of total billed charges,Implant Device,1410.5,35,,1410.5,percent of total billed charges,Implant Device,1410.5,35,,1410.5,percent of total billed charges,Implant Device,1410.5,35,,1410.5,percent of total billed charges,Implant Device,1612,40,,1612,percent of total billed charges,Implant Device,1410.5,70,,1410.5,percent of total billed charges,All Other,1370.2,34,,1370.2,percent of total billed charges,Implant Device,1370.2,34,,1370.2,percent of total billed charges,Implant Device,1410.5,35,,1410.5,percent of total billed charges,Implant Device,1410.5,35,,1410.5,percent of total billed charges,Implant Device,1410.5,35,,1410.5,percent of total billed charges,Implant Device,1410.5,35,,1410.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1370.2,34,"If Charge > 2,000, then 34 percent",1370.2,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2982.21,
DEPUY 1376-21-000 CENTRALIZER DIA 12MM,C1776,HCPCS,,79003942,CDM,278,RC,,,both,,,5280,3907.21,,,3907.21,Other,150% of Medicare + 9.63% HCRA Surcharge,2376,45,,2376,percent of total billed charges,Critical Access Hospital RCC factor,1795.2,34,,1795.2,percent of total billed charges,Implant Device,1795.2,34,,1795.2,percent of total billed charges,Implant Device,1795.2,34,,1795.2,percent of total billed charges,Implant Device,1795.2,34,,1795.2,percent of total billed charges,Implant Device,1795.2,34,,1795.2,percent of total billed charges,Implant Device,2613.6,,,2613.6,Other,110% of Medicare,1848,35,,1848,percent of total billed charges,Implant Device,1795.2,34,"Charges > $500, x 34%",1795.2,percent of total billed charges,Implant Device,1848,35,,1848,percent of total billed charges,Implant Device,1848,35,,1848,percent of total billed charges,Implant Device,1848,35,,1848,percent of total billed charges,Implant Device,1848,35,,1848,percent of total billed charges,Implant Device,1848,35,,1848,percent of total billed charges,Implant Device,2112,40,,2112,percent of total billed charges,Implant Device,1848,70,,1848,percent of total billed charges,All Other,1795.2,34,,1795.2,percent of total billed charges,Implant Device,1795.2,34,,1795.2,percent of total billed charges,Implant Device,1848,35,,1848,percent of total billed charges,Implant Device,1848,35,,1848,percent of total billed charges,Implant Device,1848,35,,1848,percent of total billed charges,Implant Device,1848,35,,1848,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1795.2,34,"If Charge > 2,000, then 34 percent",1795.2,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3907.21,
DEPUY 8157-45-032 CORT SCREW FT 4.5X32MM,C1713,HCPCS,,79003943,CDM,278,RC,,,both,,,210,155.4,,,155.4,Other,150% of Medicare + 9.63% HCRA Surcharge,94.5,45,,94.5,percent of total billed charges,Critical Access Hospital RCC factor,71.4,34,,71.4,percent of total billed charges,Implant Device,71.4,34,,71.4,percent of total billed charges,Implant Device,71.4,34,,71.4,percent of total billed charges,Implant Device,71.4,34,,71.4,percent of total billed charges,Implant Device,71.4,34,,71.4,percent of total billed charges,Implant Device,103.95,,,103.95,Other,110% of Medicare,73.5,35,,73.5,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,73.5,35,,73.5,percent of total billed charges,Implant Device,73.5,35,,73.5,percent of total billed charges,Implant Device,73.5,35,,73.5,percent of total billed charges,Implant Device,73.5,35,,73.5,percent of total billed charges,Implant Device,73.5,35,,73.5,percent of total billed charges,Implant Device,84,40,,84,percent of total billed charges,Implant Device,73.5,70,,73.5,percent of total billed charges,All Other,71.4,34,,71.4,percent of total billed charges,Implant Device,71.4,34,,71.4,percent of total billed charges,Implant Device,73.5,35,,73.5,percent of total billed charges,Implant Device,73.5,35,,73.5,percent of total billed charges,Implant Device,73.5,35,,73.5,percent of total billed charges,Implant Device,73.5,35,,73.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,155.4,
DEPUY 8154-55-070 NON LOCK SCREW 5.5X70,C1713,HCPCS,,79003944,CDM,278,RC,,,both,,,360,266.4,,,266.4,Other,150% of Medicare + 9.63% HCRA Surcharge,162,45,,162,percent of total billed charges,Critical Access Hospital RCC factor,122.4,34,,122.4,percent of total billed charges,Implant Device,122.4,34,,122.4,percent of total billed charges,Implant Device,122.4,34,,122.4,percent of total billed charges,Implant Device,122.4,34,,122.4,percent of total billed charges,Implant Device,122.4,34,,122.4,percent of total billed charges,Implant Device,178.2,,,178.2,Other,110% of Medicare,126,35,,126,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,126,35,,126,percent of total billed charges,Implant Device,126,35,,126,percent of total billed charges,Implant Device,126,35,,126,percent of total billed charges,Implant Device,126,35,,126,percent of total billed charges,Implant Device,126,35,,126,percent of total billed charges,Implant Device,144,40,,144,percent of total billed charges,Implant Device,126,70,,126,percent of total billed charges,All Other,122.4,34,,122.4,percent of total billed charges,Implant Device,122.4,34,,122.4,percent of total billed charges,Implant Device,126,35,,126,percent of total billed charges,Implant Device,126,35,,126,percent of total billed charges,Implant Device,126,35,,126,percent of total billed charges,Implant Device,126,35,,126,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,266.4,
DEPUY 8145-50-036 CORT BONE SCREW 5X36MM,C1713,HCPCS,,79003945,CDM,278,RC,,,both,,,533,394.42,,,394.42,Other,150% of Medicare + 9.63% HCRA Surcharge,239.85,45,,239.85,percent of total billed charges,Critical Access Hospital RCC factor,181.22,34,,181.22,percent of total billed charges,Implant Device,181.22,34,,181.22,percent of total billed charges,Implant Device,181.22,34,,181.22,percent of total billed charges,Implant Device,181.22,34,,181.22,percent of total billed charges,Implant Device,181.22,34,,181.22,percent of total billed charges,Implant Device,263.84,,,263.84,Other,110% of Medicare,186.55,35,,186.55,percent of total billed charges,Implant Device,181.22,34,"Charges > $500, x 34%",181.22,percent of total billed charges,Implant Device,186.55,35,,186.55,percent of total billed charges,Implant Device,186.55,35,,186.55,percent of total billed charges,Implant Device,186.55,35,,186.55,percent of total billed charges,Implant Device,186.55,35,,186.55,percent of total billed charges,Implant Device,186.55,35,,186.55,percent of total billed charges,Implant Device,213.2,40,,213.2,percent of total billed charges,Implant Device,186.55,70,,186.55,percent of total billed charges,All Other,181.22,34,,181.22,percent of total billed charges,Implant Device,181.22,34,,181.22,percent of total billed charges,Implant Device,186.55,35,,186.55,percent of total billed charges,Implant Device,186.55,35,,186.55,percent of total billed charges,Implant Device,186.55,35,,186.55,percent of total billed charges,Implant Device,186.55,35,,186.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,394.42,
DEPUY 8153-41-028 CANC SCREW 4X28MM,C1713,HCPCS,,79003948,CDM,278,RC,,,both,,,240,177.6,,,177.6,Other,150% of Medicare + 9.63% HCRA Surcharge,108,45,,108,percent of total billed charges,Critical Access Hospital RCC factor,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,118.8,,,118.8,Other,110% of Medicare,84,35,,84,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,96,40,,96,percent of total billed charges,Implant Device,84,70,,84,percent of total billed charges,All Other,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,177.6,
DEPUY 8162-06-006 LOCK PLATE L 6H 139MM,C1713,HCPCS,,79003949,CDM,278,RC,,,both,,,4020,2974.81,,,2974.81,Other,150% of Medicare + 9.63% HCRA Surcharge,1809,45,,1809,percent of total billed charges,Critical Access Hospital RCC factor,1366.8,34,,1366.8,percent of total billed charges,Implant Device,1366.8,34,,1366.8,percent of total billed charges,Implant Device,1366.8,34,,1366.8,percent of total billed charges,Implant Device,1366.8,34,,1366.8,percent of total billed charges,Implant Device,1366.8,34,,1366.8,percent of total billed charges,Implant Device,1989.9,,,1989.9,Other,110% of Medicare,1407,35,,1407,percent of total billed charges,Implant Device,1366.8,34,"Charges > $500, x 34%",1366.8,percent of total billed charges,Implant Device,1407,35,,1407,percent of total billed charges,Implant Device,1407,35,,1407,percent of total billed charges,Implant Device,1407,35,,1407,percent of total billed charges,Implant Device,1407,35,,1407,percent of total billed charges,Implant Device,1407,35,,1407,percent of total billed charges,Implant Device,1608,40,,1608,percent of total billed charges,Implant Device,1407,70,,1407,percent of total billed charges,All Other,1366.8,34,,1366.8,percent of total billed charges,Implant Device,1366.8,34,,1366.8,percent of total billed charges,Implant Device,1407,35,,1407,percent of total billed charges,Implant Device,1407,35,,1407,percent of total billed charges,Implant Device,1407,35,,1407,percent of total billed charges,Implant Device,1407,35,,1407,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1366.8,34,"If Charge > 2,000, then 34 percent",1366.8,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2974.81,
DEPUY 1987-27-012 TIB INS HINGE XXS 12MM,C1713,HCPCS,,79003952,CDM,278,RC,,,both,,,11227,8308.01,,,8308.01,Other,150% of Medicare + 9.63% HCRA Surcharge,5052.15,45,,5052.15,percent of total billed charges,Critical Access Hospital RCC factor,3817.18,34,,3817.18,percent of total billed charges,Implant Device,3817.18,34,,3817.18,percent of total billed charges,Implant Device,3817.18,34,,3817.18,percent of total billed charges,Implant Device,3817.18,34,,3817.18,percent of total billed charges,Implant Device,3817.18,34,,3817.18,percent of total billed charges,Implant Device,5557.37,,,5557.37,Other,110% of Medicare,3929.45,35,,3929.45,percent of total billed charges,Implant Device,3817.18,34,"Charges > $500, x 34%",3817.18,percent of total billed charges,Implant Device,3929.45,35,,3929.45,percent of total billed charges,Implant Device,3929.45,35,,3929.45,percent of total billed charges,Implant Device,3929.45,35,,3929.45,percent of total billed charges,Implant Device,3929.45,35,,3929.45,percent of total billed charges,Implant Device,3929.45,35,,3929.45,percent of total billed charges,Implant Device,4490.8,40,,4490.8,percent of total billed charges,Implant Device,3929.45,70,,3929.45,percent of total billed charges,All Other,3817.18,34,,3817.18,percent of total billed charges,Implant Device,3817.18,34,,3817.18,percent of total billed charges,Implant Device,3929.45,35,,3929.45,percent of total billed charges,Implant Device,3929.45,35,,3929.45,percent of total billed charges,Implant Device,3929.45,35,,3929.45,percent of total billed charges,Implant Device,3929.45,35,,3929.45,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3817.18,34,"If Charge > 2,000, then 34 percent",3817.18,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,8308.01,
DEPUY 1987-27-118 TIB INS HINGE 18MM,C1713,HCPCS,,79003953,CDM,278,RC,,,both,,,10692,7912.11,,,7912.11,Other,150% of Medicare + 9.63% HCRA Surcharge,4811.4,45,,4811.4,percent of total billed charges,Critical Access Hospital RCC factor,3635.28,34,,3635.28,percent of total billed charges,Implant Device,3635.28,34,,3635.28,percent of total billed charges,Implant Device,3635.28,34,,3635.28,percent of total billed charges,Implant Device,3635.28,34,,3635.28,percent of total billed charges,Implant Device,3635.28,34,,3635.28,percent of total billed charges,Implant Device,5292.54,,,5292.54,Other,110% of Medicare,3742.2,35,,3742.2,percent of total billed charges,Implant Device,3635.28,34,"Charges > $500, x 34%",3635.28,percent of total billed charges,Implant Device,3742.2,35,,3742.2,percent of total billed charges,Implant Device,3742.2,35,,3742.2,percent of total billed charges,Implant Device,3742.2,35,,3742.2,percent of total billed charges,Implant Device,3742.2,35,,3742.2,percent of total billed charges,Implant Device,3742.2,35,,3742.2,percent of total billed charges,Implant Device,4276.8,40,,4276.8,percent of total billed charges,Implant Device,3742.2,70,,3742.2,percent of total billed charges,All Other,3635.28,34,,3635.28,percent of total billed charges,Implant Device,3635.28,34,,3635.28,percent of total billed charges,Implant Device,3742.2,35,,3742.2,percent of total billed charges,Implant Device,3742.2,35,,3742.2,percent of total billed charges,Implant Device,3742.2,35,,3742.2,percent of total billed charges,Implant Device,3742.2,35,,3742.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3635.28,34,"If Charge > 2,000, then 34 percent",3635.28,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,7912.11,
DEPUY 1570-11-100 HIP SYS 12/14SZ4 140MM,C1776,HCPCS,,79003954,CDM,278,RC,,,both,,,10469,7747.09,,,7747.09,Other,150% of Medicare + 9.63% HCRA Surcharge,4711.05,45,,4711.05,percent of total billed charges,Critical Access Hospital RCC factor,3559.46,34,,3559.46,percent of total billed charges,Implant Device,3559.46,34,,3559.46,percent of total billed charges,Implant Device,3559.46,34,,3559.46,percent of total billed charges,Implant Device,3559.46,34,,3559.46,percent of total billed charges,Implant Device,3559.46,34,,3559.46,percent of total billed charges,Implant Device,5182.16,,,5182.16,Other,110% of Medicare,3664.15,35,,3664.15,percent of total billed charges,Implant Device,3559.46,34,"Charges > $500, x 34%",3559.46,percent of total billed charges,Implant Device,3664.15,35,,3664.15,percent of total billed charges,Implant Device,3664.15,35,,3664.15,percent of total billed charges,Implant Device,3664.15,35,,3664.15,percent of total billed charges,Implant Device,3664.15,35,,3664.15,percent of total billed charges,Implant Device,3664.15,35,,3664.15,percent of total billed charges,Implant Device,4187.6,40,,4187.6,percent of total billed charges,Implant Device,3664.15,70,,3664.15,percent of total billed charges,All Other,3559.46,34,,3559.46,percent of total billed charges,Implant Device,3559.46,34,,3559.46,percent of total billed charges,Implant Device,3664.15,35,,3664.15,percent of total billed charges,Implant Device,3664.15,35,,3664.15,percent of total billed charges,Implant Device,3664.15,35,,3664.15,percent of total billed charges,Implant Device,3664.15,35,,3664.15,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3559.46,34,"If Charge > 2,000, then 34 percent",3559.46,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,7747.09,
DEPUY 8141-33-011 POLY TIB PLATE 11 HOLE,C1713,HCPCS,,79003955,CDM,278,RC,,,both,,,7320,5416.82,,,5416.82,Other,150% of Medicare + 9.63% HCRA Surcharge,3294,45,,3294,percent of total billed charges,Critical Access Hospital RCC factor,2488.8,34,,2488.8,percent of total billed charges,Implant Device,2488.8,34,,2488.8,percent of total billed charges,Implant Device,2488.8,34,,2488.8,percent of total billed charges,Implant Device,2488.8,34,,2488.8,percent of total billed charges,Implant Device,2488.8,34,,2488.8,percent of total billed charges,Implant Device,3623.4,,,3623.4,Other,110% of Medicare,2562,35,,2562,percent of total billed charges,Implant Device,2488.8,34,"Charges > $500, x 34%",2488.8,percent of total billed charges,Implant Device,2562,35,,2562,percent of total billed charges,Implant Device,2562,35,,2562,percent of total billed charges,Implant Device,2562,35,,2562,percent of total billed charges,Implant Device,2562,35,,2562,percent of total billed charges,Implant Device,2562,35,,2562,percent of total billed charges,Implant Device,2928,40,,2928,percent of total billed charges,Implant Device,2562,70,,2562,percent of total billed charges,All Other,2488.8,34,,2488.8,percent of total billed charges,Implant Device,2488.8,34,,2488.8,percent of total billed charges,Implant Device,2562,35,,2562,percent of total billed charges,Implant Device,2562,35,,2562,percent of total billed charges,Implant Device,2562,35,,2562,percent of total billed charges,Implant Device,2562,35,,2562,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2488.8,34,"If Charge > 2,000, then 34 percent",2488.8,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5416.82,
DEPUY NLSS 90 DEG LOCK SCREW SET,C1713,HCPCS,,79003956,CDM,278,RC,,,both,,,241,178.34,,,178.34,Other,150% of Medicare + 9.63% HCRA Surcharge,108.45,45,,108.45,percent of total billed charges,Critical Access Hospital RCC factor,81.94,34,,81.94,percent of total billed charges,Implant Device,81.94,34,,81.94,percent of total billed charges,Implant Device,81.94,34,,81.94,percent of total billed charges,Implant Device,81.94,34,,81.94,percent of total billed charges,Implant Device,81.94,34,,81.94,percent of total billed charges,Implant Device,119.3,,,119.3,Other,110% of Medicare,84.35,35,,84.35,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,84.35,35,,84.35,percent of total billed charges,Implant Device,84.35,35,,84.35,percent of total billed charges,Implant Device,84.35,35,,84.35,percent of total billed charges,Implant Device,84.35,35,,84.35,percent of total billed charges,Implant Device,84.35,35,,84.35,percent of total billed charges,Implant Device,96.4,40,,96.4,percent of total billed charges,Implant Device,84.35,70,,84.35,percent of total billed charges,All Other,81.94,34,,81.94,percent of total billed charges,Implant Device,81.94,34,,81.94,percent of total billed charges,Implant Device,84.35,35,,84.35,percent of total billed charges,Implant Device,84.35,35,,84.35,percent of total billed charges,Implant Device,84.35,35,,84.35,percent of total billed charges,Implant Device,84.35,35,,84.35,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,178.34,
DEPUY MD28 MULTI DIR SCREW 3.8X28MM,C1713,HCPCS,,79003957,CDM,278,RC,,,both,,,540,399.6,,,399.6,Other,150% of Medicare + 9.63% HCRA Surcharge,243,45,,243,percent of total billed charges,Critical Access Hospital RCC factor,183.6,34,,183.6,percent of total billed charges,Implant Device,183.6,34,,183.6,percent of total billed charges,Implant Device,183.6,34,,183.6,percent of total billed charges,Implant Device,183.6,34,,183.6,percent of total billed charges,Implant Device,183.6,34,,183.6,percent of total billed charges,Implant Device,267.3,,,267.3,Other,110% of Medicare,189,35,,189,percent of total billed charges,Implant Device,183.6,34,"Charges > $500, x 34%",183.6,percent of total billed charges,Implant Device,189,35,,189,percent of total billed charges,Implant Device,189,35,,189,percent of total billed charges,Implant Device,189,35,,189,percent of total billed charges,Implant Device,189,35,,189,percent of total billed charges,Implant Device,189,35,,189,percent of total billed charges,Implant Device,216,40,,216,percent of total billed charges,Implant Device,189,70,,189,percent of total billed charges,All Other,183.6,34,,183.6,percent of total billed charges,Implant Device,183.6,34,,183.6,percent of total billed charges,Implant Device,189,35,,189,percent of total billed charges,Implant Device,189,35,,189,percent of total billed charges,Implant Device,189,35,,189,percent of total billed charges,Implant Device,189,35,,189,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,399.6,
DEPUY 1312-18036 CORT SCREW 3.5X36MM,C1713,HCPCS,,79003958,CDM,278,RC,,,both,,,300,222,,,222,Other,150% of Medicare + 9.63% HCRA Surcharge,135,45,,135,percent of total billed charges,Critical Access Hospital RCC factor,102,34,,102,percent of total billed charges,Implant Device,102,34,,102,percent of total billed charges,Implant Device,102,34,,102,percent of total billed charges,Implant Device,102,34,,102,percent of total billed charges,Implant Device,102,34,,102,percent of total billed charges,Implant Device,148.5,,,148.5,Other,110% of Medicare,105,35,,105,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,105,35,,105,percent of total billed charges,Implant Device,105,35,,105,percent of total billed charges,Implant Device,105,35,,105,percent of total billed charges,Implant Device,105,35,,105,percent of total billed charges,Implant Device,105,35,,105,percent of total billed charges,Implant Device,120,40,,120,percent of total billed charges,Implant Device,105,70,,105,percent of total billed charges,All Other,102,34,,102,percent of total billed charges,Implant Device,102,34,,102,percent of total billed charges,Implant Device,105,35,,105,percent of total billed charges,Implant Device,105,35,,105,percent of total billed charges,Implant Device,105,35,,105,percent of total billed charges,Implant Device,105,35,,105,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,222,
DEPUY 1221-36-152 POLY LINER 36X52MM,C1776,HCPCS,,79003959,CDM,278,RC,,,both,,,2565,1898.11,,,1898.11,Other,150% of Medicare + 9.63% HCRA Surcharge,1154.25,45,,1154.25,percent of total billed charges,Critical Access Hospital RCC factor,872.1,34,,872.1,percent of total billed charges,Implant Device,872.1,34,,872.1,percent of total billed charges,Implant Device,872.1,34,,872.1,percent of total billed charges,Implant Device,872.1,34,,872.1,percent of total billed charges,Implant Device,872.1,34,,872.1,percent of total billed charges,Implant Device,1269.68,,,1269.68,Other,110% of Medicare,897.75,35,,897.75,percent of total billed charges,Implant Device,872.1,34,"Charges > $500, x 34%",872.1,percent of total billed charges,Implant Device,897.75,35,,897.75,percent of total billed charges,Implant Device,897.75,35,,897.75,percent of total billed charges,Implant Device,897.75,35,,897.75,percent of total billed charges,Implant Device,897.75,35,,897.75,percent of total billed charges,Implant Device,897.75,35,,897.75,percent of total billed charges,Implant Device,1026,40,,1026,percent of total billed charges,Implant Device,897.75,70,,897.75,percent of total billed charges,All Other,872.1,34,,872.1,percent of total billed charges,Implant Device,872.1,34,,872.1,percent of total billed charges,Implant Device,897.75,35,,897.75,percent of total billed charges,Implant Device,897.75,35,,897.75,percent of total billed charges,Implant Device,897.75,35,,897.75,percent of total billed charges,Implant Device,897.75,35,,897.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,872.1,34,"If Charge > 2,000, then 34 percent",872.1,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1898.11,
DEPUY MD26 MULTI DIR SCREW 3.8X26MM,C1713,HCPCS,,79003960,CDM,278,RC,,,both,,,540,399.6,,,399.6,Other,150% of Medicare + 9.63% HCRA Surcharge,243,45,,243,percent of total billed charges,Critical Access Hospital RCC factor,183.6,34,,183.6,percent of total billed charges,Implant Device,183.6,34,,183.6,percent of total billed charges,Implant Device,183.6,34,,183.6,percent of total billed charges,Implant Device,183.6,34,,183.6,percent of total billed charges,Implant Device,183.6,34,,183.6,percent of total billed charges,Implant Device,267.3,,,267.3,Other,110% of Medicare,189,35,,189,percent of total billed charges,Implant Device,183.6,34,"Charges > $500, x 34%",183.6,percent of total billed charges,Implant Device,189,35,,189,percent of total billed charges,Implant Device,189,35,,189,percent of total billed charges,Implant Device,189,35,,189,percent of total billed charges,Implant Device,189,35,,189,percent of total billed charges,Implant Device,189,35,,189,percent of total billed charges,Implant Device,216,40,,216,percent of total billed charges,Implant Device,189,70,,189,percent of total billed charges,All Other,183.6,34,,183.6,percent of total billed charges,Implant Device,183.6,34,,183.6,percent of total billed charges,Implant Device,189,35,,189,percent of total billed charges,Implant Device,189,35,,189,percent of total billed charges,Implant Device,189,35,,189,percent of total billed charges,Implant Device,189,35,,189,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,399.6,
DEPUY 1294-35-125 TIB TRAY SZ 2.5,C1776,HCPCS,,79003961,CDM,278,RC,,,both,,,11227,8308.01,,,8308.01,Other,150% of Medicare + 9.63% HCRA Surcharge,5052.15,45,,5052.15,percent of total billed charges,Critical Access Hospital RCC factor,3817.18,34,,3817.18,percent of total billed charges,Implant Device,3817.18,34,,3817.18,percent of total billed charges,Implant Device,3817.18,34,,3817.18,percent of total billed charges,Implant Device,3817.18,34,,3817.18,percent of total billed charges,Implant Device,3817.18,34,,3817.18,percent of total billed charges,Implant Device,5557.37,,,5557.37,Other,110% of Medicare,3929.45,35,,3929.45,percent of total billed charges,Implant Device,3817.18,34,"Charges > $500, x 34%",3817.18,percent of total billed charges,Implant Device,3929.45,35,,3929.45,percent of total billed charges,Implant Device,3929.45,35,,3929.45,percent of total billed charges,Implant Device,3929.45,35,,3929.45,percent of total billed charges,Implant Device,3929.45,35,,3929.45,percent of total billed charges,Implant Device,3929.45,35,,3929.45,percent of total billed charges,Implant Device,4490.8,40,,4490.8,percent of total billed charges,Implant Device,3929.45,70,,3929.45,percent of total billed charges,All Other,3817.18,34,,3817.18,percent of total billed charges,Implant Device,3817.18,34,,3817.18,percent of total billed charges,Implant Device,3929.45,35,,3929.45,percent of total billed charges,Implant Device,3929.45,35,,3929.45,percent of total billed charges,Implant Device,3929.45,35,,3929.45,percent of total billed charges,Implant Device,3929.45,35,,3929.45,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3817.18,34,"If Charge > 2,000, then 34 percent",3817.18,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,8308.01,
DEPUY 1035-48-000 BIPOLAR HEAD 28MM,C1776,HCPCS,,79003962,CDM,278,RC,,,both,,,4030,2982.21,,,2982.21,Other,150% of Medicare + 9.63% HCRA Surcharge,1813.5,45,,1813.5,percent of total billed charges,Critical Access Hospital RCC factor,1370.2,34,,1370.2,percent of total billed charges,Implant Device,1370.2,34,,1370.2,percent of total billed charges,Implant Device,1370.2,34,,1370.2,percent of total billed charges,Implant Device,1370.2,34,,1370.2,percent of total billed charges,Implant Device,1370.2,34,,1370.2,percent of total billed charges,Implant Device,1994.85,,,1994.85,Other,110% of Medicare,1410.5,35,,1410.5,percent of total billed charges,Implant Device,1370.2,34,"Charges > $500, x 34%",1370.2,percent of total billed charges,Implant Device,1410.5,35,,1410.5,percent of total billed charges,Implant Device,1410.5,35,,1410.5,percent of total billed charges,Implant Device,1410.5,35,,1410.5,percent of total billed charges,Implant Device,1410.5,35,,1410.5,percent of total billed charges,Implant Device,1410.5,35,,1410.5,percent of total billed charges,Implant Device,1612,40,,1612,percent of total billed charges,Implant Device,1410.5,70,,1410.5,percent of total billed charges,All Other,1370.2,34,,1370.2,percent of total billed charges,Implant Device,1370.2,34,,1370.2,percent of total billed charges,Implant Device,1410.5,35,,1410.5,percent of total billed charges,Implant Device,1410.5,35,,1410.5,percent of total billed charges,Implant Device,1410.5,35,,1410.5,percent of total billed charges,Implant Device,1410.5,35,,1410.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1370.2,34,"If Charge > 2,000, then 34 percent",1370.2,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2982.21,
DEPUY 1035-55-000 BIPOLAR HEAD 28X55MM,C1776,HCPCS,,79003963,CDM,278,RC,,,both,,,1733,1282.42,,,1282.42,Other,150% of Medicare + 9.63% HCRA Surcharge,779.85,45,,779.85,percent of total billed charges,Critical Access Hospital RCC factor,589.22,34,,589.22,percent of total billed charges,Implant Device,589.22,34,,589.22,percent of total billed charges,Implant Device,589.22,34,,589.22,percent of total billed charges,Implant Device,589.22,34,,589.22,percent of total billed charges,Implant Device,589.22,34,,589.22,percent of total billed charges,Implant Device,857.84,,,857.84,Other,110% of Medicare,606.55,35,,606.55,percent of total billed charges,Implant Device,589.22,34,"Charges > $500, x 34%",589.22,percent of total billed charges,Implant Device,606.55,35,,606.55,percent of total billed charges,Implant Device,606.55,35,,606.55,percent of total billed charges,Implant Device,606.55,35,,606.55,percent of total billed charges,Implant Device,606.55,35,,606.55,percent of total billed charges,Implant Device,606.55,35,,606.55,percent of total billed charges,Implant Device,693.2,40,,693.2,percent of total billed charges,Implant Device,606.55,70,,606.55,percent of total billed charges,All Other,589.22,34,,589.22,percent of total billed charges,Implant Device,589.22,34,,589.22,percent of total billed charges,Implant Device,606.55,35,,606.55,percent of total billed charges,Implant Device,606.55,35,,606.55,percent of total billed charges,Implant Device,606.55,35,,606.55,percent of total billed charges,Implant Device,606.55,35,,606.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1282.42,
DEPUY 9215905 SCREW 1.5X5MM NEW HEAD,C1713,HCPCS,,79003964,CDM,278,RC,,,both,,,215,159.1,,,159.1,Other,150% of Medicare + 9.63% HCRA Surcharge,96.75,45,,96.75,percent of total billed charges,Critical Access Hospital RCC factor,73.1,34,,73.1,percent of total billed charges,Implant Device,73.1,34,,73.1,percent of total billed charges,Implant Device,73.1,34,,73.1,percent of total billed charges,Implant Device,73.1,34,,73.1,percent of total billed charges,Implant Device,73.1,34,,73.1,percent of total billed charges,Implant Device,106.43,,,106.43,Other,110% of Medicare,75.25,35,,75.25,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,75.25,35,,75.25,percent of total billed charges,Implant Device,75.25,35,,75.25,percent of total billed charges,Implant Device,75.25,35,,75.25,percent of total billed charges,Implant Device,75.25,35,,75.25,percent of total billed charges,Implant Device,75.25,35,,75.25,percent of total billed charges,Implant Device,86,40,,86,percent of total billed charges,Implant Device,75.25,70,,75.25,percent of total billed charges,All Other,73.1,34,,73.1,percent of total billed charges,Implant Device,73.1,34,,73.1,percent of total billed charges,Implant Device,75.25,35,,75.25,percent of total billed charges,Implant Device,75.25,35,,75.25,percent of total billed charges,Implant Device,75.25,35,,75.25,percent of total billed charges,Implant Device,75.25,35,,75.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,159.1,
STRYKER 6276-7-216 HIP STEM 195X16MM,C1776,HCPCS,,79003965,CDM,278,RC,,,both,,,15612,11552.92,,,11552.92,Other,150% of Medicare + 9.63% HCRA Surcharge,7025.4,45,,7025.4,percent of total billed charges,Critical Access Hospital RCC factor,5308.08,34,,5308.08,percent of total billed charges,Implant Device,5308.08,34,,5308.08,percent of total billed charges,Implant Device,5308.08,34,,5308.08,percent of total billed charges,Implant Device,5308.08,34,,5308.08,percent of total billed charges,Implant Device,5308.08,34,,5308.08,percent of total billed charges,Implant Device,7727.94,,,7727.94,Other,110% of Medicare,5464.2,35,,5464.2,percent of total billed charges,Implant Device,5308.08,34,"Charges > $500, x 34%",5308.08,percent of total billed charges,Implant Device,5464.2,35,,5464.2,percent of total billed charges,Implant Device,5464.2,35,,5464.2,percent of total billed charges,Implant Device,5464.2,35,,5464.2,percent of total billed charges,Implant Device,5464.2,35,,5464.2,percent of total billed charges,Implant Device,5464.2,35,,5464.2,percent of total billed charges,Implant Device,6244.8,40,,6244.8,percent of total billed charges,Implant Device,5464.2,70,,5464.2,percent of total billed charges,All Other,5308.08,34,,5308.08,percent of total billed charges,Implant Device,5308.08,34,,5308.08,percent of total billed charges,Implant Device,5464.2,35,,5464.2,percent of total billed charges,Implant Device,5464.2,35,,5464.2,percent of total billed charges,Implant Device,5464.2,35,,5464.2,percent of total billed charges,Implant Device,5464.2,35,,5464.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,5308.08,34,"If Charge > 2,000, then 34 percent",5308.08,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,11552.92,
STRYKER 629366 PLATE OLECRANON 6 HOLE RT,C1713,HCPCS,,79003967,CDM,278,RC,,,both,,,3697,2735.79,,,2735.79,Other,150% of Medicare + 9.63% HCRA Surcharge,1663.65,45,,1663.65,percent of total billed charges,Critical Access Hospital RCC factor,1256.98,34,,1256.98,percent of total billed charges,Implant Device,1256.98,34,,1256.98,percent of total billed charges,Implant Device,1256.98,34,,1256.98,percent of total billed charges,Implant Device,1256.98,34,,1256.98,percent of total billed charges,Implant Device,1256.98,34,,1256.98,percent of total billed charges,Implant Device,1830.02,,,1830.02,Other,110% of Medicare,1293.95,35,,1293.95,percent of total billed charges,Implant Device,1256.98,34,"Charges > $500, x 34%",1256.98,percent of total billed charges,Implant Device,1293.95,35,,1293.95,percent of total billed charges,Implant Device,1293.95,35,,1293.95,percent of total billed charges,Implant Device,1293.95,35,,1293.95,percent of total billed charges,Implant Device,1293.95,35,,1293.95,percent of total billed charges,Implant Device,1293.95,35,,1293.95,percent of total billed charges,Implant Device,1478.8,40,,1478.8,percent of total billed charges,Implant Device,1293.95,70,,1293.95,percent of total billed charges,All Other,1256.98,34,,1256.98,percent of total billed charges,Implant Device,1256.98,34,,1256.98,percent of total billed charges,Implant Device,1293.95,35,,1293.95,percent of total billed charges,Implant Device,1293.95,35,,1293.95,percent of total billed charges,Implant Device,1293.95,35,,1293.95,percent of total billed charges,Implant Device,1293.95,35,,1293.95,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1256.98,34,"If Charge > 2,000, then 34 percent",1256.98,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2735.79,
STRYKER 614824 NON LOCK SCREW 3.5X24MM,C1713,HCPCS,,79003968,CDM,278,RC,,,both,,,375,277.5,,,277.5,Other,150% of Medicare + 9.63% HCRA Surcharge,168.75,45,,168.75,percent of total billed charges,Critical Access Hospital RCC factor,127.5,34,,127.5,percent of total billed charges,Implant Device,127.5,34,,127.5,percent of total billed charges,Implant Device,127.5,34,,127.5,percent of total billed charges,Implant Device,127.5,34,,127.5,percent of total billed charges,Implant Device,127.5,34,,127.5,percent of total billed charges,Implant Device,185.63,,,185.63,Other,110% of Medicare,131.25,35,,131.25,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,131.25,35,,131.25,percent of total billed charges,Implant Device,131.25,35,,131.25,percent of total billed charges,Implant Device,131.25,35,,131.25,percent of total billed charges,Implant Device,131.25,35,,131.25,percent of total billed charges,Implant Device,131.25,35,,131.25,percent of total billed charges,Implant Device,150,40,,150,percent of total billed charges,Implant Device,131.25,70,,131.25,percent of total billed charges,All Other,127.5,34,,127.5,percent of total billed charges,Implant Device,127.5,34,,127.5,percent of total billed charges,Implant Device,131.25,35,,131.25,percent of total billed charges,Implant Device,131.25,35,,131.25,percent of total billed charges,Implant Device,131.25,35,,131.25,percent of total billed charges,Implant Device,131.25,35,,131.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,277.5,
STRYKER 614816 NON LOCK SCREW 3.5X16MM,C1713,HCPCS,,79003969,CDM,278,RC,,,both,,,374,276.76,,,276.76,Other,150% of Medicare + 9.63% HCRA Surcharge,168.3,45,,168.3,percent of total billed charges,Critical Access Hospital RCC factor,127.16,34,,127.16,percent of total billed charges,Implant Device,127.16,34,,127.16,percent of total billed charges,Implant Device,127.16,34,,127.16,percent of total billed charges,Implant Device,127.16,34,,127.16,percent of total billed charges,Implant Device,127.16,34,,127.16,percent of total billed charges,Implant Device,185.13,,,185.13,Other,110% of Medicare,130.9,35,,130.9,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,130.9,35,,130.9,percent of total billed charges,Implant Device,130.9,35,,130.9,percent of total billed charges,Implant Device,130.9,35,,130.9,percent of total billed charges,Implant Device,130.9,35,,130.9,percent of total billed charges,Implant Device,130.9,35,,130.9,percent of total billed charges,Implant Device,149.6,40,,149.6,percent of total billed charges,Implant Device,130.9,70,,130.9,percent of total billed charges,All Other,127.16,34,,127.16,percent of total billed charges,Implant Device,127.16,34,,127.16,percent of total billed charges,Implant Device,130.9,35,,130.9,percent of total billed charges,Implant Device,130.9,35,,130.9,percent of total billed charges,Implant Device,130.9,35,,130.9,percent of total billed charges,Implant Device,130.9,35,,130.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,276.76,
STRYKER 614626 LOCKING SCREW 3.5X26MM,C1713,HCPCS,,79003970,CDM,278,RC,,,both,,,574,424.76,,,424.76,Other,150% of Medicare + 9.63% HCRA Surcharge,258.3,45,,258.3,percent of total billed charges,Critical Access Hospital RCC factor,195.16,34,,195.16,percent of total billed charges,Implant Device,195.16,34,,195.16,percent of total billed charges,Implant Device,195.16,34,,195.16,percent of total billed charges,Implant Device,195.16,34,,195.16,percent of total billed charges,Implant Device,195.16,34,,195.16,percent of total billed charges,Implant Device,284.13,,,284.13,Other,110% of Medicare,200.9,35,,200.9,percent of total billed charges,Implant Device,195.16,34,"Charges > $500, x 34%",195.16,percent of total billed charges,Implant Device,200.9,35,,200.9,percent of total billed charges,Implant Device,200.9,35,,200.9,percent of total billed charges,Implant Device,200.9,35,,200.9,percent of total billed charges,Implant Device,200.9,35,,200.9,percent of total billed charges,Implant Device,200.9,35,,200.9,percent of total billed charges,Implant Device,229.6,40,,229.6,percent of total billed charges,Implant Device,200.9,70,,200.9,percent of total billed charges,All Other,195.16,34,,195.16,percent of total billed charges,Implant Device,195.16,34,,195.16,percent of total billed charges,Implant Device,200.9,35,,200.9,percent of total billed charges,Implant Device,200.9,35,,200.9,percent of total billed charges,Implant Device,200.9,35,,200.9,percent of total billed charges,Implant Device,200.9,35,,200.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,424.76,
STRYKER 614560 LOCKING SCREW 2.7X60MM,C1713,HCPCS,,79003971,CDM,278,RC,,,both,,,653,483.22,,,483.22,Other,150% of Medicare + 9.63% HCRA Surcharge,293.85,45,,293.85,percent of total billed charges,Critical Access Hospital RCC factor,222.02,34,,222.02,percent of total billed charges,Implant Device,222.02,34,,222.02,percent of total billed charges,Implant Device,222.02,34,,222.02,percent of total billed charges,Implant Device,222.02,34,,222.02,percent of total billed charges,Implant Device,222.02,34,,222.02,percent of total billed charges,Implant Device,323.24,,,323.24,Other,110% of Medicare,228.55,35,,228.55,percent of total billed charges,Implant Device,222.02,34,"Charges > $500, x 34%",222.02,percent of total billed charges,Implant Device,228.55,35,,228.55,percent of total billed charges,Implant Device,228.55,35,,228.55,percent of total billed charges,Implant Device,228.55,35,,228.55,percent of total billed charges,Implant Device,228.55,35,,228.55,percent of total billed charges,Implant Device,228.55,35,,228.55,percent of total billed charges,Implant Device,261.2,40,,261.2,percent of total billed charges,Implant Device,228.55,70,,228.55,percent of total billed charges,All Other,222.02,34,,222.02,percent of total billed charges,Implant Device,222.02,34,,222.02,percent of total billed charges,Implant Device,228.55,35,,228.55,percent of total billed charges,Implant Device,228.55,35,,228.55,percent of total billed charges,Implant Device,228.55,35,,228.55,percent of total billed charges,Implant Device,228.55,35,,228.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,483.22,
DEPUY 8145-10-105 LAG SCREW 10.5X105MM,C1713,HCPCS,,79003974,CDM,278,RC,,,both,,,2052,1518.49,,,1518.49,Other,150% of Medicare + 9.63% HCRA Surcharge,923.4,45,,923.4,percent of total billed charges,Critical Access Hospital RCC factor,697.68,34,,697.68,percent of total billed charges,Implant Device,697.68,34,,697.68,percent of total billed charges,Implant Device,697.68,34,,697.68,percent of total billed charges,Implant Device,697.68,34,,697.68,percent of total billed charges,Implant Device,697.68,34,,697.68,percent of total billed charges,Implant Device,1015.74,,,1015.74,Other,110% of Medicare,718.2,35,,718.2,percent of total billed charges,Implant Device,697.68,34,"Charges > $500, x 34%",697.68,percent of total billed charges,Implant Device,718.2,35,,718.2,percent of total billed charges,Implant Device,718.2,35,,718.2,percent of total billed charges,Implant Device,718.2,35,,718.2,percent of total billed charges,Implant Device,718.2,35,,718.2,percent of total billed charges,Implant Device,718.2,35,,718.2,percent of total billed charges,Implant Device,820.8,40,,820.8,percent of total billed charges,Implant Device,718.2,70,,718.2,percent of total billed charges,All Other,697.68,34,,697.68,percent of total billed charges,Implant Device,697.68,34,,697.68,percent of total billed charges,Implant Device,718.2,35,,718.2,percent of total billed charges,Implant Device,718.2,35,,718.2,percent of total billed charges,Implant Device,718.2,35,,718.2,percent of total billed charges,Implant Device,718.2,35,,718.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,697.68,34,"If Charge > 2,000, then 34 percent",697.68,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1518.49,
DEPUY 1365-12-000 ATRICULEZE FEM HD 28MM,C1776,HCPCS,,79003975,CDM,278,RC,,,both,,,1856,1373.44,,,1373.44,Other,150% of Medicare + 9.63% HCRA Surcharge,835.2,45,,835.2,percent of total billed charges,Critical Access Hospital RCC factor,631.04,34,,631.04,percent of total billed charges,Implant Device,631.04,34,,631.04,percent of total billed charges,Implant Device,631.04,34,,631.04,percent of total billed charges,Implant Device,631.04,34,,631.04,percent of total billed charges,Implant Device,631.04,34,,631.04,percent of total billed charges,Implant Device,918.72,,,918.72,Other,110% of Medicare,649.6,35,,649.6,percent of total billed charges,Implant Device,631.04,34,"Charges > $500, x 34%",631.04,percent of total billed charges,Implant Device,649.6,35,,649.6,percent of total billed charges,Implant Device,649.6,35,,649.6,percent of total billed charges,Implant Device,649.6,35,,649.6,percent of total billed charges,Implant Device,649.6,35,,649.6,percent of total billed charges,Implant Device,649.6,35,,649.6,percent of total billed charges,Implant Device,742.4,40,,742.4,percent of total billed charges,Implant Device,649.6,70,,649.6,percent of total billed charges,All Other,631.04,34,,631.04,percent of total billed charges,Implant Device,631.04,34,,631.04,percent of total billed charges,Implant Device,649.6,35,,649.6,percent of total billed charges,Implant Device,649.6,35,,649.6,percent of total billed charges,Implant Device,649.6,35,,649.6,percent of total billed charges,Implant Device,649.6,35,,649.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1373.44,
DEPUY 1312-18-065 CORT SCREW 3.5X65MM,C1713,HCPCS,,79003976,CDM,278,RC,,,both,,,300,222,,,222,Other,150% of Medicare + 9.63% HCRA Surcharge,135,45,,135,percent of total billed charges,Critical Access Hospital RCC factor,102,34,,102,percent of total billed charges,Implant Device,102,34,,102,percent of total billed charges,Implant Device,102,34,,102,percent of total billed charges,Implant Device,102,34,,102,percent of total billed charges,Implant Device,102,34,,102,percent of total billed charges,Implant Device,148.5,,,148.5,Other,110% of Medicare,105,35,,105,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,105,35,,105,percent of total billed charges,Implant Device,105,35,,105,percent of total billed charges,Implant Device,105,35,,105,percent of total billed charges,Implant Device,105,35,,105,percent of total billed charges,Implant Device,105,35,,105,percent of total billed charges,Implant Device,120,40,,120,percent of total billed charges,Implant Device,105,70,,105,percent of total billed charges,All Other,102,34,,102,percent of total billed charges,Implant Device,102,34,,102,percent of total billed charges,Implant Device,105,35,,105,percent of total billed charges,Implant Device,105,35,,105,percent of total billed charges,Implant Device,105,35,,105,percent of total billed charges,Implant Device,105,35,,105,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,222,
DEPUY 1987-07-025 SEGMENTED COMP 25MM,C1776,HCPCS,,79003977,CDM,278,RC,,,both,,,5969,4417.07,,,4417.07,Other,150% of Medicare + 9.63% HCRA Surcharge,2686.05,45,,2686.05,percent of total billed charges,Critical Access Hospital RCC factor,2029.46,34,,2029.46,percent of total billed charges,Implant Device,2029.46,34,,2029.46,percent of total billed charges,Implant Device,2029.46,34,,2029.46,percent of total billed charges,Implant Device,2029.46,34,,2029.46,percent of total billed charges,Implant Device,2029.46,34,,2029.46,percent of total billed charges,Implant Device,2954.66,,,2954.66,Other,110% of Medicare,2089.15,35,,2089.15,percent of total billed charges,Implant Device,2029.46,34,"Charges > $500, x 34%",2029.46,percent of total billed charges,Implant Device,2089.15,35,,2089.15,percent of total billed charges,Implant Device,2089.15,35,,2089.15,percent of total billed charges,Implant Device,2089.15,35,,2089.15,percent of total billed charges,Implant Device,2089.15,35,,2089.15,percent of total billed charges,Implant Device,2089.15,35,,2089.15,percent of total billed charges,Implant Device,2387.6,40,,2387.6,percent of total billed charges,Implant Device,2089.15,70,,2089.15,percent of total billed charges,All Other,2029.46,34,,2029.46,percent of total billed charges,Implant Device,2029.46,34,,2029.46,percent of total billed charges,Implant Device,2089.15,35,,2089.15,percent of total billed charges,Implant Device,2089.15,35,,2089.15,percent of total billed charges,Implant Device,2089.15,35,,2089.15,percent of total billed charges,Implant Device,2089.15,35,,2089.15,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2029.46,34,"If Charge > 2,000, then 34 percent",2029.46,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4417.07,
DEPUY 8153-55-070 POLY LCK SCREW 55X70MM,C1713,HCPCS,,79003978,CDM,278,RC,,,both,,,630,466.2,,,466.2,Other,150% of Medicare + 9.63% HCRA Surcharge,283.5,45,,283.5,percent of total billed charges,Critical Access Hospital RCC factor,214.2,34,,214.2,percent of total billed charges,Implant Device,214.2,34,,214.2,percent of total billed charges,Implant Device,214.2,34,,214.2,percent of total billed charges,Implant Device,214.2,34,,214.2,percent of total billed charges,Implant Device,214.2,34,,214.2,percent of total billed charges,Implant Device,311.85,,,311.85,Other,110% of Medicare,220.5,35,,220.5,percent of total billed charges,Implant Device,214.2,34,"Charges > $500, x 34%",214.2,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,252,40,,252,percent of total billed charges,Implant Device,220.5,70,,220.5,percent of total billed charges,All Other,214.2,34,,214.2,percent of total billed charges,Implant Device,214.2,34,,214.2,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,466.2,
DEPUY 1312-17-003 SM FRAG LOCKING PLATE,C1713,HCPCS,,79003979,CDM,278,RC,,,both,,,2700,1998.01,,,1998.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1215,45,,1215,percent of total billed charges,Critical Access Hospital RCC factor,918,34,,918,percent of total billed charges,Implant Device,918,34,,918,percent of total billed charges,Implant Device,918,34,,918,percent of total billed charges,Implant Device,918,34,,918,percent of total billed charges,Implant Device,918,34,,918,percent of total billed charges,Implant Device,1336.5,,,1336.5,Other,110% of Medicare,945,35,,945,percent of total billed charges,Implant Device,918,34,"Charges > $500, x 34%",918,percent of total billed charges,Implant Device,945,35,,945,percent of total billed charges,Implant Device,945,35,,945,percent of total billed charges,Implant Device,945,35,,945,percent of total billed charges,Implant Device,945,35,,945,percent of total billed charges,Implant Device,945,35,,945,percent of total billed charges,Implant Device,1080,40,,1080,percent of total billed charges,Implant Device,945,70,,945,percent of total billed charges,All Other,918,34,,918,percent of total billed charges,Implant Device,918,34,,918,percent of total billed charges,Implant Device,945,35,,945,percent of total billed charges,Implant Device,945,35,,945,percent of total billed charges,Implant Device,945,35,,945,percent of total billed charges,Implant Device,945,35,,945,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,918,34,"If Charge > 2,000, then 34 percent",918,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1998.01,
DEPUY 8145-50-0470 BONE SCREW 5X40MM,C1713,HCPCS,,79003980,CDM,278,RC,,,both,,,646,478.04,,,478.04,Other,150% of Medicare + 9.63% HCRA Surcharge,290.7,45,,290.7,percent of total billed charges,Critical Access Hospital RCC factor,219.64,34,,219.64,percent of total billed charges,Implant Device,219.64,34,,219.64,percent of total billed charges,Implant Device,219.64,34,,219.64,percent of total billed charges,Implant Device,219.64,34,,219.64,percent of total billed charges,Implant Device,219.64,34,,219.64,percent of total billed charges,Implant Device,319.77,,,319.77,Other,110% of Medicare,226.1,35,,226.1,percent of total billed charges,Implant Device,219.64,34,"Charges > $500, x 34%",219.64,percent of total billed charges,Implant Device,226.1,35,,226.1,percent of total billed charges,Implant Device,226.1,35,,226.1,percent of total billed charges,Implant Device,226.1,35,,226.1,percent of total billed charges,Implant Device,226.1,35,,226.1,percent of total billed charges,Implant Device,226.1,35,,226.1,percent of total billed charges,Implant Device,258.4,40,,258.4,percent of total billed charges,Implant Device,226.1,70,,226.1,percent of total billed charges,All Other,219.64,34,,219.64,percent of total billed charges,Implant Device,219.64,34,,219.64,percent of total billed charges,Implant Device,226.1,35,,226.1,percent of total billed charges,Implant Device,226.1,35,,226.1,percent of total billed charges,Implant Device,226.1,35,,226.1,percent of total billed charges,Implant Device,226.1,35,,226.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,478.04,
EV3 EHG-02P H-GENIN PUTTY 2.5CC,C1713,HCPCS,,79003981,CDM,278,RC,,,both,,,1036,766.64,,,766.64,Other,150% of Medicare + 9.63% HCRA Surcharge,466.2,45,,466.2,percent of total billed charges,Critical Access Hospital RCC factor,352.24,34,,352.24,percent of total billed charges,Implant Device,352.24,34,,352.24,percent of total billed charges,Implant Device,352.24,34,,352.24,percent of total billed charges,Implant Device,352.24,34,,352.24,percent of total billed charges,Implant Device,352.24,34,,352.24,percent of total billed charges,Implant Device,512.82,,,512.82,Other,110% of Medicare,362.6,35,,362.6,percent of total billed charges,Implant Device,352.24,34,"Charges > $500, x 34%",352.24,percent of total billed charges,Implant Device,362.6,35,,362.6,percent of total billed charges,Implant Device,362.6,35,,362.6,percent of total billed charges,Implant Device,362.6,35,,362.6,percent of total billed charges,Implant Device,362.6,35,,362.6,percent of total billed charges,Implant Device,362.6,35,,362.6,percent of total billed charges,Implant Device,414.4,40,,414.4,percent of total billed charges,Implant Device,362.6,70,,362.6,percent of total billed charges,All Other,352.24,34,,352.24,percent of total billed charges,Implant Device,352.24,34,,352.24,percent of total billed charges,Implant Device,362.6,35,,362.6,percent of total billed charges,Implant Device,362.6,35,,362.6,percent of total billed charges,Implant Device,362.6,35,,362.6,percent of total billed charges,Implant Device,362.6,35,,362.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,766.64,
EXACTECH SPS00 SHLDR KIT GENTA #1400/AG,C1713,HCPCS,,79003982,CDM,278,RC,,,both,,,10546,7804.07,,,7804.07,Other,150% of Medicare + 9.63% HCRA Surcharge,4745.7,45,,4745.7,percent of total billed charges,Critical Access Hospital RCC factor,3585.64,34,,3585.64,percent of total billed charges,Implant Device,3585.64,34,,3585.64,percent of total billed charges,Implant Device,3585.64,34,,3585.64,percent of total billed charges,Implant Device,3585.64,34,,3585.64,percent of total billed charges,Implant Device,3585.64,34,,3585.64,percent of total billed charges,Implant Device,5220.27,,,5220.27,Other,110% of Medicare,3691.1,35,,3691.1,percent of total billed charges,Implant Device,3585.64,34,"Charges > $500, x 34%",3585.64,percent of total billed charges,Implant Device,3691.1,35,,3691.1,percent of total billed charges,Implant Device,3691.1,35,,3691.1,percent of total billed charges,Implant Device,3691.1,35,,3691.1,percent of total billed charges,Implant Device,3691.1,35,,3691.1,percent of total billed charges,Implant Device,3691.1,35,,3691.1,percent of total billed charges,Implant Device,4218.4,40,,4218.4,percent of total billed charges,Implant Device,3691.1,70,,3691.1,percent of total billed charges,All Other,3585.64,34,,3585.64,percent of total billed charges,Implant Device,3585.64,34,,3585.64,percent of total billed charges,Implant Device,3691.1,35,,3691.1,percent of total billed charges,Implant Device,3691.1,35,,3691.1,percent of total billed charges,Implant Device,3691.1,35,,3691.1,percent of total billed charges,Implant Device,3691.1,35,,3691.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3585.64,34,"If Charge > 2,000, then 34 percent",3585.64,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,7804.07,
INTEGRA 330-217-SND 2 HOLE PLATE,C1713,HCPCS,,79003983,CDM,278,RC,,,both,,,5052,3738.49,,,3738.49,Other,150% of Medicare + 9.63% HCRA Surcharge,2273.4,45,,2273.4,percent of total billed charges,Critical Access Hospital RCC factor,1717.68,34,,1717.68,percent of total billed charges,Implant Device,1717.68,34,,1717.68,percent of total billed charges,Implant Device,1717.68,34,,1717.68,percent of total billed charges,Implant Device,1717.68,34,,1717.68,percent of total billed charges,Implant Device,1717.68,34,,1717.68,percent of total billed charges,Implant Device,2500.74,,,2500.74,Other,110% of Medicare,1768.2,35,,1768.2,percent of total billed charges,Implant Device,1717.68,34,"Charges > $500, x 34%",1717.68,percent of total billed charges,Implant Device,1768.2,35,,1768.2,percent of total billed charges,Implant Device,1768.2,35,,1768.2,percent of total billed charges,Implant Device,1768.2,35,,1768.2,percent of total billed charges,Implant Device,1768.2,35,,1768.2,percent of total billed charges,Implant Device,1768.2,35,,1768.2,percent of total billed charges,Implant Device,2020.8,40,,2020.8,percent of total billed charges,Implant Device,1768.2,70,,1768.2,percent of total billed charges,All Other,1717.68,34,,1717.68,percent of total billed charges,Implant Device,1717.68,34,,1717.68,percent of total billed charges,Implant Device,1768.2,35,,1768.2,percent of total billed charges,Implant Device,1768.2,35,,1768.2,percent of total billed charges,Implant Device,1768.2,35,,1768.2,percent of total billed charges,Implant Device,1768.2,35,,1768.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1717.68,34,"If Charge > 2,000, then 34 percent",1717.68,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3738.49,
INTEGRA 440-234 PART THRD SCREW 4X34MM,C1713,HCPCS,,79003984,CDM,278,RC,,,both,,,1050,777,,,777,Other,150% of Medicare + 9.63% HCRA Surcharge,472.5,45,,472.5,percent of total billed charges,Critical Access Hospital RCC factor,357,34,,357,percent of total billed charges,Implant Device,357,34,,357,percent of total billed charges,Implant Device,357,34,,357,percent of total billed charges,Implant Device,357,34,,357,percent of total billed charges,Implant Device,357,34,,357,percent of total billed charges,Implant Device,519.75,,,519.75,Other,110% of Medicare,367.5,35,,367.5,percent of total billed charges,Implant Device,357,34,"Charges > $500, x 34%",357,percent of total billed charges,Implant Device,367.5,35,,367.5,percent of total billed charges,Implant Device,367.5,35,,367.5,percent of total billed charges,Implant Device,367.5,35,,367.5,percent of total billed charges,Implant Device,367.5,35,,367.5,percent of total billed charges,Implant Device,367.5,35,,367.5,percent of total billed charges,Implant Device,420,40,,420,percent of total billed charges,Implant Device,367.5,70,,367.5,percent of total billed charges,All Other,357,34,,357,percent of total billed charges,Implant Device,357,34,,357,percent of total billed charges,Implant Device,367.5,35,,367.5,percent of total billed charges,Implant Device,367.5,35,,367.5,percent of total billed charges,Implant Device,367.5,35,,367.5,percent of total billed charges,Implant Device,367.5,35,,367.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,777,
INTEGRA 186-300-SND LOCK SCREW 3.5MM,C1713,HCPCS,,79003988,CDM,278,RC,,,both,,,472,349.28,,,349.28,Other,150% of Medicare + 9.63% HCRA Surcharge,212.4,45,,212.4,percent of total billed charges,Critical Access Hospital RCC factor,160.48,34,,160.48,percent of total billed charges,Implant Device,160.48,34,,160.48,percent of total billed charges,Implant Device,160.48,34,,160.48,percent of total billed charges,Implant Device,160.48,34,,160.48,percent of total billed charges,Implant Device,160.48,34,,160.48,percent of total billed charges,Implant Device,233.64,,,233.64,Other,110% of Medicare,165.2,35,,165.2,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,165.2,35,,165.2,percent of total billed charges,Implant Device,165.2,35,,165.2,percent of total billed charges,Implant Device,165.2,35,,165.2,percent of total billed charges,Implant Device,165.2,35,,165.2,percent of total billed charges,Implant Device,165.2,35,,165.2,percent of total billed charges,Implant Device,188.8,40,,188.8,percent of total billed charges,Implant Device,165.2,70,,165.2,percent of total billed charges,All Other,160.48,34,,160.48,percent of total billed charges,Implant Device,160.48,34,,160.48,percent of total billed charges,Implant Device,165.2,35,,165.2,percent of total billed charges,Implant Device,165.2,35,,165.2,percent of total billed charges,Implant Device,165.2,35,,165.2,percent of total billed charges,Implant Device,165.2,35,,165.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,349.28,
INTEGRA 286-318-SND SCREW 3.5X18MM,C1713,HCPCS,,79003989,CDM,278,RC,,,both,,,1054,779.96,,,779.96,Other,150% of Medicare + 9.63% HCRA Surcharge,474.3,45,,474.3,percent of total billed charges,Critical Access Hospital RCC factor,358.36,34,,358.36,percent of total billed charges,Implant Device,358.36,34,,358.36,percent of total billed charges,Implant Device,358.36,34,,358.36,percent of total billed charges,Implant Device,358.36,34,,358.36,percent of total billed charges,Implant Device,358.36,34,,358.36,percent of total billed charges,Implant Device,521.73,,,521.73,Other,110% of Medicare,368.9,35,,368.9,percent of total billed charges,Implant Device,358.36,34,"Charges > $500, x 34%",358.36,percent of total billed charges,Implant Device,368.9,35,,368.9,percent of total billed charges,Implant Device,368.9,35,,368.9,percent of total billed charges,Implant Device,368.9,35,,368.9,percent of total billed charges,Implant Device,368.9,35,,368.9,percent of total billed charges,Implant Device,368.9,35,,368.9,percent of total billed charges,Implant Device,421.6,40,,421.6,percent of total billed charges,Implant Device,368.9,70,,368.9,percent of total billed charges,All Other,358.36,34,,358.36,percent of total billed charges,Implant Device,358.36,34,,358.36,percent of total billed charges,Implant Device,368.9,35,,368.9,percent of total billed charges,Implant Device,368.9,35,,368.9,percent of total billed charges,Implant Device,368.9,35,,368.9,percent of total billed charges,Implant Device,368.9,35,,368.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,779.96,
J&J PVPM PROCEED VENTL PATCH MD CIR 2.5,C1781,HCPCS,,79003991,CDM,278,RC,,,both,,,1940,1435.6,,,1435.6,Other,150% of Medicare + 9.63% HCRA Surcharge,873,45,,873,percent of total billed charges,Critical Access Hospital RCC factor,659.6,34,,659.6,percent of total billed charges,Implant Device,659.6,34,,659.6,percent of total billed charges,Implant Device,659.6,34,,659.6,percent of total billed charges,Implant Device,659.6,34,,659.6,percent of total billed charges,Implant Device,659.6,34,,659.6,percent of total billed charges,Implant Device,960.3,,,960.3,Other,110% of Medicare,679,35,,679,percent of total billed charges,Implant Device,659.6,34,"Charges > $500, x 34%",659.6,percent of total billed charges,Implant Device,679,35,,679,percent of total billed charges,Implant Device,679,35,,679,percent of total billed charges,Implant Device,679,35,,679,percent of total billed charges,Implant Device,679,35,,679,percent of total billed charges,Implant Device,679,35,,679,percent of total billed charges,Implant Device,776,40,,776,percent of total billed charges,Implant Device,679,70,,679,percent of total billed charges,All Other,659.6,34,,659.6,percent of total billed charges,Implant Device,659.6,34,,659.6,percent of total billed charges,Implant Device,679,35,,679,percent of total billed charges,Implant Device,679,35,,679,percent of total billed charges,Implant Device,679,35,,679,percent of total billed charges,Implant Device,679,35,,679,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1435.6,
J&J HEALTH C08060SL SMART STENT 8X60MM,C1876,HCPCS,,79003992,CDM,278,RC,,,both,,,4429,3277.47,,,3277.47,Other,150% of Medicare + 9.63% HCRA Surcharge,1993.05,45,,1993.05,percent of total billed charges,Critical Access Hospital RCC factor,1505.86,34,,1505.86,percent of total billed charges,Implant Device,1505.86,34,,1505.86,percent of total billed charges,Implant Device,1505.86,34,,1505.86,percent of total billed charges,Implant Device,1505.86,34,,1505.86,percent of total billed charges,Implant Device,1505.86,34,,1505.86,percent of total billed charges,Implant Device,2192.36,,,2192.36,Other,110% of Medicare,1550.15,35,,1550.15,percent of total billed charges,Implant Device,1505.86,34,"Charges > $500, x 34%",1505.86,percent of total billed charges,Implant Device,1550.15,35,,1550.15,percent of total billed charges,Implant Device,1550.15,35,,1550.15,percent of total billed charges,Implant Device,1550.15,35,,1550.15,percent of total billed charges,Implant Device,1550.15,35,,1550.15,percent of total billed charges,Implant Device,1550.15,35,,1550.15,percent of total billed charges,Implant Device,1771.6,40,,1771.6,percent of total billed charges,Implant Device,1550.15,70,,1550.15,percent of total billed charges,All Other,1505.86,34,,1505.86,percent of total billed charges,Implant Device,1505.86,34,,1505.86,percent of total billed charges,Implant Device,1550.15,35,,1550.15,percent of total billed charges,Implant Device,1550.15,35,,1550.15,percent of total billed charges,Implant Device,1550.15,35,,1550.15,percent of total billed charges,Implant Device,1550.15,35,,1550.15,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1505.86,34,"If Charge > 2,000, then 34 percent",1505.86,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3277.47,
JRF 1033-12 TRI- CORTCL BLCK 1.5X2.5CM,C1713,HCPCS,,79003993,CDM,278,RC,,,both,,,2086,1543.65,,,1543.65,Other,150% of Medicare + 9.63% HCRA Surcharge,938.7,45,,938.7,percent of total billed charges,Critical Access Hospital RCC factor,709.24,34,,709.24,percent of total billed charges,Implant Device,709.24,34,,709.24,percent of total billed charges,Implant Device,709.24,34,,709.24,percent of total billed charges,Implant Device,709.24,34,,709.24,percent of total billed charges,Implant Device,709.24,34,,709.24,percent of total billed charges,Implant Device,1032.57,,,1032.57,Other,110% of Medicare,730.1,35,,730.1,percent of total billed charges,Implant Device,709.24,34,"Charges > $500, x 34%",709.24,percent of total billed charges,Implant Device,730.1,35,,730.1,percent of total billed charges,Implant Device,730.1,35,,730.1,percent of total billed charges,Implant Device,730.1,35,,730.1,percent of total billed charges,Implant Device,730.1,35,,730.1,percent of total billed charges,Implant Device,730.1,35,,730.1,percent of total billed charges,Implant Device,834.4,40,,834.4,percent of total billed charges,Implant Device,730.1,70,,730.1,percent of total billed charges,All Other,709.24,34,,709.24,percent of total billed charges,Implant Device,709.24,34,,709.24,percent of total billed charges,Implant Device,730.1,35,,730.1,percent of total billed charges,Implant Device,730.1,35,,730.1,percent of total billed charges,Implant Device,730.1,35,,730.1,percent of total billed charges,Implant Device,730.1,35,,730.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,709.24,34,"If Charge > 2,000, then 34 percent",709.24,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1543.65,
JRF 1021-14 TIBIALIS POST 0.85X26CM,C1713,HCPCS,,79003994,CDM,278,RC,,,both,,,6600,4884.02,,,4884.02,Other,150% of Medicare + 9.63% HCRA Surcharge,2970,45,,2970,percent of total billed charges,Critical Access Hospital RCC factor,2244,34,,2244,percent of total billed charges,Implant Device,2244,34,,2244,percent of total billed charges,Implant Device,2244,34,,2244,percent of total billed charges,Implant Device,2244,34,,2244,percent of total billed charges,Implant Device,2244,34,,2244,percent of total billed charges,Implant Device,3267,,,3267,Other,110% of Medicare,2310,35,,2310,percent of total billed charges,Implant Device,2244,34,"Charges > $500, x 34%",2244,percent of total billed charges,Implant Device,2310,35,,2310,percent of total billed charges,Implant Device,2310,35,,2310,percent of total billed charges,Implant Device,2310,35,,2310,percent of total billed charges,Implant Device,2310,35,,2310,percent of total billed charges,Implant Device,2310,35,,2310,percent of total billed charges,Implant Device,2640,40,,2640,percent of total billed charges,Implant Device,2310,70,,2310,percent of total billed charges,All Other,2244,34,,2244,percent of total billed charges,Implant Device,2244,34,,2244,percent of total billed charges,Implant Device,2310,35,,2310,percent of total billed charges,Implant Device,2310,35,,2310,percent of total billed charges,Implant Device,2310,35,,2310,percent of total billed charges,Implant Device,2310,35,,2310,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2244,34,"If Charge > 2,000, then 34 percent",2244,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4884.02,
LIFE CELL 892 HEMI PATELLA TENDON,C1713,HCPCS,,79003996,CDM,278,RC,,,both,,,10200,7548.03,,,7548.03,Other,150% of Medicare + 9.63% HCRA Surcharge,4590,45,,4590,percent of total billed charges,Critical Access Hospital RCC factor,3468,34,,3468,percent of total billed charges,Implant Device,3468,34,,3468,percent of total billed charges,Implant Device,3468,34,,3468,percent of total billed charges,Implant Device,3468,34,,3468,percent of total billed charges,Implant Device,3468,34,,3468,percent of total billed charges,Implant Device,5049,,,5049,Other,110% of Medicare,3570,35,,3570,percent of total billed charges,Implant Device,3468,34,"Charges > $500, x 34%",3468,percent of total billed charges,Implant Device,3570,35,,3570,percent of total billed charges,Implant Device,3570,35,,3570,percent of total billed charges,Implant Device,3570,35,,3570,percent of total billed charges,Implant Device,3570,35,,3570,percent of total billed charges,Implant Device,3570,35,,3570,percent of total billed charges,Implant Device,4080,40,,4080,percent of total billed charges,Implant Device,3570,70,,3570,percent of total billed charges,All Other,3468,34,,3468,percent of total billed charges,Implant Device,3468,34,,3468,percent of total billed charges,Implant Device,3570,35,,3570,percent of total billed charges,Implant Device,3570,35,,3570,percent of total billed charges,Implant Device,3570,35,,3570,percent of total billed charges,Implant Device,3570,35,,3570,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3468,34,"If Charge > 2,000, then 34 percent",3468,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,7548.03,
MEDLINE SMS38PL59P DOME LG 5.2X9CM,C1781,HCPCS,,79004001,CDM,278,RC,,,both,,,450,333,,,333,Other,150% of Medicare + 9.63% HCRA Surcharge,202.5,45,,202.5,percent of total billed charges,Critical Access Hospital RCC factor,153,34,,153,percent of total billed charges,Implant Device,153,34,,153,percent of total billed charges,Implant Device,153,34,,153,percent of total billed charges,Implant Device,153,34,,153,percent of total billed charges,Implant Device,153,34,,153,percent of total billed charges,Implant Device,222.75,,,222.75,Other,110% of Medicare,157.5,35,,157.5,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,157.5,35,,157.5,percent of total billed charges,Implant Device,157.5,35,,157.5,percent of total billed charges,Implant Device,157.5,35,,157.5,percent of total billed charges,Implant Device,157.5,35,,157.5,percent of total billed charges,Implant Device,157.5,35,,157.5,percent of total billed charges,Implant Device,180,40,,180,percent of total billed charges,Implant Device,157.5,70,,157.5,percent of total billed charges,All Other,153,34,,153,percent of total billed charges,Implant Device,153,34,,153,percent of total billed charges,Implant Device,157.5,35,,157.5,percent of total billed charges,Implant Device,157.5,35,,157.5,percent of total billed charges,Implant Device,157.5,35,,157.5,percent of total billed charges,Implant Device,157.5,35,,157.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,333,
MEDLINE SMS30PM59P DOME MED 5.2X9CM,C1781,HCPCS,,79004002,CDM,278,RC,,,both,,,463,342.62,,,342.62,Other,150% of Medicare + 9.63% HCRA Surcharge,208.35,45,,208.35,percent of total billed charges,Critical Access Hospital RCC factor,157.42,34,,157.42,percent of total billed charges,Implant Device,157.42,34,,157.42,percent of total billed charges,Implant Device,157.42,34,,157.42,percent of total billed charges,Implant Device,157.42,34,,157.42,percent of total billed charges,Implant Device,157.42,34,,157.42,percent of total billed charges,Implant Device,229.19,,,229.19,Other,110% of Medicare,162.05,35,,162.05,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,162.05,35,,162.05,percent of total billed charges,Implant Device,162.05,35,,162.05,percent of total billed charges,Implant Device,162.05,35,,162.05,percent of total billed charges,Implant Device,162.05,35,,162.05,percent of total billed charges,Implant Device,162.05,35,,162.05,percent of total billed charges,Implant Device,185.2,40,,185.2,percent of total billed charges,Implant Device,162.05,70,,162.05,percent of total billed charges,All Other,157.42,34,,157.42,percent of total billed charges,Implant Device,157.42,34,,157.42,percent of total billed charges,Implant Device,162.05,35,,162.05,percent of total billed charges,Implant Device,162.05,35,,162.05,percent of total billed charges,Implant Device,162.05,35,,162.05,percent of total billed charges,Implant Device,162.05,35,,162.05,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,342.62,
MEDTRONIC 5086MRI45 BRADYCRDIA LEAD 45CM,C1898,HCPCS,,79004003,CDM,278,RC,,,both,,,2808,2077.93,,,2077.93,Other,150% of Medicare + 9.63% HCRA Surcharge,1263.6,45,,1263.6,percent of total billed charges,Critical Access Hospital RCC factor,954.72,34,,954.72,percent of total billed charges,Implant Device,954.72,34,,954.72,percent of total billed charges,Implant Device,954.72,34,,954.72,percent of total billed charges,Implant Device,954.72,34,,954.72,percent of total billed charges,Implant Device,954.72,34,,954.72,percent of total billed charges,Implant Device,1389.96,,,1389.96,Other,110% of Medicare,982.8,35,,982.8,percent of total billed charges,Implant Device,954.72,34,"Charges > $500, x 34%",954.72,percent of total billed charges,Implant Device,982.8,35,,982.8,percent of total billed charges,Implant Device,982.8,35,,982.8,percent of total billed charges,Implant Device,982.8,35,,982.8,percent of total billed charges,Implant Device,982.8,35,,982.8,percent of total billed charges,Implant Device,982.8,35,,982.8,percent of total billed charges,Implant Device,1123.2,40,,1123.2,percent of total billed charges,Implant Device,982.8,70,,982.8,percent of total billed charges,All Other,954.72,34,,954.72,percent of total billed charges,Implant Device,954.72,34,,954.72,percent of total billed charges,Implant Device,982.8,35,,982.8,percent of total billed charges,Implant Device,982.8,35,,982.8,percent of total billed charges,Implant Device,982.8,35,,982.8,percent of total billed charges,Implant Device,982.8,35,,982.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,954.72,34,"If Charge > 2,000, then 34 percent",954.72,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2077.93,
MEDTRONIC 5086MRI58 BRADYCRDIA LEAD 58CM,C1898,HCPCS,,79004006,CDM,278,RC,,,both,,,2808,2077.93,,,2077.93,Other,150% of Medicare + 9.63% HCRA Surcharge,1263.6,45,,1263.6,percent of total billed charges,Critical Access Hospital RCC factor,954.72,34,,954.72,percent of total billed charges,Implant Device,954.72,34,,954.72,percent of total billed charges,Implant Device,954.72,34,,954.72,percent of total billed charges,Implant Device,954.72,34,,954.72,percent of total billed charges,Implant Device,954.72,34,,954.72,percent of total billed charges,Implant Device,1389.96,,,1389.96,Other,110% of Medicare,982.8,35,,982.8,percent of total billed charges,Implant Device,954.72,34,"Charges > $500, x 34%",954.72,percent of total billed charges,Implant Device,982.8,35,,982.8,percent of total billed charges,Implant Device,982.8,35,,982.8,percent of total billed charges,Implant Device,982.8,35,,982.8,percent of total billed charges,Implant Device,982.8,35,,982.8,percent of total billed charges,Implant Device,982.8,35,,982.8,percent of total billed charges,Implant Device,1123.2,40,,1123.2,percent of total billed charges,Implant Device,982.8,70,,982.8,percent of total billed charges,All Other,954.72,34,,954.72,percent of total billed charges,Implant Device,954.72,34,,954.72,percent of total billed charges,Implant Device,982.8,35,,982.8,percent of total billed charges,Implant Device,982.8,35,,982.8,percent of total billed charges,Implant Device,982.8,35,,982.8,percent of total billed charges,Implant Device,982.8,35,,982.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,954.72,34,"If Charge > 2,000, then 34 percent",954.72,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2077.93,
MEDTRONIC 5086MRI52 BRADYCRDIA LEAD 52CM,C1898,HCPCS,,79004009,CDM,278,RC,,,both,,,2808,2077.93,,,2077.93,Other,150% of Medicare + 9.63% HCRA Surcharge,1263.6,45,,1263.6,percent of total billed charges,Critical Access Hospital RCC factor,954.72,34,,954.72,percent of total billed charges,Implant Device,954.72,34,,954.72,percent of total billed charges,Implant Device,954.72,34,,954.72,percent of total billed charges,Implant Device,954.72,34,,954.72,percent of total billed charges,Implant Device,954.72,34,,954.72,percent of total billed charges,Implant Device,1389.96,,,1389.96,Other,110% of Medicare,982.8,35,,982.8,percent of total billed charges,Implant Device,954.72,34,"Charges > $500, x 34%",954.72,percent of total billed charges,Implant Device,982.8,35,,982.8,percent of total billed charges,Implant Device,982.8,35,,982.8,percent of total billed charges,Implant Device,982.8,35,,982.8,percent of total billed charges,Implant Device,982.8,35,,982.8,percent of total billed charges,Implant Device,982.8,35,,982.8,percent of total billed charges,Implant Device,1123.2,40,,1123.2,percent of total billed charges,Implant Device,982.8,70,,982.8,percent of total billed charges,All Other,954.72,34,,954.72,percent of total billed charges,Implant Device,954.72,34,,954.72,percent of total billed charges,Implant Device,982.8,35,,982.8,percent of total billed charges,Implant Device,982.8,35,,982.8,percent of total billed charges,Implant Device,982.8,35,,982.8,percent of total billed charges,Implant Device,982.8,35,,982.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,954.72,34,"If Charge > 2,000, then 34 percent",954.72,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2077.93,
MEDTRONIC 1LXCH161685 VASC STENT GRAFT,C1874,HCPCS,,79004013,CDM,278,RC,,,both,,,9450,6993.02,,,6993.02,Other,150% of Medicare + 9.63% HCRA Surcharge,4252.5,45,,4252.5,percent of total billed charges,Critical Access Hospital RCC factor,3213,34,,3213,percent of total billed charges,Implant Device,3213,34,,3213,percent of total billed charges,Implant Device,3213,34,,3213,percent of total billed charges,Implant Device,3213,34,,3213,percent of total billed charges,Implant Device,3213,34,,3213,percent of total billed charges,Implant Device,4677.75,,,4677.75,Other,110% of Medicare,3307.5,35,,3307.5,percent of total billed charges,Implant Device,3213,34,"Charges > $500, x 34%",3213,percent of total billed charges,Implant Device,3307.5,35,,3307.5,percent of total billed charges,Implant Device,3307.5,35,,3307.5,percent of total billed charges,Implant Device,3307.5,35,,3307.5,percent of total billed charges,Implant Device,3307.5,35,,3307.5,percent of total billed charges,Implant Device,3307.5,35,,3307.5,percent of total billed charges,Implant Device,3780,40,,3780,percent of total billed charges,Implant Device,3307.5,70,,3307.5,percent of total billed charges,All Other,3213,34,,3213,percent of total billed charges,Implant Device,3213,34,,3213,percent of total billed charges,Implant Device,3307.5,35,,3307.5,percent of total billed charges,Implant Device,3307.5,35,,3307.5,percent of total billed charges,Implant Device,3307.5,35,,3307.5,percent of total billed charges,Implant Device,3307.5,35,,3307.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3213,34,"If Charge > 2,000, then 34 percent",3213,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,6993.02,
MTF 430200 ACHILLES TENDON W/CALC 19.5CM,C1713,HCPCS,,79004016,CDM,278,RC,,,both,,,5056,3741.45,,,3741.45,Other,150% of Medicare + 9.63% HCRA Surcharge,2275.2,45,,2275.2,percent of total billed charges,Critical Access Hospital RCC factor,1719.04,34,,1719.04,percent of total billed charges,Implant Device,1719.04,34,,1719.04,percent of total billed charges,Implant Device,1719.04,34,,1719.04,percent of total billed charges,Implant Device,1719.04,34,,1719.04,percent of total billed charges,Implant Device,1719.04,34,,1719.04,percent of total billed charges,Implant Device,2502.72,,,2502.72,Other,110% of Medicare,1769.6,35,,1769.6,percent of total billed charges,Implant Device,1719.04,34,"Charges > $500, x 34%",1719.04,percent of total billed charges,Implant Device,1769.6,35,,1769.6,percent of total billed charges,Implant Device,1769.6,35,,1769.6,percent of total billed charges,Implant Device,1769.6,35,,1769.6,percent of total billed charges,Implant Device,1769.6,35,,1769.6,percent of total billed charges,Implant Device,1769.6,35,,1769.6,percent of total billed charges,Implant Device,2022.4,40,,2022.4,percent of total billed charges,Implant Device,1769.6,70,,1769.6,percent of total billed charges,All Other,1719.04,34,,1719.04,percent of total billed charges,Implant Device,1719.04,34,,1719.04,percent of total billed charges,Implant Device,1769.6,35,,1769.6,percent of total billed charges,Implant Device,1769.6,35,,1769.6,percent of total billed charges,Implant Device,1769.6,35,,1769.6,percent of total billed charges,Implant Device,1769.6,35,,1769.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1719.04,34,"If Charge > 2,000, then 34 percent",1719.04,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3741.45,
NAVILYST 165451020 INFUSAPORT KIT 8FR,C1751,HCPCS,,79004017,CDM,278,RC,,,both,,,898,664.52,,,664.52,Other,150% of Medicare + 9.63% HCRA Surcharge,404.1,45,,404.1,percent of total billed charges,Critical Access Hospital RCC factor,305.32,34,,305.32,percent of total billed charges,Implant Device,305.32,34,,305.32,percent of total billed charges,Implant Device,305.32,34,,305.32,percent of total billed charges,Implant Device,305.32,34,,305.32,percent of total billed charges,Implant Device,305.32,34,,305.32,percent of total billed charges,Implant Device,444.51,,,444.51,Other,110% of Medicare,314.3,35,,314.3,percent of total billed charges,Implant Device,305.32,34,"Charges > $500, x 34%",305.32,percent of total billed charges,Implant Device,314.3,35,,314.3,percent of total billed charges,Implant Device,314.3,35,,314.3,percent of total billed charges,Implant Device,314.3,35,,314.3,percent of total billed charges,Implant Device,314.3,35,,314.3,percent of total billed charges,Implant Device,314.3,35,,314.3,percent of total billed charges,Implant Device,359.2,40,,359.2,percent of total billed charges,Implant Device,314.3,70,,314.3,percent of total billed charges,All Other,305.32,34,,305.32,percent of total billed charges,Implant Device,305.32,34,,305.32,percent of total billed charges,Implant Device,314.3,35,,314.3,percent of total billed charges,Implant Device,314.3,35,,314.3,percent of total billed charges,Implant Device,314.3,35,,314.3,percent of total billed charges,Implant Device,314.3,35,,314.3,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,664.52,
ORTHOHELIX CSS-011-70-855 SCREW 7.0MM,C1713,HCPCS,,79004020,CDM,278,RC,,,both,,,978,723.72,,,723.72,Other,150% of Medicare + 9.63% HCRA Surcharge,440.1,45,,440.1,percent of total billed charges,Critical Access Hospital RCC factor,332.52,34,,332.52,percent of total billed charges,Implant Device,332.52,34,,332.52,percent of total billed charges,Implant Device,332.52,34,,332.52,percent of total billed charges,Implant Device,332.52,34,,332.52,percent of total billed charges,Implant Device,332.52,34,,332.52,percent of total billed charges,Implant Device,484.11,,,484.11,Other,110% of Medicare,342.3,35,,342.3,percent of total billed charges,Implant Device,332.52,34,"Charges > $500, x 34%",332.52,percent of total billed charges,Implant Device,342.3,35,,342.3,percent of total billed charges,Implant Device,342.3,35,,342.3,percent of total billed charges,Implant Device,342.3,35,,342.3,percent of total billed charges,Implant Device,342.3,35,,342.3,percent of total billed charges,Implant Device,342.3,35,,342.3,percent of total billed charges,Implant Device,391.2,40,,391.2,percent of total billed charges,Implant Device,342.3,70,,342.3,percent of total billed charges,All Other,332.52,34,,332.52,percent of total billed charges,Implant Device,332.52,34,,332.52,percent of total billed charges,Implant Device,342.3,35,,342.3,percent of total billed charges,Implant Device,342.3,35,,342.3,percent of total billed charges,Implant Device,342.3,35,,342.3,percent of total billed charges,Implant Device,342.3,35,,342.3,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,723.72,
ORTHOHELIX CSS-011-55-0405 SCREW 5.5X40,C1713,HCPCS,,79004021,CDM,278,RC,,,both,,,810,599.4,,,599.4,Other,150% of Medicare + 9.63% HCRA Surcharge,364.5,45,,364.5,percent of total billed charges,Critical Access Hospital RCC factor,275.4,34,,275.4,percent of total billed charges,Implant Device,275.4,34,,275.4,percent of total billed charges,Implant Device,275.4,34,,275.4,percent of total billed charges,Implant Device,275.4,34,,275.4,percent of total billed charges,Implant Device,275.4,34,,275.4,percent of total billed charges,Implant Device,400.95,,,400.95,Other,110% of Medicare,283.5,35,,283.5,percent of total billed charges,Implant Device,275.4,34,"Charges > $500, x 34%",275.4,percent of total billed charges,Implant Device,283.5,35,,283.5,percent of total billed charges,Implant Device,283.5,35,,283.5,percent of total billed charges,Implant Device,283.5,35,,283.5,percent of total billed charges,Implant Device,283.5,35,,283.5,percent of total billed charges,Implant Device,283.5,35,,283.5,percent of total billed charges,Implant Device,324,40,,324,percent of total billed charges,Implant Device,283.5,70,,283.5,percent of total billed charges,All Other,275.4,34,,275.4,percent of total billed charges,Implant Device,275.4,34,,275.4,percent of total billed charges,Implant Device,283.5,35,,283.5,percent of total billed charges,Implant Device,283.5,35,,283.5,percent of total billed charges,Implant Device,283.5,35,,283.5,percent of total billed charges,Implant Device,283.5,35,,283.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,599.4,
ORTHOHELIX TMT-022-23-ML PLATE LT STD,C1713,HCPCS,,79004022,CDM,278,RC,,,both,,,3940,2915.61,,,2915.61,Other,150% of Medicare + 9.63% HCRA Surcharge,1773,45,,1773,percent of total billed charges,Critical Access Hospital RCC factor,1339.6,34,,1339.6,percent of total billed charges,Implant Device,1339.6,34,,1339.6,percent of total billed charges,Implant Device,1339.6,34,,1339.6,percent of total billed charges,Implant Device,1339.6,34,,1339.6,percent of total billed charges,Implant Device,1339.6,34,,1339.6,percent of total billed charges,Implant Device,1950.3,,,1950.3,Other,110% of Medicare,1379,35,,1379,percent of total billed charges,Implant Device,1339.6,34,"Charges > $500, x 34%",1339.6,percent of total billed charges,Implant Device,1379,35,,1379,percent of total billed charges,Implant Device,1379,35,,1379,percent of total billed charges,Implant Device,1379,35,,1379,percent of total billed charges,Implant Device,1379,35,,1379,percent of total billed charges,Implant Device,1379,35,,1379,percent of total billed charges,Implant Device,1576,40,,1576,percent of total billed charges,Implant Device,1379,70,,1379,percent of total billed charges,All Other,1339.6,34,,1339.6,percent of total billed charges,Implant Device,1339.6,34,,1339.6,percent of total billed charges,Implant Device,1379,35,,1379,percent of total billed charges,Implant Device,1379,35,,1379,percent of total billed charges,Implant Device,1379,35,,1379,percent of total billed charges,Implant Device,1379,35,,1379,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1339.6,34,"If Charge > 2,000, then 34 percent",1339.6,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2915.61,
ORTHOHELIX MXM-022-MTP-R STD MTP PLATE,C1713,HCPCS,,79004023,CDM,278,RC,,,both,,,5236,3874.65,,,3874.65,Other,150% of Medicare + 9.63% HCRA Surcharge,2356.2,45,,2356.2,percent of total billed charges,Critical Access Hospital RCC factor,1780.24,34,,1780.24,percent of total billed charges,Implant Device,1780.24,34,,1780.24,percent of total billed charges,Implant Device,1780.24,34,,1780.24,percent of total billed charges,Implant Device,1780.24,34,,1780.24,percent of total billed charges,Implant Device,1780.24,34,,1780.24,percent of total billed charges,Implant Device,2591.82,,,2591.82,Other,110% of Medicare,1832.6,35,,1832.6,percent of total billed charges,Implant Device,1780.24,34,"Charges > $500, x 34%",1780.24,percent of total billed charges,Implant Device,1832.6,35,,1832.6,percent of total billed charges,Implant Device,1832.6,35,,1832.6,percent of total billed charges,Implant Device,1832.6,35,,1832.6,percent of total billed charges,Implant Device,1832.6,35,,1832.6,percent of total billed charges,Implant Device,1832.6,35,,1832.6,percent of total billed charges,Implant Device,2094.4,40,,2094.4,percent of total billed charges,Implant Device,1832.6,70,,1832.6,percent of total billed charges,All Other,1780.24,34,,1780.24,percent of total billed charges,Implant Device,1780.24,34,,1780.24,percent of total billed charges,Implant Device,1832.6,35,,1832.6,percent of total billed charges,Implant Device,1832.6,35,,1832.6,percent of total billed charges,Implant Device,1832.6,35,,1832.6,percent of total billed charges,Implant Device,1832.6,35,,1832.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1780.24,34,"If Charge > 2,000, then 34 percent",1780.24,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3874.65,
ORTHOHELIX MXM-011-24-10 SCREW 2.4X10MM,C1713,HCPCS,,79004024,CDM,278,RC,,,both,,,330,244.2,,,244.2,Other,150% of Medicare + 9.63% HCRA Surcharge,148.5,45,,148.5,percent of total billed charges,Critical Access Hospital RCC factor,112.2,34,,112.2,percent of total billed charges,Implant Device,112.2,34,,112.2,percent of total billed charges,Implant Device,112.2,34,,112.2,percent of total billed charges,Implant Device,112.2,34,,112.2,percent of total billed charges,Implant Device,112.2,34,,112.2,percent of total billed charges,Implant Device,163.35,,,163.35,Other,110% of Medicare,115.5,35,,115.5,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,132,40,,132,percent of total billed charges,Implant Device,115.5,70,,115.5,percent of total billed charges,All Other,112.2,34,,112.2,percent of total billed charges,Implant Device,112.2,34,,112.2,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,244.2,
ORTHOHELIX MTF-021-35-35 SCREW 3.5X35MM,C1713,HCPCS,,79004026,CDM,278,RC,,,both,,,546,404.04,,,404.04,Other,150% of Medicare + 9.63% HCRA Surcharge,245.7,45,,245.7,percent of total billed charges,Critical Access Hospital RCC factor,185.64,34,,185.64,percent of total billed charges,Implant Device,185.64,34,,185.64,percent of total billed charges,Implant Device,185.64,34,,185.64,percent of total billed charges,Implant Device,185.64,34,,185.64,percent of total billed charges,Implant Device,185.64,34,,185.64,percent of total billed charges,Implant Device,270.27,,,270.27,Other,110% of Medicare,191.1,35,,191.1,percent of total billed charges,Implant Device,185.64,34,"Charges > $500, x 34%",185.64,percent of total billed charges,Implant Device,191.1,35,,191.1,percent of total billed charges,Implant Device,191.1,35,,191.1,percent of total billed charges,Implant Device,191.1,35,,191.1,percent of total billed charges,Implant Device,191.1,35,,191.1,percent of total billed charges,Implant Device,191.1,35,,191.1,percent of total billed charges,Implant Device,218.4,40,,218.4,percent of total billed charges,Implant Device,191.1,70,,191.1,percent of total billed charges,All Other,185.64,34,,185.64,percent of total billed charges,Implant Device,185.64,34,,185.64,percent of total billed charges,Implant Device,191.1,35,,191.1,percent of total billed charges,Implant Device,191.1,35,,191.1,percent of total billed charges,Implant Device,191.1,35,,191.1,percent of total billed charges,Implant Device,191.1,35,,191.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,404.04,
PAC 3 N600102 PLATE-26MM 1 LEVEL X SPINE,C1713,HCPCS,,79004027,CDM,278,RC,,,both,,,2250,1665.01,,,1665.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1012.5,45,,1012.5,percent of total billed charges,Critical Access Hospital RCC factor,765,34,,765,percent of total billed charges,Implant Device,765,34,,765,percent of total billed charges,Implant Device,765,34,,765,percent of total billed charges,Implant Device,765,34,,765,percent of total billed charges,Implant Device,765,34,,765,percent of total billed charges,Implant Device,1113.75,,,1113.75,Other,110% of Medicare,787.5,35,,787.5,percent of total billed charges,Implant Device,765,34,"Charges > $500, x 34%",765,percent of total billed charges,Implant Device,787.5,35,,787.5,percent of total billed charges,Implant Device,787.5,35,,787.5,percent of total billed charges,Implant Device,787.5,35,,787.5,percent of total billed charges,Implant Device,787.5,35,,787.5,percent of total billed charges,Implant Device,787.5,35,,787.5,percent of total billed charges,Implant Device,900,40,,900,percent of total billed charges,Implant Device,787.5,70,,787.5,percent of total billed charges,All Other,765,34,,765,percent of total billed charges,Implant Device,765,34,,765,percent of total billed charges,Implant Device,787.5,35,,787.5,percent of total billed charges,Implant Device,787.5,35,,787.5,percent of total billed charges,Implant Device,787.5,35,,787.5,percent of total billed charges,Implant Device,787.5,35,,787.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,765,34,"If Charge > 2,000, then 34 percent",765,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1665.01,
PAC 3 N600136 X SPINE SCREW 4X14MM,C1713,HCPCS,,79004028,CDM,278,RC,,,both,,,706,522.44,,,522.44,Other,150% of Medicare + 9.63% HCRA Surcharge,317.7,45,,317.7,percent of total billed charges,Critical Access Hospital RCC factor,240.04,34,,240.04,percent of total billed charges,Implant Device,240.04,34,,240.04,percent of total billed charges,Implant Device,240.04,34,,240.04,percent of total billed charges,Implant Device,240.04,34,,240.04,percent of total billed charges,Implant Device,240.04,34,,240.04,percent of total billed charges,Implant Device,349.47,,,349.47,Other,110% of Medicare,247.1,35,,247.1,percent of total billed charges,Implant Device,240.04,34,"Charges > $500, x 34%",240.04,percent of total billed charges,Implant Device,247.1,35,,247.1,percent of total billed charges,Implant Device,247.1,35,,247.1,percent of total billed charges,Implant Device,247.1,35,,247.1,percent of total billed charges,Implant Device,247.1,35,,247.1,percent of total billed charges,Implant Device,247.1,35,,247.1,percent of total billed charges,Implant Device,282.4,40,,282.4,percent of total billed charges,Implant Device,247.1,70,,247.1,percent of total billed charges,All Other,240.04,34,,240.04,percent of total billed charges,Implant Device,240.04,34,,240.04,percent of total billed charges,Implant Device,247.1,35,,247.1,percent of total billed charges,Implant Device,247.1,35,,247.1,percent of total billed charges,Implant Device,247.1,35,,247.1,percent of total billed charges,Implant Device,247.1,35,,247.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,522.44,
PAC 3 N6000019 X SPINE PLATE 42MM 2LEVEL,C1713,HCPCS,,79004029,CDM,278,RC,,,both,,,1200,888,,,888,Other,150% of Medicare + 9.63% HCRA Surcharge,540,45,,540,percent of total billed charges,Critical Access Hospital RCC factor,408,34,,408,percent of total billed charges,Implant Device,408,34,,408,percent of total billed charges,Implant Device,408,34,,408,percent of total billed charges,Implant Device,408,34,,408,percent of total billed charges,Implant Device,408,34,,408,percent of total billed charges,Implant Device,594,,,594,Other,110% of Medicare,420,35,,420,percent of total billed charges,Implant Device,408,34,"Charges > $500, x 34%",408,percent of total billed charges,Implant Device,420,35,,420,percent of total billed charges,Implant Device,420,35,,420,percent of total billed charges,Implant Device,420,35,,420,percent of total billed charges,Implant Device,420,35,,420,percent of total billed charges,Implant Device,420,35,,420,percent of total billed charges,Implant Device,480,40,,480,percent of total billed charges,Implant Device,420,70,,420,percent of total billed charges,All Other,408,34,,408,percent of total billed charges,Implant Device,408,34,,408,percent of total billed charges,Implant Device,420,35,,420,percent of total billed charges,Implant Device,420,35,,420,percent of total billed charges,Implant Device,420,35,,420,percent of total billed charges,Implant Device,420,35,,420,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,888,
PAC 3 N60000108 XSPINE 2LEVEL PLATE 39MM,C1713,HCPCS,,79004030,CDM,278,RC,,,both,,,2700,1998.01,,,1998.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1215,45,,1215,percent of total billed charges,Critical Access Hospital RCC factor,918,34,,918,percent of total billed charges,Implant Device,918,34,,918,percent of total billed charges,Implant Device,918,34,,918,percent of total billed charges,Implant Device,918,34,,918,percent of total billed charges,Implant Device,918,34,,918,percent of total billed charges,Implant Device,1336.5,,,1336.5,Other,110% of Medicare,945,35,,945,percent of total billed charges,Implant Device,918,34,"Charges > $500, x 34%",918,percent of total billed charges,Implant Device,945,35,,945,percent of total billed charges,Implant Device,945,35,,945,percent of total billed charges,Implant Device,945,35,,945,percent of total billed charges,Implant Device,945,35,,945,percent of total billed charges,Implant Device,945,35,,945,percent of total billed charges,Implant Device,1080,40,,1080,percent of total billed charges,Implant Device,945,70,,945,percent of total billed charges,All Other,918,34,,918,percent of total billed charges,Implant Device,918,34,,918,percent of total billed charges,Implant Device,945,35,,945,percent of total billed charges,Implant Device,945,35,,945,percent of total billed charges,Implant Device,945,35,,945,percent of total billed charges,Implant Device,945,35,,945,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,918,34,"If Charge > 2,000, then 34 percent",918,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1998.01,
SMITH & NEPHEW 71338667 ACE SHELL 56MM,C1776,HCPCS,,79004031,CDM,278,RC,,,both,,,4632,3427.69,,,3427.69,Other,150% of Medicare + 9.63% HCRA Surcharge,2084.4,45,,2084.4,percent of total billed charges,Critical Access Hospital RCC factor,1574.88,34,,1574.88,percent of total billed charges,Implant Device,1574.88,34,,1574.88,percent of total billed charges,Implant Device,1574.88,34,,1574.88,percent of total billed charges,Implant Device,1574.88,34,,1574.88,percent of total billed charges,Implant Device,1574.88,34,,1574.88,percent of total billed charges,Implant Device,2292.84,,,2292.84,Other,110% of Medicare,1621.2,35,,1621.2,percent of total billed charges,Implant Device,1574.88,34,"Charges > $500, x 34%",1574.88,percent of total billed charges,Implant Device,1621.2,35,,1621.2,percent of total billed charges,Implant Device,1621.2,35,,1621.2,percent of total billed charges,Implant Device,1621.2,35,,1621.2,percent of total billed charges,Implant Device,1621.2,35,,1621.2,percent of total billed charges,Implant Device,1621.2,35,,1621.2,percent of total billed charges,Implant Device,1852.8,40,,1852.8,percent of total billed charges,Implant Device,1621.2,70,,1621.2,percent of total billed charges,All Other,1574.88,34,,1574.88,percent of total billed charges,Implant Device,1574.88,34,,1574.88,percent of total billed charges,Implant Device,1621.2,35,,1621.2,percent of total billed charges,Implant Device,1621.2,35,,1621.2,percent of total billed charges,Implant Device,1621.2,35,,1621.2,percent of total billed charges,Implant Device,1621.2,35,,1621.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1574.88,34,"If Charge > 2,000, then 34 percent",1574.88,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3427.69,
SMITH & NEPHEW 71335756 ACE LINER 36X56,C1776,HCPCS,,79004032,CDM,278,RC,,,both,,,3096,2291.05,,,2291.05,Other,150% of Medicare + 9.63% HCRA Surcharge,1393.2,45,,1393.2,percent of total billed charges,Critical Access Hospital RCC factor,1052.64,34,,1052.64,percent of total billed charges,Implant Device,1052.64,34,,1052.64,percent of total billed charges,Implant Device,1052.64,34,,1052.64,percent of total billed charges,Implant Device,1052.64,34,,1052.64,percent of total billed charges,Implant Device,1052.64,34,,1052.64,percent of total billed charges,Implant Device,1532.52,,,1532.52,Other,110% of Medicare,1083.6,35,,1083.6,percent of total billed charges,Implant Device,1052.64,34,"Charges > $500, x 34%",1052.64,percent of total billed charges,Implant Device,1083.6,35,,1083.6,percent of total billed charges,Implant Device,1083.6,35,,1083.6,percent of total billed charges,Implant Device,1083.6,35,,1083.6,percent of total billed charges,Implant Device,1083.6,35,,1083.6,percent of total billed charges,Implant Device,1083.6,35,,1083.6,percent of total billed charges,Implant Device,1238.4,40,,1238.4,percent of total billed charges,Implant Device,1083.6,70,,1083.6,percent of total billed charges,All Other,1052.64,34,,1052.64,percent of total billed charges,Implant Device,1052.64,34,,1052.64,percent of total billed charges,Implant Device,1083.6,35,,1083.6,percent of total billed charges,Implant Device,1083.6,35,,1083.6,percent of total billed charges,Implant Device,1083.6,35,,1083.6,percent of total billed charges,Implant Device,1083.6,35,,1083.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1052.64,34,"If Charge > 2,000, then 34 percent",1052.64,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2291.05,
SMITH & NEPHEW 121828 SCREW CANN 4X28MM,C1713,HCPCS,,79004033,CDM,278,RC,,,both,,,408,301.92,,,301.92,Other,150% of Medicare + 9.63% HCRA Surcharge,183.6,45,,183.6,percent of total billed charges,Critical Access Hospital RCC factor,138.72,34,,138.72,percent of total billed charges,Implant Device,138.72,34,,138.72,percent of total billed charges,Implant Device,138.72,34,,138.72,percent of total billed charges,Implant Device,138.72,34,,138.72,percent of total billed charges,Implant Device,138.72,34,,138.72,percent of total billed charges,Implant Device,201.96,,,201.96,Other,110% of Medicare,142.8,35,,142.8,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,142.8,35,,142.8,percent of total billed charges,Implant Device,142.8,35,,142.8,percent of total billed charges,Implant Device,142.8,35,,142.8,percent of total billed charges,Implant Device,142.8,35,,142.8,percent of total billed charges,Implant Device,142.8,35,,142.8,percent of total billed charges,Implant Device,163.2,40,,163.2,percent of total billed charges,Implant Device,142.8,70,,142.8,percent of total billed charges,All Other,138.72,34,,138.72,percent of total billed charges,Implant Device,138.72,34,,138.72,percent of total billed charges,Implant Device,142.8,35,,142.8,percent of total billed charges,Implant Device,142.8,35,,142.8,percent of total billed charges,Implant Device,142.8,35,,142.8,percent of total billed charges,Implant Device,142.8,35,,142.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,301.92,
SMITH & NEPHEW 71302204 FEMORL HEAD 22MM,C1776,HCPCS,,79004034,CDM,278,RC,,,both,,,1920,1420.8,,,1420.8,Other,150% of Medicare + 9.63% HCRA Surcharge,864,45,,864,percent of total billed charges,Critical Access Hospital RCC factor,652.8,34,,652.8,percent of total billed charges,Implant Device,652.8,34,,652.8,percent of total billed charges,Implant Device,652.8,34,,652.8,percent of total billed charges,Implant Device,652.8,34,,652.8,percent of total billed charges,Implant Device,652.8,34,,652.8,percent of total billed charges,Implant Device,950.4,,,950.4,Other,110% of Medicare,672,35,,672,percent of total billed charges,Implant Device,652.8,34,"Charges > $500, x 34%",652.8,percent of total billed charges,Implant Device,672,35,,672,percent of total billed charges,Implant Device,672,35,,672,percent of total billed charges,Implant Device,672,35,,672,percent of total billed charges,Implant Device,672,35,,672,percent of total billed charges,Implant Device,672,35,,672,percent of total billed charges,Implant Device,768,40,,768,percent of total billed charges,Implant Device,672,70,,672,percent of total billed charges,All Other,652.8,34,,652.8,percent of total billed charges,Implant Device,652.8,34,,652.8,percent of total billed charges,Implant Device,672,35,,672,percent of total billed charges,Implant Device,672,35,,672,percent of total billed charges,Implant Device,672,35,,672,percent of total billed charges,Implant Device,672,35,,672,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1420.8,
SMITH & NEPHEW 71430891 ART TRIAL SZ 7-8,C1776,HCPCS,,79004037,CDM,278,RC,,,both,,,540,399.6,,,399.6,Other,150% of Medicare + 9.63% HCRA Surcharge,243,45,,243,percent of total billed charges,Critical Access Hospital RCC factor,183.6,34,,183.6,percent of total billed charges,Implant Device,183.6,34,,183.6,percent of total billed charges,Implant Device,183.6,34,,183.6,percent of total billed charges,Implant Device,183.6,34,,183.6,percent of total billed charges,Implant Device,183.6,34,,183.6,percent of total billed charges,Implant Device,267.3,,,267.3,Other,110% of Medicare,189,35,,189,percent of total billed charges,Implant Device,183.6,34,"Charges > $500, x 34%",183.6,percent of total billed charges,Implant Device,189,35,,189,percent of total billed charges,Implant Device,189,35,,189,percent of total billed charges,Implant Device,189,35,,189,percent of total billed charges,Implant Device,189,35,,189,percent of total billed charges,Implant Device,189,35,,189,percent of total billed charges,Implant Device,216,40,,216,percent of total billed charges,Implant Device,189,70,,189,percent of total billed charges,All Other,183.6,34,,183.6,percent of total billed charges,Implant Device,183.6,34,,183.6,percent of total billed charges,Implant Device,189,35,,189,percent of total billed charges,Implant Device,189,35,,189,percent of total billed charges,Implant Device,189,35,,189,percent of total billed charges,Implant Device,189,35,,189,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,399.6,
SMITH & NEPH 71322042 LINR BIPOLR 22X42,C1776,HCPCS,,79004038,CDM,278,RC,,,both,,,4770,3529.81,,,3529.81,Other,150% of Medicare + 9.63% HCRA Surcharge,2146.5,45,,2146.5,percent of total billed charges,Critical Access Hospital RCC factor,1621.8,34,,1621.8,percent of total billed charges,Implant Device,1621.8,34,,1621.8,percent of total billed charges,Implant Device,1621.8,34,,1621.8,percent of total billed charges,Implant Device,1621.8,34,,1621.8,percent of total billed charges,Implant Device,1621.8,34,,1621.8,percent of total billed charges,Implant Device,2361.15,,,2361.15,Other,110% of Medicare,1669.5,35,,1669.5,percent of total billed charges,Implant Device,1621.8,34,"Charges > $500, x 34%",1621.8,percent of total billed charges,Implant Device,1669.5,35,,1669.5,percent of total billed charges,Implant Device,1669.5,35,,1669.5,percent of total billed charges,Implant Device,1669.5,35,,1669.5,percent of total billed charges,Implant Device,1669.5,35,,1669.5,percent of total billed charges,Implant Device,1669.5,35,,1669.5,percent of total billed charges,Implant Device,1908,40,,1908,percent of total billed charges,Implant Device,1669.5,70,,1669.5,percent of total billed charges,All Other,1621.8,34,,1621.8,percent of total billed charges,Implant Device,1621.8,34,,1621.8,percent of total billed charges,Implant Device,1669.5,35,,1669.5,percent of total billed charges,Implant Device,1669.5,35,,1669.5,percent of total billed charges,Implant Device,1669.5,35,,1669.5,percent of total billed charges,Implant Device,1669.5,35,,1669.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1621.8,34,"If Charge > 2,000, then 34 percent",1621.8,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3529.81,
SOLANA 5740106 LORDOTC ALLOGRAFT 6X11X14,C1713,HCPCS,,79004039,CDM,278,RC,,,both,,,4486,3319.65,,,3319.65,Other,150% of Medicare + 9.63% HCRA Surcharge,2018.7,45,,2018.7,percent of total billed charges,Critical Access Hospital RCC factor,1525.24,34,,1525.24,percent of total billed charges,Implant Device,1525.24,34,,1525.24,percent of total billed charges,Implant Device,1525.24,34,,1525.24,percent of total billed charges,Implant Device,1525.24,34,,1525.24,percent of total billed charges,Implant Device,1525.24,34,,1525.24,percent of total billed charges,Implant Device,2220.57,,,2220.57,Other,110% of Medicare,1570.1,35,,1570.1,percent of total billed charges,Implant Device,1525.24,34,"Charges > $500, x 34%",1525.24,percent of total billed charges,Implant Device,1570.1,35,,1570.1,percent of total billed charges,Implant Device,1570.1,35,,1570.1,percent of total billed charges,Implant Device,1570.1,35,,1570.1,percent of total billed charges,Implant Device,1570.1,35,,1570.1,percent of total billed charges,Implant Device,1570.1,35,,1570.1,percent of total billed charges,Implant Device,1794.4,40,,1794.4,percent of total billed charges,Implant Device,1570.1,70,,1570.1,percent of total billed charges,All Other,1525.24,34,,1525.24,percent of total billed charges,Implant Device,1525.24,34,,1525.24,percent of total billed charges,Implant Device,1570.1,35,,1570.1,percent of total billed charges,Implant Device,1570.1,35,,1570.1,percent of total billed charges,Implant Device,1570.1,35,,1570.1,percent of total billed charges,Implant Device,1570.1,35,,1570.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1525.24,34,"If Charge > 2,000, then 34 percent",1525.24,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3319.65,
SOLANA 5740107 LORDOTC ALLOGRAFT 7X11X14,C1713,HCPCS,,79004040,CDM,278,RC,,,both,,,4486,3319.65,,,3319.65,Other,150% of Medicare + 9.63% HCRA Surcharge,2018.7,45,,2018.7,percent of total billed charges,Critical Access Hospital RCC factor,1525.24,34,,1525.24,percent of total billed charges,Implant Device,1525.24,34,,1525.24,percent of total billed charges,Implant Device,1525.24,34,,1525.24,percent of total billed charges,Implant Device,1525.24,34,,1525.24,percent of total billed charges,Implant Device,1525.24,34,,1525.24,percent of total billed charges,Implant Device,2220.57,,,2220.57,Other,110% of Medicare,1570.1,35,,1570.1,percent of total billed charges,Implant Device,1525.24,34,"Charges > $500, x 34%",1525.24,percent of total billed charges,Implant Device,1570.1,35,,1570.1,percent of total billed charges,Implant Device,1570.1,35,,1570.1,percent of total billed charges,Implant Device,1570.1,35,,1570.1,percent of total billed charges,Implant Device,1570.1,35,,1570.1,percent of total billed charges,Implant Device,1570.1,35,,1570.1,percent of total billed charges,Implant Device,1794.4,40,,1794.4,percent of total billed charges,Implant Device,1570.1,70,,1570.1,percent of total billed charges,All Other,1525.24,34,,1525.24,percent of total billed charges,Implant Device,1525.24,34,,1525.24,percent of total billed charges,Implant Device,1570.1,35,,1570.1,percent of total billed charges,Implant Device,1570.1,35,,1570.1,percent of total billed charges,Implant Device,1570.1,35,,1570.1,percent of total billed charges,Implant Device,1570.1,35,,1570.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1525.24,34,"If Charge > 2,000, then 34 percent",1525.24,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3319.65,
ST JUDE 2088TC TENDRIL STS 58CM,C1898,HCPCS,,79004044,CDM,278,RC,,,both,,,1650,1221,,,1221,Other,150% of Medicare + 9.63% HCRA Surcharge,742.5,45,,742.5,percent of total billed charges,Critical Access Hospital RCC factor,561,34,,561,percent of total billed charges,Implant Device,561,34,,561,percent of total billed charges,Implant Device,561,34,,561,percent of total billed charges,Implant Device,561,34,,561,percent of total billed charges,Implant Device,561,34,,561,percent of total billed charges,Implant Device,816.75,,,816.75,Other,110% of Medicare,577.5,35,,577.5,percent of total billed charges,Implant Device,561,34,"Charges > $500, x 34%",561,percent of total billed charges,Implant Device,577.5,35,,577.5,percent of total billed charges,Implant Device,577.5,35,,577.5,percent of total billed charges,Implant Device,577.5,35,,577.5,percent of total billed charges,Implant Device,577.5,35,,577.5,percent of total billed charges,Implant Device,577.5,35,,577.5,percent of total billed charges,Implant Device,660,40,,660,percent of total billed charges,Implant Device,577.5,70,,577.5,percent of total billed charges,All Other,561,34,,561,percent of total billed charges,Implant Device,561,34,,561,percent of total billed charges,Implant Device,577.5,35,,577.5,percent of total billed charges,Implant Device,577.5,35,,577.5,percent of total billed charges,Implant Device,577.5,35,,577.5,percent of total billed charges,Implant Device,577.5,35,,577.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1221,
STRYKER 1822-0939S NAIL TIBIAL STD 9X390,C1713,HCPCS,,79004045,CDM,278,RC,,,both,,,5131,3796.95,,,3796.95,Other,150% of Medicare + 9.63% HCRA Surcharge,2308.95,45,,2308.95,percent of total billed charges,Critical Access Hospital RCC factor,1744.54,34,,1744.54,percent of total billed charges,Implant Device,1744.54,34,,1744.54,percent of total billed charges,Implant Device,1744.54,34,,1744.54,percent of total billed charges,Implant Device,1744.54,34,,1744.54,percent of total billed charges,Implant Device,1744.54,34,,1744.54,percent of total billed charges,Implant Device,2539.85,,,2539.85,Other,110% of Medicare,1795.85,35,,1795.85,percent of total billed charges,Implant Device,1744.54,34,"Charges > $500, x 34%",1744.54,percent of total billed charges,Implant Device,1795.85,35,,1795.85,percent of total billed charges,Implant Device,1795.85,35,,1795.85,percent of total billed charges,Implant Device,1795.85,35,,1795.85,percent of total billed charges,Implant Device,1795.85,35,,1795.85,percent of total billed charges,Implant Device,1795.85,35,,1795.85,percent of total billed charges,Implant Device,2052.4,40,,2052.4,percent of total billed charges,Implant Device,1795.85,70,,1795.85,percent of total billed charges,All Other,1744.54,34,,1744.54,percent of total billed charges,Implant Device,1744.54,34,,1744.54,percent of total billed charges,Implant Device,1795.85,35,,1795.85,percent of total billed charges,Implant Device,1795.85,35,,1795.85,percent of total billed charges,Implant Device,1795.85,35,,1795.85,percent of total billed charges,Implant Device,1795.85,35,,1795.85,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1744.54,34,"If Charge > 2,000, then 34 percent",1744.54,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3796.95,
STRYKER 58-23212E BONE SCREW 2.3X12MM,C1713,HCPCS,,79004046,CDM,278,RC,,,both,,,265,196.1,,,196.1,Other,150% of Medicare + 9.63% HCRA Surcharge,119.25,45,,119.25,percent of total billed charges,Critical Access Hospital RCC factor,90.1,34,,90.1,percent of total billed charges,Implant Device,90.1,34,,90.1,percent of total billed charges,Implant Device,90.1,34,,90.1,percent of total billed charges,Implant Device,90.1,34,,90.1,percent of total billed charges,Implant Device,90.1,34,,90.1,percent of total billed charges,Implant Device,131.18,,,131.18,Other,110% of Medicare,92.75,35,,92.75,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,92.75,35,,92.75,percent of total billed charges,Implant Device,92.75,35,,92.75,percent of total billed charges,Implant Device,92.75,35,,92.75,percent of total billed charges,Implant Device,92.75,35,,92.75,percent of total billed charges,Implant Device,92.75,35,,92.75,percent of total billed charges,Implant Device,106,40,,106,percent of total billed charges,Implant Device,92.75,70,,92.75,percent of total billed charges,All Other,90.1,34,,90.1,percent of total billed charges,Implant Device,90.1,34,,90.1,percent of total billed charges,Implant Device,92.75,35,,92.75,percent of total billed charges,Implant Device,92.75,35,,92.75,percent of total billed charges,Implant Device,92.75,35,,92.75,percent of total billed charges,Implant Device,92.75,35,,92.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,196.1,
STRYKER 00-7818-050-00 UNI FEM HEAD 50MM,C1776,HCPCS,,79004047,CDM,278,RC,,,both,,,1886,1395.64,,,1395.64,Other,150% of Medicare + 9.63% HCRA Surcharge,848.7,45,,848.7,percent of total billed charges,Critical Access Hospital RCC factor,641.24,34,,641.24,percent of total billed charges,Implant Device,641.24,34,,641.24,percent of total billed charges,Implant Device,641.24,34,,641.24,percent of total billed charges,Implant Device,641.24,34,,641.24,percent of total billed charges,Implant Device,641.24,34,,641.24,percent of total billed charges,Implant Device,933.57,,,933.57,Other,110% of Medicare,660.1,35,,660.1,percent of total billed charges,Implant Device,641.24,34,"Charges > $500, x 34%",641.24,percent of total billed charges,Implant Device,660.1,35,,660.1,percent of total billed charges,Implant Device,660.1,35,,660.1,percent of total billed charges,Implant Device,660.1,35,,660.1,percent of total billed charges,Implant Device,660.1,35,,660.1,percent of total billed charges,Implant Device,660.1,35,,660.1,percent of total billed charges,Implant Device,754.4,40,,754.4,percent of total billed charges,Implant Device,660.1,70,,660.1,percent of total billed charges,All Other,641.24,34,,641.24,percent of total billed charges,Implant Device,641.24,34,,641.24,percent of total billed charges,Implant Device,660.1,35,,660.1,percent of total billed charges,Implant Device,660.1,35,,660.1,percent of total billed charges,Implant Device,660.1,35,,660.1,percent of total billed charges,Implant Device,660.1,35,,660.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1395.64,
STRYKER 602700 SCREW 6.5X100,C1713,HCPCS,,79004048,CDM,278,RC,,,both,,,753,557.22,,,557.22,Other,150% of Medicare + 9.63% HCRA Surcharge,338.85,45,,338.85,percent of total billed charges,Critical Access Hospital RCC factor,256.02,34,,256.02,percent of total billed charges,Implant Device,256.02,34,,256.02,percent of total billed charges,Implant Device,256.02,34,,256.02,percent of total billed charges,Implant Device,256.02,34,,256.02,percent of total billed charges,Implant Device,256.02,34,,256.02,percent of total billed charges,Implant Device,372.74,,,372.74,Other,110% of Medicare,263.55,35,,263.55,percent of total billed charges,Implant Device,256.02,34,"Charges > $500, x 34%",256.02,percent of total billed charges,Implant Device,263.55,35,,263.55,percent of total billed charges,Implant Device,263.55,35,,263.55,percent of total billed charges,Implant Device,263.55,35,,263.55,percent of total billed charges,Implant Device,263.55,35,,263.55,percent of total billed charges,Implant Device,263.55,35,,263.55,percent of total billed charges,Implant Device,301.2,40,,301.2,percent of total billed charges,Implant Device,263.55,70,,263.55,percent of total billed charges,All Other,256.02,34,,256.02,percent of total billed charges,Implant Device,256.02,34,,256.02,percent of total billed charges,Implant Device,263.55,35,,263.55,percent of total billed charges,Implant Device,263.55,35,,263.55,percent of total billed charges,Implant Device,263.55,35,,263.55,percent of total billed charges,Implant Device,263.55,35,,263.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,557.22,
STRYKER 1363-50-000 FXHEAD HIP BALL 50MM,C1776,HCPCS,,79004049,CDM,278,RC,,,both,,,922,682.28,,,682.28,Other,150% of Medicare + 9.63% HCRA Surcharge,414.9,45,,414.9,percent of total billed charges,Critical Access Hospital RCC factor,313.48,34,,313.48,percent of total billed charges,Implant Device,313.48,34,,313.48,percent of total billed charges,Implant Device,313.48,34,,313.48,percent of total billed charges,Implant Device,313.48,34,,313.48,percent of total billed charges,Implant Device,313.48,34,,313.48,percent of total billed charges,Implant Device,456.39,,,456.39,Other,110% of Medicare,322.7,35,,322.7,percent of total billed charges,Implant Device,313.48,34,"Charges > $500, x 34%",313.48,percent of total billed charges,Implant Device,322.7,35,,322.7,percent of total billed charges,Implant Device,322.7,35,,322.7,percent of total billed charges,Implant Device,322.7,35,,322.7,percent of total billed charges,Implant Device,322.7,35,,322.7,percent of total billed charges,Implant Device,322.7,35,,322.7,percent of total billed charges,Implant Device,368.8,40,,368.8,percent of total billed charges,Implant Device,322.7,70,,322.7,percent of total billed charges,All Other,313.48,34,,313.48,percent of total billed charges,Implant Device,313.48,34,,313.48,percent of total billed charges,Implant Device,322.7,35,,322.7,percent of total billed charges,Implant Device,322.7,35,,322.7,percent of total billed charges,Implant Device,322.7,35,,322.7,percent of total billed charges,Implant Device,322.7,35,,322.7,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,682.28,
STRYKER 5542-P-0048 TSA GLENOID SZ48,C1776,HCPCS,,79004050,CDM,278,RC,,,both,,,8856,6553.46,,,6553.46,Other,150% of Medicare + 9.63% HCRA Surcharge,3985.2,45,,3985.2,percent of total billed charges,Critical Access Hospital RCC factor,3011.04,34,,3011.04,percent of total billed charges,Implant Device,3011.04,34,,3011.04,percent of total billed charges,Implant Device,3011.04,34,,3011.04,percent of total billed charges,Implant Device,3011.04,34,,3011.04,percent of total billed charges,Implant Device,3011.04,34,,3011.04,percent of total billed charges,Implant Device,4383.72,,,4383.72,Other,110% of Medicare,3099.6,35,,3099.6,percent of total billed charges,Implant Device,3011.04,34,"Charges > $500, x 34%",3011.04,percent of total billed charges,Implant Device,3099.6,35,,3099.6,percent of total billed charges,Implant Device,3099.6,35,,3099.6,percent of total billed charges,Implant Device,3099.6,35,,3099.6,percent of total billed charges,Implant Device,3099.6,35,,3099.6,percent of total billed charges,Implant Device,3099.6,35,,3099.6,percent of total billed charges,Implant Device,3542.4,40,,3542.4,percent of total billed charges,Implant Device,3099.6,70,,3099.6,percent of total billed charges,All Other,3011.04,34,,3011.04,percent of total billed charges,Implant Device,3011.04,34,,3011.04,percent of total billed charges,Implant Device,3099.6,35,,3099.6,percent of total billed charges,Implant Device,3099.6,35,,3099.6,percent of total billed charges,Implant Device,3099.6,35,,3099.6,percent of total billed charges,Implant Device,3099.6,35,,3099.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3011.04,34,"If Charge > 2,000, then 34 percent",3011.04,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,6553.46,
STRYKER 5552-E-4416 TSA HUMERAL HEAD,C1776,HCPCS,,79004051,CDM,278,RC,,,both,,,3675,2719.51,,,2719.51,Other,150% of Medicare + 9.63% HCRA Surcharge,1653.75,45,,1653.75,percent of total billed charges,Critical Access Hospital RCC factor,1249.5,34,,1249.5,percent of total billed charges,Implant Device,1249.5,34,,1249.5,percent of total billed charges,Implant Device,1249.5,34,,1249.5,percent of total billed charges,Implant Device,1249.5,34,,1249.5,percent of total billed charges,Implant Device,1249.5,34,,1249.5,percent of total billed charges,Implant Device,1819.13,,,1819.13,Other,110% of Medicare,1286.25,35,,1286.25,percent of total billed charges,Implant Device,1249.5,34,"Charges > $500, x 34%",1249.5,percent of total billed charges,Implant Device,1286.25,35,,1286.25,percent of total billed charges,Implant Device,1286.25,35,,1286.25,percent of total billed charges,Implant Device,1286.25,35,,1286.25,percent of total billed charges,Implant Device,1286.25,35,,1286.25,percent of total billed charges,Implant Device,1286.25,35,,1286.25,percent of total billed charges,Implant Device,1470,40,,1470,percent of total billed charges,Implant Device,1286.25,70,,1286.25,percent of total billed charges,All Other,1249.5,34,,1249.5,percent of total billed charges,Implant Device,1249.5,34,,1249.5,percent of total billed charges,Implant Device,1286.25,35,,1286.25,percent of total billed charges,Implant Device,1286.25,35,,1286.25,percent of total billed charges,Implant Device,1286.25,35,,1286.25,percent of total billed charges,Implant Device,1286.25,35,,1286.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1249.5,34,"If Charge > 2,000, then 34 percent",1249.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2719.51,
STRYKER 59-23015 BONE SCREW 2.3X15,C1713,HCPCS,,79004052,CDM,278,RC,,,both,,,349,258.26,,,258.26,Other,150% of Medicare + 9.63% HCRA Surcharge,157.05,45,,157.05,percent of total billed charges,Critical Access Hospital RCC factor,118.66,34,,118.66,percent of total billed charges,Implant Device,118.66,34,,118.66,percent of total billed charges,Implant Device,118.66,34,,118.66,percent of total billed charges,Implant Device,118.66,34,,118.66,percent of total billed charges,Implant Device,118.66,34,,118.66,percent of total billed charges,Implant Device,172.76,,,172.76,Other,110% of Medicare,122.15,35,,122.15,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,122.15,35,,122.15,percent of total billed charges,Implant Device,122.15,35,,122.15,percent of total billed charges,Implant Device,122.15,35,,122.15,percent of total billed charges,Implant Device,122.15,35,,122.15,percent of total billed charges,Implant Device,122.15,35,,122.15,percent of total billed charges,Implant Device,139.6,40,,139.6,percent of total billed charges,Implant Device,122.15,70,,122.15,percent of total billed charges,All Other,118.66,34,,118.66,percent of total billed charges,Implant Device,118.66,34,,118.66,percent of total billed charges,Implant Device,122.15,35,,122.15,percent of total billed charges,Implant Device,122.15,35,,122.15,percent of total billed charges,Implant Device,122.15,35,,122.15,percent of total billed charges,Implant Device,122.15,35,,122.15,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,258.26,
STRYKER 430208 8 HOLE 1/3 TUBULAR PLATE,C1713,HCPCS,,79004053,CDM,278,RC,,,both,,,202,149.48,,,149.48,Other,150% of Medicare + 9.63% HCRA Surcharge,90.9,45,,90.9,percent of total billed charges,Critical Access Hospital RCC factor,68.68,34,,68.68,percent of total billed charges,Implant Device,68.68,34,,68.68,percent of total billed charges,Implant Device,68.68,34,,68.68,percent of total billed charges,Implant Device,68.68,34,,68.68,percent of total billed charges,Implant Device,68.68,34,,68.68,percent of total billed charges,Implant Device,99.99,,,99.99,Other,110% of Medicare,70.7,35,,70.7,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,70.7,35,,70.7,percent of total billed charges,Implant Device,70.7,35,,70.7,percent of total billed charges,Implant Device,70.7,35,,70.7,percent of total billed charges,Implant Device,70.7,35,,70.7,percent of total billed charges,Implant Device,70.7,35,,70.7,percent of total billed charges,Implant Device,80.8,40,,80.8,percent of total billed charges,Implant Device,70.7,70,,70.7,percent of total billed charges,All Other,68.68,34,,68.68,percent of total billed charges,Implant Device,68.68,34,,68.68,percent of total billed charges,Implant Device,70.7,35,,70.7,percent of total billed charges,Implant Device,70.7,35,,70.7,percent of total billed charges,Implant Device,70.7,35,,70.7,percent of total billed charges,Implant Device,70.7,35,,70.7,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,149.48,
STRYKER 338655 CORTICAL SCREW 3.5X55MM,C1713,HCPCS,,79004054,CDM,278,RC,,,both,,,70,51.8,,,51.8,Other,150% of Medicare + 9.63% HCRA Surcharge,31.5,45,,31.5,percent of total billed charges,Critical Access Hospital RCC factor,23.8,34,,23.8,percent of total billed charges,Implant Device,23.8,34,,23.8,percent of total billed charges,Implant Device,23.8,34,,23.8,percent of total billed charges,Implant Device,23.8,34,,23.8,percent of total billed charges,Implant Device,23.8,34,,23.8,percent of total billed charges,Implant Device,34.65,,,34.65,Other,110% of Medicare,24.5,35,,24.5,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,24.5,35,,24.5,percent of total billed charges,Implant Device,24.5,35,,24.5,percent of total billed charges,Implant Device,24.5,35,,24.5,percent of total billed charges,Implant Device,24.5,35,,24.5,percent of total billed charges,Implant Device,24.5,35,,24.5,percent of total billed charges,Implant Device,28,40,,28,percent of total billed charges,Implant Device,24.5,70,,24.5,percent of total billed charges,All Other,23.8,34,,23.8,percent of total billed charges,Implant Device,23.8,34,,23.8,percent of total billed charges,Implant Device,24.5,35,,24.5,percent of total billed charges,Implant Device,24.5,35,,24.5,percent of total billed charges,Implant Device,24.5,35,,24.5,percent of total billed charges,Implant Device,24.5,35,,24.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,51.8,
STRYKER 1828-1234S FEMORAL NAIL 12X340MM,C1713,HCPCS,,79004055,CDM,278,RC,,,both,,,7031,5202.96,,,5202.96,Other,150% of Medicare + 9.63% HCRA Surcharge,3163.95,45,,3163.95,percent of total billed charges,Critical Access Hospital RCC factor,2390.54,34,,2390.54,percent of total billed charges,Implant Device,2390.54,34,,2390.54,percent of total billed charges,Implant Device,2390.54,34,,2390.54,percent of total billed charges,Implant Device,2390.54,34,,2390.54,percent of total billed charges,Implant Device,2390.54,34,,2390.54,percent of total billed charges,Implant Device,3480.35,,,3480.35,Other,110% of Medicare,2460.85,35,,2460.85,percent of total billed charges,Implant Device,2390.54,34,"Charges > $500, x 34%",2390.54,percent of total billed charges,Implant Device,2460.85,35,,2460.85,percent of total billed charges,Implant Device,2460.85,35,,2460.85,percent of total billed charges,Implant Device,2460.85,35,,2460.85,percent of total billed charges,Implant Device,2460.85,35,,2460.85,percent of total billed charges,Implant Device,2460.85,35,,2460.85,percent of total billed charges,Implant Device,2812.4,40,,2812.4,percent of total billed charges,Implant Device,2460.85,70,,2460.85,percent of total billed charges,All Other,2390.54,34,,2390.54,percent of total billed charges,Implant Device,2390.54,34,,2390.54,percent of total billed charges,Implant Device,2460.85,35,,2460.85,percent of total billed charges,Implant Device,2460.85,35,,2460.85,percent of total billed charges,Implant Device,2460.85,35,,2460.85,percent of total billed charges,Implant Device,2460.85,35,,2460.85,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2390.54,34,"If Charge > 2,000, then 34 percent",2390.54,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5202.96,
STRYKER 6570-0-128 DELTA V40 FEM HD 28MM,C1776,HCPCS,,79004056,CDM,278,RC,,,both,,,2503,1852.23,,,1852.23,Other,150% of Medicare + 9.63% HCRA Surcharge,1126.35,45,,1126.35,percent of total billed charges,Critical Access Hospital RCC factor,851.02,34,,851.02,percent of total billed charges,Implant Device,851.02,34,,851.02,percent of total billed charges,Implant Device,851.02,34,,851.02,percent of total billed charges,Implant Device,851.02,34,,851.02,percent of total billed charges,Implant Device,851.02,34,,851.02,percent of total billed charges,Implant Device,1238.99,,,1238.99,Other,110% of Medicare,876.05,35,,876.05,percent of total billed charges,Implant Device,851.02,34,"Charges > $500, x 34%",851.02,percent of total billed charges,Implant Device,876.05,35,,876.05,percent of total billed charges,Implant Device,876.05,35,,876.05,percent of total billed charges,Implant Device,876.05,35,,876.05,percent of total billed charges,Implant Device,876.05,35,,876.05,percent of total billed charges,Implant Device,876.05,35,,876.05,percent of total billed charges,Implant Device,1001.2,40,,1001.2,percent of total billed charges,Implant Device,876.05,70,,876.05,percent of total billed charges,All Other,851.02,34,,851.02,percent of total billed charges,Implant Device,851.02,34,,851.02,percent of total billed charges,Implant Device,876.05,35,,876.05,percent of total billed charges,Implant Device,876.05,35,,876.05,percent of total billed charges,Implant Device,876.05,35,,876.05,percent of total billed charges,Implant Device,876.05,35,,876.05,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,851.02,34,"If Charge > 2,000, then 34 percent",851.02,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1852.23,
STRYKER 59-17010 BONE SCREW 1.7X10MM,C1713,HCPCS,,79004057,CDM,278,RC,,,both,,,240,177.6,,,177.6,Other,150% of Medicare + 9.63% HCRA Surcharge,108,45,,108,percent of total billed charges,Critical Access Hospital RCC factor,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,118.8,,,118.8,Other,110% of Medicare,84,35,,84,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,96,40,,96,percent of total billed charges,Implant Device,84,70,,84,percent of total billed charges,All Other,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,177.6,
STRYKER 6495-2-030 DIST FEM COMP LT 65MM,C1776,HCPCS,,79004059,CDM,278,RC,,,both,,,19753,14617.27,,,14617.27,Other,150% of Medicare + 9.63% HCRA Surcharge,8888.85,45,,8888.85,percent of total billed charges,Critical Access Hospital RCC factor,6716.02,34,,6716.02,percent of total billed charges,Implant Device,6716.02,34,,6716.02,percent of total billed charges,Implant Device,6716.02,34,,6716.02,percent of total billed charges,Implant Device,6716.02,34,,6716.02,percent of total billed charges,Implant Device,6716.02,34,,6716.02,percent of total billed charges,Implant Device,9777.74,,,9777.74,Other,110% of Medicare,6913.55,35,,6913.55,percent of total billed charges,Implant Device,6716.02,34,"Charges > $500, x 34%",6716.02,percent of total billed charges,Implant Device,6913.55,35,,6913.55,percent of total billed charges,Implant Device,6913.55,35,,6913.55,percent of total billed charges,Implant Device,6913.55,35,,6913.55,percent of total billed charges,Implant Device,6913.55,35,,6913.55,percent of total billed charges,Implant Device,6913.55,35,,6913.55,percent of total billed charges,Implant Device,7901.2,40,,7901.2,percent of total billed charges,Implant Device,6913.55,70,,6913.55,percent of total billed charges,All Other,6716.02,34,,6716.02,percent of total billed charges,Implant Device,6716.02,34,,6716.02,percent of total billed charges,Implant Device,6913.55,35,,6913.55,percent of total billed charges,Implant Device,6913.55,35,,6913.55,percent of total billed charges,Implant Device,6913.55,35,,6913.55,percent of total billed charges,Implant Device,6913.55,35,,6913.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,6716.02,34,"If Charge > 2,000, then 34 percent",6716.02,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,14617.27,
STRYKER 3713-46 LOCKING SCREW 5X46,C1713,HCPCS,,79004060,CDM,278,RC,,,both,,,474,350.76,,,350.76,Other,150% of Medicare + 9.63% HCRA Surcharge,213.3,45,,213.3,percent of total billed charges,Critical Access Hospital RCC factor,161.16,34,,161.16,percent of total billed charges,Implant Device,161.16,34,,161.16,percent of total billed charges,Implant Device,161.16,34,,161.16,percent of total billed charges,Implant Device,161.16,34,,161.16,percent of total billed charges,Implant Device,161.16,34,,161.16,percent of total billed charges,Implant Device,234.63,,,234.63,Other,110% of Medicare,165.9,35,,165.9,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,165.9,35,,165.9,percent of total billed charges,Implant Device,165.9,35,,165.9,percent of total billed charges,Implant Device,165.9,35,,165.9,percent of total billed charges,Implant Device,165.9,35,,165.9,percent of total billed charges,Implant Device,165.9,35,,165.9,percent of total billed charges,Implant Device,189.6,40,,189.6,percent of total billed charges,Implant Device,165.9,70,,165.9,percent of total billed charges,All Other,161.16,34,,161.16,percent of total billed charges,Implant Device,161.16,34,,161.16,percent of total billed charges,Implant Device,165.9,35,,165.9,percent of total billed charges,Implant Device,165.9,35,,165.9,percent of total billed charges,Implant Device,165.9,35,,165.9,percent of total billed charges,Implant Device,165.9,35,,165.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,350.76,
STRYKER 57-13405 COMPRESSION PLATE,C1713,HCPCS,,79004061,CDM,278,RC,,,both,,,857,634.18,,,634.18,Other,150% of Medicare + 9.63% HCRA Surcharge,385.65,45,,385.65,percent of total billed charges,Critical Access Hospital RCC factor,291.38,34,,291.38,percent of total billed charges,Implant Device,291.38,34,,291.38,percent of total billed charges,Implant Device,291.38,34,,291.38,percent of total billed charges,Implant Device,291.38,34,,291.38,percent of total billed charges,Implant Device,291.38,34,,291.38,percent of total billed charges,Implant Device,424.22,,,424.22,Other,110% of Medicare,299.95,35,,299.95,percent of total billed charges,Implant Device,291.38,34,"Charges > $500, x 34%",291.38,percent of total billed charges,Implant Device,299.95,35,,299.95,percent of total billed charges,Implant Device,299.95,35,,299.95,percent of total billed charges,Implant Device,299.95,35,,299.95,percent of total billed charges,Implant Device,299.95,35,,299.95,percent of total billed charges,Implant Device,299.95,35,,299.95,percent of total billed charges,Implant Device,342.8,40,,342.8,percent of total billed charges,Implant Device,299.95,70,,299.95,percent of total billed charges,All Other,291.38,34,,291.38,percent of total billed charges,Implant Device,291.38,34,,291.38,percent of total billed charges,Implant Device,299.95,35,,299.95,percent of total billed charges,Implant Device,299.95,35,,299.95,percent of total billed charges,Implant Device,299.95,35,,299.95,percent of total billed charges,Implant Device,299.95,35,,299.95,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,634.18,
STRYKER 437530 10 HOLE PLATE DIS FEMUR,C1713,HCPCS,,79004062,CDM,278,RC,,,both,,,4954,3665.97,,,3665.97,Other,150% of Medicare + 9.63% HCRA Surcharge,2229.3,45,,2229.3,percent of total billed charges,Critical Access Hospital RCC factor,1684.36,34,,1684.36,percent of total billed charges,Implant Device,1684.36,34,,1684.36,percent of total billed charges,Implant Device,1684.36,34,,1684.36,percent of total billed charges,Implant Device,1684.36,34,,1684.36,percent of total billed charges,Implant Device,1684.36,34,,1684.36,percent of total billed charges,Implant Device,2452.23,,,2452.23,Other,110% of Medicare,1733.9,35,,1733.9,percent of total billed charges,Implant Device,1684.36,34,"Charges > $500, x 34%",1684.36,percent of total billed charges,Implant Device,1733.9,35,,1733.9,percent of total billed charges,Implant Device,1733.9,35,,1733.9,percent of total billed charges,Implant Device,1733.9,35,,1733.9,percent of total billed charges,Implant Device,1733.9,35,,1733.9,percent of total billed charges,Implant Device,1733.9,35,,1733.9,percent of total billed charges,Implant Device,1981.6,40,,1981.6,percent of total billed charges,Implant Device,1733.9,70,,1733.9,percent of total billed charges,All Other,1684.36,34,,1684.36,percent of total billed charges,Implant Device,1684.36,34,,1684.36,percent of total billed charges,Implant Device,1733.9,35,,1733.9,percent of total billed charges,Implant Device,1733.9,35,,1733.9,percent of total billed charges,Implant Device,1733.9,35,,1733.9,percent of total billed charges,Implant Device,1733.9,35,,1733.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1684.36,34,"If Charge > 2,000, then 34 percent",1684.36,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3665.97,
STRYKER 5317016E LOCK SCREW 1.7X16MM,C1713,HCPCS,,79004063,CDM,278,RC,,,both,,,306,226.44,,,226.44,Other,150% of Medicare + 9.63% HCRA Surcharge,137.7,45,,137.7,percent of total billed charges,Critical Access Hospital RCC factor,104.04,34,,104.04,percent of total billed charges,Implant Device,104.04,34,,104.04,percent of total billed charges,Implant Device,104.04,34,,104.04,percent of total billed charges,Implant Device,104.04,34,,104.04,percent of total billed charges,Implant Device,104.04,34,,104.04,percent of total billed charges,Implant Device,151.47,,,151.47,Other,110% of Medicare,107.1,35,,107.1,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,107.1,35,,107.1,percent of total billed charges,Implant Device,107.1,35,,107.1,percent of total billed charges,Implant Device,107.1,35,,107.1,percent of total billed charges,Implant Device,107.1,35,,107.1,percent of total billed charges,Implant Device,107.1,35,,107.1,percent of total billed charges,Implant Device,122.4,40,,122.4,percent of total billed charges,Implant Device,107.1,70,,107.1,percent of total billed charges,All Other,104.04,34,,104.04,percent of total billed charges,Implant Device,104.04,34,,104.04,percent of total billed charges,Implant Device,107.1,35,,107.1,percent of total billed charges,Implant Device,107.1,35,,107.1,percent of total billed charges,Implant Device,107.1,35,,107.1,percent of total billed charges,Implant Device,107.1,35,,107.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,226.44,
STRYKER 345560 CANCELLOUS SCREW 4.0X60MM,C1713,HCPCS,,79004064,CDM,278,RC,,,both,,,68,50.32,,,50.32,Other,150% of Medicare + 9.63% HCRA Surcharge,30.6,45,,30.6,percent of total billed charges,Critical Access Hospital RCC factor,23.12,34,,23.12,percent of total billed charges,Implant Device,23.12,34,,23.12,percent of total billed charges,Implant Device,23.12,34,,23.12,percent of total billed charges,Implant Device,23.12,34,,23.12,percent of total billed charges,Implant Device,23.12,34,,23.12,percent of total billed charges,Implant Device,33.66,,,33.66,Other,110% of Medicare,23.8,35,,23.8,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,23.8,35,,23.8,percent of total billed charges,Implant Device,23.8,35,,23.8,percent of total billed charges,Implant Device,23.8,35,,23.8,percent of total billed charges,Implant Device,23.8,35,,23.8,percent of total billed charges,Implant Device,23.8,35,,23.8,percent of total billed charges,Implant Device,27.2,40,,27.2,percent of total billed charges,Implant Device,23.8,70,,23.8,percent of total billed charges,All Other,23.12,34,,23.12,percent of total billed charges,Implant Device,23.12,34,,23.12,percent of total billed charges,Implant Device,23.8,35,,23.8,percent of total billed charges,Implant Device,23.8,35,,23.8,percent of total billed charges,Implant Device,23.8,35,,23.8,percent of total billed charges,Implant Device,23.8,35,,23.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,50.32,
STRYKER 006-4000 C-TAPER FEM HEAD 40MM,C1776,HCPCS,,79004065,CDM,278,RC,,,both,,,5719,4232.07,,,4232.07,Other,150% of Medicare + 9.63% HCRA Surcharge,2573.55,45,,2573.55,percent of total billed charges,Critical Access Hospital RCC factor,1944.46,34,,1944.46,percent of total billed charges,Implant Device,1944.46,34,,1944.46,percent of total billed charges,Implant Device,1944.46,34,,1944.46,percent of total billed charges,Implant Device,1944.46,34,,1944.46,percent of total billed charges,Implant Device,1944.46,34,,1944.46,percent of total billed charges,Implant Device,2830.91,,,2830.91,Other,110% of Medicare,2001.65,35,,2001.65,percent of total billed charges,Implant Device,1944.46,34,"Charges > $500, x 34%",1944.46,percent of total billed charges,Implant Device,2001.65,35,,2001.65,percent of total billed charges,Implant Device,2001.65,35,,2001.65,percent of total billed charges,Implant Device,2001.65,35,,2001.65,percent of total billed charges,Implant Device,2001.65,35,,2001.65,percent of total billed charges,Implant Device,2001.65,35,,2001.65,percent of total billed charges,Implant Device,2287.6,40,,2287.6,percent of total billed charges,Implant Device,2001.65,70,,2001.65,percent of total billed charges,All Other,1944.46,34,,1944.46,percent of total billed charges,Implant Device,1944.46,34,,1944.46,percent of total billed charges,Implant Device,2001.65,35,,2001.65,percent of total billed charges,Implant Device,2001.65,35,,2001.65,percent of total billed charges,Implant Device,2001.65,35,,2001.65,percent of total billed charges,Implant Device,2001.65,35,,2001.65,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1944.46,34,"If Charge > 2,000, then 34 percent",1944.46,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4232.07,
STRYKER 5030-4-250 APEX PINS 35MM,C1713,HCPCS,,79004066,CDM,278,RC,,,both,,,620,458.8,,,458.8,Other,150% of Medicare + 9.63% HCRA Surcharge,279,45,,279,percent of total billed charges,Critical Access Hospital RCC factor,210.8,34,,210.8,percent of total billed charges,Implant Device,210.8,34,,210.8,percent of total billed charges,Implant Device,210.8,34,,210.8,percent of total billed charges,Implant Device,210.8,34,,210.8,percent of total billed charges,Implant Device,210.8,34,,210.8,percent of total billed charges,Implant Device,306.9,,,306.9,Other,110% of Medicare,217,35,,217,percent of total billed charges,Implant Device,210.8,34,"Charges > $500, x 34%",210.8,percent of total billed charges,Implant Device,217,35,,217,percent of total billed charges,Implant Device,217,35,,217,percent of total billed charges,Implant Device,217,35,,217,percent of total billed charges,Implant Device,217,35,,217,percent of total billed charges,Implant Device,217,35,,217,percent of total billed charges,Implant Device,248,40,,248,percent of total billed charges,Implant Device,217,70,,217,percent of total billed charges,All Other,210.8,34,,210.8,percent of total billed charges,Implant Device,210.8,34,,210.8,percent of total billed charges,Implant Device,217,35,,217,percent of total billed charges,Implant Device,217,35,,217,percent of total billed charges,Implant Device,217,35,,217,percent of total billed charges,Implant Device,217,35,,217,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,458.8,
STRYKER 371544 LOCK SCREW SS 4.0X44MM,C1713,HCPCS,,79004067,CDM,278,RC,,,both,,,569,421.06,,,421.06,Other,150% of Medicare + 9.63% HCRA Surcharge,256.05,45,,256.05,percent of total billed charges,Critical Access Hospital RCC factor,193.46,34,,193.46,percent of total billed charges,Implant Device,193.46,34,,193.46,percent of total billed charges,Implant Device,193.46,34,,193.46,percent of total billed charges,Implant Device,193.46,34,,193.46,percent of total billed charges,Implant Device,193.46,34,,193.46,percent of total billed charges,Implant Device,281.66,,,281.66,Other,110% of Medicare,199.15,35,,199.15,percent of total billed charges,Implant Device,193.46,34,"Charges > $500, x 34%",193.46,percent of total billed charges,Implant Device,199.15,35,,199.15,percent of total billed charges,Implant Device,199.15,35,,199.15,percent of total billed charges,Implant Device,199.15,35,,199.15,percent of total billed charges,Implant Device,199.15,35,,199.15,percent of total billed charges,Implant Device,199.15,35,,199.15,percent of total billed charges,Implant Device,227.6,40,,227.6,percent of total billed charges,Implant Device,199.15,70,,199.15,percent of total billed charges,All Other,193.46,34,,193.46,percent of total billed charges,Implant Device,193.46,34,,193.46,percent of total billed charges,Implant Device,199.15,35,,199.15,percent of total billed charges,Implant Device,199.15,35,,199.15,percent of total billed charges,Implant Device,199.15,35,,199.15,percent of total billed charges,Implant Device,199.15,35,,199.15,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,421.06,
STRYKER 6495-6-040 GMRS EXT 40MM,C1776,HCPCS,,79004068,CDM,278,RC,,,both,,,12541,9280.37,,,9280.37,Other,150% of Medicare + 9.63% HCRA Surcharge,5643.45,45,,5643.45,percent of total billed charges,Critical Access Hospital RCC factor,4263.94,34,,4263.94,percent of total billed charges,Implant Device,4263.94,34,,4263.94,percent of total billed charges,Implant Device,4263.94,34,,4263.94,percent of total billed charges,Implant Device,4263.94,34,,4263.94,percent of total billed charges,Implant Device,4263.94,34,,4263.94,percent of total billed charges,Implant Device,6207.8,,,6207.8,Other,110% of Medicare,4389.35,35,,4389.35,percent of total billed charges,Implant Device,4263.94,34,"Charges > $500, x 34%",4263.94,percent of total billed charges,Implant Device,4389.35,35,,4389.35,percent of total billed charges,Implant Device,4389.35,35,,4389.35,percent of total billed charges,Implant Device,4389.35,35,,4389.35,percent of total billed charges,Implant Device,4389.35,35,,4389.35,percent of total billed charges,Implant Device,4389.35,35,,4389.35,percent of total billed charges,Implant Device,5016.4,40,,5016.4,percent of total billed charges,Implant Device,4389.35,70,,4389.35,percent of total billed charges,All Other,4263.94,34,,4263.94,percent of total billed charges,Implant Device,4263.94,34,,4263.94,percent of total billed charges,Implant Device,4389.35,35,,4389.35,percent of total billed charges,Implant Device,4389.35,35,,4389.35,percent of total billed charges,Implant Device,4389.35,35,,4389.35,percent of total billed charges,Implant Device,4389.35,35,,4389.35,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,4263.94,34,"If Charge > 2,000, then 34 percent",4263.94,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,9280.37,
STRYKER 437208 DIST MED TIB PLATE 8HOLE,C1713,HCPCS,,79004069,CDM,278,RC,,,both,,,5643,4175.83,,,4175.83,Other,150% of Medicare + 9.63% HCRA Surcharge,2539.35,45,,2539.35,percent of total billed charges,Critical Access Hospital RCC factor,1918.62,34,,1918.62,percent of total billed charges,Implant Device,1918.62,34,,1918.62,percent of total billed charges,Implant Device,1918.62,34,,1918.62,percent of total billed charges,Implant Device,1918.62,34,,1918.62,percent of total billed charges,Implant Device,1918.62,34,,1918.62,percent of total billed charges,Implant Device,2793.29,,,2793.29,Other,110% of Medicare,1975.05,35,,1975.05,percent of total billed charges,Implant Device,1918.62,34,"Charges > $500, x 34%",1918.62,percent of total billed charges,Implant Device,1975.05,35,,1975.05,percent of total billed charges,Implant Device,1975.05,35,,1975.05,percent of total billed charges,Implant Device,1975.05,35,,1975.05,percent of total billed charges,Implant Device,1975.05,35,,1975.05,percent of total billed charges,Implant Device,1975.05,35,,1975.05,percent of total billed charges,Implant Device,2257.2,40,,2257.2,percent of total billed charges,Implant Device,1975.05,70,,1975.05,percent of total billed charges,All Other,1918.62,34,,1918.62,percent of total billed charges,Implant Device,1918.62,34,,1918.62,percent of total billed charges,Implant Device,1975.05,35,,1975.05,percent of total billed charges,Implant Device,1975.05,35,,1975.05,percent of total billed charges,Implant Device,1975.05,35,,1975.05,percent of total billed charges,Implant Device,1975.05,35,,1975.05,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1918.62,34,"If Charge > 2,000, then 34 percent",1918.62,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4175.83,
STRYKER 53-17015E LOCK SCREW 1.7X15MM,C1713,HCPCS,,79004070,CDM,278,RC,,,both,,,423,313.02,,,313.02,Other,150% of Medicare + 9.63% HCRA Surcharge,190.35,45,,190.35,percent of total billed charges,Critical Access Hospital RCC factor,143.82,34,,143.82,percent of total billed charges,Implant Device,143.82,34,,143.82,percent of total billed charges,Implant Device,143.82,34,,143.82,percent of total billed charges,Implant Device,143.82,34,,143.82,percent of total billed charges,Implant Device,143.82,34,,143.82,percent of total billed charges,Implant Device,209.39,,,209.39,Other,110% of Medicare,148.05,35,,148.05,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,148.05,35,,148.05,percent of total billed charges,Implant Device,148.05,35,,148.05,percent of total billed charges,Implant Device,148.05,35,,148.05,percent of total billed charges,Implant Device,148.05,35,,148.05,percent of total billed charges,Implant Device,148.05,35,,148.05,percent of total billed charges,Implant Device,169.2,40,,169.2,percent of total billed charges,Implant Device,148.05,70,,148.05,percent of total billed charges,All Other,143.82,34,,143.82,percent of total billed charges,Implant Device,143.82,34,,143.82,percent of total billed charges,Implant Device,148.05,35,,148.05,percent of total billed charges,Implant Device,148.05,35,,148.05,percent of total billed charges,Implant Device,148.05,35,,148.05,percent of total billed charges,Implant Device,148.05,35,,148.05,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,313.02,
STRYKER 3225-0420S NAIL KIT R2.0 TI,C1713,HCPCS,,79004071,CDM,278,RC,,,both,,,6268,4638.34,,,4638.34,Other,150% of Medicare + 9.63% HCRA Surcharge,2820.6,45,,2820.6,percent of total billed charges,Critical Access Hospital RCC factor,2131.12,34,,2131.12,percent of total billed charges,Implant Device,2131.12,34,,2131.12,percent of total billed charges,Implant Device,2131.12,34,,2131.12,percent of total billed charges,Implant Device,2131.12,34,,2131.12,percent of total billed charges,Implant Device,2131.12,34,,2131.12,percent of total billed charges,Implant Device,3102.66,,,3102.66,Other,110% of Medicare,2193.8,35,,2193.8,percent of total billed charges,Implant Device,2131.12,34,"Charges > $500, x 34%",2131.12,percent of total billed charges,Implant Device,2193.8,35,,2193.8,percent of total billed charges,Implant Device,2193.8,35,,2193.8,percent of total billed charges,Implant Device,2193.8,35,,2193.8,percent of total billed charges,Implant Device,2193.8,35,,2193.8,percent of total billed charges,Implant Device,2193.8,35,,2193.8,percent of total billed charges,Implant Device,2507.2,40,,2507.2,percent of total billed charges,Implant Device,2193.8,70,,2193.8,percent of total billed charges,All Other,2131.12,34,,2131.12,percent of total billed charges,Implant Device,2131.12,34,,2131.12,percent of total billed charges,Implant Device,2193.8,35,,2193.8,percent of total billed charges,Implant Device,2193.8,35,,2193.8,percent of total billed charges,Implant Device,2193.8,35,,2193.8,percent of total billed charges,Implant Device,2193.8,35,,2193.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2131.12,34,"If Charge > 2,000, then 34 percent",2131.12,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4638.34,
STRYKER 502-03-56E CLSTR HOLE SHELL 56MM,C1776,HCPCS,,79004072,CDM,278,RC,,,both,,,8929,6607.48,,,6607.48,Other,150% of Medicare + 9.63% HCRA Surcharge,4018.05,45,,4018.05,percent of total billed charges,Critical Access Hospital RCC factor,3035.86,34,,3035.86,percent of total billed charges,Implant Device,3035.86,34,,3035.86,percent of total billed charges,Implant Device,3035.86,34,,3035.86,percent of total billed charges,Implant Device,3035.86,34,,3035.86,percent of total billed charges,Implant Device,3035.86,34,,3035.86,percent of total billed charges,Implant Device,4419.86,,,4419.86,Other,110% of Medicare,3125.15,35,,3125.15,percent of total billed charges,Implant Device,3035.86,34,"Charges > $500, x 34%",3035.86,percent of total billed charges,Implant Device,3125.15,35,,3125.15,percent of total billed charges,Implant Device,3125.15,35,,3125.15,percent of total billed charges,Implant Device,3125.15,35,,3125.15,percent of total billed charges,Implant Device,3125.15,35,,3125.15,percent of total billed charges,Implant Device,3125.15,35,,3125.15,percent of total billed charges,Implant Device,3571.6,40,,3571.6,percent of total billed charges,Implant Device,3125.15,70,,3125.15,percent of total billed charges,All Other,3035.86,34,,3035.86,percent of total billed charges,Implant Device,3035.86,34,,3035.86,percent of total billed charges,Implant Device,3125.15,35,,3125.15,percent of total billed charges,Implant Device,3125.15,35,,3125.15,percent of total billed charges,Implant Device,3125.15,35,,3125.15,percent of total billed charges,Implant Device,3125.15,35,,3125.15,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3035.86,34,"If Charge > 2,000, then 34 percent",3035.86,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,6607.48,
STRYKER 1832-2824S PROX HUM NAIL 8X24MM,C1713,HCPCS,,79004073,CDM,278,RC,,,both,,,5933,4390.43,,,4390.43,Other,150% of Medicare + 9.63% HCRA Surcharge,2669.85,45,,2669.85,percent of total billed charges,Critical Access Hospital RCC factor,2017.22,34,,2017.22,percent of total billed charges,Implant Device,2017.22,34,,2017.22,percent of total billed charges,Implant Device,2017.22,34,,2017.22,percent of total billed charges,Implant Device,2017.22,34,,2017.22,percent of total billed charges,Implant Device,2017.22,34,,2017.22,percent of total billed charges,Implant Device,2936.84,,,2936.84,Other,110% of Medicare,2076.55,35,,2076.55,percent of total billed charges,Implant Device,2017.22,34,"Charges > $500, x 34%",2017.22,percent of total billed charges,Implant Device,2076.55,35,,2076.55,percent of total billed charges,Implant Device,2076.55,35,,2076.55,percent of total billed charges,Implant Device,2076.55,35,,2076.55,percent of total billed charges,Implant Device,2076.55,35,,2076.55,percent of total billed charges,Implant Device,2076.55,35,,2076.55,percent of total billed charges,Implant Device,2373.2,40,,2373.2,percent of total billed charges,Implant Device,2076.55,70,,2076.55,percent of total billed charges,All Other,2017.22,34,,2017.22,percent of total billed charges,Implant Device,2017.22,34,,2017.22,percent of total billed charges,Implant Device,2076.55,35,,2076.55,percent of total billed charges,Implant Device,2076.55,35,,2076.55,percent of total billed charges,Implant Device,2076.55,35,,2076.55,percent of total billed charges,Implant Device,2076.55,35,,2076.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2017.22,34,"If Charge > 2,000, then 34 percent",2017.22,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4390.43,
STRYKER 326085S CANN SCREW 6.5CMX85MM,C1713,HCPCS,,79004074,CDM,278,RC,,,both,,,765,566.1,,,566.1,Other,150% of Medicare + 9.63% HCRA Surcharge,344.25,45,,344.25,percent of total billed charges,Critical Access Hospital RCC factor,260.1,34,,260.1,percent of total billed charges,Implant Device,260.1,34,,260.1,percent of total billed charges,Implant Device,260.1,34,,260.1,percent of total billed charges,Implant Device,260.1,34,,260.1,percent of total billed charges,Implant Device,260.1,34,,260.1,percent of total billed charges,Implant Device,378.68,,,378.68,Other,110% of Medicare,267.75,35,,267.75,percent of total billed charges,Implant Device,260.1,34,"Charges > $500, x 34%",260.1,percent of total billed charges,Implant Device,267.75,35,,267.75,percent of total billed charges,Implant Device,267.75,35,,267.75,percent of total billed charges,Implant Device,267.75,35,,267.75,percent of total billed charges,Implant Device,267.75,35,,267.75,percent of total billed charges,Implant Device,267.75,35,,267.75,percent of total billed charges,Implant Device,306,40,,306,percent of total billed charges,Implant Device,267.75,70,,267.75,percent of total billed charges,All Other,260.1,34,,260.1,percent of total billed charges,Implant Device,260.1,34,,260.1,percent of total billed charges,Implant Device,267.75,35,,267.75,percent of total billed charges,Implant Device,267.75,35,,267.75,percent of total billed charges,Implant Device,267.75,35,,267.75,percent of total billed charges,Implant Device,267.75,35,,267.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,566.1,
STRYKER 340632 NONLOCK SCREW 4.5X32MM,C1713,HCPCS,,79004075,CDM,278,RC,,,both,,,125,92.5,,,92.5,Other,150% of Medicare + 9.63% HCRA Surcharge,56.25,45,,56.25,percent of total billed charges,Critical Access Hospital RCC factor,42.5,34,,42.5,percent of total billed charges,Implant Device,42.5,34,,42.5,percent of total billed charges,Implant Device,42.5,34,,42.5,percent of total billed charges,Implant Device,42.5,34,,42.5,percent of total billed charges,Implant Device,42.5,34,,42.5,percent of total billed charges,Implant Device,61.88,,,61.88,Other,110% of Medicare,43.75,35,,43.75,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,43.75,35,,43.75,percent of total billed charges,Implant Device,43.75,35,,43.75,percent of total billed charges,Implant Device,43.75,35,,43.75,percent of total billed charges,Implant Device,43.75,35,,43.75,percent of total billed charges,Implant Device,43.75,35,,43.75,percent of total billed charges,Implant Device,50,40,,50,percent of total billed charges,Implant Device,43.75,70,,43.75,percent of total billed charges,All Other,42.5,34,,42.5,percent of total billed charges,Implant Device,42.5,34,,42.5,percent of total billed charges,Implant Device,43.75,35,,43.75,percent of total billed charges,Implant Device,43.75,35,,43.75,percent of total billed charges,Implant Device,43.75,35,,43.75,percent of total billed charges,Implant Device,43.75,35,,43.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,92.5,
STRYKER 06 2605 C-TAPR LFIT HEAD LO FRIC,C1776,HCPCS,,79004076,CDM,278,RC,,,both,,,3008,2225.93,,,2225.93,Other,150% of Medicare + 9.63% HCRA Surcharge,1353.6,45,,1353.6,percent of total billed charges,Critical Access Hospital RCC factor,1022.72,34,,1022.72,percent of total billed charges,Implant Device,1022.72,34,,1022.72,percent of total billed charges,Implant Device,1022.72,34,,1022.72,percent of total billed charges,Implant Device,1022.72,34,,1022.72,percent of total billed charges,Implant Device,1022.72,34,,1022.72,percent of total billed charges,Implant Device,1488.96,,,1488.96,Other,110% of Medicare,1052.8,35,,1052.8,percent of total billed charges,Implant Device,1022.72,34,"Charges > $500, x 34%",1022.72,percent of total billed charges,Implant Device,1052.8,35,,1052.8,percent of total billed charges,Implant Device,1052.8,35,,1052.8,percent of total billed charges,Implant Device,1052.8,35,,1052.8,percent of total billed charges,Implant Device,1052.8,35,,1052.8,percent of total billed charges,Implant Device,1052.8,35,,1052.8,percent of total billed charges,Implant Device,1203.2,40,,1203.2,percent of total billed charges,Implant Device,1052.8,70,,1052.8,percent of total billed charges,All Other,1022.72,34,,1022.72,percent of total billed charges,Implant Device,1022.72,34,,1022.72,percent of total billed charges,Implant Device,1052.8,35,,1052.8,percent of total billed charges,Implant Device,1052.8,35,,1052.8,percent of total billed charges,Implant Device,1052.8,35,,1052.8,percent of total billed charges,Implant Device,1052.8,35,,1052.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1022.72,34,"If Charge > 2,000, then 34 percent",1022.72,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2225.93,
STRYKER 5569-P-2014 HUMERAL STEM 14X133,C1776,HCPCS,,79004077,CDM,278,RC,,,both,,,12382,9162.71,,,9162.71,Other,150% of Medicare + 9.63% HCRA Surcharge,5571.9,45,,5571.9,percent of total billed charges,Critical Access Hospital RCC factor,4209.88,34,,4209.88,percent of total billed charges,Implant Device,4209.88,34,,4209.88,percent of total billed charges,Implant Device,4209.88,34,,4209.88,percent of total billed charges,Implant Device,4209.88,34,,4209.88,percent of total billed charges,Implant Device,4209.88,34,,4209.88,percent of total billed charges,Implant Device,6129.09,,,6129.09,Other,110% of Medicare,4333.7,35,,4333.7,percent of total billed charges,Implant Device,4209.88,34,"Charges > $500, x 34%",4209.88,percent of total billed charges,Implant Device,4333.7,35,,4333.7,percent of total billed charges,Implant Device,4333.7,35,,4333.7,percent of total billed charges,Implant Device,4333.7,35,,4333.7,percent of total billed charges,Implant Device,4333.7,35,,4333.7,percent of total billed charges,Implant Device,4333.7,35,,4333.7,percent of total billed charges,Implant Device,4952.8,40,,4952.8,percent of total billed charges,Implant Device,4333.7,70,,4333.7,percent of total billed charges,All Other,4209.88,34,,4209.88,percent of total billed charges,Implant Device,4209.88,34,,4209.88,percent of total billed charges,Implant Device,4333.7,35,,4333.7,percent of total billed charges,Implant Device,4333.7,35,,4333.7,percent of total billed charges,Implant Device,4333.7,35,,4333.7,percent of total billed charges,Implant Device,4333.7,35,,4333.7,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,4209.88,34,"If Charge > 2,000, then 34 percent",4209.88,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,9162.71,
STRYKER 57-10379 2 HOLE LOCK PLATE 1.7MM,C1713,HCPCS,,79004079,CDM,278,RC,,,both,,,2496,1847.05,,,1847.05,Other,150% of Medicare + 9.63% HCRA Surcharge,1123.2,45,,1123.2,percent of total billed charges,Critical Access Hospital RCC factor,848.64,34,,848.64,percent of total billed charges,Implant Device,848.64,34,,848.64,percent of total billed charges,Implant Device,848.64,34,,848.64,percent of total billed charges,Implant Device,848.64,34,,848.64,percent of total billed charges,Implant Device,848.64,34,,848.64,percent of total billed charges,Implant Device,1235.52,,,1235.52,Other,110% of Medicare,873.6,35,,873.6,percent of total billed charges,Implant Device,848.64,34,"Charges > $500, x 34%",848.64,percent of total billed charges,Implant Device,873.6,35,,873.6,percent of total billed charges,Implant Device,873.6,35,,873.6,percent of total billed charges,Implant Device,873.6,35,,873.6,percent of total billed charges,Implant Device,873.6,35,,873.6,percent of total billed charges,Implant Device,873.6,35,,873.6,percent of total billed charges,Implant Device,998.4,40,,998.4,percent of total billed charges,Implant Device,873.6,70,,873.6,percent of total billed charges,All Other,848.64,34,,848.64,percent of total billed charges,Implant Device,848.64,34,,848.64,percent of total billed charges,Implant Device,873.6,35,,873.6,percent of total billed charges,Implant Device,873.6,35,,873.6,percent of total billed charges,Implant Device,873.6,35,,873.6,percent of total billed charges,Implant Device,873.6,35,,873.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,848.64,34,"If Charge > 2,000, then 34 percent",848.64,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1847.05,
STRYKER 1830-0009S WASHER SQUARE 18X10MM,C1713,HCPCS,,79004080,CDM,278,RC,,,both,,,592,438.08,,,438.08,Other,150% of Medicare + 9.63% HCRA Surcharge,266.4,45,,266.4,percent of total billed charges,Critical Access Hospital RCC factor,201.28,34,,201.28,percent of total billed charges,Implant Device,201.28,34,,201.28,percent of total billed charges,Implant Device,201.28,34,,201.28,percent of total billed charges,Implant Device,201.28,34,,201.28,percent of total billed charges,Implant Device,201.28,34,,201.28,percent of total billed charges,Implant Device,293.04,,,293.04,Other,110% of Medicare,207.2,35,,207.2,percent of total billed charges,Implant Device,201.28,34,"Charges > $500, x 34%",201.28,percent of total billed charges,Implant Device,207.2,35,,207.2,percent of total billed charges,Implant Device,207.2,35,,207.2,percent of total billed charges,Implant Device,207.2,35,,207.2,percent of total billed charges,Implant Device,207.2,35,,207.2,percent of total billed charges,Implant Device,207.2,35,,207.2,percent of total billed charges,Implant Device,236.8,40,,236.8,percent of total billed charges,Implant Device,207.2,70,,207.2,percent of total billed charges,All Other,201.28,34,,201.28,percent of total billed charges,Implant Device,201.28,34,,201.28,percent of total billed charges,Implant Device,207.2,35,,207.2,percent of total billed charges,Implant Device,207.2,35,,207.2,percent of total billed charges,Implant Device,207.2,35,,207.2,percent of total billed charges,Implant Device,207.2,35,,207.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,438.08,
STRYKER 1830-0725S HUMERAL NAIL 7X250MM,C1713,HCPCS,,79004081,CDM,278,RC,,,both,,,4876,3608.25,,,3608.25,Other,150% of Medicare + 9.63% HCRA Surcharge,2194.2,45,,2194.2,percent of total billed charges,Critical Access Hospital RCC factor,1657.84,34,,1657.84,percent of total billed charges,Implant Device,1657.84,34,,1657.84,percent of total billed charges,Implant Device,1657.84,34,,1657.84,percent of total billed charges,Implant Device,1657.84,34,,1657.84,percent of total billed charges,Implant Device,1657.84,34,,1657.84,percent of total billed charges,Implant Device,2413.62,,,2413.62,Other,110% of Medicare,1706.6,35,,1706.6,percent of total billed charges,Implant Device,1657.84,34,"Charges > $500, x 34%",1657.84,percent of total billed charges,Implant Device,1706.6,35,,1706.6,percent of total billed charges,Implant Device,1706.6,35,,1706.6,percent of total billed charges,Implant Device,1706.6,35,,1706.6,percent of total billed charges,Implant Device,1706.6,35,,1706.6,percent of total billed charges,Implant Device,1706.6,35,,1706.6,percent of total billed charges,Implant Device,1950.4,40,,1950.4,percent of total billed charges,Implant Device,1706.6,70,,1706.6,percent of total billed charges,All Other,1657.84,34,,1657.84,percent of total billed charges,Implant Device,1657.84,34,,1657.84,percent of total billed charges,Implant Device,1706.6,35,,1706.6,percent of total billed charges,Implant Device,1706.6,35,,1706.6,percent of total billed charges,Implant Device,1706.6,35,,1706.6,percent of total billed charges,Implant Device,1706.6,35,,1706.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1657.84,34,"If Charge > 2,000, then 34 percent",1657.84,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3608.25,
STRYKER 370350 LOCKING SCREW 5X50MM,C1713,HCPCS,,79004082,CDM,278,RC,,,both,,,446,330.04,,,330.04,Other,150% of Medicare + 9.63% HCRA Surcharge,200.7,45,,200.7,percent of total billed charges,Critical Access Hospital RCC factor,151.64,34,,151.64,percent of total billed charges,Implant Device,151.64,34,,151.64,percent of total billed charges,Implant Device,151.64,34,,151.64,percent of total billed charges,Implant Device,151.64,34,,151.64,percent of total billed charges,Implant Device,151.64,34,,151.64,percent of total billed charges,Implant Device,220.77,,,220.77,Other,110% of Medicare,156.1,35,,156.1,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,156.1,35,,156.1,percent of total billed charges,Implant Device,156.1,35,,156.1,percent of total billed charges,Implant Device,156.1,35,,156.1,percent of total billed charges,Implant Device,156.1,35,,156.1,percent of total billed charges,Implant Device,156.1,35,,156.1,percent of total billed charges,Implant Device,178.4,40,,178.4,percent of total billed charges,Implant Device,156.1,70,,156.1,percent of total billed charges,All Other,151.64,34,,151.64,percent of total billed charges,Implant Device,151.64,34,,151.64,percent of total billed charges,Implant Device,156.1,35,,156.1,percent of total billed charges,Implant Device,156.1,35,,156.1,percent of total billed charges,Implant Device,156.1,35,,156.1,percent of total billed charges,Implant Device,156.1,35,,156.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,330.04,
STRYKER 6495-9-114 PREMATRIX GRAFT 4X4,C1713,HCPCS,,79004084,CDM,278,RC,,,both,,,2844,2104.57,,,2104.57,Other,150% of Medicare + 9.63% HCRA Surcharge,1279.8,45,,1279.8,percent of total billed charges,Critical Access Hospital RCC factor,966.96,34,,966.96,percent of total billed charges,Implant Device,966.96,34,,966.96,percent of total billed charges,Implant Device,966.96,34,,966.96,percent of total billed charges,Implant Device,966.96,34,,966.96,percent of total billed charges,Implant Device,966.96,34,,966.96,percent of total billed charges,Implant Device,1407.78,,,1407.78,Other,110% of Medicare,995.4,35,,995.4,percent of total billed charges,Implant Device,966.96,34,"Charges > $500, x 34%",966.96,percent of total billed charges,Implant Device,995.4,35,,995.4,percent of total billed charges,Implant Device,995.4,35,,995.4,percent of total billed charges,Implant Device,995.4,35,,995.4,percent of total billed charges,Implant Device,995.4,35,,995.4,percent of total billed charges,Implant Device,995.4,35,,995.4,percent of total billed charges,Implant Device,1137.6,40,,1137.6,percent of total billed charges,Implant Device,995.4,70,,995.4,percent of total billed charges,All Other,966.96,34,,966.96,percent of total billed charges,Implant Device,966.96,34,,966.96,percent of total billed charges,Implant Device,995.4,35,,995.4,percent of total billed charges,Implant Device,995.4,35,,995.4,percent of total billed charges,Implant Device,995.4,35,,995.4,percent of total billed charges,Implant Device,995.4,35,,995.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,966.96,34,"If Charge > 2,000, then 34 percent",966.96,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2104.57,
STRYKER 5015-5-150 APEX PIN CANC 50MM,C1713,HCPCS,,79004085,CDM,278,RC,,,both,,,468,346.32,,,346.32,Other,150% of Medicare + 9.63% HCRA Surcharge,210.6,45,,210.6,percent of total billed charges,Critical Access Hospital RCC factor,159.12,34,,159.12,percent of total billed charges,Implant Device,159.12,34,,159.12,percent of total billed charges,Implant Device,159.12,34,,159.12,percent of total billed charges,Implant Device,159.12,34,,159.12,percent of total billed charges,Implant Device,159.12,34,,159.12,percent of total billed charges,Implant Device,231.66,,,231.66,Other,110% of Medicare,163.8,35,,163.8,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,163.8,35,,163.8,percent of total billed charges,Implant Device,163.8,35,,163.8,percent of total billed charges,Implant Device,163.8,35,,163.8,percent of total billed charges,Implant Device,163.8,35,,163.8,percent of total billed charges,Implant Device,163.8,35,,163.8,percent of total billed charges,Implant Device,187.2,40,,187.2,percent of total billed charges,Implant Device,163.8,70,,163.8,percent of total billed charges,All Other,159.12,34,,159.12,percent of total billed charges,Implant Device,159.12,34,,159.12,percent of total billed charges,Implant Device,163.8,35,,163.8,percent of total billed charges,Implant Device,163.8,35,,163.8,percent of total billed charges,Implant Device,163.8,35,,163.8,percent of total billed charges,Implant Device,163.8,35,,163.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,346.32,
STRYKER 602705 SCREW 6.5X105MM,C1713,HCPCS,,79004086,CDM,278,RC,,,both,,,1285,950.9,,,950.9,Other,150% of Medicare + 9.63% HCRA Surcharge,578.25,45,,578.25,percent of total billed charges,Critical Access Hospital RCC factor,436.9,34,,436.9,percent of total billed charges,Implant Device,436.9,34,,436.9,percent of total billed charges,Implant Device,436.9,34,,436.9,percent of total billed charges,Implant Device,436.9,34,,436.9,percent of total billed charges,Implant Device,436.9,34,,436.9,percent of total billed charges,Implant Device,636.08,,,636.08,Other,110% of Medicare,449.75,35,,449.75,percent of total billed charges,Implant Device,436.9,34,"Charges > $500, x 34%",436.9,percent of total billed charges,Implant Device,449.75,35,,449.75,percent of total billed charges,Implant Device,449.75,35,,449.75,percent of total billed charges,Implant Device,449.75,35,,449.75,percent of total billed charges,Implant Device,449.75,35,,449.75,percent of total billed charges,Implant Device,449.75,35,,449.75,percent of total billed charges,Implant Device,514,40,,514,percent of total billed charges,Implant Device,449.75,70,,449.75,percent of total billed charges,All Other,436.9,34,,436.9,percent of total billed charges,Implant Device,436.9,34,,436.9,percent of total billed charges,Implant Device,449.75,35,,449.75,percent of total billed charges,Implant Device,449.75,35,,449.75,percent of total billed charges,Implant Device,449.75,35,,449.75,percent of total billed charges,Implant Device,449.75,35,,449.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,950.9,
STRYKER 345438 SCREW CANCELLOUS 4X38MM,C1713,HCPCS,,79004087,CDM,278,RC,,,both,,,74,54.76,,,54.76,Other,150% of Medicare + 9.63% HCRA Surcharge,33.3,45,,33.3,percent of total billed charges,Critical Access Hospital RCC factor,25.16,34,,25.16,percent of total billed charges,Implant Device,25.16,34,,25.16,percent of total billed charges,Implant Device,25.16,34,,25.16,percent of total billed charges,Implant Device,25.16,34,,25.16,percent of total billed charges,Implant Device,25.16,34,,25.16,percent of total billed charges,Implant Device,36.63,,,36.63,Other,110% of Medicare,25.9,35,,25.9,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,25.9,35,,25.9,percent of total billed charges,Implant Device,25.9,35,,25.9,percent of total billed charges,Implant Device,25.9,35,,25.9,percent of total billed charges,Implant Device,25.9,35,,25.9,percent of total billed charges,Implant Device,25.9,35,,25.9,percent of total billed charges,Implant Device,29.6,40,,29.6,percent of total billed charges,Implant Device,25.9,70,,25.9,percent of total billed charges,All Other,25.16,34,,25.16,percent of total billed charges,Implant Device,25.16,34,,25.16,percent of total billed charges,Implant Device,25.9,35,,25.9,percent of total billed charges,Implant Device,25.9,35,,25.9,percent of total billed charges,Implant Device,25.9,35,,25.9,percent of total billed charges,Implant Device,25.9,35,,25.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,54.76,
STRYKER 371546 LOCK SCREW 4MMX46CM,C1713,HCPCS,,79004088,CDM,278,RC,,,both,,,569,421.06,,,421.06,Other,150% of Medicare + 9.63% HCRA Surcharge,256.05,45,,256.05,percent of total billed charges,Critical Access Hospital RCC factor,193.46,34,,193.46,percent of total billed charges,Implant Device,193.46,34,,193.46,percent of total billed charges,Implant Device,193.46,34,,193.46,percent of total billed charges,Implant Device,193.46,34,,193.46,percent of total billed charges,Implant Device,193.46,34,,193.46,percent of total billed charges,Implant Device,281.66,,,281.66,Other,110% of Medicare,199.15,35,,199.15,percent of total billed charges,Implant Device,193.46,34,"Charges > $500, x 34%",193.46,percent of total billed charges,Implant Device,199.15,35,,199.15,percent of total billed charges,Implant Device,199.15,35,,199.15,percent of total billed charges,Implant Device,199.15,35,,199.15,percent of total billed charges,Implant Device,199.15,35,,199.15,percent of total billed charges,Implant Device,199.15,35,,199.15,percent of total billed charges,Implant Device,227.6,40,,227.6,percent of total billed charges,Implant Device,199.15,70,,199.15,percent of total billed charges,All Other,193.46,34,,193.46,percent of total billed charges,Implant Device,193.46,34,,193.46,percent of total billed charges,Implant Device,199.15,35,,199.15,percent of total billed charges,Implant Device,199.15,35,,199.15,percent of total billed charges,Implant Device,199.15,35,,199.15,percent of total billed charges,Implant Device,199.15,35,,199.15,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,421.06,
STRYKER 5317006E LOCK SCREW 1.7X6MM,C1713,HCPCS,,79004089,CDM,278,RC,,,both,,,306,226.44,,,226.44,Other,150% of Medicare + 9.63% HCRA Surcharge,137.7,45,,137.7,percent of total billed charges,Critical Access Hospital RCC factor,104.04,34,,104.04,percent of total billed charges,Implant Device,104.04,34,,104.04,percent of total billed charges,Implant Device,104.04,34,,104.04,percent of total billed charges,Implant Device,104.04,34,,104.04,percent of total billed charges,Implant Device,104.04,34,,104.04,percent of total billed charges,Implant Device,151.47,,,151.47,Other,110% of Medicare,107.1,35,,107.1,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,107.1,35,,107.1,percent of total billed charges,Implant Device,107.1,35,,107.1,percent of total billed charges,Implant Device,107.1,35,,107.1,percent of total billed charges,Implant Device,107.1,35,,107.1,percent of total billed charges,Implant Device,107.1,35,,107.1,percent of total billed charges,Implant Device,122.4,40,,122.4,percent of total billed charges,Implant Device,107.1,70,,107.1,percent of total billed charges,All Other,104.04,34,,104.04,percent of total billed charges,Implant Device,104.04,34,,104.04,percent of total billed charges,Implant Device,107.1,35,,107.1,percent of total billed charges,Implant Device,107.1,35,,107.1,percent of total billed charges,Implant Device,107.1,35,,107.1,percent of total billed charges,Implant Device,107.1,35,,107.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,226.44,
STRYKER 19-0000T C-TAPER ADAPTOR SLEEVE,C1776,HCPCS,,79004090,CDM,278,RC,,,both,,,427,315.98,,,315.98,Other,150% of Medicare + 9.63% HCRA Surcharge,192.15,45,,192.15,percent of total billed charges,Critical Access Hospital RCC factor,145.18,34,,145.18,percent of total billed charges,Implant Device,145.18,34,,145.18,percent of total billed charges,Implant Device,145.18,34,,145.18,percent of total billed charges,Implant Device,145.18,34,,145.18,percent of total billed charges,Implant Device,145.18,34,,145.18,percent of total billed charges,Implant Device,211.37,,,211.37,Other,110% of Medicare,149.45,35,,149.45,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,149.45,35,,149.45,percent of total billed charges,Implant Device,149.45,35,,149.45,percent of total billed charges,Implant Device,149.45,35,,149.45,percent of total billed charges,Implant Device,149.45,35,,149.45,percent of total billed charges,Implant Device,149.45,35,,149.45,percent of total billed charges,Implant Device,170.8,40,,170.8,percent of total billed charges,Implant Device,149.45,70,,149.45,percent of total billed charges,All Other,145.18,34,,145.18,percent of total billed charges,Implant Device,145.18,34,,145.18,percent of total billed charges,Implant Device,149.45,35,,149.45,percent of total billed charges,Implant Device,149.45,35,,149.45,percent of total billed charges,Implant Device,149.45,35,,149.45,percent of total billed charges,Implant Device,149.45,35,,149.45,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,315.98,
STRYKER 6481-2-133 MRH KNEE BUMPER INSRT,C1776,HCPCS,,79004091,CDM,278,RC,,,both,,,1599,1183.26,,,1183.26,Other,150% of Medicare + 9.63% HCRA Surcharge,719.55,45,,719.55,percent of total billed charges,Critical Access Hospital RCC factor,543.66,34,,543.66,percent of total billed charges,Implant Device,543.66,34,,543.66,percent of total billed charges,Implant Device,543.66,34,,543.66,percent of total billed charges,Implant Device,543.66,34,,543.66,percent of total billed charges,Implant Device,543.66,34,,543.66,percent of total billed charges,Implant Device,791.51,,,791.51,Other,110% of Medicare,559.65,35,,559.65,percent of total billed charges,Implant Device,543.66,34,"Charges > $500, x 34%",543.66,percent of total billed charges,Implant Device,559.65,35,,559.65,percent of total billed charges,Implant Device,559.65,35,,559.65,percent of total billed charges,Implant Device,559.65,35,,559.65,percent of total billed charges,Implant Device,559.65,35,,559.65,percent of total billed charges,Implant Device,559.65,35,,559.65,percent of total billed charges,Implant Device,639.6,40,,639.6,percent of total billed charges,Implant Device,559.65,70,,559.65,percent of total billed charges,All Other,543.66,34,,543.66,percent of total billed charges,Implant Device,543.66,34,,543.66,percent of total billed charges,Implant Device,559.65,35,,559.65,percent of total billed charges,Implant Device,559.65,35,,559.65,percent of total billed charges,Implant Device,559.65,35,,559.65,percent of total billed charges,Implant Device,559.65,35,,559.65,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1183.26,
STRYKER 4365-08 DIST LAT FEM PLATE 8HOLE,C1713,HCPCS,,79004092,CDM,278,RC,,,both,,,3715,2749.11,,,2749.11,Other,150% of Medicare + 9.63% HCRA Surcharge,1671.75,45,,1671.75,percent of total billed charges,Critical Access Hospital RCC factor,1263.1,34,,1263.1,percent of total billed charges,Implant Device,1263.1,34,,1263.1,percent of total billed charges,Implant Device,1263.1,34,,1263.1,percent of total billed charges,Implant Device,1263.1,34,,1263.1,percent of total billed charges,Implant Device,1263.1,34,,1263.1,percent of total billed charges,Implant Device,1838.93,,,1838.93,Other,110% of Medicare,1300.25,35,,1300.25,percent of total billed charges,Implant Device,1263.1,34,"Charges > $500, x 34%",1263.1,percent of total billed charges,Implant Device,1300.25,35,,1300.25,percent of total billed charges,Implant Device,1300.25,35,,1300.25,percent of total billed charges,Implant Device,1300.25,35,,1300.25,percent of total billed charges,Implant Device,1300.25,35,,1300.25,percent of total billed charges,Implant Device,1300.25,35,,1300.25,percent of total billed charges,Implant Device,1486,40,,1486,percent of total billed charges,Implant Device,1300.25,70,,1300.25,percent of total billed charges,All Other,1263.1,34,,1263.1,percent of total billed charges,Implant Device,1263.1,34,,1263.1,percent of total billed charges,Implant Device,1300.25,35,,1300.25,percent of total billed charges,Implant Device,1300.25,35,,1300.25,percent of total billed charges,Implant Device,1300.25,35,,1300.25,percent of total billed charges,Implant Device,1300.25,35,,1300.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1263.1,34,"If Charge > 2,000, then 34 percent",1263.1,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2749.11,
STRYKER 57-10197 STD PLATES 2.3X2X2+2,C1713,HCPCS,,79004093,CDM,278,RC,,,both,,,1276,944.24,,,944.24,Other,150% of Medicare + 9.63% HCRA Surcharge,574.2,45,,574.2,percent of total billed charges,Critical Access Hospital RCC factor,433.84,34,,433.84,percent of total billed charges,Implant Device,433.84,34,,433.84,percent of total billed charges,Implant Device,433.84,34,,433.84,percent of total billed charges,Implant Device,433.84,34,,433.84,percent of total billed charges,Implant Device,433.84,34,,433.84,percent of total billed charges,Implant Device,631.62,,,631.62,Other,110% of Medicare,446.6,35,,446.6,percent of total billed charges,Implant Device,433.84,34,"Charges > $500, x 34%",433.84,percent of total billed charges,Implant Device,446.6,35,,446.6,percent of total billed charges,Implant Device,446.6,35,,446.6,percent of total billed charges,Implant Device,446.6,35,,446.6,percent of total billed charges,Implant Device,446.6,35,,446.6,percent of total billed charges,Implant Device,446.6,35,,446.6,percent of total billed charges,Implant Device,510.4,40,,510.4,percent of total billed charges,Implant Device,446.6,70,,446.6,percent of total billed charges,All Other,433.84,34,,433.84,percent of total billed charges,Implant Device,433.84,34,,433.84,percent of total billed charges,Implant Device,446.6,35,,446.6,percent of total billed charges,Implant Device,446.6,35,,446.6,percent of total billed charges,Implant Device,446.6,35,,446.6,percent of total billed charges,Implant Device,446.6,35,,446.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,944.24,
STRYKER 340646 NON LOCK SCREW 4.5X46MM,C1713,HCPCS,,79004094,CDM,278,RC,,,both,,,84,62.16,,,62.16,Other,150% of Medicare + 9.63% HCRA Surcharge,37.8,45,,37.8,percent of total billed charges,Critical Access Hospital RCC factor,28.56,34,,28.56,percent of total billed charges,Implant Device,28.56,34,,28.56,percent of total billed charges,Implant Device,28.56,34,,28.56,percent of total billed charges,Implant Device,28.56,34,,28.56,percent of total billed charges,Implant Device,28.56,34,,28.56,percent of total billed charges,Implant Device,41.58,,,41.58,Other,110% of Medicare,29.4,35,,29.4,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,29.4,35,,29.4,percent of total billed charges,Implant Device,29.4,35,,29.4,percent of total billed charges,Implant Device,29.4,35,,29.4,percent of total billed charges,Implant Device,29.4,35,,29.4,percent of total billed charges,Implant Device,29.4,35,,29.4,percent of total billed charges,Implant Device,33.6,40,,33.6,percent of total billed charges,Implant Device,29.4,70,,29.4,percent of total billed charges,All Other,28.56,34,,28.56,percent of total billed charges,Implant Device,28.56,34,,28.56,percent of total billed charges,Implant Device,29.4,35,,29.4,percent of total billed charges,Implant Device,29.4,35,,29.4,percent of total billed charges,Implant Device,29.4,35,,29.4,percent of total billed charges,Implant Device,29.4,35,,29.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,62.16,
STRYKER 3325-0440S NAIL KIT LT 11X440MM,C1713,HCPCS,,79004095,CDM,278,RC,,,both,,,8879,6570.48,,,6570.48,Other,150% of Medicare + 9.63% HCRA Surcharge,3995.55,45,,3995.55,percent of total billed charges,Critical Access Hospital RCC factor,3018.86,34,,3018.86,percent of total billed charges,Implant Device,3018.86,34,,3018.86,percent of total billed charges,Implant Device,3018.86,34,,3018.86,percent of total billed charges,Implant Device,3018.86,34,,3018.86,percent of total billed charges,Implant Device,3018.86,34,,3018.86,percent of total billed charges,Implant Device,4395.11,,,4395.11,Other,110% of Medicare,3107.65,35,,3107.65,percent of total billed charges,Implant Device,3018.86,34,"Charges > $500, x 34%",3018.86,percent of total billed charges,Implant Device,3107.65,35,,3107.65,percent of total billed charges,Implant Device,3107.65,35,,3107.65,percent of total billed charges,Implant Device,3107.65,35,,3107.65,percent of total billed charges,Implant Device,3107.65,35,,3107.65,percent of total billed charges,Implant Device,3107.65,35,,3107.65,percent of total billed charges,Implant Device,3551.6,40,,3551.6,percent of total billed charges,Implant Device,3107.65,70,,3107.65,percent of total billed charges,All Other,3018.86,34,,3018.86,percent of total billed charges,Implant Device,3018.86,34,,3018.86,percent of total billed charges,Implant Device,3107.65,35,,3107.65,percent of total billed charges,Implant Device,3107.65,35,,3107.65,percent of total billed charges,Implant Device,3107.65,35,,3107.65,percent of total billed charges,Implant Device,3107.65,35,,3107.65,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3018.86,34,"If Charge > 2,000, then 34 percent",3018.86,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,6570.48,
STRYKER 3406-34 CORTICAL SCREW 4.5X34,C1713,HCPCS,,79004096,CDM,278,RC,,,both,,,125,92.5,,,92.5,Other,150% of Medicare + 9.63% HCRA Surcharge,56.25,45,,56.25,percent of total billed charges,Critical Access Hospital RCC factor,42.5,34,,42.5,percent of total billed charges,Implant Device,42.5,34,,42.5,percent of total billed charges,Implant Device,42.5,34,,42.5,percent of total billed charges,Implant Device,42.5,34,,42.5,percent of total billed charges,Implant Device,42.5,34,,42.5,percent of total billed charges,Implant Device,61.88,,,61.88,Other,110% of Medicare,43.75,35,,43.75,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,43.75,35,,43.75,percent of total billed charges,Implant Device,43.75,35,,43.75,percent of total billed charges,Implant Device,43.75,35,,43.75,percent of total billed charges,Implant Device,43.75,35,,43.75,percent of total billed charges,Implant Device,43.75,35,,43.75,percent of total billed charges,Implant Device,50,40,,50,percent of total billed charges,Implant Device,43.75,70,,43.75,percent of total billed charges,All Other,42.5,34,,42.5,percent of total billed charges,Implant Device,42.5,34,,42.5,percent of total billed charges,Implant Device,43.75,35,,43.75,percent of total billed charges,Implant Device,43.75,35,,43.75,percent of total billed charges,Implant Device,43.75,35,,43.75,percent of total billed charges,Implant Device,43.75,35,,43.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,92.5,
STRYKER 5118-1-340 WIRES 2.0,C1713,HCPCS,,79004098,CDM,278,RC,,,both,,,541,400.34,,,400.34,Other,150% of Medicare + 9.63% HCRA Surcharge,243.45,45,,243.45,percent of total billed charges,Critical Access Hospital RCC factor,183.94,34,,183.94,percent of total billed charges,Implant Device,183.94,34,,183.94,percent of total billed charges,Implant Device,183.94,34,,183.94,percent of total billed charges,Implant Device,183.94,34,,183.94,percent of total billed charges,Implant Device,183.94,34,,183.94,percent of total billed charges,Implant Device,267.8,,,267.8,Other,110% of Medicare,189.35,35,,189.35,percent of total billed charges,Implant Device,183.94,34,"Charges > $500, x 34%",183.94,percent of total billed charges,Implant Device,189.35,35,,189.35,percent of total billed charges,Implant Device,189.35,35,,189.35,percent of total billed charges,Implant Device,189.35,35,,189.35,percent of total billed charges,Implant Device,189.35,35,,189.35,percent of total billed charges,Implant Device,189.35,35,,189.35,percent of total billed charges,Implant Device,216.4,40,,216.4,percent of total billed charges,Implant Device,189.35,70,,189.35,percent of total billed charges,All Other,183.94,34,,183.94,percent of total billed charges,Implant Device,183.94,34,,183.94,percent of total billed charges,Implant Device,189.35,35,,189.35,percent of total billed charges,Implant Device,189.35,35,,189.35,percent of total billed charges,Implant Device,189.35,35,,189.35,percent of total billed charges,Implant Device,189.35,35,,189.35,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,400.34,
STRYKER 437105 PROX LAT HUM PLATE 5HOLE,C1713,HCPCS,,79004099,CDM,278,RC,,,both,,,5483,4057.43,,,4057.43,Other,150% of Medicare + 9.63% HCRA Surcharge,2467.35,45,,2467.35,percent of total billed charges,Critical Access Hospital RCC factor,1864.22,34,,1864.22,percent of total billed charges,Implant Device,1864.22,34,,1864.22,percent of total billed charges,Implant Device,1864.22,34,,1864.22,percent of total billed charges,Implant Device,1864.22,34,,1864.22,percent of total billed charges,Implant Device,1864.22,34,,1864.22,percent of total billed charges,Implant Device,2714.09,,,2714.09,Other,110% of Medicare,1919.05,35,,1919.05,percent of total billed charges,Implant Device,1864.22,34,"Charges > $500, x 34%",1864.22,percent of total billed charges,Implant Device,1919.05,35,,1919.05,percent of total billed charges,Implant Device,1919.05,35,,1919.05,percent of total billed charges,Implant Device,1919.05,35,,1919.05,percent of total billed charges,Implant Device,1919.05,35,,1919.05,percent of total billed charges,Implant Device,1919.05,35,,1919.05,percent of total billed charges,Implant Device,2193.2,40,,2193.2,percent of total billed charges,Implant Device,1919.05,70,,1919.05,percent of total billed charges,All Other,1864.22,34,,1864.22,percent of total billed charges,Implant Device,1864.22,34,,1864.22,percent of total billed charges,Implant Device,1919.05,35,,1919.05,percent of total billed charges,Implant Device,1919.05,35,,1919.05,percent of total billed charges,Implant Device,1919.05,35,,1919.05,percent of total billed charges,Implant Device,1919.05,35,,1919.05,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1864.22,34,"If Charge > 2,000, then 34 percent",1864.22,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4057.43,
STRYKER 51-15904 SCREW 4.MM,C1713,HCPCS,,79004100,CDM,278,RC,,,both,,,173,128.02,,,128.02,Other,150% of Medicare + 9.63% HCRA Surcharge,77.85,45,,77.85,percent of total billed charges,Critical Access Hospital RCC factor,58.82,34,,58.82,percent of total billed charges,Implant Device,58.82,34,,58.82,percent of total billed charges,Implant Device,58.82,34,,58.82,percent of total billed charges,Implant Device,58.82,34,,58.82,percent of total billed charges,Implant Device,58.82,34,,58.82,percent of total billed charges,Implant Device,85.64,,,85.64,Other,110% of Medicare,60.55,35,,60.55,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,60.55,35,,60.55,percent of total billed charges,Implant Device,60.55,35,,60.55,percent of total billed charges,Implant Device,60.55,35,,60.55,percent of total billed charges,Implant Device,60.55,35,,60.55,percent of total billed charges,Implant Device,60.55,35,,60.55,percent of total billed charges,Implant Device,69.2,40,,69.2,percent of total billed charges,Implant Device,60.55,70,,60.55,percent of total billed charges,All Other,58.82,34,,58.82,percent of total billed charges,Implant Device,58.82,34,,58.82,percent of total billed charges,Implant Device,60.55,35,,60.55,percent of total billed charges,Implant Device,60.55,35,,60.55,percent of total billed charges,Implant Device,60.55,35,,60.55,percent of total billed charges,Implant Device,60.55,35,,60.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,128.02,
STRYKER 6485-3-111 CEMENTD STEM 11X127MM,C1776,HCPCS,,79004102,CDM,278,RC,,,both,,,9974,7380.78,,,7380.78,Other,150% of Medicare + 9.63% HCRA Surcharge,4488.3,45,,4488.3,percent of total billed charges,Critical Access Hospital RCC factor,3391.16,34,,3391.16,percent of total billed charges,Implant Device,3391.16,34,,3391.16,percent of total billed charges,Implant Device,3391.16,34,,3391.16,percent of total billed charges,Implant Device,3391.16,34,,3391.16,percent of total billed charges,Implant Device,3391.16,34,,3391.16,percent of total billed charges,Implant Device,4937.13,,,4937.13,Other,110% of Medicare,3490.9,35,,3490.9,percent of total billed charges,Implant Device,3391.16,34,"Charges > $500, x 34%",3391.16,percent of total billed charges,Implant Device,3490.9,35,,3490.9,percent of total billed charges,Implant Device,3490.9,35,,3490.9,percent of total billed charges,Implant Device,3490.9,35,,3490.9,percent of total billed charges,Implant Device,3490.9,35,,3490.9,percent of total billed charges,Implant Device,3490.9,35,,3490.9,percent of total billed charges,Implant Device,3989.6,40,,3989.6,percent of total billed charges,Implant Device,3490.9,70,,3490.9,percent of total billed charges,All Other,3391.16,34,,3391.16,percent of total billed charges,Implant Device,3391.16,34,,3391.16,percent of total billed charges,Implant Device,3490.9,35,,3490.9,percent of total billed charges,Implant Device,3490.9,35,,3490.9,percent of total billed charges,Implant Device,3490.9,35,,3490.9,percent of total billed charges,Implant Device,3490.9,35,,3490.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3391.16,34,"If Charge > 2,000, then 34 percent",3391.16,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,7380.78,
STRYKER 1067-0008 DIST CEMENT SPACER 8MM,C1713,HCPCS,,79004104,CDM,278,RC,,,both,,,341,252.34,,,252.34,Other,150% of Medicare + 9.63% HCRA Surcharge,153.45,45,,153.45,percent of total billed charges,Critical Access Hospital RCC factor,115.94,34,,115.94,percent of total billed charges,Implant Device,115.94,34,,115.94,percent of total billed charges,Implant Device,115.94,34,,115.94,percent of total billed charges,Implant Device,115.94,34,,115.94,percent of total billed charges,Implant Device,115.94,34,,115.94,percent of total billed charges,Implant Device,168.8,,,168.8,Other,110% of Medicare,119.35,35,,119.35,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,119.35,35,,119.35,percent of total billed charges,Implant Device,119.35,35,,119.35,percent of total billed charges,Implant Device,119.35,35,,119.35,percent of total billed charges,Implant Device,119.35,35,,119.35,percent of total billed charges,Implant Device,119.35,35,,119.35,percent of total billed charges,Implant Device,136.4,40,,136.4,percent of total billed charges,Implant Device,119.35,70,,119.35,percent of total billed charges,All Other,115.94,34,,115.94,percent of total billed charges,Implant Device,115.94,34,,115.94,percent of total billed charges,Implant Device,119.35,35,,119.35,percent of total billed charges,Implant Device,119.35,35,,119.35,percent of total billed charges,Implant Device,119.35,35,,119.35,percent of total billed charges,Implant Device,119.35,35,,119.35,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,252.34,
STRYKER 1826-1438S SUPRCNDLR NAIL 14X380,C1713,HCPCS,,79004105,CDM,278,RC,,,both,,,6598,4882.54,,,4882.54,Other,150% of Medicare + 9.63% HCRA Surcharge,2969.1,45,,2969.1,percent of total billed charges,Critical Access Hospital RCC factor,2243.32,34,,2243.32,percent of total billed charges,Implant Device,2243.32,34,,2243.32,percent of total billed charges,Implant Device,2243.32,34,,2243.32,percent of total billed charges,Implant Device,2243.32,34,,2243.32,percent of total billed charges,Implant Device,2243.32,34,,2243.32,percent of total billed charges,Implant Device,3266.01,,,3266.01,Other,110% of Medicare,2309.3,35,,2309.3,percent of total billed charges,Implant Device,2243.32,34,"Charges > $500, x 34%",2243.32,percent of total billed charges,Implant Device,2309.3,35,,2309.3,percent of total billed charges,Implant Device,2309.3,35,,2309.3,percent of total billed charges,Implant Device,2309.3,35,,2309.3,percent of total billed charges,Implant Device,2309.3,35,,2309.3,percent of total billed charges,Implant Device,2309.3,35,,2309.3,percent of total billed charges,Implant Device,2639.2,40,,2639.2,percent of total billed charges,Implant Device,2309.3,70,,2309.3,percent of total billed charges,All Other,2243.32,34,,2243.32,percent of total billed charges,Implant Device,2243.32,34,,2243.32,percent of total billed charges,Implant Device,2309.3,35,,2309.3,percent of total billed charges,Implant Device,2309.3,35,,2309.3,percent of total billed charges,Implant Device,2309.3,35,,2309.3,percent of total billed charges,Implant Device,2309.3,35,,2309.3,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2243.32,34,"If Charge > 2,000, then 34 percent",2243.32,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4882.54,
STRYKER 1828-1436S FEMORAL NAIL 14X360MM,C1713,HCPCS,,79004106,CDM,278,RC,,,both,,,3682,2724.69,,,2724.69,Other,150% of Medicare + 9.63% HCRA Surcharge,1656.9,45,,1656.9,percent of total billed charges,Critical Access Hospital RCC factor,1251.88,34,,1251.88,percent of total billed charges,Implant Device,1251.88,34,,1251.88,percent of total billed charges,Implant Device,1251.88,34,,1251.88,percent of total billed charges,Implant Device,1251.88,34,,1251.88,percent of total billed charges,Implant Device,1251.88,34,,1251.88,percent of total billed charges,Implant Device,1822.59,,,1822.59,Other,110% of Medicare,1288.7,35,,1288.7,percent of total billed charges,Implant Device,1251.88,34,"Charges > $500, x 34%",1251.88,percent of total billed charges,Implant Device,1288.7,35,,1288.7,percent of total billed charges,Implant Device,1288.7,35,,1288.7,percent of total billed charges,Implant Device,1288.7,35,,1288.7,percent of total billed charges,Implant Device,1288.7,35,,1288.7,percent of total billed charges,Implant Device,1288.7,35,,1288.7,percent of total billed charges,Implant Device,1472.8,40,,1472.8,percent of total billed charges,Implant Device,1288.7,70,,1288.7,percent of total billed charges,All Other,1251.88,34,,1251.88,percent of total billed charges,Implant Device,1251.88,34,,1251.88,percent of total billed charges,Implant Device,1288.7,35,,1288.7,percent of total billed charges,Implant Device,1288.7,35,,1288.7,percent of total billed charges,Implant Device,1288.7,35,,1288.7,percent of total billed charges,Implant Device,1288.7,35,,1288.7,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1251.88,34,"If Charge > 2,000, then 34 percent",1251.88,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2724.69,
STRYKER 2080-0040 PLATE SCREW 6.5X40MM,C1713,HCPCS,,79004107,CDM,278,RC,,,both,,,516,381.84,,,381.84,Other,150% of Medicare + 9.63% HCRA Surcharge,232.2,45,,232.2,percent of total billed charges,Critical Access Hospital RCC factor,175.44,34,,175.44,percent of total billed charges,Implant Device,175.44,34,,175.44,percent of total billed charges,Implant Device,175.44,34,,175.44,percent of total billed charges,Implant Device,175.44,34,,175.44,percent of total billed charges,Implant Device,175.44,34,,175.44,percent of total billed charges,Implant Device,255.42,,,255.42,Other,110% of Medicare,180.6,35,,180.6,percent of total billed charges,Implant Device,175.44,34,"Charges > $500, x 34%",175.44,percent of total billed charges,Implant Device,180.6,35,,180.6,percent of total billed charges,Implant Device,180.6,35,,180.6,percent of total billed charges,Implant Device,180.6,35,,180.6,percent of total billed charges,Implant Device,180.6,35,,180.6,percent of total billed charges,Implant Device,180.6,35,,180.6,percent of total billed charges,Implant Device,206.4,40,,206.4,percent of total billed charges,Implant Device,180.6,70,,180.6,percent of total billed charges,All Other,175.44,34,,175.44,percent of total billed charges,Implant Device,175.44,34,,175.44,percent of total billed charges,Implant Device,180.6,35,,180.6,percent of total billed charges,Implant Device,180.6,35,,180.6,percent of total billed charges,Implant Device,180.6,35,,180.6,percent of total billed charges,Implant Device,180.6,35,,180.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,381.84,
STRYKER 1896-4020S LOCK SCREW 4X20MM,C1713,HCPCS,,79004108,CDM,278,RC,,,both,,,592,438.08,,,438.08,Other,150% of Medicare + 9.63% HCRA Surcharge,266.4,45,,266.4,percent of total billed charges,Critical Access Hospital RCC factor,201.28,34,,201.28,percent of total billed charges,Implant Device,201.28,34,,201.28,percent of total billed charges,Implant Device,201.28,34,,201.28,percent of total billed charges,Implant Device,201.28,34,,201.28,percent of total billed charges,Implant Device,201.28,34,,201.28,percent of total billed charges,Implant Device,293.04,,,293.04,Other,110% of Medicare,207.2,35,,207.2,percent of total billed charges,Implant Device,201.28,34,"Charges > $500, x 34%",201.28,percent of total billed charges,Implant Device,207.2,35,,207.2,percent of total billed charges,Implant Device,207.2,35,,207.2,percent of total billed charges,Implant Device,207.2,35,,207.2,percent of total billed charges,Implant Device,207.2,35,,207.2,percent of total billed charges,Implant Device,207.2,35,,207.2,percent of total billed charges,Implant Device,236.8,40,,236.8,percent of total billed charges,Implant Device,207.2,70,,207.2,percent of total billed charges,All Other,201.28,34,,201.28,percent of total billed charges,Implant Device,201.28,34,,201.28,percent of total billed charges,Implant Device,207.2,35,,207.2,percent of total billed charges,Implant Device,207.2,35,,207.2,percent of total billed charges,Implant Device,207.2,35,,207.2,percent of total billed charges,Implant Device,207.2,35,,207.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,438.08,
STRYKER 3060-0130S LAG SCREW 10.5X130MM,C1713,HCPCS,,79004109,CDM,278,RC,,,both,,,1650,1221,,,1221,Other,150% of Medicare + 9.63% HCRA Surcharge,742.5,45,,742.5,percent of total billed charges,Critical Access Hospital RCC factor,561,34,,561,percent of total billed charges,Implant Device,561,34,,561,percent of total billed charges,Implant Device,561,34,,561,percent of total billed charges,Implant Device,561,34,,561,percent of total billed charges,Implant Device,561,34,,561,percent of total billed charges,Implant Device,816.75,,,816.75,Other,110% of Medicare,577.5,35,,577.5,percent of total billed charges,Implant Device,561,34,"Charges > $500, x 34%",561,percent of total billed charges,Implant Device,577.5,35,,577.5,percent of total billed charges,Implant Device,577.5,35,,577.5,percent of total billed charges,Implant Device,577.5,35,,577.5,percent of total billed charges,Implant Device,577.5,35,,577.5,percent of total billed charges,Implant Device,577.5,35,,577.5,percent of total billed charges,Implant Device,660,40,,660,percent of total billed charges,Implant Device,577.5,70,,577.5,percent of total billed charges,All Other,561,34,,561,percent of total billed charges,Implant Device,561,34,,561,percent of total billed charges,Implant Device,577.5,35,,577.5,percent of total billed charges,Implant Device,577.5,35,,577.5,percent of total billed charges,Implant Device,577.5,35,,577.5,percent of total billed charges,Implant Device,577.5,35,,577.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1221,
STRYKER 370385 LOCKING SCREW 5X85MM,C1713,HCPCS,,79004110,CDM,278,RC,,,both,,,446,330.04,,,330.04,Other,150% of Medicare + 9.63% HCRA Surcharge,200.7,45,,200.7,percent of total billed charges,Critical Access Hospital RCC factor,151.64,34,,151.64,percent of total billed charges,Implant Device,151.64,34,,151.64,percent of total billed charges,Implant Device,151.64,34,,151.64,percent of total billed charges,Implant Device,151.64,34,,151.64,percent of total billed charges,Implant Device,151.64,34,,151.64,percent of total billed charges,Implant Device,220.77,,,220.77,Other,110% of Medicare,156.1,35,,156.1,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,156.1,35,,156.1,percent of total billed charges,Implant Device,156.1,35,,156.1,percent of total billed charges,Implant Device,156.1,35,,156.1,percent of total billed charges,Implant Device,156.1,35,,156.1,percent of total billed charges,Implant Device,156.1,35,,156.1,percent of total billed charges,Implant Device,178.4,40,,178.4,percent of total billed charges,Implant Device,156.1,70,,156.1,percent of total billed charges,All Other,151.64,34,,151.64,percent of total billed charges,Implant Device,151.64,34,,151.64,percent of total billed charges,Implant Device,156.1,35,,156.1,percent of total billed charges,Implant Device,156.1,35,,156.1,percent of total billed charges,Implant Device,156.1,35,,156.1,percent of total billed charges,Implant Device,156.1,35,,156.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,330.04,
STRYKER 2030-6535-1 CANC SCREW 6.5X35MM,C1713,HCPCS,,79004111,CDM,278,RC,,,both,,,451,333.74,,,333.74,Other,150% of Medicare + 9.63% HCRA Surcharge,202.95,45,,202.95,percent of total billed charges,Critical Access Hospital RCC factor,153.34,34,,153.34,percent of total billed charges,Implant Device,153.34,34,,153.34,percent of total billed charges,Implant Device,153.34,34,,153.34,percent of total billed charges,Implant Device,153.34,34,,153.34,percent of total billed charges,Implant Device,153.34,34,,153.34,percent of total billed charges,Implant Device,223.25,,,223.25,Other,110% of Medicare,157.85,35,,157.85,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,157.85,35,,157.85,percent of total billed charges,Implant Device,157.85,35,,157.85,percent of total billed charges,Implant Device,157.85,35,,157.85,percent of total billed charges,Implant Device,157.85,35,,157.85,percent of total billed charges,Implant Device,157.85,35,,157.85,percent of total billed charges,Implant Device,180.4,40,,180.4,percent of total billed charges,Implant Device,157.85,70,,157.85,percent of total billed charges,All Other,153.34,34,,153.34,percent of total billed charges,Implant Device,153.34,34,,153.34,percent of total billed charges,Implant Device,157.85,35,,157.85,percent of total billed charges,Implant Device,157.85,35,,157.85,percent of total billed charges,Implant Device,157.85,35,,157.85,percent of total billed charges,Implant Device,157.85,35,,157.85,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,333.74,
STRYKER 371350 LOCKING SCREW 5X50MM,C1713,HCPCS,,79004113,CDM,278,RC,,,both,,,523,387.02,,,387.02,Other,150% of Medicare + 9.63% HCRA Surcharge,235.35,45,,235.35,percent of total billed charges,Critical Access Hospital RCC factor,177.82,34,,177.82,percent of total billed charges,Implant Device,177.82,34,,177.82,percent of total billed charges,Implant Device,177.82,34,,177.82,percent of total billed charges,Implant Device,177.82,34,,177.82,percent of total billed charges,Implant Device,177.82,34,,177.82,percent of total billed charges,Implant Device,258.89,,,258.89,Other,110% of Medicare,183.05,35,,183.05,percent of total billed charges,Implant Device,177.82,34,"Charges > $500, x 34%",177.82,percent of total billed charges,Implant Device,183.05,35,,183.05,percent of total billed charges,Implant Device,183.05,35,,183.05,percent of total billed charges,Implant Device,183.05,35,,183.05,percent of total billed charges,Implant Device,183.05,35,,183.05,percent of total billed charges,Implant Device,183.05,35,,183.05,percent of total billed charges,Implant Device,209.2,40,,209.2,percent of total billed charges,Implant Device,183.05,70,,183.05,percent of total billed charges,All Other,177.82,34,,177.82,percent of total billed charges,Implant Device,177.82,34,,177.82,percent of total billed charges,Implant Device,183.05,35,,183.05,percent of total billed charges,Implant Device,183.05,35,,183.05,percent of total billed charges,Implant Device,183.05,35,,183.05,percent of total billed charges,Implant Device,183.05,35,,183.05,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,387.02,
STRYKER 32285-3380S LONG NAIL 13X380MM,C1713,HCPCS,,79004114,CDM,278,RC,,,both,,,7140,5283.62,,,5283.62,Other,150% of Medicare + 9.63% HCRA Surcharge,3213,45,,3213,percent of total billed charges,Critical Access Hospital RCC factor,2427.6,34,,2427.6,percent of total billed charges,Implant Device,2427.6,34,,2427.6,percent of total billed charges,Implant Device,2427.6,34,,2427.6,percent of total billed charges,Implant Device,2427.6,34,,2427.6,percent of total billed charges,Implant Device,2427.6,34,,2427.6,percent of total billed charges,Implant Device,3534.3,,,3534.3,Other,110% of Medicare,2499,35,,2499,percent of total billed charges,Implant Device,2427.6,34,"Charges > $500, x 34%",2427.6,percent of total billed charges,Implant Device,2499,35,,2499,percent of total billed charges,Implant Device,2499,35,,2499,percent of total billed charges,Implant Device,2499,35,,2499,percent of total billed charges,Implant Device,2499,35,,2499,percent of total billed charges,Implant Device,2499,35,,2499,percent of total billed charges,Implant Device,2856,40,,2856,percent of total billed charges,Implant Device,2499,70,,2499,percent of total billed charges,All Other,2427.6,34,,2427.6,percent of total billed charges,Implant Device,2427.6,34,,2427.6,percent of total billed charges,Implant Device,2499,35,,2499,percent of total billed charges,Implant Device,2499,35,,2499,percent of total billed charges,Implant Device,2499,35,,2499,percent of total billed charges,Implant Device,2499,35,,2499,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2427.6,34,"If Charge > 2,000, then 34 percent",2427.6,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5283.62,
STRYKER UH1-45-26 UNIVERSAL HEAD 45X26MM,C1776,HCPCS,,79004115,CDM,278,RC,,,both,,,1391,1029.34,,,1029.34,Other,150% of Medicare + 9.63% HCRA Surcharge,625.95,45,,625.95,percent of total billed charges,Critical Access Hospital RCC factor,472.94,34,,472.94,percent of total billed charges,Implant Device,472.94,34,,472.94,percent of total billed charges,Implant Device,472.94,34,,472.94,percent of total billed charges,Implant Device,472.94,34,,472.94,percent of total billed charges,Implant Device,472.94,34,,472.94,percent of total billed charges,Implant Device,688.55,,,688.55,Other,110% of Medicare,486.85,35,,486.85,percent of total billed charges,Implant Device,472.94,34,"Charges > $500, x 34%",472.94,percent of total billed charges,Implant Device,486.85,35,,486.85,percent of total billed charges,Implant Device,486.85,35,,486.85,percent of total billed charges,Implant Device,486.85,35,,486.85,percent of total billed charges,Implant Device,486.85,35,,486.85,percent of total billed charges,Implant Device,486.85,35,,486.85,percent of total billed charges,Implant Device,556.4,40,,556.4,percent of total billed charges,Implant Device,486.85,70,,486.85,percent of total billed charges,All Other,472.94,34,,472.94,percent of total billed charges,Implant Device,472.94,34,,472.94,percent of total billed charges,Implant Device,486.85,35,,486.85,percent of total billed charges,Implant Device,486.85,35,,486.85,percent of total billed charges,Implant Device,486.85,35,,486.85,percent of total billed charges,Implant Device,486.85,35,,486.85,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1029.34,
STRYKER 3430-80 CANCELLOUS SCREW 6.5X80,C1713,HCPCS,,79004116,CDM,278,RC,,,both,,,84,62.16,,,62.16,Other,150% of Medicare + 9.63% HCRA Surcharge,37.8,45,,37.8,percent of total billed charges,Critical Access Hospital RCC factor,28.56,34,,28.56,percent of total billed charges,Implant Device,28.56,34,,28.56,percent of total billed charges,Implant Device,28.56,34,,28.56,percent of total billed charges,Implant Device,28.56,34,,28.56,percent of total billed charges,Implant Device,28.56,34,,28.56,percent of total billed charges,Implant Device,41.58,,,41.58,Other,110% of Medicare,29.4,35,,29.4,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,29.4,35,,29.4,percent of total billed charges,Implant Device,29.4,35,,29.4,percent of total billed charges,Implant Device,29.4,35,,29.4,percent of total billed charges,Implant Device,29.4,35,,29.4,percent of total billed charges,Implant Device,29.4,35,,29.4,percent of total billed charges,Implant Device,33.6,40,,33.6,percent of total billed charges,Implant Device,29.4,70,,29.4,percent of total billed charges,All Other,28.56,34,,28.56,percent of total billed charges,Implant Device,28.56,34,,28.56,percent of total billed charges,Implant Device,29.4,35,,29.4,percent of total billed charges,Implant Device,29.4,35,,29.4,percent of total billed charges,Implant Device,29.4,35,,29.4,percent of total billed charges,Implant Device,29.4,35,,29.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,62.16,
STRYKER 623-00-36D POLY INSERT 36MM D,C1776,HCPCS,,79004117,CDM,278,RC,,,both,,,6575,4865.52,,,4865.52,Other,150% of Medicare + 9.63% HCRA Surcharge,2958.75,45,,2958.75,percent of total billed charges,Critical Access Hospital RCC factor,2235.5,34,,2235.5,percent of total billed charges,Implant Device,2235.5,34,,2235.5,percent of total billed charges,Implant Device,2235.5,34,,2235.5,percent of total billed charges,Implant Device,2235.5,34,,2235.5,percent of total billed charges,Implant Device,2235.5,34,,2235.5,percent of total billed charges,Implant Device,3254.63,,,3254.63,Other,110% of Medicare,2301.25,35,,2301.25,percent of total billed charges,Implant Device,2235.5,34,"Charges > $500, x 34%",2235.5,percent of total billed charges,Implant Device,2301.25,35,,2301.25,percent of total billed charges,Implant Device,2301.25,35,,2301.25,percent of total billed charges,Implant Device,2301.25,35,,2301.25,percent of total billed charges,Implant Device,2301.25,35,,2301.25,percent of total billed charges,Implant Device,2301.25,35,,2301.25,percent of total billed charges,Implant Device,2630,40,,2630,percent of total billed charges,Implant Device,2301.25,70,,2301.25,percent of total billed charges,All Other,2235.5,34,,2235.5,percent of total billed charges,Implant Device,2235.5,34,,2235.5,percent of total billed charges,Implant Device,2301.25,35,,2301.25,percent of total billed charges,Implant Device,2301.25,35,,2301.25,percent of total billed charges,Implant Device,2301.25,35,,2301.25,percent of total billed charges,Implant Device,2301.25,35,,2301.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2235.5,34,"If Charge > 2,000, then 34 percent",2235.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4865.52,
STRYKER 343085 CANCELLOUS SCREW 6.5X85,C1713,HCPCS,,79004118,CDM,278,RC,,,both,,,113,83.62,,,83.62,Other,150% of Medicare + 9.63% HCRA Surcharge,50.85,45,,50.85,percent of total billed charges,Critical Access Hospital RCC factor,38.42,34,,38.42,percent of total billed charges,Implant Device,38.42,34,,38.42,percent of total billed charges,Implant Device,38.42,34,,38.42,percent of total billed charges,Implant Device,38.42,34,,38.42,percent of total billed charges,Implant Device,38.42,34,,38.42,percent of total billed charges,Implant Device,55.94,,,55.94,Other,110% of Medicare,39.55,35,,39.55,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,39.55,35,,39.55,percent of total billed charges,Implant Device,39.55,35,,39.55,percent of total billed charges,Implant Device,39.55,35,,39.55,percent of total billed charges,Implant Device,39.55,35,,39.55,percent of total billed charges,Implant Device,39.55,35,,39.55,percent of total billed charges,Implant Device,45.2,40,,45.2,percent of total billed charges,Implant Device,39.55,70,,39.55,percent of total billed charges,All Other,38.42,34,,38.42,percent of total billed charges,Implant Device,38.42,34,,38.42,percent of total billed charges,Implant Device,39.55,35,,39.55,percent of total billed charges,Implant Device,39.55,35,,39.55,percent of total billed charges,Implant Device,39.55,35,,39.55,percent of total billed charges,Implant Device,39.55,35,,39.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,83.62,
STRYKER 343095 FT CAN SCREW 6.5X95MM,C1713,HCPCS,,79004119,CDM,278,RC,,,both,,,127,93.98,,,93.98,Other,150% of Medicare + 9.63% HCRA Surcharge,57.15,45,,57.15,percent of total billed charges,Critical Access Hospital RCC factor,43.18,34,,43.18,percent of total billed charges,Implant Device,43.18,34,,43.18,percent of total billed charges,Implant Device,43.18,34,,43.18,percent of total billed charges,Implant Device,43.18,34,,43.18,percent of total billed charges,Implant Device,43.18,34,,43.18,percent of total billed charges,Implant Device,62.87,,,62.87,Other,110% of Medicare,44.45,35,,44.45,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,44.45,35,,44.45,percent of total billed charges,Implant Device,44.45,35,,44.45,percent of total billed charges,Implant Device,44.45,35,,44.45,percent of total billed charges,Implant Device,44.45,35,,44.45,percent of total billed charges,Implant Device,44.45,35,,44.45,percent of total billed charges,Implant Device,50.8,40,,50.8,percent of total billed charges,Implant Device,44.45,70,,44.45,percent of total billed charges,All Other,43.18,34,,43.18,percent of total billed charges,Implant Device,43.18,34,,43.18,percent of total billed charges,Implant Device,44.45,35,,44.45,percent of total billed charges,Implant Device,44.45,35,,44.45,percent of total billed charges,Implant Device,44.45,35,,44.45,percent of total billed charges,Implant Device,44.45,35,,44.45,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,93.98,
STRYKER 345516 CAN PART SCREW 4X16MM,C1713,HCPCS,,79004120,CDM,278,RC,,,both,,,74,54.76,,,54.76,Other,150% of Medicare + 9.63% HCRA Surcharge,33.3,45,,33.3,percent of total billed charges,Critical Access Hospital RCC factor,25.16,34,,25.16,percent of total billed charges,Implant Device,25.16,34,,25.16,percent of total billed charges,Implant Device,25.16,34,,25.16,percent of total billed charges,Implant Device,25.16,34,,25.16,percent of total billed charges,Implant Device,25.16,34,,25.16,percent of total billed charges,Implant Device,36.63,,,36.63,Other,110% of Medicare,25.9,35,,25.9,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,25.9,35,,25.9,percent of total billed charges,Implant Device,25.9,35,,25.9,percent of total billed charges,Implant Device,25.9,35,,25.9,percent of total billed charges,Implant Device,25.9,35,,25.9,percent of total billed charges,Implant Device,25.9,35,,25.9,percent of total billed charges,Implant Device,29.6,40,,29.6,percent of total billed charges,Implant Device,25.9,70,,25.9,percent of total billed charges,All Other,25.16,34,,25.16,percent of total billed charges,Implant Device,25.16,34,,25.16,percent of total billed charges,Implant Device,25.9,35,,25.9,percent of total billed charges,Implant Device,25.9,35,,25.9,percent of total billed charges,Implant Device,25.9,35,,25.9,percent of total billed charges,Implant Device,25.9,35,,25.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,54.76,
STRYKER 502-03-50D HEMI HOLE SHELL 50MM,C1713,HCPCS,,79004121,CDM,278,RC,,,both,,,9197,6805.8,,,6805.8,Other,150% of Medicare + 9.63% HCRA Surcharge,4138.65,45,,4138.65,percent of total billed charges,Critical Access Hospital RCC factor,3126.98,34,,3126.98,percent of total billed charges,Implant Device,3126.98,34,,3126.98,percent of total billed charges,Implant Device,3126.98,34,,3126.98,percent of total billed charges,Implant Device,3126.98,34,,3126.98,percent of total billed charges,Implant Device,3126.98,34,,3126.98,percent of total billed charges,Implant Device,4552.52,,,4552.52,Other,110% of Medicare,3218.95,35,,3218.95,percent of total billed charges,Implant Device,3126.98,34,"Charges > $500, x 34%",3126.98,percent of total billed charges,Implant Device,3218.95,35,,3218.95,percent of total billed charges,Implant Device,3218.95,35,,3218.95,percent of total billed charges,Implant Device,3218.95,35,,3218.95,percent of total billed charges,Implant Device,3218.95,35,,3218.95,percent of total billed charges,Implant Device,3218.95,35,,3218.95,percent of total billed charges,Implant Device,3678.8,40,,3678.8,percent of total billed charges,Implant Device,3218.95,70,,3218.95,percent of total billed charges,All Other,3126.98,34,,3126.98,percent of total billed charges,Implant Device,3126.98,34,,3126.98,percent of total billed charges,Implant Device,3218.95,35,,3218.95,percent of total billed charges,Implant Device,3218.95,35,,3218.95,percent of total billed charges,Implant Device,3218.95,35,,3218.95,percent of total billed charges,Implant Device,3218.95,35,,3218.95,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3126.98,34,"If Charge > 2,000, then 34 percent",3126.98,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,6805.8,
STRYKER 1828-1432S FEMORAL NAIL 14X320MM,C1713,HCPCS,,79004122,CDM,278,RC,,,both,,,6258,4630.94,,,4630.94,Other,150% of Medicare + 9.63% HCRA Surcharge,2816.1,45,,2816.1,percent of total billed charges,Critical Access Hospital RCC factor,2127.72,34,,2127.72,percent of total billed charges,Implant Device,2127.72,34,,2127.72,percent of total billed charges,Implant Device,2127.72,34,,2127.72,percent of total billed charges,Implant Device,2127.72,34,,2127.72,percent of total billed charges,Implant Device,2127.72,34,,2127.72,percent of total billed charges,Implant Device,3097.71,,,3097.71,Other,110% of Medicare,2190.3,35,,2190.3,percent of total billed charges,Implant Device,2127.72,34,"Charges > $500, x 34%",2127.72,percent of total billed charges,Implant Device,2190.3,35,,2190.3,percent of total billed charges,Implant Device,2190.3,35,,2190.3,percent of total billed charges,Implant Device,2190.3,35,,2190.3,percent of total billed charges,Implant Device,2190.3,35,,2190.3,percent of total billed charges,Implant Device,2190.3,35,,2190.3,percent of total billed charges,Implant Device,2503.2,40,,2503.2,percent of total billed charges,Implant Device,2190.3,70,,2190.3,percent of total billed charges,All Other,2127.72,34,,2127.72,percent of total billed charges,Implant Device,2127.72,34,,2127.72,percent of total billed charges,Implant Device,2190.3,35,,2190.3,percent of total billed charges,Implant Device,2190.3,35,,2190.3,percent of total billed charges,Implant Device,2190.3,35,,2190.3,percent of total billed charges,Implant Device,2190.3,35,,2190.3,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2127.72,34,"If Charge > 2,000, then 34 percent",2127.72,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4630.94,
STRYKER 604665S ASNIS CANN SCREW 4X65MM,C1713,HCPCS,,79004123,CDM,278,RC,,,both,,,770,569.8,,,569.8,Other,150% of Medicare + 9.63% HCRA Surcharge,346.5,45,,346.5,percent of total billed charges,Critical Access Hospital RCC factor,261.8,34,,261.8,percent of total billed charges,Implant Device,261.8,34,,261.8,percent of total billed charges,Implant Device,261.8,34,,261.8,percent of total billed charges,Implant Device,261.8,34,,261.8,percent of total billed charges,Implant Device,261.8,34,,261.8,percent of total billed charges,Implant Device,381.15,,,381.15,Other,110% of Medicare,269.5,35,,269.5,percent of total billed charges,Implant Device,261.8,34,"Charges > $500, x 34%",261.8,percent of total billed charges,Implant Device,269.5,35,,269.5,percent of total billed charges,Implant Device,269.5,35,,269.5,percent of total billed charges,Implant Device,269.5,35,,269.5,percent of total billed charges,Implant Device,269.5,35,,269.5,percent of total billed charges,Implant Device,269.5,35,,269.5,percent of total billed charges,Implant Device,308,40,,308,percent of total billed charges,Implant Device,269.5,70,,269.5,percent of total billed charges,All Other,261.8,34,,261.8,percent of total billed charges,Implant Device,261.8,34,,261.8,percent of total billed charges,Implant Device,269.5,35,,269.5,percent of total billed charges,Implant Device,269.5,35,,269.5,percent of total billed charges,Implant Device,269.5,35,,269.5,percent of total billed charges,Implant Device,269.5,35,,269.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,569.8,
STRYKER 53-17014E LOCK SCREW 1.7X14MM,C1713,HCPCS,,79004124,CDM,278,RC,,,both,,,306,226.44,,,226.44,Other,150% of Medicare + 9.63% HCRA Surcharge,137.7,45,,137.7,percent of total billed charges,Critical Access Hospital RCC factor,104.04,34,,104.04,percent of total billed charges,Implant Device,104.04,34,,104.04,percent of total billed charges,Implant Device,104.04,34,,104.04,percent of total billed charges,Implant Device,104.04,34,,104.04,percent of total billed charges,Implant Device,104.04,34,,104.04,percent of total billed charges,Implant Device,151.47,,,151.47,Other,110% of Medicare,107.1,35,,107.1,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,107.1,35,,107.1,percent of total billed charges,Implant Device,107.1,35,,107.1,percent of total billed charges,Implant Device,107.1,35,,107.1,percent of total billed charges,Implant Device,107.1,35,,107.1,percent of total billed charges,Implant Device,107.1,35,,107.1,percent of total billed charges,Implant Device,122.4,40,,122.4,percent of total billed charges,Implant Device,107.1,70,,107.1,percent of total billed charges,All Other,104.04,34,,104.04,percent of total billed charges,Implant Device,104.04,34,,104.04,percent of total billed charges,Implant Device,107.1,35,,107.1,percent of total billed charges,Implant Device,107.1,35,,107.1,percent of total billed charges,Implant Device,107.1,35,,107.1,percent of total billed charges,Implant Device,107.1,35,,107.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,226.44,
STRYKER 40-20108 ASNIS MICRO SCREW 2X8,C1713,HCPCS,,79004125,CDM,278,RC,,,both,,,455,336.7,,,336.7,Other,150% of Medicare + 9.63% HCRA Surcharge,204.75,45,,204.75,percent of total billed charges,Critical Access Hospital RCC factor,154.7,34,,154.7,percent of total billed charges,Implant Device,154.7,34,,154.7,percent of total billed charges,Implant Device,154.7,34,,154.7,percent of total billed charges,Implant Device,154.7,34,,154.7,percent of total billed charges,Implant Device,154.7,34,,154.7,percent of total billed charges,Implant Device,225.23,,,225.23,Other,110% of Medicare,159.25,35,,159.25,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,159.25,35,,159.25,percent of total billed charges,Implant Device,159.25,35,,159.25,percent of total billed charges,Implant Device,159.25,35,,159.25,percent of total billed charges,Implant Device,159.25,35,,159.25,percent of total billed charges,Implant Device,159.25,35,,159.25,percent of total billed charges,Implant Device,182,40,,182,percent of total billed charges,Implant Device,159.25,70,,159.25,percent of total billed charges,All Other,154.7,34,,154.7,percent of total billed charges,Implant Device,154.7,34,,154.7,percent of total billed charges,Implant Device,159.25,35,,159.25,percent of total billed charges,Implant Device,159.25,35,,159.25,percent of total billed charges,Implant Device,159.25,35,,159.25,percent of total billed charges,Implant Device,159.25,35,,159.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,336.7,
STRYKER 5018-8-180 APEX PINS 5X180MM,C1713,HCPCS,,79004126,CDM,278,RC,,,both,,,474,350.76,,,350.76,Other,150% of Medicare + 9.63% HCRA Surcharge,213.3,45,,213.3,percent of total billed charges,Critical Access Hospital RCC factor,161.16,34,,161.16,percent of total billed charges,Implant Device,161.16,34,,161.16,percent of total billed charges,Implant Device,161.16,34,,161.16,percent of total billed charges,Implant Device,161.16,34,,161.16,percent of total billed charges,Implant Device,161.16,34,,161.16,percent of total billed charges,Implant Device,234.63,,,234.63,Other,110% of Medicare,165.9,35,,165.9,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,165.9,35,,165.9,percent of total billed charges,Implant Device,165.9,35,,165.9,percent of total billed charges,Implant Device,165.9,35,,165.9,percent of total billed charges,Implant Device,165.9,35,,165.9,percent of total billed charges,Implant Device,165.9,35,,165.9,percent of total billed charges,Implant Device,189.6,40,,189.6,percent of total billed charges,Implant Device,165.9,70,,165.9,percent of total billed charges,All Other,161.16,34,,161.16,percent of total billed charges,Implant Device,161.16,34,,161.16,percent of total billed charges,Implant Device,165.9,35,,165.9,percent of total billed charges,Implant Device,165.9,35,,165.9,percent of total billed charges,Implant Device,165.9,35,,165.9,percent of total billed charges,Implant Device,165.9,35,,165.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,350.76,
STRYKER S-2337-HF09 CEMENTLESS HIP STEM,C1776,HCPCS,,79004127,CDM,278,RC,,,both,,,10716,7929.87,,,7929.87,Other,150% of Medicare + 9.63% HCRA Surcharge,4822.2,45,,4822.2,percent of total billed charges,Critical Access Hospital RCC factor,3643.44,34,,3643.44,percent of total billed charges,Implant Device,3643.44,34,,3643.44,percent of total billed charges,Implant Device,3643.44,34,,3643.44,percent of total billed charges,Implant Device,3643.44,34,,3643.44,percent of total billed charges,Implant Device,3643.44,34,,3643.44,percent of total billed charges,Implant Device,5304.42,,,5304.42,Other,110% of Medicare,3750.6,35,,3750.6,percent of total billed charges,Implant Device,3643.44,34,"Charges > $500, x 34%",3643.44,percent of total billed charges,Implant Device,3750.6,35,,3750.6,percent of total billed charges,Implant Device,3750.6,35,,3750.6,percent of total billed charges,Implant Device,3750.6,35,,3750.6,percent of total billed charges,Implant Device,3750.6,35,,3750.6,percent of total billed charges,Implant Device,3750.6,35,,3750.6,percent of total billed charges,Implant Device,4286.4,40,,4286.4,percent of total billed charges,Implant Device,3750.6,70,,3750.6,percent of total billed charges,All Other,3643.44,34,,3643.44,percent of total billed charges,Implant Device,3643.44,34,,3643.44,percent of total billed charges,Implant Device,3750.6,35,,3750.6,percent of total billed charges,Implant Device,3750.6,35,,3750.6,percent of total billed charges,Implant Device,3750.6,35,,3750.6,percent of total billed charges,Implant Device,3750.6,35,,3750.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3643.44,34,"If Charge > 2,000, then 34 percent",3643.44,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,7929.87,
STRYKER 3713-70 LOCKING SCREW 5X70,C1713,HCPCS,,79004128,CDM,278,RC,,,both,,,474,350.76,,,350.76,Other,150% of Medicare + 9.63% HCRA Surcharge,213.3,45,,213.3,percent of total billed charges,Critical Access Hospital RCC factor,161.16,34,,161.16,percent of total billed charges,Implant Device,161.16,34,,161.16,percent of total billed charges,Implant Device,161.16,34,,161.16,percent of total billed charges,Implant Device,161.16,34,,161.16,percent of total billed charges,Implant Device,161.16,34,,161.16,percent of total billed charges,Implant Device,234.63,,,234.63,Other,110% of Medicare,165.9,35,,165.9,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,165.9,35,,165.9,percent of total billed charges,Implant Device,165.9,35,,165.9,percent of total billed charges,Implant Device,165.9,35,,165.9,percent of total billed charges,Implant Device,165.9,35,,165.9,percent of total billed charges,Implant Device,165.9,35,,165.9,percent of total billed charges,Implant Device,189.6,40,,189.6,percent of total billed charges,Implant Device,165.9,70,,165.9,percent of total billed charges,All Other,161.16,34,,161.16,percent of total billed charges,Implant Device,161.16,34,,161.16,percent of total billed charges,Implant Device,165.9,35,,165.9,percent of total billed charges,Implant Device,165.9,35,,165.9,percent of total billed charges,Implant Device,165.9,35,,165.9,percent of total billed charges,Implant Device,165.9,35,,165.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,350.76,
STRYKER 3225-0400S NAIL 11X400MMX125DEG,C1713,HCPCS,,79004129,CDM,278,RC,,,both,,,5021,3715.55,,,3715.55,Other,150% of Medicare + 9.63% HCRA Surcharge,2259.45,45,,2259.45,percent of total billed charges,Critical Access Hospital RCC factor,1707.14,34,,1707.14,percent of total billed charges,Implant Device,1707.14,34,,1707.14,percent of total billed charges,Implant Device,1707.14,34,,1707.14,percent of total billed charges,Implant Device,1707.14,34,,1707.14,percent of total billed charges,Implant Device,1707.14,34,,1707.14,percent of total billed charges,Implant Device,2485.4,,,2485.4,Other,110% of Medicare,1757.35,35,,1757.35,percent of total billed charges,Implant Device,1707.14,34,"Charges > $500, x 34%",1707.14,percent of total billed charges,Implant Device,1757.35,35,,1757.35,percent of total billed charges,Implant Device,1757.35,35,,1757.35,percent of total billed charges,Implant Device,1757.35,35,,1757.35,percent of total billed charges,Implant Device,1757.35,35,,1757.35,percent of total billed charges,Implant Device,1757.35,35,,1757.35,percent of total billed charges,Implant Device,2008.4,40,,2008.4,percent of total billed charges,Implant Device,1757.35,70,,1757.35,percent of total billed charges,All Other,1707.14,34,,1707.14,percent of total billed charges,Implant Device,1707.14,34,,1707.14,percent of total billed charges,Implant Device,1757.35,35,,1757.35,percent of total billed charges,Implant Device,1757.35,35,,1757.35,percent of total billed charges,Implant Device,1757.35,35,,1757.35,percent of total billed charges,Implant Device,1757.35,35,,1757.35,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1707.14,34,"If Charge > 2,000, then 34 percent",1707.14,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3715.55,
STRYKER 6481-2-103 MRH TIBIAL COMPONENT,C1776,HCPCS,,79004130,CDM,278,RC,,,both,,,8368,6192.34,,,6192.34,Other,150% of Medicare + 9.63% HCRA Surcharge,3765.6,45,,3765.6,percent of total billed charges,Critical Access Hospital RCC factor,2845.12,34,,2845.12,percent of total billed charges,Implant Device,2845.12,34,,2845.12,percent of total billed charges,Implant Device,2845.12,34,,2845.12,percent of total billed charges,Implant Device,2845.12,34,,2845.12,percent of total billed charges,Implant Device,2845.12,34,,2845.12,percent of total billed charges,Implant Device,4142.16,,,4142.16,Other,110% of Medicare,2928.8,35,,2928.8,percent of total billed charges,Implant Device,2845.12,34,"Charges > $500, x 34%",2845.12,percent of total billed charges,Implant Device,2928.8,35,,2928.8,percent of total billed charges,Implant Device,2928.8,35,,2928.8,percent of total billed charges,Implant Device,2928.8,35,,2928.8,percent of total billed charges,Implant Device,2928.8,35,,2928.8,percent of total billed charges,Implant Device,2928.8,35,,2928.8,percent of total billed charges,Implant Device,3347.2,40,,3347.2,percent of total billed charges,Implant Device,2928.8,70,,2928.8,percent of total billed charges,All Other,2845.12,34,,2845.12,percent of total billed charges,Implant Device,2845.12,34,,2845.12,percent of total billed charges,Implant Device,2928.8,35,,2928.8,percent of total billed charges,Implant Device,2928.8,35,,2928.8,percent of total billed charges,Implant Device,2928.8,35,,2928.8,percent of total billed charges,Implant Device,2928.8,35,,2928.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2845.12,34,"If Charge > 2,000, then 34 percent",2845.12,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,6192.34,
STRYKER 6485-3-000 MRS STEM 10X102MM,C1776,HCPCS,,79004131,CDM,278,RC,,,both,,,13768,10188.35,,,10188.35,Other,150% of Medicare + 9.63% HCRA Surcharge,6195.6,45,,6195.6,percent of total billed charges,Critical Access Hospital RCC factor,4681.12,34,,4681.12,percent of total billed charges,Implant Device,4681.12,34,,4681.12,percent of total billed charges,Implant Device,4681.12,34,,4681.12,percent of total billed charges,Implant Device,4681.12,34,,4681.12,percent of total billed charges,Implant Device,4681.12,34,,4681.12,percent of total billed charges,Implant Device,6815.16,,,6815.16,Other,110% of Medicare,4818.8,35,,4818.8,percent of total billed charges,Implant Device,4681.12,34,"Charges > $500, x 34%",4681.12,percent of total billed charges,Implant Device,4818.8,35,,4818.8,percent of total billed charges,Implant Device,4818.8,35,,4818.8,percent of total billed charges,Implant Device,4818.8,35,,4818.8,percent of total billed charges,Implant Device,4818.8,35,,4818.8,percent of total billed charges,Implant Device,4818.8,35,,4818.8,percent of total billed charges,Implant Device,5507.2,40,,5507.2,percent of total billed charges,Implant Device,4818.8,70,,4818.8,percent of total billed charges,All Other,4681.12,34,,4681.12,percent of total billed charges,Implant Device,4681.12,34,,4681.12,percent of total billed charges,Implant Device,4818.8,35,,4818.8,percent of total billed charges,Implant Device,4818.8,35,,4818.8,percent of total billed charges,Implant Device,4818.8,35,,4818.8,percent of total billed charges,Implant Device,4818.8,35,,4818.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,4681.12,34,"If Charge > 2,000, then 34 percent",4681.12,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,10188.35,
STRYKER 6485-2-108 ROTATNG HING KNEE 8MM,C1776,HCPCS,,79004132,CDM,278,RC,,,both,,,5424,4013.77,,,4013.77,Other,150% of Medicare + 9.63% HCRA Surcharge,2440.8,45,,2440.8,percent of total billed charges,Critical Access Hospital RCC factor,1844.16,34,,1844.16,percent of total billed charges,Implant Device,1844.16,34,,1844.16,percent of total billed charges,Implant Device,1844.16,34,,1844.16,percent of total billed charges,Implant Device,1844.16,34,,1844.16,percent of total billed charges,Implant Device,1844.16,34,,1844.16,percent of total billed charges,Implant Device,2684.88,,,2684.88,Other,110% of Medicare,1898.4,35,,1898.4,percent of total billed charges,Implant Device,1844.16,34,"Charges > $500, x 34%",1844.16,percent of total billed charges,Implant Device,1898.4,35,,1898.4,percent of total billed charges,Implant Device,1898.4,35,,1898.4,percent of total billed charges,Implant Device,1898.4,35,,1898.4,percent of total billed charges,Implant Device,1898.4,35,,1898.4,percent of total billed charges,Implant Device,1898.4,35,,1898.4,percent of total billed charges,Implant Device,2169.6,40,,2169.6,percent of total billed charges,Implant Device,1898.4,70,,1898.4,percent of total billed charges,All Other,1844.16,34,,1844.16,percent of total billed charges,Implant Device,1844.16,34,,1844.16,percent of total billed charges,Implant Device,1898.4,35,,1898.4,percent of total billed charges,Implant Device,1898.4,35,,1898.4,percent of total billed charges,Implant Device,1898.4,35,,1898.4,percent of total billed charges,Implant Device,1898.4,35,,1898.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1844.16,34,"If Charge > 2,000, then 34 percent",1844.16,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4013.77,
STRYKER 1067-0010 DIST CEMENT SPACR 10MM,C1776,HCPCS,,79004133,CDM,278,RC,,,both,,,341,252.34,,,252.34,Other,150% of Medicare + 9.63% HCRA Surcharge,153.45,45,,153.45,percent of total billed charges,Critical Access Hospital RCC factor,115.94,34,,115.94,percent of total billed charges,Implant Device,115.94,34,,115.94,percent of total billed charges,Implant Device,115.94,34,,115.94,percent of total billed charges,Implant Device,115.94,34,,115.94,percent of total billed charges,Implant Device,115.94,34,,115.94,percent of total billed charges,Implant Device,168.8,,,168.8,Other,110% of Medicare,119.35,35,,119.35,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,119.35,35,,119.35,percent of total billed charges,Implant Device,119.35,35,,119.35,percent of total billed charges,Implant Device,119.35,35,,119.35,percent of total billed charges,Implant Device,119.35,35,,119.35,percent of total billed charges,Implant Device,119.35,35,,119.35,percent of total billed charges,Implant Device,136.4,40,,136.4,percent of total billed charges,Implant Device,119.35,70,,119.35,percent of total billed charges,All Other,115.94,34,,115.94,percent of total billed charges,Implant Device,115.94,34,,115.94,percent of total billed charges,Implant Device,119.35,35,,119.35,percent of total billed charges,Implant Device,119.35,35,,119.35,percent of total billed charges,Implant Device,119.35,35,,119.35,percent of total billed charges,Implant Device,119.35,35,,119.35,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,252.34,
STRYKER 437123 PROX LAT HUM PLATE 4MM,C1713,HCPCS,,79004134,CDM,278,RC,,,both,,,5222,3864.29,,,3864.29,Other,150% of Medicare + 9.63% HCRA Surcharge,2349.9,45,,2349.9,percent of total billed charges,Critical Access Hospital RCC factor,1775.48,34,,1775.48,percent of total billed charges,Implant Device,1775.48,34,,1775.48,percent of total billed charges,Implant Device,1775.48,34,,1775.48,percent of total billed charges,Implant Device,1775.48,34,,1775.48,percent of total billed charges,Implant Device,1775.48,34,,1775.48,percent of total billed charges,Implant Device,2584.89,,,2584.89,Other,110% of Medicare,1827.7,35,,1827.7,percent of total billed charges,Implant Device,1775.48,34,"Charges > $500, x 34%",1775.48,percent of total billed charges,Implant Device,1827.7,35,,1827.7,percent of total billed charges,Implant Device,1827.7,35,,1827.7,percent of total billed charges,Implant Device,1827.7,35,,1827.7,percent of total billed charges,Implant Device,1827.7,35,,1827.7,percent of total billed charges,Implant Device,1827.7,35,,1827.7,percent of total billed charges,Implant Device,2088.8,40,,2088.8,percent of total billed charges,Implant Device,1827.7,70,,1827.7,percent of total billed charges,All Other,1775.48,34,,1775.48,percent of total billed charges,Implant Device,1775.48,34,,1775.48,percent of total billed charges,Implant Device,1827.7,35,,1827.7,percent of total billed charges,Implant Device,1827.7,35,,1827.7,percent of total billed charges,Implant Device,1827.7,35,,1827.7,percent of total billed charges,Implant Device,1827.7,35,,1827.7,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1775.48,34,"If Charge > 2,000, then 34 percent",1775.48,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3864.29,
STRYKER 1896-5057S LOCK SCREW 5X57MM,C1713,HCPCS,,79004135,CDM,278,RC,,,both,,,441,326.34,,,326.34,Other,150% of Medicare + 9.63% HCRA Surcharge,198.45,45,,198.45,percent of total billed charges,Critical Access Hospital RCC factor,149.94,34,,149.94,percent of total billed charges,Implant Device,149.94,34,,149.94,percent of total billed charges,Implant Device,149.94,34,,149.94,percent of total billed charges,Implant Device,149.94,34,,149.94,percent of total billed charges,Implant Device,149.94,34,,149.94,percent of total billed charges,Implant Device,218.3,,,218.3,Other,110% of Medicare,154.35,35,,154.35,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,154.35,35,,154.35,percent of total billed charges,Implant Device,154.35,35,,154.35,percent of total billed charges,Implant Device,154.35,35,,154.35,percent of total billed charges,Implant Device,154.35,35,,154.35,percent of total billed charges,Implant Device,154.35,35,,154.35,percent of total billed charges,Implant Device,176.4,40,,176.4,percent of total billed charges,Implant Device,154.35,70,,154.35,percent of total billed charges,All Other,149.94,34,,149.94,percent of total billed charges,Implant Device,149.94,34,,149.94,percent of total billed charges,Implant Device,154.35,35,,154.35,percent of total billed charges,Implant Device,154.35,35,,154.35,percent of total billed charges,Implant Device,154.35,35,,154.35,percent of total billed charges,Implant Device,154.35,35,,154.35,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,326.34,
STRYKER 5015-4-150 APEX PIN CANC 40MM,C1713,HCPCS,,79004136,CDM,278,RC,,,both,,,467,345.58,,,345.58,Other,150% of Medicare + 9.63% HCRA Surcharge,210.15,45,,210.15,percent of total billed charges,Critical Access Hospital RCC factor,158.78,34,,158.78,percent of total billed charges,Implant Device,158.78,34,,158.78,percent of total billed charges,Implant Device,158.78,34,,158.78,percent of total billed charges,Implant Device,158.78,34,,158.78,percent of total billed charges,Implant Device,158.78,34,,158.78,percent of total billed charges,Implant Device,231.17,,,231.17,Other,110% of Medicare,163.45,35,,163.45,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,163.45,35,,163.45,percent of total billed charges,Implant Device,163.45,35,,163.45,percent of total billed charges,Implant Device,163.45,35,,163.45,percent of total billed charges,Implant Device,163.45,35,,163.45,percent of total billed charges,Implant Device,163.45,35,,163.45,percent of total billed charges,Implant Device,186.8,40,,186.8,percent of total billed charges,Implant Device,163.45,70,,163.45,percent of total billed charges,All Other,158.78,34,,158.78,percent of total billed charges,Implant Device,158.78,34,,158.78,percent of total billed charges,Implant Device,163.45,35,,163.45,percent of total billed charges,Implant Device,163.45,35,,163.45,percent of total billed charges,Implant Device,163.45,35,,163.45,percent of total billed charges,Implant Device,163.45,35,,163.45,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,345.58,
STRYKER 59-23010 NONLOCK SCREW 2.3X10MM,C1713,HCPCS,,79004137,CDM,278,RC,,,both,,,247,182.78,,,182.78,Other,150% of Medicare + 9.63% HCRA Surcharge,111.15,45,,111.15,percent of total billed charges,Critical Access Hospital RCC factor,83.98,34,,83.98,percent of total billed charges,Implant Device,83.98,34,,83.98,percent of total billed charges,Implant Device,83.98,34,,83.98,percent of total billed charges,Implant Device,83.98,34,,83.98,percent of total billed charges,Implant Device,83.98,34,,83.98,percent of total billed charges,Implant Device,122.27,,,122.27,Other,110% of Medicare,86.45,35,,86.45,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,86.45,35,,86.45,percent of total billed charges,Implant Device,86.45,35,,86.45,percent of total billed charges,Implant Device,86.45,35,,86.45,percent of total billed charges,Implant Device,86.45,35,,86.45,percent of total billed charges,Implant Device,86.45,35,,86.45,percent of total billed charges,Implant Device,98.8,40,,98.8,percent of total billed charges,Implant Device,86.45,70,,86.45,percent of total billed charges,All Other,83.98,34,,83.98,percent of total billed charges,Implant Device,83.98,34,,83.98,percent of total billed charges,Implant Device,86.45,35,,86.45,percent of total billed charges,Implant Device,86.45,35,,86.45,percent of total billed charges,Implant Device,86.45,35,,86.45,percent of total billed charges,Implant Device,86.45,35,,86.45,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,182.78,
STRYKER 54-25290 DORSAL PLATE STD 60MM,C1713,HCPCS,,79004139,CDM,278,RC,,,both,,,2484,1838.17,,,1838.17,Other,150% of Medicare + 9.63% HCRA Surcharge,1117.8,45,,1117.8,percent of total billed charges,Critical Access Hospital RCC factor,844.56,34,,844.56,percent of total billed charges,Implant Device,844.56,34,,844.56,percent of total billed charges,Implant Device,844.56,34,,844.56,percent of total billed charges,Implant Device,844.56,34,,844.56,percent of total billed charges,Implant Device,844.56,34,,844.56,percent of total billed charges,Implant Device,1229.58,,,1229.58,Other,110% of Medicare,869.4,35,,869.4,percent of total billed charges,Implant Device,844.56,34,"Charges > $500, x 34%",844.56,percent of total billed charges,Implant Device,869.4,35,,869.4,percent of total billed charges,Implant Device,869.4,35,,869.4,percent of total billed charges,Implant Device,869.4,35,,869.4,percent of total billed charges,Implant Device,869.4,35,,869.4,percent of total billed charges,Implant Device,869.4,35,,869.4,percent of total billed charges,Implant Device,993.6,40,,993.6,percent of total billed charges,Implant Device,869.4,70,,869.4,percent of total billed charges,All Other,844.56,34,,844.56,percent of total billed charges,Implant Device,844.56,34,,844.56,percent of total billed charges,Implant Device,869.4,35,,869.4,percent of total billed charges,Implant Device,869.4,35,,869.4,percent of total billed charges,Implant Device,869.4,35,,869.4,percent of total billed charges,Implant Device,869.4,35,,869.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,844.56,34,"If Charge > 2,000, then 34 percent",844.56,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1838.17,
STRYKER 57-10368 LOCKING PLATE 10 HOLE,C1713,HCPCS,,79004140,CDM,278,RC,,,both,,,1423,1053.02,,,1053.02,Other,150% of Medicare + 9.63% HCRA Surcharge,640.35,45,,640.35,percent of total billed charges,Critical Access Hospital RCC factor,483.82,34,,483.82,percent of total billed charges,Implant Device,483.82,34,,483.82,percent of total billed charges,Implant Device,483.82,34,,483.82,percent of total billed charges,Implant Device,483.82,34,,483.82,percent of total billed charges,Implant Device,483.82,34,,483.82,percent of total billed charges,Implant Device,704.39,,,704.39,Other,110% of Medicare,498.05,35,,498.05,percent of total billed charges,Implant Device,483.82,34,"Charges > $500, x 34%",483.82,percent of total billed charges,Implant Device,498.05,35,,498.05,percent of total billed charges,Implant Device,498.05,35,,498.05,percent of total billed charges,Implant Device,498.05,35,,498.05,percent of total billed charges,Implant Device,498.05,35,,498.05,percent of total billed charges,Implant Device,498.05,35,,498.05,percent of total billed charges,Implant Device,569.2,40,,569.2,percent of total billed charges,Implant Device,498.05,70,,498.05,percent of total billed charges,All Other,483.82,34,,483.82,percent of total billed charges,Implant Device,483.82,34,,483.82,percent of total billed charges,Implant Device,498.05,35,,498.05,percent of total billed charges,Implant Device,498.05,35,,498.05,percent of total billed charges,Implant Device,498.05,35,,498.05,percent of total billed charges,Implant Device,498.05,35,,498.05,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1053.02,
STRYKER 371348 LOCKING SCREW 5X48MM,C1713,HCPCS,,79004141,CDM,278,RC,,,both,,,523,387.02,,,387.02,Other,150% of Medicare + 9.63% HCRA Surcharge,235.35,45,,235.35,percent of total billed charges,Critical Access Hospital RCC factor,177.82,34,,177.82,percent of total billed charges,Implant Device,177.82,34,,177.82,percent of total billed charges,Implant Device,177.82,34,,177.82,percent of total billed charges,Implant Device,177.82,34,,177.82,percent of total billed charges,Implant Device,177.82,34,,177.82,percent of total billed charges,Implant Device,258.89,,,258.89,Other,110% of Medicare,183.05,35,,183.05,percent of total billed charges,Implant Device,177.82,34,"Charges > $500, x 34%",177.82,percent of total billed charges,Implant Device,183.05,35,,183.05,percent of total billed charges,Implant Device,183.05,35,,183.05,percent of total billed charges,Implant Device,183.05,35,,183.05,percent of total billed charges,Implant Device,183.05,35,,183.05,percent of total billed charges,Implant Device,183.05,35,,183.05,percent of total billed charges,Implant Device,209.2,40,,209.2,percent of total billed charges,Implant Device,183.05,70,,183.05,percent of total billed charges,All Other,177.82,34,,177.82,percent of total billed charges,Implant Device,177.82,34,,177.82,percent of total billed charges,Implant Device,183.05,35,,183.05,percent of total billed charges,Implant Device,183.05,35,,183.05,percent of total billed charges,Implant Device,183.05,35,,183.05,percent of total billed charges,Implant Device,183.05,35,,183.05,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,387.02,
STRYKER 2030-6525-1 BONE SCREW 65X25MM,C1713,HCPCS,,79004142,CDM,278,RC,,,both,,,440,325.6,,,325.6,Other,150% of Medicare + 9.63% HCRA Surcharge,198,45,,198,percent of total billed charges,Critical Access Hospital RCC factor,149.6,34,,149.6,percent of total billed charges,Implant Device,149.6,34,,149.6,percent of total billed charges,Implant Device,149.6,34,,149.6,percent of total billed charges,Implant Device,149.6,34,,149.6,percent of total billed charges,Implant Device,149.6,34,,149.6,percent of total billed charges,Implant Device,217.8,,,217.8,Other,110% of Medicare,154,35,,154,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,154,35,,154,percent of total billed charges,Implant Device,154,35,,154,percent of total billed charges,Implant Device,154,35,,154,percent of total billed charges,Implant Device,154,35,,154,percent of total billed charges,Implant Device,154,35,,154,percent of total billed charges,Implant Device,176,40,,176,percent of total billed charges,Implant Device,154,70,,154,percent of total billed charges,All Other,149.6,34,,149.6,percent of total billed charges,Implant Device,149.6,34,,149.6,percent of total billed charges,Implant Device,154,35,,154,percent of total billed charges,Implant Device,154,35,,154,percent of total billed charges,Implant Device,154,35,,154,percent of total billed charges,Implant Device,154,35,,154,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,325.6,
STRYKER 1851-1340S FEMORAL NAIL 13X400MM,C1713,HCPCS,,79004143,CDM,278,RC,,,both,,,6768,5008.34,,,5008.34,Other,150% of Medicare + 9.63% HCRA Surcharge,3045.6,45,,3045.6,percent of total billed charges,Critical Access Hospital RCC factor,2301.12,34,,2301.12,percent of total billed charges,Implant Device,2301.12,34,,2301.12,percent of total billed charges,Implant Device,2301.12,34,,2301.12,percent of total billed charges,Implant Device,2301.12,34,,2301.12,percent of total billed charges,Implant Device,2301.12,34,,2301.12,percent of total billed charges,Implant Device,3350.16,,,3350.16,Other,110% of Medicare,2368.8,35,,2368.8,percent of total billed charges,Implant Device,2301.12,34,"Charges > $500, x 34%",2301.12,percent of total billed charges,Implant Device,2368.8,35,,2368.8,percent of total billed charges,Implant Device,2368.8,35,,2368.8,percent of total billed charges,Implant Device,2368.8,35,,2368.8,percent of total billed charges,Implant Device,2368.8,35,,2368.8,percent of total billed charges,Implant Device,2368.8,35,,2368.8,percent of total billed charges,Implant Device,2707.2,40,,2707.2,percent of total billed charges,Implant Device,2368.8,70,,2368.8,percent of total billed charges,All Other,2301.12,34,,2301.12,percent of total billed charges,Implant Device,2301.12,34,,2301.12,percent of total billed charges,Implant Device,2368.8,35,,2368.8,percent of total billed charges,Implant Device,2368.8,35,,2368.8,percent of total billed charges,Implant Device,2368.8,35,,2368.8,percent of total billed charges,Implant Device,2368.8,35,,2368.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2301.12,34,"If Charge > 2,000, then 34 percent",2301.12,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5008.34,
STRYKER 1832-3826S HUMERL NAIL 8CMX260MM,C1713,HCPCS,,79004144,CDM,278,RC,,,both,,,5934,4391.17,,,4391.17,Other,150% of Medicare + 9.63% HCRA Surcharge,2670.3,45,,2670.3,percent of total billed charges,Critical Access Hospital RCC factor,2017.56,34,,2017.56,percent of total billed charges,Implant Device,2017.56,34,,2017.56,percent of total billed charges,Implant Device,2017.56,34,,2017.56,percent of total billed charges,Implant Device,2017.56,34,,2017.56,percent of total billed charges,Implant Device,2017.56,34,,2017.56,percent of total billed charges,Implant Device,2937.33,,,2937.33,Other,110% of Medicare,2076.9,35,,2076.9,percent of total billed charges,Implant Device,2017.56,34,"Charges > $500, x 34%",2017.56,percent of total billed charges,Implant Device,2076.9,35,,2076.9,percent of total billed charges,Implant Device,2076.9,35,,2076.9,percent of total billed charges,Implant Device,2076.9,35,,2076.9,percent of total billed charges,Implant Device,2076.9,35,,2076.9,percent of total billed charges,Implant Device,2076.9,35,,2076.9,percent of total billed charges,Implant Device,2373.6,40,,2373.6,percent of total billed charges,Implant Device,2076.9,70,,2076.9,percent of total billed charges,All Other,2017.56,34,,2017.56,percent of total billed charges,Implant Device,2017.56,34,,2017.56,percent of total billed charges,Implant Device,2076.9,35,,2076.9,percent of total billed charges,Implant Device,2076.9,35,,2076.9,percent of total billed charges,Implant Device,2076.9,35,,2076.9,percent of total billed charges,Implant Device,2076.9,35,,2076.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2017.56,34,"If Charge > 2,000, then 34 percent",2017.56,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4391.17,
STRYKER 342095 CANCELLOUS SCREW 6.5X95MM,C1713,HCPCS,,79004147,CDM,278,RC,,,both,,,120,88.8,,,88.8,Other,150% of Medicare + 9.63% HCRA Surcharge,54,45,,54,percent of total billed charges,Critical Access Hospital RCC factor,40.8,34,,40.8,percent of total billed charges,Implant Device,40.8,34,,40.8,percent of total billed charges,Implant Device,40.8,34,,40.8,percent of total billed charges,Implant Device,40.8,34,,40.8,percent of total billed charges,Implant Device,40.8,34,,40.8,percent of total billed charges,Implant Device,59.4,,,59.4,Other,110% of Medicare,42,35,,42,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,42,35,,42,percent of total billed charges,Implant Device,42,35,,42,percent of total billed charges,Implant Device,42,35,,42,percent of total billed charges,Implant Device,42,35,,42,percent of total billed charges,Implant Device,42,35,,42,percent of total billed charges,Implant Device,48,40,,48,percent of total billed charges,Implant Device,42,70,,42,percent of total billed charges,All Other,40.8,34,,40.8,percent of total billed charges,Implant Device,40.8,34,,40.8,percent of total billed charges,Implant Device,42,35,,42,percent of total billed charges,Implant Device,42,35,,42,percent of total billed charges,Implant Device,42,35,,42,percent of total billed charges,Implant Device,42,35,,42,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,88.8,
STRYKER 57-05297 STD PLATES 2X2+2 1.7MM,C1713,HCPCS,,79004148,CDM,278,RC,,,both,,,1129,835.46,,,835.46,Other,150% of Medicare + 9.63% HCRA Surcharge,508.05,45,,508.05,percent of total billed charges,Critical Access Hospital RCC factor,383.86,34,,383.86,percent of total billed charges,Implant Device,383.86,34,,383.86,percent of total billed charges,Implant Device,383.86,34,,383.86,percent of total billed charges,Implant Device,383.86,34,,383.86,percent of total billed charges,Implant Device,383.86,34,,383.86,percent of total billed charges,Implant Device,558.86,,,558.86,Other,110% of Medicare,395.15,35,,395.15,percent of total billed charges,Implant Device,383.86,34,"Charges > $500, x 34%",383.86,percent of total billed charges,Implant Device,395.15,35,,395.15,percent of total billed charges,Implant Device,395.15,35,,395.15,percent of total billed charges,Implant Device,395.15,35,,395.15,percent of total billed charges,Implant Device,395.15,35,,395.15,percent of total billed charges,Implant Device,395.15,35,,395.15,percent of total billed charges,Implant Device,451.6,40,,451.6,percent of total billed charges,Implant Device,395.15,70,,395.15,percent of total billed charges,All Other,383.86,34,,383.86,percent of total billed charges,Implant Device,383.86,34,,383.86,percent of total billed charges,Implant Device,395.15,35,,395.15,percent of total billed charges,Implant Device,395.15,35,,395.15,percent of total billed charges,Implant Device,395.15,35,,395.15,percent of total billed charges,Implant Device,395.15,35,,395.15,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,835.46,
STRYKER 3325-0380S LONG NAIL KIT TI LEFT,C1713,HCPCS,,79004149,CDM,278,RC,,,both,,,6268,4638.34,,,4638.34,Other,150% of Medicare + 9.63% HCRA Surcharge,2820.6,45,,2820.6,percent of total billed charges,Critical Access Hospital RCC factor,2131.12,34,,2131.12,percent of total billed charges,Implant Device,2131.12,34,,2131.12,percent of total billed charges,Implant Device,2131.12,34,,2131.12,percent of total billed charges,Implant Device,2131.12,34,,2131.12,percent of total billed charges,Implant Device,2131.12,34,,2131.12,percent of total billed charges,Implant Device,3102.66,,,3102.66,Other,110% of Medicare,2193.8,35,,2193.8,percent of total billed charges,Implant Device,2131.12,34,"Charges > $500, x 34%",2131.12,percent of total billed charges,Implant Device,2193.8,35,,2193.8,percent of total billed charges,Implant Device,2193.8,35,,2193.8,percent of total billed charges,Implant Device,2193.8,35,,2193.8,percent of total billed charges,Implant Device,2193.8,35,,2193.8,percent of total billed charges,Implant Device,2193.8,35,,2193.8,percent of total billed charges,Implant Device,2507.2,40,,2507.2,percent of total billed charges,Implant Device,2193.8,70,,2193.8,percent of total billed charges,All Other,2131.12,34,,2131.12,percent of total billed charges,Implant Device,2131.12,34,,2131.12,percent of total billed charges,Implant Device,2193.8,35,,2193.8,percent of total billed charges,Implant Device,2193.8,35,,2193.8,percent of total billed charges,Implant Device,2193.8,35,,2193.8,percent of total billed charges,Implant Device,2193.8,35,,2193.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2131.12,34,"If Charge > 2,000, then 34 percent",2131.12,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4638.34,
STRYKER 53-23013E LOCKING SCREW 2.3X13MM,C1713,HCPCS,,79004150,CDM,278,RC,,,both,,,426,315.24,,,315.24,Other,150% of Medicare + 9.63% HCRA Surcharge,191.7,45,,191.7,percent of total billed charges,Critical Access Hospital RCC factor,144.84,34,,144.84,percent of total billed charges,Implant Device,144.84,34,,144.84,percent of total billed charges,Implant Device,144.84,34,,144.84,percent of total billed charges,Implant Device,144.84,34,,144.84,percent of total billed charges,Implant Device,144.84,34,,144.84,percent of total billed charges,Implant Device,210.87,,,210.87,Other,110% of Medicare,149.1,35,,149.1,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,149.1,35,,149.1,percent of total billed charges,Implant Device,149.1,35,,149.1,percent of total billed charges,Implant Device,149.1,35,,149.1,percent of total billed charges,Implant Device,149.1,35,,149.1,percent of total billed charges,Implant Device,149.1,35,,149.1,percent of total billed charges,Implant Device,170.4,40,,170.4,percent of total billed charges,Implant Device,149.1,70,,149.1,percent of total billed charges,All Other,144.84,34,,144.84,percent of total billed charges,Implant Device,144.84,34,,144.84,percent of total billed charges,Implant Device,149.1,35,,149.1,percent of total billed charges,Implant Device,149.1,35,,149.1,percent of total billed charges,Implant Device,149.1,35,,149.1,percent of total billed charges,Implant Device,149.1,35,,149.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,315.24,
STRYKER 59-17009 NONLOCK SCREW 1.7X9MM,C1713,HCPCS,,79004151,CDM,278,RC,,,both,,,240,177.6,,,177.6,Other,150% of Medicare + 9.63% HCRA Surcharge,108,45,,108,percent of total billed charges,Critical Access Hospital RCC factor,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,118.8,,,118.8,Other,110% of Medicare,84,35,,84,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,96,40,,96,percent of total billed charges,Implant Device,84,70,,84,percent of total billed charges,All Other,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,177.6,
STRYKER 371390 LOCKING SCREW 5X90MM,C1713,HCPCS,,79004152,CDM,278,RC,,,both,,,474,350.76,,,350.76,Other,150% of Medicare + 9.63% HCRA Surcharge,213.3,45,,213.3,percent of total billed charges,Critical Access Hospital RCC factor,161.16,34,,161.16,percent of total billed charges,Implant Device,161.16,34,,161.16,percent of total billed charges,Implant Device,161.16,34,,161.16,percent of total billed charges,Implant Device,161.16,34,,161.16,percent of total billed charges,Implant Device,161.16,34,,161.16,percent of total billed charges,Implant Device,234.63,,,234.63,Other,110% of Medicare,165.9,35,,165.9,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,165.9,35,,165.9,percent of total billed charges,Implant Device,165.9,35,,165.9,percent of total billed charges,Implant Device,165.9,35,,165.9,percent of total billed charges,Implant Device,165.9,35,,165.9,percent of total billed charges,Implant Device,165.9,35,,165.9,percent of total billed charges,Implant Device,189.6,40,,189.6,percent of total billed charges,Implant Device,165.9,70,,165.9,percent of total billed charges,All Other,161.16,34,,161.16,percent of total billed charges,Implant Device,161.16,34,,161.16,percent of total billed charges,Implant Device,165.9,35,,165.9,percent of total billed charges,Implant Device,165.9,35,,165.9,percent of total billed charges,Implant Device,165.9,35,,165.9,percent of total billed charges,Implant Device,165.9,35,,165.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,350.76,
STRYKER 430204 TUBULAR PLATE 1/3 4 HOLE,C1713,HCPCS,,79004153,CDM,278,RC,,,both,,,181,133.94,,,133.94,Other,150% of Medicare + 9.63% HCRA Surcharge,81.45,45,,81.45,percent of total billed charges,Critical Access Hospital RCC factor,61.54,34,,61.54,percent of total billed charges,Implant Device,61.54,34,,61.54,percent of total billed charges,Implant Device,61.54,34,,61.54,percent of total billed charges,Implant Device,61.54,34,,61.54,percent of total billed charges,Implant Device,61.54,34,,61.54,percent of total billed charges,Implant Device,89.6,,,89.6,Other,110% of Medicare,63.35,35,,63.35,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,63.35,35,,63.35,percent of total billed charges,Implant Device,63.35,35,,63.35,percent of total billed charges,Implant Device,63.35,35,,63.35,percent of total billed charges,Implant Device,63.35,35,,63.35,percent of total billed charges,Implant Device,63.35,35,,63.35,percent of total billed charges,Implant Device,72.4,40,,72.4,percent of total billed charges,Implant Device,63.35,70,,63.35,percent of total billed charges,All Other,61.54,34,,61.54,percent of total billed charges,Implant Device,61.54,34,,61.54,percent of total billed charges,Implant Device,63.35,35,,63.35,percent of total billed charges,Implant Device,63.35,35,,63.35,percent of total billed charges,Implant Device,63.35,35,,63.35,percent of total billed charges,Implant Device,63.35,35,,63.35,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,133.94,
STRYKER 6942-7-065 C-TAPER NECK SLEEVE,C1713,HCPCS,,79004154,CDM,278,RC,,,both,,,667,493.58,,,493.58,Other,150% of Medicare + 9.63% HCRA Surcharge,300.15,45,,300.15,percent of total billed charges,Critical Access Hospital RCC factor,226.78,34,,226.78,percent of total billed charges,Implant Device,226.78,34,,226.78,percent of total billed charges,Implant Device,226.78,34,,226.78,percent of total billed charges,Implant Device,226.78,34,,226.78,percent of total billed charges,Implant Device,226.78,34,,226.78,percent of total billed charges,Implant Device,330.17,,,330.17,Other,110% of Medicare,233.45,35,,233.45,percent of total billed charges,Implant Device,226.78,34,"Charges > $500, x 34%",226.78,percent of total billed charges,Implant Device,233.45,35,,233.45,percent of total billed charges,Implant Device,233.45,35,,233.45,percent of total billed charges,Implant Device,233.45,35,,233.45,percent of total billed charges,Implant Device,233.45,35,,233.45,percent of total billed charges,Implant Device,233.45,35,,233.45,percent of total billed charges,Implant Device,266.8,40,,266.8,percent of total billed charges,Implant Device,233.45,70,,233.45,percent of total billed charges,All Other,226.78,34,,226.78,percent of total billed charges,Implant Device,226.78,34,,226.78,percent of total billed charges,Implant Device,233.45,35,,233.45,percent of total billed charges,Implant Device,233.45,35,,233.45,percent of total billed charges,Implant Device,233.45,35,,233.45,percent of total billed charges,Implant Device,233.45,35,,233.45,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,493.58,
STRYKER 1822-0937S TIBIAL NAIL 9X375MM,C1713,HCPCS,,79004155,CDM,278,RC,,,both,,,3193,2362.83,,,2362.83,Other,150% of Medicare + 9.63% HCRA Surcharge,1436.85,45,,1436.85,percent of total billed charges,Critical Access Hospital RCC factor,1085.62,34,,1085.62,percent of total billed charges,Implant Device,1085.62,34,,1085.62,percent of total billed charges,Implant Device,1085.62,34,,1085.62,percent of total billed charges,Implant Device,1085.62,34,,1085.62,percent of total billed charges,Implant Device,1085.62,34,,1085.62,percent of total billed charges,Implant Device,1580.54,,,1580.54,Other,110% of Medicare,1117.55,35,,1117.55,percent of total billed charges,Implant Device,1085.62,34,"Charges > $500, x 34%",1085.62,percent of total billed charges,Implant Device,1117.55,35,,1117.55,percent of total billed charges,Implant Device,1117.55,35,,1117.55,percent of total billed charges,Implant Device,1117.55,35,,1117.55,percent of total billed charges,Implant Device,1117.55,35,,1117.55,percent of total billed charges,Implant Device,1117.55,35,,1117.55,percent of total billed charges,Implant Device,1277.2,40,,1277.2,percent of total billed charges,Implant Device,1117.55,70,,1117.55,percent of total billed charges,All Other,1085.62,34,,1085.62,percent of total billed charges,Implant Device,1085.62,34,,1085.62,percent of total billed charges,Implant Device,1117.55,35,,1117.55,percent of total billed charges,Implant Device,1117.55,35,,1117.55,percent of total billed charges,Implant Device,1117.55,35,,1117.55,percent of total billed charges,Implant Device,1117.55,35,,1117.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1085.62,34,"If Charge > 2,000, then 34 percent",1085.62,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2362.83,
STRYKER 3225-3380S LONG NAIL 13X380X125,C1713,HCPCS,,79004156,CDM,278,RC,,,both,,,7140,5283.62,,,5283.62,Other,150% of Medicare + 9.63% HCRA Surcharge,3213,45,,3213,percent of total billed charges,Critical Access Hospital RCC factor,2427.6,34,,2427.6,percent of total billed charges,Implant Device,2427.6,34,,2427.6,percent of total billed charges,Implant Device,2427.6,34,,2427.6,percent of total billed charges,Implant Device,2427.6,34,,2427.6,percent of total billed charges,Implant Device,2427.6,34,,2427.6,percent of total billed charges,Implant Device,3534.3,,,3534.3,Other,110% of Medicare,2499,35,,2499,percent of total billed charges,Implant Device,2427.6,34,"Charges > $500, x 34%",2427.6,percent of total billed charges,Implant Device,2499,35,,2499,percent of total billed charges,Implant Device,2499,35,,2499,percent of total billed charges,Implant Device,2499,35,,2499,percent of total billed charges,Implant Device,2499,35,,2499,percent of total billed charges,Implant Device,2499,35,,2499,percent of total billed charges,Implant Device,2856,40,,2856,percent of total billed charges,Implant Device,2499,70,,2499,percent of total billed charges,All Other,2427.6,34,,2427.6,percent of total billed charges,Implant Device,2427.6,34,,2427.6,percent of total billed charges,Implant Device,2499,35,,2499,percent of total billed charges,Implant Device,2499,35,,2499,percent of total billed charges,Implant Device,2499,35,,2499,percent of total billed charges,Implant Device,2499,35,,2499,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2427.6,34,"If Charge > 2,000, then 34 percent",2427.6,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5283.62,
STRYKER 5317009E LOCKING SCREW 1.7X9MM,C1713,HCPCS,,79004157,CDM,278,RC,,,both,,,306,226.44,,,226.44,Other,150% of Medicare + 9.63% HCRA Surcharge,137.7,45,,137.7,percent of total billed charges,Critical Access Hospital RCC factor,104.04,34,,104.04,percent of total billed charges,Implant Device,104.04,34,,104.04,percent of total billed charges,Implant Device,104.04,34,,104.04,percent of total billed charges,Implant Device,104.04,34,,104.04,percent of total billed charges,Implant Device,104.04,34,,104.04,percent of total billed charges,Implant Device,151.47,,,151.47,Other,110% of Medicare,107.1,35,,107.1,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,107.1,35,,107.1,percent of total billed charges,Implant Device,107.1,35,,107.1,percent of total billed charges,Implant Device,107.1,35,,107.1,percent of total billed charges,Implant Device,107.1,35,,107.1,percent of total billed charges,Implant Device,107.1,35,,107.1,percent of total billed charges,Implant Device,122.4,40,,122.4,percent of total billed charges,Implant Device,107.1,70,,107.1,percent of total billed charges,All Other,104.04,34,,104.04,percent of total billed charges,Implant Device,104.04,34,,104.04,percent of total billed charges,Implant Device,107.1,35,,107.1,percent of total billed charges,Implant Device,107.1,35,,107.1,percent of total billed charges,Implant Device,107.1,35,,107.1,percent of total billed charges,Implant Device,107.1,35,,107.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,226.44,
STRYKER 5023-2-090 APEX PIN 4X90MM,C1713,HCPCS,,79004158,CDM,278,RC,,,both,,,392,290.08,,,290.08,Other,150% of Medicare + 9.63% HCRA Surcharge,176.4,45,,176.4,percent of total billed charges,Critical Access Hospital RCC factor,133.28,34,,133.28,percent of total billed charges,Implant Device,133.28,34,,133.28,percent of total billed charges,Implant Device,133.28,34,,133.28,percent of total billed charges,Implant Device,133.28,34,,133.28,percent of total billed charges,Implant Device,133.28,34,,133.28,percent of total billed charges,Implant Device,194.04,,,194.04,Other,110% of Medicare,137.2,35,,137.2,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,137.2,35,,137.2,percent of total billed charges,Implant Device,137.2,35,,137.2,percent of total billed charges,Implant Device,137.2,35,,137.2,percent of total billed charges,Implant Device,137.2,35,,137.2,percent of total billed charges,Implant Device,137.2,35,,137.2,percent of total billed charges,Implant Device,156.8,40,,156.8,percent of total billed charges,Implant Device,137.2,70,,137.2,percent of total billed charges,All Other,133.28,34,,133.28,percent of total billed charges,Implant Device,133.28,34,,133.28,percent of total billed charges,Implant Device,137.2,35,,137.2,percent of total billed charges,Implant Device,137.2,35,,137.2,percent of total billed charges,Implant Device,137.2,35,,137.2,percent of total billed charges,Implant Device,137.2,35,,137.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,290.08,
STRYKER 3406-38 CORTICAL SCREW 4.5X38,C1713,HCPCS,,79004159,CDM,278,RC,,,both,,,84,62.16,,,62.16,Other,150% of Medicare + 9.63% HCRA Surcharge,37.8,45,,37.8,percent of total billed charges,Critical Access Hospital RCC factor,28.56,34,,28.56,percent of total billed charges,Implant Device,28.56,34,,28.56,percent of total billed charges,Implant Device,28.56,34,,28.56,percent of total billed charges,Implant Device,28.56,34,,28.56,percent of total billed charges,Implant Device,28.56,34,,28.56,percent of total billed charges,Implant Device,41.58,,,41.58,Other,110% of Medicare,29.4,35,,29.4,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,29.4,35,,29.4,percent of total billed charges,Implant Device,29.4,35,,29.4,percent of total billed charges,Implant Device,29.4,35,,29.4,percent of total billed charges,Implant Device,29.4,35,,29.4,percent of total billed charges,Implant Device,29.4,35,,29.4,percent of total billed charges,Implant Device,33.6,40,,33.6,percent of total billed charges,Implant Device,29.4,70,,29.4,percent of total billed charges,All Other,28.56,34,,28.56,percent of total billed charges,Implant Device,28.56,34,,28.56,percent of total billed charges,Implant Device,29.4,35,,29.4,percent of total billed charges,Implant Device,29.4,35,,29.4,percent of total billed charges,Implant Device,29.4,35,,29.4,percent of total billed charges,Implant Device,29.4,35,,29.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,62.16,
STRYKER 1236-2-848 X3 INSERTER SZ28/SZ42,C1713,HCPCS,,79004160,CDM,278,RC,,,both,,,2503,1852.23,,,1852.23,Other,150% of Medicare + 9.63% HCRA Surcharge,1126.35,45,,1126.35,percent of total billed charges,Critical Access Hospital RCC factor,851.02,34,,851.02,percent of total billed charges,Implant Device,851.02,34,,851.02,percent of total billed charges,Implant Device,851.02,34,,851.02,percent of total billed charges,Implant Device,851.02,34,,851.02,percent of total billed charges,Implant Device,851.02,34,,851.02,percent of total billed charges,Implant Device,1238.99,,,1238.99,Other,110% of Medicare,876.05,35,,876.05,percent of total billed charges,Implant Device,851.02,34,"Charges > $500, x 34%",851.02,percent of total billed charges,Implant Device,876.05,35,,876.05,percent of total billed charges,Implant Device,876.05,35,,876.05,percent of total billed charges,Implant Device,876.05,35,,876.05,percent of total billed charges,Implant Device,876.05,35,,876.05,percent of total billed charges,Implant Device,876.05,35,,876.05,percent of total billed charges,Implant Device,1001.2,40,,1001.2,percent of total billed charges,Implant Device,876.05,70,,876.05,percent of total billed charges,All Other,851.02,34,,851.02,percent of total billed charges,Implant Device,851.02,34,,851.02,percent of total billed charges,Implant Device,876.05,35,,876.05,percent of total billed charges,Implant Device,876.05,35,,876.05,percent of total billed charges,Implant Device,876.05,35,,876.05,percent of total billed charges,Implant Device,876.05,35,,876.05,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,851.02,34,"If Charge > 2,000, then 34 percent",851.02,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1852.23,
STRYKER 1067-00009 UNI DISTAL SPACER 9MM,C1713,HCPCS,,79004161,CDM,278,RC,,,both,,,341,252.34,,,252.34,Other,150% of Medicare + 9.63% HCRA Surcharge,153.45,45,,153.45,percent of total billed charges,Critical Access Hospital RCC factor,115.94,34,,115.94,percent of total billed charges,Implant Device,115.94,34,,115.94,percent of total billed charges,Implant Device,115.94,34,,115.94,percent of total billed charges,Implant Device,115.94,34,,115.94,percent of total billed charges,Implant Device,115.94,34,,115.94,percent of total billed charges,Implant Device,168.8,,,168.8,Other,110% of Medicare,119.35,35,,119.35,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,119.35,35,,119.35,percent of total billed charges,Implant Device,119.35,35,,119.35,percent of total billed charges,Implant Device,119.35,35,,119.35,percent of total billed charges,Implant Device,119.35,35,,119.35,percent of total billed charges,Implant Device,119.35,35,,119.35,percent of total billed charges,Implant Device,136.4,40,,136.4,percent of total billed charges,Implant Device,119.35,70,,119.35,percent of total billed charges,All Other,115.94,34,,115.94,percent of total billed charges,Implant Device,115.94,34,,115.94,percent of total billed charges,Implant Device,119.35,35,,119.35,percent of total billed charges,Implant Device,119.35,35,,119.35,percent of total billed charges,Implant Device,119.35,35,,119.35,percent of total billed charges,Implant Device,119.35,35,,119.35,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,252.34,
STRYKER 1828-1132S FEMORAL NAIL 11X320,C1713,HCPCS,,79004162,CDM,278,RC,,,both,,,5959,4409.67,,,4409.67,Other,150% of Medicare + 9.63% HCRA Surcharge,2681.55,45,,2681.55,percent of total billed charges,Critical Access Hospital RCC factor,2026.06,34,,2026.06,percent of total billed charges,Implant Device,2026.06,34,,2026.06,percent of total billed charges,Implant Device,2026.06,34,,2026.06,percent of total billed charges,Implant Device,2026.06,34,,2026.06,percent of total billed charges,Implant Device,2026.06,34,,2026.06,percent of total billed charges,Implant Device,2949.71,,,2949.71,Other,110% of Medicare,2085.65,35,,2085.65,percent of total billed charges,Implant Device,2026.06,34,"Charges > $500, x 34%",2026.06,percent of total billed charges,Implant Device,2085.65,35,,2085.65,percent of total billed charges,Implant Device,2085.65,35,,2085.65,percent of total billed charges,Implant Device,2085.65,35,,2085.65,percent of total billed charges,Implant Device,2085.65,35,,2085.65,percent of total billed charges,Implant Device,2085.65,35,,2085.65,percent of total billed charges,Implant Device,2383.6,40,,2383.6,percent of total billed charges,Implant Device,2085.65,70,,2085.65,percent of total billed charges,All Other,2026.06,34,,2026.06,percent of total billed charges,Implant Device,2026.06,34,,2026.06,percent of total billed charges,Implant Device,2085.65,35,,2085.65,percent of total billed charges,Implant Device,2085.65,35,,2085.65,percent of total billed charges,Implant Device,2085.65,35,,2085.65,percent of total billed charges,Implant Device,2085.65,35,,2085.65,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2026.06,34,"If Charge > 2,000, then 34 percent",2026.06,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4409.67,
STRYKER 1896-40-245 LOCKING SCREW 4X24MM,C1713,HCPCS,,79004163,CDM,278,RC,,,both,,,623,461.02,,,461.02,Other,150% of Medicare + 9.63% HCRA Surcharge,280.35,45,,280.35,percent of total billed charges,Critical Access Hospital RCC factor,211.82,34,,211.82,percent of total billed charges,Implant Device,211.82,34,,211.82,percent of total billed charges,Implant Device,211.82,34,,211.82,percent of total billed charges,Implant Device,211.82,34,,211.82,percent of total billed charges,Implant Device,211.82,34,,211.82,percent of total billed charges,Implant Device,308.39,,,308.39,Other,110% of Medicare,218.05,35,,218.05,percent of total billed charges,Implant Device,211.82,34,"Charges > $500, x 34%",211.82,percent of total billed charges,Implant Device,218.05,35,,218.05,percent of total billed charges,Implant Device,218.05,35,,218.05,percent of total billed charges,Implant Device,218.05,35,,218.05,percent of total billed charges,Implant Device,218.05,35,,218.05,percent of total billed charges,Implant Device,218.05,35,,218.05,percent of total billed charges,Implant Device,249.2,40,,249.2,percent of total billed charges,Implant Device,218.05,70,,218.05,percent of total billed charges,All Other,211.82,34,,211.82,percent of total billed charges,Implant Device,211.82,34,,211.82,percent of total billed charges,Implant Device,218.05,35,,218.05,percent of total billed charges,Implant Device,218.05,35,,218.05,percent of total billed charges,Implant Device,218.05,35,,218.05,percent of total billed charges,Implant Device,218.05,35,,218.05,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,461.02,
STRYKER 1896-4045S LOCK SCREW 4X45MM,C1713,HCPCS,,79004164,CDM,278,RC,,,both,,,447,330.78,,,330.78,Other,150% of Medicare + 9.63% HCRA Surcharge,201.15,45,,201.15,percent of total billed charges,Critical Access Hospital RCC factor,151.98,34,,151.98,percent of total billed charges,Implant Device,151.98,34,,151.98,percent of total billed charges,Implant Device,151.98,34,,151.98,percent of total billed charges,Implant Device,151.98,34,,151.98,percent of total billed charges,Implant Device,151.98,34,,151.98,percent of total billed charges,Implant Device,221.27,,,221.27,Other,110% of Medicare,156.45,35,,156.45,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,156.45,35,,156.45,percent of total billed charges,Implant Device,156.45,35,,156.45,percent of total billed charges,Implant Device,156.45,35,,156.45,percent of total billed charges,Implant Device,156.45,35,,156.45,percent of total billed charges,Implant Device,156.45,35,,156.45,percent of total billed charges,Implant Device,178.8,40,,178.8,percent of total billed charges,Implant Device,156.45,70,,156.45,percent of total billed charges,All Other,151.98,34,,151.98,percent of total billed charges,Implant Device,151.98,34,,151.98,percent of total billed charges,Implant Device,156.45,35,,156.45,percent of total billed charges,Implant Device,156.45,35,,156.45,percent of total billed charges,Implant Device,156.45,35,,156.45,percent of total billed charges,Implant Device,156.45,35,,156.45,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,330.78,
STRYKER 1896-4050S LOCK SCREW 4X50MM,C1713,HCPCS,,79004165,CDM,278,RC,,,both,,,405,299.7,,,299.7,Other,150% of Medicare + 9.63% HCRA Surcharge,182.25,45,,182.25,percent of total billed charges,Critical Access Hospital RCC factor,137.7,34,,137.7,percent of total billed charges,Implant Device,137.7,34,,137.7,percent of total billed charges,Implant Device,137.7,34,,137.7,percent of total billed charges,Implant Device,137.7,34,,137.7,percent of total billed charges,Implant Device,137.7,34,,137.7,percent of total billed charges,Implant Device,200.48,,,200.48,Other,110% of Medicare,141.75,35,,141.75,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,141.75,35,,141.75,percent of total billed charges,Implant Device,141.75,35,,141.75,percent of total billed charges,Implant Device,141.75,35,,141.75,percent of total billed charges,Implant Device,141.75,35,,141.75,percent of total billed charges,Implant Device,141.75,35,,141.75,percent of total billed charges,Implant Device,162,40,,162,percent of total billed charges,Implant Device,141.75,70,,141.75,percent of total billed charges,All Other,137.7,34,,137.7,percent of total billed charges,Implant Device,137.7,34,,137.7,percent of total billed charges,Implant Device,141.75,35,,141.75,percent of total billed charges,Implant Device,141.75,35,,141.75,percent of total billed charges,Implant Device,141.75,35,,141.75,percent of total billed charges,Implant Device,141.75,35,,141.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,299.7,
STRYKER 1830-0927S HUMERAL NAIL 9X270MM,C1713,HCPCS,,79004166,CDM,278,RC,,,both,,,3157,2336.19,,,2336.19,Other,150% of Medicare + 9.63% HCRA Surcharge,1420.65,45,,1420.65,percent of total billed charges,Critical Access Hospital RCC factor,1073.38,34,,1073.38,percent of total billed charges,Implant Device,1073.38,34,,1073.38,percent of total billed charges,Implant Device,1073.38,34,,1073.38,percent of total billed charges,Implant Device,1073.38,34,,1073.38,percent of total billed charges,Implant Device,1073.38,34,,1073.38,percent of total billed charges,Implant Device,1562.72,,,1562.72,Other,110% of Medicare,1104.95,35,,1104.95,percent of total billed charges,Implant Device,1073.38,34,"Charges > $500, x 34%",1073.38,percent of total billed charges,Implant Device,1104.95,35,,1104.95,percent of total billed charges,Implant Device,1104.95,35,,1104.95,percent of total billed charges,Implant Device,1104.95,35,,1104.95,percent of total billed charges,Implant Device,1104.95,35,,1104.95,percent of total billed charges,Implant Device,1104.95,35,,1104.95,percent of total billed charges,Implant Device,1262.8,40,,1262.8,percent of total billed charges,Implant Device,1104.95,70,,1104.95,percent of total billed charges,All Other,1073.38,34,,1073.38,percent of total billed charges,Implant Device,1073.38,34,,1073.38,percent of total billed charges,Implant Device,1104.95,35,,1104.95,percent of total billed charges,Implant Device,1104.95,35,,1104.95,percent of total billed charges,Implant Device,1104.95,35,,1104.95,percent of total billed charges,Implant Device,1104.95,35,,1104.95,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1073.38,34,"If Charge > 2,000, then 34 percent",1073.38,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2336.19,
STRYKER 18-3600 C-TAPER FEM HEAD 36MM,C1776,HCPCS,,79004167,CDM,278,RC,,,both,,,7366,5450.86,,,5450.86,Other,150% of Medicare + 9.63% HCRA Surcharge,3314.7,45,,3314.7,percent of total billed charges,Critical Access Hospital RCC factor,2504.44,34,,2504.44,percent of total billed charges,Implant Device,2504.44,34,,2504.44,percent of total billed charges,Implant Device,2504.44,34,,2504.44,percent of total billed charges,Implant Device,2504.44,34,,2504.44,percent of total billed charges,Implant Device,2504.44,34,,2504.44,percent of total billed charges,Implant Device,3646.17,,,3646.17,Other,110% of Medicare,2578.1,35,,2578.1,percent of total billed charges,Implant Device,2504.44,34,"Charges > $500, x 34%",2504.44,percent of total billed charges,Implant Device,2578.1,35,,2578.1,percent of total billed charges,Implant Device,2578.1,35,,2578.1,percent of total billed charges,Implant Device,2578.1,35,,2578.1,percent of total billed charges,Implant Device,2578.1,35,,2578.1,percent of total billed charges,Implant Device,2578.1,35,,2578.1,percent of total billed charges,Implant Device,2946.4,40,,2946.4,percent of total billed charges,Implant Device,2578.1,70,,2578.1,percent of total billed charges,All Other,2504.44,34,,2504.44,percent of total billed charges,Implant Device,2504.44,34,,2504.44,percent of total billed charges,Implant Device,2578.1,35,,2578.1,percent of total billed charges,Implant Device,2578.1,35,,2578.1,percent of total billed charges,Implant Device,2578.1,35,,2578.1,percent of total billed charges,Implant Device,2578.1,35,,2578.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2504.44,34,"If Charge > 2,000, then 34 percent",2504.44,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5450.86,
STRYKER 3060-0125S LAG SCREW 10.5X125MM,C1713,HCPCS,,79004168,CDM,278,RC,,,both,,,1650,1221,,,1221,Other,150% of Medicare + 9.63% HCRA Surcharge,742.5,45,,742.5,percent of total billed charges,Critical Access Hospital RCC factor,561,34,,561,percent of total billed charges,Implant Device,561,34,,561,percent of total billed charges,Implant Device,561,34,,561,percent of total billed charges,Implant Device,561,34,,561,percent of total billed charges,Implant Device,561,34,,561,percent of total billed charges,Implant Device,816.75,,,816.75,Other,110% of Medicare,577.5,35,,577.5,percent of total billed charges,Implant Device,561,34,"Charges > $500, x 34%",561,percent of total billed charges,Implant Device,577.5,35,,577.5,percent of total billed charges,Implant Device,577.5,35,,577.5,percent of total billed charges,Implant Device,577.5,35,,577.5,percent of total billed charges,Implant Device,577.5,35,,577.5,percent of total billed charges,Implant Device,577.5,35,,577.5,percent of total billed charges,Implant Device,660,40,,660,percent of total billed charges,Implant Device,577.5,70,,577.5,percent of total billed charges,All Other,561,34,,561,percent of total billed charges,Implant Device,561,34,,561,percent of total billed charges,Implant Device,577.5,35,,577.5,percent of total billed charges,Implant Device,577.5,35,,577.5,percent of total billed charges,Implant Device,577.5,35,,577.5,percent of total billed charges,Implant Device,577.5,35,,577.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1221,
STRYKER 40-35620 LOCK SCREW 3.5X20MM,C1713,HCPCS,,79004169,CDM,278,RC,,,both,,,696,515.04,,,515.04,Other,150% of Medicare + 9.63% HCRA Surcharge,313.2,45,,313.2,percent of total billed charges,Critical Access Hospital RCC factor,236.64,34,,236.64,percent of total billed charges,Implant Device,236.64,34,,236.64,percent of total billed charges,Implant Device,236.64,34,,236.64,percent of total billed charges,Implant Device,236.64,34,,236.64,percent of total billed charges,Implant Device,236.64,34,,236.64,percent of total billed charges,Implant Device,344.52,,,344.52,Other,110% of Medicare,243.6,35,,243.6,percent of total billed charges,Implant Device,236.64,34,"Charges > $500, x 34%",236.64,percent of total billed charges,Implant Device,243.6,35,,243.6,percent of total billed charges,Implant Device,243.6,35,,243.6,percent of total billed charges,Implant Device,243.6,35,,243.6,percent of total billed charges,Implant Device,243.6,35,,243.6,percent of total billed charges,Implant Device,243.6,35,,243.6,percent of total billed charges,Implant Device,278.4,40,,278.4,percent of total billed charges,Implant Device,243.6,70,,243.6,percent of total billed charges,All Other,236.64,34,,236.64,percent of total billed charges,Implant Device,236.64,34,,236.64,percent of total billed charges,Implant Device,243.6,35,,243.6,percent of total billed charges,Implant Device,243.6,35,,243.6,percent of total billed charges,Implant Device,243.6,35,,243.6,percent of total billed charges,Implant Device,243.6,35,,243.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,515.04,
STRYKER 370334 LOCKING SCREW 5X34MM,C1713,HCPCS,,79004170,CDM,278,RC,,,both,,,446,330.04,,,330.04,Other,150% of Medicare + 9.63% HCRA Surcharge,200.7,45,,200.7,percent of total billed charges,Critical Access Hospital RCC factor,151.64,34,,151.64,percent of total billed charges,Implant Device,151.64,34,,151.64,percent of total billed charges,Implant Device,151.64,34,,151.64,percent of total billed charges,Implant Device,151.64,34,,151.64,percent of total billed charges,Implant Device,151.64,34,,151.64,percent of total billed charges,Implant Device,220.77,,,220.77,Other,110% of Medicare,156.1,35,,156.1,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,156.1,35,,156.1,percent of total billed charges,Implant Device,156.1,35,,156.1,percent of total billed charges,Implant Device,156.1,35,,156.1,percent of total billed charges,Implant Device,156.1,35,,156.1,percent of total billed charges,Implant Device,156.1,35,,156.1,percent of total billed charges,Implant Device,178.4,40,,178.4,percent of total billed charges,Implant Device,156.1,70,,156.1,percent of total billed charges,All Other,151.64,34,,151.64,percent of total billed charges,Implant Device,151.64,34,,151.64,percent of total billed charges,Implant Device,156.1,35,,156.1,percent of total billed charges,Implant Device,156.1,35,,156.1,percent of total billed charges,Implant Device,156.1,35,,156.1,percent of total billed charges,Implant Device,156.1,35,,156.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,330.04,
STRYKER 3713-42 LOCKING SCREW 5X42,C1713,HCPCS,,79004172,CDM,278,RC,,,both,,,474,350.76,,,350.76,Other,150% of Medicare + 9.63% HCRA Surcharge,213.3,45,,213.3,percent of total billed charges,Critical Access Hospital RCC factor,161.16,34,,161.16,percent of total billed charges,Implant Device,161.16,34,,161.16,percent of total billed charges,Implant Device,161.16,34,,161.16,percent of total billed charges,Implant Device,161.16,34,,161.16,percent of total billed charges,Implant Device,161.16,34,,161.16,percent of total billed charges,Implant Device,234.63,,,234.63,Other,110% of Medicare,165.9,35,,165.9,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,165.9,35,,165.9,percent of total billed charges,Implant Device,165.9,35,,165.9,percent of total billed charges,Implant Device,165.9,35,,165.9,percent of total billed charges,Implant Device,165.9,35,,165.9,percent of total billed charges,Implant Device,165.9,35,,165.9,percent of total billed charges,Implant Device,189.6,40,,189.6,percent of total billed charges,Implant Device,165.9,70,,165.9,percent of total billed charges,All Other,161.16,34,,161.16,percent of total billed charges,Implant Device,161.16,34,,161.16,percent of total billed charges,Implant Device,165.9,35,,165.9,percent of total billed charges,Implant Device,165.9,35,,165.9,percent of total billed charges,Implant Device,165.9,35,,165.9,percent of total billed charges,Implant Device,165.9,35,,165.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,350.76,
STRYKER 3713-14 CORTICAL SCREW 5X14,C1713,HCPCS,,79004173,CDM,278,RC,,,both,,,474,350.76,,,350.76,Other,150% of Medicare + 9.63% HCRA Surcharge,213.3,45,,213.3,percent of total billed charges,Critical Access Hospital RCC factor,161.16,34,,161.16,percent of total billed charges,Implant Device,161.16,34,,161.16,percent of total billed charges,Implant Device,161.16,34,,161.16,percent of total billed charges,Implant Device,161.16,34,,161.16,percent of total billed charges,Implant Device,161.16,34,,161.16,percent of total billed charges,Implant Device,234.63,,,234.63,Other,110% of Medicare,165.9,35,,165.9,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,165.9,35,,165.9,percent of total billed charges,Implant Device,165.9,35,,165.9,percent of total billed charges,Implant Device,165.9,35,,165.9,percent of total billed charges,Implant Device,165.9,35,,165.9,percent of total billed charges,Implant Device,165.9,35,,165.9,percent of total billed charges,Implant Device,189.6,40,,189.6,percent of total billed charges,Implant Device,165.9,70,,165.9,percent of total billed charges,All Other,161.16,34,,161.16,percent of total billed charges,Implant Device,161.16,34,,161.16,percent of total billed charges,Implant Device,165.9,35,,165.9,percent of total billed charges,Implant Device,165.9,35,,165.9,percent of total billed charges,Implant Device,165.9,35,,165.9,percent of total billed charges,Implant Device,165.9,35,,165.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,350.76,
STRYKER 345412 CANN FT SCREW 4X12MM,C1713,HCPCS,,79004174,CDM,278,RC,,,both,,,74,54.76,,,54.76,Other,150% of Medicare + 9.63% HCRA Surcharge,33.3,45,,33.3,percent of total billed charges,Critical Access Hospital RCC factor,25.16,34,,25.16,percent of total billed charges,Implant Device,25.16,34,,25.16,percent of total billed charges,Implant Device,25.16,34,,25.16,percent of total billed charges,Implant Device,25.16,34,,25.16,percent of total billed charges,Implant Device,25.16,34,,25.16,percent of total billed charges,Implant Device,36.63,,,36.63,Other,110% of Medicare,25.9,35,,25.9,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,25.9,35,,25.9,percent of total billed charges,Implant Device,25.9,35,,25.9,percent of total billed charges,Implant Device,25.9,35,,25.9,percent of total billed charges,Implant Device,25.9,35,,25.9,percent of total billed charges,Implant Device,25.9,35,,25.9,percent of total billed charges,Implant Device,29.6,40,,29.6,percent of total billed charges,Implant Device,25.9,70,,25.9,percent of total billed charges,All Other,25.16,34,,25.16,percent of total billed charges,Implant Device,25.16,34,,25.16,percent of total billed charges,Implant Device,25.9,35,,25.9,percent of total billed charges,Implant Device,25.9,35,,25.9,percent of total billed charges,Implant Device,25.9,35,,25.9,percent of total billed charges,Implant Device,25.9,35,,25.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,54.76,
STRYKER 3425-0380S LONG NAIL R1 5 TI R,C1713,HCPCS,,79004175,CDM,278,RC,,,both,,,8249,6104.28,,,6104.28,Other,150% of Medicare + 9.63% HCRA Surcharge,3712.05,45,,3712.05,percent of total billed charges,Critical Access Hospital RCC factor,2804.66,34,,2804.66,percent of total billed charges,Implant Device,2804.66,34,,2804.66,percent of total billed charges,Implant Device,2804.66,34,,2804.66,percent of total billed charges,Implant Device,2804.66,34,,2804.66,percent of total billed charges,Implant Device,2804.66,34,,2804.66,percent of total billed charges,Implant Device,4083.26,,,4083.26,Other,110% of Medicare,2887.15,35,,2887.15,percent of total billed charges,Implant Device,2804.66,34,"Charges > $500, x 34%",2804.66,percent of total billed charges,Implant Device,2887.15,35,,2887.15,percent of total billed charges,Implant Device,2887.15,35,,2887.15,percent of total billed charges,Implant Device,2887.15,35,,2887.15,percent of total billed charges,Implant Device,2887.15,35,,2887.15,percent of total billed charges,Implant Device,2887.15,35,,2887.15,percent of total billed charges,Implant Device,3299.6,40,,3299.6,percent of total billed charges,Implant Device,2887.15,70,,2887.15,percent of total billed charges,All Other,2804.66,34,,2804.66,percent of total billed charges,Implant Device,2804.66,34,,2804.66,percent of total billed charges,Implant Device,2887.15,35,,2887.15,percent of total billed charges,Implant Device,2887.15,35,,2887.15,percent of total billed charges,Implant Device,2887.15,35,,2887.15,percent of total billed charges,Implant Device,2887.15,35,,2887.15,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2804.66,34,"If Charge > 2,000, then 34 percent",2804.66,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,6104.28,
STRYKER 113649 COMP SHOULDER SYSTEM STEM,C1776,HCPCS,,79004176,CDM,278,RC,,,both,,,12564,9297.39,,,9297.39,Other,150% of Medicare + 9.63% HCRA Surcharge,5653.8,45,,5653.8,percent of total billed charges,Critical Access Hospital RCC factor,4271.76,34,,4271.76,percent of total billed charges,Implant Device,4271.76,34,,4271.76,percent of total billed charges,Implant Device,4271.76,34,,4271.76,percent of total billed charges,Implant Device,4271.76,34,,4271.76,percent of total billed charges,Implant Device,4271.76,34,,4271.76,percent of total billed charges,Implant Device,6219.18,,,6219.18,Other,110% of Medicare,4397.4,35,,4397.4,percent of total billed charges,Implant Device,4271.76,34,"Charges > $500, x 34%",4271.76,percent of total billed charges,Implant Device,4397.4,35,,4397.4,percent of total billed charges,Implant Device,4397.4,35,,4397.4,percent of total billed charges,Implant Device,4397.4,35,,4397.4,percent of total billed charges,Implant Device,4397.4,35,,4397.4,percent of total billed charges,Implant Device,4397.4,35,,4397.4,percent of total billed charges,Implant Device,5025.6,40,,5025.6,percent of total billed charges,Implant Device,4397.4,70,,4397.4,percent of total billed charges,All Other,4271.76,34,,4271.76,percent of total billed charges,Implant Device,4271.76,34,,4271.76,percent of total billed charges,Implant Device,4397.4,35,,4397.4,percent of total billed charges,Implant Device,4397.4,35,,4397.4,percent of total billed charges,Implant Device,4397.4,35,,4397.4,percent of total billed charges,Implant Device,4397.4,35,,4397.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,4271.76,34,"If Charge > 2,000, then 34 percent",4271.76,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,9297.39,
STRYKER SPT-080000S MODULAR STEM SZ 8,C1776,HCPCS,,79004177,CDM,278,RC,,,both,,,10481,7755.97,,,7755.97,Other,150% of Medicare + 9.63% HCRA Surcharge,4716.45,45,,4716.45,percent of total billed charges,Critical Access Hospital RCC factor,3563.54,34,,3563.54,percent of total billed charges,Implant Device,3563.54,34,,3563.54,percent of total billed charges,Implant Device,3563.54,34,,3563.54,percent of total billed charges,Implant Device,3563.54,34,,3563.54,percent of total billed charges,Implant Device,3563.54,34,,3563.54,percent of total billed charges,Implant Device,5188.1,,,5188.1,Other,110% of Medicare,3668.35,35,,3668.35,percent of total billed charges,Implant Device,3563.54,34,"Charges > $500, x 34%",3563.54,percent of total billed charges,Implant Device,3668.35,35,,3668.35,percent of total billed charges,Implant Device,3668.35,35,,3668.35,percent of total billed charges,Implant Device,3668.35,35,,3668.35,percent of total billed charges,Implant Device,3668.35,35,,3668.35,percent of total billed charges,Implant Device,3668.35,35,,3668.35,percent of total billed charges,Implant Device,4192.4,40,,4192.4,percent of total billed charges,Implant Device,3668.35,70,,3668.35,percent of total billed charges,All Other,3563.54,34,,3563.54,percent of total billed charges,Implant Device,3563.54,34,,3563.54,percent of total billed charges,Implant Device,3668.35,35,,3668.35,percent of total billed charges,Implant Device,3668.35,35,,3668.35,percent of total billed charges,Implant Device,3668.35,35,,3668.35,percent of total billed charges,Implant Device,3668.35,35,,3668.35,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3563.54,34,"If Charge > 2,000, then 34 percent",3563.54,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,7755.97,
STRYKER 604660S ASNIS CANN SCREW 4X60MM,C1713,HCPCS,,79004178,CDM,278,RC,,,both,,,734,543.16,,,543.16,Other,150% of Medicare + 9.63% HCRA Surcharge,330.3,45,,330.3,percent of total billed charges,Critical Access Hospital RCC factor,249.56,34,,249.56,percent of total billed charges,Implant Device,249.56,34,,249.56,percent of total billed charges,Implant Device,249.56,34,,249.56,percent of total billed charges,Implant Device,249.56,34,,249.56,percent of total billed charges,Implant Device,249.56,34,,249.56,percent of total billed charges,Implant Device,363.33,,,363.33,Other,110% of Medicare,256.9,35,,256.9,percent of total billed charges,Implant Device,249.56,34,"Charges > $500, x 34%",249.56,percent of total billed charges,Implant Device,256.9,35,,256.9,percent of total billed charges,Implant Device,256.9,35,,256.9,percent of total billed charges,Implant Device,256.9,35,,256.9,percent of total billed charges,Implant Device,256.9,35,,256.9,percent of total billed charges,Implant Device,256.9,35,,256.9,percent of total billed charges,Implant Device,293.6,40,,293.6,percent of total billed charges,Implant Device,256.9,70,,256.9,percent of total billed charges,All Other,249.56,34,,249.56,percent of total billed charges,Implant Device,249.56,34,,249.56,percent of total billed charges,Implant Device,256.9,35,,256.9,percent of total billed charges,Implant Device,256.9,35,,256.9,percent of total billed charges,Implant Device,256.9,35,,256.9,percent of total billed charges,Implant Device,256.9,35,,256.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,543.16,
STRYKER 6481-2-120 MOD ROTATNG HING KNEE,C1776,HCPCS,,79004179,CDM,278,RC,,,both,,,2664,1971.37,,,1971.37,Other,150% of Medicare + 9.63% HCRA Surcharge,1198.8,45,,1198.8,percent of total billed charges,Critical Access Hospital RCC factor,905.76,34,,905.76,percent of total billed charges,Implant Device,905.76,34,,905.76,percent of total billed charges,Implant Device,905.76,34,,905.76,percent of total billed charges,Implant Device,905.76,34,,905.76,percent of total billed charges,Implant Device,905.76,34,,905.76,percent of total billed charges,Implant Device,1318.68,,,1318.68,Other,110% of Medicare,932.4,35,,932.4,percent of total billed charges,Implant Device,905.76,34,"Charges > $500, x 34%",905.76,percent of total billed charges,Implant Device,932.4,35,,932.4,percent of total billed charges,Implant Device,932.4,35,,932.4,percent of total billed charges,Implant Device,932.4,35,,932.4,percent of total billed charges,Implant Device,932.4,35,,932.4,percent of total billed charges,Implant Device,932.4,35,,932.4,percent of total billed charges,Implant Device,1065.6,40,,1065.6,percent of total billed charges,Implant Device,932.4,70,,932.4,percent of total billed charges,All Other,905.76,34,,905.76,percent of total billed charges,Implant Device,905.76,34,,905.76,percent of total billed charges,Implant Device,932.4,35,,932.4,percent of total billed charges,Implant Device,932.4,35,,932.4,percent of total billed charges,Implant Device,932.4,35,,932.4,percent of total billed charges,Implant Device,932.4,35,,932.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,905.76,34,"If Charge > 2,000, then 34 percent",905.76,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1971.37,
STRYKER 371340 LOCKING SCREW 5X40MM,C1713,HCPCS,,79004180,CDM,278,RC,,,both,,,451,333.74,,,333.74,Other,150% of Medicare + 9.63% HCRA Surcharge,202.95,45,,202.95,percent of total billed charges,Critical Access Hospital RCC factor,153.34,34,,153.34,percent of total billed charges,Implant Device,153.34,34,,153.34,percent of total billed charges,Implant Device,153.34,34,,153.34,percent of total billed charges,Implant Device,153.34,34,,153.34,percent of total billed charges,Implant Device,153.34,34,,153.34,percent of total billed charges,Implant Device,223.25,,,223.25,Other,110% of Medicare,157.85,35,,157.85,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,157.85,35,,157.85,percent of total billed charges,Implant Device,157.85,35,,157.85,percent of total billed charges,Implant Device,157.85,35,,157.85,percent of total billed charges,Implant Device,157.85,35,,157.85,percent of total billed charges,Implant Device,157.85,35,,157.85,percent of total billed charges,Implant Device,180.4,40,,180.4,percent of total billed charges,Implant Device,157.85,70,,157.85,percent of total billed charges,All Other,153.34,34,,153.34,percent of total billed charges,Implant Device,153.34,34,,153.34,percent of total billed charges,Implant Device,157.85,35,,157.85,percent of total billed charges,Implant Device,157.85,35,,157.85,percent of total billed charges,Implant Device,157.85,35,,157.85,percent of total billed charges,Implant Device,157.85,35,,157.85,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,333.74,
STRYKER 371520 LOCKING SCREW 4X20MM,C1713,HCPCS,,79004181,CDM,278,RC,,,both,,,541,400.34,,,400.34,Other,150% of Medicare + 9.63% HCRA Surcharge,243.45,45,,243.45,percent of total billed charges,Critical Access Hospital RCC factor,183.94,34,,183.94,percent of total billed charges,Implant Device,183.94,34,,183.94,percent of total billed charges,Implant Device,183.94,34,,183.94,percent of total billed charges,Implant Device,183.94,34,,183.94,percent of total billed charges,Implant Device,183.94,34,,183.94,percent of total billed charges,Implant Device,267.8,,,267.8,Other,110% of Medicare,189.35,35,,189.35,percent of total billed charges,Implant Device,183.94,34,"Charges > $500, x 34%",183.94,percent of total billed charges,Implant Device,189.35,35,,189.35,percent of total billed charges,Implant Device,189.35,35,,189.35,percent of total billed charges,Implant Device,189.35,35,,189.35,percent of total billed charges,Implant Device,189.35,35,,189.35,percent of total billed charges,Implant Device,189.35,35,,189.35,percent of total billed charges,Implant Device,216.4,40,,216.4,percent of total billed charges,Implant Device,189.35,70,,189.35,percent of total billed charges,All Other,183.94,34,,183.94,percent of total billed charges,Implant Device,183.94,34,,183.94,percent of total billed charges,Implant Device,189.35,35,,189.35,percent of total billed charges,Implant Device,189.35,35,,189.35,percent of total billed charges,Implant Device,189.35,35,,189.35,percent of total billed charges,Implant Device,189.35,35,,189.35,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,400.34,
STRYKER 7818-51 FEMORAL HEAD 12/14 51MM,C1776,HCPCS,,79004184,CDM,278,RC,,,both,,,1886,1395.64,,,1395.64,Other,150% of Medicare + 9.63% HCRA Surcharge,848.7,45,,848.7,percent of total billed charges,Critical Access Hospital RCC factor,641.24,34,,641.24,percent of total billed charges,Implant Device,641.24,34,,641.24,percent of total billed charges,Implant Device,641.24,34,,641.24,percent of total billed charges,Implant Device,641.24,34,,641.24,percent of total billed charges,Implant Device,641.24,34,,641.24,percent of total billed charges,Implant Device,933.57,,,933.57,Other,110% of Medicare,660.1,35,,660.1,percent of total billed charges,Implant Device,641.24,34,"Charges > $500, x 34%",641.24,percent of total billed charges,Implant Device,660.1,35,,660.1,percent of total billed charges,Implant Device,660.1,35,,660.1,percent of total billed charges,Implant Device,660.1,35,,660.1,percent of total billed charges,Implant Device,660.1,35,,660.1,percent of total billed charges,Implant Device,660.1,35,,660.1,percent of total billed charges,Implant Device,754.4,40,,754.4,percent of total billed charges,Implant Device,660.1,70,,660.1,percent of total billed charges,All Other,641.24,34,,641.24,percent of total billed charges,Implant Device,641.24,34,,641.24,percent of total billed charges,Implant Device,660.1,35,,660.1,percent of total billed charges,Implant Device,660.1,35,,660.1,percent of total billed charges,Implant Device,660.1,35,,660.1,percent of total billed charges,Implant Device,660.1,35,,660.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1395.64,
STRYKER 371360 LOCKING SCREW 5X60MM,C1713,HCPCS,,79004185,CDM,278,RC,,,both,,,474,350.76,,,350.76,Other,150% of Medicare + 9.63% HCRA Surcharge,213.3,45,,213.3,percent of total billed charges,Critical Access Hospital RCC factor,161.16,34,,161.16,percent of total billed charges,Implant Device,161.16,34,,161.16,percent of total billed charges,Implant Device,161.16,34,,161.16,percent of total billed charges,Implant Device,161.16,34,,161.16,percent of total billed charges,Implant Device,161.16,34,,161.16,percent of total billed charges,Implant Device,234.63,,,234.63,Other,110% of Medicare,165.9,35,,165.9,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,165.9,35,,165.9,percent of total billed charges,Implant Device,165.9,35,,165.9,percent of total billed charges,Implant Device,165.9,35,,165.9,percent of total billed charges,Implant Device,165.9,35,,165.9,percent of total billed charges,Implant Device,165.9,35,,165.9,percent of total billed charges,Implant Device,189.6,40,,189.6,percent of total billed charges,Implant Device,165.9,70,,165.9,percent of total billed charges,All Other,161.16,34,,161.16,percent of total billed charges,Implant Device,161.16,34,,161.16,percent of total billed charges,Implant Device,165.9,35,,165.9,percent of total billed charges,Implant Device,165.9,35,,165.9,percent of total billed charges,Implant Device,165.9,35,,165.9,percent of total billed charges,Implant Device,165.9,35,,165.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,350.76,
STRYKER 371555 CANN SCREW 4X38MM,C1713,HCPCS,,79004186,CDM,278,RC,,,both,,,541,400.34,,,400.34,Other,150% of Medicare + 9.63% HCRA Surcharge,243.45,45,,243.45,percent of total billed charges,Critical Access Hospital RCC factor,183.94,34,,183.94,percent of total billed charges,Implant Device,183.94,34,,183.94,percent of total billed charges,Implant Device,183.94,34,,183.94,percent of total billed charges,Implant Device,183.94,34,,183.94,percent of total billed charges,Implant Device,183.94,34,,183.94,percent of total billed charges,Implant Device,267.8,,,267.8,Other,110% of Medicare,189.35,35,,189.35,percent of total billed charges,Implant Device,183.94,34,"Charges > $500, x 34%",183.94,percent of total billed charges,Implant Device,189.35,35,,189.35,percent of total billed charges,Implant Device,189.35,35,,189.35,percent of total billed charges,Implant Device,189.35,35,,189.35,percent of total billed charges,Implant Device,189.35,35,,189.35,percent of total billed charges,Implant Device,189.35,35,,189.35,percent of total billed charges,Implant Device,216.4,40,,216.4,percent of total billed charges,Implant Device,189.35,70,,189.35,percent of total billed charges,All Other,183.94,34,,183.94,percent of total billed charges,Implant Device,183.94,34,,183.94,percent of total billed charges,Implant Device,189.35,35,,189.35,percent of total billed charges,Implant Device,189.35,35,,189.35,percent of total billed charges,Implant Device,189.35,35,,189.35,percent of total billed charges,Implant Device,189.35,35,,189.35,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,400.34,
STRYKER 40-35634 LOCKING SCREW 3.5X34,C1713,HCPCS,,79004187,CDM,278,RC,,,both,,,474,350.76,,,350.76,Other,150% of Medicare + 9.63% HCRA Surcharge,213.3,45,,213.3,percent of total billed charges,Critical Access Hospital RCC factor,161.16,34,,161.16,percent of total billed charges,Implant Device,161.16,34,,161.16,percent of total billed charges,Implant Device,161.16,34,,161.16,percent of total billed charges,Implant Device,161.16,34,,161.16,percent of total billed charges,Implant Device,161.16,34,,161.16,percent of total billed charges,Implant Device,234.63,,,234.63,Other,110% of Medicare,165.9,35,,165.9,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,165.9,35,,165.9,percent of total billed charges,Implant Device,165.9,35,,165.9,percent of total billed charges,Implant Device,165.9,35,,165.9,percent of total billed charges,Implant Device,165.9,35,,165.9,percent of total billed charges,Implant Device,165.9,35,,165.9,percent of total billed charges,Implant Device,189.6,40,,189.6,percent of total billed charges,Implant Device,165.9,70,,165.9,percent of total billed charges,All Other,161.16,34,,161.16,percent of total billed charges,Implant Device,161.16,34,,161.16,percent of total billed charges,Implant Device,165.9,35,,165.9,percent of total billed charges,Implant Device,165.9,35,,165.9,percent of total billed charges,Implant Device,165.9,35,,165.9,percent of total billed charges,Implant Device,165.9,35,,165.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,350.76,
STRYKER CNCF2525 NEUROFLEX  2.5X2.5MM,C1713,HCPCS,,79004188,CDM,278,RC,,,both,,,4394,3251.57,,,3251.57,Other,150% of Medicare + 9.63% HCRA Surcharge,1977.3,45,,1977.3,percent of total billed charges,Critical Access Hospital RCC factor,1493.96,34,,1493.96,percent of total billed charges,Implant Device,1493.96,34,,1493.96,percent of total billed charges,Implant Device,1493.96,34,,1493.96,percent of total billed charges,Implant Device,1493.96,34,,1493.96,percent of total billed charges,Implant Device,1493.96,34,,1493.96,percent of total billed charges,Implant Device,2175.03,,,2175.03,Other,110% of Medicare,1537.9,35,,1537.9,percent of total billed charges,Implant Device,1493.96,34,"Charges > $500, x 34%",1493.96,percent of total billed charges,Implant Device,1537.9,35,,1537.9,percent of total billed charges,Implant Device,1537.9,35,,1537.9,percent of total billed charges,Implant Device,1537.9,35,,1537.9,percent of total billed charges,Implant Device,1537.9,35,,1537.9,percent of total billed charges,Implant Device,1537.9,35,,1537.9,percent of total billed charges,Implant Device,1757.6,40,,1757.6,percent of total billed charges,Implant Device,1537.9,70,,1537.9,percent of total billed charges,All Other,1493.96,34,,1493.96,percent of total billed charges,Implant Device,1493.96,34,,1493.96,percent of total billed charges,Implant Device,1537.9,35,,1537.9,percent of total billed charges,Implant Device,1537.9,35,,1537.9,percent of total billed charges,Implant Device,1537.9,35,,1537.9,percent of total billed charges,Implant Device,1537.9,35,,1537.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1493.96,34,"If Charge > 2,000, then 34 percent",1493.96,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3251.57,
STRYKER 371336 LOCKING SCREW 5X36,C1713,HCPCS,,79004189,CDM,278,RC,,,both,,,451,333.74,,,333.74,Other,150% of Medicare + 9.63% HCRA Surcharge,202.95,45,,202.95,percent of total billed charges,Critical Access Hospital RCC factor,153.34,34,,153.34,percent of total billed charges,Implant Device,153.34,34,,153.34,percent of total billed charges,Implant Device,153.34,34,,153.34,percent of total billed charges,Implant Device,153.34,34,,153.34,percent of total billed charges,Implant Device,153.34,34,,153.34,percent of total billed charges,Implant Device,223.25,,,223.25,Other,110% of Medicare,157.85,35,,157.85,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,157.85,35,,157.85,percent of total billed charges,Implant Device,157.85,35,,157.85,percent of total billed charges,Implant Device,157.85,35,,157.85,percent of total billed charges,Implant Device,157.85,35,,157.85,percent of total billed charges,Implant Device,157.85,35,,157.85,percent of total billed charges,Implant Device,180.4,40,,180.4,percent of total billed charges,Implant Device,157.85,70,,157.85,percent of total billed charges,All Other,153.34,34,,153.34,percent of total billed charges,Implant Device,153.34,34,,153.34,percent of total billed charges,Implant Device,157.85,35,,157.85,percent of total billed charges,Implant Device,157.85,35,,157.85,percent of total billed charges,Implant Device,157.85,35,,157.85,percent of total billed charges,Implant Device,157.85,35,,157.85,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,333.74,
STRYKER 343090 CANC SCREW 6.5X90,C1713,HCPCS,,79004190,CDM,278,RC,,,both,,,113,83.62,,,83.62,Other,150% of Medicare + 9.63% HCRA Surcharge,50.85,45,,50.85,percent of total billed charges,Critical Access Hospital RCC factor,38.42,34,,38.42,percent of total billed charges,Implant Device,38.42,34,,38.42,percent of total billed charges,Implant Device,38.42,34,,38.42,percent of total billed charges,Implant Device,38.42,34,,38.42,percent of total billed charges,Implant Device,38.42,34,,38.42,percent of total billed charges,Implant Device,55.94,,,55.94,Other,110% of Medicare,39.55,35,,39.55,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,39.55,35,,39.55,percent of total billed charges,Implant Device,39.55,35,,39.55,percent of total billed charges,Implant Device,39.55,35,,39.55,percent of total billed charges,Implant Device,39.55,35,,39.55,percent of total billed charges,Implant Device,39.55,35,,39.55,percent of total billed charges,Implant Device,45.2,40,,45.2,percent of total billed charges,Implant Device,39.55,70,,39.55,percent of total billed charges,All Other,38.42,34,,38.42,percent of total billed charges,Implant Device,38.42,34,,38.42,percent of total billed charges,Implant Device,39.55,35,,39.55,percent of total billed charges,Implant Device,39.55,35,,39.55,percent of total billed charges,Implant Device,39.55,35,,39.55,percent of total billed charges,Implant Device,39.55,35,,39.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,83.62,
STRYKER NLV-340800G MOD NECK 34MM V40,C1776,HCPCS,,79004191,CDM,278,RC,,,both,,,1568,1160.32,,,1160.32,Other,150% of Medicare + 9.63% HCRA Surcharge,705.6,45,,705.6,percent of total billed charges,Critical Access Hospital RCC factor,533.12,34,,533.12,percent of total billed charges,Implant Device,533.12,34,,533.12,percent of total billed charges,Implant Device,533.12,34,,533.12,percent of total billed charges,Implant Device,533.12,34,,533.12,percent of total billed charges,Implant Device,533.12,34,,533.12,percent of total billed charges,Implant Device,776.16,,,776.16,Other,110% of Medicare,548.8,35,,548.8,percent of total billed charges,Implant Device,533.12,34,"Charges > $500, x 34%",533.12,percent of total billed charges,Implant Device,548.8,35,,548.8,percent of total billed charges,Implant Device,548.8,35,,548.8,percent of total billed charges,Implant Device,548.8,35,,548.8,percent of total billed charges,Implant Device,548.8,35,,548.8,percent of total billed charges,Implant Device,548.8,35,,548.8,percent of total billed charges,Implant Device,627.2,40,,627.2,percent of total billed charges,Implant Device,548.8,70,,548.8,percent of total billed charges,All Other,533.12,34,,533.12,percent of total billed charges,Implant Device,533.12,34,,533.12,percent of total billed charges,Implant Device,548.8,35,,548.8,percent of total billed charges,Implant Device,548.8,35,,548.8,percent of total billed charges,Implant Device,548.8,35,,548.8,percent of total billed charges,Implant Device,548.8,35,,548.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1160.32,
STRYKER 342090 PT CAN SCREW 6.5X90MM,C1713,HCPCS,,79004192,CDM,278,RC,,,both,,,127,93.98,,,93.98,Other,150% of Medicare + 9.63% HCRA Surcharge,57.15,45,,57.15,percent of total billed charges,Critical Access Hospital RCC factor,43.18,34,,43.18,percent of total billed charges,Implant Device,43.18,34,,43.18,percent of total billed charges,Implant Device,43.18,34,,43.18,percent of total billed charges,Implant Device,43.18,34,,43.18,percent of total billed charges,Implant Device,43.18,34,,43.18,percent of total billed charges,Implant Device,62.87,,,62.87,Other,110% of Medicare,44.45,35,,44.45,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,44.45,35,,44.45,percent of total billed charges,Implant Device,44.45,35,,44.45,percent of total billed charges,Implant Device,44.45,35,,44.45,percent of total billed charges,Implant Device,44.45,35,,44.45,percent of total billed charges,Implant Device,44.45,35,,44.45,percent of total billed charges,Implant Device,50.8,40,,50.8,percent of total billed charges,Implant Device,44.45,70,,44.45,percent of total billed charges,All Other,43.18,34,,43.18,percent of total billed charges,Implant Device,43.18,34,,43.18,percent of total billed charges,Implant Device,44.45,35,,44.45,percent of total billed charges,Implant Device,44.45,35,,44.45,percent of total billed charges,Implant Device,44.45,35,,44.45,percent of total billed charges,Implant Device,44.45,35,,44.45,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,93.98,
STRYKER 342085 CANCELLOUS SCREW 6.5X85MM,C1713,HCPCS,,79004193,CDM,278,RC,,,both,,,120,88.8,,,88.8,Other,150% of Medicare + 9.63% HCRA Surcharge,54,45,,54,percent of total billed charges,Critical Access Hospital RCC factor,40.8,34,,40.8,percent of total billed charges,Implant Device,40.8,34,,40.8,percent of total billed charges,Implant Device,40.8,34,,40.8,percent of total billed charges,Implant Device,40.8,34,,40.8,percent of total billed charges,Implant Device,40.8,34,,40.8,percent of total billed charges,Implant Device,59.4,,,59.4,Other,110% of Medicare,42,35,,42,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,42,35,,42,percent of total billed charges,Implant Device,42,35,,42,percent of total billed charges,Implant Device,42,35,,42,percent of total billed charges,Implant Device,42,35,,42,percent of total billed charges,Implant Device,42,35,,42,percent of total billed charges,Implant Device,48,40,,48,percent of total billed charges,Implant Device,42,70,,42,percent of total billed charges,All Other,40.8,34,,40.8,percent of total billed charges,Implant Device,40.8,34,,40.8,percent of total billed charges,Implant Device,42,35,,42,percent of total billed charges,Implant Device,42,35,,42,percent of total billed charges,Implant Device,42,35,,42,percent of total billed charges,Implant Device,42,35,,42,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,88.8,
STRYKER 371385 LOCKING SCREW 5X85MM,C1713,HCPCS,,79004194,CDM,278,RC,,,both,,,576,426.24,,,426.24,Other,150% of Medicare + 9.63% HCRA Surcharge,259.2,45,,259.2,percent of total billed charges,Critical Access Hospital RCC factor,195.84,34,,195.84,percent of total billed charges,Implant Device,195.84,34,,195.84,percent of total billed charges,Implant Device,195.84,34,,195.84,percent of total billed charges,Implant Device,195.84,34,,195.84,percent of total billed charges,Implant Device,195.84,34,,195.84,percent of total billed charges,Implant Device,285.12,,,285.12,Other,110% of Medicare,201.6,35,,201.6,percent of total billed charges,Implant Device,195.84,34,"Charges > $500, x 34%",195.84,percent of total billed charges,Implant Device,201.6,35,,201.6,percent of total billed charges,Implant Device,201.6,35,,201.6,percent of total billed charges,Implant Device,201.6,35,,201.6,percent of total billed charges,Implant Device,201.6,35,,201.6,percent of total billed charges,Implant Device,201.6,35,,201.6,percent of total billed charges,Implant Device,230.4,40,,230.4,percent of total billed charges,Implant Device,201.6,70,,201.6,percent of total billed charges,All Other,195.84,34,,195.84,percent of total billed charges,Implant Device,195.84,34,,195.84,percent of total billed charges,Implant Device,201.6,35,,201.6,percent of total billed charges,Implant Device,201.6,35,,201.6,percent of total billed charges,Implant Device,201.6,35,,201.6,percent of total billed charges,Implant Device,201.6,35,,201.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,426.24,
STRYKER 345536 CANN SCREW 4.0MM,C1713,HCPCS,,79004195,CDM,278,RC,,,both,,,74,54.76,,,54.76,Other,150% of Medicare + 9.63% HCRA Surcharge,33.3,45,,33.3,percent of total billed charges,Critical Access Hospital RCC factor,25.16,34,,25.16,percent of total billed charges,Implant Device,25.16,34,,25.16,percent of total billed charges,Implant Device,25.16,34,,25.16,percent of total billed charges,Implant Device,25.16,34,,25.16,percent of total billed charges,Implant Device,25.16,34,,25.16,percent of total billed charges,Implant Device,36.63,,,36.63,Other,110% of Medicare,25.9,35,,25.9,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,25.9,35,,25.9,percent of total billed charges,Implant Device,25.9,35,,25.9,percent of total billed charges,Implant Device,25.9,35,,25.9,percent of total billed charges,Implant Device,25.9,35,,25.9,percent of total billed charges,Implant Device,25.9,35,,25.9,percent of total billed charges,Implant Device,29.6,40,,29.6,percent of total billed charges,Implant Device,25.9,70,,25.9,percent of total billed charges,All Other,25.16,34,,25.16,percent of total billed charges,Implant Device,25.16,34,,25.16,percent of total billed charges,Implant Device,25.9,35,,25.9,percent of total billed charges,Implant Device,25.9,35,,25.9,percent of total billed charges,Implant Device,25.9,35,,25.9,percent of total billed charges,Implant Device,25.9,35,,25.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,54.76,
STRYKER 3225-5460S LONG NAIL 15X460MM,C1713,HCPCS,,79004196,CDM,278,RC,,,both,,,6671,4936.56,,,4936.56,Other,150% of Medicare + 9.63% HCRA Surcharge,3001.95,45,,3001.95,percent of total billed charges,Critical Access Hospital RCC factor,2268.14,34,,2268.14,percent of total billed charges,Implant Device,2268.14,34,,2268.14,percent of total billed charges,Implant Device,2268.14,34,,2268.14,percent of total billed charges,Implant Device,2268.14,34,,2268.14,percent of total billed charges,Implant Device,2268.14,34,,2268.14,percent of total billed charges,Implant Device,3302.15,,,3302.15,Other,110% of Medicare,2334.85,35,,2334.85,percent of total billed charges,Implant Device,2268.14,34,"Charges > $500, x 34%",2268.14,percent of total billed charges,Implant Device,2334.85,35,,2334.85,percent of total billed charges,Implant Device,2334.85,35,,2334.85,percent of total billed charges,Implant Device,2334.85,35,,2334.85,percent of total billed charges,Implant Device,2334.85,35,,2334.85,percent of total billed charges,Implant Device,2334.85,35,,2334.85,percent of total billed charges,Implant Device,2668.4,40,,2668.4,percent of total billed charges,Implant Device,2334.85,70,,2334.85,percent of total billed charges,All Other,2268.14,34,,2268.14,percent of total billed charges,Implant Device,2268.14,34,,2268.14,percent of total billed charges,Implant Device,2334.85,35,,2334.85,percent of total billed charges,Implant Device,2334.85,35,,2334.85,percent of total billed charges,Implant Device,2334.85,35,,2334.85,percent of total billed charges,Implant Device,2334.85,35,,2334.85,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2268.14,34,"If Charge > 2,000, then 34 percent",2268.14,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4936.56,
STRYKER 371380 LOCKING SCREW 5X80MM,C1713,HCPCS,,79004197,CDM,278,RC,,,both,,,576,426.24,,,426.24,Other,150% of Medicare + 9.63% HCRA Surcharge,259.2,45,,259.2,percent of total billed charges,Critical Access Hospital RCC factor,195.84,34,,195.84,percent of total billed charges,Implant Device,195.84,34,,195.84,percent of total billed charges,Implant Device,195.84,34,,195.84,percent of total billed charges,Implant Device,195.84,34,,195.84,percent of total billed charges,Implant Device,195.84,34,,195.84,percent of total billed charges,Implant Device,285.12,,,285.12,Other,110% of Medicare,201.6,35,,201.6,percent of total billed charges,Implant Device,195.84,34,"Charges > $500, x 34%",195.84,percent of total billed charges,Implant Device,201.6,35,,201.6,percent of total billed charges,Implant Device,201.6,35,,201.6,percent of total billed charges,Implant Device,201.6,35,,201.6,percent of total billed charges,Implant Device,201.6,35,,201.6,percent of total billed charges,Implant Device,201.6,35,,201.6,percent of total billed charges,Implant Device,230.4,40,,230.4,percent of total billed charges,Implant Device,201.6,70,,201.6,percent of total billed charges,All Other,195.84,34,,195.84,percent of total billed charges,Implant Device,195.84,34,,195.84,percent of total billed charges,Implant Device,201.6,35,,201.6,percent of total billed charges,Implant Device,201.6,35,,201.6,percent of total billed charges,Implant Device,201.6,35,,201.6,percent of total billed charges,Implant Device,201.6,35,,201.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,426.24,
STRYKER 40-35636 LOCKING SCREW 3.5X36,C1713,HCPCS,,79004198,CDM,278,RC,,,both,,,732,541.68,,,541.68,Other,150% of Medicare + 9.63% HCRA Surcharge,329.4,45,,329.4,percent of total billed charges,Critical Access Hospital RCC factor,248.88,34,,248.88,percent of total billed charges,Implant Device,248.88,34,,248.88,percent of total billed charges,Implant Device,248.88,34,,248.88,percent of total billed charges,Implant Device,248.88,34,,248.88,percent of total billed charges,Implant Device,248.88,34,,248.88,percent of total billed charges,Implant Device,362.34,,,362.34,Other,110% of Medicare,256.2,35,,256.2,percent of total billed charges,Implant Device,248.88,34,"Charges > $500, x 34%",248.88,percent of total billed charges,Implant Device,256.2,35,,256.2,percent of total billed charges,Implant Device,256.2,35,,256.2,percent of total billed charges,Implant Device,256.2,35,,256.2,percent of total billed charges,Implant Device,256.2,35,,256.2,percent of total billed charges,Implant Device,256.2,35,,256.2,percent of total billed charges,Implant Device,292.8,40,,292.8,percent of total billed charges,Implant Device,256.2,70,,256.2,percent of total billed charges,All Other,248.88,34,,248.88,percent of total billed charges,Implant Device,248.88,34,,248.88,percent of total billed charges,Implant Device,256.2,35,,256.2,percent of total billed charges,Implant Device,256.2,35,,256.2,percent of total billed charges,Implant Device,256.2,35,,256.2,percent of total billed charges,Implant Device,256.2,35,,256.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,541.68,
STRYKER 6481-2-110 MRH FEMORAL BUSHING,C1776,HCPCS,,79004199,CDM,278,RC,,,both,,,779,576.46,,,576.46,Other,150% of Medicare + 9.63% HCRA Surcharge,350.55,45,,350.55,percent of total billed charges,Critical Access Hospital RCC factor,264.86,34,,264.86,percent of total billed charges,Implant Device,264.86,34,,264.86,percent of total billed charges,Implant Device,264.86,34,,264.86,percent of total billed charges,Implant Device,264.86,34,,264.86,percent of total billed charges,Implant Device,264.86,34,,264.86,percent of total billed charges,Implant Device,385.61,,,385.61,Other,110% of Medicare,272.65,35,,272.65,percent of total billed charges,Implant Device,264.86,34,"Charges > $500, x 34%",264.86,percent of total billed charges,Implant Device,272.65,35,,272.65,percent of total billed charges,Implant Device,272.65,35,,272.65,percent of total billed charges,Implant Device,272.65,35,,272.65,percent of total billed charges,Implant Device,272.65,35,,272.65,percent of total billed charges,Implant Device,272.65,35,,272.65,percent of total billed charges,Implant Device,311.6,40,,311.6,percent of total billed charges,Implant Device,272.65,70,,272.65,percent of total billed charges,All Other,264.86,34,,264.86,percent of total billed charges,Implant Device,264.86,34,,264.86,percent of total billed charges,Implant Device,272.65,35,,272.65,percent of total billed charges,Implant Device,272.65,35,,272.65,percent of total billed charges,Implant Device,272.65,35,,272.65,percent of total billed charges,Implant Device,272.65,35,,272.65,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,576.46,
STRYKER 57-15379 Z PLATE 13 HOLE,C1713,HCPCS,,79004201,CDM,278,RC,,,both,,,2290,1694.61,,,1694.61,Other,150% of Medicare + 9.63% HCRA Surcharge,1030.5,45,,1030.5,percent of total billed charges,Critical Access Hospital RCC factor,778.6,34,,778.6,percent of total billed charges,Implant Device,778.6,34,,778.6,percent of total billed charges,Implant Device,778.6,34,,778.6,percent of total billed charges,Implant Device,778.6,34,,778.6,percent of total billed charges,Implant Device,778.6,34,,778.6,percent of total billed charges,Implant Device,1133.55,,,1133.55,Other,110% of Medicare,801.5,35,,801.5,percent of total billed charges,Implant Device,778.6,34,"Charges > $500, x 34%",778.6,percent of total billed charges,Implant Device,801.5,35,,801.5,percent of total billed charges,Implant Device,801.5,35,,801.5,percent of total billed charges,Implant Device,801.5,35,,801.5,percent of total billed charges,Implant Device,801.5,35,,801.5,percent of total billed charges,Implant Device,801.5,35,,801.5,percent of total billed charges,Implant Device,916,40,,916,percent of total billed charges,Implant Device,801.5,70,,801.5,percent of total billed charges,All Other,778.6,34,,778.6,percent of total billed charges,Implant Device,778.6,34,,778.6,percent of total billed charges,Implant Device,801.5,35,,801.5,percent of total billed charges,Implant Device,801.5,35,,801.5,percent of total billed charges,Implant Device,801.5,35,,801.5,percent of total billed charges,Implant Device,801.5,35,,801.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,778.6,34,"If Charge > 2,000, then 34 percent",778.6,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1694.61,
STRYKER 57-15316 PLATE 2.3 16 HOLE,C1713,HCPCS,,79004203,CDM,278,RC,,,both,,,2045,1513.31,,,1513.31,Other,150% of Medicare + 9.63% HCRA Surcharge,920.25,45,,920.25,percent of total billed charges,Critical Access Hospital RCC factor,695.3,34,,695.3,percent of total billed charges,Implant Device,695.3,34,,695.3,percent of total billed charges,Implant Device,695.3,34,,695.3,percent of total billed charges,Implant Device,695.3,34,,695.3,percent of total billed charges,Implant Device,695.3,34,,695.3,percent of total billed charges,Implant Device,1012.28,,,1012.28,Other,110% of Medicare,715.75,35,,715.75,percent of total billed charges,Implant Device,695.3,34,"Charges > $500, x 34%",695.3,percent of total billed charges,Implant Device,715.75,35,,715.75,percent of total billed charges,Implant Device,715.75,35,,715.75,percent of total billed charges,Implant Device,715.75,35,,715.75,percent of total billed charges,Implant Device,715.75,35,,715.75,percent of total billed charges,Implant Device,715.75,35,,715.75,percent of total billed charges,Implant Device,818,40,,818,percent of total billed charges,Implant Device,715.75,70,,715.75,percent of total billed charges,All Other,695.3,34,,695.3,percent of total billed charges,Implant Device,695.3,34,,695.3,percent of total billed charges,Implant Device,715.75,35,,715.75,percent of total billed charges,Implant Device,715.75,35,,715.75,percent of total billed charges,Implant Device,715.75,35,,715.75,percent of total billed charges,Implant Device,715.75,35,,715.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,695.3,34,"If Charge > 2,000, then 34 percent",695.3,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1513.31,
SYNTHES 207.734 34 LONG CANNULATED SCREW,C1713,HCPCS,,79004205,CDM,278,RC,,,both,,,685,506.9,,,506.9,Other,150% of Medicare + 9.63% HCRA Surcharge,308.25,45,,308.25,percent of total billed charges,Critical Access Hospital RCC factor,232.9,34,,232.9,percent of total billed charges,Implant Device,232.9,34,,232.9,percent of total billed charges,Implant Device,232.9,34,,232.9,percent of total billed charges,Implant Device,232.9,34,,232.9,percent of total billed charges,Implant Device,232.9,34,,232.9,percent of total billed charges,Implant Device,339.08,,,339.08,Other,110% of Medicare,239.75,35,,239.75,percent of total billed charges,Implant Device,232.9,34,"Charges > $500, x 34%",232.9,percent of total billed charges,Implant Device,239.75,35,,239.75,percent of total billed charges,Implant Device,239.75,35,,239.75,percent of total billed charges,Implant Device,239.75,35,,239.75,percent of total billed charges,Implant Device,239.75,35,,239.75,percent of total billed charges,Implant Device,239.75,35,,239.75,percent of total billed charges,Implant Device,274,40,,274,percent of total billed charges,Implant Device,239.75,70,,239.75,percent of total billed charges,All Other,232.9,34,,232.9,percent of total billed charges,Implant Device,232.9,34,,232.9,percent of total billed charges,Implant Device,239.75,35,,239.75,percent of total billed charges,Implant Device,239.75,35,,239.75,percent of total billed charges,Implant Device,239.75,35,,239.75,percent of total billed charges,Implant Device,239.75,35,,239.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,506.9,
SYNTHES 239.985S PROXIMAL MED PLATE 4.5,C1713,HCPCS,,79004207,CDM,278,RC,,,both,,,4669,3455.07,,,3455.07,Other,150% of Medicare + 9.63% HCRA Surcharge,2101.05,45,,2101.05,percent of total billed charges,Critical Access Hospital RCC factor,1587.46,34,,1587.46,percent of total billed charges,Implant Device,1587.46,34,,1587.46,percent of total billed charges,Implant Device,1587.46,34,,1587.46,percent of total billed charges,Implant Device,1587.46,34,,1587.46,percent of total billed charges,Implant Device,1587.46,34,,1587.46,percent of total billed charges,Implant Device,2311.16,,,2311.16,Other,110% of Medicare,1634.15,35,,1634.15,percent of total billed charges,Implant Device,1587.46,34,"Charges > $500, x 34%",1587.46,percent of total billed charges,Implant Device,1634.15,35,,1634.15,percent of total billed charges,Implant Device,1634.15,35,,1634.15,percent of total billed charges,Implant Device,1634.15,35,,1634.15,percent of total billed charges,Implant Device,1634.15,35,,1634.15,percent of total billed charges,Implant Device,1634.15,35,,1634.15,percent of total billed charges,Implant Device,1867.6,40,,1867.6,percent of total billed charges,Implant Device,1634.15,70,,1634.15,percent of total billed charges,All Other,1587.46,34,,1587.46,percent of total billed charges,Implant Device,1587.46,34,,1587.46,percent of total billed charges,Implant Device,1634.15,35,,1634.15,percent of total billed charges,Implant Device,1634.15,35,,1634.15,percent of total billed charges,Implant Device,1634.15,35,,1634.15,percent of total billed charges,Implant Device,1634.15,35,,1634.15,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1587.46,34,"If Charge > 2,000, then 34 percent",1587.46,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3455.07,
GORE PXC181400 LEG ENDOPROS 18X13.5MM,C1874,HCPCS,,79004209,CDM,278,RC,,,both,,,11940,8835.63,,,8835.63,Other,150% of Medicare + 9.63% HCRA Surcharge,5373,45,,5373,percent of total billed charges,Critical Access Hospital RCC factor,4059.6,34,,4059.6,percent of total billed charges,Implant Device,4059.6,34,,4059.6,percent of total billed charges,Implant Device,4059.6,34,,4059.6,percent of total billed charges,Implant Device,4059.6,34,,4059.6,percent of total billed charges,Implant Device,4059.6,34,,4059.6,percent of total billed charges,Implant Device,5910.3,,,5910.3,Other,110% of Medicare,4179,35,,4179,percent of total billed charges,Implant Device,4059.6,34,"Charges > $500, x 34%",4059.6,percent of total billed charges,Implant Device,4179,35,,4179,percent of total billed charges,Implant Device,4179,35,,4179,percent of total billed charges,Implant Device,4179,35,,4179,percent of total billed charges,Implant Device,4179,35,,4179,percent of total billed charges,Implant Device,4179,35,,4179,percent of total billed charges,Implant Device,4776,40,,4776,percent of total billed charges,Implant Device,4179,70,,4179,percent of total billed charges,All Other,4059.6,34,,4059.6,percent of total billed charges,Implant Device,4059.6,34,,4059.6,percent of total billed charges,Implant Device,4179,35,,4179,percent of total billed charges,Implant Device,4179,35,,4179,percent of total billed charges,Implant Device,4179,35,,4179,percent of total billed charges,Implant Device,4179,35,,4179,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,4059.6,34,"If Charge > 2,000, then 34 percent",4059.6,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,8835.63,
GORE PXA260300 AORTIC EXT ENDOPRS 26X30,C1874,HCPCS,,79004210,CDM,278,RC,,,both,,,8850,6549.02,,,6549.02,Other,150% of Medicare + 9.63% HCRA Surcharge,3982.5,45,,3982.5,percent of total billed charges,Critical Access Hospital RCC factor,3009,34,,3009,percent of total billed charges,Implant Device,3009,34,,3009,percent of total billed charges,Implant Device,3009,34,,3009,percent of total billed charges,Implant Device,3009,34,,3009,percent of total billed charges,Implant Device,3009,34,,3009,percent of total billed charges,Implant Device,4380.75,,,4380.75,Other,110% of Medicare,3097.5,35,,3097.5,percent of total billed charges,Implant Device,3009,34,"Charges > $500, x 34%",3009,percent of total billed charges,Implant Device,3097.5,35,,3097.5,percent of total billed charges,Implant Device,3097.5,35,,3097.5,percent of total billed charges,Implant Device,3097.5,35,,3097.5,percent of total billed charges,Implant Device,3097.5,35,,3097.5,percent of total billed charges,Implant Device,3097.5,35,,3097.5,percent of total billed charges,Implant Device,3540,40,,3540,percent of total billed charges,Implant Device,3097.5,70,,3097.5,percent of total billed charges,All Other,3009,34,,3009,percent of total billed charges,Implant Device,3009,34,,3009,percent of total billed charges,Implant Device,3097.5,35,,3097.5,percent of total billed charges,Implant Device,3097.5,35,,3097.5,percent of total billed charges,Implant Device,3097.5,35,,3097.5,percent of total billed charges,Implant Device,3097.5,35,,3097.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3009,34,"If Charge > 2,000, then 34 percent",3009,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,6549.02,
GORE V10040L VASCULAR GRAFT,C1768,HCPCS,,79004211,CDM,278,RC,,,both,,,1630,1206.2,,,1206.2,Other,150% of Medicare + 9.63% HCRA Surcharge,733.5,45,,733.5,percent of total billed charges,Critical Access Hospital RCC factor,554.2,34,,554.2,percent of total billed charges,Implant Device,554.2,34,,554.2,percent of total billed charges,Implant Device,554.2,34,,554.2,percent of total billed charges,Implant Device,554.2,34,,554.2,percent of total billed charges,Implant Device,554.2,34,,554.2,percent of total billed charges,Implant Device,806.85,,,806.85,Other,110% of Medicare,570.5,35,,570.5,percent of total billed charges,Implant Device,554.2,34,"Charges > $500, x 34%",554.2,percent of total billed charges,Implant Device,570.5,35,,570.5,percent of total billed charges,Implant Device,570.5,35,,570.5,percent of total billed charges,Implant Device,570.5,35,,570.5,percent of total billed charges,Implant Device,570.5,35,,570.5,percent of total billed charges,Implant Device,570.5,35,,570.5,percent of total billed charges,Implant Device,652,40,,652,percent of total billed charges,Implant Device,570.5,70,,570.5,percent of total billed charges,All Other,554.2,34,,554.2,percent of total billed charges,Implant Device,554.2,34,,554.2,percent of total billed charges,Implant Device,570.5,35,,570.5,percent of total billed charges,Implant Device,570.5,35,,570.5,percent of total billed charges,Implant Device,570.5,35,,570.5,percent of total billed charges,Implant Device,570.5,35,,570.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1206.2,
GORE PXC201200 LEG ENDOPROS 20X11.5,C1874,HCPCS,,79004212,CDM,278,RC,,,both,,,11940,8835.63,,,8835.63,Other,150% of Medicare + 9.63% HCRA Surcharge,5373,45,,5373,percent of total billed charges,Critical Access Hospital RCC factor,4059.6,34,,4059.6,percent of total billed charges,Implant Device,4059.6,34,,4059.6,percent of total billed charges,Implant Device,4059.6,34,,4059.6,percent of total billed charges,Implant Device,4059.6,34,,4059.6,percent of total billed charges,Implant Device,4059.6,34,,4059.6,percent of total billed charges,Implant Device,5910.3,,,5910.3,Other,110% of Medicare,4179,35,,4179,percent of total billed charges,Implant Device,4059.6,34,"Charges > $500, x 34%",4059.6,percent of total billed charges,Implant Device,4179,35,,4179,percent of total billed charges,Implant Device,4179,35,,4179,percent of total billed charges,Implant Device,4179,35,,4179,percent of total billed charges,Implant Device,4179,35,,4179,percent of total billed charges,Implant Device,4179,35,,4179,percent of total billed charges,Implant Device,4776,40,,4776,percent of total billed charges,Implant Device,4179,70,,4179,percent of total billed charges,All Other,4059.6,34,,4059.6,percent of total billed charges,Implant Device,4059.6,34,,4059.6,percent of total billed charges,Implant Device,4179,35,,4179,percent of total billed charges,Implant Device,4179,35,,4179,percent of total billed charges,Implant Device,4179,35,,4179,percent of total billed charges,Implant Device,4179,35,,4179,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,4059.6,34,"If Charge > 2,000, then 34 percent",4059.6,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,8835.63,
GORE PXC181200 LEG ENDOPROS 18X11.5MM,C1874,HCPCS,,79004213,CDM,278,RC,,,both,,,11940,8835.63,,,8835.63,Other,150% of Medicare + 9.63% HCRA Surcharge,5373,45,,5373,percent of total billed charges,Critical Access Hospital RCC factor,4059.6,34,,4059.6,percent of total billed charges,Implant Device,4059.6,34,,4059.6,percent of total billed charges,Implant Device,4059.6,34,,4059.6,percent of total billed charges,Implant Device,4059.6,34,,4059.6,percent of total billed charges,Implant Device,4059.6,34,,4059.6,percent of total billed charges,Implant Device,5910.3,,,5910.3,Other,110% of Medicare,4179,35,,4179,percent of total billed charges,Implant Device,4059.6,34,"Charges > $500, x 34%",4059.6,percent of total billed charges,Implant Device,4179,35,,4179,percent of total billed charges,Implant Device,4179,35,,4179,percent of total billed charges,Implant Device,4179,35,,4179,percent of total billed charges,Implant Device,4179,35,,4179,percent of total billed charges,Implant Device,4179,35,,4179,percent of total billed charges,Implant Device,4776,40,,4776,percent of total billed charges,Implant Device,4179,70,,4179,percent of total billed charges,All Other,4059.6,34,,4059.6,percent of total billed charges,Implant Device,4059.6,34,,4059.6,percent of total billed charges,Implant Device,4179,35,,4179,percent of total billed charges,Implant Device,4179,35,,4179,percent of total billed charges,Implant Device,4179,35,,4179,percent of total billed charges,Implant Device,4179,35,,4179,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,4059.6,34,"If Charge > 2,000, then 34 percent",4059.6,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,8835.63,
GORE RMT311415 LEG ENDOPROS 31X14.5X15CM,C1874,HCPCS,,79004214,CDM,278,RC,,,both,,,29986,22189.71,,,22189.71,Other,150% of Medicare + 9.63% HCRA Surcharge,13493.7,45,,13493.7,percent of total billed charges,Critical Access Hospital RCC factor,10195.24,34,,10195.24,percent of total billed charges,Implant Device,10195.24,34,,10195.24,percent of total billed charges,Implant Device,10195.24,34,,10195.24,percent of total billed charges,Implant Device,10195.24,34,,10195.24,percent of total billed charges,Implant Device,10195.24,34,,10195.24,percent of total billed charges,Implant Device,14843.07,,,14843.07,Other,110% of Medicare,10495.1,35,,10495.1,percent of total billed charges,Implant Device,10195.24,34,"Charges > $500, x 34%",10195.24,percent of total billed charges,Implant Device,10495.1,35,,10495.1,percent of total billed charges,Implant Device,10495.1,35,,10495.1,percent of total billed charges,Implant Device,10495.1,35,,10495.1,percent of total billed charges,Implant Device,10495.1,35,,10495.1,percent of total billed charges,Implant Device,10495.1,35,,10495.1,percent of total billed charges,Implant Device,11994.4,40,,11994.4,percent of total billed charges,Implant Device,10495.1,70,,10495.1,percent of total billed charges,All Other,10195.24,34,,10195.24,percent of total billed charges,Implant Device,10195.24,34,,10195.24,percent of total billed charges,Implant Device,10495.1,35,,10495.1,percent of total billed charges,Implant Device,10495.1,35,,10495.1,percent of total billed charges,Implant Device,10495.1,35,,10495.1,percent of total billed charges,Implant Device,10495.1,35,,10495.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,10195.24,34,"If Charge > 2,000, then 34 percent",10195.24,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,22189.71,
GORE PXA230300 AORTIC EXT ENDOPROS 23X33,C1874,HCPCS,,79004215,CDM,278,RC,,,both,,,8370,6193.82,,,6193.82,Other,150% of Medicare + 9.63% HCRA Surcharge,3766.5,45,,3766.5,percent of total billed charges,Critical Access Hospital RCC factor,2845.8,34,,2845.8,percent of total billed charges,Implant Device,2845.8,34,,2845.8,percent of total billed charges,Implant Device,2845.8,34,,2845.8,percent of total billed charges,Implant Device,2845.8,34,,2845.8,percent of total billed charges,Implant Device,2845.8,34,,2845.8,percent of total billed charges,Implant Device,4143.15,,,4143.15,Other,110% of Medicare,2929.5,35,,2929.5,percent of total billed charges,Implant Device,2845.8,34,"Charges > $500, x 34%",2845.8,percent of total billed charges,Implant Device,2929.5,35,,2929.5,percent of total billed charges,Implant Device,2929.5,35,,2929.5,percent of total billed charges,Implant Device,2929.5,35,,2929.5,percent of total billed charges,Implant Device,2929.5,35,,2929.5,percent of total billed charges,Implant Device,2929.5,35,,2929.5,percent of total billed charges,Implant Device,3348,40,,3348,percent of total billed charges,Implant Device,2929.5,70,,2929.5,percent of total billed charges,All Other,2845.8,34,,2845.8,percent of total billed charges,Implant Device,2845.8,34,,2845.8,percent of total billed charges,Implant Device,2929.5,35,,2929.5,percent of total billed charges,Implant Device,2929.5,35,,2929.5,percent of total billed charges,Implant Device,2929.5,35,,2929.5,percent of total billed charges,Implant Device,2929.5,35,,2929.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2845.8,34,"If Charge > 2,000, then 34 percent",2845.8,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,6193.82,
WRIGHT 24920018 CORTICAL SCREW 2.7X18MM,C1713,HCPCS,,79004217,CDM,278,RC,,,both,,,336,248.64,,,248.64,Other,150% of Medicare + 9.63% HCRA Surcharge,151.2,45,,151.2,percent of total billed charges,Critical Access Hospital RCC factor,114.24,34,,114.24,percent of total billed charges,Implant Device,114.24,34,,114.24,percent of total billed charges,Implant Device,114.24,34,,114.24,percent of total billed charges,Implant Device,114.24,34,,114.24,percent of total billed charges,Implant Device,114.24,34,,114.24,percent of total billed charges,Implant Device,166.32,,,166.32,Other,110% of Medicare,117.6,35,,117.6,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,117.6,35,,117.6,percent of total billed charges,Implant Device,117.6,35,,117.6,percent of total billed charges,Implant Device,117.6,35,,117.6,percent of total billed charges,Implant Device,117.6,35,,117.6,percent of total billed charges,Implant Device,117.6,35,,117.6,percent of total billed charges,Implant Device,134.4,40,,134.4,percent of total billed charges,Implant Device,117.6,70,,117.6,percent of total billed charges,All Other,114.24,34,,114.24,percent of total billed charges,Implant Device,114.24,34,,114.24,percent of total billed charges,Implant Device,117.6,35,,117.6,percent of total billed charges,Implant Device,117.6,35,,117.6,percent of total billed charges,Implant Device,117.6,35,,117.6,percent of total billed charges,Implant Device,117.6,35,,117.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,248.64,
WRIGHT 49110424 CANCELLOUS SCREW 2X24MM,C1713,HCPCS,,79004218,CDM,278,RC,,,both,,,658,486.92,,,486.92,Other,150% of Medicare + 9.63% HCRA Surcharge,296.1,45,,296.1,percent of total billed charges,Critical Access Hospital RCC factor,223.72,34,,223.72,percent of total billed charges,Implant Device,223.72,34,,223.72,percent of total billed charges,Implant Device,223.72,34,,223.72,percent of total billed charges,Implant Device,223.72,34,,223.72,percent of total billed charges,Implant Device,223.72,34,,223.72,percent of total billed charges,Implant Device,325.71,,,325.71,Other,110% of Medicare,230.3,35,,230.3,percent of total billed charges,Implant Device,223.72,34,"Charges > $500, x 34%",223.72,percent of total billed charges,Implant Device,230.3,35,,230.3,percent of total billed charges,Implant Device,230.3,35,,230.3,percent of total billed charges,Implant Device,230.3,35,,230.3,percent of total billed charges,Implant Device,230.3,35,,230.3,percent of total billed charges,Implant Device,230.3,35,,230.3,percent of total billed charges,Implant Device,263.2,40,,263.2,percent of total billed charges,Implant Device,230.3,70,,230.3,percent of total billed charges,All Other,223.72,34,,223.72,percent of total billed charges,Implant Device,223.72,34,,223.72,percent of total billed charges,Implant Device,230.3,35,,230.3,percent of total billed charges,Implant Device,230.3,35,,230.3,percent of total billed charges,Implant Device,230.3,35,,230.3,percent of total billed charges,Implant Device,230.3,35,,230.3,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,486.92,
WRIGHT 44110040 COMP SCREW 4.3X50MM,C1713,HCPCS,,79004219,CDM,278,RC,,,both,,,1192,882.08,,,882.08,Other,150% of Medicare + 9.63% HCRA Surcharge,536.4,45,,536.4,percent of total billed charges,Critical Access Hospital RCC factor,405.28,34,,405.28,percent of total billed charges,Implant Device,405.28,34,,405.28,percent of total billed charges,Implant Device,405.28,34,,405.28,percent of total billed charges,Implant Device,405.28,34,,405.28,percent of total billed charges,Implant Device,405.28,34,,405.28,percent of total billed charges,Implant Device,590.04,,,590.04,Other,110% of Medicare,417.2,35,,417.2,percent of total billed charges,Implant Device,405.28,34,"Charges > $500, x 34%",405.28,percent of total billed charges,Implant Device,417.2,35,,417.2,percent of total billed charges,Implant Device,417.2,35,,417.2,percent of total billed charges,Implant Device,417.2,35,,417.2,percent of total billed charges,Implant Device,417.2,35,,417.2,percent of total billed charges,Implant Device,417.2,35,,417.2,percent of total billed charges,Implant Device,476.8,40,,476.8,percent of total billed charges,Implant Device,417.2,70,,417.2,percent of total billed charges,All Other,405.28,34,,405.28,percent of total billed charges,Implant Device,405.28,34,,405.28,percent of total billed charges,Implant Device,417.2,35,,417.2,percent of total billed charges,Implant Device,417.2,35,,417.2,percent of total billed charges,Implant Device,417.2,35,,417.2,percent of total billed charges,Implant Device,417.2,35,,417.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,882.08,
WRIGHT DC2820124 SCREW 3.5X24MM,C1713,HCPCS,,79004220,CDM,278,RC,,,both,,,654,483.96,,,483.96,Other,150% of Medicare + 9.63% HCRA Surcharge,294.3,45,,294.3,percent of total billed charges,Critical Access Hospital RCC factor,222.36,34,,222.36,percent of total billed charges,Implant Device,222.36,34,,222.36,percent of total billed charges,Implant Device,222.36,34,,222.36,percent of total billed charges,Implant Device,222.36,34,,222.36,percent of total billed charges,Implant Device,222.36,34,,222.36,percent of total billed charges,Implant Device,323.73,,,323.73,Other,110% of Medicare,228.9,35,,228.9,percent of total billed charges,Implant Device,222.36,34,"Charges > $500, x 34%",222.36,percent of total billed charges,Implant Device,228.9,35,,228.9,percent of total billed charges,Implant Device,228.9,35,,228.9,percent of total billed charges,Implant Device,228.9,35,,228.9,percent of total billed charges,Implant Device,228.9,35,,228.9,percent of total billed charges,Implant Device,228.9,35,,228.9,percent of total billed charges,Implant Device,261.6,40,,261.6,percent of total billed charges,Implant Device,228.9,70,,228.9,percent of total billed charges,All Other,222.36,34,,222.36,percent of total billed charges,Implant Device,222.36,34,,222.36,percent of total billed charges,Implant Device,228.9,35,,228.9,percent of total billed charges,Implant Device,228.9,35,,228.9,percent of total billed charges,Implant Device,228.9,35,,228.9,percent of total billed charges,Implant Device,228.9,35,,228.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,483.96,
WRIGHT 441770116 HEADLESS SCREW 7.0X70MM,C1713,HCPCS,,79004221,CDM,278,RC,,,both,,,3202,2369.49,,,2369.49,Other,150% of Medicare + 9.63% HCRA Surcharge,1440.9,45,,1440.9,percent of total billed charges,Critical Access Hospital RCC factor,1088.68,34,,1088.68,percent of total billed charges,Implant Device,1088.68,34,,1088.68,percent of total billed charges,Implant Device,1088.68,34,,1088.68,percent of total billed charges,Implant Device,1088.68,34,,1088.68,percent of total billed charges,Implant Device,1088.68,34,,1088.68,percent of total billed charges,Implant Device,1584.99,,,1584.99,Other,110% of Medicare,1120.7,35,,1120.7,percent of total billed charges,Implant Device,1088.68,34,"Charges > $500, x 34%",1088.68,percent of total billed charges,Implant Device,1120.7,35,,1120.7,percent of total billed charges,Implant Device,1120.7,35,,1120.7,percent of total billed charges,Implant Device,1120.7,35,,1120.7,percent of total billed charges,Implant Device,1120.7,35,,1120.7,percent of total billed charges,Implant Device,1120.7,35,,1120.7,percent of total billed charges,Implant Device,1280.8,40,,1280.8,percent of total billed charges,Implant Device,1120.7,70,,1120.7,percent of total billed charges,All Other,1088.68,34,,1088.68,percent of total billed charges,Implant Device,1088.68,34,,1088.68,percent of total billed charges,Implant Device,1120.7,35,,1120.7,percent of total billed charges,Implant Device,1120.7,35,,1120.7,percent of total billed charges,Implant Device,1120.7,35,,1120.7,percent of total billed charges,Implant Device,1120.7,35,,1120.7,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1088.68,34,"If Charge > 2,000, then 34 percent",1088.68,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2369.49,
WRIGHT 86620006 ALLOPURE 6MM ALLOGRAFT,C1713,HCPCS,,79004222,CDM,278,RC,,,both,,,6150,4551.02,,,4551.02,Other,150% of Medicare + 9.63% HCRA Surcharge,2767.5,45,,2767.5,percent of total billed charges,Critical Access Hospital RCC factor,2091,34,,2091,percent of total billed charges,Implant Device,2091,34,,2091,percent of total billed charges,Implant Device,2091,34,,2091,percent of total billed charges,Implant Device,2091,34,,2091,percent of total billed charges,Implant Device,2091,34,,2091,percent of total billed charges,Implant Device,3044.25,,,3044.25,Other,110% of Medicare,2152.5,35,,2152.5,percent of total billed charges,Implant Device,2091,34,"Charges > $500, x 34%",2091,percent of total billed charges,Implant Device,2152.5,35,,2152.5,percent of total billed charges,Implant Device,2152.5,35,,2152.5,percent of total billed charges,Implant Device,2152.5,35,,2152.5,percent of total billed charges,Implant Device,2152.5,35,,2152.5,percent of total billed charges,Implant Device,2152.5,35,,2152.5,percent of total billed charges,Implant Device,2460,40,,2460,percent of total billed charges,Implant Device,2152.5,70,,2152.5,percent of total billed charges,All Other,2091,34,,2091,percent of total billed charges,Implant Device,2091,34,,2091,percent of total billed charges,Implant Device,2152.5,35,,2152.5,percent of total billed charges,Implant Device,2152.5,35,,2152.5,percent of total billed charges,Implant Device,2152.5,35,,2152.5,percent of total billed charges,Implant Device,2152.5,35,,2152.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2091,34,"If Charge > 2,000, then 34 percent",2091,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4551.02,
WRIGHT 44110032 HEADLESS SCREW 4.3X50MM,C1713,HCPCS,,79004223,CDM,278,RC,,,both,,,1156,855.44,,,855.44,Other,150% of Medicare + 9.63% HCRA Surcharge,520.2,45,,520.2,percent of total billed charges,Critical Access Hospital RCC factor,393.04,34,,393.04,percent of total billed charges,Implant Device,393.04,34,,393.04,percent of total billed charges,Implant Device,393.04,34,,393.04,percent of total billed charges,Implant Device,393.04,34,,393.04,percent of total billed charges,Implant Device,393.04,34,,393.04,percent of total billed charges,Implant Device,572.22,,,572.22,Other,110% of Medicare,404.6,35,,404.6,percent of total billed charges,Implant Device,393.04,34,"Charges > $500, x 34%",393.04,percent of total billed charges,Implant Device,404.6,35,,404.6,percent of total billed charges,Implant Device,404.6,35,,404.6,percent of total billed charges,Implant Device,404.6,35,,404.6,percent of total billed charges,Implant Device,404.6,35,,404.6,percent of total billed charges,Implant Device,404.6,35,,404.6,percent of total billed charges,Implant Device,462.4,40,,462.4,percent of total billed charges,Implant Device,404.6,70,,404.6,percent of total billed charges,All Other,393.04,34,,393.04,percent of total billed charges,Implant Device,393.04,34,,393.04,percent of total billed charges,Implant Device,404.6,35,,404.6,percent of total billed charges,Implant Device,404.6,35,,404.6,percent of total billed charges,Implant Device,404.6,35,,404.6,percent of total billed charges,Implant Device,404.6,35,,404.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,855.44,
WRIGHT 49105002 EVOLVE PLATE SIZE 2,C1713,HCPCS,,79004224,CDM,278,RC,,,both,,,4918,3639.33,,,3639.33,Other,150% of Medicare + 9.63% HCRA Surcharge,2213.1,45,,2213.1,percent of total billed charges,Critical Access Hospital RCC factor,1672.12,34,,1672.12,percent of total billed charges,Implant Device,1672.12,34,,1672.12,percent of total billed charges,Implant Device,1672.12,34,,1672.12,percent of total billed charges,Implant Device,1672.12,34,,1672.12,percent of total billed charges,Implant Device,1672.12,34,,1672.12,percent of total billed charges,Implant Device,2434.41,,,2434.41,Other,110% of Medicare,1721.3,35,,1721.3,percent of total billed charges,Implant Device,1672.12,34,"Charges > $500, x 34%",1672.12,percent of total billed charges,Implant Device,1721.3,35,,1721.3,percent of total billed charges,Implant Device,1721.3,35,,1721.3,percent of total billed charges,Implant Device,1721.3,35,,1721.3,percent of total billed charges,Implant Device,1721.3,35,,1721.3,percent of total billed charges,Implant Device,1721.3,35,,1721.3,percent of total billed charges,Implant Device,1967.2,40,,1967.2,percent of total billed charges,Implant Device,1721.3,70,,1721.3,percent of total billed charges,All Other,1672.12,34,,1672.12,percent of total billed charges,Implant Device,1672.12,34,,1672.12,percent of total billed charges,Implant Device,1721.3,35,,1721.3,percent of total billed charges,Implant Device,1721.3,35,,1721.3,percent of total billed charges,Implant Device,1721.3,35,,1721.3,percent of total billed charges,Implant Device,1721.3,35,,1721.3,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1672.12,34,"If Charge > 2,000, then 34 percent",1672.12,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3639.33,
WRIGHT 40130025 CLAW 4H .25MM 35 PLATE,C1713,HCPCS,,79004225,CDM,278,RC,,,both,,,6588,4875.14,,,4875.14,Other,150% of Medicare + 9.63% HCRA Surcharge,2964.6,45,,2964.6,percent of total billed charges,Critical Access Hospital RCC factor,2239.92,34,,2239.92,percent of total billed charges,Implant Device,2239.92,34,,2239.92,percent of total billed charges,Implant Device,2239.92,34,,2239.92,percent of total billed charges,Implant Device,2239.92,34,,2239.92,percent of total billed charges,Implant Device,2239.92,34,,2239.92,percent of total billed charges,Implant Device,3261.06,,,3261.06,Other,110% of Medicare,2305.8,35,,2305.8,percent of total billed charges,Implant Device,2239.92,34,"Charges > $500, x 34%",2239.92,percent of total billed charges,Implant Device,2305.8,35,,2305.8,percent of total billed charges,Implant Device,2305.8,35,,2305.8,percent of total billed charges,Implant Device,2305.8,35,,2305.8,percent of total billed charges,Implant Device,2305.8,35,,2305.8,percent of total billed charges,Implant Device,2305.8,35,,2305.8,percent of total billed charges,Implant Device,2635.2,40,,2635.2,percent of total billed charges,Implant Device,2305.8,70,,2305.8,percent of total billed charges,All Other,2239.92,34,,2239.92,percent of total billed charges,Implant Device,2239.92,34,,2239.92,percent of total billed charges,Implant Device,2305.8,35,,2305.8,percent of total billed charges,Implant Device,2305.8,35,,2305.8,percent of total billed charges,Implant Device,2305.8,35,,2305.8,percent of total billed charges,Implant Device,2305.8,35,,2305.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2239.92,34,"If Charge > 2,000, then 34 percent",2239.92,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4875.14,
WRIGHT DIN200145 DARTFIRE SCREW 2.0X14MM,C1713,HCPCS,,79004226,CDM,278,RC,,,both,,,634,469.16,,,469.16,Other,150% of Medicare + 9.63% HCRA Surcharge,285.3,45,,285.3,percent of total billed charges,Critical Access Hospital RCC factor,215.56,34,,215.56,percent of total billed charges,Implant Device,215.56,34,,215.56,percent of total billed charges,Implant Device,215.56,34,,215.56,percent of total billed charges,Implant Device,215.56,34,,215.56,percent of total billed charges,Implant Device,215.56,34,,215.56,percent of total billed charges,Implant Device,313.83,,,313.83,Other,110% of Medicare,221.9,35,,221.9,percent of total billed charges,Implant Device,215.56,34,"Charges > $500, x 34%",215.56,percent of total billed charges,Implant Device,221.9,35,,221.9,percent of total billed charges,Implant Device,221.9,35,,221.9,percent of total billed charges,Implant Device,221.9,35,,221.9,percent of total billed charges,Implant Device,221.9,35,,221.9,percent of total billed charges,Implant Device,221.9,35,,221.9,percent of total billed charges,Implant Device,253.6,40,,253.6,percent of total billed charges,Implant Device,221.9,70,,221.9,percent of total billed charges,All Other,215.56,34,,215.56,percent of total billed charges,Implant Device,215.56,34,,215.56,percent of total billed charges,Implant Device,221.9,35,,221.9,percent of total billed charges,Implant Device,221.9,35,,221.9,percent of total billed charges,Implant Device,221.9,35,,221.9,percent of total billed charges,Implant Device,221.9,35,,221.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,469.16,
WRIGHT 49110426 CANC SCREW 2.0X26MM,C1713,HCPCS,,79004228,CDM,278,RC,,,both,,,658,486.92,,,486.92,Other,150% of Medicare + 9.63% HCRA Surcharge,296.1,45,,296.1,percent of total billed charges,Critical Access Hospital RCC factor,223.72,34,,223.72,percent of total billed charges,Implant Device,223.72,34,,223.72,percent of total billed charges,Implant Device,223.72,34,,223.72,percent of total billed charges,Implant Device,223.72,34,,223.72,percent of total billed charges,Implant Device,223.72,34,,223.72,percent of total billed charges,Implant Device,325.71,,,325.71,Other,110% of Medicare,230.3,35,,230.3,percent of total billed charges,Implant Device,223.72,34,"Charges > $500, x 34%",223.72,percent of total billed charges,Implant Device,230.3,35,,230.3,percent of total billed charges,Implant Device,230.3,35,,230.3,percent of total billed charges,Implant Device,230.3,35,,230.3,percent of total billed charges,Implant Device,230.3,35,,230.3,percent of total billed charges,Implant Device,230.3,35,,230.3,percent of total billed charges,Implant Device,263.2,40,,263.2,percent of total billed charges,Implant Device,230.3,70,,230.3,percent of total billed charges,All Other,223.72,34,,223.72,percent of total billed charges,Implant Device,223.72,34,,223.72,percent of total billed charges,Implant Device,230.3,35,,230.3,percent of total billed charges,Implant Device,230.3,35,,230.3,percent of total billed charges,Implant Device,230.3,35,,230.3,percent of total billed charges,Implant Device,230.3,35,,230.3,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,486.92,
WRIGHT 40133520 CLAW HEX SCREW 3.5X20MM,C1713,HCPCS,,79004229,CDM,278,RC,,,both,,,816,603.84,,,603.84,Other,150% of Medicare + 9.63% HCRA Surcharge,367.2,45,,367.2,percent of total billed charges,Critical Access Hospital RCC factor,277.44,34,,277.44,percent of total billed charges,Implant Device,277.44,34,,277.44,percent of total billed charges,Implant Device,277.44,34,,277.44,percent of total billed charges,Implant Device,277.44,34,,277.44,percent of total billed charges,Implant Device,277.44,34,,277.44,percent of total billed charges,Implant Device,403.92,,,403.92,Other,110% of Medicare,285.6,35,,285.6,percent of total billed charges,Implant Device,277.44,34,"Charges > $500, x 34%",277.44,percent of total billed charges,Implant Device,285.6,35,,285.6,percent of total billed charges,Implant Device,285.6,35,,285.6,percent of total billed charges,Implant Device,285.6,35,,285.6,percent of total billed charges,Implant Device,285.6,35,,285.6,percent of total billed charges,Implant Device,285.6,35,,285.6,percent of total billed charges,Implant Device,326.4,40,,326.4,percent of total billed charges,Implant Device,285.6,70,,285.6,percent of total billed charges,All Other,277.44,34,,277.44,percent of total billed charges,Implant Device,277.44,34,,277.44,percent of total billed charges,Implant Device,285.6,35,,285.6,percent of total billed charges,Implant Device,285.6,35,,285.6,percent of total billed charges,Implant Device,285.6,35,,285.6,percent of total billed charges,Implant Device,285.6,35,,285.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,603.84,
WRIGHT 86660012 EVANS ALLOGRAFT 12X38MM,C1713,HCPCS,,79004231,CDM,278,RC,,,both,,,6556,4851.46,,,4851.46,Other,150% of Medicare + 9.63% HCRA Surcharge,2950.2,45,,2950.2,percent of total billed charges,Critical Access Hospital RCC factor,2229.04,34,,2229.04,percent of total billed charges,Implant Device,2229.04,34,,2229.04,percent of total billed charges,Implant Device,2229.04,34,,2229.04,percent of total billed charges,Implant Device,2229.04,34,,2229.04,percent of total billed charges,Implant Device,2229.04,34,,2229.04,percent of total billed charges,Implant Device,3245.22,,,3245.22,Other,110% of Medicare,2294.6,35,,2294.6,percent of total billed charges,Implant Device,2229.04,34,"Charges > $500, x 34%",2229.04,percent of total billed charges,Implant Device,2294.6,35,,2294.6,percent of total billed charges,Implant Device,2294.6,35,,2294.6,percent of total billed charges,Implant Device,2294.6,35,,2294.6,percent of total billed charges,Implant Device,2294.6,35,,2294.6,percent of total billed charges,Implant Device,2294.6,35,,2294.6,percent of total billed charges,Implant Device,2622.4,40,,2622.4,percent of total billed charges,Implant Device,2294.6,70,,2294.6,percent of total billed charges,All Other,2229.04,34,,2229.04,percent of total billed charges,Implant Device,2229.04,34,,2229.04,percent of total billed charges,Implant Device,2294.6,35,,2294.6,percent of total billed charges,Implant Device,2294.6,35,,2294.6,percent of total billed charges,Implant Device,2294.6,35,,2294.6,percent of total billed charges,Implant Device,2294.6,35,,2294.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2229.04,34,"If Charge > 2,000, then 34 percent",2229.04,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4851.46,
WRIGHT G426-0010 FLEXIBLE HINGE TOE IMP,C1776,HCPCS,,79004232,CDM,278,RC,,,both,,,5130,3796.21,,,3796.21,Other,150% of Medicare + 9.63% HCRA Surcharge,2308.5,45,,2308.5,percent of total billed charges,Critical Access Hospital RCC factor,1744.2,34,,1744.2,percent of total billed charges,Implant Device,1744.2,34,,1744.2,percent of total billed charges,Implant Device,1744.2,34,,1744.2,percent of total billed charges,Implant Device,1744.2,34,,1744.2,percent of total billed charges,Implant Device,1744.2,34,,1744.2,percent of total billed charges,Implant Device,2539.35,,,2539.35,Other,110% of Medicare,1795.5,35,,1795.5,percent of total billed charges,Implant Device,1744.2,34,"Charges > $500, x 34%",1744.2,percent of total billed charges,Implant Device,1795.5,35,,1795.5,percent of total billed charges,Implant Device,1795.5,35,,1795.5,percent of total billed charges,Implant Device,1795.5,35,,1795.5,percent of total billed charges,Implant Device,1795.5,35,,1795.5,percent of total billed charges,Implant Device,1795.5,35,,1795.5,percent of total billed charges,Implant Device,2052,40,,2052,percent of total billed charges,Implant Device,1795.5,70,,1795.5,percent of total billed charges,All Other,1744.2,34,,1744.2,percent of total billed charges,Implant Device,1744.2,34,,1744.2,percent of total billed charges,Implant Device,1795.5,35,,1795.5,percent of total billed charges,Implant Device,1795.5,35,,1795.5,percent of total billed charges,Implant Device,1795.5,35,,1795.5,percent of total billed charges,Implant Device,1795.5,35,,1795.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1744.2,34,"If Charge > 2,000, then 34 percent",1744.2,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3796.21,
WRIGHT 40133526 CLAW HEX SCREW 3.5X26MM,C1713,HCPCS,,79004233,CDM,278,RC,,,both,,,630,466.2,,,466.2,Other,150% of Medicare + 9.63% HCRA Surcharge,283.5,45,,283.5,percent of total billed charges,Critical Access Hospital RCC factor,214.2,34,,214.2,percent of total billed charges,Implant Device,214.2,34,,214.2,percent of total billed charges,Implant Device,214.2,34,,214.2,percent of total billed charges,Implant Device,214.2,34,,214.2,percent of total billed charges,Implant Device,214.2,34,,214.2,percent of total billed charges,Implant Device,311.85,,,311.85,Other,110% of Medicare,220.5,35,,220.5,percent of total billed charges,Implant Device,214.2,34,"Charges > $500, x 34%",214.2,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,252,40,,252,percent of total billed charges,Implant Device,220.5,70,,220.5,percent of total billed charges,All Other,214.2,34,,214.2,percent of total billed charges,Implant Device,214.2,34,,214.2,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,466.2,
ZIMMER 00-2232-004-18 CBL RDY ASSY,C1713,HCPCS,,79004236,CDM,278,RC,,,both,,,1038,768.12,,,768.12,Other,150% of Medicare + 9.63% HCRA Surcharge,467.1,45,,467.1,percent of total billed charges,Critical Access Hospital RCC factor,352.92,34,,352.92,percent of total billed charges,Implant Device,352.92,34,,352.92,percent of total billed charges,Implant Device,352.92,34,,352.92,percent of total billed charges,Implant Device,352.92,34,,352.92,percent of total billed charges,Implant Device,352.92,34,,352.92,percent of total billed charges,Implant Device,513.81,,,513.81,Other,110% of Medicare,363.3,35,,363.3,percent of total billed charges,Implant Device,352.92,34,"Charges > $500, x 34%",352.92,percent of total billed charges,Implant Device,363.3,35,,363.3,percent of total billed charges,Implant Device,363.3,35,,363.3,percent of total billed charges,Implant Device,363.3,35,,363.3,percent of total billed charges,Implant Device,363.3,35,,363.3,percent of total billed charges,Implant Device,363.3,35,,363.3,percent of total billed charges,Implant Device,415.2,40,,415.2,percent of total billed charges,Implant Device,363.3,70,,363.3,percent of total billed charges,All Other,352.92,34,,352.92,percent of total billed charges,Implant Device,352.92,34,,352.92,percent of total billed charges,Implant Device,363.3,35,,363.3,percent of total billed charges,Implant Device,363.3,35,,363.3,percent of total billed charges,Implant Device,363.3,35,,363.3,percent of total billed charges,Implant Device,363.3,35,,363.3,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,768.12,
ZIMMER 2253-040-55 INTRLOCK SCREW 5.5X40,C1713,HCPCS,,79004238,CDM,278,RC,,,both,,,654,483.96,,,483.96,Other,150% of Medicare + 9.63% HCRA Surcharge,294.3,45,,294.3,percent of total billed charges,Critical Access Hospital RCC factor,222.36,34,,222.36,percent of total billed charges,Implant Device,222.36,34,,222.36,percent of total billed charges,Implant Device,222.36,34,,222.36,percent of total billed charges,Implant Device,222.36,34,,222.36,percent of total billed charges,Implant Device,222.36,34,,222.36,percent of total billed charges,Implant Device,323.73,,,323.73,Other,110% of Medicare,228.9,35,,228.9,percent of total billed charges,Implant Device,222.36,34,"Charges > $500, x 34%",222.36,percent of total billed charges,Implant Device,228.9,35,,228.9,percent of total billed charges,Implant Device,228.9,35,,228.9,percent of total billed charges,Implant Device,228.9,35,,228.9,percent of total billed charges,Implant Device,228.9,35,,228.9,percent of total billed charges,Implant Device,228.9,35,,228.9,percent of total billed charges,Implant Device,261.6,40,,261.6,percent of total billed charges,Implant Device,228.9,70,,228.9,percent of total billed charges,All Other,222.36,34,,222.36,percent of total billed charges,Implant Device,222.36,34,,222.36,percent of total billed charges,Implant Device,228.9,35,,228.9,percent of total billed charges,Implant Device,228.9,35,,228.9,percent of total billed charges,Implant Device,228.9,35,,228.9,percent of total billed charges,Implant Device,228.9,35,,228.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,483.96,
ZIMMER 6043636S ASNIS SCREW 4.0X36MM,C1713,HCPCS,,79004239,CDM,278,RC,,,both,,,612,452.88,,,452.88,Other,150% of Medicare + 9.63% HCRA Surcharge,275.4,45,,275.4,percent of total billed charges,Critical Access Hospital RCC factor,208.08,34,,208.08,percent of total billed charges,Implant Device,208.08,34,,208.08,percent of total billed charges,Implant Device,208.08,34,,208.08,percent of total billed charges,Implant Device,208.08,34,,208.08,percent of total billed charges,Implant Device,208.08,34,,208.08,percent of total billed charges,Implant Device,302.94,,,302.94,Other,110% of Medicare,214.2,35,,214.2,percent of total billed charges,Implant Device,208.08,34,"Charges > $500, x 34%",208.08,percent of total billed charges,Implant Device,214.2,35,,214.2,percent of total billed charges,Implant Device,214.2,35,,214.2,percent of total billed charges,Implant Device,214.2,35,,214.2,percent of total billed charges,Implant Device,214.2,35,,214.2,percent of total billed charges,Implant Device,214.2,35,,214.2,percent of total billed charges,Implant Device,244.8,40,,244.8,percent of total billed charges,Implant Device,214.2,70,,214.2,percent of total billed charges,All Other,208.08,34,,208.08,percent of total billed charges,Implant Device,208.08,34,,208.08,percent of total billed charges,Implant Device,214.2,35,,214.2,percent of total billed charges,Implant Device,214.2,35,,214.2,percent of total billed charges,Implant Device,214.2,35,,214.2,percent of total billed charges,Implant Device,214.2,35,,214.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,452.88,
ZIMMER 00-2359-050-45 LCK SCREW 4.5X50MM,C1713,HCPCS,,79004240,CDM,278,RC,,,both,,,445,329.3,,,329.3,Other,150% of Medicare + 9.63% HCRA Surcharge,200.25,45,,200.25,percent of total billed charges,Critical Access Hospital RCC factor,151.3,34,,151.3,percent of total billed charges,Implant Device,151.3,34,,151.3,percent of total billed charges,Implant Device,151.3,34,,151.3,percent of total billed charges,Implant Device,151.3,34,,151.3,percent of total billed charges,Implant Device,151.3,34,,151.3,percent of total billed charges,Implant Device,220.28,,,220.28,Other,110% of Medicare,155.75,35,,155.75,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,155.75,35,,155.75,percent of total billed charges,Implant Device,155.75,35,,155.75,percent of total billed charges,Implant Device,155.75,35,,155.75,percent of total billed charges,Implant Device,155.75,35,,155.75,percent of total billed charges,Implant Device,155.75,35,,155.75,percent of total billed charges,Implant Device,178,40,,178,percent of total billed charges,Implant Device,155.75,70,,155.75,percent of total billed charges,All Other,151.3,34,,151.3,percent of total billed charges,Implant Device,151.3,34,,151.3,percent of total billed charges,Implant Device,155.75,35,,155.75,percent of total billed charges,Implant Device,155.75,35,,155.75,percent of total billed charges,Implant Device,155.75,35,,155.75,percent of total billed charges,Implant Device,155.75,35,,155.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,329.3,
ZIMMER 00-2359-075-55 CANN SCREW 5.5X75,C1713,HCPCS,,79004241,CDM,278,RC,,,both,,,578,427.72,,,427.72,Other,150% of Medicare + 9.63% HCRA Surcharge,260.1,45,,260.1,percent of total billed charges,Critical Access Hospital RCC factor,196.52,34,,196.52,percent of total billed charges,Implant Device,196.52,34,,196.52,percent of total billed charges,Implant Device,196.52,34,,196.52,percent of total billed charges,Implant Device,196.52,34,,196.52,percent of total billed charges,Implant Device,196.52,34,,196.52,percent of total billed charges,Implant Device,286.11,,,286.11,Other,110% of Medicare,202.3,35,,202.3,percent of total billed charges,Implant Device,196.52,34,"Charges > $500, x 34%",196.52,percent of total billed charges,Implant Device,202.3,35,,202.3,percent of total billed charges,Implant Device,202.3,35,,202.3,percent of total billed charges,Implant Device,202.3,35,,202.3,percent of total billed charges,Implant Device,202.3,35,,202.3,percent of total billed charges,Implant Device,202.3,35,,202.3,percent of total billed charges,Implant Device,231.2,40,,231.2,percent of total billed charges,Implant Device,202.3,70,,202.3,percent of total billed charges,All Other,196.52,34,,196.52,percent of total billed charges,Implant Device,196.52,34,,196.52,percent of total billed charges,Implant Device,202.3,35,,202.3,percent of total billed charges,Implant Device,202.3,35,,202.3,percent of total billed charges,Implant Device,202.3,35,,202.3,percent of total billed charges,Implant Device,202.3,35,,202.3,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,427.72,
ZIMMER 1147-65-40 CANN SCREW 4.0X65MM,C1713,HCPCS,,79004242,CDM,278,RC,,,both,,,558,412.92,,,412.92,Other,150% of Medicare + 9.63% HCRA Surcharge,251.1,45,,251.1,percent of total billed charges,Critical Access Hospital RCC factor,189.72,34,,189.72,percent of total billed charges,Implant Device,189.72,34,,189.72,percent of total billed charges,Implant Device,189.72,34,,189.72,percent of total billed charges,Implant Device,189.72,34,,189.72,percent of total billed charges,Implant Device,189.72,34,,189.72,percent of total billed charges,Implant Device,276.21,,,276.21,Other,110% of Medicare,195.3,35,,195.3,percent of total billed charges,Implant Device,189.72,34,"Charges > $500, x 34%",189.72,percent of total billed charges,Implant Device,195.3,35,,195.3,percent of total billed charges,Implant Device,195.3,35,,195.3,percent of total billed charges,Implant Device,195.3,35,,195.3,percent of total billed charges,Implant Device,195.3,35,,195.3,percent of total billed charges,Implant Device,195.3,35,,195.3,percent of total billed charges,Implant Device,223.2,40,,223.2,percent of total billed charges,Implant Device,195.3,70,,195.3,percent of total billed charges,All Other,189.72,34,,189.72,percent of total billed charges,Implant Device,189.72,34,,189.72,percent of total billed charges,Implant Device,195.3,35,,195.3,percent of total billed charges,Implant Device,195.3,35,,195.3,percent of total billed charges,Implant Device,195.3,35,,195.3,percent of total billed charges,Implant Device,195.3,35,,195.3,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,412.92,
ZIMMER 00-1147-095-45 CANN SCREW 4.5MM,C1713,HCPCS,,79004243,CDM,278,RC,,,both,,,589,435.86,,,435.86,Other,150% of Medicare + 9.63% HCRA Surcharge,265.05,45,,265.05,percent of total billed charges,Critical Access Hospital RCC factor,200.26,34,,200.26,percent of total billed charges,Implant Device,200.26,34,,200.26,percent of total billed charges,Implant Device,200.26,34,,200.26,percent of total billed charges,Implant Device,200.26,34,,200.26,percent of total billed charges,Implant Device,200.26,34,,200.26,percent of total billed charges,Implant Device,291.56,,,291.56,Other,110% of Medicare,206.15,35,,206.15,percent of total billed charges,Implant Device,200.26,34,"Charges > $500, x 34%",200.26,percent of total billed charges,Implant Device,206.15,35,,206.15,percent of total billed charges,Implant Device,206.15,35,,206.15,percent of total billed charges,Implant Device,206.15,35,,206.15,percent of total billed charges,Implant Device,206.15,35,,206.15,percent of total billed charges,Implant Device,206.15,35,,206.15,percent of total billed charges,Implant Device,235.6,40,,235.6,percent of total billed charges,Implant Device,206.15,70,,206.15,percent of total billed charges,All Other,200.26,34,,200.26,percent of total billed charges,Implant Device,200.26,34,,200.26,percent of total billed charges,Implant Device,206.15,35,,206.15,percent of total billed charges,Implant Device,206.15,35,,206.15,percent of total billed charges,Implant Device,206.15,35,,206.15,percent of total billed charges,Implant Device,206.15,35,,206.15,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,435.86,
ZIMMER 7818-46 FEM HEAD 12/14 TAPER 46MM,C1776,HCPCS,,79004244,CDM,278,RC,,,both,,,1759,1301.66,,,1301.66,Other,150% of Medicare + 9.63% HCRA Surcharge,791.55,45,,791.55,percent of total billed charges,Critical Access Hospital RCC factor,598.06,34,,598.06,percent of total billed charges,Implant Device,598.06,34,,598.06,percent of total billed charges,Implant Device,598.06,34,,598.06,percent of total billed charges,Implant Device,598.06,34,,598.06,percent of total billed charges,Implant Device,598.06,34,,598.06,percent of total billed charges,Implant Device,870.71,,,870.71,Other,110% of Medicare,615.65,35,,615.65,percent of total billed charges,Implant Device,598.06,34,"Charges > $500, x 34%",598.06,percent of total billed charges,Implant Device,615.65,35,,615.65,percent of total billed charges,Implant Device,615.65,35,,615.65,percent of total billed charges,Implant Device,615.65,35,,615.65,percent of total billed charges,Implant Device,615.65,35,,615.65,percent of total billed charges,Implant Device,615.65,35,,615.65,percent of total billed charges,Implant Device,703.6,40,,703.6,percent of total billed charges,Implant Device,615.65,70,,615.65,percent of total billed charges,All Other,598.06,34,,598.06,percent of total billed charges,Implant Device,598.06,34,,598.06,percent of total billed charges,Implant Device,615.65,35,,615.65,percent of total billed charges,Implant Device,615.65,35,,615.65,percent of total billed charges,Implant Device,615.65,35,,615.65,percent of total billed charges,Implant Device,615.65,35,,615.65,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1301.66,
ZIMMER 7818-43 FEM HEAD 12/14 TAPER 43MM,C1776,HCPCS,,79004245,CDM,278,RC,,,both,,,1885,1394.9,,,1394.9,Other,150% of Medicare + 9.63% HCRA Surcharge,848.25,45,,848.25,percent of total billed charges,Critical Access Hospital RCC factor,640.9,34,,640.9,percent of total billed charges,Implant Device,640.9,34,,640.9,percent of total billed charges,Implant Device,640.9,34,,640.9,percent of total billed charges,Implant Device,640.9,34,,640.9,percent of total billed charges,Implant Device,640.9,34,,640.9,percent of total billed charges,Implant Device,933.08,,,933.08,Other,110% of Medicare,659.75,35,,659.75,percent of total billed charges,Implant Device,640.9,34,"Charges > $500, x 34%",640.9,percent of total billed charges,Implant Device,659.75,35,,659.75,percent of total billed charges,Implant Device,659.75,35,,659.75,percent of total billed charges,Implant Device,659.75,35,,659.75,percent of total billed charges,Implant Device,659.75,35,,659.75,percent of total billed charges,Implant Device,659.75,35,,659.75,percent of total billed charges,Implant Device,754,40,,754,percent of total billed charges,Implant Device,659.75,70,,659.75,percent of total billed charges,All Other,640.9,34,,640.9,percent of total billed charges,Implant Device,640.9,34,,640.9,percent of total billed charges,Implant Device,659.75,35,,659.75,percent of total billed charges,Implant Device,659.75,35,,659.75,percent of total billed charges,Implant Device,659.75,35,,659.75,percent of total billed charges,Implant Device,659.75,35,,659.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1394.9,
ZIMMER 00-2357-004-06 TIBIAL PLATE 3.5,C1713,HCPCS,,79004246,CDM,278,RC,,,both,,,4080,3019.21,,,3019.21,Other,150% of Medicare + 9.63% HCRA Surcharge,1836,45,,1836,percent of total billed charges,Critical Access Hospital RCC factor,1387.2,34,,1387.2,percent of total billed charges,Implant Device,1387.2,34,,1387.2,percent of total billed charges,Implant Device,1387.2,34,,1387.2,percent of total billed charges,Implant Device,1387.2,34,,1387.2,percent of total billed charges,Implant Device,1387.2,34,,1387.2,percent of total billed charges,Implant Device,2019.6,,,2019.6,Other,110% of Medicare,1428,35,,1428,percent of total billed charges,Implant Device,1387.2,34,"Charges > $500, x 34%",1387.2,percent of total billed charges,Implant Device,1428,35,,1428,percent of total billed charges,Implant Device,1428,35,,1428,percent of total billed charges,Implant Device,1428,35,,1428,percent of total billed charges,Implant Device,1428,35,,1428,percent of total billed charges,Implant Device,1428,35,,1428,percent of total billed charges,Implant Device,1632,40,,1632,percent of total billed charges,Implant Device,1428,70,,1428,percent of total billed charges,All Other,1387.2,34,,1387.2,percent of total billed charges,Implant Device,1387.2,34,,1387.2,percent of total billed charges,Implant Device,1428,35,,1428,percent of total billed charges,Implant Device,1428,35,,1428,percent of total billed charges,Implant Device,1428,35,,1428,percent of total billed charges,Implant Device,1428,35,,1428,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1387.2,34,"If Charge > 2,000, then 34 percent",1387.2,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3019.21,
ZIMMER 2480-16-41 CANCELLOUS SCREW 4X16,C1713,HCPCS,,79004248,CDM,278,RC,,,both,,,175,129.5,,,129.5,Other,150% of Medicare + 9.63% HCRA Surcharge,78.75,45,,78.75,percent of total billed charges,Critical Access Hospital RCC factor,59.5,34,,59.5,percent of total billed charges,Implant Device,59.5,34,,59.5,percent of total billed charges,Implant Device,59.5,34,,59.5,percent of total billed charges,Implant Device,59.5,34,,59.5,percent of total billed charges,Implant Device,59.5,34,,59.5,percent of total billed charges,Implant Device,86.63,,,86.63,Other,110% of Medicare,61.25,35,,61.25,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,61.25,35,,61.25,percent of total billed charges,Implant Device,61.25,35,,61.25,percent of total billed charges,Implant Device,61.25,35,,61.25,percent of total billed charges,Implant Device,61.25,35,,61.25,percent of total billed charges,Implant Device,61.25,35,,61.25,percent of total billed charges,Implant Device,70,40,,70,percent of total billed charges,Implant Device,61.25,70,,61.25,percent of total billed charges,All Other,59.5,34,,59.5,percent of total billed charges,Implant Device,59.5,34,,59.5,percent of total billed charges,Implant Device,61.25,35,,61.25,percent of total billed charges,Implant Device,61.25,35,,61.25,percent of total billed charges,Implant Device,61.25,35,,61.25,percent of total billed charges,Implant Device,61.25,35,,61.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,129.5,
ZIMMER 771301100 M/L TAPER KINECTIV STEM,C1776,HCPCS,,79004249,CDM,278,RC,,,both,,,11160,8258.43,,,8258.43,Other,150% of Medicare + 9.63% HCRA Surcharge,5022,45,,5022,percent of total billed charges,Critical Access Hospital RCC factor,3794.4,34,,3794.4,percent of total billed charges,Implant Device,3794.4,34,,3794.4,percent of total billed charges,Implant Device,3794.4,34,,3794.4,percent of total billed charges,Implant Device,3794.4,34,,3794.4,percent of total billed charges,Implant Device,3794.4,34,,3794.4,percent of total billed charges,Implant Device,5524.2,,,5524.2,Other,110% of Medicare,3906,35,,3906,percent of total billed charges,Implant Device,3794.4,34,"Charges > $500, x 34%",3794.4,percent of total billed charges,Implant Device,3906,35,,3906,percent of total billed charges,Implant Device,3906,35,,3906,percent of total billed charges,Implant Device,3906,35,,3906,percent of total billed charges,Implant Device,3906,35,,3906,percent of total billed charges,Implant Device,3906,35,,3906,percent of total billed charges,Implant Device,4464,40,,4464,percent of total billed charges,Implant Device,3906,70,,3906,percent of total billed charges,All Other,3794.4,34,,3794.4,percent of total billed charges,Implant Device,3794.4,34,,3794.4,percent of total billed charges,Implant Device,3906,35,,3906,percent of total billed charges,Implant Device,3906,35,,3906,percent of total billed charges,Implant Device,3906,35,,3906,percent of total billed charges,Implant Device,3906,35,,3906,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3794.4,34,"If Charge > 2,000, then 34 percent",3794.4,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,8258.43,
ZIMMER 4835-026-01 CORTICAL SCREW 26MM,C1713,HCPCS,,79004250,CDM,278,RC,,,both,,,144,106.56,,,106.56,Other,150% of Medicare + 9.63% HCRA Surcharge,64.8,45,,64.8,percent of total billed charges,Critical Access Hospital RCC factor,48.96,34,,48.96,percent of total billed charges,Implant Device,48.96,34,,48.96,percent of total billed charges,Implant Device,48.96,34,,48.96,percent of total billed charges,Implant Device,48.96,34,,48.96,percent of total billed charges,Implant Device,48.96,34,,48.96,percent of total billed charges,Implant Device,71.28,,,71.28,Other,110% of Medicare,50.4,35,,50.4,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,50.4,35,,50.4,percent of total billed charges,Implant Device,50.4,35,,50.4,percent of total billed charges,Implant Device,50.4,35,,50.4,percent of total billed charges,Implant Device,50.4,35,,50.4,percent of total billed charges,Implant Device,50.4,35,,50.4,percent of total billed charges,Implant Device,57.6,40,,57.6,percent of total billed charges,Implant Device,50.4,70,,50.4,percent of total billed charges,All Other,48.96,34,,48.96,percent of total billed charges,Implant Device,48.96,34,,48.96,percent of total billed charges,Implant Device,50.4,35,,50.4,percent of total billed charges,Implant Device,50.4,35,,50.4,percent of total billed charges,Implant Device,50.4,35,,50.4,percent of total billed charges,Implant Device,50.4,35,,50.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,106.56,
ZIMMER 02.03155.028 CORT SCREW 4.0X28MM,C1713,HCPCS,,79004251,CDM,278,RC,,,both,,,443,327.82,,,327.82,Other,150% of Medicare + 9.63% HCRA Surcharge,199.35,45,,199.35,percent of total billed charges,Critical Access Hospital RCC factor,150.62,34,,150.62,percent of total billed charges,Implant Device,150.62,34,,150.62,percent of total billed charges,Implant Device,150.62,34,,150.62,percent of total billed charges,Implant Device,150.62,34,,150.62,percent of total billed charges,Implant Device,150.62,34,,150.62,percent of total billed charges,Implant Device,219.29,,,219.29,Other,110% of Medicare,155.05,35,,155.05,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,155.05,35,,155.05,percent of total billed charges,Implant Device,155.05,35,,155.05,percent of total billed charges,Implant Device,155.05,35,,155.05,percent of total billed charges,Implant Device,155.05,35,,155.05,percent of total billed charges,Implant Device,155.05,35,,155.05,percent of total billed charges,Implant Device,177.2,40,,177.2,percent of total billed charges,Implant Device,155.05,70,,155.05,percent of total billed charges,All Other,150.62,34,,150.62,percent of total billed charges,Implant Device,150.62,34,,150.62,percent of total billed charges,Implant Device,155.05,35,,155.05,percent of total billed charges,Implant Device,155.05,35,,155.05,percent of total billed charges,Implant Device,155.05,35,,155.05,percent of total billed charges,Implant Device,155.05,35,,155.05,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,327.82,
ZIMMER 02-03152-090 CANC SCREW 5.0X90MM,C1713,HCPCS,,79004252,CDM,278,RC,,,both,,,546,404.04,,,404.04,Other,150% of Medicare + 9.63% HCRA Surcharge,245.7,45,,245.7,percent of total billed charges,Critical Access Hospital RCC factor,185.64,34,,185.64,percent of total billed charges,Implant Device,185.64,34,,185.64,percent of total billed charges,Implant Device,185.64,34,,185.64,percent of total billed charges,Implant Device,185.64,34,,185.64,percent of total billed charges,Implant Device,185.64,34,,185.64,percent of total billed charges,Implant Device,270.27,,,270.27,Other,110% of Medicare,191.1,35,,191.1,percent of total billed charges,Implant Device,185.64,34,"Charges > $500, x 34%",185.64,percent of total billed charges,Implant Device,191.1,35,,191.1,percent of total billed charges,Implant Device,191.1,35,,191.1,percent of total billed charges,Implant Device,191.1,35,,191.1,percent of total billed charges,Implant Device,191.1,35,,191.1,percent of total billed charges,Implant Device,191.1,35,,191.1,percent of total billed charges,Implant Device,218.4,40,,218.4,percent of total billed charges,Implant Device,191.1,70,,191.1,percent of total billed charges,All Other,185.64,34,,185.64,percent of total billed charges,Implant Device,185.64,34,,185.64,percent of total billed charges,Implant Device,191.1,35,,191.1,percent of total billed charges,Implant Device,191.1,35,,191.1,percent of total billed charges,Implant Device,191.1,35,,191.1,percent of total billed charges,Implant Device,191.1,35,,191.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,404.04,
ZIMMER 00-2359-042-45 LCK SCREW 4.5X42MM,C1713,HCPCS,,79004254,CDM,278,RC,,,both,,,445,329.3,,,329.3,Other,150% of Medicare + 9.63% HCRA Surcharge,200.25,45,,200.25,percent of total billed charges,Critical Access Hospital RCC factor,151.3,34,,151.3,percent of total billed charges,Implant Device,151.3,34,,151.3,percent of total billed charges,Implant Device,151.3,34,,151.3,percent of total billed charges,Implant Device,151.3,34,,151.3,percent of total billed charges,Implant Device,151.3,34,,151.3,percent of total billed charges,Implant Device,220.28,,,220.28,Other,110% of Medicare,155.75,35,,155.75,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,155.75,35,,155.75,percent of total billed charges,Implant Device,155.75,35,,155.75,percent of total billed charges,Implant Device,155.75,35,,155.75,percent of total billed charges,Implant Device,155.75,35,,155.75,percent of total billed charges,Implant Device,155.75,35,,155.75,percent of total billed charges,Implant Device,178,40,,178,percent of total billed charges,Implant Device,155.75,70,,155.75,percent of total billed charges,All Other,151.3,34,,151.3,percent of total billed charges,Implant Device,151.3,34,,151.3,percent of total billed charges,Implant Device,155.75,35,,155.75,percent of total billed charges,Implant Device,155.75,35,,155.75,percent of total billed charges,Implant Device,155.75,35,,155.75,percent of total billed charges,Implant Device,155.75,35,,155.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,329.3,
ZIMMER 02-03150-060 CORT SCREW 5.0X60MM,C1713,HCPCS,,79004255,CDM,278,RC,,,both,,,636,470.64,,,470.64,Other,150% of Medicare + 9.63% HCRA Surcharge,286.2,45,,286.2,percent of total billed charges,Critical Access Hospital RCC factor,216.24,34,,216.24,percent of total billed charges,Implant Device,216.24,34,,216.24,percent of total billed charges,Implant Device,216.24,34,,216.24,percent of total billed charges,Implant Device,216.24,34,,216.24,percent of total billed charges,Implant Device,216.24,34,,216.24,percent of total billed charges,Implant Device,314.82,,,314.82,Other,110% of Medicare,222.6,35,,222.6,percent of total billed charges,Implant Device,216.24,34,"Charges > $500, x 34%",216.24,percent of total billed charges,Implant Device,222.6,35,,222.6,percent of total billed charges,Implant Device,222.6,35,,222.6,percent of total billed charges,Implant Device,222.6,35,,222.6,percent of total billed charges,Implant Device,222.6,35,,222.6,percent of total billed charges,Implant Device,222.6,35,,222.6,percent of total billed charges,Implant Device,254.4,40,,254.4,percent of total billed charges,Implant Device,222.6,70,,222.6,percent of total billed charges,All Other,216.24,34,,216.24,percent of total billed charges,Implant Device,216.24,34,,216.24,percent of total billed charges,Implant Device,222.6,35,,222.6,percent of total billed charges,Implant Device,222.6,35,,222.6,percent of total billed charges,Implant Device,222.6,35,,222.6,percent of total billed charges,Implant Device,222.6,35,,222.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,470.64,
ZIMMER 00-4828-018-02 LOCK SCREW 18MM,C1713,HCPCS,,79004256,CDM,278,RC,,,both,,,345,255.3,,,255.3,Other,150% of Medicare + 9.63% HCRA Surcharge,155.25,45,,155.25,percent of total billed charges,Critical Access Hospital RCC factor,117.3,34,,117.3,percent of total billed charges,Implant Device,117.3,34,,117.3,percent of total billed charges,Implant Device,117.3,34,,117.3,percent of total billed charges,Implant Device,117.3,34,,117.3,percent of total billed charges,Implant Device,117.3,34,,117.3,percent of total billed charges,Implant Device,170.78,,,170.78,Other,110% of Medicare,120.75,35,,120.75,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,120.75,35,,120.75,percent of total billed charges,Implant Device,120.75,35,,120.75,percent of total billed charges,Implant Device,120.75,35,,120.75,percent of total billed charges,Implant Device,120.75,35,,120.75,percent of total billed charges,Implant Device,120.75,35,,120.75,percent of total billed charges,Implant Device,138,40,,138,percent of total billed charges,Implant Device,120.75,70,,120.75,percent of total billed charges,All Other,117.3,34,,117.3,percent of total billed charges,Implant Device,117.3,34,,117.3,percent of total billed charges,Implant Device,120.75,35,,120.75,percent of total billed charges,Implant Device,120.75,35,,120.75,percent of total billed charges,Implant Device,120.75,35,,120.75,percent of total billed charges,Implant Device,120.75,35,,120.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,255.3,
ZIMMER 7711-12-20 M/L FEM STEM 12/14,C1713,HCPCS,,79004257,CDM,278,RC,,,both,,,6900,5106.02,,,5106.02,Other,150% of Medicare + 9.63% HCRA Surcharge,3105,45,,3105,percent of total billed charges,Critical Access Hospital RCC factor,2346,34,,2346,percent of total billed charges,Implant Device,2346,34,,2346,percent of total billed charges,Implant Device,2346,34,,2346,percent of total billed charges,Implant Device,2346,34,,2346,percent of total billed charges,Implant Device,2346,34,,2346,percent of total billed charges,Implant Device,3415.5,,,3415.5,Other,110% of Medicare,2415,35,,2415,percent of total billed charges,Implant Device,2346,34,"Charges > $500, x 34%",2346,percent of total billed charges,Implant Device,2415,35,,2415,percent of total billed charges,Implant Device,2415,35,,2415,percent of total billed charges,Implant Device,2415,35,,2415,percent of total billed charges,Implant Device,2415,35,,2415,percent of total billed charges,Implant Device,2415,35,,2415,percent of total billed charges,Implant Device,2760,40,,2760,percent of total billed charges,Implant Device,2415,70,,2415,percent of total billed charges,All Other,2346,34,,2346,percent of total billed charges,Implant Device,2346,34,,2346,percent of total billed charges,Implant Device,2415,35,,2415,percent of total billed charges,Implant Device,2415,35,,2415,percent of total billed charges,Implant Device,2415,35,,2415,percent of total billed charges,Implant Device,2415,35,,2415,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2346,34,"If Charge > 2,000, then 34 percent",2346,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5106.02,
ZIMMER 00-7711-012-00 M/L FEM STEM 12.5,C1713,HCPCS,,79004258,CDM,278,RC,,,both,,,6912,5114.9,,,5114.9,Other,150% of Medicare + 9.63% HCRA Surcharge,3110.4,45,,3110.4,percent of total billed charges,Critical Access Hospital RCC factor,2350.08,34,,2350.08,percent of total billed charges,Implant Device,2350.08,34,,2350.08,percent of total billed charges,Implant Device,2350.08,34,,2350.08,percent of total billed charges,Implant Device,2350.08,34,,2350.08,percent of total billed charges,Implant Device,2350.08,34,,2350.08,percent of total billed charges,Implant Device,3421.44,,,3421.44,Other,110% of Medicare,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2350.08,34,"Charges > $500, x 34%",2350.08,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2764.8,40,,2764.8,percent of total billed charges,Implant Device,2419.2,70,,2419.2,percent of total billed charges,All Other,2350.08,34,,2350.08,percent of total billed charges,Implant Device,2350.08,34,,2350.08,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2350.08,34,"If Charge > 2,000, then 34 percent",2350.08,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5114.9,
ZIMMER 00-4840-010-00 CANC SCREW 4X10MM,C1713,HCPCS,,79004259,CDM,278,RC,,,both,,,54,39.96,,,39.96,Other,150% of Medicare + 9.63% HCRA Surcharge,24.3,45,,24.3,percent of total billed charges,Critical Access Hospital RCC factor,18.36,34,,18.36,percent of total billed charges,Implant Device,18.36,34,,18.36,percent of total billed charges,Implant Device,18.36,34,,18.36,percent of total billed charges,Implant Device,18.36,34,,18.36,percent of total billed charges,Implant Device,18.36,34,,18.36,percent of total billed charges,Implant Device,26.73,,,26.73,Other,110% of Medicare,18.9,35,,18.9,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,18.9,35,,18.9,percent of total billed charges,Implant Device,18.9,35,,18.9,percent of total billed charges,Implant Device,18.9,35,,18.9,percent of total billed charges,Implant Device,18.9,35,,18.9,percent of total billed charges,Implant Device,18.9,35,,18.9,percent of total billed charges,Implant Device,21.6,40,,21.6,percent of total billed charges,Implant Device,18.9,70,,18.9,percent of total billed charges,All Other,18.36,34,,18.36,percent of total billed charges,Implant Device,18.36,34,,18.36,percent of total billed charges,Implant Device,18.9,35,,18.9,percent of total billed charges,Implant Device,18.9,35,,18.9,percent of total billed charges,Implant Device,18.9,35,,18.9,percent of total billed charges,Implant Device,18.9,35,,18.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,39.96,
ZIMMER 2347-20-28 CORTSCREW 3.5X28MM,C1713,HCPCS,,79004260,CDM,278,RC,,,both,,,130,96.2,,,96.2,Other,150% of Medicare + 9.63% HCRA Surcharge,58.5,45,,58.5,percent of total billed charges,Critical Access Hospital RCC factor,44.2,34,,44.2,percent of total billed charges,Implant Device,44.2,34,,44.2,percent of total billed charges,Implant Device,44.2,34,,44.2,percent of total billed charges,Implant Device,44.2,34,,44.2,percent of total billed charges,Implant Device,44.2,34,,44.2,percent of total billed charges,Implant Device,64.35,,,64.35,Other,110% of Medicare,45.5,35,,45.5,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,45.5,35,,45.5,percent of total billed charges,Implant Device,45.5,35,,45.5,percent of total billed charges,Implant Device,45.5,35,,45.5,percent of total billed charges,Implant Device,45.5,35,,45.5,percent of total billed charges,Implant Device,45.5,35,,45.5,percent of total billed charges,Implant Device,52,40,,52,percent of total billed charges,Implant Device,45.5,70,,45.5,percent of total billed charges,All Other,44.2,34,,44.2,percent of total billed charges,Implant Device,44.2,34,,44.2,percent of total billed charges,Implant Device,45.5,35,,45.5,percent of total billed charges,Implant Device,45.5,35,,45.5,percent of total billed charges,Implant Device,45.5,35,,45.5,percent of total billed charges,Implant Device,45.5,35,,45.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,96.2,
ZIMMER 00-4824-014-01 CORT SCREW 14MM ST,C1713,HCPCS,,79004261,CDM,278,RC,,,both,,,65,48.1,,,48.1,Other,150% of Medicare + 9.63% HCRA Surcharge,29.25,45,,29.25,percent of total billed charges,Critical Access Hospital RCC factor,22.1,34,,22.1,percent of total billed charges,Implant Device,22.1,34,,22.1,percent of total billed charges,Implant Device,22.1,34,,22.1,percent of total billed charges,Implant Device,22.1,34,,22.1,percent of total billed charges,Implant Device,22.1,34,,22.1,percent of total billed charges,Implant Device,32.18,,,32.18,Other,110% of Medicare,22.75,35,,22.75,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,22.75,35,,22.75,percent of total billed charges,Implant Device,22.75,35,,22.75,percent of total billed charges,Implant Device,22.75,35,,22.75,percent of total billed charges,Implant Device,22.75,35,,22.75,percent of total billed charges,Implant Device,22.75,35,,22.75,percent of total billed charges,Implant Device,26,40,,26,percent of total billed charges,Implant Device,22.75,70,,22.75,percent of total billed charges,All Other,22.1,34,,22.1,percent of total billed charges,Implant Device,22.1,34,,22.1,percent of total billed charges,Implant Device,22.75,35,,22.75,percent of total billed charges,Implant Device,22.75,35,,22.75,percent of total billed charges,Implant Device,22.75,35,,22.75,percent of total billed charges,Implant Device,22.75,35,,22.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,48.1,
ZIMMER 2480-34-40 CANC SCREW 4X34MM,C1713,HCPCS,,79004262,CDM,278,RC,,,both,,,175,129.5,,,129.5,Other,150% of Medicare + 9.63% HCRA Surcharge,78.75,45,,78.75,percent of total billed charges,Critical Access Hospital RCC factor,59.5,34,,59.5,percent of total billed charges,Implant Device,59.5,34,,59.5,percent of total billed charges,Implant Device,59.5,34,,59.5,percent of total billed charges,Implant Device,59.5,34,,59.5,percent of total billed charges,Implant Device,59.5,34,,59.5,percent of total billed charges,Implant Device,86.63,,,86.63,Other,110% of Medicare,61.25,35,,61.25,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,61.25,35,,61.25,percent of total billed charges,Implant Device,61.25,35,,61.25,percent of total billed charges,Implant Device,61.25,35,,61.25,percent of total billed charges,Implant Device,61.25,35,,61.25,percent of total billed charges,Implant Device,61.25,35,,61.25,percent of total billed charges,Implant Device,70,40,,70,percent of total billed charges,Implant Device,61.25,70,,61.25,percent of total billed charges,All Other,59.5,34,,59.5,percent of total billed charges,Implant Device,59.5,34,,59.5,percent of total billed charges,Implant Device,61.25,35,,61.25,percent of total billed charges,Implant Device,61.25,35,,61.25,percent of total billed charges,Implant Device,61.25,35,,61.25,percent of total billed charges,Implant Device,61.25,35,,61.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,129.5,
ZIMMER 00-2480-22-40 CANC SCREW 4X22MM,C1713,HCPCS,,79004263,CDM,278,RC,,,both,,,175,129.5,,,129.5,Other,150% of Medicare + 9.63% HCRA Surcharge,78.75,45,,78.75,percent of total billed charges,Critical Access Hospital RCC factor,59.5,34,,59.5,percent of total billed charges,Implant Device,59.5,34,,59.5,percent of total billed charges,Implant Device,59.5,34,,59.5,percent of total billed charges,Implant Device,59.5,34,,59.5,percent of total billed charges,Implant Device,59.5,34,,59.5,percent of total billed charges,Implant Device,86.63,,,86.63,Other,110% of Medicare,61.25,35,,61.25,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,61.25,35,,61.25,percent of total billed charges,Implant Device,61.25,35,,61.25,percent of total billed charges,Implant Device,61.25,35,,61.25,percent of total billed charges,Implant Device,61.25,35,,61.25,percent of total billed charges,Implant Device,61.25,35,,61.25,percent of total billed charges,Implant Device,70,40,,70,percent of total billed charges,Implant Device,61.25,70,,61.25,percent of total billed charges,All Other,59.5,34,,59.5,percent of total billed charges,Implant Device,59.5,34,,59.5,percent of total billed charges,Implant Device,61.25,35,,61.25,percent of total billed charges,Implant Device,61.25,35,,61.25,percent of total billed charges,Implant Device,61.25,35,,61.25,percent of total billed charges,Implant Device,61.25,35,,61.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,129.5,
ZIMMER 5990-084-01 FEM AUGMENT BLOCK,C1776,HCPCS,,79004265,CDM,278,RC,,,both,,,3520,2604.81,,,2604.81,Other,150% of Medicare + 9.63% HCRA Surcharge,1584,45,,1584,percent of total billed charges,Critical Access Hospital RCC factor,1196.8,34,,1196.8,percent of total billed charges,Implant Device,1196.8,34,,1196.8,percent of total billed charges,Implant Device,1196.8,34,,1196.8,percent of total billed charges,Implant Device,1196.8,34,,1196.8,percent of total billed charges,Implant Device,1196.8,34,,1196.8,percent of total billed charges,Implant Device,1742.4,,,1742.4,Other,110% of Medicare,1232,35,,1232,percent of total billed charges,Implant Device,1196.8,34,"Charges > $500, x 34%",1196.8,percent of total billed charges,Implant Device,1232,35,,1232,percent of total billed charges,Implant Device,1232,35,,1232,percent of total billed charges,Implant Device,1232,35,,1232,percent of total billed charges,Implant Device,1232,35,,1232,percent of total billed charges,Implant Device,1232,35,,1232,percent of total billed charges,Implant Device,1408,40,,1408,percent of total billed charges,Implant Device,1232,70,,1232,percent of total billed charges,All Other,1196.8,34,,1196.8,percent of total billed charges,Implant Device,1196.8,34,,1196.8,percent of total billed charges,Implant Device,1232,35,,1232,percent of total billed charges,Implant Device,1232,35,,1232,percent of total billed charges,Implant Device,1232,35,,1232,percent of total billed charges,Implant Device,1232,35,,1232,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1196.8,34,"If Charge > 2,000, then 34 percent",1196.8,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2604.81,
ZIMMER 00-2357-018-06 DIST FIB PLATE 6H,C1713,HCPCS,,79004266,CDM,278,RC,,,both,,,2225,1646.51,,,1646.51,Other,150% of Medicare + 9.63% HCRA Surcharge,1001.25,45,,1001.25,percent of total billed charges,Critical Access Hospital RCC factor,756.5,34,,756.5,percent of total billed charges,Implant Device,756.5,34,,756.5,percent of total billed charges,Implant Device,756.5,34,,756.5,percent of total billed charges,Implant Device,756.5,34,,756.5,percent of total billed charges,Implant Device,756.5,34,,756.5,percent of total billed charges,Implant Device,1101.38,,,1101.38,Other,110% of Medicare,778.75,35,,778.75,percent of total billed charges,Implant Device,756.5,34,"Charges > $500, x 34%",756.5,percent of total billed charges,Implant Device,778.75,35,,778.75,percent of total billed charges,Implant Device,778.75,35,,778.75,percent of total billed charges,Implant Device,778.75,35,,778.75,percent of total billed charges,Implant Device,778.75,35,,778.75,percent of total billed charges,Implant Device,778.75,35,,778.75,percent of total billed charges,Implant Device,890,40,,890,percent of total billed charges,Implant Device,778.75,70,,778.75,percent of total billed charges,All Other,756.5,34,,756.5,percent of total billed charges,Implant Device,756.5,34,,756.5,percent of total billed charges,Implant Device,778.75,35,,778.75,percent of total billed charges,Implant Device,778.75,35,,778.75,percent of total billed charges,Implant Device,778.75,35,,778.75,percent of total billed charges,Implant Device,778.75,35,,778.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,756.5,34,"If Charge > 2,000, then 34 percent",756.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1646.51,
ZIMMER 7818-53 ENDO FEM HEAD 12/14 TAPER,C1776,HCPCS,,79004267,CDM,278,RC,,,both,,,1886,1395.64,,,1395.64,Other,150% of Medicare + 9.63% HCRA Surcharge,848.7,45,,848.7,percent of total billed charges,Critical Access Hospital RCC factor,641.24,34,,641.24,percent of total billed charges,Implant Device,641.24,34,,641.24,percent of total billed charges,Implant Device,641.24,34,,641.24,percent of total billed charges,Implant Device,641.24,34,,641.24,percent of total billed charges,Implant Device,641.24,34,,641.24,percent of total billed charges,Implant Device,933.57,,,933.57,Other,110% of Medicare,660.1,35,,660.1,percent of total billed charges,Implant Device,641.24,34,"Charges > $500, x 34%",641.24,percent of total billed charges,Implant Device,660.1,35,,660.1,percent of total billed charges,Implant Device,660.1,35,,660.1,percent of total billed charges,Implant Device,660.1,35,,660.1,percent of total billed charges,Implant Device,660.1,35,,660.1,percent of total billed charges,Implant Device,660.1,35,,660.1,percent of total billed charges,Implant Device,754.4,40,,754.4,percent of total billed charges,Implant Device,660.1,70,,660.1,percent of total billed charges,All Other,641.24,34,,641.24,percent of total billed charges,Implant Device,641.24,34,,641.24,percent of total billed charges,Implant Device,660.1,35,,660.1,percent of total billed charges,Implant Device,660.1,35,,660.1,percent of total billed charges,Implant Device,660.1,35,,660.1,percent of total billed charges,Implant Device,660.1,35,,660.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1395.64,
ZIMMER 2359-55-56 CANN SCREW 5.5X55MM,C1713,HCPCS,,79004268,CDM,278,RC,,,both,,,560,414.4,,,414.4,Other,150% of Medicare + 9.63% HCRA Surcharge,252,45,,252,percent of total billed charges,Critical Access Hospital RCC factor,190.4,34,,190.4,percent of total billed charges,Implant Device,190.4,34,,190.4,percent of total billed charges,Implant Device,190.4,34,,190.4,percent of total billed charges,Implant Device,190.4,34,,190.4,percent of total billed charges,Implant Device,190.4,34,,190.4,percent of total billed charges,Implant Device,277.2,,,277.2,Other,110% of Medicare,196,35,,196,percent of total billed charges,Implant Device,190.4,34,"Charges > $500, x 34%",190.4,percent of total billed charges,Implant Device,196,35,,196,percent of total billed charges,Implant Device,196,35,,196,percent of total billed charges,Implant Device,196,35,,196,percent of total billed charges,Implant Device,196,35,,196,percent of total billed charges,Implant Device,196,35,,196,percent of total billed charges,Implant Device,224,40,,224,percent of total billed charges,Implant Device,196,70,,196,percent of total billed charges,All Other,190.4,34,,190.4,percent of total billed charges,Implant Device,190.4,34,,190.4,percent of total billed charges,Implant Device,196,35,,196,percent of total billed charges,Implant Device,196,35,,196,percent of total billed charges,Implant Device,196,35,,196,percent of total billed charges,Implant Device,196,35,,196,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,414.4,
ZIMMER 5001-57-28 BIPOLAR CUP LINER 28MM,C1776,HCPCS,,79004269,CDM,278,RC,,,both,,,1297,959.78,,,959.78,Other,150% of Medicare + 9.63% HCRA Surcharge,583.65,45,,583.65,percent of total billed charges,Critical Access Hospital RCC factor,440.98,34,,440.98,percent of total billed charges,Implant Device,440.98,34,,440.98,percent of total billed charges,Implant Device,440.98,34,,440.98,percent of total billed charges,Implant Device,440.98,34,,440.98,percent of total billed charges,Implant Device,440.98,34,,440.98,percent of total billed charges,Implant Device,642.02,,,642.02,Other,110% of Medicare,453.95,35,,453.95,percent of total billed charges,Implant Device,440.98,34,"Charges > $500, x 34%",440.98,percent of total billed charges,Implant Device,453.95,35,,453.95,percent of total billed charges,Implant Device,453.95,35,,453.95,percent of total billed charges,Implant Device,453.95,35,,453.95,percent of total billed charges,Implant Device,453.95,35,,453.95,percent of total billed charges,Implant Device,453.95,35,,453.95,percent of total billed charges,Implant Device,518.8,40,,518.8,percent of total billed charges,Implant Device,453.95,70,,453.95,percent of total billed charges,All Other,440.98,34,,440.98,percent of total billed charges,Implant Device,440.98,34,,440.98,percent of total billed charges,Implant Device,453.95,35,,453.95,percent of total billed charges,Implant Device,453.95,35,,453.95,percent of total billed charges,Implant Device,453.95,35,,453.95,percent of total billed charges,Implant Device,453.95,35,,453.95,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,959.78,
ZIMMER 2359-36-45 LOCK SCREW 4.5X36MM,C1713,HCPCS,,79004270,CDM,278,RC,,,both,,,430,318.2,,,318.2,Other,150% of Medicare + 9.63% HCRA Surcharge,193.5,45,,193.5,percent of total billed charges,Critical Access Hospital RCC factor,146.2,34,,146.2,percent of total billed charges,Implant Device,146.2,34,,146.2,percent of total billed charges,Implant Device,146.2,34,,146.2,percent of total billed charges,Implant Device,146.2,34,,146.2,percent of total billed charges,Implant Device,146.2,34,,146.2,percent of total billed charges,Implant Device,212.85,,,212.85,Other,110% of Medicare,150.5,35,,150.5,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,150.5,35,,150.5,percent of total billed charges,Implant Device,150.5,35,,150.5,percent of total billed charges,Implant Device,150.5,35,,150.5,percent of total billed charges,Implant Device,150.5,35,,150.5,percent of total billed charges,Implant Device,150.5,35,,150.5,percent of total billed charges,Implant Device,172,40,,172,percent of total billed charges,Implant Device,150.5,70,,150.5,percent of total billed charges,All Other,146.2,34,,146.2,percent of total billed charges,Implant Device,146.2,34,,146.2,percent of total billed charges,Implant Device,150.5,35,,150.5,percent of total billed charges,Implant Device,150.5,35,,150.5,percent of total billed charges,Implant Device,150.5,35,,150.5,percent of total billed charges,Implant Device,150.5,35,,150.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,318.2,
ZIMMER 2348-014-35 ST SCREW 23.5X14MM,C1713,HCPCS,,79004271,CDM,278,RC,,,both,,,113,83.62,,,83.62,Other,150% of Medicare + 9.63% HCRA Surcharge,50.85,45,,50.85,percent of total billed charges,Critical Access Hospital RCC factor,38.42,34,,38.42,percent of total billed charges,Implant Device,38.42,34,,38.42,percent of total billed charges,Implant Device,38.42,34,,38.42,percent of total billed charges,Implant Device,38.42,34,,38.42,percent of total billed charges,Implant Device,38.42,34,,38.42,percent of total billed charges,Implant Device,55.94,,,55.94,Other,110% of Medicare,39.55,35,,39.55,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,39.55,35,,39.55,percent of total billed charges,Implant Device,39.55,35,,39.55,percent of total billed charges,Implant Device,39.55,35,,39.55,percent of total billed charges,Implant Device,39.55,35,,39.55,percent of total billed charges,Implant Device,39.55,35,,39.55,percent of total billed charges,Implant Device,45.2,40,,45.2,percent of total billed charges,Implant Device,39.55,70,,39.55,percent of total billed charges,All Other,38.42,34,,38.42,percent of total billed charges,Implant Device,38.42,34,,38.42,percent of total billed charges,Implant Device,39.55,35,,39.55,percent of total billed charges,Implant Device,39.55,35,,39.55,percent of total billed charges,Implant Device,39.55,35,,39.55,percent of total billed charges,Implant Device,39.55,35,,39.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,83.62,
ZIMMER 00-1147-096-00 WASHER CANN SCREWS,C1713,HCPCS,,79004272,CDM,278,RC,,,both,,,108,79.92,,,79.92,Other,150% of Medicare + 9.63% HCRA Surcharge,48.6,45,,48.6,percent of total billed charges,Critical Access Hospital RCC factor,36.72,34,,36.72,percent of total billed charges,Implant Device,36.72,34,,36.72,percent of total billed charges,Implant Device,36.72,34,,36.72,percent of total billed charges,Implant Device,36.72,34,,36.72,percent of total billed charges,Implant Device,36.72,34,,36.72,percent of total billed charges,Implant Device,53.46,,,53.46,Other,110% of Medicare,37.8,35,,37.8,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,37.8,35,,37.8,percent of total billed charges,Implant Device,37.8,35,,37.8,percent of total billed charges,Implant Device,37.8,35,,37.8,percent of total billed charges,Implant Device,37.8,35,,37.8,percent of total billed charges,Implant Device,37.8,35,,37.8,percent of total billed charges,Implant Device,43.2,40,,43.2,percent of total billed charges,Implant Device,37.8,70,,37.8,percent of total billed charges,All Other,36.72,34,,36.72,percent of total billed charges,Implant Device,36.72,34,,36.72,percent of total billed charges,Implant Device,37.8,35,,37.8,percent of total billed charges,Implant Device,37.8,35,,37.8,percent of total billed charges,Implant Device,37.8,35,,37.8,percent of total billed charges,Implant Device,37.8,35,,37.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,79.92,
ZIMMER 4936-007-03 7 HOLE PLATE 1/3 TUB,C1713,HCPCS,,79004273,CDM,278,RC,,,both,,,470,347.8,,,347.8,Other,150% of Medicare + 9.63% HCRA Surcharge,211.5,45,,211.5,percent of total billed charges,Critical Access Hospital RCC factor,159.8,34,,159.8,percent of total billed charges,Implant Device,159.8,34,,159.8,percent of total billed charges,Implant Device,159.8,34,,159.8,percent of total billed charges,Implant Device,159.8,34,,159.8,percent of total billed charges,Implant Device,159.8,34,,159.8,percent of total billed charges,Implant Device,232.65,,,232.65,Other,110% of Medicare,164.5,35,,164.5,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,164.5,35,,164.5,percent of total billed charges,Implant Device,164.5,35,,164.5,percent of total billed charges,Implant Device,164.5,35,,164.5,percent of total billed charges,Implant Device,164.5,35,,164.5,percent of total billed charges,Implant Device,164.5,35,,164.5,percent of total billed charges,Implant Device,188,40,,188,percent of total billed charges,Implant Device,164.5,70,,164.5,percent of total billed charges,All Other,159.8,34,,159.8,percent of total billed charges,Implant Device,159.8,34,,159.8,percent of total billed charges,Implant Device,164.5,35,,164.5,percent of total billed charges,Implant Device,164.5,35,,164.5,percent of total billed charges,Implant Device,164.5,35,,164.5,percent of total billed charges,Implant Device,164.5,35,,164.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,347.8,
ZIMMER 6250-65-50 ST BONE SCREW 6.5X50MM,C1713,HCPCS,,79004274,CDM,278,RC,,,both,,,105,77.7,,,77.7,Other,150% of Medicare + 9.63% HCRA Surcharge,47.25,45,,47.25,percent of total billed charges,Critical Access Hospital RCC factor,35.7,34,,35.7,percent of total billed charges,Implant Device,35.7,34,,35.7,percent of total billed charges,Implant Device,35.7,34,,35.7,percent of total billed charges,Implant Device,35.7,34,,35.7,percent of total billed charges,Implant Device,35.7,34,,35.7,percent of total billed charges,Implant Device,51.98,,,51.98,Other,110% of Medicare,36.75,35,,36.75,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,36.75,35,,36.75,percent of total billed charges,Implant Device,36.75,35,,36.75,percent of total billed charges,Implant Device,36.75,35,,36.75,percent of total billed charges,Implant Device,36.75,35,,36.75,percent of total billed charges,Implant Device,36.75,35,,36.75,percent of total billed charges,Implant Device,42,40,,42,percent of total billed charges,Implant Device,36.75,70,,36.75,percent of total billed charges,All Other,35.7,34,,35.7,percent of total billed charges,Implant Device,35.7,34,,35.7,percent of total billed charges,Implant Device,36.75,35,,36.75,percent of total billed charges,Implant Device,36.75,35,,36.75,percent of total billed charges,Implant Device,36.75,35,,36.75,percent of total billed charges,Implant Device,36.75,35,,36.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,77.7,
ZIMMER 00-2359-016-35 SCREW 3.5X16MM,C1713,HCPCS,,79004275,CDM,278,RC,,,both,,,310,229.4,,,229.4,Other,150% of Medicare + 9.63% HCRA Surcharge,139.5,45,,139.5,percent of total billed charges,Critical Access Hospital RCC factor,105.4,34,,105.4,percent of total billed charges,Implant Device,105.4,34,,105.4,percent of total billed charges,Implant Device,105.4,34,,105.4,percent of total billed charges,Implant Device,105.4,34,,105.4,percent of total billed charges,Implant Device,105.4,34,,105.4,percent of total billed charges,Implant Device,153.45,,,153.45,Other,110% of Medicare,108.5,35,,108.5,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,108.5,35,,108.5,percent of total billed charges,Implant Device,108.5,35,,108.5,percent of total billed charges,Implant Device,108.5,35,,108.5,percent of total billed charges,Implant Device,108.5,35,,108.5,percent of total billed charges,Implant Device,108.5,35,,108.5,percent of total billed charges,Implant Device,124,40,,124,percent of total billed charges,Implant Device,108.5,70,,108.5,percent of total billed charges,All Other,105.4,34,,105.4,percent of total billed charges,Implant Device,105.4,34,,105.4,percent of total billed charges,Implant Device,108.5,35,,108.5,percent of total billed charges,Implant Device,108.5,35,,108.5,percent of total billed charges,Implant Device,108.5,35,,108.5,percent of total billed charges,Implant Device,108.5,35,,108.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,229.4,
ZIMMER 00-1147-20-41 CANN SCREW 4.0 20MM,C1713,HCPCS,,79004276,CDM,278,RC,,,both,,,558,412.92,,,412.92,Other,150% of Medicare + 9.63% HCRA Surcharge,251.1,45,,251.1,percent of total billed charges,Critical Access Hospital RCC factor,189.72,34,,189.72,percent of total billed charges,Implant Device,189.72,34,,189.72,percent of total billed charges,Implant Device,189.72,34,,189.72,percent of total billed charges,Implant Device,189.72,34,,189.72,percent of total billed charges,Implant Device,189.72,34,,189.72,percent of total billed charges,Implant Device,276.21,,,276.21,Other,110% of Medicare,195.3,35,,195.3,percent of total billed charges,Implant Device,189.72,34,"Charges > $500, x 34%",189.72,percent of total billed charges,Implant Device,195.3,35,,195.3,percent of total billed charges,Implant Device,195.3,35,,195.3,percent of total billed charges,Implant Device,195.3,35,,195.3,percent of total billed charges,Implant Device,195.3,35,,195.3,percent of total billed charges,Implant Device,195.3,35,,195.3,percent of total billed charges,Implant Device,223.2,40,,223.2,percent of total billed charges,Implant Device,195.3,70,,195.3,percent of total billed charges,All Other,189.72,34,,189.72,percent of total billed charges,Implant Device,189.72,34,,189.72,percent of total billed charges,Implant Device,195.3,35,,195.3,percent of total billed charges,Implant Device,195.3,35,,195.3,percent of total billed charges,Implant Device,195.3,35,,195.3,percent of total billed charges,Implant Device,195.3,35,,195.3,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,412.92,
ZIMMER 00-1147-018-40 CANN SCREW 4X18MM,C1713,HCPCS,,79004277,CDM,278,RC,,,both,,,560,414.4,,,414.4,Other,150% of Medicare + 9.63% HCRA Surcharge,252,45,,252,percent of total billed charges,Critical Access Hospital RCC factor,190.4,34,,190.4,percent of total billed charges,Implant Device,190.4,34,,190.4,percent of total billed charges,Implant Device,190.4,34,,190.4,percent of total billed charges,Implant Device,190.4,34,,190.4,percent of total billed charges,Implant Device,190.4,34,,190.4,percent of total billed charges,Implant Device,277.2,,,277.2,Other,110% of Medicare,196,35,,196,percent of total billed charges,Implant Device,190.4,34,"Charges > $500, x 34%",190.4,percent of total billed charges,Implant Device,196,35,,196,percent of total billed charges,Implant Device,196,35,,196,percent of total billed charges,Implant Device,196,35,,196,percent of total billed charges,Implant Device,196,35,,196,percent of total billed charges,Implant Device,196,35,,196,percent of total billed charges,Implant Device,224,40,,224,percent of total billed charges,Implant Device,196,70,,196,percent of total billed charges,All Other,190.4,34,,190.4,percent of total billed charges,Implant Device,190.4,34,,190.4,percent of total billed charges,Implant Device,196,35,,196,percent of total billed charges,Implant Device,196,35,,196,percent of total billed charges,Implant Device,196,35,,196,percent of total billed charges,Implant Device,196,35,,196,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,414.4,
ZIMMER 00-7818-044-00 UNI FEM HEAD 44MM,C1776,HCPCS,,79004278,CDM,278,RC,,,both,,,1886,1395.64,,,1395.64,Other,150% of Medicare + 9.63% HCRA Surcharge,848.7,45,,848.7,percent of total billed charges,Critical Access Hospital RCC factor,641.24,34,,641.24,percent of total billed charges,Implant Device,641.24,34,,641.24,percent of total billed charges,Implant Device,641.24,34,,641.24,percent of total billed charges,Implant Device,641.24,34,,641.24,percent of total billed charges,Implant Device,641.24,34,,641.24,percent of total billed charges,Implant Device,933.57,,,933.57,Other,110% of Medicare,660.1,35,,660.1,percent of total billed charges,Implant Device,641.24,34,"Charges > $500, x 34%",641.24,percent of total billed charges,Implant Device,660.1,35,,660.1,percent of total billed charges,Implant Device,660.1,35,,660.1,percent of total billed charges,Implant Device,660.1,35,,660.1,percent of total billed charges,Implant Device,660.1,35,,660.1,percent of total billed charges,Implant Device,660.1,35,,660.1,percent of total billed charges,Implant Device,754.4,40,,754.4,percent of total billed charges,Implant Device,660.1,70,,660.1,percent of total billed charges,All Other,641.24,34,,641.24,percent of total billed charges,Implant Device,641.24,34,,641.24,percent of total billed charges,Implant Device,660.1,35,,660.1,percent of total billed charges,Implant Device,660.1,35,,660.1,percent of total billed charges,Implant Device,660.1,35,,660.1,percent of total billed charges,Implant Device,660.1,35,,660.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1395.64,
ZIMMER 4840-022 CANC SCREW SM HEX 4X22MM,C1713,HCPCS,,79004279,CDM,278,RC,,,both,,,84,62.16,,,62.16,Other,150% of Medicare + 9.63% HCRA Surcharge,37.8,45,,37.8,percent of total billed charges,Critical Access Hospital RCC factor,28.56,34,,28.56,percent of total billed charges,Implant Device,28.56,34,,28.56,percent of total billed charges,Implant Device,28.56,34,,28.56,percent of total billed charges,Implant Device,28.56,34,,28.56,percent of total billed charges,Implant Device,28.56,34,,28.56,percent of total billed charges,Implant Device,41.58,,,41.58,Other,110% of Medicare,29.4,35,,29.4,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,29.4,35,,29.4,percent of total billed charges,Implant Device,29.4,35,,29.4,percent of total billed charges,Implant Device,29.4,35,,29.4,percent of total billed charges,Implant Device,29.4,35,,29.4,percent of total billed charges,Implant Device,29.4,35,,29.4,percent of total billed charges,Implant Device,33.6,40,,33.6,percent of total billed charges,Implant Device,29.4,70,,29.4,percent of total billed charges,All Other,28.56,34,,28.56,percent of total billed charges,Implant Device,28.56,34,,28.56,percent of total billed charges,Implant Device,29.4,35,,29.4,percent of total billed charges,Implant Device,29.4,35,,29.4,percent of total billed charges,Implant Device,29.4,35,,29.4,percent of total billed charges,Implant Device,29.4,35,,29.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,62.16,
ZIMMER 2359-34-45 LOCK SCREW 4.5X34MM,C1713,HCPCS,,79004280,CDM,278,RC,,,both,,,430,318.2,,,318.2,Other,150% of Medicare + 9.63% HCRA Surcharge,193.5,45,,193.5,percent of total billed charges,Critical Access Hospital RCC factor,146.2,34,,146.2,percent of total billed charges,Implant Device,146.2,34,,146.2,percent of total billed charges,Implant Device,146.2,34,,146.2,percent of total billed charges,Implant Device,146.2,34,,146.2,percent of total billed charges,Implant Device,146.2,34,,146.2,percent of total billed charges,Implant Device,212.85,,,212.85,Other,110% of Medicare,150.5,35,,150.5,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,150.5,35,,150.5,percent of total billed charges,Implant Device,150.5,35,,150.5,percent of total billed charges,Implant Device,150.5,35,,150.5,percent of total billed charges,Implant Device,150.5,35,,150.5,percent of total billed charges,Implant Device,150.5,35,,150.5,percent of total billed charges,Implant Device,172,40,,172,percent of total billed charges,Implant Device,150.5,70,,150.5,percent of total billed charges,All Other,146.2,34,,146.2,percent of total billed charges,Implant Device,146.2,34,,146.2,percent of total billed charges,Implant Device,150.5,35,,150.5,percent of total billed charges,Implant Device,150.5,35,,150.5,percent of total billed charges,Implant Device,150.5,35,,150.5,percent of total billed charges,Implant Device,150.5,35,,150.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,318.2,
ZIMMER 02-03150-055 CORT SCREW 5.0X55MM,C1713,HCPCS,,79004281,CDM,278,RC,,,both,,,498,368.52,,,368.52,Other,150% of Medicare + 9.63% HCRA Surcharge,224.1,45,,224.1,percent of total billed charges,Critical Access Hospital RCC factor,169.32,34,,169.32,percent of total billed charges,Implant Device,169.32,34,,169.32,percent of total billed charges,Implant Device,169.32,34,,169.32,percent of total billed charges,Implant Device,169.32,34,,169.32,percent of total billed charges,Implant Device,169.32,34,,169.32,percent of total billed charges,Implant Device,246.51,,,246.51,Other,110% of Medicare,174.3,35,,174.3,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,174.3,35,,174.3,percent of total billed charges,Implant Device,174.3,35,,174.3,percent of total billed charges,Implant Device,174.3,35,,174.3,percent of total billed charges,Implant Device,174.3,35,,174.3,percent of total billed charges,Implant Device,174.3,35,,174.3,percent of total billed charges,Implant Device,199.2,40,,199.2,percent of total billed charges,Implant Device,174.3,70,,174.3,percent of total billed charges,All Other,169.32,34,,169.32,percent of total billed charges,Implant Device,169.32,34,,169.32,percent of total billed charges,Implant Device,174.3,35,,174.3,percent of total billed charges,Implant Device,174.3,35,,174.3,percent of total billed charges,Implant Device,174.3,35,,174.3,percent of total billed charges,Implant Device,174.3,35,,174.3,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,368.52,
ZIMMER 00-2359-055-45 LCK SCREW 4.5X55MM,C1713,HCPCS,,79004283,CDM,278,RC,,,both,,,386,285.64,,,285.64,Other,150% of Medicare + 9.63% HCRA Surcharge,173.7,45,,173.7,percent of total billed charges,Critical Access Hospital RCC factor,131.24,34,,131.24,percent of total billed charges,Implant Device,131.24,34,,131.24,percent of total billed charges,Implant Device,131.24,34,,131.24,percent of total billed charges,Implant Device,131.24,34,,131.24,percent of total billed charges,Implant Device,131.24,34,,131.24,percent of total billed charges,Implant Device,191.07,,,191.07,Other,110% of Medicare,135.1,35,,135.1,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,135.1,35,,135.1,percent of total billed charges,Implant Device,135.1,35,,135.1,percent of total billed charges,Implant Device,135.1,35,,135.1,percent of total billed charges,Implant Device,135.1,35,,135.1,percent of total billed charges,Implant Device,135.1,35,,135.1,percent of total billed charges,Implant Device,154.4,40,,154.4,percent of total billed charges,Implant Device,135.1,70,,135.1,percent of total billed charges,All Other,131.24,34,,131.24,percent of total billed charges,Implant Device,131.24,34,,131.24,percent of total billed charges,Implant Device,135.1,35,,135.1,percent of total billed charges,Implant Device,135.1,35,,135.1,percent of total billed charges,Implant Device,135.1,35,,135.1,percent of total billed charges,Implant Device,135.1,35,,135.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,285.64,
ZIMMER 02-03150-075 CORT SCREW 5X75MM,C1713,HCPCS,,79004284,CDM,278,RC,,,both,,,498,368.52,,,368.52,Other,150% of Medicare + 9.63% HCRA Surcharge,224.1,45,,224.1,percent of total billed charges,Critical Access Hospital RCC factor,169.32,34,,169.32,percent of total billed charges,Implant Device,169.32,34,,169.32,percent of total billed charges,Implant Device,169.32,34,,169.32,percent of total billed charges,Implant Device,169.32,34,,169.32,percent of total billed charges,Implant Device,169.32,34,,169.32,percent of total billed charges,Implant Device,246.51,,,246.51,Other,110% of Medicare,174.3,35,,174.3,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,174.3,35,,174.3,percent of total billed charges,Implant Device,174.3,35,,174.3,percent of total billed charges,Implant Device,174.3,35,,174.3,percent of total billed charges,Implant Device,174.3,35,,174.3,percent of total billed charges,Implant Device,174.3,35,,174.3,percent of total billed charges,Implant Device,199.2,40,,199.2,percent of total billed charges,Implant Device,174.3,70,,174.3,percent of total billed charges,All Other,169.32,34,,169.32,percent of total billed charges,Implant Device,169.32,34,,169.32,percent of total billed charges,Implant Device,174.3,35,,174.3,percent of total billed charges,Implant Device,174.3,35,,174.3,percent of total billed charges,Implant Device,174.3,35,,174.3,percent of total billed charges,Implant Device,174.3,35,,174.3,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,368.52,
ZIMMER 2347-20-30 CORT SCREW 3.5X30MM,C1713,HCPCS,,79004285,CDM,278,RC,,,both,,,100,74,,,74,Other,150% of Medicare + 9.63% HCRA Surcharge,45,45,,45,percent of total billed charges,Critical Access Hospital RCC factor,34,34,,34,percent of total billed charges,Implant Device,34,34,,34,percent of total billed charges,Implant Device,34,34,,34,percent of total billed charges,Implant Device,34,34,,34,percent of total billed charges,Implant Device,34,34,,34,percent of total billed charges,Implant Device,49.5,,,49.5,Other,110% of Medicare,35,35,,35,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,35,35,,35,percent of total billed charges,Implant Device,35,35,,35,percent of total billed charges,Implant Device,35,35,,35,percent of total billed charges,Implant Device,35,35,,35,percent of total billed charges,Implant Device,35,35,,35,percent of total billed charges,Implant Device,40,40,,40,percent of total billed charges,Implant Device,35,70,,35,percent of total billed charges,All Other,34,34,,34,percent of total billed charges,Implant Device,34,34,,34,percent of total billed charges,Implant Device,35,35,,35,percent of total billed charges,Implant Device,35,35,,35,percent of total billed charges,Implant Device,35,35,,35,percent of total billed charges,Implant Device,35,35,,35,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,74,
ZIMMER 02-03510-034 CORT SCREW 5.0 X 34M,C1713,HCPCS,,79004286,CDM,278,RC,,,both,,,498,368.52,,,368.52,Other,150% of Medicare + 9.63% HCRA Surcharge,224.1,45,,224.1,percent of total billed charges,Critical Access Hospital RCC factor,169.32,34,,169.32,percent of total billed charges,Implant Device,169.32,34,,169.32,percent of total billed charges,Implant Device,169.32,34,,169.32,percent of total billed charges,Implant Device,169.32,34,,169.32,percent of total billed charges,Implant Device,169.32,34,,169.32,percent of total billed charges,Implant Device,246.51,,,246.51,Other,110% of Medicare,174.3,35,,174.3,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,174.3,35,,174.3,percent of total billed charges,Implant Device,174.3,35,,174.3,percent of total billed charges,Implant Device,174.3,35,,174.3,percent of total billed charges,Implant Device,174.3,35,,174.3,percent of total billed charges,Implant Device,174.3,35,,174.3,percent of total billed charges,Implant Device,199.2,40,,199.2,percent of total billed charges,Implant Device,174.3,70,,174.3,percent of total billed charges,All Other,169.32,34,,169.32,percent of total billed charges,Implant Device,169.32,34,,169.32,percent of total billed charges,Implant Device,174.3,35,,174.3,percent of total billed charges,Implant Device,174.3,35,,174.3,percent of total billed charges,Implant Device,174.3,35,,174.3,percent of total billed charges,Implant Device,174.3,35,,174.3,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,368.52,
ZIMMER 2480-26-40 CANC SCREW 4.0X26,C1713,HCPCS,,79004290,CDM,278,RC,,,both,,,175,129.5,,,129.5,Other,150% of Medicare + 9.63% HCRA Surcharge,78.75,45,,78.75,percent of total billed charges,Critical Access Hospital RCC factor,59.5,34,,59.5,percent of total billed charges,Implant Device,59.5,34,,59.5,percent of total billed charges,Implant Device,59.5,34,,59.5,percent of total billed charges,Implant Device,59.5,34,,59.5,percent of total billed charges,Implant Device,59.5,34,,59.5,percent of total billed charges,Implant Device,86.63,,,86.63,Other,110% of Medicare,61.25,35,,61.25,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,61.25,35,,61.25,percent of total billed charges,Implant Device,61.25,35,,61.25,percent of total billed charges,Implant Device,61.25,35,,61.25,percent of total billed charges,Implant Device,61.25,35,,61.25,percent of total billed charges,Implant Device,61.25,35,,61.25,percent of total billed charges,Implant Device,70,40,,70,percent of total billed charges,Implant Device,61.25,70,,61.25,percent of total billed charges,All Other,59.5,34,,59.5,percent of total billed charges,Implant Device,59.5,34,,59.5,percent of total billed charges,Implant Device,61.25,35,,61.25,percent of total billed charges,Implant Device,61.25,35,,61.25,percent of total billed charges,Implant Device,61.25,35,,61.25,percent of total billed charges,Implant Device,61.25,35,,61.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,129.5,
ZIMMER 00-4928-007-03 TUBE PLATE 7H 82MM,C1713,HCPCS,,79004292,CDM,278,RC,,,both,,,454,335.96,,,335.96,Other,150% of Medicare + 9.63% HCRA Surcharge,204.3,45,,204.3,percent of total billed charges,Critical Access Hospital RCC factor,154.36,34,,154.36,percent of total billed charges,Implant Device,154.36,34,,154.36,percent of total billed charges,Implant Device,154.36,34,,154.36,percent of total billed charges,Implant Device,154.36,34,,154.36,percent of total billed charges,Implant Device,154.36,34,,154.36,percent of total billed charges,Implant Device,224.73,,,224.73,Other,110% of Medicare,158.9,35,,158.9,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,158.9,35,,158.9,percent of total billed charges,Implant Device,158.9,35,,158.9,percent of total billed charges,Implant Device,158.9,35,,158.9,percent of total billed charges,Implant Device,158.9,35,,158.9,percent of total billed charges,Implant Device,158.9,35,,158.9,percent of total billed charges,Implant Device,181.6,40,,181.6,percent of total billed charges,Implant Device,158.9,70,,158.9,percent of total billed charges,All Other,154.36,34,,154.36,percent of total billed charges,Implant Device,154.36,34,,154.36,percent of total billed charges,Implant Device,158.9,35,,158.9,percent of total billed charges,Implant Device,158.9,35,,158.9,percent of total billed charges,Implant Device,158.9,35,,158.9,percent of total billed charges,Implant Device,158.9,35,,158.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,335.96,
ZIMMER 7818-52 FEM HEAD 12/14 TAPER 52MM,C1776,HCPCS,,79004293,CDM,278,RC,,,both,,,1500,1110,,,1110,Other,150% of Medicare + 9.63% HCRA Surcharge,675,45,,675,percent of total billed charges,Critical Access Hospital RCC factor,510,34,,510,percent of total billed charges,Implant Device,510,34,,510,percent of total billed charges,Implant Device,510,34,,510,percent of total billed charges,Implant Device,510,34,,510,percent of total billed charges,Implant Device,510,34,,510,percent of total billed charges,Implant Device,742.5,,,742.5,Other,110% of Medicare,525,35,,525,percent of total billed charges,Implant Device,510,34,"Charges > $500, x 34%",510,percent of total billed charges,Implant Device,525,35,,525,percent of total billed charges,Implant Device,525,35,,525,percent of total billed charges,Implant Device,525,35,,525,percent of total billed charges,Implant Device,525,35,,525,percent of total billed charges,Implant Device,525,35,,525,percent of total billed charges,Implant Device,600,40,,600,percent of total billed charges,Implant Device,525,70,,525,percent of total billed charges,All Other,510,34,,510,percent of total billed charges,Implant Device,510,34,,510,percent of total billed charges,Implant Device,525,35,,525,percent of total billed charges,Implant Device,525,35,,525,percent of total billed charges,Implant Device,525,35,,525,percent of total billed charges,Implant Device,525,35,,525,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1110,
ZIMMER 2347-23-26 4.5X26MM PERIART SCREW,C1713,HCPCS,,79004294,CDM,278,RC,,,both,,,97,71.78,,,71.78,Other,150% of Medicare + 9.63% HCRA Surcharge,43.65,45,,43.65,percent of total billed charges,Critical Access Hospital RCC factor,32.98,34,,32.98,percent of total billed charges,Implant Device,32.98,34,,32.98,percent of total billed charges,Implant Device,32.98,34,,32.98,percent of total billed charges,Implant Device,32.98,34,,32.98,percent of total billed charges,Implant Device,32.98,34,,32.98,percent of total billed charges,Implant Device,48.02,,,48.02,Other,110% of Medicare,33.95,35,,33.95,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,33.95,35,,33.95,percent of total billed charges,Implant Device,33.95,35,,33.95,percent of total billed charges,Implant Device,33.95,35,,33.95,percent of total billed charges,Implant Device,33.95,35,,33.95,percent of total billed charges,Implant Device,33.95,35,,33.95,percent of total billed charges,Implant Device,38.8,40,,38.8,percent of total billed charges,Implant Device,33.95,70,,33.95,percent of total billed charges,All Other,32.98,34,,32.98,percent of total billed charges,Implant Device,32.98,34,,32.98,percent of total billed charges,Implant Device,33.95,35,,33.95,percent of total billed charges,Implant Device,33.95,35,,33.95,percent of total billed charges,Implant Device,33.95,35,,33.95,percent of total billed charges,Implant Device,33.95,35,,33.95,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,71.78,
ZIMMER 5001-47 BIPOLAR CUP SHELL 47MM,C1776,HCPCS,,79004295,CDM,278,RC,,,both,,,960,710.4,,,710.4,Other,150% of Medicare + 9.63% HCRA Surcharge,432,45,,432,percent of total billed charges,Critical Access Hospital RCC factor,326.4,34,,326.4,percent of total billed charges,Implant Device,326.4,34,,326.4,percent of total billed charges,Implant Device,326.4,34,,326.4,percent of total billed charges,Implant Device,326.4,34,,326.4,percent of total billed charges,Implant Device,326.4,34,,326.4,percent of total billed charges,Implant Device,475.2,,,475.2,Other,110% of Medicare,336,35,,336,percent of total billed charges,Implant Device,326.4,34,"Charges > $500, x 34%",326.4,percent of total billed charges,Implant Device,336,35,,336,percent of total billed charges,Implant Device,336,35,,336,percent of total billed charges,Implant Device,336,35,,336,percent of total billed charges,Implant Device,336,35,,336,percent of total billed charges,Implant Device,336,35,,336,percent of total billed charges,Implant Device,384,40,,384,percent of total billed charges,Implant Device,336,70,,336,percent of total billed charges,All Other,326.4,34,,326.4,percent of total billed charges,Implant Device,326.4,34,,326.4,percent of total billed charges,Implant Device,336,35,,336,percent of total billed charges,Implant Device,336,35,,336,percent of total billed charges,Implant Device,336,35,,336,percent of total billed charges,Implant Device,336,35,,336,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,710.4,
ZIMMER 00-4936-006-07 CMP PLT 6H 3.5X79,C1713,HCPCS,,79004296,CDM,278,RC,,,both,,,1182,874.68,,,874.68,Other,150% of Medicare + 9.63% HCRA Surcharge,531.9,45,,531.9,percent of total billed charges,Critical Access Hospital RCC factor,401.88,34,,401.88,percent of total billed charges,Implant Device,401.88,34,,401.88,percent of total billed charges,Implant Device,401.88,34,,401.88,percent of total billed charges,Implant Device,401.88,34,,401.88,percent of total billed charges,Implant Device,401.88,34,,401.88,percent of total billed charges,Implant Device,585.09,,,585.09,Other,110% of Medicare,413.7,35,,413.7,percent of total billed charges,Implant Device,401.88,34,"Charges > $500, x 34%",401.88,percent of total billed charges,Implant Device,413.7,35,,413.7,percent of total billed charges,Implant Device,413.7,35,,413.7,percent of total billed charges,Implant Device,413.7,35,,413.7,percent of total billed charges,Implant Device,413.7,35,,413.7,percent of total billed charges,Implant Device,413.7,35,,413.7,percent of total billed charges,Implant Device,472.8,40,,472.8,percent of total billed charges,Implant Device,413.7,70,,413.7,percent of total billed charges,All Other,401.88,34,,401.88,percent of total billed charges,Implant Device,401.88,34,,401.88,percent of total billed charges,Implant Device,413.7,35,,413.7,percent of total billed charges,Implant Device,413.7,35,,413.7,percent of total billed charges,Implant Device,413.7,35,,413.7,percent of total billed charges,Implant Device,413.7,35,,413.7,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,874.68,
ZIMMER 00-4835-045-01 CORT SCREW 3.5X45,C1713,HCPCS,,79004299,CDM,278,RC,,,both,,,68,50.32,,,50.32,Other,150% of Medicare + 9.63% HCRA Surcharge,30.6,45,,30.6,percent of total billed charges,Critical Access Hospital RCC factor,23.12,34,,23.12,percent of total billed charges,Implant Device,23.12,34,,23.12,percent of total billed charges,Implant Device,23.12,34,,23.12,percent of total billed charges,Implant Device,23.12,34,,23.12,percent of total billed charges,Implant Device,23.12,34,,23.12,percent of total billed charges,Implant Device,33.66,,,33.66,Other,110% of Medicare,23.8,35,,23.8,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,23.8,35,,23.8,percent of total billed charges,Implant Device,23.8,35,,23.8,percent of total billed charges,Implant Device,23.8,35,,23.8,percent of total billed charges,Implant Device,23.8,35,,23.8,percent of total billed charges,Implant Device,23.8,35,,23.8,percent of total billed charges,Implant Device,27.2,40,,27.2,percent of total billed charges,Implant Device,23.8,70,,23.8,percent of total billed charges,All Other,23.12,34,,23.12,percent of total billed charges,Implant Device,23.12,34,,23.12,percent of total billed charges,Implant Device,23.8,35,,23.8,percent of total billed charges,Implant Device,23.8,35,,23.8,percent of total billed charges,Implant Device,23.8,35,,23.8,percent of total billed charges,Implant Device,23.8,35,,23.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,50.32,
ZIMMER 7711-10 HIP FEM STEM 12/14 SZ10,C1776,HCPCS,,79004300,CDM,278,RC,,,both,,,13500,9990.03,,,9990.03,Other,150% of Medicare + 9.63% HCRA Surcharge,6075,45,,6075,percent of total billed charges,Critical Access Hospital RCC factor,4590,34,,4590,percent of total billed charges,Implant Device,4590,34,,4590,percent of total billed charges,Implant Device,4590,34,,4590,percent of total billed charges,Implant Device,4590,34,,4590,percent of total billed charges,Implant Device,4590,34,,4590,percent of total billed charges,Implant Device,6682.5,,,6682.5,Other,110% of Medicare,4725,35,,4725,percent of total billed charges,Implant Device,4590,34,"Charges > $500, x 34%",4590,percent of total billed charges,Implant Device,4725,35,,4725,percent of total billed charges,Implant Device,4725,35,,4725,percent of total billed charges,Implant Device,4725,35,,4725,percent of total billed charges,Implant Device,4725,35,,4725,percent of total billed charges,Implant Device,4725,35,,4725,percent of total billed charges,Implant Device,5400,40,,5400,percent of total billed charges,Implant Device,4725,70,,4725,percent of total billed charges,All Other,4590,34,,4590,percent of total billed charges,Implant Device,4590,34,,4590,percent of total billed charges,Implant Device,4725,35,,4725,percent of total billed charges,Implant Device,4725,35,,4725,percent of total billed charges,Implant Device,4725,35,,4725,percent of total billed charges,Implant Device,4725,35,,4725,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,4590,34,"If Charge > 2,000, then 34 percent",4590,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,9990.03,
ZIMMER 5001-42-22 MULTI CUP LINER 22MM,C1776,HCPCS,,79004302,CDM,278,RC,,,both,,,1297,959.78,,,959.78,Other,150% of Medicare + 9.63% HCRA Surcharge,583.65,45,,583.65,percent of total billed charges,Critical Access Hospital RCC factor,440.98,34,,440.98,percent of total billed charges,Implant Device,440.98,34,,440.98,percent of total billed charges,Implant Device,440.98,34,,440.98,percent of total billed charges,Implant Device,440.98,34,,440.98,percent of total billed charges,Implant Device,440.98,34,,440.98,percent of total billed charges,Implant Device,642.02,,,642.02,Other,110% of Medicare,453.95,35,,453.95,percent of total billed charges,Implant Device,440.98,34,"Charges > $500, x 34%",440.98,percent of total billed charges,Implant Device,453.95,35,,453.95,percent of total billed charges,Implant Device,453.95,35,,453.95,percent of total billed charges,Implant Device,453.95,35,,453.95,percent of total billed charges,Implant Device,453.95,35,,453.95,percent of total billed charges,Implant Device,453.95,35,,453.95,percent of total billed charges,Implant Device,518.8,40,,518.8,percent of total billed charges,Implant Device,453.95,70,,453.95,percent of total billed charges,All Other,440.98,34,,440.98,percent of total billed charges,Implant Device,440.98,34,,440.98,percent of total billed charges,Implant Device,453.95,35,,453.95,percent of total billed charges,Implant Device,453.95,35,,453.95,percent of total billed charges,Implant Device,453.95,35,,453.95,percent of total billed charges,Implant Device,453.95,35,,453.95,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,959.78,
ZIMMER 00-2348-016-35 SCREW 3.5MM X 16MM,C1713,HCPCS,,79004303,CDM,278,RC,,,both,,,116,85.84,,,85.84,Other,150% of Medicare + 9.63% HCRA Surcharge,52.2,45,,52.2,percent of total billed charges,Critical Access Hospital RCC factor,39.44,34,,39.44,percent of total billed charges,Implant Device,39.44,34,,39.44,percent of total billed charges,Implant Device,39.44,34,,39.44,percent of total billed charges,Implant Device,39.44,34,,39.44,percent of total billed charges,Implant Device,39.44,34,,39.44,percent of total billed charges,Implant Device,57.42,,,57.42,Other,110% of Medicare,40.6,35,,40.6,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,40.6,35,,40.6,percent of total billed charges,Implant Device,40.6,35,,40.6,percent of total billed charges,Implant Device,40.6,35,,40.6,percent of total billed charges,Implant Device,40.6,35,,40.6,percent of total billed charges,Implant Device,40.6,35,,40.6,percent of total billed charges,Implant Device,46.4,40,,46.4,percent of total billed charges,Implant Device,40.6,70,,40.6,percent of total billed charges,All Other,39.44,34,,39.44,percent of total billed charges,Implant Device,39.44,34,,39.44,percent of total billed charges,Implant Device,40.6,35,,40.6,percent of total billed charges,Implant Device,40.6,35,,40.6,percent of total billed charges,Implant Device,40.6,35,,40.6,percent of total billed charges,Implant Device,40.6,35,,40.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,85.84,
ZIMMER 00-4828-014-02 SCREW 2.7X14MM,C1713,HCPCS,,79004304,CDM,278,RC,,,both,,,345,255.3,,,255.3,Other,150% of Medicare + 9.63% HCRA Surcharge,155.25,45,,155.25,percent of total billed charges,Critical Access Hospital RCC factor,117.3,34,,117.3,percent of total billed charges,Implant Device,117.3,34,,117.3,percent of total billed charges,Implant Device,117.3,34,,117.3,percent of total billed charges,Implant Device,117.3,34,,117.3,percent of total billed charges,Implant Device,117.3,34,,117.3,percent of total billed charges,Implant Device,170.78,,,170.78,Other,110% of Medicare,120.75,35,,120.75,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,120.75,35,,120.75,percent of total billed charges,Implant Device,120.75,35,,120.75,percent of total billed charges,Implant Device,120.75,35,,120.75,percent of total billed charges,Implant Device,120.75,35,,120.75,percent of total billed charges,Implant Device,120.75,35,,120.75,percent of total billed charges,Implant Device,138,40,,138,percent of total billed charges,Implant Device,120.75,70,,120.75,percent of total billed charges,All Other,117.3,34,,117.3,percent of total billed charges,Implant Device,117.3,34,,117.3,percent of total billed charges,Implant Device,120.75,35,,120.75,percent of total billed charges,Implant Device,120.75,35,,120.75,percent of total billed charges,Implant Device,120.75,35,,120.75,percent of total billed charges,Implant Device,120.75,35,,120.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,255.3,
ZIMMER 604734S ASNIS CANN SCREW 34MM,C1713,HCPCS,,79004305,CDM,278,RC,,,both,,,535,395.9,,,395.9,Other,150% of Medicare + 9.63% HCRA Surcharge,240.75,45,,240.75,percent of total billed charges,Critical Access Hospital RCC factor,181.9,34,,181.9,percent of total billed charges,Implant Device,181.9,34,,181.9,percent of total billed charges,Implant Device,181.9,34,,181.9,percent of total billed charges,Implant Device,181.9,34,,181.9,percent of total billed charges,Implant Device,181.9,34,,181.9,percent of total billed charges,Implant Device,264.83,,,264.83,Other,110% of Medicare,187.25,35,,187.25,percent of total billed charges,Implant Device,181.9,34,"Charges > $500, x 34%",181.9,percent of total billed charges,Implant Device,187.25,35,,187.25,percent of total billed charges,Implant Device,187.25,35,,187.25,percent of total billed charges,Implant Device,187.25,35,,187.25,percent of total billed charges,Implant Device,187.25,35,,187.25,percent of total billed charges,Implant Device,187.25,35,,187.25,percent of total billed charges,Implant Device,214,40,,214,percent of total billed charges,Implant Device,187.25,70,,187.25,percent of total billed charges,All Other,181.9,34,,181.9,percent of total billed charges,Implant Device,181.9,34,,181.9,percent of total billed charges,Implant Device,187.25,35,,187.25,percent of total billed charges,Implant Device,187.25,35,,187.25,percent of total billed charges,Implant Device,187.25,35,,187.25,percent of total billed charges,Implant Device,187.25,35,,187.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,395.9,
ZIMMER 121339 CBL RDY CBL FOR PL 1.8X610,C1713,HCPCS,,79004306,CDM,278,RC,,,both,,,1026,759.24,,,759.24,Other,150% of Medicare + 9.63% HCRA Surcharge,461.7,45,,461.7,percent of total billed charges,Critical Access Hospital RCC factor,348.84,34,,348.84,percent of total billed charges,Implant Device,348.84,34,,348.84,percent of total billed charges,Implant Device,348.84,34,,348.84,percent of total billed charges,Implant Device,348.84,34,,348.84,percent of total billed charges,Implant Device,348.84,34,,348.84,percent of total billed charges,Implant Device,507.87,,,507.87,Other,110% of Medicare,359.1,35,,359.1,percent of total billed charges,Implant Device,348.84,34,"Charges > $500, x 34%",348.84,percent of total billed charges,Implant Device,359.1,35,,359.1,percent of total billed charges,Implant Device,359.1,35,,359.1,percent of total billed charges,Implant Device,359.1,35,,359.1,percent of total billed charges,Implant Device,359.1,35,,359.1,percent of total billed charges,Implant Device,359.1,35,,359.1,percent of total billed charges,Implant Device,410.4,40,,410.4,percent of total billed charges,Implant Device,359.1,70,,359.1,percent of total billed charges,All Other,348.84,34,,348.84,percent of total billed charges,Implant Device,348.84,34,,348.84,percent of total billed charges,Implant Device,359.1,35,,359.1,percent of total billed charges,Implant Device,359.1,35,,359.1,percent of total billed charges,Implant Device,359.1,35,,359.1,percent of total billed charges,Implant Device,359.1,35,,359.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,759.24,
ZIMMER 2359-014-38 LOCK SCREW 3.5X2.7X14,C1713,HCPCS,,79004307,CDM,278,RC,,,both,,,313,231.62,,,231.62,Other,150% of Medicare + 9.63% HCRA Surcharge,140.85,45,,140.85,percent of total billed charges,Critical Access Hospital RCC factor,106.42,34,,106.42,percent of total billed charges,Implant Device,106.42,34,,106.42,percent of total billed charges,Implant Device,106.42,34,,106.42,percent of total billed charges,Implant Device,106.42,34,,106.42,percent of total billed charges,Implant Device,106.42,34,,106.42,percent of total billed charges,Implant Device,154.94,,,154.94,Other,110% of Medicare,109.55,35,,109.55,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,109.55,35,,109.55,percent of total billed charges,Implant Device,109.55,35,,109.55,percent of total billed charges,Implant Device,109.55,35,,109.55,percent of total billed charges,Implant Device,109.55,35,,109.55,percent of total billed charges,Implant Device,109.55,35,,109.55,percent of total billed charges,Implant Device,125.2,40,,125.2,percent of total billed charges,Implant Device,109.55,70,,109.55,percent of total billed charges,All Other,106.42,34,,106.42,percent of total billed charges,Implant Device,106.42,34,,106.42,percent of total billed charges,Implant Device,109.55,35,,109.55,percent of total billed charges,Implant Device,109.55,35,,109.55,percent of total billed charges,Implant Device,109.55,35,,109.55,percent of total billed charges,Implant Device,109.55,35,,109.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,231.62,
ZIMMER 06-136-30111 TRAB METAL SHELL,C1776,HCPCS,,79004308,CDM,278,RC,,,both,,,19074,14114.81,,,14114.81,Other,150% of Medicare + 9.63% HCRA Surcharge,8583.3,45,,8583.3,percent of total billed charges,Critical Access Hospital RCC factor,6485.16,34,,6485.16,percent of total billed charges,Implant Device,6485.16,34,,6485.16,percent of total billed charges,Implant Device,6485.16,34,,6485.16,percent of total billed charges,Implant Device,6485.16,34,,6485.16,percent of total billed charges,Implant Device,6485.16,34,,6485.16,percent of total billed charges,Implant Device,9441.63,,,9441.63,Other,110% of Medicare,6675.9,35,,6675.9,percent of total billed charges,Implant Device,6485.16,34,"Charges > $500, x 34%",6485.16,percent of total billed charges,Implant Device,6675.9,35,,6675.9,percent of total billed charges,Implant Device,6675.9,35,,6675.9,percent of total billed charges,Implant Device,6675.9,35,,6675.9,percent of total billed charges,Implant Device,6675.9,35,,6675.9,percent of total billed charges,Implant Device,6675.9,35,,6675.9,percent of total billed charges,Implant Device,7629.6,40,,7629.6,percent of total billed charges,Implant Device,6675.9,70,,6675.9,percent of total billed charges,All Other,6485.16,34,,6485.16,percent of total billed charges,Implant Device,6485.16,34,,6485.16,percent of total billed charges,Implant Device,6675.9,35,,6675.9,percent of total billed charges,Implant Device,6675.9,35,,6675.9,percent of total billed charges,Implant Device,6675.9,35,,6675.9,percent of total billed charges,Implant Device,6675.9,35,,6675.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,6485.16,34,"If Charge > 2,000, then 34 percent",6485.16,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,14114.81,
ZIMMER 00-4828-020-02 LOCK SCREW 20MM,C1713,HCPCS,,79004309,CDM,278,RC,,,both,,,302,223.48,,,223.48,Other,150% of Medicare + 9.63% HCRA Surcharge,135.9,45,,135.9,percent of total billed charges,Critical Access Hospital RCC factor,102.68,34,,102.68,percent of total billed charges,Implant Device,102.68,34,,102.68,percent of total billed charges,Implant Device,102.68,34,,102.68,percent of total billed charges,Implant Device,102.68,34,,102.68,percent of total billed charges,Implant Device,102.68,34,,102.68,percent of total billed charges,Implant Device,149.49,,,149.49,Other,110% of Medicare,105.7,35,,105.7,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,105.7,35,,105.7,percent of total billed charges,Implant Device,105.7,35,,105.7,percent of total billed charges,Implant Device,105.7,35,,105.7,percent of total billed charges,Implant Device,105.7,35,,105.7,percent of total billed charges,Implant Device,105.7,35,,105.7,percent of total billed charges,Implant Device,120.8,40,,120.8,percent of total billed charges,Implant Device,105.7,70,,105.7,percent of total billed charges,All Other,102.68,34,,102.68,percent of total billed charges,Implant Device,102.68,34,,102.68,percent of total billed charges,Implant Device,105.7,35,,105.7,percent of total billed charges,Implant Device,105.7,35,,105.7,percent of total billed charges,Implant Device,105.7,35,,105.7,percent of total billed charges,Implant Device,105.7,35,,105.7,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,223.48,
ZIMMER 00-4835-018-01 CORT SCREW 18MM,C1713,HCPCS,,79004310,CDM,278,RC,,,both,,,72,53.28,,,53.28,Other,150% of Medicare + 9.63% HCRA Surcharge,32.4,45,,32.4,percent of total billed charges,Critical Access Hospital RCC factor,24.48,34,,24.48,percent of total billed charges,Implant Device,24.48,34,,24.48,percent of total billed charges,Implant Device,24.48,34,,24.48,percent of total billed charges,Implant Device,24.48,34,,24.48,percent of total billed charges,Implant Device,24.48,34,,24.48,percent of total billed charges,Implant Device,35.64,,,35.64,Other,110% of Medicare,25.2,35,,25.2,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,25.2,35,,25.2,percent of total billed charges,Implant Device,25.2,35,,25.2,percent of total billed charges,Implant Device,25.2,35,,25.2,percent of total billed charges,Implant Device,25.2,35,,25.2,percent of total billed charges,Implant Device,25.2,35,,25.2,percent of total billed charges,Implant Device,28.8,40,,28.8,percent of total billed charges,Implant Device,25.2,70,,25.2,percent of total billed charges,All Other,24.48,34,,24.48,percent of total billed charges,Implant Device,24.48,34,,24.48,percent of total billed charges,Implant Device,25.2,35,,25.2,percent of total billed charges,Implant Device,25.2,35,,25.2,percent of total billed charges,Implant Device,25.2,35,,25.2,percent of total billed charges,Implant Device,25.2,35,,25.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,53.28,
ZIMMER 00-4835-010-01 CORT SCREW 10MM,C1713,HCPCS,,79004311,CDM,278,RC,,,both,,,71,52.54,,,52.54,Other,150% of Medicare + 9.63% HCRA Surcharge,31.95,45,,31.95,percent of total billed charges,Critical Access Hospital RCC factor,24.14,34,,24.14,percent of total billed charges,Implant Device,24.14,34,,24.14,percent of total billed charges,Implant Device,24.14,34,,24.14,percent of total billed charges,Implant Device,24.14,34,,24.14,percent of total billed charges,Implant Device,24.14,34,,24.14,percent of total billed charges,Implant Device,35.15,,,35.15,Other,110% of Medicare,24.85,35,,24.85,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,24.85,35,,24.85,percent of total billed charges,Implant Device,24.85,35,,24.85,percent of total billed charges,Implant Device,24.85,35,,24.85,percent of total billed charges,Implant Device,24.85,35,,24.85,percent of total billed charges,Implant Device,24.85,35,,24.85,percent of total billed charges,Implant Device,28.4,40,,28.4,percent of total billed charges,Implant Device,24.85,70,,24.85,percent of total billed charges,All Other,24.14,34,,24.14,percent of total billed charges,Implant Device,24.14,34,,24.14,percent of total billed charges,Implant Device,24.85,35,,24.85,percent of total billed charges,Implant Device,24.85,35,,24.85,percent of total billed charges,Implant Device,24.85,35,,24.85,percent of total billed charges,Implant Device,24.85,35,,24.85,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,52.54,
ZIMMER 00-2357-101-10 DIS LATERAL PL 10H,C1713,HCPCS,,79004312,CDM,278,RC,,,both,,,6030,4462.22,,,4462.22,Other,150% of Medicare + 9.63% HCRA Surcharge,2713.5,45,,2713.5,percent of total billed charges,Critical Access Hospital RCC factor,2050.2,34,,2050.2,percent of total billed charges,Implant Device,2050.2,34,,2050.2,percent of total billed charges,Implant Device,2050.2,34,,2050.2,percent of total billed charges,Implant Device,2050.2,34,,2050.2,percent of total billed charges,Implant Device,2050.2,34,,2050.2,percent of total billed charges,Implant Device,2984.85,,,2984.85,Other,110% of Medicare,2110.5,35,,2110.5,percent of total billed charges,Implant Device,2050.2,34,"Charges > $500, x 34%",2050.2,percent of total billed charges,Implant Device,2110.5,35,,2110.5,percent of total billed charges,Implant Device,2110.5,35,,2110.5,percent of total billed charges,Implant Device,2110.5,35,,2110.5,percent of total billed charges,Implant Device,2110.5,35,,2110.5,percent of total billed charges,Implant Device,2110.5,35,,2110.5,percent of total billed charges,Implant Device,2412,40,,2412,percent of total billed charges,Implant Device,2110.5,70,,2110.5,percent of total billed charges,All Other,2050.2,34,,2050.2,percent of total billed charges,Implant Device,2050.2,34,,2050.2,percent of total billed charges,Implant Device,2110.5,35,,2110.5,percent of total billed charges,Implant Device,2110.5,35,,2110.5,percent of total billed charges,Implant Device,2110.5,35,,2110.5,percent of total billed charges,Implant Device,2110.5,35,,2110.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2050.2,34,"If Charge > 2,000, then 34 percent",2050.2,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4462.22,
ZIMMER 1147-46-40 SCREW 46MM,C1713,HCPCS,,79004313,CDM,278,RC,,,both,,,1121,829.54,,,829.54,Other,150% of Medicare + 9.63% HCRA Surcharge,504.45,45,,504.45,percent of total billed charges,Critical Access Hospital RCC factor,381.14,34,,381.14,percent of total billed charges,Implant Device,381.14,34,,381.14,percent of total billed charges,Implant Device,381.14,34,,381.14,percent of total billed charges,Implant Device,381.14,34,,381.14,percent of total billed charges,Implant Device,381.14,34,,381.14,percent of total billed charges,Implant Device,554.9,,,554.9,Other,110% of Medicare,392.35,35,,392.35,percent of total billed charges,Implant Device,381.14,34,"Charges > $500, x 34%",381.14,percent of total billed charges,Implant Device,392.35,35,,392.35,percent of total billed charges,Implant Device,392.35,35,,392.35,percent of total billed charges,Implant Device,392.35,35,,392.35,percent of total billed charges,Implant Device,392.35,35,,392.35,percent of total billed charges,Implant Device,392.35,35,,392.35,percent of total billed charges,Implant Device,448.4,40,,448.4,percent of total billed charges,Implant Device,392.35,70,,392.35,percent of total billed charges,All Other,381.14,34,,381.14,percent of total billed charges,Implant Device,381.14,34,,381.14,percent of total billed charges,Implant Device,392.35,35,,392.35,percent of total billed charges,Implant Device,392.35,35,,392.35,percent of total billed charges,Implant Device,392.35,35,,392.35,percent of total billed charges,Implant Device,392.35,35,,392.35,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,829.54,
ZIMMER 00-2480-016-40 CANC SCREW 4 X16MM,C1713,HCPCS,,79004314,CDM,278,RC,,,both,,,180,133.2,,,133.2,Other,150% of Medicare + 9.63% HCRA Surcharge,81,45,,81,percent of total billed charges,Critical Access Hospital RCC factor,61.2,34,,61.2,percent of total billed charges,Implant Device,61.2,34,,61.2,percent of total billed charges,Implant Device,61.2,34,,61.2,percent of total billed charges,Implant Device,61.2,34,,61.2,percent of total billed charges,Implant Device,61.2,34,,61.2,percent of total billed charges,Implant Device,89.1,,,89.1,Other,110% of Medicare,63,35,,63,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,63,35,,63,percent of total billed charges,Implant Device,63,35,,63,percent of total billed charges,Implant Device,63,35,,63,percent of total billed charges,Implant Device,63,35,,63,percent of total billed charges,Implant Device,63,35,,63,percent of total billed charges,Implant Device,72,40,,72,percent of total billed charges,Implant Device,63,70,,63,percent of total billed charges,All Other,61.2,34,,61.2,percent of total billed charges,Implant Device,61.2,34,,61.2,percent of total billed charges,Implant Device,63,35,,63,percent of total billed charges,Implant Device,63,35,,63,percent of total billed charges,Implant Device,63,35,,63,percent of total billed charges,Implant Device,63,35,,63,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,133.2,
ZIMMER 00-2359-014-35 SCREW 3.5X14MM,C1713,HCPCS,,79004315,CDM,278,RC,,,both,,,324,239.76,,,239.76,Other,150% of Medicare + 9.63% HCRA Surcharge,145.8,45,,145.8,percent of total billed charges,Critical Access Hospital RCC factor,110.16,34,,110.16,percent of total billed charges,Implant Device,110.16,34,,110.16,percent of total billed charges,Implant Device,110.16,34,,110.16,percent of total billed charges,Implant Device,110.16,34,,110.16,percent of total billed charges,Implant Device,110.16,34,,110.16,percent of total billed charges,Implant Device,160.38,,,160.38,Other,110% of Medicare,113.4,35,,113.4,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,129.6,40,,129.6,percent of total billed charges,Implant Device,113.4,70,,113.4,percent of total billed charges,All Other,110.16,34,,110.16,percent of total billed charges,Implant Device,110.16,34,,110.16,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,239.76,
ZIMMER 00-2359-035-36 CANN SCREW 3.5X35,C1713,HCPCS,,79004316,CDM,278,RC,,,both,,,420,310.8,,,310.8,Other,150% of Medicare + 9.63% HCRA Surcharge,189,45,,189,percent of total billed charges,Critical Access Hospital RCC factor,142.8,34,,142.8,percent of total billed charges,Implant Device,142.8,34,,142.8,percent of total billed charges,Implant Device,142.8,34,,142.8,percent of total billed charges,Implant Device,142.8,34,,142.8,percent of total billed charges,Implant Device,142.8,34,,142.8,percent of total billed charges,Implant Device,207.9,,,207.9,Other,110% of Medicare,147,35,,147,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,147,35,,147,percent of total billed charges,Implant Device,147,35,,147,percent of total billed charges,Implant Device,147,35,,147,percent of total billed charges,Implant Device,147,35,,147,percent of total billed charges,Implant Device,147,35,,147,percent of total billed charges,Implant Device,168,40,,168,percent of total billed charges,Implant Device,147,70,,147,percent of total billed charges,All Other,142.8,34,,142.8,percent of total billed charges,Implant Device,142.8,34,,142.8,percent of total billed charges,Implant Device,147,35,,147,percent of total billed charges,Implant Device,147,35,,147,percent of total billed charges,Implant Device,147,35,,147,percent of total billed charges,Implant Device,147,35,,147,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,310.8,
ZIMMER 5001-50-28 BIPOLAR LINER 50-52X28,C1776,HCPCS,,79004317,CDM,278,RC,,,both,,,789,583.86,,,583.86,Other,150% of Medicare + 9.63% HCRA Surcharge,355.05,45,,355.05,percent of total billed charges,Critical Access Hospital RCC factor,268.26,34,,268.26,percent of total billed charges,Implant Device,268.26,34,,268.26,percent of total billed charges,Implant Device,268.26,34,,268.26,percent of total billed charges,Implant Device,268.26,34,,268.26,percent of total billed charges,Implant Device,268.26,34,,268.26,percent of total billed charges,Implant Device,390.56,,,390.56,Other,110% of Medicare,276.15,35,,276.15,percent of total billed charges,Implant Device,268.26,34,"Charges > $500, x 34%",268.26,percent of total billed charges,Implant Device,276.15,35,,276.15,percent of total billed charges,Implant Device,276.15,35,,276.15,percent of total billed charges,Implant Device,276.15,35,,276.15,percent of total billed charges,Implant Device,276.15,35,,276.15,percent of total billed charges,Implant Device,276.15,35,,276.15,percent of total billed charges,Implant Device,315.6,40,,315.6,percent of total billed charges,Implant Device,276.15,70,,276.15,percent of total billed charges,All Other,268.26,34,,268.26,percent of total billed charges,Implant Device,268.26,34,,268.26,percent of total billed charges,Implant Device,276.15,35,,276.15,percent of total billed charges,Implant Device,276.15,35,,276.15,percent of total billed charges,Implant Device,276.15,35,,276.15,percent of total billed charges,Implant Device,276.15,35,,276.15,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,583.86,
ZIMMER 00-2359-046-45 LCK SCREW 4.5X46MM,C1713,HCPCS,,79004318,CDM,278,RC,,,both,,,432,319.68,,,319.68,Other,150% of Medicare + 9.63% HCRA Surcharge,194.4,45,,194.4,percent of total billed charges,Critical Access Hospital RCC factor,146.88,34,,146.88,percent of total billed charges,Implant Device,146.88,34,,146.88,percent of total billed charges,Implant Device,146.88,34,,146.88,percent of total billed charges,Implant Device,146.88,34,,146.88,percent of total billed charges,Implant Device,146.88,34,,146.88,percent of total billed charges,Implant Device,213.84,,,213.84,Other,110% of Medicare,151.2,35,,151.2,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,151.2,35,,151.2,percent of total billed charges,Implant Device,151.2,35,,151.2,percent of total billed charges,Implant Device,151.2,35,,151.2,percent of total billed charges,Implant Device,151.2,35,,151.2,percent of total billed charges,Implant Device,151.2,35,,151.2,percent of total billed charges,Implant Device,172.8,40,,172.8,percent of total billed charges,Implant Device,151.2,70,,151.2,percent of total billed charges,All Other,146.88,34,,146.88,percent of total billed charges,Implant Device,146.88,34,,146.88,percent of total billed charges,Implant Device,151.2,35,,151.2,percent of total billed charges,Implant Device,151.2,35,,151.2,percent of total billed charges,Implant Device,151.2,35,,151.2,percent of total billed charges,Implant Device,151.2,35,,151.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,319.68,
ZIMMER 5001-57 MULTIPOLAR CUP SHELL 57MM,C1776,HCPCS,,79004319,CDM,278,RC,,,both,,,345,255.3,,,255.3,Other,150% of Medicare + 9.63% HCRA Surcharge,155.25,45,,155.25,percent of total billed charges,Critical Access Hospital RCC factor,117.3,34,,117.3,percent of total billed charges,Implant Device,117.3,34,,117.3,percent of total billed charges,Implant Device,117.3,34,,117.3,percent of total billed charges,Implant Device,117.3,34,,117.3,percent of total billed charges,Implant Device,117.3,34,,117.3,percent of total billed charges,Implant Device,170.78,,,170.78,Other,110% of Medicare,120.75,35,,120.75,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,120.75,35,,120.75,percent of total billed charges,Implant Device,120.75,35,,120.75,percent of total billed charges,Implant Device,120.75,35,,120.75,percent of total billed charges,Implant Device,120.75,35,,120.75,percent of total billed charges,Implant Device,120.75,35,,120.75,percent of total billed charges,Implant Device,138,40,,138,percent of total billed charges,Implant Device,120.75,70,,120.75,percent of total billed charges,All Other,117.3,34,,117.3,percent of total billed charges,Implant Device,117.3,34,,117.3,percent of total billed charges,Implant Device,120.75,35,,120.75,percent of total billed charges,Implant Device,120.75,35,,120.75,percent of total billed charges,Implant Device,120.75,35,,120.75,percent of total billed charges,Implant Device,120.75,35,,120.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,255.3,
ZIMMER 00-1147-040-41 CANN SCREW 40MM,C1713,HCPCS,,79004320,CDM,278,RC,,,both,,,574,424.76,,,424.76,Other,150% of Medicare + 9.63% HCRA Surcharge,258.3,45,,258.3,percent of total billed charges,Critical Access Hospital RCC factor,195.16,34,,195.16,percent of total billed charges,Implant Device,195.16,34,,195.16,percent of total billed charges,Implant Device,195.16,34,,195.16,percent of total billed charges,Implant Device,195.16,34,,195.16,percent of total billed charges,Implant Device,195.16,34,,195.16,percent of total billed charges,Implant Device,284.13,,,284.13,Other,110% of Medicare,200.9,35,,200.9,percent of total billed charges,Implant Device,195.16,34,"Charges > $500, x 34%",195.16,percent of total billed charges,Implant Device,200.9,35,,200.9,percent of total billed charges,Implant Device,200.9,35,,200.9,percent of total billed charges,Implant Device,200.9,35,,200.9,percent of total billed charges,Implant Device,200.9,35,,200.9,percent of total billed charges,Implant Device,200.9,35,,200.9,percent of total billed charges,Implant Device,229.6,40,,229.6,percent of total billed charges,Implant Device,200.9,70,,200.9,percent of total billed charges,All Other,195.16,34,,195.16,percent of total billed charges,Implant Device,195.16,34,,195.16,percent of total billed charges,Implant Device,200.9,35,,200.9,percent of total billed charges,Implant Device,200.9,35,,200.9,percent of total billed charges,Implant Device,200.9,35,,200.9,percent of total billed charges,Implant Device,200.9,35,,200.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,424.76,
ZIMMER 223203-01 CBL READY BONE PLATE 6H,C1713,HCPCS,,79004322,CDM,278,RC,,,both,,,2700,1998.01,,,1998.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1215,45,,1215,percent of total billed charges,Critical Access Hospital RCC factor,918,34,,918,percent of total billed charges,Implant Device,918,34,,918,percent of total billed charges,Implant Device,918,34,,918,percent of total billed charges,Implant Device,918,34,,918,percent of total billed charges,Implant Device,918,34,,918,percent of total billed charges,Implant Device,1336.5,,,1336.5,Other,110% of Medicare,945,35,,945,percent of total billed charges,Implant Device,918,34,"Charges > $500, x 34%",918,percent of total billed charges,Implant Device,945,35,,945,percent of total billed charges,Implant Device,945,35,,945,percent of total billed charges,Implant Device,945,35,,945,percent of total billed charges,Implant Device,945,35,,945,percent of total billed charges,Implant Device,945,35,,945,percent of total billed charges,Implant Device,1080,40,,1080,percent of total billed charges,Implant Device,945,70,,945,percent of total billed charges,All Other,918,34,,918,percent of total billed charges,Implant Device,918,34,,918,percent of total billed charges,Implant Device,945,35,,945,percent of total billed charges,Implant Device,945,35,,945,percent of total billed charges,Implant Device,945,35,,945,percent of total billed charges,Implant Device,945,35,,945,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,918,34,"If Charge > 2,000, then 34 percent",918,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1998.01,
ZIMMER 02-03152-085 CANC SCREW 5.0X85MM,C1713,HCPCS,,79004323,CDM,278,RC,,,both,,,546,404.04,,,404.04,Other,150% of Medicare + 9.63% HCRA Surcharge,245.7,45,,245.7,percent of total billed charges,Critical Access Hospital RCC factor,185.64,34,,185.64,percent of total billed charges,Implant Device,185.64,34,,185.64,percent of total billed charges,Implant Device,185.64,34,,185.64,percent of total billed charges,Implant Device,185.64,34,,185.64,percent of total billed charges,Implant Device,185.64,34,,185.64,percent of total billed charges,Implant Device,270.27,,,270.27,Other,110% of Medicare,191.1,35,,191.1,percent of total billed charges,Implant Device,185.64,34,"Charges > $500, x 34%",185.64,percent of total billed charges,Implant Device,191.1,35,,191.1,percent of total billed charges,Implant Device,191.1,35,,191.1,percent of total billed charges,Implant Device,191.1,35,,191.1,percent of total billed charges,Implant Device,191.1,35,,191.1,percent of total billed charges,Implant Device,191.1,35,,191.1,percent of total billed charges,Implant Device,218.4,40,,218.4,percent of total billed charges,Implant Device,191.1,70,,191.1,percent of total billed charges,All Other,185.64,34,,185.64,percent of total billed charges,Implant Device,185.64,34,,185.64,percent of total billed charges,Implant Device,191.1,35,,191.1,percent of total billed charges,Implant Device,191.1,35,,191.1,percent of total billed charges,Implant Device,191.1,35,,191.1,percent of total billed charges,Implant Device,191.1,35,,191.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,404.04,
ZIMMER 00-2348-018-35 SCREW 3.5X18MM,C1713,HCPCS,,79004324,CDM,278,RC,,,both,,,113,83.62,,,83.62,Other,150% of Medicare + 9.63% HCRA Surcharge,50.85,45,,50.85,percent of total billed charges,Critical Access Hospital RCC factor,38.42,34,,38.42,percent of total billed charges,Implant Device,38.42,34,,38.42,percent of total billed charges,Implant Device,38.42,34,,38.42,percent of total billed charges,Implant Device,38.42,34,,38.42,percent of total billed charges,Implant Device,38.42,34,,38.42,percent of total billed charges,Implant Device,55.94,,,55.94,Other,110% of Medicare,39.55,35,,39.55,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,39.55,35,,39.55,percent of total billed charges,Implant Device,39.55,35,,39.55,percent of total billed charges,Implant Device,39.55,35,,39.55,percent of total billed charges,Implant Device,39.55,35,,39.55,percent of total billed charges,Implant Device,39.55,35,,39.55,percent of total billed charges,Implant Device,45.2,40,,45.2,percent of total billed charges,Implant Device,39.55,70,,39.55,percent of total billed charges,All Other,38.42,34,,38.42,percent of total billed charges,Implant Device,38.42,34,,38.42,percent of total billed charges,Implant Device,39.55,35,,39.55,percent of total billed charges,Implant Device,39.55,35,,39.55,percent of total billed charges,Implant Device,39.55,35,,39.55,percent of total billed charges,Implant Device,39.55,35,,39.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,83.62,
ZIMMER 00-2348-014-35 SCREW 2.5X14MM,C1713,HCPCS,,79004325,CDM,278,RC,,,both,,,116,85.84,,,85.84,Other,150% of Medicare + 9.63% HCRA Surcharge,52.2,45,,52.2,percent of total billed charges,Critical Access Hospital RCC factor,39.44,34,,39.44,percent of total billed charges,Implant Device,39.44,34,,39.44,percent of total billed charges,Implant Device,39.44,34,,39.44,percent of total billed charges,Implant Device,39.44,34,,39.44,percent of total billed charges,Implant Device,39.44,34,,39.44,percent of total billed charges,Implant Device,57.42,,,57.42,Other,110% of Medicare,40.6,35,,40.6,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,40.6,35,,40.6,percent of total billed charges,Implant Device,40.6,35,,40.6,percent of total billed charges,Implant Device,40.6,35,,40.6,percent of total billed charges,Implant Device,40.6,35,,40.6,percent of total billed charges,Implant Device,40.6,35,,40.6,percent of total billed charges,Implant Device,46.4,40,,46.4,percent of total billed charges,Implant Device,40.6,70,,40.6,percent of total billed charges,All Other,39.44,34,,39.44,percent of total billed charges,Implant Device,39.44,34,,39.44,percent of total billed charges,Implant Device,40.6,35,,40.6,percent of total billed charges,Implant Device,40.6,35,,40.6,percent of total billed charges,Implant Device,40.6,35,,40.6,percent of total billed charges,Implant Device,40.6,35,,40.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,85.84,
ZIMMER 2253-055-55 IM SCREW 5.5X55MM,C1713,HCPCS,,79004326,CDM,278,RC,,,both,,,654,483.96,,,483.96,Other,150% of Medicare + 9.63% HCRA Surcharge,294.3,45,,294.3,percent of total billed charges,Critical Access Hospital RCC factor,222.36,34,,222.36,percent of total billed charges,Implant Device,222.36,34,,222.36,percent of total billed charges,Implant Device,222.36,34,,222.36,percent of total billed charges,Implant Device,222.36,34,,222.36,percent of total billed charges,Implant Device,222.36,34,,222.36,percent of total billed charges,Implant Device,323.73,,,323.73,Other,110% of Medicare,228.9,35,,228.9,percent of total billed charges,Implant Device,222.36,34,"Charges > $500, x 34%",222.36,percent of total billed charges,Implant Device,228.9,35,,228.9,percent of total billed charges,Implant Device,228.9,35,,228.9,percent of total billed charges,Implant Device,228.9,35,,228.9,percent of total billed charges,Implant Device,228.9,35,,228.9,percent of total billed charges,Implant Device,228.9,35,,228.9,percent of total billed charges,Implant Device,261.6,40,,261.6,percent of total billed charges,Implant Device,228.9,70,,228.9,percent of total billed charges,All Other,222.36,34,,222.36,percent of total billed charges,Implant Device,222.36,34,,222.36,percent of total billed charges,Implant Device,228.9,35,,228.9,percent of total billed charges,Implant Device,228.9,35,,228.9,percent of total billed charges,Implant Device,228.9,35,,228.9,percent of total billed charges,Implant Device,228.9,35,,228.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,483.96,
ZIMMER 1147-44-41 4X44MM CANN SCREW,C1713,HCPCS,,79004327,CDM,278,RC,,,both,,,5580,4129.21,,,4129.21,Other,150% of Medicare + 9.63% HCRA Surcharge,2511,45,,2511,percent of total billed charges,Critical Access Hospital RCC factor,1897.2,34,,1897.2,percent of total billed charges,Implant Device,1897.2,34,,1897.2,percent of total billed charges,Implant Device,1897.2,34,,1897.2,percent of total billed charges,Implant Device,1897.2,34,,1897.2,percent of total billed charges,Implant Device,1897.2,34,,1897.2,percent of total billed charges,Implant Device,2762.1,,,2762.1,Other,110% of Medicare,1953,35,,1953,percent of total billed charges,Implant Device,1897.2,34,"Charges > $500, x 34%",1897.2,percent of total billed charges,Implant Device,1953,35,,1953,percent of total billed charges,Implant Device,1953,35,,1953,percent of total billed charges,Implant Device,1953,35,,1953,percent of total billed charges,Implant Device,1953,35,,1953,percent of total billed charges,Implant Device,1953,35,,1953,percent of total billed charges,Implant Device,2232,40,,2232,percent of total billed charges,Implant Device,1953,70,,1953,percent of total billed charges,All Other,1897.2,34,,1897.2,percent of total billed charges,Implant Device,1897.2,34,,1897.2,percent of total billed charges,Implant Device,1953,35,,1953,percent of total billed charges,Implant Device,1953,35,,1953,percent of total billed charges,Implant Device,1953,35,,1953,percent of total billed charges,Implant Device,1953,35,,1953,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1897.2,34,"If Charge > 2,000, then 34 percent",1897.2,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4129.21,
ZIMMER 1147-065-40 SCREW 4.0X65MM,C1713,HCPCS,,79004329,CDM,278,RC,,,both,,,532,393.68,,,393.68,Other,150% of Medicare + 9.63% HCRA Surcharge,239.4,45,,239.4,percent of total billed charges,Critical Access Hospital RCC factor,180.88,34,,180.88,percent of total billed charges,Implant Device,180.88,34,,180.88,percent of total billed charges,Implant Device,180.88,34,,180.88,percent of total billed charges,Implant Device,180.88,34,,180.88,percent of total billed charges,Implant Device,180.88,34,,180.88,percent of total billed charges,Implant Device,263.34,,,263.34,Other,110% of Medicare,186.2,35,,186.2,percent of total billed charges,Implant Device,180.88,34,"Charges > $500, x 34%",180.88,percent of total billed charges,Implant Device,186.2,35,,186.2,percent of total billed charges,Implant Device,186.2,35,,186.2,percent of total billed charges,Implant Device,186.2,35,,186.2,percent of total billed charges,Implant Device,186.2,35,,186.2,percent of total billed charges,Implant Device,186.2,35,,186.2,percent of total billed charges,Implant Device,212.8,40,,212.8,percent of total billed charges,Implant Device,186.2,70,,186.2,percent of total billed charges,All Other,180.88,34,,180.88,percent of total billed charges,Implant Device,180.88,34,,180.88,percent of total billed charges,Implant Device,186.2,35,,186.2,percent of total billed charges,Implant Device,186.2,35,,186.2,percent of total billed charges,Implant Device,186.2,35,,186.2,percent of total billed charges,Implant Device,186.2,35,,186.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,393.68,
ZIMMER 2359-50-56 CANN SCREW 5.5X50MM,C1713,HCPCS,,79004330,CDM,278,RC,,,both,,,560,414.4,,,414.4,Other,150% of Medicare + 9.63% HCRA Surcharge,252,45,,252,percent of total billed charges,Critical Access Hospital RCC factor,190.4,34,,190.4,percent of total billed charges,Implant Device,190.4,34,,190.4,percent of total billed charges,Implant Device,190.4,34,,190.4,percent of total billed charges,Implant Device,190.4,34,,190.4,percent of total billed charges,Implant Device,190.4,34,,190.4,percent of total billed charges,Implant Device,277.2,,,277.2,Other,110% of Medicare,196,35,,196,percent of total billed charges,Implant Device,190.4,34,"Charges > $500, x 34%",190.4,percent of total billed charges,Implant Device,196,35,,196,percent of total billed charges,Implant Device,196,35,,196,percent of total billed charges,Implant Device,196,35,,196,percent of total billed charges,Implant Device,196,35,,196,percent of total billed charges,Implant Device,196,35,,196,percent of total billed charges,Implant Device,224,40,,224,percent of total billed charges,Implant Device,196,70,,196,percent of total billed charges,All Other,190.4,34,,190.4,percent of total billed charges,Implant Device,190.4,34,,190.4,percent of total billed charges,Implant Device,196,35,,196,percent of total billed charges,Implant Device,196,35,,196,percent of total billed charges,Implant Device,196,35,,196,percent of total billed charges,Implant Device,196,35,,196,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,414.4,
ZIMMER 00-2359-080-56 CANN SCREW 5.5X80,C1713,HCPCS,,79004331,CDM,278,RC,,,both,,,504,372.96,,,372.96,Other,150% of Medicare + 9.63% HCRA Surcharge,226.8,45,,226.8,percent of total billed charges,Critical Access Hospital RCC factor,171.36,34,,171.36,percent of total billed charges,Implant Device,171.36,34,,171.36,percent of total billed charges,Implant Device,171.36,34,,171.36,percent of total billed charges,Implant Device,171.36,34,,171.36,percent of total billed charges,Implant Device,171.36,34,,171.36,percent of total billed charges,Implant Device,249.48,,,249.48,Other,110% of Medicare,176.4,35,,176.4,percent of total billed charges,Implant Device,171.36,34,"Charges > $500, x 34%",171.36,percent of total billed charges,Implant Device,176.4,35,,176.4,percent of total billed charges,Implant Device,176.4,35,,176.4,percent of total billed charges,Implant Device,176.4,35,,176.4,percent of total billed charges,Implant Device,176.4,35,,176.4,percent of total billed charges,Implant Device,176.4,35,,176.4,percent of total billed charges,Implant Device,201.6,40,,201.6,percent of total billed charges,Implant Device,176.4,70,,176.4,percent of total billed charges,All Other,171.36,34,,171.36,percent of total billed charges,Implant Device,171.36,34,,171.36,percent of total billed charges,Implant Device,176.4,35,,176.4,percent of total billed charges,Implant Device,176.4,35,,176.4,percent of total billed charges,Implant Device,176.4,35,,176.4,percent of total billed charges,Implant Device,176.4,35,,176.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,372.96,
ZIMMER 00-2359-085-56 CANN SCREW 5.5X85,C1713,HCPCS,,79004332,CDM,278,RC,,,both,,,504,372.96,,,372.96,Other,150% of Medicare + 9.63% HCRA Surcharge,226.8,45,,226.8,percent of total billed charges,Critical Access Hospital RCC factor,171.36,34,,171.36,percent of total billed charges,Implant Device,171.36,34,,171.36,percent of total billed charges,Implant Device,171.36,34,,171.36,percent of total billed charges,Implant Device,171.36,34,,171.36,percent of total billed charges,Implant Device,171.36,34,,171.36,percent of total billed charges,Implant Device,249.48,,,249.48,Other,110% of Medicare,176.4,35,,176.4,percent of total billed charges,Implant Device,171.36,34,"Charges > $500, x 34%",171.36,percent of total billed charges,Implant Device,176.4,35,,176.4,percent of total billed charges,Implant Device,176.4,35,,176.4,percent of total billed charges,Implant Device,176.4,35,,176.4,percent of total billed charges,Implant Device,176.4,35,,176.4,percent of total billed charges,Implant Device,176.4,35,,176.4,percent of total billed charges,Implant Device,201.6,40,,201.6,percent of total billed charges,Implant Device,176.4,70,,176.4,percent of total billed charges,All Other,171.36,34,,171.36,percent of total billed charges,Implant Device,171.36,34,,171.36,percent of total billed charges,Implant Device,176.4,35,,176.4,percent of total billed charges,Implant Device,176.4,35,,176.4,percent of total billed charges,Implant Device,176.4,35,,176.4,percent of total billed charges,Implant Device,176.4,35,,176.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,372.96,
ZIMMER 5001-47-28 MULTIPOLAR LINER 28MM,C1776,HCPCS,,79004333,CDM,278,RC,,,both,,,789,583.86,,,583.86,Other,150% of Medicare + 9.63% HCRA Surcharge,355.05,45,,355.05,percent of total billed charges,Critical Access Hospital RCC factor,268.26,34,,268.26,percent of total billed charges,Implant Device,268.26,34,,268.26,percent of total billed charges,Implant Device,268.26,34,,268.26,percent of total billed charges,Implant Device,268.26,34,,268.26,percent of total billed charges,Implant Device,268.26,34,,268.26,percent of total billed charges,Implant Device,390.56,,,390.56,Other,110% of Medicare,276.15,35,,276.15,percent of total billed charges,Implant Device,268.26,34,"Charges > $500, x 34%",268.26,percent of total billed charges,Implant Device,276.15,35,,276.15,percent of total billed charges,Implant Device,276.15,35,,276.15,percent of total billed charges,Implant Device,276.15,35,,276.15,percent of total billed charges,Implant Device,276.15,35,,276.15,percent of total billed charges,Implant Device,276.15,35,,276.15,percent of total billed charges,Implant Device,315.6,40,,315.6,percent of total billed charges,Implant Device,276.15,70,,276.15,percent of total billed charges,All Other,268.26,34,,268.26,percent of total billed charges,Implant Device,268.26,34,,268.26,percent of total billed charges,Implant Device,276.15,35,,276.15,percent of total billed charges,Implant Device,276.15,35,,276.15,percent of total billed charges,Implant Device,276.15,35,,276.15,percent of total billed charges,Implant Device,276.15,35,,276.15,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,583.86,
ZIMMER 00-1147-065-41 CANN SCREW 4X65MM,C1713,HCPCS,,79004334,CDM,278,RC,,,both,,,558,412.92,,,412.92,Other,150% of Medicare + 9.63% HCRA Surcharge,251.1,45,,251.1,percent of total billed charges,Critical Access Hospital RCC factor,189.72,34,,189.72,percent of total billed charges,Implant Device,189.72,34,,189.72,percent of total billed charges,Implant Device,189.72,34,,189.72,percent of total billed charges,Implant Device,189.72,34,,189.72,percent of total billed charges,Implant Device,189.72,34,,189.72,percent of total billed charges,Implant Device,276.21,,,276.21,Other,110% of Medicare,195.3,35,,195.3,percent of total billed charges,Implant Device,189.72,34,"Charges > $500, x 34%",189.72,percent of total billed charges,Implant Device,195.3,35,,195.3,percent of total billed charges,Implant Device,195.3,35,,195.3,percent of total billed charges,Implant Device,195.3,35,,195.3,percent of total billed charges,Implant Device,195.3,35,,195.3,percent of total billed charges,Implant Device,195.3,35,,195.3,percent of total billed charges,Implant Device,223.2,40,,223.2,percent of total billed charges,Implant Device,195.3,70,,195.3,percent of total billed charges,All Other,189.72,34,,189.72,percent of total billed charges,Implant Device,189.72,34,,189.72,percent of total billed charges,Implant Device,195.3,35,,195.3,percent of total billed charges,Implant Device,195.3,35,,195.3,percent of total billed charges,Implant Device,195.3,35,,195.3,percent of total billed charges,Implant Device,195.3,35,,195.3,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,412.92,
ZIMMER 1147-066-45 CANN SCREW 4.5X66MM,C1713,HCPCS,,79004335,CDM,278,RC,,,both,,,601,444.74,,,444.74,Other,150% of Medicare + 9.63% HCRA Surcharge,270.45,45,,270.45,percent of total billed charges,Critical Access Hospital RCC factor,204.34,34,,204.34,percent of total billed charges,Implant Device,204.34,34,,204.34,percent of total billed charges,Implant Device,204.34,34,,204.34,percent of total billed charges,Implant Device,204.34,34,,204.34,percent of total billed charges,Implant Device,204.34,34,,204.34,percent of total billed charges,Implant Device,297.5,,,297.5,Other,110% of Medicare,210.35,35,,210.35,percent of total billed charges,Implant Device,204.34,34,"Charges > $500, x 34%",204.34,percent of total billed charges,Implant Device,210.35,35,,210.35,percent of total billed charges,Implant Device,210.35,35,,210.35,percent of total billed charges,Implant Device,210.35,35,,210.35,percent of total billed charges,Implant Device,210.35,35,,210.35,percent of total billed charges,Implant Device,210.35,35,,210.35,percent of total billed charges,Implant Device,240.4,40,,240.4,percent of total billed charges,Implant Device,210.35,70,,210.35,percent of total billed charges,All Other,204.34,34,,204.34,percent of total billed charges,Implant Device,204.34,34,,204.34,percent of total billed charges,Implant Device,210.35,35,,210.35,percent of total billed charges,Implant Device,210.35,35,,210.35,percent of total billed charges,Implant Device,210.35,35,,210.35,percent of total billed charges,Implant Device,210.35,35,,210.35,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,444.74,
ZIMMER 6043638S ASNIS SCREW 4X38MM,C1713,HCPCS,,79004336,CDM,278,RC,,,both,,,660,488.4,,,488.4,Other,150% of Medicare + 9.63% HCRA Surcharge,297,45,,297,percent of total billed charges,Critical Access Hospital RCC factor,224.4,34,,224.4,percent of total billed charges,Implant Device,224.4,34,,224.4,percent of total billed charges,Implant Device,224.4,34,,224.4,percent of total billed charges,Implant Device,224.4,34,,224.4,percent of total billed charges,Implant Device,224.4,34,,224.4,percent of total billed charges,Implant Device,326.7,,,326.7,Other,110% of Medicare,231,35,,231,percent of total billed charges,Implant Device,224.4,34,"Charges > $500, x 34%",224.4,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,264,40,,264,percent of total billed charges,Implant Device,231,70,,231,percent of total billed charges,All Other,224.4,34,,224.4,percent of total billed charges,Implant Device,224.4,34,,224.4,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,488.4,
ZIMMER 2102-1505 BONEGRAFT SUB 25X50X4MM,C1713,HCPCS,,79004338,CDM,278,RC,,,both,,,6450,4773.02,,,4773.02,Other,150% of Medicare + 9.63% HCRA Surcharge,2902.5,45,,2902.5,percent of total billed charges,Critical Access Hospital RCC factor,2193,34,,2193,percent of total billed charges,Implant Device,2193,34,,2193,percent of total billed charges,Implant Device,2193,34,,2193,percent of total billed charges,Implant Device,2193,34,,2193,percent of total billed charges,Implant Device,2193,34,,2193,percent of total billed charges,Implant Device,3192.75,,,3192.75,Other,110% of Medicare,2257.5,35,,2257.5,percent of total billed charges,Implant Device,2193,34,"Charges > $500, x 34%",2193,percent of total billed charges,Implant Device,2257.5,35,,2257.5,percent of total billed charges,Implant Device,2257.5,35,,2257.5,percent of total billed charges,Implant Device,2257.5,35,,2257.5,percent of total billed charges,Implant Device,2257.5,35,,2257.5,percent of total billed charges,Implant Device,2257.5,35,,2257.5,percent of total billed charges,Implant Device,2580,40,,2580,percent of total billed charges,Implant Device,2257.5,70,,2257.5,percent of total billed charges,All Other,2193,34,,2193,percent of total billed charges,Implant Device,2193,34,,2193,percent of total billed charges,Implant Device,2257.5,35,,2257.5,percent of total billed charges,Implant Device,2257.5,35,,2257.5,percent of total billed charges,Implant Device,2257.5,35,,2257.5,percent of total billed charges,Implant Device,2257.5,35,,2257.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2193,34,"If Charge > 2,000, then 34 percent",2193,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4773.02,
ZIMMER 2347-23-30 PERI SCREW 4.5X30MM,C1713,HCPCS,,79004339,CDM,278,RC,,,both,,,97,71.78,,,71.78,Other,150% of Medicare + 9.63% HCRA Surcharge,43.65,45,,43.65,percent of total billed charges,Critical Access Hospital RCC factor,32.98,34,,32.98,percent of total billed charges,Implant Device,32.98,34,,32.98,percent of total billed charges,Implant Device,32.98,34,,32.98,percent of total billed charges,Implant Device,32.98,34,,32.98,percent of total billed charges,Implant Device,32.98,34,,32.98,percent of total billed charges,Implant Device,48.02,,,48.02,Other,110% of Medicare,33.95,35,,33.95,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,33.95,35,,33.95,percent of total billed charges,Implant Device,33.95,35,,33.95,percent of total billed charges,Implant Device,33.95,35,,33.95,percent of total billed charges,Implant Device,33.95,35,,33.95,percent of total billed charges,Implant Device,33.95,35,,33.95,percent of total billed charges,Implant Device,38.8,40,,38.8,percent of total billed charges,Implant Device,33.95,70,,33.95,percent of total billed charges,All Other,32.98,34,,32.98,percent of total billed charges,Implant Device,32.98,34,,32.98,percent of total billed charges,Implant Device,33.95,35,,33.95,percent of total billed charges,Implant Device,33.95,35,,33.95,percent of total billed charges,Implant Device,33.95,35,,33.95,percent of total billed charges,Implant Device,33.95,35,,33.95,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,71.78,
ZIMMER 00-4835-030-01 CORT SCREW 3.5X30,C1713,HCPCS,,79004340,CDM,278,RC,,,both,,,73,54.02,,,54.02,Other,150% of Medicare + 9.63% HCRA Surcharge,32.85,45,,32.85,percent of total billed charges,Critical Access Hospital RCC factor,24.82,34,,24.82,percent of total billed charges,Implant Device,24.82,34,,24.82,percent of total billed charges,Implant Device,24.82,34,,24.82,percent of total billed charges,Implant Device,24.82,34,,24.82,percent of total billed charges,Implant Device,24.82,34,,24.82,percent of total billed charges,Implant Device,36.14,,,36.14,Other,110% of Medicare,25.55,35,,25.55,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,25.55,35,,25.55,percent of total billed charges,Implant Device,25.55,35,,25.55,percent of total billed charges,Implant Device,25.55,35,,25.55,percent of total billed charges,Implant Device,25.55,35,,25.55,percent of total billed charges,Implant Device,25.55,35,,25.55,percent of total billed charges,Implant Device,29.2,40,,29.2,percent of total billed charges,Implant Device,25.55,70,,25.55,percent of total billed charges,All Other,24.82,34,,24.82,percent of total billed charges,Implant Device,24.82,34,,24.82,percent of total billed charges,Implant Device,25.55,35,,25.55,percent of total billed charges,Implant Device,25.55,35,,25.55,percent of total billed charges,Implant Device,25.55,35,,25.55,percent of total billed charges,Implant Device,25.55,35,,25.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,54.02,
ZIMMER 00-2358-001-08 LATRL HUM PLATE 8H,C1713,HCPCS,,79004341,CDM,278,RC,,,both,,,6150,4551.02,,,4551.02,Other,150% of Medicare + 9.63% HCRA Surcharge,2767.5,45,,2767.5,percent of total billed charges,Critical Access Hospital RCC factor,2091,34,,2091,percent of total billed charges,Implant Device,2091,34,,2091,percent of total billed charges,Implant Device,2091,34,,2091,percent of total billed charges,Implant Device,2091,34,,2091,percent of total billed charges,Implant Device,2091,34,,2091,percent of total billed charges,Implant Device,3044.25,,,3044.25,Other,110% of Medicare,2152.5,35,,2152.5,percent of total billed charges,Implant Device,2091,34,"Charges > $500, x 34%",2091,percent of total billed charges,Implant Device,2152.5,35,,2152.5,percent of total billed charges,Implant Device,2152.5,35,,2152.5,percent of total billed charges,Implant Device,2152.5,35,,2152.5,percent of total billed charges,Implant Device,2152.5,35,,2152.5,percent of total billed charges,Implant Device,2152.5,35,,2152.5,percent of total billed charges,Implant Device,2460,40,,2460,percent of total billed charges,Implant Device,2152.5,70,,2152.5,percent of total billed charges,All Other,2091,34,,2091,percent of total billed charges,Implant Device,2091,34,,2091,percent of total billed charges,Implant Device,2152.5,35,,2152.5,percent of total billed charges,Implant Device,2152.5,35,,2152.5,percent of total billed charges,Implant Device,2152.5,35,,2152.5,percent of total billed charges,Implant Device,2152.5,35,,2152.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2091,34,"If Charge > 2,000, then 34 percent",2091,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4551.02,
ZIMMER 2347-23-28 4.5X28MM PERIART SCREW,C1713,HCPCS,,79004342,CDM,278,RC,,,both,,,97,71.78,,,71.78,Other,150% of Medicare + 9.63% HCRA Surcharge,43.65,45,,43.65,percent of total billed charges,Critical Access Hospital RCC factor,32.98,34,,32.98,percent of total billed charges,Implant Device,32.98,34,,32.98,percent of total billed charges,Implant Device,32.98,34,,32.98,percent of total billed charges,Implant Device,32.98,34,,32.98,percent of total billed charges,Implant Device,32.98,34,,32.98,percent of total billed charges,Implant Device,48.02,,,48.02,Other,110% of Medicare,33.95,35,,33.95,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,33.95,35,,33.95,percent of total billed charges,Implant Device,33.95,35,,33.95,percent of total billed charges,Implant Device,33.95,35,,33.95,percent of total billed charges,Implant Device,33.95,35,,33.95,percent of total billed charges,Implant Device,33.95,35,,33.95,percent of total billed charges,Implant Device,38.8,40,,38.8,percent of total billed charges,Implant Device,33.95,70,,33.95,percent of total billed charges,All Other,32.98,34,,32.98,percent of total billed charges,Implant Device,32.98,34,,32.98,percent of total billed charges,Implant Device,33.95,35,,33.95,percent of total billed charges,Implant Device,33.95,35,,33.95,percent of total billed charges,Implant Device,33.95,35,,33.95,percent of total billed charges,Implant Device,33.95,35,,33.95,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,71.78,
ZIMMER 00-7848-002-00 KINECT MOD NECK K,C1776,HCPCS,,79004344,CDM,278,RC,,,both,,,5064,3747.37,,,3747.37,Other,150% of Medicare + 9.63% HCRA Surcharge,2278.8,45,,2278.8,percent of total billed charges,Critical Access Hospital RCC factor,1721.76,34,,1721.76,percent of total billed charges,Implant Device,1721.76,34,,1721.76,percent of total billed charges,Implant Device,1721.76,34,,1721.76,percent of total billed charges,Implant Device,1721.76,34,,1721.76,percent of total billed charges,Implant Device,1721.76,34,,1721.76,percent of total billed charges,Implant Device,2506.68,,,2506.68,Other,110% of Medicare,1772.4,35,,1772.4,percent of total billed charges,Implant Device,1721.76,34,"Charges > $500, x 34%",1721.76,percent of total billed charges,Implant Device,1772.4,35,,1772.4,percent of total billed charges,Implant Device,1772.4,35,,1772.4,percent of total billed charges,Implant Device,1772.4,35,,1772.4,percent of total billed charges,Implant Device,1772.4,35,,1772.4,percent of total billed charges,Implant Device,1772.4,35,,1772.4,percent of total billed charges,Implant Device,2025.6,40,,2025.6,percent of total billed charges,Implant Device,1772.4,70,,1772.4,percent of total billed charges,All Other,1721.76,34,,1721.76,percent of total billed charges,Implant Device,1721.76,34,,1721.76,percent of total billed charges,Implant Device,1772.4,35,,1772.4,percent of total billed charges,Implant Device,1772.4,35,,1772.4,percent of total billed charges,Implant Device,1772.4,35,,1772.4,percent of total billed charges,Implant Device,1772.4,35,,1772.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1721.76,34,"If Charge > 2,000, then 34 percent",1721.76,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3747.37,
ZIMMER 00-4936-006-03 TUB PLATE 6H 1/3,C1713,HCPCS,,79004346,CDM,278,RC,,,both,,,455,336.7,,,336.7,Other,150% of Medicare + 9.63% HCRA Surcharge,204.75,45,,204.75,percent of total billed charges,Critical Access Hospital RCC factor,154.7,34,,154.7,percent of total billed charges,Implant Device,154.7,34,,154.7,percent of total billed charges,Implant Device,154.7,34,,154.7,percent of total billed charges,Implant Device,154.7,34,,154.7,percent of total billed charges,Implant Device,154.7,34,,154.7,percent of total billed charges,Implant Device,225.23,,,225.23,Other,110% of Medicare,159.25,35,,159.25,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,159.25,35,,159.25,percent of total billed charges,Implant Device,159.25,35,,159.25,percent of total billed charges,Implant Device,159.25,35,,159.25,percent of total billed charges,Implant Device,159.25,35,,159.25,percent of total billed charges,Implant Device,159.25,35,,159.25,percent of total billed charges,Implant Device,182,40,,182,percent of total billed charges,Implant Device,159.25,70,,159.25,percent of total billed charges,All Other,154.7,34,,154.7,percent of total billed charges,Implant Device,154.7,34,,154.7,percent of total billed charges,Implant Device,159.25,35,,159.25,percent of total billed charges,Implant Device,159.25,35,,159.25,percent of total billed charges,Implant Device,159.25,35,,159.25,percent of total billed charges,Implant Device,159.25,35,,159.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,336.7,
ZIMMER 00-2359-018-35 LCK SCREW 3.5MX18,C1713,HCPCS,,79004647,CDM,278,RC,,,both,,,306,226.44,,,226.44,Other,150% of Medicare + 9.63% HCRA Surcharge,137.7,45,,137.7,percent of total billed charges,Critical Access Hospital RCC factor,104.04,34,,104.04,percent of total billed charges,Implant Device,104.04,34,,104.04,percent of total billed charges,Implant Device,104.04,34,,104.04,percent of total billed charges,Implant Device,104.04,34,,104.04,percent of total billed charges,Implant Device,104.04,34,,104.04,percent of total billed charges,Implant Device,151.47,,,151.47,Other,110% of Medicare,107.1,35,,107.1,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,107.1,35,,107.1,percent of total billed charges,Implant Device,107.1,35,,107.1,percent of total billed charges,Implant Device,107.1,35,,107.1,percent of total billed charges,Implant Device,107.1,35,,107.1,percent of total billed charges,Implant Device,107.1,35,,107.1,percent of total billed charges,Implant Device,122.4,40,,122.4,percent of total billed charges,Implant Device,107.1,70,,107.1,percent of total billed charges,All Other,104.04,34,,104.04,percent of total billed charges,Implant Device,104.04,34,,104.04,percent of total billed charges,Implant Device,107.1,35,,107.1,percent of total billed charges,Implant Device,107.1,35,,107.1,percent of total billed charges,Implant Device,107.1,35,,107.1,percent of total billed charges,Implant Device,107.1,35,,107.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,226.44,
ZIMMER 00-1147-41-55 CANN SCREW 4X55M,C1713,HCPCS,,79004648,CDM,278,RC,,,both,,,558,412.92,,,412.92,Other,150% of Medicare + 9.63% HCRA Surcharge,251.1,45,,251.1,percent of total billed charges,Critical Access Hospital RCC factor,189.72,34,,189.72,percent of total billed charges,Implant Device,189.72,34,,189.72,percent of total billed charges,Implant Device,189.72,34,,189.72,percent of total billed charges,Implant Device,189.72,34,,189.72,percent of total billed charges,Implant Device,189.72,34,,189.72,percent of total billed charges,Implant Device,276.21,,,276.21,Other,110% of Medicare,195.3,35,,195.3,percent of total billed charges,Implant Device,189.72,34,"Charges > $500, x 34%",189.72,percent of total billed charges,Implant Device,195.3,35,,195.3,percent of total billed charges,Implant Device,195.3,35,,195.3,percent of total billed charges,Implant Device,195.3,35,,195.3,percent of total billed charges,Implant Device,195.3,35,,195.3,percent of total billed charges,Implant Device,195.3,35,,195.3,percent of total billed charges,Implant Device,223.2,40,,223.2,percent of total billed charges,Implant Device,195.3,70,,195.3,percent of total billed charges,All Other,189.72,34,,189.72,percent of total billed charges,Implant Device,189.72,34,,189.72,percent of total billed charges,Implant Device,195.3,35,,195.3,percent of total billed charges,Implant Device,195.3,35,,195.3,percent of total billed charges,Implant Device,195.3,35,,195.3,percent of total billed charges,Implant Device,195.3,35,,195.3,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,412.92,
ZIMMER 00-7713-005-00 MOD FEM STEM SZ 5,C1776,HCPCS,,79004649,CDM,278,RC,,,both,,,14400,10656.04,,,10656.04,Other,150% of Medicare + 9.63% HCRA Surcharge,6480,45,,6480,percent of total billed charges,Critical Access Hospital RCC factor,4896,34,,4896,percent of total billed charges,Implant Device,4896,34,,4896,percent of total billed charges,Implant Device,4896,34,,4896,percent of total billed charges,Implant Device,4896,34,,4896,percent of total billed charges,Implant Device,4896,34,,4896,percent of total billed charges,Implant Device,7128,,,7128,Other,110% of Medicare,5040,35,,5040,percent of total billed charges,Implant Device,4896,34,"Charges > $500, x 34%",4896,percent of total billed charges,Implant Device,5040,35,,5040,percent of total billed charges,Implant Device,5040,35,,5040,percent of total billed charges,Implant Device,5040,35,,5040,percent of total billed charges,Implant Device,5040,35,,5040,percent of total billed charges,Implant Device,5040,35,,5040,percent of total billed charges,Implant Device,5760,40,,5760,percent of total billed charges,Implant Device,5040,70,,5040,percent of total billed charges,All Other,4896,34,,4896,percent of total billed charges,Implant Device,4896,34,,4896,percent of total billed charges,Implant Device,5040,35,,5040,percent of total billed charges,Implant Device,5040,35,,5040,percent of total billed charges,Implant Device,5040,35,,5040,percent of total billed charges,Implant Device,5040,35,,5040,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,4896,34,"If Charge > 2,000, then 34 percent",4896,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,10656.04,
ZIMMER 00-1147-044-40 CANN SCREW 4X44MM,C1713,HCPCS,,79004650,CDM,278,RC,,,both,,,1713,1267.62,,,1267.62,Other,150% of Medicare + 9.63% HCRA Surcharge,770.85,45,,770.85,percent of total billed charges,Critical Access Hospital RCC factor,582.42,34,,582.42,percent of total billed charges,Implant Device,582.42,34,,582.42,percent of total billed charges,Implant Device,582.42,34,,582.42,percent of total billed charges,Implant Device,582.42,34,,582.42,percent of total billed charges,Implant Device,582.42,34,,582.42,percent of total billed charges,Implant Device,847.94,,,847.94,Other,110% of Medicare,599.55,35,,599.55,percent of total billed charges,Implant Device,582.42,34,"Charges > $500, x 34%",582.42,percent of total billed charges,Implant Device,599.55,35,,599.55,percent of total billed charges,Implant Device,599.55,35,,599.55,percent of total billed charges,Implant Device,599.55,35,,599.55,percent of total billed charges,Implant Device,599.55,35,,599.55,percent of total billed charges,Implant Device,599.55,35,,599.55,percent of total billed charges,Implant Device,685.2,40,,685.2,percent of total billed charges,Implant Device,599.55,70,,599.55,percent of total billed charges,All Other,582.42,34,,582.42,percent of total billed charges,Implant Device,582.42,34,,582.42,percent of total billed charges,Implant Device,599.55,35,,599.55,percent of total billed charges,Implant Device,599.55,35,,599.55,percent of total billed charges,Implant Device,599.55,35,,599.55,percent of total billed charges,Implant Device,599.55,35,,599.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1267.62,
ZIMMER 00-4827-010-01 CORT SCREW 2.7X10,C1713,HCPCS,,79004651,CDM,278,RC,,,both,,,62,45.88,,,45.88,Other,150% of Medicare + 9.63% HCRA Surcharge,27.9,45,,27.9,percent of total billed charges,Critical Access Hospital RCC factor,21.08,34,,21.08,percent of total billed charges,Implant Device,21.08,34,,21.08,percent of total billed charges,Implant Device,21.08,34,,21.08,percent of total billed charges,Implant Device,21.08,34,,21.08,percent of total billed charges,Implant Device,21.08,34,,21.08,percent of total billed charges,Implant Device,30.69,,,30.69,Other,110% of Medicare,21.7,35,,21.7,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,21.7,35,,21.7,percent of total billed charges,Implant Device,21.7,35,,21.7,percent of total billed charges,Implant Device,21.7,35,,21.7,percent of total billed charges,Implant Device,21.7,35,,21.7,percent of total billed charges,Implant Device,21.7,35,,21.7,percent of total billed charges,Implant Device,24.8,40,,24.8,percent of total billed charges,Implant Device,21.7,70,,21.7,percent of total billed charges,All Other,21.08,34,,21.08,percent of total billed charges,Implant Device,21.08,34,,21.08,percent of total billed charges,Implant Device,21.7,35,,21.7,percent of total billed charges,Implant Device,21.7,35,,21.7,percent of total billed charges,Implant Device,21.7,35,,21.7,percent of total billed charges,Implant Device,21.7,35,,21.7,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,45.88,
ZIMMER 00-2359-060-36 CANN SCREW 3.5X60,C1713,HCPCS,,79004653,CDM,278,RC,,,both,,,334,247.16,,,247.16,Other,150% of Medicare + 9.63% HCRA Surcharge,150.3,45,,150.3,percent of total billed charges,Critical Access Hospital RCC factor,113.56,34,,113.56,percent of total billed charges,Implant Device,113.56,34,,113.56,percent of total billed charges,Implant Device,113.56,34,,113.56,percent of total billed charges,Implant Device,113.56,34,,113.56,percent of total billed charges,Implant Device,113.56,34,,113.56,percent of total billed charges,Implant Device,165.33,,,165.33,Other,110% of Medicare,116.9,35,,116.9,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,116.9,35,,116.9,percent of total billed charges,Implant Device,116.9,35,,116.9,percent of total billed charges,Implant Device,116.9,35,,116.9,percent of total billed charges,Implant Device,116.9,35,,116.9,percent of total billed charges,Implant Device,116.9,35,,116.9,percent of total billed charges,Implant Device,133.6,40,,133.6,percent of total billed charges,Implant Device,116.9,70,,116.9,percent of total billed charges,All Other,113.56,34,,113.56,percent of total billed charges,Implant Device,113.56,34,,113.56,percent of total billed charges,Implant Device,116.9,35,,116.9,percent of total billed charges,Implant Device,116.9,35,,116.9,percent of total billed charges,Implant Device,116.9,35,,116.9,percent of total billed charges,Implant Device,116.9,35,,116.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,247.16,
ZIMMER 00-1103-020-05 BONE VOID FILL 5MM,C1713,HCPCS,,79004654,CDM,278,RC,,,both,,,2148,1589.53,,,1589.53,Other,150% of Medicare + 9.63% HCRA Surcharge,966.6,45,,966.6,percent of total billed charges,Critical Access Hospital RCC factor,730.32,34,,730.32,percent of total billed charges,Implant Device,730.32,34,,730.32,percent of total billed charges,Implant Device,730.32,34,,730.32,percent of total billed charges,Implant Device,730.32,34,,730.32,percent of total billed charges,Implant Device,730.32,34,,730.32,percent of total billed charges,Implant Device,1063.26,,,1063.26,Other,110% of Medicare,751.8,35,,751.8,percent of total billed charges,Implant Device,730.32,34,"Charges > $500, x 34%",730.32,percent of total billed charges,Implant Device,751.8,35,,751.8,percent of total billed charges,Implant Device,751.8,35,,751.8,percent of total billed charges,Implant Device,751.8,35,,751.8,percent of total billed charges,Implant Device,751.8,35,,751.8,percent of total billed charges,Implant Device,751.8,35,,751.8,percent of total billed charges,Implant Device,859.2,40,,859.2,percent of total billed charges,Implant Device,751.8,70,,751.8,percent of total billed charges,All Other,730.32,34,,730.32,percent of total billed charges,Implant Device,730.32,34,,730.32,percent of total billed charges,Implant Device,751.8,35,,751.8,percent of total billed charges,Implant Device,751.8,35,,751.8,percent of total billed charges,Implant Device,751.8,35,,751.8,percent of total billed charges,Implant Device,751.8,35,,751.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,730.32,34,"If Charge > 2,000, then 34 percent",730.32,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1589.53,
ZIMMER 7711-13-REV FEMORAL STEM SZ13.5,C1776,HCPCS,,79004655,CDM,278,RC,,,both,,,14400,10656.04,,,10656.04,Other,150% of Medicare + 9.63% HCRA Surcharge,6480,45,,6480,percent of total billed charges,Critical Access Hospital RCC factor,4896,34,,4896,percent of total billed charges,Implant Device,4896,34,,4896,percent of total billed charges,Implant Device,4896,34,,4896,percent of total billed charges,Implant Device,4896,34,,4896,percent of total billed charges,Implant Device,4896,34,,4896,percent of total billed charges,Implant Device,7128,,,7128,Other,110% of Medicare,5040,35,,5040,percent of total billed charges,Implant Device,4896,34,"Charges > $500, x 34%",4896,percent of total billed charges,Implant Device,5040,35,,5040,percent of total billed charges,Implant Device,5040,35,,5040,percent of total billed charges,Implant Device,5040,35,,5040,percent of total billed charges,Implant Device,5040,35,,5040,percent of total billed charges,Implant Device,5040,35,,5040,percent of total billed charges,Implant Device,5760,40,,5760,percent of total billed charges,Implant Device,5040,70,,5040,percent of total billed charges,All Other,4896,34,,4896,percent of total billed charges,Implant Device,4896,34,,4896,percent of total billed charges,Implant Device,5040,35,,5040,percent of total billed charges,Implant Device,5040,35,,5040,percent of total billed charges,Implant Device,5040,35,,5040,percent of total billed charges,Implant Device,5040,35,,5040,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,4896,34,"If Charge > 2,000, then 34 percent",4896,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,10656.04,
ZIMMER 7859-12 DISTAL CENTRALIZER 12MM,C1776,HCPCS,,79004658,CDM,278,RC,,,both,,,383,283.42,,,283.42,Other,150% of Medicare + 9.63% HCRA Surcharge,172.35,45,,172.35,percent of total billed charges,Critical Access Hospital RCC factor,130.22,34,,130.22,percent of total billed charges,Implant Device,130.22,34,,130.22,percent of total billed charges,Implant Device,130.22,34,,130.22,percent of total billed charges,Implant Device,130.22,34,,130.22,percent of total billed charges,Implant Device,130.22,34,,130.22,percent of total billed charges,Implant Device,189.59,,,189.59,Other,110% of Medicare,134.05,35,,134.05,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,134.05,35,,134.05,percent of total billed charges,Implant Device,134.05,35,,134.05,percent of total billed charges,Implant Device,134.05,35,,134.05,percent of total billed charges,Implant Device,134.05,35,,134.05,percent of total billed charges,Implant Device,134.05,35,,134.05,percent of total billed charges,Implant Device,153.2,40,,153.2,percent of total billed charges,Implant Device,134.05,70,,134.05,percent of total billed charges,All Other,130.22,34,,130.22,percent of total billed charges,Implant Device,130.22,34,,130.22,percent of total billed charges,Implant Device,134.05,35,,134.05,percent of total billed charges,Implant Device,134.05,35,,134.05,percent of total billed charges,Implant Device,134.05,35,,134.05,percent of total billed charges,Implant Device,134.05,35,,134.05,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,283.42,
ZIMMER 32-8105-53-01 C/M ULNA ASSMBLY,C1776,HCPCS,,79004659,CDM,278,RC,,,both,,,14400,10656.04,,,10656.04,Other,150% of Medicare + 9.63% HCRA Surcharge,6480,45,,6480,percent of total billed charges,Critical Access Hospital RCC factor,4896,34,,4896,percent of total billed charges,Implant Device,4896,34,,4896,percent of total billed charges,Implant Device,4896,34,,4896,percent of total billed charges,Implant Device,4896,34,,4896,percent of total billed charges,Implant Device,4896,34,,4896,percent of total billed charges,Implant Device,7128,,,7128,Other,110% of Medicare,5040,35,,5040,percent of total billed charges,Implant Device,4896,34,"Charges > $500, x 34%",4896,percent of total billed charges,Implant Device,5040,35,,5040,percent of total billed charges,Implant Device,5040,35,,5040,percent of total billed charges,Implant Device,5040,35,,5040,percent of total billed charges,Implant Device,5040,35,,5040,percent of total billed charges,Implant Device,5040,35,,5040,percent of total billed charges,Implant Device,5760,40,,5760,percent of total billed charges,Implant Device,5040,70,,5040,percent of total billed charges,All Other,4896,34,,4896,percent of total billed charges,Implant Device,4896,34,,4896,percent of total billed charges,Implant Device,5040,35,,5040,percent of total billed charges,Implant Device,5040,35,,5040,percent of total billed charges,Implant Device,5040,35,,5040,percent of total billed charges,Implant Device,5040,35,,5040,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,4896,34,"If Charge > 2,000, then 34 percent",4896,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,10656.04,
ZIMMER 8018-36-02 VERSYS FEM HEAD 36MM,C1776,HCPCS,,79004660,CDM,278,RC,,,both,,,1680,1243.2,,,1243.2,Other,150% of Medicare + 9.63% HCRA Surcharge,756,45,,756,percent of total billed charges,Critical Access Hospital RCC factor,571.2,34,,571.2,percent of total billed charges,Implant Device,571.2,34,,571.2,percent of total billed charges,Implant Device,571.2,34,,571.2,percent of total billed charges,Implant Device,571.2,34,,571.2,percent of total billed charges,Implant Device,571.2,34,,571.2,percent of total billed charges,Implant Device,831.6,,,831.6,Other,110% of Medicare,588,35,,588,percent of total billed charges,Implant Device,571.2,34,"Charges > $500, x 34%",571.2,percent of total billed charges,Implant Device,588,35,,588,percent of total billed charges,Implant Device,588,35,,588,percent of total billed charges,Implant Device,588,35,,588,percent of total billed charges,Implant Device,588,35,,588,percent of total billed charges,Implant Device,588,35,,588,percent of total billed charges,Implant Device,672,40,,672,percent of total billed charges,Implant Device,588,70,,588,percent of total billed charges,All Other,571.2,34,,571.2,percent of total billed charges,Implant Device,571.2,34,,571.2,percent of total billed charges,Implant Device,588,35,,588,percent of total billed charges,Implant Device,588,35,,588,percent of total billed charges,Implant Device,588,35,,588,percent of total billed charges,Implant Device,588,35,,588,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1243.2,
ZIMMER 02-03150-080 CORT SCREW 5X80MM,C1713,HCPCS,,79004662,CDM,278,RC,,,both,,,498,368.52,,,368.52,Other,150% of Medicare + 9.63% HCRA Surcharge,224.1,45,,224.1,percent of total billed charges,Critical Access Hospital RCC factor,169.32,34,,169.32,percent of total billed charges,Implant Device,169.32,34,,169.32,percent of total billed charges,Implant Device,169.32,34,,169.32,percent of total billed charges,Implant Device,169.32,34,,169.32,percent of total billed charges,Implant Device,169.32,34,,169.32,percent of total billed charges,Implant Device,246.51,,,246.51,Other,110% of Medicare,174.3,35,,174.3,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,174.3,35,,174.3,percent of total billed charges,Implant Device,174.3,35,,174.3,percent of total billed charges,Implant Device,174.3,35,,174.3,percent of total billed charges,Implant Device,174.3,35,,174.3,percent of total billed charges,Implant Device,174.3,35,,174.3,percent of total billed charges,Implant Device,199.2,40,,199.2,percent of total billed charges,Implant Device,174.3,70,,174.3,percent of total billed charges,All Other,169.32,34,,169.32,percent of total billed charges,Implant Device,169.32,34,,169.32,percent of total billed charges,Implant Device,174.3,35,,174.3,percent of total billed charges,Implant Device,174.3,35,,174.3,percent of total billed charges,Implant Device,174.3,35,,174.3,percent of total billed charges,Implant Device,174.3,35,,174.3,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,368.52,
ZIMMER 00-5970-000-01 CR FLEX PIN GUIDES,C1713,HCPCS,,79004663,CDM,278,RC,,,both,,,3600,2664.01,,,2664.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1620,45,,1620,percent of total billed charges,Critical Access Hospital RCC factor,1224,34,,1224,percent of total billed charges,Implant Device,1224,34,,1224,percent of total billed charges,Implant Device,1224,34,,1224,percent of total billed charges,Implant Device,1224,34,,1224,percent of total billed charges,Implant Device,1224,34,,1224,percent of total billed charges,Implant Device,1782,,,1782,Other,110% of Medicare,1260,35,,1260,percent of total billed charges,Implant Device,1224,34,"Charges > $500, x 34%",1224,percent of total billed charges,Implant Device,1260,35,,1260,percent of total billed charges,Implant Device,1260,35,,1260,percent of total billed charges,Implant Device,1260,35,,1260,percent of total billed charges,Implant Device,1260,35,,1260,percent of total billed charges,Implant Device,1260,35,,1260,percent of total billed charges,Implant Device,1440,40,,1440,percent of total billed charges,Implant Device,1260,70,,1260,percent of total billed charges,All Other,1224,34,,1224,percent of total billed charges,Implant Device,1224,34,,1224,percent of total billed charges,Implant Device,1260,35,,1260,percent of total billed charges,Implant Device,1260,35,,1260,percent of total billed charges,Implant Device,1260,35,,1260,percent of total billed charges,Implant Device,1260,35,,1260,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1224,34,"If Charge > 2,000, then 34 percent",1224,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2664.01,
ZIMMER 2359-40-55 CANN LCK SCREW 5.5X40,C1713,HCPCS,,79004664,CDM,278,RC,,,both,,,578,427.72,,,427.72,Other,150% of Medicare + 9.63% HCRA Surcharge,260.1,45,,260.1,percent of total billed charges,Critical Access Hospital RCC factor,196.52,34,,196.52,percent of total billed charges,Implant Device,196.52,34,,196.52,percent of total billed charges,Implant Device,196.52,34,,196.52,percent of total billed charges,Implant Device,196.52,34,,196.52,percent of total billed charges,Implant Device,196.52,34,,196.52,percent of total billed charges,Implant Device,286.11,,,286.11,Other,110% of Medicare,202.3,35,,202.3,percent of total billed charges,Implant Device,196.52,34,"Charges > $500, x 34%",196.52,percent of total billed charges,Implant Device,202.3,35,,202.3,percent of total billed charges,Implant Device,202.3,35,,202.3,percent of total billed charges,Implant Device,202.3,35,,202.3,percent of total billed charges,Implant Device,202.3,35,,202.3,percent of total billed charges,Implant Device,202.3,35,,202.3,percent of total billed charges,Implant Device,231.2,40,,231.2,percent of total billed charges,Implant Device,202.3,70,,202.3,percent of total billed charges,All Other,196.52,34,,196.52,percent of total billed charges,Implant Device,196.52,34,,196.52,percent of total billed charges,Implant Device,202.3,35,,202.3,percent of total billed charges,Implant Device,202.3,35,,202.3,percent of total billed charges,Implant Device,202.3,35,,202.3,percent of total billed charges,Implant Device,202.3,35,,202.3,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,427.72,
ZIMMER 50-5994-014-91 NEX FEM COMP SZ D,C1776,HCPCS,,79004665,CDM,278,RC,,,both,,,21420,15850.85,,,15850.85,Other,150% of Medicare + 9.63% HCRA Surcharge,9639,45,,9639,percent of total billed charges,Critical Access Hospital RCC factor,7282.8,34,,7282.8,percent of total billed charges,Implant Device,7282.8,34,,7282.8,percent of total billed charges,Implant Device,7282.8,34,,7282.8,percent of total billed charges,Implant Device,7282.8,34,,7282.8,percent of total billed charges,Implant Device,7282.8,34,,7282.8,percent of total billed charges,Implant Device,10602.9,,,10602.9,Other,110% of Medicare,7497,35,,7497,percent of total billed charges,Implant Device,7282.8,34,"Charges > $500, x 34%",7282.8,percent of total billed charges,Implant Device,7497,35,,7497,percent of total billed charges,Implant Device,7497,35,,7497,percent of total billed charges,Implant Device,7497,35,,7497,percent of total billed charges,Implant Device,7497,35,,7497,percent of total billed charges,Implant Device,7497,35,,7497,percent of total billed charges,Implant Device,8568,40,,8568,percent of total billed charges,Implant Device,7497,70,,7497,percent of total billed charges,All Other,7282.8,34,,7282.8,percent of total billed charges,Implant Device,7282.8,34,,7282.8,percent of total billed charges,Implant Device,7497,35,,7497,percent of total billed charges,Implant Device,7497,35,,7497,percent of total billed charges,Implant Device,7497,35,,7497,percent of total billed charges,Implant Device,7497,35,,7497,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,7282.8,34,"If Charge > 2,000, then 34 percent",7282.8,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,15850.85,
ZIMMER 02-03264-118 DIST FEM PLATE 355MM,C1713,HCPCS,,79004666,CDM,278,RC,,,both,,,4752,3516.49,,,3516.49,Other,150% of Medicare + 9.63% HCRA Surcharge,2138.4,45,,2138.4,percent of total billed charges,Critical Access Hospital RCC factor,1615.68,34,,1615.68,percent of total billed charges,Implant Device,1615.68,34,,1615.68,percent of total billed charges,Implant Device,1615.68,34,,1615.68,percent of total billed charges,Implant Device,1615.68,34,,1615.68,percent of total billed charges,Implant Device,1615.68,34,,1615.68,percent of total billed charges,Implant Device,2352.24,,,2352.24,Other,110% of Medicare,1663.2,35,,1663.2,percent of total billed charges,Implant Device,1615.68,34,"Charges > $500, x 34%",1615.68,percent of total billed charges,Implant Device,1663.2,35,,1663.2,percent of total billed charges,Implant Device,1663.2,35,,1663.2,percent of total billed charges,Implant Device,1663.2,35,,1663.2,percent of total billed charges,Implant Device,1663.2,35,,1663.2,percent of total billed charges,Implant Device,1663.2,35,,1663.2,percent of total billed charges,Implant Device,1900.8,40,,1900.8,percent of total billed charges,Implant Device,1663.2,70,,1663.2,percent of total billed charges,All Other,1615.68,34,,1615.68,percent of total billed charges,Implant Device,1615.68,34,,1615.68,percent of total billed charges,Implant Device,1663.2,35,,1663.2,percent of total billed charges,Implant Device,1663.2,35,,1663.2,percent of total billed charges,Implant Device,1663.2,35,,1663.2,percent of total billed charges,Implant Device,1663.2,35,,1663.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1615.68,34,"If Charge > 2,000, then 34 percent",1615.68,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3516.49,
ZIMMER 2348-22-35 CORT  SCREW 3.5X22MM,C1713,HCPCS,,79004667,CDM,278,RC,,,both,,,103,76.22,,,76.22,Other,150% of Medicare + 9.63% HCRA Surcharge,46.35,45,,46.35,percent of total billed charges,Critical Access Hospital RCC factor,35.02,34,,35.02,percent of total billed charges,Implant Device,35.02,34,,35.02,percent of total billed charges,Implant Device,35.02,34,,35.02,percent of total billed charges,Implant Device,35.02,34,,35.02,percent of total billed charges,Implant Device,35.02,34,,35.02,percent of total billed charges,Implant Device,50.99,,,50.99,Other,110% of Medicare,36.05,35,,36.05,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,36.05,35,,36.05,percent of total billed charges,Implant Device,36.05,35,,36.05,percent of total billed charges,Implant Device,36.05,35,,36.05,percent of total billed charges,Implant Device,36.05,35,,36.05,percent of total billed charges,Implant Device,36.05,35,,36.05,percent of total billed charges,Implant Device,41.2,40,,41.2,percent of total billed charges,Implant Device,36.05,70,,36.05,percent of total billed charges,All Other,35.02,34,,35.02,percent of total billed charges,Implant Device,35.02,34,,35.02,percent of total billed charges,Implant Device,36.05,35,,36.05,percent of total billed charges,Implant Device,36.05,35,,36.05,percent of total billed charges,Implant Device,36.05,35,,36.05,percent of total billed charges,Implant Device,36.05,35,,36.05,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,76.22,
ZIMMER 32-8105-26-06 C/M HUM ASSMBLY 6IN,C1776,HCPCS,,79004668,CDM,278,RC,,,both,,,15209,11254.7,,,11254.7,Other,150% of Medicare + 9.63% HCRA Surcharge,6844.05,45,,6844.05,percent of total billed charges,Critical Access Hospital RCC factor,5171.06,34,,5171.06,percent of total billed charges,Implant Device,5171.06,34,,5171.06,percent of total billed charges,Implant Device,5171.06,34,,5171.06,percent of total billed charges,Implant Device,5171.06,34,,5171.06,percent of total billed charges,Implant Device,5171.06,34,,5171.06,percent of total billed charges,Implant Device,7528.46,,,7528.46,Other,110% of Medicare,5323.15,35,,5323.15,percent of total billed charges,Implant Device,5171.06,34,"Charges > $500, x 34%",5171.06,percent of total billed charges,Implant Device,5323.15,35,,5323.15,percent of total billed charges,Implant Device,5323.15,35,,5323.15,percent of total billed charges,Implant Device,5323.15,35,,5323.15,percent of total billed charges,Implant Device,5323.15,35,,5323.15,percent of total billed charges,Implant Device,5323.15,35,,5323.15,percent of total billed charges,Implant Device,6083.6,40,,6083.6,percent of total billed charges,Implant Device,5323.15,70,,5323.15,percent of total billed charges,All Other,5171.06,34,,5171.06,percent of total billed charges,Implant Device,5171.06,34,,5171.06,percent of total billed charges,Implant Device,5323.15,35,,5323.15,percent of total billed charges,Implant Device,5323.15,35,,5323.15,percent of total billed charges,Implant Device,5323.15,35,,5323.15,percent of total billed charges,Implant Device,5323.15,35,,5323.15,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,5171.06,34,"If Charge > 2,000, then 34 percent",5171.06,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,11254.7,
ZIMMER 1147-96 WASHER,C1713,HCPCS,,79004669,CDM,278,RC,,,both,,,108,79.92,,,79.92,Other,150% of Medicare + 9.63% HCRA Surcharge,48.6,45,,48.6,percent of total billed charges,Critical Access Hospital RCC factor,36.72,34,,36.72,percent of total billed charges,Implant Device,36.72,34,,36.72,percent of total billed charges,Implant Device,36.72,34,,36.72,percent of total billed charges,Implant Device,36.72,34,,36.72,percent of total billed charges,Implant Device,36.72,34,,36.72,percent of total billed charges,Implant Device,53.46,,,53.46,Other,110% of Medicare,37.8,35,,37.8,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,37.8,35,,37.8,percent of total billed charges,Implant Device,37.8,35,,37.8,percent of total billed charges,Implant Device,37.8,35,,37.8,percent of total billed charges,Implant Device,37.8,35,,37.8,percent of total billed charges,Implant Device,37.8,35,,37.8,percent of total billed charges,Implant Device,43.2,40,,43.2,percent of total billed charges,Implant Device,37.8,70,,37.8,percent of total billed charges,All Other,36.72,34,,36.72,percent of total billed charges,Implant Device,36.72,34,,36.72,percent of total billed charges,Implant Device,37.8,35,,37.8,percent of total billed charges,Implant Device,37.8,35,,37.8,percent of total billed charges,Implant Device,37.8,35,,37.8,percent of total billed charges,Implant Device,37.8,35,,37.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,79.92,
ZIMMER 2253-035-55 INTERLCK SCREW5.5X35,C1713,HCPCS,,79004670,CDM,278,RC,,,both,,,654,483.96,,,483.96,Other,150% of Medicare + 9.63% HCRA Surcharge,294.3,45,,294.3,percent of total billed charges,Critical Access Hospital RCC factor,222.36,34,,222.36,percent of total billed charges,Implant Device,222.36,34,,222.36,percent of total billed charges,Implant Device,222.36,34,,222.36,percent of total billed charges,Implant Device,222.36,34,,222.36,percent of total billed charges,Implant Device,222.36,34,,222.36,percent of total billed charges,Implant Device,323.73,,,323.73,Other,110% of Medicare,228.9,35,,228.9,percent of total billed charges,Implant Device,222.36,34,"Charges > $500, x 34%",222.36,percent of total billed charges,Implant Device,228.9,35,,228.9,percent of total billed charges,Implant Device,228.9,35,,228.9,percent of total billed charges,Implant Device,228.9,35,,228.9,percent of total billed charges,Implant Device,228.9,35,,228.9,percent of total billed charges,Implant Device,228.9,35,,228.9,percent of total billed charges,Implant Device,261.6,40,,261.6,percent of total billed charges,Implant Device,228.9,70,,228.9,percent of total billed charges,All Other,222.36,34,,222.36,percent of total billed charges,Implant Device,222.36,34,,222.36,percent of total billed charges,Implant Device,228.9,35,,228.9,percent of total billed charges,Implant Device,228.9,35,,228.9,percent of total billed charges,Implant Device,228.9,35,,228.9,percent of total billed charges,Implant Device,228.9,35,,228.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,483.96,
ZIMMER 00-2359-070-36 LOCK SCREW 3.5X70,C1713,HCPCS,,79004672,CDM,278,RC,,,both,,,334,247.16,,,247.16,Other,150% of Medicare + 9.63% HCRA Surcharge,150.3,45,,150.3,percent of total billed charges,Critical Access Hospital RCC factor,113.56,34,,113.56,percent of total billed charges,Implant Device,113.56,34,,113.56,percent of total billed charges,Implant Device,113.56,34,,113.56,percent of total billed charges,Implant Device,113.56,34,,113.56,percent of total billed charges,Implant Device,113.56,34,,113.56,percent of total billed charges,Implant Device,165.33,,,165.33,Other,110% of Medicare,116.9,35,,116.9,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,116.9,35,,116.9,percent of total billed charges,Implant Device,116.9,35,,116.9,percent of total billed charges,Implant Device,116.9,35,,116.9,percent of total billed charges,Implant Device,116.9,35,,116.9,percent of total billed charges,Implant Device,116.9,35,,116.9,percent of total billed charges,Implant Device,133.6,40,,133.6,percent of total billed charges,Implant Device,116.9,70,,116.9,percent of total billed charges,All Other,113.56,34,,113.56,percent of total billed charges,Implant Device,113.56,34,,113.56,percent of total billed charges,Implant Device,116.9,35,,116.9,percent of total billed charges,Implant Device,116.9,35,,116.9,percent of total billed charges,Implant Device,116.9,35,,116.9,percent of total billed charges,Implant Device,116.9,35,,116.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,247.16,
ZIMMER 00-2359-034-45 LOCK SCREW 4.5X34,C1713,HCPCS,,79004673,CDM,278,RC,,,both,,,445,329.3,,,329.3,Other,150% of Medicare + 9.63% HCRA Surcharge,200.25,45,,200.25,percent of total billed charges,Critical Access Hospital RCC factor,151.3,34,,151.3,percent of total billed charges,Implant Device,151.3,34,,151.3,percent of total billed charges,Implant Device,151.3,34,,151.3,percent of total billed charges,Implant Device,151.3,34,,151.3,percent of total billed charges,Implant Device,151.3,34,,151.3,percent of total billed charges,Implant Device,220.28,,,220.28,Other,110% of Medicare,155.75,35,,155.75,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,155.75,35,,155.75,percent of total billed charges,Implant Device,155.75,35,,155.75,percent of total billed charges,Implant Device,155.75,35,,155.75,percent of total billed charges,Implant Device,155.75,35,,155.75,percent of total billed charges,Implant Device,155.75,35,,155.75,percent of total billed charges,Implant Device,178,40,,178,percent of total billed charges,Implant Device,155.75,70,,155.75,percent of total billed charges,All Other,151.3,34,,151.3,percent of total billed charges,Implant Device,151.3,34,,151.3,percent of total billed charges,Implant Device,155.75,35,,155.75,percent of total billed charges,Implant Device,155.75,35,,155.75,percent of total billed charges,Implant Device,155.75,35,,155.75,percent of total billed charges,Implant Device,155.75,35,,155.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,329.3,
ZIMMER 00-4835-016-01 CORT SCREW 3.5X16`,C1713,HCPCS,,79004674,CDM,278,RC,,,both,,,72,53.28,,,53.28,Other,150% of Medicare + 9.63% HCRA Surcharge,32.4,45,,32.4,percent of total billed charges,Critical Access Hospital RCC factor,24.48,34,,24.48,percent of total billed charges,Implant Device,24.48,34,,24.48,percent of total billed charges,Implant Device,24.48,34,,24.48,percent of total billed charges,Implant Device,24.48,34,,24.48,percent of total billed charges,Implant Device,24.48,34,,24.48,percent of total billed charges,Implant Device,35.64,,,35.64,Other,110% of Medicare,25.2,35,,25.2,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,25.2,35,,25.2,percent of total billed charges,Implant Device,25.2,35,,25.2,percent of total billed charges,Implant Device,25.2,35,,25.2,percent of total billed charges,Implant Device,25.2,35,,25.2,percent of total billed charges,Implant Device,25.2,35,,25.2,percent of total billed charges,Implant Device,28.8,40,,28.8,percent of total billed charges,Implant Device,25.2,70,,25.2,percent of total billed charges,All Other,24.48,34,,24.48,percent of total billed charges,Implant Device,24.48,34,,24.48,percent of total billed charges,Implant Device,25.2,35,,25.2,percent of total billed charges,Implant Device,25.2,35,,25.2,percent of total billed charges,Implant Device,25.2,35,,25.2,percent of total billed charges,Implant Device,25.2,35,,25.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,53.28,
ZIMMER 00-2359-030-55LOCK SCREW 5.5XMM,C1713,HCPCS,,79004675,CDM,278,RC,,,both,,,578,427.72,,,427.72,Other,150% of Medicare + 9.63% HCRA Surcharge,260.1,45,,260.1,percent of total billed charges,Critical Access Hospital RCC factor,196.52,34,,196.52,percent of total billed charges,Implant Device,196.52,34,,196.52,percent of total billed charges,Implant Device,196.52,34,,196.52,percent of total billed charges,Implant Device,196.52,34,,196.52,percent of total billed charges,Implant Device,196.52,34,,196.52,percent of total billed charges,Implant Device,286.11,,,286.11,Other,110% of Medicare,202.3,35,,202.3,percent of total billed charges,Implant Device,196.52,34,"Charges > $500, x 34%",196.52,percent of total billed charges,Implant Device,202.3,35,,202.3,percent of total billed charges,Implant Device,202.3,35,,202.3,percent of total billed charges,Implant Device,202.3,35,,202.3,percent of total billed charges,Implant Device,202.3,35,,202.3,percent of total billed charges,Implant Device,202.3,35,,202.3,percent of total billed charges,Implant Device,231.2,40,,231.2,percent of total billed charges,Implant Device,202.3,70,,202.3,percent of total billed charges,All Other,196.52,34,,196.52,percent of total billed charges,Implant Device,196.52,34,,196.52,percent of total billed charges,Implant Device,202.3,35,,202.3,percent of total billed charges,Implant Device,202.3,35,,202.3,percent of total billed charges,Implant Device,202.3,35,,202.3,percent of total billed charges,Implant Device,202.3,35,,202.3,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,427.72,
ZIMMER 00-2359-080-55 LOCK SCREW 5.5X80,C1713,HCPCS,,79004676,CDM,278,RC,,,both,,,578,427.72,,,427.72,Other,150% of Medicare + 9.63% HCRA Surcharge,260.1,45,,260.1,percent of total billed charges,Critical Access Hospital RCC factor,196.52,34,,196.52,percent of total billed charges,Implant Device,196.52,34,,196.52,percent of total billed charges,Implant Device,196.52,34,,196.52,percent of total billed charges,Implant Device,196.52,34,,196.52,percent of total billed charges,Implant Device,196.52,34,,196.52,percent of total billed charges,Implant Device,286.11,,,286.11,Other,110% of Medicare,202.3,35,,202.3,percent of total billed charges,Implant Device,196.52,34,"Charges > $500, x 34%",196.52,percent of total billed charges,Implant Device,202.3,35,,202.3,percent of total billed charges,Implant Device,202.3,35,,202.3,percent of total billed charges,Implant Device,202.3,35,,202.3,percent of total billed charges,Implant Device,202.3,35,,202.3,percent of total billed charges,Implant Device,202.3,35,,202.3,percent of total billed charges,Implant Device,231.2,40,,231.2,percent of total billed charges,Implant Device,202.3,70,,202.3,percent of total billed charges,All Other,196.52,34,,196.52,percent of total billed charges,Implant Device,196.52,34,,196.52,percent of total billed charges,Implant Device,202.3,35,,202.3,percent of total billed charges,Implant Device,202.3,35,,202.3,percent of total billed charges,Implant Device,202.3,35,,202.3,percent of total billed charges,Implant Device,202.3,35,,202.3,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,427.72,
ZIMMER 02-03150-070 CORT SCREW 5X70MM,C1713,HCPCS,,79004677,CDM,278,RC,,,both,,,498,368.52,,,368.52,Other,150% of Medicare + 9.63% HCRA Surcharge,224.1,45,,224.1,percent of total billed charges,Critical Access Hospital RCC factor,169.32,34,,169.32,percent of total billed charges,Implant Device,169.32,34,,169.32,percent of total billed charges,Implant Device,169.32,34,,169.32,percent of total billed charges,Implant Device,169.32,34,,169.32,percent of total billed charges,Implant Device,169.32,34,,169.32,percent of total billed charges,Implant Device,246.51,,,246.51,Other,110% of Medicare,174.3,35,,174.3,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,174.3,35,,174.3,percent of total billed charges,Implant Device,174.3,35,,174.3,percent of total billed charges,Implant Device,174.3,35,,174.3,percent of total billed charges,Implant Device,174.3,35,,174.3,percent of total billed charges,Implant Device,174.3,35,,174.3,percent of total billed charges,Implant Device,199.2,40,,199.2,percent of total billed charges,Implant Device,174.3,70,,174.3,percent of total billed charges,All Other,169.32,34,,169.32,percent of total billed charges,Implant Device,169.32,34,,169.32,percent of total billed charges,Implant Device,174.3,35,,174.3,percent of total billed charges,Implant Device,174.3,35,,174.3,percent of total billed charges,Implant Device,174.3,35,,174.3,percent of total billed charges,Implant Device,174.3,35,,174.3,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,368.52,
ZIMMER 00-4835-014-01 CORT SCREW 3.5X14,C1713,HCPCS,,79004678,CDM,278,RC,,,both,,,72,53.28,,,53.28,Other,150% of Medicare + 9.63% HCRA Surcharge,32.4,45,,32.4,percent of total billed charges,Critical Access Hospital RCC factor,24.48,34,,24.48,percent of total billed charges,Implant Device,24.48,34,,24.48,percent of total billed charges,Implant Device,24.48,34,,24.48,percent of total billed charges,Implant Device,24.48,34,,24.48,percent of total billed charges,Implant Device,24.48,34,,24.48,percent of total billed charges,Implant Device,35.64,,,35.64,Other,110% of Medicare,25.2,35,,25.2,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,25.2,35,,25.2,percent of total billed charges,Implant Device,25.2,35,,25.2,percent of total billed charges,Implant Device,25.2,35,,25.2,percent of total billed charges,Implant Device,25.2,35,,25.2,percent of total billed charges,Implant Device,25.2,35,,25.2,percent of total billed charges,Implant Device,28.8,40,,28.8,percent of total billed charges,Implant Device,25.2,70,,25.2,percent of total billed charges,All Other,24.48,34,,24.48,percent of total billed charges,Implant Device,24.48,34,,24.48,percent of total billed charges,Implant Device,25.2,35,,25.2,percent of total billed charges,Implant Device,25.2,35,,25.2,percent of total billed charges,Implant Device,25.2,35,,25.2,percent of total billed charges,Implant Device,25.2,35,,25.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,53.28,
ZIMMER 00-1147-042-40 CANN SCREW 4X42MM,C1713,HCPCS,,79004679,CDM,278,RC,,,both,,,395,292.3,,,292.3,Other,150% of Medicare + 9.63% HCRA Surcharge,177.75,45,,177.75,percent of total billed charges,Critical Access Hospital RCC factor,134.3,34,,134.3,percent of total billed charges,Implant Device,134.3,34,,134.3,percent of total billed charges,Implant Device,134.3,34,,134.3,percent of total billed charges,Implant Device,134.3,34,,134.3,percent of total billed charges,Implant Device,134.3,34,,134.3,percent of total billed charges,Implant Device,195.53,,,195.53,Other,110% of Medicare,138.25,35,,138.25,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,138.25,35,,138.25,percent of total billed charges,Implant Device,138.25,35,,138.25,percent of total billed charges,Implant Device,138.25,35,,138.25,percent of total billed charges,Implant Device,138.25,35,,138.25,percent of total billed charges,Implant Device,138.25,35,,138.25,percent of total billed charges,Implant Device,158,40,,158,percent of total billed charges,Implant Device,138.25,70,,138.25,percent of total billed charges,All Other,134.3,34,,134.3,percent of total billed charges,Implant Device,134.3,34,,134.3,percent of total billed charges,Implant Device,138.25,35,,138.25,percent of total billed charges,Implant Device,138.25,35,,138.25,percent of total billed charges,Implant Device,138.25,35,,138.25,percent of total billed charges,Implant Device,138.25,35,,138.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,292.3,
ZIMMER 002359-012-38 LOCK SCREW 3.5X12MM,C1713,HCPCS,,79004680,CDM,278,RC,,,both,,,313,231.62,,,231.62,Other,150% of Medicare + 9.63% HCRA Surcharge,140.85,45,,140.85,percent of total billed charges,Critical Access Hospital RCC factor,106.42,34,,106.42,percent of total billed charges,Implant Device,106.42,34,,106.42,percent of total billed charges,Implant Device,106.42,34,,106.42,percent of total billed charges,Implant Device,106.42,34,,106.42,percent of total billed charges,Implant Device,106.42,34,,106.42,percent of total billed charges,Implant Device,154.94,,,154.94,Other,110% of Medicare,109.55,35,,109.55,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,109.55,35,,109.55,percent of total billed charges,Implant Device,109.55,35,,109.55,percent of total billed charges,Implant Device,109.55,35,,109.55,percent of total billed charges,Implant Device,109.55,35,,109.55,percent of total billed charges,Implant Device,109.55,35,,109.55,percent of total billed charges,Implant Device,125.2,40,,125.2,percent of total billed charges,Implant Device,109.55,70,,109.55,percent of total billed charges,All Other,106.42,34,,106.42,percent of total billed charges,Implant Device,106.42,34,,106.42,percent of total billed charges,Implant Device,109.55,35,,109.55,percent of total billed charges,Implant Device,109.55,35,,109.55,percent of total billed charges,Implant Device,109.55,35,,109.55,percent of total billed charges,Implant Device,109.55,35,,109.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,231.62,
ZIMMER 4865-70-02 CANC SCREW 6.5X70MM,C1713,HCPCS,,79004681,CDM,278,RC,,,both,,,106,78.44,,,78.44,Other,150% of Medicare + 9.63% HCRA Surcharge,47.7,45,,47.7,percent of total billed charges,Critical Access Hospital RCC factor,36.04,34,,36.04,percent of total billed charges,Implant Device,36.04,34,,36.04,percent of total billed charges,Implant Device,36.04,34,,36.04,percent of total billed charges,Implant Device,36.04,34,,36.04,percent of total billed charges,Implant Device,36.04,34,,36.04,percent of total billed charges,Implant Device,52.47,,,52.47,Other,110% of Medicare,37.1,35,,37.1,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,37.1,35,,37.1,percent of total billed charges,Implant Device,37.1,35,,37.1,percent of total billed charges,Implant Device,37.1,35,,37.1,percent of total billed charges,Implant Device,37.1,35,,37.1,percent of total billed charges,Implant Device,37.1,35,,37.1,percent of total billed charges,Implant Device,42.4,40,,42.4,percent of total billed charges,Implant Device,37.1,70,,37.1,percent of total billed charges,All Other,36.04,34,,36.04,percent of total billed charges,Implant Device,36.04,34,,36.04,percent of total billed charges,Implant Device,37.1,35,,37.1,percent of total billed charges,Implant Device,37.1,35,,37.1,percent of total billed charges,Implant Device,37.1,35,,37.1,percent of total billed charges,Implant Device,37.1,35,,37.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,78.44,
ZIMMER 02.03151.020 UNICORT SCR 5X20MM,C1713,HCPCS,,79004682,CDM,278,RC,,,both,,,488,361.12,,,361.12,Other,150% of Medicare + 9.63% HCRA Surcharge,219.6,45,,219.6,percent of total billed charges,Critical Access Hospital RCC factor,165.92,34,,165.92,percent of total billed charges,Implant Device,165.92,34,,165.92,percent of total billed charges,Implant Device,165.92,34,,165.92,percent of total billed charges,Implant Device,165.92,34,,165.92,percent of total billed charges,Implant Device,165.92,34,,165.92,percent of total billed charges,Implant Device,241.56,,,241.56,Other,110% of Medicare,170.8,35,,170.8,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,170.8,35,,170.8,percent of total billed charges,Implant Device,170.8,35,,170.8,percent of total billed charges,Implant Device,170.8,35,,170.8,percent of total billed charges,Implant Device,170.8,35,,170.8,percent of total billed charges,Implant Device,170.8,35,,170.8,percent of total billed charges,Implant Device,195.2,40,,195.2,percent of total billed charges,Implant Device,170.8,70,,170.8,percent of total billed charges,All Other,165.92,34,,165.92,percent of total billed charges,Implant Device,165.92,34,,165.92,percent of total billed charges,Implant Device,170.8,35,,170.8,percent of total billed charges,Implant Device,170.8,35,,170.8,percent of total billed charges,Implant Device,170.8,35,,170.8,percent of total billed charges,Implant Device,170.8,35,,170.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,361.12,
ZIMMER 00-2480-014-40 CANC SCREW 4X14MM,C1713,HCPCS,,79004685,CDM,278,RC,,,both,,,180,133.2,,,133.2,Other,150% of Medicare + 9.63% HCRA Surcharge,81,45,,81,percent of total billed charges,Critical Access Hospital RCC factor,61.2,34,,61.2,percent of total billed charges,Implant Device,61.2,34,,61.2,percent of total billed charges,Implant Device,61.2,34,,61.2,percent of total billed charges,Implant Device,61.2,34,,61.2,percent of total billed charges,Implant Device,61.2,34,,61.2,percent of total billed charges,Implant Device,89.1,,,89.1,Other,110% of Medicare,63,35,,63,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,63,35,,63,percent of total billed charges,Implant Device,63,35,,63,percent of total billed charges,Implant Device,63,35,,63,percent of total billed charges,Implant Device,63,35,,63,percent of total billed charges,Implant Device,63,35,,63,percent of total billed charges,Implant Device,72,40,,72,percent of total billed charges,Implant Device,63,70,,63,percent of total billed charges,All Other,61.2,34,,61.2,percent of total billed charges,Implant Device,61.2,34,,61.2,percent of total billed charges,Implant Device,63,35,,63,percent of total billed charges,Implant Device,63,35,,63,percent of total billed charges,Implant Device,63,35,,63,percent of total billed charges,Implant Device,63,35,,63,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,133.2,
ZIMMER 02.03151.010 UNICORT SCR 5X10MM,C1713,HCPCS,,79004686,CDM,278,RC,,,both,,,488,361.12,,,361.12,Other,150% of Medicare + 9.63% HCRA Surcharge,219.6,45,,219.6,percent of total billed charges,Critical Access Hospital RCC factor,165.92,34,,165.92,percent of total billed charges,Implant Device,165.92,34,,165.92,percent of total billed charges,Implant Device,165.92,34,,165.92,percent of total billed charges,Implant Device,165.92,34,,165.92,percent of total billed charges,Implant Device,165.92,34,,165.92,percent of total billed charges,Implant Device,241.56,,,241.56,Other,110% of Medicare,170.8,35,,170.8,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,170.8,35,,170.8,percent of total billed charges,Implant Device,170.8,35,,170.8,percent of total billed charges,Implant Device,170.8,35,,170.8,percent of total billed charges,Implant Device,170.8,35,,170.8,percent of total billed charges,Implant Device,170.8,35,,170.8,percent of total billed charges,Implant Device,195.2,40,,195.2,percent of total billed charges,Implant Device,170.8,70,,170.8,percent of total billed charges,All Other,165.92,34,,165.92,percent of total billed charges,Implant Device,165.92,34,,165.92,percent of total billed charges,Implant Device,170.8,35,,170.8,percent of total billed charges,Implant Device,170.8,35,,170.8,percent of total billed charges,Implant Device,170.8,35,,170.8,percent of total billed charges,Implant Device,170.8,35,,170.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,361.12,
ZIMMER 00-7848-012-00 KINECTIV MOD NECK,C1776,HCPCS,,79004687,CDM,278,RC,,,both,,,900,666,,,666,Other,150% of Medicare + 9.63% HCRA Surcharge,405,45,,405,percent of total billed charges,Critical Access Hospital RCC factor,306,34,,306,percent of total billed charges,Implant Device,306,34,,306,percent of total billed charges,Implant Device,306,34,,306,percent of total billed charges,Implant Device,306,34,,306,percent of total billed charges,Implant Device,306,34,,306,percent of total billed charges,Implant Device,445.5,,,445.5,Other,110% of Medicare,315,35,,315,percent of total billed charges,Implant Device,306,34,"Charges > $500, x 34%",306,percent of total billed charges,Implant Device,315,35,,315,percent of total billed charges,Implant Device,315,35,,315,percent of total billed charges,Implant Device,315,35,,315,percent of total billed charges,Implant Device,315,35,,315,percent of total billed charges,Implant Device,315,35,,315,percent of total billed charges,Implant Device,360,40,,360,percent of total billed charges,Implant Device,315,70,,315,percent of total billed charges,All Other,306,34,,306,percent of total billed charges,Implant Device,306,34,,306,percent of total billed charges,Implant Device,315,35,,315,percent of total billed charges,Implant Device,315,35,,315,percent of total billed charges,Implant Device,315,35,,315,percent of total billed charges,Implant Device,315,35,,315,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,666,
ZIMMER 00-4936-005-03 ULS 1/3 PLT 3.5X68,C1713,HCPCS,,79004690,CDM,278,RC,,,both,,,440,325.6,,,325.6,Other,150% of Medicare + 9.63% HCRA Surcharge,198,45,,198,percent of total billed charges,Critical Access Hospital RCC factor,149.6,34,,149.6,percent of total billed charges,Implant Device,149.6,34,,149.6,percent of total billed charges,Implant Device,149.6,34,,149.6,percent of total billed charges,Implant Device,149.6,34,,149.6,percent of total billed charges,Implant Device,149.6,34,,149.6,percent of total billed charges,Implant Device,217.8,,,217.8,Other,110% of Medicare,154,35,,154,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,154,35,,154,percent of total billed charges,Implant Device,154,35,,154,percent of total billed charges,Implant Device,154,35,,154,percent of total billed charges,Implant Device,154,35,,154,percent of total billed charges,Implant Device,154,35,,154,percent of total billed charges,Implant Device,176,40,,176,percent of total billed charges,Implant Device,154,70,,154,percent of total billed charges,All Other,149.6,34,,149.6,percent of total billed charges,Implant Device,149.6,34,,149.6,percent of total billed charges,Implant Device,154,35,,154,percent of total billed charges,Implant Device,154,35,,154,percent of total billed charges,Implant Device,154,35,,154,percent of total billed charges,Implant Device,154,35,,154,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,325.6,
ZIMMER 00-7713-012-00 M/L TPR FEM STEM,C1776,HCPCS,,79004691,CDM,278,RC,,,both,,,13500,9990.03,,,9990.03,Other,150% of Medicare + 9.63% HCRA Surcharge,6075,45,,6075,percent of total billed charges,Critical Access Hospital RCC factor,4590,34,,4590,percent of total billed charges,Implant Device,4590,34,,4590,percent of total billed charges,Implant Device,4590,34,,4590,percent of total billed charges,Implant Device,4590,34,,4590,percent of total billed charges,Implant Device,4590,34,,4590,percent of total billed charges,Implant Device,6682.5,,,6682.5,Other,110% of Medicare,4725,35,,4725,percent of total billed charges,Implant Device,4590,34,"Charges > $500, x 34%",4590,percent of total billed charges,Implant Device,4725,35,,4725,percent of total billed charges,Implant Device,4725,35,,4725,percent of total billed charges,Implant Device,4725,35,,4725,percent of total billed charges,Implant Device,4725,35,,4725,percent of total billed charges,Implant Device,4725,35,,4725,percent of total billed charges,Implant Device,5400,40,,5400,percent of total billed charges,Implant Device,4725,70,,4725,percent of total billed charges,All Other,4590,34,,4590,percent of total billed charges,Implant Device,4590,34,,4590,percent of total billed charges,Implant Device,4725,35,,4725,percent of total billed charges,Implant Device,4725,35,,4725,percent of total billed charges,Implant Device,4725,35,,4725,percent of total billed charges,Implant Device,4725,35,,4725,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,4590,34,"If Charge > 2,000, then 34 percent",4590,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,9990.03,
ZIMMER 7850-13 VERSYS CEMNTD STD COLLAR,C1776,HCPCS,,79004692,CDM,278,RC,,,both,,,11730,8680.23,,,8680.23,Other,150% of Medicare + 9.63% HCRA Surcharge,5278.5,45,,5278.5,percent of total billed charges,Critical Access Hospital RCC factor,3988.2,34,,3988.2,percent of total billed charges,Implant Device,3988.2,34,,3988.2,percent of total billed charges,Implant Device,3988.2,34,,3988.2,percent of total billed charges,Implant Device,3988.2,34,,3988.2,percent of total billed charges,Implant Device,3988.2,34,,3988.2,percent of total billed charges,Implant Device,5806.35,,,5806.35,Other,110% of Medicare,4105.5,35,,4105.5,percent of total billed charges,Implant Device,3988.2,34,"Charges > $500, x 34%",3988.2,percent of total billed charges,Implant Device,4105.5,35,,4105.5,percent of total billed charges,Implant Device,4105.5,35,,4105.5,percent of total billed charges,Implant Device,4105.5,35,,4105.5,percent of total billed charges,Implant Device,4105.5,35,,4105.5,percent of total billed charges,Implant Device,4105.5,35,,4105.5,percent of total billed charges,Implant Device,4692,40,,4692,percent of total billed charges,Implant Device,4105.5,70,,4105.5,percent of total billed charges,All Other,3988.2,34,,3988.2,percent of total billed charges,Implant Device,3988.2,34,,3988.2,percent of total billed charges,Implant Device,4105.5,35,,4105.5,percent of total billed charges,Implant Device,4105.5,35,,4105.5,percent of total billed charges,Implant Device,4105.5,35,,4105.5,percent of total billed charges,Implant Device,4105.5,35,,4105.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3988.2,34,"If Charge > 2,000, then 34 percent",3988.2,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,8680.23,
ZIMMER 00-2347-020-40 PERI SCREW 35X40MM,C1713,HCPCS,,79004693,CDM,278,RC,,,both,,,100,74,,,74,Other,150% of Medicare + 9.63% HCRA Surcharge,45,45,,45,percent of total billed charges,Critical Access Hospital RCC factor,34,34,,34,percent of total billed charges,Implant Device,34,34,,34,percent of total billed charges,Implant Device,34,34,,34,percent of total billed charges,Implant Device,34,34,,34,percent of total billed charges,Implant Device,34,34,,34,percent of total billed charges,Implant Device,49.5,,,49.5,Other,110% of Medicare,35,35,,35,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,35,35,,35,percent of total billed charges,Implant Device,35,35,,35,percent of total billed charges,Implant Device,35,35,,35,percent of total billed charges,Implant Device,35,35,,35,percent of total billed charges,Implant Device,35,35,,35,percent of total billed charges,Implant Device,40,40,,40,percent of total billed charges,Implant Device,35,70,,35,percent of total billed charges,All Other,34,34,,34,percent of total billed charges,Implant Device,34,34,,34,percent of total billed charges,Implant Device,35,35,,35,percent of total billed charges,Implant Device,35,35,,35,percent of total billed charges,Implant Device,35,35,,35,percent of total billed charges,Implant Device,35,35,,35,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,74,
ZIMMER 32-8105-26-04 HUMRL ASSMBLY REG 4,C1776,HCPCS,,79004694,CDM,278,RC,,,both,,,15209,11254.7,,,11254.7,Other,150% of Medicare + 9.63% HCRA Surcharge,6844.05,45,,6844.05,percent of total billed charges,Critical Access Hospital RCC factor,5171.06,34,,5171.06,percent of total billed charges,Implant Device,5171.06,34,,5171.06,percent of total billed charges,Implant Device,5171.06,34,,5171.06,percent of total billed charges,Implant Device,5171.06,34,,5171.06,percent of total billed charges,Implant Device,5171.06,34,,5171.06,percent of total billed charges,Implant Device,7528.46,,,7528.46,Other,110% of Medicare,5323.15,35,,5323.15,percent of total billed charges,Implant Device,5171.06,34,"Charges > $500, x 34%",5171.06,percent of total billed charges,Implant Device,5323.15,35,,5323.15,percent of total billed charges,Implant Device,5323.15,35,,5323.15,percent of total billed charges,Implant Device,5323.15,35,,5323.15,percent of total billed charges,Implant Device,5323.15,35,,5323.15,percent of total billed charges,Implant Device,5323.15,35,,5323.15,percent of total billed charges,Implant Device,6083.6,40,,6083.6,percent of total billed charges,Implant Device,5323.15,70,,5323.15,percent of total billed charges,All Other,5171.06,34,,5171.06,percent of total billed charges,Implant Device,5171.06,34,,5171.06,percent of total billed charges,Implant Device,5323.15,35,,5323.15,percent of total billed charges,Implant Device,5323.15,35,,5323.15,percent of total billed charges,Implant Device,5323.15,35,,5323.15,percent of total billed charges,Implant Device,5323.15,35,,5323.15,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,5171.06,34,"If Charge > 2,000, then 34 percent",5171.06,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,11254.7,
ZIMMER 00-2348-054-35 SCREW 3.5X54X2.7,C1713,HCPCS,,79004695,CDM,278,RC,,,both,,,106,78.44,,,78.44,Other,150% of Medicare + 9.63% HCRA Surcharge,47.7,45,,47.7,percent of total billed charges,Critical Access Hospital RCC factor,36.04,34,,36.04,percent of total billed charges,Implant Device,36.04,34,,36.04,percent of total billed charges,Implant Device,36.04,34,,36.04,percent of total billed charges,Implant Device,36.04,34,,36.04,percent of total billed charges,Implant Device,36.04,34,,36.04,percent of total billed charges,Implant Device,52.47,,,52.47,Other,110% of Medicare,37.1,35,,37.1,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,37.1,35,,37.1,percent of total billed charges,Implant Device,37.1,35,,37.1,percent of total billed charges,Implant Device,37.1,35,,37.1,percent of total billed charges,Implant Device,37.1,35,,37.1,percent of total billed charges,Implant Device,37.1,35,,37.1,percent of total billed charges,Implant Device,42.4,40,,42.4,percent of total billed charges,Implant Device,37.1,70,,37.1,percent of total billed charges,All Other,36.04,34,,36.04,percent of total billed charges,Implant Device,36.04,34,,36.04,percent of total billed charges,Implant Device,37.1,35,,37.1,percent of total billed charges,Implant Device,37.1,35,,37.1,percent of total billed charges,Implant Device,37.1,35,,37.1,percent of total billed charges,Implant Device,37.1,35,,37.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,78.44,
ZIMMER 00-4835-012-01 CORT SCREW 3.5X12,C1713,HCPCS,,79004696,CDM,278,RC,,,both,,,71,52.54,,,52.54,Other,150% of Medicare + 9.63% HCRA Surcharge,31.95,45,,31.95,percent of total billed charges,Critical Access Hospital RCC factor,24.14,34,,24.14,percent of total billed charges,Implant Device,24.14,34,,24.14,percent of total billed charges,Implant Device,24.14,34,,24.14,percent of total billed charges,Implant Device,24.14,34,,24.14,percent of total billed charges,Implant Device,24.14,34,,24.14,percent of total billed charges,Implant Device,35.15,,,35.15,Other,110% of Medicare,24.85,35,,24.85,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,24.85,35,,24.85,percent of total billed charges,Implant Device,24.85,35,,24.85,percent of total billed charges,Implant Device,24.85,35,,24.85,percent of total billed charges,Implant Device,24.85,35,,24.85,percent of total billed charges,Implant Device,24.85,35,,24.85,percent of total billed charges,Implant Device,28.4,40,,28.4,percent of total billed charges,Implant Device,24.85,70,,24.85,percent of total billed charges,All Other,24.14,34,,24.14,percent of total billed charges,Implant Device,24.14,34,,24.14,percent of total billed charges,Implant Device,24.85,35,,24.85,percent of total billed charges,Implant Device,24.85,35,,24.85,percent of total billed charges,Implant Device,24.85,35,,24.85,percent of total billed charges,Implant Device,24.85,35,,24.85,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,52.54,
ZIMMER 00-4828-022-02 LOCK SCREW 2.7X22,C1713,HCPCS,,79004697,CDM,278,RC,,,both,,,302,223.48,,,223.48,Other,150% of Medicare + 9.63% HCRA Surcharge,135.9,45,,135.9,percent of total billed charges,Critical Access Hospital RCC factor,102.68,34,,102.68,percent of total billed charges,Implant Device,102.68,34,,102.68,percent of total billed charges,Implant Device,102.68,34,,102.68,percent of total billed charges,Implant Device,102.68,34,,102.68,percent of total billed charges,Implant Device,102.68,34,,102.68,percent of total billed charges,Implant Device,149.49,,,149.49,Other,110% of Medicare,105.7,35,,105.7,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,105.7,35,,105.7,percent of total billed charges,Implant Device,105.7,35,,105.7,percent of total billed charges,Implant Device,105.7,35,,105.7,percent of total billed charges,Implant Device,105.7,35,,105.7,percent of total billed charges,Implant Device,105.7,35,,105.7,percent of total billed charges,Implant Device,120.8,40,,120.8,percent of total billed charges,Implant Device,105.7,70,,105.7,percent of total billed charges,All Other,102.68,34,,102.68,percent of total billed charges,Implant Device,102.68,34,,102.68,percent of total billed charges,Implant Device,105.7,35,,105.7,percent of total billed charges,Implant Device,105.7,35,,105.7,percent of total billed charges,Implant Device,105.7,35,,105.7,percent of total billed charges,Implant Device,105.7,35,,105.7,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,223.48,
ZIMMER 00-2347-023-34 PER SCREW 4.5X34MM,C1713,HCPCS,,79004698,CDM,278,RC,,,both,,,141,104.34,,,104.34,Other,150% of Medicare + 9.63% HCRA Surcharge,63.45,45,,63.45,percent of total billed charges,Critical Access Hospital RCC factor,47.94,34,,47.94,percent of total billed charges,Implant Device,47.94,34,,47.94,percent of total billed charges,Implant Device,47.94,34,,47.94,percent of total billed charges,Implant Device,47.94,34,,47.94,percent of total billed charges,Implant Device,47.94,34,,47.94,percent of total billed charges,Implant Device,69.8,,,69.8,Other,110% of Medicare,49.35,35,,49.35,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,49.35,35,,49.35,percent of total billed charges,Implant Device,49.35,35,,49.35,percent of total billed charges,Implant Device,49.35,35,,49.35,percent of total billed charges,Implant Device,49.35,35,,49.35,percent of total billed charges,Implant Device,49.35,35,,49.35,percent of total billed charges,Implant Device,56.4,40,,56.4,percent of total billed charges,Implant Device,49.35,70,,49.35,percent of total billed charges,All Other,47.94,34,,47.94,percent of total billed charges,Implant Device,47.94,34,,47.94,percent of total billed charges,Implant Device,49.35,35,,49.35,percent of total billed charges,Implant Device,49.35,35,,49.35,percent of total billed charges,Implant Device,49.35,35,,49.35,percent of total billed charges,Implant Device,49.35,35,,49.35,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,104.34,
ZIMMER 00-2358-009-03 ULNAR LK PLATE 3H,C1713,HCPCS,,79004700,CDM,278,RC,,,both,,,2892,2140.09,,,2140.09,Other,150% of Medicare + 9.63% HCRA Surcharge,1301.4,45,,1301.4,percent of total billed charges,Critical Access Hospital RCC factor,983.28,34,,983.28,percent of total billed charges,Implant Device,983.28,34,,983.28,percent of total billed charges,Implant Device,983.28,34,,983.28,percent of total billed charges,Implant Device,983.28,34,,983.28,percent of total billed charges,Implant Device,983.28,34,,983.28,percent of total billed charges,Implant Device,1431.54,,,1431.54,Other,110% of Medicare,1012.2,35,,1012.2,percent of total billed charges,Implant Device,983.28,34,"Charges > $500, x 34%",983.28,percent of total billed charges,Implant Device,1012.2,35,,1012.2,percent of total billed charges,Implant Device,1012.2,35,,1012.2,percent of total billed charges,Implant Device,1012.2,35,,1012.2,percent of total billed charges,Implant Device,1012.2,35,,1012.2,percent of total billed charges,Implant Device,1012.2,35,,1012.2,percent of total billed charges,Implant Device,1156.8,40,,1156.8,percent of total billed charges,Implant Device,1012.2,70,,1012.2,percent of total billed charges,All Other,983.28,34,,983.28,percent of total billed charges,Implant Device,983.28,34,,983.28,percent of total billed charges,Implant Device,1012.2,35,,1012.2,percent of total billed charges,Implant Device,1012.2,35,,1012.2,percent of total billed charges,Implant Device,1012.2,35,,1012.2,percent of total billed charges,Implant Device,1012.2,35,,1012.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,983.28,34,"If Charge > 2,000, then 34 percent",983.28,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2140.09,
ZIMMER 02.03155.034 CORT SCREW 4X34MM,C1713,HCPCS,,79004701,CDM,278,RC,,,both,,,324,239.76,,,239.76,Other,150% of Medicare + 9.63% HCRA Surcharge,145.8,45,,145.8,percent of total billed charges,Critical Access Hospital RCC factor,110.16,34,,110.16,percent of total billed charges,Implant Device,110.16,34,,110.16,percent of total billed charges,Implant Device,110.16,34,,110.16,percent of total billed charges,Implant Device,110.16,34,,110.16,percent of total billed charges,Implant Device,110.16,34,,110.16,percent of total billed charges,Implant Device,160.38,,,160.38,Other,110% of Medicare,113.4,35,,113.4,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,129.6,40,,129.6,percent of total billed charges,Implant Device,113.4,70,,113.4,percent of total billed charges,All Other,110.16,34,,110.16,percent of total billed charges,Implant Device,110.16,34,,110.16,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,239.76,
ZIMMER 02-03150-065 CORT SCREW 5X65MM,C1713,HCPCS,,79004703,CDM,278,RC,,,both,,,498,368.52,,,368.52,Other,150% of Medicare + 9.63% HCRA Surcharge,224.1,45,,224.1,percent of total billed charges,Critical Access Hospital RCC factor,169.32,34,,169.32,percent of total billed charges,Implant Device,169.32,34,,169.32,percent of total billed charges,Implant Device,169.32,34,,169.32,percent of total billed charges,Implant Device,169.32,34,,169.32,percent of total billed charges,Implant Device,169.32,34,,169.32,percent of total billed charges,Implant Device,246.51,,,246.51,Other,110% of Medicare,174.3,35,,174.3,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,174.3,35,,174.3,percent of total billed charges,Implant Device,174.3,35,,174.3,percent of total billed charges,Implant Device,174.3,35,,174.3,percent of total billed charges,Implant Device,174.3,35,,174.3,percent of total billed charges,Implant Device,174.3,35,,174.3,percent of total billed charges,Implant Device,199.2,40,,199.2,percent of total billed charges,Implant Device,174.3,70,,174.3,percent of total billed charges,All Other,169.32,34,,169.32,percent of total billed charges,Implant Device,169.32,34,,169.32,percent of total billed charges,Implant Device,174.3,35,,174.3,percent of total billed charges,Implant Device,174.3,35,,174.3,percent of total billed charges,Implant Device,174.3,35,,174.3,percent of total billed charges,Implant Device,174.3,35,,174.3,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,368.52,
ZIMMER 1147-40-40 CANN SCREW 4X40MM,C1713,HCPCS,,79004704,CDM,278,RC,,,both,,,605,447.7,,,447.7,Other,150% of Medicare + 9.63% HCRA Surcharge,272.25,45,,272.25,percent of total billed charges,Critical Access Hospital RCC factor,205.7,34,,205.7,percent of total billed charges,Implant Device,205.7,34,,205.7,percent of total billed charges,Implant Device,205.7,34,,205.7,percent of total billed charges,Implant Device,205.7,34,,205.7,percent of total billed charges,Implant Device,205.7,34,,205.7,percent of total billed charges,Implant Device,299.48,,,299.48,Other,110% of Medicare,211.75,35,,211.75,percent of total billed charges,Implant Device,205.7,34,"Charges > $500, x 34%",205.7,percent of total billed charges,Implant Device,211.75,35,,211.75,percent of total billed charges,Implant Device,211.75,35,,211.75,percent of total billed charges,Implant Device,211.75,35,,211.75,percent of total billed charges,Implant Device,211.75,35,,211.75,percent of total billed charges,Implant Device,211.75,35,,211.75,percent of total billed charges,Implant Device,242,40,,242,percent of total billed charges,Implant Device,211.75,70,,211.75,percent of total billed charges,All Other,205.7,34,,205.7,percent of total billed charges,Implant Device,205.7,34,,205.7,percent of total billed charges,Implant Device,211.75,35,,211.75,percent of total billed charges,Implant Device,211.75,35,,211.75,percent of total billed charges,Implant Device,211.75,35,,211.75,percent of total billed charges,Implant Device,211.75,35,,211.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,447.7,
ZIMMER 00-1147-050-41 CANN SCREW 4X50MM,C1713,HCPCS,,79004705,CDM,278,RC,,,both,,,558,412.92,,,412.92,Other,150% of Medicare + 9.63% HCRA Surcharge,251.1,45,,251.1,percent of total billed charges,Critical Access Hospital RCC factor,189.72,34,,189.72,percent of total billed charges,Implant Device,189.72,34,,189.72,percent of total billed charges,Implant Device,189.72,34,,189.72,percent of total billed charges,Implant Device,189.72,34,,189.72,percent of total billed charges,Implant Device,189.72,34,,189.72,percent of total billed charges,Implant Device,276.21,,,276.21,Other,110% of Medicare,195.3,35,,195.3,percent of total billed charges,Implant Device,189.72,34,"Charges > $500, x 34%",189.72,percent of total billed charges,Implant Device,195.3,35,,195.3,percent of total billed charges,Implant Device,195.3,35,,195.3,percent of total billed charges,Implant Device,195.3,35,,195.3,percent of total billed charges,Implant Device,195.3,35,,195.3,percent of total billed charges,Implant Device,195.3,35,,195.3,percent of total billed charges,Implant Device,223.2,40,,223.2,percent of total billed charges,Implant Device,195.3,70,,195.3,percent of total billed charges,All Other,189.72,34,,189.72,percent of total billed charges,Implant Device,189.72,34,,189.72,percent of total billed charges,Implant Device,195.3,35,,195.3,percent of total billed charges,Implant Device,195.3,35,,195.3,percent of total billed charges,Implant Device,195.3,35,,195.3,percent of total billed charges,Implant Device,195.3,35,,195.3,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,412.92,
ZIMMER 2348-010-35 CORT SCREW 3.5X10MM,C1713,HCPCS,,79004706,CDM,278,RC,,,both,,,103,76.22,,,76.22,Other,150% of Medicare + 9.63% HCRA Surcharge,46.35,45,,46.35,percent of total billed charges,Critical Access Hospital RCC factor,35.02,34,,35.02,percent of total billed charges,Implant Device,35.02,34,,35.02,percent of total billed charges,Implant Device,35.02,34,,35.02,percent of total billed charges,Implant Device,35.02,34,,35.02,percent of total billed charges,Implant Device,35.02,34,,35.02,percent of total billed charges,Implant Device,50.99,,,50.99,Other,110% of Medicare,36.05,35,,36.05,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,36.05,35,,36.05,percent of total billed charges,Implant Device,36.05,35,,36.05,percent of total billed charges,Implant Device,36.05,35,,36.05,percent of total billed charges,Implant Device,36.05,35,,36.05,percent of total billed charges,Implant Device,36.05,35,,36.05,percent of total billed charges,Implant Device,41.2,40,,41.2,percent of total billed charges,Implant Device,36.05,70,,36.05,percent of total billed charges,All Other,35.02,34,,35.02,percent of total billed charges,Implant Device,35.02,34,,35.02,percent of total billed charges,Implant Device,36.05,35,,36.05,percent of total billed charges,Implant Device,36.05,35,,36.05,percent of total billed charges,Implant Device,36.05,35,,36.05,percent of total billed charges,Implant Device,36.05,35,,36.05,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,76.22,
ZIMMER 02.03152.075 NCB CANC SCREW 5X75,C1713,HCPCS,,79004707,CDM,278,RC,,,both,,,432,319.68,,,319.68,Other,150% of Medicare + 9.63% HCRA Surcharge,194.4,45,,194.4,percent of total billed charges,Critical Access Hospital RCC factor,146.88,34,,146.88,percent of total billed charges,Implant Device,146.88,34,,146.88,percent of total billed charges,Implant Device,146.88,34,,146.88,percent of total billed charges,Implant Device,146.88,34,,146.88,percent of total billed charges,Implant Device,146.88,34,,146.88,percent of total billed charges,Implant Device,213.84,,,213.84,Other,110% of Medicare,151.2,35,,151.2,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,151.2,35,,151.2,percent of total billed charges,Implant Device,151.2,35,,151.2,percent of total billed charges,Implant Device,151.2,35,,151.2,percent of total billed charges,Implant Device,151.2,35,,151.2,percent of total billed charges,Implant Device,151.2,35,,151.2,percent of total billed charges,Implant Device,172.8,40,,172.8,percent of total billed charges,Implant Device,151.2,70,,151.2,percent of total billed charges,All Other,146.88,34,,146.88,percent of total billed charges,Implant Device,146.88,34,,146.88,percent of total billed charges,Implant Device,151.2,35,,151.2,percent of total billed charges,Implant Device,151.2,35,,151.2,percent of total billed charges,Implant Device,151.2,35,,151.2,percent of total billed charges,Implant Device,151.2,35,,151.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,319.68,
ZIMMER 2359-65-55 LOCK SCREW 5.5X65MM,C1713,HCPCS,,79004709,CDM,278,RC,,,both,,,575,425.5,,,425.5,Other,150% of Medicare + 9.63% HCRA Surcharge,258.75,45,,258.75,percent of total billed charges,Critical Access Hospital RCC factor,195.5,34,,195.5,percent of total billed charges,Implant Device,195.5,34,,195.5,percent of total billed charges,Implant Device,195.5,34,,195.5,percent of total billed charges,Implant Device,195.5,34,,195.5,percent of total billed charges,Implant Device,195.5,34,,195.5,percent of total billed charges,Implant Device,284.63,,,284.63,Other,110% of Medicare,201.25,35,,201.25,percent of total billed charges,Implant Device,195.5,34,"Charges > $500, x 34%",195.5,percent of total billed charges,Implant Device,201.25,35,,201.25,percent of total billed charges,Implant Device,201.25,35,,201.25,percent of total billed charges,Implant Device,201.25,35,,201.25,percent of total billed charges,Implant Device,201.25,35,,201.25,percent of total billed charges,Implant Device,201.25,35,,201.25,percent of total billed charges,Implant Device,230,40,,230,percent of total billed charges,Implant Device,201.25,70,,201.25,percent of total billed charges,All Other,195.5,34,,195.5,percent of total billed charges,Implant Device,195.5,34,,195.5,percent of total billed charges,Implant Device,201.25,35,,201.25,percent of total billed charges,Implant Device,201.25,35,,201.25,percent of total billed charges,Implant Device,201.25,35,,201.25,percent of total billed charges,Implant Device,201.25,35,,201.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,425.5,
ZIMMER 02-03155-026 NCB CORT SCREW 4X26,C1713,HCPCS,,79004710,CDM,278,RC,,,both,,,402,297.48,,,297.48,Other,150% of Medicare + 9.63% HCRA Surcharge,180.9,45,,180.9,percent of total billed charges,Critical Access Hospital RCC factor,136.68,34,,136.68,percent of total billed charges,Implant Device,136.68,34,,136.68,percent of total billed charges,Implant Device,136.68,34,,136.68,percent of total billed charges,Implant Device,136.68,34,,136.68,percent of total billed charges,Implant Device,136.68,34,,136.68,percent of total billed charges,Implant Device,198.99,,,198.99,Other,110% of Medicare,140.7,35,,140.7,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,140.7,35,,140.7,percent of total billed charges,Implant Device,140.7,35,,140.7,percent of total billed charges,Implant Device,140.7,35,,140.7,percent of total billed charges,Implant Device,140.7,35,,140.7,percent of total billed charges,Implant Device,140.7,35,,140.7,percent of total billed charges,Implant Device,160.8,40,,160.8,percent of total billed charges,Implant Device,140.7,70,,140.7,percent of total billed charges,All Other,136.68,34,,136.68,percent of total billed charges,Implant Device,136.68,34,,136.68,percent of total billed charges,Implant Device,140.7,35,,140.7,percent of total billed charges,Implant Device,140.7,35,,140.7,percent of total billed charges,Implant Device,140.7,35,,140.7,percent of total billed charges,Implant Device,140.7,35,,140.7,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,297.48,
ZIMMER 00-2348-026-35 SCREW 3.5X26X2.7,C1713,HCPCS,,79004711,CDM,278,RC,,,both,,,276,204.24,,,204.24,Other,150% of Medicare + 9.63% HCRA Surcharge,124.2,45,,124.2,percent of total billed charges,Critical Access Hospital RCC factor,93.84,34,,93.84,percent of total billed charges,Implant Device,93.84,34,,93.84,percent of total billed charges,Implant Device,93.84,34,,93.84,percent of total billed charges,Implant Device,93.84,34,,93.84,percent of total billed charges,Implant Device,93.84,34,,93.84,percent of total billed charges,Implant Device,136.62,,,136.62,Other,110% of Medicare,96.6,35,,96.6,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,96.6,35,,96.6,percent of total billed charges,Implant Device,96.6,35,,96.6,percent of total billed charges,Implant Device,96.6,35,,96.6,percent of total billed charges,Implant Device,96.6,35,,96.6,percent of total billed charges,Implant Device,96.6,35,,96.6,percent of total billed charges,Implant Device,110.4,40,,110.4,percent of total billed charges,Implant Device,96.6,70,,96.6,percent of total billed charges,All Other,93.84,34,,93.84,percent of total billed charges,Implant Device,93.84,34,,93.84,percent of total billed charges,Implant Device,96.6,35,,96.6,percent of total billed charges,Implant Device,96.6,35,,96.6,percent of total billed charges,Implant Device,96.6,35,,96.6,percent of total billed charges,Implant Device,96.6,35,,96.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,204.24,
ZIMMER 7711-16 TAPER HIP FEM STEM 12/14,C1776,HCPCS,,79004712,CDM,278,RC,,,both,,,6900,5106.02,,,5106.02,Other,150% of Medicare + 9.63% HCRA Surcharge,3105,45,,3105,percent of total billed charges,Critical Access Hospital RCC factor,2346,34,,2346,percent of total billed charges,Implant Device,2346,34,,2346,percent of total billed charges,Implant Device,2346,34,,2346,percent of total billed charges,Implant Device,2346,34,,2346,percent of total billed charges,Implant Device,2346,34,,2346,percent of total billed charges,Implant Device,3415.5,,,3415.5,Other,110% of Medicare,2415,35,,2415,percent of total billed charges,Implant Device,2346,34,"Charges > $500, x 34%",2346,percent of total billed charges,Implant Device,2415,35,,2415,percent of total billed charges,Implant Device,2415,35,,2415,percent of total billed charges,Implant Device,2415,35,,2415,percent of total billed charges,Implant Device,2415,35,,2415,percent of total billed charges,Implant Device,2415,35,,2415,percent of total billed charges,Implant Device,2760,40,,2760,percent of total billed charges,Implant Device,2415,70,,2415,percent of total billed charges,All Other,2346,34,,2346,percent of total billed charges,Implant Device,2346,34,,2346,percent of total billed charges,Implant Device,2415,35,,2415,percent of total billed charges,Implant Device,2415,35,,2415,percent of total billed charges,Implant Device,2415,35,,2415,percent of total billed charges,Implant Device,2415,35,,2415,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2346,34,"If Charge > 2,000, then 34 percent",2346,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5106.02,
ZIMMER 7818-45 HIP SYSTEM 12/14 TAPR 45,C1776,HCPCS,,79004713,CDM,278,RC,,,both,,,1886,1395.64,,,1395.64,Other,150% of Medicare + 9.63% HCRA Surcharge,848.7,45,,848.7,percent of total billed charges,Critical Access Hospital RCC factor,641.24,34,,641.24,percent of total billed charges,Implant Device,641.24,34,,641.24,percent of total billed charges,Implant Device,641.24,34,,641.24,percent of total billed charges,Implant Device,641.24,34,,641.24,percent of total billed charges,Implant Device,641.24,34,,641.24,percent of total billed charges,Implant Device,933.57,,,933.57,Other,110% of Medicare,660.1,35,,660.1,percent of total billed charges,Implant Device,641.24,34,"Charges > $500, x 34%",641.24,percent of total billed charges,Implant Device,660.1,35,,660.1,percent of total billed charges,Implant Device,660.1,35,,660.1,percent of total billed charges,Implant Device,660.1,35,,660.1,percent of total billed charges,Implant Device,660.1,35,,660.1,percent of total billed charges,Implant Device,660.1,35,,660.1,percent of total billed charges,Implant Device,754.4,40,,754.4,percent of total billed charges,Implant Device,660.1,70,,660.1,percent of total billed charges,All Other,641.24,34,,641.24,percent of total billed charges,Implant Device,641.24,34,,641.24,percent of total billed charges,Implant Device,660.1,35,,660.1,percent of total billed charges,Implant Device,660.1,35,,660.1,percent of total billed charges,Implant Device,660.1,35,,660.1,percent of total billed charges,Implant Device,660.1,35,,660.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1395.64,
ZIMMER 8018-22-02 HIP SYS FEM HD 22MM,C1776,HCPCS,,79004714,CDM,278,RC,,,both,,,2100,1554.01,,,1554.01,Other,150% of Medicare + 9.63% HCRA Surcharge,945,45,,945,percent of total billed charges,Critical Access Hospital RCC factor,714,34,,714,percent of total billed charges,Implant Device,714,34,,714,percent of total billed charges,Implant Device,714,34,,714,percent of total billed charges,Implant Device,714,34,,714,percent of total billed charges,Implant Device,714,34,,714,percent of total billed charges,Implant Device,1039.5,,,1039.5,Other,110% of Medicare,735,35,,735,percent of total billed charges,Implant Device,714,34,"Charges > $500, x 34%",714,percent of total billed charges,Implant Device,735,35,,735,percent of total billed charges,Implant Device,735,35,,735,percent of total billed charges,Implant Device,735,35,,735,percent of total billed charges,Implant Device,735,35,,735,percent of total billed charges,Implant Device,735,35,,735,percent of total billed charges,Implant Device,840,40,,840,percent of total billed charges,Implant Device,735,70,,735,percent of total billed charges,All Other,714,34,,714,percent of total billed charges,Implant Device,714,34,,714,percent of total billed charges,Implant Device,735,35,,735,percent of total billed charges,Implant Device,735,35,,735,percent of total billed charges,Implant Device,735,35,,735,percent of total billed charges,Implant Device,735,35,,735,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,714,34,"If Charge > 2,000, then 34 percent",714,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1554.01,
ZIMMER 02.03150.050 NCB CORT SCREW 5X50,C1713,HCPCS,,79004716,CDM,278,RC,,,both,,,514,380.36,,,380.36,Other,150% of Medicare + 9.63% HCRA Surcharge,231.3,45,,231.3,percent of total billed charges,Critical Access Hospital RCC factor,174.76,34,,174.76,percent of total billed charges,Implant Device,174.76,34,,174.76,percent of total billed charges,Implant Device,174.76,34,,174.76,percent of total billed charges,Implant Device,174.76,34,,174.76,percent of total billed charges,Implant Device,174.76,34,,174.76,percent of total billed charges,Implant Device,254.43,,,254.43,Other,110% of Medicare,179.9,35,,179.9,percent of total billed charges,Implant Device,174.76,34,"Charges > $500, x 34%",174.76,percent of total billed charges,Implant Device,179.9,35,,179.9,percent of total billed charges,Implant Device,179.9,35,,179.9,percent of total billed charges,Implant Device,179.9,35,,179.9,percent of total billed charges,Implant Device,179.9,35,,179.9,percent of total billed charges,Implant Device,179.9,35,,179.9,percent of total billed charges,Implant Device,205.6,40,,205.6,percent of total billed charges,Implant Device,179.9,70,,179.9,percent of total billed charges,All Other,174.76,34,,174.76,percent of total billed charges,Implant Device,174.76,34,,174.76,percent of total billed charges,Implant Device,179.9,35,,179.9,percent of total billed charges,Implant Device,179.9,35,,179.9,percent of total billed charges,Implant Device,179.9,35,,179.9,percent of total billed charges,Implant Device,179.9,35,,179.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,380.36,
ZIMMER 02-03264-115 DISTAL FEMUR 15H PLT,C1713,HCPCS,,79004717,CDM,278,RC,,,both,,,4672,3457.29,,,3457.29,Other,150% of Medicare + 9.63% HCRA Surcharge,2102.4,45,,2102.4,percent of total billed charges,Critical Access Hospital RCC factor,1588.48,34,,1588.48,percent of total billed charges,Implant Device,1588.48,34,,1588.48,percent of total billed charges,Implant Device,1588.48,34,,1588.48,percent of total billed charges,Implant Device,1588.48,34,,1588.48,percent of total billed charges,Implant Device,1588.48,34,,1588.48,percent of total billed charges,Implant Device,2312.64,,,2312.64,Other,110% of Medicare,1635.2,35,,1635.2,percent of total billed charges,Implant Device,1588.48,34,"Charges > $500, x 34%",1588.48,percent of total billed charges,Implant Device,1635.2,35,,1635.2,percent of total billed charges,Implant Device,1635.2,35,,1635.2,percent of total billed charges,Implant Device,1635.2,35,,1635.2,percent of total billed charges,Implant Device,1635.2,35,,1635.2,percent of total billed charges,Implant Device,1635.2,35,,1635.2,percent of total billed charges,Implant Device,1868.8,40,,1868.8,percent of total billed charges,Implant Device,1635.2,70,,1635.2,percent of total billed charges,All Other,1588.48,34,,1588.48,percent of total billed charges,Implant Device,1588.48,34,,1588.48,percent of total billed charges,Implant Device,1635.2,35,,1635.2,percent of total billed charges,Implant Device,1635.2,35,,1635.2,percent of total billed charges,Implant Device,1635.2,35,,1635.2,percent of total billed charges,Implant Device,1635.2,35,,1635.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1588.48,34,"If Charge > 2,000, then 34 percent",1588.48,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3457.29,
ZIMMER 1147-46-41 CANN SCREW 4X46MM,C1713,HCPCS,,79004719,CDM,278,RC,,,both,,,560,414.4,,,414.4,Other,150% of Medicare + 9.63% HCRA Surcharge,252,45,,252,percent of total billed charges,Critical Access Hospital RCC factor,190.4,34,,190.4,percent of total billed charges,Implant Device,190.4,34,,190.4,percent of total billed charges,Implant Device,190.4,34,,190.4,percent of total billed charges,Implant Device,190.4,34,,190.4,percent of total billed charges,Implant Device,190.4,34,,190.4,percent of total billed charges,Implant Device,277.2,,,277.2,Other,110% of Medicare,196,35,,196,percent of total billed charges,Implant Device,190.4,34,"Charges > $500, x 34%",190.4,percent of total billed charges,Implant Device,196,35,,196,percent of total billed charges,Implant Device,196,35,,196,percent of total billed charges,Implant Device,196,35,,196,percent of total billed charges,Implant Device,196,35,,196,percent of total billed charges,Implant Device,196,35,,196,percent of total billed charges,Implant Device,224,40,,224,percent of total billed charges,Implant Device,196,70,,196,percent of total billed charges,All Other,190.4,34,,190.4,percent of total billed charges,Implant Device,190.4,34,,190.4,percent of total billed charges,Implant Device,196,35,,196,percent of total billed charges,Implant Device,196,35,,196,percent of total billed charges,Implant Device,196,35,,196,percent of total billed charges,Implant Device,196,35,,196,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,414.4,
ZIMMER 1147-065-41 CANC SCREW 4X65MM,C1713,HCPCS,,79004720,CDM,278,RC,,,both,,,558,412.92,,,412.92,Other,150% of Medicare + 9.63% HCRA Surcharge,251.1,45,,251.1,percent of total billed charges,Critical Access Hospital RCC factor,189.72,34,,189.72,percent of total billed charges,Implant Device,189.72,34,,189.72,percent of total billed charges,Implant Device,189.72,34,,189.72,percent of total billed charges,Implant Device,189.72,34,,189.72,percent of total billed charges,Implant Device,189.72,34,,189.72,percent of total billed charges,Implant Device,276.21,,,276.21,Other,110% of Medicare,195.3,35,,195.3,percent of total billed charges,Implant Device,189.72,34,"Charges > $500, x 34%",189.72,percent of total billed charges,Implant Device,195.3,35,,195.3,percent of total billed charges,Implant Device,195.3,35,,195.3,percent of total billed charges,Implant Device,195.3,35,,195.3,percent of total billed charges,Implant Device,195.3,35,,195.3,percent of total billed charges,Implant Device,195.3,35,,195.3,percent of total billed charges,Implant Device,223.2,40,,223.2,percent of total billed charges,Implant Device,195.3,70,,195.3,percent of total billed charges,All Other,189.72,34,,189.72,percent of total billed charges,Implant Device,189.72,34,,189.72,percent of total billed charges,Implant Device,195.3,35,,195.3,percent of total billed charges,Implant Device,195.3,35,,195.3,percent of total billed charges,Implant Device,195.3,35,,195.3,percent of total billed charges,Implant Device,195.3,35,,195.3,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,412.92,
ZIMMER 1147-095-45 CANN. SCREW 4.5X95MM,C1713,HCPCS,,79004721,CDM,278,RC,,,both,,,601,444.74,,,444.74,Other,150% of Medicare + 9.63% HCRA Surcharge,270.45,45,,270.45,percent of total billed charges,Critical Access Hospital RCC factor,204.34,34,,204.34,percent of total billed charges,Implant Device,204.34,34,,204.34,percent of total billed charges,Implant Device,204.34,34,,204.34,percent of total billed charges,Implant Device,204.34,34,,204.34,percent of total billed charges,Implant Device,204.34,34,,204.34,percent of total billed charges,Implant Device,297.5,,,297.5,Other,110% of Medicare,210.35,35,,210.35,percent of total billed charges,Implant Device,204.34,34,"Charges > $500, x 34%",204.34,percent of total billed charges,Implant Device,210.35,35,,210.35,percent of total billed charges,Implant Device,210.35,35,,210.35,percent of total billed charges,Implant Device,210.35,35,,210.35,percent of total billed charges,Implant Device,210.35,35,,210.35,percent of total billed charges,Implant Device,210.35,35,,210.35,percent of total billed charges,Implant Device,240.4,40,,240.4,percent of total billed charges,Implant Device,210.35,70,,210.35,percent of total billed charges,All Other,204.34,34,,204.34,percent of total billed charges,Implant Device,204.34,34,,204.34,percent of total billed charges,Implant Device,210.35,35,,210.35,percent of total billed charges,Implant Device,210.35,35,,210.35,percent of total billed charges,Implant Device,210.35,35,,210.35,percent of total billed charges,Implant Device,210.35,35,,210.35,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,444.74,
ZIMMER 2357-018-06 DISTAL FIB LCK PL 6H,C1713,HCPCS,,79004722,CDM,278,RC,,,both,,,2160,1598.41,,,1598.41,Other,150% of Medicare + 9.63% HCRA Surcharge,972,45,,972,percent of total billed charges,Critical Access Hospital RCC factor,734.4,34,,734.4,percent of total billed charges,Implant Device,734.4,34,,734.4,percent of total billed charges,Implant Device,734.4,34,,734.4,percent of total billed charges,Implant Device,734.4,34,,734.4,percent of total billed charges,Implant Device,734.4,34,,734.4,percent of total billed charges,Implant Device,1069.2,,,1069.2,Other,110% of Medicare,756,35,,756,percent of total billed charges,Implant Device,734.4,34,"Charges > $500, x 34%",734.4,percent of total billed charges,Implant Device,756,35,,756,percent of total billed charges,Implant Device,756,35,,756,percent of total billed charges,Implant Device,756,35,,756,percent of total billed charges,Implant Device,756,35,,756,percent of total billed charges,Implant Device,756,35,,756,percent of total billed charges,Implant Device,864,40,,864,percent of total billed charges,Implant Device,756,70,,756,percent of total billed charges,All Other,734.4,34,,734.4,percent of total billed charges,Implant Device,734.4,34,,734.4,percent of total billed charges,Implant Device,756,35,,756,percent of total billed charges,Implant Device,756,35,,756,percent of total billed charges,Implant Device,756,35,,756,percent of total billed charges,Implant Device,756,35,,756,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,734.4,34,"If Charge > 2,000, then 34 percent",734.4,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1598.41,
ZIMMER 00-2359-022-35 LOCK SCREW 3.5X22,C1713,HCPCS,,79004723,CDM,278,RC,,,both,,,306,226.44,,,226.44,Other,150% of Medicare + 9.63% HCRA Surcharge,137.7,45,,137.7,percent of total billed charges,Critical Access Hospital RCC factor,104.04,34,,104.04,percent of total billed charges,Implant Device,104.04,34,,104.04,percent of total billed charges,Implant Device,104.04,34,,104.04,percent of total billed charges,Implant Device,104.04,34,,104.04,percent of total billed charges,Implant Device,104.04,34,,104.04,percent of total billed charges,Implant Device,151.47,,,151.47,Other,110% of Medicare,107.1,35,,107.1,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,107.1,35,,107.1,percent of total billed charges,Implant Device,107.1,35,,107.1,percent of total billed charges,Implant Device,107.1,35,,107.1,percent of total billed charges,Implant Device,107.1,35,,107.1,percent of total billed charges,Implant Device,107.1,35,,107.1,percent of total billed charges,Implant Device,122.4,40,,122.4,percent of total billed charges,Implant Device,107.1,70,,107.1,percent of total billed charges,All Other,104.04,34,,104.04,percent of total billed charges,Implant Device,104.04,34,,104.04,percent of total billed charges,Implant Device,107.1,35,,107.1,percent of total billed charges,Implant Device,107.1,35,,107.1,percent of total billed charges,Implant Device,107.1,35,,107.1,percent of total billed charges,Implant Device,107.1,35,,107.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,226.44,
ZIMMER 5001-52 BIPOLAR CUP LINER 52MM,C1776,HCPCS,,79004724,CDM,278,RC,,,both,,,2273,1682.03,,,1682.03,Other,150% of Medicare + 9.63% HCRA Surcharge,1022.85,45,,1022.85,percent of total billed charges,Critical Access Hospital RCC factor,772.82,34,,772.82,percent of total billed charges,Implant Device,772.82,34,,772.82,percent of total billed charges,Implant Device,772.82,34,,772.82,percent of total billed charges,Implant Device,772.82,34,,772.82,percent of total billed charges,Implant Device,772.82,34,,772.82,percent of total billed charges,Implant Device,1125.14,,,1125.14,Other,110% of Medicare,795.55,35,,795.55,percent of total billed charges,Implant Device,772.82,34,"Charges > $500, x 34%",772.82,percent of total billed charges,Implant Device,795.55,35,,795.55,percent of total billed charges,Implant Device,795.55,35,,795.55,percent of total billed charges,Implant Device,795.55,35,,795.55,percent of total billed charges,Implant Device,795.55,35,,795.55,percent of total billed charges,Implant Device,795.55,35,,795.55,percent of total billed charges,Implant Device,909.2,40,,909.2,percent of total billed charges,Implant Device,795.55,70,,795.55,percent of total billed charges,All Other,772.82,34,,772.82,percent of total billed charges,Implant Device,772.82,34,,772.82,percent of total billed charges,Implant Device,795.55,35,,795.55,percent of total billed charges,Implant Device,795.55,35,,795.55,percent of total billed charges,Implant Device,795.55,35,,795.55,percent of total billed charges,Implant Device,795.55,35,,795.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,772.82,34,"If Charge > 2,000, then 34 percent",772.82,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1682.03,
ZIMMER 32-8105-53-02 ULNAR ASSMBLY SM3 R,C1776,HCPCS,,79004725,CDM,278,RC,,,both,,,11108,8219.95,,,8219.95,Other,150% of Medicare + 9.63% HCRA Surcharge,4998.6,45,,4998.6,percent of total billed charges,Critical Access Hospital RCC factor,3776.72,34,,3776.72,percent of total billed charges,Implant Device,3776.72,34,,3776.72,percent of total billed charges,Implant Device,3776.72,34,,3776.72,percent of total billed charges,Implant Device,3776.72,34,,3776.72,percent of total billed charges,Implant Device,3776.72,34,,3776.72,percent of total billed charges,Implant Device,5498.46,,,5498.46,Other,110% of Medicare,3887.8,35,,3887.8,percent of total billed charges,Implant Device,3776.72,34,"Charges > $500, x 34%",3776.72,percent of total billed charges,Implant Device,3887.8,35,,3887.8,percent of total billed charges,Implant Device,3887.8,35,,3887.8,percent of total billed charges,Implant Device,3887.8,35,,3887.8,percent of total billed charges,Implant Device,3887.8,35,,3887.8,percent of total billed charges,Implant Device,3887.8,35,,3887.8,percent of total billed charges,Implant Device,4443.2,40,,4443.2,percent of total billed charges,Implant Device,3887.8,70,,3887.8,percent of total billed charges,All Other,3776.72,34,,3776.72,percent of total billed charges,Implant Device,3776.72,34,,3776.72,percent of total billed charges,Implant Device,3887.8,35,,3887.8,percent of total billed charges,Implant Device,3887.8,35,,3887.8,percent of total billed charges,Implant Device,3887.8,35,,3887.8,percent of total billed charges,Implant Device,3887.8,35,,3887.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3776.72,34,"If Charge > 2,000, then 34 percent",3776.72,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,8219.95,
ZIMMER 06-131-10082 SPNL TRBCLR MTL IMP,C1776,HCPCS,,79004729,CDM,278,RC,,,both,,,19074,14114.81,,,14114.81,Other,150% of Medicare + 9.63% HCRA Surcharge,8583.3,45,,8583.3,percent of total billed charges,Critical Access Hospital RCC factor,6485.16,34,,6485.16,percent of total billed charges,Implant Device,6485.16,34,,6485.16,percent of total billed charges,Implant Device,6485.16,34,,6485.16,percent of total billed charges,Implant Device,6485.16,34,,6485.16,percent of total billed charges,Implant Device,6485.16,34,,6485.16,percent of total billed charges,Implant Device,9441.63,,,9441.63,Other,110% of Medicare,6675.9,35,,6675.9,percent of total billed charges,Implant Device,6485.16,34,"Charges > $500, x 34%",6485.16,percent of total billed charges,Implant Device,6675.9,35,,6675.9,percent of total billed charges,Implant Device,6675.9,35,,6675.9,percent of total billed charges,Implant Device,6675.9,35,,6675.9,percent of total billed charges,Implant Device,6675.9,35,,6675.9,percent of total billed charges,Implant Device,6675.9,35,,6675.9,percent of total billed charges,Implant Device,7629.6,40,,7629.6,percent of total billed charges,Implant Device,6675.9,70,,6675.9,percent of total billed charges,All Other,6485.16,34,,6485.16,percent of total billed charges,Implant Device,6485.16,34,,6485.16,percent of total billed charges,Implant Device,6675.9,35,,6675.9,percent of total billed charges,Implant Device,6675.9,35,,6675.9,percent of total billed charges,Implant Device,6675.9,35,,6675.9,percent of total billed charges,Implant Device,6675.9,35,,6675.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,6485.16,34,"If Charge > 2,000, then 34 percent",6485.16,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,14114.81,
ZIMMER 02-03150-038 CORT SCREW 5X38MM,C1713,HCPCS,,79004730,CDM,278,RC,,,both,,,498,368.52,,,368.52,Other,150% of Medicare + 9.63% HCRA Surcharge,224.1,45,,224.1,percent of total billed charges,Critical Access Hospital RCC factor,169.32,34,,169.32,percent of total billed charges,Implant Device,169.32,34,,169.32,percent of total billed charges,Implant Device,169.32,34,,169.32,percent of total billed charges,Implant Device,169.32,34,,169.32,percent of total billed charges,Implant Device,169.32,34,,169.32,percent of total billed charges,Implant Device,246.51,,,246.51,Other,110% of Medicare,174.3,35,,174.3,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,174.3,35,,174.3,percent of total billed charges,Implant Device,174.3,35,,174.3,percent of total billed charges,Implant Device,174.3,35,,174.3,percent of total billed charges,Implant Device,174.3,35,,174.3,percent of total billed charges,Implant Device,174.3,35,,174.3,percent of total billed charges,Implant Device,199.2,40,,199.2,percent of total billed charges,Implant Device,174.3,70,,174.3,percent of total billed charges,All Other,169.32,34,,169.32,percent of total billed charges,Implant Device,169.32,34,,169.32,percent of total billed charges,Implant Device,174.3,35,,174.3,percent of total billed charges,Implant Device,174.3,35,,174.3,percent of total billed charges,Implant Device,174.3,35,,174.3,percent of total billed charges,Implant Device,174.3,35,,174.3,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,368.52,
STRYKER 604736S ASNIS CANN SCREW 36MM,C1713,HCPCS,,79004731,CDM,278,RC,,,both,,,1058,782.92,,,782.92,Other,150% of Medicare + 9.63% HCRA Surcharge,476.1,45,,476.1,percent of total billed charges,Critical Access Hospital RCC factor,359.72,34,,359.72,percent of total billed charges,Implant Device,359.72,34,,359.72,percent of total billed charges,Implant Device,359.72,34,,359.72,percent of total billed charges,Implant Device,359.72,34,,359.72,percent of total billed charges,Implant Device,359.72,34,,359.72,percent of total billed charges,Implant Device,523.71,,,523.71,Other,110% of Medicare,370.3,35,,370.3,percent of total billed charges,Implant Device,359.72,34,"Charges > $500, x 34%",359.72,percent of total billed charges,Implant Device,370.3,35,,370.3,percent of total billed charges,Implant Device,370.3,35,,370.3,percent of total billed charges,Implant Device,370.3,35,,370.3,percent of total billed charges,Implant Device,370.3,35,,370.3,percent of total billed charges,Implant Device,370.3,35,,370.3,percent of total billed charges,Implant Device,423.2,40,,423.2,percent of total billed charges,Implant Device,370.3,70,,370.3,percent of total billed charges,All Other,359.72,34,,359.72,percent of total billed charges,Implant Device,359.72,34,,359.72,percent of total billed charges,Implant Device,370.3,35,,370.3,percent of total billed charges,Implant Device,370.3,35,,370.3,percent of total billed charges,Implant Device,370.3,35,,370.3,percent of total billed charges,Implant Device,370.3,35,,370.3,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,782.92,
ZIMMER 1147-44-40 CANN SCREW 4X44MM,C1713,HCPCS,,79004733,CDM,278,RC,,,both,,,605,447.7,,,447.7,Other,150% of Medicare + 9.63% HCRA Surcharge,272.25,45,,272.25,percent of total billed charges,Critical Access Hospital RCC factor,205.7,34,,205.7,percent of total billed charges,Implant Device,205.7,34,,205.7,percent of total billed charges,Implant Device,205.7,34,,205.7,percent of total billed charges,Implant Device,205.7,34,,205.7,percent of total billed charges,Implant Device,205.7,34,,205.7,percent of total billed charges,Implant Device,299.48,,,299.48,Other,110% of Medicare,211.75,35,,211.75,percent of total billed charges,Implant Device,205.7,34,"Charges > $500, x 34%",205.7,percent of total billed charges,Implant Device,211.75,35,,211.75,percent of total billed charges,Implant Device,211.75,35,,211.75,percent of total billed charges,Implant Device,211.75,35,,211.75,percent of total billed charges,Implant Device,211.75,35,,211.75,percent of total billed charges,Implant Device,211.75,35,,211.75,percent of total billed charges,Implant Device,242,40,,242,percent of total billed charges,Implant Device,211.75,70,,211.75,percent of total billed charges,All Other,205.7,34,,205.7,percent of total billed charges,Implant Device,205.7,34,,205.7,percent of total billed charges,Implant Device,211.75,35,,211.75,percent of total billed charges,Implant Device,211.75,35,,211.75,percent of total billed charges,Implant Device,211.75,35,,211.75,percent of total billed charges,Implant Device,211.75,35,,211.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,447.7,
ZIMMER 002359-016-38 LOCK SCREW 3.5X16MM,C1713,HCPCS,,79004734,CDM,278,RC,,,both,,,281,207.94,,,207.94,Other,150% of Medicare + 9.63% HCRA Surcharge,126.45,45,,126.45,percent of total billed charges,Critical Access Hospital RCC factor,95.54,34,,95.54,percent of total billed charges,Implant Device,95.54,34,,95.54,percent of total billed charges,Implant Device,95.54,34,,95.54,percent of total billed charges,Implant Device,95.54,34,,95.54,percent of total billed charges,Implant Device,95.54,34,,95.54,percent of total billed charges,Implant Device,139.1,,,139.1,Other,110% of Medicare,98.35,35,,98.35,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,98.35,35,,98.35,percent of total billed charges,Implant Device,98.35,35,,98.35,percent of total billed charges,Implant Device,98.35,35,,98.35,percent of total billed charges,Implant Device,98.35,35,,98.35,percent of total billed charges,Implant Device,98.35,35,,98.35,percent of total billed charges,Implant Device,112.4,40,,112.4,percent of total billed charges,Implant Device,98.35,70,,98.35,percent of total billed charges,All Other,95.54,34,,95.54,percent of total billed charges,Implant Device,95.54,34,,95.54,percent of total billed charges,Implant Device,98.35,35,,98.35,percent of total billed charges,Implant Device,98.35,35,,98.35,percent of total billed charges,Implant Device,98.35,35,,98.35,percent of total billed charges,Implant Device,98.35,35,,98.35,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,207.94,
ZIMMER 1147-050-41 CANNULATED SCREW 50MM,C1713,HCPCS,,79004735,CDM,278,RC,,,both,,,558,412.92,,,412.92,Other,150% of Medicare + 9.63% HCRA Surcharge,251.1,45,,251.1,percent of total billed charges,Critical Access Hospital RCC factor,189.72,34,,189.72,percent of total billed charges,Implant Device,189.72,34,,189.72,percent of total billed charges,Implant Device,189.72,34,,189.72,percent of total billed charges,Implant Device,189.72,34,,189.72,percent of total billed charges,Implant Device,189.72,34,,189.72,percent of total billed charges,Implant Device,276.21,,,276.21,Other,110% of Medicare,195.3,35,,195.3,percent of total billed charges,Implant Device,189.72,34,"Charges > $500, x 34%",189.72,percent of total billed charges,Implant Device,195.3,35,,195.3,percent of total billed charges,Implant Device,195.3,35,,195.3,percent of total billed charges,Implant Device,195.3,35,,195.3,percent of total billed charges,Implant Device,195.3,35,,195.3,percent of total billed charges,Implant Device,195.3,35,,195.3,percent of total billed charges,Implant Device,223.2,40,,223.2,percent of total billed charges,Implant Device,195.3,70,,195.3,percent of total billed charges,All Other,189.72,34,,189.72,percent of total billed charges,Implant Device,189.72,34,,189.72,percent of total billed charges,Implant Device,195.3,35,,195.3,percent of total billed charges,Implant Device,195.3,35,,195.3,percent of total billed charges,Implant Device,195.3,35,,195.3,percent of total billed charges,Implant Device,195.3,35,,195.3,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,412.92,
ZIMMER 00-2359-012-35 SCREW 3.5X12MM,C1713,HCPCS,,79004736,CDM,278,RC,,,both,,,324,239.76,,,239.76,Other,150% of Medicare + 9.63% HCRA Surcharge,145.8,45,,145.8,percent of total billed charges,Critical Access Hospital RCC factor,110.16,34,,110.16,percent of total billed charges,Implant Device,110.16,34,,110.16,percent of total billed charges,Implant Device,110.16,34,,110.16,percent of total billed charges,Implant Device,110.16,34,,110.16,percent of total billed charges,Implant Device,110.16,34,,110.16,percent of total billed charges,Implant Device,160.38,,,160.38,Other,110% of Medicare,113.4,35,,113.4,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,129.6,40,,129.6,percent of total billed charges,Implant Device,113.4,70,,113.4,percent of total billed charges,All Other,110.16,34,,110.16,percent of total billed charges,Implant Device,110.16,34,,110.16,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,239.76,
ZIMMER 00-2359-040-45 LOCK SCREW 4.5X40,C1713,HCPCS,,79004737,CDM,278,RC,,,both,,,432,319.68,,,319.68,Other,150% of Medicare + 9.63% HCRA Surcharge,194.4,45,,194.4,percent of total billed charges,Critical Access Hospital RCC factor,146.88,34,,146.88,percent of total billed charges,Implant Device,146.88,34,,146.88,percent of total billed charges,Implant Device,146.88,34,,146.88,percent of total billed charges,Implant Device,146.88,34,,146.88,percent of total billed charges,Implant Device,146.88,34,,146.88,percent of total billed charges,Implant Device,213.84,,,213.84,Other,110% of Medicare,151.2,35,,151.2,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,151.2,35,,151.2,percent of total billed charges,Implant Device,151.2,35,,151.2,percent of total billed charges,Implant Device,151.2,35,,151.2,percent of total billed charges,Implant Device,151.2,35,,151.2,percent of total billed charges,Implant Device,151.2,35,,151.2,percent of total billed charges,Implant Device,172.8,40,,172.8,percent of total billed charges,Implant Device,151.2,70,,151.2,percent of total billed charges,All Other,146.88,34,,146.88,percent of total billed charges,Implant Device,146.88,34,,146.88,percent of total billed charges,Implant Device,151.2,35,,151.2,percent of total billed charges,Implant Device,151.2,35,,151.2,percent of total billed charges,Implant Device,151.2,35,,151.2,percent of total billed charges,Implant Device,151.2,35,,151.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,319.68,
ZIMMER 00-2359-040-36 LOCK SCREW 3.5X40,C1713,HCPCS,,79004738,CDM,278,RC,,,both,,,420,310.8,,,310.8,Other,150% of Medicare + 9.63% HCRA Surcharge,189,45,,189,percent of total billed charges,Critical Access Hospital RCC factor,142.8,34,,142.8,percent of total billed charges,Implant Device,142.8,34,,142.8,percent of total billed charges,Implant Device,142.8,34,,142.8,percent of total billed charges,Implant Device,142.8,34,,142.8,percent of total billed charges,Implant Device,142.8,34,,142.8,percent of total billed charges,Implant Device,207.9,,,207.9,Other,110% of Medicare,147,35,,147,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,147,35,,147,percent of total billed charges,Implant Device,147,35,,147,percent of total billed charges,Implant Device,147,35,,147,percent of total billed charges,Implant Device,147,35,,147,percent of total billed charges,Implant Device,147,35,,147,percent of total billed charges,Implant Device,168,40,,168,percent of total billed charges,Implant Device,147,70,,147,percent of total billed charges,All Other,142.8,34,,142.8,percent of total billed charges,Implant Device,142.8,34,,142.8,percent of total billed charges,Implant Device,147,35,,147,percent of total billed charges,Implant Device,147,35,,147,percent of total billed charges,Implant Device,147,35,,147,percent of total billed charges,Implant Device,147,35,,147,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,310.8,
ZIMMER 00-2359-020-35 LOCK SCREW 3.5X20,C1713,HCPCS,,79004739,CDM,278,RC,,,both,,,306,226.44,,,226.44,Other,150% of Medicare + 9.63% HCRA Surcharge,137.7,45,,137.7,percent of total billed charges,Critical Access Hospital RCC factor,104.04,34,,104.04,percent of total billed charges,Implant Device,104.04,34,,104.04,percent of total billed charges,Implant Device,104.04,34,,104.04,percent of total billed charges,Implant Device,104.04,34,,104.04,percent of total billed charges,Implant Device,104.04,34,,104.04,percent of total billed charges,Implant Device,151.47,,,151.47,Other,110% of Medicare,107.1,35,,107.1,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,107.1,35,,107.1,percent of total billed charges,Implant Device,107.1,35,,107.1,percent of total billed charges,Implant Device,107.1,35,,107.1,percent of total billed charges,Implant Device,107.1,35,,107.1,percent of total billed charges,Implant Device,107.1,35,,107.1,percent of total billed charges,Implant Device,122.4,40,,122.4,percent of total billed charges,Implant Device,107.1,70,,107.1,percent of total billed charges,All Other,104.04,34,,104.04,percent of total billed charges,Implant Device,104.04,34,,104.04,percent of total billed charges,Implant Device,107.1,35,,107.1,percent of total billed charges,Implant Device,107.1,35,,107.1,percent of total billed charges,Implant Device,107.1,35,,107.1,percent of total billed charges,Implant Device,107.1,35,,107.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,226.44,
ZIMMER 00-2359-085-55 LOCK SCREW 5.5X85,C1713,HCPCS,,79004740,CDM,278,RC,,,both,,,578,427.72,,,427.72,Other,150% of Medicare + 9.63% HCRA Surcharge,260.1,45,,260.1,percent of total billed charges,Critical Access Hospital RCC factor,196.52,34,,196.52,percent of total billed charges,Implant Device,196.52,34,,196.52,percent of total billed charges,Implant Device,196.52,34,,196.52,percent of total billed charges,Implant Device,196.52,34,,196.52,percent of total billed charges,Implant Device,196.52,34,,196.52,percent of total billed charges,Implant Device,286.11,,,286.11,Other,110% of Medicare,202.3,35,,202.3,percent of total billed charges,Implant Device,196.52,34,"Charges > $500, x 34%",196.52,percent of total billed charges,Implant Device,202.3,35,,202.3,percent of total billed charges,Implant Device,202.3,35,,202.3,percent of total billed charges,Implant Device,202.3,35,,202.3,percent of total billed charges,Implant Device,202.3,35,,202.3,percent of total billed charges,Implant Device,202.3,35,,202.3,percent of total billed charges,Implant Device,231.2,40,,231.2,percent of total billed charges,Implant Device,202.3,70,,202.3,percent of total billed charges,All Other,196.52,34,,196.52,percent of total billed charges,Implant Device,196.52,34,,196.52,percent of total billed charges,Implant Device,202.3,35,,202.3,percent of total billed charges,Implant Device,202.3,35,,202.3,percent of total billed charges,Implant Device,202.3,35,,202.3,percent of total billed charges,Implant Device,202.3,35,,202.3,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,427.72,
ZIMMER 00-2359-075-36 CANN SCREW 3.5X75,C1713,HCPCS,,79004741,CDM,278,RC,,,both,,,334,247.16,,,247.16,Other,150% of Medicare + 9.63% HCRA Surcharge,150.3,45,,150.3,percent of total billed charges,Critical Access Hospital RCC factor,113.56,34,,113.56,percent of total billed charges,Implant Device,113.56,34,,113.56,percent of total billed charges,Implant Device,113.56,34,,113.56,percent of total billed charges,Implant Device,113.56,34,,113.56,percent of total billed charges,Implant Device,113.56,34,,113.56,percent of total billed charges,Implant Device,165.33,,,165.33,Other,110% of Medicare,116.9,35,,116.9,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,116.9,35,,116.9,percent of total billed charges,Implant Device,116.9,35,,116.9,percent of total billed charges,Implant Device,116.9,35,,116.9,percent of total billed charges,Implant Device,116.9,35,,116.9,percent of total billed charges,Implant Device,116.9,35,,116.9,percent of total billed charges,Implant Device,133.6,40,,133.6,percent of total billed charges,Implant Device,116.9,70,,116.9,percent of total billed charges,All Other,113.56,34,,113.56,percent of total billed charges,Implant Device,113.56,34,,113.56,percent of total billed charges,Implant Device,116.9,35,,116.9,percent of total billed charges,Implant Device,116.9,35,,116.9,percent of total billed charges,Implant Device,116.9,35,,116.9,percent of total billed charges,Implant Device,116.9,35,,116.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,247.16,
ZIMMER 00-2359-045-36 CANN SCREW 3.5X45,C1713,HCPCS,,79004742,CDM,278,RC,,,both,,,420,310.8,,,310.8,Other,150% of Medicare + 9.63% HCRA Surcharge,189,45,,189,percent of total billed charges,Critical Access Hospital RCC factor,142.8,34,,142.8,percent of total billed charges,Implant Device,142.8,34,,142.8,percent of total billed charges,Implant Device,142.8,34,,142.8,percent of total billed charges,Implant Device,142.8,34,,142.8,percent of total billed charges,Implant Device,142.8,34,,142.8,percent of total billed charges,Implant Device,207.9,,,207.9,Other,110% of Medicare,147,35,,147,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,147,35,,147,percent of total billed charges,Implant Device,147,35,,147,percent of total billed charges,Implant Device,147,35,,147,percent of total billed charges,Implant Device,147,35,,147,percent of total billed charges,Implant Device,147,35,,147,percent of total billed charges,Implant Device,168,40,,168,percent of total billed charges,Implant Device,147,70,,147,percent of total billed charges,All Other,142.8,34,,142.8,percent of total billed charges,Implant Device,142.8,34,,142.8,percent of total billed charges,Implant Device,147,35,,147,percent of total billed charges,Implant Device,147,35,,147,percent of total billed charges,Implant Device,147,35,,147,percent of total billed charges,Implant Device,147,35,,147,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,310.8,
ZIMMER 00-2360-041-55 LOCK SCREW STD 5.5,C1713,HCPCS,,79004743,CDM,278,RC,,,both,,,750,555,,,555,Other,150% of Medicare + 9.63% HCRA Surcharge,337.5,45,,337.5,percent of total billed charges,Critical Access Hospital RCC factor,255,34,,255,percent of total billed charges,Implant Device,255,34,,255,percent of total billed charges,Implant Device,255,34,,255,percent of total billed charges,Implant Device,255,34,,255,percent of total billed charges,Implant Device,255,34,,255,percent of total billed charges,Implant Device,371.25,,,371.25,Other,110% of Medicare,262.5,35,,262.5,percent of total billed charges,Implant Device,255,34,"Charges > $500, x 34%",255,percent of total billed charges,Implant Device,262.5,35,,262.5,percent of total billed charges,Implant Device,262.5,35,,262.5,percent of total billed charges,Implant Device,262.5,35,,262.5,percent of total billed charges,Implant Device,262.5,35,,262.5,percent of total billed charges,Implant Device,262.5,35,,262.5,percent of total billed charges,Implant Device,300,40,,300,percent of total billed charges,Implant Device,262.5,70,,262.5,percent of total billed charges,All Other,255,34,,255,percent of total billed charges,Implant Device,255,34,,255,percent of total billed charges,Implant Device,262.5,35,,262.5,percent of total billed charges,Implant Device,262.5,35,,262.5,percent of total billed charges,Implant Device,262.5,35,,262.5,percent of total billed charges,Implant Device,262.5,35,,262.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,555,
ZIMMER 00-4827-012-01 CORT SCREW 2.7X12,C1713,HCPCS,,79004746,CDM,278,RC,,,both,,,71,52.54,,,52.54,Other,150% of Medicare + 9.63% HCRA Surcharge,31.95,45,,31.95,percent of total billed charges,Critical Access Hospital RCC factor,24.14,34,,24.14,percent of total billed charges,Implant Device,24.14,34,,24.14,percent of total billed charges,Implant Device,24.14,34,,24.14,percent of total billed charges,Implant Device,24.14,34,,24.14,percent of total billed charges,Implant Device,24.14,34,,24.14,percent of total billed charges,Implant Device,35.15,,,35.15,Other,110% of Medicare,24.85,35,,24.85,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,24.85,35,,24.85,percent of total billed charges,Implant Device,24.85,35,,24.85,percent of total billed charges,Implant Device,24.85,35,,24.85,percent of total billed charges,Implant Device,24.85,35,,24.85,percent of total billed charges,Implant Device,24.85,35,,24.85,percent of total billed charges,Implant Device,28.4,40,,28.4,percent of total billed charges,Implant Device,24.85,70,,24.85,percent of total billed charges,All Other,24.14,34,,24.14,percent of total billed charges,Implant Device,24.14,34,,24.14,percent of total billed charges,Implant Device,24.85,35,,24.85,percent of total billed charges,Implant Device,24.85,35,,24.85,percent of total billed charges,Implant Device,24.85,35,,24.85,percent of total billed charges,Implant Device,24.85,35,,24.85,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,52.54,
ZIMMER 00-2480-032-40 CANC SCREW 4X32MM,C1713,HCPCS,,79004747,CDM,278,RC,,,both,,,175,129.5,,,129.5,Other,150% of Medicare + 9.63% HCRA Surcharge,78.75,45,,78.75,percent of total billed charges,Critical Access Hospital RCC factor,59.5,34,,59.5,percent of total billed charges,Implant Device,59.5,34,,59.5,percent of total billed charges,Implant Device,59.5,34,,59.5,percent of total billed charges,Implant Device,59.5,34,,59.5,percent of total billed charges,Implant Device,59.5,34,,59.5,percent of total billed charges,Implant Device,86.63,,,86.63,Other,110% of Medicare,61.25,35,,61.25,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,61.25,35,,61.25,percent of total billed charges,Implant Device,61.25,35,,61.25,percent of total billed charges,Implant Device,61.25,35,,61.25,percent of total billed charges,Implant Device,61.25,35,,61.25,percent of total billed charges,Implant Device,61.25,35,,61.25,percent of total billed charges,Implant Device,70,40,,70,percent of total billed charges,Implant Device,61.25,70,,61.25,percent of total billed charges,All Other,59.5,34,,59.5,percent of total billed charges,Implant Device,59.5,34,,59.5,percent of total billed charges,Implant Device,61.25,35,,61.25,percent of total billed charges,Implant Device,61.25,35,,61.25,percent of total billed charges,Implant Device,61.25,35,,61.25,percent of total billed charges,Implant Device,61.25,35,,61.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,129.5,
ZIMMER 00-2480-030-40 CANC SCREW 4X30MM,C1713,HCPCS,,79004748,CDM,278,RC,,,both,,,180,133.2,,,133.2,Other,150% of Medicare + 9.63% HCRA Surcharge,81,45,,81,percent of total billed charges,Critical Access Hospital RCC factor,61.2,34,,61.2,percent of total billed charges,Implant Device,61.2,34,,61.2,percent of total billed charges,Implant Device,61.2,34,,61.2,percent of total billed charges,Implant Device,61.2,34,,61.2,percent of total billed charges,Implant Device,61.2,34,,61.2,percent of total billed charges,Implant Device,89.1,,,89.1,Other,110% of Medicare,63,35,,63,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,63,35,,63,percent of total billed charges,Implant Device,63,35,,63,percent of total billed charges,Implant Device,63,35,,63,percent of total billed charges,Implant Device,63,35,,63,percent of total billed charges,Implant Device,63,35,,63,percent of total billed charges,Implant Device,72,40,,72,percent of total billed charges,Implant Device,63,70,,63,percent of total billed charges,All Other,61.2,34,,61.2,percent of total billed charges,Implant Device,61.2,34,,61.2,percent of total billed charges,Implant Device,63,35,,63,percent of total billed charges,Implant Device,63,35,,63,percent of total billed charges,Implant Device,63,35,,63,percent of total billed charges,Implant Device,63,35,,63,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,133.2,
ZIMMER 00-4840-016-00 CANC SCREW 4X16MM,C1713,HCPCS,,79004749,CDM,278,RC,,,both,,,58,42.92,,,42.92,Other,150% of Medicare + 9.63% HCRA Surcharge,26.1,45,,26.1,percent of total billed charges,Critical Access Hospital RCC factor,19.72,34,,19.72,percent of total billed charges,Implant Device,19.72,34,,19.72,percent of total billed charges,Implant Device,19.72,34,,19.72,percent of total billed charges,Implant Device,19.72,34,,19.72,percent of total billed charges,Implant Device,19.72,34,,19.72,percent of total billed charges,Implant Device,28.71,,,28.71,Other,110% of Medicare,20.3,35,,20.3,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,20.3,35,,20.3,percent of total billed charges,Implant Device,20.3,35,,20.3,percent of total billed charges,Implant Device,20.3,35,,20.3,percent of total billed charges,Implant Device,20.3,35,,20.3,percent of total billed charges,Implant Device,20.3,35,,20.3,percent of total billed charges,Implant Device,23.2,40,,23.2,percent of total billed charges,Implant Device,20.3,70,,20.3,percent of total billed charges,All Other,19.72,34,,19.72,percent of total billed charges,Implant Device,19.72,34,,19.72,percent of total billed charges,Implant Device,20.3,35,,20.3,percent of total billed charges,Implant Device,20.3,35,,20.3,percent of total billed charges,Implant Device,20.3,35,,20.3,percent of total billed charges,Implant Device,20.3,35,,20.3,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,42.92,
ZIMMER 00-4840-012-00 CANC SCREW 4X12MM,C1713,HCPCS,,79004750,CDM,278,RC,,,both,,,54,39.96,,,39.96,Other,150% of Medicare + 9.63% HCRA Surcharge,24.3,45,,24.3,percent of total billed charges,Critical Access Hospital RCC factor,18.36,34,,18.36,percent of total billed charges,Implant Device,18.36,34,,18.36,percent of total billed charges,Implant Device,18.36,34,,18.36,percent of total billed charges,Implant Device,18.36,34,,18.36,percent of total billed charges,Implant Device,18.36,34,,18.36,percent of total billed charges,Implant Device,26.73,,,26.73,Other,110% of Medicare,18.9,35,,18.9,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,18.9,35,,18.9,percent of total billed charges,Implant Device,18.9,35,,18.9,percent of total billed charges,Implant Device,18.9,35,,18.9,percent of total billed charges,Implant Device,18.9,35,,18.9,percent of total billed charges,Implant Device,18.9,35,,18.9,percent of total billed charges,Implant Device,21.6,40,,21.6,percent of total billed charges,Implant Device,18.9,70,,18.9,percent of total billed charges,All Other,18.36,34,,18.36,percent of total billed charges,Implant Device,18.36,34,,18.36,percent of total billed charges,Implant Device,18.9,35,,18.9,percent of total billed charges,Implant Device,18.9,35,,18.9,percent of total billed charges,Implant Device,18.9,35,,18.9,percent of total billed charges,Implant Device,18.9,35,,18.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,39.96,
ZIMMER 00-1146-064-45 CANN SCREW 4.564MM,C1713,HCPCS,,79004751,CDM,278,RC,,,both,,,589,435.86,,,435.86,Other,150% of Medicare + 9.63% HCRA Surcharge,265.05,45,,265.05,percent of total billed charges,Critical Access Hospital RCC factor,200.26,34,,200.26,percent of total billed charges,Implant Device,200.26,34,,200.26,percent of total billed charges,Implant Device,200.26,34,,200.26,percent of total billed charges,Implant Device,200.26,34,,200.26,percent of total billed charges,Implant Device,200.26,34,,200.26,percent of total billed charges,Implant Device,291.56,,,291.56,Other,110% of Medicare,206.15,35,,206.15,percent of total billed charges,Implant Device,200.26,34,"Charges > $500, x 34%",200.26,percent of total billed charges,Implant Device,206.15,35,,206.15,percent of total billed charges,Implant Device,206.15,35,,206.15,percent of total billed charges,Implant Device,206.15,35,,206.15,percent of total billed charges,Implant Device,206.15,35,,206.15,percent of total billed charges,Implant Device,206.15,35,,206.15,percent of total billed charges,Implant Device,235.6,40,,235.6,percent of total billed charges,Implant Device,206.15,70,,206.15,percent of total billed charges,All Other,200.26,34,,200.26,percent of total billed charges,Implant Device,200.26,34,,200.26,percent of total billed charges,Implant Device,206.15,35,,206.15,percent of total billed charges,Implant Device,206.15,35,,206.15,percent of total billed charges,Implant Device,206.15,35,,206.15,percent of total billed charges,Implant Device,206.15,35,,206.15,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,435.86,
ZIMMER 00-4936-007-03 ULS PLT 7H 3.5X94,C1713,HCPCS,,79004752,CDM,278,RC,,,both,,,482,356.68,,,356.68,Other,150% of Medicare + 9.63% HCRA Surcharge,216.9,45,,216.9,percent of total billed charges,Critical Access Hospital RCC factor,163.88,34,,163.88,percent of total billed charges,Implant Device,163.88,34,,163.88,percent of total billed charges,Implant Device,163.88,34,,163.88,percent of total billed charges,Implant Device,163.88,34,,163.88,percent of total billed charges,Implant Device,163.88,34,,163.88,percent of total billed charges,Implant Device,238.59,,,238.59,Other,110% of Medicare,168.7,35,,168.7,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,168.7,35,,168.7,percent of total billed charges,Implant Device,168.7,35,,168.7,percent of total billed charges,Implant Device,168.7,35,,168.7,percent of total billed charges,Implant Device,168.7,35,,168.7,percent of total billed charges,Implant Device,168.7,35,,168.7,percent of total billed charges,Implant Device,192.8,40,,192.8,percent of total billed charges,Implant Device,168.7,70,,168.7,percent of total billed charges,All Other,163.88,34,,163.88,percent of total billed charges,Implant Device,163.88,34,,163.88,percent of total billed charges,Implant Device,168.7,35,,168.7,percent of total billed charges,Implant Device,168.7,35,,168.7,percent of total billed charges,Implant Device,168.7,35,,168.7,percent of total billed charges,Implant Device,168.7,35,,168.7,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,356.68,
ZIMMER 00-5750-014-06 FLX FEM COMP SZ D,C1776,HCPCS,,79004753,CDM,278,RC,,,both,,,10966,8114.87,,,8114.87,Other,150% of Medicare + 9.63% HCRA Surcharge,4934.7,45,,4934.7,percent of total billed charges,Critical Access Hospital RCC factor,3728.44,34,,3728.44,percent of total billed charges,Implant Device,3728.44,34,,3728.44,percent of total billed charges,Implant Device,3728.44,34,,3728.44,percent of total billed charges,Implant Device,3728.44,34,,3728.44,percent of total billed charges,Implant Device,3728.44,34,,3728.44,percent of total billed charges,Implant Device,5428.17,,,5428.17,Other,110% of Medicare,3838.1,35,,3838.1,percent of total billed charges,Implant Device,3728.44,34,"Charges > $500, x 34%",3728.44,percent of total billed charges,Implant Device,3838.1,35,,3838.1,percent of total billed charges,Implant Device,3838.1,35,,3838.1,percent of total billed charges,Implant Device,3838.1,35,,3838.1,percent of total billed charges,Implant Device,3838.1,35,,3838.1,percent of total billed charges,Implant Device,3838.1,35,,3838.1,percent of total billed charges,Implant Device,4386.4,40,,4386.4,percent of total billed charges,Implant Device,3838.1,70,,3838.1,percent of total billed charges,All Other,3728.44,34,,3728.44,percent of total billed charges,Implant Device,3728.44,34,,3728.44,percent of total billed charges,Implant Device,3838.1,35,,3838.1,percent of total billed charges,Implant Device,3838.1,35,,3838.1,percent of total billed charges,Implant Device,3838.1,35,,3838.1,percent of total billed charges,Implant Device,3838.1,35,,3838.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3728.44,34,"If Charge > 2,000, then 34 percent",3728.44,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,8114.87,
ZIMMER 2240-012-30 M/DN IM NAIL 12X30CM,C1713,HCPCS,,79004754,CDM,278,RC,,,both,,,5370,3973.81,,,3973.81,Other,150% of Medicare + 9.63% HCRA Surcharge,2416.5,45,,2416.5,percent of total billed charges,Critical Access Hospital RCC factor,1825.8,34,,1825.8,percent of total billed charges,Implant Device,1825.8,34,,1825.8,percent of total billed charges,Implant Device,1825.8,34,,1825.8,percent of total billed charges,Implant Device,1825.8,34,,1825.8,percent of total billed charges,Implant Device,1825.8,34,,1825.8,percent of total billed charges,Implant Device,2658.15,,,2658.15,Other,110% of Medicare,1879.5,35,,1879.5,percent of total billed charges,Implant Device,1825.8,34,"Charges > $500, x 34%",1825.8,percent of total billed charges,Implant Device,1879.5,35,,1879.5,percent of total billed charges,Implant Device,1879.5,35,,1879.5,percent of total billed charges,Implant Device,1879.5,35,,1879.5,percent of total billed charges,Implant Device,1879.5,35,,1879.5,percent of total billed charges,Implant Device,1879.5,35,,1879.5,percent of total billed charges,Implant Device,2148,40,,2148,percent of total billed charges,Implant Device,1879.5,70,,1879.5,percent of total billed charges,All Other,1825.8,34,,1825.8,percent of total billed charges,Implant Device,1825.8,34,,1825.8,percent of total billed charges,Implant Device,1879.5,35,,1879.5,percent of total billed charges,Implant Device,1879.5,35,,1879.5,percent of total billed charges,Implant Device,1879.5,35,,1879.5,percent of total billed charges,Implant Device,1879.5,35,,1879.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1825.8,34,"If Charge > 2,000, then 34 percent",1825.8,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3973.81,
ZIMMER 00-1147-038-40 CANN SCREW 4X38MM,C1713,HCPCS,,79004755,CDM,278,RC,,,both,,,560,414.4,,,414.4,Other,150% of Medicare + 9.63% HCRA Surcharge,252,45,,252,percent of total billed charges,Critical Access Hospital RCC factor,190.4,34,,190.4,percent of total billed charges,Implant Device,190.4,34,,190.4,percent of total billed charges,Implant Device,190.4,34,,190.4,percent of total billed charges,Implant Device,190.4,34,,190.4,percent of total billed charges,Implant Device,190.4,34,,190.4,percent of total billed charges,Implant Device,277.2,,,277.2,Other,110% of Medicare,196,35,,196,percent of total billed charges,Implant Device,190.4,34,"Charges > $500, x 34%",190.4,percent of total billed charges,Implant Device,196,35,,196,percent of total billed charges,Implant Device,196,35,,196,percent of total billed charges,Implant Device,196,35,,196,percent of total billed charges,Implant Device,196,35,,196,percent of total billed charges,Implant Device,196,35,,196,percent of total billed charges,Implant Device,224,40,,224,percent of total billed charges,Implant Device,196,70,,196,percent of total billed charges,All Other,190.4,34,,190.4,percent of total billed charges,Implant Device,190.4,34,,190.4,percent of total billed charges,Implant Device,196,35,,196,percent of total billed charges,Implant Device,196,35,,196,percent of total billed charges,Implant Device,196,35,,196,percent of total billed charges,Implant Device,196,35,,196,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,414.4,
ZIMMER 00-7713-016-00 M/L FEM STEM 16.25,C1776,HCPCS,,79004756,CDM,278,RC,,,both,,,9000,6660.02,,,6660.02,Other,150% of Medicare + 9.63% HCRA Surcharge,4050,45,,4050,percent of total billed charges,Critical Access Hospital RCC factor,3060,34,,3060,percent of total billed charges,Implant Device,3060,34,,3060,percent of total billed charges,Implant Device,3060,34,,3060,percent of total billed charges,Implant Device,3060,34,,3060,percent of total billed charges,Implant Device,3060,34,,3060,percent of total billed charges,Implant Device,4455,,,4455,Other,110% of Medicare,3150,35,,3150,percent of total billed charges,Implant Device,3060,34,"Charges > $500, x 34%",3060,percent of total billed charges,Implant Device,3150,35,,3150,percent of total billed charges,Implant Device,3150,35,,3150,percent of total billed charges,Implant Device,3150,35,,3150,percent of total billed charges,Implant Device,3150,35,,3150,percent of total billed charges,Implant Device,3150,35,,3150,percent of total billed charges,Implant Device,3600,40,,3600,percent of total billed charges,Implant Device,3150,70,,3150,percent of total billed charges,All Other,3060,34,,3060,percent of total billed charges,Implant Device,3060,34,,3060,percent of total billed charges,Implant Device,3150,35,,3150,percent of total billed charges,Implant Device,3150,35,,3150,percent of total billed charges,Implant Device,3150,35,,3150,percent of total billed charges,Implant Device,3150,35,,3150,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3060,34,"If Charge > 2,000, then 34 percent",3060,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,6660.02,
ZIMMER 00-7848-022-00 KINECTIV MOD NECK,C1776,HCPCS,,79004757,CDM,278,RC,,,both,,,2998,2218.53,,,2218.53,Other,150% of Medicare + 9.63% HCRA Surcharge,1349.1,45,,1349.1,percent of total billed charges,Critical Access Hospital RCC factor,1019.32,34,,1019.32,percent of total billed charges,Implant Device,1019.32,34,,1019.32,percent of total billed charges,Implant Device,1019.32,34,,1019.32,percent of total billed charges,Implant Device,1019.32,34,,1019.32,percent of total billed charges,Implant Device,1019.32,34,,1019.32,percent of total billed charges,Implant Device,1484.01,,,1484.01,Other,110% of Medicare,1049.3,35,,1049.3,percent of total billed charges,Implant Device,1019.32,34,"Charges > $500, x 34%",1019.32,percent of total billed charges,Implant Device,1049.3,35,,1049.3,percent of total billed charges,Implant Device,1049.3,35,,1049.3,percent of total billed charges,Implant Device,1049.3,35,,1049.3,percent of total billed charges,Implant Device,1049.3,35,,1049.3,percent of total billed charges,Implant Device,1049.3,35,,1049.3,percent of total billed charges,Implant Device,1199.2,40,,1199.2,percent of total billed charges,Implant Device,1049.3,70,,1049.3,percent of total billed charges,All Other,1019.32,34,,1019.32,percent of total billed charges,Implant Device,1019.32,34,,1019.32,percent of total billed charges,Implant Device,1049.3,35,,1049.3,percent of total billed charges,Implant Device,1049.3,35,,1049.3,percent of total billed charges,Implant Device,1049.3,35,,1049.3,percent of total billed charges,Implant Device,1049.3,35,,1049.3,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1019.32,34,"If Charge > 2,000, then 34 percent",1019.32,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2218.53,
ZIMMER 00-1147-046-31 CANN SCREW 3.0MM,C1713,HCPCS,,79004758,CDM,278,RC,,,both,,,1139,842.86,,,842.86,Other,150% of Medicare + 9.63% HCRA Surcharge,512.55,45,,512.55,percent of total billed charges,Critical Access Hospital RCC factor,387.26,34,,387.26,percent of total billed charges,Implant Device,387.26,34,,387.26,percent of total billed charges,Implant Device,387.26,34,,387.26,percent of total billed charges,Implant Device,387.26,34,,387.26,percent of total billed charges,Implant Device,387.26,34,,387.26,percent of total billed charges,Implant Device,563.81,,,563.81,Other,110% of Medicare,398.65,35,,398.65,percent of total billed charges,Implant Device,387.26,34,"Charges > $500, x 34%",387.26,percent of total billed charges,Implant Device,398.65,35,,398.65,percent of total billed charges,Implant Device,398.65,35,,398.65,percent of total billed charges,Implant Device,398.65,35,,398.65,percent of total billed charges,Implant Device,398.65,35,,398.65,percent of total billed charges,Implant Device,398.65,35,,398.65,percent of total billed charges,Implant Device,455.6,40,,455.6,percent of total billed charges,Implant Device,398.65,70,,398.65,percent of total billed charges,All Other,387.26,34,,387.26,percent of total billed charges,Implant Device,387.26,34,,387.26,percent of total billed charges,Implant Device,398.65,35,,398.65,percent of total billed charges,Implant Device,398.65,35,,398.65,percent of total billed charges,Implant Device,398.65,35,,398.65,percent of total billed charges,Implant Device,398.65,35,,398.65,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,842.86,
ZIMMER 00-7713-009-00 M/L KINEC STEM SZ9,C1776,HCPCS,,79004759,CDM,278,RC,,,both,,,12000,8880.03,,,8880.03,Other,150% of Medicare + 9.63% HCRA Surcharge,5400,45,,5400,percent of total billed charges,Critical Access Hospital RCC factor,4080,34,,4080,percent of total billed charges,Implant Device,4080,34,,4080,percent of total billed charges,Implant Device,4080,34,,4080,percent of total billed charges,Implant Device,4080,34,,4080,percent of total billed charges,Implant Device,4080,34,,4080,percent of total billed charges,Implant Device,5940,,,5940,Other,110% of Medicare,4200,35,,4200,percent of total billed charges,Implant Device,4080,34,"Charges > $500, x 34%",4080,percent of total billed charges,Implant Device,4200,35,,4200,percent of total billed charges,Implant Device,4200,35,,4200,percent of total billed charges,Implant Device,4200,35,,4200,percent of total billed charges,Implant Device,4200,35,,4200,percent of total billed charges,Implant Device,4200,35,,4200,percent of total billed charges,Implant Device,4800,40,,4800,percent of total billed charges,Implant Device,4200,70,,4200,percent of total billed charges,All Other,4080,34,,4080,percent of total billed charges,Implant Device,4080,34,,4080,percent of total billed charges,Implant Device,4200,35,,4200,percent of total billed charges,Implant Device,4200,35,,4200,percent of total billed charges,Implant Device,4200,35,,4200,percent of total billed charges,Implant Device,4200,35,,4200,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,4080,34,"If Charge > 2,000, then 34 percent",4080,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,8880.03,
ZIMMER 00-9026-036-10 FEM HEAD TPR 36X52,C1776,HCPCS,,79004760,CDM,278,RC,,,both,,,3391,2509.35,,,2509.35,Other,150% of Medicare + 9.63% HCRA Surcharge,1525.95,45,,1525.95,percent of total billed charges,Critical Access Hospital RCC factor,1152.94,34,,1152.94,percent of total billed charges,Implant Device,1152.94,34,,1152.94,percent of total billed charges,Implant Device,1152.94,34,,1152.94,percent of total billed charges,Implant Device,1152.94,34,,1152.94,percent of total billed charges,Implant Device,1152.94,34,,1152.94,percent of total billed charges,Implant Device,1678.55,,,1678.55,Other,110% of Medicare,1186.85,35,,1186.85,percent of total billed charges,Implant Device,1152.94,34,"Charges > $500, x 34%",1152.94,percent of total billed charges,Implant Device,1186.85,35,,1186.85,percent of total billed charges,Implant Device,1186.85,35,,1186.85,percent of total billed charges,Implant Device,1186.85,35,,1186.85,percent of total billed charges,Implant Device,1186.85,35,,1186.85,percent of total billed charges,Implant Device,1186.85,35,,1186.85,percent of total billed charges,Implant Device,1356.4,40,,1356.4,percent of total billed charges,Implant Device,1186.85,70,,1186.85,percent of total billed charges,All Other,1152.94,34,,1152.94,percent of total billed charges,Implant Device,1152.94,34,,1152.94,percent of total billed charges,Implant Device,1186.85,35,,1186.85,percent of total billed charges,Implant Device,1186.85,35,,1186.85,percent of total billed charges,Implant Device,1186.85,35,,1186.85,percent of total billed charges,Implant Device,1186.85,35,,1186.85,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1152.94,34,"If Charge > 2,000, then 34 percent",1152.94,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2509.35,
ZIMMER 00-2348-028-35 SCREW 3.5X28X2.7MM,C1713,HCPCS,,79004762,CDM,278,RC,,,both,,,276,204.24,,,204.24,Other,150% of Medicare + 9.63% HCRA Surcharge,124.2,45,,124.2,percent of total billed charges,Critical Access Hospital RCC factor,93.84,34,,93.84,percent of total billed charges,Implant Device,93.84,34,,93.84,percent of total billed charges,Implant Device,93.84,34,,93.84,percent of total billed charges,Implant Device,93.84,34,,93.84,percent of total billed charges,Implant Device,93.84,34,,93.84,percent of total billed charges,Implant Device,136.62,,,136.62,Other,110% of Medicare,96.6,35,,96.6,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,96.6,35,,96.6,percent of total billed charges,Implant Device,96.6,35,,96.6,percent of total billed charges,Implant Device,96.6,35,,96.6,percent of total billed charges,Implant Device,96.6,35,,96.6,percent of total billed charges,Implant Device,96.6,35,,96.6,percent of total billed charges,Implant Device,110.4,40,,110.4,percent of total billed charges,Implant Device,96.6,70,,96.6,percent of total billed charges,All Other,93.84,34,,93.84,percent of total billed charges,Implant Device,93.84,34,,93.84,percent of total billed charges,Implant Device,96.6,35,,96.6,percent of total billed charges,Implant Device,96.6,35,,96.6,percent of total billed charges,Implant Device,96.6,35,,96.6,percent of total billed charges,Implant Device,96.6,35,,96.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,204.24,
ZIMMER 5791-43 HEADED SCREW 27MM,C1713,HCPCS,,79004763,CDM,278,RC,,,both,,,244,180.56,,,180.56,Other,150% of Medicare + 9.63% HCRA Surcharge,109.8,45,,109.8,percent of total billed charges,Critical Access Hospital RCC factor,82.96,34,,82.96,percent of total billed charges,Implant Device,82.96,34,,82.96,percent of total billed charges,Implant Device,82.96,34,,82.96,percent of total billed charges,Implant Device,82.96,34,,82.96,percent of total billed charges,Implant Device,82.96,34,,82.96,percent of total billed charges,Implant Device,120.78,,,120.78,Other,110% of Medicare,85.4,35,,85.4,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,85.4,35,,85.4,percent of total billed charges,Implant Device,85.4,35,,85.4,percent of total billed charges,Implant Device,85.4,35,,85.4,percent of total billed charges,Implant Device,85.4,35,,85.4,percent of total billed charges,Implant Device,85.4,35,,85.4,percent of total billed charges,Implant Device,97.6,40,,97.6,percent of total billed charges,Implant Device,85.4,70,,85.4,percent of total billed charges,All Other,82.96,34,,82.96,percent of total billed charges,Implant Device,82.96,34,,82.96,percent of total billed charges,Implant Device,85.4,35,,85.4,percent of total billed charges,Implant Device,85.4,35,,85.4,percent of total billed charges,Implant Device,85.4,35,,85.4,percent of total billed charges,Implant Device,85.4,35,,85.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,180.56,
ZIMMER 00-2359-065-36 CANN SCREW 3.5X65,C1713,HCPCS,,79004764,CDM,278,RC,,,both,,,334,247.16,,,247.16,Other,150% of Medicare + 9.63% HCRA Surcharge,150.3,45,,150.3,percent of total billed charges,Critical Access Hospital RCC factor,113.56,34,,113.56,percent of total billed charges,Implant Device,113.56,34,,113.56,percent of total billed charges,Implant Device,113.56,34,,113.56,percent of total billed charges,Implant Device,113.56,34,,113.56,percent of total billed charges,Implant Device,113.56,34,,113.56,percent of total billed charges,Implant Device,165.33,,,165.33,Other,110% of Medicare,116.9,35,,116.9,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,116.9,35,,116.9,percent of total billed charges,Implant Device,116.9,35,,116.9,percent of total billed charges,Implant Device,116.9,35,,116.9,percent of total billed charges,Implant Device,116.9,35,,116.9,percent of total billed charges,Implant Device,116.9,35,,116.9,percent of total billed charges,Implant Device,133.6,40,,133.6,percent of total billed charges,Implant Device,116.9,70,,116.9,percent of total billed charges,All Other,113.56,34,,113.56,percent of total billed charges,Implant Device,113.56,34,,113.56,percent of total billed charges,Implant Device,116.9,35,,116.9,percent of total billed charges,Implant Device,116.9,35,,116.9,percent of total billed charges,Implant Device,116.9,35,,116.9,percent of total billed charges,Implant Device,116.9,35,,116.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,247.16,
ZIMMER 2357-018-04 FIB LCK PLATE 4H 80MM,C1713,HCPCS,,79004765,CDM,278,RC,,,both,,,1938,1434.12,,,1434.12,Other,150% of Medicare + 9.63% HCRA Surcharge,872.1,45,,872.1,percent of total billed charges,Critical Access Hospital RCC factor,658.92,34,,658.92,percent of total billed charges,Implant Device,658.92,34,,658.92,percent of total billed charges,Implant Device,658.92,34,,658.92,percent of total billed charges,Implant Device,658.92,34,,658.92,percent of total billed charges,Implant Device,658.92,34,,658.92,percent of total billed charges,Implant Device,959.31,,,959.31,Other,110% of Medicare,678.3,35,,678.3,percent of total billed charges,Implant Device,658.92,34,"Charges > $500, x 34%",658.92,percent of total billed charges,Implant Device,678.3,35,,678.3,percent of total billed charges,Implant Device,678.3,35,,678.3,percent of total billed charges,Implant Device,678.3,35,,678.3,percent of total billed charges,Implant Device,678.3,35,,678.3,percent of total billed charges,Implant Device,678.3,35,,678.3,percent of total billed charges,Implant Device,775.2,40,,775.2,percent of total billed charges,Implant Device,678.3,70,,678.3,percent of total billed charges,All Other,658.92,34,,658.92,percent of total billed charges,Implant Device,658.92,34,,658.92,percent of total billed charges,Implant Device,678.3,35,,678.3,percent of total billed charges,Implant Device,678.3,35,,678.3,percent of total billed charges,Implant Device,678.3,35,,678.3,percent of total billed charges,Implant Device,678.3,35,,678.3,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1434.12,
ZIMMER 00-2348-020-35 PER SCREW 3.5X20MM,C1713,HCPCS,,79004766,CDM,278,RC,,,both,,,116,85.84,,,85.84,Other,150% of Medicare + 9.63% HCRA Surcharge,52.2,45,,52.2,percent of total billed charges,Critical Access Hospital RCC factor,39.44,34,,39.44,percent of total billed charges,Implant Device,39.44,34,,39.44,percent of total billed charges,Implant Device,39.44,34,,39.44,percent of total billed charges,Implant Device,39.44,34,,39.44,percent of total billed charges,Implant Device,39.44,34,,39.44,percent of total billed charges,Implant Device,57.42,,,57.42,Other,110% of Medicare,40.6,35,,40.6,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,40.6,35,,40.6,percent of total billed charges,Implant Device,40.6,35,,40.6,percent of total billed charges,Implant Device,40.6,35,,40.6,percent of total billed charges,Implant Device,40.6,35,,40.6,percent of total billed charges,Implant Device,40.6,35,,40.6,percent of total billed charges,Implant Device,46.4,40,,46.4,percent of total billed charges,Implant Device,40.6,70,,40.6,percent of total billed charges,All Other,39.44,34,,39.44,percent of total billed charges,Implant Device,39.44,34,,39.44,percent of total billed charges,Implant Device,40.6,35,,40.6,percent of total billed charges,Implant Device,40.6,35,,40.6,percent of total billed charges,Implant Device,40.6,35,,40.6,percent of total billed charges,Implant Device,40.6,35,,40.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,85.84,
ZIMMER 00-7713-007-00 MOD FEM STEM SZ7.5,C1776,HCPCS,,79004767,CDM,278,RC,,,both,,,10500,7770.03,,,7770.03,Other,150% of Medicare + 9.63% HCRA Surcharge,4725,45,,4725,percent of total billed charges,Critical Access Hospital RCC factor,3570,34,,3570,percent of total billed charges,Implant Device,3570,34,,3570,percent of total billed charges,Implant Device,3570,34,,3570,percent of total billed charges,Implant Device,3570,34,,3570,percent of total billed charges,Implant Device,3570,34,,3570,percent of total billed charges,Implant Device,5197.5,,,5197.5,Other,110% of Medicare,3675,35,,3675,percent of total billed charges,Implant Device,3570,34,"Charges > $500, x 34%",3570,percent of total billed charges,Implant Device,3675,35,,3675,percent of total billed charges,Implant Device,3675,35,,3675,percent of total billed charges,Implant Device,3675,35,,3675,percent of total billed charges,Implant Device,3675,35,,3675,percent of total billed charges,Implant Device,3675,35,,3675,percent of total billed charges,Implant Device,4200,40,,4200,percent of total billed charges,Implant Device,3675,70,,3675,percent of total billed charges,All Other,3570,34,,3570,percent of total billed charges,Implant Device,3570,34,,3570,percent of total billed charges,Implant Device,3675,35,,3675,percent of total billed charges,Implant Device,3675,35,,3675,percent of total billed charges,Implant Device,3675,35,,3675,percent of total billed charges,Implant Device,3675,35,,3675,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3570,34,"If Charge > 2,000, then 34 percent",3570,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,7770.03,
ZIMMER 02.03155.065 NCB CORT SCREW 4X65,C1713,HCPCS,,79004768,CDM,278,RC,,,both,,,324,239.76,,,239.76,Other,150% of Medicare + 9.63% HCRA Surcharge,145.8,45,,145.8,percent of total billed charges,Critical Access Hospital RCC factor,110.16,34,,110.16,percent of total billed charges,Implant Device,110.16,34,,110.16,percent of total billed charges,Implant Device,110.16,34,,110.16,percent of total billed charges,Implant Device,110.16,34,,110.16,percent of total billed charges,Implant Device,110.16,34,,110.16,percent of total billed charges,Implant Device,160.38,,,160.38,Other,110% of Medicare,113.4,35,,113.4,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,129.6,40,,129.6,percent of total billed charges,Implant Device,113.4,70,,113.4,percent of total billed charges,All Other,110.16,34,,110.16,percent of total billed charges,Implant Device,110.16,34,,110.16,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,239.76,
ZIMMER 4865-65-02 CANC SCREW 6.5X65MM,C1713,HCPCS,,79004769,CDM,278,RC,,,both,,,106,78.44,,,78.44,Other,150% of Medicare + 9.63% HCRA Surcharge,47.7,45,,47.7,percent of total billed charges,Critical Access Hospital RCC factor,36.04,34,,36.04,percent of total billed charges,Implant Device,36.04,34,,36.04,percent of total billed charges,Implant Device,36.04,34,,36.04,percent of total billed charges,Implant Device,36.04,34,,36.04,percent of total billed charges,Implant Device,36.04,34,,36.04,percent of total billed charges,Implant Device,52.47,,,52.47,Other,110% of Medicare,37.1,35,,37.1,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,37.1,35,,37.1,percent of total billed charges,Implant Device,37.1,35,,37.1,percent of total billed charges,Implant Device,37.1,35,,37.1,percent of total billed charges,Implant Device,37.1,35,,37.1,percent of total billed charges,Implant Device,37.1,35,,37.1,percent of total billed charges,Implant Device,42.4,40,,42.4,percent of total billed charges,Implant Device,37.1,70,,37.1,percent of total billed charges,All Other,36.04,34,,36.04,percent of total billed charges,Implant Device,36.04,34,,36.04,percent of total billed charges,Implant Device,37.1,35,,37.1,percent of total billed charges,Implant Device,37.1,35,,37.1,percent of total billed charges,Implant Device,37.1,35,,37.1,percent of total billed charges,Implant Device,37.1,35,,37.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,78.44,
ZIMMER 4936-010-07 10 HOLE 1/3 TUB PLATE,C1713,HCPCS,,79004771,CDM,278,RC,,,both,,,1426,1055.24,,,1055.24,Other,150% of Medicare + 9.63% HCRA Surcharge,641.7,45,,641.7,percent of total billed charges,Critical Access Hospital RCC factor,484.84,34,,484.84,percent of total billed charges,Implant Device,484.84,34,,484.84,percent of total billed charges,Implant Device,484.84,34,,484.84,percent of total billed charges,Implant Device,484.84,34,,484.84,percent of total billed charges,Implant Device,484.84,34,,484.84,percent of total billed charges,Implant Device,705.87,,,705.87,Other,110% of Medicare,499.1,35,,499.1,percent of total billed charges,Implant Device,484.84,34,"Charges > $500, x 34%",484.84,percent of total billed charges,Implant Device,499.1,35,,499.1,percent of total billed charges,Implant Device,499.1,35,,499.1,percent of total billed charges,Implant Device,499.1,35,,499.1,percent of total billed charges,Implant Device,499.1,35,,499.1,percent of total billed charges,Implant Device,499.1,35,,499.1,percent of total billed charges,Implant Device,570.4,40,,570.4,percent of total billed charges,Implant Device,499.1,70,,499.1,percent of total billed charges,All Other,484.84,34,,484.84,percent of total billed charges,Implant Device,484.84,34,,484.84,percent of total billed charges,Implant Device,499.1,35,,499.1,percent of total billed charges,Implant Device,499.1,35,,499.1,percent of total billed charges,Implant Device,499.1,35,,499.1,percent of total billed charges,Implant Device,499.1,35,,499.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1055.24,
ZIMMER 00-1147-070-40 CANN SCREW 4X70MM,C1713,HCPCS,,79004772,CDM,278,RC,,,both,,,574,424.76,,,424.76,Other,150% of Medicare + 9.63% HCRA Surcharge,258.3,45,,258.3,percent of total billed charges,Critical Access Hospital RCC factor,195.16,34,,195.16,percent of total billed charges,Implant Device,195.16,34,,195.16,percent of total billed charges,Implant Device,195.16,34,,195.16,percent of total billed charges,Implant Device,195.16,34,,195.16,percent of total billed charges,Implant Device,195.16,34,,195.16,percent of total billed charges,Implant Device,284.13,,,284.13,Other,110% of Medicare,200.9,35,,200.9,percent of total billed charges,Implant Device,195.16,34,"Charges > $500, x 34%",195.16,percent of total billed charges,Implant Device,200.9,35,,200.9,percent of total billed charges,Implant Device,200.9,35,,200.9,percent of total billed charges,Implant Device,200.9,35,,200.9,percent of total billed charges,Implant Device,200.9,35,,200.9,percent of total billed charges,Implant Device,200.9,35,,200.9,percent of total billed charges,Implant Device,229.6,40,,229.6,percent of total billed charges,Implant Device,200.9,70,,200.9,percent of total billed charges,All Other,195.16,34,,195.16,percent of total billed charges,Implant Device,195.16,34,,195.16,percent of total billed charges,Implant Device,200.9,35,,200.9,percent of total billed charges,Implant Device,200.9,35,,200.9,percent of total billed charges,Implant Device,200.9,35,,200.9,percent of total billed charges,Implant Device,200.9,35,,200.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,424.76,
ZIMMER 2359-30-55 CANN LOCK SCREW 5.5X30,C1713,HCPCS,,79004773,CDM,278,RC,,,both,,,562,415.88,,,415.88,Other,150% of Medicare + 9.63% HCRA Surcharge,252.9,45,,252.9,percent of total billed charges,Critical Access Hospital RCC factor,191.08,34,,191.08,percent of total billed charges,Implant Device,191.08,34,,191.08,percent of total billed charges,Implant Device,191.08,34,,191.08,percent of total billed charges,Implant Device,191.08,34,,191.08,percent of total billed charges,Implant Device,191.08,34,,191.08,percent of total billed charges,Implant Device,278.19,,,278.19,Other,110% of Medicare,196.7,35,,196.7,percent of total billed charges,Implant Device,191.08,34,"Charges > $500, x 34%",191.08,percent of total billed charges,Implant Device,196.7,35,,196.7,percent of total billed charges,Implant Device,196.7,35,,196.7,percent of total billed charges,Implant Device,196.7,35,,196.7,percent of total billed charges,Implant Device,196.7,35,,196.7,percent of total billed charges,Implant Device,196.7,35,,196.7,percent of total billed charges,Implant Device,224.8,40,,224.8,percent of total billed charges,Implant Device,196.7,70,,196.7,percent of total billed charges,All Other,191.08,34,,191.08,percent of total billed charges,Implant Device,191.08,34,,191.08,percent of total billed charges,Implant Device,196.7,35,,196.7,percent of total billed charges,Implant Device,196.7,35,,196.7,percent of total billed charges,Implant Device,196.7,35,,196.7,percent of total billed charges,Implant Device,196.7,35,,196.7,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,415.88,
ZIMMER 00-1147-50-40 CANN SCREW 4X50MM,C1713,HCPCS,,79004774,CDM,278,RC,,,both,,,558,412.92,,,412.92,Other,150% of Medicare + 9.63% HCRA Surcharge,251.1,45,,251.1,percent of total billed charges,Critical Access Hospital RCC factor,189.72,34,,189.72,percent of total billed charges,Implant Device,189.72,34,,189.72,percent of total billed charges,Implant Device,189.72,34,,189.72,percent of total billed charges,Implant Device,189.72,34,,189.72,percent of total billed charges,Implant Device,189.72,34,,189.72,percent of total billed charges,Implant Device,276.21,,,276.21,Other,110% of Medicare,195.3,35,,195.3,percent of total billed charges,Implant Device,189.72,34,"Charges > $500, x 34%",189.72,percent of total billed charges,Implant Device,195.3,35,,195.3,percent of total billed charges,Implant Device,195.3,35,,195.3,percent of total billed charges,Implant Device,195.3,35,,195.3,percent of total billed charges,Implant Device,195.3,35,,195.3,percent of total billed charges,Implant Device,195.3,35,,195.3,percent of total billed charges,Implant Device,223.2,40,,223.2,percent of total billed charges,Implant Device,195.3,70,,195.3,percent of total billed charges,All Other,189.72,34,,189.72,percent of total billed charges,Implant Device,189.72,34,,189.72,percent of total billed charges,Implant Device,195.3,35,,195.3,percent of total billed charges,Implant Device,195.3,35,,195.3,percent of total billed charges,Implant Device,195.3,35,,195.3,percent of total billed charges,Implant Device,195.3,35,,195.3,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,412.92,
ZIMMER 00-1147-20-35 CAN SCREW 3.5X20MM,C1713,HCPCS,,79004776,CDM,278,RC,,,both,,,532,393.68,,,393.68,Other,150% of Medicare + 9.63% HCRA Surcharge,239.4,45,,239.4,percent of total billed charges,Critical Access Hospital RCC factor,180.88,34,,180.88,percent of total billed charges,Implant Device,180.88,34,,180.88,percent of total billed charges,Implant Device,180.88,34,,180.88,percent of total billed charges,Implant Device,180.88,34,,180.88,percent of total billed charges,Implant Device,180.88,34,,180.88,percent of total billed charges,Implant Device,263.34,,,263.34,Other,110% of Medicare,186.2,35,,186.2,percent of total billed charges,Implant Device,180.88,34,"Charges > $500, x 34%",180.88,percent of total billed charges,Implant Device,186.2,35,,186.2,percent of total billed charges,Implant Device,186.2,35,,186.2,percent of total billed charges,Implant Device,186.2,35,,186.2,percent of total billed charges,Implant Device,186.2,35,,186.2,percent of total billed charges,Implant Device,186.2,35,,186.2,percent of total billed charges,Implant Device,212.8,40,,212.8,percent of total billed charges,Implant Device,186.2,70,,186.2,percent of total billed charges,All Other,180.88,34,,180.88,percent of total billed charges,Implant Device,180.88,34,,180.88,percent of total billed charges,Implant Device,186.2,35,,186.2,percent of total billed charges,Implant Device,186.2,35,,186.2,percent of total billed charges,Implant Device,186.2,35,,186.2,percent of total billed charges,Implant Device,186.2,35,,186.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,393.68,
ZIMMER 1147-056-45 SCREW 4.5X56MM,C1713,HCPCS,,79004781,CDM,278,RC,,,both,,,546,404.04,,,404.04,Other,150% of Medicare + 9.63% HCRA Surcharge,245.7,45,,245.7,percent of total billed charges,Critical Access Hospital RCC factor,185.64,34,,185.64,percent of total billed charges,Implant Device,185.64,34,,185.64,percent of total billed charges,Implant Device,185.64,34,,185.64,percent of total billed charges,Implant Device,185.64,34,,185.64,percent of total billed charges,Implant Device,185.64,34,,185.64,percent of total billed charges,Implant Device,270.27,,,270.27,Other,110% of Medicare,191.1,35,,191.1,percent of total billed charges,Implant Device,185.64,34,"Charges > $500, x 34%",185.64,percent of total billed charges,Implant Device,191.1,35,,191.1,percent of total billed charges,Implant Device,191.1,35,,191.1,percent of total billed charges,Implant Device,191.1,35,,191.1,percent of total billed charges,Implant Device,191.1,35,,191.1,percent of total billed charges,Implant Device,191.1,35,,191.1,percent of total billed charges,Implant Device,218.4,40,,218.4,percent of total billed charges,Implant Device,191.1,70,,191.1,percent of total billed charges,All Other,185.64,34,,185.64,percent of total billed charges,Implant Device,185.64,34,,185.64,percent of total billed charges,Implant Device,191.1,35,,191.1,percent of total billed charges,Implant Device,191.1,35,,191.1,percent of total billed charges,Implant Device,191.1,35,,191.1,percent of total billed charges,Implant Device,191.1,35,,191.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,404.04,
ZIMMER 2359-75-55 CAN LOCK SCREW 5.5X75,C1713,HCPCS,,79004783,CDM,278,RC,,,both,,,562,415.88,,,415.88,Other,150% of Medicare + 9.63% HCRA Surcharge,252.9,45,,252.9,percent of total billed charges,Critical Access Hospital RCC factor,191.08,34,,191.08,percent of total billed charges,Implant Device,191.08,34,,191.08,percent of total billed charges,Implant Device,191.08,34,,191.08,percent of total billed charges,Implant Device,191.08,34,,191.08,percent of total billed charges,Implant Device,191.08,34,,191.08,percent of total billed charges,Implant Device,278.19,,,278.19,Other,110% of Medicare,196.7,35,,196.7,percent of total billed charges,Implant Device,191.08,34,"Charges > $500, x 34%",191.08,percent of total billed charges,Implant Device,196.7,35,,196.7,percent of total billed charges,Implant Device,196.7,35,,196.7,percent of total billed charges,Implant Device,196.7,35,,196.7,percent of total billed charges,Implant Device,196.7,35,,196.7,percent of total billed charges,Implant Device,196.7,35,,196.7,percent of total billed charges,Implant Device,224.8,40,,224.8,percent of total billed charges,Implant Device,196.7,70,,196.7,percent of total billed charges,All Other,191.08,34,,191.08,percent of total billed charges,Implant Device,191.08,34,,191.08,percent of total billed charges,Implant Device,196.7,35,,196.7,percent of total billed charges,Implant Device,196.7,35,,196.7,percent of total billed charges,Implant Device,196.7,35,,196.7,percent of total billed charges,Implant Device,196.7,35,,196.7,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,415.88,
ZIMMER 2359-80-55 CANN SCREW 5.5X80MM,C1713,HCPCS,,79004785,CDM,278,RC,,,both,,,562,415.88,,,415.88,Other,150% of Medicare + 9.63% HCRA Surcharge,252.9,45,,252.9,percent of total billed charges,Critical Access Hospital RCC factor,191.08,34,,191.08,percent of total billed charges,Implant Device,191.08,34,,191.08,percent of total billed charges,Implant Device,191.08,34,,191.08,percent of total billed charges,Implant Device,191.08,34,,191.08,percent of total billed charges,Implant Device,191.08,34,,191.08,percent of total billed charges,Implant Device,278.19,,,278.19,Other,110% of Medicare,196.7,35,,196.7,percent of total billed charges,Implant Device,191.08,34,"Charges > $500, x 34%",191.08,percent of total billed charges,Implant Device,196.7,35,,196.7,percent of total billed charges,Implant Device,196.7,35,,196.7,percent of total billed charges,Implant Device,196.7,35,,196.7,percent of total billed charges,Implant Device,196.7,35,,196.7,percent of total billed charges,Implant Device,196.7,35,,196.7,percent of total billed charges,Implant Device,224.8,40,,224.8,percent of total billed charges,Implant Device,196.7,70,,196.7,percent of total billed charges,All Other,191.08,34,,191.08,percent of total billed charges,Implant Device,191.08,34,,191.08,percent of total billed charges,Implant Device,196.7,35,,196.7,percent of total billed charges,Implant Device,196.7,35,,196.7,percent of total billed charges,Implant Device,196.7,35,,196.7,percent of total billed charges,Implant Device,196.7,35,,196.7,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,415.88,
ZIMMER 00-2348-012-35 CORT SCREW 3.5X2.7,C1713,HCPCS,,79004786,CDM,278,RC,,,both,,,113,83.62,,,83.62,Other,150% of Medicare + 9.63% HCRA Surcharge,50.85,45,,50.85,percent of total billed charges,Critical Access Hospital RCC factor,38.42,34,,38.42,percent of total billed charges,Implant Device,38.42,34,,38.42,percent of total billed charges,Implant Device,38.42,34,,38.42,percent of total billed charges,Implant Device,38.42,34,,38.42,percent of total billed charges,Implant Device,38.42,34,,38.42,percent of total billed charges,Implant Device,55.94,,,55.94,Other,110% of Medicare,39.55,35,,39.55,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,39.55,35,,39.55,percent of total billed charges,Implant Device,39.55,35,,39.55,percent of total billed charges,Implant Device,39.55,35,,39.55,percent of total billed charges,Implant Device,39.55,35,,39.55,percent of total billed charges,Implant Device,39.55,35,,39.55,percent of total billed charges,Implant Device,45.2,40,,45.2,percent of total billed charges,Implant Device,39.55,70,,39.55,percent of total billed charges,All Other,38.42,34,,38.42,percent of total billed charges,Implant Device,38.42,34,,38.42,percent of total billed charges,Implant Device,39.55,35,,39.55,percent of total billed charges,Implant Device,39.55,35,,39.55,percent of total billed charges,Implant Device,39.55,35,,39.55,percent of total billed charges,Implant Device,39.55,35,,39.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,83.62,
ZIMMER 002359-014-38 LOCK SCREW 3.5X14MM,C1713,HCPCS,,79004787,CDM,278,RC,,,both,,,281,207.94,,,207.94,Other,150% of Medicare + 9.63% HCRA Surcharge,126.45,45,,126.45,percent of total billed charges,Critical Access Hospital RCC factor,95.54,34,,95.54,percent of total billed charges,Implant Device,95.54,34,,95.54,percent of total billed charges,Implant Device,95.54,34,,95.54,percent of total billed charges,Implant Device,95.54,34,,95.54,percent of total billed charges,Implant Device,95.54,34,,95.54,percent of total billed charges,Implant Device,139.1,,,139.1,Other,110% of Medicare,98.35,35,,98.35,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,98.35,35,,98.35,percent of total billed charges,Implant Device,98.35,35,,98.35,percent of total billed charges,Implant Device,98.35,35,,98.35,percent of total billed charges,Implant Device,98.35,35,,98.35,percent of total billed charges,Implant Device,98.35,35,,98.35,percent of total billed charges,Implant Device,112.4,40,,112.4,percent of total billed charges,Implant Device,98.35,70,,98.35,percent of total billed charges,All Other,95.54,34,,95.54,percent of total billed charges,Implant Device,95.54,34,,95.54,percent of total billed charges,Implant Device,98.35,35,,98.35,percent of total billed charges,Implant Device,98.35,35,,98.35,percent of total billed charges,Implant Device,98.35,35,,98.35,percent of total billed charges,Implant Device,98.35,35,,98.35,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,207.94,
ZIMMER 5001-43 MULTIPOLAR CUP SHELL 43MM,C1776,HCPCS,,79004788,CDM,278,RC,,,both,,,2292,1696.09,,,1696.09,Other,150% of Medicare + 9.63% HCRA Surcharge,1031.4,45,,1031.4,percent of total billed charges,Critical Access Hospital RCC factor,779.28,34,,779.28,percent of total billed charges,Implant Device,779.28,34,,779.28,percent of total billed charges,Implant Device,779.28,34,,779.28,percent of total billed charges,Implant Device,779.28,34,,779.28,percent of total billed charges,Implant Device,779.28,34,,779.28,percent of total billed charges,Implant Device,1134.54,,,1134.54,Other,110% of Medicare,802.2,35,,802.2,percent of total billed charges,Implant Device,779.28,34,"Charges > $500, x 34%",779.28,percent of total billed charges,Implant Device,802.2,35,,802.2,percent of total billed charges,Implant Device,802.2,35,,802.2,percent of total billed charges,Implant Device,802.2,35,,802.2,percent of total billed charges,Implant Device,802.2,35,,802.2,percent of total billed charges,Implant Device,802.2,35,,802.2,percent of total billed charges,Implant Device,916.8,40,,916.8,percent of total billed charges,Implant Device,802.2,70,,802.2,percent of total billed charges,All Other,779.28,34,,779.28,percent of total billed charges,Implant Device,779.28,34,,779.28,percent of total billed charges,Implant Device,802.2,35,,802.2,percent of total billed charges,Implant Device,802.2,35,,802.2,percent of total billed charges,Implant Device,802.2,35,,802.2,percent of total billed charges,Implant Device,802.2,35,,802.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,779.28,34,"If Charge > 2,000, then 34 percent",779.28,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1696.09,
ZIMMER 00-2480-040-40 CANC SCREW 4X40MM,C1713,HCPCS,,79004789,CDM,278,RC,,,both,,,180,133.2,,,133.2,Other,150% of Medicare + 9.63% HCRA Surcharge,81,45,,81,percent of total billed charges,Critical Access Hospital RCC factor,61.2,34,,61.2,percent of total billed charges,Implant Device,61.2,34,,61.2,percent of total billed charges,Implant Device,61.2,34,,61.2,percent of total billed charges,Implant Device,61.2,34,,61.2,percent of total billed charges,Implant Device,61.2,34,,61.2,percent of total billed charges,Implant Device,89.1,,,89.1,Other,110% of Medicare,63,35,,63,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,63,35,,63,percent of total billed charges,Implant Device,63,35,,63,percent of total billed charges,Implant Device,63,35,,63,percent of total billed charges,Implant Device,63,35,,63,percent of total billed charges,Implant Device,63,35,,63,percent of total billed charges,Implant Device,72,40,,72,percent of total billed charges,Implant Device,63,70,,63,percent of total billed charges,All Other,61.2,34,,61.2,percent of total billed charges,Implant Device,61.2,34,,61.2,percent of total billed charges,Implant Device,63,35,,63,percent of total billed charges,Implant Device,63,35,,63,percent of total billed charges,Implant Device,63,35,,63,percent of total billed charges,Implant Device,63,35,,63,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,133.2,
ZIMMER 00-1147-044-41 CANN CREW 4X44MM,C1713,HCPCS,,79004790,CDM,278,RC,,,both,,,558,412.92,,,412.92,Other,150% of Medicare + 9.63% HCRA Surcharge,251.1,45,,251.1,percent of total billed charges,Critical Access Hospital RCC factor,189.72,34,,189.72,percent of total billed charges,Implant Device,189.72,34,,189.72,percent of total billed charges,Implant Device,189.72,34,,189.72,percent of total billed charges,Implant Device,189.72,34,,189.72,percent of total billed charges,Implant Device,189.72,34,,189.72,percent of total billed charges,Implant Device,276.21,,,276.21,Other,110% of Medicare,195.3,35,,195.3,percent of total billed charges,Implant Device,189.72,34,"Charges > $500, x 34%",189.72,percent of total billed charges,Implant Device,195.3,35,,195.3,percent of total billed charges,Implant Device,195.3,35,,195.3,percent of total billed charges,Implant Device,195.3,35,,195.3,percent of total billed charges,Implant Device,195.3,35,,195.3,percent of total billed charges,Implant Device,195.3,35,,195.3,percent of total billed charges,Implant Device,223.2,40,,223.2,percent of total billed charges,Implant Device,195.3,70,,195.3,percent of total billed charges,All Other,189.72,34,,189.72,percent of total billed charges,Implant Device,189.72,34,,189.72,percent of total billed charges,Implant Device,195.3,35,,195.3,percent of total billed charges,Implant Device,195.3,35,,195.3,percent of total billed charges,Implant Device,195.3,35,,195.3,percent of total billed charges,Implant Device,195.3,35,,195.3,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,412.92,
ZIMMER 00-2357-017-06 FIB LCK PLT 6H 106,C1713,HCPCS,,79004791,CDM,278,RC,,,both,,,2160,1598.41,,,1598.41,Other,150% of Medicare + 9.63% HCRA Surcharge,972,45,,972,percent of total billed charges,Critical Access Hospital RCC factor,734.4,34,,734.4,percent of total billed charges,Implant Device,734.4,34,,734.4,percent of total billed charges,Implant Device,734.4,34,,734.4,percent of total billed charges,Implant Device,734.4,34,,734.4,percent of total billed charges,Implant Device,734.4,34,,734.4,percent of total billed charges,Implant Device,1069.2,,,1069.2,Other,110% of Medicare,756,35,,756,percent of total billed charges,Implant Device,734.4,34,"Charges > $500, x 34%",734.4,percent of total billed charges,Implant Device,756,35,,756,percent of total billed charges,Implant Device,756,35,,756,percent of total billed charges,Implant Device,756,35,,756,percent of total billed charges,Implant Device,756,35,,756,percent of total billed charges,Implant Device,756,35,,756,percent of total billed charges,Implant Device,864,40,,864,percent of total billed charges,Implant Device,756,70,,756,percent of total billed charges,All Other,734.4,34,,734.4,percent of total billed charges,Implant Device,734.4,34,,734.4,percent of total billed charges,Implant Device,756,35,,756,percent of total billed charges,Implant Device,756,35,,756,percent of total billed charges,Implant Device,756,35,,756,percent of total billed charges,Implant Device,756,35,,756,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,734.4,34,"If Charge > 2,000, then 34 percent",734.4,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1598.41,
ZIMMER 00-4840-020-00 CANC SCREW 4X20MM,C1713,HCPCS,,79004793,CDM,278,RC,,,both,,,56,41.44,,,41.44,Other,150% of Medicare + 9.63% HCRA Surcharge,25.2,45,,25.2,percent of total billed charges,Critical Access Hospital RCC factor,19.04,34,,19.04,percent of total billed charges,Implant Device,19.04,34,,19.04,percent of total billed charges,Implant Device,19.04,34,,19.04,percent of total billed charges,Implant Device,19.04,34,,19.04,percent of total billed charges,Implant Device,19.04,34,,19.04,percent of total billed charges,Implant Device,27.72,,,27.72,Other,110% of Medicare,19.6,35,,19.6,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,19.6,35,,19.6,percent of total billed charges,Implant Device,19.6,35,,19.6,percent of total billed charges,Implant Device,19.6,35,,19.6,percent of total billed charges,Implant Device,19.6,35,,19.6,percent of total billed charges,Implant Device,19.6,35,,19.6,percent of total billed charges,Implant Device,22.4,40,,22.4,percent of total billed charges,Implant Device,19.6,70,,19.6,percent of total billed charges,All Other,19.04,34,,19.04,percent of total billed charges,Implant Device,19.04,34,,19.04,percent of total billed charges,Implant Device,19.6,35,,19.6,percent of total billed charges,Implant Device,19.6,35,,19.6,percent of total billed charges,Implant Device,19.6,35,,19.6,percent of total billed charges,Implant Device,19.6,35,,19.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,41.44,
ZIMMER 4836-005-03 5H PLATE 1/3 TUBULAR,C1713,HCPCS,,79004794,CDM,278,RC,,,both,,,616,455.84,,,455.84,Other,150% of Medicare + 9.63% HCRA Surcharge,277.2,45,,277.2,percent of total billed charges,Critical Access Hospital RCC factor,209.44,34,,209.44,percent of total billed charges,Implant Device,209.44,34,,209.44,percent of total billed charges,Implant Device,209.44,34,,209.44,percent of total billed charges,Implant Device,209.44,34,,209.44,percent of total billed charges,Implant Device,209.44,34,,209.44,percent of total billed charges,Implant Device,304.92,,,304.92,Other,110% of Medicare,215.6,35,,215.6,percent of total billed charges,Implant Device,209.44,34,"Charges > $500, x 34%",209.44,percent of total billed charges,Implant Device,215.6,35,,215.6,percent of total billed charges,Implant Device,215.6,35,,215.6,percent of total billed charges,Implant Device,215.6,35,,215.6,percent of total billed charges,Implant Device,215.6,35,,215.6,percent of total billed charges,Implant Device,215.6,35,,215.6,percent of total billed charges,Implant Device,246.4,40,,246.4,percent of total billed charges,Implant Device,215.6,70,,215.6,percent of total billed charges,All Other,209.44,34,,209.44,percent of total billed charges,Implant Device,209.44,34,,209.44,percent of total billed charges,Implant Device,215.6,35,,215.6,percent of total billed charges,Implant Device,215.6,35,,215.6,percent of total billed charges,Implant Device,215.6,35,,215.6,percent of total billed charges,Implant Device,215.6,35,,215.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,455.84,
ZIMMER 00-2348-022-35 SCREW 3.5X22MM,C1713,HCPCS,,79004795,CDM,278,RC,,,both,,,276,204.24,,,204.24,Other,150% of Medicare + 9.63% HCRA Surcharge,124.2,45,,124.2,percent of total billed charges,Critical Access Hospital RCC factor,93.84,34,,93.84,percent of total billed charges,Implant Device,93.84,34,,93.84,percent of total billed charges,Implant Device,93.84,34,,93.84,percent of total billed charges,Implant Device,93.84,34,,93.84,percent of total billed charges,Implant Device,93.84,34,,93.84,percent of total billed charges,Implant Device,136.62,,,136.62,Other,110% of Medicare,96.6,35,,96.6,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,96.6,35,,96.6,percent of total billed charges,Implant Device,96.6,35,,96.6,percent of total billed charges,Implant Device,96.6,35,,96.6,percent of total billed charges,Implant Device,96.6,35,,96.6,percent of total billed charges,Implant Device,96.6,35,,96.6,percent of total billed charges,Implant Device,110.4,40,,110.4,percent of total billed charges,Implant Device,96.6,70,,96.6,percent of total billed charges,All Other,93.84,34,,93.84,percent of total billed charges,Implant Device,93.84,34,,93.84,percent of total billed charges,Implant Device,96.6,35,,96.6,percent of total billed charges,Implant Device,96.6,35,,96.6,percent of total billed charges,Implant Device,96.6,35,,96.6,percent of total billed charges,Implant Device,96.6,35,,96.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,204.24,
ZIMMER 02-03150-032 CORT SCREW 5X32MM,C1713,HCPCS,,79004796,CDM,278,RC,,,both,,,523,387.02,,,387.02,Other,150% of Medicare + 9.63% HCRA Surcharge,235.35,45,,235.35,percent of total billed charges,Critical Access Hospital RCC factor,177.82,34,,177.82,percent of total billed charges,Implant Device,177.82,34,,177.82,percent of total billed charges,Implant Device,177.82,34,,177.82,percent of total billed charges,Implant Device,177.82,34,,177.82,percent of total billed charges,Implant Device,177.82,34,,177.82,percent of total billed charges,Implant Device,258.89,,,258.89,Other,110% of Medicare,183.05,35,,183.05,percent of total billed charges,Implant Device,177.82,34,"Charges > $500, x 34%",177.82,percent of total billed charges,Implant Device,183.05,35,,183.05,percent of total billed charges,Implant Device,183.05,35,,183.05,percent of total billed charges,Implant Device,183.05,35,,183.05,percent of total billed charges,Implant Device,183.05,35,,183.05,percent of total billed charges,Implant Device,183.05,35,,183.05,percent of total billed charges,Implant Device,209.2,40,,209.2,percent of total billed charges,Implant Device,183.05,70,,183.05,percent of total billed charges,All Other,177.82,34,,177.82,percent of total billed charges,Implant Device,177.82,34,,177.82,percent of total billed charges,Implant Device,183.05,35,,183.05,percent of total billed charges,Implant Device,183.05,35,,183.05,percent of total billed charges,Implant Device,183.05,35,,183.05,percent of total billed charges,Implant Device,183.05,35,,183.05,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,387.02,
ZIMMER 2347-20-26 CORT SCREW 3.5X26MM,C1713,HCPCS,,79004799,CDM,278,RC,,,both,,,100,74,,,74,Other,150% of Medicare + 9.63% HCRA Surcharge,45,45,,45,percent of total billed charges,Critical Access Hospital RCC factor,34,34,,34,percent of total billed charges,Implant Device,34,34,,34,percent of total billed charges,Implant Device,34,34,,34,percent of total billed charges,Implant Device,34,34,,34,percent of total billed charges,Implant Device,34,34,,34,percent of total billed charges,Implant Device,49.5,,,49.5,Other,110% of Medicare,35,35,,35,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,35,35,,35,percent of total billed charges,Implant Device,35,35,,35,percent of total billed charges,Implant Device,35,35,,35,percent of total billed charges,Implant Device,35,35,,35,percent of total billed charges,Implant Device,35,35,,35,percent of total billed charges,Implant Device,40,40,,40,percent of total billed charges,Implant Device,35,70,,35,percent of total billed charges,All Other,34,34,,34,percent of total billed charges,Implant Device,34,34,,34,percent of total billed charges,Implant Device,35,35,,35,percent of total billed charges,Implant Device,35,35,,35,percent of total billed charges,Implant Device,35,35,,35,percent of total billed charges,Implant Device,35,35,,35,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,74,
ZIMMER 00-2357-017-04 FIB LCK PLT 4H 80M,C1713,HCPCS,,79004801,CDM,278,RC,,,both,,,2080,1539.21,,,1539.21,Other,150% of Medicare + 9.63% HCRA Surcharge,936,45,,936,percent of total billed charges,Critical Access Hospital RCC factor,707.2,34,,707.2,percent of total billed charges,Implant Device,707.2,34,,707.2,percent of total billed charges,Implant Device,707.2,34,,707.2,percent of total billed charges,Implant Device,707.2,34,,707.2,percent of total billed charges,Implant Device,707.2,34,,707.2,percent of total billed charges,Implant Device,1029.6,,,1029.6,Other,110% of Medicare,728,35,,728,percent of total billed charges,Implant Device,707.2,34,"Charges > $500, x 34%",707.2,percent of total billed charges,Implant Device,728,35,,728,percent of total billed charges,Implant Device,728,35,,728,percent of total billed charges,Implant Device,728,35,,728,percent of total billed charges,Implant Device,728,35,,728,percent of total billed charges,Implant Device,728,35,,728,percent of total billed charges,Implant Device,832,40,,832,percent of total billed charges,Implant Device,728,70,,728,percent of total billed charges,All Other,707.2,34,,707.2,percent of total billed charges,Implant Device,707.2,34,,707.2,percent of total billed charges,Implant Device,728,35,,728,percent of total billed charges,Implant Device,728,35,,728,percent of total billed charges,Implant Device,728,35,,728,percent of total billed charges,Implant Device,728,35,,728,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,707.2,34,"If Charge > 2,000, then 34 percent",707.2,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1539.21,
ZIMMER 4936-008-13 8 HOLE RECON PLATE,C1713,HCPCS,,79004802,CDM,278,RC,,,both,,,1493,1104.82,,,1104.82,Other,150% of Medicare + 9.63% HCRA Surcharge,671.85,45,,671.85,percent of total billed charges,Critical Access Hospital RCC factor,507.62,34,,507.62,percent of total billed charges,Implant Device,507.62,34,,507.62,percent of total billed charges,Implant Device,507.62,34,,507.62,percent of total billed charges,Implant Device,507.62,34,,507.62,percent of total billed charges,Implant Device,507.62,34,,507.62,percent of total billed charges,Implant Device,739.04,,,739.04,Other,110% of Medicare,522.55,35,,522.55,percent of total billed charges,Implant Device,507.62,34,"Charges > $500, x 34%",507.62,percent of total billed charges,Implant Device,522.55,35,,522.55,percent of total billed charges,Implant Device,522.55,35,,522.55,percent of total billed charges,Implant Device,522.55,35,,522.55,percent of total billed charges,Implant Device,522.55,35,,522.55,percent of total billed charges,Implant Device,522.55,35,,522.55,percent of total billed charges,Implant Device,597.2,40,,597.2,percent of total billed charges,Implant Device,522.55,70,,522.55,percent of total billed charges,All Other,507.62,34,,507.62,percent of total billed charges,Implant Device,507.62,34,,507.62,percent of total billed charges,Implant Device,522.55,35,,522.55,percent of total billed charges,Implant Device,522.55,35,,522.55,percent of total billed charges,Implant Device,522.55,35,,522.55,percent of total billed charges,Implant Device,522.55,35,,522.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1104.82,
ZIMMER 1147-050-40 CANN SCREW 1X3 4X50MM,C1713,HCPCS,,79004803,CDM,278,RC,,,both,,,558,412.92,,,412.92,Other,150% of Medicare + 9.63% HCRA Surcharge,251.1,45,,251.1,percent of total billed charges,Critical Access Hospital RCC factor,189.72,34,,189.72,percent of total billed charges,Implant Device,189.72,34,,189.72,percent of total billed charges,Implant Device,189.72,34,,189.72,percent of total billed charges,Implant Device,189.72,34,,189.72,percent of total billed charges,Implant Device,189.72,34,,189.72,percent of total billed charges,Implant Device,276.21,,,276.21,Other,110% of Medicare,195.3,35,,195.3,percent of total billed charges,Implant Device,189.72,34,"Charges > $500, x 34%",189.72,percent of total billed charges,Implant Device,195.3,35,,195.3,percent of total billed charges,Implant Device,195.3,35,,195.3,percent of total billed charges,Implant Device,195.3,35,,195.3,percent of total billed charges,Implant Device,195.3,35,,195.3,percent of total billed charges,Implant Device,195.3,35,,195.3,percent of total billed charges,Implant Device,223.2,40,,223.2,percent of total billed charges,Implant Device,195.3,70,,195.3,percent of total billed charges,All Other,189.72,34,,189.72,percent of total billed charges,Implant Device,189.72,34,,189.72,percent of total billed charges,Implant Device,195.3,35,,195.3,percent of total billed charges,Implant Device,195.3,35,,195.3,percent of total billed charges,Implant Device,195.3,35,,195.3,percent of total billed charges,Implant Device,195.3,35,,195.3,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,412.92,
ZIMMER 4836-006-03 LEFT PLATE,C1713,HCPCS,,79004804,CDM,278,RC,,,both,,,433,320.42,,,320.42,Other,150% of Medicare + 9.63% HCRA Surcharge,194.85,45,,194.85,percent of total billed charges,Critical Access Hospital RCC factor,147.22,34,,147.22,percent of total billed charges,Implant Device,147.22,34,,147.22,percent of total billed charges,Implant Device,147.22,34,,147.22,percent of total billed charges,Implant Device,147.22,34,,147.22,percent of total billed charges,Implant Device,147.22,34,,147.22,percent of total billed charges,Implant Device,214.34,,,214.34,Other,110% of Medicare,151.55,35,,151.55,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,151.55,35,,151.55,percent of total billed charges,Implant Device,151.55,35,,151.55,percent of total billed charges,Implant Device,151.55,35,,151.55,percent of total billed charges,Implant Device,151.55,35,,151.55,percent of total billed charges,Implant Device,151.55,35,,151.55,percent of total billed charges,Implant Device,173.2,40,,173.2,percent of total billed charges,Implant Device,151.55,70,,151.55,percent of total billed charges,All Other,147.22,34,,147.22,percent of total billed charges,Implant Device,147.22,34,,147.22,percent of total billed charges,Implant Device,151.55,35,,151.55,percent of total billed charges,Implant Device,151.55,35,,151.55,percent of total billed charges,Implant Device,151.55,35,,151.55,percent of total billed charges,Implant Device,151.55,35,,151.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,320.42,
ZIMMER 00-4828-016-02 LOCK SCREW 2.7X16,C1713,HCPCS,,79004805,CDM,278,RC,,,both,,,345,255.3,,,255.3,Other,150% of Medicare + 9.63% HCRA Surcharge,155.25,45,,155.25,percent of total billed charges,Critical Access Hospital RCC factor,117.3,34,,117.3,percent of total billed charges,Implant Device,117.3,34,,117.3,percent of total billed charges,Implant Device,117.3,34,,117.3,percent of total billed charges,Implant Device,117.3,34,,117.3,percent of total billed charges,Implant Device,117.3,34,,117.3,percent of total billed charges,Implant Device,170.78,,,170.78,Other,110% of Medicare,120.75,35,,120.75,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,120.75,35,,120.75,percent of total billed charges,Implant Device,120.75,35,,120.75,percent of total billed charges,Implant Device,120.75,35,,120.75,percent of total billed charges,Implant Device,120.75,35,,120.75,percent of total billed charges,Implant Device,120.75,35,,120.75,percent of total billed charges,Implant Device,138,40,,138,percent of total billed charges,Implant Device,120.75,70,,120.75,percent of total billed charges,All Other,117.3,34,,117.3,percent of total billed charges,Implant Device,117.3,34,,117.3,percent of total billed charges,Implant Device,120.75,35,,120.75,percent of total billed charges,Implant Device,120.75,35,,120.75,percent of total billed charges,Implant Device,120.75,35,,120.75,percent of total billed charges,Implant Device,120.75,35,,120.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,255.3,
ZIMMER 2357-018-08 DISTAL FIBULA PLATE,C1713,HCPCS,,79004806,CDM,278,RC,,,both,,,2224,1645.77,,,1645.77,Other,150% of Medicare + 9.63% HCRA Surcharge,1000.8,45,,1000.8,percent of total billed charges,Critical Access Hospital RCC factor,756.16,34,,756.16,percent of total billed charges,Implant Device,756.16,34,,756.16,percent of total billed charges,Implant Device,756.16,34,,756.16,percent of total billed charges,Implant Device,756.16,34,,756.16,percent of total billed charges,Implant Device,756.16,34,,756.16,percent of total billed charges,Implant Device,1100.88,,,1100.88,Other,110% of Medicare,778.4,35,,778.4,percent of total billed charges,Implant Device,756.16,34,"Charges > $500, x 34%",756.16,percent of total billed charges,Implant Device,778.4,35,,778.4,percent of total billed charges,Implant Device,778.4,35,,778.4,percent of total billed charges,Implant Device,778.4,35,,778.4,percent of total billed charges,Implant Device,778.4,35,,778.4,percent of total billed charges,Implant Device,778.4,35,,778.4,percent of total billed charges,Implant Device,889.6,40,,889.6,percent of total billed charges,Implant Device,778.4,70,,778.4,percent of total billed charges,All Other,756.16,34,,756.16,percent of total billed charges,Implant Device,756.16,34,,756.16,percent of total billed charges,Implant Device,778.4,35,,778.4,percent of total billed charges,Implant Device,778.4,35,,778.4,percent of total billed charges,Implant Device,778.4,35,,778.4,percent of total billed charges,Implant Device,778.4,35,,778.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,756.16,34,"If Charge > 2,000, then 34 percent",756.16,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1645.77,
ZIMMER 00-2359-012-27 LOCK SCREW 2.7X12,C1713,HCPCS,,79004807,CDM,278,RC,,,both,,,360,266.4,,,266.4,Other,150% of Medicare + 9.63% HCRA Surcharge,162,45,,162,percent of total billed charges,Critical Access Hospital RCC factor,122.4,34,,122.4,percent of total billed charges,Implant Device,122.4,34,,122.4,percent of total billed charges,Implant Device,122.4,34,,122.4,percent of total billed charges,Implant Device,122.4,34,,122.4,percent of total billed charges,Implant Device,122.4,34,,122.4,percent of total billed charges,Implant Device,178.2,,,178.2,Other,110% of Medicare,126,35,,126,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,126,35,,126,percent of total billed charges,Implant Device,126,35,,126,percent of total billed charges,Implant Device,126,35,,126,percent of total billed charges,Implant Device,126,35,,126,percent of total billed charges,Implant Device,126,35,,126,percent of total billed charges,Implant Device,144,40,,144,percent of total billed charges,Implant Device,126,70,,126,percent of total billed charges,All Other,122.4,34,,122.4,percent of total billed charges,Implant Device,122.4,34,,122.4,percent of total billed charges,Implant Device,126,35,,126,percent of total billed charges,Implant Device,126,35,,126,percent of total billed charges,Implant Device,126,35,,126,percent of total billed charges,Implant Device,126,35,,126,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,266.4,
ZIMMER 02-03155-030 NCB CORT SCREW 4X30M,C1713,HCPCS,,79004809,CDM,278,RC,,,both,,,402,297.48,,,297.48,Other,150% of Medicare + 9.63% HCRA Surcharge,180.9,45,,180.9,percent of total billed charges,Critical Access Hospital RCC factor,136.68,34,,136.68,percent of total billed charges,Implant Device,136.68,34,,136.68,percent of total billed charges,Implant Device,136.68,34,,136.68,percent of total billed charges,Implant Device,136.68,34,,136.68,percent of total billed charges,Implant Device,136.68,34,,136.68,percent of total billed charges,Implant Device,198.99,,,198.99,Other,110% of Medicare,140.7,35,,140.7,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,140.7,35,,140.7,percent of total billed charges,Implant Device,140.7,35,,140.7,percent of total billed charges,Implant Device,140.7,35,,140.7,percent of total billed charges,Implant Device,140.7,35,,140.7,percent of total billed charges,Implant Device,140.7,35,,140.7,percent of total billed charges,Implant Device,160.8,40,,160.8,percent of total billed charges,Implant Device,140.7,70,,140.7,percent of total billed charges,All Other,136.68,34,,136.68,percent of total billed charges,Implant Device,136.68,34,,136.68,percent of total billed charges,Implant Device,140.7,35,,140.7,percent of total billed charges,Implant Device,140.7,35,,140.7,percent of total billed charges,Implant Device,140.7,35,,140.7,percent of total billed charges,Implant Device,140.7,35,,140.7,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,297.48,
ZIMMER 5972-65-29 POLY PATELLA 29X8.0MM,C1776,HCPCS,,79004810,CDM,278,RC,,,both,,,1152,852.48,,,852.48,Other,150% of Medicare + 9.63% HCRA Surcharge,518.4,45,,518.4,percent of total billed charges,Critical Access Hospital RCC factor,391.68,34,,391.68,percent of total billed charges,Implant Device,391.68,34,,391.68,percent of total billed charges,Implant Device,391.68,34,,391.68,percent of total billed charges,Implant Device,391.68,34,,391.68,percent of total billed charges,Implant Device,391.68,34,,391.68,percent of total billed charges,Implant Device,570.24,,,570.24,Other,110% of Medicare,403.2,35,,403.2,percent of total billed charges,Implant Device,391.68,34,"Charges > $500, x 34%",391.68,percent of total billed charges,Implant Device,403.2,35,,403.2,percent of total billed charges,Implant Device,403.2,35,,403.2,percent of total billed charges,Implant Device,403.2,35,,403.2,percent of total billed charges,Implant Device,403.2,35,,403.2,percent of total billed charges,Implant Device,403.2,35,,403.2,percent of total billed charges,Implant Device,460.8,40,,460.8,percent of total billed charges,Implant Device,403.2,70,,403.2,percent of total billed charges,All Other,391.68,34,,391.68,percent of total billed charges,Implant Device,391.68,34,,391.68,percent of total billed charges,Implant Device,403.2,35,,403.2,percent of total billed charges,Implant Device,403.2,35,,403.2,percent of total billed charges,Implant Device,403.2,35,,403.2,percent of total billed charges,Implant Device,403.2,35,,403.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,852.48,
ZIMMER 4835-024-01 CORT SCREW 3.5X24MM,C1713,HCPCS,,79004813,CDM,278,RC,,,both,,,144,106.56,,,106.56,Other,150% of Medicare + 9.63% HCRA Surcharge,64.8,45,,64.8,percent of total billed charges,Critical Access Hospital RCC factor,48.96,34,,48.96,percent of total billed charges,Implant Device,48.96,34,,48.96,percent of total billed charges,Implant Device,48.96,34,,48.96,percent of total billed charges,Implant Device,48.96,34,,48.96,percent of total billed charges,Implant Device,48.96,34,,48.96,percent of total billed charges,Implant Device,71.28,,,71.28,Other,110% of Medicare,50.4,35,,50.4,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,50.4,35,,50.4,percent of total billed charges,Implant Device,50.4,35,,50.4,percent of total billed charges,Implant Device,50.4,35,,50.4,percent of total billed charges,Implant Device,50.4,35,,50.4,percent of total billed charges,Implant Device,50.4,35,,50.4,percent of total billed charges,Implant Device,57.6,40,,57.6,percent of total billed charges,Implant Device,50.4,70,,50.4,percent of total billed charges,All Other,48.96,34,,48.96,percent of total billed charges,Implant Device,48.96,34,,48.96,percent of total billed charges,Implant Device,50.4,35,,50.4,percent of total billed charges,Implant Device,50.4,35,,50.4,percent of total billed charges,Implant Device,50.4,35,,50.4,percent of total billed charges,Implant Device,50.4,35,,50.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,106.56,
ZIMMER 2347-20-10 CORT SCREW 3.5X10MM,C1713,HCPCS,,79004814,CDM,278,RC,,,both,,,130,96.2,,,96.2,Other,150% of Medicare + 9.63% HCRA Surcharge,58.5,45,,58.5,percent of total billed charges,Critical Access Hospital RCC factor,44.2,34,,44.2,percent of total billed charges,Implant Device,44.2,34,,44.2,percent of total billed charges,Implant Device,44.2,34,,44.2,percent of total billed charges,Implant Device,44.2,34,,44.2,percent of total billed charges,Implant Device,44.2,34,,44.2,percent of total billed charges,Implant Device,64.35,,,64.35,Other,110% of Medicare,45.5,35,,45.5,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,45.5,35,,45.5,percent of total billed charges,Implant Device,45.5,35,,45.5,percent of total billed charges,Implant Device,45.5,35,,45.5,percent of total billed charges,Implant Device,45.5,35,,45.5,percent of total billed charges,Implant Device,45.5,35,,45.5,percent of total billed charges,Implant Device,52,40,,52,percent of total billed charges,Implant Device,45.5,70,,45.5,percent of total billed charges,All Other,44.2,34,,44.2,percent of total billed charges,Implant Device,44.2,34,,44.2,percent of total billed charges,Implant Device,45.5,35,,45.5,percent of total billed charges,Implant Device,45.5,35,,45.5,percent of total billed charges,Implant Device,45.5,35,,45.5,percent of total billed charges,Implant Device,45.5,35,,45.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,96.2,
ZIMMER 00-4936-008-03 8H PLATE 3.5X107MM,C1713,HCPCS,,79004815,CDM,278,RC,,,both,,,490,362.6,,,362.6,Other,150% of Medicare + 9.63% HCRA Surcharge,220.5,45,,220.5,percent of total billed charges,Critical Access Hospital RCC factor,166.6,34,,166.6,percent of total billed charges,Implant Device,166.6,34,,166.6,percent of total billed charges,Implant Device,166.6,34,,166.6,percent of total billed charges,Implant Device,166.6,34,,166.6,percent of total billed charges,Implant Device,166.6,34,,166.6,percent of total billed charges,Implant Device,242.55,,,242.55,Other,110% of Medicare,171.5,35,,171.5,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,171.5,35,,171.5,percent of total billed charges,Implant Device,171.5,35,,171.5,percent of total billed charges,Implant Device,171.5,35,,171.5,percent of total billed charges,Implant Device,171.5,35,,171.5,percent of total billed charges,Implant Device,171.5,35,,171.5,percent of total billed charges,Implant Device,196,40,,196,percent of total billed charges,Implant Device,171.5,70,,171.5,percent of total billed charges,All Other,166.6,34,,166.6,percent of total billed charges,Implant Device,166.6,34,,166.6,percent of total billed charges,Implant Device,171.5,35,,171.5,percent of total billed charges,Implant Device,171.5,35,,171.5,percent of total billed charges,Implant Device,171.5,35,,171.5,percent of total billed charges,Implant Device,171.5,35,,171.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,362.6,
ARTHREX AR-2654CR PLATE CENTRAL THIRD,C1713,HCPCS,,79004816,CDM,278,RC,,,both,,,1650,1221,,,1221,Other,150% of Medicare + 9.63% HCRA Surcharge,742.5,45,,742.5,percent of total billed charges,Critical Access Hospital RCC factor,561,34,,561,percent of total billed charges,Implant Device,561,34,,561,percent of total billed charges,Implant Device,561,34,,561,percent of total billed charges,Implant Device,561,34,,561,percent of total billed charges,Implant Device,561,34,,561,percent of total billed charges,Implant Device,816.75,,,816.75,Other,110% of Medicare,577.5,35,,577.5,percent of total billed charges,Implant Device,561,34,"Charges > $500, x 34%",561,percent of total billed charges,Implant Device,577.5,35,,577.5,percent of total billed charges,Implant Device,577.5,35,,577.5,percent of total billed charges,Implant Device,577.5,35,,577.5,percent of total billed charges,Implant Device,577.5,35,,577.5,percent of total billed charges,Implant Device,577.5,35,,577.5,percent of total billed charges,Implant Device,660,40,,660,percent of total billed charges,Implant Device,577.5,70,,577.5,percent of total billed charges,All Other,561,34,,561,percent of total billed charges,Implant Device,561,34,,561,percent of total billed charges,Implant Device,577.5,35,,577.5,percent of total billed charges,Implant Device,577.5,35,,577.5,percent of total billed charges,Implant Device,577.5,35,,577.5,percent of total billed charges,Implant Device,577.5,35,,577.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1221,
ARTHREX AR-8835L-12 LOCK SCREW 3.5X12MM,C1713,HCPCS,,79004817,CDM,278,RC,,,both,,,495,366.3,,,366.3,Other,150% of Medicare + 9.63% HCRA Surcharge,222.75,45,,222.75,percent of total billed charges,Critical Access Hospital RCC factor,168.3,34,,168.3,percent of total billed charges,Implant Device,168.3,34,,168.3,percent of total billed charges,Implant Device,168.3,34,,168.3,percent of total billed charges,Implant Device,168.3,34,,168.3,percent of total billed charges,Implant Device,168.3,34,,168.3,percent of total billed charges,Implant Device,245.03,,,245.03,Other,110% of Medicare,173.25,35,,173.25,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,173.25,35,,173.25,percent of total billed charges,Implant Device,173.25,35,,173.25,percent of total billed charges,Implant Device,173.25,35,,173.25,percent of total billed charges,Implant Device,173.25,35,,173.25,percent of total billed charges,Implant Device,173.25,35,,173.25,percent of total billed charges,Implant Device,198,40,,198,percent of total billed charges,Implant Device,173.25,70,,173.25,percent of total billed charges,All Other,168.3,34,,168.3,percent of total billed charges,Implant Device,168.3,34,,168.3,percent of total billed charges,Implant Device,173.25,35,,173.25,percent of total billed charges,Implant Device,173.25,35,,173.25,percent of total billed charges,Implant Device,173.25,35,,173.25,percent of total billed charges,Implant Device,173.25,35,,173.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,366.3,
STRYKER 58-23022E BONE SCREW 2.3MM,C1713,HCPCS,,79004819,CDM,278,RC,,,both,,,283,209.42,,,209.42,Other,150% of Medicare + 9.63% HCRA Surcharge,127.35,45,,127.35,percent of total billed charges,Critical Access Hospital RCC factor,96.22,34,,96.22,percent of total billed charges,Implant Device,96.22,34,,96.22,percent of total billed charges,Implant Device,96.22,34,,96.22,percent of total billed charges,Implant Device,96.22,34,,96.22,percent of total billed charges,Implant Device,96.22,34,,96.22,percent of total billed charges,Implant Device,140.09,,,140.09,Other,110% of Medicare,99.05,35,,99.05,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,99.05,35,,99.05,percent of total billed charges,Implant Device,99.05,35,,99.05,percent of total billed charges,Implant Device,99.05,35,,99.05,percent of total billed charges,Implant Device,99.05,35,,99.05,percent of total billed charges,Implant Device,99.05,35,,99.05,percent of total billed charges,Implant Device,113.2,40,,113.2,percent of total billed charges,Implant Device,99.05,70,,99.05,percent of total billed charges,All Other,96.22,34,,96.22,percent of total billed charges,Implant Device,96.22,34,,96.22,percent of total billed charges,Implant Device,99.05,35,,99.05,percent of total billed charges,Implant Device,99.05,35,,99.05,percent of total billed charges,Implant Device,99.05,35,,99.05,percent of total billed charges,Implant Device,99.05,35,,99.05,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,209.42,
ZIMMER 5990-35-01 POST FEM AUG BLOCK 5MM,C1776,HCPCS,,79004822,CDM,278,RC,,,both,,,2963,2192.63,,,2192.63,Other,150% of Medicare + 9.63% HCRA Surcharge,1333.35,45,,1333.35,percent of total billed charges,Critical Access Hospital RCC factor,1007.42,34,,1007.42,percent of total billed charges,Implant Device,1007.42,34,,1007.42,percent of total billed charges,Implant Device,1007.42,34,,1007.42,percent of total billed charges,Implant Device,1007.42,34,,1007.42,percent of total billed charges,Implant Device,1007.42,34,,1007.42,percent of total billed charges,Implant Device,1466.69,,,1466.69,Other,110% of Medicare,1037.05,35,,1037.05,percent of total billed charges,Implant Device,1007.42,34,"Charges > $500, x 34%",1007.42,percent of total billed charges,Implant Device,1037.05,35,,1037.05,percent of total billed charges,Implant Device,1037.05,35,,1037.05,percent of total billed charges,Implant Device,1037.05,35,,1037.05,percent of total billed charges,Implant Device,1037.05,35,,1037.05,percent of total billed charges,Implant Device,1037.05,35,,1037.05,percent of total billed charges,Implant Device,1185.2,40,,1185.2,percent of total billed charges,Implant Device,1037.05,70,,1037.05,percent of total billed charges,All Other,1007.42,34,,1007.42,percent of total billed charges,Implant Device,1007.42,34,,1007.42,percent of total billed charges,Implant Device,1037.05,35,,1037.05,percent of total billed charges,Implant Device,1037.05,35,,1037.05,percent of total billed charges,Implant Device,1037.05,35,,1037.05,percent of total billed charges,Implant Device,1037.05,35,,1037.05,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1007.42,34,"If Charge > 2,000, then 34 percent",1007.42,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2192.63,
ZIMMER 5990-35-10 DIST FEM AUG BLOCK 5MM,C1776,HCPCS,,79004823,CDM,278,RC,,,both,,,2963,2192.63,,,2192.63,Other,150% of Medicare + 9.63% HCRA Surcharge,1333.35,45,,1333.35,percent of total billed charges,Critical Access Hospital RCC factor,1007.42,34,,1007.42,percent of total billed charges,Implant Device,1007.42,34,,1007.42,percent of total billed charges,Implant Device,1007.42,34,,1007.42,percent of total billed charges,Implant Device,1007.42,34,,1007.42,percent of total billed charges,Implant Device,1007.42,34,,1007.42,percent of total billed charges,Implant Device,1466.69,,,1466.69,Other,110% of Medicare,1037.05,35,,1037.05,percent of total billed charges,Implant Device,1007.42,34,"Charges > $500, x 34%",1007.42,percent of total billed charges,Implant Device,1037.05,35,,1037.05,percent of total billed charges,Implant Device,1037.05,35,,1037.05,percent of total billed charges,Implant Device,1037.05,35,,1037.05,percent of total billed charges,Implant Device,1037.05,35,,1037.05,percent of total billed charges,Implant Device,1037.05,35,,1037.05,percent of total billed charges,Implant Device,1185.2,40,,1185.2,percent of total billed charges,Implant Device,1037.05,70,,1037.05,percent of total billed charges,All Other,1007.42,34,,1007.42,percent of total billed charges,Implant Device,1007.42,34,,1007.42,percent of total billed charges,Implant Device,1037.05,35,,1037.05,percent of total billed charges,Implant Device,1037.05,35,,1037.05,percent of total billed charges,Implant Device,1037.05,35,,1037.05,percent of total billed charges,Implant Device,1037.05,35,,1037.05,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1007.42,34,"If Charge > 2,000, then 34 percent",1007.42,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2192.63,
ZIMMER 5994-32-23 LCCK ART SURF 23MM,C1776,HCPCS,,79004824,CDM,278,RC,,,both,,,6773,5012.04,,,5012.04,Other,150% of Medicare + 9.63% HCRA Surcharge,3047.85,45,,3047.85,percent of total billed charges,Critical Access Hospital RCC factor,2302.82,34,,2302.82,percent of total billed charges,Implant Device,2302.82,34,,2302.82,percent of total billed charges,Implant Device,2302.82,34,,2302.82,percent of total billed charges,Implant Device,2302.82,34,,2302.82,percent of total billed charges,Implant Device,2302.82,34,,2302.82,percent of total billed charges,Implant Device,3352.64,,,3352.64,Other,110% of Medicare,2370.55,35,,2370.55,percent of total billed charges,Implant Device,2302.82,34,"Charges > $500, x 34%",2302.82,percent of total billed charges,Implant Device,2370.55,35,,2370.55,percent of total billed charges,Implant Device,2370.55,35,,2370.55,percent of total billed charges,Implant Device,2370.55,35,,2370.55,percent of total billed charges,Implant Device,2370.55,35,,2370.55,percent of total billed charges,Implant Device,2370.55,35,,2370.55,percent of total billed charges,Implant Device,2709.2,40,,2709.2,percent of total billed charges,Implant Device,2370.55,70,,2370.55,percent of total billed charges,All Other,2302.82,34,,2302.82,percent of total billed charges,Implant Device,2302.82,34,,2302.82,percent of total billed charges,Implant Device,2370.55,35,,2370.55,percent of total billed charges,Implant Device,2370.55,35,,2370.55,percent of total billed charges,Implant Device,2370.55,35,,2370.55,percent of total billed charges,Implant Device,2370.55,35,,2370.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2302.82,34,"If Charge > 2,000, then 34 percent",2302.82,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5012.04,
STRYKER 3225-0380S LONG NAIL R2.0 11X380,C1713,HCPCS,,79004825,CDM,278,RC,,,both,,,10162,7519.91,,,7519.91,Other,150% of Medicare + 9.63% HCRA Surcharge,4572.9,45,,4572.9,percent of total billed charges,Critical Access Hospital RCC factor,3455.08,34,,3455.08,percent of total billed charges,Implant Device,3455.08,34,,3455.08,percent of total billed charges,Implant Device,3455.08,34,,3455.08,percent of total billed charges,Implant Device,3455.08,34,,3455.08,percent of total billed charges,Implant Device,3455.08,34,,3455.08,percent of total billed charges,Implant Device,5030.19,,,5030.19,Other,110% of Medicare,3556.7,35,,3556.7,percent of total billed charges,Implant Device,3455.08,34,"Charges > $500, x 34%",3455.08,percent of total billed charges,Implant Device,3556.7,35,,3556.7,percent of total billed charges,Implant Device,3556.7,35,,3556.7,percent of total billed charges,Implant Device,3556.7,35,,3556.7,percent of total billed charges,Implant Device,3556.7,35,,3556.7,percent of total billed charges,Implant Device,3556.7,35,,3556.7,percent of total billed charges,Implant Device,4064.8,40,,4064.8,percent of total billed charges,Implant Device,3556.7,70,,3556.7,percent of total billed charges,All Other,3455.08,34,,3455.08,percent of total billed charges,Implant Device,3455.08,34,,3455.08,percent of total billed charges,Implant Device,3556.7,35,,3556.7,percent of total billed charges,Implant Device,3556.7,35,,3556.7,percent of total billed charges,Implant Device,3556.7,35,,3556.7,percent of total billed charges,Implant Device,3556.7,35,,3556.7,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3455.08,34,"If Charge > 2,000, then 34 percent",3455.08,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,7519.91,
STRYKER 3060-105S LAG SCREW 10.5X105MM,C1713,HCPCS,,79004826,CDM,278,RC,,,both,,,2153,1593.23,,,1593.23,Other,150% of Medicare + 9.63% HCRA Surcharge,968.85,45,,968.85,percent of total billed charges,Critical Access Hospital RCC factor,732.02,34,,732.02,percent of total billed charges,Implant Device,732.02,34,,732.02,percent of total billed charges,Implant Device,732.02,34,,732.02,percent of total billed charges,Implant Device,732.02,34,,732.02,percent of total billed charges,Implant Device,732.02,34,,732.02,percent of total billed charges,Implant Device,1065.74,,,1065.74,Other,110% of Medicare,753.55,35,,753.55,percent of total billed charges,Implant Device,732.02,34,"Charges > $500, x 34%",732.02,percent of total billed charges,Implant Device,753.55,35,,753.55,percent of total billed charges,Implant Device,753.55,35,,753.55,percent of total billed charges,Implant Device,753.55,35,,753.55,percent of total billed charges,Implant Device,753.55,35,,753.55,percent of total billed charges,Implant Device,753.55,35,,753.55,percent of total billed charges,Implant Device,861.2,40,,861.2,percent of total billed charges,Implant Device,753.55,70,,753.55,percent of total billed charges,All Other,732.02,34,,732.02,percent of total billed charges,Implant Device,732.02,34,,732.02,percent of total billed charges,Implant Device,753.55,35,,753.55,percent of total billed charges,Implant Device,753.55,35,,753.55,percent of total billed charges,Implant Device,753.55,35,,753.55,percent of total billed charges,Implant Device,753.55,35,,753.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,732.02,34,"If Charge > 2,000, then 34 percent",732.02,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1593.23,
STRYKER 1896-5050S LOCKING SCREW FT 5X50,C1713,HCPCS,,79004828,CDM,278,RC,,,both,,,355,262.7,,,262.7,Other,150% of Medicare + 9.63% HCRA Surcharge,159.75,45,,159.75,percent of total billed charges,Critical Access Hospital RCC factor,120.7,34,,120.7,percent of total billed charges,Implant Device,120.7,34,,120.7,percent of total billed charges,Implant Device,120.7,34,,120.7,percent of total billed charges,Implant Device,120.7,34,,120.7,percent of total billed charges,Implant Device,120.7,34,,120.7,percent of total billed charges,Implant Device,175.73,,,175.73,Other,110% of Medicare,124.25,35,,124.25,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,124.25,35,,124.25,percent of total billed charges,Implant Device,124.25,35,,124.25,percent of total billed charges,Implant Device,124.25,35,,124.25,percent of total billed charges,Implant Device,124.25,35,,124.25,percent of total billed charges,Implant Device,124.25,35,,124.25,percent of total billed charges,Implant Device,142,40,,142,percent of total billed charges,Implant Device,124.25,70,,124.25,percent of total billed charges,All Other,120.7,34,,120.7,percent of total billed charges,Implant Device,120.7,34,,120.7,percent of total billed charges,Implant Device,124.25,35,,124.25,percent of total billed charges,Implant Device,124.25,35,,124.25,percent of total billed charges,Implant Device,124.25,35,,124.25,percent of total billed charges,Implant Device,124.25,35,,124.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,262.7,
STRYKER 54-25295 DORSAL PLATE STD 81MM,C1713,HCPCS,,79004829,CDM,278,RC,,,both,,,3570,2641.81,,,2641.81,Other,150% of Medicare + 9.63% HCRA Surcharge,1606.5,45,,1606.5,percent of total billed charges,Critical Access Hospital RCC factor,1213.8,34,,1213.8,percent of total billed charges,Implant Device,1213.8,34,,1213.8,percent of total billed charges,Implant Device,1213.8,34,,1213.8,percent of total billed charges,Implant Device,1213.8,34,,1213.8,percent of total billed charges,Implant Device,1213.8,34,,1213.8,percent of total billed charges,Implant Device,1767.15,,,1767.15,Other,110% of Medicare,1249.5,35,,1249.5,percent of total billed charges,Implant Device,1213.8,34,"Charges > $500, x 34%",1213.8,percent of total billed charges,Implant Device,1249.5,35,,1249.5,percent of total billed charges,Implant Device,1249.5,35,,1249.5,percent of total billed charges,Implant Device,1249.5,35,,1249.5,percent of total billed charges,Implant Device,1249.5,35,,1249.5,percent of total billed charges,Implant Device,1249.5,35,,1249.5,percent of total billed charges,Implant Device,1428,40,,1428,percent of total billed charges,Implant Device,1249.5,70,,1249.5,percent of total billed charges,All Other,1213.8,34,,1213.8,percent of total billed charges,Implant Device,1213.8,34,,1213.8,percent of total billed charges,Implant Device,1249.5,35,,1249.5,percent of total billed charges,Implant Device,1249.5,35,,1249.5,percent of total billed charges,Implant Device,1249.5,35,,1249.5,percent of total billed charges,Implant Device,1249.5,35,,1249.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1213.8,34,"If Charge > 2,000, then 34 percent",1213.8,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2641.81,
STRYKER 53-23622E T7 LOCK SCREW 2.3X22MM,C1713,HCPCS,,79004830,CDM,278,RC,,,both,,,518,383.32,,,383.32,Other,150% of Medicare + 9.63% HCRA Surcharge,233.1,45,,233.1,percent of total billed charges,Critical Access Hospital RCC factor,176.12,34,,176.12,percent of total billed charges,Implant Device,176.12,34,,176.12,percent of total billed charges,Implant Device,176.12,34,,176.12,percent of total billed charges,Implant Device,176.12,34,,176.12,percent of total billed charges,Implant Device,176.12,34,,176.12,percent of total billed charges,Implant Device,256.41,,,256.41,Other,110% of Medicare,181.3,35,,181.3,percent of total billed charges,Implant Device,176.12,34,"Charges > $500, x 34%",176.12,percent of total billed charges,Implant Device,181.3,35,,181.3,percent of total billed charges,Implant Device,181.3,35,,181.3,percent of total billed charges,Implant Device,181.3,35,,181.3,percent of total billed charges,Implant Device,181.3,35,,181.3,percent of total billed charges,Implant Device,181.3,35,,181.3,percent of total billed charges,Implant Device,207.2,40,,207.2,percent of total billed charges,Implant Device,181.3,70,,181.3,percent of total billed charges,All Other,176.12,34,,176.12,percent of total billed charges,Implant Device,176.12,34,,176.12,percent of total billed charges,Implant Device,181.3,35,,181.3,percent of total billed charges,Implant Device,181.3,35,,181.3,percent of total billed charges,Implant Device,181.3,35,,181.3,percent of total billed charges,Implant Device,181.3,35,,181.3,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,383.32,
STRYKER 53-23624E T7 LOCK SCREW 2.3X24MM,C1713,HCPCS,,79004831,CDM,278,RC,,,both,,,518,383.32,,,383.32,Other,150% of Medicare + 9.63% HCRA Surcharge,233.1,45,,233.1,percent of total billed charges,Critical Access Hospital RCC factor,176.12,34,,176.12,percent of total billed charges,Implant Device,176.12,34,,176.12,percent of total billed charges,Implant Device,176.12,34,,176.12,percent of total billed charges,Implant Device,176.12,34,,176.12,percent of total billed charges,Implant Device,176.12,34,,176.12,percent of total billed charges,Implant Device,256.41,,,256.41,Other,110% of Medicare,181.3,35,,181.3,percent of total billed charges,Implant Device,176.12,34,"Charges > $500, x 34%",176.12,percent of total billed charges,Implant Device,181.3,35,,181.3,percent of total billed charges,Implant Device,181.3,35,,181.3,percent of total billed charges,Implant Device,181.3,35,,181.3,percent of total billed charges,Implant Device,181.3,35,,181.3,percent of total billed charges,Implant Device,181.3,35,,181.3,percent of total billed charges,Implant Device,207.2,40,,207.2,percent of total billed charges,Implant Device,181.3,70,,181.3,percent of total billed charges,All Other,176.12,34,,176.12,percent of total billed charges,Implant Device,176.12,34,,176.12,percent of total billed charges,Implant Device,181.3,35,,181.3,percent of total billed charges,Implant Device,181.3,35,,181.3,percent of total billed charges,Implant Device,181.3,35,,181.3,percent of total billed charges,Implant Device,181.3,35,,181.3,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,383.32,
STRYKER 53-27218E T7 BONE SCREW 2.7X18MM,C1713,HCPCS,,79004833,CDM,278,RC,,,both,,,388,287.12,,,287.12,Other,150% of Medicare + 9.63% HCRA Surcharge,174.6,45,,174.6,percent of total billed charges,Critical Access Hospital RCC factor,131.92,34,,131.92,percent of total billed charges,Implant Device,131.92,34,,131.92,percent of total billed charges,Implant Device,131.92,34,,131.92,percent of total billed charges,Implant Device,131.92,34,,131.92,percent of total billed charges,Implant Device,131.92,34,,131.92,percent of total billed charges,Implant Device,192.06,,,192.06,Other,110% of Medicare,135.8,35,,135.8,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,135.8,35,,135.8,percent of total billed charges,Implant Device,135.8,35,,135.8,percent of total billed charges,Implant Device,135.8,35,,135.8,percent of total billed charges,Implant Device,135.8,35,,135.8,percent of total billed charges,Implant Device,135.8,35,,135.8,percent of total billed charges,Implant Device,155.2,40,,155.2,percent of total billed charges,Implant Device,135.8,70,,135.8,percent of total billed charges,All Other,131.92,34,,131.92,percent of total billed charges,Implant Device,131.92,34,,131.92,percent of total billed charges,Implant Device,135.8,35,,135.8,percent of total billed charges,Implant Device,135.8,35,,135.8,percent of total billed charges,Implant Device,135.8,35,,135.8,percent of total billed charges,Implant Device,135.8,35,,135.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,287.12,
STRYKER 427038 8 HOLE RECON PLATE 4.0MM,C1713,HCPCS,,79004834,CDM,278,RC,,,both,,,1913,1415.62,,,1415.62,Other,150% of Medicare + 9.63% HCRA Surcharge,860.85,45,,860.85,percent of total billed charges,Critical Access Hospital RCC factor,650.42,34,,650.42,percent of total billed charges,Implant Device,650.42,34,,650.42,percent of total billed charges,Implant Device,650.42,34,,650.42,percent of total billed charges,Implant Device,650.42,34,,650.42,percent of total billed charges,Implant Device,650.42,34,,650.42,percent of total billed charges,Implant Device,946.94,,,946.94,Other,110% of Medicare,669.55,35,,669.55,percent of total billed charges,Implant Device,650.42,34,"Charges > $500, x 34%",650.42,percent of total billed charges,Implant Device,669.55,35,,669.55,percent of total billed charges,Implant Device,669.55,35,,669.55,percent of total billed charges,Implant Device,669.55,35,,669.55,percent of total billed charges,Implant Device,669.55,35,,669.55,percent of total billed charges,Implant Device,669.55,35,,669.55,percent of total billed charges,Implant Device,765.2,40,,765.2,percent of total billed charges,Implant Device,669.55,70,,669.55,percent of total billed charges,All Other,650.42,34,,650.42,percent of total billed charges,Implant Device,650.42,34,,650.42,percent of total billed charges,Implant Device,669.55,35,,669.55,percent of total billed charges,Implant Device,669.55,35,,669.55,percent of total billed charges,Implant Device,669.55,35,,669.55,percent of total billed charges,Implant Device,669.55,35,,669.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1415.62,
STRYKER 338616 STD SCREW 3.5X16MM,C1713,HCPCS,,79004835,CDM,278,RC,,,both,,,115,85.1,,,85.1,Other,150% of Medicare + 9.63% HCRA Surcharge,51.75,45,,51.75,percent of total billed charges,Critical Access Hospital RCC factor,39.1,34,,39.1,percent of total billed charges,Implant Device,39.1,34,,39.1,percent of total billed charges,Implant Device,39.1,34,,39.1,percent of total billed charges,Implant Device,39.1,34,,39.1,percent of total billed charges,Implant Device,39.1,34,,39.1,percent of total billed charges,Implant Device,56.93,,,56.93,Other,110% of Medicare,40.25,35,,40.25,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,40.25,35,,40.25,percent of total billed charges,Implant Device,40.25,35,,40.25,percent of total billed charges,Implant Device,40.25,35,,40.25,percent of total billed charges,Implant Device,40.25,35,,40.25,percent of total billed charges,Implant Device,40.25,35,,40.25,percent of total billed charges,Implant Device,46,40,,46,percent of total billed charges,Implant Device,40.25,70,,40.25,percent of total billed charges,All Other,39.1,34,,39.1,percent of total billed charges,Implant Device,39.1,34,,39.1,percent of total billed charges,Implant Device,40.25,35,,40.25,percent of total billed charges,Implant Device,40.25,35,,40.25,percent of total billed charges,Implant Device,40.25,35,,40.25,percent of total billed charges,Implant Device,40.25,35,,40.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,85.1,
STRYKER 338618 STD SCREW 3.5X18MM,C1713,HCPCS,,79004836,CDM,278,RC,,,both,,,115,85.1,,,85.1,Other,150% of Medicare + 9.63% HCRA Surcharge,51.75,45,,51.75,percent of total billed charges,Critical Access Hospital RCC factor,39.1,34,,39.1,percent of total billed charges,Implant Device,39.1,34,,39.1,percent of total billed charges,Implant Device,39.1,34,,39.1,percent of total billed charges,Implant Device,39.1,34,,39.1,percent of total billed charges,Implant Device,39.1,34,,39.1,percent of total billed charges,Implant Device,56.93,,,56.93,Other,110% of Medicare,40.25,35,,40.25,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,40.25,35,,40.25,percent of total billed charges,Implant Device,40.25,35,,40.25,percent of total billed charges,Implant Device,40.25,35,,40.25,percent of total billed charges,Implant Device,40.25,35,,40.25,percent of total billed charges,Implant Device,40.25,35,,40.25,percent of total billed charges,Implant Device,46,40,,46,percent of total billed charges,Implant Device,40.25,70,,40.25,percent of total billed charges,All Other,39.1,34,,39.1,percent of total billed charges,Implant Device,39.1,34,,39.1,percent of total billed charges,Implant Device,40.25,35,,40.25,percent of total billed charges,Implant Device,40.25,35,,40.25,percent of total billed charges,Implant Device,40.25,35,,40.25,percent of total billed charges,Implant Device,40.25,35,,40.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,85.1,
STRYKER 338640 STD SCREW 3.5X40MM,C1713,HCPCS,,79004837,CDM,278,RC,,,both,,,102,75.48,,,75.48,Other,150% of Medicare + 9.63% HCRA Surcharge,45.9,45,,45.9,percent of total billed charges,Critical Access Hospital RCC factor,34.68,34,,34.68,percent of total billed charges,Implant Device,34.68,34,,34.68,percent of total billed charges,Implant Device,34.68,34,,34.68,percent of total billed charges,Implant Device,34.68,34,,34.68,percent of total billed charges,Implant Device,34.68,34,,34.68,percent of total billed charges,Implant Device,50.49,,,50.49,Other,110% of Medicare,35.7,35,,35.7,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,35.7,35,,35.7,percent of total billed charges,Implant Device,35.7,35,,35.7,percent of total billed charges,Implant Device,35.7,35,,35.7,percent of total billed charges,Implant Device,35.7,35,,35.7,percent of total billed charges,Implant Device,35.7,35,,35.7,percent of total billed charges,Implant Device,40.8,40,,40.8,percent of total billed charges,Implant Device,35.7,70,,35.7,percent of total billed charges,All Other,34.68,34,,34.68,percent of total billed charges,Implant Device,34.68,34,,34.68,percent of total billed charges,Implant Device,35.7,35,,35.7,percent of total billed charges,Implant Device,35.7,35,,35.7,percent of total billed charges,Implant Device,35.7,35,,35.7,percent of total billed charges,Implant Device,35.7,35,,35.7,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,75.48,
STRYKER 338646 STD SCREW 3.5X46MM,C1713,HCPCS,,79004838,CDM,278,RC,,,both,,,115,85.1,,,85.1,Other,150% of Medicare + 9.63% HCRA Surcharge,51.75,45,,51.75,percent of total billed charges,Critical Access Hospital RCC factor,39.1,34,,39.1,percent of total billed charges,Implant Device,39.1,34,,39.1,percent of total billed charges,Implant Device,39.1,34,,39.1,percent of total billed charges,Implant Device,39.1,34,,39.1,percent of total billed charges,Implant Device,39.1,34,,39.1,percent of total billed charges,Implant Device,56.93,,,56.93,Other,110% of Medicare,40.25,35,,40.25,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,40.25,35,,40.25,percent of total billed charges,Implant Device,40.25,35,,40.25,percent of total billed charges,Implant Device,40.25,35,,40.25,percent of total billed charges,Implant Device,40.25,35,,40.25,percent of total billed charges,Implant Device,40.25,35,,40.25,percent of total billed charges,Implant Device,46,40,,46,percent of total billed charges,Implant Device,40.25,70,,40.25,percent of total billed charges,All Other,39.1,34,,39.1,percent of total billed charges,Implant Device,39.1,34,,39.1,percent of total billed charges,Implant Device,40.25,35,,40.25,percent of total billed charges,Implant Device,40.25,35,,40.25,percent of total billed charges,Implant Device,40.25,35,,40.25,percent of total billed charges,Implant Device,40.25,35,,40.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,85.1,
STRYKER 338648 STD SCREW 3.5X48MM,C1713,HCPCS,,79004839,CDM,278,RC,,,both,,,120,88.8,,,88.8,Other,150% of Medicare + 9.63% HCRA Surcharge,54,45,,54,percent of total billed charges,Critical Access Hospital RCC factor,40.8,34,,40.8,percent of total billed charges,Implant Device,40.8,34,,40.8,percent of total billed charges,Implant Device,40.8,34,,40.8,percent of total billed charges,Implant Device,40.8,34,,40.8,percent of total billed charges,Implant Device,40.8,34,,40.8,percent of total billed charges,Implant Device,59.4,,,59.4,Other,110% of Medicare,42,35,,42,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,42,35,,42,percent of total billed charges,Implant Device,42,35,,42,percent of total billed charges,Implant Device,42,35,,42,percent of total billed charges,Implant Device,42,35,,42,percent of total billed charges,Implant Device,42,35,,42,percent of total billed charges,Implant Device,48,40,,48,percent of total billed charges,Implant Device,42,70,,42,percent of total billed charges,All Other,40.8,34,,40.8,percent of total billed charges,Implant Device,40.8,34,,40.8,percent of total billed charges,Implant Device,42,35,,42,percent of total billed charges,Implant Device,42,35,,42,percent of total billed charges,Implant Device,42,35,,42,percent of total billed charges,Implant Device,42,35,,42,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,88.8,
STRYKER 338612 STD SCREW 3.5X12MM,C1713,HCPCS,,79004840,CDM,278,RC,,,both,,,102,75.48,,,75.48,Other,150% of Medicare + 9.63% HCRA Surcharge,45.9,45,,45.9,percent of total billed charges,Critical Access Hospital RCC factor,34.68,34,,34.68,percent of total billed charges,Implant Device,34.68,34,,34.68,percent of total billed charges,Implant Device,34.68,34,,34.68,percent of total billed charges,Implant Device,34.68,34,,34.68,percent of total billed charges,Implant Device,34.68,34,,34.68,percent of total billed charges,Implant Device,50.49,,,50.49,Other,110% of Medicare,35.7,35,,35.7,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,35.7,35,,35.7,percent of total billed charges,Implant Device,35.7,35,,35.7,percent of total billed charges,Implant Device,35.7,35,,35.7,percent of total billed charges,Implant Device,35.7,35,,35.7,percent of total billed charges,Implant Device,35.7,35,,35.7,percent of total billed charges,Implant Device,40.8,40,,40.8,percent of total billed charges,Implant Device,35.7,70,,35.7,percent of total billed charges,All Other,34.68,34,,34.68,percent of total billed charges,Implant Device,34.68,34,,34.68,percent of total billed charges,Implant Device,35.7,35,,35.7,percent of total billed charges,Implant Device,35.7,35,,35.7,percent of total billed charges,Implant Device,35.7,35,,35.7,percent of total billed charges,Implant Device,35.7,35,,35.7,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,75.48,
STRYKER 345520 CANCLLOUS SCREW PT 4X20MM,C1713,HCPCS,,79004841,CDM,278,RC,,,both,,,89,65.86,,,65.86,Other,150% of Medicare + 9.63% HCRA Surcharge,40.05,45,,40.05,percent of total billed charges,Critical Access Hospital RCC factor,30.26,34,,30.26,percent of total billed charges,Implant Device,30.26,34,,30.26,percent of total billed charges,Implant Device,30.26,34,,30.26,percent of total billed charges,Implant Device,30.26,34,,30.26,percent of total billed charges,Implant Device,30.26,34,,30.26,percent of total billed charges,Implant Device,44.06,,,44.06,Other,110% of Medicare,31.15,35,,31.15,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,31.15,35,,31.15,percent of total billed charges,Implant Device,31.15,35,,31.15,percent of total billed charges,Implant Device,31.15,35,,31.15,percent of total billed charges,Implant Device,31.15,35,,31.15,percent of total billed charges,Implant Device,31.15,35,,31.15,percent of total billed charges,Implant Device,35.6,40,,35.6,percent of total billed charges,Implant Device,31.15,70,,31.15,percent of total billed charges,All Other,30.26,34,,30.26,percent of total billed charges,Implant Device,30.26,34,,30.26,percent of total billed charges,Implant Device,31.15,35,,31.15,percent of total billed charges,Implant Device,31.15,35,,31.15,percent of total billed charges,Implant Device,31.15,35,,31.15,percent of total billed charges,Implant Device,31.15,35,,31.15,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,65.86,
WRIGHT 4260020 FLEX HINGE TOE IMP SZ 2,C1776,HCPCS,,79004843,CDM,278,RC,,,both,,,3634,2689.17,,,2689.17,Other,150% of Medicare + 9.63% HCRA Surcharge,1635.3,45,,1635.3,percent of total billed charges,Critical Access Hospital RCC factor,1235.56,34,,1235.56,percent of total billed charges,Implant Device,1235.56,34,,1235.56,percent of total billed charges,Implant Device,1235.56,34,,1235.56,percent of total billed charges,Implant Device,1235.56,34,,1235.56,percent of total billed charges,Implant Device,1235.56,34,,1235.56,percent of total billed charges,Implant Device,1798.83,,,1798.83,Other,110% of Medicare,1271.9,35,,1271.9,percent of total billed charges,Implant Device,1235.56,34,"Charges > $500, x 34%",1235.56,percent of total billed charges,Implant Device,1271.9,35,,1271.9,percent of total billed charges,Implant Device,1271.9,35,,1271.9,percent of total billed charges,Implant Device,1271.9,35,,1271.9,percent of total billed charges,Implant Device,1271.9,35,,1271.9,percent of total billed charges,Implant Device,1271.9,35,,1271.9,percent of total billed charges,Implant Device,1453.6,40,,1453.6,percent of total billed charges,Implant Device,1271.9,70,,1271.9,percent of total billed charges,All Other,1235.56,34,,1235.56,percent of total billed charges,Implant Device,1235.56,34,,1235.56,percent of total billed charges,Implant Device,1271.9,35,,1271.9,percent of total billed charges,Implant Device,1271.9,35,,1271.9,percent of total billed charges,Implant Device,1271.9,35,,1271.9,percent of total billed charges,Implant Device,1271.9,35,,1271.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1235.56,34,"If Charge > 2,000, then 34 percent",1235.56,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2689.17,
WRIGHT G4260003 FLEX HINGE TOE IMP SZ 3,C1776,HCPCS,,79004844,CDM,278,RC,,,both,,,3634,2689.17,,,2689.17,Other,150% of Medicare + 9.63% HCRA Surcharge,1635.3,45,,1635.3,percent of total billed charges,Critical Access Hospital RCC factor,1235.56,34,,1235.56,percent of total billed charges,Implant Device,1235.56,34,,1235.56,percent of total billed charges,Implant Device,1235.56,34,,1235.56,percent of total billed charges,Implant Device,1235.56,34,,1235.56,percent of total billed charges,Implant Device,1235.56,34,,1235.56,percent of total billed charges,Implant Device,1798.83,,,1798.83,Other,110% of Medicare,1271.9,35,,1271.9,percent of total billed charges,Implant Device,1235.56,34,"Charges > $500, x 34%",1235.56,percent of total billed charges,Implant Device,1271.9,35,,1271.9,percent of total billed charges,Implant Device,1271.9,35,,1271.9,percent of total billed charges,Implant Device,1271.9,35,,1271.9,percent of total billed charges,Implant Device,1271.9,35,,1271.9,percent of total billed charges,Implant Device,1271.9,35,,1271.9,percent of total billed charges,Implant Device,1453.6,40,,1453.6,percent of total billed charges,Implant Device,1271.9,70,,1271.9,percent of total billed charges,All Other,1235.56,34,,1235.56,percent of total billed charges,Implant Device,1235.56,34,,1235.56,percent of total billed charges,Implant Device,1271.9,35,,1271.9,percent of total billed charges,Implant Device,1271.9,35,,1271.9,percent of total billed charges,Implant Device,1271.9,35,,1271.9,percent of total billed charges,Implant Device,1271.9,35,,1271.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1235.56,34,"If Charge > 2,000, then 34 percent",1235.56,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2689.17,
STRYKER 53-27222E T7 BONE SCREW 2.7X22MM,C1713,HCPCS,,79004854,CDM,278,RC,,,both,,,374,276.76,,,276.76,Other,150% of Medicare + 9.63% HCRA Surcharge,168.3,45,,168.3,percent of total billed charges,Critical Access Hospital RCC factor,127.16,34,,127.16,percent of total billed charges,Implant Device,127.16,34,,127.16,percent of total billed charges,Implant Device,127.16,34,,127.16,percent of total billed charges,Implant Device,127.16,34,,127.16,percent of total billed charges,Implant Device,127.16,34,,127.16,percent of total billed charges,Implant Device,185.13,,,185.13,Other,110% of Medicare,130.9,35,,130.9,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,130.9,35,,130.9,percent of total billed charges,Implant Device,130.9,35,,130.9,percent of total billed charges,Implant Device,130.9,35,,130.9,percent of total billed charges,Implant Device,130.9,35,,130.9,percent of total billed charges,Implant Device,130.9,35,,130.9,percent of total billed charges,Implant Device,149.6,40,,149.6,percent of total billed charges,Implant Device,130.9,70,,130.9,percent of total billed charges,All Other,127.16,34,,127.16,percent of total billed charges,Implant Device,127.16,34,,127.16,percent of total billed charges,Implant Device,130.9,35,,130.9,percent of total billed charges,Implant Device,130.9,35,,130.9,percent of total billed charges,Implant Device,130.9,35,,130.9,percent of total billed charges,Implant Device,130.9,35,,130.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,276.76,
STRYKER 3060-0095S LAG SCREW 10.5X95MM,C1713,HCPCS,,79004857,CDM,278,RC,,,both,,,1230,910.2,,,910.2,Other,150% of Medicare + 9.63% HCRA Surcharge,553.5,45,,553.5,percent of total billed charges,Critical Access Hospital RCC factor,418.2,34,,418.2,percent of total billed charges,Implant Device,418.2,34,,418.2,percent of total billed charges,Implant Device,418.2,34,,418.2,percent of total billed charges,Implant Device,418.2,34,,418.2,percent of total billed charges,Implant Device,418.2,34,,418.2,percent of total billed charges,Implant Device,608.85,,,608.85,Other,110% of Medicare,430.5,35,,430.5,percent of total billed charges,Implant Device,418.2,34,"Charges > $500, x 34%",418.2,percent of total billed charges,Implant Device,430.5,35,,430.5,percent of total billed charges,Implant Device,430.5,35,,430.5,percent of total billed charges,Implant Device,430.5,35,,430.5,percent of total billed charges,Implant Device,430.5,35,,430.5,percent of total billed charges,Implant Device,430.5,35,,430.5,percent of total billed charges,Implant Device,492,40,,492,percent of total billed charges,Implant Device,430.5,70,,430.5,percent of total billed charges,All Other,418.2,34,,418.2,percent of total billed charges,Implant Device,418.2,34,,418.2,percent of total billed charges,Implant Device,430.5,35,,430.5,percent of total billed charges,Implant Device,430.5,35,,430.5,percent of total billed charges,Implant Device,430.5,35,,430.5,percent of total billed charges,Implant Device,430.5,35,,430.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,910.2,
STRYKER 1896-5037S LOCK SCREW 5X37 5 MM,C1713,HCPCS,,79004858,CDM,278,RC,,,both,,,355,262.7,,,262.7,Other,150% of Medicare + 9.63% HCRA Surcharge,159.75,45,,159.75,percent of total billed charges,Critical Access Hospital RCC factor,120.7,34,,120.7,percent of total billed charges,Implant Device,120.7,34,,120.7,percent of total billed charges,Implant Device,120.7,34,,120.7,percent of total billed charges,Implant Device,120.7,34,,120.7,percent of total billed charges,Implant Device,120.7,34,,120.7,percent of total billed charges,Implant Device,175.73,,,175.73,Other,110% of Medicare,124.25,35,,124.25,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,124.25,35,,124.25,percent of total billed charges,Implant Device,124.25,35,,124.25,percent of total billed charges,Implant Device,124.25,35,,124.25,percent of total billed charges,Implant Device,124.25,35,,124.25,percent of total billed charges,Implant Device,124.25,35,,124.25,percent of total billed charges,Implant Device,142,40,,142,percent of total billed charges,Implant Device,124.25,70,,124.25,percent of total billed charges,All Other,120.7,34,,120.7,percent of total billed charges,Implant Device,120.7,34,,120.7,percent of total billed charges,Implant Device,124.25,35,,124.25,percent of total billed charges,Implant Device,124.25,35,,124.25,percent of total billed charges,Implant Device,124.25,35,,124.25,percent of total billed charges,Implant Device,124.25,35,,124.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,262.7,
STRYKER 1822-1139S TIBIAL NAIL 11X390MM,C1713,HCPCS,,79004859,CDM,278,RC,,,both,,,5440,4025.61,,,4025.61,Other,150% of Medicare + 9.63% HCRA Surcharge,2448,45,,2448,percent of total billed charges,Critical Access Hospital RCC factor,1849.6,34,,1849.6,percent of total billed charges,Implant Device,1849.6,34,,1849.6,percent of total billed charges,Implant Device,1849.6,34,,1849.6,percent of total billed charges,Implant Device,1849.6,34,,1849.6,percent of total billed charges,Implant Device,1849.6,34,,1849.6,percent of total billed charges,Implant Device,2692.8,,,2692.8,Other,110% of Medicare,1904,35,,1904,percent of total billed charges,Implant Device,1849.6,34,"Charges > $500, x 34%",1849.6,percent of total billed charges,Implant Device,1904,35,,1904,percent of total billed charges,Implant Device,1904,35,,1904,percent of total billed charges,Implant Device,1904,35,,1904,percent of total billed charges,Implant Device,1904,35,,1904,percent of total billed charges,Implant Device,1904,35,,1904,percent of total billed charges,Implant Device,2176,40,,2176,percent of total billed charges,Implant Device,1904,70,,1904,percent of total billed charges,All Other,1849.6,34,,1849.6,percent of total billed charges,Implant Device,1849.6,34,,1849.6,percent of total billed charges,Implant Device,1904,35,,1904,percent of total billed charges,Implant Device,1904,35,,1904,percent of total billed charges,Implant Device,1904,35,,1904,percent of total billed charges,Implant Device,1904,35,,1904,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1849.6,34,"If Charge > 2,000, then 34 percent",1849.6,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4025.61,
STRYKER 1896-5055S LOCK SCREW FT 5X55MM,C1713,HCPCS,,79004860,CDM,278,RC,,,both,,,441,326.34,,,326.34,Other,150% of Medicare + 9.63% HCRA Surcharge,198.45,45,,198.45,percent of total billed charges,Critical Access Hospital RCC factor,149.94,34,,149.94,percent of total billed charges,Implant Device,149.94,34,,149.94,percent of total billed charges,Implant Device,149.94,34,,149.94,percent of total billed charges,Implant Device,149.94,34,,149.94,percent of total billed charges,Implant Device,149.94,34,,149.94,percent of total billed charges,Implant Device,218.3,,,218.3,Other,110% of Medicare,154.35,35,,154.35,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,154.35,35,,154.35,percent of total billed charges,Implant Device,154.35,35,,154.35,percent of total billed charges,Implant Device,154.35,35,,154.35,percent of total billed charges,Implant Device,154.35,35,,154.35,percent of total billed charges,Implant Device,154.35,35,,154.35,percent of total billed charges,Implant Device,176.4,40,,176.4,percent of total billed charges,Implant Device,154.35,70,,154.35,percent of total billed charges,All Other,149.94,34,,149.94,percent of total billed charges,Implant Device,149.94,34,,149.94,percent of total billed charges,Implant Device,154.35,35,,154.35,percent of total billed charges,Implant Device,154.35,35,,154.35,percent of total billed charges,Implant Device,154.35,35,,154.35,percent of total billed charges,Implant Device,154.35,35,,154.35,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,326.34,
STRYKER 1896-5052S LOCK SCREW FT 5X52MM,C1713,HCPCS,,79004861,CDM,278,RC,,,both,,,355,262.7,,,262.7,Other,150% of Medicare + 9.63% HCRA Surcharge,159.75,45,,159.75,percent of total billed charges,Critical Access Hospital RCC factor,120.7,34,,120.7,percent of total billed charges,Implant Device,120.7,34,,120.7,percent of total billed charges,Implant Device,120.7,34,,120.7,percent of total billed charges,Implant Device,120.7,34,,120.7,percent of total billed charges,Implant Device,120.7,34,,120.7,percent of total billed charges,Implant Device,175.73,,,175.73,Other,110% of Medicare,124.25,35,,124.25,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,124.25,35,,124.25,percent of total billed charges,Implant Device,124.25,35,,124.25,percent of total billed charges,Implant Device,124.25,35,,124.25,percent of total billed charges,Implant Device,124.25,35,,124.25,percent of total billed charges,Implant Device,124.25,35,,124.25,percent of total billed charges,Implant Device,142,40,,142,percent of total billed charges,Implant Device,124.25,70,,124.25,percent of total billed charges,All Other,120.7,34,,120.7,percent of total billed charges,Implant Device,120.7,34,,120.7,percent of total billed charges,Implant Device,124.25,35,,124.25,percent of total billed charges,Implant Device,124.25,35,,124.25,percent of total billed charges,Implant Device,124.25,35,,124.25,percent of total billed charges,Implant Device,124.25,35,,124.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,262.7,
STRYKER 370520 LOCKING SCREW 4X20MM,C1713,HCPCS,,79004862,CDM,278,RC,,,both,,,464,343.36,,,343.36,Other,150% of Medicare + 9.63% HCRA Surcharge,208.8,45,,208.8,percent of total billed charges,Critical Access Hospital RCC factor,157.76,34,,157.76,percent of total billed charges,Implant Device,157.76,34,,157.76,percent of total billed charges,Implant Device,157.76,34,,157.76,percent of total billed charges,Implant Device,157.76,34,,157.76,percent of total billed charges,Implant Device,157.76,34,,157.76,percent of total billed charges,Implant Device,229.68,,,229.68,Other,110% of Medicare,162.4,35,,162.4,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,162.4,35,,162.4,percent of total billed charges,Implant Device,162.4,35,,162.4,percent of total billed charges,Implant Device,162.4,35,,162.4,percent of total billed charges,Implant Device,162.4,35,,162.4,percent of total billed charges,Implant Device,162.4,35,,162.4,percent of total billed charges,Implant Device,185.6,40,,185.6,percent of total billed charges,Implant Device,162.4,70,,162.4,percent of total billed charges,All Other,157.76,34,,157.76,percent of total billed charges,Implant Device,157.76,34,,157.76,percent of total billed charges,Implant Device,162.4,35,,162.4,percent of total billed charges,Implant Device,162.4,35,,162.4,percent of total billed charges,Implant Device,162.4,35,,162.4,percent of total billed charges,Implant Device,162.4,35,,162.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,343.36,
STRYKER 370522 LOCKING SCREW 4X22MM,C1713,HCPCS,,79004863,CDM,278,RC,,,both,,,464,343.36,,,343.36,Other,150% of Medicare + 9.63% HCRA Surcharge,208.8,45,,208.8,percent of total billed charges,Critical Access Hospital RCC factor,157.76,34,,157.76,percent of total billed charges,Implant Device,157.76,34,,157.76,percent of total billed charges,Implant Device,157.76,34,,157.76,percent of total billed charges,Implant Device,157.76,34,,157.76,percent of total billed charges,Implant Device,157.76,34,,157.76,percent of total billed charges,Implant Device,229.68,,,229.68,Other,110% of Medicare,162.4,35,,162.4,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,162.4,35,,162.4,percent of total billed charges,Implant Device,162.4,35,,162.4,percent of total billed charges,Implant Device,162.4,35,,162.4,percent of total billed charges,Implant Device,162.4,35,,162.4,percent of total billed charges,Implant Device,162.4,35,,162.4,percent of total billed charges,Implant Device,185.6,40,,185.6,percent of total billed charges,Implant Device,162.4,70,,162.4,percent of total billed charges,All Other,157.76,34,,157.76,percent of total billed charges,Implant Device,157.76,34,,157.76,percent of total billed charges,Implant Device,162.4,35,,162.4,percent of total billed charges,Implant Device,162.4,35,,162.4,percent of total billed charges,Implant Device,162.4,35,,162.4,percent of total billed charges,Implant Device,162.4,35,,162.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,343.36,
STRYKER 338614 CORTICAL SCREW 3.5X14MM,C1713,HCPCS,,79004864,CDM,278,RC,,,both,,,115,85.1,,,85.1,Other,150% of Medicare + 9.63% HCRA Surcharge,51.75,45,,51.75,percent of total billed charges,Critical Access Hospital RCC factor,39.1,34,,39.1,percent of total billed charges,Implant Device,39.1,34,,39.1,percent of total billed charges,Implant Device,39.1,34,,39.1,percent of total billed charges,Implant Device,39.1,34,,39.1,percent of total billed charges,Implant Device,39.1,34,,39.1,percent of total billed charges,Implant Device,56.93,,,56.93,Other,110% of Medicare,40.25,35,,40.25,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,40.25,35,,40.25,percent of total billed charges,Implant Device,40.25,35,,40.25,percent of total billed charges,Implant Device,40.25,35,,40.25,percent of total billed charges,Implant Device,40.25,35,,40.25,percent of total billed charges,Implant Device,40.25,35,,40.25,percent of total billed charges,Implant Device,46,40,,46,percent of total billed charges,Implant Device,40.25,70,,40.25,percent of total billed charges,All Other,39.1,34,,39.1,percent of total billed charges,Implant Device,39.1,34,,39.1,percent of total billed charges,Implant Device,40.25,35,,40.25,percent of total billed charges,Implant Device,40.25,35,,40.25,percent of total billed charges,Implant Device,40.25,35,,40.25,percent of total billed charges,Implant Device,40.25,35,,40.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,85.1,
STRYKER 345532 PT SCREW 4.0X32MM,C1713,HCPCS,,79004865,CDM,278,RC,,,both,,,89,65.86,,,65.86,Other,150% of Medicare + 9.63% HCRA Surcharge,40.05,45,,40.05,percent of total billed charges,Critical Access Hospital RCC factor,30.26,34,,30.26,percent of total billed charges,Implant Device,30.26,34,,30.26,percent of total billed charges,Implant Device,30.26,34,,30.26,percent of total billed charges,Implant Device,30.26,34,,30.26,percent of total billed charges,Implant Device,30.26,34,,30.26,percent of total billed charges,Implant Device,44.06,,,44.06,Other,110% of Medicare,31.15,35,,31.15,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,31.15,35,,31.15,percent of total billed charges,Implant Device,31.15,35,,31.15,percent of total billed charges,Implant Device,31.15,35,,31.15,percent of total billed charges,Implant Device,31.15,35,,31.15,percent of total billed charges,Implant Device,31.15,35,,31.15,percent of total billed charges,Implant Device,35.6,40,,35.6,percent of total billed charges,Implant Device,31.15,70,,31.15,percent of total billed charges,All Other,30.26,34,,30.26,percent of total billed charges,Implant Device,30.26,34,,30.26,percent of total billed charges,Implant Device,31.15,35,,31.15,percent of total billed charges,Implant Device,31.15,35,,31.15,percent of total billed charges,Implant Device,31.15,35,,31.15,percent of total billed charges,Implant Device,31.15,35,,31.15,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,65.86,
ZIMMER 00-6250-065-15 BONESCREW 6.5X15MM,C1713,HCPCS,,79004867,CDM,278,RC,,,both,,,428,316.72,,,316.72,Other,150% of Medicare + 9.63% HCRA Surcharge,192.6,45,,192.6,percent of total billed charges,Critical Access Hospital RCC factor,145.52,34,,145.52,percent of total billed charges,Implant Device,145.52,34,,145.52,percent of total billed charges,Implant Device,145.52,34,,145.52,percent of total billed charges,Implant Device,145.52,34,,145.52,percent of total billed charges,Implant Device,145.52,34,,145.52,percent of total billed charges,Implant Device,211.86,,,211.86,Other,110% of Medicare,149.8,35,,149.8,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,149.8,35,,149.8,percent of total billed charges,Implant Device,149.8,35,,149.8,percent of total billed charges,Implant Device,149.8,35,,149.8,percent of total billed charges,Implant Device,149.8,35,,149.8,percent of total billed charges,Implant Device,149.8,35,,149.8,percent of total billed charges,Implant Device,171.2,40,,171.2,percent of total billed charges,Implant Device,149.8,70,,149.8,percent of total billed charges,All Other,145.52,34,,145.52,percent of total billed charges,Implant Device,145.52,34,,145.52,percent of total billed charges,Implant Device,149.8,35,,149.8,percent of total billed charges,Implant Device,149.8,35,,149.8,percent of total billed charges,Implant Device,149.8,35,,149.8,percent of total billed charges,Implant Device,149.8,35,,149.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,316.72,
STRYKER 690-00-22E ACETABULAR INSRT SZ E,C1776,HCPCS,,79004868,CDM,278,RC,,,both,,,12217,9040.61,,,9040.61,Other,150% of Medicare + 9.63% HCRA Surcharge,5497.65,45,,5497.65,percent of total billed charges,Critical Access Hospital RCC factor,4153.78,34,,4153.78,percent of total billed charges,Implant Device,4153.78,34,,4153.78,percent of total billed charges,Implant Device,4153.78,34,,4153.78,percent of total billed charges,Implant Device,4153.78,34,,4153.78,percent of total billed charges,Implant Device,4153.78,34,,4153.78,percent of total billed charges,Implant Device,6047.42,,,6047.42,Other,110% of Medicare,4275.95,35,,4275.95,percent of total billed charges,Implant Device,4153.78,34,"Charges > $500, x 34%",4153.78,percent of total billed charges,Implant Device,4275.95,35,,4275.95,percent of total billed charges,Implant Device,4275.95,35,,4275.95,percent of total billed charges,Implant Device,4275.95,35,,4275.95,percent of total billed charges,Implant Device,4275.95,35,,4275.95,percent of total billed charges,Implant Device,4275.95,35,,4275.95,percent of total billed charges,Implant Device,4886.8,40,,4886.8,percent of total billed charges,Implant Device,4275.95,70,,4275.95,percent of total billed charges,All Other,4153.78,34,,4153.78,percent of total billed charges,Implant Device,4153.78,34,,4153.78,percent of total billed charges,Implant Device,4275.95,35,,4275.95,percent of total billed charges,Implant Device,4275.95,35,,4275.95,percent of total billed charges,Implant Device,4275.95,35,,4275.95,percent of total billed charges,Implant Device,4275.95,35,,4275.95,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,4153.78,34,"If Charge > 2,000, then 34 percent",4153.78,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,9040.61,
STRYKER 06-2200 C-TAPER LFIT HEAD 22MM,C1776,HCPCS,,79004869,CDM,278,RC,,,both,,,3175,2349.51,,,2349.51,Other,150% of Medicare + 9.63% HCRA Surcharge,1428.75,45,,1428.75,percent of total billed charges,Critical Access Hospital RCC factor,1079.5,34,,1079.5,percent of total billed charges,Implant Device,1079.5,34,,1079.5,percent of total billed charges,Implant Device,1079.5,34,,1079.5,percent of total billed charges,Implant Device,1079.5,34,,1079.5,percent of total billed charges,Implant Device,1079.5,34,,1079.5,percent of total billed charges,Implant Device,1571.63,,,1571.63,Other,110% of Medicare,1111.25,35,,1111.25,percent of total billed charges,Implant Device,1079.5,34,"Charges > $500, x 34%",1079.5,percent of total billed charges,Implant Device,1111.25,35,,1111.25,percent of total billed charges,Implant Device,1111.25,35,,1111.25,percent of total billed charges,Implant Device,1111.25,35,,1111.25,percent of total billed charges,Implant Device,1111.25,35,,1111.25,percent of total billed charges,Implant Device,1111.25,35,,1111.25,percent of total billed charges,Implant Device,1270,40,,1270,percent of total billed charges,Implant Device,1111.25,70,,1111.25,percent of total billed charges,All Other,1079.5,34,,1079.5,percent of total billed charges,Implant Device,1079.5,34,,1079.5,percent of total billed charges,Implant Device,1111.25,35,,1111.25,percent of total billed charges,Implant Device,1111.25,35,,1111.25,percent of total billed charges,Implant Device,1111.25,35,,1111.25,percent of total billed charges,Implant Device,1111.25,35,,1111.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1079.5,34,"If Charge > 2,000, then 34 percent",1079.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2349.51,
STRYKER 53-23618E LOCK SCREW T7 2.3X18MM,C1713,HCPCS,,79004870,CDM,278,RC,,,both,,,518,383.32,,,383.32,Other,150% of Medicare + 9.63% HCRA Surcharge,233.1,45,,233.1,percent of total billed charges,Critical Access Hospital RCC factor,176.12,34,,176.12,percent of total billed charges,Implant Device,176.12,34,,176.12,percent of total billed charges,Implant Device,176.12,34,,176.12,percent of total billed charges,Implant Device,176.12,34,,176.12,percent of total billed charges,Implant Device,176.12,34,,176.12,percent of total billed charges,Implant Device,256.41,,,256.41,Other,110% of Medicare,181.3,35,,181.3,percent of total billed charges,Implant Device,176.12,34,"Charges > $500, x 34%",176.12,percent of total billed charges,Implant Device,181.3,35,,181.3,percent of total billed charges,Implant Device,181.3,35,,181.3,percent of total billed charges,Implant Device,181.3,35,,181.3,percent of total billed charges,Implant Device,181.3,35,,181.3,percent of total billed charges,Implant Device,181.3,35,,181.3,percent of total billed charges,Implant Device,207.2,40,,207.2,percent of total billed charges,Implant Device,181.3,70,,181.3,percent of total billed charges,All Other,176.12,34,,176.12,percent of total billed charges,Implant Device,176.12,34,,176.12,percent of total billed charges,Implant Device,181.3,35,,181.3,percent of total billed charges,Implant Device,181.3,35,,181.3,percent of total billed charges,Implant Device,181.3,35,,181.3,percent of total billed charges,Implant Device,181.3,35,,181.3,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,383.32,
STRYKER 53-27618E LOCK SCREW T7 2.7X18MM,C1713,HCPCS,,79004871,CDM,278,RC,,,both,,,304,224.96,,,224.96,Other,150% of Medicare + 9.63% HCRA Surcharge,136.8,45,,136.8,percent of total billed charges,Critical Access Hospital RCC factor,103.36,34,,103.36,percent of total billed charges,Implant Device,103.36,34,,103.36,percent of total billed charges,Implant Device,103.36,34,,103.36,percent of total billed charges,Implant Device,103.36,34,,103.36,percent of total billed charges,Implant Device,103.36,34,,103.36,percent of total billed charges,Implant Device,150.48,,,150.48,Other,110% of Medicare,106.4,35,,106.4,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,106.4,35,,106.4,percent of total billed charges,Implant Device,106.4,35,,106.4,percent of total billed charges,Implant Device,106.4,35,,106.4,percent of total billed charges,Implant Device,106.4,35,,106.4,percent of total billed charges,Implant Device,106.4,35,,106.4,percent of total billed charges,Implant Device,121.6,40,,121.6,percent of total billed charges,Implant Device,106.4,70,,106.4,percent of total billed charges,All Other,103.36,34,,103.36,percent of total billed charges,Implant Device,103.36,34,,103.36,percent of total billed charges,Implant Device,106.4,35,,106.4,percent of total billed charges,Implant Device,106.4,35,,106.4,percent of total billed charges,Implant Device,106.4,35,,106.4,percent of total billed charges,Implant Device,106.4,35,,106.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,224.96,
STRYKER 53-27212E BONE SCREW T2 2.7X12MM,C1713,HCPCS,,79004872,CDM,278,RC,,,both,,,190,140.6,,,140.6,Other,150% of Medicare + 9.63% HCRA Surcharge,85.5,45,,85.5,percent of total billed charges,Critical Access Hospital RCC factor,64.6,34,,64.6,percent of total billed charges,Implant Device,64.6,34,,64.6,percent of total billed charges,Implant Device,64.6,34,,64.6,percent of total billed charges,Implant Device,64.6,34,,64.6,percent of total billed charges,Implant Device,64.6,34,,64.6,percent of total billed charges,Implant Device,94.05,,,94.05,Other,110% of Medicare,66.5,35,,66.5,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,66.5,35,,66.5,percent of total billed charges,Implant Device,66.5,35,,66.5,percent of total billed charges,Implant Device,66.5,35,,66.5,percent of total billed charges,Implant Device,66.5,35,,66.5,percent of total billed charges,Implant Device,66.5,35,,66.5,percent of total billed charges,Implant Device,76,40,,76,percent of total billed charges,Implant Device,66.5,70,,66.5,percent of total billed charges,All Other,64.6,34,,64.6,percent of total billed charges,Implant Device,64.6,34,,64.6,percent of total billed charges,Implant Device,66.5,35,,66.5,percent of total billed charges,Implant Device,66.5,35,,66.5,percent of total billed charges,Implant Device,66.5,35,,66.5,percent of total billed charges,Implant Device,66.5,35,,66.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,140.6,
STRYKER 40-20904 FIB LOCK PLATE 4 HOLE,C1713,HCPCS,,79004880,CDM,278,RC,,,both,,,1867,1381.58,,,1381.58,Other,150% of Medicare + 9.63% HCRA Surcharge,840.15,45,,840.15,percent of total billed charges,Critical Access Hospital RCC factor,634.78,34,,634.78,percent of total billed charges,Implant Device,634.78,34,,634.78,percent of total billed charges,Implant Device,634.78,34,,634.78,percent of total billed charges,Implant Device,634.78,34,,634.78,percent of total billed charges,Implant Device,634.78,34,,634.78,percent of total billed charges,Implant Device,924.17,,,924.17,Other,110% of Medicare,653.45,35,,653.45,percent of total billed charges,Implant Device,634.78,34,"Charges > $500, x 34%",634.78,percent of total billed charges,Implant Device,653.45,35,,653.45,percent of total billed charges,Implant Device,653.45,35,,653.45,percent of total billed charges,Implant Device,653.45,35,,653.45,percent of total billed charges,Implant Device,653.45,35,,653.45,percent of total billed charges,Implant Device,653.45,35,,653.45,percent of total billed charges,Implant Device,746.8,40,,746.8,percent of total billed charges,Implant Device,653.45,70,,653.45,percent of total billed charges,All Other,634.78,34,,634.78,percent of total billed charges,Implant Device,634.78,34,,634.78,percent of total billed charges,Implant Device,653.45,35,,653.45,percent of total billed charges,Implant Device,653.45,35,,653.45,percent of total billed charges,Implant Device,653.45,35,,653.45,percent of total billed charges,Implant Device,653.45,35,,653.45,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1381.58,
STRYKER 40-35016 NON LOCK SCREW 3.5X16MM,C1713,HCPCS,,79004881,CDM,278,RC,,,both,,,192,142.08,,,142.08,Other,150% of Medicare + 9.63% HCRA Surcharge,86.4,45,,86.4,percent of total billed charges,Critical Access Hospital RCC factor,65.28,34,,65.28,percent of total billed charges,Implant Device,65.28,34,,65.28,percent of total billed charges,Implant Device,65.28,34,,65.28,percent of total billed charges,Implant Device,65.28,34,,65.28,percent of total billed charges,Implant Device,65.28,34,,65.28,percent of total billed charges,Implant Device,95.04,,,95.04,Other,110% of Medicare,67.2,35,,67.2,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,67.2,35,,67.2,percent of total billed charges,Implant Device,67.2,35,,67.2,percent of total billed charges,Implant Device,67.2,35,,67.2,percent of total billed charges,Implant Device,67.2,35,,67.2,percent of total billed charges,Implant Device,67.2,35,,67.2,percent of total billed charges,Implant Device,76.8,40,,76.8,percent of total billed charges,Implant Device,67.2,70,,67.2,percent of total billed charges,All Other,65.28,34,,65.28,percent of total billed charges,Implant Device,65.28,34,,65.28,percent of total billed charges,Implant Device,67.2,35,,67.2,percent of total billed charges,Implant Device,67.2,35,,67.2,percent of total billed charges,Implant Device,67.2,35,,67.2,percent of total billed charges,Implant Device,67.2,35,,67.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,142.08,
ACUMED 70-0361 PLATE ACULOC WIDE 2 HOLE,C1713,HCPCS,,79004886,CDM,278,RC,,,both,,,3552,2628.49,,,2628.49,Other,150% of Medicare + 9.63% HCRA Surcharge,1598.4,45,,1598.4,percent of total billed charges,Critical Access Hospital RCC factor,1207.68,34,,1207.68,percent of total billed charges,Implant Device,1207.68,34,,1207.68,percent of total billed charges,Implant Device,1207.68,34,,1207.68,percent of total billed charges,Implant Device,1207.68,34,,1207.68,percent of total billed charges,Implant Device,1207.68,34,,1207.68,percent of total billed charges,Implant Device,1758.24,,,1758.24,Other,110% of Medicare,1243.2,35,,1243.2,percent of total billed charges,Implant Device,1207.68,34,"Charges > $500, x 34%",1207.68,percent of total billed charges,Implant Device,1243.2,35,,1243.2,percent of total billed charges,Implant Device,1243.2,35,,1243.2,percent of total billed charges,Implant Device,1243.2,35,,1243.2,percent of total billed charges,Implant Device,1243.2,35,,1243.2,percent of total billed charges,Implant Device,1243.2,35,,1243.2,percent of total billed charges,Implant Device,1420.8,40,,1420.8,percent of total billed charges,Implant Device,1243.2,70,,1243.2,percent of total billed charges,All Other,1207.68,34,,1207.68,percent of total billed charges,Implant Device,1207.68,34,,1207.68,percent of total billed charges,Implant Device,1243.2,35,,1243.2,percent of total billed charges,Implant Device,1243.2,35,,1243.2,percent of total billed charges,Implant Device,1243.2,35,,1243.2,percent of total billed charges,Implant Device,1243.2,35,,1243.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1207.68,34,"If Charge > 2,000, then 34 percent",1207.68,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2628.49,
ACUMED COT2320 LOCKING SCREW 2.3X20MM,C1713,HCPCS,,79004887,CDM,278,RC,,,both,,,312,230.88,,,230.88,Other,150% of Medicare + 9.63% HCRA Surcharge,140.4,45,,140.4,percent of total billed charges,Critical Access Hospital RCC factor,106.08,34,,106.08,percent of total billed charges,Implant Device,106.08,34,,106.08,percent of total billed charges,Implant Device,106.08,34,,106.08,percent of total billed charges,Implant Device,106.08,34,,106.08,percent of total billed charges,Implant Device,106.08,34,,106.08,percent of total billed charges,Implant Device,154.44,,,154.44,Other,110% of Medicare,109.2,35,,109.2,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,109.2,35,,109.2,percent of total billed charges,Implant Device,109.2,35,,109.2,percent of total billed charges,Implant Device,109.2,35,,109.2,percent of total billed charges,Implant Device,109.2,35,,109.2,percent of total billed charges,Implant Device,109.2,35,,109.2,percent of total billed charges,Implant Device,124.8,40,,124.8,percent of total billed charges,Implant Device,109.2,70,,109.2,percent of total billed charges,All Other,106.08,34,,106.08,percent of total billed charges,Implant Device,106.08,34,,106.08,percent of total billed charges,Implant Device,109.2,35,,109.2,percent of total billed charges,Implant Device,109.2,35,,109.2,percent of total billed charges,Implant Device,109.2,35,,109.2,percent of total billed charges,Implant Device,109.2,35,,109.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,230.88,
ACUMED COT2322 LOCKING SCREW 2.3X22MM,C1713,HCPCS,,79004888,CDM,278,RC,,,both,,,312,230.88,,,230.88,Other,150% of Medicare + 9.63% HCRA Surcharge,140.4,45,,140.4,percent of total billed charges,Critical Access Hospital RCC factor,106.08,34,,106.08,percent of total billed charges,Implant Device,106.08,34,,106.08,percent of total billed charges,Implant Device,106.08,34,,106.08,percent of total billed charges,Implant Device,106.08,34,,106.08,percent of total billed charges,Implant Device,106.08,34,,106.08,percent of total billed charges,Implant Device,154.44,,,154.44,Other,110% of Medicare,109.2,35,,109.2,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,109.2,35,,109.2,percent of total billed charges,Implant Device,109.2,35,,109.2,percent of total billed charges,Implant Device,109.2,35,,109.2,percent of total billed charges,Implant Device,109.2,35,,109.2,percent of total billed charges,Implant Device,109.2,35,,109.2,percent of total billed charges,Implant Device,124.8,40,,124.8,percent of total billed charges,Implant Device,109.2,70,,109.2,percent of total billed charges,All Other,106.08,34,,106.08,percent of total billed charges,Implant Device,106.08,34,,106.08,percent of total billed charges,Implant Device,109.2,35,,109.2,percent of total billed charges,Implant Device,109.2,35,,109.2,percent of total billed charges,Implant Device,109.2,35,,109.2,percent of total billed charges,Implant Device,109.2,35,,109.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,230.88,
ACUMED COT2326 LOCKING SCREW 2.3X26MM,C1713,HCPCS,,79004889,CDM,278,RC,,,both,,,312,230.88,,,230.88,Other,150% of Medicare + 9.63% HCRA Surcharge,140.4,45,,140.4,percent of total billed charges,Critical Access Hospital RCC factor,106.08,34,,106.08,percent of total billed charges,Implant Device,106.08,34,,106.08,percent of total billed charges,Implant Device,106.08,34,,106.08,percent of total billed charges,Implant Device,106.08,34,,106.08,percent of total billed charges,Implant Device,106.08,34,,106.08,percent of total billed charges,Implant Device,154.44,,,154.44,Other,110% of Medicare,109.2,35,,109.2,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,109.2,35,,109.2,percent of total billed charges,Implant Device,109.2,35,,109.2,percent of total billed charges,Implant Device,109.2,35,,109.2,percent of total billed charges,Implant Device,109.2,35,,109.2,percent of total billed charges,Implant Device,109.2,35,,109.2,percent of total billed charges,Implant Device,124.8,40,,124.8,percent of total billed charges,Implant Device,109.2,70,,109.2,percent of total billed charges,All Other,106.08,34,,106.08,percent of total billed charges,Implant Device,106.08,34,,106.08,percent of total billed charges,Implant Device,109.2,35,,109.2,percent of total billed charges,Implant Device,109.2,35,,109.2,percent of total billed charges,Implant Device,109.2,35,,109.2,percent of total billed charges,Implant Device,109.2,35,,109.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,230.88,
ACUMED COT2328 LOCKING SCREW 2.3X28MM,C1713,HCPCS,,79004890,CDM,278,RC,,,both,,,312,230.88,,,230.88,Other,150% of Medicare + 9.63% HCRA Surcharge,140.4,45,,140.4,percent of total billed charges,Critical Access Hospital RCC factor,106.08,34,,106.08,percent of total billed charges,Implant Device,106.08,34,,106.08,percent of total billed charges,Implant Device,106.08,34,,106.08,percent of total billed charges,Implant Device,106.08,34,,106.08,percent of total billed charges,Implant Device,106.08,34,,106.08,percent of total billed charges,Implant Device,154.44,,,154.44,Other,110% of Medicare,109.2,35,,109.2,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,109.2,35,,109.2,percent of total billed charges,Implant Device,109.2,35,,109.2,percent of total billed charges,Implant Device,109.2,35,,109.2,percent of total billed charges,Implant Device,109.2,35,,109.2,percent of total billed charges,Implant Device,109.2,35,,109.2,percent of total billed charges,Implant Device,124.8,40,,124.8,percent of total billed charges,Implant Device,109.2,70,,109.2,percent of total billed charges,All Other,106.08,34,,106.08,percent of total billed charges,Implant Device,106.08,34,,106.08,percent of total billed charges,Implant Device,109.2,35,,109.2,percent of total billed charges,Implant Device,109.2,35,,109.2,percent of total billed charges,Implant Device,109.2,35,,109.2,percent of total billed charges,Implant Device,109.2,35,,109.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,230.88,
ACUMED COT2330 LOCKING SCREW 2.3X30MM,C1713,HCPCS,,79004891,CDM,278,RC,,,both,,,312,230.88,,,230.88,Other,150% of Medicare + 9.63% HCRA Surcharge,140.4,45,,140.4,percent of total billed charges,Critical Access Hospital RCC factor,106.08,34,,106.08,percent of total billed charges,Implant Device,106.08,34,,106.08,percent of total billed charges,Implant Device,106.08,34,,106.08,percent of total billed charges,Implant Device,106.08,34,,106.08,percent of total billed charges,Implant Device,106.08,34,,106.08,percent of total billed charges,Implant Device,154.44,,,154.44,Other,110% of Medicare,109.2,35,,109.2,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,109.2,35,,109.2,percent of total billed charges,Implant Device,109.2,35,,109.2,percent of total billed charges,Implant Device,109.2,35,,109.2,percent of total billed charges,Implant Device,109.2,35,,109.2,percent of total billed charges,Implant Device,109.2,35,,109.2,percent of total billed charges,Implant Device,124.8,40,,124.8,percent of total billed charges,Implant Device,109.2,70,,109.2,percent of total billed charges,All Other,106.08,34,,106.08,percent of total billed charges,Implant Device,106.08,34,,106.08,percent of total billed charges,Implant Device,109.2,35,,109.2,percent of total billed charges,Implant Device,109.2,35,,109.2,percent of total billed charges,Implant Device,109.2,35,,109.2,percent of total billed charges,Implant Device,109.2,35,,109.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,230.88,
STRYKER 40-30115 ASNIS CANN SCREW,C1713,HCPCS,,79004894,CDM,278,RC,,,both,,,493,364.82,,,364.82,Other,150% of Medicare + 9.63% HCRA Surcharge,221.85,45,,221.85,percent of total billed charges,Critical Access Hospital RCC factor,167.62,34,,167.62,percent of total billed charges,Implant Device,167.62,34,,167.62,percent of total billed charges,Implant Device,167.62,34,,167.62,percent of total billed charges,Implant Device,167.62,34,,167.62,percent of total billed charges,Implant Device,167.62,34,,167.62,percent of total billed charges,Implant Device,244.04,,,244.04,Other,110% of Medicare,172.55,35,,172.55,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,172.55,35,,172.55,percent of total billed charges,Implant Device,172.55,35,,172.55,percent of total billed charges,Implant Device,172.55,35,,172.55,percent of total billed charges,Implant Device,172.55,35,,172.55,percent of total billed charges,Implant Device,172.55,35,,172.55,percent of total billed charges,Implant Device,197.2,40,,197.2,percent of total billed charges,Implant Device,172.55,70,,172.55,percent of total billed charges,All Other,167.62,34,,167.62,percent of total billed charges,Implant Device,167.62,34,,167.62,percent of total billed charges,Implant Device,172.55,35,,172.55,percent of total billed charges,Implant Device,172.55,35,,172.55,percent of total billed charges,Implant Device,172.55,35,,172.55,percent of total billed charges,Implant Device,172.55,35,,172.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,364.82,
ATLAS 1106-01-5545 APELO SCREW 5.5X45MM,C1713,HCPCS,,79004895,CDM,278,RC,,,both,,,630,466.2,,,466.2,Other,150% of Medicare + 9.63% HCRA Surcharge,283.5,45,,283.5,percent of total billed charges,Critical Access Hospital RCC factor,214.2,34,,214.2,percent of total billed charges,Implant Device,214.2,34,,214.2,percent of total billed charges,Implant Device,214.2,34,,214.2,percent of total billed charges,Implant Device,214.2,34,,214.2,percent of total billed charges,Implant Device,214.2,34,,214.2,percent of total billed charges,Implant Device,311.85,,,311.85,Other,110% of Medicare,220.5,35,,220.5,percent of total billed charges,Implant Device,214.2,34,"Charges > $500, x 34%",214.2,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,252,40,,252,percent of total billed charges,Implant Device,220.5,70,,220.5,percent of total billed charges,All Other,214.2,34,,214.2,percent of total billed charges,Implant Device,214.2,34,,214.2,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,466.2,
ATLAS 1106-09-0000 LOCKING COLLAR,C1713,HCPCS,,79004896,CDM,278,RC,,,both,,,662,489.88,,,489.88,Other,150% of Medicare + 9.63% HCRA Surcharge,297.9,45,,297.9,percent of total billed charges,Critical Access Hospital RCC factor,225.08,34,,225.08,percent of total billed charges,Implant Device,225.08,34,,225.08,percent of total billed charges,Implant Device,225.08,34,,225.08,percent of total billed charges,Implant Device,225.08,34,,225.08,percent of total billed charges,Implant Device,225.08,34,,225.08,percent of total billed charges,Implant Device,327.69,,,327.69,Other,110% of Medicare,231.7,35,,231.7,percent of total billed charges,Implant Device,225.08,34,"Charges > $500, x 34%",225.08,percent of total billed charges,Implant Device,231.7,35,,231.7,percent of total billed charges,Implant Device,231.7,35,,231.7,percent of total billed charges,Implant Device,231.7,35,,231.7,percent of total billed charges,Implant Device,231.7,35,,231.7,percent of total billed charges,Implant Device,231.7,35,,231.7,percent of total billed charges,Implant Device,264.8,40,,264.8,percent of total billed charges,Implant Device,231.7,70,,231.7,percent of total billed charges,All Other,225.08,34,,225.08,percent of total billed charges,Implant Device,225.08,34,,225.08,percent of total billed charges,Implant Device,231.7,35,,231.7,percent of total billed charges,Implant Device,231.7,35,,231.7,percent of total billed charges,Implant Device,231.7,35,,231.7,percent of total billed charges,Implant Device,231.7,35,,231.7,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,489.88,
ATLAS 1100-03-0045 CONTOURED ROD 45MM,C1713,HCPCS,,79004897,CDM,278,RC,,,both,,,600,444,,,444,Other,150% of Medicare + 9.63% HCRA Surcharge,270,45,,270,percent of total billed charges,Critical Access Hospital RCC factor,204,34,,204,percent of total billed charges,Implant Device,204,34,,204,percent of total billed charges,Implant Device,204,34,,204,percent of total billed charges,Implant Device,204,34,,204,percent of total billed charges,Implant Device,204,34,,204,percent of total billed charges,Implant Device,297,,,297,Other,110% of Medicare,210,35,,210,percent of total billed charges,Implant Device,204,34,"Charges > $500, x 34%",204,percent of total billed charges,Implant Device,210,35,,210,percent of total billed charges,Implant Device,210,35,,210,percent of total billed charges,Implant Device,210,35,,210,percent of total billed charges,Implant Device,210,35,,210,percent of total billed charges,Implant Device,210,35,,210,percent of total billed charges,Implant Device,240,40,,240,percent of total billed charges,Implant Device,210,70,,210,percent of total billed charges,All Other,204,34,,204,percent of total billed charges,Implant Device,204,34,,204,percent of total billed charges,Implant Device,210,35,,210,percent of total billed charges,Implant Device,210,35,,210,percent of total billed charges,Implant Device,210,35,,210,percent of total billed charges,Implant Device,210,35,,210,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,444,
STRYKER 40-35010 BONE SCREW 3.5X10MM,C1713,HCPCS,,79004902,CDM,278,RC,,,both,,,192,142.08,,,142.08,Other,150% of Medicare + 9.63% HCRA Surcharge,86.4,45,,86.4,percent of total billed charges,Critical Access Hospital RCC factor,65.28,34,,65.28,percent of total billed charges,Implant Device,65.28,34,,65.28,percent of total billed charges,Implant Device,65.28,34,,65.28,percent of total billed charges,Implant Device,65.28,34,,65.28,percent of total billed charges,Implant Device,65.28,34,,65.28,percent of total billed charges,Implant Device,95.04,,,95.04,Other,110% of Medicare,67.2,35,,67.2,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,67.2,35,,67.2,percent of total billed charges,Implant Device,67.2,35,,67.2,percent of total billed charges,Implant Device,67.2,35,,67.2,percent of total billed charges,Implant Device,67.2,35,,67.2,percent of total billed charges,Implant Device,67.2,35,,67.2,percent of total billed charges,Implant Device,76.8,40,,76.8,percent of total billed charges,Implant Device,67.2,70,,67.2,percent of total billed charges,All Other,65.28,34,,65.28,percent of total billed charges,Implant Device,65.28,34,,65.28,percent of total billed charges,Implant Device,67.2,35,,67.2,percent of total billed charges,Implant Device,67.2,35,,67.2,percent of total billed charges,Implant Device,67.2,35,,67.2,percent of total billed charges,Implant Device,67.2,35,,67.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,142.08,
STRYKER 604644 CANNULATED SCREW 4X44MM,C1713,HCPCS,,79004904,CDM,278,RC,,,both,,,480,355.2,,,355.2,Other,150% of Medicare + 9.63% HCRA Surcharge,216,45,,216,percent of total billed charges,Critical Access Hospital RCC factor,163.2,34,,163.2,percent of total billed charges,Implant Device,163.2,34,,163.2,percent of total billed charges,Implant Device,163.2,34,,163.2,percent of total billed charges,Implant Device,163.2,34,,163.2,percent of total billed charges,Implant Device,163.2,34,,163.2,percent of total billed charges,Implant Device,237.6,,,237.6,Other,110% of Medicare,168,35,,168,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,192,40,,192,percent of total billed charges,Implant Device,168,70,,168,percent of total billed charges,All Other,163.2,34,,163.2,percent of total billed charges,Implant Device,163.2,34,,163.2,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,355.2,
BIOMET TP20000 THREADED PEG 2.5X20MM,C1713,HCPCS,,79004905,CDM,278,RC,,,both,,,288,213.12,,,213.12,Other,150% of Medicare + 9.63% HCRA Surcharge,129.6,45,,129.6,percent of total billed charges,Critical Access Hospital RCC factor,97.92,34,,97.92,percent of total billed charges,Implant Device,97.92,34,,97.92,percent of total billed charges,Implant Device,97.92,34,,97.92,percent of total billed charges,Implant Device,97.92,34,,97.92,percent of total billed charges,Implant Device,97.92,34,,97.92,percent of total billed charges,Implant Device,142.56,,,142.56,Other,110% of Medicare,100.8,35,,100.8,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,100.8,35,,100.8,percent of total billed charges,Implant Device,100.8,35,,100.8,percent of total billed charges,Implant Device,100.8,35,,100.8,percent of total billed charges,Implant Device,100.8,35,,100.8,percent of total billed charges,Implant Device,100.8,35,,100.8,percent of total billed charges,Implant Device,115.2,40,,115.2,percent of total billed charges,Implant Device,100.8,70,,100.8,percent of total billed charges,All Other,97.92,34,,97.92,percent of total billed charges,Implant Device,97.92,34,,97.92,percent of total billed charges,Implant Device,100.8,35,,100.8,percent of total billed charges,Implant Device,100.8,35,,100.8,percent of total billed charges,Implant Device,100.8,35,,100.8,percent of total billed charges,Implant Device,100.8,35,,100.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,213.12,
EXACTECH 310-01-41 HUMERAL HEAD 41X16MM,C1776,HCPCS,,79004906,CDM,278,RC,,,both,,,3150,2331.01,,,2331.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1417.5,45,,1417.5,percent of total billed charges,Critical Access Hospital RCC factor,1071,34,,1071,percent of total billed charges,Implant Device,1071,34,,1071,percent of total billed charges,Implant Device,1071,34,,1071,percent of total billed charges,Implant Device,1071,34,,1071,percent of total billed charges,Implant Device,1071,34,,1071,percent of total billed charges,Implant Device,1559.25,,,1559.25,Other,110% of Medicare,1102.5,35,,1102.5,percent of total billed charges,Implant Device,1071,34,"Charges > $500, x 34%",1071,percent of total billed charges,Implant Device,1102.5,35,,1102.5,percent of total billed charges,Implant Device,1102.5,35,,1102.5,percent of total billed charges,Implant Device,1102.5,35,,1102.5,percent of total billed charges,Implant Device,1102.5,35,,1102.5,percent of total billed charges,Implant Device,1102.5,35,,1102.5,percent of total billed charges,Implant Device,1260,40,,1260,percent of total billed charges,Implant Device,1102.5,70,,1102.5,percent of total billed charges,All Other,1071,34,,1071,percent of total billed charges,Implant Device,1071,34,,1071,percent of total billed charges,Implant Device,1102.5,35,,1102.5,percent of total billed charges,Implant Device,1102.5,35,,1102.5,percent of total billed charges,Implant Device,1102.5,35,,1102.5,percent of total billed charges,Implant Device,1102.5,35,,1102.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1071,34,"If Charge > 2,000, then 34 percent",1071,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2331.01,
SOLANA FFS-1212 FUSEFORCE IMP KIT 12X12,C1713,HCPCS,,79004907,CDM,278,RC,,,both,,,5100,3774.01,,,3774.01,Other,150% of Medicare + 9.63% HCRA Surcharge,2295,45,,2295,percent of total billed charges,Critical Access Hospital RCC factor,1734,34,,1734,percent of total billed charges,Implant Device,1734,34,,1734,percent of total billed charges,Implant Device,1734,34,,1734,percent of total billed charges,Implant Device,1734,34,,1734,percent of total billed charges,Implant Device,1734,34,,1734,percent of total billed charges,Implant Device,2524.5,,,2524.5,Other,110% of Medicare,1785,35,,1785,percent of total billed charges,Implant Device,1734,34,"Charges > $500, x 34%",1734,percent of total billed charges,Implant Device,1785,35,,1785,percent of total billed charges,Implant Device,1785,35,,1785,percent of total billed charges,Implant Device,1785,35,,1785,percent of total billed charges,Implant Device,1785,35,,1785,percent of total billed charges,Implant Device,1785,35,,1785,percent of total billed charges,Implant Device,2040,40,,2040,percent of total billed charges,Implant Device,1785,70,,1785,percent of total billed charges,All Other,1734,34,,1734,percent of total billed charges,Implant Device,1734,34,,1734,percent of total billed charges,Implant Device,1785,35,,1785,percent of total billed charges,Implant Device,1785,35,,1785,percent of total billed charges,Implant Device,1785,35,,1785,percent of total billed charges,Implant Device,1785,35,,1785,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1734,34,"If Charge > 2,000, then 34 percent",1734,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3774.01,
INTEGRA 303102 SHORT BEND PLATE,C1713,HCPCS,,79004916,CDM,278,RC,,,both,,,3376,2498.25,,,2498.25,Other,150% of Medicare + 9.63% HCRA Surcharge,1519.2,45,,1519.2,percent of total billed charges,Critical Access Hospital RCC factor,1147.84,34,,1147.84,percent of total billed charges,Implant Device,1147.84,34,,1147.84,percent of total billed charges,Implant Device,1147.84,34,,1147.84,percent of total billed charges,Implant Device,1147.84,34,,1147.84,percent of total billed charges,Implant Device,1147.84,34,,1147.84,percent of total billed charges,Implant Device,1671.12,,,1671.12,Other,110% of Medicare,1181.6,35,,1181.6,percent of total billed charges,Implant Device,1147.84,34,"Charges > $500, x 34%",1147.84,percent of total billed charges,Implant Device,1181.6,35,,1181.6,percent of total billed charges,Implant Device,1181.6,35,,1181.6,percent of total billed charges,Implant Device,1181.6,35,,1181.6,percent of total billed charges,Implant Device,1181.6,35,,1181.6,percent of total billed charges,Implant Device,1181.6,35,,1181.6,percent of total billed charges,Implant Device,1350.4,40,,1350.4,percent of total billed charges,Implant Device,1181.6,70,,1181.6,percent of total billed charges,All Other,1147.84,34,,1147.84,percent of total billed charges,Implant Device,1147.84,34,,1147.84,percent of total billed charges,Implant Device,1181.6,35,,1181.6,percent of total billed charges,Implant Device,1181.6,35,,1181.6,percent of total billed charges,Implant Device,1181.6,35,,1181.6,percent of total billed charges,Implant Device,1181.6,35,,1181.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1147.84,34,"If Charge > 2,000, then 34 percent",1147.84,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2498.25,
INTEGRA 303214 CORTICAL SCREW 2.7X14MM,C1713,HCPCS,,79004917,CDM,278,RC,,,both,,,316,233.84,,,233.84,Other,150% of Medicare + 9.63% HCRA Surcharge,142.2,45,,142.2,percent of total billed charges,Critical Access Hospital RCC factor,107.44,34,,107.44,percent of total billed charges,Implant Device,107.44,34,,107.44,percent of total billed charges,Implant Device,107.44,34,,107.44,percent of total billed charges,Implant Device,107.44,34,,107.44,percent of total billed charges,Implant Device,107.44,34,,107.44,percent of total billed charges,Implant Device,156.42,,,156.42,Other,110% of Medicare,110.6,35,,110.6,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,110.6,35,,110.6,percent of total billed charges,Implant Device,110.6,35,,110.6,percent of total billed charges,Implant Device,110.6,35,,110.6,percent of total billed charges,Implant Device,110.6,35,,110.6,percent of total billed charges,Implant Device,110.6,35,,110.6,percent of total billed charges,Implant Device,126.4,40,,126.4,percent of total billed charges,Implant Device,110.6,70,,110.6,percent of total billed charges,All Other,107.44,34,,107.44,percent of total billed charges,Implant Device,107.44,34,,107.44,percent of total billed charges,Implant Device,110.6,35,,110.6,percent of total billed charges,Implant Device,110.6,35,,110.6,percent of total billed charges,Implant Device,110.6,35,,110.6,percent of total billed charges,Implant Device,110.6,35,,110.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,233.84,
INTEGRA 303216 CORTICAL SCREW 2.7X16MM,C1713,HCPCS,,79004918,CDM,278,RC,,,both,,,316,233.84,,,233.84,Other,150% of Medicare + 9.63% HCRA Surcharge,142.2,45,,142.2,percent of total billed charges,Critical Access Hospital RCC factor,107.44,34,,107.44,percent of total billed charges,Implant Device,107.44,34,,107.44,percent of total billed charges,Implant Device,107.44,34,,107.44,percent of total billed charges,Implant Device,107.44,34,,107.44,percent of total billed charges,Implant Device,107.44,34,,107.44,percent of total billed charges,Implant Device,156.42,,,156.42,Other,110% of Medicare,110.6,35,,110.6,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,110.6,35,,110.6,percent of total billed charges,Implant Device,110.6,35,,110.6,percent of total billed charges,Implant Device,110.6,35,,110.6,percent of total billed charges,Implant Device,110.6,35,,110.6,percent of total billed charges,Implant Device,110.6,35,,110.6,percent of total billed charges,Implant Device,126.4,40,,126.4,percent of total billed charges,Implant Device,110.6,70,,110.6,percent of total billed charges,All Other,107.44,34,,107.44,percent of total billed charges,Implant Device,107.44,34,,107.44,percent of total billed charges,Implant Device,110.6,35,,110.6,percent of total billed charges,Implant Device,110.6,35,,110.6,percent of total billed charges,Implant Device,110.6,35,,110.6,percent of total billed charges,Implant Device,110.6,35,,110.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,233.84,
INTEGRA 303312 CORTICAL SCREW 3.5X 12MM,C1713,HCPCS,,79004919,CDM,278,RC,,,both,,,346,256.04,,,256.04,Other,150% of Medicare + 9.63% HCRA Surcharge,155.7,45,,155.7,percent of total billed charges,Critical Access Hospital RCC factor,117.64,34,,117.64,percent of total billed charges,Implant Device,117.64,34,,117.64,percent of total billed charges,Implant Device,117.64,34,,117.64,percent of total billed charges,Implant Device,117.64,34,,117.64,percent of total billed charges,Implant Device,117.64,34,,117.64,percent of total billed charges,Implant Device,171.27,,,171.27,Other,110% of Medicare,121.1,35,,121.1,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,121.1,35,,121.1,percent of total billed charges,Implant Device,121.1,35,,121.1,percent of total billed charges,Implant Device,121.1,35,,121.1,percent of total billed charges,Implant Device,121.1,35,,121.1,percent of total billed charges,Implant Device,121.1,35,,121.1,percent of total billed charges,Implant Device,138.4,40,,138.4,percent of total billed charges,Implant Device,121.1,70,,121.1,percent of total billed charges,All Other,117.64,34,,117.64,percent of total billed charges,Implant Device,117.64,34,,117.64,percent of total billed charges,Implant Device,121.1,35,,121.1,percent of total billed charges,Implant Device,121.1,35,,121.1,percent of total billed charges,Implant Device,121.1,35,,121.1,percent of total billed charges,Implant Device,121.1,35,,121.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,256.04,
INTEGRA 303322 CORTICAL SCREW 3.5X22MM,C1713,HCPCS,,79004920,CDM,278,RC,,,both,,,346,256.04,,,256.04,Other,150% of Medicare + 9.63% HCRA Surcharge,155.7,45,,155.7,percent of total billed charges,Critical Access Hospital RCC factor,117.64,34,,117.64,percent of total billed charges,Implant Device,117.64,34,,117.64,percent of total billed charges,Implant Device,117.64,34,,117.64,percent of total billed charges,Implant Device,117.64,34,,117.64,percent of total billed charges,Implant Device,117.64,34,,117.64,percent of total billed charges,Implant Device,171.27,,,171.27,Other,110% of Medicare,121.1,35,,121.1,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,121.1,35,,121.1,percent of total billed charges,Implant Device,121.1,35,,121.1,percent of total billed charges,Implant Device,121.1,35,,121.1,percent of total billed charges,Implant Device,121.1,35,,121.1,percent of total billed charges,Implant Device,121.1,35,,121.1,percent of total billed charges,Implant Device,138.4,40,,138.4,percent of total billed charges,Implant Device,121.1,70,,121.1,percent of total billed charges,All Other,117.64,34,,117.64,percent of total billed charges,Implant Device,117.64,34,,117.64,percent of total billed charges,Implant Device,121.1,35,,121.1,percent of total billed charges,Implant Device,121.1,35,,121.1,percent of total billed charges,Implant Device,121.1,35,,121.1,percent of total billed charges,Implant Device,121.1,35,,121.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,256.04,
INTEGRA 286214ND SURFIX SCREW 2.7X14MM,C1713,HCPCS,,79004921,CDM,278,RC,,,both,,,886,655.64,,,655.64,Other,150% of Medicare + 9.63% HCRA Surcharge,398.7,45,,398.7,percent of total billed charges,Critical Access Hospital RCC factor,301.24,34,,301.24,percent of total billed charges,Implant Device,301.24,34,,301.24,percent of total billed charges,Implant Device,301.24,34,,301.24,percent of total billed charges,Implant Device,301.24,34,,301.24,percent of total billed charges,Implant Device,301.24,34,,301.24,percent of total billed charges,Implant Device,438.57,,,438.57,Other,110% of Medicare,310.1,35,,310.1,percent of total billed charges,Implant Device,301.24,34,"Charges > $500, x 34%",301.24,percent of total billed charges,Implant Device,310.1,35,,310.1,percent of total billed charges,Implant Device,310.1,35,,310.1,percent of total billed charges,Implant Device,310.1,35,,310.1,percent of total billed charges,Implant Device,310.1,35,,310.1,percent of total billed charges,Implant Device,310.1,35,,310.1,percent of total billed charges,Implant Device,354.4,40,,354.4,percent of total billed charges,Implant Device,310.1,70,,310.1,percent of total billed charges,All Other,301.24,34,,301.24,percent of total billed charges,Implant Device,301.24,34,,301.24,percent of total billed charges,Implant Device,310.1,35,,310.1,percent of total billed charges,Implant Device,310.1,35,,310.1,percent of total billed charges,Implant Device,310.1,35,,310.1,percent of total billed charges,Implant Device,310.1,35,,310.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,655.64,
INTEGRA 286222ND SURFIX SCREW 2.7X22MM,C1713,HCPCS,,79004922,CDM,278,RC,,,both,,,886,655.64,,,655.64,Other,150% of Medicare + 9.63% HCRA Surcharge,398.7,45,,398.7,percent of total billed charges,Critical Access Hospital RCC factor,301.24,34,,301.24,percent of total billed charges,Implant Device,301.24,34,,301.24,percent of total billed charges,Implant Device,301.24,34,,301.24,percent of total billed charges,Implant Device,301.24,34,,301.24,percent of total billed charges,Implant Device,301.24,34,,301.24,percent of total billed charges,Implant Device,438.57,,,438.57,Other,110% of Medicare,310.1,35,,310.1,percent of total billed charges,Implant Device,301.24,34,"Charges > $500, x 34%",301.24,percent of total billed charges,Implant Device,310.1,35,,310.1,percent of total billed charges,Implant Device,310.1,35,,310.1,percent of total billed charges,Implant Device,310.1,35,,310.1,percent of total billed charges,Implant Device,310.1,35,,310.1,percent of total billed charges,Implant Device,310.1,35,,310.1,percent of total billed charges,Implant Device,354.4,40,,354.4,percent of total billed charges,Implant Device,310.1,70,,310.1,percent of total billed charges,All Other,301.24,34,,301.24,percent of total billed charges,Implant Device,301.24,34,,301.24,percent of total billed charges,Implant Device,310.1,35,,310.1,percent of total billed charges,Implant Device,310.1,35,,310.1,percent of total billed charges,Implant Device,310.1,35,,310.1,percent of total billed charges,Implant Device,310.1,35,,310.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,655.64,
INTEGRA 186200ND SURFIX LOCK SCREW 2.7MM,C1713,HCPCS,,79004923,CDM,278,RC,,,both,,,466,344.84,,,344.84,Other,150% of Medicare + 9.63% HCRA Surcharge,209.7,45,,209.7,percent of total billed charges,Critical Access Hospital RCC factor,158.44,34,,158.44,percent of total billed charges,Implant Device,158.44,34,,158.44,percent of total billed charges,Implant Device,158.44,34,,158.44,percent of total billed charges,Implant Device,158.44,34,,158.44,percent of total billed charges,Implant Device,158.44,34,,158.44,percent of total billed charges,Implant Device,230.67,,,230.67,Other,110% of Medicare,163.1,35,,163.1,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,163.1,35,,163.1,percent of total billed charges,Implant Device,163.1,35,,163.1,percent of total billed charges,Implant Device,163.1,35,,163.1,percent of total billed charges,Implant Device,163.1,35,,163.1,percent of total billed charges,Implant Device,163.1,35,,163.1,percent of total billed charges,Implant Device,186.4,40,,186.4,percent of total billed charges,Implant Device,163.1,70,,163.1,percent of total billed charges,All Other,158.44,34,,158.44,percent of total billed charges,Implant Device,158.44,34,,158.44,percent of total billed charges,Implant Device,163.1,35,,163.1,percent of total billed charges,Implant Device,163.1,35,,163.1,percent of total billed charges,Implant Device,163.1,35,,163.1,percent of total billed charges,Implant Device,163.1,35,,163.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,344.84,
INTEGRA 286312ND SURFIX SCREW 3.5X12MM,C1713,HCPCS,,79004924,CDM,278,RC,,,both,,,1110,821.4,,,821.4,Other,150% of Medicare + 9.63% HCRA Surcharge,499.5,45,,499.5,percent of total billed charges,Critical Access Hospital RCC factor,377.4,34,,377.4,percent of total billed charges,Implant Device,377.4,34,,377.4,percent of total billed charges,Implant Device,377.4,34,,377.4,percent of total billed charges,Implant Device,377.4,34,,377.4,percent of total billed charges,Implant Device,377.4,34,,377.4,percent of total billed charges,Implant Device,549.45,,,549.45,Other,110% of Medicare,388.5,35,,388.5,percent of total billed charges,Implant Device,377.4,34,"Charges > $500, x 34%",377.4,percent of total billed charges,Implant Device,388.5,35,,388.5,percent of total billed charges,Implant Device,388.5,35,,388.5,percent of total billed charges,Implant Device,388.5,35,,388.5,percent of total billed charges,Implant Device,388.5,35,,388.5,percent of total billed charges,Implant Device,388.5,35,,388.5,percent of total billed charges,Implant Device,444,40,,444,percent of total billed charges,Implant Device,388.5,70,,388.5,percent of total billed charges,All Other,377.4,34,,377.4,percent of total billed charges,Implant Device,377.4,34,,377.4,percent of total billed charges,Implant Device,388.5,35,,388.5,percent of total billed charges,Implant Device,388.5,35,,388.5,percent of total billed charges,Implant Device,388.5,35,,388.5,percent of total billed charges,Implant Device,388.5,35,,388.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,821.4,
INTEGRA 286328ND SURFIX SCREW 3.5X28MM,C1713,HCPCS,,79004925,CDM,278,RC,,,both,,,1110,821.4,,,821.4,Other,150% of Medicare + 9.63% HCRA Surcharge,499.5,45,,499.5,percent of total billed charges,Critical Access Hospital RCC factor,377.4,34,,377.4,percent of total billed charges,Implant Device,377.4,34,,377.4,percent of total billed charges,Implant Device,377.4,34,,377.4,percent of total billed charges,Implant Device,377.4,34,,377.4,percent of total billed charges,Implant Device,377.4,34,,377.4,percent of total billed charges,Implant Device,549.45,,,549.45,Other,110% of Medicare,388.5,35,,388.5,percent of total billed charges,Implant Device,377.4,34,"Charges > $500, x 34%",377.4,percent of total billed charges,Implant Device,388.5,35,,388.5,percent of total billed charges,Implant Device,388.5,35,,388.5,percent of total billed charges,Implant Device,388.5,35,,388.5,percent of total billed charges,Implant Device,388.5,35,,388.5,percent of total billed charges,Implant Device,388.5,35,,388.5,percent of total billed charges,Implant Device,444,40,,444,percent of total billed charges,Implant Device,388.5,70,,388.5,percent of total billed charges,All Other,377.4,34,,377.4,percent of total billed charges,Implant Device,377.4,34,,377.4,percent of total billed charges,Implant Device,388.5,35,,388.5,percent of total billed charges,Implant Device,388.5,35,,388.5,percent of total billed charges,Implant Device,388.5,35,,388.5,percent of total billed charges,Implant Device,388.5,35,,388.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,821.4,
BOST SCI 7053 WALL STENT BILIARY 10X60,C1876,HCPCS,,79004929,CDM,278,RC,,,both,,,8272,6121.3,,,6121.3,Other,150% of Medicare + 9.63% HCRA Surcharge,3722.4,45,,3722.4,percent of total billed charges,Critical Access Hospital RCC factor,2812.48,34,,2812.48,percent of total billed charges,Implant Device,2812.48,34,,2812.48,percent of total billed charges,Implant Device,2812.48,34,,2812.48,percent of total billed charges,Implant Device,2812.48,34,,2812.48,percent of total billed charges,Implant Device,2812.48,34,,2812.48,percent of total billed charges,Implant Device,4094.64,,,4094.64,Other,110% of Medicare,2895.2,35,,2895.2,percent of total billed charges,Implant Device,2812.48,34,"Charges > $500, x 34%",2812.48,percent of total billed charges,Implant Device,2895.2,35,,2895.2,percent of total billed charges,Implant Device,2895.2,35,,2895.2,percent of total billed charges,Implant Device,2895.2,35,,2895.2,percent of total billed charges,Implant Device,2895.2,35,,2895.2,percent of total billed charges,Implant Device,2895.2,35,,2895.2,percent of total billed charges,Implant Device,3308.8,40,,3308.8,percent of total billed charges,Implant Device,2895.2,70,,2895.2,percent of total billed charges,All Other,2812.48,34,,2812.48,percent of total billed charges,Implant Device,2812.48,34,,2812.48,percent of total billed charges,Implant Device,2895.2,35,,2895.2,percent of total billed charges,Implant Device,2895.2,35,,2895.2,percent of total billed charges,Implant Device,2895.2,35,,2895.2,percent of total billed charges,Implant Device,2895.2,35,,2895.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2812.48,34,"If Charge > 2,000, then 34 percent",2812.48,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,6121.3,
ZIMMER 00-5880-003-00 TIBIAL COMP SZ 3,C1776,HCPCS,,79004931,CDM,278,RC,,,both,,,12690,9390.63,,,9390.63,Other,150% of Medicare + 9.63% HCRA Surcharge,5710.5,45,,5710.5,percent of total billed charges,Critical Access Hospital RCC factor,4314.6,34,,4314.6,percent of total billed charges,Implant Device,4314.6,34,,4314.6,percent of total billed charges,Implant Device,4314.6,34,,4314.6,percent of total billed charges,Implant Device,4314.6,34,,4314.6,percent of total billed charges,Implant Device,4314.6,34,,4314.6,percent of total billed charges,Implant Device,6281.55,,,6281.55,Other,110% of Medicare,4441.5,35,,4441.5,percent of total billed charges,Implant Device,4314.6,34,"Charges > $500, x 34%",4314.6,percent of total billed charges,Implant Device,4441.5,35,,4441.5,percent of total billed charges,Implant Device,4441.5,35,,4441.5,percent of total billed charges,Implant Device,4441.5,35,,4441.5,percent of total billed charges,Implant Device,4441.5,35,,4441.5,percent of total billed charges,Implant Device,4441.5,35,,4441.5,percent of total billed charges,Implant Device,5076,40,,5076,percent of total billed charges,Implant Device,4441.5,70,,4441.5,percent of total billed charges,All Other,4314.6,34,,4314.6,percent of total billed charges,Implant Device,4314.6,34,,4314.6,percent of total billed charges,Implant Device,4441.5,35,,4441.5,percent of total billed charges,Implant Device,4441.5,35,,4441.5,percent of total billed charges,Implant Device,4441.5,35,,4441.5,percent of total billed charges,Implant Device,4441.5,35,,4441.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,4314.6,34,"If Charge > 2,000, then 34 percent",4314.6,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,9390.63,
ZIMMER 00-5988-010-11 STEM EXT 11X100MM,C1776,HCPCS,,79004932,CDM,278,RC,,,both,,,2970,2197.81,,,2197.81,Other,150% of Medicare + 9.63% HCRA Surcharge,1336.5,45,,1336.5,percent of total billed charges,Critical Access Hospital RCC factor,1009.8,34,,1009.8,percent of total billed charges,Implant Device,1009.8,34,,1009.8,percent of total billed charges,Implant Device,1009.8,34,,1009.8,percent of total billed charges,Implant Device,1009.8,34,,1009.8,percent of total billed charges,Implant Device,1009.8,34,,1009.8,percent of total billed charges,Implant Device,1470.15,,,1470.15,Other,110% of Medicare,1039.5,35,,1039.5,percent of total billed charges,Implant Device,1009.8,34,"Charges > $500, x 34%",1009.8,percent of total billed charges,Implant Device,1039.5,35,,1039.5,percent of total billed charges,Implant Device,1039.5,35,,1039.5,percent of total billed charges,Implant Device,1039.5,35,,1039.5,percent of total billed charges,Implant Device,1039.5,35,,1039.5,percent of total billed charges,Implant Device,1039.5,35,,1039.5,percent of total billed charges,Implant Device,1188,40,,1188,percent of total billed charges,Implant Device,1039.5,70,,1039.5,percent of total billed charges,All Other,1009.8,34,,1009.8,percent of total billed charges,Implant Device,1009.8,34,,1009.8,percent of total billed charges,Implant Device,1039.5,35,,1039.5,percent of total billed charges,Implant Device,1039.5,35,,1039.5,percent of total billed charges,Implant Device,1039.5,35,,1039.5,percent of total billed charges,Implant Device,1039.5,35,,1039.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1009.8,34,"If Charge > 2,000, then 34 percent",1009.8,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2197.81,
ZIMMER 00-5850-012-01 DIST FEM COMP SZ B,C1776,HCPCS,,79004933,CDM,278,RC,,,both,,,24705,18281.76,,,18281.76,Other,150% of Medicare + 9.63% HCRA Surcharge,11117.25,45,,11117.25,percent of total billed charges,Critical Access Hospital RCC factor,8399.7,34,,8399.7,percent of total billed charges,Implant Device,8399.7,34,,8399.7,percent of total billed charges,Implant Device,8399.7,34,,8399.7,percent of total billed charges,Implant Device,8399.7,34,,8399.7,percent of total billed charges,Implant Device,8399.7,34,,8399.7,percent of total billed charges,Implant Device,12228.98,,,12228.98,Other,110% of Medicare,8646.75,35,,8646.75,percent of total billed charges,Implant Device,8399.7,34,"Charges > $500, x 34%",8399.7,percent of total billed charges,Implant Device,8646.75,35,,8646.75,percent of total billed charges,Implant Device,8646.75,35,,8646.75,percent of total billed charges,Implant Device,8646.75,35,,8646.75,percent of total billed charges,Implant Device,8646.75,35,,8646.75,percent of total billed charges,Implant Device,8646.75,35,,8646.75,percent of total billed charges,Implant Device,9882,40,,9882,percent of total billed charges,Implant Device,8646.75,70,,8646.75,percent of total billed charges,All Other,8399.7,34,,8399.7,percent of total billed charges,Implant Device,8399.7,34,,8399.7,percent of total billed charges,Implant Device,8646.75,35,,8646.75,percent of total billed charges,Implant Device,8646.75,35,,8646.75,percent of total billed charges,Implant Device,8646.75,35,,8646.75,percent of total billed charges,Implant Device,8646.75,35,,8646.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,8399.7,34,"If Charge > 2,000, then 34 percent",8399.7,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,18281.76,
ZIMMER 00-5850-012-95 POLY INSERT SZ B,C1776,HCPCS,,79004934,CDM,278,RC,,,both,,,967,715.58,,,715.58,Other,150% of Medicare + 9.63% HCRA Surcharge,435.15,45,,435.15,percent of total billed charges,Critical Access Hospital RCC factor,328.78,34,,328.78,percent of total billed charges,Implant Device,328.78,34,,328.78,percent of total billed charges,Implant Device,328.78,34,,328.78,percent of total billed charges,Implant Device,328.78,34,,328.78,percent of total billed charges,Implant Device,328.78,34,,328.78,percent of total billed charges,Implant Device,478.67,,,478.67,Other,110% of Medicare,338.45,35,,338.45,percent of total billed charges,Implant Device,328.78,34,"Charges > $500, x 34%",328.78,percent of total billed charges,Implant Device,338.45,35,,338.45,percent of total billed charges,Implant Device,338.45,35,,338.45,percent of total billed charges,Implant Device,338.45,35,,338.45,percent of total billed charges,Implant Device,338.45,35,,338.45,percent of total billed charges,Implant Device,338.45,35,,338.45,percent of total billed charges,Implant Device,386.8,40,,386.8,percent of total billed charges,Implant Device,338.45,70,,338.45,percent of total billed charges,All Other,328.78,34,,328.78,percent of total billed charges,Implant Device,328.78,34,,328.78,percent of total billed charges,Implant Device,338.45,35,,338.45,percent of total billed charges,Implant Device,338.45,35,,338.45,percent of total billed charges,Implant Device,338.45,35,,338.45,percent of total billed charges,Implant Device,338.45,35,,338.45,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,715.58,
ZIMMER 00-5850-020-17 ART SURF SZ B 17MM,C1776,HCPCS,,79004935,CDM,278,RC,,,both,,,5602,4145.49,,,4145.49,Other,150% of Medicare + 9.63% HCRA Surcharge,2520.9,45,,2520.9,percent of total billed charges,Critical Access Hospital RCC factor,1904.68,34,,1904.68,percent of total billed charges,Implant Device,1904.68,34,,1904.68,percent of total billed charges,Implant Device,1904.68,34,,1904.68,percent of total billed charges,Implant Device,1904.68,34,,1904.68,percent of total billed charges,Implant Device,1904.68,34,,1904.68,percent of total billed charges,Implant Device,2772.99,,,2772.99,Other,110% of Medicare,1960.7,35,,1960.7,percent of total billed charges,Implant Device,1904.68,34,"Charges > $500, x 34%",1904.68,percent of total billed charges,Implant Device,1960.7,35,,1960.7,percent of total billed charges,Implant Device,1960.7,35,,1960.7,percent of total billed charges,Implant Device,1960.7,35,,1960.7,percent of total billed charges,Implant Device,1960.7,35,,1960.7,percent of total billed charges,Implant Device,1960.7,35,,1960.7,percent of total billed charges,Implant Device,2240.8,40,,2240.8,percent of total billed charges,Implant Device,1960.7,70,,1960.7,percent of total billed charges,All Other,1904.68,34,,1904.68,percent of total billed charges,Implant Device,1904.68,34,,1904.68,percent of total billed charges,Implant Device,1960.7,35,,1960.7,percent of total billed charges,Implant Device,1960.7,35,,1960.7,percent of total billed charges,Implant Device,1960.7,35,,1960.7,percent of total billed charges,Implant Device,1960.7,35,,1960.7,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1904.68,34,"If Charge > 2,000, then 34 percent",1904.68,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4145.49,
ZIMMER 00-5850-046-04 SEGMENT TAPER 40MM,C1776,HCPCS,,79004936,CDM,278,RC,,,both,,,10306,7626.47,,,7626.47,Other,150% of Medicare + 9.63% HCRA Surcharge,4637.7,45,,4637.7,percent of total billed charges,Critical Access Hospital RCC factor,3504.04,34,,3504.04,percent of total billed charges,Implant Device,3504.04,34,,3504.04,percent of total billed charges,Implant Device,3504.04,34,,3504.04,percent of total billed charges,Implant Device,3504.04,34,,3504.04,percent of total billed charges,Implant Device,3504.04,34,,3504.04,percent of total billed charges,Implant Device,5101.47,,,5101.47,Other,110% of Medicare,3607.1,35,,3607.1,percent of total billed charges,Implant Device,3504.04,34,"Charges > $500, x 34%",3504.04,percent of total billed charges,Implant Device,3607.1,35,,3607.1,percent of total billed charges,Implant Device,3607.1,35,,3607.1,percent of total billed charges,Implant Device,3607.1,35,,3607.1,percent of total billed charges,Implant Device,3607.1,35,,3607.1,percent of total billed charges,Implant Device,3607.1,35,,3607.1,percent of total billed charges,Implant Device,4122.4,40,,4122.4,percent of total billed charges,Implant Device,3607.1,70,,3607.1,percent of total billed charges,All Other,3504.04,34,,3504.04,percent of total billed charges,Implant Device,3504.04,34,,3504.04,percent of total billed charges,Implant Device,3607.1,35,,3607.1,percent of total billed charges,Implant Device,3607.1,35,,3607.1,percent of total billed charges,Implant Device,3607.1,35,,3607.1,percent of total billed charges,Implant Device,3607.1,35,,3607.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3504.04,34,"If Charge > 2,000, then 34 percent",3504.04,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,7626.47,
ZIMMER 00-5850-070-12 FEM HINGE KIT SZ B,C1776,HCPCS,,79004937,CDM,278,RC,,,both,,,6143,4545.84,,,4545.84,Other,150% of Medicare + 9.63% HCRA Surcharge,2764.35,45,,2764.35,percent of total billed charges,Critical Access Hospital RCC factor,2088.62,34,,2088.62,percent of total billed charges,Implant Device,2088.62,34,,2088.62,percent of total billed charges,Implant Device,2088.62,34,,2088.62,percent of total billed charges,Implant Device,2088.62,34,,2088.62,percent of total billed charges,Implant Device,2088.62,34,,2088.62,percent of total billed charges,Implant Device,3040.79,,,3040.79,Other,110% of Medicare,2150.05,35,,2150.05,percent of total billed charges,Implant Device,2088.62,34,"Charges > $500, x 34%",2088.62,percent of total billed charges,Implant Device,2150.05,35,,2150.05,percent of total billed charges,Implant Device,2150.05,35,,2150.05,percent of total billed charges,Implant Device,2150.05,35,,2150.05,percent of total billed charges,Implant Device,2150.05,35,,2150.05,percent of total billed charges,Implant Device,2150.05,35,,2150.05,percent of total billed charges,Implant Device,2457.2,40,,2457.2,percent of total billed charges,Implant Device,2150.05,70,,2150.05,percent of total billed charges,All Other,2088.62,34,,2088.62,percent of total billed charges,Implant Device,2088.62,34,,2088.62,percent of total billed charges,Implant Device,2150.05,35,,2150.05,percent of total billed charges,Implant Device,2150.05,35,,2150.05,percent of total billed charges,Implant Device,2150.05,35,,2150.05,percent of total billed charges,Implant Device,2150.05,35,,2150.05,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2088.62,34,"If Charge > 2,000, then 34 percent",2088.62,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4545.84,
ZIMMER 00-5852-042-09 STEM COLLAR 30MM,C1776,HCPCS,,79004938,CDM,278,RC,,,both,,,5737,4245.39,,,4245.39,Other,150% of Medicare + 9.63% HCRA Surcharge,2581.65,45,,2581.65,percent of total billed charges,Critical Access Hospital RCC factor,1950.58,34,,1950.58,percent of total billed charges,Implant Device,1950.58,34,,1950.58,percent of total billed charges,Implant Device,1950.58,34,,1950.58,percent of total billed charges,Implant Device,1950.58,34,,1950.58,percent of total billed charges,Implant Device,1950.58,34,,1950.58,percent of total billed charges,Implant Device,2839.82,,,2839.82,Other,110% of Medicare,2007.95,35,,2007.95,percent of total billed charges,Implant Device,1950.58,34,"Charges > $500, x 34%",1950.58,percent of total billed charges,Implant Device,2007.95,35,,2007.95,percent of total billed charges,Implant Device,2007.95,35,,2007.95,percent of total billed charges,Implant Device,2007.95,35,,2007.95,percent of total billed charges,Implant Device,2007.95,35,,2007.95,percent of total billed charges,Implant Device,2007.95,35,,2007.95,percent of total billed charges,Implant Device,2294.8,40,,2294.8,percent of total billed charges,Implant Device,2007.95,70,,2007.95,percent of total billed charges,All Other,1950.58,34,,1950.58,percent of total billed charges,Implant Device,1950.58,34,,1950.58,percent of total billed charges,Implant Device,2007.95,35,,2007.95,percent of total billed charges,Implant Device,2007.95,35,,2007.95,percent of total billed charges,Implant Device,2007.95,35,,2007.95,percent of total billed charges,Implant Device,2007.95,35,,2007.95,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1950.58,34,"If Charge > 2,000, then 34 percent",1950.58,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4245.39,
ZIMMER 00-5852-050-14 STEM EXT 14X130MM,C1776,HCPCS,,79004939,CDM,278,RC,,,both,,,12540,9279.63,,,9279.63,Other,150% of Medicare + 9.63% HCRA Surcharge,5643,45,,5643,percent of total billed charges,Critical Access Hospital RCC factor,4263.6,34,,4263.6,percent of total billed charges,Implant Device,4263.6,34,,4263.6,percent of total billed charges,Implant Device,4263.6,34,,4263.6,percent of total billed charges,Implant Device,4263.6,34,,4263.6,percent of total billed charges,Implant Device,4263.6,34,,4263.6,percent of total billed charges,Implant Device,6207.3,,,6207.3,Other,110% of Medicare,4389,35,,4389,percent of total billed charges,Implant Device,4263.6,34,"Charges > $500, x 34%",4263.6,percent of total billed charges,Implant Device,4389,35,,4389,percent of total billed charges,Implant Device,4389,35,,4389,percent of total billed charges,Implant Device,4389,35,,4389,percent of total billed charges,Implant Device,4389,35,,4389,percent of total billed charges,Implant Device,4389,35,,4389,percent of total billed charges,Implant Device,5016,40,,5016,percent of total billed charges,Implant Device,4389,70,,4389,percent of total billed charges,All Other,4263.6,34,,4263.6,percent of total billed charges,Implant Device,4263.6,34,,4263.6,percent of total billed charges,Implant Device,4389,35,,4389,percent of total billed charges,Implant Device,4389,35,,4389,percent of total billed charges,Implant Device,4389,35,,4389,percent of total billed charges,Implant Device,4389,35,,4389,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,4263.6,34,"If Charge > 2,000, then 34 percent",4263.6,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,9279.63,
ZIMMER 00-5880-003-00 TIBIAL COMP SZ 3,C1776,HCPCS,,79004940,CDM,278,RC,,,both,,,13023,9637.05,,,9637.05,Other,150% of Medicare + 9.63% HCRA Surcharge,5860.35,45,,5860.35,percent of total billed charges,Critical Access Hospital RCC factor,4427.82,34,,4427.82,percent of total billed charges,Implant Device,4427.82,34,,4427.82,percent of total billed charges,Implant Device,4427.82,34,,4427.82,percent of total billed charges,Implant Device,4427.82,34,,4427.82,percent of total billed charges,Implant Device,4427.82,34,,4427.82,percent of total billed charges,Implant Device,6446.39,,,6446.39,Other,110% of Medicare,4558.05,35,,4558.05,percent of total billed charges,Implant Device,4427.82,34,"Charges > $500, x 34%",4427.82,percent of total billed charges,Implant Device,4558.05,35,,4558.05,percent of total billed charges,Implant Device,4558.05,35,,4558.05,percent of total billed charges,Implant Device,4558.05,35,,4558.05,percent of total billed charges,Implant Device,4558.05,35,,4558.05,percent of total billed charges,Implant Device,4558.05,35,,4558.05,percent of total billed charges,Implant Device,5209.2,40,,5209.2,percent of total billed charges,Implant Device,4558.05,70,,4558.05,percent of total billed charges,All Other,4427.82,34,,4427.82,percent of total billed charges,Implant Device,4427.82,34,,4427.82,percent of total billed charges,Implant Device,4558.05,35,,4558.05,percent of total billed charges,Implant Device,4558.05,35,,4558.05,percent of total billed charges,Implant Device,4558.05,35,,4558.05,percent of total billed charges,Implant Device,4558.05,35,,4558.05,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,4427.82,34,"If Charge > 2,000, then 34 percent",4427.82,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,9637.05,
BIOMET 01-7123 PLATE 4 HOLE,C1713,HCPCS,,79004941,CDM,278,RC,,,both,,,1119,828.06,,,828.06,Other,150% of Medicare + 9.63% HCRA Surcharge,503.55,45,,503.55,percent of total billed charges,Critical Access Hospital RCC factor,380.46,34,,380.46,percent of total billed charges,Implant Device,380.46,34,,380.46,percent of total billed charges,Implant Device,380.46,34,,380.46,percent of total billed charges,Implant Device,380.46,34,,380.46,percent of total billed charges,Implant Device,380.46,34,,380.46,percent of total billed charges,Implant Device,553.91,,,553.91,Other,110% of Medicare,391.65,35,,391.65,percent of total billed charges,Implant Device,380.46,34,"Charges > $500, x 34%",380.46,percent of total billed charges,Implant Device,391.65,35,,391.65,percent of total billed charges,Implant Device,391.65,35,,391.65,percent of total billed charges,Implant Device,391.65,35,,391.65,percent of total billed charges,Implant Device,391.65,35,,391.65,percent of total billed charges,Implant Device,391.65,35,,391.65,percent of total billed charges,Implant Device,447.6,40,,447.6,percent of total billed charges,Implant Device,391.65,70,,391.65,percent of total billed charges,All Other,380.46,34,,380.46,percent of total billed charges,Implant Device,380.46,34,,380.46,percent of total billed charges,Implant Device,391.65,35,,391.65,percent of total billed charges,Implant Device,391.65,35,,391.65,percent of total billed charges,Implant Device,391.65,35,,391.65,percent of total billed charges,Implant Device,391.65,35,,391.65,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,828.06,
BIOMET 01-7104 PLATE 5 HOLE X LARGE,C1713,HCPCS,,79004942,CDM,278,RC,,,both,,,742,549.08,,,549.08,Other,150% of Medicare + 9.63% HCRA Surcharge,333.9,45,,333.9,percent of total billed charges,Critical Access Hospital RCC factor,252.28,34,,252.28,percent of total billed charges,Implant Device,252.28,34,,252.28,percent of total billed charges,Implant Device,252.28,34,,252.28,percent of total billed charges,Implant Device,252.28,34,,252.28,percent of total billed charges,Implant Device,252.28,34,,252.28,percent of total billed charges,Implant Device,367.29,,,367.29,Other,110% of Medicare,259.7,35,,259.7,percent of total billed charges,Implant Device,252.28,34,"Charges > $500, x 34%",252.28,percent of total billed charges,Implant Device,259.7,35,,259.7,percent of total billed charges,Implant Device,259.7,35,,259.7,percent of total billed charges,Implant Device,259.7,35,,259.7,percent of total billed charges,Implant Device,259.7,35,,259.7,percent of total billed charges,Implant Device,259.7,35,,259.7,percent of total billed charges,Implant Device,296.8,40,,296.8,percent of total billed charges,Implant Device,259.7,70,,259.7,percent of total billed charges,All Other,252.28,34,,252.28,percent of total billed charges,Implant Device,252.28,34,,252.28,percent of total billed charges,Implant Device,259.7,35,,259.7,percent of total billed charges,Implant Device,259.7,35,,259.7,percent of total billed charges,Implant Device,259.7,35,,259.7,percent of total billed charges,Implant Device,259.7,35,,259.7,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,549.08,
BIOMET 43-1005 PLATE 4 HOLE,C1713,HCPCS,,79004943,CDM,278,RC,,,both,,,2316,1713.85,,,1713.85,Other,150% of Medicare + 9.63% HCRA Surcharge,1042.2,45,,1042.2,percent of total billed charges,Critical Access Hospital RCC factor,787.44,34,,787.44,percent of total billed charges,Implant Device,787.44,34,,787.44,percent of total billed charges,Implant Device,787.44,34,,787.44,percent of total billed charges,Implant Device,787.44,34,,787.44,percent of total billed charges,Implant Device,787.44,34,,787.44,percent of total billed charges,Implant Device,1146.42,,,1146.42,Other,110% of Medicare,810.6,35,,810.6,percent of total billed charges,Implant Device,787.44,34,"Charges > $500, x 34%",787.44,percent of total billed charges,Implant Device,810.6,35,,810.6,percent of total billed charges,Implant Device,810.6,35,,810.6,percent of total billed charges,Implant Device,810.6,35,,810.6,percent of total billed charges,Implant Device,810.6,35,,810.6,percent of total billed charges,Implant Device,810.6,35,,810.6,percent of total billed charges,Implant Device,926.4,40,,926.4,percent of total billed charges,Implant Device,810.6,70,,810.6,percent of total billed charges,All Other,787.44,34,,787.44,percent of total billed charges,Implant Device,787.44,34,,787.44,percent of total billed charges,Implant Device,810.6,35,,810.6,percent of total billed charges,Implant Device,810.6,35,,810.6,percent of total billed charges,Implant Device,810.6,35,,810.6,percent of total billed charges,Implant Device,810.6,35,,810.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,787.44,34,"If Charge > 2,000, then 34 percent",787.44,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1713.85,
BIOMET 43-1004 PLATE 4 HOLE LARGE,C1713,HCPCS,,79004944,CDM,278,RC,,,both,,,2316,1713.85,,,1713.85,Other,150% of Medicare + 9.63% HCRA Surcharge,1042.2,45,,1042.2,percent of total billed charges,Critical Access Hospital RCC factor,787.44,34,,787.44,percent of total billed charges,Implant Device,787.44,34,,787.44,percent of total billed charges,Implant Device,787.44,34,,787.44,percent of total billed charges,Implant Device,787.44,34,,787.44,percent of total billed charges,Implant Device,787.44,34,,787.44,percent of total billed charges,Implant Device,1146.42,,,1146.42,Other,110% of Medicare,810.6,35,,810.6,percent of total billed charges,Implant Device,787.44,34,"Charges > $500, x 34%",787.44,percent of total billed charges,Implant Device,810.6,35,,810.6,percent of total billed charges,Implant Device,810.6,35,,810.6,percent of total billed charges,Implant Device,810.6,35,,810.6,percent of total billed charges,Implant Device,810.6,35,,810.6,percent of total billed charges,Implant Device,810.6,35,,810.6,percent of total billed charges,Implant Device,926.4,40,,926.4,percent of total billed charges,Implant Device,810.6,70,,810.6,percent of total billed charges,All Other,787.44,34,,787.44,percent of total billed charges,Implant Device,787.44,34,,787.44,percent of total billed charges,Implant Device,810.6,35,,810.6,percent of total billed charges,Implant Device,810.6,35,,810.6,percent of total billed charges,Implant Device,810.6,35,,810.6,percent of total billed charges,Implant Device,810.6,35,,810.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,787.44,34,"If Charge > 2,000, then 34 percent",787.44,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1713.85,
BIOMET 41-2314 NON LOCK SCREW 2.3X14MM,C1713,HCPCS,,79004945,CDM,278,RC,,,both,,,354,261.96,,,261.96,Other,150% of Medicare + 9.63% HCRA Surcharge,159.3,45,,159.3,percent of total billed charges,Critical Access Hospital RCC factor,120.36,34,,120.36,percent of total billed charges,Implant Device,120.36,34,,120.36,percent of total billed charges,Implant Device,120.36,34,,120.36,percent of total billed charges,Implant Device,120.36,34,,120.36,percent of total billed charges,Implant Device,120.36,34,,120.36,percent of total billed charges,Implant Device,175.23,,,175.23,Other,110% of Medicare,123.9,35,,123.9,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,123.9,35,,123.9,percent of total billed charges,Implant Device,123.9,35,,123.9,percent of total billed charges,Implant Device,123.9,35,,123.9,percent of total billed charges,Implant Device,123.9,35,,123.9,percent of total billed charges,Implant Device,123.9,35,,123.9,percent of total billed charges,Implant Device,141.6,40,,141.6,percent of total billed charges,Implant Device,123.9,70,,123.9,percent of total billed charges,All Other,120.36,34,,120.36,percent of total billed charges,Implant Device,120.36,34,,120.36,percent of total billed charges,Implant Device,123.9,35,,123.9,percent of total billed charges,Implant Device,123.9,35,,123.9,percent of total billed charges,Implant Device,123.9,35,,123.9,percent of total billed charges,Implant Device,123.9,35,,123.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,261.96,
BIOMET 41-2310 NON LOCK SCREW 2.3X10MM,C1713,HCPCS,,79004946,CDM,278,RC,,,both,,,354,261.96,,,261.96,Other,150% of Medicare + 9.63% HCRA Surcharge,159.3,45,,159.3,percent of total billed charges,Critical Access Hospital RCC factor,120.36,34,,120.36,percent of total billed charges,Implant Device,120.36,34,,120.36,percent of total billed charges,Implant Device,120.36,34,,120.36,percent of total billed charges,Implant Device,120.36,34,,120.36,percent of total billed charges,Implant Device,120.36,34,,120.36,percent of total billed charges,Implant Device,175.23,,,175.23,Other,110% of Medicare,123.9,35,,123.9,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,123.9,35,,123.9,percent of total billed charges,Implant Device,123.9,35,,123.9,percent of total billed charges,Implant Device,123.9,35,,123.9,percent of total billed charges,Implant Device,123.9,35,,123.9,percent of total billed charges,Implant Device,123.9,35,,123.9,percent of total billed charges,Implant Device,141.6,40,,141.6,percent of total billed charges,Implant Device,123.9,70,,123.9,percent of total billed charges,All Other,120.36,34,,120.36,percent of total billed charges,Implant Device,120.36,34,,120.36,percent of total billed charges,Implant Device,123.9,35,,123.9,percent of total billed charges,Implant Device,123.9,35,,123.9,percent of total billed charges,Implant Device,123.9,35,,123.9,percent of total billed charges,Implant Device,123.9,35,,123.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,261.96,
BIOMET 41-2308 NON LOCK SCREW 2.3X8MM,C1713,HCPCS,,79004947,CDM,278,RC,,,both,,,354,261.96,,,261.96,Other,150% of Medicare + 9.63% HCRA Surcharge,159.3,45,,159.3,percent of total billed charges,Critical Access Hospital RCC factor,120.36,34,,120.36,percent of total billed charges,Implant Device,120.36,34,,120.36,percent of total billed charges,Implant Device,120.36,34,,120.36,percent of total billed charges,Implant Device,120.36,34,,120.36,percent of total billed charges,Implant Device,120.36,34,,120.36,percent of total billed charges,Implant Device,175.23,,,175.23,Other,110% of Medicare,123.9,35,,123.9,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,123.9,35,,123.9,percent of total billed charges,Implant Device,123.9,35,,123.9,percent of total billed charges,Implant Device,123.9,35,,123.9,percent of total billed charges,Implant Device,123.9,35,,123.9,percent of total billed charges,Implant Device,123.9,35,,123.9,percent of total billed charges,Implant Device,141.6,40,,141.6,percent of total billed charges,Implant Device,123.9,70,,123.9,percent of total billed charges,All Other,120.36,34,,120.36,percent of total billed charges,Implant Device,120.36,34,,120.36,percent of total billed charges,Implant Device,123.9,35,,123.9,percent of total billed charges,Implant Device,123.9,35,,123.9,percent of total billed charges,Implant Device,123.9,35,,123.9,percent of total billed charges,Implant Device,123.9,35,,123.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,261.96,
BIOMET 41-2306 NON LOCK SCREW 2.3X6MM,C1713,HCPCS,,79004948,CDM,278,RC,,,both,,,354,261.96,,,261.96,Other,150% of Medicare + 9.63% HCRA Surcharge,159.3,45,,159.3,percent of total billed charges,Critical Access Hospital RCC factor,120.36,34,,120.36,percent of total billed charges,Implant Device,120.36,34,,120.36,percent of total billed charges,Implant Device,120.36,34,,120.36,percent of total billed charges,Implant Device,120.36,34,,120.36,percent of total billed charges,Implant Device,120.36,34,,120.36,percent of total billed charges,Implant Device,175.23,,,175.23,Other,110% of Medicare,123.9,35,,123.9,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,123.9,35,,123.9,percent of total billed charges,Implant Device,123.9,35,,123.9,percent of total billed charges,Implant Device,123.9,35,,123.9,percent of total billed charges,Implant Device,123.9,35,,123.9,percent of total billed charges,Implant Device,123.9,35,,123.9,percent of total billed charges,Implant Device,141.6,40,,141.6,percent of total billed charges,Implant Device,123.9,70,,123.9,percent of total billed charges,All Other,120.36,34,,120.36,percent of total billed charges,Implant Device,120.36,34,,120.36,percent of total billed charges,Implant Device,123.9,35,,123.9,percent of total billed charges,Implant Device,123.9,35,,123.9,percent of total billed charges,Implant Device,123.9,35,,123.9,percent of total billed charges,Implant Device,123.9,35,,123.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,261.96,
BIOMET 41-2318 NON LOCK SCREW 2.3X18MM,C1713,HCPCS,,79004949,CDM,278,RC,,,both,,,354,261.96,,,261.96,Other,150% of Medicare + 9.63% HCRA Surcharge,159.3,45,,159.3,percent of total billed charges,Critical Access Hospital RCC factor,120.36,34,,120.36,percent of total billed charges,Implant Device,120.36,34,,120.36,percent of total billed charges,Implant Device,120.36,34,,120.36,percent of total billed charges,Implant Device,120.36,34,,120.36,percent of total billed charges,Implant Device,120.36,34,,120.36,percent of total billed charges,Implant Device,175.23,,,175.23,Other,110% of Medicare,123.9,35,,123.9,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,123.9,35,,123.9,percent of total billed charges,Implant Device,123.9,35,,123.9,percent of total billed charges,Implant Device,123.9,35,,123.9,percent of total billed charges,Implant Device,123.9,35,,123.9,percent of total billed charges,Implant Device,123.9,35,,123.9,percent of total billed charges,Implant Device,141.6,40,,141.6,percent of total billed charges,Implant Device,123.9,70,,123.9,percent of total billed charges,All Other,120.36,34,,120.36,percent of total billed charges,Implant Device,120.36,34,,120.36,percent of total billed charges,Implant Device,123.9,35,,123.9,percent of total billed charges,Implant Device,123.9,35,,123.9,percent of total billed charges,Implant Device,123.9,35,,123.9,percent of total billed charges,Implant Device,123.9,35,,123.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,261.96,
BIOMET 41-2714 NON LOCK SCREW 2.7X14MM,C1713,HCPCS,,79004950,CDM,278,RC,,,both,,,354,261.96,,,261.96,Other,150% of Medicare + 9.63% HCRA Surcharge,159.3,45,,159.3,percent of total billed charges,Critical Access Hospital RCC factor,120.36,34,,120.36,percent of total billed charges,Implant Device,120.36,34,,120.36,percent of total billed charges,Implant Device,120.36,34,,120.36,percent of total billed charges,Implant Device,120.36,34,,120.36,percent of total billed charges,Implant Device,120.36,34,,120.36,percent of total billed charges,Implant Device,175.23,,,175.23,Other,110% of Medicare,123.9,35,,123.9,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,123.9,35,,123.9,percent of total billed charges,Implant Device,123.9,35,,123.9,percent of total billed charges,Implant Device,123.9,35,,123.9,percent of total billed charges,Implant Device,123.9,35,,123.9,percent of total billed charges,Implant Device,123.9,35,,123.9,percent of total billed charges,Implant Device,141.6,40,,141.6,percent of total billed charges,Implant Device,123.9,70,,123.9,percent of total billed charges,All Other,120.36,34,,120.36,percent of total billed charges,Implant Device,120.36,34,,120.36,percent of total billed charges,Implant Device,123.9,35,,123.9,percent of total billed charges,Implant Device,123.9,35,,123.9,percent of total billed charges,Implant Device,123.9,35,,123.9,percent of total billed charges,Implant Device,123.9,35,,123.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,261.96,
PAC 3 62004-07 CURVED ROD 7CM,C1713,HCPCS,,79004953,CDM,278,RC,,,both,,,600,444,,,444,Other,150% of Medicare + 9.63% HCRA Surcharge,270,45,,270,percent of total billed charges,Critical Access Hospital RCC factor,204,34,,204,percent of total billed charges,Implant Device,204,34,,204,percent of total billed charges,Implant Device,204,34,,204,percent of total billed charges,Implant Device,204,34,,204,percent of total billed charges,Implant Device,204,34,,204,percent of total billed charges,Implant Device,297,,,297,Other,110% of Medicare,210,35,,210,percent of total billed charges,Implant Device,204,34,"Charges > $500, x 34%",204,percent of total billed charges,Implant Device,210,35,,210,percent of total billed charges,Implant Device,210,35,,210,percent of total billed charges,Implant Device,210,35,,210,percent of total billed charges,Implant Device,210,35,,210,percent of total billed charges,Implant Device,210,35,,210,percent of total billed charges,Implant Device,240,40,,240,percent of total billed charges,Implant Device,210,70,,210,percent of total billed charges,All Other,204,34,,204,percent of total billed charges,Implant Device,204,34,,204,percent of total billed charges,Implant Device,210,35,,210,percent of total billed charges,Implant Device,210,35,,210,percent of total billed charges,Implant Device,210,35,,210,percent of total billed charges,Implant Device,210,35,,210,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,444,
PAC 3 62005 SET SCREW,C1713,HCPCS,,79004954,CDM,278,RC,,,both,,,540,399.6,,,399.6,Other,150% of Medicare + 9.63% HCRA Surcharge,243,45,,243,percent of total billed charges,Critical Access Hospital RCC factor,183.6,34,,183.6,percent of total billed charges,Implant Device,183.6,34,,183.6,percent of total billed charges,Implant Device,183.6,34,,183.6,percent of total billed charges,Implant Device,183.6,34,,183.6,percent of total billed charges,Implant Device,183.6,34,,183.6,percent of total billed charges,Implant Device,267.3,,,267.3,Other,110% of Medicare,189,35,,189,percent of total billed charges,Implant Device,183.6,34,"Charges > $500, x 34%",183.6,percent of total billed charges,Implant Device,189,35,,189,percent of total billed charges,Implant Device,189,35,,189,percent of total billed charges,Implant Device,189,35,,189,percent of total billed charges,Implant Device,189,35,,189,percent of total billed charges,Implant Device,189,35,,189,percent of total billed charges,Implant Device,216,40,,216,percent of total billed charges,Implant Device,189,70,,189,percent of total billed charges,All Other,183.6,34,,183.6,percent of total billed charges,Implant Device,183.6,34,,183.6,percent of total billed charges,Implant Device,189,35,,189,percent of total billed charges,Implant Device,189,35,,189,percent of total billed charges,Implant Device,189,35,,189,percent of total billed charges,Implant Device,189,35,,189,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,399.6,
PAC 3 11-2075 LARGE X-CONNECTOR,C1713,HCPCS,,79004955,CDM,278,RC,,,both,,,3750,2775.01,,,2775.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1687.5,45,,1687.5,percent of total billed charges,Critical Access Hospital RCC factor,1275,34,,1275,percent of total billed charges,Implant Device,1275,34,,1275,percent of total billed charges,Implant Device,1275,34,,1275,percent of total billed charges,Implant Device,1275,34,,1275,percent of total billed charges,Implant Device,1275,34,,1275,percent of total billed charges,Implant Device,1856.25,,,1856.25,Other,110% of Medicare,1312.5,35,,1312.5,percent of total billed charges,Implant Device,1275,34,"Charges > $500, x 34%",1275,percent of total billed charges,Implant Device,1312.5,35,,1312.5,percent of total billed charges,Implant Device,1312.5,35,,1312.5,percent of total billed charges,Implant Device,1312.5,35,,1312.5,percent of total billed charges,Implant Device,1312.5,35,,1312.5,percent of total billed charges,Implant Device,1312.5,35,,1312.5,percent of total billed charges,Implant Device,1500,40,,1500,percent of total billed charges,Implant Device,1312.5,70,,1312.5,percent of total billed charges,All Other,1275,34,,1275,percent of total billed charges,Implant Device,1275,34,,1275,percent of total billed charges,Implant Device,1312.5,35,,1312.5,percent of total billed charges,Implant Device,1312.5,35,,1312.5,percent of total billed charges,Implant Device,1312.5,35,,1312.5,percent of total billed charges,Implant Device,1312.5,35,,1312.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1275,34,"If Charge > 2,000, then 34 percent",1275,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2775.01,
ARTHREX AR-8840P-50 CANN SCREW 4X50MM,C1713,HCPCS,,79004960,CDM,278,RC,,,both,,,150,111,,,111,Other,150% of Medicare + 9.63% HCRA Surcharge,67.5,45,,67.5,percent of total billed charges,Critical Access Hospital RCC factor,51,34,,51,percent of total billed charges,Implant Device,51,34,,51,percent of total billed charges,Implant Device,51,34,,51,percent of total billed charges,Implant Device,51,34,,51,percent of total billed charges,Implant Device,51,34,,51,percent of total billed charges,Implant Device,74.25,,,74.25,Other,110% of Medicare,52.5,35,,52.5,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,52.5,35,,52.5,percent of total billed charges,Implant Device,52.5,35,,52.5,percent of total billed charges,Implant Device,52.5,35,,52.5,percent of total billed charges,Implant Device,52.5,35,,52.5,percent of total billed charges,Implant Device,52.5,35,,52.5,percent of total billed charges,Implant Device,60,40,,60,percent of total billed charges,Implant Device,52.5,70,,52.5,percent of total billed charges,All Other,51,34,,51,percent of total billed charges,Implant Device,51,34,,51,percent of total billed charges,Implant Device,52.5,35,,52.5,percent of total billed charges,Implant Device,52.5,35,,52.5,percent of total billed charges,Implant Device,52.5,35,,52.5,percent of total billed charges,Implant Device,52.5,35,,52.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,111,
ARTHREX AR-8926SS KNOTLESS TIGHTROPE,C1713,HCPCS,,79004961,CDM,278,RC,,,both,,,2640,1953.61,,,1953.61,Other,150% of Medicare + 9.63% HCRA Surcharge,1188,45,,1188,percent of total billed charges,Critical Access Hospital RCC factor,897.6,34,,897.6,percent of total billed charges,Implant Device,897.6,34,,897.6,percent of total billed charges,Implant Device,897.6,34,,897.6,percent of total billed charges,Implant Device,897.6,34,,897.6,percent of total billed charges,Implant Device,897.6,34,,897.6,percent of total billed charges,Implant Device,1306.8,,,1306.8,Other,110% of Medicare,924,35,,924,percent of total billed charges,Implant Device,897.6,34,"Charges > $500, x 34%",897.6,percent of total billed charges,Implant Device,924,35,,924,percent of total billed charges,Implant Device,924,35,,924,percent of total billed charges,Implant Device,924,35,,924,percent of total billed charges,Implant Device,924,35,,924,percent of total billed charges,Implant Device,924,35,,924,percent of total billed charges,Implant Device,1056,40,,1056,percent of total billed charges,Implant Device,924,70,,924,percent of total billed charges,All Other,897.6,34,,897.6,percent of total billed charges,Implant Device,897.6,34,,897.6,percent of total billed charges,Implant Device,924,35,,924,percent of total billed charges,Implant Device,924,35,,924,percent of total billed charges,Implant Device,924,35,,924,percent of total billed charges,Implant Device,924,35,,924,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,897.6,34,"If Charge > 2,000, then 34 percent",897.6,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1953.61,
GORE RMT261416 EXCLUDER AAA ENDOPROS,C1874,HCPCS,,79004962,CDM,278,RC,,,both,,,30736,22744.72,,,22744.72,Other,150% of Medicare + 9.63% HCRA Surcharge,13831.2,45,,13831.2,percent of total billed charges,Critical Access Hospital RCC factor,10450.24,34,,10450.24,percent of total billed charges,Implant Device,10450.24,34,,10450.24,percent of total billed charges,Implant Device,10450.24,34,,10450.24,percent of total billed charges,Implant Device,10450.24,34,,10450.24,percent of total billed charges,Implant Device,10450.24,34,,10450.24,percent of total billed charges,Implant Device,15214.32,,,15214.32,Other,110% of Medicare,10757.6,35,,10757.6,percent of total billed charges,Implant Device,10450.24,34,"Charges > $500, x 34%",10450.24,percent of total billed charges,Implant Device,10757.6,35,,10757.6,percent of total billed charges,Implant Device,10757.6,35,,10757.6,percent of total billed charges,Implant Device,10757.6,35,,10757.6,percent of total billed charges,Implant Device,10757.6,35,,10757.6,percent of total billed charges,Implant Device,10757.6,35,,10757.6,percent of total billed charges,Implant Device,12294.4,40,,12294.4,percent of total billed charges,Implant Device,10757.6,70,,10757.6,percent of total billed charges,All Other,10450.24,34,,10450.24,percent of total billed charges,Implant Device,10450.24,34,,10450.24,percent of total billed charges,Implant Device,10757.6,35,,10757.6,percent of total billed charges,Implant Device,10757.6,35,,10757.6,percent of total billed charges,Implant Device,10757.6,35,,10757.6,percent of total billed charges,Implant Device,10757.6,35,,10757.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,10450.24,34,"If Charge > 2,000, then 34 percent",10450.24,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,22744.72,
GORE PXL161007 EXCLUDER AAA ENDOPROS,C1874,HCPCS,,79004964,CDM,278,RC,,,both,,,9076,6716.26,,,6716.26,Other,150% of Medicare + 9.63% HCRA Surcharge,4084.2,45,,4084.2,percent of total billed charges,Critical Access Hospital RCC factor,3085.84,34,,3085.84,percent of total billed charges,Implant Device,3085.84,34,,3085.84,percent of total billed charges,Implant Device,3085.84,34,,3085.84,percent of total billed charges,Implant Device,3085.84,34,,3085.84,percent of total billed charges,Implant Device,3085.84,34,,3085.84,percent of total billed charges,Implant Device,4492.62,,,4492.62,Other,110% of Medicare,3176.6,35,,3176.6,percent of total billed charges,Implant Device,3085.84,34,"Charges > $500, x 34%",3085.84,percent of total billed charges,Implant Device,3176.6,35,,3176.6,percent of total billed charges,Implant Device,3176.6,35,,3176.6,percent of total billed charges,Implant Device,3176.6,35,,3176.6,percent of total billed charges,Implant Device,3176.6,35,,3176.6,percent of total billed charges,Implant Device,3176.6,35,,3176.6,percent of total billed charges,Implant Device,3630.4,40,,3630.4,percent of total billed charges,Implant Device,3176.6,70,,3176.6,percent of total billed charges,All Other,3085.84,34,,3085.84,percent of total billed charges,Implant Device,3085.84,34,,3085.84,percent of total billed charges,Implant Device,3176.6,35,,3176.6,percent of total billed charges,Implant Device,3176.6,35,,3176.6,percent of total billed charges,Implant Device,3176.6,35,,3176.6,percent of total billed charges,Implant Device,3176.6,35,,3176.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3085.84,34,"If Charge > 2,000, then 34 percent",3085.84,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,6716.26,
MENTOR 354-9314 BREAST IMPLANT,C1789,HCPCS,,79004965,CDM,278,RC,,,both,,,5085,3762.91,,,3762.91,Other,150% of Medicare + 9.63% HCRA Surcharge,2288.25,45,,2288.25,percent of total billed charges,Critical Access Hospital RCC factor,1728.9,34,,1728.9,percent of total billed charges,Implant Device,1728.9,34,,1728.9,percent of total billed charges,Implant Device,1728.9,34,,1728.9,percent of total billed charges,Implant Device,1728.9,34,,1728.9,percent of total billed charges,Implant Device,1728.9,34,,1728.9,percent of total billed charges,Implant Device,2517.08,,,2517.08,Other,110% of Medicare,1779.75,35,,1779.75,percent of total billed charges,Implant Device,1728.9,34,"Charges > $500, x 34%",1728.9,percent of total billed charges,Implant Device,1779.75,35,,1779.75,percent of total billed charges,Implant Device,1779.75,35,,1779.75,percent of total billed charges,Implant Device,1779.75,35,,1779.75,percent of total billed charges,Implant Device,1779.75,35,,1779.75,percent of total billed charges,Implant Device,1779.75,35,,1779.75,percent of total billed charges,Implant Device,2034,40,,2034,percent of total billed charges,Implant Device,1779.75,70,,1779.75,percent of total billed charges,All Other,1728.9,34,,1728.9,percent of total billed charges,Implant Device,1728.9,34,,1728.9,percent of total billed charges,Implant Device,1779.75,35,,1779.75,percent of total billed charges,Implant Device,1779.75,35,,1779.75,percent of total billed charges,Implant Device,1779.75,35,,1779.75,percent of total billed charges,Implant Device,1779.75,35,,1779.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1728.9,34,"If Charge > 2,000, then 34 percent",1728.9,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3762.91,
MENTOR 354-0315 BREAST IMPLANT,C1789,HCPCS,,79004966,CDM,278,RC,,,both,,,4936,3652.65,,,3652.65,Other,150% of Medicare + 9.63% HCRA Surcharge,2221.2,45,,2221.2,percent of total billed charges,Critical Access Hospital RCC factor,1678.24,34,,1678.24,percent of total billed charges,Implant Device,1678.24,34,,1678.24,percent of total billed charges,Implant Device,1678.24,34,,1678.24,percent of total billed charges,Implant Device,1678.24,34,,1678.24,percent of total billed charges,Implant Device,1678.24,34,,1678.24,percent of total billed charges,Implant Device,2443.32,,,2443.32,Other,110% of Medicare,1727.6,35,,1727.6,percent of total billed charges,Implant Device,1678.24,34,"Charges > $500, x 34%",1678.24,percent of total billed charges,Implant Device,1727.6,35,,1727.6,percent of total billed charges,Implant Device,1727.6,35,,1727.6,percent of total billed charges,Implant Device,1727.6,35,,1727.6,percent of total billed charges,Implant Device,1727.6,35,,1727.6,percent of total billed charges,Implant Device,1727.6,35,,1727.6,percent of total billed charges,Implant Device,1974.4,40,,1974.4,percent of total billed charges,Implant Device,1727.6,70,,1727.6,percent of total billed charges,All Other,1678.24,34,,1678.24,percent of total billed charges,Implant Device,1678.24,34,,1678.24,percent of total billed charges,Implant Device,1727.6,35,,1727.6,percent of total billed charges,Implant Device,1727.6,35,,1727.6,percent of total billed charges,Implant Device,1727.6,35,,1727.6,percent of total billed charges,Implant Device,1727.6,35,,1727.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1678.24,34,"If Charge > 2,000, then 34 percent",1678.24,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3652.65,
LIFE CELL 1520160 ALLODERM RTU 8X20CM,C1781,HCPCS,,79004967,CDM,278,RC,,,both,,,20244,14980.61,,,14980.61,Other,150% of Medicare + 9.63% HCRA Surcharge,9109.8,45,,9109.8,percent of total billed charges,Critical Access Hospital RCC factor,6882.96,34,,6882.96,percent of total billed charges,Implant Device,6882.96,34,,6882.96,percent of total billed charges,Implant Device,6882.96,34,,6882.96,percent of total billed charges,Implant Device,6882.96,34,,6882.96,percent of total billed charges,Implant Device,6882.96,34,,6882.96,percent of total billed charges,Implant Device,10020.78,,,10020.78,Other,110% of Medicare,7085.4,35,,7085.4,percent of total billed charges,Implant Device,6882.96,34,"Charges > $500, x 34%",6882.96,percent of total billed charges,Implant Device,7085.4,35,,7085.4,percent of total billed charges,Implant Device,7085.4,35,,7085.4,percent of total billed charges,Implant Device,7085.4,35,,7085.4,percent of total billed charges,Implant Device,7085.4,35,,7085.4,percent of total billed charges,Implant Device,7085.4,35,,7085.4,percent of total billed charges,Implant Device,8097.6,40,,8097.6,percent of total billed charges,Implant Device,7085.4,70,,7085.4,percent of total billed charges,All Other,6882.96,34,,6882.96,percent of total billed charges,Implant Device,6882.96,34,,6882.96,percent of total billed charges,Implant Device,7085.4,35,,7085.4,percent of total billed charges,Implant Device,7085.4,35,,7085.4,percent of total billed charges,Implant Device,7085.4,35,,7085.4,percent of total billed charges,Implant Device,7085.4,35,,7085.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,6882.96,34,"If Charge > 2,000, then 34 percent",6882.96,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,14980.61,
STRYKER 57-10140 PLATE 2.3MM,C1713,HCPCS,,79004974,CDM,278,RC,,,both,,,1107,819.18,,,819.18,Other,150% of Medicare + 9.63% HCRA Surcharge,498.15,45,,498.15,percent of total billed charges,Critical Access Hospital RCC factor,376.38,34,,376.38,percent of total billed charges,Implant Device,376.38,34,,376.38,percent of total billed charges,Implant Device,376.38,34,,376.38,percent of total billed charges,Implant Device,376.38,34,,376.38,percent of total billed charges,Implant Device,376.38,34,,376.38,percent of total billed charges,Implant Device,547.97,,,547.97,Other,110% of Medicare,387.45,35,,387.45,percent of total billed charges,Implant Device,376.38,34,"Charges > $500, x 34%",376.38,percent of total billed charges,Implant Device,387.45,35,,387.45,percent of total billed charges,Implant Device,387.45,35,,387.45,percent of total billed charges,Implant Device,387.45,35,,387.45,percent of total billed charges,Implant Device,387.45,35,,387.45,percent of total billed charges,Implant Device,387.45,35,,387.45,percent of total billed charges,Implant Device,442.8,40,,442.8,percent of total billed charges,Implant Device,387.45,70,,387.45,percent of total billed charges,All Other,376.38,34,,376.38,percent of total billed charges,Implant Device,376.38,34,,376.38,percent of total billed charges,Implant Device,387.45,35,,387.45,percent of total billed charges,Implant Device,387.45,35,,387.45,percent of total billed charges,Implant Device,387.45,35,,387.45,percent of total billed charges,Implant Device,387.45,35,,387.45,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,819.18,
STRYKER 57-05282 PLATE,C1713,HCPCS,,79004975,CDM,278,RC,,,both,,,1276,944.24,,,944.24,Other,150% of Medicare + 9.63% HCRA Surcharge,574.2,45,,574.2,percent of total billed charges,Critical Access Hospital RCC factor,433.84,34,,433.84,percent of total billed charges,Implant Device,433.84,34,,433.84,percent of total billed charges,Implant Device,433.84,34,,433.84,percent of total billed charges,Implant Device,433.84,34,,433.84,percent of total billed charges,Implant Device,433.84,34,,433.84,percent of total billed charges,Implant Device,631.62,,,631.62,Other,110% of Medicare,446.6,35,,446.6,percent of total billed charges,Implant Device,433.84,34,"Charges > $500, x 34%",433.84,percent of total billed charges,Implant Device,446.6,35,,446.6,percent of total billed charges,Implant Device,446.6,35,,446.6,percent of total billed charges,Implant Device,446.6,35,,446.6,percent of total billed charges,Implant Device,446.6,35,,446.6,percent of total billed charges,Implant Device,446.6,35,,446.6,percent of total billed charges,Implant Device,510.4,40,,510.4,percent of total billed charges,Implant Device,446.6,70,,446.6,percent of total billed charges,All Other,433.84,34,,433.84,percent of total billed charges,Implant Device,433.84,34,,433.84,percent of total billed charges,Implant Device,446.6,35,,446.6,percent of total billed charges,Implant Device,446.6,35,,446.6,percent of total billed charges,Implant Device,446.6,35,,446.6,percent of total billed charges,Implant Device,446.6,35,,446.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,944.24,
STRYKER 53-23010E LOCKING SCREW 2.3MM,C1713,HCPCS,,79004976,CDM,278,RC,,,both,,,515,381.1,,,381.1,Other,150% of Medicare + 9.63% HCRA Surcharge,231.75,45,,231.75,percent of total billed charges,Critical Access Hospital RCC factor,175.1,34,,175.1,percent of total billed charges,Implant Device,175.1,34,,175.1,percent of total billed charges,Implant Device,175.1,34,,175.1,percent of total billed charges,Implant Device,175.1,34,,175.1,percent of total billed charges,Implant Device,175.1,34,,175.1,percent of total billed charges,Implant Device,254.93,,,254.93,Other,110% of Medicare,180.25,35,,180.25,percent of total billed charges,Implant Device,175.1,34,"Charges > $500, x 34%",175.1,percent of total billed charges,Implant Device,180.25,35,,180.25,percent of total billed charges,Implant Device,180.25,35,,180.25,percent of total billed charges,Implant Device,180.25,35,,180.25,percent of total billed charges,Implant Device,180.25,35,,180.25,percent of total billed charges,Implant Device,180.25,35,,180.25,percent of total billed charges,Implant Device,206,40,,206,percent of total billed charges,Implant Device,180.25,70,,180.25,percent of total billed charges,All Other,175.1,34,,175.1,percent of total billed charges,Implant Device,175.1,34,,175.1,percent of total billed charges,Implant Device,180.25,35,,180.25,percent of total billed charges,Implant Device,180.25,35,,180.25,percent of total billed charges,Implant Device,180.25,35,,180.25,percent of total billed charges,Implant Device,180.25,35,,180.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,381.1,
GORE VBJ081502 8X15X120 VIABAHN ENDOPROS,C1874,HCPCS,,79004977,CDM,278,RC,,,both,,,11686,8647.67,,,8647.67,Other,150% of Medicare + 9.63% HCRA Surcharge,5258.7,45,,5258.7,percent of total billed charges,Critical Access Hospital RCC factor,3973.24,34,,3973.24,percent of total billed charges,Implant Device,3973.24,34,,3973.24,percent of total billed charges,Implant Device,3973.24,34,,3973.24,percent of total billed charges,Implant Device,3973.24,34,,3973.24,percent of total billed charges,Implant Device,3973.24,34,,3973.24,percent of total billed charges,Implant Device,5784.57,,,5784.57,Other,110% of Medicare,4090.1,35,,4090.1,percent of total billed charges,Implant Device,3973.24,34,"Charges > $500, x 34%",3973.24,percent of total billed charges,Implant Device,4090.1,35,,4090.1,percent of total billed charges,Implant Device,4090.1,35,,4090.1,percent of total billed charges,Implant Device,4090.1,35,,4090.1,percent of total billed charges,Implant Device,4090.1,35,,4090.1,percent of total billed charges,Implant Device,4090.1,35,,4090.1,percent of total billed charges,Implant Device,4674.4,40,,4674.4,percent of total billed charges,Implant Device,4090.1,70,,4090.1,percent of total billed charges,All Other,3973.24,34,,3973.24,percent of total billed charges,Implant Device,3973.24,34,,3973.24,percent of total billed charges,Implant Device,4090.1,35,,4090.1,percent of total billed charges,Implant Device,4090.1,35,,4090.1,percent of total billed charges,Implant Device,4090.1,35,,4090.1,percent of total billed charges,Implant Device,4090.1,35,,4090.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3973.24,34,"If Charge > 2,000, then 34 percent",3973.24,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,8647.67,
ATLAS 1106-01-6560 MODULAR SCREW 6.5X60,C1713,HCPCS,,79004982,CDM,278,RC,,,both,,,630,466.2,,,466.2,Other,150% of Medicare + 9.63% HCRA Surcharge,283.5,45,,283.5,percent of total billed charges,Critical Access Hospital RCC factor,214.2,34,,214.2,percent of total billed charges,Implant Device,214.2,34,,214.2,percent of total billed charges,Implant Device,214.2,34,,214.2,percent of total billed charges,Implant Device,214.2,34,,214.2,percent of total billed charges,Implant Device,214.2,34,,214.2,percent of total billed charges,Implant Device,311.85,,,311.85,Other,110% of Medicare,220.5,35,,220.5,percent of total billed charges,Implant Device,214.2,34,"Charges > $500, x 34%",214.2,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,252,40,,252,percent of total billed charges,Implant Device,220.5,70,,220.5,percent of total billed charges,All Other,214.2,34,,214.2,percent of total billed charges,Implant Device,214.2,34,,214.2,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,466.2,
ATLAS 1100-01-0070 STRAIGHT ROD 5.5X70MM,C1713,HCPCS,,79004983,CDM,278,RC,,,both,,,736,544.64,,,544.64,Other,150% of Medicare + 9.63% HCRA Surcharge,331.2,45,,331.2,percent of total billed charges,Critical Access Hospital RCC factor,250.24,34,,250.24,percent of total billed charges,Implant Device,250.24,34,,250.24,percent of total billed charges,Implant Device,250.24,34,,250.24,percent of total billed charges,Implant Device,250.24,34,,250.24,percent of total billed charges,Implant Device,250.24,34,,250.24,percent of total billed charges,Implant Device,364.32,,,364.32,Other,110% of Medicare,257.6,35,,257.6,percent of total billed charges,Implant Device,250.24,34,"Charges > $500, x 34%",250.24,percent of total billed charges,Implant Device,257.6,35,,257.6,percent of total billed charges,Implant Device,257.6,35,,257.6,percent of total billed charges,Implant Device,257.6,35,,257.6,percent of total billed charges,Implant Device,257.6,35,,257.6,percent of total billed charges,Implant Device,257.6,35,,257.6,percent of total billed charges,Implant Device,294.4,40,,294.4,percent of total billed charges,Implant Device,257.6,70,,257.6,percent of total billed charges,All Other,250.24,34,,250.24,percent of total billed charges,Implant Device,250.24,34,,250.24,percent of total billed charges,Implant Device,257.6,35,,257.6,percent of total billed charges,Implant Device,257.6,35,,257.6,percent of total billed charges,Implant Device,257.6,35,,257.6,percent of total billed charges,Implant Device,257.6,35,,257.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,544.64,
BIOMET 28234 TROCH NAIL LONG 11MM 34CM,C1713,HCPCS,,79004984,CDM,278,RC,,,both,,,11040,8169.63,,,8169.63,Other,150% of Medicare + 9.63% HCRA Surcharge,4968,45,,4968,percent of total billed charges,Critical Access Hospital RCC factor,3753.6,34,,3753.6,percent of total billed charges,Implant Device,3753.6,34,,3753.6,percent of total billed charges,Implant Device,3753.6,34,,3753.6,percent of total billed charges,Implant Device,3753.6,34,,3753.6,percent of total billed charges,Implant Device,3753.6,34,,3753.6,percent of total billed charges,Implant Device,5464.8,,,5464.8,Other,110% of Medicare,3864,35,,3864,percent of total billed charges,Implant Device,3753.6,34,"Charges > $500, x 34%",3753.6,percent of total billed charges,Implant Device,3864,35,,3864,percent of total billed charges,Implant Device,3864,35,,3864,percent of total billed charges,Implant Device,3864,35,,3864,percent of total billed charges,Implant Device,3864,35,,3864,percent of total billed charges,Implant Device,3864,35,,3864,percent of total billed charges,Implant Device,4416,40,,4416,percent of total billed charges,Implant Device,3864,70,,3864,percent of total billed charges,All Other,3753.6,34,,3753.6,percent of total billed charges,Implant Device,3753.6,34,,3753.6,percent of total billed charges,Implant Device,3864,35,,3864,percent of total billed charges,Implant Device,3864,35,,3864,percent of total billed charges,Implant Device,3864,35,,3864,percent of total billed charges,Implant Device,3864,35,,3864,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3753.6,34,"If Charge > 2,000, then 34 percent",3753.6,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,8169.63,
BIOMET 29278 LAG SCREW SOLID SLIDNG 95MM,C1713,HCPCS,,79004985,CDM,278,RC,,,both,,,2670,1975.81,,,1975.81,Other,150% of Medicare + 9.63% HCRA Surcharge,1201.5,45,,1201.5,percent of total billed charges,Critical Access Hospital RCC factor,907.8,34,,907.8,percent of total billed charges,Implant Device,907.8,34,,907.8,percent of total billed charges,Implant Device,907.8,34,,907.8,percent of total billed charges,Implant Device,907.8,34,,907.8,percent of total billed charges,Implant Device,907.8,34,,907.8,percent of total billed charges,Implant Device,1321.65,,,1321.65,Other,110% of Medicare,934.5,35,,934.5,percent of total billed charges,Implant Device,907.8,34,"Charges > $500, x 34%",907.8,percent of total billed charges,Implant Device,934.5,35,,934.5,percent of total billed charges,Implant Device,934.5,35,,934.5,percent of total billed charges,Implant Device,934.5,35,,934.5,percent of total billed charges,Implant Device,934.5,35,,934.5,percent of total billed charges,Implant Device,934.5,35,,934.5,percent of total billed charges,Implant Device,1068,40,,1068,percent of total billed charges,Implant Device,934.5,70,,934.5,percent of total billed charges,All Other,907.8,34,,907.8,percent of total billed charges,Implant Device,907.8,34,,907.8,percent of total billed charges,Implant Device,934.5,35,,934.5,percent of total billed charges,Implant Device,934.5,35,,934.5,percent of total billed charges,Implant Device,934.5,35,,934.5,percent of total billed charges,Implant Device,934.5,35,,934.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,907.8,34,"If Charge > 2,000, then 34 percent",907.8,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1975.81,
ZIMMER 00-8757-056-01 TRAB SHELL 56MM,C1776,HCPCS,,79004991,CDM,278,RC,,,both,,,4145,3067.31,,,3067.31,Other,150% of Medicare + 9.63% HCRA Surcharge,1865.25,45,,1865.25,percent of total billed charges,Critical Access Hospital RCC factor,1409.3,34,,1409.3,percent of total billed charges,Implant Device,1409.3,34,,1409.3,percent of total billed charges,Implant Device,1409.3,34,,1409.3,percent of total billed charges,Implant Device,1409.3,34,,1409.3,percent of total billed charges,Implant Device,1409.3,34,,1409.3,percent of total billed charges,Implant Device,2051.78,,,2051.78,Other,110% of Medicare,1450.75,35,,1450.75,percent of total billed charges,Implant Device,1409.3,34,"Charges > $500, x 34%",1409.3,percent of total billed charges,Implant Device,1450.75,35,,1450.75,percent of total billed charges,Implant Device,1450.75,35,,1450.75,percent of total billed charges,Implant Device,1450.75,35,,1450.75,percent of total billed charges,Implant Device,1450.75,35,,1450.75,percent of total billed charges,Implant Device,1450.75,35,,1450.75,percent of total billed charges,Implant Device,1658,40,,1658,percent of total billed charges,Implant Device,1450.75,70,,1450.75,percent of total billed charges,All Other,1409.3,34,,1409.3,percent of total billed charges,Implant Device,1409.3,34,,1409.3,percent of total billed charges,Implant Device,1450.75,35,,1450.75,percent of total billed charges,Implant Device,1450.75,35,,1450.75,percent of total billed charges,Implant Device,1450.75,35,,1450.75,percent of total billed charges,Implant Device,1450.75,35,,1450.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1409.3,34,"If Charge > 2,000, then 34 percent",1409.3,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3067.31,
ZIMMER 00-7711-010-20 FEM STEM SZ 10,C1776,HCPCS,,79004992,CDM,278,RC,,,both,,,6900,5106.02,,,5106.02,Other,150% of Medicare + 9.63% HCRA Surcharge,3105,45,,3105,percent of total billed charges,Critical Access Hospital RCC factor,2346,34,,2346,percent of total billed charges,Implant Device,2346,34,,2346,percent of total billed charges,Implant Device,2346,34,,2346,percent of total billed charges,Implant Device,2346,34,,2346,percent of total billed charges,Implant Device,2346,34,,2346,percent of total billed charges,Implant Device,3415.5,,,3415.5,Other,110% of Medicare,2415,35,,2415,percent of total billed charges,Implant Device,2346,34,"Charges > $500, x 34%",2346,percent of total billed charges,Implant Device,2415,35,,2415,percent of total billed charges,Implant Device,2415,35,,2415,percent of total billed charges,Implant Device,2415,35,,2415,percent of total billed charges,Implant Device,2415,35,,2415,percent of total billed charges,Implant Device,2415,35,,2415,percent of total billed charges,Implant Device,2760,40,,2760,percent of total billed charges,Implant Device,2415,70,,2415,percent of total billed charges,All Other,2346,34,,2346,percent of total billed charges,Implant Device,2346,34,,2346,percent of total billed charges,Implant Device,2415,35,,2415,percent of total billed charges,Implant Device,2415,35,,2415,percent of total billed charges,Implant Device,2415,35,,2415,percent of total billed charges,Implant Device,2415,35,,2415,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2346,34,"If Charge > 2,000, then 34 percent",2346,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5106.02,
ZIMMER 00-8775-036-02 FEMORAL HEAD,C1776,HCPCS,,79004993,CDM,278,RC,,,both,,,3834,2837.17,,,2837.17,Other,150% of Medicare + 9.63% HCRA Surcharge,1725.3,45,,1725.3,percent of total billed charges,Critical Access Hospital RCC factor,1303.56,34,,1303.56,percent of total billed charges,Implant Device,1303.56,34,,1303.56,percent of total billed charges,Implant Device,1303.56,34,,1303.56,percent of total billed charges,Implant Device,1303.56,34,,1303.56,percent of total billed charges,Implant Device,1303.56,34,,1303.56,percent of total billed charges,Implant Device,1897.83,,,1897.83,Other,110% of Medicare,1341.9,35,,1341.9,percent of total billed charges,Implant Device,1303.56,34,"Charges > $500, x 34%",1303.56,percent of total billed charges,Implant Device,1341.9,35,,1341.9,percent of total billed charges,Implant Device,1341.9,35,,1341.9,percent of total billed charges,Implant Device,1341.9,35,,1341.9,percent of total billed charges,Implant Device,1341.9,35,,1341.9,percent of total billed charges,Implant Device,1341.9,35,,1341.9,percent of total billed charges,Implant Device,1533.6,40,,1533.6,percent of total billed charges,Implant Device,1341.9,70,,1341.9,percent of total billed charges,All Other,1303.56,34,,1303.56,percent of total billed charges,Implant Device,1303.56,34,,1303.56,percent of total billed charges,Implant Device,1341.9,35,,1341.9,percent of total billed charges,Implant Device,1341.9,35,,1341.9,percent of total billed charges,Implant Device,1341.9,35,,1341.9,percent of total billed charges,Implant Device,1341.9,35,,1341.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1303.56,34,"If Charge > 2,000, then 34 percent",1303.56,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2837.17,
STRYKER 3704-0-050 BEAD CABLE SLEEVE 2MM,C1713,HCPCS,,79004994,CDM,278,RC,,,both,,,1536,1136.64,,,1136.64,Other,150% of Medicare + 9.63% HCRA Surcharge,691.2,45,,691.2,percent of total billed charges,Critical Access Hospital RCC factor,522.24,34,,522.24,percent of total billed charges,Implant Device,522.24,34,,522.24,percent of total billed charges,Implant Device,522.24,34,,522.24,percent of total billed charges,Implant Device,522.24,34,,522.24,percent of total billed charges,Implant Device,522.24,34,,522.24,percent of total billed charges,Implant Device,760.32,,,760.32,Other,110% of Medicare,537.6,35,,537.6,percent of total billed charges,Implant Device,522.24,34,"Charges > $500, x 34%",522.24,percent of total billed charges,Implant Device,537.6,35,,537.6,percent of total billed charges,Implant Device,537.6,35,,537.6,percent of total billed charges,Implant Device,537.6,35,,537.6,percent of total billed charges,Implant Device,537.6,35,,537.6,percent of total billed charges,Implant Device,537.6,35,,537.6,percent of total billed charges,Implant Device,614.4,40,,614.4,percent of total billed charges,Implant Device,537.6,70,,537.6,percent of total billed charges,All Other,522.24,34,,522.24,percent of total billed charges,Implant Device,522.24,34,,522.24,percent of total billed charges,Implant Device,537.6,35,,537.6,percent of total billed charges,Implant Device,537.6,35,,537.6,percent of total billed charges,Implant Device,537.6,35,,537.6,percent of total billed charges,Implant Device,537.6,35,,537.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1136.64,
ARTHREX AR-13200-075 WEDGE PLATE 7.5MM,C1713,HCPCS,,79004995,CDM,278,RC,,,both,,,2230,1650.21,,,1650.21,Other,150% of Medicare + 9.63% HCRA Surcharge,1003.5,45,,1003.5,percent of total billed charges,Critical Access Hospital RCC factor,758.2,34,,758.2,percent of total billed charges,Implant Device,758.2,34,,758.2,percent of total billed charges,Implant Device,758.2,34,,758.2,percent of total billed charges,Implant Device,758.2,34,,758.2,percent of total billed charges,Implant Device,758.2,34,,758.2,percent of total billed charges,Implant Device,1103.85,,,1103.85,Other,110% of Medicare,780.5,35,,780.5,percent of total billed charges,Implant Device,758.2,34,"Charges > $500, x 34%",758.2,percent of total billed charges,Implant Device,780.5,35,,780.5,percent of total billed charges,Implant Device,780.5,35,,780.5,percent of total billed charges,Implant Device,780.5,35,,780.5,percent of total billed charges,Implant Device,780.5,35,,780.5,percent of total billed charges,Implant Device,780.5,35,,780.5,percent of total billed charges,Implant Device,892,40,,892,percent of total billed charges,Implant Device,780.5,70,,780.5,percent of total billed charges,All Other,758.2,34,,758.2,percent of total billed charges,Implant Device,758.2,34,,758.2,percent of total billed charges,Implant Device,780.5,35,,780.5,percent of total billed charges,Implant Device,780.5,35,,780.5,percent of total billed charges,Implant Device,780.5,35,,780.5,percent of total billed charges,Implant Device,780.5,35,,780.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,758.2,34,"If Charge > 2,000, then 34 percent",758.2,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1650.21,
BIOMET 8161-35-016 LOCK SCREW 3.5X16MM,C1713,HCPCS,,79004998,CDM,278,RC,,,both,,,660,488.4,,,488.4,Other,150% of Medicare + 9.63% HCRA Surcharge,297,45,,297,percent of total billed charges,Critical Access Hospital RCC factor,224.4,34,,224.4,percent of total billed charges,Implant Device,224.4,34,,224.4,percent of total billed charges,Implant Device,224.4,34,,224.4,percent of total billed charges,Implant Device,224.4,34,,224.4,percent of total billed charges,Implant Device,224.4,34,,224.4,percent of total billed charges,Implant Device,326.7,,,326.7,Other,110% of Medicare,231,35,,231,percent of total billed charges,Implant Device,224.4,34,"Charges > $500, x 34%",224.4,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,264,40,,264,percent of total billed charges,Implant Device,231,70,,231,percent of total billed charges,All Other,224.4,34,,224.4,percent of total billed charges,Implant Device,224.4,34,,224.4,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,488.4,
BIOMET 1312-18-014 CORT SCREW 3.5X14MM,C1713,HCPCS,,79004999,CDM,278,RC,,,both,,,300,222,,,222,Other,150% of Medicare + 9.63% HCRA Surcharge,135,45,,135,percent of total billed charges,Critical Access Hospital RCC factor,102,34,,102,percent of total billed charges,Implant Device,102,34,,102,percent of total billed charges,Implant Device,102,34,,102,percent of total billed charges,Implant Device,102,34,,102,percent of total billed charges,Implant Device,102,34,,102,percent of total billed charges,Implant Device,148.5,,,148.5,Other,110% of Medicare,105,35,,105,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,105,35,,105,percent of total billed charges,Implant Device,105,35,,105,percent of total billed charges,Implant Device,105,35,,105,percent of total billed charges,Implant Device,105,35,,105,percent of total billed charges,Implant Device,105,35,,105,percent of total billed charges,Implant Device,120,40,,120,percent of total billed charges,Implant Device,105,70,,105,percent of total billed charges,All Other,102,34,,102,percent of total billed charges,Implant Device,102,34,,102,percent of total billed charges,Implant Device,105,35,,105,percent of total billed charges,Implant Device,105,35,,105,percent of total billed charges,Implant Device,105,35,,105,percent of total billed charges,Implant Device,105,35,,105,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,222,
BIOMET 1312-18-016 CORT SCREW 3.5X16MM,C1713,HCPCS,,79005000,CDM,278,RC,,,both,,,300,222,,,222,Other,150% of Medicare + 9.63% HCRA Surcharge,135,45,,135,percent of total billed charges,Critical Access Hospital RCC factor,102,34,,102,percent of total billed charges,Implant Device,102,34,,102,percent of total billed charges,Implant Device,102,34,,102,percent of total billed charges,Implant Device,102,34,,102,percent of total billed charges,Implant Device,102,34,,102,percent of total billed charges,Implant Device,148.5,,,148.5,Other,110% of Medicare,105,35,,105,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,105,35,,105,percent of total billed charges,Implant Device,105,35,,105,percent of total billed charges,Implant Device,105,35,,105,percent of total billed charges,Implant Device,105,35,,105,percent of total billed charges,Implant Device,105,35,,105,percent of total billed charges,Implant Device,120,40,,120,percent of total billed charges,Implant Device,105,70,,105,percent of total billed charges,All Other,102,34,,102,percent of total billed charges,Implant Device,102,34,,102,percent of total billed charges,Implant Device,105,35,,105,percent of total billed charges,Implant Device,105,35,,105,percent of total billed charges,Implant Device,105,35,,105,percent of total billed charges,Implant Device,105,35,,105,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,222,
BIOMET 8162-06-004 FIBULA LOCK LT 4 HOLE,C1713,HCPCS,,79005001,CDM,278,RC,,,both,,,3480,2575.21,,,2575.21,Other,150% of Medicare + 9.63% HCRA Surcharge,1566,45,,1566,percent of total billed charges,Critical Access Hospital RCC factor,1183.2,34,,1183.2,percent of total billed charges,Implant Device,1183.2,34,,1183.2,percent of total billed charges,Implant Device,1183.2,34,,1183.2,percent of total billed charges,Implant Device,1183.2,34,,1183.2,percent of total billed charges,Implant Device,1183.2,34,,1183.2,percent of total billed charges,Implant Device,1722.6,,,1722.6,Other,110% of Medicare,1218,35,,1218,percent of total billed charges,Implant Device,1183.2,34,"Charges > $500, x 34%",1183.2,percent of total billed charges,Implant Device,1218,35,,1218,percent of total billed charges,Implant Device,1218,35,,1218,percent of total billed charges,Implant Device,1218,35,,1218,percent of total billed charges,Implant Device,1218,35,,1218,percent of total billed charges,Implant Device,1218,35,,1218,percent of total billed charges,Implant Device,1392,40,,1392,percent of total billed charges,Implant Device,1218,70,,1218,percent of total billed charges,All Other,1183.2,34,,1183.2,percent of total billed charges,Implant Device,1183.2,34,,1183.2,percent of total billed charges,Implant Device,1218,35,,1218,percent of total billed charges,Implant Device,1218,35,,1218,percent of total billed charges,Implant Device,1218,35,,1218,percent of total billed charges,Implant Device,1218,35,,1218,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1183.2,34,"If Charge > 2,000, then 34 percent",1183.2,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2575.21,
ZIMMER 2347-23-36 PERIART SCREW 4.5X36MM,C1713,HCPCS,,79005004,CDM,278,RC,,,both,,,109,80.66,,,80.66,Other,150% of Medicare + 9.63% HCRA Surcharge,49.05,45,,49.05,percent of total billed charges,Critical Access Hospital RCC factor,37.06,34,,37.06,percent of total billed charges,Implant Device,37.06,34,,37.06,percent of total billed charges,Implant Device,37.06,34,,37.06,percent of total billed charges,Implant Device,37.06,34,,37.06,percent of total billed charges,Implant Device,37.06,34,,37.06,percent of total billed charges,Implant Device,53.96,,,53.96,Other,110% of Medicare,38.15,35,,38.15,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,38.15,35,,38.15,percent of total billed charges,Implant Device,38.15,35,,38.15,percent of total billed charges,Implant Device,38.15,35,,38.15,percent of total billed charges,Implant Device,38.15,35,,38.15,percent of total billed charges,Implant Device,38.15,35,,38.15,percent of total billed charges,Implant Device,43.6,40,,43.6,percent of total billed charges,Implant Device,38.15,70,,38.15,percent of total billed charges,All Other,37.06,34,,37.06,percent of total billed charges,Implant Device,37.06,34,,37.06,percent of total billed charges,Implant Device,38.15,35,,38.15,percent of total billed charges,Implant Device,38.15,35,,38.15,percent of total billed charges,Implant Device,38.15,35,,38.15,percent of total billed charges,Implant Device,38.15,35,,38.15,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,80.66,
ZIMMER 2347-23-40 PERIART SCREW 4.5X40MM,C1713,HCPCS,,79005005,CDM,278,RC,,,both,,,109,80.66,,,80.66,Other,150% of Medicare + 9.63% HCRA Surcharge,49.05,45,,49.05,percent of total billed charges,Critical Access Hospital RCC factor,37.06,34,,37.06,percent of total billed charges,Implant Device,37.06,34,,37.06,percent of total billed charges,Implant Device,37.06,34,,37.06,percent of total billed charges,Implant Device,37.06,34,,37.06,percent of total billed charges,Implant Device,37.06,34,,37.06,percent of total billed charges,Implant Device,53.96,,,53.96,Other,110% of Medicare,38.15,35,,38.15,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,38.15,35,,38.15,percent of total billed charges,Implant Device,38.15,35,,38.15,percent of total billed charges,Implant Device,38.15,35,,38.15,percent of total billed charges,Implant Device,38.15,35,,38.15,percent of total billed charges,Implant Device,38.15,35,,38.15,percent of total billed charges,Implant Device,43.6,40,,43.6,percent of total billed charges,Implant Device,38.15,70,,38.15,percent of total billed charges,All Other,37.06,34,,37.06,percent of total billed charges,Implant Device,37.06,34,,37.06,percent of total billed charges,Implant Device,38.15,35,,38.15,percent of total billed charges,Implant Device,38.15,35,,38.15,percent of total billed charges,Implant Device,38.15,35,,38.15,percent of total billed charges,Implant Device,38.15,35,,38.15,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,80.66,
ZIMMER 2347-23-42 PERIART SCREW 4.5X42MM,C1713,HCPCS,,79005006,CDM,278,RC,,,both,,,109,80.66,,,80.66,Other,150% of Medicare + 9.63% HCRA Surcharge,49.05,45,,49.05,percent of total billed charges,Critical Access Hospital RCC factor,37.06,34,,37.06,percent of total billed charges,Implant Device,37.06,34,,37.06,percent of total billed charges,Implant Device,37.06,34,,37.06,percent of total billed charges,Implant Device,37.06,34,,37.06,percent of total billed charges,Implant Device,37.06,34,,37.06,percent of total billed charges,Implant Device,53.96,,,53.96,Other,110% of Medicare,38.15,35,,38.15,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,38.15,35,,38.15,percent of total billed charges,Implant Device,38.15,35,,38.15,percent of total billed charges,Implant Device,38.15,35,,38.15,percent of total billed charges,Implant Device,38.15,35,,38.15,percent of total billed charges,Implant Device,38.15,35,,38.15,percent of total billed charges,Implant Device,43.6,40,,43.6,percent of total billed charges,Implant Device,38.15,70,,38.15,percent of total billed charges,All Other,37.06,34,,37.06,percent of total billed charges,Implant Device,37.06,34,,37.06,percent of total billed charges,Implant Device,38.15,35,,38.15,percent of total billed charges,Implant Device,38.15,35,,38.15,percent of total billed charges,Implant Device,38.15,35,,38.15,percent of total billed charges,Implant Device,38.15,35,,38.15,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,80.66,
ZIMMER 2347-23-44 PERIART SCREW 4.5X44MM,C1713,HCPCS,,79005007,CDM,278,RC,,,both,,,109,80.66,,,80.66,Other,150% of Medicare + 9.63% HCRA Surcharge,49.05,45,,49.05,percent of total billed charges,Critical Access Hospital RCC factor,37.06,34,,37.06,percent of total billed charges,Implant Device,37.06,34,,37.06,percent of total billed charges,Implant Device,37.06,34,,37.06,percent of total billed charges,Implant Device,37.06,34,,37.06,percent of total billed charges,Implant Device,37.06,34,,37.06,percent of total billed charges,Implant Device,53.96,,,53.96,Other,110% of Medicare,38.15,35,,38.15,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,38.15,35,,38.15,percent of total billed charges,Implant Device,38.15,35,,38.15,percent of total billed charges,Implant Device,38.15,35,,38.15,percent of total billed charges,Implant Device,38.15,35,,38.15,percent of total billed charges,Implant Device,38.15,35,,38.15,percent of total billed charges,Implant Device,43.6,40,,43.6,percent of total billed charges,Implant Device,38.15,70,,38.15,percent of total billed charges,All Other,37.06,34,,37.06,percent of total billed charges,Implant Device,37.06,34,,37.06,percent of total billed charges,Implant Device,38.15,35,,38.15,percent of total billed charges,Implant Device,38.15,35,,38.15,percent of total billed charges,Implant Device,38.15,35,,38.15,percent of total billed charges,Implant Device,38.15,35,,38.15,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,80.66,
ZIMMER 2347-23-50 PERIART SCREW 4.5X50MM,C1713,HCPCS,,79005008,CDM,278,RC,,,both,,,91,67.34,,,67.34,Other,150% of Medicare + 9.63% HCRA Surcharge,40.95,45,,40.95,percent of total billed charges,Critical Access Hospital RCC factor,30.94,34,,30.94,percent of total billed charges,Implant Device,30.94,34,,30.94,percent of total billed charges,Implant Device,30.94,34,,30.94,percent of total billed charges,Implant Device,30.94,34,,30.94,percent of total billed charges,Implant Device,30.94,34,,30.94,percent of total billed charges,Implant Device,45.05,,,45.05,Other,110% of Medicare,31.85,35,,31.85,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,31.85,35,,31.85,percent of total billed charges,Implant Device,31.85,35,,31.85,percent of total billed charges,Implant Device,31.85,35,,31.85,percent of total billed charges,Implant Device,31.85,35,,31.85,percent of total billed charges,Implant Device,31.85,35,,31.85,percent of total billed charges,Implant Device,36.4,40,,36.4,percent of total billed charges,Implant Device,31.85,70,,31.85,percent of total billed charges,All Other,30.94,34,,30.94,percent of total billed charges,Implant Device,30.94,34,,30.94,percent of total billed charges,Implant Device,31.85,35,,31.85,percent of total billed charges,Implant Device,31.85,35,,31.85,percent of total billed charges,Implant Device,31.85,35,,31.85,percent of total billed charges,Implant Device,31.85,35,,31.85,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,67.34,
ZIMMER 2347-26-40 PERIART SCREW 6.5X40MM,C1713,HCPCS,,79005009,CDM,278,RC,,,both,,,101,74.74,,,74.74,Other,150% of Medicare + 9.63% HCRA Surcharge,45.45,45,,45.45,percent of total billed charges,Critical Access Hospital RCC factor,34.34,34,,34.34,percent of total billed charges,Implant Device,34.34,34,,34.34,percent of total billed charges,Implant Device,34.34,34,,34.34,percent of total billed charges,Implant Device,34.34,34,,34.34,percent of total billed charges,Implant Device,34.34,34,,34.34,percent of total billed charges,Implant Device,50,,,50,Other,110% of Medicare,35.35,35,,35.35,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,35.35,35,,35.35,percent of total billed charges,Implant Device,35.35,35,,35.35,percent of total billed charges,Implant Device,35.35,35,,35.35,percent of total billed charges,Implant Device,35.35,35,,35.35,percent of total billed charges,Implant Device,35.35,35,,35.35,percent of total billed charges,Implant Device,40.4,40,,40.4,percent of total billed charges,Implant Device,35.35,70,,35.35,percent of total billed charges,All Other,34.34,34,,34.34,percent of total billed charges,Implant Device,34.34,34,,34.34,percent of total billed charges,Implant Device,35.35,35,,35.35,percent of total billed charges,Implant Device,35.35,35,,35.35,percent of total billed charges,Implant Device,35.35,35,,35.35,percent of total billed charges,Implant Device,35.35,35,,35.35,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,74.74,
ZIMMER 2347-26-45 PERIART SCREW 6.5X45MM,C1713,HCPCS,,79005010,CDM,278,RC,,,both,,,101,74.74,,,74.74,Other,150% of Medicare + 9.63% HCRA Surcharge,45.45,45,,45.45,percent of total billed charges,Critical Access Hospital RCC factor,34.34,34,,34.34,percent of total billed charges,Implant Device,34.34,34,,34.34,percent of total billed charges,Implant Device,34.34,34,,34.34,percent of total billed charges,Implant Device,34.34,34,,34.34,percent of total billed charges,Implant Device,34.34,34,,34.34,percent of total billed charges,Implant Device,50,,,50,Other,110% of Medicare,35.35,35,,35.35,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,35.35,35,,35.35,percent of total billed charges,Implant Device,35.35,35,,35.35,percent of total billed charges,Implant Device,35.35,35,,35.35,percent of total billed charges,Implant Device,35.35,35,,35.35,percent of total billed charges,Implant Device,35.35,35,,35.35,percent of total billed charges,Implant Device,40.4,40,,40.4,percent of total billed charges,Implant Device,35.35,70,,35.35,percent of total billed charges,All Other,34.34,34,,34.34,percent of total billed charges,Implant Device,34.34,34,,34.34,percent of total billed charges,Implant Device,35.35,35,,35.35,percent of total billed charges,Implant Device,35.35,35,,35.35,percent of total billed charges,Implant Device,35.35,35,,35.35,percent of total billed charges,Implant Device,35.35,35,,35.35,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,74.74,
ZIMMER 2347-26-50 PERIART SCREW 6.5X50MM,C1713,HCPCS,,79005011,CDM,278,RC,,,both,,,101,74.74,,,74.74,Other,150% of Medicare + 9.63% HCRA Surcharge,45.45,45,,45.45,percent of total billed charges,Critical Access Hospital RCC factor,34.34,34,,34.34,percent of total billed charges,Implant Device,34.34,34,,34.34,percent of total billed charges,Implant Device,34.34,34,,34.34,percent of total billed charges,Implant Device,34.34,34,,34.34,percent of total billed charges,Implant Device,34.34,34,,34.34,percent of total billed charges,Implant Device,50,,,50,Other,110% of Medicare,35.35,35,,35.35,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,35.35,35,,35.35,percent of total billed charges,Implant Device,35.35,35,,35.35,percent of total billed charges,Implant Device,35.35,35,,35.35,percent of total billed charges,Implant Device,35.35,35,,35.35,percent of total billed charges,Implant Device,35.35,35,,35.35,percent of total billed charges,Implant Device,40.4,40,,40.4,percent of total billed charges,Implant Device,35.35,70,,35.35,percent of total billed charges,All Other,34.34,34,,34.34,percent of total billed charges,Implant Device,34.34,34,,34.34,percent of total billed charges,Implant Device,35.35,35,,35.35,percent of total billed charges,Implant Device,35.35,35,,35.35,percent of total billed charges,Implant Device,35.35,35,,35.35,percent of total billed charges,Implant Device,35.35,35,,35.35,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,74.74,
BIOMET 8162-35-707 TIB LOCK PLATE 7 HOLE,C1713,HCPCS,,79005012,CDM,278,RC,,,both,,,6300,4662.02,,,4662.02,Other,150% of Medicare + 9.63% HCRA Surcharge,2835,45,,2835,percent of total billed charges,Critical Access Hospital RCC factor,2142,34,,2142,percent of total billed charges,Implant Device,2142,34,,2142,percent of total billed charges,Implant Device,2142,34,,2142,percent of total billed charges,Implant Device,2142,34,,2142,percent of total billed charges,Implant Device,2142,34,,2142,percent of total billed charges,Implant Device,3118.5,,,3118.5,Other,110% of Medicare,2205,35,,2205,percent of total billed charges,Implant Device,2142,34,"Charges > $500, x 34%",2142,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2520,40,,2520,percent of total billed charges,Implant Device,2205,70,,2205,percent of total billed charges,All Other,2142,34,,2142,percent of total billed charges,Implant Device,2142,34,,2142,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2142,34,"If Charge > 2,000, then 34 percent",2142,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4662.02,
BIOMET 1312-18-040 CORT SCREW 3.5X40MM,C1713,HCPCS,,79005013,CDM,278,RC,,,both,,,216,159.84,,,159.84,Other,150% of Medicare + 9.63% HCRA Surcharge,97.2,45,,97.2,percent of total billed charges,Critical Access Hospital RCC factor,73.44,34,,73.44,percent of total billed charges,Implant Device,73.44,34,,73.44,percent of total billed charges,Implant Device,73.44,34,,73.44,percent of total billed charges,Implant Device,73.44,34,,73.44,percent of total billed charges,Implant Device,73.44,34,,73.44,percent of total billed charges,Implant Device,106.92,,,106.92,Other,110% of Medicare,75.6,35,,75.6,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,75.6,35,,75.6,percent of total billed charges,Implant Device,75.6,35,,75.6,percent of total billed charges,Implant Device,75.6,35,,75.6,percent of total billed charges,Implant Device,75.6,35,,75.6,percent of total billed charges,Implant Device,75.6,35,,75.6,percent of total billed charges,Implant Device,86.4,40,,86.4,percent of total billed charges,Implant Device,75.6,70,,75.6,percent of total billed charges,All Other,73.44,34,,73.44,percent of total billed charges,Implant Device,73.44,34,,73.44,percent of total billed charges,Implant Device,75.6,35,,75.6,percent of total billed charges,Implant Device,75.6,35,,75.6,percent of total billed charges,Implant Device,75.6,35,,75.6,percent of total billed charges,Implant Device,75.6,35,,75.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,159.84,
BIOMET 1312-18-044 CORT SCREW 3.5X44MM,C1713,HCPCS,,79005014,CDM,278,RC,,,both,,,300,222,,,222,Other,150% of Medicare + 9.63% HCRA Surcharge,135,45,,135,percent of total billed charges,Critical Access Hospital RCC factor,102,34,,102,percent of total billed charges,Implant Device,102,34,,102,percent of total billed charges,Implant Device,102,34,,102,percent of total billed charges,Implant Device,102,34,,102,percent of total billed charges,Implant Device,102,34,,102,percent of total billed charges,Implant Device,148.5,,,148.5,Other,110% of Medicare,105,35,,105,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,105,35,,105,percent of total billed charges,Implant Device,105,35,,105,percent of total billed charges,Implant Device,105,35,,105,percent of total billed charges,Implant Device,105,35,,105,percent of total billed charges,Implant Device,105,35,,105,percent of total billed charges,Implant Device,120,40,,120,percent of total billed charges,Implant Device,105,70,,105,percent of total billed charges,All Other,102,34,,102,percent of total billed charges,Implant Device,102,34,,102,percent of total billed charges,Implant Device,105,35,,105,percent of total billed charges,Implant Device,105,35,,105,percent of total billed charges,Implant Device,105,35,,105,percent of total billed charges,Implant Device,105,35,,105,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,222,
BIOMET 8163-35-070 LOCK SCREW 3.5X70MM,C1713,HCPCS,,79005015,CDM,278,RC,,,both,,,930,688.2,,,688.2,Other,150% of Medicare + 9.63% HCRA Surcharge,418.5,45,,418.5,percent of total billed charges,Critical Access Hospital RCC factor,316.2,34,,316.2,percent of total billed charges,Implant Device,316.2,34,,316.2,percent of total billed charges,Implant Device,316.2,34,,316.2,percent of total billed charges,Implant Device,316.2,34,,316.2,percent of total billed charges,Implant Device,316.2,34,,316.2,percent of total billed charges,Implant Device,460.35,,,460.35,Other,110% of Medicare,325.5,35,,325.5,percent of total billed charges,Implant Device,316.2,34,"Charges > $500, x 34%",316.2,percent of total billed charges,Implant Device,325.5,35,,325.5,percent of total billed charges,Implant Device,325.5,35,,325.5,percent of total billed charges,Implant Device,325.5,35,,325.5,percent of total billed charges,Implant Device,325.5,35,,325.5,percent of total billed charges,Implant Device,325.5,35,,325.5,percent of total billed charges,Implant Device,372,40,,372,percent of total billed charges,Implant Device,325.5,70,,325.5,percent of total billed charges,All Other,316.2,34,,316.2,percent of total billed charges,Implant Device,316.2,34,,316.2,percent of total billed charges,Implant Device,325.5,35,,325.5,percent of total billed charges,Implant Device,325.5,35,,325.5,percent of total billed charges,Implant Device,325.5,35,,325.5,percent of total billed charges,Implant Device,325.5,35,,325.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,688.2,
BIOMET 8161-35-050 CORT SCREW 3.5X50MM,C1713,HCPCS,,79005016,CDM,278,RC,,,both,,,660,488.4,,,488.4,Other,150% of Medicare + 9.63% HCRA Surcharge,297,45,,297,percent of total billed charges,Critical Access Hospital RCC factor,224.4,34,,224.4,percent of total billed charges,Implant Device,224.4,34,,224.4,percent of total billed charges,Implant Device,224.4,34,,224.4,percent of total billed charges,Implant Device,224.4,34,,224.4,percent of total billed charges,Implant Device,224.4,34,,224.4,percent of total billed charges,Implant Device,326.7,,,326.7,Other,110% of Medicare,231,35,,231,percent of total billed charges,Implant Device,224.4,34,"Charges > $500, x 34%",224.4,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,264,40,,264,percent of total billed charges,Implant Device,231,70,,231,percent of total billed charges,All Other,224.4,34,,224.4,percent of total billed charges,Implant Device,224.4,34,,224.4,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,488.4,
BIOMET 8161-35-075 CORT SCREW 3.5X75MM,C1713,HCPCS,,79005017,CDM,278,RC,,,both,,,660,488.4,,,488.4,Other,150% of Medicare + 9.63% HCRA Surcharge,297,45,,297,percent of total billed charges,Critical Access Hospital RCC factor,224.4,34,,224.4,percent of total billed charges,Implant Device,224.4,34,,224.4,percent of total billed charges,Implant Device,224.4,34,,224.4,percent of total billed charges,Implant Device,224.4,34,,224.4,percent of total billed charges,Implant Device,224.4,34,,224.4,percent of total billed charges,Implant Device,326.7,,,326.7,Other,110% of Medicare,231,35,,231,percent of total billed charges,Implant Device,224.4,34,"Charges > $500, x 34%",224.4,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,264,40,,264,percent of total billed charges,Implant Device,231,70,,231,percent of total billed charges,All Other,224.4,34,,224.4,percent of total billed charges,Implant Device,224.4,34,,224.4,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,488.4,
BIOMET 8161-35-080 CORT SCREW 3.5X80MM,C1713,HCPCS,,79005018,CDM,278,RC,,,both,,,660,488.4,,,488.4,Other,150% of Medicare + 9.63% HCRA Surcharge,297,45,,297,percent of total billed charges,Critical Access Hospital RCC factor,224.4,34,,224.4,percent of total billed charges,Implant Device,224.4,34,,224.4,percent of total billed charges,Implant Device,224.4,34,,224.4,percent of total billed charges,Implant Device,224.4,34,,224.4,percent of total billed charges,Implant Device,224.4,34,,224.4,percent of total billed charges,Implant Device,326.7,,,326.7,Other,110% of Medicare,231,35,,231,percent of total billed charges,Implant Device,224.4,34,"Charges > $500, x 34%",224.4,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,264,40,,264,percent of total billed charges,Implant Device,231,70,,231,percent of total billed charges,All Other,224.4,34,,224.4,percent of total billed charges,Implant Device,224.4,34,,224.4,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,488.4,
BIOMET 8161-35-085 CORT SCREW 3.5X85MM,C1713,HCPCS,,79005019,CDM,278,RC,,,both,,,660,488.4,,,488.4,Other,150% of Medicare + 9.63% HCRA Surcharge,297,45,,297,percent of total billed charges,Critical Access Hospital RCC factor,224.4,34,,224.4,percent of total billed charges,Implant Device,224.4,34,,224.4,percent of total billed charges,Implant Device,224.4,34,,224.4,percent of total billed charges,Implant Device,224.4,34,,224.4,percent of total billed charges,Implant Device,224.4,34,,224.4,percent of total billed charges,Implant Device,326.7,,,326.7,Other,110% of Medicare,231,35,,231,percent of total billed charges,Implant Device,224.4,34,"Charges > $500, x 34%",224.4,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,264,40,,264,percent of total billed charges,Implant Device,231,70,,231,percent of total billed charges,All Other,224.4,34,,224.4,percent of total billed charges,Implant Device,224.4,34,,224.4,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,488.4,
ARTHREX AR-8730-28PT CANN SCREW 3X28MM,C1713,HCPCS,,79005020,CDM,278,RC,,,both,,,390,288.6,,,288.6,Other,150% of Medicare + 9.63% HCRA Surcharge,175.5,45,,175.5,percent of total billed charges,Critical Access Hospital RCC factor,132.6,34,,132.6,percent of total billed charges,Implant Device,132.6,34,,132.6,percent of total billed charges,Implant Device,132.6,34,,132.6,percent of total billed charges,Implant Device,132.6,34,,132.6,percent of total billed charges,Implant Device,132.6,34,,132.6,percent of total billed charges,Implant Device,193.05,,,193.05,Other,110% of Medicare,136.5,35,,136.5,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,136.5,35,,136.5,percent of total billed charges,Implant Device,136.5,35,,136.5,percent of total billed charges,Implant Device,136.5,35,,136.5,percent of total billed charges,Implant Device,136.5,35,,136.5,percent of total billed charges,Implant Device,136.5,35,,136.5,percent of total billed charges,Implant Device,156,40,,156,percent of total billed charges,Implant Device,136.5,70,,136.5,percent of total billed charges,All Other,132.6,34,,132.6,percent of total billed charges,Implant Device,132.6,34,,132.6,percent of total billed charges,Implant Device,136.5,35,,136.5,percent of total billed charges,Implant Device,136.5,35,,136.5,percent of total billed charges,Implant Device,136.5,35,,136.5,percent of total billed charges,Implant Device,136.5,35,,136.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,288.6,
ARTHREX AR-8967-1880 CANN SCREW 6.7X80MM,C1713,HCPCS,,79005024,CDM,278,RC,,,both,,,1074,794.76,,,794.76,Other,150% of Medicare + 9.63% HCRA Surcharge,483.3,45,,483.3,percent of total billed charges,Critical Access Hospital RCC factor,365.16,34,,365.16,percent of total billed charges,Implant Device,365.16,34,,365.16,percent of total billed charges,Implant Device,365.16,34,,365.16,percent of total billed charges,Implant Device,365.16,34,,365.16,percent of total billed charges,Implant Device,365.16,34,,365.16,percent of total billed charges,Implant Device,531.63,,,531.63,Other,110% of Medicare,375.9,35,,375.9,percent of total billed charges,Implant Device,365.16,34,"Charges > $500, x 34%",365.16,percent of total billed charges,Implant Device,375.9,35,,375.9,percent of total billed charges,Implant Device,375.9,35,,375.9,percent of total billed charges,Implant Device,375.9,35,,375.9,percent of total billed charges,Implant Device,375.9,35,,375.9,percent of total billed charges,Implant Device,375.9,35,,375.9,percent of total billed charges,Implant Device,429.6,40,,429.6,percent of total billed charges,Implant Device,375.9,70,,375.9,percent of total billed charges,All Other,365.16,34,,365.16,percent of total billed charges,Implant Device,365.16,34,,365.16,percent of total billed charges,Implant Device,375.9,35,,375.9,percent of total billed charges,Implant Device,375.9,35,,375.9,percent of total billed charges,Implant Device,375.9,35,,375.9,percent of total billed charges,Implant Device,375.9,35,,375.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,794.76,
ARTHREX AR-8967-1885 CANN SCREW 6.7X85MM,C1713,HCPCS,,79005025,CDM,278,RC,,,both,,,1074,794.76,,,794.76,Other,150% of Medicare + 9.63% HCRA Surcharge,483.3,45,,483.3,percent of total billed charges,Critical Access Hospital RCC factor,365.16,34,,365.16,percent of total billed charges,Implant Device,365.16,34,,365.16,percent of total billed charges,Implant Device,365.16,34,,365.16,percent of total billed charges,Implant Device,365.16,34,,365.16,percent of total billed charges,Implant Device,365.16,34,,365.16,percent of total billed charges,Implant Device,531.63,,,531.63,Other,110% of Medicare,375.9,35,,375.9,percent of total billed charges,Implant Device,365.16,34,"Charges > $500, x 34%",365.16,percent of total billed charges,Implant Device,375.9,35,,375.9,percent of total billed charges,Implant Device,375.9,35,,375.9,percent of total billed charges,Implant Device,375.9,35,,375.9,percent of total billed charges,Implant Device,375.9,35,,375.9,percent of total billed charges,Implant Device,375.9,35,,375.9,percent of total billed charges,Implant Device,429.6,40,,429.6,percent of total billed charges,Implant Device,375.9,70,,375.9,percent of total billed charges,All Other,365.16,34,,365.16,percent of total billed charges,Implant Device,365.16,34,,365.16,percent of total billed charges,Implant Device,375.9,35,,375.9,percent of total billed charges,Implant Device,375.9,35,,375.9,percent of total billed charges,Implant Device,375.9,35,,375.9,percent of total billed charges,Implant Device,375.9,35,,375.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,794.76,
ALPHATEC SPINE 71001-034 2LEV PLATE 34MM,C1713,HCPCS,,79005026,CDM,278,RC,,,both,,,2700,1998.01,,,1998.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1215,45,,1215,percent of total billed charges,Critical Access Hospital RCC factor,918,34,,918,percent of total billed charges,Implant Device,918,34,,918,percent of total billed charges,Implant Device,918,34,,918,percent of total billed charges,Implant Device,918,34,,918,percent of total billed charges,Implant Device,918,34,,918,percent of total billed charges,Implant Device,1336.5,,,1336.5,Other,110% of Medicare,945,35,,945,percent of total billed charges,Implant Device,918,34,"Charges > $500, x 34%",918,percent of total billed charges,Implant Device,945,35,,945,percent of total billed charges,Implant Device,945,35,,945,percent of total billed charges,Implant Device,945,35,,945,percent of total billed charges,Implant Device,945,35,,945,percent of total billed charges,Implant Device,945,35,,945,percent of total billed charges,Implant Device,1080,40,,1080,percent of total billed charges,Implant Device,945,70,,945,percent of total billed charges,All Other,918,34,,918,percent of total billed charges,Implant Device,918,34,,918,percent of total billed charges,Implant Device,945,35,,945,percent of total billed charges,Implant Device,945,35,,945,percent of total billed charges,Implant Device,945,35,,945,percent of total billed charges,Implant Device,945,35,,945,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,918,34,"If Charge > 2,000, then 34 percent",918,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1998.01,
ALPHATEC SPINE 71240-14 VAR SCREW 4X14MM,C1713,HCPCS,,79005027,CDM,278,RC,,,both,,,705,521.7,,,521.7,Other,150% of Medicare + 9.63% HCRA Surcharge,317.25,45,,317.25,percent of total billed charges,Critical Access Hospital RCC factor,239.7,34,,239.7,percent of total billed charges,Implant Device,239.7,34,,239.7,percent of total billed charges,Implant Device,239.7,34,,239.7,percent of total billed charges,Implant Device,239.7,34,,239.7,percent of total billed charges,Implant Device,239.7,34,,239.7,percent of total billed charges,Implant Device,348.98,,,348.98,Other,110% of Medicare,246.75,35,,246.75,percent of total billed charges,Implant Device,239.7,34,"Charges > $500, x 34%",239.7,percent of total billed charges,Implant Device,246.75,35,,246.75,percent of total billed charges,Implant Device,246.75,35,,246.75,percent of total billed charges,Implant Device,246.75,35,,246.75,percent of total billed charges,Implant Device,246.75,35,,246.75,percent of total billed charges,Implant Device,246.75,35,,246.75,percent of total billed charges,Implant Device,282,40,,282,percent of total billed charges,Implant Device,246.75,70,,246.75,percent of total billed charges,All Other,239.7,34,,239.7,percent of total billed charges,Implant Device,239.7,34,,239.7,percent of total billed charges,Implant Device,246.75,35,,246.75,percent of total billed charges,Implant Device,246.75,35,,246.75,percent of total billed charges,Implant Device,246.75,35,,246.75,percent of total billed charges,Implant Device,246.75,35,,246.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,521.7,
ACUMED COT2324 LOCKING SCREW 2.3X24MM,C1713,HCPCS,,79005034,CDM,278,RC,,,both,,,312,230.88,,,230.88,Other,150% of Medicare + 9.63% HCRA Surcharge,140.4,45,,140.4,percent of total billed charges,Critical Access Hospital RCC factor,106.08,34,,106.08,percent of total billed charges,Implant Device,106.08,34,,106.08,percent of total billed charges,Implant Device,106.08,34,,106.08,percent of total billed charges,Implant Device,106.08,34,,106.08,percent of total billed charges,Implant Device,106.08,34,,106.08,percent of total billed charges,Implant Device,154.44,,,154.44,Other,110% of Medicare,109.2,35,,109.2,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,109.2,35,,109.2,percent of total billed charges,Implant Device,109.2,35,,109.2,percent of total billed charges,Implant Device,109.2,35,,109.2,percent of total billed charges,Implant Device,109.2,35,,109.2,percent of total billed charges,Implant Device,109.2,35,,109.2,percent of total billed charges,Implant Device,124.8,40,,124.8,percent of total billed charges,Implant Device,109.2,70,,109.2,percent of total billed charges,All Other,106.08,34,,106.08,percent of total billed charges,Implant Device,106.08,34,,106.08,percent of total billed charges,Implant Device,109.2,35,,109.2,percent of total billed charges,Implant Device,109.2,35,,109.2,percent of total billed charges,Implant Device,109.2,35,,109.2,percent of total billed charges,Implant Device,109.2,35,,109.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,230.88,
ACUMED COT2322 LOCKING SCREW 2.3X22MM,C1713,HCPCS,,79005035,CDM,278,RC,,,both,,,312,230.88,,,230.88,Other,150% of Medicare + 9.63% HCRA Surcharge,140.4,45,,140.4,percent of total billed charges,Critical Access Hospital RCC factor,106.08,34,,106.08,percent of total billed charges,Implant Device,106.08,34,,106.08,percent of total billed charges,Implant Device,106.08,34,,106.08,percent of total billed charges,Implant Device,106.08,34,,106.08,percent of total billed charges,Implant Device,106.08,34,,106.08,percent of total billed charges,Implant Device,154.44,,,154.44,Other,110% of Medicare,109.2,35,,109.2,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,109.2,35,,109.2,percent of total billed charges,Implant Device,109.2,35,,109.2,percent of total billed charges,Implant Device,109.2,35,,109.2,percent of total billed charges,Implant Device,109.2,35,,109.2,percent of total billed charges,Implant Device,109.2,35,,109.2,percent of total billed charges,Implant Device,124.8,40,,124.8,percent of total billed charges,Implant Device,109.2,70,,109.2,percent of total billed charges,All Other,106.08,34,,106.08,percent of total billed charges,Implant Device,106.08,34,,106.08,percent of total billed charges,Implant Device,109.2,35,,109.2,percent of total billed charges,Implant Device,109.2,35,,109.2,percent of total billed charges,Implant Device,109.2,35,,109.2,percent of total billed charges,Implant Device,109.2,35,,109.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,230.88,
ACUMED COT2314 LOCKING SCREW 2.3X14MM,C1713,HCPCS,,79005036,CDM,278,RC,,,both,,,312,230.88,,,230.88,Other,150% of Medicare + 9.63% HCRA Surcharge,140.4,45,,140.4,percent of total billed charges,Critical Access Hospital RCC factor,106.08,34,,106.08,percent of total billed charges,Implant Device,106.08,34,,106.08,percent of total billed charges,Implant Device,106.08,34,,106.08,percent of total billed charges,Implant Device,106.08,34,,106.08,percent of total billed charges,Implant Device,106.08,34,,106.08,percent of total billed charges,Implant Device,154.44,,,154.44,Other,110% of Medicare,109.2,35,,109.2,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,109.2,35,,109.2,percent of total billed charges,Implant Device,109.2,35,,109.2,percent of total billed charges,Implant Device,109.2,35,,109.2,percent of total billed charges,Implant Device,109.2,35,,109.2,percent of total billed charges,Implant Device,109.2,35,,109.2,percent of total billed charges,Implant Device,124.8,40,,124.8,percent of total billed charges,Implant Device,109.2,70,,109.2,percent of total billed charges,All Other,106.08,34,,106.08,percent of total billed charges,Implant Device,106.08,34,,106.08,percent of total billed charges,Implant Device,109.2,35,,109.2,percent of total billed charges,Implant Device,109.2,35,,109.2,percent of total billed charges,Implant Device,109.2,35,,109.2,percent of total billed charges,Implant Device,109.2,35,,109.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,230.88,
ACUMED COT2316 LOCKING SCREW 2.3X16MM,C1713,HCPCS,,79005037,CDM,278,RC,,,both,,,312,230.88,,,230.88,Other,150% of Medicare + 9.63% HCRA Surcharge,140.4,45,,140.4,percent of total billed charges,Critical Access Hospital RCC factor,106.08,34,,106.08,percent of total billed charges,Implant Device,106.08,34,,106.08,percent of total billed charges,Implant Device,106.08,34,,106.08,percent of total billed charges,Implant Device,106.08,34,,106.08,percent of total billed charges,Implant Device,106.08,34,,106.08,percent of total billed charges,Implant Device,154.44,,,154.44,Other,110% of Medicare,109.2,35,,109.2,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,109.2,35,,109.2,percent of total billed charges,Implant Device,109.2,35,,109.2,percent of total billed charges,Implant Device,109.2,35,,109.2,percent of total billed charges,Implant Device,109.2,35,,109.2,percent of total billed charges,Implant Device,109.2,35,,109.2,percent of total billed charges,Implant Device,124.8,40,,124.8,percent of total billed charges,Implant Device,109.2,70,,109.2,percent of total billed charges,All Other,106.08,34,,106.08,percent of total billed charges,Implant Device,106.08,34,,106.08,percent of total billed charges,Implant Device,109.2,35,,109.2,percent of total billed charges,Implant Device,109.2,35,,109.2,percent of total billed charges,Implant Device,109.2,35,,109.2,percent of total billed charges,Implant Device,109.2,35,,109.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,230.88,
ACUMED COT2318 LOCKING SCREW 2.3X18MM,C1713,HCPCS,,79005039,CDM,278,RC,,,both,,,312,230.88,,,230.88,Other,150% of Medicare + 9.63% HCRA Surcharge,140.4,45,,140.4,percent of total billed charges,Critical Access Hospital RCC factor,106.08,34,,106.08,percent of total billed charges,Implant Device,106.08,34,,106.08,percent of total billed charges,Implant Device,106.08,34,,106.08,percent of total billed charges,Implant Device,106.08,34,,106.08,percent of total billed charges,Implant Device,106.08,34,,106.08,percent of total billed charges,Implant Device,154.44,,,154.44,Other,110% of Medicare,109.2,35,,109.2,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,109.2,35,,109.2,percent of total billed charges,Implant Device,109.2,35,,109.2,percent of total billed charges,Implant Device,109.2,35,,109.2,percent of total billed charges,Implant Device,109.2,35,,109.2,percent of total billed charges,Implant Device,109.2,35,,109.2,percent of total billed charges,Implant Device,124.8,40,,124.8,percent of total billed charges,Implant Device,109.2,70,,109.2,percent of total billed charges,All Other,106.08,34,,106.08,percent of total billed charges,Implant Device,106.08,34,,106.08,percent of total billed charges,Implant Device,109.2,35,,109.2,percent of total billed charges,Implant Device,109.2,35,,109.2,percent of total billed charges,Implant Device,109.2,35,,109.2,percent of total billed charges,Implant Device,109.2,35,,109.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,230.88,
LIFENET VG2C-T57P VG2 CERVICL BONE GRAFT,C1713,HCPCS,,79005040,CDM,278,RC,,,both,,,3516,2601.85,,,2601.85,Other,150% of Medicare + 9.63% HCRA Surcharge,1582.2,45,,1582.2,percent of total billed charges,Critical Access Hospital RCC factor,1195.44,34,,1195.44,percent of total billed charges,Implant Device,1195.44,34,,1195.44,percent of total billed charges,Implant Device,1195.44,34,,1195.44,percent of total billed charges,Implant Device,1195.44,34,,1195.44,percent of total billed charges,Implant Device,1195.44,34,,1195.44,percent of total billed charges,Implant Device,1740.42,,,1740.42,Other,110% of Medicare,1230.6,35,,1230.6,percent of total billed charges,Implant Device,1195.44,34,"Charges > $500, x 34%",1195.44,percent of total billed charges,Implant Device,1230.6,35,,1230.6,percent of total billed charges,Implant Device,1230.6,35,,1230.6,percent of total billed charges,Implant Device,1230.6,35,,1230.6,percent of total billed charges,Implant Device,1230.6,35,,1230.6,percent of total billed charges,Implant Device,1230.6,35,,1230.6,percent of total billed charges,Implant Device,1406.4,40,,1406.4,percent of total billed charges,Implant Device,1230.6,70,,1230.6,percent of total billed charges,All Other,1195.44,34,,1195.44,percent of total billed charges,Implant Device,1195.44,34,,1195.44,percent of total billed charges,Implant Device,1230.6,35,,1230.6,percent of total billed charges,Implant Device,1230.6,35,,1230.6,percent of total billed charges,Implant Device,1230.6,35,,1230.6,percent of total billed charges,Implant Device,1230.6,35,,1230.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1195.44,34,"If Charge > 2,000, then 34 percent",1195.44,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2601.85,
LIFENET VG2C-T68P VG2 CERVICL BONE GRAFT,C1713,HCPCS,,79005041,CDM,278,RC,,,both,,,3518,2603.33,,,2603.33,Other,150% of Medicare + 9.63% HCRA Surcharge,1583.1,45,,1583.1,percent of total billed charges,Critical Access Hospital RCC factor,1196.12,34,,1196.12,percent of total billed charges,Implant Device,1196.12,34,,1196.12,percent of total billed charges,Implant Device,1196.12,34,,1196.12,percent of total billed charges,Implant Device,1196.12,34,,1196.12,percent of total billed charges,Implant Device,1196.12,34,,1196.12,percent of total billed charges,Implant Device,1741.41,,,1741.41,Other,110% of Medicare,1231.3,35,,1231.3,percent of total billed charges,Implant Device,1196.12,34,"Charges > $500, x 34%",1196.12,percent of total billed charges,Implant Device,1231.3,35,,1231.3,percent of total billed charges,Implant Device,1231.3,35,,1231.3,percent of total billed charges,Implant Device,1231.3,35,,1231.3,percent of total billed charges,Implant Device,1231.3,35,,1231.3,percent of total billed charges,Implant Device,1231.3,35,,1231.3,percent of total billed charges,Implant Device,1407.2,40,,1407.2,percent of total billed charges,Implant Device,1231.3,70,,1231.3,percent of total billed charges,All Other,1196.12,34,,1196.12,percent of total billed charges,Implant Device,1196.12,34,,1196.12,percent of total billed charges,Implant Device,1231.3,35,,1231.3,percent of total billed charges,Implant Device,1231.3,35,,1231.3,percent of total billed charges,Implant Device,1231.3,35,,1231.3,percent of total billed charges,Implant Device,1231.3,35,,1231.3,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1196.12,34,"If Charge > 2,000, then 34 percent",1196.12,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2603.33,
LIFENET VG2C-T79P VG2 CERVICL BONE GRAFT,C1713,HCPCS,,79005042,CDM,278,RC,,,both,,,3516,2601.85,,,2601.85,Other,150% of Medicare + 9.63% HCRA Surcharge,1582.2,45,,1582.2,percent of total billed charges,Critical Access Hospital RCC factor,1195.44,34,,1195.44,percent of total billed charges,Implant Device,1195.44,34,,1195.44,percent of total billed charges,Implant Device,1195.44,34,,1195.44,percent of total billed charges,Implant Device,1195.44,34,,1195.44,percent of total billed charges,Implant Device,1195.44,34,,1195.44,percent of total billed charges,Implant Device,1740.42,,,1740.42,Other,110% of Medicare,1230.6,35,,1230.6,percent of total billed charges,Implant Device,1195.44,34,"Charges > $500, x 34%",1195.44,percent of total billed charges,Implant Device,1230.6,35,,1230.6,percent of total billed charges,Implant Device,1230.6,35,,1230.6,percent of total billed charges,Implant Device,1230.6,35,,1230.6,percent of total billed charges,Implant Device,1230.6,35,,1230.6,percent of total billed charges,Implant Device,1230.6,35,,1230.6,percent of total billed charges,Implant Device,1406.4,40,,1406.4,percent of total billed charges,Implant Device,1230.6,70,,1230.6,percent of total billed charges,All Other,1195.44,34,,1195.44,percent of total billed charges,Implant Device,1195.44,34,,1195.44,percent of total billed charges,Implant Device,1230.6,35,,1230.6,percent of total billed charges,Implant Device,1230.6,35,,1230.6,percent of total billed charges,Implant Device,1230.6,35,,1230.6,percent of total billed charges,Implant Device,1230.6,35,,1230.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1195.44,34,"If Charge > 2,000, then 34 percent",1195.44,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2601.85,
LIFENET VG2C-T810P VG2 CERVCL BONE GRAFT,C1713,HCPCS,,79005043,CDM,278,RC,,,both,,,3516,2601.85,,,2601.85,Other,150% of Medicare + 9.63% HCRA Surcharge,1582.2,45,,1582.2,percent of total billed charges,Critical Access Hospital RCC factor,1195.44,34,,1195.44,percent of total billed charges,Implant Device,1195.44,34,,1195.44,percent of total billed charges,Implant Device,1195.44,34,,1195.44,percent of total billed charges,Implant Device,1195.44,34,,1195.44,percent of total billed charges,Implant Device,1195.44,34,,1195.44,percent of total billed charges,Implant Device,1740.42,,,1740.42,Other,110% of Medicare,1230.6,35,,1230.6,percent of total billed charges,Implant Device,1195.44,34,"Charges > $500, x 34%",1195.44,percent of total billed charges,Implant Device,1230.6,35,,1230.6,percent of total billed charges,Implant Device,1230.6,35,,1230.6,percent of total billed charges,Implant Device,1230.6,35,,1230.6,percent of total billed charges,Implant Device,1230.6,35,,1230.6,percent of total billed charges,Implant Device,1230.6,35,,1230.6,percent of total billed charges,Implant Device,1406.4,40,,1406.4,percent of total billed charges,Implant Device,1230.6,70,,1230.6,percent of total billed charges,All Other,1195.44,34,,1195.44,percent of total billed charges,Implant Device,1195.44,34,,1195.44,percent of total billed charges,Implant Device,1230.6,35,,1230.6,percent of total billed charges,Implant Device,1230.6,35,,1230.6,percent of total billed charges,Implant Device,1230.6,35,,1230.6,percent of total billed charges,Implant Device,1230.6,35,,1230.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1195.44,34,"If Charge > 2,000, then 34 percent",1195.44,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2601.85,
BIOMET 8157-61-045 CANN SCREW 45X6.5MM,C1713,HCPCS,,79005048,CDM,278,RC,,,both,,,270,199.8,,,199.8,Other,150% of Medicare + 9.63% HCRA Surcharge,121.5,45,,121.5,percent of total billed charges,Critical Access Hospital RCC factor,91.8,34,,91.8,percent of total billed charges,Implant Device,91.8,34,,91.8,percent of total billed charges,Implant Device,91.8,34,,91.8,percent of total billed charges,Implant Device,91.8,34,,91.8,percent of total billed charges,Implant Device,91.8,34,,91.8,percent of total billed charges,Implant Device,133.65,,,133.65,Other,110% of Medicare,94.5,35,,94.5,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,94.5,35,,94.5,percent of total billed charges,Implant Device,94.5,35,,94.5,percent of total billed charges,Implant Device,94.5,35,,94.5,percent of total billed charges,Implant Device,94.5,35,,94.5,percent of total billed charges,Implant Device,94.5,35,,94.5,percent of total billed charges,Implant Device,108,40,,108,percent of total billed charges,Implant Device,94.5,70,,94.5,percent of total billed charges,All Other,91.8,34,,91.8,percent of total billed charges,Implant Device,91.8,34,,91.8,percent of total billed charges,Implant Device,94.5,35,,94.5,percent of total billed charges,Implant Device,94.5,35,,94.5,percent of total billed charges,Implant Device,94.5,35,,94.5,percent of total billed charges,Implant Device,94.5,35,,94.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,199.8,
ARTHREX AR-2655CR CLAVICLE PLATE RT,C1713,HCPCS,,79005053,CDM,278,RC,,,both,,,1650,1221,,,1221,Other,150% of Medicare + 9.63% HCRA Surcharge,742.5,45,,742.5,percent of total billed charges,Critical Access Hospital RCC factor,561,34,,561,percent of total billed charges,Implant Device,561,34,,561,percent of total billed charges,Implant Device,561,34,,561,percent of total billed charges,Implant Device,561,34,,561,percent of total billed charges,Implant Device,561,34,,561,percent of total billed charges,Implant Device,816.75,,,816.75,Other,110% of Medicare,577.5,35,,577.5,percent of total billed charges,Implant Device,561,34,"Charges > $500, x 34%",561,percent of total billed charges,Implant Device,577.5,35,,577.5,percent of total billed charges,Implant Device,577.5,35,,577.5,percent of total billed charges,Implant Device,577.5,35,,577.5,percent of total billed charges,Implant Device,577.5,35,,577.5,percent of total billed charges,Implant Device,577.5,35,,577.5,percent of total billed charges,Implant Device,660,40,,660,percent of total billed charges,Implant Device,577.5,70,,577.5,percent of total billed charges,All Other,561,34,,561,percent of total billed charges,Implant Device,561,34,,561,percent of total billed charges,Implant Device,577.5,35,,577.5,percent of total billed charges,Implant Device,577.5,35,,577.5,percent of total billed charges,Implant Device,577.5,35,,577.5,percent of total billed charges,Implant Device,577.5,35,,577.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1221,
ARTHREX AR-8835L-14 LOCK SCREW 3.5X14MM,C1713,HCPCS,,79005054,CDM,278,RC,,,both,,,330,244.2,,,244.2,Other,150% of Medicare + 9.63% HCRA Surcharge,148.5,45,,148.5,percent of total billed charges,Critical Access Hospital RCC factor,112.2,34,,112.2,percent of total billed charges,Implant Device,112.2,34,,112.2,percent of total billed charges,Implant Device,112.2,34,,112.2,percent of total billed charges,Implant Device,112.2,34,,112.2,percent of total billed charges,Implant Device,112.2,34,,112.2,percent of total billed charges,Implant Device,163.35,,,163.35,Other,110% of Medicare,115.5,35,,115.5,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,132,40,,132,percent of total billed charges,Implant Device,115.5,70,,115.5,percent of total billed charges,All Other,112.2,34,,112.2,percent of total billed charges,Implant Device,112.2,34,,112.2,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,244.2,
STRYKER 3130-1180S TROCH NAIL 11X180MM,C1713,HCPCS,,79005059,CDM,278,RC,,,both,,,2928,2166.73,,,2166.73,Other,150% of Medicare + 9.63% HCRA Surcharge,1317.6,45,,1317.6,percent of total billed charges,Critical Access Hospital RCC factor,995.52,34,,995.52,percent of total billed charges,Implant Device,995.52,34,,995.52,percent of total billed charges,Implant Device,995.52,34,,995.52,percent of total billed charges,Implant Device,995.52,34,,995.52,percent of total billed charges,Implant Device,995.52,34,,995.52,percent of total billed charges,Implant Device,1449.36,,,1449.36,Other,110% of Medicare,1024.8,35,,1024.8,percent of total billed charges,Implant Device,995.52,34,"Charges > $500, x 34%",995.52,percent of total billed charges,Implant Device,1024.8,35,,1024.8,percent of total billed charges,Implant Device,1024.8,35,,1024.8,percent of total billed charges,Implant Device,1024.8,35,,1024.8,percent of total billed charges,Implant Device,1024.8,35,,1024.8,percent of total billed charges,Implant Device,1024.8,35,,1024.8,percent of total billed charges,Implant Device,1171.2,40,,1171.2,percent of total billed charges,Implant Device,1024.8,70,,1024.8,percent of total billed charges,All Other,995.52,34,,995.52,percent of total billed charges,Implant Device,995.52,34,,995.52,percent of total billed charges,Implant Device,1024.8,35,,1024.8,percent of total billed charges,Implant Device,1024.8,35,,1024.8,percent of total billed charges,Implant Device,1024.8,35,,1024.8,percent of total billed charges,Implant Device,1024.8,35,,1024.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,995.52,34,"If Charge > 2,000, then 34 percent",995.52,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2166.73,
ARTHREX AR-1926BC PUSHLOCK 3.5,C1713,HCPCS,,79005060,CDM,278,RC,,,both,,,1200,888,,,888,Other,150% of Medicare + 9.63% HCRA Surcharge,540,45,,540,percent of total billed charges,Critical Access Hospital RCC factor,408,34,,408,percent of total billed charges,Implant Device,408,34,,408,percent of total billed charges,Implant Device,408,34,,408,percent of total billed charges,Implant Device,408,34,,408,percent of total billed charges,Implant Device,408,34,,408,percent of total billed charges,Implant Device,594,,,594,Other,110% of Medicare,420,35,,420,percent of total billed charges,Implant Device,408,34,"Charges > $500, x 34%",408,percent of total billed charges,Implant Device,420,35,,420,percent of total billed charges,Implant Device,420,35,,420,percent of total billed charges,Implant Device,420,35,,420,percent of total billed charges,Implant Device,420,35,,420,percent of total billed charges,Implant Device,420,35,,420,percent of total billed charges,Implant Device,480,40,,480,percent of total billed charges,Implant Device,420,70,,420,percent of total billed charges,All Other,408,34,,408,percent of total billed charges,Implant Device,408,34,,408,percent of total billed charges,Implant Device,420,35,,420,percent of total billed charges,Implant Device,420,35,,420,percent of total billed charges,Implant Device,420,35,,420,percent of total billed charges,Implant Device,420,35,,420,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,888,
ARTHROSURF 9070-0013-W TAPER POST 7MM,C1776,HCPCS,,79005061,CDM,278,RC,,,both,,,1308,967.92,,,967.92,Other,150% of Medicare + 9.63% HCRA Surcharge,588.6,45,,588.6,percent of total billed charges,Critical Access Hospital RCC factor,444.72,34,,444.72,percent of total billed charges,Implant Device,444.72,34,,444.72,percent of total billed charges,Implant Device,444.72,34,,444.72,percent of total billed charges,Implant Device,444.72,34,,444.72,percent of total billed charges,Implant Device,444.72,34,,444.72,percent of total billed charges,Implant Device,647.46,,,647.46,Other,110% of Medicare,457.8,35,,457.8,percent of total billed charges,Implant Device,444.72,34,"Charges > $500, x 34%",444.72,percent of total billed charges,Implant Device,457.8,35,,457.8,percent of total billed charges,Implant Device,457.8,35,,457.8,percent of total billed charges,Implant Device,457.8,35,,457.8,percent of total billed charges,Implant Device,457.8,35,,457.8,percent of total billed charges,Implant Device,457.8,35,,457.8,percent of total billed charges,Implant Device,523.2,40,,523.2,percent of total billed charges,Implant Device,457.8,70,,457.8,percent of total billed charges,All Other,444.72,34,,444.72,percent of total billed charges,Implant Device,444.72,34,,444.72,percent of total billed charges,Implant Device,457.8,35,,457.8,percent of total billed charges,Implant Device,457.8,35,,457.8,percent of total billed charges,Implant Device,457.8,35,,457.8,percent of total billed charges,Implant Device,457.8,35,,457.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,967.92,
ARTHREX AR-1926DS PUSHLOCK 3.5,C1713,HCPCS,,79005063,CDM,278,RC,,,both,,,525,388.5,,,388.5,Other,150% of Medicare + 9.63% HCRA Surcharge,236.25,45,,236.25,percent of total billed charges,Critical Access Hospital RCC factor,178.5,34,,178.5,percent of total billed charges,Implant Device,178.5,34,,178.5,percent of total billed charges,Implant Device,178.5,34,,178.5,percent of total billed charges,Implant Device,178.5,34,,178.5,percent of total billed charges,Implant Device,178.5,34,,178.5,percent of total billed charges,Implant Device,259.88,,,259.88,Other,110% of Medicare,183.75,35,,183.75,percent of total billed charges,Implant Device,178.5,34,"Charges > $500, x 34%",178.5,percent of total billed charges,Implant Device,183.75,35,,183.75,percent of total billed charges,Implant Device,183.75,35,,183.75,percent of total billed charges,Implant Device,183.75,35,,183.75,percent of total billed charges,Implant Device,183.75,35,,183.75,percent of total billed charges,Implant Device,183.75,35,,183.75,percent of total billed charges,Implant Device,210,40,,210,percent of total billed charges,Implant Device,183.75,70,,183.75,percent of total billed charges,All Other,178.5,34,,178.5,percent of total billed charges,Implant Device,178.5,34,,178.5,percent of total billed charges,Implant Device,183.75,35,,183.75,percent of total billed charges,Implant Device,183.75,35,,183.75,percent of total billed charges,Implant Device,183.75,35,,183.75,percent of total billed charges,Implant Device,183.75,35,,183.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,388.5,
ARTHREX AR-4151DS DRILL PIN 1.5X100MM,C1713,HCPCS,,79005066,CDM,278,RC,,,both,,,630,466.2,,,466.2,Other,150% of Medicare + 9.63% HCRA Surcharge,283.5,45,,283.5,percent of total billed charges,Critical Access Hospital RCC factor,214.2,34,,214.2,percent of total billed charges,Implant Device,214.2,34,,214.2,percent of total billed charges,Implant Device,214.2,34,,214.2,percent of total billed charges,Implant Device,214.2,34,,214.2,percent of total billed charges,Implant Device,214.2,34,,214.2,percent of total billed charges,Implant Device,311.85,,,311.85,Other,110% of Medicare,220.5,35,,220.5,percent of total billed charges,Implant Device,214.2,34,"Charges > $500, x 34%",214.2,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,252,40,,252,percent of total billed charges,Implant Device,220.5,70,,220.5,percent of total billed charges,All Other,214.2,34,,214.2,percent of total billed charges,Implant Device,214.2,34,,214.2,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,466.2,
ACUMED COL-3120 LOCKING SCREW 3.5X12MM,C1713,HCPCS,,79005067,CDM,278,RC,,,both,,,382,282.68,,,282.68,Other,150% of Medicare + 9.63% HCRA Surcharge,171.9,45,,171.9,percent of total billed charges,Critical Access Hospital RCC factor,129.88,34,,129.88,percent of total billed charges,Implant Device,129.88,34,,129.88,percent of total billed charges,Implant Device,129.88,34,,129.88,percent of total billed charges,Implant Device,129.88,34,,129.88,percent of total billed charges,Implant Device,129.88,34,,129.88,percent of total billed charges,Implant Device,189.09,,,189.09,Other,110% of Medicare,133.7,35,,133.7,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,133.7,35,,133.7,percent of total billed charges,Implant Device,133.7,35,,133.7,percent of total billed charges,Implant Device,133.7,35,,133.7,percent of total billed charges,Implant Device,133.7,35,,133.7,percent of total billed charges,Implant Device,133.7,35,,133.7,percent of total billed charges,Implant Device,152.8,40,,152.8,percent of total billed charges,Implant Device,133.7,70,,133.7,percent of total billed charges,All Other,129.88,34,,129.88,percent of total billed charges,Implant Device,129.88,34,,129.88,percent of total billed charges,Implant Device,133.7,35,,133.7,percent of total billed charges,Implant Device,133.7,35,,133.7,percent of total billed charges,Implant Device,133.7,35,,133.7,percent of total billed charges,Implant Device,133.7,35,,133.7,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,282.68,
ST JUDE 7122Q/58 DURATA ACTIVE LEAD,C1895,HCPCS,,79005068,CDM,278,RC,,,both,,,11471,8488.57,,,8488.57,Other,150% of Medicare + 9.63% HCRA Surcharge,5161.95,45,,5161.95,percent of total billed charges,Critical Access Hospital RCC factor,3900.14,34,,3900.14,percent of total billed charges,Implant Device,3900.14,34,,3900.14,percent of total billed charges,Implant Device,3900.14,34,,3900.14,percent of total billed charges,Implant Device,3900.14,34,,3900.14,percent of total billed charges,Implant Device,3900.14,34,,3900.14,percent of total billed charges,Implant Device,5678.15,,,5678.15,Other,110% of Medicare,4014.85,35,,4014.85,percent of total billed charges,Implant Device,3900.14,34,"Charges > $500, x 34%",3900.14,percent of total billed charges,Implant Device,4014.85,35,,4014.85,percent of total billed charges,Implant Device,4014.85,35,,4014.85,percent of total billed charges,Implant Device,4014.85,35,,4014.85,percent of total billed charges,Implant Device,4014.85,35,,4014.85,percent of total billed charges,Implant Device,4014.85,35,,4014.85,percent of total billed charges,Implant Device,4588.4,40,,4588.4,percent of total billed charges,Implant Device,4014.85,70,,4014.85,percent of total billed charges,All Other,3900.14,34,,3900.14,percent of total billed charges,Implant Device,3900.14,34,,3900.14,percent of total billed charges,Implant Device,4014.85,35,,4014.85,percent of total billed charges,Implant Device,4014.85,35,,4014.85,percent of total billed charges,Implant Device,4014.85,35,,4014.85,percent of total billed charges,Implant Device,4014.85,35,,4014.85,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3900.14,34,"If Charge > 2,000, then 34 percent",3900.14,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,8488.57,
SMITH & NEPHEW 121860 CANN SCREW 4X60MM,C1713,HCPCS,,79005069,CDM,278,RC,,,both,,,587,434.38,,,434.38,Other,150% of Medicare + 9.63% HCRA Surcharge,264.15,45,,264.15,percent of total billed charges,Critical Access Hospital RCC factor,199.58,34,,199.58,percent of total billed charges,Implant Device,199.58,34,,199.58,percent of total billed charges,Implant Device,199.58,34,,199.58,percent of total billed charges,Implant Device,199.58,34,,199.58,percent of total billed charges,Implant Device,199.58,34,,199.58,percent of total billed charges,Implant Device,290.57,,,290.57,Other,110% of Medicare,205.45,35,,205.45,percent of total billed charges,Implant Device,199.58,34,"Charges > $500, x 34%",199.58,percent of total billed charges,Implant Device,205.45,35,,205.45,percent of total billed charges,Implant Device,205.45,35,,205.45,percent of total billed charges,Implant Device,205.45,35,,205.45,percent of total billed charges,Implant Device,205.45,35,,205.45,percent of total billed charges,Implant Device,205.45,35,,205.45,percent of total billed charges,Implant Device,234.8,40,,234.8,percent of total billed charges,Implant Device,205.45,70,,205.45,percent of total billed charges,All Other,199.58,34,,199.58,percent of total billed charges,Implant Device,199.58,34,,199.58,percent of total billed charges,Implant Device,205.45,35,,205.45,percent of total billed charges,Implant Device,205.45,35,,205.45,percent of total billed charges,Implant Device,205.45,35,,205.45,percent of total billed charges,Implant Device,205.45,35,,205.45,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,434.38,
DEPUY 86-6401 MODULAR STEM 13X30MM,C1713,HCPCS,,79005070,CDM,278,RC,,,both,,,3862,2857.89,,,2857.89,Other,150% of Medicare + 9.63% HCRA Surcharge,1737.9,45,,1737.9,percent of total billed charges,Critical Access Hospital RCC factor,1313.08,34,,1313.08,percent of total billed charges,Implant Device,1313.08,34,,1313.08,percent of total billed charges,Implant Device,1313.08,34,,1313.08,percent of total billed charges,Implant Device,1313.08,34,,1313.08,percent of total billed charges,Implant Device,1313.08,34,,1313.08,percent of total billed charges,Implant Device,1911.69,,,1911.69,Other,110% of Medicare,1351.7,35,,1351.7,percent of total billed charges,Implant Device,1313.08,34,"Charges > $500, x 34%",1313.08,percent of total billed charges,Implant Device,1351.7,35,,1351.7,percent of total billed charges,Implant Device,1351.7,35,,1351.7,percent of total billed charges,Implant Device,1351.7,35,,1351.7,percent of total billed charges,Implant Device,1351.7,35,,1351.7,percent of total billed charges,Implant Device,1351.7,35,,1351.7,percent of total billed charges,Implant Device,1544.8,40,,1544.8,percent of total billed charges,Implant Device,1351.7,70,,1351.7,percent of total billed charges,All Other,1313.08,34,,1313.08,percent of total billed charges,Implant Device,1313.08,34,,1313.08,percent of total billed charges,Implant Device,1351.7,35,,1351.7,percent of total billed charges,Implant Device,1351.7,35,,1351.7,percent of total billed charges,Implant Device,1351.7,35,,1351.7,percent of total billed charges,Implant Device,1351.7,35,,1351.7,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1313.08,34,"If Charge > 2,000, then 34 percent",1313.08,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2857.89,
DEPUY 96-2042 TIBIAL INSERT CURVD 12.5MM,C1713,HCPCS,,79005071,CDM,278,RC,,,both,,,3696,2735.05,,,2735.05,Other,150% of Medicare + 9.63% HCRA Surcharge,1663.2,45,,1663.2,percent of total billed charges,Critical Access Hospital RCC factor,1256.64,34,,1256.64,percent of total billed charges,Implant Device,1256.64,34,,1256.64,percent of total billed charges,Implant Device,1256.64,34,,1256.64,percent of total billed charges,Implant Device,1256.64,34,,1256.64,percent of total billed charges,Implant Device,1256.64,34,,1256.64,percent of total billed charges,Implant Device,1829.52,,,1829.52,Other,110% of Medicare,1293.6,35,,1293.6,percent of total billed charges,Implant Device,1256.64,34,"Charges > $500, x 34%",1256.64,percent of total billed charges,Implant Device,1293.6,35,,1293.6,percent of total billed charges,Implant Device,1293.6,35,,1293.6,percent of total billed charges,Implant Device,1293.6,35,,1293.6,percent of total billed charges,Implant Device,1293.6,35,,1293.6,percent of total billed charges,Implant Device,1293.6,35,,1293.6,percent of total billed charges,Implant Device,1478.4,40,,1478.4,percent of total billed charges,Implant Device,1293.6,70,,1293.6,percent of total billed charges,All Other,1256.64,34,,1256.64,percent of total billed charges,Implant Device,1256.64,34,,1256.64,percent of total billed charges,Implant Device,1293.6,35,,1293.6,percent of total billed charges,Implant Device,1293.6,35,,1293.6,percent of total billed charges,Implant Device,1293.6,35,,1293.6,percent of total billed charges,Implant Device,1293.6,35,,1293.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1256.64,34,"If Charge > 2,000, then 34 percent",1256.64,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2735.05,
ARTHREX AR-8730-32PT CANN SCREW 3X32MM,C1713,HCPCS,,79005077,CDM,278,RC,,,both,,,390,288.6,,,288.6,Other,150% of Medicare + 9.63% HCRA Surcharge,175.5,45,,175.5,percent of total billed charges,Critical Access Hospital RCC factor,132.6,34,,132.6,percent of total billed charges,Implant Device,132.6,34,,132.6,percent of total billed charges,Implant Device,132.6,34,,132.6,percent of total billed charges,Implant Device,132.6,34,,132.6,percent of total billed charges,Implant Device,132.6,34,,132.6,percent of total billed charges,Implant Device,193.05,,,193.05,Other,110% of Medicare,136.5,35,,136.5,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,136.5,35,,136.5,percent of total billed charges,Implant Device,136.5,35,,136.5,percent of total billed charges,Implant Device,136.5,35,,136.5,percent of total billed charges,Implant Device,136.5,35,,136.5,percent of total billed charges,Implant Device,136.5,35,,136.5,percent of total billed charges,Implant Device,156,40,,156,percent of total billed charges,Implant Device,136.5,70,,136.5,percent of total billed charges,All Other,132.6,34,,132.6,percent of total billed charges,Implant Device,132.6,34,,132.6,percent of total billed charges,Implant Device,136.5,35,,136.5,percent of total billed charges,Implant Device,136.5,35,,136.5,percent of total billed charges,Implant Device,136.5,35,,136.5,percent of total billed charges,Implant Device,136.5,35,,136.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,288.6,
ARTHREX AR-8953-00 FLAT WEDGE PLATE,C1713,HCPCS,,79005078,CDM,278,RC,,,both,,,2909,2152.67,,,2152.67,Other,150% of Medicare + 9.63% HCRA Surcharge,1309.05,45,,1309.05,percent of total billed charges,Critical Access Hospital RCC factor,989.06,34,,989.06,percent of total billed charges,Implant Device,989.06,34,,989.06,percent of total billed charges,Implant Device,989.06,34,,989.06,percent of total billed charges,Implant Device,989.06,34,,989.06,percent of total billed charges,Implant Device,989.06,34,,989.06,percent of total billed charges,Implant Device,1439.96,,,1439.96,Other,110% of Medicare,1018.15,35,,1018.15,percent of total billed charges,Implant Device,989.06,34,"Charges > $500, x 34%",989.06,percent of total billed charges,Implant Device,1018.15,35,,1018.15,percent of total billed charges,Implant Device,1018.15,35,,1018.15,percent of total billed charges,Implant Device,1018.15,35,,1018.15,percent of total billed charges,Implant Device,1018.15,35,,1018.15,percent of total billed charges,Implant Device,1018.15,35,,1018.15,percent of total billed charges,Implant Device,1163.6,40,,1163.6,percent of total billed charges,Implant Device,1018.15,70,,1018.15,percent of total billed charges,All Other,989.06,34,,989.06,percent of total billed charges,Implant Device,989.06,34,,989.06,percent of total billed charges,Implant Device,1018.15,35,,1018.15,percent of total billed charges,Implant Device,1018.15,35,,1018.15,percent of total billed charges,Implant Device,1018.15,35,,1018.15,percent of total billed charges,Implant Device,1018.15,35,,1018.15,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,989.06,34,"If Charge > 2,000, then 34 percent",989.06,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2152.67,
SOLANA SURGICAL FFS-1010 FUSEFORCE 10X10,C1713,HCPCS,,79005079,CDM,278,RC,,,both,,,4068,3010.33,,,3010.33,Other,150% of Medicare + 9.63% HCRA Surcharge,1830.6,45,,1830.6,percent of total billed charges,Critical Access Hospital RCC factor,1383.12,34,,1383.12,percent of total billed charges,Implant Device,1383.12,34,,1383.12,percent of total billed charges,Implant Device,1383.12,34,,1383.12,percent of total billed charges,Implant Device,1383.12,34,,1383.12,percent of total billed charges,Implant Device,1383.12,34,,1383.12,percent of total billed charges,Implant Device,2013.66,,,2013.66,Other,110% of Medicare,1423.8,35,,1423.8,percent of total billed charges,Implant Device,1383.12,34,"Charges > $500, x 34%",1383.12,percent of total billed charges,Implant Device,1423.8,35,,1423.8,percent of total billed charges,Implant Device,1423.8,35,,1423.8,percent of total billed charges,Implant Device,1423.8,35,,1423.8,percent of total billed charges,Implant Device,1423.8,35,,1423.8,percent of total billed charges,Implant Device,1423.8,35,,1423.8,percent of total billed charges,Implant Device,1627.2,40,,1627.2,percent of total billed charges,Implant Device,1423.8,70,,1423.8,percent of total billed charges,All Other,1383.12,34,,1383.12,percent of total billed charges,Implant Device,1383.12,34,,1383.12,percent of total billed charges,Implant Device,1423.8,35,,1423.8,percent of total billed charges,Implant Device,1423.8,35,,1423.8,percent of total billed charges,Implant Device,1423.8,35,,1423.8,percent of total billed charges,Implant Device,1423.8,35,,1423.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1383.12,34,"If Charge > 2,000, then 34 percent",1383.12,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3010.33,
SOLANA SURGICAL FFS-0808 FUSEFORCE 8X8MM,C1713,HCPCS,,79005080,CDM,278,RC,,,both,,,5100,3774.01,,,3774.01,Other,150% of Medicare + 9.63% HCRA Surcharge,2295,45,,2295,percent of total billed charges,Critical Access Hospital RCC factor,1734,34,,1734,percent of total billed charges,Implant Device,1734,34,,1734,percent of total billed charges,Implant Device,1734,34,,1734,percent of total billed charges,Implant Device,1734,34,,1734,percent of total billed charges,Implant Device,1734,34,,1734,percent of total billed charges,Implant Device,2524.5,,,2524.5,Other,110% of Medicare,1785,35,,1785,percent of total billed charges,Implant Device,1734,34,"Charges > $500, x 34%",1734,percent of total billed charges,Implant Device,1785,35,,1785,percent of total billed charges,Implant Device,1785,35,,1785,percent of total billed charges,Implant Device,1785,35,,1785,percent of total billed charges,Implant Device,1785,35,,1785,percent of total billed charges,Implant Device,1785,35,,1785,percent of total billed charges,Implant Device,2040,40,,2040,percent of total billed charges,Implant Device,1785,70,,1785,percent of total billed charges,All Other,1734,34,,1734,percent of total billed charges,Implant Device,1734,34,,1734,percent of total billed charges,Implant Device,1785,35,,1785,percent of total billed charges,Implant Device,1785,35,,1785,percent of total billed charges,Implant Device,1785,35,,1785,percent of total billed charges,Implant Device,1785,35,,1785,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1734,34,"If Charge > 2,000, then 34 percent",1734,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3774.01,
ZIMMER 5001-049-00 BIPOLAR SHELL 49MM OD,C1776,HCPCS,,79005081,CDM,278,RC,,,both,,,960,710.4,,,710.4,Other,150% of Medicare + 9.63% HCRA Surcharge,432,45,,432,percent of total billed charges,Critical Access Hospital RCC factor,326.4,34,,326.4,percent of total billed charges,Implant Device,326.4,34,,326.4,percent of total billed charges,Implant Device,326.4,34,,326.4,percent of total billed charges,Implant Device,326.4,34,,326.4,percent of total billed charges,Implant Device,326.4,34,,326.4,percent of total billed charges,Implant Device,475.2,,,475.2,Other,110% of Medicare,336,35,,336,percent of total billed charges,Implant Device,326.4,34,"Charges > $500, x 34%",326.4,percent of total billed charges,Implant Device,336,35,,336,percent of total billed charges,Implant Device,336,35,,336,percent of total billed charges,Implant Device,336,35,,336,percent of total billed charges,Implant Device,336,35,,336,percent of total billed charges,Implant Device,336,35,,336,percent of total billed charges,Implant Device,384,40,,384,percent of total billed charges,Implant Device,336,70,,336,percent of total billed charges,All Other,326.4,34,,326.4,percent of total billed charges,Implant Device,326.4,34,,326.4,percent of total billed charges,Implant Device,336,35,,336,percent of total billed charges,Implant Device,336,35,,336,percent of total billed charges,Implant Device,336,35,,336,percent of total billed charges,Implant Device,336,35,,336,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,710.4,
ZIMMER 8018-028-01 COCR FEM HEAD 28MM,C1776,HCPCS,,79005082,CDM,278,RC,,,both,,,2543,1881.83,,,1881.83,Other,150% of Medicare + 9.63% HCRA Surcharge,1144.35,45,,1144.35,percent of total billed charges,Critical Access Hospital RCC factor,864.62,34,,864.62,percent of total billed charges,Implant Device,864.62,34,,864.62,percent of total billed charges,Implant Device,864.62,34,,864.62,percent of total billed charges,Implant Device,864.62,34,,864.62,percent of total billed charges,Implant Device,864.62,34,,864.62,percent of total billed charges,Implant Device,1258.79,,,1258.79,Other,110% of Medicare,890.05,35,,890.05,percent of total billed charges,Implant Device,864.62,34,"Charges > $500, x 34%",864.62,percent of total billed charges,Implant Device,890.05,35,,890.05,percent of total billed charges,Implant Device,890.05,35,,890.05,percent of total billed charges,Implant Device,890.05,35,,890.05,percent of total billed charges,Implant Device,890.05,35,,890.05,percent of total billed charges,Implant Device,890.05,35,,890.05,percent of total billed charges,Implant Device,1017.2,40,,1017.2,percent of total billed charges,Implant Device,890.05,70,,890.05,percent of total billed charges,All Other,864.62,34,,864.62,percent of total billed charges,Implant Device,864.62,34,,864.62,percent of total billed charges,Implant Device,890.05,35,,890.05,percent of total billed charges,Implant Device,890.05,35,,890.05,percent of total billed charges,Implant Device,890.05,35,,890.05,percent of total billed charges,Implant Device,890.05,35,,890.05,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,864.62,34,"If Charge > 2,000, then 34 percent",864.62,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1881.83,
STRYKER 6495-9-004 TISSUEMEND 6CMX10CM,C1713,HCPCS,,79005084,CDM,278,RC,,,both,,,10014,7410.39,,,7410.39,Other,150% of Medicare + 9.63% HCRA Surcharge,4506.3,45,,4506.3,percent of total billed charges,Critical Access Hospital RCC factor,3404.76,34,,3404.76,percent of total billed charges,Implant Device,3404.76,34,,3404.76,percent of total billed charges,Implant Device,3404.76,34,,3404.76,percent of total billed charges,Implant Device,3404.76,34,,3404.76,percent of total billed charges,Implant Device,3404.76,34,,3404.76,percent of total billed charges,Implant Device,4956.93,,,4956.93,Other,110% of Medicare,3504.9,35,,3504.9,percent of total billed charges,Implant Device,3404.76,34,"Charges > $500, x 34%",3404.76,percent of total billed charges,Implant Device,3504.9,35,,3504.9,percent of total billed charges,Implant Device,3504.9,35,,3504.9,percent of total billed charges,Implant Device,3504.9,35,,3504.9,percent of total billed charges,Implant Device,3504.9,35,,3504.9,percent of total billed charges,Implant Device,3504.9,35,,3504.9,percent of total billed charges,Implant Device,4005.6,40,,4005.6,percent of total billed charges,Implant Device,3504.9,70,,3504.9,percent of total billed charges,All Other,3404.76,34,,3404.76,percent of total billed charges,Implant Device,3404.76,34,,3404.76,percent of total billed charges,Implant Device,3504.9,35,,3504.9,percent of total billed charges,Implant Device,3504.9,35,,3504.9,percent of total billed charges,Implant Device,3504.9,35,,3504.9,percent of total billed charges,Implant Device,3504.9,35,,3504.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3404.76,34,"If Charge > 2,000, then 34 percent",3404.76,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,7410.39,
STRYKER ST0XS-11 SMART TOE -11,C1776,HCPCS,,79005085,CDM,278,RC,,,both,,,3582,2650.69,,,2650.69,Other,150% of Medicare + 9.63% HCRA Surcharge,1611.9,45,,1611.9,percent of total billed charges,Critical Access Hospital RCC factor,1217.88,34,,1217.88,percent of total billed charges,Implant Device,1217.88,34,,1217.88,percent of total billed charges,Implant Device,1217.88,34,,1217.88,percent of total billed charges,Implant Device,1217.88,34,,1217.88,percent of total billed charges,Implant Device,1217.88,34,,1217.88,percent of total billed charges,Implant Device,1773.09,,,1773.09,Other,110% of Medicare,1253.7,35,,1253.7,percent of total billed charges,Implant Device,1217.88,34,"Charges > $500, x 34%",1217.88,percent of total billed charges,Implant Device,1253.7,35,,1253.7,percent of total billed charges,Implant Device,1253.7,35,,1253.7,percent of total billed charges,Implant Device,1253.7,35,,1253.7,percent of total billed charges,Implant Device,1253.7,35,,1253.7,percent of total billed charges,Implant Device,1253.7,35,,1253.7,percent of total billed charges,Implant Device,1432.8,40,,1432.8,percent of total billed charges,Implant Device,1253.7,70,,1253.7,percent of total billed charges,All Other,1217.88,34,,1217.88,percent of total billed charges,Implant Device,1217.88,34,,1217.88,percent of total billed charges,Implant Device,1253.7,35,,1253.7,percent of total billed charges,Implant Device,1253.7,35,,1253.7,percent of total billed charges,Implant Device,1253.7,35,,1253.7,percent of total billed charges,Implant Device,1253.7,35,,1253.7,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1217.88,34,"If Charge > 2,000, then 34 percent",1217.88,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2650.69,
ZIMMER 5971-65-32 PATELLA 8.5MM,C1776,HCPCS,,79005087,CDM,278,RC,,,both,,,120,88.8,,,88.8,Other,150% of Medicare + 9.63% HCRA Surcharge,54,45,,54,percent of total billed charges,Critical Access Hospital RCC factor,40.8,34,,40.8,percent of total billed charges,Implant Device,40.8,34,,40.8,percent of total billed charges,Implant Device,40.8,34,,40.8,percent of total billed charges,Implant Device,40.8,34,,40.8,percent of total billed charges,Implant Device,40.8,34,,40.8,percent of total billed charges,Implant Device,59.4,,,59.4,Other,110% of Medicare,42,35,,42,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,42,35,,42,percent of total billed charges,Implant Device,42,35,,42,percent of total billed charges,Implant Device,42,35,,42,percent of total billed charges,Implant Device,42,35,,42,percent of total billed charges,Implant Device,42,35,,42,percent of total billed charges,Implant Device,48,40,,48,percent of total billed charges,Implant Device,42,70,,42,percent of total billed charges,All Other,40.8,34,,40.8,percent of total billed charges,Implant Device,40.8,34,,40.8,percent of total billed charges,Implant Device,42,35,,42,percent of total billed charges,Implant Device,42,35,,42,percent of total billed charges,Implant Device,42,35,,42,percent of total billed charges,Implant Device,42,35,,42,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,88.8,
STRYKER 1822-0934S T2 TIBIA NAIL 9X345MM,C1713,HCPCS,,79005088,CDM,278,RC,,,both,,,7143,5285.84,,,5285.84,Other,150% of Medicare + 9.63% HCRA Surcharge,3214.35,45,,3214.35,percent of total billed charges,Critical Access Hospital RCC factor,2428.62,34,,2428.62,percent of total billed charges,Implant Device,2428.62,34,,2428.62,percent of total billed charges,Implant Device,2428.62,34,,2428.62,percent of total billed charges,Implant Device,2428.62,34,,2428.62,percent of total billed charges,Implant Device,2428.62,34,,2428.62,percent of total billed charges,Implant Device,3535.79,,,3535.79,Other,110% of Medicare,2500.05,35,,2500.05,percent of total billed charges,Implant Device,2428.62,34,"Charges > $500, x 34%",2428.62,percent of total billed charges,Implant Device,2500.05,35,,2500.05,percent of total billed charges,Implant Device,2500.05,35,,2500.05,percent of total billed charges,Implant Device,2500.05,35,,2500.05,percent of total billed charges,Implant Device,2500.05,35,,2500.05,percent of total billed charges,Implant Device,2500.05,35,,2500.05,percent of total billed charges,Implant Device,2857.2,40,,2857.2,percent of total billed charges,Implant Device,2500.05,70,,2500.05,percent of total billed charges,All Other,2428.62,34,,2428.62,percent of total billed charges,Implant Device,2428.62,34,,2428.62,percent of total billed charges,Implant Device,2500.05,35,,2500.05,percent of total billed charges,Implant Device,2500.05,35,,2500.05,percent of total billed charges,Implant Device,2500.05,35,,2500.05,percent of total billed charges,Implant Device,2500.05,35,,2500.05,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2428.62,34,"If Charge > 2,000, then 34 percent",2428.62,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5285.84,
STRYKER 1896-5042S LOCKING SCREW 5X42MM,C1713,HCPCS,,79005089,CDM,278,RC,,,both,,,355,262.7,,,262.7,Other,150% of Medicare + 9.63% HCRA Surcharge,159.75,45,,159.75,percent of total billed charges,Critical Access Hospital RCC factor,120.7,34,,120.7,percent of total billed charges,Implant Device,120.7,34,,120.7,percent of total billed charges,Implant Device,120.7,34,,120.7,percent of total billed charges,Implant Device,120.7,34,,120.7,percent of total billed charges,Implant Device,120.7,34,,120.7,percent of total billed charges,Implant Device,175.73,,,175.73,Other,110% of Medicare,124.25,35,,124.25,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,124.25,35,,124.25,percent of total billed charges,Implant Device,124.25,35,,124.25,percent of total billed charges,Implant Device,124.25,35,,124.25,percent of total billed charges,Implant Device,124.25,35,,124.25,percent of total billed charges,Implant Device,124.25,35,,124.25,percent of total billed charges,Implant Device,142,40,,142,percent of total billed charges,Implant Device,124.25,70,,124.25,percent of total billed charges,All Other,120.7,34,,120.7,percent of total billed charges,Implant Device,120.7,34,,120.7,percent of total billed charges,Implant Device,124.25,35,,124.25,percent of total billed charges,Implant Device,124.25,35,,124.25,percent of total billed charges,Implant Device,124.25,35,,124.25,percent of total billed charges,Implant Device,124.25,35,,124.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,262.7,
STRYKER 5512-F-401 FEMORAL COMPONENT SZ4,C1776,HCPCS,,79005090,CDM,278,RC,,,both,,,26158,19356.99,,,19356.99,Other,150% of Medicare + 9.63% HCRA Surcharge,11771.1,45,,11771.1,percent of total billed charges,Critical Access Hospital RCC factor,8893.72,34,,8893.72,percent of total billed charges,Implant Device,8893.72,34,,8893.72,percent of total billed charges,Implant Device,8893.72,34,,8893.72,percent of total billed charges,Implant Device,8893.72,34,,8893.72,percent of total billed charges,Implant Device,8893.72,34,,8893.72,percent of total billed charges,Implant Device,12948.21,,,12948.21,Other,110% of Medicare,9155.3,35,,9155.3,percent of total billed charges,Implant Device,8893.72,34,"Charges > $500, x 34%",8893.72,percent of total billed charges,Implant Device,9155.3,35,,9155.3,percent of total billed charges,Implant Device,9155.3,35,,9155.3,percent of total billed charges,Implant Device,9155.3,35,,9155.3,percent of total billed charges,Implant Device,9155.3,35,,9155.3,percent of total billed charges,Implant Device,9155.3,35,,9155.3,percent of total billed charges,Implant Device,10463.2,40,,10463.2,percent of total billed charges,Implant Device,9155.3,70,,9155.3,percent of total billed charges,All Other,8893.72,34,,8893.72,percent of total billed charges,Implant Device,8893.72,34,,8893.72,percent of total billed charges,Implant Device,9155.3,35,,9155.3,percent of total billed charges,Implant Device,9155.3,35,,9155.3,percent of total billed charges,Implant Device,9155.3,35,,9155.3,percent of total billed charges,Implant Device,9155.3,35,,9155.3,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,8893.72,34,"If Charge > 2,000, then 34 percent",8893.72,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,19356.99,
STRYKER 5521-B-400 TIBIAL BASEPLATE SZ 4,C1776,HCPCS,,79005091,CDM,278,RC,,,both,,,3337,2469.39,,,2469.39,Other,150% of Medicare + 9.63% HCRA Surcharge,1501.65,45,,1501.65,percent of total billed charges,Critical Access Hospital RCC factor,1134.58,34,,1134.58,percent of total billed charges,Implant Device,1134.58,34,,1134.58,percent of total billed charges,Implant Device,1134.58,34,,1134.58,percent of total billed charges,Implant Device,1134.58,34,,1134.58,percent of total billed charges,Implant Device,1134.58,34,,1134.58,percent of total billed charges,Implant Device,1651.82,,,1651.82,Other,110% of Medicare,1167.95,35,,1167.95,percent of total billed charges,Implant Device,1134.58,34,"Charges > $500, x 34%",1134.58,percent of total billed charges,Implant Device,1167.95,35,,1167.95,percent of total billed charges,Implant Device,1167.95,35,,1167.95,percent of total billed charges,Implant Device,1167.95,35,,1167.95,percent of total billed charges,Implant Device,1167.95,35,,1167.95,percent of total billed charges,Implant Device,1167.95,35,,1167.95,percent of total billed charges,Implant Device,1334.8,40,,1334.8,percent of total billed charges,Implant Device,1167.95,70,,1167.95,percent of total billed charges,All Other,1134.58,34,,1134.58,percent of total billed charges,Implant Device,1134.58,34,,1134.58,percent of total billed charges,Implant Device,1167.95,35,,1167.95,percent of total billed charges,Implant Device,1167.95,35,,1167.95,percent of total billed charges,Implant Device,1167.95,35,,1167.95,percent of total billed charges,Implant Device,1167.95,35,,1167.95,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1134.58,34,"If Charge > 2,000, then 34 percent",1134.58,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2469.39,
STRYKER 5551-G-320 PATELLA SZ A32X10MM,C1776,HCPCS,,79005092,CDM,278,RC,,,both,,,1500,1110,,,1110,Other,150% of Medicare + 9.63% HCRA Surcharge,675,45,,675,percent of total billed charges,Critical Access Hospital RCC factor,510,34,,510,percent of total billed charges,Implant Device,510,34,,510,percent of total billed charges,Implant Device,510,34,,510,percent of total billed charges,Implant Device,510,34,,510,percent of total billed charges,Implant Device,510,34,,510,percent of total billed charges,Implant Device,742.5,,,742.5,Other,110% of Medicare,525,35,,525,percent of total billed charges,Implant Device,510,34,"Charges > $500, x 34%",510,percent of total billed charges,Implant Device,525,35,,525,percent of total billed charges,Implant Device,525,35,,525,percent of total billed charges,Implant Device,525,35,,525,percent of total billed charges,Implant Device,525,35,,525,percent of total billed charges,Implant Device,525,35,,525,percent of total billed charges,Implant Device,600,40,,600,percent of total billed charges,Implant Device,525,70,,525,percent of total billed charges,All Other,510,34,,510,percent of total billed charges,Implant Device,510,34,,510,percent of total billed charges,Implant Device,525,35,,525,percent of total billed charges,Implant Device,525,35,,525,percent of total billed charges,Implant Device,525,35,,525,percent of total billed charges,Implant Device,525,35,,525,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1110,
STRYKER 5537-G-409 TIBIAL INSRT SZ 4X9MM,C1776,HCPCS,,79005093,CDM,278,RC,,,both,,,10128,7494.75,,,7494.75,Other,150% of Medicare + 9.63% HCRA Surcharge,4557.6,45,,4557.6,percent of total billed charges,Critical Access Hospital RCC factor,3443.52,34,,3443.52,percent of total billed charges,Implant Device,3443.52,34,,3443.52,percent of total billed charges,Implant Device,3443.52,34,,3443.52,percent of total billed charges,Implant Device,3443.52,34,,3443.52,percent of total billed charges,Implant Device,3443.52,34,,3443.52,percent of total billed charges,Implant Device,5013.36,,,5013.36,Other,110% of Medicare,3544.8,35,,3544.8,percent of total billed charges,Implant Device,3443.52,34,"Charges > $500, x 34%",3443.52,percent of total billed charges,Implant Device,3544.8,35,,3544.8,percent of total billed charges,Implant Device,3544.8,35,,3544.8,percent of total billed charges,Implant Device,3544.8,35,,3544.8,percent of total billed charges,Implant Device,3544.8,35,,3544.8,percent of total billed charges,Implant Device,3544.8,35,,3544.8,percent of total billed charges,Implant Device,4051.2,40,,4051.2,percent of total billed charges,Implant Device,3544.8,70,,3544.8,percent of total billed charges,All Other,3443.52,34,,3443.52,percent of total billed charges,Implant Device,3443.52,34,,3443.52,percent of total billed charges,Implant Device,3544.8,35,,3544.8,percent of total billed charges,Implant Device,3544.8,35,,3544.8,percent of total billed charges,Implant Device,3544.8,35,,3544.8,percent of total billed charges,Implant Device,3544.8,35,,3544.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3443.52,34,"If Charge > 2,000, then 34 percent",3443.52,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,7494.75,
STRYKER 5566-S-013 FLUTED STEM 13X150MM,C1776,HCPCS,,79005094,CDM,278,RC,,,both,,,5527,4089.99,,,4089.99,Other,150% of Medicare + 9.63% HCRA Surcharge,2487.15,45,,2487.15,percent of total billed charges,Critical Access Hospital RCC factor,1879.18,34,,1879.18,percent of total billed charges,Implant Device,1879.18,34,,1879.18,percent of total billed charges,Implant Device,1879.18,34,,1879.18,percent of total billed charges,Implant Device,1879.18,34,,1879.18,percent of total billed charges,Implant Device,1879.18,34,,1879.18,percent of total billed charges,Implant Device,2735.87,,,2735.87,Other,110% of Medicare,1934.45,35,,1934.45,percent of total billed charges,Implant Device,1879.18,34,"Charges > $500, x 34%",1879.18,percent of total billed charges,Implant Device,1934.45,35,,1934.45,percent of total billed charges,Implant Device,1934.45,35,,1934.45,percent of total billed charges,Implant Device,1934.45,35,,1934.45,percent of total billed charges,Implant Device,1934.45,35,,1934.45,percent of total billed charges,Implant Device,1934.45,35,,1934.45,percent of total billed charges,Implant Device,2210.8,40,,2210.8,percent of total billed charges,Implant Device,1934.45,70,,1934.45,percent of total billed charges,All Other,1879.18,34,,1879.18,percent of total billed charges,Implant Device,1879.18,34,,1879.18,percent of total billed charges,Implant Device,1934.45,35,,1934.45,percent of total billed charges,Implant Device,1934.45,35,,1934.45,percent of total billed charges,Implant Device,1934.45,35,,1934.45,percent of total billed charges,Implant Device,1934.45,35,,1934.45,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1879.18,34,"If Charge > 2,000, then 34 percent",1879.18,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4089.99,
STRYKER 5566-S-015 FLUTED STEM 15X150MM,C1776,HCPCS,,79005095,CDM,278,RC,,,both,,,5527,4089.99,,,4089.99,Other,150% of Medicare + 9.63% HCRA Surcharge,2487.15,45,,2487.15,percent of total billed charges,Critical Access Hospital RCC factor,1879.18,34,,1879.18,percent of total billed charges,Implant Device,1879.18,34,,1879.18,percent of total billed charges,Implant Device,1879.18,34,,1879.18,percent of total billed charges,Implant Device,1879.18,34,,1879.18,percent of total billed charges,Implant Device,1879.18,34,,1879.18,percent of total billed charges,Implant Device,2735.87,,,2735.87,Other,110% of Medicare,1934.45,35,,1934.45,percent of total billed charges,Implant Device,1879.18,34,"Charges > $500, x 34%",1879.18,percent of total billed charges,Implant Device,1934.45,35,,1934.45,percent of total billed charges,Implant Device,1934.45,35,,1934.45,percent of total billed charges,Implant Device,1934.45,35,,1934.45,percent of total billed charges,Implant Device,1934.45,35,,1934.45,percent of total billed charges,Implant Device,1934.45,35,,1934.45,percent of total billed charges,Implant Device,2210.8,40,,2210.8,percent of total billed charges,Implant Device,1934.45,70,,1934.45,percent of total billed charges,All Other,1879.18,34,,1879.18,percent of total billed charges,Implant Device,1879.18,34,,1879.18,percent of total billed charges,Implant Device,1934.45,35,,1934.45,percent of total billed charges,Implant Device,1934.45,35,,1934.45,percent of total billed charges,Implant Device,1934.45,35,,1934.45,percent of total billed charges,Implant Device,1934.45,35,,1934.45,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1879.18,34,"If Charge > 2,000, then 34 percent",1879.18,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4089.99,
STRYKER 5546-A-402 TIBIAL AUG SZ 4 10MM,C1776,HCPCS,,79005096,CDM,278,RC,,,both,,,4493,3324.83,,,3324.83,Other,150% of Medicare + 9.63% HCRA Surcharge,2021.85,45,,2021.85,percent of total billed charges,Critical Access Hospital RCC factor,1527.62,34,,1527.62,percent of total billed charges,Implant Device,1527.62,34,,1527.62,percent of total billed charges,Implant Device,1527.62,34,,1527.62,percent of total billed charges,Implant Device,1527.62,34,,1527.62,percent of total billed charges,Implant Device,1527.62,34,,1527.62,percent of total billed charges,Implant Device,2224.04,,,2224.04,Other,110% of Medicare,1572.55,35,,1572.55,percent of total billed charges,Implant Device,1527.62,34,"Charges > $500, x 34%",1527.62,percent of total billed charges,Implant Device,1572.55,35,,1572.55,percent of total billed charges,Implant Device,1572.55,35,,1572.55,percent of total billed charges,Implant Device,1572.55,35,,1572.55,percent of total billed charges,Implant Device,1572.55,35,,1572.55,percent of total billed charges,Implant Device,1572.55,35,,1572.55,percent of total billed charges,Implant Device,1797.2,40,,1797.2,percent of total billed charges,Implant Device,1572.55,70,,1572.55,percent of total billed charges,All Other,1527.62,34,,1527.62,percent of total billed charges,Implant Device,1527.62,34,,1527.62,percent of total billed charges,Implant Device,1572.55,35,,1572.55,percent of total billed charges,Implant Device,1572.55,35,,1572.55,percent of total billed charges,Implant Device,1572.55,35,,1572.55,percent of total billed charges,Implant Device,1572.55,35,,1572.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1527.62,34,"If Charge > 2,000, then 34 percent",1527.62,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3324.83,
STRYKER 5543-A-400 FEMORAL AUGMENT 5MM,C1776,HCPCS,,79005097,CDM,278,RC,,,both,,,5041,3730.35,,,3730.35,Other,150% of Medicare + 9.63% HCRA Surcharge,2268.45,45,,2268.45,percent of total billed charges,Critical Access Hospital RCC factor,1713.94,34,,1713.94,percent of total billed charges,Implant Device,1713.94,34,,1713.94,percent of total billed charges,Implant Device,1713.94,34,,1713.94,percent of total billed charges,Implant Device,1713.94,34,,1713.94,percent of total billed charges,Implant Device,1713.94,34,,1713.94,percent of total billed charges,Implant Device,2495.3,,,2495.3,Other,110% of Medicare,1764.35,35,,1764.35,percent of total billed charges,Implant Device,1713.94,34,"Charges > $500, x 34%",1713.94,percent of total billed charges,Implant Device,1764.35,35,,1764.35,percent of total billed charges,Implant Device,1764.35,35,,1764.35,percent of total billed charges,Implant Device,1764.35,35,,1764.35,percent of total billed charges,Implant Device,1764.35,35,,1764.35,percent of total billed charges,Implant Device,1764.35,35,,1764.35,percent of total billed charges,Implant Device,2016.4,40,,2016.4,percent of total billed charges,Implant Device,1764.35,70,,1764.35,percent of total billed charges,All Other,1713.94,34,,1713.94,percent of total billed charges,Implant Device,1713.94,34,,1713.94,percent of total billed charges,Implant Device,1764.35,35,,1764.35,percent of total billed charges,Implant Device,1764.35,35,,1764.35,percent of total billed charges,Implant Device,1764.35,35,,1764.35,percent of total billed charges,Implant Device,1764.35,35,,1764.35,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1713.94,34,"If Charge > 2,000, then 34 percent",1713.94,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3730.35,
ZIMMER 5988-10-17 STEM EXT STR 17X100MM,C1776,HCPCS,,79005098,CDM,278,RC,,,both,,,2970,2197.81,,,2197.81,Other,150% of Medicare + 9.63% HCRA Surcharge,1336.5,45,,1336.5,percent of total billed charges,Critical Access Hospital RCC factor,1009.8,34,,1009.8,percent of total billed charges,Implant Device,1009.8,34,,1009.8,percent of total billed charges,Implant Device,1009.8,34,,1009.8,percent of total billed charges,Implant Device,1009.8,34,,1009.8,percent of total billed charges,Implant Device,1009.8,34,,1009.8,percent of total billed charges,Implant Device,1470.15,,,1470.15,Other,110% of Medicare,1039.5,35,,1039.5,percent of total billed charges,Implant Device,1009.8,34,"Charges > $500, x 34%",1009.8,percent of total billed charges,Implant Device,1039.5,35,,1039.5,percent of total billed charges,Implant Device,1039.5,35,,1039.5,percent of total billed charges,Implant Device,1039.5,35,,1039.5,percent of total billed charges,Implant Device,1039.5,35,,1039.5,percent of total billed charges,Implant Device,1039.5,35,,1039.5,percent of total billed charges,Implant Device,1188,40,,1188,percent of total billed charges,Implant Device,1039.5,70,,1039.5,percent of total billed charges,All Other,1009.8,34,,1009.8,percent of total billed charges,Implant Device,1009.8,34,,1009.8,percent of total billed charges,Implant Device,1039.5,35,,1039.5,percent of total billed charges,Implant Device,1039.5,35,,1039.5,percent of total billed charges,Implant Device,1039.5,35,,1039.5,percent of total billed charges,Implant Device,1039.5,35,,1039.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1009.8,34,"If Charge > 2,000, then 34 percent",1009.8,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2197.81,
ZIMMER 5994-32-14 ARTICULAR SURFACE 14MM,C1776,HCPCS,,79005099,CDM,278,RC,,,both,,,6773,5012.04,,,5012.04,Other,150% of Medicare + 9.63% HCRA Surcharge,3047.85,45,,3047.85,percent of total billed charges,Critical Access Hospital RCC factor,2302.82,34,,2302.82,percent of total billed charges,Implant Device,2302.82,34,,2302.82,percent of total billed charges,Implant Device,2302.82,34,,2302.82,percent of total billed charges,Implant Device,2302.82,34,,2302.82,percent of total billed charges,Implant Device,2302.82,34,,2302.82,percent of total billed charges,Implant Device,3352.64,,,3352.64,Other,110% of Medicare,2370.55,35,,2370.55,percent of total billed charges,Implant Device,2302.82,34,"Charges > $500, x 34%",2302.82,percent of total billed charges,Implant Device,2370.55,35,,2370.55,percent of total billed charges,Implant Device,2370.55,35,,2370.55,percent of total billed charges,Implant Device,2370.55,35,,2370.55,percent of total billed charges,Implant Device,2370.55,35,,2370.55,percent of total billed charges,Implant Device,2370.55,35,,2370.55,percent of total billed charges,Implant Device,2709.2,40,,2709.2,percent of total billed charges,Implant Device,2370.55,70,,2370.55,percent of total billed charges,All Other,2302.82,34,,2302.82,percent of total billed charges,Implant Device,2302.82,34,,2302.82,percent of total billed charges,Implant Device,2370.55,35,,2370.55,percent of total billed charges,Implant Device,2370.55,35,,2370.55,percent of total billed charges,Implant Device,2370.55,35,,2370.55,percent of total billed charges,Implant Device,2370.55,35,,2370.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2302.82,34,"If Charge > 2,000, then 34 percent",2302.82,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5012.04,
STRYKER 437302 TIBIA LOCK PLATE 2 HOLE,C1713,HCPCS,,79005100,CDM,278,RC,,,both,,,5315,3933.11,,,3933.11,Other,150% of Medicare + 9.63% HCRA Surcharge,2391.75,45,,2391.75,percent of total billed charges,Critical Access Hospital RCC factor,1807.1,34,,1807.1,percent of total billed charges,Implant Device,1807.1,34,,1807.1,percent of total billed charges,Implant Device,1807.1,34,,1807.1,percent of total billed charges,Implant Device,1807.1,34,,1807.1,percent of total billed charges,Implant Device,1807.1,34,,1807.1,percent of total billed charges,Implant Device,2630.93,,,2630.93,Other,110% of Medicare,1860.25,35,,1860.25,percent of total billed charges,Implant Device,1807.1,34,"Charges > $500, x 34%",1807.1,percent of total billed charges,Implant Device,1860.25,35,,1860.25,percent of total billed charges,Implant Device,1860.25,35,,1860.25,percent of total billed charges,Implant Device,1860.25,35,,1860.25,percent of total billed charges,Implant Device,1860.25,35,,1860.25,percent of total billed charges,Implant Device,1860.25,35,,1860.25,percent of total billed charges,Implant Device,2126,40,,2126,percent of total billed charges,Implant Device,1860.25,70,,1860.25,percent of total billed charges,All Other,1807.1,34,,1807.1,percent of total billed charges,Implant Device,1807.1,34,,1807.1,percent of total billed charges,Implant Device,1860.25,35,,1860.25,percent of total billed charges,Implant Device,1860.25,35,,1860.25,percent of total billed charges,Implant Device,1860.25,35,,1860.25,percent of total billed charges,Implant Device,1860.25,35,,1860.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1807.1,34,"If Charge > 2,000, then 34 percent",1807.1,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3933.11,
STRYKER 427036S LOCK PLATE 6 HOLE 4MM,C1713,HCPCS,,79005101,CDM,278,RC,,,both,,,1826,1351.24,,,1351.24,Other,150% of Medicare + 9.63% HCRA Surcharge,821.7,45,,821.7,percent of total billed charges,Critical Access Hospital RCC factor,620.84,34,,620.84,percent of total billed charges,Implant Device,620.84,34,,620.84,percent of total billed charges,Implant Device,620.84,34,,620.84,percent of total billed charges,Implant Device,620.84,34,,620.84,percent of total billed charges,Implant Device,620.84,34,,620.84,percent of total billed charges,Implant Device,903.87,,,903.87,Other,110% of Medicare,639.1,35,,639.1,percent of total billed charges,Implant Device,620.84,34,"Charges > $500, x 34%",620.84,percent of total billed charges,Implant Device,639.1,35,,639.1,percent of total billed charges,Implant Device,639.1,35,,639.1,percent of total billed charges,Implant Device,639.1,35,,639.1,percent of total billed charges,Implant Device,639.1,35,,639.1,percent of total billed charges,Implant Device,639.1,35,,639.1,percent of total billed charges,Implant Device,730.4,40,,730.4,percent of total billed charges,Implant Device,639.1,70,,639.1,percent of total billed charges,All Other,620.84,34,,620.84,percent of total billed charges,Implant Device,620.84,34,,620.84,percent of total billed charges,Implant Device,639.1,35,,639.1,percent of total billed charges,Implant Device,639.1,35,,639.1,percent of total billed charges,Implant Device,639.1,35,,639.1,percent of total billed charges,Implant Device,639.1,35,,639.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1351.24,
STRYKER 371565 LOCKING SCREW 4X65MM,C1713,HCPCS,,79005102,CDM,278,RC,,,both,,,541,400.34,,,400.34,Other,150% of Medicare + 9.63% HCRA Surcharge,243.45,45,,243.45,percent of total billed charges,Critical Access Hospital RCC factor,183.94,34,,183.94,percent of total billed charges,Implant Device,183.94,34,,183.94,percent of total billed charges,Implant Device,183.94,34,,183.94,percent of total billed charges,Implant Device,183.94,34,,183.94,percent of total billed charges,Implant Device,183.94,34,,183.94,percent of total billed charges,Implant Device,267.8,,,267.8,Other,110% of Medicare,189.35,35,,189.35,percent of total billed charges,Implant Device,183.94,34,"Charges > $500, x 34%",183.94,percent of total billed charges,Implant Device,189.35,35,,189.35,percent of total billed charges,Implant Device,189.35,35,,189.35,percent of total billed charges,Implant Device,189.35,35,,189.35,percent of total billed charges,Implant Device,189.35,35,,189.35,percent of total billed charges,Implant Device,189.35,35,,189.35,percent of total billed charges,Implant Device,216.4,40,,216.4,percent of total billed charges,Implant Device,189.35,70,,189.35,percent of total billed charges,All Other,183.94,34,,183.94,percent of total billed charges,Implant Device,183.94,34,,183.94,percent of total billed charges,Implant Device,189.35,35,,189.35,percent of total billed charges,Implant Device,189.35,35,,189.35,percent of total billed charges,Implant Device,189.35,35,,189.35,percent of total billed charges,Implant Device,189.35,35,,189.35,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,400.34,
STRYKER 371580 LOCKING SCREW 4X80MM,C1713,HCPCS,,79005103,CDM,278,RC,,,both,,,541,400.34,,,400.34,Other,150% of Medicare + 9.63% HCRA Surcharge,243.45,45,,243.45,percent of total billed charges,Critical Access Hospital RCC factor,183.94,34,,183.94,percent of total billed charges,Implant Device,183.94,34,,183.94,percent of total billed charges,Implant Device,183.94,34,,183.94,percent of total billed charges,Implant Device,183.94,34,,183.94,percent of total billed charges,Implant Device,183.94,34,,183.94,percent of total billed charges,Implant Device,267.8,,,267.8,Other,110% of Medicare,189.35,35,,189.35,percent of total billed charges,Implant Device,183.94,34,"Charges > $500, x 34%",183.94,percent of total billed charges,Implant Device,189.35,35,,189.35,percent of total billed charges,Implant Device,189.35,35,,189.35,percent of total billed charges,Implant Device,189.35,35,,189.35,percent of total billed charges,Implant Device,189.35,35,,189.35,percent of total billed charges,Implant Device,189.35,35,,189.35,percent of total billed charges,Implant Device,216.4,40,,216.4,percent of total billed charges,Implant Device,189.35,70,,189.35,percent of total billed charges,All Other,183.94,34,,183.94,percent of total billed charges,Implant Device,183.94,34,,183.94,percent of total billed charges,Implant Device,189.35,35,,189.35,percent of total billed charges,Implant Device,189.35,35,,189.35,percent of total billed charges,Implant Device,189.35,35,,189.35,percent of total billed charges,Implant Device,189.35,35,,189.35,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,400.34,
STRYKER 371585 LOCKING SCREW 4X85MM,C1713,HCPCS,,79005104,CDM,278,RC,,,both,,,541,400.34,,,400.34,Other,150% of Medicare + 9.63% HCRA Surcharge,243.45,45,,243.45,percent of total billed charges,Critical Access Hospital RCC factor,183.94,34,,183.94,percent of total billed charges,Implant Device,183.94,34,,183.94,percent of total billed charges,Implant Device,183.94,34,,183.94,percent of total billed charges,Implant Device,183.94,34,,183.94,percent of total billed charges,Implant Device,183.94,34,,183.94,percent of total billed charges,Implant Device,267.8,,,267.8,Other,110% of Medicare,189.35,35,,189.35,percent of total billed charges,Implant Device,183.94,34,"Charges > $500, x 34%",183.94,percent of total billed charges,Implant Device,189.35,35,,189.35,percent of total billed charges,Implant Device,189.35,35,,189.35,percent of total billed charges,Implant Device,189.35,35,,189.35,percent of total billed charges,Implant Device,189.35,35,,189.35,percent of total billed charges,Implant Device,189.35,35,,189.35,percent of total billed charges,Implant Device,216.4,40,,216.4,percent of total billed charges,Implant Device,189.35,70,,189.35,percent of total billed charges,All Other,183.94,34,,183.94,percent of total billed charges,Implant Device,183.94,34,,183.94,percent of total billed charges,Implant Device,189.35,35,,189.35,percent of total billed charges,Implant Device,189.35,35,,189.35,percent of total billed charges,Implant Device,189.35,35,,189.35,percent of total billed charges,Implant Device,189.35,35,,189.35,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,400.34,
STRYKER 371590 LOCKING SCREW 4X90MM,C1713,HCPCS,,79005105,CDM,278,RC,,,both,,,541,400.34,,,400.34,Other,150% of Medicare + 9.63% HCRA Surcharge,243.45,45,,243.45,percent of total billed charges,Critical Access Hospital RCC factor,183.94,34,,183.94,percent of total billed charges,Implant Device,183.94,34,,183.94,percent of total billed charges,Implant Device,183.94,34,,183.94,percent of total billed charges,Implant Device,183.94,34,,183.94,percent of total billed charges,Implant Device,183.94,34,,183.94,percent of total billed charges,Implant Device,267.8,,,267.8,Other,110% of Medicare,189.35,35,,189.35,percent of total billed charges,Implant Device,183.94,34,"Charges > $500, x 34%",183.94,percent of total billed charges,Implant Device,189.35,35,,189.35,percent of total billed charges,Implant Device,189.35,35,,189.35,percent of total billed charges,Implant Device,189.35,35,,189.35,percent of total billed charges,Implant Device,189.35,35,,189.35,percent of total billed charges,Implant Device,189.35,35,,189.35,percent of total billed charges,Implant Device,216.4,40,,216.4,percent of total billed charges,Implant Device,189.35,70,,189.35,percent of total billed charges,All Other,183.94,34,,183.94,percent of total billed charges,Implant Device,183.94,34,,183.94,percent of total billed charges,Implant Device,189.35,35,,189.35,percent of total billed charges,Implant Device,189.35,35,,189.35,percent of total billed charges,Implant Device,189.35,35,,189.35,percent of total billed charges,Implant Device,189.35,35,,189.35,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,400.34,
STRYKER 338644 CORTICAL SCREW 3.5X44MM,C1713,HCPCS,,79005106,CDM,278,RC,,,both,,,115,85.1,,,85.1,Other,150% of Medicare + 9.63% HCRA Surcharge,51.75,45,,51.75,percent of total billed charges,Critical Access Hospital RCC factor,39.1,34,,39.1,percent of total billed charges,Implant Device,39.1,34,,39.1,percent of total billed charges,Implant Device,39.1,34,,39.1,percent of total billed charges,Implant Device,39.1,34,,39.1,percent of total billed charges,Implant Device,39.1,34,,39.1,percent of total billed charges,Implant Device,56.93,,,56.93,Other,110% of Medicare,40.25,35,,40.25,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,40.25,35,,40.25,percent of total billed charges,Implant Device,40.25,35,,40.25,percent of total billed charges,Implant Device,40.25,35,,40.25,percent of total billed charges,Implant Device,40.25,35,,40.25,percent of total billed charges,Implant Device,40.25,35,,40.25,percent of total billed charges,Implant Device,46,40,,46,percent of total billed charges,Implant Device,40.25,70,,40.25,percent of total billed charges,All Other,39.1,34,,39.1,percent of total billed charges,Implant Device,39.1,34,,39.1,percent of total billed charges,Implant Device,40.25,35,,40.25,percent of total billed charges,Implant Device,40.25,35,,40.25,percent of total billed charges,Implant Device,40.25,35,,40.25,percent of total billed charges,Implant Device,40.25,35,,40.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,85.1,
STRYKER 338695 CORTICAL SCREW 3.5X95MM,C1713,HCPCS,,79005107,CDM,278,RC,,,both,,,115,85.1,,,85.1,Other,150% of Medicare + 9.63% HCRA Surcharge,51.75,45,,51.75,percent of total billed charges,Critical Access Hospital RCC factor,39.1,34,,39.1,percent of total billed charges,Implant Device,39.1,34,,39.1,percent of total billed charges,Implant Device,39.1,34,,39.1,percent of total billed charges,Implant Device,39.1,34,,39.1,percent of total billed charges,Implant Device,39.1,34,,39.1,percent of total billed charges,Implant Device,56.93,,,56.93,Other,110% of Medicare,40.25,35,,40.25,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,40.25,35,,40.25,percent of total billed charges,Implant Device,40.25,35,,40.25,percent of total billed charges,Implant Device,40.25,35,,40.25,percent of total billed charges,Implant Device,40.25,35,,40.25,percent of total billed charges,Implant Device,40.25,35,,40.25,percent of total billed charges,Implant Device,46,40,,46,percent of total billed charges,Implant Device,40.25,70,,40.25,percent of total billed charges,All Other,39.1,34,,39.1,percent of total billed charges,Implant Device,39.1,34,,39.1,percent of total billed charges,Implant Device,40.25,35,,40.25,percent of total billed charges,Implant Device,40.25,35,,40.25,percent of total billed charges,Implant Device,40.25,35,,40.25,percent of total billed charges,Implant Device,40.25,35,,40.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,85.1,
STRYKER 7650-2038A HEADLESS PIN 3.2X89MM,C1713,HCPCS,,79005110,CDM,278,RC,,,both,,,1353,1001.22,,,1001.22,Other,150% of Medicare + 9.63% HCRA Surcharge,608.85,45,,608.85,percent of total billed charges,Critical Access Hospital RCC factor,460.02,34,,460.02,percent of total billed charges,Implant Device,460.02,34,,460.02,percent of total billed charges,Implant Device,460.02,34,,460.02,percent of total billed charges,Implant Device,460.02,34,,460.02,percent of total billed charges,Implant Device,460.02,34,,460.02,percent of total billed charges,Implant Device,669.74,,,669.74,Other,110% of Medicare,473.55,35,,473.55,percent of total billed charges,Implant Device,460.02,34,"Charges > $500, x 34%",460.02,percent of total billed charges,Implant Device,473.55,35,,473.55,percent of total billed charges,Implant Device,473.55,35,,473.55,percent of total billed charges,Implant Device,473.55,35,,473.55,percent of total billed charges,Implant Device,473.55,35,,473.55,percent of total billed charges,Implant Device,473.55,35,,473.55,percent of total billed charges,Implant Device,541.2,40,,541.2,percent of total billed charges,Implant Device,473.55,70,,473.55,percent of total billed charges,All Other,460.02,34,,460.02,percent of total billed charges,Implant Device,460.02,34,,460.02,percent of total billed charges,Implant Device,473.55,35,,473.55,percent of total billed charges,Implant Device,473.55,35,,473.55,percent of total billed charges,Implant Device,473.55,35,,473.55,percent of total billed charges,Implant Device,473.55,35,,473.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1001.22,
EXACTECH 320-38-00 HUMERAL LINER 38 +0MM,C1776,HCPCS,,79005111,CDM,278,RC,,,both,,,2325,1720.51,,,1720.51,Other,150% of Medicare + 9.63% HCRA Surcharge,1046.25,45,,1046.25,percent of total billed charges,Critical Access Hospital RCC factor,790.5,34,,790.5,percent of total billed charges,Implant Device,790.5,34,,790.5,percent of total billed charges,Implant Device,790.5,34,,790.5,percent of total billed charges,Implant Device,790.5,34,,790.5,percent of total billed charges,Implant Device,790.5,34,,790.5,percent of total billed charges,Implant Device,1150.88,,,1150.88,Other,110% of Medicare,813.75,35,,813.75,percent of total billed charges,Implant Device,790.5,34,"Charges > $500, x 34%",790.5,percent of total billed charges,Implant Device,813.75,35,,813.75,percent of total billed charges,Implant Device,813.75,35,,813.75,percent of total billed charges,Implant Device,813.75,35,,813.75,percent of total billed charges,Implant Device,813.75,35,,813.75,percent of total billed charges,Implant Device,813.75,35,,813.75,percent of total billed charges,Implant Device,930,40,,930,percent of total billed charges,Implant Device,813.75,70,,813.75,percent of total billed charges,All Other,790.5,34,,790.5,percent of total billed charges,Implant Device,790.5,34,,790.5,percent of total billed charges,Implant Device,813.75,35,,813.75,percent of total billed charges,Implant Device,813.75,35,,813.75,percent of total billed charges,Implant Device,813.75,35,,813.75,percent of total billed charges,Implant Device,813.75,35,,813.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,790.5,34,"If Charge > 2,000, then 34 percent",790.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1720.51,
GORE ECH060040A VASCULAR GRAFT,C1768,HCPCS,,79005112,CDM,278,RC,,,both,,,3840,2841.61,,,2841.61,Other,150% of Medicare + 9.63% HCRA Surcharge,1728,45,,1728,percent of total billed charges,Critical Access Hospital RCC factor,1305.6,34,,1305.6,percent of total billed charges,Implant Device,1305.6,34,,1305.6,percent of total billed charges,Implant Device,1305.6,34,,1305.6,percent of total billed charges,Implant Device,1305.6,34,,1305.6,percent of total billed charges,Implant Device,1305.6,34,,1305.6,percent of total billed charges,Implant Device,1900.8,,,1900.8,Other,110% of Medicare,1344,35,,1344,percent of total billed charges,Implant Device,1305.6,34,"Charges > $500, x 34%",1305.6,percent of total billed charges,Implant Device,1344,35,,1344,percent of total billed charges,Implant Device,1344,35,,1344,percent of total billed charges,Implant Device,1344,35,,1344,percent of total billed charges,Implant Device,1344,35,,1344,percent of total billed charges,Implant Device,1344,35,,1344,percent of total billed charges,Implant Device,1536,40,,1536,percent of total billed charges,Implant Device,1344,70,,1344,percent of total billed charges,All Other,1305.6,34,,1305.6,percent of total billed charges,Implant Device,1305.6,34,,1305.6,percent of total billed charges,Implant Device,1344,35,,1344,percent of total billed charges,Implant Device,1344,35,,1344,percent of total billed charges,Implant Device,1344,35,,1344,percent of total billed charges,Implant Device,1344,35,,1344,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1305.6,34,"If Charge > 2,000, then 34 percent",1305.6,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2841.61,
BIOMET 0495 FEMUR HEAD 45-0039,C1776,HCPCS,,79005115,CDM,278,RC,,,both,,,4044,2992.57,,,2992.57,Other,150% of Medicare + 9.63% HCRA Surcharge,1819.8,45,,1819.8,percent of total billed charges,Critical Access Hospital RCC factor,1374.96,34,,1374.96,percent of total billed charges,Implant Device,1374.96,34,,1374.96,percent of total billed charges,Implant Device,1374.96,34,,1374.96,percent of total billed charges,Implant Device,1374.96,34,,1374.96,percent of total billed charges,Implant Device,1374.96,34,,1374.96,percent of total billed charges,Implant Device,2001.78,,,2001.78,Other,110% of Medicare,1415.4,35,,1415.4,percent of total billed charges,Implant Device,1374.96,34,"Charges > $500, x 34%",1374.96,percent of total billed charges,Implant Device,1415.4,35,,1415.4,percent of total billed charges,Implant Device,1415.4,35,,1415.4,percent of total billed charges,Implant Device,1415.4,35,,1415.4,percent of total billed charges,Implant Device,1415.4,35,,1415.4,percent of total billed charges,Implant Device,1415.4,35,,1415.4,percent of total billed charges,Implant Device,1617.6,40,,1617.6,percent of total billed charges,Implant Device,1415.4,70,,1415.4,percent of total billed charges,All Other,1374.96,34,,1374.96,percent of total billed charges,Implant Device,1374.96,34,,1374.96,percent of total billed charges,Implant Device,1415.4,35,,1415.4,percent of total billed charges,Implant Device,1415.4,35,,1415.4,percent of total billed charges,Implant Device,1415.4,35,,1415.4,percent of total billed charges,Implant Device,1415.4,35,,1415.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1374.96,34,"If Charge > 2,000, then 34 percent",1374.96,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2992.57,
ALPHATEC SPINE 22015 ALPHATEC SET SCREW,C1713,HCPCS,,79005116,CDM,278,RC,,,both,,,540,399.6,,,399.6,Other,150% of Medicare + 9.63% HCRA Surcharge,243,45,,243,percent of total billed charges,Critical Access Hospital RCC factor,183.6,34,,183.6,percent of total billed charges,Implant Device,183.6,34,,183.6,percent of total billed charges,Implant Device,183.6,34,,183.6,percent of total billed charges,Implant Device,183.6,34,,183.6,percent of total billed charges,Implant Device,183.6,34,,183.6,percent of total billed charges,Implant Device,267.3,,,267.3,Other,110% of Medicare,189,35,,189,percent of total billed charges,Implant Device,183.6,34,"Charges > $500, x 34%",183.6,percent of total billed charges,Implant Device,189,35,,189,percent of total billed charges,Implant Device,189,35,,189,percent of total billed charges,Implant Device,189,35,,189,percent of total billed charges,Implant Device,189,35,,189,percent of total billed charges,Implant Device,189,35,,189,percent of total billed charges,Implant Device,216,40,,216,percent of total billed charges,Implant Device,189,70,,189,percent of total billed charges,All Other,183.6,34,,183.6,percent of total billed charges,Implant Device,183.6,34,,183.6,percent of total billed charges,Implant Device,189,35,,189,percent of total billed charges,Implant Device,189,35,,189,percent of total billed charges,Implant Device,189,35,,189,percent of total billed charges,Implant Device,189,35,,189,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,399.6,
STRYKER 628068 RT CLAVICLE PLATE 8 HOLE,C1713,HCPCS,,79005118,CDM,278,RC,,,both,,,3374,2496.77,,,2496.77,Other,150% of Medicare + 9.63% HCRA Surcharge,1518.3,45,,1518.3,percent of total billed charges,Critical Access Hospital RCC factor,1147.16,34,,1147.16,percent of total billed charges,Implant Device,1147.16,34,,1147.16,percent of total billed charges,Implant Device,1147.16,34,,1147.16,percent of total billed charges,Implant Device,1147.16,34,,1147.16,percent of total billed charges,Implant Device,1147.16,34,,1147.16,percent of total billed charges,Implant Device,1670.13,,,1670.13,Other,110% of Medicare,1180.9,35,,1180.9,percent of total billed charges,Implant Device,1147.16,34,"Charges > $500, x 34%",1147.16,percent of total billed charges,Implant Device,1180.9,35,,1180.9,percent of total billed charges,Implant Device,1180.9,35,,1180.9,percent of total billed charges,Implant Device,1180.9,35,,1180.9,percent of total billed charges,Implant Device,1180.9,35,,1180.9,percent of total billed charges,Implant Device,1180.9,35,,1180.9,percent of total billed charges,Implant Device,1349.6,40,,1349.6,percent of total billed charges,Implant Device,1180.9,70,,1180.9,percent of total billed charges,All Other,1147.16,34,,1147.16,percent of total billed charges,Implant Device,1147.16,34,,1147.16,percent of total billed charges,Implant Device,1180.9,35,,1180.9,percent of total billed charges,Implant Device,1180.9,35,,1180.9,percent of total billed charges,Implant Device,1180.9,35,,1180.9,percent of total billed charges,Implant Device,1180.9,35,,1180.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1147.16,34,"If Charge > 2,000, then 34 percent",1147.16,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2496.77,
BIOMET 8157-61-075 CANC SCREW 6.5X75MM,C1713,HCPCS,,79005120,CDM,278,RC,,,both,,,270,199.8,,,199.8,Other,150% of Medicare + 9.63% HCRA Surcharge,121.5,45,,121.5,percent of total billed charges,Critical Access Hospital RCC factor,91.8,34,,91.8,percent of total billed charges,Implant Device,91.8,34,,91.8,percent of total billed charges,Implant Device,91.8,34,,91.8,percent of total billed charges,Implant Device,91.8,34,,91.8,percent of total billed charges,Implant Device,91.8,34,,91.8,percent of total billed charges,Implant Device,133.65,,,133.65,Other,110% of Medicare,94.5,35,,94.5,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,94.5,35,,94.5,percent of total billed charges,Implant Device,94.5,35,,94.5,percent of total billed charges,Implant Device,94.5,35,,94.5,percent of total billed charges,Implant Device,94.5,35,,94.5,percent of total billed charges,Implant Device,94.5,35,,94.5,percent of total billed charges,Implant Device,108,40,,108,percent of total billed charges,Implant Device,94.5,70,,94.5,percent of total billed charges,All Other,91.8,34,,91.8,percent of total billed charges,Implant Device,91.8,34,,91.8,percent of total billed charges,Implant Device,94.5,35,,94.5,percent of total billed charges,Implant Device,94.5,35,,94.5,percent of total billed charges,Implant Device,94.5,35,,94.5,percent of total billed charges,Implant Device,94.5,35,,94.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,199.8,
BIOMET 8157-61-080 CANC SCREW 6.5X80MM,C1713,HCPCS,,79005121,CDM,278,RC,,,both,,,270,199.8,,,199.8,Other,150% of Medicare + 9.63% HCRA Surcharge,121.5,45,,121.5,percent of total billed charges,Critical Access Hospital RCC factor,91.8,34,,91.8,percent of total billed charges,Implant Device,91.8,34,,91.8,percent of total billed charges,Implant Device,91.8,34,,91.8,percent of total billed charges,Implant Device,91.8,34,,91.8,percent of total billed charges,Implant Device,91.8,34,,91.8,percent of total billed charges,Implant Device,133.65,,,133.65,Other,110% of Medicare,94.5,35,,94.5,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,94.5,35,,94.5,percent of total billed charges,Implant Device,94.5,35,,94.5,percent of total billed charges,Implant Device,94.5,35,,94.5,percent of total billed charges,Implant Device,94.5,35,,94.5,percent of total billed charges,Implant Device,94.5,35,,94.5,percent of total billed charges,Implant Device,108,40,,108,percent of total billed charges,Implant Device,94.5,70,,94.5,percent of total billed charges,All Other,91.8,34,,91.8,percent of total billed charges,Implant Device,91.8,34,,91.8,percent of total billed charges,Implant Device,94.5,35,,94.5,percent of total billed charges,Implant Device,94.5,35,,94.5,percent of total billed charges,Implant Device,94.5,35,,94.5,percent of total billed charges,Implant Device,94.5,35,,94.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,199.8,
BIOMET 8157-61-085 CANC SCREW 6.5X85MM,C1713,HCPCS,,79005122,CDM,278,RC,,,both,,,270,199.8,,,199.8,Other,150% of Medicare + 9.63% HCRA Surcharge,121.5,45,,121.5,percent of total billed charges,Critical Access Hospital RCC factor,91.8,34,,91.8,percent of total billed charges,Implant Device,91.8,34,,91.8,percent of total billed charges,Implant Device,91.8,34,,91.8,percent of total billed charges,Implant Device,91.8,34,,91.8,percent of total billed charges,Implant Device,91.8,34,,91.8,percent of total billed charges,Implant Device,133.65,,,133.65,Other,110% of Medicare,94.5,35,,94.5,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,94.5,35,,94.5,percent of total billed charges,Implant Device,94.5,35,,94.5,percent of total billed charges,Implant Device,94.5,35,,94.5,percent of total billed charges,Implant Device,94.5,35,,94.5,percent of total billed charges,Implant Device,94.5,35,,94.5,percent of total billed charges,Implant Device,108,40,,108,percent of total billed charges,Implant Device,94.5,70,,94.5,percent of total billed charges,All Other,91.8,34,,91.8,percent of total billed charges,Implant Device,91.8,34,,91.8,percent of total billed charges,Implant Device,94.5,35,,94.5,percent of total billed charges,Implant Device,94.5,35,,94.5,percent of total billed charges,Implant Device,94.5,35,,94.5,percent of total billed charges,Implant Device,94.5,35,,94.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,199.8,
BIOMET 8157-62-040 CANC SCREW 6.5X40MM,C1713,HCPCS,,79005123,CDM,278,RC,,,both,,,240,177.6,,,177.6,Other,150% of Medicare + 9.63% HCRA Surcharge,108,45,,108,percent of total billed charges,Critical Access Hospital RCC factor,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,118.8,,,118.8,Other,110% of Medicare,84,35,,84,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,96,40,,96,percent of total billed charges,Implant Device,84,70,,84,percent of total billed charges,All Other,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,177.6,
STRYKER 3325-0340S LONG NAIL LT 11X340,C1713,HCPCS,,79005124,CDM,278,RC,,,both,,,9323,6899.04,,,6899.04,Other,150% of Medicare + 9.63% HCRA Surcharge,4195.35,45,,4195.35,percent of total billed charges,Critical Access Hospital RCC factor,3169.82,34,,3169.82,percent of total billed charges,Implant Device,3169.82,34,,3169.82,percent of total billed charges,Implant Device,3169.82,34,,3169.82,percent of total billed charges,Implant Device,3169.82,34,,3169.82,percent of total billed charges,Implant Device,3169.82,34,,3169.82,percent of total billed charges,Implant Device,4614.89,,,4614.89,Other,110% of Medicare,3263.05,35,,3263.05,percent of total billed charges,Implant Device,3169.82,34,"Charges > $500, x 34%",3169.82,percent of total billed charges,Implant Device,3263.05,35,,3263.05,percent of total billed charges,Implant Device,3263.05,35,,3263.05,percent of total billed charges,Implant Device,3263.05,35,,3263.05,percent of total billed charges,Implant Device,3263.05,35,,3263.05,percent of total billed charges,Implant Device,3263.05,35,,3263.05,percent of total billed charges,Implant Device,3729.2,40,,3729.2,percent of total billed charges,Implant Device,3263.05,70,,3263.05,percent of total billed charges,All Other,3169.82,34,,3169.82,percent of total billed charges,Implant Device,3169.82,34,,3169.82,percent of total billed charges,Implant Device,3263.05,35,,3263.05,percent of total billed charges,Implant Device,3263.05,35,,3263.05,percent of total billed charges,Implant Device,3263.05,35,,3263.05,percent of total billed charges,Implant Device,3263.05,35,,3263.05,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3169.82,34,"If Charge > 2,000, then 34 percent",3169.82,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,6899.04,
STRYKER 3060-0080S LAG SCREW 10.5X80MM,C1713,HCPCS,,79005125,CDM,278,RC,,,both,,,1230,910.2,,,910.2,Other,150% of Medicare + 9.63% HCRA Surcharge,553.5,45,,553.5,percent of total billed charges,Critical Access Hospital RCC factor,418.2,34,,418.2,percent of total billed charges,Implant Device,418.2,34,,418.2,percent of total billed charges,Implant Device,418.2,34,,418.2,percent of total billed charges,Implant Device,418.2,34,,418.2,percent of total billed charges,Implant Device,418.2,34,,418.2,percent of total billed charges,Implant Device,608.85,,,608.85,Other,110% of Medicare,430.5,35,,430.5,percent of total billed charges,Implant Device,418.2,34,"Charges > $500, x 34%",418.2,percent of total billed charges,Implant Device,430.5,35,,430.5,percent of total billed charges,Implant Device,430.5,35,,430.5,percent of total billed charges,Implant Device,430.5,35,,430.5,percent of total billed charges,Implant Device,430.5,35,,430.5,percent of total billed charges,Implant Device,430.5,35,,430.5,percent of total billed charges,Implant Device,492,40,,492,percent of total billed charges,Implant Device,430.5,70,,430.5,percent of total billed charges,All Other,418.2,34,,418.2,percent of total billed charges,Implant Device,418.2,34,,418.2,percent of total billed charges,Implant Device,430.5,35,,430.5,percent of total billed charges,Implant Device,430.5,35,,430.5,percent of total billed charges,Implant Device,430.5,35,,430.5,percent of total billed charges,Implant Device,430.5,35,,430.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,910.2,
MENTOR H/S 350-2425 SILICONE IMPLANT,C1789,HCPCS,,79005132,CDM,278,RC,,,both,,,2010,1487.41,,,1487.41,Other,150% of Medicare + 9.63% HCRA Surcharge,904.5,45,,904.5,percent of total billed charges,Critical Access Hospital RCC factor,683.4,34,,683.4,percent of total billed charges,Implant Device,683.4,34,,683.4,percent of total billed charges,Implant Device,683.4,34,,683.4,percent of total billed charges,Implant Device,683.4,34,,683.4,percent of total billed charges,Implant Device,683.4,34,,683.4,percent of total billed charges,Implant Device,994.95,,,994.95,Other,110% of Medicare,703.5,35,,703.5,percent of total billed charges,Implant Device,683.4,34,"Charges > $500, x 34%",683.4,percent of total billed charges,Implant Device,703.5,35,,703.5,percent of total billed charges,Implant Device,703.5,35,,703.5,percent of total billed charges,Implant Device,703.5,35,,703.5,percent of total billed charges,Implant Device,703.5,35,,703.5,percent of total billed charges,Implant Device,703.5,35,,703.5,percent of total billed charges,Implant Device,804,40,,804,percent of total billed charges,Implant Device,703.5,70,,703.5,percent of total billed charges,All Other,683.4,34,,683.4,percent of total billed charges,Implant Device,683.4,34,,683.4,percent of total billed charges,Implant Device,703.5,35,,703.5,percent of total billed charges,Implant Device,703.5,35,,703.5,percent of total billed charges,Implant Device,703.5,35,,703.5,percent of total billed charges,Implant Device,703.5,35,,703.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,683.4,34,"If Charge > 2,000, then 34 percent",683.4,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1487.41,
WRIGHT G47000003 FINGER JOINT IMP SZ 3,C1776,HCPCS,,79005134,CDM,278,RC,,,both,,,6756,4999.46,,,4999.46,Other,150% of Medicare + 9.63% HCRA Surcharge,3040.2,45,,3040.2,percent of total billed charges,Critical Access Hospital RCC factor,2297.04,34,,2297.04,percent of total billed charges,Implant Device,2297.04,34,,2297.04,percent of total billed charges,Implant Device,2297.04,34,,2297.04,percent of total billed charges,Implant Device,2297.04,34,,2297.04,percent of total billed charges,Implant Device,2297.04,34,,2297.04,percent of total billed charges,Implant Device,3344.22,,,3344.22,Other,110% of Medicare,2364.6,35,,2364.6,percent of total billed charges,Implant Device,2297.04,34,"Charges > $500, x 34%",2297.04,percent of total billed charges,Implant Device,2364.6,35,,2364.6,percent of total billed charges,Implant Device,2364.6,35,,2364.6,percent of total billed charges,Implant Device,2364.6,35,,2364.6,percent of total billed charges,Implant Device,2364.6,35,,2364.6,percent of total billed charges,Implant Device,2364.6,35,,2364.6,percent of total billed charges,Implant Device,2702.4,40,,2702.4,percent of total billed charges,Implant Device,2364.6,70,,2364.6,percent of total billed charges,All Other,2297.04,34,,2297.04,percent of total billed charges,Implant Device,2297.04,34,,2297.04,percent of total billed charges,Implant Device,2364.6,35,,2364.6,percent of total billed charges,Implant Device,2364.6,35,,2364.6,percent of total billed charges,Implant Device,2364.6,35,,2364.6,percent of total billed charges,Implant Device,2364.6,35,,2364.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2297.04,34,"If Charge > 2,000, then 34 percent",2297.04,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4999.46,
STRYKER 338626 3.5 CORTICAL SCREW 26MM,C1713,HCPCS,,79005148,CDM,278,RC,,,both,,,115,85.1,,,85.1,Other,150% of Medicare + 9.63% HCRA Surcharge,51.75,45,,51.75,percent of total billed charges,Critical Access Hospital RCC factor,39.1,34,,39.1,percent of total billed charges,Implant Device,39.1,34,,39.1,percent of total billed charges,Implant Device,39.1,34,,39.1,percent of total billed charges,Implant Device,39.1,34,,39.1,percent of total billed charges,Implant Device,39.1,34,,39.1,percent of total billed charges,Implant Device,56.93,,,56.93,Other,110% of Medicare,40.25,35,,40.25,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,40.25,35,,40.25,percent of total billed charges,Implant Device,40.25,35,,40.25,percent of total billed charges,Implant Device,40.25,35,,40.25,percent of total billed charges,Implant Device,40.25,35,,40.25,percent of total billed charges,Implant Device,40.25,35,,40.25,percent of total billed charges,Implant Device,46,40,,46,percent of total billed charges,Implant Device,40.25,70,,40.25,percent of total billed charges,All Other,39.1,34,,39.1,percent of total billed charges,Implant Device,39.1,34,,39.1,percent of total billed charges,Implant Device,40.25,35,,40.25,percent of total billed charges,Implant Device,40.25,35,,40.25,percent of total billed charges,Implant Device,40.25,35,,40.25,percent of total billed charges,Implant Device,40.25,35,,40.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,85.1,
STRYKER 371524 LOCKING SCREW 4X24MM,C1713,HCPCS,,79005149,CDM,278,RC,,,both,,,569,421.06,,,421.06,Other,150% of Medicare + 9.63% HCRA Surcharge,256.05,45,,256.05,percent of total billed charges,Critical Access Hospital RCC factor,193.46,34,,193.46,percent of total billed charges,Implant Device,193.46,34,,193.46,percent of total billed charges,Implant Device,193.46,34,,193.46,percent of total billed charges,Implant Device,193.46,34,,193.46,percent of total billed charges,Implant Device,193.46,34,,193.46,percent of total billed charges,Implant Device,281.66,,,281.66,Other,110% of Medicare,199.15,35,,199.15,percent of total billed charges,Implant Device,193.46,34,"Charges > $500, x 34%",193.46,percent of total billed charges,Implant Device,199.15,35,,199.15,percent of total billed charges,Implant Device,199.15,35,,199.15,percent of total billed charges,Implant Device,199.15,35,,199.15,percent of total billed charges,Implant Device,199.15,35,,199.15,percent of total billed charges,Implant Device,199.15,35,,199.15,percent of total billed charges,Implant Device,227.6,40,,227.6,percent of total billed charges,Implant Device,199.15,70,,199.15,percent of total billed charges,All Other,193.46,34,,193.46,percent of total billed charges,Implant Device,193.46,34,,193.46,percent of total billed charges,Implant Device,199.15,35,,199.15,percent of total billed charges,Implant Device,199.15,35,,199.15,percent of total billed charges,Implant Device,199.15,35,,199.15,percent of total billed charges,Implant Device,199.15,35,,199.15,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,421.06,
STRYKER 338624 CORTICAL SCREW 3.5X24MM,C1713,HCPCS,,79005150,CDM,278,RC,,,both,,,115,85.1,,,85.1,Other,150% of Medicare + 9.63% HCRA Surcharge,51.75,45,,51.75,percent of total billed charges,Critical Access Hospital RCC factor,39.1,34,,39.1,percent of total billed charges,Implant Device,39.1,34,,39.1,percent of total billed charges,Implant Device,39.1,34,,39.1,percent of total billed charges,Implant Device,39.1,34,,39.1,percent of total billed charges,Implant Device,39.1,34,,39.1,percent of total billed charges,Implant Device,56.93,,,56.93,Other,110% of Medicare,40.25,35,,40.25,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,40.25,35,,40.25,percent of total billed charges,Implant Device,40.25,35,,40.25,percent of total billed charges,Implant Device,40.25,35,,40.25,percent of total billed charges,Implant Device,40.25,35,,40.25,percent of total billed charges,Implant Device,40.25,35,,40.25,percent of total billed charges,Implant Device,46,40,,46,percent of total billed charges,Implant Device,40.25,70,,40.25,percent of total billed charges,All Other,39.1,34,,39.1,percent of total billed charges,Implant Device,39.1,34,,39.1,percent of total billed charges,Implant Device,40.25,35,,40.25,percent of total billed charges,Implant Device,40.25,35,,40.25,percent of total billed charges,Implant Device,40.25,35,,40.25,percent of total billed charges,Implant Device,40.25,35,,40.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,85.1,
ARTHREX AR-8943BR-05 LOCKING PLATE 5HOLE,C1713,HCPCS,,79005151,CDM,278,RC,,,both,,,1950,1443,,,1443,Other,150% of Medicare + 9.63% HCRA Surcharge,877.5,45,,877.5,percent of total billed charges,Critical Access Hospital RCC factor,663,34,,663,percent of total billed charges,Implant Device,663,34,,663,percent of total billed charges,Implant Device,663,34,,663,percent of total billed charges,Implant Device,663,34,,663,percent of total billed charges,Implant Device,663,34,,663,percent of total billed charges,Implant Device,965.25,,,965.25,Other,110% of Medicare,682.5,35,,682.5,percent of total billed charges,Implant Device,663,34,"Charges > $500, x 34%",663,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,780,40,,780,percent of total billed charges,Implant Device,682.5,70,,682.5,percent of total billed charges,All Other,663,34,,663,percent of total billed charges,Implant Device,663,34,,663,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1443,
ARTHREX AR-8835-32 CORTICAL SCREW 3.5X32,C1713,HCPCS,,79005152,CDM,278,RC,,,both,,,106,78.44,,,78.44,Other,150% of Medicare + 9.63% HCRA Surcharge,47.7,45,,47.7,percent of total billed charges,Critical Access Hospital RCC factor,36.04,34,,36.04,percent of total billed charges,Implant Device,36.04,34,,36.04,percent of total billed charges,Implant Device,36.04,34,,36.04,percent of total billed charges,Implant Device,36.04,34,,36.04,percent of total billed charges,Implant Device,36.04,34,,36.04,percent of total billed charges,Implant Device,52.47,,,52.47,Other,110% of Medicare,37.1,35,,37.1,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,37.1,35,,37.1,percent of total billed charges,Implant Device,37.1,35,,37.1,percent of total billed charges,Implant Device,37.1,35,,37.1,percent of total billed charges,Implant Device,37.1,35,,37.1,percent of total billed charges,Implant Device,37.1,35,,37.1,percent of total billed charges,Implant Device,42.4,40,,42.4,percent of total billed charges,Implant Device,37.1,70,,37.1,percent of total billed charges,All Other,36.04,34,,36.04,percent of total billed charges,Implant Device,36.04,34,,36.04,percent of total billed charges,Implant Device,37.1,35,,37.1,percent of total billed charges,Implant Device,37.1,35,,37.1,percent of total billed charges,Implant Device,37.1,35,,37.1,percent of total billed charges,Implant Device,37.1,35,,37.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,78.44,
ARTHREX AR-8835-38 CORTICAL SCREW 3.5X38,C1713,HCPCS,,79005153,CDM,278,RC,,,both,,,106,78.44,,,78.44,Other,150% of Medicare + 9.63% HCRA Surcharge,47.7,45,,47.7,percent of total billed charges,Critical Access Hospital RCC factor,36.04,34,,36.04,percent of total billed charges,Implant Device,36.04,34,,36.04,percent of total billed charges,Implant Device,36.04,34,,36.04,percent of total billed charges,Implant Device,36.04,34,,36.04,percent of total billed charges,Implant Device,36.04,34,,36.04,percent of total billed charges,Implant Device,52.47,,,52.47,Other,110% of Medicare,37.1,35,,37.1,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,37.1,35,,37.1,percent of total billed charges,Implant Device,37.1,35,,37.1,percent of total billed charges,Implant Device,37.1,35,,37.1,percent of total billed charges,Implant Device,37.1,35,,37.1,percent of total billed charges,Implant Device,37.1,35,,37.1,percent of total billed charges,Implant Device,42.4,40,,42.4,percent of total billed charges,Implant Device,37.1,70,,37.1,percent of total billed charges,All Other,36.04,34,,36.04,percent of total billed charges,Implant Device,36.04,34,,36.04,percent of total billed charges,Implant Device,37.1,35,,37.1,percent of total billed charges,Implant Device,37.1,35,,37.1,percent of total billed charges,Implant Device,37.1,35,,37.1,percent of total billed charges,Implant Device,37.1,35,,37.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,78.44,
ARTHREX AR-8835-20 CORTICAL SCREW 3.5X20,C1713,HCPCS,,79005154,CDM,278,RC,,,both,,,106,78.44,,,78.44,Other,150% of Medicare + 9.63% HCRA Surcharge,47.7,45,,47.7,percent of total billed charges,Critical Access Hospital RCC factor,36.04,34,,36.04,percent of total billed charges,Implant Device,36.04,34,,36.04,percent of total billed charges,Implant Device,36.04,34,,36.04,percent of total billed charges,Implant Device,36.04,34,,36.04,percent of total billed charges,Implant Device,36.04,34,,36.04,percent of total billed charges,Implant Device,52.47,,,52.47,Other,110% of Medicare,37.1,35,,37.1,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,37.1,35,,37.1,percent of total billed charges,Implant Device,37.1,35,,37.1,percent of total billed charges,Implant Device,37.1,35,,37.1,percent of total billed charges,Implant Device,37.1,35,,37.1,percent of total billed charges,Implant Device,37.1,35,,37.1,percent of total billed charges,Implant Device,42.4,40,,42.4,percent of total billed charges,Implant Device,37.1,70,,37.1,percent of total billed charges,All Other,36.04,34,,36.04,percent of total billed charges,Implant Device,36.04,34,,36.04,percent of total billed charges,Implant Device,37.1,35,,37.1,percent of total billed charges,Implant Device,37.1,35,,37.1,percent of total billed charges,Implant Device,37.1,35,,37.1,percent of total billed charges,Implant Device,37.1,35,,37.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,78.44,
ARTHREX AR-8827L-16 LOCKING SCREW 2.7X16,C1713,HCPCS,,79005155,CDM,278,RC,,,both,,,495,366.3,,,366.3,Other,150% of Medicare + 9.63% HCRA Surcharge,222.75,45,,222.75,percent of total billed charges,Critical Access Hospital RCC factor,168.3,34,,168.3,percent of total billed charges,Implant Device,168.3,34,,168.3,percent of total billed charges,Implant Device,168.3,34,,168.3,percent of total billed charges,Implant Device,168.3,34,,168.3,percent of total billed charges,Implant Device,168.3,34,,168.3,percent of total billed charges,Implant Device,245.03,,,245.03,Other,110% of Medicare,173.25,35,,173.25,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,173.25,35,,173.25,percent of total billed charges,Implant Device,173.25,35,,173.25,percent of total billed charges,Implant Device,173.25,35,,173.25,percent of total billed charges,Implant Device,173.25,35,,173.25,percent of total billed charges,Implant Device,173.25,35,,173.25,percent of total billed charges,Implant Device,198,40,,198,percent of total billed charges,Implant Device,173.25,70,,173.25,percent of total billed charges,All Other,168.3,34,,168.3,percent of total billed charges,Implant Device,168.3,34,,168.3,percent of total billed charges,Implant Device,173.25,35,,173.25,percent of total billed charges,Implant Device,173.25,35,,173.25,percent of total billed charges,Implant Device,173.25,35,,173.25,percent of total billed charges,Implant Device,173.25,35,,173.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,366.3,
ARTHREX 6265-2-005 RELAINCE STR HIP SZ5,C1776,HCPCS,,79005156,CDM,278,RC,,,both,,,3511,2598.15,,,2598.15,Other,150% of Medicare + 9.63% HCRA Surcharge,1579.95,45,,1579.95,percent of total billed charges,Critical Access Hospital RCC factor,1193.74,34,,1193.74,percent of total billed charges,Implant Device,1193.74,34,,1193.74,percent of total billed charges,Implant Device,1193.74,34,,1193.74,percent of total billed charges,Implant Device,1193.74,34,,1193.74,percent of total billed charges,Implant Device,1193.74,34,,1193.74,percent of total billed charges,Implant Device,1737.95,,,1737.95,Other,110% of Medicare,1228.85,35,,1228.85,percent of total billed charges,Implant Device,1193.74,34,"Charges > $500, x 34%",1193.74,percent of total billed charges,Implant Device,1228.85,35,,1228.85,percent of total billed charges,Implant Device,1228.85,35,,1228.85,percent of total billed charges,Implant Device,1228.85,35,,1228.85,percent of total billed charges,Implant Device,1228.85,35,,1228.85,percent of total billed charges,Implant Device,1228.85,35,,1228.85,percent of total billed charges,Implant Device,1404.4,40,,1404.4,percent of total billed charges,Implant Device,1228.85,70,,1228.85,percent of total billed charges,All Other,1193.74,34,,1193.74,percent of total billed charges,Implant Device,1193.74,34,,1193.74,percent of total billed charges,Implant Device,1228.85,35,,1228.85,percent of total billed charges,Implant Device,1228.85,35,,1228.85,percent of total billed charges,Implant Device,1228.85,35,,1228.85,percent of total billed charges,Implant Device,1228.85,35,,1228.85,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1193.74,34,"If Charge > 2,000, then 34 percent",1193.74,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2598.15,
ARTHREX AR-13120T-14 SCREW 2.3X14MM,C1713,HCPCS,,79005157,CDM,278,RC,,,both,,,408,301.92,,,301.92,Other,150% of Medicare + 9.63% HCRA Surcharge,183.6,45,,183.6,percent of total billed charges,Critical Access Hospital RCC factor,138.72,34,,138.72,percent of total billed charges,Implant Device,138.72,34,,138.72,percent of total billed charges,Implant Device,138.72,34,,138.72,percent of total billed charges,Implant Device,138.72,34,,138.72,percent of total billed charges,Implant Device,138.72,34,,138.72,percent of total billed charges,Implant Device,201.96,,,201.96,Other,110% of Medicare,142.8,35,,142.8,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,142.8,35,,142.8,percent of total billed charges,Implant Device,142.8,35,,142.8,percent of total billed charges,Implant Device,142.8,35,,142.8,percent of total billed charges,Implant Device,142.8,35,,142.8,percent of total billed charges,Implant Device,142.8,35,,142.8,percent of total billed charges,Implant Device,163.2,40,,163.2,percent of total billed charges,Implant Device,142.8,70,,142.8,percent of total billed charges,All Other,138.72,34,,138.72,percent of total billed charges,Implant Device,138.72,34,,138.72,percent of total billed charges,Implant Device,142.8,35,,142.8,percent of total billed charges,Implant Device,142.8,35,,142.8,percent of total billed charges,Implant Device,142.8,35,,142.8,percent of total billed charges,Implant Device,142.8,35,,142.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,301.92,
EXACTECH 314-02-33 POST AUGMENT GLENOID,C1713,HCPCS,,79005159,CDM,278,RC,,,both,,,7992,5914.1,,,5914.1,Other,150% of Medicare + 9.63% HCRA Surcharge,3596.4,45,,3596.4,percent of total billed charges,Critical Access Hospital RCC factor,2717.28,34,,2717.28,percent of total billed charges,Implant Device,2717.28,34,,2717.28,percent of total billed charges,Implant Device,2717.28,34,,2717.28,percent of total billed charges,Implant Device,2717.28,34,,2717.28,percent of total billed charges,Implant Device,2717.28,34,,2717.28,percent of total billed charges,Implant Device,3956.04,,,3956.04,Other,110% of Medicare,2797.2,35,,2797.2,percent of total billed charges,Implant Device,2717.28,34,"Charges > $500, x 34%",2717.28,percent of total billed charges,Implant Device,2797.2,35,,2797.2,percent of total billed charges,Implant Device,2797.2,35,,2797.2,percent of total billed charges,Implant Device,2797.2,35,,2797.2,percent of total billed charges,Implant Device,2797.2,35,,2797.2,percent of total billed charges,Implant Device,2797.2,35,,2797.2,percent of total billed charges,Implant Device,3196.8,40,,3196.8,percent of total billed charges,Implant Device,2797.2,70,,2797.2,percent of total billed charges,All Other,2717.28,34,,2717.28,percent of total billed charges,Implant Device,2717.28,34,,2717.28,percent of total billed charges,Implant Device,2797.2,35,,2797.2,percent of total billed charges,Implant Device,2797.2,35,,2797.2,percent of total billed charges,Implant Device,2797.2,35,,2797.2,percent of total billed charges,Implant Device,2797.2,35,,2797.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2717.28,34,"If Charge > 2,000, then 34 percent",2717.28,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5914.1,
BIOMET M30-070020T CORTICAL SCEW 3X2.5MM,C1713,HCPCS,,79005160,CDM,278,RC,,,both,,,448,331.52,,,331.52,Other,150% of Medicare + 9.63% HCRA Surcharge,201.6,45,,201.6,percent of total billed charges,Critical Access Hospital RCC factor,152.32,34,,152.32,percent of total billed charges,Implant Device,152.32,34,,152.32,percent of total billed charges,Implant Device,152.32,34,,152.32,percent of total billed charges,Implant Device,152.32,34,,152.32,percent of total billed charges,Implant Device,152.32,34,,152.32,percent of total billed charges,Implant Device,221.76,,,221.76,Other,110% of Medicare,156.8,35,,156.8,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,156.8,35,,156.8,percent of total billed charges,Implant Device,156.8,35,,156.8,percent of total billed charges,Implant Device,156.8,35,,156.8,percent of total billed charges,Implant Device,156.8,35,,156.8,percent of total billed charges,Implant Device,156.8,35,,156.8,percent of total billed charges,Implant Device,179.2,40,,179.2,percent of total billed charges,Implant Device,156.8,70,,156.8,percent of total billed charges,All Other,152.32,34,,152.32,percent of total billed charges,Implant Device,152.32,34,,152.32,percent of total billed charges,Implant Device,156.8,35,,156.8,percent of total billed charges,Implant Device,156.8,35,,156.8,percent of total billed charges,Implant Device,156.8,35,,156.8,percent of total billed charges,Implant Device,156.8,35,,156.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,331.52,
BIOMET 1802-49-048 TIMAX CANN SCREW 4X48,C1713,HCPCS,,79005161,CDM,278,RC,,,both,,,750,555,,,555,Other,150% of Medicare + 9.63% HCRA Surcharge,337.5,45,,337.5,percent of total billed charges,Critical Access Hospital RCC factor,255,34,,255,percent of total billed charges,Implant Device,255,34,,255,percent of total billed charges,Implant Device,255,34,,255,percent of total billed charges,Implant Device,255,34,,255,percent of total billed charges,Implant Device,255,34,,255,percent of total billed charges,Implant Device,371.25,,,371.25,Other,110% of Medicare,262.5,35,,262.5,percent of total billed charges,Implant Device,255,34,"Charges > $500, x 34%",255,percent of total billed charges,Implant Device,262.5,35,,262.5,percent of total billed charges,Implant Device,262.5,35,,262.5,percent of total billed charges,Implant Device,262.5,35,,262.5,percent of total billed charges,Implant Device,262.5,35,,262.5,percent of total billed charges,Implant Device,262.5,35,,262.5,percent of total billed charges,Implant Device,300,40,,300,percent of total billed charges,Implant Device,262.5,70,,262.5,percent of total billed charges,All Other,255,34,,255,percent of total billed charges,Implant Device,255,34,,255,percent of total billed charges,Implant Device,262.5,35,,262.5,percent of total billed charges,Implant Device,262.5,35,,262.5,percent of total billed charges,Implant Device,262.5,35,,262.5,percent of total billed charges,Implant Device,262.5,35,,262.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,555,
BIOMET 1802-49-060 TIMAX CANN SCREW 4X60,C1713,HCPCS,,79005162,CDM,278,RC,,,both,,,750,555,,,555,Other,150% of Medicare + 9.63% HCRA Surcharge,337.5,45,,337.5,percent of total billed charges,Critical Access Hospital RCC factor,255,34,,255,percent of total billed charges,Implant Device,255,34,,255,percent of total billed charges,Implant Device,255,34,,255,percent of total billed charges,Implant Device,255,34,,255,percent of total billed charges,Implant Device,255,34,,255,percent of total billed charges,Implant Device,371.25,,,371.25,Other,110% of Medicare,262.5,35,,262.5,percent of total billed charges,Implant Device,255,34,"Charges > $500, x 34%",255,percent of total billed charges,Implant Device,262.5,35,,262.5,percent of total billed charges,Implant Device,262.5,35,,262.5,percent of total billed charges,Implant Device,262.5,35,,262.5,percent of total billed charges,Implant Device,262.5,35,,262.5,percent of total billed charges,Implant Device,262.5,35,,262.5,percent of total billed charges,Implant Device,300,40,,300,percent of total billed charges,Implant Device,262.5,70,,262.5,percent of total billed charges,All Other,255,34,,255,percent of total billed charges,Implant Device,255,34,,255,percent of total billed charges,Implant Device,262.5,35,,262.5,percent of total billed charges,Implant Device,262.5,35,,262.5,percent of total billed charges,Implant Device,262.5,35,,262.5,percent of total billed charges,Implant Device,262.5,35,,262.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,555,
BIOMET 1802-49-040 TIMAX CANN SCREW 4X40,C1713,HCPCS,,79005163,CDM,278,RC,,,both,,,750,555,,,555,Other,150% of Medicare + 9.63% HCRA Surcharge,337.5,45,,337.5,percent of total billed charges,Critical Access Hospital RCC factor,255,34,,255,percent of total billed charges,Implant Device,255,34,,255,percent of total billed charges,Implant Device,255,34,,255,percent of total billed charges,Implant Device,255,34,,255,percent of total billed charges,Implant Device,255,34,,255,percent of total billed charges,Implant Device,371.25,,,371.25,Other,110% of Medicare,262.5,35,,262.5,percent of total billed charges,Implant Device,255,34,"Charges > $500, x 34%",255,percent of total billed charges,Implant Device,262.5,35,,262.5,percent of total billed charges,Implant Device,262.5,35,,262.5,percent of total billed charges,Implant Device,262.5,35,,262.5,percent of total billed charges,Implant Device,262.5,35,,262.5,percent of total billed charges,Implant Device,262.5,35,,262.5,percent of total billed charges,Implant Device,300,40,,300,percent of total billed charges,Implant Device,262.5,70,,262.5,percent of total billed charges,All Other,255,34,,255,percent of total billed charges,Implant Device,255,34,,255,percent of total billed charges,Implant Device,262.5,35,,262.5,percent of total billed charges,Implant Device,262.5,35,,262.5,percent of total billed charges,Implant Device,262.5,35,,262.5,percent of total billed charges,Implant Device,262.5,35,,262.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,555,
BIOMET 1802-49-042 TIMAX CANN SCREW 4X42,C1713,HCPCS,,79005164,CDM,278,RC,,,both,,,750,555,,,555,Other,150% of Medicare + 9.63% HCRA Surcharge,337.5,45,,337.5,percent of total billed charges,Critical Access Hospital RCC factor,255,34,,255,percent of total billed charges,Implant Device,255,34,,255,percent of total billed charges,Implant Device,255,34,,255,percent of total billed charges,Implant Device,255,34,,255,percent of total billed charges,Implant Device,255,34,,255,percent of total billed charges,Implant Device,371.25,,,371.25,Other,110% of Medicare,262.5,35,,262.5,percent of total billed charges,Implant Device,255,34,"Charges > $500, x 34%",255,percent of total billed charges,Implant Device,262.5,35,,262.5,percent of total billed charges,Implant Device,262.5,35,,262.5,percent of total billed charges,Implant Device,262.5,35,,262.5,percent of total billed charges,Implant Device,262.5,35,,262.5,percent of total billed charges,Implant Device,262.5,35,,262.5,percent of total billed charges,Implant Device,300,40,,300,percent of total billed charges,Implant Device,262.5,70,,262.5,percent of total billed charges,All Other,255,34,,255,percent of total billed charges,Implant Device,255,34,,255,percent of total billed charges,Implant Device,262.5,35,,262.5,percent of total billed charges,Implant Device,262.5,35,,262.5,percent of total billed charges,Implant Device,262.5,35,,262.5,percent of total billed charges,Implant Device,262.5,35,,262.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,555,
BIOMET 1802-49-046 TIMAX CANN SCREW 4X46,C1713,HCPCS,,79005165,CDM,278,RC,,,both,,,750,555,,,555,Other,150% of Medicare + 9.63% HCRA Surcharge,337.5,45,,337.5,percent of total billed charges,Critical Access Hospital RCC factor,255,34,,255,percent of total billed charges,Implant Device,255,34,,255,percent of total billed charges,Implant Device,255,34,,255,percent of total billed charges,Implant Device,255,34,,255,percent of total billed charges,Implant Device,255,34,,255,percent of total billed charges,Implant Device,371.25,,,371.25,Other,110% of Medicare,262.5,35,,262.5,percent of total billed charges,Implant Device,255,34,"Charges > $500, x 34%",255,percent of total billed charges,Implant Device,262.5,35,,262.5,percent of total billed charges,Implant Device,262.5,35,,262.5,percent of total billed charges,Implant Device,262.5,35,,262.5,percent of total billed charges,Implant Device,262.5,35,,262.5,percent of total billed charges,Implant Device,262.5,35,,262.5,percent of total billed charges,Implant Device,300,40,,300,percent of total billed charges,Implant Device,262.5,70,,262.5,percent of total billed charges,All Other,255,34,,255,percent of total billed charges,Implant Device,255,34,,255,percent of total billed charges,Implant Device,262.5,35,,262.5,percent of total billed charges,Implant Device,262.5,35,,262.5,percent of total billed charges,Implant Device,262.5,35,,262.5,percent of total billed charges,Implant Device,262.5,35,,262.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,555,
BIOMET 1802-48-038 TIMAX CANN SCREW 4X38,C1713,HCPCS,,79005166,CDM,278,RC,,,both,,,780,577.2,,,577.2,Other,150% of Medicare + 9.63% HCRA Surcharge,351,45,,351,percent of total billed charges,Critical Access Hospital RCC factor,265.2,34,,265.2,percent of total billed charges,Implant Device,265.2,34,,265.2,percent of total billed charges,Implant Device,265.2,34,,265.2,percent of total billed charges,Implant Device,265.2,34,,265.2,percent of total billed charges,Implant Device,265.2,34,,265.2,percent of total billed charges,Implant Device,386.1,,,386.1,Other,110% of Medicare,273,35,,273,percent of total billed charges,Implant Device,265.2,34,"Charges > $500, x 34%",265.2,percent of total billed charges,Implant Device,273,35,,273,percent of total billed charges,Implant Device,273,35,,273,percent of total billed charges,Implant Device,273,35,,273,percent of total billed charges,Implant Device,273,35,,273,percent of total billed charges,Implant Device,273,35,,273,percent of total billed charges,Implant Device,312,40,,312,percent of total billed charges,Implant Device,273,70,,273,percent of total billed charges,All Other,265.2,34,,265.2,percent of total billed charges,Implant Device,265.2,34,,265.2,percent of total billed charges,Implant Device,273,35,,273,percent of total billed charges,Implant Device,273,35,,273,percent of total billed charges,Implant Device,273,35,,273,percent of total billed charges,Implant Device,273,35,,273,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,577.2,
BIOMET 07020 LONG MINI FIXATOR,C1713,HCPCS,,79005167,CDM,278,RC,,,both,,,6196,4585.06,,,4585.06,Other,150% of Medicare + 9.63% HCRA Surcharge,2788.2,45,,2788.2,percent of total billed charges,Critical Access Hospital RCC factor,2106.64,34,,2106.64,percent of total billed charges,Implant Device,2106.64,34,,2106.64,percent of total billed charges,Implant Device,2106.64,34,,2106.64,percent of total billed charges,Implant Device,2106.64,34,,2106.64,percent of total billed charges,Implant Device,2106.64,34,,2106.64,percent of total billed charges,Implant Device,3067.02,,,3067.02,Other,110% of Medicare,2168.6,35,,2168.6,percent of total billed charges,Implant Device,2106.64,34,"Charges > $500, x 34%",2106.64,percent of total billed charges,Implant Device,2168.6,35,,2168.6,percent of total billed charges,Implant Device,2168.6,35,,2168.6,percent of total billed charges,Implant Device,2168.6,35,,2168.6,percent of total billed charges,Implant Device,2168.6,35,,2168.6,percent of total billed charges,Implant Device,2168.6,35,,2168.6,percent of total billed charges,Implant Device,2478.4,40,,2478.4,percent of total billed charges,Implant Device,2168.6,70,,2168.6,percent of total billed charges,All Other,2106.64,34,,2106.64,percent of total billed charges,Implant Device,2106.64,34,,2106.64,percent of total billed charges,Implant Device,2168.6,35,,2168.6,percent of total billed charges,Implant Device,2168.6,35,,2168.6,percent of total billed charges,Implant Device,2168.6,35,,2168.6,percent of total billed charges,Implant Device,2168.6,35,,2168.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2106.64,34,"If Charge > 2,000, then 34 percent",2106.64,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4585.06,
COOK G43827 7X60X125 ZILVER 635 STENT,C1876,HCPCS,,79005171,CDM,278,RC,,,both,,,4050,2997.01,,,2997.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1822.5,45,,1822.5,percent of total billed charges,Critical Access Hospital RCC factor,1377,34,,1377,percent of total billed charges,Implant Device,1377,34,,1377,percent of total billed charges,Implant Device,1377,34,,1377,percent of total billed charges,Implant Device,1377,34,,1377,percent of total billed charges,Implant Device,1377,34,,1377,percent of total billed charges,Implant Device,2004.75,,,2004.75,Other,110% of Medicare,1417.5,35,,1417.5,percent of total billed charges,Implant Device,1377,34,"Charges > $500, x 34%",1377,percent of total billed charges,Implant Device,1417.5,35,,1417.5,percent of total billed charges,Implant Device,1417.5,35,,1417.5,percent of total billed charges,Implant Device,1417.5,35,,1417.5,percent of total billed charges,Implant Device,1417.5,35,,1417.5,percent of total billed charges,Implant Device,1417.5,35,,1417.5,percent of total billed charges,Implant Device,1620,40,,1620,percent of total billed charges,Implant Device,1417.5,70,,1417.5,percent of total billed charges,All Other,1377,34,,1377,percent of total billed charges,Implant Device,1377,34,,1377,percent of total billed charges,Implant Device,1417.5,35,,1417.5,percent of total billed charges,Implant Device,1417.5,35,,1417.5,percent of total billed charges,Implant Device,1417.5,35,,1417.5,percent of total billed charges,Implant Device,1417.5,35,,1417.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1377,34,"If Charge > 2,000, then 34 percent",1377,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2997.01,
ALPHATEC 71001-045 PLATE 3 LEVEL 45MM,C1713,HCPCS,,79005172,CDM,278,RC,,,both,,,3136,2320.65,,,2320.65,Other,150% of Medicare + 9.63% HCRA Surcharge,1411.2,45,,1411.2,percent of total billed charges,Critical Access Hospital RCC factor,1066.24,34,,1066.24,percent of total billed charges,Implant Device,1066.24,34,,1066.24,percent of total billed charges,Implant Device,1066.24,34,,1066.24,percent of total billed charges,Implant Device,1066.24,34,,1066.24,percent of total billed charges,Implant Device,1066.24,34,,1066.24,percent of total billed charges,Implant Device,1552.32,,,1552.32,Other,110% of Medicare,1097.6,35,,1097.6,percent of total billed charges,Implant Device,1066.24,34,"Charges > $500, x 34%",1066.24,percent of total billed charges,Implant Device,1097.6,35,,1097.6,percent of total billed charges,Implant Device,1097.6,35,,1097.6,percent of total billed charges,Implant Device,1097.6,35,,1097.6,percent of total billed charges,Implant Device,1097.6,35,,1097.6,percent of total billed charges,Implant Device,1097.6,35,,1097.6,percent of total billed charges,Implant Device,1254.4,40,,1254.4,percent of total billed charges,Implant Device,1097.6,70,,1097.6,percent of total billed charges,All Other,1066.24,34,,1066.24,percent of total billed charges,Implant Device,1066.24,34,,1066.24,percent of total billed charges,Implant Device,1097.6,35,,1097.6,percent of total billed charges,Implant Device,1097.6,35,,1097.6,percent of total billed charges,Implant Device,1097.6,35,,1097.6,percent of total billed charges,Implant Device,1097.6,35,,1097.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1066.24,34,"If Charge > 2,000, then 34 percent",1066.24,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2320.65,
ALPHATEC 71240-12 SD SCREW 4X12MM,C1713,HCPCS,,79005173,CDM,278,RC,,,both,,,705,521.7,,,521.7,Other,150% of Medicare + 9.63% HCRA Surcharge,317.25,45,,317.25,percent of total billed charges,Critical Access Hospital RCC factor,239.7,34,,239.7,percent of total billed charges,Implant Device,239.7,34,,239.7,percent of total billed charges,Implant Device,239.7,34,,239.7,percent of total billed charges,Implant Device,239.7,34,,239.7,percent of total billed charges,Implant Device,239.7,34,,239.7,percent of total billed charges,Implant Device,348.98,,,348.98,Other,110% of Medicare,246.75,35,,246.75,percent of total billed charges,Implant Device,239.7,34,"Charges > $500, x 34%",239.7,percent of total billed charges,Implant Device,246.75,35,,246.75,percent of total billed charges,Implant Device,246.75,35,,246.75,percent of total billed charges,Implant Device,246.75,35,,246.75,percent of total billed charges,Implant Device,246.75,35,,246.75,percent of total billed charges,Implant Device,246.75,35,,246.75,percent of total billed charges,Implant Device,282,40,,282,percent of total billed charges,Implant Device,246.75,70,,246.75,percent of total billed charges,All Other,239.7,34,,239.7,percent of total billed charges,Implant Device,239.7,34,,239.7,percent of total billed charges,Implant Device,246.75,35,,246.75,percent of total billed charges,Implant Device,246.75,35,,246.75,percent of total billed charges,Implant Device,246.75,35,,246.75,percent of total billed charges,Implant Device,246.75,35,,246.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,521.7,
STRYKER 54-25292 WRIST PLATE RT DORSAL,C1713,HCPCS,,79005174,CDM,278,RC,,,both,,,3316,2453.85,,,2453.85,Other,150% of Medicare + 9.63% HCRA Surcharge,1492.2,45,,1492.2,percent of total billed charges,Critical Access Hospital RCC factor,1127.44,34,,1127.44,percent of total billed charges,Implant Device,1127.44,34,,1127.44,percent of total billed charges,Implant Device,1127.44,34,,1127.44,percent of total billed charges,Implant Device,1127.44,34,,1127.44,percent of total billed charges,Implant Device,1127.44,34,,1127.44,percent of total billed charges,Implant Device,1641.42,,,1641.42,Other,110% of Medicare,1160.6,35,,1160.6,percent of total billed charges,Implant Device,1127.44,34,"Charges > $500, x 34%",1127.44,percent of total billed charges,Implant Device,1160.6,35,,1160.6,percent of total billed charges,Implant Device,1160.6,35,,1160.6,percent of total billed charges,Implant Device,1160.6,35,,1160.6,percent of total billed charges,Implant Device,1160.6,35,,1160.6,percent of total billed charges,Implant Device,1160.6,35,,1160.6,percent of total billed charges,Implant Device,1326.4,40,,1326.4,percent of total billed charges,Implant Device,1160.6,70,,1160.6,percent of total billed charges,All Other,1127.44,34,,1127.44,percent of total billed charges,Implant Device,1127.44,34,,1127.44,percent of total billed charges,Implant Device,1160.6,35,,1160.6,percent of total billed charges,Implant Device,1160.6,35,,1160.6,percent of total billed charges,Implant Device,1160.6,35,,1160.6,percent of total billed charges,Implant Device,1160.6,35,,1160.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1127.44,34,"If Charge > 2,000, then 34 percent",1127.44,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2453.85,
STRYKER 53-23630E LOCKING SCREW 2.3X30MM,C1713,HCPCS,,79005175,CDM,278,RC,,,both,,,446,330.04,,,330.04,Other,150% of Medicare + 9.63% HCRA Surcharge,200.7,45,,200.7,percent of total billed charges,Critical Access Hospital RCC factor,151.64,34,,151.64,percent of total billed charges,Implant Device,151.64,34,,151.64,percent of total billed charges,Implant Device,151.64,34,,151.64,percent of total billed charges,Implant Device,151.64,34,,151.64,percent of total billed charges,Implant Device,151.64,34,,151.64,percent of total billed charges,Implant Device,220.77,,,220.77,Other,110% of Medicare,156.1,35,,156.1,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,156.1,35,,156.1,percent of total billed charges,Implant Device,156.1,35,,156.1,percent of total billed charges,Implant Device,156.1,35,,156.1,percent of total billed charges,Implant Device,156.1,35,,156.1,percent of total billed charges,Implant Device,156.1,35,,156.1,percent of total billed charges,Implant Device,178.4,40,,178.4,percent of total billed charges,Implant Device,156.1,70,,156.1,percent of total billed charges,All Other,151.64,34,,151.64,percent of total billed charges,Implant Device,151.64,34,,151.64,percent of total billed charges,Implant Device,156.1,35,,156.1,percent of total billed charges,Implant Device,156.1,35,,156.1,percent of total billed charges,Implant Device,156.1,35,,156.1,percent of total billed charges,Implant Device,156.1,35,,156.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,330.04,
ALAMO TISS AT392FF SEMI-TENOD ALLGRAFT,C1713,HCPCS,,79005176,CDM,278,RC,,,both,,,4500,3330.01,,,3330.01,Other,150% of Medicare + 9.63% HCRA Surcharge,2025,45,,2025,percent of total billed charges,Critical Access Hospital RCC factor,1530,34,,1530,percent of total billed charges,Implant Device,1530,34,,1530,percent of total billed charges,Implant Device,1530,34,,1530,percent of total billed charges,Implant Device,1530,34,,1530,percent of total billed charges,Implant Device,1530,34,,1530,percent of total billed charges,Implant Device,2227.5,,,2227.5,Other,110% of Medicare,1575,35,,1575,percent of total billed charges,Implant Device,1530,34,"Charges > $500, x 34%",1530,percent of total billed charges,Implant Device,1575,35,,1575,percent of total billed charges,Implant Device,1575,35,,1575,percent of total billed charges,Implant Device,1575,35,,1575,percent of total billed charges,Implant Device,1575,35,,1575,percent of total billed charges,Implant Device,1575,35,,1575,percent of total billed charges,Implant Device,1800,40,,1800,percent of total billed charges,Implant Device,1575,70,,1575,percent of total billed charges,All Other,1530,34,,1530,percent of total billed charges,Implant Device,1530,34,,1530,percent of total billed charges,Implant Device,1575,35,,1575,percent of total billed charges,Implant Device,1575,35,,1575,percent of total billed charges,Implant Device,1575,35,,1575,percent of total billed charges,Implant Device,1575,35,,1575,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1530,34,"If Charge > 2,000, then 34 percent",1530,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3330.01,
EXACTECH 304-21-09 HUMERAL STEM LT 8.5MM,C1713,HCPCS,,79005177,CDM,278,RC,,,both,,,6225,4606.52,,,4606.52,Other,150% of Medicare + 9.63% HCRA Surcharge,2801.25,45,,2801.25,percent of total billed charges,Critical Access Hospital RCC factor,2116.5,34,,2116.5,percent of total billed charges,Implant Device,2116.5,34,,2116.5,percent of total billed charges,Implant Device,2116.5,34,,2116.5,percent of total billed charges,Implant Device,2116.5,34,,2116.5,percent of total billed charges,Implant Device,2116.5,34,,2116.5,percent of total billed charges,Implant Device,3081.38,,,3081.38,Other,110% of Medicare,2178.75,35,,2178.75,percent of total billed charges,Implant Device,2116.5,34,"Charges > $500, x 34%",2116.5,percent of total billed charges,Implant Device,2178.75,35,,2178.75,percent of total billed charges,Implant Device,2178.75,35,,2178.75,percent of total billed charges,Implant Device,2178.75,35,,2178.75,percent of total billed charges,Implant Device,2178.75,35,,2178.75,percent of total billed charges,Implant Device,2178.75,35,,2178.75,percent of total billed charges,Implant Device,2490,40,,2490,percent of total billed charges,Implant Device,2178.75,70,,2178.75,percent of total billed charges,All Other,2116.5,34,,2116.5,percent of total billed charges,Implant Device,2116.5,34,,2116.5,percent of total billed charges,Implant Device,2178.75,35,,2178.75,percent of total billed charges,Implant Device,2178.75,35,,2178.75,percent of total billed charges,Implant Device,2178.75,35,,2178.75,percent of total billed charges,Implant Device,2178.75,35,,2178.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2116.5,34,"If Charge > 2,000, then 34 percent",2116.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4606.52,
ALPHATEC 71240-10 SD SCREW 4X10MM,C1713,HCPCS,,79005178,CDM,278,RC,,,both,,,706,522.44,,,522.44,Other,150% of Medicare + 9.63% HCRA Surcharge,317.7,45,,317.7,percent of total billed charges,Critical Access Hospital RCC factor,240.04,34,,240.04,percent of total billed charges,Implant Device,240.04,34,,240.04,percent of total billed charges,Implant Device,240.04,34,,240.04,percent of total billed charges,Implant Device,240.04,34,,240.04,percent of total billed charges,Implant Device,240.04,34,,240.04,percent of total billed charges,Implant Device,349.47,,,349.47,Other,110% of Medicare,247.1,35,,247.1,percent of total billed charges,Implant Device,240.04,34,"Charges > $500, x 34%",240.04,percent of total billed charges,Implant Device,247.1,35,,247.1,percent of total billed charges,Implant Device,247.1,35,,247.1,percent of total billed charges,Implant Device,247.1,35,,247.1,percent of total billed charges,Implant Device,247.1,35,,247.1,percent of total billed charges,Implant Device,247.1,35,,247.1,percent of total billed charges,Implant Device,282.4,40,,282.4,percent of total billed charges,Implant Device,247.1,70,,247.1,percent of total billed charges,All Other,240.04,34,,240.04,percent of total billed charges,Implant Device,240.04,34,,240.04,percent of total billed charges,Implant Device,247.1,35,,247.1,percent of total billed charges,Implant Device,247.1,35,,247.1,percent of total billed charges,Implant Device,247.1,35,,247.1,percent of total billed charges,Implant Device,247.1,35,,247.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,522.44,
BOST SCI 4563 RE STENT 10FRX12CM,C2625,HCPCS,,79005179,CDM,278,RC,,,both,,,444,328.56,,,328.56,Other,150% of Medicare + 9.63% HCRA Surcharge,199.8,45,,199.8,percent of total billed charges,Critical Access Hospital RCC factor,150.96,34,,150.96,percent of total billed charges,Implant Device,150.96,34,,150.96,percent of total billed charges,Implant Device,150.96,34,,150.96,percent of total billed charges,Implant Device,150.96,34,,150.96,percent of total billed charges,Implant Device,150.96,34,,150.96,percent of total billed charges,Implant Device,219.78,,,219.78,Other,110% of Medicare,155.4,35,,155.4,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,155.4,35,,155.4,percent of total billed charges,Implant Device,155.4,35,,155.4,percent of total billed charges,Implant Device,155.4,35,,155.4,percent of total billed charges,Implant Device,155.4,35,,155.4,percent of total billed charges,Implant Device,155.4,35,,155.4,percent of total billed charges,Implant Device,177.6,40,,177.6,percent of total billed charges,Implant Device,155.4,70,,155.4,percent of total billed charges,All Other,150.96,34,,150.96,percent of total billed charges,Implant Device,150.96,34,,150.96,percent of total billed charges,Implant Device,155.4,35,,155.4,percent of total billed charges,Implant Device,155.4,35,,155.4,percent of total billed charges,Implant Device,155.4,35,,155.4,percent of total billed charges,Implant Device,155.4,35,,155.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,328.56,
ZIMMER 5842-04-02 TIBIAL COMPONENT SZ 4,C1776,HCPCS,,79005180,CDM,278,RC,,,both,,,6346,4696.06,,,4696.06,Other,150% of Medicare + 9.63% HCRA Surcharge,2855.7,45,,2855.7,percent of total billed charges,Critical Access Hospital RCC factor,2157.64,34,,2157.64,percent of total billed charges,Implant Device,2157.64,34,,2157.64,percent of total billed charges,Implant Device,2157.64,34,,2157.64,percent of total billed charges,Implant Device,2157.64,34,,2157.64,percent of total billed charges,Implant Device,2157.64,34,,2157.64,percent of total billed charges,Implant Device,3141.27,,,3141.27,Other,110% of Medicare,2221.1,35,,2221.1,percent of total billed charges,Implant Device,2157.64,34,"Charges > $500, x 34%",2157.64,percent of total billed charges,Implant Device,2221.1,35,,2221.1,percent of total billed charges,Implant Device,2221.1,35,,2221.1,percent of total billed charges,Implant Device,2221.1,35,,2221.1,percent of total billed charges,Implant Device,2221.1,35,,2221.1,percent of total billed charges,Implant Device,2221.1,35,,2221.1,percent of total billed charges,Implant Device,2538.4,40,,2538.4,percent of total billed charges,Implant Device,2221.1,70,,2221.1,percent of total billed charges,All Other,2157.64,34,,2157.64,percent of total billed charges,Implant Device,2157.64,34,,2157.64,percent of total billed charges,Implant Device,2221.1,35,,2221.1,percent of total billed charges,Implant Device,2221.1,35,,2221.1,percent of total billed charges,Implant Device,2221.1,35,,2221.1,percent of total billed charges,Implant Device,2221.1,35,,2221.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2157.64,34,"If Charge > 2,000, then 34 percent",2157.64,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4696.06,
ZIMMER 5842-24-08 ART SURF FEM SZ4 8MM,C1776,HCPCS,,79005181,CDM,278,RC,,,both,,,2677,1980.99,,,1980.99,Other,150% of Medicare + 9.63% HCRA Surcharge,1204.65,45,,1204.65,percent of total billed charges,Critical Access Hospital RCC factor,910.18,34,,910.18,percent of total billed charges,Implant Device,910.18,34,,910.18,percent of total billed charges,Implant Device,910.18,34,,910.18,percent of total billed charges,Implant Device,910.18,34,,910.18,percent of total billed charges,Implant Device,910.18,34,,910.18,percent of total billed charges,Implant Device,1325.12,,,1325.12,Other,110% of Medicare,936.95,35,,936.95,percent of total billed charges,Implant Device,910.18,34,"Charges > $500, x 34%",910.18,percent of total billed charges,Implant Device,936.95,35,,936.95,percent of total billed charges,Implant Device,936.95,35,,936.95,percent of total billed charges,Implant Device,936.95,35,,936.95,percent of total billed charges,Implant Device,936.95,35,,936.95,percent of total billed charges,Implant Device,936.95,35,,936.95,percent of total billed charges,Implant Device,1070.8,40,,1070.8,percent of total billed charges,Implant Device,936.95,70,,936.95,percent of total billed charges,All Other,910.18,34,,910.18,percent of total billed charges,Implant Device,910.18,34,,910.18,percent of total billed charges,Implant Device,936.95,35,,936.95,percent of total billed charges,Implant Device,936.95,35,,936.95,percent of total billed charges,Implant Device,936.95,35,,936.95,percent of total billed charges,Implant Device,936.95,35,,936.95,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,910.18,34,"If Charge > 2,000, then 34 percent",910.18,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1980.99,
ZIMMER 5972-65-35 PATELLA SZ 35 9MM,C1776,HCPCS,,79005182,CDM,278,RC,,,both,,,1152,852.48,,,852.48,Other,150% of Medicare + 9.63% HCRA Surcharge,518.4,45,,518.4,percent of total billed charges,Critical Access Hospital RCC factor,391.68,34,,391.68,percent of total billed charges,Implant Device,391.68,34,,391.68,percent of total billed charges,Implant Device,391.68,34,,391.68,percent of total billed charges,Implant Device,391.68,34,,391.68,percent of total billed charges,Implant Device,391.68,34,,391.68,percent of total billed charges,Implant Device,570.24,,,570.24,Other,110% of Medicare,403.2,35,,403.2,percent of total billed charges,Implant Device,391.68,34,"Charges > $500, x 34%",391.68,percent of total billed charges,Implant Device,403.2,35,,403.2,percent of total billed charges,Implant Device,403.2,35,,403.2,percent of total billed charges,Implant Device,403.2,35,,403.2,percent of total billed charges,Implant Device,403.2,35,,403.2,percent of total billed charges,Implant Device,403.2,35,,403.2,percent of total billed charges,Implant Device,460.8,40,,460.8,percent of total billed charges,Implant Device,403.2,70,,403.2,percent of total billed charges,All Other,391.68,34,,391.68,percent of total billed charges,Implant Device,391.68,34,,391.68,percent of total billed charges,Implant Device,403.2,35,,403.2,percent of total billed charges,Implant Device,403.2,35,,403.2,percent of total billed charges,Implant Device,403.2,35,,403.2,percent of total billed charges,Implant Device,403.2,35,,403.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,852.48,
ZIMMER 5988-10-11 STEM EXT 11X100MM,C1776,HCPCS,,79005183,CDM,278,RC,,,both,,,3757,2780.19,,,2780.19,Other,150% of Medicare + 9.63% HCRA Surcharge,1690.65,45,,1690.65,percent of total billed charges,Critical Access Hospital RCC factor,1277.38,34,,1277.38,percent of total billed charges,Implant Device,1277.38,34,,1277.38,percent of total billed charges,Implant Device,1277.38,34,,1277.38,percent of total billed charges,Implant Device,1277.38,34,,1277.38,percent of total billed charges,Implant Device,1277.38,34,,1277.38,percent of total billed charges,Implant Device,1859.72,,,1859.72,Other,110% of Medicare,1314.95,35,,1314.95,percent of total billed charges,Implant Device,1277.38,34,"Charges > $500, x 34%",1277.38,percent of total billed charges,Implant Device,1314.95,35,,1314.95,percent of total billed charges,Implant Device,1314.95,35,,1314.95,percent of total billed charges,Implant Device,1314.95,35,,1314.95,percent of total billed charges,Implant Device,1314.95,35,,1314.95,percent of total billed charges,Implant Device,1314.95,35,,1314.95,percent of total billed charges,Implant Device,1502.8,40,,1502.8,percent of total billed charges,Implant Device,1314.95,70,,1314.95,percent of total billed charges,All Other,1277.38,34,,1277.38,percent of total billed charges,Implant Device,1277.38,34,,1277.38,percent of total billed charges,Implant Device,1314.95,35,,1314.95,percent of total billed charges,Implant Device,1314.95,35,,1314.95,percent of total billed charges,Implant Device,1314.95,35,,1314.95,percent of total billed charges,Implant Device,1314.95,35,,1314.95,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1277.38,34,"If Charge > 2,000, then 34 percent",1277.38,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2780.19,
ZIMMER 5990-35-20 FEM AUG BLOCK SZ E,C1776,HCPCS,,79005184,CDM,278,RC,,,both,,,2963,2192.63,,,2192.63,Other,150% of Medicare + 9.63% HCRA Surcharge,1333.35,45,,1333.35,percent of total billed charges,Critical Access Hospital RCC factor,1007.42,34,,1007.42,percent of total billed charges,Implant Device,1007.42,34,,1007.42,percent of total billed charges,Implant Device,1007.42,34,,1007.42,percent of total billed charges,Implant Device,1007.42,34,,1007.42,percent of total billed charges,Implant Device,1007.42,34,,1007.42,percent of total billed charges,Implant Device,1466.69,,,1466.69,Other,110% of Medicare,1037.05,35,,1037.05,percent of total billed charges,Implant Device,1007.42,34,"Charges > $500, x 34%",1007.42,percent of total billed charges,Implant Device,1037.05,35,,1037.05,percent of total billed charges,Implant Device,1037.05,35,,1037.05,percent of total billed charges,Implant Device,1037.05,35,,1037.05,percent of total billed charges,Implant Device,1037.05,35,,1037.05,percent of total billed charges,Implant Device,1037.05,35,,1037.05,percent of total billed charges,Implant Device,1185.2,40,,1185.2,percent of total billed charges,Implant Device,1037.05,70,,1037.05,percent of total billed charges,All Other,1007.42,34,,1007.42,percent of total billed charges,Implant Device,1007.42,34,,1007.42,percent of total billed charges,Implant Device,1037.05,35,,1037.05,percent of total billed charges,Implant Device,1037.05,35,,1037.05,percent of total billed charges,Implant Device,1037.05,35,,1037.05,percent of total billed charges,Implant Device,1037.05,35,,1037.05,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1007.42,34,"If Charge > 2,000, then 34 percent",1007.42,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2192.63,
ZIMMER 5994-32-17 ART SURF 17MM,C1776,HCPCS,,79005185,CDM,278,RC,,,both,,,6465,4784.12,,,4784.12,Other,150% of Medicare + 9.63% HCRA Surcharge,2909.25,45,,2909.25,percent of total billed charges,Critical Access Hospital RCC factor,2198.1,34,,2198.1,percent of total billed charges,Implant Device,2198.1,34,,2198.1,percent of total billed charges,Implant Device,2198.1,34,,2198.1,percent of total billed charges,Implant Device,2198.1,34,,2198.1,percent of total billed charges,Implant Device,2198.1,34,,2198.1,percent of total billed charges,Implant Device,3200.18,,,3200.18,Other,110% of Medicare,2262.75,35,,2262.75,percent of total billed charges,Implant Device,2198.1,34,"Charges > $500, x 34%",2198.1,percent of total billed charges,Implant Device,2262.75,35,,2262.75,percent of total billed charges,Implant Device,2262.75,35,,2262.75,percent of total billed charges,Implant Device,2262.75,35,,2262.75,percent of total billed charges,Implant Device,2262.75,35,,2262.75,percent of total billed charges,Implant Device,2262.75,35,,2262.75,percent of total billed charges,Implant Device,2586,40,,2586,percent of total billed charges,Implant Device,2262.75,70,,2262.75,percent of total billed charges,All Other,2198.1,34,,2198.1,percent of total billed charges,Implant Device,2198.1,34,,2198.1,percent of total billed charges,Implant Device,2262.75,35,,2262.75,percent of total billed charges,Implant Device,2262.75,35,,2262.75,percent of total billed charges,Implant Device,2262.75,35,,2262.75,percent of total billed charges,Implant Device,2262.75,35,,2262.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2198.1,34,"If Charge > 2,000, then 34 percent",2198.1,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4784.12,
STRYKER 58-23008E BONE SCREW 2.3X8MM,C1713,HCPCS,,79005189,CDM,278,RC,,,both,,,426,315.24,,,315.24,Other,150% of Medicare + 9.63% HCRA Surcharge,191.7,45,,191.7,percent of total billed charges,Critical Access Hospital RCC factor,144.84,34,,144.84,percent of total billed charges,Implant Device,144.84,34,,144.84,percent of total billed charges,Implant Device,144.84,34,,144.84,percent of total billed charges,Implant Device,144.84,34,,144.84,percent of total billed charges,Implant Device,144.84,34,,144.84,percent of total billed charges,Implant Device,210.87,,,210.87,Other,110% of Medicare,149.1,35,,149.1,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,149.1,35,,149.1,percent of total billed charges,Implant Device,149.1,35,,149.1,percent of total billed charges,Implant Device,149.1,35,,149.1,percent of total billed charges,Implant Device,149.1,35,,149.1,percent of total billed charges,Implant Device,149.1,35,,149.1,percent of total billed charges,Implant Device,170.4,40,,170.4,percent of total billed charges,Implant Device,149.1,70,,149.1,percent of total billed charges,All Other,144.84,34,,144.84,percent of total billed charges,Implant Device,144.84,34,,144.84,percent of total billed charges,Implant Device,149.1,35,,149.1,percent of total billed charges,Implant Device,149.1,35,,149.1,percent of total billed charges,Implant Device,149.1,35,,149.1,percent of total billed charges,Implant Device,149.1,35,,149.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,315.24,
STRYKER 58-23009E BONE SCREW 2.3X9MM,C1713,HCPCS,,79005190,CDM,278,RC,,,both,,,426,315.24,,,315.24,Other,150% of Medicare + 9.63% HCRA Surcharge,191.7,45,,191.7,percent of total billed charges,Critical Access Hospital RCC factor,144.84,34,,144.84,percent of total billed charges,Implant Device,144.84,34,,144.84,percent of total billed charges,Implant Device,144.84,34,,144.84,percent of total billed charges,Implant Device,144.84,34,,144.84,percent of total billed charges,Implant Device,144.84,34,,144.84,percent of total billed charges,Implant Device,210.87,,,210.87,Other,110% of Medicare,149.1,35,,149.1,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,149.1,35,,149.1,percent of total billed charges,Implant Device,149.1,35,,149.1,percent of total billed charges,Implant Device,149.1,35,,149.1,percent of total billed charges,Implant Device,149.1,35,,149.1,percent of total billed charges,Implant Device,149.1,35,,149.1,percent of total billed charges,Implant Device,170.4,40,,170.4,percent of total billed charges,Implant Device,149.1,70,,149.1,percent of total billed charges,All Other,144.84,34,,144.84,percent of total billed charges,Implant Device,144.84,34,,144.84,percent of total billed charges,Implant Device,149.1,35,,149.1,percent of total billed charges,Implant Device,149.1,35,,149.1,percent of total billed charges,Implant Device,149.1,35,,149.1,percent of total billed charges,Implant Device,149.1,35,,149.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,315.24,
BIOMET PT-113950 HYBRID GLENOID POST,C1713,HCPCS,,79005191,CDM,278,RC,,,both,,,2310,1709.41,,,1709.41,Other,150% of Medicare + 9.63% HCRA Surcharge,1039.5,45,,1039.5,percent of total billed charges,Critical Access Hospital RCC factor,785.4,34,,785.4,percent of total billed charges,Implant Device,785.4,34,,785.4,percent of total billed charges,Implant Device,785.4,34,,785.4,percent of total billed charges,Implant Device,785.4,34,,785.4,percent of total billed charges,Implant Device,785.4,34,,785.4,percent of total billed charges,Implant Device,1143.45,,,1143.45,Other,110% of Medicare,808.5,35,,808.5,percent of total billed charges,Implant Device,785.4,34,"Charges > $500, x 34%",785.4,percent of total billed charges,Implant Device,808.5,35,,808.5,percent of total billed charges,Implant Device,808.5,35,,808.5,percent of total billed charges,Implant Device,808.5,35,,808.5,percent of total billed charges,Implant Device,808.5,35,,808.5,percent of total billed charges,Implant Device,808.5,35,,808.5,percent of total billed charges,Implant Device,924,40,,924,percent of total billed charges,Implant Device,808.5,70,,808.5,percent of total billed charges,All Other,785.4,34,,785.4,percent of total billed charges,Implant Device,785.4,34,,785.4,percent of total billed charges,Implant Device,808.5,35,,808.5,percent of total billed charges,Implant Device,808.5,35,,808.5,percent of total billed charges,Implant Device,808.5,35,,808.5,percent of total billed charges,Implant Device,808.5,35,,808.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,785.4,34,"If Charge > 2,000, then 34 percent",785.4,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1709.41,
BIOMET 118001 COMPREHENSIVE STD ADAPTOR,C1713,HCPCS,,79005192,CDM,278,RC,,,both,,,960,710.4,,,710.4,Other,150% of Medicare + 9.63% HCRA Surcharge,432,45,,432,percent of total billed charges,Critical Access Hospital RCC factor,326.4,34,,326.4,percent of total billed charges,Implant Device,326.4,34,,326.4,percent of total billed charges,Implant Device,326.4,34,,326.4,percent of total billed charges,Implant Device,326.4,34,,326.4,percent of total billed charges,Implant Device,326.4,34,,326.4,percent of total billed charges,Implant Device,475.2,,,475.2,Other,110% of Medicare,336,35,,336,percent of total billed charges,Implant Device,326.4,34,"Charges > $500, x 34%",326.4,percent of total billed charges,Implant Device,336,35,,336,percent of total billed charges,Implant Device,336,35,,336,percent of total billed charges,Implant Device,336,35,,336,percent of total billed charges,Implant Device,336,35,,336,percent of total billed charges,Implant Device,336,35,,336,percent of total billed charges,Implant Device,384,40,,384,percent of total billed charges,Implant Device,336,70,,336,percent of total billed charges,All Other,326.4,34,,326.4,percent of total billed charges,Implant Device,326.4,34,,326.4,percent of total billed charges,Implant Device,336,35,,336,percent of total billed charges,Implant Device,336,35,,336,percent of total billed charges,Implant Device,336,35,,336,percent of total billed charges,Implant Device,336,35,,336,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,710.4,
ARTHREX AR-1360C-CP MPFL BIOCMP IMPL SYS,C1713,HCPCS,,79005193,CDM,278,RC,,,both,,,4462,3301.89,,,3301.89,Other,150% of Medicare + 9.63% HCRA Surcharge,2007.9,45,,2007.9,percent of total billed charges,Critical Access Hospital RCC factor,1517.08,34,,1517.08,percent of total billed charges,Implant Device,1517.08,34,,1517.08,percent of total billed charges,Implant Device,1517.08,34,,1517.08,percent of total billed charges,Implant Device,1517.08,34,,1517.08,percent of total billed charges,Implant Device,1517.08,34,,1517.08,percent of total billed charges,Implant Device,2208.69,,,2208.69,Other,110% of Medicare,1561.7,35,,1561.7,percent of total billed charges,Implant Device,1517.08,34,"Charges > $500, x 34%",1517.08,percent of total billed charges,Implant Device,1561.7,35,,1561.7,percent of total billed charges,Implant Device,1561.7,35,,1561.7,percent of total billed charges,Implant Device,1561.7,35,,1561.7,percent of total billed charges,Implant Device,1561.7,35,,1561.7,percent of total billed charges,Implant Device,1561.7,35,,1561.7,percent of total billed charges,Implant Device,1784.8,40,,1784.8,percent of total billed charges,Implant Device,1561.7,70,,1561.7,percent of total billed charges,All Other,1517.08,34,,1517.08,percent of total billed charges,Implant Device,1517.08,34,,1517.08,percent of total billed charges,Implant Device,1561.7,35,,1561.7,percent of total billed charges,Implant Device,1561.7,35,,1561.7,percent of total billed charges,Implant Device,1561.7,35,,1561.7,percent of total billed charges,Implant Device,1561.7,35,,1561.7,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1517.08,34,"If Charge > 2,000, then 34 percent",1517.08,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3301.89,
BIOMET 110003484 ACCSS THRD STEINMAN PIN,C1713,HCPCS,,79005196,CDM,278,RC,,,both,,,660,488.4,,,488.4,Other,150% of Medicare + 9.63% HCRA Surcharge,297,45,,297,percent of total billed charges,Critical Access Hospital RCC factor,224.4,34,,224.4,percent of total billed charges,Implant Device,224.4,34,,224.4,percent of total billed charges,Implant Device,224.4,34,,224.4,percent of total billed charges,Implant Device,224.4,34,,224.4,percent of total billed charges,Implant Device,224.4,34,,224.4,percent of total billed charges,Implant Device,326.7,,,326.7,Other,110% of Medicare,231,35,,231,percent of total billed charges,Implant Device,224.4,34,"Charges > $500, x 34%",224.4,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,264,40,,264,percent of total billed charges,Implant Device,231,70,,231,percent of total billed charges,All Other,224.4,34,,224.4,percent of total billed charges,Implant Device,224.4,34,,224.4,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,488.4,
STRYKER 54-25396 VOLAR PLATE,C1713,HCPCS,,79005197,CDM,278,RC,,,both,,,3057,2262.19,,,2262.19,Other,150% of Medicare + 9.63% HCRA Surcharge,1375.65,45,,1375.65,percent of total billed charges,Critical Access Hospital RCC factor,1039.38,34,,1039.38,percent of total billed charges,Implant Device,1039.38,34,,1039.38,percent of total billed charges,Implant Device,1039.38,34,,1039.38,percent of total billed charges,Implant Device,1039.38,34,,1039.38,percent of total billed charges,Implant Device,1039.38,34,,1039.38,percent of total billed charges,Implant Device,1513.22,,,1513.22,Other,110% of Medicare,1069.95,35,,1069.95,percent of total billed charges,Implant Device,1039.38,34,"Charges > $500, x 34%",1039.38,percent of total billed charges,Implant Device,1069.95,35,,1069.95,percent of total billed charges,Implant Device,1069.95,35,,1069.95,percent of total billed charges,Implant Device,1069.95,35,,1069.95,percent of total billed charges,Implant Device,1069.95,35,,1069.95,percent of total billed charges,Implant Device,1069.95,35,,1069.95,percent of total billed charges,Implant Device,1222.8,40,,1222.8,percent of total billed charges,Implant Device,1069.95,70,,1069.95,percent of total billed charges,All Other,1039.38,34,,1039.38,percent of total billed charges,Implant Device,1039.38,34,,1039.38,percent of total billed charges,Implant Device,1069.95,35,,1069.95,percent of total billed charges,Implant Device,1069.95,35,,1069.95,percent of total billed charges,Implant Device,1069.95,35,,1069.95,percent of total billed charges,Implant Device,1069.95,35,,1069.95,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1039.38,34,"If Charge > 2,000, then 34 percent",1039.38,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2262.19,
STRYKER 53-27622E LOCKING SCREW 2.7X22MM,C1713,HCPCS,,79005198,CDM,278,RC,,,both,,,304,224.96,,,224.96,Other,150% of Medicare + 9.63% HCRA Surcharge,136.8,45,,136.8,percent of total billed charges,Critical Access Hospital RCC factor,103.36,34,,103.36,percent of total billed charges,Implant Device,103.36,34,,103.36,percent of total billed charges,Implant Device,103.36,34,,103.36,percent of total billed charges,Implant Device,103.36,34,,103.36,percent of total billed charges,Implant Device,103.36,34,,103.36,percent of total billed charges,Implant Device,150.48,,,150.48,Other,110% of Medicare,106.4,35,,106.4,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,106.4,35,,106.4,percent of total billed charges,Implant Device,106.4,35,,106.4,percent of total billed charges,Implant Device,106.4,35,,106.4,percent of total billed charges,Implant Device,106.4,35,,106.4,percent of total billed charges,Implant Device,106.4,35,,106.4,percent of total billed charges,Implant Device,121.6,40,,121.6,percent of total billed charges,Implant Device,106.4,70,,106.4,percent of total billed charges,All Other,103.36,34,,103.36,percent of total billed charges,Implant Device,103.36,34,,103.36,percent of total billed charges,Implant Device,106.4,35,,106.4,percent of total billed charges,Implant Device,106.4,35,,106.4,percent of total billed charges,Implant Device,106.4,35,,106.4,percent of total billed charges,Implant Device,106.4,35,,106.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,224.96,
STRYKER 53-27214E CORT SCREW 2.7X14MM,C1713,HCPCS,,79005199,CDM,278,RC,,,both,,,344,254.56,,,254.56,Other,150% of Medicare + 9.63% HCRA Surcharge,154.8,45,,154.8,percent of total billed charges,Critical Access Hospital RCC factor,116.96,34,,116.96,percent of total billed charges,Implant Device,116.96,34,,116.96,percent of total billed charges,Implant Device,116.96,34,,116.96,percent of total billed charges,Implant Device,116.96,34,,116.96,percent of total billed charges,Implant Device,116.96,34,,116.96,percent of total billed charges,Implant Device,170.28,,,170.28,Other,110% of Medicare,120.4,35,,120.4,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,120.4,35,,120.4,percent of total billed charges,Implant Device,120.4,35,,120.4,percent of total billed charges,Implant Device,120.4,35,,120.4,percent of total billed charges,Implant Device,120.4,35,,120.4,percent of total billed charges,Implant Device,120.4,35,,120.4,percent of total billed charges,Implant Device,137.6,40,,137.6,percent of total billed charges,Implant Device,120.4,70,,120.4,percent of total billed charges,All Other,116.96,34,,116.96,percent of total billed charges,Implant Device,116.96,34,,116.96,percent of total billed charges,Implant Device,120.4,35,,120.4,percent of total billed charges,Implant Device,120.4,35,,120.4,percent of total billed charges,Implant Device,120.4,35,,120.4,percent of total billed charges,Implant Device,120.4,35,,120.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,254.56,
SYNTHES XM106.2020S TISSUE MATRX 20X20CM,C1713,HCPCS,,79005202,CDM,278,RC,,,both,,,37707,27903.27,,,27903.27,Other,150% of Medicare + 9.63% HCRA Surcharge,16968.15,45,,16968.15,percent of total billed charges,Critical Access Hospital RCC factor,12820.38,34,,12820.38,percent of total billed charges,Implant Device,12820.38,34,,12820.38,percent of total billed charges,Implant Device,12820.38,34,,12820.38,percent of total billed charges,Implant Device,12820.38,34,,12820.38,percent of total billed charges,Implant Device,12820.38,34,,12820.38,percent of total billed charges,Implant Device,18664.97,,,18664.97,Other,110% of Medicare,13197.45,35,,13197.45,percent of total billed charges,Implant Device,12820.38,34,"Charges > $500, x 34%",12820.38,percent of total billed charges,Implant Device,13197.45,35,,13197.45,percent of total billed charges,Implant Device,13197.45,35,,13197.45,percent of total billed charges,Implant Device,13197.45,35,,13197.45,percent of total billed charges,Implant Device,13197.45,35,,13197.45,percent of total billed charges,Implant Device,13197.45,35,,13197.45,percent of total billed charges,Implant Device,15082.8,40,,15082.8,percent of total billed charges,Implant Device,13197.45,70,,13197.45,percent of total billed charges,All Other,12820.38,34,,12820.38,percent of total billed charges,Implant Device,12820.38,34,,12820.38,percent of total billed charges,Implant Device,13197.45,35,,13197.45,percent of total billed charges,Implant Device,13197.45,35,,13197.45,percent of total billed charges,Implant Device,13197.45,35,,13197.45,percent of total billed charges,Implant Device,13197.45,35,,13197.45,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,12820.38,34,"If Charge > 2,000, then 34 percent",12820.38,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,27903.27,
STRYKER 6276-7-215 MOD HIP SYS 195X15MM,C1776,HCPCS,,79005204,CDM,278,RC,,,both,,,15277,11305.02,,,11305.02,Other,150% of Medicare + 9.63% HCRA Surcharge,6874.65,45,,6874.65,percent of total billed charges,Critical Access Hospital RCC factor,5194.18,34,,5194.18,percent of total billed charges,Implant Device,5194.18,34,,5194.18,percent of total billed charges,Implant Device,5194.18,34,,5194.18,percent of total billed charges,Implant Device,5194.18,34,,5194.18,percent of total billed charges,Implant Device,5194.18,34,,5194.18,percent of total billed charges,Implant Device,7562.12,,,7562.12,Other,110% of Medicare,5346.95,35,,5346.95,percent of total billed charges,Implant Device,5194.18,34,"Charges > $500, x 34%",5194.18,percent of total billed charges,Implant Device,5346.95,35,,5346.95,percent of total billed charges,Implant Device,5346.95,35,,5346.95,percent of total billed charges,Implant Device,5346.95,35,,5346.95,percent of total billed charges,Implant Device,5346.95,35,,5346.95,percent of total billed charges,Implant Device,5346.95,35,,5346.95,percent of total billed charges,Implant Device,6110.8,40,,6110.8,percent of total billed charges,Implant Device,5346.95,70,,5346.95,percent of total billed charges,All Other,5194.18,34,,5194.18,percent of total billed charges,Implant Device,5194.18,34,,5194.18,percent of total billed charges,Implant Device,5346.95,35,,5346.95,percent of total billed charges,Implant Device,5346.95,35,,5346.95,percent of total billed charges,Implant Device,5346.95,35,,5346.95,percent of total billed charges,Implant Device,5346.95,35,,5346.95,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,5194.18,34,"If Charge > 2,000, then 34 percent",5194.18,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,11305.02,
STRYKER 6276-1-125 MOD HIP SYS V40 25MM,C1776,HCPCS,,79005205,CDM,278,RC,,,both,,,19076,14116.29,,,14116.29,Other,150% of Medicare + 9.63% HCRA Surcharge,8584.2,45,,8584.2,percent of total billed charges,Critical Access Hospital RCC factor,6485.84,34,,6485.84,percent of total billed charges,Implant Device,6485.84,34,,6485.84,percent of total billed charges,Implant Device,6485.84,34,,6485.84,percent of total billed charges,Implant Device,6485.84,34,,6485.84,percent of total billed charges,Implant Device,6485.84,34,,6485.84,percent of total billed charges,Implant Device,9442.62,,,9442.62,Other,110% of Medicare,6676.6,35,,6676.6,percent of total billed charges,Implant Device,6485.84,34,"Charges > $500, x 34%",6485.84,percent of total billed charges,Implant Device,6676.6,35,,6676.6,percent of total billed charges,Implant Device,6676.6,35,,6676.6,percent of total billed charges,Implant Device,6676.6,35,,6676.6,percent of total billed charges,Implant Device,6676.6,35,,6676.6,percent of total billed charges,Implant Device,6676.6,35,,6676.6,percent of total billed charges,Implant Device,7630.4,40,,7630.4,percent of total billed charges,Implant Device,6676.6,70,,6676.6,percent of total billed charges,All Other,6485.84,34,,6485.84,percent of total billed charges,Implant Device,6485.84,34,,6485.84,percent of total billed charges,Implant Device,6676.6,35,,6676.6,percent of total billed charges,Implant Device,6676.6,35,,6676.6,percent of total billed charges,Implant Device,6676.6,35,,6676.6,percent of total billed charges,Implant Device,6676.6,35,,6676.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,6485.84,34,"If Charge > 2,000, then 34 percent",6485.84,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,14116.29,
STRYKER UH1-42-26 UNI HEAD 42X26MM,C1776,HCPCS,,79005206,CDM,278,RC,,,both,,,1391,1029.34,,,1029.34,Other,150% of Medicare + 9.63% HCRA Surcharge,625.95,45,,625.95,percent of total billed charges,Critical Access Hospital RCC factor,472.94,34,,472.94,percent of total billed charges,Implant Device,472.94,34,,472.94,percent of total billed charges,Implant Device,472.94,34,,472.94,percent of total billed charges,Implant Device,472.94,34,,472.94,percent of total billed charges,Implant Device,472.94,34,,472.94,percent of total billed charges,Implant Device,688.55,,,688.55,Other,110% of Medicare,486.85,35,,486.85,percent of total billed charges,Implant Device,472.94,34,"Charges > $500, x 34%",472.94,percent of total billed charges,Implant Device,486.85,35,,486.85,percent of total billed charges,Implant Device,486.85,35,,486.85,percent of total billed charges,Implant Device,486.85,35,,486.85,percent of total billed charges,Implant Device,486.85,35,,486.85,percent of total billed charges,Implant Device,486.85,35,,486.85,percent of total billed charges,Implant Device,556.4,40,,556.4,percent of total billed charges,Implant Device,486.85,70,,486.85,percent of total billed charges,All Other,472.94,34,,472.94,percent of total billed charges,Implant Device,472.94,34,,472.94,percent of total billed charges,Implant Device,486.85,35,,486.85,percent of total billed charges,Implant Device,486.85,35,,486.85,percent of total billed charges,Implant Device,486.85,35,,486.85,percent of total billed charges,Implant Device,486.85,35,,486.85,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1029.34,
ARTHREX AR-2656DR DISTAL CLAV PLATE SHRT,C1713,HCPCS,,79005207,CDM,278,RC,,,both,,,1650,1221,,,1221,Other,150% of Medicare + 9.63% HCRA Surcharge,742.5,45,,742.5,percent of total billed charges,Critical Access Hospital RCC factor,561,34,,561,percent of total billed charges,Implant Device,561,34,,561,percent of total billed charges,Implant Device,561,34,,561,percent of total billed charges,Implant Device,561,34,,561,percent of total billed charges,Implant Device,561,34,,561,percent of total billed charges,Implant Device,816.75,,,816.75,Other,110% of Medicare,577.5,35,,577.5,percent of total billed charges,Implant Device,561,34,"Charges > $500, x 34%",561,percent of total billed charges,Implant Device,577.5,35,,577.5,percent of total billed charges,Implant Device,577.5,35,,577.5,percent of total billed charges,Implant Device,577.5,35,,577.5,percent of total billed charges,Implant Device,577.5,35,,577.5,percent of total billed charges,Implant Device,577.5,35,,577.5,percent of total billed charges,Implant Device,660,40,,660,percent of total billed charges,Implant Device,577.5,70,,577.5,percent of total billed charges,All Other,561,34,,561,percent of total billed charges,Implant Device,561,34,,561,percent of total billed charges,Implant Device,577.5,35,,577.5,percent of total billed charges,Implant Device,577.5,35,,577.5,percent of total billed charges,Implant Device,577.5,35,,577.5,percent of total billed charges,Implant Device,577.5,35,,577.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1221,
STRYKER 2030-6530-1 CANC SCREW 6.5X30MM,C1713,HCPCS,,79005208,CDM,278,RC,,,both,,,533,394.42,,,394.42,Other,150% of Medicare + 9.63% HCRA Surcharge,239.85,45,,239.85,percent of total billed charges,Critical Access Hospital RCC factor,181.22,34,,181.22,percent of total billed charges,Implant Device,181.22,34,,181.22,percent of total billed charges,Implant Device,181.22,34,,181.22,percent of total billed charges,Implant Device,181.22,34,,181.22,percent of total billed charges,Implant Device,181.22,34,,181.22,percent of total billed charges,Implant Device,263.84,,,263.84,Other,110% of Medicare,186.55,35,,186.55,percent of total billed charges,Implant Device,181.22,34,"Charges > $500, x 34%",181.22,percent of total billed charges,Implant Device,186.55,35,,186.55,percent of total billed charges,Implant Device,186.55,35,,186.55,percent of total billed charges,Implant Device,186.55,35,,186.55,percent of total billed charges,Implant Device,186.55,35,,186.55,percent of total billed charges,Implant Device,186.55,35,,186.55,percent of total billed charges,Implant Device,213.2,40,,213.2,percent of total billed charges,Implant Device,186.55,70,,186.55,percent of total billed charges,All Other,181.22,34,,181.22,percent of total billed charges,Implant Device,181.22,34,,181.22,percent of total billed charges,Implant Device,186.55,35,,186.55,percent of total billed charges,Implant Device,186.55,35,,186.55,percent of total billed charges,Implant Device,186.55,35,,186.55,percent of total billed charges,Implant Device,186.55,35,,186.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,394.42,
STRYKER 06-4000 ANATOMIC FEM HEAD 40X0MM,C1776,HCPCS,,79005209,CDM,278,RC,,,both,,,6232,4611.7,,,4611.7,Other,150% of Medicare + 9.63% HCRA Surcharge,2804.4,45,,2804.4,percent of total billed charges,Critical Access Hospital RCC factor,2118.88,34,,2118.88,percent of total billed charges,Implant Device,2118.88,34,,2118.88,percent of total billed charges,Implant Device,2118.88,34,,2118.88,percent of total billed charges,Implant Device,2118.88,34,,2118.88,percent of total billed charges,Implant Device,2118.88,34,,2118.88,percent of total billed charges,Implant Device,3084.84,,,3084.84,Other,110% of Medicare,2181.2,35,,2181.2,percent of total billed charges,Implant Device,2118.88,34,"Charges > $500, x 34%",2118.88,percent of total billed charges,Implant Device,2181.2,35,,2181.2,percent of total billed charges,Implant Device,2181.2,35,,2181.2,percent of total billed charges,Implant Device,2181.2,35,,2181.2,percent of total billed charges,Implant Device,2181.2,35,,2181.2,percent of total billed charges,Implant Device,2181.2,35,,2181.2,percent of total billed charges,Implant Device,2492.8,40,,2492.8,percent of total billed charges,Implant Device,2181.2,70,,2181.2,percent of total billed charges,All Other,2118.88,34,,2118.88,percent of total billed charges,Implant Device,2118.88,34,,2118.88,percent of total billed charges,Implant Device,2181.2,35,,2181.2,percent of total billed charges,Implant Device,2181.2,35,,2181.2,percent of total billed charges,Implant Device,2181.2,35,,2181.2,percent of total billed charges,Implant Device,2181.2,35,,2181.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2118.88,34,"If Charge > 2,000, then 34 percent",2118.88,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4611.7,
STRYKER 2030-6520-1 CANC SCREW 6.5X20MM,C1713,HCPCS,,79005210,CDM,278,RC,,,both,,,488,361.12,,,361.12,Other,150% of Medicare + 9.63% HCRA Surcharge,219.6,45,,219.6,percent of total billed charges,Critical Access Hospital RCC factor,165.92,34,,165.92,percent of total billed charges,Implant Device,165.92,34,,165.92,percent of total billed charges,Implant Device,165.92,34,,165.92,percent of total billed charges,Implant Device,165.92,34,,165.92,percent of total billed charges,Implant Device,165.92,34,,165.92,percent of total billed charges,Implant Device,241.56,,,241.56,Other,110% of Medicare,170.8,35,,170.8,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,170.8,35,,170.8,percent of total billed charges,Implant Device,170.8,35,,170.8,percent of total billed charges,Implant Device,170.8,35,,170.8,percent of total billed charges,Implant Device,170.8,35,,170.8,percent of total billed charges,Implant Device,170.8,35,,170.8,percent of total billed charges,Implant Device,195.2,40,,195.2,percent of total billed charges,Implant Device,170.8,70,,170.8,percent of total billed charges,All Other,165.92,34,,165.92,percent of total billed charges,Implant Device,165.92,34,,165.92,percent of total billed charges,Implant Device,170.8,35,,170.8,percent of total billed charges,Implant Device,170.8,35,,170.8,percent of total billed charges,Implant Device,170.8,35,,170.8,percent of total billed charges,Implant Device,170.8,35,,170.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,361.12,
STRYKER 502-03-54E CLUST HOLE SHELL 54MM,C1776,HCPCS,,79005211,CDM,278,RC,,,both,,,9823,7269.04,,,7269.04,Other,150% of Medicare + 9.63% HCRA Surcharge,4420.35,45,,4420.35,percent of total billed charges,Critical Access Hospital RCC factor,3339.82,34,,3339.82,percent of total billed charges,Implant Device,3339.82,34,,3339.82,percent of total billed charges,Implant Device,3339.82,34,,3339.82,percent of total billed charges,Implant Device,3339.82,34,,3339.82,percent of total billed charges,Implant Device,3339.82,34,,3339.82,percent of total billed charges,Implant Device,4862.39,,,4862.39,Other,110% of Medicare,3438.05,35,,3438.05,percent of total billed charges,Implant Device,3339.82,34,"Charges > $500, x 34%",3339.82,percent of total billed charges,Implant Device,3438.05,35,,3438.05,percent of total billed charges,Implant Device,3438.05,35,,3438.05,percent of total billed charges,Implant Device,3438.05,35,,3438.05,percent of total billed charges,Implant Device,3438.05,35,,3438.05,percent of total billed charges,Implant Device,3438.05,35,,3438.05,percent of total billed charges,Implant Device,3929.2,40,,3929.2,percent of total billed charges,Implant Device,3438.05,70,,3438.05,percent of total billed charges,All Other,3339.82,34,,3339.82,percent of total billed charges,Implant Device,3339.82,34,,3339.82,percent of total billed charges,Implant Device,3438.05,35,,3438.05,percent of total billed charges,Implant Device,3438.05,35,,3438.05,percent of total billed charges,Implant Device,3438.05,35,,3438.05,percent of total billed charges,Implant Device,3438.05,35,,3438.05,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3339.82,34,"If Charge > 2,000, then 34 percent",3339.82,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,7269.04,
ZIMMER 00-5850-020-12 ART SUR SZ B 12MM,C1776,HCPCS,,79005212,CDM,278,RC,,,both,,,5603,4146.23,,,4146.23,Other,150% of Medicare + 9.63% HCRA Surcharge,2521.35,45,,2521.35,percent of total billed charges,Critical Access Hospital RCC factor,1905.02,34,,1905.02,percent of total billed charges,Implant Device,1905.02,34,,1905.02,percent of total billed charges,Implant Device,1905.02,34,,1905.02,percent of total billed charges,Implant Device,1905.02,34,,1905.02,percent of total billed charges,Implant Device,1905.02,34,,1905.02,percent of total billed charges,Implant Device,2773.49,,,2773.49,Other,110% of Medicare,1961.05,35,,1961.05,percent of total billed charges,Implant Device,1905.02,34,"Charges > $500, x 34%",1905.02,percent of total billed charges,Implant Device,1961.05,35,,1961.05,percent of total billed charges,Implant Device,1961.05,35,,1961.05,percent of total billed charges,Implant Device,1961.05,35,,1961.05,percent of total billed charges,Implant Device,1961.05,35,,1961.05,percent of total billed charges,Implant Device,1961.05,35,,1961.05,percent of total billed charges,Implant Device,2241.2,40,,2241.2,percent of total billed charges,Implant Device,1961.05,70,,1961.05,percent of total billed charges,All Other,1905.02,34,,1905.02,percent of total billed charges,Implant Device,1905.02,34,,1905.02,percent of total billed charges,Implant Device,1961.05,35,,1961.05,percent of total billed charges,Implant Device,1961.05,35,,1961.05,percent of total billed charges,Implant Device,1961.05,35,,1961.05,percent of total billed charges,Implant Device,1961.05,35,,1961.05,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1905.02,34,"If Charge > 2,000, then 34 percent",1905.02,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4146.23,
ZIMMER 00-5852-050-12 STEM EXT 12X130MM,C1776,HCPCS,,79005213,CDM,278,RC,,,both,,,11453,8475.25,,,8475.25,Other,150% of Medicare + 9.63% HCRA Surcharge,5153.85,45,,5153.85,percent of total billed charges,Critical Access Hospital RCC factor,3894.02,34,,3894.02,percent of total billed charges,Implant Device,3894.02,34,,3894.02,percent of total billed charges,Implant Device,3894.02,34,,3894.02,percent of total billed charges,Implant Device,3894.02,34,,3894.02,percent of total billed charges,Implant Device,3894.02,34,,3894.02,percent of total billed charges,Implant Device,5669.24,,,5669.24,Other,110% of Medicare,4008.55,35,,4008.55,percent of total billed charges,Implant Device,3894.02,34,"Charges > $500, x 34%",3894.02,percent of total billed charges,Implant Device,4008.55,35,,4008.55,percent of total billed charges,Implant Device,4008.55,35,,4008.55,percent of total billed charges,Implant Device,4008.55,35,,4008.55,percent of total billed charges,Implant Device,4008.55,35,,4008.55,percent of total billed charges,Implant Device,4008.55,35,,4008.55,percent of total billed charges,Implant Device,4581.2,40,,4581.2,percent of total billed charges,Implant Device,4008.55,70,,4008.55,percent of total billed charges,All Other,3894.02,34,,3894.02,percent of total billed charges,Implant Device,3894.02,34,,3894.02,percent of total billed charges,Implant Device,4008.55,35,,4008.55,percent of total billed charges,Implant Device,4008.55,35,,4008.55,percent of total billed charges,Implant Device,4008.55,35,,4008.55,percent of total billed charges,Implant Device,4008.55,35,,4008.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3894.02,34,"If Charge > 2,000, then 34 percent",3894.02,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,8475.25,
ZIMMER 00-5852-040-35 STEM COLLAR 35MM,C1776,HCPCS,,79005214,CDM,278,RC,,,both,,,7874,5826.78,,,5826.78,Other,150% of Medicare + 9.63% HCRA Surcharge,3543.3,45,,3543.3,percent of total billed charges,Critical Access Hospital RCC factor,2677.16,34,,2677.16,percent of total billed charges,Implant Device,2677.16,34,,2677.16,percent of total billed charges,Implant Device,2677.16,34,,2677.16,percent of total billed charges,Implant Device,2677.16,34,,2677.16,percent of total billed charges,Implant Device,2677.16,34,,2677.16,percent of total billed charges,Implant Device,3897.63,,,3897.63,Other,110% of Medicare,2755.9,35,,2755.9,percent of total billed charges,Implant Device,2677.16,34,"Charges > $500, x 34%",2677.16,percent of total billed charges,Implant Device,2755.9,35,,2755.9,percent of total billed charges,Implant Device,2755.9,35,,2755.9,percent of total billed charges,Implant Device,2755.9,35,,2755.9,percent of total billed charges,Implant Device,2755.9,35,,2755.9,percent of total billed charges,Implant Device,2755.9,35,,2755.9,percent of total billed charges,Implant Device,3149.6,40,,3149.6,percent of total billed charges,Implant Device,2755.9,70,,2755.9,percent of total billed charges,All Other,2677.16,34,,2677.16,percent of total billed charges,Implant Device,2677.16,34,,2677.16,percent of total billed charges,Implant Device,2755.9,35,,2755.9,percent of total billed charges,Implant Device,2755.9,35,,2755.9,percent of total billed charges,Implant Device,2755.9,35,,2755.9,percent of total billed charges,Implant Device,2755.9,35,,2755.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2677.16,34,"If Charge > 2,000, then 34 percent",2677.16,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5826.78,
ZIMMER 00-5850-012-02 DIST FEM COMP SZ B,C1776,HCPCS,,79005215,CDM,278,RC,,,both,,,24706,18282.5,,,18282.5,Other,150% of Medicare + 9.63% HCRA Surcharge,11117.7,45,,11117.7,percent of total billed charges,Critical Access Hospital RCC factor,8400.04,34,,8400.04,percent of total billed charges,Implant Device,8400.04,34,,8400.04,percent of total billed charges,Implant Device,8400.04,34,,8400.04,percent of total billed charges,Implant Device,8400.04,34,,8400.04,percent of total billed charges,Implant Device,8400.04,34,,8400.04,percent of total billed charges,Implant Device,12229.47,,,12229.47,Other,110% of Medicare,8647.1,35,,8647.1,percent of total billed charges,Implant Device,8400.04,34,"Charges > $500, x 34%",8400.04,percent of total billed charges,Implant Device,8647.1,35,,8647.1,percent of total billed charges,Implant Device,8647.1,35,,8647.1,percent of total billed charges,Implant Device,8647.1,35,,8647.1,percent of total billed charges,Implant Device,8647.1,35,,8647.1,percent of total billed charges,Implant Device,8647.1,35,,8647.1,percent of total billed charges,Implant Device,9882.4,40,,9882.4,percent of total billed charges,Implant Device,8647.1,70,,8647.1,percent of total billed charges,All Other,8400.04,34,,8400.04,percent of total billed charges,Implant Device,8400.04,34,,8400.04,percent of total billed charges,Implant Device,8647.1,35,,8647.1,percent of total billed charges,Implant Device,8647.1,35,,8647.1,percent of total billed charges,Implant Device,8647.1,35,,8647.1,percent of total billed charges,Implant Device,8647.1,35,,8647.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,8400.04,34,"If Charge > 2,000, then 34 percent",8400.04,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,18282.5,
GORE RMT231212 EXCLUDER AAA ENDO GRAFT,C1874,HCPCS,,79005216,CDM,278,RC,,,both,,,30736,22744.72,,,22744.72,Other,150% of Medicare + 9.63% HCRA Surcharge,13831.2,45,,13831.2,percent of total billed charges,Critical Access Hospital RCC factor,10450.24,34,,10450.24,percent of total billed charges,Implant Device,10450.24,34,,10450.24,percent of total billed charges,Implant Device,10450.24,34,,10450.24,percent of total billed charges,Implant Device,10450.24,34,,10450.24,percent of total billed charges,Implant Device,10450.24,34,,10450.24,percent of total billed charges,Implant Device,15214.32,,,15214.32,Other,110% of Medicare,10757.6,35,,10757.6,percent of total billed charges,Implant Device,10450.24,34,"Charges > $500, x 34%",10450.24,percent of total billed charges,Implant Device,10757.6,35,,10757.6,percent of total billed charges,Implant Device,10757.6,35,,10757.6,percent of total billed charges,Implant Device,10757.6,35,,10757.6,percent of total billed charges,Implant Device,10757.6,35,,10757.6,percent of total billed charges,Implant Device,10757.6,35,,10757.6,percent of total billed charges,Implant Device,12294.4,40,,12294.4,percent of total billed charges,Implant Device,10757.6,70,,10757.6,percent of total billed charges,All Other,10450.24,34,,10450.24,percent of total billed charges,Implant Device,10450.24,34,,10450.24,percent of total billed charges,Implant Device,10757.6,35,,10757.6,percent of total billed charges,Implant Device,10757.6,35,,10757.6,percent of total billed charges,Implant Device,10757.6,35,,10757.6,percent of total billed charges,Implant Device,10757.6,35,,10757.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,10450.24,34,"If Charge > 2,000, then 34 percent",10450.24,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,22744.72,
GORE PXC121200 EXCLUDER AAA ENDO GRAFT,C1874,HCPCS,,79005217,CDM,278,RC,,,both,,,13200,9768.03,,,9768.03,Other,150% of Medicare + 9.63% HCRA Surcharge,5940,45,,5940,percent of total billed charges,Critical Access Hospital RCC factor,4488,34,,4488,percent of total billed charges,Implant Device,4488,34,,4488,percent of total billed charges,Implant Device,4488,34,,4488,percent of total billed charges,Implant Device,4488,34,,4488,percent of total billed charges,Implant Device,4488,34,,4488,percent of total billed charges,Implant Device,6534,,,6534,Other,110% of Medicare,4620,35,,4620,percent of total billed charges,Implant Device,4488,34,"Charges > $500, x 34%",4488,percent of total billed charges,Implant Device,4620,35,,4620,percent of total billed charges,Implant Device,4620,35,,4620,percent of total billed charges,Implant Device,4620,35,,4620,percent of total billed charges,Implant Device,4620,35,,4620,percent of total billed charges,Implant Device,4620,35,,4620,percent of total billed charges,Implant Device,5280,40,,5280,percent of total billed charges,Implant Device,4620,70,,4620,percent of total billed charges,All Other,4488,34,,4488,percent of total billed charges,Implant Device,4488,34,,4488,percent of total billed charges,Implant Device,4620,35,,4620,percent of total billed charges,Implant Device,4620,35,,4620,percent of total billed charges,Implant Device,4620,35,,4620,percent of total billed charges,Implant Device,4620,35,,4620,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,4488,34,"If Charge > 2,000, then 34 percent",4488,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,9768.03,
ARTHREX AR-8948-08 COTTON PLATE 8MM,C1713,HCPCS,,79005218,CDM,278,RC,,,both,,,2386,1765.65,,,1765.65,Other,150% of Medicare + 9.63% HCRA Surcharge,1073.7,45,,1073.7,percent of total billed charges,Critical Access Hospital RCC factor,811.24,34,,811.24,percent of total billed charges,Implant Device,811.24,34,,811.24,percent of total billed charges,Implant Device,811.24,34,,811.24,percent of total billed charges,Implant Device,811.24,34,,811.24,percent of total billed charges,Implant Device,811.24,34,,811.24,percent of total billed charges,Implant Device,1181.07,,,1181.07,Other,110% of Medicare,835.1,35,,835.1,percent of total billed charges,Implant Device,811.24,34,"Charges > $500, x 34%",811.24,percent of total billed charges,Implant Device,835.1,35,,835.1,percent of total billed charges,Implant Device,835.1,35,,835.1,percent of total billed charges,Implant Device,835.1,35,,835.1,percent of total billed charges,Implant Device,835.1,35,,835.1,percent of total billed charges,Implant Device,835.1,35,,835.1,percent of total billed charges,Implant Device,954.4,40,,954.4,percent of total billed charges,Implant Device,835.1,70,,835.1,percent of total billed charges,All Other,811.24,34,,811.24,percent of total billed charges,Implant Device,811.24,34,,811.24,percent of total billed charges,Implant Device,835.1,35,,835.1,percent of total billed charges,Implant Device,835.1,35,,835.1,percent of total billed charges,Implant Device,835.1,35,,835.1,percent of total billed charges,Implant Device,835.1,35,,835.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,811.24,34,"If Charge > 2,000, then 34 percent",811.24,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1765.65,
ARTHREX AR-13120T-16 SCREW 2.3X16MM,C1713,HCPCS,,79005219,CDM,278,RC,,,both,,,196,145.04,,,145.04,Other,150% of Medicare + 9.63% HCRA Surcharge,88.2,45,,88.2,percent of total billed charges,Critical Access Hospital RCC factor,66.64,34,,66.64,percent of total billed charges,Implant Device,66.64,34,,66.64,percent of total billed charges,Implant Device,66.64,34,,66.64,percent of total billed charges,Implant Device,66.64,34,,66.64,percent of total billed charges,Implant Device,66.64,34,,66.64,percent of total billed charges,Implant Device,97.02,,,97.02,Other,110% of Medicare,68.6,35,,68.6,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,68.6,35,,68.6,percent of total billed charges,Implant Device,68.6,35,,68.6,percent of total billed charges,Implant Device,68.6,35,,68.6,percent of total billed charges,Implant Device,68.6,35,,68.6,percent of total billed charges,Implant Device,68.6,35,,68.6,percent of total billed charges,Implant Device,78.4,40,,78.4,percent of total billed charges,Implant Device,68.6,70,,68.6,percent of total billed charges,All Other,66.64,34,,66.64,percent of total billed charges,Implant Device,66.64,34,,66.64,percent of total billed charges,Implant Device,68.6,35,,68.6,percent of total billed charges,Implant Device,68.6,35,,68.6,percent of total billed charges,Implant Device,68.6,35,,68.6,percent of total billed charges,Implant Device,68.6,35,,68.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,145.04,
ARTHREX AR-13120T-20 SCREW 2.3X20MM,C1713,HCPCS,,79005220,CDM,278,RC,,,both,,,408,301.92,,,301.92,Other,150% of Medicare + 9.63% HCRA Surcharge,183.6,45,,183.6,percent of total billed charges,Critical Access Hospital RCC factor,138.72,34,,138.72,percent of total billed charges,Implant Device,138.72,34,,138.72,percent of total billed charges,Implant Device,138.72,34,,138.72,percent of total billed charges,Implant Device,138.72,34,,138.72,percent of total billed charges,Implant Device,138.72,34,,138.72,percent of total billed charges,Implant Device,201.96,,,201.96,Other,110% of Medicare,142.8,35,,142.8,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,142.8,35,,142.8,percent of total billed charges,Implant Device,142.8,35,,142.8,percent of total billed charges,Implant Device,142.8,35,,142.8,percent of total billed charges,Implant Device,142.8,35,,142.8,percent of total billed charges,Implant Device,142.8,35,,142.8,percent of total billed charges,Implant Device,163.2,40,,163.2,percent of total billed charges,Implant Device,142.8,70,,142.8,percent of total billed charges,All Other,138.72,34,,138.72,percent of total billed charges,Implant Device,138.72,34,,138.72,percent of total billed charges,Implant Device,142.8,35,,142.8,percent of total billed charges,Implant Device,142.8,35,,142.8,percent of total billed charges,Implant Device,142.8,35,,142.8,percent of total billed charges,Implant Device,142.8,35,,142.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,301.92,
ARTHREX AR-13120T-24 SCREW 2.3X24MM,C1713,HCPCS,,79005221,CDM,278,RC,,,both,,,196,145.04,,,145.04,Other,150% of Medicare + 9.63% HCRA Surcharge,88.2,45,,88.2,percent of total billed charges,Critical Access Hospital RCC factor,66.64,34,,66.64,percent of total billed charges,Implant Device,66.64,34,,66.64,percent of total billed charges,Implant Device,66.64,34,,66.64,percent of total billed charges,Implant Device,66.64,34,,66.64,percent of total billed charges,Implant Device,66.64,34,,66.64,percent of total billed charges,Implant Device,97.02,,,97.02,Other,110% of Medicare,68.6,35,,68.6,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,68.6,35,,68.6,percent of total billed charges,Implant Device,68.6,35,,68.6,percent of total billed charges,Implant Device,68.6,35,,68.6,percent of total billed charges,Implant Device,68.6,35,,68.6,percent of total billed charges,Implant Device,68.6,35,,68.6,percent of total billed charges,Implant Device,78.4,40,,78.4,percent of total billed charges,Implant Device,68.6,70,,68.6,percent of total billed charges,All Other,66.64,34,,66.64,percent of total billed charges,Implant Device,66.64,34,,66.64,percent of total billed charges,Implant Device,68.6,35,,68.6,percent of total billed charges,Implant Device,68.6,35,,68.6,percent of total billed charges,Implant Device,68.6,35,,68.6,percent of total billed charges,Implant Device,68.6,35,,68.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,145.04,
ARTRHEX AR-13120T-26 SCREW 2.3X26MM,C1713,HCPCS,,79005222,CDM,278,RC,,,both,,,196,145.04,,,145.04,Other,150% of Medicare + 9.63% HCRA Surcharge,88.2,45,,88.2,percent of total billed charges,Critical Access Hospital RCC factor,66.64,34,,66.64,percent of total billed charges,Implant Device,66.64,34,,66.64,percent of total billed charges,Implant Device,66.64,34,,66.64,percent of total billed charges,Implant Device,66.64,34,,66.64,percent of total billed charges,Implant Device,66.64,34,,66.64,percent of total billed charges,Implant Device,97.02,,,97.02,Other,110% of Medicare,68.6,35,,68.6,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,68.6,35,,68.6,percent of total billed charges,Implant Device,68.6,35,,68.6,percent of total billed charges,Implant Device,68.6,35,,68.6,percent of total billed charges,Implant Device,68.6,35,,68.6,percent of total billed charges,Implant Device,68.6,35,,68.6,percent of total billed charges,Implant Device,78.4,40,,78.4,percent of total billed charges,Implant Device,68.6,70,,68.6,percent of total billed charges,All Other,66.64,34,,66.64,percent of total billed charges,Implant Device,66.64,34,,66.64,percent of total billed charges,Implant Device,68.6,35,,68.6,percent of total billed charges,Implant Device,68.6,35,,68.6,percent of total billed charges,Implant Device,68.6,35,,68.6,percent of total billed charges,Implant Device,68.6,35,,68.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,145.04,
ARTHREX AR-8967-1855 CANN SCREW 6.7X55MM,C1713,HCPCS,,79005223,CDM,278,RC,,,both,,,1074,794.76,,,794.76,Other,150% of Medicare + 9.63% HCRA Surcharge,483.3,45,,483.3,percent of total billed charges,Critical Access Hospital RCC factor,365.16,34,,365.16,percent of total billed charges,Implant Device,365.16,34,,365.16,percent of total billed charges,Implant Device,365.16,34,,365.16,percent of total billed charges,Implant Device,365.16,34,,365.16,percent of total billed charges,Implant Device,365.16,34,,365.16,percent of total billed charges,Implant Device,531.63,,,531.63,Other,110% of Medicare,375.9,35,,375.9,percent of total billed charges,Implant Device,365.16,34,"Charges > $500, x 34%",365.16,percent of total billed charges,Implant Device,375.9,35,,375.9,percent of total billed charges,Implant Device,375.9,35,,375.9,percent of total billed charges,Implant Device,375.9,35,,375.9,percent of total billed charges,Implant Device,375.9,35,,375.9,percent of total billed charges,Implant Device,375.9,35,,375.9,percent of total billed charges,Implant Device,429.6,40,,429.6,percent of total billed charges,Implant Device,375.9,70,,375.9,percent of total billed charges,All Other,365.16,34,,365.16,percent of total billed charges,Implant Device,365.16,34,,365.16,percent of total billed charges,Implant Device,375.9,35,,375.9,percent of total billed charges,Implant Device,375.9,35,,375.9,percent of total billed charges,Implant Device,375.9,35,,375.9,percent of total billed charges,Implant Device,375.9,35,,375.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,794.76,
ARTHREX AR-8967-1850 CANN SCREW 6.7X50MM,C1713,HCPCS,,79005224,CDM,278,RC,,,both,,,1074,794.76,,,794.76,Other,150% of Medicare + 9.63% HCRA Surcharge,483.3,45,,483.3,percent of total billed charges,Critical Access Hospital RCC factor,365.16,34,,365.16,percent of total billed charges,Implant Device,365.16,34,,365.16,percent of total billed charges,Implant Device,365.16,34,,365.16,percent of total billed charges,Implant Device,365.16,34,,365.16,percent of total billed charges,Implant Device,365.16,34,,365.16,percent of total billed charges,Implant Device,531.63,,,531.63,Other,110% of Medicare,375.9,35,,375.9,percent of total billed charges,Implant Device,365.16,34,"Charges > $500, x 34%",365.16,percent of total billed charges,Implant Device,375.9,35,,375.9,percent of total billed charges,Implant Device,375.9,35,,375.9,percent of total billed charges,Implant Device,375.9,35,,375.9,percent of total billed charges,Implant Device,375.9,35,,375.9,percent of total billed charges,Implant Device,375.9,35,,375.9,percent of total billed charges,Implant Device,429.6,40,,429.6,percent of total billed charges,Implant Device,375.9,70,,375.9,percent of total billed charges,All Other,365.16,34,,365.16,percent of total billed charges,Implant Device,365.16,34,,365.16,percent of total billed charges,Implant Device,375.9,35,,375.9,percent of total billed charges,Implant Device,375.9,35,,375.9,percent of total billed charges,Implant Device,375.9,35,,375.9,percent of total billed charges,Implant Device,375.9,35,,375.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,794.76,
EXACTECH 310-02-41 HUMERAL HEAD 41X20MM,C1776,HCPCS,,79005225,CDM,278,RC,,,both,,,4968,3676.33,,,3676.33,Other,150% of Medicare + 9.63% HCRA Surcharge,2235.6,45,,2235.6,percent of total billed charges,Critical Access Hospital RCC factor,1689.12,34,,1689.12,percent of total billed charges,Implant Device,1689.12,34,,1689.12,percent of total billed charges,Implant Device,1689.12,34,,1689.12,percent of total billed charges,Implant Device,1689.12,34,,1689.12,percent of total billed charges,Implant Device,1689.12,34,,1689.12,percent of total billed charges,Implant Device,2459.16,,,2459.16,Other,110% of Medicare,1738.8,35,,1738.8,percent of total billed charges,Implant Device,1689.12,34,"Charges > $500, x 34%",1689.12,percent of total billed charges,Implant Device,1738.8,35,,1738.8,percent of total billed charges,Implant Device,1738.8,35,,1738.8,percent of total billed charges,Implant Device,1738.8,35,,1738.8,percent of total billed charges,Implant Device,1738.8,35,,1738.8,percent of total billed charges,Implant Device,1738.8,35,,1738.8,percent of total billed charges,Implant Device,1987.2,40,,1987.2,percent of total billed charges,Implant Device,1738.8,70,,1738.8,percent of total billed charges,All Other,1689.12,34,,1689.12,percent of total billed charges,Implant Device,1689.12,34,,1689.12,percent of total billed charges,Implant Device,1738.8,35,,1738.8,percent of total billed charges,Implant Device,1738.8,35,,1738.8,percent of total billed charges,Implant Device,1738.8,35,,1738.8,percent of total billed charges,Implant Device,1738.8,35,,1738.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1689.12,34,"If Charge > 2,000, then 34 percent",1689.12,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3676.33,
EXACTECH 314-02-23 POST GLENOID AUGMENT,C1776,HCPCS,,79005226,CDM,278,RC,,,both,,,7992,5914.1,,,5914.1,Other,150% of Medicare + 9.63% HCRA Surcharge,3596.4,45,,3596.4,percent of total billed charges,Critical Access Hospital RCC factor,2717.28,34,,2717.28,percent of total billed charges,Implant Device,2717.28,34,,2717.28,percent of total billed charges,Implant Device,2717.28,34,,2717.28,percent of total billed charges,Implant Device,2717.28,34,,2717.28,percent of total billed charges,Implant Device,2717.28,34,,2717.28,percent of total billed charges,Implant Device,3956.04,,,3956.04,Other,110% of Medicare,2797.2,35,,2797.2,percent of total billed charges,Implant Device,2717.28,34,"Charges > $500, x 34%",2717.28,percent of total billed charges,Implant Device,2797.2,35,,2797.2,percent of total billed charges,Implant Device,2797.2,35,,2797.2,percent of total billed charges,Implant Device,2797.2,35,,2797.2,percent of total billed charges,Implant Device,2797.2,35,,2797.2,percent of total billed charges,Implant Device,2797.2,35,,2797.2,percent of total billed charges,Implant Device,3196.8,40,,3196.8,percent of total billed charges,Implant Device,2797.2,70,,2797.2,percent of total billed charges,All Other,2717.28,34,,2717.28,percent of total billed charges,Implant Device,2717.28,34,,2717.28,percent of total billed charges,Implant Device,2797.2,35,,2797.2,percent of total billed charges,Implant Device,2797.2,35,,2797.2,percent of total billed charges,Implant Device,2797.2,35,,2797.2,percent of total billed charges,Implant Device,2797.2,35,,2797.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2717.28,34,"If Charge > 2,000, then 34 percent",2717.28,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5914.1,
ARTHREX AR-8933-30PT SCREW 3.0X30MM,C1713,HCPCS,,79005227,CDM,278,RC,,,both,,,316,233.84,,,233.84,Other,150% of Medicare + 9.63% HCRA Surcharge,142.2,45,,142.2,percent of total billed charges,Critical Access Hospital RCC factor,107.44,34,,107.44,percent of total billed charges,Implant Device,107.44,34,,107.44,percent of total billed charges,Implant Device,107.44,34,,107.44,percent of total billed charges,Implant Device,107.44,34,,107.44,percent of total billed charges,Implant Device,107.44,34,,107.44,percent of total billed charges,Implant Device,156.42,,,156.42,Other,110% of Medicare,110.6,35,,110.6,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,110.6,35,,110.6,percent of total billed charges,Implant Device,110.6,35,,110.6,percent of total billed charges,Implant Device,110.6,35,,110.6,percent of total billed charges,Implant Device,110.6,35,,110.6,percent of total billed charges,Implant Device,110.6,35,,110.6,percent of total billed charges,Implant Device,126.4,40,,126.4,percent of total billed charges,Implant Device,110.6,70,,110.6,percent of total billed charges,All Other,107.44,34,,107.44,percent of total billed charges,Implant Device,107.44,34,,107.44,percent of total billed charges,Implant Device,110.6,35,,110.6,percent of total billed charges,Implant Device,110.6,35,,110.6,percent of total billed charges,Implant Device,110.6,35,,110.6,percent of total billed charges,Implant Device,110.6,35,,110.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,233.84,
ARTHREX AR-8931-13 QUICK FIX SCRW 3X13MM,C1713,HCPCS,,79005228,CDM,278,RC,,,both,,,720,532.8,,,532.8,Other,150% of Medicare + 9.63% HCRA Surcharge,324,45,,324,percent of total billed charges,Critical Access Hospital RCC factor,244.8,34,,244.8,percent of total billed charges,Implant Device,244.8,34,,244.8,percent of total billed charges,Implant Device,244.8,34,,244.8,percent of total billed charges,Implant Device,244.8,34,,244.8,percent of total billed charges,Implant Device,244.8,34,,244.8,percent of total billed charges,Implant Device,356.4,,,356.4,Other,110% of Medicare,252,35,,252,percent of total billed charges,Implant Device,244.8,34,"Charges > $500, x 34%",244.8,percent of total billed charges,Implant Device,252,35,,252,percent of total billed charges,Implant Device,252,35,,252,percent of total billed charges,Implant Device,252,35,,252,percent of total billed charges,Implant Device,252,35,,252,percent of total billed charges,Implant Device,252,35,,252,percent of total billed charges,Implant Device,288,40,,288,percent of total billed charges,Implant Device,252,70,,252,percent of total billed charges,All Other,244.8,34,,244.8,percent of total billed charges,Implant Device,244.8,34,,244.8,percent of total billed charges,Implant Device,252,35,,252,percent of total billed charges,Implant Device,252,35,,252,percent of total billed charges,Implant Device,252,35,,252,percent of total billed charges,Implant Device,252,35,,252,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,532.8,
BIOMET 41-2014 NON LOCKING SCREW 2X14MM,C1713,HCPCS,,79005243,CDM,278,RC,,,both,,,268,198.32,,,198.32,Other,150% of Medicare + 9.63% HCRA Surcharge,120.6,45,,120.6,percent of total billed charges,Critical Access Hospital RCC factor,91.12,34,,91.12,percent of total billed charges,Implant Device,91.12,34,,91.12,percent of total billed charges,Implant Device,91.12,34,,91.12,percent of total billed charges,Implant Device,91.12,34,,91.12,percent of total billed charges,Implant Device,91.12,34,,91.12,percent of total billed charges,Implant Device,132.66,,,132.66,Other,110% of Medicare,93.8,35,,93.8,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,93.8,35,,93.8,percent of total billed charges,Implant Device,93.8,35,,93.8,percent of total billed charges,Implant Device,93.8,35,,93.8,percent of total billed charges,Implant Device,93.8,35,,93.8,percent of total billed charges,Implant Device,93.8,35,,93.8,percent of total billed charges,Implant Device,107.2,40,,107.2,percent of total billed charges,Implant Device,93.8,70,,93.8,percent of total billed charges,All Other,91.12,34,,91.12,percent of total billed charges,Implant Device,91.12,34,,91.12,percent of total billed charges,Implant Device,93.8,35,,93.8,percent of total billed charges,Implant Device,93.8,35,,93.8,percent of total billed charges,Implant Device,93.8,35,,93.8,percent of total billed charges,Implant Device,93.8,35,,93.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,198.32,
BIOMET 91-5607 SCREW SD IMF 2X7MM,C1713,HCPCS,,79005244,CDM,278,RC,,,both,,,454,335.96,,,335.96,Other,150% of Medicare + 9.63% HCRA Surcharge,204.3,45,,204.3,percent of total billed charges,Critical Access Hospital RCC factor,154.36,34,,154.36,percent of total billed charges,Implant Device,154.36,34,,154.36,percent of total billed charges,Implant Device,154.36,34,,154.36,percent of total billed charges,Implant Device,154.36,34,,154.36,percent of total billed charges,Implant Device,154.36,34,,154.36,percent of total billed charges,Implant Device,224.73,,,224.73,Other,110% of Medicare,158.9,35,,158.9,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,158.9,35,,158.9,percent of total billed charges,Implant Device,158.9,35,,158.9,percent of total billed charges,Implant Device,158.9,35,,158.9,percent of total billed charges,Implant Device,158.9,35,,158.9,percent of total billed charges,Implant Device,158.9,35,,158.9,percent of total billed charges,Implant Device,181.6,40,,181.6,percent of total billed charges,Implant Device,158.9,70,,158.9,percent of total billed charges,All Other,154.36,34,,154.36,percent of total billed charges,Implant Device,154.36,34,,154.36,percent of total billed charges,Implant Device,158.9,35,,158.9,percent of total billed charges,Implant Device,158.9,35,,158.9,percent of total billed charges,Implant Device,158.9,35,,158.9,percent of total billed charges,Implant Device,158.9,35,,158.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,335.96,
BIOMET 42-1004 4 HOLE PLATE 1.5,C1713,HCPCS,,79005246,CDM,278,RC,,,both,,,2316,1713.85,,,1713.85,Other,150% of Medicare + 9.63% HCRA Surcharge,1042.2,45,,1042.2,percent of total billed charges,Critical Access Hospital RCC factor,787.44,34,,787.44,percent of total billed charges,Implant Device,787.44,34,,787.44,percent of total billed charges,Implant Device,787.44,34,,787.44,percent of total billed charges,Implant Device,787.44,34,,787.44,percent of total billed charges,Implant Device,787.44,34,,787.44,percent of total billed charges,Implant Device,1146.42,,,1146.42,Other,110% of Medicare,810.6,35,,810.6,percent of total billed charges,Implant Device,787.44,34,"Charges > $500, x 34%",787.44,percent of total billed charges,Implant Device,810.6,35,,810.6,percent of total billed charges,Implant Device,810.6,35,,810.6,percent of total billed charges,Implant Device,810.6,35,,810.6,percent of total billed charges,Implant Device,810.6,35,,810.6,percent of total billed charges,Implant Device,810.6,35,,810.6,percent of total billed charges,Implant Device,926.4,40,,926.4,percent of total billed charges,Implant Device,810.6,70,,810.6,percent of total billed charges,All Other,787.44,34,,787.44,percent of total billed charges,Implant Device,787.44,34,,787.44,percent of total billed charges,Implant Device,810.6,35,,810.6,percent of total billed charges,Implant Device,810.6,35,,810.6,percent of total billed charges,Implant Device,810.6,35,,810.6,percent of total billed charges,Implant Device,810.6,35,,810.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,787.44,34,"If Charge > 2,000, then 34 percent",787.44,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1713.85,
GORE PLC161000 ENDOPROSTHESIS GRAFT,C1874,HCPCS,,79005252,CDM,278,RC,,,both,,,14217,10520.62,,,10520.62,Other,150% of Medicare + 9.63% HCRA Surcharge,6397.65,45,,6397.65,percent of total billed charges,Critical Access Hospital RCC factor,4833.78,34,,4833.78,percent of total billed charges,Implant Device,4833.78,34,,4833.78,percent of total billed charges,Implant Device,4833.78,34,,4833.78,percent of total billed charges,Implant Device,4833.78,34,,4833.78,percent of total billed charges,Implant Device,4833.78,34,,4833.78,percent of total billed charges,Implant Device,7037.42,,,7037.42,Other,110% of Medicare,4975.95,35,,4975.95,percent of total billed charges,Implant Device,4833.78,34,"Charges > $500, x 34%",4833.78,percent of total billed charges,Implant Device,4975.95,35,,4975.95,percent of total billed charges,Implant Device,4975.95,35,,4975.95,percent of total billed charges,Implant Device,4975.95,35,,4975.95,percent of total billed charges,Implant Device,4975.95,35,,4975.95,percent of total billed charges,Implant Device,4975.95,35,,4975.95,percent of total billed charges,Implant Device,5686.8,40,,5686.8,percent of total billed charges,Implant Device,4975.95,70,,4975.95,percent of total billed charges,All Other,4833.78,34,,4833.78,percent of total billed charges,Implant Device,4833.78,34,,4833.78,percent of total billed charges,Implant Device,4975.95,35,,4975.95,percent of total billed charges,Implant Device,4975.95,35,,4975.95,percent of total billed charges,Implant Device,4975.95,35,,4975.95,percent of total billed charges,Implant Device,4975.95,35,,4975.95,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,4833.78,34,"If Charge > 2,000, then 34 percent",4833.78,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,10520.62,
GORE PLC161200 ENDOPROSTHESIS GRAFT,C1874,HCPCS,,79005253,CDM,278,RC,,,both,,,13869,10263.09,,,10263.09,Other,150% of Medicare + 9.63% HCRA Surcharge,6241.05,45,,6241.05,percent of total billed charges,Critical Access Hospital RCC factor,4715.46,34,,4715.46,percent of total billed charges,Implant Device,4715.46,34,,4715.46,percent of total billed charges,Implant Device,4715.46,34,,4715.46,percent of total billed charges,Implant Device,4715.46,34,,4715.46,percent of total billed charges,Implant Device,4715.46,34,,4715.46,percent of total billed charges,Implant Device,6865.16,,,6865.16,Other,110% of Medicare,4854.15,35,,4854.15,percent of total billed charges,Implant Device,4715.46,34,"Charges > $500, x 34%",4715.46,percent of total billed charges,Implant Device,4854.15,35,,4854.15,percent of total billed charges,Implant Device,4854.15,35,,4854.15,percent of total billed charges,Implant Device,4854.15,35,,4854.15,percent of total billed charges,Implant Device,4854.15,35,,4854.15,percent of total billed charges,Implant Device,4854.15,35,,4854.15,percent of total billed charges,Implant Device,5547.6,40,,5547.6,percent of total billed charges,Implant Device,4854.15,70,,4854.15,percent of total billed charges,All Other,4715.46,34,,4715.46,percent of total billed charges,Implant Device,4715.46,34,,4715.46,percent of total billed charges,Implant Device,4854.15,35,,4854.15,percent of total billed charges,Implant Device,4854.15,35,,4854.15,percent of total billed charges,Implant Device,4854.15,35,,4854.15,percent of total billed charges,Implant Device,4854.15,35,,4854.15,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,4715.46,34,"If Charge > 2,000, then 34 percent",4715.46,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,10263.09,
ARTHREX AR-7000-30 SCREW 3.75X30MM,C1713,HCPCS,,79005254,CDM,278,RC,,,both,,,600,444,,,444,Other,150% of Medicare + 9.63% HCRA Surcharge,270,45,,270,percent of total billed charges,Critical Access Hospital RCC factor,204,34,,204,percent of total billed charges,Implant Device,204,34,,204,percent of total billed charges,Implant Device,204,34,,204,percent of total billed charges,Implant Device,204,34,,204,percent of total billed charges,Implant Device,204,34,,204,percent of total billed charges,Implant Device,297,,,297,Other,110% of Medicare,210,35,,210,percent of total billed charges,Implant Device,204,34,"Charges > $500, x 34%",204,percent of total billed charges,Implant Device,210,35,,210,percent of total billed charges,Implant Device,210,35,,210,percent of total billed charges,Implant Device,210,35,,210,percent of total billed charges,Implant Device,210,35,,210,percent of total billed charges,Implant Device,210,35,,210,percent of total billed charges,Implant Device,240,40,,240,percent of total billed charges,Implant Device,210,70,,210,percent of total billed charges,All Other,204,34,,204,percent of total billed charges,Implant Device,204,34,,204,percent of total billed charges,Implant Device,210,35,,210,percent of total billed charges,Implant Device,210,35,,210,percent of total billed charges,Implant Device,210,35,,210,percent of total billed charges,Implant Device,210,35,,210,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,444,
ARTHREX AR-14226 LOCKING SCREW 4.0X26MM,C1713,HCPCS,,79005257,CDM,278,RC,,,both,,,336,248.64,,,248.64,Other,150% of Medicare + 9.63% HCRA Surcharge,151.2,45,,151.2,percent of total billed charges,Critical Access Hospital RCC factor,114.24,34,,114.24,percent of total billed charges,Implant Device,114.24,34,,114.24,percent of total billed charges,Implant Device,114.24,34,,114.24,percent of total billed charges,Implant Device,114.24,34,,114.24,percent of total billed charges,Implant Device,114.24,34,,114.24,percent of total billed charges,Implant Device,166.32,,,166.32,Other,110% of Medicare,117.6,35,,117.6,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,117.6,35,,117.6,percent of total billed charges,Implant Device,117.6,35,,117.6,percent of total billed charges,Implant Device,117.6,35,,117.6,percent of total billed charges,Implant Device,117.6,35,,117.6,percent of total billed charges,Implant Device,117.6,35,,117.6,percent of total billed charges,Implant Device,134.4,40,,134.4,percent of total billed charges,Implant Device,117.6,70,,117.6,percent of total billed charges,All Other,114.24,34,,114.24,percent of total billed charges,Implant Device,114.24,34,,114.24,percent of total billed charges,Implant Device,117.6,35,,117.6,percent of total billed charges,Implant Device,117.6,35,,117.6,percent of total billed charges,Implant Device,117.6,35,,117.6,percent of total billed charges,Implant Device,117.6,35,,117.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,248.64,
ARTHREX AR-14230 LOCKING SCREW 4.0X30MM,C1713,HCPCS,,79005258,CDM,278,RC,,,both,,,336,248.64,,,248.64,Other,150% of Medicare + 9.63% HCRA Surcharge,151.2,45,,151.2,percent of total billed charges,Critical Access Hospital RCC factor,114.24,34,,114.24,percent of total billed charges,Implant Device,114.24,34,,114.24,percent of total billed charges,Implant Device,114.24,34,,114.24,percent of total billed charges,Implant Device,114.24,34,,114.24,percent of total billed charges,Implant Device,114.24,34,,114.24,percent of total billed charges,Implant Device,166.32,,,166.32,Other,110% of Medicare,117.6,35,,117.6,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,117.6,35,,117.6,percent of total billed charges,Implant Device,117.6,35,,117.6,percent of total billed charges,Implant Device,117.6,35,,117.6,percent of total billed charges,Implant Device,117.6,35,,117.6,percent of total billed charges,Implant Device,117.6,35,,117.6,percent of total billed charges,Implant Device,134.4,40,,134.4,percent of total billed charges,Implant Device,117.6,70,,117.6,percent of total billed charges,All Other,114.24,34,,114.24,percent of total billed charges,Implant Device,114.24,34,,114.24,percent of total billed charges,Implant Device,117.6,35,,117.6,percent of total billed charges,Implant Device,117.6,35,,117.6,percent of total billed charges,Implant Device,117.6,35,,117.6,percent of total billed charges,Implant Device,117.6,35,,117.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,248.64,
ARTHREX AR-14236 LOCKING SCREW 4.0X36MM,C1713,HCPCS,,79005259,CDM,278,RC,,,both,,,336,248.64,,,248.64,Other,150% of Medicare + 9.63% HCRA Surcharge,151.2,45,,151.2,percent of total billed charges,Critical Access Hospital RCC factor,114.24,34,,114.24,percent of total billed charges,Implant Device,114.24,34,,114.24,percent of total billed charges,Implant Device,114.24,34,,114.24,percent of total billed charges,Implant Device,114.24,34,,114.24,percent of total billed charges,Implant Device,114.24,34,,114.24,percent of total billed charges,Implant Device,166.32,,,166.32,Other,110% of Medicare,117.6,35,,117.6,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,117.6,35,,117.6,percent of total billed charges,Implant Device,117.6,35,,117.6,percent of total billed charges,Implant Device,117.6,35,,117.6,percent of total billed charges,Implant Device,117.6,35,,117.6,percent of total billed charges,Implant Device,117.6,35,,117.6,percent of total billed charges,Implant Device,134.4,40,,134.4,percent of total billed charges,Implant Device,117.6,70,,117.6,percent of total billed charges,All Other,114.24,34,,114.24,percent of total billed charges,Implant Device,114.24,34,,114.24,percent of total billed charges,Implant Device,117.6,35,,117.6,percent of total billed charges,Implant Device,117.6,35,,117.6,percent of total billed charges,Implant Device,117.6,35,,117.6,percent of total billed charges,Implant Device,117.6,35,,117.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,248.64,
ARTRHEX AR-14120NL SCREW 3.5X22MM,C1713,HCPCS,,79005260,CDM,278,RC,,,both,,,136,100.64,,,100.64,Other,150% of Medicare + 9.63% HCRA Surcharge,61.2,45,,61.2,percent of total billed charges,Critical Access Hospital RCC factor,46.24,34,,46.24,percent of total billed charges,Implant Device,46.24,34,,46.24,percent of total billed charges,Implant Device,46.24,34,,46.24,percent of total billed charges,Implant Device,46.24,34,,46.24,percent of total billed charges,Implant Device,46.24,34,,46.24,percent of total billed charges,Implant Device,67.32,,,67.32,Other,110% of Medicare,47.6,35,,47.6,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,47.6,35,,47.6,percent of total billed charges,Implant Device,47.6,35,,47.6,percent of total billed charges,Implant Device,47.6,35,,47.6,percent of total billed charges,Implant Device,47.6,35,,47.6,percent of total billed charges,Implant Device,47.6,35,,47.6,percent of total billed charges,Implant Device,54.4,40,,54.4,percent of total billed charges,Implant Device,47.6,70,,47.6,percent of total billed charges,All Other,46.24,34,,46.24,percent of total billed charges,Implant Device,46.24,34,,46.24,percent of total billed charges,Implant Device,47.6,35,,47.6,percent of total billed charges,Implant Device,47.6,35,,47.6,percent of total billed charges,Implant Device,47.6,35,,47.6,percent of total billed charges,Implant Device,47.6,35,,47.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,100.64,
ARTHREX AR-14124NL SCREW 3.5X24MM,C1713,HCPCS,,79005261,CDM,278,RC,,,both,,,136,100.64,,,100.64,Other,150% of Medicare + 9.63% HCRA Surcharge,61.2,45,,61.2,percent of total billed charges,Critical Access Hospital RCC factor,46.24,34,,46.24,percent of total billed charges,Implant Device,46.24,34,,46.24,percent of total billed charges,Implant Device,46.24,34,,46.24,percent of total billed charges,Implant Device,46.24,34,,46.24,percent of total billed charges,Implant Device,46.24,34,,46.24,percent of total billed charges,Implant Device,67.32,,,67.32,Other,110% of Medicare,47.6,35,,47.6,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,47.6,35,,47.6,percent of total billed charges,Implant Device,47.6,35,,47.6,percent of total billed charges,Implant Device,47.6,35,,47.6,percent of total billed charges,Implant Device,47.6,35,,47.6,percent of total billed charges,Implant Device,47.6,35,,47.6,percent of total billed charges,Implant Device,54.4,40,,54.4,percent of total billed charges,Implant Device,47.6,70,,47.6,percent of total billed charges,All Other,46.24,34,,46.24,percent of total billed charges,Implant Device,46.24,34,,46.24,percent of total billed charges,Implant Device,47.6,35,,47.6,percent of total billed charges,Implant Device,47.6,35,,47.6,percent of total billed charges,Implant Device,47.6,35,,47.6,percent of total billed charges,Implant Device,47.6,35,,47.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,100.64,
ZIMMER 5001-50 BIPOLAR CUP SHELL 50MM,C1776,HCPCS,,79005262,CDM,278,RC,,,both,,,2273,1682.03,,,1682.03,Other,150% of Medicare + 9.63% HCRA Surcharge,1022.85,45,,1022.85,percent of total billed charges,Critical Access Hospital RCC factor,772.82,34,,772.82,percent of total billed charges,Implant Device,772.82,34,,772.82,percent of total billed charges,Implant Device,772.82,34,,772.82,percent of total billed charges,Implant Device,772.82,34,,772.82,percent of total billed charges,Implant Device,772.82,34,,772.82,percent of total billed charges,Implant Device,1125.14,,,1125.14,Other,110% of Medicare,795.55,35,,795.55,percent of total billed charges,Implant Device,772.82,34,"Charges > $500, x 34%",772.82,percent of total billed charges,Implant Device,795.55,35,,795.55,percent of total billed charges,Implant Device,795.55,35,,795.55,percent of total billed charges,Implant Device,795.55,35,,795.55,percent of total billed charges,Implant Device,795.55,35,,795.55,percent of total billed charges,Implant Device,795.55,35,,795.55,percent of total billed charges,Implant Device,909.2,40,,909.2,percent of total billed charges,Implant Device,795.55,70,,795.55,percent of total billed charges,All Other,772.82,34,,772.82,percent of total billed charges,Implant Device,772.82,34,,772.82,percent of total billed charges,Implant Device,795.55,35,,795.55,percent of total billed charges,Implant Device,795.55,35,,795.55,percent of total billed charges,Implant Device,795.55,35,,795.55,percent of total billed charges,Implant Device,795.55,35,,795.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,772.82,34,"If Charge > 2,000, then 34 percent",772.82,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1682.03,
ZIMMER 7711-09 FEM STEM 12/14 NECK SZ 9,C1776,HCPCS,,79005263,CDM,278,RC,,,both,,,6900,5106.02,,,5106.02,Other,150% of Medicare + 9.63% HCRA Surcharge,3105,45,,3105,percent of total billed charges,Critical Access Hospital RCC factor,2346,34,,2346,percent of total billed charges,Implant Device,2346,34,,2346,percent of total billed charges,Implant Device,2346,34,,2346,percent of total billed charges,Implant Device,2346,34,,2346,percent of total billed charges,Implant Device,2346,34,,2346,percent of total billed charges,Implant Device,3415.5,,,3415.5,Other,110% of Medicare,2415,35,,2415,percent of total billed charges,Implant Device,2346,34,"Charges > $500, x 34%",2346,percent of total billed charges,Implant Device,2415,35,,2415,percent of total billed charges,Implant Device,2415,35,,2415,percent of total billed charges,Implant Device,2415,35,,2415,percent of total billed charges,Implant Device,2415,35,,2415,percent of total billed charges,Implant Device,2415,35,,2415,percent of total billed charges,Implant Device,2760,40,,2760,percent of total billed charges,Implant Device,2415,70,,2415,percent of total billed charges,All Other,2346,34,,2346,percent of total billed charges,Implant Device,2346,34,,2346,percent of total billed charges,Implant Device,2415,35,,2415,percent of total billed charges,Implant Device,2415,35,,2415,percent of total billed charges,Implant Device,2415,35,,2415,percent of total billed charges,Implant Device,2415,35,,2415,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2346,34,"If Charge > 2,000, then 34 percent",2346,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5106.02,
BIOMET 8161-45-226 CORT SCREW 4.5X26MM,C1713,HCPCS,,79005264,CDM,278,RC,,,both,,,600,444,,,444,Other,150% of Medicare + 9.63% HCRA Surcharge,270,45,,270,percent of total billed charges,Critical Access Hospital RCC factor,204,34,,204,percent of total billed charges,Implant Device,204,34,,204,percent of total billed charges,Implant Device,204,34,,204,percent of total billed charges,Implant Device,204,34,,204,percent of total billed charges,Implant Device,204,34,,204,percent of total billed charges,Implant Device,297,,,297,Other,110% of Medicare,210,35,,210,percent of total billed charges,Implant Device,204,34,"Charges > $500, x 34%",204,percent of total billed charges,Implant Device,210,35,,210,percent of total billed charges,Implant Device,210,35,,210,percent of total billed charges,Implant Device,210,35,,210,percent of total billed charges,Implant Device,210,35,,210,percent of total billed charges,Implant Device,210,35,,210,percent of total billed charges,Implant Device,240,40,,240,percent of total billed charges,Implant Device,210,70,,210,percent of total billed charges,All Other,204,34,,204,percent of total billed charges,Implant Device,204,34,,204,percent of total billed charges,Implant Device,210,35,,210,percent of total billed charges,Implant Device,210,35,,210,percent of total billed charges,Implant Device,210,35,,210,percent of total billed charges,Implant Device,210,35,,210,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,444,
BIOMET 8161-45-230 CORT SCREW 4.5X30MM,C1713,HCPCS,,79005265,CDM,278,RC,,,both,,,600,444,,,444,Other,150% of Medicare + 9.63% HCRA Surcharge,270,45,,270,percent of total billed charges,Critical Access Hospital RCC factor,204,34,,204,percent of total billed charges,Implant Device,204,34,,204,percent of total billed charges,Implant Device,204,34,,204,percent of total billed charges,Implant Device,204,34,,204,percent of total billed charges,Implant Device,204,34,,204,percent of total billed charges,Implant Device,297,,,297,Other,110% of Medicare,210,35,,210,percent of total billed charges,Implant Device,204,34,"Charges > $500, x 34%",204,percent of total billed charges,Implant Device,210,35,,210,percent of total billed charges,Implant Device,210,35,,210,percent of total billed charges,Implant Device,210,35,,210,percent of total billed charges,Implant Device,210,35,,210,percent of total billed charges,Implant Device,210,35,,210,percent of total billed charges,Implant Device,240,40,,240,percent of total billed charges,Implant Device,210,70,,210,percent of total billed charges,All Other,204,34,,204,percent of total billed charges,Implant Device,204,34,,204,percent of total billed charges,Implant Device,210,35,,210,percent of total billed charges,Implant Device,210,35,,210,percent of total billed charges,Implant Device,210,35,,210,percent of total billed charges,Implant Device,210,35,,210,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,444,
BIOMET 8161-45-232 CORT SCREW 4.5X32MM,C1713,HCPCS,,79005266,CDM,278,RC,,,both,,,600,444,,,444,Other,150% of Medicare + 9.63% HCRA Surcharge,270,45,,270,percent of total billed charges,Critical Access Hospital RCC factor,204,34,,204,percent of total billed charges,Implant Device,204,34,,204,percent of total billed charges,Implant Device,204,34,,204,percent of total billed charges,Implant Device,204,34,,204,percent of total billed charges,Implant Device,204,34,,204,percent of total billed charges,Implant Device,297,,,297,Other,110% of Medicare,210,35,,210,percent of total billed charges,Implant Device,204,34,"Charges > $500, x 34%",204,percent of total billed charges,Implant Device,210,35,,210,percent of total billed charges,Implant Device,210,35,,210,percent of total billed charges,Implant Device,210,35,,210,percent of total billed charges,Implant Device,210,35,,210,percent of total billed charges,Implant Device,210,35,,210,percent of total billed charges,Implant Device,240,40,,240,percent of total billed charges,Implant Device,210,70,,210,percent of total billed charges,All Other,204,34,,204,percent of total billed charges,Implant Device,204,34,,204,percent of total billed charges,Implant Device,210,35,,210,percent of total billed charges,Implant Device,210,35,,210,percent of total billed charges,Implant Device,210,35,,210,percent of total billed charges,Implant Device,210,35,,210,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,444,
BIOMET 8161-45-234 CORT SCREW 4.5X34MM,C1713,HCPCS,,79005267,CDM,278,RC,,,both,,,600,444,,,444,Other,150% of Medicare + 9.63% HCRA Surcharge,270,45,,270,percent of total billed charges,Critical Access Hospital RCC factor,204,34,,204,percent of total billed charges,Implant Device,204,34,,204,percent of total billed charges,Implant Device,204,34,,204,percent of total billed charges,Implant Device,204,34,,204,percent of total billed charges,Implant Device,204,34,,204,percent of total billed charges,Implant Device,297,,,297,Other,110% of Medicare,210,35,,210,percent of total billed charges,Implant Device,204,34,"Charges > $500, x 34%",204,percent of total billed charges,Implant Device,210,35,,210,percent of total billed charges,Implant Device,210,35,,210,percent of total billed charges,Implant Device,210,35,,210,percent of total billed charges,Implant Device,210,35,,210,percent of total billed charges,Implant Device,210,35,,210,percent of total billed charges,Implant Device,240,40,,240,percent of total billed charges,Implant Device,210,70,,210,percent of total billed charges,All Other,204,34,,204,percent of total billed charges,Implant Device,204,34,,204,percent of total billed charges,Implant Device,210,35,,210,percent of total billed charges,Implant Device,210,35,,210,percent of total billed charges,Implant Device,210,35,,210,percent of total billed charges,Implant Device,210,35,,210,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,444,
BIOMET 8157-45-034 NON LOCK SCREW 4.5X34,C1713,HCPCS,,79005268,CDM,278,RC,,,both,,,210,155.4,,,155.4,Other,150% of Medicare + 9.63% HCRA Surcharge,94.5,45,,94.5,percent of total billed charges,Critical Access Hospital RCC factor,71.4,34,,71.4,percent of total billed charges,Implant Device,71.4,34,,71.4,percent of total billed charges,Implant Device,71.4,34,,71.4,percent of total billed charges,Implant Device,71.4,34,,71.4,percent of total billed charges,Implant Device,71.4,34,,71.4,percent of total billed charges,Implant Device,103.95,,,103.95,Other,110% of Medicare,73.5,35,,73.5,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,73.5,35,,73.5,percent of total billed charges,Implant Device,73.5,35,,73.5,percent of total billed charges,Implant Device,73.5,35,,73.5,percent of total billed charges,Implant Device,73.5,35,,73.5,percent of total billed charges,Implant Device,73.5,35,,73.5,percent of total billed charges,Implant Device,84,40,,84,percent of total billed charges,Implant Device,73.5,70,,73.5,percent of total billed charges,All Other,71.4,34,,71.4,percent of total billed charges,Implant Device,71.4,34,,71.4,percent of total billed charges,Implant Device,73.5,35,,73.5,percent of total billed charges,Implant Device,73.5,35,,73.5,percent of total billed charges,Implant Device,73.5,35,,73.5,percent of total billed charges,Implant Device,73.5,35,,73.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,155.4,
BIOMET 8157-45-046 NON LOCK SCREW 4.5X46,C1713,HCPCS,,79005269,CDM,278,RC,,,both,,,210,155.4,,,155.4,Other,150% of Medicare + 9.63% HCRA Surcharge,94.5,45,,94.5,percent of total billed charges,Critical Access Hospital RCC factor,71.4,34,,71.4,percent of total billed charges,Implant Device,71.4,34,,71.4,percent of total billed charges,Implant Device,71.4,34,,71.4,percent of total billed charges,Implant Device,71.4,34,,71.4,percent of total billed charges,Implant Device,71.4,34,,71.4,percent of total billed charges,Implant Device,103.95,,,103.95,Other,110% of Medicare,73.5,35,,73.5,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,73.5,35,,73.5,percent of total billed charges,Implant Device,73.5,35,,73.5,percent of total billed charges,Implant Device,73.5,35,,73.5,percent of total billed charges,Implant Device,73.5,35,,73.5,percent of total billed charges,Implant Device,73.5,35,,73.5,percent of total billed charges,Implant Device,84,40,,84,percent of total billed charges,Implant Device,73.5,70,,73.5,percent of total billed charges,All Other,71.4,34,,71.4,percent of total billed charges,Implant Device,71.4,34,,71.4,percent of total billed charges,Implant Device,73.5,35,,73.5,percent of total billed charges,Implant Device,73.5,35,,73.5,percent of total billed charges,Implant Device,73.5,35,,73.5,percent of total billed charges,Implant Device,73.5,35,,73.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,155.4,
BIOMET 8157-45-048 NON LOCK SCREW 4.5X48,C1713,HCPCS,,79005270,CDM,278,RC,,,both,,,120,88.8,,,88.8,Other,150% of Medicare + 9.63% HCRA Surcharge,54,45,,54,percent of total billed charges,Critical Access Hospital RCC factor,40.8,34,,40.8,percent of total billed charges,Implant Device,40.8,34,,40.8,percent of total billed charges,Implant Device,40.8,34,,40.8,percent of total billed charges,Implant Device,40.8,34,,40.8,percent of total billed charges,Implant Device,40.8,34,,40.8,percent of total billed charges,Implant Device,59.4,,,59.4,Other,110% of Medicare,42,35,,42,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,42,35,,42,percent of total billed charges,Implant Device,42,35,,42,percent of total billed charges,Implant Device,42,35,,42,percent of total billed charges,Implant Device,42,35,,42,percent of total billed charges,Implant Device,42,35,,42,percent of total billed charges,Implant Device,48,40,,48,percent of total billed charges,Implant Device,42,70,,42,percent of total billed charges,All Other,40.8,34,,40.8,percent of total billed charges,Implant Device,40.8,34,,40.8,percent of total billed charges,Implant Device,42,35,,42,percent of total billed charges,Implant Device,42,35,,42,percent of total billed charges,Implant Device,42,35,,42,percent of total billed charges,Implant Device,42,35,,42,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,88.8,
BIOMET 8157-45-050 NON LOCK SCREW 4.5X50,C1713,HCPCS,,79005271,CDM,278,RC,,,both,,,210,155.4,,,155.4,Other,150% of Medicare + 9.63% HCRA Surcharge,94.5,45,,94.5,percent of total billed charges,Critical Access Hospital RCC factor,71.4,34,,71.4,percent of total billed charges,Implant Device,71.4,34,,71.4,percent of total billed charges,Implant Device,71.4,34,,71.4,percent of total billed charges,Implant Device,71.4,34,,71.4,percent of total billed charges,Implant Device,71.4,34,,71.4,percent of total billed charges,Implant Device,103.95,,,103.95,Other,110% of Medicare,73.5,35,,73.5,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,73.5,35,,73.5,percent of total billed charges,Implant Device,73.5,35,,73.5,percent of total billed charges,Implant Device,73.5,35,,73.5,percent of total billed charges,Implant Device,73.5,35,,73.5,percent of total billed charges,Implant Device,73.5,35,,73.5,percent of total billed charges,Implant Device,84,40,,84,percent of total billed charges,Implant Device,73.5,70,,73.5,percent of total billed charges,All Other,71.4,34,,71.4,percent of total billed charges,Implant Device,71.4,34,,71.4,percent of total billed charges,Implant Device,73.5,35,,73.5,percent of total billed charges,Implant Device,73.5,35,,73.5,percent of total billed charges,Implant Device,73.5,35,,73.5,percent of total billed charges,Implant Device,73.5,35,,73.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,155.4,
SYNTHES 241.351 PLATE 5 HOLE 57MM,C1713,HCPCS,,79005273,CDM,278,RC,,,both,,,696,515.04,,,515.04,Other,150% of Medicare + 9.63% HCRA Surcharge,313.2,45,,313.2,percent of total billed charges,Critical Access Hospital RCC factor,236.64,34,,236.64,percent of total billed charges,Implant Device,236.64,34,,236.64,percent of total billed charges,Implant Device,236.64,34,,236.64,percent of total billed charges,Implant Device,236.64,34,,236.64,percent of total billed charges,Implant Device,236.64,34,,236.64,percent of total billed charges,Implant Device,344.52,,,344.52,Other,110% of Medicare,243.6,35,,243.6,percent of total billed charges,Implant Device,236.64,34,"Charges > $500, x 34%",236.64,percent of total billed charges,Implant Device,243.6,35,,243.6,percent of total billed charges,Implant Device,243.6,35,,243.6,percent of total billed charges,Implant Device,243.6,35,,243.6,percent of total billed charges,Implant Device,243.6,35,,243.6,percent of total billed charges,Implant Device,243.6,35,,243.6,percent of total billed charges,Implant Device,278.4,40,,278.4,percent of total billed charges,Implant Device,243.6,70,,243.6,percent of total billed charges,All Other,236.64,34,,236.64,percent of total billed charges,Implant Device,236.64,34,,236.64,percent of total billed charges,Implant Device,243.6,35,,243.6,percent of total billed charges,Implant Device,243.6,35,,243.6,percent of total billed charges,Implant Device,243.6,35,,243.6,percent of total billed charges,Implant Device,243.6,35,,243.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,515.04,
SYNTHES 241.381 PLATE 8 HOLE 93MM,C1713,HCPCS,,79005274,CDM,278,RC,,,both,,,804,594.96,,,594.96,Other,150% of Medicare + 9.63% HCRA Surcharge,361.8,45,,361.8,percent of total billed charges,Critical Access Hospital RCC factor,273.36,34,,273.36,percent of total billed charges,Implant Device,273.36,34,,273.36,percent of total billed charges,Implant Device,273.36,34,,273.36,percent of total billed charges,Implant Device,273.36,34,,273.36,percent of total billed charges,Implant Device,273.36,34,,273.36,percent of total billed charges,Implant Device,397.98,,,397.98,Other,110% of Medicare,281.4,35,,281.4,percent of total billed charges,Implant Device,273.36,34,"Charges > $500, x 34%",273.36,percent of total billed charges,Implant Device,281.4,35,,281.4,percent of total billed charges,Implant Device,281.4,35,,281.4,percent of total billed charges,Implant Device,281.4,35,,281.4,percent of total billed charges,Implant Device,281.4,35,,281.4,percent of total billed charges,Implant Device,281.4,35,,281.4,percent of total billed charges,Implant Device,321.6,40,,321.6,percent of total billed charges,Implant Device,281.4,70,,281.4,percent of total billed charges,All Other,273.36,34,,273.36,percent of total billed charges,Implant Device,273.36,34,,273.36,percent of total billed charges,Implant Device,281.4,35,,281.4,percent of total billed charges,Implant Device,281.4,35,,281.4,percent of total billed charges,Implant Device,281.4,35,,281.4,percent of total billed charges,Implant Device,281.4,35,,281.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,594.96,
SYNTHES 241.401 PLATE 10 HOLE 117MM,C1713,HCPCS,,79005275,CDM,278,RC,,,both,,,700,518,,,518,Other,150% of Medicare + 9.63% HCRA Surcharge,315,45,,315,percent of total billed charges,Critical Access Hospital RCC factor,238,34,,238,percent of total billed charges,Implant Device,238,34,,238,percent of total billed charges,Implant Device,238,34,,238,percent of total billed charges,Implant Device,238,34,,238,percent of total billed charges,Implant Device,238,34,,238,percent of total billed charges,Implant Device,346.5,,,346.5,Other,110% of Medicare,245,35,,245,percent of total billed charges,Implant Device,238,34,"Charges > $500, x 34%",238,percent of total billed charges,Implant Device,245,35,,245,percent of total billed charges,Implant Device,245,35,,245,percent of total billed charges,Implant Device,245,35,,245,percent of total billed charges,Implant Device,245,35,,245,percent of total billed charges,Implant Device,245,35,,245,percent of total billed charges,Implant Device,280,40,,280,percent of total billed charges,Implant Device,245,70,,245,percent of total billed charges,All Other,238,34,,238,percent of total billed charges,Implant Device,238,34,,238,percent of total billed charges,Implant Device,245,35,,245,percent of total billed charges,Implant Device,245,35,,245,percent of total billed charges,Implant Device,245,35,,245,percent of total billed charges,Implant Device,245,35,,245,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,518,
SYNTHES 223.641 PLATE 14 HOLE 189MM,C1713,HCPCS,,79005276,CDM,278,RC,,,both,,,2338,1730.13,,,1730.13,Other,150% of Medicare + 9.63% HCRA Surcharge,1052.1,45,,1052.1,percent of total billed charges,Critical Access Hospital RCC factor,794.92,34,,794.92,percent of total billed charges,Implant Device,794.92,34,,794.92,percent of total billed charges,Implant Device,794.92,34,,794.92,percent of total billed charges,Implant Device,794.92,34,,794.92,percent of total billed charges,Implant Device,794.92,34,,794.92,percent of total billed charges,Implant Device,1157.31,,,1157.31,Other,110% of Medicare,818.3,35,,818.3,percent of total billed charges,Implant Device,794.92,34,"Charges > $500, x 34%",794.92,percent of total billed charges,Implant Device,818.3,35,,818.3,percent of total billed charges,Implant Device,818.3,35,,818.3,percent of total billed charges,Implant Device,818.3,35,,818.3,percent of total billed charges,Implant Device,818.3,35,,818.3,percent of total billed charges,Implant Device,818.3,35,,818.3,percent of total billed charges,Implant Device,935.2,40,,935.2,percent of total billed charges,Implant Device,818.3,70,,818.3,percent of total billed charges,All Other,794.92,34,,794.92,percent of total billed charges,Implant Device,794.92,34,,794.92,percent of total billed charges,Implant Device,818.3,35,,818.3,percent of total billed charges,Implant Device,818.3,35,,818.3,percent of total billed charges,Implant Device,818.3,35,,818.3,percent of total billed charges,Implant Device,818.3,35,,818.3,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,794.92,34,"If Charge > 2,000, then 34 percent",794.92,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1730.13,
SYNTHES 223.621 PLATE 12 HOLE 163MM,C1713,HCPCS,,79005277,CDM,278,RC,,,both,,,1558,1152.92,,,1152.92,Other,150% of Medicare + 9.63% HCRA Surcharge,701.1,45,,701.1,percent of total billed charges,Critical Access Hospital RCC factor,529.72,34,,529.72,percent of total billed charges,Implant Device,529.72,34,,529.72,percent of total billed charges,Implant Device,529.72,34,,529.72,percent of total billed charges,Implant Device,529.72,34,,529.72,percent of total billed charges,Implant Device,529.72,34,,529.72,percent of total billed charges,Implant Device,771.21,,,771.21,Other,110% of Medicare,545.3,35,,545.3,percent of total billed charges,Implant Device,529.72,34,"Charges > $500, x 34%",529.72,percent of total billed charges,Implant Device,545.3,35,,545.3,percent of total billed charges,Implant Device,545.3,35,,545.3,percent of total billed charges,Implant Device,545.3,35,,545.3,percent of total billed charges,Implant Device,545.3,35,,545.3,percent of total billed charges,Implant Device,545.3,35,,545.3,percent of total billed charges,Implant Device,623.2,40,,623.2,percent of total billed charges,Implant Device,545.3,70,,545.3,percent of total billed charges,All Other,529.72,34,,529.72,percent of total billed charges,Implant Device,529.72,34,,529.72,percent of total billed charges,Implant Device,545.3,35,,545.3,percent of total billed charges,Implant Device,545.3,35,,545.3,percent of total billed charges,Implant Device,545.3,35,,545.3,percent of total billed charges,Implant Device,545.3,35,,545.3,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1152.92,
SYNTHES 223.591 PLATE 9 HOLE 124MM,C1713,HCPCS,,79005278,CDM,278,RC,,,both,,,1372,1015.28,,,1015.28,Other,150% of Medicare + 9.63% HCRA Surcharge,617.4,45,,617.4,percent of total billed charges,Critical Access Hospital RCC factor,466.48,34,,466.48,percent of total billed charges,Implant Device,466.48,34,,466.48,percent of total billed charges,Implant Device,466.48,34,,466.48,percent of total billed charges,Implant Device,466.48,34,,466.48,percent of total billed charges,Implant Device,466.48,34,,466.48,percent of total billed charges,Implant Device,679.14,,,679.14,Other,110% of Medicare,480.2,35,,480.2,percent of total billed charges,Implant Device,466.48,34,"Charges > $500, x 34%",466.48,percent of total billed charges,Implant Device,480.2,35,,480.2,percent of total billed charges,Implant Device,480.2,35,,480.2,percent of total billed charges,Implant Device,480.2,35,,480.2,percent of total billed charges,Implant Device,480.2,35,,480.2,percent of total billed charges,Implant Device,480.2,35,,480.2,percent of total billed charges,Implant Device,548.8,40,,548.8,percent of total billed charges,Implant Device,480.2,70,,480.2,percent of total billed charges,All Other,466.48,34,,466.48,percent of total billed charges,Implant Device,466.48,34,,466.48,percent of total billed charges,Implant Device,480.2,35,,480.2,percent of total billed charges,Implant Device,480.2,35,,480.2,percent of total billed charges,Implant Device,480.2,35,,480.2,percent of total billed charges,Implant Device,480.2,35,,480.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1015.28,
SYNTHES 315.28 DRILL BIT 2.7X125MM,C1713,HCPCS,,79005279,CDM,278,RC,,,both,,,240,177.6,,,177.6,Other,150% of Medicare + 9.63% HCRA Surcharge,108,45,,108,percent of total billed charges,Critical Access Hospital RCC factor,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,118.8,,,118.8,Other,110% of Medicare,84,35,,84,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,96,40,,96,percent of total billed charges,Implant Device,84,70,,84,percent of total billed charges,All Other,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,177.6,
MENTOR 350-2375 BREAST IMPLANT,C1789,HCPCS,,79005280,CDM,278,RC,,,both,,,2010,1487.41,,,1487.41,Other,150% of Medicare + 9.63% HCRA Surcharge,904.5,45,,904.5,percent of total billed charges,Critical Access Hospital RCC factor,683.4,34,,683.4,percent of total billed charges,Implant Device,683.4,34,,683.4,percent of total billed charges,Implant Device,683.4,34,,683.4,percent of total billed charges,Implant Device,683.4,34,,683.4,percent of total billed charges,Implant Device,683.4,34,,683.4,percent of total billed charges,Implant Device,994.95,,,994.95,Other,110% of Medicare,703.5,35,,703.5,percent of total billed charges,Implant Device,683.4,34,"Charges > $500, x 34%",683.4,percent of total billed charges,Implant Device,703.5,35,,703.5,percent of total billed charges,Implant Device,703.5,35,,703.5,percent of total billed charges,Implant Device,703.5,35,,703.5,percent of total billed charges,Implant Device,703.5,35,,703.5,percent of total billed charges,Implant Device,703.5,35,,703.5,percent of total billed charges,Implant Device,804,40,,804,percent of total billed charges,Implant Device,703.5,70,,703.5,percent of total billed charges,All Other,683.4,34,,683.4,percent of total billed charges,Implant Device,683.4,34,,683.4,percent of total billed charges,Implant Device,703.5,35,,703.5,percent of total billed charges,Implant Device,703.5,35,,703.5,percent of total billed charges,Implant Device,703.5,35,,703.5,percent of total billed charges,Implant Device,703.5,35,,703.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,683.4,34,"If Charge > 2,000, then 34 percent",683.4,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1487.41,
STRYKER 5036-1-580 BLUNT PIN 3X80X15MM,C1713,HCPCS,,79005281,CDM,278,RC,,,both,,,322,238.28,,,238.28,Other,150% of Medicare + 9.63% HCRA Surcharge,144.9,45,,144.9,percent of total billed charges,Critical Access Hospital RCC factor,109.48,34,,109.48,percent of total billed charges,Implant Device,109.48,34,,109.48,percent of total billed charges,Implant Device,109.48,34,,109.48,percent of total billed charges,Implant Device,109.48,34,,109.48,percent of total billed charges,Implant Device,109.48,34,,109.48,percent of total billed charges,Implant Device,159.39,,,159.39,Other,110% of Medicare,112.7,35,,112.7,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,112.7,35,,112.7,percent of total billed charges,Implant Device,112.7,35,,112.7,percent of total billed charges,Implant Device,112.7,35,,112.7,percent of total billed charges,Implant Device,112.7,35,,112.7,percent of total billed charges,Implant Device,112.7,35,,112.7,percent of total billed charges,Implant Device,128.8,40,,128.8,percent of total billed charges,Implant Device,112.7,70,,112.7,percent of total billed charges,All Other,109.48,34,,109.48,percent of total billed charges,Implant Device,109.48,34,,109.48,percent of total billed charges,Implant Device,112.7,35,,112.7,percent of total billed charges,Implant Device,112.7,35,,112.7,percent of total billed charges,Implant Device,112.7,35,,112.7,percent of total billed charges,Implant Device,112.7,35,,112.7,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,238.28,
STRYKER 5036-1-110 BLUNT PIN 3X110X25MM,C1713,HCPCS,,79005282,CDM,278,RC,,,both,,,322,238.28,,,238.28,Other,150% of Medicare + 9.63% HCRA Surcharge,144.9,45,,144.9,percent of total billed charges,Critical Access Hospital RCC factor,109.48,34,,109.48,percent of total billed charges,Implant Device,109.48,34,,109.48,percent of total billed charges,Implant Device,109.48,34,,109.48,percent of total billed charges,Implant Device,109.48,34,,109.48,percent of total billed charges,Implant Device,109.48,34,,109.48,percent of total billed charges,Implant Device,159.39,,,159.39,Other,110% of Medicare,112.7,35,,112.7,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,112.7,35,,112.7,percent of total billed charges,Implant Device,112.7,35,,112.7,percent of total billed charges,Implant Device,112.7,35,,112.7,percent of total billed charges,Implant Device,112.7,35,,112.7,percent of total billed charges,Implant Device,112.7,35,,112.7,percent of total billed charges,Implant Device,128.8,40,,128.8,percent of total billed charges,Implant Device,112.7,70,,112.7,percent of total billed charges,All Other,109.48,34,,109.48,percent of total billed charges,Implant Device,109.48,34,,109.48,percent of total billed charges,Implant Device,112.7,35,,112.7,percent of total billed charges,Implant Device,112.7,35,,112.7,percent of total billed charges,Implant Device,112.7,35,,112.7,percent of total billed charges,Implant Device,112.7,35,,112.7,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,238.28,
STRYKER 5048-5-100 CARBON ROD 5X100MM,C1713,HCPCS,,79005283,CDM,278,RC,,,both,,,285,210.9,,,210.9,Other,150% of Medicare + 9.63% HCRA Surcharge,128.25,45,,128.25,percent of total billed charges,Critical Access Hospital RCC factor,96.9,34,,96.9,percent of total billed charges,Implant Device,96.9,34,,96.9,percent of total billed charges,Implant Device,96.9,34,,96.9,percent of total billed charges,Implant Device,96.9,34,,96.9,percent of total billed charges,Implant Device,96.9,34,,96.9,percent of total billed charges,Implant Device,141.08,,,141.08,Other,110% of Medicare,99.75,35,,99.75,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,99.75,35,,99.75,percent of total billed charges,Implant Device,99.75,35,,99.75,percent of total billed charges,Implant Device,99.75,35,,99.75,percent of total billed charges,Implant Device,99.75,35,,99.75,percent of total billed charges,Implant Device,99.75,35,,99.75,percent of total billed charges,Implant Device,114,40,,114,percent of total billed charges,Implant Device,99.75,70,,99.75,percent of total billed charges,All Other,96.9,34,,96.9,percent of total billed charges,Implant Device,96.9,34,,96.9,percent of total billed charges,Implant Device,99.75,35,,99.75,percent of total billed charges,Implant Device,99.75,35,,99.75,percent of total billed charges,Implant Device,99.75,35,,99.75,percent of total billed charges,Implant Device,99.75,35,,99.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,210.9,
ARTHREX AR-8943C-08 LOCKING PLATE 8 HOLE,C1713,HCPCS,,79005287,CDM,278,RC,,,both,,,1650,1221,,,1221,Other,150% of Medicare + 9.63% HCRA Surcharge,742.5,45,,742.5,percent of total billed charges,Critical Access Hospital RCC factor,561,34,,561,percent of total billed charges,Implant Device,561,34,,561,percent of total billed charges,Implant Device,561,34,,561,percent of total billed charges,Implant Device,561,34,,561,percent of total billed charges,Implant Device,561,34,,561,percent of total billed charges,Implant Device,816.75,,,816.75,Other,110% of Medicare,577.5,35,,577.5,percent of total billed charges,Implant Device,561,34,"Charges > $500, x 34%",561,percent of total billed charges,Implant Device,577.5,35,,577.5,percent of total billed charges,Implant Device,577.5,35,,577.5,percent of total billed charges,Implant Device,577.5,35,,577.5,percent of total billed charges,Implant Device,577.5,35,,577.5,percent of total billed charges,Implant Device,577.5,35,,577.5,percent of total billed charges,Implant Device,660,40,,660,percent of total billed charges,Implant Device,577.5,70,,577.5,percent of total billed charges,All Other,561,34,,561,percent of total billed charges,Implant Device,561,34,,561,percent of total billed charges,Implant Device,577.5,35,,577.5,percent of total billed charges,Implant Device,577.5,35,,577.5,percent of total billed charges,Implant Device,577.5,35,,577.5,percent of total billed charges,Implant Device,577.5,35,,577.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1221,
"ZIMMER 32-8105-35-06 HUM LONG FLANGE 6""",C1776,HCPCS,,79005289,CDM,278,RC,,,both,,,15900,11766.04,,,11766.04,Other,150% of Medicare + 9.63% HCRA Surcharge,7155,45,,7155,percent of total billed charges,Critical Access Hospital RCC factor,5406,34,,5406,percent of total billed charges,Implant Device,5406,34,,5406,percent of total billed charges,Implant Device,5406,34,,5406,percent of total billed charges,Implant Device,5406,34,,5406,percent of total billed charges,Implant Device,5406,34,,5406,percent of total billed charges,Implant Device,7870.5,,,7870.5,Other,110% of Medicare,5565,35,,5565,percent of total billed charges,Implant Device,5406,34,"Charges > $500, x 34%",5406,percent of total billed charges,Implant Device,5565,35,,5565,percent of total billed charges,Implant Device,5565,35,,5565,percent of total billed charges,Implant Device,5565,35,,5565,percent of total billed charges,Implant Device,5565,35,,5565,percent of total billed charges,Implant Device,5565,35,,5565,percent of total billed charges,Implant Device,6360,40,,6360,percent of total billed charges,Implant Device,5565,70,,5565,percent of total billed charges,All Other,5406,34,,5406,percent of total billed charges,Implant Device,5406,34,,5406,percent of total billed charges,Implant Device,5565,35,,5565,percent of total billed charges,Implant Device,5565,35,,5565,percent of total billed charges,Implant Device,5565,35,,5565,percent of total billed charges,Implant Device,5565,35,,5565,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,5406,34,"If Charge > 2,000, then 34 percent",5406,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,11766.04,
ARTHREX AR-8944CL-L MTP FUSION PLATE LG,C1713,HCPCS,,79005291,CDM,278,RC,,,both,,,2400,1776.01,,,1776.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1080,45,,1080,percent of total billed charges,Critical Access Hospital RCC factor,816,34,,816,percent of total billed charges,Implant Device,816,34,,816,percent of total billed charges,Implant Device,816,34,,816,percent of total billed charges,Implant Device,816,34,,816,percent of total billed charges,Implant Device,816,34,,816,percent of total billed charges,Implant Device,1188,,,1188,Other,110% of Medicare,840,35,,840,percent of total billed charges,Implant Device,816,34,"Charges > $500, x 34%",816,percent of total billed charges,Implant Device,840,35,,840,percent of total billed charges,Implant Device,840,35,,840,percent of total billed charges,Implant Device,840,35,,840,percent of total billed charges,Implant Device,840,35,,840,percent of total billed charges,Implant Device,840,35,,840,percent of total billed charges,Implant Device,960,40,,960,percent of total billed charges,Implant Device,840,70,,840,percent of total billed charges,All Other,816,34,,816,percent of total billed charges,Implant Device,816,34,,816,percent of total billed charges,Implant Device,840,35,,840,percent of total billed charges,Implant Device,840,35,,840,percent of total billed charges,Implant Device,840,35,,840,percent of total billed charges,Implant Device,840,35,,840,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,816,34,"If Charge > 2,000, then 34 percent",816,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1776.01,
ARTHREX AR-8933-22 SCREW 3X22MM,C1713,HCPCS,,79005292,CDM,278,RC,,,both,,,330,244.2,,,244.2,Other,150% of Medicare + 9.63% HCRA Surcharge,148.5,45,,148.5,percent of total billed charges,Critical Access Hospital RCC factor,112.2,34,,112.2,percent of total billed charges,Implant Device,112.2,34,,112.2,percent of total billed charges,Implant Device,112.2,34,,112.2,percent of total billed charges,Implant Device,112.2,34,,112.2,percent of total billed charges,Implant Device,112.2,34,,112.2,percent of total billed charges,Implant Device,163.35,,,163.35,Other,110% of Medicare,115.5,35,,115.5,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,132,40,,132,percent of total billed charges,Implant Device,115.5,70,,115.5,percent of total billed charges,All Other,112.2,34,,112.2,percent of total billed charges,Implant Device,112.2,34,,112.2,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,244.2,
ARTHREX AR-8933L-20 LOCKING SCREW 3X20MM,C1713,HCPCS,,79005293,CDM,278,RC,,,both,,,256,189.44,,,189.44,Other,150% of Medicare + 9.63% HCRA Surcharge,115.2,45,,115.2,percent of total billed charges,Critical Access Hospital RCC factor,87.04,34,,87.04,percent of total billed charges,Implant Device,87.04,34,,87.04,percent of total billed charges,Implant Device,87.04,34,,87.04,percent of total billed charges,Implant Device,87.04,34,,87.04,percent of total billed charges,Implant Device,87.04,34,,87.04,percent of total billed charges,Implant Device,126.72,,,126.72,Other,110% of Medicare,89.6,35,,89.6,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,89.6,35,,89.6,percent of total billed charges,Implant Device,89.6,35,,89.6,percent of total billed charges,Implant Device,89.6,35,,89.6,percent of total billed charges,Implant Device,89.6,35,,89.6,percent of total billed charges,Implant Device,89.6,35,,89.6,percent of total billed charges,Implant Device,102.4,40,,102.4,percent of total billed charges,Implant Device,89.6,70,,89.6,percent of total billed charges,All Other,87.04,34,,87.04,percent of total billed charges,Implant Device,87.04,34,,87.04,percent of total billed charges,Implant Device,89.6,35,,89.6,percent of total billed charges,Implant Device,89.6,35,,89.6,percent of total billed charges,Implant Device,89.6,35,,89.6,percent of total billed charges,Implant Device,89.6,35,,89.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,189.44,
ATRIUM 31626 3X6 TAC SHIELD,C1781,HCPCS,,79005294,CDM,278,RC,,,both,,,1280,947.2,,,947.2,Other,150% of Medicare + 9.63% HCRA Surcharge,576,45,,576,percent of total billed charges,Critical Access Hospital RCC factor,435.2,34,,435.2,percent of total billed charges,Implant Device,435.2,34,,435.2,percent of total billed charges,Implant Device,435.2,34,,435.2,percent of total billed charges,Implant Device,435.2,34,,435.2,percent of total billed charges,Implant Device,435.2,34,,435.2,percent of total billed charges,Implant Device,633.6,,,633.6,Other,110% of Medicare,448,35,,448,percent of total billed charges,Implant Device,435.2,34,"Charges > $500, x 34%",435.2,percent of total billed charges,Implant Device,448,35,,448,percent of total billed charges,Implant Device,448,35,,448,percent of total billed charges,Implant Device,448,35,,448,percent of total billed charges,Implant Device,448,35,,448,percent of total billed charges,Implant Device,448,35,,448,percent of total billed charges,Implant Device,512,40,,512,percent of total billed charges,Implant Device,448,70,,448,percent of total billed charges,All Other,435.2,34,,435.2,percent of total billed charges,Implant Device,435.2,34,,435.2,percent of total billed charges,Implant Device,448,35,,448,percent of total billed charges,Implant Device,448,35,,448,percent of total billed charges,Implant Device,448,35,,448,percent of total billed charges,Implant Device,448,35,,448,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,947.2,
EXACTECH 320-02-38 GLENOSPHERE 38X44MM,C1776,HCPCS,,79005295,CDM,278,RC,,,both,,,9018,6673.34,,,6673.34,Other,150% of Medicare + 9.63% HCRA Surcharge,4058.1,45,,4058.1,percent of total billed charges,Critical Access Hospital RCC factor,3066.12,34,,3066.12,percent of total billed charges,Implant Device,3066.12,34,,3066.12,percent of total billed charges,Implant Device,3066.12,34,,3066.12,percent of total billed charges,Implant Device,3066.12,34,,3066.12,percent of total billed charges,Implant Device,3066.12,34,,3066.12,percent of total billed charges,Implant Device,4463.91,,,4463.91,Other,110% of Medicare,3156.3,35,,3156.3,percent of total billed charges,Implant Device,3066.12,34,"Charges > $500, x 34%",3066.12,percent of total billed charges,Implant Device,3156.3,35,,3156.3,percent of total billed charges,Implant Device,3156.3,35,,3156.3,percent of total billed charges,Implant Device,3156.3,35,,3156.3,percent of total billed charges,Implant Device,3156.3,35,,3156.3,percent of total billed charges,Implant Device,3156.3,35,,3156.3,percent of total billed charges,Implant Device,3607.2,40,,3607.2,percent of total billed charges,Implant Device,3156.3,70,,3156.3,percent of total billed charges,All Other,3066.12,34,,3066.12,percent of total billed charges,Implant Device,3066.12,34,,3066.12,percent of total billed charges,Implant Device,3156.3,35,,3156.3,percent of total billed charges,Implant Device,3156.3,35,,3156.3,percent of total billed charges,Implant Device,3156.3,35,,3156.3,percent of total billed charges,Implant Device,3156.3,35,,3156.3,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3066.12,34,"If Charge > 2,000, then 34 percent",3066.12,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,6673.34,
EXACTECH 320-20-00 REVERSE TORQUE SCREW,C1713,HCPCS,,79005296,CDM,278,RC,,,both,,,1404,1038.96,,,1038.96,Other,150% of Medicare + 9.63% HCRA Surcharge,631.8,45,,631.8,percent of total billed charges,Critical Access Hospital RCC factor,477.36,34,,477.36,percent of total billed charges,Implant Device,477.36,34,,477.36,percent of total billed charges,Implant Device,477.36,34,,477.36,percent of total billed charges,Implant Device,477.36,34,,477.36,percent of total billed charges,Implant Device,477.36,34,,477.36,percent of total billed charges,Implant Device,694.98,,,694.98,Other,110% of Medicare,491.4,35,,491.4,percent of total billed charges,Implant Device,477.36,34,"Charges > $500, x 34%",477.36,percent of total billed charges,Implant Device,491.4,35,,491.4,percent of total billed charges,Implant Device,491.4,35,,491.4,percent of total billed charges,Implant Device,491.4,35,,491.4,percent of total billed charges,Implant Device,491.4,35,,491.4,percent of total billed charges,Implant Device,491.4,35,,491.4,percent of total billed charges,Implant Device,561.6,40,,561.6,percent of total billed charges,Implant Device,491.4,70,,491.4,percent of total billed charges,All Other,477.36,34,,477.36,percent of total billed charges,Implant Device,477.36,34,,477.36,percent of total billed charges,Implant Device,491.4,35,,491.4,percent of total billed charges,Implant Device,491.4,35,,491.4,percent of total billed charges,Implant Device,491.4,35,,491.4,percent of total billed charges,Implant Device,491.4,35,,491.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1038.96,
ZIMMER 7711-015-00 M/L TAPER 15 STD,C1776,HCPCS,,79005299,CDM,278,RC,,,both,,,13500,9990.03,,,9990.03,Other,150% of Medicare + 9.63% HCRA Surcharge,6075,45,,6075,percent of total billed charges,Critical Access Hospital RCC factor,4590,34,,4590,percent of total billed charges,Implant Device,4590,34,,4590,percent of total billed charges,Implant Device,4590,34,,4590,percent of total billed charges,Implant Device,4590,34,,4590,percent of total billed charges,Implant Device,4590,34,,4590,percent of total billed charges,Implant Device,6682.5,,,6682.5,Other,110% of Medicare,4725,35,,4725,percent of total billed charges,Implant Device,4590,34,"Charges > $500, x 34%",4590,percent of total billed charges,Implant Device,4725,35,,4725,percent of total billed charges,Implant Device,4725,35,,4725,percent of total billed charges,Implant Device,4725,35,,4725,percent of total billed charges,Implant Device,4725,35,,4725,percent of total billed charges,Implant Device,4725,35,,4725,percent of total billed charges,Implant Device,5400,40,,5400,percent of total billed charges,Implant Device,4725,70,,4725,percent of total billed charges,All Other,4590,34,,4590,percent of total billed charges,Implant Device,4590,34,,4590,percent of total billed charges,Implant Device,4725,35,,4725,percent of total billed charges,Implant Device,4725,35,,4725,percent of total billed charges,Implant Device,4725,35,,4725,percent of total billed charges,Implant Device,4725,35,,4725,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,4590,34,"If Charge > 2,000, then 34 percent",4590,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,9990.03,
ZIMMER 5001-055-00 BIPOLAR CUPSHELL 55MM,C1776,HCPCS,,79005300,CDM,278,RC,,,both,,,1568,1160.32,,,1160.32,Other,150% of Medicare + 9.63% HCRA Surcharge,705.6,45,,705.6,percent of total billed charges,Critical Access Hospital RCC factor,533.12,34,,533.12,percent of total billed charges,Implant Device,533.12,34,,533.12,percent of total billed charges,Implant Device,533.12,34,,533.12,percent of total billed charges,Implant Device,533.12,34,,533.12,percent of total billed charges,Implant Device,533.12,34,,533.12,percent of total billed charges,Implant Device,776.16,,,776.16,Other,110% of Medicare,548.8,35,,548.8,percent of total billed charges,Implant Device,533.12,34,"Charges > $500, x 34%",533.12,percent of total billed charges,Implant Device,548.8,35,,548.8,percent of total billed charges,Implant Device,548.8,35,,548.8,percent of total billed charges,Implant Device,548.8,35,,548.8,percent of total billed charges,Implant Device,548.8,35,,548.8,percent of total billed charges,Implant Device,548.8,35,,548.8,percent of total billed charges,Implant Device,627.2,40,,627.2,percent of total billed charges,Implant Device,548.8,70,,548.8,percent of total billed charges,All Other,533.12,34,,533.12,percent of total billed charges,Implant Device,533.12,34,,533.12,percent of total billed charges,Implant Device,548.8,35,,548.8,percent of total billed charges,Implant Device,548.8,35,,548.8,percent of total billed charges,Implant Device,548.8,35,,548.8,percent of total billed charges,Implant Device,548.8,35,,548.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1160.32,
ZIMMER 5001-053-28 BIPOLAR LINER 28MM,C1776,HCPCS,,79005301,CDM,278,RC,,,both,,,789,583.86,,,583.86,Other,150% of Medicare + 9.63% HCRA Surcharge,355.05,45,,355.05,percent of total billed charges,Critical Access Hospital RCC factor,268.26,34,,268.26,percent of total billed charges,Implant Device,268.26,34,,268.26,percent of total billed charges,Implant Device,268.26,34,,268.26,percent of total billed charges,Implant Device,268.26,34,,268.26,percent of total billed charges,Implant Device,268.26,34,,268.26,percent of total billed charges,Implant Device,390.56,,,390.56,Other,110% of Medicare,276.15,35,,276.15,percent of total billed charges,Implant Device,268.26,34,"Charges > $500, x 34%",268.26,percent of total billed charges,Implant Device,276.15,35,,276.15,percent of total billed charges,Implant Device,276.15,35,,276.15,percent of total billed charges,Implant Device,276.15,35,,276.15,percent of total billed charges,Implant Device,276.15,35,,276.15,percent of total billed charges,Implant Device,276.15,35,,276.15,percent of total billed charges,Implant Device,315.6,40,,315.6,percent of total billed charges,Implant Device,276.15,70,,276.15,percent of total billed charges,All Other,268.26,34,,268.26,percent of total billed charges,Implant Device,268.26,34,,268.26,percent of total billed charges,Implant Device,276.15,35,,276.15,percent of total billed charges,Implant Device,276.15,35,,276.15,percent of total billed charges,Implant Device,276.15,35,,276.15,percent of total billed charges,Implant Device,276.15,35,,276.15,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,583.86,
ARTHREX AR-8720-10PT CANN SCREW 2X10MM,C1713,HCPCS,,79005302,CDM,278,RC,,,both,,,420,310.8,,,310.8,Other,150% of Medicare + 9.63% HCRA Surcharge,189,45,,189,percent of total billed charges,Critical Access Hospital RCC factor,142.8,34,,142.8,percent of total billed charges,Implant Device,142.8,34,,142.8,percent of total billed charges,Implant Device,142.8,34,,142.8,percent of total billed charges,Implant Device,142.8,34,,142.8,percent of total billed charges,Implant Device,142.8,34,,142.8,percent of total billed charges,Implant Device,207.9,,,207.9,Other,110% of Medicare,147,35,,147,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,147,35,,147,percent of total billed charges,Implant Device,147,35,,147,percent of total billed charges,Implant Device,147,35,,147,percent of total billed charges,Implant Device,147,35,,147,percent of total billed charges,Implant Device,147,35,,147,percent of total billed charges,Implant Device,168,40,,168,percent of total billed charges,Implant Device,147,70,,147,percent of total billed charges,All Other,142.8,34,,142.8,percent of total billed charges,Implant Device,142.8,34,,142.8,percent of total billed charges,Implant Device,147,35,,147,percent of total billed charges,Implant Device,147,35,,147,percent of total billed charges,Implant Device,147,35,,147,percent of total billed charges,Implant Device,147,35,,147,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,310.8,
STRYKER 6260-9-128 FEM HEAD 28MM +0MM,C1776,HCPCS,,79005303,CDM,278,RC,,,both,,,1391,1029.34,,,1029.34,Other,150% of Medicare + 9.63% HCRA Surcharge,625.95,45,,625.95,percent of total billed charges,Critical Access Hospital RCC factor,472.94,34,,472.94,percent of total billed charges,Implant Device,472.94,34,,472.94,percent of total billed charges,Implant Device,472.94,34,,472.94,percent of total billed charges,Implant Device,472.94,34,,472.94,percent of total billed charges,Implant Device,472.94,34,,472.94,percent of total billed charges,Implant Device,688.55,,,688.55,Other,110% of Medicare,486.85,35,,486.85,percent of total billed charges,Implant Device,472.94,34,"Charges > $500, x 34%",472.94,percent of total billed charges,Implant Device,486.85,35,,486.85,percent of total billed charges,Implant Device,486.85,35,,486.85,percent of total billed charges,Implant Device,486.85,35,,486.85,percent of total billed charges,Implant Device,486.85,35,,486.85,percent of total billed charges,Implant Device,486.85,35,,486.85,percent of total billed charges,Implant Device,556.4,40,,556.4,percent of total billed charges,Implant Device,486.85,70,,486.85,percent of total billed charges,All Other,472.94,34,,472.94,percent of total billed charges,Implant Device,472.94,34,,472.94,percent of total billed charges,Implant Device,486.85,35,,486.85,percent of total billed charges,Implant Device,486.85,35,,486.85,percent of total billed charges,Implant Device,486.85,35,,486.85,percent of total billed charges,Implant Device,486.85,35,,486.85,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1029.34,
SYNTHES 222.658 8 HOLE PLATE 4.5MM,C1713,HCPCS,,79005304,CDM,278,RC,,,both,,,6064,4487.38,,,4487.38,Other,150% of Medicare + 9.63% HCRA Surcharge,2728.8,45,,2728.8,percent of total billed charges,Critical Access Hospital RCC factor,2061.76,34,,2061.76,percent of total billed charges,Implant Device,2061.76,34,,2061.76,percent of total billed charges,Implant Device,2061.76,34,,2061.76,percent of total billed charges,Implant Device,2061.76,34,,2061.76,percent of total billed charges,Implant Device,2061.76,34,,2061.76,percent of total billed charges,Implant Device,3001.68,,,3001.68,Other,110% of Medicare,2122.4,35,,2122.4,percent of total billed charges,Implant Device,2061.76,34,"Charges > $500, x 34%",2061.76,percent of total billed charges,Implant Device,2122.4,35,,2122.4,percent of total billed charges,Implant Device,2122.4,35,,2122.4,percent of total billed charges,Implant Device,2122.4,35,,2122.4,percent of total billed charges,Implant Device,2122.4,35,,2122.4,percent of total billed charges,Implant Device,2122.4,35,,2122.4,percent of total billed charges,Implant Device,2425.6,40,,2425.6,percent of total billed charges,Implant Device,2122.4,70,,2122.4,percent of total billed charges,All Other,2061.76,34,,2061.76,percent of total billed charges,Implant Device,2061.76,34,,2061.76,percent of total billed charges,Implant Device,2122.4,35,,2122.4,percent of total billed charges,Implant Device,2122.4,35,,2122.4,percent of total billed charges,Implant Device,2122.4,35,,2122.4,percent of total billed charges,Implant Device,2122.4,35,,2122.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2061.76,34,"If Charge > 2,000, then 34 percent",2061.76,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4487.38,
SYNTHES 02.207.070 CANN LCK SCREW 7.3X70,C1713,HCPCS,,79005305,CDM,278,RC,,,both,,,1126,833.24,,,833.24,Other,150% of Medicare + 9.63% HCRA Surcharge,506.7,45,,506.7,percent of total billed charges,Critical Access Hospital RCC factor,382.84,34,,382.84,percent of total billed charges,Implant Device,382.84,34,,382.84,percent of total billed charges,Implant Device,382.84,34,,382.84,percent of total billed charges,Implant Device,382.84,34,,382.84,percent of total billed charges,Implant Device,382.84,34,,382.84,percent of total billed charges,Implant Device,557.37,,,557.37,Other,110% of Medicare,394.1,35,,394.1,percent of total billed charges,Implant Device,382.84,34,"Charges > $500, x 34%",382.84,percent of total billed charges,Implant Device,394.1,35,,394.1,percent of total billed charges,Implant Device,394.1,35,,394.1,percent of total billed charges,Implant Device,394.1,35,,394.1,percent of total billed charges,Implant Device,394.1,35,,394.1,percent of total billed charges,Implant Device,394.1,35,,394.1,percent of total billed charges,Implant Device,450.4,40,,450.4,percent of total billed charges,Implant Device,394.1,70,,394.1,percent of total billed charges,All Other,382.84,34,,382.84,percent of total billed charges,Implant Device,382.84,34,,382.84,percent of total billed charges,Implant Device,394.1,35,,394.1,percent of total billed charges,Implant Device,394.1,35,,394.1,percent of total billed charges,Implant Device,394.1,35,,394.1,percent of total billed charges,Implant Device,394.1,35,,394.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,833.24,
SYNTHES 02.205.030 CANN LOCK SCREW 5X30,C1713,HCPCS,,79005306,CDM,278,RC,,,both,,,760,562.4,,,562.4,Other,150% of Medicare + 9.63% HCRA Surcharge,342,45,,342,percent of total billed charges,Critical Access Hospital RCC factor,258.4,34,,258.4,percent of total billed charges,Implant Device,258.4,34,,258.4,percent of total billed charges,Implant Device,258.4,34,,258.4,percent of total billed charges,Implant Device,258.4,34,,258.4,percent of total billed charges,Implant Device,258.4,34,,258.4,percent of total billed charges,Implant Device,376.2,,,376.2,Other,110% of Medicare,266,35,,266,percent of total billed charges,Implant Device,258.4,34,"Charges > $500, x 34%",258.4,percent of total billed charges,Implant Device,266,35,,266,percent of total billed charges,Implant Device,266,35,,266,percent of total billed charges,Implant Device,266,35,,266,percent of total billed charges,Implant Device,266,35,,266,percent of total billed charges,Implant Device,266,35,,266,percent of total billed charges,Implant Device,304,40,,304,percent of total billed charges,Implant Device,266,70,,266,percent of total billed charges,All Other,258.4,34,,258.4,percent of total billed charges,Implant Device,258.4,34,,258.4,percent of total billed charges,Implant Device,266,35,,266,percent of total billed charges,Implant Device,266,35,,266,percent of total billed charges,Implant Device,266,35,,266,percent of total billed charges,Implant Device,266,35,,266,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,562.4,
SYNTHES 02.205.035 CANN LOCK SCREW 5X35,C1713,HCPCS,,79005307,CDM,278,RC,,,both,,,760,562.4,,,562.4,Other,150% of Medicare + 9.63% HCRA Surcharge,342,45,,342,percent of total billed charges,Critical Access Hospital RCC factor,258.4,34,,258.4,percent of total billed charges,Implant Device,258.4,34,,258.4,percent of total billed charges,Implant Device,258.4,34,,258.4,percent of total billed charges,Implant Device,258.4,34,,258.4,percent of total billed charges,Implant Device,258.4,34,,258.4,percent of total billed charges,Implant Device,376.2,,,376.2,Other,110% of Medicare,266,35,,266,percent of total billed charges,Implant Device,258.4,34,"Charges > $500, x 34%",258.4,percent of total billed charges,Implant Device,266,35,,266,percent of total billed charges,Implant Device,266,35,,266,percent of total billed charges,Implant Device,266,35,,266,percent of total billed charges,Implant Device,266,35,,266,percent of total billed charges,Implant Device,266,35,,266,percent of total billed charges,Implant Device,304,40,,304,percent of total billed charges,Implant Device,266,70,,266,percent of total billed charges,All Other,258.4,34,,258.4,percent of total billed charges,Implant Device,258.4,34,,258.4,percent of total billed charges,Implant Device,266,35,,266,percent of total billed charges,Implant Device,266,35,,266,percent of total billed charges,Implant Device,266,35,,266,percent of total billed charges,Implant Device,266,35,,266,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,562.4,
SYNTHES 02.205.045 CANN LOCK SCREW 5X45,C1713,HCPCS,,79005308,CDM,278,RC,,,both,,,810,599.4,,,599.4,Other,150% of Medicare + 9.63% HCRA Surcharge,364.5,45,,364.5,percent of total billed charges,Critical Access Hospital RCC factor,275.4,34,,275.4,percent of total billed charges,Implant Device,275.4,34,,275.4,percent of total billed charges,Implant Device,275.4,34,,275.4,percent of total billed charges,Implant Device,275.4,34,,275.4,percent of total billed charges,Implant Device,275.4,34,,275.4,percent of total billed charges,Implant Device,400.95,,,400.95,Other,110% of Medicare,283.5,35,,283.5,percent of total billed charges,Implant Device,275.4,34,"Charges > $500, x 34%",275.4,percent of total billed charges,Implant Device,283.5,35,,283.5,percent of total billed charges,Implant Device,283.5,35,,283.5,percent of total billed charges,Implant Device,283.5,35,,283.5,percent of total billed charges,Implant Device,283.5,35,,283.5,percent of total billed charges,Implant Device,283.5,35,,283.5,percent of total billed charges,Implant Device,324,40,,324,percent of total billed charges,Implant Device,283.5,70,,283.5,percent of total billed charges,All Other,275.4,34,,275.4,percent of total billed charges,Implant Device,275.4,34,,275.4,percent of total billed charges,Implant Device,283.5,35,,283.5,percent of total billed charges,Implant Device,283.5,35,,283.5,percent of total billed charges,Implant Device,283.5,35,,283.5,percent of total billed charges,Implant Device,283.5,35,,283.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,599.4,
SYNTHES 02.205.055 CANN LOCK SCREW 5X55,C1713,HCPCS,,79005309,CDM,278,RC,,,both,,,760,562.4,,,562.4,Other,150% of Medicare + 9.63% HCRA Surcharge,342,45,,342,percent of total billed charges,Critical Access Hospital RCC factor,258.4,34,,258.4,percent of total billed charges,Implant Device,258.4,34,,258.4,percent of total billed charges,Implant Device,258.4,34,,258.4,percent of total billed charges,Implant Device,258.4,34,,258.4,percent of total billed charges,Implant Device,258.4,34,,258.4,percent of total billed charges,Implant Device,376.2,,,376.2,Other,110% of Medicare,266,35,,266,percent of total billed charges,Implant Device,258.4,34,"Charges > $500, x 34%",258.4,percent of total billed charges,Implant Device,266,35,,266,percent of total billed charges,Implant Device,266,35,,266,percent of total billed charges,Implant Device,266,35,,266,percent of total billed charges,Implant Device,266,35,,266,percent of total billed charges,Implant Device,266,35,,266,percent of total billed charges,Implant Device,304,40,,304,percent of total billed charges,Implant Device,266,70,,266,percent of total billed charges,All Other,258.4,34,,258.4,percent of total billed charges,Implant Device,258.4,34,,258.4,percent of total billed charges,Implant Device,266,35,,266,percent of total billed charges,Implant Device,266,35,,266,percent of total billed charges,Implant Device,266,35,,266,percent of total billed charges,Implant Device,266,35,,266,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,562.4,
SYNTHES 02.205.060 CANN LOCK SCREW 5X60,C1713,HCPCS,,79005310,CDM,278,RC,,,both,,,810,599.4,,,599.4,Other,150% of Medicare + 9.63% HCRA Surcharge,364.5,45,,364.5,percent of total billed charges,Critical Access Hospital RCC factor,275.4,34,,275.4,percent of total billed charges,Implant Device,275.4,34,,275.4,percent of total billed charges,Implant Device,275.4,34,,275.4,percent of total billed charges,Implant Device,275.4,34,,275.4,percent of total billed charges,Implant Device,275.4,34,,275.4,percent of total billed charges,Implant Device,400.95,,,400.95,Other,110% of Medicare,283.5,35,,283.5,percent of total billed charges,Implant Device,275.4,34,"Charges > $500, x 34%",275.4,percent of total billed charges,Implant Device,283.5,35,,283.5,percent of total billed charges,Implant Device,283.5,35,,283.5,percent of total billed charges,Implant Device,283.5,35,,283.5,percent of total billed charges,Implant Device,283.5,35,,283.5,percent of total billed charges,Implant Device,283.5,35,,283.5,percent of total billed charges,Implant Device,324,40,,324,percent of total billed charges,Implant Device,283.5,70,,283.5,percent of total billed charges,All Other,275.4,34,,275.4,percent of total billed charges,Implant Device,275.4,34,,275.4,percent of total billed charges,Implant Device,283.5,35,,283.5,percent of total billed charges,Implant Device,283.5,35,,283.5,percent of total billed charges,Implant Device,283.5,35,,283.5,percent of total billed charges,Implant Device,283.5,35,,283.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,599.4,
SYNTHES 02.205.065 CANN LOCK SCREW 5X65,C1713,HCPCS,,79005311,CDM,278,RC,,,both,,,868,642.32,,,642.32,Other,150% of Medicare + 9.63% HCRA Surcharge,390.6,45,,390.6,percent of total billed charges,Critical Access Hospital RCC factor,295.12,34,,295.12,percent of total billed charges,Implant Device,295.12,34,,295.12,percent of total billed charges,Implant Device,295.12,34,,295.12,percent of total billed charges,Implant Device,295.12,34,,295.12,percent of total billed charges,Implant Device,295.12,34,,295.12,percent of total billed charges,Implant Device,429.66,,,429.66,Other,110% of Medicare,303.8,35,,303.8,percent of total billed charges,Implant Device,295.12,34,"Charges > $500, x 34%",295.12,percent of total billed charges,Implant Device,303.8,35,,303.8,percent of total billed charges,Implant Device,303.8,35,,303.8,percent of total billed charges,Implant Device,303.8,35,,303.8,percent of total billed charges,Implant Device,303.8,35,,303.8,percent of total billed charges,Implant Device,303.8,35,,303.8,percent of total billed charges,Implant Device,347.2,40,,347.2,percent of total billed charges,Implant Device,303.8,70,,303.8,percent of total billed charges,All Other,295.12,34,,295.12,percent of total billed charges,Implant Device,295.12,34,,295.12,percent of total billed charges,Implant Device,303.8,35,,303.8,percent of total billed charges,Implant Device,303.8,35,,303.8,percent of total billed charges,Implant Device,303.8,35,,303.8,percent of total billed charges,Implant Device,303.8,35,,303.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,642.32,
SYNTHES XM106.2030S TISSUE MATRIX 20X30,C1713,HCPCS,,79005312,CDM,278,RC,,,both,,,56560,41854.54,,,41854.54,Other,150% of Medicare + 9.63% HCRA Surcharge,25452,45,,25452,percent of total billed charges,Critical Access Hospital RCC factor,19230.4,34,,19230.4,percent of total billed charges,Implant Device,19230.4,34,,19230.4,percent of total billed charges,Implant Device,19230.4,34,,19230.4,percent of total billed charges,Implant Device,19230.4,34,,19230.4,percent of total billed charges,Implant Device,19230.4,34,,19230.4,percent of total billed charges,Implant Device,27997.2,,,27997.2,Other,110% of Medicare,19796,35,,19796,percent of total billed charges,Implant Device,19230.4,34,"Charges > $500, x 34%",19230.4,percent of total billed charges,Implant Device,19796,35,,19796,percent of total billed charges,Implant Device,19796,35,,19796,percent of total billed charges,Implant Device,19796,35,,19796,percent of total billed charges,Implant Device,19796,35,,19796,percent of total billed charges,Implant Device,19796,35,,19796,percent of total billed charges,Implant Device,22624,40,,22624,percent of total billed charges,Implant Device,19796,70,,19796,percent of total billed charges,All Other,19230.4,34,,19230.4,percent of total billed charges,Implant Device,19230.4,34,,19230.4,percent of total billed charges,Implant Device,19796,35,,19796,percent of total billed charges,Implant Device,19796,35,,19796,percent of total billed charges,Implant Device,19796,35,,19796,percent of total billed charges,Implant Device,19796,35,,19796,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,19230.4,34,"If Charge > 2,000, then 34 percent",19230.4,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,41854.54,
SYNTHES 222.571 CANN SCREW 7.3X70MM,C1713,HCPCS,,79005313,CDM,278,RC,,,both,,,582,430.68,,,430.68,Other,150% of Medicare + 9.63% HCRA Surcharge,261.9,45,,261.9,percent of total billed charges,Critical Access Hospital RCC factor,197.88,34,,197.88,percent of total billed charges,Implant Device,197.88,34,,197.88,percent of total billed charges,Implant Device,197.88,34,,197.88,percent of total billed charges,Implant Device,197.88,34,,197.88,percent of total billed charges,Implant Device,197.88,34,,197.88,percent of total billed charges,Implant Device,288.09,,,288.09,Other,110% of Medicare,203.7,35,,203.7,percent of total billed charges,Implant Device,197.88,34,"Charges > $500, x 34%",197.88,percent of total billed charges,Implant Device,203.7,35,,203.7,percent of total billed charges,Implant Device,203.7,35,,203.7,percent of total billed charges,Implant Device,203.7,35,,203.7,percent of total billed charges,Implant Device,203.7,35,,203.7,percent of total billed charges,Implant Device,203.7,35,,203.7,percent of total billed charges,Implant Device,232.8,40,,232.8,percent of total billed charges,Implant Device,203.7,70,,203.7,percent of total billed charges,All Other,197.88,34,,197.88,percent of total billed charges,Implant Device,197.88,34,,197.88,percent of total billed charges,Implant Device,203.7,35,,203.7,percent of total billed charges,Implant Device,203.7,35,,203.7,percent of total billed charges,Implant Device,203.7,35,,203.7,percent of total billed charges,Implant Device,203.7,35,,203.7,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,430.68,
SYNTHES 222.536 CANN SCREW 5.0X30MM,C1713,HCPCS,,79005314,CDM,278,RC,,,both,,,390,288.6,,,288.6,Other,150% of Medicare + 9.63% HCRA Surcharge,175.5,45,,175.5,percent of total billed charges,Critical Access Hospital RCC factor,132.6,34,,132.6,percent of total billed charges,Implant Device,132.6,34,,132.6,percent of total billed charges,Implant Device,132.6,34,,132.6,percent of total billed charges,Implant Device,132.6,34,,132.6,percent of total billed charges,Implant Device,132.6,34,,132.6,percent of total billed charges,Implant Device,193.05,,,193.05,Other,110% of Medicare,136.5,35,,136.5,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,136.5,35,,136.5,percent of total billed charges,Implant Device,136.5,35,,136.5,percent of total billed charges,Implant Device,136.5,35,,136.5,percent of total billed charges,Implant Device,136.5,35,,136.5,percent of total billed charges,Implant Device,136.5,35,,136.5,percent of total billed charges,Implant Device,156,40,,156,percent of total billed charges,Implant Device,136.5,70,,136.5,percent of total billed charges,All Other,132.6,34,,132.6,percent of total billed charges,Implant Device,132.6,34,,132.6,percent of total billed charges,Implant Device,136.5,35,,136.5,percent of total billed charges,Implant Device,136.5,35,,136.5,percent of total billed charges,Implant Device,136.5,35,,136.5,percent of total billed charges,Implant Device,136.5,35,,136.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,288.6,
SYTNHES 222.537 CANN SCREW 5.0X35MM,C1713,HCPCS,,79005315,CDM,278,RC,,,both,,,496,367.04,,,367.04,Other,150% of Medicare + 9.63% HCRA Surcharge,223.2,45,,223.2,percent of total billed charges,Critical Access Hospital RCC factor,168.64,34,,168.64,percent of total billed charges,Implant Device,168.64,34,,168.64,percent of total billed charges,Implant Device,168.64,34,,168.64,percent of total billed charges,Implant Device,168.64,34,,168.64,percent of total billed charges,Implant Device,168.64,34,,168.64,percent of total billed charges,Implant Device,245.52,,,245.52,Other,110% of Medicare,173.6,35,,173.6,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,173.6,35,,173.6,percent of total billed charges,Implant Device,173.6,35,,173.6,percent of total billed charges,Implant Device,173.6,35,,173.6,percent of total billed charges,Implant Device,173.6,35,,173.6,percent of total billed charges,Implant Device,173.6,35,,173.6,percent of total billed charges,Implant Device,198.4,40,,198.4,percent of total billed charges,Implant Device,173.6,70,,173.6,percent of total billed charges,All Other,168.64,34,,168.64,percent of total billed charges,Implant Device,168.64,34,,168.64,percent of total billed charges,Implant Device,173.6,35,,173.6,percent of total billed charges,Implant Device,173.6,35,,173.6,percent of total billed charges,Implant Device,173.6,35,,173.6,percent of total billed charges,Implant Device,173.6,35,,173.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,367.04,
SYNTHES 222.539 CANN SCREW 5.0X45MM,C1713,HCPCS,,79005316,CDM,278,RC,,,both,,,390,288.6,,,288.6,Other,150% of Medicare + 9.63% HCRA Surcharge,175.5,45,,175.5,percent of total billed charges,Critical Access Hospital RCC factor,132.6,34,,132.6,percent of total billed charges,Implant Device,132.6,34,,132.6,percent of total billed charges,Implant Device,132.6,34,,132.6,percent of total billed charges,Implant Device,132.6,34,,132.6,percent of total billed charges,Implant Device,132.6,34,,132.6,percent of total billed charges,Implant Device,193.05,,,193.05,Other,110% of Medicare,136.5,35,,136.5,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,136.5,35,,136.5,percent of total billed charges,Implant Device,136.5,35,,136.5,percent of total billed charges,Implant Device,136.5,35,,136.5,percent of total billed charges,Implant Device,136.5,35,,136.5,percent of total billed charges,Implant Device,136.5,35,,136.5,percent of total billed charges,Implant Device,156,40,,156,percent of total billed charges,Implant Device,136.5,70,,136.5,percent of total billed charges,All Other,132.6,34,,132.6,percent of total billed charges,Implant Device,132.6,34,,132.6,percent of total billed charges,Implant Device,136.5,35,,136.5,percent of total billed charges,Implant Device,136.5,35,,136.5,percent of total billed charges,Implant Device,136.5,35,,136.5,percent of total billed charges,Implant Device,136.5,35,,136.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,288.6,
SYNTHES 222.541 CANN SCREW 5.0X55MM,C1713,HCPCS,,79005317,CDM,278,RC,,,both,,,496,367.04,,,367.04,Other,150% of Medicare + 9.63% HCRA Surcharge,223.2,45,,223.2,percent of total billed charges,Critical Access Hospital RCC factor,168.64,34,,168.64,percent of total billed charges,Implant Device,168.64,34,,168.64,percent of total billed charges,Implant Device,168.64,34,,168.64,percent of total billed charges,Implant Device,168.64,34,,168.64,percent of total billed charges,Implant Device,168.64,34,,168.64,percent of total billed charges,Implant Device,245.52,,,245.52,Other,110% of Medicare,173.6,35,,173.6,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,173.6,35,,173.6,percent of total billed charges,Implant Device,173.6,35,,173.6,percent of total billed charges,Implant Device,173.6,35,,173.6,percent of total billed charges,Implant Device,173.6,35,,173.6,percent of total billed charges,Implant Device,173.6,35,,173.6,percent of total billed charges,Implant Device,198.4,40,,198.4,percent of total billed charges,Implant Device,173.6,70,,173.6,percent of total billed charges,All Other,168.64,34,,168.64,percent of total billed charges,Implant Device,168.64,34,,168.64,percent of total billed charges,Implant Device,173.6,35,,173.6,percent of total billed charges,Implant Device,173.6,35,,173.6,percent of total billed charges,Implant Device,173.6,35,,173.6,percent of total billed charges,Implant Device,173.6,35,,173.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,367.04,
SYNTHES 222.542 CANN SCREW 5.0X60MM,C1713,HCPCS,,79005318,CDM,278,RC,,,both,,,390,288.6,,,288.6,Other,150% of Medicare + 9.63% HCRA Surcharge,175.5,45,,175.5,percent of total billed charges,Critical Access Hospital RCC factor,132.6,34,,132.6,percent of total billed charges,Implant Device,132.6,34,,132.6,percent of total billed charges,Implant Device,132.6,34,,132.6,percent of total billed charges,Implant Device,132.6,34,,132.6,percent of total billed charges,Implant Device,132.6,34,,132.6,percent of total billed charges,Implant Device,193.05,,,193.05,Other,110% of Medicare,136.5,35,,136.5,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,136.5,35,,136.5,percent of total billed charges,Implant Device,136.5,35,,136.5,percent of total billed charges,Implant Device,136.5,35,,136.5,percent of total billed charges,Implant Device,136.5,35,,136.5,percent of total billed charges,Implant Device,136.5,35,,136.5,percent of total billed charges,Implant Device,156,40,,156,percent of total billed charges,Implant Device,136.5,70,,136.5,percent of total billed charges,All Other,132.6,34,,132.6,percent of total billed charges,Implant Device,132.6,34,,132.6,percent of total billed charges,Implant Device,136.5,35,,136.5,percent of total billed charges,Implant Device,136.5,35,,136.5,percent of total billed charges,Implant Device,136.5,35,,136.5,percent of total billed charges,Implant Device,136.5,35,,136.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,288.6,
SYNTHES 222.543 CANN SCREW 5.0X65MM,C1713,HCPCS,,79005319,CDM,278,RC,,,both,,,390,288.6,,,288.6,Other,150% of Medicare + 9.63% HCRA Surcharge,175.5,45,,175.5,percent of total billed charges,Critical Access Hospital RCC factor,132.6,34,,132.6,percent of total billed charges,Implant Device,132.6,34,,132.6,percent of total billed charges,Implant Device,132.6,34,,132.6,percent of total billed charges,Implant Device,132.6,34,,132.6,percent of total billed charges,Implant Device,132.6,34,,132.6,percent of total billed charges,Implant Device,193.05,,,193.05,Other,110% of Medicare,136.5,35,,136.5,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,136.5,35,,136.5,percent of total billed charges,Implant Device,136.5,35,,136.5,percent of total billed charges,Implant Device,136.5,35,,136.5,percent of total billed charges,Implant Device,136.5,35,,136.5,percent of total billed charges,Implant Device,136.5,35,,136.5,percent of total billed charges,Implant Device,156,40,,156,percent of total billed charges,Implant Device,136.5,70,,136.5,percent of total billed charges,All Other,132.6,34,,132.6,percent of total billed charges,Implant Device,132.6,34,,132.6,percent of total billed charges,Implant Device,136.5,35,,136.5,percent of total billed charges,Implant Device,136.5,35,,136.5,percent of total billed charges,Implant Device,136.5,35,,136.5,percent of total billed charges,Implant Device,136.5,35,,136.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,288.6,
ZIMMER 7711-13 FEMORAL STEM SIZE 13.5,C1776,HCPCS,,79005321,CDM,278,RC,,,both,,,6912,5114.9,,,5114.9,Other,150% of Medicare + 9.63% HCRA Surcharge,3110.4,45,,3110.4,percent of total billed charges,Critical Access Hospital RCC factor,2350.08,34,,2350.08,percent of total billed charges,Implant Device,2350.08,34,,2350.08,percent of total billed charges,Implant Device,2350.08,34,,2350.08,percent of total billed charges,Implant Device,2350.08,34,,2350.08,percent of total billed charges,Implant Device,2350.08,34,,2350.08,percent of total billed charges,Implant Device,3421.44,,,3421.44,Other,110% of Medicare,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2350.08,34,"Charges > $500, x 34%",2350.08,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2764.8,40,,2764.8,percent of total billed charges,Implant Device,2419.2,70,,2419.2,percent of total billed charges,All Other,2350.08,34,,2350.08,percent of total billed charges,Implant Device,2350.08,34,,2350.08,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2350.08,34,"If Charge > 2,000, then 34 percent",2350.08,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5114.9,
STRYKER 338630 CORTICAL SCREW 3.5X30MM,C1713,HCPCS,,79005322,CDM,278,RC,,,both,,,120,88.8,,,88.8,Other,150% of Medicare + 9.63% HCRA Surcharge,54,45,,54,percent of total billed charges,Critical Access Hospital RCC factor,40.8,34,,40.8,percent of total billed charges,Implant Device,40.8,34,,40.8,percent of total billed charges,Implant Device,40.8,34,,40.8,percent of total billed charges,Implant Device,40.8,34,,40.8,percent of total billed charges,Implant Device,40.8,34,,40.8,percent of total billed charges,Implant Device,59.4,,,59.4,Other,110% of Medicare,42,35,,42,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,42,35,,42,percent of total billed charges,Implant Device,42,35,,42,percent of total billed charges,Implant Device,42,35,,42,percent of total billed charges,Implant Device,42,35,,42,percent of total billed charges,Implant Device,42,35,,42,percent of total billed charges,Implant Device,48,40,,48,percent of total billed charges,Implant Device,42,70,,42,percent of total billed charges,All Other,40.8,34,,40.8,percent of total billed charges,Implant Device,40.8,34,,40.8,percent of total billed charges,Implant Device,42,35,,42,percent of total billed charges,Implant Device,42,35,,42,percent of total billed charges,Implant Device,42,35,,42,percent of total billed charges,Implant Device,42,35,,42,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,88.8,
STRYKER 371526 LOCKING SCREW 4X26MM,C1713,HCPCS,,79005323,CDM,278,RC,,,both,,,569,421.06,,,421.06,Other,150% of Medicare + 9.63% HCRA Surcharge,256.05,45,,256.05,percent of total billed charges,Critical Access Hospital RCC factor,193.46,34,,193.46,percent of total billed charges,Implant Device,193.46,34,,193.46,percent of total billed charges,Implant Device,193.46,34,,193.46,percent of total billed charges,Implant Device,193.46,34,,193.46,percent of total billed charges,Implant Device,193.46,34,,193.46,percent of total billed charges,Implant Device,281.66,,,281.66,Other,110% of Medicare,199.15,35,,199.15,percent of total billed charges,Implant Device,193.46,34,"Charges > $500, x 34%",193.46,percent of total billed charges,Implant Device,199.15,35,,199.15,percent of total billed charges,Implant Device,199.15,35,,199.15,percent of total billed charges,Implant Device,199.15,35,,199.15,percent of total billed charges,Implant Device,199.15,35,,199.15,percent of total billed charges,Implant Device,199.15,35,,199.15,percent of total billed charges,Implant Device,227.6,40,,227.6,percent of total billed charges,Implant Device,199.15,70,,199.15,percent of total billed charges,All Other,193.46,34,,193.46,percent of total billed charges,Implant Device,193.46,34,,193.46,percent of total billed charges,Implant Device,199.15,35,,199.15,percent of total billed charges,Implant Device,199.15,35,,199.15,percent of total billed charges,Implant Device,199.15,35,,199.15,percent of total billed charges,Implant Device,199.15,35,,199.15,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,421.06,
STRYKER 371538 LOCKING SCREW 4X38MM,C1713,HCPCS,,79005324,CDM,278,RC,,,both,,,569,421.06,,,421.06,Other,150% of Medicare + 9.63% HCRA Surcharge,256.05,45,,256.05,percent of total billed charges,Critical Access Hospital RCC factor,193.46,34,,193.46,percent of total billed charges,Implant Device,193.46,34,,193.46,percent of total billed charges,Implant Device,193.46,34,,193.46,percent of total billed charges,Implant Device,193.46,34,,193.46,percent of total billed charges,Implant Device,193.46,34,,193.46,percent of total billed charges,Implant Device,281.66,,,281.66,Other,110% of Medicare,199.15,35,,199.15,percent of total billed charges,Implant Device,193.46,34,"Charges > $500, x 34%",193.46,percent of total billed charges,Implant Device,199.15,35,,199.15,percent of total billed charges,Implant Device,199.15,35,,199.15,percent of total billed charges,Implant Device,199.15,35,,199.15,percent of total billed charges,Implant Device,199.15,35,,199.15,percent of total billed charges,Implant Device,199.15,35,,199.15,percent of total billed charges,Implant Device,227.6,40,,227.6,percent of total billed charges,Implant Device,199.15,70,,199.15,percent of total billed charges,All Other,193.46,34,,193.46,percent of total billed charges,Implant Device,193.46,34,,193.46,percent of total billed charges,Implant Device,199.15,35,,199.15,percent of total billed charges,Implant Device,199.15,35,,199.15,percent of total billed charges,Implant Device,199.15,35,,199.15,percent of total billed charges,Implant Device,199.15,35,,199.15,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,421.06,
STRYKER 54-25291 DORSAL DR PLATE LEFT,C1713,HCPCS,,79005325,CDM,278,RC,,,both,,,2484,1838.17,,,1838.17,Other,150% of Medicare + 9.63% HCRA Surcharge,1117.8,45,,1117.8,percent of total billed charges,Critical Access Hospital RCC factor,844.56,34,,844.56,percent of total billed charges,Implant Device,844.56,34,,844.56,percent of total billed charges,Implant Device,844.56,34,,844.56,percent of total billed charges,Implant Device,844.56,34,,844.56,percent of total billed charges,Implant Device,844.56,34,,844.56,percent of total billed charges,Implant Device,1229.58,,,1229.58,Other,110% of Medicare,869.4,35,,869.4,percent of total billed charges,Implant Device,844.56,34,"Charges > $500, x 34%",844.56,percent of total billed charges,Implant Device,869.4,35,,869.4,percent of total billed charges,Implant Device,869.4,35,,869.4,percent of total billed charges,Implant Device,869.4,35,,869.4,percent of total billed charges,Implant Device,869.4,35,,869.4,percent of total billed charges,Implant Device,869.4,35,,869.4,percent of total billed charges,Implant Device,993.6,40,,993.6,percent of total billed charges,Implant Device,869.4,70,,869.4,percent of total billed charges,All Other,844.56,34,,844.56,percent of total billed charges,Implant Device,844.56,34,,844.56,percent of total billed charges,Implant Device,869.4,35,,869.4,percent of total billed charges,Implant Device,869.4,35,,869.4,percent of total billed charges,Implant Device,869.4,35,,869.4,percent of total billed charges,Implant Device,869.4,35,,869.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,844.56,34,"If Charge > 2,000, then 34 percent",844.56,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1838.17,
STRYKER 53-23612E LOCKING SCREW 2.3X12MM,C1713,HCPCS,,79005326,CDM,278,RC,,,both,,,469,347.06,,,347.06,Other,150% of Medicare + 9.63% HCRA Surcharge,211.05,45,,211.05,percent of total billed charges,Critical Access Hospital RCC factor,159.46,34,,159.46,percent of total billed charges,Implant Device,159.46,34,,159.46,percent of total billed charges,Implant Device,159.46,34,,159.46,percent of total billed charges,Implant Device,159.46,34,,159.46,percent of total billed charges,Implant Device,159.46,34,,159.46,percent of total billed charges,Implant Device,232.16,,,232.16,Other,110% of Medicare,164.15,35,,164.15,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,164.15,35,,164.15,percent of total billed charges,Implant Device,164.15,35,,164.15,percent of total billed charges,Implant Device,164.15,35,,164.15,percent of total billed charges,Implant Device,164.15,35,,164.15,percent of total billed charges,Implant Device,164.15,35,,164.15,percent of total billed charges,Implant Device,187.6,40,,187.6,percent of total billed charges,Implant Device,164.15,70,,164.15,percent of total billed charges,All Other,159.46,34,,159.46,percent of total billed charges,Implant Device,159.46,34,,159.46,percent of total billed charges,Implant Device,164.15,35,,164.15,percent of total billed charges,Implant Device,164.15,35,,164.15,percent of total billed charges,Implant Device,164.15,35,,164.15,percent of total billed charges,Implant Device,164.15,35,,164.15,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,347.06,
STRYKER 53-23618E LOCKING SCREW 2.3X18MM,C1713,HCPCS,,79005327,CDM,278,RC,,,both,,,492,364.08,,,364.08,Other,150% of Medicare + 9.63% HCRA Surcharge,221.4,45,,221.4,percent of total billed charges,Critical Access Hospital RCC factor,167.28,34,,167.28,percent of total billed charges,Implant Device,167.28,34,,167.28,percent of total billed charges,Implant Device,167.28,34,,167.28,percent of total billed charges,Implant Device,167.28,34,,167.28,percent of total billed charges,Implant Device,167.28,34,,167.28,percent of total billed charges,Implant Device,243.54,,,243.54,Other,110% of Medicare,172.2,35,,172.2,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,172.2,35,,172.2,percent of total billed charges,Implant Device,172.2,35,,172.2,percent of total billed charges,Implant Device,172.2,35,,172.2,percent of total billed charges,Implant Device,172.2,35,,172.2,percent of total billed charges,Implant Device,172.2,35,,172.2,percent of total billed charges,Implant Device,196.8,40,,196.8,percent of total billed charges,Implant Device,172.2,70,,172.2,percent of total billed charges,All Other,167.28,34,,167.28,percent of total billed charges,Implant Device,167.28,34,,167.28,percent of total billed charges,Implant Device,172.2,35,,172.2,percent of total billed charges,Implant Device,172.2,35,,172.2,percent of total billed charges,Implant Device,172.2,35,,172.2,percent of total billed charges,Implant Device,172.2,35,,172.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,364.08,
SYNTHES 206.014 CANCELLOUS SCREW 4X14MM,C1713,HCPCS,,79005330,CDM,278,RC,,,both,,,80,59.2,,,59.2,Other,150% of Medicare + 9.63% HCRA Surcharge,36,45,,36,percent of total billed charges,Critical Access Hospital RCC factor,27.2,34,,27.2,percent of total billed charges,Implant Device,27.2,34,,27.2,percent of total billed charges,Implant Device,27.2,34,,27.2,percent of total billed charges,Implant Device,27.2,34,,27.2,percent of total billed charges,Implant Device,27.2,34,,27.2,percent of total billed charges,Implant Device,39.6,,,39.6,Other,110% of Medicare,28,35,,28,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,28,35,,28,percent of total billed charges,Implant Device,28,35,,28,percent of total billed charges,Implant Device,28,35,,28,percent of total billed charges,Implant Device,28,35,,28,percent of total billed charges,Implant Device,28,35,,28,percent of total billed charges,Implant Device,32,40,,32,percent of total billed charges,Implant Device,28,70,,28,percent of total billed charges,All Other,27.2,34,,27.2,percent of total billed charges,Implant Device,27.2,34,,27.2,percent of total billed charges,Implant Device,28,35,,28,percent of total billed charges,Implant Device,28,35,,28,percent of total billed charges,Implant Device,28,35,,28,percent of total billed charges,Implant Device,28,35,,28,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,59.2,
ARTHERX AR-8943BR-08 FIBULA PLATE 8 HOLE,C1713,HCPCS,,79005331,CDM,278,RC,,,both,,,3408,2521.93,,,2521.93,Other,150% of Medicare + 9.63% HCRA Surcharge,1533.6,45,,1533.6,percent of total billed charges,Critical Access Hospital RCC factor,1158.72,34,,1158.72,percent of total billed charges,Implant Device,1158.72,34,,1158.72,percent of total billed charges,Implant Device,1158.72,34,,1158.72,percent of total billed charges,Implant Device,1158.72,34,,1158.72,percent of total billed charges,Implant Device,1158.72,34,,1158.72,percent of total billed charges,Implant Device,1686.96,,,1686.96,Other,110% of Medicare,1192.8,35,,1192.8,percent of total billed charges,Implant Device,1158.72,34,"Charges > $500, x 34%",1158.72,percent of total billed charges,Implant Device,1192.8,35,,1192.8,percent of total billed charges,Implant Device,1192.8,35,,1192.8,percent of total billed charges,Implant Device,1192.8,35,,1192.8,percent of total billed charges,Implant Device,1192.8,35,,1192.8,percent of total billed charges,Implant Device,1192.8,35,,1192.8,percent of total billed charges,Implant Device,1363.2,40,,1363.2,percent of total billed charges,Implant Device,1192.8,70,,1192.8,percent of total billed charges,All Other,1158.72,34,,1158.72,percent of total billed charges,Implant Device,1158.72,34,,1158.72,percent of total billed charges,Implant Device,1192.8,35,,1192.8,percent of total billed charges,Implant Device,1192.8,35,,1192.8,percent of total billed charges,Implant Device,1192.8,35,,1192.8,percent of total billed charges,Implant Device,1192.8,35,,1192.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1158.72,34,"If Charge > 2,000, then 34 percent",1158.72,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2521.93,
ARTHREX AR-8827L-10 LOCK SCREW 2.7X10MM,C1713,HCPCS,,79005332,CDM,278,RC,,,both,,,316,233.84,,,233.84,Other,150% of Medicare + 9.63% HCRA Surcharge,142.2,45,,142.2,percent of total billed charges,Critical Access Hospital RCC factor,107.44,34,,107.44,percent of total billed charges,Implant Device,107.44,34,,107.44,percent of total billed charges,Implant Device,107.44,34,,107.44,percent of total billed charges,Implant Device,107.44,34,,107.44,percent of total billed charges,Implant Device,107.44,34,,107.44,percent of total billed charges,Implant Device,156.42,,,156.42,Other,110% of Medicare,110.6,35,,110.6,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,110.6,35,,110.6,percent of total billed charges,Implant Device,110.6,35,,110.6,percent of total billed charges,Implant Device,110.6,35,,110.6,percent of total billed charges,Implant Device,110.6,35,,110.6,percent of total billed charges,Implant Device,110.6,35,,110.6,percent of total billed charges,Implant Device,126.4,40,,126.4,percent of total billed charges,Implant Device,110.6,70,,110.6,percent of total billed charges,All Other,107.44,34,,107.44,percent of total billed charges,Implant Device,107.44,34,,107.44,percent of total billed charges,Implant Device,110.6,35,,110.6,percent of total billed charges,Implant Device,110.6,35,,110.6,percent of total billed charges,Implant Device,110.6,35,,110.6,percent of total billed charges,Implant Device,110.6,35,,110.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,233.84,
ARTHREX AR-8830-20 SCREW 3X20MM,C1713,HCPCS,,79005333,CDM,278,RC,,,both,,,106,78.44,,,78.44,Other,150% of Medicare + 9.63% HCRA Surcharge,47.7,45,,47.7,percent of total billed charges,Critical Access Hospital RCC factor,36.04,34,,36.04,percent of total billed charges,Implant Device,36.04,34,,36.04,percent of total billed charges,Implant Device,36.04,34,,36.04,percent of total billed charges,Implant Device,36.04,34,,36.04,percent of total billed charges,Implant Device,36.04,34,,36.04,percent of total billed charges,Implant Device,52.47,,,52.47,Other,110% of Medicare,37.1,35,,37.1,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,37.1,35,,37.1,percent of total billed charges,Implant Device,37.1,35,,37.1,percent of total billed charges,Implant Device,37.1,35,,37.1,percent of total billed charges,Implant Device,37.1,35,,37.1,percent of total billed charges,Implant Device,37.1,35,,37.1,percent of total billed charges,Implant Device,42.4,40,,42.4,percent of total billed charges,Implant Device,37.1,70,,37.1,percent of total billed charges,All Other,36.04,34,,36.04,percent of total billed charges,Implant Device,36.04,34,,36.04,percent of total billed charges,Implant Device,37.1,35,,37.1,percent of total billed charges,Implant Device,37.1,35,,37.1,percent of total billed charges,Implant Device,37.1,35,,37.1,percent of total billed charges,Implant Device,37.1,35,,37.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,78.44,
ARTHERX AR-8835-10 SCREW 3.5X10MM,C1713,HCPCS,,79005334,CDM,278,RC,,,both,,,106,78.44,,,78.44,Other,150% of Medicare + 9.63% HCRA Surcharge,47.7,45,,47.7,percent of total billed charges,Critical Access Hospital RCC factor,36.04,34,,36.04,percent of total billed charges,Implant Device,36.04,34,,36.04,percent of total billed charges,Implant Device,36.04,34,,36.04,percent of total billed charges,Implant Device,36.04,34,,36.04,percent of total billed charges,Implant Device,36.04,34,,36.04,percent of total billed charges,Implant Device,52.47,,,52.47,Other,110% of Medicare,37.1,35,,37.1,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,37.1,35,,37.1,percent of total billed charges,Implant Device,37.1,35,,37.1,percent of total billed charges,Implant Device,37.1,35,,37.1,percent of total billed charges,Implant Device,37.1,35,,37.1,percent of total billed charges,Implant Device,37.1,35,,37.1,percent of total billed charges,Implant Device,42.4,40,,42.4,percent of total billed charges,Implant Device,37.1,70,,37.1,percent of total billed charges,All Other,36.04,34,,36.04,percent of total billed charges,Implant Device,36.04,34,,36.04,percent of total billed charges,Implant Device,37.1,35,,37.1,percent of total billed charges,Implant Device,37.1,35,,37.1,percent of total billed charges,Implant Device,37.1,35,,37.1,percent of total billed charges,Implant Device,37.1,35,,37.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,78.44,
GORE RMT281416 EXCLUDER ENDOPROS GRAFT,C1874,HCPCS,,79005337,CDM,278,RC,,,both,,,31500,23310.08,,,23310.08,Other,150% of Medicare + 9.63% HCRA Surcharge,14175,45,,14175,percent of total billed charges,Critical Access Hospital RCC factor,10710,34,,10710,percent of total billed charges,Implant Device,10710,34,,10710,percent of total billed charges,Implant Device,10710,34,,10710,percent of total billed charges,Implant Device,10710,34,,10710,percent of total billed charges,Implant Device,10710,34,,10710,percent of total billed charges,Implant Device,15592.5,,,15592.5,Other,110% of Medicare,11025,35,,11025,percent of total billed charges,Implant Device,10710,34,"Charges > $500, x 34%",10710,percent of total billed charges,Implant Device,11025,35,,11025,percent of total billed charges,Implant Device,11025,35,,11025,percent of total billed charges,Implant Device,11025,35,,11025,percent of total billed charges,Implant Device,11025,35,,11025,percent of total billed charges,Implant Device,11025,35,,11025,percent of total billed charges,Implant Device,12600,40,,12600,percent of total billed charges,Implant Device,11025,70,,11025,percent of total billed charges,All Other,10710,34,,10710,percent of total billed charges,Implant Device,10710,34,,10710,percent of total billed charges,Implant Device,11025,35,,11025,percent of total billed charges,Implant Device,11025,35,,11025,percent of total billed charges,Implant Device,11025,35,,11025,percent of total billed charges,Implant Device,11025,35,,11025,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,10710,34,"If Charge > 2,000, then 34 percent",10710,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,23310.08,
BME SE-1818 SPEED IMPLANT 18X18X18MM,C1713,HCPCS,,79005339,CDM,278,RC,,,both,,,4710,3485.41,,,3485.41,Other,150% of Medicare + 9.63% HCRA Surcharge,2119.5,45,,2119.5,percent of total billed charges,Critical Access Hospital RCC factor,1601.4,34,,1601.4,percent of total billed charges,Implant Device,1601.4,34,,1601.4,percent of total billed charges,Implant Device,1601.4,34,,1601.4,percent of total billed charges,Implant Device,1601.4,34,,1601.4,percent of total billed charges,Implant Device,1601.4,34,,1601.4,percent of total billed charges,Implant Device,2331.45,,,2331.45,Other,110% of Medicare,1648.5,35,,1648.5,percent of total billed charges,Implant Device,1601.4,34,"Charges > $500, x 34%",1601.4,percent of total billed charges,Implant Device,1648.5,35,,1648.5,percent of total billed charges,Implant Device,1648.5,35,,1648.5,percent of total billed charges,Implant Device,1648.5,35,,1648.5,percent of total billed charges,Implant Device,1648.5,35,,1648.5,percent of total billed charges,Implant Device,1648.5,35,,1648.5,percent of total billed charges,Implant Device,1884,40,,1884,percent of total billed charges,Implant Device,1648.5,70,,1648.5,percent of total billed charges,All Other,1601.4,34,,1601.4,percent of total billed charges,Implant Device,1601.4,34,,1601.4,percent of total billed charges,Implant Device,1648.5,35,,1648.5,percent of total billed charges,Implant Device,1648.5,35,,1648.5,percent of total billed charges,Implant Device,1648.5,35,,1648.5,percent of total billed charges,Implant Device,1648.5,35,,1648.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1601.4,34,"If Charge > 2,000, then 34 percent",1601.4,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3485.41,
ARTHREX AR-8724-12 SCREW 2.4X12MM,C1713,HCPCS,,79005340,CDM,278,RC,,,both,,,474,350.76,,,350.76,Other,150% of Medicare + 9.63% HCRA Surcharge,213.3,45,,213.3,percent of total billed charges,Critical Access Hospital RCC factor,161.16,34,,161.16,percent of total billed charges,Implant Device,161.16,34,,161.16,percent of total billed charges,Implant Device,161.16,34,,161.16,percent of total billed charges,Implant Device,161.16,34,,161.16,percent of total billed charges,Implant Device,161.16,34,,161.16,percent of total billed charges,Implant Device,234.63,,,234.63,Other,110% of Medicare,165.9,35,,165.9,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,165.9,35,,165.9,percent of total billed charges,Implant Device,165.9,35,,165.9,percent of total billed charges,Implant Device,165.9,35,,165.9,percent of total billed charges,Implant Device,165.9,35,,165.9,percent of total billed charges,Implant Device,165.9,35,,165.9,percent of total billed charges,Implant Device,189.6,40,,189.6,percent of total billed charges,Implant Device,165.9,70,,165.9,percent of total billed charges,All Other,161.16,34,,161.16,percent of total billed charges,Implant Device,161.16,34,,161.16,percent of total billed charges,Implant Device,165.9,35,,165.9,percent of total billed charges,Implant Device,165.9,35,,165.9,percent of total billed charges,Implant Device,165.9,35,,165.9,percent of total billed charges,Implant Device,165.9,35,,165.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,350.76,
ARTHREX AR-8724-14 SCREW 2.4X14MM,C1713,HCPCS,,79005341,CDM,278,RC,,,both,,,474,350.76,,,350.76,Other,150% of Medicare + 9.63% HCRA Surcharge,213.3,45,,213.3,percent of total billed charges,Critical Access Hospital RCC factor,161.16,34,,161.16,percent of total billed charges,Implant Device,161.16,34,,161.16,percent of total billed charges,Implant Device,161.16,34,,161.16,percent of total billed charges,Implant Device,161.16,34,,161.16,percent of total billed charges,Implant Device,161.16,34,,161.16,percent of total billed charges,Implant Device,234.63,,,234.63,Other,110% of Medicare,165.9,35,,165.9,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,165.9,35,,165.9,percent of total billed charges,Implant Device,165.9,35,,165.9,percent of total billed charges,Implant Device,165.9,35,,165.9,percent of total billed charges,Implant Device,165.9,35,,165.9,percent of total billed charges,Implant Device,165.9,35,,165.9,percent of total billed charges,Implant Device,189.6,40,,189.6,percent of total billed charges,Implant Device,165.9,70,,165.9,percent of total billed charges,All Other,161.16,34,,161.16,percent of total billed charges,Implant Device,161.16,34,,161.16,percent of total billed charges,Implant Device,165.9,35,,165.9,percent of total billed charges,Implant Device,165.9,35,,165.9,percent of total billed charges,Implant Device,165.9,35,,165.9,percent of total billed charges,Implant Device,165.9,35,,165.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,350.76,
OLYMPUS 005280-901 FALOPE RING APP W/TRO,C1713,HCPCS,,79005343,CDM,278,RC,,,both,,,1402,1037.48,,,1037.48,Other,150% of Medicare + 9.63% HCRA Surcharge,630.9,45,,630.9,percent of total billed charges,Critical Access Hospital RCC factor,476.68,34,,476.68,percent of total billed charges,Implant Device,476.68,34,,476.68,percent of total billed charges,Implant Device,476.68,34,,476.68,percent of total billed charges,Implant Device,476.68,34,,476.68,percent of total billed charges,Implant Device,476.68,34,,476.68,percent of total billed charges,Implant Device,693.99,,,693.99,Other,110% of Medicare,490.7,35,,490.7,percent of total billed charges,Implant Device,476.68,34,"Charges > $500, x 34%",476.68,percent of total billed charges,Implant Device,490.7,35,,490.7,percent of total billed charges,Implant Device,490.7,35,,490.7,percent of total billed charges,Implant Device,490.7,35,,490.7,percent of total billed charges,Implant Device,490.7,35,,490.7,percent of total billed charges,Implant Device,490.7,35,,490.7,percent of total billed charges,Implant Device,560.8,40,,560.8,percent of total billed charges,Implant Device,490.7,70,,490.7,percent of total billed charges,All Other,476.68,34,,476.68,percent of total billed charges,Implant Device,476.68,34,,476.68,percent of total billed charges,Implant Device,490.7,35,,490.7,percent of total billed charges,Implant Device,490.7,35,,490.7,percent of total billed charges,Implant Device,490.7,35,,490.7,percent of total billed charges,Implant Device,490.7,35,,490.7,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1037.48,
ACUMED 70-0303 OLECRANON PLATE RT 3 HOLE,C1713,HCPCS,,79005345,CDM,278,RC,,,both,,,3639,2692.87,,,2692.87,Other,150% of Medicare + 9.63% HCRA Surcharge,1637.55,45,,1637.55,percent of total billed charges,Critical Access Hospital RCC factor,1237.26,34,,1237.26,percent of total billed charges,Implant Device,1237.26,34,,1237.26,percent of total billed charges,Implant Device,1237.26,34,,1237.26,percent of total billed charges,Implant Device,1237.26,34,,1237.26,percent of total billed charges,Implant Device,1237.26,34,,1237.26,percent of total billed charges,Implant Device,1801.31,,,1801.31,Other,110% of Medicare,1273.65,35,,1273.65,percent of total billed charges,Implant Device,1237.26,34,"Charges > $500, x 34%",1237.26,percent of total billed charges,Implant Device,1273.65,35,,1273.65,percent of total billed charges,Implant Device,1273.65,35,,1273.65,percent of total billed charges,Implant Device,1273.65,35,,1273.65,percent of total billed charges,Implant Device,1273.65,35,,1273.65,percent of total billed charges,Implant Device,1273.65,35,,1273.65,percent of total billed charges,Implant Device,1455.6,40,,1455.6,percent of total billed charges,Implant Device,1273.65,70,,1273.65,percent of total billed charges,All Other,1237.26,34,,1237.26,percent of total billed charges,Implant Device,1237.26,34,,1237.26,percent of total billed charges,Implant Device,1273.65,35,,1273.65,percent of total billed charges,Implant Device,1273.65,35,,1273.65,percent of total billed charges,Implant Device,1273.65,35,,1273.65,percent of total billed charges,Implant Device,1273.65,35,,1273.65,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1237.26,34,"If Charge > 2,000, then 34 percent",1237.26,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2692.87,
ACUMED 30-0264 NON LOCK SCREW 3.5X26MM,C1713,HCPCS,,79005346,CDM,278,RC,,,both,,,270,199.8,,,199.8,Other,150% of Medicare + 9.63% HCRA Surcharge,121.5,45,,121.5,percent of total billed charges,Critical Access Hospital RCC factor,91.8,34,,91.8,percent of total billed charges,Implant Device,91.8,34,,91.8,percent of total billed charges,Implant Device,91.8,34,,91.8,percent of total billed charges,Implant Device,91.8,34,,91.8,percent of total billed charges,Implant Device,91.8,34,,91.8,percent of total billed charges,Implant Device,133.65,,,133.65,Other,110% of Medicare,94.5,35,,94.5,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,94.5,35,,94.5,percent of total billed charges,Implant Device,94.5,35,,94.5,percent of total billed charges,Implant Device,94.5,35,,94.5,percent of total billed charges,Implant Device,94.5,35,,94.5,percent of total billed charges,Implant Device,94.5,35,,94.5,percent of total billed charges,Implant Device,108,40,,108,percent of total billed charges,Implant Device,94.5,70,,94.5,percent of total billed charges,All Other,91.8,34,,91.8,percent of total billed charges,Implant Device,91.8,34,,91.8,percent of total billed charges,Implant Device,94.5,35,,94.5,percent of total billed charges,Implant Device,94.5,35,,94.5,percent of total billed charges,Implant Device,94.5,35,,94.5,percent of total billed charges,Implant Device,94.5,35,,94.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,199.8,
ACUMED 30-0261 NON LOCK SCREW 3.5X20MM,C1713,HCPCS,,79005347,CDM,278,RC,,,both,,,262,193.88,,,193.88,Other,150% of Medicare + 9.63% HCRA Surcharge,117.9,45,,117.9,percent of total billed charges,Critical Access Hospital RCC factor,89.08,34,,89.08,percent of total billed charges,Implant Device,89.08,34,,89.08,percent of total billed charges,Implant Device,89.08,34,,89.08,percent of total billed charges,Implant Device,89.08,34,,89.08,percent of total billed charges,Implant Device,89.08,34,,89.08,percent of total billed charges,Implant Device,129.69,,,129.69,Other,110% of Medicare,91.7,35,,91.7,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,91.7,35,,91.7,percent of total billed charges,Implant Device,91.7,35,,91.7,percent of total billed charges,Implant Device,91.7,35,,91.7,percent of total billed charges,Implant Device,91.7,35,,91.7,percent of total billed charges,Implant Device,91.7,35,,91.7,percent of total billed charges,Implant Device,104.8,40,,104.8,percent of total billed charges,Implant Device,91.7,70,,91.7,percent of total billed charges,All Other,89.08,34,,89.08,percent of total billed charges,Implant Device,89.08,34,,89.08,percent of total billed charges,Implant Device,91.7,35,,91.7,percent of total billed charges,Implant Device,91.7,35,,91.7,percent of total billed charges,Implant Device,91.7,35,,91.7,percent of total billed charges,Implant Device,91.7,35,,91.7,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,193.88,
ACUMED 30-0271 NON LOCK SCREW 3.5X40MM,C1713,HCPCS,,79005348,CDM,278,RC,,,both,,,315,233.1,,,233.1,Other,150% of Medicare + 9.63% HCRA Surcharge,141.75,45,,141.75,percent of total billed charges,Critical Access Hospital RCC factor,107.1,34,,107.1,percent of total billed charges,Implant Device,107.1,34,,107.1,percent of total billed charges,Implant Device,107.1,34,,107.1,percent of total billed charges,Implant Device,107.1,34,,107.1,percent of total billed charges,Implant Device,107.1,34,,107.1,percent of total billed charges,Implant Device,155.93,,,155.93,Other,110% of Medicare,110.25,35,,110.25,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,110.25,35,,110.25,percent of total billed charges,Implant Device,110.25,35,,110.25,percent of total billed charges,Implant Device,110.25,35,,110.25,percent of total billed charges,Implant Device,110.25,35,,110.25,percent of total billed charges,Implant Device,110.25,35,,110.25,percent of total billed charges,Implant Device,126,40,,126,percent of total billed charges,Implant Device,110.25,70,,110.25,percent of total billed charges,All Other,107.1,34,,107.1,percent of total billed charges,Implant Device,107.1,34,,107.1,percent of total billed charges,Implant Device,110.25,35,,110.25,percent of total billed charges,Implant Device,110.25,35,,110.25,percent of total billed charges,Implant Device,110.25,35,,110.25,percent of total billed charges,Implant Device,110.25,35,,110.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,233.1,
ALPHATEC 71001-060 4 LEVEL PLATE 60CM,C1713,HCPCS,,79005349,CDM,278,RC,,,both,,,3750,2775.01,,,2775.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1687.5,45,,1687.5,percent of total billed charges,Critical Access Hospital RCC factor,1275,34,,1275,percent of total billed charges,Implant Device,1275,34,,1275,percent of total billed charges,Implant Device,1275,34,,1275,percent of total billed charges,Implant Device,1275,34,,1275,percent of total billed charges,Implant Device,1275,34,,1275,percent of total billed charges,Implant Device,1856.25,,,1856.25,Other,110% of Medicare,1312.5,35,,1312.5,percent of total billed charges,Implant Device,1275,34,"Charges > $500, x 34%",1275,percent of total billed charges,Implant Device,1312.5,35,,1312.5,percent of total billed charges,Implant Device,1312.5,35,,1312.5,percent of total billed charges,Implant Device,1312.5,35,,1312.5,percent of total billed charges,Implant Device,1312.5,35,,1312.5,percent of total billed charges,Implant Device,1312.5,35,,1312.5,percent of total billed charges,Implant Device,1500,40,,1500,percent of total billed charges,Implant Device,1312.5,70,,1312.5,percent of total billed charges,All Other,1275,34,,1275,percent of total billed charges,Implant Device,1275,34,,1275,percent of total billed charges,Implant Device,1312.5,35,,1312.5,percent of total billed charges,Implant Device,1312.5,35,,1312.5,percent of total billed charges,Implant Device,1312.5,35,,1312.5,percent of total billed charges,Implant Device,1312.5,35,,1312.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1275,34,"If Charge > 2,000, then 34 percent",1275,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2775.01,
ALPHATEC 71001-012 ONE LEVE PLATE 12MM,C1713,HCPCS,,79005350,CDM,278,RC,,,both,,,2280,1687.21,,,1687.21,Other,150% of Medicare + 9.63% HCRA Surcharge,1026,45,,1026,percent of total billed charges,Critical Access Hospital RCC factor,775.2,34,,775.2,percent of total billed charges,Implant Device,775.2,34,,775.2,percent of total billed charges,Implant Device,775.2,34,,775.2,percent of total billed charges,Implant Device,775.2,34,,775.2,percent of total billed charges,Implant Device,775.2,34,,775.2,percent of total billed charges,Implant Device,1128.6,,,1128.6,Other,110% of Medicare,798,35,,798,percent of total billed charges,Implant Device,775.2,34,"Charges > $500, x 34%",775.2,percent of total billed charges,Implant Device,798,35,,798,percent of total billed charges,Implant Device,798,35,,798,percent of total billed charges,Implant Device,798,35,,798,percent of total billed charges,Implant Device,798,35,,798,percent of total billed charges,Implant Device,798,35,,798,percent of total billed charges,Implant Device,912,40,,912,percent of total billed charges,Implant Device,798,70,,798,percent of total billed charges,All Other,775.2,34,,775.2,percent of total billed charges,Implant Device,775.2,34,,775.2,percent of total billed charges,Implant Device,798,35,,798,percent of total billed charges,Implant Device,798,35,,798,percent of total billed charges,Implant Device,798,35,,798,percent of total billed charges,Implant Device,798,35,,798,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,775.2,34,"If Charge > 2,000, then 34 percent",775.2,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1687.21,
S&N 410236 GUIDE PIN 230X2.4MM,C1713,HCPCS,,79005356,CDM,278,RC,,,both,,,124,91.76,,,91.76,Other,150% of Medicare + 9.63% HCRA Surcharge,55.8,45,,55.8,percent of total billed charges,Critical Access Hospital RCC factor,42.16,34,,42.16,percent of total billed charges,Implant Device,42.16,34,,42.16,percent of total billed charges,Implant Device,42.16,34,,42.16,percent of total billed charges,Implant Device,42.16,34,,42.16,percent of total billed charges,Implant Device,42.16,34,,42.16,percent of total billed charges,Implant Device,61.38,,,61.38,Other,110% of Medicare,43.4,35,,43.4,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,43.4,35,,43.4,percent of total billed charges,Implant Device,43.4,35,,43.4,percent of total billed charges,Implant Device,43.4,35,,43.4,percent of total billed charges,Implant Device,43.4,35,,43.4,percent of total billed charges,Implant Device,43.4,35,,43.4,percent of total billed charges,Implant Device,49.6,40,,49.6,percent of total billed charges,Implant Device,43.4,70,,43.4,percent of total billed charges,All Other,42.16,34,,42.16,percent of total billed charges,Implant Device,42.16,34,,42.16,percent of total billed charges,Implant Device,43.4,35,,43.4,percent of total billed charges,Implant Device,43.4,35,,43.4,percent of total billed charges,Implant Device,43.4,35,,43.4,percent of total billed charges,Implant Device,43.4,35,,43.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,91.76,
S&N 202.824 CORTEX SCREW SELF TAP 2.7X24,C1713,HCPCS,,79005357,CDM,278,RC,,,both,,,85,62.9,,,62.9,Other,150% of Medicare + 9.63% HCRA Surcharge,38.25,45,,38.25,percent of total billed charges,Critical Access Hospital RCC factor,28.9,34,,28.9,percent of total billed charges,Implant Device,28.9,34,,28.9,percent of total billed charges,Implant Device,28.9,34,,28.9,percent of total billed charges,Implant Device,28.9,34,,28.9,percent of total billed charges,Implant Device,28.9,34,,28.9,percent of total billed charges,Implant Device,42.08,,,42.08,Other,110% of Medicare,29.75,35,,29.75,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,29.75,35,,29.75,percent of total billed charges,Implant Device,29.75,35,,29.75,percent of total billed charges,Implant Device,29.75,35,,29.75,percent of total billed charges,Implant Device,29.75,35,,29.75,percent of total billed charges,Implant Device,29.75,35,,29.75,percent of total billed charges,Implant Device,34,40,,34,percent of total billed charges,Implant Device,29.75,70,,29.75,percent of total billed charges,All Other,28.9,34,,28.9,percent of total billed charges,Implant Device,28.9,34,,28.9,percent of total billed charges,Implant Device,29.75,35,,29.75,percent of total billed charges,Implant Device,29.75,35,,29.75,percent of total billed charges,Implant Device,29.75,35,,29.75,percent of total billed charges,Implant Device,29.75,35,,29.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,62.9,
S&N 242.05 PLATE W/COLLAR 5 HOLE 39MM,C1713,HCPCS,,79005358,CDM,278,RC,,,both,,,263,194.62,,,194.62,Other,150% of Medicare + 9.63% HCRA Surcharge,118.35,45,,118.35,percent of total billed charges,Critical Access Hospital RCC factor,89.42,34,,89.42,percent of total billed charges,Implant Device,89.42,34,,89.42,percent of total billed charges,Implant Device,89.42,34,,89.42,percent of total billed charges,Implant Device,89.42,34,,89.42,percent of total billed charges,Implant Device,89.42,34,,89.42,percent of total billed charges,Implant Device,130.19,,,130.19,Other,110% of Medicare,92.05,35,,92.05,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,92.05,35,,92.05,percent of total billed charges,Implant Device,92.05,35,,92.05,percent of total billed charges,Implant Device,92.05,35,,92.05,percent of total billed charges,Implant Device,92.05,35,,92.05,percent of total billed charges,Implant Device,92.05,35,,92.05,percent of total billed charges,Implant Device,105.2,40,,105.2,percent of total billed charges,Implant Device,92.05,70,,92.05,percent of total billed charges,All Other,89.42,34,,89.42,percent of total billed charges,Implant Device,89.42,34,,89.42,percent of total billed charges,Implant Device,92.05,35,,92.05,percent of total billed charges,Implant Device,92.05,35,,92.05,percent of total billed charges,Implant Device,92.05,35,,92.05,percent of total billed charges,Implant Device,92.05,35,,92.05,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,194.62,
MICRO AIRE 1600-1962 K WIRE .062,C1713,HCPCS,,79005360,CDM,278,RC,,,both,,,19,14.06,,,14.06,Other,150% of Medicare + 9.63% HCRA Surcharge,8.55,45,,8.55,percent of total billed charges,Critical Access Hospital RCC factor,6.46,34,,6.46,percent of total billed charges,Implant Device,6.46,34,,6.46,percent of total billed charges,Implant Device,6.46,34,,6.46,percent of total billed charges,Implant Device,6.46,34,,6.46,percent of total billed charges,Implant Device,6.46,34,,6.46,percent of total billed charges,Implant Device,9.41,,,9.41,Other,110% of Medicare,6.65,35,,6.65,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,6.65,35,,6.65,percent of total billed charges,Implant Device,6.65,35,,6.65,percent of total billed charges,Implant Device,6.65,35,,6.65,percent of total billed charges,Implant Device,6.65,35,,6.65,percent of total billed charges,Implant Device,6.65,35,,6.65,percent of total billed charges,Implant Device,7.6,40,,7.6,percent of total billed charges,Implant Device,6.65,70,,6.65,percent of total billed charges,All Other,6.46,34,,6.46,percent of total billed charges,Implant Device,6.46,34,,6.46,percent of total billed charges,Implant Device,6.65,35,,6.65,percent of total billed charges,Implant Device,6.65,35,,6.65,percent of total billed charges,Implant Device,6.65,35,,6.65,percent of total billed charges,Implant Device,6.65,35,,6.65,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,14.06,
SYNTHES 202.812 CORTEX SCREW 2.7X12MM,C1713,HCPCS,,79005362,CDM,278,RC,,,both,,,128,94.72,,,94.72,Other,150% of Medicare + 9.63% HCRA Surcharge,57.6,45,,57.6,percent of total billed charges,Critical Access Hospital RCC factor,43.52,34,,43.52,percent of total billed charges,Implant Device,43.52,34,,43.52,percent of total billed charges,Implant Device,43.52,34,,43.52,percent of total billed charges,Implant Device,43.52,34,,43.52,percent of total billed charges,Implant Device,43.52,34,,43.52,percent of total billed charges,Implant Device,63.36,,,63.36,Other,110% of Medicare,44.8,35,,44.8,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,44.8,35,,44.8,percent of total billed charges,Implant Device,44.8,35,,44.8,percent of total billed charges,Implant Device,44.8,35,,44.8,percent of total billed charges,Implant Device,44.8,35,,44.8,percent of total billed charges,Implant Device,44.8,35,,44.8,percent of total billed charges,Implant Device,51.2,40,,51.2,percent of total billed charges,Implant Device,44.8,70,,44.8,percent of total billed charges,All Other,43.52,34,,43.52,percent of total billed charges,Implant Device,43.52,34,,43.52,percent of total billed charges,Implant Device,44.8,35,,44.8,percent of total billed charges,Implant Device,44.8,35,,44.8,percent of total billed charges,Implant Device,44.8,35,,44.8,percent of total billed charges,Implant Device,44.8,35,,44.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,94.72,
SYNTHES 202.810 CORTEX SCREW 2.7X10MM,C1713,HCPCS,,79005363,CDM,278,RC,,,both,,,128,94.72,,,94.72,Other,150% of Medicare + 9.63% HCRA Surcharge,57.6,45,,57.6,percent of total billed charges,Critical Access Hospital RCC factor,43.52,34,,43.52,percent of total billed charges,Implant Device,43.52,34,,43.52,percent of total billed charges,Implant Device,43.52,34,,43.52,percent of total billed charges,Implant Device,43.52,34,,43.52,percent of total billed charges,Implant Device,43.52,34,,43.52,percent of total billed charges,Implant Device,63.36,,,63.36,Other,110% of Medicare,44.8,35,,44.8,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,44.8,35,,44.8,percent of total billed charges,Implant Device,44.8,35,,44.8,percent of total billed charges,Implant Device,44.8,35,,44.8,percent of total billed charges,Implant Device,44.8,35,,44.8,percent of total billed charges,Implant Device,44.8,35,,44.8,percent of total billed charges,Implant Device,51.2,40,,51.2,percent of total billed charges,Implant Device,44.8,70,,44.8,percent of total billed charges,All Other,43.52,34,,43.52,percent of total billed charges,Implant Device,43.52,34,,43.52,percent of total billed charges,Implant Device,44.8,35,,44.8,percent of total billed charges,Implant Device,44.8,35,,44.8,percent of total billed charges,Implant Device,44.8,35,,44.8,percent of total billed charges,Implant Device,44.8,35,,44.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,94.72,
J&J C07060ML 7X60X120CM SMART STENT,C1876,HCPCS,,79005365,CDM,278,RC,,,both,,,2100,1554.01,,,1554.01,Other,150% of Medicare + 9.63% HCRA Surcharge,945,45,,945,percent of total billed charges,Critical Access Hospital RCC factor,714,34,,714,percent of total billed charges,Implant Device,714,34,,714,percent of total billed charges,Implant Device,714,34,,714,percent of total billed charges,Implant Device,714,34,,714,percent of total billed charges,Implant Device,714,34,,714,percent of total billed charges,Implant Device,1039.5,,,1039.5,Other,110% of Medicare,735,35,,735,percent of total billed charges,Implant Device,714,34,"Charges > $500, x 34%",714,percent of total billed charges,Implant Device,735,35,,735,percent of total billed charges,Implant Device,735,35,,735,percent of total billed charges,Implant Device,735,35,,735,percent of total billed charges,Implant Device,735,35,,735,percent of total billed charges,Implant Device,735,35,,735,percent of total billed charges,Implant Device,840,40,,840,percent of total billed charges,Implant Device,735,70,,735,percent of total billed charges,All Other,714,34,,714,percent of total billed charges,Implant Device,714,34,,714,percent of total billed charges,Implant Device,735,35,,735,percent of total billed charges,Implant Device,735,35,,735,percent of total billed charges,Implant Device,735,35,,735,percent of total billed charges,Implant Device,735,35,,735,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,714,34,"If Charge > 2,000, then 34 percent",714,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1554.01,
S&N 71453232 ARTICULAR INSERT 11MM,C1776,HCPCS,,79005366,CDM,278,RC,,,both,,,5212,3856.89,,,3856.89,Other,150% of Medicare + 9.63% HCRA Surcharge,2345.4,45,,2345.4,percent of total billed charges,Critical Access Hospital RCC factor,1772.08,34,,1772.08,percent of total billed charges,Implant Device,1772.08,34,,1772.08,percent of total billed charges,Implant Device,1772.08,34,,1772.08,percent of total billed charges,Implant Device,1772.08,34,,1772.08,percent of total billed charges,Implant Device,1772.08,34,,1772.08,percent of total billed charges,Implant Device,2579.94,,,2579.94,Other,110% of Medicare,1824.2,35,,1824.2,percent of total billed charges,Implant Device,1772.08,34,"Charges > $500, x 34%",1772.08,percent of total billed charges,Implant Device,1824.2,35,,1824.2,percent of total billed charges,Implant Device,1824.2,35,,1824.2,percent of total billed charges,Implant Device,1824.2,35,,1824.2,percent of total billed charges,Implant Device,1824.2,35,,1824.2,percent of total billed charges,Implant Device,1824.2,35,,1824.2,percent of total billed charges,Implant Device,2084.8,40,,2084.8,percent of total billed charges,Implant Device,1824.2,70,,1824.2,percent of total billed charges,All Other,1772.08,34,,1772.08,percent of total billed charges,Implant Device,1772.08,34,,1772.08,percent of total billed charges,Implant Device,1824.2,35,,1824.2,percent of total billed charges,Implant Device,1824.2,35,,1824.2,percent of total billed charges,Implant Device,1824.2,35,,1824.2,percent of total billed charges,Implant Device,1824.2,35,,1824.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1772.08,34,"If Charge > 2,000, then 34 percent",1772.08,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3856.89,
S&N 71453233 ARTICULAR INSERT 13MM,C1776,HCPCS,,79005367,CDM,278,RC,,,both,,,5212,3856.89,,,3856.89,Other,150% of Medicare + 9.63% HCRA Surcharge,2345.4,45,,2345.4,percent of total billed charges,Critical Access Hospital RCC factor,1772.08,34,,1772.08,percent of total billed charges,Implant Device,1772.08,34,,1772.08,percent of total billed charges,Implant Device,1772.08,34,,1772.08,percent of total billed charges,Implant Device,1772.08,34,,1772.08,percent of total billed charges,Implant Device,1772.08,34,,1772.08,percent of total billed charges,Implant Device,2579.94,,,2579.94,Other,110% of Medicare,1824.2,35,,1824.2,percent of total billed charges,Implant Device,1772.08,34,"Charges > $500, x 34%",1772.08,percent of total billed charges,Implant Device,1824.2,35,,1824.2,percent of total billed charges,Implant Device,1824.2,35,,1824.2,percent of total billed charges,Implant Device,1824.2,35,,1824.2,percent of total billed charges,Implant Device,1824.2,35,,1824.2,percent of total billed charges,Implant Device,1824.2,35,,1824.2,percent of total billed charges,Implant Device,2084.8,40,,2084.8,percent of total billed charges,Implant Device,1824.2,70,,1824.2,percent of total billed charges,All Other,1772.08,34,,1772.08,percent of total billed charges,Implant Device,1772.08,34,,1772.08,percent of total billed charges,Implant Device,1824.2,35,,1824.2,percent of total billed charges,Implant Device,1824.2,35,,1824.2,percent of total billed charges,Implant Device,1824.2,35,,1824.2,percent of total billed charges,Implant Device,1824.2,35,,1824.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1772.08,34,"If Charge > 2,000, then 34 percent",1772.08,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3856.89,
DEPUY HEMIARTHROPLASTY HIP PRIMARY STEM,C1776,HCPCS,,79005369,CDM,278,RC,,,both,,,12000,8880.03,,,8880.03,Other,150% of Medicare + 9.63% HCRA Surcharge,5400,45,,5400,percent of total billed charges,Critical Access Hospital RCC factor,4080,34,,4080,percent of total billed charges,Implant Device,4080,34,,4080,percent of total billed charges,Implant Device,4080,34,,4080,percent of total billed charges,Implant Device,4080,34,,4080,percent of total billed charges,Implant Device,4080,34,,4080,percent of total billed charges,Implant Device,5940,,,5940,Other,110% of Medicare,4200,35,,4200,percent of total billed charges,Implant Device,4080,34,"Charges > $500, x 34%",4080,percent of total billed charges,Implant Device,4200,35,,4200,percent of total billed charges,Implant Device,4200,35,,4200,percent of total billed charges,Implant Device,4200,35,,4200,percent of total billed charges,Implant Device,4200,35,,4200,percent of total billed charges,Implant Device,4200,35,,4200,percent of total billed charges,Implant Device,4800,40,,4800,percent of total billed charges,Implant Device,4200,70,,4200,percent of total billed charges,All Other,4080,34,,4080,percent of total billed charges,Implant Device,4080,34,,4080,percent of total billed charges,Implant Device,4200,35,,4200,percent of total billed charges,Implant Device,4200,35,,4200,percent of total billed charges,Implant Device,4200,35,,4200,percent of total billed charges,Implant Device,4200,35,,4200,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,4080,34,"If Charge > 2,000, then 34 percent",4080,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,8880.03,
STRYKER 6704-3-092 TROCHANTRC GRIP PLATE,C1776,HCPCS,,79005370,CDM,278,RC,,,both,,,7050,5217.02,,,5217.02,Other,150% of Medicare + 9.63% HCRA Surcharge,3172.5,45,,3172.5,percent of total billed charges,Critical Access Hospital RCC factor,2397,34,,2397,percent of total billed charges,Implant Device,2397,34,,2397,percent of total billed charges,Implant Device,2397,34,,2397,percent of total billed charges,Implant Device,2397,34,,2397,percent of total billed charges,Implant Device,2397,34,,2397,percent of total billed charges,Implant Device,3489.75,,,3489.75,Other,110% of Medicare,2467.5,35,,2467.5,percent of total billed charges,Implant Device,2397,34,"Charges > $500, x 34%",2397,percent of total billed charges,Implant Device,2467.5,35,,2467.5,percent of total billed charges,Implant Device,2467.5,35,,2467.5,percent of total billed charges,Implant Device,2467.5,35,,2467.5,percent of total billed charges,Implant Device,2467.5,35,,2467.5,percent of total billed charges,Implant Device,2467.5,35,,2467.5,percent of total billed charges,Implant Device,2820,40,,2820,percent of total billed charges,Implant Device,2467.5,70,,2467.5,percent of total billed charges,All Other,2397,34,,2397,percent of total billed charges,Implant Device,2397,34,,2397,percent of total billed charges,Implant Device,2467.5,35,,2467.5,percent of total billed charges,Implant Device,2467.5,35,,2467.5,percent of total billed charges,Implant Device,2467.5,35,,2467.5,percent of total billed charges,Implant Device,2467.5,35,,2467.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2397,34,"If Charge > 2,000, then 34 percent",2397,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5217.02,
STRYKER 6276-7-317 MOD HIP SYS 235X17MM,C1776,HCPCS,,79005371,CDM,278,RC,,,both,,,16433,12160.46,,,12160.46,Other,150% of Medicare + 9.63% HCRA Surcharge,7394.85,45,,7394.85,percent of total billed charges,Critical Access Hospital RCC factor,5587.22,34,,5587.22,percent of total billed charges,Implant Device,5587.22,34,,5587.22,percent of total billed charges,Implant Device,5587.22,34,,5587.22,percent of total billed charges,Implant Device,5587.22,34,,5587.22,percent of total billed charges,Implant Device,5587.22,34,,5587.22,percent of total billed charges,Implant Device,8134.34,,,8134.34,Other,110% of Medicare,5751.55,35,,5751.55,percent of total billed charges,Implant Device,5587.22,34,"Charges > $500, x 34%",5587.22,percent of total billed charges,Implant Device,5751.55,35,,5751.55,percent of total billed charges,Implant Device,5751.55,35,,5751.55,percent of total billed charges,Implant Device,5751.55,35,,5751.55,percent of total billed charges,Implant Device,5751.55,35,,5751.55,percent of total billed charges,Implant Device,5751.55,35,,5751.55,percent of total billed charges,Implant Device,6573.2,40,,6573.2,percent of total billed charges,Implant Device,5751.55,70,,5751.55,percent of total billed charges,All Other,5587.22,34,,5587.22,percent of total billed charges,Implant Device,5587.22,34,,5587.22,percent of total billed charges,Implant Device,5751.55,35,,5751.55,percent of total billed charges,Implant Device,5751.55,35,,5751.55,percent of total billed charges,Implant Device,5751.55,35,,5751.55,percent of total billed charges,Implant Device,5751.55,35,,5751.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,5587.22,34,"If Charge > 2,000, then 34 percent",5587.22,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,12160.46,
STRYKER 6570-0-032 V40 FEM HEAD 32X-4MM,C1776,HCPCS,,79005372,CDM,278,RC,,,both,,,2503,1852.23,,,1852.23,Other,150% of Medicare + 9.63% HCRA Surcharge,1126.35,45,,1126.35,percent of total billed charges,Critical Access Hospital RCC factor,851.02,34,,851.02,percent of total billed charges,Implant Device,851.02,34,,851.02,percent of total billed charges,Implant Device,851.02,34,,851.02,percent of total billed charges,Implant Device,851.02,34,,851.02,percent of total billed charges,Implant Device,851.02,34,,851.02,percent of total billed charges,Implant Device,1238.99,,,1238.99,Other,110% of Medicare,876.05,35,,876.05,percent of total billed charges,Implant Device,851.02,34,"Charges > $500, x 34%",851.02,percent of total billed charges,Implant Device,876.05,35,,876.05,percent of total billed charges,Implant Device,876.05,35,,876.05,percent of total billed charges,Implant Device,876.05,35,,876.05,percent of total billed charges,Implant Device,876.05,35,,876.05,percent of total billed charges,Implant Device,876.05,35,,876.05,percent of total billed charges,Implant Device,1001.2,40,,1001.2,percent of total billed charges,Implant Device,876.05,70,,876.05,percent of total billed charges,All Other,851.02,34,,851.02,percent of total billed charges,Implant Device,851.02,34,,851.02,percent of total billed charges,Implant Device,876.05,35,,876.05,percent of total billed charges,Implant Device,876.05,35,,876.05,percent of total billed charges,Implant Device,876.05,35,,876.05,percent of total billed charges,Implant Device,876.05,35,,876.05,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,851.02,34,"If Charge > 2,000, then 34 percent",851.02,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1852.23,
STRYKER 6570-0-436 V40 FEM HEAD 36X-2.5,C1776,HCPCS,,79005373,CDM,278,RC,,,both,,,2503,1852.23,,,1852.23,Other,150% of Medicare + 9.63% HCRA Surcharge,1126.35,45,,1126.35,percent of total billed charges,Critical Access Hospital RCC factor,851.02,34,,851.02,percent of total billed charges,Implant Device,851.02,34,,851.02,percent of total billed charges,Implant Device,851.02,34,,851.02,percent of total billed charges,Implant Device,851.02,34,,851.02,percent of total billed charges,Implant Device,851.02,34,,851.02,percent of total billed charges,Implant Device,1238.99,,,1238.99,Other,110% of Medicare,876.05,35,,876.05,percent of total billed charges,Implant Device,851.02,34,"Charges > $500, x 34%",851.02,percent of total billed charges,Implant Device,876.05,35,,876.05,percent of total billed charges,Implant Device,876.05,35,,876.05,percent of total billed charges,Implant Device,876.05,35,,876.05,percent of total billed charges,Implant Device,876.05,35,,876.05,percent of total billed charges,Implant Device,876.05,35,,876.05,percent of total billed charges,Implant Device,1001.2,40,,1001.2,percent of total billed charges,Implant Device,876.05,70,,876.05,percent of total billed charges,All Other,851.02,34,,851.02,percent of total billed charges,Implant Device,851.02,34,,851.02,percent of total billed charges,Implant Device,876.05,35,,876.05,percent of total billed charges,Implant Device,876.05,35,,876.05,percent of total billed charges,Implant Device,876.05,35,,876.05,percent of total billed charges,Implant Device,876.05,35,,876.05,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,851.02,34,"If Charge > 2,000, then 34 percent",851.02,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1852.23,
ZIMMER 7110-54-32 TRAB RV SHELL LNR 32MM,C1776,HCPCS,,79005374,CDM,278,RC,,,both,,,5603,4146.23,,,4146.23,Other,150% of Medicare + 9.63% HCRA Surcharge,2521.35,45,,2521.35,percent of total billed charges,Critical Access Hospital RCC factor,1905.02,34,,1905.02,percent of total billed charges,Implant Device,1905.02,34,,1905.02,percent of total billed charges,Implant Device,1905.02,34,,1905.02,percent of total billed charges,Implant Device,1905.02,34,,1905.02,percent of total billed charges,Implant Device,1905.02,34,,1905.02,percent of total billed charges,Implant Device,2773.49,,,2773.49,Other,110% of Medicare,1961.05,35,,1961.05,percent of total billed charges,Implant Device,1905.02,34,"Charges > $500, x 34%",1905.02,percent of total billed charges,Implant Device,1961.05,35,,1961.05,percent of total billed charges,Implant Device,1961.05,35,,1961.05,percent of total billed charges,Implant Device,1961.05,35,,1961.05,percent of total billed charges,Implant Device,1961.05,35,,1961.05,percent of total billed charges,Implant Device,1961.05,35,,1961.05,percent of total billed charges,Implant Device,2241.2,40,,2241.2,percent of total billed charges,Implant Device,1961.05,70,,1961.05,percent of total billed charges,All Other,1905.02,34,,1905.02,percent of total billed charges,Implant Device,1905.02,34,,1905.02,percent of total billed charges,Implant Device,1961.05,35,,1961.05,percent of total billed charges,Implant Device,1961.05,35,,1961.05,percent of total billed charges,Implant Device,1961.05,35,,1961.05,percent of total billed charges,Implant Device,1961.05,35,,1961.05,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1905.02,34,"If Charge > 2,000, then 34 percent",1905.02,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4146.23,
ZIMMER 00-8752-011-36 RIM LNR 36MM SZ JJ,C1776,HCPCS,,79005375,CDM,278,RC,,,both,,,2304,1704.97,,,1704.97,Other,150% of Medicare + 9.63% HCRA Surcharge,1036.8,45,,1036.8,percent of total billed charges,Critical Access Hospital RCC factor,783.36,34,,783.36,percent of total billed charges,Implant Device,783.36,34,,783.36,percent of total billed charges,Implant Device,783.36,34,,783.36,percent of total billed charges,Implant Device,783.36,34,,783.36,percent of total billed charges,Implant Device,783.36,34,,783.36,percent of total billed charges,Implant Device,1140.48,,,1140.48,Other,110% of Medicare,806.4,35,,806.4,percent of total billed charges,Implant Device,783.36,34,"Charges > $500, x 34%",783.36,percent of total billed charges,Implant Device,806.4,35,,806.4,percent of total billed charges,Implant Device,806.4,35,,806.4,percent of total billed charges,Implant Device,806.4,35,,806.4,percent of total billed charges,Implant Device,806.4,35,,806.4,percent of total billed charges,Implant Device,806.4,35,,806.4,percent of total billed charges,Implant Device,921.6,40,,921.6,percent of total billed charges,Implant Device,806.4,70,,806.4,percent of total billed charges,All Other,783.36,34,,783.36,percent of total billed charges,Implant Device,783.36,34,,783.36,percent of total billed charges,Implant Device,806.4,35,,806.4,percent of total billed charges,Implant Device,806.4,35,,806.4,percent of total billed charges,Implant Device,806.4,35,,806.4,percent of total billed charges,Implant Device,806.4,35,,806.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,783.36,34,"If Charge > 2,000, then 34 percent",783.36,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1704.97,
ZIMMER 00-1105-200-002 PUROS DBM 20CC,C1713,HCPCS,,79005376,CDM,278,RC,,,both,,,8764,6485.38,,,6485.38,Other,150% of Medicare + 9.63% HCRA Surcharge,3943.8,45,,3943.8,percent of total billed charges,Critical Access Hospital RCC factor,2979.76,34,,2979.76,percent of total billed charges,Implant Device,2979.76,34,,2979.76,percent of total billed charges,Implant Device,2979.76,34,,2979.76,percent of total billed charges,Implant Device,2979.76,34,,2979.76,percent of total billed charges,Implant Device,2979.76,34,,2979.76,percent of total billed charges,Implant Device,4338.18,,,4338.18,Other,110% of Medicare,3067.4,35,,3067.4,percent of total billed charges,Implant Device,2979.76,34,"Charges > $500, x 34%",2979.76,percent of total billed charges,Implant Device,3067.4,35,,3067.4,percent of total billed charges,Implant Device,3067.4,35,,3067.4,percent of total billed charges,Implant Device,3067.4,35,,3067.4,percent of total billed charges,Implant Device,3067.4,35,,3067.4,percent of total billed charges,Implant Device,3067.4,35,,3067.4,percent of total billed charges,Implant Device,3505.6,40,,3505.6,percent of total billed charges,Implant Device,3067.4,70,,3067.4,percent of total billed charges,All Other,2979.76,34,,2979.76,percent of total billed charges,Implant Device,2979.76,34,,2979.76,percent of total billed charges,Implant Device,3067.4,35,,3067.4,percent of total billed charges,Implant Device,3067.4,35,,3067.4,percent of total billed charges,Implant Device,3067.4,35,,3067.4,percent of total billed charges,Implant Device,3067.4,35,,3067.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2979.76,34,"If Charge > 2,000, then 34 percent",2979.76,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,6485.38,
SOLANA FFS-1515 FUSEFORCE IMPLNT 15X15MM,C1713,HCPCS,,79005377,CDM,278,RC,,,both,,,5508,4075.93,,,4075.93,Other,150% of Medicare + 9.63% HCRA Surcharge,2478.6,45,,2478.6,percent of total billed charges,Critical Access Hospital RCC factor,1872.72,34,,1872.72,percent of total billed charges,Implant Device,1872.72,34,,1872.72,percent of total billed charges,Implant Device,1872.72,34,,1872.72,percent of total billed charges,Implant Device,1872.72,34,,1872.72,percent of total billed charges,Implant Device,1872.72,34,,1872.72,percent of total billed charges,Implant Device,2726.46,,,2726.46,Other,110% of Medicare,1927.8,35,,1927.8,percent of total billed charges,Implant Device,1872.72,34,"Charges > $500, x 34%",1872.72,percent of total billed charges,Implant Device,1927.8,35,,1927.8,percent of total billed charges,Implant Device,1927.8,35,,1927.8,percent of total billed charges,Implant Device,1927.8,35,,1927.8,percent of total billed charges,Implant Device,1927.8,35,,1927.8,percent of total billed charges,Implant Device,1927.8,35,,1927.8,percent of total billed charges,Implant Device,2203.2,40,,2203.2,percent of total billed charges,Implant Device,1927.8,70,,1927.8,percent of total billed charges,All Other,1872.72,34,,1872.72,percent of total billed charges,Implant Device,1872.72,34,,1872.72,percent of total billed charges,Implant Device,1927.8,35,,1927.8,percent of total billed charges,Implant Device,1927.8,35,,1927.8,percent of total billed charges,Implant Device,1927.8,35,,1927.8,percent of total billed charges,Implant Device,1927.8,35,,1927.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1872.72,34,"If Charge > 2,000, then 34 percent",1872.72,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4075.93,
BIOMET 14-522357 MAKAM PLATE 57MM,C1713,HCPCS,,79005378,CDM,278,RC,,,both,,,7447,5510.8,,,5510.8,Other,150% of Medicare + 9.63% HCRA Surcharge,3351.15,45,,3351.15,percent of total billed charges,Critical Access Hospital RCC factor,2531.98,34,,2531.98,percent of total billed charges,Implant Device,2531.98,34,,2531.98,percent of total billed charges,Implant Device,2531.98,34,,2531.98,percent of total billed charges,Implant Device,2531.98,34,,2531.98,percent of total billed charges,Implant Device,2531.98,34,,2531.98,percent of total billed charges,Implant Device,3686.27,,,3686.27,Other,110% of Medicare,2606.45,35,,2606.45,percent of total billed charges,Implant Device,2531.98,34,"Charges > $500, x 34%",2531.98,percent of total billed charges,Implant Device,2606.45,35,,2606.45,percent of total billed charges,Implant Device,2606.45,35,,2606.45,percent of total billed charges,Implant Device,2606.45,35,,2606.45,percent of total billed charges,Implant Device,2606.45,35,,2606.45,percent of total billed charges,Implant Device,2606.45,35,,2606.45,percent of total billed charges,Implant Device,2978.8,40,,2978.8,percent of total billed charges,Implant Device,2606.45,70,,2606.45,percent of total billed charges,All Other,2531.98,34,,2531.98,percent of total billed charges,Implant Device,2531.98,34,,2531.98,percent of total billed charges,Implant Device,2606.45,35,,2606.45,percent of total billed charges,Implant Device,2606.45,35,,2606.45,percent of total billed charges,Implant Device,2606.45,35,,2606.45,percent of total billed charges,Implant Device,2606.45,35,,2606.45,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2531.98,34,"If Charge > 2,000, then 34 percent",2531.98,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5510.8,
ARTHREX AR-8967-1855 CANN SCREW 6.7X55MM,C1713,HCPCS,,79005380,CDM,278,RC,,,both,,,660,488.4,,,488.4,Other,150% of Medicare + 9.63% HCRA Surcharge,297,45,,297,percent of total billed charges,Critical Access Hospital RCC factor,224.4,34,,224.4,percent of total billed charges,Implant Device,224.4,34,,224.4,percent of total billed charges,Implant Device,224.4,34,,224.4,percent of total billed charges,Implant Device,224.4,34,,224.4,percent of total billed charges,Implant Device,224.4,34,,224.4,percent of total billed charges,Implant Device,326.7,,,326.7,Other,110% of Medicare,231,35,,231,percent of total billed charges,Implant Device,224.4,34,"Charges > $500, x 34%",224.4,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,264,40,,264,percent of total billed charges,Implant Device,231,70,,231,percent of total billed charges,All Other,224.4,34,,224.4,percent of total billed charges,Implant Device,224.4,34,,224.4,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,488.4,
ARTHREX AR-8952TS-04 PLATE STR 4 HOLE,C1713,HCPCS,,79005381,CDM,278,RC,,,both,,,2400,1776.01,,,1776.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1080,45,,1080,percent of total billed charges,Critical Access Hospital RCC factor,816,34,,816,percent of total billed charges,Implant Device,816,34,,816,percent of total billed charges,Implant Device,816,34,,816,percent of total billed charges,Implant Device,816,34,,816,percent of total billed charges,Implant Device,816,34,,816,percent of total billed charges,Implant Device,1188,,,1188,Other,110% of Medicare,840,35,,840,percent of total billed charges,Implant Device,816,34,"Charges > $500, x 34%",816,percent of total billed charges,Implant Device,840,35,,840,percent of total billed charges,Implant Device,840,35,,840,percent of total billed charges,Implant Device,840,35,,840,percent of total billed charges,Implant Device,840,35,,840,percent of total billed charges,Implant Device,840,35,,840,percent of total billed charges,Implant Device,960,40,,960,percent of total billed charges,Implant Device,840,70,,840,percent of total billed charges,All Other,816,34,,816,percent of total billed charges,Implant Device,816,34,,816,percent of total billed charges,Implant Device,840,35,,840,percent of total billed charges,Implant Device,840,35,,840,percent of total billed charges,Implant Device,840,35,,840,percent of total billed charges,Implant Device,840,35,,840,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,816,34,"If Charge > 2,000, then 34 percent",816,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1776.01,
ARTHREX AR-8730-16PT SCREW 3.0X16MM,C1713,HCPCS,,79005382,CDM,278,RC,,,both,,,488,361.12,,,361.12,Other,150% of Medicare + 9.63% HCRA Surcharge,219.6,45,,219.6,percent of total billed charges,Critical Access Hospital RCC factor,165.92,34,,165.92,percent of total billed charges,Implant Device,165.92,34,,165.92,percent of total billed charges,Implant Device,165.92,34,,165.92,percent of total billed charges,Implant Device,165.92,34,,165.92,percent of total billed charges,Implant Device,165.92,34,,165.92,percent of total billed charges,Implant Device,241.56,,,241.56,Other,110% of Medicare,170.8,35,,170.8,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,170.8,35,,170.8,percent of total billed charges,Implant Device,170.8,35,,170.8,percent of total billed charges,Implant Device,170.8,35,,170.8,percent of total billed charges,Implant Device,170.8,35,,170.8,percent of total billed charges,Implant Device,170.8,35,,170.8,percent of total billed charges,Implant Device,195.2,40,,195.2,percent of total billed charges,Implant Device,170.8,70,,170.8,percent of total billed charges,All Other,165.92,34,,165.92,percent of total billed charges,Implant Device,165.92,34,,165.92,percent of total billed charges,Implant Device,170.8,35,,170.8,percent of total billed charges,Implant Device,170.8,35,,170.8,percent of total billed charges,Implant Device,170.8,35,,170.8,percent of total billed charges,Implant Device,170.8,35,,170.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,361.12,
ARTHROSURFACE 8H02-4844-W ART COMP 48X44,C1776,HCPCS,,79005385,CDM,278,RC,,,both,,,16764,12405.4,,,12405.4,Other,150% of Medicare + 9.63% HCRA Surcharge,7543.8,45,,7543.8,percent of total billed charges,Critical Access Hospital RCC factor,5699.76,34,,5699.76,percent of total billed charges,Implant Device,5699.76,34,,5699.76,percent of total billed charges,Implant Device,5699.76,34,,5699.76,percent of total billed charges,Implant Device,5699.76,34,,5699.76,percent of total billed charges,Implant Device,5699.76,34,,5699.76,percent of total billed charges,Implant Device,8298.18,,,8298.18,Other,110% of Medicare,5867.4,35,,5867.4,percent of total billed charges,Implant Device,5699.76,34,"Charges > $500, x 34%",5699.76,percent of total billed charges,Implant Device,5867.4,35,,5867.4,percent of total billed charges,Implant Device,5867.4,35,,5867.4,percent of total billed charges,Implant Device,5867.4,35,,5867.4,percent of total billed charges,Implant Device,5867.4,35,,5867.4,percent of total billed charges,Implant Device,5867.4,35,,5867.4,percent of total billed charges,Implant Device,6705.6,40,,6705.6,percent of total billed charges,Implant Device,5867.4,70,,5867.4,percent of total billed charges,All Other,5699.76,34,,5699.76,percent of total billed charges,Implant Device,5699.76,34,,5699.76,percent of total billed charges,Implant Device,5867.4,35,,5867.4,percent of total billed charges,Implant Device,5867.4,35,,5867.4,percent of total billed charges,Implant Device,5867.4,35,,5867.4,percent of total billed charges,Implant Device,5867.4,35,,5867.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,5699.76,34,"If Charge > 2,000, then 34 percent",5699.76,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,12405.4,
STRYKER 40-30116 ASNIS CANN SCREW 3X16MM,C1713,HCPCS,,79005386,CDM,278,RC,,,both,,,818,605.32,,,605.32,Other,150% of Medicare + 9.63% HCRA Surcharge,368.1,45,,368.1,percent of total billed charges,Critical Access Hospital RCC factor,278.12,34,,278.12,percent of total billed charges,Implant Device,278.12,34,,278.12,percent of total billed charges,Implant Device,278.12,34,,278.12,percent of total billed charges,Implant Device,278.12,34,,278.12,percent of total billed charges,Implant Device,278.12,34,,278.12,percent of total billed charges,Implant Device,404.91,,,404.91,Other,110% of Medicare,286.3,35,,286.3,percent of total billed charges,Implant Device,278.12,34,"Charges > $500, x 34%",278.12,percent of total billed charges,Implant Device,286.3,35,,286.3,percent of total billed charges,Implant Device,286.3,35,,286.3,percent of total billed charges,Implant Device,286.3,35,,286.3,percent of total billed charges,Implant Device,286.3,35,,286.3,percent of total billed charges,Implant Device,286.3,35,,286.3,percent of total billed charges,Implant Device,327.2,40,,327.2,percent of total billed charges,Implant Device,286.3,70,,286.3,percent of total billed charges,All Other,278.12,34,,278.12,percent of total billed charges,Implant Device,278.12,34,,278.12,percent of total billed charges,Implant Device,286.3,35,,286.3,percent of total billed charges,Implant Device,286.3,35,,286.3,percent of total billed charges,Implant Device,286.3,35,,286.3,percent of total billed charges,Implant Device,286.3,35,,286.3,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,605.32,
ZIMMER 47-2484-030-50 NAIL 5X30 CORT SCR,C1713,HCPCS,,79005389,CDM,278,RC,,,both,,,665,492.1,,,492.1,Other,150% of Medicare + 9.63% HCRA Surcharge,299.25,45,,299.25,percent of total billed charges,Critical Access Hospital RCC factor,226.1,34,,226.1,percent of total billed charges,Implant Device,226.1,34,,226.1,percent of total billed charges,Implant Device,226.1,34,,226.1,percent of total billed charges,Implant Device,226.1,34,,226.1,percent of total billed charges,Implant Device,226.1,34,,226.1,percent of total billed charges,Implant Device,329.18,,,329.18,Other,110% of Medicare,232.75,35,,232.75,percent of total billed charges,Implant Device,226.1,34,"Charges > $500, x 34%",226.1,percent of total billed charges,Implant Device,232.75,35,,232.75,percent of total billed charges,Implant Device,232.75,35,,232.75,percent of total billed charges,Implant Device,232.75,35,,232.75,percent of total billed charges,Implant Device,232.75,35,,232.75,percent of total billed charges,Implant Device,232.75,35,,232.75,percent of total billed charges,Implant Device,266,40,,266,percent of total billed charges,Implant Device,232.75,70,,232.75,percent of total billed charges,All Other,226.1,34,,226.1,percent of total billed charges,Implant Device,226.1,34,,226.1,percent of total billed charges,Implant Device,232.75,35,,232.75,percent of total billed charges,Implant Device,232.75,35,,232.75,percent of total billed charges,Implant Device,232.75,35,,232.75,percent of total billed charges,Implant Device,232.75,35,,232.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,492.1,
EV3 PRB35-08-030-120 PROTEGE STENT,C1876,HCPCS,,79005391,CDM,278,RC,,,both,,,3900,2886.01,,,2886.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1755,45,,1755,percent of total billed charges,Critical Access Hospital RCC factor,1326,34,,1326,percent of total billed charges,Implant Device,1326,34,,1326,percent of total billed charges,Implant Device,1326,34,,1326,percent of total billed charges,Implant Device,1326,34,,1326,percent of total billed charges,Implant Device,1326,34,,1326,percent of total billed charges,Implant Device,1930.5,,,1930.5,Other,110% of Medicare,1365,35,,1365,percent of total billed charges,Implant Device,1326,34,"Charges > $500, x 34%",1326,percent of total billed charges,Implant Device,1365,35,,1365,percent of total billed charges,Implant Device,1365,35,,1365,percent of total billed charges,Implant Device,1365,35,,1365,percent of total billed charges,Implant Device,1365,35,,1365,percent of total billed charges,Implant Device,1365,35,,1365,percent of total billed charges,Implant Device,1560,40,,1560,percent of total billed charges,Implant Device,1365,70,,1365,percent of total billed charges,All Other,1326,34,,1326,percent of total billed charges,Implant Device,1326,34,,1326,percent of total billed charges,Implant Device,1365,35,,1365,percent of total billed charges,Implant Device,1365,35,,1365,percent of total billed charges,Implant Device,1365,35,,1365,percent of total billed charges,Implant Device,1365,35,,1365,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1326,34,"If Charge > 2,000, then 34 percent",1326,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2886.01,
EV3 PXB35-06-37-080 VISI-PRO STENT,C1876,HCPCS,,79005417,CDM,278,RC,,,both,,,1950,1443,,,1443,Other,150% of Medicare + 9.63% HCRA Surcharge,877.5,45,,877.5,percent of total billed charges,Critical Access Hospital RCC factor,663,34,,663,percent of total billed charges,Implant Device,663,34,,663,percent of total billed charges,Implant Device,663,34,,663,percent of total billed charges,Implant Device,663,34,,663,percent of total billed charges,Implant Device,663,34,,663,percent of total billed charges,Implant Device,965.25,,,965.25,Other,110% of Medicare,682.5,35,,682.5,percent of total billed charges,Implant Device,663,34,"Charges > $500, x 34%",663,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,780,40,,780,percent of total billed charges,Implant Device,682.5,70,,682.5,percent of total billed charges,All Other,663,34,,663,percent of total billed charges,Implant Device,663,34,,663,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1443,
EV3 PXB35-07-27-135 VISI-PRO STENT,C1876,HCPCS,,79005418,CDM,278,RC,,,both,,,3119,2308.07,,,2308.07,Other,150% of Medicare + 9.63% HCRA Surcharge,1403.55,45,,1403.55,percent of total billed charges,Critical Access Hospital RCC factor,1060.46,34,,1060.46,percent of total billed charges,Implant Device,1060.46,34,,1060.46,percent of total billed charges,Implant Device,1060.46,34,,1060.46,percent of total billed charges,Implant Device,1060.46,34,,1060.46,percent of total billed charges,Implant Device,1060.46,34,,1060.46,percent of total billed charges,Implant Device,1543.91,,,1543.91,Other,110% of Medicare,1091.65,35,,1091.65,percent of total billed charges,Implant Device,1060.46,34,"Charges > $500, x 34%",1060.46,percent of total billed charges,Implant Device,1091.65,35,,1091.65,percent of total billed charges,Implant Device,1091.65,35,,1091.65,percent of total billed charges,Implant Device,1091.65,35,,1091.65,percent of total billed charges,Implant Device,1091.65,35,,1091.65,percent of total billed charges,Implant Device,1091.65,35,,1091.65,percent of total billed charges,Implant Device,1247.6,40,,1247.6,percent of total billed charges,Implant Device,1091.65,70,,1091.65,percent of total billed charges,All Other,1060.46,34,,1060.46,percent of total billed charges,Implant Device,1060.46,34,,1060.46,percent of total billed charges,Implant Device,1091.65,35,,1091.65,percent of total billed charges,Implant Device,1091.65,35,,1091.65,percent of total billed charges,Implant Device,1091.65,35,,1091.65,percent of total billed charges,Implant Device,1091.65,35,,1091.65,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1060.46,34,"If Charge > 2,000, then 34 percent",1060.46,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2308.07,
EV3 PXB35-07-37-80 VISI-PRO STENT,C1876,HCPCS,,79005419,CDM,278,RC,,,both,,,3119,2308.07,,,2308.07,Other,150% of Medicare + 9.63% HCRA Surcharge,1403.55,45,,1403.55,percent of total billed charges,Critical Access Hospital RCC factor,1060.46,34,,1060.46,percent of total billed charges,Implant Device,1060.46,34,,1060.46,percent of total billed charges,Implant Device,1060.46,34,,1060.46,percent of total billed charges,Implant Device,1060.46,34,,1060.46,percent of total billed charges,Implant Device,1060.46,34,,1060.46,percent of total billed charges,Implant Device,1543.91,,,1543.91,Other,110% of Medicare,1091.65,35,,1091.65,percent of total billed charges,Implant Device,1060.46,34,"Charges > $500, x 34%",1060.46,percent of total billed charges,Implant Device,1091.65,35,,1091.65,percent of total billed charges,Implant Device,1091.65,35,,1091.65,percent of total billed charges,Implant Device,1091.65,35,,1091.65,percent of total billed charges,Implant Device,1091.65,35,,1091.65,percent of total billed charges,Implant Device,1091.65,35,,1091.65,percent of total billed charges,Implant Device,1247.6,40,,1247.6,percent of total billed charges,Implant Device,1091.65,70,,1091.65,percent of total billed charges,All Other,1060.46,34,,1060.46,percent of total billed charges,Implant Device,1060.46,34,,1060.46,percent of total billed charges,Implant Device,1091.65,35,,1091.65,percent of total billed charges,Implant Device,1091.65,35,,1091.65,percent of total billed charges,Implant Device,1091.65,35,,1091.65,percent of total billed charges,Implant Device,1091.65,35,,1091.65,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1060.46,34,"If Charge > 2,000, then 34 percent",1060.46,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2308.07,
EV3 PXB35-07-37-135 VISI-PRO STENT,C1876,HCPCS,,79005420,CDM,278,RC,,,both,,,1950,1443,,,1443,Other,150% of Medicare + 9.63% HCRA Surcharge,877.5,45,,877.5,percent of total billed charges,Critical Access Hospital RCC factor,663,34,,663,percent of total billed charges,Implant Device,663,34,,663,percent of total billed charges,Implant Device,663,34,,663,percent of total billed charges,Implant Device,663,34,,663,percent of total billed charges,Implant Device,663,34,,663,percent of total billed charges,Implant Device,965.25,,,965.25,Other,110% of Medicare,682.5,35,,682.5,percent of total billed charges,Implant Device,663,34,"Charges > $500, x 34%",663,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,780,40,,780,percent of total billed charges,Implant Device,682.5,70,,682.5,percent of total billed charges,All Other,663,34,,663,percent of total billed charges,Implant Device,663,34,,663,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1443,
EV3 PXB35-08-37-080 VISI-PRO STENT,C1876,HCPCS,,79005421,CDM,278,RC,,,both,,,3119,2308.07,,,2308.07,Other,150% of Medicare + 9.63% HCRA Surcharge,1403.55,45,,1403.55,percent of total billed charges,Critical Access Hospital RCC factor,1060.46,34,,1060.46,percent of total billed charges,Implant Device,1060.46,34,,1060.46,percent of total billed charges,Implant Device,1060.46,34,,1060.46,percent of total billed charges,Implant Device,1060.46,34,,1060.46,percent of total billed charges,Implant Device,1060.46,34,,1060.46,percent of total billed charges,Implant Device,1543.91,,,1543.91,Other,110% of Medicare,1091.65,35,,1091.65,percent of total billed charges,Implant Device,1060.46,34,"Charges > $500, x 34%",1060.46,percent of total billed charges,Implant Device,1091.65,35,,1091.65,percent of total billed charges,Implant Device,1091.65,35,,1091.65,percent of total billed charges,Implant Device,1091.65,35,,1091.65,percent of total billed charges,Implant Device,1091.65,35,,1091.65,percent of total billed charges,Implant Device,1091.65,35,,1091.65,percent of total billed charges,Implant Device,1247.6,40,,1247.6,percent of total billed charges,Implant Device,1091.65,70,,1091.65,percent of total billed charges,All Other,1060.46,34,,1060.46,percent of total billed charges,Implant Device,1060.46,34,,1060.46,percent of total billed charges,Implant Device,1091.65,35,,1091.65,percent of total billed charges,Implant Device,1091.65,35,,1091.65,percent of total billed charges,Implant Device,1091.65,35,,1091.65,percent of total billed charges,Implant Device,1091.65,35,,1091.65,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1060.46,34,"If Charge > 2,000, then 34 percent",1060.46,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2308.07,
EV3 PXB35-08-57-080 VISI-PRO STENT,C1876,HCPCS,,79005422,CDM,278,RC,,,both,,,3119,2308.07,,,2308.07,Other,150% of Medicare + 9.63% HCRA Surcharge,1403.55,45,,1403.55,percent of total billed charges,Critical Access Hospital RCC factor,1060.46,34,,1060.46,percent of total billed charges,Implant Device,1060.46,34,,1060.46,percent of total billed charges,Implant Device,1060.46,34,,1060.46,percent of total billed charges,Implant Device,1060.46,34,,1060.46,percent of total billed charges,Implant Device,1060.46,34,,1060.46,percent of total billed charges,Implant Device,1543.91,,,1543.91,Other,110% of Medicare,1091.65,35,,1091.65,percent of total billed charges,Implant Device,1060.46,34,"Charges > $500, x 34%",1060.46,percent of total billed charges,Implant Device,1091.65,35,,1091.65,percent of total billed charges,Implant Device,1091.65,35,,1091.65,percent of total billed charges,Implant Device,1091.65,35,,1091.65,percent of total billed charges,Implant Device,1091.65,35,,1091.65,percent of total billed charges,Implant Device,1091.65,35,,1091.65,percent of total billed charges,Implant Device,1247.6,40,,1247.6,percent of total billed charges,Implant Device,1091.65,70,,1091.65,percent of total billed charges,All Other,1060.46,34,,1060.46,percent of total billed charges,Implant Device,1060.46,34,,1060.46,percent of total billed charges,Implant Device,1091.65,35,,1091.65,percent of total billed charges,Implant Device,1091.65,35,,1091.65,percent of total billed charges,Implant Device,1091.65,35,,1091.65,percent of total billed charges,Implant Device,1091.65,35,,1091.65,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1060.46,34,"If Charge > 2,000, then 34 percent",1060.46,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2308.07,
EV3 SERB65-09-30-80 PROTEGE STENT,C1876,HCPCS,,79005423,CDM,278,RC,,,both,,,1950,1443,,,1443,Other,150% of Medicare + 9.63% HCRA Surcharge,877.5,45,,877.5,percent of total billed charges,Critical Access Hospital RCC factor,663,34,,663,percent of total billed charges,Implant Device,663,34,,663,percent of total billed charges,Implant Device,663,34,,663,percent of total billed charges,Implant Device,663,34,,663,percent of total billed charges,Implant Device,663,34,,663,percent of total billed charges,Implant Device,965.25,,,965.25,Other,110% of Medicare,682.5,35,,682.5,percent of total billed charges,Implant Device,663,34,"Charges > $500, x 34%",663,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,780,40,,780,percent of total billed charges,Implant Device,682.5,70,,682.5,percent of total billed charges,All Other,663,34,,663,percent of total billed charges,Implant Device,663,34,,663,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1443,
EV3 PRB35-07-030-080 EVERFLEX STENT,C1876,HCPCS,,79005424,CDM,278,RC,,,both,,,3975,2941.51,,,2941.51,Other,150% of Medicare + 9.63% HCRA Surcharge,1788.75,45,,1788.75,percent of total billed charges,Critical Access Hospital RCC factor,1351.5,34,,1351.5,percent of total billed charges,Implant Device,1351.5,34,,1351.5,percent of total billed charges,Implant Device,1351.5,34,,1351.5,percent of total billed charges,Implant Device,1351.5,34,,1351.5,percent of total billed charges,Implant Device,1351.5,34,,1351.5,percent of total billed charges,Implant Device,1967.63,,,1967.63,Other,110% of Medicare,1391.25,35,,1391.25,percent of total billed charges,Implant Device,1351.5,34,"Charges > $500, x 34%",1351.5,percent of total billed charges,Implant Device,1391.25,35,,1391.25,percent of total billed charges,Implant Device,1391.25,35,,1391.25,percent of total billed charges,Implant Device,1391.25,35,,1391.25,percent of total billed charges,Implant Device,1391.25,35,,1391.25,percent of total billed charges,Implant Device,1391.25,35,,1391.25,percent of total billed charges,Implant Device,1590,40,,1590,percent of total billed charges,Implant Device,1391.25,70,,1391.25,percent of total billed charges,All Other,1351.5,34,,1351.5,percent of total billed charges,Implant Device,1351.5,34,,1351.5,percent of total billed charges,Implant Device,1391.25,35,,1391.25,percent of total billed charges,Implant Device,1391.25,35,,1391.25,percent of total billed charges,Implant Device,1391.25,35,,1391.25,percent of total billed charges,Implant Device,1391.25,35,,1391.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1351.5,34,"If Charge > 2,000, then 34 percent",1351.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2941.51,
EV3 PRB35-06060-080 EVERFLEX STENT,C1876,HCPCS,,79005425,CDM,278,RC,,,both,,,1950,1443,,,1443,Other,150% of Medicare + 9.63% HCRA Surcharge,877.5,45,,877.5,percent of total billed charges,Critical Access Hospital RCC factor,663,34,,663,percent of total billed charges,Implant Device,663,34,,663,percent of total billed charges,Implant Device,663,34,,663,percent of total billed charges,Implant Device,663,34,,663,percent of total billed charges,Implant Device,663,34,,663,percent of total billed charges,Implant Device,965.25,,,965.25,Other,110% of Medicare,682.5,35,,682.5,percent of total billed charges,Implant Device,663,34,"Charges > $500, x 34%",663,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,780,40,,780,percent of total billed charges,Implant Device,682.5,70,,682.5,percent of total billed charges,All Other,663,34,,663,percent of total billed charges,Implant Device,663,34,,663,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1443,
EV3 PRB35-06-040-080 EVERFLEX STENT,C1876,HCPCS,,79005426,CDM,278,RC,,,both,,,3975,2941.51,,,2941.51,Other,150% of Medicare + 9.63% HCRA Surcharge,1788.75,45,,1788.75,percent of total billed charges,Critical Access Hospital RCC factor,1351.5,34,,1351.5,percent of total billed charges,Implant Device,1351.5,34,,1351.5,percent of total billed charges,Implant Device,1351.5,34,,1351.5,percent of total billed charges,Implant Device,1351.5,34,,1351.5,percent of total billed charges,Implant Device,1351.5,34,,1351.5,percent of total billed charges,Implant Device,1967.63,,,1967.63,Other,110% of Medicare,1391.25,35,,1391.25,percent of total billed charges,Implant Device,1351.5,34,"Charges > $500, x 34%",1351.5,percent of total billed charges,Implant Device,1391.25,35,,1391.25,percent of total billed charges,Implant Device,1391.25,35,,1391.25,percent of total billed charges,Implant Device,1391.25,35,,1391.25,percent of total billed charges,Implant Device,1391.25,35,,1391.25,percent of total billed charges,Implant Device,1391.25,35,,1391.25,percent of total billed charges,Implant Device,1590,40,,1590,percent of total billed charges,Implant Device,1391.25,70,,1391.25,percent of total billed charges,All Other,1351.5,34,,1351.5,percent of total billed charges,Implant Device,1351.5,34,,1351.5,percent of total billed charges,Implant Device,1391.25,35,,1391.25,percent of total billed charges,Implant Device,1391.25,35,,1391.25,percent of total billed charges,Implant Device,1391.25,35,,1391.25,percent of total billed charges,Implant Device,1391.25,35,,1391.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1351.5,34,"If Charge > 2,000, then 34 percent",1351.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2941.51,
EV3 PRB35-06-030-080 EVERFLEX STENT,C1876,HCPCS,,79005427,CDM,278,RC,,,both,,,1950,1443,,,1443,Other,150% of Medicare + 9.63% HCRA Surcharge,877.5,45,,877.5,percent of total billed charges,Critical Access Hospital RCC factor,663,34,,663,percent of total billed charges,Implant Device,663,34,,663,percent of total billed charges,Implant Device,663,34,,663,percent of total billed charges,Implant Device,663,34,,663,percent of total billed charges,Implant Device,663,34,,663,percent of total billed charges,Implant Device,965.25,,,965.25,Other,110% of Medicare,682.5,35,,682.5,percent of total billed charges,Implant Device,663,34,"Charges > $500, x 34%",663,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,780,40,,780,percent of total billed charges,Implant Device,682.5,70,,682.5,percent of total billed charges,All Other,663,34,,663,percent of total billed charges,Implant Device,663,34,,663,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1443,
EV3 PRB35-08-060-120 EVERFLEX STENT,C1876,HCPCS,,79005428,CDM,278,RC,,,both,,,3975,2941.51,,,2941.51,Other,150% of Medicare + 9.63% HCRA Surcharge,1788.75,45,,1788.75,percent of total billed charges,Critical Access Hospital RCC factor,1351.5,34,,1351.5,percent of total billed charges,Implant Device,1351.5,34,,1351.5,percent of total billed charges,Implant Device,1351.5,34,,1351.5,percent of total billed charges,Implant Device,1351.5,34,,1351.5,percent of total billed charges,Implant Device,1351.5,34,,1351.5,percent of total billed charges,Implant Device,1967.63,,,1967.63,Other,110% of Medicare,1391.25,35,,1391.25,percent of total billed charges,Implant Device,1351.5,34,"Charges > $500, x 34%",1351.5,percent of total billed charges,Implant Device,1391.25,35,,1391.25,percent of total billed charges,Implant Device,1391.25,35,,1391.25,percent of total billed charges,Implant Device,1391.25,35,,1391.25,percent of total billed charges,Implant Device,1391.25,35,,1391.25,percent of total billed charges,Implant Device,1391.25,35,,1391.25,percent of total billed charges,Implant Device,1590,40,,1590,percent of total billed charges,Implant Device,1391.25,70,,1391.25,percent of total billed charges,All Other,1351.5,34,,1351.5,percent of total billed charges,Implant Device,1351.5,34,,1351.5,percent of total billed charges,Implant Device,1391.25,35,,1391.25,percent of total billed charges,Implant Device,1391.25,35,,1391.25,percent of total billed charges,Implant Device,1391.25,35,,1391.25,percent of total billed charges,Implant Device,1391.25,35,,1391.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1351.5,34,"If Charge > 2,000, then 34 percent",1351.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2941.51,
EV3 PRB35-07-040-120 EVERFLEX STENT,C1876,HCPCS,,79005429,CDM,278,RC,,,both,,,1950,1443,,,1443,Other,150% of Medicare + 9.63% HCRA Surcharge,877.5,45,,877.5,percent of total billed charges,Critical Access Hospital RCC factor,663,34,,663,percent of total billed charges,Implant Device,663,34,,663,percent of total billed charges,Implant Device,663,34,,663,percent of total billed charges,Implant Device,663,34,,663,percent of total billed charges,Implant Device,663,34,,663,percent of total billed charges,Implant Device,965.25,,,965.25,Other,110% of Medicare,682.5,35,,682.5,percent of total billed charges,Implant Device,663,34,"Charges > $500, x 34%",663,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,780,40,,780,percent of total billed charges,Implant Device,682.5,70,,682.5,percent of total billed charges,All Other,663,34,,663,percent of total billed charges,Implant Device,663,34,,663,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1443,
EV3 PRB35-07-080-120 EVERFLEX STENT,C1876,HCPCS,,79005430,CDM,278,RC,,,both,,,3975,2941.51,,,2941.51,Other,150% of Medicare + 9.63% HCRA Surcharge,1788.75,45,,1788.75,percent of total billed charges,Critical Access Hospital RCC factor,1351.5,34,,1351.5,percent of total billed charges,Implant Device,1351.5,34,,1351.5,percent of total billed charges,Implant Device,1351.5,34,,1351.5,percent of total billed charges,Implant Device,1351.5,34,,1351.5,percent of total billed charges,Implant Device,1351.5,34,,1351.5,percent of total billed charges,Implant Device,1967.63,,,1967.63,Other,110% of Medicare,1391.25,35,,1391.25,percent of total billed charges,Implant Device,1351.5,34,"Charges > $500, x 34%",1351.5,percent of total billed charges,Implant Device,1391.25,35,,1391.25,percent of total billed charges,Implant Device,1391.25,35,,1391.25,percent of total billed charges,Implant Device,1391.25,35,,1391.25,percent of total billed charges,Implant Device,1391.25,35,,1391.25,percent of total billed charges,Implant Device,1391.25,35,,1391.25,percent of total billed charges,Implant Device,1590,40,,1590,percent of total billed charges,Implant Device,1391.25,70,,1391.25,percent of total billed charges,All Other,1351.5,34,,1351.5,percent of total billed charges,Implant Device,1351.5,34,,1351.5,percent of total billed charges,Implant Device,1391.25,35,,1391.25,percent of total billed charges,Implant Device,1391.25,35,,1391.25,percent of total billed charges,Implant Device,1391.25,35,,1391.25,percent of total billed charges,Implant Device,1391.25,35,,1391.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1351.5,34,"If Charge > 2,000, then 34 percent",1351.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2941.51,
EV3 PRB35-05-120-120 EVERFLEX STENT,C1876,HCPCS,,79005431,CDM,278,RC,,,both,,,4950,3663.01,,,3663.01,Other,150% of Medicare + 9.63% HCRA Surcharge,2227.5,45,,2227.5,percent of total billed charges,Critical Access Hospital RCC factor,1683,34,,1683,percent of total billed charges,Implant Device,1683,34,,1683,percent of total billed charges,Implant Device,1683,34,,1683,percent of total billed charges,Implant Device,1683,34,,1683,percent of total billed charges,Implant Device,1683,34,,1683,percent of total billed charges,Implant Device,2450.25,,,2450.25,Other,110% of Medicare,1732.5,35,,1732.5,percent of total billed charges,Implant Device,1683,34,"Charges > $500, x 34%",1683,percent of total billed charges,Implant Device,1732.5,35,,1732.5,percent of total billed charges,Implant Device,1732.5,35,,1732.5,percent of total billed charges,Implant Device,1732.5,35,,1732.5,percent of total billed charges,Implant Device,1732.5,35,,1732.5,percent of total billed charges,Implant Device,1732.5,35,,1732.5,percent of total billed charges,Implant Device,1980,40,,1980,percent of total billed charges,Implant Device,1732.5,70,,1732.5,percent of total billed charges,All Other,1683,34,,1683,percent of total billed charges,Implant Device,1683,34,,1683,percent of total billed charges,Implant Device,1732.5,35,,1732.5,percent of total billed charges,Implant Device,1732.5,35,,1732.5,percent of total billed charges,Implant Device,1732.5,35,,1732.5,percent of total billed charges,Implant Device,1732.5,35,,1732.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1683,34,"If Charge > 2,000, then 34 percent",1683,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3663.01,
ZIMMER  00-5450-019-31 FEMORAL CONE 30MM,C1776,HCPCS,,79005434,CDM,278,RC,,,both,,,12646,9358.07,,,9358.07,Other,150% of Medicare + 9.63% HCRA Surcharge,5690.7,45,,5690.7,percent of total billed charges,Critical Access Hospital RCC factor,4299.64,34,,4299.64,percent of total billed charges,Implant Device,4299.64,34,,4299.64,percent of total billed charges,Implant Device,4299.64,34,,4299.64,percent of total billed charges,Implant Device,4299.64,34,,4299.64,percent of total billed charges,Implant Device,4299.64,34,,4299.64,percent of total billed charges,Implant Device,6259.77,,,6259.77,Other,110% of Medicare,4426.1,35,,4426.1,percent of total billed charges,Implant Device,4299.64,34,"Charges > $500, x 34%",4299.64,percent of total billed charges,Implant Device,4426.1,35,,4426.1,percent of total billed charges,Implant Device,4426.1,35,,4426.1,percent of total billed charges,Implant Device,4426.1,35,,4426.1,percent of total billed charges,Implant Device,4426.1,35,,4426.1,percent of total billed charges,Implant Device,4426.1,35,,4426.1,percent of total billed charges,Implant Device,5058.4,40,,5058.4,percent of total billed charges,Implant Device,4426.1,70,,4426.1,percent of total billed charges,All Other,4299.64,34,,4299.64,percent of total billed charges,Implant Device,4299.64,34,,4299.64,percent of total billed charges,Implant Device,4426.1,35,,4426.1,percent of total billed charges,Implant Device,4426.1,35,,4426.1,percent of total billed charges,Implant Device,4426.1,35,,4426.1,percent of total billed charges,Implant Device,4426.1,35,,4426.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,4299.64,34,"If Charge > 2,000, then 34 percent",4299.64,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,9358.07,
ZIMMER  00-5450-020-36 FEMORAL CONE 35MM,C1776,HCPCS,,79005435,CDM,278,RC,,,both,,,14400,10656.04,,,10656.04,Other,150% of Medicare + 9.63% HCRA Surcharge,6480,45,,6480,percent of total billed charges,Critical Access Hospital RCC factor,4896,34,,4896,percent of total billed charges,Implant Device,4896,34,,4896,percent of total billed charges,Implant Device,4896,34,,4896,percent of total billed charges,Implant Device,4896,34,,4896,percent of total billed charges,Implant Device,4896,34,,4896,percent of total billed charges,Implant Device,7128,,,7128,Other,110% of Medicare,5040,35,,5040,percent of total billed charges,Implant Device,4896,34,"Charges > $500, x 34%",4896,percent of total billed charges,Implant Device,5040,35,,5040,percent of total billed charges,Implant Device,5040,35,,5040,percent of total billed charges,Implant Device,5040,35,,5040,percent of total billed charges,Implant Device,5040,35,,5040,percent of total billed charges,Implant Device,5040,35,,5040,percent of total billed charges,Implant Device,5760,40,,5760,percent of total billed charges,Implant Device,5040,70,,5040,percent of total billed charges,All Other,4896,34,,4896,percent of total billed charges,Implant Device,4896,34,,4896,percent of total billed charges,Implant Device,5040,35,,5040,percent of total billed charges,Implant Device,5040,35,,5040,percent of total billed charges,Implant Device,5040,35,,5040,percent of total billed charges,Implant Device,5040,35,,5040,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,4896,34,"If Charge > 2,000, then 34 percent",4896,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,10656.04,
ZIMMER  5994-40-20 ART SURFACE 5-6 20MM,C1776,HCPCS,,79005436,CDM,278,RC,,,both,,,6773,5012.04,,,5012.04,Other,150% of Medicare + 9.63% HCRA Surcharge,3047.85,45,,3047.85,percent of total billed charges,Critical Access Hospital RCC factor,2302.82,34,,2302.82,percent of total billed charges,Implant Device,2302.82,34,,2302.82,percent of total billed charges,Implant Device,2302.82,34,,2302.82,percent of total billed charges,Implant Device,2302.82,34,,2302.82,percent of total billed charges,Implant Device,2302.82,34,,2302.82,percent of total billed charges,Implant Device,3352.64,,,3352.64,Other,110% of Medicare,2370.55,35,,2370.55,percent of total billed charges,Implant Device,2302.82,34,"Charges > $500, x 34%",2302.82,percent of total billed charges,Implant Device,2370.55,35,,2370.55,percent of total billed charges,Implant Device,2370.55,35,,2370.55,percent of total billed charges,Implant Device,2370.55,35,,2370.55,percent of total billed charges,Implant Device,2370.55,35,,2370.55,percent of total billed charges,Implant Device,2370.55,35,,2370.55,percent of total billed charges,Implant Device,2709.2,40,,2709.2,percent of total billed charges,Implant Device,2370.55,70,,2370.55,percent of total billed charges,All Other,2302.82,34,,2302.82,percent of total billed charges,Implant Device,2302.82,34,,2302.82,percent of total billed charges,Implant Device,2370.55,35,,2370.55,percent of total billed charges,Implant Device,2370.55,35,,2370.55,percent of total billed charges,Implant Device,2370.55,35,,2370.55,percent of total billed charges,Implant Device,2370.55,35,,2370.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2302.82,34,"If Charge > 2,000, then 34 percent",2302.82,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5012.04,
ZIMMER  00-5791-054-00 UNI HOLDING PIN,C1713,HCPCS,,79005437,CDM,278,RC,,,both,,,529,391.46,,,391.46,Other,150% of Medicare + 9.63% HCRA Surcharge,238.05,45,,238.05,percent of total billed charges,Critical Access Hospital RCC factor,179.86,34,,179.86,percent of total billed charges,Implant Device,179.86,34,,179.86,percent of total billed charges,Implant Device,179.86,34,,179.86,percent of total billed charges,Implant Device,179.86,34,,179.86,percent of total billed charges,Implant Device,179.86,34,,179.86,percent of total billed charges,Implant Device,261.86,,,261.86,Other,110% of Medicare,185.15,35,,185.15,percent of total billed charges,Implant Device,179.86,34,"Charges > $500, x 34%",179.86,percent of total billed charges,Implant Device,185.15,35,,185.15,percent of total billed charges,Implant Device,185.15,35,,185.15,percent of total billed charges,Implant Device,185.15,35,,185.15,percent of total billed charges,Implant Device,185.15,35,,185.15,percent of total billed charges,Implant Device,185.15,35,,185.15,percent of total billed charges,Implant Device,211.6,40,,211.6,percent of total billed charges,Implant Device,185.15,70,,185.15,percent of total billed charges,All Other,179.86,34,,179.86,percent of total billed charges,Implant Device,179.86,34,,179.86,percent of total billed charges,Implant Device,185.15,35,,185.15,percent of total billed charges,Implant Device,185.15,35,,185.15,percent of total billed charges,Implant Device,185.15,35,,185.15,percent of total billed charges,Implant Device,185.15,35,,185.15,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,391.46,
ZIMMER  00-2357-018-04 PLATE 4 HOLE 80MM,C1713,HCPCS,,79005439,CDM,278,RC,,,both,,,2020,1494.81,,,1494.81,Other,150% of Medicare + 9.63% HCRA Surcharge,909,45,,909,percent of total billed charges,Critical Access Hospital RCC factor,686.8,34,,686.8,percent of total billed charges,Implant Device,686.8,34,,686.8,percent of total billed charges,Implant Device,686.8,34,,686.8,percent of total billed charges,Implant Device,686.8,34,,686.8,percent of total billed charges,Implant Device,686.8,34,,686.8,percent of total billed charges,Implant Device,999.9,,,999.9,Other,110% of Medicare,707,35,,707,percent of total billed charges,Implant Device,686.8,34,"Charges > $500, x 34%",686.8,percent of total billed charges,Implant Device,707,35,,707,percent of total billed charges,Implant Device,707,35,,707,percent of total billed charges,Implant Device,707,35,,707,percent of total billed charges,Implant Device,707,35,,707,percent of total billed charges,Implant Device,707,35,,707,percent of total billed charges,Implant Device,808,40,,808,percent of total billed charges,Implant Device,707,70,,707,percent of total billed charges,All Other,686.8,34,,686.8,percent of total billed charges,Implant Device,686.8,34,,686.8,percent of total billed charges,Implant Device,707,35,,707,percent of total billed charges,Implant Device,707,35,,707,percent of total billed charges,Implant Device,707,35,,707,percent of total billed charges,Implant Device,707,35,,707,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,686.8,34,"If Charge > 2,000, then 34 percent",686.8,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1494.81,
EV3 PRB35-08-040-120 EVERFLEX STENT,C1876,HCPCS,,79005443,CDM,278,RC,,,both,,,1950,1443,,,1443,Other,150% of Medicare + 9.63% HCRA Surcharge,877.5,45,,877.5,percent of total billed charges,Critical Access Hospital RCC factor,663,34,,663,percent of total billed charges,Implant Device,663,34,,663,percent of total billed charges,Implant Device,663,34,,663,percent of total billed charges,Implant Device,663,34,,663,percent of total billed charges,Implant Device,663,34,,663,percent of total billed charges,Implant Device,965.25,,,965.25,Other,110% of Medicare,682.5,35,,682.5,percent of total billed charges,Implant Device,663,34,"Charges > $500, x 34%",663,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,780,40,,780,percent of total billed charges,Implant Device,682.5,70,,682.5,percent of total billed charges,All Other,663,34,,663,percent of total billed charges,Implant Device,663,34,,663,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1443,
EV3 PMB8-5-18-80 PARAMOUNT MIN GPS STENT,C1876,HCPCS,,79005444,CDM,278,RC,,,both,,,1950,1443,,,1443,Other,150% of Medicare + 9.63% HCRA Surcharge,877.5,45,,877.5,percent of total billed charges,Critical Access Hospital RCC factor,663,34,,663,percent of total billed charges,Implant Device,663,34,,663,percent of total billed charges,Implant Device,663,34,,663,percent of total billed charges,Implant Device,663,34,,663,percent of total billed charges,Implant Device,663,34,,663,percent of total billed charges,Implant Device,965.25,,,965.25,Other,110% of Medicare,682.5,35,,682.5,percent of total billed charges,Implant Device,663,34,"Charges > $500, x 34%",663,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,780,40,,780,percent of total billed charges,Implant Device,682.5,70,,682.5,percent of total billed charges,All Other,663,34,,663,percent of total billed charges,Implant Device,663,34,,663,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1443,
EV3 PMB8-6-18-80 PARAMOUNT MIN GPS STENT,C1876,HCPCS,,79005445,CDM,278,RC,,,both,,,1950,1443,,,1443,Other,150% of Medicare + 9.63% HCRA Surcharge,877.5,45,,877.5,percent of total billed charges,Critical Access Hospital RCC factor,663,34,,663,percent of total billed charges,Implant Device,663,34,,663,percent of total billed charges,Implant Device,663,34,,663,percent of total billed charges,Implant Device,663,34,,663,percent of total billed charges,Implant Device,663,34,,663,percent of total billed charges,Implant Device,965.25,,,965.25,Other,110% of Medicare,682.5,35,,682.5,percent of total billed charges,Implant Device,663,34,"Charges > $500, x 34%",663,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,780,40,,780,percent of total billed charges,Implant Device,682.5,70,,682.5,percent of total billed charges,All Other,663,34,,663,percent of total billed charges,Implant Device,663,34,,663,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1443,
EV3 PMB8-7-18-80 PARAMOUNT MIN GPS STENT,C1876,HCPCS,,79005446,CDM,278,RC,,,both,,,1950,1443,,,1443,Other,150% of Medicare + 9.63% HCRA Surcharge,877.5,45,,877.5,percent of total billed charges,Critical Access Hospital RCC factor,663,34,,663,percent of total billed charges,Implant Device,663,34,,663,percent of total billed charges,Implant Device,663,34,,663,percent of total billed charges,Implant Device,663,34,,663,percent of total billed charges,Implant Device,663,34,,663,percent of total billed charges,Implant Device,965.25,,,965.25,Other,110% of Medicare,682.5,35,,682.5,percent of total billed charges,Implant Device,663,34,"Charges > $500, x 34%",663,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,780,40,,780,percent of total billed charges,Implant Device,682.5,70,,682.5,percent of total billed charges,All Other,663,34,,663,percent of total billed charges,Implant Device,663,34,,663,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1443,
EV3 PMB8-7-21-80 PARAMOUNT MIN GPS STENT,C1876,HCPCS,,79005447,CDM,278,RC,,,both,,,1950,1443,,,1443,Other,150% of Medicare + 9.63% HCRA Surcharge,877.5,45,,877.5,percent of total billed charges,Critical Access Hospital RCC factor,663,34,,663,percent of total billed charges,Implant Device,663,34,,663,percent of total billed charges,Implant Device,663,34,,663,percent of total billed charges,Implant Device,663,34,,663,percent of total billed charges,Implant Device,663,34,,663,percent of total billed charges,Implant Device,965.25,,,965.25,Other,110% of Medicare,682.5,35,,682.5,percent of total billed charges,Implant Device,663,34,"Charges > $500, x 34%",663,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,780,40,,780,percent of total billed charges,Implant Device,682.5,70,,682.5,percent of total billed charges,All Other,663,34,,663,percent of total billed charges,Implant Device,663,34,,663,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1443,
JRF 32147002 LEFT LAT HEMI CONDYLE GRAFT,C1713,HCPCS,,79005460,CDM,278,RC,,,both,,,32850,24309.08,,,24309.08,Other,150% of Medicare + 9.63% HCRA Surcharge,14782.5,45,,14782.5,percent of total billed charges,Critical Access Hospital RCC factor,11169,34,,11169,percent of total billed charges,Implant Device,11169,34,,11169,percent of total billed charges,Implant Device,11169,34,,11169,percent of total billed charges,Implant Device,11169,34,,11169,percent of total billed charges,Implant Device,11169,34,,11169,percent of total billed charges,Implant Device,16260.75,,,16260.75,Other,110% of Medicare,11497.5,35,,11497.5,percent of total billed charges,Implant Device,11169,34,"Charges > $500, x 34%",11169,percent of total billed charges,Implant Device,11497.5,35,,11497.5,percent of total billed charges,Implant Device,11497.5,35,,11497.5,percent of total billed charges,Implant Device,11497.5,35,,11497.5,percent of total billed charges,Implant Device,11497.5,35,,11497.5,percent of total billed charges,Implant Device,11497.5,35,,11497.5,percent of total billed charges,Implant Device,13140,40,,13140,percent of total billed charges,Implant Device,11497.5,70,,11497.5,percent of total billed charges,All Other,11169,34,,11169,percent of total billed charges,Implant Device,11169,34,,11169,percent of total billed charges,Implant Device,11497.5,35,,11497.5,percent of total billed charges,Implant Device,11497.5,35,,11497.5,percent of total billed charges,Implant Device,11497.5,35,,11497.5,percent of total billed charges,Implant Device,11497.5,35,,11497.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,11169,34,"If Charge > 2,000, then 34 percent",11169,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,24309.08,
BIOMET 139247 ENDO II HEAD 48MM,C1776,HCPCS,,79005461,CDM,278,RC,,,both,,,630,466.2,,,466.2,Other,150% of Medicare + 9.63% HCRA Surcharge,283.5,45,,283.5,percent of total billed charges,Critical Access Hospital RCC factor,214.2,34,,214.2,percent of total billed charges,Implant Device,214.2,34,,214.2,percent of total billed charges,Implant Device,214.2,34,,214.2,percent of total billed charges,Implant Device,214.2,34,,214.2,percent of total billed charges,Implant Device,214.2,34,,214.2,percent of total billed charges,Implant Device,311.85,,,311.85,Other,110% of Medicare,220.5,35,,220.5,percent of total billed charges,Implant Device,214.2,34,"Charges > $500, x 34%",214.2,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,252,40,,252,percent of total billed charges,Implant Device,220.5,70,,220.5,percent of total billed charges,All Other,214.2,34,,214.2,percent of total billed charges,Implant Device,214.2,34,,214.2,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,466.2,
BIOMET 12-139020 ENDO II HEAD 48MM,C1776,HCPCS,,79005462,CDM,278,RC,,,both,,,2280,1687.21,,,1687.21,Other,150% of Medicare + 9.63% HCRA Surcharge,1026,45,,1026,percent of total billed charges,Critical Access Hospital RCC factor,775.2,34,,775.2,percent of total billed charges,Implant Device,775.2,34,,775.2,percent of total billed charges,Implant Device,775.2,34,,775.2,percent of total billed charges,Implant Device,775.2,34,,775.2,percent of total billed charges,Implant Device,775.2,34,,775.2,percent of total billed charges,Implant Device,1128.6,,,1128.6,Other,110% of Medicare,798,35,,798,percent of total billed charges,Implant Device,775.2,34,"Charges > $500, x 34%",775.2,percent of total billed charges,Implant Device,798,35,,798,percent of total billed charges,Implant Device,798,35,,798,percent of total billed charges,Implant Device,798,35,,798,percent of total billed charges,Implant Device,798,35,,798,percent of total billed charges,Implant Device,798,35,,798,percent of total billed charges,Implant Device,912,40,,912,percent of total billed charges,Implant Device,798,70,,798,percent of total billed charges,All Other,775.2,34,,775.2,percent of total billed charges,Implant Device,775.2,34,,775.2,percent of total billed charges,Implant Device,798,35,,798,percent of total billed charges,Implant Device,798,35,,798,percent of total billed charges,Implant Device,798,35,,798,percent of total billed charges,Implant Device,798,35,,798,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,775.2,34,"If Charge > 2,000, then 34 percent",775.2,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1687.21,
STRYKER 1896-5045S LOCK SCREW 5X45MM FT,C1713,HCPCS,,79005466,CDM,278,RC,,,both,,,355,262.7,,,262.7,Other,150% of Medicare + 9.63% HCRA Surcharge,159.75,45,,159.75,percent of total billed charges,Critical Access Hospital RCC factor,120.7,34,,120.7,percent of total billed charges,Implant Device,120.7,34,,120.7,percent of total billed charges,Implant Device,120.7,34,,120.7,percent of total billed charges,Implant Device,120.7,34,,120.7,percent of total billed charges,Implant Device,120.7,34,,120.7,percent of total billed charges,Implant Device,175.73,,,175.73,Other,110% of Medicare,124.25,35,,124.25,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,124.25,35,,124.25,percent of total billed charges,Implant Device,124.25,35,,124.25,percent of total billed charges,Implant Device,124.25,35,,124.25,percent of total billed charges,Implant Device,124.25,35,,124.25,percent of total billed charges,Implant Device,124.25,35,,124.25,percent of total billed charges,Implant Device,142,40,,142,percent of total billed charges,Implant Device,124.25,70,,124.25,percent of total billed charges,All Other,120.7,34,,120.7,percent of total billed charges,Implant Device,120.7,34,,120.7,percent of total billed charges,Implant Device,124.25,35,,124.25,percent of total billed charges,Implant Device,124.25,35,,124.25,percent of total billed charges,Implant Device,124.25,35,,124.25,percent of total billed charges,Implant Device,124.25,35,,124.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,262.7,
STRYKER 1822-1233S TIBIAL NAIL 12X30MM,C1713,HCPCS,,79005467,CDM,278,RC,,,both,,,5819,4306.07,,,4306.07,Other,150% of Medicare + 9.63% HCRA Surcharge,2618.55,45,,2618.55,percent of total billed charges,Critical Access Hospital RCC factor,1978.46,34,,1978.46,percent of total billed charges,Implant Device,1978.46,34,,1978.46,percent of total billed charges,Implant Device,1978.46,34,,1978.46,percent of total billed charges,Implant Device,1978.46,34,,1978.46,percent of total billed charges,Implant Device,1978.46,34,,1978.46,percent of total billed charges,Implant Device,2880.41,,,2880.41,Other,110% of Medicare,2036.65,35,,2036.65,percent of total billed charges,Implant Device,1978.46,34,"Charges > $500, x 34%",1978.46,percent of total billed charges,Implant Device,2036.65,35,,2036.65,percent of total billed charges,Implant Device,2036.65,35,,2036.65,percent of total billed charges,Implant Device,2036.65,35,,2036.65,percent of total billed charges,Implant Device,2036.65,35,,2036.65,percent of total billed charges,Implant Device,2036.65,35,,2036.65,percent of total billed charges,Implant Device,2327.6,40,,2327.6,percent of total billed charges,Implant Device,2036.65,70,,2036.65,percent of total billed charges,All Other,1978.46,34,,1978.46,percent of total billed charges,Implant Device,1978.46,34,,1978.46,percent of total billed charges,Implant Device,2036.65,35,,2036.65,percent of total billed charges,Implant Device,2036.65,35,,2036.65,percent of total billed charges,Implant Device,2036.65,35,,2036.65,percent of total billed charges,Implant Device,2036.65,35,,2036.65,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1978.46,34,"If Charge > 2,000, then 34 percent",1978.46,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4306.07,
ATRIUM 85455 ICAST STENT GRAFT 7X22X120,C1874,HCPCS,,79005471,CDM,278,RC,,,both,,,7546,5584.06,,,5584.06,Other,150% of Medicare + 9.63% HCRA Surcharge,3395.7,45,,3395.7,percent of total billed charges,Critical Access Hospital RCC factor,2565.64,34,,2565.64,percent of total billed charges,Implant Device,2565.64,34,,2565.64,percent of total billed charges,Implant Device,2565.64,34,,2565.64,percent of total billed charges,Implant Device,2565.64,34,,2565.64,percent of total billed charges,Implant Device,2565.64,34,,2565.64,percent of total billed charges,Implant Device,3735.27,,,3735.27,Other,110% of Medicare,2641.1,35,,2641.1,percent of total billed charges,Implant Device,2565.64,34,"Charges > $500, x 34%",2565.64,percent of total billed charges,Implant Device,2641.1,35,,2641.1,percent of total billed charges,Implant Device,2641.1,35,,2641.1,percent of total billed charges,Implant Device,2641.1,35,,2641.1,percent of total billed charges,Implant Device,2641.1,35,,2641.1,percent of total billed charges,Implant Device,2641.1,35,,2641.1,percent of total billed charges,Implant Device,3018.4,40,,3018.4,percent of total billed charges,Implant Device,2641.1,70,,2641.1,percent of total billed charges,All Other,2565.64,34,,2565.64,percent of total billed charges,Implant Device,2565.64,34,,2565.64,percent of total billed charges,Implant Device,2641.1,35,,2641.1,percent of total billed charges,Implant Device,2641.1,35,,2641.1,percent of total billed charges,Implant Device,2641.1,35,,2641.1,percent of total billed charges,Implant Device,2641.1,35,,2641.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2565.64,34,"If Charge > 2,000, then 34 percent",2565.64,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5584.06,
GORE RLT351414 EXCLUDER ENDOPROS GRAFT,C1768,HCPCS,,79005472,CDM,278,RC,,,both,,,32250,23865.08,,,23865.08,Other,150% of Medicare + 9.63% HCRA Surcharge,14512.5,45,,14512.5,percent of total billed charges,Critical Access Hospital RCC factor,10965,34,,10965,percent of total billed charges,Implant Device,10965,34,,10965,percent of total billed charges,Implant Device,10965,34,,10965,percent of total billed charges,Implant Device,10965,34,,10965,percent of total billed charges,Implant Device,10965,34,,10965,percent of total billed charges,Implant Device,15963.75,,,15963.75,Other,110% of Medicare,11287.5,35,,11287.5,percent of total billed charges,Implant Device,10965,34,"Charges > $500, x 34%",10965,percent of total billed charges,Implant Device,11287.5,35,,11287.5,percent of total billed charges,Implant Device,11287.5,35,,11287.5,percent of total billed charges,Implant Device,11287.5,35,,11287.5,percent of total billed charges,Implant Device,11287.5,35,,11287.5,percent of total billed charges,Implant Device,11287.5,35,,11287.5,percent of total billed charges,Implant Device,12900,40,,12900,percent of total billed charges,Implant Device,11287.5,70,,11287.5,percent of total billed charges,All Other,10965,34,,10965,percent of total billed charges,Implant Device,10965,34,,10965,percent of total billed charges,Implant Device,11287.5,35,,11287.5,percent of total billed charges,Implant Device,11287.5,35,,11287.5,percent of total billed charges,Implant Device,11287.5,35,,11287.5,percent of total billed charges,Implant Device,11287.5,35,,11287.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,10965,34,"If Charge > 2,000, then 34 percent",10965,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,23865.08,
GORE PLC181200 EXCLUDER ENDOPROS GRAFT,C1768,HCPCS,,79005473,CDM,278,RC,,,both,,,12600,9324.03,,,9324.03,Other,150% of Medicare + 9.63% HCRA Surcharge,5670,45,,5670,percent of total billed charges,Critical Access Hospital RCC factor,4284,34,,4284,percent of total billed charges,Implant Device,4284,34,,4284,percent of total billed charges,Implant Device,4284,34,,4284,percent of total billed charges,Implant Device,4284,34,,4284,percent of total billed charges,Implant Device,4284,34,,4284,percent of total billed charges,Implant Device,6237,,,6237,Other,110% of Medicare,4410,35,,4410,percent of total billed charges,Implant Device,4284,34,"Charges > $500, x 34%",4284,percent of total billed charges,Implant Device,4410,35,,4410,percent of total billed charges,Implant Device,4410,35,,4410,percent of total billed charges,Implant Device,4410,35,,4410,percent of total billed charges,Implant Device,4410,35,,4410,percent of total billed charges,Implant Device,4410,35,,4410,percent of total billed charges,Implant Device,5040,40,,5040,percent of total billed charges,Implant Device,4410,70,,4410,percent of total billed charges,All Other,4284,34,,4284,percent of total billed charges,Implant Device,4284,34,,4284,percent of total billed charges,Implant Device,4410,35,,4410,percent of total billed charges,Implant Device,4410,35,,4410,percent of total billed charges,Implant Device,4410,35,,4410,percent of total billed charges,Implant Device,4410,35,,4410,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,4284,34,"If Charge > 2,000, then 34 percent",4284,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,9324.03,
EXACTECH 320-20-38 COMPRESSN SCREW SZ 38,C1713,HCPCS,,79005474,CDM,278,RC,,,both,,,300,222,,,222,Other,150% of Medicare + 9.63% HCRA Surcharge,135,45,,135,percent of total billed charges,Critical Access Hospital RCC factor,102,34,,102,percent of total billed charges,Implant Device,102,34,,102,percent of total billed charges,Implant Device,102,34,,102,percent of total billed charges,Implant Device,102,34,,102,percent of total billed charges,Implant Device,102,34,,102,percent of total billed charges,Implant Device,148.5,,,148.5,Other,110% of Medicare,105,35,,105,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,105,35,,105,percent of total billed charges,Implant Device,105,35,,105,percent of total billed charges,Implant Device,105,35,,105,percent of total billed charges,Implant Device,105,35,,105,percent of total billed charges,Implant Device,105,35,,105,percent of total billed charges,Implant Device,120,40,,120,percent of total billed charges,Implant Device,105,70,,105,percent of total billed charges,All Other,102,34,,102,percent of total billed charges,Implant Device,102,34,,102,percent of total billed charges,Implant Device,105,35,,105,percent of total billed charges,Implant Device,105,35,,105,percent of total billed charges,Implant Device,105,35,,105,percent of total billed charges,Implant Device,105,35,,105,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,222,
STRYKER 606670 CANNULATED SCREW 4X70,C1713,HCPCS,,79005477,CDM,278,RC,,,both,,,660,488.4,,,488.4,Other,150% of Medicare + 9.63% HCRA Surcharge,297,45,,297,percent of total billed charges,Critical Access Hospital RCC factor,224.4,34,,224.4,percent of total billed charges,Implant Device,224.4,34,,224.4,percent of total billed charges,Implant Device,224.4,34,,224.4,percent of total billed charges,Implant Device,224.4,34,,224.4,percent of total billed charges,Implant Device,224.4,34,,224.4,percent of total billed charges,Implant Device,326.7,,,326.7,Other,110% of Medicare,231,35,,231,percent of total billed charges,Implant Device,224.4,34,"Charges > $500, x 34%",224.4,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,264,40,,264,percent of total billed charges,Implant Device,231,70,,231,percent of total billed charges,All Other,224.4,34,,224.4,percent of total billed charges,Implant Device,224.4,34,,224.4,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,488.4,
STABILITY BIOLOGICS 904 GRACILIS TENDON,C1713,HCPCS,,79005478,CDM,278,RC,,,both,,,5326,3941.25,,,3941.25,Other,150% of Medicare + 9.63% HCRA Surcharge,2396.7,45,,2396.7,percent of total billed charges,Critical Access Hospital RCC factor,1810.84,34,,1810.84,percent of total billed charges,Implant Device,1810.84,34,,1810.84,percent of total billed charges,Implant Device,1810.84,34,,1810.84,percent of total billed charges,Implant Device,1810.84,34,,1810.84,percent of total billed charges,Implant Device,1810.84,34,,1810.84,percent of total billed charges,Implant Device,2636.37,,,2636.37,Other,110% of Medicare,1864.1,35,,1864.1,percent of total billed charges,Implant Device,1810.84,34,"Charges > $500, x 34%",1810.84,percent of total billed charges,Implant Device,1864.1,35,,1864.1,percent of total billed charges,Implant Device,1864.1,35,,1864.1,percent of total billed charges,Implant Device,1864.1,35,,1864.1,percent of total billed charges,Implant Device,1864.1,35,,1864.1,percent of total billed charges,Implant Device,1864.1,35,,1864.1,percent of total billed charges,Implant Device,2130.4,40,,2130.4,percent of total billed charges,Implant Device,1864.1,70,,1864.1,percent of total billed charges,All Other,1810.84,34,,1810.84,percent of total billed charges,Implant Device,1810.84,34,,1810.84,percent of total billed charges,Implant Device,1864.1,35,,1864.1,percent of total billed charges,Implant Device,1864.1,35,,1864.1,percent of total billed charges,Implant Device,1864.1,35,,1864.1,percent of total billed charges,Implant Device,1864.1,35,,1864.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1810.84,34,"If Charge > 2,000, then 34 percent",1810.84,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3941.25,
STRYKER 4921-2-120 STRAIGHT POST,C1713,HCPCS,,79005479,CDM,278,RC,,,both,,,581,429.94,,,429.94,Other,150% of Medicare + 9.63% HCRA Surcharge,261.45,45,,261.45,percent of total billed charges,Critical Access Hospital RCC factor,197.54,34,,197.54,percent of total billed charges,Implant Device,197.54,34,,197.54,percent of total billed charges,Implant Device,197.54,34,,197.54,percent of total billed charges,Implant Device,197.54,34,,197.54,percent of total billed charges,Implant Device,197.54,34,,197.54,percent of total billed charges,Implant Device,287.6,,,287.6,Other,110% of Medicare,203.35,35,,203.35,percent of total billed charges,Implant Device,197.54,34,"Charges > $500, x 34%",197.54,percent of total billed charges,Implant Device,203.35,35,,203.35,percent of total billed charges,Implant Device,203.35,35,,203.35,percent of total billed charges,Implant Device,203.35,35,,203.35,percent of total billed charges,Implant Device,203.35,35,,203.35,percent of total billed charges,Implant Device,203.35,35,,203.35,percent of total billed charges,Implant Device,232.4,40,,232.4,percent of total billed charges,Implant Device,203.35,70,,203.35,percent of total billed charges,All Other,197.54,34,,197.54,percent of total billed charges,Implant Device,197.54,34,,197.54,percent of total billed charges,Implant Device,203.35,35,,203.35,percent of total billed charges,Implant Device,203.35,35,,203.35,percent of total billed charges,Implant Device,203.35,35,,203.35,percent of total billed charges,Implant Device,203.35,35,,203.35,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,429.94,
STRYKER 5028-7-030 SEMI-CIRCLE ROD,C1713,HCPCS,,79005480,CDM,278,RC,,,both,,,768,568.32,,,568.32,Other,150% of Medicare + 9.63% HCRA Surcharge,345.6,45,,345.6,percent of total billed charges,Critical Access Hospital RCC factor,261.12,34,,261.12,percent of total billed charges,Implant Device,261.12,34,,261.12,percent of total billed charges,Implant Device,261.12,34,,261.12,percent of total billed charges,Implant Device,261.12,34,,261.12,percent of total billed charges,Implant Device,261.12,34,,261.12,percent of total billed charges,Implant Device,380.16,,,380.16,Other,110% of Medicare,268.8,35,,268.8,percent of total billed charges,Implant Device,261.12,34,"Charges > $500, x 34%",261.12,percent of total billed charges,Implant Device,268.8,35,,268.8,percent of total billed charges,Implant Device,268.8,35,,268.8,percent of total billed charges,Implant Device,268.8,35,,268.8,percent of total billed charges,Implant Device,268.8,35,,268.8,percent of total billed charges,Implant Device,268.8,35,,268.8,percent of total billed charges,Implant Device,307.2,40,,307.2,percent of total billed charges,Implant Device,268.8,70,,268.8,percent of total billed charges,All Other,261.12,34,,261.12,percent of total billed charges,Implant Device,261.12,34,,261.12,percent of total billed charges,Implant Device,268.8,35,,268.8,percent of total billed charges,Implant Device,268.8,35,,268.8,percent of total billed charges,Implant Device,268.8,35,,268.8,percent of total billed charges,Implant Device,268.8,35,,268.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,568.32,
STRYKER 427067 3.0 LOCKING SCREW,C1713,HCPCS,,79005481,CDM,278,RC,,,both,,,587,434.38,,,434.38,Other,150% of Medicare + 9.63% HCRA Surcharge,264.15,45,,264.15,percent of total billed charges,Critical Access Hospital RCC factor,199.58,34,,199.58,percent of total billed charges,Implant Device,199.58,34,,199.58,percent of total billed charges,Implant Device,199.58,34,,199.58,percent of total billed charges,Implant Device,199.58,34,,199.58,percent of total billed charges,Implant Device,199.58,34,,199.58,percent of total billed charges,Implant Device,290.57,,,290.57,Other,110% of Medicare,205.45,35,,205.45,percent of total billed charges,Implant Device,199.58,34,"Charges > $500, x 34%",199.58,percent of total billed charges,Implant Device,205.45,35,,205.45,percent of total billed charges,Implant Device,205.45,35,,205.45,percent of total billed charges,Implant Device,205.45,35,,205.45,percent of total billed charges,Implant Device,205.45,35,,205.45,percent of total billed charges,Implant Device,205.45,35,,205.45,percent of total billed charges,Implant Device,234.8,40,,234.8,percent of total billed charges,Implant Device,205.45,70,,205.45,percent of total billed charges,All Other,199.58,34,,199.58,percent of total billed charges,Implant Device,199.58,34,,199.58,percent of total billed charges,Implant Device,205.45,35,,205.45,percent of total billed charges,Implant Device,205.45,35,,205.45,percent of total billed charges,Implant Device,205.45,35,,205.45,percent of total billed charges,Implant Device,205.45,35,,205.45,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,434.38,
STRYKER 388622 LOCKING SCREW 3.5X22MM,C1713,HCPCS,,79005482,CDM,278,RC,,,both,,,115,85.1,,,85.1,Other,150% of Medicare + 9.63% HCRA Surcharge,51.75,45,,51.75,percent of total billed charges,Critical Access Hospital RCC factor,39.1,34,,39.1,percent of total billed charges,Implant Device,39.1,34,,39.1,percent of total billed charges,Implant Device,39.1,34,,39.1,percent of total billed charges,Implant Device,39.1,34,,39.1,percent of total billed charges,Implant Device,39.1,34,,39.1,percent of total billed charges,Implant Device,56.93,,,56.93,Other,110% of Medicare,40.25,35,,40.25,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,40.25,35,,40.25,percent of total billed charges,Implant Device,40.25,35,,40.25,percent of total billed charges,Implant Device,40.25,35,,40.25,percent of total billed charges,Implant Device,40.25,35,,40.25,percent of total billed charges,Implant Device,40.25,35,,40.25,percent of total billed charges,Implant Device,46,40,,46,percent of total billed charges,Implant Device,40.25,70,,40.25,percent of total billed charges,All Other,39.1,34,,39.1,percent of total billed charges,Implant Device,39.1,34,,39.1,percent of total billed charges,Implant Device,40.25,35,,40.25,percent of total billed charges,Implant Device,40.25,35,,40.25,percent of total billed charges,Implant Device,40.25,35,,40.25,percent of total billed charges,Implant Device,40.25,35,,40.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,85.1,
STRYKER 388620 LOCKING SCREW 3.0X20MM,C1713,HCPCS,,79005483,CDM,278,RC,,,both,,,115,85.1,,,85.1,Other,150% of Medicare + 9.63% HCRA Surcharge,51.75,45,,51.75,percent of total billed charges,Critical Access Hospital RCC factor,39.1,34,,39.1,percent of total billed charges,Implant Device,39.1,34,,39.1,percent of total billed charges,Implant Device,39.1,34,,39.1,percent of total billed charges,Implant Device,39.1,34,,39.1,percent of total billed charges,Implant Device,39.1,34,,39.1,percent of total billed charges,Implant Device,56.93,,,56.93,Other,110% of Medicare,40.25,35,,40.25,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,40.25,35,,40.25,percent of total billed charges,Implant Device,40.25,35,,40.25,percent of total billed charges,Implant Device,40.25,35,,40.25,percent of total billed charges,Implant Device,40.25,35,,40.25,percent of total billed charges,Implant Device,40.25,35,,40.25,percent of total billed charges,Implant Device,46,40,,46,percent of total billed charges,Implant Device,40.25,70,,40.25,percent of total billed charges,All Other,39.1,34,,39.1,percent of total billed charges,Implant Device,39.1,34,,39.1,percent of total billed charges,Implant Device,40.25,35,,40.25,percent of total billed charges,Implant Device,40.25,35,,40.25,percent of total billed charges,Implant Device,40.25,35,,40.25,percent of total billed charges,Implant Device,40.25,35,,40.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,85.1,
STRYKER 325042 CANNULATED SCREW 4.0,C1713,HCPCS,,79005484,CDM,278,RC,,,both,,,446,330.04,,,330.04,Other,150% of Medicare + 9.63% HCRA Surcharge,200.7,45,,200.7,percent of total billed charges,Critical Access Hospital RCC factor,151.64,34,,151.64,percent of total billed charges,Implant Device,151.64,34,,151.64,percent of total billed charges,Implant Device,151.64,34,,151.64,percent of total billed charges,Implant Device,151.64,34,,151.64,percent of total billed charges,Implant Device,151.64,34,,151.64,percent of total billed charges,Implant Device,220.77,,,220.77,Other,110% of Medicare,156.1,35,,156.1,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,156.1,35,,156.1,percent of total billed charges,Implant Device,156.1,35,,156.1,percent of total billed charges,Implant Device,156.1,35,,156.1,percent of total billed charges,Implant Device,156.1,35,,156.1,percent of total billed charges,Implant Device,156.1,35,,156.1,percent of total billed charges,Implant Device,178.4,40,,178.4,percent of total billed charges,Implant Device,156.1,70,,156.1,percent of total billed charges,All Other,151.64,34,,151.64,percent of total billed charges,Implant Device,151.64,34,,151.64,percent of total billed charges,Implant Device,156.1,35,,156.1,percent of total billed charges,Implant Device,156.1,35,,156.1,percent of total billed charges,Implant Device,156.1,35,,156.1,percent of total billed charges,Implant Device,156.1,35,,156.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,330.04,
BIOMET 139248 ENDO II TAPER INSERT 3MM,C1776,HCPCS,,79005487,CDM,278,RC,,,both,,,630,466.2,,,466.2,Other,150% of Medicare + 9.63% HCRA Surcharge,283.5,45,,283.5,percent of total billed charges,Critical Access Hospital RCC factor,214.2,34,,214.2,percent of total billed charges,Implant Device,214.2,34,,214.2,percent of total billed charges,Implant Device,214.2,34,,214.2,percent of total billed charges,Implant Device,214.2,34,,214.2,percent of total billed charges,Implant Device,214.2,34,,214.2,percent of total billed charges,Implant Device,311.85,,,311.85,Other,110% of Medicare,220.5,35,,220.5,percent of total billed charges,Implant Device,214.2,34,"Charges > $500, x 34%",214.2,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,252,40,,252,percent of total billed charges,Implant Device,220.5,70,,220.5,percent of total billed charges,All Other,214.2,34,,214.2,percent of total billed charges,Implant Device,214.2,34,,214.2,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,466.2,
ZIMMER 5990-35-23 NEXGEN FEM AUG SZ E,C1713,HCPCS,,79005488,CDM,278,RC,,,both,,,3617,2676.59,,,2676.59,Other,150% of Medicare + 9.63% HCRA Surcharge,1627.65,45,,1627.65,percent of total billed charges,Critical Access Hospital RCC factor,1229.78,34,,1229.78,percent of total billed charges,Implant Device,1229.78,34,,1229.78,percent of total billed charges,Implant Device,1229.78,34,,1229.78,percent of total billed charges,Implant Device,1229.78,34,,1229.78,percent of total billed charges,Implant Device,1229.78,34,,1229.78,percent of total billed charges,Implant Device,1790.42,,,1790.42,Other,110% of Medicare,1265.95,35,,1265.95,percent of total billed charges,Implant Device,1229.78,34,"Charges > $500, x 34%",1229.78,percent of total billed charges,Implant Device,1265.95,35,,1265.95,percent of total billed charges,Implant Device,1265.95,35,,1265.95,percent of total billed charges,Implant Device,1265.95,35,,1265.95,percent of total billed charges,Implant Device,1265.95,35,,1265.95,percent of total billed charges,Implant Device,1265.95,35,,1265.95,percent of total billed charges,Implant Device,1446.8,40,,1446.8,percent of total billed charges,Implant Device,1265.95,70,,1265.95,percent of total billed charges,All Other,1229.78,34,,1229.78,percent of total billed charges,Implant Device,1229.78,34,,1229.78,percent of total billed charges,Implant Device,1265.95,35,,1265.95,percent of total billed charges,Implant Device,1265.95,35,,1265.95,percent of total billed charges,Implant Device,1265.95,35,,1265.95,percent of total billed charges,Implant Device,1265.95,35,,1265.95,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1229.78,34,"If Charge > 2,000, then 34 percent",1229.78,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2676.59,
ARTHREX AR-2651CR CLAVICLE PLATE,C1713,HCPCS,,79005489,CDM,278,RC,,,both,,,1650,1221,,,1221,Other,150% of Medicare + 9.63% HCRA Surcharge,742.5,45,,742.5,percent of total billed charges,Critical Access Hospital RCC factor,561,34,,561,percent of total billed charges,Implant Device,561,34,,561,percent of total billed charges,Implant Device,561,34,,561,percent of total billed charges,Implant Device,561,34,,561,percent of total billed charges,Implant Device,561,34,,561,percent of total billed charges,Implant Device,816.75,,,816.75,Other,110% of Medicare,577.5,35,,577.5,percent of total billed charges,Implant Device,561,34,"Charges > $500, x 34%",561,percent of total billed charges,Implant Device,577.5,35,,577.5,percent of total billed charges,Implant Device,577.5,35,,577.5,percent of total billed charges,Implant Device,577.5,35,,577.5,percent of total billed charges,Implant Device,577.5,35,,577.5,percent of total billed charges,Implant Device,577.5,35,,577.5,percent of total billed charges,Implant Device,660,40,,660,percent of total billed charges,Implant Device,577.5,70,,577.5,percent of total billed charges,All Other,561,34,,561,percent of total billed charges,Implant Device,561,34,,561,percent of total billed charges,Implant Device,577.5,35,,577.5,percent of total billed charges,Implant Device,577.5,35,,577.5,percent of total billed charges,Implant Device,577.5,35,,577.5,percent of total billed charges,Implant Device,577.5,35,,577.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1221,
GORE PLC181400 EXCLUDER ENDOPROSTHETIC,C1874,HCPCS,,79005491,CDM,278,RC,,,both,,,12900,9546.03,,,9546.03,Other,150% of Medicare + 9.63% HCRA Surcharge,5805,45,,5805,percent of total billed charges,Critical Access Hospital RCC factor,4386,34,,4386,percent of total billed charges,Implant Device,4386,34,,4386,percent of total billed charges,Implant Device,4386,34,,4386,percent of total billed charges,Implant Device,4386,34,,4386,percent of total billed charges,Implant Device,4386,34,,4386,percent of total billed charges,Implant Device,6385.5,,,6385.5,Other,110% of Medicare,4515,35,,4515,percent of total billed charges,Implant Device,4386,34,"Charges > $500, x 34%",4386,percent of total billed charges,Implant Device,4515,35,,4515,percent of total billed charges,Implant Device,4515,35,,4515,percent of total billed charges,Implant Device,4515,35,,4515,percent of total billed charges,Implant Device,4515,35,,4515,percent of total billed charges,Implant Device,4515,35,,4515,percent of total billed charges,Implant Device,5160,40,,5160,percent of total billed charges,Implant Device,4515,70,,4515,percent of total billed charges,All Other,4386,34,,4386,percent of total billed charges,Implant Device,4386,34,,4386,percent of total billed charges,Implant Device,4515,35,,4515,percent of total billed charges,Implant Device,4515,35,,4515,percent of total billed charges,Implant Device,4515,35,,4515,percent of total billed charges,Implant Device,4515,35,,4515,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,4386,34,"If Charge > 2,000, then 34 percent",4386,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,9546.03,
ARTHREX AR-8724-22 SCREW 2.4X22MM,C1713,HCPCS,,79005493,CDM,278,RC,,,both,,,474,350.76,,,350.76,Other,150% of Medicare + 9.63% HCRA Surcharge,213.3,45,,213.3,percent of total billed charges,Critical Access Hospital RCC factor,161.16,34,,161.16,percent of total billed charges,Implant Device,161.16,34,,161.16,percent of total billed charges,Implant Device,161.16,34,,161.16,percent of total billed charges,Implant Device,161.16,34,,161.16,percent of total billed charges,Implant Device,161.16,34,,161.16,percent of total billed charges,Implant Device,234.63,,,234.63,Other,110% of Medicare,165.9,35,,165.9,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,165.9,35,,165.9,percent of total billed charges,Implant Device,165.9,35,,165.9,percent of total billed charges,Implant Device,165.9,35,,165.9,percent of total billed charges,Implant Device,165.9,35,,165.9,percent of total billed charges,Implant Device,165.9,35,,165.9,percent of total billed charges,Implant Device,189.6,40,,189.6,percent of total billed charges,Implant Device,165.9,70,,165.9,percent of total billed charges,All Other,161.16,34,,161.16,percent of total billed charges,Implant Device,161.16,34,,161.16,percent of total billed charges,Implant Device,165.9,35,,165.9,percent of total billed charges,Implant Device,165.9,35,,165.9,percent of total billed charges,Implant Device,165.9,35,,165.9,percent of total billed charges,Implant Device,165.9,35,,165.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,350.76,
ARTHREX AR-8724-24 SCREW 2.4X24MM,C1713,HCPCS,,79005494,CDM,278,RC,,,both,,,474,350.76,,,350.76,Other,150% of Medicare + 9.63% HCRA Surcharge,213.3,45,,213.3,percent of total billed charges,Critical Access Hospital RCC factor,161.16,34,,161.16,percent of total billed charges,Implant Device,161.16,34,,161.16,percent of total billed charges,Implant Device,161.16,34,,161.16,percent of total billed charges,Implant Device,161.16,34,,161.16,percent of total billed charges,Implant Device,161.16,34,,161.16,percent of total billed charges,Implant Device,234.63,,,234.63,Other,110% of Medicare,165.9,35,,165.9,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,165.9,35,,165.9,percent of total billed charges,Implant Device,165.9,35,,165.9,percent of total billed charges,Implant Device,165.9,35,,165.9,percent of total billed charges,Implant Device,165.9,35,,165.9,percent of total billed charges,Implant Device,165.9,35,,165.9,percent of total billed charges,Implant Device,189.6,40,,189.6,percent of total billed charges,Implant Device,165.9,70,,165.9,percent of total billed charges,All Other,161.16,34,,161.16,percent of total billed charges,Implant Device,161.16,34,,161.16,percent of total billed charges,Implant Device,165.9,35,,165.9,percent of total billed charges,Implant Device,165.9,35,,165.9,percent of total billed charges,Implant Device,165.9,35,,165.9,percent of total billed charges,Implant Device,165.9,35,,165.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,350.76,
ARTHREX AR-8724-28 SCREW 2.4X28MM,C1713,HCPCS,,79005495,CDM,278,RC,,,both,,,330,244.2,,,244.2,Other,150% of Medicare + 9.63% HCRA Surcharge,148.5,45,,148.5,percent of total billed charges,Critical Access Hospital RCC factor,112.2,34,,112.2,percent of total billed charges,Implant Device,112.2,34,,112.2,percent of total billed charges,Implant Device,112.2,34,,112.2,percent of total billed charges,Implant Device,112.2,34,,112.2,percent of total billed charges,Implant Device,112.2,34,,112.2,percent of total billed charges,Implant Device,163.35,,,163.35,Other,110% of Medicare,115.5,35,,115.5,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,132,40,,132,percent of total billed charges,Implant Device,115.5,70,,115.5,percent of total billed charges,All Other,112.2,34,,112.2,percent of total billed charges,Implant Device,112.2,34,,112.2,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,244.2,
ARTHREX AR-8740-50PTS CANN SCREW 4.0X50,C1713,HCPCS,,79005496,CDM,278,RC,,,both,,,450,333,,,333,Other,150% of Medicare + 9.63% HCRA Surcharge,202.5,45,,202.5,percent of total billed charges,Critical Access Hospital RCC factor,153,34,,153,percent of total billed charges,Implant Device,153,34,,153,percent of total billed charges,Implant Device,153,34,,153,percent of total billed charges,Implant Device,153,34,,153,percent of total billed charges,Implant Device,153,34,,153,percent of total billed charges,Implant Device,222.75,,,222.75,Other,110% of Medicare,157.5,35,,157.5,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,157.5,35,,157.5,percent of total billed charges,Implant Device,157.5,35,,157.5,percent of total billed charges,Implant Device,157.5,35,,157.5,percent of total billed charges,Implant Device,157.5,35,,157.5,percent of total billed charges,Implant Device,157.5,35,,157.5,percent of total billed charges,Implant Device,180,40,,180,percent of total billed charges,Implant Device,157.5,70,,157.5,percent of total billed charges,All Other,153,34,,153,percent of total billed charges,Implant Device,153,34,,153,percent of total billed charges,Implant Device,157.5,35,,157.5,percent of total billed charges,Implant Device,157.5,35,,157.5,percent of total billed charges,Implant Device,157.5,35,,157.5,percent of total billed charges,Implant Device,157.5,35,,157.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,333,
ARTHREX AR-8740-32PTS CANN SCREW 4.0X32,C1713,HCPCS,,79005497,CDM,278,RC,,,both,,,708,523.92,,,523.92,Other,150% of Medicare + 9.63% HCRA Surcharge,318.6,45,,318.6,percent of total billed charges,Critical Access Hospital RCC factor,240.72,34,,240.72,percent of total billed charges,Implant Device,240.72,34,,240.72,percent of total billed charges,Implant Device,240.72,34,,240.72,percent of total billed charges,Implant Device,240.72,34,,240.72,percent of total billed charges,Implant Device,240.72,34,,240.72,percent of total billed charges,Implant Device,350.46,,,350.46,Other,110% of Medicare,247.8,35,,247.8,percent of total billed charges,Implant Device,240.72,34,"Charges > $500, x 34%",240.72,percent of total billed charges,Implant Device,247.8,35,,247.8,percent of total billed charges,Implant Device,247.8,35,,247.8,percent of total billed charges,Implant Device,247.8,35,,247.8,percent of total billed charges,Implant Device,247.8,35,,247.8,percent of total billed charges,Implant Device,247.8,35,,247.8,percent of total billed charges,Implant Device,283.2,40,,283.2,percent of total billed charges,Implant Device,247.8,70,,247.8,percent of total billed charges,All Other,240.72,34,,240.72,percent of total billed charges,Implant Device,240.72,34,,240.72,percent of total billed charges,Implant Device,247.8,35,,247.8,percent of total billed charges,Implant Device,247.8,35,,247.8,percent of total billed charges,Implant Device,247.8,35,,247.8,percent of total billed charges,Implant Device,247.8,35,,247.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,523.92,
ACUMED 70-0125 DISTAL CLAVICLE PLATE 2.3,C1713,HCPCS,,79005498,CDM,278,RC,,,both,,,3603,2666.23,,,2666.23,Other,150% of Medicare + 9.63% HCRA Surcharge,1621.35,45,,1621.35,percent of total billed charges,Critical Access Hospital RCC factor,1225.02,34,,1225.02,percent of total billed charges,Implant Device,1225.02,34,,1225.02,percent of total billed charges,Implant Device,1225.02,34,,1225.02,percent of total billed charges,Implant Device,1225.02,34,,1225.02,percent of total billed charges,Implant Device,1225.02,34,,1225.02,percent of total billed charges,Implant Device,1783.49,,,1783.49,Other,110% of Medicare,1261.05,35,,1261.05,percent of total billed charges,Implant Device,1225.02,34,"Charges > $500, x 34%",1225.02,percent of total billed charges,Implant Device,1261.05,35,,1261.05,percent of total billed charges,Implant Device,1261.05,35,,1261.05,percent of total billed charges,Implant Device,1261.05,35,,1261.05,percent of total billed charges,Implant Device,1261.05,35,,1261.05,percent of total billed charges,Implant Device,1261.05,35,,1261.05,percent of total billed charges,Implant Device,1441.2,40,,1441.2,percent of total billed charges,Implant Device,1261.05,70,,1261.05,percent of total billed charges,All Other,1225.02,34,,1225.02,percent of total billed charges,Implant Device,1225.02,34,,1225.02,percent of total billed charges,Implant Device,1261.05,35,,1261.05,percent of total billed charges,Implant Device,1261.05,35,,1261.05,percent of total billed charges,Implant Device,1261.05,35,,1261.05,percent of total billed charges,Implant Device,1261.05,35,,1261.05,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1225.02,34,"If Charge > 2,000, then 34 percent",1225.02,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2666.23,
STRYKER 3060-0100S LAG SCREW 10.5X100MM,C1713,HCPCS,,79005501,CDM,278,RC,,,both,,,2153,1593.23,,,1593.23,Other,150% of Medicare + 9.63% HCRA Surcharge,968.85,45,,968.85,percent of total billed charges,Critical Access Hospital RCC factor,732.02,34,,732.02,percent of total billed charges,Implant Device,732.02,34,,732.02,percent of total billed charges,Implant Device,732.02,34,,732.02,percent of total billed charges,Implant Device,732.02,34,,732.02,percent of total billed charges,Implant Device,732.02,34,,732.02,percent of total billed charges,Implant Device,1065.74,,,1065.74,Other,110% of Medicare,753.55,35,,753.55,percent of total billed charges,Implant Device,732.02,34,"Charges > $500, x 34%",732.02,percent of total billed charges,Implant Device,753.55,35,,753.55,percent of total billed charges,Implant Device,753.55,35,,753.55,percent of total billed charges,Implant Device,753.55,35,,753.55,percent of total billed charges,Implant Device,753.55,35,,753.55,percent of total billed charges,Implant Device,753.55,35,,753.55,percent of total billed charges,Implant Device,861.2,40,,861.2,percent of total billed charges,Implant Device,753.55,70,,753.55,percent of total billed charges,All Other,732.02,34,,732.02,percent of total billed charges,Implant Device,732.02,34,,732.02,percent of total billed charges,Implant Device,753.55,35,,753.55,percent of total billed charges,Implant Device,753.55,35,,753.55,percent of total billed charges,Implant Device,753.55,35,,753.55,percent of total billed charges,Implant Device,753.55,35,,753.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,732.02,34,"If Charge > 2,000, then 34 percent",732.02,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1593.23,
BOST SCI 1670 18X20 WALL FLEX,C1876,HCPCS,,79005506,CDM,278,RC,,,both,,,7726,5717.26,,,5717.26,Other,150% of Medicare + 9.63% HCRA Surcharge,3476.7,45,,3476.7,percent of total billed charges,Critical Access Hospital RCC factor,2626.84,34,,2626.84,percent of total billed charges,Implant Device,2626.84,34,,2626.84,percent of total billed charges,Implant Device,2626.84,34,,2626.84,percent of total billed charges,Implant Device,2626.84,34,,2626.84,percent of total billed charges,Implant Device,2626.84,34,,2626.84,percent of total billed charges,Implant Device,3824.37,,,3824.37,Other,110% of Medicare,2704.1,35,,2704.1,percent of total billed charges,Implant Device,2626.84,34,"Charges > $500, x 34%",2626.84,percent of total billed charges,Implant Device,2704.1,35,,2704.1,percent of total billed charges,Implant Device,2704.1,35,,2704.1,percent of total billed charges,Implant Device,2704.1,35,,2704.1,percent of total billed charges,Implant Device,2704.1,35,,2704.1,percent of total billed charges,Implant Device,2704.1,35,,2704.1,percent of total billed charges,Implant Device,3090.4,40,,3090.4,percent of total billed charges,Implant Device,2704.1,70,,2704.1,percent of total billed charges,All Other,2626.84,34,,2626.84,percent of total billed charges,Implant Device,2626.84,34,,2626.84,percent of total billed charges,Implant Device,2704.1,35,,2704.1,percent of total billed charges,Implant Device,2704.1,35,,2704.1,percent of total billed charges,Implant Device,2704.1,35,,2704.1,percent of total billed charges,Implant Device,2704.1,35,,2704.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2626.84,34,"If Charge > 2,000, then 34 percent",2626.84,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5717.26,
BOST SCI 1671 WALL FLEX ESOPH 18/23-25MM,C1876,HCPCS,,79005507,CDM,278,RC,,,both,,,7726,5717.26,,,5717.26,Other,150% of Medicare + 9.63% HCRA Surcharge,3476.7,45,,3476.7,percent of total billed charges,Critical Access Hospital RCC factor,2626.84,34,,2626.84,percent of total billed charges,Implant Device,2626.84,34,,2626.84,percent of total billed charges,Implant Device,2626.84,34,,2626.84,percent of total billed charges,Implant Device,2626.84,34,,2626.84,percent of total billed charges,Implant Device,2626.84,34,,2626.84,percent of total billed charges,Implant Device,3824.37,,,3824.37,Other,110% of Medicare,2704.1,35,,2704.1,percent of total billed charges,Implant Device,2626.84,34,"Charges > $500, x 34%",2626.84,percent of total billed charges,Implant Device,2704.1,35,,2704.1,percent of total billed charges,Implant Device,2704.1,35,,2704.1,percent of total billed charges,Implant Device,2704.1,35,,2704.1,percent of total billed charges,Implant Device,2704.1,35,,2704.1,percent of total billed charges,Implant Device,2704.1,35,,2704.1,percent of total billed charges,Implant Device,3090.4,40,,3090.4,percent of total billed charges,Implant Device,2704.1,70,,2704.1,percent of total billed charges,All Other,2626.84,34,,2626.84,percent of total billed charges,Implant Device,2626.84,34,,2626.84,percent of total billed charges,Implant Device,2704.1,35,,2704.1,percent of total billed charges,Implant Device,2704.1,35,,2704.1,percent of total billed charges,Implant Device,2704.1,35,,2704.1,percent of total billed charges,Implant Device,2704.1,35,,2704.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2626.84,34,"If Charge > 2,000, then 34 percent",2626.84,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5717.26,
BOST SCI 4556 RE STENTS 7FRX7CM,C2625,HCPCS,,79005512,CDM,278,RC,,,both,,,444,328.56,,,328.56,Other,150% of Medicare + 9.63% HCRA Surcharge,199.8,45,,199.8,percent of total billed charges,Critical Access Hospital RCC factor,150.96,34,,150.96,percent of total billed charges,Implant Device,150.96,34,,150.96,percent of total billed charges,Implant Device,150.96,34,,150.96,percent of total billed charges,Implant Device,150.96,34,,150.96,percent of total billed charges,Implant Device,150.96,34,,150.96,percent of total billed charges,Implant Device,219.78,,,219.78,Other,110% of Medicare,155.4,35,,155.4,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,155.4,35,,155.4,percent of total billed charges,Implant Device,155.4,35,,155.4,percent of total billed charges,Implant Device,155.4,35,,155.4,percent of total billed charges,Implant Device,155.4,35,,155.4,percent of total billed charges,Implant Device,155.4,35,,155.4,percent of total billed charges,Implant Device,177.6,40,,177.6,percent of total billed charges,Implant Device,155.4,70,,155.4,percent of total billed charges,All Other,150.96,34,,150.96,percent of total billed charges,Implant Device,150.96,34,,150.96,percent of total billed charges,Implant Device,155.4,35,,155.4,percent of total billed charges,Implant Device,155.4,35,,155.4,percent of total billed charges,Implant Device,155.4,35,,155.4,percent of total billed charges,Implant Device,155.4,35,,155.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,328.56,
BOST SCI 4557 RE STENTS 7FRX10CM,C2625,HCPCS,,79005513,CDM,278,RC,,,both,,,444,328.56,,,328.56,Other,150% of Medicare + 9.63% HCRA Surcharge,199.8,45,,199.8,percent of total billed charges,Critical Access Hospital RCC factor,150.96,34,,150.96,percent of total billed charges,Implant Device,150.96,34,,150.96,percent of total billed charges,Implant Device,150.96,34,,150.96,percent of total billed charges,Implant Device,150.96,34,,150.96,percent of total billed charges,Implant Device,150.96,34,,150.96,percent of total billed charges,Implant Device,219.78,,,219.78,Other,110% of Medicare,155.4,35,,155.4,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,155.4,35,,155.4,percent of total billed charges,Implant Device,155.4,35,,155.4,percent of total billed charges,Implant Device,155.4,35,,155.4,percent of total billed charges,Implant Device,155.4,35,,155.4,percent of total billed charges,Implant Device,155.4,35,,155.4,percent of total billed charges,Implant Device,177.6,40,,177.6,percent of total billed charges,Implant Device,155.4,70,,155.4,percent of total billed charges,All Other,150.96,34,,150.96,percent of total billed charges,Implant Device,150.96,34,,150.96,percent of total billed charges,Implant Device,155.4,35,,155.4,percent of total billed charges,Implant Device,155.4,35,,155.4,percent of total billed charges,Implant Device,155.4,35,,155.4,percent of total billed charges,Implant Device,155.4,35,,155.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,328.56,
BOST SCI 4560 RE STENTS 10FRX5CM,C2625,HCPCS,,79005514,CDM,278,RC,,,both,,,444,328.56,,,328.56,Other,150% of Medicare + 9.63% HCRA Surcharge,199.8,45,,199.8,percent of total billed charges,Critical Access Hospital RCC factor,150.96,34,,150.96,percent of total billed charges,Implant Device,150.96,34,,150.96,percent of total billed charges,Implant Device,150.96,34,,150.96,percent of total billed charges,Implant Device,150.96,34,,150.96,percent of total billed charges,Implant Device,150.96,34,,150.96,percent of total billed charges,Implant Device,219.78,,,219.78,Other,110% of Medicare,155.4,35,,155.4,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,155.4,35,,155.4,percent of total billed charges,Implant Device,155.4,35,,155.4,percent of total billed charges,Implant Device,155.4,35,,155.4,percent of total billed charges,Implant Device,155.4,35,,155.4,percent of total billed charges,Implant Device,155.4,35,,155.4,percent of total billed charges,Implant Device,177.6,40,,177.6,percent of total billed charges,Implant Device,155.4,70,,155.4,percent of total billed charges,All Other,150.96,34,,150.96,percent of total billed charges,Implant Device,150.96,34,,150.96,percent of total billed charges,Implant Device,155.4,35,,155.4,percent of total billed charges,Implant Device,155.4,35,,155.4,percent of total billed charges,Implant Device,155.4,35,,155.4,percent of total billed charges,Implant Device,155.4,35,,155.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,328.56,
BOST SCI 4561 RE STENTS 10FRX7CM,C2625,HCPCS,,79005515,CDM,278,RC,,,both,,,444,328.56,,,328.56,Other,150% of Medicare + 9.63% HCRA Surcharge,199.8,45,,199.8,percent of total billed charges,Critical Access Hospital RCC factor,150.96,34,,150.96,percent of total billed charges,Implant Device,150.96,34,,150.96,percent of total billed charges,Implant Device,150.96,34,,150.96,percent of total billed charges,Implant Device,150.96,34,,150.96,percent of total billed charges,Implant Device,150.96,34,,150.96,percent of total billed charges,Implant Device,219.78,,,219.78,Other,110% of Medicare,155.4,35,,155.4,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,155.4,35,,155.4,percent of total billed charges,Implant Device,155.4,35,,155.4,percent of total billed charges,Implant Device,155.4,35,,155.4,percent of total billed charges,Implant Device,155.4,35,,155.4,percent of total billed charges,Implant Device,155.4,35,,155.4,percent of total billed charges,Implant Device,177.6,40,,177.6,percent of total billed charges,Implant Device,155.4,70,,155.4,percent of total billed charges,All Other,150.96,34,,150.96,percent of total billed charges,Implant Device,150.96,34,,150.96,percent of total billed charges,Implant Device,155.4,35,,155.4,percent of total billed charges,Implant Device,155.4,35,,155.4,percent of total billed charges,Implant Device,155.4,35,,155.4,percent of total billed charges,Implant Device,155.4,35,,155.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,328.56,
BOST SCI 4562 RE STENTS 10FRX10CM,C2625,HCPCS,,79005516,CDM,278,RC,,,both,,,444,328.56,,,328.56,Other,150% of Medicare + 9.63% HCRA Surcharge,199.8,45,,199.8,percent of total billed charges,Critical Access Hospital RCC factor,150.96,34,,150.96,percent of total billed charges,Implant Device,150.96,34,,150.96,percent of total billed charges,Implant Device,150.96,34,,150.96,percent of total billed charges,Implant Device,150.96,34,,150.96,percent of total billed charges,Implant Device,150.96,34,,150.96,percent of total billed charges,Implant Device,219.78,,,219.78,Other,110% of Medicare,155.4,35,,155.4,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,155.4,35,,155.4,percent of total billed charges,Implant Device,155.4,35,,155.4,percent of total billed charges,Implant Device,155.4,35,,155.4,percent of total billed charges,Implant Device,155.4,35,,155.4,percent of total billed charges,Implant Device,155.4,35,,155.4,percent of total billed charges,Implant Device,177.6,40,,177.6,percent of total billed charges,Implant Device,155.4,70,,155.4,percent of total billed charges,All Other,150.96,34,,150.96,percent of total billed charges,Implant Device,150.96,34,,150.96,percent of total billed charges,Implant Device,155.4,35,,155.4,percent of total billed charges,Implant Device,155.4,35,,155.4,percent of total billed charges,Implant Device,155.4,35,,155.4,percent of total billed charges,Implant Device,155.4,35,,155.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,328.56,
BOST SCI 7054 WALL STENT BILIARY 10X80,C1874,HCPCS,,79005531,CDM,278,RC,,,both,,,8550,6327.02,,,6327.02,Other,150% of Medicare + 9.63% HCRA Surcharge,3847.5,45,,3847.5,percent of total billed charges,Critical Access Hospital RCC factor,2907,34,,2907,percent of total billed charges,Implant Device,2907,34,,2907,percent of total billed charges,Implant Device,2907,34,,2907,percent of total billed charges,Implant Device,2907,34,,2907,percent of total billed charges,Implant Device,2907,34,,2907,percent of total billed charges,Implant Device,4232.25,,,4232.25,Other,110% of Medicare,2992.5,35,,2992.5,percent of total billed charges,Implant Device,2907,34,"Charges > $500, x 34%",2907,percent of total billed charges,Implant Device,2992.5,35,,2992.5,percent of total billed charges,Implant Device,2992.5,35,,2992.5,percent of total billed charges,Implant Device,2992.5,35,,2992.5,percent of total billed charges,Implant Device,2992.5,35,,2992.5,percent of total billed charges,Implant Device,2992.5,35,,2992.5,percent of total billed charges,Implant Device,3420,40,,3420,percent of total billed charges,Implant Device,2992.5,70,,2992.5,percent of total billed charges,All Other,2907,34,,2907,percent of total billed charges,Implant Device,2907,34,,2907,percent of total billed charges,Implant Device,2992.5,35,,2992.5,percent of total billed charges,Implant Device,2992.5,35,,2992.5,percent of total billed charges,Implant Device,2992.5,35,,2992.5,percent of total billed charges,Implant Device,2992.5,35,,2992.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2907,34,"If Charge > 2,000, then 34 percent",2907,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,6327.02,
BOST SCI 4555 RE STENTS 7FR X 5CM,C2625,HCPCS,,79005536,CDM,278,RC,,,both,,,444,328.56,,,328.56,Other,150% of Medicare + 9.63% HCRA Surcharge,199.8,45,,199.8,percent of total billed charges,Critical Access Hospital RCC factor,150.96,34,,150.96,percent of total billed charges,Implant Device,150.96,34,,150.96,percent of total billed charges,Implant Device,150.96,34,,150.96,percent of total billed charges,Implant Device,150.96,34,,150.96,percent of total billed charges,Implant Device,150.96,34,,150.96,percent of total billed charges,Implant Device,219.78,,,219.78,Other,110% of Medicare,155.4,35,,155.4,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,155.4,35,,155.4,percent of total billed charges,Implant Device,155.4,35,,155.4,percent of total billed charges,Implant Device,155.4,35,,155.4,percent of total billed charges,Implant Device,155.4,35,,155.4,percent of total billed charges,Implant Device,155.4,35,,155.4,percent of total billed charges,Implant Device,177.6,40,,177.6,percent of total billed charges,Implant Device,155.4,70,,155.4,percent of total billed charges,All Other,150.96,34,,150.96,percent of total billed charges,Implant Device,150.96,34,,150.96,percent of total billed charges,Implant Device,155.4,35,,155.4,percent of total billed charges,Implant Device,155.4,35,,155.4,percent of total billed charges,Implant Device,155.4,35,,155.4,percent of total billed charges,Implant Device,155.4,35,,155.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,328.56,
BOST SCI 4558 RE STENTS 7FR X 12CM,C2625,HCPCS,,79005537,CDM,278,RC,,,both,,,384,284.16,,,284.16,Other,150% of Medicare + 9.63% HCRA Surcharge,172.8,45,,172.8,percent of total billed charges,Critical Access Hospital RCC factor,130.56,34,,130.56,percent of total billed charges,Implant Device,130.56,34,,130.56,percent of total billed charges,Implant Device,130.56,34,,130.56,percent of total billed charges,Implant Device,130.56,34,,130.56,percent of total billed charges,Implant Device,130.56,34,,130.56,percent of total billed charges,Implant Device,190.08,,,190.08,Other,110% of Medicare,134.4,35,,134.4,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,134.4,35,,134.4,percent of total billed charges,Implant Device,134.4,35,,134.4,percent of total billed charges,Implant Device,134.4,35,,134.4,percent of total billed charges,Implant Device,134.4,35,,134.4,percent of total billed charges,Implant Device,134.4,35,,134.4,percent of total billed charges,Implant Device,153.6,40,,153.6,percent of total billed charges,Implant Device,134.4,70,,134.4,percent of total billed charges,All Other,130.56,34,,130.56,percent of total billed charges,Implant Device,130.56,34,,130.56,percent of total billed charges,Implant Device,134.4,35,,134.4,percent of total billed charges,Implant Device,134.4,35,,134.4,percent of total billed charges,Implant Device,134.4,35,,134.4,percent of total billed charges,Implant Device,134.4,35,,134.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,284.16,
BOST SCI 1415 ULTRAFLEX ESOPH METL STENT,C1874,HCPCS,,79005541,CDM,278,RC,,,both,,,4756,3519.45,,,3519.45,Other,150% of Medicare + 9.63% HCRA Surcharge,2140.2,45,,2140.2,percent of total billed charges,Critical Access Hospital RCC factor,1617.04,34,,1617.04,percent of total billed charges,Implant Device,1617.04,34,,1617.04,percent of total billed charges,Implant Device,1617.04,34,,1617.04,percent of total billed charges,Implant Device,1617.04,34,,1617.04,percent of total billed charges,Implant Device,1617.04,34,,1617.04,percent of total billed charges,Implant Device,2354.22,,,2354.22,Other,110% of Medicare,1664.6,35,,1664.6,percent of total billed charges,Implant Device,1617.04,34,"Charges > $500, x 34%",1617.04,percent of total billed charges,Implant Device,1664.6,35,,1664.6,percent of total billed charges,Implant Device,1664.6,35,,1664.6,percent of total billed charges,Implant Device,1664.6,35,,1664.6,percent of total billed charges,Implant Device,1664.6,35,,1664.6,percent of total billed charges,Implant Device,1664.6,35,,1664.6,percent of total billed charges,Implant Device,1902.4,40,,1902.4,percent of total billed charges,Implant Device,1664.6,70,,1664.6,percent of total billed charges,All Other,1617.04,34,,1617.04,percent of total billed charges,Implant Device,1617.04,34,,1617.04,percent of total billed charges,Implant Device,1664.6,35,,1664.6,percent of total billed charges,Implant Device,1664.6,35,,1664.6,percent of total billed charges,Implant Device,1664.6,35,,1664.6,percent of total billed charges,Implant Device,1664.6,35,,1664.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1617.04,34,"If Charge > 2,000, then 34 percent",1617.04,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3519.45,
COOK G27192 STENT GEENEN PANCR 3FRX8CM1,C2617,HCPCS,,79005546,CDM,278,RC,,,both,,,180,133.2,,,133.2,Other,150% of Medicare + 9.63% HCRA Surcharge,81,45,,81,percent of total billed charges,Critical Access Hospital RCC factor,61.2,34,,61.2,percent of total billed charges,Implant Device,61.2,34,,61.2,percent of total billed charges,Implant Device,61.2,34,,61.2,percent of total billed charges,Implant Device,61.2,34,,61.2,percent of total billed charges,Implant Device,61.2,34,,61.2,percent of total billed charges,Implant Device,89.1,,,89.1,Other,110% of Medicare,63,35,,63,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,63,35,,63,percent of total billed charges,Implant Device,63,35,,63,percent of total billed charges,Implant Device,63,35,,63,percent of total billed charges,Implant Device,63,35,,63,percent of total billed charges,Implant Device,63,35,,63,percent of total billed charges,Implant Device,72,40,,72,percent of total billed charges,Implant Device,63,70,,63,percent of total billed charges,All Other,61.2,34,,61.2,percent of total billed charges,Implant Device,61.2,34,,61.2,percent of total billed charges,Implant Device,63,35,,63,percent of total billed charges,Implant Device,63,35,,63,percent of total billed charges,Implant Device,63,35,,63,percent of total billed charges,Implant Device,63,35,,63,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,133.2,
STRYKER 604630 ASNIS 4X30MM SCREW,C1713,HCPCS,,79005550,CDM,278,RC,,,both,,,480,355.2,,,355.2,Other,150% of Medicare + 9.63% HCRA Surcharge,216,45,,216,percent of total billed charges,Critical Access Hospital RCC factor,163.2,34,,163.2,percent of total billed charges,Implant Device,163.2,34,,163.2,percent of total billed charges,Implant Device,163.2,34,,163.2,percent of total billed charges,Implant Device,163.2,34,,163.2,percent of total billed charges,Implant Device,163.2,34,,163.2,percent of total billed charges,Implant Device,237.6,,,237.6,Other,110% of Medicare,168,35,,168,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,192,40,,192,percent of total billed charges,Implant Device,168,70,,168,percent of total billed charges,All Other,163.2,34,,163.2,percent of total billed charges,Implant Device,163.2,34,,163.2,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,355.2,
INTEGRA MWM2021 WOUND MATRIX 2X2,C9363,HCPCS,,79005551,CDM,278,RC,,,both,,,7546,5584.06,,,5584.06,Other,150% of Medicare + 9.63% HCRA Surcharge,3395.7,45,,3395.7,percent of total billed charges,Critical Access Hospital RCC factor,2565.64,34,,2565.64,percent of total billed charges,Implant Device,2565.64,34,,2565.64,percent of total billed charges,Implant Device,2565.64,34,,2565.64,percent of total billed charges,Implant Device,2565.64,34,,2565.64,percent of total billed charges,Implant Device,2565.64,34,,2565.64,percent of total billed charges,Implant Device,3735.27,,,3735.27,Other,110% of Medicare,2641.1,35,,2641.1,percent of total billed charges,Implant Device,2565.64,34,"Charges > $500, x 34%",2565.64,percent of total billed charges,Implant Device,2641.1,35,,2641.1,percent of total billed charges,Implant Device,2641.1,35,,2641.1,percent of total billed charges,Implant Device,2641.1,35,,2641.1,percent of total billed charges,Implant Device,2641.1,35,,2641.1,percent of total billed charges,Implant Device,2641.1,35,,2641.1,percent of total billed charges,Implant Device,3018.4,40,,3018.4,percent of total billed charges,Implant Device,2641.1,70,,2641.1,percent of total billed charges,All Other,2565.64,34,,2565.64,percent of total billed charges,Implant Device,2565.64,34,,2565.64,percent of total billed charges,Implant Device,2641.1,35,,2641.1,percent of total billed charges,Implant Device,2641.1,35,,2641.1,percent of total billed charges,Implant Device,2641.1,35,,2641.1,percent of total billed charges,Implant Device,2641.1,35,,2641.1,percent of total billed charges,Implant Device,976.07,,,976.07,Other,100% of Medicaid,976.07,,,976.07,Other,100% of Medicaid,976.07,,,976.07,Other,100% of Medicaid,976.07,,,976.07,Other,100% of Medicaid,2196.16,,,2196.16,Other,225% of Medicaid,1493.39,,,1493.39,Other,153% of Medicaid,2196.16,,,2196.16,Other,225% of Medicaid,1366.5,,,1366.5,Other,140% of Medicaid,2565.64,34,"If Charge > 2,000, then 34 percent",2565.64,percent of total billed charges,Implants,2537.78,,,2537.78,Other,260% of Medicaid,3162.47,,,3162.47,Other,324% of Medicaid,2098.55,,,2098.55,Other,215% of Medicaid,2098.55,,,2098.55,Other,215% of Medicaid,1220.09,,,1220.09,Other,125% of Medicaid,976.07,5584.06,
INTEGRA TG221 TENOGLIDE SHEET 2X2,C9356,HCPCS,,79005552,CDM,278,RC,,,both,,,7276,5384.26,,,5384.26,Other,150% of Medicare + 9.63% HCRA Surcharge,3274.2,45,,3274.2,percent of total billed charges,Critical Access Hospital RCC factor,2473.84,34,,2473.84,percent of total billed charges,Implant Device,2473.84,34,,2473.84,percent of total billed charges,Implant Device,2473.84,34,,2473.84,percent of total billed charges,Implant Device,2473.84,34,,2473.84,percent of total billed charges,Implant Device,2473.84,34,,2473.84,percent of total billed charges,Implant Device,3601.62,,,3601.62,Other,110% of Medicare,2546.6,35,,2546.6,percent of total billed charges,Implant Device,2473.84,34,"Charges > $500, x 34%",2473.84,percent of total billed charges,Implant Device,2546.6,35,,2546.6,percent of total billed charges,Implant Device,2546.6,35,,2546.6,percent of total billed charges,Implant Device,2546.6,35,,2546.6,percent of total billed charges,Implant Device,2546.6,35,,2546.6,percent of total billed charges,Implant Device,2546.6,35,,2546.6,percent of total billed charges,Implant Device,2910.4,40,,2910.4,percent of total billed charges,Implant Device,2546.6,70,,2546.6,percent of total billed charges,All Other,2473.84,34,,2473.84,percent of total billed charges,Implant Device,2473.84,34,,2473.84,percent of total billed charges,Implant Device,2546.6,35,,2546.6,percent of total billed charges,Implant Device,2546.6,35,,2546.6,percent of total billed charges,Implant Device,2546.6,35,,2546.6,percent of total billed charges,Implant Device,2546.6,35,,2546.6,percent of total billed charges,Implant Device,976.07,,,976.07,Other,100% of Medicaid,976.07,,,976.07,Other,100% of Medicaid,976.07,,,976.07,Other,100% of Medicaid,976.07,,,976.07,Other,100% of Medicaid,2196.15,,,2196.15,Other,225% of Medicaid,1493.38,,,1493.38,Other,153% of Medicaid,2196.15,,,2196.15,Other,225% of Medicaid,1366.49,,,1366.49,Other,140% of Medicaid,2473.84,34,"If Charge > 2,000, then 34 percent",2473.84,percent of total billed charges,Implants,2537.77,,,2537.77,Other,260% of Medicaid,3162.45,,,3162.45,Other,324% of Medicaid,2098.54,,,2098.54,Other,215% of Medicaid,2098.54,,,2098.54,Other,215% of Medicaid,1220.08,,,1220.08,Other,125% of Medicaid,976.07,5384.26,
STRYKER 3120-1180S TROCH NAIL 11X180X120,C1713,HCPCS,,79005553,CDM,278,RC,,,both,,,3287,2432.39,,,2432.39,Other,150% of Medicare + 9.63% HCRA Surcharge,1479.15,45,,1479.15,percent of total billed charges,Critical Access Hospital RCC factor,1117.58,34,,1117.58,percent of total billed charges,Implant Device,1117.58,34,,1117.58,percent of total billed charges,Implant Device,1117.58,34,,1117.58,percent of total billed charges,Implant Device,1117.58,34,,1117.58,percent of total billed charges,Implant Device,1117.58,34,,1117.58,percent of total billed charges,Implant Device,1627.07,,,1627.07,Other,110% of Medicare,1150.45,35,,1150.45,percent of total billed charges,Implant Device,1117.58,34,"Charges > $500, x 34%",1117.58,percent of total billed charges,Implant Device,1150.45,35,,1150.45,percent of total billed charges,Implant Device,1150.45,35,,1150.45,percent of total billed charges,Implant Device,1150.45,35,,1150.45,percent of total billed charges,Implant Device,1150.45,35,,1150.45,percent of total billed charges,Implant Device,1150.45,35,,1150.45,percent of total billed charges,Implant Device,1314.8,40,,1314.8,percent of total billed charges,Implant Device,1150.45,70,,1150.45,percent of total billed charges,All Other,1117.58,34,,1117.58,percent of total billed charges,Implant Device,1117.58,34,,1117.58,percent of total billed charges,Implant Device,1150.45,35,,1150.45,percent of total billed charges,Implant Device,1150.45,35,,1150.45,percent of total billed charges,Implant Device,1150.45,35,,1150.45,percent of total billed charges,Implant Device,1150.45,35,,1150.45,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1117.58,34,"If Charge > 2,000, then 34 percent",1117.58,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2432.39,
DEVICOR MMK0801 8G MAMMOMARK BOWTIE,A4648,HCPCS,,79005556,CDM,278,RC,,,both,,,228,168.72,,,168.72,Other,150% of Medicare + 9.63% HCRA Surcharge,102.6,45,,102.6,percent of total billed charges,Critical Access Hospital RCC factor,77.52,34,,77.52,percent of total billed charges,Implant Device,77.52,34,,77.52,percent of total billed charges,Implant Device,77.52,34,,77.52,percent of total billed charges,Implant Device,77.52,34,,77.52,percent of total billed charges,Implant Device,77.52,34,,77.52,percent of total billed charges,Implant Device,112.86,,,112.86,Other,110% of Medicare,79.8,35,,79.8,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,79.8,35,,79.8,percent of total billed charges,Implant Device,79.8,35,,79.8,percent of total billed charges,Implant Device,79.8,35,,79.8,percent of total billed charges,Implant Device,79.8,35,,79.8,percent of total billed charges,Implant Device,79.8,35,,79.8,percent of total billed charges,Implant Device,91.2,40,,91.2,percent of total billed charges,Implant Device,79.8,70,,79.8,percent of total billed charges,All Other,77.52,34,,77.52,percent of total billed charges,Implant Device,77.52,34,,77.52,percent of total billed charges,Implant Device,79.8,35,,79.8,percent of total billed charges,Implant Device,79.8,35,,79.8,percent of total billed charges,Implant Device,79.8,35,,79.8,percent of total billed charges,Implant Device,79.8,35,,79.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,168.72,
DEVICOR MMK0802 8G MAMMOMARK V SHAPE,A4648,HCPCS,,79005557,CDM,278,RC,,,both,,,228,168.72,,,168.72,Other,150% of Medicare + 9.63% HCRA Surcharge,102.6,45,,102.6,percent of total billed charges,Critical Access Hospital RCC factor,77.52,34,,77.52,percent of total billed charges,Implant Device,77.52,34,,77.52,percent of total billed charges,Implant Device,77.52,34,,77.52,percent of total billed charges,Implant Device,77.52,34,,77.52,percent of total billed charges,Implant Device,77.52,34,,77.52,percent of total billed charges,Implant Device,112.86,,,112.86,Other,110% of Medicare,79.8,35,,79.8,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,79.8,35,,79.8,percent of total billed charges,Implant Device,79.8,35,,79.8,percent of total billed charges,Implant Device,79.8,35,,79.8,percent of total billed charges,Implant Device,79.8,35,,79.8,percent of total billed charges,Implant Device,79.8,35,,79.8,percent of total billed charges,Implant Device,91.2,40,,91.2,percent of total billed charges,Implant Device,79.8,70,,79.8,percent of total billed charges,All Other,77.52,34,,77.52,percent of total billed charges,Implant Device,77.52,34,,77.52,percent of total billed charges,Implant Device,79.8,35,,79.8,percent of total billed charges,Implant Device,79.8,35,,79.8,percent of total billed charges,Implant Device,79.8,35,,79.8,percent of total billed charges,Implant Device,79.8,35,,79.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,168.72,
ALPHATEC 62055-55 SCREW 5.5X55MM,C1713,HCPCS,,79005564,CDM,278,RC,,,both,,,2550,1887.01,,,1887.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1147.5,45,,1147.5,percent of total billed charges,Critical Access Hospital RCC factor,867,34,,867,percent of total billed charges,Implant Device,867,34,,867,percent of total billed charges,Implant Device,867,34,,867,percent of total billed charges,Implant Device,867,34,,867,percent of total billed charges,Implant Device,867,34,,867,percent of total billed charges,Implant Device,1262.25,,,1262.25,Other,110% of Medicare,892.5,35,,892.5,percent of total billed charges,Implant Device,867,34,"Charges > $500, x 34%",867,percent of total billed charges,Implant Device,892.5,35,,892.5,percent of total billed charges,Implant Device,892.5,35,,892.5,percent of total billed charges,Implant Device,892.5,35,,892.5,percent of total billed charges,Implant Device,892.5,35,,892.5,percent of total billed charges,Implant Device,892.5,35,,892.5,percent of total billed charges,Implant Device,1020,40,,1020,percent of total billed charges,Implant Device,892.5,70,,892.5,percent of total billed charges,All Other,867,34,,867,percent of total billed charges,Implant Device,867,34,,867,percent of total billed charges,Implant Device,892.5,35,,892.5,percent of total billed charges,Implant Device,892.5,35,,892.5,percent of total billed charges,Implant Device,892.5,35,,892.5,percent of total billed charges,Implant Device,892.5,35,,892.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,867,34,"If Charge > 2,000, then 34 percent",867,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1887.01,
ALPHATEC 71002-032 PLATE 2 LEVEL 32MM,C1713,HCPCS,,79005565,CDM,278,RC,,,both,,,2700,1998.01,,,1998.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1215,45,,1215,percent of total billed charges,Critical Access Hospital RCC factor,918,34,,918,percent of total billed charges,Implant Device,918,34,,918,percent of total billed charges,Implant Device,918,34,,918,percent of total billed charges,Implant Device,918,34,,918,percent of total billed charges,Implant Device,918,34,,918,percent of total billed charges,Implant Device,1336.5,,,1336.5,Other,110% of Medicare,945,35,,945,percent of total billed charges,Implant Device,918,34,"Charges > $500, x 34%",918,percent of total billed charges,Implant Device,945,35,,945,percent of total billed charges,Implant Device,945,35,,945,percent of total billed charges,Implant Device,945,35,,945,percent of total billed charges,Implant Device,945,35,,945,percent of total billed charges,Implant Device,945,35,,945,percent of total billed charges,Implant Device,1080,40,,1080,percent of total billed charges,Implant Device,945,70,,945,percent of total billed charges,All Other,918,34,,918,percent of total billed charges,Implant Device,918,34,,918,percent of total billed charges,Implant Device,945,35,,945,percent of total billed charges,Implant Device,945,35,,945,percent of total billed charges,Implant Device,945,35,,945,percent of total billed charges,Implant Device,945,35,,945,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,918,34,"If Charge > 2,000, then 34 percent",918,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1998.01,
STRYKER 371570 LOCKING SCREW 4.0X70MM,C1713,HCPCS,,79005570,CDM,278,RC,,,both,,,541,400.34,,,400.34,Other,150% of Medicare + 9.63% HCRA Surcharge,243.45,45,,243.45,percent of total billed charges,Critical Access Hospital RCC factor,183.94,34,,183.94,percent of total billed charges,Implant Device,183.94,34,,183.94,percent of total billed charges,Implant Device,183.94,34,,183.94,percent of total billed charges,Implant Device,183.94,34,,183.94,percent of total billed charges,Implant Device,183.94,34,,183.94,percent of total billed charges,Implant Device,267.8,,,267.8,Other,110% of Medicare,189.35,35,,189.35,percent of total billed charges,Implant Device,183.94,34,"Charges > $500, x 34%",183.94,percent of total billed charges,Implant Device,189.35,35,,189.35,percent of total billed charges,Implant Device,189.35,35,,189.35,percent of total billed charges,Implant Device,189.35,35,,189.35,percent of total billed charges,Implant Device,189.35,35,,189.35,percent of total billed charges,Implant Device,189.35,35,,189.35,percent of total billed charges,Implant Device,216.4,40,,216.4,percent of total billed charges,Implant Device,189.35,70,,189.35,percent of total billed charges,All Other,183.94,34,,183.94,percent of total billed charges,Implant Device,183.94,34,,183.94,percent of total billed charges,Implant Device,189.35,35,,189.35,percent of total billed charges,Implant Device,189.35,35,,189.35,percent of total billed charges,Implant Device,189.35,35,,189.35,percent of total billed charges,Implant Device,189.35,35,,189.35,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,400.34,
STRYKER 371575 LOCKING SCREW 4.0X75MM,C1713,HCPCS,,79005571,CDM,278,RC,,,both,,,541,400.34,,,400.34,Other,150% of Medicare + 9.63% HCRA Surcharge,243.45,45,,243.45,percent of total billed charges,Critical Access Hospital RCC factor,183.94,34,,183.94,percent of total billed charges,Implant Device,183.94,34,,183.94,percent of total billed charges,Implant Device,183.94,34,,183.94,percent of total billed charges,Implant Device,183.94,34,,183.94,percent of total billed charges,Implant Device,183.94,34,,183.94,percent of total billed charges,Implant Device,267.8,,,267.8,Other,110% of Medicare,189.35,35,,189.35,percent of total billed charges,Implant Device,183.94,34,"Charges > $500, x 34%",183.94,percent of total billed charges,Implant Device,189.35,35,,189.35,percent of total billed charges,Implant Device,189.35,35,,189.35,percent of total billed charges,Implant Device,189.35,35,,189.35,percent of total billed charges,Implant Device,189.35,35,,189.35,percent of total billed charges,Implant Device,189.35,35,,189.35,percent of total billed charges,Implant Device,216.4,40,,216.4,percent of total billed charges,Implant Device,189.35,70,,189.35,percent of total billed charges,All Other,183.94,34,,183.94,percent of total billed charges,Implant Device,183.94,34,,183.94,percent of total billed charges,Implant Device,189.35,35,,189.35,percent of total billed charges,Implant Device,189.35,35,,189.35,percent of total billed charges,Implant Device,189.35,35,,189.35,percent of total billed charges,Implant Device,189.35,35,,189.35,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,400.34,
STRYKER 437226 DISTAL MEDIAL TIBIA 120MM,C1776,HCPCS,,79005573,CDM,278,RC,,,both,,,5480,4055.21,,,4055.21,Other,150% of Medicare + 9.63% HCRA Surcharge,2466,45,,2466,percent of total billed charges,Critical Access Hospital RCC factor,1863.2,34,,1863.2,percent of total billed charges,Implant Device,1863.2,34,,1863.2,percent of total billed charges,Implant Device,1863.2,34,,1863.2,percent of total billed charges,Implant Device,1863.2,34,,1863.2,percent of total billed charges,Implant Device,1863.2,34,,1863.2,percent of total billed charges,Implant Device,2712.6,,,2712.6,Other,110% of Medicare,1918,35,,1918,percent of total billed charges,Implant Device,1863.2,34,"Charges > $500, x 34%",1863.2,percent of total billed charges,Implant Device,1918,35,,1918,percent of total billed charges,Implant Device,1918,35,,1918,percent of total billed charges,Implant Device,1918,35,,1918,percent of total billed charges,Implant Device,1918,35,,1918,percent of total billed charges,Implant Device,1918,35,,1918,percent of total billed charges,Implant Device,2192,40,,2192,percent of total billed charges,Implant Device,1918,70,,1918,percent of total billed charges,All Other,1863.2,34,,1863.2,percent of total billed charges,Implant Device,1863.2,34,,1863.2,percent of total billed charges,Implant Device,1918,35,,1918,percent of total billed charges,Implant Device,1918,35,,1918,percent of total billed charges,Implant Device,1918,35,,1918,percent of total billed charges,Implant Device,1918,35,,1918,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1863.2,34,"If Charge > 2,000, then 34 percent",1863.2,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4055.21,
STRYKER 371528 LOCKING SCREW 4.0X28MM,C1713,HCPCS,,79005574,CDM,278,RC,,,both,,,1081,799.94,,,799.94,Other,150% of Medicare + 9.63% HCRA Surcharge,486.45,45,,486.45,percent of total billed charges,Critical Access Hospital RCC factor,367.54,34,,367.54,percent of total billed charges,Implant Device,367.54,34,,367.54,percent of total billed charges,Implant Device,367.54,34,,367.54,percent of total billed charges,Implant Device,367.54,34,,367.54,percent of total billed charges,Implant Device,367.54,34,,367.54,percent of total billed charges,Implant Device,535.1,,,535.1,Other,110% of Medicare,378.35,35,,378.35,percent of total billed charges,Implant Device,367.54,34,"Charges > $500, x 34%",367.54,percent of total billed charges,Implant Device,378.35,35,,378.35,percent of total billed charges,Implant Device,378.35,35,,378.35,percent of total billed charges,Implant Device,378.35,35,,378.35,percent of total billed charges,Implant Device,378.35,35,,378.35,percent of total billed charges,Implant Device,378.35,35,,378.35,percent of total billed charges,Implant Device,432.4,40,,432.4,percent of total billed charges,Implant Device,378.35,70,,378.35,percent of total billed charges,All Other,367.54,34,,367.54,percent of total billed charges,Implant Device,367.54,34,,367.54,percent of total billed charges,Implant Device,378.35,35,,378.35,percent of total billed charges,Implant Device,378.35,35,,378.35,percent of total billed charges,Implant Device,378.35,35,,378.35,percent of total billed charges,Implant Device,378.35,35,,378.35,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,799.94,
STRYKER 371555 LOCKING SCREW 4.0X55MM,C1713,HCPCS,,79005575,CDM,278,RC,,,both,,,541,400.34,,,400.34,Other,150% of Medicare + 9.63% HCRA Surcharge,243.45,45,,243.45,percent of total billed charges,Critical Access Hospital RCC factor,183.94,34,,183.94,percent of total billed charges,Implant Device,183.94,34,,183.94,percent of total billed charges,Implant Device,183.94,34,,183.94,percent of total billed charges,Implant Device,183.94,34,,183.94,percent of total billed charges,Implant Device,183.94,34,,183.94,percent of total billed charges,Implant Device,267.8,,,267.8,Other,110% of Medicare,189.35,35,,189.35,percent of total billed charges,Implant Device,183.94,34,"Charges > $500, x 34%",183.94,percent of total billed charges,Implant Device,189.35,35,,189.35,percent of total billed charges,Implant Device,189.35,35,,189.35,percent of total billed charges,Implant Device,189.35,35,,189.35,percent of total billed charges,Implant Device,189.35,35,,189.35,percent of total billed charges,Implant Device,189.35,35,,189.35,percent of total billed charges,Implant Device,216.4,40,,216.4,percent of total billed charges,Implant Device,189.35,70,,189.35,percent of total billed charges,All Other,183.94,34,,183.94,percent of total billed charges,Implant Device,183.94,34,,183.94,percent of total billed charges,Implant Device,189.35,35,,189.35,percent of total billed charges,Implant Device,189.35,35,,189.35,percent of total billed charges,Implant Device,189.35,35,,189.35,percent of total billed charges,Implant Device,189.35,35,,189.35,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,400.34,
STRYKER 338628 CORTICAL SCREW 3.5X28MM,C1713,HCPCS,,79005576,CDM,278,RC,,,both,,,120,88.8,,,88.8,Other,150% of Medicare + 9.63% HCRA Surcharge,54,45,,54,percent of total billed charges,Critical Access Hospital RCC factor,40.8,34,,40.8,percent of total billed charges,Implant Device,40.8,34,,40.8,percent of total billed charges,Implant Device,40.8,34,,40.8,percent of total billed charges,Implant Device,40.8,34,,40.8,percent of total billed charges,Implant Device,40.8,34,,40.8,percent of total billed charges,Implant Device,59.4,,,59.4,Other,110% of Medicare,42,35,,42,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,42,35,,42,percent of total billed charges,Implant Device,42,35,,42,percent of total billed charges,Implant Device,42,35,,42,percent of total billed charges,Implant Device,42,35,,42,percent of total billed charges,Implant Device,42,35,,42,percent of total billed charges,Implant Device,48,40,,48,percent of total billed charges,Implant Device,42,70,,42,percent of total billed charges,All Other,40.8,34,,40.8,percent of total billed charges,Implant Device,40.8,34,,40.8,percent of total billed charges,Implant Device,42,35,,42,percent of total billed charges,Implant Device,42,35,,42,percent of total billed charges,Implant Device,42,35,,42,percent of total billed charges,Implant Device,42,35,,42,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,88.8,
STRYKER 345540 CANC SCREW PT 4.0X40MM,C1713,HCPCS,,79005577,CDM,278,RC,,,both,,,100,74,,,74,Other,150% of Medicare + 9.63% HCRA Surcharge,45,45,,45,percent of total billed charges,Critical Access Hospital RCC factor,34,34,,34,percent of total billed charges,Implant Device,34,34,,34,percent of total billed charges,Implant Device,34,34,,34,percent of total billed charges,Implant Device,34,34,,34,percent of total billed charges,Implant Device,34,34,,34,percent of total billed charges,Implant Device,49.5,,,49.5,Other,110% of Medicare,35,35,,35,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,35,35,,35,percent of total billed charges,Implant Device,35,35,,35,percent of total billed charges,Implant Device,35,35,,35,percent of total billed charges,Implant Device,35,35,,35,percent of total billed charges,Implant Device,35,35,,35,percent of total billed charges,Implant Device,40,40,,40,percent of total billed charges,Implant Device,35,70,,35,percent of total billed charges,All Other,34,34,,34,percent of total billed charges,Implant Device,34,34,,34,percent of total billed charges,Implant Device,35,35,,35,percent of total billed charges,Implant Device,35,35,,35,percent of total billed charges,Implant Device,35,35,,35,percent of total billed charges,Implant Device,35,35,,35,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,74,
STRYKER 345570 CANC SCREW PT 4.0X70MM,C1713,HCPCS,,79005578,CDM,278,RC,,,both,,,118,87.32,,,87.32,Other,150% of Medicare + 9.63% HCRA Surcharge,53.1,45,,53.1,percent of total billed charges,Critical Access Hospital RCC factor,40.12,34,,40.12,percent of total billed charges,Implant Device,40.12,34,,40.12,percent of total billed charges,Implant Device,40.12,34,,40.12,percent of total billed charges,Implant Device,40.12,34,,40.12,percent of total billed charges,Implant Device,40.12,34,,40.12,percent of total billed charges,Implant Device,58.41,,,58.41,Other,110% of Medicare,41.3,35,,41.3,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,41.3,35,,41.3,percent of total billed charges,Implant Device,41.3,35,,41.3,percent of total billed charges,Implant Device,41.3,35,,41.3,percent of total billed charges,Implant Device,41.3,35,,41.3,percent of total billed charges,Implant Device,41.3,35,,41.3,percent of total billed charges,Implant Device,47.2,40,,47.2,percent of total billed charges,Implant Device,41.3,70,,41.3,percent of total billed charges,All Other,40.12,34,,40.12,percent of total billed charges,Implant Device,40.12,34,,40.12,percent of total billed charges,Implant Device,41.3,35,,41.3,percent of total billed charges,Implant Device,41.3,35,,41.3,percent of total billed charges,Implant Device,41.3,35,,41.3,percent of total billed charges,Implant Device,41.3,35,,41.3,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,87.32,
STRYKER 2102-2205 VITOSS BB TRAUMA,C1713,HCPCS,,79005579,CDM,278,RC,,,both,,,5334,3947.17,,,3947.17,Other,150% of Medicare + 9.63% HCRA Surcharge,2400.3,45,,2400.3,percent of total billed charges,Critical Access Hospital RCC factor,1813.56,34,,1813.56,percent of total billed charges,Implant Device,1813.56,34,,1813.56,percent of total billed charges,Implant Device,1813.56,34,,1813.56,percent of total billed charges,Implant Device,1813.56,34,,1813.56,percent of total billed charges,Implant Device,1813.56,34,,1813.56,percent of total billed charges,Implant Device,2640.33,,,2640.33,Other,110% of Medicare,1866.9,35,,1866.9,percent of total billed charges,Implant Device,1813.56,34,"Charges > $500, x 34%",1813.56,percent of total billed charges,Implant Device,1866.9,35,,1866.9,percent of total billed charges,Implant Device,1866.9,35,,1866.9,percent of total billed charges,Implant Device,1866.9,35,,1866.9,percent of total billed charges,Implant Device,1866.9,35,,1866.9,percent of total billed charges,Implant Device,1866.9,35,,1866.9,percent of total billed charges,Implant Device,2133.6,40,,2133.6,percent of total billed charges,Implant Device,1866.9,70,,1866.9,percent of total billed charges,All Other,1813.56,34,,1813.56,percent of total billed charges,Implant Device,1813.56,34,,1813.56,percent of total billed charges,Implant Device,1866.9,35,,1866.9,percent of total billed charges,Implant Device,1866.9,35,,1866.9,percent of total billed charges,Implant Device,1866.9,35,,1866.9,percent of total billed charges,Implant Device,1866.9,35,,1866.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1813.56,34,"If Charge > 2,000, then 34 percent",1813.56,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3947.17,
STRYKER 604655S PT SCREW TITANIUM 4X55MM,C1713,HCPCS,,79005580,CDM,278,RC,,,both,,,824,609.76,,,609.76,Other,150% of Medicare + 9.63% HCRA Surcharge,370.8,45,,370.8,percent of total billed charges,Critical Access Hospital RCC factor,280.16,34,,280.16,percent of total billed charges,Implant Device,280.16,34,,280.16,percent of total billed charges,Implant Device,280.16,34,,280.16,percent of total billed charges,Implant Device,280.16,34,,280.16,percent of total billed charges,Implant Device,280.16,34,,280.16,percent of total billed charges,Implant Device,407.88,,,407.88,Other,110% of Medicare,288.4,35,,288.4,percent of total billed charges,Implant Device,280.16,34,"Charges > $500, x 34%",280.16,percent of total billed charges,Implant Device,288.4,35,,288.4,percent of total billed charges,Implant Device,288.4,35,,288.4,percent of total billed charges,Implant Device,288.4,35,,288.4,percent of total billed charges,Implant Device,288.4,35,,288.4,percent of total billed charges,Implant Device,288.4,35,,288.4,percent of total billed charges,Implant Device,329.6,40,,329.6,percent of total billed charges,Implant Device,288.4,70,,288.4,percent of total billed charges,All Other,280.16,34,,280.16,percent of total billed charges,Implant Device,280.16,34,,280.16,percent of total billed charges,Implant Device,288.4,35,,288.4,percent of total billed charges,Implant Device,288.4,35,,288.4,percent of total billed charges,Implant Device,288.4,35,,288.4,percent of total billed charges,Implant Device,288.4,35,,288.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,609.76,
STRYKER 604638 ASNIS SCREW 4.0 X 38MM,C1713,HCPCS,,79005581,CDM,278,RC,,,both,,,446,330.04,,,330.04,Other,150% of Medicare + 9.63% HCRA Surcharge,200.7,45,,200.7,percent of total billed charges,Critical Access Hospital RCC factor,151.64,34,,151.64,percent of total billed charges,Implant Device,151.64,34,,151.64,percent of total billed charges,Implant Device,151.64,34,,151.64,percent of total billed charges,Implant Device,151.64,34,,151.64,percent of total billed charges,Implant Device,151.64,34,,151.64,percent of total billed charges,Implant Device,220.77,,,220.77,Other,110% of Medicare,156.1,35,,156.1,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,156.1,35,,156.1,percent of total billed charges,Implant Device,156.1,35,,156.1,percent of total billed charges,Implant Device,156.1,35,,156.1,percent of total billed charges,Implant Device,156.1,35,,156.1,percent of total billed charges,Implant Device,156.1,35,,156.1,percent of total billed charges,Implant Device,178.4,40,,178.4,percent of total billed charges,Implant Device,156.1,70,,156.1,percent of total billed charges,All Other,151.64,34,,151.64,percent of total billed charges,Implant Device,151.64,34,,151.64,percent of total billed charges,Implant Device,156.1,35,,156.1,percent of total billed charges,Implant Device,156.1,35,,156.1,percent of total billed charges,Implant Device,156.1,35,,156.1,percent of total billed charges,Implant Device,156.1,35,,156.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,330.04,
EXACTECH 304-21-11 PLATFORM STEM LT 10.5,C1776,HCPCS,,79005582,CDM,278,RC,,,both,,,6225,4606.52,,,4606.52,Other,150% of Medicare + 9.63% HCRA Surcharge,2801.25,45,,2801.25,percent of total billed charges,Critical Access Hospital RCC factor,2116.5,34,,2116.5,percent of total billed charges,Implant Device,2116.5,34,,2116.5,percent of total billed charges,Implant Device,2116.5,34,,2116.5,percent of total billed charges,Implant Device,2116.5,34,,2116.5,percent of total billed charges,Implant Device,2116.5,34,,2116.5,percent of total billed charges,Implant Device,3081.38,,,3081.38,Other,110% of Medicare,2178.75,35,,2178.75,percent of total billed charges,Implant Device,2116.5,34,"Charges > $500, x 34%",2116.5,percent of total billed charges,Implant Device,2178.75,35,,2178.75,percent of total billed charges,Implant Device,2178.75,35,,2178.75,percent of total billed charges,Implant Device,2178.75,35,,2178.75,percent of total billed charges,Implant Device,2178.75,35,,2178.75,percent of total billed charges,Implant Device,2178.75,35,,2178.75,percent of total billed charges,Implant Device,2490,40,,2490,percent of total billed charges,Implant Device,2178.75,70,,2178.75,percent of total billed charges,All Other,2116.5,34,,2116.5,percent of total billed charges,Implant Device,2116.5,34,,2116.5,percent of total billed charges,Implant Device,2178.75,35,,2178.75,percent of total billed charges,Implant Device,2178.75,35,,2178.75,percent of total billed charges,Implant Device,2178.75,35,,2178.75,percent of total billed charges,Implant Device,2178.75,35,,2178.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2116.5,34,"If Charge > 2,000, then 34 percent",2116.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4606.52,
BIOMET 11-165212 BIPOLAR ACETAB CUP 28MM,C1776,HCPCS,,79005583,CDM,278,RC,,,both,,,6540,4839.62,,,4839.62,Other,150% of Medicare + 9.63% HCRA Surcharge,2943,45,,2943,percent of total billed charges,Critical Access Hospital RCC factor,2223.6,34,,2223.6,percent of total billed charges,Implant Device,2223.6,34,,2223.6,percent of total billed charges,Implant Device,2223.6,34,,2223.6,percent of total billed charges,Implant Device,2223.6,34,,2223.6,percent of total billed charges,Implant Device,2223.6,34,,2223.6,percent of total billed charges,Implant Device,3237.3,,,3237.3,Other,110% of Medicare,2289,35,,2289,percent of total billed charges,Implant Device,2223.6,34,"Charges > $500, x 34%",2223.6,percent of total billed charges,Implant Device,2289,35,,2289,percent of total billed charges,Implant Device,2289,35,,2289,percent of total billed charges,Implant Device,2289,35,,2289,percent of total billed charges,Implant Device,2289,35,,2289,percent of total billed charges,Implant Device,2289,35,,2289,percent of total billed charges,Implant Device,2616,40,,2616,percent of total billed charges,Implant Device,2289,70,,2289,percent of total billed charges,All Other,2223.6,34,,2223.6,percent of total billed charges,Implant Device,2223.6,34,,2223.6,percent of total billed charges,Implant Device,2289,35,,2289,percent of total billed charges,Implant Device,2289,35,,2289,percent of total billed charges,Implant Device,2289,35,,2289,percent of total billed charges,Implant Device,2289,35,,2289,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2223.6,34,"If Charge > 2,000, then 34 percent",2223.6,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4839.62,
BIOMET 12-150312 ECHO HIP 12X145MM,C1776,HCPCS,,79005584,CDM,278,RC,,,both,,,15240,11277.64,,,11277.64,Other,150% of Medicare + 9.63% HCRA Surcharge,6858,45,,6858,percent of total billed charges,Critical Access Hospital RCC factor,5181.6,34,,5181.6,percent of total billed charges,Implant Device,5181.6,34,,5181.6,percent of total billed charges,Implant Device,5181.6,34,,5181.6,percent of total billed charges,Implant Device,5181.6,34,,5181.6,percent of total billed charges,Implant Device,5181.6,34,,5181.6,percent of total billed charges,Implant Device,7543.8,,,7543.8,Other,110% of Medicare,5334,35,,5334,percent of total billed charges,Implant Device,5181.6,34,"Charges > $500, x 34%",5181.6,percent of total billed charges,Implant Device,5334,35,,5334,percent of total billed charges,Implant Device,5334,35,,5334,percent of total billed charges,Implant Device,5334,35,,5334,percent of total billed charges,Implant Device,5334,35,,5334,percent of total billed charges,Implant Device,5334,35,,5334,percent of total billed charges,Implant Device,6096,40,,6096,percent of total billed charges,Implant Device,5334,70,,5334,percent of total billed charges,All Other,5181.6,34,,5181.6,percent of total billed charges,Implant Device,5181.6,34,,5181.6,percent of total billed charges,Implant Device,5334,35,,5334,percent of total billed charges,Implant Device,5334,35,,5334,percent of total billed charges,Implant Device,5334,35,,5334,percent of total billed charges,Implant Device,5334,35,,5334,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,5181.6,34,"If Charge > 2,000, then 34 percent",5181.6,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,11277.64,
EXACTECH 340-38-44 CANC SCREW 3.9X44MM,C1713,HCPCS,,79005585,CDM,278,RC,,,both,,,499,369.26,,,369.26,Other,150% of Medicare + 9.63% HCRA Surcharge,224.55,45,,224.55,percent of total billed charges,Critical Access Hospital RCC factor,169.66,34,,169.66,percent of total billed charges,Implant Device,169.66,34,,169.66,percent of total billed charges,Implant Device,169.66,34,,169.66,percent of total billed charges,Implant Device,169.66,34,,169.66,percent of total billed charges,Implant Device,169.66,34,,169.66,percent of total billed charges,Implant Device,247.01,,,247.01,Other,110% of Medicare,174.65,35,,174.65,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,174.65,35,,174.65,percent of total billed charges,Implant Device,174.65,35,,174.65,percent of total billed charges,Implant Device,174.65,35,,174.65,percent of total billed charges,Implant Device,174.65,35,,174.65,percent of total billed charges,Implant Device,174.65,35,,174.65,percent of total billed charges,Implant Device,199.6,40,,199.6,percent of total billed charges,Implant Device,174.65,70,,174.65,percent of total billed charges,All Other,169.66,34,,169.66,percent of total billed charges,Implant Device,169.66,34,,169.66,percent of total billed charges,Implant Device,174.65,35,,174.65,percent of total billed charges,Implant Device,174.65,35,,174.65,percent of total billed charges,Implant Device,174.65,35,,174.65,percent of total billed charges,Implant Device,174.65,35,,174.65,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,369.26,
ZIMMER 5952-40-10 ART SURF SZ GRN/C-H 10,C1776,HCPCS,,79005586,CDM,278,RC,,,both,,,2496,1847.05,,,1847.05,Other,150% of Medicare + 9.63% HCRA Surcharge,1123.2,45,,1123.2,percent of total billed charges,Critical Access Hospital RCC factor,848.64,34,,848.64,percent of total billed charges,Implant Device,848.64,34,,848.64,percent of total billed charges,Implant Device,848.64,34,,848.64,percent of total billed charges,Implant Device,848.64,34,,848.64,percent of total billed charges,Implant Device,848.64,34,,848.64,percent of total billed charges,Implant Device,1235.52,,,1235.52,Other,110% of Medicare,873.6,35,,873.6,percent of total billed charges,Implant Device,848.64,34,"Charges > $500, x 34%",848.64,percent of total billed charges,Implant Device,873.6,35,,873.6,percent of total billed charges,Implant Device,873.6,35,,873.6,percent of total billed charges,Implant Device,873.6,35,,873.6,percent of total billed charges,Implant Device,873.6,35,,873.6,percent of total billed charges,Implant Device,873.6,35,,873.6,percent of total billed charges,Implant Device,998.4,40,,998.4,percent of total billed charges,Implant Device,873.6,70,,873.6,percent of total billed charges,All Other,848.64,34,,848.64,percent of total billed charges,Implant Device,848.64,34,,848.64,percent of total billed charges,Implant Device,873.6,35,,873.6,percent of total billed charges,Implant Device,873.6,35,,873.6,percent of total billed charges,Implant Device,873.6,35,,873.6,percent of total billed charges,Implant Device,873.6,35,,873.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,848.64,34,"If Charge > 2,000, then 34 percent",848.64,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1847.05,
BIOMET 162658 DISTAL CENTRALIZER 13MM,C1776,HCPCS,,79005588,CDM,278,RC,,,both,,,960,710.4,,,710.4,Other,150% of Medicare + 9.63% HCRA Surcharge,432,45,,432,percent of total billed charges,Critical Access Hospital RCC factor,326.4,34,,326.4,percent of total billed charges,Implant Device,326.4,34,,326.4,percent of total billed charges,Implant Device,326.4,34,,326.4,percent of total billed charges,Implant Device,326.4,34,,326.4,percent of total billed charges,Implant Device,326.4,34,,326.4,percent of total billed charges,Implant Device,475.2,,,475.2,Other,110% of Medicare,336,35,,336,percent of total billed charges,Implant Device,326.4,34,"Charges > $500, x 34%",326.4,percent of total billed charges,Implant Device,336,35,,336,percent of total billed charges,Implant Device,336,35,,336,percent of total billed charges,Implant Device,336,35,,336,percent of total billed charges,Implant Device,336,35,,336,percent of total billed charges,Implant Device,336,35,,336,percent of total billed charges,Implant Device,384,40,,384,percent of total billed charges,Implant Device,336,70,,336,percent of total billed charges,All Other,326.4,34,,326.4,percent of total billed charges,Implant Device,326.4,34,,326.4,percent of total billed charges,Implant Device,336,35,,336,percent of total billed charges,Implant Device,336,35,,336,percent of total billed charges,Implant Device,336,35,,336,percent of total billed charges,Implant Device,336,35,,336,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,710.4,
BIOMET 12-151311 ECHO HIP 11X148MM,C1776,HCPCS,,79005589,CDM,278,RC,,,both,,,8820,6526.82,,,6526.82,Other,150% of Medicare + 9.63% HCRA Surcharge,3969,45,,3969,percent of total billed charges,Critical Access Hospital RCC factor,2998.8,34,,2998.8,percent of total billed charges,Implant Device,2998.8,34,,2998.8,percent of total billed charges,Implant Device,2998.8,34,,2998.8,percent of total billed charges,Implant Device,2998.8,34,,2998.8,percent of total billed charges,Implant Device,2998.8,34,,2998.8,percent of total billed charges,Implant Device,4365.9,,,4365.9,Other,110% of Medicare,3087,35,,3087,percent of total billed charges,Implant Device,2998.8,34,"Charges > $500, x 34%",2998.8,percent of total billed charges,Implant Device,3087,35,,3087,percent of total billed charges,Implant Device,3087,35,,3087,percent of total billed charges,Implant Device,3087,35,,3087,percent of total billed charges,Implant Device,3087,35,,3087,percent of total billed charges,Implant Device,3087,35,,3087,percent of total billed charges,Implant Device,3528,40,,3528,percent of total billed charges,Implant Device,3087,70,,3087,percent of total billed charges,All Other,2998.8,34,,2998.8,percent of total billed charges,Implant Device,2998.8,34,,2998.8,percent of total billed charges,Implant Device,3087,35,,3087,percent of total billed charges,Implant Device,3087,35,,3087,percent of total billed charges,Implant Device,3087,35,,3087,percent of total billed charges,Implant Device,3087,35,,3087,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2998.8,34,"If Charge > 2,000, then 34 percent",2998.8,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,6526.82,
ZIMMER 47-2484-035-50 Z NAIL 5X35MM,C1713,HCPCS,,79005593,CDM,278,RC,,,both,,,605,447.7,,,447.7,Other,150% of Medicare + 9.63% HCRA Surcharge,272.25,45,,272.25,percent of total billed charges,Critical Access Hospital RCC factor,205.7,34,,205.7,percent of total billed charges,Implant Device,205.7,34,,205.7,percent of total billed charges,Implant Device,205.7,34,,205.7,percent of total billed charges,Implant Device,205.7,34,,205.7,percent of total billed charges,Implant Device,205.7,34,,205.7,percent of total billed charges,Implant Device,299.48,,,299.48,Other,110% of Medicare,211.75,35,,211.75,percent of total billed charges,Implant Device,205.7,34,"Charges > $500, x 34%",205.7,percent of total billed charges,Implant Device,211.75,35,,211.75,percent of total billed charges,Implant Device,211.75,35,,211.75,percent of total billed charges,Implant Device,211.75,35,,211.75,percent of total billed charges,Implant Device,211.75,35,,211.75,percent of total billed charges,Implant Device,211.75,35,,211.75,percent of total billed charges,Implant Device,242,40,,242,percent of total billed charges,Implant Device,211.75,70,,211.75,percent of total billed charges,All Other,205.7,34,,205.7,percent of total billed charges,Implant Device,205.7,34,,205.7,percent of total billed charges,Implant Device,211.75,35,,211.75,percent of total billed charges,Implant Device,211.75,35,,211.75,percent of total billed charges,Implant Device,211.75,35,,211.75,percent of total billed charges,Implant Device,211.75,35,,211.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,447.7,
BOST SCI 7065 WALLFLEX BILIARY 10X80MM,C1876,HCPCS,,79005594,CDM,278,RC,,,both,,,5550,4107.01,,,4107.01,Other,150% of Medicare + 9.63% HCRA Surcharge,2497.5,45,,2497.5,percent of total billed charges,Critical Access Hospital RCC factor,1887,34,,1887,percent of total billed charges,Implant Device,1887,34,,1887,percent of total billed charges,Implant Device,1887,34,,1887,percent of total billed charges,Implant Device,1887,34,,1887,percent of total billed charges,Implant Device,1887,34,,1887,percent of total billed charges,Implant Device,2747.25,,,2747.25,Other,110% of Medicare,1942.5,35,,1942.5,percent of total billed charges,Implant Device,1887,34,"Charges > $500, x 34%",1887,percent of total billed charges,Implant Device,1942.5,35,,1942.5,percent of total billed charges,Implant Device,1942.5,35,,1942.5,percent of total billed charges,Implant Device,1942.5,35,,1942.5,percent of total billed charges,Implant Device,1942.5,35,,1942.5,percent of total billed charges,Implant Device,1942.5,35,,1942.5,percent of total billed charges,Implant Device,2220,40,,2220,percent of total billed charges,Implant Device,1942.5,70,,1942.5,percent of total billed charges,All Other,1887,34,,1887,percent of total billed charges,Implant Device,1887,34,,1887,percent of total billed charges,Implant Device,1942.5,35,,1942.5,percent of total billed charges,Implant Device,1942.5,35,,1942.5,percent of total billed charges,Implant Device,1942.5,35,,1942.5,percent of total billed charges,Implant Device,1942.5,35,,1942.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1887,34,"If Charge > 2,000, then 34 percent",1887,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4107.01,
ZIMMER 47-4936-007-03 PLATE 7HOLE 3.5X94,C1713,HCPCS,,79005595,CDM,278,RC,,,both,,,529,391.46,,,391.46,Other,150% of Medicare + 9.63% HCRA Surcharge,238.05,45,,238.05,percent of total billed charges,Critical Access Hospital RCC factor,179.86,34,,179.86,percent of total billed charges,Implant Device,179.86,34,,179.86,percent of total billed charges,Implant Device,179.86,34,,179.86,percent of total billed charges,Implant Device,179.86,34,,179.86,percent of total billed charges,Implant Device,179.86,34,,179.86,percent of total billed charges,Implant Device,261.86,,,261.86,Other,110% of Medicare,185.15,35,,185.15,percent of total billed charges,Implant Device,179.86,34,"Charges > $500, x 34%",179.86,percent of total billed charges,Implant Device,185.15,35,,185.15,percent of total billed charges,Implant Device,185.15,35,,185.15,percent of total billed charges,Implant Device,185.15,35,,185.15,percent of total billed charges,Implant Device,185.15,35,,185.15,percent of total billed charges,Implant Device,185.15,35,,185.15,percent of total billed charges,Implant Device,211.6,40,,211.6,percent of total billed charges,Implant Device,185.15,70,,185.15,percent of total billed charges,All Other,179.86,34,,179.86,percent of total billed charges,Implant Device,179.86,34,,179.86,percent of total billed charges,Implant Device,185.15,35,,185.15,percent of total billed charges,Implant Device,185.15,35,,185.15,percent of total billed charges,Implant Device,185.15,35,,185.15,percent of total billed charges,Implant Device,185.15,35,,185.15,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,391.46,
ALAMO TISSUE SVC AT290FF ACHILLES TENDON,C1713,HCPCS,,79005596,CDM,278,RC,,,both,,,5400,3996.01,,,3996.01,Other,150% of Medicare + 9.63% HCRA Surcharge,2430,45,,2430,percent of total billed charges,Critical Access Hospital RCC factor,1836,34,,1836,percent of total billed charges,Implant Device,1836,34,,1836,percent of total billed charges,Implant Device,1836,34,,1836,percent of total billed charges,Implant Device,1836,34,,1836,percent of total billed charges,Implant Device,1836,34,,1836,percent of total billed charges,Implant Device,2673,,,2673,Other,110% of Medicare,1890,35,,1890,percent of total billed charges,Implant Device,1836,34,"Charges > $500, x 34%",1836,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,2160,40,,2160,percent of total billed charges,Implant Device,1890,70,,1890,percent of total billed charges,All Other,1836,34,,1836,percent of total billed charges,Implant Device,1836,34,,1836,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1836,34,"If Charge > 2,000, then 34 percent",1836,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3996.01,
ZIMMER 5842-03-01 TIBIAL COMPONENT SZ 3,C1776,HCPCS,,79005598,CDM,278,RC,,,both,,,6346,4696.06,,,4696.06,Other,150% of Medicare + 9.63% HCRA Surcharge,2855.7,45,,2855.7,percent of total billed charges,Critical Access Hospital RCC factor,2157.64,34,,2157.64,percent of total billed charges,Implant Device,2157.64,34,,2157.64,percent of total billed charges,Implant Device,2157.64,34,,2157.64,percent of total billed charges,Implant Device,2157.64,34,,2157.64,percent of total billed charges,Implant Device,2157.64,34,,2157.64,percent of total billed charges,Implant Device,3141.27,,,3141.27,Other,110% of Medicare,2221.1,35,,2221.1,percent of total billed charges,Implant Device,2157.64,34,"Charges > $500, x 34%",2157.64,percent of total billed charges,Implant Device,2221.1,35,,2221.1,percent of total billed charges,Implant Device,2221.1,35,,2221.1,percent of total billed charges,Implant Device,2221.1,35,,2221.1,percent of total billed charges,Implant Device,2221.1,35,,2221.1,percent of total billed charges,Implant Device,2221.1,35,,2221.1,percent of total billed charges,Implant Device,2538.4,40,,2538.4,percent of total billed charges,Implant Device,2221.1,70,,2221.1,percent of total billed charges,All Other,2157.64,34,,2157.64,percent of total billed charges,Implant Device,2157.64,34,,2157.64,percent of total billed charges,Implant Device,2221.1,35,,2221.1,percent of total billed charges,Implant Device,2221.1,35,,2221.1,percent of total billed charges,Implant Device,2221.1,35,,2221.1,percent of total billed charges,Implant Device,2221.1,35,,2221.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2157.64,34,"If Charge > 2,000, then 34 percent",2157.64,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4696.06,
ZIMMER 5842-14-01 FEMORAL COMPONENT SZ D,C1776,HCPCS,,79005599,CDM,278,RC,,,both,,,10486,7759.67,,,7759.67,Other,150% of Medicare + 9.63% HCRA Surcharge,4718.7,45,,4718.7,percent of total billed charges,Critical Access Hospital RCC factor,3565.24,34,,3565.24,percent of total billed charges,Implant Device,3565.24,34,,3565.24,percent of total billed charges,Implant Device,3565.24,34,,3565.24,percent of total billed charges,Implant Device,3565.24,34,,3565.24,percent of total billed charges,Implant Device,3565.24,34,,3565.24,percent of total billed charges,Implant Device,5190.57,,,5190.57,Other,110% of Medicare,3670.1,35,,3670.1,percent of total billed charges,Implant Device,3565.24,34,"Charges > $500, x 34%",3565.24,percent of total billed charges,Implant Device,3670.1,35,,3670.1,percent of total billed charges,Implant Device,3670.1,35,,3670.1,percent of total billed charges,Implant Device,3670.1,35,,3670.1,percent of total billed charges,Implant Device,3670.1,35,,3670.1,percent of total billed charges,Implant Device,3670.1,35,,3670.1,percent of total billed charges,Implant Device,4194.4,40,,4194.4,percent of total billed charges,Implant Device,3670.1,70,,3670.1,percent of total billed charges,All Other,3565.24,34,,3565.24,percent of total billed charges,Implant Device,3565.24,34,,3565.24,percent of total billed charges,Implant Device,3670.1,35,,3670.1,percent of total billed charges,Implant Device,3670.1,35,,3670.1,percent of total billed charges,Implant Device,3670.1,35,,3670.1,percent of total billed charges,Implant Device,3670.1,35,,3670.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3565.24,34,"If Charge > 2,000, then 34 percent",3565.24,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,7759.67,
ZIMMER 5842-24-09 ARTICULAR SURFACE SZ 4,C1776,HCPCS,,79005600,CDM,278,RC,,,both,,,2677,1980.99,,,1980.99,Other,150% of Medicare + 9.63% HCRA Surcharge,1204.65,45,,1204.65,percent of total billed charges,Critical Access Hospital RCC factor,910.18,34,,910.18,percent of total billed charges,Implant Device,910.18,34,,910.18,percent of total billed charges,Implant Device,910.18,34,,910.18,percent of total billed charges,Implant Device,910.18,34,,910.18,percent of total billed charges,Implant Device,910.18,34,,910.18,percent of total billed charges,Implant Device,1325.12,,,1325.12,Other,110% of Medicare,936.95,35,,936.95,percent of total billed charges,Implant Device,910.18,34,"Charges > $500, x 34%",910.18,percent of total billed charges,Implant Device,936.95,35,,936.95,percent of total billed charges,Implant Device,936.95,35,,936.95,percent of total billed charges,Implant Device,936.95,35,,936.95,percent of total billed charges,Implant Device,936.95,35,,936.95,percent of total billed charges,Implant Device,936.95,35,,936.95,percent of total billed charges,Implant Device,1070.8,40,,1070.8,percent of total billed charges,Implant Device,936.95,70,,936.95,percent of total billed charges,All Other,910.18,34,,910.18,percent of total billed charges,Implant Device,910.18,34,,910.18,percent of total billed charges,Implant Device,936.95,35,,936.95,percent of total billed charges,Implant Device,936.95,35,,936.95,percent of total billed charges,Implant Device,936.95,35,,936.95,percent of total billed charges,Implant Device,936.95,35,,936.95,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,910.18,34,"If Charge > 2,000, then 34 percent",910.18,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1980.99,
STRYKER 437322 PROX LATERAL TIBIA PLATE,C1776,HCPCS,,79005601,CDM,278,RC,,,both,,,5315,3933.11,,,3933.11,Other,150% of Medicare + 9.63% HCRA Surcharge,2391.75,45,,2391.75,percent of total billed charges,Critical Access Hospital RCC factor,1807.1,34,,1807.1,percent of total billed charges,Implant Device,1807.1,34,,1807.1,percent of total billed charges,Implant Device,1807.1,34,,1807.1,percent of total billed charges,Implant Device,1807.1,34,,1807.1,percent of total billed charges,Implant Device,1807.1,34,,1807.1,percent of total billed charges,Implant Device,2630.93,,,2630.93,Other,110% of Medicare,1860.25,35,,1860.25,percent of total billed charges,Implant Device,1807.1,34,"Charges > $500, x 34%",1807.1,percent of total billed charges,Implant Device,1860.25,35,,1860.25,percent of total billed charges,Implant Device,1860.25,35,,1860.25,percent of total billed charges,Implant Device,1860.25,35,,1860.25,percent of total billed charges,Implant Device,1860.25,35,,1860.25,percent of total billed charges,Implant Device,1860.25,35,,1860.25,percent of total billed charges,Implant Device,2126,40,,2126,percent of total billed charges,Implant Device,1860.25,70,,1860.25,percent of total billed charges,All Other,1807.1,34,,1807.1,percent of total billed charges,Implant Device,1807.1,34,,1807.1,percent of total billed charges,Implant Device,1860.25,35,,1860.25,percent of total billed charges,Implant Device,1860.25,35,,1860.25,percent of total billed charges,Implant Device,1860.25,35,,1860.25,percent of total billed charges,Implant Device,1860.25,35,,1860.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1807.1,34,"If Charge > 2,000, then 34 percent",1807.1,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3933.11,
STRYKER 397015 HYDROSET 15CC,C1713,HCPCS,,79005602,CDM,278,RC,,,both,,,13861,10257.17,,,10257.17,Other,150% of Medicare + 9.63% HCRA Surcharge,6237.45,45,,6237.45,percent of total billed charges,Critical Access Hospital RCC factor,4712.74,34,,4712.74,percent of total billed charges,Implant Device,4712.74,34,,4712.74,percent of total billed charges,Implant Device,4712.74,34,,4712.74,percent of total billed charges,Implant Device,4712.74,34,,4712.74,percent of total billed charges,Implant Device,4712.74,34,,4712.74,percent of total billed charges,Implant Device,6861.2,,,6861.2,Other,110% of Medicare,4851.35,35,,4851.35,percent of total billed charges,Implant Device,4712.74,34,"Charges > $500, x 34%",4712.74,percent of total billed charges,Implant Device,4851.35,35,,4851.35,percent of total billed charges,Implant Device,4851.35,35,,4851.35,percent of total billed charges,Implant Device,4851.35,35,,4851.35,percent of total billed charges,Implant Device,4851.35,35,,4851.35,percent of total billed charges,Implant Device,4851.35,35,,4851.35,percent of total billed charges,Implant Device,5544.4,40,,5544.4,percent of total billed charges,Implant Device,4851.35,70,,4851.35,percent of total billed charges,All Other,4712.74,34,,4712.74,percent of total billed charges,Implant Device,4712.74,34,,4712.74,percent of total billed charges,Implant Device,4851.35,35,,4851.35,percent of total billed charges,Implant Device,4851.35,35,,4851.35,percent of total billed charges,Implant Device,4851.35,35,,4851.35,percent of total billed charges,Implant Device,4851.35,35,,4851.35,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,4712.74,34,"If Charge > 2,000, then 34 percent",4712.74,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,10257.17,
DEPUY 1035-49-000 BIPOLAR HEAD 28X49MM,C1776,HCPCS,,79005603,CDM,278,RC,,,both,,,4030,2982.21,,,2982.21,Other,150% of Medicare + 9.63% HCRA Surcharge,1813.5,45,,1813.5,percent of total billed charges,Critical Access Hospital RCC factor,1370.2,34,,1370.2,percent of total billed charges,Implant Device,1370.2,34,,1370.2,percent of total billed charges,Implant Device,1370.2,34,,1370.2,percent of total billed charges,Implant Device,1370.2,34,,1370.2,percent of total billed charges,Implant Device,1370.2,34,,1370.2,percent of total billed charges,Implant Device,1994.85,,,1994.85,Other,110% of Medicare,1410.5,35,,1410.5,percent of total billed charges,Implant Device,1370.2,34,"Charges > $500, x 34%",1370.2,percent of total billed charges,Implant Device,1410.5,35,,1410.5,percent of total billed charges,Implant Device,1410.5,35,,1410.5,percent of total billed charges,Implant Device,1410.5,35,,1410.5,percent of total billed charges,Implant Device,1410.5,35,,1410.5,percent of total billed charges,Implant Device,1410.5,35,,1410.5,percent of total billed charges,Implant Device,1612,40,,1612,percent of total billed charges,Implant Device,1410.5,70,,1410.5,percent of total billed charges,All Other,1370.2,34,,1370.2,percent of total billed charges,Implant Device,1370.2,34,,1370.2,percent of total billed charges,Implant Device,1410.5,35,,1410.5,percent of total billed charges,Implant Device,1410.5,35,,1410.5,percent of total billed charges,Implant Device,1410.5,35,,1410.5,percent of total billed charges,Implant Device,1410.5,35,,1410.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1370.2,34,"If Charge > 2,000, then 34 percent",1370.2,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2982.21,
DEPUY 1365-11-000 FEMORAL HEAD 28MM,C1776,HCPCS,,79005604,CDM,278,RC,,,both,,,1710,1265.4,,,1265.4,Other,150% of Medicare + 9.63% HCRA Surcharge,769.5,45,,769.5,percent of total billed charges,Critical Access Hospital RCC factor,581.4,34,,581.4,percent of total billed charges,Implant Device,581.4,34,,581.4,percent of total billed charges,Implant Device,581.4,34,,581.4,percent of total billed charges,Implant Device,581.4,34,,581.4,percent of total billed charges,Implant Device,581.4,34,,581.4,percent of total billed charges,Implant Device,846.45,,,846.45,Other,110% of Medicare,598.5,35,,598.5,percent of total billed charges,Implant Device,581.4,34,"Charges > $500, x 34%",581.4,percent of total billed charges,Implant Device,598.5,35,,598.5,percent of total billed charges,Implant Device,598.5,35,,598.5,percent of total billed charges,Implant Device,598.5,35,,598.5,percent of total billed charges,Implant Device,598.5,35,,598.5,percent of total billed charges,Implant Device,598.5,35,,598.5,percent of total billed charges,Implant Device,684,40,,684,percent of total billed charges,Implant Device,598.5,70,,598.5,percent of total billed charges,All Other,581.4,34,,581.4,percent of total billed charges,Implant Device,581.4,34,,581.4,percent of total billed charges,Implant Device,598.5,35,,598.5,percent of total billed charges,Implant Device,598.5,35,,598.5,percent of total billed charges,Implant Device,598.5,35,,598.5,percent of total billed charges,Implant Device,598.5,35,,598.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1265.4,
DEPUY 1975-20-085 RECLAIM LCK BOLT 20X85,C1713,HCPCS,,79005605,CDM,278,RC,,,both,,,16910,12513.44,,,12513.44,Other,150% of Medicare + 9.63% HCRA Surcharge,7609.5,45,,7609.5,percent of total billed charges,Critical Access Hospital RCC factor,5749.4,34,,5749.4,percent of total billed charges,Implant Device,5749.4,34,,5749.4,percent of total billed charges,Implant Device,5749.4,34,,5749.4,percent of total billed charges,Implant Device,5749.4,34,,5749.4,percent of total billed charges,Implant Device,5749.4,34,,5749.4,percent of total billed charges,Implant Device,8370.45,,,8370.45,Other,110% of Medicare,5918.5,35,,5918.5,percent of total billed charges,Implant Device,5749.4,34,"Charges > $500, x 34%",5749.4,percent of total billed charges,Implant Device,5918.5,35,,5918.5,percent of total billed charges,Implant Device,5918.5,35,,5918.5,percent of total billed charges,Implant Device,5918.5,35,,5918.5,percent of total billed charges,Implant Device,5918.5,35,,5918.5,percent of total billed charges,Implant Device,5918.5,35,,5918.5,percent of total billed charges,Implant Device,6764,40,,6764,percent of total billed charges,Implant Device,5918.5,70,,5918.5,percent of total billed charges,All Other,5749.4,34,,5749.4,percent of total billed charges,Implant Device,5749.4,34,,5749.4,percent of total billed charges,Implant Device,5918.5,35,,5918.5,percent of total billed charges,Implant Device,5918.5,35,,5918.5,percent of total billed charges,Implant Device,5918.5,35,,5918.5,percent of total billed charges,Implant Device,5918.5,35,,5918.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,5749.4,34,"If Charge > 2,000, then 34 percent",5749.4,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,12513.44,
DEPUY 1976-15-140 RECLAIM STEM 15X140,C1776,HCPCS,,79005606,CDM,278,RC,,,both,,,14138,10462.16,,,10462.16,Other,150% of Medicare + 9.63% HCRA Surcharge,6362.1,45,,6362.1,percent of total billed charges,Critical Access Hospital RCC factor,4806.92,34,,4806.92,percent of total billed charges,Implant Device,4806.92,34,,4806.92,percent of total billed charges,Implant Device,4806.92,34,,4806.92,percent of total billed charges,Implant Device,4806.92,34,,4806.92,percent of total billed charges,Implant Device,4806.92,34,,4806.92,percent of total billed charges,Implant Device,6998.31,,,6998.31,Other,110% of Medicare,4948.3,35,,4948.3,percent of total billed charges,Implant Device,4806.92,34,"Charges > $500, x 34%",4806.92,percent of total billed charges,Implant Device,4948.3,35,,4948.3,percent of total billed charges,Implant Device,4948.3,35,,4948.3,percent of total billed charges,Implant Device,4948.3,35,,4948.3,percent of total billed charges,Implant Device,4948.3,35,,4948.3,percent of total billed charges,Implant Device,4948.3,35,,4948.3,percent of total billed charges,Implant Device,5655.2,40,,5655.2,percent of total billed charges,Implant Device,4948.3,70,,4948.3,percent of total billed charges,All Other,4806.92,34,,4806.92,percent of total billed charges,Implant Device,4806.92,34,,4806.92,percent of total billed charges,Implant Device,4948.3,35,,4948.3,percent of total billed charges,Implant Device,4948.3,35,,4948.3,percent of total billed charges,Implant Device,4948.3,35,,4948.3,percent of total billed charges,Implant Device,4948.3,35,,4948.3,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,4806.92,34,"If Charge > 2,000, then 34 percent",4806.92,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,10462.16,
STRYKER 3225-0420S LONG NAIL KIT 11X420,C1713,HCPCS,,79005610,CDM,278,RC,,,both,,,8221,6083.56,,,6083.56,Other,150% of Medicare + 9.63% HCRA Surcharge,3699.45,45,,3699.45,percent of total billed charges,Critical Access Hospital RCC factor,2795.14,34,,2795.14,percent of total billed charges,Implant Device,2795.14,34,,2795.14,percent of total billed charges,Implant Device,2795.14,34,,2795.14,percent of total billed charges,Implant Device,2795.14,34,,2795.14,percent of total billed charges,Implant Device,2795.14,34,,2795.14,percent of total billed charges,Implant Device,4069.4,,,4069.4,Other,110% of Medicare,2877.35,35,,2877.35,percent of total billed charges,Implant Device,2795.14,34,"Charges > $500, x 34%",2795.14,percent of total billed charges,Implant Device,2877.35,35,,2877.35,percent of total billed charges,Implant Device,2877.35,35,,2877.35,percent of total billed charges,Implant Device,2877.35,35,,2877.35,percent of total billed charges,Implant Device,2877.35,35,,2877.35,percent of total billed charges,Implant Device,2877.35,35,,2877.35,percent of total billed charges,Implant Device,3288.4,40,,3288.4,percent of total billed charges,Implant Device,2877.35,70,,2877.35,percent of total billed charges,All Other,2795.14,34,,2795.14,percent of total billed charges,Implant Device,2795.14,34,,2795.14,percent of total billed charges,Implant Device,2877.35,35,,2877.35,percent of total billed charges,Implant Device,2877.35,35,,2877.35,percent of total billed charges,Implant Device,2877.35,35,,2877.35,percent of total billed charges,Implant Device,2877.35,35,,2877.35,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2795.14,34,"If Charge > 2,000, then 34 percent",2795.14,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,6083.56,
STRYKER 3060-0115S LAG SCREW 10.5X115MM,C1713,HCPCS,,79005611,CDM,278,RC,,,both,,,1230,910.2,,,910.2,Other,150% of Medicare + 9.63% HCRA Surcharge,553.5,45,,553.5,percent of total billed charges,Critical Access Hospital RCC factor,418.2,34,,418.2,percent of total billed charges,Implant Device,418.2,34,,418.2,percent of total billed charges,Implant Device,418.2,34,,418.2,percent of total billed charges,Implant Device,418.2,34,,418.2,percent of total billed charges,Implant Device,418.2,34,,418.2,percent of total billed charges,Implant Device,608.85,,,608.85,Other,110% of Medicare,430.5,35,,430.5,percent of total billed charges,Implant Device,418.2,34,"Charges > $500, x 34%",418.2,percent of total billed charges,Implant Device,430.5,35,,430.5,percent of total billed charges,Implant Device,430.5,35,,430.5,percent of total billed charges,Implant Device,430.5,35,,430.5,percent of total billed charges,Implant Device,430.5,35,,430.5,percent of total billed charges,Implant Device,430.5,35,,430.5,percent of total billed charges,Implant Device,492,40,,492,percent of total billed charges,Implant Device,430.5,70,,430.5,percent of total billed charges,All Other,418.2,34,,418.2,percent of total billed charges,Implant Device,418.2,34,,418.2,percent of total billed charges,Implant Device,430.5,35,,430.5,percent of total billed charges,Implant Device,430.5,35,,430.5,percent of total billed charges,Implant Device,430.5,35,,430.5,percent of total billed charges,Implant Device,430.5,35,,430.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,910.2,
STRYKER 1896-5047S LOCKING SCREW FT 5X47,C1713,HCPCS,,79005612,CDM,278,RC,,,both,,,355,262.7,,,262.7,Other,150% of Medicare + 9.63% HCRA Surcharge,159.75,45,,159.75,percent of total billed charges,Critical Access Hospital RCC factor,120.7,34,,120.7,percent of total billed charges,Implant Device,120.7,34,,120.7,percent of total billed charges,Implant Device,120.7,34,,120.7,percent of total billed charges,Implant Device,120.7,34,,120.7,percent of total billed charges,Implant Device,120.7,34,,120.7,percent of total billed charges,Implant Device,175.73,,,175.73,Other,110% of Medicare,124.25,35,,124.25,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,124.25,35,,124.25,percent of total billed charges,Implant Device,124.25,35,,124.25,percent of total billed charges,Implant Device,124.25,35,,124.25,percent of total billed charges,Implant Device,124.25,35,,124.25,percent of total billed charges,Implant Device,124.25,35,,124.25,percent of total billed charges,Implant Device,142,40,,142,percent of total billed charges,Implant Device,124.25,70,,124.25,percent of total billed charges,All Other,120.7,34,,120.7,percent of total billed charges,Implant Device,120.7,34,,120.7,percent of total billed charges,Implant Device,124.25,35,,124.25,percent of total billed charges,Implant Device,124.25,35,,124.25,percent of total billed charges,Implant Device,124.25,35,,124.25,percent of total billed charges,Implant Device,124.25,35,,124.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,262.7,
AMS 720127-01 ELEVATE POSTERIOR SLING,C1781,HCPCS,,79005613,CDM,278,RC,,,both,,,4500,3330.01,,,3330.01,Other,150% of Medicare + 9.63% HCRA Surcharge,2025,45,,2025,percent of total billed charges,Critical Access Hospital RCC factor,1530,34,,1530,percent of total billed charges,Implant Device,1530,34,,1530,percent of total billed charges,Implant Device,1530,34,,1530,percent of total billed charges,Implant Device,1530,34,,1530,percent of total billed charges,Implant Device,1530,34,,1530,percent of total billed charges,Implant Device,2227.5,,,2227.5,Other,110% of Medicare,1575,35,,1575,percent of total billed charges,Implant Device,1530,34,"Charges > $500, x 34%",1530,percent of total billed charges,Implant Device,1575,35,,1575,percent of total billed charges,Implant Device,1575,35,,1575,percent of total billed charges,Implant Device,1575,35,,1575,percent of total billed charges,Implant Device,1575,35,,1575,percent of total billed charges,Implant Device,1575,35,,1575,percent of total billed charges,Implant Device,1800,40,,1800,percent of total billed charges,Implant Device,1575,70,,1575,percent of total billed charges,All Other,1530,34,,1530,percent of total billed charges,Implant Device,1530,34,,1530,percent of total billed charges,Implant Device,1575,35,,1575,percent of total billed charges,Implant Device,1575,35,,1575,percent of total billed charges,Implant Device,1575,35,,1575,percent of total billed charges,Implant Device,1575,35,,1575,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1530,34,"If Charge > 2,000, then 34 percent",1530,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3330.01,
CL MEDICAL IS-5 I-STOP DEVICE,C1771,HCPCS,,79005614,CDM,278,RC,,,both,,,2400,1776.01,,,1776.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1080,45,,1080,percent of total billed charges,Critical Access Hospital RCC factor,816,34,,816,percent of total billed charges,Implant Device,816,34,,816,percent of total billed charges,Implant Device,816,34,,816,percent of total billed charges,Implant Device,816,34,,816,percent of total billed charges,Implant Device,816,34,,816,percent of total billed charges,Implant Device,1188,,,1188,Other,110% of Medicare,840,35,,840,percent of total billed charges,Implant Device,816,34,"Charges > $500, x 34%",816,percent of total billed charges,Implant Device,840,35,,840,percent of total billed charges,Implant Device,840,35,,840,percent of total billed charges,Implant Device,840,35,,840,percent of total billed charges,Implant Device,840,35,,840,percent of total billed charges,Implant Device,840,35,,840,percent of total billed charges,Implant Device,960,40,,960,percent of total billed charges,Implant Device,840,70,,840,percent of total billed charges,All Other,816,34,,816,percent of total billed charges,Implant Device,816,34,,816,percent of total billed charges,Implant Device,840,35,,840,percent of total billed charges,Implant Device,840,35,,840,percent of total billed charges,Implant Device,840,35,,840,percent of total billed charges,Implant Device,840,35,,840,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,816,34,"If Charge > 2,000, then 34 percent",816,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1776.01,
BIOMET 8153-41-055 CANC SCREW 4.0X55MM,C1713,HCPCS,,79005615,CDM,278,RC,,,both,,,240,177.6,,,177.6,Other,150% of Medicare + 9.63% HCRA Surcharge,108,45,,108,percent of total billed charges,Critical Access Hospital RCC factor,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,118.8,,,118.8,Other,110% of Medicare,84,35,,84,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,96,40,,96,percent of total billed charges,Implant Device,84,70,,84,percent of total billed charges,All Other,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,177.6,
BIOMET 8153-41-024 CANC SCREW 4.0X24MM,C1713,HCPCS,,79005616,CDM,278,RC,,,both,,,240,177.6,,,177.6,Other,150% of Medicare + 9.63% HCRA Surcharge,108,45,,108,percent of total billed charges,Critical Access Hospital RCC factor,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,118.8,,,118.8,Other,110% of Medicare,84,35,,84,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,96,40,,96,percent of total billed charges,Implant Device,84,70,,84,percent of total billed charges,All Other,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,177.6,
DEVICOR MMK1001 10G MAMMOMARK BOWTIE,A4648,HCPCS,,79005618,CDM,278,RC,,,both,,,228,168.72,,,168.72,Other,150% of Medicare + 9.63% HCRA Surcharge,102.6,45,,102.6,percent of total billed charges,Critical Access Hospital RCC factor,77.52,34,,77.52,percent of total billed charges,Implant Device,77.52,34,,77.52,percent of total billed charges,Implant Device,77.52,34,,77.52,percent of total billed charges,Implant Device,77.52,34,,77.52,percent of total billed charges,Implant Device,77.52,34,,77.52,percent of total billed charges,Implant Device,112.86,,,112.86,Other,110% of Medicare,79.8,35,,79.8,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,79.8,35,,79.8,percent of total billed charges,Implant Device,79.8,35,,79.8,percent of total billed charges,Implant Device,79.8,35,,79.8,percent of total billed charges,Implant Device,79.8,35,,79.8,percent of total billed charges,Implant Device,79.8,35,,79.8,percent of total billed charges,Implant Device,91.2,40,,91.2,percent of total billed charges,Implant Device,79.8,70,,79.8,percent of total billed charges,All Other,77.52,34,,77.52,percent of total billed charges,Implant Device,77.52,34,,77.52,percent of total billed charges,Implant Device,79.8,35,,79.8,percent of total billed charges,Implant Device,79.8,35,,79.8,percent of total billed charges,Implant Device,79.8,35,,79.8,percent of total billed charges,Implant Device,79.8,35,,79.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,168.72,
DEVICOR MMK1002 10G MAMMOMARK V SHAPE,A4648,HCPCS,,79005619,CDM,278,RC,,,both,,,213,157.62,,,157.62,Other,150% of Medicare + 9.63% HCRA Surcharge,95.85,45,,95.85,percent of total billed charges,Critical Access Hospital RCC factor,72.42,34,,72.42,percent of total billed charges,Implant Device,72.42,34,,72.42,percent of total billed charges,Implant Device,72.42,34,,72.42,percent of total billed charges,Implant Device,72.42,34,,72.42,percent of total billed charges,Implant Device,72.42,34,,72.42,percent of total billed charges,Implant Device,105.44,,,105.44,Other,110% of Medicare,74.55,35,,74.55,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,74.55,35,,74.55,percent of total billed charges,Implant Device,74.55,35,,74.55,percent of total billed charges,Implant Device,74.55,35,,74.55,percent of total billed charges,Implant Device,74.55,35,,74.55,percent of total billed charges,Implant Device,74.55,35,,74.55,percent of total billed charges,Implant Device,85.2,40,,85.2,percent of total billed charges,Implant Device,74.55,70,,74.55,percent of total billed charges,All Other,72.42,34,,72.42,percent of total billed charges,Implant Device,72.42,34,,72.42,percent of total billed charges,Implant Device,74.55,35,,74.55,percent of total billed charges,Implant Device,74.55,35,,74.55,percent of total billed charges,Implant Device,74.55,35,,74.55,percent of total billed charges,Implant Device,74.55,35,,74.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,157.62,
ALAMO TISSUE SVC AT393FF GRACILIS TENDON,C1762,HCPCS,,79005623,CDM,278,RC,,,both,,,3600,2664.01,,,2664.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1620,45,,1620,percent of total billed charges,Critical Access Hospital RCC factor,1224,34,,1224,percent of total billed charges,Implant Device,1224,34,,1224,percent of total billed charges,Implant Device,1224,34,,1224,percent of total billed charges,Implant Device,1224,34,,1224,percent of total billed charges,Implant Device,1224,34,,1224,percent of total billed charges,Implant Device,1782,,,1782,Other,110% of Medicare,1260,35,,1260,percent of total billed charges,Implant Device,1224,34,"Charges > $500, x 34%",1224,percent of total billed charges,Implant Device,1260,35,,1260,percent of total billed charges,Implant Device,1260,35,,1260,percent of total billed charges,Implant Device,1260,35,,1260,percent of total billed charges,Implant Device,1260,35,,1260,percent of total billed charges,Implant Device,1260,35,,1260,percent of total billed charges,Implant Device,1440,40,,1440,percent of total billed charges,Implant Device,1260,70,,1260,percent of total billed charges,All Other,1224,34,,1224,percent of total billed charges,Implant Device,1224,34,,1224,percent of total billed charges,Implant Device,1260,35,,1260,percent of total billed charges,Implant Device,1260,35,,1260,percent of total billed charges,Implant Device,1260,35,,1260,percent of total billed charges,Implant Device,1260,35,,1260,percent of total billed charges,Implant Device,976.07,,,976.07,Other,100% of Medicaid,976.07,,,976.07,Other,100% of Medicaid,976.07,,,976.07,Other,100% of Medicaid,976.07,,,976.07,Other,100% of Medicaid,2196.16,,,2196.16,Other,225% of Medicaid,1493.39,,,1493.39,Other,153% of Medicaid,2196.16,,,2196.16,Other,225% of Medicaid,1366.5,,,1366.5,Other,140% of Medicaid,1224,34,"If Charge > 2,000, then 34 percent",1224,percent of total billed charges,Implants,2537.78,,,2537.78,Other,260% of Medicaid,3162.47,,,3162.47,Other,324% of Medicaid,2098.55,,,2098.55,Other,215% of Medicaid,2098.55,,,2098.55,Other,215% of Medicaid,1220.09,,,1220.09,Other,125% of Medicaid,976.07,3162.47,
BARD D8006C DISTAFLO VASCULAR GRAFT,C1768,HCPCS,,79005624,CDM,278,RC,,,both,,,5231,3870.95,,,3870.95,Other,150% of Medicare + 9.63% HCRA Surcharge,2353.95,45,,2353.95,percent of total billed charges,Critical Access Hospital RCC factor,1778.54,34,,1778.54,percent of total billed charges,Implant Device,1778.54,34,,1778.54,percent of total billed charges,Implant Device,1778.54,34,,1778.54,percent of total billed charges,Implant Device,1778.54,34,,1778.54,percent of total billed charges,Implant Device,1778.54,34,,1778.54,percent of total billed charges,Implant Device,2589.35,,,2589.35,Other,110% of Medicare,1830.85,35,,1830.85,percent of total billed charges,Implant Device,1778.54,34,"Charges > $500, x 34%",1778.54,percent of total billed charges,Implant Device,1830.85,35,,1830.85,percent of total billed charges,Implant Device,1830.85,35,,1830.85,percent of total billed charges,Implant Device,1830.85,35,,1830.85,percent of total billed charges,Implant Device,1830.85,35,,1830.85,percent of total billed charges,Implant Device,1830.85,35,,1830.85,percent of total billed charges,Implant Device,2092.4,40,,2092.4,percent of total billed charges,Implant Device,1830.85,70,,1830.85,percent of total billed charges,All Other,1778.54,34,,1778.54,percent of total billed charges,Implant Device,1778.54,34,,1778.54,percent of total billed charges,Implant Device,1830.85,35,,1830.85,percent of total billed charges,Implant Device,1830.85,35,,1830.85,percent of total billed charges,Implant Device,1830.85,35,,1830.85,percent of total billed charges,Implant Device,1830.85,35,,1830.85,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1778.54,34,"If Charge > 2,000, then 34 percent",1778.54,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3870.95,
DEPUY 86-7426 UNI STEM FLUTED 115X12MM,C1776,HCPCS,,79005628,CDM,278,RC,,,both,,,5964,4413.37,,,4413.37,Other,150% of Medicare + 9.63% HCRA Surcharge,2683.8,45,,2683.8,percent of total billed charges,Critical Access Hospital RCC factor,2027.76,34,,2027.76,percent of total billed charges,Implant Device,2027.76,34,,2027.76,percent of total billed charges,Implant Device,2027.76,34,,2027.76,percent of total billed charges,Implant Device,2027.76,34,,2027.76,percent of total billed charges,Implant Device,2027.76,34,,2027.76,percent of total billed charges,Implant Device,2952.18,,,2952.18,Other,110% of Medicare,2087.4,35,,2087.4,percent of total billed charges,Implant Device,2027.76,34,"Charges > $500, x 34%",2027.76,percent of total billed charges,Implant Device,2087.4,35,,2087.4,percent of total billed charges,Implant Device,2087.4,35,,2087.4,percent of total billed charges,Implant Device,2087.4,35,,2087.4,percent of total billed charges,Implant Device,2087.4,35,,2087.4,percent of total billed charges,Implant Device,2087.4,35,,2087.4,percent of total billed charges,Implant Device,2385.6,40,,2385.6,percent of total billed charges,Implant Device,2087.4,70,,2087.4,percent of total billed charges,All Other,2027.76,34,,2027.76,percent of total billed charges,Implant Device,2027.76,34,,2027.76,percent of total billed charges,Implant Device,2087.4,35,,2087.4,percent of total billed charges,Implant Device,2087.4,35,,2087.4,percent of total billed charges,Implant Device,2087.4,35,,2087.4,percent of total billed charges,Implant Device,2087.4,35,,2087.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2027.76,34,"If Charge > 2,000, then 34 percent",2027.76,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4413.37,
DEPUY 1294-35-150 REV CEM TIB TRAY SZ 5,C1776,HCPCS,,79005629,CDM,278,RC,,,both,,,18967,14035.63,,,14035.63,Other,150% of Medicare + 9.63% HCRA Surcharge,8535.15,45,,8535.15,percent of total billed charges,Critical Access Hospital RCC factor,6448.78,34,,6448.78,percent of total billed charges,Implant Device,6448.78,34,,6448.78,percent of total billed charges,Implant Device,6448.78,34,,6448.78,percent of total billed charges,Implant Device,6448.78,34,,6448.78,percent of total billed charges,Implant Device,6448.78,34,,6448.78,percent of total billed charges,Implant Device,9388.67,,,9388.67,Other,110% of Medicare,6638.45,35,,6638.45,percent of total billed charges,Implant Device,6448.78,34,"Charges > $500, x 34%",6448.78,percent of total billed charges,Implant Device,6638.45,35,,6638.45,percent of total billed charges,Implant Device,6638.45,35,,6638.45,percent of total billed charges,Implant Device,6638.45,35,,6638.45,percent of total billed charges,Implant Device,6638.45,35,,6638.45,percent of total billed charges,Implant Device,6638.45,35,,6638.45,percent of total billed charges,Implant Device,7586.8,40,,7586.8,percent of total billed charges,Implant Device,6638.45,70,,6638.45,percent of total billed charges,All Other,6448.78,34,,6448.78,percent of total billed charges,Implant Device,6448.78,34,,6448.78,percent of total billed charges,Implant Device,6638.45,35,,6638.45,percent of total billed charges,Implant Device,6638.45,35,,6638.45,percent of total billed charges,Implant Device,6638.45,35,,6638.45,percent of total billed charges,Implant Device,6638.45,35,,6638.45,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,6448.78,34,"If Charge > 2,000, then 34 percent",6448.78,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,14035.63,
DEPUY 1294-53-216 UNI FEMORL SLEEVE 31MM,C1776,HCPCS,,79005630,CDM,278,RC,,,both,,,12557,9292.21,,,9292.21,Other,150% of Medicare + 9.63% HCRA Surcharge,5650.65,45,,5650.65,percent of total billed charges,Critical Access Hospital RCC factor,4269.38,34,,4269.38,percent of total billed charges,Implant Device,4269.38,34,,4269.38,percent of total billed charges,Implant Device,4269.38,34,,4269.38,percent of total billed charges,Implant Device,4269.38,34,,4269.38,percent of total billed charges,Implant Device,4269.38,34,,4269.38,percent of total billed charges,Implant Device,6215.72,,,6215.72,Other,110% of Medicare,4394.95,35,,4394.95,percent of total billed charges,Implant Device,4269.38,34,"Charges > $500, x 34%",4269.38,percent of total billed charges,Implant Device,4394.95,35,,4394.95,percent of total billed charges,Implant Device,4394.95,35,,4394.95,percent of total billed charges,Implant Device,4394.95,35,,4394.95,percent of total billed charges,Implant Device,4394.95,35,,4394.95,percent of total billed charges,Implant Device,4394.95,35,,4394.95,percent of total billed charges,Implant Device,5022.8,40,,5022.8,percent of total billed charges,Implant Device,4394.95,70,,4394.95,percent of total billed charges,All Other,4269.38,34,,4269.38,percent of total billed charges,Implant Device,4269.38,34,,4269.38,percent of total billed charges,Implant Device,4394.95,35,,4394.95,percent of total billed charges,Implant Device,4394.95,35,,4394.95,percent of total billed charges,Implant Device,4394.95,35,,4394.95,percent of total billed charges,Implant Device,4394.95,35,,4394.95,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,4269.38,34,"If Charge > 2,000, then 34 percent",4269.38,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,9292.21,
DEPUY 1987-06-005 FEMORL SLEEVE ADAPT +5,C1776,HCPCS,,79005631,CDM,278,RC,,,both,,,2124,1571.77,,,1571.77,Other,150% of Medicare + 9.63% HCRA Surcharge,955.8,45,,955.8,percent of total billed charges,Critical Access Hospital RCC factor,722.16,34,,722.16,percent of total billed charges,Implant Device,722.16,34,,722.16,percent of total billed charges,Implant Device,722.16,34,,722.16,percent of total billed charges,Implant Device,722.16,34,,722.16,percent of total billed charges,Implant Device,722.16,34,,722.16,percent of total billed charges,Implant Device,1051.38,,,1051.38,Other,110% of Medicare,743.4,35,,743.4,percent of total billed charges,Implant Device,722.16,34,"Charges > $500, x 34%",722.16,percent of total billed charges,Implant Device,743.4,35,,743.4,percent of total billed charges,Implant Device,743.4,35,,743.4,percent of total billed charges,Implant Device,743.4,35,,743.4,percent of total billed charges,Implant Device,743.4,35,,743.4,percent of total billed charges,Implant Device,743.4,35,,743.4,percent of total billed charges,Implant Device,849.6,40,,849.6,percent of total billed charges,Implant Device,743.4,70,,743.4,percent of total billed charges,All Other,722.16,34,,722.16,percent of total billed charges,Implant Device,722.16,34,,722.16,percent of total billed charges,Implant Device,743.4,35,,743.4,percent of total billed charges,Implant Device,743.4,35,,743.4,percent of total billed charges,Implant Device,743.4,35,,743.4,percent of total billed charges,Implant Device,743.4,35,,743.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,722.16,34,"If Charge > 2,000, then 34 percent",722.16,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1571.77,
DEPUY 1987-14-105 LPS DIST FEM COMP XS,C1776,HCPCS,,79005632,CDM,278,RC,,,both,,,32693,24192.9,,,24192.9,Other,150% of Medicare + 9.63% HCRA Surcharge,14711.85,45,,14711.85,percent of total billed charges,Critical Access Hospital RCC factor,11115.62,34,,11115.62,percent of total billed charges,Implant Device,11115.62,34,,11115.62,percent of total billed charges,Implant Device,11115.62,34,,11115.62,percent of total billed charges,Implant Device,11115.62,34,,11115.62,percent of total billed charges,Implant Device,11115.62,34,,11115.62,percent of total billed charges,Implant Device,16183.04,,,16183.04,Other,110% of Medicare,11442.55,35,,11442.55,percent of total billed charges,Implant Device,11115.62,34,"Charges > $500, x 34%",11115.62,percent of total billed charges,Implant Device,11442.55,35,,11442.55,percent of total billed charges,Implant Device,11442.55,35,,11442.55,percent of total billed charges,Implant Device,11442.55,35,,11442.55,percent of total billed charges,Implant Device,11442.55,35,,11442.55,percent of total billed charges,Implant Device,11442.55,35,,11442.55,percent of total billed charges,Implant Device,13077.2,40,,13077.2,percent of total billed charges,Implant Device,11442.55,70,,11442.55,percent of total billed charges,All Other,11115.62,34,,11115.62,percent of total billed charges,Implant Device,11115.62,34,,11115.62,percent of total billed charges,Implant Device,11442.55,35,,11442.55,percent of total billed charges,Implant Device,11442.55,35,,11442.55,percent of total billed charges,Implant Device,11442.55,35,,11442.55,percent of total billed charges,Implant Device,11442.55,35,,11442.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,11115.62,34,"If Charge > 2,000, then 34 percent",11115.62,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,24192.9,
DEPUY 1987-27-112 LPS HINGE XSMALL 12MM,C1776,HCPCS,,79005633,CDM,278,RC,,,both,,,11227,8308.01,,,8308.01,Other,150% of Medicare + 9.63% HCRA Surcharge,5052.15,45,,5052.15,percent of total billed charges,Critical Access Hospital RCC factor,3817.18,34,,3817.18,percent of total billed charges,Implant Device,3817.18,34,,3817.18,percent of total billed charges,Implant Device,3817.18,34,,3817.18,percent of total billed charges,Implant Device,3817.18,34,,3817.18,percent of total billed charges,Implant Device,3817.18,34,,3817.18,percent of total billed charges,Implant Device,5557.37,,,5557.37,Other,110% of Medicare,3929.45,35,,3929.45,percent of total billed charges,Implant Device,3817.18,34,"Charges > $500, x 34%",3817.18,percent of total billed charges,Implant Device,3929.45,35,,3929.45,percent of total billed charges,Implant Device,3929.45,35,,3929.45,percent of total billed charges,Implant Device,3929.45,35,,3929.45,percent of total billed charges,Implant Device,3929.45,35,,3929.45,percent of total billed charges,Implant Device,3929.45,35,,3929.45,percent of total billed charges,Implant Device,4490.8,40,,4490.8,percent of total billed charges,Implant Device,3929.45,70,,3929.45,percent of total billed charges,All Other,3817.18,34,,3817.18,percent of total billed charges,Implant Device,3817.18,34,,3817.18,percent of total billed charges,Implant Device,3929.45,35,,3929.45,percent of total billed charges,Implant Device,3929.45,35,,3929.45,percent of total billed charges,Implant Device,3929.45,35,,3929.45,percent of total billed charges,Implant Device,3929.45,35,,3929.45,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3817.18,34,"If Charge > 2,000, then 34 percent",3817.18,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,8308.01,
DEPUY 86-7428 UNI STEM FLUTED 115X14MM,C1776,HCPCS,,79005634,CDM,278,RC,,,both,,,5964,4413.37,,,4413.37,Other,150% of Medicare + 9.63% HCRA Surcharge,2683.8,45,,2683.8,percent of total billed charges,Critical Access Hospital RCC factor,2027.76,34,,2027.76,percent of total billed charges,Implant Device,2027.76,34,,2027.76,percent of total billed charges,Implant Device,2027.76,34,,2027.76,percent of total billed charges,Implant Device,2027.76,34,,2027.76,percent of total billed charges,Implant Device,2027.76,34,,2027.76,percent of total billed charges,Implant Device,2952.18,,,2952.18,Other,110% of Medicare,2087.4,35,,2087.4,percent of total billed charges,Implant Device,2027.76,34,"Charges > $500, x 34%",2027.76,percent of total billed charges,Implant Device,2087.4,35,,2087.4,percent of total billed charges,Implant Device,2087.4,35,,2087.4,percent of total billed charges,Implant Device,2087.4,35,,2087.4,percent of total billed charges,Implant Device,2087.4,35,,2087.4,percent of total billed charges,Implant Device,2087.4,35,,2087.4,percent of total billed charges,Implant Device,2385.6,40,,2385.6,percent of total billed charges,Implant Device,2087.4,70,,2087.4,percent of total billed charges,All Other,2027.76,34,,2027.76,percent of total billed charges,Implant Device,2027.76,34,,2027.76,percent of total billed charges,Implant Device,2087.4,35,,2087.4,percent of total billed charges,Implant Device,2087.4,35,,2087.4,percent of total billed charges,Implant Device,2087.4,35,,2087.4,percent of total billed charges,Implant Device,2087.4,35,,2087.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2027.76,34,"If Charge > 2,000, then 34 percent",2027.76,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4413.37,
ALAMO AT290FF ACHILLES TENDON W/CALCNEUS,C1762,HCPCS,,79005637,CDM,278,RC,,,both,,,5400,3996.01,,,3996.01,Other,150% of Medicare + 9.63% HCRA Surcharge,2430,45,,2430,percent of total billed charges,Critical Access Hospital RCC factor,1836,34,,1836,percent of total billed charges,Implant Device,1836,34,,1836,percent of total billed charges,Implant Device,1836,34,,1836,percent of total billed charges,Implant Device,1836,34,,1836,percent of total billed charges,Implant Device,1836,34,,1836,percent of total billed charges,Implant Device,2673,,,2673,Other,110% of Medicare,1890,35,,1890,percent of total billed charges,Implant Device,1836,34,"Charges > $500, x 34%",1836,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,2160,40,,2160,percent of total billed charges,Implant Device,1890,70,,1890,percent of total billed charges,All Other,1836,34,,1836,percent of total billed charges,Implant Device,1836,34,,1836,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,976.07,,,976.07,Other,100% of Medicaid,976.07,,,976.07,Other,100% of Medicaid,976.07,,,976.07,Other,100% of Medicaid,976.07,,,976.07,Other,100% of Medicaid,2196.16,,,2196.16,Other,225% of Medicaid,1493.39,,,1493.39,Other,153% of Medicaid,2196.16,,,2196.16,Other,225% of Medicaid,1366.5,,,1366.5,Other,140% of Medicaid,1836,34,"If Charge > 2,000, then 34 percent",1836,percent of total billed charges,Implants,2537.78,,,2537.78,Other,260% of Medicaid,3162.47,,,3162.47,Other,324% of Medicaid,2098.55,,,2098.55,Other,215% of Medicaid,2098.55,,,2098.55,Other,215% of Medicaid,1220.09,,,1220.09,Other,125% of Medicaid,976.07,3996.01,
STRYKER 5018-6-180 APEX PIN 6 X 180MM,C1713,HCPCS,,79005641,CDM,278,RC,,,both,,,297,219.78,,,219.78,Other,150% of Medicare + 9.63% HCRA Surcharge,133.65,45,,133.65,percent of total billed charges,Critical Access Hospital RCC factor,100.98,34,,100.98,percent of total billed charges,Implant Device,100.98,34,,100.98,percent of total billed charges,Implant Device,100.98,34,,100.98,percent of total billed charges,Implant Device,100.98,34,,100.98,percent of total billed charges,Implant Device,100.98,34,,100.98,percent of total billed charges,Implant Device,147.02,,,147.02,Other,110% of Medicare,103.95,35,,103.95,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,103.95,35,,103.95,percent of total billed charges,Implant Device,103.95,35,,103.95,percent of total billed charges,Implant Device,103.95,35,,103.95,percent of total billed charges,Implant Device,103.95,35,,103.95,percent of total billed charges,Implant Device,103.95,35,,103.95,percent of total billed charges,Implant Device,118.8,40,,118.8,percent of total billed charges,Implant Device,103.95,70,,103.95,percent of total billed charges,All Other,100.98,34,,100.98,percent of total billed charges,Implant Device,100.98,34,,100.98,percent of total billed charges,Implant Device,103.95,35,,103.95,percent of total billed charges,Implant Device,103.95,35,,103.95,percent of total billed charges,Implant Device,103.95,35,,103.95,percent of total billed charges,Implant Device,103.95,35,,103.95,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,219.78,
STRYKER 4936-2-010 RING CLAMP,C1713,HCPCS,,79005642,CDM,278,RC,,,both,,,1700,1258,,,1258,Other,150% of Medicare + 9.63% HCRA Surcharge,765,45,,765,percent of total billed charges,Critical Access Hospital RCC factor,578,34,,578,percent of total billed charges,Implant Device,578,34,,578,percent of total billed charges,Implant Device,578,34,,578,percent of total billed charges,Implant Device,578,34,,578,percent of total billed charges,Implant Device,578,34,,578,percent of total billed charges,Implant Device,841.5,,,841.5,Other,110% of Medicare,595,35,,595,percent of total billed charges,Implant Device,578,34,"Charges > $500, x 34%",578,percent of total billed charges,Implant Device,595,35,,595,percent of total billed charges,Implant Device,595,35,,595,percent of total billed charges,Implant Device,595,35,,595,percent of total billed charges,Implant Device,595,35,,595,percent of total billed charges,Implant Device,595,35,,595,percent of total billed charges,Implant Device,680,40,,680,percent of total billed charges,Implant Device,595,70,,595,percent of total billed charges,All Other,578,34,,578,percent of total billed charges,Implant Device,578,34,,578,percent of total billed charges,Implant Device,595,35,,595,percent of total billed charges,Implant Device,595,35,,595,percent of total billed charges,Implant Device,595,35,,595,percent of total billed charges,Implant Device,595,35,,595,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1258,
STRYKER 4936-2-040 WIRE POST,C1713,HCPCS,,79005643,CDM,278,RC,,,both,,,1229,909.46,,,909.46,Other,150% of Medicare + 9.63% HCRA Surcharge,553.05,45,,553.05,percent of total billed charges,Critical Access Hospital RCC factor,417.86,34,,417.86,percent of total billed charges,Implant Device,417.86,34,,417.86,percent of total billed charges,Implant Device,417.86,34,,417.86,percent of total billed charges,Implant Device,417.86,34,,417.86,percent of total billed charges,Implant Device,417.86,34,,417.86,percent of total billed charges,Implant Device,608.36,,,608.36,Other,110% of Medicare,430.15,35,,430.15,percent of total billed charges,Implant Device,417.86,34,"Charges > $500, x 34%",417.86,percent of total billed charges,Implant Device,430.15,35,,430.15,percent of total billed charges,Implant Device,430.15,35,,430.15,percent of total billed charges,Implant Device,430.15,35,,430.15,percent of total billed charges,Implant Device,430.15,35,,430.15,percent of total billed charges,Implant Device,430.15,35,,430.15,percent of total billed charges,Implant Device,491.6,40,,491.6,percent of total billed charges,Implant Device,430.15,70,,430.15,percent of total billed charges,All Other,417.86,34,,417.86,percent of total billed charges,Implant Device,417.86,34,,417.86,percent of total billed charges,Implant Device,430.15,35,,430.15,percent of total billed charges,Implant Device,430.15,35,,430.15,percent of total billed charges,Implant Device,430.15,35,,430.15,percent of total billed charges,Implant Device,430.15,35,,430.15,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,909.46,
STRYKER 4936-0-015 150MM OPEN RING,C1713,HCPCS,,79005645,CDM,278,RC,,,both,,,2099,1553.27,,,1553.27,Other,150% of Medicare + 9.63% HCRA Surcharge,944.55,45,,944.55,percent of total billed charges,Critical Access Hospital RCC factor,713.66,34,,713.66,percent of total billed charges,Implant Device,713.66,34,,713.66,percent of total billed charges,Implant Device,713.66,34,,713.66,percent of total billed charges,Implant Device,713.66,34,,713.66,percent of total billed charges,Implant Device,713.66,34,,713.66,percent of total billed charges,Implant Device,1039.01,,,1039.01,Other,110% of Medicare,734.65,35,,734.65,percent of total billed charges,Implant Device,713.66,34,"Charges > $500, x 34%",713.66,percent of total billed charges,Implant Device,734.65,35,,734.65,percent of total billed charges,Implant Device,734.65,35,,734.65,percent of total billed charges,Implant Device,734.65,35,,734.65,percent of total billed charges,Implant Device,734.65,35,,734.65,percent of total billed charges,Implant Device,734.65,35,,734.65,percent of total billed charges,Implant Device,839.6,40,,839.6,percent of total billed charges,Implant Device,734.65,70,,734.65,percent of total billed charges,All Other,713.66,34,,713.66,percent of total billed charges,Implant Device,713.66,34,,713.66,percent of total billed charges,Implant Device,734.65,35,,734.65,percent of total billed charges,Implant Device,734.65,35,,734.65,percent of total billed charges,Implant Device,734.65,35,,734.65,percent of total billed charges,Implant Device,734.65,35,,734.65,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,713.66,34,"If Charge > 2,000, then 34 percent",713.66,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1553.27,
ZIMMER 00-8758-014-36 LINR 36MM ID SZ MM,C1776,HCPCS,,79005646,CDM,278,RC,,,both,,,11566,8558.87,,,8558.87,Other,150% of Medicare + 9.63% HCRA Surcharge,5204.7,45,,5204.7,percent of total billed charges,Critical Access Hospital RCC factor,3932.44,34,,3932.44,percent of total billed charges,Implant Device,3932.44,34,,3932.44,percent of total billed charges,Implant Device,3932.44,34,,3932.44,percent of total billed charges,Implant Device,3932.44,34,,3932.44,percent of total billed charges,Implant Device,3932.44,34,,3932.44,percent of total billed charges,Implant Device,5725.17,,,5725.17,Other,110% of Medicare,4048.1,35,,4048.1,percent of total billed charges,Implant Device,3932.44,34,"Charges > $500, x 34%",3932.44,percent of total billed charges,Implant Device,4048.1,35,,4048.1,percent of total billed charges,Implant Device,4048.1,35,,4048.1,percent of total billed charges,Implant Device,4048.1,35,,4048.1,percent of total billed charges,Implant Device,4048.1,35,,4048.1,percent of total billed charges,Implant Device,4048.1,35,,4048.1,percent of total billed charges,Implant Device,4626.4,40,,4626.4,percent of total billed charges,Implant Device,4048.1,70,,4048.1,percent of total billed charges,All Other,3932.44,34,,3932.44,percent of total billed charges,Implant Device,3932.44,34,,3932.44,percent of total billed charges,Implant Device,4048.1,35,,4048.1,percent of total billed charges,Implant Device,4048.1,35,,4048.1,percent of total billed charges,Implant Device,4048.1,35,,4048.1,percent of total billed charges,Implant Device,4048.1,35,,4048.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3932.44,34,"If Charge > 2,000, then 34 percent",3932.44,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,8558.87,
EXACTECH 314-13-03 CAGE GLENOID MED,C1776,HCPCS,,79005650,CDM,278,RC,,,both,,,4125,3052.51,,,3052.51,Other,150% of Medicare + 9.63% HCRA Surcharge,1856.25,45,,1856.25,percent of total billed charges,Critical Access Hospital RCC factor,1402.5,34,,1402.5,percent of total billed charges,Implant Device,1402.5,34,,1402.5,percent of total billed charges,Implant Device,1402.5,34,,1402.5,percent of total billed charges,Implant Device,1402.5,34,,1402.5,percent of total billed charges,Implant Device,1402.5,34,,1402.5,percent of total billed charges,Implant Device,2041.88,,,2041.88,Other,110% of Medicare,1443.75,35,,1443.75,percent of total billed charges,Implant Device,1402.5,34,"Charges > $500, x 34%",1402.5,percent of total billed charges,Implant Device,1443.75,35,,1443.75,percent of total billed charges,Implant Device,1443.75,35,,1443.75,percent of total billed charges,Implant Device,1443.75,35,,1443.75,percent of total billed charges,Implant Device,1443.75,35,,1443.75,percent of total billed charges,Implant Device,1443.75,35,,1443.75,percent of total billed charges,Implant Device,1650,40,,1650,percent of total billed charges,Implant Device,1443.75,70,,1443.75,percent of total billed charges,All Other,1402.5,34,,1402.5,percent of total billed charges,Implant Device,1402.5,34,,1402.5,percent of total billed charges,Implant Device,1443.75,35,,1443.75,percent of total billed charges,Implant Device,1443.75,35,,1443.75,percent of total billed charges,Implant Device,1443.75,35,,1443.75,percent of total billed charges,Implant Device,1443.75,35,,1443.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1402.5,34,"If Charge > 2,000, then 34 percent",1402.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3052.51,
BOST SCI 38046-73075RR EXPRESS LD STENT,C1876,HCPCS,,79005671,CDM,278,RC,,,both,,,1410,1043.4,,,1043.4,Other,150% of Medicare + 9.63% HCRA Surcharge,634.5,45,,634.5,percent of total billed charges,Critical Access Hospital RCC factor,479.4,34,,479.4,percent of total billed charges,Implant Device,479.4,34,,479.4,percent of total billed charges,Implant Device,479.4,34,,479.4,percent of total billed charges,Implant Device,479.4,34,,479.4,percent of total billed charges,Implant Device,479.4,34,,479.4,percent of total billed charges,Implant Device,697.95,,,697.95,Other,110% of Medicare,493.5,35,,493.5,percent of total billed charges,Implant Device,479.4,34,"Charges > $500, x 34%",479.4,percent of total billed charges,Implant Device,493.5,35,,493.5,percent of total billed charges,Implant Device,493.5,35,,493.5,percent of total billed charges,Implant Device,493.5,35,,493.5,percent of total billed charges,Implant Device,493.5,35,,493.5,percent of total billed charges,Implant Device,493.5,35,,493.5,percent of total billed charges,Implant Device,564,40,,564,percent of total billed charges,Implant Device,493.5,70,,493.5,percent of total billed charges,All Other,479.4,34,,479.4,percent of total billed charges,Implant Device,479.4,34,,479.4,percent of total billed charges,Implant Device,493.5,35,,493.5,percent of total billed charges,Implant Device,493.5,35,,493.5,percent of total billed charges,Implant Device,493.5,35,,493.5,percent of total billed charges,Implant Device,493.5,35,,493.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1043.4,
MTI 41047-01RR INFUSION CATH 5FRX65CM,C1751,HCPCS,,79005673,CDM,278,RC,,,both,,,156,115.44,,,115.44,Other,150% of Medicare + 9.63% HCRA Surcharge,70.2,45,,70.2,percent of total billed charges,Critical Access Hospital RCC factor,53.04,34,,53.04,percent of total billed charges,Implant Device,53.04,34,,53.04,percent of total billed charges,Implant Device,53.04,34,,53.04,percent of total billed charges,Implant Device,53.04,34,,53.04,percent of total billed charges,Implant Device,53.04,34,,53.04,percent of total billed charges,Implant Device,77.22,,,77.22,Other,110% of Medicare,54.6,35,,54.6,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,54.6,35,,54.6,percent of total billed charges,Implant Device,54.6,35,,54.6,percent of total billed charges,Implant Device,54.6,35,,54.6,percent of total billed charges,Implant Device,54.6,35,,54.6,percent of total billed charges,Implant Device,54.6,35,,54.6,percent of total billed charges,Implant Device,62.4,40,,62.4,percent of total billed charges,Implant Device,54.6,70,,54.6,percent of total billed charges,All Other,53.04,34,,53.04,percent of total billed charges,Implant Device,53.04,34,,53.04,percent of total billed charges,Implant Device,54.6,35,,54.6,percent of total billed charges,Implant Device,54.6,35,,54.6,percent of total billed charges,Implant Device,54.6,35,,54.6,percent of total billed charges,Implant Device,54.6,35,,54.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,115.44,
ARROW AU-22122-FRR DIALYSIS CATH 12X16,C1752,HCPCS,,79005682,CDM,278,RC,,,both,,,100,74,,,74,Other,150% of Medicare + 9.63% HCRA Surcharge,45,45,,45,percent of total billed charges,Critical Access Hospital RCC factor,34,34,,34,percent of total billed charges,Implant Device,34,34,,34,percent of total billed charges,Implant Device,34,34,,34,percent of total billed charges,Implant Device,34,34,,34,percent of total billed charges,Implant Device,34,34,,34,percent of total billed charges,Implant Device,49.5,,,49.5,Other,110% of Medicare,35,35,,35,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,35,35,,35,percent of total billed charges,Implant Device,35,35,,35,percent of total billed charges,Implant Device,35,35,,35,percent of total billed charges,Implant Device,35,35,,35,percent of total billed charges,Implant Device,35,35,,35,percent of total billed charges,Implant Device,40,40,,40,percent of total billed charges,Implant Device,35,70,,35,percent of total billed charges,All Other,34,34,,34,percent of total billed charges,Implant Device,34,34,,34,percent of total billed charges,Implant Device,35,35,,35,percent of total billed charges,Implant Device,35,35,,35,percent of total billed charges,Implant Device,35,35,,35,percent of total billed charges,Implant Device,35,35,,35,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,74,
LIFENET AFLEX100 DECELLURIZED DERMIS,C1762,HCPCS,,79005688,CDM,278,RC,,,both,,,5986,4429.65,,,4429.65,Other,150% of Medicare + 9.63% HCRA Surcharge,2693.7,45,,2693.7,percent of total billed charges,Critical Access Hospital RCC factor,2035.24,34,,2035.24,percent of total billed charges,Implant Device,2035.24,34,,2035.24,percent of total billed charges,Implant Device,2035.24,34,,2035.24,percent of total billed charges,Implant Device,2035.24,34,,2035.24,percent of total billed charges,Implant Device,2035.24,34,,2035.24,percent of total billed charges,Implant Device,2963.07,,,2963.07,Other,110% of Medicare,2095.1,35,,2095.1,percent of total billed charges,Implant Device,2035.24,34,"Charges > $500, x 34%",2035.24,percent of total billed charges,Implant Device,2095.1,35,,2095.1,percent of total billed charges,Implant Device,2095.1,35,,2095.1,percent of total billed charges,Implant Device,2095.1,35,,2095.1,percent of total billed charges,Implant Device,2095.1,35,,2095.1,percent of total billed charges,Implant Device,2095.1,35,,2095.1,percent of total billed charges,Implant Device,2394.4,40,,2394.4,percent of total billed charges,Implant Device,2095.1,70,,2095.1,percent of total billed charges,All Other,2035.24,34,,2035.24,percent of total billed charges,Implant Device,2035.24,34,,2035.24,percent of total billed charges,Implant Device,2095.1,35,,2095.1,percent of total billed charges,Implant Device,2095.1,35,,2095.1,percent of total billed charges,Implant Device,2095.1,35,,2095.1,percent of total billed charges,Implant Device,2095.1,35,,2095.1,percent of total billed charges,Implant Device,976.07,,,976.07,Other,100% of Medicaid,976.07,,,976.07,Other,100% of Medicaid,976.07,,,976.07,Other,100% of Medicaid,976.07,,,976.07,Other,100% of Medicaid,2196.16,,,2196.16,Other,225% of Medicaid,1493.39,,,1493.39,Other,153% of Medicaid,2196.16,,,2196.16,Other,225% of Medicaid,1366.5,,,1366.5,Other,140% of Medicaid,2035.24,34,"If Charge > 2,000, then 34 percent",2035.24,percent of total billed charges,Implants,2537.78,,,2537.78,Other,260% of Medicaid,3162.47,,,3162.47,Other,324% of Medicaid,2098.55,,,2098.55,Other,215% of Medicaid,2098.55,,,2098.55,Other,215% of Medicaid,1220.09,,,1220.09,Other,125% of Medicaid,976.07,4429.65,
STRYKER 40-20805 PLATE FIBULA STR 5 HOLE,C1713,HCPCS,,79005689,CDM,278,RC,,,both,,,2340,1731.61,,,1731.61,Other,150% of Medicare + 9.63% HCRA Surcharge,1053,45,,1053,percent of total billed charges,Critical Access Hospital RCC factor,795.6,34,,795.6,percent of total billed charges,Implant Device,795.6,34,,795.6,percent of total billed charges,Implant Device,795.6,34,,795.6,percent of total billed charges,Implant Device,795.6,34,,795.6,percent of total billed charges,Implant Device,795.6,34,,795.6,percent of total billed charges,Implant Device,1158.3,,,1158.3,Other,110% of Medicare,819,35,,819,percent of total billed charges,Implant Device,795.6,34,"Charges > $500, x 34%",795.6,percent of total billed charges,Implant Device,819,35,,819,percent of total billed charges,Implant Device,819,35,,819,percent of total billed charges,Implant Device,819,35,,819,percent of total billed charges,Implant Device,819,35,,819,percent of total billed charges,Implant Device,819,35,,819,percent of total billed charges,Implant Device,936,40,,936,percent of total billed charges,Implant Device,819,70,,819,percent of total billed charges,All Other,795.6,34,,795.6,percent of total billed charges,Implant Device,795.6,34,,795.6,percent of total billed charges,Implant Device,819,35,,819,percent of total billed charges,Implant Device,819,35,,819,percent of total billed charges,Implant Device,819,35,,819,percent of total billed charges,Implant Device,819,35,,819,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,795.6,34,"If Charge > 2,000, then 34 percent",795.6,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1731.61,
STRYKER 604626 CANN SCREW 26X4.0MM,C1713,HCPCS,,79005690,CDM,278,RC,,,both,,,660,488.4,,,488.4,Other,150% of Medicare + 9.63% HCRA Surcharge,297,45,,297,percent of total billed charges,Critical Access Hospital RCC factor,224.4,34,,224.4,percent of total billed charges,Implant Device,224.4,34,,224.4,percent of total billed charges,Implant Device,224.4,34,,224.4,percent of total billed charges,Implant Device,224.4,34,,224.4,percent of total billed charges,Implant Device,224.4,34,,224.4,percent of total billed charges,Implant Device,326.7,,,326.7,Other,110% of Medicare,231,35,,231,percent of total billed charges,Implant Device,224.4,34,"Charges > $500, x 34%",224.4,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,264,40,,264,percent of total billed charges,Implant Device,231,70,,231,percent of total billed charges,All Other,224.4,34,,224.4,percent of total billed charges,Implant Device,224.4,34,,224.4,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,488.4,
ALPHATEC 71002-030 PLATE 2 LEVEL 30MM,C1713,HCPCS,,79005692,CDM,278,RC,,,both,,,2700,1998.01,,,1998.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1215,45,,1215,percent of total billed charges,Critical Access Hospital RCC factor,918,34,,918,percent of total billed charges,Implant Device,918,34,,918,percent of total billed charges,Implant Device,918,34,,918,percent of total billed charges,Implant Device,918,34,,918,percent of total billed charges,Implant Device,918,34,,918,percent of total billed charges,Implant Device,1336.5,,,1336.5,Other,110% of Medicare,945,35,,945,percent of total billed charges,Implant Device,918,34,"Charges > $500, x 34%",918,percent of total billed charges,Implant Device,945,35,,945,percent of total billed charges,Implant Device,945,35,,945,percent of total billed charges,Implant Device,945,35,,945,percent of total billed charges,Implant Device,945,35,,945,percent of total billed charges,Implant Device,945,35,,945,percent of total billed charges,Implant Device,1080,40,,1080,percent of total billed charges,Implant Device,945,70,,945,percent of total billed charges,All Other,918,34,,918,percent of total billed charges,Implant Device,918,34,,918,percent of total billed charges,Implant Device,945,35,,945,percent of total billed charges,Implant Device,945,35,,945,percent of total billed charges,Implant Device,945,35,,945,percent of total billed charges,Implant Device,945,35,,945,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,918,34,"If Charge > 2,000, then 34 percent",918,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1998.01,
ZIMMER 5880-60-14 ART SURFACE SZ F 14MM,C1713,HCPCS,,79005693,CDM,278,RC,,,both,,,5765,4266.11,,,4266.11,Other,150% of Medicare + 9.63% HCRA Surcharge,2594.25,45,,2594.25,percent of total billed charges,Critical Access Hospital RCC factor,1960.1,34,,1960.1,percent of total billed charges,Implant Device,1960.1,34,,1960.1,percent of total billed charges,Implant Device,1960.1,34,,1960.1,percent of total billed charges,Implant Device,1960.1,34,,1960.1,percent of total billed charges,Implant Device,1960.1,34,,1960.1,percent of total billed charges,Implant Device,2853.68,,,2853.68,Other,110% of Medicare,2017.75,35,,2017.75,percent of total billed charges,Implant Device,1960.1,34,"Charges > $500, x 34%",1960.1,percent of total billed charges,Implant Device,2017.75,35,,2017.75,percent of total billed charges,Implant Device,2017.75,35,,2017.75,percent of total billed charges,Implant Device,2017.75,35,,2017.75,percent of total billed charges,Implant Device,2017.75,35,,2017.75,percent of total billed charges,Implant Device,2017.75,35,,2017.75,percent of total billed charges,Implant Device,2306,40,,2306,percent of total billed charges,Implant Device,2017.75,70,,2017.75,percent of total billed charges,All Other,1960.1,34,,1960.1,percent of total billed charges,Implant Device,1960.1,34,,1960.1,percent of total billed charges,Implant Device,2017.75,35,,2017.75,percent of total billed charges,Implant Device,2017.75,35,,2017.75,percent of total billed charges,Implant Device,2017.75,35,,2017.75,percent of total billed charges,Implant Device,2017.75,35,,2017.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1960.1,34,"If Charge > 2,000, then 34 percent",1960.1,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4266.11,
ARTHREX AR-1555PS TENOD SCREW 5.5X15MM,C1713,HCPCS,,79005697,CDM,278,RC,,,both,,,946,700.04,,,700.04,Other,150% of Medicare + 9.63% HCRA Surcharge,425.7,45,,425.7,percent of total billed charges,Critical Access Hospital RCC factor,321.64,34,,321.64,percent of total billed charges,Implant Device,321.64,34,,321.64,percent of total billed charges,Implant Device,321.64,34,,321.64,percent of total billed charges,Implant Device,321.64,34,,321.64,percent of total billed charges,Implant Device,321.64,34,,321.64,percent of total billed charges,Implant Device,468.27,,,468.27,Other,110% of Medicare,331.1,35,,331.1,percent of total billed charges,Implant Device,321.64,34,"Charges > $500, x 34%",321.64,percent of total billed charges,Implant Device,331.1,35,,331.1,percent of total billed charges,Implant Device,331.1,35,,331.1,percent of total billed charges,Implant Device,331.1,35,,331.1,percent of total billed charges,Implant Device,331.1,35,,331.1,percent of total billed charges,Implant Device,331.1,35,,331.1,percent of total billed charges,Implant Device,378.4,40,,378.4,percent of total billed charges,Implant Device,331.1,70,,331.1,percent of total billed charges,All Other,321.64,34,,321.64,percent of total billed charges,Implant Device,321.64,34,,321.64,percent of total billed charges,Implant Device,331.1,35,,331.1,percent of total billed charges,Implant Device,331.1,35,,331.1,percent of total billed charges,Implant Device,331.1,35,,331.1,percent of total billed charges,Implant Device,331.1,35,,331.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,700.04,
STRYKER 6276-7-316 MOD HIP SYS 235X16MM,C1776,HCPCS,,79005698,CDM,278,RC,,,both,,,16079,11898.5,,,11898.5,Other,150% of Medicare + 9.63% HCRA Surcharge,7235.55,45,,7235.55,percent of total billed charges,Critical Access Hospital RCC factor,5466.86,34,,5466.86,percent of total billed charges,Implant Device,5466.86,34,,5466.86,percent of total billed charges,Implant Device,5466.86,34,,5466.86,percent of total billed charges,Implant Device,5466.86,34,,5466.86,percent of total billed charges,Implant Device,5466.86,34,,5466.86,percent of total billed charges,Implant Device,7959.11,,,7959.11,Other,110% of Medicare,5627.65,35,,5627.65,percent of total billed charges,Implant Device,5466.86,34,"Charges > $500, x 34%",5466.86,percent of total billed charges,Implant Device,5627.65,35,,5627.65,percent of total billed charges,Implant Device,5627.65,35,,5627.65,percent of total billed charges,Implant Device,5627.65,35,,5627.65,percent of total billed charges,Implant Device,5627.65,35,,5627.65,percent of total billed charges,Implant Device,5627.65,35,,5627.65,percent of total billed charges,Implant Device,6431.6,40,,6431.6,percent of total billed charges,Implant Device,5627.65,70,,5627.65,percent of total billed charges,All Other,5466.86,34,,5466.86,percent of total billed charges,Implant Device,5466.86,34,,5466.86,percent of total billed charges,Implant Device,5627.65,35,,5627.65,percent of total billed charges,Implant Device,5627.65,35,,5627.65,percent of total billed charges,Implant Device,5627.65,35,,5627.65,percent of total billed charges,Implant Device,5627.65,35,,5627.65,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,5466.86,34,"If Charge > 2,000, then 34 percent",5466.86,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,11898.5,
STRYKER 40-35622 LOCKING SCREW 3.5X22MM,C1713,HCPCS,,79005702,CDM,278,RC,,,both,,,696,515.04,,,515.04,Other,150% of Medicare + 9.63% HCRA Surcharge,313.2,45,,313.2,percent of total billed charges,Critical Access Hospital RCC factor,236.64,34,,236.64,percent of total billed charges,Implant Device,236.64,34,,236.64,percent of total billed charges,Implant Device,236.64,34,,236.64,percent of total billed charges,Implant Device,236.64,34,,236.64,percent of total billed charges,Implant Device,236.64,34,,236.64,percent of total billed charges,Implant Device,344.52,,,344.52,Other,110% of Medicare,243.6,35,,243.6,percent of total billed charges,Implant Device,236.64,34,"Charges > $500, x 34%",236.64,percent of total billed charges,Implant Device,243.6,35,,243.6,percent of total billed charges,Implant Device,243.6,35,,243.6,percent of total billed charges,Implant Device,243.6,35,,243.6,percent of total billed charges,Implant Device,243.6,35,,243.6,percent of total billed charges,Implant Device,243.6,35,,243.6,percent of total billed charges,Implant Device,278.4,40,,278.4,percent of total billed charges,Implant Device,243.6,70,,243.6,percent of total billed charges,All Other,236.64,34,,236.64,percent of total billed charges,Implant Device,236.64,34,,236.64,percent of total billed charges,Implant Device,243.6,35,,243.6,percent of total billed charges,Implant Device,243.6,35,,243.6,percent of total billed charges,Implant Device,243.6,35,,243.6,percent of total billed charges,Implant Device,243.6,35,,243.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,515.04,
ALLERGAN 133MX-12-T TISSUE EXPANDER,C1789,HCPCS,,79005703,CDM,278,RC,,,both,,,4650,3441.01,,,3441.01,Other,150% of Medicare + 9.63% HCRA Surcharge,2092.5,45,,2092.5,percent of total billed charges,Critical Access Hospital RCC factor,1581,34,,1581,percent of total billed charges,Implant Device,1581,34,,1581,percent of total billed charges,Implant Device,1581,34,,1581,percent of total billed charges,Implant Device,1581,34,,1581,percent of total billed charges,Implant Device,1581,34,,1581,percent of total billed charges,Implant Device,2301.75,,,2301.75,Other,110% of Medicare,1627.5,35,,1627.5,percent of total billed charges,Implant Device,1581,34,"Charges > $500, x 34%",1581,percent of total billed charges,Implant Device,1627.5,35,,1627.5,percent of total billed charges,Implant Device,1627.5,35,,1627.5,percent of total billed charges,Implant Device,1627.5,35,,1627.5,percent of total billed charges,Implant Device,1627.5,35,,1627.5,percent of total billed charges,Implant Device,1627.5,35,,1627.5,percent of total billed charges,Implant Device,1860,40,,1860,percent of total billed charges,Implant Device,1627.5,70,,1627.5,percent of total billed charges,All Other,1581,34,,1581,percent of total billed charges,Implant Device,1581,34,,1581,percent of total billed charges,Implant Device,1627.5,35,,1627.5,percent of total billed charges,Implant Device,1627.5,35,,1627.5,percent of total billed charges,Implant Device,1627.5,35,,1627.5,percent of total billed charges,Implant Device,1627.5,35,,1627.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1581,34,"If Charge > 2,000, then 34 percent",1581,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3441.01,
ALLERGAN 133MX-15-T TISSUE EXPANDER,C1789,HCPCS,,79005704,CDM,278,RC,,,both,,,4650,3441.01,,,3441.01,Other,150% of Medicare + 9.63% HCRA Surcharge,2092.5,45,,2092.5,percent of total billed charges,Critical Access Hospital RCC factor,1581,34,,1581,percent of total billed charges,Implant Device,1581,34,,1581,percent of total billed charges,Implant Device,1581,34,,1581,percent of total billed charges,Implant Device,1581,34,,1581,percent of total billed charges,Implant Device,1581,34,,1581,percent of total billed charges,Implant Device,2301.75,,,2301.75,Other,110% of Medicare,1627.5,35,,1627.5,percent of total billed charges,Implant Device,1581,34,"Charges > $500, x 34%",1581,percent of total billed charges,Implant Device,1627.5,35,,1627.5,percent of total billed charges,Implant Device,1627.5,35,,1627.5,percent of total billed charges,Implant Device,1627.5,35,,1627.5,percent of total billed charges,Implant Device,1627.5,35,,1627.5,percent of total billed charges,Implant Device,1627.5,35,,1627.5,percent of total billed charges,Implant Device,1860,40,,1860,percent of total billed charges,Implant Device,1627.5,70,,1627.5,percent of total billed charges,All Other,1581,34,,1581,percent of total billed charges,Implant Device,1581,34,,1581,percent of total billed charges,Implant Device,1627.5,35,,1627.5,percent of total billed charges,Implant Device,1627.5,35,,1627.5,percent of total billed charges,Implant Device,1627.5,35,,1627.5,percent of total billed charges,Implant Device,1627.5,35,,1627.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1581,34,"If Charge > 2,000, then 34 percent",1581,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3441.01,
ALLERGAN 133MX-16-T TISSUE EXPANDER,C1789,HCPCS,,79005705,CDM,278,RC,,,both,,,4650,3441.01,,,3441.01,Other,150% of Medicare + 9.63% HCRA Surcharge,2092.5,45,,2092.5,percent of total billed charges,Critical Access Hospital RCC factor,1581,34,,1581,percent of total billed charges,Implant Device,1581,34,,1581,percent of total billed charges,Implant Device,1581,34,,1581,percent of total billed charges,Implant Device,1581,34,,1581,percent of total billed charges,Implant Device,1581,34,,1581,percent of total billed charges,Implant Device,2301.75,,,2301.75,Other,110% of Medicare,1627.5,35,,1627.5,percent of total billed charges,Implant Device,1581,34,"Charges > $500, x 34%",1581,percent of total billed charges,Implant Device,1627.5,35,,1627.5,percent of total billed charges,Implant Device,1627.5,35,,1627.5,percent of total billed charges,Implant Device,1627.5,35,,1627.5,percent of total billed charges,Implant Device,1627.5,35,,1627.5,percent of total billed charges,Implant Device,1627.5,35,,1627.5,percent of total billed charges,Implant Device,1860,40,,1860,percent of total billed charges,Implant Device,1627.5,70,,1627.5,percent of total billed charges,All Other,1581,34,,1581,percent of total billed charges,Implant Device,1581,34,,1581,percent of total billed charges,Implant Device,1627.5,35,,1627.5,percent of total billed charges,Implant Device,1627.5,35,,1627.5,percent of total billed charges,Implant Device,1627.5,35,,1627.5,percent of total billed charges,Implant Device,1627.5,35,,1627.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1581,34,"If Charge > 2,000, then 34 percent",1581,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3441.01,
ATRIUM 085201 HEMASHIELD VASCULAR GRAFT,C1768,HCPCS,,79005707,CDM,278,RC,,,both,,,2437,1803.39,,,1803.39,Other,150% of Medicare + 9.63% HCRA Surcharge,1096.65,45,,1096.65,percent of total billed charges,Critical Access Hospital RCC factor,828.58,34,,828.58,percent of total billed charges,Implant Device,828.58,34,,828.58,percent of total billed charges,Implant Device,828.58,34,,828.58,percent of total billed charges,Implant Device,828.58,34,,828.58,percent of total billed charges,Implant Device,828.58,34,,828.58,percent of total billed charges,Implant Device,1206.32,,,1206.32,Other,110% of Medicare,852.95,35,,852.95,percent of total billed charges,Implant Device,828.58,34,"Charges > $500, x 34%",828.58,percent of total billed charges,Implant Device,852.95,35,,852.95,percent of total billed charges,Implant Device,852.95,35,,852.95,percent of total billed charges,Implant Device,852.95,35,,852.95,percent of total billed charges,Implant Device,852.95,35,,852.95,percent of total billed charges,Implant Device,852.95,35,,852.95,percent of total billed charges,Implant Device,974.8,40,,974.8,percent of total billed charges,Implant Device,852.95,70,,852.95,percent of total billed charges,All Other,828.58,34,,828.58,percent of total billed charges,Implant Device,828.58,34,,828.58,percent of total billed charges,Implant Device,852.95,35,,852.95,percent of total billed charges,Implant Device,852.95,35,,852.95,percent of total billed charges,Implant Device,852.95,35,,852.95,percent of total billed charges,Implant Device,852.95,35,,852.95,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,828.58,34,"If Charge > 2,000, then 34 percent",828.58,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1803.39,
STRYKER 1822-0928S TIBIAL NAIL 9X285MM,C1713,HCPCS,,79005709,CDM,278,RC,,,both,,,6110,4521.42,,,4521.42,Other,150% of Medicare + 9.63% HCRA Surcharge,2749.5,45,,2749.5,percent of total billed charges,Critical Access Hospital RCC factor,2077.4,34,,2077.4,percent of total billed charges,Implant Device,2077.4,34,,2077.4,percent of total billed charges,Implant Device,2077.4,34,,2077.4,percent of total billed charges,Implant Device,2077.4,34,,2077.4,percent of total billed charges,Implant Device,2077.4,34,,2077.4,percent of total billed charges,Implant Device,3024.45,,,3024.45,Other,110% of Medicare,2138.5,35,,2138.5,percent of total billed charges,Implant Device,2077.4,34,"Charges > $500, x 34%",2077.4,percent of total billed charges,Implant Device,2138.5,35,,2138.5,percent of total billed charges,Implant Device,2138.5,35,,2138.5,percent of total billed charges,Implant Device,2138.5,35,,2138.5,percent of total billed charges,Implant Device,2138.5,35,,2138.5,percent of total billed charges,Implant Device,2138.5,35,,2138.5,percent of total billed charges,Implant Device,2444,40,,2444,percent of total billed charges,Implant Device,2138.5,70,,2138.5,percent of total billed charges,All Other,2077.4,34,,2077.4,percent of total billed charges,Implant Device,2077.4,34,,2077.4,percent of total billed charges,Implant Device,2138.5,35,,2138.5,percent of total billed charges,Implant Device,2138.5,35,,2138.5,percent of total billed charges,Implant Device,2138.5,35,,2138.5,percent of total billed charges,Implant Device,2138.5,35,,2138.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2077.4,34,"If Charge > 2,000, then 34 percent",2077.4,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4521.42,
STRYKER 1826-5027S LOCK SCREW FT 5X27MM,C1713,HCPCS,,79005710,CDM,278,RC,,,both,,,714,528.36,,,528.36,Other,150% of Medicare + 9.63% HCRA Surcharge,321.3,45,,321.3,percent of total billed charges,Critical Access Hospital RCC factor,242.76,34,,242.76,percent of total billed charges,Implant Device,242.76,34,,242.76,percent of total billed charges,Implant Device,242.76,34,,242.76,percent of total billed charges,Implant Device,242.76,34,,242.76,percent of total billed charges,Implant Device,242.76,34,,242.76,percent of total billed charges,Implant Device,353.43,,,353.43,Other,110% of Medicare,249.9,35,,249.9,percent of total billed charges,Implant Device,242.76,34,"Charges > $500, x 34%",242.76,percent of total billed charges,Implant Device,249.9,35,,249.9,percent of total billed charges,Implant Device,249.9,35,,249.9,percent of total billed charges,Implant Device,249.9,35,,249.9,percent of total billed charges,Implant Device,249.9,35,,249.9,percent of total billed charges,Implant Device,249.9,35,,249.9,percent of total billed charges,Implant Device,285.6,40,,285.6,percent of total billed charges,Implant Device,249.9,70,,249.9,percent of total billed charges,All Other,242.76,34,,242.76,percent of total billed charges,Implant Device,242.76,34,,242.76,percent of total billed charges,Implant Device,249.9,35,,249.9,percent of total billed charges,Implant Device,249.9,35,,249.9,percent of total billed charges,Implant Device,249.9,35,,249.9,percent of total billed charges,Implant Device,249.9,35,,249.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,528.36,
ACUMED AT2-M16S ACUTRAK BONE SCREW 16MM,C1713,HCPCS,,79005712,CDM,278,RC,,,both,,,1570,1161.8,,,1161.8,Other,150% of Medicare + 9.63% HCRA Surcharge,706.5,45,,706.5,percent of total billed charges,Critical Access Hospital RCC factor,533.8,34,,533.8,percent of total billed charges,Implant Device,533.8,34,,533.8,percent of total billed charges,Implant Device,533.8,34,,533.8,percent of total billed charges,Implant Device,533.8,34,,533.8,percent of total billed charges,Implant Device,533.8,34,,533.8,percent of total billed charges,Implant Device,777.15,,,777.15,Other,110% of Medicare,549.5,35,,549.5,percent of total billed charges,Implant Device,533.8,34,"Charges > $500, x 34%",533.8,percent of total billed charges,Implant Device,549.5,35,,549.5,percent of total billed charges,Implant Device,549.5,35,,549.5,percent of total billed charges,Implant Device,549.5,35,,549.5,percent of total billed charges,Implant Device,549.5,35,,549.5,percent of total billed charges,Implant Device,549.5,35,,549.5,percent of total billed charges,Implant Device,628,40,,628,percent of total billed charges,Implant Device,549.5,70,,549.5,percent of total billed charges,All Other,533.8,34,,533.8,percent of total billed charges,Implant Device,533.8,34,,533.8,percent of total billed charges,Implant Device,549.5,35,,549.5,percent of total billed charges,Implant Device,549.5,35,,549.5,percent of total billed charges,Implant Device,549.5,35,,549.5,percent of total billed charges,Implant Device,549.5,35,,549.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1161.8,
BARD 0010101 KUGEL PATCH 3.25X4.75 OVAL,C1781,HCPCS,,79005715,CDM,278,RC,,,both,,,804,594.96,,,594.96,Other,150% of Medicare + 9.63% HCRA Surcharge,361.8,45,,361.8,percent of total billed charges,Critical Access Hospital RCC factor,273.36,34,,273.36,percent of total billed charges,Implant Device,273.36,34,,273.36,percent of total billed charges,Implant Device,273.36,34,,273.36,percent of total billed charges,Implant Device,273.36,34,,273.36,percent of total billed charges,Implant Device,273.36,34,,273.36,percent of total billed charges,Implant Device,397.98,,,397.98,Other,110% of Medicare,281.4,35,,281.4,percent of total billed charges,Implant Device,273.36,34,"Charges > $500, x 34%",273.36,percent of total billed charges,Implant Device,281.4,35,,281.4,percent of total billed charges,Implant Device,281.4,35,,281.4,percent of total billed charges,Implant Device,281.4,35,,281.4,percent of total billed charges,Implant Device,281.4,35,,281.4,percent of total billed charges,Implant Device,281.4,35,,281.4,percent of total billed charges,Implant Device,321.6,40,,321.6,percent of total billed charges,Implant Device,281.4,70,,281.4,percent of total billed charges,All Other,273.36,34,,273.36,percent of total billed charges,Implant Device,273.36,34,,273.36,percent of total billed charges,Implant Device,281.4,35,,281.4,percent of total billed charges,Implant Device,281.4,35,,281.4,percent of total billed charges,Implant Device,281.4,35,,281.4,percent of total billed charges,Implant Device,281.4,35,,281.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,594.96,
BARD 0010102 KUGEL PATCH 5.5X7,C1781,HCPCS,,79005716,CDM,278,RC,,,both,,,1152,852.48,,,852.48,Other,150% of Medicare + 9.63% HCRA Surcharge,518.4,45,,518.4,percent of total billed charges,Critical Access Hospital RCC factor,391.68,34,,391.68,percent of total billed charges,Implant Device,391.68,34,,391.68,percent of total billed charges,Implant Device,391.68,34,,391.68,percent of total billed charges,Implant Device,391.68,34,,391.68,percent of total billed charges,Implant Device,391.68,34,,391.68,percent of total billed charges,Implant Device,570.24,,,570.24,Other,110% of Medicare,403.2,35,,403.2,percent of total billed charges,Implant Device,391.68,34,"Charges > $500, x 34%",391.68,percent of total billed charges,Implant Device,403.2,35,,403.2,percent of total billed charges,Implant Device,403.2,35,,403.2,percent of total billed charges,Implant Device,403.2,35,,403.2,percent of total billed charges,Implant Device,403.2,35,,403.2,percent of total billed charges,Implant Device,403.2,35,,403.2,percent of total billed charges,Implant Device,460.8,40,,460.8,percent of total billed charges,Implant Device,403.2,70,,403.2,percent of total billed charges,All Other,391.68,34,,391.68,percent of total billed charges,Implant Device,391.68,34,,391.68,percent of total billed charges,Implant Device,403.2,35,,403.2,percent of total billed charges,Implant Device,403.2,35,,403.2,percent of total billed charges,Implant Device,403.2,35,,403.2,percent of total billed charges,Implant Device,403.2,35,,403.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,852.48,
BARD 0010103 CIRCLE HERNIA PATCH,C1781,HCPCS,,79005717,CDM,278,RC,,,both,,,900,666,,,666,Other,150% of Medicare + 9.63% HCRA Surcharge,405,45,,405,percent of total billed charges,Critical Access Hospital RCC factor,306,34,,306,percent of total billed charges,Implant Device,306,34,,306,percent of total billed charges,Implant Device,306,34,,306,percent of total billed charges,Implant Device,306,34,,306,percent of total billed charges,Implant Device,306,34,,306,percent of total billed charges,Implant Device,445.5,,,445.5,Other,110% of Medicare,315,35,,315,percent of total billed charges,Implant Device,306,34,"Charges > $500, x 34%",306,percent of total billed charges,Implant Device,315,35,,315,percent of total billed charges,Implant Device,315,35,,315,percent of total billed charges,Implant Device,315,35,,315,percent of total billed charges,Implant Device,315,35,,315,percent of total billed charges,Implant Device,315,35,,315,percent of total billed charges,Implant Device,360,40,,360,percent of total billed charges,Implant Device,315,70,,315,percent of total billed charges,All Other,306,34,,306,percent of total billed charges,Implant Device,306,34,,306,percent of total billed charges,Implant Device,315,35,,315,percent of total billed charges,Implant Device,315,35,,315,percent of total billed charges,Implant Device,315,35,,315,percent of total billed charges,Implant Device,315,35,,315,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,666,
BARD 0010104 KUGEL PATCH 12X12,C1781,HCPCS,,79005718,CDM,278,RC,,,both,,,1008,745.92,,,745.92,Other,150% of Medicare + 9.63% HCRA Surcharge,453.6,45,,453.6,percent of total billed charges,Critical Access Hospital RCC factor,342.72,34,,342.72,percent of total billed charges,Implant Device,342.72,34,,342.72,percent of total billed charges,Implant Device,342.72,34,,342.72,percent of total billed charges,Implant Device,342.72,34,,342.72,percent of total billed charges,Implant Device,342.72,34,,342.72,percent of total billed charges,Implant Device,498.96,,,498.96,Other,110% of Medicare,352.8,35,,352.8,percent of total billed charges,Implant Device,342.72,34,"Charges > $500, x 34%",342.72,percent of total billed charges,Implant Device,352.8,35,,352.8,percent of total billed charges,Implant Device,352.8,35,,352.8,percent of total billed charges,Implant Device,352.8,35,,352.8,percent of total billed charges,Implant Device,352.8,35,,352.8,percent of total billed charges,Implant Device,352.8,35,,352.8,percent of total billed charges,Implant Device,403.2,40,,403.2,percent of total billed charges,Implant Device,352.8,70,,352.8,percent of total billed charges,All Other,342.72,34,,342.72,percent of total billed charges,Implant Device,342.72,34,,342.72,percent of total billed charges,Implant Device,352.8,35,,352.8,percent of total billed charges,Implant Device,352.8,35,,352.8,percent of total billed charges,Implant Device,352.8,35,,352.8,percent of total billed charges,Implant Device,352.8,35,,352.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,745.92,
MTF 40004 CORT CANCELLOUS CHIPS 30CC,C1713,HCPCS,,79005719,CDM,278,RC,,,both,,,1566,1158.84,,,1158.84,Other,150% of Medicare + 9.63% HCRA Surcharge,704.7,45,,704.7,percent of total billed charges,Critical Access Hospital RCC factor,532.44,34,,532.44,percent of total billed charges,Implant Device,532.44,34,,532.44,percent of total billed charges,Implant Device,532.44,34,,532.44,percent of total billed charges,Implant Device,532.44,34,,532.44,percent of total billed charges,Implant Device,532.44,34,,532.44,percent of total billed charges,Implant Device,775.17,,,775.17,Other,110% of Medicare,548.1,35,,548.1,percent of total billed charges,Implant Device,532.44,34,"Charges > $500, x 34%",532.44,percent of total billed charges,Implant Device,548.1,35,,548.1,percent of total billed charges,Implant Device,548.1,35,,548.1,percent of total billed charges,Implant Device,548.1,35,,548.1,percent of total billed charges,Implant Device,548.1,35,,548.1,percent of total billed charges,Implant Device,548.1,35,,548.1,percent of total billed charges,Implant Device,626.4,40,,626.4,percent of total billed charges,Implant Device,548.1,70,,548.1,percent of total billed charges,All Other,532.44,34,,532.44,percent of total billed charges,Implant Device,532.44,34,,532.44,percent of total billed charges,Implant Device,548.1,35,,548.1,percent of total billed charges,Implant Device,548.1,35,,548.1,percent of total billed charges,Implant Device,548.1,35,,548.1,percent of total billed charges,Implant Device,548.1,35,,548.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1158.84,
SYNTHES 201.361.97 CORTEX SCREW 2.0X11MM,C1713,HCPCS,,79005732,CDM,278,RC,,,both,,,142,105.08,,,105.08,Other,150% of Medicare + 9.63% HCRA Surcharge,63.9,45,,63.9,percent of total billed charges,Critical Access Hospital RCC factor,48.28,34,,48.28,percent of total billed charges,Implant Device,48.28,34,,48.28,percent of total billed charges,Implant Device,48.28,34,,48.28,percent of total billed charges,Implant Device,48.28,34,,48.28,percent of total billed charges,Implant Device,48.28,34,,48.28,percent of total billed charges,Implant Device,70.29,,,70.29,Other,110% of Medicare,49.7,35,,49.7,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,49.7,35,,49.7,percent of total billed charges,Implant Device,49.7,35,,49.7,percent of total billed charges,Implant Device,49.7,35,,49.7,percent of total billed charges,Implant Device,49.7,35,,49.7,percent of total billed charges,Implant Device,49.7,35,,49.7,percent of total billed charges,Implant Device,56.8,40,,56.8,percent of total billed charges,Implant Device,49.7,70,,49.7,percent of total billed charges,All Other,48.28,34,,48.28,percent of total billed charges,Implant Device,48.28,34,,48.28,percent of total billed charges,Implant Device,49.7,35,,49.7,percent of total billed charges,Implant Device,49.7,35,,49.7,percent of total billed charges,Implant Device,49.7,35,,49.7,percent of total billed charges,Implant Device,49.7,35,,49.7,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,105.08,
SYNTHES 243.15 PLATE STRAIGHT 5 HOLE 2MM,C1713,HCPCS,,79005734,CDM,278,RC,,,both,,,174,128.76,,,128.76,Other,150% of Medicare + 9.63% HCRA Surcharge,78.3,45,,78.3,percent of total billed charges,Critical Access Hospital RCC factor,59.16,34,,59.16,percent of total billed charges,Implant Device,59.16,34,,59.16,percent of total billed charges,Implant Device,59.16,34,,59.16,percent of total billed charges,Implant Device,59.16,34,,59.16,percent of total billed charges,Implant Device,59.16,34,,59.16,percent of total billed charges,Implant Device,86.13,,,86.13,Other,110% of Medicare,60.9,35,,60.9,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,60.9,35,,60.9,percent of total billed charges,Implant Device,60.9,35,,60.9,percent of total billed charges,Implant Device,60.9,35,,60.9,percent of total billed charges,Implant Device,60.9,35,,60.9,percent of total billed charges,Implant Device,60.9,35,,60.9,percent of total billed charges,Implant Device,69.6,40,,69.6,percent of total billed charges,Implant Device,60.9,70,,60.9,percent of total billed charges,All Other,59.16,34,,59.16,percent of total billed charges,Implant Device,59.16,34,,59.16,percent of total billed charges,Implant Device,60.9,35,,60.9,percent of total billed charges,Implant Device,60.9,35,,60.9,percent of total billed charges,Implant Device,60.9,35,,60.9,percent of total billed charges,Implant Device,60.9,35,,60.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,128.76,
STRYKER 3325-0380S LONG NAIL 11X380MM,C1713,HCPCS,,79005736,CDM,278,RC,,,both,,,10162,7519.91,,,7519.91,Other,150% of Medicare + 9.63% HCRA Surcharge,4572.9,45,,4572.9,percent of total billed charges,Critical Access Hospital RCC factor,3455.08,34,,3455.08,percent of total billed charges,Implant Device,3455.08,34,,3455.08,percent of total billed charges,Implant Device,3455.08,34,,3455.08,percent of total billed charges,Implant Device,3455.08,34,,3455.08,percent of total billed charges,Implant Device,3455.08,34,,3455.08,percent of total billed charges,Implant Device,5030.19,,,5030.19,Other,110% of Medicare,3556.7,35,,3556.7,percent of total billed charges,Implant Device,3455.08,34,"Charges > $500, x 34%",3455.08,percent of total billed charges,Implant Device,3556.7,35,,3556.7,percent of total billed charges,Implant Device,3556.7,35,,3556.7,percent of total billed charges,Implant Device,3556.7,35,,3556.7,percent of total billed charges,Implant Device,3556.7,35,,3556.7,percent of total billed charges,Implant Device,3556.7,35,,3556.7,percent of total billed charges,Implant Device,4064.8,40,,4064.8,percent of total billed charges,Implant Device,3556.7,70,,3556.7,percent of total billed charges,All Other,3455.08,34,,3455.08,percent of total billed charges,Implant Device,3455.08,34,,3455.08,percent of total billed charges,Implant Device,3556.7,35,,3556.7,percent of total billed charges,Implant Device,3556.7,35,,3556.7,percent of total billed charges,Implant Device,3556.7,35,,3556.7,percent of total billed charges,Implant Device,3556.7,35,,3556.7,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3455.08,34,"If Charge > 2,000, then 34 percent",3455.08,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,7519.91,
STRYKER 3060-0120S LAG SCREW 10.5X120MM,C1713,HCPCS,,79005737,CDM,278,RC,,,both,,,2616,1935.85,,,1935.85,Other,150% of Medicare + 9.63% HCRA Surcharge,1177.2,45,,1177.2,percent of total billed charges,Critical Access Hospital RCC factor,889.44,34,,889.44,percent of total billed charges,Implant Device,889.44,34,,889.44,percent of total billed charges,Implant Device,889.44,34,,889.44,percent of total billed charges,Implant Device,889.44,34,,889.44,percent of total billed charges,Implant Device,889.44,34,,889.44,percent of total billed charges,Implant Device,1294.92,,,1294.92,Other,110% of Medicare,915.6,35,,915.6,percent of total billed charges,Implant Device,889.44,34,"Charges > $500, x 34%",889.44,percent of total billed charges,Implant Device,915.6,35,,915.6,percent of total billed charges,Implant Device,915.6,35,,915.6,percent of total billed charges,Implant Device,915.6,35,,915.6,percent of total billed charges,Implant Device,915.6,35,,915.6,percent of total billed charges,Implant Device,915.6,35,,915.6,percent of total billed charges,Implant Device,1046.4,40,,1046.4,percent of total billed charges,Implant Device,915.6,70,,915.6,percent of total billed charges,All Other,889.44,34,,889.44,percent of total billed charges,Implant Device,889.44,34,,889.44,percent of total billed charges,Implant Device,915.6,35,,915.6,percent of total billed charges,Implant Device,915.6,35,,915.6,percent of total billed charges,Implant Device,915.6,35,,915.6,percent of total billed charges,Implant Device,915.6,35,,915.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,889.44,34,"If Charge > 2,000, then 34 percent",889.44,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1935.85,
STRYKER 604646S CANNULATED SCREW 4X46MM,C1713,HCPCS,,79005738,CDM,278,RC,,,both,,,480,355.2,,,355.2,Other,150% of Medicare + 9.63% HCRA Surcharge,216,45,,216,percent of total billed charges,Critical Access Hospital RCC factor,163.2,34,,163.2,percent of total billed charges,Implant Device,163.2,34,,163.2,percent of total billed charges,Implant Device,163.2,34,,163.2,percent of total billed charges,Implant Device,163.2,34,,163.2,percent of total billed charges,Implant Device,163.2,34,,163.2,percent of total billed charges,Implant Device,237.6,,,237.6,Other,110% of Medicare,168,35,,168,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,192,40,,192,percent of total billed charges,Implant Device,168,70,,168,percent of total billed charges,All Other,163.2,34,,163.2,percent of total billed charges,Implant Device,163.2,34,,163.2,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,355.2,
SYNTHES 207.646 CANNULATED SCREW 4X46MM,C1713,HCPCS,,79005743,CDM,278,RC,,,both,,,915,677.1,,,677.1,Other,150% of Medicare + 9.63% HCRA Surcharge,411.75,45,,411.75,percent of total billed charges,Critical Access Hospital RCC factor,311.1,34,,311.1,percent of total billed charges,Implant Device,311.1,34,,311.1,percent of total billed charges,Implant Device,311.1,34,,311.1,percent of total billed charges,Implant Device,311.1,34,,311.1,percent of total billed charges,Implant Device,311.1,34,,311.1,percent of total billed charges,Implant Device,452.93,,,452.93,Other,110% of Medicare,320.25,35,,320.25,percent of total billed charges,Implant Device,311.1,34,"Charges > $500, x 34%",311.1,percent of total billed charges,Implant Device,320.25,35,,320.25,percent of total billed charges,Implant Device,320.25,35,,320.25,percent of total billed charges,Implant Device,320.25,35,,320.25,percent of total billed charges,Implant Device,320.25,35,,320.25,percent of total billed charges,Implant Device,320.25,35,,320.25,percent of total billed charges,Implant Device,366,40,,366,percent of total billed charges,Implant Device,320.25,70,,320.25,percent of total billed charges,All Other,311.1,34,,311.1,percent of total billed charges,Implant Device,311.1,34,,311.1,percent of total billed charges,Implant Device,320.25,35,,320.25,percent of total billed charges,Implant Device,320.25,35,,320.25,percent of total billed charges,Implant Device,320.25,35,,320.25,percent of total billed charges,Implant Device,320.25,35,,320.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,677.1,
STRYKER 5028-8-400 CARBON ROD 8X400MM,C1713,HCPCS,,79005744,CDM,278,RC,,,both,,,1533,1134.42,,,1134.42,Other,150% of Medicare + 9.63% HCRA Surcharge,689.85,45,,689.85,percent of total billed charges,Critical Access Hospital RCC factor,521.22,34,,521.22,percent of total billed charges,Implant Device,521.22,34,,521.22,percent of total billed charges,Implant Device,521.22,34,,521.22,percent of total billed charges,Implant Device,521.22,34,,521.22,percent of total billed charges,Implant Device,521.22,34,,521.22,percent of total billed charges,Implant Device,758.84,,,758.84,Other,110% of Medicare,536.55,35,,536.55,percent of total billed charges,Implant Device,521.22,34,"Charges > $500, x 34%",521.22,percent of total billed charges,Implant Device,536.55,35,,536.55,percent of total billed charges,Implant Device,536.55,35,,536.55,percent of total billed charges,Implant Device,536.55,35,,536.55,percent of total billed charges,Implant Device,536.55,35,,536.55,percent of total billed charges,Implant Device,536.55,35,,536.55,percent of total billed charges,Implant Device,613.2,40,,613.2,percent of total billed charges,Implant Device,536.55,70,,536.55,percent of total billed charges,All Other,521.22,34,,521.22,percent of total billed charges,Implant Device,521.22,34,,521.22,percent of total billed charges,Implant Device,536.55,35,,536.55,percent of total billed charges,Implant Device,536.55,35,,536.55,percent of total billed charges,Implant Device,536.55,35,,536.55,percent of total billed charges,Implant Device,536.55,35,,536.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1134.42,
STRYKER 1822-1130S TIBIAL NAIL 11X300MM,C1713,HCPCS,,79005745,CDM,278,RC,,,both,,,5819,4306.07,,,4306.07,Other,150% of Medicare + 9.63% HCRA Surcharge,2618.55,45,,2618.55,percent of total billed charges,Critical Access Hospital RCC factor,1978.46,34,,1978.46,percent of total billed charges,Implant Device,1978.46,34,,1978.46,percent of total billed charges,Implant Device,1978.46,34,,1978.46,percent of total billed charges,Implant Device,1978.46,34,,1978.46,percent of total billed charges,Implant Device,1978.46,34,,1978.46,percent of total billed charges,Implant Device,2880.41,,,2880.41,Other,110% of Medicare,2036.65,35,,2036.65,percent of total billed charges,Implant Device,1978.46,34,"Charges > $500, x 34%",1978.46,percent of total billed charges,Implant Device,2036.65,35,,2036.65,percent of total billed charges,Implant Device,2036.65,35,,2036.65,percent of total billed charges,Implant Device,2036.65,35,,2036.65,percent of total billed charges,Implant Device,2036.65,35,,2036.65,percent of total billed charges,Implant Device,2036.65,35,,2036.65,percent of total billed charges,Implant Device,2327.6,40,,2327.6,percent of total billed charges,Implant Device,2036.65,70,,2036.65,percent of total billed charges,All Other,1978.46,34,,1978.46,percent of total billed charges,Implant Device,1978.46,34,,1978.46,percent of total billed charges,Implant Device,2036.65,35,,2036.65,percent of total billed charges,Implant Device,2036.65,35,,2036.65,percent of total billed charges,Implant Device,2036.65,35,,2036.65,percent of total billed charges,Implant Device,2036.65,35,,2036.65,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1978.46,34,"If Charge > 2,000, then 34 percent",1978.46,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4306.07,
STRYKER 1822-1033S TIBIAL NAIL 11X330MM,C1713,HCPCS,,79005747,CDM,278,RC,,,both,,,3529,2611.47,,,2611.47,Other,150% of Medicare + 9.63% HCRA Surcharge,1588.05,45,,1588.05,percent of total billed charges,Critical Access Hospital RCC factor,1199.86,34,,1199.86,percent of total billed charges,Implant Device,1199.86,34,,1199.86,percent of total billed charges,Implant Device,1199.86,34,,1199.86,percent of total billed charges,Implant Device,1199.86,34,,1199.86,percent of total billed charges,Implant Device,1199.86,34,,1199.86,percent of total billed charges,Implant Device,1746.86,,,1746.86,Other,110% of Medicare,1235.15,35,,1235.15,percent of total billed charges,Implant Device,1199.86,34,"Charges > $500, x 34%",1199.86,percent of total billed charges,Implant Device,1235.15,35,,1235.15,percent of total billed charges,Implant Device,1235.15,35,,1235.15,percent of total billed charges,Implant Device,1235.15,35,,1235.15,percent of total billed charges,Implant Device,1235.15,35,,1235.15,percent of total billed charges,Implant Device,1235.15,35,,1235.15,percent of total billed charges,Implant Device,1411.6,40,,1411.6,percent of total billed charges,Implant Device,1235.15,70,,1235.15,percent of total billed charges,All Other,1199.86,34,,1199.86,percent of total billed charges,Implant Device,1199.86,34,,1199.86,percent of total billed charges,Implant Device,1235.15,35,,1235.15,percent of total billed charges,Implant Device,1235.15,35,,1235.15,percent of total billed charges,Implant Device,1235.15,35,,1235.15,percent of total billed charges,Implant Device,1235.15,35,,1235.15,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1199.86,34,"If Charge > 2,000, then 34 percent",1199.86,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2611.47,
STRYKER 1896-5065S LOCKING SCREW 5X65MM,C1713,HCPCS,,79005748,CDM,278,RC,,,both,,,893,660.82,,,660.82,Other,150% of Medicare + 9.63% HCRA Surcharge,401.85,45,,401.85,percent of total billed charges,Critical Access Hospital RCC factor,303.62,34,,303.62,percent of total billed charges,Implant Device,303.62,34,,303.62,percent of total billed charges,Implant Device,303.62,34,,303.62,percent of total billed charges,Implant Device,303.62,34,,303.62,percent of total billed charges,Implant Device,303.62,34,,303.62,percent of total billed charges,Implant Device,442.04,,,442.04,Other,110% of Medicare,312.55,35,,312.55,percent of total billed charges,Implant Device,303.62,34,"Charges > $500, x 34%",303.62,percent of total billed charges,Implant Device,312.55,35,,312.55,percent of total billed charges,Implant Device,312.55,35,,312.55,percent of total billed charges,Implant Device,312.55,35,,312.55,percent of total billed charges,Implant Device,312.55,35,,312.55,percent of total billed charges,Implant Device,312.55,35,,312.55,percent of total billed charges,Implant Device,357.2,40,,357.2,percent of total billed charges,Implant Device,312.55,70,,312.55,percent of total billed charges,All Other,303.62,34,,303.62,percent of total billed charges,Implant Device,303.62,34,,303.62,percent of total billed charges,Implant Device,312.55,35,,312.55,percent of total billed charges,Implant Device,312.55,35,,312.55,percent of total billed charges,Implant Device,312.55,35,,312.55,percent of total billed charges,Implant Device,312.55,35,,312.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,660.82,
ARTHREX AR-1390C BCMP INTER SCREW 9X23MM,C1713,HCPCS,,79005749,CDM,278,RC,,,both,,,966,714.84,,,714.84,Other,150% of Medicare + 9.63% HCRA Surcharge,434.7,45,,434.7,percent of total billed charges,Critical Access Hospital RCC factor,328.44,34,,328.44,percent of total billed charges,Implant Device,328.44,34,,328.44,percent of total billed charges,Implant Device,328.44,34,,328.44,percent of total billed charges,Implant Device,328.44,34,,328.44,percent of total billed charges,Implant Device,328.44,34,,328.44,percent of total billed charges,Implant Device,478.17,,,478.17,Other,110% of Medicare,338.1,35,,338.1,percent of total billed charges,Implant Device,328.44,34,"Charges > $500, x 34%",328.44,percent of total billed charges,Implant Device,338.1,35,,338.1,percent of total billed charges,Implant Device,338.1,35,,338.1,percent of total billed charges,Implant Device,338.1,35,,338.1,percent of total billed charges,Implant Device,338.1,35,,338.1,percent of total billed charges,Implant Device,338.1,35,,338.1,percent of total billed charges,Implant Device,386.4,40,,386.4,percent of total billed charges,Implant Device,338.1,70,,338.1,percent of total billed charges,All Other,328.44,34,,328.44,percent of total billed charges,Implant Device,328.44,34,,328.44,percent of total billed charges,Implant Device,338.1,35,,338.1,percent of total billed charges,Implant Device,338.1,35,,338.1,percent of total billed charges,Implant Device,338.1,35,,338.1,percent of total billed charges,Implant Device,338.1,35,,338.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,714.84,
ZIMMER 5990-35-21 FEM AUG BLCK SZ E 10MM,C1776,HCPCS,,79005750,CDM,278,RC,,,both,,,3240,2397.61,,,2397.61,Other,150% of Medicare + 9.63% HCRA Surcharge,1458,45,,1458,percent of total billed charges,Critical Access Hospital RCC factor,1101.6,34,,1101.6,percent of total billed charges,Implant Device,1101.6,34,,1101.6,percent of total billed charges,Implant Device,1101.6,34,,1101.6,percent of total billed charges,Implant Device,1101.6,34,,1101.6,percent of total billed charges,Implant Device,1101.6,34,,1101.6,percent of total billed charges,Implant Device,1603.8,,,1603.8,Other,110% of Medicare,1134,35,,1134,percent of total billed charges,Implant Device,1101.6,34,"Charges > $500, x 34%",1101.6,percent of total billed charges,Implant Device,1134,35,,1134,percent of total billed charges,Implant Device,1134,35,,1134,percent of total billed charges,Implant Device,1134,35,,1134,percent of total billed charges,Implant Device,1134,35,,1134,percent of total billed charges,Implant Device,1134,35,,1134,percent of total billed charges,Implant Device,1296,40,,1296,percent of total billed charges,Implant Device,1134,70,,1134,percent of total billed charges,All Other,1101.6,34,,1101.6,percent of total billed charges,Implant Device,1101.6,34,,1101.6,percent of total billed charges,Implant Device,1134,35,,1134,percent of total billed charges,Implant Device,1134,35,,1134,percent of total billed charges,Implant Device,1134,35,,1134,percent of total billed charges,Implant Device,1134,35,,1134,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1101.6,34,"If Charge > 2,000, then 34 percent",1101.6,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2397.61,
ZIMMER 5988-10-10 STEM EXTNSION 10X100MM,C1776,HCPCS,,79005751,CDM,278,RC,,,both,,,3325,2460.51,,,2460.51,Other,150% of Medicare + 9.63% HCRA Surcharge,1496.25,45,,1496.25,percent of total billed charges,Critical Access Hospital RCC factor,1130.5,34,,1130.5,percent of total billed charges,Implant Device,1130.5,34,,1130.5,percent of total billed charges,Implant Device,1130.5,34,,1130.5,percent of total billed charges,Implant Device,1130.5,34,,1130.5,percent of total billed charges,Implant Device,1130.5,34,,1130.5,percent of total billed charges,Implant Device,1645.88,,,1645.88,Other,110% of Medicare,1163.75,35,,1163.75,percent of total billed charges,Implant Device,1130.5,34,"Charges > $500, x 34%",1130.5,percent of total billed charges,Implant Device,1163.75,35,,1163.75,percent of total billed charges,Implant Device,1163.75,35,,1163.75,percent of total billed charges,Implant Device,1163.75,35,,1163.75,percent of total billed charges,Implant Device,1163.75,35,,1163.75,percent of total billed charges,Implant Device,1163.75,35,,1163.75,percent of total billed charges,Implant Device,1330,40,,1330,percent of total billed charges,Implant Device,1163.75,70,,1163.75,percent of total billed charges,All Other,1130.5,34,,1130.5,percent of total billed charges,Implant Device,1130.5,34,,1130.5,percent of total billed charges,Implant Device,1163.75,35,,1163.75,percent of total billed charges,Implant Device,1163.75,35,,1163.75,percent of total billed charges,Implant Device,1163.75,35,,1163.75,percent of total billed charges,Implant Device,1163.75,35,,1163.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1130.5,34,"If Charge > 2,000, then 34 percent",1130.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2460.51,
ZIMMER 5994-40-10 ART SURF SZ GREEN 10MM,C1776,HCPCS,,79005752,CDM,278,RC,,,both,,,6465,4784.12,,,4784.12,Other,150% of Medicare + 9.63% HCRA Surcharge,2909.25,45,,2909.25,percent of total billed charges,Critical Access Hospital RCC factor,2198.1,34,,2198.1,percent of total billed charges,Implant Device,2198.1,34,,2198.1,percent of total billed charges,Implant Device,2198.1,34,,2198.1,percent of total billed charges,Implant Device,2198.1,34,,2198.1,percent of total billed charges,Implant Device,2198.1,34,,2198.1,percent of total billed charges,Implant Device,3200.18,,,3200.18,Other,110% of Medicare,2262.75,35,,2262.75,percent of total billed charges,Implant Device,2198.1,34,"Charges > $500, x 34%",2198.1,percent of total billed charges,Implant Device,2262.75,35,,2262.75,percent of total billed charges,Implant Device,2262.75,35,,2262.75,percent of total billed charges,Implant Device,2262.75,35,,2262.75,percent of total billed charges,Implant Device,2262.75,35,,2262.75,percent of total billed charges,Implant Device,2262.75,35,,2262.75,percent of total billed charges,Implant Device,2586,40,,2586,percent of total billed charges,Implant Device,2262.75,70,,2262.75,percent of total billed charges,All Other,2198.1,34,,2198.1,percent of total billed charges,Implant Device,2198.1,34,,2198.1,percent of total billed charges,Implant Device,2262.75,35,,2262.75,percent of total billed charges,Implant Device,2262.75,35,,2262.75,percent of total billed charges,Implant Device,2262.75,35,,2262.75,percent of total billed charges,Implant Device,2262.75,35,,2262.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2198.1,34,"If Charge > 2,000, then 34 percent",2198.1,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4784.12,
BIOMET 1817-09-281 HUMERAL NAIL 9X280MM,C1713,HCPCS,,79005753,CDM,278,RC,,,both,,,7560,5594.42,,,5594.42,Other,150% of Medicare + 9.63% HCRA Surcharge,3402,45,,3402,percent of total billed charges,Critical Access Hospital RCC factor,2570.4,34,,2570.4,percent of total billed charges,Implant Device,2570.4,34,,2570.4,percent of total billed charges,Implant Device,2570.4,34,,2570.4,percent of total billed charges,Implant Device,2570.4,34,,2570.4,percent of total billed charges,Implant Device,2570.4,34,,2570.4,percent of total billed charges,Implant Device,3742.2,,,3742.2,Other,110% of Medicare,2646,35,,2646,percent of total billed charges,Implant Device,2570.4,34,"Charges > $500, x 34%",2570.4,percent of total billed charges,Implant Device,2646,35,,2646,percent of total billed charges,Implant Device,2646,35,,2646,percent of total billed charges,Implant Device,2646,35,,2646,percent of total billed charges,Implant Device,2646,35,,2646,percent of total billed charges,Implant Device,2646,35,,2646,percent of total billed charges,Implant Device,3024,40,,3024,percent of total billed charges,Implant Device,2646,70,,2646,percent of total billed charges,All Other,2570.4,34,,2570.4,percent of total billed charges,Implant Device,2570.4,34,,2570.4,percent of total billed charges,Implant Device,2646,35,,2646,percent of total billed charges,Implant Device,2646,35,,2646,percent of total billed charges,Implant Device,2646,35,,2646,percent of total billed charges,Implant Device,2646,35,,2646,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2570.4,34,"If Charge > 2,000, then 34 percent",2570.4,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5594.42,
BIOMET 1817-01-101 UNIV HUMERAL ADD 10MM,C1776,HCPCS,,79005756,CDM,278,RC,,,both,,,840,621.6,,,621.6,Other,150% of Medicare + 9.63% HCRA Surcharge,378,45,,378,percent of total billed charges,Critical Access Hospital RCC factor,285.6,34,,285.6,percent of total billed charges,Implant Device,285.6,34,,285.6,percent of total billed charges,Implant Device,285.6,34,,285.6,percent of total billed charges,Implant Device,285.6,34,,285.6,percent of total billed charges,Implant Device,285.6,34,,285.6,percent of total billed charges,Implant Device,415.8,,,415.8,Other,110% of Medicare,294,35,,294,percent of total billed charges,Implant Device,285.6,34,"Charges > $500, x 34%",285.6,percent of total billed charges,Implant Device,294,35,,294,percent of total billed charges,Implant Device,294,35,,294,percent of total billed charges,Implant Device,294,35,,294,percent of total billed charges,Implant Device,294,35,,294,percent of total billed charges,Implant Device,294,35,,294,percent of total billed charges,Implant Device,336,40,,336,percent of total billed charges,Implant Device,294,70,,294,percent of total billed charges,All Other,285.6,34,,285.6,percent of total billed charges,Implant Device,285.6,34,,285.6,percent of total billed charges,Implant Device,294,35,,294,percent of total billed charges,Implant Device,294,35,,294,percent of total billed charges,Implant Device,294,35,,294,percent of total billed charges,Implant Device,294,35,,294,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,621.6,
BIOMET 1819-48-040 CANCELLOUS SCREW 40MM,C1713,HCPCS,,79005757,CDM,278,RC,,,both,,,660,488.4,,,488.4,Other,150% of Medicare + 9.63% HCRA Surcharge,297,45,,297,percent of total billed charges,Critical Access Hospital RCC factor,224.4,34,,224.4,percent of total billed charges,Implant Device,224.4,34,,224.4,percent of total billed charges,Implant Device,224.4,34,,224.4,percent of total billed charges,Implant Device,224.4,34,,224.4,percent of total billed charges,Implant Device,224.4,34,,224.4,percent of total billed charges,Implant Device,326.7,,,326.7,Other,110% of Medicare,231,35,,231,percent of total billed charges,Implant Device,224.4,34,"Charges > $500, x 34%",224.4,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,264,40,,264,percent of total billed charges,Implant Device,231,70,,231,percent of total billed charges,All Other,224.4,34,,224.4,percent of total billed charges,Implant Device,224.4,34,,224.4,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,488.4,
BIOMET 1819-48-042 CANCELLOUS SCREW 42MM,C1713,HCPCS,,79005758,CDM,278,RC,,,both,,,660,488.4,,,488.4,Other,150% of Medicare + 9.63% HCRA Surcharge,297,45,,297,percent of total billed charges,Critical Access Hospital RCC factor,224.4,34,,224.4,percent of total billed charges,Implant Device,224.4,34,,224.4,percent of total billed charges,Implant Device,224.4,34,,224.4,percent of total billed charges,Implant Device,224.4,34,,224.4,percent of total billed charges,Implant Device,224.4,34,,224.4,percent of total billed charges,Implant Device,326.7,,,326.7,Other,110% of Medicare,231,35,,231,percent of total billed charges,Implant Device,224.4,34,"Charges > $500, x 34%",224.4,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,264,40,,264,percent of total billed charges,Implant Device,231,70,,231,percent of total billed charges,All Other,224.4,34,,224.4,percent of total billed charges,Implant Device,224.4,34,,224.4,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,488.4,
BIOMET 1819-48-044 CANCELLOUS SCREW 44MM,C1713,HCPCS,,79005759,CDM,278,RC,,,both,,,660,488.4,,,488.4,Other,150% of Medicare + 9.63% HCRA Surcharge,297,45,,297,percent of total billed charges,Critical Access Hospital RCC factor,224.4,34,,224.4,percent of total billed charges,Implant Device,224.4,34,,224.4,percent of total billed charges,Implant Device,224.4,34,,224.4,percent of total billed charges,Implant Device,224.4,34,,224.4,percent of total billed charges,Implant Device,224.4,34,,224.4,percent of total billed charges,Implant Device,326.7,,,326.7,Other,110% of Medicare,231,35,,231,percent of total billed charges,Implant Device,224.4,34,"Charges > $500, x 34%",224.4,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,264,40,,264,percent of total billed charges,Implant Device,231,70,,231,percent of total billed charges,All Other,224.4,34,,224.4,percent of total billed charges,Implant Device,224.4,34,,224.4,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,488.4,
BIOMET 1819-48-052 CANCELLOUS SCREW 52MM,C1713,HCPCS,,79005760,CDM,278,RC,,,both,,,660,488.4,,,488.4,Other,150% of Medicare + 9.63% HCRA Surcharge,297,45,,297,percent of total billed charges,Critical Access Hospital RCC factor,224.4,34,,224.4,percent of total billed charges,Implant Device,224.4,34,,224.4,percent of total billed charges,Implant Device,224.4,34,,224.4,percent of total billed charges,Implant Device,224.4,34,,224.4,percent of total billed charges,Implant Device,224.4,34,,224.4,percent of total billed charges,Implant Device,326.7,,,326.7,Other,110% of Medicare,231,35,,231,percent of total billed charges,Implant Device,224.4,34,"Charges > $500, x 34%",224.4,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,264,40,,264,percent of total billed charges,Implant Device,231,70,,231,percent of total billed charges,All Other,224.4,34,,224.4,percent of total billed charges,Implant Device,224.4,34,,224.4,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,488.4,
BIOMET 1402230 CORTICAL SCREW 30MM,C1713,HCPCS,,79005761,CDM,278,RC,,,both,,,210,155.4,,,155.4,Other,150% of Medicare + 9.63% HCRA Surcharge,94.5,45,,94.5,percent of total billed charges,Critical Access Hospital RCC factor,71.4,34,,71.4,percent of total billed charges,Implant Device,71.4,34,,71.4,percent of total billed charges,Implant Device,71.4,34,,71.4,percent of total billed charges,Implant Device,71.4,34,,71.4,percent of total billed charges,Implant Device,71.4,34,,71.4,percent of total billed charges,Implant Device,103.95,,,103.95,Other,110% of Medicare,73.5,35,,73.5,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,73.5,35,,73.5,percent of total billed charges,Implant Device,73.5,35,,73.5,percent of total billed charges,Implant Device,73.5,35,,73.5,percent of total billed charges,Implant Device,73.5,35,,73.5,percent of total billed charges,Implant Device,73.5,35,,73.5,percent of total billed charges,Implant Device,84,40,,84,percent of total billed charges,Implant Device,73.5,70,,73.5,percent of total billed charges,All Other,71.4,34,,71.4,percent of total billed charges,Implant Device,71.4,34,,71.4,percent of total billed charges,Implant Device,73.5,35,,73.5,percent of total billed charges,Implant Device,73.5,35,,73.5,percent of total billed charges,Implant Device,73.5,35,,73.5,percent of total billed charges,Implant Device,73.5,35,,73.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,155.4,
S&N 71453223 ART INSERT 13MM SIZE 5-8,C1776,HCPCS,,79005766,CDM,278,RC,,,both,,,5212,3856.89,,,3856.89,Other,150% of Medicare + 9.63% HCRA Surcharge,2345.4,45,,2345.4,percent of total billed charges,Critical Access Hospital RCC factor,1772.08,34,,1772.08,percent of total billed charges,Implant Device,1772.08,34,,1772.08,percent of total billed charges,Implant Device,1772.08,34,,1772.08,percent of total billed charges,Implant Device,1772.08,34,,1772.08,percent of total billed charges,Implant Device,1772.08,34,,1772.08,percent of total billed charges,Implant Device,2579.94,,,2579.94,Other,110% of Medicare,1824.2,35,,1824.2,percent of total billed charges,Implant Device,1772.08,34,"Charges > $500, x 34%",1772.08,percent of total billed charges,Implant Device,1824.2,35,,1824.2,percent of total billed charges,Implant Device,1824.2,35,,1824.2,percent of total billed charges,Implant Device,1824.2,35,,1824.2,percent of total billed charges,Implant Device,1824.2,35,,1824.2,percent of total billed charges,Implant Device,1824.2,35,,1824.2,percent of total billed charges,Implant Device,2084.8,40,,2084.8,percent of total billed charges,Implant Device,1824.2,70,,1824.2,percent of total billed charges,All Other,1772.08,34,,1772.08,percent of total billed charges,Implant Device,1772.08,34,,1772.08,percent of total billed charges,Implant Device,1824.2,35,,1824.2,percent of total billed charges,Implant Device,1824.2,35,,1824.2,percent of total billed charges,Implant Device,1824.2,35,,1824.2,percent of total billed charges,Implant Device,1824.2,35,,1824.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1772.08,34,"If Charge > 2,000, then 34 percent",1772.08,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3856.89,
BIOMET 113653 SHOULDER STEM 13X122MM,C1776,HCPCS,,79005767,CDM,278,RC,,,both,,,18630,13786.25,,,13786.25,Other,150% of Medicare + 9.63% HCRA Surcharge,8383.5,45,,8383.5,percent of total billed charges,Critical Access Hospital RCC factor,6334.2,34,,6334.2,percent of total billed charges,Implant Device,6334.2,34,,6334.2,percent of total billed charges,Implant Device,6334.2,34,,6334.2,percent of total billed charges,Implant Device,6334.2,34,,6334.2,percent of total billed charges,Implant Device,6334.2,34,,6334.2,percent of total billed charges,Implant Device,9221.85,,,9221.85,Other,110% of Medicare,6520.5,35,,6520.5,percent of total billed charges,Implant Device,6334.2,34,"Charges > $500, x 34%",6334.2,percent of total billed charges,Implant Device,6520.5,35,,6520.5,percent of total billed charges,Implant Device,6520.5,35,,6520.5,percent of total billed charges,Implant Device,6520.5,35,,6520.5,percent of total billed charges,Implant Device,6520.5,35,,6520.5,percent of total billed charges,Implant Device,6520.5,35,,6520.5,percent of total billed charges,Implant Device,7452,40,,7452,percent of total billed charges,Implant Device,6520.5,70,,6520.5,percent of total billed charges,All Other,6334.2,34,,6334.2,percent of total billed charges,Implant Device,6334.2,34,,6334.2,percent of total billed charges,Implant Device,6520.5,35,,6520.5,percent of total billed charges,Implant Device,6520.5,35,,6520.5,percent of total billed charges,Implant Device,6520.5,35,,6520.5,percent of total billed charges,Implant Device,6520.5,35,,6520.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,6334.2,34,"If Charge > 2,000, then 34 percent",6334.2,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,13786.25,
BIOMET 113053 HUMERAL HEAD 50X21X57MM,C1776,HCPCS,,79005768,CDM,278,RC,,,both,,,9120,6748.82,,,6748.82,Other,150% of Medicare + 9.63% HCRA Surcharge,4104,45,,4104,percent of total billed charges,Critical Access Hospital RCC factor,3100.8,34,,3100.8,percent of total billed charges,Implant Device,3100.8,34,,3100.8,percent of total billed charges,Implant Device,3100.8,34,,3100.8,percent of total billed charges,Implant Device,3100.8,34,,3100.8,percent of total billed charges,Implant Device,3100.8,34,,3100.8,percent of total billed charges,Implant Device,4514.4,,,4514.4,Other,110% of Medicare,3192,35,,3192,percent of total billed charges,Implant Device,3100.8,34,"Charges > $500, x 34%",3100.8,percent of total billed charges,Implant Device,3192,35,,3192,percent of total billed charges,Implant Device,3192,35,,3192,percent of total billed charges,Implant Device,3192,35,,3192,percent of total billed charges,Implant Device,3192,35,,3192,percent of total billed charges,Implant Device,3192,35,,3192,percent of total billed charges,Implant Device,3648,40,,3648,percent of total billed charges,Implant Device,3192,70,,3192,percent of total billed charges,All Other,3100.8,34,,3100.8,percent of total billed charges,Implant Device,3100.8,34,,3100.8,percent of total billed charges,Implant Device,3192,35,,3192,percent of total billed charges,Implant Device,3192,35,,3192,percent of total billed charges,Implant Device,3192,35,,3192,percent of total billed charges,Implant Device,3192,35,,3192,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3100.8,34,"If Charge > 2,000, then 34 percent",3100.8,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,6748.82,
BIOMET 113954 GLENOID BASE 4MM,C1776,HCPCS,,79005769,CDM,278,RC,,,both,,,7800,5772.02,,,5772.02,Other,150% of Medicare + 9.63% HCRA Surcharge,3510,45,,3510,percent of total billed charges,Critical Access Hospital RCC factor,2652,34,,2652,percent of total billed charges,Implant Device,2652,34,,2652,percent of total billed charges,Implant Device,2652,34,,2652,percent of total billed charges,Implant Device,2652,34,,2652,percent of total billed charges,Implant Device,2652,34,,2652,percent of total billed charges,Implant Device,3861,,,3861,Other,110% of Medicare,2730,35,,2730,percent of total billed charges,Implant Device,2652,34,"Charges > $500, x 34%",2652,percent of total billed charges,Implant Device,2730,35,,2730,percent of total billed charges,Implant Device,2730,35,,2730,percent of total billed charges,Implant Device,2730,35,,2730,percent of total billed charges,Implant Device,2730,35,,2730,percent of total billed charges,Implant Device,2730,35,,2730,percent of total billed charges,Implant Device,3120,40,,3120,percent of total billed charges,Implant Device,2730,70,,2730,percent of total billed charges,All Other,2652,34,,2652,percent of total billed charges,Implant Device,2652,34,,2652,percent of total billed charges,Implant Device,2730,35,,2730,percent of total billed charges,Implant Device,2730,35,,2730,percent of total billed charges,Implant Device,2730,35,,2730,percent of total billed charges,Implant Device,2730,35,,2730,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2652,34,"If Charge > 2,000, then 34 percent",2652,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5772.02,
ARTHREX AR-1934BCF SUTURE ANCHOR 3X14.5M,C1713,HCPCS,,79005770,CDM,278,RC,,,both,,,915,677.1,,,677.1,Other,150% of Medicare + 9.63% HCRA Surcharge,411.75,45,,411.75,percent of total billed charges,Critical Access Hospital RCC factor,311.1,34,,311.1,percent of total billed charges,Implant Device,311.1,34,,311.1,percent of total billed charges,Implant Device,311.1,34,,311.1,percent of total billed charges,Implant Device,311.1,34,,311.1,percent of total billed charges,Implant Device,311.1,34,,311.1,percent of total billed charges,Implant Device,452.93,,,452.93,Other,110% of Medicare,320.25,35,,320.25,percent of total billed charges,Implant Device,311.1,34,"Charges > $500, x 34%",311.1,percent of total billed charges,Implant Device,320.25,35,,320.25,percent of total billed charges,Implant Device,320.25,35,,320.25,percent of total billed charges,Implant Device,320.25,35,,320.25,percent of total billed charges,Implant Device,320.25,35,,320.25,percent of total billed charges,Implant Device,320.25,35,,320.25,percent of total billed charges,Implant Device,366,40,,366,percent of total billed charges,Implant Device,320.25,70,,320.25,percent of total billed charges,All Other,311.1,34,,311.1,percent of total billed charges,Implant Device,311.1,34,,311.1,percent of total billed charges,Implant Device,320.25,35,,320.25,percent of total billed charges,Implant Device,320.25,35,,320.25,percent of total billed charges,Implant Device,320.25,35,,320.25,percent of total billed charges,Implant Device,320.25,35,,320.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,677.1,
STRYKER 58-17015E BONE SCREW 1.7X15MM,C1713,HCPCS,,79005771,CDM,278,RC,,,both,,,349,258.26,,,258.26,Other,150% of Medicare + 9.63% HCRA Surcharge,157.05,45,,157.05,percent of total billed charges,Critical Access Hospital RCC factor,118.66,34,,118.66,percent of total billed charges,Implant Device,118.66,34,,118.66,percent of total billed charges,Implant Device,118.66,34,,118.66,percent of total billed charges,Implant Device,118.66,34,,118.66,percent of total billed charges,Implant Device,118.66,34,,118.66,percent of total billed charges,Implant Device,172.76,,,172.76,Other,110% of Medicare,122.15,35,,122.15,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,122.15,35,,122.15,percent of total billed charges,Implant Device,122.15,35,,122.15,percent of total billed charges,Implant Device,122.15,35,,122.15,percent of total billed charges,Implant Device,122.15,35,,122.15,percent of total billed charges,Implant Device,122.15,35,,122.15,percent of total billed charges,Implant Device,139.6,40,,139.6,percent of total billed charges,Implant Device,122.15,70,,122.15,percent of total billed charges,All Other,118.66,34,,118.66,percent of total billed charges,Implant Device,118.66,34,,118.66,percent of total billed charges,Implant Device,122.15,35,,122.15,percent of total billed charges,Implant Device,122.15,35,,122.15,percent of total billed charges,Implant Device,122.15,35,,122.15,percent of total billed charges,Implant Device,122.15,35,,122.15,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,258.26,
SYNTHES 214.036 4.5MM CORTEX SCREW 36MM,C1713,HCPCS,,79005772,CDM,278,RC,,,both,,,53,39.22,,,39.22,Other,150% of Medicare + 9.63% HCRA Surcharge,23.85,45,,23.85,percent of total billed charges,Critical Access Hospital RCC factor,18.02,34,,18.02,percent of total billed charges,Implant Device,18.02,34,,18.02,percent of total billed charges,Implant Device,18.02,34,,18.02,percent of total billed charges,Implant Device,18.02,34,,18.02,percent of total billed charges,Implant Device,18.02,34,,18.02,percent of total billed charges,Implant Device,26.24,,,26.24,Other,110% of Medicare,18.55,35,,18.55,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,18.55,35,,18.55,percent of total billed charges,Implant Device,18.55,35,,18.55,percent of total billed charges,Implant Device,18.55,35,,18.55,percent of total billed charges,Implant Device,18.55,35,,18.55,percent of total billed charges,Implant Device,18.55,35,,18.55,percent of total billed charges,Implant Device,21.2,40,,21.2,percent of total billed charges,Implant Device,18.55,70,,18.55,percent of total billed charges,All Other,18.02,34,,18.02,percent of total billed charges,Implant Device,18.02,34,,18.02,percent of total billed charges,Implant Device,18.55,35,,18.55,percent of total billed charges,Implant Device,18.55,35,,18.55,percent of total billed charges,Implant Device,18.55,35,,18.55,percent of total billed charges,Implant Device,18.55,35,,18.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,39.22,
SYNTHES 214.028 4.5MM CORTEX SCREW 28MM,C1713,HCPCS,,79005773,CDM,278,RC,,,both,,,53,39.22,,,39.22,Other,150% of Medicare + 9.63% HCRA Surcharge,23.85,45,,23.85,percent of total billed charges,Critical Access Hospital RCC factor,18.02,34,,18.02,percent of total billed charges,Implant Device,18.02,34,,18.02,percent of total billed charges,Implant Device,18.02,34,,18.02,percent of total billed charges,Implant Device,18.02,34,,18.02,percent of total billed charges,Implant Device,18.02,34,,18.02,percent of total billed charges,Implant Device,26.24,,,26.24,Other,110% of Medicare,18.55,35,,18.55,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,18.55,35,,18.55,percent of total billed charges,Implant Device,18.55,35,,18.55,percent of total billed charges,Implant Device,18.55,35,,18.55,percent of total billed charges,Implant Device,18.55,35,,18.55,percent of total billed charges,Implant Device,18.55,35,,18.55,percent of total billed charges,Implant Device,21.2,40,,21.2,percent of total billed charges,Implant Device,18.55,70,,18.55,percent of total billed charges,All Other,18.02,34,,18.02,percent of total billed charges,Implant Device,18.02,34,,18.02,percent of total billed charges,Implant Device,18.55,35,,18.55,percent of total billed charges,Implant Device,18.55,35,,18.55,percent of total billed charges,Implant Device,18.55,35,,18.55,percent of total billed charges,Implant Device,18.55,35,,18.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,39.22,
SYNTHES 214.026 4.5MM CORTEX SCREW 26MM,C1713,HCPCS,,79005774,CDM,278,RC,,,both,,,53,39.22,,,39.22,Other,150% of Medicare + 9.63% HCRA Surcharge,23.85,45,,23.85,percent of total billed charges,Critical Access Hospital RCC factor,18.02,34,,18.02,percent of total billed charges,Implant Device,18.02,34,,18.02,percent of total billed charges,Implant Device,18.02,34,,18.02,percent of total billed charges,Implant Device,18.02,34,,18.02,percent of total billed charges,Implant Device,18.02,34,,18.02,percent of total billed charges,Implant Device,26.24,,,26.24,Other,110% of Medicare,18.55,35,,18.55,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,18.55,35,,18.55,percent of total billed charges,Implant Device,18.55,35,,18.55,percent of total billed charges,Implant Device,18.55,35,,18.55,percent of total billed charges,Implant Device,18.55,35,,18.55,percent of total billed charges,Implant Device,18.55,35,,18.55,percent of total billed charges,Implant Device,21.2,40,,21.2,percent of total billed charges,Implant Device,18.55,70,,18.55,percent of total billed charges,All Other,18.02,34,,18.02,percent of total billed charges,Implant Device,18.02,34,,18.02,percent of total billed charges,Implant Device,18.55,35,,18.55,percent of total billed charges,Implant Device,18.55,35,,18.55,percent of total billed charges,Implant Device,18.55,35,,18.55,percent of total billed charges,Implant Device,18.55,35,,18.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,39.22,
SYNTHES 214.032 4.5MM CORTEX SCREW 32MM,C1713,HCPCS,,79005775,CDM,278,RC,,,both,,,53,39.22,,,39.22,Other,150% of Medicare + 9.63% HCRA Surcharge,23.85,45,,23.85,percent of total billed charges,Critical Access Hospital RCC factor,18.02,34,,18.02,percent of total billed charges,Implant Device,18.02,34,,18.02,percent of total billed charges,Implant Device,18.02,34,,18.02,percent of total billed charges,Implant Device,18.02,34,,18.02,percent of total billed charges,Implant Device,18.02,34,,18.02,percent of total billed charges,Implant Device,26.24,,,26.24,Other,110% of Medicare,18.55,35,,18.55,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,18.55,35,,18.55,percent of total billed charges,Implant Device,18.55,35,,18.55,percent of total billed charges,Implant Device,18.55,35,,18.55,percent of total billed charges,Implant Device,18.55,35,,18.55,percent of total billed charges,Implant Device,18.55,35,,18.55,percent of total billed charges,Implant Device,21.2,40,,21.2,percent of total billed charges,Implant Device,18.55,70,,18.55,percent of total billed charges,All Other,18.02,34,,18.02,percent of total billed charges,Implant Device,18.02,34,,18.02,percent of total billed charges,Implant Device,18.55,35,,18.55,percent of total billed charges,Implant Device,18.55,35,,18.55,percent of total billed charges,Implant Device,18.55,35,,18.55,percent of total billed charges,Implant Device,18.55,35,,18.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,39.22,
SYNTHES 214.024 4.5MM CORTEX SCREW 24MM,C1713,HCPCS,,79005776,CDM,278,RC,,,both,,,53,39.22,,,39.22,Other,150% of Medicare + 9.63% HCRA Surcharge,23.85,45,,23.85,percent of total billed charges,Critical Access Hospital RCC factor,18.02,34,,18.02,percent of total billed charges,Implant Device,18.02,34,,18.02,percent of total billed charges,Implant Device,18.02,34,,18.02,percent of total billed charges,Implant Device,18.02,34,,18.02,percent of total billed charges,Implant Device,18.02,34,,18.02,percent of total billed charges,Implant Device,26.24,,,26.24,Other,110% of Medicare,18.55,35,,18.55,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,18.55,35,,18.55,percent of total billed charges,Implant Device,18.55,35,,18.55,percent of total billed charges,Implant Device,18.55,35,,18.55,percent of total billed charges,Implant Device,18.55,35,,18.55,percent of total billed charges,Implant Device,18.55,35,,18.55,percent of total billed charges,Implant Device,21.2,40,,21.2,percent of total billed charges,Implant Device,18.55,70,,18.55,percent of total billed charges,All Other,18.02,34,,18.02,percent of total billed charges,Implant Device,18.02,34,,18.02,percent of total billed charges,Implant Device,18.55,35,,18.55,percent of total billed charges,Implant Device,18.55,35,,18.55,percent of total billed charges,Implant Device,18.55,35,,18.55,percent of total billed charges,Implant Device,18.55,35,,18.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,39.22,
SYNTHES 214.034 4.5MM CORTEX SCREW 34MM,C1713,HCPCS,,79005777,CDM,278,RC,,,both,,,53,39.22,,,39.22,Other,150% of Medicare + 9.63% HCRA Surcharge,23.85,45,,23.85,percent of total billed charges,Critical Access Hospital RCC factor,18.02,34,,18.02,percent of total billed charges,Implant Device,18.02,34,,18.02,percent of total billed charges,Implant Device,18.02,34,,18.02,percent of total billed charges,Implant Device,18.02,34,,18.02,percent of total billed charges,Implant Device,18.02,34,,18.02,percent of total billed charges,Implant Device,26.24,,,26.24,Other,110% of Medicare,18.55,35,,18.55,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,18.55,35,,18.55,percent of total billed charges,Implant Device,18.55,35,,18.55,percent of total billed charges,Implant Device,18.55,35,,18.55,percent of total billed charges,Implant Device,18.55,35,,18.55,percent of total billed charges,Implant Device,18.55,35,,18.55,percent of total billed charges,Implant Device,21.2,40,,21.2,percent of total billed charges,Implant Device,18.55,70,,18.55,percent of total billed charges,All Other,18.02,34,,18.02,percent of total billed charges,Implant Device,18.02,34,,18.02,percent of total billed charges,Implant Device,18.55,35,,18.55,percent of total billed charges,Implant Device,18.55,35,,18.55,percent of total billed charges,Implant Device,18.55,35,,18.55,percent of total billed charges,Implant Device,18.55,35,,18.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,39.22,
SYNTHES 224.57 PLATE 7 HOLE 4.5X124MM,C1713,HCPCS,,79005778,CDM,278,RC,,,both,,,557,412.18,,,412.18,Other,150% of Medicare + 9.63% HCRA Surcharge,250.65,45,,250.65,percent of total billed charges,Critical Access Hospital RCC factor,189.38,34,,189.38,percent of total billed charges,Implant Device,189.38,34,,189.38,percent of total billed charges,Implant Device,189.38,34,,189.38,percent of total billed charges,Implant Device,189.38,34,,189.38,percent of total billed charges,Implant Device,189.38,34,,189.38,percent of total billed charges,Implant Device,275.72,,,275.72,Other,110% of Medicare,194.95,35,,194.95,percent of total billed charges,Implant Device,189.38,34,"Charges > $500, x 34%",189.38,percent of total billed charges,Implant Device,194.95,35,,194.95,percent of total billed charges,Implant Device,194.95,35,,194.95,percent of total billed charges,Implant Device,194.95,35,,194.95,percent of total billed charges,Implant Device,194.95,35,,194.95,percent of total billed charges,Implant Device,194.95,35,,194.95,percent of total billed charges,Implant Device,222.8,40,,222.8,percent of total billed charges,Implant Device,194.95,70,,194.95,percent of total billed charges,All Other,189.38,34,,189.38,percent of total billed charges,Implant Device,189.38,34,,189.38,percent of total billed charges,Implant Device,194.95,35,,194.95,percent of total billed charges,Implant Device,194.95,35,,194.95,percent of total billed charges,Implant Device,194.95,35,,194.95,percent of total billed charges,Implant Device,194.95,35,,194.95,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,412.18,
ZIMMER 2347-23-45 CORTICAL SCRW 4.5X45MM,C1713,HCPCS,,79005779,CDM,278,RC,,,both,,,109,80.66,,,80.66,Other,150% of Medicare + 9.63% HCRA Surcharge,49.05,45,,49.05,percent of total billed charges,Critical Access Hospital RCC factor,37.06,34,,37.06,percent of total billed charges,Implant Device,37.06,34,,37.06,percent of total billed charges,Implant Device,37.06,34,,37.06,percent of total billed charges,Implant Device,37.06,34,,37.06,percent of total billed charges,Implant Device,37.06,34,,37.06,percent of total billed charges,Implant Device,53.96,,,53.96,Other,110% of Medicare,38.15,35,,38.15,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,38.15,35,,38.15,percent of total billed charges,Implant Device,38.15,35,,38.15,percent of total billed charges,Implant Device,38.15,35,,38.15,percent of total billed charges,Implant Device,38.15,35,,38.15,percent of total billed charges,Implant Device,38.15,35,,38.15,percent of total billed charges,Implant Device,43.6,40,,43.6,percent of total billed charges,Implant Device,38.15,70,,38.15,percent of total billed charges,All Other,37.06,34,,37.06,percent of total billed charges,Implant Device,37.06,34,,37.06,percent of total billed charges,Implant Device,38.15,35,,38.15,percent of total billed charges,Implant Device,38.15,35,,38.15,percent of total billed charges,Implant Device,38.15,35,,38.15,percent of total billed charges,Implant Device,38.15,35,,38.15,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,80.66,
ZIMMER 2357-102-06 PLATE LEFT,C1713,HCPCS,,79005780,CDM,278,RC,,,both,,,4255,3148.71,,,3148.71,Other,150% of Medicare + 9.63% HCRA Surcharge,1914.75,45,,1914.75,percent of total billed charges,Critical Access Hospital RCC factor,1446.7,34,,1446.7,percent of total billed charges,Implant Device,1446.7,34,,1446.7,percent of total billed charges,Implant Device,1446.7,34,,1446.7,percent of total billed charges,Implant Device,1446.7,34,,1446.7,percent of total billed charges,Implant Device,1446.7,34,,1446.7,percent of total billed charges,Implant Device,2106.23,,,2106.23,Other,110% of Medicare,1489.25,35,,1489.25,percent of total billed charges,Implant Device,1446.7,34,"Charges > $500, x 34%",1446.7,percent of total billed charges,Implant Device,1489.25,35,,1489.25,percent of total billed charges,Implant Device,1489.25,35,,1489.25,percent of total billed charges,Implant Device,1489.25,35,,1489.25,percent of total billed charges,Implant Device,1489.25,35,,1489.25,percent of total billed charges,Implant Device,1489.25,35,,1489.25,percent of total billed charges,Implant Device,1702,40,,1702,percent of total billed charges,Implant Device,1489.25,70,,1489.25,percent of total billed charges,All Other,1446.7,34,,1446.7,percent of total billed charges,Implant Device,1446.7,34,,1446.7,percent of total billed charges,Implant Device,1489.25,35,,1489.25,percent of total billed charges,Implant Device,1489.25,35,,1489.25,percent of total billed charges,Implant Device,1489.25,35,,1489.25,percent of total billed charges,Implant Device,1489.25,35,,1489.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1446.7,34,"If Charge > 2,000, then 34 percent",1446.7,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3148.71,
ZIMMER 2359-70-55  5.5MM CANN LOCK SCREW,C1713,HCPCS,,79005781,CDM,278,RC,,,both,,,562,415.88,,,415.88,Other,150% of Medicare + 9.63% HCRA Surcharge,252.9,45,,252.9,percent of total billed charges,Critical Access Hospital RCC factor,191.08,34,,191.08,percent of total billed charges,Implant Device,191.08,34,,191.08,percent of total billed charges,Implant Device,191.08,34,,191.08,percent of total billed charges,Implant Device,191.08,34,,191.08,percent of total billed charges,Implant Device,191.08,34,,191.08,percent of total billed charges,Implant Device,278.19,,,278.19,Other,110% of Medicare,196.7,35,,196.7,percent of total billed charges,Implant Device,191.08,34,"Charges > $500, x 34%",191.08,percent of total billed charges,Implant Device,196.7,35,,196.7,percent of total billed charges,Implant Device,196.7,35,,196.7,percent of total billed charges,Implant Device,196.7,35,,196.7,percent of total billed charges,Implant Device,196.7,35,,196.7,percent of total billed charges,Implant Device,196.7,35,,196.7,percent of total billed charges,Implant Device,224.8,40,,224.8,percent of total billed charges,Implant Device,196.7,70,,196.7,percent of total billed charges,All Other,191.08,34,,191.08,percent of total billed charges,Implant Device,191.08,34,,191.08,percent of total billed charges,Implant Device,196.7,35,,196.7,percent of total billed charges,Implant Device,196.7,35,,196.7,percent of total billed charges,Implant Device,196.7,35,,196.7,percent of total billed charges,Implant Device,196.7,35,,196.7,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,415.88,
SOLANA CCP-UTN3 UTILITY COMP LOCK PLATE,C1713,HCPCS,,79005782,CDM,278,RC,,,both,,,6586,4873.66,,,4873.66,Other,150% of Medicare + 9.63% HCRA Surcharge,2963.7,45,,2963.7,percent of total billed charges,Critical Access Hospital RCC factor,2239.24,34,,2239.24,percent of total billed charges,Implant Device,2239.24,34,,2239.24,percent of total billed charges,Implant Device,2239.24,34,,2239.24,percent of total billed charges,Implant Device,2239.24,34,,2239.24,percent of total billed charges,Implant Device,2239.24,34,,2239.24,percent of total billed charges,Implant Device,3260.07,,,3260.07,Other,110% of Medicare,2305.1,35,,2305.1,percent of total billed charges,Implant Device,2239.24,34,"Charges > $500, x 34%",2239.24,percent of total billed charges,Implant Device,2305.1,35,,2305.1,percent of total billed charges,Implant Device,2305.1,35,,2305.1,percent of total billed charges,Implant Device,2305.1,35,,2305.1,percent of total billed charges,Implant Device,2305.1,35,,2305.1,percent of total billed charges,Implant Device,2305.1,35,,2305.1,percent of total billed charges,Implant Device,2634.4,40,,2634.4,percent of total billed charges,Implant Device,2305.1,70,,2305.1,percent of total billed charges,All Other,2239.24,34,,2239.24,percent of total billed charges,Implant Device,2239.24,34,,2239.24,percent of total billed charges,Implant Device,2305.1,35,,2305.1,percent of total billed charges,Implant Device,2305.1,35,,2305.1,percent of total billed charges,Implant Device,2305.1,35,,2305.1,percent of total billed charges,Implant Device,2305.1,35,,2305.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2239.24,34,"If Charge > 2,000, then 34 percent",2239.24,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4873.66,
SOLANA L3020 LOCKING SCREW 3.0X20MM,C1713,HCPCS,,79005783,CDM,278,RC,,,both,,,1126,833.24,,,833.24,Other,150% of Medicare + 9.63% HCRA Surcharge,506.7,45,,506.7,percent of total billed charges,Critical Access Hospital RCC factor,382.84,34,,382.84,percent of total billed charges,Implant Device,382.84,34,,382.84,percent of total billed charges,Implant Device,382.84,34,,382.84,percent of total billed charges,Implant Device,382.84,34,,382.84,percent of total billed charges,Implant Device,382.84,34,,382.84,percent of total billed charges,Implant Device,557.37,,,557.37,Other,110% of Medicare,394.1,35,,394.1,percent of total billed charges,Implant Device,382.84,34,"Charges > $500, x 34%",382.84,percent of total billed charges,Implant Device,394.1,35,,394.1,percent of total billed charges,Implant Device,394.1,35,,394.1,percent of total billed charges,Implant Device,394.1,35,,394.1,percent of total billed charges,Implant Device,394.1,35,,394.1,percent of total billed charges,Implant Device,394.1,35,,394.1,percent of total billed charges,Implant Device,450.4,40,,450.4,percent of total billed charges,Implant Device,394.1,70,,394.1,percent of total billed charges,All Other,382.84,34,,382.84,percent of total billed charges,Implant Device,382.84,34,,382.84,percent of total billed charges,Implant Device,394.1,35,,394.1,percent of total billed charges,Implant Device,394.1,35,,394.1,percent of total billed charges,Implant Device,394.1,35,,394.1,percent of total billed charges,Implant Device,394.1,35,,394.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,833.24,
SOLANA L3022 LOCKING SCREW 3.0X22MM,C1713,HCPCS,,79005784,CDM,278,RC,,,both,,,1126,833.24,,,833.24,Other,150% of Medicare + 9.63% HCRA Surcharge,506.7,45,,506.7,percent of total billed charges,Critical Access Hospital RCC factor,382.84,34,,382.84,percent of total billed charges,Implant Device,382.84,34,,382.84,percent of total billed charges,Implant Device,382.84,34,,382.84,percent of total billed charges,Implant Device,382.84,34,,382.84,percent of total billed charges,Implant Device,382.84,34,,382.84,percent of total billed charges,Implant Device,557.37,,,557.37,Other,110% of Medicare,394.1,35,,394.1,percent of total billed charges,Implant Device,382.84,34,"Charges > $500, x 34%",382.84,percent of total billed charges,Implant Device,394.1,35,,394.1,percent of total billed charges,Implant Device,394.1,35,,394.1,percent of total billed charges,Implant Device,394.1,35,,394.1,percent of total billed charges,Implant Device,394.1,35,,394.1,percent of total billed charges,Implant Device,394.1,35,,394.1,percent of total billed charges,Implant Device,450.4,40,,450.4,percent of total billed charges,Implant Device,394.1,70,,394.1,percent of total billed charges,All Other,382.84,34,,382.84,percent of total billed charges,Implant Device,382.84,34,,382.84,percent of total billed charges,Implant Device,394.1,35,,394.1,percent of total billed charges,Implant Device,394.1,35,,394.1,percent of total billed charges,Implant Device,394.1,35,,394.1,percent of total billed charges,Implant Device,394.1,35,,394.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,833.24,
SOLANA N3020 NONLOCK SCREW 3.0X20MM,C1713,HCPCS,,79005785,CDM,278,RC,,,both,,,886,655.64,,,655.64,Other,150% of Medicare + 9.63% HCRA Surcharge,398.7,45,,398.7,percent of total billed charges,Critical Access Hospital RCC factor,301.24,34,,301.24,percent of total billed charges,Implant Device,301.24,34,,301.24,percent of total billed charges,Implant Device,301.24,34,,301.24,percent of total billed charges,Implant Device,301.24,34,,301.24,percent of total billed charges,Implant Device,301.24,34,,301.24,percent of total billed charges,Implant Device,438.57,,,438.57,Other,110% of Medicare,310.1,35,,310.1,percent of total billed charges,Implant Device,301.24,34,"Charges > $500, x 34%",301.24,percent of total billed charges,Implant Device,310.1,35,,310.1,percent of total billed charges,Implant Device,310.1,35,,310.1,percent of total billed charges,Implant Device,310.1,35,,310.1,percent of total billed charges,Implant Device,310.1,35,,310.1,percent of total billed charges,Implant Device,310.1,35,,310.1,percent of total billed charges,Implant Device,354.4,40,,354.4,percent of total billed charges,Implant Device,310.1,70,,310.1,percent of total billed charges,All Other,301.24,34,,301.24,percent of total billed charges,Implant Device,301.24,34,,301.24,percent of total billed charges,Implant Device,310.1,35,,310.1,percent of total billed charges,Implant Device,310.1,35,,310.1,percent of total billed charges,Implant Device,310.1,35,,310.1,percent of total billed charges,Implant Device,310.1,35,,310.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,655.64,
BIOMET 14196-75 CANN SCREW 6.5X75MM,C1713,HCPCS,,79005789,CDM,278,RC,,,both,,,1290,954.6,,,954.6,Other,150% of Medicare + 9.63% HCRA Surcharge,580.5,45,,580.5,percent of total billed charges,Critical Access Hospital RCC factor,438.6,34,,438.6,percent of total billed charges,Implant Device,438.6,34,,438.6,percent of total billed charges,Implant Device,438.6,34,,438.6,percent of total billed charges,Implant Device,438.6,34,,438.6,percent of total billed charges,Implant Device,438.6,34,,438.6,percent of total billed charges,Implant Device,638.55,,,638.55,Other,110% of Medicare,451.5,35,,451.5,percent of total billed charges,Implant Device,438.6,34,"Charges > $500, x 34%",438.6,percent of total billed charges,Implant Device,451.5,35,,451.5,percent of total billed charges,Implant Device,451.5,35,,451.5,percent of total billed charges,Implant Device,451.5,35,,451.5,percent of total billed charges,Implant Device,451.5,35,,451.5,percent of total billed charges,Implant Device,451.5,35,,451.5,percent of total billed charges,Implant Device,516,40,,516,percent of total billed charges,Implant Device,451.5,70,,451.5,percent of total billed charges,All Other,438.6,34,,438.6,percent of total billed charges,Implant Device,438.6,34,,438.6,percent of total billed charges,Implant Device,451.5,35,,451.5,percent of total billed charges,Implant Device,451.5,35,,451.5,percent of total billed charges,Implant Device,451.5,35,,451.5,percent of total billed charges,Implant Device,451.5,35,,451.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,954.6,
BIOMET 1802-53-055 CANN SCREW 5.0X55MM,C1713,HCPCS,,79005790,CDM,278,RC,,,both,,,870,643.8,,,643.8,Other,150% of Medicare + 9.63% HCRA Surcharge,391.5,45,,391.5,percent of total billed charges,Critical Access Hospital RCC factor,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,430.65,,,430.65,Other,110% of Medicare,304.5,35,,304.5,percent of total billed charges,Implant Device,295.8,34,"Charges > $500, x 34%",295.8,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,348,40,,348,percent of total billed charges,Implant Device,304.5,70,,304.5,percent of total billed charges,All Other,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,643.8,
BIOMET 12-139040 ENDO II MOD HEAD SZ 58,C1776,HCPCS,,79005792,CDM,278,RC,,,both,,,2280,1687.21,,,1687.21,Other,150% of Medicare + 9.63% HCRA Surcharge,1026,45,,1026,percent of total billed charges,Critical Access Hospital RCC factor,775.2,34,,775.2,percent of total billed charges,Implant Device,775.2,34,,775.2,percent of total billed charges,Implant Device,775.2,34,,775.2,percent of total billed charges,Implant Device,775.2,34,,775.2,percent of total billed charges,Implant Device,775.2,34,,775.2,percent of total billed charges,Implant Device,1128.6,,,1128.6,Other,110% of Medicare,798,35,,798,percent of total billed charges,Implant Device,775.2,34,"Charges > $500, x 34%",775.2,percent of total billed charges,Implant Device,798,35,,798,percent of total billed charges,Implant Device,798,35,,798,percent of total billed charges,Implant Device,798,35,,798,percent of total billed charges,Implant Device,798,35,,798,percent of total billed charges,Implant Device,798,35,,798,percent of total billed charges,Implant Device,912,40,,912,percent of total billed charges,Implant Device,798,70,,798,percent of total billed charges,All Other,775.2,34,,775.2,percent of total billed charges,Implant Device,775.2,34,,775.2,percent of total billed charges,Implant Device,798,35,,798,percent of total billed charges,Implant Device,798,35,,798,percent of total billed charges,Implant Device,798,35,,798,percent of total billed charges,Implant Device,798,35,,798,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,775.2,34,"If Charge > 2,000, then 34 percent",775.2,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1687.21,
TYRX CMRM6122US-S PM ANTIBAC ENVELOPE,C1781,HCPCS,,79005793,CDM,278,RC,,,both,,,2985,2208.91,,,2208.91,Other,150% of Medicare + 9.63% HCRA Surcharge,1343.25,45,,1343.25,percent of total billed charges,Critical Access Hospital RCC factor,1014.9,34,,1014.9,percent of total billed charges,Implant Device,1014.9,34,,1014.9,percent of total billed charges,Implant Device,1014.9,34,,1014.9,percent of total billed charges,Implant Device,1014.9,34,,1014.9,percent of total billed charges,Implant Device,1014.9,34,,1014.9,percent of total billed charges,Implant Device,1477.58,,,1477.58,Other,110% of Medicare,1044.75,35,,1044.75,percent of total billed charges,Implant Device,1014.9,34,"Charges > $500, x 34%",1014.9,percent of total billed charges,Implant Device,1044.75,35,,1044.75,percent of total billed charges,Implant Device,1044.75,35,,1044.75,percent of total billed charges,Implant Device,1044.75,35,,1044.75,percent of total billed charges,Implant Device,1044.75,35,,1044.75,percent of total billed charges,Implant Device,1044.75,35,,1044.75,percent of total billed charges,Implant Device,1194,40,,1194,percent of total billed charges,Implant Device,1044.75,70,,1044.75,percent of total billed charges,All Other,1014.9,34,,1014.9,percent of total billed charges,Implant Device,1014.9,34,,1014.9,percent of total billed charges,Implant Device,1044.75,35,,1044.75,percent of total billed charges,Implant Device,1044.75,35,,1044.75,percent of total billed charges,Implant Device,1044.75,35,,1044.75,percent of total billed charges,Implant Device,1044.75,35,,1044.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1014.9,34,"If Charge > 2,000, then 34 percent",1014.9,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2208.91,
STRYKER 338610 CORTICAL SCREW 3.5X10MM,C1713,HCPCS,,79005795,CDM,278,RC,,,both,,,115,85.1,,,85.1,Other,150% of Medicare + 9.63% HCRA Surcharge,51.75,45,,51.75,percent of total billed charges,Critical Access Hospital RCC factor,39.1,34,,39.1,percent of total billed charges,Implant Device,39.1,34,,39.1,percent of total billed charges,Implant Device,39.1,34,,39.1,percent of total billed charges,Implant Device,39.1,34,,39.1,percent of total billed charges,Implant Device,39.1,34,,39.1,percent of total billed charges,Implant Device,56.93,,,56.93,Other,110% of Medicare,40.25,35,,40.25,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,40.25,35,,40.25,percent of total billed charges,Implant Device,40.25,35,,40.25,percent of total billed charges,Implant Device,40.25,35,,40.25,percent of total billed charges,Implant Device,40.25,35,,40.25,percent of total billed charges,Implant Device,40.25,35,,40.25,percent of total billed charges,Implant Device,46,40,,46,percent of total billed charges,Implant Device,40.25,70,,40.25,percent of total billed charges,All Other,39.1,34,,39.1,percent of total billed charges,Implant Device,39.1,34,,39.1,percent of total billed charges,Implant Device,40.25,35,,40.25,percent of total billed charges,Implant Device,40.25,35,,40.25,percent of total billed charges,Implant Device,40.25,35,,40.25,percent of total billed charges,Implant Device,40.25,35,,40.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,85.1,
STRYKER 430205 5 HOLE 1/3 TUBULAR PLATE,C1713,HCPCS,,79005796,CDM,278,RC,,,both,,,235,173.9,,,173.9,Other,150% of Medicare + 9.63% HCRA Surcharge,105.75,45,,105.75,percent of total billed charges,Critical Access Hospital RCC factor,79.9,34,,79.9,percent of total billed charges,Implant Device,79.9,34,,79.9,percent of total billed charges,Implant Device,79.9,34,,79.9,percent of total billed charges,Implant Device,79.9,34,,79.9,percent of total billed charges,Implant Device,79.9,34,,79.9,percent of total billed charges,Implant Device,116.33,,,116.33,Other,110% of Medicare,82.25,35,,82.25,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,82.25,35,,82.25,percent of total billed charges,Implant Device,82.25,35,,82.25,percent of total billed charges,Implant Device,82.25,35,,82.25,percent of total billed charges,Implant Device,82.25,35,,82.25,percent of total billed charges,Implant Device,82.25,35,,82.25,percent of total billed charges,Implant Device,94,40,,94,percent of total billed charges,Implant Device,82.25,70,,82.25,percent of total billed charges,All Other,79.9,34,,79.9,percent of total billed charges,Implant Device,79.9,34,,79.9,percent of total billed charges,Implant Device,82.25,35,,82.25,percent of total billed charges,Implant Device,82.25,35,,82.25,percent of total billed charges,Implant Device,82.25,35,,82.25,percent of total billed charges,Implant Device,82.25,35,,82.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,173.9,
STRYKER 390018 WASHER,C1713,HCPCS,,79005797,CDM,278,RC,,,both,,,76,56.24,,,56.24,Other,150% of Medicare + 9.63% HCRA Surcharge,34.2,45,,34.2,percent of total billed charges,Critical Access Hospital RCC factor,25.84,34,,25.84,percent of total billed charges,Implant Device,25.84,34,,25.84,percent of total billed charges,Implant Device,25.84,34,,25.84,percent of total billed charges,Implant Device,25.84,34,,25.84,percent of total billed charges,Implant Device,25.84,34,,25.84,percent of total billed charges,Implant Device,37.62,,,37.62,Other,110% of Medicare,26.6,35,,26.6,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,26.6,35,,26.6,percent of total billed charges,Implant Device,26.6,35,,26.6,percent of total billed charges,Implant Device,26.6,35,,26.6,percent of total billed charges,Implant Device,26.6,35,,26.6,percent of total billed charges,Implant Device,26.6,35,,26.6,percent of total billed charges,Implant Device,30.4,40,,30.4,percent of total billed charges,Implant Device,26.6,70,,26.6,percent of total billed charges,All Other,25.84,34,,25.84,percent of total billed charges,Implant Device,25.84,34,,25.84,percent of total billed charges,Implant Device,26.6,35,,26.6,percent of total billed charges,Implant Device,26.6,35,,26.6,percent of total billed charges,Implant Device,26.6,35,,26.6,percent of total billed charges,Implant Device,26.6,35,,26.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,56.24,
STRYKER 40-65044 BONE SCREW 3.5X44MM,C1713,HCPCS,,79005798,CDM,278,RC,,,both,,,268,198.32,,,198.32,Other,150% of Medicare + 9.63% HCRA Surcharge,120.6,45,,120.6,percent of total billed charges,Critical Access Hospital RCC factor,91.12,34,,91.12,percent of total billed charges,Implant Device,91.12,34,,91.12,percent of total billed charges,Implant Device,91.12,34,,91.12,percent of total billed charges,Implant Device,91.12,34,,91.12,percent of total billed charges,Implant Device,91.12,34,,91.12,percent of total billed charges,Implant Device,132.66,,,132.66,Other,110% of Medicare,93.8,35,,93.8,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,93.8,35,,93.8,percent of total billed charges,Implant Device,93.8,35,,93.8,percent of total billed charges,Implant Device,93.8,35,,93.8,percent of total billed charges,Implant Device,93.8,35,,93.8,percent of total billed charges,Implant Device,93.8,35,,93.8,percent of total billed charges,Implant Device,107.2,40,,107.2,percent of total billed charges,Implant Device,93.8,70,,93.8,percent of total billed charges,All Other,91.12,34,,91.12,percent of total billed charges,Implant Device,91.12,34,,91.12,percent of total billed charges,Implant Device,93.8,35,,93.8,percent of total billed charges,Implant Device,93.8,35,,93.8,percent of total billed charges,Implant Device,93.8,35,,93.8,percent of total billed charges,Implant Device,93.8,35,,93.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,198.32,
STRYKER 40-35016 NON-LOCK SCREW 16X12MM,C1713,HCPCS,,79005801,CDM,278,RC,,,both,,,268,198.32,,,198.32,Other,150% of Medicare + 9.63% HCRA Surcharge,120.6,45,,120.6,percent of total billed charges,Critical Access Hospital RCC factor,91.12,34,,91.12,percent of total billed charges,Implant Device,91.12,34,,91.12,percent of total billed charges,Implant Device,91.12,34,,91.12,percent of total billed charges,Implant Device,91.12,34,,91.12,percent of total billed charges,Implant Device,91.12,34,,91.12,percent of total billed charges,Implant Device,132.66,,,132.66,Other,110% of Medicare,93.8,35,,93.8,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,93.8,35,,93.8,percent of total billed charges,Implant Device,93.8,35,,93.8,percent of total billed charges,Implant Device,93.8,35,,93.8,percent of total billed charges,Implant Device,93.8,35,,93.8,percent of total billed charges,Implant Device,93.8,35,,93.8,percent of total billed charges,Implant Device,107.2,40,,107.2,percent of total billed charges,Implant Device,93.8,70,,93.8,percent of total billed charges,All Other,91.12,34,,91.12,percent of total billed charges,Implant Device,91.12,34,,91.12,percent of total billed charges,Implant Device,93.8,35,,93.8,percent of total billed charges,Implant Device,93.8,35,,93.8,percent of total billed charges,Implant Device,93.8,35,,93.8,percent of total billed charges,Implant Device,93.8,35,,93.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,198.32,
STRYKER 40-35018 NON-LOCK SCREW 16X12MM,C1713,HCPCS,,79005802,CDM,278,RC,,,both,,,192,142.08,,,142.08,Other,150% of Medicare + 9.63% HCRA Surcharge,86.4,45,,86.4,percent of total billed charges,Critical Access Hospital RCC factor,65.28,34,,65.28,percent of total billed charges,Implant Device,65.28,34,,65.28,percent of total billed charges,Implant Device,65.28,34,,65.28,percent of total billed charges,Implant Device,65.28,34,,65.28,percent of total billed charges,Implant Device,65.28,34,,65.28,percent of total billed charges,Implant Device,95.04,,,95.04,Other,110% of Medicare,67.2,35,,67.2,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,67.2,35,,67.2,percent of total billed charges,Implant Device,67.2,35,,67.2,percent of total billed charges,Implant Device,67.2,35,,67.2,percent of total billed charges,Implant Device,67.2,35,,67.2,percent of total billed charges,Implant Device,67.2,35,,67.2,percent of total billed charges,Implant Device,76.8,40,,76.8,percent of total billed charges,Implant Device,67.2,70,,67.2,percent of total billed charges,All Other,65.28,34,,65.28,percent of total billed charges,Implant Device,65.28,34,,65.28,percent of total billed charges,Implant Device,67.2,35,,67.2,percent of total billed charges,Implant Device,67.2,35,,67.2,percent of total billed charges,Implant Device,67.2,35,,67.2,percent of total billed charges,Implant Device,67.2,35,,67.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,142.08,
STRYKER 40-20812 VARIAX STR PLATE 10HOLE,C1713,HCPCS,,79005803,CDM,278,RC,,,both,,,1864,1379.36,,,1379.36,Other,150% of Medicare + 9.63% HCRA Surcharge,838.8,45,,838.8,percent of total billed charges,Critical Access Hospital RCC factor,633.76,34,,633.76,percent of total billed charges,Implant Device,633.76,34,,633.76,percent of total billed charges,Implant Device,633.76,34,,633.76,percent of total billed charges,Implant Device,633.76,34,,633.76,percent of total billed charges,Implant Device,633.76,34,,633.76,percent of total billed charges,Implant Device,922.68,,,922.68,Other,110% of Medicare,652.4,35,,652.4,percent of total billed charges,Implant Device,633.76,34,"Charges > $500, x 34%",633.76,percent of total billed charges,Implant Device,652.4,35,,652.4,percent of total billed charges,Implant Device,652.4,35,,652.4,percent of total billed charges,Implant Device,652.4,35,,652.4,percent of total billed charges,Implant Device,652.4,35,,652.4,percent of total billed charges,Implant Device,652.4,35,,652.4,percent of total billed charges,Implant Device,745.6,40,,745.6,percent of total billed charges,Implant Device,652.4,70,,652.4,percent of total billed charges,All Other,633.76,34,,633.76,percent of total billed charges,Implant Device,633.76,34,,633.76,percent of total billed charges,Implant Device,652.4,35,,652.4,percent of total billed charges,Implant Device,652.4,35,,652.4,percent of total billed charges,Implant Device,652.4,35,,652.4,percent of total billed charges,Implant Device,652.4,35,,652.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1379.36,
STRYKER 57-10407 ST PLATE 2.3MM 6 HOLE,C1713,HCPCS,,79005804,CDM,278,RC,,,both,,,1147,848.78,,,848.78,Other,150% of Medicare + 9.63% HCRA Surcharge,516.15,45,,516.15,percent of total billed charges,Critical Access Hospital RCC factor,389.98,34,,389.98,percent of total billed charges,Implant Device,389.98,34,,389.98,percent of total billed charges,Implant Device,389.98,34,,389.98,percent of total billed charges,Implant Device,389.98,34,,389.98,percent of total billed charges,Implant Device,389.98,34,,389.98,percent of total billed charges,Implant Device,567.77,,,567.77,Other,110% of Medicare,401.45,35,,401.45,percent of total billed charges,Implant Device,389.98,34,"Charges > $500, x 34%",389.98,percent of total billed charges,Implant Device,401.45,35,,401.45,percent of total billed charges,Implant Device,401.45,35,,401.45,percent of total billed charges,Implant Device,401.45,35,,401.45,percent of total billed charges,Implant Device,401.45,35,,401.45,percent of total billed charges,Implant Device,401.45,35,,401.45,percent of total billed charges,Implant Device,458.8,40,,458.8,percent of total billed charges,Implant Device,401.45,70,,401.45,percent of total billed charges,All Other,389.98,34,,389.98,percent of total billed charges,Implant Device,389.98,34,,389.98,percent of total billed charges,Implant Device,401.45,35,,401.45,percent of total billed charges,Implant Device,401.45,35,,401.45,percent of total billed charges,Implant Device,401.45,35,,401.45,percent of total billed charges,Implant Device,401.45,35,,401.45,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,848.78,
STRYKER 58-23010E NONLOCK SCREW 2.3X10MM,C1713,HCPCS,,79005805,CDM,278,RC,,,both,,,439,324.86,,,324.86,Other,150% of Medicare + 9.63% HCRA Surcharge,197.55,45,,197.55,percent of total billed charges,Critical Access Hospital RCC factor,149.26,34,,149.26,percent of total billed charges,Implant Device,149.26,34,,149.26,percent of total billed charges,Implant Device,149.26,34,,149.26,percent of total billed charges,Implant Device,149.26,34,,149.26,percent of total billed charges,Implant Device,149.26,34,,149.26,percent of total billed charges,Implant Device,217.31,,,217.31,Other,110% of Medicare,153.65,35,,153.65,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,153.65,35,,153.65,percent of total billed charges,Implant Device,153.65,35,,153.65,percent of total billed charges,Implant Device,153.65,35,,153.65,percent of total billed charges,Implant Device,153.65,35,,153.65,percent of total billed charges,Implant Device,153.65,35,,153.65,percent of total billed charges,Implant Device,175.6,40,,175.6,percent of total billed charges,Implant Device,153.65,70,,153.65,percent of total billed charges,All Other,149.26,34,,149.26,percent of total billed charges,Implant Device,149.26,34,,149.26,percent of total billed charges,Implant Device,153.65,35,,153.65,percent of total billed charges,Implant Device,153.65,35,,153.65,percent of total billed charges,Implant Device,153.65,35,,153.65,percent of total billed charges,Implant Device,153.65,35,,153.65,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,324.86,
STRYKER 58-23011E NONLOCK SCREW 2.3X11MM,C1713,HCPCS,,79005806,CDM,278,RC,,,both,,,426,315.24,,,315.24,Other,150% of Medicare + 9.63% HCRA Surcharge,191.7,45,,191.7,percent of total billed charges,Critical Access Hospital RCC factor,144.84,34,,144.84,percent of total billed charges,Implant Device,144.84,34,,144.84,percent of total billed charges,Implant Device,144.84,34,,144.84,percent of total billed charges,Implant Device,144.84,34,,144.84,percent of total billed charges,Implant Device,144.84,34,,144.84,percent of total billed charges,Implant Device,210.87,,,210.87,Other,110% of Medicare,149.1,35,,149.1,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,149.1,35,,149.1,percent of total billed charges,Implant Device,149.1,35,,149.1,percent of total billed charges,Implant Device,149.1,35,,149.1,percent of total billed charges,Implant Device,149.1,35,,149.1,percent of total billed charges,Implant Device,149.1,35,,149.1,percent of total billed charges,Implant Device,170.4,40,,170.4,percent of total billed charges,Implant Device,149.1,70,,149.1,percent of total billed charges,All Other,144.84,34,,144.84,percent of total billed charges,Implant Device,144.84,34,,144.84,percent of total billed charges,Implant Device,149.1,35,,149.1,percent of total billed charges,Implant Device,149.1,35,,149.1,percent of total billed charges,Implant Device,149.1,35,,149.1,percent of total billed charges,Implant Device,149.1,35,,149.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,315.24,
STRYKER 58-23012E NONLOCK SCREW 2.3X12MM,C1713,HCPCS,,79005807,CDM,278,RC,,,both,,,202,149.48,,,149.48,Other,150% of Medicare + 9.63% HCRA Surcharge,90.9,45,,90.9,percent of total billed charges,Critical Access Hospital RCC factor,68.68,34,,68.68,percent of total billed charges,Implant Device,68.68,34,,68.68,percent of total billed charges,Implant Device,68.68,34,,68.68,percent of total billed charges,Implant Device,68.68,34,,68.68,percent of total billed charges,Implant Device,68.68,34,,68.68,percent of total billed charges,Implant Device,99.99,,,99.99,Other,110% of Medicare,70.7,35,,70.7,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,70.7,35,,70.7,percent of total billed charges,Implant Device,70.7,35,,70.7,percent of total billed charges,Implant Device,70.7,35,,70.7,percent of total billed charges,Implant Device,70.7,35,,70.7,percent of total billed charges,Implant Device,70.7,35,,70.7,percent of total billed charges,Implant Device,80.8,40,,80.8,percent of total billed charges,Implant Device,70.7,70,,70.7,percent of total billed charges,All Other,68.68,34,,68.68,percent of total billed charges,Implant Device,68.68,34,,68.68,percent of total billed charges,Implant Device,70.7,35,,70.7,percent of total billed charges,Implant Device,70.7,35,,70.7,percent of total billed charges,Implant Device,70.7,35,,70.7,percent of total billed charges,Implant Device,70.7,35,,70.7,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,149.48,
STRYKER 58-23014E NONLOCK SCREW 2.3X14MM,C1713,HCPCS,,79005808,CDM,278,RC,,,both,,,170,125.8,,,125.8,Other,150% of Medicare + 9.63% HCRA Surcharge,76.5,45,,76.5,percent of total billed charges,Critical Access Hospital RCC factor,57.8,34,,57.8,percent of total billed charges,Implant Device,57.8,34,,57.8,percent of total billed charges,Implant Device,57.8,34,,57.8,percent of total billed charges,Implant Device,57.8,34,,57.8,percent of total billed charges,Implant Device,57.8,34,,57.8,percent of total billed charges,Implant Device,84.15,,,84.15,Other,110% of Medicare,59.5,35,,59.5,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,59.5,35,,59.5,percent of total billed charges,Implant Device,59.5,35,,59.5,percent of total billed charges,Implant Device,59.5,35,,59.5,percent of total billed charges,Implant Device,59.5,35,,59.5,percent of total billed charges,Implant Device,59.5,35,,59.5,percent of total billed charges,Implant Device,68,40,,68,percent of total billed charges,Implant Device,59.5,70,,59.5,percent of total billed charges,All Other,57.8,34,,57.8,percent of total billed charges,Implant Device,57.8,34,,57.8,percent of total billed charges,Implant Device,59.5,35,,59.5,percent of total billed charges,Implant Device,59.5,35,,59.5,percent of total billed charges,Implant Device,59.5,35,,59.5,percent of total billed charges,Implant Device,59.5,35,,59.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,125.8,
STRYKER 58-23016E NONLOCK SCREW 2.3X16MM,C1713,HCPCS,,79005809,CDM,278,RC,,,both,,,426,315.24,,,315.24,Other,150% of Medicare + 9.63% HCRA Surcharge,191.7,45,,191.7,percent of total billed charges,Critical Access Hospital RCC factor,144.84,34,,144.84,percent of total billed charges,Implant Device,144.84,34,,144.84,percent of total billed charges,Implant Device,144.84,34,,144.84,percent of total billed charges,Implant Device,144.84,34,,144.84,percent of total billed charges,Implant Device,144.84,34,,144.84,percent of total billed charges,Implant Device,210.87,,,210.87,Other,110% of Medicare,149.1,35,,149.1,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,149.1,35,,149.1,percent of total billed charges,Implant Device,149.1,35,,149.1,percent of total billed charges,Implant Device,149.1,35,,149.1,percent of total billed charges,Implant Device,149.1,35,,149.1,percent of total billed charges,Implant Device,149.1,35,,149.1,percent of total billed charges,Implant Device,170.4,40,,170.4,percent of total billed charges,Implant Device,149.1,70,,149.1,percent of total billed charges,All Other,144.84,34,,144.84,percent of total billed charges,Implant Device,144.84,34,,144.84,percent of total billed charges,Implant Device,149.1,35,,149.1,percent of total billed charges,Implant Device,149.1,35,,149.1,percent of total billed charges,Implant Device,149.1,35,,149.1,percent of total billed charges,Implant Device,149.1,35,,149.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,315.24,
STRYKER 58-17012E NONLOCK SCREW 1.7X12MM,C1713,HCPCS,,79005810,CDM,278,RC,,,both,,,169,125.06,,,125.06,Other,150% of Medicare + 9.63% HCRA Surcharge,76.05,45,,76.05,percent of total billed charges,Critical Access Hospital RCC factor,57.46,34,,57.46,percent of total billed charges,Implant Device,57.46,34,,57.46,percent of total billed charges,Implant Device,57.46,34,,57.46,percent of total billed charges,Implant Device,57.46,34,,57.46,percent of total billed charges,Implant Device,57.46,34,,57.46,percent of total billed charges,Implant Device,83.66,,,83.66,Other,110% of Medicare,59.15,35,,59.15,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,59.15,35,,59.15,percent of total billed charges,Implant Device,59.15,35,,59.15,percent of total billed charges,Implant Device,59.15,35,,59.15,percent of total billed charges,Implant Device,59.15,35,,59.15,percent of total billed charges,Implant Device,59.15,35,,59.15,percent of total billed charges,Implant Device,67.6,40,,67.6,percent of total billed charges,Implant Device,59.15,70,,59.15,percent of total billed charges,All Other,57.46,34,,57.46,percent of total billed charges,Implant Device,57.46,34,,57.46,percent of total billed charges,Implant Device,59.15,35,,59.15,percent of total billed charges,Implant Device,59.15,35,,59.15,percent of total billed charges,Implant Device,59.15,35,,59.15,percent of total billed charges,Implant Device,59.15,35,,59.15,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,125.06,
STRYKER 57-15320 L SHAPED PLATE,C1713,HCPCS,,79005812,CDM,278,RC,,,both,,,1276,944.24,,,944.24,Other,150% of Medicare + 9.63% HCRA Surcharge,574.2,45,,574.2,percent of total billed charges,Critical Access Hospital RCC factor,433.84,34,,433.84,percent of total billed charges,Implant Device,433.84,34,,433.84,percent of total billed charges,Implant Device,433.84,34,,433.84,percent of total billed charges,Implant Device,433.84,34,,433.84,percent of total billed charges,Implant Device,433.84,34,,433.84,percent of total billed charges,Implant Device,631.62,,,631.62,Other,110% of Medicare,446.6,35,,446.6,percent of total billed charges,Implant Device,433.84,34,"Charges > $500, x 34%",433.84,percent of total billed charges,Implant Device,446.6,35,,446.6,percent of total billed charges,Implant Device,446.6,35,,446.6,percent of total billed charges,Implant Device,446.6,35,,446.6,percent of total billed charges,Implant Device,446.6,35,,446.6,percent of total billed charges,Implant Device,446.6,35,,446.6,percent of total billed charges,Implant Device,510.4,40,,510.4,percent of total billed charges,Implant Device,446.6,70,,446.6,percent of total billed charges,All Other,433.84,34,,433.84,percent of total billed charges,Implant Device,433.84,34,,433.84,percent of total billed charges,Implant Device,446.6,35,,446.6,percent of total billed charges,Implant Device,446.6,35,,446.6,percent of total billed charges,Implant Device,446.6,35,,446.6,percent of total billed charges,Implant Device,446.6,35,,446.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,944.24,
STRYKER 57-15302 4 HOLE PLATE,C1713,HCPCS,,79005813,CDM,278,RC,,,both,,,1390,1028.6,,,1028.6,Other,150% of Medicare + 9.63% HCRA Surcharge,625.5,45,,625.5,percent of total billed charges,Critical Access Hospital RCC factor,472.6,34,,472.6,percent of total billed charges,Implant Device,472.6,34,,472.6,percent of total billed charges,Implant Device,472.6,34,,472.6,percent of total billed charges,Implant Device,472.6,34,,472.6,percent of total billed charges,Implant Device,472.6,34,,472.6,percent of total billed charges,Implant Device,688.05,,,688.05,Other,110% of Medicare,486.5,35,,486.5,percent of total billed charges,Implant Device,472.6,34,"Charges > $500, x 34%",472.6,percent of total billed charges,Implant Device,486.5,35,,486.5,percent of total billed charges,Implant Device,486.5,35,,486.5,percent of total billed charges,Implant Device,486.5,35,,486.5,percent of total billed charges,Implant Device,486.5,35,,486.5,percent of total billed charges,Implant Device,486.5,35,,486.5,percent of total billed charges,Implant Device,556,40,,556,percent of total billed charges,Implant Device,486.5,70,,486.5,percent of total billed charges,All Other,472.6,34,,472.6,percent of total billed charges,Implant Device,472.6,34,,472.6,percent of total billed charges,Implant Device,486.5,35,,486.5,percent of total billed charges,Implant Device,486.5,35,,486.5,percent of total billed charges,Implant Device,486.5,35,,486.5,percent of total billed charges,Implant Device,486.5,35,,486.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1028.6,
ST JUDE 7122Q/65 DURATA ACTIVE LEAD,C1895,HCPCS,,79005814,CDM,278,RC,,,both,,,11471,8488.57,,,8488.57,Other,150% of Medicare + 9.63% HCRA Surcharge,5161.95,45,,5161.95,percent of total billed charges,Critical Access Hospital RCC factor,3900.14,34,,3900.14,percent of total billed charges,Implant Device,3900.14,34,,3900.14,percent of total billed charges,Implant Device,3900.14,34,,3900.14,percent of total billed charges,Implant Device,3900.14,34,,3900.14,percent of total billed charges,Implant Device,3900.14,34,,3900.14,percent of total billed charges,Implant Device,5678.15,,,5678.15,Other,110% of Medicare,4014.85,35,,4014.85,percent of total billed charges,Implant Device,3900.14,34,"Charges > $500, x 34%",3900.14,percent of total billed charges,Implant Device,4014.85,35,,4014.85,percent of total billed charges,Implant Device,4014.85,35,,4014.85,percent of total billed charges,Implant Device,4014.85,35,,4014.85,percent of total billed charges,Implant Device,4014.85,35,,4014.85,percent of total billed charges,Implant Device,4014.85,35,,4014.85,percent of total billed charges,Implant Device,4588.4,40,,4588.4,percent of total billed charges,Implant Device,4014.85,70,,4014.85,percent of total billed charges,All Other,3900.14,34,,3900.14,percent of total billed charges,Implant Device,3900.14,34,,3900.14,percent of total billed charges,Implant Device,4014.85,35,,4014.85,percent of total billed charges,Implant Device,4014.85,35,,4014.85,percent of total billed charges,Implant Device,4014.85,35,,4014.85,percent of total billed charges,Implant Device,4014.85,35,,4014.85,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3900.14,34,"If Charge > 2,000, then 34 percent",3900.14,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,8488.57,
ALPHATEC SPINE 62004-09 ROD 90MM,C1713,HCPCS,,79005815,CDM,278,RC,,,both,,,600,444,,,444,Other,150% of Medicare + 9.63% HCRA Surcharge,270,45,,270,percent of total billed charges,Critical Access Hospital RCC factor,204,34,,204,percent of total billed charges,Implant Device,204,34,,204,percent of total billed charges,Implant Device,204,34,,204,percent of total billed charges,Implant Device,204,34,,204,percent of total billed charges,Implant Device,204,34,,204,percent of total billed charges,Implant Device,297,,,297,Other,110% of Medicare,210,35,,210,percent of total billed charges,Implant Device,204,34,"Charges > $500, x 34%",204,percent of total billed charges,Implant Device,210,35,,210,percent of total billed charges,Implant Device,210,35,,210,percent of total billed charges,Implant Device,210,35,,210,percent of total billed charges,Implant Device,210,35,,210,percent of total billed charges,Implant Device,210,35,,210,percent of total billed charges,Implant Device,240,40,,240,percent of total billed charges,Implant Device,210,70,,210,percent of total billed charges,All Other,204,34,,204,percent of total billed charges,Implant Device,204,34,,204,percent of total billed charges,Implant Device,210,35,,210,percent of total billed charges,Implant Device,210,35,,210,percent of total billed charges,Implant Device,210,35,,210,percent of total billed charges,Implant Device,210,35,,210,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,444,
MIMEDX AL-5020 AMNIOFIX 2ML,C1713,HCPCS,,79005817,CDM,278,RC,,,both,,,1186,877.64,,,877.64,Other,150% of Medicare + 9.63% HCRA Surcharge,533.7,45,,533.7,percent of total billed charges,Critical Access Hospital RCC factor,403.24,34,,403.24,percent of total billed charges,Implant Device,403.24,34,,403.24,percent of total billed charges,Implant Device,403.24,34,,403.24,percent of total billed charges,Implant Device,403.24,34,,403.24,percent of total billed charges,Implant Device,403.24,34,,403.24,percent of total billed charges,Implant Device,587.07,,,587.07,Other,110% of Medicare,415.1,35,,415.1,percent of total billed charges,Implant Device,403.24,34,"Charges > $500, x 34%",403.24,percent of total billed charges,Implant Device,415.1,35,,415.1,percent of total billed charges,Implant Device,415.1,35,,415.1,percent of total billed charges,Implant Device,415.1,35,,415.1,percent of total billed charges,Implant Device,415.1,35,,415.1,percent of total billed charges,Implant Device,415.1,35,,415.1,percent of total billed charges,Implant Device,474.4,40,,474.4,percent of total billed charges,Implant Device,415.1,70,,415.1,percent of total billed charges,All Other,403.24,34,,403.24,percent of total billed charges,Implant Device,403.24,34,,403.24,percent of total billed charges,Implant Device,415.1,35,,415.1,percent of total billed charges,Implant Device,415.1,35,,415.1,percent of total billed charges,Implant Device,415.1,35,,415.1,percent of total billed charges,Implant Device,415.1,35,,415.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,877.64,
DEPUY 1987-07-065 SEGMENTAL COMP 65MM,C1776,HCPCS,,79005818,CDM,278,RC,,,both,,,5686,4207.65,,,4207.65,Other,150% of Medicare + 9.63% HCRA Surcharge,2558.7,45,,2558.7,percent of total billed charges,Critical Access Hospital RCC factor,1933.24,34,,1933.24,percent of total billed charges,Implant Device,1933.24,34,,1933.24,percent of total billed charges,Implant Device,1933.24,34,,1933.24,percent of total billed charges,Implant Device,1933.24,34,,1933.24,percent of total billed charges,Implant Device,1933.24,34,,1933.24,percent of total billed charges,Implant Device,2814.57,,,2814.57,Other,110% of Medicare,1990.1,35,,1990.1,percent of total billed charges,Implant Device,1933.24,34,"Charges > $500, x 34%",1933.24,percent of total billed charges,Implant Device,1990.1,35,,1990.1,percent of total billed charges,Implant Device,1990.1,35,,1990.1,percent of total billed charges,Implant Device,1990.1,35,,1990.1,percent of total billed charges,Implant Device,1990.1,35,,1990.1,percent of total billed charges,Implant Device,1990.1,35,,1990.1,percent of total billed charges,Implant Device,2274.4,40,,2274.4,percent of total billed charges,Implant Device,1990.1,70,,1990.1,percent of total billed charges,All Other,1933.24,34,,1933.24,percent of total billed charges,Implant Device,1933.24,34,,1933.24,percent of total billed charges,Implant Device,1990.1,35,,1990.1,percent of total billed charges,Implant Device,1990.1,35,,1990.1,percent of total billed charges,Implant Device,1990.1,35,,1990.1,percent of total billed charges,Implant Device,1990.1,35,,1990.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1933.24,34,"If Charge > 2,000, then 34 percent",1933.24,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4207.65,
DEPUY 1987-15-215 FEMORAL STEM 15X150MM,C1776,HCPCS,,79005819,CDM,278,RC,,,both,,,13620,10078.83,,,10078.83,Other,150% of Medicare + 9.63% HCRA Surcharge,6129,45,,6129,percent of total billed charges,Critical Access Hospital RCC factor,4630.8,34,,4630.8,percent of total billed charges,Implant Device,4630.8,34,,4630.8,percent of total billed charges,Implant Device,4630.8,34,,4630.8,percent of total billed charges,Implant Device,4630.8,34,,4630.8,percent of total billed charges,Implant Device,4630.8,34,,4630.8,percent of total billed charges,Implant Device,6741.9,,,6741.9,Other,110% of Medicare,4767,35,,4767,percent of total billed charges,Implant Device,4630.8,34,"Charges > $500, x 34%",4630.8,percent of total billed charges,Implant Device,4767,35,,4767,percent of total billed charges,Implant Device,4767,35,,4767,percent of total billed charges,Implant Device,4767,35,,4767,percent of total billed charges,Implant Device,4767,35,,4767,percent of total billed charges,Implant Device,4767,35,,4767,percent of total billed charges,Implant Device,5448,40,,5448,percent of total billed charges,Implant Device,4767,70,,4767,percent of total billed charges,All Other,4630.8,34,,4630.8,percent of total billed charges,Implant Device,4630.8,34,,4630.8,percent of total billed charges,Implant Device,4767,35,,4767,percent of total billed charges,Implant Device,4767,35,,4767,percent of total billed charges,Implant Device,4767,35,,4767,percent of total billed charges,Implant Device,4767,35,,4767,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,4630.8,34,"If Charge > 2,000, then 34 percent",4630.8,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,10078.83,
ARTHREX AR-1360B-CP MPFL IMPLANT SYSTEM,C1713,HCPCS,,79005823,CDM,278,RC,,,both,,,5910,4373.41,,,4373.41,Other,150% of Medicare + 9.63% HCRA Surcharge,2659.5,45,,2659.5,percent of total billed charges,Critical Access Hospital RCC factor,2009.4,34,,2009.4,percent of total billed charges,Implant Device,2009.4,34,,2009.4,percent of total billed charges,Implant Device,2009.4,34,,2009.4,percent of total billed charges,Implant Device,2009.4,34,,2009.4,percent of total billed charges,Implant Device,2009.4,34,,2009.4,percent of total billed charges,Implant Device,2925.45,,,2925.45,Other,110% of Medicare,2068.5,35,,2068.5,percent of total billed charges,Implant Device,2009.4,34,"Charges > $500, x 34%",2009.4,percent of total billed charges,Implant Device,2068.5,35,,2068.5,percent of total billed charges,Implant Device,2068.5,35,,2068.5,percent of total billed charges,Implant Device,2068.5,35,,2068.5,percent of total billed charges,Implant Device,2068.5,35,,2068.5,percent of total billed charges,Implant Device,2068.5,35,,2068.5,percent of total billed charges,Implant Device,2364,40,,2364,percent of total billed charges,Implant Device,2068.5,70,,2068.5,percent of total billed charges,All Other,2009.4,34,,2009.4,percent of total billed charges,Implant Device,2009.4,34,,2009.4,percent of total billed charges,Implant Device,2068.5,35,,2068.5,percent of total billed charges,Implant Device,2068.5,35,,2068.5,percent of total billed charges,Implant Device,2068.5,35,,2068.5,percent of total billed charges,Implant Device,2068.5,35,,2068.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2009.4,34,"If Charge > 2,000, then 34 percent",2009.4,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4373.41,
SOLANA CCP-MPX1L CROSSCHECK MTP PLATE LT,C1713,HCPCS,,79005824,CDM,278,RC,,,both,,,7245,5361.32,,,5361.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3260.25,45,,3260.25,percent of total billed charges,Critical Access Hospital RCC factor,2463.3,34,,2463.3,percent of total billed charges,Implant Device,2463.3,34,,2463.3,percent of total billed charges,Implant Device,2463.3,34,,2463.3,percent of total billed charges,Implant Device,2463.3,34,,2463.3,percent of total billed charges,Implant Device,2463.3,34,,2463.3,percent of total billed charges,Implant Device,3586.28,,,3586.28,Other,110% of Medicare,2535.75,35,,2535.75,percent of total billed charges,Implant Device,2463.3,34,"Charges > $500, x 34%",2463.3,percent of total billed charges,Implant Device,2535.75,35,,2535.75,percent of total billed charges,Implant Device,2535.75,35,,2535.75,percent of total billed charges,Implant Device,2535.75,35,,2535.75,percent of total billed charges,Implant Device,2535.75,35,,2535.75,percent of total billed charges,Implant Device,2535.75,35,,2535.75,percent of total billed charges,Implant Device,2898,40,,2898,percent of total billed charges,Implant Device,2535.75,70,,2535.75,percent of total billed charges,All Other,2463.3,34,,2463.3,percent of total billed charges,Implant Device,2463.3,34,,2463.3,percent of total billed charges,Implant Device,2535.75,35,,2535.75,percent of total billed charges,Implant Device,2535.75,35,,2535.75,percent of total billed charges,Implant Device,2535.75,35,,2535.75,percent of total billed charges,Implant Device,2535.75,35,,2535.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2463.3,34,"If Charge > 2,000, then 34 percent",2463.3,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5361.32,
SOLANA CCP-L3008 XCHECK LOCK SCREW 3X8MM,C1713,HCPCS,,79005825,CDM,278,RC,,,both,,,1126,833.24,,,833.24,Other,150% of Medicare + 9.63% HCRA Surcharge,506.7,45,,506.7,percent of total billed charges,Critical Access Hospital RCC factor,382.84,34,,382.84,percent of total billed charges,Implant Device,382.84,34,,382.84,percent of total billed charges,Implant Device,382.84,34,,382.84,percent of total billed charges,Implant Device,382.84,34,,382.84,percent of total billed charges,Implant Device,382.84,34,,382.84,percent of total billed charges,Implant Device,557.37,,,557.37,Other,110% of Medicare,394.1,35,,394.1,percent of total billed charges,Implant Device,382.84,34,"Charges > $500, x 34%",382.84,percent of total billed charges,Implant Device,394.1,35,,394.1,percent of total billed charges,Implant Device,394.1,35,,394.1,percent of total billed charges,Implant Device,394.1,35,,394.1,percent of total billed charges,Implant Device,394.1,35,,394.1,percent of total billed charges,Implant Device,394.1,35,,394.1,percent of total billed charges,Implant Device,450.4,40,,450.4,percent of total billed charges,Implant Device,394.1,70,,394.1,percent of total billed charges,All Other,382.84,34,,382.84,percent of total billed charges,Implant Device,382.84,34,,382.84,percent of total billed charges,Implant Device,394.1,35,,394.1,percent of total billed charges,Implant Device,394.1,35,,394.1,percent of total billed charges,Implant Device,394.1,35,,394.1,percent of total billed charges,Implant Device,394.1,35,,394.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,833.24,
SOLANA CCP-L3010 XCHECK LOCK SCREW 3X10,C1713,HCPCS,,79005826,CDM,278,RC,,,both,,,1125,832.5,,,832.5,Other,150% of Medicare + 9.63% HCRA Surcharge,506.25,45,,506.25,percent of total billed charges,Critical Access Hospital RCC factor,382.5,34,,382.5,percent of total billed charges,Implant Device,382.5,34,,382.5,percent of total billed charges,Implant Device,382.5,34,,382.5,percent of total billed charges,Implant Device,382.5,34,,382.5,percent of total billed charges,Implant Device,382.5,34,,382.5,percent of total billed charges,Implant Device,556.88,,,556.88,Other,110% of Medicare,393.75,35,,393.75,percent of total billed charges,Implant Device,382.5,34,"Charges > $500, x 34%",382.5,percent of total billed charges,Implant Device,393.75,35,,393.75,percent of total billed charges,Implant Device,393.75,35,,393.75,percent of total billed charges,Implant Device,393.75,35,,393.75,percent of total billed charges,Implant Device,393.75,35,,393.75,percent of total billed charges,Implant Device,393.75,35,,393.75,percent of total billed charges,Implant Device,450,40,,450,percent of total billed charges,Implant Device,393.75,70,,393.75,percent of total billed charges,All Other,382.5,34,,382.5,percent of total billed charges,Implant Device,382.5,34,,382.5,percent of total billed charges,Implant Device,393.75,35,,393.75,percent of total billed charges,Implant Device,393.75,35,,393.75,percent of total billed charges,Implant Device,393.75,35,,393.75,percent of total billed charges,Implant Device,393.75,35,,393.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,832.5,
SOLANA CCP-L3012 XCHECK LOCK SCREW 3X12,C1713,HCPCS,,79005827,CDM,278,RC,,,both,,,1125,832.5,,,832.5,Other,150% of Medicare + 9.63% HCRA Surcharge,506.25,45,,506.25,percent of total billed charges,Critical Access Hospital RCC factor,382.5,34,,382.5,percent of total billed charges,Implant Device,382.5,34,,382.5,percent of total billed charges,Implant Device,382.5,34,,382.5,percent of total billed charges,Implant Device,382.5,34,,382.5,percent of total billed charges,Implant Device,382.5,34,,382.5,percent of total billed charges,Implant Device,556.88,,,556.88,Other,110% of Medicare,393.75,35,,393.75,percent of total billed charges,Implant Device,382.5,34,"Charges > $500, x 34%",382.5,percent of total billed charges,Implant Device,393.75,35,,393.75,percent of total billed charges,Implant Device,393.75,35,,393.75,percent of total billed charges,Implant Device,393.75,35,,393.75,percent of total billed charges,Implant Device,393.75,35,,393.75,percent of total billed charges,Implant Device,393.75,35,,393.75,percent of total billed charges,Implant Device,450,40,,450,percent of total billed charges,Implant Device,393.75,70,,393.75,percent of total billed charges,All Other,382.5,34,,382.5,percent of total billed charges,Implant Device,382.5,34,,382.5,percent of total billed charges,Implant Device,393.75,35,,393.75,percent of total billed charges,Implant Device,393.75,35,,393.75,percent of total billed charges,Implant Device,393.75,35,,393.75,percent of total billed charges,Implant Device,393.75,35,,393.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,832.5,
SOLANA CCP-L3014 XCHECK LOCK SCREW 3X14,C1713,HCPCS,,79005828,CDM,278,RC,,,both,,,1126,833.24,,,833.24,Other,150% of Medicare + 9.63% HCRA Surcharge,506.7,45,,506.7,percent of total billed charges,Critical Access Hospital RCC factor,382.84,34,,382.84,percent of total billed charges,Implant Device,382.84,34,,382.84,percent of total billed charges,Implant Device,382.84,34,,382.84,percent of total billed charges,Implant Device,382.84,34,,382.84,percent of total billed charges,Implant Device,382.84,34,,382.84,percent of total billed charges,Implant Device,557.37,,,557.37,Other,110% of Medicare,394.1,35,,394.1,percent of total billed charges,Implant Device,382.84,34,"Charges > $500, x 34%",382.84,percent of total billed charges,Implant Device,394.1,35,,394.1,percent of total billed charges,Implant Device,394.1,35,,394.1,percent of total billed charges,Implant Device,394.1,35,,394.1,percent of total billed charges,Implant Device,394.1,35,,394.1,percent of total billed charges,Implant Device,394.1,35,,394.1,percent of total billed charges,Implant Device,450.4,40,,450.4,percent of total billed charges,Implant Device,394.1,70,,394.1,percent of total billed charges,All Other,382.84,34,,382.84,percent of total billed charges,Implant Device,382.84,34,,382.84,percent of total billed charges,Implant Device,394.1,35,,394.1,percent of total billed charges,Implant Device,394.1,35,,394.1,percent of total billed charges,Implant Device,394.1,35,,394.1,percent of total billed charges,Implant Device,394.1,35,,394.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,833.24,
SOLANA CCP-X3520 XCHECK LAG SCREW 3.5X20,C1713,HCPCS,,79005829,CDM,278,RC,,,both,,,1125,832.5,,,832.5,Other,150% of Medicare + 9.63% HCRA Surcharge,506.25,45,,506.25,percent of total billed charges,Critical Access Hospital RCC factor,382.5,34,,382.5,percent of total billed charges,Implant Device,382.5,34,,382.5,percent of total billed charges,Implant Device,382.5,34,,382.5,percent of total billed charges,Implant Device,382.5,34,,382.5,percent of total billed charges,Implant Device,382.5,34,,382.5,percent of total billed charges,Implant Device,556.88,,,556.88,Other,110% of Medicare,393.75,35,,393.75,percent of total billed charges,Implant Device,382.5,34,"Charges > $500, x 34%",382.5,percent of total billed charges,Implant Device,393.75,35,,393.75,percent of total billed charges,Implant Device,393.75,35,,393.75,percent of total billed charges,Implant Device,393.75,35,,393.75,percent of total billed charges,Implant Device,393.75,35,,393.75,percent of total billed charges,Implant Device,393.75,35,,393.75,percent of total billed charges,Implant Device,450,40,,450,percent of total billed charges,Implant Device,393.75,70,,393.75,percent of total billed charges,All Other,382.5,34,,382.5,percent of total billed charges,Implant Device,382.5,34,,382.5,percent of total billed charges,Implant Device,393.75,35,,393.75,percent of total billed charges,Implant Device,393.75,35,,393.75,percent of total billed charges,Implant Device,393.75,35,,393.75,percent of total billed charges,Implant Device,393.75,35,,393.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,832.5,
DEPUY 1987-15-212 FEMORAL STEM 12X150MM,C1776,HCPCS,,79005831,CDM,278,RC,,,both,,,13620,10078.83,,,10078.83,Other,150% of Medicare + 9.63% HCRA Surcharge,6129,45,,6129,percent of total billed charges,Critical Access Hospital RCC factor,4630.8,34,,4630.8,percent of total billed charges,Implant Device,4630.8,34,,4630.8,percent of total billed charges,Implant Device,4630.8,34,,4630.8,percent of total billed charges,Implant Device,4630.8,34,,4630.8,percent of total billed charges,Implant Device,4630.8,34,,4630.8,percent of total billed charges,Implant Device,6741.9,,,6741.9,Other,110% of Medicare,4767,35,,4767,percent of total billed charges,Implant Device,4630.8,34,"Charges > $500, x 34%",4630.8,percent of total billed charges,Implant Device,4767,35,,4767,percent of total billed charges,Implant Device,4767,35,,4767,percent of total billed charges,Implant Device,4767,35,,4767,percent of total billed charges,Implant Device,4767,35,,4767,percent of total billed charges,Implant Device,4767,35,,4767,percent of total billed charges,Implant Device,5448,40,,5448,percent of total billed charges,Implant Device,4767,70,,4767,percent of total billed charges,All Other,4630.8,34,,4630.8,percent of total billed charges,Implant Device,4630.8,34,,4630.8,percent of total billed charges,Implant Device,4767,35,,4767,percent of total billed charges,Implant Device,4767,35,,4767,percent of total billed charges,Implant Device,4767,35,,4767,percent of total billed charges,Implant Device,4767,35,,4767,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,4630.8,34,"If Charge > 2,000, then 34 percent",4630.8,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,10078.83,
BIOMET 8155-40-016 NON LOCK SCREW 4X16MM,C1713,HCPCS,,79005832,CDM,278,RC,,,both,,,240,177.6,,,177.6,Other,150% of Medicare + 9.63% HCRA Surcharge,108,45,,108,percent of total billed charges,Critical Access Hospital RCC factor,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,118.8,,,118.8,Other,110% of Medicare,84,35,,84,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,96,40,,96,percent of total billed charges,Implant Device,84,70,,84,percent of total billed charges,All Other,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,177.6,
STRYKER 57-15340 LOCK PLATE 6 HOLE 2.3MM,C1713,HCPCS,,79005836,CDM,278,RC,,,both,,,1276,944.24,,,944.24,Other,150% of Medicare + 9.63% HCRA Surcharge,574.2,45,,574.2,percent of total billed charges,Critical Access Hospital RCC factor,433.84,34,,433.84,percent of total billed charges,Implant Device,433.84,34,,433.84,percent of total billed charges,Implant Device,433.84,34,,433.84,percent of total billed charges,Implant Device,433.84,34,,433.84,percent of total billed charges,Implant Device,433.84,34,,433.84,percent of total billed charges,Implant Device,631.62,,,631.62,Other,110% of Medicare,446.6,35,,446.6,percent of total billed charges,Implant Device,433.84,34,"Charges > $500, x 34%",433.84,percent of total billed charges,Implant Device,446.6,35,,446.6,percent of total billed charges,Implant Device,446.6,35,,446.6,percent of total billed charges,Implant Device,446.6,35,,446.6,percent of total billed charges,Implant Device,446.6,35,,446.6,percent of total billed charges,Implant Device,446.6,35,,446.6,percent of total billed charges,Implant Device,510.4,40,,510.4,percent of total billed charges,Implant Device,446.6,70,,446.6,percent of total billed charges,All Other,433.84,34,,433.84,percent of total billed charges,Implant Device,433.84,34,,433.84,percent of total billed charges,Implant Device,446.6,35,,446.6,percent of total billed charges,Implant Device,446.6,35,,446.6,percent of total billed charges,Implant Device,446.6,35,,446.6,percent of total billed charges,Implant Device,446.6,35,,446.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,944.24,
STRYKER 53-23008E LOCKING SCREW 2.3X8MM,C1713,HCPCS,,79005837,CDM,278,RC,,,both,,,515,381.1,,,381.1,Other,150% of Medicare + 9.63% HCRA Surcharge,231.75,45,,231.75,percent of total billed charges,Critical Access Hospital RCC factor,175.1,34,,175.1,percent of total billed charges,Implant Device,175.1,34,,175.1,percent of total billed charges,Implant Device,175.1,34,,175.1,percent of total billed charges,Implant Device,175.1,34,,175.1,percent of total billed charges,Implant Device,175.1,34,,175.1,percent of total billed charges,Implant Device,254.93,,,254.93,Other,110% of Medicare,180.25,35,,180.25,percent of total billed charges,Implant Device,175.1,34,"Charges > $500, x 34%",175.1,percent of total billed charges,Implant Device,180.25,35,,180.25,percent of total billed charges,Implant Device,180.25,35,,180.25,percent of total billed charges,Implant Device,180.25,35,,180.25,percent of total billed charges,Implant Device,180.25,35,,180.25,percent of total billed charges,Implant Device,180.25,35,,180.25,percent of total billed charges,Implant Device,206,40,,206,percent of total billed charges,Implant Device,180.25,70,,180.25,percent of total billed charges,All Other,175.1,34,,175.1,percent of total billed charges,Implant Device,175.1,34,,175.1,percent of total billed charges,Implant Device,180.25,35,,180.25,percent of total billed charges,Implant Device,180.25,35,,180.25,percent of total billed charges,Implant Device,180.25,35,,180.25,percent of total billed charges,Implant Device,180.25,35,,180.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,381.1,
STRYKER 53-23006E LOCKING SCREW 2.3X6MM,C1713,HCPCS,,79005838,CDM,278,RC,,,both,,,515,381.1,,,381.1,Other,150% of Medicare + 9.63% HCRA Surcharge,231.75,45,,231.75,percent of total billed charges,Critical Access Hospital RCC factor,175.1,34,,175.1,percent of total billed charges,Implant Device,175.1,34,,175.1,percent of total billed charges,Implant Device,175.1,34,,175.1,percent of total billed charges,Implant Device,175.1,34,,175.1,percent of total billed charges,Implant Device,175.1,34,,175.1,percent of total billed charges,Implant Device,254.93,,,254.93,Other,110% of Medicare,180.25,35,,180.25,percent of total billed charges,Implant Device,175.1,34,"Charges > $500, x 34%",175.1,percent of total billed charges,Implant Device,180.25,35,,180.25,percent of total billed charges,Implant Device,180.25,35,,180.25,percent of total billed charges,Implant Device,180.25,35,,180.25,percent of total billed charges,Implant Device,180.25,35,,180.25,percent of total billed charges,Implant Device,180.25,35,,180.25,percent of total billed charges,Implant Device,206,40,,206,percent of total billed charges,Implant Device,180.25,70,,180.25,percent of total billed charges,All Other,175.1,34,,175.1,percent of total billed charges,Implant Device,175.1,34,,175.1,percent of total billed charges,Implant Device,180.25,35,,180.25,percent of total billed charges,Implant Device,180.25,35,,180.25,percent of total billed charges,Implant Device,180.25,35,,180.25,percent of total billed charges,Implant Device,180.25,35,,180.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,381.1,
SYNTHES 212.117 LOCKING SCREW 3.5MM,C1713,HCPCS,,79005839,CDM,278,RC,,,both,,,315,233.1,,,233.1,Other,150% of Medicare + 9.63% HCRA Surcharge,141.75,45,,141.75,percent of total billed charges,Critical Access Hospital RCC factor,107.1,34,,107.1,percent of total billed charges,Implant Device,107.1,34,,107.1,percent of total billed charges,Implant Device,107.1,34,,107.1,percent of total billed charges,Implant Device,107.1,34,,107.1,percent of total billed charges,Implant Device,107.1,34,,107.1,percent of total billed charges,Implant Device,155.93,,,155.93,Other,110% of Medicare,110.25,35,,110.25,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,110.25,35,,110.25,percent of total billed charges,Implant Device,110.25,35,,110.25,percent of total billed charges,Implant Device,110.25,35,,110.25,percent of total billed charges,Implant Device,110.25,35,,110.25,percent of total billed charges,Implant Device,110.25,35,,110.25,percent of total billed charges,Implant Device,126,40,,126,percent of total billed charges,Implant Device,110.25,70,,110.25,percent of total billed charges,All Other,107.1,34,,107.1,percent of total billed charges,Implant Device,107.1,34,,107.1,percent of total billed charges,Implant Device,110.25,35,,110.25,percent of total billed charges,Implant Device,110.25,35,,110.25,percent of total billed charges,Implant Device,110.25,35,,110.25,percent of total billed charges,Implant Device,110.25,35,,110.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,233.1,
SYNTHES 212-121 LOCKING SCREW 3.5MM,C1713,HCPCS,,79005840,CDM,278,RC,,,both,,,315,233.1,,,233.1,Other,150% of Medicare + 9.63% HCRA Surcharge,141.75,45,,141.75,percent of total billed charges,Critical Access Hospital RCC factor,107.1,34,,107.1,percent of total billed charges,Implant Device,107.1,34,,107.1,percent of total billed charges,Implant Device,107.1,34,,107.1,percent of total billed charges,Implant Device,107.1,34,,107.1,percent of total billed charges,Implant Device,107.1,34,,107.1,percent of total billed charges,Implant Device,155.93,,,155.93,Other,110% of Medicare,110.25,35,,110.25,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,110.25,35,,110.25,percent of total billed charges,Implant Device,110.25,35,,110.25,percent of total billed charges,Implant Device,110.25,35,,110.25,percent of total billed charges,Implant Device,110.25,35,,110.25,percent of total billed charges,Implant Device,110.25,35,,110.25,percent of total billed charges,Implant Device,126,40,,126,percent of total billed charges,Implant Device,110.25,70,,110.25,percent of total billed charges,All Other,107.1,34,,107.1,percent of total billed charges,Implant Device,107.1,34,,107.1,percent of total billed charges,Implant Device,110.25,35,,110.25,percent of total billed charges,Implant Device,110.25,35,,110.25,percent of total billed charges,Implant Device,110.25,35,,110.25,percent of total billed charges,Implant Device,110.25,35,,110.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,233.1,
SYNTHES 02.200.032 CORTEX SCEW 3.5MM,C1713,HCPCS,,79005841,CDM,278,RC,,,both,,,101,74.74,,,74.74,Other,150% of Medicare + 9.63% HCRA Surcharge,45.45,45,,45.45,percent of total billed charges,Critical Access Hospital RCC factor,34.34,34,,34.34,percent of total billed charges,Implant Device,34.34,34,,34.34,percent of total billed charges,Implant Device,34.34,34,,34.34,percent of total billed charges,Implant Device,34.34,34,,34.34,percent of total billed charges,Implant Device,34.34,34,,34.34,percent of total billed charges,Implant Device,50,,,50,Other,110% of Medicare,35.35,35,,35.35,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,35.35,35,,35.35,percent of total billed charges,Implant Device,35.35,35,,35.35,percent of total billed charges,Implant Device,35.35,35,,35.35,percent of total billed charges,Implant Device,35.35,35,,35.35,percent of total billed charges,Implant Device,35.35,35,,35.35,percent of total billed charges,Implant Device,40.4,40,,40.4,percent of total billed charges,Implant Device,35.35,70,,35.35,percent of total billed charges,All Other,34.34,34,,34.34,percent of total billed charges,Implant Device,34.34,34,,34.34,percent of total billed charges,Implant Device,35.35,35,,35.35,percent of total billed charges,Implant Device,35.35,35,,35.35,percent of total billed charges,Implant Device,35.35,35,,35.35,percent of total billed charges,Implant Device,35.35,35,,35.35,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,74.74,
SYNTHES 02.120.702S LCP PLATE 2 HOLE 3.5,C1713,HCPCS,,79005843,CDM,278,RC,,,both,,,2444,1808.57,,,1808.57,Other,150% of Medicare + 9.63% HCRA Surcharge,1099.8,45,,1099.8,percent of total billed charges,Critical Access Hospital RCC factor,830.96,34,,830.96,percent of total billed charges,Implant Device,830.96,34,,830.96,percent of total billed charges,Implant Device,830.96,34,,830.96,percent of total billed charges,Implant Device,830.96,34,,830.96,percent of total billed charges,Implant Device,830.96,34,,830.96,percent of total billed charges,Implant Device,1209.78,,,1209.78,Other,110% of Medicare,855.4,35,,855.4,percent of total billed charges,Implant Device,830.96,34,"Charges > $500, x 34%",830.96,percent of total billed charges,Implant Device,855.4,35,,855.4,percent of total billed charges,Implant Device,855.4,35,,855.4,percent of total billed charges,Implant Device,855.4,35,,855.4,percent of total billed charges,Implant Device,855.4,35,,855.4,percent of total billed charges,Implant Device,855.4,35,,855.4,percent of total billed charges,Implant Device,977.6,40,,977.6,percent of total billed charges,Implant Device,855.4,70,,855.4,percent of total billed charges,All Other,830.96,34,,830.96,percent of total billed charges,Implant Device,830.96,34,,830.96,percent of total billed charges,Implant Device,855.4,35,,855.4,percent of total billed charges,Implant Device,855.4,35,,855.4,percent of total billed charges,Implant Device,855.4,35,,855.4,percent of total billed charges,Implant Device,855.4,35,,855.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,830.96,34,"If Charge > 2,000, then 34 percent",830.96,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1808.57,
SYNTHES 02.127.211 VA-LCP PLATE 4HOLE3.5,C1713,HCPCS,,79005844,CDM,278,RC,,,both,,,6130,4536.22,,,4536.22,Other,150% of Medicare + 9.63% HCRA Surcharge,2758.5,45,,2758.5,percent of total billed charges,Critical Access Hospital RCC factor,2084.2,34,,2084.2,percent of total billed charges,Implant Device,2084.2,34,,2084.2,percent of total billed charges,Implant Device,2084.2,34,,2084.2,percent of total billed charges,Implant Device,2084.2,34,,2084.2,percent of total billed charges,Implant Device,2084.2,34,,2084.2,percent of total billed charges,Implant Device,3034.35,,,3034.35,Other,110% of Medicare,2145.5,35,,2145.5,percent of total billed charges,Implant Device,2084.2,34,"Charges > $500, x 34%",2084.2,percent of total billed charges,Implant Device,2145.5,35,,2145.5,percent of total billed charges,Implant Device,2145.5,35,,2145.5,percent of total billed charges,Implant Device,2145.5,35,,2145.5,percent of total billed charges,Implant Device,2145.5,35,,2145.5,percent of total billed charges,Implant Device,2145.5,35,,2145.5,percent of total billed charges,Implant Device,2452,40,,2452,percent of total billed charges,Implant Device,2145.5,70,,2145.5,percent of total billed charges,All Other,2084.2,34,,2084.2,percent of total billed charges,Implant Device,2084.2,34,,2084.2,percent of total billed charges,Implant Device,2145.5,35,,2145.5,percent of total billed charges,Implant Device,2145.5,35,,2145.5,percent of total billed charges,Implant Device,2145.5,35,,2145.5,percent of total billed charges,Implant Device,2145.5,35,,2145.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2084.2,34,"If Charge > 2,000, then 34 percent",2084.2,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4536.22,
SYNTHES 02.127.154 LOCK SCREW 3.5X54MM,C1713,HCPCS,,79005846,CDM,278,RC,,,both,,,414,306.36,,,306.36,Other,150% of Medicare + 9.63% HCRA Surcharge,186.3,45,,186.3,percent of total billed charges,Critical Access Hospital RCC factor,140.76,34,,140.76,percent of total billed charges,Implant Device,140.76,34,,140.76,percent of total billed charges,Implant Device,140.76,34,,140.76,percent of total billed charges,Implant Device,140.76,34,,140.76,percent of total billed charges,Implant Device,140.76,34,,140.76,percent of total billed charges,Implant Device,204.93,,,204.93,Other,110% of Medicare,144.9,35,,144.9,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,144.9,35,,144.9,percent of total billed charges,Implant Device,144.9,35,,144.9,percent of total billed charges,Implant Device,144.9,35,,144.9,percent of total billed charges,Implant Device,144.9,35,,144.9,percent of total billed charges,Implant Device,144.9,35,,144.9,percent of total billed charges,Implant Device,165.6,40,,165.6,percent of total billed charges,Implant Device,144.9,70,,144.9,percent of total billed charges,All Other,140.76,34,,140.76,percent of total billed charges,Implant Device,140.76,34,,140.76,percent of total billed charges,Implant Device,144.9,35,,144.9,percent of total billed charges,Implant Device,144.9,35,,144.9,percent of total billed charges,Implant Device,144.9,35,,144.9,percent of total billed charges,Implant Device,144.9,35,,144.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,306.36,
SYNTHES 02.127.165 LOCK SCREW 3.5X65MM,C1713,HCPCS,,79005847,CDM,278,RC,,,both,,,414,306.36,,,306.36,Other,150% of Medicare + 9.63% HCRA Surcharge,186.3,45,,186.3,percent of total billed charges,Critical Access Hospital RCC factor,140.76,34,,140.76,percent of total billed charges,Implant Device,140.76,34,,140.76,percent of total billed charges,Implant Device,140.76,34,,140.76,percent of total billed charges,Implant Device,140.76,34,,140.76,percent of total billed charges,Implant Device,140.76,34,,140.76,percent of total billed charges,Implant Device,204.93,,,204.93,Other,110% of Medicare,144.9,35,,144.9,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,144.9,35,,144.9,percent of total billed charges,Implant Device,144.9,35,,144.9,percent of total billed charges,Implant Device,144.9,35,,144.9,percent of total billed charges,Implant Device,144.9,35,,144.9,percent of total billed charges,Implant Device,144.9,35,,144.9,percent of total billed charges,Implant Device,165.6,40,,165.6,percent of total billed charges,Implant Device,144.9,70,,144.9,percent of total billed charges,All Other,140.76,34,,140.76,percent of total billed charges,Implant Device,140.76,34,,140.76,percent of total billed charges,Implant Device,144.9,35,,144.9,percent of total billed charges,Implant Device,144.9,35,,144.9,percent of total billed charges,Implant Device,144.9,35,,144.9,percent of total billed charges,Implant Device,144.9,35,,144.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,306.36,
SYNTHES 02.127.170 LOCK SCREW 3.5X70MM,C1713,HCPCS,,79005848,CDM,278,RC,,,both,,,414,306.36,,,306.36,Other,150% of Medicare + 9.63% HCRA Surcharge,186.3,45,,186.3,percent of total billed charges,Critical Access Hospital RCC factor,140.76,34,,140.76,percent of total billed charges,Implant Device,140.76,34,,140.76,percent of total billed charges,Implant Device,140.76,34,,140.76,percent of total billed charges,Implant Device,140.76,34,,140.76,percent of total billed charges,Implant Device,140.76,34,,140.76,percent of total billed charges,Implant Device,204.93,,,204.93,Other,110% of Medicare,144.9,35,,144.9,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,144.9,35,,144.9,percent of total billed charges,Implant Device,144.9,35,,144.9,percent of total billed charges,Implant Device,144.9,35,,144.9,percent of total billed charges,Implant Device,144.9,35,,144.9,percent of total billed charges,Implant Device,144.9,35,,144.9,percent of total billed charges,Implant Device,165.6,40,,165.6,percent of total billed charges,Implant Device,144.9,70,,144.9,percent of total billed charges,All Other,140.76,34,,140.76,percent of total billed charges,Implant Device,140.76,34,,140.76,percent of total billed charges,Implant Device,144.9,35,,144.9,percent of total billed charges,Implant Device,144.9,35,,144.9,percent of total billed charges,Implant Device,144.9,35,,144.9,percent of total billed charges,Implant Device,144.9,35,,144.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,306.36,
SYNTHES 07-704-010S DRILLABL CEMENT 10CC,C1713,HCPCS,,79005850,CDM,278,RC,,,both,,,3531,2612.95,,,2612.95,Other,150% of Medicare + 9.63% HCRA Surcharge,1588.95,45,,1588.95,percent of total billed charges,Critical Access Hospital RCC factor,1200.54,34,,1200.54,percent of total billed charges,Implant Device,1200.54,34,,1200.54,percent of total billed charges,Implant Device,1200.54,34,,1200.54,percent of total billed charges,Implant Device,1200.54,34,,1200.54,percent of total billed charges,Implant Device,1200.54,34,,1200.54,percent of total billed charges,Implant Device,1747.85,,,1747.85,Other,110% of Medicare,1235.85,35,,1235.85,percent of total billed charges,Implant Device,1200.54,34,"Charges > $500, x 34%",1200.54,percent of total billed charges,Implant Device,1235.85,35,,1235.85,percent of total billed charges,Implant Device,1235.85,35,,1235.85,percent of total billed charges,Implant Device,1235.85,35,,1235.85,percent of total billed charges,Implant Device,1235.85,35,,1235.85,percent of total billed charges,Implant Device,1235.85,35,,1235.85,percent of total billed charges,Implant Device,1412.4,40,,1412.4,percent of total billed charges,Implant Device,1235.85,70,,1235.85,percent of total billed charges,All Other,1200.54,34,,1200.54,percent of total billed charges,Implant Device,1200.54,34,,1200.54,percent of total billed charges,Implant Device,1235.85,35,,1235.85,percent of total billed charges,Implant Device,1235.85,35,,1235.85,percent of total billed charges,Implant Device,1235.85,35,,1235.85,percent of total billed charges,Implant Device,1235.85,35,,1235.85,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1200.54,34,"If Charge > 2,000, then 34 percent",1200.54,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2612.95,
SYNTHES 204.818 CORTEX SCREW 3.5X18MM,C1713,HCPCS,,79005852,CDM,278,RC,,,both,,,82,60.68,,,60.68,Other,150% of Medicare + 9.63% HCRA Surcharge,36.9,45,,36.9,percent of total billed charges,Critical Access Hospital RCC factor,27.88,34,,27.88,percent of total billed charges,Implant Device,27.88,34,,27.88,percent of total billed charges,Implant Device,27.88,34,,27.88,percent of total billed charges,Implant Device,27.88,34,,27.88,percent of total billed charges,Implant Device,27.88,34,,27.88,percent of total billed charges,Implant Device,40.59,,,40.59,Other,110% of Medicare,28.7,35,,28.7,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,28.7,35,,28.7,percent of total billed charges,Implant Device,28.7,35,,28.7,percent of total billed charges,Implant Device,28.7,35,,28.7,percent of total billed charges,Implant Device,28.7,35,,28.7,percent of total billed charges,Implant Device,28.7,35,,28.7,percent of total billed charges,Implant Device,32.8,40,,32.8,percent of total billed charges,Implant Device,28.7,70,,28.7,percent of total billed charges,All Other,27.88,34,,27.88,percent of total billed charges,Implant Device,27.88,34,,27.88,percent of total billed charges,Implant Device,28.7,35,,28.7,percent of total billed charges,Implant Device,28.7,35,,28.7,percent of total billed charges,Implant Device,28.7,35,,28.7,percent of total billed charges,Implant Device,28.7,35,,28.7,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,60.68,
SYNTHES 204.820 CORTEX SCREW 3.5X20MM,C1713,HCPCS,,79005853,CDM,278,RC,,,both,,,57,42.18,,,42.18,Other,150% of Medicare + 9.63% HCRA Surcharge,25.65,45,,25.65,percent of total billed charges,Critical Access Hospital RCC factor,19.38,34,,19.38,percent of total billed charges,Implant Device,19.38,34,,19.38,percent of total billed charges,Implant Device,19.38,34,,19.38,percent of total billed charges,Implant Device,19.38,34,,19.38,percent of total billed charges,Implant Device,19.38,34,,19.38,percent of total billed charges,Implant Device,28.22,,,28.22,Other,110% of Medicare,19.95,35,,19.95,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,19.95,35,,19.95,percent of total billed charges,Implant Device,19.95,35,,19.95,percent of total billed charges,Implant Device,19.95,35,,19.95,percent of total billed charges,Implant Device,19.95,35,,19.95,percent of total billed charges,Implant Device,19.95,35,,19.95,percent of total billed charges,Implant Device,22.8,40,,22.8,percent of total billed charges,Implant Device,19.95,70,,19.95,percent of total billed charges,All Other,19.38,34,,19.38,percent of total billed charges,Implant Device,19.38,34,,19.38,percent of total billed charges,Implant Device,19.95,35,,19.95,percent of total billed charges,Implant Device,19.95,35,,19.95,percent of total billed charges,Implant Device,19.95,35,,19.95,percent of total billed charges,Implant Device,19.95,35,,19.95,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,42.18,
SYNTHES 206.016 CANCELLOUS SCREW 4X16MM,C1713,HCPCS,,79005854,CDM,278,RC,,,both,,,73,54.02,,,54.02,Other,150% of Medicare + 9.63% HCRA Surcharge,32.85,45,,32.85,percent of total billed charges,Critical Access Hospital RCC factor,24.82,34,,24.82,percent of total billed charges,Implant Device,24.82,34,,24.82,percent of total billed charges,Implant Device,24.82,34,,24.82,percent of total billed charges,Implant Device,24.82,34,,24.82,percent of total billed charges,Implant Device,24.82,34,,24.82,percent of total billed charges,Implant Device,36.14,,,36.14,Other,110% of Medicare,25.55,35,,25.55,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,25.55,35,,25.55,percent of total billed charges,Implant Device,25.55,35,,25.55,percent of total billed charges,Implant Device,25.55,35,,25.55,percent of total billed charges,Implant Device,25.55,35,,25.55,percent of total billed charges,Implant Device,25.55,35,,25.55,percent of total billed charges,Implant Device,29.2,40,,29.2,percent of total billed charges,Implant Device,25.55,70,,25.55,percent of total billed charges,All Other,24.82,34,,24.82,percent of total billed charges,Implant Device,24.82,34,,24.82,percent of total billed charges,Implant Device,25.55,35,,25.55,percent of total billed charges,Implant Device,25.55,35,,25.55,percent of total billed charges,Implant Device,25.55,35,,25.55,percent of total billed charges,Implant Device,25.55,35,,25.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,54.02,
SYNTHES 206.018 CANCELLOUS SCREW 4X18MM,C1713,HCPCS,,79005855,CDM,278,RC,,,both,,,68,50.32,,,50.32,Other,150% of Medicare + 9.63% HCRA Surcharge,30.6,45,,30.6,percent of total billed charges,Critical Access Hospital RCC factor,23.12,34,,23.12,percent of total billed charges,Implant Device,23.12,34,,23.12,percent of total billed charges,Implant Device,23.12,34,,23.12,percent of total billed charges,Implant Device,23.12,34,,23.12,percent of total billed charges,Implant Device,23.12,34,,23.12,percent of total billed charges,Implant Device,33.66,,,33.66,Other,110% of Medicare,23.8,35,,23.8,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,23.8,35,,23.8,percent of total billed charges,Implant Device,23.8,35,,23.8,percent of total billed charges,Implant Device,23.8,35,,23.8,percent of total billed charges,Implant Device,23.8,35,,23.8,percent of total billed charges,Implant Device,23.8,35,,23.8,percent of total billed charges,Implant Device,27.2,40,,27.2,percent of total billed charges,Implant Device,23.8,70,,23.8,percent of total billed charges,All Other,23.12,34,,23.12,percent of total billed charges,Implant Device,23.12,34,,23.12,percent of total billed charges,Implant Device,23.8,35,,23.8,percent of total billed charges,Implant Device,23.8,35,,23.8,percent of total billed charges,Implant Device,23.8,35,,23.8,percent of total billed charges,Implant Device,23.8,35,,23.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,50.32,
SYNTHES 206.020 CANCELLOUS SCREW 4X20MM,C1713,HCPCS,,79005856,CDM,278,RC,,,both,,,59,43.66,,,43.66,Other,150% of Medicare + 9.63% HCRA Surcharge,26.55,45,,26.55,percent of total billed charges,Critical Access Hospital RCC factor,20.06,34,,20.06,percent of total billed charges,Implant Device,20.06,34,,20.06,percent of total billed charges,Implant Device,20.06,34,,20.06,percent of total billed charges,Implant Device,20.06,34,,20.06,percent of total billed charges,Implant Device,20.06,34,,20.06,percent of total billed charges,Implant Device,29.21,,,29.21,Other,110% of Medicare,20.65,35,,20.65,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,20.65,35,,20.65,percent of total billed charges,Implant Device,20.65,35,,20.65,percent of total billed charges,Implant Device,20.65,35,,20.65,percent of total billed charges,Implant Device,20.65,35,,20.65,percent of total billed charges,Implant Device,20.65,35,,20.65,percent of total billed charges,Implant Device,23.6,40,,23.6,percent of total billed charges,Implant Device,20.65,70,,20.65,percent of total billed charges,All Other,20.06,34,,20.06,percent of total billed charges,Implant Device,20.06,34,,20.06,percent of total billed charges,Implant Device,20.65,35,,20.65,percent of total billed charges,Implant Device,20.65,35,,20.65,percent of total billed charges,Implant Device,20.65,35,,20.65,percent of total billed charges,Implant Device,20.65,35,,20.65,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,43.66,
SYNTHES 04.211.220 NAVCLR PLATE 2.4/2.7,C1713,HCPCS,,79005857,CDM,278,RC,,,both,,,4630,3426.21,,,3426.21,Other,150% of Medicare + 9.63% HCRA Surcharge,2083.5,45,,2083.5,percent of total billed charges,Critical Access Hospital RCC factor,1574.2,34,,1574.2,percent of total billed charges,Implant Device,1574.2,34,,1574.2,percent of total billed charges,Implant Device,1574.2,34,,1574.2,percent of total billed charges,Implant Device,1574.2,34,,1574.2,percent of total billed charges,Implant Device,1574.2,34,,1574.2,percent of total billed charges,Implant Device,2291.85,,,2291.85,Other,110% of Medicare,1620.5,35,,1620.5,percent of total billed charges,Implant Device,1574.2,34,"Charges > $500, x 34%",1574.2,percent of total billed charges,Implant Device,1620.5,35,,1620.5,percent of total billed charges,Implant Device,1620.5,35,,1620.5,percent of total billed charges,Implant Device,1620.5,35,,1620.5,percent of total billed charges,Implant Device,1620.5,35,,1620.5,percent of total billed charges,Implant Device,1620.5,35,,1620.5,percent of total billed charges,Implant Device,1852,40,,1852,percent of total billed charges,Implant Device,1620.5,70,,1620.5,percent of total billed charges,All Other,1574.2,34,,1574.2,percent of total billed charges,Implant Device,1574.2,34,,1574.2,percent of total billed charges,Implant Device,1620.5,35,,1620.5,percent of total billed charges,Implant Device,1620.5,35,,1620.5,percent of total billed charges,Implant Device,1620.5,35,,1620.5,percent of total billed charges,Implant Device,1620.5,35,,1620.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1574.2,34,"If Charge > 2,000, then 34 percent",1574.2,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3426.21,
SYNTHES 04.210-118 LOCK VA SCREW 2.4X18,C1713,HCPCS,,79005859,CDM,278,RC,,,both,,,330,244.2,,,244.2,Other,150% of Medicare + 9.63% HCRA Surcharge,148.5,45,,148.5,percent of total billed charges,Critical Access Hospital RCC factor,112.2,34,,112.2,percent of total billed charges,Implant Device,112.2,34,,112.2,percent of total billed charges,Implant Device,112.2,34,,112.2,percent of total billed charges,Implant Device,112.2,34,,112.2,percent of total billed charges,Implant Device,112.2,34,,112.2,percent of total billed charges,Implant Device,163.35,,,163.35,Other,110% of Medicare,115.5,35,,115.5,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,132,40,,132,percent of total billed charges,Implant Device,115.5,70,,115.5,percent of total billed charges,All Other,112.2,34,,112.2,percent of total billed charges,Implant Device,112.2,34,,112.2,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,244.2,
SYNTHES 04.210.120 LOCK VA SCREW 2.4X20,C1713,HCPCS,,79005861,CDM,278,RC,,,both,,,534,395.16,,,395.16,Other,150% of Medicare + 9.63% HCRA Surcharge,240.3,45,,240.3,percent of total billed charges,Critical Access Hospital RCC factor,181.56,34,,181.56,percent of total billed charges,Implant Device,181.56,34,,181.56,percent of total billed charges,Implant Device,181.56,34,,181.56,percent of total billed charges,Implant Device,181.56,34,,181.56,percent of total billed charges,Implant Device,181.56,34,,181.56,percent of total billed charges,Implant Device,264.33,,,264.33,Other,110% of Medicare,186.9,35,,186.9,percent of total billed charges,Implant Device,181.56,34,"Charges > $500, x 34%",181.56,percent of total billed charges,Implant Device,186.9,35,,186.9,percent of total billed charges,Implant Device,186.9,35,,186.9,percent of total billed charges,Implant Device,186.9,35,,186.9,percent of total billed charges,Implant Device,186.9,35,,186.9,percent of total billed charges,Implant Device,186.9,35,,186.9,percent of total billed charges,Implant Device,213.6,40,,213.6,percent of total billed charges,Implant Device,186.9,70,,186.9,percent of total billed charges,All Other,181.56,34,,181.56,percent of total billed charges,Implant Device,181.56,34,,181.56,percent of total billed charges,Implant Device,186.9,35,,186.9,percent of total billed charges,Implant Device,186.9,35,,186.9,percent of total billed charges,Implant Device,186.9,35,,186.9,percent of total billed charges,Implant Device,186.9,35,,186.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,395.16,
SYNTHES 04.210-112 LOCK VA SCREW 2.4X14,C1713,HCPCS,,79005862,CDM,278,RC,,,both,,,534,395.16,,,395.16,Other,150% of Medicare + 9.63% HCRA Surcharge,240.3,45,,240.3,percent of total billed charges,Critical Access Hospital RCC factor,181.56,34,,181.56,percent of total billed charges,Implant Device,181.56,34,,181.56,percent of total billed charges,Implant Device,181.56,34,,181.56,percent of total billed charges,Implant Device,181.56,34,,181.56,percent of total billed charges,Implant Device,181.56,34,,181.56,percent of total billed charges,Implant Device,264.33,,,264.33,Other,110% of Medicare,186.9,35,,186.9,percent of total billed charges,Implant Device,181.56,34,"Charges > $500, x 34%",181.56,percent of total billed charges,Implant Device,186.9,35,,186.9,percent of total billed charges,Implant Device,186.9,35,,186.9,percent of total billed charges,Implant Device,186.9,35,,186.9,percent of total billed charges,Implant Device,186.9,35,,186.9,percent of total billed charges,Implant Device,186.9,35,,186.9,percent of total billed charges,Implant Device,213.6,40,,213.6,percent of total billed charges,Implant Device,186.9,70,,186.9,percent of total billed charges,All Other,181.56,34,,181.56,percent of total billed charges,Implant Device,181.56,34,,181.56,percent of total billed charges,Implant Device,186.9,35,,186.9,percent of total billed charges,Implant Device,186.9,35,,186.9,percent of total billed charges,Implant Device,186.9,35,,186.9,percent of total billed charges,Implant Device,186.9,35,,186.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,395.16,
SYNTHES 04.210.114 LOCK VA SCREW 2.4X14,C1713,HCPCS,,79005863,CDM,278,RC,,,both,,,534,395.16,,,395.16,Other,150% of Medicare + 9.63% HCRA Surcharge,240.3,45,,240.3,percent of total billed charges,Critical Access Hospital RCC factor,181.56,34,,181.56,percent of total billed charges,Implant Device,181.56,34,,181.56,percent of total billed charges,Implant Device,181.56,34,,181.56,percent of total billed charges,Implant Device,181.56,34,,181.56,percent of total billed charges,Implant Device,181.56,34,,181.56,percent of total billed charges,Implant Device,264.33,,,264.33,Other,110% of Medicare,186.9,35,,186.9,percent of total billed charges,Implant Device,181.56,34,"Charges > $500, x 34%",181.56,percent of total billed charges,Implant Device,186.9,35,,186.9,percent of total billed charges,Implant Device,186.9,35,,186.9,percent of total billed charges,Implant Device,186.9,35,,186.9,percent of total billed charges,Implant Device,186.9,35,,186.9,percent of total billed charges,Implant Device,186.9,35,,186.9,percent of total billed charges,Implant Device,213.6,40,,213.6,percent of total billed charges,Implant Device,186.9,70,,186.9,percent of total billed charges,All Other,181.56,34,,181.56,percent of total billed charges,Implant Device,181.56,34,,181.56,percent of total billed charges,Implant Device,186.9,35,,186.9,percent of total billed charges,Implant Device,186.9,35,,186.9,percent of total billed charges,Implant Device,186.9,35,,186.9,percent of total billed charges,Implant Device,186.9,35,,186.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,395.16,
SYNTHES 207.638 CANNULATED SCREW 4X38MM,C1713,HCPCS,,79005864,CDM,278,RC,,,both,,,855,632.7,,,632.7,Other,150% of Medicare + 9.63% HCRA Surcharge,384.75,45,,384.75,percent of total billed charges,Critical Access Hospital RCC factor,290.7,34,,290.7,percent of total billed charges,Implant Device,290.7,34,,290.7,percent of total billed charges,Implant Device,290.7,34,,290.7,percent of total billed charges,Implant Device,290.7,34,,290.7,percent of total billed charges,Implant Device,290.7,34,,290.7,percent of total billed charges,Implant Device,423.23,,,423.23,Other,110% of Medicare,299.25,35,,299.25,percent of total billed charges,Implant Device,290.7,34,"Charges > $500, x 34%",290.7,percent of total billed charges,Implant Device,299.25,35,,299.25,percent of total billed charges,Implant Device,299.25,35,,299.25,percent of total billed charges,Implant Device,299.25,35,,299.25,percent of total billed charges,Implant Device,299.25,35,,299.25,percent of total billed charges,Implant Device,299.25,35,,299.25,percent of total billed charges,Implant Device,342,40,,342,percent of total billed charges,Implant Device,299.25,70,,299.25,percent of total billed charges,All Other,290.7,34,,290.7,percent of total billed charges,Implant Device,290.7,34,,290.7,percent of total billed charges,Implant Device,299.25,35,,299.25,percent of total billed charges,Implant Device,299.25,35,,299.25,percent of total billed charges,Implant Device,299.25,35,,299.25,percent of total billed charges,Implant Device,299.25,35,,299.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,632.7,
SYNTHES 207.644 CANNULATED SCREW 4X44MM,C1713,HCPCS,,79005865,CDM,278,RC,,,both,,,519,384.06,,,384.06,Other,150% of Medicare + 9.63% HCRA Surcharge,233.55,45,,233.55,percent of total billed charges,Critical Access Hospital RCC factor,176.46,34,,176.46,percent of total billed charges,Implant Device,176.46,34,,176.46,percent of total billed charges,Implant Device,176.46,34,,176.46,percent of total billed charges,Implant Device,176.46,34,,176.46,percent of total billed charges,Implant Device,176.46,34,,176.46,percent of total billed charges,Implant Device,256.91,,,256.91,Other,110% of Medicare,181.65,35,,181.65,percent of total billed charges,Implant Device,176.46,34,"Charges > $500, x 34%",176.46,percent of total billed charges,Implant Device,181.65,35,,181.65,percent of total billed charges,Implant Device,181.65,35,,181.65,percent of total billed charges,Implant Device,181.65,35,,181.65,percent of total billed charges,Implant Device,181.65,35,,181.65,percent of total billed charges,Implant Device,181.65,35,,181.65,percent of total billed charges,Implant Device,207.6,40,,207.6,percent of total billed charges,Implant Device,181.65,70,,181.65,percent of total billed charges,All Other,176.46,34,,176.46,percent of total billed charges,Implant Device,176.46,34,,176.46,percent of total billed charges,Implant Device,181.65,35,,181.65,percent of total billed charges,Implant Device,181.65,35,,181.65,percent of total billed charges,Implant Device,181.65,35,,181.65,percent of total billed charges,Implant Device,181.65,35,,181.65,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,384.06,
SYNTHES 219.98 WASHER 7.0MM,C1713,HCPCS,,79005868,CDM,278,RC,,,both,,,66,48.84,,,48.84,Other,150% of Medicare + 9.63% HCRA Surcharge,29.7,45,,29.7,percent of total billed charges,Critical Access Hospital RCC factor,22.44,34,,22.44,percent of total billed charges,Implant Device,22.44,34,,22.44,percent of total billed charges,Implant Device,22.44,34,,22.44,percent of total billed charges,Implant Device,22.44,34,,22.44,percent of total billed charges,Implant Device,22.44,34,,22.44,percent of total billed charges,Implant Device,32.67,,,32.67,Other,110% of Medicare,23.1,35,,23.1,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,23.1,35,,23.1,percent of total billed charges,Implant Device,23.1,35,,23.1,percent of total billed charges,Implant Device,23.1,35,,23.1,percent of total billed charges,Implant Device,23.1,35,,23.1,percent of total billed charges,Implant Device,23.1,35,,23.1,percent of total billed charges,Implant Device,26.4,40,,26.4,percent of total billed charges,Implant Device,23.1,70,,23.1,percent of total billed charges,All Other,22.44,34,,22.44,percent of total billed charges,Implant Device,22.44,34,,22.44,percent of total billed charges,Implant Device,23.1,35,,23.1,percent of total billed charges,Implant Device,23.1,35,,23.1,percent of total billed charges,Implant Device,23.1,35,,23.1,percent of total billed charges,Implant Device,23.1,35,,23.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,48.84,
STRYKER 59-23014 BONE SCREW 2.3X14MM,C1713,HCPCS,,79005869,CDM,278,RC,,,both,,,459,339.66,,,339.66,Other,150% of Medicare + 9.63% HCRA Surcharge,206.55,45,,206.55,percent of total billed charges,Critical Access Hospital RCC factor,156.06,34,,156.06,percent of total billed charges,Implant Device,156.06,34,,156.06,percent of total billed charges,Implant Device,156.06,34,,156.06,percent of total billed charges,Implant Device,156.06,34,,156.06,percent of total billed charges,Implant Device,156.06,34,,156.06,percent of total billed charges,Implant Device,227.21,,,227.21,Other,110% of Medicare,160.65,35,,160.65,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,160.65,35,,160.65,percent of total billed charges,Implant Device,160.65,35,,160.65,percent of total billed charges,Implant Device,160.65,35,,160.65,percent of total billed charges,Implant Device,160.65,35,,160.65,percent of total billed charges,Implant Device,160.65,35,,160.65,percent of total billed charges,Implant Device,183.6,40,,183.6,percent of total billed charges,Implant Device,160.65,70,,160.65,percent of total billed charges,All Other,156.06,34,,156.06,percent of total billed charges,Implant Device,156.06,34,,156.06,percent of total billed charges,Implant Device,160.65,35,,160.65,percent of total billed charges,Implant Device,160.65,35,,160.65,percent of total billed charges,Implant Device,160.65,35,,160.65,percent of total billed charges,Implant Device,160.65,35,,160.65,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,339.66,
STRYKER 59-23018 BONE SCREW 2.3X18MM,C1713,HCPCS,,79005870,CDM,278,RC,,,both,,,331,244.94,,,244.94,Other,150% of Medicare + 9.63% HCRA Surcharge,148.95,45,,148.95,percent of total billed charges,Critical Access Hospital RCC factor,112.54,34,,112.54,percent of total billed charges,Implant Device,112.54,34,,112.54,percent of total billed charges,Implant Device,112.54,34,,112.54,percent of total billed charges,Implant Device,112.54,34,,112.54,percent of total billed charges,Implant Device,112.54,34,,112.54,percent of total billed charges,Implant Device,163.85,,,163.85,Other,110% of Medicare,115.85,35,,115.85,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,115.85,35,,115.85,percent of total billed charges,Implant Device,115.85,35,,115.85,percent of total billed charges,Implant Device,115.85,35,,115.85,percent of total billed charges,Implant Device,115.85,35,,115.85,percent of total billed charges,Implant Device,115.85,35,,115.85,percent of total billed charges,Implant Device,132.4,40,,132.4,percent of total billed charges,Implant Device,115.85,70,,115.85,percent of total billed charges,All Other,112.54,34,,112.54,percent of total billed charges,Implant Device,112.54,34,,112.54,percent of total billed charges,Implant Device,115.85,35,,115.85,percent of total billed charges,Implant Device,115.85,35,,115.85,percent of total billed charges,Implant Device,115.85,35,,115.85,percent of total billed charges,Implant Device,115.85,35,,115.85,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,244.94,
STRYKER 59-23020 BONE SCREW 2.3X20MM,C1713,HCPCS,,79005871,CDM,278,RC,,,both,,,331,244.94,,,244.94,Other,150% of Medicare + 9.63% HCRA Surcharge,148.95,45,,148.95,percent of total billed charges,Critical Access Hospital RCC factor,112.54,34,,112.54,percent of total billed charges,Implant Device,112.54,34,,112.54,percent of total billed charges,Implant Device,112.54,34,,112.54,percent of total billed charges,Implant Device,112.54,34,,112.54,percent of total billed charges,Implant Device,112.54,34,,112.54,percent of total billed charges,Implant Device,163.85,,,163.85,Other,110% of Medicare,115.85,35,,115.85,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,115.85,35,,115.85,percent of total billed charges,Implant Device,115.85,35,,115.85,percent of total billed charges,Implant Device,115.85,35,,115.85,percent of total billed charges,Implant Device,115.85,35,,115.85,percent of total billed charges,Implant Device,115.85,35,,115.85,percent of total billed charges,Implant Device,132.4,40,,132.4,percent of total billed charges,Implant Device,115.85,70,,115.85,percent of total billed charges,All Other,112.54,34,,112.54,percent of total billed charges,Implant Device,112.54,34,,112.54,percent of total billed charges,Implant Device,115.85,35,,115.85,percent of total billed charges,Implant Device,115.85,35,,115.85,percent of total billed charges,Implant Device,115.85,35,,115.85,percent of total billed charges,Implant Device,115.85,35,,115.85,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,244.94,
STRYKER 59-23022 BONE SCREW 2.3X22MM,C1713,HCPCS,,79005872,CDM,278,RC,,,both,,,331,244.94,,,244.94,Other,150% of Medicare + 9.63% HCRA Surcharge,148.95,45,,148.95,percent of total billed charges,Critical Access Hospital RCC factor,112.54,34,,112.54,percent of total billed charges,Implant Device,112.54,34,,112.54,percent of total billed charges,Implant Device,112.54,34,,112.54,percent of total billed charges,Implant Device,112.54,34,,112.54,percent of total billed charges,Implant Device,112.54,34,,112.54,percent of total billed charges,Implant Device,163.85,,,163.85,Other,110% of Medicare,115.85,35,,115.85,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,115.85,35,,115.85,percent of total billed charges,Implant Device,115.85,35,,115.85,percent of total billed charges,Implant Device,115.85,35,,115.85,percent of total billed charges,Implant Device,115.85,35,,115.85,percent of total billed charges,Implant Device,115.85,35,,115.85,percent of total billed charges,Implant Device,132.4,40,,132.4,percent of total billed charges,Implant Device,115.85,70,,115.85,percent of total billed charges,All Other,112.54,34,,112.54,percent of total billed charges,Implant Device,112.54,34,,112.54,percent of total billed charges,Implant Device,115.85,35,,115.85,percent of total billed charges,Implant Device,115.85,35,,115.85,percent of total billed charges,Implant Device,115.85,35,,115.85,percent of total billed charges,Implant Device,115.85,35,,115.85,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,244.94,
STRYKER 59-17012 BONE SCREW 1.7X12MM,C1713,HCPCS,,79005873,CDM,278,RC,,,both,,,331,244.94,,,244.94,Other,150% of Medicare + 9.63% HCRA Surcharge,148.95,45,,148.95,percent of total billed charges,Critical Access Hospital RCC factor,112.54,34,,112.54,percent of total billed charges,Implant Device,112.54,34,,112.54,percent of total billed charges,Implant Device,112.54,34,,112.54,percent of total billed charges,Implant Device,112.54,34,,112.54,percent of total billed charges,Implant Device,112.54,34,,112.54,percent of total billed charges,Implant Device,163.85,,,163.85,Other,110% of Medicare,115.85,35,,115.85,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,115.85,35,,115.85,percent of total billed charges,Implant Device,115.85,35,,115.85,percent of total billed charges,Implant Device,115.85,35,,115.85,percent of total billed charges,Implant Device,115.85,35,,115.85,percent of total billed charges,Implant Device,115.85,35,,115.85,percent of total billed charges,Implant Device,132.4,40,,132.4,percent of total billed charges,Implant Device,115.85,70,,115.85,percent of total billed charges,All Other,112.54,34,,112.54,percent of total billed charges,Implant Device,112.54,34,,112.54,percent of total billed charges,Implant Device,115.85,35,,115.85,percent of total billed charges,Implant Device,115.85,35,,115.85,percent of total billed charges,Implant Device,115.85,35,,115.85,percent of total billed charges,Implant Device,115.85,35,,115.85,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,244.94,
STRYKER 5038-2-110 PIN 3 X 110MM,C1713,HCPCS,,79005874,CDM,278,RC,,,both,,,174,128.76,,,128.76,Other,150% of Medicare + 9.63% HCRA Surcharge,78.3,45,,78.3,percent of total billed charges,Critical Access Hospital RCC factor,59.16,34,,59.16,percent of total billed charges,Implant Device,59.16,34,,59.16,percent of total billed charges,Implant Device,59.16,34,,59.16,percent of total billed charges,Implant Device,59.16,34,,59.16,percent of total billed charges,Implant Device,59.16,34,,59.16,percent of total billed charges,Implant Device,86.13,,,86.13,Other,110% of Medicare,60.9,35,,60.9,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,60.9,35,,60.9,percent of total billed charges,Implant Device,60.9,35,,60.9,percent of total billed charges,Implant Device,60.9,35,,60.9,percent of total billed charges,Implant Device,60.9,35,,60.9,percent of total billed charges,Implant Device,60.9,35,,60.9,percent of total billed charges,Implant Device,69.6,40,,69.6,percent of total billed charges,Implant Device,60.9,70,,60.9,percent of total billed charges,All Other,59.16,34,,59.16,percent of total billed charges,Implant Device,59.16,34,,59.16,percent of total billed charges,Implant Device,60.9,35,,60.9,percent of total billed charges,Implant Device,60.9,35,,60.9,percent of total billed charges,Implant Device,60.9,35,,60.9,percent of total billed charges,Implant Device,60.9,35,,60.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,128.76,
STRYKER 57-13402 COMPRESSION PLATE,C1713,HCPCS,,79005877,CDM,278,RC,,,both,,,803,594.22,,,594.22,Other,150% of Medicare + 9.63% HCRA Surcharge,361.35,45,,361.35,percent of total billed charges,Critical Access Hospital RCC factor,273.02,34,,273.02,percent of total billed charges,Implant Device,273.02,34,,273.02,percent of total billed charges,Implant Device,273.02,34,,273.02,percent of total billed charges,Implant Device,273.02,34,,273.02,percent of total billed charges,Implant Device,273.02,34,,273.02,percent of total billed charges,Implant Device,397.49,,,397.49,Other,110% of Medicare,281.05,35,,281.05,percent of total billed charges,Implant Device,273.02,34,"Charges > $500, x 34%",273.02,percent of total billed charges,Implant Device,281.05,35,,281.05,percent of total billed charges,Implant Device,281.05,35,,281.05,percent of total billed charges,Implant Device,281.05,35,,281.05,percent of total billed charges,Implant Device,281.05,35,,281.05,percent of total billed charges,Implant Device,281.05,35,,281.05,percent of total billed charges,Implant Device,321.2,40,,321.2,percent of total billed charges,Implant Device,281.05,70,,281.05,percent of total billed charges,All Other,273.02,34,,273.02,percent of total billed charges,Implant Device,273.02,34,,273.02,percent of total billed charges,Implant Device,281.05,35,,281.05,percent of total billed charges,Implant Device,281.05,35,,281.05,percent of total billed charges,Implant Device,281.05,35,,281.05,percent of total billed charges,Implant Device,281.05,35,,281.05,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,594.22,
STRYKER PLP21342 LAPIDUS PLATE STEP 1 RT,C1713,HCPCS,,79005878,CDM,278,RC,,,both,,,5836,4318.65,,,4318.65,Other,150% of Medicare + 9.63% HCRA Surcharge,2626.2,45,,2626.2,percent of total billed charges,Critical Access Hospital RCC factor,1984.24,34,,1984.24,percent of total billed charges,Implant Device,1984.24,34,,1984.24,percent of total billed charges,Implant Device,1984.24,34,,1984.24,percent of total billed charges,Implant Device,1984.24,34,,1984.24,percent of total billed charges,Implant Device,1984.24,34,,1984.24,percent of total billed charges,Implant Device,2888.82,,,2888.82,Other,110% of Medicare,2042.6,35,,2042.6,percent of total billed charges,Implant Device,1984.24,34,"Charges > $500, x 34%",1984.24,percent of total billed charges,Implant Device,2042.6,35,,2042.6,percent of total billed charges,Implant Device,2042.6,35,,2042.6,percent of total billed charges,Implant Device,2042.6,35,,2042.6,percent of total billed charges,Implant Device,2042.6,35,,2042.6,percent of total billed charges,Implant Device,2042.6,35,,2042.6,percent of total billed charges,Implant Device,2334.4,40,,2334.4,percent of total billed charges,Implant Device,2042.6,70,,2042.6,percent of total billed charges,All Other,1984.24,34,,1984.24,percent of total billed charges,Implant Device,1984.24,34,,1984.24,percent of total billed charges,Implant Device,2042.6,35,,2042.6,percent of total billed charges,Implant Device,2042.6,35,,2042.6,percent of total billed charges,Implant Device,2042.6,35,,2042.6,percent of total billed charges,Implant Device,2042.6,35,,2042.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1984.24,34,"If Charge > 2,000, then 34 percent",1984.24,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4318.65,
STRYKER PLSL3014 LOCKING SCREW T8 3X14MM,C1713,HCPCS,,79005879,CDM,278,RC,,,both,,,1119,828.06,,,828.06,Other,150% of Medicare + 9.63% HCRA Surcharge,503.55,45,,503.55,percent of total billed charges,Critical Access Hospital RCC factor,380.46,34,,380.46,percent of total billed charges,Implant Device,380.46,34,,380.46,percent of total billed charges,Implant Device,380.46,34,,380.46,percent of total billed charges,Implant Device,380.46,34,,380.46,percent of total billed charges,Implant Device,380.46,34,,380.46,percent of total billed charges,Implant Device,553.91,,,553.91,Other,110% of Medicare,391.65,35,,391.65,percent of total billed charges,Implant Device,380.46,34,"Charges > $500, x 34%",380.46,percent of total billed charges,Implant Device,391.65,35,,391.65,percent of total billed charges,Implant Device,391.65,35,,391.65,percent of total billed charges,Implant Device,391.65,35,,391.65,percent of total billed charges,Implant Device,391.65,35,,391.65,percent of total billed charges,Implant Device,391.65,35,,391.65,percent of total billed charges,Implant Device,447.6,40,,447.6,percent of total billed charges,Implant Device,391.65,70,,391.65,percent of total billed charges,All Other,380.46,34,,380.46,percent of total billed charges,Implant Device,380.46,34,,380.46,percent of total billed charges,Implant Device,391.65,35,,391.65,percent of total billed charges,Implant Device,391.65,35,,391.65,percent of total billed charges,Implant Device,391.65,35,,391.65,percent of total billed charges,Implant Device,391.65,35,,391.65,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,828.06,
STRYKER PLSS3026 NONLOCK SCREW T8 3X26MM,C1713,HCPCS,,79005880,CDM,278,RC,,,both,,,570,421.8,,,421.8,Other,150% of Medicare + 9.63% HCRA Surcharge,256.5,45,,256.5,percent of total billed charges,Critical Access Hospital RCC factor,193.8,34,,193.8,percent of total billed charges,Implant Device,193.8,34,,193.8,percent of total billed charges,Implant Device,193.8,34,,193.8,percent of total billed charges,Implant Device,193.8,34,,193.8,percent of total billed charges,Implant Device,193.8,34,,193.8,percent of total billed charges,Implant Device,282.15,,,282.15,Other,110% of Medicare,199.5,35,,199.5,percent of total billed charges,Implant Device,193.8,34,"Charges > $500, x 34%",193.8,percent of total billed charges,Implant Device,199.5,35,,199.5,percent of total billed charges,Implant Device,199.5,35,,199.5,percent of total billed charges,Implant Device,199.5,35,,199.5,percent of total billed charges,Implant Device,199.5,35,,199.5,percent of total billed charges,Implant Device,199.5,35,,199.5,percent of total billed charges,Implant Device,228,40,,228,percent of total billed charges,Implant Device,199.5,70,,199.5,percent of total billed charges,All Other,193.8,34,,193.8,percent of total billed charges,Implant Device,193.8,34,,193.8,percent of total billed charges,Implant Device,199.5,35,,199.5,percent of total billed charges,Implant Device,199.5,35,,199.5,percent of total billed charges,Implant Device,199.5,35,,199.5,percent of total billed charges,Implant Device,199.5,35,,199.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,421.8,
STRYKER PLSS3022 NONLOCK SCREW T8 3X22MM,C1713,HCPCS,,79005881,CDM,278,RC,,,both,,,570,421.8,,,421.8,Other,150% of Medicare + 9.63% HCRA Surcharge,256.5,45,,256.5,percent of total billed charges,Critical Access Hospital RCC factor,193.8,34,,193.8,percent of total billed charges,Implant Device,193.8,34,,193.8,percent of total billed charges,Implant Device,193.8,34,,193.8,percent of total billed charges,Implant Device,193.8,34,,193.8,percent of total billed charges,Implant Device,193.8,34,,193.8,percent of total billed charges,Implant Device,282.15,,,282.15,Other,110% of Medicare,199.5,35,,199.5,percent of total billed charges,Implant Device,193.8,34,"Charges > $500, x 34%",193.8,percent of total billed charges,Implant Device,199.5,35,,199.5,percent of total billed charges,Implant Device,199.5,35,,199.5,percent of total billed charges,Implant Device,199.5,35,,199.5,percent of total billed charges,Implant Device,199.5,35,,199.5,percent of total billed charges,Implant Device,199.5,35,,199.5,percent of total billed charges,Implant Device,228,40,,228,percent of total billed charges,Implant Device,199.5,70,,199.5,percent of total billed charges,All Other,193.8,34,,193.8,percent of total billed charges,Implant Device,193.8,34,,193.8,percent of total billed charges,Implant Device,199.5,35,,199.5,percent of total billed charges,Implant Device,199.5,35,,199.5,percent of total billed charges,Implant Device,199.5,35,,199.5,percent of total billed charges,Implant Device,199.5,35,,199.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,421.8,
STRYKER 59-23049 WASHER,C1713,HCPCS,,79005884,CDM,278,RC,,,both,,,194,143.56,,,143.56,Other,150% of Medicare + 9.63% HCRA Surcharge,87.3,45,,87.3,percent of total billed charges,Critical Access Hospital RCC factor,65.96,34,,65.96,percent of total billed charges,Implant Device,65.96,34,,65.96,percent of total billed charges,Implant Device,65.96,34,,65.96,percent of total billed charges,Implant Device,65.96,34,,65.96,percent of total billed charges,Implant Device,65.96,34,,65.96,percent of total billed charges,Implant Device,96.03,,,96.03,Other,110% of Medicare,67.9,35,,67.9,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,67.9,35,,67.9,percent of total billed charges,Implant Device,67.9,35,,67.9,percent of total billed charges,Implant Device,67.9,35,,67.9,percent of total billed charges,Implant Device,67.9,35,,67.9,percent of total billed charges,Implant Device,67.9,35,,67.9,percent of total billed charges,Implant Device,77.6,40,,77.6,percent of total billed charges,Implant Device,67.9,70,,67.9,percent of total billed charges,All Other,65.96,34,,65.96,percent of total billed charges,Implant Device,65.96,34,,65.96,percent of total billed charges,Implant Device,67.9,35,,67.9,percent of total billed charges,Implant Device,67.9,35,,67.9,percent of total billed charges,Implant Device,67.9,35,,67.9,percent of total billed charges,Implant Device,67.9,35,,67.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,143.56,
ALLERGAN 133FX-14T TISSUE EXPANDER,C1789,HCPCS,,79005886,CDM,278,RC,,,both,,,4650,3441.01,,,3441.01,Other,150% of Medicare + 9.63% HCRA Surcharge,2092.5,45,,2092.5,percent of total billed charges,Critical Access Hospital RCC factor,1581,34,,1581,percent of total billed charges,Implant Device,1581,34,,1581,percent of total billed charges,Implant Device,1581,34,,1581,percent of total billed charges,Implant Device,1581,34,,1581,percent of total billed charges,Implant Device,1581,34,,1581,percent of total billed charges,Implant Device,2301.75,,,2301.75,Other,110% of Medicare,1627.5,35,,1627.5,percent of total billed charges,Implant Device,1581,34,"Charges > $500, x 34%",1581,percent of total billed charges,Implant Device,1627.5,35,,1627.5,percent of total billed charges,Implant Device,1627.5,35,,1627.5,percent of total billed charges,Implant Device,1627.5,35,,1627.5,percent of total billed charges,Implant Device,1627.5,35,,1627.5,percent of total billed charges,Implant Device,1627.5,35,,1627.5,percent of total billed charges,Implant Device,1860,40,,1860,percent of total billed charges,Implant Device,1627.5,70,,1627.5,percent of total billed charges,All Other,1581,34,,1581,percent of total billed charges,Implant Device,1581,34,,1581,percent of total billed charges,Implant Device,1627.5,35,,1627.5,percent of total billed charges,Implant Device,1627.5,35,,1627.5,percent of total billed charges,Implant Device,1627.5,35,,1627.5,percent of total billed charges,Implant Device,1627.5,35,,1627.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1581,34,"If Charge > 2,000, then 34 percent",1581,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3441.01,
ALLERGAN FM410550 SILICONE IMPLANT,C1789,HCPCS,,79005887,CDM,278,RC,,,both,,,3976,2942.25,,,2942.25,Other,150% of Medicare + 9.63% HCRA Surcharge,1789.2,45,,1789.2,percent of total billed charges,Critical Access Hospital RCC factor,1351.84,34,,1351.84,percent of total billed charges,Implant Device,1351.84,34,,1351.84,percent of total billed charges,Implant Device,1351.84,34,,1351.84,percent of total billed charges,Implant Device,1351.84,34,,1351.84,percent of total billed charges,Implant Device,1351.84,34,,1351.84,percent of total billed charges,Implant Device,1968.12,,,1968.12,Other,110% of Medicare,1391.6,35,,1391.6,percent of total billed charges,Implant Device,1351.84,34,"Charges > $500, x 34%",1351.84,percent of total billed charges,Implant Device,1391.6,35,,1391.6,percent of total billed charges,Implant Device,1391.6,35,,1391.6,percent of total billed charges,Implant Device,1391.6,35,,1391.6,percent of total billed charges,Implant Device,1391.6,35,,1391.6,percent of total billed charges,Implant Device,1391.6,35,,1391.6,percent of total billed charges,Implant Device,1590.4,40,,1590.4,percent of total billed charges,Implant Device,1391.6,70,,1391.6,percent of total billed charges,All Other,1351.84,34,,1351.84,percent of total billed charges,Implant Device,1351.84,34,,1351.84,percent of total billed charges,Implant Device,1391.6,35,,1391.6,percent of total billed charges,Implant Device,1391.6,35,,1391.6,percent of total billed charges,Implant Device,1391.6,35,,1391.6,percent of total billed charges,Implant Device,1391.6,35,,1391.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1351.84,34,"If Charge > 2,000, then 34 percent",1351.84,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2942.25,
ALLERGAN FM410605 SILICONE IMPLANT,C1789,HCPCS,,79005888,CDM,278,RC,,,both,,,3976,2942.25,,,2942.25,Other,150% of Medicare + 9.63% HCRA Surcharge,1789.2,45,,1789.2,percent of total billed charges,Critical Access Hospital RCC factor,1351.84,34,,1351.84,percent of total billed charges,Implant Device,1351.84,34,,1351.84,percent of total billed charges,Implant Device,1351.84,34,,1351.84,percent of total billed charges,Implant Device,1351.84,34,,1351.84,percent of total billed charges,Implant Device,1351.84,34,,1351.84,percent of total billed charges,Implant Device,1968.12,,,1968.12,Other,110% of Medicare,1391.6,35,,1391.6,percent of total billed charges,Implant Device,1351.84,34,"Charges > $500, x 34%",1351.84,percent of total billed charges,Implant Device,1391.6,35,,1391.6,percent of total billed charges,Implant Device,1391.6,35,,1391.6,percent of total billed charges,Implant Device,1391.6,35,,1391.6,percent of total billed charges,Implant Device,1391.6,35,,1391.6,percent of total billed charges,Implant Device,1391.6,35,,1391.6,percent of total billed charges,Implant Device,1590.4,40,,1590.4,percent of total billed charges,Implant Device,1391.6,70,,1391.6,percent of total billed charges,All Other,1351.84,34,,1351.84,percent of total billed charges,Implant Device,1351.84,34,,1351.84,percent of total billed charges,Implant Device,1391.6,35,,1391.6,percent of total billed charges,Implant Device,1391.6,35,,1391.6,percent of total billed charges,Implant Device,1391.6,35,,1391.6,percent of total billed charges,Implant Device,1391.6,35,,1391.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1351.84,34,"If Charge > 2,000, then 34 percent",1351.84,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2942.25,
ALLERGAN FM410655 SILICONE IMPLANT,C1789,HCPCS,,79005889,CDM,278,RC,,,both,,,3976,2942.25,,,2942.25,Other,150% of Medicare + 9.63% HCRA Surcharge,1789.2,45,,1789.2,percent of total billed charges,Critical Access Hospital RCC factor,1351.84,34,,1351.84,percent of total billed charges,Implant Device,1351.84,34,,1351.84,percent of total billed charges,Implant Device,1351.84,34,,1351.84,percent of total billed charges,Implant Device,1351.84,34,,1351.84,percent of total billed charges,Implant Device,1351.84,34,,1351.84,percent of total billed charges,Implant Device,1968.12,,,1968.12,Other,110% of Medicare,1391.6,35,,1391.6,percent of total billed charges,Implant Device,1351.84,34,"Charges > $500, x 34%",1351.84,percent of total billed charges,Implant Device,1391.6,35,,1391.6,percent of total billed charges,Implant Device,1391.6,35,,1391.6,percent of total billed charges,Implant Device,1391.6,35,,1391.6,percent of total billed charges,Implant Device,1391.6,35,,1391.6,percent of total billed charges,Implant Device,1391.6,35,,1391.6,percent of total billed charges,Implant Device,1590.4,40,,1590.4,percent of total billed charges,Implant Device,1391.6,70,,1391.6,percent of total billed charges,All Other,1351.84,34,,1351.84,percent of total billed charges,Implant Device,1351.84,34,,1351.84,percent of total billed charges,Implant Device,1391.6,35,,1391.6,percent of total billed charges,Implant Device,1391.6,35,,1391.6,percent of total billed charges,Implant Device,1391.6,35,,1391.6,percent of total billed charges,Implant Device,1391.6,35,,1391.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1351.84,34,"If Charge > 2,000, then 34 percent",1351.84,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2942.25,
STRYKER 1851-1244S FEMORAL NAIL 12X440MM,C1713,HCPCS,,79005891,CDM,278,RC,,,both,,,7640,5653.62,,,5653.62,Other,150% of Medicare + 9.63% HCRA Surcharge,3438,45,,3438,percent of total billed charges,Critical Access Hospital RCC factor,2597.6,34,,2597.6,percent of total billed charges,Implant Device,2597.6,34,,2597.6,percent of total billed charges,Implant Device,2597.6,34,,2597.6,percent of total billed charges,Implant Device,2597.6,34,,2597.6,percent of total billed charges,Implant Device,2597.6,34,,2597.6,percent of total billed charges,Implant Device,3781.8,,,3781.8,Other,110% of Medicare,2674,35,,2674,percent of total billed charges,Implant Device,2597.6,34,"Charges > $500, x 34%",2597.6,percent of total billed charges,Implant Device,2674,35,,2674,percent of total billed charges,Implant Device,2674,35,,2674,percent of total billed charges,Implant Device,2674,35,,2674,percent of total billed charges,Implant Device,2674,35,,2674,percent of total billed charges,Implant Device,2674,35,,2674,percent of total billed charges,Implant Device,3056,40,,3056,percent of total billed charges,Implant Device,2674,70,,2674,percent of total billed charges,All Other,2597.6,34,,2597.6,percent of total billed charges,Implant Device,2597.6,34,,2597.6,percent of total billed charges,Implant Device,2674,35,,2674,percent of total billed charges,Implant Device,2674,35,,2674,percent of total billed charges,Implant Device,2674,35,,2674,percent of total billed charges,Implant Device,2674,35,,2674,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2597.6,34,"If Charge > 2,000, then 34 percent",2597.6,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5653.62,
STRYKER 1896-5060S LOCKING SCREW FT 5X55,C1713,HCPCS,,79005892,CDM,278,RC,,,both,,,441,326.34,,,326.34,Other,150% of Medicare + 9.63% HCRA Surcharge,198.45,45,,198.45,percent of total billed charges,Critical Access Hospital RCC factor,149.94,34,,149.94,percent of total billed charges,Implant Device,149.94,34,,149.94,percent of total billed charges,Implant Device,149.94,34,,149.94,percent of total billed charges,Implant Device,149.94,34,,149.94,percent of total billed charges,Implant Device,149.94,34,,149.94,percent of total billed charges,Implant Device,218.3,,,218.3,Other,110% of Medicare,154.35,35,,154.35,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,154.35,35,,154.35,percent of total billed charges,Implant Device,154.35,35,,154.35,percent of total billed charges,Implant Device,154.35,35,,154.35,percent of total billed charges,Implant Device,154.35,35,,154.35,percent of total billed charges,Implant Device,154.35,35,,154.35,percent of total billed charges,Implant Device,176.4,40,,176.4,percent of total billed charges,Implant Device,154.35,70,,154.35,percent of total billed charges,All Other,149.94,34,,149.94,percent of total billed charges,Implant Device,149.94,34,,149.94,percent of total billed charges,Implant Device,154.35,35,,154.35,percent of total billed charges,Implant Device,154.35,35,,154.35,percent of total billed charges,Implant Device,154.35,35,,154.35,percent of total billed charges,Implant Device,154.35,35,,154.35,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,326.34,
SYNTHES 207.724 CANNULATED SCREW 4X24MM,C1713,HCPCS,,79005893,CDM,278,RC,,,both,,,685,506.9,,,506.9,Other,150% of Medicare + 9.63% HCRA Surcharge,308.25,45,,308.25,percent of total billed charges,Critical Access Hospital RCC factor,232.9,34,,232.9,percent of total billed charges,Implant Device,232.9,34,,232.9,percent of total billed charges,Implant Device,232.9,34,,232.9,percent of total billed charges,Implant Device,232.9,34,,232.9,percent of total billed charges,Implant Device,232.9,34,,232.9,percent of total billed charges,Implant Device,339.08,,,339.08,Other,110% of Medicare,239.75,35,,239.75,percent of total billed charges,Implant Device,232.9,34,"Charges > $500, x 34%",232.9,percent of total billed charges,Implant Device,239.75,35,,239.75,percent of total billed charges,Implant Device,239.75,35,,239.75,percent of total billed charges,Implant Device,239.75,35,,239.75,percent of total billed charges,Implant Device,239.75,35,,239.75,percent of total billed charges,Implant Device,239.75,35,,239.75,percent of total billed charges,Implant Device,274,40,,274,percent of total billed charges,Implant Device,239.75,70,,239.75,percent of total billed charges,All Other,232.9,34,,232.9,percent of total billed charges,Implant Device,232.9,34,,232.9,percent of total billed charges,Implant Device,239.75,35,,239.75,percent of total billed charges,Implant Device,239.75,35,,239.75,percent of total billed charges,Implant Device,239.75,35,,239.75,percent of total billed charges,Implant Device,239.75,35,,239.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,506.9,
STRYKER 1822-0930S TIBIAL NAIL 9X300MM,C1713,HCPCS,,79005895,CDM,278,RC,,,both,,,7143,5285.84,,,5285.84,Other,150% of Medicare + 9.63% HCRA Surcharge,3214.35,45,,3214.35,percent of total billed charges,Critical Access Hospital RCC factor,2428.62,34,,2428.62,percent of total billed charges,Implant Device,2428.62,34,,2428.62,percent of total billed charges,Implant Device,2428.62,34,,2428.62,percent of total billed charges,Implant Device,2428.62,34,,2428.62,percent of total billed charges,Implant Device,2428.62,34,,2428.62,percent of total billed charges,Implant Device,3535.79,,,3535.79,Other,110% of Medicare,2500.05,35,,2500.05,percent of total billed charges,Implant Device,2428.62,34,"Charges > $500, x 34%",2428.62,percent of total billed charges,Implant Device,2500.05,35,,2500.05,percent of total billed charges,Implant Device,2500.05,35,,2500.05,percent of total billed charges,Implant Device,2500.05,35,,2500.05,percent of total billed charges,Implant Device,2500.05,35,,2500.05,percent of total billed charges,Implant Device,2500.05,35,,2500.05,percent of total billed charges,Implant Device,2857.2,40,,2857.2,percent of total billed charges,Implant Device,2500.05,70,,2500.05,percent of total billed charges,All Other,2428.62,34,,2428.62,percent of total billed charges,Implant Device,2428.62,34,,2428.62,percent of total billed charges,Implant Device,2500.05,35,,2500.05,percent of total billed charges,Implant Device,2500.05,35,,2500.05,percent of total billed charges,Implant Device,2500.05,35,,2500.05,percent of total billed charges,Implant Device,2500.05,35,,2500.05,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2428.62,34,"If Charge > 2,000, then 34 percent",2428.62,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5285.84,
STRYKER 40-20807 7 HOLE VARIAX STR PLATE,C1713,HCPCS,,79005896,CDM,278,RC,,,both,,,1170,865.8,,,865.8,Other,150% of Medicare + 9.63% HCRA Surcharge,526.5,45,,526.5,percent of total billed charges,Critical Access Hospital RCC factor,397.8,34,,397.8,percent of total billed charges,Implant Device,397.8,34,,397.8,percent of total billed charges,Implant Device,397.8,34,,397.8,percent of total billed charges,Implant Device,397.8,34,,397.8,percent of total billed charges,Implant Device,397.8,34,,397.8,percent of total billed charges,Implant Device,579.15,,,579.15,Other,110% of Medicare,409.5,35,,409.5,percent of total billed charges,Implant Device,397.8,34,"Charges > $500, x 34%",397.8,percent of total billed charges,Implant Device,409.5,35,,409.5,percent of total billed charges,Implant Device,409.5,35,,409.5,percent of total billed charges,Implant Device,409.5,35,,409.5,percent of total billed charges,Implant Device,409.5,35,,409.5,percent of total billed charges,Implant Device,409.5,35,,409.5,percent of total billed charges,Implant Device,468,40,,468,percent of total billed charges,Implant Device,409.5,70,,409.5,percent of total billed charges,All Other,397.8,34,,397.8,percent of total billed charges,Implant Device,397.8,34,,397.8,percent of total billed charges,Implant Device,409.5,35,,409.5,percent of total billed charges,Implant Device,409.5,35,,409.5,percent of total billed charges,Implant Device,409.5,35,,409.5,percent of total billed charges,Implant Device,409.5,35,,409.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,865.8,
MENTOR 350-2350 BREAST IMPLANT,C1789,HCPCS,,79005898,CDM,278,RC,,,both,,,2010,1487.41,,,1487.41,Other,150% of Medicare + 9.63% HCRA Surcharge,904.5,45,,904.5,percent of total billed charges,Critical Access Hospital RCC factor,683.4,34,,683.4,percent of total billed charges,Implant Device,683.4,34,,683.4,percent of total billed charges,Implant Device,683.4,34,,683.4,percent of total billed charges,Implant Device,683.4,34,,683.4,percent of total billed charges,Implant Device,683.4,34,,683.4,percent of total billed charges,Implant Device,994.95,,,994.95,Other,110% of Medicare,703.5,35,,703.5,percent of total billed charges,Implant Device,683.4,34,"Charges > $500, x 34%",683.4,percent of total billed charges,Implant Device,703.5,35,,703.5,percent of total billed charges,Implant Device,703.5,35,,703.5,percent of total billed charges,Implant Device,703.5,35,,703.5,percent of total billed charges,Implant Device,703.5,35,,703.5,percent of total billed charges,Implant Device,703.5,35,,703.5,percent of total billed charges,Implant Device,804,40,,804,percent of total billed charges,Implant Device,703.5,70,,703.5,percent of total billed charges,All Other,683.4,34,,683.4,percent of total billed charges,Implant Device,683.4,34,,683.4,percent of total billed charges,Implant Device,703.5,35,,703.5,percent of total billed charges,Implant Device,703.5,35,,703.5,percent of total billed charges,Implant Device,703.5,35,,703.5,percent of total billed charges,Implant Device,703.5,35,,703.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,683.4,34,"If Charge > 2,000, then 34 percent",683.4,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1487.41,
ALLERGAN 133MV-15-T BREAST EXPANDER,C1789,HCPCS,,79005900,CDM,278,RC,,,both,,,4650,3441.01,,,3441.01,Other,150% of Medicare + 9.63% HCRA Surcharge,2092.5,45,,2092.5,percent of total billed charges,Critical Access Hospital RCC factor,1581,34,,1581,percent of total billed charges,Implant Device,1581,34,,1581,percent of total billed charges,Implant Device,1581,34,,1581,percent of total billed charges,Implant Device,1581,34,,1581,percent of total billed charges,Implant Device,1581,34,,1581,percent of total billed charges,Implant Device,2301.75,,,2301.75,Other,110% of Medicare,1627.5,35,,1627.5,percent of total billed charges,Implant Device,1581,34,"Charges > $500, x 34%",1581,percent of total billed charges,Implant Device,1627.5,35,,1627.5,percent of total billed charges,Implant Device,1627.5,35,,1627.5,percent of total billed charges,Implant Device,1627.5,35,,1627.5,percent of total billed charges,Implant Device,1627.5,35,,1627.5,percent of total billed charges,Implant Device,1627.5,35,,1627.5,percent of total billed charges,Implant Device,1860,40,,1860,percent of total billed charges,Implant Device,1627.5,70,,1627.5,percent of total billed charges,All Other,1581,34,,1581,percent of total billed charges,Implant Device,1581,34,,1581,percent of total billed charges,Implant Device,1627.5,35,,1627.5,percent of total billed charges,Implant Device,1627.5,35,,1627.5,percent of total billed charges,Implant Device,1627.5,35,,1627.5,percent of total billed charges,Implant Device,1627.5,35,,1627.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1581,34,"If Charge > 2,000, then 34 percent",1581,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3441.01,
ALLERGAN 133MV-16-T BREAST EXPANDER,C1789,HCPCS,,79005901,CDM,278,RC,,,both,,,4650,3441.01,,,3441.01,Other,150% of Medicare + 9.63% HCRA Surcharge,2092.5,45,,2092.5,percent of total billed charges,Critical Access Hospital RCC factor,1581,34,,1581,percent of total billed charges,Implant Device,1581,34,,1581,percent of total billed charges,Implant Device,1581,34,,1581,percent of total billed charges,Implant Device,1581,34,,1581,percent of total billed charges,Implant Device,1581,34,,1581,percent of total billed charges,Implant Device,2301.75,,,2301.75,Other,110% of Medicare,1627.5,35,,1627.5,percent of total billed charges,Implant Device,1581,34,"Charges > $500, x 34%",1581,percent of total billed charges,Implant Device,1627.5,35,,1627.5,percent of total billed charges,Implant Device,1627.5,35,,1627.5,percent of total billed charges,Implant Device,1627.5,35,,1627.5,percent of total billed charges,Implant Device,1627.5,35,,1627.5,percent of total billed charges,Implant Device,1627.5,35,,1627.5,percent of total billed charges,Implant Device,1860,40,,1860,percent of total billed charges,Implant Device,1627.5,70,,1627.5,percent of total billed charges,All Other,1581,34,,1581,percent of total billed charges,Implant Device,1581,34,,1581,percent of total billed charges,Implant Device,1627.5,35,,1627.5,percent of total billed charges,Implant Device,1627.5,35,,1627.5,percent of total billed charges,Implant Device,1627.5,35,,1627.5,percent of total billed charges,Implant Device,1627.5,35,,1627.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1581,34,"If Charge > 2,000, then 34 percent",1581,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3441.01,
SOLANA LPX2R LAPIDUS CX PLATE 2MM RIGHT,C1713,HCPCS,,79005902,CDM,278,RC,,,both,,,6708,4963.94,,,4963.94,Other,150% of Medicare + 9.63% HCRA Surcharge,3018.6,45,,3018.6,percent of total billed charges,Critical Access Hospital RCC factor,2280.72,34,,2280.72,percent of total billed charges,Implant Device,2280.72,34,,2280.72,percent of total billed charges,Implant Device,2280.72,34,,2280.72,percent of total billed charges,Implant Device,2280.72,34,,2280.72,percent of total billed charges,Implant Device,2280.72,34,,2280.72,percent of total billed charges,Implant Device,3320.46,,,3320.46,Other,110% of Medicare,2347.8,35,,2347.8,percent of total billed charges,Implant Device,2280.72,34,"Charges > $500, x 34%",2280.72,percent of total billed charges,Implant Device,2347.8,35,,2347.8,percent of total billed charges,Implant Device,2347.8,35,,2347.8,percent of total billed charges,Implant Device,2347.8,35,,2347.8,percent of total billed charges,Implant Device,2347.8,35,,2347.8,percent of total billed charges,Implant Device,2347.8,35,,2347.8,percent of total billed charges,Implant Device,2683.2,40,,2683.2,percent of total billed charges,Implant Device,2347.8,70,,2347.8,percent of total billed charges,All Other,2280.72,34,,2280.72,percent of total billed charges,Implant Device,2280.72,34,,2280.72,percent of total billed charges,Implant Device,2347.8,35,,2347.8,percent of total billed charges,Implant Device,2347.8,35,,2347.8,percent of total billed charges,Implant Device,2347.8,35,,2347.8,percent of total billed charges,Implant Device,2347.8,35,,2347.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2280.72,34,"If Charge > 2,000, then 34 percent",2280.72,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4963.94,
SOLANA XGP2545 OLIVE STABILIZER .045X2.5,C1713,HCPCS,,79005904,CDM,278,RC,,,both,,,585,432.9,,,432.9,Other,150% of Medicare + 9.63% HCRA Surcharge,263.25,45,,263.25,percent of total billed charges,Critical Access Hospital RCC factor,198.9,34,,198.9,percent of total billed charges,Implant Device,198.9,34,,198.9,percent of total billed charges,Implant Device,198.9,34,,198.9,percent of total billed charges,Implant Device,198.9,34,,198.9,percent of total billed charges,Implant Device,198.9,34,,198.9,percent of total billed charges,Implant Device,289.58,,,289.58,Other,110% of Medicare,204.75,35,,204.75,percent of total billed charges,Implant Device,198.9,34,"Charges > $500, x 34%",198.9,percent of total billed charges,Implant Device,204.75,35,,204.75,percent of total billed charges,Implant Device,204.75,35,,204.75,percent of total billed charges,Implant Device,204.75,35,,204.75,percent of total billed charges,Implant Device,204.75,35,,204.75,percent of total billed charges,Implant Device,204.75,35,,204.75,percent of total billed charges,Implant Device,234,40,,234,percent of total billed charges,Implant Device,204.75,70,,204.75,percent of total billed charges,All Other,198.9,34,,198.9,percent of total billed charges,Implant Device,198.9,34,,198.9,percent of total billed charges,Implant Device,204.75,35,,204.75,percent of total billed charges,Implant Device,204.75,35,,204.75,percent of total billed charges,Implant Device,204.75,35,,204.75,percent of total billed charges,Implant Device,204.75,35,,204.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,432.9,
SOLANA CCP-X3530 LAG SCREW 3.5X30MM,C1713,HCPCS,,79005905,CDM,278,RC,,,both,,,900,666,,,666,Other,150% of Medicare + 9.63% HCRA Surcharge,405,45,,405,percent of total billed charges,Critical Access Hospital RCC factor,306,34,,306,percent of total billed charges,Implant Device,306,34,,306,percent of total billed charges,Implant Device,306,34,,306,percent of total billed charges,Implant Device,306,34,,306,percent of total billed charges,Implant Device,306,34,,306,percent of total billed charges,Implant Device,445.5,,,445.5,Other,110% of Medicare,315,35,,315,percent of total billed charges,Implant Device,306,34,"Charges > $500, x 34%",306,percent of total billed charges,Implant Device,315,35,,315,percent of total billed charges,Implant Device,315,35,,315,percent of total billed charges,Implant Device,315,35,,315,percent of total billed charges,Implant Device,315,35,,315,percent of total billed charges,Implant Device,315,35,,315,percent of total billed charges,Implant Device,360,40,,360,percent of total billed charges,Implant Device,315,70,,315,percent of total billed charges,All Other,306,34,,306,percent of total billed charges,Implant Device,306,34,,306,percent of total billed charges,Implant Device,315,35,,315,percent of total billed charges,Implant Device,315,35,,315,percent of total billed charges,Implant Device,315,35,,315,percent of total billed charges,Implant Device,315,35,,315,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,666,
SOLANA CCP-L3014 LOCKING SCREW 3.0X14MM,C1713,HCPCS,,79005906,CDM,278,RC,,,both,,,900,666,,,666,Other,150% of Medicare + 9.63% HCRA Surcharge,405,45,,405,percent of total billed charges,Critical Access Hospital RCC factor,306,34,,306,percent of total billed charges,Implant Device,306,34,,306,percent of total billed charges,Implant Device,306,34,,306,percent of total billed charges,Implant Device,306,34,,306,percent of total billed charges,Implant Device,306,34,,306,percent of total billed charges,Implant Device,445.5,,,445.5,Other,110% of Medicare,315,35,,315,percent of total billed charges,Implant Device,306,34,"Charges > $500, x 34%",306,percent of total billed charges,Implant Device,315,35,,315,percent of total billed charges,Implant Device,315,35,,315,percent of total billed charges,Implant Device,315,35,,315,percent of total billed charges,Implant Device,315,35,,315,percent of total billed charges,Implant Device,315,35,,315,percent of total billed charges,Implant Device,360,40,,360,percent of total billed charges,Implant Device,315,70,,315,percent of total billed charges,All Other,306,34,,306,percent of total billed charges,Implant Device,306,34,,306,percent of total billed charges,Implant Device,315,35,,315,percent of total billed charges,Implant Device,315,35,,315,percent of total billed charges,Implant Device,315,35,,315,percent of total billed charges,Implant Device,315,35,,315,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,666,
SOLANA CCP-L3016 LOCKING SCREW 3.0X16MM,C1713,HCPCS,,79005907,CDM,278,RC,,,both,,,1125,832.5,,,832.5,Other,150% of Medicare + 9.63% HCRA Surcharge,506.25,45,,506.25,percent of total billed charges,Critical Access Hospital RCC factor,382.5,34,,382.5,percent of total billed charges,Implant Device,382.5,34,,382.5,percent of total billed charges,Implant Device,382.5,34,,382.5,percent of total billed charges,Implant Device,382.5,34,,382.5,percent of total billed charges,Implant Device,382.5,34,,382.5,percent of total billed charges,Implant Device,556.88,,,556.88,Other,110% of Medicare,393.75,35,,393.75,percent of total billed charges,Implant Device,382.5,34,"Charges > $500, x 34%",382.5,percent of total billed charges,Implant Device,393.75,35,,393.75,percent of total billed charges,Implant Device,393.75,35,,393.75,percent of total billed charges,Implant Device,393.75,35,,393.75,percent of total billed charges,Implant Device,393.75,35,,393.75,percent of total billed charges,Implant Device,393.75,35,,393.75,percent of total billed charges,Implant Device,450,40,,450,percent of total billed charges,Implant Device,393.75,70,,393.75,percent of total billed charges,All Other,382.5,34,,382.5,percent of total billed charges,Implant Device,382.5,34,,382.5,percent of total billed charges,Implant Device,393.75,35,,393.75,percent of total billed charges,Implant Device,393.75,35,,393.75,percent of total billed charges,Implant Device,393.75,35,,393.75,percent of total billed charges,Implant Device,393.75,35,,393.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,832.5,
SOLANA CCP-LPX2R PLATE LAPIDUS CX 2MM,C1713,HCPCS,,79005908,CDM,278,RC,,,both,,,6708,4963.94,,,4963.94,Other,150% of Medicare + 9.63% HCRA Surcharge,3018.6,45,,3018.6,percent of total billed charges,Critical Access Hospital RCC factor,2280.72,34,,2280.72,percent of total billed charges,Implant Device,2280.72,34,,2280.72,percent of total billed charges,Implant Device,2280.72,34,,2280.72,percent of total billed charges,Implant Device,2280.72,34,,2280.72,percent of total billed charges,Implant Device,2280.72,34,,2280.72,percent of total billed charges,Implant Device,3320.46,,,3320.46,Other,110% of Medicare,2347.8,35,,2347.8,percent of total billed charges,Implant Device,2280.72,34,"Charges > $500, x 34%",2280.72,percent of total billed charges,Implant Device,2347.8,35,,2347.8,percent of total billed charges,Implant Device,2347.8,35,,2347.8,percent of total billed charges,Implant Device,2347.8,35,,2347.8,percent of total billed charges,Implant Device,2347.8,35,,2347.8,percent of total billed charges,Implant Device,2347.8,35,,2347.8,percent of total billed charges,Implant Device,2683.2,40,,2683.2,percent of total billed charges,Implant Device,2347.8,70,,2347.8,percent of total billed charges,All Other,2280.72,34,,2280.72,percent of total billed charges,Implant Device,2280.72,34,,2280.72,percent of total billed charges,Implant Device,2347.8,35,,2347.8,percent of total billed charges,Implant Device,2347.8,35,,2347.8,percent of total billed charges,Implant Device,2347.8,35,,2347.8,percent of total billed charges,Implant Device,2347.8,35,,2347.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2280.72,34,"If Charge > 2,000, then 34 percent",2280.72,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4963.94,
BIOMET 1802-49-050 CANN CANC SCREW 4X50,C1713,HCPCS,,79005909,CDM,278,RC,,,both,,,750,555,,,555,Other,150% of Medicare + 9.63% HCRA Surcharge,337.5,45,,337.5,percent of total billed charges,Critical Access Hospital RCC factor,255,34,,255,percent of total billed charges,Implant Device,255,34,,255,percent of total billed charges,Implant Device,255,34,,255,percent of total billed charges,Implant Device,255,34,,255,percent of total billed charges,Implant Device,255,34,,255,percent of total billed charges,Implant Device,371.25,,,371.25,Other,110% of Medicare,262.5,35,,262.5,percent of total billed charges,Implant Device,255,34,"Charges > $500, x 34%",255,percent of total billed charges,Implant Device,262.5,35,,262.5,percent of total billed charges,Implant Device,262.5,35,,262.5,percent of total billed charges,Implant Device,262.5,35,,262.5,percent of total billed charges,Implant Device,262.5,35,,262.5,percent of total billed charges,Implant Device,262.5,35,,262.5,percent of total billed charges,Implant Device,300,40,,300,percent of total billed charges,Implant Device,262.5,70,,262.5,percent of total billed charges,All Other,255,34,,255,percent of total billed charges,Implant Device,255,34,,255,percent of total billed charges,Implant Device,262.5,35,,262.5,percent of total billed charges,Implant Device,262.5,35,,262.5,percent of total billed charges,Implant Device,262.5,35,,262.5,percent of total billed charges,Implant Device,262.5,35,,262.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,555,
BIOMET 1802-49-036 CANN CANC SCREW 4X36,C1713,HCPCS,,79005910,CDM,278,RC,,,both,,,750,555,,,555,Other,150% of Medicare + 9.63% HCRA Surcharge,337.5,45,,337.5,percent of total billed charges,Critical Access Hospital RCC factor,255,34,,255,percent of total billed charges,Implant Device,255,34,,255,percent of total billed charges,Implant Device,255,34,,255,percent of total billed charges,Implant Device,255,34,,255,percent of total billed charges,Implant Device,255,34,,255,percent of total billed charges,Implant Device,371.25,,,371.25,Other,110% of Medicare,262.5,35,,262.5,percent of total billed charges,Implant Device,255,34,"Charges > $500, x 34%",255,percent of total billed charges,Implant Device,262.5,35,,262.5,percent of total billed charges,Implant Device,262.5,35,,262.5,percent of total billed charges,Implant Device,262.5,35,,262.5,percent of total billed charges,Implant Device,262.5,35,,262.5,percent of total billed charges,Implant Device,262.5,35,,262.5,percent of total billed charges,Implant Device,300,40,,300,percent of total billed charges,Implant Device,262.5,70,,262.5,percent of total billed charges,All Other,255,34,,255,percent of total billed charges,Implant Device,255,34,,255,percent of total billed charges,Implant Device,262.5,35,,262.5,percent of total billed charges,Implant Device,262.5,35,,262.5,percent of total billed charges,Implant Device,262.5,35,,262.5,percent of total billed charges,Implant Device,262.5,35,,262.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,555,
ACUMED AT2-S18-S BONE SCREW ACUTRAK 22MM,C1713,HCPCS,,79005911,CDM,278,RC,,,both,,,1584,1172.16,,,1172.16,Other,150% of Medicare + 9.63% HCRA Surcharge,712.8,45,,712.8,percent of total billed charges,Critical Access Hospital RCC factor,538.56,34,,538.56,percent of total billed charges,Implant Device,538.56,34,,538.56,percent of total billed charges,Implant Device,538.56,34,,538.56,percent of total billed charges,Implant Device,538.56,34,,538.56,percent of total billed charges,Implant Device,538.56,34,,538.56,percent of total billed charges,Implant Device,784.08,,,784.08,Other,110% of Medicare,554.4,35,,554.4,percent of total billed charges,Implant Device,538.56,34,"Charges > $500, x 34%",538.56,percent of total billed charges,Implant Device,554.4,35,,554.4,percent of total billed charges,Implant Device,554.4,35,,554.4,percent of total billed charges,Implant Device,554.4,35,,554.4,percent of total billed charges,Implant Device,554.4,35,,554.4,percent of total billed charges,Implant Device,554.4,35,,554.4,percent of total billed charges,Implant Device,633.6,40,,633.6,percent of total billed charges,Implant Device,554.4,70,,554.4,percent of total billed charges,All Other,538.56,34,,538.56,percent of total billed charges,Implant Device,538.56,34,,538.56,percent of total billed charges,Implant Device,554.4,35,,554.4,percent of total billed charges,Implant Device,554.4,35,,554.4,percent of total billed charges,Implant Device,554.4,35,,554.4,percent of total billed charges,Implant Device,554.4,35,,554.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1172.16,
ACUMED AT2-S22-S BONE SCREW ACUTRAK 18MM,C1713,HCPCS,,79005912,CDM,278,RC,,,both,,,1584,1172.16,,,1172.16,Other,150% of Medicare + 9.63% HCRA Surcharge,712.8,45,,712.8,percent of total billed charges,Critical Access Hospital RCC factor,538.56,34,,538.56,percent of total billed charges,Implant Device,538.56,34,,538.56,percent of total billed charges,Implant Device,538.56,34,,538.56,percent of total billed charges,Implant Device,538.56,34,,538.56,percent of total billed charges,Implant Device,538.56,34,,538.56,percent of total billed charges,Implant Device,784.08,,,784.08,Other,110% of Medicare,554.4,35,,554.4,percent of total billed charges,Implant Device,538.56,34,"Charges > $500, x 34%",538.56,percent of total billed charges,Implant Device,554.4,35,,554.4,percent of total billed charges,Implant Device,554.4,35,,554.4,percent of total billed charges,Implant Device,554.4,35,,554.4,percent of total billed charges,Implant Device,554.4,35,,554.4,percent of total billed charges,Implant Device,554.4,35,,554.4,percent of total billed charges,Implant Device,633.6,40,,633.6,percent of total billed charges,Implant Device,554.4,70,,554.4,percent of total billed charges,All Other,538.56,34,,538.56,percent of total billed charges,Implant Device,538.56,34,,538.56,percent of total billed charges,Implant Device,554.4,35,,554.4,percent of total billed charges,Implant Device,554.4,35,,554.4,percent of total billed charges,Implant Device,554.4,35,,554.4,percent of total billed charges,Implant Device,554.4,35,,554.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1172.16,
ACUMED AT2-M18-S BONE SCREW ACUTRAK 18MM,C1713,HCPCS,,79005915,CDM,278,RC,,,both,,,1584,1172.16,,,1172.16,Other,150% of Medicare + 9.63% HCRA Surcharge,712.8,45,,712.8,percent of total billed charges,Critical Access Hospital RCC factor,538.56,34,,538.56,percent of total billed charges,Implant Device,538.56,34,,538.56,percent of total billed charges,Implant Device,538.56,34,,538.56,percent of total billed charges,Implant Device,538.56,34,,538.56,percent of total billed charges,Implant Device,538.56,34,,538.56,percent of total billed charges,Implant Device,784.08,,,784.08,Other,110% of Medicare,554.4,35,,554.4,percent of total billed charges,Implant Device,538.56,34,"Charges > $500, x 34%",538.56,percent of total billed charges,Implant Device,554.4,35,,554.4,percent of total billed charges,Implant Device,554.4,35,,554.4,percent of total billed charges,Implant Device,554.4,35,,554.4,percent of total billed charges,Implant Device,554.4,35,,554.4,percent of total billed charges,Implant Device,554.4,35,,554.4,percent of total billed charges,Implant Device,633.6,40,,633.6,percent of total billed charges,Implant Device,554.4,70,,554.4,percent of total billed charges,All Other,538.56,34,,538.56,percent of total billed charges,Implant Device,538.56,34,,538.56,percent of total billed charges,Implant Device,554.4,35,,554.4,percent of total billed charges,Implant Device,554.4,35,,554.4,percent of total billed charges,Implant Device,554.4,35,,554.4,percent of total billed charges,Implant Device,554.4,35,,554.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1172.16,
ZIMMER 5001-045-00 BIPOLAR SHELL 45MM OD,C1776,HCPCS,,79005919,CDM,278,RC,,,both,,,960,710.4,,,710.4,Other,150% of Medicare + 9.63% HCRA Surcharge,432,45,,432,percent of total billed charges,Critical Access Hospital RCC factor,326.4,34,,326.4,percent of total billed charges,Implant Device,326.4,34,,326.4,percent of total billed charges,Implant Device,326.4,34,,326.4,percent of total billed charges,Implant Device,326.4,34,,326.4,percent of total billed charges,Implant Device,326.4,34,,326.4,percent of total billed charges,Implant Device,475.2,,,475.2,Other,110% of Medicare,336,35,,336,percent of total billed charges,Implant Device,326.4,34,"Charges > $500, x 34%",326.4,percent of total billed charges,Implant Device,336,35,,336,percent of total billed charges,Implant Device,336,35,,336,percent of total billed charges,Implant Device,336,35,,336,percent of total billed charges,Implant Device,336,35,,336,percent of total billed charges,Implant Device,336,35,,336,percent of total billed charges,Implant Device,384,40,,384,percent of total billed charges,Implant Device,336,70,,336,percent of total billed charges,All Other,326.4,34,,326.4,percent of total billed charges,Implant Device,326.4,34,,326.4,percent of total billed charges,Implant Device,336,35,,336,percent of total billed charges,Implant Device,336,35,,336,percent of total billed charges,Implant Device,336,35,,336,percent of total billed charges,Implant Device,336,35,,336,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,710.4,
ZIMMER 7850-014-00 VERSYS STEM 14X135,C1776,HCPCS,,79005920,CDM,278,RC,,,both,,,5760,4262.41,,,4262.41,Other,150% of Medicare + 9.63% HCRA Surcharge,2592,45,,2592,percent of total billed charges,Critical Access Hospital RCC factor,1958.4,34,,1958.4,percent of total billed charges,Implant Device,1958.4,34,,1958.4,percent of total billed charges,Implant Device,1958.4,34,,1958.4,percent of total billed charges,Implant Device,1958.4,34,,1958.4,percent of total billed charges,Implant Device,1958.4,34,,1958.4,percent of total billed charges,Implant Device,2851.2,,,2851.2,Other,110% of Medicare,2016,35,,2016,percent of total billed charges,Implant Device,1958.4,34,"Charges > $500, x 34%",1958.4,percent of total billed charges,Implant Device,2016,35,,2016,percent of total billed charges,Implant Device,2016,35,,2016,percent of total billed charges,Implant Device,2016,35,,2016,percent of total billed charges,Implant Device,2016,35,,2016,percent of total billed charges,Implant Device,2016,35,,2016,percent of total billed charges,Implant Device,2304,40,,2304,percent of total billed charges,Implant Device,2016,70,,2016,percent of total billed charges,All Other,1958.4,34,,1958.4,percent of total billed charges,Implant Device,1958.4,34,,1958.4,percent of total billed charges,Implant Device,2016,35,,2016,percent of total billed charges,Implant Device,2016,35,,2016,percent of total billed charges,Implant Device,2016,35,,2016,percent of total billed charges,Implant Device,2016,35,,2016,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1958.4,34,"If Charge > 2,000, then 34 percent",1958.4,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4262.41,
ZIMMER 7859-012-00 VERSYS CENTRALZR 12MM,C1776,HCPCS,,79005921,CDM,278,RC,,,both,,,360,266.4,,,266.4,Other,150% of Medicare + 9.63% HCRA Surcharge,162,45,,162,percent of total billed charges,Critical Access Hospital RCC factor,122.4,34,,122.4,percent of total billed charges,Implant Device,122.4,34,,122.4,percent of total billed charges,Implant Device,122.4,34,,122.4,percent of total billed charges,Implant Device,122.4,34,,122.4,percent of total billed charges,Implant Device,122.4,34,,122.4,percent of total billed charges,Implant Device,178.2,,,178.2,Other,110% of Medicare,126,35,,126,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,126,35,,126,percent of total billed charges,Implant Device,126,35,,126,percent of total billed charges,Implant Device,126,35,,126,percent of total billed charges,Implant Device,126,35,,126,percent of total billed charges,Implant Device,126,35,,126,percent of total billed charges,Implant Device,144,40,,144,percent of total billed charges,Implant Device,126,70,,126,percent of total billed charges,All Other,122.4,34,,122.4,percent of total billed charges,Implant Device,122.4,34,,122.4,percent of total billed charges,Implant Device,126,35,,126,percent of total billed charges,Implant Device,126,35,,126,percent of total billed charges,Implant Device,126,35,,126,percent of total billed charges,Implant Device,126,35,,126,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,266.4,
AMS 9000262 ARC RETROPUBIC SLING SYSTEM,C1781,HCPCS,,79005922,CDM,278,RC,,,both,,,2400,1776.01,,,1776.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1080,45,,1080,percent of total billed charges,Critical Access Hospital RCC factor,816,34,,816,percent of total billed charges,Implant Device,816,34,,816,percent of total billed charges,Implant Device,816,34,,816,percent of total billed charges,Implant Device,816,34,,816,percent of total billed charges,Implant Device,816,34,,816,percent of total billed charges,Implant Device,1188,,,1188,Other,110% of Medicare,840,35,,840,percent of total billed charges,Implant Device,816,34,"Charges > $500, x 34%",816,percent of total billed charges,Implant Device,840,35,,840,percent of total billed charges,Implant Device,840,35,,840,percent of total billed charges,Implant Device,840,35,,840,percent of total billed charges,Implant Device,840,35,,840,percent of total billed charges,Implant Device,840,35,,840,percent of total billed charges,Implant Device,960,40,,960,percent of total billed charges,Implant Device,840,70,,840,percent of total billed charges,All Other,816,34,,816,percent of total billed charges,Implant Device,816,34,,816,percent of total billed charges,Implant Device,840,35,,840,percent of total billed charges,Implant Device,840,35,,840,percent of total billed charges,Implant Device,840,35,,840,percent of total billed charges,Implant Device,840,35,,840,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,816,34,"If Charge > 2,000, then 34 percent",816,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1776.01,
DEPUY TOTAL KNEE HIGH CAP,C1776,HCPCS,,79005932,CDM,278,RC,,,both,,,16350,12099.04,,,12099.04,Other,150% of Medicare + 9.63% HCRA Surcharge,7357.5,45,,7357.5,percent of total billed charges,Critical Access Hospital RCC factor,5559,34,,5559,percent of total billed charges,Implant Device,5559,34,,5559,percent of total billed charges,Implant Device,5559,34,,5559,percent of total billed charges,Implant Device,5559,34,,5559,percent of total billed charges,Implant Device,5559,34,,5559,percent of total billed charges,Implant Device,8093.25,,,8093.25,Other,110% of Medicare,5722.5,35,,5722.5,percent of total billed charges,Implant Device,5559,34,"Charges > $500, x 34%",5559,percent of total billed charges,Implant Device,5722.5,35,,5722.5,percent of total billed charges,Implant Device,5722.5,35,,5722.5,percent of total billed charges,Implant Device,5722.5,35,,5722.5,percent of total billed charges,Implant Device,5722.5,35,,5722.5,percent of total billed charges,Implant Device,5722.5,35,,5722.5,percent of total billed charges,Implant Device,6540,40,,6540,percent of total billed charges,Implant Device,5722.5,70,,5722.5,percent of total billed charges,All Other,5559,34,,5559,percent of total billed charges,Implant Device,5559,34,,5559,percent of total billed charges,Implant Device,5722.5,35,,5722.5,percent of total billed charges,Implant Device,5722.5,35,,5722.5,percent of total billed charges,Implant Device,5722.5,35,,5722.5,percent of total billed charges,Implant Device,5722.5,35,,5722.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,5559,34,"If Charge > 2,000, then 34 percent",5559,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,12099.04,
DEPUY TOTAL KNEE LOW CAP,C1776,HCPCS,,79005933,CDM,278,RC,,,both,,,15106,11178.48,,,11178.48,Other,150% of Medicare + 9.63% HCRA Surcharge,6797.7,45,,6797.7,percent of total billed charges,Critical Access Hospital RCC factor,5136.04,34,,5136.04,percent of total billed charges,Implant Device,5136.04,34,,5136.04,percent of total billed charges,Implant Device,5136.04,34,,5136.04,percent of total billed charges,Implant Device,5136.04,34,,5136.04,percent of total billed charges,Implant Device,5136.04,34,,5136.04,percent of total billed charges,Implant Device,7477.47,,,7477.47,Other,110% of Medicare,5287.1,35,,5287.1,percent of total billed charges,Implant Device,5136.04,34,"Charges > $500, x 34%",5136.04,percent of total billed charges,Implant Device,5287.1,35,,5287.1,percent of total billed charges,Implant Device,5287.1,35,,5287.1,percent of total billed charges,Implant Device,5287.1,35,,5287.1,percent of total billed charges,Implant Device,5287.1,35,,5287.1,percent of total billed charges,Implant Device,5287.1,35,,5287.1,percent of total billed charges,Implant Device,6042.4,40,,6042.4,percent of total billed charges,Implant Device,5287.1,70,,5287.1,percent of total billed charges,All Other,5136.04,34,,5136.04,percent of total billed charges,Implant Device,5136.04,34,,5136.04,percent of total billed charges,Implant Device,5287.1,35,,5287.1,percent of total billed charges,Implant Device,5287.1,35,,5287.1,percent of total billed charges,Implant Device,5287.1,35,,5287.1,percent of total billed charges,Implant Device,5287.1,35,,5287.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,5136.04,34,"If Charge > 2,000, then 34 percent",5136.04,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,11178.48,
SOLANA CCP-LP2XL LAPIDUS PLATE 2MMM LEFT,C1713,HCPCS,,79005934,CDM,278,RC,,,both,,,6708,4963.94,,,4963.94,Other,150% of Medicare + 9.63% HCRA Surcharge,3018.6,45,,3018.6,percent of total billed charges,Critical Access Hospital RCC factor,2280.72,34,,2280.72,percent of total billed charges,Implant Device,2280.72,34,,2280.72,percent of total billed charges,Implant Device,2280.72,34,,2280.72,percent of total billed charges,Implant Device,2280.72,34,,2280.72,percent of total billed charges,Implant Device,2280.72,34,,2280.72,percent of total billed charges,Implant Device,3320.46,,,3320.46,Other,110% of Medicare,2347.8,35,,2347.8,percent of total billed charges,Implant Device,2280.72,34,"Charges > $500, x 34%",2280.72,percent of total billed charges,Implant Device,2347.8,35,,2347.8,percent of total billed charges,Implant Device,2347.8,35,,2347.8,percent of total billed charges,Implant Device,2347.8,35,,2347.8,percent of total billed charges,Implant Device,2347.8,35,,2347.8,percent of total billed charges,Implant Device,2347.8,35,,2347.8,percent of total billed charges,Implant Device,2683.2,40,,2683.2,percent of total billed charges,Implant Device,2347.8,70,,2347.8,percent of total billed charges,All Other,2280.72,34,,2280.72,percent of total billed charges,Implant Device,2280.72,34,,2280.72,percent of total billed charges,Implant Device,2347.8,35,,2347.8,percent of total billed charges,Implant Device,2347.8,35,,2347.8,percent of total billed charges,Implant Device,2347.8,35,,2347.8,percent of total billed charges,Implant Device,2347.8,35,,2347.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2280.72,34,"If Charge > 2,000, then 34 percent",2280.72,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4963.94,
SOLANA CCP-L3018 LOCKING SCREW 3X18MM,C1713,HCPCS,,79005935,CDM,278,RC,,,both,,,1125,832.5,,,832.5,Other,150% of Medicare + 9.63% HCRA Surcharge,506.25,45,,506.25,percent of total billed charges,Critical Access Hospital RCC factor,382.5,34,,382.5,percent of total billed charges,Implant Device,382.5,34,,382.5,percent of total billed charges,Implant Device,382.5,34,,382.5,percent of total billed charges,Implant Device,382.5,34,,382.5,percent of total billed charges,Implant Device,382.5,34,,382.5,percent of total billed charges,Implant Device,556.88,,,556.88,Other,110% of Medicare,393.75,35,,393.75,percent of total billed charges,Implant Device,382.5,34,"Charges > $500, x 34%",382.5,percent of total billed charges,Implant Device,393.75,35,,393.75,percent of total billed charges,Implant Device,393.75,35,,393.75,percent of total billed charges,Implant Device,393.75,35,,393.75,percent of total billed charges,Implant Device,393.75,35,,393.75,percent of total billed charges,Implant Device,393.75,35,,393.75,percent of total billed charges,Implant Device,450,40,,450,percent of total billed charges,Implant Device,393.75,70,,393.75,percent of total billed charges,All Other,382.5,34,,382.5,percent of total billed charges,Implant Device,382.5,34,,382.5,percent of total billed charges,Implant Device,393.75,35,,393.75,percent of total billed charges,Implant Device,393.75,35,,393.75,percent of total billed charges,Implant Device,393.75,35,,393.75,percent of total billed charges,Implant Device,393.75,35,,393.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,832.5,
SOLANA CCP-X3532 LAG SCREW 3.5X32MM,C1713,HCPCS,,79005936,CDM,278,RC,,,both,,,900,666,,,666,Other,150% of Medicare + 9.63% HCRA Surcharge,405,45,,405,percent of total billed charges,Critical Access Hospital RCC factor,306,34,,306,percent of total billed charges,Implant Device,306,34,,306,percent of total billed charges,Implant Device,306,34,,306,percent of total billed charges,Implant Device,306,34,,306,percent of total billed charges,Implant Device,306,34,,306,percent of total billed charges,Implant Device,445.5,,,445.5,Other,110% of Medicare,315,35,,315,percent of total billed charges,Implant Device,306,34,"Charges > $500, x 34%",306,percent of total billed charges,Implant Device,315,35,,315,percent of total billed charges,Implant Device,315,35,,315,percent of total billed charges,Implant Device,315,35,,315,percent of total billed charges,Implant Device,315,35,,315,percent of total billed charges,Implant Device,315,35,,315,percent of total billed charges,Implant Device,360,40,,360,percent of total billed charges,Implant Device,315,70,,315,percent of total billed charges,All Other,306,34,,306,percent of total billed charges,Implant Device,306,34,,306,percent of total billed charges,Implant Device,315,35,,315,percent of total billed charges,Implant Device,315,35,,315,percent of total billed charges,Implant Device,315,35,,315,percent of total billed charges,Implant Device,315,35,,315,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,666,
BIOMET 14-405042 CORT SCREW TI 5X42MM,C1713,HCPCS,,79005937,CDM,278,RC,,,both,,,1020,754.8,,,754.8,Other,150% of Medicare + 9.63% HCRA Surcharge,459,45,,459,percent of total billed charges,Critical Access Hospital RCC factor,346.8,34,,346.8,percent of total billed charges,Implant Device,346.8,34,,346.8,percent of total billed charges,Implant Device,346.8,34,,346.8,percent of total billed charges,Implant Device,346.8,34,,346.8,percent of total billed charges,Implant Device,346.8,34,,346.8,percent of total billed charges,Implant Device,504.9,,,504.9,Other,110% of Medicare,357,35,,357,percent of total billed charges,Implant Device,346.8,34,"Charges > $500, x 34%",346.8,percent of total billed charges,Implant Device,357,35,,357,percent of total billed charges,Implant Device,357,35,,357,percent of total billed charges,Implant Device,357,35,,357,percent of total billed charges,Implant Device,357,35,,357,percent of total billed charges,Implant Device,357,35,,357,percent of total billed charges,Implant Device,408,40,,408,percent of total billed charges,Implant Device,357,70,,357,percent of total billed charges,All Other,346.8,34,,346.8,percent of total billed charges,Implant Device,346.8,34,,346.8,percent of total billed charges,Implant Device,357,35,,357,percent of total billed charges,Implant Device,357,35,,357,percent of total billed charges,Implant Device,357,35,,357,percent of total billed charges,Implant Device,357,35,,357,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,754.8,
BIOMET 29242 LAG SCREW ASSY 115MM,C1713,HCPCS,,79005938,CDM,278,RC,,,both,,,3330,2464.21,,,2464.21,Other,150% of Medicare + 9.63% HCRA Surcharge,1498.5,45,,1498.5,percent of total billed charges,Critical Access Hospital RCC factor,1132.2,34,,1132.2,percent of total billed charges,Implant Device,1132.2,34,,1132.2,percent of total billed charges,Implant Device,1132.2,34,,1132.2,percent of total billed charges,Implant Device,1132.2,34,,1132.2,percent of total billed charges,Implant Device,1132.2,34,,1132.2,percent of total billed charges,Implant Device,1648.35,,,1648.35,Other,110% of Medicare,1165.5,35,,1165.5,percent of total billed charges,Implant Device,1132.2,34,"Charges > $500, x 34%",1132.2,percent of total billed charges,Implant Device,1165.5,35,,1165.5,percent of total billed charges,Implant Device,1165.5,35,,1165.5,percent of total billed charges,Implant Device,1165.5,35,,1165.5,percent of total billed charges,Implant Device,1165.5,35,,1165.5,percent of total billed charges,Implant Device,1165.5,35,,1165.5,percent of total billed charges,Implant Device,1332,40,,1332,percent of total billed charges,Implant Device,1165.5,70,,1165.5,percent of total billed charges,All Other,1132.2,34,,1132.2,percent of total billed charges,Implant Device,1132.2,34,,1132.2,percent of total billed charges,Implant Device,1165.5,35,,1165.5,percent of total billed charges,Implant Device,1165.5,35,,1165.5,percent of total billed charges,Implant Device,1165.5,35,,1165.5,percent of total billed charges,Implant Device,1165.5,35,,1165.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1132.2,34,"If Charge > 2,000, then 34 percent",1132.2,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2464.21,
STRYKER 349616 2.7X16MM CORTICAL SCREW,C1713,HCPCS,,79005939,CDM,278,RC,,,both,,,138,102.12,,,102.12,Other,150% of Medicare + 9.63% HCRA Surcharge,62.1,45,,62.1,percent of total billed charges,Critical Access Hospital RCC factor,46.92,34,,46.92,percent of total billed charges,Implant Device,46.92,34,,46.92,percent of total billed charges,Implant Device,46.92,34,,46.92,percent of total billed charges,Implant Device,46.92,34,,46.92,percent of total billed charges,Implant Device,46.92,34,,46.92,percent of total billed charges,Implant Device,68.31,,,68.31,Other,110% of Medicare,48.3,35,,48.3,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,48.3,35,,48.3,percent of total billed charges,Implant Device,48.3,35,,48.3,percent of total billed charges,Implant Device,48.3,35,,48.3,percent of total billed charges,Implant Device,48.3,35,,48.3,percent of total billed charges,Implant Device,48.3,35,,48.3,percent of total billed charges,Implant Device,55.2,40,,55.2,percent of total billed charges,Implant Device,48.3,70,,48.3,percent of total billed charges,All Other,46.92,34,,46.92,percent of total billed charges,Implant Device,46.92,34,,46.92,percent of total billed charges,Implant Device,48.3,35,,48.3,percent of total billed charges,Implant Device,48.3,35,,48.3,percent of total billed charges,Implant Device,48.3,35,,48.3,percent of total billed charges,Implant Device,48.3,35,,48.3,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,102.12,
STRYKER 371012 3.0X12MM LOCKING SCREW,C1713,HCPCS,,79005940,CDM,278,RC,,,both,,,352,260.48,,,260.48,Other,150% of Medicare + 9.63% HCRA Surcharge,158.4,45,,158.4,percent of total billed charges,Critical Access Hospital RCC factor,119.68,34,,119.68,percent of total billed charges,Implant Device,119.68,34,,119.68,percent of total billed charges,Implant Device,119.68,34,,119.68,percent of total billed charges,Implant Device,119.68,34,,119.68,percent of total billed charges,Implant Device,119.68,34,,119.68,percent of total billed charges,Implant Device,174.24,,,174.24,Other,110% of Medicare,123.2,35,,123.2,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,123.2,35,,123.2,percent of total billed charges,Implant Device,123.2,35,,123.2,percent of total billed charges,Implant Device,123.2,35,,123.2,percent of total billed charges,Implant Device,123.2,35,,123.2,percent of total billed charges,Implant Device,123.2,35,,123.2,percent of total billed charges,Implant Device,140.8,40,,140.8,percent of total billed charges,Implant Device,123.2,70,,123.2,percent of total billed charges,All Other,119.68,34,,119.68,percent of total billed charges,Implant Device,119.68,34,,119.68,percent of total billed charges,Implant Device,123.2,35,,123.2,percent of total billed charges,Implant Device,123.2,35,,123.2,percent of total billed charges,Implant Device,123.2,35,,123.2,percent of total billed charges,Implant Device,123.2,35,,123.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,260.48,
STRYKER 371014 3.0X14MM LOCKING SCREW,C1713,HCPCS,,79005941,CDM,278,RC,,,both,,,352,260.48,,,260.48,Other,150% of Medicare + 9.63% HCRA Surcharge,158.4,45,,158.4,percent of total billed charges,Critical Access Hospital RCC factor,119.68,34,,119.68,percent of total billed charges,Implant Device,119.68,34,,119.68,percent of total billed charges,Implant Device,119.68,34,,119.68,percent of total billed charges,Implant Device,119.68,34,,119.68,percent of total billed charges,Implant Device,119.68,34,,119.68,percent of total billed charges,Implant Device,174.24,,,174.24,Other,110% of Medicare,123.2,35,,123.2,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,123.2,35,,123.2,percent of total billed charges,Implant Device,123.2,35,,123.2,percent of total billed charges,Implant Device,123.2,35,,123.2,percent of total billed charges,Implant Device,123.2,35,,123.2,percent of total billed charges,Implant Device,123.2,35,,123.2,percent of total billed charges,Implant Device,140.8,40,,140.8,percent of total billed charges,Implant Device,123.2,70,,123.2,percent of total billed charges,All Other,119.68,34,,119.68,percent of total billed charges,Implant Device,119.68,34,,119.68,percent of total billed charges,Implant Device,123.2,35,,123.2,percent of total billed charges,Implant Device,123.2,35,,123.2,percent of total billed charges,Implant Device,123.2,35,,123.2,percent of total billed charges,Implant Device,123.2,35,,123.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,260.48,
STRYKER 371016 3.0X16MM LOCKING SCREW,C1713,HCPCS,,79005942,CDM,278,RC,,,both,,,352,260.48,,,260.48,Other,150% of Medicare + 9.63% HCRA Surcharge,158.4,45,,158.4,percent of total billed charges,Critical Access Hospital RCC factor,119.68,34,,119.68,percent of total billed charges,Implant Device,119.68,34,,119.68,percent of total billed charges,Implant Device,119.68,34,,119.68,percent of total billed charges,Implant Device,119.68,34,,119.68,percent of total billed charges,Implant Device,119.68,34,,119.68,percent of total billed charges,Implant Device,174.24,,,174.24,Other,110% of Medicare,123.2,35,,123.2,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,123.2,35,,123.2,percent of total billed charges,Implant Device,123.2,35,,123.2,percent of total billed charges,Implant Device,123.2,35,,123.2,percent of total billed charges,Implant Device,123.2,35,,123.2,percent of total billed charges,Implant Device,123.2,35,,123.2,percent of total billed charges,Implant Device,140.8,40,,140.8,percent of total billed charges,Implant Device,123.2,70,,123.2,percent of total billed charges,All Other,119.68,34,,119.68,percent of total billed charges,Implant Device,119.68,34,,119.68,percent of total billed charges,Implant Device,123.2,35,,123.2,percent of total billed charges,Implant Device,123.2,35,,123.2,percent of total billed charges,Implant Device,123.2,35,,123.2,percent of total billed charges,Implant Device,123.2,35,,123.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,260.48,
STRYKER 371018 3.0X18MM LOCKING SCREW,C1713,HCPCS,,79005943,CDM,278,RC,,,both,,,319,236.06,,,236.06,Other,150% of Medicare + 9.63% HCRA Surcharge,143.55,45,,143.55,percent of total billed charges,Critical Access Hospital RCC factor,108.46,34,,108.46,percent of total billed charges,Implant Device,108.46,34,,108.46,percent of total billed charges,Implant Device,108.46,34,,108.46,percent of total billed charges,Implant Device,108.46,34,,108.46,percent of total billed charges,Implant Device,108.46,34,,108.46,percent of total billed charges,Implant Device,157.91,,,157.91,Other,110% of Medicare,111.65,35,,111.65,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,111.65,35,,111.65,percent of total billed charges,Implant Device,111.65,35,,111.65,percent of total billed charges,Implant Device,111.65,35,,111.65,percent of total billed charges,Implant Device,111.65,35,,111.65,percent of total billed charges,Implant Device,111.65,35,,111.65,percent of total billed charges,Implant Device,127.6,40,,127.6,percent of total billed charges,Implant Device,111.65,70,,111.65,percent of total billed charges,All Other,108.46,34,,108.46,percent of total billed charges,Implant Device,108.46,34,,108.46,percent of total billed charges,Implant Device,111.65,35,,111.65,percent of total billed charges,Implant Device,111.65,35,,111.65,percent of total billed charges,Implant Device,111.65,35,,111.65,percent of total billed charges,Implant Device,111.65,35,,111.65,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,236.06,
STRYKER 427066S 6 HOLE TUBLAR PLATES 1/3,C1713,HCPCS,,79005944,CDM,278,RC,,,both,,,602,445.48,,,445.48,Other,150% of Medicare + 9.63% HCRA Surcharge,270.9,45,,270.9,percent of total billed charges,Critical Access Hospital RCC factor,204.68,34,,204.68,percent of total billed charges,Implant Device,204.68,34,,204.68,percent of total billed charges,Implant Device,204.68,34,,204.68,percent of total billed charges,Implant Device,204.68,34,,204.68,percent of total billed charges,Implant Device,204.68,34,,204.68,percent of total billed charges,Implant Device,297.99,,,297.99,Other,110% of Medicare,210.7,35,,210.7,percent of total billed charges,Implant Device,204.68,34,"Charges > $500, x 34%",204.68,percent of total billed charges,Implant Device,210.7,35,,210.7,percent of total billed charges,Implant Device,210.7,35,,210.7,percent of total billed charges,Implant Device,210.7,35,,210.7,percent of total billed charges,Implant Device,210.7,35,,210.7,percent of total billed charges,Implant Device,210.7,35,,210.7,percent of total billed charges,Implant Device,240.8,40,,240.8,percent of total billed charges,Implant Device,210.7,70,,210.7,percent of total billed charges,All Other,204.68,34,,204.68,percent of total billed charges,Implant Device,204.68,34,,204.68,percent of total billed charges,Implant Device,210.7,35,,210.7,percent of total billed charges,Implant Device,210.7,35,,210.7,percent of total billed charges,Implant Device,210.7,35,,210.7,percent of total billed charges,Implant Device,210.7,35,,210.7,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,445.48,
STRYKER 54-25376 DISTAL RADIUS PLATE STD,C1713,HCPCS,,79005947,CDM,278,RC,,,both,,,3316,2453.85,,,2453.85,Other,150% of Medicare + 9.63% HCRA Surcharge,1492.2,45,,1492.2,percent of total billed charges,Critical Access Hospital RCC factor,1127.44,34,,1127.44,percent of total billed charges,Implant Device,1127.44,34,,1127.44,percent of total billed charges,Implant Device,1127.44,34,,1127.44,percent of total billed charges,Implant Device,1127.44,34,,1127.44,percent of total billed charges,Implant Device,1127.44,34,,1127.44,percent of total billed charges,Implant Device,1641.42,,,1641.42,Other,110% of Medicare,1160.6,35,,1160.6,percent of total billed charges,Implant Device,1127.44,34,"Charges > $500, x 34%",1127.44,percent of total billed charges,Implant Device,1160.6,35,,1160.6,percent of total billed charges,Implant Device,1160.6,35,,1160.6,percent of total billed charges,Implant Device,1160.6,35,,1160.6,percent of total billed charges,Implant Device,1160.6,35,,1160.6,percent of total billed charges,Implant Device,1160.6,35,,1160.6,percent of total billed charges,Implant Device,1326.4,40,,1326.4,percent of total billed charges,Implant Device,1160.6,70,,1160.6,percent of total billed charges,All Other,1127.44,34,,1127.44,percent of total billed charges,Implant Device,1127.44,34,,1127.44,percent of total billed charges,Implant Device,1160.6,35,,1160.6,percent of total billed charges,Implant Device,1160.6,35,,1160.6,percent of total billed charges,Implant Device,1160.6,35,,1160.6,percent of total billed charges,Implant Device,1160.6,35,,1160.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1127.44,34,"If Charge > 2,000, then 34 percent",1127.44,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2453.85,
STRYKER 40-35030 3.5X30MM LOCKING SCREW,C1713,HCPCS,,79005948,CDM,278,RC,,,both,,,408,301.92,,,301.92,Other,150% of Medicare + 9.63% HCRA Surcharge,183.6,45,,183.6,percent of total billed charges,Critical Access Hospital RCC factor,138.72,34,,138.72,percent of total billed charges,Implant Device,138.72,34,,138.72,percent of total billed charges,Implant Device,138.72,34,,138.72,percent of total billed charges,Implant Device,138.72,34,,138.72,percent of total billed charges,Implant Device,138.72,34,,138.72,percent of total billed charges,Implant Device,201.96,,,201.96,Other,110% of Medicare,142.8,35,,142.8,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,142.8,35,,142.8,percent of total billed charges,Implant Device,142.8,35,,142.8,percent of total billed charges,Implant Device,142.8,35,,142.8,percent of total billed charges,Implant Device,142.8,35,,142.8,percent of total billed charges,Implant Device,142.8,35,,142.8,percent of total billed charges,Implant Device,163.2,40,,163.2,percent of total billed charges,Implant Device,142.8,70,,142.8,percent of total billed charges,All Other,138.72,34,,138.72,percent of total billed charges,Implant Device,138.72,34,,138.72,percent of total billed charges,Implant Device,142.8,35,,142.8,percent of total billed charges,Implant Device,142.8,35,,142.8,percent of total billed charges,Implant Device,142.8,35,,142.8,percent of total billed charges,Implant Device,142.8,35,,142.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,301.92,
STRYKER 1822-1013S TIBIAL NAIL 10X315MM,C1713,HCPCS,,79005949,CDM,278,RC,,,both,,,5819,4306.07,,,4306.07,Other,150% of Medicare + 9.63% HCRA Surcharge,2618.55,45,,2618.55,percent of total billed charges,Critical Access Hospital RCC factor,1978.46,34,,1978.46,percent of total billed charges,Implant Device,1978.46,34,,1978.46,percent of total billed charges,Implant Device,1978.46,34,,1978.46,percent of total billed charges,Implant Device,1978.46,34,,1978.46,percent of total billed charges,Implant Device,1978.46,34,,1978.46,percent of total billed charges,Implant Device,2880.41,,,2880.41,Other,110% of Medicare,2036.65,35,,2036.65,percent of total billed charges,Implant Device,1978.46,34,"Charges > $500, x 34%",1978.46,percent of total billed charges,Implant Device,2036.65,35,,2036.65,percent of total billed charges,Implant Device,2036.65,35,,2036.65,percent of total billed charges,Implant Device,2036.65,35,,2036.65,percent of total billed charges,Implant Device,2036.65,35,,2036.65,percent of total billed charges,Implant Device,2036.65,35,,2036.65,percent of total billed charges,Implant Device,2327.6,40,,2327.6,percent of total billed charges,Implant Device,2036.65,70,,2036.65,percent of total billed charges,All Other,1978.46,34,,1978.46,percent of total billed charges,Implant Device,1978.46,34,,1978.46,percent of total billed charges,Implant Device,2036.65,35,,2036.65,percent of total billed charges,Implant Device,2036.65,35,,2036.65,percent of total billed charges,Implant Device,2036.65,35,,2036.65,percent of total billed charges,Implant Device,2036.65,35,,2036.65,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1978.46,34,"If Charge > 2,000, then 34 percent",1978.46,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4306.07,
STRYKER 325050 CANNULATED SCREW 4X50MM,C1713,HCPCS,,79005950,CDM,278,RC,,,both,,,660,488.4,,,488.4,Other,150% of Medicare + 9.63% HCRA Surcharge,297,45,,297,percent of total billed charges,Critical Access Hospital RCC factor,224.4,34,,224.4,percent of total billed charges,Implant Device,224.4,34,,224.4,percent of total billed charges,Implant Device,224.4,34,,224.4,percent of total billed charges,Implant Device,224.4,34,,224.4,percent of total billed charges,Implant Device,224.4,34,,224.4,percent of total billed charges,Implant Device,326.7,,,326.7,Other,110% of Medicare,231,35,,231,percent of total billed charges,Implant Device,224.4,34,"Charges > $500, x 34%",224.4,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,264,40,,264,percent of total billed charges,Implant Device,231,70,,231,percent of total billed charges,All Other,224.4,34,,224.4,percent of total billed charges,Implant Device,224.4,34,,224.4,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,488.4,
STRYKER 3120-0170S TROCHANT NAIL 170X120,C1713,HCPCS,,79005951,CDM,278,RC,,,both,,,6689,4949.88,,,4949.88,Other,150% of Medicare + 9.63% HCRA Surcharge,3010.05,45,,3010.05,percent of total billed charges,Critical Access Hospital RCC factor,2274.26,34,,2274.26,percent of total billed charges,Implant Device,2274.26,34,,2274.26,percent of total billed charges,Implant Device,2274.26,34,,2274.26,percent of total billed charges,Implant Device,2274.26,34,,2274.26,percent of total billed charges,Implant Device,2274.26,34,,2274.26,percent of total billed charges,Implant Device,3311.06,,,3311.06,Other,110% of Medicare,2341.15,35,,2341.15,percent of total billed charges,Implant Device,2274.26,34,"Charges > $500, x 34%",2274.26,percent of total billed charges,Implant Device,2341.15,35,,2341.15,percent of total billed charges,Implant Device,2341.15,35,,2341.15,percent of total billed charges,Implant Device,2341.15,35,,2341.15,percent of total billed charges,Implant Device,2341.15,35,,2341.15,percent of total billed charges,Implant Device,2341.15,35,,2341.15,percent of total billed charges,Implant Device,2675.6,40,,2675.6,percent of total billed charges,Implant Device,2341.15,70,,2341.15,percent of total billed charges,All Other,2274.26,34,,2274.26,percent of total billed charges,Implant Device,2274.26,34,,2274.26,percent of total billed charges,Implant Device,2341.15,35,,2341.15,percent of total billed charges,Implant Device,2341.15,35,,2341.15,percent of total billed charges,Implant Device,2341.15,35,,2341.15,percent of total billed charges,Implant Device,2341.15,35,,2341.15,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2274.26,34,"If Charge > 2,000, then 34 percent",2274.26,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4949.88,
STRYKER 3060-0075S LAG SCREW 10.5X75MM,C1713,HCPCS,,79005952,CDM,278,RC,,,both,,,2371,1754.55,,,1754.55,Other,150% of Medicare + 9.63% HCRA Surcharge,1066.95,45,,1066.95,percent of total billed charges,Critical Access Hospital RCC factor,806.14,34,,806.14,percent of total billed charges,Implant Device,806.14,34,,806.14,percent of total billed charges,Implant Device,806.14,34,,806.14,percent of total billed charges,Implant Device,806.14,34,,806.14,percent of total billed charges,Implant Device,806.14,34,,806.14,percent of total billed charges,Implant Device,1173.65,,,1173.65,Other,110% of Medicare,829.85,35,,829.85,percent of total billed charges,Implant Device,806.14,34,"Charges > $500, x 34%",806.14,percent of total billed charges,Implant Device,829.85,35,,829.85,percent of total billed charges,Implant Device,829.85,35,,829.85,percent of total billed charges,Implant Device,829.85,35,,829.85,percent of total billed charges,Implant Device,829.85,35,,829.85,percent of total billed charges,Implant Device,829.85,35,,829.85,percent of total billed charges,Implant Device,948.4,40,,948.4,percent of total billed charges,Implant Device,829.85,70,,829.85,percent of total billed charges,All Other,806.14,34,,806.14,percent of total billed charges,Implant Device,806.14,34,,806.14,percent of total billed charges,Implant Device,829.85,35,,829.85,percent of total billed charges,Implant Device,829.85,35,,829.85,percent of total billed charges,Implant Device,829.85,35,,829.85,percent of total billed charges,Implant Device,829.85,35,,829.85,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,806.14,34,"If Charge > 2,000, then 34 percent",806.14,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1754.55,
STRYKER 18-3675 FEMORAL HEAD 36X+7.5MM,C1776,HCPCS,,79005953,CDM,278,RC,,,both,,,8038,5948.14,,,5948.14,Other,150% of Medicare + 9.63% HCRA Surcharge,3617.1,45,,3617.1,percent of total billed charges,Critical Access Hospital RCC factor,2732.92,34,,2732.92,percent of total billed charges,Implant Device,2732.92,34,,2732.92,percent of total billed charges,Implant Device,2732.92,34,,2732.92,percent of total billed charges,Implant Device,2732.92,34,,2732.92,percent of total billed charges,Implant Device,2732.92,34,,2732.92,percent of total billed charges,Implant Device,3978.81,,,3978.81,Other,110% of Medicare,2813.3,35,,2813.3,percent of total billed charges,Implant Device,2732.92,34,"Charges > $500, x 34%",2732.92,percent of total billed charges,Implant Device,2813.3,35,,2813.3,percent of total billed charges,Implant Device,2813.3,35,,2813.3,percent of total billed charges,Implant Device,2813.3,35,,2813.3,percent of total billed charges,Implant Device,2813.3,35,,2813.3,percent of total billed charges,Implant Device,2813.3,35,,2813.3,percent of total billed charges,Implant Device,3215.2,40,,3215.2,percent of total billed charges,Implant Device,2813.3,70,,2813.3,percent of total billed charges,All Other,2732.92,34,,2732.92,percent of total billed charges,Implant Device,2732.92,34,,2732.92,percent of total billed charges,Implant Device,2813.3,35,,2813.3,percent of total billed charges,Implant Device,2813.3,35,,2813.3,percent of total billed charges,Implant Device,2813.3,35,,2813.3,percent of total billed charges,Implant Device,2813.3,35,,2813.3,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2732.92,34,"If Charge > 2,000, then 34 percent",2732.92,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5948.14,
STRYKER 06-3610 FEMORAL HEAD 36X+10MM,C1776,HCPCS,,79005954,CDM,278,RC,,,both,,,6232,4611.7,,,4611.7,Other,150% of Medicare + 9.63% HCRA Surcharge,2804.4,45,,2804.4,percent of total billed charges,Critical Access Hospital RCC factor,2118.88,34,,2118.88,percent of total billed charges,Implant Device,2118.88,34,,2118.88,percent of total billed charges,Implant Device,2118.88,34,,2118.88,percent of total billed charges,Implant Device,2118.88,34,,2118.88,percent of total billed charges,Implant Device,2118.88,34,,2118.88,percent of total billed charges,Implant Device,3084.84,,,3084.84,Other,110% of Medicare,2181.2,35,,2181.2,percent of total billed charges,Implant Device,2118.88,34,"Charges > $500, x 34%",2118.88,percent of total billed charges,Implant Device,2181.2,35,,2181.2,percent of total billed charges,Implant Device,2181.2,35,,2181.2,percent of total billed charges,Implant Device,2181.2,35,,2181.2,percent of total billed charges,Implant Device,2181.2,35,,2181.2,percent of total billed charges,Implant Device,2181.2,35,,2181.2,percent of total billed charges,Implant Device,2492.8,40,,2492.8,percent of total billed charges,Implant Device,2181.2,70,,2181.2,percent of total billed charges,All Other,2118.88,34,,2118.88,percent of total billed charges,Implant Device,2118.88,34,,2118.88,percent of total billed charges,Implant Device,2181.2,35,,2181.2,percent of total billed charges,Implant Device,2181.2,35,,2181.2,percent of total billed charges,Implant Device,2181.2,35,,2181.2,percent of total billed charges,Implant Device,2181.2,35,,2181.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2118.88,34,"If Charge > 2,000, then 34 percent",2118.88,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4611.7,
ZIMMER 5952-40-12 ART SURF SZ GREEN 12MM,C1776,HCPCS,,79005956,CDM,278,RC,,,both,,,2496,1847.05,,,1847.05,Other,150% of Medicare + 9.63% HCRA Surcharge,1123.2,45,,1123.2,percent of total billed charges,Critical Access Hospital RCC factor,848.64,34,,848.64,percent of total billed charges,Implant Device,848.64,34,,848.64,percent of total billed charges,Implant Device,848.64,34,,848.64,percent of total billed charges,Implant Device,848.64,34,,848.64,percent of total billed charges,Implant Device,848.64,34,,848.64,percent of total billed charges,Implant Device,1235.52,,,1235.52,Other,110% of Medicare,873.6,35,,873.6,percent of total billed charges,Implant Device,848.64,34,"Charges > $500, x 34%",848.64,percent of total billed charges,Implant Device,873.6,35,,873.6,percent of total billed charges,Implant Device,873.6,35,,873.6,percent of total billed charges,Implant Device,873.6,35,,873.6,percent of total billed charges,Implant Device,873.6,35,,873.6,percent of total billed charges,Implant Device,873.6,35,,873.6,percent of total billed charges,Implant Device,998.4,40,,998.4,percent of total billed charges,Implant Device,873.6,70,,873.6,percent of total billed charges,All Other,848.64,34,,848.64,percent of total billed charges,Implant Device,848.64,34,,848.64,percent of total billed charges,Implant Device,873.6,35,,873.6,percent of total billed charges,Implant Device,873.6,35,,873.6,percent of total billed charges,Implant Device,873.6,35,,873.6,percent of total billed charges,Implant Device,873.6,35,,873.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,848.64,34,"If Charge > 2,000, then 34 percent",848.64,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1847.05,
ARTHREX AR-2257 AC TIGHTROPE REPAIR KIT,C1713,HCPCS,,79005957,CDM,278,RC,,,both,,,1350,999,,,999,Other,150% of Medicare + 9.63% HCRA Surcharge,607.5,45,,607.5,percent of total billed charges,Critical Access Hospital RCC factor,459,34,,459,percent of total billed charges,Implant Device,459,34,,459,percent of total billed charges,Implant Device,459,34,,459,percent of total billed charges,Implant Device,459,34,,459,percent of total billed charges,Implant Device,459,34,,459,percent of total billed charges,Implant Device,668.25,,,668.25,Other,110% of Medicare,472.5,35,,472.5,percent of total billed charges,Implant Device,459,34,"Charges > $500, x 34%",459,percent of total billed charges,Implant Device,472.5,35,,472.5,percent of total billed charges,Implant Device,472.5,35,,472.5,percent of total billed charges,Implant Device,472.5,35,,472.5,percent of total billed charges,Implant Device,472.5,35,,472.5,percent of total billed charges,Implant Device,472.5,35,,472.5,percent of total billed charges,Implant Device,540,40,,540,percent of total billed charges,Implant Device,472.5,70,,472.5,percent of total billed charges,All Other,459,34,,459,percent of total billed charges,Implant Device,459,34,,459,percent of total billed charges,Implant Device,472.5,35,,472.5,percent of total billed charges,Implant Device,472.5,35,,472.5,percent of total billed charges,Implant Device,472.5,35,,472.5,percent of total billed charges,Implant Device,472.5,35,,472.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,999,
ARTHREX AR-8724-22PT CANN SCREW 2.4X22MM,C1713,HCPCS,,79005958,CDM,278,RC,,,both,,,376,278.24,,,278.24,Other,150% of Medicare + 9.63% HCRA Surcharge,169.2,45,,169.2,percent of total billed charges,Critical Access Hospital RCC factor,127.84,34,,127.84,percent of total billed charges,Implant Device,127.84,34,,127.84,percent of total billed charges,Implant Device,127.84,34,,127.84,percent of total billed charges,Implant Device,127.84,34,,127.84,percent of total billed charges,Implant Device,127.84,34,,127.84,percent of total billed charges,Implant Device,186.12,,,186.12,Other,110% of Medicare,131.6,35,,131.6,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,131.6,35,,131.6,percent of total billed charges,Implant Device,131.6,35,,131.6,percent of total billed charges,Implant Device,131.6,35,,131.6,percent of total billed charges,Implant Device,131.6,35,,131.6,percent of total billed charges,Implant Device,131.6,35,,131.6,percent of total billed charges,Implant Device,150.4,40,,150.4,percent of total billed charges,Implant Device,131.6,70,,131.6,percent of total billed charges,All Other,127.84,34,,127.84,percent of total billed charges,Implant Device,127.84,34,,127.84,percent of total billed charges,Implant Device,131.6,35,,131.6,percent of total billed charges,Implant Device,131.6,35,,131.6,percent of total billed charges,Implant Device,131.6,35,,131.6,percent of total billed charges,Implant Device,131.6,35,,131.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,278.24,
BIOMET 12-150310 ECHO STD FEMORAL 10MM,C1776,HCPCS,,79005961,CDM,278,RC,,,both,,,15240,11277.64,,,11277.64,Other,150% of Medicare + 9.63% HCRA Surcharge,6858,45,,6858,percent of total billed charges,Critical Access Hospital RCC factor,5181.6,34,,5181.6,percent of total billed charges,Implant Device,5181.6,34,,5181.6,percent of total billed charges,Implant Device,5181.6,34,,5181.6,percent of total billed charges,Implant Device,5181.6,34,,5181.6,percent of total billed charges,Implant Device,5181.6,34,,5181.6,percent of total billed charges,Implant Device,7543.8,,,7543.8,Other,110% of Medicare,5334,35,,5334,percent of total billed charges,Implant Device,5181.6,34,"Charges > $500, x 34%",5181.6,percent of total billed charges,Implant Device,5334,35,,5334,percent of total billed charges,Implant Device,5334,35,,5334,percent of total billed charges,Implant Device,5334,35,,5334,percent of total billed charges,Implant Device,5334,35,,5334,percent of total billed charges,Implant Device,5334,35,,5334,percent of total billed charges,Implant Device,6096,40,,6096,percent of total billed charges,Implant Device,5334,70,,5334,percent of total billed charges,All Other,5181.6,34,,5181.6,percent of total billed charges,Implant Device,5181.6,34,,5181.6,percent of total billed charges,Implant Device,5334,35,,5334,percent of total billed charges,Implant Device,5334,35,,5334,percent of total billed charges,Implant Device,5334,35,,5334,percent of total billed charges,Implant Device,5334,35,,5334,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,5181.6,34,"If Charge > 2,000, then 34 percent",5181.6,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,11277.64,
BIOMET 11-165240 BIPOLAR RINGLOC 28X58MM,C1776,HCPCS,,79005962,CDM,278,RC,,,both,,,6540,4839.62,,,4839.62,Other,150% of Medicare + 9.63% HCRA Surcharge,2943,45,,2943,percent of total billed charges,Critical Access Hospital RCC factor,2223.6,34,,2223.6,percent of total billed charges,Implant Device,2223.6,34,,2223.6,percent of total billed charges,Implant Device,2223.6,34,,2223.6,percent of total billed charges,Implant Device,2223.6,34,,2223.6,percent of total billed charges,Implant Device,2223.6,34,,2223.6,percent of total billed charges,Implant Device,3237.3,,,3237.3,Other,110% of Medicare,2289,35,,2289,percent of total billed charges,Implant Device,2223.6,34,"Charges > $500, x 34%",2223.6,percent of total billed charges,Implant Device,2289,35,,2289,percent of total billed charges,Implant Device,2289,35,,2289,percent of total billed charges,Implant Device,2289,35,,2289,percent of total billed charges,Implant Device,2289,35,,2289,percent of total billed charges,Implant Device,2289,35,,2289,percent of total billed charges,Implant Device,2616,40,,2616,percent of total billed charges,Implant Device,2289,70,,2289,percent of total billed charges,All Other,2223.6,34,,2223.6,percent of total billed charges,Implant Device,2223.6,34,,2223.6,percent of total billed charges,Implant Device,2289,35,,2289,percent of total billed charges,Implant Device,2289,35,,2289,percent of total billed charges,Implant Device,2289,35,,2289,percent of total billed charges,Implant Device,2289,35,,2289,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2223.6,34,"If Charge > 2,000, then 34 percent",2223.6,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4839.62,
SYNTHES 223.581 PLATE 8 HOLE 3.5X111MM,C1713,HCPCS,,79005963,CDM,278,RC,,,both,,,1506,1114.44,,,1114.44,Other,150% of Medicare + 9.63% HCRA Surcharge,677.7,45,,677.7,percent of total billed charges,Critical Access Hospital RCC factor,512.04,34,,512.04,percent of total billed charges,Implant Device,512.04,34,,512.04,percent of total billed charges,Implant Device,512.04,34,,512.04,percent of total billed charges,Implant Device,512.04,34,,512.04,percent of total billed charges,Implant Device,512.04,34,,512.04,percent of total billed charges,Implant Device,745.47,,,745.47,Other,110% of Medicare,527.1,35,,527.1,percent of total billed charges,Implant Device,512.04,34,"Charges > $500, x 34%",512.04,percent of total billed charges,Implant Device,527.1,35,,527.1,percent of total billed charges,Implant Device,527.1,35,,527.1,percent of total billed charges,Implant Device,527.1,35,,527.1,percent of total billed charges,Implant Device,527.1,35,,527.1,percent of total billed charges,Implant Device,527.1,35,,527.1,percent of total billed charges,Implant Device,602.4,40,,602.4,percent of total billed charges,Implant Device,527.1,70,,527.1,percent of total billed charges,All Other,512.04,34,,512.04,percent of total billed charges,Implant Device,512.04,34,,512.04,percent of total billed charges,Implant Device,527.1,35,,527.1,percent of total billed charges,Implant Device,527.1,35,,527.1,percent of total billed charges,Implant Device,527.1,35,,527.1,percent of total billed charges,Implant Device,527.1,35,,527.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1114.44,
SYNTHES 212.104 LOCKING SCREW 3.5X16MM,C1713,HCPCS,,79005964,CDM,278,RC,,,both,,,488,361.12,,,361.12,Other,150% of Medicare + 9.63% HCRA Surcharge,219.6,45,,219.6,percent of total billed charges,Critical Access Hospital RCC factor,165.92,34,,165.92,percent of total billed charges,Implant Device,165.92,34,,165.92,percent of total billed charges,Implant Device,165.92,34,,165.92,percent of total billed charges,Implant Device,165.92,34,,165.92,percent of total billed charges,Implant Device,165.92,34,,165.92,percent of total billed charges,Implant Device,241.56,,,241.56,Other,110% of Medicare,170.8,35,,170.8,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,170.8,35,,170.8,percent of total billed charges,Implant Device,170.8,35,,170.8,percent of total billed charges,Implant Device,170.8,35,,170.8,percent of total billed charges,Implant Device,170.8,35,,170.8,percent of total billed charges,Implant Device,170.8,35,,170.8,percent of total billed charges,Implant Device,195.2,40,,195.2,percent of total billed charges,Implant Device,170.8,70,,170.8,percent of total billed charges,All Other,165.92,34,,165.92,percent of total billed charges,Implant Device,165.92,34,,165.92,percent of total billed charges,Implant Device,170.8,35,,170.8,percent of total billed charges,Implant Device,170.8,35,,170.8,percent of total billed charges,Implant Device,170.8,35,,170.8,percent of total billed charges,Implant Device,170.8,35,,170.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,361.12,
SYNTHES 212.105 LOCKING SCREW 3.5X18MM,C1713,HCPCS,,79005965,CDM,278,RC,,,both,,,488,361.12,,,361.12,Other,150% of Medicare + 9.63% HCRA Surcharge,219.6,45,,219.6,percent of total billed charges,Critical Access Hospital RCC factor,165.92,34,,165.92,percent of total billed charges,Implant Device,165.92,34,,165.92,percent of total billed charges,Implant Device,165.92,34,,165.92,percent of total billed charges,Implant Device,165.92,34,,165.92,percent of total billed charges,Implant Device,165.92,34,,165.92,percent of total billed charges,Implant Device,241.56,,,241.56,Other,110% of Medicare,170.8,35,,170.8,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,170.8,35,,170.8,percent of total billed charges,Implant Device,170.8,35,,170.8,percent of total billed charges,Implant Device,170.8,35,,170.8,percent of total billed charges,Implant Device,170.8,35,,170.8,percent of total billed charges,Implant Device,170.8,35,,170.8,percent of total billed charges,Implant Device,195.2,40,,195.2,percent of total billed charges,Implant Device,170.8,70,,170.8,percent of total billed charges,All Other,165.92,34,,165.92,percent of total billed charges,Implant Device,165.92,34,,165.92,percent of total billed charges,Implant Device,170.8,35,,170.8,percent of total billed charges,Implant Device,170.8,35,,170.8,percent of total billed charges,Implant Device,170.8,35,,170.8,percent of total billed charges,Implant Device,170.8,35,,170.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,361.12,
SYNTHES 212.103 LOCKING SCREW 3.5X14MM,C1713,HCPCS,,79005966,CDM,278,RC,,,both,,,488,361.12,,,361.12,Other,150% of Medicare + 9.63% HCRA Surcharge,219.6,45,,219.6,percent of total billed charges,Critical Access Hospital RCC factor,165.92,34,,165.92,percent of total billed charges,Implant Device,165.92,34,,165.92,percent of total billed charges,Implant Device,165.92,34,,165.92,percent of total billed charges,Implant Device,165.92,34,,165.92,percent of total billed charges,Implant Device,165.92,34,,165.92,percent of total billed charges,Implant Device,241.56,,,241.56,Other,110% of Medicare,170.8,35,,170.8,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,170.8,35,,170.8,percent of total billed charges,Implant Device,170.8,35,,170.8,percent of total billed charges,Implant Device,170.8,35,,170.8,percent of total billed charges,Implant Device,170.8,35,,170.8,percent of total billed charges,Implant Device,170.8,35,,170.8,percent of total billed charges,Implant Device,195.2,40,,195.2,percent of total billed charges,Implant Device,170.8,70,,170.8,percent of total billed charges,All Other,165.92,34,,165.92,percent of total billed charges,Implant Device,165.92,34,,165.92,percent of total billed charges,Implant Device,170.8,35,,170.8,percent of total billed charges,Implant Device,170.8,35,,170.8,percent of total billed charges,Implant Device,170.8,35,,170.8,percent of total billed charges,Implant Device,170.8,35,,170.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,361.12,
STRYKER 59-17014 BONE SCREW 1.7X14MM,C1713,HCPCS,,79005968,CDM,278,RC,,,both,,,349,258.26,,,258.26,Other,150% of Medicare + 9.63% HCRA Surcharge,157.05,45,,157.05,percent of total billed charges,Critical Access Hospital RCC factor,118.66,34,,118.66,percent of total billed charges,Implant Device,118.66,34,,118.66,percent of total billed charges,Implant Device,118.66,34,,118.66,percent of total billed charges,Implant Device,118.66,34,,118.66,percent of total billed charges,Implant Device,118.66,34,,118.66,percent of total billed charges,Implant Device,172.76,,,172.76,Other,110% of Medicare,122.15,35,,122.15,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,122.15,35,,122.15,percent of total billed charges,Implant Device,122.15,35,,122.15,percent of total billed charges,Implant Device,122.15,35,,122.15,percent of total billed charges,Implant Device,122.15,35,,122.15,percent of total billed charges,Implant Device,122.15,35,,122.15,percent of total billed charges,Implant Device,139.6,40,,139.6,percent of total billed charges,Implant Device,122.15,70,,122.15,percent of total billed charges,All Other,118.66,34,,118.66,percent of total billed charges,Implant Device,118.66,34,,118.66,percent of total billed charges,Implant Device,122.15,35,,122.15,percent of total billed charges,Implant Device,122.15,35,,122.15,percent of total billed charges,Implant Device,122.15,35,,122.15,percent of total billed charges,Implant Device,122.15,35,,122.15,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,258.26,
STABILITY BIO 447-13808 ANT TIB ALLOGRFT,C1713,HCPCS,,79005969,CDM,278,RC,,,both,,,5326,3941.25,,,3941.25,Other,150% of Medicare + 9.63% HCRA Surcharge,2396.7,45,,2396.7,percent of total billed charges,Critical Access Hospital RCC factor,1810.84,34,,1810.84,percent of total billed charges,Implant Device,1810.84,34,,1810.84,percent of total billed charges,Implant Device,1810.84,34,,1810.84,percent of total billed charges,Implant Device,1810.84,34,,1810.84,percent of total billed charges,Implant Device,1810.84,34,,1810.84,percent of total billed charges,Implant Device,2636.37,,,2636.37,Other,110% of Medicare,1864.1,35,,1864.1,percent of total billed charges,Implant Device,1810.84,34,"Charges > $500, x 34%",1810.84,percent of total billed charges,Implant Device,1864.1,35,,1864.1,percent of total billed charges,Implant Device,1864.1,35,,1864.1,percent of total billed charges,Implant Device,1864.1,35,,1864.1,percent of total billed charges,Implant Device,1864.1,35,,1864.1,percent of total billed charges,Implant Device,1864.1,35,,1864.1,percent of total billed charges,Implant Device,2130.4,40,,2130.4,percent of total billed charges,Implant Device,1864.1,70,,1864.1,percent of total billed charges,All Other,1810.84,34,,1810.84,percent of total billed charges,Implant Device,1810.84,34,,1810.84,percent of total billed charges,Implant Device,1864.1,35,,1864.1,percent of total billed charges,Implant Device,1864.1,35,,1864.1,percent of total billed charges,Implant Device,1864.1,35,,1864.1,percent of total billed charges,Implant Device,1864.1,35,,1864.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1810.84,34,"If Charge > 2,000, then 34 percent",1810.84,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3941.25,
BIOMET DVRANL DVR ANATOMIC PLATE LT,C1776,HCPCS,,79005971,CDM,278,RC,,,both,,,2394,1771.57,,,1771.57,Other,150% of Medicare + 9.63% HCRA Surcharge,1077.3,45,,1077.3,percent of total billed charges,Critical Access Hospital RCC factor,813.96,34,,813.96,percent of total billed charges,Implant Device,813.96,34,,813.96,percent of total billed charges,Implant Device,813.96,34,,813.96,percent of total billed charges,Implant Device,813.96,34,,813.96,percent of total billed charges,Implant Device,813.96,34,,813.96,percent of total billed charges,Implant Device,1185.03,,,1185.03,Other,110% of Medicare,837.9,35,,837.9,percent of total billed charges,Implant Device,813.96,34,"Charges > $500, x 34%",813.96,percent of total billed charges,Implant Device,837.9,35,,837.9,percent of total billed charges,Implant Device,837.9,35,,837.9,percent of total billed charges,Implant Device,837.9,35,,837.9,percent of total billed charges,Implant Device,837.9,35,,837.9,percent of total billed charges,Implant Device,837.9,35,,837.9,percent of total billed charges,Implant Device,957.6,40,,957.6,percent of total billed charges,Implant Device,837.9,70,,837.9,percent of total billed charges,All Other,813.96,34,,813.96,percent of total billed charges,Implant Device,813.96,34,,813.96,percent of total billed charges,Implant Device,837.9,35,,837.9,percent of total billed charges,Implant Device,837.9,35,,837.9,percent of total billed charges,Implant Device,837.9,35,,837.9,percent of total billed charges,Implant Device,837.9,35,,837.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,813.96,34,"If Charge > 2,000, then 34 percent",813.96,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1771.57,
STRYKER 6194-1-001 SIMPLEX HV CEMENT,C1713,HCPCS,,79005972,CDM,278,RC,,,both,,,314,232.36,,,232.36,Other,150% of Medicare + 9.63% HCRA Surcharge,141.3,45,,141.3,percent of total billed charges,Critical Access Hospital RCC factor,106.76,34,,106.76,percent of total billed charges,Implant Device,106.76,34,,106.76,percent of total billed charges,Implant Device,106.76,34,,106.76,percent of total billed charges,Implant Device,106.76,34,,106.76,percent of total billed charges,Implant Device,106.76,34,,106.76,percent of total billed charges,Implant Device,155.43,,,155.43,Other,110% of Medicare,109.9,35,,109.9,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,109.9,35,,109.9,percent of total billed charges,Implant Device,109.9,35,,109.9,percent of total billed charges,Implant Device,109.9,35,,109.9,percent of total billed charges,Implant Device,109.9,35,,109.9,percent of total billed charges,Implant Device,109.9,35,,109.9,percent of total billed charges,Implant Device,125.6,40,,125.6,percent of total billed charges,Implant Device,109.9,70,,109.9,percent of total billed charges,All Other,106.76,34,,106.76,percent of total billed charges,Implant Device,106.76,34,,106.76,percent of total billed charges,Implant Device,109.9,35,,109.9,percent of total billed charges,Implant Device,109.9,35,,109.9,percent of total billed charges,Implant Device,109.9,35,,109.9,percent of total billed charges,Implant Device,109.9,35,,109.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,232.36,
ARTHREX AR-14120 LOCKING SCREW 3.5X28MM,C1713,HCPCS,,79005973,CDM,278,RC,,,both,,,336,248.64,,,248.64,Other,150% of Medicare + 9.63% HCRA Surcharge,151.2,45,,151.2,percent of total billed charges,Critical Access Hospital RCC factor,114.24,34,,114.24,percent of total billed charges,Implant Device,114.24,34,,114.24,percent of total billed charges,Implant Device,114.24,34,,114.24,percent of total billed charges,Implant Device,114.24,34,,114.24,percent of total billed charges,Implant Device,114.24,34,,114.24,percent of total billed charges,Implant Device,166.32,,,166.32,Other,110% of Medicare,117.6,35,,117.6,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,117.6,35,,117.6,percent of total billed charges,Implant Device,117.6,35,,117.6,percent of total billed charges,Implant Device,117.6,35,,117.6,percent of total billed charges,Implant Device,117.6,35,,117.6,percent of total billed charges,Implant Device,117.6,35,,117.6,percent of total billed charges,Implant Device,134.4,40,,134.4,percent of total billed charges,Implant Device,117.6,70,,117.6,percent of total billed charges,All Other,114.24,34,,114.24,percent of total billed charges,Implant Device,114.24,34,,114.24,percent of total billed charges,Implant Device,117.6,35,,117.6,percent of total billed charges,Implant Device,117.6,35,,117.6,percent of total billed charges,Implant Device,117.6,35,,117.6,percent of total billed charges,Implant Device,117.6,35,,117.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,248.64,
ARTHREX AR-14244 LOCKING SCREW 4.0X44MM,C1713,HCPCS,,79005974,CDM,278,RC,,,both,,,336,248.64,,,248.64,Other,150% of Medicare + 9.63% HCRA Surcharge,151.2,45,,151.2,percent of total billed charges,Critical Access Hospital RCC factor,114.24,34,,114.24,percent of total billed charges,Implant Device,114.24,34,,114.24,percent of total billed charges,Implant Device,114.24,34,,114.24,percent of total billed charges,Implant Device,114.24,34,,114.24,percent of total billed charges,Implant Device,114.24,34,,114.24,percent of total billed charges,Implant Device,166.32,,,166.32,Other,110% of Medicare,117.6,35,,117.6,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,117.6,35,,117.6,percent of total billed charges,Implant Device,117.6,35,,117.6,percent of total billed charges,Implant Device,117.6,35,,117.6,percent of total billed charges,Implant Device,117.6,35,,117.6,percent of total billed charges,Implant Device,117.6,35,,117.6,percent of total billed charges,Implant Device,134.4,40,,134.4,percent of total billed charges,Implant Device,117.6,70,,117.6,percent of total billed charges,All Other,114.24,34,,114.24,percent of total billed charges,Implant Device,114.24,34,,114.24,percent of total billed charges,Implant Device,117.6,35,,117.6,percent of total billed charges,Implant Device,117.6,35,,117.6,percent of total billed charges,Implant Device,117.6,35,,117.6,percent of total billed charges,Implant Device,117.6,35,,117.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,248.64,
SYNTHES 214.056 CORTEX SCREW 4.5X56MM,C1713,HCPCS,,79005975,CDM,278,RC,,,both,,,53,39.22,,,39.22,Other,150% of Medicare + 9.63% HCRA Surcharge,23.85,45,,23.85,percent of total billed charges,Critical Access Hospital RCC factor,18.02,34,,18.02,percent of total billed charges,Implant Device,18.02,34,,18.02,percent of total billed charges,Implant Device,18.02,34,,18.02,percent of total billed charges,Implant Device,18.02,34,,18.02,percent of total billed charges,Implant Device,18.02,34,,18.02,percent of total billed charges,Implant Device,26.24,,,26.24,Other,110% of Medicare,18.55,35,,18.55,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,18.55,35,,18.55,percent of total billed charges,Implant Device,18.55,35,,18.55,percent of total billed charges,Implant Device,18.55,35,,18.55,percent of total billed charges,Implant Device,18.55,35,,18.55,percent of total billed charges,Implant Device,18.55,35,,18.55,percent of total billed charges,Implant Device,21.2,40,,21.2,percent of total billed charges,Implant Device,18.55,70,,18.55,percent of total billed charges,All Other,18.02,34,,18.02,percent of total billed charges,Implant Device,18.02,34,,18.02,percent of total billed charges,Implant Device,18.55,35,,18.55,percent of total billed charges,Implant Device,18.55,35,,18.55,percent of total billed charges,Implant Device,18.55,35,,18.55,percent of total billed charges,Implant Device,18.55,35,,18.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,39.22,
SYNTHES 214.050 CORTEX SCREW 4.5X50MM,C1713,HCPCS,,79005976,CDM,278,RC,,,both,,,56,41.44,,,41.44,Other,150% of Medicare + 9.63% HCRA Surcharge,25.2,45,,25.2,percent of total billed charges,Critical Access Hospital RCC factor,19.04,34,,19.04,percent of total billed charges,Implant Device,19.04,34,,19.04,percent of total billed charges,Implant Device,19.04,34,,19.04,percent of total billed charges,Implant Device,19.04,34,,19.04,percent of total billed charges,Implant Device,19.04,34,,19.04,percent of total billed charges,Implant Device,27.72,,,27.72,Other,110% of Medicare,19.6,35,,19.6,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,19.6,35,,19.6,percent of total billed charges,Implant Device,19.6,35,,19.6,percent of total billed charges,Implant Device,19.6,35,,19.6,percent of total billed charges,Implant Device,19.6,35,,19.6,percent of total billed charges,Implant Device,19.6,35,,19.6,percent of total billed charges,Implant Device,22.4,40,,22.4,percent of total billed charges,Implant Device,19.6,70,,19.6,percent of total billed charges,All Other,19.04,34,,19.04,percent of total billed charges,Implant Device,19.04,34,,19.04,percent of total billed charges,Implant Device,19.6,35,,19.6,percent of total billed charges,Implant Device,19.6,35,,19.6,percent of total billed charges,Implant Device,19.6,35,,19.6,percent of total billed charges,Implant Device,19.6,35,,19.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,41.44,
STRYKER 629286 PLATE EXT MEDIAL 6 HOLE,C1713,HCPCS,,79005977,CDM,278,RC,,,both,,,3883,2873.43,,,2873.43,Other,150% of Medicare + 9.63% HCRA Surcharge,1747.35,45,,1747.35,percent of total billed charges,Critical Access Hospital RCC factor,1320.22,34,,1320.22,percent of total billed charges,Implant Device,1320.22,34,,1320.22,percent of total billed charges,Implant Device,1320.22,34,,1320.22,percent of total billed charges,Implant Device,1320.22,34,,1320.22,percent of total billed charges,Implant Device,1320.22,34,,1320.22,percent of total billed charges,Implant Device,1922.09,,,1922.09,Other,110% of Medicare,1359.05,35,,1359.05,percent of total billed charges,Implant Device,1320.22,34,"Charges > $500, x 34%",1320.22,percent of total billed charges,Implant Device,1359.05,35,,1359.05,percent of total billed charges,Implant Device,1359.05,35,,1359.05,percent of total billed charges,Implant Device,1359.05,35,,1359.05,percent of total billed charges,Implant Device,1359.05,35,,1359.05,percent of total billed charges,Implant Device,1359.05,35,,1359.05,percent of total billed charges,Implant Device,1553.2,40,,1553.2,percent of total billed charges,Implant Device,1359.05,70,,1359.05,percent of total billed charges,All Other,1320.22,34,,1320.22,percent of total billed charges,Implant Device,1320.22,34,,1320.22,percent of total billed charges,Implant Device,1359.05,35,,1359.05,percent of total billed charges,Implant Device,1359.05,35,,1359.05,percent of total billed charges,Implant Device,1359.05,35,,1359.05,percent of total billed charges,Implant Device,1359.05,35,,1359.05,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1320.22,34,"If Charge > 2,000, then 34 percent",1320.22,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2873.43,
STRYKER 614865 CORTICAL SCREW 3.5X65MM,C1713,HCPCS,,79005978,CDM,278,RC,,,both,,,331,244.94,,,244.94,Other,150% of Medicare + 9.63% HCRA Surcharge,148.95,45,,148.95,percent of total billed charges,Critical Access Hospital RCC factor,112.54,34,,112.54,percent of total billed charges,Implant Device,112.54,34,,112.54,percent of total billed charges,Implant Device,112.54,34,,112.54,percent of total billed charges,Implant Device,112.54,34,,112.54,percent of total billed charges,Implant Device,112.54,34,,112.54,percent of total billed charges,Implant Device,163.85,,,163.85,Other,110% of Medicare,115.85,35,,115.85,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,115.85,35,,115.85,percent of total billed charges,Implant Device,115.85,35,,115.85,percent of total billed charges,Implant Device,115.85,35,,115.85,percent of total billed charges,Implant Device,115.85,35,,115.85,percent of total billed charges,Implant Device,115.85,35,,115.85,percent of total billed charges,Implant Device,132.4,40,,132.4,percent of total billed charges,Implant Device,115.85,70,,115.85,percent of total billed charges,All Other,112.54,34,,112.54,percent of total billed charges,Implant Device,112.54,34,,112.54,percent of total billed charges,Implant Device,115.85,35,,115.85,percent of total billed charges,Implant Device,115.85,35,,115.85,percent of total billed charges,Implant Device,115.85,35,,115.85,percent of total billed charges,Implant Device,115.85,35,,115.85,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,244.94,
STRYKER 614660 LOCKING SCREW 3.5X60MM,C1713,HCPCS,,79005979,CDM,278,RC,,,both,,,666,492.84,,,492.84,Other,150% of Medicare + 9.63% HCRA Surcharge,299.7,45,,299.7,percent of total billed charges,Critical Access Hospital RCC factor,226.44,34,,226.44,percent of total billed charges,Implant Device,226.44,34,,226.44,percent of total billed charges,Implant Device,226.44,34,,226.44,percent of total billed charges,Implant Device,226.44,34,,226.44,percent of total billed charges,Implant Device,226.44,34,,226.44,percent of total billed charges,Implant Device,329.67,,,329.67,Other,110% of Medicare,233.1,35,,233.1,percent of total billed charges,Implant Device,226.44,34,"Charges > $500, x 34%",226.44,percent of total billed charges,Implant Device,233.1,35,,233.1,percent of total billed charges,Implant Device,233.1,35,,233.1,percent of total billed charges,Implant Device,233.1,35,,233.1,percent of total billed charges,Implant Device,233.1,35,,233.1,percent of total billed charges,Implant Device,233.1,35,,233.1,percent of total billed charges,Implant Device,266.4,40,,266.4,percent of total billed charges,Implant Device,233.1,70,,233.1,percent of total billed charges,All Other,226.44,34,,226.44,percent of total billed charges,Implant Device,226.44,34,,226.44,percent of total billed charges,Implant Device,233.1,35,,233.1,percent of total billed charges,Implant Device,233.1,35,,233.1,percent of total billed charges,Implant Device,233.1,35,,233.1,percent of total billed charges,Implant Device,233.1,35,,233.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,492.84,
STRYKER 614630 LOCKING SCREW 3.5X30MM,C1713,HCPCS,,79005980,CDM,278,RC,,,both,,,666,492.84,,,492.84,Other,150% of Medicare + 9.63% HCRA Surcharge,299.7,45,,299.7,percent of total billed charges,Critical Access Hospital RCC factor,226.44,34,,226.44,percent of total billed charges,Implant Device,226.44,34,,226.44,percent of total billed charges,Implant Device,226.44,34,,226.44,percent of total billed charges,Implant Device,226.44,34,,226.44,percent of total billed charges,Implant Device,226.44,34,,226.44,percent of total billed charges,Implant Device,329.67,,,329.67,Other,110% of Medicare,233.1,35,,233.1,percent of total billed charges,Implant Device,226.44,34,"Charges > $500, x 34%",226.44,percent of total billed charges,Implant Device,233.1,35,,233.1,percent of total billed charges,Implant Device,233.1,35,,233.1,percent of total billed charges,Implant Device,233.1,35,,233.1,percent of total billed charges,Implant Device,233.1,35,,233.1,percent of total billed charges,Implant Device,233.1,35,,233.1,percent of total billed charges,Implant Device,266.4,40,,266.4,percent of total billed charges,Implant Device,233.1,70,,233.1,percent of total billed charges,All Other,226.44,34,,226.44,percent of total billed charges,Implant Device,226.44,34,,226.44,percent of total billed charges,Implant Device,233.1,35,,233.1,percent of total billed charges,Implant Device,233.1,35,,233.1,percent of total billed charges,Implant Device,233.1,35,,233.1,percent of total billed charges,Implant Device,233.1,35,,233.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,492.84,
STRYKER 629244 PLATE POSTERIOR LATERAL,C1713,HCPCS,,79005981,CDM,278,RC,,,both,,,3051,2257.75,,,2257.75,Other,150% of Medicare + 9.63% HCRA Surcharge,1372.95,45,,1372.95,percent of total billed charges,Critical Access Hospital RCC factor,1037.34,34,,1037.34,percent of total billed charges,Implant Device,1037.34,34,,1037.34,percent of total billed charges,Implant Device,1037.34,34,,1037.34,percent of total billed charges,Implant Device,1037.34,34,,1037.34,percent of total billed charges,Implant Device,1037.34,34,,1037.34,percent of total billed charges,Implant Device,1510.25,,,1510.25,Other,110% of Medicare,1067.85,35,,1067.85,percent of total billed charges,Implant Device,1037.34,34,"Charges > $500, x 34%",1037.34,percent of total billed charges,Implant Device,1067.85,35,,1067.85,percent of total billed charges,Implant Device,1067.85,35,,1067.85,percent of total billed charges,Implant Device,1067.85,35,,1067.85,percent of total billed charges,Implant Device,1067.85,35,,1067.85,percent of total billed charges,Implant Device,1067.85,35,,1067.85,percent of total billed charges,Implant Device,1220.4,40,,1220.4,percent of total billed charges,Implant Device,1067.85,70,,1067.85,percent of total billed charges,All Other,1037.34,34,,1037.34,percent of total billed charges,Implant Device,1037.34,34,,1037.34,percent of total billed charges,Implant Device,1067.85,35,,1067.85,percent of total billed charges,Implant Device,1067.85,35,,1067.85,percent of total billed charges,Implant Device,1067.85,35,,1067.85,percent of total billed charges,Implant Device,1067.85,35,,1067.85,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1037.34,34,"If Charge > 2,000, then 34 percent",1037.34,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2257.75,
STRYKER 614812 CORTICAL SCREW 3.5X12MM,C1713,HCPCS,,79005982,CDM,278,RC,,,both,,,331,244.94,,,244.94,Other,150% of Medicare + 9.63% HCRA Surcharge,148.95,45,,148.95,percent of total billed charges,Critical Access Hospital RCC factor,112.54,34,,112.54,percent of total billed charges,Implant Device,112.54,34,,112.54,percent of total billed charges,Implant Device,112.54,34,,112.54,percent of total billed charges,Implant Device,112.54,34,,112.54,percent of total billed charges,Implant Device,112.54,34,,112.54,percent of total billed charges,Implant Device,163.85,,,163.85,Other,110% of Medicare,115.85,35,,115.85,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,115.85,35,,115.85,percent of total billed charges,Implant Device,115.85,35,,115.85,percent of total billed charges,Implant Device,115.85,35,,115.85,percent of total billed charges,Implant Device,115.85,35,,115.85,percent of total billed charges,Implant Device,115.85,35,,115.85,percent of total billed charges,Implant Device,132.4,40,,132.4,percent of total billed charges,Implant Device,115.85,70,,115.85,percent of total billed charges,All Other,112.54,34,,112.54,percent of total billed charges,Implant Device,112.54,34,,112.54,percent of total billed charges,Implant Device,115.85,35,,115.85,percent of total billed charges,Implant Device,115.85,35,,115.85,percent of total billed charges,Implant Device,115.85,35,,115.85,percent of total billed charges,Implant Device,115.85,35,,115.85,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,244.94,
ARTHREX AR-14128 LOCKING SCREW 3.5X28MM,C1713,HCPCS,,79005984,CDM,278,RC,,,both,,,336,248.64,,,248.64,Other,150% of Medicare + 9.63% HCRA Surcharge,151.2,45,,151.2,percent of total billed charges,Critical Access Hospital RCC factor,114.24,34,,114.24,percent of total billed charges,Implant Device,114.24,34,,114.24,percent of total billed charges,Implant Device,114.24,34,,114.24,percent of total billed charges,Implant Device,114.24,34,,114.24,percent of total billed charges,Implant Device,114.24,34,,114.24,percent of total billed charges,Implant Device,166.32,,,166.32,Other,110% of Medicare,117.6,35,,117.6,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,117.6,35,,117.6,percent of total billed charges,Implant Device,117.6,35,,117.6,percent of total billed charges,Implant Device,117.6,35,,117.6,percent of total billed charges,Implant Device,117.6,35,,117.6,percent of total billed charges,Implant Device,117.6,35,,117.6,percent of total billed charges,Implant Device,134.4,40,,134.4,percent of total billed charges,Implant Device,117.6,70,,117.6,percent of total billed charges,All Other,114.24,34,,114.24,percent of total billed charges,Implant Device,114.24,34,,114.24,percent of total billed charges,Implant Device,117.6,35,,117.6,percent of total billed charges,Implant Device,117.6,35,,117.6,percent of total billed charges,Implant Device,117.6,35,,117.6,percent of total billed charges,Implant Device,117.6,35,,117.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,248.64,
MIMEDX AI-5050 AMNIOFIX MEMBRANE 0.5ML,C1713,HCPCS,,79005985,CDM,278,RC,,,both,,,2242,1659.09,,,1659.09,Other,150% of Medicare + 9.63% HCRA Surcharge,1008.9,45,,1008.9,percent of total billed charges,Critical Access Hospital RCC factor,762.28,34,,762.28,percent of total billed charges,Implant Device,762.28,34,,762.28,percent of total billed charges,Implant Device,762.28,34,,762.28,percent of total billed charges,Implant Device,762.28,34,,762.28,percent of total billed charges,Implant Device,762.28,34,,762.28,percent of total billed charges,Implant Device,1109.79,,,1109.79,Other,110% of Medicare,784.7,35,,784.7,percent of total billed charges,Implant Device,762.28,34,"Charges > $500, x 34%",762.28,percent of total billed charges,Implant Device,784.7,35,,784.7,percent of total billed charges,Implant Device,784.7,35,,784.7,percent of total billed charges,Implant Device,784.7,35,,784.7,percent of total billed charges,Implant Device,784.7,35,,784.7,percent of total billed charges,Implant Device,784.7,35,,784.7,percent of total billed charges,Implant Device,896.8,40,,896.8,percent of total billed charges,Implant Device,784.7,70,,784.7,percent of total billed charges,All Other,762.28,34,,762.28,percent of total billed charges,Implant Device,762.28,34,,762.28,percent of total billed charges,Implant Device,784.7,35,,784.7,percent of total billed charges,Implant Device,784.7,35,,784.7,percent of total billed charges,Implant Device,784.7,35,,784.7,percent of total billed charges,Implant Device,784.7,35,,784.7,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,762.28,34,"If Charge > 2,000, then 34 percent",762.28,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1659.09,
MIMEDX TN-5240 AMNIOFIX MEMBRANE 2X4CM,C1713,HCPCS,,79005986,CDM,278,RC,,,both,,,3885,2874.91,,,2874.91,Other,150% of Medicare + 9.63% HCRA Surcharge,1748.25,45,,1748.25,percent of total billed charges,Critical Access Hospital RCC factor,1320.9,34,,1320.9,percent of total billed charges,Implant Device,1320.9,34,,1320.9,percent of total billed charges,Implant Device,1320.9,34,,1320.9,percent of total billed charges,Implant Device,1320.9,34,,1320.9,percent of total billed charges,Implant Device,1320.9,34,,1320.9,percent of total billed charges,Implant Device,1923.08,,,1923.08,Other,110% of Medicare,1359.75,35,,1359.75,percent of total billed charges,Implant Device,1320.9,34,"Charges > $500, x 34%",1320.9,percent of total billed charges,Implant Device,1359.75,35,,1359.75,percent of total billed charges,Implant Device,1359.75,35,,1359.75,percent of total billed charges,Implant Device,1359.75,35,,1359.75,percent of total billed charges,Implant Device,1359.75,35,,1359.75,percent of total billed charges,Implant Device,1359.75,35,,1359.75,percent of total billed charges,Implant Device,1554,40,,1554,percent of total billed charges,Implant Device,1359.75,70,,1359.75,percent of total billed charges,All Other,1320.9,34,,1320.9,percent of total billed charges,Implant Device,1320.9,34,,1320.9,percent of total billed charges,Implant Device,1359.75,35,,1359.75,percent of total billed charges,Implant Device,1359.75,35,,1359.75,percent of total billed charges,Implant Device,1359.75,35,,1359.75,percent of total billed charges,Implant Device,1359.75,35,,1359.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1320.9,34,"If Charge > 2,000, then 34 percent",1320.9,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2874.91,
STRYKER 40-35610 LOCKING SCREW 3.5X10MM,C1713,HCPCS,,79005988,CDM,278,RC,,,both,,,379,280.46,,,280.46,Other,150% of Medicare + 9.63% HCRA Surcharge,170.55,45,,170.55,percent of total billed charges,Critical Access Hospital RCC factor,128.86,34,,128.86,percent of total billed charges,Implant Device,128.86,34,,128.86,percent of total billed charges,Implant Device,128.86,34,,128.86,percent of total billed charges,Implant Device,128.86,34,,128.86,percent of total billed charges,Implant Device,128.86,34,,128.86,percent of total billed charges,Implant Device,187.61,,,187.61,Other,110% of Medicare,132.65,35,,132.65,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,132.65,35,,132.65,percent of total billed charges,Implant Device,132.65,35,,132.65,percent of total billed charges,Implant Device,132.65,35,,132.65,percent of total billed charges,Implant Device,132.65,35,,132.65,percent of total billed charges,Implant Device,132.65,35,,132.65,percent of total billed charges,Implant Device,151.6,40,,151.6,percent of total billed charges,Implant Device,132.65,70,,132.65,percent of total billed charges,All Other,128.86,34,,128.86,percent of total billed charges,Implant Device,128.86,34,,128.86,percent of total billed charges,Implant Device,132.65,35,,132.65,percent of total billed charges,Implant Device,132.65,35,,132.65,percent of total billed charges,Implant Device,132.65,35,,132.65,percent of total billed charges,Implant Device,132.65,35,,132.65,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,280.46,
STRYKER 325240S CANNULATED SCREW 4X40MM,C1713,HCPCS,,79005989,CDM,278,RC,,,both,,,660,488.4,,,488.4,Other,150% of Medicare + 9.63% HCRA Surcharge,297,45,,297,percent of total billed charges,Critical Access Hospital RCC factor,224.4,34,,224.4,percent of total billed charges,Implant Device,224.4,34,,224.4,percent of total billed charges,Implant Device,224.4,34,,224.4,percent of total billed charges,Implant Device,224.4,34,,224.4,percent of total billed charges,Implant Device,224.4,34,,224.4,percent of total billed charges,Implant Device,326.7,,,326.7,Other,110% of Medicare,231,35,,231,percent of total billed charges,Implant Device,224.4,34,"Charges > $500, x 34%",224.4,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,264,40,,264,percent of total billed charges,Implant Device,231,70,,231,percent of total billed charges,All Other,224.4,34,,224.4,percent of total billed charges,Implant Device,224.4,34,,224.4,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,488.4,
EXACTECH 652-00-02 OPTECURE DBM 2CC,C1713,HCPCS,,79005990,CDM,278,RC,,,both,,,2085,1542.91,,,1542.91,Other,150% of Medicare + 9.63% HCRA Surcharge,938.25,45,,938.25,percent of total billed charges,Critical Access Hospital RCC factor,708.9,34,,708.9,percent of total billed charges,Implant Device,708.9,34,,708.9,percent of total billed charges,Implant Device,708.9,34,,708.9,percent of total billed charges,Implant Device,708.9,34,,708.9,percent of total billed charges,Implant Device,708.9,34,,708.9,percent of total billed charges,Implant Device,1032.08,,,1032.08,Other,110% of Medicare,729.75,35,,729.75,percent of total billed charges,Implant Device,708.9,34,"Charges > $500, x 34%",708.9,percent of total billed charges,Implant Device,729.75,35,,729.75,percent of total billed charges,Implant Device,729.75,35,,729.75,percent of total billed charges,Implant Device,729.75,35,,729.75,percent of total billed charges,Implant Device,729.75,35,,729.75,percent of total billed charges,Implant Device,729.75,35,,729.75,percent of total billed charges,Implant Device,834,40,,834,percent of total billed charges,Implant Device,729.75,70,,729.75,percent of total billed charges,All Other,708.9,34,,708.9,percent of total billed charges,Implant Device,708.9,34,,708.9,percent of total billed charges,Implant Device,729.75,35,,729.75,percent of total billed charges,Implant Device,729.75,35,,729.75,percent of total billed charges,Implant Device,729.75,35,,729.75,percent of total billed charges,Implant Device,729.75,35,,729.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,708.9,34,"If Charge > 2,000, then 34 percent",708.9,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1542.91,
BIOMET/EBI 8162-35-010 PLATE 10 HOLE,C1713,HCPCS,,79005991,CDM,278,RC,,,both,,,1230,910.2,,,910.2,Other,150% of Medicare + 9.63% HCRA Surcharge,553.5,45,,553.5,percent of total billed charges,Critical Access Hospital RCC factor,418.2,34,,418.2,percent of total billed charges,Implant Device,418.2,34,,418.2,percent of total billed charges,Implant Device,418.2,34,,418.2,percent of total billed charges,Implant Device,418.2,34,,418.2,percent of total billed charges,Implant Device,418.2,34,,418.2,percent of total billed charges,Implant Device,608.85,,,608.85,Other,110% of Medicare,430.5,35,,430.5,percent of total billed charges,Implant Device,418.2,34,"Charges > $500, x 34%",418.2,percent of total billed charges,Implant Device,430.5,35,,430.5,percent of total billed charges,Implant Device,430.5,35,,430.5,percent of total billed charges,Implant Device,430.5,35,,430.5,percent of total billed charges,Implant Device,430.5,35,,430.5,percent of total billed charges,Implant Device,430.5,35,,430.5,percent of total billed charges,Implant Device,492,40,,492,percent of total billed charges,Implant Device,430.5,70,,430.5,percent of total billed charges,All Other,418.2,34,,418.2,percent of total billed charges,Implant Device,418.2,34,,418.2,percent of total billed charges,Implant Device,430.5,35,,430.5,percent of total billed charges,Implant Device,430.5,35,,430.5,percent of total billed charges,Implant Device,430.5,35,,430.5,percent of total billed charges,Implant Device,430.5,35,,430.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,910.2,
ARTHREX AR-8967-1860 CANN SCREW 6.7X60MM,C1713,HCPCS,,79005992,CDM,278,RC,,,both,,,1074,794.76,,,794.76,Other,150% of Medicare + 9.63% HCRA Surcharge,483.3,45,,483.3,percent of total billed charges,Critical Access Hospital RCC factor,365.16,34,,365.16,percent of total billed charges,Implant Device,365.16,34,,365.16,percent of total billed charges,Implant Device,365.16,34,,365.16,percent of total billed charges,Implant Device,365.16,34,,365.16,percent of total billed charges,Implant Device,365.16,34,,365.16,percent of total billed charges,Implant Device,531.63,,,531.63,Other,110% of Medicare,375.9,35,,375.9,percent of total billed charges,Implant Device,365.16,34,"Charges > $500, x 34%",365.16,percent of total billed charges,Implant Device,375.9,35,,375.9,percent of total billed charges,Implant Device,375.9,35,,375.9,percent of total billed charges,Implant Device,375.9,35,,375.9,percent of total billed charges,Implant Device,375.9,35,,375.9,percent of total billed charges,Implant Device,375.9,35,,375.9,percent of total billed charges,Implant Device,429.6,40,,429.6,percent of total billed charges,Implant Device,375.9,70,,375.9,percent of total billed charges,All Other,365.16,34,,365.16,percent of total billed charges,Implant Device,365.16,34,,365.16,percent of total billed charges,Implant Device,375.9,35,,375.9,percent of total billed charges,Implant Device,375.9,35,,375.9,percent of total billed charges,Implant Device,375.9,35,,375.9,percent of total billed charges,Implant Device,375.9,35,,375.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,794.76,
ARTHREX AR-1680PS TENODESIS SCREW 8X12MM,C1713,HCPCS,,79005994,CDM,278,RC,,,both,,,946,700.04,,,700.04,Other,150% of Medicare + 9.63% HCRA Surcharge,425.7,45,,425.7,percent of total billed charges,Critical Access Hospital RCC factor,321.64,34,,321.64,percent of total billed charges,Implant Device,321.64,34,,321.64,percent of total billed charges,Implant Device,321.64,34,,321.64,percent of total billed charges,Implant Device,321.64,34,,321.64,percent of total billed charges,Implant Device,321.64,34,,321.64,percent of total billed charges,Implant Device,468.27,,,468.27,Other,110% of Medicare,331.1,35,,331.1,percent of total billed charges,Implant Device,321.64,34,"Charges > $500, x 34%",321.64,percent of total billed charges,Implant Device,331.1,35,,331.1,percent of total billed charges,Implant Device,331.1,35,,331.1,percent of total billed charges,Implant Device,331.1,35,,331.1,percent of total billed charges,Implant Device,331.1,35,,331.1,percent of total billed charges,Implant Device,331.1,35,,331.1,percent of total billed charges,Implant Device,378.4,40,,378.4,percent of total billed charges,Implant Device,331.1,70,,331.1,percent of total billed charges,All Other,321.64,34,,321.64,percent of total billed charges,Implant Device,321.64,34,,321.64,percent of total billed charges,Implant Device,331.1,35,,331.1,percent of total billed charges,Implant Device,331.1,35,,331.1,percent of total billed charges,Implant Device,331.1,35,,331.1,percent of total billed charges,Implant Device,331.1,35,,331.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,700.04,
ARTHREX AR-2657DL CLAVICLE PLATE 8 HOLE,C1713,HCPCS,,79005995,CDM,278,RC,,,both,,,1650,1221,,,1221,Other,150% of Medicare + 9.63% HCRA Surcharge,742.5,45,,742.5,percent of total billed charges,Critical Access Hospital RCC factor,561,34,,561,percent of total billed charges,Implant Device,561,34,,561,percent of total billed charges,Implant Device,561,34,,561,percent of total billed charges,Implant Device,561,34,,561,percent of total billed charges,Implant Device,561,34,,561,percent of total billed charges,Implant Device,816.75,,,816.75,Other,110% of Medicare,577.5,35,,577.5,percent of total billed charges,Implant Device,561,34,"Charges > $500, x 34%",561,percent of total billed charges,Implant Device,577.5,35,,577.5,percent of total billed charges,Implant Device,577.5,35,,577.5,percent of total billed charges,Implant Device,577.5,35,,577.5,percent of total billed charges,Implant Device,577.5,35,,577.5,percent of total billed charges,Implant Device,577.5,35,,577.5,percent of total billed charges,Implant Device,660,40,,660,percent of total billed charges,Implant Device,577.5,70,,577.5,percent of total billed charges,All Other,561,34,,561,percent of total billed charges,Implant Device,561,34,,561,percent of total billed charges,Implant Device,577.5,35,,577.5,percent of total billed charges,Implant Device,577.5,35,,577.5,percent of total billed charges,Implant Device,577.5,35,,577.5,percent of total billed charges,Implant Device,577.5,35,,577.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1221,
ARTHREX AR-8830-12 CANC SCREW 3X12MM,C1713,HCPCS,,79005996,CDM,278,RC,,,both,,,106,78.44,,,78.44,Other,150% of Medicare + 9.63% HCRA Surcharge,47.7,45,,47.7,percent of total billed charges,Critical Access Hospital RCC factor,36.04,34,,36.04,percent of total billed charges,Implant Device,36.04,34,,36.04,percent of total billed charges,Implant Device,36.04,34,,36.04,percent of total billed charges,Implant Device,36.04,34,,36.04,percent of total billed charges,Implant Device,36.04,34,,36.04,percent of total billed charges,Implant Device,52.47,,,52.47,Other,110% of Medicare,37.1,35,,37.1,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,37.1,35,,37.1,percent of total billed charges,Implant Device,37.1,35,,37.1,percent of total billed charges,Implant Device,37.1,35,,37.1,percent of total billed charges,Implant Device,37.1,35,,37.1,percent of total billed charges,Implant Device,37.1,35,,37.1,percent of total billed charges,Implant Device,42.4,40,,42.4,percent of total billed charges,Implant Device,37.1,70,,37.1,percent of total billed charges,All Other,36.04,34,,36.04,percent of total billed charges,Implant Device,36.04,34,,36.04,percent of total billed charges,Implant Device,37.1,35,,37.1,percent of total billed charges,Implant Device,37.1,35,,37.1,percent of total billed charges,Implant Device,37.1,35,,37.1,percent of total billed charges,Implant Device,37.1,35,,37.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,78.44,
ZIMMER 2347-23-28 PERIART SCREW 4.5X28MM,C1713,HCPCS,,79005997,CDM,278,RC,,,both,,,106,78.44,,,78.44,Other,150% of Medicare + 9.63% HCRA Surcharge,47.7,45,,47.7,percent of total billed charges,Critical Access Hospital RCC factor,36.04,34,,36.04,percent of total billed charges,Implant Device,36.04,34,,36.04,percent of total billed charges,Implant Device,36.04,34,,36.04,percent of total billed charges,Implant Device,36.04,34,,36.04,percent of total billed charges,Implant Device,36.04,34,,36.04,percent of total billed charges,Implant Device,52.47,,,52.47,Other,110% of Medicare,37.1,35,,37.1,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,37.1,35,,37.1,percent of total billed charges,Implant Device,37.1,35,,37.1,percent of total billed charges,Implant Device,37.1,35,,37.1,percent of total billed charges,Implant Device,37.1,35,,37.1,percent of total billed charges,Implant Device,37.1,35,,37.1,percent of total billed charges,Implant Device,42.4,40,,42.4,percent of total billed charges,Implant Device,37.1,70,,37.1,percent of total billed charges,All Other,36.04,34,,36.04,percent of total billed charges,Implant Device,36.04,34,,36.04,percent of total billed charges,Implant Device,37.1,35,,37.1,percent of total billed charges,Implant Device,37.1,35,,37.1,percent of total billed charges,Implant Device,37.1,35,,37.1,percent of total billed charges,Implant Device,37.1,35,,37.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,78.44,
ZIMMER 2347-23-30 PERIART SCREW 4.5X30MM,C1713,HCPCS,,79005998,CDM,278,RC,,,both,,,106,78.44,,,78.44,Other,150% of Medicare + 9.63% HCRA Surcharge,47.7,45,,47.7,percent of total billed charges,Critical Access Hospital RCC factor,36.04,34,,36.04,percent of total billed charges,Implant Device,36.04,34,,36.04,percent of total billed charges,Implant Device,36.04,34,,36.04,percent of total billed charges,Implant Device,36.04,34,,36.04,percent of total billed charges,Implant Device,36.04,34,,36.04,percent of total billed charges,Implant Device,52.47,,,52.47,Other,110% of Medicare,37.1,35,,37.1,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,37.1,35,,37.1,percent of total billed charges,Implant Device,37.1,35,,37.1,percent of total billed charges,Implant Device,37.1,35,,37.1,percent of total billed charges,Implant Device,37.1,35,,37.1,percent of total billed charges,Implant Device,37.1,35,,37.1,percent of total billed charges,Implant Device,42.4,40,,42.4,percent of total billed charges,Implant Device,37.1,70,,37.1,percent of total billed charges,All Other,36.04,34,,36.04,percent of total billed charges,Implant Device,36.04,34,,36.04,percent of total billed charges,Implant Device,37.1,35,,37.1,percent of total billed charges,Implant Device,37.1,35,,37.1,percent of total billed charges,Implant Device,37.1,35,,37.1,percent of total billed charges,Implant Device,37.1,35,,37.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,78.44,
ZIMMER 2357-102-10 LOCKING PLATE 10 HOLE,C1713,HCPCS,,79005999,CDM,278,RC,,,both,,,4536,3356.65,,,3356.65,Other,150% of Medicare + 9.63% HCRA Surcharge,2041.2,45,,2041.2,percent of total billed charges,Critical Access Hospital RCC factor,1542.24,34,,1542.24,percent of total billed charges,Implant Device,1542.24,34,,1542.24,percent of total billed charges,Implant Device,1542.24,34,,1542.24,percent of total billed charges,Implant Device,1542.24,34,,1542.24,percent of total billed charges,Implant Device,1542.24,34,,1542.24,percent of total billed charges,Implant Device,2245.32,,,2245.32,Other,110% of Medicare,1587.6,35,,1587.6,percent of total billed charges,Implant Device,1542.24,34,"Charges > $500, x 34%",1542.24,percent of total billed charges,Implant Device,1587.6,35,,1587.6,percent of total billed charges,Implant Device,1587.6,35,,1587.6,percent of total billed charges,Implant Device,1587.6,35,,1587.6,percent of total billed charges,Implant Device,1587.6,35,,1587.6,percent of total billed charges,Implant Device,1587.6,35,,1587.6,percent of total billed charges,Implant Device,1814.4,40,,1814.4,percent of total billed charges,Implant Device,1587.6,70,,1587.6,percent of total billed charges,All Other,1542.24,34,,1542.24,percent of total billed charges,Implant Device,1542.24,34,,1542.24,percent of total billed charges,Implant Device,1587.6,35,,1587.6,percent of total billed charges,Implant Device,1587.6,35,,1587.6,percent of total billed charges,Implant Device,1587.6,35,,1587.6,percent of total billed charges,Implant Device,1587.6,35,,1587.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1542.24,34,"If Charge > 2,000, then 34 percent",1542.24,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3356.65,
ZIMMER 2359-30-45 LOCKING SCREW 4.5X30MM,C1713,HCPCS,,79006000,CDM,278,RC,,,both,,,432,319.68,,,319.68,Other,150% of Medicare + 9.63% HCRA Surcharge,194.4,45,,194.4,percent of total billed charges,Critical Access Hospital RCC factor,146.88,34,,146.88,percent of total billed charges,Implant Device,146.88,34,,146.88,percent of total billed charges,Implant Device,146.88,34,,146.88,percent of total billed charges,Implant Device,146.88,34,,146.88,percent of total billed charges,Implant Device,146.88,34,,146.88,percent of total billed charges,Implant Device,213.84,,,213.84,Other,110% of Medicare,151.2,35,,151.2,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,151.2,35,,151.2,percent of total billed charges,Implant Device,151.2,35,,151.2,percent of total billed charges,Implant Device,151.2,35,,151.2,percent of total billed charges,Implant Device,151.2,35,,151.2,percent of total billed charges,Implant Device,151.2,35,,151.2,percent of total billed charges,Implant Device,172.8,40,,172.8,percent of total billed charges,Implant Device,151.2,70,,151.2,percent of total billed charges,All Other,146.88,34,,146.88,percent of total billed charges,Implant Device,146.88,34,,146.88,percent of total billed charges,Implant Device,151.2,35,,151.2,percent of total billed charges,Implant Device,151.2,35,,151.2,percent of total billed charges,Implant Device,151.2,35,,151.2,percent of total billed charges,Implant Device,151.2,35,,151.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,319.68,
ZIMMER 2359-35-55 LOCKING SCREW 5.5X35MM,C1713,HCPCS,,79006001,CDM,278,RC,,,both,,,578,427.72,,,427.72,Other,150% of Medicare + 9.63% HCRA Surcharge,260.1,45,,260.1,percent of total billed charges,Critical Access Hospital RCC factor,196.52,34,,196.52,percent of total billed charges,Implant Device,196.52,34,,196.52,percent of total billed charges,Implant Device,196.52,34,,196.52,percent of total billed charges,Implant Device,196.52,34,,196.52,percent of total billed charges,Implant Device,196.52,34,,196.52,percent of total billed charges,Implant Device,286.11,,,286.11,Other,110% of Medicare,202.3,35,,202.3,percent of total billed charges,Implant Device,196.52,34,"Charges > $500, x 34%",196.52,percent of total billed charges,Implant Device,202.3,35,,202.3,percent of total billed charges,Implant Device,202.3,35,,202.3,percent of total billed charges,Implant Device,202.3,35,,202.3,percent of total billed charges,Implant Device,202.3,35,,202.3,percent of total billed charges,Implant Device,202.3,35,,202.3,percent of total billed charges,Implant Device,231.2,40,,231.2,percent of total billed charges,Implant Device,202.3,70,,202.3,percent of total billed charges,All Other,196.52,34,,196.52,percent of total billed charges,Implant Device,196.52,34,,196.52,percent of total billed charges,Implant Device,202.3,35,,202.3,percent of total billed charges,Implant Device,202.3,35,,202.3,percent of total billed charges,Implant Device,202.3,35,,202.3,percent of total billed charges,Implant Device,202.3,35,,202.3,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,427.72,
ZIMMER 2359-50-55 LOCKING SCREW 5.5X50MM,C1713,HCPCS,,79006002,CDM,278,RC,,,both,,,578,427.72,,,427.72,Other,150% of Medicare + 9.63% HCRA Surcharge,260.1,45,,260.1,percent of total billed charges,Critical Access Hospital RCC factor,196.52,34,,196.52,percent of total billed charges,Implant Device,196.52,34,,196.52,percent of total billed charges,Implant Device,196.52,34,,196.52,percent of total billed charges,Implant Device,196.52,34,,196.52,percent of total billed charges,Implant Device,196.52,34,,196.52,percent of total billed charges,Implant Device,286.11,,,286.11,Other,110% of Medicare,202.3,35,,202.3,percent of total billed charges,Implant Device,196.52,34,"Charges > $500, x 34%",196.52,percent of total billed charges,Implant Device,202.3,35,,202.3,percent of total billed charges,Implant Device,202.3,35,,202.3,percent of total billed charges,Implant Device,202.3,35,,202.3,percent of total billed charges,Implant Device,202.3,35,,202.3,percent of total billed charges,Implant Device,202.3,35,,202.3,percent of total billed charges,Implant Device,231.2,40,,231.2,percent of total billed charges,Implant Device,202.3,70,,202.3,percent of total billed charges,All Other,196.52,34,,196.52,percent of total billed charges,Implant Device,196.52,34,,196.52,percent of total billed charges,Implant Device,202.3,35,,202.3,percent of total billed charges,Implant Device,202.3,35,,202.3,percent of total billed charges,Implant Device,202.3,35,,202.3,percent of total billed charges,Implant Device,202.3,35,,202.3,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,427.72,
ZIMMER 2359-55-55 LOCKING SCREW 5.5X55MM,C1713,HCPCS,,79006003,CDM,278,RC,,,both,,,578,427.72,,,427.72,Other,150% of Medicare + 9.63% HCRA Surcharge,260.1,45,,260.1,percent of total billed charges,Critical Access Hospital RCC factor,196.52,34,,196.52,percent of total billed charges,Implant Device,196.52,34,,196.52,percent of total billed charges,Implant Device,196.52,34,,196.52,percent of total billed charges,Implant Device,196.52,34,,196.52,percent of total billed charges,Implant Device,196.52,34,,196.52,percent of total billed charges,Implant Device,286.11,,,286.11,Other,110% of Medicare,202.3,35,,202.3,percent of total billed charges,Implant Device,196.52,34,"Charges > $500, x 34%",196.52,percent of total billed charges,Implant Device,202.3,35,,202.3,percent of total billed charges,Implant Device,202.3,35,,202.3,percent of total billed charges,Implant Device,202.3,35,,202.3,percent of total billed charges,Implant Device,202.3,35,,202.3,percent of total billed charges,Implant Device,202.3,35,,202.3,percent of total billed charges,Implant Device,231.2,40,,231.2,percent of total billed charges,Implant Device,202.3,70,,202.3,percent of total billed charges,All Other,196.52,34,,196.52,percent of total billed charges,Implant Device,196.52,34,,196.52,percent of total billed charges,Implant Device,202.3,35,,202.3,percent of total billed charges,Implant Device,202.3,35,,202.3,percent of total billed charges,Implant Device,202.3,35,,202.3,percent of total billed charges,Implant Device,202.3,35,,202.3,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,427.72,
ZIMMER 2359-60-55 LOCKING SCREW 5.5X60MM,C1713,HCPCS,,79006004,CDM,278,RC,,,both,,,562,415.88,,,415.88,Other,150% of Medicare + 9.63% HCRA Surcharge,252.9,45,,252.9,percent of total billed charges,Critical Access Hospital RCC factor,191.08,34,,191.08,percent of total billed charges,Implant Device,191.08,34,,191.08,percent of total billed charges,Implant Device,191.08,34,,191.08,percent of total billed charges,Implant Device,191.08,34,,191.08,percent of total billed charges,Implant Device,191.08,34,,191.08,percent of total billed charges,Implant Device,278.19,,,278.19,Other,110% of Medicare,196.7,35,,196.7,percent of total billed charges,Implant Device,191.08,34,"Charges > $500, x 34%",191.08,percent of total billed charges,Implant Device,196.7,35,,196.7,percent of total billed charges,Implant Device,196.7,35,,196.7,percent of total billed charges,Implant Device,196.7,35,,196.7,percent of total billed charges,Implant Device,196.7,35,,196.7,percent of total billed charges,Implant Device,196.7,35,,196.7,percent of total billed charges,Implant Device,224.8,40,,224.8,percent of total billed charges,Implant Device,196.7,70,,196.7,percent of total billed charges,All Other,191.08,34,,191.08,percent of total billed charges,Implant Device,191.08,34,,191.08,percent of total billed charges,Implant Device,196.7,35,,196.7,percent of total billed charges,Implant Device,196.7,35,,196.7,percent of total billed charges,Implant Device,196.7,35,,196.7,percent of total billed charges,Implant Device,196.7,35,,196.7,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,415.88,
S&N 71420634 GENESIS II LONG STEM 16X100,C1776,HCPCS,,79006005,CDM,278,RC,,,both,,,4006,2964.45,,,2964.45,Other,150% of Medicare + 9.63% HCRA Surcharge,1802.7,45,,1802.7,percent of total billed charges,Critical Access Hospital RCC factor,1362.04,34,,1362.04,percent of total billed charges,Implant Device,1362.04,34,,1362.04,percent of total billed charges,Implant Device,1362.04,34,,1362.04,percent of total billed charges,Implant Device,1362.04,34,,1362.04,percent of total billed charges,Implant Device,1362.04,34,,1362.04,percent of total billed charges,Implant Device,1982.97,,,1982.97,Other,110% of Medicare,1402.1,35,,1402.1,percent of total billed charges,Implant Device,1362.04,34,"Charges > $500, x 34%",1362.04,percent of total billed charges,Implant Device,1402.1,35,,1402.1,percent of total billed charges,Implant Device,1402.1,35,,1402.1,percent of total billed charges,Implant Device,1402.1,35,,1402.1,percent of total billed charges,Implant Device,1402.1,35,,1402.1,percent of total billed charges,Implant Device,1402.1,35,,1402.1,percent of total billed charges,Implant Device,1602.4,40,,1602.4,percent of total billed charges,Implant Device,1402.1,70,,1402.1,percent of total billed charges,All Other,1362.04,34,,1362.04,percent of total billed charges,Implant Device,1362.04,34,,1362.04,percent of total billed charges,Implant Device,1402.1,35,,1402.1,percent of total billed charges,Implant Device,1402.1,35,,1402.1,percent of total billed charges,Implant Device,1402.1,35,,1402.1,percent of total billed charges,Implant Device,1402.1,35,,1402.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1362.04,34,"If Charge > 2,000, then 34 percent",1362.04,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2964.45,
STRYKER 627302 PROX LAT TIB PLATE 2 HOLE,C1713,HCPCS,,79006006,CDM,278,RC,,,both,,,5922,4382.29,,,4382.29,Other,150% of Medicare + 9.63% HCRA Surcharge,2664.9,45,,2664.9,percent of total billed charges,Critical Access Hospital RCC factor,2013.48,34,,2013.48,percent of total billed charges,Implant Device,2013.48,34,,2013.48,percent of total billed charges,Implant Device,2013.48,34,,2013.48,percent of total billed charges,Implant Device,2013.48,34,,2013.48,percent of total billed charges,Implant Device,2013.48,34,,2013.48,percent of total billed charges,Implant Device,2931.39,,,2931.39,Other,110% of Medicare,2072.7,35,,2072.7,percent of total billed charges,Implant Device,2013.48,34,"Charges > $500, x 34%",2013.48,percent of total billed charges,Implant Device,2072.7,35,,2072.7,percent of total billed charges,Implant Device,2072.7,35,,2072.7,percent of total billed charges,Implant Device,2072.7,35,,2072.7,percent of total billed charges,Implant Device,2072.7,35,,2072.7,percent of total billed charges,Implant Device,2072.7,35,,2072.7,percent of total billed charges,Implant Device,2368.8,40,,2368.8,percent of total billed charges,Implant Device,2072.7,70,,2072.7,percent of total billed charges,All Other,2013.48,34,,2013.48,percent of total billed charges,Implant Device,2013.48,34,,2013.48,percent of total billed charges,Implant Device,2072.7,35,,2072.7,percent of total billed charges,Implant Device,2072.7,35,,2072.7,percent of total billed charges,Implant Device,2072.7,35,,2072.7,percent of total billed charges,Implant Device,2072.7,35,,2072.7,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2013.48,34,"If Charge > 2,000, then 34 percent",2013.48,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4382.29,
STRYKER 661036 LOCKING SCREW 4.0X36MM,C1713,HCPCS,,79006007,CDM,278,RC,,,both,,,630,466.2,,,466.2,Other,150% of Medicare + 9.63% HCRA Surcharge,283.5,45,,283.5,percent of total billed charges,Critical Access Hospital RCC factor,214.2,34,,214.2,percent of total billed charges,Implant Device,214.2,34,,214.2,percent of total billed charges,Implant Device,214.2,34,,214.2,percent of total billed charges,Implant Device,214.2,34,,214.2,percent of total billed charges,Implant Device,214.2,34,,214.2,percent of total billed charges,Implant Device,311.85,,,311.85,Other,110% of Medicare,220.5,35,,220.5,percent of total billed charges,Implant Device,214.2,34,"Charges > $500, x 34%",214.2,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,252,40,,252,percent of total billed charges,Implant Device,220.5,70,,220.5,percent of total billed charges,All Other,214.2,34,,214.2,percent of total billed charges,Implant Device,214.2,34,,214.2,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,466.2,
STRYKER 661070 LOCKING SCREW 4.0X70MM,C1713,HCPCS,,79006008,CDM,278,RC,,,both,,,583,431.42,,,431.42,Other,150% of Medicare + 9.63% HCRA Surcharge,262.35,45,,262.35,percent of total billed charges,Critical Access Hospital RCC factor,198.22,34,,198.22,percent of total billed charges,Implant Device,198.22,34,,198.22,percent of total billed charges,Implant Device,198.22,34,,198.22,percent of total billed charges,Implant Device,198.22,34,,198.22,percent of total billed charges,Implant Device,198.22,34,,198.22,percent of total billed charges,Implant Device,288.59,,,288.59,Other,110% of Medicare,204.05,35,,204.05,percent of total billed charges,Implant Device,198.22,34,"Charges > $500, x 34%",198.22,percent of total billed charges,Implant Device,204.05,35,,204.05,percent of total billed charges,Implant Device,204.05,35,,204.05,percent of total billed charges,Implant Device,204.05,35,,204.05,percent of total billed charges,Implant Device,204.05,35,,204.05,percent of total billed charges,Implant Device,204.05,35,,204.05,percent of total billed charges,Implant Device,233.2,40,,233.2,percent of total billed charges,Implant Device,204.05,70,,204.05,percent of total billed charges,All Other,198.22,34,,198.22,percent of total billed charges,Implant Device,198.22,34,,198.22,percent of total billed charges,Implant Device,204.05,35,,204.05,percent of total billed charges,Implant Device,204.05,35,,204.05,percent of total billed charges,Implant Device,204.05,35,,204.05,percent of total billed charges,Implant Device,204.05,35,,204.05,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,431.42,
STRYKER 661075 LOCKING SCERW 4.0X75MM,C1713,HCPCS,,79006009,CDM,278,RC,,,both,,,583,431.42,,,431.42,Other,150% of Medicare + 9.63% HCRA Surcharge,262.35,45,,262.35,percent of total billed charges,Critical Access Hospital RCC factor,198.22,34,,198.22,percent of total billed charges,Implant Device,198.22,34,,198.22,percent of total billed charges,Implant Device,198.22,34,,198.22,percent of total billed charges,Implant Device,198.22,34,,198.22,percent of total billed charges,Implant Device,198.22,34,,198.22,percent of total billed charges,Implant Device,288.59,,,288.59,Other,110% of Medicare,204.05,35,,204.05,percent of total billed charges,Implant Device,198.22,34,"Charges > $500, x 34%",198.22,percent of total billed charges,Implant Device,204.05,35,,204.05,percent of total billed charges,Implant Device,204.05,35,,204.05,percent of total billed charges,Implant Device,204.05,35,,204.05,percent of total billed charges,Implant Device,204.05,35,,204.05,percent of total billed charges,Implant Device,204.05,35,,204.05,percent of total billed charges,Implant Device,233.2,40,,233.2,percent of total billed charges,Implant Device,204.05,70,,204.05,percent of total billed charges,All Other,198.22,34,,198.22,percent of total billed charges,Implant Device,198.22,34,,198.22,percent of total billed charges,Implant Device,204.05,35,,204.05,percent of total billed charges,Implant Device,204.05,35,,204.05,percent of total billed charges,Implant Device,204.05,35,,204.05,percent of total billed charges,Implant Device,204.05,35,,204.05,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,431.42,
STRYKER 661065 LOCKING SCREW 4.0X665MM,C1713,HCPCS,,79006010,CDM,278,RC,,,both,,,630,466.2,,,466.2,Other,150% of Medicare + 9.63% HCRA Surcharge,283.5,45,,283.5,percent of total billed charges,Critical Access Hospital RCC factor,214.2,34,,214.2,percent of total billed charges,Implant Device,214.2,34,,214.2,percent of total billed charges,Implant Device,214.2,34,,214.2,percent of total billed charges,Implant Device,214.2,34,,214.2,percent of total billed charges,Implant Device,214.2,34,,214.2,percent of total billed charges,Implant Device,311.85,,,311.85,Other,110% of Medicare,220.5,35,,220.5,percent of total billed charges,Implant Device,214.2,34,"Charges > $500, x 34%",214.2,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,252,40,,252,percent of total billed charges,Implant Device,220.5,70,,220.5,percent of total billed charges,All Other,214.2,34,,214.2,percent of total billed charges,Implant Device,214.2,34,,214.2,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,466.2,
STRYKER 601438 CORTICAL SCREW 3.5X38MM,C1713,HCPCS,,79006011,CDM,278,RC,,,both,,,118,87.32,,,87.32,Other,150% of Medicare + 9.63% HCRA Surcharge,53.1,45,,53.1,percent of total billed charges,Critical Access Hospital RCC factor,40.12,34,,40.12,percent of total billed charges,Implant Device,40.12,34,,40.12,percent of total billed charges,Implant Device,40.12,34,,40.12,percent of total billed charges,Implant Device,40.12,34,,40.12,percent of total billed charges,Implant Device,40.12,34,,40.12,percent of total billed charges,Implant Device,58.41,,,58.41,Other,110% of Medicare,41.3,35,,41.3,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,41.3,35,,41.3,percent of total billed charges,Implant Device,41.3,35,,41.3,percent of total billed charges,Implant Device,41.3,35,,41.3,percent of total billed charges,Implant Device,41.3,35,,41.3,percent of total billed charges,Implant Device,41.3,35,,41.3,percent of total billed charges,Implant Device,47.2,40,,47.2,percent of total billed charges,Implant Device,41.3,70,,41.3,percent of total billed charges,All Other,40.12,34,,40.12,percent of total billed charges,Implant Device,40.12,34,,40.12,percent of total billed charges,Implant Device,41.3,35,,41.3,percent of total billed charges,Implant Device,41.3,35,,41.3,percent of total billed charges,Implant Device,41.3,35,,41.3,percent of total billed charges,Implant Device,41.3,35,,41.3,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,87.32,
STRYKER 1851-1038S FEMORAL NAIL 10X380MM,C1713,HCPCS,,79006012,CDM,278,RC,,,both,,,7640,5653.62,,,5653.62,Other,150% of Medicare + 9.63% HCRA Surcharge,3438,45,,3438,percent of total billed charges,Critical Access Hospital RCC factor,2597.6,34,,2597.6,percent of total billed charges,Implant Device,2597.6,34,,2597.6,percent of total billed charges,Implant Device,2597.6,34,,2597.6,percent of total billed charges,Implant Device,2597.6,34,,2597.6,percent of total billed charges,Implant Device,2597.6,34,,2597.6,percent of total billed charges,Implant Device,3781.8,,,3781.8,Other,110% of Medicare,2674,35,,2674,percent of total billed charges,Implant Device,2597.6,34,"Charges > $500, x 34%",2597.6,percent of total billed charges,Implant Device,2674,35,,2674,percent of total billed charges,Implant Device,2674,35,,2674,percent of total billed charges,Implant Device,2674,35,,2674,percent of total billed charges,Implant Device,2674,35,,2674,percent of total billed charges,Implant Device,2674,35,,2674,percent of total billed charges,Implant Device,3056,40,,3056,percent of total billed charges,Implant Device,2674,70,,2674,percent of total billed charges,All Other,2597.6,34,,2597.6,percent of total billed charges,Implant Device,2597.6,34,,2597.6,percent of total billed charges,Implant Device,2674,35,,2674,percent of total billed charges,Implant Device,2674,35,,2674,percent of total billed charges,Implant Device,2674,35,,2674,percent of total billed charges,Implant Device,2674,35,,2674,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2597.6,34,"If Charge > 2,000, then 34 percent",2597.6,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5653.62,
STRYKER 1896-5030S LOCK SCREW FT 5X30MM,C1713,HCPCS,,79006026,CDM,278,RC,,,both,,,441,326.34,,,326.34,Other,150% of Medicare + 9.63% HCRA Surcharge,198.45,45,,198.45,percent of total billed charges,Critical Access Hospital RCC factor,149.94,34,,149.94,percent of total billed charges,Implant Device,149.94,34,,149.94,percent of total billed charges,Implant Device,149.94,34,,149.94,percent of total billed charges,Implant Device,149.94,34,,149.94,percent of total billed charges,Implant Device,149.94,34,,149.94,percent of total billed charges,Implant Device,218.3,,,218.3,Other,110% of Medicare,154.35,35,,154.35,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,154.35,35,,154.35,percent of total billed charges,Implant Device,154.35,35,,154.35,percent of total billed charges,Implant Device,154.35,35,,154.35,percent of total billed charges,Implant Device,154.35,35,,154.35,percent of total billed charges,Implant Device,154.35,35,,154.35,percent of total billed charges,Implant Device,176.4,40,,176.4,percent of total billed charges,Implant Device,154.35,70,,154.35,percent of total billed charges,All Other,149.94,34,,149.94,percent of total billed charges,Implant Device,149.94,34,,149.94,percent of total billed charges,Implant Device,154.35,35,,154.35,percent of total billed charges,Implant Device,154.35,35,,154.35,percent of total billed charges,Implant Device,154.35,35,,154.35,percent of total billed charges,Implant Device,154.35,35,,154.35,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,326.34,
STRYKER 5010-4-200S HALF PIN 6X200X4MM,C1713,HCPCS,,79006027,CDM,278,RC,,,both,,,684,506.16,,,506.16,Other,150% of Medicare + 9.63% HCRA Surcharge,307.8,45,,307.8,percent of total billed charges,Critical Access Hospital RCC factor,232.56,34,,232.56,percent of total billed charges,Implant Device,232.56,34,,232.56,percent of total billed charges,Implant Device,232.56,34,,232.56,percent of total billed charges,Implant Device,232.56,34,,232.56,percent of total billed charges,Implant Device,232.56,34,,232.56,percent of total billed charges,Implant Device,338.58,,,338.58,Other,110% of Medicare,239.4,35,,239.4,percent of total billed charges,Implant Device,232.56,34,"Charges > $500, x 34%",232.56,percent of total billed charges,Implant Device,239.4,35,,239.4,percent of total billed charges,Implant Device,239.4,35,,239.4,percent of total billed charges,Implant Device,239.4,35,,239.4,percent of total billed charges,Implant Device,239.4,35,,239.4,percent of total billed charges,Implant Device,239.4,35,,239.4,percent of total billed charges,Implant Device,273.6,40,,273.6,percent of total billed charges,Implant Device,239.4,70,,239.4,percent of total billed charges,All Other,232.56,34,,232.56,percent of total billed charges,Implant Device,232.56,34,,232.56,percent of total billed charges,Implant Device,239.4,35,,239.4,percent of total billed charges,Implant Device,239.4,35,,239.4,percent of total billed charges,Implant Device,239.4,35,,239.4,percent of total billed charges,Implant Device,239.4,35,,239.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,506.16,
STRYKER 5010-8-200S HALF PIN 6X200X25MM,C1713,HCPCS,,79006028,CDM,278,RC,,,both,,,684,506.16,,,506.16,Other,150% of Medicare + 9.63% HCRA Surcharge,307.8,45,,307.8,percent of total billed charges,Critical Access Hospital RCC factor,232.56,34,,232.56,percent of total billed charges,Implant Device,232.56,34,,232.56,percent of total billed charges,Implant Device,232.56,34,,232.56,percent of total billed charges,Implant Device,232.56,34,,232.56,percent of total billed charges,Implant Device,232.56,34,,232.56,percent of total billed charges,Implant Device,338.58,,,338.58,Other,110% of Medicare,239.4,35,,239.4,percent of total billed charges,Implant Device,232.56,34,"Charges > $500, x 34%",232.56,percent of total billed charges,Implant Device,239.4,35,,239.4,percent of total billed charges,Implant Device,239.4,35,,239.4,percent of total billed charges,Implant Device,239.4,35,,239.4,percent of total billed charges,Implant Device,239.4,35,,239.4,percent of total billed charges,Implant Device,239.4,35,,239.4,percent of total billed charges,Implant Device,273.6,40,,273.6,percent of total billed charges,Implant Device,239.4,70,,239.4,percent of total billed charges,All Other,232.56,34,,232.56,percent of total billed charges,Implant Device,232.56,34,,232.56,percent of total billed charges,Implant Device,239.4,35,,239.4,percent of total billed charges,Implant Device,239.4,35,,239.4,percent of total billed charges,Implant Device,239.4,35,,239.4,percent of total billed charges,Implant Device,239.4,35,,239.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,506.16,
STRYKER 5010-3-200S HALF PIN 6X200X30MM,C1713,HCPCS,,79006029,CDM,278,RC,,,both,,,684,506.16,,,506.16,Other,150% of Medicare + 9.63% HCRA Surcharge,307.8,45,,307.8,percent of total billed charges,Critical Access Hospital RCC factor,232.56,34,,232.56,percent of total billed charges,Implant Device,232.56,34,,232.56,percent of total billed charges,Implant Device,232.56,34,,232.56,percent of total billed charges,Implant Device,232.56,34,,232.56,percent of total billed charges,Implant Device,232.56,34,,232.56,percent of total billed charges,Implant Device,338.58,,,338.58,Other,110% of Medicare,239.4,35,,239.4,percent of total billed charges,Implant Device,232.56,34,"Charges > $500, x 34%",232.56,percent of total billed charges,Implant Device,239.4,35,,239.4,percent of total billed charges,Implant Device,239.4,35,,239.4,percent of total billed charges,Implant Device,239.4,35,,239.4,percent of total billed charges,Implant Device,239.4,35,,239.4,percent of total billed charges,Implant Device,239.4,35,,239.4,percent of total billed charges,Implant Device,273.6,40,,273.6,percent of total billed charges,Implant Device,239.4,70,,239.4,percent of total billed charges,All Other,232.56,34,,232.56,percent of total billed charges,Implant Device,232.56,34,,232.56,percent of total billed charges,Implant Device,239.4,35,,239.4,percent of total billed charges,Implant Device,239.4,35,,239.4,percent of total billed charges,Implant Device,239.4,35,,239.4,percent of total billed charges,Implant Device,239.4,35,,239.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,506.16,
STRYKER ORTHO 4933-1-001 WIRE BOLT SHORT,C1713,HCPCS,,79006031,CDM,278,RC,,,both,,,290,214.6,,,214.6,Other,150% of Medicare + 9.63% HCRA Surcharge,130.5,45,,130.5,percent of total billed charges,Critical Access Hospital RCC factor,98.6,34,,98.6,percent of total billed charges,Implant Device,98.6,34,,98.6,percent of total billed charges,Implant Device,98.6,34,,98.6,percent of total billed charges,Implant Device,98.6,34,,98.6,percent of total billed charges,Implant Device,98.6,34,,98.6,percent of total billed charges,Implant Device,143.55,,,143.55,Other,110% of Medicare,101.5,35,,101.5,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,101.5,35,,101.5,percent of total billed charges,Implant Device,101.5,35,,101.5,percent of total billed charges,Implant Device,101.5,35,,101.5,percent of total billed charges,Implant Device,101.5,35,,101.5,percent of total billed charges,Implant Device,101.5,35,,101.5,percent of total billed charges,Implant Device,116,40,,116,percent of total billed charges,Implant Device,101.5,70,,101.5,percent of total billed charges,All Other,98.6,34,,98.6,percent of total billed charges,Implant Device,98.6,34,,98.6,percent of total billed charges,Implant Device,101.5,35,,101.5,percent of total billed charges,Implant Device,101.5,35,,101.5,percent of total billed charges,Implant Device,101.5,35,,101.5,percent of total billed charges,Implant Device,101.5,35,,101.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,214.6,
STRYKER 4933-1-002 WIRE BOLT MEDIUM,C1713,HCPCS,,79006032,CDM,278,RC,,,both,,,405,299.7,,,299.7,Other,150% of Medicare + 9.63% HCRA Surcharge,182.25,45,,182.25,percent of total billed charges,Critical Access Hospital RCC factor,137.7,34,,137.7,percent of total billed charges,Implant Device,137.7,34,,137.7,percent of total billed charges,Implant Device,137.7,34,,137.7,percent of total billed charges,Implant Device,137.7,34,,137.7,percent of total billed charges,Implant Device,137.7,34,,137.7,percent of total billed charges,Implant Device,200.48,,,200.48,Other,110% of Medicare,141.75,35,,141.75,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,141.75,35,,141.75,percent of total billed charges,Implant Device,141.75,35,,141.75,percent of total billed charges,Implant Device,141.75,35,,141.75,percent of total billed charges,Implant Device,141.75,35,,141.75,percent of total billed charges,Implant Device,141.75,35,,141.75,percent of total billed charges,Implant Device,162,40,,162,percent of total billed charges,Implant Device,141.75,70,,141.75,percent of total billed charges,All Other,137.7,34,,137.7,percent of total billed charges,Implant Device,137.7,34,,137.7,percent of total billed charges,Implant Device,141.75,35,,141.75,percent of total billed charges,Implant Device,141.75,35,,141.75,percent of total billed charges,Implant Device,141.75,35,,141.75,percent of total billed charges,Implant Device,141.75,35,,141.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,299.7,
STRYKER 4933-1-005 WIRE BOLT ADAPT LONG,C1713,HCPCS,,79006033,CDM,278,RC,,,both,,,1245,921.3,,,921.3,Other,150% of Medicare + 9.63% HCRA Surcharge,560.25,45,,560.25,percent of total billed charges,Critical Access Hospital RCC factor,423.3,34,,423.3,percent of total billed charges,Implant Device,423.3,34,,423.3,percent of total billed charges,Implant Device,423.3,34,,423.3,percent of total billed charges,Implant Device,423.3,34,,423.3,percent of total billed charges,Implant Device,423.3,34,,423.3,percent of total billed charges,Implant Device,616.28,,,616.28,Other,110% of Medicare,435.75,35,,435.75,percent of total billed charges,Implant Device,423.3,34,"Charges > $500, x 34%",423.3,percent of total billed charges,Implant Device,435.75,35,,435.75,percent of total billed charges,Implant Device,435.75,35,,435.75,percent of total billed charges,Implant Device,435.75,35,,435.75,percent of total billed charges,Implant Device,435.75,35,,435.75,percent of total billed charges,Implant Device,435.75,35,,435.75,percent of total billed charges,Implant Device,498,40,,498,percent of total billed charges,Implant Device,435.75,70,,435.75,percent of total billed charges,All Other,423.3,34,,423.3,percent of total billed charges,Implant Device,423.3,34,,423.3,percent of total billed charges,Implant Device,435.75,35,,435.75,percent of total billed charges,Implant Device,435.75,35,,435.75,percent of total billed charges,Implant Device,435.75,35,,435.75,percent of total billed charges,Implant Device,435.75,35,,435.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,921.3,
ARTHREX AR-8840-14 CANC SCREW 4.0X14MM,C1713,HCPCS,,79006043,CDM,278,RC,,,both,,,106,78.44,,,78.44,Other,150% of Medicare + 9.63% HCRA Surcharge,47.7,45,,47.7,percent of total billed charges,Critical Access Hospital RCC factor,36.04,34,,36.04,percent of total billed charges,Implant Device,36.04,34,,36.04,percent of total billed charges,Implant Device,36.04,34,,36.04,percent of total billed charges,Implant Device,36.04,34,,36.04,percent of total billed charges,Implant Device,36.04,34,,36.04,percent of total billed charges,Implant Device,52.47,,,52.47,Other,110% of Medicare,37.1,35,,37.1,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,37.1,35,,37.1,percent of total billed charges,Implant Device,37.1,35,,37.1,percent of total billed charges,Implant Device,37.1,35,,37.1,percent of total billed charges,Implant Device,37.1,35,,37.1,percent of total billed charges,Implant Device,37.1,35,,37.1,percent of total billed charges,Implant Device,42.4,40,,42.4,percent of total billed charges,Implant Device,37.1,70,,37.1,percent of total billed charges,All Other,36.04,34,,36.04,percent of total billed charges,Implant Device,36.04,34,,36.04,percent of total billed charges,Implant Device,37.1,35,,37.1,percent of total billed charges,Implant Device,37.1,35,,37.1,percent of total billed charges,Implant Device,37.1,35,,37.1,percent of total billed charges,Implant Device,37.1,35,,37.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,78.44,
ZIMMER 2357-017-06 DIST LAT PLATE 6 HOLE,C1713,HCPCS,,79006047,CDM,278,RC,,,both,,,2160,1598.41,,,1598.41,Other,150% of Medicare + 9.63% HCRA Surcharge,972,45,,972,percent of total billed charges,Critical Access Hospital RCC factor,734.4,34,,734.4,percent of total billed charges,Implant Device,734.4,34,,734.4,percent of total billed charges,Implant Device,734.4,34,,734.4,percent of total billed charges,Implant Device,734.4,34,,734.4,percent of total billed charges,Implant Device,734.4,34,,734.4,percent of total billed charges,Implant Device,1069.2,,,1069.2,Other,110% of Medicare,756,35,,756,percent of total billed charges,Implant Device,734.4,34,"Charges > $500, x 34%",734.4,percent of total billed charges,Implant Device,756,35,,756,percent of total billed charges,Implant Device,756,35,,756,percent of total billed charges,Implant Device,756,35,,756,percent of total billed charges,Implant Device,756,35,,756,percent of total billed charges,Implant Device,756,35,,756,percent of total billed charges,Implant Device,864,40,,864,percent of total billed charges,Implant Device,756,70,,756,percent of total billed charges,All Other,734.4,34,,734.4,percent of total billed charges,Implant Device,734.4,34,,734.4,percent of total billed charges,Implant Device,756,35,,756,percent of total billed charges,Implant Device,756,35,,756,percent of total billed charges,Implant Device,756,35,,756,percent of total billed charges,Implant Device,756,35,,756,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,734.4,34,"If Charge > 2,000, then 34 percent",734.4,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1598.41,
ZIMMER 2348-012-35 PERIART SCREW 3.5X12,C1713,HCPCS,,79006048,CDM,278,RC,,,both,,,116,85.84,,,85.84,Other,150% of Medicare + 9.63% HCRA Surcharge,52.2,45,,52.2,percent of total billed charges,Critical Access Hospital RCC factor,39.44,34,,39.44,percent of total billed charges,Implant Device,39.44,34,,39.44,percent of total billed charges,Implant Device,39.44,34,,39.44,percent of total billed charges,Implant Device,39.44,34,,39.44,percent of total billed charges,Implant Device,39.44,34,,39.44,percent of total billed charges,Implant Device,57.42,,,57.42,Other,110% of Medicare,40.6,35,,40.6,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,40.6,35,,40.6,percent of total billed charges,Implant Device,40.6,35,,40.6,percent of total billed charges,Implant Device,40.6,35,,40.6,percent of total billed charges,Implant Device,40.6,35,,40.6,percent of total billed charges,Implant Device,40.6,35,,40.6,percent of total billed charges,Implant Device,46.4,40,,46.4,percent of total billed charges,Implant Device,40.6,70,,40.6,percent of total billed charges,All Other,39.44,34,,39.44,percent of total billed charges,Implant Device,39.44,34,,39.44,percent of total billed charges,Implant Device,40.6,35,,40.6,percent of total billed charges,Implant Device,40.6,35,,40.6,percent of total billed charges,Implant Device,40.6,35,,40.6,percent of total billed charges,Implant Device,40.6,35,,40.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,85.84,
ZIMMER 2357-017-08 DIST LAT PLATE 8 HOLE,C1713,HCPCS,,79006049,CDM,278,RC,,,both,,,2333,1726.43,,,1726.43,Other,150% of Medicare + 9.63% HCRA Surcharge,1049.85,45,,1049.85,percent of total billed charges,Critical Access Hospital RCC factor,793.22,34,,793.22,percent of total billed charges,Implant Device,793.22,34,,793.22,percent of total billed charges,Implant Device,793.22,34,,793.22,percent of total billed charges,Implant Device,793.22,34,,793.22,percent of total billed charges,Implant Device,793.22,34,,793.22,percent of total billed charges,Implant Device,1154.84,,,1154.84,Other,110% of Medicare,816.55,35,,816.55,percent of total billed charges,Implant Device,793.22,34,"Charges > $500, x 34%",793.22,percent of total billed charges,Implant Device,816.55,35,,816.55,percent of total billed charges,Implant Device,816.55,35,,816.55,percent of total billed charges,Implant Device,816.55,35,,816.55,percent of total billed charges,Implant Device,816.55,35,,816.55,percent of total billed charges,Implant Device,816.55,35,,816.55,percent of total billed charges,Implant Device,933.2,40,,933.2,percent of total billed charges,Implant Device,816.55,70,,816.55,percent of total billed charges,All Other,793.22,34,,793.22,percent of total billed charges,Implant Device,793.22,34,,793.22,percent of total billed charges,Implant Device,816.55,35,,816.55,percent of total billed charges,Implant Device,816.55,35,,816.55,percent of total billed charges,Implant Device,816.55,35,,816.55,percent of total billed charges,Implant Device,816.55,35,,816.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,793.22,34,"If Charge > 2,000, then 34 percent",793.22,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1726.43,
ZIMMER 4828-010-02 LOCK SCREW 2.7X10MM,C1713,HCPCS,,79006050,CDM,278,RC,,,both,,,335,247.9,,,247.9,Other,150% of Medicare + 9.63% HCRA Surcharge,150.75,45,,150.75,percent of total billed charges,Critical Access Hospital RCC factor,113.9,34,,113.9,percent of total billed charges,Implant Device,113.9,34,,113.9,percent of total billed charges,Implant Device,113.9,34,,113.9,percent of total billed charges,Implant Device,113.9,34,,113.9,percent of total billed charges,Implant Device,113.9,34,,113.9,percent of total billed charges,Implant Device,165.83,,,165.83,Other,110% of Medicare,117.25,35,,117.25,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,117.25,35,,117.25,percent of total billed charges,Implant Device,117.25,35,,117.25,percent of total billed charges,Implant Device,117.25,35,,117.25,percent of total billed charges,Implant Device,117.25,35,,117.25,percent of total billed charges,Implant Device,117.25,35,,117.25,percent of total billed charges,Implant Device,134,40,,134,percent of total billed charges,Implant Device,117.25,70,,117.25,percent of total billed charges,All Other,113.9,34,,113.9,percent of total billed charges,Implant Device,113.9,34,,113.9,percent of total billed charges,Implant Device,117.25,35,,117.25,percent of total billed charges,Implant Device,117.25,35,,117.25,percent of total billed charges,Implant Device,117.25,35,,117.25,percent of total billed charges,Implant Device,117.25,35,,117.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,247.9,
ZIMMER 7711-05 FEML STEM 12/14 NECK SZ 5,C1776,HCPCS,,79006051,CDM,278,RC,,,both,,,2273,1682.03,,,1682.03,Other,150% of Medicare + 9.63% HCRA Surcharge,1022.85,45,,1022.85,percent of total billed charges,Critical Access Hospital RCC factor,772.82,34,,772.82,percent of total billed charges,Implant Device,772.82,34,,772.82,percent of total billed charges,Implant Device,772.82,34,,772.82,percent of total billed charges,Implant Device,772.82,34,,772.82,percent of total billed charges,Implant Device,772.82,34,,772.82,percent of total billed charges,Implant Device,1125.14,,,1125.14,Other,110% of Medicare,795.55,35,,795.55,percent of total billed charges,Implant Device,772.82,34,"Charges > $500, x 34%",772.82,percent of total billed charges,Implant Device,795.55,35,,795.55,percent of total billed charges,Implant Device,795.55,35,,795.55,percent of total billed charges,Implant Device,795.55,35,,795.55,percent of total billed charges,Implant Device,795.55,35,,795.55,percent of total billed charges,Implant Device,795.55,35,,795.55,percent of total billed charges,Implant Device,909.2,40,,909.2,percent of total billed charges,Implant Device,795.55,70,,795.55,percent of total billed charges,All Other,772.82,34,,772.82,percent of total billed charges,Implant Device,772.82,34,,772.82,percent of total billed charges,Implant Device,795.55,35,,795.55,percent of total billed charges,Implant Device,795.55,35,,795.55,percent of total billed charges,Implant Device,795.55,35,,795.55,percent of total billed charges,Implant Device,795.55,35,,795.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,772.82,34,"If Charge > 2,000, then 34 percent",772.82,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1682.03,
ZIMMER 5001-42 BIPOLAR CUP SHELL 42MM,C1776,HCPCS,,79006052,CDM,278,RC,,,both,,,960,710.4,,,710.4,Other,150% of Medicare + 9.63% HCRA Surcharge,432,45,,432,percent of total billed charges,Critical Access Hospital RCC factor,326.4,34,,326.4,percent of total billed charges,Implant Device,326.4,34,,326.4,percent of total billed charges,Implant Device,326.4,34,,326.4,percent of total billed charges,Implant Device,326.4,34,,326.4,percent of total billed charges,Implant Device,326.4,34,,326.4,percent of total billed charges,Implant Device,475.2,,,475.2,Other,110% of Medicare,336,35,,336,percent of total billed charges,Implant Device,326.4,34,"Charges > $500, x 34%",326.4,percent of total billed charges,Implant Device,336,35,,336,percent of total billed charges,Implant Device,336,35,,336,percent of total billed charges,Implant Device,336,35,,336,percent of total billed charges,Implant Device,336,35,,336,percent of total billed charges,Implant Device,336,35,,336,percent of total billed charges,Implant Device,384,40,,384,percent of total billed charges,Implant Device,336,70,,336,percent of total billed charges,All Other,326.4,34,,326.4,percent of total billed charges,Implant Device,326.4,34,,326.4,percent of total billed charges,Implant Device,336,35,,336,percent of total billed charges,Implant Device,336,35,,336,percent of total billed charges,Implant Device,336,35,,336,percent of total billed charges,Implant Device,336,35,,336,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,710.4,
SOLANA CCP-LPX1L LAPIDUS 1MM LEFT PLATE,C1713,HCPCS,,79006053,CDM,278,RC,,,both,,,8386,6205.66,,,6205.66,Other,150% of Medicare + 9.63% HCRA Surcharge,3773.7,45,,3773.7,percent of total billed charges,Critical Access Hospital RCC factor,2851.24,34,,2851.24,percent of total billed charges,Implant Device,2851.24,34,,2851.24,percent of total billed charges,Implant Device,2851.24,34,,2851.24,percent of total billed charges,Implant Device,2851.24,34,,2851.24,percent of total billed charges,Implant Device,2851.24,34,,2851.24,percent of total billed charges,Implant Device,4151.07,,,4151.07,Other,110% of Medicare,2935.1,35,,2935.1,percent of total billed charges,Implant Device,2851.24,34,"Charges > $500, x 34%",2851.24,percent of total billed charges,Implant Device,2935.1,35,,2935.1,percent of total billed charges,Implant Device,2935.1,35,,2935.1,percent of total billed charges,Implant Device,2935.1,35,,2935.1,percent of total billed charges,Implant Device,2935.1,35,,2935.1,percent of total billed charges,Implant Device,2935.1,35,,2935.1,percent of total billed charges,Implant Device,3354.4,40,,3354.4,percent of total billed charges,Implant Device,2935.1,70,,2935.1,percent of total billed charges,All Other,2851.24,34,,2851.24,percent of total billed charges,Implant Device,2851.24,34,,2851.24,percent of total billed charges,Implant Device,2935.1,35,,2935.1,percent of total billed charges,Implant Device,2935.1,35,,2935.1,percent of total billed charges,Implant Device,2935.1,35,,2935.1,percent of total billed charges,Implant Device,2935.1,35,,2935.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2851.24,34,"If Charge > 2,000, then 34 percent",2851.24,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,6205.66,
SOLANA CCP-X3526 LAG SCREW 3.5X26MM,C1713,HCPCS,,79006054,CDM,278,RC,,,both,,,1125,832.5,,,832.5,Other,150% of Medicare + 9.63% HCRA Surcharge,506.25,45,,506.25,percent of total billed charges,Critical Access Hospital RCC factor,382.5,34,,382.5,percent of total billed charges,Implant Device,382.5,34,,382.5,percent of total billed charges,Implant Device,382.5,34,,382.5,percent of total billed charges,Implant Device,382.5,34,,382.5,percent of total billed charges,Implant Device,382.5,34,,382.5,percent of total billed charges,Implant Device,556.88,,,556.88,Other,110% of Medicare,393.75,35,,393.75,percent of total billed charges,Implant Device,382.5,34,"Charges > $500, x 34%",382.5,percent of total billed charges,Implant Device,393.75,35,,393.75,percent of total billed charges,Implant Device,393.75,35,,393.75,percent of total billed charges,Implant Device,393.75,35,,393.75,percent of total billed charges,Implant Device,393.75,35,,393.75,percent of total billed charges,Implant Device,393.75,35,,393.75,percent of total billed charges,Implant Device,450,40,,450,percent of total billed charges,Implant Device,393.75,70,,393.75,percent of total billed charges,All Other,382.5,34,,382.5,percent of total billed charges,Implant Device,382.5,34,,382.5,percent of total billed charges,Implant Device,393.75,35,,393.75,percent of total billed charges,Implant Device,393.75,35,,393.75,percent of total billed charges,Implant Device,393.75,35,,393.75,percent of total billed charges,Implant Device,393.75,35,,393.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,832.5,
SOLANA CCP-X3020 NON LOCK SCREW 3.5X20MM,C1713,HCPCS,,79006055,CDM,278,RC,,,both,,,886,655.64,,,655.64,Other,150% of Medicare + 9.63% HCRA Surcharge,398.7,45,,398.7,percent of total billed charges,Critical Access Hospital RCC factor,301.24,34,,301.24,percent of total billed charges,Implant Device,301.24,34,,301.24,percent of total billed charges,Implant Device,301.24,34,,301.24,percent of total billed charges,Implant Device,301.24,34,,301.24,percent of total billed charges,Implant Device,301.24,34,,301.24,percent of total billed charges,Implant Device,438.57,,,438.57,Other,110% of Medicare,310.1,35,,310.1,percent of total billed charges,Implant Device,301.24,34,"Charges > $500, x 34%",301.24,percent of total billed charges,Implant Device,310.1,35,,310.1,percent of total billed charges,Implant Device,310.1,35,,310.1,percent of total billed charges,Implant Device,310.1,35,,310.1,percent of total billed charges,Implant Device,310.1,35,,310.1,percent of total billed charges,Implant Device,310.1,35,,310.1,percent of total billed charges,Implant Device,354.4,40,,354.4,percent of total billed charges,Implant Device,310.1,70,,310.1,percent of total billed charges,All Other,301.24,34,,301.24,percent of total billed charges,Implant Device,301.24,34,,301.24,percent of total billed charges,Implant Device,310.1,35,,310.1,percent of total billed charges,Implant Device,310.1,35,,310.1,percent of total billed charges,Implant Device,310.1,35,,310.1,percent of total billed charges,Implant Device,310.1,35,,310.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,655.64,
SOLANA CCP-N3526 NON LOCK SCREW 3.5X26MM,C1713,HCPCS,,79006056,CDM,278,RC,,,both,,,886,655.64,,,655.64,Other,150% of Medicare + 9.63% HCRA Surcharge,398.7,45,,398.7,percent of total billed charges,Critical Access Hospital RCC factor,301.24,34,,301.24,percent of total billed charges,Implant Device,301.24,34,,301.24,percent of total billed charges,Implant Device,301.24,34,,301.24,percent of total billed charges,Implant Device,301.24,34,,301.24,percent of total billed charges,Implant Device,301.24,34,,301.24,percent of total billed charges,Implant Device,438.57,,,438.57,Other,110% of Medicare,310.1,35,,310.1,percent of total billed charges,Implant Device,301.24,34,"Charges > $500, x 34%",301.24,percent of total billed charges,Implant Device,310.1,35,,310.1,percent of total billed charges,Implant Device,310.1,35,,310.1,percent of total billed charges,Implant Device,310.1,35,,310.1,percent of total billed charges,Implant Device,310.1,35,,310.1,percent of total billed charges,Implant Device,310.1,35,,310.1,percent of total billed charges,Implant Device,354.4,40,,354.4,percent of total billed charges,Implant Device,310.1,70,,310.1,percent of total billed charges,All Other,301.24,34,,301.24,percent of total billed charges,Implant Device,301.24,34,,301.24,percent of total billed charges,Implant Device,310.1,35,,310.1,percent of total billed charges,Implant Device,310.1,35,,310.1,percent of total billed charges,Implant Device,310.1,35,,310.1,percent of total billed charges,Implant Device,310.1,35,,310.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,655.64,
STRYKER 59-23016 BONE SCREW 2.3X16MM,C1713,HCPCS,,79006059,CDM,278,RC,,,both,,,349,258.26,,,258.26,Other,150% of Medicare + 9.63% HCRA Surcharge,157.05,45,,157.05,percent of total billed charges,Critical Access Hospital RCC factor,118.66,34,,118.66,percent of total billed charges,Implant Device,118.66,34,,118.66,percent of total billed charges,Implant Device,118.66,34,,118.66,percent of total billed charges,Implant Device,118.66,34,,118.66,percent of total billed charges,Implant Device,118.66,34,,118.66,percent of total billed charges,Implant Device,172.76,,,172.76,Other,110% of Medicare,122.15,35,,122.15,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,122.15,35,,122.15,percent of total billed charges,Implant Device,122.15,35,,122.15,percent of total billed charges,Implant Device,122.15,35,,122.15,percent of total billed charges,Implant Device,122.15,35,,122.15,percent of total billed charges,Implant Device,122.15,35,,122.15,percent of total billed charges,Implant Device,139.6,40,,139.6,percent of total billed charges,Implant Device,122.15,70,,122.15,percent of total billed charges,All Other,118.66,34,,118.66,percent of total billed charges,Implant Device,118.66,34,,118.66,percent of total billed charges,Implant Device,122.15,35,,122.15,percent of total billed charges,Implant Device,122.15,35,,122.15,percent of total billed charges,Implant Device,122.15,35,,122.15,percent of total billed charges,Implant Device,122.15,35,,122.15,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,258.26,
MTF 410105 MTF TRINITY EVOLUTION 5CC,C1713,HCPCS,,79006062,CDM,278,RC,,,both,,,7555,5590.72,,,5590.72,Other,150% of Medicare + 9.63% HCRA Surcharge,3399.75,45,,3399.75,percent of total billed charges,Critical Access Hospital RCC factor,2568.7,34,,2568.7,percent of total billed charges,Implant Device,2568.7,34,,2568.7,percent of total billed charges,Implant Device,2568.7,34,,2568.7,percent of total billed charges,Implant Device,2568.7,34,,2568.7,percent of total billed charges,Implant Device,2568.7,34,,2568.7,percent of total billed charges,Implant Device,3739.73,,,3739.73,Other,110% of Medicare,2644.25,35,,2644.25,percent of total billed charges,Implant Device,2568.7,34,"Charges > $500, x 34%",2568.7,percent of total billed charges,Implant Device,2644.25,35,,2644.25,percent of total billed charges,Implant Device,2644.25,35,,2644.25,percent of total billed charges,Implant Device,2644.25,35,,2644.25,percent of total billed charges,Implant Device,2644.25,35,,2644.25,percent of total billed charges,Implant Device,2644.25,35,,2644.25,percent of total billed charges,Implant Device,3022,40,,3022,percent of total billed charges,Implant Device,2644.25,70,,2644.25,percent of total billed charges,All Other,2568.7,34,,2568.7,percent of total billed charges,Implant Device,2568.7,34,,2568.7,percent of total billed charges,Implant Device,2644.25,35,,2644.25,percent of total billed charges,Implant Device,2644.25,35,,2644.25,percent of total billed charges,Implant Device,2644.25,35,,2644.25,percent of total billed charges,Implant Device,2644.25,35,,2644.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2568.7,34,"If Charge > 2,000, then 34 percent",2568.7,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5590.72,
STRYKER 40-20806 DISTAL FIB PLATE 6 HOLE,C1713,HCPCS,,79006063,CDM,278,RC,,,both,,,1170,865.8,,,865.8,Other,150% of Medicare + 9.63% HCRA Surcharge,526.5,45,,526.5,percent of total billed charges,Critical Access Hospital RCC factor,397.8,34,,397.8,percent of total billed charges,Implant Device,397.8,34,,397.8,percent of total billed charges,Implant Device,397.8,34,,397.8,percent of total billed charges,Implant Device,397.8,34,,397.8,percent of total billed charges,Implant Device,397.8,34,,397.8,percent of total billed charges,Implant Device,579.15,,,579.15,Other,110% of Medicare,409.5,35,,409.5,percent of total billed charges,Implant Device,397.8,34,"Charges > $500, x 34%",397.8,percent of total billed charges,Implant Device,409.5,35,,409.5,percent of total billed charges,Implant Device,409.5,35,,409.5,percent of total billed charges,Implant Device,409.5,35,,409.5,percent of total billed charges,Implant Device,409.5,35,,409.5,percent of total billed charges,Implant Device,409.5,35,,409.5,percent of total billed charges,Implant Device,468,40,,468,percent of total billed charges,Implant Device,409.5,70,,409.5,percent of total billed charges,All Other,397.8,34,,397.8,percent of total billed charges,Implant Device,397.8,34,,397.8,percent of total billed charges,Implant Device,409.5,35,,409.5,percent of total billed charges,Implant Device,409.5,35,,409.5,percent of total billed charges,Implant Device,409.5,35,,409.5,percent of total billed charges,Implant Device,409.5,35,,409.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,865.8,
STRYKER 604670 CANNULATED SCREW 4X70MM,C1713,HCPCS,,79006064,CDM,278,RC,,,both,,,480,355.2,,,355.2,Other,150% of Medicare + 9.63% HCRA Surcharge,216,45,,216,percent of total billed charges,Critical Access Hospital RCC factor,163.2,34,,163.2,percent of total billed charges,Implant Device,163.2,34,,163.2,percent of total billed charges,Implant Device,163.2,34,,163.2,percent of total billed charges,Implant Device,163.2,34,,163.2,percent of total billed charges,Implant Device,163.2,34,,163.2,percent of total billed charges,Implant Device,237.6,,,237.6,Other,110% of Medicare,168,35,,168,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,192,40,,192,percent of total billed charges,Implant Device,168,70,,168,percent of total billed charges,All Other,163.2,34,,163.2,percent of total billed charges,Implant Device,163.2,34,,163.2,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,355.2,
ZIMMER 5994-30-14 ART SURF S YELLOW 14MM,C1776,HCPCS,,79006066,CDM,278,RC,,,both,,,6465,4784.12,,,4784.12,Other,150% of Medicare + 9.63% HCRA Surcharge,2909.25,45,,2909.25,percent of total billed charges,Critical Access Hospital RCC factor,2198.1,34,,2198.1,percent of total billed charges,Implant Device,2198.1,34,,2198.1,percent of total billed charges,Implant Device,2198.1,34,,2198.1,percent of total billed charges,Implant Device,2198.1,34,,2198.1,percent of total billed charges,Implant Device,2198.1,34,,2198.1,percent of total billed charges,Implant Device,3200.18,,,3200.18,Other,110% of Medicare,2262.75,35,,2262.75,percent of total billed charges,Implant Device,2198.1,34,"Charges > $500, x 34%",2198.1,percent of total billed charges,Implant Device,2262.75,35,,2262.75,percent of total billed charges,Implant Device,2262.75,35,,2262.75,percent of total billed charges,Implant Device,2262.75,35,,2262.75,percent of total billed charges,Implant Device,2262.75,35,,2262.75,percent of total billed charges,Implant Device,2262.75,35,,2262.75,percent of total billed charges,Implant Device,2586,40,,2586,percent of total billed charges,Implant Device,2262.75,70,,2262.75,percent of total billed charges,All Other,2198.1,34,,2198.1,percent of total billed charges,Implant Device,2198.1,34,,2198.1,percent of total billed charges,Implant Device,2262.75,35,,2262.75,percent of total billed charges,Implant Device,2262.75,35,,2262.75,percent of total billed charges,Implant Device,2262.75,35,,2262.75,percent of total billed charges,Implant Device,2262.75,35,,2262.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2198.1,34,"If Charge > 2,000, then 34 percent",2198.1,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4784.12,
MARQUET PPBF3030 VITAMESH BLUE 12X12,C1781,HCPCS,,79006067,CDM,278,RC,,,both,,,517,382.58,,,382.58,Other,150% of Medicare + 9.63% HCRA Surcharge,232.65,45,,232.65,percent of total billed charges,Critical Access Hospital RCC factor,175.78,34,,175.78,percent of total billed charges,Implant Device,175.78,34,,175.78,percent of total billed charges,Implant Device,175.78,34,,175.78,percent of total billed charges,Implant Device,175.78,34,,175.78,percent of total billed charges,Implant Device,175.78,34,,175.78,percent of total billed charges,Implant Device,255.92,,,255.92,Other,110% of Medicare,180.95,35,,180.95,percent of total billed charges,Implant Device,175.78,34,"Charges > $500, x 34%",175.78,percent of total billed charges,Implant Device,180.95,35,,180.95,percent of total billed charges,Implant Device,180.95,35,,180.95,percent of total billed charges,Implant Device,180.95,35,,180.95,percent of total billed charges,Implant Device,180.95,35,,180.95,percent of total billed charges,Implant Device,180.95,35,,180.95,percent of total billed charges,Implant Device,206.8,40,,206.8,percent of total billed charges,Implant Device,180.95,70,,180.95,percent of total billed charges,All Other,175.78,34,,175.78,percent of total billed charges,Implant Device,175.78,34,,175.78,percent of total billed charges,Implant Device,180.95,35,,180.95,percent of total billed charges,Implant Device,180.95,35,,180.95,percent of total billed charges,Implant Device,180.95,35,,180.95,percent of total billed charges,Implant Device,180.95,35,,180.95,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,382.58,
MARQUET PPVF1515 VITAMESH  RECTANGLE 6X6,C1781,HCPCS,,79006068,CDM,278,RC,,,both,,,185,136.9,,,136.9,Other,150% of Medicare + 9.63% HCRA Surcharge,83.25,45,,83.25,percent of total billed charges,Critical Access Hospital RCC factor,62.9,34,,62.9,percent of total billed charges,Implant Device,62.9,34,,62.9,percent of total billed charges,Implant Device,62.9,34,,62.9,percent of total billed charges,Implant Device,62.9,34,,62.9,percent of total billed charges,Implant Device,62.9,34,,62.9,percent of total billed charges,Implant Device,91.58,,,91.58,Other,110% of Medicare,64.75,35,,64.75,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,64.75,35,,64.75,percent of total billed charges,Implant Device,64.75,35,,64.75,percent of total billed charges,Implant Device,64.75,35,,64.75,percent of total billed charges,Implant Device,64.75,35,,64.75,percent of total billed charges,Implant Device,64.75,35,,64.75,percent of total billed charges,Implant Device,74,40,,74,percent of total billed charges,Implant Device,64.75,70,,64.75,percent of total billed charges,All Other,62.9,34,,62.9,percent of total billed charges,Implant Device,62.9,34,,62.9,percent of total billed charges,Implant Device,64.75,35,,64.75,percent of total billed charges,Implant Device,64.75,35,,64.75,percent of total billed charges,Implant Device,64.75,35,,64.75,percent of total billed charges,Implant Device,64.75,35,,64.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,136.9,
MTF 410002 TRINITY ELITE MEDIUM,C1713,HCPCS,,79006069,CDM,278,RC,,,both,,,9108,6739.94,,,6739.94,Other,150% of Medicare + 9.63% HCRA Surcharge,4098.6,45,,4098.6,percent of total billed charges,Critical Access Hospital RCC factor,3096.72,34,,3096.72,percent of total billed charges,Implant Device,3096.72,34,,3096.72,percent of total billed charges,Implant Device,3096.72,34,,3096.72,percent of total billed charges,Implant Device,3096.72,34,,3096.72,percent of total billed charges,Implant Device,3096.72,34,,3096.72,percent of total billed charges,Implant Device,4508.46,,,4508.46,Other,110% of Medicare,3187.8,35,,3187.8,percent of total billed charges,Implant Device,3096.72,34,"Charges > $500, x 34%",3096.72,percent of total billed charges,Implant Device,3187.8,35,,3187.8,percent of total billed charges,Implant Device,3187.8,35,,3187.8,percent of total billed charges,Implant Device,3187.8,35,,3187.8,percent of total billed charges,Implant Device,3187.8,35,,3187.8,percent of total billed charges,Implant Device,3187.8,35,,3187.8,percent of total billed charges,Implant Device,3643.2,40,,3643.2,percent of total billed charges,Implant Device,3187.8,70,,3187.8,percent of total billed charges,All Other,3096.72,34,,3096.72,percent of total billed charges,Implant Device,3096.72,34,,3096.72,percent of total billed charges,Implant Device,3187.8,35,,3187.8,percent of total billed charges,Implant Device,3187.8,35,,3187.8,percent of total billed charges,Implant Device,3187.8,35,,3187.8,percent of total billed charges,Implant Device,3187.8,35,,3187.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3096.72,34,"If Charge > 2,000, then 34 percent",3096.72,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,6739.94,
GORE TGU404010 THORACIC ENDOPROS GRAFT,C1768,HCPCS,,79006070,CDM,278,RC,,,both,,,46500,34410.12,,,34410.12,Other,150% of Medicare + 9.63% HCRA Surcharge,20925,45,,20925,percent of total billed charges,Critical Access Hospital RCC factor,15810,34,,15810,percent of total billed charges,Implant Device,15810,34,,15810,percent of total billed charges,Implant Device,15810,34,,15810,percent of total billed charges,Implant Device,15810,34,,15810,percent of total billed charges,Implant Device,15810,34,,15810,percent of total billed charges,Implant Device,23017.5,,,23017.5,Other,110% of Medicare,16275,35,,16275,percent of total billed charges,Implant Device,15810,34,"Charges > $500, x 34%",15810,percent of total billed charges,Implant Device,16275,35,,16275,percent of total billed charges,Implant Device,16275,35,,16275,percent of total billed charges,Implant Device,16275,35,,16275,percent of total billed charges,Implant Device,16275,35,,16275,percent of total billed charges,Implant Device,16275,35,,16275,percent of total billed charges,Implant Device,18600,40,,18600,percent of total billed charges,Implant Device,16275,70,,16275,percent of total billed charges,All Other,15810,34,,15810,percent of total billed charges,Implant Device,15810,34,,15810,percent of total billed charges,Implant Device,16275,35,,16275,percent of total billed charges,Implant Device,16275,35,,16275,percent of total billed charges,Implant Device,16275,35,,16275,percent of total billed charges,Implant Device,16275,35,,16275,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,15810,34,"If Charge > 2,000, then 34 percent",15810,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,34410.12,
STRYKER 427109 9 HOLE 5M COMPRSSN PLATE,C1713,HCPCS,,79006076,CDM,278,RC,,,both,,,732,541.68,,,541.68,Other,150% of Medicare + 9.63% HCRA Surcharge,329.4,45,,329.4,percent of total billed charges,Critical Access Hospital RCC factor,248.88,34,,248.88,percent of total billed charges,Implant Device,248.88,34,,248.88,percent of total billed charges,Implant Device,248.88,34,,248.88,percent of total billed charges,Implant Device,248.88,34,,248.88,percent of total billed charges,Implant Device,248.88,34,,248.88,percent of total billed charges,Implant Device,362.34,,,362.34,Other,110% of Medicare,256.2,35,,256.2,percent of total billed charges,Implant Device,248.88,34,"Charges > $500, x 34%",248.88,percent of total billed charges,Implant Device,256.2,35,,256.2,percent of total billed charges,Implant Device,256.2,35,,256.2,percent of total billed charges,Implant Device,256.2,35,,256.2,percent of total billed charges,Implant Device,256.2,35,,256.2,percent of total billed charges,Implant Device,256.2,35,,256.2,percent of total billed charges,Implant Device,292.8,40,,292.8,percent of total billed charges,Implant Device,256.2,70,,256.2,percent of total billed charges,All Other,248.88,34,,248.88,percent of total billed charges,Implant Device,248.88,34,,248.88,percent of total billed charges,Implant Device,256.2,35,,256.2,percent of total billed charges,Implant Device,256.2,35,,256.2,percent of total billed charges,Implant Device,256.2,35,,256.2,percent of total billed charges,Implant Device,256.2,35,,256.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,541.68,
STRYKER 340636 CORTICAL SCREW 4.5X36MM,C1713,HCPCS,,79006077,CDM,278,RC,,,both,,,125,92.5,,,92.5,Other,150% of Medicare + 9.63% HCRA Surcharge,56.25,45,,56.25,percent of total billed charges,Critical Access Hospital RCC factor,42.5,34,,42.5,percent of total billed charges,Implant Device,42.5,34,,42.5,percent of total billed charges,Implant Device,42.5,34,,42.5,percent of total billed charges,Implant Device,42.5,34,,42.5,percent of total billed charges,Implant Device,42.5,34,,42.5,percent of total billed charges,Implant Device,61.88,,,61.88,Other,110% of Medicare,43.75,35,,43.75,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,43.75,35,,43.75,percent of total billed charges,Implant Device,43.75,35,,43.75,percent of total billed charges,Implant Device,43.75,35,,43.75,percent of total billed charges,Implant Device,43.75,35,,43.75,percent of total billed charges,Implant Device,43.75,35,,43.75,percent of total billed charges,Implant Device,50,40,,50,percent of total billed charges,Implant Device,43.75,70,,43.75,percent of total billed charges,All Other,42.5,34,,42.5,percent of total billed charges,Implant Device,42.5,34,,42.5,percent of total billed charges,Implant Device,43.75,35,,43.75,percent of total billed charges,Implant Device,43.75,35,,43.75,percent of total billed charges,Implant Device,43.75,35,,43.75,percent of total billed charges,Implant Device,43.75,35,,43.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,92.5,
STRYKER 340630 CORTICAL SCREW 4.5X30MM,C1713,HCPCS,,79006078,CDM,278,RC,,,both,,,125,92.5,,,92.5,Other,150% of Medicare + 9.63% HCRA Surcharge,56.25,45,,56.25,percent of total billed charges,Critical Access Hospital RCC factor,42.5,34,,42.5,percent of total billed charges,Implant Device,42.5,34,,42.5,percent of total billed charges,Implant Device,42.5,34,,42.5,percent of total billed charges,Implant Device,42.5,34,,42.5,percent of total billed charges,Implant Device,42.5,34,,42.5,percent of total billed charges,Implant Device,61.88,,,61.88,Other,110% of Medicare,43.75,35,,43.75,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,43.75,35,,43.75,percent of total billed charges,Implant Device,43.75,35,,43.75,percent of total billed charges,Implant Device,43.75,35,,43.75,percent of total billed charges,Implant Device,43.75,35,,43.75,percent of total billed charges,Implant Device,43.75,35,,43.75,percent of total billed charges,Implant Device,50,40,,50,percent of total billed charges,Implant Device,43.75,70,,43.75,percent of total billed charges,All Other,42.5,34,,42.5,percent of total billed charges,Implant Device,42.5,34,,42.5,percent of total billed charges,Implant Device,43.75,35,,43.75,percent of total billed charges,Implant Device,43.75,35,,43.75,percent of total billed charges,Implant Device,43.75,35,,43.75,percent of total billed charges,Implant Device,43.75,35,,43.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,92.5,
STRYKER 340626 CORTICAL SCREW 4.5X26MM,C1713,HCPCS,,79006079,CDM,278,RC,,,both,,,125,92.5,,,92.5,Other,150% of Medicare + 9.63% HCRA Surcharge,56.25,45,,56.25,percent of total billed charges,Critical Access Hospital RCC factor,42.5,34,,42.5,percent of total billed charges,Implant Device,42.5,34,,42.5,percent of total billed charges,Implant Device,42.5,34,,42.5,percent of total billed charges,Implant Device,42.5,34,,42.5,percent of total billed charges,Implant Device,42.5,34,,42.5,percent of total billed charges,Implant Device,61.88,,,61.88,Other,110% of Medicare,43.75,35,,43.75,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,43.75,35,,43.75,percent of total billed charges,Implant Device,43.75,35,,43.75,percent of total billed charges,Implant Device,43.75,35,,43.75,percent of total billed charges,Implant Device,43.75,35,,43.75,percent of total billed charges,Implant Device,43.75,35,,43.75,percent of total billed charges,Implant Device,50,40,,50,percent of total billed charges,Implant Device,43.75,70,,43.75,percent of total billed charges,All Other,42.5,34,,42.5,percent of total billed charges,Implant Device,42.5,34,,42.5,percent of total billed charges,Implant Device,43.75,35,,43.75,percent of total billed charges,Implant Device,43.75,35,,43.75,percent of total billed charges,Implant Device,43.75,35,,43.75,percent of total billed charges,Implant Device,43.75,35,,43.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,92.5,
STRYKER 340640 CORTICAL SCREW 4.5X40MM,C1713,HCPCS,,79006080,CDM,278,RC,,,both,,,125,92.5,,,92.5,Other,150% of Medicare + 9.63% HCRA Surcharge,56.25,45,,56.25,percent of total billed charges,Critical Access Hospital RCC factor,42.5,34,,42.5,percent of total billed charges,Implant Device,42.5,34,,42.5,percent of total billed charges,Implant Device,42.5,34,,42.5,percent of total billed charges,Implant Device,42.5,34,,42.5,percent of total billed charges,Implant Device,42.5,34,,42.5,percent of total billed charges,Implant Device,61.88,,,61.88,Other,110% of Medicare,43.75,35,,43.75,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,43.75,35,,43.75,percent of total billed charges,Implant Device,43.75,35,,43.75,percent of total billed charges,Implant Device,43.75,35,,43.75,percent of total billed charges,Implant Device,43.75,35,,43.75,percent of total billed charges,Implant Device,43.75,35,,43.75,percent of total billed charges,Implant Device,50,40,,50,percent of total billed charges,Implant Device,43.75,70,,43.75,percent of total billed charges,All Other,42.5,34,,42.5,percent of total billed charges,Implant Device,42.5,34,,42.5,percent of total billed charges,Implant Device,43.75,35,,43.75,percent of total billed charges,Implant Device,43.75,35,,43.75,percent of total billed charges,Implant Device,43.75,35,,43.75,percent of total billed charges,Implant Device,43.75,35,,43.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,92.5,
STRYKER 340628 CORTICAL SCREW 4.5X28MM,C1713,HCPCS,,79006081,CDM,278,RC,,,both,,,125,92.5,,,92.5,Other,150% of Medicare + 9.63% HCRA Surcharge,56.25,45,,56.25,percent of total billed charges,Critical Access Hospital RCC factor,42.5,34,,42.5,percent of total billed charges,Implant Device,42.5,34,,42.5,percent of total billed charges,Implant Device,42.5,34,,42.5,percent of total billed charges,Implant Device,42.5,34,,42.5,percent of total billed charges,Implant Device,42.5,34,,42.5,percent of total billed charges,Implant Device,61.88,,,61.88,Other,110% of Medicare,43.75,35,,43.75,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,43.75,35,,43.75,percent of total billed charges,Implant Device,43.75,35,,43.75,percent of total billed charges,Implant Device,43.75,35,,43.75,percent of total billed charges,Implant Device,43.75,35,,43.75,percent of total billed charges,Implant Device,43.75,35,,43.75,percent of total billed charges,Implant Device,50,40,,50,percent of total billed charges,Implant Device,43.75,70,,43.75,percent of total billed charges,All Other,42.5,34,,42.5,percent of total billed charges,Implant Device,42.5,34,,42.5,percent of total billed charges,Implant Device,43.75,35,,43.75,percent of total billed charges,Implant Device,43.75,35,,43.75,percent of total billed charges,Implant Device,43.75,35,,43.75,percent of total billed charges,Implant Device,43.75,35,,43.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,92.5,
STRYKER 371326 LOCKING SCREW 5.0X26MM,C1713,HCPCS,,79006082,CDM,278,RC,,,both,,,576,426.24,,,426.24,Other,150% of Medicare + 9.63% HCRA Surcharge,259.2,45,,259.2,percent of total billed charges,Critical Access Hospital RCC factor,195.84,34,,195.84,percent of total billed charges,Implant Device,195.84,34,,195.84,percent of total billed charges,Implant Device,195.84,34,,195.84,percent of total billed charges,Implant Device,195.84,34,,195.84,percent of total billed charges,Implant Device,195.84,34,,195.84,percent of total billed charges,Implant Device,285.12,,,285.12,Other,110% of Medicare,201.6,35,,201.6,percent of total billed charges,Implant Device,195.84,34,"Charges > $500, x 34%",195.84,percent of total billed charges,Implant Device,201.6,35,,201.6,percent of total billed charges,Implant Device,201.6,35,,201.6,percent of total billed charges,Implant Device,201.6,35,,201.6,percent of total billed charges,Implant Device,201.6,35,,201.6,percent of total billed charges,Implant Device,201.6,35,,201.6,percent of total billed charges,Implant Device,230.4,40,,230.4,percent of total billed charges,Implant Device,201.6,70,,201.6,percent of total billed charges,All Other,195.84,34,,195.84,percent of total billed charges,Implant Device,195.84,34,,195.84,percent of total billed charges,Implant Device,201.6,35,,201.6,percent of total billed charges,Implant Device,201.6,35,,201.6,percent of total billed charges,Implant Device,201.6,35,,201.6,percent of total billed charges,Implant Device,201.6,35,,201.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,426.24,
STRYKER 371328 LOCKING SCREW 5.0X28MM,C1713,HCPCS,,79006083,CDM,278,RC,,,both,,,576,426.24,,,426.24,Other,150% of Medicare + 9.63% HCRA Surcharge,259.2,45,,259.2,percent of total billed charges,Critical Access Hospital RCC factor,195.84,34,,195.84,percent of total billed charges,Implant Device,195.84,34,,195.84,percent of total billed charges,Implant Device,195.84,34,,195.84,percent of total billed charges,Implant Device,195.84,34,,195.84,percent of total billed charges,Implant Device,195.84,34,,195.84,percent of total billed charges,Implant Device,285.12,,,285.12,Other,110% of Medicare,201.6,35,,201.6,percent of total billed charges,Implant Device,195.84,34,"Charges > $500, x 34%",195.84,percent of total billed charges,Implant Device,201.6,35,,201.6,percent of total billed charges,Implant Device,201.6,35,,201.6,percent of total billed charges,Implant Device,201.6,35,,201.6,percent of total billed charges,Implant Device,201.6,35,,201.6,percent of total billed charges,Implant Device,201.6,35,,201.6,percent of total billed charges,Implant Device,230.4,40,,230.4,percent of total billed charges,Implant Device,201.6,70,,201.6,percent of total billed charges,All Other,195.84,34,,195.84,percent of total billed charges,Implant Device,195.84,34,,195.84,percent of total billed charges,Implant Device,201.6,35,,201.6,percent of total billed charges,Implant Device,201.6,35,,201.6,percent of total billed charges,Implant Device,201.6,35,,201.6,percent of total billed charges,Implant Device,201.6,35,,201.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,426.24,
STRYKER 370003 LOCKING WASHER 5.0,C1713,HCPCS,,79006084,CDM,278,RC,,,both,,,268,198.32,,,198.32,Other,150% of Medicare + 9.63% HCRA Surcharge,120.6,45,,120.6,percent of total billed charges,Critical Access Hospital RCC factor,91.12,34,,91.12,percent of total billed charges,Implant Device,91.12,34,,91.12,percent of total billed charges,Implant Device,91.12,34,,91.12,percent of total billed charges,Implant Device,91.12,34,,91.12,percent of total billed charges,Implant Device,91.12,34,,91.12,percent of total billed charges,Implant Device,132.66,,,132.66,Other,110% of Medicare,93.8,35,,93.8,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,93.8,35,,93.8,percent of total billed charges,Implant Device,93.8,35,,93.8,percent of total billed charges,Implant Device,93.8,35,,93.8,percent of total billed charges,Implant Device,93.8,35,,93.8,percent of total billed charges,Implant Device,93.8,35,,93.8,percent of total billed charges,Implant Device,107.2,40,,107.2,percent of total billed charges,Implant Device,93.8,70,,93.8,percent of total billed charges,All Other,91.12,34,,91.12,percent of total billed charges,Implant Device,91.12,34,,91.12,percent of total billed charges,Implant Device,93.8,35,,93.8,percent of total billed charges,Implant Device,93.8,35,,93.8,percent of total billed charges,Implant Device,93.8,35,,93.8,percent of total billed charges,Implant Device,93.8,35,,93.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,198.32,
SYNTHES 207.648 CANNULATED SCREW 4X48MM,C1713,HCPCS,,79006087,CDM,278,RC,,,both,,,828,612.72,,,612.72,Other,150% of Medicare + 9.63% HCRA Surcharge,372.6,45,,372.6,percent of total billed charges,Critical Access Hospital RCC factor,281.52,34,,281.52,percent of total billed charges,Implant Device,281.52,34,,281.52,percent of total billed charges,Implant Device,281.52,34,,281.52,percent of total billed charges,Implant Device,281.52,34,,281.52,percent of total billed charges,Implant Device,281.52,34,,281.52,percent of total billed charges,Implant Device,409.86,,,409.86,Other,110% of Medicare,289.8,35,,289.8,percent of total billed charges,Implant Device,281.52,34,"Charges > $500, x 34%",281.52,percent of total billed charges,Implant Device,289.8,35,,289.8,percent of total billed charges,Implant Device,289.8,35,,289.8,percent of total billed charges,Implant Device,289.8,35,,289.8,percent of total billed charges,Implant Device,289.8,35,,289.8,percent of total billed charges,Implant Device,289.8,35,,289.8,percent of total billed charges,Implant Device,331.2,40,,331.2,percent of total billed charges,Implant Device,289.8,70,,289.8,percent of total billed charges,All Other,281.52,34,,281.52,percent of total billed charges,Implant Device,281.52,34,,281.52,percent of total billed charges,Implant Device,289.8,35,,289.8,percent of total billed charges,Implant Device,289.8,35,,289.8,percent of total billed charges,Implant Device,289.8,35,,289.8,percent of total billed charges,Implant Device,289.8,35,,289.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,612.72,
ACUMED 70-0290 CLAVICLE PLATE 8 HOLE,C1713,HCPCS,,79006089,CDM,278,RC,,,both,,,3498,2588.53,,,2588.53,Other,150% of Medicare + 9.63% HCRA Surcharge,1574.1,45,,1574.1,percent of total billed charges,Critical Access Hospital RCC factor,1189.32,34,,1189.32,percent of total billed charges,Implant Device,1189.32,34,,1189.32,percent of total billed charges,Implant Device,1189.32,34,,1189.32,percent of total billed charges,Implant Device,1189.32,34,,1189.32,percent of total billed charges,Implant Device,1189.32,34,,1189.32,percent of total billed charges,Implant Device,1731.51,,,1731.51,Other,110% of Medicare,1224.3,35,,1224.3,percent of total billed charges,Implant Device,1189.32,34,"Charges > $500, x 34%",1189.32,percent of total billed charges,Implant Device,1224.3,35,,1224.3,percent of total billed charges,Implant Device,1224.3,35,,1224.3,percent of total billed charges,Implant Device,1224.3,35,,1224.3,percent of total billed charges,Implant Device,1224.3,35,,1224.3,percent of total billed charges,Implant Device,1224.3,35,,1224.3,percent of total billed charges,Implant Device,1399.2,40,,1399.2,percent of total billed charges,Implant Device,1224.3,70,,1224.3,percent of total billed charges,All Other,1189.32,34,,1189.32,percent of total billed charges,Implant Device,1189.32,34,,1189.32,percent of total billed charges,Implant Device,1224.3,35,,1224.3,percent of total billed charges,Implant Device,1224.3,35,,1224.3,percent of total billed charges,Implant Device,1224.3,35,,1224.3,percent of total billed charges,Implant Device,1224.3,35,,1224.3,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1189.32,34,"If Charge > 2,000, then 34 percent",1189.32,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2588.53,
STRYKER 6276-7-017 MOD HIP SYS 155X17MM,C1776,HCPCS,,79006090,CDM,278,RC,,,both,,,8561,6335.16,,,6335.16,Other,150% of Medicare + 9.63% HCRA Surcharge,3852.45,45,,3852.45,percent of total billed charges,Critical Access Hospital RCC factor,2910.74,34,,2910.74,percent of total billed charges,Implant Device,2910.74,34,,2910.74,percent of total billed charges,Implant Device,2910.74,34,,2910.74,percent of total billed charges,Implant Device,2910.74,34,,2910.74,percent of total billed charges,Implant Device,2910.74,34,,2910.74,percent of total billed charges,Implant Device,4237.7,,,4237.7,Other,110% of Medicare,2996.35,35,,2996.35,percent of total billed charges,Implant Device,2910.74,34,"Charges > $500, x 34%",2910.74,percent of total billed charges,Implant Device,2996.35,35,,2996.35,percent of total billed charges,Implant Device,2996.35,35,,2996.35,percent of total billed charges,Implant Device,2996.35,35,,2996.35,percent of total billed charges,Implant Device,2996.35,35,,2996.35,percent of total billed charges,Implant Device,2996.35,35,,2996.35,percent of total billed charges,Implant Device,3424.4,40,,3424.4,percent of total billed charges,Implant Device,2996.35,70,,2996.35,percent of total billed charges,All Other,2910.74,34,,2910.74,percent of total billed charges,Implant Device,2910.74,34,,2910.74,percent of total billed charges,Implant Device,2996.35,35,,2996.35,percent of total billed charges,Implant Device,2996.35,35,,2996.35,percent of total billed charges,Implant Device,2996.35,35,,2996.35,percent of total billed charges,Implant Device,2996.35,35,,2996.35,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2910.74,34,"If Charge > 2,000, then 34 percent",2910.74,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,6335.16,
ACUMED CO-T2320 LOCKING SCREW 2.3X10MM,C1713,HCPCS,,79006091,CDM,278,RC,,,both,,,324,239.76,,,239.76,Other,150% of Medicare + 9.63% HCRA Surcharge,145.8,45,,145.8,percent of total billed charges,Critical Access Hospital RCC factor,110.16,34,,110.16,percent of total billed charges,Implant Device,110.16,34,,110.16,percent of total billed charges,Implant Device,110.16,34,,110.16,percent of total billed charges,Implant Device,110.16,34,,110.16,percent of total billed charges,Implant Device,110.16,34,,110.16,percent of total billed charges,Implant Device,160.38,,,160.38,Other,110% of Medicare,113.4,35,,113.4,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,129.6,40,,129.6,percent of total billed charges,Implant Device,113.4,70,,113.4,percent of total billed charges,All Other,110.16,34,,110.16,percent of total billed charges,Implant Device,110.16,34,,110.16,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,239.76,
MEDTRONIC 419678 ATTAIN ABILITY LEAD,C1900,HCPCS,,79006093,CDM,278,RC,,,both,,,7236,5354.66,,,5354.66,Other,150% of Medicare + 9.63% HCRA Surcharge,3256.2,45,,3256.2,percent of total billed charges,Critical Access Hospital RCC factor,2460.24,34,,2460.24,percent of total billed charges,Implant Device,2460.24,34,,2460.24,percent of total billed charges,Implant Device,2460.24,34,,2460.24,percent of total billed charges,Implant Device,2460.24,34,,2460.24,percent of total billed charges,Implant Device,2460.24,34,,2460.24,percent of total billed charges,Implant Device,3581.82,,,3581.82,Other,110% of Medicare,2532.6,35,,2532.6,percent of total billed charges,Implant Device,2460.24,34,"Charges > $500, x 34%",2460.24,percent of total billed charges,Implant Device,2532.6,35,,2532.6,percent of total billed charges,Implant Device,2532.6,35,,2532.6,percent of total billed charges,Implant Device,2532.6,35,,2532.6,percent of total billed charges,Implant Device,2532.6,35,,2532.6,percent of total billed charges,Implant Device,2532.6,35,,2532.6,percent of total billed charges,Implant Device,2894.4,40,,2894.4,percent of total billed charges,Implant Device,2532.6,70,,2532.6,percent of total billed charges,All Other,2460.24,34,,2460.24,percent of total billed charges,Implant Device,2460.24,34,,2460.24,percent of total billed charges,Implant Device,2532.6,35,,2532.6,percent of total billed charges,Implant Device,2532.6,35,,2532.6,percent of total billed charges,Implant Device,2532.6,35,,2532.6,percent of total billed charges,Implant Device,2532.6,35,,2532.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2460.24,34,"If Charge > 2,000, then 34 percent",2460.24,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5354.66,
MEDTRONIC 407645 CAPSUREFIX NOVUS LEAD,C1898,HCPCS,,79006094,CDM,278,RC,,,both,,,2058,1522.93,,,1522.93,Other,150% of Medicare + 9.63% HCRA Surcharge,926.1,45,,926.1,percent of total billed charges,Critical Access Hospital RCC factor,699.72,34,,699.72,percent of total billed charges,Implant Device,699.72,34,,699.72,percent of total billed charges,Implant Device,699.72,34,,699.72,percent of total billed charges,Implant Device,699.72,34,,699.72,percent of total billed charges,Implant Device,699.72,34,,699.72,percent of total billed charges,Implant Device,1018.71,,,1018.71,Other,110% of Medicare,720.3,35,,720.3,percent of total billed charges,Implant Device,699.72,34,"Charges > $500, x 34%",699.72,percent of total billed charges,Implant Device,720.3,35,,720.3,percent of total billed charges,Implant Device,720.3,35,,720.3,percent of total billed charges,Implant Device,720.3,35,,720.3,percent of total billed charges,Implant Device,720.3,35,,720.3,percent of total billed charges,Implant Device,720.3,35,,720.3,percent of total billed charges,Implant Device,823.2,40,,823.2,percent of total billed charges,Implant Device,720.3,70,,720.3,percent of total billed charges,All Other,699.72,34,,699.72,percent of total billed charges,Implant Device,699.72,34,,699.72,percent of total billed charges,Implant Device,720.3,35,,720.3,percent of total billed charges,Implant Device,720.3,35,,720.3,percent of total billed charges,Implant Device,720.3,35,,720.3,percent of total billed charges,Implant Device,720.3,35,,720.3,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,699.72,34,"If Charge > 2,000, then 34 percent",699.72,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1522.93,
ZIMMER 5842-22-08 ART SURFACE SZ 2 8MM,C1776,HCPCS,,79006097,CDM,278,RC,,,both,,,2677,1980.99,,,1980.99,Other,150% of Medicare + 9.63% HCRA Surcharge,1204.65,45,,1204.65,percent of total billed charges,Critical Access Hospital RCC factor,910.18,34,,910.18,percent of total billed charges,Implant Device,910.18,34,,910.18,percent of total billed charges,Implant Device,910.18,34,,910.18,percent of total billed charges,Implant Device,910.18,34,,910.18,percent of total billed charges,Implant Device,910.18,34,,910.18,percent of total billed charges,Implant Device,1325.12,,,1325.12,Other,110% of Medicare,936.95,35,,936.95,percent of total billed charges,Implant Device,910.18,34,"Charges > $500, x 34%",910.18,percent of total billed charges,Implant Device,936.95,35,,936.95,percent of total billed charges,Implant Device,936.95,35,,936.95,percent of total billed charges,Implant Device,936.95,35,,936.95,percent of total billed charges,Implant Device,936.95,35,,936.95,percent of total billed charges,Implant Device,936.95,35,,936.95,percent of total billed charges,Implant Device,1070.8,40,,1070.8,percent of total billed charges,Implant Device,936.95,70,,936.95,percent of total billed charges,All Other,910.18,34,,910.18,percent of total billed charges,Implant Device,910.18,34,,910.18,percent of total billed charges,Implant Device,936.95,35,,936.95,percent of total billed charges,Implant Device,936.95,35,,936.95,percent of total billed charges,Implant Device,936.95,35,,936.95,percent of total billed charges,Implant Device,936.95,35,,936.95,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,910.18,34,"If Charge > 2,000, then 34 percent",910.18,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1980.99,
ZIMMER 5842-12-01 FEM COMP SZ B,C1776,HCPCS,,79006098,CDM,278,RC,,,both,,,10486,7759.67,,,7759.67,Other,150% of Medicare + 9.63% HCRA Surcharge,4718.7,45,,4718.7,percent of total billed charges,Critical Access Hospital RCC factor,3565.24,34,,3565.24,percent of total billed charges,Implant Device,3565.24,34,,3565.24,percent of total billed charges,Implant Device,3565.24,34,,3565.24,percent of total billed charges,Implant Device,3565.24,34,,3565.24,percent of total billed charges,Implant Device,3565.24,34,,3565.24,percent of total billed charges,Implant Device,5190.57,,,5190.57,Other,110% of Medicare,3670.1,35,,3670.1,percent of total billed charges,Implant Device,3565.24,34,"Charges > $500, x 34%",3565.24,percent of total billed charges,Implant Device,3670.1,35,,3670.1,percent of total billed charges,Implant Device,3670.1,35,,3670.1,percent of total billed charges,Implant Device,3670.1,35,,3670.1,percent of total billed charges,Implant Device,3670.1,35,,3670.1,percent of total billed charges,Implant Device,3670.1,35,,3670.1,percent of total billed charges,Implant Device,4194.4,40,,4194.4,percent of total billed charges,Implant Device,3670.1,70,,3670.1,percent of total billed charges,All Other,3565.24,34,,3565.24,percent of total billed charges,Implant Device,3565.24,34,,3565.24,percent of total billed charges,Implant Device,3670.1,35,,3670.1,percent of total billed charges,Implant Device,3670.1,35,,3670.1,percent of total billed charges,Implant Device,3670.1,35,,3670.1,percent of total billed charges,Implant Device,3670.1,35,,3670.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3565.24,34,"If Charge > 2,000, then 34 percent",3565.24,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,7759.67,
ZIMMER 00-8775-028-02 FEM HEAD 28/+0MM,C1776,HCPCS,,79006099,CDM,278,RC,,,both,,,2880,2131.21,,,2131.21,Other,150% of Medicare + 9.63% HCRA Surcharge,1296,45,,1296,percent of total billed charges,Critical Access Hospital RCC factor,979.2,34,,979.2,percent of total billed charges,Implant Device,979.2,34,,979.2,percent of total billed charges,Implant Device,979.2,34,,979.2,percent of total billed charges,Implant Device,979.2,34,,979.2,percent of total billed charges,Implant Device,979.2,34,,979.2,percent of total billed charges,Implant Device,1425.6,,,1425.6,Other,110% of Medicare,1008,35,,1008,percent of total billed charges,Implant Device,979.2,34,"Charges > $500, x 34%",979.2,percent of total billed charges,Implant Device,1008,35,,1008,percent of total billed charges,Implant Device,1008,35,,1008,percent of total billed charges,Implant Device,1008,35,,1008,percent of total billed charges,Implant Device,1008,35,,1008,percent of total billed charges,Implant Device,1008,35,,1008,percent of total billed charges,Implant Device,1152,40,,1152,percent of total billed charges,Implant Device,1008,70,,1008,percent of total billed charges,All Other,979.2,34,,979.2,percent of total billed charges,Implant Device,979.2,34,,979.2,percent of total billed charges,Implant Device,1008,35,,1008,percent of total billed charges,Implant Device,1008,35,,1008,percent of total billed charges,Implant Device,1008,35,,1008,percent of total billed charges,Implant Device,1008,35,,1008,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,979.2,34,"If Charge > 2,000, then 34 percent",979.2,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2131.21,
ZIMMER 7711-04-10 FEM STEM SIZE 4,C1776,HCPCS,,79006100,CDM,278,RC,,,both,,,8910,6593.42,,,6593.42,Other,150% of Medicare + 9.63% HCRA Surcharge,4009.5,45,,4009.5,percent of total billed charges,Critical Access Hospital RCC factor,3029.4,34,,3029.4,percent of total billed charges,Implant Device,3029.4,34,,3029.4,percent of total billed charges,Implant Device,3029.4,34,,3029.4,percent of total billed charges,Implant Device,3029.4,34,,3029.4,percent of total billed charges,Implant Device,3029.4,34,,3029.4,percent of total billed charges,Implant Device,4410.45,,,4410.45,Other,110% of Medicare,3118.5,35,,3118.5,percent of total billed charges,Implant Device,3029.4,34,"Charges > $500, x 34%",3029.4,percent of total billed charges,Implant Device,3118.5,35,,3118.5,percent of total billed charges,Implant Device,3118.5,35,,3118.5,percent of total billed charges,Implant Device,3118.5,35,,3118.5,percent of total billed charges,Implant Device,3118.5,35,,3118.5,percent of total billed charges,Implant Device,3118.5,35,,3118.5,percent of total billed charges,Implant Device,3564,40,,3564,percent of total billed charges,Implant Device,3118.5,70,,3118.5,percent of total billed charges,All Other,3029.4,34,,3029.4,percent of total billed charges,Implant Device,3029.4,34,,3029.4,percent of total billed charges,Implant Device,3118.5,35,,3118.5,percent of total billed charges,Implant Device,3118.5,35,,3118.5,percent of total billed charges,Implant Device,3118.5,35,,3118.5,percent of total billed charges,Implant Device,3118.5,35,,3118.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3029.4,34,"If Charge > 2,000, then 34 percent",3029.4,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,6593.42,
ZIMMER 5001-44 BIPOLAR SHELL 44MM OD,C1776,HCPCS,,79006101,CDM,278,RC,,,both,,,960,710.4,,,710.4,Other,150% of Medicare + 9.63% HCRA Surcharge,432,45,,432,percent of total billed charges,Critical Access Hospital RCC factor,326.4,34,,326.4,percent of total billed charges,Implant Device,326.4,34,,326.4,percent of total billed charges,Implant Device,326.4,34,,326.4,percent of total billed charges,Implant Device,326.4,34,,326.4,percent of total billed charges,Implant Device,326.4,34,,326.4,percent of total billed charges,Implant Device,475.2,,,475.2,Other,110% of Medicare,336,35,,336,percent of total billed charges,Implant Device,326.4,34,"Charges > $500, x 34%",326.4,percent of total billed charges,Implant Device,336,35,,336,percent of total billed charges,Implant Device,336,35,,336,percent of total billed charges,Implant Device,336,35,,336,percent of total billed charges,Implant Device,336,35,,336,percent of total billed charges,Implant Device,336,35,,336,percent of total billed charges,Implant Device,384,40,,384,percent of total billed charges,Implant Device,336,70,,336,percent of total billed charges,All Other,326.4,34,,326.4,percent of total billed charges,Implant Device,326.4,34,,326.4,percent of total billed charges,Implant Device,336,35,,336,percent of total billed charges,Implant Device,336,35,,336,percent of total billed charges,Implant Device,336,35,,336,percent of total billed charges,Implant Device,336,35,,336,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,710.4,
BIOMET 14196-85 6.5X80MM CANN SCREW,C1713,HCPCS,,79006103,CDM,278,RC,,,both,,,1290,954.6,,,954.6,Other,150% of Medicare + 9.63% HCRA Surcharge,580.5,45,,580.5,percent of total billed charges,Critical Access Hospital RCC factor,438.6,34,,438.6,percent of total billed charges,Implant Device,438.6,34,,438.6,percent of total billed charges,Implant Device,438.6,34,,438.6,percent of total billed charges,Implant Device,438.6,34,,438.6,percent of total billed charges,Implant Device,438.6,34,,438.6,percent of total billed charges,Implant Device,638.55,,,638.55,Other,110% of Medicare,451.5,35,,451.5,percent of total billed charges,Implant Device,438.6,34,"Charges > $500, x 34%",438.6,percent of total billed charges,Implant Device,451.5,35,,451.5,percent of total billed charges,Implant Device,451.5,35,,451.5,percent of total billed charges,Implant Device,451.5,35,,451.5,percent of total billed charges,Implant Device,451.5,35,,451.5,percent of total billed charges,Implant Device,451.5,35,,451.5,percent of total billed charges,Implant Device,516,40,,516,percent of total billed charges,Implant Device,451.5,70,,451.5,percent of total billed charges,All Other,438.6,34,,438.6,percent of total billed charges,Implant Device,438.6,34,,438.6,percent of total billed charges,Implant Device,451.5,35,,451.5,percent of total billed charges,Implant Device,451.5,35,,451.5,percent of total billed charges,Implant Device,451.5,35,,451.5,percent of total billed charges,Implant Device,451.5,35,,451.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,954.6,
BIOMET 14196-90 6.5X90MM CANN SCREW,C1713,HCPCS,,79006104,CDM,278,RC,,,both,,,1290,954.6,,,954.6,Other,150% of Medicare + 9.63% HCRA Surcharge,580.5,45,,580.5,percent of total billed charges,Critical Access Hospital RCC factor,438.6,34,,438.6,percent of total billed charges,Implant Device,438.6,34,,438.6,percent of total billed charges,Implant Device,438.6,34,,438.6,percent of total billed charges,Implant Device,438.6,34,,438.6,percent of total billed charges,Implant Device,438.6,34,,438.6,percent of total billed charges,Implant Device,638.55,,,638.55,Other,110% of Medicare,451.5,35,,451.5,percent of total billed charges,Implant Device,438.6,34,"Charges > $500, x 34%",438.6,percent of total billed charges,Implant Device,451.5,35,,451.5,percent of total billed charges,Implant Device,451.5,35,,451.5,percent of total billed charges,Implant Device,451.5,35,,451.5,percent of total billed charges,Implant Device,451.5,35,,451.5,percent of total billed charges,Implant Device,451.5,35,,451.5,percent of total billed charges,Implant Device,516,40,,516,percent of total billed charges,Implant Device,451.5,70,,451.5,percent of total billed charges,All Other,438.6,34,,438.6,percent of total billed charges,Implant Device,438.6,34,,438.6,percent of total billed charges,Implant Device,451.5,35,,451.5,percent of total billed charges,Implant Device,451.5,35,,451.5,percent of total billed charges,Implant Device,451.5,35,,451.5,percent of total billed charges,Implant Device,451.5,35,,451.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,954.6,
BIOMET 14196-95 6.5X95MM CANN SCREW,C1713,HCPCS,,79006105,CDM,278,RC,,,both,,,1290,954.6,,,954.6,Other,150% of Medicare + 9.63% HCRA Surcharge,580.5,45,,580.5,percent of total billed charges,Critical Access Hospital RCC factor,438.6,34,,438.6,percent of total billed charges,Implant Device,438.6,34,,438.6,percent of total billed charges,Implant Device,438.6,34,,438.6,percent of total billed charges,Implant Device,438.6,34,,438.6,percent of total billed charges,Implant Device,438.6,34,,438.6,percent of total billed charges,Implant Device,638.55,,,638.55,Other,110% of Medicare,451.5,35,,451.5,percent of total billed charges,Implant Device,438.6,34,"Charges > $500, x 34%",438.6,percent of total billed charges,Implant Device,451.5,35,,451.5,percent of total billed charges,Implant Device,451.5,35,,451.5,percent of total billed charges,Implant Device,451.5,35,,451.5,percent of total billed charges,Implant Device,451.5,35,,451.5,percent of total billed charges,Implant Device,451.5,35,,451.5,percent of total billed charges,Implant Device,516,40,,516,percent of total billed charges,Implant Device,451.5,70,,451.5,percent of total billed charges,All Other,438.6,34,,438.6,percent of total billed charges,Implant Device,438.6,34,,438.6,percent of total billed charges,Implant Device,451.5,35,,451.5,percent of total billed charges,Implant Device,451.5,35,,451.5,percent of total billed charges,Implant Device,451.5,35,,451.5,percent of total billed charges,Implant Device,451.5,35,,451.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,954.6,
STRYKER 437532 DIST FEM PLATE RT 12 HOLE,C1713,HCPCS,,79006108,CDM,278,RC,,,both,,,6492,4804.1,,,4804.1,Other,150% of Medicare + 9.63% HCRA Surcharge,2921.4,45,,2921.4,percent of total billed charges,Critical Access Hospital RCC factor,2207.28,34,,2207.28,percent of total billed charges,Implant Device,2207.28,34,,2207.28,percent of total billed charges,Implant Device,2207.28,34,,2207.28,percent of total billed charges,Implant Device,2207.28,34,,2207.28,percent of total billed charges,Implant Device,2207.28,34,,2207.28,percent of total billed charges,Implant Device,3213.54,,,3213.54,Other,110% of Medicare,2272.2,35,,2272.2,percent of total billed charges,Implant Device,2207.28,34,"Charges > $500, x 34%",2207.28,percent of total billed charges,Implant Device,2272.2,35,,2272.2,percent of total billed charges,Implant Device,2272.2,35,,2272.2,percent of total billed charges,Implant Device,2272.2,35,,2272.2,percent of total billed charges,Implant Device,2272.2,35,,2272.2,percent of total billed charges,Implant Device,2272.2,35,,2272.2,percent of total billed charges,Implant Device,2596.8,40,,2596.8,percent of total billed charges,Implant Device,2272.2,70,,2272.2,percent of total billed charges,All Other,2207.28,34,,2207.28,percent of total billed charges,Implant Device,2207.28,34,,2207.28,percent of total billed charges,Implant Device,2272.2,35,,2272.2,percent of total billed charges,Implant Device,2272.2,35,,2272.2,percent of total billed charges,Implant Device,2272.2,35,,2272.2,percent of total billed charges,Implant Device,2272.2,35,,2272.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2207.28,34,"If Charge > 2,000, then 34 percent",2207.28,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4804.1,
STRYKER 370112 LOCKING SCREW 5.0X2MM,C1713,HCPCS,,79006109,CDM,278,RC,,,both,,,737,545.38,,,545.38,Other,150% of Medicare + 9.63% HCRA Surcharge,331.65,45,,331.65,percent of total billed charges,Critical Access Hospital RCC factor,250.58,34,,250.58,percent of total billed charges,Implant Device,250.58,34,,250.58,percent of total billed charges,Implant Device,250.58,34,,250.58,percent of total billed charges,Implant Device,250.58,34,,250.58,percent of total billed charges,Implant Device,250.58,34,,250.58,percent of total billed charges,Implant Device,364.82,,,364.82,Other,110% of Medicare,257.95,35,,257.95,percent of total billed charges,Implant Device,250.58,34,"Charges > $500, x 34%",250.58,percent of total billed charges,Implant Device,257.95,35,,257.95,percent of total billed charges,Implant Device,257.95,35,,257.95,percent of total billed charges,Implant Device,257.95,35,,257.95,percent of total billed charges,Implant Device,257.95,35,,257.95,percent of total billed charges,Implant Device,257.95,35,,257.95,percent of total billed charges,Implant Device,294.8,40,,294.8,percent of total billed charges,Implant Device,257.95,70,,257.95,percent of total billed charges,All Other,250.58,34,,250.58,percent of total billed charges,Implant Device,250.58,34,,250.58,percent of total billed charges,Implant Device,257.95,35,,257.95,percent of total billed charges,Implant Device,257.95,35,,257.95,percent of total billed charges,Implant Device,257.95,35,,257.95,percent of total billed charges,Implant Device,257.95,35,,257.95,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,545.38,
STRYKER 371338 LOCKING SCREW 5.0X38MM,C1713,HCPCS,,79006110,CDM,278,RC,,,both,,,576,426.24,,,426.24,Other,150% of Medicare + 9.63% HCRA Surcharge,259.2,45,,259.2,percent of total billed charges,Critical Access Hospital RCC factor,195.84,34,,195.84,percent of total billed charges,Implant Device,195.84,34,,195.84,percent of total billed charges,Implant Device,195.84,34,,195.84,percent of total billed charges,Implant Device,195.84,34,,195.84,percent of total billed charges,Implant Device,195.84,34,,195.84,percent of total billed charges,Implant Device,285.12,,,285.12,Other,110% of Medicare,201.6,35,,201.6,percent of total billed charges,Implant Device,195.84,34,"Charges > $500, x 34%",195.84,percent of total billed charges,Implant Device,201.6,35,,201.6,percent of total billed charges,Implant Device,201.6,35,,201.6,percent of total billed charges,Implant Device,201.6,35,,201.6,percent of total billed charges,Implant Device,201.6,35,,201.6,percent of total billed charges,Implant Device,201.6,35,,201.6,percent of total billed charges,Implant Device,230.4,40,,230.4,percent of total billed charges,Implant Device,201.6,70,,201.6,percent of total billed charges,All Other,195.84,34,,195.84,percent of total billed charges,Implant Device,195.84,34,,195.84,percent of total billed charges,Implant Device,201.6,35,,201.6,percent of total billed charges,Implant Device,201.6,35,,201.6,percent of total billed charges,Implant Device,201.6,35,,201.6,percent of total billed charges,Implant Device,201.6,35,,201.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,426.24,
STRYKER 371370 LOCKING SCREW 5.0X70MM,C1713,HCPCS,,79006111,CDM,278,RC,,,both,,,576,426.24,,,426.24,Other,150% of Medicare + 9.63% HCRA Surcharge,259.2,45,,259.2,percent of total billed charges,Critical Access Hospital RCC factor,195.84,34,,195.84,percent of total billed charges,Implant Device,195.84,34,,195.84,percent of total billed charges,Implant Device,195.84,34,,195.84,percent of total billed charges,Implant Device,195.84,34,,195.84,percent of total billed charges,Implant Device,195.84,34,,195.84,percent of total billed charges,Implant Device,285.12,,,285.12,Other,110% of Medicare,201.6,35,,201.6,percent of total billed charges,Implant Device,195.84,34,"Charges > $500, x 34%",195.84,percent of total billed charges,Implant Device,201.6,35,,201.6,percent of total billed charges,Implant Device,201.6,35,,201.6,percent of total billed charges,Implant Device,201.6,35,,201.6,percent of total billed charges,Implant Device,201.6,35,,201.6,percent of total billed charges,Implant Device,201.6,35,,201.6,percent of total billed charges,Implant Device,230.4,40,,230.4,percent of total billed charges,Implant Device,201.6,70,,201.6,percent of total billed charges,All Other,195.84,34,,195.84,percent of total billed charges,Implant Device,195.84,34,,195.84,percent of total billed charges,Implant Device,201.6,35,,201.6,percent of total billed charges,Implant Device,201.6,35,,201.6,percent of total billed charges,Implant Device,201.6,35,,201.6,percent of total billed charges,Implant Device,201.6,35,,201.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,426.24,
STRYKER 340655 CORTICAL SCREW 4.5X55MM,C1713,HCPCS,,79006112,CDM,278,RC,,,both,,,125,92.5,,,92.5,Other,150% of Medicare + 9.63% HCRA Surcharge,56.25,45,,56.25,percent of total billed charges,Critical Access Hospital RCC factor,42.5,34,,42.5,percent of total billed charges,Implant Device,42.5,34,,42.5,percent of total billed charges,Implant Device,42.5,34,,42.5,percent of total billed charges,Implant Device,42.5,34,,42.5,percent of total billed charges,Implant Device,42.5,34,,42.5,percent of total billed charges,Implant Device,61.88,,,61.88,Other,110% of Medicare,43.75,35,,43.75,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,43.75,35,,43.75,percent of total billed charges,Implant Device,43.75,35,,43.75,percent of total billed charges,Implant Device,43.75,35,,43.75,percent of total billed charges,Implant Device,43.75,35,,43.75,percent of total billed charges,Implant Device,43.75,35,,43.75,percent of total billed charges,Implant Device,50,40,,50,percent of total billed charges,Implant Device,43.75,70,,43.75,percent of total billed charges,All Other,42.5,34,,42.5,percent of total billed charges,Implant Device,42.5,34,,42.5,percent of total billed charges,Implant Device,43.75,35,,43.75,percent of total billed charges,Implant Device,43.75,35,,43.75,percent of total billed charges,Implant Device,43.75,35,,43.75,percent of total billed charges,Implant Device,43.75,35,,43.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,92.5,
STRYKER 340648 CORTICAL SCREW 4.5X48MM,C1713,HCPCS,,79006113,CDM,278,RC,,,both,,,125,92.5,,,92.5,Other,150% of Medicare + 9.63% HCRA Surcharge,56.25,45,,56.25,percent of total billed charges,Critical Access Hospital RCC factor,42.5,34,,42.5,percent of total billed charges,Implant Device,42.5,34,,42.5,percent of total billed charges,Implant Device,42.5,34,,42.5,percent of total billed charges,Implant Device,42.5,34,,42.5,percent of total billed charges,Implant Device,42.5,34,,42.5,percent of total billed charges,Implant Device,61.88,,,61.88,Other,110% of Medicare,43.75,35,,43.75,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,43.75,35,,43.75,percent of total billed charges,Implant Device,43.75,35,,43.75,percent of total billed charges,Implant Device,43.75,35,,43.75,percent of total billed charges,Implant Device,43.75,35,,43.75,percent of total billed charges,Implant Device,43.75,35,,43.75,percent of total billed charges,Implant Device,50,40,,50,percent of total billed charges,Implant Device,43.75,70,,43.75,percent of total billed charges,All Other,42.5,34,,42.5,percent of total billed charges,Implant Device,42.5,34,,42.5,percent of total billed charges,Implant Device,43.75,35,,43.75,percent of total billed charges,Implant Device,43.75,35,,43.75,percent of total billed charges,Implant Device,43.75,35,,43.75,percent of total billed charges,Implant Device,43.75,35,,43.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,92.5,
EXACTECH 310-02-47 HUMERAL HEAD 47MM,C1776,HCPCS,,79006115,CDM,278,RC,,,both,,,4968,3676.33,,,3676.33,Other,150% of Medicare + 9.63% HCRA Surcharge,2235.6,45,,2235.6,percent of total billed charges,Critical Access Hospital RCC factor,1689.12,34,,1689.12,percent of total billed charges,Implant Device,1689.12,34,,1689.12,percent of total billed charges,Implant Device,1689.12,34,,1689.12,percent of total billed charges,Implant Device,1689.12,34,,1689.12,percent of total billed charges,Implant Device,1689.12,34,,1689.12,percent of total billed charges,Implant Device,2459.16,,,2459.16,Other,110% of Medicare,1738.8,35,,1738.8,percent of total billed charges,Implant Device,1689.12,34,"Charges > $500, x 34%",1689.12,percent of total billed charges,Implant Device,1738.8,35,,1738.8,percent of total billed charges,Implant Device,1738.8,35,,1738.8,percent of total billed charges,Implant Device,1738.8,35,,1738.8,percent of total billed charges,Implant Device,1738.8,35,,1738.8,percent of total billed charges,Implant Device,1738.8,35,,1738.8,percent of total billed charges,Implant Device,1987.2,40,,1987.2,percent of total billed charges,Implant Device,1738.8,70,,1738.8,percent of total billed charges,All Other,1689.12,34,,1689.12,percent of total billed charges,Implant Device,1689.12,34,,1689.12,percent of total billed charges,Implant Device,1738.8,35,,1738.8,percent of total billed charges,Implant Device,1738.8,35,,1738.8,percent of total billed charges,Implant Device,1738.8,35,,1738.8,percent of total billed charges,Implant Device,1738.8,35,,1738.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1689.12,34,"If Charge > 2,000, then 34 percent",1689.12,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3676.33,
EXACTECH 300-01-15 HUMERAL STEM 15MM,C1776,HCPCS,,79006116,CDM,278,RC,,,both,,,4425,3274.51,,,3274.51,Other,150% of Medicare + 9.63% HCRA Surcharge,1991.25,45,,1991.25,percent of total billed charges,Critical Access Hospital RCC factor,1504.5,34,,1504.5,percent of total billed charges,Implant Device,1504.5,34,,1504.5,percent of total billed charges,Implant Device,1504.5,34,,1504.5,percent of total billed charges,Implant Device,1504.5,34,,1504.5,percent of total billed charges,Implant Device,1504.5,34,,1504.5,percent of total billed charges,Implant Device,2190.38,,,2190.38,Other,110% of Medicare,1548.75,35,,1548.75,percent of total billed charges,Implant Device,1504.5,34,"Charges > $500, x 34%",1504.5,percent of total billed charges,Implant Device,1548.75,35,,1548.75,percent of total billed charges,Implant Device,1548.75,35,,1548.75,percent of total billed charges,Implant Device,1548.75,35,,1548.75,percent of total billed charges,Implant Device,1548.75,35,,1548.75,percent of total billed charges,Implant Device,1548.75,35,,1548.75,percent of total billed charges,Implant Device,1770,40,,1770,percent of total billed charges,Implant Device,1548.75,70,,1548.75,percent of total billed charges,All Other,1504.5,34,,1504.5,percent of total billed charges,Implant Device,1504.5,34,,1504.5,percent of total billed charges,Implant Device,1548.75,35,,1548.75,percent of total billed charges,Implant Device,1548.75,35,,1548.75,percent of total billed charges,Implant Device,1548.75,35,,1548.75,percent of total billed charges,Implant Device,1548.75,35,,1548.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1504.5,34,"If Charge > 2,000, then 34 percent",1504.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3274.51,
GORE PLC231000 EXCLUDER ENDOPROS 23X10CM,C1874,HCPCS,,79006117,CDM,278,RC,,,both,,,12900,9546.03,,,9546.03,Other,150% of Medicare + 9.63% HCRA Surcharge,5805,45,,5805,percent of total billed charges,Critical Access Hospital RCC factor,4386,34,,4386,percent of total billed charges,Implant Device,4386,34,,4386,percent of total billed charges,Implant Device,4386,34,,4386,percent of total billed charges,Implant Device,4386,34,,4386,percent of total billed charges,Implant Device,4386,34,,4386,percent of total billed charges,Implant Device,6385.5,,,6385.5,Other,110% of Medicare,4515,35,,4515,percent of total billed charges,Implant Device,4386,34,"Charges > $500, x 34%",4386,percent of total billed charges,Implant Device,4515,35,,4515,percent of total billed charges,Implant Device,4515,35,,4515,percent of total billed charges,Implant Device,4515,35,,4515,percent of total billed charges,Implant Device,4515,35,,4515,percent of total billed charges,Implant Device,4515,35,,4515,percent of total billed charges,Implant Device,5160,40,,5160,percent of total billed charges,Implant Device,4515,70,,4515,percent of total billed charges,All Other,4386,34,,4386,percent of total billed charges,Implant Device,4386,34,,4386,percent of total billed charges,Implant Device,4515,35,,4515,percent of total billed charges,Implant Device,4515,35,,4515,percent of total billed charges,Implant Device,4515,35,,4515,percent of total billed charges,Implant Device,4515,35,,4515,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,4386,34,"If Charge > 2,000, then 34 percent",4386,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,9546.03,
BME SE-0910 SPEED IMPLANT 9X10X10MM,C1713,HCPCS,,79006120,CDM,278,RC,,,both,,,3630,2686.21,,,2686.21,Other,150% of Medicare + 9.63% HCRA Surcharge,1633.5,45,,1633.5,percent of total billed charges,Critical Access Hospital RCC factor,1234.2,34,,1234.2,percent of total billed charges,Implant Device,1234.2,34,,1234.2,percent of total billed charges,Implant Device,1234.2,34,,1234.2,percent of total billed charges,Implant Device,1234.2,34,,1234.2,percent of total billed charges,Implant Device,1234.2,34,,1234.2,percent of total billed charges,Implant Device,1796.85,,,1796.85,Other,110% of Medicare,1270.5,35,,1270.5,percent of total billed charges,Implant Device,1234.2,34,"Charges > $500, x 34%",1234.2,percent of total billed charges,Implant Device,1270.5,35,,1270.5,percent of total billed charges,Implant Device,1270.5,35,,1270.5,percent of total billed charges,Implant Device,1270.5,35,,1270.5,percent of total billed charges,Implant Device,1270.5,35,,1270.5,percent of total billed charges,Implant Device,1270.5,35,,1270.5,percent of total billed charges,Implant Device,1452,40,,1452,percent of total billed charges,Implant Device,1270.5,70,,1270.5,percent of total billed charges,All Other,1234.2,34,,1234.2,percent of total billed charges,Implant Device,1234.2,34,,1234.2,percent of total billed charges,Implant Device,1270.5,35,,1270.5,percent of total billed charges,Implant Device,1270.5,35,,1270.5,percent of total billed charges,Implant Device,1270.5,35,,1270.5,percent of total billed charges,Implant Device,1270.5,35,,1270.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1234.2,34,"If Charge > 2,000, then 34 percent",1234.2,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2686.21,
PARAGON28 P20-055-WF00 FLAT WASHER 5.5MM,C1713,HCPCS,,79006122,CDM,278,RC,,,both,,,542,401.08,,,401.08,Other,150% of Medicare + 9.63% HCRA Surcharge,243.9,45,,243.9,percent of total billed charges,Critical Access Hospital RCC factor,184.28,34,,184.28,percent of total billed charges,Implant Device,184.28,34,,184.28,percent of total billed charges,Implant Device,184.28,34,,184.28,percent of total billed charges,Implant Device,184.28,34,,184.28,percent of total billed charges,Implant Device,184.28,34,,184.28,percent of total billed charges,Implant Device,268.29,,,268.29,Other,110% of Medicare,189.7,35,,189.7,percent of total billed charges,Implant Device,184.28,34,"Charges > $500, x 34%",184.28,percent of total billed charges,Implant Device,189.7,35,,189.7,percent of total billed charges,Implant Device,189.7,35,,189.7,percent of total billed charges,Implant Device,189.7,35,,189.7,percent of total billed charges,Implant Device,189.7,35,,189.7,percent of total billed charges,Implant Device,189.7,35,,189.7,percent of total billed charges,Implant Device,216.8,40,,216.8,percent of total billed charges,Implant Device,189.7,70,,189.7,percent of total billed charges,All Other,184.28,34,,184.28,percent of total billed charges,Implant Device,184.28,34,,184.28,percent of total billed charges,Implant Device,189.7,35,,189.7,percent of total billed charges,Implant Device,189.7,35,,189.7,percent of total billed charges,Implant Device,189.7,35,,189.7,percent of total billed charges,Implant Device,189.7,35,,189.7,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,401.08,
PARAGON28 P20-155-056S CANN SCREW 5.5X56,C1713,HCPCS,,79006123,CDM,278,RC,,,both,,,1324,979.76,,,979.76,Other,150% of Medicare + 9.63% HCRA Surcharge,595.8,45,,595.8,percent of total billed charges,Critical Access Hospital RCC factor,450.16,34,,450.16,percent of total billed charges,Implant Device,450.16,34,,450.16,percent of total billed charges,Implant Device,450.16,34,,450.16,percent of total billed charges,Implant Device,450.16,34,,450.16,percent of total billed charges,Implant Device,450.16,34,,450.16,percent of total billed charges,Implant Device,655.38,,,655.38,Other,110% of Medicare,463.4,35,,463.4,percent of total billed charges,Implant Device,450.16,34,"Charges > $500, x 34%",450.16,percent of total billed charges,Implant Device,463.4,35,,463.4,percent of total billed charges,Implant Device,463.4,35,,463.4,percent of total billed charges,Implant Device,463.4,35,,463.4,percent of total billed charges,Implant Device,463.4,35,,463.4,percent of total billed charges,Implant Device,463.4,35,,463.4,percent of total billed charges,Implant Device,529.6,40,,529.6,percent of total billed charges,Implant Device,463.4,70,,463.4,percent of total billed charges,All Other,450.16,34,,450.16,percent of total billed charges,Implant Device,450.16,34,,450.16,percent of total billed charges,Implant Device,463.4,35,,463.4,percent of total billed charges,Implant Device,463.4,35,,463.4,percent of total billed charges,Implant Device,463.4,35,,463.4,percent of total billed charges,Implant Device,463.4,35,,463.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,979.76,
PARAGON28 P20-155-060S CANN SCREW 5.5X60,C1713,HCPCS,,79006124,CDM,278,RC,,,both,,,1236,914.64,,,914.64,Other,150% of Medicare + 9.63% HCRA Surcharge,556.2,45,,556.2,percent of total billed charges,Critical Access Hospital RCC factor,420.24,34,,420.24,percent of total billed charges,Implant Device,420.24,34,,420.24,percent of total billed charges,Implant Device,420.24,34,,420.24,percent of total billed charges,Implant Device,420.24,34,,420.24,percent of total billed charges,Implant Device,420.24,34,,420.24,percent of total billed charges,Implant Device,611.82,,,611.82,Other,110% of Medicare,432.6,35,,432.6,percent of total billed charges,Implant Device,420.24,34,"Charges > $500, x 34%",420.24,percent of total billed charges,Implant Device,432.6,35,,432.6,percent of total billed charges,Implant Device,432.6,35,,432.6,percent of total billed charges,Implant Device,432.6,35,,432.6,percent of total billed charges,Implant Device,432.6,35,,432.6,percent of total billed charges,Implant Device,432.6,35,,432.6,percent of total billed charges,Implant Device,494.4,40,,494.4,percent of total billed charges,Implant Device,432.6,70,,432.6,percent of total billed charges,All Other,420.24,34,,420.24,percent of total billed charges,Implant Device,420.24,34,,420.24,percent of total billed charges,Implant Device,432.6,35,,432.6,percent of total billed charges,Implant Device,432.6,35,,432.6,percent of total billed charges,Implant Device,432.6,35,,432.6,percent of total billed charges,Implant Device,432.6,35,,432.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,914.64,
PARAGON28 P20-170-090M CANN SCREW 7X90,C1713,HCPCS,,79006125,CDM,278,RC,,,both,,,1860,1376.4,,,1376.4,Other,150% of Medicare + 9.63% HCRA Surcharge,837,45,,837,percent of total billed charges,Critical Access Hospital RCC factor,632.4,34,,632.4,percent of total billed charges,Implant Device,632.4,34,,632.4,percent of total billed charges,Implant Device,632.4,34,,632.4,percent of total billed charges,Implant Device,632.4,34,,632.4,percent of total billed charges,Implant Device,632.4,34,,632.4,percent of total billed charges,Implant Device,920.7,,,920.7,Other,110% of Medicare,651,35,,651,percent of total billed charges,Implant Device,632.4,34,"Charges > $500, x 34%",632.4,percent of total billed charges,Implant Device,651,35,,651,percent of total billed charges,Implant Device,651,35,,651,percent of total billed charges,Implant Device,651,35,,651,percent of total billed charges,Implant Device,651,35,,651,percent of total billed charges,Implant Device,651,35,,651,percent of total billed charges,Implant Device,744,40,,744,percent of total billed charges,Implant Device,651,70,,651,percent of total billed charges,All Other,632.4,34,,632.4,percent of total billed charges,Implant Device,632.4,34,,632.4,percent of total billed charges,Implant Device,651,35,,651,percent of total billed charges,Implant Device,651,35,,651,percent of total billed charges,Implant Device,651,35,,651,percent of total billed charges,Implant Device,651,35,,651,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1376.4,
BME SE-2020 SPEED IMPLANT 20X20X20MM,C1713,HCPCS,,79006131,CDM,278,RC,,,both,,,5016,3711.85,,,3711.85,Other,150% of Medicare + 9.63% HCRA Surcharge,2257.2,45,,2257.2,percent of total billed charges,Critical Access Hospital RCC factor,1705.44,34,,1705.44,percent of total billed charges,Implant Device,1705.44,34,,1705.44,percent of total billed charges,Implant Device,1705.44,34,,1705.44,percent of total billed charges,Implant Device,1705.44,34,,1705.44,percent of total billed charges,Implant Device,1705.44,34,,1705.44,percent of total billed charges,Implant Device,2482.92,,,2482.92,Other,110% of Medicare,1755.6,35,,1755.6,percent of total billed charges,Implant Device,1705.44,34,"Charges > $500, x 34%",1705.44,percent of total billed charges,Implant Device,1755.6,35,,1755.6,percent of total billed charges,Implant Device,1755.6,35,,1755.6,percent of total billed charges,Implant Device,1755.6,35,,1755.6,percent of total billed charges,Implant Device,1755.6,35,,1755.6,percent of total billed charges,Implant Device,1755.6,35,,1755.6,percent of total billed charges,Implant Device,2006.4,40,,2006.4,percent of total billed charges,Implant Device,1755.6,70,,1755.6,percent of total billed charges,All Other,1705.44,34,,1705.44,percent of total billed charges,Implant Device,1705.44,34,,1705.44,percent of total billed charges,Implant Device,1755.6,35,,1755.6,percent of total billed charges,Implant Device,1755.6,35,,1755.6,percent of total billed charges,Implant Device,1755.6,35,,1755.6,percent of total billed charges,Implant Device,1755.6,35,,1755.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1705.44,34,"If Charge > 2,000, then 34 percent",1705.44,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3711.85,
BME SE-1818 SPEED IMPLANT 18X18X18MM,C1713,HCPCS,,79006132,CDM,278,RC,,,both,,,3960,2930.41,,,2930.41,Other,150% of Medicare + 9.63% HCRA Surcharge,1782,45,,1782,percent of total billed charges,Critical Access Hospital RCC factor,1346.4,34,,1346.4,percent of total billed charges,Implant Device,1346.4,34,,1346.4,percent of total billed charges,Implant Device,1346.4,34,,1346.4,percent of total billed charges,Implant Device,1346.4,34,,1346.4,percent of total billed charges,Implant Device,1346.4,34,,1346.4,percent of total billed charges,Implant Device,1960.2,,,1960.2,Other,110% of Medicare,1386,35,,1386,percent of total billed charges,Implant Device,1346.4,34,"Charges > $500, x 34%",1346.4,percent of total billed charges,Implant Device,1386,35,,1386,percent of total billed charges,Implant Device,1386,35,,1386,percent of total billed charges,Implant Device,1386,35,,1386,percent of total billed charges,Implant Device,1386,35,,1386,percent of total billed charges,Implant Device,1386,35,,1386,percent of total billed charges,Implant Device,1584,40,,1584,percent of total billed charges,Implant Device,1386,70,,1386,percent of total billed charges,All Other,1346.4,34,,1346.4,percent of total billed charges,Implant Device,1346.4,34,,1346.4,percent of total billed charges,Implant Device,1386,35,,1386,percent of total billed charges,Implant Device,1386,35,,1386,percent of total billed charges,Implant Device,1386,35,,1386,percent of total billed charges,Implant Device,1386,35,,1386,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1346.4,34,"If Charge > 2,000, then 34 percent",1346.4,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2930.41,
ARTHREX AR-8740-42PTS SCREW 4X42MM,C1713,HCPCS,,79006133,CDM,278,RC,,,both,,,496,367.04,,,367.04,Other,150% of Medicare + 9.63% HCRA Surcharge,223.2,45,,223.2,percent of total billed charges,Critical Access Hospital RCC factor,168.64,34,,168.64,percent of total billed charges,Implant Device,168.64,34,,168.64,percent of total billed charges,Implant Device,168.64,34,,168.64,percent of total billed charges,Implant Device,168.64,34,,168.64,percent of total billed charges,Implant Device,168.64,34,,168.64,percent of total billed charges,Implant Device,245.52,,,245.52,Other,110% of Medicare,173.6,35,,173.6,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,173.6,35,,173.6,percent of total billed charges,Implant Device,173.6,35,,173.6,percent of total billed charges,Implant Device,173.6,35,,173.6,percent of total billed charges,Implant Device,173.6,35,,173.6,percent of total billed charges,Implant Device,173.6,35,,173.6,percent of total billed charges,Implant Device,198.4,40,,198.4,percent of total billed charges,Implant Device,173.6,70,,173.6,percent of total billed charges,All Other,168.64,34,,168.64,percent of total billed charges,Implant Device,168.64,34,,168.64,percent of total billed charges,Implant Device,173.6,35,,173.6,percent of total billed charges,Implant Device,173.6,35,,173.6,percent of total billed charges,Implant Device,173.6,35,,173.6,percent of total billed charges,Implant Device,173.6,35,,173.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,367.04,
SYNTHES 201.766 CORTEX SCREW 2.4X16MM,C1713,HCPCS,,79006134,CDM,278,RC,,,both,,,130,96.2,,,96.2,Other,150% of Medicare + 9.63% HCRA Surcharge,58.5,45,,58.5,percent of total billed charges,Critical Access Hospital RCC factor,44.2,34,,44.2,percent of total billed charges,Implant Device,44.2,34,,44.2,percent of total billed charges,Implant Device,44.2,34,,44.2,percent of total billed charges,Implant Device,44.2,34,,44.2,percent of total billed charges,Implant Device,44.2,34,,44.2,percent of total billed charges,Implant Device,64.35,,,64.35,Other,110% of Medicare,45.5,35,,45.5,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,45.5,35,,45.5,percent of total billed charges,Implant Device,45.5,35,,45.5,percent of total billed charges,Implant Device,45.5,35,,45.5,percent of total billed charges,Implant Device,45.5,35,,45.5,percent of total billed charges,Implant Device,45.5,35,,45.5,percent of total billed charges,Implant Device,52,40,,52,percent of total billed charges,Implant Device,45.5,70,,45.5,percent of total billed charges,All Other,44.2,34,,44.2,percent of total billed charges,Implant Device,44.2,34,,44.2,percent of total billed charges,Implant Device,45.5,35,,45.5,percent of total billed charges,Implant Device,45.5,35,,45.5,percent of total billed charges,Implant Device,45.5,35,,45.5,percent of total billed charges,Implant Device,45.5,35,,45.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,96.2,
BIOMET/EBI 12-139016 ENDO HEAD SZ 46MM,C1776,HCPCS,,79006135,CDM,278,RC,,,both,,,2280,1687.21,,,1687.21,Other,150% of Medicare + 9.63% HCRA Surcharge,1026,45,,1026,percent of total billed charges,Critical Access Hospital RCC factor,775.2,34,,775.2,percent of total billed charges,Implant Device,775.2,34,,775.2,percent of total billed charges,Implant Device,775.2,34,,775.2,percent of total billed charges,Implant Device,775.2,34,,775.2,percent of total billed charges,Implant Device,775.2,34,,775.2,percent of total billed charges,Implant Device,1128.6,,,1128.6,Other,110% of Medicare,798,35,,798,percent of total billed charges,Implant Device,775.2,34,"Charges > $500, x 34%",775.2,percent of total billed charges,Implant Device,798,35,,798,percent of total billed charges,Implant Device,798,35,,798,percent of total billed charges,Implant Device,798,35,,798,percent of total billed charges,Implant Device,798,35,,798,percent of total billed charges,Implant Device,798,35,,798,percent of total billed charges,Implant Device,912,40,,912,percent of total billed charges,Implant Device,798,70,,798,percent of total billed charges,All Other,775.2,34,,775.2,percent of total billed charges,Implant Device,775.2,34,,775.2,percent of total billed charges,Implant Device,798,35,,798,percent of total billed charges,Implant Device,798,35,,798,percent of total billed charges,Implant Device,798,35,,798,percent of total billed charges,Implant Device,798,35,,798,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,775.2,34,"If Charge > 2,000, then 34 percent",775.2,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1687.21,
METASURG DF-2010S DIGIFUSE SCREW 2.0,C1713,HCPCS,,79006136,CDM,278,RC,,,both,,,3450,2553.01,,,2553.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1552.5,45,,1552.5,percent of total billed charges,Critical Access Hospital RCC factor,1173,34,,1173,percent of total billed charges,Implant Device,1173,34,,1173,percent of total billed charges,Implant Device,1173,34,,1173,percent of total billed charges,Implant Device,1173,34,,1173,percent of total billed charges,Implant Device,1173,34,,1173,percent of total billed charges,Implant Device,1707.75,,,1707.75,Other,110% of Medicare,1207.5,35,,1207.5,percent of total billed charges,Implant Device,1173,34,"Charges > $500, x 34%",1173,percent of total billed charges,Implant Device,1207.5,35,,1207.5,percent of total billed charges,Implant Device,1207.5,35,,1207.5,percent of total billed charges,Implant Device,1207.5,35,,1207.5,percent of total billed charges,Implant Device,1207.5,35,,1207.5,percent of total billed charges,Implant Device,1207.5,35,,1207.5,percent of total billed charges,Implant Device,1380,40,,1380,percent of total billed charges,Implant Device,1207.5,70,,1207.5,percent of total billed charges,All Other,1173,34,,1173,percent of total billed charges,Implant Device,1173,34,,1173,percent of total billed charges,Implant Device,1207.5,35,,1207.5,percent of total billed charges,Implant Device,1207.5,35,,1207.5,percent of total billed charges,Implant Device,1207.5,35,,1207.5,percent of total billed charges,Implant Device,1207.5,35,,1207.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1173,34,"If Charge > 2,000, then 34 percent",1173,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2553.01,
STRYKER 1830-0722S HUMERAL NAIL 7X220MM,C1713,HCPCS,,79006138,CDM,278,RC,,,both,,,5868,4342.33,,,4342.33,Other,150% of Medicare + 9.63% HCRA Surcharge,2640.6,45,,2640.6,percent of total billed charges,Critical Access Hospital RCC factor,1995.12,34,,1995.12,percent of total billed charges,Implant Device,1995.12,34,,1995.12,percent of total billed charges,Implant Device,1995.12,34,,1995.12,percent of total billed charges,Implant Device,1995.12,34,,1995.12,percent of total billed charges,Implant Device,1995.12,34,,1995.12,percent of total billed charges,Implant Device,2904.66,,,2904.66,Other,110% of Medicare,2053.8,35,,2053.8,percent of total billed charges,Implant Device,1995.12,34,"Charges > $500, x 34%",1995.12,percent of total billed charges,Implant Device,2053.8,35,,2053.8,percent of total billed charges,Implant Device,2053.8,35,,2053.8,percent of total billed charges,Implant Device,2053.8,35,,2053.8,percent of total billed charges,Implant Device,2053.8,35,,2053.8,percent of total billed charges,Implant Device,2053.8,35,,2053.8,percent of total billed charges,Implant Device,2347.2,40,,2347.2,percent of total billed charges,Implant Device,2053.8,70,,2053.8,percent of total billed charges,All Other,1995.12,34,,1995.12,percent of total billed charges,Implant Device,1995.12,34,,1995.12,percent of total billed charges,Implant Device,2053.8,35,,2053.8,percent of total billed charges,Implant Device,2053.8,35,,2053.8,percent of total billed charges,Implant Device,2053.8,35,,2053.8,percent of total billed charges,Implant Device,2053.8,35,,2053.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1995.12,34,"If Charge > 2,000, then 34 percent",1995.12,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4342.33,
STRYKER 1896-4032S LOCKING SCREW 4X32MM,C1713,HCPCS,,79006139,CDM,278,RC,,,both,,,447,330.78,,,330.78,Other,150% of Medicare + 9.63% HCRA Surcharge,201.15,45,,201.15,percent of total billed charges,Critical Access Hospital RCC factor,151.98,34,,151.98,percent of total billed charges,Implant Device,151.98,34,,151.98,percent of total billed charges,Implant Device,151.98,34,,151.98,percent of total billed charges,Implant Device,151.98,34,,151.98,percent of total billed charges,Implant Device,151.98,34,,151.98,percent of total billed charges,Implant Device,221.27,,,221.27,Other,110% of Medicare,156.45,35,,156.45,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,156.45,35,,156.45,percent of total billed charges,Implant Device,156.45,35,,156.45,percent of total billed charges,Implant Device,156.45,35,,156.45,percent of total billed charges,Implant Device,156.45,35,,156.45,percent of total billed charges,Implant Device,156.45,35,,156.45,percent of total billed charges,Implant Device,178.8,40,,178.8,percent of total billed charges,Implant Device,156.45,70,,156.45,percent of total billed charges,All Other,151.98,34,,151.98,percent of total billed charges,Implant Device,151.98,34,,151.98,percent of total billed charges,Implant Device,156.45,35,,156.45,percent of total billed charges,Implant Device,156.45,35,,156.45,percent of total billed charges,Implant Device,156.45,35,,156.45,percent of total billed charges,Implant Device,156.45,35,,156.45,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,330.78,
GORE PLC181000 EXCLUDER ENDOPROS 18X3.5,C1874,HCPCS,,79006141,CDM,278,RC,,,both,,,12900,9546.03,,,9546.03,Other,150% of Medicare + 9.63% HCRA Surcharge,5805,45,,5805,percent of total billed charges,Critical Access Hospital RCC factor,4386,34,,4386,percent of total billed charges,Implant Device,4386,34,,4386,percent of total billed charges,Implant Device,4386,34,,4386,percent of total billed charges,Implant Device,4386,34,,4386,percent of total billed charges,Implant Device,4386,34,,4386,percent of total billed charges,Implant Device,6385.5,,,6385.5,Other,110% of Medicare,4515,35,,4515,percent of total billed charges,Implant Device,4386,34,"Charges > $500, x 34%",4386,percent of total billed charges,Implant Device,4515,35,,4515,percent of total billed charges,Implant Device,4515,35,,4515,percent of total billed charges,Implant Device,4515,35,,4515,percent of total billed charges,Implant Device,4515,35,,4515,percent of total billed charges,Implant Device,4515,35,,4515,percent of total billed charges,Implant Device,5160,40,,5160,percent of total billed charges,Implant Device,4515,70,,4515,percent of total billed charges,All Other,4386,34,,4386,percent of total billed charges,Implant Device,4386,34,,4386,percent of total billed charges,Implant Device,4515,35,,4515,percent of total billed charges,Implant Device,4515,35,,4515,percent of total billed charges,Implant Device,4515,35,,4515,percent of total billed charges,Implant Device,4515,35,,4515,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,4386,34,"If Charge > 2,000, then 34 percent",4386,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,9546.03,
GORE PLC271400 EXCLUDER ENDOPROS 27X14,C1874,HCPCS,,79006142,CDM,278,RC,,,both,,,13869,10263.09,,,10263.09,Other,150% of Medicare + 9.63% HCRA Surcharge,6241.05,45,,6241.05,percent of total billed charges,Critical Access Hospital RCC factor,4715.46,34,,4715.46,percent of total billed charges,Implant Device,4715.46,34,,4715.46,percent of total billed charges,Implant Device,4715.46,34,,4715.46,percent of total billed charges,Implant Device,4715.46,34,,4715.46,percent of total billed charges,Implant Device,4715.46,34,,4715.46,percent of total billed charges,Implant Device,6865.16,,,6865.16,Other,110% of Medicare,4854.15,35,,4854.15,percent of total billed charges,Implant Device,4715.46,34,"Charges > $500, x 34%",4715.46,percent of total billed charges,Implant Device,4854.15,35,,4854.15,percent of total billed charges,Implant Device,4854.15,35,,4854.15,percent of total billed charges,Implant Device,4854.15,35,,4854.15,percent of total billed charges,Implant Device,4854.15,35,,4854.15,percent of total billed charges,Implant Device,4854.15,35,,4854.15,percent of total billed charges,Implant Device,5547.6,40,,5547.6,percent of total billed charges,Implant Device,4854.15,70,,4854.15,percent of total billed charges,All Other,4715.46,34,,4715.46,percent of total billed charges,Implant Device,4715.46,34,,4715.46,percent of total billed charges,Implant Device,4854.15,35,,4854.15,percent of total billed charges,Implant Device,4854.15,35,,4854.15,percent of total billed charges,Implant Device,4854.15,35,,4854.15,percent of total billed charges,Implant Device,4854.15,35,,4854.15,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,4715.46,34,"If Charge > 2,000, then 34 percent",4715.46,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,10263.09,
SOLANA CCP-MPX1R CROSSCHECK PLATE RT SZ1,C1713,HCPCS,,79006145,CDM,278,RC,,,both,,,7246,5362.06,,,5362.06,Other,150% of Medicare + 9.63% HCRA Surcharge,3260.7,45,,3260.7,percent of total billed charges,Critical Access Hospital RCC factor,2463.64,34,,2463.64,percent of total billed charges,Implant Device,2463.64,34,,2463.64,percent of total billed charges,Implant Device,2463.64,34,,2463.64,percent of total billed charges,Implant Device,2463.64,34,,2463.64,percent of total billed charges,Implant Device,2463.64,34,,2463.64,percent of total billed charges,Implant Device,3586.77,,,3586.77,Other,110% of Medicare,2536.1,35,,2536.1,percent of total billed charges,Implant Device,2463.64,34,"Charges > $500, x 34%",2463.64,percent of total billed charges,Implant Device,2536.1,35,,2536.1,percent of total billed charges,Implant Device,2536.1,35,,2536.1,percent of total billed charges,Implant Device,2536.1,35,,2536.1,percent of total billed charges,Implant Device,2536.1,35,,2536.1,percent of total billed charges,Implant Device,2536.1,35,,2536.1,percent of total billed charges,Implant Device,2898.4,40,,2898.4,percent of total billed charges,Implant Device,2536.1,70,,2536.1,percent of total billed charges,All Other,2463.64,34,,2463.64,percent of total billed charges,Implant Device,2463.64,34,,2463.64,percent of total billed charges,Implant Device,2536.1,35,,2536.1,percent of total billed charges,Implant Device,2536.1,35,,2536.1,percent of total billed charges,Implant Device,2536.1,35,,2536.1,percent of total billed charges,Implant Device,2536.1,35,,2536.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2463.64,34,"If Charge > 2,000, then 34 percent",2463.64,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5362.06,
SOLANA CCP-L3514 LOCKING SCREW 3.5X14MM,C1713,HCPCS,,79006146,CDM,278,RC,,,both,,,1125,832.5,,,832.5,Other,150% of Medicare + 9.63% HCRA Surcharge,506.25,45,,506.25,percent of total billed charges,Critical Access Hospital RCC factor,382.5,34,,382.5,percent of total billed charges,Implant Device,382.5,34,,382.5,percent of total billed charges,Implant Device,382.5,34,,382.5,percent of total billed charges,Implant Device,382.5,34,,382.5,percent of total billed charges,Implant Device,382.5,34,,382.5,percent of total billed charges,Implant Device,556.88,,,556.88,Other,110% of Medicare,393.75,35,,393.75,percent of total billed charges,Implant Device,382.5,34,"Charges > $500, x 34%",382.5,percent of total billed charges,Implant Device,393.75,35,,393.75,percent of total billed charges,Implant Device,393.75,35,,393.75,percent of total billed charges,Implant Device,393.75,35,,393.75,percent of total billed charges,Implant Device,393.75,35,,393.75,percent of total billed charges,Implant Device,393.75,35,,393.75,percent of total billed charges,Implant Device,450,40,,450,percent of total billed charges,Implant Device,393.75,70,,393.75,percent of total billed charges,All Other,382.5,34,,382.5,percent of total billed charges,Implant Device,382.5,34,,382.5,percent of total billed charges,Implant Device,393.75,35,,393.75,percent of total billed charges,Implant Device,393.75,35,,393.75,percent of total billed charges,Implant Device,393.75,35,,393.75,percent of total billed charges,Implant Device,393.75,35,,393.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,832.5,
SOLANA CCP-N3016 NONLOCK SCREW 3X16MM,C1713,HCPCS,,79006149,CDM,278,RC,,,both,,,1126,833.24,,,833.24,Other,150% of Medicare + 9.63% HCRA Surcharge,506.7,45,,506.7,percent of total billed charges,Critical Access Hospital RCC factor,382.84,34,,382.84,percent of total billed charges,Implant Device,382.84,34,,382.84,percent of total billed charges,Implant Device,382.84,34,,382.84,percent of total billed charges,Implant Device,382.84,34,,382.84,percent of total billed charges,Implant Device,382.84,34,,382.84,percent of total billed charges,Implant Device,557.37,,,557.37,Other,110% of Medicare,394.1,35,,394.1,percent of total billed charges,Implant Device,382.84,34,"Charges > $500, x 34%",382.84,percent of total billed charges,Implant Device,394.1,35,,394.1,percent of total billed charges,Implant Device,394.1,35,,394.1,percent of total billed charges,Implant Device,394.1,35,,394.1,percent of total billed charges,Implant Device,394.1,35,,394.1,percent of total billed charges,Implant Device,394.1,35,,394.1,percent of total billed charges,Implant Device,450.4,40,,450.4,percent of total billed charges,Implant Device,394.1,70,,394.1,percent of total billed charges,All Other,382.84,34,,382.84,percent of total billed charges,Implant Device,382.84,34,,382.84,percent of total billed charges,Implant Device,394.1,35,,394.1,percent of total billed charges,Implant Device,394.1,35,,394.1,percent of total billed charges,Implant Device,394.1,35,,394.1,percent of total billed charges,Implant Device,394.1,35,,394.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,833.24,
ARTHREX AR-8967-1875 CANN SCREW 6.7X75MM,C1713,HCPCS,,79006150,CDM,278,RC,,,both,,,750,555,,,555,Other,150% of Medicare + 9.63% HCRA Surcharge,337.5,45,,337.5,percent of total billed charges,Critical Access Hospital RCC factor,255,34,,255,percent of total billed charges,Implant Device,255,34,,255,percent of total billed charges,Implant Device,255,34,,255,percent of total billed charges,Implant Device,255,34,,255,percent of total billed charges,Implant Device,255,34,,255,percent of total billed charges,Implant Device,371.25,,,371.25,Other,110% of Medicare,262.5,35,,262.5,percent of total billed charges,Implant Device,255,34,"Charges > $500, x 34%",255,percent of total billed charges,Implant Device,262.5,35,,262.5,percent of total billed charges,Implant Device,262.5,35,,262.5,percent of total billed charges,Implant Device,262.5,35,,262.5,percent of total billed charges,Implant Device,262.5,35,,262.5,percent of total billed charges,Implant Device,262.5,35,,262.5,percent of total billed charges,Implant Device,300,40,,300,percent of total billed charges,Implant Device,262.5,70,,262.5,percent of total billed charges,All Other,255,34,,255,percent of total billed charges,Implant Device,255,34,,255,percent of total billed charges,Implant Device,262.5,35,,262.5,percent of total billed charges,Implant Device,262.5,35,,262.5,percent of total billed charges,Implant Device,262.5,35,,262.5,percent of total billed charges,Implant Device,262.5,35,,262.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,555,
INTEGRA 050108 SUBTALAR MBA IMPLANT 8MM,C1713,HCPCS,,79006151,CDM,278,RC,,,both,,,3749,2774.27,,,2774.27,Other,150% of Medicare + 9.63% HCRA Surcharge,1687.05,45,,1687.05,percent of total billed charges,Critical Access Hospital RCC factor,1274.66,34,,1274.66,percent of total billed charges,Implant Device,1274.66,34,,1274.66,percent of total billed charges,Implant Device,1274.66,34,,1274.66,percent of total billed charges,Implant Device,1274.66,34,,1274.66,percent of total billed charges,Implant Device,1274.66,34,,1274.66,percent of total billed charges,Implant Device,1855.76,,,1855.76,Other,110% of Medicare,1312.15,35,,1312.15,percent of total billed charges,Implant Device,1274.66,34,"Charges > $500, x 34%",1274.66,percent of total billed charges,Implant Device,1312.15,35,,1312.15,percent of total billed charges,Implant Device,1312.15,35,,1312.15,percent of total billed charges,Implant Device,1312.15,35,,1312.15,percent of total billed charges,Implant Device,1312.15,35,,1312.15,percent of total billed charges,Implant Device,1312.15,35,,1312.15,percent of total billed charges,Implant Device,1499.6,40,,1499.6,percent of total billed charges,Implant Device,1312.15,70,,1312.15,percent of total billed charges,All Other,1274.66,34,,1274.66,percent of total billed charges,Implant Device,1274.66,34,,1274.66,percent of total billed charges,Implant Device,1312.15,35,,1312.15,percent of total billed charges,Implant Device,1312.15,35,,1312.15,percent of total billed charges,Implant Device,1312.15,35,,1312.15,percent of total billed charges,Implant Device,1312.15,35,,1312.15,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1274.66,34,"If Charge > 2,000, then 34 percent",1274.66,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2774.27,
SYNTHES 201.366.97 CORTEX SCREW 2.0X16MM,C1713,HCPCS,,79006155,CDM,278,RC,,,both,,,93,68.82,,,68.82,Other,150% of Medicare + 9.63% HCRA Surcharge,41.85,45,,41.85,percent of total billed charges,Critical Access Hospital RCC factor,31.62,34,,31.62,percent of total billed charges,Implant Device,31.62,34,,31.62,percent of total billed charges,Implant Device,31.62,34,,31.62,percent of total billed charges,Implant Device,31.62,34,,31.62,percent of total billed charges,Implant Device,31.62,34,,31.62,percent of total billed charges,Implant Device,46.04,,,46.04,Other,110% of Medicare,32.55,35,,32.55,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,32.55,35,,32.55,percent of total billed charges,Implant Device,32.55,35,,32.55,percent of total billed charges,Implant Device,32.55,35,,32.55,percent of total billed charges,Implant Device,32.55,35,,32.55,percent of total billed charges,Implant Device,32.55,35,,32.55,percent of total billed charges,Implant Device,37.2,40,,37.2,percent of total billed charges,Implant Device,32.55,70,,32.55,percent of total billed charges,All Other,31.62,34,,31.62,percent of total billed charges,Implant Device,31.62,34,,31.62,percent of total billed charges,Implant Device,32.55,35,,32.55,percent of total billed charges,Implant Device,32.55,35,,32.55,percent of total billed charges,Implant Device,32.55,35,,32.55,percent of total billed charges,Implant Device,32.55,35,,32.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,68.82,
SYNTHES 201.764 CORTEX SCREW 2.4X14MM,C1713,HCPCS,,79006158,CDM,278,RC,,,both,,,130,96.2,,,96.2,Other,150% of Medicare + 9.63% HCRA Surcharge,58.5,45,,58.5,percent of total billed charges,Critical Access Hospital RCC factor,44.2,34,,44.2,percent of total billed charges,Implant Device,44.2,34,,44.2,percent of total billed charges,Implant Device,44.2,34,,44.2,percent of total billed charges,Implant Device,44.2,34,,44.2,percent of total billed charges,Implant Device,44.2,34,,44.2,percent of total billed charges,Implant Device,64.35,,,64.35,Other,110% of Medicare,45.5,35,,45.5,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,45.5,35,,45.5,percent of total billed charges,Implant Device,45.5,35,,45.5,percent of total billed charges,Implant Device,45.5,35,,45.5,percent of total billed charges,Implant Device,45.5,35,,45.5,percent of total billed charges,Implant Device,45.5,35,,45.5,percent of total billed charges,Implant Device,52,40,,52,percent of total billed charges,Implant Device,45.5,70,,45.5,percent of total billed charges,All Other,44.2,34,,44.2,percent of total billed charges,Implant Device,44.2,34,,44.2,percent of total billed charges,Implant Device,45.5,35,,45.5,percent of total billed charges,Implant Device,45.5,35,,45.5,percent of total billed charges,Implant Device,45.5,35,,45.5,percent of total billed charges,Implant Device,45.5,35,,45.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,96.2,
ARTRHEX AR-1390TC INTERFRNCE SCREW 9X28,C1713,HCPCS,,79006159,CDM,278,RC,,,both,,,1008,745.92,,,745.92,Other,150% of Medicare + 9.63% HCRA Surcharge,453.6,45,,453.6,percent of total billed charges,Critical Access Hospital RCC factor,342.72,34,,342.72,percent of total billed charges,Implant Device,342.72,34,,342.72,percent of total billed charges,Implant Device,342.72,34,,342.72,percent of total billed charges,Implant Device,342.72,34,,342.72,percent of total billed charges,Implant Device,342.72,34,,342.72,percent of total billed charges,Implant Device,498.96,,,498.96,Other,110% of Medicare,352.8,35,,352.8,percent of total billed charges,Implant Device,342.72,34,"Charges > $500, x 34%",342.72,percent of total billed charges,Implant Device,352.8,35,,352.8,percent of total billed charges,Implant Device,352.8,35,,352.8,percent of total billed charges,Implant Device,352.8,35,,352.8,percent of total billed charges,Implant Device,352.8,35,,352.8,percent of total billed charges,Implant Device,352.8,35,,352.8,percent of total billed charges,Implant Device,403.2,40,,403.2,percent of total billed charges,Implant Device,352.8,70,,352.8,percent of total billed charges,All Other,342.72,34,,342.72,percent of total billed charges,Implant Device,342.72,34,,342.72,percent of total billed charges,Implant Device,352.8,35,,352.8,percent of total billed charges,Implant Device,352.8,35,,352.8,percent of total billed charges,Implant Device,352.8,35,,352.8,percent of total billed charges,Implant Device,352.8,35,,352.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,745.92,
STRYKER 5551-G-381 PATELLA A38X11MM,C1776,HCPCS,,79006160,CDM,278,RC,,,both,,,1500,1110,,,1110,Other,150% of Medicare + 9.63% HCRA Surcharge,675,45,,675,percent of total billed charges,Critical Access Hospital RCC factor,510,34,,510,percent of total billed charges,Implant Device,510,34,,510,percent of total billed charges,Implant Device,510,34,,510,percent of total billed charges,Implant Device,510,34,,510,percent of total billed charges,Implant Device,510,34,,510,percent of total billed charges,Implant Device,742.5,,,742.5,Other,110% of Medicare,525,35,,525,percent of total billed charges,Implant Device,510,34,"Charges > $500, x 34%",510,percent of total billed charges,Implant Device,525,35,,525,percent of total billed charges,Implant Device,525,35,,525,percent of total billed charges,Implant Device,525,35,,525,percent of total billed charges,Implant Device,525,35,,525,percent of total billed charges,Implant Device,525,35,,525,percent of total billed charges,Implant Device,600,40,,600,percent of total billed charges,Implant Device,525,70,,525,percent of total billed charges,All Other,510,34,,510,percent of total billed charges,Implant Device,510,34,,510,percent of total billed charges,Implant Device,525,35,,525,percent of total billed charges,Implant Device,525,35,,525,percent of total billed charges,Implant Device,525,35,,525,percent of total billed charges,Implant Device,525,35,,525,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1110,
SOLANA CCP-X3522 LAG SCREW 3.5X22M,C1713,HCPCS,,79006161,CDM,278,RC,,,both,,,1125,832.5,,,832.5,Other,150% of Medicare + 9.63% HCRA Surcharge,506.25,45,,506.25,percent of total billed charges,Critical Access Hospital RCC factor,382.5,34,,382.5,percent of total billed charges,Implant Device,382.5,34,,382.5,percent of total billed charges,Implant Device,382.5,34,,382.5,percent of total billed charges,Implant Device,382.5,34,,382.5,percent of total billed charges,Implant Device,382.5,34,,382.5,percent of total billed charges,Implant Device,556.88,,,556.88,Other,110% of Medicare,393.75,35,,393.75,percent of total billed charges,Implant Device,382.5,34,"Charges > $500, x 34%",382.5,percent of total billed charges,Implant Device,393.75,35,,393.75,percent of total billed charges,Implant Device,393.75,35,,393.75,percent of total billed charges,Implant Device,393.75,35,,393.75,percent of total billed charges,Implant Device,393.75,35,,393.75,percent of total billed charges,Implant Device,393.75,35,,393.75,percent of total billed charges,Implant Device,450,40,,450,percent of total billed charges,Implant Device,393.75,70,,393.75,percent of total billed charges,All Other,382.5,34,,382.5,percent of total billed charges,Implant Device,382.5,34,,382.5,percent of total billed charges,Implant Device,393.75,35,,393.75,percent of total billed charges,Implant Device,393.75,35,,393.75,percent of total billed charges,Implant Device,393.75,35,,393.75,percent of total billed charges,Implant Device,393.75,35,,393.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,832.5,
SOLANA CCP-L3516 LOCKING SCREW 3.5X16MM,C1713,HCPCS,,79006162,CDM,278,RC,,,both,,,1125,832.5,,,832.5,Other,150% of Medicare + 9.63% HCRA Surcharge,506.25,45,,506.25,percent of total billed charges,Critical Access Hospital RCC factor,382.5,34,,382.5,percent of total billed charges,Implant Device,382.5,34,,382.5,percent of total billed charges,Implant Device,382.5,34,,382.5,percent of total billed charges,Implant Device,382.5,34,,382.5,percent of total billed charges,Implant Device,382.5,34,,382.5,percent of total billed charges,Implant Device,556.88,,,556.88,Other,110% of Medicare,393.75,35,,393.75,percent of total billed charges,Implant Device,382.5,34,"Charges > $500, x 34%",382.5,percent of total billed charges,Implant Device,393.75,35,,393.75,percent of total billed charges,Implant Device,393.75,35,,393.75,percent of total billed charges,Implant Device,393.75,35,,393.75,percent of total billed charges,Implant Device,393.75,35,,393.75,percent of total billed charges,Implant Device,393.75,35,,393.75,percent of total billed charges,Implant Device,450,40,,450,percent of total billed charges,Implant Device,393.75,70,,393.75,percent of total billed charges,All Other,382.5,34,,382.5,percent of total billed charges,Implant Device,382.5,34,,382.5,percent of total billed charges,Implant Device,393.75,35,,393.75,percent of total billed charges,Implant Device,393.75,35,,393.75,percent of total billed charges,Implant Device,393.75,35,,393.75,percent of total billed charges,Implant Device,393.75,35,,393.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,832.5,
BIOMET 12-151309 ECHO HIP FEMORL 9X130MM,C1776,HCPCS,,79006163,CDM,278,RC,,,both,,,4992,3694.09,,,3694.09,Other,150% of Medicare + 9.63% HCRA Surcharge,2246.4,45,,2246.4,percent of total billed charges,Critical Access Hospital RCC factor,1697.28,34,,1697.28,percent of total billed charges,Implant Device,1697.28,34,,1697.28,percent of total billed charges,Implant Device,1697.28,34,,1697.28,percent of total billed charges,Implant Device,1697.28,34,,1697.28,percent of total billed charges,Implant Device,1697.28,34,,1697.28,percent of total billed charges,Implant Device,2471.04,,,2471.04,Other,110% of Medicare,1747.2,35,,1747.2,percent of total billed charges,Implant Device,1697.28,34,"Charges > $500, x 34%",1697.28,percent of total billed charges,Implant Device,1747.2,35,,1747.2,percent of total billed charges,Implant Device,1747.2,35,,1747.2,percent of total billed charges,Implant Device,1747.2,35,,1747.2,percent of total billed charges,Implant Device,1747.2,35,,1747.2,percent of total billed charges,Implant Device,1747.2,35,,1747.2,percent of total billed charges,Implant Device,1996.8,40,,1996.8,percent of total billed charges,Implant Device,1747.2,70,,1747.2,percent of total billed charges,All Other,1697.28,34,,1697.28,percent of total billed charges,Implant Device,1697.28,34,,1697.28,percent of total billed charges,Implant Device,1747.2,35,,1747.2,percent of total billed charges,Implant Device,1747.2,35,,1747.2,percent of total billed charges,Implant Device,1747.2,35,,1747.2,percent of total billed charges,Implant Device,1747.2,35,,1747.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1697.28,34,"If Charge > 2,000, then 34 percent",1697.28,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3694.09,
ARTHREX AR-8943BR-04 FIBULA PLATE 4 HOLE,C1776,HCPCS,,79006164,CDM,278,RC,,,both,,,2358,1744.93,,,1744.93,Other,150% of Medicare + 9.63% HCRA Surcharge,1061.1,45,,1061.1,percent of total billed charges,Critical Access Hospital RCC factor,801.72,34,,801.72,percent of total billed charges,Implant Device,801.72,34,,801.72,percent of total billed charges,Implant Device,801.72,34,,801.72,percent of total billed charges,Implant Device,801.72,34,,801.72,percent of total billed charges,Implant Device,801.72,34,,801.72,percent of total billed charges,Implant Device,1167.21,,,1167.21,Other,110% of Medicare,825.3,35,,825.3,percent of total billed charges,Implant Device,801.72,34,"Charges > $500, x 34%",801.72,percent of total billed charges,Implant Device,825.3,35,,825.3,percent of total billed charges,Implant Device,825.3,35,,825.3,percent of total billed charges,Implant Device,825.3,35,,825.3,percent of total billed charges,Implant Device,825.3,35,,825.3,percent of total billed charges,Implant Device,825.3,35,,825.3,percent of total billed charges,Implant Device,943.2,40,,943.2,percent of total billed charges,Implant Device,825.3,70,,825.3,percent of total billed charges,All Other,801.72,34,,801.72,percent of total billed charges,Implant Device,801.72,34,,801.72,percent of total billed charges,Implant Device,825.3,35,,825.3,percent of total billed charges,Implant Device,825.3,35,,825.3,percent of total billed charges,Implant Device,825.3,35,,825.3,percent of total billed charges,Implant Device,825.3,35,,825.3,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,801.72,34,"If Charge > 2,000, then 34 percent",801.72,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1744.93,
ARTHREX AR-8840CL-44 CANN SCREW 4X44MM,C1713,HCPCS,,79006165,CDM,278,RC,,,both,,,708,523.92,,,523.92,Other,150% of Medicare + 9.63% HCRA Surcharge,318.6,45,,318.6,percent of total billed charges,Critical Access Hospital RCC factor,240.72,34,,240.72,percent of total billed charges,Implant Device,240.72,34,,240.72,percent of total billed charges,Implant Device,240.72,34,,240.72,percent of total billed charges,Implant Device,240.72,34,,240.72,percent of total billed charges,Implant Device,240.72,34,,240.72,percent of total billed charges,Implant Device,350.46,,,350.46,Other,110% of Medicare,247.8,35,,247.8,percent of total billed charges,Implant Device,240.72,34,"Charges > $500, x 34%",240.72,percent of total billed charges,Implant Device,247.8,35,,247.8,percent of total billed charges,Implant Device,247.8,35,,247.8,percent of total billed charges,Implant Device,247.8,35,,247.8,percent of total billed charges,Implant Device,247.8,35,,247.8,percent of total billed charges,Implant Device,247.8,35,,247.8,percent of total billed charges,Implant Device,283.2,40,,283.2,percent of total billed charges,Implant Device,247.8,70,,247.8,percent of total billed charges,All Other,240.72,34,,240.72,percent of total billed charges,Implant Device,240.72,34,,240.72,percent of total billed charges,Implant Device,247.8,35,,247.8,percent of total billed charges,Implant Device,247.8,35,,247.8,percent of total billed charges,Implant Device,247.8,35,,247.8,percent of total billed charges,Implant Device,247.8,35,,247.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,523.92,
DEPUY 1987-25-412 LPS STEM STR 12X125MM,C1776,HCPCS,,79006166,CDM,278,RC,,,both,,,19157,14176.23,,,14176.23,Other,150% of Medicare + 9.63% HCRA Surcharge,8620.65,45,,8620.65,percent of total billed charges,Critical Access Hospital RCC factor,6513.38,34,,6513.38,percent of total billed charges,Implant Device,6513.38,34,,6513.38,percent of total billed charges,Implant Device,6513.38,34,,6513.38,percent of total billed charges,Implant Device,6513.38,34,,6513.38,percent of total billed charges,Implant Device,6513.38,34,,6513.38,percent of total billed charges,Implant Device,9482.72,,,9482.72,Other,110% of Medicare,6704.95,35,,6704.95,percent of total billed charges,Implant Device,6513.38,34,"Charges > $500, x 34%",6513.38,percent of total billed charges,Implant Device,6704.95,35,,6704.95,percent of total billed charges,Implant Device,6704.95,35,,6704.95,percent of total billed charges,Implant Device,6704.95,35,,6704.95,percent of total billed charges,Implant Device,6704.95,35,,6704.95,percent of total billed charges,Implant Device,6704.95,35,,6704.95,percent of total billed charges,Implant Device,7662.8,40,,7662.8,percent of total billed charges,Implant Device,6704.95,70,,6704.95,percent of total billed charges,All Other,6513.38,34,,6513.38,percent of total billed charges,Implant Device,6513.38,34,,6513.38,percent of total billed charges,Implant Device,6704.95,35,,6704.95,percent of total billed charges,Implant Device,6704.95,35,,6704.95,percent of total billed charges,Implant Device,6704.95,35,,6704.95,percent of total billed charges,Implant Device,6704.95,35,,6704.95,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,6513.38,34,"If Charge > 2,000, then 34 percent",6513.38,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,14176.23,
DEPUY 1987-07-035 LPS SEGMENT COMP 35MM,C1776,HCPCS,,79006167,CDM,278,RC,,,both,,,5686,4207.65,,,4207.65,Other,150% of Medicare + 9.63% HCRA Surcharge,2558.7,45,,2558.7,percent of total billed charges,Critical Access Hospital RCC factor,1933.24,34,,1933.24,percent of total billed charges,Implant Device,1933.24,34,,1933.24,percent of total billed charges,Implant Device,1933.24,34,,1933.24,percent of total billed charges,Implant Device,1933.24,34,,1933.24,percent of total billed charges,Implant Device,1933.24,34,,1933.24,percent of total billed charges,Implant Device,2814.57,,,2814.57,Other,110% of Medicare,1990.1,35,,1990.1,percent of total billed charges,Implant Device,1933.24,34,"Charges > $500, x 34%",1933.24,percent of total billed charges,Implant Device,1990.1,35,,1990.1,percent of total billed charges,Implant Device,1990.1,35,,1990.1,percent of total billed charges,Implant Device,1990.1,35,,1990.1,percent of total billed charges,Implant Device,1990.1,35,,1990.1,percent of total billed charges,Implant Device,1990.1,35,,1990.1,percent of total billed charges,Implant Device,2274.4,40,,2274.4,percent of total billed charges,Implant Device,1990.1,70,,1990.1,percent of total billed charges,All Other,1933.24,34,,1933.24,percent of total billed charges,Implant Device,1933.24,34,,1933.24,percent of total billed charges,Implant Device,1990.1,35,,1990.1,percent of total billed charges,Implant Device,1990.1,35,,1990.1,percent of total billed charges,Implant Device,1990.1,35,,1990.1,percent of total billed charges,Implant Device,1990.1,35,,1990.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1933.24,34,"If Charge > 2,000, then 34 percent",1933.24,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4207.65,
DEPUY 1987-27-014 LPS TIB INS HINGE 14MM,C1776,HCPCS,,79006168,CDM,278,RC,,,both,,,11227,8308.01,,,8308.01,Other,150% of Medicare + 9.63% HCRA Surcharge,5052.15,45,,5052.15,percent of total billed charges,Critical Access Hospital RCC factor,3817.18,34,,3817.18,percent of total billed charges,Implant Device,3817.18,34,,3817.18,percent of total billed charges,Implant Device,3817.18,34,,3817.18,percent of total billed charges,Implant Device,3817.18,34,,3817.18,percent of total billed charges,Implant Device,3817.18,34,,3817.18,percent of total billed charges,Implant Device,5557.37,,,5557.37,Other,110% of Medicare,3929.45,35,,3929.45,percent of total billed charges,Implant Device,3817.18,34,"Charges > $500, x 34%",3817.18,percent of total billed charges,Implant Device,3929.45,35,,3929.45,percent of total billed charges,Implant Device,3929.45,35,,3929.45,percent of total billed charges,Implant Device,3929.45,35,,3929.45,percent of total billed charges,Implant Device,3929.45,35,,3929.45,percent of total billed charges,Implant Device,3929.45,35,,3929.45,percent of total billed charges,Implant Device,4490.8,40,,4490.8,percent of total billed charges,Implant Device,3929.45,70,,3929.45,percent of total billed charges,All Other,3817.18,34,,3817.18,percent of total billed charges,Implant Device,3817.18,34,,3817.18,percent of total billed charges,Implant Device,3929.45,35,,3929.45,percent of total billed charges,Implant Device,3929.45,35,,3929.45,percent of total billed charges,Implant Device,3929.45,35,,3929.45,percent of total billed charges,Implant Device,3929.45,35,,3929.45,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3817.18,34,"If Charge > 2,000, then 34 percent",3817.18,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,8308.01,
SOLANA CCP-X3524 LAG SCREW 3.5X24MM,C1713,HCPCS,,79006169,CDM,278,RC,,,both,,,1125,832.5,,,832.5,Other,150% of Medicare + 9.63% HCRA Surcharge,506.25,45,,506.25,percent of total billed charges,Critical Access Hospital RCC factor,382.5,34,,382.5,percent of total billed charges,Implant Device,382.5,34,,382.5,percent of total billed charges,Implant Device,382.5,34,,382.5,percent of total billed charges,Implant Device,382.5,34,,382.5,percent of total billed charges,Implant Device,382.5,34,,382.5,percent of total billed charges,Implant Device,556.88,,,556.88,Other,110% of Medicare,393.75,35,,393.75,percent of total billed charges,Implant Device,382.5,34,"Charges > $500, x 34%",382.5,percent of total billed charges,Implant Device,393.75,35,,393.75,percent of total billed charges,Implant Device,393.75,35,,393.75,percent of total billed charges,Implant Device,393.75,35,,393.75,percent of total billed charges,Implant Device,393.75,35,,393.75,percent of total billed charges,Implant Device,393.75,35,,393.75,percent of total billed charges,Implant Device,450,40,,450,percent of total billed charges,Implant Device,393.75,70,,393.75,percent of total billed charges,All Other,382.5,34,,382.5,percent of total billed charges,Implant Device,382.5,34,,382.5,percent of total billed charges,Implant Device,393.75,35,,393.75,percent of total billed charges,Implant Device,393.75,35,,393.75,percent of total billed charges,Implant Device,393.75,35,,393.75,percent of total billed charges,Implant Device,393.75,35,,393.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,832.5,
STRYKER 59-17013 BONE SCREW 1.7X13MM,C1713,HCPCS,,79006170,CDM,278,RC,,,both,,,331,244.94,,,244.94,Other,150% of Medicare + 9.63% HCRA Surcharge,148.95,45,,148.95,percent of total billed charges,Critical Access Hospital RCC factor,112.54,34,,112.54,percent of total billed charges,Implant Device,112.54,34,,112.54,percent of total billed charges,Implant Device,112.54,34,,112.54,percent of total billed charges,Implant Device,112.54,34,,112.54,percent of total billed charges,Implant Device,112.54,34,,112.54,percent of total billed charges,Implant Device,163.85,,,163.85,Other,110% of Medicare,115.85,35,,115.85,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,115.85,35,,115.85,percent of total billed charges,Implant Device,115.85,35,,115.85,percent of total billed charges,Implant Device,115.85,35,,115.85,percent of total billed charges,Implant Device,115.85,35,,115.85,percent of total billed charges,Implant Device,115.85,35,,115.85,percent of total billed charges,Implant Device,132.4,40,,132.4,percent of total billed charges,Implant Device,115.85,70,,115.85,percent of total billed charges,All Other,112.54,34,,112.54,percent of total billed charges,Implant Device,112.54,34,,112.54,percent of total billed charges,Implant Device,115.85,35,,115.85,percent of total billed charges,Implant Device,115.85,35,,115.85,percent of total billed charges,Implant Device,115.85,35,,115.85,percent of total billed charges,Implant Device,115.85,35,,115.85,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,244.94,
STRYKER R5350-4021 SHLDR HUM HD 40X21MM,C1776,HCPCS,,79006171,CDM,278,RC,,,both,,,7523,5567.04,,,5567.04,Other,150% of Medicare + 9.63% HCRA Surcharge,3385.35,45,,3385.35,percent of total billed charges,Critical Access Hospital RCC factor,2557.82,34,,2557.82,percent of total billed charges,Implant Device,2557.82,34,,2557.82,percent of total billed charges,Implant Device,2557.82,34,,2557.82,percent of total billed charges,Implant Device,2557.82,34,,2557.82,percent of total billed charges,Implant Device,2557.82,34,,2557.82,percent of total billed charges,Implant Device,3723.89,,,3723.89,Other,110% of Medicare,2633.05,35,,2633.05,percent of total billed charges,Implant Device,2557.82,34,"Charges > $500, x 34%",2557.82,percent of total billed charges,Implant Device,2633.05,35,,2633.05,percent of total billed charges,Implant Device,2633.05,35,,2633.05,percent of total billed charges,Implant Device,2633.05,35,,2633.05,percent of total billed charges,Implant Device,2633.05,35,,2633.05,percent of total billed charges,Implant Device,2633.05,35,,2633.05,percent of total billed charges,Implant Device,3009.2,40,,3009.2,percent of total billed charges,Implant Device,2633.05,70,,2633.05,percent of total billed charges,All Other,2557.82,34,,2557.82,percent of total billed charges,Implant Device,2557.82,34,,2557.82,percent of total billed charges,Implant Device,2633.05,35,,2633.05,percent of total billed charges,Implant Device,2633.05,35,,2633.05,percent of total billed charges,Implant Device,2633.05,35,,2633.05,percent of total billed charges,Implant Device,2633.05,35,,2633.05,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2557.82,34,"If Charge > 2,000, then 34 percent",2557.82,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5567.04,
STRYKER R5351-4509 REUNION HA STEM COMP,C1776,HCPCS,,79006172,CDM,278,RC,,,both,,,14372,10635.32,,,10635.32,Other,150% of Medicare + 9.63% HCRA Surcharge,6467.4,45,,6467.4,percent of total billed charges,Critical Access Hospital RCC factor,4886.48,34,,4886.48,percent of total billed charges,Implant Device,4886.48,34,,4886.48,percent of total billed charges,Implant Device,4886.48,34,,4886.48,percent of total billed charges,Implant Device,4886.48,34,,4886.48,percent of total billed charges,Implant Device,4886.48,34,,4886.48,percent of total billed charges,Implant Device,7114.14,,,7114.14,Other,110% of Medicare,5030.2,35,,5030.2,percent of total billed charges,Implant Device,4886.48,34,"Charges > $500, x 34%",4886.48,percent of total billed charges,Implant Device,5030.2,35,,5030.2,percent of total billed charges,Implant Device,5030.2,35,,5030.2,percent of total billed charges,Implant Device,5030.2,35,,5030.2,percent of total billed charges,Implant Device,5030.2,35,,5030.2,percent of total billed charges,Implant Device,5030.2,35,,5030.2,percent of total billed charges,Implant Device,5748.8,40,,5748.8,percent of total billed charges,Implant Device,5030.2,70,,5030.2,percent of total billed charges,All Other,4886.48,34,,4886.48,percent of total billed charges,Implant Device,4886.48,34,,4886.48,percent of total billed charges,Implant Device,5030.2,35,,5030.2,percent of total billed charges,Implant Device,5030.2,35,,5030.2,percent of total billed charges,Implant Device,5030.2,35,,5030.2,percent of total billed charges,Implant Device,5030.2,35,,5030.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,4886.48,34,"If Charge > 2,000, then 34 percent",4886.48,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,10635.32,
SOLANA TFF-2015A TENFUSE ALLOGRAFT 2X15,C1713,HCPCS,,79006173,CDM,278,RC,,,both,,,3497,2587.79,,,2587.79,Other,150% of Medicare + 9.63% HCRA Surcharge,1573.65,45,,1573.65,percent of total billed charges,Critical Access Hospital RCC factor,1188.98,34,,1188.98,percent of total billed charges,Implant Device,1188.98,34,,1188.98,percent of total billed charges,Implant Device,1188.98,34,,1188.98,percent of total billed charges,Implant Device,1188.98,34,,1188.98,percent of total billed charges,Implant Device,1188.98,34,,1188.98,percent of total billed charges,Implant Device,1731.02,,,1731.02,Other,110% of Medicare,1223.95,35,,1223.95,percent of total billed charges,Implant Device,1188.98,34,"Charges > $500, x 34%",1188.98,percent of total billed charges,Implant Device,1223.95,35,,1223.95,percent of total billed charges,Implant Device,1223.95,35,,1223.95,percent of total billed charges,Implant Device,1223.95,35,,1223.95,percent of total billed charges,Implant Device,1223.95,35,,1223.95,percent of total billed charges,Implant Device,1223.95,35,,1223.95,percent of total billed charges,Implant Device,1398.8,40,,1398.8,percent of total billed charges,Implant Device,1223.95,70,,1223.95,percent of total billed charges,All Other,1188.98,34,,1188.98,percent of total billed charges,Implant Device,1188.98,34,,1188.98,percent of total billed charges,Implant Device,1223.95,35,,1223.95,percent of total billed charges,Implant Device,1223.95,35,,1223.95,percent of total billed charges,Implant Device,1223.95,35,,1223.95,percent of total billed charges,Implant Device,1223.95,35,,1223.95,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1188.98,34,"If Charge > 2,000, then 34 percent",1188.98,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2587.79,
MTF 410001 TRINITY ELITE 1CC,C1713,HCPCS,,79006176,CDM,278,RC,,,both,,,2081,1539.95,,,1539.95,Other,150% of Medicare + 9.63% HCRA Surcharge,936.45,45,,936.45,percent of total billed charges,Critical Access Hospital RCC factor,707.54,34,,707.54,percent of total billed charges,Implant Device,707.54,34,,707.54,percent of total billed charges,Implant Device,707.54,34,,707.54,percent of total billed charges,Implant Device,707.54,34,,707.54,percent of total billed charges,Implant Device,707.54,34,,707.54,percent of total billed charges,Implant Device,1030.1,,,1030.1,Other,110% of Medicare,728.35,35,,728.35,percent of total billed charges,Implant Device,707.54,34,"Charges > $500, x 34%",707.54,percent of total billed charges,Implant Device,728.35,35,,728.35,percent of total billed charges,Implant Device,728.35,35,,728.35,percent of total billed charges,Implant Device,728.35,35,,728.35,percent of total billed charges,Implant Device,728.35,35,,728.35,percent of total billed charges,Implant Device,728.35,35,,728.35,percent of total billed charges,Implant Device,832.4,40,,832.4,percent of total billed charges,Implant Device,728.35,70,,728.35,percent of total billed charges,All Other,707.54,34,,707.54,percent of total billed charges,Implant Device,707.54,34,,707.54,percent of total billed charges,Implant Device,728.35,35,,728.35,percent of total billed charges,Implant Device,728.35,35,,728.35,percent of total billed charges,Implant Device,728.35,35,,728.35,percent of total billed charges,Implant Device,728.35,35,,728.35,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,707.54,34,"If Charge > 2,000, then 34 percent",707.54,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1539.95,
ZIMMER 5842-04-01 TIBIAL COMPONENT SZ 4,C1776,HCPCS,,79006177,CDM,278,RC,,,both,,,6346,4696.06,,,4696.06,Other,150% of Medicare + 9.63% HCRA Surcharge,2855.7,45,,2855.7,percent of total billed charges,Critical Access Hospital RCC factor,2157.64,34,,2157.64,percent of total billed charges,Implant Device,2157.64,34,,2157.64,percent of total billed charges,Implant Device,2157.64,34,,2157.64,percent of total billed charges,Implant Device,2157.64,34,,2157.64,percent of total billed charges,Implant Device,2157.64,34,,2157.64,percent of total billed charges,Implant Device,3141.27,,,3141.27,Other,110% of Medicare,2221.1,35,,2221.1,percent of total billed charges,Implant Device,2157.64,34,"Charges > $500, x 34%",2157.64,percent of total billed charges,Implant Device,2221.1,35,,2221.1,percent of total billed charges,Implant Device,2221.1,35,,2221.1,percent of total billed charges,Implant Device,2221.1,35,,2221.1,percent of total billed charges,Implant Device,2221.1,35,,2221.1,percent of total billed charges,Implant Device,2221.1,35,,2221.1,percent of total billed charges,Implant Device,2538.4,40,,2538.4,percent of total billed charges,Implant Device,2221.1,70,,2221.1,percent of total billed charges,All Other,2157.64,34,,2157.64,percent of total billed charges,Implant Device,2157.64,34,,2157.64,percent of total billed charges,Implant Device,2221.1,35,,2221.1,percent of total billed charges,Implant Device,2221.1,35,,2221.1,percent of total billed charges,Implant Device,2221.1,35,,2221.1,percent of total billed charges,Implant Device,2221.1,35,,2221.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2157.64,34,"If Charge > 2,000, then 34 percent",2157.64,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4696.06,
ZIMMER 5842-24-10 ARTCLR SURF SZ 4 10MM,C1776,HCPCS,,79006178,CDM,278,RC,,,both,,,2677,1980.99,,,1980.99,Other,150% of Medicare + 9.63% HCRA Surcharge,1204.65,45,,1204.65,percent of total billed charges,Critical Access Hospital RCC factor,910.18,34,,910.18,percent of total billed charges,Implant Device,910.18,34,,910.18,percent of total billed charges,Implant Device,910.18,34,,910.18,percent of total billed charges,Implant Device,910.18,34,,910.18,percent of total billed charges,Implant Device,910.18,34,,910.18,percent of total billed charges,Implant Device,1325.12,,,1325.12,Other,110% of Medicare,936.95,35,,936.95,percent of total billed charges,Implant Device,910.18,34,"Charges > $500, x 34%",910.18,percent of total billed charges,Implant Device,936.95,35,,936.95,percent of total billed charges,Implant Device,936.95,35,,936.95,percent of total billed charges,Implant Device,936.95,35,,936.95,percent of total billed charges,Implant Device,936.95,35,,936.95,percent of total billed charges,Implant Device,936.95,35,,936.95,percent of total billed charges,Implant Device,1070.8,40,,1070.8,percent of total billed charges,Implant Device,936.95,70,,936.95,percent of total billed charges,All Other,910.18,34,,910.18,percent of total billed charges,Implant Device,910.18,34,,910.18,percent of total billed charges,Implant Device,936.95,35,,936.95,percent of total billed charges,Implant Device,936.95,35,,936.95,percent of total billed charges,Implant Device,936.95,35,,936.95,percent of total billed charges,Implant Device,936.95,35,,936.95,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,910.18,34,"If Charge > 2,000, then 34 percent",910.18,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1980.99,
EV3 PMB4-5-14-80 PARAMOUNT STENT 5X14X80,C1876,HCPCS,,79006179,CDM,278,RC,,,both,,,1950,1443,,,1443,Other,150% of Medicare + 9.63% HCRA Surcharge,877.5,45,,877.5,percent of total billed charges,Critical Access Hospital RCC factor,663,34,,663,percent of total billed charges,Implant Device,663,34,,663,percent of total billed charges,Implant Device,663,34,,663,percent of total billed charges,Implant Device,663,34,,663,percent of total billed charges,Implant Device,663,34,,663,percent of total billed charges,Implant Device,965.25,,,965.25,Other,110% of Medicare,682.5,35,,682.5,percent of total billed charges,Implant Device,663,34,"Charges > $500, x 34%",663,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,780,40,,780,percent of total billed charges,Implant Device,682.5,70,,682.5,percent of total billed charges,All Other,663,34,,663,percent of total billed charges,Implant Device,663,34,,663,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1443,
EV3 PMB4-5-18-80 PARAMOUNT STENT 5X18X80,C1876,HCPCS,,79006180,CDM,278,RC,,,both,,,1950,1443,,,1443,Other,150% of Medicare + 9.63% HCRA Surcharge,877.5,45,,877.5,percent of total billed charges,Critical Access Hospital RCC factor,663,34,,663,percent of total billed charges,Implant Device,663,34,,663,percent of total billed charges,Implant Device,663,34,,663,percent of total billed charges,Implant Device,663,34,,663,percent of total billed charges,Implant Device,663,34,,663,percent of total billed charges,Implant Device,965.25,,,965.25,Other,110% of Medicare,682.5,35,,682.5,percent of total billed charges,Implant Device,663,34,"Charges > $500, x 34%",663,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,780,40,,780,percent of total billed charges,Implant Device,682.5,70,,682.5,percent of total billed charges,All Other,663,34,,663,percent of total billed charges,Implant Device,663,34,,663,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1443,
EV3 PMB8-6-14-80 PARAMOUNT STENT 6X14X80,C1876,HCPCS,,79006181,CDM,278,RC,,,both,,,1950,1443,,,1443,Other,150% of Medicare + 9.63% HCRA Surcharge,877.5,45,,877.5,percent of total billed charges,Critical Access Hospital RCC factor,663,34,,663,percent of total billed charges,Implant Device,663,34,,663,percent of total billed charges,Implant Device,663,34,,663,percent of total billed charges,Implant Device,663,34,,663,percent of total billed charges,Implant Device,663,34,,663,percent of total billed charges,Implant Device,965.25,,,965.25,Other,110% of Medicare,682.5,35,,682.5,percent of total billed charges,Implant Device,663,34,"Charges > $500, x 34%",663,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,780,40,,780,percent of total billed charges,Implant Device,682.5,70,,682.5,percent of total billed charges,All Other,663,34,,663,percent of total billed charges,Implant Device,663,34,,663,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1443,
EV3 PMB4-6-14-80 PARAMOUNT STENT 6X14X80,C1876,HCPCS,,79006182,CDM,278,RC,,,both,,,1950,1443,,,1443,Other,150% of Medicare + 9.63% HCRA Surcharge,877.5,45,,877.5,percent of total billed charges,Critical Access Hospital RCC factor,663,34,,663,percent of total billed charges,Implant Device,663,34,,663,percent of total billed charges,Implant Device,663,34,,663,percent of total billed charges,Implant Device,663,34,,663,percent of total billed charges,Implant Device,663,34,,663,percent of total billed charges,Implant Device,965.25,,,965.25,Other,110% of Medicare,682.5,35,,682.5,percent of total billed charges,Implant Device,663,34,"Charges > $500, x 34%",663,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,780,40,,780,percent of total billed charges,Implant Device,682.5,70,,682.5,percent of total billed charges,All Other,663,34,,663,percent of total billed charges,Implant Device,663,34,,663,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1443,
EV3 PMB4-6-18-80 PARAMOUNT STENT 6X18X80,C1876,HCPCS,,79006183,CDM,278,RC,,,both,,,1950,1443,,,1443,Other,150% of Medicare + 9.63% HCRA Surcharge,877.5,45,,877.5,percent of total billed charges,Critical Access Hospital RCC factor,663,34,,663,percent of total billed charges,Implant Device,663,34,,663,percent of total billed charges,Implant Device,663,34,,663,percent of total billed charges,Implant Device,663,34,,663,percent of total billed charges,Implant Device,663,34,,663,percent of total billed charges,Implant Device,965.25,,,965.25,Other,110% of Medicare,682.5,35,,682.5,percent of total billed charges,Implant Device,663,34,"Charges > $500, x 34%",663,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,780,40,,780,percent of total billed charges,Implant Device,682.5,70,,682.5,percent of total billed charges,All Other,663,34,,663,percent of total billed charges,Implant Device,663,34,,663,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1443,
EV3 PMB8-6-21-80 PARAMOUNT STENT 6X21X80,C1876,HCPCS,,79006185,CDM,278,RC,,,both,,,3119,2308.07,,,2308.07,Other,150% of Medicare + 9.63% HCRA Surcharge,1403.55,45,,1403.55,percent of total billed charges,Critical Access Hospital RCC factor,1060.46,34,,1060.46,percent of total billed charges,Implant Device,1060.46,34,,1060.46,percent of total billed charges,Implant Device,1060.46,34,,1060.46,percent of total billed charges,Implant Device,1060.46,34,,1060.46,percent of total billed charges,Implant Device,1060.46,34,,1060.46,percent of total billed charges,Implant Device,1543.91,,,1543.91,Other,110% of Medicare,1091.65,35,,1091.65,percent of total billed charges,Implant Device,1060.46,34,"Charges > $500, x 34%",1060.46,percent of total billed charges,Implant Device,1091.65,35,,1091.65,percent of total billed charges,Implant Device,1091.65,35,,1091.65,percent of total billed charges,Implant Device,1091.65,35,,1091.65,percent of total billed charges,Implant Device,1091.65,35,,1091.65,percent of total billed charges,Implant Device,1091.65,35,,1091.65,percent of total billed charges,Implant Device,1247.6,40,,1247.6,percent of total billed charges,Implant Device,1091.65,70,,1091.65,percent of total billed charges,All Other,1060.46,34,,1060.46,percent of total billed charges,Implant Device,1060.46,34,,1060.46,percent of total billed charges,Implant Device,1091.65,35,,1091.65,percent of total billed charges,Implant Device,1091.65,35,,1091.65,percent of total billed charges,Implant Device,1091.65,35,,1091.65,percent of total billed charges,Implant Device,1091.65,35,,1091.65,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1060.46,34,"If Charge > 2,000, then 34 percent",1060.46,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2308.07,
EV3 PMB4-7-14-80 PARAMOUNT STENT 7X14X80,C1876,HCPCS,,79006186,CDM,278,RC,,,both,,,1950,1443,,,1443,Other,150% of Medicare + 9.63% HCRA Surcharge,877.5,45,,877.5,percent of total billed charges,Critical Access Hospital RCC factor,663,34,,663,percent of total billed charges,Implant Device,663,34,,663,percent of total billed charges,Implant Device,663,34,,663,percent of total billed charges,Implant Device,663,34,,663,percent of total billed charges,Implant Device,663,34,,663,percent of total billed charges,Implant Device,965.25,,,965.25,Other,110% of Medicare,682.5,35,,682.5,percent of total billed charges,Implant Device,663,34,"Charges > $500, x 34%",663,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,780,40,,780,percent of total billed charges,Implant Device,682.5,70,,682.5,percent of total billed charges,All Other,663,34,,663,percent of total billed charges,Implant Device,663,34,,663,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1443,
EV3 PMB4-7-18-80 PARAMOUNT STENT 7X18X80,C1876,HCPCS,,79006187,CDM,278,RC,,,both,,,1950,1443,,,1443,Other,150% of Medicare + 9.63% HCRA Surcharge,877.5,45,,877.5,percent of total billed charges,Critical Access Hospital RCC factor,663,34,,663,percent of total billed charges,Implant Device,663,34,,663,percent of total billed charges,Implant Device,663,34,,663,percent of total billed charges,Implant Device,663,34,,663,percent of total billed charges,Implant Device,663,34,,663,percent of total billed charges,Implant Device,965.25,,,965.25,Other,110% of Medicare,682.5,35,,682.5,percent of total billed charges,Implant Device,663,34,"Charges > $500, x 34%",663,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,780,40,,780,percent of total billed charges,Implant Device,682.5,70,,682.5,percent of total billed charges,All Other,663,34,,663,percent of total billed charges,Implant Device,663,34,,663,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1443,
BIOMET/EBI 29241 LAG SCREW ASSY 110MM,C1713,HCPCS,,79006210,CDM,278,RC,,,both,,,3330,2464.21,,,2464.21,Other,150% of Medicare + 9.63% HCRA Surcharge,1498.5,45,,1498.5,percent of total billed charges,Critical Access Hospital RCC factor,1132.2,34,,1132.2,percent of total billed charges,Implant Device,1132.2,34,,1132.2,percent of total billed charges,Implant Device,1132.2,34,,1132.2,percent of total billed charges,Implant Device,1132.2,34,,1132.2,percent of total billed charges,Implant Device,1132.2,34,,1132.2,percent of total billed charges,Implant Device,1648.35,,,1648.35,Other,110% of Medicare,1165.5,35,,1165.5,percent of total billed charges,Implant Device,1132.2,34,"Charges > $500, x 34%",1132.2,percent of total billed charges,Implant Device,1165.5,35,,1165.5,percent of total billed charges,Implant Device,1165.5,35,,1165.5,percent of total billed charges,Implant Device,1165.5,35,,1165.5,percent of total billed charges,Implant Device,1165.5,35,,1165.5,percent of total billed charges,Implant Device,1165.5,35,,1165.5,percent of total billed charges,Implant Device,1332,40,,1332,percent of total billed charges,Implant Device,1165.5,70,,1165.5,percent of total billed charges,All Other,1132.2,34,,1132.2,percent of total billed charges,Implant Device,1132.2,34,,1132.2,percent of total billed charges,Implant Device,1165.5,35,,1165.5,percent of total billed charges,Implant Device,1165.5,35,,1165.5,percent of total billed charges,Implant Device,1165.5,35,,1165.5,percent of total billed charges,Implant Device,1165.5,35,,1165.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1132.2,34,"If Charge > 2,000, then 34 percent",1132.2,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2464.21,
ZIMMER 7711-010-00  M/L TAPER 10 STD,C1776,HCPCS,,79006211,CDM,278,RC,,,both,,,7398,5474.54,,,5474.54,Other,150% of Medicare + 9.63% HCRA Surcharge,3329.1,45,,3329.1,percent of total billed charges,Critical Access Hospital RCC factor,2515.32,34,,2515.32,percent of total billed charges,Implant Device,2515.32,34,,2515.32,percent of total billed charges,Implant Device,2515.32,34,,2515.32,percent of total billed charges,Implant Device,2515.32,34,,2515.32,percent of total billed charges,Implant Device,2515.32,34,,2515.32,percent of total billed charges,Implant Device,3662.01,,,3662.01,Other,110% of Medicare,2589.3,35,,2589.3,percent of total billed charges,Implant Device,2515.32,34,"Charges > $500, x 34%",2515.32,percent of total billed charges,Implant Device,2589.3,35,,2589.3,percent of total billed charges,Implant Device,2589.3,35,,2589.3,percent of total billed charges,Implant Device,2589.3,35,,2589.3,percent of total billed charges,Implant Device,2589.3,35,,2589.3,percent of total billed charges,Implant Device,2589.3,35,,2589.3,percent of total billed charges,Implant Device,2959.2,40,,2959.2,percent of total billed charges,Implant Device,2589.3,70,,2589.3,percent of total billed charges,All Other,2515.32,34,,2515.32,percent of total billed charges,Implant Device,2515.32,34,,2515.32,percent of total billed charges,Implant Device,2589.3,35,,2589.3,percent of total billed charges,Implant Device,2589.3,35,,2589.3,percent of total billed charges,Implant Device,2589.3,35,,2589.3,percent of total billed charges,Implant Device,2589.3,35,,2589.3,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2515.32,34,"If Charge > 2,000, then 34 percent",2515.32,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5474.54,
ACUMED AT2-S34-S STD BONE SCREW 34MM,C1713,HCPCS,,79006212,CDM,278,RC,,,both,,,1584,1172.16,,,1172.16,Other,150% of Medicare + 9.63% HCRA Surcharge,712.8,45,,712.8,percent of total billed charges,Critical Access Hospital RCC factor,538.56,34,,538.56,percent of total billed charges,Implant Device,538.56,34,,538.56,percent of total billed charges,Implant Device,538.56,34,,538.56,percent of total billed charges,Implant Device,538.56,34,,538.56,percent of total billed charges,Implant Device,538.56,34,,538.56,percent of total billed charges,Implant Device,784.08,,,784.08,Other,110% of Medicare,554.4,35,,554.4,percent of total billed charges,Implant Device,538.56,34,"Charges > $500, x 34%",538.56,percent of total billed charges,Implant Device,554.4,35,,554.4,percent of total billed charges,Implant Device,554.4,35,,554.4,percent of total billed charges,Implant Device,554.4,35,,554.4,percent of total billed charges,Implant Device,554.4,35,,554.4,percent of total billed charges,Implant Device,554.4,35,,554.4,percent of total billed charges,Implant Device,633.6,40,,633.6,percent of total billed charges,Implant Device,554.4,70,,554.4,percent of total billed charges,All Other,538.56,34,,538.56,percent of total billed charges,Implant Device,538.56,34,,538.56,percent of total billed charges,Implant Device,554.4,35,,554.4,percent of total billed charges,Implant Device,554.4,35,,554.4,percent of total billed charges,Implant Device,554.4,35,,554.4,percent of total billed charges,Implant Device,554.4,35,,554.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1172.16,
BIOMET/EBI 29240 LAG SCREW ASSY 105MM,C1713,HCPCS,,79006213,CDM,278,RC,,,both,,,3330,2464.21,,,2464.21,Other,150% of Medicare + 9.63% HCRA Surcharge,1498.5,45,,1498.5,percent of total billed charges,Critical Access Hospital RCC factor,1132.2,34,,1132.2,percent of total billed charges,Implant Device,1132.2,34,,1132.2,percent of total billed charges,Implant Device,1132.2,34,,1132.2,percent of total billed charges,Implant Device,1132.2,34,,1132.2,percent of total billed charges,Implant Device,1132.2,34,,1132.2,percent of total billed charges,Implant Device,1648.35,,,1648.35,Other,110% of Medicare,1165.5,35,,1165.5,percent of total billed charges,Implant Device,1132.2,34,"Charges > $500, x 34%",1132.2,percent of total billed charges,Implant Device,1165.5,35,,1165.5,percent of total billed charges,Implant Device,1165.5,35,,1165.5,percent of total billed charges,Implant Device,1165.5,35,,1165.5,percent of total billed charges,Implant Device,1165.5,35,,1165.5,percent of total billed charges,Implant Device,1165.5,35,,1165.5,percent of total billed charges,Implant Device,1332,40,,1332,percent of total billed charges,Implant Device,1165.5,70,,1165.5,percent of total billed charges,All Other,1132.2,34,,1132.2,percent of total billed charges,Implant Device,1132.2,34,,1132.2,percent of total billed charges,Implant Device,1165.5,35,,1165.5,percent of total billed charges,Implant Device,1165.5,35,,1165.5,percent of total billed charges,Implant Device,1165.5,35,,1165.5,percent of total billed charges,Implant Device,1165.5,35,,1165.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1132.2,34,"If Charge > 2,000, then 34 percent",1132.2,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2464.21,
ZIMMER 2348-12-35 PERI SCREW 3.5X12MM,C1713,HCPCS,,79006214,CDM,278,RC,,,both,,,113,83.62,,,83.62,Other,150% of Medicare + 9.63% HCRA Surcharge,50.85,45,,50.85,percent of total billed charges,Critical Access Hospital RCC factor,38.42,34,,38.42,percent of total billed charges,Implant Device,38.42,34,,38.42,percent of total billed charges,Implant Device,38.42,34,,38.42,percent of total billed charges,Implant Device,38.42,34,,38.42,percent of total billed charges,Implant Device,38.42,34,,38.42,percent of total billed charges,Implant Device,55.94,,,55.94,Other,110% of Medicare,39.55,35,,39.55,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,39.55,35,,39.55,percent of total billed charges,Implant Device,39.55,35,,39.55,percent of total billed charges,Implant Device,39.55,35,,39.55,percent of total billed charges,Implant Device,39.55,35,,39.55,percent of total billed charges,Implant Device,39.55,35,,39.55,percent of total billed charges,Implant Device,45.2,40,,45.2,percent of total billed charges,Implant Device,39.55,70,,39.55,percent of total billed charges,All Other,38.42,34,,38.42,percent of total billed charges,Implant Device,38.42,34,,38.42,percent of total billed charges,Implant Device,39.55,35,,39.55,percent of total billed charges,Implant Device,39.55,35,,39.55,percent of total billed charges,Implant Device,39.55,35,,39.55,percent of total billed charges,Implant Device,39.55,35,,39.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,83.62,
ZIMMER 2348-14-35 PERI SCREW 3.5X14MM,C1713,HCPCS,,79006215,CDM,278,RC,,,both,,,113,83.62,,,83.62,Other,150% of Medicare + 9.63% HCRA Surcharge,50.85,45,,50.85,percent of total billed charges,Critical Access Hospital RCC factor,38.42,34,,38.42,percent of total billed charges,Implant Device,38.42,34,,38.42,percent of total billed charges,Implant Device,38.42,34,,38.42,percent of total billed charges,Implant Device,38.42,34,,38.42,percent of total billed charges,Implant Device,38.42,34,,38.42,percent of total billed charges,Implant Device,55.94,,,55.94,Other,110% of Medicare,39.55,35,,39.55,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,39.55,35,,39.55,percent of total billed charges,Implant Device,39.55,35,,39.55,percent of total billed charges,Implant Device,39.55,35,,39.55,percent of total billed charges,Implant Device,39.55,35,,39.55,percent of total billed charges,Implant Device,39.55,35,,39.55,percent of total billed charges,Implant Device,45.2,40,,45.2,percent of total billed charges,Implant Device,39.55,70,,39.55,percent of total billed charges,All Other,38.42,34,,38.42,percent of total billed charges,Implant Device,38.42,34,,38.42,percent of total billed charges,Implant Device,39.55,35,,39.55,percent of total billed charges,Implant Device,39.55,35,,39.55,percent of total billed charges,Implant Device,39.55,35,,39.55,percent of total billed charges,Implant Device,39.55,35,,39.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,83.62,
ZIMMER 2348-16-35 PERI SCREW 3.5X16MM,C1713,HCPCS,,79006216,CDM,278,RC,,,both,,,113,83.62,,,83.62,Other,150% of Medicare + 9.63% HCRA Surcharge,50.85,45,,50.85,percent of total billed charges,Critical Access Hospital RCC factor,38.42,34,,38.42,percent of total billed charges,Implant Device,38.42,34,,38.42,percent of total billed charges,Implant Device,38.42,34,,38.42,percent of total billed charges,Implant Device,38.42,34,,38.42,percent of total billed charges,Implant Device,38.42,34,,38.42,percent of total billed charges,Implant Device,55.94,,,55.94,Other,110% of Medicare,39.55,35,,39.55,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,39.55,35,,39.55,percent of total billed charges,Implant Device,39.55,35,,39.55,percent of total billed charges,Implant Device,39.55,35,,39.55,percent of total billed charges,Implant Device,39.55,35,,39.55,percent of total billed charges,Implant Device,39.55,35,,39.55,percent of total billed charges,Implant Device,45.2,40,,45.2,percent of total billed charges,Implant Device,39.55,70,,39.55,percent of total billed charges,All Other,38.42,34,,38.42,percent of total billed charges,Implant Device,38.42,34,,38.42,percent of total billed charges,Implant Device,39.55,35,,39.55,percent of total billed charges,Implant Device,39.55,35,,39.55,percent of total billed charges,Implant Device,39.55,35,,39.55,percent of total billed charges,Implant Device,39.55,35,,39.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,83.62,
ZIMMER 2357-17-04 LAT LOCK PLATE 4H 80MM,C1713,HCPCS,,79006217,CDM,278,RC,,,both,,,2020,1494.81,,,1494.81,Other,150% of Medicare + 9.63% HCRA Surcharge,909,45,,909,percent of total billed charges,Critical Access Hospital RCC factor,686.8,34,,686.8,percent of total billed charges,Implant Device,686.8,34,,686.8,percent of total billed charges,Implant Device,686.8,34,,686.8,percent of total billed charges,Implant Device,686.8,34,,686.8,percent of total billed charges,Implant Device,686.8,34,,686.8,percent of total billed charges,Implant Device,999.9,,,999.9,Other,110% of Medicare,707,35,,707,percent of total billed charges,Implant Device,686.8,34,"Charges > $500, x 34%",686.8,percent of total billed charges,Implant Device,707,35,,707,percent of total billed charges,Implant Device,707,35,,707,percent of total billed charges,Implant Device,707,35,,707,percent of total billed charges,Implant Device,707,35,,707,percent of total billed charges,Implant Device,707,35,,707,percent of total billed charges,Implant Device,808,40,,808,percent of total billed charges,Implant Device,707,70,,707,percent of total billed charges,All Other,686.8,34,,686.8,percent of total billed charges,Implant Device,686.8,34,,686.8,percent of total billed charges,Implant Device,707,35,,707,percent of total billed charges,Implant Device,707,35,,707,percent of total billed charges,Implant Device,707,35,,707,percent of total billed charges,Implant Device,707,35,,707,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,686.8,34,"If Charge > 2,000, then 34 percent",686.8,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1494.81,
ZIMMER 2359-12-38 LOCK SCREW 3.5X12MM,C1713,HCPCS,,79006218,CDM,278,RC,,,both,,,313,231.62,,,231.62,Other,150% of Medicare + 9.63% HCRA Surcharge,140.85,45,,140.85,percent of total billed charges,Critical Access Hospital RCC factor,106.42,34,,106.42,percent of total billed charges,Implant Device,106.42,34,,106.42,percent of total billed charges,Implant Device,106.42,34,,106.42,percent of total billed charges,Implant Device,106.42,34,,106.42,percent of total billed charges,Implant Device,106.42,34,,106.42,percent of total billed charges,Implant Device,154.94,,,154.94,Other,110% of Medicare,109.55,35,,109.55,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,109.55,35,,109.55,percent of total billed charges,Implant Device,109.55,35,,109.55,percent of total billed charges,Implant Device,109.55,35,,109.55,percent of total billed charges,Implant Device,109.55,35,,109.55,percent of total billed charges,Implant Device,109.55,35,,109.55,percent of total billed charges,Implant Device,125.2,40,,125.2,percent of total billed charges,Implant Device,109.55,70,,109.55,percent of total billed charges,All Other,106.42,34,,106.42,percent of total billed charges,Implant Device,106.42,34,,106.42,percent of total billed charges,Implant Device,109.55,35,,109.55,percent of total billed charges,Implant Device,109.55,35,,109.55,percent of total billed charges,Implant Device,109.55,35,,109.55,percent of total billed charges,Implant Device,109.55,35,,109.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,231.62,
ZIMMER 2360-153-35 3.5MM LOCKING SCREW,C1713,HCPCS,,79006219,CDM,278,RC,,,both,,,540,399.6,,,399.6,Other,150% of Medicare + 9.63% HCRA Surcharge,243,45,,243,percent of total billed charges,Critical Access Hospital RCC factor,183.6,34,,183.6,percent of total billed charges,Implant Device,183.6,34,,183.6,percent of total billed charges,Implant Device,183.6,34,,183.6,percent of total billed charges,Implant Device,183.6,34,,183.6,percent of total billed charges,Implant Device,183.6,34,,183.6,percent of total billed charges,Implant Device,267.3,,,267.3,Other,110% of Medicare,189,35,,189,percent of total billed charges,Implant Device,183.6,34,"Charges > $500, x 34%",183.6,percent of total billed charges,Implant Device,189,35,,189,percent of total billed charges,Implant Device,189,35,,189,percent of total billed charges,Implant Device,189,35,,189,percent of total billed charges,Implant Device,189,35,,189,percent of total billed charges,Implant Device,189,35,,189,percent of total billed charges,Implant Device,216,40,,216,percent of total billed charges,Implant Device,189,70,,189,percent of total billed charges,All Other,183.6,34,,183.6,percent of total billed charges,Implant Device,183.6,34,,183.6,percent of total billed charges,Implant Device,189,35,,189,percent of total billed charges,Implant Device,189,35,,189,percent of total billed charges,Implant Device,189,35,,189,percent of total billed charges,Implant Device,189,35,,189,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,399.6,
ZIMMER 4828-12-02 LOCK SCREW 2.7X12MM,C1713,HCPCS,,79006222,CDM,278,RC,,,both,,,335,247.9,,,247.9,Other,150% of Medicare + 9.63% HCRA Surcharge,150.75,45,,150.75,percent of total billed charges,Critical Access Hospital RCC factor,113.9,34,,113.9,percent of total billed charges,Implant Device,113.9,34,,113.9,percent of total billed charges,Implant Device,113.9,34,,113.9,percent of total billed charges,Implant Device,113.9,34,,113.9,percent of total billed charges,Implant Device,113.9,34,,113.9,percent of total billed charges,Implant Device,165.83,,,165.83,Other,110% of Medicare,117.25,35,,117.25,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,117.25,35,,117.25,percent of total billed charges,Implant Device,117.25,35,,117.25,percent of total billed charges,Implant Device,117.25,35,,117.25,percent of total billed charges,Implant Device,117.25,35,,117.25,percent of total billed charges,Implant Device,117.25,35,,117.25,percent of total billed charges,Implant Device,134,40,,134,percent of total billed charges,Implant Device,117.25,70,,117.25,percent of total billed charges,All Other,113.9,34,,113.9,percent of total billed charges,Implant Device,113.9,34,,113.9,percent of total billed charges,Implant Device,117.25,35,,117.25,percent of total billed charges,Implant Device,117.25,35,,117.25,percent of total billed charges,Implant Device,117.25,35,,117.25,percent of total billed charges,Implant Device,117.25,35,,117.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,247.9,
ZIMMER 4828-16-02 LOCK SCREW 2.7X16MM,C1713,HCPCS,,79006223,CDM,278,RC,,,both,,,335,247.9,,,247.9,Other,150% of Medicare + 9.63% HCRA Surcharge,150.75,45,,150.75,percent of total billed charges,Critical Access Hospital RCC factor,113.9,34,,113.9,percent of total billed charges,Implant Device,113.9,34,,113.9,percent of total billed charges,Implant Device,113.9,34,,113.9,percent of total billed charges,Implant Device,113.9,34,,113.9,percent of total billed charges,Implant Device,113.9,34,,113.9,percent of total billed charges,Implant Device,165.83,,,165.83,Other,110% of Medicare,117.25,35,,117.25,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,117.25,35,,117.25,percent of total billed charges,Implant Device,117.25,35,,117.25,percent of total billed charges,Implant Device,117.25,35,,117.25,percent of total billed charges,Implant Device,117.25,35,,117.25,percent of total billed charges,Implant Device,117.25,35,,117.25,percent of total billed charges,Implant Device,134,40,,134,percent of total billed charges,Implant Device,117.25,70,,117.25,percent of total billed charges,All Other,113.9,34,,113.9,percent of total billed charges,Implant Device,113.9,34,,113.9,percent of total billed charges,Implant Device,117.25,35,,117.25,percent of total billed charges,Implant Device,117.25,35,,117.25,percent of total billed charges,Implant Device,117.25,35,,117.25,percent of total billed charges,Implant Device,117.25,35,,117.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,247.9,
GORE 0650HYB0810A VASCULAR GRAFT 8X10,C1768,HCPCS,,79006224,CDM,278,RC,,,both,,,8340,6171.62,,,6171.62,Other,150% of Medicare + 9.63% HCRA Surcharge,3753,45,,3753,percent of total billed charges,Critical Access Hospital RCC factor,2835.6,34,,2835.6,percent of total billed charges,Implant Device,2835.6,34,,2835.6,percent of total billed charges,Implant Device,2835.6,34,,2835.6,percent of total billed charges,Implant Device,2835.6,34,,2835.6,percent of total billed charges,Implant Device,2835.6,34,,2835.6,percent of total billed charges,Implant Device,4128.3,,,4128.3,Other,110% of Medicare,2919,35,,2919,percent of total billed charges,Implant Device,2835.6,34,"Charges > $500, x 34%",2835.6,percent of total billed charges,Implant Device,2919,35,,2919,percent of total billed charges,Implant Device,2919,35,,2919,percent of total billed charges,Implant Device,2919,35,,2919,percent of total billed charges,Implant Device,2919,35,,2919,percent of total billed charges,Implant Device,2919,35,,2919,percent of total billed charges,Implant Device,3336,40,,3336,percent of total billed charges,Implant Device,2919,70,,2919,percent of total billed charges,All Other,2835.6,34,,2835.6,percent of total billed charges,Implant Device,2835.6,34,,2835.6,percent of total billed charges,Implant Device,2919,35,,2919,percent of total billed charges,Implant Device,2919,35,,2919,percent of total billed charges,Implant Device,2919,35,,2919,percent of total billed charges,Implant Device,2919,35,,2919,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2835.6,34,"If Charge > 2,000, then 34 percent",2835.6,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,6171.62,
GORE 0650HYB0910A VASCULAR GRAFT 9X10,C1768,HCPCS,,79006225,CDM,278,RC,,,both,,,8340,6171.62,,,6171.62,Other,150% of Medicare + 9.63% HCRA Surcharge,3753,45,,3753,percent of total billed charges,Critical Access Hospital RCC factor,2835.6,34,,2835.6,percent of total billed charges,Implant Device,2835.6,34,,2835.6,percent of total billed charges,Implant Device,2835.6,34,,2835.6,percent of total billed charges,Implant Device,2835.6,34,,2835.6,percent of total billed charges,Implant Device,2835.6,34,,2835.6,percent of total billed charges,Implant Device,4128.3,,,4128.3,Other,110% of Medicare,2919,35,,2919,percent of total billed charges,Implant Device,2835.6,34,"Charges > $500, x 34%",2835.6,percent of total billed charges,Implant Device,2919,35,,2919,percent of total billed charges,Implant Device,2919,35,,2919,percent of total billed charges,Implant Device,2919,35,,2919,percent of total billed charges,Implant Device,2919,35,,2919,percent of total billed charges,Implant Device,2919,35,,2919,percent of total billed charges,Implant Device,3336,40,,3336,percent of total billed charges,Implant Device,2919,70,,2919,percent of total billed charges,All Other,2835.6,34,,2835.6,percent of total billed charges,Implant Device,2835.6,34,,2835.6,percent of total billed charges,Implant Device,2919,35,,2919,percent of total billed charges,Implant Device,2919,35,,2919,percent of total billed charges,Implant Device,2919,35,,2919,percent of total billed charges,Implant Device,2919,35,,2919,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2835.6,34,"If Charge > 2,000, then 34 percent",2835.6,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,6171.62,
ACUMED 70-0356 LEFT STD VDR PLATE,C1713,HCPCS,,79006226,CDM,278,RC,,,both,,,3801,2812.75,,,2812.75,Other,150% of Medicare + 9.63% HCRA Surcharge,1710.45,45,,1710.45,percent of total billed charges,Critical Access Hospital RCC factor,1292.34,34,,1292.34,percent of total billed charges,Implant Device,1292.34,34,,1292.34,percent of total billed charges,Implant Device,1292.34,34,,1292.34,percent of total billed charges,Implant Device,1292.34,34,,1292.34,percent of total billed charges,Implant Device,1292.34,34,,1292.34,percent of total billed charges,Implant Device,1881.5,,,1881.5,Other,110% of Medicare,1330.35,35,,1330.35,percent of total billed charges,Implant Device,1292.34,34,"Charges > $500, x 34%",1292.34,percent of total billed charges,Implant Device,1330.35,35,,1330.35,percent of total billed charges,Implant Device,1330.35,35,,1330.35,percent of total billed charges,Implant Device,1330.35,35,,1330.35,percent of total billed charges,Implant Device,1330.35,35,,1330.35,percent of total billed charges,Implant Device,1330.35,35,,1330.35,percent of total billed charges,Implant Device,1520.4,40,,1520.4,percent of total billed charges,Implant Device,1330.35,70,,1330.35,percent of total billed charges,All Other,1292.34,34,,1292.34,percent of total billed charges,Implant Device,1292.34,34,,1292.34,percent of total billed charges,Implant Device,1330.35,35,,1330.35,percent of total billed charges,Implant Device,1330.35,35,,1330.35,percent of total billed charges,Implant Device,1330.35,35,,1330.35,percent of total billed charges,Implant Device,1330.35,35,,1330.35,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1292.34,34,"If Charge > 2,000, then 34 percent",1292.34,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2812.75,
ACUMED CO-T2318 LOCKING SCREW 2.3X18MM,C1713,HCPCS,,79006227,CDM,278,RC,,,both,,,324,239.76,,,239.76,Other,150% of Medicare + 9.63% HCRA Surcharge,145.8,45,,145.8,percent of total billed charges,Critical Access Hospital RCC factor,110.16,34,,110.16,percent of total billed charges,Implant Device,110.16,34,,110.16,percent of total billed charges,Implant Device,110.16,34,,110.16,percent of total billed charges,Implant Device,110.16,34,,110.16,percent of total billed charges,Implant Device,110.16,34,,110.16,percent of total billed charges,Implant Device,160.38,,,160.38,Other,110% of Medicare,113.4,35,,113.4,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,129.6,40,,129.6,percent of total billed charges,Implant Device,113.4,70,,113.4,percent of total billed charges,All Other,110.16,34,,110.16,percent of total billed charges,Implant Device,110.16,34,,110.16,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,239.76,
ACUMED CO-T2316 LOCKING SCREW 2.3X16MM,C1713,HCPCS,,79006228,CDM,278,RC,,,both,,,324,239.76,,,239.76,Other,150% of Medicare + 9.63% HCRA Surcharge,145.8,45,,145.8,percent of total billed charges,Critical Access Hospital RCC factor,110.16,34,,110.16,percent of total billed charges,Implant Device,110.16,34,,110.16,percent of total billed charges,Implant Device,110.16,34,,110.16,percent of total billed charges,Implant Device,110.16,34,,110.16,percent of total billed charges,Implant Device,110.16,34,,110.16,percent of total billed charges,Implant Device,160.38,,,160.38,Other,110% of Medicare,113.4,35,,113.4,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,129.6,40,,129.6,percent of total billed charges,Implant Device,113.4,70,,113.4,percent of total billed charges,All Other,110.16,34,,110.16,percent of total billed charges,Implant Device,110.16,34,,110.16,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,239.76,
ACUMED CO-T2314 LOCKING SCREW 2.3X14MM,C1713,HCPCS,,79006229,CDM,278,RC,,,both,,,324,239.76,,,239.76,Other,150% of Medicare + 9.63% HCRA Surcharge,145.8,45,,145.8,percent of total billed charges,Critical Access Hospital RCC factor,110.16,34,,110.16,percent of total billed charges,Implant Device,110.16,34,,110.16,percent of total billed charges,Implant Device,110.16,34,,110.16,percent of total billed charges,Implant Device,110.16,34,,110.16,percent of total billed charges,Implant Device,110.16,34,,110.16,percent of total billed charges,Implant Device,160.38,,,160.38,Other,110% of Medicare,113.4,35,,113.4,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,129.6,40,,129.6,percent of total billed charges,Implant Device,113.4,70,,113.4,percent of total billed charges,All Other,110.16,34,,110.16,percent of total billed charges,Implant Device,110.16,34,,110.16,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,239.76,
ZIMMER 5880-15-01 FEMORAL COMP SZ E LT,C1776,HCPCS,,79006230,CDM,278,RC,,,both,,,26254,19428.03,,,19428.03,Other,150% of Medicare + 9.63% HCRA Surcharge,11814.3,45,,11814.3,percent of total billed charges,Critical Access Hospital RCC factor,8926.36,34,,8926.36,percent of total billed charges,Implant Device,8926.36,34,,8926.36,percent of total billed charges,Implant Device,8926.36,34,,8926.36,percent of total billed charges,Implant Device,8926.36,34,,8926.36,percent of total billed charges,Implant Device,8926.36,34,,8926.36,percent of total billed charges,Implant Device,12995.73,,,12995.73,Other,110% of Medicare,9188.9,35,,9188.9,percent of total billed charges,Implant Device,8926.36,34,"Charges > $500, x 34%",8926.36,percent of total billed charges,Implant Device,9188.9,35,,9188.9,percent of total billed charges,Implant Device,9188.9,35,,9188.9,percent of total billed charges,Implant Device,9188.9,35,,9188.9,percent of total billed charges,Implant Device,9188.9,35,,9188.9,percent of total billed charges,Implant Device,9188.9,35,,9188.9,percent of total billed charges,Implant Device,10501.6,40,,10501.6,percent of total billed charges,Implant Device,9188.9,70,,9188.9,percent of total billed charges,All Other,8926.36,34,,8926.36,percent of total billed charges,Implant Device,8926.36,34,,8926.36,percent of total billed charges,Implant Device,9188.9,35,,9188.9,percent of total billed charges,Implant Device,9188.9,35,,9188.9,percent of total billed charges,Implant Device,9188.9,35,,9188.9,percent of total billed charges,Implant Device,9188.9,35,,9188.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,8926.36,34,"If Charge > 2,000, then 34 percent",8926.36,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,19428.03,
ZIMMER 5972-65-32 PATELLA SZ 32 8.5MM,C1776,HCPCS,,79006231,CDM,278,RC,,,both,,,1152,852.48,,,852.48,Other,150% of Medicare + 9.63% HCRA Surcharge,518.4,45,,518.4,percent of total billed charges,Critical Access Hospital RCC factor,391.68,34,,391.68,percent of total billed charges,Implant Device,391.68,34,,391.68,percent of total billed charges,Implant Device,391.68,34,,391.68,percent of total billed charges,Implant Device,391.68,34,,391.68,percent of total billed charges,Implant Device,391.68,34,,391.68,percent of total billed charges,Implant Device,570.24,,,570.24,Other,110% of Medicare,403.2,35,,403.2,percent of total billed charges,Implant Device,391.68,34,"Charges > $500, x 34%",391.68,percent of total billed charges,Implant Device,403.2,35,,403.2,percent of total billed charges,Implant Device,403.2,35,,403.2,percent of total billed charges,Implant Device,403.2,35,,403.2,percent of total billed charges,Implant Device,403.2,35,,403.2,percent of total billed charges,Implant Device,403.2,35,,403.2,percent of total billed charges,Implant Device,460.8,40,,460.8,percent of total billed charges,Implant Device,403.2,70,,403.2,percent of total billed charges,All Other,391.68,34,,391.68,percent of total billed charges,Implant Device,391.68,34,,391.68,percent of total billed charges,Implant Device,403.2,35,,403.2,percent of total billed charges,Implant Device,403.2,35,,403.2,percent of total billed charges,Implant Device,403.2,35,,403.2,percent of total billed charges,Implant Device,403.2,35,,403.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,852.48,
GORE 0650HYB0610A VASCULAR GRAFT 6X10,C1768,HCPCS,,79006232,CDM,278,RC,,,both,,,8340,6171.62,,,6171.62,Other,150% of Medicare + 9.63% HCRA Surcharge,3753,45,,3753,percent of total billed charges,Critical Access Hospital RCC factor,2835.6,34,,2835.6,percent of total billed charges,Implant Device,2835.6,34,,2835.6,percent of total billed charges,Implant Device,2835.6,34,,2835.6,percent of total billed charges,Implant Device,2835.6,34,,2835.6,percent of total billed charges,Implant Device,2835.6,34,,2835.6,percent of total billed charges,Implant Device,4128.3,,,4128.3,Other,110% of Medicare,2919,35,,2919,percent of total billed charges,Implant Device,2835.6,34,"Charges > $500, x 34%",2835.6,percent of total billed charges,Implant Device,2919,35,,2919,percent of total billed charges,Implant Device,2919,35,,2919,percent of total billed charges,Implant Device,2919,35,,2919,percent of total billed charges,Implant Device,2919,35,,2919,percent of total billed charges,Implant Device,2919,35,,2919,percent of total billed charges,Implant Device,3336,40,,3336,percent of total billed charges,Implant Device,2919,70,,2919,percent of total billed charges,All Other,2835.6,34,,2835.6,percent of total billed charges,Implant Device,2835.6,34,,2835.6,percent of total billed charges,Implant Device,2919,35,,2919,percent of total billed charges,Implant Device,2919,35,,2919,percent of total billed charges,Implant Device,2919,35,,2919,percent of total billed charges,Implant Device,2919,35,,2919,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2835.6,34,"If Charge > 2,000, then 34 percent",2835.6,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,6171.62,
ACUMED 70-0300 CLAVICLE PLATE 8 HOLE,C1713,HCPCS,,79006233,CDM,278,RC,,,both,,,6567,4859.6,,,4859.6,Other,150% of Medicare + 9.63% HCRA Surcharge,2955.15,45,,2955.15,percent of total billed charges,Critical Access Hospital RCC factor,2232.78,34,,2232.78,percent of total billed charges,Implant Device,2232.78,34,,2232.78,percent of total billed charges,Implant Device,2232.78,34,,2232.78,percent of total billed charges,Implant Device,2232.78,34,,2232.78,percent of total billed charges,Implant Device,2232.78,34,,2232.78,percent of total billed charges,Implant Device,3250.67,,,3250.67,Other,110% of Medicare,2298.45,35,,2298.45,percent of total billed charges,Implant Device,2232.78,34,"Charges > $500, x 34%",2232.78,percent of total billed charges,Implant Device,2298.45,35,,2298.45,percent of total billed charges,Implant Device,2298.45,35,,2298.45,percent of total billed charges,Implant Device,2298.45,35,,2298.45,percent of total billed charges,Implant Device,2298.45,35,,2298.45,percent of total billed charges,Implant Device,2298.45,35,,2298.45,percent of total billed charges,Implant Device,2626.8,40,,2626.8,percent of total billed charges,Implant Device,2298.45,70,,2298.45,percent of total billed charges,All Other,2232.78,34,,2232.78,percent of total billed charges,Implant Device,2232.78,34,,2232.78,percent of total billed charges,Implant Device,2298.45,35,,2298.45,percent of total billed charges,Implant Device,2298.45,35,,2298.45,percent of total billed charges,Implant Device,2298.45,35,,2298.45,percent of total billed charges,Implant Device,2298.45,35,,2298.45,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2232.78,34,"If Charge > 2,000, then 34 percent",2232.78,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4859.6,
EV3 SF07150MB SMART FLEX 7X150MM STENT,C1876,HCPCS,,79006234,CDM,278,RC,,,both,,,3300,2442.01,,,2442.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1485,45,,1485,percent of total billed charges,Critical Access Hospital RCC factor,1122,34,,1122,percent of total billed charges,Implant Device,1122,34,,1122,percent of total billed charges,Implant Device,1122,34,,1122,percent of total billed charges,Implant Device,1122,34,,1122,percent of total billed charges,Implant Device,1122,34,,1122,percent of total billed charges,Implant Device,1633.5,,,1633.5,Other,110% of Medicare,1155,35,,1155,percent of total billed charges,Implant Device,1122,34,"Charges > $500, x 34%",1122,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,1320,40,,1320,percent of total billed charges,Implant Device,1155,70,,1155,percent of total billed charges,All Other,1122,34,,1122,percent of total billed charges,Implant Device,1122,34,,1122,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1122,34,"If Charge > 2,000, then 34 percent",1122,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2442.01,
BARD GMUTC005SS GELMARK ULTRACOR 14G RBN,A4648,HCPCS,,79006236,CDM,278,RC,,,both,,,327,241.98,,,241.98,Other,150% of Medicare + 9.63% HCRA Surcharge,147.15,45,,147.15,percent of total billed charges,Critical Access Hospital RCC factor,111.18,34,,111.18,percent of total billed charges,Implant Device,111.18,34,,111.18,percent of total billed charges,Implant Device,111.18,34,,111.18,percent of total billed charges,Implant Device,111.18,34,,111.18,percent of total billed charges,Implant Device,111.18,34,,111.18,percent of total billed charges,Implant Device,161.87,,,161.87,Other,110% of Medicare,114.45,35,,114.45,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,114.45,35,,114.45,percent of total billed charges,Implant Device,114.45,35,,114.45,percent of total billed charges,Implant Device,114.45,35,,114.45,percent of total billed charges,Implant Device,114.45,35,,114.45,percent of total billed charges,Implant Device,114.45,35,,114.45,percent of total billed charges,Implant Device,130.8,40,,130.8,percent of total billed charges,Implant Device,114.45,70,,114.45,percent of total billed charges,All Other,111.18,34,,111.18,percent of total billed charges,Implant Device,111.18,34,,111.18,percent of total billed charges,Implant Device,114.45,35,,114.45,percent of total billed charges,Implant Device,114.45,35,,114.45,percent of total billed charges,Implant Device,114.45,35,,114.45,percent of total billed charges,Implant Device,114.45,35,,114.45,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,241.98,
BARD GMUTC005T GELMARK ULTRACOR US 14G S,A4648,HCPCS,,79006237,CDM,278,RC,,,both,,,357,264.18,,,264.18,Other,150% of Medicare + 9.63% HCRA Surcharge,160.65,45,,160.65,percent of total billed charges,Critical Access Hospital RCC factor,121.38,34,,121.38,percent of total billed charges,Implant Device,121.38,34,,121.38,percent of total billed charges,Implant Device,121.38,34,,121.38,percent of total billed charges,Implant Device,121.38,34,,121.38,percent of total billed charges,Implant Device,121.38,34,,121.38,percent of total billed charges,Implant Device,176.72,,,176.72,Other,110% of Medicare,124.95,35,,124.95,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,124.95,35,,124.95,percent of total billed charges,Implant Device,124.95,35,,124.95,percent of total billed charges,Implant Device,124.95,35,,124.95,percent of total billed charges,Implant Device,124.95,35,,124.95,percent of total billed charges,Implant Device,124.95,35,,124.95,percent of total billed charges,Implant Device,142.8,40,,142.8,percent of total billed charges,Implant Device,124.95,70,,124.95,percent of total billed charges,All Other,121.38,34,,121.38,percent of total billed charges,Implant Device,121.38,34,,121.38,percent of total billed charges,Implant Device,124.95,35,,124.95,percent of total billed charges,Implant Device,124.95,35,,124.95,percent of total billed charges,Implant Device,124.95,35,,124.95,percent of total billed charges,Implant Device,124.95,35,,124.95,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,264.18,
STRYKER 3060-0105S LAG SCREW 10.5X105MM,C1713,HCPCS,,79006270,CDM,278,RC,,,both,,,1230,910.2,,,910.2,Other,150% of Medicare + 9.63% HCRA Surcharge,553.5,45,,553.5,percent of total billed charges,Critical Access Hospital RCC factor,418.2,34,,418.2,percent of total billed charges,Implant Device,418.2,34,,418.2,percent of total billed charges,Implant Device,418.2,34,,418.2,percent of total billed charges,Implant Device,418.2,34,,418.2,percent of total billed charges,Implant Device,418.2,34,,418.2,percent of total billed charges,Implant Device,608.85,,,608.85,Other,110% of Medicare,430.5,35,,430.5,percent of total billed charges,Implant Device,418.2,34,"Charges > $500, x 34%",418.2,percent of total billed charges,Implant Device,430.5,35,,430.5,percent of total billed charges,Implant Device,430.5,35,,430.5,percent of total billed charges,Implant Device,430.5,35,,430.5,percent of total billed charges,Implant Device,430.5,35,,430.5,percent of total billed charges,Implant Device,430.5,35,,430.5,percent of total billed charges,Implant Device,492,40,,492,percent of total billed charges,Implant Device,430.5,70,,430.5,percent of total billed charges,All Other,418.2,34,,418.2,percent of total billed charges,Implant Device,418.2,34,,418.2,percent of total billed charges,Implant Device,430.5,35,,430.5,percent of total billed charges,Implant Device,430.5,35,,430.5,percent of total billed charges,Implant Device,430.5,35,,430.5,percent of total billed charges,Implant Device,430.5,35,,430.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,910.2,
STRYKER 192-134-R POLARIS STENT 6X28CM,C1758,HCPCS,,79006273,CDM,278,RC,,,both,,,180,133.2,,,133.2,Other,150% of Medicare + 9.63% HCRA Surcharge,81,45,,81,percent of total billed charges,Critical Access Hospital RCC factor,61.2,34,,61.2,percent of total billed charges,Implant Device,61.2,34,,61.2,percent of total billed charges,Implant Device,61.2,34,,61.2,percent of total billed charges,Implant Device,61.2,34,,61.2,percent of total billed charges,Implant Device,61.2,34,,61.2,percent of total billed charges,Implant Device,89.1,,,89.1,Other,110% of Medicare,63,35,,63,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,63,35,,63,percent of total billed charges,Implant Device,63,35,,63,percent of total billed charges,Implant Device,63,35,,63,percent of total billed charges,Implant Device,63,35,,63,percent of total billed charges,Implant Device,63,35,,63,percent of total billed charges,Implant Device,72,40,,72,percent of total billed charges,Implant Device,63,70,,63,percent of total billed charges,All Other,61.2,34,,61.2,percent of total billed charges,Implant Device,61.2,34,,61.2,percent of total billed charges,Implant Device,63,35,,63,percent of total billed charges,Implant Device,63,35,,63,percent of total billed charges,Implant Device,63,35,,63,percent of total billed charges,Implant Device,63,35,,63,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,133.2,
STRYKER 192-151-R POLARIS STENT 8X22CM,C1758,HCPCS,,79006274,CDM,278,RC,,,both,,,180,133.2,,,133.2,Other,150% of Medicare + 9.63% HCRA Surcharge,81,45,,81,percent of total billed charges,Critical Access Hospital RCC factor,61.2,34,,61.2,percent of total billed charges,Implant Device,61.2,34,,61.2,percent of total billed charges,Implant Device,61.2,34,,61.2,percent of total billed charges,Implant Device,61.2,34,,61.2,percent of total billed charges,Implant Device,61.2,34,,61.2,percent of total billed charges,Implant Device,89.1,,,89.1,Other,110% of Medicare,63,35,,63,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,63,35,,63,percent of total billed charges,Implant Device,63,35,,63,percent of total billed charges,Implant Device,63,35,,63,percent of total billed charges,Implant Device,63,35,,63,percent of total billed charges,Implant Device,63,35,,63,percent of total billed charges,Implant Device,72,40,,72,percent of total billed charges,Implant Device,63,70,,63,percent of total billed charges,All Other,61.2,34,,61.2,percent of total billed charges,Implant Device,61.2,34,,61.2,percent of total billed charges,Implant Device,63,35,,63,percent of total billed charges,Implant Device,63,35,,63,percent of total billed charges,Implant Device,63,35,,63,percent of total billed charges,Implant Device,63,35,,63,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,133.2,
THERACOM ESS305 ESSURE BIRTH CNTRL IMPL,A4264,HCPCS,,79006278,CDM,278,RC,,,both,,,5550,4107.01,,,4107.01,Other,150% of Medicare + 9.63% HCRA Surcharge,2497.5,45,,2497.5,percent of total billed charges,Critical Access Hospital RCC factor,1887,34,,1887,percent of total billed charges,Implant Device,1887,34,,1887,percent of total billed charges,Implant Device,1887,34,,1887,percent of total billed charges,Implant Device,1887,34,,1887,percent of total billed charges,Implant Device,1887,34,,1887,percent of total billed charges,Implant Device,2747.25,,,2747.25,Other,110% of Medicare,1942.5,35,,1942.5,percent of total billed charges,Implant Device,1887,34,"Charges > $500, x 34%",1887,percent of total billed charges,Implant Device,1942.5,35,,1942.5,percent of total billed charges,Implant Device,1942.5,35,,1942.5,percent of total billed charges,Implant Device,1942.5,35,,1942.5,percent of total billed charges,Implant Device,1942.5,35,,1942.5,percent of total billed charges,Implant Device,1942.5,35,,1942.5,percent of total billed charges,Implant Device,2220,40,,2220,percent of total billed charges,Implant Device,1942.5,70,,1942.5,percent of total billed charges,All Other,1887,34,,1887,percent of total billed charges,Implant Device,1887,34,,1887,percent of total billed charges,Implant Device,1942.5,35,,1942.5,percent of total billed charges,Implant Device,1942.5,35,,1942.5,percent of total billed charges,Implant Device,1942.5,35,,1942.5,percent of total billed charges,Implant Device,1942.5,35,,1942.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1887,34,"If Charge > 2,000, then 34 percent",1887,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4107.01,
ZIMMER 5842-13-02 FEM COMP SZ C,C1776,HCPCS,,79006279,CDM,278,RC,,,both,,,10486,7759.67,,,7759.67,Other,150% of Medicare + 9.63% HCRA Surcharge,4718.7,45,,4718.7,percent of total billed charges,Critical Access Hospital RCC factor,3565.24,34,,3565.24,percent of total billed charges,Implant Device,3565.24,34,,3565.24,percent of total billed charges,Implant Device,3565.24,34,,3565.24,percent of total billed charges,Implant Device,3565.24,34,,3565.24,percent of total billed charges,Implant Device,3565.24,34,,3565.24,percent of total billed charges,Implant Device,5190.57,,,5190.57,Other,110% of Medicare,3670.1,35,,3670.1,percent of total billed charges,Implant Device,3565.24,34,"Charges > $500, x 34%",3565.24,percent of total billed charges,Implant Device,3670.1,35,,3670.1,percent of total billed charges,Implant Device,3670.1,35,,3670.1,percent of total billed charges,Implant Device,3670.1,35,,3670.1,percent of total billed charges,Implant Device,3670.1,35,,3670.1,percent of total billed charges,Implant Device,3670.1,35,,3670.1,percent of total billed charges,Implant Device,4194.4,40,,4194.4,percent of total billed charges,Implant Device,3670.1,70,,3670.1,percent of total billed charges,All Other,3565.24,34,,3565.24,percent of total billed charges,Implant Device,3565.24,34,,3565.24,percent of total billed charges,Implant Device,3670.1,35,,3670.1,percent of total billed charges,Implant Device,3670.1,35,,3670.1,percent of total billed charges,Implant Device,3670.1,35,,3670.1,percent of total billed charges,Implant Device,3670.1,35,,3670.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3565.24,34,"If Charge > 2,000, then 34 percent",3565.24,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,7759.67,
ZIMMER 5842-23-11 ART SURF SZ 3 11MM,C1776,HCPCS,,79006280,CDM,278,RC,,,both,,,2677,1980.99,,,1980.99,Other,150% of Medicare + 9.63% HCRA Surcharge,1204.65,45,,1204.65,percent of total billed charges,Critical Access Hospital RCC factor,910.18,34,,910.18,percent of total billed charges,Implant Device,910.18,34,,910.18,percent of total billed charges,Implant Device,910.18,34,,910.18,percent of total billed charges,Implant Device,910.18,34,,910.18,percent of total billed charges,Implant Device,910.18,34,,910.18,percent of total billed charges,Implant Device,1325.12,,,1325.12,Other,110% of Medicare,936.95,35,,936.95,percent of total billed charges,Implant Device,910.18,34,"Charges > $500, x 34%",910.18,percent of total billed charges,Implant Device,936.95,35,,936.95,percent of total billed charges,Implant Device,936.95,35,,936.95,percent of total billed charges,Implant Device,936.95,35,,936.95,percent of total billed charges,Implant Device,936.95,35,,936.95,percent of total billed charges,Implant Device,936.95,35,,936.95,percent of total billed charges,Implant Device,1070.8,40,,1070.8,percent of total billed charges,Implant Device,936.95,70,,936.95,percent of total billed charges,All Other,910.18,34,,910.18,percent of total billed charges,Implant Device,910.18,34,,910.18,percent of total billed charges,Implant Device,936.95,35,,936.95,percent of total billed charges,Implant Device,936.95,35,,936.95,percent of total billed charges,Implant Device,936.95,35,,936.95,percent of total billed charges,Implant Device,936.95,35,,936.95,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,910.18,34,"If Charge > 2,000, then 34 percent",910.18,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1980.99,
STRYKER 40-35055 NON LOCK SCREW 3.5X55MM,C1713,HCPCS,,79006290,CDM,278,RC,,,both,,,334,247.16,,,247.16,Other,150% of Medicare + 9.63% HCRA Surcharge,150.3,45,,150.3,percent of total billed charges,Critical Access Hospital RCC factor,113.56,34,,113.56,percent of total billed charges,Implant Device,113.56,34,,113.56,percent of total billed charges,Implant Device,113.56,34,,113.56,percent of total billed charges,Implant Device,113.56,34,,113.56,percent of total billed charges,Implant Device,113.56,34,,113.56,percent of total billed charges,Implant Device,165.33,,,165.33,Other,110% of Medicare,116.9,35,,116.9,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,116.9,35,,116.9,percent of total billed charges,Implant Device,116.9,35,,116.9,percent of total billed charges,Implant Device,116.9,35,,116.9,percent of total billed charges,Implant Device,116.9,35,,116.9,percent of total billed charges,Implant Device,116.9,35,,116.9,percent of total billed charges,Implant Device,133.6,40,,133.6,percent of total billed charges,Implant Device,116.9,70,,116.9,percent of total billed charges,All Other,113.56,34,,113.56,percent of total billed charges,Implant Device,113.56,34,,113.56,percent of total billed charges,Implant Device,116.9,35,,116.9,percent of total billed charges,Implant Device,116.9,35,,116.9,percent of total billed charges,Implant Device,116.9,35,,116.9,percent of total billed charges,Implant Device,116.9,35,,116.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,247.16,
STRYKER 53-27616E LOCKING SCREW 2.7X16MM,C1713,HCPCS,,79006293,CDM,278,RC,,,both,,,253,187.22,,,187.22,Other,150% of Medicare + 9.63% HCRA Surcharge,113.85,45,,113.85,percent of total billed charges,Critical Access Hospital RCC factor,86.02,34,,86.02,percent of total billed charges,Implant Device,86.02,34,,86.02,percent of total billed charges,Implant Device,86.02,34,,86.02,percent of total billed charges,Implant Device,86.02,34,,86.02,percent of total billed charges,Implant Device,86.02,34,,86.02,percent of total billed charges,Implant Device,125.24,,,125.24,Other,110% of Medicare,88.55,35,,88.55,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,88.55,35,,88.55,percent of total billed charges,Implant Device,88.55,35,,88.55,percent of total billed charges,Implant Device,88.55,35,,88.55,percent of total billed charges,Implant Device,88.55,35,,88.55,percent of total billed charges,Implant Device,88.55,35,,88.55,percent of total billed charges,Implant Device,101.2,40,,101.2,percent of total billed charges,Implant Device,88.55,70,,88.55,percent of total billed charges,All Other,86.02,34,,86.02,percent of total billed charges,Implant Device,86.02,34,,86.02,percent of total billed charges,Implant Device,88.55,35,,88.55,percent of total billed charges,Implant Device,88.55,35,,88.55,percent of total billed charges,Implant Device,88.55,35,,88.55,percent of total billed charges,Implant Device,88.55,35,,88.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,187.22,
BIOMET 41-2205 SCREW 2.0X5MM,C1713,HCPCS,,79006294,CDM,278,RC,,,both,,,328,242.72,,,242.72,Other,150% of Medicare + 9.63% HCRA Surcharge,147.6,45,,147.6,percent of total billed charges,Critical Access Hospital RCC factor,111.52,34,,111.52,percent of total billed charges,Implant Device,111.52,34,,111.52,percent of total billed charges,Implant Device,111.52,34,,111.52,percent of total billed charges,Implant Device,111.52,34,,111.52,percent of total billed charges,Implant Device,111.52,34,,111.52,percent of total billed charges,Implant Device,162.36,,,162.36,Other,110% of Medicare,114.8,35,,114.8,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,114.8,35,,114.8,percent of total billed charges,Implant Device,114.8,35,,114.8,percent of total billed charges,Implant Device,114.8,35,,114.8,percent of total billed charges,Implant Device,114.8,35,,114.8,percent of total billed charges,Implant Device,114.8,35,,114.8,percent of total billed charges,Implant Device,131.2,40,,131.2,percent of total billed charges,Implant Device,114.8,70,,114.8,percent of total billed charges,All Other,111.52,34,,111.52,percent of total billed charges,Implant Device,111.52,34,,111.52,percent of total billed charges,Implant Device,114.8,35,,114.8,percent of total billed charges,Implant Device,114.8,35,,114.8,percent of total billed charges,Implant Device,114.8,35,,114.8,percent of total billed charges,Implant Device,114.8,35,,114.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,242.72,
BIOMET 41-2106 SCREW 2.0X6MM,C1713,HCPCS,,79006296,CDM,278,RC,,,both,,,468,346.32,,,346.32,Other,150% of Medicare + 9.63% HCRA Surcharge,210.6,45,,210.6,percent of total billed charges,Critical Access Hospital RCC factor,159.12,34,,159.12,percent of total billed charges,Implant Device,159.12,34,,159.12,percent of total billed charges,Implant Device,159.12,34,,159.12,percent of total billed charges,Implant Device,159.12,34,,159.12,percent of total billed charges,Implant Device,159.12,34,,159.12,percent of total billed charges,Implant Device,231.66,,,231.66,Other,110% of Medicare,163.8,35,,163.8,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,163.8,35,,163.8,percent of total billed charges,Implant Device,163.8,35,,163.8,percent of total billed charges,Implant Device,163.8,35,,163.8,percent of total billed charges,Implant Device,163.8,35,,163.8,percent of total billed charges,Implant Device,163.8,35,,163.8,percent of total billed charges,Implant Device,187.2,40,,187.2,percent of total billed charges,Implant Device,163.8,70,,163.8,percent of total billed charges,All Other,159.12,34,,159.12,percent of total billed charges,Implant Device,159.12,34,,159.12,percent of total billed charges,Implant Device,163.8,35,,163.8,percent of total billed charges,Implant Device,163.8,35,,163.8,percent of total billed charges,Implant Device,163.8,35,,163.8,percent of total billed charges,Implant Device,163.8,35,,163.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,346.32,
NOVABONE NB0602 NOVABONE PUTTY 2.5CC,C1713,HCPCS,,79006298,CDM,278,RC,,,both,,,2550,1887.01,,,1887.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1147.5,45,,1147.5,percent of total billed charges,Critical Access Hospital RCC factor,867,34,,867,percent of total billed charges,Implant Device,867,34,,867,percent of total billed charges,Implant Device,867,34,,867,percent of total billed charges,Implant Device,867,34,,867,percent of total billed charges,Implant Device,867,34,,867,percent of total billed charges,Implant Device,1262.25,,,1262.25,Other,110% of Medicare,892.5,35,,892.5,percent of total billed charges,Implant Device,867,34,"Charges > $500, x 34%",867,percent of total billed charges,Implant Device,892.5,35,,892.5,percent of total billed charges,Implant Device,892.5,35,,892.5,percent of total billed charges,Implant Device,892.5,35,,892.5,percent of total billed charges,Implant Device,892.5,35,,892.5,percent of total billed charges,Implant Device,892.5,35,,892.5,percent of total billed charges,Implant Device,1020,40,,1020,percent of total billed charges,Implant Device,892.5,70,,892.5,percent of total billed charges,All Other,867,34,,867,percent of total billed charges,Implant Device,867,34,,867,percent of total billed charges,Implant Device,892.5,35,,892.5,percent of total billed charges,Implant Device,892.5,35,,892.5,percent of total billed charges,Implant Device,892.5,35,,892.5,percent of total billed charges,Implant Device,892.5,35,,892.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,867,34,"If Charge > 2,000, then 34 percent",867,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1887.01,
"LIFESPINE  20-1613-708 PROLINK 8MM 7""",C1713,HCPCS,,79006299,CDM,278,RC,,,both,,,17940,13275.64,,,13275.64,Other,150% of Medicare + 9.63% HCRA Surcharge,8073,45,,8073,percent of total billed charges,Critical Access Hospital RCC factor,6099.6,34,,6099.6,percent of total billed charges,Implant Device,6099.6,34,,6099.6,percent of total billed charges,Implant Device,6099.6,34,,6099.6,percent of total billed charges,Implant Device,6099.6,34,,6099.6,percent of total billed charges,Implant Device,6099.6,34,,6099.6,percent of total billed charges,Implant Device,8880.3,,,8880.3,Other,110% of Medicare,6279,35,,6279,percent of total billed charges,Implant Device,6099.6,34,"Charges > $500, x 34%",6099.6,percent of total billed charges,Implant Device,6279,35,,6279,percent of total billed charges,Implant Device,6279,35,,6279,percent of total billed charges,Implant Device,6279,35,,6279,percent of total billed charges,Implant Device,6279,35,,6279,percent of total billed charges,Implant Device,6279,35,,6279,percent of total billed charges,Implant Device,7176,40,,7176,percent of total billed charges,Implant Device,6279,70,,6279,percent of total billed charges,All Other,6099.6,34,,6099.6,percent of total billed charges,Implant Device,6099.6,34,,6099.6,percent of total billed charges,Implant Device,6279,35,,6279,percent of total billed charges,Implant Device,6279,35,,6279,percent of total billed charges,Implant Device,6279,35,,6279,percent of total billed charges,Implant Device,6279,35,,6279,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,6099.6,34,"If Charge > 2,000, then 34 percent",6099.6,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,13275.64,
LIFESPINE  129-010 ANGLE SCREW 3X10MM,C1713,HCPCS,,79006300,CDM,278,RC,,,both,,,1980,1465.2,,,1465.2,Other,150% of Medicare + 9.63% HCRA Surcharge,891,45,,891,percent of total billed charges,Critical Access Hospital RCC factor,673.2,34,,673.2,percent of total billed charges,Implant Device,673.2,34,,673.2,percent of total billed charges,Implant Device,673.2,34,,673.2,percent of total billed charges,Implant Device,673.2,34,,673.2,percent of total billed charges,Implant Device,673.2,34,,673.2,percent of total billed charges,Implant Device,980.1,,,980.1,Other,110% of Medicare,693,35,,693,percent of total billed charges,Implant Device,673.2,34,"Charges > $500, x 34%",673.2,percent of total billed charges,Implant Device,693,35,,693,percent of total billed charges,Implant Device,693,35,,693,percent of total billed charges,Implant Device,693,35,,693,percent of total billed charges,Implant Device,693,35,,693,percent of total billed charges,Implant Device,693,35,,693,percent of total billed charges,Implant Device,792,40,,792,percent of total billed charges,Implant Device,693,70,,693,percent of total billed charges,All Other,673.2,34,,673.2,percent of total billed charges,Implant Device,673.2,34,,673.2,percent of total billed charges,Implant Device,693,35,,693,percent of total billed charges,Implant Device,693,35,,693,percent of total billed charges,Implant Device,693,35,,693,percent of total billed charges,Implant Device,693,35,,693,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1465.2,
LIFESPINE  129-012 ANGLE SCREW 3X10MM,C1713,HCPCS,,79006301,CDM,278,RC,,,both,,,1980,1465.2,,,1465.2,Other,150% of Medicare + 9.63% HCRA Surcharge,891,45,,891,percent of total billed charges,Critical Access Hospital RCC factor,673.2,34,,673.2,percent of total billed charges,Implant Device,673.2,34,,673.2,percent of total billed charges,Implant Device,673.2,34,,673.2,percent of total billed charges,Implant Device,673.2,34,,673.2,percent of total billed charges,Implant Device,673.2,34,,673.2,percent of total billed charges,Implant Device,980.1,,,980.1,Other,110% of Medicare,693,35,,693,percent of total billed charges,Implant Device,673.2,34,"Charges > $500, x 34%",673.2,percent of total billed charges,Implant Device,693,35,,693,percent of total billed charges,Implant Device,693,35,,693,percent of total billed charges,Implant Device,693,35,,693,percent of total billed charges,Implant Device,693,35,,693,percent of total billed charges,Implant Device,693,35,,693,percent of total billed charges,Implant Device,792,40,,792,percent of total billed charges,Implant Device,693,70,,693,percent of total billed charges,All Other,673.2,34,,673.2,percent of total billed charges,Implant Device,673.2,34,,673.2,percent of total billed charges,Implant Device,693,35,,693,percent of total billed charges,Implant Device,693,35,,693,percent of total billed charges,Implant Device,693,35,,693,percent of total billed charges,Implant Device,693,35,,693,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1465.2,
LIFESPINE  129-002 LOCK PLATE,C1713,HCPCS,,79006302,CDM,278,RC,,,both,,,1992,1474.08,,,1474.08,Other,150% of Medicare + 9.63% HCRA Surcharge,896.4,45,,896.4,percent of total billed charges,Critical Access Hospital RCC factor,677.28,34,,677.28,percent of total billed charges,Implant Device,677.28,34,,677.28,percent of total billed charges,Implant Device,677.28,34,,677.28,percent of total billed charges,Implant Device,677.28,34,,677.28,percent of total billed charges,Implant Device,677.28,34,,677.28,percent of total billed charges,Implant Device,986.04,,,986.04,Other,110% of Medicare,697.2,35,,697.2,percent of total billed charges,Implant Device,677.28,34,"Charges > $500, x 34%",677.28,percent of total billed charges,Implant Device,697.2,35,,697.2,percent of total billed charges,Implant Device,697.2,35,,697.2,percent of total billed charges,Implant Device,697.2,35,,697.2,percent of total billed charges,Implant Device,697.2,35,,697.2,percent of total billed charges,Implant Device,697.2,35,,697.2,percent of total billed charges,Implant Device,796.8,40,,796.8,percent of total billed charges,Implant Device,697.2,70,,697.2,percent of total billed charges,All Other,677.28,34,,677.28,percent of total billed charges,Implant Device,677.28,34,,677.28,percent of total billed charges,Implant Device,697.2,35,,697.2,percent of total billed charges,Implant Device,697.2,35,,697.2,percent of total billed charges,Implant Device,697.2,35,,697.2,percent of total billed charges,Implant Device,697.2,35,,697.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1474.08,
BOST SCI 40430 WALL STENT 20MMX40MMX75CM,C1876,HCPCS,,79006303,CDM,278,RC,,,both,,,3548,2625.53,,,2625.53,Other,150% of Medicare + 9.63% HCRA Surcharge,1596.6,45,,1596.6,percent of total billed charges,Critical Access Hospital RCC factor,1206.32,34,,1206.32,percent of total billed charges,Implant Device,1206.32,34,,1206.32,percent of total billed charges,Implant Device,1206.32,34,,1206.32,percent of total billed charges,Implant Device,1206.32,34,,1206.32,percent of total billed charges,Implant Device,1206.32,34,,1206.32,percent of total billed charges,Implant Device,1756.26,,,1756.26,Other,110% of Medicare,1241.8,35,,1241.8,percent of total billed charges,Implant Device,1206.32,34,"Charges > $500, x 34%",1206.32,percent of total billed charges,Implant Device,1241.8,35,,1241.8,percent of total billed charges,Implant Device,1241.8,35,,1241.8,percent of total billed charges,Implant Device,1241.8,35,,1241.8,percent of total billed charges,Implant Device,1241.8,35,,1241.8,percent of total billed charges,Implant Device,1241.8,35,,1241.8,percent of total billed charges,Implant Device,1419.2,40,,1419.2,percent of total billed charges,Implant Device,1241.8,70,,1241.8,percent of total billed charges,All Other,1206.32,34,,1206.32,percent of total billed charges,Implant Device,1206.32,34,,1206.32,percent of total billed charges,Implant Device,1241.8,35,,1241.8,percent of total billed charges,Implant Device,1241.8,35,,1241.8,percent of total billed charges,Implant Device,1241.8,35,,1241.8,percent of total billed charges,Implant Device,1241.8,35,,1241.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1206.32,34,"If Charge > 2,000, then 34 percent",1206.32,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2625.53,
BIOMET 115378 HUMERAL TRAY 44MM,C1776,HCPCS,,79006304,CDM,278,RC,,,both,,,8670,6415.82,,,6415.82,Other,150% of Medicare + 9.63% HCRA Surcharge,3901.5,45,,3901.5,percent of total billed charges,Critical Access Hospital RCC factor,2947.8,34,,2947.8,percent of total billed charges,Implant Device,2947.8,34,,2947.8,percent of total billed charges,Implant Device,2947.8,34,,2947.8,percent of total billed charges,Implant Device,2947.8,34,,2947.8,percent of total billed charges,Implant Device,2947.8,34,,2947.8,percent of total billed charges,Implant Device,4291.65,,,4291.65,Other,110% of Medicare,3034.5,35,,3034.5,percent of total billed charges,Implant Device,2947.8,34,"Charges > $500, x 34%",2947.8,percent of total billed charges,Implant Device,3034.5,35,,3034.5,percent of total billed charges,Implant Device,3034.5,35,,3034.5,percent of total billed charges,Implant Device,3034.5,35,,3034.5,percent of total billed charges,Implant Device,3034.5,35,,3034.5,percent of total billed charges,Implant Device,3034.5,35,,3034.5,percent of total billed charges,Implant Device,3468,40,,3468,percent of total billed charges,Implant Device,3034.5,70,,3034.5,percent of total billed charges,All Other,2947.8,34,,2947.8,percent of total billed charges,Implant Device,2947.8,34,,2947.8,percent of total billed charges,Implant Device,3034.5,35,,3034.5,percent of total billed charges,Implant Device,3034.5,35,,3034.5,percent of total billed charges,Implant Device,3034.5,35,,3034.5,percent of total billed charges,Implant Device,3034.5,35,,3034.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2947.8,34,"If Charge > 2,000, then 34 percent",2947.8,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,6415.82,
BIOMET 115380 6.5MM CENTRAL SCREW 20MM,C1713,HCPCS,,79006305,CDM,278,RC,,,both,,,780,577.2,,,577.2,Other,150% of Medicare + 9.63% HCRA Surcharge,351,45,,351,percent of total billed charges,Critical Access Hospital RCC factor,265.2,34,,265.2,percent of total billed charges,Implant Device,265.2,34,,265.2,percent of total billed charges,Implant Device,265.2,34,,265.2,percent of total billed charges,Implant Device,265.2,34,,265.2,percent of total billed charges,Implant Device,265.2,34,,265.2,percent of total billed charges,Implant Device,386.1,,,386.1,Other,110% of Medicare,273,35,,273,percent of total billed charges,Implant Device,265.2,34,"Charges > $500, x 34%",265.2,percent of total billed charges,Implant Device,273,35,,273,percent of total billed charges,Implant Device,273,35,,273,percent of total billed charges,Implant Device,273,35,,273,percent of total billed charges,Implant Device,273,35,,273,percent of total billed charges,Implant Device,273,35,,273,percent of total billed charges,Implant Device,312,40,,312,percent of total billed charges,Implant Device,273,70,,273,percent of total billed charges,All Other,265.2,34,,265.2,percent of total billed charges,Implant Device,265.2,34,,265.2,percent of total billed charges,Implant Device,273,35,,273,percent of total billed charges,Implant Device,273,35,,273,percent of total billed charges,Implant Device,273,35,,273,percent of total billed charges,Implant Device,273,35,,273,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,577.2,
BIOMET 180550 LOCK SCREW 3.5HEX 4.76X15,C1713,HCPCS,,79006306,CDM,278,RC,,,both,,,810,599.4,,,599.4,Other,150% of Medicare + 9.63% HCRA Surcharge,364.5,45,,364.5,percent of total billed charges,Critical Access Hospital RCC factor,275.4,34,,275.4,percent of total billed charges,Implant Device,275.4,34,,275.4,percent of total billed charges,Implant Device,275.4,34,,275.4,percent of total billed charges,Implant Device,275.4,34,,275.4,percent of total billed charges,Implant Device,275.4,34,,275.4,percent of total billed charges,Implant Device,400.95,,,400.95,Other,110% of Medicare,283.5,35,,283.5,percent of total billed charges,Implant Device,275.4,34,"Charges > $500, x 34%",275.4,percent of total billed charges,Implant Device,283.5,35,,283.5,percent of total billed charges,Implant Device,283.5,35,,283.5,percent of total billed charges,Implant Device,283.5,35,,283.5,percent of total billed charges,Implant Device,283.5,35,,283.5,percent of total billed charges,Implant Device,283.5,35,,283.5,percent of total billed charges,Implant Device,324,40,,324,percent of total billed charges,Implant Device,283.5,70,,283.5,percent of total billed charges,All Other,275.4,34,,275.4,percent of total billed charges,Implant Device,275.4,34,,275.4,percent of total billed charges,Implant Device,283.5,35,,283.5,percent of total billed charges,Implant Device,283.5,35,,283.5,percent of total billed charges,Implant Device,283.5,35,,283.5,percent of total billed charges,Implant Device,283.5,35,,283.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,599.4,
BIOMET 115313 GLENOSPHERE 36MM DIA,C1776,HCPCS,,79006307,CDM,278,RC,,,both,,,7500,5550.02,,,5550.02,Other,150% of Medicare + 9.63% HCRA Surcharge,3375,45,,3375,percent of total billed charges,Critical Access Hospital RCC factor,2550,34,,2550,percent of total billed charges,Implant Device,2550,34,,2550,percent of total billed charges,Implant Device,2550,34,,2550,percent of total billed charges,Implant Device,2550,34,,2550,percent of total billed charges,Implant Device,2550,34,,2550,percent of total billed charges,Implant Device,3712.5,,,3712.5,Other,110% of Medicare,2625,35,,2625,percent of total billed charges,Implant Device,2550,34,"Charges > $500, x 34%",2550,percent of total billed charges,Implant Device,2625,35,,2625,percent of total billed charges,Implant Device,2625,35,,2625,percent of total billed charges,Implant Device,2625,35,,2625,percent of total billed charges,Implant Device,2625,35,,2625,percent of total billed charges,Implant Device,2625,35,,2625,percent of total billed charges,Implant Device,3000,40,,3000,percent of total billed charges,Implant Device,2625,70,,2625,percent of total billed charges,All Other,2550,34,,2550,percent of total billed charges,Implant Device,2550,34,,2550,percent of total billed charges,Implant Device,2625,35,,2625,percent of total billed charges,Implant Device,2625,35,,2625,percent of total billed charges,Implant Device,2625,35,,2625,percent of total billed charges,Implant Device,2625,35,,2625,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2550,34,"If Charge > 2,000, then 34 percent",2550,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5550.02,
BIOMET 180552 LOCK SCREW 3.5HEX 4.75X25,C1713,HCPCS,,79006308,CDM,278,RC,,,both,,,211,156.14,,,156.14,Other,150% of Medicare + 9.63% HCRA Surcharge,94.95,45,,94.95,percent of total billed charges,Critical Access Hospital RCC factor,71.74,34,,71.74,percent of total billed charges,Implant Device,71.74,34,,71.74,percent of total billed charges,Implant Device,71.74,34,,71.74,percent of total billed charges,Implant Device,71.74,34,,71.74,percent of total billed charges,Implant Device,71.74,34,,71.74,percent of total billed charges,Implant Device,104.45,,,104.45,Other,110% of Medicare,73.85,35,,73.85,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,73.85,35,,73.85,percent of total billed charges,Implant Device,73.85,35,,73.85,percent of total billed charges,Implant Device,73.85,35,,73.85,percent of total billed charges,Implant Device,73.85,35,,73.85,percent of total billed charges,Implant Device,73.85,35,,73.85,percent of total billed charges,Implant Device,84.4,40,,84.4,percent of total billed charges,Implant Device,73.85,70,,73.85,percent of total billed charges,All Other,71.74,34,,71.74,percent of total billed charges,Implant Device,71.74,34,,71.74,percent of total billed charges,Implant Device,73.85,35,,73.85,percent of total billed charges,Implant Device,73.85,35,,73.85,percent of total billed charges,Implant Device,73.85,35,,73.85,percent of total billed charges,Implant Device,73.85,35,,73.85,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,156.14,
BIOMET EP-115394 HUMERAL BEARING 44-36MM,C1776,HCPCS,,79006309,CDM,278,RC,,,both,,,7740,5727.62,,,5727.62,Other,150% of Medicare + 9.63% HCRA Surcharge,3483,45,,3483,percent of total billed charges,Critical Access Hospital RCC factor,2631.6,34,,2631.6,percent of total billed charges,Implant Device,2631.6,34,,2631.6,percent of total billed charges,Implant Device,2631.6,34,,2631.6,percent of total billed charges,Implant Device,2631.6,34,,2631.6,percent of total billed charges,Implant Device,2631.6,34,,2631.6,percent of total billed charges,Implant Device,3831.3,,,3831.3,Other,110% of Medicare,2709,35,,2709,percent of total billed charges,Implant Device,2631.6,34,"Charges > $500, x 34%",2631.6,percent of total billed charges,Implant Device,2709,35,,2709,percent of total billed charges,Implant Device,2709,35,,2709,percent of total billed charges,Implant Device,2709,35,,2709,percent of total billed charges,Implant Device,2709,35,,2709,percent of total billed charges,Implant Device,2709,35,,2709,percent of total billed charges,Implant Device,3096,40,,3096,percent of total billed charges,Implant Device,2709,70,,2709,percent of total billed charges,All Other,2631.6,34,,2631.6,percent of total billed charges,Implant Device,2631.6,34,,2631.6,percent of total billed charges,Implant Device,2709,35,,2709,percent of total billed charges,Implant Device,2709,35,,2709,percent of total billed charges,Implant Device,2709,35,,2709,percent of total billed charges,Implant Device,2709,35,,2709,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2631.6,34,"If Charge > 2,000, then 34 percent",2631.6,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5727.62,
BIOMET 180551 LOCK SCREW 3.5HEX 4.75X20,C1713,HCPCS,,79006310,CDM,278,RC,,,both,,,211,156.14,,,156.14,Other,150% of Medicare + 9.63% HCRA Surcharge,94.95,45,,94.95,percent of total billed charges,Critical Access Hospital RCC factor,71.74,34,,71.74,percent of total billed charges,Implant Device,71.74,34,,71.74,percent of total billed charges,Implant Device,71.74,34,,71.74,percent of total billed charges,Implant Device,71.74,34,,71.74,percent of total billed charges,Implant Device,71.74,34,,71.74,percent of total billed charges,Implant Device,104.45,,,104.45,Other,110% of Medicare,73.85,35,,73.85,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,73.85,35,,73.85,percent of total billed charges,Implant Device,73.85,35,,73.85,percent of total billed charges,Implant Device,73.85,35,,73.85,percent of total billed charges,Implant Device,73.85,35,,73.85,percent of total billed charges,Implant Device,73.85,35,,73.85,percent of total billed charges,Implant Device,84.4,40,,84.4,percent of total billed charges,Implant Device,73.85,70,,73.85,percent of total billed charges,All Other,71.74,34,,71.74,percent of total billed charges,Implant Device,71.74,34,,71.74,percent of total billed charges,Implant Device,73.85,35,,73.85,percent of total billed charges,Implant Device,73.85,35,,73.85,percent of total billed charges,Implant Device,73.85,35,,73.85,percent of total billed charges,Implant Device,73.85,35,,73.85,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,156.14,
ACUMED 70-0302 OLECRANON PLATE 3 HOLE LT,C1713,HCPCS,,79006311,CDM,278,RC,,,both,,,4575,3385.51,,,3385.51,Other,150% of Medicare + 9.63% HCRA Surcharge,2058.75,45,,2058.75,percent of total billed charges,Critical Access Hospital RCC factor,1555.5,34,,1555.5,percent of total billed charges,Implant Device,1555.5,34,,1555.5,percent of total billed charges,Implant Device,1555.5,34,,1555.5,percent of total billed charges,Implant Device,1555.5,34,,1555.5,percent of total billed charges,Implant Device,1555.5,34,,1555.5,percent of total billed charges,Implant Device,2264.63,,,2264.63,Other,110% of Medicare,1601.25,35,,1601.25,percent of total billed charges,Implant Device,1555.5,34,"Charges > $500, x 34%",1555.5,percent of total billed charges,Implant Device,1601.25,35,,1601.25,percent of total billed charges,Implant Device,1601.25,35,,1601.25,percent of total billed charges,Implant Device,1601.25,35,,1601.25,percent of total billed charges,Implant Device,1601.25,35,,1601.25,percent of total billed charges,Implant Device,1601.25,35,,1601.25,percent of total billed charges,Implant Device,1830,40,,1830,percent of total billed charges,Implant Device,1601.25,70,,1601.25,percent of total billed charges,All Other,1555.5,34,,1555.5,percent of total billed charges,Implant Device,1555.5,34,,1555.5,percent of total billed charges,Implant Device,1601.25,35,,1601.25,percent of total billed charges,Implant Device,1601.25,35,,1601.25,percent of total billed charges,Implant Device,1601.25,35,,1601.25,percent of total billed charges,Implant Device,1601.25,35,,1601.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1555.5,34,"If Charge > 2,000, then 34 percent",1555.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3385.51,
SYNTHES 201.818 CORTEX SCREW 2X18MM,C1713,HCPCS,,79006313,CDM,278,RC,,,both,,,78,57.72,,,57.72,Other,150% of Medicare + 9.63% HCRA Surcharge,35.1,45,,35.1,percent of total billed charges,Critical Access Hospital RCC factor,26.52,34,,26.52,percent of total billed charges,Implant Device,26.52,34,,26.52,percent of total billed charges,Implant Device,26.52,34,,26.52,percent of total billed charges,Implant Device,26.52,34,,26.52,percent of total billed charges,Implant Device,26.52,34,,26.52,percent of total billed charges,Implant Device,38.61,,,38.61,Other,110% of Medicare,27.3,35,,27.3,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,27.3,35,,27.3,percent of total billed charges,Implant Device,27.3,35,,27.3,percent of total billed charges,Implant Device,27.3,35,,27.3,percent of total billed charges,Implant Device,27.3,35,,27.3,percent of total billed charges,Implant Device,27.3,35,,27.3,percent of total billed charges,Implant Device,31.2,40,,31.2,percent of total billed charges,Implant Device,27.3,70,,27.3,percent of total billed charges,All Other,26.52,34,,26.52,percent of total billed charges,Implant Device,26.52,34,,26.52,percent of total billed charges,Implant Device,27.3,35,,27.3,percent of total billed charges,Implant Device,27.3,35,,27.3,percent of total billed charges,Implant Device,27.3,35,,27.3,percent of total billed charges,Implant Device,27.3,35,,27.3,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,57.72,
STRYKER 4933-1.003 LONG WIRE BOLT,C1713,HCPCS,,79006321,CDM,278,RC,,,both,,,345,255.3,,,255.3,Other,150% of Medicare + 9.63% HCRA Surcharge,155.25,45,,155.25,percent of total billed charges,Critical Access Hospital RCC factor,117.3,34,,117.3,percent of total billed charges,Implant Device,117.3,34,,117.3,percent of total billed charges,Implant Device,117.3,34,,117.3,percent of total billed charges,Implant Device,117.3,34,,117.3,percent of total billed charges,Implant Device,117.3,34,,117.3,percent of total billed charges,Implant Device,170.78,,,170.78,Other,110% of Medicare,120.75,35,,120.75,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,120.75,35,,120.75,percent of total billed charges,Implant Device,120.75,35,,120.75,percent of total billed charges,Implant Device,120.75,35,,120.75,percent of total billed charges,Implant Device,120.75,35,,120.75,percent of total billed charges,Implant Device,120.75,35,,120.75,percent of total billed charges,Implant Device,138,40,,138,percent of total billed charges,Implant Device,120.75,70,,120.75,percent of total billed charges,All Other,117.3,34,,117.3,percent of total billed charges,Implant Device,117.3,34,,117.3,percent of total billed charges,Implant Device,120.75,35,,120.75,percent of total billed charges,Implant Device,120.75,35,,120.75,percent of total billed charges,Implant Device,120.75,35,,120.75,percent of total billed charges,Implant Device,120.75,35,,120.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,255.3,
STRYKER 611065 8x65 CANNULATED SCREW,C1713,HCPCS,,79006331,CDM,278,RC,,,both,,,1020,754.8,,,754.8,Other,150% of Medicare + 9.63% HCRA Surcharge,459,45,,459,percent of total billed charges,Critical Access Hospital RCC factor,346.8,34,,346.8,percent of total billed charges,Implant Device,346.8,34,,346.8,percent of total billed charges,Implant Device,346.8,34,,346.8,percent of total billed charges,Implant Device,346.8,34,,346.8,percent of total billed charges,Implant Device,346.8,34,,346.8,percent of total billed charges,Implant Device,504.9,,,504.9,Other,110% of Medicare,357,35,,357,percent of total billed charges,Implant Device,346.8,34,"Charges > $500, x 34%",346.8,percent of total billed charges,Implant Device,357,35,,357,percent of total billed charges,Implant Device,357,35,,357,percent of total billed charges,Implant Device,357,35,,357,percent of total billed charges,Implant Device,357,35,,357,percent of total billed charges,Implant Device,357,35,,357,percent of total billed charges,Implant Device,408,40,,408,percent of total billed charges,Implant Device,357,70,,357,percent of total billed charges,All Other,346.8,34,,346.8,percent of total billed charges,Implant Device,346.8,34,,346.8,percent of total billed charges,Implant Device,357,35,,357,percent of total billed charges,Implant Device,357,35,,357,percent of total billed charges,Implant Device,357,35,,357,percent of total billed charges,Implant Device,357,35,,357,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,754.8,
STRYKER 611060 8X60 CANNULATED SCREW,C1713,HCPCS,,79006332,CDM,278,RC,,,both,,,1020,754.8,,,754.8,Other,150% of Medicare + 9.63% HCRA Surcharge,459,45,,459,percent of total billed charges,Critical Access Hospital RCC factor,346.8,34,,346.8,percent of total billed charges,Implant Device,346.8,34,,346.8,percent of total billed charges,Implant Device,346.8,34,,346.8,percent of total billed charges,Implant Device,346.8,34,,346.8,percent of total billed charges,Implant Device,346.8,34,,346.8,percent of total billed charges,Implant Device,504.9,,,504.9,Other,110% of Medicare,357,35,,357,percent of total billed charges,Implant Device,346.8,34,"Charges > $500, x 34%",346.8,percent of total billed charges,Implant Device,357,35,,357,percent of total billed charges,Implant Device,357,35,,357,percent of total billed charges,Implant Device,357,35,,357,percent of total billed charges,Implant Device,357,35,,357,percent of total billed charges,Implant Device,357,35,,357,percent of total billed charges,Implant Device,408,40,,408,percent of total billed charges,Implant Device,357,70,,357,percent of total billed charges,All Other,346.8,34,,346.8,percent of total billed charges,Implant Device,346.8,34,,346.8,percent of total billed charges,Implant Device,357,35,,357,percent of total billed charges,Implant Device,357,35,,357,percent of total billed charges,Implant Device,357,35,,357,percent of total billed charges,Implant Device,357,35,,357,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,754.8,
STRYKER EZ18-14-14 EASYCLIP EZ18-14-14,C1713,HCPCS,,79006333,CDM,278,RC,,,both,,,2567,1899.59,,,1899.59,Other,150% of Medicare + 9.63% HCRA Surcharge,1155.15,45,,1155.15,percent of total billed charges,Critical Access Hospital RCC factor,872.78,34,,872.78,percent of total billed charges,Implant Device,872.78,34,,872.78,percent of total billed charges,Implant Device,872.78,34,,872.78,percent of total billed charges,Implant Device,872.78,34,,872.78,percent of total billed charges,Implant Device,872.78,34,,872.78,percent of total billed charges,Implant Device,1270.67,,,1270.67,Other,110% of Medicare,898.45,35,,898.45,percent of total billed charges,Implant Device,872.78,34,"Charges > $500, x 34%",872.78,percent of total billed charges,Implant Device,898.45,35,,898.45,percent of total billed charges,Implant Device,898.45,35,,898.45,percent of total billed charges,Implant Device,898.45,35,,898.45,percent of total billed charges,Implant Device,898.45,35,,898.45,percent of total billed charges,Implant Device,898.45,35,,898.45,percent of total billed charges,Implant Device,1026.8,40,,1026.8,percent of total billed charges,Implant Device,898.45,70,,898.45,percent of total billed charges,All Other,872.78,34,,872.78,percent of total billed charges,Implant Device,872.78,34,,872.78,percent of total billed charges,Implant Device,898.45,35,,898.45,percent of total billed charges,Implant Device,898.45,35,,898.45,percent of total billed charges,Implant Device,898.45,35,,898.45,percent of total billed charges,Implant Device,898.45,35,,898.45,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,872.78,34,"If Charge > 2,000, then 34 percent",872.78,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1899.59,
S&N 121639 CANNULATED SCREW  6.5X95MM,C1713,HCPCS,,79006334,CDM,278,RC,,,both,,,974,720.76,,,720.76,Other,150% of Medicare + 9.63% HCRA Surcharge,438.3,45,,438.3,percent of total billed charges,Critical Access Hospital RCC factor,331.16,34,,331.16,percent of total billed charges,Implant Device,331.16,34,,331.16,percent of total billed charges,Implant Device,331.16,34,,331.16,percent of total billed charges,Implant Device,331.16,34,,331.16,percent of total billed charges,Implant Device,331.16,34,,331.16,percent of total billed charges,Implant Device,482.13,,,482.13,Other,110% of Medicare,340.9,35,,340.9,percent of total billed charges,Implant Device,331.16,34,"Charges > $500, x 34%",331.16,percent of total billed charges,Implant Device,340.9,35,,340.9,percent of total billed charges,Implant Device,340.9,35,,340.9,percent of total billed charges,Implant Device,340.9,35,,340.9,percent of total billed charges,Implant Device,340.9,35,,340.9,percent of total billed charges,Implant Device,340.9,35,,340.9,percent of total billed charges,Implant Device,389.6,40,,389.6,percent of total billed charges,Implant Device,340.9,70,,340.9,percent of total billed charges,All Other,331.16,34,,331.16,percent of total billed charges,Implant Device,331.16,34,,331.16,percent of total billed charges,Implant Device,340.9,35,,340.9,percent of total billed charges,Implant Device,340.9,35,,340.9,percent of total billed charges,Implant Device,340.9,35,,340.9,percent of total billed charges,Implant Device,340.9,35,,340.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,720.76,
BIOMET 41-2108 LOCKING SCREW 2.0X8MM,C1713,HCPCS,,79006335,CDM,278,RC,,,both,,,468,346.32,,,346.32,Other,150% of Medicare + 9.63% HCRA Surcharge,210.6,45,,210.6,percent of total billed charges,Critical Access Hospital RCC factor,159.12,34,,159.12,percent of total billed charges,Implant Device,159.12,34,,159.12,percent of total billed charges,Implant Device,159.12,34,,159.12,percent of total billed charges,Implant Device,159.12,34,,159.12,percent of total billed charges,Implant Device,159.12,34,,159.12,percent of total billed charges,Implant Device,231.66,,,231.66,Other,110% of Medicare,163.8,35,,163.8,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,163.8,35,,163.8,percent of total billed charges,Implant Device,163.8,35,,163.8,percent of total billed charges,Implant Device,163.8,35,,163.8,percent of total billed charges,Implant Device,163.8,35,,163.8,percent of total billed charges,Implant Device,163.8,35,,163.8,percent of total billed charges,Implant Device,187.2,40,,187.2,percent of total billed charges,Implant Device,163.8,70,,163.8,percent of total billed charges,All Other,159.12,34,,159.12,percent of total billed charges,Implant Device,159.12,34,,159.12,percent of total billed charges,Implant Device,163.8,35,,163.8,percent of total billed charges,Implant Device,163.8,35,,163.8,percent of total billed charges,Implant Device,163.8,35,,163.8,percent of total billed charges,Implant Device,163.8,35,,163.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,346.32,
BIOMET 41-2110 LOCKING SCREW 2.0X10MM,C1713,HCPCS,,79006336,CDM,278,RC,,,both,,,468,346.32,,,346.32,Other,150% of Medicare + 9.63% HCRA Surcharge,210.6,45,,210.6,percent of total billed charges,Critical Access Hospital RCC factor,159.12,34,,159.12,percent of total billed charges,Implant Device,159.12,34,,159.12,percent of total billed charges,Implant Device,159.12,34,,159.12,percent of total billed charges,Implant Device,159.12,34,,159.12,percent of total billed charges,Implant Device,159.12,34,,159.12,percent of total billed charges,Implant Device,231.66,,,231.66,Other,110% of Medicare,163.8,35,,163.8,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,163.8,35,,163.8,percent of total billed charges,Implant Device,163.8,35,,163.8,percent of total billed charges,Implant Device,163.8,35,,163.8,percent of total billed charges,Implant Device,163.8,35,,163.8,percent of total billed charges,Implant Device,163.8,35,,163.8,percent of total billed charges,Implant Device,187.2,40,,187.2,percent of total billed charges,Implant Device,163.8,70,,163.8,percent of total billed charges,All Other,159.12,34,,159.12,percent of total billed charges,Implant Device,159.12,34,,159.12,percent of total billed charges,Implant Device,163.8,35,,163.8,percent of total billed charges,Implant Device,163.8,35,,163.8,percent of total billed charges,Implant Device,163.8,35,,163.8,percent of total billed charges,Implant Device,163.8,35,,163.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,346.32,
BIOMET 41-2112 LOCKING SCREW 2.0X12MM,C1713,HCPCS,,79006337,CDM,278,RC,,,both,,,468,346.32,,,346.32,Other,150% of Medicare + 9.63% HCRA Surcharge,210.6,45,,210.6,percent of total billed charges,Critical Access Hospital RCC factor,159.12,34,,159.12,percent of total billed charges,Implant Device,159.12,34,,159.12,percent of total billed charges,Implant Device,159.12,34,,159.12,percent of total billed charges,Implant Device,159.12,34,,159.12,percent of total billed charges,Implant Device,159.12,34,,159.12,percent of total billed charges,Implant Device,231.66,,,231.66,Other,110% of Medicare,163.8,35,,163.8,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,163.8,35,,163.8,percent of total billed charges,Implant Device,163.8,35,,163.8,percent of total billed charges,Implant Device,163.8,35,,163.8,percent of total billed charges,Implant Device,163.8,35,,163.8,percent of total billed charges,Implant Device,163.8,35,,163.8,percent of total billed charges,Implant Device,187.2,40,,187.2,percent of total billed charges,Implant Device,163.8,70,,163.8,percent of total billed charges,All Other,159.12,34,,159.12,percent of total billed charges,Implant Device,159.12,34,,159.12,percent of total billed charges,Implant Device,163.8,35,,163.8,percent of total billed charges,Implant Device,163.8,35,,163.8,percent of total billed charges,Implant Device,163.8,35,,163.8,percent of total billed charges,Implant Device,163.8,35,,163.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,346.32,
ALPHATEC SPINE 62004-70 ROD 70MM,C1713,HCPCS,,79006339,CDM,278,RC,,,both,,,600,444,,,444,Other,150% of Medicare + 9.63% HCRA Surcharge,270,45,,270,percent of total billed charges,Critical Access Hospital RCC factor,204,34,,204,percent of total billed charges,Implant Device,204,34,,204,percent of total billed charges,Implant Device,204,34,,204,percent of total billed charges,Implant Device,204,34,,204,percent of total billed charges,Implant Device,204,34,,204,percent of total billed charges,Implant Device,297,,,297,Other,110% of Medicare,210,35,,210,percent of total billed charges,Implant Device,204,34,"Charges > $500, x 34%",204,percent of total billed charges,Implant Device,210,35,,210,percent of total billed charges,Implant Device,210,35,,210,percent of total billed charges,Implant Device,210,35,,210,percent of total billed charges,Implant Device,210,35,,210,percent of total billed charges,Implant Device,210,35,,210,percent of total billed charges,Implant Device,240,40,,240,percent of total billed charges,Implant Device,210,70,,210,percent of total billed charges,All Other,204,34,,204,percent of total billed charges,Implant Device,204,34,,204,percent of total billed charges,Implant Device,210,35,,210,percent of total billed charges,Implant Device,210,35,,210,percent of total billed charges,Implant Device,210,35,,210,percent of total billed charges,Implant Device,210,35,,210,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,444,
DEPUY HEMIARTHROPLASTY HIP FRACTURE STEM,C1776,HCPCS,,79006341,CDM,278,RC,,,both,,,6000,4440.02,,,4440.02,Other,150% of Medicare + 9.63% HCRA Surcharge,2700,45,,2700,percent of total billed charges,Critical Access Hospital RCC factor,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2970,,,2970,Other,110% of Medicare,2100,35,,2100,percent of total billed charges,Implant Device,2040,34,"Charges > $500, x 34%",2040,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2400,40,,2400,percent of total billed charges,Implant Device,2100,70,,2100,percent of total billed charges,All Other,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2040,34,"If Charge > 2,000, then 34 percent",2040,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4440.02,
SOLANA SFT-2015 SNAP OFF SCREW 2X15MM,C1713,HCPCS,,79006342,CDM,278,RC,,,both,,,1380,1021.2,,,1021.2,Other,150% of Medicare + 9.63% HCRA Surcharge,621,45,,621,percent of total billed charges,Critical Access Hospital RCC factor,469.2,34,,469.2,percent of total billed charges,Implant Device,469.2,34,,469.2,percent of total billed charges,Implant Device,469.2,34,,469.2,percent of total billed charges,Implant Device,469.2,34,,469.2,percent of total billed charges,Implant Device,469.2,34,,469.2,percent of total billed charges,Implant Device,683.1,,,683.1,Other,110% of Medicare,483,35,,483,percent of total billed charges,Implant Device,469.2,34,"Charges > $500, x 34%",469.2,percent of total billed charges,Implant Device,483,35,,483,percent of total billed charges,Implant Device,483,35,,483,percent of total billed charges,Implant Device,483,35,,483,percent of total billed charges,Implant Device,483,35,,483,percent of total billed charges,Implant Device,483,35,,483,percent of total billed charges,Implant Device,552,40,,552,percent of total billed charges,Implant Device,483,70,,483,percent of total billed charges,All Other,469.2,34,,469.2,percent of total billed charges,Implant Device,469.2,34,,469.2,percent of total billed charges,Implant Device,483,35,,483,percent of total billed charges,Implant Device,483,35,,483,percent of total billed charges,Implant Device,483,35,,483,percent of total billed charges,Implant Device,483,35,,483,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1021.2,
ALPHATEC 71003-54 PLATE 3 LEVEL 54MM,C1713,HCPCS,,79006343,CDM,278,RC,,,both,,,3136,2320.65,,,2320.65,Other,150% of Medicare + 9.63% HCRA Surcharge,1411.2,45,,1411.2,percent of total billed charges,Critical Access Hospital RCC factor,1066.24,34,,1066.24,percent of total billed charges,Implant Device,1066.24,34,,1066.24,percent of total billed charges,Implant Device,1066.24,34,,1066.24,percent of total billed charges,Implant Device,1066.24,34,,1066.24,percent of total billed charges,Implant Device,1066.24,34,,1066.24,percent of total billed charges,Implant Device,1552.32,,,1552.32,Other,110% of Medicare,1097.6,35,,1097.6,percent of total billed charges,Implant Device,1066.24,34,"Charges > $500, x 34%",1066.24,percent of total billed charges,Implant Device,1097.6,35,,1097.6,percent of total billed charges,Implant Device,1097.6,35,,1097.6,percent of total billed charges,Implant Device,1097.6,35,,1097.6,percent of total billed charges,Implant Device,1097.6,35,,1097.6,percent of total billed charges,Implant Device,1097.6,35,,1097.6,percent of total billed charges,Implant Device,1254.4,40,,1254.4,percent of total billed charges,Implant Device,1097.6,70,,1097.6,percent of total billed charges,All Other,1066.24,34,,1066.24,percent of total billed charges,Implant Device,1066.24,34,,1066.24,percent of total billed charges,Implant Device,1097.6,35,,1097.6,percent of total billed charges,Implant Device,1097.6,35,,1097.6,percent of total billed charges,Implant Device,1097.6,35,,1097.6,percent of total billed charges,Implant Device,1097.6,35,,1097.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1066.24,34,"If Charge > 2,000, then 34 percent",1066.24,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2320.65,
ARTHREX AR-9045-40PT SCREW 4.5X40MM,C1713,HCPCS,,79006344,CDM,278,RC,,,both,,,2386,1765.65,,,1765.65,Other,150% of Medicare + 9.63% HCRA Surcharge,1073.7,45,,1073.7,percent of total billed charges,Critical Access Hospital RCC factor,811.24,34,,811.24,percent of total billed charges,Implant Device,811.24,34,,811.24,percent of total billed charges,Implant Device,811.24,34,,811.24,percent of total billed charges,Implant Device,811.24,34,,811.24,percent of total billed charges,Implant Device,811.24,34,,811.24,percent of total billed charges,Implant Device,1181.07,,,1181.07,Other,110% of Medicare,835.1,35,,835.1,percent of total billed charges,Implant Device,811.24,34,"Charges > $500, x 34%",811.24,percent of total billed charges,Implant Device,835.1,35,,835.1,percent of total billed charges,Implant Device,835.1,35,,835.1,percent of total billed charges,Implant Device,835.1,35,,835.1,percent of total billed charges,Implant Device,835.1,35,,835.1,percent of total billed charges,Implant Device,835.1,35,,835.1,percent of total billed charges,Implant Device,954.4,40,,954.4,percent of total billed charges,Implant Device,835.1,70,,835.1,percent of total billed charges,All Other,811.24,34,,811.24,percent of total billed charges,Implant Device,811.24,34,,811.24,percent of total billed charges,Implant Device,835.1,35,,835.1,percent of total billed charges,Implant Device,835.1,35,,835.1,percent of total billed charges,Implant Device,835.1,35,,835.1,percent of total billed charges,Implant Device,835.1,35,,835.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,811.24,34,"If Charge > 2,000, then 34 percent",811.24,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1765.65,
ZIMMER 5001-50-00 BIPOLAR SHELL 50MM,C1776,HCPCS,,79006347,CDM,278,RC,,,both,,,2273,1682.03,,,1682.03,Other,150% of Medicare + 9.63% HCRA Surcharge,1022.85,45,,1022.85,percent of total billed charges,Critical Access Hospital RCC factor,772.82,34,,772.82,percent of total billed charges,Implant Device,772.82,34,,772.82,percent of total billed charges,Implant Device,772.82,34,,772.82,percent of total billed charges,Implant Device,772.82,34,,772.82,percent of total billed charges,Implant Device,772.82,34,,772.82,percent of total billed charges,Implant Device,1125.14,,,1125.14,Other,110% of Medicare,795.55,35,,795.55,percent of total billed charges,Implant Device,772.82,34,"Charges > $500, x 34%",772.82,percent of total billed charges,Implant Device,795.55,35,,795.55,percent of total billed charges,Implant Device,795.55,35,,795.55,percent of total billed charges,Implant Device,795.55,35,,795.55,percent of total billed charges,Implant Device,795.55,35,,795.55,percent of total billed charges,Implant Device,795.55,35,,795.55,percent of total billed charges,Implant Device,909.2,40,,909.2,percent of total billed charges,Implant Device,795.55,70,,795.55,percent of total billed charges,All Other,772.82,34,,772.82,percent of total billed charges,Implant Device,772.82,34,,772.82,percent of total billed charges,Implant Device,795.55,35,,795.55,percent of total billed charges,Implant Device,795.55,35,,795.55,percent of total billed charges,Implant Device,795.55,35,,795.55,percent of total billed charges,Implant Device,795.55,35,,795.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,772.82,34,"If Charge > 2,000, then 34 percent",772.82,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1682.03,
ZIMMER 5001-50-28 BIPLR LINR 50-52X28MM,C1776,HCPCS,,79006348,CDM,278,RC,,,both,,,1373,1016.02,,,1016.02,Other,150% of Medicare + 9.63% HCRA Surcharge,617.85,45,,617.85,percent of total billed charges,Critical Access Hospital RCC factor,466.82,34,,466.82,percent of total billed charges,Implant Device,466.82,34,,466.82,percent of total billed charges,Implant Device,466.82,34,,466.82,percent of total billed charges,Implant Device,466.82,34,,466.82,percent of total billed charges,Implant Device,466.82,34,,466.82,percent of total billed charges,Implant Device,679.64,,,679.64,Other,110% of Medicare,480.55,35,,480.55,percent of total billed charges,Implant Device,466.82,34,"Charges > $500, x 34%",466.82,percent of total billed charges,Implant Device,480.55,35,,480.55,percent of total billed charges,Implant Device,480.55,35,,480.55,percent of total billed charges,Implant Device,480.55,35,,480.55,percent of total billed charges,Implant Device,480.55,35,,480.55,percent of total billed charges,Implant Device,480.55,35,,480.55,percent of total billed charges,Implant Device,549.2,40,,549.2,percent of total billed charges,Implant Device,480.55,70,,480.55,percent of total billed charges,All Other,466.82,34,,466.82,percent of total billed charges,Implant Device,466.82,34,,466.82,percent of total billed charges,Implant Device,480.55,35,,480.55,percent of total billed charges,Implant Device,480.55,35,,480.55,percent of total billed charges,Implant Device,480.55,35,,480.55,percent of total billed charges,Implant Device,480.55,35,,480.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1016.02,
ZIMMER 7711-10-40 M/L TAPER 10 EXT NECK,C1776,HCPCS,,79006350,CDM,278,RC,,,both,,,6900,5106.02,,,5106.02,Other,150% of Medicare + 9.63% HCRA Surcharge,3105,45,,3105,percent of total billed charges,Critical Access Hospital RCC factor,2346,34,,2346,percent of total billed charges,Implant Device,2346,34,,2346,percent of total billed charges,Implant Device,2346,34,,2346,percent of total billed charges,Implant Device,2346,34,,2346,percent of total billed charges,Implant Device,2346,34,,2346,percent of total billed charges,Implant Device,3415.5,,,3415.5,Other,110% of Medicare,2415,35,,2415,percent of total billed charges,Implant Device,2346,34,"Charges > $500, x 34%",2346,percent of total billed charges,Implant Device,2415,35,,2415,percent of total billed charges,Implant Device,2415,35,,2415,percent of total billed charges,Implant Device,2415,35,,2415,percent of total billed charges,Implant Device,2415,35,,2415,percent of total billed charges,Implant Device,2415,35,,2415,percent of total billed charges,Implant Device,2760,40,,2760,percent of total billed charges,Implant Device,2415,70,,2415,percent of total billed charges,All Other,2346,34,,2346,percent of total billed charges,Implant Device,2346,34,,2346,percent of total billed charges,Implant Device,2415,35,,2415,percent of total billed charges,Implant Device,2415,35,,2415,percent of total billed charges,Implant Device,2415,35,,2415,percent of total billed charges,Implant Device,2415,35,,2415,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2346,34,"If Charge > 2,000, then 34 percent",2346,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5106.02,
ZIMMER 8775-28-01 BIOLOX FEM HD 28X-3.5,C1776,HCPCS,,79006351,CDM,278,RC,,,both,,,2880,2131.21,,,2131.21,Other,150% of Medicare + 9.63% HCRA Surcharge,1296,45,,1296,percent of total billed charges,Critical Access Hospital RCC factor,979.2,34,,979.2,percent of total billed charges,Implant Device,979.2,34,,979.2,percent of total billed charges,Implant Device,979.2,34,,979.2,percent of total billed charges,Implant Device,979.2,34,,979.2,percent of total billed charges,Implant Device,979.2,34,,979.2,percent of total billed charges,Implant Device,1425.6,,,1425.6,Other,110% of Medicare,1008,35,,1008,percent of total billed charges,Implant Device,979.2,34,"Charges > $500, x 34%",979.2,percent of total billed charges,Implant Device,1008,35,,1008,percent of total billed charges,Implant Device,1008,35,,1008,percent of total billed charges,Implant Device,1008,35,,1008,percent of total billed charges,Implant Device,1008,35,,1008,percent of total billed charges,Implant Device,1008,35,,1008,percent of total billed charges,Implant Device,1152,40,,1152,percent of total billed charges,Implant Device,1008,70,,1008,percent of total billed charges,All Other,979.2,34,,979.2,percent of total billed charges,Implant Device,979.2,34,,979.2,percent of total billed charges,Implant Device,1008,35,,1008,percent of total billed charges,Implant Device,1008,35,,1008,percent of total billed charges,Implant Device,1008,35,,1008,percent of total billed charges,Implant Device,1008,35,,1008,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,979.2,34,"If Charge > 2,000, then 34 percent",979.2,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2131.21,
BIOMET 1312-18-018 CORT SCREW 3.5X18MM,C1713,HCPCS,,79006352,CDM,278,RC,,,both,,,300,222,,,222,Other,150% of Medicare + 9.63% HCRA Surcharge,135,45,,135,percent of total billed charges,Critical Access Hospital RCC factor,102,34,,102,percent of total billed charges,Implant Device,102,34,,102,percent of total billed charges,Implant Device,102,34,,102,percent of total billed charges,Implant Device,102,34,,102,percent of total billed charges,Implant Device,102,34,,102,percent of total billed charges,Implant Device,148.5,,,148.5,Other,110% of Medicare,105,35,,105,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,105,35,,105,percent of total billed charges,Implant Device,105,35,,105,percent of total billed charges,Implant Device,105,35,,105,percent of total billed charges,Implant Device,105,35,,105,percent of total billed charges,Implant Device,105,35,,105,percent of total billed charges,Implant Device,120,40,,120,percent of total billed charges,Implant Device,105,70,,105,percent of total billed charges,All Other,102,34,,102,percent of total billed charges,Implant Device,102,34,,102,percent of total billed charges,Implant Device,105,35,,105,percent of total billed charges,Implant Device,105,35,,105,percent of total billed charges,Implant Device,105,35,,105,percent of total billed charges,Implant Device,105,35,,105,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,222,
BIOMET 1312-18-024 CORT SCREW 3.5X24MM,C1713,HCPCS,,79006353,CDM,278,RC,,,both,,,300,222,,,222,Other,150% of Medicare + 9.63% HCRA Surcharge,135,45,,135,percent of total billed charges,Critical Access Hospital RCC factor,102,34,,102,percent of total billed charges,Implant Device,102,34,,102,percent of total billed charges,Implant Device,102,34,,102,percent of total billed charges,Implant Device,102,34,,102,percent of total billed charges,Implant Device,102,34,,102,percent of total billed charges,Implant Device,148.5,,,148.5,Other,110% of Medicare,105,35,,105,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,105,35,,105,percent of total billed charges,Implant Device,105,35,,105,percent of total billed charges,Implant Device,105,35,,105,percent of total billed charges,Implant Device,105,35,,105,percent of total billed charges,Implant Device,105,35,,105,percent of total billed charges,Implant Device,120,40,,120,percent of total billed charges,Implant Device,105,70,,105,percent of total billed charges,All Other,102,34,,102,percent of total billed charges,Implant Device,102,34,,102,percent of total billed charges,Implant Device,105,35,,105,percent of total billed charges,Implant Device,105,35,,105,percent of total billed charges,Implant Device,105,35,,105,percent of total billed charges,Implant Device,105,35,,105,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,222,
BIOMET 1312-18-010 CORT SCREW 3.5X10MM,C1713,HCPCS,,79006354,CDM,278,RC,,,both,,,300,222,,,222,Other,150% of Medicare + 9.63% HCRA Surcharge,135,45,,135,percent of total billed charges,Critical Access Hospital RCC factor,102,34,,102,percent of total billed charges,Implant Device,102,34,,102,percent of total billed charges,Implant Device,102,34,,102,percent of total billed charges,Implant Device,102,34,,102,percent of total billed charges,Implant Device,102,34,,102,percent of total billed charges,Implant Device,148.5,,,148.5,Other,110% of Medicare,105,35,,105,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,105,35,,105,percent of total billed charges,Implant Device,105,35,,105,percent of total billed charges,Implant Device,105,35,,105,percent of total billed charges,Implant Device,105,35,,105,percent of total billed charges,Implant Device,105,35,,105,percent of total billed charges,Implant Device,120,40,,120,percent of total billed charges,Implant Device,105,70,,105,percent of total billed charges,All Other,102,34,,102,percent of total billed charges,Implant Device,102,34,,102,percent of total billed charges,Implant Device,105,35,,105,percent of total billed charges,Implant Device,105,35,,105,percent of total billed charges,Implant Device,105,35,,105,percent of total billed charges,Implant Device,105,35,,105,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,222,
BIOMET 1425-6 1.6MM WIRE,C1713,HCPCS,,79006355,CDM,278,RC,,,both,,,132,97.68,,,97.68,Other,150% of Medicare + 9.63% HCRA Surcharge,59.4,45,,59.4,percent of total billed charges,Critical Access Hospital RCC factor,44.88,34,,44.88,percent of total billed charges,Implant Device,44.88,34,,44.88,percent of total billed charges,Implant Device,44.88,34,,44.88,percent of total billed charges,Implant Device,44.88,34,,44.88,percent of total billed charges,Implant Device,44.88,34,,44.88,percent of total billed charges,Implant Device,65.34,,,65.34,Other,110% of Medicare,46.2,35,,46.2,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,46.2,35,,46.2,percent of total billed charges,Implant Device,46.2,35,,46.2,percent of total billed charges,Implant Device,46.2,35,,46.2,percent of total billed charges,Implant Device,46.2,35,,46.2,percent of total billed charges,Implant Device,46.2,35,,46.2,percent of total billed charges,Implant Device,52.8,40,,52.8,percent of total billed charges,Implant Device,46.2,70,,46.2,percent of total billed charges,All Other,44.88,34,,44.88,percent of total billed charges,Implant Device,44.88,34,,44.88,percent of total billed charges,Implant Device,46.2,35,,46.2,percent of total billed charges,Implant Device,46.2,35,,46.2,percent of total billed charges,Implant Device,46.2,35,,46.2,percent of total billed charges,Implant Device,46.2,35,,46.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,97.68,
BIOMET 8140-27-048 CANNULATED NL 4X48MM,C1713,HCPCS,,79006356,CDM,278,RC,,,both,,,240,177.6,,,177.6,Other,150% of Medicare + 9.63% HCRA Surcharge,108,45,,108,percent of total billed charges,Critical Access Hospital RCC factor,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,118.8,,,118.8,Other,110% of Medicare,84,35,,84,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,96,40,,96,percent of total billed charges,Implant Device,84,70,,84,percent of total billed charges,All Other,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,177.6,
BIOMET 8140-27-050 CANN SCREW 4X50MM,C1713,HCPCS,,79006357,CDM,278,RC,,,both,,,240,177.6,,,177.6,Other,150% of Medicare + 9.63% HCRA Surcharge,108,45,,108,percent of total billed charges,Critical Access Hospital RCC factor,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,118.8,,,118.8,Other,110% of Medicare,84,35,,84,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,96,40,,96,percent of total billed charges,Implant Device,84,70,,84,percent of total billed charges,All Other,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,177.6,
BIOMET 8150-37-044 CANN SCREW 3.5X44MM,C1713,HCPCS,,79006358,CDM,278,RC,,,both,,,240,177.6,,,177.6,Other,150% of Medicare + 9.63% HCRA Surcharge,108,45,,108,percent of total billed charges,Critical Access Hospital RCC factor,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,118.8,,,118.8,Other,110% of Medicare,84,35,,84,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,96,40,,96,percent of total billed charges,Implant Device,84,70,,84,percent of total billed charges,All Other,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,177.6,
BIOMET 8140-27-040 CANN SCREW 4X40MM,C1713,HCPCS,,79006359,CDM,278,RC,,,both,,,240,177.6,,,177.6,Other,150% of Medicare + 9.63% HCRA Surcharge,108,45,,108,percent of total billed charges,Critical Access Hospital RCC factor,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,118.8,,,118.8,Other,110% of Medicare,84,35,,84,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,96,40,,96,percent of total billed charges,Implant Device,84,70,,84,percent of total billed charges,All Other,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,177.6,
METASURG TC2514 CANN SCREW 2.5X14MM,C1713,HCPCS,,79006360,CDM,278,RC,,,both,,,586,433.64,,,433.64,Other,150% of Medicare + 9.63% HCRA Surcharge,263.7,45,,263.7,percent of total billed charges,Critical Access Hospital RCC factor,199.24,34,,199.24,percent of total billed charges,Implant Device,199.24,34,,199.24,percent of total billed charges,Implant Device,199.24,34,,199.24,percent of total billed charges,Implant Device,199.24,34,,199.24,percent of total billed charges,Implant Device,199.24,34,,199.24,percent of total billed charges,Implant Device,290.07,,,290.07,Other,110% of Medicare,205.1,35,,205.1,percent of total billed charges,Implant Device,199.24,34,"Charges > $500, x 34%",199.24,percent of total billed charges,Implant Device,205.1,35,,205.1,percent of total billed charges,Implant Device,205.1,35,,205.1,percent of total billed charges,Implant Device,205.1,35,,205.1,percent of total billed charges,Implant Device,205.1,35,,205.1,percent of total billed charges,Implant Device,205.1,35,,205.1,percent of total billed charges,Implant Device,234.4,40,,234.4,percent of total billed charges,Implant Device,205.1,70,,205.1,percent of total billed charges,All Other,199.24,34,,199.24,percent of total billed charges,Implant Device,199.24,34,,199.24,percent of total billed charges,Implant Device,205.1,35,,205.1,percent of total billed charges,Implant Device,205.1,35,,205.1,percent of total billed charges,Implant Device,205.1,35,,205.1,percent of total billed charges,Implant Device,205.1,35,,205.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,433.64,
METASURG TC2516 CANN SCREW 2.5X16MM,C1713,HCPCS,,79006361,CDM,278,RC,,,both,,,586,433.64,,,433.64,Other,150% of Medicare + 9.63% HCRA Surcharge,263.7,45,,263.7,percent of total billed charges,Critical Access Hospital RCC factor,199.24,34,,199.24,percent of total billed charges,Implant Device,199.24,34,,199.24,percent of total billed charges,Implant Device,199.24,34,,199.24,percent of total billed charges,Implant Device,199.24,34,,199.24,percent of total billed charges,Implant Device,199.24,34,,199.24,percent of total billed charges,Implant Device,290.07,,,290.07,Other,110% of Medicare,205.1,35,,205.1,percent of total billed charges,Implant Device,199.24,34,"Charges > $500, x 34%",199.24,percent of total billed charges,Implant Device,205.1,35,,205.1,percent of total billed charges,Implant Device,205.1,35,,205.1,percent of total billed charges,Implant Device,205.1,35,,205.1,percent of total billed charges,Implant Device,205.1,35,,205.1,percent of total billed charges,Implant Device,205.1,35,,205.1,percent of total billed charges,Implant Device,234.4,40,,234.4,percent of total billed charges,Implant Device,205.1,70,,205.1,percent of total billed charges,All Other,199.24,34,,199.24,percent of total billed charges,Implant Device,199.24,34,,199.24,percent of total billed charges,Implant Device,205.1,35,,205.1,percent of total billed charges,Implant Device,205.1,35,,205.1,percent of total billed charges,Implant Device,205.1,35,,205.1,percent of total billed charges,Implant Device,205.1,35,,205.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,433.64,
METASURG TH2514 HEADLESS SCREW 2.5X14MM,C1713,HCPCS,,79006363,CDM,278,RC,,,both,,,750,555,,,555,Other,150% of Medicare + 9.63% HCRA Surcharge,337.5,45,,337.5,percent of total billed charges,Critical Access Hospital RCC factor,255,34,,255,percent of total billed charges,Implant Device,255,34,,255,percent of total billed charges,Implant Device,255,34,,255,percent of total billed charges,Implant Device,255,34,,255,percent of total billed charges,Implant Device,255,34,,255,percent of total billed charges,Implant Device,371.25,,,371.25,Other,110% of Medicare,262.5,35,,262.5,percent of total billed charges,Implant Device,255,34,"Charges > $500, x 34%",255,percent of total billed charges,Implant Device,262.5,35,,262.5,percent of total billed charges,Implant Device,262.5,35,,262.5,percent of total billed charges,Implant Device,262.5,35,,262.5,percent of total billed charges,Implant Device,262.5,35,,262.5,percent of total billed charges,Implant Device,262.5,35,,262.5,percent of total billed charges,Implant Device,300,40,,300,percent of total billed charges,Implant Device,262.5,70,,262.5,percent of total billed charges,All Other,255,34,,255,percent of total billed charges,Implant Device,255,34,,255,percent of total billed charges,Implant Device,262.5,35,,262.5,percent of total billed charges,Implant Device,262.5,35,,262.5,percent of total billed charges,Implant Device,262.5,35,,262.5,percent of total billed charges,Implant Device,262.5,35,,262.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,555,
BME SE-1110 SPEED IMPLANT 11X10X10MM,C1713,HCPCS,,79006365,CDM,278,RC,,,both,,,3085,2282.91,,,2282.91,Other,150% of Medicare + 9.63% HCRA Surcharge,1388.25,45,,1388.25,percent of total billed charges,Critical Access Hospital RCC factor,1048.9,34,,1048.9,percent of total billed charges,Implant Device,1048.9,34,,1048.9,percent of total billed charges,Implant Device,1048.9,34,,1048.9,percent of total billed charges,Implant Device,1048.9,34,,1048.9,percent of total billed charges,Implant Device,1048.9,34,,1048.9,percent of total billed charges,Implant Device,1527.08,,,1527.08,Other,110% of Medicare,1079.75,35,,1079.75,percent of total billed charges,Implant Device,1048.9,34,"Charges > $500, x 34%",1048.9,percent of total billed charges,Implant Device,1079.75,35,,1079.75,percent of total billed charges,Implant Device,1079.75,35,,1079.75,percent of total billed charges,Implant Device,1079.75,35,,1079.75,percent of total billed charges,Implant Device,1079.75,35,,1079.75,percent of total billed charges,Implant Device,1079.75,35,,1079.75,percent of total billed charges,Implant Device,1234,40,,1234,percent of total billed charges,Implant Device,1079.75,70,,1079.75,percent of total billed charges,All Other,1048.9,34,,1048.9,percent of total billed charges,Implant Device,1048.9,34,,1048.9,percent of total billed charges,Implant Device,1079.75,35,,1079.75,percent of total billed charges,Implant Device,1079.75,35,,1079.75,percent of total billed charges,Implant Device,1079.75,35,,1079.75,percent of total billed charges,Implant Device,1079.75,35,,1079.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1048.9,34,"If Charge > 2,000, then 34 percent",1048.9,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2282.91,
BIOMET 8161-35-022 LOCKNG SCREW 3.5X22MM,C1713,HCPCS,,79006366,CDM,278,RC,,,both,,,780,577.2,,,577.2,Other,150% of Medicare + 9.63% HCRA Surcharge,351,45,,351,percent of total billed charges,Critical Access Hospital RCC factor,265.2,34,,265.2,percent of total billed charges,Implant Device,265.2,34,,265.2,percent of total billed charges,Implant Device,265.2,34,,265.2,percent of total billed charges,Implant Device,265.2,34,,265.2,percent of total billed charges,Implant Device,265.2,34,,265.2,percent of total billed charges,Implant Device,386.1,,,386.1,Other,110% of Medicare,273,35,,273,percent of total billed charges,Implant Device,265.2,34,"Charges > $500, x 34%",265.2,percent of total billed charges,Implant Device,273,35,,273,percent of total billed charges,Implant Device,273,35,,273,percent of total billed charges,Implant Device,273,35,,273,percent of total billed charges,Implant Device,273,35,,273,percent of total billed charges,Implant Device,273,35,,273,percent of total billed charges,Implant Device,312,40,,312,percent of total billed charges,Implant Device,273,70,,273,percent of total billed charges,All Other,265.2,34,,265.2,percent of total billed charges,Implant Device,265.2,34,,265.2,percent of total billed charges,Implant Device,273,35,,273,percent of total billed charges,Implant Device,273,35,,273,percent of total billed charges,Implant Device,273,35,,273,percent of total billed charges,Implant Device,273,35,,273,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,577.2,
ACUMED 70-0304 5 HOLE PLATE LEFT,C1713,HCPCS,,79006367,CDM,278,RC,,,both,,,3430,2538.21,,,2538.21,Other,150% of Medicare + 9.63% HCRA Surcharge,1543.5,45,,1543.5,percent of total billed charges,Critical Access Hospital RCC factor,1166.2,34,,1166.2,percent of total billed charges,Implant Device,1166.2,34,,1166.2,percent of total billed charges,Implant Device,1166.2,34,,1166.2,percent of total billed charges,Implant Device,1166.2,34,,1166.2,percent of total billed charges,Implant Device,1166.2,34,,1166.2,percent of total billed charges,Implant Device,1697.85,,,1697.85,Other,110% of Medicare,1200.5,35,,1200.5,percent of total billed charges,Implant Device,1166.2,34,"Charges > $500, x 34%",1166.2,percent of total billed charges,Implant Device,1200.5,35,,1200.5,percent of total billed charges,Implant Device,1200.5,35,,1200.5,percent of total billed charges,Implant Device,1200.5,35,,1200.5,percent of total billed charges,Implant Device,1200.5,35,,1200.5,percent of total billed charges,Implant Device,1200.5,35,,1200.5,percent of total billed charges,Implant Device,1372,40,,1372,percent of total billed charges,Implant Device,1200.5,70,,1200.5,percent of total billed charges,All Other,1166.2,34,,1166.2,percent of total billed charges,Implant Device,1166.2,34,,1166.2,percent of total billed charges,Implant Device,1200.5,35,,1200.5,percent of total billed charges,Implant Device,1200.5,35,,1200.5,percent of total billed charges,Implant Device,1200.5,35,,1200.5,percent of total billed charges,Implant Device,1200.5,35,,1200.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1166.2,34,"If Charge > 2,000, then 34 percent",1166.2,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2538.21,
ACUMED 30-0331 LOCKING SCREW 2.7X22MM,C1713,HCPCS,,79006368,CDM,278,RC,,,both,,,450,333,,,333,Other,150% of Medicare + 9.63% HCRA Surcharge,202.5,45,,202.5,percent of total billed charges,Critical Access Hospital RCC factor,153,34,,153,percent of total billed charges,Implant Device,153,34,,153,percent of total billed charges,Implant Device,153,34,,153,percent of total billed charges,Implant Device,153,34,,153,percent of total billed charges,Implant Device,153,34,,153,percent of total billed charges,Implant Device,222.75,,,222.75,Other,110% of Medicare,157.5,35,,157.5,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,157.5,35,,157.5,percent of total billed charges,Implant Device,157.5,35,,157.5,percent of total billed charges,Implant Device,157.5,35,,157.5,percent of total billed charges,Implant Device,157.5,35,,157.5,percent of total billed charges,Implant Device,157.5,35,,157.5,percent of total billed charges,Implant Device,180,40,,180,percent of total billed charges,Implant Device,157.5,70,,157.5,percent of total billed charges,All Other,153,34,,153,percent of total billed charges,Implant Device,153,34,,153,percent of total billed charges,Implant Device,157.5,35,,157.5,percent of total billed charges,Implant Device,157.5,35,,157.5,percent of total billed charges,Implant Device,157.5,35,,157.5,percent of total billed charges,Implant Device,157.5,35,,157.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,333,
ACUMED 30-0328 LOCKING SCREW 2.7X16MM,C1713,HCPCS,,79006369,CDM,278,RC,,,both,,,426,315.24,,,315.24,Other,150% of Medicare + 9.63% HCRA Surcharge,191.7,45,,191.7,percent of total billed charges,Critical Access Hospital RCC factor,144.84,34,,144.84,percent of total billed charges,Implant Device,144.84,34,,144.84,percent of total billed charges,Implant Device,144.84,34,,144.84,percent of total billed charges,Implant Device,144.84,34,,144.84,percent of total billed charges,Implant Device,144.84,34,,144.84,percent of total billed charges,Implant Device,210.87,,,210.87,Other,110% of Medicare,149.1,35,,149.1,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,149.1,35,,149.1,percent of total billed charges,Implant Device,149.1,35,,149.1,percent of total billed charges,Implant Device,149.1,35,,149.1,percent of total billed charges,Implant Device,149.1,35,,149.1,percent of total billed charges,Implant Device,149.1,35,,149.1,percent of total billed charges,Implant Device,170.4,40,,170.4,percent of total billed charges,Implant Device,149.1,70,,149.1,percent of total billed charges,All Other,144.84,34,,144.84,percent of total billed charges,Implant Device,144.84,34,,144.84,percent of total billed charges,Implant Device,149.1,35,,149.1,percent of total billed charges,Implant Device,149.1,35,,149.1,percent of total billed charges,Implant Device,149.1,35,,149.1,percent of total billed charges,Implant Device,149.1,35,,149.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,315.24,
ACUMED 30-0349 LOCKING SCREW 2.7X120MM,C1713,HCPCS,,79006370,CDM,278,RC,,,both,,,262,193.88,,,193.88,Other,150% of Medicare + 9.63% HCRA Surcharge,117.9,45,,117.9,percent of total billed charges,Critical Access Hospital RCC factor,89.08,34,,89.08,percent of total billed charges,Implant Device,89.08,34,,89.08,percent of total billed charges,Implant Device,89.08,34,,89.08,percent of total billed charges,Implant Device,89.08,34,,89.08,percent of total billed charges,Implant Device,89.08,34,,89.08,percent of total billed charges,Implant Device,129.69,,,129.69,Other,110% of Medicare,91.7,35,,91.7,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,91.7,35,,91.7,percent of total billed charges,Implant Device,91.7,35,,91.7,percent of total billed charges,Implant Device,91.7,35,,91.7,percent of total billed charges,Implant Device,91.7,35,,91.7,percent of total billed charges,Implant Device,91.7,35,,91.7,percent of total billed charges,Implant Device,104.8,40,,104.8,percent of total billed charges,Implant Device,91.7,70,,91.7,percent of total billed charges,All Other,89.08,34,,89.08,percent of total billed charges,Implant Device,89.08,34,,89.08,percent of total billed charges,Implant Device,91.7,35,,91.7,percent of total billed charges,Implant Device,91.7,35,,91.7,percent of total billed charges,Implant Device,91.7,35,,91.7,percent of total billed charges,Implant Device,91.7,35,,91.7,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,193.88,
ACUMED 30-0332 NONLOCKING SCREW 2.7X24MM,C1713,HCPCS,,79006372,CDM,278,RC,,,both,,,450,333,,,333,Other,150% of Medicare + 9.63% HCRA Surcharge,202.5,45,,202.5,percent of total billed charges,Critical Access Hospital RCC factor,153,34,,153,percent of total billed charges,Implant Device,153,34,,153,percent of total billed charges,Implant Device,153,34,,153,percent of total billed charges,Implant Device,153,34,,153,percent of total billed charges,Implant Device,153,34,,153,percent of total billed charges,Implant Device,222.75,,,222.75,Other,110% of Medicare,157.5,35,,157.5,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,157.5,35,,157.5,percent of total billed charges,Implant Device,157.5,35,,157.5,percent of total billed charges,Implant Device,157.5,35,,157.5,percent of total billed charges,Implant Device,157.5,35,,157.5,percent of total billed charges,Implant Device,157.5,35,,157.5,percent of total billed charges,Implant Device,180,40,,180,percent of total billed charges,Implant Device,157.5,70,,157.5,percent of total billed charges,All Other,153,34,,153,percent of total billed charges,Implant Device,153,34,,153,percent of total billed charges,Implant Device,157.5,35,,157.5,percent of total billed charges,Implant Device,157.5,35,,157.5,percent of total billed charges,Implant Device,157.5,35,,157.5,percent of total billed charges,Implant Device,157.5,35,,157.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,333,
ACUMED 30-0235 LOCKING SCREW 3.5X14MM,C1713,HCPCS,,79006373,CDM,278,RC,,,both,,,450,333,,,333,Other,150% of Medicare + 9.63% HCRA Surcharge,202.5,45,,202.5,percent of total billed charges,Critical Access Hospital RCC factor,153,34,,153,percent of total billed charges,Implant Device,153,34,,153,percent of total billed charges,Implant Device,153,34,,153,percent of total billed charges,Implant Device,153,34,,153,percent of total billed charges,Implant Device,153,34,,153,percent of total billed charges,Implant Device,222.75,,,222.75,Other,110% of Medicare,157.5,35,,157.5,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,157.5,35,,157.5,percent of total billed charges,Implant Device,157.5,35,,157.5,percent of total billed charges,Implant Device,157.5,35,,157.5,percent of total billed charges,Implant Device,157.5,35,,157.5,percent of total billed charges,Implant Device,157.5,35,,157.5,percent of total billed charges,Implant Device,180,40,,180,percent of total billed charges,Implant Device,157.5,70,,157.5,percent of total billed charges,All Other,153,34,,153,percent of total billed charges,Implant Device,153,34,,153,percent of total billed charges,Implant Device,157.5,35,,157.5,percent of total billed charges,Implant Device,157.5,35,,157.5,percent of total billed charges,Implant Device,157.5,35,,157.5,percent of total billed charges,Implant Device,157.5,35,,157.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,333,
SYNTHES 02.127.180 LOCKNG SCREW 3.5X80MM,C1713,HCPCS,,79006375,CDM,278,RC,,,both,,,414,306.36,,,306.36,Other,150% of Medicare + 9.63% HCRA Surcharge,186.3,45,,186.3,percent of total billed charges,Critical Access Hospital RCC factor,140.76,34,,140.76,percent of total billed charges,Implant Device,140.76,34,,140.76,percent of total billed charges,Implant Device,140.76,34,,140.76,percent of total billed charges,Implant Device,140.76,34,,140.76,percent of total billed charges,Implant Device,140.76,34,,140.76,percent of total billed charges,Implant Device,204.93,,,204.93,Other,110% of Medicare,144.9,35,,144.9,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,144.9,35,,144.9,percent of total billed charges,Implant Device,144.9,35,,144.9,percent of total billed charges,Implant Device,144.9,35,,144.9,percent of total billed charges,Implant Device,144.9,35,,144.9,percent of total billed charges,Implant Device,144.9,35,,144.9,percent of total billed charges,Implant Device,165.6,40,,165.6,percent of total billed charges,Implant Device,144.9,70,,144.9,percent of total billed charges,All Other,140.76,34,,140.76,percent of total billed charges,Implant Device,140.76,34,,140.76,percent of total billed charges,Implant Device,144.9,35,,144.9,percent of total billed charges,Implant Device,144.9,35,,144.9,percent of total billed charges,Implant Device,144.9,35,,144.9,percent of total billed charges,Implant Device,144.9,35,,144.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,306.36,
SYNTHES 02.127.185 LOCKNG SCREW 3.5X85MM,C1713,HCPCS,,79006376,CDM,278,RC,,,both,,,414,306.36,,,306.36,Other,150% of Medicare + 9.63% HCRA Surcharge,186.3,45,,186.3,percent of total billed charges,Critical Access Hospital RCC factor,140.76,34,,140.76,percent of total billed charges,Implant Device,140.76,34,,140.76,percent of total billed charges,Implant Device,140.76,34,,140.76,percent of total billed charges,Implant Device,140.76,34,,140.76,percent of total billed charges,Implant Device,140.76,34,,140.76,percent of total billed charges,Implant Device,204.93,,,204.93,Other,110% of Medicare,144.9,35,,144.9,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,144.9,35,,144.9,percent of total billed charges,Implant Device,144.9,35,,144.9,percent of total billed charges,Implant Device,144.9,35,,144.9,percent of total billed charges,Implant Device,144.9,35,,144.9,percent of total billed charges,Implant Device,144.9,35,,144.9,percent of total billed charges,Implant Device,165.6,40,,165.6,percent of total billed charges,Implant Device,144.9,70,,144.9,percent of total billed charges,All Other,140.76,34,,140.76,percent of total billed charges,Implant Device,140.76,34,,140.76,percent of total billed charges,Implant Device,144.9,35,,144.9,percent of total billed charges,Implant Device,144.9,35,,144.9,percent of total billed charges,Implant Device,144.9,35,,144.9,percent of total billed charges,Implant Device,144.9,35,,144.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,306.36,
SYNTHES 02.127.190 LOCKNG SCREW 3.5X90MM,C1713,HCPCS,,79006377,CDM,278,RC,,,both,,,604,446.96,,,446.96,Other,150% of Medicare + 9.63% HCRA Surcharge,271.8,45,,271.8,percent of total billed charges,Critical Access Hospital RCC factor,205.36,34,,205.36,percent of total billed charges,Implant Device,205.36,34,,205.36,percent of total billed charges,Implant Device,205.36,34,,205.36,percent of total billed charges,Implant Device,205.36,34,,205.36,percent of total billed charges,Implant Device,205.36,34,,205.36,percent of total billed charges,Implant Device,298.98,,,298.98,Other,110% of Medicare,211.4,35,,211.4,percent of total billed charges,Implant Device,205.36,34,"Charges > $500, x 34%",205.36,percent of total billed charges,Implant Device,211.4,35,,211.4,percent of total billed charges,Implant Device,211.4,35,,211.4,percent of total billed charges,Implant Device,211.4,35,,211.4,percent of total billed charges,Implant Device,211.4,35,,211.4,percent of total billed charges,Implant Device,211.4,35,,211.4,percent of total billed charges,Implant Device,241.6,40,,241.6,percent of total billed charges,Implant Device,211.4,70,,211.4,percent of total billed charges,All Other,205.36,34,,205.36,percent of total billed charges,Implant Device,205.36,34,,205.36,percent of total billed charges,Implant Device,211.4,35,,211.4,percent of total billed charges,Implant Device,211.4,35,,211.4,percent of total billed charges,Implant Device,211.4,35,,211.4,percent of total billed charges,Implant Device,211.4,35,,211.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,446.96,
SYNTHES 07.704-005S BONE VOID FILLER 5CC,C1713,HCPCS,,79006379,CDM,278,RC,,,both,,,3531,2612.95,,,2612.95,Other,150% of Medicare + 9.63% HCRA Surcharge,1588.95,45,,1588.95,percent of total billed charges,Critical Access Hospital RCC factor,1200.54,34,,1200.54,percent of total billed charges,Implant Device,1200.54,34,,1200.54,percent of total billed charges,Implant Device,1200.54,34,,1200.54,percent of total billed charges,Implant Device,1200.54,34,,1200.54,percent of total billed charges,Implant Device,1200.54,34,,1200.54,percent of total billed charges,Implant Device,1747.85,,,1747.85,Other,110% of Medicare,1235.85,35,,1235.85,percent of total billed charges,Implant Device,1200.54,34,"Charges > $500, x 34%",1200.54,percent of total billed charges,Implant Device,1235.85,35,,1235.85,percent of total billed charges,Implant Device,1235.85,35,,1235.85,percent of total billed charges,Implant Device,1235.85,35,,1235.85,percent of total billed charges,Implant Device,1235.85,35,,1235.85,percent of total billed charges,Implant Device,1235.85,35,,1235.85,percent of total billed charges,Implant Device,1412.4,40,,1412.4,percent of total billed charges,Implant Device,1235.85,70,,1235.85,percent of total billed charges,All Other,1200.54,34,,1200.54,percent of total billed charges,Implant Device,1200.54,34,,1200.54,percent of total billed charges,Implant Device,1235.85,35,,1235.85,percent of total billed charges,Implant Device,1235.85,35,,1235.85,percent of total billed charges,Implant Device,1235.85,35,,1235.85,percent of total billed charges,Implant Device,1235.85,35,,1235.85,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1200.54,34,"If Charge > 2,000, then 34 percent",1200.54,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2612.95,
DEPUY 207.738 CANNULATED SCREW 4X38MM,C1713,HCPCS,,79006388,CDM,278,RC,,,both,,,686,507.64,,,507.64,Other,150% of Medicare + 9.63% HCRA Surcharge,308.7,45,,308.7,percent of total billed charges,Critical Access Hospital RCC factor,233.24,34,,233.24,percent of total billed charges,Implant Device,233.24,34,,233.24,percent of total billed charges,Implant Device,233.24,34,,233.24,percent of total billed charges,Implant Device,233.24,34,,233.24,percent of total billed charges,Implant Device,233.24,34,,233.24,percent of total billed charges,Implant Device,339.57,,,339.57,Other,110% of Medicare,240.1,35,,240.1,percent of total billed charges,Implant Device,233.24,34,"Charges > $500, x 34%",233.24,percent of total billed charges,Implant Device,240.1,35,,240.1,percent of total billed charges,Implant Device,240.1,35,,240.1,percent of total billed charges,Implant Device,240.1,35,,240.1,percent of total billed charges,Implant Device,240.1,35,,240.1,percent of total billed charges,Implant Device,240.1,35,,240.1,percent of total billed charges,Implant Device,274.4,40,,274.4,percent of total billed charges,Implant Device,240.1,70,,240.1,percent of total billed charges,All Other,233.24,34,,233.24,percent of total billed charges,Implant Device,233.24,34,,233.24,percent of total billed charges,Implant Device,240.1,35,,240.1,percent of total billed charges,Implant Device,240.1,35,,240.1,percent of total billed charges,Implant Device,240.1,35,,240.1,percent of total billed charges,Implant Device,240.1,35,,240.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,507.64,
DEPUY 207.750 CANNULATED SCREW 4X50MM,C1713,HCPCS,,79006389,CDM,278,RC,,,both,,,686,507.64,,,507.64,Other,150% of Medicare + 9.63% HCRA Surcharge,308.7,45,,308.7,percent of total billed charges,Critical Access Hospital RCC factor,233.24,34,,233.24,percent of total billed charges,Implant Device,233.24,34,,233.24,percent of total billed charges,Implant Device,233.24,34,,233.24,percent of total billed charges,Implant Device,233.24,34,,233.24,percent of total billed charges,Implant Device,233.24,34,,233.24,percent of total billed charges,Implant Device,339.57,,,339.57,Other,110% of Medicare,240.1,35,,240.1,percent of total billed charges,Implant Device,233.24,34,"Charges > $500, x 34%",233.24,percent of total billed charges,Implant Device,240.1,35,,240.1,percent of total billed charges,Implant Device,240.1,35,,240.1,percent of total billed charges,Implant Device,240.1,35,,240.1,percent of total billed charges,Implant Device,240.1,35,,240.1,percent of total billed charges,Implant Device,240.1,35,,240.1,percent of total billed charges,Implant Device,274.4,40,,274.4,percent of total billed charges,Implant Device,240.1,70,,240.1,percent of total billed charges,All Other,233.24,34,,233.24,percent of total billed charges,Implant Device,233.24,34,,233.24,percent of total billed charges,Implant Device,240.1,35,,240.1,percent of total billed charges,Implant Device,240.1,35,,240.1,percent of total billed charges,Implant Device,240.1,35,,240.1,percent of total billed charges,Implant Device,240.1,35,,240.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,507.64,
BIOMET 8140-27-038 CANNULATED SCREW 4X38,C1713,HCPCS,,79006390,CDM,278,RC,,,both,,,240,177.6,,,177.6,Other,150% of Medicare + 9.63% HCRA Surcharge,108,45,,108,percent of total billed charges,Critical Access Hospital RCC factor,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,118.8,,,118.8,Other,110% of Medicare,84,35,,84,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,96,40,,96,percent of total billed charges,Implant Device,84,70,,84,percent of total billed charges,All Other,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,177.6,
SYNTHES 204.840 LOCKING SCREW 3.5X40MM,C1713,HCPCS,,79006391,CDM,278,RC,,,both,,,98,72.52,,,72.52,Other,150% of Medicare + 9.63% HCRA Surcharge,44.1,45,,44.1,percent of total billed charges,Critical Access Hospital RCC factor,33.32,34,,33.32,percent of total billed charges,Implant Device,33.32,34,,33.32,percent of total billed charges,Implant Device,33.32,34,,33.32,percent of total billed charges,Implant Device,33.32,34,,33.32,percent of total billed charges,Implant Device,33.32,34,,33.32,percent of total billed charges,Implant Device,48.51,,,48.51,Other,110% of Medicare,34.3,35,,34.3,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,34.3,35,,34.3,percent of total billed charges,Implant Device,34.3,35,,34.3,percent of total billed charges,Implant Device,34.3,35,,34.3,percent of total billed charges,Implant Device,34.3,35,,34.3,percent of total billed charges,Implant Device,34.3,35,,34.3,percent of total billed charges,Implant Device,39.2,40,,39.2,percent of total billed charges,Implant Device,34.3,70,,34.3,percent of total billed charges,All Other,33.32,34,,33.32,percent of total billed charges,Implant Device,33.32,34,,33.32,percent of total billed charges,Implant Device,34.3,35,,34.3,percent of total billed charges,Implant Device,34.3,35,,34.3,percent of total billed charges,Implant Device,34.3,35,,34.3,percent of total billed charges,Implant Device,34.3,35,,34.3,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,72.52,
SYNTHES 204.845 LOCKING SCREW 3.5X45MM,C1713,HCPCS,,79006392,CDM,278,RC,,,both,,,82,60.68,,,60.68,Other,150% of Medicare + 9.63% HCRA Surcharge,36.9,45,,36.9,percent of total billed charges,Critical Access Hospital RCC factor,27.88,34,,27.88,percent of total billed charges,Implant Device,27.88,34,,27.88,percent of total billed charges,Implant Device,27.88,34,,27.88,percent of total billed charges,Implant Device,27.88,34,,27.88,percent of total billed charges,Implant Device,27.88,34,,27.88,percent of total billed charges,Implant Device,40.59,,,40.59,Other,110% of Medicare,28.7,35,,28.7,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,28.7,35,,28.7,percent of total billed charges,Implant Device,28.7,35,,28.7,percent of total billed charges,Implant Device,28.7,35,,28.7,percent of total billed charges,Implant Device,28.7,35,,28.7,percent of total billed charges,Implant Device,28.7,35,,28.7,percent of total billed charges,Implant Device,32.8,40,,32.8,percent of total billed charges,Implant Device,28.7,70,,28.7,percent of total billed charges,All Other,27.88,34,,27.88,percent of total billed charges,Implant Device,27.88,34,,27.88,percent of total billed charges,Implant Device,28.7,35,,28.7,percent of total billed charges,Implant Device,28.7,35,,28.7,percent of total billed charges,Implant Device,28.7,35,,28.7,percent of total billed charges,Implant Device,28.7,35,,28.7,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,60.68,
GORE RMT281212 EXCLUDER GRAFT 28.5X12X18,C1874,HCPCS,,79006393,CDM,278,RC,,,both,,,31500,23310.08,,,23310.08,Other,150% of Medicare + 9.63% HCRA Surcharge,14175,45,,14175,percent of total billed charges,Critical Access Hospital RCC factor,10710,34,,10710,percent of total billed charges,Implant Device,10710,34,,10710,percent of total billed charges,Implant Device,10710,34,,10710,percent of total billed charges,Implant Device,10710,34,,10710,percent of total billed charges,Implant Device,10710,34,,10710,percent of total billed charges,Implant Device,15592.5,,,15592.5,Other,110% of Medicare,11025,35,,11025,percent of total billed charges,Implant Device,10710,34,"Charges > $500, x 34%",10710,percent of total billed charges,Implant Device,11025,35,,11025,percent of total billed charges,Implant Device,11025,35,,11025,percent of total billed charges,Implant Device,11025,35,,11025,percent of total billed charges,Implant Device,11025,35,,11025,percent of total billed charges,Implant Device,11025,35,,11025,percent of total billed charges,Implant Device,12600,40,,12600,percent of total billed charges,Implant Device,11025,70,,11025,percent of total billed charges,All Other,10710,34,,10710,percent of total billed charges,Implant Device,10710,34,,10710,percent of total billed charges,Implant Device,11025,35,,11025,percent of total billed charges,Implant Device,11025,35,,11025,percent of total billed charges,Implant Device,11025,35,,11025,percent of total billed charges,Implant Device,11025,35,,11025,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,10710,34,"If Charge > 2,000, then 34 percent",10710,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,23310.08,
PARAGON 28 P20-070-WD00 DOME WASHER 7MM,C1713,HCPCS,,79006394,CDM,278,RC,,,both,,,730,540.2,,,540.2,Other,150% of Medicare + 9.63% HCRA Surcharge,328.5,45,,328.5,percent of total billed charges,Critical Access Hospital RCC factor,248.2,34,,248.2,percent of total billed charges,Implant Device,248.2,34,,248.2,percent of total billed charges,Implant Device,248.2,34,,248.2,percent of total billed charges,Implant Device,248.2,34,,248.2,percent of total billed charges,Implant Device,248.2,34,,248.2,percent of total billed charges,Implant Device,361.35,,,361.35,Other,110% of Medicare,255.5,35,,255.5,percent of total billed charges,Implant Device,248.2,34,"Charges > $500, x 34%",248.2,percent of total billed charges,Implant Device,255.5,35,,255.5,percent of total billed charges,Implant Device,255.5,35,,255.5,percent of total billed charges,Implant Device,255.5,35,,255.5,percent of total billed charges,Implant Device,255.5,35,,255.5,percent of total billed charges,Implant Device,255.5,35,,255.5,percent of total billed charges,Implant Device,292,40,,292,percent of total billed charges,Implant Device,255.5,70,,255.5,percent of total billed charges,All Other,248.2,34,,248.2,percent of total billed charges,Implant Device,248.2,34,,248.2,percent of total billed charges,Implant Device,255.5,35,,255.5,percent of total billed charges,Implant Device,255.5,35,,255.5,percent of total billed charges,Implant Device,255.5,35,,255.5,percent of total billed charges,Implant Device,255.5,35,,255.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,540.2,
PARAGON 28 P20-170-078M CANN SCREW 7X7.8,C1713,HCPCS,,79006395,CDM,278,RC,,,both,,,1771,1310.54,,,1310.54,Other,150% of Medicare + 9.63% HCRA Surcharge,796.95,45,,796.95,percent of total billed charges,Critical Access Hospital RCC factor,602.14,34,,602.14,percent of total billed charges,Implant Device,602.14,34,,602.14,percent of total billed charges,Implant Device,602.14,34,,602.14,percent of total billed charges,Implant Device,602.14,34,,602.14,percent of total billed charges,Implant Device,602.14,34,,602.14,percent of total billed charges,Implant Device,876.65,,,876.65,Other,110% of Medicare,619.85,35,,619.85,percent of total billed charges,Implant Device,602.14,34,"Charges > $500, x 34%",602.14,percent of total billed charges,Implant Device,619.85,35,,619.85,percent of total billed charges,Implant Device,619.85,35,,619.85,percent of total billed charges,Implant Device,619.85,35,,619.85,percent of total billed charges,Implant Device,619.85,35,,619.85,percent of total billed charges,Implant Device,619.85,35,,619.85,percent of total billed charges,Implant Device,708.4,40,,708.4,percent of total billed charges,Implant Device,619.85,70,,619.85,percent of total billed charges,All Other,602.14,34,,602.14,percent of total billed charges,Implant Device,602.14,34,,602.14,percent of total billed charges,Implant Device,619.85,35,,619.85,percent of total billed charges,Implant Device,619.85,35,,619.85,percent of total billed charges,Implant Device,619.85,35,,619.85,percent of total billed charges,Implant Device,619.85,35,,619.85,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1310.54,
PARAGON 28 P20-170-082M CANN SCREW 7X82,C1713,HCPCS,,79006396,CDM,278,RC,,,both,,,1860,1376.4,,,1376.4,Other,150% of Medicare + 9.63% HCRA Surcharge,837,45,,837,percent of total billed charges,Critical Access Hospital RCC factor,632.4,34,,632.4,percent of total billed charges,Implant Device,632.4,34,,632.4,percent of total billed charges,Implant Device,632.4,34,,632.4,percent of total billed charges,Implant Device,632.4,34,,632.4,percent of total billed charges,Implant Device,632.4,34,,632.4,percent of total billed charges,Implant Device,920.7,,,920.7,Other,110% of Medicare,651,35,,651,percent of total billed charges,Implant Device,632.4,34,"Charges > $500, x 34%",632.4,percent of total billed charges,Implant Device,651,35,,651,percent of total billed charges,Implant Device,651,35,,651,percent of total billed charges,Implant Device,651,35,,651,percent of total billed charges,Implant Device,651,35,,651,percent of total billed charges,Implant Device,651,35,,651,percent of total billed charges,Implant Device,744,40,,744,percent of total billed charges,Implant Device,651,70,,651,percent of total billed charges,All Other,632.4,34,,632.4,percent of total billed charges,Implant Device,632.4,34,,632.4,percent of total billed charges,Implant Device,651,35,,651,percent of total billed charges,Implant Device,651,35,,651,percent of total billed charges,Implant Device,651,35,,651,percent of total billed charges,Implant Device,651,35,,651,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1376.4,
STRYKER 340634 CORTICAL SCREW 4.5X34MM,C1713,HCPCS,,79006398,CDM,278,RC,,,both,,,158,116.92,,,116.92,Other,150% of Medicare + 9.63% HCRA Surcharge,71.1,45,,71.1,percent of total billed charges,Critical Access Hospital RCC factor,53.72,34,,53.72,percent of total billed charges,Implant Device,53.72,34,,53.72,percent of total billed charges,Implant Device,53.72,34,,53.72,percent of total billed charges,Implant Device,53.72,34,,53.72,percent of total billed charges,Implant Device,53.72,34,,53.72,percent of total billed charges,Implant Device,78.21,,,78.21,Other,110% of Medicare,55.3,35,,55.3,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,55.3,35,,55.3,percent of total billed charges,Implant Device,55.3,35,,55.3,percent of total billed charges,Implant Device,55.3,35,,55.3,percent of total billed charges,Implant Device,55.3,35,,55.3,percent of total billed charges,Implant Device,55.3,35,,55.3,percent of total billed charges,Implant Device,63.2,40,,63.2,percent of total billed charges,Implant Device,55.3,70,,55.3,percent of total billed charges,All Other,53.72,34,,53.72,percent of total billed charges,Implant Device,53.72,34,,53.72,percent of total billed charges,Implant Device,55.3,35,,55.3,percent of total billed charges,Implant Device,55.3,35,,55.3,percent of total billed charges,Implant Device,55.3,35,,55.3,percent of total billed charges,Implant Device,55.3,35,,55.3,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,116.92,
STRYKER 340638 CORTICAL SCREW 4.5X38MM,C1713,HCPCS,,79006399,CDM,278,RC,,,both,,,158,116.92,,,116.92,Other,150% of Medicare + 9.63% HCRA Surcharge,71.1,45,,71.1,percent of total billed charges,Critical Access Hospital RCC factor,53.72,34,,53.72,percent of total billed charges,Implant Device,53.72,34,,53.72,percent of total billed charges,Implant Device,53.72,34,,53.72,percent of total billed charges,Implant Device,53.72,34,,53.72,percent of total billed charges,Implant Device,53.72,34,,53.72,percent of total billed charges,Implant Device,78.21,,,78.21,Other,110% of Medicare,55.3,35,,55.3,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,55.3,35,,55.3,percent of total billed charges,Implant Device,55.3,35,,55.3,percent of total billed charges,Implant Device,55.3,35,,55.3,percent of total billed charges,Implant Device,55.3,35,,55.3,percent of total billed charges,Implant Device,55.3,35,,55.3,percent of total billed charges,Implant Device,63.2,40,,63.2,percent of total billed charges,Implant Device,55.3,70,,55.3,percent of total billed charges,All Other,53.72,34,,53.72,percent of total billed charges,Implant Device,53.72,34,,53.72,percent of total billed charges,Implant Device,55.3,35,,55.3,percent of total billed charges,Implant Device,55.3,35,,55.3,percent of total billed charges,Implant Device,55.3,35,,55.3,percent of total billed charges,Implant Device,55.3,35,,55.3,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,116.92,
STRYKER 371375 LOCKING SCREW 5.0X75MM,C1713,HCPCS,,79006400,CDM,278,RC,,,both,,,576,426.24,,,426.24,Other,150% of Medicare + 9.63% HCRA Surcharge,259.2,45,,259.2,percent of total billed charges,Critical Access Hospital RCC factor,195.84,34,,195.84,percent of total billed charges,Implant Device,195.84,34,,195.84,percent of total billed charges,Implant Device,195.84,34,,195.84,percent of total billed charges,Implant Device,195.84,34,,195.84,percent of total billed charges,Implant Device,195.84,34,,195.84,percent of total billed charges,Implant Device,285.12,,,285.12,Other,110% of Medicare,201.6,35,,201.6,percent of total billed charges,Implant Device,195.84,34,"Charges > $500, x 34%",195.84,percent of total billed charges,Implant Device,201.6,35,,201.6,percent of total billed charges,Implant Device,201.6,35,,201.6,percent of total billed charges,Implant Device,201.6,35,,201.6,percent of total billed charges,Implant Device,201.6,35,,201.6,percent of total billed charges,Implant Device,201.6,35,,201.6,percent of total billed charges,Implant Device,230.4,40,,230.4,percent of total billed charges,Implant Device,201.6,70,,201.6,percent of total billed charges,All Other,195.84,34,,195.84,percent of total billed charges,Implant Device,195.84,34,,195.84,percent of total billed charges,Implant Device,201.6,35,,201.6,percent of total billed charges,Implant Device,201.6,35,,201.6,percent of total billed charges,Implant Device,201.6,35,,201.6,percent of total billed charges,Implant Device,201.6,35,,201.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,426.24,
STRYKER 371365 LOCKING SCREW 5.0X65MM,C1713,HCPCS,,79006401,CDM,278,RC,,,both,,,576,426.24,,,426.24,Other,150% of Medicare + 9.63% HCRA Surcharge,259.2,45,,259.2,percent of total billed charges,Critical Access Hospital RCC factor,195.84,34,,195.84,percent of total billed charges,Implant Device,195.84,34,,195.84,percent of total billed charges,Implant Device,195.84,34,,195.84,percent of total billed charges,Implant Device,195.84,34,,195.84,percent of total billed charges,Implant Device,195.84,34,,195.84,percent of total billed charges,Implant Device,285.12,,,285.12,Other,110% of Medicare,201.6,35,,201.6,percent of total billed charges,Implant Device,195.84,34,"Charges > $500, x 34%",195.84,percent of total billed charges,Implant Device,201.6,35,,201.6,percent of total billed charges,Implant Device,201.6,35,,201.6,percent of total billed charges,Implant Device,201.6,35,,201.6,percent of total billed charges,Implant Device,201.6,35,,201.6,percent of total billed charges,Implant Device,201.6,35,,201.6,percent of total billed charges,Implant Device,230.4,40,,230.4,percent of total billed charges,Implant Device,201.6,70,,201.6,percent of total billed charges,All Other,195.84,34,,195.84,percent of total billed charges,Implant Device,195.84,34,,195.84,percent of total billed charges,Implant Device,201.6,35,,201.6,percent of total billed charges,Implant Device,201.6,35,,201.6,percent of total billed charges,Implant Device,201.6,35,,201.6,percent of total billed charges,Implant Device,201.6,35,,201.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,426.24,
STRYKER 370116 LOCKING SCREW 5.0X16MM,C1713,HCPCS,,79006402,CDM,278,RC,,,both,,,737,545.38,,,545.38,Other,150% of Medicare + 9.63% HCRA Surcharge,331.65,45,,331.65,percent of total billed charges,Critical Access Hospital RCC factor,250.58,34,,250.58,percent of total billed charges,Implant Device,250.58,34,,250.58,percent of total billed charges,Implant Device,250.58,34,,250.58,percent of total billed charges,Implant Device,250.58,34,,250.58,percent of total billed charges,Implant Device,250.58,34,,250.58,percent of total billed charges,Implant Device,364.82,,,364.82,Other,110% of Medicare,257.95,35,,257.95,percent of total billed charges,Implant Device,250.58,34,"Charges > $500, x 34%",250.58,percent of total billed charges,Implant Device,257.95,35,,257.95,percent of total billed charges,Implant Device,257.95,35,,257.95,percent of total billed charges,Implant Device,257.95,35,,257.95,percent of total billed charges,Implant Device,257.95,35,,257.95,percent of total billed charges,Implant Device,257.95,35,,257.95,percent of total billed charges,Implant Device,294.8,40,,294.8,percent of total billed charges,Implant Device,257.95,70,,257.95,percent of total billed charges,All Other,250.58,34,,250.58,percent of total billed charges,Implant Device,250.58,34,,250.58,percent of total billed charges,Implant Device,257.95,35,,257.95,percent of total billed charges,Implant Device,257.95,35,,257.95,percent of total billed charges,Implant Device,257.95,35,,257.95,percent of total billed charges,Implant Device,257.95,35,,257.95,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,545.38,
STRYKER 342065 CANCELLOUS SCREW 6.5X65MM,C1713,HCPCS,,79006403,CDM,278,RC,,,both,,,140,103.6,,,103.6,Other,150% of Medicare + 9.63% HCRA Surcharge,63,45,,63,percent of total billed charges,Critical Access Hospital RCC factor,47.6,34,,47.6,percent of total billed charges,Implant Device,47.6,34,,47.6,percent of total billed charges,Implant Device,47.6,34,,47.6,percent of total billed charges,Implant Device,47.6,34,,47.6,percent of total billed charges,Implant Device,47.6,34,,47.6,percent of total billed charges,Implant Device,69.3,,,69.3,Other,110% of Medicare,49,35,,49,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,49,35,,49,percent of total billed charges,Implant Device,49,35,,49,percent of total billed charges,Implant Device,49,35,,49,percent of total billed charges,Implant Device,49,35,,49,percent of total billed charges,Implant Device,49,35,,49,percent of total billed charges,Implant Device,56,40,,56,percent of total billed charges,Implant Device,49,70,,49,percent of total billed charges,All Other,47.6,34,,47.6,percent of total billed charges,Implant Device,47.6,34,,47.6,percent of total billed charges,Implant Device,49,35,,49,percent of total billed charges,Implant Device,49,35,,49,percent of total billed charges,Implant Device,49,35,,49,percent of total billed charges,Implant Device,49,35,,49,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,103.6,
STRYKER 371324 LOCKING SCREW 5.0X24MM,C1713,HCPCS,,79006404,CDM,278,RC,,,both,,,576,426.24,,,426.24,Other,150% of Medicare + 9.63% HCRA Surcharge,259.2,45,,259.2,percent of total billed charges,Critical Access Hospital RCC factor,195.84,34,,195.84,percent of total billed charges,Implant Device,195.84,34,,195.84,percent of total billed charges,Implant Device,195.84,34,,195.84,percent of total billed charges,Implant Device,195.84,34,,195.84,percent of total billed charges,Implant Device,195.84,34,,195.84,percent of total billed charges,Implant Device,285.12,,,285.12,Other,110% of Medicare,201.6,35,,201.6,percent of total billed charges,Implant Device,195.84,34,"Charges > $500, x 34%",195.84,percent of total billed charges,Implant Device,201.6,35,,201.6,percent of total billed charges,Implant Device,201.6,35,,201.6,percent of total billed charges,Implant Device,201.6,35,,201.6,percent of total billed charges,Implant Device,201.6,35,,201.6,percent of total billed charges,Implant Device,201.6,35,,201.6,percent of total billed charges,Implant Device,230.4,40,,230.4,percent of total billed charges,Implant Device,201.6,70,,201.6,percent of total billed charges,All Other,195.84,34,,195.84,percent of total billed charges,Implant Device,195.84,34,,195.84,percent of total billed charges,Implant Device,201.6,35,,201.6,percent of total billed charges,Implant Device,201.6,35,,201.6,percent of total billed charges,Implant Device,201.6,35,,201.6,percent of total billed charges,Implant Device,201.6,35,,201.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,426.24,
STRYKER 437526 PLATE 6 HOLE RIGHT,C1713,HCPCS,,79006405,CDM,278,RC,,,both,,,6492,4804.1,,,4804.1,Other,150% of Medicare + 9.63% HCRA Surcharge,2921.4,45,,2921.4,percent of total billed charges,Critical Access Hospital RCC factor,2207.28,34,,2207.28,percent of total billed charges,Implant Device,2207.28,34,,2207.28,percent of total billed charges,Implant Device,2207.28,34,,2207.28,percent of total billed charges,Implant Device,2207.28,34,,2207.28,percent of total billed charges,Implant Device,2207.28,34,,2207.28,percent of total billed charges,Implant Device,3213.54,,,3213.54,Other,110% of Medicare,2272.2,35,,2272.2,percent of total billed charges,Implant Device,2207.28,34,"Charges > $500, x 34%",2207.28,percent of total billed charges,Implant Device,2272.2,35,,2272.2,percent of total billed charges,Implant Device,2272.2,35,,2272.2,percent of total billed charges,Implant Device,2272.2,35,,2272.2,percent of total billed charges,Implant Device,2272.2,35,,2272.2,percent of total billed charges,Implant Device,2272.2,35,,2272.2,percent of total billed charges,Implant Device,2596.8,40,,2596.8,percent of total billed charges,Implant Device,2272.2,70,,2272.2,percent of total billed charges,All Other,2207.28,34,,2207.28,percent of total billed charges,Implant Device,2207.28,34,,2207.28,percent of total billed charges,Implant Device,2272.2,35,,2272.2,percent of total billed charges,Implant Device,2272.2,35,,2272.2,percent of total billed charges,Implant Device,2272.2,35,,2272.2,percent of total billed charges,Implant Device,2272.2,35,,2272.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2207.28,34,"If Charge > 2,000, then 34 percent",2207.28,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4804.1,
BIOMET 113042 VERSDIAL SHOULDER 46X18MM,C1776,HCPCS,,79006406,CDM,278,RC,,,both,,,9120,6748.82,,,6748.82,Other,150% of Medicare + 9.63% HCRA Surcharge,4104,45,,4104,percent of total billed charges,Critical Access Hospital RCC factor,3100.8,34,,3100.8,percent of total billed charges,Implant Device,3100.8,34,,3100.8,percent of total billed charges,Implant Device,3100.8,34,,3100.8,percent of total billed charges,Implant Device,3100.8,34,,3100.8,percent of total billed charges,Implant Device,3100.8,34,,3100.8,percent of total billed charges,Implant Device,4514.4,,,4514.4,Other,110% of Medicare,3192,35,,3192,percent of total billed charges,Implant Device,3100.8,34,"Charges > $500, x 34%",3100.8,percent of total billed charges,Implant Device,3192,35,,3192,percent of total billed charges,Implant Device,3192,35,,3192,percent of total billed charges,Implant Device,3192,35,,3192,percent of total billed charges,Implant Device,3192,35,,3192,percent of total billed charges,Implant Device,3192,35,,3192,percent of total billed charges,Implant Device,3648,40,,3648,percent of total billed charges,Implant Device,3192,70,,3192,percent of total billed charges,All Other,3100.8,34,,3100.8,percent of total billed charges,Implant Device,3100.8,34,,3100.8,percent of total billed charges,Implant Device,3192,35,,3192,percent of total billed charges,Implant Device,3192,35,,3192,percent of total billed charges,Implant Device,3192,35,,3192,percent of total billed charges,Implant Device,3192,35,,3192,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3100.8,34,"If Charge > 2,000, then 34 percent",3100.8,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,6748.82,
BARD DL900F DENALI VENA CAVA FILTER 55CM,C1880,HCPCS,,79006407,CDM,278,RC,,,both,,,3000,2220.01,,,2220.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1350,45,,1350,percent of total billed charges,Critical Access Hospital RCC factor,1020,34,,1020,percent of total billed charges,Implant Device,1020,34,,1020,percent of total billed charges,Implant Device,1020,34,,1020,percent of total billed charges,Implant Device,1020,34,,1020,percent of total billed charges,Implant Device,1020,34,,1020,percent of total billed charges,Implant Device,1485,,,1485,Other,110% of Medicare,1050,35,,1050,percent of total billed charges,Implant Device,1020,34,"Charges > $500, x 34%",1020,percent of total billed charges,Implant Device,1050,35,,1050,percent of total billed charges,Implant Device,1050,35,,1050,percent of total billed charges,Implant Device,1050,35,,1050,percent of total billed charges,Implant Device,1050,35,,1050,percent of total billed charges,Implant Device,1050,35,,1050,percent of total billed charges,Implant Device,1200,40,,1200,percent of total billed charges,Implant Device,1050,70,,1050,percent of total billed charges,All Other,1020,34,,1020,percent of total billed charges,Implant Device,1020,34,,1020,percent of total billed charges,Implant Device,1050,35,,1050,percent of total billed charges,Implant Device,1050,35,,1050,percent of total billed charges,Implant Device,1050,35,,1050,percent of total billed charges,Implant Device,1050,35,,1050,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1020,34,"If Charge > 2,000, then 34 percent",1020,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2220.01,
ZIMMER 00-8775-032-02 FEM HEAD 32M 12/14,C1776,HCPCS,,79006410,CDM,278,RC,,,both,,,2880,2131.21,,,2131.21,Other,150% of Medicare + 9.63% HCRA Surcharge,1296,45,,1296,percent of total billed charges,Critical Access Hospital RCC factor,979.2,34,,979.2,percent of total billed charges,Implant Device,979.2,34,,979.2,percent of total billed charges,Implant Device,979.2,34,,979.2,percent of total billed charges,Implant Device,979.2,34,,979.2,percent of total billed charges,Implant Device,979.2,34,,979.2,percent of total billed charges,Implant Device,1425.6,,,1425.6,Other,110% of Medicare,1008,35,,1008,percent of total billed charges,Implant Device,979.2,34,"Charges > $500, x 34%",979.2,percent of total billed charges,Implant Device,1008,35,,1008,percent of total billed charges,Implant Device,1008,35,,1008,percent of total billed charges,Implant Device,1008,35,,1008,percent of total billed charges,Implant Device,1008,35,,1008,percent of total billed charges,Implant Device,1008,35,,1008,percent of total billed charges,Implant Device,1152,40,,1152,percent of total billed charges,Implant Device,1008,70,,1008,percent of total billed charges,All Other,979.2,34,,979.2,percent of total billed charges,Implant Device,979.2,34,,979.2,percent of total billed charges,Implant Device,1008,35,,1008,percent of total billed charges,Implant Device,1008,35,,1008,percent of total billed charges,Implant Device,1008,35,,1008,percent of total billed charges,Implant Device,1008,35,,1008,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,979.2,34,"If Charge > 2,000, then 34 percent",979.2,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2131.21,
ACUMED CO-N2316 NON LOCK SCREW 2.3X16MM,C1713,HCPCS,,79006412,CDM,278,RC,,,both,,,316,233.84,,,233.84,Other,150% of Medicare + 9.63% HCRA Surcharge,142.2,45,,142.2,percent of total billed charges,Critical Access Hospital RCC factor,107.44,34,,107.44,percent of total billed charges,Implant Device,107.44,34,,107.44,percent of total billed charges,Implant Device,107.44,34,,107.44,percent of total billed charges,Implant Device,107.44,34,,107.44,percent of total billed charges,Implant Device,107.44,34,,107.44,percent of total billed charges,Implant Device,156.42,,,156.42,Other,110% of Medicare,110.6,35,,110.6,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,110.6,35,,110.6,percent of total billed charges,Implant Device,110.6,35,,110.6,percent of total billed charges,Implant Device,110.6,35,,110.6,percent of total billed charges,Implant Device,110.6,35,,110.6,percent of total billed charges,Implant Device,110.6,35,,110.6,percent of total billed charges,Implant Device,126.4,40,,126.4,percent of total billed charges,Implant Device,110.6,70,,110.6,percent of total billed charges,All Other,107.44,34,,107.44,percent of total billed charges,Implant Device,107.44,34,,107.44,percent of total billed charges,Implant Device,110.6,35,,110.6,percent of total billed charges,Implant Device,110.6,35,,110.6,percent of total billed charges,Implant Device,110.6,35,,110.6,percent of total billed charges,Implant Device,110.6,35,,110.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,233.84,
ALAMO AT4F7FF FEM HEAD ALLOGRAFT FORZ,C1713,HCPCS,,79006415,CDM,278,RC,,,both,,,3000,2220.01,,,2220.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1350,45,,1350,percent of total billed charges,Critical Access Hospital RCC factor,1020,34,,1020,percent of total billed charges,Implant Device,1020,34,,1020,percent of total billed charges,Implant Device,1020,34,,1020,percent of total billed charges,Implant Device,1020,34,,1020,percent of total billed charges,Implant Device,1020,34,,1020,percent of total billed charges,Implant Device,1485,,,1485,Other,110% of Medicare,1050,35,,1050,percent of total billed charges,Implant Device,1020,34,"Charges > $500, x 34%",1020,percent of total billed charges,Implant Device,1050,35,,1050,percent of total billed charges,Implant Device,1050,35,,1050,percent of total billed charges,Implant Device,1050,35,,1050,percent of total billed charges,Implant Device,1050,35,,1050,percent of total billed charges,Implant Device,1050,35,,1050,percent of total billed charges,Implant Device,1200,40,,1200,percent of total billed charges,Implant Device,1050,70,,1050,percent of total billed charges,All Other,1020,34,,1020,percent of total billed charges,Implant Device,1020,34,,1020,percent of total billed charges,Implant Device,1050,35,,1050,percent of total billed charges,Implant Device,1050,35,,1050,percent of total billed charges,Implant Device,1050,35,,1050,percent of total billed charges,Implant Device,1050,35,,1050,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1020,34,"If Charge > 2,000, then 34 percent",1020,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2220.01,
BIOMET 28240 TROCH NAIL LONG 11MM LEFT,C1713,HCPCS,,79006416,CDM,278,RC,,,both,,,11040,8169.63,,,8169.63,Other,150% of Medicare + 9.63% HCRA Surcharge,4968,45,,4968,percent of total billed charges,Critical Access Hospital RCC factor,3753.6,34,,3753.6,percent of total billed charges,Implant Device,3753.6,34,,3753.6,percent of total billed charges,Implant Device,3753.6,34,,3753.6,percent of total billed charges,Implant Device,3753.6,34,,3753.6,percent of total billed charges,Implant Device,3753.6,34,,3753.6,percent of total billed charges,Implant Device,5464.8,,,5464.8,Other,110% of Medicare,3864,35,,3864,percent of total billed charges,Implant Device,3753.6,34,"Charges > $500, x 34%",3753.6,percent of total billed charges,Implant Device,3864,35,,3864,percent of total billed charges,Implant Device,3864,35,,3864,percent of total billed charges,Implant Device,3864,35,,3864,percent of total billed charges,Implant Device,3864,35,,3864,percent of total billed charges,Implant Device,3864,35,,3864,percent of total billed charges,Implant Device,4416,40,,4416,percent of total billed charges,Implant Device,3864,70,,3864,percent of total billed charges,All Other,3753.6,34,,3753.6,percent of total billed charges,Implant Device,3753.6,34,,3753.6,percent of total billed charges,Implant Device,3864,35,,3864,percent of total billed charges,Implant Device,3864,35,,3864,percent of total billed charges,Implant Device,3864,35,,3864,percent of total billed charges,Implant Device,3864,35,,3864,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3753.6,34,"If Charge > 2,000, then 34 percent",3753.6,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,8169.63,
BIOMET 29283 LAG SCREW 120MM,C1713,HCPCS,,79006417,CDM,278,RC,,,both,,,2670,1975.81,,,1975.81,Other,150% of Medicare + 9.63% HCRA Surcharge,1201.5,45,,1201.5,percent of total billed charges,Critical Access Hospital RCC factor,907.8,34,,907.8,percent of total billed charges,Implant Device,907.8,34,,907.8,percent of total billed charges,Implant Device,907.8,34,,907.8,percent of total billed charges,Implant Device,907.8,34,,907.8,percent of total billed charges,Implant Device,907.8,34,,907.8,percent of total billed charges,Implant Device,1321.65,,,1321.65,Other,110% of Medicare,934.5,35,,934.5,percent of total billed charges,Implant Device,907.8,34,"Charges > $500, x 34%",907.8,percent of total billed charges,Implant Device,934.5,35,,934.5,percent of total billed charges,Implant Device,934.5,35,,934.5,percent of total billed charges,Implant Device,934.5,35,,934.5,percent of total billed charges,Implant Device,934.5,35,,934.5,percent of total billed charges,Implant Device,934.5,35,,934.5,percent of total billed charges,Implant Device,1068,40,,1068,percent of total billed charges,Implant Device,934.5,70,,934.5,percent of total billed charges,All Other,907.8,34,,907.8,percent of total billed charges,Implant Device,907.8,34,,907.8,percent of total billed charges,Implant Device,934.5,35,,934.5,percent of total billed charges,Implant Device,934.5,35,,934.5,percent of total billed charges,Implant Device,934.5,35,,934.5,percent of total billed charges,Implant Device,934.5,35,,934.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,907.8,34,"If Charge > 2,000, then 34 percent",907.8,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1975.81,
BIOMET 14-405060 CORTICAL SCREW 5X60MM,C1713,HCPCS,,79006418,CDM,278,RC,,,both,,,1020,754.8,,,754.8,Other,150% of Medicare + 9.63% HCRA Surcharge,459,45,,459,percent of total billed charges,Critical Access Hospital RCC factor,346.8,34,,346.8,percent of total billed charges,Implant Device,346.8,34,,346.8,percent of total billed charges,Implant Device,346.8,34,,346.8,percent of total billed charges,Implant Device,346.8,34,,346.8,percent of total billed charges,Implant Device,346.8,34,,346.8,percent of total billed charges,Implant Device,504.9,,,504.9,Other,110% of Medicare,357,35,,357,percent of total billed charges,Implant Device,346.8,34,"Charges > $500, x 34%",346.8,percent of total billed charges,Implant Device,357,35,,357,percent of total billed charges,Implant Device,357,35,,357,percent of total billed charges,Implant Device,357,35,,357,percent of total billed charges,Implant Device,357,35,,357,percent of total billed charges,Implant Device,357,35,,357,percent of total billed charges,Implant Device,408,40,,408,percent of total billed charges,Implant Device,357,70,,357,percent of total billed charges,All Other,346.8,34,,346.8,percent of total billed charges,Implant Device,346.8,34,,346.8,percent of total billed charges,Implant Device,357,35,,357,percent of total billed charges,Implant Device,357,35,,357,percent of total billed charges,Implant Device,357,35,,357,percent of total billed charges,Implant Device,357,35,,357,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,754.8,
STRYKER 1806-1417S FIXATION K-WIRE 3X285,C1713,HCPCS,,79006419,CDM,278,RC,,,both,,,245,181.3,,,181.3,Other,150% of Medicare + 9.63% HCRA Surcharge,110.25,45,,110.25,percent of total billed charges,Critical Access Hospital RCC factor,83.3,34,,83.3,percent of total billed charges,Implant Device,83.3,34,,83.3,percent of total billed charges,Implant Device,83.3,34,,83.3,percent of total billed charges,Implant Device,83.3,34,,83.3,percent of total billed charges,Implant Device,83.3,34,,83.3,percent of total billed charges,Implant Device,121.28,,,121.28,Other,110% of Medicare,85.75,35,,85.75,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,85.75,35,,85.75,percent of total billed charges,Implant Device,85.75,35,,85.75,percent of total billed charges,Implant Device,85.75,35,,85.75,percent of total billed charges,Implant Device,85.75,35,,85.75,percent of total billed charges,Implant Device,85.75,35,,85.75,percent of total billed charges,Implant Device,98,40,,98,percent of total billed charges,Implant Device,85.75,70,,85.75,percent of total billed charges,All Other,83.3,34,,83.3,percent of total billed charges,Implant Device,83.3,34,,83.3,percent of total billed charges,Implant Device,85.75,35,,85.75,percent of total billed charges,Implant Device,85.75,35,,85.75,percent of total billed charges,Implant Device,85.75,35,,85.75,percent of total billed charges,Implant Device,85.75,35,,85.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,181.3,
STRYKER 1806-1407S NAIL INSERT SLEEVE T2,C1713,HCPCS,,79006420,CDM,278,RC,,,both,,,616,455.84,,,455.84,Other,150% of Medicare + 9.63% HCRA Surcharge,277.2,45,,277.2,percent of total billed charges,Critical Access Hospital RCC factor,209.44,34,,209.44,percent of total billed charges,Implant Device,209.44,34,,209.44,percent of total billed charges,Implant Device,209.44,34,,209.44,percent of total billed charges,Implant Device,209.44,34,,209.44,percent of total billed charges,Implant Device,209.44,34,,209.44,percent of total billed charges,Implant Device,304.92,,,304.92,Other,110% of Medicare,215.6,35,,215.6,percent of total billed charges,Implant Device,209.44,34,"Charges > $500, x 34%",209.44,percent of total billed charges,Implant Device,215.6,35,,215.6,percent of total billed charges,Implant Device,215.6,35,,215.6,percent of total billed charges,Implant Device,215.6,35,,215.6,percent of total billed charges,Implant Device,215.6,35,,215.6,percent of total billed charges,Implant Device,215.6,35,,215.6,percent of total billed charges,Implant Device,246.4,40,,246.4,percent of total billed charges,Implant Device,215.6,70,,215.6,percent of total billed charges,All Other,209.44,34,,209.44,percent of total billed charges,Implant Device,209.44,34,,209.44,percent of total billed charges,Implant Device,215.6,35,,215.6,percent of total billed charges,Implant Device,215.6,35,,215.6,percent of total billed charges,Implant Device,215.6,35,,215.6,percent of total billed charges,Implant Device,215.6,35,,215.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,455.84,
BIOMET 92-0495 FEMUR HEAD FD IR 43MM,C1776,HCPCS,,79006422,CDM,278,RC,,,both,,,4044,2992.57,,,2992.57,Other,150% of Medicare + 9.63% HCRA Surcharge,1819.8,45,,1819.8,percent of total billed charges,Critical Access Hospital RCC factor,1374.96,34,,1374.96,percent of total billed charges,Implant Device,1374.96,34,,1374.96,percent of total billed charges,Implant Device,1374.96,34,,1374.96,percent of total billed charges,Implant Device,1374.96,34,,1374.96,percent of total billed charges,Implant Device,1374.96,34,,1374.96,percent of total billed charges,Implant Device,2001.78,,,2001.78,Other,110% of Medicare,1415.4,35,,1415.4,percent of total billed charges,Implant Device,1374.96,34,"Charges > $500, x 34%",1374.96,percent of total billed charges,Implant Device,1415.4,35,,1415.4,percent of total billed charges,Implant Device,1415.4,35,,1415.4,percent of total billed charges,Implant Device,1415.4,35,,1415.4,percent of total billed charges,Implant Device,1415.4,35,,1415.4,percent of total billed charges,Implant Device,1415.4,35,,1415.4,percent of total billed charges,Implant Device,1617.6,40,,1617.6,percent of total billed charges,Implant Device,1415.4,70,,1415.4,percent of total billed charges,All Other,1374.96,34,,1374.96,percent of total billed charges,Implant Device,1374.96,34,,1374.96,percent of total billed charges,Implant Device,1415.4,35,,1415.4,percent of total billed charges,Implant Device,1415.4,35,,1415.4,percent of total billed charges,Implant Device,1415.4,35,,1415.4,percent of total billed charges,Implant Device,1415.4,35,,1415.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1374.96,34,"If Charge > 2,000, then 34 percent",1374.96,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2992.57,
STRYKER 430210 10 HOLE 1/3 TUBULAR PLATE,C1713,HCPCS,,79006424,CDM,278,RC,,,both,,,290,214.6,,,214.6,Other,150% of Medicare + 9.63% HCRA Surcharge,130.5,45,,130.5,percent of total billed charges,Critical Access Hospital RCC factor,98.6,34,,98.6,percent of total billed charges,Implant Device,98.6,34,,98.6,percent of total billed charges,Implant Device,98.6,34,,98.6,percent of total billed charges,Implant Device,98.6,34,,98.6,percent of total billed charges,Implant Device,98.6,34,,98.6,percent of total billed charges,Implant Device,143.55,,,143.55,Other,110% of Medicare,101.5,35,,101.5,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,101.5,35,,101.5,percent of total billed charges,Implant Device,101.5,35,,101.5,percent of total billed charges,Implant Device,101.5,35,,101.5,percent of total billed charges,Implant Device,101.5,35,,101.5,percent of total billed charges,Implant Device,101.5,35,,101.5,percent of total billed charges,Implant Device,116,40,,116,percent of total billed charges,Implant Device,101.5,70,,101.5,percent of total billed charges,All Other,98.6,34,,98.6,percent of total billed charges,Implant Device,98.6,34,,98.6,percent of total billed charges,Implant Device,101.5,35,,101.5,percent of total billed charges,Implant Device,101.5,35,,101.5,percent of total billed charges,Implant Device,101.5,35,,101.5,percent of total billed charges,Implant Device,101.5,35,,101.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,214.6,
STRYKER 345418 4X18MM CANCELLLOUS SCREW,C1713,HCPCS,,79006425,CDM,278,RC,,,both,,,100,74,,,74,Other,150% of Medicare + 9.63% HCRA Surcharge,45,45,,45,percent of total billed charges,Critical Access Hospital RCC factor,34,34,,34,percent of total billed charges,Implant Device,34,34,,34,percent of total billed charges,Implant Device,34,34,,34,percent of total billed charges,Implant Device,34,34,,34,percent of total billed charges,Implant Device,34,34,,34,percent of total billed charges,Implant Device,49.5,,,49.5,Other,110% of Medicare,35,35,,35,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,35,35,,35,percent of total billed charges,Implant Device,35,35,,35,percent of total billed charges,Implant Device,35,35,,35,percent of total billed charges,Implant Device,35,35,,35,percent of total billed charges,Implant Device,35,35,,35,percent of total billed charges,Implant Device,40,40,,40,percent of total billed charges,Implant Device,35,70,,35,percent of total billed charges,All Other,34,34,,34,percent of total billed charges,Implant Device,34,34,,34,percent of total billed charges,Implant Device,35,35,,35,percent of total billed charges,Implant Device,35,35,,35,percent of total billed charges,Implant Device,35,35,,35,percent of total billed charges,Implant Device,35,35,,35,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,74,
STRYKER 345545 4X45MM CANCELLLOUS SCREW,C1713,HCPCS,,79006426,CDM,278,RC,,,both,,,100,74,,,74,Other,150% of Medicare + 9.63% HCRA Surcharge,45,45,,45,percent of total billed charges,Critical Access Hospital RCC factor,34,34,,34,percent of total billed charges,Implant Device,34,34,,34,percent of total billed charges,Implant Device,34,34,,34,percent of total billed charges,Implant Device,34,34,,34,percent of total billed charges,Implant Device,34,34,,34,percent of total billed charges,Implant Device,49.5,,,49.5,Other,110% of Medicare,35,35,,35,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,35,35,,35,percent of total billed charges,Implant Device,35,35,,35,percent of total billed charges,Implant Device,35,35,,35,percent of total billed charges,Implant Device,35,35,,35,percent of total billed charges,Implant Device,35,35,,35,percent of total billed charges,Implant Device,40,40,,40,percent of total billed charges,Implant Device,35,70,,35,percent of total billed charges,All Other,34,34,,34,percent of total billed charges,Implant Device,34,34,,34,percent of total billed charges,Implant Device,35,35,,35,percent of total billed charges,Implant Device,35,35,,35,percent of total billed charges,Implant Device,35,35,,35,percent of total billed charges,Implant Device,35,35,,35,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,74,
MAQUET 31144 CQUR MOSAC MESH 12.5X12.5CM,C1781,HCPCS,,79006427,CDM,278,RC,,,both,,,1187,878.38,,,878.38,Other,150% of Medicare + 9.63% HCRA Surcharge,534.15,45,,534.15,percent of total billed charges,Critical Access Hospital RCC factor,403.58,34,,403.58,percent of total billed charges,Implant Device,403.58,34,,403.58,percent of total billed charges,Implant Device,403.58,34,,403.58,percent of total billed charges,Implant Device,403.58,34,,403.58,percent of total billed charges,Implant Device,403.58,34,,403.58,percent of total billed charges,Implant Device,587.57,,,587.57,Other,110% of Medicare,415.45,35,,415.45,percent of total billed charges,Implant Device,403.58,34,"Charges > $500, x 34%",403.58,percent of total billed charges,Implant Device,415.45,35,,415.45,percent of total billed charges,Implant Device,415.45,35,,415.45,percent of total billed charges,Implant Device,415.45,35,,415.45,percent of total billed charges,Implant Device,415.45,35,,415.45,percent of total billed charges,Implant Device,415.45,35,,415.45,percent of total billed charges,Implant Device,474.8,40,,474.8,percent of total billed charges,Implant Device,415.45,70,,415.45,percent of total billed charges,All Other,403.58,34,,403.58,percent of total billed charges,Implant Device,403.58,34,,403.58,percent of total billed charges,Implant Device,415.45,35,,415.45,percent of total billed charges,Implant Device,415.45,35,,415.45,percent of total billed charges,Implant Device,415.45,35,,415.45,percent of total billed charges,Implant Device,415.45,35,,415.45,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,878.38,
MAQUET 31143 CQUR MOSAIC MESH 8.9X8.9CM,C1781,HCPCS,,79006428,CDM,278,RC,,,both,,,853,631.22,,,631.22,Other,150% of Medicare + 9.63% HCRA Surcharge,383.85,45,,383.85,percent of total billed charges,Critical Access Hospital RCC factor,290.02,34,,290.02,percent of total billed charges,Implant Device,290.02,34,,290.02,percent of total billed charges,Implant Device,290.02,34,,290.02,percent of total billed charges,Implant Device,290.02,34,,290.02,percent of total billed charges,Implant Device,290.02,34,,290.02,percent of total billed charges,Implant Device,422.24,,,422.24,Other,110% of Medicare,298.55,35,,298.55,percent of total billed charges,Implant Device,290.02,34,"Charges > $500, x 34%",290.02,percent of total billed charges,Implant Device,298.55,35,,298.55,percent of total billed charges,Implant Device,298.55,35,,298.55,percent of total billed charges,Implant Device,298.55,35,,298.55,percent of total billed charges,Implant Device,298.55,35,,298.55,percent of total billed charges,Implant Device,298.55,35,,298.55,percent of total billed charges,Implant Device,341.2,40,,341.2,percent of total billed charges,Implant Device,298.55,70,,298.55,percent of total billed charges,All Other,290.02,34,,290.02,percent of total billed charges,Implant Device,290.02,34,,290.02,percent of total billed charges,Implant Device,298.55,35,,298.55,percent of total billed charges,Implant Device,298.55,35,,298.55,percent of total billed charges,Implant Device,298.55,35,,298.55,percent of total billed charges,Implant Device,298.55,35,,298.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,631.22,
BOST SCI 1690 WALLFLEX ESPH STENT 18X103,C1876,HCPCS,,79006430,CDM,278,RC,,,both,,,7516,5561.86,,,5561.86,Other,150% of Medicare + 9.63% HCRA Surcharge,3382.2,45,,3382.2,percent of total billed charges,Critical Access Hospital RCC factor,2555.44,34,,2555.44,percent of total billed charges,Implant Device,2555.44,34,,2555.44,percent of total billed charges,Implant Device,2555.44,34,,2555.44,percent of total billed charges,Implant Device,2555.44,34,,2555.44,percent of total billed charges,Implant Device,2555.44,34,,2555.44,percent of total billed charges,Implant Device,3720.42,,,3720.42,Other,110% of Medicare,2630.6,35,,2630.6,percent of total billed charges,Implant Device,2555.44,34,"Charges > $500, x 34%",2555.44,percent of total billed charges,Implant Device,2630.6,35,,2630.6,percent of total billed charges,Implant Device,2630.6,35,,2630.6,percent of total billed charges,Implant Device,2630.6,35,,2630.6,percent of total billed charges,Implant Device,2630.6,35,,2630.6,percent of total billed charges,Implant Device,2630.6,35,,2630.6,percent of total billed charges,Implant Device,3006.4,40,,3006.4,percent of total billed charges,Implant Device,2630.6,70,,2630.6,percent of total billed charges,All Other,2555.44,34,,2555.44,percent of total billed charges,Implant Device,2555.44,34,,2555.44,percent of total billed charges,Implant Device,2630.6,35,,2630.6,percent of total billed charges,Implant Device,2630.6,35,,2630.6,percent of total billed charges,Implant Device,2630.6,35,,2630.6,percent of total billed charges,Implant Device,2630.6,35,,2630.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2555.44,34,"If Charge > 2,000, then 34 percent",2555.44,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5561.86,
ZIMMER 5001-44-28 BIPOLAR LINER 28MM ID,C1776,HCPCS,,79006431,CDM,278,RC,,,both,,,789,583.86,,,583.86,Other,150% of Medicare + 9.63% HCRA Surcharge,355.05,45,,355.05,percent of total billed charges,Critical Access Hospital RCC factor,268.26,34,,268.26,percent of total billed charges,Implant Device,268.26,34,,268.26,percent of total billed charges,Implant Device,268.26,34,,268.26,percent of total billed charges,Implant Device,268.26,34,,268.26,percent of total billed charges,Implant Device,268.26,34,,268.26,percent of total billed charges,Implant Device,390.56,,,390.56,Other,110% of Medicare,276.15,35,,276.15,percent of total billed charges,Implant Device,268.26,34,"Charges > $500, x 34%",268.26,percent of total billed charges,Implant Device,276.15,35,,276.15,percent of total billed charges,Implant Device,276.15,35,,276.15,percent of total billed charges,Implant Device,276.15,35,,276.15,percent of total billed charges,Implant Device,276.15,35,,276.15,percent of total billed charges,Implant Device,276.15,35,,276.15,percent of total billed charges,Implant Device,315.6,40,,315.6,percent of total billed charges,Implant Device,276.15,70,,276.15,percent of total billed charges,All Other,268.26,34,,268.26,percent of total billed charges,Implant Device,268.26,34,,268.26,percent of total billed charges,Implant Device,276.15,35,,276.15,percent of total billed charges,Implant Device,276.15,35,,276.15,percent of total billed charges,Implant Device,276.15,35,,276.15,percent of total billed charges,Implant Device,276.15,35,,276.15,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,583.86,
ZIMMER 5001-45 BIPOLAR SHELL 45MM OD,C1776,HCPCS,,79006432,CDM,278,RC,,,both,,,2273,1682.03,,,1682.03,Other,150% of Medicare + 9.63% HCRA Surcharge,1022.85,45,,1022.85,percent of total billed charges,Critical Access Hospital RCC factor,772.82,34,,772.82,percent of total billed charges,Implant Device,772.82,34,,772.82,percent of total billed charges,Implant Device,772.82,34,,772.82,percent of total billed charges,Implant Device,772.82,34,,772.82,percent of total billed charges,Implant Device,772.82,34,,772.82,percent of total billed charges,Implant Device,1125.14,,,1125.14,Other,110% of Medicare,795.55,35,,795.55,percent of total billed charges,Implant Device,772.82,34,"Charges > $500, x 34%",772.82,percent of total billed charges,Implant Device,795.55,35,,795.55,percent of total billed charges,Implant Device,795.55,35,,795.55,percent of total billed charges,Implant Device,795.55,35,,795.55,percent of total billed charges,Implant Device,795.55,35,,795.55,percent of total billed charges,Implant Device,795.55,35,,795.55,percent of total billed charges,Implant Device,909.2,40,,909.2,percent of total billed charges,Implant Device,795.55,70,,795.55,percent of total billed charges,All Other,772.82,34,,772.82,percent of total billed charges,Implant Device,772.82,34,,772.82,percent of total billed charges,Implant Device,795.55,35,,795.55,percent of total billed charges,Implant Device,795.55,35,,795.55,percent of total billed charges,Implant Device,795.55,35,,795.55,percent of total billed charges,Implant Device,795.55,35,,795.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,772.82,34,"If Charge > 2,000, then 34 percent",772.82,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1682.03,
ZIMMER 7859-13 DISTAL CENTRALIZER 13MM,C1776,HCPCS,,79006433,CDM,278,RC,,,both,,,192,142.08,,,142.08,Other,150% of Medicare + 9.63% HCRA Surcharge,86.4,45,,86.4,percent of total billed charges,Critical Access Hospital RCC factor,65.28,34,,65.28,percent of total billed charges,Implant Device,65.28,34,,65.28,percent of total billed charges,Implant Device,65.28,34,,65.28,percent of total billed charges,Implant Device,65.28,34,,65.28,percent of total billed charges,Implant Device,65.28,34,,65.28,percent of total billed charges,Implant Device,95.04,,,95.04,Other,110% of Medicare,67.2,35,,67.2,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,67.2,35,,67.2,percent of total billed charges,Implant Device,67.2,35,,67.2,percent of total billed charges,Implant Device,67.2,35,,67.2,percent of total billed charges,Implant Device,67.2,35,,67.2,percent of total billed charges,Implant Device,67.2,35,,67.2,percent of total billed charges,Implant Device,76.8,40,,76.8,percent of total billed charges,Implant Device,67.2,70,,67.2,percent of total billed charges,All Other,65.28,34,,65.28,percent of total billed charges,Implant Device,65.28,34,,65.28,percent of total billed charges,Implant Device,67.2,35,,67.2,percent of total billed charges,Implant Device,67.2,35,,67.2,percent of total billed charges,Implant Device,67.2,35,,67.2,percent of total billed charges,Implant Device,67.2,35,,67.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,142.08,
ZIMMER 00-8775-028-03 FEM HEAD 28MM,C1776,HCPCS,,79006434,CDM,278,RC,,,both,,,2880,2131.21,,,2131.21,Other,150% of Medicare + 9.63% HCRA Surcharge,1296,45,,1296,percent of total billed charges,Critical Access Hospital RCC factor,979.2,34,,979.2,percent of total billed charges,Implant Device,979.2,34,,979.2,percent of total billed charges,Implant Device,979.2,34,,979.2,percent of total billed charges,Implant Device,979.2,34,,979.2,percent of total billed charges,Implant Device,979.2,34,,979.2,percent of total billed charges,Implant Device,1425.6,,,1425.6,Other,110% of Medicare,1008,35,,1008,percent of total billed charges,Implant Device,979.2,34,"Charges > $500, x 34%",979.2,percent of total billed charges,Implant Device,1008,35,,1008,percent of total billed charges,Implant Device,1008,35,,1008,percent of total billed charges,Implant Device,1008,35,,1008,percent of total billed charges,Implant Device,1008,35,,1008,percent of total billed charges,Implant Device,1008,35,,1008,percent of total billed charges,Implant Device,1152,40,,1152,percent of total billed charges,Implant Device,1008,70,,1008,percent of total billed charges,All Other,979.2,34,,979.2,percent of total billed charges,Implant Device,979.2,34,,979.2,percent of total billed charges,Implant Device,1008,35,,1008,percent of total billed charges,Implant Device,1008,35,,1008,percent of total billed charges,Implant Device,1008,35,,1008,percent of total billed charges,Implant Device,1008,35,,1008,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,979.2,34,"If Charge > 2,000, then 34 percent",979.2,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2131.21,
EXACTECH SPS0021K INTERSPACE SHOULDR KIT,C1776,HCPCS,,79006435,CDM,278,RC,,,both,,,11761,8703.17,,,8703.17,Other,150% of Medicare + 9.63% HCRA Surcharge,5292.45,45,,5292.45,percent of total billed charges,Critical Access Hospital RCC factor,3998.74,34,,3998.74,percent of total billed charges,Implant Device,3998.74,34,,3998.74,percent of total billed charges,Implant Device,3998.74,34,,3998.74,percent of total billed charges,Implant Device,3998.74,34,,3998.74,percent of total billed charges,Implant Device,3998.74,34,,3998.74,percent of total billed charges,Implant Device,5821.7,,,5821.7,Other,110% of Medicare,4116.35,35,,4116.35,percent of total billed charges,Implant Device,3998.74,34,"Charges > $500, x 34%",3998.74,percent of total billed charges,Implant Device,4116.35,35,,4116.35,percent of total billed charges,Implant Device,4116.35,35,,4116.35,percent of total billed charges,Implant Device,4116.35,35,,4116.35,percent of total billed charges,Implant Device,4116.35,35,,4116.35,percent of total billed charges,Implant Device,4116.35,35,,4116.35,percent of total billed charges,Implant Device,4704.4,40,,4704.4,percent of total billed charges,Implant Device,4116.35,70,,4116.35,percent of total billed charges,All Other,3998.74,34,,3998.74,percent of total billed charges,Implant Device,3998.74,34,,3998.74,percent of total billed charges,Implant Device,4116.35,35,,4116.35,percent of total billed charges,Implant Device,4116.35,35,,4116.35,percent of total billed charges,Implant Device,4116.35,35,,4116.35,percent of total billed charges,Implant Device,4116.35,35,,4116.35,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3998.74,34,"If Charge > 2,000, then 34 percent",3998.74,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,8703.17,
MAQUET 31133 CQUR MOSAIC MESH 6X8,C1781,HCPCS,,79006436,CDM,278,RC,,,both,,,1877,1388.98,,,1388.98,Other,150% of Medicare + 9.63% HCRA Surcharge,844.65,45,,844.65,percent of total billed charges,Critical Access Hospital RCC factor,638.18,34,,638.18,percent of total billed charges,Implant Device,638.18,34,,638.18,percent of total billed charges,Implant Device,638.18,34,,638.18,percent of total billed charges,Implant Device,638.18,34,,638.18,percent of total billed charges,Implant Device,638.18,34,,638.18,percent of total billed charges,Implant Device,929.12,,,929.12,Other,110% of Medicare,656.95,35,,656.95,percent of total billed charges,Implant Device,638.18,34,"Charges > $500, x 34%",638.18,percent of total billed charges,Implant Device,656.95,35,,656.95,percent of total billed charges,Implant Device,656.95,35,,656.95,percent of total billed charges,Implant Device,656.95,35,,656.95,percent of total billed charges,Implant Device,656.95,35,,656.95,percent of total billed charges,Implant Device,656.95,35,,656.95,percent of total billed charges,Implant Device,750.8,40,,750.8,percent of total billed charges,Implant Device,656.95,70,,656.95,percent of total billed charges,All Other,638.18,34,,638.18,percent of total billed charges,Implant Device,638.18,34,,638.18,percent of total billed charges,Implant Device,656.95,35,,656.95,percent of total billed charges,Implant Device,656.95,35,,656.95,percent of total billed charges,Implant Device,656.95,35,,656.95,percent of total billed charges,Implant Device,656.95,35,,656.95,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1388.98,
BIOMET 28244 TROCH NAIL LONG 11MM LEFT,C1713,HCPCS,,79006437,CDM,278,RC,,,both,,,11040,8169.63,,,8169.63,Other,150% of Medicare + 9.63% HCRA Surcharge,4968,45,,4968,percent of total billed charges,Critical Access Hospital RCC factor,3753.6,34,,3753.6,percent of total billed charges,Implant Device,3753.6,34,,3753.6,percent of total billed charges,Implant Device,3753.6,34,,3753.6,percent of total billed charges,Implant Device,3753.6,34,,3753.6,percent of total billed charges,Implant Device,3753.6,34,,3753.6,percent of total billed charges,Implant Device,5464.8,,,5464.8,Other,110% of Medicare,3864,35,,3864,percent of total billed charges,Implant Device,3753.6,34,"Charges > $500, x 34%",3753.6,percent of total billed charges,Implant Device,3864,35,,3864,percent of total billed charges,Implant Device,3864,35,,3864,percent of total billed charges,Implant Device,3864,35,,3864,percent of total billed charges,Implant Device,3864,35,,3864,percent of total billed charges,Implant Device,3864,35,,3864,percent of total billed charges,Implant Device,4416,40,,4416,percent of total billed charges,Implant Device,3864,70,,3864,percent of total billed charges,All Other,3753.6,34,,3753.6,percent of total billed charges,Implant Device,3753.6,34,,3753.6,percent of total billed charges,Implant Device,3864,35,,3864,percent of total billed charges,Implant Device,3864,35,,3864,percent of total billed charges,Implant Device,3864,35,,3864,percent of total billed charges,Implant Device,3864,35,,3864,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3753.6,34,"If Charge > 2,000, then 34 percent",3753.6,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,8169.63,
STRYKER 611080S CANN CANC SCREW 8X80MM,C1713,HCPCS,,79006438,CDM,278,RC,,,both,,,1020,754.8,,,754.8,Other,150% of Medicare + 9.63% HCRA Surcharge,459,45,,459,percent of total billed charges,Critical Access Hospital RCC factor,346.8,34,,346.8,percent of total billed charges,Implant Device,346.8,34,,346.8,percent of total billed charges,Implant Device,346.8,34,,346.8,percent of total billed charges,Implant Device,346.8,34,,346.8,percent of total billed charges,Implant Device,346.8,34,,346.8,percent of total billed charges,Implant Device,504.9,,,504.9,Other,110% of Medicare,357,35,,357,percent of total billed charges,Implant Device,346.8,34,"Charges > $500, x 34%",346.8,percent of total billed charges,Implant Device,357,35,,357,percent of total billed charges,Implant Device,357,35,,357,percent of total billed charges,Implant Device,357,35,,357,percent of total billed charges,Implant Device,357,35,,357,percent of total billed charges,Implant Device,357,35,,357,percent of total billed charges,Implant Device,408,40,,408,percent of total billed charges,Implant Device,357,70,,357,percent of total billed charges,All Other,346.8,34,,346.8,percent of total billed charges,Implant Device,346.8,34,,346.8,percent of total billed charges,Implant Device,357,35,,357,percent of total billed charges,Implant Device,357,35,,357,percent of total billed charges,Implant Device,357,35,,357,percent of total billed charges,Implant Device,357,35,,357,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,754.8,
STRYKER 601660S CANNULATED SCREW 5X6MM,C1713,HCPCS,,79006439,CDM,278,RC,,,both,,,725,536.5,,,536.5,Other,150% of Medicare + 9.63% HCRA Surcharge,326.25,45,,326.25,percent of total billed charges,Critical Access Hospital RCC factor,246.5,34,,246.5,percent of total billed charges,Implant Device,246.5,34,,246.5,percent of total billed charges,Implant Device,246.5,34,,246.5,percent of total billed charges,Implant Device,246.5,34,,246.5,percent of total billed charges,Implant Device,246.5,34,,246.5,percent of total billed charges,Implant Device,358.88,,,358.88,Other,110% of Medicare,253.75,35,,253.75,percent of total billed charges,Implant Device,246.5,34,"Charges > $500, x 34%",246.5,percent of total billed charges,Implant Device,253.75,35,,253.75,percent of total billed charges,Implant Device,253.75,35,,253.75,percent of total billed charges,Implant Device,253.75,35,,253.75,percent of total billed charges,Implant Device,253.75,35,,253.75,percent of total billed charges,Implant Device,253.75,35,,253.75,percent of total billed charges,Implant Device,290,40,,290,percent of total billed charges,Implant Device,253.75,70,,253.75,percent of total billed charges,All Other,246.5,34,,246.5,percent of total billed charges,Implant Device,246.5,34,,246.5,percent of total billed charges,Implant Device,253.75,35,,253.75,percent of total billed charges,Implant Device,253.75,35,,253.75,percent of total billed charges,Implant Device,253.75,35,,253.75,percent of total billed charges,Implant Device,253.75,35,,253.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,536.5,
STRYKER 5030-5-200 04/5 TRANSFIXION PIN,C1713,HCPCS,,79006443,CDM,278,RC,,,both,,,510,377.4,,,377.4,Other,150% of Medicare + 9.63% HCRA Surcharge,229.5,45,,229.5,percent of total billed charges,Critical Access Hospital RCC factor,173.4,34,,173.4,percent of total billed charges,Implant Device,173.4,34,,173.4,percent of total billed charges,Implant Device,173.4,34,,173.4,percent of total billed charges,Implant Device,173.4,34,,173.4,percent of total billed charges,Implant Device,173.4,34,,173.4,percent of total billed charges,Implant Device,252.45,,,252.45,Other,110% of Medicare,178.5,35,,178.5,percent of total billed charges,Implant Device,173.4,34,"Charges > $500, x 34%",173.4,percent of total billed charges,Implant Device,178.5,35,,178.5,percent of total billed charges,Implant Device,178.5,35,,178.5,percent of total billed charges,Implant Device,178.5,35,,178.5,percent of total billed charges,Implant Device,178.5,35,,178.5,percent of total billed charges,Implant Device,178.5,35,,178.5,percent of total billed charges,Implant Device,204,40,,204,percent of total billed charges,Implant Device,178.5,70,,178.5,percent of total billed charges,All Other,173.4,34,,173.4,percent of total billed charges,Implant Device,173.4,34,,173.4,percent of total billed charges,Implant Device,178.5,35,,178.5,percent of total billed charges,Implant Device,178.5,35,,178.5,percent of total billed charges,Implant Device,178.5,35,,178.5,percent of total billed charges,Implant Device,178.5,35,,178.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,377.4,
STRYKER EZ20-20-20 EASYCLIP,C1713,HCPCS,,79006444,CDM,278,RC,,,both,,,3646,2698.05,,,2698.05,Other,150% of Medicare + 9.63% HCRA Surcharge,1640.7,45,,1640.7,percent of total billed charges,Critical Access Hospital RCC factor,1239.64,34,,1239.64,percent of total billed charges,Implant Device,1239.64,34,,1239.64,percent of total billed charges,Implant Device,1239.64,34,,1239.64,percent of total billed charges,Implant Device,1239.64,34,,1239.64,percent of total billed charges,Implant Device,1239.64,34,,1239.64,percent of total billed charges,Implant Device,1804.77,,,1804.77,Other,110% of Medicare,1276.1,35,,1276.1,percent of total billed charges,Implant Device,1239.64,34,"Charges > $500, x 34%",1239.64,percent of total billed charges,Implant Device,1276.1,35,,1276.1,percent of total billed charges,Implant Device,1276.1,35,,1276.1,percent of total billed charges,Implant Device,1276.1,35,,1276.1,percent of total billed charges,Implant Device,1276.1,35,,1276.1,percent of total billed charges,Implant Device,1276.1,35,,1276.1,percent of total billed charges,Implant Device,1458.4,40,,1458.4,percent of total billed charges,Implant Device,1276.1,70,,1276.1,percent of total billed charges,All Other,1239.64,34,,1239.64,percent of total billed charges,Implant Device,1239.64,34,,1239.64,percent of total billed charges,Implant Device,1276.1,35,,1276.1,percent of total billed charges,Implant Device,1276.1,35,,1276.1,percent of total billed charges,Implant Device,1276.1,35,,1276.1,percent of total billed charges,Implant Device,1276.1,35,,1276.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1239.64,34,"If Charge > 2,000, then 34 percent",1239.64,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2698.05,
STRYKER EZ25-22-22 EASYCLIP,C1713,HCPCS,,79006445,CDM,278,RC,,,both,,,6246,4622.06,,,4622.06,Other,150% of Medicare + 9.63% HCRA Surcharge,2810.7,45,,2810.7,percent of total billed charges,Critical Access Hospital RCC factor,2123.64,34,,2123.64,percent of total billed charges,Implant Device,2123.64,34,,2123.64,percent of total billed charges,Implant Device,2123.64,34,,2123.64,percent of total billed charges,Implant Device,2123.64,34,,2123.64,percent of total billed charges,Implant Device,2123.64,34,,2123.64,percent of total billed charges,Implant Device,3091.77,,,3091.77,Other,110% of Medicare,2186.1,35,,2186.1,percent of total billed charges,Implant Device,2123.64,34,"Charges > $500, x 34%",2123.64,percent of total billed charges,Implant Device,2186.1,35,,2186.1,percent of total billed charges,Implant Device,2186.1,35,,2186.1,percent of total billed charges,Implant Device,2186.1,35,,2186.1,percent of total billed charges,Implant Device,2186.1,35,,2186.1,percent of total billed charges,Implant Device,2186.1,35,,2186.1,percent of total billed charges,Implant Device,2498.4,40,,2498.4,percent of total billed charges,Implant Device,2186.1,70,,2186.1,percent of total billed charges,All Other,2123.64,34,,2123.64,percent of total billed charges,Implant Device,2123.64,34,,2123.64,percent of total billed charges,Implant Device,2186.1,35,,2186.1,percent of total billed charges,Implant Device,2186.1,35,,2186.1,percent of total billed charges,Implant Device,2186.1,35,,2186.1,percent of total billed charges,Implant Device,2186.1,35,,2186.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2123.64,34,"If Charge > 2,000, then 34 percent",2123.64,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4622.06,
STRYKER 629344 OLECRANON PLATE 4 HOLE LT,C1713,HCPCS,,79006446,CDM,278,RC,,,both,,,3051,2257.75,,,2257.75,Other,150% of Medicare + 9.63% HCRA Surcharge,1372.95,45,,1372.95,percent of total billed charges,Critical Access Hospital RCC factor,1037.34,34,,1037.34,percent of total billed charges,Implant Device,1037.34,34,,1037.34,percent of total billed charges,Implant Device,1037.34,34,,1037.34,percent of total billed charges,Implant Device,1037.34,34,,1037.34,percent of total billed charges,Implant Device,1037.34,34,,1037.34,percent of total billed charges,Implant Device,1510.25,,,1510.25,Other,110% of Medicare,1067.85,35,,1067.85,percent of total billed charges,Implant Device,1037.34,34,"Charges > $500, x 34%",1037.34,percent of total billed charges,Implant Device,1067.85,35,,1067.85,percent of total billed charges,Implant Device,1067.85,35,,1067.85,percent of total billed charges,Implant Device,1067.85,35,,1067.85,percent of total billed charges,Implant Device,1067.85,35,,1067.85,percent of total billed charges,Implant Device,1067.85,35,,1067.85,percent of total billed charges,Implant Device,1220.4,40,,1220.4,percent of total billed charges,Implant Device,1067.85,70,,1067.85,percent of total billed charges,All Other,1037.34,34,,1037.34,percent of total billed charges,Implant Device,1037.34,34,,1037.34,percent of total billed charges,Implant Device,1067.85,35,,1067.85,percent of total billed charges,Implant Device,1067.85,35,,1067.85,percent of total billed charges,Implant Device,1067.85,35,,1067.85,percent of total billed charges,Implant Device,1067.85,35,,1067.85,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1037.34,34,"If Charge > 2,000, then 34 percent",1037.34,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2257.75,
ALPHATEC SPINE 71002-34 PLATE 2 LEV 34MM,C1713,HCPCS,,79006448,CDM,278,RC,,,both,,,2700,1998.01,,,1998.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1215,45,,1215,percent of total billed charges,Critical Access Hospital RCC factor,918,34,,918,percent of total billed charges,Implant Device,918,34,,918,percent of total billed charges,Implant Device,918,34,,918,percent of total billed charges,Implant Device,918,34,,918,percent of total billed charges,Implant Device,918,34,,918,percent of total billed charges,Implant Device,1336.5,,,1336.5,Other,110% of Medicare,945,35,,945,percent of total billed charges,Implant Device,918,34,"Charges > $500, x 34%",918,percent of total billed charges,Implant Device,945,35,,945,percent of total billed charges,Implant Device,945,35,,945,percent of total billed charges,Implant Device,945,35,,945,percent of total billed charges,Implant Device,945,35,,945,percent of total billed charges,Implant Device,945,35,,945,percent of total billed charges,Implant Device,1080,40,,1080,percent of total billed charges,Implant Device,945,70,,945,percent of total billed charges,All Other,918,34,,918,percent of total billed charges,Implant Device,918,34,,918,percent of total billed charges,Implant Device,945,35,,945,percent of total billed charges,Implant Device,945,35,,945,percent of total billed charges,Implant Device,945,35,,945,percent of total billed charges,Implant Device,945,35,,945,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,918,34,"If Charge > 2,000, then 34 percent",918,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1998.01,
STRYKER 6495-9-006 TISSUE MEND 3X3CM,C1713,HCPCS,,79006449,CDM,278,RC,,,both,,,3936,2912.65,,,2912.65,Other,150% of Medicare + 9.63% HCRA Surcharge,1771.2,45,,1771.2,percent of total billed charges,Critical Access Hospital RCC factor,1338.24,34,,1338.24,percent of total billed charges,Implant Device,1338.24,34,,1338.24,percent of total billed charges,Implant Device,1338.24,34,,1338.24,percent of total billed charges,Implant Device,1338.24,34,,1338.24,percent of total billed charges,Implant Device,1338.24,34,,1338.24,percent of total billed charges,Implant Device,1948.32,,,1948.32,Other,110% of Medicare,1377.6,35,,1377.6,percent of total billed charges,Implant Device,1338.24,34,"Charges > $500, x 34%",1338.24,percent of total billed charges,Implant Device,1377.6,35,,1377.6,percent of total billed charges,Implant Device,1377.6,35,,1377.6,percent of total billed charges,Implant Device,1377.6,35,,1377.6,percent of total billed charges,Implant Device,1377.6,35,,1377.6,percent of total billed charges,Implant Device,1377.6,35,,1377.6,percent of total billed charges,Implant Device,1574.4,40,,1574.4,percent of total billed charges,Implant Device,1377.6,70,,1377.6,percent of total billed charges,All Other,1338.24,34,,1338.24,percent of total billed charges,Implant Device,1338.24,34,,1338.24,percent of total billed charges,Implant Device,1377.6,35,,1377.6,percent of total billed charges,Implant Device,1377.6,35,,1377.6,percent of total billed charges,Implant Device,1377.6,35,,1377.6,percent of total billed charges,Implant Device,1377.6,35,,1377.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1338.24,34,"If Charge > 2,000, then 34 percent",1338.24,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2912.65,
ALPHATEC 62075-45 POLYAX SCREW 7.5X45MM,C1713,HCPCS,,79006450,CDM,278,RC,,,both,,,2550,1887.01,,,1887.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1147.5,45,,1147.5,percent of total billed charges,Critical Access Hospital RCC factor,867,34,,867,percent of total billed charges,Implant Device,867,34,,867,percent of total billed charges,Implant Device,867,34,,867,percent of total billed charges,Implant Device,867,34,,867,percent of total billed charges,Implant Device,867,34,,867,percent of total billed charges,Implant Device,1262.25,,,1262.25,Other,110% of Medicare,892.5,35,,892.5,percent of total billed charges,Implant Device,867,34,"Charges > $500, x 34%",867,percent of total billed charges,Implant Device,892.5,35,,892.5,percent of total billed charges,Implant Device,892.5,35,,892.5,percent of total billed charges,Implant Device,892.5,35,,892.5,percent of total billed charges,Implant Device,892.5,35,,892.5,percent of total billed charges,Implant Device,892.5,35,,892.5,percent of total billed charges,Implant Device,1020,40,,1020,percent of total billed charges,Implant Device,892.5,70,,892.5,percent of total billed charges,All Other,867,34,,867,percent of total billed charges,Implant Device,867,34,,867,percent of total billed charges,Implant Device,892.5,35,,892.5,percent of total billed charges,Implant Device,892.5,35,,892.5,percent of total billed charges,Implant Device,892.5,35,,892.5,percent of total billed charges,Implant Device,892.5,35,,892.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,867,34,"If Charge > 2,000, then 34 percent",867,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1887.01,
ALPHATEC SPINE 11-2053 CROSSLINK MEDIUM,C1713,HCPCS,,79006451,CDM,278,RC,,,both,,,3750,2775.01,,,2775.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1687.5,45,,1687.5,percent of total billed charges,Critical Access Hospital RCC factor,1275,34,,1275,percent of total billed charges,Implant Device,1275,34,,1275,percent of total billed charges,Implant Device,1275,34,,1275,percent of total billed charges,Implant Device,1275,34,,1275,percent of total billed charges,Implant Device,1275,34,,1275,percent of total billed charges,Implant Device,1856.25,,,1856.25,Other,110% of Medicare,1312.5,35,,1312.5,percent of total billed charges,Implant Device,1275,34,"Charges > $500, x 34%",1275,percent of total billed charges,Implant Device,1312.5,35,,1312.5,percent of total billed charges,Implant Device,1312.5,35,,1312.5,percent of total billed charges,Implant Device,1312.5,35,,1312.5,percent of total billed charges,Implant Device,1312.5,35,,1312.5,percent of total billed charges,Implant Device,1312.5,35,,1312.5,percent of total billed charges,Implant Device,1500,40,,1500,percent of total billed charges,Implant Device,1312.5,70,,1312.5,percent of total billed charges,All Other,1275,34,,1275,percent of total billed charges,Implant Device,1275,34,,1275,percent of total billed charges,Implant Device,1312.5,35,,1312.5,percent of total billed charges,Implant Device,1312.5,35,,1312.5,percent of total billed charges,Implant Device,1312.5,35,,1312.5,percent of total billed charges,Implant Device,1312.5,35,,1312.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1275,34,"If Charge > 2,000, then 34 percent",1275,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2775.01,
ALPHATEC SPINE 62004-90 ROD 90MM,C1713,HCPCS,,79006452,CDM,278,RC,,,both,,,600,444,,,444,Other,150% of Medicare + 9.63% HCRA Surcharge,270,45,,270,percent of total billed charges,Critical Access Hospital RCC factor,204,34,,204,percent of total billed charges,Implant Device,204,34,,204,percent of total billed charges,Implant Device,204,34,,204,percent of total billed charges,Implant Device,204,34,,204,percent of total billed charges,Implant Device,204,34,,204,percent of total billed charges,Implant Device,297,,,297,Other,110% of Medicare,210,35,,210,percent of total billed charges,Implant Device,204,34,"Charges > $500, x 34%",204,percent of total billed charges,Implant Device,210,35,,210,percent of total billed charges,Implant Device,210,35,,210,percent of total billed charges,Implant Device,210,35,,210,percent of total billed charges,Implant Device,210,35,,210,percent of total billed charges,Implant Device,210,35,,210,percent of total billed charges,Implant Device,240,40,,240,percent of total billed charges,Implant Device,210,70,,210,percent of total billed charges,All Other,204,34,,204,percent of total billed charges,Implant Device,204,34,,204,percent of total billed charges,Implant Device,210,35,,210,percent of total billed charges,Implant Device,210,35,,210,percent of total billed charges,Implant Device,210,35,,210,percent of total billed charges,Implant Device,210,35,,210,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,444,
ALPHATEC SPINE 71001-20 PLATE 1 LEV 20MM,C1713,HCPCS,,79006453,CDM,278,RC,,,both,,,2280,1687.21,,,1687.21,Other,150% of Medicare + 9.63% HCRA Surcharge,1026,45,,1026,percent of total billed charges,Critical Access Hospital RCC factor,775.2,34,,775.2,percent of total billed charges,Implant Device,775.2,34,,775.2,percent of total billed charges,Implant Device,775.2,34,,775.2,percent of total billed charges,Implant Device,775.2,34,,775.2,percent of total billed charges,Implant Device,775.2,34,,775.2,percent of total billed charges,Implant Device,1128.6,,,1128.6,Other,110% of Medicare,798,35,,798,percent of total billed charges,Implant Device,775.2,34,"Charges > $500, x 34%",775.2,percent of total billed charges,Implant Device,798,35,,798,percent of total billed charges,Implant Device,798,35,,798,percent of total billed charges,Implant Device,798,35,,798,percent of total billed charges,Implant Device,798,35,,798,percent of total billed charges,Implant Device,798,35,,798,percent of total billed charges,Implant Device,912,40,,912,percent of total billed charges,Implant Device,798,70,,798,percent of total billed charges,All Other,775.2,34,,775.2,percent of total billed charges,Implant Device,775.2,34,,775.2,percent of total billed charges,Implant Device,798,35,,798,percent of total billed charges,Implant Device,798,35,,798,percent of total billed charges,Implant Device,798,35,,798,percent of total billed charges,Implant Device,798,35,,798,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,775.2,34,"If Charge > 2,000, then 34 percent",775.2,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1687.21,
ALPHATEC SPINE 71345-14 RSCUE SCREW 14MM,C1713,HCPCS,,79006454,CDM,278,RC,,,both,,,706,522.44,,,522.44,Other,150% of Medicare + 9.63% HCRA Surcharge,317.7,45,,317.7,percent of total billed charges,Critical Access Hospital RCC factor,240.04,34,,240.04,percent of total billed charges,Implant Device,240.04,34,,240.04,percent of total billed charges,Implant Device,240.04,34,,240.04,percent of total billed charges,Implant Device,240.04,34,,240.04,percent of total billed charges,Implant Device,240.04,34,,240.04,percent of total billed charges,Implant Device,349.47,,,349.47,Other,110% of Medicare,247.1,35,,247.1,percent of total billed charges,Implant Device,240.04,34,"Charges > $500, x 34%",240.04,percent of total billed charges,Implant Device,247.1,35,,247.1,percent of total billed charges,Implant Device,247.1,35,,247.1,percent of total billed charges,Implant Device,247.1,35,,247.1,percent of total billed charges,Implant Device,247.1,35,,247.1,percent of total billed charges,Implant Device,247.1,35,,247.1,percent of total billed charges,Implant Device,282.4,40,,282.4,percent of total billed charges,Implant Device,247.1,70,,247.1,percent of total billed charges,All Other,240.04,34,,240.04,percent of total billed charges,Implant Device,240.04,34,,240.04,percent of total billed charges,Implant Device,247.1,35,,247.1,percent of total billed charges,Implant Device,247.1,35,,247.1,percent of total billed charges,Implant Device,247.1,35,,247.1,percent of total billed charges,Implant Device,247.1,35,,247.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,522.44,
BIOMET 28336 TROCH NAIL LONG 11MM RT,C1713,HCPCS,,79006462,CDM,278,RC,,,both,,,11040,8169.63,,,8169.63,Other,150% of Medicare + 9.63% HCRA Surcharge,4968,45,,4968,percent of total billed charges,Critical Access Hospital RCC factor,3753.6,34,,3753.6,percent of total billed charges,Implant Device,3753.6,34,,3753.6,percent of total billed charges,Implant Device,3753.6,34,,3753.6,percent of total billed charges,Implant Device,3753.6,34,,3753.6,percent of total billed charges,Implant Device,3753.6,34,,3753.6,percent of total billed charges,Implant Device,5464.8,,,5464.8,Other,110% of Medicare,3864,35,,3864,percent of total billed charges,Implant Device,3753.6,34,"Charges > $500, x 34%",3753.6,percent of total billed charges,Implant Device,3864,35,,3864,percent of total billed charges,Implant Device,3864,35,,3864,percent of total billed charges,Implant Device,3864,35,,3864,percent of total billed charges,Implant Device,3864,35,,3864,percent of total billed charges,Implant Device,3864,35,,3864,percent of total billed charges,Implant Device,4416,40,,4416,percent of total billed charges,Implant Device,3864,70,,3864,percent of total billed charges,All Other,3753.6,34,,3753.6,percent of total billed charges,Implant Device,3753.6,34,,3753.6,percent of total billed charges,Implant Device,3864,35,,3864,percent of total billed charges,Implant Device,3864,35,,3864,percent of total billed charges,Implant Device,3864,35,,3864,percent of total billed charges,Implant Device,3864,35,,3864,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3753.6,34,"If Charge > 2,000, then 34 percent",3753.6,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,8169.63,
BIOMET 29239 LAG SCREW ASSY 100MM,C1713,HCPCS,,79006463,CDM,278,RC,,,both,,,3330,2464.21,,,2464.21,Other,150% of Medicare + 9.63% HCRA Surcharge,1498.5,45,,1498.5,percent of total billed charges,Critical Access Hospital RCC factor,1132.2,34,,1132.2,percent of total billed charges,Implant Device,1132.2,34,,1132.2,percent of total billed charges,Implant Device,1132.2,34,,1132.2,percent of total billed charges,Implant Device,1132.2,34,,1132.2,percent of total billed charges,Implant Device,1132.2,34,,1132.2,percent of total billed charges,Implant Device,1648.35,,,1648.35,Other,110% of Medicare,1165.5,35,,1165.5,percent of total billed charges,Implant Device,1132.2,34,"Charges > $500, x 34%",1132.2,percent of total billed charges,Implant Device,1165.5,35,,1165.5,percent of total billed charges,Implant Device,1165.5,35,,1165.5,percent of total billed charges,Implant Device,1165.5,35,,1165.5,percent of total billed charges,Implant Device,1165.5,35,,1165.5,percent of total billed charges,Implant Device,1165.5,35,,1165.5,percent of total billed charges,Implant Device,1332,40,,1332,percent of total billed charges,Implant Device,1165.5,70,,1165.5,percent of total billed charges,All Other,1132.2,34,,1132.2,percent of total billed charges,Implant Device,1132.2,34,,1132.2,percent of total billed charges,Implant Device,1165.5,35,,1165.5,percent of total billed charges,Implant Device,1165.5,35,,1165.5,percent of total billed charges,Implant Device,1165.5,35,,1165.5,percent of total billed charges,Implant Device,1165.5,35,,1165.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1132.2,34,"If Charge > 2,000, then 34 percent",1132.2,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2464.21,
BIOMET 14-405040 CORT SCREW 5X40MM,C1713,HCPCS,,79006464,CDM,278,RC,,,both,,,1020,754.8,,,754.8,Other,150% of Medicare + 9.63% HCRA Surcharge,459,45,,459,percent of total billed charges,Critical Access Hospital RCC factor,346.8,34,,346.8,percent of total billed charges,Implant Device,346.8,34,,346.8,percent of total billed charges,Implant Device,346.8,34,,346.8,percent of total billed charges,Implant Device,346.8,34,,346.8,percent of total billed charges,Implant Device,346.8,34,,346.8,percent of total billed charges,Implant Device,504.9,,,504.9,Other,110% of Medicare,357,35,,357,percent of total billed charges,Implant Device,346.8,34,"Charges > $500, x 34%",346.8,percent of total billed charges,Implant Device,357,35,,357,percent of total billed charges,Implant Device,357,35,,357,percent of total billed charges,Implant Device,357,35,,357,percent of total billed charges,Implant Device,357,35,,357,percent of total billed charges,Implant Device,357,35,,357,percent of total billed charges,Implant Device,408,40,,408,percent of total billed charges,Implant Device,357,70,,357,percent of total billed charges,All Other,346.8,34,,346.8,percent of total billed charges,Implant Device,346.8,34,,346.8,percent of total billed charges,Implant Device,357,35,,357,percent of total billed charges,Implant Device,357,35,,357,percent of total billed charges,Implant Device,357,35,,357,percent of total billed charges,Implant Device,357,35,,357,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,754.8,
ZIMMER 00-5994-032-12 ART SURFACE 12MM,C1713,HCPCS,,79006465,CDM,278,RC,,,both,,,6257,4630.2,,,4630.2,Other,150% of Medicare + 9.63% HCRA Surcharge,2815.65,45,,2815.65,percent of total billed charges,Critical Access Hospital RCC factor,2127.38,34,,2127.38,percent of total billed charges,Implant Device,2127.38,34,,2127.38,percent of total billed charges,Implant Device,2127.38,34,,2127.38,percent of total billed charges,Implant Device,2127.38,34,,2127.38,percent of total billed charges,Implant Device,2127.38,34,,2127.38,percent of total billed charges,Implant Device,3097.22,,,3097.22,Other,110% of Medicare,2189.95,35,,2189.95,percent of total billed charges,Implant Device,2127.38,34,"Charges > $500, x 34%",2127.38,percent of total billed charges,Implant Device,2189.95,35,,2189.95,percent of total billed charges,Implant Device,2189.95,35,,2189.95,percent of total billed charges,Implant Device,2189.95,35,,2189.95,percent of total billed charges,Implant Device,2189.95,35,,2189.95,percent of total billed charges,Implant Device,2189.95,35,,2189.95,percent of total billed charges,Implant Device,2502.8,40,,2502.8,percent of total billed charges,Implant Device,2189.95,70,,2189.95,percent of total billed charges,All Other,2127.38,34,,2127.38,percent of total billed charges,Implant Device,2127.38,34,,2127.38,percent of total billed charges,Implant Device,2189.95,35,,2189.95,percent of total billed charges,Implant Device,2189.95,35,,2189.95,percent of total billed charges,Implant Device,2189.95,35,,2189.95,percent of total billed charges,Implant Device,2189.95,35,,2189.95,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2127.38,34,"If Charge > 2,000, then 34 percent",2127.38,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4630.2,
ZIMMER 00-5842-023-09 ART SURFCE SZ3 9MM,C1713,HCPCS,,79006467,CDM,278,RC,,,both,,,2677,1980.99,,,1980.99,Other,150% of Medicare + 9.63% HCRA Surcharge,1204.65,45,,1204.65,percent of total billed charges,Critical Access Hospital RCC factor,910.18,34,,910.18,percent of total billed charges,Implant Device,910.18,34,,910.18,percent of total billed charges,Implant Device,910.18,34,,910.18,percent of total billed charges,Implant Device,910.18,34,,910.18,percent of total billed charges,Implant Device,910.18,34,,910.18,percent of total billed charges,Implant Device,1325.12,,,1325.12,Other,110% of Medicare,936.95,35,,936.95,percent of total billed charges,Implant Device,910.18,34,"Charges > $500, x 34%",910.18,percent of total billed charges,Implant Device,936.95,35,,936.95,percent of total billed charges,Implant Device,936.95,35,,936.95,percent of total billed charges,Implant Device,936.95,35,,936.95,percent of total billed charges,Implant Device,936.95,35,,936.95,percent of total billed charges,Implant Device,936.95,35,,936.95,percent of total billed charges,Implant Device,1070.8,40,,1070.8,percent of total billed charges,Implant Device,936.95,70,,936.95,percent of total billed charges,All Other,910.18,34,,910.18,percent of total billed charges,Implant Device,910.18,34,,910.18,percent of total billed charges,Implant Device,936.95,35,,936.95,percent of total billed charges,Implant Device,936.95,35,,936.95,percent of total billed charges,Implant Device,936.95,35,,936.95,percent of total billed charges,Implant Device,936.95,35,,936.95,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,910.18,34,"If Charge > 2,000, then 34 percent",910.18,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1980.99,
SYNTHES 207.746 SCREW CANNULATED 4X46MM,C1713,HCPCS,,79006470,CDM,278,RC,,,both,,,686,507.64,,,507.64,Other,150% of Medicare + 9.63% HCRA Surcharge,308.7,45,,308.7,percent of total billed charges,Critical Access Hospital RCC factor,233.24,34,,233.24,percent of total billed charges,Implant Device,233.24,34,,233.24,percent of total billed charges,Implant Device,233.24,34,,233.24,percent of total billed charges,Implant Device,233.24,34,,233.24,percent of total billed charges,Implant Device,233.24,34,,233.24,percent of total billed charges,Implant Device,339.57,,,339.57,Other,110% of Medicare,240.1,35,,240.1,percent of total billed charges,Implant Device,233.24,34,"Charges > $500, x 34%",233.24,percent of total billed charges,Implant Device,240.1,35,,240.1,percent of total billed charges,Implant Device,240.1,35,,240.1,percent of total billed charges,Implant Device,240.1,35,,240.1,percent of total billed charges,Implant Device,240.1,35,,240.1,percent of total billed charges,Implant Device,240.1,35,,240.1,percent of total billed charges,Implant Device,274.4,40,,274.4,percent of total billed charges,Implant Device,240.1,70,,240.1,percent of total billed charges,All Other,233.24,34,,233.24,percent of total billed charges,Implant Device,233.24,34,,233.24,percent of total billed charges,Implant Device,240.1,35,,240.1,percent of total billed charges,Implant Device,240.1,35,,240.1,percent of total billed charges,Implant Device,240.1,35,,240.1,percent of total billed charges,Implant Device,240.1,35,,240.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,507.64,
SYNTHES 207.742 SCREW CANNULATED 4X42MM,C1713,HCPCS,,79006471,CDM,278,RC,,,both,,,685,506.9,,,506.9,Other,150% of Medicare + 9.63% HCRA Surcharge,308.25,45,,308.25,percent of total billed charges,Critical Access Hospital RCC factor,232.9,34,,232.9,percent of total billed charges,Implant Device,232.9,34,,232.9,percent of total billed charges,Implant Device,232.9,34,,232.9,percent of total billed charges,Implant Device,232.9,34,,232.9,percent of total billed charges,Implant Device,232.9,34,,232.9,percent of total billed charges,Implant Device,339.08,,,339.08,Other,110% of Medicare,239.75,35,,239.75,percent of total billed charges,Implant Device,232.9,34,"Charges > $500, x 34%",232.9,percent of total billed charges,Implant Device,239.75,35,,239.75,percent of total billed charges,Implant Device,239.75,35,,239.75,percent of total billed charges,Implant Device,239.75,35,,239.75,percent of total billed charges,Implant Device,239.75,35,,239.75,percent of total billed charges,Implant Device,239.75,35,,239.75,percent of total billed charges,Implant Device,274,40,,274,percent of total billed charges,Implant Device,239.75,70,,239.75,percent of total billed charges,All Other,232.9,34,,232.9,percent of total billed charges,Implant Device,232.9,34,,232.9,percent of total billed charges,Implant Device,239.75,35,,239.75,percent of total billed charges,Implant Device,239.75,35,,239.75,percent of total billed charges,Implant Device,239.75,35,,239.75,percent of total billed charges,Implant Device,239.75,35,,239.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,506.9,
STRYKER 57-15370 2.3MM 7 HOLE Y PLATE,C1713,HCPCS,,79006473,CDM,278,RC,,,both,,,2496,1847.05,,,1847.05,Other,150% of Medicare + 9.63% HCRA Surcharge,1123.2,45,,1123.2,percent of total billed charges,Critical Access Hospital RCC factor,848.64,34,,848.64,percent of total billed charges,Implant Device,848.64,34,,848.64,percent of total billed charges,Implant Device,848.64,34,,848.64,percent of total billed charges,Implant Device,848.64,34,,848.64,percent of total billed charges,Implant Device,848.64,34,,848.64,percent of total billed charges,Implant Device,1235.52,,,1235.52,Other,110% of Medicare,873.6,35,,873.6,percent of total billed charges,Implant Device,848.64,34,"Charges > $500, x 34%",848.64,percent of total billed charges,Implant Device,873.6,35,,873.6,percent of total billed charges,Implant Device,873.6,35,,873.6,percent of total billed charges,Implant Device,873.6,35,,873.6,percent of total billed charges,Implant Device,873.6,35,,873.6,percent of total billed charges,Implant Device,873.6,35,,873.6,percent of total billed charges,Implant Device,998.4,40,,998.4,percent of total billed charges,Implant Device,873.6,70,,873.6,percent of total billed charges,All Other,848.64,34,,848.64,percent of total billed charges,Implant Device,848.64,34,,848.64,percent of total billed charges,Implant Device,873.6,35,,873.6,percent of total billed charges,Implant Device,873.6,35,,873.6,percent of total billed charges,Implant Device,873.6,35,,873.6,percent of total billed charges,Implant Device,873.6,35,,873.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,848.64,34,"If Charge > 2,000, then 34 percent",848.64,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1847.05,
SYNTHES 241.331 LCP PLATE 3 HOLE 33MM,C1713,HCPCS,,79006474,CDM,278,RC,,,both,,,604,446.96,,,446.96,Other,150% of Medicare + 9.63% HCRA Surcharge,271.8,45,,271.8,percent of total billed charges,Critical Access Hospital RCC factor,205.36,34,,205.36,percent of total billed charges,Implant Device,205.36,34,,205.36,percent of total billed charges,Implant Device,205.36,34,,205.36,percent of total billed charges,Implant Device,205.36,34,,205.36,percent of total billed charges,Implant Device,205.36,34,,205.36,percent of total billed charges,Implant Device,298.98,,,298.98,Other,110% of Medicare,211.4,35,,211.4,percent of total billed charges,Implant Device,205.36,34,"Charges > $500, x 34%",205.36,percent of total billed charges,Implant Device,211.4,35,,211.4,percent of total billed charges,Implant Device,211.4,35,,211.4,percent of total billed charges,Implant Device,211.4,35,,211.4,percent of total billed charges,Implant Device,211.4,35,,211.4,percent of total billed charges,Implant Device,211.4,35,,211.4,percent of total billed charges,Implant Device,241.6,40,,241.6,percent of total billed charges,Implant Device,211.4,70,,211.4,percent of total billed charges,All Other,205.36,34,,205.36,percent of total billed charges,Implant Device,205.36,34,,205.36,percent of total billed charges,Implant Device,211.4,35,,211.4,percent of total billed charges,Implant Device,211.4,35,,211.4,percent of total billed charges,Implant Device,211.4,35,,211.4,percent of total billed charges,Implant Device,211.4,35,,211.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,446.96,
ALLERGAN FF410535 SILICONE IMPLANT,C1789,HCPCS,,79006475,CDM,278,RC,,,both,,,3976,2942.25,,,2942.25,Other,150% of Medicare + 9.63% HCRA Surcharge,1789.2,45,,1789.2,percent of total billed charges,Critical Access Hospital RCC factor,1351.84,34,,1351.84,percent of total billed charges,Implant Device,1351.84,34,,1351.84,percent of total billed charges,Implant Device,1351.84,34,,1351.84,percent of total billed charges,Implant Device,1351.84,34,,1351.84,percent of total billed charges,Implant Device,1351.84,34,,1351.84,percent of total billed charges,Implant Device,1968.12,,,1968.12,Other,110% of Medicare,1391.6,35,,1391.6,percent of total billed charges,Implant Device,1351.84,34,"Charges > $500, x 34%",1351.84,percent of total billed charges,Implant Device,1391.6,35,,1391.6,percent of total billed charges,Implant Device,1391.6,35,,1391.6,percent of total billed charges,Implant Device,1391.6,35,,1391.6,percent of total billed charges,Implant Device,1391.6,35,,1391.6,percent of total billed charges,Implant Device,1391.6,35,,1391.6,percent of total billed charges,Implant Device,1590.4,40,,1590.4,percent of total billed charges,Implant Device,1391.6,70,,1391.6,percent of total billed charges,All Other,1351.84,34,,1351.84,percent of total billed charges,Implant Device,1351.84,34,,1351.84,percent of total billed charges,Implant Device,1391.6,35,,1391.6,percent of total billed charges,Implant Device,1391.6,35,,1391.6,percent of total billed charges,Implant Device,1391.6,35,,1391.6,percent of total billed charges,Implant Device,1391.6,35,,1391.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1351.84,34,"If Charge > 2,000, then 34 percent",1351.84,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2942.25,
ALLERGAN FF410475 SILICONE IMPLANT,C1789,HCPCS,,79006476,CDM,278,RC,,,both,,,3976,2942.25,,,2942.25,Other,150% of Medicare + 9.63% HCRA Surcharge,1789.2,45,,1789.2,percent of total billed charges,Critical Access Hospital RCC factor,1351.84,34,,1351.84,percent of total billed charges,Implant Device,1351.84,34,,1351.84,percent of total billed charges,Implant Device,1351.84,34,,1351.84,percent of total billed charges,Implant Device,1351.84,34,,1351.84,percent of total billed charges,Implant Device,1351.84,34,,1351.84,percent of total billed charges,Implant Device,1968.12,,,1968.12,Other,110% of Medicare,1391.6,35,,1391.6,percent of total billed charges,Implant Device,1351.84,34,"Charges > $500, x 34%",1351.84,percent of total billed charges,Implant Device,1391.6,35,,1391.6,percent of total billed charges,Implant Device,1391.6,35,,1391.6,percent of total billed charges,Implant Device,1391.6,35,,1391.6,percent of total billed charges,Implant Device,1391.6,35,,1391.6,percent of total billed charges,Implant Device,1391.6,35,,1391.6,percent of total billed charges,Implant Device,1590.4,40,,1590.4,percent of total billed charges,Implant Device,1391.6,70,,1391.6,percent of total billed charges,All Other,1351.84,34,,1351.84,percent of total billed charges,Implant Device,1351.84,34,,1351.84,percent of total billed charges,Implant Device,1391.6,35,,1391.6,percent of total billed charges,Implant Device,1391.6,35,,1391.6,percent of total billed charges,Implant Device,1391.6,35,,1391.6,percent of total billed charges,Implant Device,1391.6,35,,1391.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1351.84,34,"If Charge > 2,000, then 34 percent",1351.84,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2942.25,
ALLERGAN FF410595 SILICONE IMPLANT,C1789,HCPCS,,79006477,CDM,278,RC,,,both,,,3976,2942.25,,,2942.25,Other,150% of Medicare + 9.63% HCRA Surcharge,1789.2,45,,1789.2,percent of total billed charges,Critical Access Hospital RCC factor,1351.84,34,,1351.84,percent of total billed charges,Implant Device,1351.84,34,,1351.84,percent of total billed charges,Implant Device,1351.84,34,,1351.84,percent of total billed charges,Implant Device,1351.84,34,,1351.84,percent of total billed charges,Implant Device,1351.84,34,,1351.84,percent of total billed charges,Implant Device,1968.12,,,1968.12,Other,110% of Medicare,1391.6,35,,1391.6,percent of total billed charges,Implant Device,1351.84,34,"Charges > $500, x 34%",1351.84,percent of total billed charges,Implant Device,1391.6,35,,1391.6,percent of total billed charges,Implant Device,1391.6,35,,1391.6,percent of total billed charges,Implant Device,1391.6,35,,1391.6,percent of total billed charges,Implant Device,1391.6,35,,1391.6,percent of total billed charges,Implant Device,1391.6,35,,1391.6,percent of total billed charges,Implant Device,1590.4,40,,1590.4,percent of total billed charges,Implant Device,1391.6,70,,1391.6,percent of total billed charges,All Other,1351.84,34,,1351.84,percent of total billed charges,Implant Device,1351.84,34,,1351.84,percent of total billed charges,Implant Device,1391.6,35,,1391.6,percent of total billed charges,Implant Device,1391.6,35,,1391.6,percent of total billed charges,Implant Device,1391.6,35,,1391.6,percent of total billed charges,Implant Device,1391.6,35,,1391.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1351.84,34,"If Charge > 2,000, then 34 percent",1351.84,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2942.25,
GORE RMT281418 EXCLUDER AAA ENDO GRAFT,C1874,HCPCS,,79006479,CDM,278,RC,,,both,,,31500,23310.08,,,23310.08,Other,150% of Medicare + 9.63% HCRA Surcharge,14175,45,,14175,percent of total billed charges,Critical Access Hospital RCC factor,10710,34,,10710,percent of total billed charges,Implant Device,10710,34,,10710,percent of total billed charges,Implant Device,10710,34,,10710,percent of total billed charges,Implant Device,10710,34,,10710,percent of total billed charges,Implant Device,10710,34,,10710,percent of total billed charges,Implant Device,15592.5,,,15592.5,Other,110% of Medicare,11025,35,,11025,percent of total billed charges,Implant Device,10710,34,"Charges > $500, x 34%",10710,percent of total billed charges,Implant Device,11025,35,,11025,percent of total billed charges,Implant Device,11025,35,,11025,percent of total billed charges,Implant Device,11025,35,,11025,percent of total billed charges,Implant Device,11025,35,,11025,percent of total billed charges,Implant Device,11025,35,,11025,percent of total billed charges,Implant Device,12600,40,,12600,percent of total billed charges,Implant Device,11025,70,,11025,percent of total billed charges,All Other,10710,34,,10710,percent of total billed charges,Implant Device,10710,34,,10710,percent of total billed charges,Implant Device,11025,35,,11025,percent of total billed charges,Implant Device,11025,35,,11025,percent of total billed charges,Implant Device,11025,35,,11025,percent of total billed charges,Implant Device,11025,35,,11025,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,10710,34,"If Charge > 2,000, then 34 percent",10710,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,23310.08,
GORE PXL161407 EXCLUDER AAA ENDO GRAFT,C1874,HCPCS,,79006480,CDM,278,RC,,,both,,,9525,7048.52,,,7048.52,Other,150% of Medicare + 9.63% HCRA Surcharge,4286.25,45,,4286.25,percent of total billed charges,Critical Access Hospital RCC factor,3238.5,34,,3238.5,percent of total billed charges,Implant Device,3238.5,34,,3238.5,percent of total billed charges,Implant Device,3238.5,34,,3238.5,percent of total billed charges,Implant Device,3238.5,34,,3238.5,percent of total billed charges,Implant Device,3238.5,34,,3238.5,percent of total billed charges,Implant Device,4714.88,,,4714.88,Other,110% of Medicare,3333.75,35,,3333.75,percent of total billed charges,Implant Device,3238.5,34,"Charges > $500, x 34%",3238.5,percent of total billed charges,Implant Device,3333.75,35,,3333.75,percent of total billed charges,Implant Device,3333.75,35,,3333.75,percent of total billed charges,Implant Device,3333.75,35,,3333.75,percent of total billed charges,Implant Device,3333.75,35,,3333.75,percent of total billed charges,Implant Device,3333.75,35,,3333.75,percent of total billed charges,Implant Device,3810,40,,3810,percent of total billed charges,Implant Device,3333.75,70,,3333.75,percent of total billed charges,All Other,3238.5,34,,3238.5,percent of total billed charges,Implant Device,3238.5,34,,3238.5,percent of total billed charges,Implant Device,3333.75,35,,3333.75,percent of total billed charges,Implant Device,3333.75,35,,3333.75,percent of total billed charges,Implant Device,3333.75,35,,3333.75,percent of total billed charges,Implant Device,3333.75,35,,3333.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3238.5,34,"If Charge > 2,000, then 34 percent",3238.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,7048.52,
GORE PXC141400 EXCLUDER AAA ENDO GRAFT,C1874,HCPCS,,79006481,CDM,278,RC,,,both,,,13530,10012.23,,,10012.23,Other,150% of Medicare + 9.63% HCRA Surcharge,6088.5,45,,6088.5,percent of total billed charges,Critical Access Hospital RCC factor,4600.2,34,,4600.2,percent of total billed charges,Implant Device,4600.2,34,,4600.2,percent of total billed charges,Implant Device,4600.2,34,,4600.2,percent of total billed charges,Implant Device,4600.2,34,,4600.2,percent of total billed charges,Implant Device,4600.2,34,,4600.2,percent of total billed charges,Implant Device,6697.35,,,6697.35,Other,110% of Medicare,4735.5,35,,4735.5,percent of total billed charges,Implant Device,4600.2,34,"Charges > $500, x 34%",4600.2,percent of total billed charges,Implant Device,4735.5,35,,4735.5,percent of total billed charges,Implant Device,4735.5,35,,4735.5,percent of total billed charges,Implant Device,4735.5,35,,4735.5,percent of total billed charges,Implant Device,4735.5,35,,4735.5,percent of total billed charges,Implant Device,4735.5,35,,4735.5,percent of total billed charges,Implant Device,5412,40,,5412,percent of total billed charges,Implant Device,4735.5,70,,4735.5,percent of total billed charges,All Other,4600.2,34,,4600.2,percent of total billed charges,Implant Device,4600.2,34,,4600.2,percent of total billed charges,Implant Device,4735.5,35,,4735.5,percent of total billed charges,Implant Device,4735.5,35,,4735.5,percent of total billed charges,Implant Device,4735.5,35,,4735.5,percent of total billed charges,Implant Device,4735.5,35,,4735.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,4600.2,34,"If Charge > 2,000, then 34 percent",4600.2,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,10012.23,
BIOMET 8162-45-209 PLATE 9 HOLE 4.5MM,C1713,HCPCS,,79006482,CDM,278,RC,,,both,,,1980,1465.2,,,1465.2,Other,150% of Medicare + 9.63% HCRA Surcharge,891,45,,891,percent of total billed charges,Critical Access Hospital RCC factor,673.2,34,,673.2,percent of total billed charges,Implant Device,673.2,34,,673.2,percent of total billed charges,Implant Device,673.2,34,,673.2,percent of total billed charges,Implant Device,673.2,34,,673.2,percent of total billed charges,Implant Device,673.2,34,,673.2,percent of total billed charges,Implant Device,980.1,,,980.1,Other,110% of Medicare,693,35,,693,percent of total billed charges,Implant Device,673.2,34,"Charges > $500, x 34%",673.2,percent of total billed charges,Implant Device,693,35,,693,percent of total billed charges,Implant Device,693,35,,693,percent of total billed charges,Implant Device,693,35,,693,percent of total billed charges,Implant Device,693,35,,693,percent of total billed charges,Implant Device,693,35,,693,percent of total billed charges,Implant Device,792,40,,792,percent of total billed charges,Implant Device,693,70,,693,percent of total billed charges,All Other,673.2,34,,673.2,percent of total billed charges,Implant Device,673.2,34,,673.2,percent of total billed charges,Implant Device,693,35,,693,percent of total billed charges,Implant Device,693,35,,693,percent of total billed charges,Implant Device,693,35,,693,percent of total billed charges,Implant Device,693,35,,693,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1465.2,
BIOMET 8157-45-026 CORTICAL SCREW 4.5X26,C1713,HCPCS,,79006483,CDM,278,RC,,,both,,,210,155.4,,,155.4,Other,150% of Medicare + 9.63% HCRA Surcharge,94.5,45,,94.5,percent of total billed charges,Critical Access Hospital RCC factor,71.4,34,,71.4,percent of total billed charges,Implant Device,71.4,34,,71.4,percent of total billed charges,Implant Device,71.4,34,,71.4,percent of total billed charges,Implant Device,71.4,34,,71.4,percent of total billed charges,Implant Device,71.4,34,,71.4,percent of total billed charges,Implant Device,103.95,,,103.95,Other,110% of Medicare,73.5,35,,73.5,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,73.5,35,,73.5,percent of total billed charges,Implant Device,73.5,35,,73.5,percent of total billed charges,Implant Device,73.5,35,,73.5,percent of total billed charges,Implant Device,73.5,35,,73.5,percent of total billed charges,Implant Device,73.5,35,,73.5,percent of total billed charges,Implant Device,84,40,,84,percent of total billed charges,Implant Device,73.5,70,,73.5,percent of total billed charges,All Other,71.4,34,,71.4,percent of total billed charges,Implant Device,71.4,34,,71.4,percent of total billed charges,Implant Device,73.5,35,,73.5,percent of total billed charges,Implant Device,73.5,35,,73.5,percent of total billed charges,Implant Device,73.5,35,,73.5,percent of total billed charges,Implant Device,73.5,35,,73.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,155.4,
BIOMET 8157-45-030 CORTICAL SCREW 4.5X30,C1713,HCPCS,,79006484,CDM,278,RC,,,both,,,210,155.4,,,155.4,Other,150% of Medicare + 9.63% HCRA Surcharge,94.5,45,,94.5,percent of total billed charges,Critical Access Hospital RCC factor,71.4,34,,71.4,percent of total billed charges,Implant Device,71.4,34,,71.4,percent of total billed charges,Implant Device,71.4,34,,71.4,percent of total billed charges,Implant Device,71.4,34,,71.4,percent of total billed charges,Implant Device,71.4,34,,71.4,percent of total billed charges,Implant Device,103.95,,,103.95,Other,110% of Medicare,73.5,35,,73.5,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,73.5,35,,73.5,percent of total billed charges,Implant Device,73.5,35,,73.5,percent of total billed charges,Implant Device,73.5,35,,73.5,percent of total billed charges,Implant Device,73.5,35,,73.5,percent of total billed charges,Implant Device,73.5,35,,73.5,percent of total billed charges,Implant Device,84,40,,84,percent of total billed charges,Implant Device,73.5,70,,73.5,percent of total billed charges,All Other,71.4,34,,71.4,percent of total billed charges,Implant Device,71.4,34,,71.4,percent of total billed charges,Implant Device,73.5,35,,73.5,percent of total billed charges,Implant Device,73.5,35,,73.5,percent of total billed charges,Implant Device,73.5,35,,73.5,percent of total billed charges,Implant Device,73.5,35,,73.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,155.4,
ALLERGAN 133MV-11-T TISSUE EXPANDER,C1789,HCPCS,,79006486,CDM,278,RC,,,both,,,4650,3441.01,,,3441.01,Other,150% of Medicare + 9.63% HCRA Surcharge,2092.5,45,,2092.5,percent of total billed charges,Critical Access Hospital RCC factor,1581,34,,1581,percent of total billed charges,Implant Device,1581,34,,1581,percent of total billed charges,Implant Device,1581,34,,1581,percent of total billed charges,Implant Device,1581,34,,1581,percent of total billed charges,Implant Device,1581,34,,1581,percent of total billed charges,Implant Device,2301.75,,,2301.75,Other,110% of Medicare,1627.5,35,,1627.5,percent of total billed charges,Implant Device,1581,34,"Charges > $500, x 34%",1581,percent of total billed charges,Implant Device,1627.5,35,,1627.5,percent of total billed charges,Implant Device,1627.5,35,,1627.5,percent of total billed charges,Implant Device,1627.5,35,,1627.5,percent of total billed charges,Implant Device,1627.5,35,,1627.5,percent of total billed charges,Implant Device,1627.5,35,,1627.5,percent of total billed charges,Implant Device,1860,40,,1860,percent of total billed charges,Implant Device,1627.5,70,,1627.5,percent of total billed charges,All Other,1581,34,,1581,percent of total billed charges,Implant Device,1581,34,,1581,percent of total billed charges,Implant Device,1627.5,35,,1627.5,percent of total billed charges,Implant Device,1627.5,35,,1627.5,percent of total billed charges,Implant Device,1627.5,35,,1627.5,percent of total billed charges,Implant Device,1627.5,35,,1627.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1581,34,"If Charge > 2,000, then 34 percent",1581,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3441.01,
ALLERGAN 133MV-12-T TISSUE EXPANDER,C1789,HCPCS,,79006487,CDM,278,RC,,,both,,,4650,3441.01,,,3441.01,Other,150% of Medicare + 9.63% HCRA Surcharge,2092.5,45,,2092.5,percent of total billed charges,Critical Access Hospital RCC factor,1581,34,,1581,percent of total billed charges,Implant Device,1581,34,,1581,percent of total billed charges,Implant Device,1581,34,,1581,percent of total billed charges,Implant Device,1581,34,,1581,percent of total billed charges,Implant Device,1581,34,,1581,percent of total billed charges,Implant Device,2301.75,,,2301.75,Other,110% of Medicare,1627.5,35,,1627.5,percent of total billed charges,Implant Device,1581,34,"Charges > $500, x 34%",1581,percent of total billed charges,Implant Device,1627.5,35,,1627.5,percent of total billed charges,Implant Device,1627.5,35,,1627.5,percent of total billed charges,Implant Device,1627.5,35,,1627.5,percent of total billed charges,Implant Device,1627.5,35,,1627.5,percent of total billed charges,Implant Device,1627.5,35,,1627.5,percent of total billed charges,Implant Device,1860,40,,1860,percent of total billed charges,Implant Device,1627.5,70,,1627.5,percent of total billed charges,All Other,1581,34,,1581,percent of total billed charges,Implant Device,1581,34,,1581,percent of total billed charges,Implant Device,1627.5,35,,1627.5,percent of total billed charges,Implant Device,1627.5,35,,1627.5,percent of total billed charges,Implant Device,1627.5,35,,1627.5,percent of total billed charges,Implant Device,1627.5,35,,1627.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1581,34,"If Charge > 2,000, then 34 percent",1581,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3441.01,
DEPUY 1294-35-115 TIBIAL TRAY SZ 1.5,C1776,HCPCS,,79006489,CDM,278,RC,,,both,,,19157,14176.23,,,14176.23,Other,150% of Medicare + 9.63% HCRA Surcharge,8620.65,45,,8620.65,percent of total billed charges,Critical Access Hospital RCC factor,6513.38,34,,6513.38,percent of total billed charges,Implant Device,6513.38,34,,6513.38,percent of total billed charges,Implant Device,6513.38,34,,6513.38,percent of total billed charges,Implant Device,6513.38,34,,6513.38,percent of total billed charges,Implant Device,6513.38,34,,6513.38,percent of total billed charges,Implant Device,9482.72,,,9482.72,Other,110% of Medicare,6704.95,35,,6704.95,percent of total billed charges,Implant Device,6513.38,34,"Charges > $500, x 34%",6513.38,percent of total billed charges,Implant Device,6704.95,35,,6704.95,percent of total billed charges,Implant Device,6704.95,35,,6704.95,percent of total billed charges,Implant Device,6704.95,35,,6704.95,percent of total billed charges,Implant Device,6704.95,35,,6704.95,percent of total billed charges,Implant Device,6704.95,35,,6704.95,percent of total billed charges,Implant Device,7662.8,40,,7662.8,percent of total billed charges,Implant Device,6704.95,70,,6704.95,percent of total billed charges,All Other,6513.38,34,,6513.38,percent of total billed charges,Implant Device,6513.38,34,,6513.38,percent of total billed charges,Implant Device,6704.95,35,,6704.95,percent of total billed charges,Implant Device,6704.95,35,,6704.95,percent of total billed charges,Implant Device,6704.95,35,,6704.95,percent of total billed charges,Implant Device,6704.95,35,,6704.95,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,6513.38,34,"If Charge > 2,000, then 34 percent",6513.38,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,14176.23,
DEPUY 1987-27-121 TIBIAL INSERT SM 21MM,C1776,HCPCS,,79006490,CDM,278,RC,,,both,,,10692,7912.11,,,7912.11,Other,150% of Medicare + 9.63% HCRA Surcharge,4811.4,45,,4811.4,percent of total billed charges,Critical Access Hospital RCC factor,3635.28,34,,3635.28,percent of total billed charges,Implant Device,3635.28,34,,3635.28,percent of total billed charges,Implant Device,3635.28,34,,3635.28,percent of total billed charges,Implant Device,3635.28,34,,3635.28,percent of total billed charges,Implant Device,3635.28,34,,3635.28,percent of total billed charges,Implant Device,5292.54,,,5292.54,Other,110% of Medicare,3742.2,35,,3742.2,percent of total billed charges,Implant Device,3635.28,34,"Charges > $500, x 34%",3635.28,percent of total billed charges,Implant Device,3742.2,35,,3742.2,percent of total billed charges,Implant Device,3742.2,35,,3742.2,percent of total billed charges,Implant Device,3742.2,35,,3742.2,percent of total billed charges,Implant Device,3742.2,35,,3742.2,percent of total billed charges,Implant Device,3742.2,35,,3742.2,percent of total billed charges,Implant Device,4276.8,40,,4276.8,percent of total billed charges,Implant Device,3742.2,70,,3742.2,percent of total billed charges,All Other,3635.28,34,,3635.28,percent of total billed charges,Implant Device,3635.28,34,,3635.28,percent of total billed charges,Implant Device,3742.2,35,,3742.2,percent of total billed charges,Implant Device,3742.2,35,,3742.2,percent of total billed charges,Implant Device,3742.2,35,,3742.2,percent of total billed charges,Implant Device,3742.2,35,,3742.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3635.28,34,"If Charge > 2,000, then 34 percent",3635.28,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,7912.11,
DEPUY 62-3421R FEMORAL ROTATING HINGE RT,C1776,HCPCS,,79006491,CDM,278,RC,,,both,,,24955,18466.76,,,18466.76,Other,150% of Medicare + 9.63% HCRA Surcharge,11229.75,45,,11229.75,percent of total billed charges,Critical Access Hospital RCC factor,8484.7,34,,8484.7,percent of total billed charges,Implant Device,8484.7,34,,8484.7,percent of total billed charges,Implant Device,8484.7,34,,8484.7,percent of total billed charges,Implant Device,8484.7,34,,8484.7,percent of total billed charges,Implant Device,8484.7,34,,8484.7,percent of total billed charges,Implant Device,12352.73,,,12352.73,Other,110% of Medicare,8734.25,35,,8734.25,percent of total billed charges,Implant Device,8484.7,34,"Charges > $500, x 34%",8484.7,percent of total billed charges,Implant Device,8734.25,35,,8734.25,percent of total billed charges,Implant Device,8734.25,35,,8734.25,percent of total billed charges,Implant Device,8734.25,35,,8734.25,percent of total billed charges,Implant Device,8734.25,35,,8734.25,percent of total billed charges,Implant Device,8734.25,35,,8734.25,percent of total billed charges,Implant Device,9982,40,,9982,percent of total billed charges,Implant Device,8734.25,70,,8734.25,percent of total billed charges,All Other,8484.7,34,,8484.7,percent of total billed charges,Implant Device,8484.7,34,,8484.7,percent of total billed charges,Implant Device,8734.25,35,,8734.25,percent of total billed charges,Implant Device,8734.25,35,,8734.25,percent of total billed charges,Implant Device,8734.25,35,,8734.25,percent of total billed charges,Implant Device,8734.25,35,,8734.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,8484.7,34,"If Charge > 2,000, then 34 percent",8484.7,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,18466.76,
DEPUY 62-3810 DISTAL FEM AUG BLOCK 10MM,C1776,HCPCS,,79006492,CDM,278,RC,,,both,,,3065,2268.11,,,2268.11,Other,150% of Medicare + 9.63% HCRA Surcharge,1379.25,45,,1379.25,percent of total billed charges,Critical Access Hospital RCC factor,1042.1,34,,1042.1,percent of total billed charges,Implant Device,1042.1,34,,1042.1,percent of total billed charges,Implant Device,1042.1,34,,1042.1,percent of total billed charges,Implant Device,1042.1,34,,1042.1,percent of total billed charges,Implant Device,1042.1,34,,1042.1,percent of total billed charges,Implant Device,1517.18,,,1517.18,Other,110% of Medicare,1072.75,35,,1072.75,percent of total billed charges,Implant Device,1042.1,34,"Charges > $500, x 34%",1042.1,percent of total billed charges,Implant Device,1072.75,35,,1072.75,percent of total billed charges,Implant Device,1072.75,35,,1072.75,percent of total billed charges,Implant Device,1072.75,35,,1072.75,percent of total billed charges,Implant Device,1072.75,35,,1072.75,percent of total billed charges,Implant Device,1072.75,35,,1072.75,percent of total billed charges,Implant Device,1226,40,,1226,percent of total billed charges,Implant Device,1072.75,70,,1072.75,percent of total billed charges,All Other,1042.1,34,,1042.1,percent of total billed charges,Implant Device,1042.1,34,,1042.1,percent of total billed charges,Implant Device,1072.75,35,,1072.75,percent of total billed charges,Implant Device,1072.75,35,,1072.75,percent of total billed charges,Implant Device,1072.75,35,,1072.75,percent of total billed charges,Implant Device,1072.75,35,,1072.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1042.1,34,"If Charge > 2,000, then 34 percent",1042.1,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2268.11,
DEPUY 86-7442 UNVRSL STEM FLUTED 150X14,C1776,HCPCS,,79006493,CDM,278,RC,,,both,,,5964,4413.37,,,4413.37,Other,150% of Medicare + 9.63% HCRA Surcharge,2683.8,45,,2683.8,percent of total billed charges,Critical Access Hospital RCC factor,2027.76,34,,2027.76,percent of total billed charges,Implant Device,2027.76,34,,2027.76,percent of total billed charges,Implant Device,2027.76,34,,2027.76,percent of total billed charges,Implant Device,2027.76,34,,2027.76,percent of total billed charges,Implant Device,2027.76,34,,2027.76,percent of total billed charges,Implant Device,2952.18,,,2952.18,Other,110% of Medicare,2087.4,35,,2087.4,percent of total billed charges,Implant Device,2027.76,34,"Charges > $500, x 34%",2027.76,percent of total billed charges,Implant Device,2087.4,35,,2087.4,percent of total billed charges,Implant Device,2087.4,35,,2087.4,percent of total billed charges,Implant Device,2087.4,35,,2087.4,percent of total billed charges,Implant Device,2087.4,35,,2087.4,percent of total billed charges,Implant Device,2087.4,35,,2087.4,percent of total billed charges,Implant Device,2385.6,40,,2385.6,percent of total billed charges,Implant Device,2087.4,70,,2087.4,percent of total billed charges,All Other,2027.76,34,,2027.76,percent of total billed charges,Implant Device,2027.76,34,,2027.76,percent of total billed charges,Implant Device,2087.4,35,,2087.4,percent of total billed charges,Implant Device,2087.4,35,,2087.4,percent of total billed charges,Implant Device,2087.4,35,,2087.4,percent of total billed charges,Implant Device,2087.4,35,,2087.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2027.76,34,"If Charge > 2,000, then 34 percent",2027.76,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4413.37,
ARTHREX AR-1934BCF SUTURE ANHOR 14.5X3,C1713,HCPCS,,79006495,CDM,278,RC,,,both,,,915,677.1,,,677.1,Other,150% of Medicare + 9.63% HCRA Surcharge,411.75,45,,411.75,percent of total billed charges,Critical Access Hospital RCC factor,311.1,34,,311.1,percent of total billed charges,Implant Device,311.1,34,,311.1,percent of total billed charges,Implant Device,311.1,34,,311.1,percent of total billed charges,Implant Device,311.1,34,,311.1,percent of total billed charges,Implant Device,311.1,34,,311.1,percent of total billed charges,Implant Device,452.93,,,452.93,Other,110% of Medicare,320.25,35,,320.25,percent of total billed charges,Implant Device,311.1,34,"Charges > $500, x 34%",311.1,percent of total billed charges,Implant Device,320.25,35,,320.25,percent of total billed charges,Implant Device,320.25,35,,320.25,percent of total billed charges,Implant Device,320.25,35,,320.25,percent of total billed charges,Implant Device,320.25,35,,320.25,percent of total billed charges,Implant Device,320.25,35,,320.25,percent of total billed charges,Implant Device,366,40,,366,percent of total billed charges,Implant Device,320.25,70,,320.25,percent of total billed charges,All Other,311.1,34,,311.1,percent of total billed charges,Implant Device,311.1,34,,311.1,percent of total billed charges,Implant Device,320.25,35,,320.25,percent of total billed charges,Implant Device,320.25,35,,320.25,percent of total billed charges,Implant Device,320.25,35,,320.25,percent of total billed charges,Implant Device,320.25,35,,320.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,677.1,
EXACTECH 314-13-14 CAGED GLENOID LARGE,C1776,HCPCS,,79006496,CDM,278,RC,,,both,,,4125,3052.51,,,3052.51,Other,150% of Medicare + 9.63% HCRA Surcharge,1856.25,45,,1856.25,percent of total billed charges,Critical Access Hospital RCC factor,1402.5,34,,1402.5,percent of total billed charges,Implant Device,1402.5,34,,1402.5,percent of total billed charges,Implant Device,1402.5,34,,1402.5,percent of total billed charges,Implant Device,1402.5,34,,1402.5,percent of total billed charges,Implant Device,1402.5,34,,1402.5,percent of total billed charges,Implant Device,2041.88,,,2041.88,Other,110% of Medicare,1443.75,35,,1443.75,percent of total billed charges,Implant Device,1402.5,34,"Charges > $500, x 34%",1402.5,percent of total billed charges,Implant Device,1443.75,35,,1443.75,percent of total billed charges,Implant Device,1443.75,35,,1443.75,percent of total billed charges,Implant Device,1443.75,35,,1443.75,percent of total billed charges,Implant Device,1443.75,35,,1443.75,percent of total billed charges,Implant Device,1443.75,35,,1443.75,percent of total billed charges,Implant Device,1650,40,,1650,percent of total billed charges,Implant Device,1443.75,70,,1443.75,percent of total billed charges,All Other,1402.5,34,,1402.5,percent of total billed charges,Implant Device,1402.5,34,,1402.5,percent of total billed charges,Implant Device,1443.75,35,,1443.75,percent of total billed charges,Implant Device,1443.75,35,,1443.75,percent of total billed charges,Implant Device,1443.75,35,,1443.75,percent of total billed charges,Implant Device,1443.75,35,,1443.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1402.5,34,"If Charge > 2,000, then 34 percent",1402.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3052.51,
METASURG DF2510 DIGIFUSE 2.5MM-10 ANGLE,C1776,HCPCS,,79006497,CDM,278,RC,,,both,,,3450,2553.01,,,2553.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1552.5,45,,1552.5,percent of total billed charges,Critical Access Hospital RCC factor,1173,34,,1173,percent of total billed charges,Implant Device,1173,34,,1173,percent of total billed charges,Implant Device,1173,34,,1173,percent of total billed charges,Implant Device,1173,34,,1173,percent of total billed charges,Implant Device,1173,34,,1173,percent of total billed charges,Implant Device,1707.75,,,1707.75,Other,110% of Medicare,1207.5,35,,1207.5,percent of total billed charges,Implant Device,1173,34,"Charges > $500, x 34%",1173,percent of total billed charges,Implant Device,1207.5,35,,1207.5,percent of total billed charges,Implant Device,1207.5,35,,1207.5,percent of total billed charges,Implant Device,1207.5,35,,1207.5,percent of total billed charges,Implant Device,1207.5,35,,1207.5,percent of total billed charges,Implant Device,1207.5,35,,1207.5,percent of total billed charges,Implant Device,1380,40,,1380,percent of total billed charges,Implant Device,1207.5,70,,1207.5,percent of total billed charges,All Other,1173,34,,1173,percent of total billed charges,Implant Device,1173,34,,1173,percent of total billed charges,Implant Device,1207.5,35,,1207.5,percent of total billed charges,Implant Device,1207.5,35,,1207.5,percent of total billed charges,Implant Device,1207.5,35,,1207.5,percent of total billed charges,Implant Device,1207.5,35,,1207.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1173,34,"If Charge > 2,000, then 34 percent",1173,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2553.01,
METASURG TQ2012 QUICK SNAP IMPLANT,C1776,HCPCS,,79006498,CDM,278,RC,,,both,,,720,532.8,,,532.8,Other,150% of Medicare + 9.63% HCRA Surcharge,324,45,,324,percent of total billed charges,Critical Access Hospital RCC factor,244.8,34,,244.8,percent of total billed charges,Implant Device,244.8,34,,244.8,percent of total billed charges,Implant Device,244.8,34,,244.8,percent of total billed charges,Implant Device,244.8,34,,244.8,percent of total billed charges,Implant Device,244.8,34,,244.8,percent of total billed charges,Implant Device,356.4,,,356.4,Other,110% of Medicare,252,35,,252,percent of total billed charges,Implant Device,244.8,34,"Charges > $500, x 34%",244.8,percent of total billed charges,Implant Device,252,35,,252,percent of total billed charges,Implant Device,252,35,,252,percent of total billed charges,Implant Device,252,35,,252,percent of total billed charges,Implant Device,252,35,,252,percent of total billed charges,Implant Device,252,35,,252,percent of total billed charges,Implant Device,288,40,,288,percent of total billed charges,Implant Device,252,70,,252,percent of total billed charges,All Other,244.8,34,,244.8,percent of total billed charges,Implant Device,244.8,34,,244.8,percent of total billed charges,Implant Device,252,35,,252,percent of total billed charges,Implant Device,252,35,,252,percent of total billed charges,Implant Device,252,35,,252,percent of total billed charges,Implant Device,252,35,,252,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,532.8,
TRISTATE BIOLOGICS AI-5125 ALLOGRAFT,C1713,HCPCS,,79006499,CDM,278,RC,,,both,,,5502,4071.49,,,4071.49,Other,150% of Medicare + 9.63% HCRA Surcharge,2475.9,45,,2475.9,percent of total billed charges,Critical Access Hospital RCC factor,1870.68,34,,1870.68,percent of total billed charges,Implant Device,1870.68,34,,1870.68,percent of total billed charges,Implant Device,1870.68,34,,1870.68,percent of total billed charges,Implant Device,1870.68,34,,1870.68,percent of total billed charges,Implant Device,1870.68,34,,1870.68,percent of total billed charges,Implant Device,2723.49,,,2723.49,Other,110% of Medicare,1925.7,35,,1925.7,percent of total billed charges,Implant Device,1870.68,34,"Charges > $500, x 34%",1870.68,percent of total billed charges,Implant Device,1925.7,35,,1925.7,percent of total billed charges,Implant Device,1925.7,35,,1925.7,percent of total billed charges,Implant Device,1925.7,35,,1925.7,percent of total billed charges,Implant Device,1925.7,35,,1925.7,percent of total billed charges,Implant Device,1925.7,35,,1925.7,percent of total billed charges,Implant Device,2200.8,40,,2200.8,percent of total billed charges,Implant Device,1925.7,70,,1925.7,percent of total billed charges,All Other,1870.68,34,,1870.68,percent of total billed charges,Implant Device,1870.68,34,,1870.68,percent of total billed charges,Implant Device,1925.7,35,,1925.7,percent of total billed charges,Implant Device,1925.7,35,,1925.7,percent of total billed charges,Implant Device,1925.7,35,,1925.7,percent of total billed charges,Implant Device,1925.7,35,,1925.7,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1870.68,34,"If Charge > 2,000, then 34 percent",1870.68,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4071.49,
METASURG BF46200 BIOFIX ALLOGRAFT,C1713,HCPCS,,79006500,CDM,278,RC,,,both,,,12623,9341.05,,,9341.05,Other,150% of Medicare + 9.63% HCRA Surcharge,5680.35,45,,5680.35,percent of total billed charges,Critical Access Hospital RCC factor,4291.82,34,,4291.82,percent of total billed charges,Implant Device,4291.82,34,,4291.82,percent of total billed charges,Implant Device,4291.82,34,,4291.82,percent of total billed charges,Implant Device,4291.82,34,,4291.82,percent of total billed charges,Implant Device,4291.82,34,,4291.82,percent of total billed charges,Implant Device,6248.39,,,6248.39,Other,110% of Medicare,4418.05,35,,4418.05,percent of total billed charges,Implant Device,4291.82,34,"Charges > $500, x 34%",4291.82,percent of total billed charges,Implant Device,4418.05,35,,4418.05,percent of total billed charges,Implant Device,4418.05,35,,4418.05,percent of total billed charges,Implant Device,4418.05,35,,4418.05,percent of total billed charges,Implant Device,4418.05,35,,4418.05,percent of total billed charges,Implant Device,4418.05,35,,4418.05,percent of total billed charges,Implant Device,5049.2,40,,5049.2,percent of total billed charges,Implant Device,4418.05,70,,4418.05,percent of total billed charges,All Other,4291.82,34,,4291.82,percent of total billed charges,Implant Device,4291.82,34,,4291.82,percent of total billed charges,Implant Device,4418.05,35,,4418.05,percent of total billed charges,Implant Device,4418.05,35,,4418.05,percent of total billed charges,Implant Device,4418.05,35,,4418.05,percent of total billed charges,Implant Device,4418.05,35,,4418.05,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,4291.82,34,"If Charge > 2,000, then 34 percent",4291.82,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,9341.05,
WRIGHT MEDICAL CCP-LPNIR LAPIDUS PLATE,C1713,HCPCS,,79006501,CDM,278,RC,,,both,,,6708,4963.94,,,4963.94,Other,150% of Medicare + 9.63% HCRA Surcharge,3018.6,45,,3018.6,percent of total billed charges,Critical Access Hospital RCC factor,2280.72,34,,2280.72,percent of total billed charges,Implant Device,2280.72,34,,2280.72,percent of total billed charges,Implant Device,2280.72,34,,2280.72,percent of total billed charges,Implant Device,2280.72,34,,2280.72,percent of total billed charges,Implant Device,2280.72,34,,2280.72,percent of total billed charges,Implant Device,3320.46,,,3320.46,Other,110% of Medicare,2347.8,35,,2347.8,percent of total billed charges,Implant Device,2280.72,34,"Charges > $500, x 34%",2280.72,percent of total billed charges,Implant Device,2347.8,35,,2347.8,percent of total billed charges,Implant Device,2347.8,35,,2347.8,percent of total billed charges,Implant Device,2347.8,35,,2347.8,percent of total billed charges,Implant Device,2347.8,35,,2347.8,percent of total billed charges,Implant Device,2347.8,35,,2347.8,percent of total billed charges,Implant Device,2683.2,40,,2683.2,percent of total billed charges,Implant Device,2347.8,70,,2347.8,percent of total billed charges,All Other,2280.72,34,,2280.72,percent of total billed charges,Implant Device,2280.72,34,,2280.72,percent of total billed charges,Implant Device,2347.8,35,,2347.8,percent of total billed charges,Implant Device,2347.8,35,,2347.8,percent of total billed charges,Implant Device,2347.8,35,,2347.8,percent of total billed charges,Implant Device,2347.8,35,,2347.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2280.72,34,"If Charge > 2,000, then 34 percent",2280.72,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4963.94,
WRIGHT MEDICAL CCP-L3022 LOCK SCREW 3X22,C1713,HCPCS,,79006502,CDM,278,RC,,,both,,,1126,833.24,,,833.24,Other,150% of Medicare + 9.63% HCRA Surcharge,506.7,45,,506.7,percent of total billed charges,Critical Access Hospital RCC factor,382.84,34,,382.84,percent of total billed charges,Implant Device,382.84,34,,382.84,percent of total billed charges,Implant Device,382.84,34,,382.84,percent of total billed charges,Implant Device,382.84,34,,382.84,percent of total billed charges,Implant Device,382.84,34,,382.84,percent of total billed charges,Implant Device,557.37,,,557.37,Other,110% of Medicare,394.1,35,,394.1,percent of total billed charges,Implant Device,382.84,34,"Charges > $500, x 34%",382.84,percent of total billed charges,Implant Device,394.1,35,,394.1,percent of total billed charges,Implant Device,394.1,35,,394.1,percent of total billed charges,Implant Device,394.1,35,,394.1,percent of total billed charges,Implant Device,394.1,35,,394.1,percent of total billed charges,Implant Device,394.1,35,,394.1,percent of total billed charges,Implant Device,450.4,40,,450.4,percent of total billed charges,Implant Device,394.1,70,,394.1,percent of total billed charges,All Other,382.84,34,,382.84,percent of total billed charges,Implant Device,382.84,34,,382.84,percent of total billed charges,Implant Device,394.1,35,,394.1,percent of total billed charges,Implant Device,394.1,35,,394.1,percent of total billed charges,Implant Device,394.1,35,,394.1,percent of total billed charges,Implant Device,394.1,35,,394.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,833.24,
ZIMMER 00-5880-005-00 TIBIAL COMP SIZE 5,C1776,HCPCS,,79006506,CDM,278,RC,,,both,,,13023,9637.05,,,9637.05,Other,150% of Medicare + 9.63% HCRA Surcharge,5860.35,45,,5860.35,percent of total billed charges,Critical Access Hospital RCC factor,4427.82,34,,4427.82,percent of total billed charges,Implant Device,4427.82,34,,4427.82,percent of total billed charges,Implant Device,4427.82,34,,4427.82,percent of total billed charges,Implant Device,4427.82,34,,4427.82,percent of total billed charges,Implant Device,4427.82,34,,4427.82,percent of total billed charges,Implant Device,6446.39,,,6446.39,Other,110% of Medicare,4558.05,35,,4558.05,percent of total billed charges,Implant Device,4427.82,34,"Charges > $500, x 34%",4427.82,percent of total billed charges,Implant Device,4558.05,35,,4558.05,percent of total billed charges,Implant Device,4558.05,35,,4558.05,percent of total billed charges,Implant Device,4558.05,35,,4558.05,percent of total billed charges,Implant Device,4558.05,35,,4558.05,percent of total billed charges,Implant Device,4558.05,35,,4558.05,percent of total billed charges,Implant Device,5209.2,40,,5209.2,percent of total billed charges,Implant Device,4558.05,70,,4558.05,percent of total billed charges,All Other,4427.82,34,,4427.82,percent of total billed charges,Implant Device,4427.82,34,,4427.82,percent of total billed charges,Implant Device,4558.05,35,,4558.05,percent of total billed charges,Implant Device,4558.05,35,,4558.05,percent of total billed charges,Implant Device,4558.05,35,,4558.05,percent of total billed charges,Implant Device,4558.05,35,,4558.05,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,4427.82,34,"If Charge > 2,000, then 34 percent",4427.82,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,9637.05,
ZIMMER 00-5880-016-02 FEM COMP SIZE F RT,C1776,HCPCS,,79006507,CDM,278,RC,,,both,,,26254,19428.03,,,19428.03,Other,150% of Medicare + 9.63% HCRA Surcharge,11814.3,45,,11814.3,percent of total billed charges,Critical Access Hospital RCC factor,8926.36,34,,8926.36,percent of total billed charges,Implant Device,8926.36,34,,8926.36,percent of total billed charges,Implant Device,8926.36,34,,8926.36,percent of total billed charges,Implant Device,8926.36,34,,8926.36,percent of total billed charges,Implant Device,8926.36,34,,8926.36,percent of total billed charges,Implant Device,12995.73,,,12995.73,Other,110% of Medicare,9188.9,35,,9188.9,percent of total billed charges,Implant Device,8926.36,34,"Charges > $500, x 34%",8926.36,percent of total billed charges,Implant Device,9188.9,35,,9188.9,percent of total billed charges,Implant Device,9188.9,35,,9188.9,percent of total billed charges,Implant Device,9188.9,35,,9188.9,percent of total billed charges,Implant Device,9188.9,35,,9188.9,percent of total billed charges,Implant Device,9188.9,35,,9188.9,percent of total billed charges,Implant Device,10501.6,40,,10501.6,percent of total billed charges,Implant Device,9188.9,70,,9188.9,percent of total billed charges,All Other,8926.36,34,,8926.36,percent of total billed charges,Implant Device,8926.36,34,,8926.36,percent of total billed charges,Implant Device,9188.9,35,,9188.9,percent of total billed charges,Implant Device,9188.9,35,,9188.9,percent of total billed charges,Implant Device,9188.9,35,,9188.9,percent of total billed charges,Implant Device,9188.9,35,,9188.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,8926.36,34,"If Charge > 2,000, then 34 percent",8926.36,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,19428.03,
ZIMMER 00-5880-060-20 ART SURF SZ F 20MM,C1776,HCPCS,,79006508,CDM,278,RC,,,both,,,5603,4146.23,,,4146.23,Other,150% of Medicare + 9.63% HCRA Surcharge,2521.35,45,,2521.35,percent of total billed charges,Critical Access Hospital RCC factor,1905.02,34,,1905.02,percent of total billed charges,Implant Device,1905.02,34,,1905.02,percent of total billed charges,Implant Device,1905.02,34,,1905.02,percent of total billed charges,Implant Device,1905.02,34,,1905.02,percent of total billed charges,Implant Device,1905.02,34,,1905.02,percent of total billed charges,Implant Device,2773.49,,,2773.49,Other,110% of Medicare,1961.05,35,,1961.05,percent of total billed charges,Implant Device,1905.02,34,"Charges > $500, x 34%",1905.02,percent of total billed charges,Implant Device,1961.05,35,,1961.05,percent of total billed charges,Implant Device,1961.05,35,,1961.05,percent of total billed charges,Implant Device,1961.05,35,,1961.05,percent of total billed charges,Implant Device,1961.05,35,,1961.05,percent of total billed charges,Implant Device,1961.05,35,,1961.05,percent of total billed charges,Implant Device,2241.2,40,,2241.2,percent of total billed charges,Implant Device,1961.05,70,,1961.05,percent of total billed charges,All Other,1905.02,34,,1905.02,percent of total billed charges,Implant Device,1905.02,34,,1905.02,percent of total billed charges,Implant Device,1961.05,35,,1961.05,percent of total billed charges,Implant Device,1961.05,35,,1961.05,percent of total billed charges,Implant Device,1961.05,35,,1961.05,percent of total billed charges,Implant Device,1961.05,35,,1961.05,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1905.02,34,"If Charge > 2,000, then 34 percent",1905.02,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4146.23,
DEPUY 1035-42-000 BI-POLAR HEAD 28X42MM,C1776,HCPCS,,79006509,CDM,278,RC,,,both,,,3314,2452.37,,,2452.37,Other,150% of Medicare + 9.63% HCRA Surcharge,1491.3,45,,1491.3,percent of total billed charges,Critical Access Hospital RCC factor,1126.76,34,,1126.76,percent of total billed charges,Implant Device,1126.76,34,,1126.76,percent of total billed charges,Implant Device,1126.76,34,,1126.76,percent of total billed charges,Implant Device,1126.76,34,,1126.76,percent of total billed charges,Implant Device,1126.76,34,,1126.76,percent of total billed charges,Implant Device,1640.43,,,1640.43,Other,110% of Medicare,1159.9,35,,1159.9,percent of total billed charges,Implant Device,1126.76,34,"Charges > $500, x 34%",1126.76,percent of total billed charges,Implant Device,1159.9,35,,1159.9,percent of total billed charges,Implant Device,1159.9,35,,1159.9,percent of total billed charges,Implant Device,1159.9,35,,1159.9,percent of total billed charges,Implant Device,1159.9,35,,1159.9,percent of total billed charges,Implant Device,1159.9,35,,1159.9,percent of total billed charges,Implant Device,1325.6,40,,1325.6,percent of total billed charges,Implant Device,1159.9,70,,1159.9,percent of total billed charges,All Other,1126.76,34,,1126.76,percent of total billed charges,Implant Device,1126.76,34,,1126.76,percent of total billed charges,Implant Device,1159.9,35,,1159.9,percent of total billed charges,Implant Device,1159.9,35,,1159.9,percent of total billed charges,Implant Device,1159.9,35,,1159.9,percent of total billed charges,Implant Device,1159.9,35,,1159.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1126.76,34,"If Charge > 2,000, then 34 percent",1126.76,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2452.37,
DEPUY 1365-28-330 FEMORAL HEAD +8.5 28MM,C1776,HCPCS,,79006510,CDM,278,RC,,,both,,,4746,3512.05,,,3512.05,Other,150% of Medicare + 9.63% HCRA Surcharge,2135.7,45,,2135.7,percent of total billed charges,Critical Access Hospital RCC factor,1613.64,34,,1613.64,percent of total billed charges,Implant Device,1613.64,34,,1613.64,percent of total billed charges,Implant Device,1613.64,34,,1613.64,percent of total billed charges,Implant Device,1613.64,34,,1613.64,percent of total billed charges,Implant Device,1613.64,34,,1613.64,percent of total billed charges,Implant Device,2349.27,,,2349.27,Other,110% of Medicare,1661.1,35,,1661.1,percent of total billed charges,Implant Device,1613.64,34,"Charges > $500, x 34%",1613.64,percent of total billed charges,Implant Device,1661.1,35,,1661.1,percent of total billed charges,Implant Device,1661.1,35,,1661.1,percent of total billed charges,Implant Device,1661.1,35,,1661.1,percent of total billed charges,Implant Device,1661.1,35,,1661.1,percent of total billed charges,Implant Device,1661.1,35,,1661.1,percent of total billed charges,Implant Device,1898.4,40,,1898.4,percent of total billed charges,Implant Device,1661.1,70,,1661.1,percent of total billed charges,All Other,1613.64,34,,1613.64,percent of total billed charges,Implant Device,1613.64,34,,1613.64,percent of total billed charges,Implant Device,1661.1,35,,1661.1,percent of total billed charges,Implant Device,1661.1,35,,1661.1,percent of total billed charges,Implant Device,1661.1,35,,1661.1,percent of total billed charges,Implant Device,1661.1,35,,1661.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1613.64,34,"If Charge > 2,000, then 34 percent",1613.64,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3512.05,
BIOCOMPOSITES 620-010 RAPIDCURE 10CC,C1713,HCPCS,,79006512,CDM,278,RC,,,both,,,4785,3540.91,,,3540.91,Other,150% of Medicare + 9.63% HCRA Surcharge,2153.25,45,,2153.25,percent of total billed charges,Critical Access Hospital RCC factor,1626.9,34,,1626.9,percent of total billed charges,Implant Device,1626.9,34,,1626.9,percent of total billed charges,Implant Device,1626.9,34,,1626.9,percent of total billed charges,Implant Device,1626.9,34,,1626.9,percent of total billed charges,Implant Device,1626.9,34,,1626.9,percent of total billed charges,Implant Device,2368.58,,,2368.58,Other,110% of Medicare,1674.75,35,,1674.75,percent of total billed charges,Implant Device,1626.9,34,"Charges > $500, x 34%",1626.9,percent of total billed charges,Implant Device,1674.75,35,,1674.75,percent of total billed charges,Implant Device,1674.75,35,,1674.75,percent of total billed charges,Implant Device,1674.75,35,,1674.75,percent of total billed charges,Implant Device,1674.75,35,,1674.75,percent of total billed charges,Implant Device,1674.75,35,,1674.75,percent of total billed charges,Implant Device,1914,40,,1914,percent of total billed charges,Implant Device,1674.75,70,,1674.75,percent of total billed charges,All Other,1626.9,34,,1626.9,percent of total billed charges,Implant Device,1626.9,34,,1626.9,percent of total billed charges,Implant Device,1674.75,35,,1674.75,percent of total billed charges,Implant Device,1674.75,35,,1674.75,percent of total billed charges,Implant Device,1674.75,35,,1674.75,percent of total billed charges,Implant Device,1674.75,35,,1674.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1626.9,34,"If Charge > 2,000, then 34 percent",1626.9,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3540.91,
DEPUY 1246-03-000 HOLE ELIMINATOR,C1713,HCPCS,,79006513,CDM,278,RC,,,both,,,524,387.76,,,387.76,Other,150% of Medicare + 9.63% HCRA Surcharge,235.8,45,,235.8,percent of total billed charges,Critical Access Hospital RCC factor,178.16,34,,178.16,percent of total billed charges,Implant Device,178.16,34,,178.16,percent of total billed charges,Implant Device,178.16,34,,178.16,percent of total billed charges,Implant Device,178.16,34,,178.16,percent of total billed charges,Implant Device,178.16,34,,178.16,percent of total billed charges,Implant Device,259.38,,,259.38,Other,110% of Medicare,183.4,35,,183.4,percent of total billed charges,Implant Device,178.16,34,"Charges > $500, x 34%",178.16,percent of total billed charges,Implant Device,183.4,35,,183.4,percent of total billed charges,Implant Device,183.4,35,,183.4,percent of total billed charges,Implant Device,183.4,35,,183.4,percent of total billed charges,Implant Device,183.4,35,,183.4,percent of total billed charges,Implant Device,183.4,35,,183.4,percent of total billed charges,Implant Device,209.6,40,,209.6,percent of total billed charges,Implant Device,183.4,70,,183.4,percent of total billed charges,All Other,178.16,34,,178.16,percent of total billed charges,Implant Device,178.16,34,,178.16,percent of total billed charges,Implant Device,183.4,35,,183.4,percent of total billed charges,Implant Device,183.4,35,,183.4,percent of total billed charges,Implant Device,183.4,35,,183.4,percent of total billed charges,Implant Device,183.4,35,,183.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,387.76,
DEPUY 1365-28-310 FEM HEAD +1.5 28MM DIA,C1776,HCPCS,,79006514,CDM,278,RC,,,both,,,2636,1950.65,,,1950.65,Other,150% of Medicare + 9.63% HCRA Surcharge,1186.2,45,,1186.2,percent of total billed charges,Critical Access Hospital RCC factor,896.24,34,,896.24,percent of total billed charges,Implant Device,896.24,34,,896.24,percent of total billed charges,Implant Device,896.24,34,,896.24,percent of total billed charges,Implant Device,896.24,34,,896.24,percent of total billed charges,Implant Device,896.24,34,,896.24,percent of total billed charges,Implant Device,1304.82,,,1304.82,Other,110% of Medicare,922.6,35,,922.6,percent of total billed charges,Implant Device,896.24,34,"Charges > $500, x 34%",896.24,percent of total billed charges,Implant Device,922.6,35,,922.6,percent of total billed charges,Implant Device,922.6,35,,922.6,percent of total billed charges,Implant Device,922.6,35,,922.6,percent of total billed charges,Implant Device,922.6,35,,922.6,percent of total billed charges,Implant Device,922.6,35,,922.6,percent of total billed charges,Implant Device,1054.4,40,,1054.4,percent of total billed charges,Implant Device,922.6,70,,922.6,percent of total billed charges,All Other,896.24,34,,896.24,percent of total billed charges,Implant Device,896.24,34,,896.24,percent of total billed charges,Implant Device,922.6,35,,922.6,percent of total billed charges,Implant Device,922.6,35,,922.6,percent of total billed charges,Implant Device,922.6,35,,922.6,percent of total billed charges,Implant Device,922.6,35,,922.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,896.24,34,"If Charge > 2,000, then 34 percent",896.24,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1950.65,
DEPUY 3L92501 FEM STEM SZ 11 STND COLLAR,C1776,HCPCS,,79006515,CDM,278,RC,,,both,,,13446,9950.07,,,9950.07,Other,150% of Medicare + 9.63% HCRA Surcharge,6050.7,45,,6050.7,percent of total billed charges,Critical Access Hospital RCC factor,4571.64,34,,4571.64,percent of total billed charges,Implant Device,4571.64,34,,4571.64,percent of total billed charges,Implant Device,4571.64,34,,4571.64,percent of total billed charges,Implant Device,4571.64,34,,4571.64,percent of total billed charges,Implant Device,4571.64,34,,4571.64,percent of total billed charges,Implant Device,6655.77,,,6655.77,Other,110% of Medicare,4706.1,35,,4706.1,percent of total billed charges,Implant Device,4571.64,34,"Charges > $500, x 34%",4571.64,percent of total billed charges,Implant Device,4706.1,35,,4706.1,percent of total billed charges,Implant Device,4706.1,35,,4706.1,percent of total billed charges,Implant Device,4706.1,35,,4706.1,percent of total billed charges,Implant Device,4706.1,35,,4706.1,percent of total billed charges,Implant Device,4706.1,35,,4706.1,percent of total billed charges,Implant Device,5378.4,40,,5378.4,percent of total billed charges,Implant Device,4706.1,70,,4706.1,percent of total billed charges,All Other,4571.64,34,,4571.64,percent of total billed charges,Implant Device,4571.64,34,,4571.64,percent of total billed charges,Implant Device,4706.1,35,,4706.1,percent of total billed charges,Implant Device,4706.1,35,,4706.1,percent of total billed charges,Implant Device,4706.1,35,,4706.1,percent of total billed charges,Implant Device,4706.1,35,,4706.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,4571.64,34,"If Charge > 2,000, then 34 percent",4571.64,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,9950.07,
WRIGHT MEDICAL CCP-LPNOL LAPIDUS PLATE,C1713,HCPCS,,79006518,CDM,278,RC,,,both,,,6708,4963.94,,,4963.94,Other,150% of Medicare + 9.63% HCRA Surcharge,3018.6,45,,3018.6,percent of total billed charges,Critical Access Hospital RCC factor,2280.72,34,,2280.72,percent of total billed charges,Implant Device,2280.72,34,,2280.72,percent of total billed charges,Implant Device,2280.72,34,,2280.72,percent of total billed charges,Implant Device,2280.72,34,,2280.72,percent of total billed charges,Implant Device,2280.72,34,,2280.72,percent of total billed charges,Implant Device,3320.46,,,3320.46,Other,110% of Medicare,2347.8,35,,2347.8,percent of total billed charges,Implant Device,2280.72,34,"Charges > $500, x 34%",2280.72,percent of total billed charges,Implant Device,2347.8,35,,2347.8,percent of total billed charges,Implant Device,2347.8,35,,2347.8,percent of total billed charges,Implant Device,2347.8,35,,2347.8,percent of total billed charges,Implant Device,2347.8,35,,2347.8,percent of total billed charges,Implant Device,2347.8,35,,2347.8,percent of total billed charges,Implant Device,2683.2,40,,2683.2,percent of total billed charges,Implant Device,2347.8,70,,2347.8,percent of total billed charges,All Other,2280.72,34,,2280.72,percent of total billed charges,Implant Device,2280.72,34,,2280.72,percent of total billed charges,Implant Device,2347.8,35,,2347.8,percent of total billed charges,Implant Device,2347.8,35,,2347.8,percent of total billed charges,Implant Device,2347.8,35,,2347.8,percent of total billed charges,Implant Device,2347.8,35,,2347.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2280.72,34,"If Charge > 2,000, then 34 percent",2280.72,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4963.94,
WRIGHT MEDICAL CCP-L3022 LOCK SCREW 3X22,C1713,HCPCS,,79006519,CDM,278,RC,,,both,,,1125,832.5,,,832.5,Other,150% of Medicare + 9.63% HCRA Surcharge,506.25,45,,506.25,percent of total billed charges,Critical Access Hospital RCC factor,382.5,34,,382.5,percent of total billed charges,Implant Device,382.5,34,,382.5,percent of total billed charges,Implant Device,382.5,34,,382.5,percent of total billed charges,Implant Device,382.5,34,,382.5,percent of total billed charges,Implant Device,382.5,34,,382.5,percent of total billed charges,Implant Device,556.88,,,556.88,Other,110% of Medicare,393.75,35,,393.75,percent of total billed charges,Implant Device,382.5,34,"Charges > $500, x 34%",382.5,percent of total billed charges,Implant Device,393.75,35,,393.75,percent of total billed charges,Implant Device,393.75,35,,393.75,percent of total billed charges,Implant Device,393.75,35,,393.75,percent of total billed charges,Implant Device,393.75,35,,393.75,percent of total billed charges,Implant Device,393.75,35,,393.75,percent of total billed charges,Implant Device,450,40,,450,percent of total billed charges,Implant Device,393.75,70,,393.75,percent of total billed charges,All Other,382.5,34,,382.5,percent of total billed charges,Implant Device,382.5,34,,382.5,percent of total billed charges,Implant Device,393.75,35,,393.75,percent of total billed charges,Implant Device,393.75,35,,393.75,percent of total billed charges,Implant Device,393.75,35,,393.75,percent of total billed charges,Implant Device,393.75,35,,393.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,832.5,
STRYKER 5050-4-300 TRANSFIXING PIN,C1713,HCPCS,,79006522,CDM,278,RC,,,both,,,275,203.5,,,203.5,Other,150% of Medicare + 9.63% HCRA Surcharge,123.75,45,,123.75,percent of total billed charges,Critical Access Hospital RCC factor,93.5,34,,93.5,percent of total billed charges,Implant Device,93.5,34,,93.5,percent of total billed charges,Implant Device,93.5,34,,93.5,percent of total billed charges,Implant Device,93.5,34,,93.5,percent of total billed charges,Implant Device,93.5,34,,93.5,percent of total billed charges,Implant Device,136.13,,,136.13,Other,110% of Medicare,96.25,35,,96.25,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,96.25,35,,96.25,percent of total billed charges,Implant Device,96.25,35,,96.25,percent of total billed charges,Implant Device,96.25,35,,96.25,percent of total billed charges,Implant Device,96.25,35,,96.25,percent of total billed charges,Implant Device,96.25,35,,96.25,percent of total billed charges,Implant Device,110,40,,110,percent of total billed charges,Implant Device,96.25,70,,96.25,percent of total billed charges,All Other,93.5,34,,93.5,percent of total billed charges,Implant Device,93.5,34,,93.5,percent of total billed charges,Implant Device,96.25,35,,96.25,percent of total billed charges,Implant Device,96.25,35,,96.25,percent of total billed charges,Implant Device,96.25,35,,96.25,percent of total billed charges,Implant Device,96.25,35,,96.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,203.5,
SYNTHES 208.860 7.3MM CANNULATED SCREW,C1713,HCPCS,,79006523,CDM,278,RC,,,both,,,906,670.44,,,670.44,Other,150% of Medicare + 9.63% HCRA Surcharge,407.7,45,,407.7,percent of total billed charges,Critical Access Hospital RCC factor,308.04,34,,308.04,percent of total billed charges,Implant Device,308.04,34,,308.04,percent of total billed charges,Implant Device,308.04,34,,308.04,percent of total billed charges,Implant Device,308.04,34,,308.04,percent of total billed charges,Implant Device,308.04,34,,308.04,percent of total billed charges,Implant Device,448.47,,,448.47,Other,110% of Medicare,317.1,35,,317.1,percent of total billed charges,Implant Device,308.04,34,"Charges > $500, x 34%",308.04,percent of total billed charges,Implant Device,317.1,35,,317.1,percent of total billed charges,Implant Device,317.1,35,,317.1,percent of total billed charges,Implant Device,317.1,35,,317.1,percent of total billed charges,Implant Device,317.1,35,,317.1,percent of total billed charges,Implant Device,317.1,35,,317.1,percent of total billed charges,Implant Device,362.4,40,,362.4,percent of total billed charges,Implant Device,317.1,70,,317.1,percent of total billed charges,All Other,308.04,34,,308.04,percent of total billed charges,Implant Device,308.04,34,,308.04,percent of total billed charges,Implant Device,317.1,35,,317.1,percent of total billed charges,Implant Device,317.1,35,,317.1,percent of total billed charges,Implant Device,317.1,35,,317.1,percent of total billed charges,Implant Device,317.1,35,,317.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,670.44,
SYNTHES 208.865 7.3MM CANNULATED SCREW,C1713,HCPCS,,79006524,CDM,278,RC,,,both,,,906,670.44,,,670.44,Other,150% of Medicare + 9.63% HCRA Surcharge,407.7,45,,407.7,percent of total billed charges,Critical Access Hospital RCC factor,308.04,34,,308.04,percent of total billed charges,Implant Device,308.04,34,,308.04,percent of total billed charges,Implant Device,308.04,34,,308.04,percent of total billed charges,Implant Device,308.04,34,,308.04,percent of total billed charges,Implant Device,308.04,34,,308.04,percent of total billed charges,Implant Device,448.47,,,448.47,Other,110% of Medicare,317.1,35,,317.1,percent of total billed charges,Implant Device,308.04,34,"Charges > $500, x 34%",308.04,percent of total billed charges,Implant Device,317.1,35,,317.1,percent of total billed charges,Implant Device,317.1,35,,317.1,percent of total billed charges,Implant Device,317.1,35,,317.1,percent of total billed charges,Implant Device,317.1,35,,317.1,percent of total billed charges,Implant Device,317.1,35,,317.1,percent of total billed charges,Implant Device,362.4,40,,362.4,percent of total billed charges,Implant Device,317.1,70,,317.1,percent of total billed charges,All Other,308.04,34,,308.04,percent of total billed charges,Implant Device,308.04,34,,308.04,percent of total billed charges,Implant Device,317.1,35,,317.1,percent of total billed charges,Implant Device,317.1,35,,317.1,percent of total billed charges,Implant Device,317.1,35,,317.1,percent of total billed charges,Implant Device,317.1,35,,317.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,670.44,
SYNTHES 208.870 7.3MM CANNULATED SCREW,C1713,HCPCS,,79006525,CDM,278,RC,,,both,,,906,670.44,,,670.44,Other,150% of Medicare + 9.63% HCRA Surcharge,407.7,45,,407.7,percent of total billed charges,Critical Access Hospital RCC factor,308.04,34,,308.04,percent of total billed charges,Implant Device,308.04,34,,308.04,percent of total billed charges,Implant Device,308.04,34,,308.04,percent of total billed charges,Implant Device,308.04,34,,308.04,percent of total billed charges,Implant Device,308.04,34,,308.04,percent of total billed charges,Implant Device,448.47,,,448.47,Other,110% of Medicare,317.1,35,,317.1,percent of total billed charges,Implant Device,308.04,34,"Charges > $500, x 34%",308.04,percent of total billed charges,Implant Device,317.1,35,,317.1,percent of total billed charges,Implant Device,317.1,35,,317.1,percent of total billed charges,Implant Device,317.1,35,,317.1,percent of total billed charges,Implant Device,317.1,35,,317.1,percent of total billed charges,Implant Device,317.1,35,,317.1,percent of total billed charges,Implant Device,362.4,40,,362.4,percent of total billed charges,Implant Device,317.1,70,,317.1,percent of total billed charges,All Other,308.04,34,,308.04,percent of total billed charges,Implant Device,308.04,34,,308.04,percent of total billed charges,Implant Device,317.1,35,,317.1,percent of total billed charges,Implant Device,317.1,35,,317.1,percent of total billed charges,Implant Device,317.1,35,,317.1,percent of total billed charges,Implant Device,317.1,35,,317.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,670.44,
STRYKER 3225-0360S LONG NAIL KIT 11X125,C1713,HCPCS,,79006529,CDM,278,RC,,,both,,,9323,6899.04,,,6899.04,Other,150% of Medicare + 9.63% HCRA Surcharge,4195.35,45,,4195.35,percent of total billed charges,Critical Access Hospital RCC factor,3169.82,34,,3169.82,percent of total billed charges,Implant Device,3169.82,34,,3169.82,percent of total billed charges,Implant Device,3169.82,34,,3169.82,percent of total billed charges,Implant Device,3169.82,34,,3169.82,percent of total billed charges,Implant Device,3169.82,34,,3169.82,percent of total billed charges,Implant Device,4614.89,,,4614.89,Other,110% of Medicare,3263.05,35,,3263.05,percent of total billed charges,Implant Device,3169.82,34,"Charges > $500, x 34%",3169.82,percent of total billed charges,Implant Device,3263.05,35,,3263.05,percent of total billed charges,Implant Device,3263.05,35,,3263.05,percent of total billed charges,Implant Device,3263.05,35,,3263.05,percent of total billed charges,Implant Device,3263.05,35,,3263.05,percent of total billed charges,Implant Device,3263.05,35,,3263.05,percent of total billed charges,Implant Device,3729.2,40,,3729.2,percent of total billed charges,Implant Device,3263.05,70,,3263.05,percent of total billed charges,All Other,3169.82,34,,3169.82,percent of total billed charges,Implant Device,3169.82,34,,3169.82,percent of total billed charges,Implant Device,3263.05,35,,3263.05,percent of total billed charges,Implant Device,3263.05,35,,3263.05,percent of total billed charges,Implant Device,3263.05,35,,3263.05,percent of total billed charges,Implant Device,3263.05,35,,3263.05,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3169.82,34,"If Charge > 2,000, then 34 percent",3169.82,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,6899.04,
DEPUY 1365-23-000 FEM HEAD 32MM +9 12/14,C1776,HCPCS,,79006531,CDM,278,RC,,,both,,,1792,1326.08,,,1326.08,Other,150% of Medicare + 9.63% HCRA Surcharge,806.4,45,,806.4,percent of total billed charges,Critical Access Hospital RCC factor,609.28,34,,609.28,percent of total billed charges,Implant Device,609.28,34,,609.28,percent of total billed charges,Implant Device,609.28,34,,609.28,percent of total billed charges,Implant Device,609.28,34,,609.28,percent of total billed charges,Implant Device,609.28,34,,609.28,percent of total billed charges,Implant Device,887.04,,,887.04,Other,110% of Medicare,627.2,35,,627.2,percent of total billed charges,Implant Device,609.28,34,"Charges > $500, x 34%",609.28,percent of total billed charges,Implant Device,627.2,35,,627.2,percent of total billed charges,Implant Device,627.2,35,,627.2,percent of total billed charges,Implant Device,627.2,35,,627.2,percent of total billed charges,Implant Device,627.2,35,,627.2,percent of total billed charges,Implant Device,627.2,35,,627.2,percent of total billed charges,Implant Device,716.8,40,,716.8,percent of total billed charges,Implant Device,627.2,70,,627.2,percent of total billed charges,All Other,609.28,34,,609.28,percent of total billed charges,Implant Device,609.28,34,,609.28,percent of total billed charges,Implant Device,627.2,35,,627.2,percent of total billed charges,Implant Device,627.2,35,,627.2,percent of total billed charges,Implant Device,627.2,35,,627.2,percent of total billed charges,Implant Device,627.2,35,,627.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1326.08,
DEPUY 1541-18-000 HIP STEM SIZE 3 150MM,C1776,HCPCS,,79006532,CDM,278,RC,,,both,,,13615,10075.13,,,10075.13,Other,150% of Medicare + 9.63% HCRA Surcharge,6126.75,45,,6126.75,percent of total billed charges,Critical Access Hospital RCC factor,4629.1,34,,4629.1,percent of total billed charges,Implant Device,4629.1,34,,4629.1,percent of total billed charges,Implant Device,4629.1,34,,4629.1,percent of total billed charges,Implant Device,4629.1,34,,4629.1,percent of total billed charges,Implant Device,4629.1,34,,4629.1,percent of total billed charges,Implant Device,6739.43,,,6739.43,Other,110% of Medicare,4765.25,35,,4765.25,percent of total billed charges,Implant Device,4629.1,34,"Charges > $500, x 34%",4629.1,percent of total billed charges,Implant Device,4765.25,35,,4765.25,percent of total billed charges,Implant Device,4765.25,35,,4765.25,percent of total billed charges,Implant Device,4765.25,35,,4765.25,percent of total billed charges,Implant Device,4765.25,35,,4765.25,percent of total billed charges,Implant Device,4765.25,35,,4765.25,percent of total billed charges,Implant Device,5446,40,,5446,percent of total billed charges,Implant Device,4765.25,70,,4765.25,percent of total billed charges,All Other,4629.1,34,,4629.1,percent of total billed charges,Implant Device,4629.1,34,,4629.1,percent of total billed charges,Implant Device,4765.25,35,,4765.25,percent of total billed charges,Implant Device,4765.25,35,,4765.25,percent of total billed charges,Implant Device,4765.25,35,,4765.25,percent of total billed charges,Implant Device,4765.25,35,,4765.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,4629.1,34,"If Charge > 2,000, then 34 percent",4629.1,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,10075.13,
DEPUY 1541-42-320 ACETABULAR CUP 42X32MM,C1776,HCPCS,,79006533,CDM,278,RC,,,both,,,2834,2097.17,,,2097.17,Other,150% of Medicare + 9.63% HCRA Surcharge,1275.3,45,,1275.3,percent of total billed charges,Critical Access Hospital RCC factor,963.56,34,,963.56,percent of total billed charges,Implant Device,963.56,34,,963.56,percent of total billed charges,Implant Device,963.56,34,,963.56,percent of total billed charges,Implant Device,963.56,34,,963.56,percent of total billed charges,Implant Device,963.56,34,,963.56,percent of total billed charges,Implant Device,1402.83,,,1402.83,Other,110% of Medicare,991.9,35,,991.9,percent of total billed charges,Implant Device,963.56,34,"Charges > $500, x 34%",963.56,percent of total billed charges,Implant Device,991.9,35,,991.9,percent of total billed charges,Implant Device,991.9,35,,991.9,percent of total billed charges,Implant Device,991.9,35,,991.9,percent of total billed charges,Implant Device,991.9,35,,991.9,percent of total billed charges,Implant Device,991.9,35,,991.9,percent of total billed charges,Implant Device,1133.6,40,,1133.6,percent of total billed charges,Implant Device,991.9,70,,991.9,percent of total billed charges,All Other,963.56,34,,963.56,percent of total billed charges,Implant Device,963.56,34,,963.56,percent of total billed charges,Implant Device,991.9,35,,991.9,percent of total billed charges,Implant Device,991.9,35,,991.9,percent of total billed charges,Implant Device,991.9,35,,991.9,percent of total billed charges,Implant Device,991.9,35,,991.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,963.56,34,"If Charge > 2,000, then 34 percent",963.56,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2097.17,
ACUMED 30-0350 NONLOCKING SCREW 2.7X22MM,C1713,HCPCS,,79006534,CDM,278,RC,,,both,,,262,193.88,,,193.88,Other,150% of Medicare + 9.63% HCRA Surcharge,117.9,45,,117.9,percent of total billed charges,Critical Access Hospital RCC factor,89.08,34,,89.08,percent of total billed charges,Implant Device,89.08,34,,89.08,percent of total billed charges,Implant Device,89.08,34,,89.08,percent of total billed charges,Implant Device,89.08,34,,89.08,percent of total billed charges,Implant Device,89.08,34,,89.08,percent of total billed charges,Implant Device,129.69,,,129.69,Other,110% of Medicare,91.7,35,,91.7,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,91.7,35,,91.7,percent of total billed charges,Implant Device,91.7,35,,91.7,percent of total billed charges,Implant Device,91.7,35,,91.7,percent of total billed charges,Implant Device,91.7,35,,91.7,percent of total billed charges,Implant Device,91.7,35,,91.7,percent of total billed charges,Implant Device,104.8,40,,104.8,percent of total billed charges,Implant Device,91.7,70,,91.7,percent of total billed charges,All Other,89.08,34,,89.08,percent of total billed charges,Implant Device,89.08,34,,89.08,percent of total billed charges,Implant Device,91.7,35,,91.7,percent of total billed charges,Implant Device,91.7,35,,91.7,percent of total billed charges,Implant Device,91.7,35,,91.7,percent of total billed charges,Implant Device,91.7,35,,91.7,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,193.88,
ACUMED 30-0274 NONLOCKING SCREW 3.5X55MM,C1713,HCPCS,,79006535,CDM,278,RC,,,both,,,405,299.7,,,299.7,Other,150% of Medicare + 9.63% HCRA Surcharge,182.25,45,,182.25,percent of total billed charges,Critical Access Hospital RCC factor,137.7,34,,137.7,percent of total billed charges,Implant Device,137.7,34,,137.7,percent of total billed charges,Implant Device,137.7,34,,137.7,percent of total billed charges,Implant Device,137.7,34,,137.7,percent of total billed charges,Implant Device,137.7,34,,137.7,percent of total billed charges,Implant Device,200.48,,,200.48,Other,110% of Medicare,141.75,35,,141.75,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,141.75,35,,141.75,percent of total billed charges,Implant Device,141.75,35,,141.75,percent of total billed charges,Implant Device,141.75,35,,141.75,percent of total billed charges,Implant Device,141.75,35,,141.75,percent of total billed charges,Implant Device,141.75,35,,141.75,percent of total billed charges,Implant Device,162,40,,162,percent of total billed charges,Implant Device,141.75,70,,141.75,percent of total billed charges,All Other,137.7,34,,137.7,percent of total billed charges,Implant Device,137.7,34,,137.7,percent of total billed charges,Implant Device,141.75,35,,141.75,percent of total billed charges,Implant Device,141.75,35,,141.75,percent of total billed charges,Implant Device,141.75,35,,141.75,percent of total billed charges,Implant Device,141.75,35,,141.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,299.7,
ACUMED 30-0263 NONLOCKING SCREW 3.5X24MM,C1713,HCPCS,,79006536,CDM,278,RC,,,both,,,315,233.1,,,233.1,Other,150% of Medicare + 9.63% HCRA Surcharge,141.75,45,,141.75,percent of total billed charges,Critical Access Hospital RCC factor,107.1,34,,107.1,percent of total billed charges,Implant Device,107.1,34,,107.1,percent of total billed charges,Implant Device,107.1,34,,107.1,percent of total billed charges,Implant Device,107.1,34,,107.1,percent of total billed charges,Implant Device,107.1,34,,107.1,percent of total billed charges,Implant Device,155.93,,,155.93,Other,110% of Medicare,110.25,35,,110.25,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,110.25,35,,110.25,percent of total billed charges,Implant Device,110.25,35,,110.25,percent of total billed charges,Implant Device,110.25,35,,110.25,percent of total billed charges,Implant Device,110.25,35,,110.25,percent of total billed charges,Implant Device,110.25,35,,110.25,percent of total billed charges,Implant Device,126,40,,126,percent of total billed charges,Implant Device,110.25,70,,110.25,percent of total billed charges,All Other,107.1,34,,107.1,percent of total billed charges,Implant Device,107.1,34,,107.1,percent of total billed charges,Implant Device,110.25,35,,110.25,percent of total billed charges,Implant Device,110.25,35,,110.25,percent of total billed charges,Implant Device,110.25,35,,110.25,percent of total billed charges,Implant Device,110.25,35,,110.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,233.1,
ACUMED 30-0237 LOCKING SCREW 3.5X18MM,C1713,HCPCS,,79006537,CDM,278,RC,,,both,,,507,375.18,,,375.18,Other,150% of Medicare + 9.63% HCRA Surcharge,228.15,45,,228.15,percent of total billed charges,Critical Access Hospital RCC factor,172.38,34,,172.38,percent of total billed charges,Implant Device,172.38,34,,172.38,percent of total billed charges,Implant Device,172.38,34,,172.38,percent of total billed charges,Implant Device,172.38,34,,172.38,percent of total billed charges,Implant Device,172.38,34,,172.38,percent of total billed charges,Implant Device,250.97,,,250.97,Other,110% of Medicare,177.45,35,,177.45,percent of total billed charges,Implant Device,172.38,34,"Charges > $500, x 34%",172.38,percent of total billed charges,Implant Device,177.45,35,,177.45,percent of total billed charges,Implant Device,177.45,35,,177.45,percent of total billed charges,Implant Device,177.45,35,,177.45,percent of total billed charges,Implant Device,177.45,35,,177.45,percent of total billed charges,Implant Device,177.45,35,,177.45,percent of total billed charges,Implant Device,202.8,40,,202.8,percent of total billed charges,Implant Device,177.45,70,,177.45,percent of total billed charges,All Other,172.38,34,,172.38,percent of total billed charges,Implant Device,172.38,34,,172.38,percent of total billed charges,Implant Device,177.45,35,,177.45,percent of total billed charges,Implant Device,177.45,35,,177.45,percent of total billed charges,Implant Device,177.45,35,,177.45,percent of total billed charges,Implant Device,177.45,35,,177.45,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,375.18,
ACUMED 30-0251 LOCKING SCREW 3.5X55MM,C1713,HCPCS,,79006538,CDM,278,RC,,,both,,,546,404.04,,,404.04,Other,150% of Medicare + 9.63% HCRA Surcharge,245.7,45,,245.7,percent of total billed charges,Critical Access Hospital RCC factor,185.64,34,,185.64,percent of total billed charges,Implant Device,185.64,34,,185.64,percent of total billed charges,Implant Device,185.64,34,,185.64,percent of total billed charges,Implant Device,185.64,34,,185.64,percent of total billed charges,Implant Device,185.64,34,,185.64,percent of total billed charges,Implant Device,270.27,,,270.27,Other,110% of Medicare,191.1,35,,191.1,percent of total billed charges,Implant Device,185.64,34,"Charges > $500, x 34%",185.64,percent of total billed charges,Implant Device,191.1,35,,191.1,percent of total billed charges,Implant Device,191.1,35,,191.1,percent of total billed charges,Implant Device,191.1,35,,191.1,percent of total billed charges,Implant Device,191.1,35,,191.1,percent of total billed charges,Implant Device,191.1,35,,191.1,percent of total billed charges,Implant Device,218.4,40,,218.4,percent of total billed charges,Implant Device,191.1,70,,191.1,percent of total billed charges,All Other,185.64,34,,185.64,percent of total billed charges,Implant Device,185.64,34,,185.64,percent of total billed charges,Implant Device,191.1,35,,191.1,percent of total billed charges,Implant Device,191.1,35,,191.1,percent of total billed charges,Implant Device,191.1,35,,191.1,percent of total billed charges,Implant Device,191.1,35,,191.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,404.04,
ACUMED CO-N2318 NONLOCK SCREW 2.3X18MM,C1713,HCPCS,,79006539,CDM,278,RC,,,both,,,316,233.84,,,233.84,Other,150% of Medicare + 9.63% HCRA Surcharge,142.2,45,,142.2,percent of total billed charges,Critical Access Hospital RCC factor,107.44,34,,107.44,percent of total billed charges,Implant Device,107.44,34,,107.44,percent of total billed charges,Implant Device,107.44,34,,107.44,percent of total billed charges,Implant Device,107.44,34,,107.44,percent of total billed charges,Implant Device,107.44,34,,107.44,percent of total billed charges,Implant Device,156.42,,,156.42,Other,110% of Medicare,110.6,35,,110.6,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,110.6,35,,110.6,percent of total billed charges,Implant Device,110.6,35,,110.6,percent of total billed charges,Implant Device,110.6,35,,110.6,percent of total billed charges,Implant Device,110.6,35,,110.6,percent of total billed charges,Implant Device,110.6,35,,110.6,percent of total billed charges,Implant Device,126.4,40,,126.4,percent of total billed charges,Implant Device,110.6,70,,110.6,percent of total billed charges,All Other,107.44,34,,107.44,percent of total billed charges,Implant Device,107.44,34,,107.44,percent of total billed charges,Implant Device,110.6,35,,110.6,percent of total billed charges,Implant Device,110.6,35,,110.6,percent of total billed charges,Implant Device,110.6,35,,110.6,percent of total billed charges,Implant Device,110.6,35,,110.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,233.84,
MENTOR 350-2475 BREAST IMPLANT 425CC,C1789,HCPCS,,79006542,CDM,278,RC,,,both,,,2010,1487.41,,,1487.41,Other,150% of Medicare + 9.63% HCRA Surcharge,904.5,45,,904.5,percent of total billed charges,Critical Access Hospital RCC factor,683.4,34,,683.4,percent of total billed charges,Implant Device,683.4,34,,683.4,percent of total billed charges,Implant Device,683.4,34,,683.4,percent of total billed charges,Implant Device,683.4,34,,683.4,percent of total billed charges,Implant Device,683.4,34,,683.4,percent of total billed charges,Implant Device,994.95,,,994.95,Other,110% of Medicare,703.5,35,,703.5,percent of total billed charges,Implant Device,683.4,34,"Charges > $500, x 34%",683.4,percent of total billed charges,Implant Device,703.5,35,,703.5,percent of total billed charges,Implant Device,703.5,35,,703.5,percent of total billed charges,Implant Device,703.5,35,,703.5,percent of total billed charges,Implant Device,703.5,35,,703.5,percent of total billed charges,Implant Device,703.5,35,,703.5,percent of total billed charges,Implant Device,804,40,,804,percent of total billed charges,Implant Device,703.5,70,,703.5,percent of total billed charges,All Other,683.4,34,,683.4,percent of total billed charges,Implant Device,683.4,34,,683.4,percent of total billed charges,Implant Device,703.5,35,,703.5,percent of total billed charges,Implant Device,703.5,35,,703.5,percent of total billed charges,Implant Device,703.5,35,,703.5,percent of total billed charges,Implant Device,703.5,35,,703.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,683.4,34,"If Charge > 2,000, then 34 percent",683.4,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1487.41,
GORE RLT351418 EXCLUDER ENDOPROS GRAFT,C1874,HCPCS,,79006547,CDM,278,RC,,,both,,,31500,23310.08,,,23310.08,Other,150% of Medicare + 9.63% HCRA Surcharge,14175,45,,14175,percent of total billed charges,Critical Access Hospital RCC factor,10710,34,,10710,percent of total billed charges,Implant Device,10710,34,,10710,percent of total billed charges,Implant Device,10710,34,,10710,percent of total billed charges,Implant Device,10710,34,,10710,percent of total billed charges,Implant Device,10710,34,,10710,percent of total billed charges,Implant Device,15592.5,,,15592.5,Other,110% of Medicare,11025,35,,11025,percent of total billed charges,Implant Device,10710,34,"Charges > $500, x 34%",10710,percent of total billed charges,Implant Device,11025,35,,11025,percent of total billed charges,Implant Device,11025,35,,11025,percent of total billed charges,Implant Device,11025,35,,11025,percent of total billed charges,Implant Device,11025,35,,11025,percent of total billed charges,Implant Device,11025,35,,11025,percent of total billed charges,Implant Device,12600,40,,12600,percent of total billed charges,Implant Device,11025,70,,11025,percent of total billed charges,All Other,10710,34,,10710,percent of total billed charges,Implant Device,10710,34,,10710,percent of total billed charges,Implant Device,11025,35,,11025,percent of total billed charges,Implant Device,11025,35,,11025,percent of total billed charges,Implant Device,11025,35,,11025,percent of total billed charges,Implant Device,11025,35,,11025,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,10710,34,"If Charge > 2,000, then 34 percent",10710,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,23310.08,
GORE PLC231200 EXCLUDER ENDOPROS GRAFT,C1874,HCPCS,,79006548,CDM,278,RC,,,both,,,14571,10782.58,,,10782.58,Other,150% of Medicare + 9.63% HCRA Surcharge,6556.95,45,,6556.95,percent of total billed charges,Critical Access Hospital RCC factor,4954.14,34,,4954.14,percent of total billed charges,Implant Device,4954.14,34,,4954.14,percent of total billed charges,Implant Device,4954.14,34,,4954.14,percent of total billed charges,Implant Device,4954.14,34,,4954.14,percent of total billed charges,Implant Device,4954.14,34,,4954.14,percent of total billed charges,Implant Device,7212.65,,,7212.65,Other,110% of Medicare,5099.85,35,,5099.85,percent of total billed charges,Implant Device,4954.14,34,"Charges > $500, x 34%",4954.14,percent of total billed charges,Implant Device,5099.85,35,,5099.85,percent of total billed charges,Implant Device,5099.85,35,,5099.85,percent of total billed charges,Implant Device,5099.85,35,,5099.85,percent of total billed charges,Implant Device,5099.85,35,,5099.85,percent of total billed charges,Implant Device,5099.85,35,,5099.85,percent of total billed charges,Implant Device,5828.4,40,,5828.4,percent of total billed charges,Implant Device,5099.85,70,,5099.85,percent of total billed charges,All Other,4954.14,34,,4954.14,percent of total billed charges,Implant Device,4954.14,34,,4954.14,percent of total billed charges,Implant Device,5099.85,35,,5099.85,percent of total billed charges,Implant Device,5099.85,35,,5099.85,percent of total billed charges,Implant Device,5099.85,35,,5099.85,percent of total billed charges,Implant Device,5099.85,35,,5099.85,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,4954.14,34,"If Charge > 2,000, then 34 percent",4954.14,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,10782.58,
S&N 121832 SCREW CANNULATED 4X32MM,C1713,HCPCS,,79006549,CDM,278,RC,,,both,,,721,533.54,,,533.54,Other,150% of Medicare + 9.63% HCRA Surcharge,324.45,45,,324.45,percent of total billed charges,Critical Access Hospital RCC factor,245.14,34,,245.14,percent of total billed charges,Implant Device,245.14,34,,245.14,percent of total billed charges,Implant Device,245.14,34,,245.14,percent of total billed charges,Implant Device,245.14,34,,245.14,percent of total billed charges,Implant Device,245.14,34,,245.14,percent of total billed charges,Implant Device,356.9,,,356.9,Other,110% of Medicare,252.35,35,,252.35,percent of total billed charges,Implant Device,245.14,34,"Charges > $500, x 34%",245.14,percent of total billed charges,Implant Device,252.35,35,,252.35,percent of total billed charges,Implant Device,252.35,35,,252.35,percent of total billed charges,Implant Device,252.35,35,,252.35,percent of total billed charges,Implant Device,252.35,35,,252.35,percent of total billed charges,Implant Device,252.35,35,,252.35,percent of total billed charges,Implant Device,288.4,40,,288.4,percent of total billed charges,Implant Device,252.35,70,,252.35,percent of total billed charges,All Other,245.14,34,,245.14,percent of total billed charges,Implant Device,245.14,34,,245.14,percent of total billed charges,Implant Device,252.35,35,,252.35,percent of total billed charges,Implant Device,252.35,35,,252.35,percent of total billed charges,Implant Device,252.35,35,,252.35,percent of total billed charges,Implant Device,252.35,35,,252.35,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,533.54,
EXACTECH 340-01-03 FRACTURE PLATE 150MM,C1713,HCPCS,,79006550,CDM,278,RC,,,both,,,4644,3436.57,,,3436.57,Other,150% of Medicare + 9.63% HCRA Surcharge,2089.8,45,,2089.8,percent of total billed charges,Critical Access Hospital RCC factor,1578.96,34,,1578.96,percent of total billed charges,Implant Device,1578.96,34,,1578.96,percent of total billed charges,Implant Device,1578.96,34,,1578.96,percent of total billed charges,Implant Device,1578.96,34,,1578.96,percent of total billed charges,Implant Device,1578.96,34,,1578.96,percent of total billed charges,Implant Device,2298.78,,,2298.78,Other,110% of Medicare,1625.4,35,,1625.4,percent of total billed charges,Implant Device,1578.96,34,"Charges > $500, x 34%",1578.96,percent of total billed charges,Implant Device,1625.4,35,,1625.4,percent of total billed charges,Implant Device,1625.4,35,,1625.4,percent of total billed charges,Implant Device,1625.4,35,,1625.4,percent of total billed charges,Implant Device,1625.4,35,,1625.4,percent of total billed charges,Implant Device,1625.4,35,,1625.4,percent of total billed charges,Implant Device,1857.6,40,,1857.6,percent of total billed charges,Implant Device,1625.4,70,,1625.4,percent of total billed charges,All Other,1578.96,34,,1578.96,percent of total billed charges,Implant Device,1578.96,34,,1578.96,percent of total billed charges,Implant Device,1625.4,35,,1625.4,percent of total billed charges,Implant Device,1625.4,35,,1625.4,percent of total billed charges,Implant Device,1625.4,35,,1625.4,percent of total billed charges,Implant Device,1625.4,35,,1625.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1578.96,34,"If Charge > 2,000, then 34 percent",1578.96,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3436.57,
ARTHREX AR-8927BNF-CP ACHLLES SUT BRIDGE,C1713,HCPCS,,79006552,CDM,278,RC,,,both,,,3720,2752.81,,,2752.81,Other,150% of Medicare + 9.63% HCRA Surcharge,1674,45,,1674,percent of total billed charges,Critical Access Hospital RCC factor,1264.8,34,,1264.8,percent of total billed charges,Implant Device,1264.8,34,,1264.8,percent of total billed charges,Implant Device,1264.8,34,,1264.8,percent of total billed charges,Implant Device,1264.8,34,,1264.8,percent of total billed charges,Implant Device,1264.8,34,,1264.8,percent of total billed charges,Implant Device,1841.4,,,1841.4,Other,110% of Medicare,1302,35,,1302,percent of total billed charges,Implant Device,1264.8,34,"Charges > $500, x 34%",1264.8,percent of total billed charges,Implant Device,1302,35,,1302,percent of total billed charges,Implant Device,1302,35,,1302,percent of total billed charges,Implant Device,1302,35,,1302,percent of total billed charges,Implant Device,1302,35,,1302,percent of total billed charges,Implant Device,1302,35,,1302,percent of total billed charges,Implant Device,1488,40,,1488,percent of total billed charges,Implant Device,1302,70,,1302,percent of total billed charges,All Other,1264.8,34,,1264.8,percent of total billed charges,Implant Device,1264.8,34,,1264.8,percent of total billed charges,Implant Device,1302,35,,1302,percent of total billed charges,Implant Device,1302,35,,1302,percent of total billed charges,Implant Device,1302,35,,1302,percent of total billed charges,Implant Device,1302,35,,1302,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1264.8,34,"If Charge > 2,000, then 34 percent",1264.8,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2752.81,
MAQUET PPBF1515 VITAMESH BLUE 15X15CM,C1781,HCPCS,,79006553,CDM,278,RC,,,both,,,553,409.22,,,409.22,Other,150% of Medicare + 9.63% HCRA Surcharge,248.85,45,,248.85,percent of total billed charges,Critical Access Hospital RCC factor,188.02,34,,188.02,percent of total billed charges,Implant Device,188.02,34,,188.02,percent of total billed charges,Implant Device,188.02,34,,188.02,percent of total billed charges,Implant Device,188.02,34,,188.02,percent of total billed charges,Implant Device,188.02,34,,188.02,percent of total billed charges,Implant Device,273.74,,,273.74,Other,110% of Medicare,193.55,35,,193.55,percent of total billed charges,Implant Device,188.02,34,"Charges > $500, x 34%",188.02,percent of total billed charges,Implant Device,193.55,35,,193.55,percent of total billed charges,Implant Device,193.55,35,,193.55,percent of total billed charges,Implant Device,193.55,35,,193.55,percent of total billed charges,Implant Device,193.55,35,,193.55,percent of total billed charges,Implant Device,193.55,35,,193.55,percent of total billed charges,Implant Device,221.2,40,,221.2,percent of total billed charges,Implant Device,193.55,70,,193.55,percent of total billed charges,All Other,188.02,34,,188.02,percent of total billed charges,Implant Device,188.02,34,,188.02,percent of total billed charges,Implant Device,193.55,35,,193.55,percent of total billed charges,Implant Device,193.55,35,,193.55,percent of total billed charges,Implant Device,193.55,35,,193.55,percent of total billed charges,Implant Device,193.55,35,,193.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,409.22,
MAQUET PPVF3030 VITAMESH 30X30CM,C1781,HCPCS,,79006554,CDM,278,RC,,,both,,,517,382.58,,,382.58,Other,150% of Medicare + 9.63% HCRA Surcharge,232.65,45,,232.65,percent of total billed charges,Critical Access Hospital RCC factor,175.78,34,,175.78,percent of total billed charges,Implant Device,175.78,34,,175.78,percent of total billed charges,Implant Device,175.78,34,,175.78,percent of total billed charges,Implant Device,175.78,34,,175.78,percent of total billed charges,Implant Device,175.78,34,,175.78,percent of total billed charges,Implant Device,255.92,,,255.92,Other,110% of Medicare,180.95,35,,180.95,percent of total billed charges,Implant Device,175.78,34,"Charges > $500, x 34%",175.78,percent of total billed charges,Implant Device,180.95,35,,180.95,percent of total billed charges,Implant Device,180.95,35,,180.95,percent of total billed charges,Implant Device,180.95,35,,180.95,percent of total billed charges,Implant Device,180.95,35,,180.95,percent of total billed charges,Implant Device,180.95,35,,180.95,percent of total billed charges,Implant Device,206.8,40,,206.8,percent of total billed charges,Implant Device,180.95,70,,180.95,percent of total billed charges,All Other,175.78,34,,175.78,percent of total billed charges,Implant Device,175.78,34,,175.78,percent of total billed charges,Implant Device,180.95,35,,180.95,percent of total billed charges,Implant Device,180.95,35,,180.95,percent of total billed charges,Implant Device,180.95,35,,180.95,percent of total billed charges,Implant Device,180.95,35,,180.95,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,382.58,
STRYKER 1896-5070S LOCKING SCREW 5X70MM,C1713,HCPCS,,79006555,CDM,278,RC,,,both,,,714,528.36,,,528.36,Other,150% of Medicare + 9.63% HCRA Surcharge,321.3,45,,321.3,percent of total billed charges,Critical Access Hospital RCC factor,242.76,34,,242.76,percent of total billed charges,Implant Device,242.76,34,,242.76,percent of total billed charges,Implant Device,242.76,34,,242.76,percent of total billed charges,Implant Device,242.76,34,,242.76,percent of total billed charges,Implant Device,242.76,34,,242.76,percent of total billed charges,Implant Device,353.43,,,353.43,Other,110% of Medicare,249.9,35,,249.9,percent of total billed charges,Implant Device,242.76,34,"Charges > $500, x 34%",242.76,percent of total billed charges,Implant Device,249.9,35,,249.9,percent of total billed charges,Implant Device,249.9,35,,249.9,percent of total billed charges,Implant Device,249.9,35,,249.9,percent of total billed charges,Implant Device,249.9,35,,249.9,percent of total billed charges,Implant Device,249.9,35,,249.9,percent of total billed charges,Implant Device,285.6,40,,285.6,percent of total billed charges,Implant Device,249.9,70,,249.9,percent of total billed charges,All Other,242.76,34,,242.76,percent of total billed charges,Implant Device,242.76,34,,242.76,percent of total billed charges,Implant Device,249.9,35,,249.9,percent of total billed charges,Implant Device,249.9,35,,249.9,percent of total billed charges,Implant Device,249.9,35,,249.9,percent of total billed charges,Implant Device,249.9,35,,249.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,528.36,
ALLERGAN 133MV-13-T TISSUE EXPANDER,C1789,HCPCS,,79006556,CDM,278,RC,,,both,,,4650,3441.01,,,3441.01,Other,150% of Medicare + 9.63% HCRA Surcharge,2092.5,45,,2092.5,percent of total billed charges,Critical Access Hospital RCC factor,1581,34,,1581,percent of total billed charges,Implant Device,1581,34,,1581,percent of total billed charges,Implant Device,1581,34,,1581,percent of total billed charges,Implant Device,1581,34,,1581,percent of total billed charges,Implant Device,1581,34,,1581,percent of total billed charges,Implant Device,2301.75,,,2301.75,Other,110% of Medicare,1627.5,35,,1627.5,percent of total billed charges,Implant Device,1581,34,"Charges > $500, x 34%",1581,percent of total billed charges,Implant Device,1627.5,35,,1627.5,percent of total billed charges,Implant Device,1627.5,35,,1627.5,percent of total billed charges,Implant Device,1627.5,35,,1627.5,percent of total billed charges,Implant Device,1627.5,35,,1627.5,percent of total billed charges,Implant Device,1627.5,35,,1627.5,percent of total billed charges,Implant Device,1860,40,,1860,percent of total billed charges,Implant Device,1627.5,70,,1627.5,percent of total billed charges,All Other,1581,34,,1581,percent of total billed charges,Implant Device,1581,34,,1581,percent of total billed charges,Implant Device,1627.5,35,,1627.5,percent of total billed charges,Implant Device,1627.5,35,,1627.5,percent of total billed charges,Implant Device,1627.5,35,,1627.5,percent of total billed charges,Implant Device,1627.5,35,,1627.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1581,34,"If Charge > 2,000, then 34 percent",1581,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3441.01,
ALLERGAN 133MV-14-T TISSUE EXPANDER,C1789,HCPCS,,79006557,CDM,278,RC,,,both,,,4650,3441.01,,,3441.01,Other,150% of Medicare + 9.63% HCRA Surcharge,2092.5,45,,2092.5,percent of total billed charges,Critical Access Hospital RCC factor,1581,34,,1581,percent of total billed charges,Implant Device,1581,34,,1581,percent of total billed charges,Implant Device,1581,34,,1581,percent of total billed charges,Implant Device,1581,34,,1581,percent of total billed charges,Implant Device,1581,34,,1581,percent of total billed charges,Implant Device,2301.75,,,2301.75,Other,110% of Medicare,1627.5,35,,1627.5,percent of total billed charges,Implant Device,1581,34,"Charges > $500, x 34%",1581,percent of total billed charges,Implant Device,1627.5,35,,1627.5,percent of total billed charges,Implant Device,1627.5,35,,1627.5,percent of total billed charges,Implant Device,1627.5,35,,1627.5,percent of total billed charges,Implant Device,1627.5,35,,1627.5,percent of total billed charges,Implant Device,1627.5,35,,1627.5,percent of total billed charges,Implant Device,1860,40,,1860,percent of total billed charges,Implant Device,1627.5,70,,1627.5,percent of total billed charges,All Other,1581,34,,1581,percent of total billed charges,Implant Device,1581,34,,1581,percent of total billed charges,Implant Device,1627.5,35,,1627.5,percent of total billed charges,Implant Device,1627.5,35,,1627.5,percent of total billed charges,Implant Device,1627.5,35,,1627.5,percent of total billed charges,Implant Device,1627.5,35,,1627.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1581,34,"If Charge > 2,000, then 34 percent",1581,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3441.01,
ALLERGAN 133MX-13-T TISSUE EXPANDER,C1789,HCPCS,,79006558,CDM,278,RC,,,both,,,4650,3441.01,,,3441.01,Other,150% of Medicare + 9.63% HCRA Surcharge,2092.5,45,,2092.5,percent of total billed charges,Critical Access Hospital RCC factor,1581,34,,1581,percent of total billed charges,Implant Device,1581,34,,1581,percent of total billed charges,Implant Device,1581,34,,1581,percent of total billed charges,Implant Device,1581,34,,1581,percent of total billed charges,Implant Device,1581,34,,1581,percent of total billed charges,Implant Device,2301.75,,,2301.75,Other,110% of Medicare,1627.5,35,,1627.5,percent of total billed charges,Implant Device,1581,34,"Charges > $500, x 34%",1581,percent of total billed charges,Implant Device,1627.5,35,,1627.5,percent of total billed charges,Implant Device,1627.5,35,,1627.5,percent of total billed charges,Implant Device,1627.5,35,,1627.5,percent of total billed charges,Implant Device,1627.5,35,,1627.5,percent of total billed charges,Implant Device,1627.5,35,,1627.5,percent of total billed charges,Implant Device,1860,40,,1860,percent of total billed charges,Implant Device,1627.5,70,,1627.5,percent of total billed charges,All Other,1581,34,,1581,percent of total billed charges,Implant Device,1581,34,,1581,percent of total billed charges,Implant Device,1627.5,35,,1627.5,percent of total billed charges,Implant Device,1627.5,35,,1627.5,percent of total billed charges,Implant Device,1627.5,35,,1627.5,percent of total billed charges,Implant Device,1627.5,35,,1627.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1581,34,"If Charge > 2,000, then 34 percent",1581,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3441.01,
J&J SF06150MB SMART FLEX 6X150MM STENT,C1876,HCPCS,,79006561,CDM,278,RC,,,both,,,3300,2442.01,,,2442.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1485,45,,1485,percent of total billed charges,Critical Access Hospital RCC factor,1122,34,,1122,percent of total billed charges,Implant Device,1122,34,,1122,percent of total billed charges,Implant Device,1122,34,,1122,percent of total billed charges,Implant Device,1122,34,,1122,percent of total billed charges,Implant Device,1122,34,,1122,percent of total billed charges,Implant Device,1633.5,,,1633.5,Other,110% of Medicare,1155,35,,1155,percent of total billed charges,Implant Device,1122,34,"Charges > $500, x 34%",1122,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,1320,40,,1320,percent of total billed charges,Implant Device,1155,70,,1155,percent of total billed charges,All Other,1122,34,,1122,percent of total billed charges,Implant Device,1122,34,,1122,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1122,34,"If Charge > 2,000, then 34 percent",1122,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2442.01,
ZIMMER 00-5994-016-91 FEMORAL COMP SZ F,C1776,HCPCS,,79006562,CDM,278,RC,,,both,,,18586,13753.69,,,13753.69,Other,150% of Medicare + 9.63% HCRA Surcharge,8363.7,45,,8363.7,percent of total billed charges,Critical Access Hospital RCC factor,6319.24,34,,6319.24,percent of total billed charges,Implant Device,6319.24,34,,6319.24,percent of total billed charges,Implant Device,6319.24,34,,6319.24,percent of total billed charges,Implant Device,6319.24,34,,6319.24,percent of total billed charges,Implant Device,6319.24,34,,6319.24,percent of total billed charges,Implant Device,9200.07,,,9200.07,Other,110% of Medicare,6505.1,35,,6505.1,percent of total billed charges,Implant Device,6319.24,34,"Charges > $500, x 34%",6319.24,percent of total billed charges,Implant Device,6505.1,35,,6505.1,percent of total billed charges,Implant Device,6505.1,35,,6505.1,percent of total billed charges,Implant Device,6505.1,35,,6505.1,percent of total billed charges,Implant Device,6505.1,35,,6505.1,percent of total billed charges,Implant Device,6505.1,35,,6505.1,percent of total billed charges,Implant Device,7434.4,40,,7434.4,percent of total billed charges,Implant Device,6505.1,70,,6505.1,percent of total billed charges,All Other,6319.24,34,,6319.24,percent of total billed charges,Implant Device,6319.24,34,,6319.24,percent of total billed charges,Implant Device,6505.1,35,,6505.1,percent of total billed charges,Implant Device,6505.1,35,,6505.1,percent of total billed charges,Implant Device,6505.1,35,,6505.1,percent of total billed charges,Implant Device,6505.1,35,,6505.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,6319.24,34,"If Charge > 2,000, then 34 percent",6319.24,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,13753.69,
MENTOR 350-2250 BREAST IMPLANT,C1789,HCPCS,,79006563,CDM,278,RC,,,both,,,2010,1487.41,,,1487.41,Other,150% of Medicare + 9.63% HCRA Surcharge,904.5,45,,904.5,percent of total billed charges,Critical Access Hospital RCC factor,683.4,34,,683.4,percent of total billed charges,Implant Device,683.4,34,,683.4,percent of total billed charges,Implant Device,683.4,34,,683.4,percent of total billed charges,Implant Device,683.4,34,,683.4,percent of total billed charges,Implant Device,683.4,34,,683.4,percent of total billed charges,Implant Device,994.95,,,994.95,Other,110% of Medicare,703.5,35,,703.5,percent of total billed charges,Implant Device,683.4,34,"Charges > $500, x 34%",683.4,percent of total billed charges,Implant Device,703.5,35,,703.5,percent of total billed charges,Implant Device,703.5,35,,703.5,percent of total billed charges,Implant Device,703.5,35,,703.5,percent of total billed charges,Implant Device,703.5,35,,703.5,percent of total billed charges,Implant Device,703.5,35,,703.5,percent of total billed charges,Implant Device,804,40,,804,percent of total billed charges,Implant Device,703.5,70,,703.5,percent of total billed charges,All Other,683.4,34,,683.4,percent of total billed charges,Implant Device,683.4,34,,683.4,percent of total billed charges,Implant Device,703.5,35,,703.5,percent of total billed charges,Implant Device,703.5,35,,703.5,percent of total billed charges,Implant Device,703.5,35,,703.5,percent of total billed charges,Implant Device,703.5,35,,703.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,683.4,34,"If Charge > 2,000, then 34 percent",683.4,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1487.41,
ALLERGAN 133MX-11-T TISSUE EXPANDER,C1789,HCPCS,,79006564,CDM,278,RC,,,both,,,4650,3441.01,,,3441.01,Other,150% of Medicare + 9.63% HCRA Surcharge,2092.5,45,,2092.5,percent of total billed charges,Critical Access Hospital RCC factor,1581,34,,1581,percent of total billed charges,Implant Device,1581,34,,1581,percent of total billed charges,Implant Device,1581,34,,1581,percent of total billed charges,Implant Device,1581,34,,1581,percent of total billed charges,Implant Device,1581,34,,1581,percent of total billed charges,Implant Device,2301.75,,,2301.75,Other,110% of Medicare,1627.5,35,,1627.5,percent of total billed charges,Implant Device,1581,34,"Charges > $500, x 34%",1581,percent of total billed charges,Implant Device,1627.5,35,,1627.5,percent of total billed charges,Implant Device,1627.5,35,,1627.5,percent of total billed charges,Implant Device,1627.5,35,,1627.5,percent of total billed charges,Implant Device,1627.5,35,,1627.5,percent of total billed charges,Implant Device,1627.5,35,,1627.5,percent of total billed charges,Implant Device,1860,40,,1860,percent of total billed charges,Implant Device,1627.5,70,,1627.5,percent of total billed charges,All Other,1581,34,,1581,percent of total billed charges,Implant Device,1581,34,,1581,percent of total billed charges,Implant Device,1627.5,35,,1627.5,percent of total billed charges,Implant Device,1627.5,35,,1627.5,percent of total billed charges,Implant Device,1627.5,35,,1627.5,percent of total billed charges,Implant Device,1627.5,35,,1627.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1581,34,"If Charge > 2,000, then 34 percent",1581,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3441.01,
ALLERGAN MM-410280 SILICONE BREAST IMP,C1789,HCPCS,,79006565,CDM,278,RC,,,both,,,3976,2942.25,,,2942.25,Other,150% of Medicare + 9.63% HCRA Surcharge,1789.2,45,,1789.2,percent of total billed charges,Critical Access Hospital RCC factor,1351.84,34,,1351.84,percent of total billed charges,Implant Device,1351.84,34,,1351.84,percent of total billed charges,Implant Device,1351.84,34,,1351.84,percent of total billed charges,Implant Device,1351.84,34,,1351.84,percent of total billed charges,Implant Device,1351.84,34,,1351.84,percent of total billed charges,Implant Device,1968.12,,,1968.12,Other,110% of Medicare,1391.6,35,,1391.6,percent of total billed charges,Implant Device,1351.84,34,"Charges > $500, x 34%",1351.84,percent of total billed charges,Implant Device,1391.6,35,,1391.6,percent of total billed charges,Implant Device,1391.6,35,,1391.6,percent of total billed charges,Implant Device,1391.6,35,,1391.6,percent of total billed charges,Implant Device,1391.6,35,,1391.6,percent of total billed charges,Implant Device,1391.6,35,,1391.6,percent of total billed charges,Implant Device,1590.4,40,,1590.4,percent of total billed charges,Implant Device,1391.6,70,,1391.6,percent of total billed charges,All Other,1351.84,34,,1351.84,percent of total billed charges,Implant Device,1351.84,34,,1351.84,percent of total billed charges,Implant Device,1391.6,35,,1391.6,percent of total billed charges,Implant Device,1391.6,35,,1391.6,percent of total billed charges,Implant Device,1391.6,35,,1391.6,percent of total billed charges,Implant Device,1391.6,35,,1391.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1351.84,34,"If Charge > 2,000, then 34 percent",1351.84,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2942.25,
ALLERGAN MM-410320 SILICONE BREAST IMP,C1789,HCPCS,,79006566,CDM,278,RC,,,both,,,3976,2942.25,,,2942.25,Other,150% of Medicare + 9.63% HCRA Surcharge,1789.2,45,,1789.2,percent of total billed charges,Critical Access Hospital RCC factor,1351.84,34,,1351.84,percent of total billed charges,Implant Device,1351.84,34,,1351.84,percent of total billed charges,Implant Device,1351.84,34,,1351.84,percent of total billed charges,Implant Device,1351.84,34,,1351.84,percent of total billed charges,Implant Device,1351.84,34,,1351.84,percent of total billed charges,Implant Device,1968.12,,,1968.12,Other,110% of Medicare,1391.6,35,,1391.6,percent of total billed charges,Implant Device,1351.84,34,"Charges > $500, x 34%",1351.84,percent of total billed charges,Implant Device,1391.6,35,,1391.6,percent of total billed charges,Implant Device,1391.6,35,,1391.6,percent of total billed charges,Implant Device,1391.6,35,,1391.6,percent of total billed charges,Implant Device,1391.6,35,,1391.6,percent of total billed charges,Implant Device,1391.6,35,,1391.6,percent of total billed charges,Implant Device,1590.4,40,,1590.4,percent of total billed charges,Implant Device,1391.6,70,,1391.6,percent of total billed charges,All Other,1351.84,34,,1351.84,percent of total billed charges,Implant Device,1351.84,34,,1351.84,percent of total billed charges,Implant Device,1391.6,35,,1391.6,percent of total billed charges,Implant Device,1391.6,35,,1391.6,percent of total billed charges,Implant Device,1391.6,35,,1391.6,percent of total billed charges,Implant Device,1391.6,35,,1391.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1351.84,34,"If Charge > 2,000, then 34 percent",1351.84,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2942.25,
ALLERGAN MM-410360 SILICONE BREAST IMP,C1789,HCPCS,,79006567,CDM,278,RC,,,both,,,3975,2941.51,,,2941.51,Other,150% of Medicare + 9.63% HCRA Surcharge,1788.75,45,,1788.75,percent of total billed charges,Critical Access Hospital RCC factor,1351.5,34,,1351.5,percent of total billed charges,Implant Device,1351.5,34,,1351.5,percent of total billed charges,Implant Device,1351.5,34,,1351.5,percent of total billed charges,Implant Device,1351.5,34,,1351.5,percent of total billed charges,Implant Device,1351.5,34,,1351.5,percent of total billed charges,Implant Device,1967.63,,,1967.63,Other,110% of Medicare,1391.25,35,,1391.25,percent of total billed charges,Implant Device,1351.5,34,"Charges > $500, x 34%",1351.5,percent of total billed charges,Implant Device,1391.25,35,,1391.25,percent of total billed charges,Implant Device,1391.25,35,,1391.25,percent of total billed charges,Implant Device,1391.25,35,,1391.25,percent of total billed charges,Implant Device,1391.25,35,,1391.25,percent of total billed charges,Implant Device,1391.25,35,,1391.25,percent of total billed charges,Implant Device,1590,40,,1590,percent of total billed charges,Implant Device,1391.25,70,,1391.25,percent of total billed charges,All Other,1351.5,34,,1351.5,percent of total billed charges,Implant Device,1351.5,34,,1351.5,percent of total billed charges,Implant Device,1391.25,35,,1391.25,percent of total billed charges,Implant Device,1391.25,35,,1391.25,percent of total billed charges,Implant Device,1391.25,35,,1391.25,percent of total billed charges,Implant Device,1391.25,35,,1391.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1351.5,34,"If Charge > 2,000, then 34 percent",1351.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2941.51,
DEPUY 202.876 CORTEX ST SCRW T8 2.7X16MM,C1713,HCPCS,,79006571,CDM,278,RC,,,both,,,88,65.12,,,65.12,Other,150% of Medicare + 9.63% HCRA Surcharge,39.6,45,,39.6,percent of total billed charges,Critical Access Hospital RCC factor,29.92,34,,29.92,percent of total billed charges,Implant Device,29.92,34,,29.92,percent of total billed charges,Implant Device,29.92,34,,29.92,percent of total billed charges,Implant Device,29.92,34,,29.92,percent of total billed charges,Implant Device,29.92,34,,29.92,percent of total billed charges,Implant Device,43.56,,,43.56,Other,110% of Medicare,30.8,35,,30.8,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,30.8,35,,30.8,percent of total billed charges,Implant Device,30.8,35,,30.8,percent of total billed charges,Implant Device,30.8,35,,30.8,percent of total billed charges,Implant Device,30.8,35,,30.8,percent of total billed charges,Implant Device,30.8,35,,30.8,percent of total billed charges,Implant Device,35.2,40,,35.2,percent of total billed charges,Implant Device,30.8,70,,30.8,percent of total billed charges,All Other,29.92,34,,29.92,percent of total billed charges,Implant Device,29.92,34,,29.92,percent of total billed charges,Implant Device,30.8,35,,30.8,percent of total billed charges,Implant Device,30.8,35,,30.8,percent of total billed charges,Implant Device,30.8,35,,30.8,percent of total billed charges,Implant Device,30.8,35,,30.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,65.12,
DEPUY 202.878 CORTEX ST SCRW T8 2.7X18MM,C1713,HCPCS,,79006572,CDM,278,RC,,,both,,,88,65.12,,,65.12,Other,150% of Medicare + 9.63% HCRA Surcharge,39.6,45,,39.6,percent of total billed charges,Critical Access Hospital RCC factor,29.92,34,,29.92,percent of total billed charges,Implant Device,29.92,34,,29.92,percent of total billed charges,Implant Device,29.92,34,,29.92,percent of total billed charges,Implant Device,29.92,34,,29.92,percent of total billed charges,Implant Device,29.92,34,,29.92,percent of total billed charges,Implant Device,43.56,,,43.56,Other,110% of Medicare,30.8,35,,30.8,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,30.8,35,,30.8,percent of total billed charges,Implant Device,30.8,35,,30.8,percent of total billed charges,Implant Device,30.8,35,,30.8,percent of total billed charges,Implant Device,30.8,35,,30.8,percent of total billed charges,Implant Device,30.8,35,,30.8,percent of total billed charges,Implant Device,35.2,40,,35.2,percent of total billed charges,Implant Device,30.8,70,,30.8,percent of total billed charges,All Other,29.92,34,,29.92,percent of total billed charges,Implant Device,29.92,34,,29.92,percent of total billed charges,Implant Device,30.8,35,,30.8,percent of total billed charges,Implant Device,30.8,35,,30.8,percent of total billed charges,Implant Device,30.8,35,,30.8,percent of total billed charges,Implant Device,30.8,35,,30.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,65.12,
DEPUY 02.211.016 VA LOCK SCREW 2.7X16MM,C1713,HCPCS,,79006573,CDM,278,RC,,,both,,,343,253.82,,,253.82,Other,150% of Medicare + 9.63% HCRA Surcharge,154.35,45,,154.35,percent of total billed charges,Critical Access Hospital RCC factor,116.62,34,,116.62,percent of total billed charges,Implant Device,116.62,34,,116.62,percent of total billed charges,Implant Device,116.62,34,,116.62,percent of total billed charges,Implant Device,116.62,34,,116.62,percent of total billed charges,Implant Device,116.62,34,,116.62,percent of total billed charges,Implant Device,169.79,,,169.79,Other,110% of Medicare,120.05,35,,120.05,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,120.05,35,,120.05,percent of total billed charges,Implant Device,120.05,35,,120.05,percent of total billed charges,Implant Device,120.05,35,,120.05,percent of total billed charges,Implant Device,120.05,35,,120.05,percent of total billed charges,Implant Device,120.05,35,,120.05,percent of total billed charges,Implant Device,137.2,40,,137.2,percent of total billed charges,Implant Device,120.05,70,,120.05,percent of total billed charges,All Other,116.62,34,,116.62,percent of total billed charges,Implant Device,116.62,34,,116.62,percent of total billed charges,Implant Device,120.05,35,,120.05,percent of total billed charges,Implant Device,120.05,35,,120.05,percent of total billed charges,Implant Device,120.05,35,,120.05,percent of total billed charges,Implant Device,120.05,35,,120.05,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,253.82,
DEPUY 02.211.018 VA LOCK SCREW 2.7X18MM,C1713,HCPCS,,79006574,CDM,278,RC,,,both,,,536,396.64,,,396.64,Other,150% of Medicare + 9.63% HCRA Surcharge,241.2,45,,241.2,percent of total billed charges,Critical Access Hospital RCC factor,182.24,34,,182.24,percent of total billed charges,Implant Device,182.24,34,,182.24,percent of total billed charges,Implant Device,182.24,34,,182.24,percent of total billed charges,Implant Device,182.24,34,,182.24,percent of total billed charges,Implant Device,182.24,34,,182.24,percent of total billed charges,Implant Device,265.32,,,265.32,Other,110% of Medicare,187.6,35,,187.6,percent of total billed charges,Implant Device,182.24,34,"Charges > $500, x 34%",182.24,percent of total billed charges,Implant Device,187.6,35,,187.6,percent of total billed charges,Implant Device,187.6,35,,187.6,percent of total billed charges,Implant Device,187.6,35,,187.6,percent of total billed charges,Implant Device,187.6,35,,187.6,percent of total billed charges,Implant Device,187.6,35,,187.6,percent of total billed charges,Implant Device,214.4,40,,214.4,percent of total billed charges,Implant Device,187.6,70,,187.6,percent of total billed charges,All Other,182.24,34,,182.24,percent of total billed charges,Implant Device,182.24,34,,182.24,percent of total billed charges,Implant Device,187.6,35,,187.6,percent of total billed charges,Implant Device,187.6,35,,187.6,percent of total billed charges,Implant Device,187.6,35,,187.6,percent of total billed charges,Implant Device,187.6,35,,187.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,396.64,
DEPUY 02.118.407 DIST FIB PLATE 6 HOLE,C1713,HCPCS,,79006575,CDM,278,RC,,,both,,,3266,2416.85,,,2416.85,Other,150% of Medicare + 9.63% HCRA Surcharge,1469.7,45,,1469.7,percent of total billed charges,Critical Access Hospital RCC factor,1110.44,34,,1110.44,percent of total billed charges,Implant Device,1110.44,34,,1110.44,percent of total billed charges,Implant Device,1110.44,34,,1110.44,percent of total billed charges,Implant Device,1110.44,34,,1110.44,percent of total billed charges,Implant Device,1110.44,34,,1110.44,percent of total billed charges,Implant Device,1616.67,,,1616.67,Other,110% of Medicare,1143.1,35,,1143.1,percent of total billed charges,Implant Device,1110.44,34,"Charges > $500, x 34%",1110.44,percent of total billed charges,Implant Device,1143.1,35,,1143.1,percent of total billed charges,Implant Device,1143.1,35,,1143.1,percent of total billed charges,Implant Device,1143.1,35,,1143.1,percent of total billed charges,Implant Device,1143.1,35,,1143.1,percent of total billed charges,Implant Device,1143.1,35,,1143.1,percent of total billed charges,Implant Device,1306.4,40,,1306.4,percent of total billed charges,Implant Device,1143.1,70,,1143.1,percent of total billed charges,All Other,1110.44,34,,1110.44,percent of total billed charges,Implant Device,1110.44,34,,1110.44,percent of total billed charges,Implant Device,1143.1,35,,1143.1,percent of total billed charges,Implant Device,1143.1,35,,1143.1,percent of total billed charges,Implant Device,1143.1,35,,1143.1,percent of total billed charges,Implant Device,1143.1,35,,1143.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1110.44,34,"If Charge > 2,000, then 34 percent",1110.44,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2416.85,
DEPUY 1035-44-000 BI POLAR HEAD 28X44MM,C1776,HCPCS,,79006576,CDM,278,RC,,,both,,,1733,1282.42,,,1282.42,Other,150% of Medicare + 9.63% HCRA Surcharge,779.85,45,,779.85,percent of total billed charges,Critical Access Hospital RCC factor,589.22,34,,589.22,percent of total billed charges,Implant Device,589.22,34,,589.22,percent of total billed charges,Implant Device,589.22,34,,589.22,percent of total billed charges,Implant Device,589.22,34,,589.22,percent of total billed charges,Implant Device,589.22,34,,589.22,percent of total billed charges,Implant Device,857.84,,,857.84,Other,110% of Medicare,606.55,35,,606.55,percent of total billed charges,Implant Device,589.22,34,"Charges > $500, x 34%",589.22,percent of total billed charges,Implant Device,606.55,35,,606.55,percent of total billed charges,Implant Device,606.55,35,,606.55,percent of total billed charges,Implant Device,606.55,35,,606.55,percent of total billed charges,Implant Device,606.55,35,,606.55,percent of total billed charges,Implant Device,606.55,35,,606.55,percent of total billed charges,Implant Device,693.2,40,,693.2,percent of total billed charges,Implant Device,606.55,70,,606.55,percent of total billed charges,All Other,589.22,34,,589.22,percent of total billed charges,Implant Device,589.22,34,,589.22,percent of total billed charges,Implant Device,606.55,35,,606.55,percent of total billed charges,Implant Device,606.55,35,,606.55,percent of total billed charges,Implant Device,606.55,35,,606.55,percent of total billed charges,Implant Device,606.55,35,,606.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1282.42,
DEPUY 207.045 4X45MM CANC SCREW PT,C1713,HCPCS,,79006577,CDM,278,RC,,,both,,,56,41.44,,,41.44,Other,150% of Medicare + 9.63% HCRA Surcharge,25.2,45,,25.2,percent of total billed charges,Critical Access Hospital RCC factor,19.04,34,,19.04,percent of total billed charges,Implant Device,19.04,34,,19.04,percent of total billed charges,Implant Device,19.04,34,,19.04,percent of total billed charges,Implant Device,19.04,34,,19.04,percent of total billed charges,Implant Device,19.04,34,,19.04,percent of total billed charges,Implant Device,27.72,,,27.72,Other,110% of Medicare,19.6,35,,19.6,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,19.6,35,,19.6,percent of total billed charges,Implant Device,19.6,35,,19.6,percent of total billed charges,Implant Device,19.6,35,,19.6,percent of total billed charges,Implant Device,19.6,35,,19.6,percent of total billed charges,Implant Device,19.6,35,,19.6,percent of total billed charges,Implant Device,22.4,40,,22.4,percent of total billed charges,Implant Device,19.6,70,,19.6,percent of total billed charges,All Other,19.04,34,,19.04,percent of total billed charges,Implant Device,19.04,34,,19.04,percent of total billed charges,Implant Device,19.6,35,,19.6,percent of total billed charges,Implant Device,19.6,35,,19.6,percent of total billed charges,Implant Device,19.6,35,,19.6,percent of total billed charges,Implant Device,19.6,35,,19.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,41.44,
DEPUY 207.045 4X45MM CANC SCREW PT,C1713,HCPCS,,79006579,CDM,278,RC,,,both,,,78,57.72,,,57.72,Other,150% of Medicare + 9.63% HCRA Surcharge,35.1,45,,35.1,percent of total billed charges,Critical Access Hospital RCC factor,26.52,34,,26.52,percent of total billed charges,Implant Device,26.52,34,,26.52,percent of total billed charges,Implant Device,26.52,34,,26.52,percent of total billed charges,Implant Device,26.52,34,,26.52,percent of total billed charges,Implant Device,26.52,34,,26.52,percent of total billed charges,Implant Device,38.61,,,38.61,Other,110% of Medicare,27.3,35,,27.3,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,27.3,35,,27.3,percent of total billed charges,Implant Device,27.3,35,,27.3,percent of total billed charges,Implant Device,27.3,35,,27.3,percent of total billed charges,Implant Device,27.3,35,,27.3,percent of total billed charges,Implant Device,27.3,35,,27.3,percent of total billed charges,Implant Device,31.2,40,,31.2,percent of total billed charges,Implant Device,27.3,70,,27.3,percent of total billed charges,All Other,26.52,34,,26.52,percent of total billed charges,Implant Device,26.52,34,,26.52,percent of total billed charges,Implant Device,27.3,35,,27.3,percent of total billed charges,Implant Device,27.3,35,,27.3,percent of total billed charges,Implant Device,27.3,35,,27.3,percent of total billed charges,Implant Device,27.3,35,,27.3,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,57.72,
ACUMED AT2-S20-S ACUTRAK BONE SCREW 20MM,C1713,HCPCS,,79006580,CDM,278,RC,,,both,,,1584,1172.16,,,1172.16,Other,150% of Medicare + 9.63% HCRA Surcharge,712.8,45,,712.8,percent of total billed charges,Critical Access Hospital RCC factor,538.56,34,,538.56,percent of total billed charges,Implant Device,538.56,34,,538.56,percent of total billed charges,Implant Device,538.56,34,,538.56,percent of total billed charges,Implant Device,538.56,34,,538.56,percent of total billed charges,Implant Device,538.56,34,,538.56,percent of total billed charges,Implant Device,784.08,,,784.08,Other,110% of Medicare,554.4,35,,554.4,percent of total billed charges,Implant Device,538.56,34,"Charges > $500, x 34%",538.56,percent of total billed charges,Implant Device,554.4,35,,554.4,percent of total billed charges,Implant Device,554.4,35,,554.4,percent of total billed charges,Implant Device,554.4,35,,554.4,percent of total billed charges,Implant Device,554.4,35,,554.4,percent of total billed charges,Implant Device,554.4,35,,554.4,percent of total billed charges,Implant Device,633.6,40,,633.6,percent of total billed charges,Implant Device,554.4,70,,554.4,percent of total billed charges,All Other,538.56,34,,538.56,percent of total billed charges,Implant Device,538.56,34,,538.56,percent of total billed charges,Implant Device,554.4,35,,554.4,percent of total billed charges,Implant Device,554.4,35,,554.4,percent of total billed charges,Implant Device,554.4,35,,554.4,percent of total billed charges,Implant Device,554.4,35,,554.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1172.16,
STRYKER 1822-1036S TIBIAL NAIL 10X360MM,C1713,HCPCS,,79006583,CDM,278,RC,,,both,,,3529,2611.47,,,2611.47,Other,150% of Medicare + 9.63% HCRA Surcharge,1588.05,45,,1588.05,percent of total billed charges,Critical Access Hospital RCC factor,1199.86,34,,1199.86,percent of total billed charges,Implant Device,1199.86,34,,1199.86,percent of total billed charges,Implant Device,1199.86,34,,1199.86,percent of total billed charges,Implant Device,1199.86,34,,1199.86,percent of total billed charges,Implant Device,1199.86,34,,1199.86,percent of total billed charges,Implant Device,1746.86,,,1746.86,Other,110% of Medicare,1235.15,35,,1235.15,percent of total billed charges,Implant Device,1199.86,34,"Charges > $500, x 34%",1199.86,percent of total billed charges,Implant Device,1235.15,35,,1235.15,percent of total billed charges,Implant Device,1235.15,35,,1235.15,percent of total billed charges,Implant Device,1235.15,35,,1235.15,percent of total billed charges,Implant Device,1235.15,35,,1235.15,percent of total billed charges,Implant Device,1235.15,35,,1235.15,percent of total billed charges,Implant Device,1411.6,40,,1411.6,percent of total billed charges,Implant Device,1235.15,70,,1235.15,percent of total billed charges,All Other,1199.86,34,,1199.86,percent of total billed charges,Implant Device,1199.86,34,,1199.86,percent of total billed charges,Implant Device,1235.15,35,,1235.15,percent of total billed charges,Implant Device,1235.15,35,,1235.15,percent of total billed charges,Implant Device,1235.15,35,,1235.15,percent of total billed charges,Implant Device,1235.15,35,,1235.15,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1199.86,34,"If Charge > 2,000, then 34 percent",1199.86,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2611.47,
ARTHREX 1850 BIOCARTILAGE 1CC,C1713,HCPCS,,79006584,CDM,278,RC,,,both,,,2310,1709.41,,,1709.41,Other,150% of Medicare + 9.63% HCRA Surcharge,1039.5,45,,1039.5,percent of total billed charges,Critical Access Hospital RCC factor,785.4,34,,785.4,percent of total billed charges,Implant Device,785.4,34,,785.4,percent of total billed charges,Implant Device,785.4,34,,785.4,percent of total billed charges,Implant Device,785.4,34,,785.4,percent of total billed charges,Implant Device,785.4,34,,785.4,percent of total billed charges,Implant Device,1143.45,,,1143.45,Other,110% of Medicare,808.5,35,,808.5,percent of total billed charges,Implant Device,785.4,34,"Charges > $500, x 34%",785.4,percent of total billed charges,Implant Device,808.5,35,,808.5,percent of total billed charges,Implant Device,808.5,35,,808.5,percent of total billed charges,Implant Device,808.5,35,,808.5,percent of total billed charges,Implant Device,808.5,35,,808.5,percent of total billed charges,Implant Device,808.5,35,,808.5,percent of total billed charges,Implant Device,924,40,,924,percent of total billed charges,Implant Device,808.5,70,,808.5,percent of total billed charges,All Other,785.4,34,,785.4,percent of total billed charges,Implant Device,785.4,34,,785.4,percent of total billed charges,Implant Device,808.5,35,,808.5,percent of total billed charges,Implant Device,808.5,35,,808.5,percent of total billed charges,Implant Device,808.5,35,,808.5,percent of total billed charges,Implant Device,808.5,35,,808.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,785.4,34,"If Charge > 2,000, then 34 percent",785.4,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1709.41,
ARTHREX AR-8943TH-03 PLATE HOOK 3 HOLE,C1713,HCPCS,,79006590,CDM,278,RC,,,both,,,2100,1554.01,,,1554.01,Other,150% of Medicare + 9.63% HCRA Surcharge,945,45,,945,percent of total billed charges,Critical Access Hospital RCC factor,714,34,,714,percent of total billed charges,Implant Device,714,34,,714,percent of total billed charges,Implant Device,714,34,,714,percent of total billed charges,Implant Device,714,34,,714,percent of total billed charges,Implant Device,714,34,,714,percent of total billed charges,Implant Device,1039.5,,,1039.5,Other,110% of Medicare,735,35,,735,percent of total billed charges,Implant Device,714,34,"Charges > $500, x 34%",714,percent of total billed charges,Implant Device,735,35,,735,percent of total billed charges,Implant Device,735,35,,735,percent of total billed charges,Implant Device,735,35,,735,percent of total billed charges,Implant Device,735,35,,735,percent of total billed charges,Implant Device,735,35,,735,percent of total billed charges,Implant Device,840,40,,840,percent of total billed charges,Implant Device,735,70,,735,percent of total billed charges,All Other,714,34,,714,percent of total billed charges,Implant Device,714,34,,714,percent of total billed charges,Implant Device,735,35,,735,percent of total billed charges,Implant Device,735,35,,735,percent of total billed charges,Implant Device,735,35,,735,percent of total billed charges,Implant Device,735,35,,735,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,714,34,"If Charge > 2,000, then 34 percent",714,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1554.01,
ARTHREX AR-8835-36 CORTCL SCREW 3.5X36MM,C1713,HCPCS,,79006591,CDM,278,RC,,,both,,,106,78.44,,,78.44,Other,150% of Medicare + 9.63% HCRA Surcharge,47.7,45,,47.7,percent of total billed charges,Critical Access Hospital RCC factor,36.04,34,,36.04,percent of total billed charges,Implant Device,36.04,34,,36.04,percent of total billed charges,Implant Device,36.04,34,,36.04,percent of total billed charges,Implant Device,36.04,34,,36.04,percent of total billed charges,Implant Device,36.04,34,,36.04,percent of total billed charges,Implant Device,52.47,,,52.47,Other,110% of Medicare,37.1,35,,37.1,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,37.1,35,,37.1,percent of total billed charges,Implant Device,37.1,35,,37.1,percent of total billed charges,Implant Device,37.1,35,,37.1,percent of total billed charges,Implant Device,37.1,35,,37.1,percent of total billed charges,Implant Device,37.1,35,,37.1,percent of total billed charges,Implant Device,42.4,40,,42.4,percent of total billed charges,Implant Device,37.1,70,,37.1,percent of total billed charges,All Other,36.04,34,,36.04,percent of total billed charges,Implant Device,36.04,34,,36.04,percent of total billed charges,Implant Device,37.1,35,,37.1,percent of total billed charges,Implant Device,37.1,35,,37.1,percent of total billed charges,Implant Device,37.1,35,,37.1,percent of total billed charges,Implant Device,37.1,35,,37.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,78.44,
ARTHREX AR-8835-40 CORTCL SCREW 3.5X40MM,C1713,HCPCS,,79006592,CDM,278,RC,,,both,,,106,78.44,,,78.44,Other,150% of Medicare + 9.63% HCRA Surcharge,47.7,45,,47.7,percent of total billed charges,Critical Access Hospital RCC factor,36.04,34,,36.04,percent of total billed charges,Implant Device,36.04,34,,36.04,percent of total billed charges,Implant Device,36.04,34,,36.04,percent of total billed charges,Implant Device,36.04,34,,36.04,percent of total billed charges,Implant Device,36.04,34,,36.04,percent of total billed charges,Implant Device,52.47,,,52.47,Other,110% of Medicare,37.1,35,,37.1,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,37.1,35,,37.1,percent of total billed charges,Implant Device,37.1,35,,37.1,percent of total billed charges,Implant Device,37.1,35,,37.1,percent of total billed charges,Implant Device,37.1,35,,37.1,percent of total billed charges,Implant Device,37.1,35,,37.1,percent of total billed charges,Implant Device,42.4,40,,42.4,percent of total billed charges,Implant Device,37.1,70,,37.1,percent of total billed charges,All Other,36.04,34,,36.04,percent of total billed charges,Implant Device,36.04,34,,36.04,percent of total billed charges,Implant Device,37.1,35,,37.1,percent of total billed charges,Implant Device,37.1,35,,37.1,percent of total billed charges,Implant Device,37.1,35,,37.1,percent of total billed charges,Implant Device,37.1,35,,37.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,78.44,
ARTHREX AR-13400L-06 HTO IMP I BAL LG/XL,C1713,HCPCS,,79006595,CDM,278,RC,,,both,,,8146,6028.06,,,6028.06,Other,150% of Medicare + 9.63% HCRA Surcharge,3665.7,45,,3665.7,percent of total billed charges,Critical Access Hospital RCC factor,2769.64,34,,2769.64,percent of total billed charges,Implant Device,2769.64,34,,2769.64,percent of total billed charges,Implant Device,2769.64,34,,2769.64,percent of total billed charges,Implant Device,2769.64,34,,2769.64,percent of total billed charges,Implant Device,2769.64,34,,2769.64,percent of total billed charges,Implant Device,4032.27,,,4032.27,Other,110% of Medicare,2851.1,35,,2851.1,percent of total billed charges,Implant Device,2769.64,34,"Charges > $500, x 34%",2769.64,percent of total billed charges,Implant Device,2851.1,35,,2851.1,percent of total billed charges,Implant Device,2851.1,35,,2851.1,percent of total billed charges,Implant Device,2851.1,35,,2851.1,percent of total billed charges,Implant Device,2851.1,35,,2851.1,percent of total billed charges,Implant Device,2851.1,35,,2851.1,percent of total billed charges,Implant Device,3258.4,40,,3258.4,percent of total billed charges,Implant Device,2851.1,70,,2851.1,percent of total billed charges,All Other,2769.64,34,,2769.64,percent of total billed charges,Implant Device,2769.64,34,,2769.64,percent of total billed charges,Implant Device,2851.1,35,,2851.1,percent of total billed charges,Implant Device,2851.1,35,,2851.1,percent of total billed charges,Implant Device,2851.1,35,,2851.1,percent of total billed charges,Implant Device,2851.1,35,,2851.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2769.64,34,"If Charge > 2,000, then 34 percent",2769.64,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,6028.06,
ARTHREX AR-13370-1 BONE VOID FILLER 12MM,C1713,HCPCS,,79006596,CDM,278,RC,,,both,,,2124,1571.77,,,1571.77,Other,150% of Medicare + 9.63% HCRA Surcharge,955.8,45,,955.8,percent of total billed charges,Critical Access Hospital RCC factor,722.16,34,,722.16,percent of total billed charges,Implant Device,722.16,34,,722.16,percent of total billed charges,Implant Device,722.16,34,,722.16,percent of total billed charges,Implant Device,722.16,34,,722.16,percent of total billed charges,Implant Device,722.16,34,,722.16,percent of total billed charges,Implant Device,1051.38,,,1051.38,Other,110% of Medicare,743.4,35,,743.4,percent of total billed charges,Implant Device,722.16,34,"Charges > $500, x 34%",722.16,percent of total billed charges,Implant Device,743.4,35,,743.4,percent of total billed charges,Implant Device,743.4,35,,743.4,percent of total billed charges,Implant Device,743.4,35,,743.4,percent of total billed charges,Implant Device,743.4,35,,743.4,percent of total billed charges,Implant Device,743.4,35,,743.4,percent of total billed charges,Implant Device,849.6,40,,849.6,percent of total billed charges,Implant Device,743.4,70,,743.4,percent of total billed charges,All Other,722.16,34,,722.16,percent of total billed charges,Implant Device,722.16,34,,722.16,percent of total billed charges,Implant Device,743.4,35,,743.4,percent of total billed charges,Implant Device,743.4,35,,743.4,percent of total billed charges,Implant Device,743.4,35,,743.4,percent of total billed charges,Implant Device,743.4,35,,743.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,722.16,34,"If Charge > 2,000, then 34 percent",722.16,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1571.77,
ARTHREX AR-13402-38 HTO ANCHOR 4.5X38MM,C1713,HCPCS,,79006597,CDM,278,RC,,,both,,,1074,794.76,,,794.76,Other,150% of Medicare + 9.63% HCRA Surcharge,483.3,45,,483.3,percent of total billed charges,Critical Access Hospital RCC factor,365.16,34,,365.16,percent of total billed charges,Implant Device,365.16,34,,365.16,percent of total billed charges,Implant Device,365.16,34,,365.16,percent of total billed charges,Implant Device,365.16,34,,365.16,percent of total billed charges,Implant Device,365.16,34,,365.16,percent of total billed charges,Implant Device,531.63,,,531.63,Other,110% of Medicare,375.9,35,,375.9,percent of total billed charges,Implant Device,365.16,34,"Charges > $500, x 34%",365.16,percent of total billed charges,Implant Device,375.9,35,,375.9,percent of total billed charges,Implant Device,375.9,35,,375.9,percent of total billed charges,Implant Device,375.9,35,,375.9,percent of total billed charges,Implant Device,375.9,35,,375.9,percent of total billed charges,Implant Device,375.9,35,,375.9,percent of total billed charges,Implant Device,429.6,40,,429.6,percent of total billed charges,Implant Device,375.9,70,,375.9,percent of total billed charges,All Other,365.16,34,,365.16,percent of total billed charges,Implant Device,365.16,34,,365.16,percent of total billed charges,Implant Device,375.9,35,,375.9,percent of total billed charges,Implant Device,375.9,35,,375.9,percent of total billed charges,Implant Device,375.9,35,,375.9,percent of total billed charges,Implant Device,375.9,35,,375.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,794.76,
ARTHREX AR-13401-26 HTO ANCHOR 6.5X26MM,C1713,HCPCS,,79006598,CDM,278,RC,,,both,,,1074,794.76,,,794.76,Other,150% of Medicare + 9.63% HCRA Surcharge,483.3,45,,483.3,percent of total billed charges,Critical Access Hospital RCC factor,365.16,34,,365.16,percent of total billed charges,Implant Device,365.16,34,,365.16,percent of total billed charges,Implant Device,365.16,34,,365.16,percent of total billed charges,Implant Device,365.16,34,,365.16,percent of total billed charges,Implant Device,365.16,34,,365.16,percent of total billed charges,Implant Device,531.63,,,531.63,Other,110% of Medicare,375.9,35,,375.9,percent of total billed charges,Implant Device,365.16,34,"Charges > $500, x 34%",365.16,percent of total billed charges,Implant Device,375.9,35,,375.9,percent of total billed charges,Implant Device,375.9,35,,375.9,percent of total billed charges,Implant Device,375.9,35,,375.9,percent of total billed charges,Implant Device,375.9,35,,375.9,percent of total billed charges,Implant Device,375.9,35,,375.9,percent of total billed charges,Implant Device,429.6,40,,429.6,percent of total billed charges,Implant Device,375.9,70,,375.9,percent of total billed charges,All Other,365.16,34,,365.16,percent of total billed charges,Implant Device,365.16,34,,365.16,percent of total billed charges,Implant Device,375.9,35,,375.9,percent of total billed charges,Implant Device,375.9,35,,375.9,percent of total billed charges,Implant Device,375.9,35,,375.9,percent of total billed charges,Implant Device,375.9,35,,375.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,794.76,
ARTHREX AR-13401-30 HTO ANCHOR 6.5X30MM,C1713,HCPCS,,79006599,CDM,278,RC,,,both,,,1074,794.76,,,794.76,Other,150% of Medicare + 9.63% HCRA Surcharge,483.3,45,,483.3,percent of total billed charges,Critical Access Hospital RCC factor,365.16,34,,365.16,percent of total billed charges,Implant Device,365.16,34,,365.16,percent of total billed charges,Implant Device,365.16,34,,365.16,percent of total billed charges,Implant Device,365.16,34,,365.16,percent of total billed charges,Implant Device,365.16,34,,365.16,percent of total billed charges,Implant Device,531.63,,,531.63,Other,110% of Medicare,375.9,35,,375.9,percent of total billed charges,Implant Device,365.16,34,"Charges > $500, x 34%",365.16,percent of total billed charges,Implant Device,375.9,35,,375.9,percent of total billed charges,Implant Device,375.9,35,,375.9,percent of total billed charges,Implant Device,375.9,35,,375.9,percent of total billed charges,Implant Device,375.9,35,,375.9,percent of total billed charges,Implant Device,375.9,35,,375.9,percent of total billed charges,Implant Device,429.6,40,,429.6,percent of total billed charges,Implant Device,375.9,70,,375.9,percent of total billed charges,All Other,365.16,34,,365.16,percent of total billed charges,Implant Device,365.16,34,,365.16,percent of total billed charges,Implant Device,375.9,35,,375.9,percent of total billed charges,Implant Device,375.9,35,,375.9,percent of total billed charges,Implant Device,375.9,35,,375.9,percent of total billed charges,Implant Device,375.9,35,,375.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,794.76,
ZIMMER 00-5604-020-07 CHONDROFIX ALLGRFT,C1713,HCPCS,,79006601,CDM,278,RC,,,both,,,8142,6025.1,,,6025.1,Other,150% of Medicare + 9.63% HCRA Surcharge,3663.9,45,,3663.9,percent of total billed charges,Critical Access Hospital RCC factor,2768.28,34,,2768.28,percent of total billed charges,Implant Device,2768.28,34,,2768.28,percent of total billed charges,Implant Device,2768.28,34,,2768.28,percent of total billed charges,Implant Device,2768.28,34,,2768.28,percent of total billed charges,Implant Device,2768.28,34,,2768.28,percent of total billed charges,Implant Device,4030.29,,,4030.29,Other,110% of Medicare,2849.7,35,,2849.7,percent of total billed charges,Implant Device,2768.28,34,"Charges > $500, x 34%",2768.28,percent of total billed charges,Implant Device,2849.7,35,,2849.7,percent of total billed charges,Implant Device,2849.7,35,,2849.7,percent of total billed charges,Implant Device,2849.7,35,,2849.7,percent of total billed charges,Implant Device,2849.7,35,,2849.7,percent of total billed charges,Implant Device,2849.7,35,,2849.7,percent of total billed charges,Implant Device,3256.8,40,,3256.8,percent of total billed charges,Implant Device,2849.7,70,,2849.7,percent of total billed charges,All Other,2768.28,34,,2768.28,percent of total billed charges,Implant Device,2768.28,34,,2768.28,percent of total billed charges,Implant Device,2849.7,35,,2849.7,percent of total billed charges,Implant Device,2849.7,35,,2849.7,percent of total billed charges,Implant Device,2849.7,35,,2849.7,percent of total billed charges,Implant Device,2849.7,35,,2849.7,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2768.28,34,"If Charge > 2,000, then 34 percent",2768.28,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,6025.1,
ZIMMER 00-5990-034-23 NEXGEN AUG BLCK 15,C1713,HCPCS,,79006604,CDM,278,RC,,,both,,,3456,2557.45,,,2557.45,Other,150% of Medicare + 9.63% HCRA Surcharge,1555.2,45,,1555.2,percent of total billed charges,Critical Access Hospital RCC factor,1175.04,34,,1175.04,percent of total billed charges,Implant Device,1175.04,34,,1175.04,percent of total billed charges,Implant Device,1175.04,34,,1175.04,percent of total billed charges,Implant Device,1175.04,34,,1175.04,percent of total billed charges,Implant Device,1175.04,34,,1175.04,percent of total billed charges,Implant Device,1710.72,,,1710.72,Other,110% of Medicare,1209.6,35,,1209.6,percent of total billed charges,Implant Device,1175.04,34,"Charges > $500, x 34%",1175.04,percent of total billed charges,Implant Device,1209.6,35,,1209.6,percent of total billed charges,Implant Device,1209.6,35,,1209.6,percent of total billed charges,Implant Device,1209.6,35,,1209.6,percent of total billed charges,Implant Device,1209.6,35,,1209.6,percent of total billed charges,Implant Device,1209.6,35,,1209.6,percent of total billed charges,Implant Device,1382.4,40,,1382.4,percent of total billed charges,Implant Device,1209.6,70,,1209.6,percent of total billed charges,All Other,1175.04,34,,1175.04,percent of total billed charges,Implant Device,1175.04,34,,1175.04,percent of total billed charges,Implant Device,1209.6,35,,1209.6,percent of total billed charges,Implant Device,1209.6,35,,1209.6,percent of total billed charges,Implant Device,1209.6,35,,1209.6,percent of total billed charges,Implant Device,1209.6,35,,1209.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1175.04,34,"If Charge > 2,000, then 34 percent",1175.04,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2557.45,
ZIMMER 00-5990-034-24 NEXGEN AUG BLCK 20,C1713,HCPCS,,79006605,CDM,278,RC,,,both,,,3488,2581.13,,,2581.13,Other,150% of Medicare + 9.63% HCRA Surcharge,1569.6,45,,1569.6,percent of total billed charges,Critical Access Hospital RCC factor,1185.92,34,,1185.92,percent of total billed charges,Implant Device,1185.92,34,,1185.92,percent of total billed charges,Implant Device,1185.92,34,,1185.92,percent of total billed charges,Implant Device,1185.92,34,,1185.92,percent of total billed charges,Implant Device,1185.92,34,,1185.92,percent of total billed charges,Implant Device,1726.56,,,1726.56,Other,110% of Medicare,1220.8,35,,1220.8,percent of total billed charges,Implant Device,1185.92,34,"Charges > $500, x 34%",1185.92,percent of total billed charges,Implant Device,1220.8,35,,1220.8,percent of total billed charges,Implant Device,1220.8,35,,1220.8,percent of total billed charges,Implant Device,1220.8,35,,1220.8,percent of total billed charges,Implant Device,1220.8,35,,1220.8,percent of total billed charges,Implant Device,1220.8,35,,1220.8,percent of total billed charges,Implant Device,1395.2,40,,1395.2,percent of total billed charges,Implant Device,1220.8,70,,1220.8,percent of total billed charges,All Other,1185.92,34,,1185.92,percent of total billed charges,Implant Device,1185.92,34,,1185.92,percent of total billed charges,Implant Device,1220.8,35,,1220.8,percent of total billed charges,Implant Device,1220.8,35,,1220.8,percent of total billed charges,Implant Device,1220.8,35,,1220.8,percent of total billed charges,Implant Device,1220.8,35,,1220.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1185.92,34,"If Charge > 2,000, then 34 percent",1185.92,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2581.13,
S&N 74023266 ARTICULAR INSRT SZ 5-6 18MM,C1713,HCPCS,,79006606,CDM,278,RC,,,both,,,8610,6371.42,,,6371.42,Other,150% of Medicare + 9.63% HCRA Surcharge,3874.5,45,,3874.5,percent of total billed charges,Critical Access Hospital RCC factor,2927.4,34,,2927.4,percent of total billed charges,Implant Device,2927.4,34,,2927.4,percent of total billed charges,Implant Device,2927.4,34,,2927.4,percent of total billed charges,Implant Device,2927.4,34,,2927.4,percent of total billed charges,Implant Device,2927.4,34,,2927.4,percent of total billed charges,Implant Device,4261.95,,,4261.95,Other,110% of Medicare,3013.5,35,,3013.5,percent of total billed charges,Implant Device,2927.4,34,"Charges > $500, x 34%",2927.4,percent of total billed charges,Implant Device,3013.5,35,,3013.5,percent of total billed charges,Implant Device,3013.5,35,,3013.5,percent of total billed charges,Implant Device,3013.5,35,,3013.5,percent of total billed charges,Implant Device,3013.5,35,,3013.5,percent of total billed charges,Implant Device,3013.5,35,,3013.5,percent of total billed charges,Implant Device,3444,40,,3444,percent of total billed charges,Implant Device,3013.5,70,,3013.5,percent of total billed charges,All Other,2927.4,34,,2927.4,percent of total billed charges,Implant Device,2927.4,34,,2927.4,percent of total billed charges,Implant Device,3013.5,35,,3013.5,percent of total billed charges,Implant Device,3013.5,35,,3013.5,percent of total billed charges,Implant Device,3013.5,35,,3013.5,percent of total billed charges,Implant Device,3013.5,35,,3013.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2927.4,34,"If Charge > 2,000, then 34 percent",2927.4,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,6371.42,
ZIMMER 187-06-69 STEINMN PIN SMOOTH 5/32,C1713,HCPCS,,79006607,CDM,278,RC,,,both,,,26,19.24,,,19.24,Other,150% of Medicare + 9.63% HCRA Surcharge,11.7,45,,11.7,percent of total billed charges,Critical Access Hospital RCC factor,8.84,34,,8.84,percent of total billed charges,Implant Device,8.84,34,,8.84,percent of total billed charges,Implant Device,8.84,34,,8.84,percent of total billed charges,Implant Device,8.84,34,,8.84,percent of total billed charges,Implant Device,8.84,34,,8.84,percent of total billed charges,Implant Device,12.87,,,12.87,Other,110% of Medicare,9.1,35,,9.1,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,9.1,35,,9.1,percent of total billed charges,Implant Device,9.1,35,,9.1,percent of total billed charges,Implant Device,9.1,35,,9.1,percent of total billed charges,Implant Device,9.1,35,,9.1,percent of total billed charges,Implant Device,9.1,35,,9.1,percent of total billed charges,Implant Device,10.4,40,,10.4,percent of total billed charges,Implant Device,9.1,70,,9.1,percent of total billed charges,All Other,8.84,34,,8.84,percent of total billed charges,Implant Device,8.84,34,,8.84,percent of total billed charges,Implant Device,9.1,35,,9.1,percent of total billed charges,Implant Device,9.1,35,,9.1,percent of total billed charges,Implant Device,9.1,35,,9.1,percent of total billed charges,Implant Device,9.1,35,,9.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,19.24,
DEPUY 9505-02-303 PIN THREADED HEADED,C1713,HCPCS,,79006608,CDM,278,RC,,,both,,,1552,1148.48,,,1148.48,Other,150% of Medicare + 9.63% HCRA Surcharge,698.4,45,,698.4,percent of total billed charges,Critical Access Hospital RCC factor,527.68,34,,527.68,percent of total billed charges,Implant Device,527.68,34,,527.68,percent of total billed charges,Implant Device,527.68,34,,527.68,percent of total billed charges,Implant Device,527.68,34,,527.68,percent of total billed charges,Implant Device,527.68,34,,527.68,percent of total billed charges,Implant Device,768.24,,,768.24,Other,110% of Medicare,543.2,35,,543.2,percent of total billed charges,Implant Device,527.68,34,"Charges > $500, x 34%",527.68,percent of total billed charges,Implant Device,543.2,35,,543.2,percent of total billed charges,Implant Device,543.2,35,,543.2,percent of total billed charges,Implant Device,543.2,35,,543.2,percent of total billed charges,Implant Device,543.2,35,,543.2,percent of total billed charges,Implant Device,543.2,35,,543.2,percent of total billed charges,Implant Device,620.8,40,,620.8,percent of total billed charges,Implant Device,543.2,70,,543.2,percent of total billed charges,All Other,527.68,34,,527.68,percent of total billed charges,Implant Device,527.68,34,,527.68,percent of total billed charges,Implant Device,543.2,35,,543.2,percent of total billed charges,Implant Device,543.2,35,,543.2,percent of total billed charges,Implant Device,543.2,35,,543.2,percent of total billed charges,Implant Device,543.2,35,,543.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1148.48,
DEPUY 1960-40-300 FEM POST STABLZD SZ 3,C1776,HCPCS,,79006609,CDM,278,RC,,,both,,,7927,5866,,,5866,Other,150% of Medicare + 9.63% HCRA Surcharge,3567.15,45,,3567.15,percent of total billed charges,Critical Access Hospital RCC factor,2695.18,34,,2695.18,percent of total billed charges,Implant Device,2695.18,34,,2695.18,percent of total billed charges,Implant Device,2695.18,34,,2695.18,percent of total billed charges,Implant Device,2695.18,34,,2695.18,percent of total billed charges,Implant Device,2695.18,34,,2695.18,percent of total billed charges,Implant Device,3923.87,,,3923.87,Other,110% of Medicare,2774.45,35,,2774.45,percent of total billed charges,Implant Device,2695.18,34,"Charges > $500, x 34%",2695.18,percent of total billed charges,Implant Device,2774.45,35,,2774.45,percent of total billed charges,Implant Device,2774.45,35,,2774.45,percent of total billed charges,Implant Device,2774.45,35,,2774.45,percent of total billed charges,Implant Device,2774.45,35,,2774.45,percent of total billed charges,Implant Device,2774.45,35,,2774.45,percent of total billed charges,Implant Device,3170.8,40,,3170.8,percent of total billed charges,Implant Device,2774.45,70,,2774.45,percent of total billed charges,All Other,2695.18,34,,2695.18,percent of total billed charges,Implant Device,2695.18,34,,2695.18,percent of total billed charges,Implant Device,2774.45,35,,2774.45,percent of total billed charges,Implant Device,2774.45,35,,2774.45,percent of total billed charges,Implant Device,2774.45,35,,2774.45,percent of total billed charges,Implant Device,2774.45,35,,2774.45,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2695.18,34,"If Charge > 2,000, then 34 percent",2695.18,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5866,
DEPUY 96-0100 DOME PATELLA 3-PEG 32MM,C1776,HCPCS,,79006610,CDM,278,RC,,,both,,,1836,1358.64,,,1358.64,Other,150% of Medicare + 9.63% HCRA Surcharge,826.2,45,,826.2,percent of total billed charges,Critical Access Hospital RCC factor,624.24,34,,624.24,percent of total billed charges,Implant Device,624.24,34,,624.24,percent of total billed charges,Implant Device,624.24,34,,624.24,percent of total billed charges,Implant Device,624.24,34,,624.24,percent of total billed charges,Implant Device,624.24,34,,624.24,percent of total billed charges,Implant Device,908.82,,,908.82,Other,110% of Medicare,642.6,35,,642.6,percent of total billed charges,Implant Device,624.24,34,"Charges > $500, x 34%",624.24,percent of total billed charges,Implant Device,642.6,35,,642.6,percent of total billed charges,Implant Device,642.6,35,,642.6,percent of total billed charges,Implant Device,642.6,35,,642.6,percent of total billed charges,Implant Device,642.6,35,,642.6,percent of total billed charges,Implant Device,642.6,35,,642.6,percent of total billed charges,Implant Device,734.4,40,,734.4,percent of total billed charges,Implant Device,642.6,70,,642.6,percent of total billed charges,All Other,624.24,34,,624.24,percent of total billed charges,Implant Device,624.24,34,,624.24,percent of total billed charges,Implant Device,642.6,35,,642.6,percent of total billed charges,Implant Device,642.6,35,,642.6,percent of total billed charges,Implant Device,642.6,35,,642.6,percent of total billed charges,Implant Device,642.6,35,,642.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1358.64,
DEPUY 96-2132 TIBIAL INS ROTATING 12.5MM,C1776,HCPCS,,79006611,CDM,278,RC,,,both,,,4080,3019.21,,,3019.21,Other,150% of Medicare + 9.63% HCRA Surcharge,1836,45,,1836,percent of total billed charges,Critical Access Hospital RCC factor,1387.2,34,,1387.2,percent of total billed charges,Implant Device,1387.2,34,,1387.2,percent of total billed charges,Implant Device,1387.2,34,,1387.2,percent of total billed charges,Implant Device,1387.2,34,,1387.2,percent of total billed charges,Implant Device,1387.2,34,,1387.2,percent of total billed charges,Implant Device,2019.6,,,2019.6,Other,110% of Medicare,1428,35,,1428,percent of total billed charges,Implant Device,1387.2,34,"Charges > $500, x 34%",1387.2,percent of total billed charges,Implant Device,1428,35,,1428,percent of total billed charges,Implant Device,1428,35,,1428,percent of total billed charges,Implant Device,1428,35,,1428,percent of total billed charges,Implant Device,1428,35,,1428,percent of total billed charges,Implant Device,1428,35,,1428,percent of total billed charges,Implant Device,1632,40,,1632,percent of total billed charges,Implant Device,1428,70,,1428,percent of total billed charges,All Other,1387.2,34,,1387.2,percent of total billed charges,Implant Device,1387.2,34,,1387.2,percent of total billed charges,Implant Device,1428,35,,1428,percent of total billed charges,Implant Device,1428,35,,1428,percent of total billed charges,Implant Device,1428,35,,1428,percent of total billed charges,Implant Device,1428,35,,1428,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1387.2,34,"If Charge > 2,000, then 34 percent",1387.2,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3019.21,
ARTHREX AR-1927PSF-3 SUTURE ANCHOR 5.5,C1713,HCPCS,,79006612,CDM,278,RC,,,both,,,1288,953.12,,,953.12,Other,150% of Medicare + 9.63% HCRA Surcharge,579.6,45,,579.6,percent of total billed charges,Critical Access Hospital RCC factor,437.92,34,,437.92,percent of total billed charges,Implant Device,437.92,34,,437.92,percent of total billed charges,Implant Device,437.92,34,,437.92,percent of total billed charges,Implant Device,437.92,34,,437.92,percent of total billed charges,Implant Device,437.92,34,,437.92,percent of total billed charges,Implant Device,637.56,,,637.56,Other,110% of Medicare,450.8,35,,450.8,percent of total billed charges,Implant Device,437.92,34,"Charges > $500, x 34%",437.92,percent of total billed charges,Implant Device,450.8,35,,450.8,percent of total billed charges,Implant Device,450.8,35,,450.8,percent of total billed charges,Implant Device,450.8,35,,450.8,percent of total billed charges,Implant Device,450.8,35,,450.8,percent of total billed charges,Implant Device,450.8,35,,450.8,percent of total billed charges,Implant Device,515.2,40,,515.2,percent of total billed charges,Implant Device,450.8,70,,450.8,percent of total billed charges,All Other,437.92,34,,437.92,percent of total billed charges,Implant Device,437.92,34,,437.92,percent of total billed charges,Implant Device,450.8,35,,450.8,percent of total billed charges,Implant Device,450.8,35,,450.8,percent of total billed charges,Implant Device,450.8,35,,450.8,percent of total billed charges,Implant Device,450.8,35,,450.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,953.12,
SYNTHES 202.626 CANNULATED SCREW 3X26MM,C1713,HCPCS,,79006613,CDM,278,RC,,,both,,,852,630.48,,,630.48,Other,150% of Medicare + 9.63% HCRA Surcharge,383.4,45,,383.4,percent of total billed charges,Critical Access Hospital RCC factor,289.68,34,,289.68,percent of total billed charges,Implant Device,289.68,34,,289.68,percent of total billed charges,Implant Device,289.68,34,,289.68,percent of total billed charges,Implant Device,289.68,34,,289.68,percent of total billed charges,Implant Device,289.68,34,,289.68,percent of total billed charges,Implant Device,421.74,,,421.74,Other,110% of Medicare,298.2,35,,298.2,percent of total billed charges,Implant Device,289.68,34,"Charges > $500, x 34%",289.68,percent of total billed charges,Implant Device,298.2,35,,298.2,percent of total billed charges,Implant Device,298.2,35,,298.2,percent of total billed charges,Implant Device,298.2,35,,298.2,percent of total billed charges,Implant Device,298.2,35,,298.2,percent of total billed charges,Implant Device,298.2,35,,298.2,percent of total billed charges,Implant Device,340.8,40,,340.8,percent of total billed charges,Implant Device,298.2,70,,298.2,percent of total billed charges,All Other,289.68,34,,289.68,percent of total billed charges,Implant Device,289.68,34,,289.68,percent of total billed charges,Implant Device,298.2,35,,298.2,percent of total billed charges,Implant Device,298.2,35,,298.2,percent of total billed charges,Implant Device,298.2,35,,298.2,percent of total billed charges,Implant Device,298.2,35,,298.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,630.48,
SYNTHES 202.630 CANNULATED SCREW 3X30MM,C1713,HCPCS,,79006614,CDM,278,RC,,,both,,,852,630.48,,,630.48,Other,150% of Medicare + 9.63% HCRA Surcharge,383.4,45,,383.4,percent of total billed charges,Critical Access Hospital RCC factor,289.68,34,,289.68,percent of total billed charges,Implant Device,289.68,34,,289.68,percent of total billed charges,Implant Device,289.68,34,,289.68,percent of total billed charges,Implant Device,289.68,34,,289.68,percent of total billed charges,Implant Device,289.68,34,,289.68,percent of total billed charges,Implant Device,421.74,,,421.74,Other,110% of Medicare,298.2,35,,298.2,percent of total billed charges,Implant Device,289.68,34,"Charges > $500, x 34%",289.68,percent of total billed charges,Implant Device,298.2,35,,298.2,percent of total billed charges,Implant Device,298.2,35,,298.2,percent of total billed charges,Implant Device,298.2,35,,298.2,percent of total billed charges,Implant Device,298.2,35,,298.2,percent of total billed charges,Implant Device,298.2,35,,298.2,percent of total billed charges,Implant Device,340.8,40,,340.8,percent of total billed charges,Implant Device,298.2,70,,298.2,percent of total billed charges,All Other,289.68,34,,289.68,percent of total billed charges,Implant Device,289.68,34,,289.68,percent of total billed charges,Implant Device,298.2,35,,298.2,percent of total billed charges,Implant Device,298.2,35,,298.2,percent of total billed charges,Implant Device,298.2,35,,298.2,percent of total billed charges,Implant Device,298.2,35,,298.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,630.48,
SYNTHES 202.638 CANNULATED SCREW 3X38MM,C1713,HCPCS,,79006615,CDM,278,RC,,,both,,,852,630.48,,,630.48,Other,150% of Medicare + 9.63% HCRA Surcharge,383.4,45,,383.4,percent of total billed charges,Critical Access Hospital RCC factor,289.68,34,,289.68,percent of total billed charges,Implant Device,289.68,34,,289.68,percent of total billed charges,Implant Device,289.68,34,,289.68,percent of total billed charges,Implant Device,289.68,34,,289.68,percent of total billed charges,Implant Device,289.68,34,,289.68,percent of total billed charges,Implant Device,421.74,,,421.74,Other,110% of Medicare,298.2,35,,298.2,percent of total billed charges,Implant Device,289.68,34,"Charges > $500, x 34%",289.68,percent of total billed charges,Implant Device,298.2,35,,298.2,percent of total billed charges,Implant Device,298.2,35,,298.2,percent of total billed charges,Implant Device,298.2,35,,298.2,percent of total billed charges,Implant Device,298.2,35,,298.2,percent of total billed charges,Implant Device,298.2,35,,298.2,percent of total billed charges,Implant Device,340.8,40,,340.8,percent of total billed charges,Implant Device,298.2,70,,298.2,percent of total billed charges,All Other,289.68,34,,289.68,percent of total billed charges,Implant Device,289.68,34,,289.68,percent of total billed charges,Implant Device,298.2,35,,298.2,percent of total billed charges,Implant Device,298.2,35,,298.2,percent of total billed charges,Implant Device,298.2,35,,298.2,percent of total billed charges,Implant Device,298.2,35,,298.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,630.48,
STRYKER 54-25683 DISTAL PLATE RT X-SHORT,C1713,HCPCS,,79006616,CDM,278,RC,,,both,,,2834,2097.17,,,2097.17,Other,150% of Medicare + 9.63% HCRA Surcharge,1275.3,45,,1275.3,percent of total billed charges,Critical Access Hospital RCC factor,963.56,34,,963.56,percent of total billed charges,Implant Device,963.56,34,,963.56,percent of total billed charges,Implant Device,963.56,34,,963.56,percent of total billed charges,Implant Device,963.56,34,,963.56,percent of total billed charges,Implant Device,963.56,34,,963.56,percent of total billed charges,Implant Device,1402.83,,,1402.83,Other,110% of Medicare,991.9,35,,991.9,percent of total billed charges,Implant Device,963.56,34,"Charges > $500, x 34%",963.56,percent of total billed charges,Implant Device,991.9,35,,991.9,percent of total billed charges,Implant Device,991.9,35,,991.9,percent of total billed charges,Implant Device,991.9,35,,991.9,percent of total billed charges,Implant Device,991.9,35,,991.9,percent of total billed charges,Implant Device,991.9,35,,991.9,percent of total billed charges,Implant Device,1133.6,40,,1133.6,percent of total billed charges,Implant Device,991.9,70,,991.9,percent of total billed charges,All Other,963.56,34,,963.56,percent of total billed charges,Implant Device,963.56,34,,963.56,percent of total billed charges,Implant Device,991.9,35,,991.9,percent of total billed charges,Implant Device,991.9,35,,991.9,percent of total billed charges,Implant Device,991.9,35,,991.9,percent of total billed charges,Implant Device,991.9,35,,991.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,963.56,34,"If Charge > 2,000, then 34 percent",963.56,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2097.17,
DEPUY ORTHO TOTAL ATTUNE RP KNEE CAP,C1776,HCPCS,,79006617,CDM,278,RC,,,both,,,17985,13308.94,,,13308.94,Other,150% of Medicare + 9.63% HCRA Surcharge,8093.25,45,,8093.25,percent of total billed charges,Critical Access Hospital RCC factor,6114.9,34,,6114.9,percent of total billed charges,Implant Device,6114.9,34,,6114.9,percent of total billed charges,Implant Device,6114.9,34,,6114.9,percent of total billed charges,Implant Device,6114.9,34,,6114.9,percent of total billed charges,Implant Device,6114.9,34,,6114.9,percent of total billed charges,Implant Device,8902.58,,,8902.58,Other,110% of Medicare,6294.75,35,,6294.75,percent of total billed charges,Implant Device,6114.9,34,"Charges > $500, x 34%",6114.9,percent of total billed charges,Implant Device,6294.75,35,,6294.75,percent of total billed charges,Implant Device,6294.75,35,,6294.75,percent of total billed charges,Implant Device,6294.75,35,,6294.75,percent of total billed charges,Implant Device,6294.75,35,,6294.75,percent of total billed charges,Implant Device,6294.75,35,,6294.75,percent of total billed charges,Implant Device,7194,40,,7194,percent of total billed charges,Implant Device,6294.75,70,,6294.75,percent of total billed charges,All Other,6114.9,34,,6114.9,percent of total billed charges,Implant Device,6114.9,34,,6114.9,percent of total billed charges,Implant Device,6294.75,35,,6294.75,percent of total billed charges,Implant Device,6294.75,35,,6294.75,percent of total billed charges,Implant Device,6294.75,35,,6294.75,percent of total billed charges,Implant Device,6294.75,35,,6294.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,6114.9,34,"If Charge > 2,000, then 34 percent",6114.9,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,13308.94,
MEDTRONIC 407652 CAPSURE NOVUS LEAD 52CM,C1898,HCPCS,,79006618,CDM,278,RC,,,both,,,2058,1522.93,,,1522.93,Other,150% of Medicare + 9.63% HCRA Surcharge,926.1,45,,926.1,percent of total billed charges,Critical Access Hospital RCC factor,699.72,34,,699.72,percent of total billed charges,Implant Device,699.72,34,,699.72,percent of total billed charges,Implant Device,699.72,34,,699.72,percent of total billed charges,Implant Device,699.72,34,,699.72,percent of total billed charges,Implant Device,699.72,34,,699.72,percent of total billed charges,Implant Device,1018.71,,,1018.71,Other,110% of Medicare,720.3,35,,720.3,percent of total billed charges,Implant Device,699.72,34,"Charges > $500, x 34%",699.72,percent of total billed charges,Implant Device,720.3,35,,720.3,percent of total billed charges,Implant Device,720.3,35,,720.3,percent of total billed charges,Implant Device,720.3,35,,720.3,percent of total billed charges,Implant Device,720.3,35,,720.3,percent of total billed charges,Implant Device,720.3,35,,720.3,percent of total billed charges,Implant Device,823.2,40,,823.2,percent of total billed charges,Implant Device,720.3,70,,720.3,percent of total billed charges,All Other,699.72,34,,699.72,percent of total billed charges,Implant Device,699.72,34,,699.72,percent of total billed charges,Implant Device,720.3,35,,720.3,percent of total billed charges,Implant Device,720.3,35,,720.3,percent of total billed charges,Implant Device,720.3,35,,720.3,percent of total billed charges,Implant Device,720.3,35,,720.3,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,699.72,34,"If Charge > 2,000, then 34 percent",699.72,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1522.93,
MEDTRONIC 407658 CAPSURE NOVUS LEAD 58CM,C1898,HCPCS,,79006619,CDM,278,RC,,,both,,,2058,1522.93,,,1522.93,Other,150% of Medicare + 9.63% HCRA Surcharge,926.1,45,,926.1,percent of total billed charges,Critical Access Hospital RCC factor,699.72,34,,699.72,percent of total billed charges,Implant Device,699.72,34,,699.72,percent of total billed charges,Implant Device,699.72,34,,699.72,percent of total billed charges,Implant Device,699.72,34,,699.72,percent of total billed charges,Implant Device,699.72,34,,699.72,percent of total billed charges,Implant Device,1018.71,,,1018.71,Other,110% of Medicare,720.3,35,,720.3,percent of total billed charges,Implant Device,699.72,34,"Charges > $500, x 34%",699.72,percent of total billed charges,Implant Device,720.3,35,,720.3,percent of total billed charges,Implant Device,720.3,35,,720.3,percent of total billed charges,Implant Device,720.3,35,,720.3,percent of total billed charges,Implant Device,720.3,35,,720.3,percent of total billed charges,Implant Device,720.3,35,,720.3,percent of total billed charges,Implant Device,823.2,40,,823.2,percent of total billed charges,Implant Device,720.3,70,,720.3,percent of total billed charges,All Other,699.72,34,,699.72,percent of total billed charges,Implant Device,699.72,34,,699.72,percent of total billed charges,Implant Device,720.3,35,,720.3,percent of total billed charges,Implant Device,720.3,35,,720.3,percent of total billed charges,Implant Device,720.3,35,,720.3,percent of total billed charges,Implant Device,720.3,35,,720.3,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,699.72,34,"If Charge > 2,000, then 34 percent",699.72,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1522.93,
MENTOR 350-3501BC BREAST IMPLANT 350CC,C1789,HCPCS,,79006620,CDM,278,RC,,,both,,,2866,2120.85,,,2120.85,Other,150% of Medicare + 9.63% HCRA Surcharge,1289.7,45,,1289.7,percent of total billed charges,Critical Access Hospital RCC factor,974.44,34,,974.44,percent of total billed charges,Implant Device,974.44,34,,974.44,percent of total billed charges,Implant Device,974.44,34,,974.44,percent of total billed charges,Implant Device,974.44,34,,974.44,percent of total billed charges,Implant Device,974.44,34,,974.44,percent of total billed charges,Implant Device,1418.67,,,1418.67,Other,110% of Medicare,1003.1,35,,1003.1,percent of total billed charges,Implant Device,974.44,34,"Charges > $500, x 34%",974.44,percent of total billed charges,Implant Device,1003.1,35,,1003.1,percent of total billed charges,Implant Device,1003.1,35,,1003.1,percent of total billed charges,Implant Device,1003.1,35,,1003.1,percent of total billed charges,Implant Device,1003.1,35,,1003.1,percent of total billed charges,Implant Device,1003.1,35,,1003.1,percent of total billed charges,Implant Device,1146.4,40,,1146.4,percent of total billed charges,Implant Device,1003.1,70,,1003.1,percent of total billed charges,All Other,974.44,34,,974.44,percent of total billed charges,Implant Device,974.44,34,,974.44,percent of total billed charges,Implant Device,1003.1,35,,1003.1,percent of total billed charges,Implant Device,1003.1,35,,1003.1,percent of total billed charges,Implant Device,1003.1,35,,1003.1,percent of total billed charges,Implant Device,1003.1,35,,1003.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,974.44,34,"If Charge > 2,000, then 34 percent",974.44,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2120.85,
MENTOR 350-3001BC BREAST IMPLANT 300CC,C1789,HCPCS,,79006621,CDM,278,RC,,,both,,,2866,2120.85,,,2120.85,Other,150% of Medicare + 9.63% HCRA Surcharge,1289.7,45,,1289.7,percent of total billed charges,Critical Access Hospital RCC factor,974.44,34,,974.44,percent of total billed charges,Implant Device,974.44,34,,974.44,percent of total billed charges,Implant Device,974.44,34,,974.44,percent of total billed charges,Implant Device,974.44,34,,974.44,percent of total billed charges,Implant Device,974.44,34,,974.44,percent of total billed charges,Implant Device,1418.67,,,1418.67,Other,110% of Medicare,1003.1,35,,1003.1,percent of total billed charges,Implant Device,974.44,34,"Charges > $500, x 34%",974.44,percent of total billed charges,Implant Device,1003.1,35,,1003.1,percent of total billed charges,Implant Device,1003.1,35,,1003.1,percent of total billed charges,Implant Device,1003.1,35,,1003.1,percent of total billed charges,Implant Device,1003.1,35,,1003.1,percent of total billed charges,Implant Device,1003.1,35,,1003.1,percent of total billed charges,Implant Device,1146.4,40,,1146.4,percent of total billed charges,Implant Device,1003.1,70,,1003.1,percent of total billed charges,All Other,974.44,34,,974.44,percent of total billed charges,Implant Device,974.44,34,,974.44,percent of total billed charges,Implant Device,1003.1,35,,1003.1,percent of total billed charges,Implant Device,1003.1,35,,1003.1,percent of total billed charges,Implant Device,1003.1,35,,1003.1,percent of total billed charges,Implant Device,1003.1,35,,1003.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,974.44,34,"If Charge > 2,000, then 34 percent",974.44,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2120.85,
ZIMMER 00-5842-023-10 ART SURF SZ 3 10MM,C1713,HCPCS,,79006622,CDM,278,RC,,,both,,,2677,1980.99,,,1980.99,Other,150% of Medicare + 9.63% HCRA Surcharge,1204.65,45,,1204.65,percent of total billed charges,Critical Access Hospital RCC factor,910.18,34,,910.18,percent of total billed charges,Implant Device,910.18,34,,910.18,percent of total billed charges,Implant Device,910.18,34,,910.18,percent of total billed charges,Implant Device,910.18,34,,910.18,percent of total billed charges,Implant Device,910.18,34,,910.18,percent of total billed charges,Implant Device,1325.12,,,1325.12,Other,110% of Medicare,936.95,35,,936.95,percent of total billed charges,Implant Device,910.18,34,"Charges > $500, x 34%",910.18,percent of total billed charges,Implant Device,936.95,35,,936.95,percent of total billed charges,Implant Device,936.95,35,,936.95,percent of total billed charges,Implant Device,936.95,35,,936.95,percent of total billed charges,Implant Device,936.95,35,,936.95,percent of total billed charges,Implant Device,936.95,35,,936.95,percent of total billed charges,Implant Device,1070.8,40,,1070.8,percent of total billed charges,Implant Device,936.95,70,,936.95,percent of total billed charges,All Other,910.18,34,,910.18,percent of total billed charges,Implant Device,910.18,34,,910.18,percent of total billed charges,Implant Device,936.95,35,,936.95,percent of total billed charges,Implant Device,936.95,35,,936.95,percent of total billed charges,Implant Device,936.95,35,,936.95,percent of total billed charges,Implant Device,936.95,35,,936.95,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,910.18,34,"If Charge > 2,000, then 34 percent",910.18,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1980.99,
SYNTHES 219.972 WASHER 6.5MM,C1713,HCPCS,,79006623,CDM,278,RC,,,both,,,119,88.06,,,88.06,Other,150% of Medicare + 9.63% HCRA Surcharge,53.55,45,,53.55,percent of total billed charges,Critical Access Hospital RCC factor,40.46,34,,40.46,percent of total billed charges,Implant Device,40.46,34,,40.46,percent of total billed charges,Implant Device,40.46,34,,40.46,percent of total billed charges,Implant Device,40.46,34,,40.46,percent of total billed charges,Implant Device,40.46,34,,40.46,percent of total billed charges,Implant Device,58.91,,,58.91,Other,110% of Medicare,41.65,35,,41.65,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,41.65,35,,41.65,percent of total billed charges,Implant Device,41.65,35,,41.65,percent of total billed charges,Implant Device,41.65,35,,41.65,percent of total billed charges,Implant Device,41.65,35,,41.65,percent of total billed charges,Implant Device,41.65,35,,41.65,percent of total billed charges,Implant Device,47.6,40,,47.6,percent of total billed charges,Implant Device,41.65,70,,41.65,percent of total billed charges,All Other,40.46,34,,40.46,percent of total billed charges,Implant Device,40.46,34,,40.46,percent of total billed charges,Implant Device,41.65,35,,41.65,percent of total billed charges,Implant Device,41.65,35,,41.65,percent of total billed charges,Implant Device,41.65,35,,41.65,percent of total billed charges,Implant Device,41.65,35,,41.65,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,88.06,
SYNTHES 207.620 CANNULATED SCREW 4X20MM,C1713,HCPCS,,79006624,CDM,278,RC,,,both,,,828,612.72,,,612.72,Other,150% of Medicare + 9.63% HCRA Surcharge,372.6,45,,372.6,percent of total billed charges,Critical Access Hospital RCC factor,281.52,34,,281.52,percent of total billed charges,Implant Device,281.52,34,,281.52,percent of total billed charges,Implant Device,281.52,34,,281.52,percent of total billed charges,Implant Device,281.52,34,,281.52,percent of total billed charges,Implant Device,281.52,34,,281.52,percent of total billed charges,Implant Device,409.86,,,409.86,Other,110% of Medicare,289.8,35,,289.8,percent of total billed charges,Implant Device,281.52,34,"Charges > $500, x 34%",281.52,percent of total billed charges,Implant Device,289.8,35,,289.8,percent of total billed charges,Implant Device,289.8,35,,289.8,percent of total billed charges,Implant Device,289.8,35,,289.8,percent of total billed charges,Implant Device,289.8,35,,289.8,percent of total billed charges,Implant Device,289.8,35,,289.8,percent of total billed charges,Implant Device,331.2,40,,331.2,percent of total billed charges,Implant Device,289.8,70,,289.8,percent of total billed charges,All Other,281.52,34,,281.52,percent of total billed charges,Implant Device,281.52,34,,281.52,percent of total billed charges,Implant Device,289.8,35,,289.8,percent of total billed charges,Implant Device,289.8,35,,289.8,percent of total billed charges,Implant Device,289.8,35,,289.8,percent of total billed charges,Implant Device,289.8,35,,289.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,612.72,
GORE RLT311413 EXCLUDER ENDOPROS GRAFT,C1768,HCPCS,,79006626,CDM,278,RC,,,both,,,32250,23865.08,,,23865.08,Other,150% of Medicare + 9.63% HCRA Surcharge,14512.5,45,,14512.5,percent of total billed charges,Critical Access Hospital RCC factor,10965,34,,10965,percent of total billed charges,Implant Device,10965,34,,10965,percent of total billed charges,Implant Device,10965,34,,10965,percent of total billed charges,Implant Device,10965,34,,10965,percent of total billed charges,Implant Device,10965,34,,10965,percent of total billed charges,Implant Device,15963.75,,,15963.75,Other,110% of Medicare,11287.5,35,,11287.5,percent of total billed charges,Implant Device,10965,34,"Charges > $500, x 34%",10965,percent of total billed charges,Implant Device,11287.5,35,,11287.5,percent of total billed charges,Implant Device,11287.5,35,,11287.5,percent of total billed charges,Implant Device,11287.5,35,,11287.5,percent of total billed charges,Implant Device,11287.5,35,,11287.5,percent of total billed charges,Implant Device,11287.5,35,,11287.5,percent of total billed charges,Implant Device,12900,40,,12900,percent of total billed charges,Implant Device,11287.5,70,,11287.5,percent of total billed charges,All Other,10965,34,,10965,percent of total billed charges,Implant Device,10965,34,,10965,percent of total billed charges,Implant Device,11287.5,35,,11287.5,percent of total billed charges,Implant Device,11287.5,35,,11287.5,percent of total billed charges,Implant Device,11287.5,35,,11287.5,percent of total billed charges,Implant Device,11287.5,35,,11287.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,10965,34,"If Charge > 2,000, then 34 percent",10965,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,23865.08,
MEDTRONIC 429678 ATTAIN ABILITY PLUS,C1900,HCPCS,,79006627,CDM,278,RC,,,both,,,7236,5354.66,,,5354.66,Other,150% of Medicare + 9.63% HCRA Surcharge,3256.2,45,,3256.2,percent of total billed charges,Critical Access Hospital RCC factor,2460.24,34,,2460.24,percent of total billed charges,Implant Device,2460.24,34,,2460.24,percent of total billed charges,Implant Device,2460.24,34,,2460.24,percent of total billed charges,Implant Device,2460.24,34,,2460.24,percent of total billed charges,Implant Device,2460.24,34,,2460.24,percent of total billed charges,Implant Device,3581.82,,,3581.82,Other,110% of Medicare,2532.6,35,,2532.6,percent of total billed charges,Implant Device,2460.24,34,"Charges > $500, x 34%",2460.24,percent of total billed charges,Implant Device,2532.6,35,,2532.6,percent of total billed charges,Implant Device,2532.6,35,,2532.6,percent of total billed charges,Implant Device,2532.6,35,,2532.6,percent of total billed charges,Implant Device,2532.6,35,,2532.6,percent of total billed charges,Implant Device,2532.6,35,,2532.6,percent of total billed charges,Implant Device,2894.4,40,,2894.4,percent of total billed charges,Implant Device,2532.6,70,,2532.6,percent of total billed charges,All Other,2460.24,34,,2460.24,percent of total billed charges,Implant Device,2460.24,34,,2460.24,percent of total billed charges,Implant Device,2532.6,35,,2532.6,percent of total billed charges,Implant Device,2532.6,35,,2532.6,percent of total billed charges,Implant Device,2532.6,35,,2532.6,percent of total billed charges,Implant Device,2532.6,35,,2532.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2460.24,34,"If Charge > 2,000, then 34 percent",2460.24,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5354.66,
PGON28 P20-155-036S CANN SCREW 5.5X36,C1713,HCPCS,,79006645,CDM,278,RC,,,both,,,1324,979.76,,,979.76,Other,150% of Medicare + 9.63% HCRA Surcharge,595.8,45,,595.8,percent of total billed charges,Critical Access Hospital RCC factor,450.16,34,,450.16,percent of total billed charges,Implant Device,450.16,34,,450.16,percent of total billed charges,Implant Device,450.16,34,,450.16,percent of total billed charges,Implant Device,450.16,34,,450.16,percent of total billed charges,Implant Device,450.16,34,,450.16,percent of total billed charges,Implant Device,655.38,,,655.38,Other,110% of Medicare,463.4,35,,463.4,percent of total billed charges,Implant Device,450.16,34,"Charges > $500, x 34%",450.16,percent of total billed charges,Implant Device,463.4,35,,463.4,percent of total billed charges,Implant Device,463.4,35,,463.4,percent of total billed charges,Implant Device,463.4,35,,463.4,percent of total billed charges,Implant Device,463.4,35,,463.4,percent of total billed charges,Implant Device,463.4,35,,463.4,percent of total billed charges,Implant Device,529.6,40,,529.6,percent of total billed charges,Implant Device,463.4,70,,463.4,percent of total billed charges,All Other,450.16,34,,450.16,percent of total billed charges,Implant Device,450.16,34,,450.16,percent of total billed charges,Implant Device,463.4,35,,463.4,percent of total billed charges,Implant Device,463.4,35,,463.4,percent of total billed charges,Implant Device,463.4,35,,463.4,percent of total billed charges,Implant Device,463.4,35,,463.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,979.76,
PGON28 P28-08-207 ARROW PLATE XL LEFT,C1713,HCPCS,,79006646,CDM,278,RC,,,both,,,7426,5495.26,,,5495.26,Other,150% of Medicare + 9.63% HCRA Surcharge,3341.7,45,,3341.7,percent of total billed charges,Critical Access Hospital RCC factor,2524.84,34,,2524.84,percent of total billed charges,Implant Device,2524.84,34,,2524.84,percent of total billed charges,Implant Device,2524.84,34,,2524.84,percent of total billed charges,Implant Device,2524.84,34,,2524.84,percent of total billed charges,Implant Device,2524.84,34,,2524.84,percent of total billed charges,Implant Device,3675.87,,,3675.87,Other,110% of Medicare,2599.1,35,,2599.1,percent of total billed charges,Implant Device,2524.84,34,"Charges > $500, x 34%",2524.84,percent of total billed charges,Implant Device,2599.1,35,,2599.1,percent of total billed charges,Implant Device,2599.1,35,,2599.1,percent of total billed charges,Implant Device,2599.1,35,,2599.1,percent of total billed charges,Implant Device,2599.1,35,,2599.1,percent of total billed charges,Implant Device,2599.1,35,,2599.1,percent of total billed charges,Implant Device,2970.4,40,,2970.4,percent of total billed charges,Implant Device,2599.1,70,,2599.1,percent of total billed charges,All Other,2524.84,34,,2524.84,percent of total billed charges,Implant Device,2524.84,34,,2524.84,percent of total billed charges,Implant Device,2599.1,35,,2599.1,percent of total billed charges,Implant Device,2599.1,35,,2599.1,percent of total billed charges,Implant Device,2599.1,35,,2599.1,percent of total billed charges,Implant Device,2599.1,35,,2599.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2524.84,34,"If Charge > 2,000, then 34 percent",2524.84,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5495.26,
PGON28 P28-20-020 LOCKPLATE SCREW 3.5X20,C1713,HCPCS,,79006647,CDM,278,RC,,,both,,,586,433.64,,,433.64,Other,150% of Medicare + 9.63% HCRA Surcharge,263.7,45,,263.7,percent of total billed charges,Critical Access Hospital RCC factor,199.24,34,,199.24,percent of total billed charges,Implant Device,199.24,34,,199.24,percent of total billed charges,Implant Device,199.24,34,,199.24,percent of total billed charges,Implant Device,199.24,34,,199.24,percent of total billed charges,Implant Device,199.24,34,,199.24,percent of total billed charges,Implant Device,290.07,,,290.07,Other,110% of Medicare,205.1,35,,205.1,percent of total billed charges,Implant Device,199.24,34,"Charges > $500, x 34%",199.24,percent of total billed charges,Implant Device,205.1,35,,205.1,percent of total billed charges,Implant Device,205.1,35,,205.1,percent of total billed charges,Implant Device,205.1,35,,205.1,percent of total billed charges,Implant Device,205.1,35,,205.1,percent of total billed charges,Implant Device,205.1,35,,205.1,percent of total billed charges,Implant Device,234.4,40,,234.4,percent of total billed charges,Implant Device,205.1,70,,205.1,percent of total billed charges,All Other,199.24,34,,199.24,percent of total billed charges,Implant Device,199.24,34,,199.24,percent of total billed charges,Implant Device,205.1,35,,205.1,percent of total billed charges,Implant Device,205.1,35,,205.1,percent of total billed charges,Implant Device,205.1,35,,205.1,percent of total billed charges,Implant Device,205.1,35,,205.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,433.64,
PGON28 P28-20-022 LOCKPLATE SCREW 3.5X22,C1713,HCPCS,,79006648,CDM,278,RC,,,both,,,586,433.64,,,433.64,Other,150% of Medicare + 9.63% HCRA Surcharge,263.7,45,,263.7,percent of total billed charges,Critical Access Hospital RCC factor,199.24,34,,199.24,percent of total billed charges,Implant Device,199.24,34,,199.24,percent of total billed charges,Implant Device,199.24,34,,199.24,percent of total billed charges,Implant Device,199.24,34,,199.24,percent of total billed charges,Implant Device,199.24,34,,199.24,percent of total billed charges,Implant Device,290.07,,,290.07,Other,110% of Medicare,205.1,35,,205.1,percent of total billed charges,Implant Device,199.24,34,"Charges > $500, x 34%",199.24,percent of total billed charges,Implant Device,205.1,35,,205.1,percent of total billed charges,Implant Device,205.1,35,,205.1,percent of total billed charges,Implant Device,205.1,35,,205.1,percent of total billed charges,Implant Device,205.1,35,,205.1,percent of total billed charges,Implant Device,205.1,35,,205.1,percent of total billed charges,Implant Device,234.4,40,,234.4,percent of total billed charges,Implant Device,205.1,70,,205.1,percent of total billed charges,All Other,199.24,34,,199.24,percent of total billed charges,Implant Device,199.24,34,,199.24,percent of total billed charges,Implant Device,205.1,35,,205.1,percent of total billed charges,Implant Device,205.1,35,,205.1,percent of total billed charges,Implant Device,205.1,35,,205.1,percent of total billed charges,Implant Device,205.1,35,,205.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,433.64,
PGON28 P28-20-024 LOCKPLATE SCREW 3.5X24,C1713,HCPCS,,79006649,CDM,278,RC,,,both,,,586,433.64,,,433.64,Other,150% of Medicare + 9.63% HCRA Surcharge,263.7,45,,263.7,percent of total billed charges,Critical Access Hospital RCC factor,199.24,34,,199.24,percent of total billed charges,Implant Device,199.24,34,,199.24,percent of total billed charges,Implant Device,199.24,34,,199.24,percent of total billed charges,Implant Device,199.24,34,,199.24,percent of total billed charges,Implant Device,199.24,34,,199.24,percent of total billed charges,Implant Device,290.07,,,290.07,Other,110% of Medicare,205.1,35,,205.1,percent of total billed charges,Implant Device,199.24,34,"Charges > $500, x 34%",199.24,percent of total billed charges,Implant Device,205.1,35,,205.1,percent of total billed charges,Implant Device,205.1,35,,205.1,percent of total billed charges,Implant Device,205.1,35,,205.1,percent of total billed charges,Implant Device,205.1,35,,205.1,percent of total billed charges,Implant Device,205.1,35,,205.1,percent of total billed charges,Implant Device,234.4,40,,234.4,percent of total billed charges,Implant Device,205.1,70,,205.1,percent of total billed charges,All Other,199.24,34,,199.24,percent of total billed charges,Implant Device,199.24,34,,199.24,percent of total billed charges,Implant Device,205.1,35,,205.1,percent of total billed charges,Implant Device,205.1,35,,205.1,percent of total billed charges,Implant Device,205.1,35,,205.1,percent of total billed charges,Implant Device,205.1,35,,205.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,433.64,
PGON28 P28-20-026 LOCKPLATE SCREW 3.5X26,C1713,HCPCS,,79006650,CDM,278,RC,,,both,,,586,433.64,,,433.64,Other,150% of Medicare + 9.63% HCRA Surcharge,263.7,45,,263.7,percent of total billed charges,Critical Access Hospital RCC factor,199.24,34,,199.24,percent of total billed charges,Implant Device,199.24,34,,199.24,percent of total billed charges,Implant Device,199.24,34,,199.24,percent of total billed charges,Implant Device,199.24,34,,199.24,percent of total billed charges,Implant Device,199.24,34,,199.24,percent of total billed charges,Implant Device,290.07,,,290.07,Other,110% of Medicare,205.1,35,,205.1,percent of total billed charges,Implant Device,199.24,34,"Charges > $500, x 34%",199.24,percent of total billed charges,Implant Device,205.1,35,,205.1,percent of total billed charges,Implant Device,205.1,35,,205.1,percent of total billed charges,Implant Device,205.1,35,,205.1,percent of total billed charges,Implant Device,205.1,35,,205.1,percent of total billed charges,Implant Device,205.1,35,,205.1,percent of total billed charges,Implant Device,234.4,40,,234.4,percent of total billed charges,Implant Device,205.1,70,,205.1,percent of total billed charges,All Other,199.24,34,,199.24,percent of total billed charges,Implant Device,199.24,34,,199.24,percent of total billed charges,Implant Device,205.1,35,,205.1,percent of total billed charges,Implant Device,205.1,35,,205.1,percent of total billed charges,Implant Device,205.1,35,,205.1,percent of total billed charges,Implant Device,205.1,35,,205.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,433.64,
PGON28 P50-053-3520 PLATE SCREW 3.5X20,C1713,HCPCS,,79006651,CDM,278,RC,,,both,,,619,458.06,,,458.06,Other,150% of Medicare + 9.63% HCRA Surcharge,278.55,45,,278.55,percent of total billed charges,Critical Access Hospital RCC factor,210.46,34,,210.46,percent of total billed charges,Implant Device,210.46,34,,210.46,percent of total billed charges,Implant Device,210.46,34,,210.46,percent of total billed charges,Implant Device,210.46,34,,210.46,percent of total billed charges,Implant Device,210.46,34,,210.46,percent of total billed charges,Implant Device,306.41,,,306.41,Other,110% of Medicare,216.65,35,,216.65,percent of total billed charges,Implant Device,210.46,34,"Charges > $500, x 34%",210.46,percent of total billed charges,Implant Device,216.65,35,,216.65,percent of total billed charges,Implant Device,216.65,35,,216.65,percent of total billed charges,Implant Device,216.65,35,,216.65,percent of total billed charges,Implant Device,216.65,35,,216.65,percent of total billed charges,Implant Device,216.65,35,,216.65,percent of total billed charges,Implant Device,247.6,40,,247.6,percent of total billed charges,Implant Device,216.65,70,,216.65,percent of total billed charges,All Other,210.46,34,,210.46,percent of total billed charges,Implant Device,210.46,34,,210.46,percent of total billed charges,Implant Device,216.65,35,,216.65,percent of total billed charges,Implant Device,216.65,35,,216.65,percent of total billed charges,Implant Device,216.65,35,,216.65,percent of total billed charges,Implant Device,216.65,35,,216.65,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,458.06,
PGON28 P50-053-3530 PLATE SCREW 3.5X30,C1713,HCPCS,,79006652,CDM,278,RC,,,both,,,694,513.56,,,513.56,Other,150% of Medicare + 9.63% HCRA Surcharge,312.3,45,,312.3,percent of total billed charges,Critical Access Hospital RCC factor,235.96,34,,235.96,percent of total billed charges,Implant Device,235.96,34,,235.96,percent of total billed charges,Implant Device,235.96,34,,235.96,percent of total billed charges,Implant Device,235.96,34,,235.96,percent of total billed charges,Implant Device,235.96,34,,235.96,percent of total billed charges,Implant Device,343.53,,,343.53,Other,110% of Medicare,242.9,35,,242.9,percent of total billed charges,Implant Device,235.96,34,"Charges > $500, x 34%",235.96,percent of total billed charges,Implant Device,242.9,35,,242.9,percent of total billed charges,Implant Device,242.9,35,,242.9,percent of total billed charges,Implant Device,242.9,35,,242.9,percent of total billed charges,Implant Device,242.9,35,,242.9,percent of total billed charges,Implant Device,242.9,35,,242.9,percent of total billed charges,Implant Device,277.6,40,,277.6,percent of total billed charges,Implant Device,242.9,70,,242.9,percent of total billed charges,All Other,235.96,34,,235.96,percent of total billed charges,Implant Device,235.96,34,,235.96,percent of total billed charges,Implant Device,242.9,35,,242.9,percent of total billed charges,Implant Device,242.9,35,,242.9,percent of total billed charges,Implant Device,242.9,35,,242.9,percent of total billed charges,Implant Device,242.9,35,,242.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,513.56,
PGON28 P53-154-0003 TEDDYBEAR PLATE LG,C1713,HCPCS,,79006653,CDM,278,RC,,,both,,,5117,3786.59,,,3786.59,Other,150% of Medicare + 9.63% HCRA Surcharge,2302.65,45,,2302.65,percent of total billed charges,Critical Access Hospital RCC factor,1739.78,34,,1739.78,percent of total billed charges,Implant Device,1739.78,34,,1739.78,percent of total billed charges,Implant Device,1739.78,34,,1739.78,percent of total billed charges,Implant Device,1739.78,34,,1739.78,percent of total billed charges,Implant Device,1739.78,34,,1739.78,percent of total billed charges,Implant Device,2532.92,,,2532.92,Other,110% of Medicare,1790.95,35,,1790.95,percent of total billed charges,Implant Device,1739.78,34,"Charges > $500, x 34%",1739.78,percent of total billed charges,Implant Device,1790.95,35,,1790.95,percent of total billed charges,Implant Device,1790.95,35,,1790.95,percent of total billed charges,Implant Device,1790.95,35,,1790.95,percent of total billed charges,Implant Device,1790.95,35,,1790.95,percent of total billed charges,Implant Device,1790.95,35,,1790.95,percent of total billed charges,Implant Device,2046.8,40,,2046.8,percent of total billed charges,Implant Device,1790.95,70,,1790.95,percent of total billed charges,All Other,1739.78,34,,1739.78,percent of total billed charges,Implant Device,1739.78,34,,1739.78,percent of total billed charges,Implant Device,1790.95,35,,1790.95,percent of total billed charges,Implant Device,1790.95,35,,1790.95,percent of total billed charges,Implant Device,1790.95,35,,1790.95,percent of total billed charges,Implant Device,1790.95,35,,1790.95,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1739.78,34,"If Charge > 2,000, then 34 percent",1739.78,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3786.59,
STRYKER 370518 LOCKING SCREW 4.0 X 18MM,C1713,HCPCS,,79006656,CDM,278,RC,,,both,,,482,356.68,,,356.68,Other,150% of Medicare + 9.63% HCRA Surcharge,216.9,45,,216.9,percent of total billed charges,Critical Access Hospital RCC factor,163.88,34,,163.88,percent of total billed charges,Implant Device,163.88,34,,163.88,percent of total billed charges,Implant Device,163.88,34,,163.88,percent of total billed charges,Implant Device,163.88,34,,163.88,percent of total billed charges,Implant Device,163.88,34,,163.88,percent of total billed charges,Implant Device,238.59,,,238.59,Other,110% of Medicare,168.7,35,,168.7,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,168.7,35,,168.7,percent of total billed charges,Implant Device,168.7,35,,168.7,percent of total billed charges,Implant Device,168.7,35,,168.7,percent of total billed charges,Implant Device,168.7,35,,168.7,percent of total billed charges,Implant Device,168.7,35,,168.7,percent of total billed charges,Implant Device,192.8,40,,192.8,percent of total billed charges,Implant Device,168.7,70,,168.7,percent of total billed charges,All Other,163.88,34,,163.88,percent of total billed charges,Implant Device,163.88,34,,163.88,percent of total billed charges,Implant Device,168.7,35,,168.7,percent of total billed charges,Implant Device,168.7,35,,168.7,percent of total billed charges,Implant Device,168.7,35,,168.7,percent of total billed charges,Implant Device,168.7,35,,168.7,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,356.68,
STRYKER 370516 LOCKING SCREW 4.0 X 16MM,C1713,HCPCS,,79006657,CDM,278,RC,,,both,,,482,356.68,,,356.68,Other,150% of Medicare + 9.63% HCRA Surcharge,216.9,45,,216.9,percent of total billed charges,Critical Access Hospital RCC factor,163.88,34,,163.88,percent of total billed charges,Implant Device,163.88,34,,163.88,percent of total billed charges,Implant Device,163.88,34,,163.88,percent of total billed charges,Implant Device,163.88,34,,163.88,percent of total billed charges,Implant Device,163.88,34,,163.88,percent of total billed charges,Implant Device,238.59,,,238.59,Other,110% of Medicare,168.7,35,,168.7,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,168.7,35,,168.7,percent of total billed charges,Implant Device,168.7,35,,168.7,percent of total billed charges,Implant Device,168.7,35,,168.7,percent of total billed charges,Implant Device,168.7,35,,168.7,percent of total billed charges,Implant Device,168.7,35,,168.7,percent of total billed charges,Implant Device,192.8,40,,192.8,percent of total billed charges,Implant Device,168.7,70,,168.7,percent of total billed charges,All Other,163.88,34,,163.88,percent of total billed charges,Implant Device,163.88,34,,163.88,percent of total billed charges,Implant Device,168.7,35,,168.7,percent of total billed charges,Implant Device,168.7,35,,168.7,percent of total billed charges,Implant Device,168.7,35,,168.7,percent of total billed charges,Implant Device,168.7,35,,168.7,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,356.68,
STRYKER 370514 LOCKING SCREW 4.0 X 14MM,C1713,HCPCS,,79006658,CDM,278,RC,,,both,,,482,356.68,,,356.68,Other,150% of Medicare + 9.63% HCRA Surcharge,216.9,45,,216.9,percent of total billed charges,Critical Access Hospital RCC factor,163.88,34,,163.88,percent of total billed charges,Implant Device,163.88,34,,163.88,percent of total billed charges,Implant Device,163.88,34,,163.88,percent of total billed charges,Implant Device,163.88,34,,163.88,percent of total billed charges,Implant Device,163.88,34,,163.88,percent of total billed charges,Implant Device,238.59,,,238.59,Other,110% of Medicare,168.7,35,,168.7,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,168.7,35,,168.7,percent of total billed charges,Implant Device,168.7,35,,168.7,percent of total billed charges,Implant Device,168.7,35,,168.7,percent of total billed charges,Implant Device,168.7,35,,168.7,percent of total billed charges,Implant Device,168.7,35,,168.7,percent of total billed charges,Implant Device,192.8,40,,192.8,percent of total billed charges,Implant Device,168.7,70,,168.7,percent of total billed charges,All Other,163.88,34,,163.88,percent of total billed charges,Implant Device,163.88,34,,163.88,percent of total billed charges,Implant Device,168.7,35,,168.7,percent of total billed charges,Implant Device,168.7,35,,168.7,percent of total billed charges,Implant Device,168.7,35,,168.7,percent of total billed charges,Implant Device,168.7,35,,168.7,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,356.68,
STRYKER 345416 NON LOCKING SCREW 4.0MM,C1713,HCPCS,,79006659,CDM,278,RC,,,both,,,100,74,,,74,Other,150% of Medicare + 9.63% HCRA Surcharge,45,45,,45,percent of total billed charges,Critical Access Hospital RCC factor,34,34,,34,percent of total billed charges,Implant Device,34,34,,34,percent of total billed charges,Implant Device,34,34,,34,percent of total billed charges,Implant Device,34,34,,34,percent of total billed charges,Implant Device,34,34,,34,percent of total billed charges,Implant Device,49.5,,,49.5,Other,110% of Medicare,35,35,,35,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,35,35,,35,percent of total billed charges,Implant Device,35,35,,35,percent of total billed charges,Implant Device,35,35,,35,percent of total billed charges,Implant Device,35,35,,35,percent of total billed charges,Implant Device,35,35,,35,percent of total billed charges,Implant Device,40,40,,40,percent of total billed charges,Implant Device,35,70,,35,percent of total billed charges,All Other,34,34,,34,percent of total billed charges,Implant Device,34,34,,34,percent of total billed charges,Implant Device,35,35,,35,percent of total billed charges,Implant Device,35,35,,35,percent of total billed charges,Implant Device,35,35,,35,percent of total billed charges,Implant Device,35,35,,35,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,74,
MAQUET 85407 8X59X80 ATRIUM COVER STENT,C1874,HCPCS,,79006661,CDM,278,RC,,,both,,,8325,6160.52,,,6160.52,Other,150% of Medicare + 9.63% HCRA Surcharge,3746.25,45,,3746.25,percent of total billed charges,Critical Access Hospital RCC factor,2830.5,34,,2830.5,percent of total billed charges,Implant Device,2830.5,34,,2830.5,percent of total billed charges,Implant Device,2830.5,34,,2830.5,percent of total billed charges,Implant Device,2830.5,34,,2830.5,percent of total billed charges,Implant Device,2830.5,34,,2830.5,percent of total billed charges,Implant Device,4120.88,,,4120.88,Other,110% of Medicare,2913.75,35,,2913.75,percent of total billed charges,Implant Device,2830.5,34,"Charges > $500, x 34%",2830.5,percent of total billed charges,Implant Device,2913.75,35,,2913.75,percent of total billed charges,Implant Device,2913.75,35,,2913.75,percent of total billed charges,Implant Device,2913.75,35,,2913.75,percent of total billed charges,Implant Device,2913.75,35,,2913.75,percent of total billed charges,Implant Device,2913.75,35,,2913.75,percent of total billed charges,Implant Device,3330,40,,3330,percent of total billed charges,Implant Device,2913.75,70,,2913.75,percent of total billed charges,All Other,2830.5,34,,2830.5,percent of total billed charges,Implant Device,2830.5,34,,2830.5,percent of total billed charges,Implant Device,2913.75,35,,2913.75,percent of total billed charges,Implant Device,2913.75,35,,2913.75,percent of total billed charges,Implant Device,2913.75,35,,2913.75,percent of total billed charges,Implant Device,2913.75,35,,2913.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2830.5,34,"If Charge > 2,000, then 34 percent",2830.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,6160.52,
DEPUY 458.938S 5.0 C 38MM TI LOCK SCREW,C1713,HCPCS,,79006665,CDM,278,RC,,,both,,,888,657.12,,,657.12,Other,150% of Medicare + 9.63% HCRA Surcharge,399.6,45,,399.6,percent of total billed charges,Critical Access Hospital RCC factor,301.92,34,,301.92,percent of total billed charges,Implant Device,301.92,34,,301.92,percent of total billed charges,Implant Device,301.92,34,,301.92,percent of total billed charges,Implant Device,301.92,34,,301.92,percent of total billed charges,Implant Device,301.92,34,,301.92,percent of total billed charges,Implant Device,439.56,,,439.56,Other,110% of Medicare,310.8,35,,310.8,percent of total billed charges,Implant Device,301.92,34,"Charges > $500, x 34%",301.92,percent of total billed charges,Implant Device,310.8,35,,310.8,percent of total billed charges,Implant Device,310.8,35,,310.8,percent of total billed charges,Implant Device,310.8,35,,310.8,percent of total billed charges,Implant Device,310.8,35,,310.8,percent of total billed charges,Implant Device,310.8,35,,310.8,percent of total billed charges,Implant Device,355.2,40,,355.2,percent of total billed charges,Implant Device,310.8,70,,310.8,percent of total billed charges,All Other,301.92,34,,301.92,percent of total billed charges,Implant Device,301.92,34,,301.92,percent of total billed charges,Implant Device,310.8,35,,310.8,percent of total billed charges,Implant Device,310.8,35,,310.8,percent of total billed charges,Implant Device,310.8,35,,310.8,percent of total billed charges,Implant Device,310.8,35,,310.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,657.12,
DEPUY 456.328S TI CANN FIX NAIL 235MM,C1713,HCPCS,,79006666,CDM,278,RC,,,both,,,2738,2026.13,,,2026.13,Other,150% of Medicare + 9.63% HCRA Surcharge,1232.1,45,,1232.1,percent of total billed charges,Critical Access Hospital RCC factor,930.92,34,,930.92,percent of total billed charges,Implant Device,930.92,34,,930.92,percent of total billed charges,Implant Device,930.92,34,,930.92,percent of total billed charges,Implant Device,930.92,34,,930.92,percent of total billed charges,Implant Device,930.92,34,,930.92,percent of total billed charges,Implant Device,1355.31,,,1355.31,Other,110% of Medicare,958.3,35,,958.3,percent of total billed charges,Implant Device,930.92,34,"Charges > $500, x 34%",930.92,percent of total billed charges,Implant Device,958.3,35,,958.3,percent of total billed charges,Implant Device,958.3,35,,958.3,percent of total billed charges,Implant Device,958.3,35,,958.3,percent of total billed charges,Implant Device,958.3,35,,958.3,percent of total billed charges,Implant Device,958.3,35,,958.3,percent of total billed charges,Implant Device,1095.2,40,,1095.2,percent of total billed charges,Implant Device,958.3,70,,958.3,percent of total billed charges,All Other,930.92,34,,930.92,percent of total billed charges,Implant Device,930.92,34,,930.92,percent of total billed charges,Implant Device,958.3,35,,958.3,percent of total billed charges,Implant Device,958.3,35,,958.3,percent of total billed charges,Implant Device,958.3,35,,958.3,percent of total billed charges,Implant Device,958.3,35,,958.3,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,930.92,34,"If Charge > 2,000, then 34 percent",930.92,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2026.13,
DEPUY 456.306S 11X105MM HELICAL BLADE,C1713,HCPCS,,79006667,CDM,278,RC,,,both,,,2226,1647.25,,,1647.25,Other,150% of Medicare + 9.63% HCRA Surcharge,1001.7,45,,1001.7,percent of total billed charges,Critical Access Hospital RCC factor,756.84,34,,756.84,percent of total billed charges,Implant Device,756.84,34,,756.84,percent of total billed charges,Implant Device,756.84,34,,756.84,percent of total billed charges,Implant Device,756.84,34,,756.84,percent of total billed charges,Implant Device,756.84,34,,756.84,percent of total billed charges,Implant Device,1101.87,,,1101.87,Other,110% of Medicare,779.1,35,,779.1,percent of total billed charges,Implant Device,756.84,34,"Charges > $500, x 34%",756.84,percent of total billed charges,Implant Device,779.1,35,,779.1,percent of total billed charges,Implant Device,779.1,35,,779.1,percent of total billed charges,Implant Device,779.1,35,,779.1,percent of total billed charges,Implant Device,779.1,35,,779.1,percent of total billed charges,Implant Device,779.1,35,,779.1,percent of total billed charges,Implant Device,890.4,40,,890.4,percent of total billed charges,Implant Device,779.1,70,,779.1,percent of total billed charges,All Other,756.84,34,,756.84,percent of total billed charges,Implant Device,756.84,34,,756.84,percent of total billed charges,Implant Device,779.1,35,,779.1,percent of total billed charges,Implant Device,779.1,35,,779.1,percent of total billed charges,Implant Device,779.1,35,,779.1,percent of total billed charges,Implant Device,779.1,35,,779.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,756.84,34,"If Charge > 2,000, then 34 percent",756.84,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1647.25,
STRYKER 1822-1031S TIBIAL NAIL 10X315MM,C1713,HCPCS,,79006669,CDM,278,RC,,,both,,,6416,4747.86,,,4747.86,Other,150% of Medicare + 9.63% HCRA Surcharge,2887.2,45,,2887.2,percent of total billed charges,Critical Access Hospital RCC factor,2181.44,34,,2181.44,percent of total billed charges,Implant Device,2181.44,34,,2181.44,percent of total billed charges,Implant Device,2181.44,34,,2181.44,percent of total billed charges,Implant Device,2181.44,34,,2181.44,percent of total billed charges,Implant Device,2181.44,34,,2181.44,percent of total billed charges,Implant Device,3175.92,,,3175.92,Other,110% of Medicare,2245.6,35,,2245.6,percent of total billed charges,Implant Device,2181.44,34,"Charges > $500, x 34%",2181.44,percent of total billed charges,Implant Device,2245.6,35,,2245.6,percent of total billed charges,Implant Device,2245.6,35,,2245.6,percent of total billed charges,Implant Device,2245.6,35,,2245.6,percent of total billed charges,Implant Device,2245.6,35,,2245.6,percent of total billed charges,Implant Device,2245.6,35,,2245.6,percent of total billed charges,Implant Device,2566.4,40,,2566.4,percent of total billed charges,Implant Device,2245.6,70,,2245.6,percent of total billed charges,All Other,2181.44,34,,2181.44,percent of total billed charges,Implant Device,2181.44,34,,2181.44,percent of total billed charges,Implant Device,2245.6,35,,2245.6,percent of total billed charges,Implant Device,2245.6,35,,2245.6,percent of total billed charges,Implant Device,2245.6,35,,2245.6,percent of total billed charges,Implant Device,2245.6,35,,2245.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2181.44,34,"If Charge > 2,000, then 34 percent",2181.44,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4747.86,
BOST SCI 3420 ADVANIX DOUDENAL BEND 7X5,C2625,HCPCS,,79006671,CDM,278,RC,,,both,,,440,325.6,,,325.6,Other,150% of Medicare + 9.63% HCRA Surcharge,198,45,,198,percent of total billed charges,Critical Access Hospital RCC factor,149.6,34,,149.6,percent of total billed charges,Implant Device,149.6,34,,149.6,percent of total billed charges,Implant Device,149.6,34,,149.6,percent of total billed charges,Implant Device,149.6,34,,149.6,percent of total billed charges,Implant Device,149.6,34,,149.6,percent of total billed charges,Implant Device,217.8,,,217.8,Other,110% of Medicare,154,35,,154,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,154,35,,154,percent of total billed charges,Implant Device,154,35,,154,percent of total billed charges,Implant Device,154,35,,154,percent of total billed charges,Implant Device,154,35,,154,percent of total billed charges,Implant Device,154,35,,154,percent of total billed charges,Implant Device,176,40,,176,percent of total billed charges,Implant Device,154,70,,154,percent of total billed charges,All Other,149.6,34,,149.6,percent of total billed charges,Implant Device,149.6,34,,149.6,percent of total billed charges,Implant Device,154,35,,154,percent of total billed charges,Implant Device,154,35,,154,percent of total billed charges,Implant Device,154,35,,154,percent of total billed charges,Implant Device,154,35,,154,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,325.6,
BOST SCI 3420 ADVANIX DOUDENAL BEND 7X7,C2625,HCPCS,,79006672,CDM,278,RC,,,both,,,514,380.36,,,380.36,Other,150% of Medicare + 9.63% HCRA Surcharge,231.3,45,,231.3,percent of total billed charges,Critical Access Hospital RCC factor,174.76,34,,174.76,percent of total billed charges,Implant Device,174.76,34,,174.76,percent of total billed charges,Implant Device,174.76,34,,174.76,percent of total billed charges,Implant Device,174.76,34,,174.76,percent of total billed charges,Implant Device,174.76,34,,174.76,percent of total billed charges,Implant Device,254.43,,,254.43,Other,110% of Medicare,179.9,35,,179.9,percent of total billed charges,Implant Device,174.76,34,"Charges > $500, x 34%",174.76,percent of total billed charges,Implant Device,179.9,35,,179.9,percent of total billed charges,Implant Device,179.9,35,,179.9,percent of total billed charges,Implant Device,179.9,35,,179.9,percent of total billed charges,Implant Device,179.9,35,,179.9,percent of total billed charges,Implant Device,179.9,35,,179.9,percent of total billed charges,Implant Device,205.6,40,,205.6,percent of total billed charges,Implant Device,179.9,70,,179.9,percent of total billed charges,All Other,174.76,34,,174.76,percent of total billed charges,Implant Device,174.76,34,,174.76,percent of total billed charges,Implant Device,179.9,35,,179.9,percent of total billed charges,Implant Device,179.9,35,,179.9,percent of total billed charges,Implant Device,179.9,35,,179.9,percent of total billed charges,Implant Device,179.9,35,,179.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,380.36,
BOST SCI 3420 ADVANIX DOUDENAL BEND 7X9,C2625,HCPCS,,79006673,CDM,278,RC,,,both,,,432,319.68,,,319.68,Other,150% of Medicare + 9.63% HCRA Surcharge,194.4,45,,194.4,percent of total billed charges,Critical Access Hospital RCC factor,146.88,34,,146.88,percent of total billed charges,Implant Device,146.88,34,,146.88,percent of total billed charges,Implant Device,146.88,34,,146.88,percent of total billed charges,Implant Device,146.88,34,,146.88,percent of total billed charges,Implant Device,146.88,34,,146.88,percent of total billed charges,Implant Device,213.84,,,213.84,Other,110% of Medicare,151.2,35,,151.2,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,151.2,35,,151.2,percent of total billed charges,Implant Device,151.2,35,,151.2,percent of total billed charges,Implant Device,151.2,35,,151.2,percent of total billed charges,Implant Device,151.2,35,,151.2,percent of total billed charges,Implant Device,151.2,35,,151.2,percent of total billed charges,Implant Device,172.8,40,,172.8,percent of total billed charges,Implant Device,151.2,70,,151.2,percent of total billed charges,All Other,146.88,34,,146.88,percent of total billed charges,Implant Device,146.88,34,,146.88,percent of total billed charges,Implant Device,151.2,35,,151.2,percent of total billed charges,Implant Device,151.2,35,,151.2,percent of total billed charges,Implant Device,151.2,35,,151.2,percent of total billed charges,Implant Device,151.2,35,,151.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,319.68,
BOST SCI 3420 ADVANIX DOUDENAL BEND 10X5,C2625,HCPCS,,79006674,CDM,278,RC,,,both,,,432,319.68,,,319.68,Other,150% of Medicare + 9.63% HCRA Surcharge,194.4,45,,194.4,percent of total billed charges,Critical Access Hospital RCC factor,146.88,34,,146.88,percent of total billed charges,Implant Device,146.88,34,,146.88,percent of total billed charges,Implant Device,146.88,34,,146.88,percent of total billed charges,Implant Device,146.88,34,,146.88,percent of total billed charges,Implant Device,146.88,34,,146.88,percent of total billed charges,Implant Device,213.84,,,213.84,Other,110% of Medicare,151.2,35,,151.2,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,151.2,35,,151.2,percent of total billed charges,Implant Device,151.2,35,,151.2,percent of total billed charges,Implant Device,151.2,35,,151.2,percent of total billed charges,Implant Device,151.2,35,,151.2,percent of total billed charges,Implant Device,151.2,35,,151.2,percent of total billed charges,Implant Device,172.8,40,,172.8,percent of total billed charges,Implant Device,151.2,70,,151.2,percent of total billed charges,All Other,146.88,34,,146.88,percent of total billed charges,Implant Device,146.88,34,,146.88,percent of total billed charges,Implant Device,151.2,35,,151.2,percent of total billed charges,Implant Device,151.2,35,,151.2,percent of total billed charges,Implant Device,151.2,35,,151.2,percent of total billed charges,Implant Device,151.2,35,,151.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,319.68,
BOST SCI 3420 ADVANIX DOUDENAL BEND 10X7,C2625,HCPCS,,79006675,CDM,278,RC,,,both,,,432,319.68,,,319.68,Other,150% of Medicare + 9.63% HCRA Surcharge,194.4,45,,194.4,percent of total billed charges,Critical Access Hospital RCC factor,146.88,34,,146.88,percent of total billed charges,Implant Device,146.88,34,,146.88,percent of total billed charges,Implant Device,146.88,34,,146.88,percent of total billed charges,Implant Device,146.88,34,,146.88,percent of total billed charges,Implant Device,146.88,34,,146.88,percent of total billed charges,Implant Device,213.84,,,213.84,Other,110% of Medicare,151.2,35,,151.2,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,151.2,35,,151.2,percent of total billed charges,Implant Device,151.2,35,,151.2,percent of total billed charges,Implant Device,151.2,35,,151.2,percent of total billed charges,Implant Device,151.2,35,,151.2,percent of total billed charges,Implant Device,151.2,35,,151.2,percent of total billed charges,Implant Device,172.8,40,,172.8,percent of total billed charges,Implant Device,151.2,70,,151.2,percent of total billed charges,All Other,146.88,34,,146.88,percent of total billed charges,Implant Device,146.88,34,,146.88,percent of total billed charges,Implant Device,151.2,35,,151.2,percent of total billed charges,Implant Device,151.2,35,,151.2,percent of total billed charges,Implant Device,151.2,35,,151.2,percent of total billed charges,Implant Device,151.2,35,,151.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,319.68,
BOST SCI 3420 ADVANIX DOUDENAL BEND 10X9,C2625,HCPCS,,79006676,CDM,278,RC,,,both,,,432,319.68,,,319.68,Other,150% of Medicare + 9.63% HCRA Surcharge,194.4,45,,194.4,percent of total billed charges,Critical Access Hospital RCC factor,146.88,34,,146.88,percent of total billed charges,Implant Device,146.88,34,,146.88,percent of total billed charges,Implant Device,146.88,34,,146.88,percent of total billed charges,Implant Device,146.88,34,,146.88,percent of total billed charges,Implant Device,146.88,34,,146.88,percent of total billed charges,Implant Device,213.84,,,213.84,Other,110% of Medicare,151.2,35,,151.2,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,151.2,35,,151.2,percent of total billed charges,Implant Device,151.2,35,,151.2,percent of total billed charges,Implant Device,151.2,35,,151.2,percent of total billed charges,Implant Device,151.2,35,,151.2,percent of total billed charges,Implant Device,151.2,35,,151.2,percent of total billed charges,Implant Device,172.8,40,,172.8,percent of total billed charges,Implant Device,151.2,70,,151.2,percent of total billed charges,All Other,146.88,34,,146.88,percent of total billed charges,Implant Device,146.88,34,,146.88,percent of total billed charges,Implant Device,151.2,35,,151.2,percent of total billed charges,Implant Device,151.2,35,,151.2,percent of total billed charges,Implant Device,151.2,35,,151.2,percent of total billed charges,Implant Device,151.2,35,,151.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,319.68,
BOST SCI 3435 ADVANX DOUDENAL BEND 10X12,C2625,HCPCS,,79006677,CDM,278,RC,,,both,,,432,319.68,,,319.68,Other,150% of Medicare + 9.63% HCRA Surcharge,194.4,45,,194.4,percent of total billed charges,Critical Access Hospital RCC factor,146.88,34,,146.88,percent of total billed charges,Implant Device,146.88,34,,146.88,percent of total billed charges,Implant Device,146.88,34,,146.88,percent of total billed charges,Implant Device,146.88,34,,146.88,percent of total billed charges,Implant Device,146.88,34,,146.88,percent of total billed charges,Implant Device,213.84,,,213.84,Other,110% of Medicare,151.2,35,,151.2,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,151.2,35,,151.2,percent of total billed charges,Implant Device,151.2,35,,151.2,percent of total billed charges,Implant Device,151.2,35,,151.2,percent of total billed charges,Implant Device,151.2,35,,151.2,percent of total billed charges,Implant Device,151.2,35,,151.2,percent of total billed charges,Implant Device,172.8,40,,172.8,percent of total billed charges,Implant Device,151.2,70,,151.2,percent of total billed charges,All Other,146.88,34,,146.88,percent of total billed charges,Implant Device,146.88,34,,146.88,percent of total billed charges,Implant Device,151.2,35,,151.2,percent of total billed charges,Implant Device,151.2,35,,151.2,percent of total billed charges,Implant Device,151.2,35,,151.2,percent of total billed charges,Implant Device,151.2,35,,151.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,319.68,
ZIMMER 00-5990-037-01 FEM AUG BLOCK 5MM,C1713,HCPCS,,79006678,CDM,278,RC,,,both,,,3061,2265.15,,,2265.15,Other,150% of Medicare + 9.63% HCRA Surcharge,1377.45,45,,1377.45,percent of total billed charges,Critical Access Hospital RCC factor,1040.74,34,,1040.74,percent of total billed charges,Implant Device,1040.74,34,,1040.74,percent of total billed charges,Implant Device,1040.74,34,,1040.74,percent of total billed charges,Implant Device,1040.74,34,,1040.74,percent of total billed charges,Implant Device,1040.74,34,,1040.74,percent of total billed charges,Implant Device,1515.2,,,1515.2,Other,110% of Medicare,1071.35,35,,1071.35,percent of total billed charges,Implant Device,1040.74,34,"Charges > $500, x 34%",1040.74,percent of total billed charges,Implant Device,1071.35,35,,1071.35,percent of total billed charges,Implant Device,1071.35,35,,1071.35,percent of total billed charges,Implant Device,1071.35,35,,1071.35,percent of total billed charges,Implant Device,1071.35,35,,1071.35,percent of total billed charges,Implant Device,1071.35,35,,1071.35,percent of total billed charges,Implant Device,1224.4,40,,1224.4,percent of total billed charges,Implant Device,1071.35,70,,1071.35,percent of total billed charges,All Other,1040.74,34,,1040.74,percent of total billed charges,Implant Device,1040.74,34,,1040.74,percent of total billed charges,Implant Device,1071.35,35,,1071.35,percent of total billed charges,Implant Device,1071.35,35,,1071.35,percent of total billed charges,Implant Device,1071.35,35,,1071.35,percent of total billed charges,Implant Device,1071.35,35,,1071.35,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1040.74,34,"If Charge > 2,000, then 34 percent",1040.74,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2265.15,
ZIMMER 00-5990-037-20 FEM AUG BLOCK 10MM,C1713,HCPCS,,79006679,CDM,278,RC,,,both,,,3061,2265.15,,,2265.15,Other,150% of Medicare + 9.63% HCRA Surcharge,1377.45,45,,1377.45,percent of total billed charges,Critical Access Hospital RCC factor,1040.74,34,,1040.74,percent of total billed charges,Implant Device,1040.74,34,,1040.74,percent of total billed charges,Implant Device,1040.74,34,,1040.74,percent of total billed charges,Implant Device,1040.74,34,,1040.74,percent of total billed charges,Implant Device,1040.74,34,,1040.74,percent of total billed charges,Implant Device,1515.2,,,1515.2,Other,110% of Medicare,1071.35,35,,1071.35,percent of total billed charges,Implant Device,1040.74,34,"Charges > $500, x 34%",1040.74,percent of total billed charges,Implant Device,1071.35,35,,1071.35,percent of total billed charges,Implant Device,1071.35,35,,1071.35,percent of total billed charges,Implant Device,1071.35,35,,1071.35,percent of total billed charges,Implant Device,1071.35,35,,1071.35,percent of total billed charges,Implant Device,1071.35,35,,1071.35,percent of total billed charges,Implant Device,1224.4,40,,1224.4,percent of total billed charges,Implant Device,1071.35,70,,1071.35,percent of total billed charges,All Other,1040.74,34,,1040.74,percent of total billed charges,Implant Device,1040.74,34,,1040.74,percent of total billed charges,Implant Device,1071.35,35,,1071.35,percent of total billed charges,Implant Device,1071.35,35,,1071.35,percent of total billed charges,Implant Device,1071.35,35,,1071.35,percent of total billed charges,Implant Device,1071.35,35,,1071.35,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1040.74,34,"If Charge > 2,000, then 34 percent",1040.74,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2265.15,
ZIMMER 00-5994-017-91 FEM COMP SZ G LT,C1713,HCPCS,,79006680,CDM,278,RC,,,both,,,18586,13753.69,,,13753.69,Other,150% of Medicare + 9.63% HCRA Surcharge,8363.7,45,,8363.7,percent of total billed charges,Critical Access Hospital RCC factor,6319.24,34,,6319.24,percent of total billed charges,Implant Device,6319.24,34,,6319.24,percent of total billed charges,Implant Device,6319.24,34,,6319.24,percent of total billed charges,Implant Device,6319.24,34,,6319.24,percent of total billed charges,Implant Device,6319.24,34,,6319.24,percent of total billed charges,Implant Device,9200.07,,,9200.07,Other,110% of Medicare,6505.1,35,,6505.1,percent of total billed charges,Implant Device,6319.24,34,"Charges > $500, x 34%",6319.24,percent of total billed charges,Implant Device,6505.1,35,,6505.1,percent of total billed charges,Implant Device,6505.1,35,,6505.1,percent of total billed charges,Implant Device,6505.1,35,,6505.1,percent of total billed charges,Implant Device,6505.1,35,,6505.1,percent of total billed charges,Implant Device,6505.1,35,,6505.1,percent of total billed charges,Implant Device,7434.4,40,,7434.4,percent of total billed charges,Implant Device,6505.1,70,,6505.1,percent of total billed charges,All Other,6319.24,34,,6319.24,percent of total billed charges,Implant Device,6319.24,34,,6319.24,percent of total billed charges,Implant Device,6505.1,35,,6505.1,percent of total billed charges,Implant Device,6505.1,35,,6505.1,percent of total billed charges,Implant Device,6505.1,35,,6505.1,percent of total billed charges,Implant Device,6505.1,35,,6505.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,6319.24,34,"If Charge > 2,000, then 34 percent",6319.24,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,13753.69,
ZIMMER 00-5994-042-10 ART SURF 10MM,C1713,HCPCS,,79006681,CDM,278,RC,,,both,,,6465,4784.12,,,4784.12,Other,150% of Medicare + 9.63% HCRA Surcharge,2909.25,45,,2909.25,percent of total billed charges,Critical Access Hospital RCC factor,2198.1,34,,2198.1,percent of total billed charges,Implant Device,2198.1,34,,2198.1,percent of total billed charges,Implant Device,2198.1,34,,2198.1,percent of total billed charges,Implant Device,2198.1,34,,2198.1,percent of total billed charges,Implant Device,2198.1,34,,2198.1,percent of total billed charges,Implant Device,3200.18,,,3200.18,Other,110% of Medicare,2262.75,35,,2262.75,percent of total billed charges,Implant Device,2198.1,34,"Charges > $500, x 34%",2198.1,percent of total billed charges,Implant Device,2262.75,35,,2262.75,percent of total billed charges,Implant Device,2262.75,35,,2262.75,percent of total billed charges,Implant Device,2262.75,35,,2262.75,percent of total billed charges,Implant Device,2262.75,35,,2262.75,percent of total billed charges,Implant Device,2262.75,35,,2262.75,percent of total billed charges,Implant Device,2586,40,,2586,percent of total billed charges,Implant Device,2262.75,70,,2262.75,percent of total billed charges,All Other,2198.1,34,,2198.1,percent of total billed charges,Implant Device,2198.1,34,,2198.1,percent of total billed charges,Implant Device,2262.75,35,,2262.75,percent of total billed charges,Implant Device,2262.75,35,,2262.75,percent of total billed charges,Implant Device,2262.75,35,,2262.75,percent of total billed charges,Implant Device,2262.75,35,,2262.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2198.1,34,"If Charge > 2,000, then 34 percent",2198.1,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4784.12,
DEPUY 96-2044 TIB INS ROTTNG PLAT 17.5MM,C1713,HCPCS,,79006682,CDM,278,RC,,,both,,,3696,2735.05,,,2735.05,Other,150% of Medicare + 9.63% HCRA Surcharge,1663.2,45,,1663.2,percent of total billed charges,Critical Access Hospital RCC factor,1256.64,34,,1256.64,percent of total billed charges,Implant Device,1256.64,34,,1256.64,percent of total billed charges,Implant Device,1256.64,34,,1256.64,percent of total billed charges,Implant Device,1256.64,34,,1256.64,percent of total billed charges,Implant Device,1256.64,34,,1256.64,percent of total billed charges,Implant Device,1829.52,,,1829.52,Other,110% of Medicare,1293.6,35,,1293.6,percent of total billed charges,Implant Device,1256.64,34,"Charges > $500, x 34%",1256.64,percent of total billed charges,Implant Device,1293.6,35,,1293.6,percent of total billed charges,Implant Device,1293.6,35,,1293.6,percent of total billed charges,Implant Device,1293.6,35,,1293.6,percent of total billed charges,Implant Device,1293.6,35,,1293.6,percent of total billed charges,Implant Device,1293.6,35,,1293.6,percent of total billed charges,Implant Device,1478.4,40,,1478.4,percent of total billed charges,Implant Device,1293.6,70,,1293.6,percent of total billed charges,All Other,1256.64,34,,1256.64,percent of total billed charges,Implant Device,1256.64,34,,1256.64,percent of total billed charges,Implant Device,1293.6,35,,1293.6,percent of total billed charges,Implant Device,1293.6,35,,1293.6,percent of total billed charges,Implant Device,1293.6,35,,1293.6,percent of total billed charges,Implant Device,1293.6,35,,1293.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1256.64,34,"If Charge > 2,000, then 34 percent",1256.64,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2735.05,
ARTHREX AR-8954-01 SHANZ PINS,C1713,HCPCS,,79006685,CDM,278,RC,,,both,,,900,666,,,666,Other,150% of Medicare + 9.63% HCRA Surcharge,405,45,,405,percent of total billed charges,Critical Access Hospital RCC factor,306,34,,306,percent of total billed charges,Implant Device,306,34,,306,percent of total billed charges,Implant Device,306,34,,306,percent of total billed charges,Implant Device,306,34,,306,percent of total billed charges,Implant Device,306,34,,306,percent of total billed charges,Implant Device,445.5,,,445.5,Other,110% of Medicare,315,35,,315,percent of total billed charges,Implant Device,306,34,"Charges > $500, x 34%",306,percent of total billed charges,Implant Device,315,35,,315,percent of total billed charges,Implant Device,315,35,,315,percent of total billed charges,Implant Device,315,35,,315,percent of total billed charges,Implant Device,315,35,,315,percent of total billed charges,Implant Device,315,35,,315,percent of total billed charges,Implant Device,360,40,,360,percent of total billed charges,Implant Device,315,70,,315,percent of total billed charges,All Other,306,34,,306,percent of total billed charges,Implant Device,306,34,,306,percent of total billed charges,Implant Device,315,35,,315,percent of total billed charges,Implant Device,315,35,,315,percent of total billed charges,Implant Device,315,35,,315,percent of total billed charges,Implant Device,315,35,,315,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,666,
ARTHREX AR-8954PR-M PLATE MED RT PERIM,C1713,HCPCS,,79006686,CDM,278,RC,,,both,,,3286,2431.65,,,2431.65,Other,150% of Medicare + 9.63% HCRA Surcharge,1478.7,45,,1478.7,percent of total billed charges,Critical Access Hospital RCC factor,1117.24,34,,1117.24,percent of total billed charges,Implant Device,1117.24,34,,1117.24,percent of total billed charges,Implant Device,1117.24,34,,1117.24,percent of total billed charges,Implant Device,1117.24,34,,1117.24,percent of total billed charges,Implant Device,1117.24,34,,1117.24,percent of total billed charges,Implant Device,1626.57,,,1626.57,Other,110% of Medicare,1150.1,35,,1150.1,percent of total billed charges,Implant Device,1117.24,34,"Charges > $500, x 34%",1117.24,percent of total billed charges,Implant Device,1150.1,35,,1150.1,percent of total billed charges,Implant Device,1150.1,35,,1150.1,percent of total billed charges,Implant Device,1150.1,35,,1150.1,percent of total billed charges,Implant Device,1150.1,35,,1150.1,percent of total billed charges,Implant Device,1150.1,35,,1150.1,percent of total billed charges,Implant Device,1314.4,40,,1314.4,percent of total billed charges,Implant Device,1150.1,70,,1150.1,percent of total billed charges,All Other,1117.24,34,,1117.24,percent of total billed charges,Implant Device,1117.24,34,,1117.24,percent of total billed charges,Implant Device,1150.1,35,,1150.1,percent of total billed charges,Implant Device,1150.1,35,,1150.1,percent of total billed charges,Implant Device,1150.1,35,,1150.1,percent of total billed charges,Implant Device,1150.1,35,,1150.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1117.24,34,"If Charge > 2,000, then 34 percent",1117.24,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2431.65,
ARTHREX AR-8935-32 CORTICAL SCREW 3.5X32,C1713,HCPCS,,79006687,CDM,278,RC,,,both,,,180,133.2,,,133.2,Other,150% of Medicare + 9.63% HCRA Surcharge,81,45,,81,percent of total billed charges,Critical Access Hospital RCC factor,61.2,34,,61.2,percent of total billed charges,Implant Device,61.2,34,,61.2,percent of total billed charges,Implant Device,61.2,34,,61.2,percent of total billed charges,Implant Device,61.2,34,,61.2,percent of total billed charges,Implant Device,61.2,34,,61.2,percent of total billed charges,Implant Device,89.1,,,89.1,Other,110% of Medicare,63,35,,63,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,63,35,,63,percent of total billed charges,Implant Device,63,35,,63,percent of total billed charges,Implant Device,63,35,,63,percent of total billed charges,Implant Device,63,35,,63,percent of total billed charges,Implant Device,63,35,,63,percent of total billed charges,Implant Device,72,40,,72,percent of total billed charges,Implant Device,63,70,,63,percent of total billed charges,All Other,61.2,34,,61.2,percent of total billed charges,Implant Device,61.2,34,,61.2,percent of total billed charges,Implant Device,63,35,,63,percent of total billed charges,Implant Device,63,35,,63,percent of total billed charges,Implant Device,63,35,,63,percent of total billed charges,Implant Device,63,35,,63,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,133.2,
ARTHREX AR-8935-36 CORTICAL SCREW 3.5X36,C1713,HCPCS,,79006688,CDM,278,RC,,,both,,,180,133.2,,,133.2,Other,150% of Medicare + 9.63% HCRA Surcharge,81,45,,81,percent of total billed charges,Critical Access Hospital RCC factor,61.2,34,,61.2,percent of total billed charges,Implant Device,61.2,34,,61.2,percent of total billed charges,Implant Device,61.2,34,,61.2,percent of total billed charges,Implant Device,61.2,34,,61.2,percent of total billed charges,Implant Device,61.2,34,,61.2,percent of total billed charges,Implant Device,89.1,,,89.1,Other,110% of Medicare,63,35,,63,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,63,35,,63,percent of total billed charges,Implant Device,63,35,,63,percent of total billed charges,Implant Device,63,35,,63,percent of total billed charges,Implant Device,63,35,,63,percent of total billed charges,Implant Device,63,35,,63,percent of total billed charges,Implant Device,72,40,,72,percent of total billed charges,Implant Device,63,70,,63,percent of total billed charges,All Other,61.2,34,,61.2,percent of total billed charges,Implant Device,61.2,34,,61.2,percent of total billed charges,Implant Device,63,35,,63,percent of total billed charges,Implant Device,63,35,,63,percent of total billed charges,Implant Device,63,35,,63,percent of total billed charges,Implant Device,63,35,,63,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,133.2,
ARTHREX AR-8935-34 CORTICAL SCREW 3.5X34,C1713,HCPCS,,79006689,CDM,278,RC,,,both,,,258,190.92,,,190.92,Other,150% of Medicare + 9.63% HCRA Surcharge,116.1,45,,116.1,percent of total billed charges,Critical Access Hospital RCC factor,87.72,34,,87.72,percent of total billed charges,Implant Device,87.72,34,,87.72,percent of total billed charges,Implant Device,87.72,34,,87.72,percent of total billed charges,Implant Device,87.72,34,,87.72,percent of total billed charges,Implant Device,87.72,34,,87.72,percent of total billed charges,Implant Device,127.71,,,127.71,Other,110% of Medicare,90.3,35,,90.3,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,90.3,35,,90.3,percent of total billed charges,Implant Device,90.3,35,,90.3,percent of total billed charges,Implant Device,90.3,35,,90.3,percent of total billed charges,Implant Device,90.3,35,,90.3,percent of total billed charges,Implant Device,90.3,35,,90.3,percent of total billed charges,Implant Device,103.2,40,,103.2,percent of total billed charges,Implant Device,90.3,70,,90.3,percent of total billed charges,All Other,87.72,34,,87.72,percent of total billed charges,Implant Device,87.72,34,,87.72,percent of total billed charges,Implant Device,90.3,35,,90.3,percent of total billed charges,Implant Device,90.3,35,,90.3,percent of total billed charges,Implant Device,90.3,35,,90.3,percent of total billed charges,Implant Device,90.3,35,,90.3,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,190.92,
ARTHREX AR-8935L-28 LOCKING SCREW 3.5X28,C1713,HCPCS,,79006690,CDM,278,RC,,,both,,,180,133.2,,,133.2,Other,150% of Medicare + 9.63% HCRA Surcharge,81,45,,81,percent of total billed charges,Critical Access Hospital RCC factor,61.2,34,,61.2,percent of total billed charges,Implant Device,61.2,34,,61.2,percent of total billed charges,Implant Device,61.2,34,,61.2,percent of total billed charges,Implant Device,61.2,34,,61.2,percent of total billed charges,Implant Device,61.2,34,,61.2,percent of total billed charges,Implant Device,89.1,,,89.1,Other,110% of Medicare,63,35,,63,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,63,35,,63,percent of total billed charges,Implant Device,63,35,,63,percent of total billed charges,Implant Device,63,35,,63,percent of total billed charges,Implant Device,63,35,,63,percent of total billed charges,Implant Device,63,35,,63,percent of total billed charges,Implant Device,72,40,,72,percent of total billed charges,Implant Device,63,70,,63,percent of total billed charges,All Other,61.2,34,,61.2,percent of total billed charges,Implant Device,61.2,34,,61.2,percent of total billed charges,Implant Device,63,35,,63,percent of total billed charges,Implant Device,63,35,,63,percent of total billed charges,Implant Device,63,35,,63,percent of total billed charges,Implant Device,63,35,,63,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,133.2,
ARTHREX AR-8935L-30 LOCKING SCREW 3.5X30,C1713,HCPCS,,79006691,CDM,278,RC,,,both,,,645,477.3,,,477.3,Other,150% of Medicare + 9.63% HCRA Surcharge,290.25,45,,290.25,percent of total billed charges,Critical Access Hospital RCC factor,219.3,34,,219.3,percent of total billed charges,Implant Device,219.3,34,,219.3,percent of total billed charges,Implant Device,219.3,34,,219.3,percent of total billed charges,Implant Device,219.3,34,,219.3,percent of total billed charges,Implant Device,219.3,34,,219.3,percent of total billed charges,Implant Device,319.28,,,319.28,Other,110% of Medicare,225.75,35,,225.75,percent of total billed charges,Implant Device,219.3,34,"Charges > $500, x 34%",219.3,percent of total billed charges,Implant Device,225.75,35,,225.75,percent of total billed charges,Implant Device,225.75,35,,225.75,percent of total billed charges,Implant Device,225.75,35,,225.75,percent of total billed charges,Implant Device,225.75,35,,225.75,percent of total billed charges,Implant Device,225.75,35,,225.75,percent of total billed charges,Implant Device,258,40,,258,percent of total billed charges,Implant Device,225.75,70,,225.75,percent of total billed charges,All Other,219.3,34,,219.3,percent of total billed charges,Implant Device,219.3,34,,219.3,percent of total billed charges,Implant Device,225.75,35,,225.75,percent of total billed charges,Implant Device,225.75,35,,225.75,percent of total billed charges,Implant Device,225.75,35,,225.75,percent of total billed charges,Implant Device,225.75,35,,225.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,477.3,
ARTHREX AR-8935L-32 LOCKING SCREW 3.5X32,C1713,HCPCS,,79006692,CDM,278,RC,,,both,,,645,477.3,,,477.3,Other,150% of Medicare + 9.63% HCRA Surcharge,290.25,45,,290.25,percent of total billed charges,Critical Access Hospital RCC factor,219.3,34,,219.3,percent of total billed charges,Implant Device,219.3,34,,219.3,percent of total billed charges,Implant Device,219.3,34,,219.3,percent of total billed charges,Implant Device,219.3,34,,219.3,percent of total billed charges,Implant Device,219.3,34,,219.3,percent of total billed charges,Implant Device,319.28,,,319.28,Other,110% of Medicare,225.75,35,,225.75,percent of total billed charges,Implant Device,219.3,34,"Charges > $500, x 34%",219.3,percent of total billed charges,Implant Device,225.75,35,,225.75,percent of total billed charges,Implant Device,225.75,35,,225.75,percent of total billed charges,Implant Device,225.75,35,,225.75,percent of total billed charges,Implant Device,225.75,35,,225.75,percent of total billed charges,Implant Device,225.75,35,,225.75,percent of total billed charges,Implant Device,258,40,,258,percent of total billed charges,Implant Device,225.75,70,,225.75,percent of total billed charges,All Other,219.3,34,,219.3,percent of total billed charges,Implant Device,219.3,34,,219.3,percent of total billed charges,Implant Device,225.75,35,,225.75,percent of total billed charges,Implant Device,225.75,35,,225.75,percent of total billed charges,Implant Device,225.75,35,,225.75,percent of total billed charges,Implant Device,225.75,35,,225.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,477.3,
STRYKER 338636 NONLOCK SCREW 3.5X36MM,C1713,HCPCS,,79006694,CDM,278,RC,,,both,,,120,88.8,,,88.8,Other,150% of Medicare + 9.63% HCRA Surcharge,54,45,,54,percent of total billed charges,Critical Access Hospital RCC factor,40.8,34,,40.8,percent of total billed charges,Implant Device,40.8,34,,40.8,percent of total billed charges,Implant Device,40.8,34,,40.8,percent of total billed charges,Implant Device,40.8,34,,40.8,percent of total billed charges,Implant Device,40.8,34,,40.8,percent of total billed charges,Implant Device,59.4,,,59.4,Other,110% of Medicare,42,35,,42,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,42,35,,42,percent of total billed charges,Implant Device,42,35,,42,percent of total billed charges,Implant Device,42,35,,42,percent of total billed charges,Implant Device,42,35,,42,percent of total billed charges,Implant Device,42,35,,42,percent of total billed charges,Implant Device,48,40,,48,percent of total billed charges,Implant Device,42,70,,42,percent of total billed charges,All Other,40.8,34,,40.8,percent of total billed charges,Implant Device,40.8,34,,40.8,percent of total billed charges,Implant Device,42,35,,42,percent of total billed charges,Implant Device,42,35,,42,percent of total billed charges,Implant Device,42,35,,42,percent of total billed charges,Implant Device,42,35,,42,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,88.8,
ARTHREX AR-1322BCNF MINI SUTURTAK ANCHOR,C1713,HCPCS,,79006695,CDM,278,RC,,,both,,,975,721.5,,,721.5,Other,150% of Medicare + 9.63% HCRA Surcharge,438.75,45,,438.75,percent of total billed charges,Critical Access Hospital RCC factor,331.5,34,,331.5,percent of total billed charges,Implant Device,331.5,34,,331.5,percent of total billed charges,Implant Device,331.5,34,,331.5,percent of total billed charges,Implant Device,331.5,34,,331.5,percent of total billed charges,Implant Device,331.5,34,,331.5,percent of total billed charges,Implant Device,482.63,,,482.63,Other,110% of Medicare,341.25,35,,341.25,percent of total billed charges,Implant Device,331.5,34,"Charges > $500, x 34%",331.5,percent of total billed charges,Implant Device,341.25,35,,341.25,percent of total billed charges,Implant Device,341.25,35,,341.25,percent of total billed charges,Implant Device,341.25,35,,341.25,percent of total billed charges,Implant Device,341.25,35,,341.25,percent of total billed charges,Implant Device,341.25,35,,341.25,percent of total billed charges,Implant Device,390,40,,390,percent of total billed charges,Implant Device,341.25,70,,341.25,percent of total billed charges,All Other,331.5,34,,331.5,percent of total billed charges,Implant Device,331.5,34,,331.5,percent of total billed charges,Implant Device,341.25,35,,341.25,percent of total billed charges,Implant Device,341.25,35,,341.25,percent of total billed charges,Implant Device,341.25,35,,341.25,percent of total billed charges,Implant Device,341.25,35,,341.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,721.5,
ARROW CS-15312-X NEXTSTEP CATHETER 31CM,C1750,HCPCS,,79006697,CDM,278,RC,,,both,,,903,668.22,,,668.22,Other,150% of Medicare + 9.63% HCRA Surcharge,406.35,45,,406.35,percent of total billed charges,Critical Access Hospital RCC factor,307.02,34,,307.02,percent of total billed charges,Implant Device,307.02,34,,307.02,percent of total billed charges,Implant Device,307.02,34,,307.02,percent of total billed charges,Implant Device,307.02,34,,307.02,percent of total billed charges,Implant Device,307.02,34,,307.02,percent of total billed charges,Implant Device,446.99,,,446.99,Other,110% of Medicare,316.05,35,,316.05,percent of total billed charges,Implant Device,307.02,34,"Charges > $500, x 34%",307.02,percent of total billed charges,Implant Device,316.05,35,,316.05,percent of total billed charges,Implant Device,316.05,35,,316.05,percent of total billed charges,Implant Device,316.05,35,,316.05,percent of total billed charges,Implant Device,316.05,35,,316.05,percent of total billed charges,Implant Device,316.05,35,,316.05,percent of total billed charges,Implant Device,361.2,40,,361.2,percent of total billed charges,Implant Device,316.05,70,,316.05,percent of total billed charges,All Other,307.02,34,,307.02,percent of total billed charges,Implant Device,307.02,34,,307.02,percent of total billed charges,Implant Device,316.05,35,,316.05,percent of total billed charges,Implant Device,316.05,35,,316.05,percent of total billed charges,Implant Device,316.05,35,,316.05,percent of total billed charges,Implant Device,316.05,35,,316.05,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,668.22,
SYNTHES XM106.1020A TISSUEMATRIX 10X20CM,C1713,HCPCS,,79006701,CDM,278,RC,,,both,,,19632,14527.73,,,14527.73,Other,150% of Medicare + 9.63% HCRA Surcharge,8834.4,45,,8834.4,percent of total billed charges,Critical Access Hospital RCC factor,6674.88,34,,6674.88,percent of total billed charges,Implant Device,6674.88,34,,6674.88,percent of total billed charges,Implant Device,6674.88,34,,6674.88,percent of total billed charges,Implant Device,6674.88,34,,6674.88,percent of total billed charges,Implant Device,6674.88,34,,6674.88,percent of total billed charges,Implant Device,9717.84,,,9717.84,Other,110% of Medicare,6871.2,35,,6871.2,percent of total billed charges,Implant Device,6674.88,34,"Charges > $500, x 34%",6674.88,percent of total billed charges,Implant Device,6871.2,35,,6871.2,percent of total billed charges,Implant Device,6871.2,35,,6871.2,percent of total billed charges,Implant Device,6871.2,35,,6871.2,percent of total billed charges,Implant Device,6871.2,35,,6871.2,percent of total billed charges,Implant Device,6871.2,35,,6871.2,percent of total billed charges,Implant Device,7852.8,40,,7852.8,percent of total billed charges,Implant Device,6871.2,70,,6871.2,percent of total billed charges,All Other,6674.88,34,,6674.88,percent of total billed charges,Implant Device,6674.88,34,,6674.88,percent of total billed charges,Implant Device,6871.2,35,,6871.2,percent of total billed charges,Implant Device,6871.2,35,,6871.2,percent of total billed charges,Implant Device,6871.2,35,,6871.2,percent of total billed charges,Implant Device,6871.2,35,,6871.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,6674.88,34,"If Charge > 2,000, then 34 percent",6674.88,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,14527.73,
ALLERGAN MM410215 SILICON BREAST IMPLANT,C1789,HCPCS,,79006702,CDM,278,RC,,,both,,,3976,2942.25,,,2942.25,Other,150% of Medicare + 9.63% HCRA Surcharge,1789.2,45,,1789.2,percent of total billed charges,Critical Access Hospital RCC factor,1351.84,34,,1351.84,percent of total billed charges,Implant Device,1351.84,34,,1351.84,percent of total billed charges,Implant Device,1351.84,34,,1351.84,percent of total billed charges,Implant Device,1351.84,34,,1351.84,percent of total billed charges,Implant Device,1351.84,34,,1351.84,percent of total billed charges,Implant Device,1968.12,,,1968.12,Other,110% of Medicare,1391.6,35,,1391.6,percent of total billed charges,Implant Device,1351.84,34,"Charges > $500, x 34%",1351.84,percent of total billed charges,Implant Device,1391.6,35,,1391.6,percent of total billed charges,Implant Device,1391.6,35,,1391.6,percent of total billed charges,Implant Device,1391.6,35,,1391.6,percent of total billed charges,Implant Device,1391.6,35,,1391.6,percent of total billed charges,Implant Device,1391.6,35,,1391.6,percent of total billed charges,Implant Device,1590.4,40,,1590.4,percent of total billed charges,Implant Device,1391.6,70,,1391.6,percent of total billed charges,All Other,1351.84,34,,1351.84,percent of total billed charges,Implant Device,1351.84,34,,1351.84,percent of total billed charges,Implant Device,1391.6,35,,1391.6,percent of total billed charges,Implant Device,1391.6,35,,1391.6,percent of total billed charges,Implant Device,1391.6,35,,1391.6,percent of total billed charges,Implant Device,1391.6,35,,1391.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1351.84,34,"If Charge > 2,000, then 34 percent",1351.84,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2942.25,
ALLERGAN MF410225 SILICON BREAST IMPLANT,C1789,HCPCS,,79006703,CDM,278,RC,,,both,,,3976,2942.25,,,2942.25,Other,150% of Medicare + 9.63% HCRA Surcharge,1789.2,45,,1789.2,percent of total billed charges,Critical Access Hospital RCC factor,1351.84,34,,1351.84,percent of total billed charges,Implant Device,1351.84,34,,1351.84,percent of total billed charges,Implant Device,1351.84,34,,1351.84,percent of total billed charges,Implant Device,1351.84,34,,1351.84,percent of total billed charges,Implant Device,1351.84,34,,1351.84,percent of total billed charges,Implant Device,1968.12,,,1968.12,Other,110% of Medicare,1391.6,35,,1391.6,percent of total billed charges,Implant Device,1351.84,34,"Charges > $500, x 34%",1351.84,percent of total billed charges,Implant Device,1391.6,35,,1391.6,percent of total billed charges,Implant Device,1391.6,35,,1391.6,percent of total billed charges,Implant Device,1391.6,35,,1391.6,percent of total billed charges,Implant Device,1391.6,35,,1391.6,percent of total billed charges,Implant Device,1391.6,35,,1391.6,percent of total billed charges,Implant Device,1590.4,40,,1590.4,percent of total billed charges,Implant Device,1391.6,70,,1391.6,percent of total billed charges,All Other,1351.84,34,,1351.84,percent of total billed charges,Implant Device,1351.84,34,,1351.84,percent of total billed charges,Implant Device,1391.6,35,,1391.6,percent of total billed charges,Implant Device,1391.6,35,,1391.6,percent of total billed charges,Implant Device,1391.6,35,,1391.6,percent of total billed charges,Implant Device,1391.6,35,,1391.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1351.84,34,"If Charge > 2,000, then 34 percent",1351.84,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2942.25,
SIENTRA 20645-250MP BREAST IMPLANT,C1789,HCPCS,,79006712,CDM,278,RC,,,both,,,2986,2209.65,,,2209.65,Other,150% of Medicare + 9.63% HCRA Surcharge,1343.7,45,,1343.7,percent of total billed charges,Critical Access Hospital RCC factor,1015.24,34,,1015.24,percent of total billed charges,Implant Device,1015.24,34,,1015.24,percent of total billed charges,Implant Device,1015.24,34,,1015.24,percent of total billed charges,Implant Device,1015.24,34,,1015.24,percent of total billed charges,Implant Device,1015.24,34,,1015.24,percent of total billed charges,Implant Device,1478.07,,,1478.07,Other,110% of Medicare,1045.1,35,,1045.1,percent of total billed charges,Implant Device,1015.24,34,"Charges > $500, x 34%",1015.24,percent of total billed charges,Implant Device,1045.1,35,,1045.1,percent of total billed charges,Implant Device,1045.1,35,,1045.1,percent of total billed charges,Implant Device,1045.1,35,,1045.1,percent of total billed charges,Implant Device,1045.1,35,,1045.1,percent of total billed charges,Implant Device,1045.1,35,,1045.1,percent of total billed charges,Implant Device,1194.4,40,,1194.4,percent of total billed charges,Implant Device,1045.1,70,,1045.1,percent of total billed charges,All Other,1015.24,34,,1015.24,percent of total billed charges,Implant Device,1015.24,34,,1015.24,percent of total billed charges,Implant Device,1045.1,35,,1045.1,percent of total billed charges,Implant Device,1045.1,35,,1045.1,percent of total billed charges,Implant Device,1045.1,35,,1045.1,percent of total billed charges,Implant Device,1045.1,35,,1045.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1015.24,34,"If Charge > 2,000, then 34 percent",1015.24,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2209.65,
SIENTRA 20645-290MP BREAST IMPLANT,C1789,HCPCS,,79006713,CDM,278,RC,,,both,,,2986,2209.65,,,2209.65,Other,150% of Medicare + 9.63% HCRA Surcharge,1343.7,45,,1343.7,percent of total billed charges,Critical Access Hospital RCC factor,1015.24,34,,1015.24,percent of total billed charges,Implant Device,1015.24,34,,1015.24,percent of total billed charges,Implant Device,1015.24,34,,1015.24,percent of total billed charges,Implant Device,1015.24,34,,1015.24,percent of total billed charges,Implant Device,1015.24,34,,1015.24,percent of total billed charges,Implant Device,1478.07,,,1478.07,Other,110% of Medicare,1045.1,35,,1045.1,percent of total billed charges,Implant Device,1015.24,34,"Charges > $500, x 34%",1015.24,percent of total billed charges,Implant Device,1045.1,35,,1045.1,percent of total billed charges,Implant Device,1045.1,35,,1045.1,percent of total billed charges,Implant Device,1045.1,35,,1045.1,percent of total billed charges,Implant Device,1045.1,35,,1045.1,percent of total billed charges,Implant Device,1045.1,35,,1045.1,percent of total billed charges,Implant Device,1194.4,40,,1194.4,percent of total billed charges,Implant Device,1045.1,70,,1045.1,percent of total billed charges,All Other,1015.24,34,,1015.24,percent of total billed charges,Implant Device,1015.24,34,,1015.24,percent of total billed charges,Implant Device,1045.1,35,,1045.1,percent of total billed charges,Implant Device,1045.1,35,,1045.1,percent of total billed charges,Implant Device,1045.1,35,,1045.1,percent of total billed charges,Implant Device,1045.1,35,,1045.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1015.24,34,"If Charge > 2,000, then 34 percent",1015.24,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2209.65,
SIENTRA 20645-330MP BREAST IMPLANT,C1789,HCPCS,,79006714,CDM,278,RC,,,both,,,2986,2209.65,,,2209.65,Other,150% of Medicare + 9.63% HCRA Surcharge,1343.7,45,,1343.7,percent of total billed charges,Critical Access Hospital RCC factor,1015.24,34,,1015.24,percent of total billed charges,Implant Device,1015.24,34,,1015.24,percent of total billed charges,Implant Device,1015.24,34,,1015.24,percent of total billed charges,Implant Device,1015.24,34,,1015.24,percent of total billed charges,Implant Device,1015.24,34,,1015.24,percent of total billed charges,Implant Device,1478.07,,,1478.07,Other,110% of Medicare,1045.1,35,,1045.1,percent of total billed charges,Implant Device,1015.24,34,"Charges > $500, x 34%",1015.24,percent of total billed charges,Implant Device,1045.1,35,,1045.1,percent of total billed charges,Implant Device,1045.1,35,,1045.1,percent of total billed charges,Implant Device,1045.1,35,,1045.1,percent of total billed charges,Implant Device,1045.1,35,,1045.1,percent of total billed charges,Implant Device,1045.1,35,,1045.1,percent of total billed charges,Implant Device,1194.4,40,,1194.4,percent of total billed charges,Implant Device,1045.1,70,,1045.1,percent of total billed charges,All Other,1015.24,34,,1015.24,percent of total billed charges,Implant Device,1015.24,34,,1015.24,percent of total billed charges,Implant Device,1045.1,35,,1045.1,percent of total billed charges,Implant Device,1045.1,35,,1045.1,percent of total billed charges,Implant Device,1045.1,35,,1045.1,percent of total billed charges,Implant Device,1045.1,35,,1045.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1015.24,34,"If Charge > 2,000, then 34 percent",1015.24,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2209.65,
ZIMMER 00-5842-022-11 ART SURF SZ2 11MM,C1713,HCPCS,,79006716,CDM,278,RC,,,both,,,2677,1980.99,,,1980.99,Other,150% of Medicare + 9.63% HCRA Surcharge,1204.65,45,,1204.65,percent of total billed charges,Critical Access Hospital RCC factor,910.18,34,,910.18,percent of total billed charges,Implant Device,910.18,34,,910.18,percent of total billed charges,Implant Device,910.18,34,,910.18,percent of total billed charges,Implant Device,910.18,34,,910.18,percent of total billed charges,Implant Device,910.18,34,,910.18,percent of total billed charges,Implant Device,1325.12,,,1325.12,Other,110% of Medicare,936.95,35,,936.95,percent of total billed charges,Implant Device,910.18,34,"Charges > $500, x 34%",910.18,percent of total billed charges,Implant Device,936.95,35,,936.95,percent of total billed charges,Implant Device,936.95,35,,936.95,percent of total billed charges,Implant Device,936.95,35,,936.95,percent of total billed charges,Implant Device,936.95,35,,936.95,percent of total billed charges,Implant Device,936.95,35,,936.95,percent of total billed charges,Implant Device,1070.8,40,,1070.8,percent of total billed charges,Implant Device,936.95,70,,936.95,percent of total billed charges,All Other,910.18,34,,910.18,percent of total billed charges,Implant Device,910.18,34,,910.18,percent of total billed charges,Implant Device,936.95,35,,936.95,percent of total billed charges,Implant Device,936.95,35,,936.95,percent of total billed charges,Implant Device,936.95,35,,936.95,percent of total billed charges,Implant Device,936.95,35,,936.95,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,910.18,34,"If Charge > 2,000, then 34 percent",910.18,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1980.99,
DEPUY 1960-50-300 FEM POST STABL SZ 3 RT,C1776,HCPCS,,79006717,CDM,278,RC,,,both,,,7927,5866,,,5866,Other,150% of Medicare + 9.63% HCRA Surcharge,3567.15,45,,3567.15,percent of total billed charges,Critical Access Hospital RCC factor,2695.18,34,,2695.18,percent of total billed charges,Implant Device,2695.18,34,,2695.18,percent of total billed charges,Implant Device,2695.18,34,,2695.18,percent of total billed charges,Implant Device,2695.18,34,,2695.18,percent of total billed charges,Implant Device,2695.18,34,,2695.18,percent of total billed charges,Implant Device,3923.87,,,3923.87,Other,110% of Medicare,2774.45,35,,2774.45,percent of total billed charges,Implant Device,2695.18,34,"Charges > $500, x 34%",2695.18,percent of total billed charges,Implant Device,2774.45,35,,2774.45,percent of total billed charges,Implant Device,2774.45,35,,2774.45,percent of total billed charges,Implant Device,2774.45,35,,2774.45,percent of total billed charges,Implant Device,2774.45,35,,2774.45,percent of total billed charges,Implant Device,2774.45,35,,2774.45,percent of total billed charges,Implant Device,3170.8,40,,3170.8,percent of total billed charges,Implant Device,2774.45,70,,2774.45,percent of total billed charges,All Other,2695.18,34,,2695.18,percent of total billed charges,Implant Device,2695.18,34,,2695.18,percent of total billed charges,Implant Device,2774.45,35,,2774.45,percent of total billed charges,Implant Device,2774.45,35,,2774.45,percent of total billed charges,Implant Device,2774.45,35,,2774.45,percent of total billed charges,Implant Device,2774.45,35,,2774.45,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2695.18,34,"If Charge > 2,000, then 34 percent",2695.18,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5866,
DEPUY 96-2131 TIBIAL INSERT 10MM,C1776,HCPCS,,79006718,CDM,278,RC,,,both,,,4080,3019.21,,,3019.21,Other,150% of Medicare + 9.63% HCRA Surcharge,1836,45,,1836,percent of total billed charges,Critical Access Hospital RCC factor,1387.2,34,,1387.2,percent of total billed charges,Implant Device,1387.2,34,,1387.2,percent of total billed charges,Implant Device,1387.2,34,,1387.2,percent of total billed charges,Implant Device,1387.2,34,,1387.2,percent of total billed charges,Implant Device,1387.2,34,,1387.2,percent of total billed charges,Implant Device,2019.6,,,2019.6,Other,110% of Medicare,1428,35,,1428,percent of total billed charges,Implant Device,1387.2,34,"Charges > $500, x 34%",1387.2,percent of total billed charges,Implant Device,1428,35,,1428,percent of total billed charges,Implant Device,1428,35,,1428,percent of total billed charges,Implant Device,1428,35,,1428,percent of total billed charges,Implant Device,1428,35,,1428,percent of total billed charges,Implant Device,1428,35,,1428,percent of total billed charges,Implant Device,1632,40,,1632,percent of total billed charges,Implant Device,1428,70,,1428,percent of total billed charges,All Other,1387.2,34,,1387.2,percent of total billed charges,Implant Device,1387.2,34,,1387.2,percent of total billed charges,Implant Device,1428,35,,1428,percent of total billed charges,Implant Device,1428,35,,1428,percent of total billed charges,Implant Device,1428,35,,1428,percent of total billed charges,Implant Device,1428,35,,1428,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1387.2,34,"If Charge > 2,000, then 34 percent",1387.2,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3019.21,
DEPUY 1024-08-400 FEM UNICONDYLAR SZ 4,C1776,HCPCS,,79006719,CDM,278,RC,,,both,,,4200,3108.01,,,3108.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1890,45,,1890,percent of total billed charges,Critical Access Hospital RCC factor,1428,34,,1428,percent of total billed charges,Implant Device,1428,34,,1428,percent of total billed charges,Implant Device,1428,34,,1428,percent of total billed charges,Implant Device,1428,34,,1428,percent of total billed charges,Implant Device,1428,34,,1428,percent of total billed charges,Implant Device,2079,,,2079,Other,110% of Medicare,1470,35,,1470,percent of total billed charges,Implant Device,1428,34,"Charges > $500, x 34%",1428,percent of total billed charges,Implant Device,1470,35,,1470,percent of total billed charges,Implant Device,1470,35,,1470,percent of total billed charges,Implant Device,1470,35,,1470,percent of total billed charges,Implant Device,1470,35,,1470,percent of total billed charges,Implant Device,1470,35,,1470,percent of total billed charges,Implant Device,1680,40,,1680,percent of total billed charges,Implant Device,1470,70,,1470,percent of total billed charges,All Other,1428,34,,1428,percent of total billed charges,Implant Device,1428,34,,1428,percent of total billed charges,Implant Device,1470,35,,1470,percent of total billed charges,Implant Device,1470,35,,1470,percent of total billed charges,Implant Device,1470,35,,1470,percent of total billed charges,Implant Device,1470,35,,1470,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1428,34,"If Charge > 2,000, then 34 percent",1428,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3108.01,
DEPUY 1024-52-300 TIBIAL TRAY UNICND SZ3,C1776,HCPCS,,79006720,CDM,278,RC,,,both,,,4157,3076.19,,,3076.19,Other,150% of Medicare + 9.63% HCRA Surcharge,1870.65,45,,1870.65,percent of total billed charges,Critical Access Hospital RCC factor,1413.38,34,,1413.38,percent of total billed charges,Implant Device,1413.38,34,,1413.38,percent of total billed charges,Implant Device,1413.38,34,,1413.38,percent of total billed charges,Implant Device,1413.38,34,,1413.38,percent of total billed charges,Implant Device,1413.38,34,,1413.38,percent of total billed charges,Implant Device,2057.72,,,2057.72,Other,110% of Medicare,1454.95,35,,1454.95,percent of total billed charges,Implant Device,1413.38,34,"Charges > $500, x 34%",1413.38,percent of total billed charges,Implant Device,1454.95,35,,1454.95,percent of total billed charges,Implant Device,1454.95,35,,1454.95,percent of total billed charges,Implant Device,1454.95,35,,1454.95,percent of total billed charges,Implant Device,1454.95,35,,1454.95,percent of total billed charges,Implant Device,1454.95,35,,1454.95,percent of total billed charges,Implant Device,1662.8,40,,1662.8,percent of total billed charges,Implant Device,1454.95,70,,1454.95,percent of total billed charges,All Other,1413.38,34,,1413.38,percent of total billed charges,Implant Device,1413.38,34,,1413.38,percent of total billed charges,Implant Device,1454.95,35,,1454.95,percent of total billed charges,Implant Device,1454.95,35,,1454.95,percent of total billed charges,Implant Device,1454.95,35,,1454.95,percent of total billed charges,Implant Device,1454.95,35,,1454.95,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1413.38,34,"If Charge > 2,000, then 34 percent",1413.38,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3076.19,
DEPUY 1024-54-307 TIBIAL INS UNICND SZ3,C1776,HCPCS,,79006721,CDM,278,RC,,,both,,,2423,1793.03,,,1793.03,Other,150% of Medicare + 9.63% HCRA Surcharge,1090.35,45,,1090.35,percent of total billed charges,Critical Access Hospital RCC factor,823.82,34,,823.82,percent of total billed charges,Implant Device,823.82,34,,823.82,percent of total billed charges,Implant Device,823.82,34,,823.82,percent of total billed charges,Implant Device,823.82,34,,823.82,percent of total billed charges,Implant Device,823.82,34,,823.82,percent of total billed charges,Implant Device,1199.39,,,1199.39,Other,110% of Medicare,848.05,35,,848.05,percent of total billed charges,Implant Device,823.82,34,"Charges > $500, x 34%",823.82,percent of total billed charges,Implant Device,848.05,35,,848.05,percent of total billed charges,Implant Device,848.05,35,,848.05,percent of total billed charges,Implant Device,848.05,35,,848.05,percent of total billed charges,Implant Device,848.05,35,,848.05,percent of total billed charges,Implant Device,848.05,35,,848.05,percent of total billed charges,Implant Device,969.2,40,,969.2,percent of total billed charges,Implant Device,848.05,70,,848.05,percent of total billed charges,All Other,823.82,34,,823.82,percent of total billed charges,Implant Device,823.82,34,,823.82,percent of total billed charges,Implant Device,848.05,35,,848.05,percent of total billed charges,Implant Device,848.05,35,,848.05,percent of total billed charges,Implant Device,848.05,35,,848.05,percent of total billed charges,Implant Device,848.05,35,,848.05,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,823.82,34,"If Charge > 2,000, then 34 percent",823.82,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1793.03,
ALLERGAN 133MX-14-T TISSUE EXPANDER,C1789,HCPCS,,79006722,CDM,278,RC,,,both,,,4650,3441.01,,,3441.01,Other,150% of Medicare + 9.63% HCRA Surcharge,2092.5,45,,2092.5,percent of total billed charges,Critical Access Hospital RCC factor,1581,34,,1581,percent of total billed charges,Implant Device,1581,34,,1581,percent of total billed charges,Implant Device,1581,34,,1581,percent of total billed charges,Implant Device,1581,34,,1581,percent of total billed charges,Implant Device,1581,34,,1581,percent of total billed charges,Implant Device,2301.75,,,2301.75,Other,110% of Medicare,1627.5,35,,1627.5,percent of total billed charges,Implant Device,1581,34,"Charges > $500, x 34%",1581,percent of total billed charges,Implant Device,1627.5,35,,1627.5,percent of total billed charges,Implant Device,1627.5,35,,1627.5,percent of total billed charges,Implant Device,1627.5,35,,1627.5,percent of total billed charges,Implant Device,1627.5,35,,1627.5,percent of total billed charges,Implant Device,1627.5,35,,1627.5,percent of total billed charges,Implant Device,1860,40,,1860,percent of total billed charges,Implant Device,1627.5,70,,1627.5,percent of total billed charges,All Other,1581,34,,1581,percent of total billed charges,Implant Device,1581,34,,1581,percent of total billed charges,Implant Device,1627.5,35,,1627.5,percent of total billed charges,Implant Device,1627.5,35,,1627.5,percent of total billed charges,Implant Device,1627.5,35,,1627.5,percent of total billed charges,Implant Device,1627.5,35,,1627.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1581,34,"If Charge > 2,000, then 34 percent",1581,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3441.01,
STRYKER 59-23012 2.3X12MM BONE SCREW,C1713,HCPCS,,79006725,CDM,278,RC,,,both,,,380,281.2,,,281.2,Other,150% of Medicare + 9.63% HCRA Surcharge,171,45,,171,percent of total billed charges,Critical Access Hospital RCC factor,129.2,34,,129.2,percent of total billed charges,Implant Device,129.2,34,,129.2,percent of total billed charges,Implant Device,129.2,34,,129.2,percent of total billed charges,Implant Device,129.2,34,,129.2,percent of total billed charges,Implant Device,129.2,34,,129.2,percent of total billed charges,Implant Device,188.1,,,188.1,Other,110% of Medicare,133,35,,133,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,133,35,,133,percent of total billed charges,Implant Device,133,35,,133,percent of total billed charges,Implant Device,133,35,,133,percent of total billed charges,Implant Device,133,35,,133,percent of total billed charges,Implant Device,133,35,,133,percent of total billed charges,Implant Device,152,40,,152,percent of total billed charges,Implant Device,133,70,,133,percent of total billed charges,All Other,129.2,34,,129.2,percent of total billed charges,Implant Device,129.2,34,,129.2,percent of total billed charges,Implant Device,133,35,,133,percent of total billed charges,Implant Device,133,35,,133,percent of total billed charges,Implant Device,133,35,,133,percent of total billed charges,Implant Device,133,35,,133,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,281.2,
STRYKER 59-23013 2.3X13MM BONE SCREW,C1713,HCPCS,,79006726,CDM,278,RC,,,both,,,459,339.66,,,339.66,Other,150% of Medicare + 9.63% HCRA Surcharge,206.55,45,,206.55,percent of total billed charges,Critical Access Hospital RCC factor,156.06,34,,156.06,percent of total billed charges,Implant Device,156.06,34,,156.06,percent of total billed charges,Implant Device,156.06,34,,156.06,percent of total billed charges,Implant Device,156.06,34,,156.06,percent of total billed charges,Implant Device,156.06,34,,156.06,percent of total billed charges,Implant Device,227.21,,,227.21,Other,110% of Medicare,160.65,35,,160.65,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,160.65,35,,160.65,percent of total billed charges,Implant Device,160.65,35,,160.65,percent of total billed charges,Implant Device,160.65,35,,160.65,percent of total billed charges,Implant Device,160.65,35,,160.65,percent of total billed charges,Implant Device,160.65,35,,160.65,percent of total billed charges,Implant Device,183.6,40,,183.6,percent of total billed charges,Implant Device,160.65,70,,160.65,percent of total billed charges,All Other,156.06,34,,156.06,percent of total billed charges,Implant Device,156.06,34,,156.06,percent of total billed charges,Implant Device,160.65,35,,160.65,percent of total billed charges,Implant Device,160.65,35,,160.65,percent of total billed charges,Implant Device,160.65,35,,160.65,percent of total billed charges,Implant Device,160.65,35,,160.65,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,339.66,
STRYKER 59-25012 2.5X12MM EMERGNCY SCREW,C1713,HCPCS,,79006727,CDM,278,RC,,,both,,,349,258.26,,,258.26,Other,150% of Medicare + 9.63% HCRA Surcharge,157.05,45,,157.05,percent of total billed charges,Critical Access Hospital RCC factor,118.66,34,,118.66,percent of total billed charges,Implant Device,118.66,34,,118.66,percent of total billed charges,Implant Device,118.66,34,,118.66,percent of total billed charges,Implant Device,118.66,34,,118.66,percent of total billed charges,Implant Device,118.66,34,,118.66,percent of total billed charges,Implant Device,172.76,,,172.76,Other,110% of Medicare,122.15,35,,122.15,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,122.15,35,,122.15,percent of total billed charges,Implant Device,122.15,35,,122.15,percent of total billed charges,Implant Device,122.15,35,,122.15,percent of total billed charges,Implant Device,122.15,35,,122.15,percent of total billed charges,Implant Device,122.15,35,,122.15,percent of total billed charges,Implant Device,139.6,40,,139.6,percent of total billed charges,Implant Device,122.15,70,,122.15,percent of total billed charges,All Other,118.66,34,,118.66,percent of total billed charges,Implant Device,118.66,34,,118.66,percent of total billed charges,Implant Device,122.15,35,,122.15,percent of total billed charges,Implant Device,122.15,35,,122.15,percent of total billed charges,Implant Device,122.15,35,,122.15,percent of total billed charges,Implant Device,122.15,35,,122.15,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,258.26,
STRYKER 40-30113 ASNIS CANN SCREW 3X13MM,C1713,HCPCS,,79006729,CDM,278,RC,,,both,,,773,572.02,,,572.02,Other,150% of Medicare + 9.63% HCRA Surcharge,347.85,45,,347.85,percent of total billed charges,Critical Access Hospital RCC factor,262.82,34,,262.82,percent of total billed charges,Implant Device,262.82,34,,262.82,percent of total billed charges,Implant Device,262.82,34,,262.82,percent of total billed charges,Implant Device,262.82,34,,262.82,percent of total billed charges,Implant Device,262.82,34,,262.82,percent of total billed charges,Implant Device,382.64,,,382.64,Other,110% of Medicare,270.55,35,,270.55,percent of total billed charges,Implant Device,262.82,34,"Charges > $500, x 34%",262.82,percent of total billed charges,Implant Device,270.55,35,,270.55,percent of total billed charges,Implant Device,270.55,35,,270.55,percent of total billed charges,Implant Device,270.55,35,,270.55,percent of total billed charges,Implant Device,270.55,35,,270.55,percent of total billed charges,Implant Device,270.55,35,,270.55,percent of total billed charges,Implant Device,309.2,40,,309.2,percent of total billed charges,Implant Device,270.55,70,,270.55,percent of total billed charges,All Other,262.82,34,,262.82,percent of total billed charges,Implant Device,262.82,34,,262.82,percent of total billed charges,Implant Device,270.55,35,,270.55,percent of total billed charges,Implant Device,270.55,35,,270.55,percent of total billed charges,Implant Device,270.55,35,,270.55,percent of total billed charges,Implant Device,270.55,35,,270.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,572.02,
DAVOL 1180816M ALLOMAX SURG GRAFT 8X16CM,C1713,HCPCS,,79006730,CDM,278,RC,,,both,,,11250,8325.03,,,8325.03,Other,150% of Medicare + 9.63% HCRA Surcharge,5062.5,45,,5062.5,percent of total billed charges,Critical Access Hospital RCC factor,3825,34,,3825,percent of total billed charges,Implant Device,3825,34,,3825,percent of total billed charges,Implant Device,3825,34,,3825,percent of total billed charges,Implant Device,3825,34,,3825,percent of total billed charges,Implant Device,3825,34,,3825,percent of total billed charges,Implant Device,5568.75,,,5568.75,Other,110% of Medicare,3937.5,35,,3937.5,percent of total billed charges,Implant Device,3825,34,"Charges > $500, x 34%",3825,percent of total billed charges,Implant Device,3937.5,35,,3937.5,percent of total billed charges,Implant Device,3937.5,35,,3937.5,percent of total billed charges,Implant Device,3937.5,35,,3937.5,percent of total billed charges,Implant Device,3937.5,35,,3937.5,percent of total billed charges,Implant Device,3937.5,35,,3937.5,percent of total billed charges,Implant Device,4500,40,,4500,percent of total billed charges,Implant Device,3937.5,70,,3937.5,percent of total billed charges,All Other,3825,34,,3825,percent of total billed charges,Implant Device,3825,34,,3825,percent of total billed charges,Implant Device,3937.5,35,,3937.5,percent of total billed charges,Implant Device,3937.5,35,,3937.5,percent of total billed charges,Implant Device,3937.5,35,,3937.5,percent of total billed charges,Implant Device,3937.5,35,,3937.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3825,34,"If Charge > 2,000, then 34 percent",3825,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,8325.03,
ATLAS 1100-03-0065 ROD CONTOURED 65MM,C1713,HCPCS,,79006731,CDM,278,RC,,,both,,,840,621.6,,,621.6,Other,150% of Medicare + 9.63% HCRA Surcharge,378,45,,378,percent of total billed charges,Critical Access Hospital RCC factor,285.6,34,,285.6,percent of total billed charges,Implant Device,285.6,34,,285.6,percent of total billed charges,Implant Device,285.6,34,,285.6,percent of total billed charges,Implant Device,285.6,34,,285.6,percent of total billed charges,Implant Device,285.6,34,,285.6,percent of total billed charges,Implant Device,415.8,,,415.8,Other,110% of Medicare,294,35,,294,percent of total billed charges,Implant Device,285.6,34,"Charges > $500, x 34%",285.6,percent of total billed charges,Implant Device,294,35,,294,percent of total billed charges,Implant Device,294,35,,294,percent of total billed charges,Implant Device,294,35,,294,percent of total billed charges,Implant Device,294,35,,294,percent of total billed charges,Implant Device,294,35,,294,percent of total billed charges,Implant Device,336,40,,336,percent of total billed charges,Implant Device,294,70,,294,percent of total billed charges,All Other,285.6,34,,285.6,percent of total billed charges,Implant Device,285.6,34,,285.6,percent of total billed charges,Implant Device,294,35,,294,percent of total billed charges,Implant Device,294,35,,294,percent of total billed charges,Implant Device,294,35,,294,percent of total billed charges,Implant Device,294,35,,294,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,621.6,
STRYKER 5630-G-428 TIBIAL INSERT 4X8MM,C1776,HCPCS,,79006732,CDM,278,RC,,,both,,,3232,2391.69,,,2391.69,Other,150% of Medicare + 9.63% HCRA Surcharge,1454.4,45,,1454.4,percent of total billed charges,Critical Access Hospital RCC factor,1098.88,34,,1098.88,percent of total billed charges,Implant Device,1098.88,34,,1098.88,percent of total billed charges,Implant Device,1098.88,34,,1098.88,percent of total billed charges,Implant Device,1098.88,34,,1098.88,percent of total billed charges,Implant Device,1098.88,34,,1098.88,percent of total billed charges,Implant Device,1599.84,,,1599.84,Other,110% of Medicare,1131.2,35,,1131.2,percent of total billed charges,Implant Device,1098.88,34,"Charges > $500, x 34%",1098.88,percent of total billed charges,Implant Device,1131.2,35,,1131.2,percent of total billed charges,Implant Device,1131.2,35,,1131.2,percent of total billed charges,Implant Device,1131.2,35,,1131.2,percent of total billed charges,Implant Device,1131.2,35,,1131.2,percent of total billed charges,Implant Device,1131.2,35,,1131.2,percent of total billed charges,Implant Device,1292.8,40,,1292.8,percent of total billed charges,Implant Device,1131.2,70,,1131.2,percent of total billed charges,All Other,1098.88,34,,1098.88,percent of total billed charges,Implant Device,1098.88,34,,1098.88,percent of total billed charges,Implant Device,1131.2,35,,1131.2,percent of total billed charges,Implant Device,1131.2,35,,1131.2,percent of total billed charges,Implant Device,1131.2,35,,1131.2,percent of total billed charges,Implant Device,1131.2,35,,1131.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1098.88,34,"If Charge > 2,000, then 34 percent",1098.88,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2391.69,
STRYKER 5620-B-402 TIBIAL BASEPLATE SZ 4,C1713,HCPCS,,79006733,CDM,278,RC,,,both,,,4937,3653.39,,,3653.39,Other,150% of Medicare + 9.63% HCRA Surcharge,2221.65,45,,2221.65,percent of total billed charges,Critical Access Hospital RCC factor,1678.58,34,,1678.58,percent of total billed charges,Implant Device,1678.58,34,,1678.58,percent of total billed charges,Implant Device,1678.58,34,,1678.58,percent of total billed charges,Implant Device,1678.58,34,,1678.58,percent of total billed charges,Implant Device,1678.58,34,,1678.58,percent of total billed charges,Implant Device,2443.82,,,2443.82,Other,110% of Medicare,1727.95,35,,1727.95,percent of total billed charges,Implant Device,1678.58,34,"Charges > $500, x 34%",1678.58,percent of total billed charges,Implant Device,1727.95,35,,1727.95,percent of total billed charges,Implant Device,1727.95,35,,1727.95,percent of total billed charges,Implant Device,1727.95,35,,1727.95,percent of total billed charges,Implant Device,1727.95,35,,1727.95,percent of total billed charges,Implant Device,1727.95,35,,1727.95,percent of total billed charges,Implant Device,1974.8,40,,1974.8,percent of total billed charges,Implant Device,1727.95,70,,1727.95,percent of total billed charges,All Other,1678.58,34,,1678.58,percent of total billed charges,Implant Device,1678.58,34,,1678.58,percent of total billed charges,Implant Device,1727.95,35,,1727.95,percent of total billed charges,Implant Device,1727.95,35,,1727.95,percent of total billed charges,Implant Device,1727.95,35,,1727.95,percent of total billed charges,Implant Device,1727.95,35,,1727.95,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1678.58,34,"If Charge > 2,000, then 34 percent",1678.58,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3653.39,
STRYKER 5610-F-502 FEMORAL COMP SZ 5,C1776,HCPCS,,79006734,CDM,278,RC,,,both,,,8352,6180.5,,,6180.5,Other,150% of Medicare + 9.63% HCRA Surcharge,3758.4,45,,3758.4,percent of total billed charges,Critical Access Hospital RCC factor,2839.68,34,,2839.68,percent of total billed charges,Implant Device,2839.68,34,,2839.68,percent of total billed charges,Implant Device,2839.68,34,,2839.68,percent of total billed charges,Implant Device,2839.68,34,,2839.68,percent of total billed charges,Implant Device,2839.68,34,,2839.68,percent of total billed charges,Implant Device,4134.24,,,4134.24,Other,110% of Medicare,2923.2,35,,2923.2,percent of total billed charges,Implant Device,2839.68,34,"Charges > $500, x 34%",2839.68,percent of total billed charges,Implant Device,2923.2,35,,2923.2,percent of total billed charges,Implant Device,2923.2,35,,2923.2,percent of total billed charges,Implant Device,2923.2,35,,2923.2,percent of total billed charges,Implant Device,2923.2,35,,2923.2,percent of total billed charges,Implant Device,2923.2,35,,2923.2,percent of total billed charges,Implant Device,3340.8,40,,3340.8,percent of total billed charges,Implant Device,2923.2,70,,2923.2,percent of total billed charges,All Other,2839.68,34,,2839.68,percent of total billed charges,Implant Device,2839.68,34,,2839.68,percent of total billed charges,Implant Device,2923.2,35,,2923.2,percent of total billed charges,Implant Device,2923.2,35,,2923.2,percent of total billed charges,Implant Device,2923.2,35,,2923.2,percent of total billed charges,Implant Device,2923.2,35,,2923.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2839.68,34,"If Charge > 2,000, then 34 percent",2839.68,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,6180.5,
ALPHATEC SPINE 71003-57 PLATE 57MM,C1713,HCPCS,,79006735,CDM,278,RC,,,both,,,3136,2320.65,,,2320.65,Other,150% of Medicare + 9.63% HCRA Surcharge,1411.2,45,,1411.2,percent of total billed charges,Critical Access Hospital RCC factor,1066.24,34,,1066.24,percent of total billed charges,Implant Device,1066.24,34,,1066.24,percent of total billed charges,Implant Device,1066.24,34,,1066.24,percent of total billed charges,Implant Device,1066.24,34,,1066.24,percent of total billed charges,Implant Device,1066.24,34,,1066.24,percent of total billed charges,Implant Device,1552.32,,,1552.32,Other,110% of Medicare,1097.6,35,,1097.6,percent of total billed charges,Implant Device,1066.24,34,"Charges > $500, x 34%",1066.24,percent of total billed charges,Implant Device,1097.6,35,,1097.6,percent of total billed charges,Implant Device,1097.6,35,,1097.6,percent of total billed charges,Implant Device,1097.6,35,,1097.6,percent of total billed charges,Implant Device,1097.6,35,,1097.6,percent of total billed charges,Implant Device,1097.6,35,,1097.6,percent of total billed charges,Implant Device,1254.4,40,,1254.4,percent of total billed charges,Implant Device,1097.6,70,,1097.6,percent of total billed charges,All Other,1066.24,34,,1066.24,percent of total billed charges,Implant Device,1066.24,34,,1066.24,percent of total billed charges,Implant Device,1097.6,35,,1097.6,percent of total billed charges,Implant Device,1097.6,35,,1097.6,percent of total billed charges,Implant Device,1097.6,35,,1097.6,percent of total billed charges,Implant Device,1097.6,35,,1097.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1066.24,34,"If Charge > 2,000, then 34 percent",1066.24,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2320.65,
ARTHREX AR-8931-15 QUICKFIX SCREW 3X15MM,C1713,HCPCS,,79006738,CDM,278,RC,,,both,,,720,532.8,,,532.8,Other,150% of Medicare + 9.63% HCRA Surcharge,324,45,,324,percent of total billed charges,Critical Access Hospital RCC factor,244.8,34,,244.8,percent of total billed charges,Implant Device,244.8,34,,244.8,percent of total billed charges,Implant Device,244.8,34,,244.8,percent of total billed charges,Implant Device,244.8,34,,244.8,percent of total billed charges,Implant Device,244.8,34,,244.8,percent of total billed charges,Implant Device,356.4,,,356.4,Other,110% of Medicare,252,35,,252,percent of total billed charges,Implant Device,244.8,34,"Charges > $500, x 34%",244.8,percent of total billed charges,Implant Device,252,35,,252,percent of total billed charges,Implant Device,252,35,,252,percent of total billed charges,Implant Device,252,35,,252,percent of total billed charges,Implant Device,252,35,,252,percent of total billed charges,Implant Device,252,35,,252,percent of total billed charges,Implant Device,288,40,,288,percent of total billed charges,Implant Device,252,70,,252,percent of total billed charges,All Other,244.8,34,,244.8,percent of total billed charges,Implant Device,244.8,34,,244.8,percent of total billed charges,Implant Device,252,35,,252,percent of total billed charges,Implant Device,252,35,,252,percent of total billed charges,Implant Device,252,35,,252,percent of total billed charges,Implant Device,252,35,,252,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,532.8,
ARTHERX AR-8730-34PT CANN SCREW 3X34MM,C1713,HCPCS,,79006739,CDM,278,RC,,,both,,,450,333,,,333,Other,150% of Medicare + 9.63% HCRA Surcharge,202.5,45,,202.5,percent of total billed charges,Critical Access Hospital RCC factor,153,34,,153,percent of total billed charges,Implant Device,153,34,,153,percent of total billed charges,Implant Device,153,34,,153,percent of total billed charges,Implant Device,153,34,,153,percent of total billed charges,Implant Device,153,34,,153,percent of total billed charges,Implant Device,222.75,,,222.75,Other,110% of Medicare,157.5,35,,157.5,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,157.5,35,,157.5,percent of total billed charges,Implant Device,157.5,35,,157.5,percent of total billed charges,Implant Device,157.5,35,,157.5,percent of total billed charges,Implant Device,157.5,35,,157.5,percent of total billed charges,Implant Device,157.5,35,,157.5,percent of total billed charges,Implant Device,180,40,,180,percent of total billed charges,Implant Device,157.5,70,,157.5,percent of total billed charges,All Other,153,34,,153,percent of total billed charges,Implant Device,153,34,,153,percent of total billed charges,Implant Device,157.5,35,,157.5,percent of total billed charges,Implant Device,157.5,35,,157.5,percent of total billed charges,Implant Device,157.5,35,,157.5,percent of total billed charges,Implant Device,157.5,35,,157.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,333,
EXACTECH 320-15-03 GLENOID PLATE 8 DEG,C1713,HCPCS,,79006740,CDM,278,RC,,,both,,,5925,4384.51,,,4384.51,Other,150% of Medicare + 9.63% HCRA Surcharge,2666.25,45,,2666.25,percent of total billed charges,Critical Access Hospital RCC factor,2014.5,34,,2014.5,percent of total billed charges,Implant Device,2014.5,34,,2014.5,percent of total billed charges,Implant Device,2014.5,34,,2014.5,percent of total billed charges,Implant Device,2014.5,34,,2014.5,percent of total billed charges,Implant Device,2014.5,34,,2014.5,percent of total billed charges,Implant Device,2932.88,,,2932.88,Other,110% of Medicare,2073.75,35,,2073.75,percent of total billed charges,Implant Device,2014.5,34,"Charges > $500, x 34%",2014.5,percent of total billed charges,Implant Device,2073.75,35,,2073.75,percent of total billed charges,Implant Device,2073.75,35,,2073.75,percent of total billed charges,Implant Device,2073.75,35,,2073.75,percent of total billed charges,Implant Device,2073.75,35,,2073.75,percent of total billed charges,Implant Device,2073.75,35,,2073.75,percent of total billed charges,Implant Device,2370,40,,2370,percent of total billed charges,Implant Device,2073.75,70,,2073.75,percent of total billed charges,All Other,2014.5,34,,2014.5,percent of total billed charges,Implant Device,2014.5,34,,2014.5,percent of total billed charges,Implant Device,2073.75,35,,2073.75,percent of total billed charges,Implant Device,2073.75,35,,2073.75,percent of total billed charges,Implant Device,2073.75,35,,2073.75,percent of total billed charges,Implant Device,2073.75,35,,2073.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2014.5,34,"If Charge > 2,000, then 34 percent",2014.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4384.51,
ARTHREX AR-8930-12 QUICKFIX SCREW 2X12MM,C1713,HCPCS,,79006742,CDM,278,RC,,,both,,,720,532.8,,,532.8,Other,150% of Medicare + 9.63% HCRA Surcharge,324,45,,324,percent of total billed charges,Critical Access Hospital RCC factor,244.8,34,,244.8,percent of total billed charges,Implant Device,244.8,34,,244.8,percent of total billed charges,Implant Device,244.8,34,,244.8,percent of total billed charges,Implant Device,244.8,34,,244.8,percent of total billed charges,Implant Device,244.8,34,,244.8,percent of total billed charges,Implant Device,356.4,,,356.4,Other,110% of Medicare,252,35,,252,percent of total billed charges,Implant Device,244.8,34,"Charges > $500, x 34%",244.8,percent of total billed charges,Implant Device,252,35,,252,percent of total billed charges,Implant Device,252,35,,252,percent of total billed charges,Implant Device,252,35,,252,percent of total billed charges,Implant Device,252,35,,252,percent of total billed charges,Implant Device,252,35,,252,percent of total billed charges,Implant Device,288,40,,288,percent of total billed charges,Implant Device,252,70,,252,percent of total billed charges,All Other,244.8,34,,244.8,percent of total billed charges,Implant Device,244.8,34,,244.8,percent of total billed charges,Implant Device,252,35,,252,percent of total billed charges,Implant Device,252,35,,252,percent of total billed charges,Implant Device,252,35,,252,percent of total billed charges,Implant Device,252,35,,252,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,532.8,
ZIMMER 0107Z BIOMEND MEMBRANE 30X40MM,C1713,HCPCS,,79006743,CDM,278,RC,,,both,,,726,537.24,,,537.24,Other,150% of Medicare + 9.63% HCRA Surcharge,326.7,45,,326.7,percent of total billed charges,Critical Access Hospital RCC factor,246.84,34,,246.84,percent of total billed charges,Implant Device,246.84,34,,246.84,percent of total billed charges,Implant Device,246.84,34,,246.84,percent of total billed charges,Implant Device,246.84,34,,246.84,percent of total billed charges,Implant Device,246.84,34,,246.84,percent of total billed charges,Implant Device,359.37,,,359.37,Other,110% of Medicare,254.1,35,,254.1,percent of total billed charges,Implant Device,246.84,34,"Charges > $500, x 34%",246.84,percent of total billed charges,Implant Device,254.1,35,,254.1,percent of total billed charges,Implant Device,254.1,35,,254.1,percent of total billed charges,Implant Device,254.1,35,,254.1,percent of total billed charges,Implant Device,254.1,35,,254.1,percent of total billed charges,Implant Device,254.1,35,,254.1,percent of total billed charges,Implant Device,290.4,40,,290.4,percent of total billed charges,Implant Device,254.1,70,,254.1,percent of total billed charges,All Other,246.84,34,,246.84,percent of total billed charges,Implant Device,246.84,34,,246.84,percent of total billed charges,Implant Device,254.1,35,,254.1,percent of total billed charges,Implant Device,254.1,35,,254.1,percent of total billed charges,Implant Device,254.1,35,,254.1,percent of total billed charges,Implant Device,254.1,35,,254.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,537.24,
ZIMMER 5001-46 BIPOLAR CUP SHELL 46MM OD,C1776,HCPCS,,79006746,CDM,278,RC,,,both,,,960,710.4,,,710.4,Other,150% of Medicare + 9.63% HCRA Surcharge,432,45,,432,percent of total billed charges,Critical Access Hospital RCC factor,326.4,34,,326.4,percent of total billed charges,Implant Device,326.4,34,,326.4,percent of total billed charges,Implant Device,326.4,34,,326.4,percent of total billed charges,Implant Device,326.4,34,,326.4,percent of total billed charges,Implant Device,326.4,34,,326.4,percent of total billed charges,Implant Device,475.2,,,475.2,Other,110% of Medicare,336,35,,336,percent of total billed charges,Implant Device,326.4,34,"Charges > $500, x 34%",326.4,percent of total billed charges,Implant Device,336,35,,336,percent of total billed charges,Implant Device,336,35,,336,percent of total billed charges,Implant Device,336,35,,336,percent of total billed charges,Implant Device,336,35,,336,percent of total billed charges,Implant Device,336,35,,336,percent of total billed charges,Implant Device,384,40,,384,percent of total billed charges,Implant Device,336,70,,336,percent of total billed charges,All Other,326.4,34,,326.4,percent of total billed charges,Implant Device,326.4,34,,326.4,percent of total billed charges,Implant Device,336,35,,336,percent of total billed charges,Implant Device,336,35,,336,percent of total billed charges,Implant Device,336,35,,336,percent of total billed charges,Implant Device,336,35,,336,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,710.4,
STRYKER 5620-B-502 TIBIAL BASEPLATE SZ 5,C1776,HCPCS,,79006747,CDM,278,RC,,,both,,,4937,3653.39,,,3653.39,Other,150% of Medicare + 9.63% HCRA Surcharge,2221.65,45,,2221.65,percent of total billed charges,Critical Access Hospital RCC factor,1678.58,34,,1678.58,percent of total billed charges,Implant Device,1678.58,34,,1678.58,percent of total billed charges,Implant Device,1678.58,34,,1678.58,percent of total billed charges,Implant Device,1678.58,34,,1678.58,percent of total billed charges,Implant Device,1678.58,34,,1678.58,percent of total billed charges,Implant Device,2443.82,,,2443.82,Other,110% of Medicare,1727.95,35,,1727.95,percent of total billed charges,Implant Device,1678.58,34,"Charges > $500, x 34%",1678.58,percent of total billed charges,Implant Device,1727.95,35,,1727.95,percent of total billed charges,Implant Device,1727.95,35,,1727.95,percent of total billed charges,Implant Device,1727.95,35,,1727.95,percent of total billed charges,Implant Device,1727.95,35,,1727.95,percent of total billed charges,Implant Device,1727.95,35,,1727.95,percent of total billed charges,Implant Device,1974.8,40,,1974.8,percent of total billed charges,Implant Device,1727.95,70,,1727.95,percent of total billed charges,All Other,1678.58,34,,1678.58,percent of total billed charges,Implant Device,1678.58,34,,1678.58,percent of total billed charges,Implant Device,1727.95,35,,1727.95,percent of total billed charges,Implant Device,1727.95,35,,1727.95,percent of total billed charges,Implant Device,1727.95,35,,1727.95,percent of total billed charges,Implant Device,1727.95,35,,1727.95,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1678.58,34,"If Charge > 2,000, then 34 percent",1678.58,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3653.39,
STRYKER 5630-G-528 TIBIAL INSRT SZ 5 8MM,C1776,HCPCS,,79006748,CDM,278,RC,,,both,,,3232,2391.69,,,2391.69,Other,150% of Medicare + 9.63% HCRA Surcharge,1454.4,45,,1454.4,percent of total billed charges,Critical Access Hospital RCC factor,1098.88,34,,1098.88,percent of total billed charges,Implant Device,1098.88,34,,1098.88,percent of total billed charges,Implant Device,1098.88,34,,1098.88,percent of total billed charges,Implant Device,1098.88,34,,1098.88,percent of total billed charges,Implant Device,1098.88,34,,1098.88,percent of total billed charges,Implant Device,1599.84,,,1599.84,Other,110% of Medicare,1131.2,35,,1131.2,percent of total billed charges,Implant Device,1098.88,34,"Charges > $500, x 34%",1098.88,percent of total billed charges,Implant Device,1131.2,35,,1131.2,percent of total billed charges,Implant Device,1131.2,35,,1131.2,percent of total billed charges,Implant Device,1131.2,35,,1131.2,percent of total billed charges,Implant Device,1131.2,35,,1131.2,percent of total billed charges,Implant Device,1131.2,35,,1131.2,percent of total billed charges,Implant Device,1292.8,40,,1292.8,percent of total billed charges,Implant Device,1131.2,70,,1131.2,percent of total billed charges,All Other,1098.88,34,,1098.88,percent of total billed charges,Implant Device,1098.88,34,,1098.88,percent of total billed charges,Implant Device,1131.2,35,,1131.2,percent of total billed charges,Implant Device,1131.2,35,,1131.2,percent of total billed charges,Implant Device,1131.2,35,,1131.2,percent of total billed charges,Implant Device,1131.2,35,,1131.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1098.88,34,"If Charge > 2,000, then 34 percent",1098.88,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2391.69,
ZIMMER 187-01-69 PIN SMOOTH K WIRE 5/64,C1713,HCPCS,,79006749,CDM,278,RC,,,both,,,24,17.76,,,17.76,Other,150% of Medicare + 9.63% HCRA Surcharge,10.8,45,,10.8,percent of total billed charges,Critical Access Hospital RCC factor,8.16,34,,8.16,percent of total billed charges,Implant Device,8.16,34,,8.16,percent of total billed charges,Implant Device,8.16,34,,8.16,percent of total billed charges,Implant Device,8.16,34,,8.16,percent of total billed charges,Implant Device,8.16,34,,8.16,percent of total billed charges,Implant Device,11.88,,,11.88,Other,110% of Medicare,8.4,35,,8.4,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,8.4,35,,8.4,percent of total billed charges,Implant Device,8.4,35,,8.4,percent of total billed charges,Implant Device,8.4,35,,8.4,percent of total billed charges,Implant Device,8.4,35,,8.4,percent of total billed charges,Implant Device,8.4,35,,8.4,percent of total billed charges,Implant Device,9.6,40,,9.6,percent of total billed charges,Implant Device,8.4,70,,8.4,percent of total billed charges,All Other,8.16,34,,8.16,percent of total billed charges,Implant Device,8.16,34,,8.16,percent of total billed charges,Implant Device,8.4,35,,8.4,percent of total billed charges,Implant Device,8.4,35,,8.4,percent of total billed charges,Implant Device,8.4,35,,8.4,percent of total billed charges,Implant Device,8.4,35,,8.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,17.76,
ARTHREX AR-8935-26 CORTICAL SCREW 3.5X26,C1713,HCPCS,,79006750,CDM,278,RC,,,both,,,258,190.92,,,190.92,Other,150% of Medicare + 9.63% HCRA Surcharge,116.1,45,,116.1,percent of total billed charges,Critical Access Hospital RCC factor,87.72,34,,87.72,percent of total billed charges,Implant Device,87.72,34,,87.72,percent of total billed charges,Implant Device,87.72,34,,87.72,percent of total billed charges,Implant Device,87.72,34,,87.72,percent of total billed charges,Implant Device,87.72,34,,87.72,percent of total billed charges,Implant Device,127.71,,,127.71,Other,110% of Medicare,90.3,35,,90.3,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,90.3,35,,90.3,percent of total billed charges,Implant Device,90.3,35,,90.3,percent of total billed charges,Implant Device,90.3,35,,90.3,percent of total billed charges,Implant Device,90.3,35,,90.3,percent of total billed charges,Implant Device,90.3,35,,90.3,percent of total billed charges,Implant Device,103.2,40,,103.2,percent of total billed charges,Implant Device,90.3,70,,90.3,percent of total billed charges,All Other,87.72,34,,87.72,percent of total billed charges,Implant Device,87.72,34,,87.72,percent of total billed charges,Implant Device,90.3,35,,90.3,percent of total billed charges,Implant Device,90.3,35,,90.3,percent of total billed charges,Implant Device,90.3,35,,90.3,percent of total billed charges,Implant Device,90.3,35,,90.3,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,190.92,
ARTHREX AR-8935L-26 LOCKING SCREW 3.5X26,C1713,HCPCS,,79006751,CDM,278,RC,,,both,,,645,477.3,,,477.3,Other,150% of Medicare + 9.63% HCRA Surcharge,290.25,45,,290.25,percent of total billed charges,Critical Access Hospital RCC factor,219.3,34,,219.3,percent of total billed charges,Implant Device,219.3,34,,219.3,percent of total billed charges,Implant Device,219.3,34,,219.3,percent of total billed charges,Implant Device,219.3,34,,219.3,percent of total billed charges,Implant Device,219.3,34,,219.3,percent of total billed charges,Implant Device,319.28,,,319.28,Other,110% of Medicare,225.75,35,,225.75,percent of total billed charges,Implant Device,219.3,34,"Charges > $500, x 34%",219.3,percent of total billed charges,Implant Device,225.75,35,,225.75,percent of total billed charges,Implant Device,225.75,35,,225.75,percent of total billed charges,Implant Device,225.75,35,,225.75,percent of total billed charges,Implant Device,225.75,35,,225.75,percent of total billed charges,Implant Device,225.75,35,,225.75,percent of total billed charges,Implant Device,258,40,,258,percent of total billed charges,Implant Device,225.75,70,,225.75,percent of total billed charges,All Other,219.3,34,,219.3,percent of total billed charges,Implant Device,219.3,34,,219.3,percent of total billed charges,Implant Device,225.75,35,,225.75,percent of total billed charges,Implant Device,225.75,35,,225.75,percent of total billed charges,Implant Device,225.75,35,,225.75,percent of total billed charges,Implant Device,225.75,35,,225.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,477.3,
EXACTECH 310-03-50 HUMERAL HEAD 50X27MM,C1776,HCPCS,,79006754,CDM,278,RC,,,both,,,4968,3676.33,,,3676.33,Other,150% of Medicare + 9.63% HCRA Surcharge,2235.6,45,,2235.6,percent of total billed charges,Critical Access Hospital RCC factor,1689.12,34,,1689.12,percent of total billed charges,Implant Device,1689.12,34,,1689.12,percent of total billed charges,Implant Device,1689.12,34,,1689.12,percent of total billed charges,Implant Device,1689.12,34,,1689.12,percent of total billed charges,Implant Device,1689.12,34,,1689.12,percent of total billed charges,Implant Device,2459.16,,,2459.16,Other,110% of Medicare,1738.8,35,,1738.8,percent of total billed charges,Implant Device,1689.12,34,"Charges > $500, x 34%",1689.12,percent of total billed charges,Implant Device,1738.8,35,,1738.8,percent of total billed charges,Implant Device,1738.8,35,,1738.8,percent of total billed charges,Implant Device,1738.8,35,,1738.8,percent of total billed charges,Implant Device,1738.8,35,,1738.8,percent of total billed charges,Implant Device,1738.8,35,,1738.8,percent of total billed charges,Implant Device,1987.2,40,,1987.2,percent of total billed charges,Implant Device,1738.8,70,,1738.8,percent of total billed charges,All Other,1689.12,34,,1689.12,percent of total billed charges,Implant Device,1689.12,34,,1689.12,percent of total billed charges,Implant Device,1738.8,35,,1738.8,percent of total billed charges,Implant Device,1738.8,35,,1738.8,percent of total billed charges,Implant Device,1738.8,35,,1738.8,percent of total billed charges,Implant Device,1738.8,35,,1738.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1689.12,34,"If Charge > 2,000, then 34 percent",1689.12,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3676.33,
ZIMMER 187-02-69 PIN SMOOTH K WIRE 3/32,C1713,HCPCS,,79006755,CDM,278,RC,,,both,,,20,14.8,,,14.8,Other,150% of Medicare + 9.63% HCRA Surcharge,9,45,,9,percent of total billed charges,Critical Access Hospital RCC factor,6.8,34,,6.8,percent of total billed charges,Implant Device,6.8,34,,6.8,percent of total billed charges,Implant Device,6.8,34,,6.8,percent of total billed charges,Implant Device,6.8,34,,6.8,percent of total billed charges,Implant Device,6.8,34,,6.8,percent of total billed charges,Implant Device,9.9,,,9.9,Other,110% of Medicare,7,35,,7,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,7,35,,7,percent of total billed charges,Implant Device,7,35,,7,percent of total billed charges,Implant Device,7,35,,7,percent of total billed charges,Implant Device,7,35,,7,percent of total billed charges,Implant Device,7,35,,7,percent of total billed charges,Implant Device,8,40,,8,percent of total billed charges,Implant Device,7,70,,7,percent of total billed charges,All Other,6.8,34,,6.8,percent of total billed charges,Implant Device,6.8,34,,6.8,percent of total billed charges,Implant Device,7,35,,7,percent of total billed charges,Implant Device,7,35,,7,percent of total billed charges,Implant Device,7,35,,7,percent of total billed charges,Implant Device,7,35,,7,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,14.8,
ARTHREX AR-8942R-L PLATE LARGE H RIGHT,C1713,HCPCS,,79006756,CDM,278,RC,,,both,,,1800,1332,,,1332,Other,150% of Medicare + 9.63% HCRA Surcharge,810,45,,810,percent of total billed charges,Critical Access Hospital RCC factor,612,34,,612,percent of total billed charges,Implant Device,612,34,,612,percent of total billed charges,Implant Device,612,34,,612,percent of total billed charges,Implant Device,612,34,,612,percent of total billed charges,Implant Device,612,34,,612,percent of total billed charges,Implant Device,891,,,891,Other,110% of Medicare,630,35,,630,percent of total billed charges,Implant Device,612,34,"Charges > $500, x 34%",612,percent of total billed charges,Implant Device,630,35,,630,percent of total billed charges,Implant Device,630,35,,630,percent of total billed charges,Implant Device,630,35,,630,percent of total billed charges,Implant Device,630,35,,630,percent of total billed charges,Implant Device,630,35,,630,percent of total billed charges,Implant Device,720,40,,720,percent of total billed charges,Implant Device,630,70,,630,percent of total billed charges,All Other,612,34,,612,percent of total billed charges,Implant Device,612,34,,612,percent of total billed charges,Implant Device,630,35,,630,percent of total billed charges,Implant Device,630,35,,630,percent of total billed charges,Implant Device,630,35,,630,percent of total billed charges,Implant Device,630,35,,630,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1332,
DEPUY 1100-08-100 GLOBE UNITE STEM SZ 8,C1776,HCPCS,,79006757,CDM,278,RC,,,both,,,9828,7272.74,,,7272.74,Other,150% of Medicare + 9.63% HCRA Surcharge,4422.6,45,,4422.6,percent of total billed charges,Critical Access Hospital RCC factor,3341.52,34,,3341.52,percent of total billed charges,Implant Device,3341.52,34,,3341.52,percent of total billed charges,Implant Device,3341.52,34,,3341.52,percent of total billed charges,Implant Device,3341.52,34,,3341.52,percent of total billed charges,Implant Device,3341.52,34,,3341.52,percent of total billed charges,Implant Device,4864.86,,,4864.86,Other,110% of Medicare,3439.8,35,,3439.8,percent of total billed charges,Implant Device,3341.52,34,"Charges > $500, x 34%",3341.52,percent of total billed charges,Implant Device,3439.8,35,,3439.8,percent of total billed charges,Implant Device,3439.8,35,,3439.8,percent of total billed charges,Implant Device,3439.8,35,,3439.8,percent of total billed charges,Implant Device,3439.8,35,,3439.8,percent of total billed charges,Implant Device,3439.8,35,,3439.8,percent of total billed charges,Implant Device,3931.2,40,,3931.2,percent of total billed charges,Implant Device,3439.8,70,,3439.8,percent of total billed charges,All Other,3341.52,34,,3341.52,percent of total billed charges,Implant Device,3341.52,34,,3341.52,percent of total billed charges,Implant Device,3439.8,35,,3439.8,percent of total billed charges,Implant Device,3439.8,35,,3439.8,percent of total billed charges,Implant Device,3439.8,35,,3439.8,percent of total billed charges,Implant Device,3439.8,35,,3439.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3341.52,34,"If Charge > 2,000, then 34 percent",3341.52,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,7272.74,
DEPUY 1100-20-200 GLOBE UNTE COLLAR SZ44,C1776,HCPCS,,79006758,CDM,278,RC,,,both,,,2250,1665.01,,,1665.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1012.5,45,,1012.5,percent of total billed charges,Critical Access Hospital RCC factor,765,34,,765,percent of total billed charges,Implant Device,765,34,,765,percent of total billed charges,Implant Device,765,34,,765,percent of total billed charges,Implant Device,765,34,,765,percent of total billed charges,Implant Device,765,34,,765,percent of total billed charges,Implant Device,1113.75,,,1113.75,Other,110% of Medicare,787.5,35,,787.5,percent of total billed charges,Implant Device,765,34,"Charges > $500, x 34%",765,percent of total billed charges,Implant Device,787.5,35,,787.5,percent of total billed charges,Implant Device,787.5,35,,787.5,percent of total billed charges,Implant Device,787.5,35,,787.5,percent of total billed charges,Implant Device,787.5,35,,787.5,percent of total billed charges,Implant Device,787.5,35,,787.5,percent of total billed charges,Implant Device,900,40,,900,percent of total billed charges,Implant Device,787.5,70,,787.5,percent of total billed charges,All Other,765,34,,765,percent of total billed charges,Implant Device,765,34,,765,percent of total billed charges,Implant Device,787.5,35,,787.5,percent of total billed charges,Implant Device,787.5,35,,787.5,percent of total billed charges,Implant Device,787.5,35,,787.5,percent of total billed charges,Implant Device,787.5,35,,787.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,765,34,"If Charge > 2,000, then 34 percent",765,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1665.01,
DEPUY 1100-30-110 GLOBE UNITE BODY SZ10,C1776,HCPCS,,79006759,CDM,278,RC,,,both,,,4474,3310.77,,,3310.77,Other,150% of Medicare + 9.63% HCRA Surcharge,2013.3,45,,2013.3,percent of total billed charges,Critical Access Hospital RCC factor,1521.16,34,,1521.16,percent of total billed charges,Implant Device,1521.16,34,,1521.16,percent of total billed charges,Implant Device,1521.16,34,,1521.16,percent of total billed charges,Implant Device,1521.16,34,,1521.16,percent of total billed charges,Implant Device,1521.16,34,,1521.16,percent of total billed charges,Implant Device,2214.63,,,2214.63,Other,110% of Medicare,1565.9,35,,1565.9,percent of total billed charges,Implant Device,1521.16,34,"Charges > $500, x 34%",1521.16,percent of total billed charges,Implant Device,1565.9,35,,1565.9,percent of total billed charges,Implant Device,1565.9,35,,1565.9,percent of total billed charges,Implant Device,1565.9,35,,1565.9,percent of total billed charges,Implant Device,1565.9,35,,1565.9,percent of total billed charges,Implant Device,1565.9,35,,1565.9,percent of total billed charges,Implant Device,1789.6,40,,1789.6,percent of total billed charges,Implant Device,1565.9,70,,1565.9,percent of total billed charges,All Other,1521.16,34,,1521.16,percent of total billed charges,Implant Device,1521.16,34,,1521.16,percent of total billed charges,Implant Device,1565.9,35,,1565.9,percent of total billed charges,Implant Device,1565.9,35,,1565.9,percent of total billed charges,Implant Device,1565.9,35,,1565.9,percent of total billed charges,Implant Device,1565.9,35,,1565.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1521.16,34,"If Charge > 2,000, then 34 percent",1521.16,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3310.77,
DEPUY 1100-44-510 GLOBE UNITE HEAD 44X18,C1776,HCPCS,,79006760,CDM,278,RC,,,both,,,6442,4767.1,,,4767.1,Other,150% of Medicare + 9.63% HCRA Surcharge,2898.9,45,,2898.9,percent of total billed charges,Critical Access Hospital RCC factor,2190.28,34,,2190.28,percent of total billed charges,Implant Device,2190.28,34,,2190.28,percent of total billed charges,Implant Device,2190.28,34,,2190.28,percent of total billed charges,Implant Device,2190.28,34,,2190.28,percent of total billed charges,Implant Device,2190.28,34,,2190.28,percent of total billed charges,Implant Device,3188.79,,,3188.79,Other,110% of Medicare,2254.7,35,,2254.7,percent of total billed charges,Implant Device,2190.28,34,"Charges > $500, x 34%",2190.28,percent of total billed charges,Implant Device,2254.7,35,,2254.7,percent of total billed charges,Implant Device,2254.7,35,,2254.7,percent of total billed charges,Implant Device,2254.7,35,,2254.7,percent of total billed charges,Implant Device,2254.7,35,,2254.7,percent of total billed charges,Implant Device,2254.7,35,,2254.7,percent of total billed charges,Implant Device,2576.8,40,,2576.8,percent of total billed charges,Implant Device,2254.7,70,,2254.7,percent of total billed charges,All Other,2190.28,34,,2190.28,percent of total billed charges,Implant Device,2190.28,34,,2190.28,percent of total billed charges,Implant Device,2254.7,35,,2254.7,percent of total billed charges,Implant Device,2254.7,35,,2254.7,percent of total billed charges,Implant Device,2254.7,35,,2254.7,percent of total billed charges,Implant Device,2254.7,35,,2254.7,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2190.28,34,"If Charge > 2,000, then 34 percent",2190.28,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4767.1,
LIFESPINE 132-308-1 ALLERON SM CORE GEN3,C1713,HCPCS,,79006762,CDM,278,RC,,,both,,,20640,15273.65,,,15273.65,Other,150% of Medicare + 9.63% HCRA Surcharge,9288,45,,9288,percent of total billed charges,Critical Access Hospital RCC factor,7017.6,34,,7017.6,percent of total billed charges,Implant Device,7017.6,34,,7017.6,percent of total billed charges,Implant Device,7017.6,34,,7017.6,percent of total billed charges,Implant Device,7017.6,34,,7017.6,percent of total billed charges,Implant Device,7017.6,34,,7017.6,percent of total billed charges,Implant Device,10216.8,,,10216.8,Other,110% of Medicare,7224,35,,7224,percent of total billed charges,Implant Device,7017.6,34,"Charges > $500, x 34%",7017.6,percent of total billed charges,Implant Device,7224,35,,7224,percent of total billed charges,Implant Device,7224,35,,7224,percent of total billed charges,Implant Device,7224,35,,7224,percent of total billed charges,Implant Device,7224,35,,7224,percent of total billed charges,Implant Device,7224,35,,7224,percent of total billed charges,Implant Device,8256,40,,8256,percent of total billed charges,Implant Device,7224,70,,7224,percent of total billed charges,All Other,7017.6,34,,7017.6,percent of total billed charges,Implant Device,7017.6,34,,7017.6,percent of total billed charges,Implant Device,7224,35,,7224,percent of total billed charges,Implant Device,7224,35,,7224,percent of total billed charges,Implant Device,7224,35,,7224,percent of total billed charges,Implant Device,7224,35,,7224,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,7017.6,34,"If Charge > 2,000, then 34 percent",7017.6,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,15273.65,
LIFESPINE 132-308-2 ALLERON SM PLTE GEN3,C1713,HCPCS,,79006763,CDM,278,RC,,,both,,,13680,10123.23,,,10123.23,Other,150% of Medicare + 9.63% HCRA Surcharge,6156,45,,6156,percent of total billed charges,Critical Access Hospital RCC factor,4651.2,34,,4651.2,percent of total billed charges,Implant Device,4651.2,34,,4651.2,percent of total billed charges,Implant Device,4651.2,34,,4651.2,percent of total billed charges,Implant Device,4651.2,34,,4651.2,percent of total billed charges,Implant Device,4651.2,34,,4651.2,percent of total billed charges,Implant Device,6771.6,,,6771.6,Other,110% of Medicare,4788,35,,4788,percent of total billed charges,Implant Device,4651.2,34,"Charges > $500, x 34%",4651.2,percent of total billed charges,Implant Device,4788,35,,4788,percent of total billed charges,Implant Device,4788,35,,4788,percent of total billed charges,Implant Device,4788,35,,4788,percent of total billed charges,Implant Device,4788,35,,4788,percent of total billed charges,Implant Device,4788,35,,4788,percent of total billed charges,Implant Device,5472,40,,5472,percent of total billed charges,Implant Device,4788,70,,4788,percent of total billed charges,All Other,4651.2,34,,4651.2,percent of total billed charges,Implant Device,4651.2,34,,4651.2,percent of total billed charges,Implant Device,4788,35,,4788,percent of total billed charges,Implant Device,4788,35,,4788,percent of total billed charges,Implant Device,4788,35,,4788,percent of total billed charges,Implant Device,4788,35,,4788,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,4651.2,34,"If Charge > 2,000, then 34 percent",4651.2,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,10123.23,
STRYKER 5610-F-602 FEM COMPONENT SZ 6,C1776,HCPCS,,79006764,CDM,278,RC,,,both,,,8352,6180.5,,,6180.5,Other,150% of Medicare + 9.63% HCRA Surcharge,3758.4,45,,3758.4,percent of total billed charges,Critical Access Hospital RCC factor,2839.68,34,,2839.68,percent of total billed charges,Implant Device,2839.68,34,,2839.68,percent of total billed charges,Implant Device,2839.68,34,,2839.68,percent of total billed charges,Implant Device,2839.68,34,,2839.68,percent of total billed charges,Implant Device,2839.68,34,,2839.68,percent of total billed charges,Implant Device,4134.24,,,4134.24,Other,110% of Medicare,2923.2,35,,2923.2,percent of total billed charges,Implant Device,2839.68,34,"Charges > $500, x 34%",2839.68,percent of total billed charges,Implant Device,2923.2,35,,2923.2,percent of total billed charges,Implant Device,2923.2,35,,2923.2,percent of total billed charges,Implant Device,2923.2,35,,2923.2,percent of total billed charges,Implant Device,2923.2,35,,2923.2,percent of total billed charges,Implant Device,2923.2,35,,2923.2,percent of total billed charges,Implant Device,3340.8,40,,3340.8,percent of total billed charges,Implant Device,2923.2,70,,2923.2,percent of total billed charges,All Other,2839.68,34,,2839.68,percent of total billed charges,Implant Device,2839.68,34,,2839.68,percent of total billed charges,Implant Device,2923.2,35,,2923.2,percent of total billed charges,Implant Device,2923.2,35,,2923.2,percent of total billed charges,Implant Device,2923.2,35,,2923.2,percent of total billed charges,Implant Device,2923.2,35,,2923.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2839.68,34,"If Charge > 2,000, then 34 percent",2839.68,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,6180.5,
STRYKER 5620-B-602 TIBIAL BASEPLATE SZ 6,C1776,HCPCS,,79006765,CDM,278,RC,,,both,,,4937,3653.39,,,3653.39,Other,150% of Medicare + 9.63% HCRA Surcharge,2221.65,45,,2221.65,percent of total billed charges,Critical Access Hospital RCC factor,1678.58,34,,1678.58,percent of total billed charges,Implant Device,1678.58,34,,1678.58,percent of total billed charges,Implant Device,1678.58,34,,1678.58,percent of total billed charges,Implant Device,1678.58,34,,1678.58,percent of total billed charges,Implant Device,1678.58,34,,1678.58,percent of total billed charges,Implant Device,2443.82,,,2443.82,Other,110% of Medicare,1727.95,35,,1727.95,percent of total billed charges,Implant Device,1678.58,34,"Charges > $500, x 34%",1678.58,percent of total billed charges,Implant Device,1727.95,35,,1727.95,percent of total billed charges,Implant Device,1727.95,35,,1727.95,percent of total billed charges,Implant Device,1727.95,35,,1727.95,percent of total billed charges,Implant Device,1727.95,35,,1727.95,percent of total billed charges,Implant Device,1727.95,35,,1727.95,percent of total billed charges,Implant Device,1974.8,40,,1974.8,percent of total billed charges,Implant Device,1727.95,70,,1727.95,percent of total billed charges,All Other,1678.58,34,,1678.58,percent of total billed charges,Implant Device,1678.58,34,,1678.58,percent of total billed charges,Implant Device,1727.95,35,,1727.95,percent of total billed charges,Implant Device,1727.95,35,,1727.95,percent of total billed charges,Implant Device,1727.95,35,,1727.95,percent of total billed charges,Implant Device,1727.95,35,,1727.95,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1678.58,34,"If Charge > 2,000, then 34 percent",1678.58,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3653.39,
STRYKER 5630-G-628 TIBIAL INSRT SZ 6X8MM,C1776,HCPCS,,79006766,CDM,278,RC,,,both,,,3232,2391.69,,,2391.69,Other,150% of Medicare + 9.63% HCRA Surcharge,1454.4,45,,1454.4,percent of total billed charges,Critical Access Hospital RCC factor,1098.88,34,,1098.88,percent of total billed charges,Implant Device,1098.88,34,,1098.88,percent of total billed charges,Implant Device,1098.88,34,,1098.88,percent of total billed charges,Implant Device,1098.88,34,,1098.88,percent of total billed charges,Implant Device,1098.88,34,,1098.88,percent of total billed charges,Implant Device,1599.84,,,1599.84,Other,110% of Medicare,1131.2,35,,1131.2,percent of total billed charges,Implant Device,1098.88,34,"Charges > $500, x 34%",1098.88,percent of total billed charges,Implant Device,1131.2,35,,1131.2,percent of total billed charges,Implant Device,1131.2,35,,1131.2,percent of total billed charges,Implant Device,1131.2,35,,1131.2,percent of total billed charges,Implant Device,1131.2,35,,1131.2,percent of total billed charges,Implant Device,1131.2,35,,1131.2,percent of total billed charges,Implant Device,1292.8,40,,1292.8,percent of total billed charges,Implant Device,1131.2,70,,1131.2,percent of total billed charges,All Other,1098.88,34,,1098.88,percent of total billed charges,Implant Device,1098.88,34,,1098.88,percent of total billed charges,Implant Device,1131.2,35,,1131.2,percent of total billed charges,Implant Device,1131.2,35,,1131.2,percent of total billed charges,Implant Device,1131.2,35,,1131.2,percent of total billed charges,Implant Device,1131.2,35,,1131.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1098.88,34,"If Charge > 2,000, then 34 percent",1098.88,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2391.69,
ZIMMER 00-8752-015-36 EL RIM LINER 36X62,C1776,HCPCS,,79006769,CDM,278,RC,,,both,,,4973,3680.03,,,3680.03,Other,150% of Medicare + 9.63% HCRA Surcharge,2237.85,45,,2237.85,percent of total billed charges,Critical Access Hospital RCC factor,1690.82,34,,1690.82,percent of total billed charges,Implant Device,1690.82,34,,1690.82,percent of total billed charges,Implant Device,1690.82,34,,1690.82,percent of total billed charges,Implant Device,1690.82,34,,1690.82,percent of total billed charges,Implant Device,1690.82,34,,1690.82,percent of total billed charges,Implant Device,2461.64,,,2461.64,Other,110% of Medicare,1740.55,35,,1740.55,percent of total billed charges,Implant Device,1690.82,34,"Charges > $500, x 34%",1690.82,percent of total billed charges,Implant Device,1740.55,35,,1740.55,percent of total billed charges,Implant Device,1740.55,35,,1740.55,percent of total billed charges,Implant Device,1740.55,35,,1740.55,percent of total billed charges,Implant Device,1740.55,35,,1740.55,percent of total billed charges,Implant Device,1740.55,35,,1740.55,percent of total billed charges,Implant Device,1989.2,40,,1989.2,percent of total billed charges,Implant Device,1740.55,70,,1740.55,percent of total billed charges,All Other,1690.82,34,,1690.82,percent of total billed charges,Implant Device,1690.82,34,,1690.82,percent of total billed charges,Implant Device,1740.55,35,,1740.55,percent of total billed charges,Implant Device,1740.55,35,,1740.55,percent of total billed charges,Implant Device,1740.55,35,,1740.55,percent of total billed charges,Implant Device,1740.55,35,,1740.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1690.82,34,"If Charge > 2,000, then 34 percent",1690.82,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3680.03,
ZIMMER 00-8757-062-01 TRAB METL SHELL 62,C1776,HCPCS,,79006770,CDM,278,RC,,,both,,,3450,2553.01,,,2553.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1552.5,45,,1552.5,percent of total billed charges,Critical Access Hospital RCC factor,1173,34,,1173,percent of total billed charges,Implant Device,1173,34,,1173,percent of total billed charges,Implant Device,1173,34,,1173,percent of total billed charges,Implant Device,1173,34,,1173,percent of total billed charges,Implant Device,1173,34,,1173,percent of total billed charges,Implant Device,1707.75,,,1707.75,Other,110% of Medicare,1207.5,35,,1207.5,percent of total billed charges,Implant Device,1173,34,"Charges > $500, x 34%",1173,percent of total billed charges,Implant Device,1207.5,35,,1207.5,percent of total billed charges,Implant Device,1207.5,35,,1207.5,percent of total billed charges,Implant Device,1207.5,35,,1207.5,percent of total billed charges,Implant Device,1207.5,35,,1207.5,percent of total billed charges,Implant Device,1207.5,35,,1207.5,percent of total billed charges,Implant Device,1380,40,,1380,percent of total billed charges,Implant Device,1207.5,70,,1207.5,percent of total billed charges,All Other,1173,34,,1173,percent of total billed charges,Implant Device,1173,34,,1173,percent of total billed charges,Implant Device,1207.5,35,,1207.5,percent of total billed charges,Implant Device,1207.5,35,,1207.5,percent of total billed charges,Implant Device,1207.5,35,,1207.5,percent of total billed charges,Implant Device,1207.5,35,,1207.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1173,34,"If Charge > 2,000, then 34 percent",1173,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2553.01,
S&N 128694 STAPLE FIXATION LONG LEG MED,C1713,HCPCS,,79006773,CDM,278,RC,,,both,,,410,303.4,,,303.4,Other,150% of Medicare + 9.63% HCRA Surcharge,184.5,45,,184.5,percent of total billed charges,Critical Access Hospital RCC factor,139.4,34,,139.4,percent of total billed charges,Implant Device,139.4,34,,139.4,percent of total billed charges,Implant Device,139.4,34,,139.4,percent of total billed charges,Implant Device,139.4,34,,139.4,percent of total billed charges,Implant Device,139.4,34,,139.4,percent of total billed charges,Implant Device,202.95,,,202.95,Other,110% of Medicare,143.5,35,,143.5,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,143.5,35,,143.5,percent of total billed charges,Implant Device,143.5,35,,143.5,percent of total billed charges,Implant Device,143.5,35,,143.5,percent of total billed charges,Implant Device,143.5,35,,143.5,percent of total billed charges,Implant Device,143.5,35,,143.5,percent of total billed charges,Implant Device,164,40,,164,percent of total billed charges,Implant Device,143.5,70,,143.5,percent of total billed charges,All Other,139.4,34,,139.4,percent of total billed charges,Implant Device,139.4,34,,139.4,percent of total billed charges,Implant Device,143.5,35,,143.5,percent of total billed charges,Implant Device,143.5,35,,143.5,percent of total billed charges,Implant Device,143.5,35,,143.5,percent of total billed charges,Implant Device,143.5,35,,143.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,303.4,
ARTHREX AR-1370C BIOCOMP INTR SCREW 7X23,C1713,HCPCS,,79006774,CDM,278,RC,,,both,,,705,521.7,,,521.7,Other,150% of Medicare + 9.63% HCRA Surcharge,317.25,45,,317.25,percent of total billed charges,Critical Access Hospital RCC factor,239.7,34,,239.7,percent of total billed charges,Implant Device,239.7,34,,239.7,percent of total billed charges,Implant Device,239.7,34,,239.7,percent of total billed charges,Implant Device,239.7,34,,239.7,percent of total billed charges,Implant Device,239.7,34,,239.7,percent of total billed charges,Implant Device,348.98,,,348.98,Other,110% of Medicare,246.75,35,,246.75,percent of total billed charges,Implant Device,239.7,34,"Charges > $500, x 34%",239.7,percent of total billed charges,Implant Device,246.75,35,,246.75,percent of total billed charges,Implant Device,246.75,35,,246.75,percent of total billed charges,Implant Device,246.75,35,,246.75,percent of total billed charges,Implant Device,246.75,35,,246.75,percent of total billed charges,Implant Device,246.75,35,,246.75,percent of total billed charges,Implant Device,282,40,,282,percent of total billed charges,Implant Device,246.75,70,,246.75,percent of total billed charges,All Other,239.7,34,,239.7,percent of total billed charges,Implant Device,239.7,34,,239.7,percent of total billed charges,Implant Device,246.75,35,,246.75,percent of total billed charges,Implant Device,246.75,35,,246.75,percent of total billed charges,Implant Device,246.75,35,,246.75,percent of total billed charges,Implant Device,246.75,35,,246.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,521.7,
STRYKER 6276-7-219 RM HIP SYSTEM 195X19,C1776,HCPCS,,79006775,CDM,278,RC,,,both,,,9569,7081.08,,,7081.08,Other,150% of Medicare + 9.63% HCRA Surcharge,4306.05,45,,4306.05,percent of total billed charges,Critical Access Hospital RCC factor,3253.46,34,,3253.46,percent of total billed charges,Implant Device,3253.46,34,,3253.46,percent of total billed charges,Implant Device,3253.46,34,,3253.46,percent of total billed charges,Implant Device,3253.46,34,,3253.46,percent of total billed charges,Implant Device,3253.46,34,,3253.46,percent of total billed charges,Implant Device,4736.66,,,4736.66,Other,110% of Medicare,3349.15,35,,3349.15,percent of total billed charges,Implant Device,3253.46,34,"Charges > $500, x 34%",3253.46,percent of total billed charges,Implant Device,3349.15,35,,3349.15,percent of total billed charges,Implant Device,3349.15,35,,3349.15,percent of total billed charges,Implant Device,3349.15,35,,3349.15,percent of total billed charges,Implant Device,3349.15,35,,3349.15,percent of total billed charges,Implant Device,3349.15,35,,3349.15,percent of total billed charges,Implant Device,3827.6,40,,3827.6,percent of total billed charges,Implant Device,3349.15,70,,3349.15,percent of total billed charges,All Other,3253.46,34,,3253.46,percent of total billed charges,Implant Device,3253.46,34,,3253.46,percent of total billed charges,Implant Device,3349.15,35,,3349.15,percent of total billed charges,Implant Device,3349.15,35,,3349.15,percent of total billed charges,Implant Device,3349.15,35,,3349.15,percent of total billed charges,Implant Device,3349.15,35,,3349.15,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3253.46,34,"If Charge > 2,000, then 34 percent",3253.46,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,7081.08,
ARTHREX AR-8943T-10 PLATE TUBULAR 10HOLE,C1713,HCPCS,,79006778,CDM,278,RC,,,both,,,1200,888,,,888,Other,150% of Medicare + 9.63% HCRA Surcharge,540,45,,540,percent of total billed charges,Critical Access Hospital RCC factor,408,34,,408,percent of total billed charges,Implant Device,408,34,,408,percent of total billed charges,Implant Device,408,34,,408,percent of total billed charges,Implant Device,408,34,,408,percent of total billed charges,Implant Device,408,34,,408,percent of total billed charges,Implant Device,594,,,594,Other,110% of Medicare,420,35,,420,percent of total billed charges,Implant Device,408,34,"Charges > $500, x 34%",408,percent of total billed charges,Implant Device,420,35,,420,percent of total billed charges,Implant Device,420,35,,420,percent of total billed charges,Implant Device,420,35,,420,percent of total billed charges,Implant Device,420,35,,420,percent of total billed charges,Implant Device,420,35,,420,percent of total billed charges,Implant Device,480,40,,480,percent of total billed charges,Implant Device,420,70,,420,percent of total billed charges,All Other,408,34,,408,percent of total billed charges,Implant Device,408,34,,408,percent of total billed charges,Implant Device,420,35,,420,percent of total billed charges,Implant Device,420,35,,420,percent of total billed charges,Implant Device,420,35,,420,percent of total billed charges,Implant Device,420,35,,420,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,888,
ZIMMER 02-03150-034 CORTCAL SCREW 5X34MM,C1713,HCPCS,,79006779,CDM,278,RC,,,both,,,508,375.92,,,375.92,Other,150% of Medicare + 9.63% HCRA Surcharge,228.6,45,,228.6,percent of total billed charges,Critical Access Hospital RCC factor,172.72,34,,172.72,percent of total billed charges,Implant Device,172.72,34,,172.72,percent of total billed charges,Implant Device,172.72,34,,172.72,percent of total billed charges,Implant Device,172.72,34,,172.72,percent of total billed charges,Implant Device,172.72,34,,172.72,percent of total billed charges,Implant Device,251.46,,,251.46,Other,110% of Medicare,177.8,35,,177.8,percent of total billed charges,Implant Device,172.72,34,"Charges > $500, x 34%",172.72,percent of total billed charges,Implant Device,177.8,35,,177.8,percent of total billed charges,Implant Device,177.8,35,,177.8,percent of total billed charges,Implant Device,177.8,35,,177.8,percent of total billed charges,Implant Device,177.8,35,,177.8,percent of total billed charges,Implant Device,177.8,35,,177.8,percent of total billed charges,Implant Device,203.2,40,,203.2,percent of total billed charges,Implant Device,177.8,70,,177.8,percent of total billed charges,All Other,172.72,34,,172.72,percent of total billed charges,Implant Device,172.72,34,,172.72,percent of total billed charges,Implant Device,177.8,35,,177.8,percent of total billed charges,Implant Device,177.8,35,,177.8,percent of total billed charges,Implant Device,177.8,35,,177.8,percent of total billed charges,Implant Device,177.8,35,,177.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,375.92,
ZIMMER 02-03150-036 CORTCAL SCREW 5X36MM,C1713,HCPCS,,79006780,CDM,278,RC,,,both,,,508,375.92,,,375.92,Other,150% of Medicare + 9.63% HCRA Surcharge,228.6,45,,228.6,percent of total billed charges,Critical Access Hospital RCC factor,172.72,34,,172.72,percent of total billed charges,Implant Device,172.72,34,,172.72,percent of total billed charges,Implant Device,172.72,34,,172.72,percent of total billed charges,Implant Device,172.72,34,,172.72,percent of total billed charges,Implant Device,172.72,34,,172.72,percent of total billed charges,Implant Device,251.46,,,251.46,Other,110% of Medicare,177.8,35,,177.8,percent of total billed charges,Implant Device,172.72,34,"Charges > $500, x 34%",172.72,percent of total billed charges,Implant Device,177.8,35,,177.8,percent of total billed charges,Implant Device,177.8,35,,177.8,percent of total billed charges,Implant Device,177.8,35,,177.8,percent of total billed charges,Implant Device,177.8,35,,177.8,percent of total billed charges,Implant Device,177.8,35,,177.8,percent of total billed charges,Implant Device,203.2,40,,203.2,percent of total billed charges,Implant Device,177.8,70,,177.8,percent of total billed charges,All Other,172.72,34,,172.72,percent of total billed charges,Implant Device,172.72,34,,172.72,percent of total billed charges,Implant Device,177.8,35,,177.8,percent of total billed charges,Implant Device,177.8,35,,177.8,percent of total billed charges,Implant Device,177.8,35,,177.8,percent of total billed charges,Implant Device,177.8,35,,177.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,375.92,
ZIMMER 02-03150-042 CORTCAL SCREW 5X42MM,C1713,HCPCS,,79006781,CDM,278,RC,,,both,,,508,375.92,,,375.92,Other,150% of Medicare + 9.63% HCRA Surcharge,228.6,45,,228.6,percent of total billed charges,Critical Access Hospital RCC factor,172.72,34,,172.72,percent of total billed charges,Implant Device,172.72,34,,172.72,percent of total billed charges,Implant Device,172.72,34,,172.72,percent of total billed charges,Implant Device,172.72,34,,172.72,percent of total billed charges,Implant Device,172.72,34,,172.72,percent of total billed charges,Implant Device,251.46,,,251.46,Other,110% of Medicare,177.8,35,,177.8,percent of total billed charges,Implant Device,172.72,34,"Charges > $500, x 34%",172.72,percent of total billed charges,Implant Device,177.8,35,,177.8,percent of total billed charges,Implant Device,177.8,35,,177.8,percent of total billed charges,Implant Device,177.8,35,,177.8,percent of total billed charges,Implant Device,177.8,35,,177.8,percent of total billed charges,Implant Device,177.8,35,,177.8,percent of total billed charges,Implant Device,203.2,40,,203.2,percent of total billed charges,Implant Device,177.8,70,,177.8,percent of total billed charges,All Other,172.72,34,,172.72,percent of total billed charges,Implant Device,172.72,34,,172.72,percent of total billed charges,Implant Device,177.8,35,,177.8,percent of total billed charges,Implant Device,177.8,35,,177.8,percent of total billed charges,Implant Device,177.8,35,,177.8,percent of total billed charges,Implant Device,177.8,35,,177.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,375.92,
ZIMMER 02-03151-012 UNICORT SCREW 5X12MM,C1713,HCPCS,,79006782,CDM,278,RC,,,both,,,478,353.72,,,353.72,Other,150% of Medicare + 9.63% HCRA Surcharge,215.1,45,,215.1,percent of total billed charges,Critical Access Hospital RCC factor,162.52,34,,162.52,percent of total billed charges,Implant Device,162.52,34,,162.52,percent of total billed charges,Implant Device,162.52,34,,162.52,percent of total billed charges,Implant Device,162.52,34,,162.52,percent of total billed charges,Implant Device,162.52,34,,162.52,percent of total billed charges,Implant Device,236.61,,,236.61,Other,110% of Medicare,167.3,35,,167.3,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,167.3,35,,167.3,percent of total billed charges,Implant Device,167.3,35,,167.3,percent of total billed charges,Implant Device,167.3,35,,167.3,percent of total billed charges,Implant Device,167.3,35,,167.3,percent of total billed charges,Implant Device,167.3,35,,167.3,percent of total billed charges,Implant Device,191.2,40,,191.2,percent of total billed charges,Implant Device,167.3,70,,167.3,percent of total billed charges,All Other,162.52,34,,162.52,percent of total billed charges,Implant Device,162.52,34,,162.52,percent of total billed charges,Implant Device,167.3,35,,167.3,percent of total billed charges,Implant Device,167.3,35,,167.3,percent of total billed charges,Implant Device,167.3,35,,167.3,percent of total billed charges,Implant Device,167.3,35,,167.3,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,353.72,
ZIMMER 02-03151-014 UNICORT SCREW 5X14MM,C1713,HCPCS,,79006783,CDM,278,RC,,,both,,,478,353.72,,,353.72,Other,150% of Medicare + 9.63% HCRA Surcharge,215.1,45,,215.1,percent of total billed charges,Critical Access Hospital RCC factor,162.52,34,,162.52,percent of total billed charges,Implant Device,162.52,34,,162.52,percent of total billed charges,Implant Device,162.52,34,,162.52,percent of total billed charges,Implant Device,162.52,34,,162.52,percent of total billed charges,Implant Device,162.52,34,,162.52,percent of total billed charges,Implant Device,236.61,,,236.61,Other,110% of Medicare,167.3,35,,167.3,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,167.3,35,,167.3,percent of total billed charges,Implant Device,167.3,35,,167.3,percent of total billed charges,Implant Device,167.3,35,,167.3,percent of total billed charges,Implant Device,167.3,35,,167.3,percent of total billed charges,Implant Device,167.3,35,,167.3,percent of total billed charges,Implant Device,191.2,40,,191.2,percent of total billed charges,Implant Device,167.3,70,,167.3,percent of total billed charges,All Other,162.52,34,,162.52,percent of total billed charges,Implant Device,162.52,34,,162.52,percent of total billed charges,Implant Device,167.3,35,,167.3,percent of total billed charges,Implant Device,167.3,35,,167.3,percent of total billed charges,Implant Device,167.3,35,,167.3,percent of total billed charges,Implant Device,167.3,35,,167.3,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,353.72,
ZIMMER 02-03152-055 CANC SCREW 5X55MM,C1713,HCPCS,,79006784,CDM,278,RC,,,both,,,432,319.68,,,319.68,Other,150% of Medicare + 9.63% HCRA Surcharge,194.4,45,,194.4,percent of total billed charges,Critical Access Hospital RCC factor,146.88,34,,146.88,percent of total billed charges,Implant Device,146.88,34,,146.88,percent of total billed charges,Implant Device,146.88,34,,146.88,percent of total billed charges,Implant Device,146.88,34,,146.88,percent of total billed charges,Implant Device,146.88,34,,146.88,percent of total billed charges,Implant Device,213.84,,,213.84,Other,110% of Medicare,151.2,35,,151.2,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,151.2,35,,151.2,percent of total billed charges,Implant Device,151.2,35,,151.2,percent of total billed charges,Implant Device,151.2,35,,151.2,percent of total billed charges,Implant Device,151.2,35,,151.2,percent of total billed charges,Implant Device,151.2,35,,151.2,percent of total billed charges,Implant Device,172.8,40,,172.8,percent of total billed charges,Implant Device,151.2,70,,151.2,percent of total billed charges,All Other,146.88,34,,146.88,percent of total billed charges,Implant Device,146.88,34,,146.88,percent of total billed charges,Implant Device,151.2,35,,151.2,percent of total billed charges,Implant Device,151.2,35,,151.2,percent of total billed charges,Implant Device,151.2,35,,151.2,percent of total billed charges,Implant Device,151.2,35,,151.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,319.68,
ZIMMER 02-03152-060 CANC SCREW 5X60MM,C1713,HCPCS,,79006785,CDM,278,RC,,,both,,,432,319.68,,,319.68,Other,150% of Medicare + 9.63% HCRA Surcharge,194.4,45,,194.4,percent of total billed charges,Critical Access Hospital RCC factor,146.88,34,,146.88,percent of total billed charges,Implant Device,146.88,34,,146.88,percent of total billed charges,Implant Device,146.88,34,,146.88,percent of total billed charges,Implant Device,146.88,34,,146.88,percent of total billed charges,Implant Device,146.88,34,,146.88,percent of total billed charges,Implant Device,213.84,,,213.84,Other,110% of Medicare,151.2,35,,151.2,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,151.2,35,,151.2,percent of total billed charges,Implant Device,151.2,35,,151.2,percent of total billed charges,Implant Device,151.2,35,,151.2,percent of total billed charges,Implant Device,151.2,35,,151.2,percent of total billed charges,Implant Device,151.2,35,,151.2,percent of total billed charges,Implant Device,172.8,40,,172.8,percent of total billed charges,Implant Device,151.2,70,,151.2,percent of total billed charges,All Other,146.88,34,,146.88,percent of total billed charges,Implant Device,146.88,34,,146.88,percent of total billed charges,Implant Device,151.2,35,,151.2,percent of total billed charges,Implant Device,151.2,35,,151.2,percent of total billed charges,Implant Device,151.2,35,,151.2,percent of total billed charges,Implant Device,151.2,35,,151.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,319.68,
ZIMMER 02-03152-065 CANC SCREW 5X65MM,C1713,HCPCS,,79006786,CDM,278,RC,,,both,,,432,319.68,,,319.68,Other,150% of Medicare + 9.63% HCRA Surcharge,194.4,45,,194.4,percent of total billed charges,Critical Access Hospital RCC factor,146.88,34,,146.88,percent of total billed charges,Implant Device,146.88,34,,146.88,percent of total billed charges,Implant Device,146.88,34,,146.88,percent of total billed charges,Implant Device,146.88,34,,146.88,percent of total billed charges,Implant Device,146.88,34,,146.88,percent of total billed charges,Implant Device,213.84,,,213.84,Other,110% of Medicare,151.2,35,,151.2,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,151.2,35,,151.2,percent of total billed charges,Implant Device,151.2,35,,151.2,percent of total billed charges,Implant Device,151.2,35,,151.2,percent of total billed charges,Implant Device,151.2,35,,151.2,percent of total billed charges,Implant Device,151.2,35,,151.2,percent of total billed charges,Implant Device,172.8,40,,172.8,percent of total billed charges,Implant Device,151.2,70,,151.2,percent of total billed charges,All Other,146.88,34,,146.88,percent of total billed charges,Implant Device,146.88,34,,146.88,percent of total billed charges,Implant Device,151.2,35,,151.2,percent of total billed charges,Implant Device,151.2,35,,151.2,percent of total billed charges,Implant Device,151.2,35,,151.2,percent of total billed charges,Implant Device,151.2,35,,151.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,319.68,
ARTHREX AR-2600SBS-4 SPEEDBRIDGE IMPLANT,C1713,HCPCS,,79006791,CDM,278,RC,,,both,,,5220,3862.81,,,3862.81,Other,150% of Medicare + 9.63% HCRA Surcharge,2349,45,,2349,percent of total billed charges,Critical Access Hospital RCC factor,1774.8,34,,1774.8,percent of total billed charges,Implant Device,1774.8,34,,1774.8,percent of total billed charges,Implant Device,1774.8,34,,1774.8,percent of total billed charges,Implant Device,1774.8,34,,1774.8,percent of total billed charges,Implant Device,1774.8,34,,1774.8,percent of total billed charges,Implant Device,2583.9,,,2583.9,Other,110% of Medicare,1827,35,,1827,percent of total billed charges,Implant Device,1774.8,34,"Charges > $500, x 34%",1774.8,percent of total billed charges,Implant Device,1827,35,,1827,percent of total billed charges,Implant Device,1827,35,,1827,percent of total billed charges,Implant Device,1827,35,,1827,percent of total billed charges,Implant Device,1827,35,,1827,percent of total billed charges,Implant Device,1827,35,,1827,percent of total billed charges,Implant Device,2088,40,,2088,percent of total billed charges,Implant Device,1827,70,,1827,percent of total billed charges,All Other,1774.8,34,,1774.8,percent of total billed charges,Implant Device,1774.8,34,,1774.8,percent of total billed charges,Implant Device,1827,35,,1827,percent of total billed charges,Implant Device,1827,35,,1827,percent of total billed charges,Implant Device,1827,35,,1827,percent of total billed charges,Implant Device,1827,35,,1827,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1774.8,34,"If Charge > 2,000, then 34 percent",1774.8,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3862.81,
BIOMET 41-2008 NONLOCK SCREW X DRIVE 2X8,C1713,HCPCS,,79006792,CDM,278,RC,,,both,,,268,198.32,,,198.32,Other,150% of Medicare + 9.63% HCRA Surcharge,120.6,45,,120.6,percent of total billed charges,Critical Access Hospital RCC factor,91.12,34,,91.12,percent of total billed charges,Implant Device,91.12,34,,91.12,percent of total billed charges,Implant Device,91.12,34,,91.12,percent of total billed charges,Implant Device,91.12,34,,91.12,percent of total billed charges,Implant Device,91.12,34,,91.12,percent of total billed charges,Implant Device,132.66,,,132.66,Other,110% of Medicare,93.8,35,,93.8,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,93.8,35,,93.8,percent of total billed charges,Implant Device,93.8,35,,93.8,percent of total billed charges,Implant Device,93.8,35,,93.8,percent of total billed charges,Implant Device,93.8,35,,93.8,percent of total billed charges,Implant Device,93.8,35,,93.8,percent of total billed charges,Implant Device,107.2,40,,107.2,percent of total billed charges,Implant Device,93.8,70,,93.8,percent of total billed charges,All Other,91.12,34,,91.12,percent of total billed charges,Implant Device,91.12,34,,91.12,percent of total billed charges,Implant Device,93.8,35,,93.8,percent of total billed charges,Implant Device,93.8,35,,93.8,percent of total billed charges,Implant Device,93.8,35,,93.8,percent of total billed charges,Implant Device,93.8,35,,93.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,198.32,
BIOMET 45-0557 CRUSHED CANCELLOUS 15CC,C1713,HCPCS,,79006793,CDM,278,RC,,,both,,,846,626.04,,,626.04,Other,150% of Medicare + 9.63% HCRA Surcharge,380.7,45,,380.7,percent of total billed charges,Critical Access Hospital RCC factor,287.64,34,,287.64,percent of total billed charges,Implant Device,287.64,34,,287.64,percent of total billed charges,Implant Device,287.64,34,,287.64,percent of total billed charges,Implant Device,287.64,34,,287.64,percent of total billed charges,Implant Device,287.64,34,,287.64,percent of total billed charges,Implant Device,418.77,,,418.77,Other,110% of Medicare,296.1,35,,296.1,percent of total billed charges,Implant Device,287.64,34,"Charges > $500, x 34%",287.64,percent of total billed charges,Implant Device,296.1,35,,296.1,percent of total billed charges,Implant Device,296.1,35,,296.1,percent of total billed charges,Implant Device,296.1,35,,296.1,percent of total billed charges,Implant Device,296.1,35,,296.1,percent of total billed charges,Implant Device,296.1,35,,296.1,percent of total billed charges,Implant Device,338.4,40,,338.4,percent of total billed charges,Implant Device,296.1,70,,296.1,percent of total billed charges,All Other,287.64,34,,287.64,percent of total billed charges,Implant Device,287.64,34,,287.64,percent of total billed charges,Implant Device,296.1,35,,296.1,percent of total billed charges,Implant Device,296.1,35,,296.1,percent of total billed charges,Implant Device,296.1,35,,296.1,percent of total billed charges,Implant Device,296.1,35,,296.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,626.04,
STRYKER 5620-B-401 TIBIAL BASEPLATE SZ 4,C1776,HCPCS,,79006794,CDM,278,RC,,,both,,,4937,3653.39,,,3653.39,Other,150% of Medicare + 9.63% HCRA Surcharge,2221.65,45,,2221.65,percent of total billed charges,Critical Access Hospital RCC factor,1678.58,34,,1678.58,percent of total billed charges,Implant Device,1678.58,34,,1678.58,percent of total billed charges,Implant Device,1678.58,34,,1678.58,percent of total billed charges,Implant Device,1678.58,34,,1678.58,percent of total billed charges,Implant Device,1678.58,34,,1678.58,percent of total billed charges,Implant Device,2443.82,,,2443.82,Other,110% of Medicare,1727.95,35,,1727.95,percent of total billed charges,Implant Device,1678.58,34,"Charges > $500, x 34%",1678.58,percent of total billed charges,Implant Device,1727.95,35,,1727.95,percent of total billed charges,Implant Device,1727.95,35,,1727.95,percent of total billed charges,Implant Device,1727.95,35,,1727.95,percent of total billed charges,Implant Device,1727.95,35,,1727.95,percent of total billed charges,Implant Device,1727.95,35,,1727.95,percent of total billed charges,Implant Device,1974.8,40,,1974.8,percent of total billed charges,Implant Device,1727.95,70,,1727.95,percent of total billed charges,All Other,1678.58,34,,1678.58,percent of total billed charges,Implant Device,1678.58,34,,1678.58,percent of total billed charges,Implant Device,1727.95,35,,1727.95,percent of total billed charges,Implant Device,1727.95,35,,1727.95,percent of total billed charges,Implant Device,1727.95,35,,1727.95,percent of total billed charges,Implant Device,1727.95,35,,1727.95,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1678.58,34,"If Charge > 2,000, then 34 percent",1678.58,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3653.39,
STRYKER 5610-F-501 FEMORAL COMP SZ 5,C1776,HCPCS,,79006795,CDM,278,RC,,,both,,,8352,6180.5,,,6180.5,Other,150% of Medicare + 9.63% HCRA Surcharge,3758.4,45,,3758.4,percent of total billed charges,Critical Access Hospital RCC factor,2839.68,34,,2839.68,percent of total billed charges,Implant Device,2839.68,34,,2839.68,percent of total billed charges,Implant Device,2839.68,34,,2839.68,percent of total billed charges,Implant Device,2839.68,34,,2839.68,percent of total billed charges,Implant Device,2839.68,34,,2839.68,percent of total billed charges,Implant Device,4134.24,,,4134.24,Other,110% of Medicare,2923.2,35,,2923.2,percent of total billed charges,Implant Device,2839.68,34,"Charges > $500, x 34%",2839.68,percent of total billed charges,Implant Device,2923.2,35,,2923.2,percent of total billed charges,Implant Device,2923.2,35,,2923.2,percent of total billed charges,Implant Device,2923.2,35,,2923.2,percent of total billed charges,Implant Device,2923.2,35,,2923.2,percent of total billed charges,Implant Device,2923.2,35,,2923.2,percent of total billed charges,Implant Device,3340.8,40,,3340.8,percent of total billed charges,Implant Device,2923.2,70,,2923.2,percent of total billed charges,All Other,2839.68,34,,2839.68,percent of total billed charges,Implant Device,2839.68,34,,2839.68,percent of total billed charges,Implant Device,2923.2,35,,2923.2,percent of total billed charges,Implant Device,2923.2,35,,2923.2,percent of total billed charges,Implant Device,2923.2,35,,2923.2,percent of total billed charges,Implant Device,2923.2,35,,2923.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2839.68,34,"If Charge > 2,000, then 34 percent",2839.68,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,6180.5,
STRYKER 5630-G-408 TIBIAL INSERT 4X8MM,C1776,HCPCS,,79006796,CDM,278,RC,,,both,,,3232,2391.69,,,2391.69,Other,150% of Medicare + 9.63% HCRA Surcharge,1454.4,45,,1454.4,percent of total billed charges,Critical Access Hospital RCC factor,1098.88,34,,1098.88,percent of total billed charges,Implant Device,1098.88,34,,1098.88,percent of total billed charges,Implant Device,1098.88,34,,1098.88,percent of total billed charges,Implant Device,1098.88,34,,1098.88,percent of total billed charges,Implant Device,1098.88,34,,1098.88,percent of total billed charges,Implant Device,1599.84,,,1599.84,Other,110% of Medicare,1131.2,35,,1131.2,percent of total billed charges,Implant Device,1098.88,34,"Charges > $500, x 34%",1098.88,percent of total billed charges,Implant Device,1131.2,35,,1131.2,percent of total billed charges,Implant Device,1131.2,35,,1131.2,percent of total billed charges,Implant Device,1131.2,35,,1131.2,percent of total billed charges,Implant Device,1131.2,35,,1131.2,percent of total billed charges,Implant Device,1131.2,35,,1131.2,percent of total billed charges,Implant Device,1292.8,40,,1292.8,percent of total billed charges,Implant Device,1131.2,70,,1131.2,percent of total billed charges,All Other,1098.88,34,,1098.88,percent of total billed charges,Implant Device,1098.88,34,,1098.88,percent of total billed charges,Implant Device,1131.2,35,,1131.2,percent of total billed charges,Implant Device,1131.2,35,,1131.2,percent of total billed charges,Implant Device,1131.2,35,,1131.2,percent of total billed charges,Implant Device,1131.2,35,,1131.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1098.88,34,"If Charge > 2,000, then 34 percent",1098.88,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2391.69,
STRYKER 5630-G-508 TIBIAL INSERT 5X8MM,C1776,HCPCS,,79006797,CDM,278,RC,,,both,,,3232,2391.69,,,2391.69,Other,150% of Medicare + 9.63% HCRA Surcharge,1454.4,45,,1454.4,percent of total billed charges,Critical Access Hospital RCC factor,1098.88,34,,1098.88,percent of total billed charges,Implant Device,1098.88,34,,1098.88,percent of total billed charges,Implant Device,1098.88,34,,1098.88,percent of total billed charges,Implant Device,1098.88,34,,1098.88,percent of total billed charges,Implant Device,1098.88,34,,1098.88,percent of total billed charges,Implant Device,1599.84,,,1599.84,Other,110% of Medicare,1131.2,35,,1131.2,percent of total billed charges,Implant Device,1098.88,34,"Charges > $500, x 34%",1098.88,percent of total billed charges,Implant Device,1131.2,35,,1131.2,percent of total billed charges,Implant Device,1131.2,35,,1131.2,percent of total billed charges,Implant Device,1131.2,35,,1131.2,percent of total billed charges,Implant Device,1131.2,35,,1131.2,percent of total billed charges,Implant Device,1131.2,35,,1131.2,percent of total billed charges,Implant Device,1292.8,40,,1292.8,percent of total billed charges,Implant Device,1131.2,70,,1131.2,percent of total billed charges,All Other,1098.88,34,,1098.88,percent of total billed charges,Implant Device,1098.88,34,,1098.88,percent of total billed charges,Implant Device,1131.2,35,,1131.2,percent of total billed charges,Implant Device,1131.2,35,,1131.2,percent of total billed charges,Implant Device,1131.2,35,,1131.2,percent of total billed charges,Implant Device,1131.2,35,,1131.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1098.88,34,"If Charge > 2,000, then 34 percent",1098.88,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2391.69,
STRYKER 5620-B-501 TIBIAL BASEPLATE SZ 5,C1776,HCPCS,,79006798,CDM,278,RC,,,both,,,4937,3653.39,,,3653.39,Other,150% of Medicare + 9.63% HCRA Surcharge,2221.65,45,,2221.65,percent of total billed charges,Critical Access Hospital RCC factor,1678.58,34,,1678.58,percent of total billed charges,Implant Device,1678.58,34,,1678.58,percent of total billed charges,Implant Device,1678.58,34,,1678.58,percent of total billed charges,Implant Device,1678.58,34,,1678.58,percent of total billed charges,Implant Device,1678.58,34,,1678.58,percent of total billed charges,Implant Device,2443.82,,,2443.82,Other,110% of Medicare,1727.95,35,,1727.95,percent of total billed charges,Implant Device,1678.58,34,"Charges > $500, x 34%",1678.58,percent of total billed charges,Implant Device,1727.95,35,,1727.95,percent of total billed charges,Implant Device,1727.95,35,,1727.95,percent of total billed charges,Implant Device,1727.95,35,,1727.95,percent of total billed charges,Implant Device,1727.95,35,,1727.95,percent of total billed charges,Implant Device,1727.95,35,,1727.95,percent of total billed charges,Implant Device,1974.8,40,,1974.8,percent of total billed charges,Implant Device,1727.95,70,,1727.95,percent of total billed charges,All Other,1678.58,34,,1678.58,percent of total billed charges,Implant Device,1678.58,34,,1678.58,percent of total billed charges,Implant Device,1727.95,35,,1727.95,percent of total billed charges,Implant Device,1727.95,35,,1727.95,percent of total billed charges,Implant Device,1727.95,35,,1727.95,percent of total billed charges,Implant Device,1727.95,35,,1727.95,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1678.58,34,"If Charge > 2,000, then 34 percent",1678.58,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3653.39,
STRYKER 5610-F-601 FEMORAL COMP SZ 6,C1776,HCPCS,,79006799,CDM,278,RC,,,both,,,8352,6180.5,,,6180.5,Other,150% of Medicare + 9.63% HCRA Surcharge,3758.4,45,,3758.4,percent of total billed charges,Critical Access Hospital RCC factor,2839.68,34,,2839.68,percent of total billed charges,Implant Device,2839.68,34,,2839.68,percent of total billed charges,Implant Device,2839.68,34,,2839.68,percent of total billed charges,Implant Device,2839.68,34,,2839.68,percent of total billed charges,Implant Device,2839.68,34,,2839.68,percent of total billed charges,Implant Device,4134.24,,,4134.24,Other,110% of Medicare,2923.2,35,,2923.2,percent of total billed charges,Implant Device,2839.68,34,"Charges > $500, x 34%",2839.68,percent of total billed charges,Implant Device,2923.2,35,,2923.2,percent of total billed charges,Implant Device,2923.2,35,,2923.2,percent of total billed charges,Implant Device,2923.2,35,,2923.2,percent of total billed charges,Implant Device,2923.2,35,,2923.2,percent of total billed charges,Implant Device,2923.2,35,,2923.2,percent of total billed charges,Implant Device,3340.8,40,,3340.8,percent of total billed charges,Implant Device,2923.2,70,,2923.2,percent of total billed charges,All Other,2839.68,34,,2839.68,percent of total billed charges,Implant Device,2839.68,34,,2839.68,percent of total billed charges,Implant Device,2923.2,35,,2923.2,percent of total billed charges,Implant Device,2923.2,35,,2923.2,percent of total billed charges,Implant Device,2923.2,35,,2923.2,percent of total billed charges,Implant Device,2923.2,35,,2923.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2839.68,34,"If Charge > 2,000, then 34 percent",2839.68,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,6180.5,
SYNTHES 02.240.046 CAN LOCK SCREW 3.7X46,C1713,HCPCS,,79006803,CDM,278,RC,,,both,,,476,352.24,,,352.24,Other,150% of Medicare + 9.63% HCRA Surcharge,214.2,45,,214.2,percent of total billed charges,Critical Access Hospital RCC factor,161.84,34,,161.84,percent of total billed charges,Implant Device,161.84,34,,161.84,percent of total billed charges,Implant Device,161.84,34,,161.84,percent of total billed charges,Implant Device,161.84,34,,161.84,percent of total billed charges,Implant Device,161.84,34,,161.84,percent of total billed charges,Implant Device,235.62,,,235.62,Other,110% of Medicare,166.6,35,,166.6,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,166.6,35,,166.6,percent of total billed charges,Implant Device,166.6,35,,166.6,percent of total billed charges,Implant Device,166.6,35,,166.6,percent of total billed charges,Implant Device,166.6,35,,166.6,percent of total billed charges,Implant Device,166.6,35,,166.6,percent of total billed charges,Implant Device,190.4,40,,190.4,percent of total billed charges,Implant Device,166.6,70,,166.6,percent of total billed charges,All Other,161.84,34,,161.84,percent of total billed charges,Implant Device,161.84,34,,161.84,percent of total billed charges,Implant Device,166.6,35,,166.6,percent of total billed charges,Implant Device,166.6,35,,166.6,percent of total billed charges,Implant Device,166.6,35,,166.6,percent of total billed charges,Implant Device,166.6,35,,166.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,352.24,
SYNTHES 02.240.050 CAN LOCK SCREW 3.7X50,C1713,HCPCS,,79006804,CDM,278,RC,,,both,,,476,352.24,,,352.24,Other,150% of Medicare + 9.63% HCRA Surcharge,214.2,45,,214.2,percent of total billed charges,Critical Access Hospital RCC factor,161.84,34,,161.84,percent of total billed charges,Implant Device,161.84,34,,161.84,percent of total billed charges,Implant Device,161.84,34,,161.84,percent of total billed charges,Implant Device,161.84,34,,161.84,percent of total billed charges,Implant Device,161.84,34,,161.84,percent of total billed charges,Implant Device,235.62,,,235.62,Other,110% of Medicare,166.6,35,,166.6,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,166.6,35,,166.6,percent of total billed charges,Implant Device,166.6,35,,166.6,percent of total billed charges,Implant Device,166.6,35,,166.6,percent of total billed charges,Implant Device,166.6,35,,166.6,percent of total billed charges,Implant Device,166.6,35,,166.6,percent of total billed charges,Implant Device,190.4,40,,190.4,percent of total billed charges,Implant Device,166.6,70,,166.6,percent of total billed charges,All Other,161.84,34,,161.84,percent of total billed charges,Implant Device,161.84,34,,161.84,percent of total billed charges,Implant Device,166.6,35,,166.6,percent of total billed charges,Implant Device,166.6,35,,166.6,percent of total billed charges,Implant Device,166.6,35,,166.6,percent of total billed charges,Implant Device,166.6,35,,166.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,352.24,
SYNTHES 02.240.038 CAN LOCK SCREW 3.7X38,C1713,HCPCS,,79006805,CDM,278,RC,,,both,,,476,352.24,,,352.24,Other,150% of Medicare + 9.63% HCRA Surcharge,214.2,45,,214.2,percent of total billed charges,Critical Access Hospital RCC factor,161.84,34,,161.84,percent of total billed charges,Implant Device,161.84,34,,161.84,percent of total billed charges,Implant Device,161.84,34,,161.84,percent of total billed charges,Implant Device,161.84,34,,161.84,percent of total billed charges,Implant Device,161.84,34,,161.84,percent of total billed charges,Implant Device,235.62,,,235.62,Other,110% of Medicare,166.6,35,,166.6,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,166.6,35,,166.6,percent of total billed charges,Implant Device,166.6,35,,166.6,percent of total billed charges,Implant Device,166.6,35,,166.6,percent of total billed charges,Implant Device,166.6,35,,166.6,percent of total billed charges,Implant Device,166.6,35,,166.6,percent of total billed charges,Implant Device,190.4,40,,190.4,percent of total billed charges,Implant Device,166.6,70,,166.6,percent of total billed charges,All Other,161.84,34,,161.84,percent of total billed charges,Implant Device,161.84,34,,161.84,percent of total billed charges,Implant Device,166.6,35,,166.6,percent of total billed charges,Implant Device,166.6,35,,166.6,percent of total billed charges,Implant Device,166.6,35,,166.6,percent of total billed charges,Implant Device,166.6,35,,166.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,352.24,
SYNTHES 02.240.032 CAN LOCK SCREW 3.7X32,C1713,HCPCS,,79006806,CDM,278,RC,,,both,,,476,352.24,,,352.24,Other,150% of Medicare + 9.63% HCRA Surcharge,214.2,45,,214.2,percent of total billed charges,Critical Access Hospital RCC factor,161.84,34,,161.84,percent of total billed charges,Implant Device,161.84,34,,161.84,percent of total billed charges,Implant Device,161.84,34,,161.84,percent of total billed charges,Implant Device,161.84,34,,161.84,percent of total billed charges,Implant Device,161.84,34,,161.84,percent of total billed charges,Implant Device,235.62,,,235.62,Other,110% of Medicare,166.6,35,,166.6,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,166.6,35,,166.6,percent of total billed charges,Implant Device,166.6,35,,166.6,percent of total billed charges,Implant Device,166.6,35,,166.6,percent of total billed charges,Implant Device,166.6,35,,166.6,percent of total billed charges,Implant Device,166.6,35,,166.6,percent of total billed charges,Implant Device,190.4,40,,190.4,percent of total billed charges,Implant Device,166.6,70,,166.6,percent of total billed charges,All Other,161.84,34,,161.84,percent of total billed charges,Implant Device,161.84,34,,161.84,percent of total billed charges,Implant Device,166.6,35,,166.6,percent of total billed charges,Implant Device,166.6,35,,166.6,percent of total billed charges,Implant Device,166.6,35,,166.6,percent of total billed charges,Implant Device,166.6,35,,166.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,352.24,
SYNTHES 02.240.042 CAN LOCK SCREW 3.7X42,C1713,HCPCS,,79006807,CDM,278,RC,,,both,,,476,352.24,,,352.24,Other,150% of Medicare + 9.63% HCRA Surcharge,214.2,45,,214.2,percent of total billed charges,Critical Access Hospital RCC factor,161.84,34,,161.84,percent of total billed charges,Implant Device,161.84,34,,161.84,percent of total billed charges,Implant Device,161.84,34,,161.84,percent of total billed charges,Implant Device,161.84,34,,161.84,percent of total billed charges,Implant Device,161.84,34,,161.84,percent of total billed charges,Implant Device,235.62,,,235.62,Other,110% of Medicare,166.6,35,,166.6,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,166.6,35,,166.6,percent of total billed charges,Implant Device,166.6,35,,166.6,percent of total billed charges,Implant Device,166.6,35,,166.6,percent of total billed charges,Implant Device,166.6,35,,166.6,percent of total billed charges,Implant Device,166.6,35,,166.6,percent of total billed charges,Implant Device,190.4,40,,190.4,percent of total billed charges,Implant Device,166.6,70,,166.6,percent of total billed charges,All Other,161.84,34,,161.84,percent of total billed charges,Implant Device,161.84,34,,161.84,percent of total billed charges,Implant Device,166.6,35,,166.6,percent of total billed charges,Implant Device,166.6,35,,166.6,percent of total billed charges,Implant Device,166.6,35,,166.6,percent of total billed charges,Implant Device,166.6,35,,166.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,352.24,
SYNTHES 02.123.023 HUMERUS PLATE 3.5X127,C1713,HCPCS,,79006808,CDM,278,RC,,,both,,,4155,3074.71,,,3074.71,Other,150% of Medicare + 9.63% HCRA Surcharge,1869.75,45,,1869.75,percent of total billed charges,Critical Access Hospital RCC factor,1412.7,34,,1412.7,percent of total billed charges,Implant Device,1412.7,34,,1412.7,percent of total billed charges,Implant Device,1412.7,34,,1412.7,percent of total billed charges,Implant Device,1412.7,34,,1412.7,percent of total billed charges,Implant Device,1412.7,34,,1412.7,percent of total billed charges,Implant Device,2056.73,,,2056.73,Other,110% of Medicare,1454.25,35,,1454.25,percent of total billed charges,Implant Device,1412.7,34,"Charges > $500, x 34%",1412.7,percent of total billed charges,Implant Device,1454.25,35,,1454.25,percent of total billed charges,Implant Device,1454.25,35,,1454.25,percent of total billed charges,Implant Device,1454.25,35,,1454.25,percent of total billed charges,Implant Device,1454.25,35,,1454.25,percent of total billed charges,Implant Device,1454.25,35,,1454.25,percent of total billed charges,Implant Device,1662,40,,1662,percent of total billed charges,Implant Device,1454.25,70,,1454.25,percent of total billed charges,All Other,1412.7,34,,1412.7,percent of total billed charges,Implant Device,1412.7,34,,1412.7,percent of total billed charges,Implant Device,1454.25,35,,1454.25,percent of total billed charges,Implant Device,1454.25,35,,1454.25,percent of total billed charges,Implant Device,1454.25,35,,1454.25,percent of total billed charges,Implant Device,1454.25,35,,1454.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1412.7,34,"If Charge > 2,000, then 34 percent",1412.7,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3074.71,
SYNTHES 02.240.052 CAN LOCK SCREW 3.7X52,C1713,HCPCS,,79006809,CDM,278,RC,,,both,,,476,352.24,,,352.24,Other,150% of Medicare + 9.63% HCRA Surcharge,214.2,45,,214.2,percent of total billed charges,Critical Access Hospital RCC factor,161.84,34,,161.84,percent of total billed charges,Implant Device,161.84,34,,161.84,percent of total billed charges,Implant Device,161.84,34,,161.84,percent of total billed charges,Implant Device,161.84,34,,161.84,percent of total billed charges,Implant Device,161.84,34,,161.84,percent of total billed charges,Implant Device,235.62,,,235.62,Other,110% of Medicare,166.6,35,,166.6,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,166.6,35,,166.6,percent of total billed charges,Implant Device,166.6,35,,166.6,percent of total billed charges,Implant Device,166.6,35,,166.6,percent of total billed charges,Implant Device,166.6,35,,166.6,percent of total billed charges,Implant Device,166.6,35,,166.6,percent of total billed charges,Implant Device,190.4,40,,190.4,percent of total billed charges,Implant Device,166.6,70,,166.6,percent of total billed charges,All Other,161.84,34,,161.84,percent of total billed charges,Implant Device,161.84,34,,161.84,percent of total billed charges,Implant Device,166.6,35,,166.6,percent of total billed charges,Implant Device,166.6,35,,166.6,percent of total billed charges,Implant Device,166.6,35,,166.6,percent of total billed charges,Implant Device,166.6,35,,166.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,352.24,
SYNTHES 204.850 CORTEX SCREW 3.5X50MM,C1713,HCPCS,,79006811,CDM,278,RC,,,both,,,82,60.68,,,60.68,Other,150% of Medicare + 9.63% HCRA Surcharge,36.9,45,,36.9,percent of total billed charges,Critical Access Hospital RCC factor,27.88,34,,27.88,percent of total billed charges,Implant Device,27.88,34,,27.88,percent of total billed charges,Implant Device,27.88,34,,27.88,percent of total billed charges,Implant Device,27.88,34,,27.88,percent of total billed charges,Implant Device,27.88,34,,27.88,percent of total billed charges,Implant Device,40.59,,,40.59,Other,110% of Medicare,28.7,35,,28.7,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,28.7,35,,28.7,percent of total billed charges,Implant Device,28.7,35,,28.7,percent of total billed charges,Implant Device,28.7,35,,28.7,percent of total billed charges,Implant Device,28.7,35,,28.7,percent of total billed charges,Implant Device,28.7,35,,28.7,percent of total billed charges,Implant Device,32.8,40,,32.8,percent of total billed charges,Implant Device,28.7,70,,28.7,percent of total billed charges,All Other,27.88,34,,27.88,percent of total billed charges,Implant Device,27.88,34,,27.88,percent of total billed charges,Implant Device,28.7,35,,28.7,percent of total billed charges,Implant Device,28.7,35,,28.7,percent of total billed charges,Implant Device,28.7,35,,28.7,percent of total billed charges,Implant Device,28.7,35,,28.7,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,60.68,
SYNTHES 204.834 CORTEX SCREW 3.5X34MM,C1713,HCPCS,,79006812,CDM,278,RC,,,both,,,59,43.66,,,43.66,Other,150% of Medicare + 9.63% HCRA Surcharge,26.55,45,,26.55,percent of total billed charges,Critical Access Hospital RCC factor,20.06,34,,20.06,percent of total billed charges,Implant Device,20.06,34,,20.06,percent of total billed charges,Implant Device,20.06,34,,20.06,percent of total billed charges,Implant Device,20.06,34,,20.06,percent of total billed charges,Implant Device,20.06,34,,20.06,percent of total billed charges,Implant Device,29.21,,,29.21,Other,110% of Medicare,20.65,35,,20.65,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,20.65,35,,20.65,percent of total billed charges,Implant Device,20.65,35,,20.65,percent of total billed charges,Implant Device,20.65,35,,20.65,percent of total billed charges,Implant Device,20.65,35,,20.65,percent of total billed charges,Implant Device,20.65,35,,20.65,percent of total billed charges,Implant Device,23.6,40,,23.6,percent of total billed charges,Implant Device,20.65,70,,20.65,percent of total billed charges,All Other,20.06,34,,20.06,percent of total billed charges,Implant Device,20.06,34,,20.06,percent of total billed charges,Implant Device,20.65,35,,20.65,percent of total billed charges,Implant Device,20.65,35,,20.65,percent of total billed charges,Implant Device,20.65,35,,20.65,percent of total billed charges,Implant Device,20.65,35,,20.65,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,43.66,
SYNTHES 204.836 CORTEX SCREW 3.5X36MM,C1713,HCPCS,,79006813,CDM,278,RC,,,both,,,59,43.66,,,43.66,Other,150% of Medicare + 9.63% HCRA Surcharge,26.55,45,,26.55,percent of total billed charges,Critical Access Hospital RCC factor,20.06,34,,20.06,percent of total billed charges,Implant Device,20.06,34,,20.06,percent of total billed charges,Implant Device,20.06,34,,20.06,percent of total billed charges,Implant Device,20.06,34,,20.06,percent of total billed charges,Implant Device,20.06,34,,20.06,percent of total billed charges,Implant Device,29.21,,,29.21,Other,110% of Medicare,20.65,35,,20.65,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,20.65,35,,20.65,percent of total billed charges,Implant Device,20.65,35,,20.65,percent of total billed charges,Implant Device,20.65,35,,20.65,percent of total billed charges,Implant Device,20.65,35,,20.65,percent of total billed charges,Implant Device,20.65,35,,20.65,percent of total billed charges,Implant Device,23.6,40,,23.6,percent of total billed charges,Implant Device,20.65,70,,20.65,percent of total billed charges,All Other,20.06,34,,20.06,percent of total billed charges,Implant Device,20.06,34,,20.06,percent of total billed charges,Implant Device,20.65,35,,20.65,percent of total billed charges,Implant Device,20.65,35,,20.65,percent of total billed charges,Implant Device,20.65,35,,20.65,percent of total billed charges,Implant Device,20.65,35,,20.65,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,43.66,
ARTHREX AR-1688-CP LIGAMENT AUGMENTATION,C1713,HCPCS,,79006814,CDM,278,RC,,,both,,,3225,2386.51,,,2386.51,Other,150% of Medicare + 9.63% HCRA Surcharge,1451.25,45,,1451.25,percent of total billed charges,Critical Access Hospital RCC factor,1096.5,34,,1096.5,percent of total billed charges,Implant Device,1096.5,34,,1096.5,percent of total billed charges,Implant Device,1096.5,34,,1096.5,percent of total billed charges,Implant Device,1096.5,34,,1096.5,percent of total billed charges,Implant Device,1096.5,34,,1096.5,percent of total billed charges,Implant Device,1596.38,,,1596.38,Other,110% of Medicare,1128.75,35,,1128.75,percent of total billed charges,Implant Device,1096.5,34,"Charges > $500, x 34%",1096.5,percent of total billed charges,Implant Device,1128.75,35,,1128.75,percent of total billed charges,Implant Device,1128.75,35,,1128.75,percent of total billed charges,Implant Device,1128.75,35,,1128.75,percent of total billed charges,Implant Device,1128.75,35,,1128.75,percent of total billed charges,Implant Device,1128.75,35,,1128.75,percent of total billed charges,Implant Device,1290,40,,1290,percent of total billed charges,Implant Device,1128.75,70,,1128.75,percent of total billed charges,All Other,1096.5,34,,1096.5,percent of total billed charges,Implant Device,1096.5,34,,1096.5,percent of total billed charges,Implant Device,1128.75,35,,1128.75,percent of total billed charges,Implant Device,1128.75,35,,1128.75,percent of total billed charges,Implant Device,1128.75,35,,1128.75,percent of total billed charges,Implant Device,1128.75,35,,1128.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1096.5,34,"If Charge > 2,000, then 34 percent",1096.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2386.51,
GORE RLT261216 EXCLUDER ENDOPROS GRAFT,C1768,HCPCS,,79006815,CDM,278,RC,,,both,,,31500,23310.08,,,23310.08,Other,150% of Medicare + 9.63% HCRA Surcharge,14175,45,,14175,percent of total billed charges,Critical Access Hospital RCC factor,10710,34,,10710,percent of total billed charges,Implant Device,10710,34,,10710,percent of total billed charges,Implant Device,10710,34,,10710,percent of total billed charges,Implant Device,10710,34,,10710,percent of total billed charges,Implant Device,10710,34,,10710,percent of total billed charges,Implant Device,15592.5,,,15592.5,Other,110% of Medicare,11025,35,,11025,percent of total billed charges,Implant Device,10710,34,"Charges > $500, x 34%",10710,percent of total billed charges,Implant Device,11025,35,,11025,percent of total billed charges,Implant Device,11025,35,,11025,percent of total billed charges,Implant Device,11025,35,,11025,percent of total billed charges,Implant Device,11025,35,,11025,percent of total billed charges,Implant Device,11025,35,,11025,percent of total billed charges,Implant Device,12600,40,,12600,percent of total billed charges,Implant Device,11025,70,,11025,percent of total billed charges,All Other,10710,34,,10710,percent of total billed charges,Implant Device,10710,34,,10710,percent of total billed charges,Implant Device,11025,35,,11025,percent of total billed charges,Implant Device,11025,35,,11025,percent of total billed charges,Implant Device,11025,35,,11025,percent of total billed charges,Implant Device,11025,35,,11025,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,10710,34,"If Charge > 2,000, then 34 percent",10710,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,23310.08,
ARTHREX AR-8943BL-05 FIB LOCK PLATE 5H,C1713,HCPCS,,79006818,CDM,278,RC,,,both,,,1950,1443,,,1443,Other,150% of Medicare + 9.63% HCRA Surcharge,877.5,45,,877.5,percent of total billed charges,Critical Access Hospital RCC factor,663,34,,663,percent of total billed charges,Implant Device,663,34,,663,percent of total billed charges,Implant Device,663,34,,663,percent of total billed charges,Implant Device,663,34,,663,percent of total billed charges,Implant Device,663,34,,663,percent of total billed charges,Implant Device,965.25,,,965.25,Other,110% of Medicare,682.5,35,,682.5,percent of total billed charges,Implant Device,663,34,"Charges > $500, x 34%",663,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,780,40,,780,percent of total billed charges,Implant Device,682.5,70,,682.5,percent of total billed charges,All Other,663,34,,663,percent of total billed charges,Implant Device,663,34,,663,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1443,
ARTHREX AR-8840C-44 CANN SCREW 4.0X44MM,C1713,HCPCS,,79006819,CDM,278,RC,,,both,,,496,367.04,,,367.04,Other,150% of Medicare + 9.63% HCRA Surcharge,223.2,45,,223.2,percent of total billed charges,Critical Access Hospital RCC factor,168.64,34,,168.64,percent of total billed charges,Implant Device,168.64,34,,168.64,percent of total billed charges,Implant Device,168.64,34,,168.64,percent of total billed charges,Implant Device,168.64,34,,168.64,percent of total billed charges,Implant Device,168.64,34,,168.64,percent of total billed charges,Implant Device,245.52,,,245.52,Other,110% of Medicare,173.6,35,,173.6,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,173.6,35,,173.6,percent of total billed charges,Implant Device,173.6,35,,173.6,percent of total billed charges,Implant Device,173.6,35,,173.6,percent of total billed charges,Implant Device,173.6,35,,173.6,percent of total billed charges,Implant Device,173.6,35,,173.6,percent of total billed charges,Implant Device,198.4,40,,198.4,percent of total billed charges,Implant Device,173.6,70,,173.6,percent of total billed charges,All Other,168.64,34,,168.64,percent of total billed charges,Implant Device,168.64,34,,168.64,percent of total billed charges,Implant Device,173.6,35,,173.6,percent of total billed charges,Implant Device,173.6,35,,173.6,percent of total billed charges,Implant Device,173.6,35,,173.6,percent of total billed charges,Implant Device,173.6,35,,173.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,367.04,
LIFE SPINE 9035-14 POLY SCREW 3.5X14MM,C1713,HCPCS,,79006820,CDM,278,RC,,,both,,,4320,3196.81,,,3196.81,Other,150% of Medicare + 9.63% HCRA Surcharge,1944,45,,1944,percent of total billed charges,Critical Access Hospital RCC factor,1468.8,34,,1468.8,percent of total billed charges,Implant Device,1468.8,34,,1468.8,percent of total billed charges,Implant Device,1468.8,34,,1468.8,percent of total billed charges,Implant Device,1468.8,34,,1468.8,percent of total billed charges,Implant Device,1468.8,34,,1468.8,percent of total billed charges,Implant Device,2138.4,,,2138.4,Other,110% of Medicare,1512,35,,1512,percent of total billed charges,Implant Device,1468.8,34,"Charges > $500, x 34%",1468.8,percent of total billed charges,Implant Device,1512,35,,1512,percent of total billed charges,Implant Device,1512,35,,1512,percent of total billed charges,Implant Device,1512,35,,1512,percent of total billed charges,Implant Device,1512,35,,1512,percent of total billed charges,Implant Device,1512,35,,1512,percent of total billed charges,Implant Device,1728,40,,1728,percent of total billed charges,Implant Device,1512,70,,1512,percent of total billed charges,All Other,1468.8,34,,1468.8,percent of total billed charges,Implant Device,1468.8,34,,1468.8,percent of total billed charges,Implant Device,1512,35,,1512,percent of total billed charges,Implant Device,1512,35,,1512,percent of total billed charges,Implant Device,1512,35,,1512,percent of total billed charges,Implant Device,1512,35,,1512,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1468.8,34,"If Charge > 2,000, then 34 percent",1468.8,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3196.81,
LIFE SPINE 4350-080 ROD 3.5X80MM,C1713,HCPCS,,79006821,CDM,278,RC,,,both,,,900,666,,,666,Other,150% of Medicare + 9.63% HCRA Surcharge,405,45,,405,percent of total billed charges,Critical Access Hospital RCC factor,306,34,,306,percent of total billed charges,Implant Device,306,34,,306,percent of total billed charges,Implant Device,306,34,,306,percent of total billed charges,Implant Device,306,34,,306,percent of total billed charges,Implant Device,306,34,,306,percent of total billed charges,Implant Device,445.5,,,445.5,Other,110% of Medicare,315,35,,315,percent of total billed charges,Implant Device,306,34,"Charges > $500, x 34%",306,percent of total billed charges,Implant Device,315,35,,315,percent of total billed charges,Implant Device,315,35,,315,percent of total billed charges,Implant Device,315,35,,315,percent of total billed charges,Implant Device,315,35,,315,percent of total billed charges,Implant Device,315,35,,315,percent of total billed charges,Implant Device,360,40,,360,percent of total billed charges,Implant Device,315,70,,315,percent of total billed charges,All Other,306,34,,306,percent of total billed charges,Implant Device,306,34,,306,percent of total billed charges,Implant Device,315,35,,315,percent of total billed charges,Implant Device,315,35,,315,percent of total billed charges,Implant Device,315,35,,315,percent of total billed charges,Implant Device,315,35,,315,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,666,
LIFE SPINE 3350-120 STRGHT ROD 3.5X120MM,C1713,HCPCS,,79006822,CDM,278,RC,,,both,,,804,594.96,,,594.96,Other,150% of Medicare + 9.63% HCRA Surcharge,361.8,45,,361.8,percent of total billed charges,Critical Access Hospital RCC factor,273.36,34,,273.36,percent of total billed charges,Implant Device,273.36,34,,273.36,percent of total billed charges,Implant Device,273.36,34,,273.36,percent of total billed charges,Implant Device,273.36,34,,273.36,percent of total billed charges,Implant Device,273.36,34,,273.36,percent of total billed charges,Implant Device,397.98,,,397.98,Other,110% of Medicare,281.4,35,,281.4,percent of total billed charges,Implant Device,273.36,34,"Charges > $500, x 34%",273.36,percent of total billed charges,Implant Device,281.4,35,,281.4,percent of total billed charges,Implant Device,281.4,35,,281.4,percent of total billed charges,Implant Device,281.4,35,,281.4,percent of total billed charges,Implant Device,281.4,35,,281.4,percent of total billed charges,Implant Device,281.4,35,,281.4,percent of total billed charges,Implant Device,321.6,40,,321.6,percent of total billed charges,Implant Device,281.4,70,,281.4,percent of total billed charges,All Other,273.36,34,,273.36,percent of total billed charges,Implant Device,273.36,34,,273.36,percent of total billed charges,Implant Device,281.4,35,,281.4,percent of total billed charges,Implant Device,281.4,35,,281.4,percent of total billed charges,Implant Device,281.4,35,,281.4,percent of total billed charges,Implant Device,281.4,35,,281.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,594.96,
LIFE SPINE 900-003 LOCKING CAP ASSEMBLY,C1713,HCPCS,,79006823,CDM,278,RC,,,both,,,600,444,,,444,Other,150% of Medicare + 9.63% HCRA Surcharge,270,45,,270,percent of total billed charges,Critical Access Hospital RCC factor,204,34,,204,percent of total billed charges,Implant Device,204,34,,204,percent of total billed charges,Implant Device,204,34,,204,percent of total billed charges,Implant Device,204,34,,204,percent of total billed charges,Implant Device,204,34,,204,percent of total billed charges,Implant Device,297,,,297,Other,110% of Medicare,210,35,,210,percent of total billed charges,Implant Device,204,34,"Charges > $500, x 34%",204,percent of total billed charges,Implant Device,210,35,,210,percent of total billed charges,Implant Device,210,35,,210,percent of total billed charges,Implant Device,210,35,,210,percent of total billed charges,Implant Device,210,35,,210,percent of total billed charges,Implant Device,210,35,,210,percent of total billed charges,Implant Device,240,40,,240,percent of total billed charges,Implant Device,210,70,,210,percent of total billed charges,All Other,204,34,,204,percent of total billed charges,Implant Device,204,34,,204,percent of total billed charges,Implant Device,210,35,,210,percent of total billed charges,Implant Device,210,35,,210,percent of total billed charges,Implant Device,210,35,,210,percent of total billed charges,Implant Device,210,35,,210,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,444,
STRYKER 3425-0400S LONG NAIL KIT R1 5 RT,C1713,HCPCS,,79006825,CDM,278,RC,,,both,,,9415,6967.12,,,6967.12,Other,150% of Medicare + 9.63% HCRA Surcharge,4236.75,45,,4236.75,percent of total billed charges,Critical Access Hospital RCC factor,3201.1,34,,3201.1,percent of total billed charges,Implant Device,3201.1,34,,3201.1,percent of total billed charges,Implant Device,3201.1,34,,3201.1,percent of total billed charges,Implant Device,3201.1,34,,3201.1,percent of total billed charges,Implant Device,3201.1,34,,3201.1,percent of total billed charges,Implant Device,4660.43,,,4660.43,Other,110% of Medicare,3295.25,35,,3295.25,percent of total billed charges,Implant Device,3201.1,34,"Charges > $500, x 34%",3201.1,percent of total billed charges,Implant Device,3295.25,35,,3295.25,percent of total billed charges,Implant Device,3295.25,35,,3295.25,percent of total billed charges,Implant Device,3295.25,35,,3295.25,percent of total billed charges,Implant Device,3295.25,35,,3295.25,percent of total billed charges,Implant Device,3295.25,35,,3295.25,percent of total billed charges,Implant Device,3766,40,,3766,percent of total billed charges,Implant Device,3295.25,70,,3295.25,percent of total billed charges,All Other,3201.1,34,,3201.1,percent of total billed charges,Implant Device,3201.1,34,,3201.1,percent of total billed charges,Implant Device,3295.25,35,,3295.25,percent of total billed charges,Implant Device,3295.25,35,,3295.25,percent of total billed charges,Implant Device,3295.25,35,,3295.25,percent of total billed charges,Implant Device,3295.25,35,,3295.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3201.1,34,"If Charge > 2,000, then 34 percent",3201.1,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,6967.12,
STRYKER 5630-G-328 TIB INSERT SZ 3X8MM,C1776,HCPCS,,79006828,CDM,278,RC,,,both,,,3232,2391.69,,,2391.69,Other,150% of Medicare + 9.63% HCRA Surcharge,1454.4,45,,1454.4,percent of total billed charges,Critical Access Hospital RCC factor,1098.88,34,,1098.88,percent of total billed charges,Implant Device,1098.88,34,,1098.88,percent of total billed charges,Implant Device,1098.88,34,,1098.88,percent of total billed charges,Implant Device,1098.88,34,,1098.88,percent of total billed charges,Implant Device,1098.88,34,,1098.88,percent of total billed charges,Implant Device,1599.84,,,1599.84,Other,110% of Medicare,1131.2,35,,1131.2,percent of total billed charges,Implant Device,1098.88,34,"Charges > $500, x 34%",1098.88,percent of total billed charges,Implant Device,1131.2,35,,1131.2,percent of total billed charges,Implant Device,1131.2,35,,1131.2,percent of total billed charges,Implant Device,1131.2,35,,1131.2,percent of total billed charges,Implant Device,1131.2,35,,1131.2,percent of total billed charges,Implant Device,1131.2,35,,1131.2,percent of total billed charges,Implant Device,1292.8,40,,1292.8,percent of total billed charges,Implant Device,1131.2,70,,1131.2,percent of total billed charges,All Other,1098.88,34,,1098.88,percent of total billed charges,Implant Device,1098.88,34,,1098.88,percent of total billed charges,Implant Device,1131.2,35,,1131.2,percent of total billed charges,Implant Device,1131.2,35,,1131.2,percent of total billed charges,Implant Device,1131.2,35,,1131.2,percent of total billed charges,Implant Device,1131.2,35,,1131.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1098.88,34,"If Charge > 2,000, then 34 percent",1098.88,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2391.69,
STRYKER 5620-B-302 TIBIAL BASEPLATE SZ 3,C1776,HCPCS,,79006829,CDM,278,RC,,,both,,,4937,3653.39,,,3653.39,Other,150% of Medicare + 9.63% HCRA Surcharge,2221.65,45,,2221.65,percent of total billed charges,Critical Access Hospital RCC factor,1678.58,34,,1678.58,percent of total billed charges,Implant Device,1678.58,34,,1678.58,percent of total billed charges,Implant Device,1678.58,34,,1678.58,percent of total billed charges,Implant Device,1678.58,34,,1678.58,percent of total billed charges,Implant Device,1678.58,34,,1678.58,percent of total billed charges,Implant Device,2443.82,,,2443.82,Other,110% of Medicare,1727.95,35,,1727.95,percent of total billed charges,Implant Device,1678.58,34,"Charges > $500, x 34%",1678.58,percent of total billed charges,Implant Device,1727.95,35,,1727.95,percent of total billed charges,Implant Device,1727.95,35,,1727.95,percent of total billed charges,Implant Device,1727.95,35,,1727.95,percent of total billed charges,Implant Device,1727.95,35,,1727.95,percent of total billed charges,Implant Device,1727.95,35,,1727.95,percent of total billed charges,Implant Device,1974.8,40,,1974.8,percent of total billed charges,Implant Device,1727.95,70,,1727.95,percent of total billed charges,All Other,1678.58,34,,1678.58,percent of total billed charges,Implant Device,1678.58,34,,1678.58,percent of total billed charges,Implant Device,1727.95,35,,1727.95,percent of total billed charges,Implant Device,1727.95,35,,1727.95,percent of total billed charges,Implant Device,1727.95,35,,1727.95,percent of total billed charges,Implant Device,1727.95,35,,1727.95,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1678.58,34,"If Charge > 2,000, then 34 percent",1678.58,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3653.39,
STRYKER 5610-F-402 FEMORAL COMP SIZE 4,C1776,HCPCS,,79006830,CDM,278,RC,,,both,,,8352,6180.5,,,6180.5,Other,150% of Medicare + 9.63% HCRA Surcharge,3758.4,45,,3758.4,percent of total billed charges,Critical Access Hospital RCC factor,2839.68,34,,2839.68,percent of total billed charges,Implant Device,2839.68,34,,2839.68,percent of total billed charges,Implant Device,2839.68,34,,2839.68,percent of total billed charges,Implant Device,2839.68,34,,2839.68,percent of total billed charges,Implant Device,2839.68,34,,2839.68,percent of total billed charges,Implant Device,4134.24,,,4134.24,Other,110% of Medicare,2923.2,35,,2923.2,percent of total billed charges,Implant Device,2839.68,34,"Charges > $500, x 34%",2839.68,percent of total billed charges,Implant Device,2923.2,35,,2923.2,percent of total billed charges,Implant Device,2923.2,35,,2923.2,percent of total billed charges,Implant Device,2923.2,35,,2923.2,percent of total billed charges,Implant Device,2923.2,35,,2923.2,percent of total billed charges,Implant Device,2923.2,35,,2923.2,percent of total billed charges,Implant Device,3340.8,40,,3340.8,percent of total billed charges,Implant Device,2923.2,70,,2923.2,percent of total billed charges,All Other,2839.68,34,,2839.68,percent of total billed charges,Implant Device,2839.68,34,,2839.68,percent of total billed charges,Implant Device,2923.2,35,,2923.2,percent of total billed charges,Implant Device,2923.2,35,,2923.2,percent of total billed charges,Implant Device,2923.2,35,,2923.2,percent of total billed charges,Implant Device,2923.2,35,,2923.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2839.68,34,"If Charge > 2,000, then 34 percent",2839.68,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,6180.5,
ARTHREX AR-9055-55PT SCREW 5.5X55MM,C1713,HCPCS,,79006831,CDM,278,RC,,,both,,,3408,2521.93,,,2521.93,Other,150% of Medicare + 9.63% HCRA Surcharge,1533.6,45,,1533.6,percent of total billed charges,Critical Access Hospital RCC factor,1158.72,34,,1158.72,percent of total billed charges,Implant Device,1158.72,34,,1158.72,percent of total billed charges,Implant Device,1158.72,34,,1158.72,percent of total billed charges,Implant Device,1158.72,34,,1158.72,percent of total billed charges,Implant Device,1158.72,34,,1158.72,percent of total billed charges,Implant Device,1686.96,,,1686.96,Other,110% of Medicare,1192.8,35,,1192.8,percent of total billed charges,Implant Device,1158.72,34,"Charges > $500, x 34%",1158.72,percent of total billed charges,Implant Device,1192.8,35,,1192.8,percent of total billed charges,Implant Device,1192.8,35,,1192.8,percent of total billed charges,Implant Device,1192.8,35,,1192.8,percent of total billed charges,Implant Device,1192.8,35,,1192.8,percent of total billed charges,Implant Device,1192.8,35,,1192.8,percent of total billed charges,Implant Device,1363.2,40,,1363.2,percent of total billed charges,Implant Device,1192.8,70,,1192.8,percent of total billed charges,All Other,1158.72,34,,1158.72,percent of total billed charges,Implant Device,1158.72,34,,1158.72,percent of total billed charges,Implant Device,1192.8,35,,1192.8,percent of total billed charges,Implant Device,1192.8,35,,1192.8,percent of total billed charges,Implant Device,1192.8,35,,1192.8,percent of total billed charges,Implant Device,1192.8,35,,1192.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1158.72,34,"If Charge > 2,000, then 34 percent",1158.72,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2521.93,
STRYKER 58-19008E NON LOCK SCREW 1.9X8M,C1713,HCPCS,,79006832,CDM,278,RC,,,both,,,349,258.26,,,258.26,Other,150% of Medicare + 9.63% HCRA Surcharge,157.05,45,,157.05,percent of total billed charges,Critical Access Hospital RCC factor,118.66,34,,118.66,percent of total billed charges,Implant Device,118.66,34,,118.66,percent of total billed charges,Implant Device,118.66,34,,118.66,percent of total billed charges,Implant Device,118.66,34,,118.66,percent of total billed charges,Implant Device,118.66,34,,118.66,percent of total billed charges,Implant Device,172.76,,,172.76,Other,110% of Medicare,122.15,35,,122.15,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,122.15,35,,122.15,percent of total billed charges,Implant Device,122.15,35,,122.15,percent of total billed charges,Implant Device,122.15,35,,122.15,percent of total billed charges,Implant Device,122.15,35,,122.15,percent of total billed charges,Implant Device,122.15,35,,122.15,percent of total billed charges,Implant Device,139.6,40,,139.6,percent of total billed charges,Implant Device,122.15,70,,122.15,percent of total billed charges,All Other,118.66,34,,118.66,percent of total billed charges,Implant Device,118.66,34,,118.66,percent of total billed charges,Implant Device,122.15,35,,122.15,percent of total billed charges,Implant Device,122.15,35,,122.15,percent of total billed charges,Implant Device,122.15,35,,122.15,percent of total billed charges,Implant Device,122.15,35,,122.15,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,258.26,
STRYKER 57-13408 PLATE STRAIGHT 6 HOLE,C1713,HCPCS,,79006833,CDM,278,RC,,,both,,,1206,892.44,,,892.44,Other,150% of Medicare + 9.63% HCRA Surcharge,542.7,45,,542.7,percent of total billed charges,Critical Access Hospital RCC factor,410.04,34,,410.04,percent of total billed charges,Implant Device,410.04,34,,410.04,percent of total billed charges,Implant Device,410.04,34,,410.04,percent of total billed charges,Implant Device,410.04,34,,410.04,percent of total billed charges,Implant Device,410.04,34,,410.04,percent of total billed charges,Implant Device,596.97,,,596.97,Other,110% of Medicare,422.1,35,,422.1,percent of total billed charges,Implant Device,410.04,34,"Charges > $500, x 34%",410.04,percent of total billed charges,Implant Device,422.1,35,,422.1,percent of total billed charges,Implant Device,422.1,35,,422.1,percent of total billed charges,Implant Device,422.1,35,,422.1,percent of total billed charges,Implant Device,422.1,35,,422.1,percent of total billed charges,Implant Device,422.1,35,,422.1,percent of total billed charges,Implant Device,482.4,40,,482.4,percent of total billed charges,Implant Device,422.1,70,,422.1,percent of total billed charges,All Other,410.04,34,,410.04,percent of total billed charges,Implant Device,410.04,34,,410.04,percent of total billed charges,Implant Device,422.1,35,,422.1,percent of total billed charges,Implant Device,422.1,35,,422.1,percent of total billed charges,Implant Device,422.1,35,,422.1,percent of total billed charges,Implant Device,422.1,35,,422.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,892.44,
MEDTRONIC DDBB1D1 EVERA XT ICD-DR,C1721,HCPCS,,79006835,CDM,278,RC,,,both,,,60608,44850.07,,,44850.07,Other,150% of Medicare + 9.63% HCRA Surcharge,27273.6,45,,27273.6,percent of total billed charges,Critical Access Hospital RCC factor,20606.72,34,,20606.72,percent of total billed charges,Implant Device,20606.72,34,,20606.72,percent of total billed charges,Implant Device,20606.72,34,,20606.72,percent of total billed charges,Implant Device,20606.72,34,,20606.72,percent of total billed charges,Implant Device,20606.72,34,,20606.72,percent of total billed charges,Implant Device,30000.96,,,30000.96,Other,110% of Medicare,21212.8,35,,21212.8,percent of total billed charges,Implant Device,20606.72,34,"Charges > $500, x 34%",20606.72,percent of total billed charges,Implant Device,21212.8,35,,21212.8,percent of total billed charges,Implant Device,21212.8,35,,21212.8,percent of total billed charges,Implant Device,21212.8,35,,21212.8,percent of total billed charges,Implant Device,21212.8,35,,21212.8,percent of total billed charges,Implant Device,21212.8,35,,21212.8,percent of total billed charges,Implant Device,24243.2,40,,24243.2,percent of total billed charges,Implant Device,21212.8,70,,21212.8,percent of total billed charges,All Other,20606.72,34,,20606.72,percent of total billed charges,Implant Device,20606.72,34,,20606.72,percent of total billed charges,Implant Device,21212.8,35,,21212.8,percent of total billed charges,Implant Device,21212.8,35,,21212.8,percent of total billed charges,Implant Device,21212.8,35,,21212.8,percent of total billed charges,Implant Device,21212.8,35,,21212.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,20606.72,34,"If Charge > 2,000, then 34 percent",20606.72,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,44850.07,
MEDTRONIC DTBA1Q1 VIVA QUAD XT CRT-D,C1882,HCPCS,,79006836,CDM,278,RC,,,both,,,75731,56041.13,,,56041.13,Other,150% of Medicare + 9.63% HCRA Surcharge,34078.95,45,,34078.95,percent of total billed charges,Critical Access Hospital RCC factor,25748.54,34,,25748.54,percent of total billed charges,Implant Device,25748.54,34,,25748.54,percent of total billed charges,Implant Device,25748.54,34,,25748.54,percent of total billed charges,Implant Device,25748.54,34,,25748.54,percent of total billed charges,Implant Device,25748.54,34,,25748.54,percent of total billed charges,Implant Device,37486.85,,,37486.85,Other,110% of Medicare,26505.85,35,,26505.85,percent of total billed charges,Implant Device,25748.54,34,"Charges > $500, x 34%",25748.54,percent of total billed charges,Implant Device,26505.85,35,,26505.85,percent of total billed charges,Implant Device,26505.85,35,,26505.85,percent of total billed charges,Implant Device,26505.85,35,,26505.85,percent of total billed charges,Implant Device,26505.85,35,,26505.85,percent of total billed charges,Implant Device,26505.85,35,,26505.85,percent of total billed charges,Implant Device,30292.4,40,,30292.4,percent of total billed charges,Implant Device,26505.85,70,,26505.85,percent of total billed charges,All Other,25748.54,34,,25748.54,percent of total billed charges,Implant Device,25748.54,34,,25748.54,percent of total billed charges,Implant Device,26505.85,35,,26505.85,percent of total billed charges,Implant Device,26505.85,35,,26505.85,percent of total billed charges,Implant Device,26505.85,35,,26505.85,percent of total billed charges,Implant Device,26505.85,35,,26505.85,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,25748.54,34,"If Charge > 2,000, then 34 percent",25748.54,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,56041.13,
MEDTRONIC 4298XX ATTAIN PERFORMA LEAD,C1900,HCPCS,,79006838,CDM,278,RC,,,both,,,6875,5087.52,,,5087.52,Other,150% of Medicare + 9.63% HCRA Surcharge,3093.75,45,,3093.75,percent of total billed charges,Critical Access Hospital RCC factor,2337.5,34,,2337.5,percent of total billed charges,Implant Device,2337.5,34,,2337.5,percent of total billed charges,Implant Device,2337.5,34,,2337.5,percent of total billed charges,Implant Device,2337.5,34,,2337.5,percent of total billed charges,Implant Device,2337.5,34,,2337.5,percent of total billed charges,Implant Device,3403.13,,,3403.13,Other,110% of Medicare,2406.25,35,,2406.25,percent of total billed charges,Implant Device,2337.5,34,"Charges > $500, x 34%",2337.5,percent of total billed charges,Implant Device,2406.25,35,,2406.25,percent of total billed charges,Implant Device,2406.25,35,,2406.25,percent of total billed charges,Implant Device,2406.25,35,,2406.25,percent of total billed charges,Implant Device,2406.25,35,,2406.25,percent of total billed charges,Implant Device,2406.25,35,,2406.25,percent of total billed charges,Implant Device,2750,40,,2750,percent of total billed charges,Implant Device,2406.25,70,,2406.25,percent of total billed charges,All Other,2337.5,34,,2337.5,percent of total billed charges,Implant Device,2337.5,34,,2337.5,percent of total billed charges,Implant Device,2406.25,35,,2406.25,percent of total billed charges,Implant Device,2406.25,35,,2406.25,percent of total billed charges,Implant Device,2406.25,35,,2406.25,percent of total billed charges,Implant Device,2406.25,35,,2406.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2337.5,34,"If Charge > 2,000, then 34 percent",2337.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5087.52,
GORE VBJ061002 VIABAHN 6MMX10CM STENT,C1876,HCPCS,,79006839,CDM,278,RC,,,both,,,10185,7536.93,,,7536.93,Other,150% of Medicare + 9.63% HCRA Surcharge,4583.25,45,,4583.25,percent of total billed charges,Critical Access Hospital RCC factor,3462.9,34,,3462.9,percent of total billed charges,Implant Device,3462.9,34,,3462.9,percent of total billed charges,Implant Device,3462.9,34,,3462.9,percent of total billed charges,Implant Device,3462.9,34,,3462.9,percent of total billed charges,Implant Device,3462.9,34,,3462.9,percent of total billed charges,Implant Device,5041.58,,,5041.58,Other,110% of Medicare,3564.75,35,,3564.75,percent of total billed charges,Implant Device,3462.9,34,"Charges > $500, x 34%",3462.9,percent of total billed charges,Implant Device,3564.75,35,,3564.75,percent of total billed charges,Implant Device,3564.75,35,,3564.75,percent of total billed charges,Implant Device,3564.75,35,,3564.75,percent of total billed charges,Implant Device,3564.75,35,,3564.75,percent of total billed charges,Implant Device,3564.75,35,,3564.75,percent of total billed charges,Implant Device,4074,40,,4074,percent of total billed charges,Implant Device,3564.75,70,,3564.75,percent of total billed charges,All Other,3462.9,34,,3462.9,percent of total billed charges,Implant Device,3462.9,34,,3462.9,percent of total billed charges,Implant Device,3564.75,35,,3564.75,percent of total billed charges,Implant Device,3564.75,35,,3564.75,percent of total billed charges,Implant Device,3564.75,35,,3564.75,percent of total billed charges,Implant Device,3564.75,35,,3564.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3462.9,34,"If Charge > 2,000, then 34 percent",3462.9,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,7536.93,
GORE VBJ061502 VIABAHN 6MMX15CM STENT,C1876,HCPCS,,79006840,CDM,278,RC,,,both,,,12270,9079.83,,,9079.83,Other,150% of Medicare + 9.63% HCRA Surcharge,5521.5,45,,5521.5,percent of total billed charges,Critical Access Hospital RCC factor,4171.8,34,,4171.8,percent of total billed charges,Implant Device,4171.8,34,,4171.8,percent of total billed charges,Implant Device,4171.8,34,,4171.8,percent of total billed charges,Implant Device,4171.8,34,,4171.8,percent of total billed charges,Implant Device,4171.8,34,,4171.8,percent of total billed charges,Implant Device,6073.65,,,6073.65,Other,110% of Medicare,4294.5,35,,4294.5,percent of total billed charges,Implant Device,4171.8,34,"Charges > $500, x 34%",4171.8,percent of total billed charges,Implant Device,4294.5,35,,4294.5,percent of total billed charges,Implant Device,4294.5,35,,4294.5,percent of total billed charges,Implant Device,4294.5,35,,4294.5,percent of total billed charges,Implant Device,4294.5,35,,4294.5,percent of total billed charges,Implant Device,4294.5,35,,4294.5,percent of total billed charges,Implant Device,4908,40,,4908,percent of total billed charges,Implant Device,4294.5,70,,4294.5,percent of total billed charges,All Other,4171.8,34,,4171.8,percent of total billed charges,Implant Device,4171.8,34,,4171.8,percent of total billed charges,Implant Device,4294.5,35,,4294.5,percent of total billed charges,Implant Device,4294.5,35,,4294.5,percent of total billed charges,Implant Device,4294.5,35,,4294.5,percent of total billed charges,Implant Device,4294.5,35,,4294.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,4171.8,34,"If Charge > 2,000, then 34 percent",4171.8,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,9079.83,
BIOCOMPOSITES 620-020 STIMULAN 20CC,C1713,HCPCS,,79006841,CDM,278,RC,,,both,,,9570,7081.82,,,7081.82,Other,150% of Medicare + 9.63% HCRA Surcharge,4306.5,45,,4306.5,percent of total billed charges,Critical Access Hospital RCC factor,3253.8,34,,3253.8,percent of total billed charges,Implant Device,3253.8,34,,3253.8,percent of total billed charges,Implant Device,3253.8,34,,3253.8,percent of total billed charges,Implant Device,3253.8,34,,3253.8,percent of total billed charges,Implant Device,3253.8,34,,3253.8,percent of total billed charges,Implant Device,4737.15,,,4737.15,Other,110% of Medicare,3349.5,35,,3349.5,percent of total billed charges,Implant Device,3253.8,34,"Charges > $500, x 34%",3253.8,percent of total billed charges,Implant Device,3349.5,35,,3349.5,percent of total billed charges,Implant Device,3349.5,35,,3349.5,percent of total billed charges,Implant Device,3349.5,35,,3349.5,percent of total billed charges,Implant Device,3349.5,35,,3349.5,percent of total billed charges,Implant Device,3349.5,35,,3349.5,percent of total billed charges,Implant Device,3828,40,,3828,percent of total billed charges,Implant Device,3349.5,70,,3349.5,percent of total billed charges,All Other,3253.8,34,,3253.8,percent of total billed charges,Implant Device,3253.8,34,,3253.8,percent of total billed charges,Implant Device,3349.5,35,,3349.5,percent of total billed charges,Implant Device,3349.5,35,,3349.5,percent of total billed charges,Implant Device,3349.5,35,,3349.5,percent of total billed charges,Implant Device,3349.5,35,,3349.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3253.8,34,"If Charge > 2,000, then 34 percent",3253.8,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,7081.82,
BOST SCI M00616720 18X153 ESOPH STENT,C1874,HCPCS,,79006844,CDM,278,RC,,,both,,,7726,5717.26,,,5717.26,Other,150% of Medicare + 9.63% HCRA Surcharge,3476.7,45,,3476.7,percent of total billed charges,Critical Access Hospital RCC factor,2626.84,34,,2626.84,percent of total billed charges,Implant Device,2626.84,34,,2626.84,percent of total billed charges,Implant Device,2626.84,34,,2626.84,percent of total billed charges,Implant Device,2626.84,34,,2626.84,percent of total billed charges,Implant Device,2626.84,34,,2626.84,percent of total billed charges,Implant Device,3824.37,,,3824.37,Other,110% of Medicare,2704.1,35,,2704.1,percent of total billed charges,Implant Device,2626.84,34,"Charges > $500, x 34%",2626.84,percent of total billed charges,Implant Device,2704.1,35,,2704.1,percent of total billed charges,Implant Device,2704.1,35,,2704.1,percent of total billed charges,Implant Device,2704.1,35,,2704.1,percent of total billed charges,Implant Device,2704.1,35,,2704.1,percent of total billed charges,Implant Device,2704.1,35,,2704.1,percent of total billed charges,Implant Device,3090.4,40,,3090.4,percent of total billed charges,Implant Device,2704.1,70,,2704.1,percent of total billed charges,All Other,2626.84,34,,2626.84,percent of total billed charges,Implant Device,2626.84,34,,2626.84,percent of total billed charges,Implant Device,2704.1,35,,2704.1,percent of total billed charges,Implant Device,2704.1,35,,2704.1,percent of total billed charges,Implant Device,2704.1,35,,2704.1,percent of total billed charges,Implant Device,2704.1,35,,2704.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2626.84,34,"If Charge > 2,000, then 34 percent",2626.84,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5717.26,
DEPUY 02.200.018 3.5X18MM CORTEX SCREW,C1713,HCPCS,,79006846,CDM,278,RC,,,both,,,95,70.3,,,70.3,Other,150% of Medicare + 9.63% HCRA Surcharge,42.75,45,,42.75,percent of total billed charges,Critical Access Hospital RCC factor,32.3,34,,32.3,percent of total billed charges,Implant Device,32.3,34,,32.3,percent of total billed charges,Implant Device,32.3,34,,32.3,percent of total billed charges,Implant Device,32.3,34,,32.3,percent of total billed charges,Implant Device,32.3,34,,32.3,percent of total billed charges,Implant Device,47.03,,,47.03,Other,110% of Medicare,33.25,35,,33.25,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,33.25,35,,33.25,percent of total billed charges,Implant Device,33.25,35,,33.25,percent of total billed charges,Implant Device,33.25,35,,33.25,percent of total billed charges,Implant Device,33.25,35,,33.25,percent of total billed charges,Implant Device,33.25,35,,33.25,percent of total billed charges,Implant Device,38,40,,38,percent of total billed charges,Implant Device,33.25,70,,33.25,percent of total billed charges,All Other,32.3,34,,32.3,percent of total billed charges,Implant Device,32.3,34,,32.3,percent of total billed charges,Implant Device,33.25,35,,33.25,percent of total billed charges,Implant Device,33.25,35,,33.25,percent of total billed charges,Implant Device,33.25,35,,33.25,percent of total billed charges,Implant Device,33.25,35,,33.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,70.3,
DEPUY 02.200.016 3.5X16MM CORTEX SCREW,C1713,HCPCS,,79006847,CDM,278,RC,,,both,,,99,73.26,,,73.26,Other,150% of Medicare + 9.63% HCRA Surcharge,44.55,45,,44.55,percent of total billed charges,Critical Access Hospital RCC factor,33.66,34,,33.66,percent of total billed charges,Implant Device,33.66,34,,33.66,percent of total billed charges,Implant Device,33.66,34,,33.66,percent of total billed charges,Implant Device,33.66,34,,33.66,percent of total billed charges,Implant Device,33.66,34,,33.66,percent of total billed charges,Implant Device,49.01,,,49.01,Other,110% of Medicare,34.65,35,,34.65,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,34.65,35,,34.65,percent of total billed charges,Implant Device,34.65,35,,34.65,percent of total billed charges,Implant Device,34.65,35,,34.65,percent of total billed charges,Implant Device,34.65,35,,34.65,percent of total billed charges,Implant Device,34.65,35,,34.65,percent of total billed charges,Implant Device,39.6,40,,39.6,percent of total billed charges,Implant Device,34.65,70,,34.65,percent of total billed charges,All Other,33.66,34,,33.66,percent of total billed charges,Implant Device,33.66,34,,33.66,percent of total billed charges,Implant Device,34.65,35,,34.65,percent of total billed charges,Implant Device,34.65,35,,34.65,percent of total billed charges,Implant Device,34.65,35,,34.65,percent of total billed charges,Implant Device,34.65,35,,34.65,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,73.26,
ZIMMER 5630-G-608 TIBIAL INSERT #6 X 8MM,C1776,HCPCS,,79006850,CDM,278,RC,,,both,,,3232,2391.69,,,2391.69,Other,150% of Medicare + 9.63% HCRA Surcharge,1454.4,45,,1454.4,percent of total billed charges,Critical Access Hospital RCC factor,1098.88,34,,1098.88,percent of total billed charges,Implant Device,1098.88,34,,1098.88,percent of total billed charges,Implant Device,1098.88,34,,1098.88,percent of total billed charges,Implant Device,1098.88,34,,1098.88,percent of total billed charges,Implant Device,1098.88,34,,1098.88,percent of total billed charges,Implant Device,1599.84,,,1599.84,Other,110% of Medicare,1131.2,35,,1131.2,percent of total billed charges,Implant Device,1098.88,34,"Charges > $500, x 34%",1098.88,percent of total billed charges,Implant Device,1131.2,35,,1131.2,percent of total billed charges,Implant Device,1131.2,35,,1131.2,percent of total billed charges,Implant Device,1131.2,35,,1131.2,percent of total billed charges,Implant Device,1131.2,35,,1131.2,percent of total billed charges,Implant Device,1131.2,35,,1131.2,percent of total billed charges,Implant Device,1292.8,40,,1292.8,percent of total billed charges,Implant Device,1131.2,70,,1131.2,percent of total billed charges,All Other,1098.88,34,,1098.88,percent of total billed charges,Implant Device,1098.88,34,,1098.88,percent of total billed charges,Implant Device,1131.2,35,,1131.2,percent of total billed charges,Implant Device,1131.2,35,,1131.2,percent of total billed charges,Implant Device,1131.2,35,,1131.2,percent of total billed charges,Implant Device,1131.2,35,,1131.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1098.88,34,"If Charge > 2,000, then 34 percent",1098.88,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2391.69,
ZIMMER 5620-B-601 TIBIAL BASEPLATE #6,C1776,HCPCS,,79006851,CDM,278,RC,,,both,,,4937,3653.39,,,3653.39,Other,150% of Medicare + 9.63% HCRA Surcharge,2221.65,45,,2221.65,percent of total billed charges,Critical Access Hospital RCC factor,1678.58,34,,1678.58,percent of total billed charges,Implant Device,1678.58,34,,1678.58,percent of total billed charges,Implant Device,1678.58,34,,1678.58,percent of total billed charges,Implant Device,1678.58,34,,1678.58,percent of total billed charges,Implant Device,1678.58,34,,1678.58,percent of total billed charges,Implant Device,2443.82,,,2443.82,Other,110% of Medicare,1727.95,35,,1727.95,percent of total billed charges,Implant Device,1678.58,34,"Charges > $500, x 34%",1678.58,percent of total billed charges,Implant Device,1727.95,35,,1727.95,percent of total billed charges,Implant Device,1727.95,35,,1727.95,percent of total billed charges,Implant Device,1727.95,35,,1727.95,percent of total billed charges,Implant Device,1727.95,35,,1727.95,percent of total billed charges,Implant Device,1727.95,35,,1727.95,percent of total billed charges,Implant Device,1974.8,40,,1974.8,percent of total billed charges,Implant Device,1727.95,70,,1727.95,percent of total billed charges,All Other,1678.58,34,,1678.58,percent of total billed charges,Implant Device,1678.58,34,,1678.58,percent of total billed charges,Implant Device,1727.95,35,,1727.95,percent of total billed charges,Implant Device,1727.95,35,,1727.95,percent of total billed charges,Implant Device,1727.95,35,,1727.95,percent of total billed charges,Implant Device,1727.95,35,,1727.95,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1678.58,34,"If Charge > 2,000, then 34 percent",1678.58,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3653.39,
ARTHREX AR-8740-20PTS 4X20MM SCREW,C1713,HCPCS,,79006852,CDM,278,RC,,,both,,,496,367.04,,,367.04,Other,150% of Medicare + 9.63% HCRA Surcharge,223.2,45,,223.2,percent of total billed charges,Critical Access Hospital RCC factor,168.64,34,,168.64,percent of total billed charges,Implant Device,168.64,34,,168.64,percent of total billed charges,Implant Device,168.64,34,,168.64,percent of total billed charges,Implant Device,168.64,34,,168.64,percent of total billed charges,Implant Device,168.64,34,,168.64,percent of total billed charges,Implant Device,245.52,,,245.52,Other,110% of Medicare,173.6,35,,173.6,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,173.6,35,,173.6,percent of total billed charges,Implant Device,173.6,35,,173.6,percent of total billed charges,Implant Device,173.6,35,,173.6,percent of total billed charges,Implant Device,173.6,35,,173.6,percent of total billed charges,Implant Device,173.6,35,,173.6,percent of total billed charges,Implant Device,198.4,40,,198.4,percent of total billed charges,Implant Device,173.6,70,,173.6,percent of total billed charges,All Other,168.64,34,,168.64,percent of total billed charges,Implant Device,168.64,34,,168.64,percent of total billed charges,Implant Device,173.6,35,,173.6,percent of total billed charges,Implant Device,173.6,35,,173.6,percent of total billed charges,Implant Device,173.6,35,,173.6,percent of total billed charges,Implant Device,173.6,35,,173.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,367.04,
ARTHREX AR-8740-30PTS 4X30MM SCREW,C1713,HCPCS,,79006853,CDM,278,RC,,,both,,,495,366.3,,,366.3,Other,150% of Medicare + 9.63% HCRA Surcharge,222.75,45,,222.75,percent of total billed charges,Critical Access Hospital RCC factor,168.3,34,,168.3,percent of total billed charges,Implant Device,168.3,34,,168.3,percent of total billed charges,Implant Device,168.3,34,,168.3,percent of total billed charges,Implant Device,168.3,34,,168.3,percent of total billed charges,Implant Device,168.3,34,,168.3,percent of total billed charges,Implant Device,245.03,,,245.03,Other,110% of Medicare,173.25,35,,173.25,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,173.25,35,,173.25,percent of total billed charges,Implant Device,173.25,35,,173.25,percent of total billed charges,Implant Device,173.25,35,,173.25,percent of total billed charges,Implant Device,173.25,35,,173.25,percent of total billed charges,Implant Device,173.25,35,,173.25,percent of total billed charges,Implant Device,198,40,,198,percent of total billed charges,Implant Device,173.25,70,,173.25,percent of total billed charges,All Other,168.3,34,,168.3,percent of total billed charges,Implant Device,168.3,34,,168.3,percent of total billed charges,Implant Device,173.25,35,,173.25,percent of total billed charges,Implant Device,173.25,35,,173.25,percent of total billed charges,Implant Device,173.25,35,,173.25,percent of total billed charges,Implant Device,173.25,35,,173.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,366.3,
ARTHREX AR-8740-28H 4X28MM THREAD SCREW,C1713,HCPCS,,79006854,CDM,278,RC,,,both,,,886,655.64,,,655.64,Other,150% of Medicare + 9.63% HCRA Surcharge,398.7,45,,398.7,percent of total billed charges,Critical Access Hospital RCC factor,301.24,34,,301.24,percent of total billed charges,Implant Device,301.24,34,,301.24,percent of total billed charges,Implant Device,301.24,34,,301.24,percent of total billed charges,Implant Device,301.24,34,,301.24,percent of total billed charges,Implant Device,301.24,34,,301.24,percent of total billed charges,Implant Device,438.57,,,438.57,Other,110% of Medicare,310.1,35,,310.1,percent of total billed charges,Implant Device,301.24,34,"Charges > $500, x 34%",301.24,percent of total billed charges,Implant Device,310.1,35,,310.1,percent of total billed charges,Implant Device,310.1,35,,310.1,percent of total billed charges,Implant Device,310.1,35,,310.1,percent of total billed charges,Implant Device,310.1,35,,310.1,percent of total billed charges,Implant Device,310.1,35,,310.1,percent of total billed charges,Implant Device,354.4,40,,354.4,percent of total billed charges,Implant Device,310.1,70,,310.1,percent of total billed charges,All Other,301.24,34,,301.24,percent of total billed charges,Implant Device,301.24,34,,301.24,percent of total billed charges,Implant Device,310.1,35,,310.1,percent of total billed charges,Implant Device,310.1,35,,310.1,percent of total billed charges,Implant Device,310.1,35,,310.1,percent of total billed charges,Implant Device,310.1,35,,310.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,655.64,
ARTHREX AR-8737-42 1.1 K WIRE,C1713,HCPCS,,79006855,CDM,278,RC,,,both,,,78,57.72,,,57.72,Other,150% of Medicare + 9.63% HCRA Surcharge,35.1,45,,35.1,percent of total billed charges,Critical Access Hospital RCC factor,26.52,34,,26.52,percent of total billed charges,Implant Device,26.52,34,,26.52,percent of total billed charges,Implant Device,26.52,34,,26.52,percent of total billed charges,Implant Device,26.52,34,,26.52,percent of total billed charges,Implant Device,26.52,34,,26.52,percent of total billed charges,Implant Device,38.61,,,38.61,Other,110% of Medicare,27.3,35,,27.3,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,27.3,35,,27.3,percent of total billed charges,Implant Device,27.3,35,,27.3,percent of total billed charges,Implant Device,27.3,35,,27.3,percent of total billed charges,Implant Device,27.3,35,,27.3,percent of total billed charges,Implant Device,27.3,35,,27.3,percent of total billed charges,Implant Device,31.2,40,,31.2,percent of total billed charges,Implant Device,27.3,70,,27.3,percent of total billed charges,All Other,26.52,34,,26.52,percent of total billed charges,Implant Device,26.52,34,,26.52,percent of total billed charges,Implant Device,27.3,35,,27.3,percent of total billed charges,Implant Device,27.3,35,,27.3,percent of total billed charges,Implant Device,27.3,35,,27.3,percent of total billed charges,Implant Device,27.3,35,,27.3,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,57.72,
ARTHREX AR-8737-22 .86 THREAD TIP K-WIRE,C1713,HCPCS,,79006856,CDM,278,RC,,,both,,,60,44.4,,,44.4,Other,150% of Medicare + 9.63% HCRA Surcharge,27,45,,27,percent of total billed charges,Critical Access Hospital RCC factor,20.4,34,,20.4,percent of total billed charges,Implant Device,20.4,34,,20.4,percent of total billed charges,Implant Device,20.4,34,,20.4,percent of total billed charges,Implant Device,20.4,34,,20.4,percent of total billed charges,Implant Device,20.4,34,,20.4,percent of total billed charges,Implant Device,29.7,,,29.7,Other,110% of Medicare,21,35,,21,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,21,35,,21,percent of total billed charges,Implant Device,21,35,,21,percent of total billed charges,Implant Device,21,35,,21,percent of total billed charges,Implant Device,21,35,,21,percent of total billed charges,Implant Device,21,35,,21,percent of total billed charges,Implant Device,24,40,,24,percent of total billed charges,Implant Device,21,70,,21,percent of total billed charges,All Other,20.4,34,,20.4,percent of total billed charges,Implant Device,20.4,34,,20.4,percent of total billed charges,Implant Device,21,35,,21,percent of total billed charges,Implant Device,21,35,,21,percent of total billed charges,Implant Device,21,35,,21,percent of total billed charges,Implant Device,21,35,,21,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,44.4,
ARTHREX AR-8956-01 5TH MERAT HOOK PLATE,C1713,HCPCS,,79006857,CDM,278,RC,,,both,,,2775,2053.51,,,2053.51,Other,150% of Medicare + 9.63% HCRA Surcharge,1248.75,45,,1248.75,percent of total billed charges,Critical Access Hospital RCC factor,943.5,34,,943.5,percent of total billed charges,Implant Device,943.5,34,,943.5,percent of total billed charges,Implant Device,943.5,34,,943.5,percent of total billed charges,Implant Device,943.5,34,,943.5,percent of total billed charges,Implant Device,943.5,34,,943.5,percent of total billed charges,Implant Device,1373.63,,,1373.63,Other,110% of Medicare,971.25,35,,971.25,percent of total billed charges,Implant Device,943.5,34,"Charges > $500, x 34%",943.5,percent of total billed charges,Implant Device,971.25,35,,971.25,percent of total billed charges,Implant Device,971.25,35,,971.25,percent of total billed charges,Implant Device,971.25,35,,971.25,percent of total billed charges,Implant Device,971.25,35,,971.25,percent of total billed charges,Implant Device,971.25,35,,971.25,percent of total billed charges,Implant Device,1110,40,,1110,percent of total billed charges,Implant Device,971.25,70,,971.25,percent of total billed charges,All Other,943.5,34,,943.5,percent of total billed charges,Implant Device,943.5,34,,943.5,percent of total billed charges,Implant Device,971.25,35,,971.25,percent of total billed charges,Implant Device,971.25,35,,971.25,percent of total billed charges,Implant Device,971.25,35,,971.25,percent of total billed charges,Implant Device,971.25,35,,971.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,943.5,34,"If Charge > 2,000, then 34 percent",943.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2053.51,
ARTHREX AR-8724V-08 2.4X8MM LOCK SCREW,C1713,HCPCS,,79006858,CDM,278,RC,,,both,,,420,310.8,,,310.8,Other,150% of Medicare + 9.63% HCRA Surcharge,189,45,,189,percent of total billed charges,Critical Access Hospital RCC factor,142.8,34,,142.8,percent of total billed charges,Implant Device,142.8,34,,142.8,percent of total billed charges,Implant Device,142.8,34,,142.8,percent of total billed charges,Implant Device,142.8,34,,142.8,percent of total billed charges,Implant Device,142.8,34,,142.8,percent of total billed charges,Implant Device,207.9,,,207.9,Other,110% of Medicare,147,35,,147,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,147,35,,147,percent of total billed charges,Implant Device,147,35,,147,percent of total billed charges,Implant Device,147,35,,147,percent of total billed charges,Implant Device,147,35,,147,percent of total billed charges,Implant Device,147,35,,147,percent of total billed charges,Implant Device,168,40,,168,percent of total billed charges,Implant Device,147,70,,147,percent of total billed charges,All Other,142.8,34,,142.8,percent of total billed charges,Implant Device,142.8,34,,142.8,percent of total billed charges,Implant Device,147,35,,147,percent of total billed charges,Implant Device,147,35,,147,percent of total billed charges,Implant Device,147,35,,147,percent of total billed charges,Implant Device,147,35,,147,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,310.8,
ARTHREX AR-8724-10 2.4X10MM NON-LCK SCRW,C1713,HCPCS,,79006859,CDM,278,RC,,,both,,,330,244.2,,,244.2,Other,150% of Medicare + 9.63% HCRA Surcharge,148.5,45,,148.5,percent of total billed charges,Critical Access Hospital RCC factor,112.2,34,,112.2,percent of total billed charges,Implant Device,112.2,34,,112.2,percent of total billed charges,Implant Device,112.2,34,,112.2,percent of total billed charges,Implant Device,112.2,34,,112.2,percent of total billed charges,Implant Device,112.2,34,,112.2,percent of total billed charges,Implant Device,163.35,,,163.35,Other,110% of Medicare,115.5,35,,115.5,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,132,40,,132,percent of total billed charges,Implant Device,115.5,70,,115.5,percent of total billed charges,All Other,112.2,34,,112.2,percent of total billed charges,Implant Device,112.2,34,,112.2,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,244.2,
STRYKER ORTHO 437123 3 HOLE RT PROX PLTE,C1713,HCPCS,,79006860,CDM,278,RC,,,both,,,5483,4057.43,,,4057.43,Other,150% of Medicare + 9.63% HCRA Surcharge,2467.35,45,,2467.35,percent of total billed charges,Critical Access Hospital RCC factor,1864.22,34,,1864.22,percent of total billed charges,Implant Device,1864.22,34,,1864.22,percent of total billed charges,Implant Device,1864.22,34,,1864.22,percent of total billed charges,Implant Device,1864.22,34,,1864.22,percent of total billed charges,Implant Device,1864.22,34,,1864.22,percent of total billed charges,Implant Device,2714.09,,,2714.09,Other,110% of Medicare,1919.05,35,,1919.05,percent of total billed charges,Implant Device,1864.22,34,"Charges > $500, x 34%",1864.22,percent of total billed charges,Implant Device,1919.05,35,,1919.05,percent of total billed charges,Implant Device,1919.05,35,,1919.05,percent of total billed charges,Implant Device,1919.05,35,,1919.05,percent of total billed charges,Implant Device,1919.05,35,,1919.05,percent of total billed charges,Implant Device,1919.05,35,,1919.05,percent of total billed charges,Implant Device,2193.2,40,,2193.2,percent of total billed charges,Implant Device,1919.05,70,,1919.05,percent of total billed charges,All Other,1864.22,34,,1864.22,percent of total billed charges,Implant Device,1864.22,34,,1864.22,percent of total billed charges,Implant Device,1919.05,35,,1919.05,percent of total billed charges,Implant Device,1919.05,35,,1919.05,percent of total billed charges,Implant Device,1919.05,35,,1919.05,percent of total billed charges,Implant Device,1919.05,35,,1919.05,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1864.22,34,"If Charge > 2,000, then 34 percent",1864.22,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4057.43,
STRYKER ORTHO 338620 3.5X20MM CORT SCREW,C1713,HCPCS,,79006861,CDM,278,RC,,,both,,,120,88.8,,,88.8,Other,150% of Medicare + 9.63% HCRA Surcharge,54,45,,54,percent of total billed charges,Critical Access Hospital RCC factor,40.8,34,,40.8,percent of total billed charges,Implant Device,40.8,34,,40.8,percent of total billed charges,Implant Device,40.8,34,,40.8,percent of total billed charges,Implant Device,40.8,34,,40.8,percent of total billed charges,Implant Device,40.8,34,,40.8,percent of total billed charges,Implant Device,59.4,,,59.4,Other,110% of Medicare,42,35,,42,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,42,35,,42,percent of total billed charges,Implant Device,42,35,,42,percent of total billed charges,Implant Device,42,35,,42,percent of total billed charges,Implant Device,42,35,,42,percent of total billed charges,Implant Device,42,35,,42,percent of total billed charges,Implant Device,48,40,,48,percent of total billed charges,Implant Device,42,70,,42,percent of total billed charges,All Other,40.8,34,,40.8,percent of total billed charges,Implant Device,40.8,34,,40.8,percent of total billed charges,Implant Device,42,35,,42,percent of total billed charges,Implant Device,42,35,,42,percent of total billed charges,Implant Device,42,35,,42,percent of total billed charges,Implant Device,42,35,,42,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,88.8,
STRYKER ORTHO 345430 4X30MM CANCEL SCREW,C1713,HCPCS,,79006862,CDM,278,RC,,,both,,,104,76.96,,,76.96,Other,150% of Medicare + 9.63% HCRA Surcharge,46.8,45,,46.8,percent of total billed charges,Critical Access Hospital RCC factor,35.36,34,,35.36,percent of total billed charges,Implant Device,35.36,34,,35.36,percent of total billed charges,Implant Device,35.36,34,,35.36,percent of total billed charges,Implant Device,35.36,34,,35.36,percent of total billed charges,Implant Device,35.36,34,,35.36,percent of total billed charges,Implant Device,51.48,,,51.48,Other,110% of Medicare,36.4,35,,36.4,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,36.4,35,,36.4,percent of total billed charges,Implant Device,36.4,35,,36.4,percent of total billed charges,Implant Device,36.4,35,,36.4,percent of total billed charges,Implant Device,36.4,35,,36.4,percent of total billed charges,Implant Device,36.4,35,,36.4,percent of total billed charges,Implant Device,41.6,40,,41.6,percent of total billed charges,Implant Device,36.4,70,,36.4,percent of total billed charges,All Other,35.36,34,,35.36,percent of total billed charges,Implant Device,35.36,34,,35.36,percent of total billed charges,Implant Device,36.4,35,,36.4,percent of total billed charges,Implant Device,36.4,35,,36.4,percent of total billed charges,Implant Device,36.4,35,,36.4,percent of total billed charges,Implant Device,36.4,35,,36.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,76.96,
SYNTHES 204.826 CORTEX SCREW 3.5X26MM,C1713,HCPCS,,79006868,CDM,278,RC,,,both,,,57,42.18,,,42.18,Other,150% of Medicare + 9.63% HCRA Surcharge,25.65,45,,25.65,percent of total billed charges,Critical Access Hospital RCC factor,19.38,34,,19.38,percent of total billed charges,Implant Device,19.38,34,,19.38,percent of total billed charges,Implant Device,19.38,34,,19.38,percent of total billed charges,Implant Device,19.38,34,,19.38,percent of total billed charges,Implant Device,19.38,34,,19.38,percent of total billed charges,Implant Device,28.22,,,28.22,Other,110% of Medicare,19.95,35,,19.95,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,19.95,35,,19.95,percent of total billed charges,Implant Device,19.95,35,,19.95,percent of total billed charges,Implant Device,19.95,35,,19.95,percent of total billed charges,Implant Device,19.95,35,,19.95,percent of total billed charges,Implant Device,19.95,35,,19.95,percent of total billed charges,Implant Device,22.8,40,,22.8,percent of total billed charges,Implant Device,19.95,70,,19.95,percent of total billed charges,All Other,19.38,34,,19.38,percent of total billed charges,Implant Device,19.38,34,,19.38,percent of total billed charges,Implant Device,19.95,35,,19.95,percent of total billed charges,Implant Device,19.95,35,,19.95,percent of total billed charges,Implant Device,19.95,35,,19.95,percent of total billed charges,Implant Device,19.95,35,,19.95,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,42.18,
SYNTHES 02.211.020 LOCK SCREW 2.7X20MM,C1713,HCPCS,,79006869,CDM,278,RC,,,both,,,343,253.82,,,253.82,Other,150% of Medicare + 9.63% HCRA Surcharge,154.35,45,,154.35,percent of total billed charges,Critical Access Hospital RCC factor,116.62,34,,116.62,percent of total billed charges,Implant Device,116.62,34,,116.62,percent of total billed charges,Implant Device,116.62,34,,116.62,percent of total billed charges,Implant Device,116.62,34,,116.62,percent of total billed charges,Implant Device,116.62,34,,116.62,percent of total billed charges,Implant Device,169.79,,,169.79,Other,110% of Medicare,120.05,35,,120.05,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,120.05,35,,120.05,percent of total billed charges,Implant Device,120.05,35,,120.05,percent of total billed charges,Implant Device,120.05,35,,120.05,percent of total billed charges,Implant Device,120.05,35,,120.05,percent of total billed charges,Implant Device,120.05,35,,120.05,percent of total billed charges,Implant Device,137.2,40,,137.2,percent of total billed charges,Implant Device,120.05,70,,120.05,percent of total billed charges,All Other,116.62,34,,116.62,percent of total billed charges,Implant Device,116.62,34,,116.62,percent of total billed charges,Implant Device,120.05,35,,120.05,percent of total billed charges,Implant Device,120.05,35,,120.05,percent of total billed charges,Implant Device,120.05,35,,120.05,percent of total billed charges,Implant Device,120.05,35,,120.05,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,253.82,
SYNTHES 02.118.532 SELF TAP SCREW 2.7X32,C1713,HCPCS,,79006870,CDM,278,RC,,,both,,,184,136.16,,,136.16,Other,150% of Medicare + 9.63% HCRA Surcharge,82.8,45,,82.8,percent of total billed charges,Critical Access Hospital RCC factor,62.56,34,,62.56,percent of total billed charges,Implant Device,62.56,34,,62.56,percent of total billed charges,Implant Device,62.56,34,,62.56,percent of total billed charges,Implant Device,62.56,34,,62.56,percent of total billed charges,Implant Device,62.56,34,,62.56,percent of total billed charges,Implant Device,91.08,,,91.08,Other,110% of Medicare,64.4,35,,64.4,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,64.4,35,,64.4,percent of total billed charges,Implant Device,64.4,35,,64.4,percent of total billed charges,Implant Device,64.4,35,,64.4,percent of total billed charges,Implant Device,64.4,35,,64.4,percent of total billed charges,Implant Device,64.4,35,,64.4,percent of total billed charges,Implant Device,73.6,40,,73.6,percent of total billed charges,Implant Device,64.4,70,,64.4,percent of total billed charges,All Other,62.56,34,,62.56,percent of total billed charges,Implant Device,62.56,34,,62.56,percent of total billed charges,Implant Device,64.4,35,,64.4,percent of total billed charges,Implant Device,64.4,35,,64.4,percent of total billed charges,Implant Device,64.4,35,,64.4,percent of total billed charges,Implant Device,64.4,35,,64.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,136.16,
SYNTHES 02.211.030 LOCK SCREW 2.7X30MM,C1713,HCPCS,,79006871,CDM,278,RC,,,both,,,343,253.82,,,253.82,Other,150% of Medicare + 9.63% HCRA Surcharge,154.35,45,,154.35,percent of total billed charges,Critical Access Hospital RCC factor,116.62,34,,116.62,percent of total billed charges,Implant Device,116.62,34,,116.62,percent of total billed charges,Implant Device,116.62,34,,116.62,percent of total billed charges,Implant Device,116.62,34,,116.62,percent of total billed charges,Implant Device,116.62,34,,116.62,percent of total billed charges,Implant Device,169.79,,,169.79,Other,110% of Medicare,120.05,35,,120.05,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,120.05,35,,120.05,percent of total billed charges,Implant Device,120.05,35,,120.05,percent of total billed charges,Implant Device,120.05,35,,120.05,percent of total billed charges,Implant Device,120.05,35,,120.05,percent of total billed charges,Implant Device,120.05,35,,120.05,percent of total billed charges,Implant Device,137.2,40,,137.2,percent of total billed charges,Implant Device,120.05,70,,120.05,percent of total billed charges,All Other,116.62,34,,116.62,percent of total billed charges,Implant Device,116.62,34,,116.62,percent of total billed charges,Implant Device,120.05,35,,120.05,percent of total billed charges,Implant Device,120.05,35,,120.05,percent of total billed charges,Implant Device,120.05,35,,120.05,percent of total billed charges,Implant Device,120.05,35,,120.05,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,253.82,
SYNTHES 02.211.056 LOCK SCREW 2.7X56MM,C1713,HCPCS,,79006872,CDM,278,RC,,,both,,,553,409.22,,,409.22,Other,150% of Medicare + 9.63% HCRA Surcharge,248.85,45,,248.85,percent of total billed charges,Critical Access Hospital RCC factor,188.02,34,,188.02,percent of total billed charges,Implant Device,188.02,34,,188.02,percent of total billed charges,Implant Device,188.02,34,,188.02,percent of total billed charges,Implant Device,188.02,34,,188.02,percent of total billed charges,Implant Device,188.02,34,,188.02,percent of total billed charges,Implant Device,273.74,,,273.74,Other,110% of Medicare,193.55,35,,193.55,percent of total billed charges,Implant Device,188.02,34,"Charges > $500, x 34%",188.02,percent of total billed charges,Implant Device,193.55,35,,193.55,percent of total billed charges,Implant Device,193.55,35,,193.55,percent of total billed charges,Implant Device,193.55,35,,193.55,percent of total billed charges,Implant Device,193.55,35,,193.55,percent of total billed charges,Implant Device,193.55,35,,193.55,percent of total billed charges,Implant Device,221.2,40,,221.2,percent of total billed charges,Implant Device,193.55,70,,193.55,percent of total billed charges,All Other,188.02,34,,188.02,percent of total billed charges,Implant Device,188.02,34,,188.02,percent of total billed charges,Implant Device,193.55,35,,193.55,percent of total billed charges,Implant Device,193.55,35,,193.55,percent of total billed charges,Implant Device,193.55,35,,193.55,percent of total billed charges,Implant Device,193.55,35,,193.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,409.22,
SYNTHES 02.211.016 LOCK SCREW 2.7X16MM,C1713,HCPCS,,79006873,CDM,278,RC,,,both,,,570,421.8,,,421.8,Other,150% of Medicare + 9.63% HCRA Surcharge,256.5,45,,256.5,percent of total billed charges,Critical Access Hospital RCC factor,193.8,34,,193.8,percent of total billed charges,Implant Device,193.8,34,,193.8,percent of total billed charges,Implant Device,193.8,34,,193.8,percent of total billed charges,Implant Device,193.8,34,,193.8,percent of total billed charges,Implant Device,193.8,34,,193.8,percent of total billed charges,Implant Device,282.15,,,282.15,Other,110% of Medicare,199.5,35,,199.5,percent of total billed charges,Implant Device,193.8,34,"Charges > $500, x 34%",193.8,percent of total billed charges,Implant Device,199.5,35,,199.5,percent of total billed charges,Implant Device,199.5,35,,199.5,percent of total billed charges,Implant Device,199.5,35,,199.5,percent of total billed charges,Implant Device,199.5,35,,199.5,percent of total billed charges,Implant Device,199.5,35,,199.5,percent of total billed charges,Implant Device,228,40,,228,percent of total billed charges,Implant Device,199.5,70,,199.5,percent of total billed charges,All Other,193.8,34,,193.8,percent of total billed charges,Implant Device,193.8,34,,193.8,percent of total billed charges,Implant Device,199.5,35,,199.5,percent of total billed charges,Implant Device,199.5,35,,199.5,percent of total billed charges,Implant Device,199.5,35,,199.5,percent of total billed charges,Implant Device,199.5,35,,199.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,421.8,
SYNTHES 02.107.302 OLECRN PLATE 2.7X3.5,C1713,HCPCS,,79006874,CDM,278,RC,,,both,,,2826,2091.25,,,2091.25,Other,150% of Medicare + 9.63% HCRA Surcharge,1271.7,45,,1271.7,percent of total billed charges,Critical Access Hospital RCC factor,960.84,34,,960.84,percent of total billed charges,Implant Device,960.84,34,,960.84,percent of total billed charges,Implant Device,960.84,34,,960.84,percent of total billed charges,Implant Device,960.84,34,,960.84,percent of total billed charges,Implant Device,960.84,34,,960.84,percent of total billed charges,Implant Device,1398.87,,,1398.87,Other,110% of Medicare,989.1,35,,989.1,percent of total billed charges,Implant Device,960.84,34,"Charges > $500, x 34%",960.84,percent of total billed charges,Implant Device,989.1,35,,989.1,percent of total billed charges,Implant Device,989.1,35,,989.1,percent of total billed charges,Implant Device,989.1,35,,989.1,percent of total billed charges,Implant Device,989.1,35,,989.1,percent of total billed charges,Implant Device,989.1,35,,989.1,percent of total billed charges,Implant Device,1130.4,40,,1130.4,percent of total billed charges,Implant Device,989.1,70,,989.1,percent of total billed charges,All Other,960.84,34,,960.84,percent of total billed charges,Implant Device,960.84,34,,960.84,percent of total billed charges,Implant Device,989.1,35,,989.1,percent of total billed charges,Implant Device,989.1,35,,989.1,percent of total billed charges,Implant Device,989.1,35,,989.1,percent of total billed charges,Implant Device,989.1,35,,989.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,960.84,34,"If Charge > 2,000, then 34 percent",960.84,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2091.25,
SYNTHES 02.211.040 LOCK SCREW 2.7X40MM,C1713,HCPCS,,79006875,CDM,278,RC,,,both,,,343,253.82,,,253.82,Other,150% of Medicare + 9.63% HCRA Surcharge,154.35,45,,154.35,percent of total billed charges,Critical Access Hospital RCC factor,116.62,34,,116.62,percent of total billed charges,Implant Device,116.62,34,,116.62,percent of total billed charges,Implant Device,116.62,34,,116.62,percent of total billed charges,Implant Device,116.62,34,,116.62,percent of total billed charges,Implant Device,116.62,34,,116.62,percent of total billed charges,Implant Device,169.79,,,169.79,Other,110% of Medicare,120.05,35,,120.05,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,120.05,35,,120.05,percent of total billed charges,Implant Device,120.05,35,,120.05,percent of total billed charges,Implant Device,120.05,35,,120.05,percent of total billed charges,Implant Device,120.05,35,,120.05,percent of total billed charges,Implant Device,120.05,35,,120.05,percent of total billed charges,Implant Device,137.2,40,,137.2,percent of total billed charges,Implant Device,120.05,70,,120.05,percent of total billed charges,All Other,116.62,34,,116.62,percent of total billed charges,Implant Device,116.62,34,,116.62,percent of total billed charges,Implant Device,120.05,35,,120.05,percent of total billed charges,Implant Device,120.05,35,,120.05,percent of total billed charges,Implant Device,120.05,35,,120.05,percent of total billed charges,Implant Device,120.05,35,,120.05,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,253.82,
ARTHREX AR-8724V-12 LOCKING SCREW 2.4X12,C1713,HCPCS,,79006877,CDM,278,RC,,,both,,,420,310.8,,,310.8,Other,150% of Medicare + 9.63% HCRA Surcharge,189,45,,189,percent of total billed charges,Critical Access Hospital RCC factor,142.8,34,,142.8,percent of total billed charges,Implant Device,142.8,34,,142.8,percent of total billed charges,Implant Device,142.8,34,,142.8,percent of total billed charges,Implant Device,142.8,34,,142.8,percent of total billed charges,Implant Device,142.8,34,,142.8,percent of total billed charges,Implant Device,207.9,,,207.9,Other,110% of Medicare,147,35,,147,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,147,35,,147,percent of total billed charges,Implant Device,147,35,,147,percent of total billed charges,Implant Device,147,35,,147,percent of total billed charges,Implant Device,147,35,,147,percent of total billed charges,Implant Device,147,35,,147,percent of total billed charges,Implant Device,168,40,,168,percent of total billed charges,Implant Device,147,70,,147,percent of total billed charges,All Other,142.8,34,,142.8,percent of total billed charges,Implant Device,142.8,34,,142.8,percent of total billed charges,Implant Device,147,35,,147,percent of total billed charges,Implant Device,147,35,,147,percent of total billed charges,Implant Device,147,35,,147,percent of total billed charges,Implant Device,147,35,,147,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,310.8,
ZIMMER 5001-051-00 BIPOLAR SHELL 51MM OD,C1776,HCPCS,,79006878,CDM,278,RC,,,both,,,1323,979.02,,,979.02,Other,150% of Medicare + 9.63% HCRA Surcharge,595.35,45,,595.35,percent of total billed charges,Critical Access Hospital RCC factor,449.82,34,,449.82,percent of total billed charges,Implant Device,449.82,34,,449.82,percent of total billed charges,Implant Device,449.82,34,,449.82,percent of total billed charges,Implant Device,449.82,34,,449.82,percent of total billed charges,Implant Device,449.82,34,,449.82,percent of total billed charges,Implant Device,654.89,,,654.89,Other,110% of Medicare,463.05,35,,463.05,percent of total billed charges,Implant Device,449.82,34,"Charges > $500, x 34%",449.82,percent of total billed charges,Implant Device,463.05,35,,463.05,percent of total billed charges,Implant Device,463.05,35,,463.05,percent of total billed charges,Implant Device,463.05,35,,463.05,percent of total billed charges,Implant Device,463.05,35,,463.05,percent of total billed charges,Implant Device,463.05,35,,463.05,percent of total billed charges,Implant Device,529.2,40,,529.2,percent of total billed charges,Implant Device,463.05,70,,463.05,percent of total billed charges,All Other,449.82,34,,449.82,percent of total billed charges,Implant Device,449.82,34,,449.82,percent of total billed charges,Implant Device,463.05,35,,463.05,percent of total billed charges,Implant Device,463.05,35,,463.05,percent of total billed charges,Implant Device,463.05,35,,463.05,percent of total billed charges,Implant Device,463.05,35,,463.05,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,979.02,
TIDES MEDICAL TAH1202 AMNIOHEAL PLUS 2X2,V2790,HCPCS,,79006879,CDM,278,RC,,,both,,,2693,1992.83,,,1992.83,Other,150% of Medicare + 9.63% HCRA Surcharge,1211.85,45,,1211.85,percent of total billed charges,Critical Access Hospital RCC factor,915.62,34,,915.62,percent of total billed charges,Implant Device,915.62,34,,915.62,percent of total billed charges,Implant Device,915.62,34,,915.62,percent of total billed charges,Implant Device,915.62,34,,915.62,percent of total billed charges,Implant Device,915.62,34,,915.62,percent of total billed charges,Implant Device,1333.04,,,1333.04,Other,110% of Medicare,942.55,35,,942.55,percent of total billed charges,Implant Device,915.62,34,"Charges > $500, x 34%",915.62,percent of total billed charges,Implant Device,942.55,35,,942.55,percent of total billed charges,Implant Device,942.55,35,,942.55,percent of total billed charges,Implant Device,942.55,35,,942.55,percent of total billed charges,Implant Device,942.55,35,,942.55,percent of total billed charges,Implant Device,942.55,35,,942.55,percent of total billed charges,Implant Device,1077.2,40,,1077.2,percent of total billed charges,Implant Device,942.55,70,,942.55,percent of total billed charges,All Other,915.62,34,,915.62,percent of total billed charges,Implant Device,915.62,34,,915.62,percent of total billed charges,Implant Device,942.55,35,,942.55,percent of total billed charges,Implant Device,942.55,35,,942.55,percent of total billed charges,Implant Device,942.55,35,,942.55,percent of total billed charges,Implant Device,942.55,35,,942.55,percent of total billed charges,Implant Device,976.07,,,976.07,Other,100% of Medicaid,976.07,,,976.07,Other,100% of Medicaid,976.07,,,976.07,Other,100% of Medicaid,976.07,,,976.07,Other,100% of Medicaid,2196.15,,,2196.15,Other,225% of Medicaid,1493.38,,,1493.38,Other,153% of Medicaid,2196.15,,,2196.15,Other,225% of Medicaid,1366.49,,,1366.49,Other,140% of Medicaid,915.62,34,"If Charge > 2,000, then 34 percent",915.62,percent of total billed charges,Implants,2537.77,,,2537.77,Other,260% of Medicaid,3162.45,,,3162.45,Other,324% of Medicaid,2098.54,,,2098.54,Other,215% of Medicaid,2098.54,,,2098.54,Other,215% of Medicaid,1220.08,,,1220.08,Other,125% of Medicaid,915.62,3162.45,
TIDES MEDICAL TAH1203 AMNIOHEAL PLUS 2X3,V2790,HCPCS,,79006880,CDM,278,RC,,,both,,,3893,2880.83,,,2880.83,Other,150% of Medicare + 9.63% HCRA Surcharge,1751.85,45,,1751.85,percent of total billed charges,Critical Access Hospital RCC factor,1323.62,34,,1323.62,percent of total billed charges,Implant Device,1323.62,34,,1323.62,percent of total billed charges,Implant Device,1323.62,34,,1323.62,percent of total billed charges,Implant Device,1323.62,34,,1323.62,percent of total billed charges,Implant Device,1323.62,34,,1323.62,percent of total billed charges,Implant Device,1927.04,,,1927.04,Other,110% of Medicare,1362.55,35,,1362.55,percent of total billed charges,Implant Device,1323.62,34,"Charges > $500, x 34%",1323.62,percent of total billed charges,Implant Device,1362.55,35,,1362.55,percent of total billed charges,Implant Device,1362.55,35,,1362.55,percent of total billed charges,Implant Device,1362.55,35,,1362.55,percent of total billed charges,Implant Device,1362.55,35,,1362.55,percent of total billed charges,Implant Device,1362.55,35,,1362.55,percent of total billed charges,Implant Device,1557.2,40,,1557.2,percent of total billed charges,Implant Device,1362.55,70,,1362.55,percent of total billed charges,All Other,1323.62,34,,1323.62,percent of total billed charges,Implant Device,1323.62,34,,1323.62,percent of total billed charges,Implant Device,1362.55,35,,1362.55,percent of total billed charges,Implant Device,1362.55,35,,1362.55,percent of total billed charges,Implant Device,1362.55,35,,1362.55,percent of total billed charges,Implant Device,1362.55,35,,1362.55,percent of total billed charges,Implant Device,976.07,,,976.07,Other,100% of Medicaid,976.07,,,976.07,Other,100% of Medicaid,976.07,,,976.07,Other,100% of Medicaid,976.07,,,976.07,Other,100% of Medicaid,2196.15,,,2196.15,Other,225% of Medicaid,1493.38,,,1493.38,Other,153% of Medicaid,2196.15,,,2196.15,Other,225% of Medicaid,1366.49,,,1366.49,Other,140% of Medicaid,1323.62,34,"If Charge > 2,000, then 34 percent",1323.62,percent of total billed charges,Implants,2537.77,,,2537.77,Other,260% of Medicaid,3162.45,,,3162.45,Other,324% of Medicaid,2098.54,,,2098.54,Other,215% of Medicaid,2098.54,,,2098.54,Other,215% of Medicaid,1220.08,,,1220.08,Other,125% of Medicaid,976.07,3162.45,
EXACTECH 314-13-13 CAGED GLENOID MEDIUM,C1776,HCPCS,,79006881,CDM,278,RC,,,both,,,4125,3052.51,,,3052.51,Other,150% of Medicare + 9.63% HCRA Surcharge,1856.25,45,,1856.25,percent of total billed charges,Critical Access Hospital RCC factor,1402.5,34,,1402.5,percent of total billed charges,Implant Device,1402.5,34,,1402.5,percent of total billed charges,Implant Device,1402.5,34,,1402.5,percent of total billed charges,Implant Device,1402.5,34,,1402.5,percent of total billed charges,Implant Device,1402.5,34,,1402.5,percent of total billed charges,Implant Device,2041.88,,,2041.88,Other,110% of Medicare,1443.75,35,,1443.75,percent of total billed charges,Implant Device,1402.5,34,"Charges > $500, x 34%",1402.5,percent of total billed charges,Implant Device,1443.75,35,,1443.75,percent of total billed charges,Implant Device,1443.75,35,,1443.75,percent of total billed charges,Implant Device,1443.75,35,,1443.75,percent of total billed charges,Implant Device,1443.75,35,,1443.75,percent of total billed charges,Implant Device,1443.75,35,,1443.75,percent of total billed charges,Implant Device,1650,40,,1650,percent of total billed charges,Implant Device,1443.75,70,,1443.75,percent of total billed charges,All Other,1402.5,34,,1402.5,percent of total billed charges,Implant Device,1402.5,34,,1402.5,percent of total billed charges,Implant Device,1443.75,35,,1443.75,percent of total billed charges,Implant Device,1443.75,35,,1443.75,percent of total billed charges,Implant Device,1443.75,35,,1443.75,percent of total billed charges,Implant Device,1443.75,35,,1443.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1402.5,34,"If Charge > 2,000, then 34 percent",1402.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3052.51,
EXACTECH 310-02-50 HUMERAL HEAD 50X23MM,C1776,HCPCS,,79006882,CDM,278,RC,,,both,,,4968,3676.33,,,3676.33,Other,150% of Medicare + 9.63% HCRA Surcharge,2235.6,45,,2235.6,percent of total billed charges,Critical Access Hospital RCC factor,1689.12,34,,1689.12,percent of total billed charges,Implant Device,1689.12,34,,1689.12,percent of total billed charges,Implant Device,1689.12,34,,1689.12,percent of total billed charges,Implant Device,1689.12,34,,1689.12,percent of total billed charges,Implant Device,1689.12,34,,1689.12,percent of total billed charges,Implant Device,2459.16,,,2459.16,Other,110% of Medicare,1738.8,35,,1738.8,percent of total billed charges,Implant Device,1689.12,34,"Charges > $500, x 34%",1689.12,percent of total billed charges,Implant Device,1738.8,35,,1738.8,percent of total billed charges,Implant Device,1738.8,35,,1738.8,percent of total billed charges,Implant Device,1738.8,35,,1738.8,percent of total billed charges,Implant Device,1738.8,35,,1738.8,percent of total billed charges,Implant Device,1738.8,35,,1738.8,percent of total billed charges,Implant Device,1987.2,40,,1987.2,percent of total billed charges,Implant Device,1738.8,70,,1738.8,percent of total billed charges,All Other,1689.12,34,,1689.12,percent of total billed charges,Implant Device,1689.12,34,,1689.12,percent of total billed charges,Implant Device,1738.8,35,,1738.8,percent of total billed charges,Implant Device,1738.8,35,,1738.8,percent of total billed charges,Implant Device,1738.8,35,,1738.8,percent of total billed charges,Implant Device,1738.8,35,,1738.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1689.12,34,"If Charge > 2,000, then 34 percent",1689.12,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3676.33,
STRYKER 5630-G-228 TIBIAL INSERT 2X8MM,C1776,HCPCS,,79006885,CDM,278,RC,,,both,,,3232,2391.69,,,2391.69,Other,150% of Medicare + 9.63% HCRA Surcharge,1454.4,45,,1454.4,percent of total billed charges,Critical Access Hospital RCC factor,1098.88,34,,1098.88,percent of total billed charges,Implant Device,1098.88,34,,1098.88,percent of total billed charges,Implant Device,1098.88,34,,1098.88,percent of total billed charges,Implant Device,1098.88,34,,1098.88,percent of total billed charges,Implant Device,1098.88,34,,1098.88,percent of total billed charges,Implant Device,1599.84,,,1599.84,Other,110% of Medicare,1131.2,35,,1131.2,percent of total billed charges,Implant Device,1098.88,34,"Charges > $500, x 34%",1098.88,percent of total billed charges,Implant Device,1131.2,35,,1131.2,percent of total billed charges,Implant Device,1131.2,35,,1131.2,percent of total billed charges,Implant Device,1131.2,35,,1131.2,percent of total billed charges,Implant Device,1131.2,35,,1131.2,percent of total billed charges,Implant Device,1131.2,35,,1131.2,percent of total billed charges,Implant Device,1292.8,40,,1292.8,percent of total billed charges,Implant Device,1131.2,70,,1131.2,percent of total billed charges,All Other,1098.88,34,,1098.88,percent of total billed charges,Implant Device,1098.88,34,,1098.88,percent of total billed charges,Implant Device,1131.2,35,,1131.2,percent of total billed charges,Implant Device,1131.2,35,,1131.2,percent of total billed charges,Implant Device,1131.2,35,,1131.2,percent of total billed charges,Implant Device,1131.2,35,,1131.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1098.88,34,"If Charge > 2,000, then 34 percent",1098.88,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2391.69,
STRYKER 5620-B-202 TIBIAL BASEPLATE SZ 2,C1776,HCPCS,,79006886,CDM,278,RC,,,both,,,4937,3653.39,,,3653.39,Other,150% of Medicare + 9.63% HCRA Surcharge,2221.65,45,,2221.65,percent of total billed charges,Critical Access Hospital RCC factor,1678.58,34,,1678.58,percent of total billed charges,Implant Device,1678.58,34,,1678.58,percent of total billed charges,Implant Device,1678.58,34,,1678.58,percent of total billed charges,Implant Device,1678.58,34,,1678.58,percent of total billed charges,Implant Device,1678.58,34,,1678.58,percent of total billed charges,Implant Device,2443.82,,,2443.82,Other,110% of Medicare,1727.95,35,,1727.95,percent of total billed charges,Implant Device,1678.58,34,"Charges > $500, x 34%",1678.58,percent of total billed charges,Implant Device,1727.95,35,,1727.95,percent of total billed charges,Implant Device,1727.95,35,,1727.95,percent of total billed charges,Implant Device,1727.95,35,,1727.95,percent of total billed charges,Implant Device,1727.95,35,,1727.95,percent of total billed charges,Implant Device,1727.95,35,,1727.95,percent of total billed charges,Implant Device,1974.8,40,,1974.8,percent of total billed charges,Implant Device,1727.95,70,,1727.95,percent of total billed charges,All Other,1678.58,34,,1678.58,percent of total billed charges,Implant Device,1678.58,34,,1678.58,percent of total billed charges,Implant Device,1727.95,35,,1727.95,percent of total billed charges,Implant Device,1727.95,35,,1727.95,percent of total billed charges,Implant Device,1727.95,35,,1727.95,percent of total billed charges,Implant Device,1727.95,35,,1727.95,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1678.58,34,"If Charge > 2,000, then 34 percent",1678.58,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3653.39,
STRYKER 5610-F-202 FEMORAL COMPONENT SZ,C1776,HCPCS,,79006887,CDM,278,RC,,,both,,,8352,6180.5,,,6180.5,Other,150% of Medicare + 9.63% HCRA Surcharge,3758.4,45,,3758.4,percent of total billed charges,Critical Access Hospital RCC factor,2839.68,34,,2839.68,percent of total billed charges,Implant Device,2839.68,34,,2839.68,percent of total billed charges,Implant Device,2839.68,34,,2839.68,percent of total billed charges,Implant Device,2839.68,34,,2839.68,percent of total billed charges,Implant Device,2839.68,34,,2839.68,percent of total billed charges,Implant Device,4134.24,,,4134.24,Other,110% of Medicare,2923.2,35,,2923.2,percent of total billed charges,Implant Device,2839.68,34,"Charges > $500, x 34%",2839.68,percent of total billed charges,Implant Device,2923.2,35,,2923.2,percent of total billed charges,Implant Device,2923.2,35,,2923.2,percent of total billed charges,Implant Device,2923.2,35,,2923.2,percent of total billed charges,Implant Device,2923.2,35,,2923.2,percent of total billed charges,Implant Device,2923.2,35,,2923.2,percent of total billed charges,Implant Device,3340.8,40,,3340.8,percent of total billed charges,Implant Device,2923.2,70,,2923.2,percent of total billed charges,All Other,2839.68,34,,2839.68,percent of total billed charges,Implant Device,2839.68,34,,2839.68,percent of total billed charges,Implant Device,2923.2,35,,2923.2,percent of total billed charges,Implant Device,2923.2,35,,2923.2,percent of total billed charges,Implant Device,2923.2,35,,2923.2,percent of total billed charges,Implant Device,2923.2,35,,2923.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2839.68,34,"If Charge > 2,000, then 34 percent",2839.68,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,6180.5,
SYNTHES 02.123.041 HUMERUS PLATE 3.5MM,C1713,HCPCS,,79006888,CDM,278,RC,,,both,,,3987,2950.39,,,2950.39,Other,150% of Medicare + 9.63% HCRA Surcharge,1794.15,45,,1794.15,percent of total billed charges,Critical Access Hospital RCC factor,1355.58,34,,1355.58,percent of total billed charges,Implant Device,1355.58,34,,1355.58,percent of total billed charges,Implant Device,1355.58,34,,1355.58,percent of total billed charges,Implant Device,1355.58,34,,1355.58,percent of total billed charges,Implant Device,1355.58,34,,1355.58,percent of total billed charges,Implant Device,1973.57,,,1973.57,Other,110% of Medicare,1395.45,35,,1395.45,percent of total billed charges,Implant Device,1355.58,34,"Charges > $500, x 34%",1355.58,percent of total billed charges,Implant Device,1395.45,35,,1395.45,percent of total billed charges,Implant Device,1395.45,35,,1395.45,percent of total billed charges,Implant Device,1395.45,35,,1395.45,percent of total billed charges,Implant Device,1395.45,35,,1395.45,percent of total billed charges,Implant Device,1395.45,35,,1395.45,percent of total billed charges,Implant Device,1594.8,40,,1594.8,percent of total billed charges,Implant Device,1395.45,70,,1395.45,percent of total billed charges,All Other,1355.58,34,,1355.58,percent of total billed charges,Implant Device,1355.58,34,,1355.58,percent of total billed charges,Implant Device,1395.45,35,,1395.45,percent of total billed charges,Implant Device,1395.45,35,,1395.45,percent of total billed charges,Implant Device,1395.45,35,,1395.45,percent of total billed charges,Implant Device,1395.45,35,,1395.45,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1355.58,34,"If Charge > 2,000, then 34 percent",1355.58,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2950.39,
SYNTHES 02.240.034 CANN LCK SCREW 3.7X34,C1713,HCPCS,,79006889,CDM,278,RC,,,both,,,476,352.24,,,352.24,Other,150% of Medicare + 9.63% HCRA Surcharge,214.2,45,,214.2,percent of total billed charges,Critical Access Hospital RCC factor,161.84,34,,161.84,percent of total billed charges,Implant Device,161.84,34,,161.84,percent of total billed charges,Implant Device,161.84,34,,161.84,percent of total billed charges,Implant Device,161.84,34,,161.84,percent of total billed charges,Implant Device,161.84,34,,161.84,percent of total billed charges,Implant Device,235.62,,,235.62,Other,110% of Medicare,166.6,35,,166.6,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,166.6,35,,166.6,percent of total billed charges,Implant Device,166.6,35,,166.6,percent of total billed charges,Implant Device,166.6,35,,166.6,percent of total billed charges,Implant Device,166.6,35,,166.6,percent of total billed charges,Implant Device,166.6,35,,166.6,percent of total billed charges,Implant Device,190.4,40,,190.4,percent of total billed charges,Implant Device,166.6,70,,166.6,percent of total billed charges,All Other,161.84,34,,161.84,percent of total billed charges,Implant Device,161.84,34,,161.84,percent of total billed charges,Implant Device,166.6,35,,166.6,percent of total billed charges,Implant Device,166.6,35,,166.6,percent of total billed charges,Implant Device,166.6,35,,166.6,percent of total billed charges,Implant Device,166.6,35,,166.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,352.24,
SYNTHES 02.240.036 CANN LCK SCREW 3.7X36,C1713,HCPCS,,79006890,CDM,278,RC,,,both,,,476,352.24,,,352.24,Other,150% of Medicare + 9.63% HCRA Surcharge,214.2,45,,214.2,percent of total billed charges,Critical Access Hospital RCC factor,161.84,34,,161.84,percent of total billed charges,Implant Device,161.84,34,,161.84,percent of total billed charges,Implant Device,161.84,34,,161.84,percent of total billed charges,Implant Device,161.84,34,,161.84,percent of total billed charges,Implant Device,161.84,34,,161.84,percent of total billed charges,Implant Device,235.62,,,235.62,Other,110% of Medicare,166.6,35,,166.6,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,166.6,35,,166.6,percent of total billed charges,Implant Device,166.6,35,,166.6,percent of total billed charges,Implant Device,166.6,35,,166.6,percent of total billed charges,Implant Device,166.6,35,,166.6,percent of total billed charges,Implant Device,166.6,35,,166.6,percent of total billed charges,Implant Device,190.4,40,,190.4,percent of total billed charges,Implant Device,166.6,70,,166.6,percent of total billed charges,All Other,161.84,34,,161.84,percent of total billed charges,Implant Device,161.84,34,,161.84,percent of total billed charges,Implant Device,166.6,35,,166.6,percent of total billed charges,Implant Device,166.6,35,,166.6,percent of total billed charges,Implant Device,166.6,35,,166.6,percent of total billed charges,Implant Device,166.6,35,,166.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,352.24,
SYNTHES 02.240.048 CANN LCK SCREW 3.7X48,C1713,HCPCS,,79006891,CDM,278,RC,,,both,,,476,352.24,,,352.24,Other,150% of Medicare + 9.63% HCRA Surcharge,214.2,45,,214.2,percent of total billed charges,Critical Access Hospital RCC factor,161.84,34,,161.84,percent of total billed charges,Implant Device,161.84,34,,161.84,percent of total billed charges,Implant Device,161.84,34,,161.84,percent of total billed charges,Implant Device,161.84,34,,161.84,percent of total billed charges,Implant Device,161.84,34,,161.84,percent of total billed charges,Implant Device,235.62,,,235.62,Other,110% of Medicare,166.6,35,,166.6,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,166.6,35,,166.6,percent of total billed charges,Implant Device,166.6,35,,166.6,percent of total billed charges,Implant Device,166.6,35,,166.6,percent of total billed charges,Implant Device,166.6,35,,166.6,percent of total billed charges,Implant Device,166.6,35,,166.6,percent of total billed charges,Implant Device,190.4,40,,190.4,percent of total billed charges,Implant Device,166.6,70,,166.6,percent of total billed charges,All Other,161.84,34,,161.84,percent of total billed charges,Implant Device,161.84,34,,161.84,percent of total billed charges,Implant Device,166.6,35,,166.6,percent of total billed charges,Implant Device,166.6,35,,166.6,percent of total billed charges,Implant Device,166.6,35,,166.6,percent of total billed charges,Implant Device,166.6,35,,166.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,352.24,
SYNTHES 02.240.054 CANN LCK SCREW 3.7X54,C1713,HCPCS,,79006892,CDM,278,RC,,,both,,,476,352.24,,,352.24,Other,150% of Medicare + 9.63% HCRA Surcharge,214.2,45,,214.2,percent of total billed charges,Critical Access Hospital RCC factor,161.84,34,,161.84,percent of total billed charges,Implant Device,161.84,34,,161.84,percent of total billed charges,Implant Device,161.84,34,,161.84,percent of total billed charges,Implant Device,161.84,34,,161.84,percent of total billed charges,Implant Device,161.84,34,,161.84,percent of total billed charges,Implant Device,235.62,,,235.62,Other,110% of Medicare,166.6,35,,166.6,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,166.6,35,,166.6,percent of total billed charges,Implant Device,166.6,35,,166.6,percent of total billed charges,Implant Device,166.6,35,,166.6,percent of total billed charges,Implant Device,166.6,35,,166.6,percent of total billed charges,Implant Device,166.6,35,,166.6,percent of total billed charges,Implant Device,190.4,40,,190.4,percent of total billed charges,Implant Device,166.6,70,,166.6,percent of total billed charges,All Other,161.84,34,,161.84,percent of total billed charges,Implant Device,161.84,34,,161.84,percent of total billed charges,Implant Device,166.6,35,,166.6,percent of total billed charges,Implant Device,166.6,35,,166.6,percent of total billed charges,Implant Device,166.6,35,,166.6,percent of total billed charges,Implant Device,166.6,35,,166.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,352.24,
SYNTHES 204.830 CORTEX SCREW 3.5X30MM,C1713,HCPCS,,79006893,CDM,278,RC,,,both,,,59,43.66,,,43.66,Other,150% of Medicare + 9.63% HCRA Surcharge,26.55,45,,26.55,percent of total billed charges,Critical Access Hospital RCC factor,20.06,34,,20.06,percent of total billed charges,Implant Device,20.06,34,,20.06,percent of total billed charges,Implant Device,20.06,34,,20.06,percent of total billed charges,Implant Device,20.06,34,,20.06,percent of total billed charges,Implant Device,20.06,34,,20.06,percent of total billed charges,Implant Device,29.21,,,29.21,Other,110% of Medicare,20.65,35,,20.65,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,20.65,35,,20.65,percent of total billed charges,Implant Device,20.65,35,,20.65,percent of total billed charges,Implant Device,20.65,35,,20.65,percent of total billed charges,Implant Device,20.65,35,,20.65,percent of total billed charges,Implant Device,20.65,35,,20.65,percent of total billed charges,Implant Device,23.6,40,,23.6,percent of total billed charges,Implant Device,20.65,70,,20.65,percent of total billed charges,All Other,20.06,34,,20.06,percent of total billed charges,Implant Device,20.06,34,,20.06,percent of total billed charges,Implant Device,20.65,35,,20.65,percent of total billed charges,Implant Device,20.65,35,,20.65,percent of total billed charges,Implant Device,20.65,35,,20.65,percent of total billed charges,Implant Device,20.65,35,,20.65,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,43.66,
SYNTHES 204.828 CORTEX SCREW 3.5X28MM,C1713,HCPCS,,79006894,CDM,278,RC,,,both,,,57,42.18,,,42.18,Other,150% of Medicare + 9.63% HCRA Surcharge,25.65,45,,25.65,percent of total billed charges,Critical Access Hospital RCC factor,19.38,34,,19.38,percent of total billed charges,Implant Device,19.38,34,,19.38,percent of total billed charges,Implant Device,19.38,34,,19.38,percent of total billed charges,Implant Device,19.38,34,,19.38,percent of total billed charges,Implant Device,19.38,34,,19.38,percent of total billed charges,Implant Device,28.22,,,28.22,Other,110% of Medicare,19.95,35,,19.95,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,19.95,35,,19.95,percent of total billed charges,Implant Device,19.95,35,,19.95,percent of total billed charges,Implant Device,19.95,35,,19.95,percent of total billed charges,Implant Device,19.95,35,,19.95,percent of total billed charges,Implant Device,19.95,35,,19.95,percent of total billed charges,Implant Device,22.8,40,,22.8,percent of total billed charges,Implant Device,19.95,70,,19.95,percent of total billed charges,All Other,19.38,34,,19.38,percent of total billed charges,Implant Device,19.38,34,,19.38,percent of total billed charges,Implant Device,19.95,35,,19.95,percent of total billed charges,Implant Device,19.95,35,,19.95,percent of total billed charges,Implant Device,19.95,35,,19.95,percent of total billed charges,Implant Device,19.95,35,,19.95,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,42.18,
SYNTHES 212.109 LOCKING SCREW 3.5X26MM,C1713,HCPCS,,79006895,CDM,278,RC,,,both,,,327,241.98,,,241.98,Other,150% of Medicare + 9.63% HCRA Surcharge,147.15,45,,147.15,percent of total billed charges,Critical Access Hospital RCC factor,111.18,34,,111.18,percent of total billed charges,Implant Device,111.18,34,,111.18,percent of total billed charges,Implant Device,111.18,34,,111.18,percent of total billed charges,Implant Device,111.18,34,,111.18,percent of total billed charges,Implant Device,111.18,34,,111.18,percent of total billed charges,Implant Device,161.87,,,161.87,Other,110% of Medicare,114.45,35,,114.45,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,114.45,35,,114.45,percent of total billed charges,Implant Device,114.45,35,,114.45,percent of total billed charges,Implant Device,114.45,35,,114.45,percent of total billed charges,Implant Device,114.45,35,,114.45,percent of total billed charges,Implant Device,114.45,35,,114.45,percent of total billed charges,Implant Device,130.8,40,,130.8,percent of total billed charges,Implant Device,114.45,70,,114.45,percent of total billed charges,All Other,111.18,34,,111.18,percent of total billed charges,Implant Device,111.18,34,,111.18,percent of total billed charges,Implant Device,114.45,35,,114.45,percent of total billed charges,Implant Device,114.45,35,,114.45,percent of total billed charges,Implant Device,114.45,35,,114.45,percent of total billed charges,Implant Device,114.45,35,,114.45,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,241.98,
ZIMMER 00-8751-015-36 LINER 36MM SZ NN,C1776,HCPCS,,79006896,CDM,278,RC,,,both,,,4973,3680.03,,,3680.03,Other,150% of Medicare + 9.63% HCRA Surcharge,2237.85,45,,2237.85,percent of total billed charges,Critical Access Hospital RCC factor,1690.82,34,,1690.82,percent of total billed charges,Implant Device,1690.82,34,,1690.82,percent of total billed charges,Implant Device,1690.82,34,,1690.82,percent of total billed charges,Implant Device,1690.82,34,,1690.82,percent of total billed charges,Implant Device,1690.82,34,,1690.82,percent of total billed charges,Implant Device,2461.64,,,2461.64,Other,110% of Medicare,1740.55,35,,1740.55,percent of total billed charges,Implant Device,1690.82,34,"Charges > $500, x 34%",1690.82,percent of total billed charges,Implant Device,1740.55,35,,1740.55,percent of total billed charges,Implant Device,1740.55,35,,1740.55,percent of total billed charges,Implant Device,1740.55,35,,1740.55,percent of total billed charges,Implant Device,1740.55,35,,1740.55,percent of total billed charges,Implant Device,1740.55,35,,1740.55,percent of total billed charges,Implant Device,1989.2,40,,1989.2,percent of total billed charges,Implant Device,1740.55,70,,1740.55,percent of total billed charges,All Other,1690.82,34,,1690.82,percent of total billed charges,Implant Device,1690.82,34,,1690.82,percent of total billed charges,Implant Device,1740.55,35,,1740.55,percent of total billed charges,Implant Device,1740.55,35,,1740.55,percent of total billed charges,Implant Device,1740.55,35,,1740.55,percent of total billed charges,Implant Device,1740.55,35,,1740.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1690.82,34,"If Charge > 2,000, then 34 percent",1690.82,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3680.03,
BIOMET 11-165226 RINGLOC ACETABULAR CUP,C1776,HCPCS,,79006897,CDM,278,RC,,,both,,,6540,4839.62,,,4839.62,Other,150% of Medicare + 9.63% HCRA Surcharge,2943,45,,2943,percent of total billed charges,Critical Access Hospital RCC factor,2223.6,34,,2223.6,percent of total billed charges,Implant Device,2223.6,34,,2223.6,percent of total billed charges,Implant Device,2223.6,34,,2223.6,percent of total billed charges,Implant Device,2223.6,34,,2223.6,percent of total billed charges,Implant Device,2223.6,34,,2223.6,percent of total billed charges,Implant Device,3237.3,,,3237.3,Other,110% of Medicare,2289,35,,2289,percent of total billed charges,Implant Device,2223.6,34,"Charges > $500, x 34%",2223.6,percent of total billed charges,Implant Device,2289,35,,2289,percent of total billed charges,Implant Device,2289,35,,2289,percent of total billed charges,Implant Device,2289,35,,2289,percent of total billed charges,Implant Device,2289,35,,2289,percent of total billed charges,Implant Device,2289,35,,2289,percent of total billed charges,Implant Device,2616,40,,2616,percent of total billed charges,Implant Device,2289,70,,2289,percent of total billed charges,All Other,2223.6,34,,2223.6,percent of total billed charges,Implant Device,2223.6,34,,2223.6,percent of total billed charges,Implant Device,2289,35,,2289,percent of total billed charges,Implant Device,2289,35,,2289,percent of total billed charges,Implant Device,2289,35,,2289,percent of total billed charges,Implant Device,2289,35,,2289,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2223.6,34,"If Charge > 2,000, then 34 percent",2223.6,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4839.62,
BIOMET 12-150313 ECHO PRESSFIT FEMORAL,C1776,HCPCS,,79006898,CDM,278,RC,,,both,,,15240,11277.64,,,11277.64,Other,150% of Medicare + 9.63% HCRA Surcharge,6858,45,,6858,percent of total billed charges,Critical Access Hospital RCC factor,5181.6,34,,5181.6,percent of total billed charges,Implant Device,5181.6,34,,5181.6,percent of total billed charges,Implant Device,5181.6,34,,5181.6,percent of total billed charges,Implant Device,5181.6,34,,5181.6,percent of total billed charges,Implant Device,5181.6,34,,5181.6,percent of total billed charges,Implant Device,7543.8,,,7543.8,Other,110% of Medicare,5334,35,,5334,percent of total billed charges,Implant Device,5181.6,34,"Charges > $500, x 34%",5181.6,percent of total billed charges,Implant Device,5334,35,,5334,percent of total billed charges,Implant Device,5334,35,,5334,percent of total billed charges,Implant Device,5334,35,,5334,percent of total billed charges,Implant Device,5334,35,,5334,percent of total billed charges,Implant Device,5334,35,,5334,percent of total billed charges,Implant Device,6096,40,,6096,percent of total billed charges,Implant Device,5334,70,,5334,percent of total billed charges,All Other,5181.6,34,,5181.6,percent of total billed charges,Implant Device,5181.6,34,,5181.6,percent of total billed charges,Implant Device,5334,35,,5334,percent of total billed charges,Implant Device,5334,35,,5334,percent of total billed charges,Implant Device,5334,35,,5334,percent of total billed charges,Implant Device,5334,35,,5334,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,5181.6,34,"If Charge > 2,000, then 34 percent",5181.6,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,11277.64,
BIOMET 163661 MODULAR HEAD 28-3MM NECK,C1776,HCPCS,,79006899,CDM,278,RC,,,both,,,4830,3574.21,,,3574.21,Other,150% of Medicare + 9.63% HCRA Surcharge,2173.5,45,,2173.5,percent of total billed charges,Critical Access Hospital RCC factor,1642.2,34,,1642.2,percent of total billed charges,Implant Device,1642.2,34,,1642.2,percent of total billed charges,Implant Device,1642.2,34,,1642.2,percent of total billed charges,Implant Device,1642.2,34,,1642.2,percent of total billed charges,Implant Device,1642.2,34,,1642.2,percent of total billed charges,Implant Device,2390.85,,,2390.85,Other,110% of Medicare,1690.5,35,,1690.5,percent of total billed charges,Implant Device,1642.2,34,"Charges > $500, x 34%",1642.2,percent of total billed charges,Implant Device,1690.5,35,,1690.5,percent of total billed charges,Implant Device,1690.5,35,,1690.5,percent of total billed charges,Implant Device,1690.5,35,,1690.5,percent of total billed charges,Implant Device,1690.5,35,,1690.5,percent of total billed charges,Implant Device,1690.5,35,,1690.5,percent of total billed charges,Implant Device,1932,40,,1932,percent of total billed charges,Implant Device,1690.5,70,,1690.5,percent of total billed charges,All Other,1642.2,34,,1642.2,percent of total billed charges,Implant Device,1642.2,34,,1642.2,percent of total billed charges,Implant Device,1690.5,35,,1690.5,percent of total billed charges,Implant Device,1690.5,35,,1690.5,percent of total billed charges,Implant Device,1690.5,35,,1690.5,percent of total billed charges,Implant Device,1690.5,35,,1690.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1642.2,34,"If Charge > 2,000, then 34 percent",1642.2,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3574.21,
VILEX TH-25-20T-1100 HAMMERFUZE 2.5X2,C1713,HCPCS,,79006900,CDM,278,RC,,,both,,,3450,2553.01,,,2553.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1552.5,45,,1552.5,percent of total billed charges,Critical Access Hospital RCC factor,1173,34,,1173,percent of total billed charges,Implant Device,1173,34,,1173,percent of total billed charges,Implant Device,1173,34,,1173,percent of total billed charges,Implant Device,1173,34,,1173,percent of total billed charges,Implant Device,1173,34,,1173,percent of total billed charges,Implant Device,1707.75,,,1707.75,Other,110% of Medicare,1207.5,35,,1207.5,percent of total billed charges,Implant Device,1173,34,"Charges > $500, x 34%",1173,percent of total billed charges,Implant Device,1207.5,35,,1207.5,percent of total billed charges,Implant Device,1207.5,35,,1207.5,percent of total billed charges,Implant Device,1207.5,35,,1207.5,percent of total billed charges,Implant Device,1207.5,35,,1207.5,percent of total billed charges,Implant Device,1207.5,35,,1207.5,percent of total billed charges,Implant Device,1380,40,,1380,percent of total billed charges,Implant Device,1207.5,70,,1207.5,percent of total billed charges,All Other,1173,34,,1173,percent of total billed charges,Implant Device,1173,34,,1173,percent of total billed charges,Implant Device,1207.5,35,,1207.5,percent of total billed charges,Implant Device,1207.5,35,,1207.5,percent of total billed charges,Implant Device,1207.5,35,,1207.5,percent of total billed charges,Implant Device,1207.5,35,,1207.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1173,34,"If Charge > 2,000, then 34 percent",1173,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2553.01,
STRYKER 6570-0-132 FEM HEAD V40 32MM +O,C1776,HCPCS,,79006903,CDM,278,RC,,,both,,,7139,5282.88,,,5282.88,Other,150% of Medicare + 9.63% HCRA Surcharge,3212.55,45,,3212.55,percent of total billed charges,Critical Access Hospital RCC factor,2427.26,34,,2427.26,percent of total billed charges,Implant Device,2427.26,34,,2427.26,percent of total billed charges,Implant Device,2427.26,34,,2427.26,percent of total billed charges,Implant Device,2427.26,34,,2427.26,percent of total billed charges,Implant Device,2427.26,34,,2427.26,percent of total billed charges,Implant Device,3533.81,,,3533.81,Other,110% of Medicare,2498.65,35,,2498.65,percent of total billed charges,Implant Device,2427.26,34,"Charges > $500, x 34%",2427.26,percent of total billed charges,Implant Device,2498.65,35,,2498.65,percent of total billed charges,Implant Device,2498.65,35,,2498.65,percent of total billed charges,Implant Device,2498.65,35,,2498.65,percent of total billed charges,Implant Device,2498.65,35,,2498.65,percent of total billed charges,Implant Device,2498.65,35,,2498.65,percent of total billed charges,Implant Device,2855.6,40,,2855.6,percent of total billed charges,Implant Device,2498.65,70,,2498.65,percent of total billed charges,All Other,2427.26,34,,2427.26,percent of total billed charges,Implant Device,2427.26,34,,2427.26,percent of total billed charges,Implant Device,2498.65,35,,2498.65,percent of total billed charges,Implant Device,2498.65,35,,2498.65,percent of total billed charges,Implant Device,2498.65,35,,2498.65,percent of total billed charges,Implant Device,2498.65,35,,2498.65,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2427.26,34,"If Charge > 2,000, then 34 percent",2427.26,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5282.88,
STRYKER 6276-7-318 MODULAR HIP 235X18MM,C1776,HCPCS,,79006904,CDM,278,RC,,,both,,,16079,11898.5,,,11898.5,Other,150% of Medicare + 9.63% HCRA Surcharge,7235.55,45,,7235.55,percent of total billed charges,Critical Access Hospital RCC factor,5466.86,34,,5466.86,percent of total billed charges,Implant Device,5466.86,34,,5466.86,percent of total billed charges,Implant Device,5466.86,34,,5466.86,percent of total billed charges,Implant Device,5466.86,34,,5466.86,percent of total billed charges,Implant Device,5466.86,34,,5466.86,percent of total billed charges,Implant Device,7959.11,,,7959.11,Other,110% of Medicare,5627.65,35,,5627.65,percent of total billed charges,Implant Device,5466.86,34,"Charges > $500, x 34%",5466.86,percent of total billed charges,Implant Device,5627.65,35,,5627.65,percent of total billed charges,Implant Device,5627.65,35,,5627.65,percent of total billed charges,Implant Device,5627.65,35,,5627.65,percent of total billed charges,Implant Device,5627.65,35,,5627.65,percent of total billed charges,Implant Device,5627.65,35,,5627.65,percent of total billed charges,Implant Device,6431.6,40,,6431.6,percent of total billed charges,Implant Device,5627.65,70,,5627.65,percent of total billed charges,All Other,5466.86,34,,5466.86,percent of total billed charges,Implant Device,5466.86,34,,5466.86,percent of total billed charges,Implant Device,5627.65,35,,5627.65,percent of total billed charges,Implant Device,5627.65,35,,5627.65,percent of total billed charges,Implant Device,5627.65,35,,5627.65,percent of total billed charges,Implant Device,5627.65,35,,5627.65,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,5466.86,34,"If Charge > 2,000, then 34 percent",5466.86,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,11898.5,
STRYKER 5620-B-201 TIBIAL BASEPLATE SZ 2,C1776,HCPCS,,79006905,CDM,278,RC,,,both,,,4937,3653.39,,,3653.39,Other,150% of Medicare + 9.63% HCRA Surcharge,2221.65,45,,2221.65,percent of total billed charges,Critical Access Hospital RCC factor,1678.58,34,,1678.58,percent of total billed charges,Implant Device,1678.58,34,,1678.58,percent of total billed charges,Implant Device,1678.58,34,,1678.58,percent of total billed charges,Implant Device,1678.58,34,,1678.58,percent of total billed charges,Implant Device,1678.58,34,,1678.58,percent of total billed charges,Implant Device,2443.82,,,2443.82,Other,110% of Medicare,1727.95,35,,1727.95,percent of total billed charges,Implant Device,1678.58,34,"Charges > $500, x 34%",1678.58,percent of total billed charges,Implant Device,1727.95,35,,1727.95,percent of total billed charges,Implant Device,1727.95,35,,1727.95,percent of total billed charges,Implant Device,1727.95,35,,1727.95,percent of total billed charges,Implant Device,1727.95,35,,1727.95,percent of total billed charges,Implant Device,1727.95,35,,1727.95,percent of total billed charges,Implant Device,1974.8,40,,1974.8,percent of total billed charges,Implant Device,1727.95,70,,1727.95,percent of total billed charges,All Other,1678.58,34,,1678.58,percent of total billed charges,Implant Device,1678.58,34,,1678.58,percent of total billed charges,Implant Device,1727.95,35,,1727.95,percent of total billed charges,Implant Device,1727.95,35,,1727.95,percent of total billed charges,Implant Device,1727.95,35,,1727.95,percent of total billed charges,Implant Device,1727.95,35,,1727.95,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1678.58,34,"If Charge > 2,000, then 34 percent",1678.58,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3653.39,
STRYKER 5610-F-201 FEMORAL COMPNENT SZ 2,C1776,HCPCS,,79006906,CDM,278,RC,,,both,,,8352,6180.5,,,6180.5,Other,150% of Medicare + 9.63% HCRA Surcharge,3758.4,45,,3758.4,percent of total billed charges,Critical Access Hospital RCC factor,2839.68,34,,2839.68,percent of total billed charges,Implant Device,2839.68,34,,2839.68,percent of total billed charges,Implant Device,2839.68,34,,2839.68,percent of total billed charges,Implant Device,2839.68,34,,2839.68,percent of total billed charges,Implant Device,2839.68,34,,2839.68,percent of total billed charges,Implant Device,4134.24,,,4134.24,Other,110% of Medicare,2923.2,35,,2923.2,percent of total billed charges,Implant Device,2839.68,34,"Charges > $500, x 34%",2839.68,percent of total billed charges,Implant Device,2923.2,35,,2923.2,percent of total billed charges,Implant Device,2923.2,35,,2923.2,percent of total billed charges,Implant Device,2923.2,35,,2923.2,percent of total billed charges,Implant Device,2923.2,35,,2923.2,percent of total billed charges,Implant Device,2923.2,35,,2923.2,percent of total billed charges,Implant Device,3340.8,40,,3340.8,percent of total billed charges,Implant Device,2923.2,70,,2923.2,percent of total billed charges,All Other,2839.68,34,,2839.68,percent of total billed charges,Implant Device,2839.68,34,,2839.68,percent of total billed charges,Implant Device,2923.2,35,,2923.2,percent of total billed charges,Implant Device,2923.2,35,,2923.2,percent of total billed charges,Implant Device,2923.2,35,,2923.2,percent of total billed charges,Implant Device,2923.2,35,,2923.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2839.68,34,"If Charge > 2,000, then 34 percent",2839.68,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,6180.5,
STRYKER 5630-G-208 TIBIAL INSRT SZ 2 8MM,C1776,HCPCS,,79006907,CDM,278,RC,,,both,,,3232,2391.69,,,2391.69,Other,150% of Medicare + 9.63% HCRA Surcharge,1454.4,45,,1454.4,percent of total billed charges,Critical Access Hospital RCC factor,1098.88,34,,1098.88,percent of total billed charges,Implant Device,1098.88,34,,1098.88,percent of total billed charges,Implant Device,1098.88,34,,1098.88,percent of total billed charges,Implant Device,1098.88,34,,1098.88,percent of total billed charges,Implant Device,1098.88,34,,1098.88,percent of total billed charges,Implant Device,1599.84,,,1599.84,Other,110% of Medicare,1131.2,35,,1131.2,percent of total billed charges,Implant Device,1098.88,34,"Charges > $500, x 34%",1098.88,percent of total billed charges,Implant Device,1131.2,35,,1131.2,percent of total billed charges,Implant Device,1131.2,35,,1131.2,percent of total billed charges,Implant Device,1131.2,35,,1131.2,percent of total billed charges,Implant Device,1131.2,35,,1131.2,percent of total billed charges,Implant Device,1131.2,35,,1131.2,percent of total billed charges,Implant Device,1292.8,40,,1292.8,percent of total billed charges,Implant Device,1131.2,70,,1131.2,percent of total billed charges,All Other,1098.88,34,,1098.88,percent of total billed charges,Implant Device,1098.88,34,,1098.88,percent of total billed charges,Implant Device,1131.2,35,,1131.2,percent of total billed charges,Implant Device,1131.2,35,,1131.2,percent of total billed charges,Implant Device,1131.2,35,,1131.2,percent of total billed charges,Implant Device,1131.2,35,,1131.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1098.88,34,"If Charge > 2,000, then 34 percent",1098.88,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2391.69,
ARTHREX AR-8916VNR-03 VOLAR PLATE 3HOLE,C1713,HCPCS,,79006908,CDM,278,RC,,,both,,,2386,1765.65,,,1765.65,Other,150% of Medicare + 9.63% HCRA Surcharge,1073.7,45,,1073.7,percent of total billed charges,Critical Access Hospital RCC factor,811.24,34,,811.24,percent of total billed charges,Implant Device,811.24,34,,811.24,percent of total billed charges,Implant Device,811.24,34,,811.24,percent of total billed charges,Implant Device,811.24,34,,811.24,percent of total billed charges,Implant Device,811.24,34,,811.24,percent of total billed charges,Implant Device,1181.07,,,1181.07,Other,110% of Medicare,835.1,35,,835.1,percent of total billed charges,Implant Device,811.24,34,"Charges > $500, x 34%",811.24,percent of total billed charges,Implant Device,835.1,35,,835.1,percent of total billed charges,Implant Device,835.1,35,,835.1,percent of total billed charges,Implant Device,835.1,35,,835.1,percent of total billed charges,Implant Device,835.1,35,,835.1,percent of total billed charges,Implant Device,835.1,35,,835.1,percent of total billed charges,Implant Device,954.4,40,,954.4,percent of total billed charges,Implant Device,835.1,70,,835.1,percent of total billed charges,All Other,811.24,34,,811.24,percent of total billed charges,Implant Device,811.24,34,,811.24,percent of total billed charges,Implant Device,835.1,35,,835.1,percent of total billed charges,Implant Device,835.1,35,,835.1,percent of total billed charges,Implant Device,835.1,35,,835.1,percent of total billed charges,Implant Device,835.1,35,,835.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,811.24,34,"If Charge > 2,000, then 34 percent",811.24,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1765.65,
ARTHREX AR-8935-14 CORT SCREW 3.5X14MM,C1713,HCPCS,,79006909,CDM,278,RC,,,both,,,195,144.3,,,144.3,Other,150% of Medicare + 9.63% HCRA Surcharge,87.75,45,,87.75,percent of total billed charges,Critical Access Hospital RCC factor,66.3,34,,66.3,percent of total billed charges,Implant Device,66.3,34,,66.3,percent of total billed charges,Implant Device,66.3,34,,66.3,percent of total billed charges,Implant Device,66.3,34,,66.3,percent of total billed charges,Implant Device,66.3,34,,66.3,percent of total billed charges,Implant Device,96.53,,,96.53,Other,110% of Medicare,68.25,35,,68.25,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,68.25,35,,68.25,percent of total billed charges,Implant Device,68.25,35,,68.25,percent of total billed charges,Implant Device,68.25,35,,68.25,percent of total billed charges,Implant Device,68.25,35,,68.25,percent of total billed charges,Implant Device,68.25,35,,68.25,percent of total billed charges,Implant Device,78,40,,78,percent of total billed charges,Implant Device,68.25,70,,68.25,percent of total billed charges,All Other,66.3,34,,66.3,percent of total billed charges,Implant Device,66.3,34,,66.3,percent of total billed charges,Implant Device,68.25,35,,68.25,percent of total billed charges,Implant Device,68.25,35,,68.25,percent of total billed charges,Implant Device,68.25,35,,68.25,percent of total billed charges,Implant Device,68.25,35,,68.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,144.3,
ARTHREX AR-8935-16 CORT SCREW 3.5X16MM,C1713,HCPCS,,79006910,CDM,278,RC,,,both,,,195,144.3,,,144.3,Other,150% of Medicare + 9.63% HCRA Surcharge,87.75,45,,87.75,percent of total billed charges,Critical Access Hospital RCC factor,66.3,34,,66.3,percent of total billed charges,Implant Device,66.3,34,,66.3,percent of total billed charges,Implant Device,66.3,34,,66.3,percent of total billed charges,Implant Device,66.3,34,,66.3,percent of total billed charges,Implant Device,66.3,34,,66.3,percent of total billed charges,Implant Device,96.53,,,96.53,Other,110% of Medicare,68.25,35,,68.25,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,68.25,35,,68.25,percent of total billed charges,Implant Device,68.25,35,,68.25,percent of total billed charges,Implant Device,68.25,35,,68.25,percent of total billed charges,Implant Device,68.25,35,,68.25,percent of total billed charges,Implant Device,68.25,35,,68.25,percent of total billed charges,Implant Device,78,40,,78,percent of total billed charges,Implant Device,68.25,70,,68.25,percent of total billed charges,All Other,66.3,34,,66.3,percent of total billed charges,Implant Device,66.3,34,,66.3,percent of total billed charges,Implant Device,68.25,35,,68.25,percent of total billed charges,Implant Device,68.25,35,,68.25,percent of total billed charges,Implant Device,68.25,35,,68.25,percent of total billed charges,Implant Device,68.25,35,,68.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,144.3,
ARTHREX AR-8924V-16 LOCK SCREW 2.4X16MM,C1713,HCPCS,,79006911,CDM,278,RC,,,both,,,420,310.8,,,310.8,Other,150% of Medicare + 9.63% HCRA Surcharge,189,45,,189,percent of total billed charges,Critical Access Hospital RCC factor,142.8,34,,142.8,percent of total billed charges,Implant Device,142.8,34,,142.8,percent of total billed charges,Implant Device,142.8,34,,142.8,percent of total billed charges,Implant Device,142.8,34,,142.8,percent of total billed charges,Implant Device,142.8,34,,142.8,percent of total billed charges,Implant Device,207.9,,,207.9,Other,110% of Medicare,147,35,,147,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,147,35,,147,percent of total billed charges,Implant Device,147,35,,147,percent of total billed charges,Implant Device,147,35,,147,percent of total billed charges,Implant Device,147,35,,147,percent of total billed charges,Implant Device,147,35,,147,percent of total billed charges,Implant Device,168,40,,168,percent of total billed charges,Implant Device,147,70,,147,percent of total billed charges,All Other,142.8,34,,142.8,percent of total billed charges,Implant Device,142.8,34,,142.8,percent of total billed charges,Implant Device,147,35,,147,percent of total billed charges,Implant Device,147,35,,147,percent of total billed charges,Implant Device,147,35,,147,percent of total billed charges,Implant Device,147,35,,147,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,310.8,
ARTHREX AR-8724V-18 LOCK SCREW 2.4X18MM,C1713,HCPCS,,79006912,CDM,278,RC,,,both,,,420,310.8,,,310.8,Other,150% of Medicare + 9.63% HCRA Surcharge,189,45,,189,percent of total billed charges,Critical Access Hospital RCC factor,142.8,34,,142.8,percent of total billed charges,Implant Device,142.8,34,,142.8,percent of total billed charges,Implant Device,142.8,34,,142.8,percent of total billed charges,Implant Device,142.8,34,,142.8,percent of total billed charges,Implant Device,142.8,34,,142.8,percent of total billed charges,Implant Device,207.9,,,207.9,Other,110% of Medicare,147,35,,147,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,147,35,,147,percent of total billed charges,Implant Device,147,35,,147,percent of total billed charges,Implant Device,147,35,,147,percent of total billed charges,Implant Device,147,35,,147,percent of total billed charges,Implant Device,147,35,,147,percent of total billed charges,Implant Device,168,40,,168,percent of total billed charges,Implant Device,147,70,,147,percent of total billed charges,All Other,142.8,34,,142.8,percent of total billed charges,Implant Device,142.8,34,,142.8,percent of total billed charges,Implant Device,147,35,,147,percent of total billed charges,Implant Device,147,35,,147,percent of total billed charges,Implant Device,147,35,,147,percent of total billed charges,Implant Device,147,35,,147,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,310.8,
ARTHREX AR-8924V-22 LOCK SCREW 2.4X22MM,C1713,HCPCS,,79006913,CDM,278,RC,,,both,,,420,310.8,,,310.8,Other,150% of Medicare + 9.63% HCRA Surcharge,189,45,,189,percent of total billed charges,Critical Access Hospital RCC factor,142.8,34,,142.8,percent of total billed charges,Implant Device,142.8,34,,142.8,percent of total billed charges,Implant Device,142.8,34,,142.8,percent of total billed charges,Implant Device,142.8,34,,142.8,percent of total billed charges,Implant Device,142.8,34,,142.8,percent of total billed charges,Implant Device,207.9,,,207.9,Other,110% of Medicare,147,35,,147,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,147,35,,147,percent of total billed charges,Implant Device,147,35,,147,percent of total billed charges,Implant Device,147,35,,147,percent of total billed charges,Implant Device,147,35,,147,percent of total billed charges,Implant Device,147,35,,147,percent of total billed charges,Implant Device,168,40,,168,percent of total billed charges,Implant Device,147,70,,147,percent of total billed charges,All Other,142.8,34,,142.8,percent of total billed charges,Implant Device,142.8,34,,142.8,percent of total billed charges,Implant Device,147,35,,147,percent of total billed charges,Implant Device,147,35,,147,percent of total billed charges,Implant Device,147,35,,147,percent of total billed charges,Implant Device,147,35,,147,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,310.8,
ARTHREX AR-8720V-20 LOCK SCREW 2.4X20MM,C1713,HCPCS,,79006914,CDM,278,RC,,,both,,,420,310.8,,,310.8,Other,150% of Medicare + 9.63% HCRA Surcharge,189,45,,189,percent of total billed charges,Critical Access Hospital RCC factor,142.8,34,,142.8,percent of total billed charges,Implant Device,142.8,34,,142.8,percent of total billed charges,Implant Device,142.8,34,,142.8,percent of total billed charges,Implant Device,142.8,34,,142.8,percent of total billed charges,Implant Device,142.8,34,,142.8,percent of total billed charges,Implant Device,207.9,,,207.9,Other,110% of Medicare,147,35,,147,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,147,35,,147,percent of total billed charges,Implant Device,147,35,,147,percent of total billed charges,Implant Device,147,35,,147,percent of total billed charges,Implant Device,147,35,,147,percent of total billed charges,Implant Device,147,35,,147,percent of total billed charges,Implant Device,168,40,,168,percent of total billed charges,Implant Device,147,70,,147,percent of total billed charges,All Other,142.8,34,,142.8,percent of total billed charges,Implant Device,142.8,34,,142.8,percent of total billed charges,Implant Device,147,35,,147,percent of total billed charges,Implant Device,147,35,,147,percent of total billed charges,Implant Device,147,35,,147,percent of total billed charges,Implant Device,147,35,,147,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,310.8,
ALPHATEC SPINE 71001-14 PLATE 14MM,C1713,HCPCS,,79006922,CDM,278,RC,,,both,,,2280,1687.21,,,1687.21,Other,150% of Medicare + 9.63% HCRA Surcharge,1026,45,,1026,percent of total billed charges,Critical Access Hospital RCC factor,775.2,34,,775.2,percent of total billed charges,Implant Device,775.2,34,,775.2,percent of total billed charges,Implant Device,775.2,34,,775.2,percent of total billed charges,Implant Device,775.2,34,,775.2,percent of total billed charges,Implant Device,775.2,34,,775.2,percent of total billed charges,Implant Device,1128.6,,,1128.6,Other,110% of Medicare,798,35,,798,percent of total billed charges,Implant Device,775.2,34,"Charges > $500, x 34%",775.2,percent of total billed charges,Implant Device,798,35,,798,percent of total billed charges,Implant Device,798,35,,798,percent of total billed charges,Implant Device,798,35,,798,percent of total billed charges,Implant Device,798,35,,798,percent of total billed charges,Implant Device,798,35,,798,percent of total billed charges,Implant Device,912,40,,912,percent of total billed charges,Implant Device,798,70,,798,percent of total billed charges,All Other,775.2,34,,775.2,percent of total billed charges,Implant Device,775.2,34,,775.2,percent of total billed charges,Implant Device,798,35,,798,percent of total billed charges,Implant Device,798,35,,798,percent of total billed charges,Implant Device,798,35,,798,percent of total billed charges,Implant Device,798,35,,798,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,775.2,34,"If Charge > 2,000, then 34 percent",775.2,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1687.21,
ALPHATEC SPINE 71002-37 PLATE 2 LEV 37MM,C1713,HCPCS,,79006923,CDM,278,RC,,,both,,,2700,1998.01,,,1998.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1215,45,,1215,percent of total billed charges,Critical Access Hospital RCC factor,918,34,,918,percent of total billed charges,Implant Device,918,34,,918,percent of total billed charges,Implant Device,918,34,,918,percent of total billed charges,Implant Device,918,34,,918,percent of total billed charges,Implant Device,918,34,,918,percent of total billed charges,Implant Device,1336.5,,,1336.5,Other,110% of Medicare,945,35,,945,percent of total billed charges,Implant Device,918,34,"Charges > $500, x 34%",918,percent of total billed charges,Implant Device,945,35,,945,percent of total billed charges,Implant Device,945,35,,945,percent of total billed charges,Implant Device,945,35,,945,percent of total billed charges,Implant Device,945,35,,945,percent of total billed charges,Implant Device,945,35,,945,percent of total billed charges,Implant Device,1080,40,,1080,percent of total billed charges,Implant Device,945,70,,945,percent of total billed charges,All Other,918,34,,918,percent of total billed charges,Implant Device,918,34,,918,percent of total billed charges,Implant Device,945,35,,945,percent of total billed charges,Implant Device,945,35,,945,percent of total billed charges,Implant Device,945,35,,945,percent of total billed charges,Implant Device,945,35,,945,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,918,34,"If Charge > 2,000, then 34 percent",918,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1998.01,
ALLERGAN MF410525 SILICONE BREAST IMPLNT,C1789,HCPCS,,79006933,CDM,278,RC,,,both,,,3976,2942.25,,,2942.25,Other,150% of Medicare + 9.63% HCRA Surcharge,1789.2,45,,1789.2,percent of total billed charges,Critical Access Hospital RCC factor,1351.84,34,,1351.84,percent of total billed charges,Implant Device,1351.84,34,,1351.84,percent of total billed charges,Implant Device,1351.84,34,,1351.84,percent of total billed charges,Implant Device,1351.84,34,,1351.84,percent of total billed charges,Implant Device,1351.84,34,,1351.84,percent of total billed charges,Implant Device,1968.12,,,1968.12,Other,110% of Medicare,1391.6,35,,1391.6,percent of total billed charges,Implant Device,1351.84,34,"Charges > $500, x 34%",1351.84,percent of total billed charges,Implant Device,1391.6,35,,1391.6,percent of total billed charges,Implant Device,1391.6,35,,1391.6,percent of total billed charges,Implant Device,1391.6,35,,1391.6,percent of total billed charges,Implant Device,1391.6,35,,1391.6,percent of total billed charges,Implant Device,1391.6,35,,1391.6,percent of total billed charges,Implant Device,1590.4,40,,1590.4,percent of total billed charges,Implant Device,1391.6,70,,1391.6,percent of total billed charges,All Other,1351.84,34,,1351.84,percent of total billed charges,Implant Device,1351.84,34,,1351.84,percent of total billed charges,Implant Device,1391.6,35,,1391.6,percent of total billed charges,Implant Device,1391.6,35,,1391.6,percent of total billed charges,Implant Device,1391.6,35,,1391.6,percent of total billed charges,Implant Device,1391.6,35,,1391.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1351.84,34,"If Charge > 2,000, then 34 percent",1351.84,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2942.25,
ALLERGAN MF420580 SILICONE BREAST IMPLNT,C1789,HCPCS,,79006934,CDM,278,RC,,,both,,,3975,2941.51,,,2941.51,Other,150% of Medicare + 9.63% HCRA Surcharge,1788.75,45,,1788.75,percent of total billed charges,Critical Access Hospital RCC factor,1351.5,34,,1351.5,percent of total billed charges,Implant Device,1351.5,34,,1351.5,percent of total billed charges,Implant Device,1351.5,34,,1351.5,percent of total billed charges,Implant Device,1351.5,34,,1351.5,percent of total billed charges,Implant Device,1351.5,34,,1351.5,percent of total billed charges,Implant Device,1967.63,,,1967.63,Other,110% of Medicare,1391.25,35,,1391.25,percent of total billed charges,Implant Device,1351.5,34,"Charges > $500, x 34%",1351.5,percent of total billed charges,Implant Device,1391.25,35,,1391.25,percent of total billed charges,Implant Device,1391.25,35,,1391.25,percent of total billed charges,Implant Device,1391.25,35,,1391.25,percent of total billed charges,Implant Device,1391.25,35,,1391.25,percent of total billed charges,Implant Device,1391.25,35,,1391.25,percent of total billed charges,Implant Device,1590,40,,1590,percent of total billed charges,Implant Device,1391.25,70,,1391.25,percent of total billed charges,All Other,1351.5,34,,1351.5,percent of total billed charges,Implant Device,1351.5,34,,1351.5,percent of total billed charges,Implant Device,1391.25,35,,1391.25,percent of total billed charges,Implant Device,1391.25,35,,1391.25,percent of total billed charges,Implant Device,1391.25,35,,1391.25,percent of total billed charges,Implant Device,1391.25,35,,1391.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1351.5,34,"If Charge > 2,000, then 34 percent",1351.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2941.51,
ALLERGAN MF410640 SILICONE BREAST IMPLNT,C1789,HCPCS,,79006935,CDM,278,RC,,,both,,,3976,2942.25,,,2942.25,Other,150% of Medicare + 9.63% HCRA Surcharge,1789.2,45,,1789.2,percent of total billed charges,Critical Access Hospital RCC factor,1351.84,34,,1351.84,percent of total billed charges,Implant Device,1351.84,34,,1351.84,percent of total billed charges,Implant Device,1351.84,34,,1351.84,percent of total billed charges,Implant Device,1351.84,34,,1351.84,percent of total billed charges,Implant Device,1351.84,34,,1351.84,percent of total billed charges,Implant Device,1968.12,,,1968.12,Other,110% of Medicare,1391.6,35,,1391.6,percent of total billed charges,Implant Device,1351.84,34,"Charges > $500, x 34%",1351.84,percent of total billed charges,Implant Device,1391.6,35,,1391.6,percent of total billed charges,Implant Device,1391.6,35,,1391.6,percent of total billed charges,Implant Device,1391.6,35,,1391.6,percent of total billed charges,Implant Device,1391.6,35,,1391.6,percent of total billed charges,Implant Device,1391.6,35,,1391.6,percent of total billed charges,Implant Device,1590.4,40,,1590.4,percent of total billed charges,Implant Device,1391.6,70,,1391.6,percent of total billed charges,All Other,1351.84,34,,1351.84,percent of total billed charges,Implant Device,1351.84,34,,1351.84,percent of total billed charges,Implant Device,1391.6,35,,1391.6,percent of total billed charges,Implant Device,1391.6,35,,1391.6,percent of total billed charges,Implant Device,1391.6,35,,1391.6,percent of total billed charges,Implant Device,1391.6,35,,1391.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1351.84,34,"If Charge > 2,000, then 34 percent",1351.84,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2942.25,
ZIMMER 00-8852-012-36 RIM LINER 36MM KK,C1776,HCPCS,,79006937,CDM,278,RC,,,both,,,4403,3258.23,,,3258.23,Other,150% of Medicare + 9.63% HCRA Surcharge,1981.35,45,,1981.35,percent of total billed charges,Critical Access Hospital RCC factor,1497.02,34,,1497.02,percent of total billed charges,Implant Device,1497.02,34,,1497.02,percent of total billed charges,Implant Device,1497.02,34,,1497.02,percent of total billed charges,Implant Device,1497.02,34,,1497.02,percent of total billed charges,Implant Device,1497.02,34,,1497.02,percent of total billed charges,Implant Device,2179.49,,,2179.49,Other,110% of Medicare,1541.05,35,,1541.05,percent of total billed charges,Implant Device,1497.02,34,"Charges > $500, x 34%",1497.02,percent of total billed charges,Implant Device,1541.05,35,,1541.05,percent of total billed charges,Implant Device,1541.05,35,,1541.05,percent of total billed charges,Implant Device,1541.05,35,,1541.05,percent of total billed charges,Implant Device,1541.05,35,,1541.05,percent of total billed charges,Implant Device,1541.05,35,,1541.05,percent of total billed charges,Implant Device,1761.2,40,,1761.2,percent of total billed charges,Implant Device,1541.05,70,,1541.05,percent of total billed charges,All Other,1497.02,34,,1497.02,percent of total billed charges,Implant Device,1497.02,34,,1497.02,percent of total billed charges,Implant Device,1541.05,35,,1541.05,percent of total billed charges,Implant Device,1541.05,35,,1541.05,percent of total billed charges,Implant Device,1541.05,35,,1541.05,percent of total billed charges,Implant Device,1541.05,35,,1541.05,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1497.02,34,"If Charge > 2,000, then 34 percent",1497.02,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3258.23,
SYNTHES 208.406 CANN SCREW 6.5X55MM,C1713,HCPCS,,79006938,CDM,278,RC,,,both,,,1120,828.8,,,828.8,Other,150% of Medicare + 9.63% HCRA Surcharge,504,45,,504,percent of total billed charges,Critical Access Hospital RCC factor,380.8,34,,380.8,percent of total billed charges,Implant Device,380.8,34,,380.8,percent of total billed charges,Implant Device,380.8,34,,380.8,percent of total billed charges,Implant Device,380.8,34,,380.8,percent of total billed charges,Implant Device,380.8,34,,380.8,percent of total billed charges,Implant Device,554.4,,,554.4,Other,110% of Medicare,392,35,,392,percent of total billed charges,Implant Device,380.8,34,"Charges > $500, x 34%",380.8,percent of total billed charges,Implant Device,392,35,,392,percent of total billed charges,Implant Device,392,35,,392,percent of total billed charges,Implant Device,392,35,,392,percent of total billed charges,Implant Device,392,35,,392,percent of total billed charges,Implant Device,392,35,,392,percent of total billed charges,Implant Device,448,40,,448,percent of total billed charges,Implant Device,392,70,,392,percent of total billed charges,All Other,380.8,34,,380.8,percent of total billed charges,Implant Device,380.8,34,,380.8,percent of total billed charges,Implant Device,392,35,,392,percent of total billed charges,Implant Device,392,35,,392,percent of total billed charges,Implant Device,392,35,,392,percent of total billed charges,Implant Device,392,35,,392,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,828.8,
SYNTHES 214.064 CORTEX SCREW 4.5X64MM,C1713,HCPCS,,79006939,CDM,278,RC,,,both,,,79,58.46,,,58.46,Other,150% of Medicare + 9.63% HCRA Surcharge,35.55,45,,35.55,percent of total billed charges,Critical Access Hospital RCC factor,26.86,34,,26.86,percent of total billed charges,Implant Device,26.86,34,,26.86,percent of total billed charges,Implant Device,26.86,34,,26.86,percent of total billed charges,Implant Device,26.86,34,,26.86,percent of total billed charges,Implant Device,26.86,34,,26.86,percent of total billed charges,Implant Device,39.11,,,39.11,Other,110% of Medicare,27.65,35,,27.65,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,27.65,35,,27.65,percent of total billed charges,Implant Device,27.65,35,,27.65,percent of total billed charges,Implant Device,27.65,35,,27.65,percent of total billed charges,Implant Device,27.65,35,,27.65,percent of total billed charges,Implant Device,27.65,35,,27.65,percent of total billed charges,Implant Device,31.6,40,,31.6,percent of total billed charges,Implant Device,27.65,70,,27.65,percent of total billed charges,All Other,26.86,34,,26.86,percent of total billed charges,Implant Device,26.86,34,,26.86,percent of total billed charges,Implant Device,27.65,35,,27.65,percent of total billed charges,Implant Device,27.65,35,,27.65,percent of total billed charges,Implant Device,27.65,35,,27.65,percent of total billed charges,Implant Device,27.65,35,,27.65,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,58.46,
ZIMMER 00-8755-012-36 LINER 36X56MM,C1776,HCPCS,,79006940,CDM,278,RC,,,both,,,4973,3680.03,,,3680.03,Other,150% of Medicare + 9.63% HCRA Surcharge,2237.85,45,,2237.85,percent of total billed charges,Critical Access Hospital RCC factor,1690.82,34,,1690.82,percent of total billed charges,Implant Device,1690.82,34,,1690.82,percent of total billed charges,Implant Device,1690.82,34,,1690.82,percent of total billed charges,Implant Device,1690.82,34,,1690.82,percent of total billed charges,Implant Device,1690.82,34,,1690.82,percent of total billed charges,Implant Device,2461.64,,,2461.64,Other,110% of Medicare,1740.55,35,,1740.55,percent of total billed charges,Implant Device,1690.82,34,"Charges > $500, x 34%",1690.82,percent of total billed charges,Implant Device,1740.55,35,,1740.55,percent of total billed charges,Implant Device,1740.55,35,,1740.55,percent of total billed charges,Implant Device,1740.55,35,,1740.55,percent of total billed charges,Implant Device,1740.55,35,,1740.55,percent of total billed charges,Implant Device,1740.55,35,,1740.55,percent of total billed charges,Implant Device,1989.2,40,,1989.2,percent of total billed charges,Implant Device,1740.55,70,,1740.55,percent of total billed charges,All Other,1690.82,34,,1690.82,percent of total billed charges,Implant Device,1690.82,34,,1690.82,percent of total billed charges,Implant Device,1740.55,35,,1740.55,percent of total billed charges,Implant Device,1740.55,35,,1740.55,percent of total billed charges,Implant Device,1740.55,35,,1740.55,percent of total billed charges,Implant Device,1740.55,35,,1740.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1690.82,34,"If Charge > 2,000, then 34 percent",1690.82,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3680.03,
ZIMMER 00-5980-047-02 TIBIAL PLATE SZ 6,C1713,HCPCS,,79006941,CDM,278,RC,,,both,,,2304,1704.97,,,1704.97,Other,150% of Medicare + 9.63% HCRA Surcharge,1036.8,45,,1036.8,percent of total billed charges,Critical Access Hospital RCC factor,783.36,34,,783.36,percent of total billed charges,Implant Device,783.36,34,,783.36,percent of total billed charges,Implant Device,783.36,34,,783.36,percent of total billed charges,Implant Device,783.36,34,,783.36,percent of total billed charges,Implant Device,783.36,34,,783.36,percent of total billed charges,Implant Device,1140.48,,,1140.48,Other,110% of Medicare,806.4,35,,806.4,percent of total billed charges,Implant Device,783.36,34,"Charges > $500, x 34%",783.36,percent of total billed charges,Implant Device,806.4,35,,806.4,percent of total billed charges,Implant Device,806.4,35,,806.4,percent of total billed charges,Implant Device,806.4,35,,806.4,percent of total billed charges,Implant Device,806.4,35,,806.4,percent of total billed charges,Implant Device,806.4,35,,806.4,percent of total billed charges,Implant Device,921.6,40,,921.6,percent of total billed charges,Implant Device,806.4,70,,806.4,percent of total billed charges,All Other,783.36,34,,783.36,percent of total billed charges,Implant Device,783.36,34,,783.36,percent of total billed charges,Implant Device,806.4,35,,806.4,percent of total billed charges,Implant Device,806.4,35,,806.4,percent of total billed charges,Implant Device,806.4,35,,806.4,percent of total billed charges,Implant Device,806.4,35,,806.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,783.36,34,"If Charge > 2,000, then 34 percent",783.36,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1704.97,
ZIMMER 00-5994-040-17 ART SURF 17MM 5-6,C1776,HCPCS,,79006942,CDM,278,RC,,,both,,,6257,4630.2,,,4630.2,Other,150% of Medicare + 9.63% HCRA Surcharge,2815.65,45,,2815.65,percent of total billed charges,Critical Access Hospital RCC factor,2127.38,34,,2127.38,percent of total billed charges,Implant Device,2127.38,34,,2127.38,percent of total billed charges,Implant Device,2127.38,34,,2127.38,percent of total billed charges,Implant Device,2127.38,34,,2127.38,percent of total billed charges,Implant Device,2127.38,34,,2127.38,percent of total billed charges,Implant Device,3097.22,,,3097.22,Other,110% of Medicare,2189.95,35,,2189.95,percent of total billed charges,Implant Device,2127.38,34,"Charges > $500, x 34%",2127.38,percent of total billed charges,Implant Device,2189.95,35,,2189.95,percent of total billed charges,Implant Device,2189.95,35,,2189.95,percent of total billed charges,Implant Device,2189.95,35,,2189.95,percent of total billed charges,Implant Device,2189.95,35,,2189.95,percent of total billed charges,Implant Device,2189.95,35,,2189.95,percent of total billed charges,Implant Device,2502.8,40,,2502.8,percent of total billed charges,Implant Device,2189.95,70,,2189.95,percent of total billed charges,All Other,2127.38,34,,2127.38,percent of total billed charges,Implant Device,2127.38,34,,2127.38,percent of total billed charges,Implant Device,2189.95,35,,2189.95,percent of total billed charges,Implant Device,2189.95,35,,2189.95,percent of total billed charges,Implant Device,2189.95,35,,2189.95,percent of total billed charges,Implant Device,2189.95,35,,2189.95,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2127.38,34,"If Charge > 2,000, then 34 percent",2127.38,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4630.2,
DEPUY 02.118.402 2.7 MM 4 HOLE PLATE,C1713,HCPCS,,79006944,CDM,278,RC,,,both,,,3169,2345.07,,,2345.07,Other,150% of Medicare + 9.63% HCRA Surcharge,1426.05,45,,1426.05,percent of total billed charges,Critical Access Hospital RCC factor,1077.46,34,,1077.46,percent of total billed charges,Implant Device,1077.46,34,,1077.46,percent of total billed charges,Implant Device,1077.46,34,,1077.46,percent of total billed charges,Implant Device,1077.46,34,,1077.46,percent of total billed charges,Implant Device,1077.46,34,,1077.46,percent of total billed charges,Implant Device,1568.66,,,1568.66,Other,110% of Medicare,1109.15,35,,1109.15,percent of total billed charges,Implant Device,1077.46,34,"Charges > $500, x 34%",1077.46,percent of total billed charges,Implant Device,1109.15,35,,1109.15,percent of total billed charges,Implant Device,1109.15,35,,1109.15,percent of total billed charges,Implant Device,1109.15,35,,1109.15,percent of total billed charges,Implant Device,1109.15,35,,1109.15,percent of total billed charges,Implant Device,1109.15,35,,1109.15,percent of total billed charges,Implant Device,1267.6,40,,1267.6,percent of total billed charges,Implant Device,1109.15,70,,1109.15,percent of total billed charges,All Other,1077.46,34,,1077.46,percent of total billed charges,Implant Device,1077.46,34,,1077.46,percent of total billed charges,Implant Device,1109.15,35,,1109.15,percent of total billed charges,Implant Device,1109.15,35,,1109.15,percent of total billed charges,Implant Device,1109.15,35,,1109.15,percent of total billed charges,Implant Device,1109.15,35,,1109.15,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1077.46,34,"If Charge > 2,000, then 34 percent",1077.46,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2345.07,
DEPUY 202.884 2.7 X 24MM CORTEX SCREW,C1713,HCPCS,,79006945,CDM,278,RC,,,both,,,88,65.12,,,65.12,Other,150% of Medicare + 9.63% HCRA Surcharge,39.6,45,,39.6,percent of total billed charges,Critical Access Hospital RCC factor,29.92,34,,29.92,percent of total billed charges,Implant Device,29.92,34,,29.92,percent of total billed charges,Implant Device,29.92,34,,29.92,percent of total billed charges,Implant Device,29.92,34,,29.92,percent of total billed charges,Implant Device,29.92,34,,29.92,percent of total billed charges,Implant Device,43.56,,,43.56,Other,110% of Medicare,30.8,35,,30.8,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,30.8,35,,30.8,percent of total billed charges,Implant Device,30.8,35,,30.8,percent of total billed charges,Implant Device,30.8,35,,30.8,percent of total billed charges,Implant Device,30.8,35,,30.8,percent of total billed charges,Implant Device,30.8,35,,30.8,percent of total billed charges,Implant Device,35.2,40,,35.2,percent of total billed charges,Implant Device,30.8,70,,30.8,percent of total billed charges,All Other,29.92,34,,29.92,percent of total billed charges,Implant Device,29.92,34,,29.92,percent of total billed charges,Implant Device,30.8,35,,30.8,percent of total billed charges,Implant Device,30.8,35,,30.8,percent of total billed charges,Implant Device,30.8,35,,30.8,percent of total billed charges,Implant Device,30.8,35,,30.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,65.12,
DEPUY 02.206.216 3.5X16MM CORTEX SCREW,C1713,HCPCS,,79006946,CDM,278,RC,,,both,,,79,58.46,,,58.46,Other,150% of Medicare + 9.63% HCRA Surcharge,35.55,45,,35.55,percent of total billed charges,Critical Access Hospital RCC factor,26.86,34,,26.86,percent of total billed charges,Implant Device,26.86,34,,26.86,percent of total billed charges,Implant Device,26.86,34,,26.86,percent of total billed charges,Implant Device,26.86,34,,26.86,percent of total billed charges,Implant Device,26.86,34,,26.86,percent of total billed charges,Implant Device,39.11,,,39.11,Other,110% of Medicare,27.65,35,,27.65,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,27.65,35,,27.65,percent of total billed charges,Implant Device,27.65,35,,27.65,percent of total billed charges,Implant Device,27.65,35,,27.65,percent of total billed charges,Implant Device,27.65,35,,27.65,percent of total billed charges,Implant Device,27.65,35,,27.65,percent of total billed charges,Implant Device,31.6,40,,31.6,percent of total billed charges,Implant Device,27.65,70,,27.65,percent of total billed charges,All Other,26.86,34,,26.86,percent of total billed charges,Implant Device,26.86,34,,26.86,percent of total billed charges,Implant Device,27.65,35,,27.65,percent of total billed charges,Implant Device,27.65,35,,27.65,percent of total billed charges,Implant Device,27.65,35,,27.65,percent of total billed charges,Implant Device,27.65,35,,27.65,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,58.46,
DEPUY 02.118.516 2.7 C 16MM META SCREW,C1713,HCPCS,,79006947,CDM,278,RC,,,both,,,178,131.72,,,131.72,Other,150% of Medicare + 9.63% HCRA Surcharge,80.1,45,,80.1,percent of total billed charges,Critical Access Hospital RCC factor,60.52,34,,60.52,percent of total billed charges,Implant Device,60.52,34,,60.52,percent of total billed charges,Implant Device,60.52,34,,60.52,percent of total billed charges,Implant Device,60.52,34,,60.52,percent of total billed charges,Implant Device,60.52,34,,60.52,percent of total billed charges,Implant Device,88.11,,,88.11,Other,110% of Medicare,62.3,35,,62.3,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,62.3,35,,62.3,percent of total billed charges,Implant Device,62.3,35,,62.3,percent of total billed charges,Implant Device,62.3,35,,62.3,percent of total billed charges,Implant Device,62.3,35,,62.3,percent of total billed charges,Implant Device,62.3,35,,62.3,percent of total billed charges,Implant Device,71.2,40,,71.2,percent of total billed charges,Implant Device,62.3,70,,62.3,percent of total billed charges,All Other,60.52,34,,60.52,percent of total billed charges,Implant Device,60.52,34,,60.52,percent of total billed charges,Implant Device,62.3,35,,62.3,percent of total billed charges,Implant Device,62.3,35,,62.3,percent of total billed charges,Implant Device,62.3,35,,62.3,percent of total billed charges,Implant Device,62.3,35,,62.3,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,131.72,
DEPUY 02.211.018 2.7X18MM VA LCKNG SCREW,C1713,HCPCS,,79006948,CDM,278,RC,,,both,,,343,253.82,,,253.82,Other,150% of Medicare + 9.63% HCRA Surcharge,154.35,45,,154.35,percent of total billed charges,Critical Access Hospital RCC factor,116.62,34,,116.62,percent of total billed charges,Implant Device,116.62,34,,116.62,percent of total billed charges,Implant Device,116.62,34,,116.62,percent of total billed charges,Implant Device,116.62,34,,116.62,percent of total billed charges,Implant Device,116.62,34,,116.62,percent of total billed charges,Implant Device,169.79,,,169.79,Other,110% of Medicare,120.05,35,,120.05,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,120.05,35,,120.05,percent of total billed charges,Implant Device,120.05,35,,120.05,percent of total billed charges,Implant Device,120.05,35,,120.05,percent of total billed charges,Implant Device,120.05,35,,120.05,percent of total billed charges,Implant Device,120.05,35,,120.05,percent of total billed charges,Implant Device,137.2,40,,137.2,percent of total billed charges,Implant Device,120.05,70,,120.05,percent of total billed charges,All Other,116.62,34,,116.62,percent of total billed charges,Implant Device,116.62,34,,116.62,percent of total billed charges,Implant Device,120.05,35,,120.05,percent of total billed charges,Implant Device,120.05,35,,120.05,percent of total billed charges,Implant Device,120.05,35,,120.05,percent of total billed charges,Implant Device,120.05,35,,120.05,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,253.82,
DEPUY 02.118.400 2.7MM 3 HOLE PLATE,C1713,HCPCS,,79006949,CDM,278,RC,,,both,,,3125,2312.51,,,2312.51,Other,150% of Medicare + 9.63% HCRA Surcharge,1406.25,45,,1406.25,percent of total billed charges,Critical Access Hospital RCC factor,1062.5,34,,1062.5,percent of total billed charges,Implant Device,1062.5,34,,1062.5,percent of total billed charges,Implant Device,1062.5,34,,1062.5,percent of total billed charges,Implant Device,1062.5,34,,1062.5,percent of total billed charges,Implant Device,1062.5,34,,1062.5,percent of total billed charges,Implant Device,1546.88,,,1546.88,Other,110% of Medicare,1093.75,35,,1093.75,percent of total billed charges,Implant Device,1062.5,34,"Charges > $500, x 34%",1062.5,percent of total billed charges,Implant Device,1093.75,35,,1093.75,percent of total billed charges,Implant Device,1093.75,35,,1093.75,percent of total billed charges,Implant Device,1093.75,35,,1093.75,percent of total billed charges,Implant Device,1093.75,35,,1093.75,percent of total billed charges,Implant Device,1093.75,35,,1093.75,percent of total billed charges,Implant Device,1250,40,,1250,percent of total billed charges,Implant Device,1093.75,70,,1093.75,percent of total billed charges,All Other,1062.5,34,,1062.5,percent of total billed charges,Implant Device,1062.5,34,,1062.5,percent of total billed charges,Implant Device,1093.75,35,,1093.75,percent of total billed charges,Implant Device,1093.75,35,,1093.75,percent of total billed charges,Implant Device,1093.75,35,,1093.75,percent of total billed charges,Implant Device,1093.75,35,,1093.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1062.5,34,"If Charge > 2,000, then 34 percent",1062.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2312.51,
DEPUY 02.118.518 2.7 C 18MM META SCREW,C1713,HCPCS,,79006950,CDM,278,RC,,,both,,,125,92.5,,,92.5,Other,150% of Medicare + 9.63% HCRA Surcharge,56.25,45,,56.25,percent of total billed charges,Critical Access Hospital RCC factor,42.5,34,,42.5,percent of total billed charges,Implant Device,42.5,34,,42.5,percent of total billed charges,Implant Device,42.5,34,,42.5,percent of total billed charges,Implant Device,42.5,34,,42.5,percent of total billed charges,Implant Device,42.5,34,,42.5,percent of total billed charges,Implant Device,61.88,,,61.88,Other,110% of Medicare,43.75,35,,43.75,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,43.75,35,,43.75,percent of total billed charges,Implant Device,43.75,35,,43.75,percent of total billed charges,Implant Device,43.75,35,,43.75,percent of total billed charges,Implant Device,43.75,35,,43.75,percent of total billed charges,Implant Device,43.75,35,,43.75,percent of total billed charges,Implant Device,50,40,,50,percent of total billed charges,Implant Device,43.75,70,,43.75,percent of total billed charges,All Other,42.5,34,,42.5,percent of total billed charges,Implant Device,42.5,34,,42.5,percent of total billed charges,Implant Device,43.75,35,,43.75,percent of total billed charges,Implant Device,43.75,35,,43.75,percent of total billed charges,Implant Device,43.75,35,,43.75,percent of total billed charges,Implant Device,43.75,35,,43.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,92.5,
DEPUY 02.211.012 2.7 X 12MM LCKNG SCREW,C1713,HCPCS,,79006951,CDM,278,RC,,,both,,,343,253.82,,,253.82,Other,150% of Medicare + 9.63% HCRA Surcharge,154.35,45,,154.35,percent of total billed charges,Critical Access Hospital RCC factor,116.62,34,,116.62,percent of total billed charges,Implant Device,116.62,34,,116.62,percent of total billed charges,Implant Device,116.62,34,,116.62,percent of total billed charges,Implant Device,116.62,34,,116.62,percent of total billed charges,Implant Device,116.62,34,,116.62,percent of total billed charges,Implant Device,169.79,,,169.79,Other,110% of Medicare,120.05,35,,120.05,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,120.05,35,,120.05,percent of total billed charges,Implant Device,120.05,35,,120.05,percent of total billed charges,Implant Device,120.05,35,,120.05,percent of total billed charges,Implant Device,120.05,35,,120.05,percent of total billed charges,Implant Device,120.05,35,,120.05,percent of total billed charges,Implant Device,137.2,40,,137.2,percent of total billed charges,Implant Device,120.05,70,,120.05,percent of total billed charges,All Other,116.62,34,,116.62,percent of total billed charges,Implant Device,116.62,34,,116.62,percent of total billed charges,Implant Device,120.05,35,,120.05,percent of total billed charges,Implant Device,120.05,35,,120.05,percent of total billed charges,Implant Device,120.05,35,,120.05,percent of total billed charges,Implant Device,120.05,35,,120.05,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,253.82,
DEPUY 202.874 2.7 X 14MM CORTEX SCREW,C1713,HCPCS,,79006952,CDM,278,RC,,,both,,,88,65.12,,,65.12,Other,150% of Medicare + 9.63% HCRA Surcharge,39.6,45,,39.6,percent of total billed charges,Critical Access Hospital RCC factor,29.92,34,,29.92,percent of total billed charges,Implant Device,29.92,34,,29.92,percent of total billed charges,Implant Device,29.92,34,,29.92,percent of total billed charges,Implant Device,29.92,34,,29.92,percent of total billed charges,Implant Device,29.92,34,,29.92,percent of total billed charges,Implant Device,43.56,,,43.56,Other,110% of Medicare,30.8,35,,30.8,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,30.8,35,,30.8,percent of total billed charges,Implant Device,30.8,35,,30.8,percent of total billed charges,Implant Device,30.8,35,,30.8,percent of total billed charges,Implant Device,30.8,35,,30.8,percent of total billed charges,Implant Device,30.8,35,,30.8,percent of total billed charges,Implant Device,35.2,40,,35.2,percent of total billed charges,Implant Device,30.8,70,,30.8,percent of total billed charges,All Other,29.92,34,,29.92,percent of total billed charges,Implant Device,29.92,34,,29.92,percent of total billed charges,Implant Device,30.8,35,,30.8,percent of total billed charges,Implant Device,30.8,35,,30.8,percent of total billed charges,Implant Device,30.8,35,,30.8,percent of total billed charges,Implant Device,30.8,35,,30.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,65.12,
DEPUY 02.206.214 3.5X14MM CORTEX SCREW,C1713,HCPCS,,79006953,CDM,278,RC,,,both,,,79,58.46,,,58.46,Other,150% of Medicare + 9.63% HCRA Surcharge,35.55,45,,35.55,percent of total billed charges,Critical Access Hospital RCC factor,26.86,34,,26.86,percent of total billed charges,Implant Device,26.86,34,,26.86,percent of total billed charges,Implant Device,26.86,34,,26.86,percent of total billed charges,Implant Device,26.86,34,,26.86,percent of total billed charges,Implant Device,26.86,34,,26.86,percent of total billed charges,Implant Device,39.11,,,39.11,Other,110% of Medicare,27.65,35,,27.65,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,27.65,35,,27.65,percent of total billed charges,Implant Device,27.65,35,,27.65,percent of total billed charges,Implant Device,27.65,35,,27.65,percent of total billed charges,Implant Device,27.65,35,,27.65,percent of total billed charges,Implant Device,27.65,35,,27.65,percent of total billed charges,Implant Device,31.6,40,,31.6,percent of total billed charges,Implant Device,27.65,70,,27.65,percent of total billed charges,All Other,26.86,34,,26.86,percent of total billed charges,Implant Device,26.86,34,,26.86,percent of total billed charges,Implant Device,27.65,35,,27.65,percent of total billed charges,Implant Device,27.65,35,,27.65,percent of total billed charges,Implant Device,27.65,35,,27.65,percent of total billed charges,Implant Device,27.65,35,,27.65,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,58.46,
DEPUY 207.744 4X44MM CANNUALTED SCREW,C1713,HCPCS,,79006954,CDM,278,RC,,,both,,,685,506.9,,,506.9,Other,150% of Medicare + 9.63% HCRA Surcharge,308.25,45,,308.25,percent of total billed charges,Critical Access Hospital RCC factor,232.9,34,,232.9,percent of total billed charges,Implant Device,232.9,34,,232.9,percent of total billed charges,Implant Device,232.9,34,,232.9,percent of total billed charges,Implant Device,232.9,34,,232.9,percent of total billed charges,Implant Device,232.9,34,,232.9,percent of total billed charges,Implant Device,339.08,,,339.08,Other,110% of Medicare,239.75,35,,239.75,percent of total billed charges,Implant Device,232.9,34,"Charges > $500, x 34%",232.9,percent of total billed charges,Implant Device,239.75,35,,239.75,percent of total billed charges,Implant Device,239.75,35,,239.75,percent of total billed charges,Implant Device,239.75,35,,239.75,percent of total billed charges,Implant Device,239.75,35,,239.75,percent of total billed charges,Implant Device,239.75,35,,239.75,percent of total billed charges,Implant Device,274,40,,274,percent of total billed charges,Implant Device,239.75,70,,239.75,percent of total billed charges,All Other,232.9,34,,232.9,percent of total billed charges,Implant Device,232.9,34,,232.9,percent of total billed charges,Implant Device,239.75,35,,239.75,percent of total billed charges,Implant Device,239.75,35,,239.75,percent of total billed charges,Implant Device,239.75,35,,239.75,percent of total billed charges,Implant Device,239.75,35,,239.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,506.9,
GORE VBJR07150A VIABAHN 7MMX15CM STENT,C1876,HCPCS,,79006956,CDM,278,RC,,,both,,,11970,8857.83,,,8857.83,Other,150% of Medicare + 9.63% HCRA Surcharge,5386.5,45,,5386.5,percent of total billed charges,Critical Access Hospital RCC factor,4069.8,34,,4069.8,percent of total billed charges,Implant Device,4069.8,34,,4069.8,percent of total billed charges,Implant Device,4069.8,34,,4069.8,percent of total billed charges,Implant Device,4069.8,34,,4069.8,percent of total billed charges,Implant Device,4069.8,34,,4069.8,percent of total billed charges,Implant Device,5925.15,,,5925.15,Other,110% of Medicare,4189.5,35,,4189.5,percent of total billed charges,Implant Device,4069.8,34,"Charges > $500, x 34%",4069.8,percent of total billed charges,Implant Device,4189.5,35,,4189.5,percent of total billed charges,Implant Device,4189.5,35,,4189.5,percent of total billed charges,Implant Device,4189.5,35,,4189.5,percent of total billed charges,Implant Device,4189.5,35,,4189.5,percent of total billed charges,Implant Device,4189.5,35,,4189.5,percent of total billed charges,Implant Device,4788,40,,4788,percent of total billed charges,Implant Device,4189.5,70,,4189.5,percent of total billed charges,All Other,4069.8,34,,4069.8,percent of total billed charges,Implant Device,4069.8,34,,4069.8,percent of total billed charges,Implant Device,4189.5,35,,4189.5,percent of total billed charges,Implant Device,4189.5,35,,4189.5,percent of total billed charges,Implant Device,4189.5,35,,4189.5,percent of total billed charges,Implant Device,4189.5,35,,4189.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,4069.8,34,"If Charge > 2,000, then 34 percent",4069.8,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,8857.83,
STRYKER 54-25374 VOLAR PLATE LEFT,C1713,HCPCS,,79006958,CDM,278,RC,,,both,,,2438,1804.13,,,1804.13,Other,150% of Medicare + 9.63% HCRA Surcharge,1097.1,45,,1097.1,percent of total billed charges,Critical Access Hospital RCC factor,828.92,34,,828.92,percent of total billed charges,Implant Device,828.92,34,,828.92,percent of total billed charges,Implant Device,828.92,34,,828.92,percent of total billed charges,Implant Device,828.92,34,,828.92,percent of total billed charges,Implant Device,828.92,34,,828.92,percent of total billed charges,Implant Device,1206.81,,,1206.81,Other,110% of Medicare,853.3,35,,853.3,percent of total billed charges,Implant Device,828.92,34,"Charges > $500, x 34%",828.92,percent of total billed charges,Implant Device,853.3,35,,853.3,percent of total billed charges,Implant Device,853.3,35,,853.3,percent of total billed charges,Implant Device,853.3,35,,853.3,percent of total billed charges,Implant Device,853.3,35,,853.3,percent of total billed charges,Implant Device,853.3,35,,853.3,percent of total billed charges,Implant Device,975.2,40,,975.2,percent of total billed charges,Implant Device,853.3,70,,853.3,percent of total billed charges,All Other,828.92,34,,828.92,percent of total billed charges,Implant Device,828.92,34,,828.92,percent of total billed charges,Implant Device,853.3,35,,853.3,percent of total billed charges,Implant Device,853.3,35,,853.3,percent of total billed charges,Implant Device,853.3,35,,853.3,percent of total billed charges,Implant Device,853.3,35,,853.3,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,828.92,34,"If Charge > 2,000, then 34 percent",828.92,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1804.13,
ARTHREX AR-8835L-20 3.5X20MM LOCK SCREW,C1713,HCPCS,,79006959,CDM,278,RC,,,both,,,346,256.04,,,256.04,Other,150% of Medicare + 9.63% HCRA Surcharge,155.7,45,,155.7,percent of total billed charges,Critical Access Hospital RCC factor,117.64,34,,117.64,percent of total billed charges,Implant Device,117.64,34,,117.64,percent of total billed charges,Implant Device,117.64,34,,117.64,percent of total billed charges,Implant Device,117.64,34,,117.64,percent of total billed charges,Implant Device,117.64,34,,117.64,percent of total billed charges,Implant Device,171.27,,,171.27,Other,110% of Medicare,121.1,35,,121.1,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,121.1,35,,121.1,percent of total billed charges,Implant Device,121.1,35,,121.1,percent of total billed charges,Implant Device,121.1,35,,121.1,percent of total billed charges,Implant Device,121.1,35,,121.1,percent of total billed charges,Implant Device,121.1,35,,121.1,percent of total billed charges,Implant Device,138.4,40,,138.4,percent of total billed charges,Implant Device,121.1,70,,121.1,percent of total billed charges,All Other,117.64,34,,117.64,percent of total billed charges,Implant Device,117.64,34,,117.64,percent of total billed charges,Implant Device,121.1,35,,121.1,percent of total billed charges,Implant Device,121.1,35,,121.1,percent of total billed charges,Implant Device,121.1,35,,121.1,percent of total billed charges,Implant Device,121.1,35,,121.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,256.04,
SYNTHES 212.111 LOCKING SCREW 3.5X30MM,C1713,HCPCS,,79006960,CDM,278,RC,,,both,,,327,241.98,,,241.98,Other,150% of Medicare + 9.63% HCRA Surcharge,147.15,45,,147.15,percent of total billed charges,Critical Access Hospital RCC factor,111.18,34,,111.18,percent of total billed charges,Implant Device,111.18,34,,111.18,percent of total billed charges,Implant Device,111.18,34,,111.18,percent of total billed charges,Implant Device,111.18,34,,111.18,percent of total billed charges,Implant Device,111.18,34,,111.18,percent of total billed charges,Implant Device,161.87,,,161.87,Other,110% of Medicare,114.45,35,,114.45,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,114.45,35,,114.45,percent of total billed charges,Implant Device,114.45,35,,114.45,percent of total billed charges,Implant Device,114.45,35,,114.45,percent of total billed charges,Implant Device,114.45,35,,114.45,percent of total billed charges,Implant Device,114.45,35,,114.45,percent of total billed charges,Implant Device,130.8,40,,130.8,percent of total billed charges,Implant Device,114.45,70,,114.45,percent of total billed charges,All Other,111.18,34,,111.18,percent of total billed charges,Implant Device,111.18,34,,111.18,percent of total billed charges,Implant Device,114.45,35,,114.45,percent of total billed charges,Implant Device,114.45,35,,114.45,percent of total billed charges,Implant Device,114.45,35,,114.45,percent of total billed charges,Implant Device,114.45,35,,114.45,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,241.98,
GORE RLT261218 EXCLUDER ENDOPROS GRAFT,C1874,HCPCS,,79006961,CDM,278,RC,,,both,,,31500,23310.08,,,23310.08,Other,150% of Medicare + 9.63% HCRA Surcharge,14175,45,,14175,percent of total billed charges,Critical Access Hospital RCC factor,10710,34,,10710,percent of total billed charges,Implant Device,10710,34,,10710,percent of total billed charges,Implant Device,10710,34,,10710,percent of total billed charges,Implant Device,10710,34,,10710,percent of total billed charges,Implant Device,10710,34,,10710,percent of total billed charges,Implant Device,15592.5,,,15592.5,Other,110% of Medicare,11025,35,,11025,percent of total billed charges,Implant Device,10710,34,"Charges > $500, x 34%",10710,percent of total billed charges,Implant Device,11025,35,,11025,percent of total billed charges,Implant Device,11025,35,,11025,percent of total billed charges,Implant Device,11025,35,,11025,percent of total billed charges,Implant Device,11025,35,,11025,percent of total billed charges,Implant Device,11025,35,,11025,percent of total billed charges,Implant Device,12600,40,,12600,percent of total billed charges,Implant Device,11025,70,,11025,percent of total billed charges,All Other,10710,34,,10710,percent of total billed charges,Implant Device,10710,34,,10710,percent of total billed charges,Implant Device,11025,35,,11025,percent of total billed charges,Implant Device,11025,35,,11025,percent of total billed charges,Implant Device,11025,35,,11025,percent of total billed charges,Implant Device,11025,35,,11025,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,10710,34,"If Charge > 2,000, then 34 percent",10710,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,23310.08,
GORE PLC231400 EXCLUDER ENDOPROS GRAFT,C1874,HCPCS,,79006962,CDM,278,RC,,,both,,,13200,9768.03,,,9768.03,Other,150% of Medicare + 9.63% HCRA Surcharge,5940,45,,5940,percent of total billed charges,Critical Access Hospital RCC factor,4488,34,,4488,percent of total billed charges,Implant Device,4488,34,,4488,percent of total billed charges,Implant Device,4488,34,,4488,percent of total billed charges,Implant Device,4488,34,,4488,percent of total billed charges,Implant Device,4488,34,,4488,percent of total billed charges,Implant Device,6534,,,6534,Other,110% of Medicare,4620,35,,4620,percent of total billed charges,Implant Device,4488,34,"Charges > $500, x 34%",4488,percent of total billed charges,Implant Device,4620,35,,4620,percent of total billed charges,Implant Device,4620,35,,4620,percent of total billed charges,Implant Device,4620,35,,4620,percent of total billed charges,Implant Device,4620,35,,4620,percent of total billed charges,Implant Device,4620,35,,4620,percent of total billed charges,Implant Device,5280,40,,5280,percent of total billed charges,Implant Device,4620,70,,4620,percent of total billed charges,All Other,4488,34,,4488,percent of total billed charges,Implant Device,4488,34,,4488,percent of total billed charges,Implant Device,4620,35,,4620,percent of total billed charges,Implant Device,4620,35,,4620,percent of total billed charges,Implant Device,4620,35,,4620,percent of total billed charges,Implant Device,4620,35,,4620,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,4488,34,"If Charge > 2,000, then 34 percent",4488,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,9768.03,
GORE PXC121000 EXCLUDER ENDOPROS GRAFT,C1874,HCPCS,,79006963,CDM,278,RC,,,both,,,13200,9768.03,,,9768.03,Other,150% of Medicare + 9.63% HCRA Surcharge,5940,45,,5940,percent of total billed charges,Critical Access Hospital RCC factor,4488,34,,4488,percent of total billed charges,Implant Device,4488,34,,4488,percent of total billed charges,Implant Device,4488,34,,4488,percent of total billed charges,Implant Device,4488,34,,4488,percent of total billed charges,Implant Device,4488,34,,4488,percent of total billed charges,Implant Device,6534,,,6534,Other,110% of Medicare,4620,35,,4620,percent of total billed charges,Implant Device,4488,34,"Charges > $500, x 34%",4488,percent of total billed charges,Implant Device,4620,35,,4620,percent of total billed charges,Implant Device,4620,35,,4620,percent of total billed charges,Implant Device,4620,35,,4620,percent of total billed charges,Implant Device,4620,35,,4620,percent of total billed charges,Implant Device,4620,35,,4620,percent of total billed charges,Implant Device,5280,40,,5280,percent of total billed charges,Implant Device,4620,70,,4620,percent of total billed charges,All Other,4488,34,,4488,percent of total billed charges,Implant Device,4488,34,,4488,percent of total billed charges,Implant Device,4620,35,,4620,percent of total billed charges,Implant Device,4620,35,,4620,percent of total billed charges,Implant Device,4620,35,,4620,percent of total billed charges,Implant Device,4620,35,,4620,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,4488,34,"If Charge > 2,000, then 34 percent",4488,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,9768.03,
DEPUY 02.240.030 CANN LOCK SCREW 3.7X30,C1713,HCPCS,,79006966,CDM,278,RC,,,both,,,476,352.24,,,352.24,Other,150% of Medicare + 9.63% HCRA Surcharge,214.2,45,,214.2,percent of total billed charges,Critical Access Hospital RCC factor,161.84,34,,161.84,percent of total billed charges,Implant Device,161.84,34,,161.84,percent of total billed charges,Implant Device,161.84,34,,161.84,percent of total billed charges,Implant Device,161.84,34,,161.84,percent of total billed charges,Implant Device,161.84,34,,161.84,percent of total billed charges,Implant Device,235.62,,,235.62,Other,110% of Medicare,166.6,35,,166.6,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,166.6,35,,166.6,percent of total billed charges,Implant Device,166.6,35,,166.6,percent of total billed charges,Implant Device,166.6,35,,166.6,percent of total billed charges,Implant Device,166.6,35,,166.6,percent of total billed charges,Implant Device,166.6,35,,166.6,percent of total billed charges,Implant Device,190.4,40,,190.4,percent of total billed charges,Implant Device,166.6,70,,166.6,percent of total billed charges,All Other,161.84,34,,161.84,percent of total billed charges,Implant Device,161.84,34,,161.84,percent of total billed charges,Implant Device,166.6,35,,166.6,percent of total billed charges,Implant Device,166.6,35,,166.6,percent of total billed charges,Implant Device,166.6,35,,166.6,percent of total billed charges,Implant Device,166.6,35,,166.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,352.24,
DEPUY 02.240.044 CANN LOCK SCREW 3.7X44,C1713,HCPCS,,79006967,CDM,278,RC,,,both,,,476,352.24,,,352.24,Other,150% of Medicare + 9.63% HCRA Surcharge,214.2,45,,214.2,percent of total billed charges,Critical Access Hospital RCC factor,161.84,34,,161.84,percent of total billed charges,Implant Device,161.84,34,,161.84,percent of total billed charges,Implant Device,161.84,34,,161.84,percent of total billed charges,Implant Device,161.84,34,,161.84,percent of total billed charges,Implant Device,161.84,34,,161.84,percent of total billed charges,Implant Device,235.62,,,235.62,Other,110% of Medicare,166.6,35,,166.6,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,166.6,35,,166.6,percent of total billed charges,Implant Device,166.6,35,,166.6,percent of total billed charges,Implant Device,166.6,35,,166.6,percent of total billed charges,Implant Device,166.6,35,,166.6,percent of total billed charges,Implant Device,166.6,35,,166.6,percent of total billed charges,Implant Device,190.4,40,,190.4,percent of total billed charges,Implant Device,166.6,70,,166.6,percent of total billed charges,All Other,161.84,34,,161.84,percent of total billed charges,Implant Device,161.84,34,,161.84,percent of total billed charges,Implant Device,166.6,35,,166.6,percent of total billed charges,Implant Device,166.6,35,,166.6,percent of total billed charges,Implant Device,166.6,35,,166.6,percent of total billed charges,Implant Device,166.6,35,,166.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,352.24,
STRYKER 5630-G-629 TIBIAL INSRT 6X9MM,C1776,HCPCS,,79006968,CDM,278,RC,,,both,,,3232,2391.69,,,2391.69,Other,150% of Medicare + 9.63% HCRA Surcharge,1454.4,45,,1454.4,percent of total billed charges,Critical Access Hospital RCC factor,1098.88,34,,1098.88,percent of total billed charges,Implant Device,1098.88,34,,1098.88,percent of total billed charges,Implant Device,1098.88,34,,1098.88,percent of total billed charges,Implant Device,1098.88,34,,1098.88,percent of total billed charges,Implant Device,1098.88,34,,1098.88,percent of total billed charges,Implant Device,1599.84,,,1599.84,Other,110% of Medicare,1131.2,35,,1131.2,percent of total billed charges,Implant Device,1098.88,34,"Charges > $500, x 34%",1098.88,percent of total billed charges,Implant Device,1131.2,35,,1131.2,percent of total billed charges,Implant Device,1131.2,35,,1131.2,percent of total billed charges,Implant Device,1131.2,35,,1131.2,percent of total billed charges,Implant Device,1131.2,35,,1131.2,percent of total billed charges,Implant Device,1131.2,35,,1131.2,percent of total billed charges,Implant Device,1292.8,40,,1292.8,percent of total billed charges,Implant Device,1131.2,70,,1131.2,percent of total billed charges,All Other,1098.88,34,,1098.88,percent of total billed charges,Implant Device,1098.88,34,,1098.88,percent of total billed charges,Implant Device,1131.2,35,,1131.2,percent of total billed charges,Implant Device,1131.2,35,,1131.2,percent of total billed charges,Implant Device,1131.2,35,,1131.2,percent of total billed charges,Implant Device,1131.2,35,,1131.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1098.88,34,"If Charge > 2,000, then 34 percent",1098.88,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2391.69,
STRYKER 180705-2 RESTORIS TIBIAL INS 5X9,C1776,HCPCS,,79006969,CDM,278,RC,,,both,,,4156,3075.45,,,3075.45,Other,150% of Medicare + 9.63% HCRA Surcharge,1870.2,45,,1870.2,percent of total billed charges,Critical Access Hospital RCC factor,1413.04,34,,1413.04,percent of total billed charges,Implant Device,1413.04,34,,1413.04,percent of total billed charges,Implant Device,1413.04,34,,1413.04,percent of total billed charges,Implant Device,1413.04,34,,1413.04,percent of total billed charges,Implant Device,1413.04,34,,1413.04,percent of total billed charges,Implant Device,2057.22,,,2057.22,Other,110% of Medicare,1454.6,35,,1454.6,percent of total billed charges,Implant Device,1413.04,34,"Charges > $500, x 34%",1413.04,percent of total billed charges,Implant Device,1454.6,35,,1454.6,percent of total billed charges,Implant Device,1454.6,35,,1454.6,percent of total billed charges,Implant Device,1454.6,35,,1454.6,percent of total billed charges,Implant Device,1454.6,35,,1454.6,percent of total billed charges,Implant Device,1454.6,35,,1454.6,percent of total billed charges,Implant Device,1662.4,40,,1662.4,percent of total billed charges,Implant Device,1454.6,70,,1454.6,percent of total billed charges,All Other,1413.04,34,,1413.04,percent of total billed charges,Implant Device,1413.04,34,,1413.04,percent of total billed charges,Implant Device,1454.6,35,,1454.6,percent of total billed charges,Implant Device,1454.6,35,,1454.6,percent of total billed charges,Implant Device,1454.6,35,,1454.6,percent of total billed charges,Implant Device,1454.6,35,,1454.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1413.04,34,"If Charge > 2,000, then 34 percent",1413.04,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3075.45,
DEPUY 02.123.021 HUMERUS PLATE 2HOLE 3.5,C1713,HCPCS,,79006977,CDM,278,RC,,,both,,,3929,2907.47,,,2907.47,Other,150% of Medicare + 9.63% HCRA Surcharge,1768.05,45,,1768.05,percent of total billed charges,Critical Access Hospital RCC factor,1335.86,34,,1335.86,percent of total billed charges,Implant Device,1335.86,34,,1335.86,percent of total billed charges,Implant Device,1335.86,34,,1335.86,percent of total billed charges,Implant Device,1335.86,34,,1335.86,percent of total billed charges,Implant Device,1335.86,34,,1335.86,percent of total billed charges,Implant Device,1944.86,,,1944.86,Other,110% of Medicare,1375.15,35,,1375.15,percent of total billed charges,Implant Device,1335.86,34,"Charges > $500, x 34%",1335.86,percent of total billed charges,Implant Device,1375.15,35,,1375.15,percent of total billed charges,Implant Device,1375.15,35,,1375.15,percent of total billed charges,Implant Device,1375.15,35,,1375.15,percent of total billed charges,Implant Device,1375.15,35,,1375.15,percent of total billed charges,Implant Device,1375.15,35,,1375.15,percent of total billed charges,Implant Device,1571.6,40,,1571.6,percent of total billed charges,Implant Device,1375.15,70,,1375.15,percent of total billed charges,All Other,1335.86,34,,1335.86,percent of total billed charges,Implant Device,1335.86,34,,1335.86,percent of total billed charges,Implant Device,1375.15,35,,1375.15,percent of total billed charges,Implant Device,1375.15,35,,1375.15,percent of total billed charges,Implant Device,1375.15,35,,1375.15,percent of total billed charges,Implant Device,1375.15,35,,1375.15,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1335.86,34,"If Charge > 2,000, then 34 percent",1335.86,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2907.47,
DEPUY 204.824 CORTEX SCREW 3.5X24MM,C1713,HCPCS,,79006978,CDM,278,RC,,,both,,,57,42.18,,,42.18,Other,150% of Medicare + 9.63% HCRA Surcharge,25.65,45,,25.65,percent of total billed charges,Critical Access Hospital RCC factor,19.38,34,,19.38,percent of total billed charges,Implant Device,19.38,34,,19.38,percent of total billed charges,Implant Device,19.38,34,,19.38,percent of total billed charges,Implant Device,19.38,34,,19.38,percent of total billed charges,Implant Device,19.38,34,,19.38,percent of total billed charges,Implant Device,28.22,,,28.22,Other,110% of Medicare,19.95,35,,19.95,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,19.95,35,,19.95,percent of total billed charges,Implant Device,19.95,35,,19.95,percent of total billed charges,Implant Device,19.95,35,,19.95,percent of total billed charges,Implant Device,19.95,35,,19.95,percent of total billed charges,Implant Device,19.95,35,,19.95,percent of total billed charges,Implant Device,22.8,40,,22.8,percent of total billed charges,Implant Device,19.95,70,,19.95,percent of total billed charges,All Other,19.38,34,,19.38,percent of total billed charges,Implant Device,19.38,34,,19.38,percent of total billed charges,Implant Device,19.95,35,,19.95,percent of total billed charges,Implant Device,19.95,35,,19.95,percent of total billed charges,Implant Device,19.95,35,,19.95,percent of total billed charges,Implant Device,19.95,35,,19.95,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,42.18,
STRYKER 349614 2.7X14MM CORTEX SCREW SS,C1713,HCPCS,,79006979,CDM,278,RC,,,both,,,138,102.12,,,102.12,Other,150% of Medicare + 9.63% HCRA Surcharge,62.1,45,,62.1,percent of total billed charges,Critical Access Hospital RCC factor,46.92,34,,46.92,percent of total billed charges,Implant Device,46.92,34,,46.92,percent of total billed charges,Implant Device,46.92,34,,46.92,percent of total billed charges,Implant Device,46.92,34,,46.92,percent of total billed charges,Implant Device,46.92,34,,46.92,percent of total billed charges,Implant Device,68.31,,,68.31,Other,110% of Medicare,48.3,35,,48.3,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,48.3,35,,48.3,percent of total billed charges,Implant Device,48.3,35,,48.3,percent of total billed charges,Implant Device,48.3,35,,48.3,percent of total billed charges,Implant Device,48.3,35,,48.3,percent of total billed charges,Implant Device,48.3,35,,48.3,percent of total billed charges,Implant Device,55.2,40,,55.2,percent of total billed charges,Implant Device,48.3,70,,48.3,percent of total billed charges,All Other,46.92,34,,46.92,percent of total billed charges,Implant Device,46.92,34,,46.92,percent of total billed charges,Implant Device,48.3,35,,48.3,percent of total billed charges,Implant Device,48.3,35,,48.3,percent of total billed charges,Implant Device,48.3,35,,48.3,percent of total billed charges,Implant Device,48.3,35,,48.3,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,102.12,
STRYKER 371008 3X8MM LOCKING SCREW SS,C1713,HCPCS,,79006980,CDM,278,RC,,,both,,,334,247.16,,,247.16,Other,150% of Medicare + 9.63% HCRA Surcharge,150.3,45,,150.3,percent of total billed charges,Critical Access Hospital RCC factor,113.56,34,,113.56,percent of total billed charges,Implant Device,113.56,34,,113.56,percent of total billed charges,Implant Device,113.56,34,,113.56,percent of total billed charges,Implant Device,113.56,34,,113.56,percent of total billed charges,Implant Device,113.56,34,,113.56,percent of total billed charges,Implant Device,165.33,,,165.33,Other,110% of Medicare,116.9,35,,116.9,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,116.9,35,,116.9,percent of total billed charges,Implant Device,116.9,35,,116.9,percent of total billed charges,Implant Device,116.9,35,,116.9,percent of total billed charges,Implant Device,116.9,35,,116.9,percent of total billed charges,Implant Device,116.9,35,,116.9,percent of total billed charges,Implant Device,133.6,40,,133.6,percent of total billed charges,Implant Device,116.9,70,,116.9,percent of total billed charges,All Other,113.56,34,,113.56,percent of total billed charges,Implant Device,113.56,34,,113.56,percent of total billed charges,Implant Device,116.9,35,,116.9,percent of total billed charges,Implant Device,116.9,35,,116.9,percent of total billed charges,Implant Device,116.9,35,,116.9,percent of total billed charges,Implant Device,116.9,35,,116.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,247.16,
STRYKER 371020 3X20MM LOCKING SCREW SS,C1713,HCPCS,,79006981,CDM,278,RC,,,both,,,334,247.16,,,247.16,Other,150% of Medicare + 9.63% HCRA Surcharge,150.3,45,,150.3,percent of total billed charges,Critical Access Hospital RCC factor,113.56,34,,113.56,percent of total billed charges,Implant Device,113.56,34,,113.56,percent of total billed charges,Implant Device,113.56,34,,113.56,percent of total billed charges,Implant Device,113.56,34,,113.56,percent of total billed charges,Implant Device,113.56,34,,113.56,percent of total billed charges,Implant Device,165.33,,,165.33,Other,110% of Medicare,116.9,35,,116.9,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,116.9,35,,116.9,percent of total billed charges,Implant Device,116.9,35,,116.9,percent of total billed charges,Implant Device,116.9,35,,116.9,percent of total billed charges,Implant Device,116.9,35,,116.9,percent of total billed charges,Implant Device,116.9,35,,116.9,percent of total billed charges,Implant Device,133.6,40,,133.6,percent of total billed charges,Implant Device,116.9,70,,116.9,percent of total billed charges,All Other,113.56,34,,113.56,percent of total billed charges,Implant Device,113.56,34,,113.56,percent of total billed charges,Implant Device,116.9,35,,116.9,percent of total billed charges,Implant Device,116.9,35,,116.9,percent of total billed charges,Implant Device,116.9,35,,116.9,percent of total billed charges,Implant Device,116.9,35,,116.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,247.16,
STRYKER 371022 3X22MM LOCKING SCREW SS,C1713,HCPCS,,79006982,CDM,278,RC,,,both,,,334,247.16,,,247.16,Other,150% of Medicare + 9.63% HCRA Surcharge,150.3,45,,150.3,percent of total billed charges,Critical Access Hospital RCC factor,113.56,34,,113.56,percent of total billed charges,Implant Device,113.56,34,,113.56,percent of total billed charges,Implant Device,113.56,34,,113.56,percent of total billed charges,Implant Device,113.56,34,,113.56,percent of total billed charges,Implant Device,113.56,34,,113.56,percent of total billed charges,Implant Device,165.33,,,165.33,Other,110% of Medicare,116.9,35,,116.9,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,116.9,35,,116.9,percent of total billed charges,Implant Device,116.9,35,,116.9,percent of total billed charges,Implant Device,116.9,35,,116.9,percent of total billed charges,Implant Device,116.9,35,,116.9,percent of total billed charges,Implant Device,116.9,35,,116.9,percent of total billed charges,Implant Device,133.6,40,,133.6,percent of total billed charges,Implant Device,116.9,70,,116.9,percent of total billed charges,All Other,113.56,34,,113.56,percent of total billed charges,Implant Device,113.56,34,,113.56,percent of total billed charges,Implant Device,116.9,35,,116.9,percent of total billed charges,Implant Device,116.9,35,,116.9,percent of total billed charges,Implant Device,116.9,35,,116.9,percent of total billed charges,Implant Device,116.9,35,,116.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,247.16,
ARTHREX AR-8692DS IMPLANT SYS CPR VIPER,C1713,HCPCS,,79006983,CDM,278,RC,,,both,,,2850,2109.01,,,2109.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1282.5,45,,1282.5,percent of total billed charges,Critical Access Hospital RCC factor,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,1410.75,,,1410.75,Other,110% of Medicare,997.5,35,,997.5,percent of total billed charges,Implant Device,969,34,"Charges > $500, x 34%",969,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,1140,40,,1140,percent of total billed charges,Implant Device,997.5,70,,997.5,percent of total billed charges,All Other,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,969,34,"If Charge > 2,000, then 34 percent",969,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2109.01,
DEPUY 456.317S 11X125MM TROCH NAIL 170MM,C1713,HCPCS,,79006984,CDM,278,RC,,,both,,,2738,2026.13,,,2026.13,Other,150% of Medicare + 9.63% HCRA Surcharge,1232.1,45,,1232.1,percent of total billed charges,Critical Access Hospital RCC factor,930.92,34,,930.92,percent of total billed charges,Implant Device,930.92,34,,930.92,percent of total billed charges,Implant Device,930.92,34,,930.92,percent of total billed charges,Implant Device,930.92,34,,930.92,percent of total billed charges,Implant Device,930.92,34,,930.92,percent of total billed charges,Implant Device,1355.31,,,1355.31,Other,110% of Medicare,958.3,35,,958.3,percent of total billed charges,Implant Device,930.92,34,"Charges > $500, x 34%",930.92,percent of total billed charges,Implant Device,958.3,35,,958.3,percent of total billed charges,Implant Device,958.3,35,,958.3,percent of total billed charges,Implant Device,958.3,35,,958.3,percent of total billed charges,Implant Device,958.3,35,,958.3,percent of total billed charges,Implant Device,958.3,35,,958.3,percent of total billed charges,Implant Device,1095.2,40,,1095.2,percent of total billed charges,Implant Device,958.3,70,,958.3,percent of total billed charges,All Other,930.92,34,,930.92,percent of total billed charges,Implant Device,930.92,34,,930.92,percent of total billed charges,Implant Device,958.3,35,,958.3,percent of total billed charges,Implant Device,958.3,35,,958.3,percent of total billed charges,Implant Device,958.3,35,,958.3,percent of total billed charges,Implant Device,958.3,35,,958.3,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,930.92,34,"If Charge > 2,000, then 34 percent",930.92,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2026.13,
DEPUY 458.936S 5X36MM LOCK SCREW,C1713,HCPCS,,79006985,CDM,278,RC,,,both,,,456,337.44,,,337.44,Other,150% of Medicare + 9.63% HCRA Surcharge,205.2,45,,205.2,percent of total billed charges,Critical Access Hospital RCC factor,155.04,34,,155.04,percent of total billed charges,Implant Device,155.04,34,,155.04,percent of total billed charges,Implant Device,155.04,34,,155.04,percent of total billed charges,Implant Device,155.04,34,,155.04,percent of total billed charges,Implant Device,155.04,34,,155.04,percent of total billed charges,Implant Device,225.72,,,225.72,Other,110% of Medicare,159.6,35,,159.6,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,159.6,35,,159.6,percent of total billed charges,Implant Device,159.6,35,,159.6,percent of total billed charges,Implant Device,159.6,35,,159.6,percent of total billed charges,Implant Device,159.6,35,,159.6,percent of total billed charges,Implant Device,159.6,35,,159.6,percent of total billed charges,Implant Device,182.4,40,,182.4,percent of total billed charges,Implant Device,159.6,70,,159.6,percent of total billed charges,All Other,155.04,34,,155.04,percent of total billed charges,Implant Device,155.04,34,,155.04,percent of total billed charges,Implant Device,159.6,35,,159.6,percent of total billed charges,Implant Device,159.6,35,,159.6,percent of total billed charges,Implant Device,159.6,35,,159.6,percent of total billed charges,Implant Device,159.6,35,,159.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,337.44,
DEPUY 04.02.095S 11X95MM TROCH SCREW,C1713,HCPCS,,79006986,CDM,278,RC,,,both,,,1900,1406,,,1406,Other,150% of Medicare + 9.63% HCRA Surcharge,855,45,,855,percent of total billed charges,Critical Access Hospital RCC factor,646,34,,646,percent of total billed charges,Implant Device,646,34,,646,percent of total billed charges,Implant Device,646,34,,646,percent of total billed charges,Implant Device,646,34,,646,percent of total billed charges,Implant Device,646,34,,646,percent of total billed charges,Implant Device,940.5,,,940.5,Other,110% of Medicare,665,35,,665,percent of total billed charges,Implant Device,646,34,"Charges > $500, x 34%",646,percent of total billed charges,Implant Device,665,35,,665,percent of total billed charges,Implant Device,665,35,,665,percent of total billed charges,Implant Device,665,35,,665,percent of total billed charges,Implant Device,665,35,,665,percent of total billed charges,Implant Device,665,35,,665,percent of total billed charges,Implant Device,760,40,,760,percent of total billed charges,Implant Device,665,70,,665,percent of total billed charges,All Other,646,34,,646,percent of total billed charges,Implant Device,646,34,,646,percent of total billed charges,Implant Device,665,35,,665,percent of total billed charges,Implant Device,665,35,,665,percent of total billed charges,Implant Device,665,35,,665,percent of total billed charges,Implant Device,665,35,,665,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1406,
EXACTECH SPC0522 INTERSPACE HIP INS 60MM,C1776,HCPCS,,79006987,CDM,278,RC,,,both,,,9774,7232.78,,,7232.78,Other,150% of Medicare + 9.63% HCRA Surcharge,4398.3,45,,4398.3,percent of total billed charges,Critical Access Hospital RCC factor,3323.16,34,,3323.16,percent of total billed charges,Implant Device,3323.16,34,,3323.16,percent of total billed charges,Implant Device,3323.16,34,,3323.16,percent of total billed charges,Implant Device,3323.16,34,,3323.16,percent of total billed charges,Implant Device,3323.16,34,,3323.16,percent of total billed charges,Implant Device,4838.13,,,4838.13,Other,110% of Medicare,3420.9,35,,3420.9,percent of total billed charges,Implant Device,3323.16,34,"Charges > $500, x 34%",3323.16,percent of total billed charges,Implant Device,3420.9,35,,3420.9,percent of total billed charges,Implant Device,3420.9,35,,3420.9,percent of total billed charges,Implant Device,3420.9,35,,3420.9,percent of total billed charges,Implant Device,3420.9,35,,3420.9,percent of total billed charges,Implant Device,3420.9,35,,3420.9,percent of total billed charges,Implant Device,3909.6,40,,3909.6,percent of total billed charges,Implant Device,3420.9,70,,3420.9,percent of total billed charges,All Other,3323.16,34,,3323.16,percent of total billed charges,Implant Device,3323.16,34,,3323.16,percent of total billed charges,Implant Device,3420.9,35,,3420.9,percent of total billed charges,Implant Device,3420.9,35,,3420.9,percent of total billed charges,Implant Device,3420.9,35,,3420.9,percent of total billed charges,Implant Device,3420.9,35,,3420.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3323.16,34,"If Charge > 2,000, then 34 percent",3323.16,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,7232.78,
EXACTECH SPK0122 INTERSPAC KNEE INS 64MM,C1776,HCPCS,,79006988,CDM,278,RC,,,both,,,9776,7234.26,,,7234.26,Other,150% of Medicare + 9.63% HCRA Surcharge,4399.2,45,,4399.2,percent of total billed charges,Critical Access Hospital RCC factor,3323.84,34,,3323.84,percent of total billed charges,Implant Device,3323.84,34,,3323.84,percent of total billed charges,Implant Device,3323.84,34,,3323.84,percent of total billed charges,Implant Device,3323.84,34,,3323.84,percent of total billed charges,Implant Device,3323.84,34,,3323.84,percent of total billed charges,Implant Device,4839.12,,,4839.12,Other,110% of Medicare,3421.6,35,,3421.6,percent of total billed charges,Implant Device,3323.84,34,"Charges > $500, x 34%",3323.84,percent of total billed charges,Implant Device,3421.6,35,,3421.6,percent of total billed charges,Implant Device,3421.6,35,,3421.6,percent of total billed charges,Implant Device,3421.6,35,,3421.6,percent of total billed charges,Implant Device,3421.6,35,,3421.6,percent of total billed charges,Implant Device,3421.6,35,,3421.6,percent of total billed charges,Implant Device,3910.4,40,,3910.4,percent of total billed charges,Implant Device,3421.6,70,,3421.6,percent of total billed charges,All Other,3323.84,34,,3323.84,percent of total billed charges,Implant Device,3323.84,34,,3323.84,percent of total billed charges,Implant Device,3421.6,35,,3421.6,percent of total billed charges,Implant Device,3421.6,35,,3421.6,percent of total billed charges,Implant Device,3421.6,35,,3421.6,percent of total billed charges,Implant Device,3421.6,35,,3421.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3323.84,34,"If Charge > 2,000, then 34 percent",3323.84,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,7234.26,
EXACTECH 320-20-46 COMPRESSN SCREW 46MM,C1713,HCPCS,,79006990,CDM,278,RC,,,both,,,300,222,,,222,Other,150% of Medicare + 9.63% HCRA Surcharge,135,45,,135,percent of total billed charges,Critical Access Hospital RCC factor,102,34,,102,percent of total billed charges,Implant Device,102,34,,102,percent of total billed charges,Implant Device,102,34,,102,percent of total billed charges,Implant Device,102,34,,102,percent of total billed charges,Implant Device,102,34,,102,percent of total billed charges,Implant Device,148.5,,,148.5,Other,110% of Medicare,105,35,,105,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,105,35,,105,percent of total billed charges,Implant Device,105,35,,105,percent of total billed charges,Implant Device,105,35,,105,percent of total billed charges,Implant Device,105,35,,105,percent of total billed charges,Implant Device,105,35,,105,percent of total billed charges,Implant Device,120,40,,120,percent of total billed charges,Implant Device,105,70,,105,percent of total billed charges,All Other,102,34,,102,percent of total billed charges,Implant Device,102,34,,102,percent of total billed charges,Implant Device,105,35,,105,percent of total billed charges,Implant Device,105,35,,105,percent of total billed charges,Implant Device,105,35,,105,percent of total billed charges,Implant Device,105,35,,105,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,222,
ARTHREX AR-8945-36PT CANN SCREW 4.5X36MM,C1713,HCPCS,,79006998,CDM,278,RC,,,both,,,750,555,,,555,Other,150% of Medicare + 9.63% HCRA Surcharge,337.5,45,,337.5,percent of total billed charges,Critical Access Hospital RCC factor,255,34,,255,percent of total billed charges,Implant Device,255,34,,255,percent of total billed charges,Implant Device,255,34,,255,percent of total billed charges,Implant Device,255,34,,255,percent of total billed charges,Implant Device,255,34,,255,percent of total billed charges,Implant Device,371.25,,,371.25,Other,110% of Medicare,262.5,35,,262.5,percent of total billed charges,Implant Device,255,34,"Charges > $500, x 34%",255,percent of total billed charges,Implant Device,262.5,35,,262.5,percent of total billed charges,Implant Device,262.5,35,,262.5,percent of total billed charges,Implant Device,262.5,35,,262.5,percent of total billed charges,Implant Device,262.5,35,,262.5,percent of total billed charges,Implant Device,262.5,35,,262.5,percent of total billed charges,Implant Device,300,40,,300,percent of total billed charges,Implant Device,262.5,70,,262.5,percent of total billed charges,All Other,255,34,,255,percent of total billed charges,Implant Device,255,34,,255,percent of total billed charges,Implant Device,262.5,35,,262.5,percent of total billed charges,Implant Device,262.5,35,,262.5,percent of total billed charges,Implant Device,262.5,35,,262.5,percent of total billed charges,Implant Device,262.5,35,,262.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,555,
ARTHREX AR-8930-11 SNAP OFF SCREW 2X11MM,C1713,HCPCS,,79006999,CDM,278,RC,,,both,,,1029,761.46,,,761.46,Other,150% of Medicare + 9.63% HCRA Surcharge,463.05,45,,463.05,percent of total billed charges,Critical Access Hospital RCC factor,349.86,34,,349.86,percent of total billed charges,Implant Device,349.86,34,,349.86,percent of total billed charges,Implant Device,349.86,34,,349.86,percent of total billed charges,Implant Device,349.86,34,,349.86,percent of total billed charges,Implant Device,349.86,34,,349.86,percent of total billed charges,Implant Device,509.36,,,509.36,Other,110% of Medicare,360.15,35,,360.15,percent of total billed charges,Implant Device,349.86,34,"Charges > $500, x 34%",349.86,percent of total billed charges,Implant Device,360.15,35,,360.15,percent of total billed charges,Implant Device,360.15,35,,360.15,percent of total billed charges,Implant Device,360.15,35,,360.15,percent of total billed charges,Implant Device,360.15,35,,360.15,percent of total billed charges,Implant Device,360.15,35,,360.15,percent of total billed charges,Implant Device,411.6,40,,411.6,percent of total billed charges,Implant Device,360.15,70,,360.15,percent of total billed charges,All Other,349.86,34,,349.86,percent of total billed charges,Implant Device,349.86,34,,349.86,percent of total billed charges,Implant Device,360.15,35,,360.15,percent of total billed charges,Implant Device,360.15,35,,360.15,percent of total billed charges,Implant Device,360.15,35,,360.15,percent of total billed charges,Implant Device,360.15,35,,360.15,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,761.46,
ZIMMER 402.202 SUBCHONDROPLASTY KNEE KIT,C1713,HCPCS,,79007001,CDM,278,RC,,,both,,,9885,7314.92,,,7314.92,Other,150% of Medicare + 9.63% HCRA Surcharge,4448.25,45,,4448.25,percent of total billed charges,Critical Access Hospital RCC factor,3360.9,34,,3360.9,percent of total billed charges,Implant Device,3360.9,34,,3360.9,percent of total billed charges,Implant Device,3360.9,34,,3360.9,percent of total billed charges,Implant Device,3360.9,34,,3360.9,percent of total billed charges,Implant Device,3360.9,34,,3360.9,percent of total billed charges,Implant Device,4893.08,,,4893.08,Other,110% of Medicare,3459.75,35,,3459.75,percent of total billed charges,Implant Device,3360.9,34,"Charges > $500, x 34%",3360.9,percent of total billed charges,Implant Device,3459.75,35,,3459.75,percent of total billed charges,Implant Device,3459.75,35,,3459.75,percent of total billed charges,Implant Device,3459.75,35,,3459.75,percent of total billed charges,Implant Device,3459.75,35,,3459.75,percent of total billed charges,Implant Device,3459.75,35,,3459.75,percent of total billed charges,Implant Device,3954,40,,3954,percent of total billed charges,Implant Device,3459.75,70,,3459.75,percent of total billed charges,All Other,3360.9,34,,3360.9,percent of total billed charges,Implant Device,3360.9,34,,3360.9,percent of total billed charges,Implant Device,3459.75,35,,3459.75,percent of total billed charges,Implant Device,3459.75,35,,3459.75,percent of total billed charges,Implant Device,3459.75,35,,3459.75,percent of total billed charges,Implant Device,3459.75,35,,3459.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3360.9,34,"If Charge > 2,000, then 34 percent",3360.9,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,7314.92,
DEPUY 1365-32-320 FEM HEAD +5.0 32MM,C1776,HCPCS,,79007003,CDM,278,RC,,,both,,,2636,1950.65,,,1950.65,Other,150% of Medicare + 9.63% HCRA Surcharge,1186.2,45,,1186.2,percent of total billed charges,Critical Access Hospital RCC factor,896.24,34,,896.24,percent of total billed charges,Implant Device,896.24,34,,896.24,percent of total billed charges,Implant Device,896.24,34,,896.24,percent of total billed charges,Implant Device,896.24,34,,896.24,percent of total billed charges,Implant Device,896.24,34,,896.24,percent of total billed charges,Implant Device,1304.82,,,1304.82,Other,110% of Medicare,922.6,35,,922.6,percent of total billed charges,Implant Device,896.24,34,"Charges > $500, x 34%",896.24,percent of total billed charges,Implant Device,922.6,35,,922.6,percent of total billed charges,Implant Device,922.6,35,,922.6,percent of total billed charges,Implant Device,922.6,35,,922.6,percent of total billed charges,Implant Device,922.6,35,,922.6,percent of total billed charges,Implant Device,922.6,35,,922.6,percent of total billed charges,Implant Device,1054.4,40,,1054.4,percent of total billed charges,Implant Device,922.6,70,,922.6,percent of total billed charges,All Other,896.24,34,,896.24,percent of total billed charges,Implant Device,896.24,34,,896.24,percent of total billed charges,Implant Device,922.6,35,,922.6,percent of total billed charges,Implant Device,922.6,35,,922.6,percent of total billed charges,Implant Device,922.6,35,,922.6,percent of total billed charges,Implant Device,922.6,35,,922.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,896.24,34,"If Charge > 2,000, then 34 percent",896.24,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1950.65,
DEPUY 1365-32-330 FEM HEAD +9 32MM DIA,C1776,HCPCS,,79007004,CDM,278,RC,,,both,,,4764,3525.37,,,3525.37,Other,150% of Medicare + 9.63% HCRA Surcharge,2143.8,45,,2143.8,percent of total billed charges,Critical Access Hospital RCC factor,1619.76,34,,1619.76,percent of total billed charges,Implant Device,1619.76,34,,1619.76,percent of total billed charges,Implant Device,1619.76,34,,1619.76,percent of total billed charges,Implant Device,1619.76,34,,1619.76,percent of total billed charges,Implant Device,1619.76,34,,1619.76,percent of total billed charges,Implant Device,2358.18,,,2358.18,Other,110% of Medicare,1667.4,35,,1667.4,percent of total billed charges,Implant Device,1619.76,34,"Charges > $500, x 34%",1619.76,percent of total billed charges,Implant Device,1667.4,35,,1667.4,percent of total billed charges,Implant Device,1667.4,35,,1667.4,percent of total billed charges,Implant Device,1667.4,35,,1667.4,percent of total billed charges,Implant Device,1667.4,35,,1667.4,percent of total billed charges,Implant Device,1667.4,35,,1667.4,percent of total billed charges,Implant Device,1905.6,40,,1905.6,percent of total billed charges,Implant Device,1667.4,70,,1667.4,percent of total billed charges,All Other,1619.76,34,,1619.76,percent of total billed charges,Implant Device,1619.76,34,,1619.76,percent of total billed charges,Implant Device,1667.4,35,,1667.4,percent of total billed charges,Implant Device,1667.4,35,,1667.4,percent of total billed charges,Implant Device,1667.4,35,,1667.4,percent of total billed charges,Implant Device,1667.4,35,,1667.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1619.76,34,"If Charge > 2,000, then 34 percent",1619.76,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3525.37,
DEPUY 1541-28-000 HIP STEM SZ 3 200MM,C1776,HCPCS,,79007005,CDM,278,RC,,,both,,,14227,10528.02,,,10528.02,Other,150% of Medicare + 9.63% HCRA Surcharge,6402.15,45,,6402.15,percent of total billed charges,Critical Access Hospital RCC factor,4837.18,34,,4837.18,percent of total billed charges,Implant Device,4837.18,34,,4837.18,percent of total billed charges,Implant Device,4837.18,34,,4837.18,percent of total billed charges,Implant Device,4837.18,34,,4837.18,percent of total billed charges,Implant Device,4837.18,34,,4837.18,percent of total billed charges,Implant Device,7042.37,,,7042.37,Other,110% of Medicare,4979.45,35,,4979.45,percent of total billed charges,Implant Device,4837.18,34,"Charges > $500, x 34%",4837.18,percent of total billed charges,Implant Device,4979.45,35,,4979.45,percent of total billed charges,Implant Device,4979.45,35,,4979.45,percent of total billed charges,Implant Device,4979.45,35,,4979.45,percent of total billed charges,Implant Device,4979.45,35,,4979.45,percent of total billed charges,Implant Device,4979.45,35,,4979.45,percent of total billed charges,Implant Device,5690.8,40,,5690.8,percent of total billed charges,Implant Device,4979.45,70,,4979.45,percent of total billed charges,All Other,4837.18,34,,4837.18,percent of total billed charges,Implant Device,4837.18,34,,4837.18,percent of total billed charges,Implant Device,4979.45,35,,4979.45,percent of total billed charges,Implant Device,4979.45,35,,4979.45,percent of total billed charges,Implant Device,4979.45,35,,4979.45,percent of total billed charges,Implant Device,4979.45,35,,4979.45,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,4837.18,34,"If Charge > 2,000, then 34 percent",4837.18,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,10528.02,
WRIGHT CCP-RPNOL LAPIDUS NEUTAL PLATE,C1713,HCPCS,,79007006,CDM,278,RC,,,both,,,6708,4963.94,,,4963.94,Other,150% of Medicare + 9.63% HCRA Surcharge,3018.6,45,,3018.6,percent of total billed charges,Critical Access Hospital RCC factor,2280.72,34,,2280.72,percent of total billed charges,Implant Device,2280.72,34,,2280.72,percent of total billed charges,Implant Device,2280.72,34,,2280.72,percent of total billed charges,Implant Device,2280.72,34,,2280.72,percent of total billed charges,Implant Device,2280.72,34,,2280.72,percent of total billed charges,Implant Device,3320.46,,,3320.46,Other,110% of Medicare,2347.8,35,,2347.8,percent of total billed charges,Implant Device,2280.72,34,"Charges > $500, x 34%",2280.72,percent of total billed charges,Implant Device,2347.8,35,,2347.8,percent of total billed charges,Implant Device,2347.8,35,,2347.8,percent of total billed charges,Implant Device,2347.8,35,,2347.8,percent of total billed charges,Implant Device,2347.8,35,,2347.8,percent of total billed charges,Implant Device,2347.8,35,,2347.8,percent of total billed charges,Implant Device,2683.2,40,,2683.2,percent of total billed charges,Implant Device,2347.8,70,,2347.8,percent of total billed charges,All Other,2280.72,34,,2280.72,percent of total billed charges,Implant Device,2280.72,34,,2280.72,percent of total billed charges,Implant Device,2347.8,35,,2347.8,percent of total billed charges,Implant Device,2347.8,35,,2347.8,percent of total billed charges,Implant Device,2347.8,35,,2347.8,percent of total billed charges,Implant Device,2347.8,35,,2347.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2280.72,34,"If Charge > 2,000, then 34 percent",2280.72,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4963.94,
WRIGHT CCP-L3020 LOCKING SCREW 2X20MM,C1713,HCPCS,,79007007,CDM,278,RC,,,both,,,1126,833.24,,,833.24,Other,150% of Medicare + 9.63% HCRA Surcharge,506.7,45,,506.7,percent of total billed charges,Critical Access Hospital RCC factor,382.84,34,,382.84,percent of total billed charges,Implant Device,382.84,34,,382.84,percent of total billed charges,Implant Device,382.84,34,,382.84,percent of total billed charges,Implant Device,382.84,34,,382.84,percent of total billed charges,Implant Device,382.84,34,,382.84,percent of total billed charges,Implant Device,557.37,,,557.37,Other,110% of Medicare,394.1,35,,394.1,percent of total billed charges,Implant Device,382.84,34,"Charges > $500, x 34%",382.84,percent of total billed charges,Implant Device,394.1,35,,394.1,percent of total billed charges,Implant Device,394.1,35,,394.1,percent of total billed charges,Implant Device,394.1,35,,394.1,percent of total billed charges,Implant Device,394.1,35,,394.1,percent of total billed charges,Implant Device,394.1,35,,394.1,percent of total billed charges,Implant Device,450.4,40,,450.4,percent of total billed charges,Implant Device,394.1,70,,394.1,percent of total billed charges,All Other,382.84,34,,382.84,percent of total billed charges,Implant Device,382.84,34,,382.84,percent of total billed charges,Implant Device,394.1,35,,394.1,percent of total billed charges,Implant Device,394.1,35,,394.1,percent of total billed charges,Implant Device,394.1,35,,394.1,percent of total billed charges,Implant Device,394.1,35,,394.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,833.24,
WRIGHT CCP-N3018 NONLOCKING SCREW 3X18MM,C1713,HCPCS,,79007008,CDM,278,RC,,,both,,,886,655.64,,,655.64,Other,150% of Medicare + 9.63% HCRA Surcharge,398.7,45,,398.7,percent of total billed charges,Critical Access Hospital RCC factor,301.24,34,,301.24,percent of total billed charges,Implant Device,301.24,34,,301.24,percent of total billed charges,Implant Device,301.24,34,,301.24,percent of total billed charges,Implant Device,301.24,34,,301.24,percent of total billed charges,Implant Device,301.24,34,,301.24,percent of total billed charges,Implant Device,438.57,,,438.57,Other,110% of Medicare,310.1,35,,310.1,percent of total billed charges,Implant Device,301.24,34,"Charges > $500, x 34%",301.24,percent of total billed charges,Implant Device,310.1,35,,310.1,percent of total billed charges,Implant Device,310.1,35,,310.1,percent of total billed charges,Implant Device,310.1,35,,310.1,percent of total billed charges,Implant Device,310.1,35,,310.1,percent of total billed charges,Implant Device,310.1,35,,310.1,percent of total billed charges,Implant Device,354.4,40,,354.4,percent of total billed charges,Implant Device,310.1,70,,310.1,percent of total billed charges,All Other,301.24,34,,301.24,percent of total billed charges,Implant Device,301.24,34,,301.24,percent of total billed charges,Implant Device,310.1,35,,310.1,percent of total billed charges,Implant Device,310.1,35,,310.1,percent of total billed charges,Implant Device,310.1,35,,310.1,percent of total billed charges,Implant Device,310.1,35,,310.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,655.64,
P28 P20-135-022S CANN SCREW 3.5X22MM,C1713,HCPCS,,79007011,CDM,278,RC,,,both,,,686,507.64,,,507.64,Other,150% of Medicare + 9.63% HCRA Surcharge,308.7,45,,308.7,percent of total billed charges,Critical Access Hospital RCC factor,233.24,34,,233.24,percent of total billed charges,Implant Device,233.24,34,,233.24,percent of total billed charges,Implant Device,233.24,34,,233.24,percent of total billed charges,Implant Device,233.24,34,,233.24,percent of total billed charges,Implant Device,233.24,34,,233.24,percent of total billed charges,Implant Device,339.57,,,339.57,Other,110% of Medicare,240.1,35,,240.1,percent of total billed charges,Implant Device,233.24,34,"Charges > $500, x 34%",233.24,percent of total billed charges,Implant Device,240.1,35,,240.1,percent of total billed charges,Implant Device,240.1,35,,240.1,percent of total billed charges,Implant Device,240.1,35,,240.1,percent of total billed charges,Implant Device,240.1,35,,240.1,percent of total billed charges,Implant Device,240.1,35,,240.1,percent of total billed charges,Implant Device,274.4,40,,274.4,percent of total billed charges,Implant Device,240.1,70,,240.1,percent of total billed charges,All Other,233.24,34,,233.24,percent of total billed charges,Implant Device,233.24,34,,233.24,percent of total billed charges,Implant Device,240.1,35,,240.1,percent of total billed charges,Implant Device,240.1,35,,240.1,percent of total billed charges,Implant Device,240.1,35,,240.1,percent of total billed charges,Implant Device,240.1,35,,240.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,507.64,
P28 P50-053-2714 LOCK PLATE SCREW 2.7X14,C1713,HCPCS,,79007012,CDM,278,RC,,,both,,,667,493.58,,,493.58,Other,150% of Medicare + 9.63% HCRA Surcharge,300.15,45,,300.15,percent of total billed charges,Critical Access Hospital RCC factor,226.78,34,,226.78,percent of total billed charges,Implant Device,226.78,34,,226.78,percent of total billed charges,Implant Device,226.78,34,,226.78,percent of total billed charges,Implant Device,226.78,34,,226.78,percent of total billed charges,Implant Device,226.78,34,,226.78,percent of total billed charges,Implant Device,330.17,,,330.17,Other,110% of Medicare,233.45,35,,233.45,percent of total billed charges,Implant Device,226.78,34,"Charges > $500, x 34%",226.78,percent of total billed charges,Implant Device,233.45,35,,233.45,percent of total billed charges,Implant Device,233.45,35,,233.45,percent of total billed charges,Implant Device,233.45,35,,233.45,percent of total billed charges,Implant Device,233.45,35,,233.45,percent of total billed charges,Implant Device,233.45,35,,233.45,percent of total billed charges,Implant Device,266.8,40,,266.8,percent of total billed charges,Implant Device,233.45,70,,233.45,percent of total billed charges,All Other,226.78,34,,226.78,percent of total billed charges,Implant Device,226.78,34,,226.78,percent of total billed charges,Implant Device,233.45,35,,233.45,percent of total billed charges,Implant Device,233.45,35,,233.45,percent of total billed charges,Implant Device,233.45,35,,233.45,percent of total billed charges,Implant Device,233.45,35,,233.45,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,493.58,
P28 P50-053-2715 LOCK PLATE SCREW 2.7X15,C1713,HCPCS,,79007013,CDM,278,RC,,,both,,,667,493.58,,,493.58,Other,150% of Medicare + 9.63% HCRA Surcharge,300.15,45,,300.15,percent of total billed charges,Critical Access Hospital RCC factor,226.78,34,,226.78,percent of total billed charges,Implant Device,226.78,34,,226.78,percent of total billed charges,Implant Device,226.78,34,,226.78,percent of total billed charges,Implant Device,226.78,34,,226.78,percent of total billed charges,Implant Device,226.78,34,,226.78,percent of total billed charges,Implant Device,330.17,,,330.17,Other,110% of Medicare,233.45,35,,233.45,percent of total billed charges,Implant Device,226.78,34,"Charges > $500, x 34%",226.78,percent of total billed charges,Implant Device,233.45,35,,233.45,percent of total billed charges,Implant Device,233.45,35,,233.45,percent of total billed charges,Implant Device,233.45,35,,233.45,percent of total billed charges,Implant Device,233.45,35,,233.45,percent of total billed charges,Implant Device,233.45,35,,233.45,percent of total billed charges,Implant Device,266.8,40,,266.8,percent of total billed charges,Implant Device,233.45,70,,233.45,percent of total billed charges,All Other,226.78,34,,226.78,percent of total billed charges,Implant Device,226.78,34,,226.78,percent of total billed charges,Implant Device,233.45,35,,233.45,percent of total billed charges,Implant Device,233.45,35,,233.45,percent of total billed charges,Implant Device,233.45,35,,233.45,percent of total billed charges,Implant Device,233.45,35,,233.45,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,493.58,
P28 P50-053-3516 LOCK PLATE SCREW 3.5X16,C1713,HCPCS,,79007014,CDM,278,RC,,,both,,,880,651.2,,,651.2,Other,150% of Medicare + 9.63% HCRA Surcharge,396,45,,396,percent of total billed charges,Critical Access Hospital RCC factor,299.2,34,,299.2,percent of total billed charges,Implant Device,299.2,34,,299.2,percent of total billed charges,Implant Device,299.2,34,,299.2,percent of total billed charges,Implant Device,299.2,34,,299.2,percent of total billed charges,Implant Device,299.2,34,,299.2,percent of total billed charges,Implant Device,435.6,,,435.6,Other,110% of Medicare,308,35,,308,percent of total billed charges,Implant Device,299.2,34,"Charges > $500, x 34%",299.2,percent of total billed charges,Implant Device,308,35,,308,percent of total billed charges,Implant Device,308,35,,308,percent of total billed charges,Implant Device,308,35,,308,percent of total billed charges,Implant Device,308,35,,308,percent of total billed charges,Implant Device,308,35,,308,percent of total billed charges,Implant Device,352,40,,352,percent of total billed charges,Implant Device,308,70,,308,percent of total billed charges,All Other,299.2,34,,299.2,percent of total billed charges,Implant Device,299.2,34,,299.2,percent of total billed charges,Implant Device,308,35,,308,percent of total billed charges,Implant Device,308,35,,308,percent of total billed charges,Implant Device,308,35,,308,percent of total billed charges,Implant Device,308,35,,308,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,651.2,
P28 P50-153-3516 NON LOCK SCREW 3.5X16,C1713,HCPCS,,79007015,CDM,278,RC,,,both,,,727,537.98,,,537.98,Other,150% of Medicare + 9.63% HCRA Surcharge,327.15,45,,327.15,percent of total billed charges,Critical Access Hospital RCC factor,247.18,34,,247.18,percent of total billed charges,Implant Device,247.18,34,,247.18,percent of total billed charges,Implant Device,247.18,34,,247.18,percent of total billed charges,Implant Device,247.18,34,,247.18,percent of total billed charges,Implant Device,247.18,34,,247.18,percent of total billed charges,Implant Device,359.87,,,359.87,Other,110% of Medicare,254.45,35,,254.45,percent of total billed charges,Implant Device,247.18,34,"Charges > $500, x 34%",247.18,percent of total billed charges,Implant Device,254.45,35,,254.45,percent of total billed charges,Implant Device,254.45,35,,254.45,percent of total billed charges,Implant Device,254.45,35,,254.45,percent of total billed charges,Implant Device,254.45,35,,254.45,percent of total billed charges,Implant Device,254.45,35,,254.45,percent of total billed charges,Implant Device,290.8,40,,290.8,percent of total billed charges,Implant Device,254.45,70,,254.45,percent of total billed charges,All Other,247.18,34,,247.18,percent of total billed charges,Implant Device,247.18,34,,247.18,percent of total billed charges,Implant Device,254.45,35,,254.45,percent of total billed charges,Implant Device,254.45,35,,254.45,percent of total billed charges,Implant Device,254.45,35,,254.45,percent of total billed charges,Implant Device,254.45,35,,254.45,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,537.98,
P28 P53-103-L052 PLATE MED LT 5 DEG MTP,C1713,HCPCS,,79007016,CDM,278,RC,,,both,,,4837,3579.39,,,3579.39,Other,150% of Medicare + 9.63% HCRA Surcharge,2176.65,45,,2176.65,percent of total billed charges,Critical Access Hospital RCC factor,1644.58,34,,1644.58,percent of total billed charges,Implant Device,1644.58,34,,1644.58,percent of total billed charges,Implant Device,1644.58,34,,1644.58,percent of total billed charges,Implant Device,1644.58,34,,1644.58,percent of total billed charges,Implant Device,1644.58,34,,1644.58,percent of total billed charges,Implant Device,2394.32,,,2394.32,Other,110% of Medicare,1692.95,35,,1692.95,percent of total billed charges,Implant Device,1644.58,34,"Charges > $500, x 34%",1644.58,percent of total billed charges,Implant Device,1692.95,35,,1692.95,percent of total billed charges,Implant Device,1692.95,35,,1692.95,percent of total billed charges,Implant Device,1692.95,35,,1692.95,percent of total billed charges,Implant Device,1692.95,35,,1692.95,percent of total billed charges,Implant Device,1692.95,35,,1692.95,percent of total billed charges,Implant Device,1934.8,40,,1934.8,percent of total billed charges,Implant Device,1692.95,70,,1692.95,percent of total billed charges,All Other,1644.58,34,,1644.58,percent of total billed charges,Implant Device,1644.58,34,,1644.58,percent of total billed charges,Implant Device,1692.95,35,,1692.95,percent of total billed charges,Implant Device,1692.95,35,,1692.95,percent of total billed charges,Implant Device,1692.95,35,,1692.95,percent of total billed charges,Implant Device,1692.95,35,,1692.95,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1644.58,34,"If Charge > 2,000, then 34 percent",1644.58,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3579.39,
ARTHREX AR-8952TS-02 COMP PLATE 2 HOLE,C1713,HCPCS,,79007020,CDM,278,RC,,,both,,,3429,2537.47,,,2537.47,Other,150% of Medicare + 9.63% HCRA Surcharge,1543.05,45,,1543.05,percent of total billed charges,Critical Access Hospital RCC factor,1165.86,34,,1165.86,percent of total billed charges,Implant Device,1165.86,34,,1165.86,percent of total billed charges,Implant Device,1165.86,34,,1165.86,percent of total billed charges,Implant Device,1165.86,34,,1165.86,percent of total billed charges,Implant Device,1165.86,34,,1165.86,percent of total billed charges,Implant Device,1697.36,,,1697.36,Other,110% of Medicare,1200.15,35,,1200.15,percent of total billed charges,Implant Device,1165.86,34,"Charges > $500, x 34%",1165.86,percent of total billed charges,Implant Device,1200.15,35,,1200.15,percent of total billed charges,Implant Device,1200.15,35,,1200.15,percent of total billed charges,Implant Device,1200.15,35,,1200.15,percent of total billed charges,Implant Device,1200.15,35,,1200.15,percent of total billed charges,Implant Device,1200.15,35,,1200.15,percent of total billed charges,Implant Device,1371.6,40,,1371.6,percent of total billed charges,Implant Device,1200.15,70,,1200.15,percent of total billed charges,All Other,1165.86,34,,1165.86,percent of total billed charges,Implant Device,1165.86,34,,1165.86,percent of total billed charges,Implant Device,1200.15,35,,1200.15,percent of total billed charges,Implant Device,1200.15,35,,1200.15,percent of total billed charges,Implant Device,1200.15,35,,1200.15,percent of total billed charges,Implant Device,1200.15,35,,1200.15,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1165.86,34,"If Charge > 2,000, then 34 percent",1165.86,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2537.47,
STRYKER ORTHO 54-25674 VDR PLATE SHORT L,C1713,HCPCS,,79007021,CDM,278,RC,,,both,,,2604,1926.97,,,1926.97,Other,150% of Medicare + 9.63% HCRA Surcharge,1171.8,45,,1171.8,percent of total billed charges,Critical Access Hospital RCC factor,885.36,34,,885.36,percent of total billed charges,Implant Device,885.36,34,,885.36,percent of total billed charges,Implant Device,885.36,34,,885.36,percent of total billed charges,Implant Device,885.36,34,,885.36,percent of total billed charges,Implant Device,885.36,34,,885.36,percent of total billed charges,Implant Device,1288.98,,,1288.98,Other,110% of Medicare,911.4,35,,911.4,percent of total billed charges,Implant Device,885.36,34,"Charges > $500, x 34%",885.36,percent of total billed charges,Implant Device,911.4,35,,911.4,percent of total billed charges,Implant Device,911.4,35,,911.4,percent of total billed charges,Implant Device,911.4,35,,911.4,percent of total billed charges,Implant Device,911.4,35,,911.4,percent of total billed charges,Implant Device,911.4,35,,911.4,percent of total billed charges,Implant Device,1041.6,40,,1041.6,percent of total billed charges,Implant Device,911.4,70,,911.4,percent of total billed charges,All Other,885.36,34,,885.36,percent of total billed charges,Implant Device,885.36,34,,885.36,percent of total billed charges,Implant Device,911.4,35,,911.4,percent of total billed charges,Implant Device,911.4,35,,911.4,percent of total billed charges,Implant Device,911.4,35,,911.4,percent of total billed charges,Implant Device,911.4,35,,911.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,885.36,34,"If Charge > 2,000, then 34 percent",885.36,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1926.97,
ARTHREX AR-7000-18T SUTURE WASHER TITAN,C1713,HCPCS,,79007024,CDM,278,RC,,,both,,,375,277.5,,,277.5,Other,150% of Medicare + 9.63% HCRA Surcharge,168.75,45,,168.75,percent of total billed charges,Critical Access Hospital RCC factor,127.5,34,,127.5,percent of total billed charges,Implant Device,127.5,34,,127.5,percent of total billed charges,Implant Device,127.5,34,,127.5,percent of total billed charges,Implant Device,127.5,34,,127.5,percent of total billed charges,Implant Device,127.5,34,,127.5,percent of total billed charges,Implant Device,185.63,,,185.63,Other,110% of Medicare,131.25,35,,131.25,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,131.25,35,,131.25,percent of total billed charges,Implant Device,131.25,35,,131.25,percent of total billed charges,Implant Device,131.25,35,,131.25,percent of total billed charges,Implant Device,131.25,35,,131.25,percent of total billed charges,Implant Device,131.25,35,,131.25,percent of total billed charges,Implant Device,150,40,,150,percent of total billed charges,Implant Device,131.25,70,,131.25,percent of total billed charges,All Other,127.5,34,,127.5,percent of total billed charges,Implant Device,127.5,34,,127.5,percent of total billed charges,Implant Device,131.25,35,,131.25,percent of total billed charges,Implant Device,131.25,35,,131.25,percent of total billed charges,Implant Device,131.25,35,,131.25,percent of total billed charges,Implant Device,131.25,35,,131.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,277.5,
ARTHREX AR-7000-36 PT SCREW 3.75X36MM,C1713,HCPCS,,79007025,CDM,278,RC,,,both,,,858,634.92,,,634.92,Other,150% of Medicare + 9.63% HCRA Surcharge,386.1,45,,386.1,percent of total billed charges,Critical Access Hospital RCC factor,291.72,34,,291.72,percent of total billed charges,Implant Device,291.72,34,,291.72,percent of total billed charges,Implant Device,291.72,34,,291.72,percent of total billed charges,Implant Device,291.72,34,,291.72,percent of total billed charges,Implant Device,291.72,34,,291.72,percent of total billed charges,Implant Device,424.71,,,424.71,Other,110% of Medicare,300.3,35,,300.3,percent of total billed charges,Implant Device,291.72,34,"Charges > $500, x 34%",291.72,percent of total billed charges,Implant Device,300.3,35,,300.3,percent of total billed charges,Implant Device,300.3,35,,300.3,percent of total billed charges,Implant Device,300.3,35,,300.3,percent of total billed charges,Implant Device,300.3,35,,300.3,percent of total billed charges,Implant Device,300.3,35,,300.3,percent of total billed charges,Implant Device,343.2,40,,343.2,percent of total billed charges,Implant Device,300.3,70,,300.3,percent of total billed charges,All Other,291.72,34,,291.72,percent of total billed charges,Implant Device,291.72,34,,291.72,percent of total billed charges,Implant Device,300.3,35,,300.3,percent of total billed charges,Implant Device,300.3,35,,300.3,percent of total billed charges,Implant Device,300.3,35,,300.3,percent of total billed charges,Implant Device,300.3,35,,300.3,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,634.92,
EXACTECH SPC0422 HIP INSERT 54MM XLONG,C1776,HCPCS,,79007029,CDM,278,RC,,,both,,,9775,7233.52,,,7233.52,Other,150% of Medicare + 9.63% HCRA Surcharge,4398.75,45,,4398.75,percent of total billed charges,Critical Access Hospital RCC factor,3323.5,34,,3323.5,percent of total billed charges,Implant Device,3323.5,34,,3323.5,percent of total billed charges,Implant Device,3323.5,34,,3323.5,percent of total billed charges,Implant Device,3323.5,34,,3323.5,percent of total billed charges,Implant Device,3323.5,34,,3323.5,percent of total billed charges,Implant Device,4838.63,,,4838.63,Other,110% of Medicare,3421.25,35,,3421.25,percent of total billed charges,Implant Device,3323.5,34,"Charges > $500, x 34%",3323.5,percent of total billed charges,Implant Device,3421.25,35,,3421.25,percent of total billed charges,Implant Device,3421.25,35,,3421.25,percent of total billed charges,Implant Device,3421.25,35,,3421.25,percent of total billed charges,Implant Device,3421.25,35,,3421.25,percent of total billed charges,Implant Device,3421.25,35,,3421.25,percent of total billed charges,Implant Device,3910,40,,3910,percent of total billed charges,Implant Device,3421.25,70,,3421.25,percent of total billed charges,All Other,3323.5,34,,3323.5,percent of total billed charges,Implant Device,3323.5,34,,3323.5,percent of total billed charges,Implant Device,3421.25,35,,3421.25,percent of total billed charges,Implant Device,3421.25,35,,3421.25,percent of total billed charges,Implant Device,3421.25,35,,3421.25,percent of total billed charges,Implant Device,3421.25,35,,3421.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3323.5,34,"If Charge > 2,000, then 34 percent",3323.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,7233.52,
ARTHREX AR-8692DS IMPLANT SYS CPR VIPER,C1713,HCPCS,,79007033,CDM,278,RC,,,both,,,2850,2109.01,,,2109.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1282.5,45,,1282.5,percent of total billed charges,Critical Access Hospital RCC factor,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,1410.75,,,1410.75,Other,110% of Medicare,997.5,35,,997.5,percent of total billed charges,Implant Device,969,34,"Charges > $500, x 34%",969,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,1140,40,,1140,percent of total billed charges,Implant Device,997.5,70,,997.5,percent of total billed charges,All Other,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,969,34,"If Charge > 2,000, then 34 percent",969,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2109.01,
ARTHREX AR-8690DS IMPLANT SYS CPR SCORPN,C1713,HCPCS,,79007034,CDM,278,RC,,,both,,,2850,2109.01,,,2109.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1282.5,45,,1282.5,percent of total billed charges,Critical Access Hospital RCC factor,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,1410.75,,,1410.75,Other,110% of Medicare,997.5,35,,997.5,percent of total billed charges,Implant Device,969,34,"Charges > $500, x 34%",969,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,1140,40,,1140,percent of total billed charges,Implant Device,997.5,70,,997.5,percent of total billed charges,All Other,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,969,34,"If Charge > 2,000, then 34 percent",969,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2109.01,
GORE VBJ071502 VIABAHN 7MMX15CM STENT,C1874,HCPCS,,79007035,CDM,278,RC,,,both,,,11686,8647.67,,,8647.67,Other,150% of Medicare + 9.63% HCRA Surcharge,5258.7,45,,5258.7,percent of total billed charges,Critical Access Hospital RCC factor,3973.24,34,,3973.24,percent of total billed charges,Implant Device,3973.24,34,,3973.24,percent of total billed charges,Implant Device,3973.24,34,,3973.24,percent of total billed charges,Implant Device,3973.24,34,,3973.24,percent of total billed charges,Implant Device,3973.24,34,,3973.24,percent of total billed charges,Implant Device,5784.57,,,5784.57,Other,110% of Medicare,4090.1,35,,4090.1,percent of total billed charges,Implant Device,3973.24,34,"Charges > $500, x 34%",3973.24,percent of total billed charges,Implant Device,4090.1,35,,4090.1,percent of total billed charges,Implant Device,4090.1,35,,4090.1,percent of total billed charges,Implant Device,4090.1,35,,4090.1,percent of total billed charges,Implant Device,4090.1,35,,4090.1,percent of total billed charges,Implant Device,4090.1,35,,4090.1,percent of total billed charges,Implant Device,4674.4,40,,4674.4,percent of total billed charges,Implant Device,4090.1,70,,4090.1,percent of total billed charges,All Other,3973.24,34,,3973.24,percent of total billed charges,Implant Device,3973.24,34,,3973.24,percent of total billed charges,Implant Device,4090.1,35,,4090.1,percent of total billed charges,Implant Device,4090.1,35,,4090.1,percent of total billed charges,Implant Device,4090.1,35,,4090.1,percent of total billed charges,Implant Device,4090.1,35,,4090.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3973.24,34,"If Charge > 2,000, then 34 percent",3973.24,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,8647.67,
GORE VBH091502 VIABAHN 9MMX15CM STENT,C1874,HCPCS,,79007036,CDM,278,RC,,,both,,,11386,8425.67,,,8425.67,Other,150% of Medicare + 9.63% HCRA Surcharge,5123.7,45,,5123.7,percent of total billed charges,Critical Access Hospital RCC factor,3871.24,34,,3871.24,percent of total billed charges,Implant Device,3871.24,34,,3871.24,percent of total billed charges,Implant Device,3871.24,34,,3871.24,percent of total billed charges,Implant Device,3871.24,34,,3871.24,percent of total billed charges,Implant Device,3871.24,34,,3871.24,percent of total billed charges,Implant Device,5636.07,,,5636.07,Other,110% of Medicare,3985.1,35,,3985.1,percent of total billed charges,Implant Device,3871.24,34,"Charges > $500, x 34%",3871.24,percent of total billed charges,Implant Device,3985.1,35,,3985.1,percent of total billed charges,Implant Device,3985.1,35,,3985.1,percent of total billed charges,Implant Device,3985.1,35,,3985.1,percent of total billed charges,Implant Device,3985.1,35,,3985.1,percent of total billed charges,Implant Device,3985.1,35,,3985.1,percent of total billed charges,Implant Device,4554.4,40,,4554.4,percent of total billed charges,Implant Device,3985.1,70,,3985.1,percent of total billed charges,All Other,3871.24,34,,3871.24,percent of total billed charges,Implant Device,3871.24,34,,3871.24,percent of total billed charges,Implant Device,3985.1,35,,3985.1,percent of total billed charges,Implant Device,3985.1,35,,3985.1,percent of total billed charges,Implant Device,3985.1,35,,3985.1,percent of total billed charges,Implant Device,3985.1,35,,3985.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3871.24,34,"If Charge > 2,000, then 34 percent",3871.24,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,8425.67,
ZIMMER 00-5852-50-09 FLUTED STEM 9X130MM,C1776,HCPCS,,79007037,CDM,278,RC,,,both,,,11453,8475.25,,,8475.25,Other,150% of Medicare + 9.63% HCRA Surcharge,5153.85,45,,5153.85,percent of total billed charges,Critical Access Hospital RCC factor,3894.02,34,,3894.02,percent of total billed charges,Implant Device,3894.02,34,,3894.02,percent of total billed charges,Implant Device,3894.02,34,,3894.02,percent of total billed charges,Implant Device,3894.02,34,,3894.02,percent of total billed charges,Implant Device,3894.02,34,,3894.02,percent of total billed charges,Implant Device,5669.24,,,5669.24,Other,110% of Medicare,4008.55,35,,4008.55,percent of total billed charges,Implant Device,3894.02,34,"Charges > $500, x 34%",3894.02,percent of total billed charges,Implant Device,4008.55,35,,4008.55,percent of total billed charges,Implant Device,4008.55,35,,4008.55,percent of total billed charges,Implant Device,4008.55,35,,4008.55,percent of total billed charges,Implant Device,4008.55,35,,4008.55,percent of total billed charges,Implant Device,4008.55,35,,4008.55,percent of total billed charges,Implant Device,4581.2,40,,4581.2,percent of total billed charges,Implant Device,4008.55,70,,4008.55,percent of total billed charges,All Other,3894.02,34,,3894.02,percent of total billed charges,Implant Device,3894.02,34,,3894.02,percent of total billed charges,Implant Device,4008.55,35,,4008.55,percent of total billed charges,Implant Device,4008.55,35,,4008.55,percent of total billed charges,Implant Device,4008.55,35,,4008.55,percent of total billed charges,Implant Device,4008.55,35,,4008.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3894.02,34,"If Charge > 2,000, then 34 percent",3894.02,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,8475.25,
INTEGRA 50112 SUBTALAR MBA IMPLANT 12MM,C1713,HCPCS,,79007038,CDM,278,RC,,,both,,,5398,3994.53,,,3994.53,Other,150% of Medicare + 9.63% HCRA Surcharge,2429.1,45,,2429.1,percent of total billed charges,Critical Access Hospital RCC factor,1835.32,34,,1835.32,percent of total billed charges,Implant Device,1835.32,34,,1835.32,percent of total billed charges,Implant Device,1835.32,34,,1835.32,percent of total billed charges,Implant Device,1835.32,34,,1835.32,percent of total billed charges,Implant Device,1835.32,34,,1835.32,percent of total billed charges,Implant Device,2672.01,,,2672.01,Other,110% of Medicare,1889.3,35,,1889.3,percent of total billed charges,Implant Device,1835.32,34,"Charges > $500, x 34%",1835.32,percent of total billed charges,Implant Device,1889.3,35,,1889.3,percent of total billed charges,Implant Device,1889.3,35,,1889.3,percent of total billed charges,Implant Device,1889.3,35,,1889.3,percent of total billed charges,Implant Device,1889.3,35,,1889.3,percent of total billed charges,Implant Device,1889.3,35,,1889.3,percent of total billed charges,Implant Device,2159.2,40,,2159.2,percent of total billed charges,Implant Device,1889.3,70,,1889.3,percent of total billed charges,All Other,1835.32,34,,1835.32,percent of total billed charges,Implant Device,1835.32,34,,1835.32,percent of total billed charges,Implant Device,1889.3,35,,1889.3,percent of total billed charges,Implant Device,1889.3,35,,1889.3,percent of total billed charges,Implant Device,1889.3,35,,1889.3,percent of total billed charges,Implant Device,1889.3,35,,1889.3,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1835.32,34,"If Charge > 2,000, then 34 percent",1835.32,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3994.53,
MTF 450-636 FIBULA ALLOGRAFT 18CM,C1713,HCPCS,,79007040,CDM,278,RC,,,both,,,3053,2259.23,,,2259.23,Other,150% of Medicare + 9.63% HCRA Surcharge,1373.85,45,,1373.85,percent of total billed charges,Critical Access Hospital RCC factor,1038.02,34,,1038.02,percent of total billed charges,Implant Device,1038.02,34,,1038.02,percent of total billed charges,Implant Device,1038.02,34,,1038.02,percent of total billed charges,Implant Device,1038.02,34,,1038.02,percent of total billed charges,Implant Device,1038.02,34,,1038.02,percent of total billed charges,Implant Device,1511.24,,,1511.24,Other,110% of Medicare,1068.55,35,,1068.55,percent of total billed charges,Implant Device,1038.02,34,"Charges > $500, x 34%",1038.02,percent of total billed charges,Implant Device,1068.55,35,,1068.55,percent of total billed charges,Implant Device,1068.55,35,,1068.55,percent of total billed charges,Implant Device,1068.55,35,,1068.55,percent of total billed charges,Implant Device,1068.55,35,,1068.55,percent of total billed charges,Implant Device,1068.55,35,,1068.55,percent of total billed charges,Implant Device,1221.2,40,,1221.2,percent of total billed charges,Implant Device,1068.55,70,,1068.55,percent of total billed charges,All Other,1038.02,34,,1038.02,percent of total billed charges,Implant Device,1038.02,34,,1038.02,percent of total billed charges,Implant Device,1068.55,35,,1068.55,percent of total billed charges,Implant Device,1068.55,35,,1068.55,percent of total billed charges,Implant Device,1068.55,35,,1068.55,percent of total billed charges,Implant Device,1068.55,35,,1068.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1038.02,34,"If Charge > 2,000, then 34 percent",1038.02,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2259.23,
METASURG DF2010 DIGIFUSE DF2010,C1776,HCPCS,,79007041,CDM,278,RC,,,both,,,3450,2553.01,,,2553.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1552.5,45,,1552.5,percent of total billed charges,Critical Access Hospital RCC factor,1173,34,,1173,percent of total billed charges,Implant Device,1173,34,,1173,percent of total billed charges,Implant Device,1173,34,,1173,percent of total billed charges,Implant Device,1173,34,,1173,percent of total billed charges,Implant Device,1173,34,,1173,percent of total billed charges,Implant Device,1707.75,,,1707.75,Other,110% of Medicare,1207.5,35,,1207.5,percent of total billed charges,Implant Device,1173,34,"Charges > $500, x 34%",1173,percent of total billed charges,Implant Device,1207.5,35,,1207.5,percent of total billed charges,Implant Device,1207.5,35,,1207.5,percent of total billed charges,Implant Device,1207.5,35,,1207.5,percent of total billed charges,Implant Device,1207.5,35,,1207.5,percent of total billed charges,Implant Device,1207.5,35,,1207.5,percent of total billed charges,Implant Device,1380,40,,1380,percent of total billed charges,Implant Device,1207.5,70,,1207.5,percent of total billed charges,All Other,1173,34,,1173,percent of total billed charges,Implant Device,1173,34,,1173,percent of total billed charges,Implant Device,1207.5,35,,1207.5,percent of total billed charges,Implant Device,1207.5,35,,1207.5,percent of total billed charges,Implant Device,1207.5,35,,1207.5,percent of total billed charges,Implant Device,1207.5,35,,1207.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1173,34,"If Charge > 2,000, then 34 percent",1173,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2553.01,
STRYKER 602690SS 6.5X90MM CANN SCREW,C1713,HCPCS,,79007042,CDM,278,RC,,,both,,,702,519.48,,,519.48,Other,150% of Medicare + 9.63% HCRA Surcharge,315.9,45,,315.9,percent of total billed charges,Critical Access Hospital RCC factor,238.68,34,,238.68,percent of total billed charges,Implant Device,238.68,34,,238.68,percent of total billed charges,Implant Device,238.68,34,,238.68,percent of total billed charges,Implant Device,238.68,34,,238.68,percent of total billed charges,Implant Device,238.68,34,,238.68,percent of total billed charges,Implant Device,347.49,,,347.49,Other,110% of Medicare,245.7,35,,245.7,percent of total billed charges,Implant Device,238.68,34,"Charges > $500, x 34%",238.68,percent of total billed charges,Implant Device,245.7,35,,245.7,percent of total billed charges,Implant Device,245.7,35,,245.7,percent of total billed charges,Implant Device,245.7,35,,245.7,percent of total billed charges,Implant Device,245.7,35,,245.7,percent of total billed charges,Implant Device,245.7,35,,245.7,percent of total billed charges,Implant Device,280.8,40,,280.8,percent of total billed charges,Implant Device,245.7,70,,245.7,percent of total billed charges,All Other,238.68,34,,238.68,percent of total billed charges,Implant Device,238.68,34,,238.68,percent of total billed charges,Implant Device,245.7,35,,245.7,percent of total billed charges,Implant Device,245.7,35,,245.7,percent of total billed charges,Implant Device,245.7,35,,245.7,percent of total billed charges,Implant Device,245.7,35,,245.7,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,519.48,
STRYKER 602695S 6.4X95MM CANN SCREW,C1713,HCPCS,,79007043,CDM,278,RC,,,both,,,753,557.22,,,557.22,Other,150% of Medicare + 9.63% HCRA Surcharge,338.85,45,,338.85,percent of total billed charges,Critical Access Hospital RCC factor,256.02,34,,256.02,percent of total billed charges,Implant Device,256.02,34,,256.02,percent of total billed charges,Implant Device,256.02,34,,256.02,percent of total billed charges,Implant Device,256.02,34,,256.02,percent of total billed charges,Implant Device,256.02,34,,256.02,percent of total billed charges,Implant Device,372.74,,,372.74,Other,110% of Medicare,263.55,35,,263.55,percent of total billed charges,Implant Device,256.02,34,"Charges > $500, x 34%",256.02,percent of total billed charges,Implant Device,263.55,35,,263.55,percent of total billed charges,Implant Device,263.55,35,,263.55,percent of total billed charges,Implant Device,263.55,35,,263.55,percent of total billed charges,Implant Device,263.55,35,,263.55,percent of total billed charges,Implant Device,263.55,35,,263.55,percent of total billed charges,Implant Device,301.2,40,,301.2,percent of total billed charges,Implant Device,263.55,70,,263.55,percent of total billed charges,All Other,256.02,34,,256.02,percent of total billed charges,Implant Device,256.02,34,,256.02,percent of total billed charges,Implant Device,263.55,35,,263.55,percent of total billed charges,Implant Device,263.55,35,,263.55,percent of total billed charges,Implant Device,263.55,35,,263.55,percent of total billed charges,Implant Device,263.55,35,,263.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,557.22,
TELEFLEX KM-71-742 STEINMAN PIN 9/64 3.5,C1713,HCPCS,,79007044,CDM,278,RC,,,both,,,41,30.34,,,30.34,Other,150% of Medicare + 9.63% HCRA Surcharge,18.45,45,,18.45,percent of total billed charges,Critical Access Hospital RCC factor,13.94,34,,13.94,percent of total billed charges,Implant Device,13.94,34,,13.94,percent of total billed charges,Implant Device,13.94,34,,13.94,percent of total billed charges,Implant Device,13.94,34,,13.94,percent of total billed charges,Implant Device,13.94,34,,13.94,percent of total billed charges,Implant Device,20.3,,,20.3,Other,110% of Medicare,14.35,35,,14.35,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,14.35,35,,14.35,percent of total billed charges,Implant Device,14.35,35,,14.35,percent of total billed charges,Implant Device,14.35,35,,14.35,percent of total billed charges,Implant Device,14.35,35,,14.35,percent of total billed charges,Implant Device,14.35,35,,14.35,percent of total billed charges,Implant Device,16.4,40,,16.4,percent of total billed charges,Implant Device,14.35,70,,14.35,percent of total billed charges,All Other,13.94,34,,13.94,percent of total billed charges,Implant Device,13.94,34,,13.94,percent of total billed charges,Implant Device,14.35,35,,14.35,percent of total billed charges,Implant Device,14.35,35,,14.35,percent of total billed charges,Implant Device,14.35,35,,14.35,percent of total billed charges,Implant Device,14.35,35,,14.35,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,30.34,
TELEFLEX KM-71-745 STEINMAN PIN 5/32 4MM,C1713,HCPCS,,79007045,CDM,278,RC,,,both,,,44,32.56,,,32.56,Other,150% of Medicare + 9.63% HCRA Surcharge,19.8,45,,19.8,percent of total billed charges,Critical Access Hospital RCC factor,14.96,34,,14.96,percent of total billed charges,Implant Device,14.96,34,,14.96,percent of total billed charges,Implant Device,14.96,34,,14.96,percent of total billed charges,Implant Device,14.96,34,,14.96,percent of total billed charges,Implant Device,14.96,34,,14.96,percent of total billed charges,Implant Device,21.78,,,21.78,Other,110% of Medicare,15.4,35,,15.4,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,15.4,35,,15.4,percent of total billed charges,Implant Device,15.4,35,,15.4,percent of total billed charges,Implant Device,15.4,35,,15.4,percent of total billed charges,Implant Device,15.4,35,,15.4,percent of total billed charges,Implant Device,15.4,35,,15.4,percent of total billed charges,Implant Device,17.6,40,,17.6,percent of total billed charges,Implant Device,15.4,70,,15.4,percent of total billed charges,All Other,14.96,34,,14.96,percent of total billed charges,Implant Device,14.96,34,,14.96,percent of total billed charges,Implant Device,15.4,35,,15.4,percent of total billed charges,Implant Device,15.4,35,,15.4,percent of total billed charges,Implant Device,15.4,35,,15.4,percent of total billed charges,Implant Device,15.4,35,,15.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,32.56,
DEPUY 02.123.020 PERIART HUMERS PLATE 2H,C1713,HCPCS,,79007046,CDM,278,RC,,,both,,,3929,2907.47,,,2907.47,Other,150% of Medicare + 9.63% HCRA Surcharge,1768.05,45,,1768.05,percent of total billed charges,Critical Access Hospital RCC factor,1335.86,34,,1335.86,percent of total billed charges,Implant Device,1335.86,34,,1335.86,percent of total billed charges,Implant Device,1335.86,34,,1335.86,percent of total billed charges,Implant Device,1335.86,34,,1335.86,percent of total billed charges,Implant Device,1335.86,34,,1335.86,percent of total billed charges,Implant Device,1944.86,,,1944.86,Other,110% of Medicare,1375.15,35,,1375.15,percent of total billed charges,Implant Device,1335.86,34,"Charges > $500, x 34%",1335.86,percent of total billed charges,Implant Device,1375.15,35,,1375.15,percent of total billed charges,Implant Device,1375.15,35,,1375.15,percent of total billed charges,Implant Device,1375.15,35,,1375.15,percent of total billed charges,Implant Device,1375.15,35,,1375.15,percent of total billed charges,Implant Device,1375.15,35,,1375.15,percent of total billed charges,Implant Device,1571.6,40,,1571.6,percent of total billed charges,Implant Device,1375.15,70,,1375.15,percent of total billed charges,All Other,1335.86,34,,1335.86,percent of total billed charges,Implant Device,1335.86,34,,1335.86,percent of total billed charges,Implant Device,1375.15,35,,1375.15,percent of total billed charges,Implant Device,1375.15,35,,1375.15,percent of total billed charges,Implant Device,1375.15,35,,1375.15,percent of total billed charges,Implant Device,1375.15,35,,1375.15,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1335.86,34,"If Charge > 2,000, then 34 percent",1335.86,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2907.47,
DEPUY 02.240.040 CANN LOCK SCREW 3.7X40M,C1713,HCPCS,,79007047,CDM,278,RC,,,both,,,476,352.24,,,352.24,Other,150% of Medicare + 9.63% HCRA Surcharge,214.2,45,,214.2,percent of total billed charges,Critical Access Hospital RCC factor,161.84,34,,161.84,percent of total billed charges,Implant Device,161.84,34,,161.84,percent of total billed charges,Implant Device,161.84,34,,161.84,percent of total billed charges,Implant Device,161.84,34,,161.84,percent of total billed charges,Implant Device,161.84,34,,161.84,percent of total billed charges,Implant Device,235.62,,,235.62,Other,110% of Medicare,166.6,35,,166.6,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,166.6,35,,166.6,percent of total billed charges,Implant Device,166.6,35,,166.6,percent of total billed charges,Implant Device,166.6,35,,166.6,percent of total billed charges,Implant Device,166.6,35,,166.6,percent of total billed charges,Implant Device,166.6,35,,166.6,percent of total billed charges,Implant Device,190.4,40,,190.4,percent of total billed charges,Implant Device,166.6,70,,166.6,percent of total billed charges,All Other,161.84,34,,161.84,percent of total billed charges,Implant Device,161.84,34,,161.84,percent of total billed charges,Implant Device,166.6,35,,166.6,percent of total billed charges,Implant Device,166.6,35,,166.6,percent of total billed charges,Implant Device,166.6,35,,166.6,percent of total billed charges,Implant Device,166.6,35,,166.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,352.24,
DEPUY 456.304S TI NAIL HELCL BLADE 11X95,C1713,HCPCS,,79007056,CDM,278,RC,,,both,,,1301,962.74,,,962.74,Other,150% of Medicare + 9.63% HCRA Surcharge,585.45,45,,585.45,percent of total billed charges,Critical Access Hospital RCC factor,442.34,34,,442.34,percent of total billed charges,Implant Device,442.34,34,,442.34,percent of total billed charges,Implant Device,442.34,34,,442.34,percent of total billed charges,Implant Device,442.34,34,,442.34,percent of total billed charges,Implant Device,442.34,34,,442.34,percent of total billed charges,Implant Device,644,,,644,Other,110% of Medicare,455.35,35,,455.35,percent of total billed charges,Implant Device,442.34,34,"Charges > $500, x 34%",442.34,percent of total billed charges,Implant Device,455.35,35,,455.35,percent of total billed charges,Implant Device,455.35,35,,455.35,percent of total billed charges,Implant Device,455.35,35,,455.35,percent of total billed charges,Implant Device,455.35,35,,455.35,percent of total billed charges,Implant Device,455.35,35,,455.35,percent of total billed charges,Implant Device,520.4,40,,520.4,percent of total billed charges,Implant Device,455.35,70,,455.35,percent of total billed charges,All Other,442.34,34,,442.34,percent of total billed charges,Implant Device,442.34,34,,442.34,percent of total billed charges,Implant Device,455.35,35,,455.35,percent of total billed charges,Implant Device,455.35,35,,455.35,percent of total billed charges,Implant Device,455.35,35,,455.35,percent of total billed charges,Implant Device,455.35,35,,455.35,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,962.74,
ZIMMER 5001-046-00 BIPOLAR SHELL 46MM OD,C1713,HCPCS,,79007057,CDM,278,RC,,,both,,,2273,1682.03,,,1682.03,Other,150% of Medicare + 9.63% HCRA Surcharge,1022.85,45,,1022.85,percent of total billed charges,Critical Access Hospital RCC factor,772.82,34,,772.82,percent of total billed charges,Implant Device,772.82,34,,772.82,percent of total billed charges,Implant Device,772.82,34,,772.82,percent of total billed charges,Implant Device,772.82,34,,772.82,percent of total billed charges,Implant Device,772.82,34,,772.82,percent of total billed charges,Implant Device,1125.14,,,1125.14,Other,110% of Medicare,795.55,35,,795.55,percent of total billed charges,Implant Device,772.82,34,"Charges > $500, x 34%",772.82,percent of total billed charges,Implant Device,795.55,35,,795.55,percent of total billed charges,Implant Device,795.55,35,,795.55,percent of total billed charges,Implant Device,795.55,35,,795.55,percent of total billed charges,Implant Device,795.55,35,,795.55,percent of total billed charges,Implant Device,795.55,35,,795.55,percent of total billed charges,Implant Device,909.2,40,,909.2,percent of total billed charges,Implant Device,795.55,70,,795.55,percent of total billed charges,All Other,772.82,34,,772.82,percent of total billed charges,Implant Device,772.82,34,,772.82,percent of total billed charges,Implant Device,795.55,35,,795.55,percent of total billed charges,Implant Device,795.55,35,,795.55,percent of total billed charges,Implant Device,795.55,35,,795.55,percent of total billed charges,Implant Device,795.55,35,,795.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,772.82,34,"If Charge > 2,000, then 34 percent",772.82,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1682.03,
DEPUY 3L92503 CORAIL FEMORAL STEM SZ 13,C1776,HCPCS,,79007060,CDM,278,RC,,,both,,,13446,9950.07,,,9950.07,Other,150% of Medicare + 9.63% HCRA Surcharge,6050.7,45,,6050.7,percent of total billed charges,Critical Access Hospital RCC factor,4571.64,34,,4571.64,percent of total billed charges,Implant Device,4571.64,34,,4571.64,percent of total billed charges,Implant Device,4571.64,34,,4571.64,percent of total billed charges,Implant Device,4571.64,34,,4571.64,percent of total billed charges,Implant Device,4571.64,34,,4571.64,percent of total billed charges,Implant Device,6655.77,,,6655.77,Other,110% of Medicare,4706.1,35,,4706.1,percent of total billed charges,Implant Device,4571.64,34,"Charges > $500, x 34%",4571.64,percent of total billed charges,Implant Device,4706.1,35,,4706.1,percent of total billed charges,Implant Device,4706.1,35,,4706.1,percent of total billed charges,Implant Device,4706.1,35,,4706.1,percent of total billed charges,Implant Device,4706.1,35,,4706.1,percent of total billed charges,Implant Device,4706.1,35,,4706.1,percent of total billed charges,Implant Device,5378.4,40,,5378.4,percent of total billed charges,Implant Device,4706.1,70,,4706.1,percent of total billed charges,All Other,4571.64,34,,4571.64,percent of total billed charges,Implant Device,4571.64,34,,4571.64,percent of total billed charges,Implant Device,4706.1,35,,4706.1,percent of total billed charges,Implant Device,4706.1,35,,4706.1,percent of total billed charges,Implant Device,4706.1,35,,4706.1,percent of total billed charges,Implant Device,4706.1,35,,4706.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,4571.64,34,"If Charge > 2,000, then 34 percent",4571.64,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,9950.07,
STRYKER 6276-7-217 RESTMOD HIP SYS 195MM,C1776,HCPCS,,79007061,CDM,278,RC,,,both,,,15277,11305.02,,,11305.02,Other,150% of Medicare + 9.63% HCRA Surcharge,6874.65,45,,6874.65,percent of total billed charges,Critical Access Hospital RCC factor,5194.18,34,,5194.18,percent of total billed charges,Implant Device,5194.18,34,,5194.18,percent of total billed charges,Implant Device,5194.18,34,,5194.18,percent of total billed charges,Implant Device,5194.18,34,,5194.18,percent of total billed charges,Implant Device,5194.18,34,,5194.18,percent of total billed charges,Implant Device,7562.12,,,7562.12,Other,110% of Medicare,5346.95,35,,5346.95,percent of total billed charges,Implant Device,5194.18,34,"Charges > $500, x 34%",5194.18,percent of total billed charges,Implant Device,5346.95,35,,5346.95,percent of total billed charges,Implant Device,5346.95,35,,5346.95,percent of total billed charges,Implant Device,5346.95,35,,5346.95,percent of total billed charges,Implant Device,5346.95,35,,5346.95,percent of total billed charges,Implant Device,5346.95,35,,5346.95,percent of total billed charges,Implant Device,6110.8,40,,6110.8,percent of total billed charges,Implant Device,5346.95,70,,5346.95,percent of total billed charges,All Other,5194.18,34,,5194.18,percent of total billed charges,Implant Device,5194.18,34,,5194.18,percent of total billed charges,Implant Device,5346.95,35,,5346.95,percent of total billed charges,Implant Device,5346.95,35,,5346.95,percent of total billed charges,Implant Device,5346.95,35,,5346.95,percent of total billed charges,Implant Device,5346.95,35,,5346.95,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,5194.18,34,"If Charge > 2,000, then 34 percent",5194.18,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,11305.02,
STRYKER 3003-0822S SET SCREW TI 8X17MM,C1713,HCPCS,,79007062,CDM,278,RC,,,both,,,464,343.36,,,343.36,Other,150% of Medicare + 9.63% HCRA Surcharge,208.8,45,,208.8,percent of total billed charges,Critical Access Hospital RCC factor,157.76,34,,157.76,percent of total billed charges,Implant Device,157.76,34,,157.76,percent of total billed charges,Implant Device,157.76,34,,157.76,percent of total billed charges,Implant Device,157.76,34,,157.76,percent of total billed charges,Implant Device,157.76,34,,157.76,percent of total billed charges,Implant Device,229.68,,,229.68,Other,110% of Medicare,162.4,35,,162.4,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,162.4,35,,162.4,percent of total billed charges,Implant Device,162.4,35,,162.4,percent of total billed charges,Implant Device,162.4,35,,162.4,percent of total billed charges,Implant Device,162.4,35,,162.4,percent of total billed charges,Implant Device,162.4,35,,162.4,percent of total billed charges,Implant Device,185.6,40,,185.6,percent of total billed charges,Implant Device,162.4,70,,162.4,percent of total billed charges,All Other,157.76,34,,157.76,percent of total billed charges,Implant Device,157.76,34,,157.76,percent of total billed charges,Implant Device,162.4,35,,162.4,percent of total billed charges,Implant Device,162.4,35,,162.4,percent of total billed charges,Implant Device,162.4,35,,162.4,percent of total billed charges,Implant Device,162.4,35,,162.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,343.36,
DEPUY 298.801.01S CABLE W CRIMP 1.7X750,C1713,HCPCS,,79007065,CDM,278,RC,,,both,,,1211,896.14,,,896.14,Other,150% of Medicare + 9.63% HCRA Surcharge,544.95,45,,544.95,percent of total billed charges,Critical Access Hospital RCC factor,411.74,34,,411.74,percent of total billed charges,Implant Device,411.74,34,,411.74,percent of total billed charges,Implant Device,411.74,34,,411.74,percent of total billed charges,Implant Device,411.74,34,,411.74,percent of total billed charges,Implant Device,411.74,34,,411.74,percent of total billed charges,Implant Device,599.45,,,599.45,Other,110% of Medicare,423.85,35,,423.85,percent of total billed charges,Implant Device,411.74,34,"Charges > $500, x 34%",411.74,percent of total billed charges,Implant Device,423.85,35,,423.85,percent of total billed charges,Implant Device,423.85,35,,423.85,percent of total billed charges,Implant Device,423.85,35,,423.85,percent of total billed charges,Implant Device,423.85,35,,423.85,percent of total billed charges,Implant Device,423.85,35,,423.85,percent of total billed charges,Implant Device,484.4,40,,484.4,percent of total billed charges,Implant Device,423.85,70,,423.85,percent of total billed charges,All Other,411.74,34,,411.74,percent of total billed charges,Implant Device,411.74,34,,411.74,percent of total billed charges,Implant Device,423.85,35,,423.85,percent of total billed charges,Implant Device,423.85,35,,423.85,percent of total billed charges,Implant Device,423.85,35,,423.85,percent of total billed charges,Implant Device,423.85,35,,423.85,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,896.14,
LIFE SPINE 165-45-5 PEDICLE SCREW 6.5X45,C1713,HCPCS,,79007066,CDM,278,RC,,,both,,,6000,4440.02,,,4440.02,Other,150% of Medicare + 9.63% HCRA Surcharge,2700,45,,2700,percent of total billed charges,Critical Access Hospital RCC factor,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2970,,,2970,Other,110% of Medicare,2100,35,,2100,percent of total billed charges,Implant Device,2040,34,"Charges > $500, x 34%",2040,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2400,40,,2400,percent of total billed charges,Implant Device,2100,70,,2100,percent of total billed charges,All Other,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2040,34,"If Charge > 2,000, then 34 percent",2040,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4440.02,
LIFE SPINE 175-40-5 PEDICLE SCREW 7.5X40,C1713,HCPCS,,79007067,CDM,278,RC,,,both,,,6000,4440.02,,,4440.02,Other,150% of Medicare + 9.63% HCRA Surcharge,2700,45,,2700,percent of total billed charges,Critical Access Hospital RCC factor,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2970,,,2970,Other,110% of Medicare,2100,35,,2100,percent of total billed charges,Implant Device,2040,34,"Charges > $500, x 34%",2040,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2400,40,,2400,percent of total billed charges,Implant Device,2100,70,,2100,percent of total billed charges,All Other,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2040,34,"If Charge > 2,000, then 34 percent",2040,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4440.02,
LIFE SPINE 500-029 LOCK SCREW CONQUEST,C1713,HCPCS,,79007068,CDM,278,RC,,,both,,,1920,1420.8,,,1420.8,Other,150% of Medicare + 9.63% HCRA Surcharge,864,45,,864,percent of total billed charges,Critical Access Hospital RCC factor,652.8,34,,652.8,percent of total billed charges,Implant Device,652.8,34,,652.8,percent of total billed charges,Implant Device,652.8,34,,652.8,percent of total billed charges,Implant Device,652.8,34,,652.8,percent of total billed charges,Implant Device,652.8,34,,652.8,percent of total billed charges,Implant Device,950.4,,,950.4,Other,110% of Medicare,672,35,,672,percent of total billed charges,Implant Device,652.8,34,"Charges > $500, x 34%",652.8,percent of total billed charges,Implant Device,672,35,,672,percent of total billed charges,Implant Device,672,35,,672,percent of total billed charges,Implant Device,672,35,,672,percent of total billed charges,Implant Device,672,35,,672,percent of total billed charges,Implant Device,672,35,,672,percent of total billed charges,Implant Device,768,40,,768,percent of total billed charges,Implant Device,672,70,,672,percent of total billed charges,All Other,652.8,34,,652.8,percent of total billed charges,Implant Device,652.8,34,,652.8,percent of total billed charges,Implant Device,672,35,,672,percent of total billed charges,Implant Device,672,35,,672,percent of total billed charges,Implant Device,672,35,,672,percent of total billed charges,Implant Device,672,35,,672,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1420.8,
LIFE SPINE 4550-070 ROD 5.5X70MM,C1713,HCPCS,,79007069,CDM,278,RC,,,both,,,960,710.4,,,710.4,Other,150% of Medicare + 9.63% HCRA Surcharge,432,45,,432,percent of total billed charges,Critical Access Hospital RCC factor,326.4,34,,326.4,percent of total billed charges,Implant Device,326.4,34,,326.4,percent of total billed charges,Implant Device,326.4,34,,326.4,percent of total billed charges,Implant Device,326.4,34,,326.4,percent of total billed charges,Implant Device,326.4,34,,326.4,percent of total billed charges,Implant Device,475.2,,,475.2,Other,110% of Medicare,336,35,,336,percent of total billed charges,Implant Device,326.4,34,"Charges > $500, x 34%",326.4,percent of total billed charges,Implant Device,336,35,,336,percent of total billed charges,Implant Device,336,35,,336,percent of total billed charges,Implant Device,336,35,,336,percent of total billed charges,Implant Device,336,35,,336,percent of total billed charges,Implant Device,336,35,,336,percent of total billed charges,Implant Device,384,40,,384,percent of total billed charges,Implant Device,336,70,,336,percent of total billed charges,All Other,326.4,34,,326.4,percent of total billed charges,Implant Device,326.4,34,,326.4,percent of total billed charges,Implant Device,336,35,,336,percent of total billed charges,Implant Device,336,35,,336,percent of total billed charges,Implant Device,336,35,,336,percent of total billed charges,Implant Device,336,35,,336,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,710.4,
LIFE SPINE 32-1024-09 PLATE STR 10X24X9,C1713,HCPCS,,79007070,CDM,278,RC,,,both,,,14400,10656.04,,,10656.04,Other,150% of Medicare + 9.63% HCRA Surcharge,6480,45,,6480,percent of total billed charges,Critical Access Hospital RCC factor,4896,34,,4896,percent of total billed charges,Implant Device,4896,34,,4896,percent of total billed charges,Implant Device,4896,34,,4896,percent of total billed charges,Implant Device,4896,34,,4896,percent of total billed charges,Implant Device,4896,34,,4896,percent of total billed charges,Implant Device,7128,,,7128,Other,110% of Medicare,5040,35,,5040,percent of total billed charges,Implant Device,4896,34,"Charges > $500, x 34%",4896,percent of total billed charges,Implant Device,5040,35,,5040,percent of total billed charges,Implant Device,5040,35,,5040,percent of total billed charges,Implant Device,5040,35,,5040,percent of total billed charges,Implant Device,5040,35,,5040,percent of total billed charges,Implant Device,5040,35,,5040,percent of total billed charges,Implant Device,5760,40,,5760,percent of total billed charges,Implant Device,5040,70,,5040,percent of total billed charges,All Other,4896,34,,4896,percent of total billed charges,Implant Device,4896,34,,4896,percent of total billed charges,Implant Device,5040,35,,5040,percent of total billed charges,Implant Device,5040,35,,5040,percent of total billed charges,Implant Device,5040,35,,5040,percent of total billed charges,Implant Device,5040,35,,5040,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,4896,34,"If Charge > 2,000, then 34 percent",4896,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,10656.04,
ARTHREX AR-5035TC-11 INTER SCREW 11X35MM,C1713,HCPCS,,79007071,CDM,278,RC,,,both,,,705,521.7,,,521.7,Other,150% of Medicare + 9.63% HCRA Surcharge,317.25,45,,317.25,percent of total billed charges,Critical Access Hospital RCC factor,239.7,34,,239.7,percent of total billed charges,Implant Device,239.7,34,,239.7,percent of total billed charges,Implant Device,239.7,34,,239.7,percent of total billed charges,Implant Device,239.7,34,,239.7,percent of total billed charges,Implant Device,239.7,34,,239.7,percent of total billed charges,Implant Device,348.98,,,348.98,Other,110% of Medicare,246.75,35,,246.75,percent of total billed charges,Implant Device,239.7,34,"Charges > $500, x 34%",239.7,percent of total billed charges,Implant Device,246.75,35,,246.75,percent of total billed charges,Implant Device,246.75,35,,246.75,percent of total billed charges,Implant Device,246.75,35,,246.75,percent of total billed charges,Implant Device,246.75,35,,246.75,percent of total billed charges,Implant Device,246.75,35,,246.75,percent of total billed charges,Implant Device,282,40,,282,percent of total billed charges,Implant Device,246.75,70,,246.75,percent of total billed charges,All Other,239.7,34,,239.7,percent of total billed charges,Implant Device,239.7,34,,239.7,percent of total billed charges,Implant Device,246.75,35,,246.75,percent of total billed charges,Implant Device,246.75,35,,246.75,percent of total billed charges,Implant Device,246.75,35,,246.75,percent of total billed charges,Implant Device,246.75,35,,246.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,521.7,
TIDES MEDICAL TAH1406 AMNIOHEAL 4X6CM,V2790,HCPCS,,79007073,CDM,278,RC,,,both,,,10493,7764.85,,,7764.85,Other,150% of Medicare + 9.63% HCRA Surcharge,4721.85,45,,4721.85,percent of total billed charges,Critical Access Hospital RCC factor,3567.62,34,,3567.62,percent of total billed charges,Implant Device,3567.62,34,,3567.62,percent of total billed charges,Implant Device,3567.62,34,,3567.62,percent of total billed charges,Implant Device,3567.62,34,,3567.62,percent of total billed charges,Implant Device,3567.62,34,,3567.62,percent of total billed charges,Implant Device,5194.04,,,5194.04,Other,110% of Medicare,3672.55,35,,3672.55,percent of total billed charges,Implant Device,3567.62,34,"Charges > $500, x 34%",3567.62,percent of total billed charges,Implant Device,3672.55,35,,3672.55,percent of total billed charges,Implant Device,3672.55,35,,3672.55,percent of total billed charges,Implant Device,3672.55,35,,3672.55,percent of total billed charges,Implant Device,3672.55,35,,3672.55,percent of total billed charges,Implant Device,3672.55,35,,3672.55,percent of total billed charges,Implant Device,4197.2,40,,4197.2,percent of total billed charges,Implant Device,3672.55,70,,3672.55,percent of total billed charges,All Other,3567.62,34,,3567.62,percent of total billed charges,Implant Device,3567.62,34,,3567.62,percent of total billed charges,Implant Device,3672.55,35,,3672.55,percent of total billed charges,Implant Device,3672.55,35,,3672.55,percent of total billed charges,Implant Device,3672.55,35,,3672.55,percent of total billed charges,Implant Device,3672.55,35,,3672.55,percent of total billed charges,Implant Device,976.07,,,976.07,Other,100% of Medicaid,976.07,,,976.07,Other,100% of Medicaid,976.07,,,976.07,Other,100% of Medicaid,976.07,,,976.07,Other,100% of Medicaid,2196.15,,,2196.15,Other,225% of Medicaid,1493.38,,,1493.38,Other,153% of Medicaid,2196.15,,,2196.15,Other,225% of Medicaid,1366.49,,,1366.49,Other,140% of Medicaid,3567.62,34,"If Charge > 2,000, then 34 percent",3567.62,percent of total billed charges,Implants,2537.77,,,2537.77,Other,260% of Medicaid,3162.45,,,3162.45,Other,324% of Medicaid,2098.54,,,2098.54,Other,215% of Medicaid,2098.54,,,2098.54,Other,215% of Medicaid,1220.08,,,1220.08,Other,125% of Medicaid,976.07,7764.85,
INTEGRA 206520 DURASEAL SEALANT,C1713,HCPCS,,79007074,CDM,278,RC,,,both,,,3770,2789.81,,,2789.81,Other,150% of Medicare + 9.63% HCRA Surcharge,1696.5,45,,1696.5,percent of total billed charges,Critical Access Hospital RCC factor,1281.8,34,,1281.8,percent of total billed charges,Implant Device,1281.8,34,,1281.8,percent of total billed charges,Implant Device,1281.8,34,,1281.8,percent of total billed charges,Implant Device,1281.8,34,,1281.8,percent of total billed charges,Implant Device,1281.8,34,,1281.8,percent of total billed charges,Implant Device,1866.15,,,1866.15,Other,110% of Medicare,1319.5,35,,1319.5,percent of total billed charges,Implant Device,1281.8,34,"Charges > $500, x 34%",1281.8,percent of total billed charges,Implant Device,1319.5,35,,1319.5,percent of total billed charges,Implant Device,1319.5,35,,1319.5,percent of total billed charges,Implant Device,1319.5,35,,1319.5,percent of total billed charges,Implant Device,1319.5,35,,1319.5,percent of total billed charges,Implant Device,1319.5,35,,1319.5,percent of total billed charges,Implant Device,1508,40,,1508,percent of total billed charges,Implant Device,1319.5,70,,1319.5,percent of total billed charges,All Other,1281.8,34,,1281.8,percent of total billed charges,Implant Device,1281.8,34,,1281.8,percent of total billed charges,Implant Device,1319.5,35,,1319.5,percent of total billed charges,Implant Device,1319.5,35,,1319.5,percent of total billed charges,Implant Device,1319.5,35,,1319.5,percent of total billed charges,Implant Device,1319.5,35,,1319.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1281.8,34,"If Charge > 2,000, then 34 percent",1281.8,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2789.81,
ZIMMER 00-5952-050-10 NEXGEN ART SURF 10,C1776,HCPCS,,79007075,CDM,278,RC,,,both,,,2672,1977.29,,,1977.29,Other,150% of Medicare + 9.63% HCRA Surcharge,1202.4,45,,1202.4,percent of total billed charges,Critical Access Hospital RCC factor,908.48,34,,908.48,percent of total billed charges,Implant Device,908.48,34,,908.48,percent of total billed charges,Implant Device,908.48,34,,908.48,percent of total billed charges,Implant Device,908.48,34,,908.48,percent of total billed charges,Implant Device,908.48,34,,908.48,percent of total billed charges,Implant Device,1322.64,,,1322.64,Other,110% of Medicare,935.2,35,,935.2,percent of total billed charges,Implant Device,908.48,34,"Charges > $500, x 34%",908.48,percent of total billed charges,Implant Device,935.2,35,,935.2,percent of total billed charges,Implant Device,935.2,35,,935.2,percent of total billed charges,Implant Device,935.2,35,,935.2,percent of total billed charges,Implant Device,935.2,35,,935.2,percent of total billed charges,Implant Device,935.2,35,,935.2,percent of total billed charges,Implant Device,1068.8,40,,1068.8,percent of total billed charges,Implant Device,935.2,70,,935.2,percent of total billed charges,All Other,908.48,34,,908.48,percent of total billed charges,Implant Device,908.48,34,,908.48,percent of total billed charges,Implant Device,935.2,35,,935.2,percent of total billed charges,Implant Device,935.2,35,,935.2,percent of total billed charges,Implant Device,935.2,35,,935.2,percent of total billed charges,Implant Device,935.2,35,,935.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,908.48,34,"If Charge > 2,000, then 34 percent",908.48,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1977.29,
DEPUY ORTHO TOTAL ATTUNE FB KNEE CAP,C1776,HCPCS,,79007076,CDM,278,RC,,,both,,,17334,12827.2,,,12827.2,Other,150% of Medicare + 9.63% HCRA Surcharge,7800.3,45,,7800.3,percent of total billed charges,Critical Access Hospital RCC factor,5893.56,34,,5893.56,percent of total billed charges,Implant Device,5893.56,34,,5893.56,percent of total billed charges,Implant Device,5893.56,34,,5893.56,percent of total billed charges,Implant Device,5893.56,34,,5893.56,percent of total billed charges,Implant Device,5893.56,34,,5893.56,percent of total billed charges,Implant Device,8580.33,,,8580.33,Other,110% of Medicare,6066.9,35,,6066.9,percent of total billed charges,Implant Device,5893.56,34,"Charges > $500, x 34%",5893.56,percent of total billed charges,Implant Device,6066.9,35,,6066.9,percent of total billed charges,Implant Device,6066.9,35,,6066.9,percent of total billed charges,Implant Device,6066.9,35,,6066.9,percent of total billed charges,Implant Device,6066.9,35,,6066.9,percent of total billed charges,Implant Device,6066.9,35,,6066.9,percent of total billed charges,Implant Device,6933.6,40,,6933.6,percent of total billed charges,Implant Device,6066.9,70,,6066.9,percent of total billed charges,All Other,5893.56,34,,5893.56,percent of total billed charges,Implant Device,5893.56,34,,5893.56,percent of total billed charges,Implant Device,6066.9,35,,6066.9,percent of total billed charges,Implant Device,6066.9,35,,6066.9,percent of total billed charges,Implant Device,6066.9,35,,6066.9,percent of total billed charges,Implant Device,6066.9,35,,6066.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,5893.56,34,"If Charge > 2,000, then 34 percent",5893.56,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,12827.2,
DEPUY 1221-36-456 ACETAB LINR +4 36X56MM,C1776,HCPCS,,79007077,CDM,278,RC,,,both,,,4743,3509.83,,,3509.83,Other,150% of Medicare + 9.63% HCRA Surcharge,2134.35,45,,2134.35,percent of total billed charges,Critical Access Hospital RCC factor,1612.62,34,,1612.62,percent of total billed charges,Implant Device,1612.62,34,,1612.62,percent of total billed charges,Implant Device,1612.62,34,,1612.62,percent of total billed charges,Implant Device,1612.62,34,,1612.62,percent of total billed charges,Implant Device,1612.62,34,,1612.62,percent of total billed charges,Implant Device,2347.79,,,2347.79,Other,110% of Medicare,1660.05,35,,1660.05,percent of total billed charges,Implant Device,1612.62,34,"Charges > $500, x 34%",1612.62,percent of total billed charges,Implant Device,1660.05,35,,1660.05,percent of total billed charges,Implant Device,1660.05,35,,1660.05,percent of total billed charges,Implant Device,1660.05,35,,1660.05,percent of total billed charges,Implant Device,1660.05,35,,1660.05,percent of total billed charges,Implant Device,1660.05,35,,1660.05,percent of total billed charges,Implant Device,1897.2,40,,1897.2,percent of total billed charges,Implant Device,1660.05,70,,1660.05,percent of total billed charges,All Other,1612.62,34,,1612.62,percent of total billed charges,Implant Device,1612.62,34,,1612.62,percent of total billed charges,Implant Device,1660.05,35,,1660.05,percent of total billed charges,Implant Device,1660.05,35,,1660.05,percent of total billed charges,Implant Device,1660.05,35,,1660.05,percent of total billed charges,Implant Device,1660.05,35,,1660.05,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1612.62,34,"If Charge > 2,000, then 34 percent",1612.62,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3509.83,
GORE RLT311415 EXCLUDER ENDOPROS GRAFT,C1768,HCPCS,,79007078,CDM,278,RC,,,both,,,32250,23865.08,,,23865.08,Other,150% of Medicare + 9.63% HCRA Surcharge,14512.5,45,,14512.5,percent of total billed charges,Critical Access Hospital RCC factor,10965,34,,10965,percent of total billed charges,Implant Device,10965,34,,10965,percent of total billed charges,Implant Device,10965,34,,10965,percent of total billed charges,Implant Device,10965,34,,10965,percent of total billed charges,Implant Device,10965,34,,10965,percent of total billed charges,Implant Device,15963.75,,,15963.75,Other,110% of Medicare,11287.5,35,,11287.5,percent of total billed charges,Implant Device,10965,34,"Charges > $500, x 34%",10965,percent of total billed charges,Implant Device,11287.5,35,,11287.5,percent of total billed charges,Implant Device,11287.5,35,,11287.5,percent of total billed charges,Implant Device,11287.5,35,,11287.5,percent of total billed charges,Implant Device,11287.5,35,,11287.5,percent of total billed charges,Implant Device,11287.5,35,,11287.5,percent of total billed charges,Implant Device,12900,40,,12900,percent of total billed charges,Implant Device,11287.5,70,,11287.5,percent of total billed charges,All Other,10965,34,,10965,percent of total billed charges,Implant Device,10965,34,,10965,percent of total billed charges,Implant Device,11287.5,35,,11287.5,percent of total billed charges,Implant Device,11287.5,35,,11287.5,percent of total billed charges,Implant Device,11287.5,35,,11287.5,percent of total billed charges,Implant Device,11287.5,35,,11287.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,10965,34,"If Charge > 2,000, then 34 percent",10965,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,23865.08,
DEPUY 456.318S CANN FIX NAIL 11X170MM,C1713,HCPCS,,79007083,CDM,278,RC,,,both,,,2738,2026.13,,,2026.13,Other,150% of Medicare + 9.63% HCRA Surcharge,1232.1,45,,1232.1,percent of total billed charges,Critical Access Hospital RCC factor,930.92,34,,930.92,percent of total billed charges,Implant Device,930.92,34,,930.92,percent of total billed charges,Implant Device,930.92,34,,930.92,percent of total billed charges,Implant Device,930.92,34,,930.92,percent of total billed charges,Implant Device,930.92,34,,930.92,percent of total billed charges,Implant Device,1355.31,,,1355.31,Other,110% of Medicare,958.3,35,,958.3,percent of total billed charges,Implant Device,930.92,34,"Charges > $500, x 34%",930.92,percent of total billed charges,Implant Device,958.3,35,,958.3,percent of total billed charges,Implant Device,958.3,35,,958.3,percent of total billed charges,Implant Device,958.3,35,,958.3,percent of total billed charges,Implant Device,958.3,35,,958.3,percent of total billed charges,Implant Device,958.3,35,,958.3,percent of total billed charges,Implant Device,1095.2,40,,1095.2,percent of total billed charges,Implant Device,958.3,70,,958.3,percent of total billed charges,All Other,930.92,34,,930.92,percent of total billed charges,Implant Device,930.92,34,,930.92,percent of total billed charges,Implant Device,958.3,35,,958.3,percent of total billed charges,Implant Device,958.3,35,,958.3,percent of total billed charges,Implant Device,958.3,35,,958.3,percent of total billed charges,Implant Device,958.3,35,,958.3,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,930.92,34,"If Charge > 2,000, then 34 percent",930.92,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2026.13,
DEPUY 458.932S LOCKING SCREW 5X32MM,C1713,HCPCS,,79007084,CDM,278,RC,,,both,,,888,657.12,,,657.12,Other,150% of Medicare + 9.63% HCRA Surcharge,399.6,45,,399.6,percent of total billed charges,Critical Access Hospital RCC factor,301.92,34,,301.92,percent of total billed charges,Implant Device,301.92,34,,301.92,percent of total billed charges,Implant Device,301.92,34,,301.92,percent of total billed charges,Implant Device,301.92,34,,301.92,percent of total billed charges,Implant Device,301.92,34,,301.92,percent of total billed charges,Implant Device,439.56,,,439.56,Other,110% of Medicare,310.8,35,,310.8,percent of total billed charges,Implant Device,301.92,34,"Charges > $500, x 34%",301.92,percent of total billed charges,Implant Device,310.8,35,,310.8,percent of total billed charges,Implant Device,310.8,35,,310.8,percent of total billed charges,Implant Device,310.8,35,,310.8,percent of total billed charges,Implant Device,310.8,35,,310.8,percent of total billed charges,Implant Device,310.8,35,,310.8,percent of total billed charges,Implant Device,355.2,40,,355.2,percent of total billed charges,Implant Device,310.8,70,,310.8,percent of total billed charges,All Other,301.92,34,,301.92,percent of total billed charges,Implant Device,301.92,34,,301.92,percent of total billed charges,Implant Device,310.8,35,,310.8,percent of total billed charges,Implant Device,310.8,35,,310.8,percent of total billed charges,Implant Device,310.8,35,,310.8,percent of total billed charges,Implant Device,310.8,35,,310.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,657.12,
DEPUY 459.934S LOCKING SCREW 5X34MM,C1713,HCPCS,,79007085,CDM,278,RC,,,both,,,767,567.58,,,567.58,Other,150% of Medicare + 9.63% HCRA Surcharge,345.15,45,,345.15,percent of total billed charges,Critical Access Hospital RCC factor,260.78,34,,260.78,percent of total billed charges,Implant Device,260.78,34,,260.78,percent of total billed charges,Implant Device,260.78,34,,260.78,percent of total billed charges,Implant Device,260.78,34,,260.78,percent of total billed charges,Implant Device,260.78,34,,260.78,percent of total billed charges,Implant Device,379.67,,,379.67,Other,110% of Medicare,268.45,35,,268.45,percent of total billed charges,Implant Device,260.78,34,"Charges > $500, x 34%",260.78,percent of total billed charges,Implant Device,268.45,35,,268.45,percent of total billed charges,Implant Device,268.45,35,,268.45,percent of total billed charges,Implant Device,268.45,35,,268.45,percent of total billed charges,Implant Device,268.45,35,,268.45,percent of total billed charges,Implant Device,268.45,35,,268.45,percent of total billed charges,Implant Device,306.8,40,,306.8,percent of total billed charges,Implant Device,268.45,70,,268.45,percent of total billed charges,All Other,260.78,34,,260.78,percent of total billed charges,Implant Device,260.78,34,,260.78,percent of total billed charges,Implant Device,268.45,35,,268.45,percent of total billed charges,Implant Device,268.45,35,,268.45,percent of total billed charges,Implant Device,268.45,35,,268.45,percent of total billed charges,Implant Device,268.45,35,,268.45,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,567.58,
TELEFLEX KM-71612 STEIN PIN 9/64 3.5MM,C1713,HCPCS,,79007087,CDM,278,RC,,,both,,,23,17.02,,,17.02,Other,150% of Medicare + 9.63% HCRA Surcharge,10.35,45,,10.35,percent of total billed charges,Critical Access Hospital RCC factor,7.82,34,,7.82,percent of total billed charges,Implant Device,7.82,34,,7.82,percent of total billed charges,Implant Device,7.82,34,,7.82,percent of total billed charges,Implant Device,7.82,34,,7.82,percent of total billed charges,Implant Device,7.82,34,,7.82,percent of total billed charges,Implant Device,11.39,,,11.39,Other,110% of Medicare,8.05,35,,8.05,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,8.05,35,,8.05,percent of total billed charges,Implant Device,8.05,35,,8.05,percent of total billed charges,Implant Device,8.05,35,,8.05,percent of total billed charges,Implant Device,8.05,35,,8.05,percent of total billed charges,Implant Device,8.05,35,,8.05,percent of total billed charges,Implant Device,9.2,40,,9.2,percent of total billed charges,Implant Device,8.05,70,,8.05,percent of total billed charges,All Other,7.82,34,,7.82,percent of total billed charges,Implant Device,7.82,34,,7.82,percent of total billed charges,Implant Device,8.05,35,,8.05,percent of total billed charges,Implant Device,8.05,35,,8.05,percent of total billed charges,Implant Device,8.05,35,,8.05,percent of total billed charges,Implant Device,8.05,35,,8.05,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,17.02,
TELEFLEX KM-71615 STEIN PIN 5/32 4.0MM,C1713,HCPCS,,79007088,CDM,278,RC,,,both,,,24,17.76,,,17.76,Other,150% of Medicare + 9.63% HCRA Surcharge,10.8,45,,10.8,percent of total billed charges,Critical Access Hospital RCC factor,8.16,34,,8.16,percent of total billed charges,Implant Device,8.16,34,,8.16,percent of total billed charges,Implant Device,8.16,34,,8.16,percent of total billed charges,Implant Device,8.16,34,,8.16,percent of total billed charges,Implant Device,8.16,34,,8.16,percent of total billed charges,Implant Device,11.88,,,11.88,Other,110% of Medicare,8.4,35,,8.4,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,8.4,35,,8.4,percent of total billed charges,Implant Device,8.4,35,,8.4,percent of total billed charges,Implant Device,8.4,35,,8.4,percent of total billed charges,Implant Device,8.4,35,,8.4,percent of total billed charges,Implant Device,8.4,35,,8.4,percent of total billed charges,Implant Device,9.6,40,,9.6,percent of total billed charges,Implant Device,8.4,70,,8.4,percent of total billed charges,All Other,8.16,34,,8.16,percent of total billed charges,Implant Device,8.16,34,,8.16,percent of total billed charges,Implant Device,8.4,35,,8.4,percent of total billed charges,Implant Device,8.4,35,,8.4,percent of total billed charges,Implant Device,8.4,35,,8.4,percent of total billed charges,Implant Device,8.4,35,,8.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,17.76,
DEPUY 456.477S 130DEG CAN NAIL 12X360MM,C1713,HCPCS,,79007090,CDM,278,RC,,,both,,,6225,4606.52,,,4606.52,Other,150% of Medicare + 9.63% HCRA Surcharge,2801.25,45,,2801.25,percent of total billed charges,Critical Access Hospital RCC factor,2116.5,34,,2116.5,percent of total billed charges,Implant Device,2116.5,34,,2116.5,percent of total billed charges,Implant Device,2116.5,34,,2116.5,percent of total billed charges,Implant Device,2116.5,34,,2116.5,percent of total billed charges,Implant Device,2116.5,34,,2116.5,percent of total billed charges,Implant Device,3081.38,,,3081.38,Other,110% of Medicare,2178.75,35,,2178.75,percent of total billed charges,Implant Device,2116.5,34,"Charges > $500, x 34%",2116.5,percent of total billed charges,Implant Device,2178.75,35,,2178.75,percent of total billed charges,Implant Device,2178.75,35,,2178.75,percent of total billed charges,Implant Device,2178.75,35,,2178.75,percent of total billed charges,Implant Device,2178.75,35,,2178.75,percent of total billed charges,Implant Device,2178.75,35,,2178.75,percent of total billed charges,Implant Device,2490,40,,2490,percent of total billed charges,Implant Device,2178.75,70,,2178.75,percent of total billed charges,All Other,2116.5,34,,2116.5,percent of total billed charges,Implant Device,2116.5,34,,2116.5,percent of total billed charges,Implant Device,2178.75,35,,2178.75,percent of total billed charges,Implant Device,2178.75,35,,2178.75,percent of total billed charges,Implant Device,2178.75,35,,2178.75,percent of total billed charges,Implant Device,2178.75,35,,2178.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2116.5,34,"If Charge > 2,000, then 34 percent",2116.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4606.52,
DEPUY 04.032.100S TI NAIL SCREW 11X100MM,C1713,HCPCS,,79007091,CDM,278,RC,,,both,,,2197,1625.79,,,1625.79,Other,150% of Medicare + 9.63% HCRA Surcharge,988.65,45,,988.65,percent of total billed charges,Critical Access Hospital RCC factor,746.98,34,,746.98,percent of total billed charges,Implant Device,746.98,34,,746.98,percent of total billed charges,Implant Device,746.98,34,,746.98,percent of total billed charges,Implant Device,746.98,34,,746.98,percent of total billed charges,Implant Device,746.98,34,,746.98,percent of total billed charges,Implant Device,1087.52,,,1087.52,Other,110% of Medicare,768.95,35,,768.95,percent of total billed charges,Implant Device,746.98,34,"Charges > $500, x 34%",746.98,percent of total billed charges,Implant Device,768.95,35,,768.95,percent of total billed charges,Implant Device,768.95,35,,768.95,percent of total billed charges,Implant Device,768.95,35,,768.95,percent of total billed charges,Implant Device,768.95,35,,768.95,percent of total billed charges,Implant Device,768.95,35,,768.95,percent of total billed charges,Implant Device,878.8,40,,878.8,percent of total billed charges,Implant Device,768.95,70,,768.95,percent of total billed charges,All Other,746.98,34,,746.98,percent of total billed charges,Implant Device,746.98,34,,746.98,percent of total billed charges,Implant Device,768.95,35,,768.95,percent of total billed charges,Implant Device,768.95,35,,768.95,percent of total billed charges,Implant Device,768.95,35,,768.95,percent of total billed charges,Implant Device,768.95,35,,768.95,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,746.98,34,"If Charge > 2,000, then 34 percent",746.98,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1625.79,
DEPUY 458.944S LOCKING SCREW 5X44MM,C1713,HCPCS,,79007092,CDM,278,RC,,,both,,,888,657.12,,,657.12,Other,150% of Medicare + 9.63% HCRA Surcharge,399.6,45,,399.6,percent of total billed charges,Critical Access Hospital RCC factor,301.92,34,,301.92,percent of total billed charges,Implant Device,301.92,34,,301.92,percent of total billed charges,Implant Device,301.92,34,,301.92,percent of total billed charges,Implant Device,301.92,34,,301.92,percent of total billed charges,Implant Device,301.92,34,,301.92,percent of total billed charges,Implant Device,439.56,,,439.56,Other,110% of Medicare,310.8,35,,310.8,percent of total billed charges,Implant Device,301.92,34,"Charges > $500, x 34%",301.92,percent of total billed charges,Implant Device,310.8,35,,310.8,percent of total billed charges,Implant Device,310.8,35,,310.8,percent of total billed charges,Implant Device,310.8,35,,310.8,percent of total billed charges,Implant Device,310.8,35,,310.8,percent of total billed charges,Implant Device,310.8,35,,310.8,percent of total billed charges,Implant Device,355.2,40,,355.2,percent of total billed charges,Implant Device,310.8,70,,310.8,percent of total billed charges,All Other,301.92,34,,301.92,percent of total billed charges,Implant Device,301.92,34,,301.92,percent of total billed charges,Implant Device,310.8,35,,310.8,percent of total billed charges,Implant Device,310.8,35,,310.8,percent of total billed charges,Implant Device,310.8,35,,310.8,percent of total billed charges,Implant Device,310.8,35,,310.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,657.12,
DEPUY 458.940S LOCKING SCREW 5X40MM,C1713,HCPCS,,79007093,CDM,278,RC,,,both,,,959,709.66,,,709.66,Other,150% of Medicare + 9.63% HCRA Surcharge,431.55,45,,431.55,percent of total billed charges,Critical Access Hospital RCC factor,326.06,34,,326.06,percent of total billed charges,Implant Device,326.06,34,,326.06,percent of total billed charges,Implant Device,326.06,34,,326.06,percent of total billed charges,Implant Device,326.06,34,,326.06,percent of total billed charges,Implant Device,326.06,34,,326.06,percent of total billed charges,Implant Device,474.71,,,474.71,Other,110% of Medicare,335.65,35,,335.65,percent of total billed charges,Implant Device,326.06,34,"Charges > $500, x 34%",326.06,percent of total billed charges,Implant Device,335.65,35,,335.65,percent of total billed charges,Implant Device,335.65,35,,335.65,percent of total billed charges,Implant Device,335.65,35,,335.65,percent of total billed charges,Implant Device,335.65,35,,335.65,percent of total billed charges,Implant Device,335.65,35,,335.65,percent of total billed charges,Implant Device,383.6,40,,383.6,percent of total billed charges,Implant Device,335.65,70,,335.65,percent of total billed charges,All Other,326.06,34,,326.06,percent of total billed charges,Implant Device,326.06,34,,326.06,percent of total billed charges,Implant Device,335.65,35,,335.65,percent of total billed charges,Implant Device,335.65,35,,335.65,percent of total billed charges,Implant Device,335.65,35,,335.65,percent of total billed charges,Implant Device,335.65,35,,335.65,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,709.66,
ZIMMER 00-1147-046-40 CANN SCREW 4X46MM,C1713,HCPCS,,79007095,CDM,278,RC,,,both,,,605,447.7,,,447.7,Other,150% of Medicare + 9.63% HCRA Surcharge,272.25,45,,272.25,percent of total billed charges,Critical Access Hospital RCC factor,205.7,34,,205.7,percent of total billed charges,Implant Device,205.7,34,,205.7,percent of total billed charges,Implant Device,205.7,34,,205.7,percent of total billed charges,Implant Device,205.7,34,,205.7,percent of total billed charges,Implant Device,205.7,34,,205.7,percent of total billed charges,Implant Device,299.48,,,299.48,Other,110% of Medicare,211.75,35,,211.75,percent of total billed charges,Implant Device,205.7,34,"Charges > $500, x 34%",205.7,percent of total billed charges,Implant Device,211.75,35,,211.75,percent of total billed charges,Implant Device,211.75,35,,211.75,percent of total billed charges,Implant Device,211.75,35,,211.75,percent of total billed charges,Implant Device,211.75,35,,211.75,percent of total billed charges,Implant Device,211.75,35,,211.75,percent of total billed charges,Implant Device,242,40,,242,percent of total billed charges,Implant Device,211.75,70,,211.75,percent of total billed charges,All Other,205.7,34,,205.7,percent of total billed charges,Implant Device,205.7,34,,205.7,percent of total billed charges,Implant Device,211.75,35,,211.75,percent of total billed charges,Implant Device,211.75,35,,211.75,percent of total billed charges,Implant Device,211.75,35,,211.75,percent of total billed charges,Implant Device,211.75,35,,211.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,447.7,
EXACTECH SPK0222 INTERSPACE KNEE SPACER,C1776,HCPCS,,79007096,CDM,278,RC,,,both,,,8505,6293.72,,,6293.72,Other,150% of Medicare + 9.63% HCRA Surcharge,3827.25,45,,3827.25,percent of total billed charges,Critical Access Hospital RCC factor,2891.7,34,,2891.7,percent of total billed charges,Implant Device,2891.7,34,,2891.7,percent of total billed charges,Implant Device,2891.7,34,,2891.7,percent of total billed charges,Implant Device,2891.7,34,,2891.7,percent of total billed charges,Implant Device,2891.7,34,,2891.7,percent of total billed charges,Implant Device,4209.98,,,4209.98,Other,110% of Medicare,2976.75,35,,2976.75,percent of total billed charges,Implant Device,2891.7,34,"Charges > $500, x 34%",2891.7,percent of total billed charges,Implant Device,2976.75,35,,2976.75,percent of total billed charges,Implant Device,2976.75,35,,2976.75,percent of total billed charges,Implant Device,2976.75,35,,2976.75,percent of total billed charges,Implant Device,2976.75,35,,2976.75,percent of total billed charges,Implant Device,2976.75,35,,2976.75,percent of total billed charges,Implant Device,3402,40,,3402,percent of total billed charges,Implant Device,2976.75,70,,2976.75,percent of total billed charges,All Other,2891.7,34,,2891.7,percent of total billed charges,Implant Device,2891.7,34,,2891.7,percent of total billed charges,Implant Device,2976.75,35,,2976.75,percent of total billed charges,Implant Device,2976.75,35,,2976.75,percent of total billed charges,Implant Device,2976.75,35,,2976.75,percent of total billed charges,Implant Device,2976.75,35,,2976.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2891.7,34,"If Charge > 2,000, then 34 percent",2891.7,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,6293.72,
DEPUY 04.032.095S 11X95MM TI NAIL SCREW,C1713,HCPCS,,79007097,CDM,278,RC,,,both,,,2197,1625.79,,,1625.79,Other,150% of Medicare + 9.63% HCRA Surcharge,988.65,45,,988.65,percent of total billed charges,Critical Access Hospital RCC factor,746.98,34,,746.98,percent of total billed charges,Implant Device,746.98,34,,746.98,percent of total billed charges,Implant Device,746.98,34,,746.98,percent of total billed charges,Implant Device,746.98,34,,746.98,percent of total billed charges,Implant Device,746.98,34,,746.98,percent of total billed charges,Implant Device,1087.52,,,1087.52,Other,110% of Medicare,768.95,35,,768.95,percent of total billed charges,Implant Device,746.98,34,"Charges > $500, x 34%",746.98,percent of total billed charges,Implant Device,768.95,35,,768.95,percent of total billed charges,Implant Device,768.95,35,,768.95,percent of total billed charges,Implant Device,768.95,35,,768.95,percent of total billed charges,Implant Device,768.95,35,,768.95,percent of total billed charges,Implant Device,768.95,35,,768.95,percent of total billed charges,Implant Device,878.8,40,,878.8,percent of total billed charges,Implant Device,768.95,70,,768.95,percent of total billed charges,All Other,746.98,34,,746.98,percent of total billed charges,Implant Device,746.98,34,,746.98,percent of total billed charges,Implant Device,768.95,35,,768.95,percent of total billed charges,Implant Device,768.95,35,,768.95,percent of total billed charges,Implant Device,768.95,35,,768.95,percent of total billed charges,Implant Device,768.95,35,,768.95,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,746.98,34,"If Charge > 2,000, then 34 percent",746.98,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1625.79,
DEPUY 456.325S CAN FIX NAIL 10X235MM,C1713,HCPCS,,79007098,CDM,278,RC,,,both,,,5795,4288.31,,,4288.31,Other,150% of Medicare + 9.63% HCRA Surcharge,2607.75,45,,2607.75,percent of total billed charges,Critical Access Hospital RCC factor,1970.3,34,,1970.3,percent of total billed charges,Implant Device,1970.3,34,,1970.3,percent of total billed charges,Implant Device,1970.3,34,,1970.3,percent of total billed charges,Implant Device,1970.3,34,,1970.3,percent of total billed charges,Implant Device,1970.3,34,,1970.3,percent of total billed charges,Implant Device,2868.53,,,2868.53,Other,110% of Medicare,2028.25,35,,2028.25,percent of total billed charges,Implant Device,1970.3,34,"Charges > $500, x 34%",1970.3,percent of total billed charges,Implant Device,2028.25,35,,2028.25,percent of total billed charges,Implant Device,2028.25,35,,2028.25,percent of total billed charges,Implant Device,2028.25,35,,2028.25,percent of total billed charges,Implant Device,2028.25,35,,2028.25,percent of total billed charges,Implant Device,2028.25,35,,2028.25,percent of total billed charges,Implant Device,2318,40,,2318,percent of total billed charges,Implant Device,2028.25,70,,2028.25,percent of total billed charges,All Other,1970.3,34,,1970.3,percent of total billed charges,Implant Device,1970.3,34,,1970.3,percent of total billed charges,Implant Device,2028.25,35,,2028.25,percent of total billed charges,Implant Device,2028.25,35,,2028.25,percent of total billed charges,Implant Device,2028.25,35,,2028.25,percent of total billed charges,Implant Device,2028.25,35,,2028.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1970.3,34,"If Charge > 2,000, then 34 percent",1970.3,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4288.31,
WRIGHT CCP-MPNIL CROSSCHECK PLATE,C1713,HCPCS,,79007100,CDM,278,RC,,,both,,,6708,4963.94,,,4963.94,Other,150% of Medicare + 9.63% HCRA Surcharge,3018.6,45,,3018.6,percent of total billed charges,Critical Access Hospital RCC factor,2280.72,34,,2280.72,percent of total billed charges,Implant Device,2280.72,34,,2280.72,percent of total billed charges,Implant Device,2280.72,34,,2280.72,percent of total billed charges,Implant Device,2280.72,34,,2280.72,percent of total billed charges,Implant Device,2280.72,34,,2280.72,percent of total billed charges,Implant Device,3320.46,,,3320.46,Other,110% of Medicare,2347.8,35,,2347.8,percent of total billed charges,Implant Device,2280.72,34,"Charges > $500, x 34%",2280.72,percent of total billed charges,Implant Device,2347.8,35,,2347.8,percent of total billed charges,Implant Device,2347.8,35,,2347.8,percent of total billed charges,Implant Device,2347.8,35,,2347.8,percent of total billed charges,Implant Device,2347.8,35,,2347.8,percent of total billed charges,Implant Device,2347.8,35,,2347.8,percent of total billed charges,Implant Device,2683.2,40,,2683.2,percent of total billed charges,Implant Device,2347.8,70,,2347.8,percent of total billed charges,All Other,2280.72,34,,2280.72,percent of total billed charges,Implant Device,2280.72,34,,2280.72,percent of total billed charges,Implant Device,2347.8,35,,2347.8,percent of total billed charges,Implant Device,2347.8,35,,2347.8,percent of total billed charges,Implant Device,2347.8,35,,2347.8,percent of total billed charges,Implant Device,2347.8,35,,2347.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2280.72,34,"If Charge > 2,000, then 34 percent",2280.72,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4963.94,
WRIGHT CCP-X3518 LAG SCREW 3.5X18MM,C1713,HCPCS,,79007101,CDM,278,RC,,,both,,,1125,832.5,,,832.5,Other,150% of Medicare + 9.63% HCRA Surcharge,506.25,45,,506.25,percent of total billed charges,Critical Access Hospital RCC factor,382.5,34,,382.5,percent of total billed charges,Implant Device,382.5,34,,382.5,percent of total billed charges,Implant Device,382.5,34,,382.5,percent of total billed charges,Implant Device,382.5,34,,382.5,percent of total billed charges,Implant Device,382.5,34,,382.5,percent of total billed charges,Implant Device,556.88,,,556.88,Other,110% of Medicare,393.75,35,,393.75,percent of total billed charges,Implant Device,382.5,34,"Charges > $500, x 34%",382.5,percent of total billed charges,Implant Device,393.75,35,,393.75,percent of total billed charges,Implant Device,393.75,35,,393.75,percent of total billed charges,Implant Device,393.75,35,,393.75,percent of total billed charges,Implant Device,393.75,35,,393.75,percent of total billed charges,Implant Device,393.75,35,,393.75,percent of total billed charges,Implant Device,450,40,,450,percent of total billed charges,Implant Device,393.75,70,,393.75,percent of total billed charges,All Other,382.5,34,,382.5,percent of total billed charges,Implant Device,382.5,34,,382.5,percent of total billed charges,Implant Device,393.75,35,,393.75,percent of total billed charges,Implant Device,393.75,35,,393.75,percent of total billed charges,Implant Device,393.75,35,,393.75,percent of total billed charges,Implant Device,393.75,35,,393.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,832.5,
STRYKER 3325-0300S LONG NAIL 11X300MM,C1713,HCPCS,,79007102,CDM,278,RC,,,both,,,8221,6083.56,,,6083.56,Other,150% of Medicare + 9.63% HCRA Surcharge,3699.45,45,,3699.45,percent of total billed charges,Critical Access Hospital RCC factor,2795.14,34,,2795.14,percent of total billed charges,Implant Device,2795.14,34,,2795.14,percent of total billed charges,Implant Device,2795.14,34,,2795.14,percent of total billed charges,Implant Device,2795.14,34,,2795.14,percent of total billed charges,Implant Device,2795.14,34,,2795.14,percent of total billed charges,Implant Device,4069.4,,,4069.4,Other,110% of Medicare,2877.35,35,,2877.35,percent of total billed charges,Implant Device,2795.14,34,"Charges > $500, x 34%",2795.14,percent of total billed charges,Implant Device,2877.35,35,,2877.35,percent of total billed charges,Implant Device,2877.35,35,,2877.35,percent of total billed charges,Implant Device,2877.35,35,,2877.35,percent of total billed charges,Implant Device,2877.35,35,,2877.35,percent of total billed charges,Implant Device,2877.35,35,,2877.35,percent of total billed charges,Implant Device,3288.4,40,,3288.4,percent of total billed charges,Implant Device,2877.35,70,,2877.35,percent of total billed charges,All Other,2795.14,34,,2795.14,percent of total billed charges,Implant Device,2795.14,34,,2795.14,percent of total billed charges,Implant Device,2877.35,35,,2877.35,percent of total billed charges,Implant Device,2877.35,35,,2877.35,percent of total billed charges,Implant Device,2877.35,35,,2877.35,percent of total billed charges,Implant Device,2877.35,35,,2877.35,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2795.14,34,"If Charge > 2,000, then 34 percent",2795.14,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,6083.56,
ARTHREX AR-8916VSR-03 STD PLATE RT 3HOLE,C1713,HCPCS,,79007103,CDM,278,RC,,,both,,,3408,2521.93,,,2521.93,Other,150% of Medicare + 9.63% HCRA Surcharge,1533.6,45,,1533.6,percent of total billed charges,Critical Access Hospital RCC factor,1158.72,34,,1158.72,percent of total billed charges,Implant Device,1158.72,34,,1158.72,percent of total billed charges,Implant Device,1158.72,34,,1158.72,percent of total billed charges,Implant Device,1158.72,34,,1158.72,percent of total billed charges,Implant Device,1158.72,34,,1158.72,percent of total billed charges,Implant Device,1686.96,,,1686.96,Other,110% of Medicare,1192.8,35,,1192.8,percent of total billed charges,Implant Device,1158.72,34,"Charges > $500, x 34%",1158.72,percent of total billed charges,Implant Device,1192.8,35,,1192.8,percent of total billed charges,Implant Device,1192.8,35,,1192.8,percent of total billed charges,Implant Device,1192.8,35,,1192.8,percent of total billed charges,Implant Device,1192.8,35,,1192.8,percent of total billed charges,Implant Device,1192.8,35,,1192.8,percent of total billed charges,Implant Device,1363.2,40,,1363.2,percent of total billed charges,Implant Device,1192.8,70,,1192.8,percent of total billed charges,All Other,1158.72,34,,1158.72,percent of total billed charges,Implant Device,1158.72,34,,1158.72,percent of total billed charges,Implant Device,1192.8,35,,1192.8,percent of total billed charges,Implant Device,1192.8,35,,1192.8,percent of total billed charges,Implant Device,1192.8,35,,1192.8,percent of total billed charges,Implant Device,1192.8,35,,1192.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1158.72,34,"If Charge > 2,000, then 34 percent",1158.72,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2521.93,
ARTHREX AR-8724V-20 LOCK SCREW 2.4X20MM,C1713,HCPCS,,79007104,CDM,278,RC,,,both,,,420,310.8,,,310.8,Other,150% of Medicare + 9.63% HCRA Surcharge,189,45,,189,percent of total billed charges,Critical Access Hospital RCC factor,142.8,34,,142.8,percent of total billed charges,Implant Device,142.8,34,,142.8,percent of total billed charges,Implant Device,142.8,34,,142.8,percent of total billed charges,Implant Device,142.8,34,,142.8,percent of total billed charges,Implant Device,142.8,34,,142.8,percent of total billed charges,Implant Device,207.9,,,207.9,Other,110% of Medicare,147,35,,147,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,147,35,,147,percent of total billed charges,Implant Device,147,35,,147,percent of total billed charges,Implant Device,147,35,,147,percent of total billed charges,Implant Device,147,35,,147,percent of total billed charges,Implant Device,147,35,,147,percent of total billed charges,Implant Device,168,40,,168,percent of total billed charges,Implant Device,147,70,,147,percent of total billed charges,All Other,142.8,34,,142.8,percent of total billed charges,Implant Device,142.8,34,,142.8,percent of total billed charges,Implant Device,147,35,,147,percent of total billed charges,Implant Device,147,35,,147,percent of total billed charges,Implant Device,147,35,,147,percent of total billed charges,Implant Device,147,35,,147,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,310.8,
ARTHREX AR-8724V-22 LOCK SCREW 2.4X22MM,C1713,HCPCS,,79007105,CDM,278,RC,,,both,,,420,310.8,,,310.8,Other,150% of Medicare + 9.63% HCRA Surcharge,189,45,,189,percent of total billed charges,Critical Access Hospital RCC factor,142.8,34,,142.8,percent of total billed charges,Implant Device,142.8,34,,142.8,percent of total billed charges,Implant Device,142.8,34,,142.8,percent of total billed charges,Implant Device,142.8,34,,142.8,percent of total billed charges,Implant Device,142.8,34,,142.8,percent of total billed charges,Implant Device,207.9,,,207.9,Other,110% of Medicare,147,35,,147,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,147,35,,147,percent of total billed charges,Implant Device,147,35,,147,percent of total billed charges,Implant Device,147,35,,147,percent of total billed charges,Implant Device,147,35,,147,percent of total billed charges,Implant Device,147,35,,147,percent of total billed charges,Implant Device,168,40,,168,percent of total billed charges,Implant Device,147,70,,147,percent of total billed charges,All Other,142.8,34,,142.8,percent of total billed charges,Implant Device,142.8,34,,142.8,percent of total billed charges,Implant Device,147,35,,147,percent of total billed charges,Implant Device,147,35,,147,percent of total billed charges,Implant Device,147,35,,147,percent of total billed charges,Implant Device,147,35,,147,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,310.8,
STRYKER 54-25673 VOLAR PLATE SHORT LEFT,C1713,HCPCS,,79007106,CDM,278,RC,,,both,,,2834,2097.17,,,2097.17,Other,150% of Medicare + 9.63% HCRA Surcharge,1275.3,45,,1275.3,percent of total billed charges,Critical Access Hospital RCC factor,963.56,34,,963.56,percent of total billed charges,Implant Device,963.56,34,,963.56,percent of total billed charges,Implant Device,963.56,34,,963.56,percent of total billed charges,Implant Device,963.56,34,,963.56,percent of total billed charges,Implant Device,963.56,34,,963.56,percent of total billed charges,Implant Device,1402.83,,,1402.83,Other,110% of Medicare,991.9,35,,991.9,percent of total billed charges,Implant Device,963.56,34,"Charges > $500, x 34%",963.56,percent of total billed charges,Implant Device,991.9,35,,991.9,percent of total billed charges,Implant Device,991.9,35,,991.9,percent of total billed charges,Implant Device,991.9,35,,991.9,percent of total billed charges,Implant Device,991.9,35,,991.9,percent of total billed charges,Implant Device,991.9,35,,991.9,percent of total billed charges,Implant Device,1133.6,40,,1133.6,percent of total billed charges,Implant Device,991.9,70,,991.9,percent of total billed charges,All Other,963.56,34,,963.56,percent of total billed charges,Implant Device,963.56,34,,963.56,percent of total billed charges,Implant Device,991.9,35,,991.9,percent of total billed charges,Implant Device,991.9,35,,991.9,percent of total billed charges,Implant Device,991.9,35,,991.9,percent of total billed charges,Implant Device,991.9,35,,991.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,963.56,34,"If Charge > 2,000, then 34 percent",963.56,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2097.17,
STRYKER 656414 NON LOCK SCREW 2.7X14MM,C1713,HCPCS,,79007107,CDM,278,RC,,,both,,,282,208.68,,,208.68,Other,150% of Medicare + 9.63% HCRA Surcharge,126.9,45,,126.9,percent of total billed charges,Critical Access Hospital RCC factor,95.88,34,,95.88,percent of total billed charges,Implant Device,95.88,34,,95.88,percent of total billed charges,Implant Device,95.88,34,,95.88,percent of total billed charges,Implant Device,95.88,34,,95.88,percent of total billed charges,Implant Device,95.88,34,,95.88,percent of total billed charges,Implant Device,139.59,,,139.59,Other,110% of Medicare,98.7,35,,98.7,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,98.7,35,,98.7,percent of total billed charges,Implant Device,98.7,35,,98.7,percent of total billed charges,Implant Device,98.7,35,,98.7,percent of total billed charges,Implant Device,98.7,35,,98.7,percent of total billed charges,Implant Device,98.7,35,,98.7,percent of total billed charges,Implant Device,112.8,40,,112.8,percent of total billed charges,Implant Device,98.7,70,,98.7,percent of total billed charges,All Other,95.88,34,,95.88,percent of total billed charges,Implant Device,95.88,34,,95.88,percent of total billed charges,Implant Device,98.7,35,,98.7,percent of total billed charges,Implant Device,98.7,35,,98.7,percent of total billed charges,Implant Device,98.7,35,,98.7,percent of total billed charges,Implant Device,98.7,35,,98.7,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,208.68,
STRYKER 656018 LOCKING SCREW 2.4X18MM,C1713,HCPCS,,79007108,CDM,278,RC,,,both,,,480,355.2,,,355.2,Other,150% of Medicare + 9.63% HCRA Surcharge,216,45,,216,percent of total billed charges,Critical Access Hospital RCC factor,163.2,34,,163.2,percent of total billed charges,Implant Device,163.2,34,,163.2,percent of total billed charges,Implant Device,163.2,34,,163.2,percent of total billed charges,Implant Device,163.2,34,,163.2,percent of total billed charges,Implant Device,163.2,34,,163.2,percent of total billed charges,Implant Device,237.6,,,237.6,Other,110% of Medicare,168,35,,168,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,192,40,,192,percent of total billed charges,Implant Device,168,70,,168,percent of total billed charges,All Other,163.2,34,,163.2,percent of total billed charges,Implant Device,163.2,34,,163.2,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,355.2,
STRYKER 656022 LOCKING SCREW 2.4X22MM,C1713,HCPCS,,79007109,CDM,278,RC,,,both,,,480,355.2,,,355.2,Other,150% of Medicare + 9.63% HCRA Surcharge,216,45,,216,percent of total billed charges,Critical Access Hospital RCC factor,163.2,34,,163.2,percent of total billed charges,Implant Device,163.2,34,,163.2,percent of total billed charges,Implant Device,163.2,34,,163.2,percent of total billed charges,Implant Device,163.2,34,,163.2,percent of total billed charges,Implant Device,163.2,34,,163.2,percent of total billed charges,Implant Device,237.6,,,237.6,Other,110% of Medicare,168,35,,168,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,192,40,,192,percent of total billed charges,Implant Device,168,70,,168,percent of total billed charges,All Other,163.2,34,,163.2,percent of total billed charges,Implant Device,163.2,34,,163.2,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,355.2,
STRYKER 656024 LOCKING SCREW 2.4X24MM,C1713,HCPCS,,79007110,CDM,278,RC,,,both,,,443,327.82,,,327.82,Other,150% of Medicare + 9.63% HCRA Surcharge,199.35,45,,199.35,percent of total billed charges,Critical Access Hospital RCC factor,150.62,34,,150.62,percent of total billed charges,Implant Device,150.62,34,,150.62,percent of total billed charges,Implant Device,150.62,34,,150.62,percent of total billed charges,Implant Device,150.62,34,,150.62,percent of total billed charges,Implant Device,150.62,34,,150.62,percent of total billed charges,Implant Device,219.29,,,219.29,Other,110% of Medicare,155.05,35,,155.05,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,155.05,35,,155.05,percent of total billed charges,Implant Device,155.05,35,,155.05,percent of total billed charges,Implant Device,155.05,35,,155.05,percent of total billed charges,Implant Device,155.05,35,,155.05,percent of total billed charges,Implant Device,155.05,35,,155.05,percent of total billed charges,Implant Device,177.2,40,,177.2,percent of total billed charges,Implant Device,155.05,70,,155.05,percent of total billed charges,All Other,150.62,34,,150.62,percent of total billed charges,Implant Device,150.62,34,,150.62,percent of total billed charges,Implant Device,155.05,35,,155.05,percent of total billed charges,Implant Device,155.05,35,,155.05,percent of total billed charges,Implant Device,155.05,35,,155.05,percent of total billed charges,Implant Device,155.05,35,,155.05,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,327.82,
LIFE SPINE 132-314-1 AILERON CORE MEDIUM,C1713,HCPCS,,79007111,CDM,278,RC,,,both,,,20640,15273.65,,,15273.65,Other,150% of Medicare + 9.63% HCRA Surcharge,9288,45,,9288,percent of total billed charges,Critical Access Hospital RCC factor,7017.6,34,,7017.6,percent of total billed charges,Implant Device,7017.6,34,,7017.6,percent of total billed charges,Implant Device,7017.6,34,,7017.6,percent of total billed charges,Implant Device,7017.6,34,,7017.6,percent of total billed charges,Implant Device,7017.6,34,,7017.6,percent of total billed charges,Implant Device,10216.8,,,10216.8,Other,110% of Medicare,7224,35,,7224,percent of total billed charges,Implant Device,7017.6,34,"Charges > $500, x 34%",7017.6,percent of total billed charges,Implant Device,7224,35,,7224,percent of total billed charges,Implant Device,7224,35,,7224,percent of total billed charges,Implant Device,7224,35,,7224,percent of total billed charges,Implant Device,7224,35,,7224,percent of total billed charges,Implant Device,7224,35,,7224,percent of total billed charges,Implant Device,8256,40,,8256,percent of total billed charges,Implant Device,7224,70,,7224,percent of total billed charges,All Other,7017.6,34,,7017.6,percent of total billed charges,Implant Device,7017.6,34,,7017.6,percent of total billed charges,Implant Device,7224,35,,7224,percent of total billed charges,Implant Device,7224,35,,7224,percent of total billed charges,Implant Device,7224,35,,7224,percent of total billed charges,Implant Device,7224,35,,7224,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,7017.6,34,"If Charge > 2,000, then 34 percent",7017.6,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,15273.65,
LIFE SPINE 132-314-2 AILERON PLATE MED,C1713,HCPCS,,79007112,CDM,278,RC,,,both,,,13680,10123.23,,,10123.23,Other,150% of Medicare + 9.63% HCRA Surcharge,6156,45,,6156,percent of total billed charges,Critical Access Hospital RCC factor,4651.2,34,,4651.2,percent of total billed charges,Implant Device,4651.2,34,,4651.2,percent of total billed charges,Implant Device,4651.2,34,,4651.2,percent of total billed charges,Implant Device,4651.2,34,,4651.2,percent of total billed charges,Implant Device,4651.2,34,,4651.2,percent of total billed charges,Implant Device,6771.6,,,6771.6,Other,110% of Medicare,4788,35,,4788,percent of total billed charges,Implant Device,4651.2,34,"Charges > $500, x 34%",4651.2,percent of total billed charges,Implant Device,4788,35,,4788,percent of total billed charges,Implant Device,4788,35,,4788,percent of total billed charges,Implant Device,4788,35,,4788,percent of total billed charges,Implant Device,4788,35,,4788,percent of total billed charges,Implant Device,4788,35,,4788,percent of total billed charges,Implant Device,5472,40,,5472,percent of total billed charges,Implant Device,4788,70,,4788,percent of total billed charges,All Other,4651.2,34,,4651.2,percent of total billed charges,Implant Device,4651.2,34,,4651.2,percent of total billed charges,Implant Device,4788,35,,4788,percent of total billed charges,Implant Device,4788,35,,4788,percent of total billed charges,Implant Device,4788,35,,4788,percent of total billed charges,Implant Device,4788,35,,4788,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,4651.2,34,"If Charge > 2,000, then 34 percent",4651.2,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,10123.23,
STRYKER 338642 CORTEX SCREW 3.5X42MM,C1713,HCPCS,,79007113,CDM,278,RC,,,both,,,120,88.8,,,88.8,Other,150% of Medicare + 9.63% HCRA Surcharge,54,45,,54,percent of total billed charges,Critical Access Hospital RCC factor,40.8,34,,40.8,percent of total billed charges,Implant Device,40.8,34,,40.8,percent of total billed charges,Implant Device,40.8,34,,40.8,percent of total billed charges,Implant Device,40.8,34,,40.8,percent of total billed charges,Implant Device,40.8,34,,40.8,percent of total billed charges,Implant Device,59.4,,,59.4,Other,110% of Medicare,42,35,,42,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,42,35,,42,percent of total billed charges,Implant Device,42,35,,42,percent of total billed charges,Implant Device,42,35,,42,percent of total billed charges,Implant Device,42,35,,42,percent of total billed charges,Implant Device,42,35,,42,percent of total billed charges,Implant Device,48,40,,48,percent of total billed charges,Implant Device,42,70,,42,percent of total billed charges,All Other,40.8,34,,40.8,percent of total billed charges,Implant Device,40.8,34,,40.8,percent of total billed charges,Implant Device,42,35,,42,percent of total billed charges,Implant Device,42,35,,42,percent of total billed charges,Implant Device,42,35,,42,percent of total billed charges,Implant Device,42,35,,42,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,88.8,
STRYKER 338622 CORTEX SCREW 3.5X22MM,C1713,HCPCS,,79007114,CDM,278,RC,,,both,,,120,88.8,,,88.8,Other,150% of Medicare + 9.63% HCRA Surcharge,54,45,,54,percent of total billed charges,Critical Access Hospital RCC factor,40.8,34,,40.8,percent of total billed charges,Implant Device,40.8,34,,40.8,percent of total billed charges,Implant Device,40.8,34,,40.8,percent of total billed charges,Implant Device,40.8,34,,40.8,percent of total billed charges,Implant Device,40.8,34,,40.8,percent of total billed charges,Implant Device,59.4,,,59.4,Other,110% of Medicare,42,35,,42,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,42,35,,42,percent of total billed charges,Implant Device,42,35,,42,percent of total billed charges,Implant Device,42,35,,42,percent of total billed charges,Implant Device,42,35,,42,percent of total billed charges,Implant Device,42,35,,42,percent of total billed charges,Implant Device,48,40,,48,percent of total billed charges,Implant Device,42,70,,42,percent of total billed charges,All Other,40.8,34,,40.8,percent of total billed charges,Implant Device,40.8,34,,40.8,percent of total billed charges,Implant Device,42,35,,42,percent of total billed charges,Implant Device,42,35,,42,percent of total billed charges,Implant Device,42,35,,42,percent of total billed charges,Implant Device,42,35,,42,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,88.8,
STRYKER 436208 DISTAL MED 8 HOLE PLATE,C1713,HCPCS,,79007115,CDM,278,RC,,,both,,,5643,4175.83,,,4175.83,Other,150% of Medicare + 9.63% HCRA Surcharge,2539.35,45,,2539.35,percent of total billed charges,Critical Access Hospital RCC factor,1918.62,34,,1918.62,percent of total billed charges,Implant Device,1918.62,34,,1918.62,percent of total billed charges,Implant Device,1918.62,34,,1918.62,percent of total billed charges,Implant Device,1918.62,34,,1918.62,percent of total billed charges,Implant Device,1918.62,34,,1918.62,percent of total billed charges,Implant Device,2793.29,,,2793.29,Other,110% of Medicare,1975.05,35,,1975.05,percent of total billed charges,Implant Device,1918.62,34,"Charges > $500, x 34%",1918.62,percent of total billed charges,Implant Device,1975.05,35,,1975.05,percent of total billed charges,Implant Device,1975.05,35,,1975.05,percent of total billed charges,Implant Device,1975.05,35,,1975.05,percent of total billed charges,Implant Device,1975.05,35,,1975.05,percent of total billed charges,Implant Device,1975.05,35,,1975.05,percent of total billed charges,Implant Device,2257.2,40,,2257.2,percent of total billed charges,Implant Device,1975.05,70,,1975.05,percent of total billed charges,All Other,1918.62,34,,1918.62,percent of total billed charges,Implant Device,1918.62,34,,1918.62,percent of total billed charges,Implant Device,1975.05,35,,1975.05,percent of total billed charges,Implant Device,1975.05,35,,1975.05,percent of total billed charges,Implant Device,1975.05,35,,1975.05,percent of total billed charges,Implant Device,1975.05,35,,1975.05,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1918.62,34,"If Charge > 2,000, then 34 percent",1918.62,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4175.83,
DEPUY 208.411 CANNULATED SCREW 6.5X16MM,C1713,HCPCS,,79007116,CDM,278,RC,,,both,,,908,671.92,,,671.92,Other,150% of Medicare + 9.63% HCRA Surcharge,408.6,45,,408.6,percent of total billed charges,Critical Access Hospital RCC factor,308.72,34,,308.72,percent of total billed charges,Implant Device,308.72,34,,308.72,percent of total billed charges,Implant Device,308.72,34,,308.72,percent of total billed charges,Implant Device,308.72,34,,308.72,percent of total billed charges,Implant Device,308.72,34,,308.72,percent of total billed charges,Implant Device,449.46,,,449.46,Other,110% of Medicare,317.8,35,,317.8,percent of total billed charges,Implant Device,308.72,34,"Charges > $500, x 34%",308.72,percent of total billed charges,Implant Device,317.8,35,,317.8,percent of total billed charges,Implant Device,317.8,35,,317.8,percent of total billed charges,Implant Device,317.8,35,,317.8,percent of total billed charges,Implant Device,317.8,35,,317.8,percent of total billed charges,Implant Device,317.8,35,,317.8,percent of total billed charges,Implant Device,363.2,40,,363.2,percent of total billed charges,Implant Device,317.8,70,,317.8,percent of total billed charges,All Other,308.72,34,,308.72,percent of total billed charges,Implant Device,308.72,34,,308.72,percent of total billed charges,Implant Device,317.8,35,,317.8,percent of total billed charges,Implant Device,317.8,35,,317.8,percent of total billed charges,Implant Device,317.8,35,,317.8,percent of total billed charges,Implant Device,317.8,35,,317.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,671.92,
STRYKER STRYKER BIPOLAR HIP-CAP,C1776,HCPCS,,79007117,CDM,278,RC,,,both,,,13209,9774.69,,,9774.69,Other,150% of Medicare + 9.63% HCRA Surcharge,5944.05,45,,5944.05,percent of total billed charges,Critical Access Hospital RCC factor,4491.06,34,,4491.06,percent of total billed charges,Implant Device,4491.06,34,,4491.06,percent of total billed charges,Implant Device,4491.06,34,,4491.06,percent of total billed charges,Implant Device,4491.06,34,,4491.06,percent of total billed charges,Implant Device,4491.06,34,,4491.06,percent of total billed charges,Implant Device,6538.46,,,6538.46,Other,110% of Medicare,4623.15,35,,4623.15,percent of total billed charges,Implant Device,4491.06,34,"Charges > $500, x 34%",4491.06,percent of total billed charges,Implant Device,4623.15,35,,4623.15,percent of total billed charges,Implant Device,4623.15,35,,4623.15,percent of total billed charges,Implant Device,4623.15,35,,4623.15,percent of total billed charges,Implant Device,4623.15,35,,4623.15,percent of total billed charges,Implant Device,4623.15,35,,4623.15,percent of total billed charges,Implant Device,5283.6,40,,5283.6,percent of total billed charges,Implant Device,4623.15,70,,4623.15,percent of total billed charges,All Other,4491.06,34,,4491.06,percent of total billed charges,Implant Device,4491.06,34,,4491.06,percent of total billed charges,Implant Device,4623.15,35,,4623.15,percent of total billed charges,Implant Device,4623.15,35,,4623.15,percent of total billed charges,Implant Device,4623.15,35,,4623.15,percent of total billed charges,Implant Device,4623.15,35,,4623.15,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,4491.06,34,"If Charge > 2,000, then 34 percent",4491.06,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,9774.69,
ARTHREX AR-8949-075 CALAC PLATE 7.5MM,C1713,HCPCS,,79007119,CDM,278,RC,,,both,,,3558,2632.93,,,2632.93,Other,150% of Medicare + 9.63% HCRA Surcharge,1601.1,45,,1601.1,percent of total billed charges,Critical Access Hospital RCC factor,1209.72,34,,1209.72,percent of total billed charges,Implant Device,1209.72,34,,1209.72,percent of total billed charges,Implant Device,1209.72,34,,1209.72,percent of total billed charges,Implant Device,1209.72,34,,1209.72,percent of total billed charges,Implant Device,1209.72,34,,1209.72,percent of total billed charges,Implant Device,1761.21,,,1761.21,Other,110% of Medicare,1245.3,35,,1245.3,percent of total billed charges,Implant Device,1209.72,34,"Charges > $500, x 34%",1209.72,percent of total billed charges,Implant Device,1245.3,35,,1245.3,percent of total billed charges,Implant Device,1245.3,35,,1245.3,percent of total billed charges,Implant Device,1245.3,35,,1245.3,percent of total billed charges,Implant Device,1245.3,35,,1245.3,percent of total billed charges,Implant Device,1245.3,35,,1245.3,percent of total billed charges,Implant Device,1423.2,40,,1423.2,percent of total billed charges,Implant Device,1245.3,70,,1245.3,percent of total billed charges,All Other,1209.72,34,,1209.72,percent of total billed charges,Implant Device,1209.72,34,,1209.72,percent of total billed charges,Implant Device,1245.3,35,,1245.3,percent of total billed charges,Implant Device,1245.3,35,,1245.3,percent of total billed charges,Implant Device,1245.3,35,,1245.3,percent of total billed charges,Implant Device,1245.3,35,,1245.3,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1209.72,34,"If Charge > 2,000, then 34 percent",1209.72,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2632.93,
ARTHREX AR-8940-32 CANCLLS SCREW 4X32MM,C1713,HCPCS,,79007120,CDM,278,RC,,,both,,,180,133.2,,,133.2,Other,150% of Medicare + 9.63% HCRA Surcharge,81,45,,81,percent of total billed charges,Critical Access Hospital RCC factor,61.2,34,,61.2,percent of total billed charges,Implant Device,61.2,34,,61.2,percent of total billed charges,Implant Device,61.2,34,,61.2,percent of total billed charges,Implant Device,61.2,34,,61.2,percent of total billed charges,Implant Device,61.2,34,,61.2,percent of total billed charges,Implant Device,89.1,,,89.1,Other,110% of Medicare,63,35,,63,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,63,35,,63,percent of total billed charges,Implant Device,63,35,,63,percent of total billed charges,Implant Device,63,35,,63,percent of total billed charges,Implant Device,63,35,,63,percent of total billed charges,Implant Device,63,35,,63,percent of total billed charges,Implant Device,72,40,,72,percent of total billed charges,Implant Device,63,70,,63,percent of total billed charges,All Other,61.2,34,,61.2,percent of total billed charges,Implant Device,61.2,34,,61.2,percent of total billed charges,Implant Device,63,35,,63,percent of total billed charges,Implant Device,63,35,,63,percent of total billed charges,Implant Device,63,35,,63,percent of total billed charges,Implant Device,63,35,,63,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,133.2,
ARTHREX AR-8940-24 CANCLLS SCREW 4X24MM,C1713,HCPCS,,79007121,CDM,278,RC,,,both,,,180,133.2,,,133.2,Other,150% of Medicare + 9.63% HCRA Surcharge,81,45,,81,percent of total billed charges,Critical Access Hospital RCC factor,61.2,34,,61.2,percent of total billed charges,Implant Device,61.2,34,,61.2,percent of total billed charges,Implant Device,61.2,34,,61.2,percent of total billed charges,Implant Device,61.2,34,,61.2,percent of total billed charges,Implant Device,61.2,34,,61.2,percent of total billed charges,Implant Device,89.1,,,89.1,Other,110% of Medicare,63,35,,63,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,63,35,,63,percent of total billed charges,Implant Device,63,35,,63,percent of total billed charges,Implant Device,63,35,,63,percent of total billed charges,Implant Device,63,35,,63,percent of total billed charges,Implant Device,63,35,,63,percent of total billed charges,Implant Device,72,40,,72,percent of total billed charges,Implant Device,63,70,,63,percent of total billed charges,All Other,61.2,34,,61.2,percent of total billed charges,Implant Device,61.2,34,,61.2,percent of total billed charges,Implant Device,63,35,,63,percent of total billed charges,Implant Device,63,35,,63,percent of total billed charges,Implant Device,63,35,,63,percent of total billed charges,Implant Device,63,35,,63,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,133.2,
ARTHREX AR-8935L-34 LOCK SCREW 3.5X34MM,C1713,HCPCS,,79007122,CDM,278,RC,,,both,,,366,270.84,,,270.84,Other,150% of Medicare + 9.63% HCRA Surcharge,164.7,45,,164.7,percent of total billed charges,Critical Access Hospital RCC factor,124.44,34,,124.44,percent of total billed charges,Implant Device,124.44,34,,124.44,percent of total billed charges,Implant Device,124.44,34,,124.44,percent of total billed charges,Implant Device,124.44,34,,124.44,percent of total billed charges,Implant Device,124.44,34,,124.44,percent of total billed charges,Implant Device,181.17,,,181.17,Other,110% of Medicare,128.1,35,,128.1,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,128.1,35,,128.1,percent of total billed charges,Implant Device,128.1,35,,128.1,percent of total billed charges,Implant Device,128.1,35,,128.1,percent of total billed charges,Implant Device,128.1,35,,128.1,percent of total billed charges,Implant Device,128.1,35,,128.1,percent of total billed charges,Implant Device,146.4,40,,146.4,percent of total billed charges,Implant Device,128.1,70,,128.1,percent of total billed charges,All Other,124.44,34,,124.44,percent of total billed charges,Implant Device,124.44,34,,124.44,percent of total billed charges,Implant Device,128.1,35,,128.1,percent of total billed charges,Implant Device,128.1,35,,128.1,percent of total billed charges,Implant Device,128.1,35,,128.1,percent of total billed charges,Implant Device,128.1,35,,128.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,270.84,
DEPUY 02.107.304 OLEC PLATE 4HOLE 116MM,C1713,HCPCS,,79007125,CDM,278,RC,,,both,,,2826,2091.25,,,2091.25,Other,150% of Medicare + 9.63% HCRA Surcharge,1271.7,45,,1271.7,percent of total billed charges,Critical Access Hospital RCC factor,960.84,34,,960.84,percent of total billed charges,Implant Device,960.84,34,,960.84,percent of total billed charges,Implant Device,960.84,34,,960.84,percent of total billed charges,Implant Device,960.84,34,,960.84,percent of total billed charges,Implant Device,960.84,34,,960.84,percent of total billed charges,Implant Device,1398.87,,,1398.87,Other,110% of Medicare,989.1,35,,989.1,percent of total billed charges,Implant Device,960.84,34,"Charges > $500, x 34%",960.84,percent of total billed charges,Implant Device,989.1,35,,989.1,percent of total billed charges,Implant Device,989.1,35,,989.1,percent of total billed charges,Implant Device,989.1,35,,989.1,percent of total billed charges,Implant Device,989.1,35,,989.1,percent of total billed charges,Implant Device,989.1,35,,989.1,percent of total billed charges,Implant Device,1130.4,40,,1130.4,percent of total billed charges,Implant Device,989.1,70,,989.1,percent of total billed charges,All Other,960.84,34,,960.84,percent of total billed charges,Implant Device,960.84,34,,960.84,percent of total billed charges,Implant Device,989.1,35,,989.1,percent of total billed charges,Implant Device,989.1,35,,989.1,percent of total billed charges,Implant Device,989.1,35,,989.1,percent of total billed charges,Implant Device,989.1,35,,989.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,960.84,34,"If Charge > 2,000, then 34 percent",960.84,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2091.25,
DEPUY 02.211.022 LOCKING SCREW 2.7X22MM,C1713,HCPCS,,79007126,CDM,278,RC,,,both,,,343,253.82,,,253.82,Other,150% of Medicare + 9.63% HCRA Surcharge,154.35,45,,154.35,percent of total billed charges,Critical Access Hospital RCC factor,116.62,34,,116.62,percent of total billed charges,Implant Device,116.62,34,,116.62,percent of total billed charges,Implant Device,116.62,34,,116.62,percent of total billed charges,Implant Device,116.62,34,,116.62,percent of total billed charges,Implant Device,116.62,34,,116.62,percent of total billed charges,Implant Device,169.79,,,169.79,Other,110% of Medicare,120.05,35,,120.05,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,120.05,35,,120.05,percent of total billed charges,Implant Device,120.05,35,,120.05,percent of total billed charges,Implant Device,120.05,35,,120.05,percent of total billed charges,Implant Device,120.05,35,,120.05,percent of total billed charges,Implant Device,120.05,35,,120.05,percent of total billed charges,Implant Device,137.2,40,,137.2,percent of total billed charges,Implant Device,120.05,70,,120.05,percent of total billed charges,All Other,116.62,34,,116.62,percent of total billed charges,Implant Device,116.62,34,,116.62,percent of total billed charges,Implant Device,120.05,35,,120.05,percent of total billed charges,Implant Device,120.05,35,,120.05,percent of total billed charges,Implant Device,120.05,35,,120.05,percent of total billed charges,Implant Device,120.05,35,,120.05,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,253.82,
DEPUY 02.211.038 LOCKING SCREW 2.7X38MM,C1713,HCPCS,,79007127,CDM,278,RC,,,both,,,343,253.82,,,253.82,Other,150% of Medicare + 9.63% HCRA Surcharge,154.35,45,,154.35,percent of total billed charges,Critical Access Hospital RCC factor,116.62,34,,116.62,percent of total billed charges,Implant Device,116.62,34,,116.62,percent of total billed charges,Implant Device,116.62,34,,116.62,percent of total billed charges,Implant Device,116.62,34,,116.62,percent of total billed charges,Implant Device,116.62,34,,116.62,percent of total billed charges,Implant Device,169.79,,,169.79,Other,110% of Medicare,120.05,35,,120.05,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,120.05,35,,120.05,percent of total billed charges,Implant Device,120.05,35,,120.05,percent of total billed charges,Implant Device,120.05,35,,120.05,percent of total billed charges,Implant Device,120.05,35,,120.05,percent of total billed charges,Implant Device,120.05,35,,120.05,percent of total billed charges,Implant Device,137.2,40,,137.2,percent of total billed charges,Implant Device,120.05,70,,120.05,percent of total billed charges,All Other,116.62,34,,116.62,percent of total billed charges,Implant Device,116.62,34,,116.62,percent of total billed charges,Implant Device,120.05,35,,120.05,percent of total billed charges,Implant Device,120.05,35,,120.05,percent of total billed charges,Implant Device,120.05,35,,120.05,percent of total billed charges,Implant Device,120.05,35,,120.05,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,253.82,
DEPUY 02.211.024 LOCKING SCREW 2.7X34MM,C1713,HCPCS,,79007128,CDM,278,RC,,,both,,,343,253.82,,,253.82,Other,150% of Medicare + 9.63% HCRA Surcharge,154.35,45,,154.35,percent of total billed charges,Critical Access Hospital RCC factor,116.62,34,,116.62,percent of total billed charges,Implant Device,116.62,34,,116.62,percent of total billed charges,Implant Device,116.62,34,,116.62,percent of total billed charges,Implant Device,116.62,34,,116.62,percent of total billed charges,Implant Device,116.62,34,,116.62,percent of total billed charges,Implant Device,169.79,,,169.79,Other,110% of Medicare,120.05,35,,120.05,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,120.05,35,,120.05,percent of total billed charges,Implant Device,120.05,35,,120.05,percent of total billed charges,Implant Device,120.05,35,,120.05,percent of total billed charges,Implant Device,120.05,35,,120.05,percent of total billed charges,Implant Device,120.05,35,,120.05,percent of total billed charges,Implant Device,137.2,40,,137.2,percent of total billed charges,Implant Device,120.05,70,,120.05,percent of total billed charges,All Other,116.62,34,,116.62,percent of total billed charges,Implant Device,116.62,34,,116.62,percent of total billed charges,Implant Device,120.05,35,,120.05,percent of total billed charges,Implant Device,120.05,35,,120.05,percent of total billed charges,Implant Device,120.05,35,,120.05,percent of total billed charges,Implant Device,120.05,35,,120.05,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,253.82,
DEPUY 02.211.026 LOCKING SCREW 2.7X26MM,C1713,HCPCS,,79007129,CDM,278,RC,,,both,,,343,253.82,,,253.82,Other,150% of Medicare + 9.63% HCRA Surcharge,154.35,45,,154.35,percent of total billed charges,Critical Access Hospital RCC factor,116.62,34,,116.62,percent of total billed charges,Implant Device,116.62,34,,116.62,percent of total billed charges,Implant Device,116.62,34,,116.62,percent of total billed charges,Implant Device,116.62,34,,116.62,percent of total billed charges,Implant Device,116.62,34,,116.62,percent of total billed charges,Implant Device,169.79,,,169.79,Other,110% of Medicare,120.05,35,,120.05,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,120.05,35,,120.05,percent of total billed charges,Implant Device,120.05,35,,120.05,percent of total billed charges,Implant Device,120.05,35,,120.05,percent of total billed charges,Implant Device,120.05,35,,120.05,percent of total billed charges,Implant Device,120.05,35,,120.05,percent of total billed charges,Implant Device,137.2,40,,137.2,percent of total billed charges,Implant Device,120.05,70,,120.05,percent of total billed charges,All Other,116.62,34,,116.62,percent of total billed charges,Implant Device,116.62,34,,116.62,percent of total billed charges,Implant Device,120.05,35,,120.05,percent of total billed charges,Implant Device,120.05,35,,120.05,percent of total billed charges,Implant Device,120.05,35,,120.05,percent of total billed charges,Implant Device,120.05,35,,120.05,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,253.82,
ARTHREX AR-5035TC-09 ACL SCREW 9X35MM,C1713,HCPCS,,79007130,CDM,278,RC,,,both,,,705,521.7,,,521.7,Other,150% of Medicare + 9.63% HCRA Surcharge,317.25,45,,317.25,percent of total billed charges,Critical Access Hospital RCC factor,239.7,34,,239.7,percent of total billed charges,Implant Device,239.7,34,,239.7,percent of total billed charges,Implant Device,239.7,34,,239.7,percent of total billed charges,Implant Device,239.7,34,,239.7,percent of total billed charges,Implant Device,239.7,34,,239.7,percent of total billed charges,Implant Device,348.98,,,348.98,Other,110% of Medicare,246.75,35,,246.75,percent of total billed charges,Implant Device,239.7,34,"Charges > $500, x 34%",239.7,percent of total billed charges,Implant Device,246.75,35,,246.75,percent of total billed charges,Implant Device,246.75,35,,246.75,percent of total billed charges,Implant Device,246.75,35,,246.75,percent of total billed charges,Implant Device,246.75,35,,246.75,percent of total billed charges,Implant Device,246.75,35,,246.75,percent of total billed charges,Implant Device,282,40,,282,percent of total billed charges,Implant Device,246.75,70,,246.75,percent of total billed charges,All Other,239.7,34,,239.7,percent of total billed charges,Implant Device,239.7,34,,239.7,percent of total billed charges,Implant Device,246.75,35,,246.75,percent of total billed charges,Implant Device,246.75,35,,246.75,percent of total billed charges,Implant Device,246.75,35,,246.75,percent of total billed charges,Implant Device,246.75,35,,246.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,521.7,
EXACTECH 314-13-02 CAGE GLENOID SM ALPHA,C1713,HCPCS,,79007131,CDM,278,RC,,,both,,,8559,6333.68,,,6333.68,Other,150% of Medicare + 9.63% HCRA Surcharge,3851.55,45,,3851.55,percent of total billed charges,Critical Access Hospital RCC factor,2910.06,34,,2910.06,percent of total billed charges,Implant Device,2910.06,34,,2910.06,percent of total billed charges,Implant Device,2910.06,34,,2910.06,percent of total billed charges,Implant Device,2910.06,34,,2910.06,percent of total billed charges,Implant Device,2910.06,34,,2910.06,percent of total billed charges,Implant Device,4236.71,,,4236.71,Other,110% of Medicare,2995.65,35,,2995.65,percent of total billed charges,Implant Device,2910.06,34,"Charges > $500, x 34%",2910.06,percent of total billed charges,Implant Device,2995.65,35,,2995.65,percent of total billed charges,Implant Device,2995.65,35,,2995.65,percent of total billed charges,Implant Device,2995.65,35,,2995.65,percent of total billed charges,Implant Device,2995.65,35,,2995.65,percent of total billed charges,Implant Device,2995.65,35,,2995.65,percent of total billed charges,Implant Device,3423.6,40,,3423.6,percent of total billed charges,Implant Device,2995.65,70,,2995.65,percent of total billed charges,All Other,2910.06,34,,2910.06,percent of total billed charges,Implant Device,2910.06,34,,2910.06,percent of total billed charges,Implant Device,2995.65,35,,2995.65,percent of total billed charges,Implant Device,2995.65,35,,2995.65,percent of total billed charges,Implant Device,2995.65,35,,2995.65,percent of total billed charges,Implant Device,2995.65,35,,2995.65,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2910.06,34,"If Charge > 2,000, then 34 percent",2910.06,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,6333.68,
STRYKER 54-25386 ANATOMIC VOLAR PLATE,C1713,HCPCS,,79007132,CDM,278,RC,,,both,,,2274,1682.77,,,1682.77,Other,150% of Medicare + 9.63% HCRA Surcharge,1023.3,45,,1023.3,percent of total billed charges,Critical Access Hospital RCC factor,773.16,34,,773.16,percent of total billed charges,Implant Device,773.16,34,,773.16,percent of total billed charges,Implant Device,773.16,34,,773.16,percent of total billed charges,Implant Device,773.16,34,,773.16,percent of total billed charges,Implant Device,773.16,34,,773.16,percent of total billed charges,Implant Device,1125.63,,,1125.63,Other,110% of Medicare,795.9,35,,795.9,percent of total billed charges,Implant Device,773.16,34,"Charges > $500, x 34%",773.16,percent of total billed charges,Implant Device,795.9,35,,795.9,percent of total billed charges,Implant Device,795.9,35,,795.9,percent of total billed charges,Implant Device,795.9,35,,795.9,percent of total billed charges,Implant Device,795.9,35,,795.9,percent of total billed charges,Implant Device,795.9,35,,795.9,percent of total billed charges,Implant Device,909.6,40,,909.6,percent of total billed charges,Implant Device,795.9,70,,795.9,percent of total billed charges,All Other,773.16,34,,773.16,percent of total billed charges,Implant Device,773.16,34,,773.16,percent of total billed charges,Implant Device,795.9,35,,795.9,percent of total billed charges,Implant Device,795.9,35,,795.9,percent of total billed charges,Implant Device,795.9,35,,795.9,percent of total billed charges,Implant Device,795.9,35,,795.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,773.16,34,"If Charge > 2,000, then 34 percent",773.16,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1682.77,
STRYKER 5630-G-409 TIBIAL INSRT SZ 4 9MM,C1776,HCPCS,,79007133,CDM,278,RC,,,both,,,3232,2391.69,,,2391.69,Other,150% of Medicare + 9.63% HCRA Surcharge,1454.4,45,,1454.4,percent of total billed charges,Critical Access Hospital RCC factor,1098.88,34,,1098.88,percent of total billed charges,Implant Device,1098.88,34,,1098.88,percent of total billed charges,Implant Device,1098.88,34,,1098.88,percent of total billed charges,Implant Device,1098.88,34,,1098.88,percent of total billed charges,Implant Device,1098.88,34,,1098.88,percent of total billed charges,Implant Device,1599.84,,,1599.84,Other,110% of Medicare,1131.2,35,,1131.2,percent of total billed charges,Implant Device,1098.88,34,"Charges > $500, x 34%",1098.88,percent of total billed charges,Implant Device,1131.2,35,,1131.2,percent of total billed charges,Implant Device,1131.2,35,,1131.2,percent of total billed charges,Implant Device,1131.2,35,,1131.2,percent of total billed charges,Implant Device,1131.2,35,,1131.2,percent of total billed charges,Implant Device,1131.2,35,,1131.2,percent of total billed charges,Implant Device,1292.8,40,,1292.8,percent of total billed charges,Implant Device,1131.2,70,,1131.2,percent of total billed charges,All Other,1098.88,34,,1098.88,percent of total billed charges,Implant Device,1098.88,34,,1098.88,percent of total billed charges,Implant Device,1131.2,35,,1131.2,percent of total billed charges,Implant Device,1131.2,35,,1131.2,percent of total billed charges,Implant Device,1131.2,35,,1131.2,percent of total billed charges,Implant Device,1131.2,35,,1131.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1098.88,34,"If Charge > 2,000, then 34 percent",1098.88,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2391.69,
STRYKER 5610-F-401 FEMORAL COMP SZ 4,C1776,HCPCS,,79007134,CDM,278,RC,,,both,,,8352,6180.5,,,6180.5,Other,150% of Medicare + 9.63% HCRA Surcharge,3758.4,45,,3758.4,percent of total billed charges,Critical Access Hospital RCC factor,2839.68,34,,2839.68,percent of total billed charges,Implant Device,2839.68,34,,2839.68,percent of total billed charges,Implant Device,2839.68,34,,2839.68,percent of total billed charges,Implant Device,2839.68,34,,2839.68,percent of total billed charges,Implant Device,2839.68,34,,2839.68,percent of total billed charges,Implant Device,4134.24,,,4134.24,Other,110% of Medicare,2923.2,35,,2923.2,percent of total billed charges,Implant Device,2839.68,34,"Charges > $500, x 34%",2839.68,percent of total billed charges,Implant Device,2923.2,35,,2923.2,percent of total billed charges,Implant Device,2923.2,35,,2923.2,percent of total billed charges,Implant Device,2923.2,35,,2923.2,percent of total billed charges,Implant Device,2923.2,35,,2923.2,percent of total billed charges,Implant Device,2923.2,35,,2923.2,percent of total billed charges,Implant Device,3340.8,40,,3340.8,percent of total billed charges,Implant Device,2923.2,70,,2923.2,percent of total billed charges,All Other,2839.68,34,,2839.68,percent of total billed charges,Implant Device,2839.68,34,,2839.68,percent of total billed charges,Implant Device,2923.2,35,,2923.2,percent of total billed charges,Implant Device,2923.2,35,,2923.2,percent of total billed charges,Implant Device,2923.2,35,,2923.2,percent of total billed charges,Implant Device,2923.2,35,,2923.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2839.68,34,"If Charge > 2,000, then 34 percent",2839.68,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,6180.5,
STRYKER 1822-0933S TIBIAL NAIL STD 9X330,C1713,HCPCS,,79007135,CDM,278,RC,,,both,,,6110,4521.42,,,4521.42,Other,150% of Medicare + 9.63% HCRA Surcharge,2749.5,45,,2749.5,percent of total billed charges,Critical Access Hospital RCC factor,2077.4,34,,2077.4,percent of total billed charges,Implant Device,2077.4,34,,2077.4,percent of total billed charges,Implant Device,2077.4,34,,2077.4,percent of total billed charges,Implant Device,2077.4,34,,2077.4,percent of total billed charges,Implant Device,2077.4,34,,2077.4,percent of total billed charges,Implant Device,3024.45,,,3024.45,Other,110% of Medicare,2138.5,35,,2138.5,percent of total billed charges,Implant Device,2077.4,34,"Charges > $500, x 34%",2077.4,percent of total billed charges,Implant Device,2138.5,35,,2138.5,percent of total billed charges,Implant Device,2138.5,35,,2138.5,percent of total billed charges,Implant Device,2138.5,35,,2138.5,percent of total billed charges,Implant Device,2138.5,35,,2138.5,percent of total billed charges,Implant Device,2138.5,35,,2138.5,percent of total billed charges,Implant Device,2444,40,,2444,percent of total billed charges,Implant Device,2138.5,70,,2138.5,percent of total billed charges,All Other,2077.4,34,,2077.4,percent of total billed charges,Implant Device,2077.4,34,,2077.4,percent of total billed charges,Implant Device,2138.5,35,,2138.5,percent of total billed charges,Implant Device,2138.5,35,,2138.5,percent of total billed charges,Implant Device,2138.5,35,,2138.5,percent of total billed charges,Implant Device,2138.5,35,,2138.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2077.4,34,"If Charge > 2,000, then 34 percent",2077.4,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4521.42,
DEPUY 458.934S TI LOCKING SCREW 5X34MM,C1713,HCPCS,,79007137,CDM,278,RC,,,both,,,456,337.44,,,337.44,Other,150% of Medicare + 9.63% HCRA Surcharge,205.2,45,,205.2,percent of total billed charges,Critical Access Hospital RCC factor,155.04,34,,155.04,percent of total billed charges,Implant Device,155.04,34,,155.04,percent of total billed charges,Implant Device,155.04,34,,155.04,percent of total billed charges,Implant Device,155.04,34,,155.04,percent of total billed charges,Implant Device,155.04,34,,155.04,percent of total billed charges,Implant Device,225.72,,,225.72,Other,110% of Medicare,159.6,35,,159.6,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,159.6,35,,159.6,percent of total billed charges,Implant Device,159.6,35,,159.6,percent of total billed charges,Implant Device,159.6,35,,159.6,percent of total billed charges,Implant Device,159.6,35,,159.6,percent of total billed charges,Implant Device,159.6,35,,159.6,percent of total billed charges,Implant Device,182.4,40,,182.4,percent of total billed charges,Implant Device,159.6,70,,159.6,percent of total billed charges,All Other,155.04,34,,155.04,percent of total billed charges,Implant Device,155.04,34,,155.04,percent of total billed charges,Implant Device,159.6,35,,159.6,percent of total billed charges,Implant Device,159.6,35,,159.6,percent of total billed charges,Implant Device,159.6,35,,159.6,percent of total billed charges,Implant Device,159.6,35,,159.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,337.44,
DEPUY 07.704.010S BONE VOID FILLER 10CC,C1713,HCPCS,,79007138,CDM,278,RC,,,both,,,11232,8311.71,,,8311.71,Other,150% of Medicare + 9.63% HCRA Surcharge,5054.4,45,,5054.4,percent of total billed charges,Critical Access Hospital RCC factor,3818.88,34,,3818.88,percent of total billed charges,Implant Device,3818.88,34,,3818.88,percent of total billed charges,Implant Device,3818.88,34,,3818.88,percent of total billed charges,Implant Device,3818.88,34,,3818.88,percent of total billed charges,Implant Device,3818.88,34,,3818.88,percent of total billed charges,Implant Device,5559.84,,,5559.84,Other,110% of Medicare,3931.2,35,,3931.2,percent of total billed charges,Implant Device,3818.88,34,"Charges > $500, x 34%",3818.88,percent of total billed charges,Implant Device,3931.2,35,,3931.2,percent of total billed charges,Implant Device,3931.2,35,,3931.2,percent of total billed charges,Implant Device,3931.2,35,,3931.2,percent of total billed charges,Implant Device,3931.2,35,,3931.2,percent of total billed charges,Implant Device,3931.2,35,,3931.2,percent of total billed charges,Implant Device,4492.8,40,,4492.8,percent of total billed charges,Implant Device,3931.2,70,,3931.2,percent of total billed charges,All Other,3818.88,34,,3818.88,percent of total billed charges,Implant Device,3818.88,34,,3818.88,percent of total billed charges,Implant Device,3931.2,35,,3931.2,percent of total billed charges,Implant Device,3931.2,35,,3931.2,percent of total billed charges,Implant Device,3931.2,35,,3931.2,percent of total billed charges,Implant Device,3931.2,35,,3931.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3818.88,34,"If Charge > 2,000, then 34 percent",3818.88,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,8311.71,
DEPUY 02.240.060 CANNLOCK SCREW 3.7X60MM,C1713,HCPCS,,79007139,CDM,278,RC,,,both,,,789,583.86,,,583.86,Other,150% of Medicare + 9.63% HCRA Surcharge,355.05,45,,355.05,percent of total billed charges,Critical Access Hospital RCC factor,268.26,34,,268.26,percent of total billed charges,Implant Device,268.26,34,,268.26,percent of total billed charges,Implant Device,268.26,34,,268.26,percent of total billed charges,Implant Device,268.26,34,,268.26,percent of total billed charges,Implant Device,268.26,34,,268.26,percent of total billed charges,Implant Device,390.56,,,390.56,Other,110% of Medicare,276.15,35,,276.15,percent of total billed charges,Implant Device,268.26,34,"Charges > $500, x 34%",268.26,percent of total billed charges,Implant Device,276.15,35,,276.15,percent of total billed charges,Implant Device,276.15,35,,276.15,percent of total billed charges,Implant Device,276.15,35,,276.15,percent of total billed charges,Implant Device,276.15,35,,276.15,percent of total billed charges,Implant Device,276.15,35,,276.15,percent of total billed charges,Implant Device,315.6,40,,315.6,percent of total billed charges,Implant Device,276.15,70,,276.15,percent of total billed charges,All Other,268.26,34,,268.26,percent of total billed charges,Implant Device,268.26,34,,268.26,percent of total billed charges,Implant Device,276.15,35,,276.15,percent of total billed charges,Implant Device,276.15,35,,276.15,percent of total billed charges,Implant Device,276.15,35,,276.15,percent of total billed charges,Implant Device,276.15,35,,276.15,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,583.86,
DEPUY 02.240.058 CANNLOCK SCREW 3.7X58MM,C1713,HCPCS,,79007140,CDM,278,RC,,,both,,,476,352.24,,,352.24,Other,150% of Medicare + 9.63% HCRA Surcharge,214.2,45,,214.2,percent of total billed charges,Critical Access Hospital RCC factor,161.84,34,,161.84,percent of total billed charges,Implant Device,161.84,34,,161.84,percent of total billed charges,Implant Device,161.84,34,,161.84,percent of total billed charges,Implant Device,161.84,34,,161.84,percent of total billed charges,Implant Device,161.84,34,,161.84,percent of total billed charges,Implant Device,235.62,,,235.62,Other,110% of Medicare,166.6,35,,166.6,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,166.6,35,,166.6,percent of total billed charges,Implant Device,166.6,35,,166.6,percent of total billed charges,Implant Device,166.6,35,,166.6,percent of total billed charges,Implant Device,166.6,35,,166.6,percent of total billed charges,Implant Device,166.6,35,,166.6,percent of total billed charges,Implant Device,190.4,40,,190.4,percent of total billed charges,Implant Device,166.6,70,,166.6,percent of total billed charges,All Other,161.84,34,,161.84,percent of total billed charges,Implant Device,161.84,34,,161.84,percent of total billed charges,Implant Device,166.6,35,,166.6,percent of total billed charges,Implant Device,166.6,35,,166.6,percent of total billed charges,Implant Device,166.6,35,,166.6,percent of total billed charges,Implant Device,166.6,35,,166.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,352.24,
DEPUY 204.832 CORTEX SCREW 3.5X32MM,C1713,HCPCS,,79007141,CDM,278,RC,,,both,,,57,42.18,,,42.18,Other,150% of Medicare + 9.63% HCRA Surcharge,25.65,45,,25.65,percent of total billed charges,Critical Access Hospital RCC factor,19.38,34,,19.38,percent of total billed charges,Implant Device,19.38,34,,19.38,percent of total billed charges,Implant Device,19.38,34,,19.38,percent of total billed charges,Implant Device,19.38,34,,19.38,percent of total billed charges,Implant Device,19.38,34,,19.38,percent of total billed charges,Implant Device,28.22,,,28.22,Other,110% of Medicare,19.95,35,,19.95,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,19.95,35,,19.95,percent of total billed charges,Implant Device,19.95,35,,19.95,percent of total billed charges,Implant Device,19.95,35,,19.95,percent of total billed charges,Implant Device,19.95,35,,19.95,percent of total billed charges,Implant Device,19.95,35,,19.95,percent of total billed charges,Implant Device,22.8,40,,22.8,percent of total billed charges,Implant Device,19.95,70,,19.95,percent of total billed charges,All Other,19.38,34,,19.38,percent of total billed charges,Implant Device,19.38,34,,19.38,percent of total billed charges,Implant Device,19.95,35,,19.95,percent of total billed charges,Implant Device,19.95,35,,19.95,percent of total billed charges,Implant Device,19.95,35,,19.95,percent of total billed charges,Implant Device,19.95,35,,19.95,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,42.18,
DEPUY 1035-51-000 BIPOLAR HEAD 28X51MM,C1776,HCPCS,,79007143,CDM,278,RC,,,both,,,4030,2982.21,,,2982.21,Other,150% of Medicare + 9.63% HCRA Surcharge,1813.5,45,,1813.5,percent of total billed charges,Critical Access Hospital RCC factor,1370.2,34,,1370.2,percent of total billed charges,Implant Device,1370.2,34,,1370.2,percent of total billed charges,Implant Device,1370.2,34,,1370.2,percent of total billed charges,Implant Device,1370.2,34,,1370.2,percent of total billed charges,Implant Device,1370.2,34,,1370.2,percent of total billed charges,Implant Device,1994.85,,,1994.85,Other,110% of Medicare,1410.5,35,,1410.5,percent of total billed charges,Implant Device,1370.2,34,"Charges > $500, x 34%",1370.2,percent of total billed charges,Implant Device,1410.5,35,,1410.5,percent of total billed charges,Implant Device,1410.5,35,,1410.5,percent of total billed charges,Implant Device,1410.5,35,,1410.5,percent of total billed charges,Implant Device,1410.5,35,,1410.5,percent of total billed charges,Implant Device,1410.5,35,,1410.5,percent of total billed charges,Implant Device,1612,40,,1612,percent of total billed charges,Implant Device,1410.5,70,,1410.5,percent of total billed charges,All Other,1370.2,34,,1370.2,percent of total billed charges,Implant Device,1370.2,34,,1370.2,percent of total billed charges,Implant Device,1410.5,35,,1410.5,percent of total billed charges,Implant Device,1410.5,35,,1410.5,percent of total billed charges,Implant Device,1410.5,35,,1410.5,percent of total billed charges,Implant Device,1410.5,35,,1410.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1370.2,34,"If Charge > 2,000, then 34 percent",1370.2,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2982.21,
DEPUY 1365-28-320 FEM HEAD 28MM +5MM,C1776,HCPCS,,79007144,CDM,278,RC,,,both,,,4539,3358.87,,,3358.87,Other,150% of Medicare + 9.63% HCRA Surcharge,2042.55,45,,2042.55,percent of total billed charges,Critical Access Hospital RCC factor,1543.26,34,,1543.26,percent of total billed charges,Implant Device,1543.26,34,,1543.26,percent of total billed charges,Implant Device,1543.26,34,,1543.26,percent of total billed charges,Implant Device,1543.26,34,,1543.26,percent of total billed charges,Implant Device,1543.26,34,,1543.26,percent of total billed charges,Implant Device,2246.81,,,2246.81,Other,110% of Medicare,1588.65,35,,1588.65,percent of total billed charges,Implant Device,1543.26,34,"Charges > $500, x 34%",1543.26,percent of total billed charges,Implant Device,1588.65,35,,1588.65,percent of total billed charges,Implant Device,1588.65,35,,1588.65,percent of total billed charges,Implant Device,1588.65,35,,1588.65,percent of total billed charges,Implant Device,1588.65,35,,1588.65,percent of total billed charges,Implant Device,1588.65,35,,1588.65,percent of total billed charges,Implant Device,1815.6,40,,1815.6,percent of total billed charges,Implant Device,1588.65,70,,1588.65,percent of total billed charges,All Other,1543.26,34,,1543.26,percent of total billed charges,Implant Device,1543.26,34,,1543.26,percent of total billed charges,Implant Device,1588.65,35,,1588.65,percent of total billed charges,Implant Device,1588.65,35,,1588.65,percent of total billed charges,Implant Device,1588.65,35,,1588.65,percent of total billed charges,Implant Device,1588.65,35,,1588.65,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1543.26,34,"If Charge > 2,000, then 34 percent",1543.26,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3358.87,
DEPUY 3L93716 CORAIL 2 LAT SZ 16,C1776,HCPCS,,79007145,CDM,278,RC,,,both,,,12861,9517.17,,,9517.17,Other,150% of Medicare + 9.63% HCRA Surcharge,5787.45,45,,5787.45,percent of total billed charges,Critical Access Hospital RCC factor,4372.74,34,,4372.74,percent of total billed charges,Implant Device,4372.74,34,,4372.74,percent of total billed charges,Implant Device,4372.74,34,,4372.74,percent of total billed charges,Implant Device,4372.74,34,,4372.74,percent of total billed charges,Implant Device,4372.74,34,,4372.74,percent of total billed charges,Implant Device,6366.2,,,6366.2,Other,110% of Medicare,4501.35,35,,4501.35,percent of total billed charges,Implant Device,4372.74,34,"Charges > $500, x 34%",4372.74,percent of total billed charges,Implant Device,4501.35,35,,4501.35,percent of total billed charges,Implant Device,4501.35,35,,4501.35,percent of total billed charges,Implant Device,4501.35,35,,4501.35,percent of total billed charges,Implant Device,4501.35,35,,4501.35,percent of total billed charges,Implant Device,4501.35,35,,4501.35,percent of total billed charges,Implant Device,5144.4,40,,5144.4,percent of total billed charges,Implant Device,4501.35,70,,4501.35,percent of total billed charges,All Other,4372.74,34,,4372.74,percent of total billed charges,Implant Device,4372.74,34,,4372.74,percent of total billed charges,Implant Device,4501.35,35,,4501.35,percent of total billed charges,Implant Device,4501.35,35,,4501.35,percent of total billed charges,Implant Device,4501.35,35,,4501.35,percent of total billed charges,Implant Device,4501.35,35,,4501.35,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,4372.74,34,"If Charge > 2,000, then 34 percent",4372.74,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,9517.17,
BIOMET EP-115395 E1 HUMERAL BEARING +3MM,C1776,HCPCS,,79007146,CDM,278,RC,,,both,,,7740,5727.62,,,5727.62,Other,150% of Medicare + 9.63% HCRA Surcharge,3483,45,,3483,percent of total billed charges,Critical Access Hospital RCC factor,2631.6,34,,2631.6,percent of total billed charges,Implant Device,2631.6,34,,2631.6,percent of total billed charges,Implant Device,2631.6,34,,2631.6,percent of total billed charges,Implant Device,2631.6,34,,2631.6,percent of total billed charges,Implant Device,2631.6,34,,2631.6,percent of total billed charges,Implant Device,3831.3,,,3831.3,Other,110% of Medicare,2709,35,,2709,percent of total billed charges,Implant Device,2631.6,34,"Charges > $500, x 34%",2631.6,percent of total billed charges,Implant Device,2709,35,,2709,percent of total billed charges,Implant Device,2709,35,,2709,percent of total billed charges,Implant Device,2709,35,,2709,percent of total billed charges,Implant Device,2709,35,,2709,percent of total billed charges,Implant Device,2709,35,,2709,percent of total billed charges,Implant Device,3096,40,,3096,percent of total billed charges,Implant Device,2709,70,,2709,percent of total billed charges,All Other,2631.6,34,,2631.6,percent of total billed charges,Implant Device,2631.6,34,,2631.6,percent of total billed charges,Implant Device,2709,35,,2709,percent of total billed charges,Implant Device,2709,35,,2709,percent of total billed charges,Implant Device,2709,35,,2709,percent of total billed charges,Implant Device,2709,35,,2709,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2631.6,34,"If Charge > 2,000, then 34 percent",2631.6,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5727.62,
STRYKER 427064 4 HOLE LOCKING PLATE,C1713,HCPCS,,79007147,CDM,278,RC,,,both,,,574,424.76,,,424.76,Other,150% of Medicare + 9.63% HCRA Surcharge,258.3,45,,258.3,percent of total billed charges,Critical Access Hospital RCC factor,195.16,34,,195.16,percent of total billed charges,Implant Device,195.16,34,,195.16,percent of total billed charges,Implant Device,195.16,34,,195.16,percent of total billed charges,Implant Device,195.16,34,,195.16,percent of total billed charges,Implant Device,195.16,34,,195.16,percent of total billed charges,Implant Device,284.13,,,284.13,Other,110% of Medicare,200.9,35,,200.9,percent of total billed charges,Implant Device,195.16,34,"Charges > $500, x 34%",195.16,percent of total billed charges,Implant Device,200.9,35,,200.9,percent of total billed charges,Implant Device,200.9,35,,200.9,percent of total billed charges,Implant Device,200.9,35,,200.9,percent of total billed charges,Implant Device,200.9,35,,200.9,percent of total billed charges,Implant Device,200.9,35,,200.9,percent of total billed charges,Implant Device,229.6,40,,229.6,percent of total billed charges,Implant Device,200.9,70,,200.9,percent of total billed charges,All Other,195.16,34,,195.16,percent of total billed charges,Implant Device,195.16,34,,195.16,percent of total billed charges,Implant Device,200.9,35,,200.9,percent of total billed charges,Implant Device,200.9,35,,200.9,percent of total billed charges,Implant Device,200.9,35,,200.9,percent of total billed charges,Implant Device,200.9,35,,200.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,424.76,
STRYKER 371010 LOCKING SCREW 3X10MM,C1713,HCPCS,,79007148,CDM,278,RC,,,both,,,334,247.16,,,247.16,Other,150% of Medicare + 9.63% HCRA Surcharge,150.3,45,,150.3,percent of total billed charges,Critical Access Hospital RCC factor,113.56,34,,113.56,percent of total billed charges,Implant Device,113.56,34,,113.56,percent of total billed charges,Implant Device,113.56,34,,113.56,percent of total billed charges,Implant Device,113.56,34,,113.56,percent of total billed charges,Implant Device,113.56,34,,113.56,percent of total billed charges,Implant Device,165.33,,,165.33,Other,110% of Medicare,116.9,35,,116.9,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,116.9,35,,116.9,percent of total billed charges,Implant Device,116.9,35,,116.9,percent of total billed charges,Implant Device,116.9,35,,116.9,percent of total billed charges,Implant Device,116.9,35,,116.9,percent of total billed charges,Implant Device,116.9,35,,116.9,percent of total billed charges,Implant Device,133.6,40,,133.6,percent of total billed charges,Implant Device,116.9,70,,116.9,percent of total billed charges,All Other,113.56,34,,113.56,percent of total billed charges,Implant Device,113.56,34,,113.56,percent of total billed charges,Implant Device,116.9,35,,116.9,percent of total billed charges,Implant Device,116.9,35,,116.9,percent of total billed charges,Implant Device,116.9,35,,116.9,percent of total billed charges,Implant Device,116.9,35,,116.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,247.16,
DEPUY 208.438 CANNULATED SCREW 6.5X32MM,C1713,HCPCS,,79007149,CDM,278,RC,,,both,,,683,505.42,,,505.42,Other,150% of Medicare + 9.63% HCRA Surcharge,307.35,45,,307.35,percent of total billed charges,Critical Access Hospital RCC factor,232.22,34,,232.22,percent of total billed charges,Implant Device,232.22,34,,232.22,percent of total billed charges,Implant Device,232.22,34,,232.22,percent of total billed charges,Implant Device,232.22,34,,232.22,percent of total billed charges,Implant Device,232.22,34,,232.22,percent of total billed charges,Implant Device,338.09,,,338.09,Other,110% of Medicare,239.05,35,,239.05,percent of total billed charges,Implant Device,232.22,34,"Charges > $500, x 34%",232.22,percent of total billed charges,Implant Device,239.05,35,,239.05,percent of total billed charges,Implant Device,239.05,35,,239.05,percent of total billed charges,Implant Device,239.05,35,,239.05,percent of total billed charges,Implant Device,239.05,35,,239.05,percent of total billed charges,Implant Device,239.05,35,,239.05,percent of total billed charges,Implant Device,273.2,40,,273.2,percent of total billed charges,Implant Device,239.05,70,,239.05,percent of total billed charges,All Other,232.22,34,,232.22,percent of total billed charges,Implant Device,232.22,34,,232.22,percent of total billed charges,Implant Device,239.05,35,,239.05,percent of total billed charges,Implant Device,239.05,35,,239.05,percent of total billed charges,Implant Device,239.05,35,,239.05,percent of total billed charges,Implant Device,239.05,35,,239.05,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,505.42,
DEPUY 208.408 CANNULATED SCREW 6.5X16MM,C1713,HCPCS,,79007150,CDM,278,RC,,,both,,,1021,755.54,,,755.54,Other,150% of Medicare + 9.63% HCRA Surcharge,459.45,45,,459.45,percent of total billed charges,Critical Access Hospital RCC factor,347.14,34,,347.14,percent of total billed charges,Implant Device,347.14,34,,347.14,percent of total billed charges,Implant Device,347.14,34,,347.14,percent of total billed charges,Implant Device,347.14,34,,347.14,percent of total billed charges,Implant Device,347.14,34,,347.14,percent of total billed charges,Implant Device,505.4,,,505.4,Other,110% of Medicare,357.35,35,,357.35,percent of total billed charges,Implant Device,347.14,34,"Charges > $500, x 34%",347.14,percent of total billed charges,Implant Device,357.35,35,,357.35,percent of total billed charges,Implant Device,357.35,35,,357.35,percent of total billed charges,Implant Device,357.35,35,,357.35,percent of total billed charges,Implant Device,357.35,35,,357.35,percent of total billed charges,Implant Device,357.35,35,,357.35,percent of total billed charges,Implant Device,408.4,40,,408.4,percent of total billed charges,Implant Device,357.35,70,,357.35,percent of total billed charges,All Other,347.14,34,,347.14,percent of total billed charges,Implant Device,347.14,34,,347.14,percent of total billed charges,Implant Device,357.35,35,,357.35,percent of total billed charges,Implant Device,357.35,35,,357.35,percent of total billed charges,Implant Device,357.35,35,,357.35,percent of total billed charges,Implant Device,357.35,35,,357.35,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,755.54,
LIFE SPINE 465-45-5 POLY SCREW 6.5X45MM,C1713,HCPCS,,79007151,CDM,278,RC,,,both,,,6720,4972.82,,,4972.82,Other,150% of Medicare + 9.63% HCRA Surcharge,3024,45,,3024,percent of total billed charges,Critical Access Hospital RCC factor,2284.8,34,,2284.8,percent of total billed charges,Implant Device,2284.8,34,,2284.8,percent of total billed charges,Implant Device,2284.8,34,,2284.8,percent of total billed charges,Implant Device,2284.8,34,,2284.8,percent of total billed charges,Implant Device,2284.8,34,,2284.8,percent of total billed charges,Implant Device,3326.4,,,3326.4,Other,110% of Medicare,2352,35,,2352,percent of total billed charges,Implant Device,2284.8,34,"Charges > $500, x 34%",2284.8,percent of total billed charges,Implant Device,2352,35,,2352,percent of total billed charges,Implant Device,2352,35,,2352,percent of total billed charges,Implant Device,2352,35,,2352,percent of total billed charges,Implant Device,2352,35,,2352,percent of total billed charges,Implant Device,2352,35,,2352,percent of total billed charges,Implant Device,2688,40,,2688,percent of total billed charges,Implant Device,2352,70,,2352,percent of total billed charges,All Other,2284.8,34,,2284.8,percent of total billed charges,Implant Device,2284.8,34,,2284.8,percent of total billed charges,Implant Device,2352,35,,2352,percent of total billed charges,Implant Device,2352,35,,2352,percent of total billed charges,Implant Device,2352,35,,2352,percent of total billed charges,Implant Device,2352,35,,2352,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2284.8,34,"If Charge > 2,000, then 34 percent",2284.8,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4972.82,
LIFE SPINE 465-50-5 POLY SCREW 6.5X50MM,C1713,HCPCS,,79007152,CDM,278,RC,,,both,,,6720,4972.82,,,4972.82,Other,150% of Medicare + 9.63% HCRA Surcharge,3024,45,,3024,percent of total billed charges,Critical Access Hospital RCC factor,2284.8,34,,2284.8,percent of total billed charges,Implant Device,2284.8,34,,2284.8,percent of total billed charges,Implant Device,2284.8,34,,2284.8,percent of total billed charges,Implant Device,2284.8,34,,2284.8,percent of total billed charges,Implant Device,2284.8,34,,2284.8,percent of total billed charges,Implant Device,3326.4,,,3326.4,Other,110% of Medicare,2352,35,,2352,percent of total billed charges,Implant Device,2284.8,34,"Charges > $500, x 34%",2284.8,percent of total billed charges,Implant Device,2352,35,,2352,percent of total billed charges,Implant Device,2352,35,,2352,percent of total billed charges,Implant Device,2352,35,,2352,percent of total billed charges,Implant Device,2352,35,,2352,percent of total billed charges,Implant Device,2352,35,,2352,percent of total billed charges,Implant Device,2688,40,,2688,percent of total billed charges,Implant Device,2352,70,,2352,percent of total billed charges,All Other,2284.8,34,,2284.8,percent of total billed charges,Implant Device,2284.8,34,,2284.8,percent of total billed charges,Implant Device,2352,35,,2352,percent of total billed charges,Implant Device,2352,35,,2352,percent of total billed charges,Implant Device,2352,35,,2352,percent of total billed charges,Implant Device,2352,35,,2352,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2284.8,34,"If Charge > 2,000, then 34 percent",2284.8,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4972.82,
LIFE SPINE 475-40-5 POLY SCREW 7.5X40MM,C1713,HCPCS,,79007153,CDM,278,RC,,,both,,,6720,4972.82,,,4972.82,Other,150% of Medicare + 9.63% HCRA Surcharge,3024,45,,3024,percent of total billed charges,Critical Access Hospital RCC factor,2284.8,34,,2284.8,percent of total billed charges,Implant Device,2284.8,34,,2284.8,percent of total billed charges,Implant Device,2284.8,34,,2284.8,percent of total billed charges,Implant Device,2284.8,34,,2284.8,percent of total billed charges,Implant Device,2284.8,34,,2284.8,percent of total billed charges,Implant Device,3326.4,,,3326.4,Other,110% of Medicare,2352,35,,2352,percent of total billed charges,Implant Device,2284.8,34,"Charges > $500, x 34%",2284.8,percent of total billed charges,Implant Device,2352,35,,2352,percent of total billed charges,Implant Device,2352,35,,2352,percent of total billed charges,Implant Device,2352,35,,2352,percent of total billed charges,Implant Device,2352,35,,2352,percent of total billed charges,Implant Device,2352,35,,2352,percent of total billed charges,Implant Device,2688,40,,2688,percent of total billed charges,Implant Device,2352,70,,2352,percent of total billed charges,All Other,2284.8,34,,2284.8,percent of total billed charges,Implant Device,2284.8,34,,2284.8,percent of total billed charges,Implant Device,2352,35,,2352,percent of total billed charges,Implant Device,2352,35,,2352,percent of total billed charges,Implant Device,2352,35,,2352,percent of total billed charges,Implant Device,2352,35,,2352,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2284.8,34,"If Charge > 2,000, then 34 percent",2284.8,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4972.82,
LIFE SPINE 4550-075 PREBENT ROD 5.5X75MM,C1713,HCPCS,,79007154,CDM,278,RC,,,both,,,1020,754.8,,,754.8,Other,150% of Medicare + 9.63% HCRA Surcharge,459,45,,459,percent of total billed charges,Critical Access Hospital RCC factor,346.8,34,,346.8,percent of total billed charges,Implant Device,346.8,34,,346.8,percent of total billed charges,Implant Device,346.8,34,,346.8,percent of total billed charges,Implant Device,346.8,34,,346.8,percent of total billed charges,Implant Device,346.8,34,,346.8,percent of total billed charges,Implant Device,504.9,,,504.9,Other,110% of Medicare,357,35,,357,percent of total billed charges,Implant Device,346.8,34,"Charges > $500, x 34%",346.8,percent of total billed charges,Implant Device,357,35,,357,percent of total billed charges,Implant Device,357,35,,357,percent of total billed charges,Implant Device,357,35,,357,percent of total billed charges,Implant Device,357,35,,357,percent of total billed charges,Implant Device,357,35,,357,percent of total billed charges,Implant Device,408,40,,408,percent of total billed charges,Implant Device,357,70,,357,percent of total billed charges,All Other,346.8,34,,346.8,percent of total billed charges,Implant Device,346.8,34,,346.8,percent of total billed charges,Implant Device,357,35,,357,percent of total billed charges,Implant Device,357,35,,357,percent of total billed charges,Implant Device,357,35,,357,percent of total billed charges,Implant Device,357,35,,357,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,754.8,
LIFE SPINE 148-003 LOCKING CAP,C1713,HCPCS,,79007155,CDM,278,RC,,,both,,,1920,1420.8,,,1420.8,Other,150% of Medicare + 9.63% HCRA Surcharge,864,45,,864,percent of total billed charges,Critical Access Hospital RCC factor,652.8,34,,652.8,percent of total billed charges,Implant Device,652.8,34,,652.8,percent of total billed charges,Implant Device,652.8,34,,652.8,percent of total billed charges,Implant Device,652.8,34,,652.8,percent of total billed charges,Implant Device,652.8,34,,652.8,percent of total billed charges,Implant Device,950.4,,,950.4,Other,110% of Medicare,672,35,,672,percent of total billed charges,Implant Device,652.8,34,"Charges > $500, x 34%",652.8,percent of total billed charges,Implant Device,672,35,,672,percent of total billed charges,Implant Device,672,35,,672,percent of total billed charges,Implant Device,672,35,,672,percent of total billed charges,Implant Device,672,35,,672,percent of total billed charges,Implant Device,672,35,,672,percent of total billed charges,Implant Device,768,40,,768,percent of total billed charges,Implant Device,672,70,,672,percent of total billed charges,All Other,652.8,34,,652.8,percent of total billed charges,Implant Device,652.8,34,,652.8,percent of total billed charges,Implant Device,672,35,,672,percent of total billed charges,Implant Device,672,35,,672,percent of total billed charges,Implant Device,672,35,,672,percent of total billed charges,Implant Device,672,35,,672,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1420.8,
LIFE SPINE 800-316-55 XCONNECT LYNX 55MM,C1713,HCPCS,,79007156,CDM,278,RC,,,both,,,9480,7015.22,,,7015.22,Other,150% of Medicare + 9.63% HCRA Surcharge,4266,45,,4266,percent of total billed charges,Critical Access Hospital RCC factor,3223.2,34,,3223.2,percent of total billed charges,Implant Device,3223.2,34,,3223.2,percent of total billed charges,Implant Device,3223.2,34,,3223.2,percent of total billed charges,Implant Device,3223.2,34,,3223.2,percent of total billed charges,Implant Device,3223.2,34,,3223.2,percent of total billed charges,Implant Device,4692.6,,,4692.6,Other,110% of Medicare,3318,35,,3318,percent of total billed charges,Implant Device,3223.2,34,"Charges > $500, x 34%",3223.2,percent of total billed charges,Implant Device,3318,35,,3318,percent of total billed charges,Implant Device,3318,35,,3318,percent of total billed charges,Implant Device,3318,35,,3318,percent of total billed charges,Implant Device,3318,35,,3318,percent of total billed charges,Implant Device,3318,35,,3318,percent of total billed charges,Implant Device,3792,40,,3792,percent of total billed charges,Implant Device,3318,70,,3318,percent of total billed charges,All Other,3223.2,34,,3223.2,percent of total billed charges,Implant Device,3223.2,34,,3223.2,percent of total billed charges,Implant Device,3318,35,,3318,percent of total billed charges,Implant Device,3318,35,,3318,percent of total billed charges,Implant Device,3318,35,,3318,percent of total billed charges,Implant Device,3318,35,,3318,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3223.2,34,"If Charge > 2,000, then 34 percent",3223.2,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,7015.22,
STRYKER 5630-G-308 TIBIAL INSRT SZ 3 8MM,C1776,HCPCS,,79007158,CDM,278,RC,,,both,,,3232,2391.69,,,2391.69,Other,150% of Medicare + 9.63% HCRA Surcharge,1454.4,45,,1454.4,percent of total billed charges,Critical Access Hospital RCC factor,1098.88,34,,1098.88,percent of total billed charges,Implant Device,1098.88,34,,1098.88,percent of total billed charges,Implant Device,1098.88,34,,1098.88,percent of total billed charges,Implant Device,1098.88,34,,1098.88,percent of total billed charges,Implant Device,1098.88,34,,1098.88,percent of total billed charges,Implant Device,1599.84,,,1599.84,Other,110% of Medicare,1131.2,35,,1131.2,percent of total billed charges,Implant Device,1098.88,34,"Charges > $500, x 34%",1098.88,percent of total billed charges,Implant Device,1131.2,35,,1131.2,percent of total billed charges,Implant Device,1131.2,35,,1131.2,percent of total billed charges,Implant Device,1131.2,35,,1131.2,percent of total billed charges,Implant Device,1131.2,35,,1131.2,percent of total billed charges,Implant Device,1131.2,35,,1131.2,percent of total billed charges,Implant Device,1292.8,40,,1292.8,percent of total billed charges,Implant Device,1131.2,70,,1131.2,percent of total billed charges,All Other,1098.88,34,,1098.88,percent of total billed charges,Implant Device,1098.88,34,,1098.88,percent of total billed charges,Implant Device,1131.2,35,,1131.2,percent of total billed charges,Implant Device,1131.2,35,,1131.2,percent of total billed charges,Implant Device,1131.2,35,,1131.2,percent of total billed charges,Implant Device,1131.2,35,,1131.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1098.88,34,"If Charge > 2,000, then 34 percent",1098.88,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2391.69,
STRYKER 5620-B-301 TIBIAL BASEPLATE SZ 3,C1776,HCPCS,,79007159,CDM,278,RC,,,both,,,4937,3653.39,,,3653.39,Other,150% of Medicare + 9.63% HCRA Surcharge,2221.65,45,,2221.65,percent of total billed charges,Critical Access Hospital RCC factor,1678.58,34,,1678.58,percent of total billed charges,Implant Device,1678.58,34,,1678.58,percent of total billed charges,Implant Device,1678.58,34,,1678.58,percent of total billed charges,Implant Device,1678.58,34,,1678.58,percent of total billed charges,Implant Device,1678.58,34,,1678.58,percent of total billed charges,Implant Device,2443.82,,,2443.82,Other,110% of Medicare,1727.95,35,,1727.95,percent of total billed charges,Implant Device,1678.58,34,"Charges > $500, x 34%",1678.58,percent of total billed charges,Implant Device,1727.95,35,,1727.95,percent of total billed charges,Implant Device,1727.95,35,,1727.95,percent of total billed charges,Implant Device,1727.95,35,,1727.95,percent of total billed charges,Implant Device,1727.95,35,,1727.95,percent of total billed charges,Implant Device,1727.95,35,,1727.95,percent of total billed charges,Implant Device,1974.8,40,,1974.8,percent of total billed charges,Implant Device,1727.95,70,,1727.95,percent of total billed charges,All Other,1678.58,34,,1678.58,percent of total billed charges,Implant Device,1678.58,34,,1678.58,percent of total billed charges,Implant Device,1727.95,35,,1727.95,percent of total billed charges,Implant Device,1727.95,35,,1727.95,percent of total billed charges,Implant Device,1727.95,35,,1727.95,percent of total billed charges,Implant Device,1727.95,35,,1727.95,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1678.58,34,"If Charge > 2,000, then 34 percent",1678.58,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3653.39,
STRYKER 5610-F-301 FEMORAL COMPNENT SZ 3,C1776,HCPCS,,79007160,CDM,278,RC,,,both,,,8352,6180.5,,,6180.5,Other,150% of Medicare + 9.63% HCRA Surcharge,3758.4,45,,3758.4,percent of total billed charges,Critical Access Hospital RCC factor,2839.68,34,,2839.68,percent of total billed charges,Implant Device,2839.68,34,,2839.68,percent of total billed charges,Implant Device,2839.68,34,,2839.68,percent of total billed charges,Implant Device,2839.68,34,,2839.68,percent of total billed charges,Implant Device,2839.68,34,,2839.68,percent of total billed charges,Implant Device,4134.24,,,4134.24,Other,110% of Medicare,2923.2,35,,2923.2,percent of total billed charges,Implant Device,2839.68,34,"Charges > $500, x 34%",2839.68,percent of total billed charges,Implant Device,2923.2,35,,2923.2,percent of total billed charges,Implant Device,2923.2,35,,2923.2,percent of total billed charges,Implant Device,2923.2,35,,2923.2,percent of total billed charges,Implant Device,2923.2,35,,2923.2,percent of total billed charges,Implant Device,2923.2,35,,2923.2,percent of total billed charges,Implant Device,3340.8,40,,3340.8,percent of total billed charges,Implant Device,2923.2,70,,2923.2,percent of total billed charges,All Other,2839.68,34,,2839.68,percent of total billed charges,Implant Device,2839.68,34,,2839.68,percent of total billed charges,Implant Device,2923.2,35,,2923.2,percent of total billed charges,Implant Device,2923.2,35,,2923.2,percent of total billed charges,Implant Device,2923.2,35,,2923.2,percent of total billed charges,Implant Device,2923.2,35,,2923.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2839.68,34,"If Charge > 2,000, then 34 percent",2839.68,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,6180.5,
STRYKER 4922-8-400 11X400MM CARBON ROD,C1713,HCPCS,,79007161,CDM,278,RC,,,both,,,2121,1569.55,,,1569.55,Other,150% of Medicare + 9.63% HCRA Surcharge,954.45,45,,954.45,percent of total billed charges,Critical Access Hospital RCC factor,721.14,34,,721.14,percent of total billed charges,Implant Device,721.14,34,,721.14,percent of total billed charges,Implant Device,721.14,34,,721.14,percent of total billed charges,Implant Device,721.14,34,,721.14,percent of total billed charges,Implant Device,721.14,34,,721.14,percent of total billed charges,Implant Device,1049.9,,,1049.9,Other,110% of Medicare,742.35,35,,742.35,percent of total billed charges,Implant Device,721.14,34,"Charges > $500, x 34%",721.14,percent of total billed charges,Implant Device,742.35,35,,742.35,percent of total billed charges,Implant Device,742.35,35,,742.35,percent of total billed charges,Implant Device,742.35,35,,742.35,percent of total billed charges,Implant Device,742.35,35,,742.35,percent of total billed charges,Implant Device,742.35,35,,742.35,percent of total billed charges,Implant Device,848.4,40,,848.4,percent of total billed charges,Implant Device,742.35,70,,742.35,percent of total billed charges,All Other,721.14,34,,721.14,percent of total billed charges,Implant Device,721.14,34,,721.14,percent of total billed charges,Implant Device,742.35,35,,742.35,percent of total billed charges,Implant Device,742.35,35,,742.35,percent of total billed charges,Implant Device,742.35,35,,742.35,percent of total billed charges,Implant Device,742.35,35,,742.35,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,721.14,34,"If Charge > 2,000, then 34 percent",721.14,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1569.55,
STRYKER 4922-2-020 5 PIN CLAMP,C1713,HCPCS,,79007163,CDM,278,RC,,,both,,,1646,1218.04,,,1218.04,Other,150% of Medicare + 9.63% HCRA Surcharge,740.7,45,,740.7,percent of total billed charges,Critical Access Hospital RCC factor,559.64,34,,559.64,percent of total billed charges,Implant Device,559.64,34,,559.64,percent of total billed charges,Implant Device,559.64,34,,559.64,percent of total billed charges,Implant Device,559.64,34,,559.64,percent of total billed charges,Implant Device,559.64,34,,559.64,percent of total billed charges,Implant Device,814.77,,,814.77,Other,110% of Medicare,576.1,35,,576.1,percent of total billed charges,Implant Device,559.64,34,"Charges > $500, x 34%",559.64,percent of total billed charges,Implant Device,576.1,35,,576.1,percent of total billed charges,Implant Device,576.1,35,,576.1,percent of total billed charges,Implant Device,576.1,35,,576.1,percent of total billed charges,Implant Device,576.1,35,,576.1,percent of total billed charges,Implant Device,576.1,35,,576.1,percent of total billed charges,Implant Device,658.4,40,,658.4,percent of total billed charges,Implant Device,576.1,70,,576.1,percent of total billed charges,All Other,559.64,34,,559.64,percent of total billed charges,Implant Device,559.64,34,,559.64,percent of total billed charges,Implant Device,576.1,35,,576.1,percent of total billed charges,Implant Device,576.1,35,,576.1,percent of total billed charges,Implant Device,576.1,35,,576.1,percent of total billed charges,Implant Device,576.1,35,,576.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1218.04,
STRYKER 4922-2-140 11X30DEG ANGELED POST,C1713,HCPCS,,79007164,CDM,278,RC,,,both,,,289,213.86,,,213.86,Other,150% of Medicare + 9.63% HCRA Surcharge,130.05,45,,130.05,percent of total billed charges,Critical Access Hospital RCC factor,98.26,34,,98.26,percent of total billed charges,Implant Device,98.26,34,,98.26,percent of total billed charges,Implant Device,98.26,34,,98.26,percent of total billed charges,Implant Device,98.26,34,,98.26,percent of total billed charges,Implant Device,98.26,34,,98.26,percent of total billed charges,Implant Device,143.06,,,143.06,Other,110% of Medicare,101.15,35,,101.15,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,101.15,35,,101.15,percent of total billed charges,Implant Device,101.15,35,,101.15,percent of total billed charges,Implant Device,101.15,35,,101.15,percent of total billed charges,Implant Device,101.15,35,,101.15,percent of total billed charges,Implant Device,101.15,35,,101.15,percent of total billed charges,Implant Device,115.6,40,,115.6,percent of total billed charges,Implant Device,101.15,70,,101.15,percent of total billed charges,All Other,98.26,34,,98.26,percent of total billed charges,Implant Device,98.26,34,,98.26,percent of total billed charges,Implant Device,101.15,35,,101.15,percent of total billed charges,Implant Device,101.15,35,,101.15,percent of total billed charges,Implant Device,101.15,35,,101.15,percent of total billed charges,Implant Device,101.15,35,,101.15,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,213.86,
ARROW CS-15192-SFX NEXT STEP CATH 19CM,C1750,HCPCS,,79007165,CDM,278,RC,,,both,,,946,700.04,,,700.04,Other,150% of Medicare + 9.63% HCRA Surcharge,425.7,45,,425.7,percent of total billed charges,Critical Access Hospital RCC factor,321.64,34,,321.64,percent of total billed charges,Implant Device,321.64,34,,321.64,percent of total billed charges,Implant Device,321.64,34,,321.64,percent of total billed charges,Implant Device,321.64,34,,321.64,percent of total billed charges,Implant Device,321.64,34,,321.64,percent of total billed charges,Implant Device,468.27,,,468.27,Other,110% of Medicare,331.1,35,,331.1,percent of total billed charges,Implant Device,321.64,34,"Charges > $500, x 34%",321.64,percent of total billed charges,Implant Device,331.1,35,,331.1,percent of total billed charges,Implant Device,331.1,35,,331.1,percent of total billed charges,Implant Device,331.1,35,,331.1,percent of total billed charges,Implant Device,331.1,35,,331.1,percent of total billed charges,Implant Device,331.1,35,,331.1,percent of total billed charges,Implant Device,378.4,40,,378.4,percent of total billed charges,Implant Device,331.1,70,,331.1,percent of total billed charges,All Other,321.64,34,,321.64,percent of total billed charges,Implant Device,321.64,34,,321.64,percent of total billed charges,Implant Device,331.1,35,,331.1,percent of total billed charges,Implant Device,331.1,35,,331.1,percent of total billed charges,Implant Device,331.1,35,,331.1,percent of total billed charges,Implant Device,331.1,35,,331.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,700.04,
ARROW CS-15232-SFX NEXT STEP CATH 23CM,C1750,HCPCS,,79007166,CDM,278,RC,,,both,,,946,700.04,,,700.04,Other,150% of Medicare + 9.63% HCRA Surcharge,425.7,45,,425.7,percent of total billed charges,Critical Access Hospital RCC factor,321.64,34,,321.64,percent of total billed charges,Implant Device,321.64,34,,321.64,percent of total billed charges,Implant Device,321.64,34,,321.64,percent of total billed charges,Implant Device,321.64,34,,321.64,percent of total billed charges,Implant Device,321.64,34,,321.64,percent of total billed charges,Implant Device,468.27,,,468.27,Other,110% of Medicare,331.1,35,,331.1,percent of total billed charges,Implant Device,321.64,34,"Charges > $500, x 34%",321.64,percent of total billed charges,Implant Device,331.1,35,,331.1,percent of total billed charges,Implant Device,331.1,35,,331.1,percent of total billed charges,Implant Device,331.1,35,,331.1,percent of total billed charges,Implant Device,331.1,35,,331.1,percent of total billed charges,Implant Device,331.1,35,,331.1,percent of total billed charges,Implant Device,378.4,40,,378.4,percent of total billed charges,Implant Device,331.1,70,,331.1,percent of total billed charges,All Other,321.64,34,,321.64,percent of total billed charges,Implant Device,321.64,34,,321.64,percent of total billed charges,Implant Device,331.1,35,,331.1,percent of total billed charges,Implant Device,331.1,35,,331.1,percent of total billed charges,Implant Device,331.1,35,,331.1,percent of total billed charges,Implant Device,331.1,35,,331.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,700.04,
ARROW CS-15272-SFX NEXT STEP CATH 27CM,C1750,HCPCS,,79007167,CDM,278,RC,,,both,,,946,700.04,,,700.04,Other,150% of Medicare + 9.63% HCRA Surcharge,425.7,45,,425.7,percent of total billed charges,Critical Access Hospital RCC factor,321.64,34,,321.64,percent of total billed charges,Implant Device,321.64,34,,321.64,percent of total billed charges,Implant Device,321.64,34,,321.64,percent of total billed charges,Implant Device,321.64,34,,321.64,percent of total billed charges,Implant Device,321.64,34,,321.64,percent of total billed charges,Implant Device,468.27,,,468.27,Other,110% of Medicare,331.1,35,,331.1,percent of total billed charges,Implant Device,321.64,34,"Charges > $500, x 34%",321.64,percent of total billed charges,Implant Device,331.1,35,,331.1,percent of total billed charges,Implant Device,331.1,35,,331.1,percent of total billed charges,Implant Device,331.1,35,,331.1,percent of total billed charges,Implant Device,331.1,35,,331.1,percent of total billed charges,Implant Device,331.1,35,,331.1,percent of total billed charges,Implant Device,378.4,40,,378.4,percent of total billed charges,Implant Device,331.1,70,,331.1,percent of total billed charges,All Other,321.64,34,,321.64,percent of total billed charges,Implant Device,321.64,34,,321.64,percent of total billed charges,Implant Device,331.1,35,,331.1,percent of total billed charges,Implant Device,331.1,35,,331.1,percent of total billed charges,Implant Device,331.1,35,,331.1,percent of total billed charges,Implant Device,331.1,35,,331.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,700.04,
STRYKER 604648S 4X48MM PT SCREW,C1713,HCPCS,,79007169,CDM,278,RC,,,both,,,446,330.04,,,330.04,Other,150% of Medicare + 9.63% HCRA Surcharge,200.7,45,,200.7,percent of total billed charges,Critical Access Hospital RCC factor,151.64,34,,151.64,percent of total billed charges,Implant Device,151.64,34,,151.64,percent of total billed charges,Implant Device,151.64,34,,151.64,percent of total billed charges,Implant Device,151.64,34,,151.64,percent of total billed charges,Implant Device,151.64,34,,151.64,percent of total billed charges,Implant Device,220.77,,,220.77,Other,110% of Medicare,156.1,35,,156.1,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,156.1,35,,156.1,percent of total billed charges,Implant Device,156.1,35,,156.1,percent of total billed charges,Implant Device,156.1,35,,156.1,percent of total billed charges,Implant Device,156.1,35,,156.1,percent of total billed charges,Implant Device,156.1,35,,156.1,percent of total billed charges,Implant Device,178.4,40,,178.4,percent of total billed charges,Implant Device,156.1,70,,156.1,percent of total billed charges,All Other,151.64,34,,151.64,percent of total billed charges,Implant Device,151.64,34,,151.64,percent of total billed charges,Implant Device,156.1,35,,156.1,percent of total billed charges,Implant Device,156.1,35,,156.1,percent of total billed charges,Implant Device,156.1,35,,156.1,percent of total billed charges,Implant Device,156.1,35,,156.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,330.04,
EXACTECH 304-21-13 HUMERAL STEM 12.5MM,C1776,HCPCS,,79007170,CDM,278,RC,,,both,,,12015,8891.13,,,8891.13,Other,150% of Medicare + 9.63% HCRA Surcharge,5406.75,45,,5406.75,percent of total billed charges,Critical Access Hospital RCC factor,4085.1,34,,4085.1,percent of total billed charges,Implant Device,4085.1,34,,4085.1,percent of total billed charges,Implant Device,4085.1,34,,4085.1,percent of total billed charges,Implant Device,4085.1,34,,4085.1,percent of total billed charges,Implant Device,4085.1,34,,4085.1,percent of total billed charges,Implant Device,5947.43,,,5947.43,Other,110% of Medicare,4205.25,35,,4205.25,percent of total billed charges,Implant Device,4085.1,34,"Charges > $500, x 34%",4085.1,percent of total billed charges,Implant Device,4205.25,35,,4205.25,percent of total billed charges,Implant Device,4205.25,35,,4205.25,percent of total billed charges,Implant Device,4205.25,35,,4205.25,percent of total billed charges,Implant Device,4205.25,35,,4205.25,percent of total billed charges,Implant Device,4205.25,35,,4205.25,percent of total billed charges,Implant Device,4806,40,,4806,percent of total billed charges,Implant Device,4205.25,70,,4205.25,percent of total billed charges,All Other,4085.1,34,,4085.1,percent of total billed charges,Implant Device,4085.1,34,,4085.1,percent of total billed charges,Implant Device,4205.25,35,,4205.25,percent of total billed charges,Implant Device,4205.25,35,,4205.25,percent of total billed charges,Implant Device,4205.25,35,,4205.25,percent of total billed charges,Implant Device,4205.25,35,,4205.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,4085.1,34,"If Charge > 2,000, then 34 percent",4085.1,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,8891.13,
ARTHREX AR-2324BCC-2 SWIVELOCK 4.75MM,C1713,HCPCS,,79007171,CDM,278,RC,,,both,,,1251,925.74,,,925.74,Other,150% of Medicare + 9.63% HCRA Surcharge,562.95,45,,562.95,percent of total billed charges,Critical Access Hospital RCC factor,425.34,34,,425.34,percent of total billed charges,Implant Device,425.34,34,,425.34,percent of total billed charges,Implant Device,425.34,34,,425.34,percent of total billed charges,Implant Device,425.34,34,,425.34,percent of total billed charges,Implant Device,425.34,34,,425.34,percent of total billed charges,Implant Device,619.25,,,619.25,Other,110% of Medicare,437.85,35,,437.85,percent of total billed charges,Implant Device,425.34,34,"Charges > $500, x 34%",425.34,percent of total billed charges,Implant Device,437.85,35,,437.85,percent of total billed charges,Implant Device,437.85,35,,437.85,percent of total billed charges,Implant Device,437.85,35,,437.85,percent of total billed charges,Implant Device,437.85,35,,437.85,percent of total billed charges,Implant Device,437.85,35,,437.85,percent of total billed charges,Implant Device,500.4,40,,500.4,percent of total billed charges,Implant Device,437.85,70,,437.85,percent of total billed charges,All Other,425.34,34,,425.34,percent of total billed charges,Implant Device,425.34,34,,425.34,percent of total billed charges,Implant Device,437.85,35,,437.85,percent of total billed charges,Implant Device,437.85,35,,437.85,percent of total billed charges,Implant Device,437.85,35,,437.85,percent of total billed charges,Implant Device,437.85,35,,437.85,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,925.74,
ALPHATEC 62085-50 SCREW 8.5X50MM,C1713,HCPCS,,79007172,CDM,278,RC,,,both,,,2550,1887.01,,,1887.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1147.5,45,,1147.5,percent of total billed charges,Critical Access Hospital RCC factor,867,34,,867,percent of total billed charges,Implant Device,867,34,,867,percent of total billed charges,Implant Device,867,34,,867,percent of total billed charges,Implant Device,867,34,,867,percent of total billed charges,Implant Device,867,34,,867,percent of total billed charges,Implant Device,1262.25,,,1262.25,Other,110% of Medicare,892.5,35,,892.5,percent of total billed charges,Implant Device,867,34,"Charges > $500, x 34%",867,percent of total billed charges,Implant Device,892.5,35,,892.5,percent of total billed charges,Implant Device,892.5,35,,892.5,percent of total billed charges,Implant Device,892.5,35,,892.5,percent of total billed charges,Implant Device,892.5,35,,892.5,percent of total billed charges,Implant Device,892.5,35,,892.5,percent of total billed charges,Implant Device,1020,40,,1020,percent of total billed charges,Implant Device,892.5,70,,892.5,percent of total billed charges,All Other,867,34,,867,percent of total billed charges,Implant Device,867,34,,867,percent of total billed charges,Implant Device,892.5,35,,892.5,percent of total billed charges,Implant Device,892.5,35,,892.5,percent of total billed charges,Implant Device,892.5,35,,892.5,percent of total billed charges,Implant Device,892.5,35,,892.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,867,34,"If Charge > 2,000, then 34 percent",867,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1887.01,
ALPHATEC 62004-12 ROD 120MM,C1713,HCPCS,,79007173,CDM,278,RC,,,both,,,600,444,,,444,Other,150% of Medicare + 9.63% HCRA Surcharge,270,45,,270,percent of total billed charges,Critical Access Hospital RCC factor,204,34,,204,percent of total billed charges,Implant Device,204,34,,204,percent of total billed charges,Implant Device,204,34,,204,percent of total billed charges,Implant Device,204,34,,204,percent of total billed charges,Implant Device,204,34,,204,percent of total billed charges,Implant Device,297,,,297,Other,110% of Medicare,210,35,,210,percent of total billed charges,Implant Device,204,34,"Charges > $500, x 34%",204,percent of total billed charges,Implant Device,210,35,,210,percent of total billed charges,Implant Device,210,35,,210,percent of total billed charges,Implant Device,210,35,,210,percent of total billed charges,Implant Device,210,35,,210,percent of total billed charges,Implant Device,210,35,,210,percent of total billed charges,Implant Device,240,40,,240,percent of total billed charges,Implant Device,210,70,,210,percent of total billed charges,All Other,204,34,,204,percent of total billed charges,Implant Device,204,34,,204,percent of total billed charges,Implant Device,210,35,,210,percent of total billed charges,Implant Device,210,35,,210,percent of total billed charges,Implant Device,210,35,,210,percent of total billed charges,Implant Device,210,35,,210,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,444,
ALPHATEC 22085 SET SCREW FOR 8.5 SCREW,C1713,HCPCS,,79007174,CDM,278,RC,,,both,,,540,399.6,,,399.6,Other,150% of Medicare + 9.63% HCRA Surcharge,243,45,,243,percent of total billed charges,Critical Access Hospital RCC factor,183.6,34,,183.6,percent of total billed charges,Implant Device,183.6,34,,183.6,percent of total billed charges,Implant Device,183.6,34,,183.6,percent of total billed charges,Implant Device,183.6,34,,183.6,percent of total billed charges,Implant Device,183.6,34,,183.6,percent of total billed charges,Implant Device,267.3,,,267.3,Other,110% of Medicare,189,35,,189,percent of total billed charges,Implant Device,183.6,34,"Charges > $500, x 34%",183.6,percent of total billed charges,Implant Device,189,35,,189,percent of total billed charges,Implant Device,189,35,,189,percent of total billed charges,Implant Device,189,35,,189,percent of total billed charges,Implant Device,189,35,,189,percent of total billed charges,Implant Device,189,35,,189,percent of total billed charges,Implant Device,216,40,,216,percent of total billed charges,Implant Device,189,70,,189,percent of total billed charges,All Other,183.6,34,,183.6,percent of total billed charges,Implant Device,183.6,34,,183.6,percent of total billed charges,Implant Device,189,35,,189,percent of total billed charges,Implant Device,189,35,,189,percent of total billed charges,Implant Device,189,35,,189,percent of total billed charges,Implant Device,189,35,,189,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,399.6,
ALPHATEC 71003-51 PLATE 3 LEVEL 51MM,C1713,HCPCS,,79007175,CDM,278,RC,,,both,,,3135,2319.91,,,2319.91,Other,150% of Medicare + 9.63% HCRA Surcharge,1410.75,45,,1410.75,percent of total billed charges,Critical Access Hospital RCC factor,1065.9,34,,1065.9,percent of total billed charges,Implant Device,1065.9,34,,1065.9,percent of total billed charges,Implant Device,1065.9,34,,1065.9,percent of total billed charges,Implant Device,1065.9,34,,1065.9,percent of total billed charges,Implant Device,1065.9,34,,1065.9,percent of total billed charges,Implant Device,1551.83,,,1551.83,Other,110% of Medicare,1097.25,35,,1097.25,percent of total billed charges,Implant Device,1065.9,34,"Charges > $500, x 34%",1065.9,percent of total billed charges,Implant Device,1097.25,35,,1097.25,percent of total billed charges,Implant Device,1097.25,35,,1097.25,percent of total billed charges,Implant Device,1097.25,35,,1097.25,percent of total billed charges,Implant Device,1097.25,35,,1097.25,percent of total billed charges,Implant Device,1097.25,35,,1097.25,percent of total billed charges,Implant Device,1254,40,,1254,percent of total billed charges,Implant Device,1097.25,70,,1097.25,percent of total billed charges,All Other,1065.9,34,,1065.9,percent of total billed charges,Implant Device,1065.9,34,,1065.9,percent of total billed charges,Implant Device,1097.25,35,,1097.25,percent of total billed charges,Implant Device,1097.25,35,,1097.25,percent of total billed charges,Implant Device,1097.25,35,,1097.25,percent of total billed charges,Implant Device,1097.25,35,,1097.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1065.9,34,"If Charge > 2,000, then 34 percent",1065.9,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2319.91,
MEDTRONIC 429878 ATTAIN PERFORMA LEAD,C1900,HCPCS,,79007179,CDM,278,RC,,,both,,,7236,5354.66,,,5354.66,Other,150% of Medicare + 9.63% HCRA Surcharge,3256.2,45,,3256.2,percent of total billed charges,Critical Access Hospital RCC factor,2460.24,34,,2460.24,percent of total billed charges,Implant Device,2460.24,34,,2460.24,percent of total billed charges,Implant Device,2460.24,34,,2460.24,percent of total billed charges,Implant Device,2460.24,34,,2460.24,percent of total billed charges,Implant Device,2460.24,34,,2460.24,percent of total billed charges,Implant Device,3581.82,,,3581.82,Other,110% of Medicare,2532.6,35,,2532.6,percent of total billed charges,Implant Device,2460.24,34,"Charges > $500, x 34%",2460.24,percent of total billed charges,Implant Device,2532.6,35,,2532.6,percent of total billed charges,Implant Device,2532.6,35,,2532.6,percent of total billed charges,Implant Device,2532.6,35,,2532.6,percent of total billed charges,Implant Device,2532.6,35,,2532.6,percent of total billed charges,Implant Device,2532.6,35,,2532.6,percent of total billed charges,Implant Device,2894.4,40,,2894.4,percent of total billed charges,Implant Device,2532.6,70,,2532.6,percent of total billed charges,All Other,2460.24,34,,2460.24,percent of total billed charges,Implant Device,2460.24,34,,2460.24,percent of total billed charges,Implant Device,2532.6,35,,2532.6,percent of total billed charges,Implant Device,2532.6,35,,2532.6,percent of total billed charges,Implant Device,2532.6,35,,2532.6,percent of total billed charges,Implant Device,2532.6,35,,2532.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2460.24,34,"If Charge > 2,000, then 34 percent",2460.24,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5354.66,
MEDTRONIC 429888 ATTAIN PERFORMA LEAD,C1900,HCPCS,,79007180,CDM,278,RC,,,both,,,7236,5354.66,,,5354.66,Other,150% of Medicare + 9.63% HCRA Surcharge,3256.2,45,,3256.2,percent of total billed charges,Critical Access Hospital RCC factor,2460.24,34,,2460.24,percent of total billed charges,Implant Device,2460.24,34,,2460.24,percent of total billed charges,Implant Device,2460.24,34,,2460.24,percent of total billed charges,Implant Device,2460.24,34,,2460.24,percent of total billed charges,Implant Device,2460.24,34,,2460.24,percent of total billed charges,Implant Device,3581.82,,,3581.82,Other,110% of Medicare,2532.6,35,,2532.6,percent of total billed charges,Implant Device,2460.24,34,"Charges > $500, x 34%",2460.24,percent of total billed charges,Implant Device,2532.6,35,,2532.6,percent of total billed charges,Implant Device,2532.6,35,,2532.6,percent of total billed charges,Implant Device,2532.6,35,,2532.6,percent of total billed charges,Implant Device,2532.6,35,,2532.6,percent of total billed charges,Implant Device,2532.6,35,,2532.6,percent of total billed charges,Implant Device,2894.4,40,,2894.4,percent of total billed charges,Implant Device,2532.6,70,,2532.6,percent of total billed charges,All Other,2460.24,34,,2460.24,percent of total billed charges,Implant Device,2460.24,34,,2460.24,percent of total billed charges,Implant Device,2532.6,35,,2532.6,percent of total billed charges,Implant Device,2532.6,35,,2532.6,percent of total billed charges,Implant Device,2532.6,35,,2532.6,percent of total billed charges,Implant Device,2532.6,35,,2532.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2460.24,34,"If Charge > 2,000, then 34 percent",2460.24,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5354.66,
DEPUY 96-2135 TIBIAL INSERT #3 20MM,C1776,HCPCS,,79007185,CDM,278,RC,,,both,,,4121,3049.55,,,3049.55,Other,150% of Medicare + 9.63% HCRA Surcharge,1854.45,45,,1854.45,percent of total billed charges,Critical Access Hospital RCC factor,1401.14,34,,1401.14,percent of total billed charges,Implant Device,1401.14,34,,1401.14,percent of total billed charges,Implant Device,1401.14,34,,1401.14,percent of total billed charges,Implant Device,1401.14,34,,1401.14,percent of total billed charges,Implant Device,1401.14,34,,1401.14,percent of total billed charges,Implant Device,2039.9,,,2039.9,Other,110% of Medicare,1442.35,35,,1442.35,percent of total billed charges,Implant Device,1401.14,34,"Charges > $500, x 34%",1401.14,percent of total billed charges,Implant Device,1442.35,35,,1442.35,percent of total billed charges,Implant Device,1442.35,35,,1442.35,percent of total billed charges,Implant Device,1442.35,35,,1442.35,percent of total billed charges,Implant Device,1442.35,35,,1442.35,percent of total billed charges,Implant Device,1442.35,35,,1442.35,percent of total billed charges,Implant Device,1648.4,40,,1648.4,percent of total billed charges,Implant Device,1442.35,70,,1442.35,percent of total billed charges,All Other,1401.14,34,,1401.14,percent of total billed charges,Implant Device,1401.14,34,,1401.14,percent of total billed charges,Implant Device,1442.35,35,,1442.35,percent of total billed charges,Implant Device,1442.35,35,,1442.35,percent of total billed charges,Implant Device,1442.35,35,,1442.35,percent of total billed charges,Implant Device,1442.35,35,,1442.35,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1401.14,34,"If Charge > 2,000, then 34 percent",1401.14,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3049.55,
ZIMMER 00-7711-011-00 FEMORAL STEM SZ 11,C1776,HCPCS,,79007186,CDM,278,RC,,,both,,,6912,5114.9,,,5114.9,Other,150% of Medicare + 9.63% HCRA Surcharge,3110.4,45,,3110.4,percent of total billed charges,Critical Access Hospital RCC factor,2350.08,34,,2350.08,percent of total billed charges,Implant Device,2350.08,34,,2350.08,percent of total billed charges,Implant Device,2350.08,34,,2350.08,percent of total billed charges,Implant Device,2350.08,34,,2350.08,percent of total billed charges,Implant Device,2350.08,34,,2350.08,percent of total billed charges,Implant Device,3421.44,,,3421.44,Other,110% of Medicare,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2350.08,34,"Charges > $500, x 34%",2350.08,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2764.8,40,,2764.8,percent of total billed charges,Implant Device,2419.2,70,,2419.2,percent of total billed charges,All Other,2350.08,34,,2350.08,percent of total billed charges,Implant Device,2350.08,34,,2350.08,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2350.08,34,"If Charge > 2,000, then 34 percent",2350.08,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5114.9,
ZIMMER 00-2357-003-06 LOCK PLATE 6H 3.5,C1713,HCPCS,,79007187,CDM,278,RC,,,both,,,4116,3045.85,,,3045.85,Other,150% of Medicare + 9.63% HCRA Surcharge,1852.2,45,,1852.2,percent of total billed charges,Critical Access Hospital RCC factor,1399.44,34,,1399.44,percent of total billed charges,Implant Device,1399.44,34,,1399.44,percent of total billed charges,Implant Device,1399.44,34,,1399.44,percent of total billed charges,Implant Device,1399.44,34,,1399.44,percent of total billed charges,Implant Device,1399.44,34,,1399.44,percent of total billed charges,Implant Device,2037.42,,,2037.42,Other,110% of Medicare,1440.6,35,,1440.6,percent of total billed charges,Implant Device,1399.44,34,"Charges > $500, x 34%",1399.44,percent of total billed charges,Implant Device,1440.6,35,,1440.6,percent of total billed charges,Implant Device,1440.6,35,,1440.6,percent of total billed charges,Implant Device,1440.6,35,,1440.6,percent of total billed charges,Implant Device,1440.6,35,,1440.6,percent of total billed charges,Implant Device,1440.6,35,,1440.6,percent of total billed charges,Implant Device,1646.4,40,,1646.4,percent of total billed charges,Implant Device,1440.6,70,,1440.6,percent of total billed charges,All Other,1399.44,34,,1399.44,percent of total billed charges,Implant Device,1399.44,34,,1399.44,percent of total billed charges,Implant Device,1440.6,35,,1440.6,percent of total billed charges,Implant Device,1440.6,35,,1440.6,percent of total billed charges,Implant Device,1440.6,35,,1440.6,percent of total billed charges,Implant Device,1440.6,35,,1440.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1399.44,34,"If Charge > 2,000, then 34 percent",1399.44,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3045.85,
ZIMMER 00-2359-036-35 LOCK SCREW 3.5X36,C1713,HCPCS,,79007188,CDM,278,RC,,,both,,,324,239.76,,,239.76,Other,150% of Medicare + 9.63% HCRA Surcharge,145.8,45,,145.8,percent of total billed charges,Critical Access Hospital RCC factor,110.16,34,,110.16,percent of total billed charges,Implant Device,110.16,34,,110.16,percent of total billed charges,Implant Device,110.16,34,,110.16,percent of total billed charges,Implant Device,110.16,34,,110.16,percent of total billed charges,Implant Device,110.16,34,,110.16,percent of total billed charges,Implant Device,160.38,,,160.38,Other,110% of Medicare,113.4,35,,113.4,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,129.6,40,,129.6,percent of total billed charges,Implant Device,113.4,70,,113.4,percent of total billed charges,All Other,110.16,34,,110.16,percent of total billed charges,Implant Device,110.16,34,,110.16,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,239.76,
ZIMMER 00-2359-070-35 LOCK SCREW 3.5X70,C1713,HCPCS,,79007189,CDM,278,RC,,,both,,,367,271.58,,,271.58,Other,150% of Medicare + 9.63% HCRA Surcharge,165.15,45,,165.15,percent of total billed charges,Critical Access Hospital RCC factor,124.78,34,,124.78,percent of total billed charges,Implant Device,124.78,34,,124.78,percent of total billed charges,Implant Device,124.78,34,,124.78,percent of total billed charges,Implant Device,124.78,34,,124.78,percent of total billed charges,Implant Device,124.78,34,,124.78,percent of total billed charges,Implant Device,181.67,,,181.67,Other,110% of Medicare,128.45,35,,128.45,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,128.45,35,,128.45,percent of total billed charges,Implant Device,128.45,35,,128.45,percent of total billed charges,Implant Device,128.45,35,,128.45,percent of total billed charges,Implant Device,128.45,35,,128.45,percent of total billed charges,Implant Device,128.45,35,,128.45,percent of total billed charges,Implant Device,146.8,40,,146.8,percent of total billed charges,Implant Device,128.45,70,,128.45,percent of total billed charges,All Other,124.78,34,,124.78,percent of total billed charges,Implant Device,124.78,34,,124.78,percent of total billed charges,Implant Device,128.45,35,,128.45,percent of total billed charges,Implant Device,128.45,35,,128.45,percent of total billed charges,Implant Device,128.45,35,,128.45,percent of total billed charges,Implant Device,128.45,35,,128.45,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,271.58,
ZIMMER 00-2359-080-36 CANN SCREW 3.5X80,C1713,HCPCS,,79007190,CDM,278,RC,,,both,,,334,247.16,,,247.16,Other,150% of Medicare + 9.63% HCRA Surcharge,150.3,45,,150.3,percent of total billed charges,Critical Access Hospital RCC factor,113.56,34,,113.56,percent of total billed charges,Implant Device,113.56,34,,113.56,percent of total billed charges,Implant Device,113.56,34,,113.56,percent of total billed charges,Implant Device,113.56,34,,113.56,percent of total billed charges,Implant Device,113.56,34,,113.56,percent of total billed charges,Implant Device,165.33,,,165.33,Other,110% of Medicare,116.9,35,,116.9,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,116.9,35,,116.9,percent of total billed charges,Implant Device,116.9,35,,116.9,percent of total billed charges,Implant Device,116.9,35,,116.9,percent of total billed charges,Implant Device,116.9,35,,116.9,percent of total billed charges,Implant Device,116.9,35,,116.9,percent of total billed charges,Implant Device,133.6,40,,133.6,percent of total billed charges,Implant Device,116.9,70,,116.9,percent of total billed charges,All Other,113.56,34,,113.56,percent of total billed charges,Implant Device,113.56,34,,113.56,percent of total billed charges,Implant Device,116.9,35,,116.9,percent of total billed charges,Implant Device,116.9,35,,116.9,percent of total billed charges,Implant Device,116.9,35,,116.9,percent of total billed charges,Implant Device,116.9,35,,116.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,247.16,
ZIMMER 00-2359-085-36 CANN SCREW 3.5X85,C1713,HCPCS,,79007191,CDM,278,RC,,,both,,,324,239.76,,,239.76,Other,150% of Medicare + 9.63% HCRA Surcharge,145.8,45,,145.8,percent of total billed charges,Critical Access Hospital RCC factor,110.16,34,,110.16,percent of total billed charges,Implant Device,110.16,34,,110.16,percent of total billed charges,Implant Device,110.16,34,,110.16,percent of total billed charges,Implant Device,110.16,34,,110.16,percent of total billed charges,Implant Device,110.16,34,,110.16,percent of total billed charges,Implant Device,160.38,,,160.38,Other,110% of Medicare,113.4,35,,113.4,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,129.6,40,,129.6,percent of total billed charges,Implant Device,113.4,70,,113.4,percent of total billed charges,All Other,110.16,34,,110.16,percent of total billed charges,Implant Device,110.16,34,,110.16,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,239.76,
ZIMMER 00-2347-020-36 PERI SCREW 3.5X36,C1713,HCPCS,,79007192,CDM,278,RC,,,both,,,97,71.78,,,71.78,Other,150% of Medicare + 9.63% HCRA Surcharge,43.65,45,,43.65,percent of total billed charges,Critical Access Hospital RCC factor,32.98,34,,32.98,percent of total billed charges,Implant Device,32.98,34,,32.98,percent of total billed charges,Implant Device,32.98,34,,32.98,percent of total billed charges,Implant Device,32.98,34,,32.98,percent of total billed charges,Implant Device,32.98,34,,32.98,percent of total billed charges,Implant Device,48.02,,,48.02,Other,110% of Medicare,33.95,35,,33.95,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,33.95,35,,33.95,percent of total billed charges,Implant Device,33.95,35,,33.95,percent of total billed charges,Implant Device,33.95,35,,33.95,percent of total billed charges,Implant Device,33.95,35,,33.95,percent of total billed charges,Implant Device,33.95,35,,33.95,percent of total billed charges,Implant Device,38.8,40,,38.8,percent of total billed charges,Implant Device,33.95,70,,33.95,percent of total billed charges,All Other,32.98,34,,32.98,percent of total billed charges,Implant Device,32.98,34,,32.98,percent of total billed charges,Implant Device,33.95,35,,33.95,percent of total billed charges,Implant Device,33.95,35,,33.95,percent of total billed charges,Implant Device,33.95,35,,33.95,percent of total billed charges,Implant Device,33.95,35,,33.95,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,71.78,
ZIMMER 00-2347-020-42 PERI SCREW 3.5X42,C1713,HCPCS,,79007193,CDM,278,RC,,,both,,,97,71.78,,,71.78,Other,150% of Medicare + 9.63% HCRA Surcharge,43.65,45,,43.65,percent of total billed charges,Critical Access Hospital RCC factor,32.98,34,,32.98,percent of total billed charges,Implant Device,32.98,34,,32.98,percent of total billed charges,Implant Device,32.98,34,,32.98,percent of total billed charges,Implant Device,32.98,34,,32.98,percent of total billed charges,Implant Device,32.98,34,,32.98,percent of total billed charges,Implant Device,48.02,,,48.02,Other,110% of Medicare,33.95,35,,33.95,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,33.95,35,,33.95,percent of total billed charges,Implant Device,33.95,35,,33.95,percent of total billed charges,Implant Device,33.95,35,,33.95,percent of total billed charges,Implant Device,33.95,35,,33.95,percent of total billed charges,Implant Device,33.95,35,,33.95,percent of total billed charges,Implant Device,38.8,40,,38.8,percent of total billed charges,Implant Device,33.95,70,,33.95,percent of total billed charges,All Other,32.98,34,,32.98,percent of total billed charges,Implant Device,32.98,34,,32.98,percent of total billed charges,Implant Device,33.95,35,,33.95,percent of total billed charges,Implant Device,33.95,35,,33.95,percent of total billed charges,Implant Device,33.95,35,,33.95,percent of total billed charges,Implant Device,33.95,35,,33.95,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,71.78,
ZIMMER 00-2347-020-48 PERI SCREW 3.5X48,C1713,HCPCS,,79007194,CDM,278,RC,,,both,,,97,71.78,,,71.78,Other,150% of Medicare + 9.63% HCRA Surcharge,43.65,45,,43.65,percent of total billed charges,Critical Access Hospital RCC factor,32.98,34,,32.98,percent of total billed charges,Implant Device,32.98,34,,32.98,percent of total billed charges,Implant Device,32.98,34,,32.98,percent of total billed charges,Implant Device,32.98,34,,32.98,percent of total billed charges,Implant Device,32.98,34,,32.98,percent of total billed charges,Implant Device,48.02,,,48.02,Other,110% of Medicare,33.95,35,,33.95,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,33.95,35,,33.95,percent of total billed charges,Implant Device,33.95,35,,33.95,percent of total billed charges,Implant Device,33.95,35,,33.95,percent of total billed charges,Implant Device,33.95,35,,33.95,percent of total billed charges,Implant Device,33.95,35,,33.95,percent of total billed charges,Implant Device,38.8,40,,38.8,percent of total billed charges,Implant Device,33.95,70,,33.95,percent of total billed charges,All Other,32.98,34,,32.98,percent of total billed charges,Implant Device,32.98,34,,32.98,percent of total billed charges,Implant Device,33.95,35,,33.95,percent of total billed charges,Implant Device,33.95,35,,33.95,percent of total billed charges,Implant Device,33.95,35,,33.95,percent of total billed charges,Implant Device,33.95,35,,33.95,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,71.78,
ZIMMER 00-2347-020-50 PERI SCREW 3.5X50,C1713,HCPCS,,79007195,CDM,278,RC,,,both,,,97,71.78,,,71.78,Other,150% of Medicare + 9.63% HCRA Surcharge,43.65,45,,43.65,percent of total billed charges,Critical Access Hospital RCC factor,32.98,34,,32.98,percent of total billed charges,Implant Device,32.98,34,,32.98,percent of total billed charges,Implant Device,32.98,34,,32.98,percent of total billed charges,Implant Device,32.98,34,,32.98,percent of total billed charges,Implant Device,32.98,34,,32.98,percent of total billed charges,Implant Device,48.02,,,48.02,Other,110% of Medicare,33.95,35,,33.95,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,33.95,35,,33.95,percent of total billed charges,Implant Device,33.95,35,,33.95,percent of total billed charges,Implant Device,33.95,35,,33.95,percent of total billed charges,Implant Device,33.95,35,,33.95,percent of total billed charges,Implant Device,33.95,35,,33.95,percent of total billed charges,Implant Device,38.8,40,,38.8,percent of total billed charges,Implant Device,33.95,70,,33.95,percent of total billed charges,All Other,32.98,34,,32.98,percent of total billed charges,Implant Device,32.98,34,,32.98,percent of total billed charges,Implant Device,33.95,35,,33.95,percent of total billed charges,Implant Device,33.95,35,,33.95,percent of total billed charges,Implant Device,33.95,35,,33.95,percent of total billed charges,Implant Device,33.95,35,,33.95,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,71.78,
ZIMMER 00-2347-020-95 PERI SCREW 3.5X95,C1713,HCPCS,,79007196,CDM,278,RC,,,both,,,97,71.78,,,71.78,Other,150% of Medicare + 9.63% HCRA Surcharge,43.65,45,,43.65,percent of total billed charges,Critical Access Hospital RCC factor,32.98,34,,32.98,percent of total billed charges,Implant Device,32.98,34,,32.98,percent of total billed charges,Implant Device,32.98,34,,32.98,percent of total billed charges,Implant Device,32.98,34,,32.98,percent of total billed charges,Implant Device,32.98,34,,32.98,percent of total billed charges,Implant Device,48.02,,,48.02,Other,110% of Medicare,33.95,35,,33.95,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,33.95,35,,33.95,percent of total billed charges,Implant Device,33.95,35,,33.95,percent of total billed charges,Implant Device,33.95,35,,33.95,percent of total billed charges,Implant Device,33.95,35,,33.95,percent of total billed charges,Implant Device,33.95,35,,33.95,percent of total billed charges,Implant Device,38.8,40,,38.8,percent of total billed charges,Implant Device,33.95,70,,33.95,percent of total billed charges,All Other,32.98,34,,32.98,percent of total billed charges,Implant Device,32.98,34,,32.98,percent of total billed charges,Implant Device,33.95,35,,33.95,percent of total billed charges,Implant Device,33.95,35,,33.95,percent of total billed charges,Implant Device,33.95,35,,33.95,percent of total billed charges,Implant Device,33.95,35,,33.95,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,71.78,
ZIMMER 00-2347-020-90 PERI SCREW 3.5X90,C1713,HCPCS,,79007197,CDM,278,RC,,,both,,,97,71.78,,,71.78,Other,150% of Medicare + 9.63% HCRA Surcharge,43.65,45,,43.65,percent of total billed charges,Critical Access Hospital RCC factor,32.98,34,,32.98,percent of total billed charges,Implant Device,32.98,34,,32.98,percent of total billed charges,Implant Device,32.98,34,,32.98,percent of total billed charges,Implant Device,32.98,34,,32.98,percent of total billed charges,Implant Device,32.98,34,,32.98,percent of total billed charges,Implant Device,48.02,,,48.02,Other,110% of Medicare,33.95,35,,33.95,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,33.95,35,,33.95,percent of total billed charges,Implant Device,33.95,35,,33.95,percent of total billed charges,Implant Device,33.95,35,,33.95,percent of total billed charges,Implant Device,33.95,35,,33.95,percent of total billed charges,Implant Device,33.95,35,,33.95,percent of total billed charges,Implant Device,38.8,40,,38.8,percent of total billed charges,Implant Device,33.95,70,,33.95,percent of total billed charges,All Other,32.98,34,,32.98,percent of total billed charges,Implant Device,32.98,34,,32.98,percent of total billed charges,Implant Device,33.95,35,,33.95,percent of total billed charges,Implant Device,33.95,35,,33.95,percent of total billed charges,Implant Device,33.95,35,,33.95,percent of total billed charges,Implant Device,33.95,35,,33.95,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,71.78,
ZIMMER 00-2347-020-85 PERI SCREW 3.5X85,C1713,HCPCS,,79007198,CDM,278,RC,,,both,,,97,71.78,,,71.78,Other,150% of Medicare + 9.63% HCRA Surcharge,43.65,45,,43.65,percent of total billed charges,Critical Access Hospital RCC factor,32.98,34,,32.98,percent of total billed charges,Implant Device,32.98,34,,32.98,percent of total billed charges,Implant Device,32.98,34,,32.98,percent of total billed charges,Implant Device,32.98,34,,32.98,percent of total billed charges,Implant Device,32.98,34,,32.98,percent of total billed charges,Implant Device,48.02,,,48.02,Other,110% of Medicare,33.95,35,,33.95,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,33.95,35,,33.95,percent of total billed charges,Implant Device,33.95,35,,33.95,percent of total billed charges,Implant Device,33.95,35,,33.95,percent of total billed charges,Implant Device,33.95,35,,33.95,percent of total billed charges,Implant Device,33.95,35,,33.95,percent of total billed charges,Implant Device,38.8,40,,38.8,percent of total billed charges,Implant Device,33.95,70,,33.95,percent of total billed charges,All Other,32.98,34,,32.98,percent of total billed charges,Implant Device,32.98,34,,32.98,percent of total billed charges,Implant Device,33.95,35,,33.95,percent of total billed charges,Implant Device,33.95,35,,33.95,percent of total billed charges,Implant Device,33.95,35,,33.95,percent of total billed charges,Implant Device,33.95,35,,33.95,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,71.78,
ZIMMER 00-8852-011-36 RIM LINER 36MM JJ,C1776,HCPCS,,79007199,CDM,278,RC,,,both,,,4403,3258.23,,,3258.23,Other,150% of Medicare + 9.63% HCRA Surcharge,1981.35,45,,1981.35,percent of total billed charges,Critical Access Hospital RCC factor,1497.02,34,,1497.02,percent of total billed charges,Implant Device,1497.02,34,,1497.02,percent of total billed charges,Implant Device,1497.02,34,,1497.02,percent of total billed charges,Implant Device,1497.02,34,,1497.02,percent of total billed charges,Implant Device,1497.02,34,,1497.02,percent of total billed charges,Implant Device,2179.49,,,2179.49,Other,110% of Medicare,1541.05,35,,1541.05,percent of total billed charges,Implant Device,1497.02,34,"Charges > $500, x 34%",1497.02,percent of total billed charges,Implant Device,1541.05,35,,1541.05,percent of total billed charges,Implant Device,1541.05,35,,1541.05,percent of total billed charges,Implant Device,1541.05,35,,1541.05,percent of total billed charges,Implant Device,1541.05,35,,1541.05,percent of total billed charges,Implant Device,1541.05,35,,1541.05,percent of total billed charges,Implant Device,1761.2,40,,1761.2,percent of total billed charges,Implant Device,1541.05,70,,1541.05,percent of total billed charges,All Other,1497.02,34,,1497.02,percent of total billed charges,Implant Device,1497.02,34,,1497.02,percent of total billed charges,Implant Device,1541.05,35,,1541.05,percent of total billed charges,Implant Device,1541.05,35,,1541.05,percent of total billed charges,Implant Device,1541.05,35,,1541.05,percent of total billed charges,Implant Device,1541.05,35,,1541.05,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1497.02,34,"If Charge > 2,000, then 34 percent",1497.02,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3258.23,
STRYKER 6276-7-319 REST MOD HIP 235X19MM,C1776,HCPCS,,79007201,CDM,278,RC,,,both,,,16079,11898.5,,,11898.5,Other,150% of Medicare + 9.63% HCRA Surcharge,7235.55,45,,7235.55,percent of total billed charges,Critical Access Hospital RCC factor,5466.86,34,,5466.86,percent of total billed charges,Implant Device,5466.86,34,,5466.86,percent of total billed charges,Implant Device,5466.86,34,,5466.86,percent of total billed charges,Implant Device,5466.86,34,,5466.86,percent of total billed charges,Implant Device,5466.86,34,,5466.86,percent of total billed charges,Implant Device,7959.11,,,7959.11,Other,110% of Medicare,5627.65,35,,5627.65,percent of total billed charges,Implant Device,5466.86,34,"Charges > $500, x 34%",5466.86,percent of total billed charges,Implant Device,5627.65,35,,5627.65,percent of total billed charges,Implant Device,5627.65,35,,5627.65,percent of total billed charges,Implant Device,5627.65,35,,5627.65,percent of total billed charges,Implant Device,5627.65,35,,5627.65,percent of total billed charges,Implant Device,5627.65,35,,5627.65,percent of total billed charges,Implant Device,6431.6,40,,6431.6,percent of total billed charges,Implant Device,5627.65,70,,5627.65,percent of total billed charges,All Other,5466.86,34,,5466.86,percent of total billed charges,Implant Device,5466.86,34,,5466.86,percent of total billed charges,Implant Device,5627.65,35,,5627.65,percent of total billed charges,Implant Device,5627.65,35,,5627.65,percent of total billed charges,Implant Device,5627.65,35,,5627.65,percent of total billed charges,Implant Device,5627.65,35,,5627.65,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,5466.86,34,"If Charge > 2,000, then 34 percent",5466.86,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,11898.5,
EXACTECH 310-21-47 HUMERAL HEAD 47MM,C1776,HCPCS,,79007202,CDM,278,RC,,,both,,,8910,6593.42,,,6593.42,Other,150% of Medicare + 9.63% HCRA Surcharge,4009.5,45,,4009.5,percent of total billed charges,Critical Access Hospital RCC factor,3029.4,34,,3029.4,percent of total billed charges,Implant Device,3029.4,34,,3029.4,percent of total billed charges,Implant Device,3029.4,34,,3029.4,percent of total billed charges,Implant Device,3029.4,34,,3029.4,percent of total billed charges,Implant Device,3029.4,34,,3029.4,percent of total billed charges,Implant Device,4410.45,,,4410.45,Other,110% of Medicare,3118.5,35,,3118.5,percent of total billed charges,Implant Device,3029.4,34,"Charges > $500, x 34%",3029.4,percent of total billed charges,Implant Device,3118.5,35,,3118.5,percent of total billed charges,Implant Device,3118.5,35,,3118.5,percent of total billed charges,Implant Device,3118.5,35,,3118.5,percent of total billed charges,Implant Device,3118.5,35,,3118.5,percent of total billed charges,Implant Device,3118.5,35,,3118.5,percent of total billed charges,Implant Device,3564,40,,3564,percent of total billed charges,Implant Device,3118.5,70,,3118.5,percent of total billed charges,All Other,3029.4,34,,3029.4,percent of total billed charges,Implant Device,3029.4,34,,3029.4,percent of total billed charges,Implant Device,3118.5,35,,3118.5,percent of total billed charges,Implant Device,3118.5,35,,3118.5,percent of total billed charges,Implant Device,3118.5,35,,3118.5,percent of total billed charges,Implant Device,3118.5,35,,3118.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3029.4,34,"If Charge > 2,000, then 34 percent",3029.4,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,6593.42,
DEPUY 207.628 CANNULATED SCREW 4X28MM,C1713,HCPCS,,79007203,CDM,278,RC,,,both,,,491,363.34,,,363.34,Other,150% of Medicare + 9.63% HCRA Surcharge,220.95,45,,220.95,percent of total billed charges,Critical Access Hospital RCC factor,166.94,34,,166.94,percent of total billed charges,Implant Device,166.94,34,,166.94,percent of total billed charges,Implant Device,166.94,34,,166.94,percent of total billed charges,Implant Device,166.94,34,,166.94,percent of total billed charges,Implant Device,166.94,34,,166.94,percent of total billed charges,Implant Device,243.05,,,243.05,Other,110% of Medicare,171.85,35,,171.85,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,171.85,35,,171.85,percent of total billed charges,Implant Device,171.85,35,,171.85,percent of total billed charges,Implant Device,171.85,35,,171.85,percent of total billed charges,Implant Device,171.85,35,,171.85,percent of total billed charges,Implant Device,171.85,35,,171.85,percent of total billed charges,Implant Device,196.4,40,,196.4,percent of total billed charges,Implant Device,171.85,70,,171.85,percent of total billed charges,All Other,166.94,34,,166.94,percent of total billed charges,Implant Device,166.94,34,,166.94,percent of total billed charges,Implant Device,171.85,35,,171.85,percent of total billed charges,Implant Device,171.85,35,,171.85,percent of total billed charges,Implant Device,171.85,35,,171.85,percent of total billed charges,Implant Device,171.85,35,,171.85,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,363.34,
MEDLINE MDS9091212 DISTRACTION PIN 12MM,C1713,HCPCS,,79007204,CDM,278,RC,,,both,,,81,59.94,,,59.94,Other,150% of Medicare + 9.63% HCRA Surcharge,36.45,45,,36.45,percent of total billed charges,Critical Access Hospital RCC factor,27.54,34,,27.54,percent of total billed charges,Implant Device,27.54,34,,27.54,percent of total billed charges,Implant Device,27.54,34,,27.54,percent of total billed charges,Implant Device,27.54,34,,27.54,percent of total billed charges,Implant Device,27.54,34,,27.54,percent of total billed charges,Implant Device,40.1,,,40.1,Other,110% of Medicare,28.35,35,,28.35,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,28.35,35,,28.35,percent of total billed charges,Implant Device,28.35,35,,28.35,percent of total billed charges,Implant Device,28.35,35,,28.35,percent of total billed charges,Implant Device,28.35,35,,28.35,percent of total billed charges,Implant Device,28.35,35,,28.35,percent of total billed charges,Implant Device,32.4,40,,32.4,percent of total billed charges,Implant Device,28.35,70,,28.35,percent of total billed charges,All Other,27.54,34,,27.54,percent of total billed charges,Implant Device,27.54,34,,27.54,percent of total billed charges,Implant Device,28.35,35,,28.35,percent of total billed charges,Implant Device,28.35,35,,28.35,percent of total billed charges,Implant Device,28.35,35,,28.35,percent of total billed charges,Implant Device,28.35,35,,28.35,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,59.94,
MEDLINE MDS9091414 DISTRACTION PIN 14MM,C1713,HCPCS,,79007205,CDM,278,RC,,,both,,,74,54.76,,,54.76,Other,150% of Medicare + 9.63% HCRA Surcharge,33.3,45,,33.3,percent of total billed charges,Critical Access Hospital RCC factor,25.16,34,,25.16,percent of total billed charges,Implant Device,25.16,34,,25.16,percent of total billed charges,Implant Device,25.16,34,,25.16,percent of total billed charges,Implant Device,25.16,34,,25.16,percent of total billed charges,Implant Device,25.16,34,,25.16,percent of total billed charges,Implant Device,36.63,,,36.63,Other,110% of Medicare,25.9,35,,25.9,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,25.9,35,,25.9,percent of total billed charges,Implant Device,25.9,35,,25.9,percent of total billed charges,Implant Device,25.9,35,,25.9,percent of total billed charges,Implant Device,25.9,35,,25.9,percent of total billed charges,Implant Device,25.9,35,,25.9,percent of total billed charges,Implant Device,29.6,40,,29.6,percent of total billed charges,Implant Device,25.9,70,,25.9,percent of total billed charges,All Other,25.16,34,,25.16,percent of total billed charges,Implant Device,25.16,34,,25.16,percent of total billed charges,Implant Device,25.9,35,,25.9,percent of total billed charges,Implant Device,25.9,35,,25.9,percent of total billed charges,Implant Device,25.9,35,,25.9,percent of total billed charges,Implant Device,25.9,35,,25.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,54.76,
MEDLINE MDS9091616 DISTRACTION PIN 16MM,C1713,HCPCS,,79007206,CDM,278,RC,,,both,,,74,54.76,,,54.76,Other,150% of Medicare + 9.63% HCRA Surcharge,33.3,45,,33.3,percent of total billed charges,Critical Access Hospital RCC factor,25.16,34,,25.16,percent of total billed charges,Implant Device,25.16,34,,25.16,percent of total billed charges,Implant Device,25.16,34,,25.16,percent of total billed charges,Implant Device,25.16,34,,25.16,percent of total billed charges,Implant Device,25.16,34,,25.16,percent of total billed charges,Implant Device,36.63,,,36.63,Other,110% of Medicare,25.9,35,,25.9,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,25.9,35,,25.9,percent of total billed charges,Implant Device,25.9,35,,25.9,percent of total billed charges,Implant Device,25.9,35,,25.9,percent of total billed charges,Implant Device,25.9,35,,25.9,percent of total billed charges,Implant Device,25.9,35,,25.9,percent of total billed charges,Implant Device,29.6,40,,29.6,percent of total billed charges,Implant Device,25.9,70,,25.9,percent of total billed charges,All Other,25.16,34,,25.16,percent of total billed charges,Implant Device,25.16,34,,25.16,percent of total billed charges,Implant Device,25.9,35,,25.9,percent of total billed charges,Implant Device,25.9,35,,25.9,percent of total billed charges,Implant Device,25.9,35,,25.9,percent of total billed charges,Implant Device,25.9,35,,25.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,54.76,
DEPUY SYNTHES 226.581 PLATE 8 HOLE 4.5MM,C1713,HCPCS,,79007208,CDM,278,RC,,,both,,,2241,1658.35,,,1658.35,Other,150% of Medicare + 9.63% HCRA Surcharge,1008.45,45,,1008.45,percent of total billed charges,Critical Access Hospital RCC factor,761.94,34,,761.94,percent of total billed charges,Implant Device,761.94,34,,761.94,percent of total billed charges,Implant Device,761.94,34,,761.94,percent of total billed charges,Implant Device,761.94,34,,761.94,percent of total billed charges,Implant Device,761.94,34,,761.94,percent of total billed charges,Implant Device,1109.3,,,1109.3,Other,110% of Medicare,784.35,35,,784.35,percent of total billed charges,Implant Device,761.94,34,"Charges > $500, x 34%",761.94,percent of total billed charges,Implant Device,784.35,35,,784.35,percent of total billed charges,Implant Device,784.35,35,,784.35,percent of total billed charges,Implant Device,784.35,35,,784.35,percent of total billed charges,Implant Device,784.35,35,,784.35,percent of total billed charges,Implant Device,784.35,35,,784.35,percent of total billed charges,Implant Device,896.4,40,,896.4,percent of total billed charges,Implant Device,784.35,70,,784.35,percent of total billed charges,All Other,761.94,34,,761.94,percent of total billed charges,Implant Device,761.94,34,,761.94,percent of total billed charges,Implant Device,784.35,35,,784.35,percent of total billed charges,Implant Device,784.35,35,,784.35,percent of total billed charges,Implant Device,784.35,35,,784.35,percent of total billed charges,Implant Device,784.35,35,,784.35,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,761.94,34,"If Charge > 2,000, then 34 percent",761.94,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1658.35,
DEPUY 214.832 CORTEX SCREW 4.5X32MM,C1713,HCPCS,,79007210,CDM,278,RC,,,both,,,57,42.18,,,42.18,Other,150% of Medicare + 9.63% HCRA Surcharge,25.65,45,,25.65,percent of total billed charges,Critical Access Hospital RCC factor,19.38,34,,19.38,percent of total billed charges,Implant Device,19.38,34,,19.38,percent of total billed charges,Implant Device,19.38,34,,19.38,percent of total billed charges,Implant Device,19.38,34,,19.38,percent of total billed charges,Implant Device,19.38,34,,19.38,percent of total billed charges,Implant Device,28.22,,,28.22,Other,110% of Medicare,19.95,35,,19.95,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,19.95,35,,19.95,percent of total billed charges,Implant Device,19.95,35,,19.95,percent of total billed charges,Implant Device,19.95,35,,19.95,percent of total billed charges,Implant Device,19.95,35,,19.95,percent of total billed charges,Implant Device,19.95,35,,19.95,percent of total billed charges,Implant Device,22.8,40,,22.8,percent of total billed charges,Implant Device,19.95,70,,19.95,percent of total billed charges,All Other,19.38,34,,19.38,percent of total billed charges,Implant Device,19.38,34,,19.38,percent of total billed charges,Implant Device,19.95,35,,19.95,percent of total billed charges,Implant Device,19.95,35,,19.95,percent of total billed charges,Implant Device,19.95,35,,19.95,percent of total billed charges,Implant Device,19.95,35,,19.95,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,42.18,
DEPUY 214.830 CORTEX SCREW 4.5X30MM,C1713,HCPCS,,79007211,CDM,278,RC,,,both,,,57,42.18,,,42.18,Other,150% of Medicare + 9.63% HCRA Surcharge,25.65,45,,25.65,percent of total billed charges,Critical Access Hospital RCC factor,19.38,34,,19.38,percent of total billed charges,Implant Device,19.38,34,,19.38,percent of total billed charges,Implant Device,19.38,34,,19.38,percent of total billed charges,Implant Device,19.38,34,,19.38,percent of total billed charges,Implant Device,19.38,34,,19.38,percent of total billed charges,Implant Device,28.22,,,28.22,Other,110% of Medicare,19.95,35,,19.95,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,19.95,35,,19.95,percent of total billed charges,Implant Device,19.95,35,,19.95,percent of total billed charges,Implant Device,19.95,35,,19.95,percent of total billed charges,Implant Device,19.95,35,,19.95,percent of total billed charges,Implant Device,19.95,35,,19.95,percent of total billed charges,Implant Device,22.8,40,,22.8,percent of total billed charges,Implant Device,19.95,70,,19.95,percent of total billed charges,All Other,19.38,34,,19.38,percent of total billed charges,Implant Device,19.38,34,,19.38,percent of total billed charges,Implant Device,19.95,35,,19.95,percent of total billed charges,Implant Device,19.95,35,,19.95,percent of total billed charges,Implant Device,19.95,35,,19.95,percent of total billed charges,Implant Device,19.95,35,,19.95,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,42.18,
DEPUY 214.834 CORTEX SCREW 4.5X34MM,C1713,HCPCS,,79007212,CDM,278,RC,,,both,,,57,42.18,,,42.18,Other,150% of Medicare + 9.63% HCRA Surcharge,25.65,45,,25.65,percent of total billed charges,Critical Access Hospital RCC factor,19.38,34,,19.38,percent of total billed charges,Implant Device,19.38,34,,19.38,percent of total billed charges,Implant Device,19.38,34,,19.38,percent of total billed charges,Implant Device,19.38,34,,19.38,percent of total billed charges,Implant Device,19.38,34,,19.38,percent of total billed charges,Implant Device,28.22,,,28.22,Other,110% of Medicare,19.95,35,,19.95,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,19.95,35,,19.95,percent of total billed charges,Implant Device,19.95,35,,19.95,percent of total billed charges,Implant Device,19.95,35,,19.95,percent of total billed charges,Implant Device,19.95,35,,19.95,percent of total billed charges,Implant Device,19.95,35,,19.95,percent of total billed charges,Implant Device,22.8,40,,22.8,percent of total billed charges,Implant Device,19.95,70,,19.95,percent of total billed charges,All Other,19.38,34,,19.38,percent of total billed charges,Implant Device,19.38,34,,19.38,percent of total billed charges,Implant Device,19.95,35,,19.95,percent of total billed charges,Implant Device,19.95,35,,19.95,percent of total billed charges,Implant Device,19.95,35,,19.95,percent of total billed charges,Implant Device,19.95,35,,19.95,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,42.18,
DEPUY 214.842 CORTEX SCREW 4.5X42MM,C1713,HCPCS,,79007213,CDM,278,RC,,,both,,,57,42.18,,,42.18,Other,150% of Medicare + 9.63% HCRA Surcharge,25.65,45,,25.65,percent of total billed charges,Critical Access Hospital RCC factor,19.38,34,,19.38,percent of total billed charges,Implant Device,19.38,34,,19.38,percent of total billed charges,Implant Device,19.38,34,,19.38,percent of total billed charges,Implant Device,19.38,34,,19.38,percent of total billed charges,Implant Device,19.38,34,,19.38,percent of total billed charges,Implant Device,28.22,,,28.22,Other,110% of Medicare,19.95,35,,19.95,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,19.95,35,,19.95,percent of total billed charges,Implant Device,19.95,35,,19.95,percent of total billed charges,Implant Device,19.95,35,,19.95,percent of total billed charges,Implant Device,19.95,35,,19.95,percent of total billed charges,Implant Device,19.95,35,,19.95,percent of total billed charges,Implant Device,22.8,40,,22.8,percent of total billed charges,Implant Device,19.95,70,,19.95,percent of total billed charges,All Other,19.38,34,,19.38,percent of total billed charges,Implant Device,19.38,34,,19.38,percent of total billed charges,Implant Device,19.95,35,,19.95,percent of total billed charges,Implant Device,19.95,35,,19.95,percent of total billed charges,Implant Device,19.95,35,,19.95,percent of total billed charges,Implant Device,19.95,35,,19.95,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,42.18,
DEPUY 214.838 CORTEX SCREW 4.5X38MM,C1713,HCPCS,,79007214,CDM,278,RC,,,both,,,57,42.18,,,42.18,Other,150% of Medicare + 9.63% HCRA Surcharge,25.65,45,,25.65,percent of total billed charges,Critical Access Hospital RCC factor,19.38,34,,19.38,percent of total billed charges,Implant Device,19.38,34,,19.38,percent of total billed charges,Implant Device,19.38,34,,19.38,percent of total billed charges,Implant Device,19.38,34,,19.38,percent of total billed charges,Implant Device,19.38,34,,19.38,percent of total billed charges,Implant Device,28.22,,,28.22,Other,110% of Medicare,19.95,35,,19.95,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,19.95,35,,19.95,percent of total billed charges,Implant Device,19.95,35,,19.95,percent of total billed charges,Implant Device,19.95,35,,19.95,percent of total billed charges,Implant Device,19.95,35,,19.95,percent of total billed charges,Implant Device,19.95,35,,19.95,percent of total billed charges,Implant Device,22.8,40,,22.8,percent of total billed charges,Implant Device,19.95,70,,19.95,percent of total billed charges,All Other,19.38,34,,19.38,percent of total billed charges,Implant Device,19.38,34,,19.38,percent of total billed charges,Implant Device,19.95,35,,19.95,percent of total billed charges,Implant Device,19.95,35,,19.95,percent of total billed charges,Implant Device,19.95,35,,19.95,percent of total billed charges,Implant Device,19.95,35,,19.95,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,42.18,
DEPUY 214.828 CORTEX SCREW 4.5X28MM,C1713,HCPCS,,79007215,CDM,278,RC,,,both,,,57,42.18,,,42.18,Other,150% of Medicare + 9.63% HCRA Surcharge,25.65,45,,25.65,percent of total billed charges,Critical Access Hospital RCC factor,19.38,34,,19.38,percent of total billed charges,Implant Device,19.38,34,,19.38,percent of total billed charges,Implant Device,19.38,34,,19.38,percent of total billed charges,Implant Device,19.38,34,,19.38,percent of total billed charges,Implant Device,19.38,34,,19.38,percent of total billed charges,Implant Device,28.22,,,28.22,Other,110% of Medicare,19.95,35,,19.95,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,19.95,35,,19.95,percent of total billed charges,Implant Device,19.95,35,,19.95,percent of total billed charges,Implant Device,19.95,35,,19.95,percent of total billed charges,Implant Device,19.95,35,,19.95,percent of total billed charges,Implant Device,19.95,35,,19.95,percent of total billed charges,Implant Device,22.8,40,,22.8,percent of total billed charges,Implant Device,19.95,70,,19.95,percent of total billed charges,All Other,19.38,34,,19.38,percent of total billed charges,Implant Device,19.38,34,,19.38,percent of total billed charges,Implant Device,19.95,35,,19.95,percent of total billed charges,Implant Device,19.95,35,,19.95,percent of total billed charges,Implant Device,19.95,35,,19.95,percent of total billed charges,Implant Device,19.95,35,,19.95,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,42.18,
ZIMMER 00-8852-010-36 RIM LINER 36MM,C1776,HCPCS,,79007216,CDM,278,RC,,,both,,,4403,3258.23,,,3258.23,Other,150% of Medicare + 9.63% HCRA Surcharge,1981.35,45,,1981.35,percent of total billed charges,Critical Access Hospital RCC factor,1497.02,34,,1497.02,percent of total billed charges,Implant Device,1497.02,34,,1497.02,percent of total billed charges,Implant Device,1497.02,34,,1497.02,percent of total billed charges,Implant Device,1497.02,34,,1497.02,percent of total billed charges,Implant Device,1497.02,34,,1497.02,percent of total billed charges,Implant Device,2179.49,,,2179.49,Other,110% of Medicare,1541.05,35,,1541.05,percent of total billed charges,Implant Device,1497.02,34,"Charges > $500, x 34%",1497.02,percent of total billed charges,Implant Device,1541.05,35,,1541.05,percent of total billed charges,Implant Device,1541.05,35,,1541.05,percent of total billed charges,Implant Device,1541.05,35,,1541.05,percent of total billed charges,Implant Device,1541.05,35,,1541.05,percent of total billed charges,Implant Device,1541.05,35,,1541.05,percent of total billed charges,Implant Device,1761.2,40,,1761.2,percent of total billed charges,Implant Device,1541.05,70,,1541.05,percent of total billed charges,All Other,1497.02,34,,1497.02,percent of total billed charges,Implant Device,1497.02,34,,1497.02,percent of total billed charges,Implant Device,1541.05,35,,1541.05,percent of total billed charges,Implant Device,1541.05,35,,1541.05,percent of total billed charges,Implant Device,1541.05,35,,1541.05,percent of total billed charges,Implant Device,1541.05,35,,1541.05,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1497.02,34,"If Charge > 2,000, then 34 percent",1497.02,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3258.23,
WRIGHT CCP-MPN1R MTP PLATE RIGHT,C1713,HCPCS,,79007218,CDM,278,RC,,,both,,,7245,5361.32,,,5361.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3260.25,45,,3260.25,percent of total billed charges,Critical Access Hospital RCC factor,2463.3,34,,2463.3,percent of total billed charges,Implant Device,2463.3,34,,2463.3,percent of total billed charges,Implant Device,2463.3,34,,2463.3,percent of total billed charges,Implant Device,2463.3,34,,2463.3,percent of total billed charges,Implant Device,2463.3,34,,2463.3,percent of total billed charges,Implant Device,3586.28,,,3586.28,Other,110% of Medicare,2535.75,35,,2535.75,percent of total billed charges,Implant Device,2463.3,34,"Charges > $500, x 34%",2463.3,percent of total billed charges,Implant Device,2535.75,35,,2535.75,percent of total billed charges,Implant Device,2535.75,35,,2535.75,percent of total billed charges,Implant Device,2535.75,35,,2535.75,percent of total billed charges,Implant Device,2535.75,35,,2535.75,percent of total billed charges,Implant Device,2535.75,35,,2535.75,percent of total billed charges,Implant Device,2898,40,,2898,percent of total billed charges,Implant Device,2535.75,70,,2535.75,percent of total billed charges,All Other,2463.3,34,,2463.3,percent of total billed charges,Implant Device,2463.3,34,,2463.3,percent of total billed charges,Implant Device,2535.75,35,,2535.75,percent of total billed charges,Implant Device,2535.75,35,,2535.75,percent of total billed charges,Implant Device,2535.75,35,,2535.75,percent of total billed charges,Implant Device,2535.75,35,,2535.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2463.3,34,"If Charge > 2,000, then 34 percent",2463.3,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5361.32,
WRIGHT CCP-N3010 NON LOCK SCREW 3X10MM,C1713,HCPCS,,79007219,CDM,278,RC,,,both,,,958,708.92,,,708.92,Other,150% of Medicare + 9.63% HCRA Surcharge,431.1,45,,431.1,percent of total billed charges,Critical Access Hospital RCC factor,325.72,34,,325.72,percent of total billed charges,Implant Device,325.72,34,,325.72,percent of total billed charges,Implant Device,325.72,34,,325.72,percent of total billed charges,Implant Device,325.72,34,,325.72,percent of total billed charges,Implant Device,325.72,34,,325.72,percent of total billed charges,Implant Device,474.21,,,474.21,Other,110% of Medicare,335.3,35,,335.3,percent of total billed charges,Implant Device,325.72,34,"Charges > $500, x 34%",325.72,percent of total billed charges,Implant Device,335.3,35,,335.3,percent of total billed charges,Implant Device,335.3,35,,335.3,percent of total billed charges,Implant Device,335.3,35,,335.3,percent of total billed charges,Implant Device,335.3,35,,335.3,percent of total billed charges,Implant Device,335.3,35,,335.3,percent of total billed charges,Implant Device,383.2,40,,383.2,percent of total billed charges,Implant Device,335.3,70,,335.3,percent of total billed charges,All Other,325.72,34,,325.72,percent of total billed charges,Implant Device,325.72,34,,325.72,percent of total billed charges,Implant Device,335.3,35,,335.3,percent of total billed charges,Implant Device,335.3,35,,335.3,percent of total billed charges,Implant Device,335.3,35,,335.3,percent of total billed charges,Implant Device,335.3,35,,335.3,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,708.92,
TRILLIANT 204-30-006 HAMMERTOE IMP 3.4X6,C1776,HCPCS,,79007222,CDM,278,RC,,,both,,,2370,1753.81,,,1753.81,Other,150% of Medicare + 9.63% HCRA Surcharge,1066.5,45,,1066.5,percent of total billed charges,Critical Access Hospital RCC factor,805.8,34,,805.8,percent of total billed charges,Implant Device,805.8,34,,805.8,percent of total billed charges,Implant Device,805.8,34,,805.8,percent of total billed charges,Implant Device,805.8,34,,805.8,percent of total billed charges,Implant Device,805.8,34,,805.8,percent of total billed charges,Implant Device,1173.15,,,1173.15,Other,110% of Medicare,829.5,35,,829.5,percent of total billed charges,Implant Device,805.8,34,"Charges > $500, x 34%",805.8,percent of total billed charges,Implant Device,829.5,35,,829.5,percent of total billed charges,Implant Device,829.5,35,,829.5,percent of total billed charges,Implant Device,829.5,35,,829.5,percent of total billed charges,Implant Device,829.5,35,,829.5,percent of total billed charges,Implant Device,829.5,35,,829.5,percent of total billed charges,Implant Device,948,40,,948,percent of total billed charges,Implant Device,829.5,70,,829.5,percent of total billed charges,All Other,805.8,34,,805.8,percent of total billed charges,Implant Device,805.8,34,,805.8,percent of total billed charges,Implant Device,829.5,35,,829.5,percent of total billed charges,Implant Device,829.5,35,,829.5,percent of total billed charges,Implant Device,829.5,35,,829.5,percent of total billed charges,Implant Device,829.5,35,,829.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,805.8,34,"If Charge > 2,000, then 34 percent",805.8,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1753.81,
TRILLIANT SURG 210-40-006 K WIRE .045,C1713,HCPCS,,79007223,CDM,278,RC,,,both,,,30,22.2,,,22.2,Other,150% of Medicare + 9.63% HCRA Surcharge,13.5,45,,13.5,percent of total billed charges,Critical Access Hospital RCC factor,10.2,34,,10.2,percent of total billed charges,Implant Device,10.2,34,,10.2,percent of total billed charges,Implant Device,10.2,34,,10.2,percent of total billed charges,Implant Device,10.2,34,,10.2,percent of total billed charges,Implant Device,10.2,34,,10.2,percent of total billed charges,Implant Device,14.85,,,14.85,Other,110% of Medicare,10.5,35,,10.5,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,10.5,35,,10.5,percent of total billed charges,Implant Device,10.5,35,,10.5,percent of total billed charges,Implant Device,10.5,35,,10.5,percent of total billed charges,Implant Device,10.5,35,,10.5,percent of total billed charges,Implant Device,10.5,35,,10.5,percent of total billed charges,Implant Device,12,40,,12,percent of total billed charges,Implant Device,10.5,70,,10.5,percent of total billed charges,All Other,10.2,34,,10.2,percent of total billed charges,Implant Device,10.2,34,,10.2,percent of total billed charges,Implant Device,10.5,35,,10.5,percent of total billed charges,Implant Device,10.5,35,,10.5,percent of total billed charges,Implant Device,10.5,35,,10.5,percent of total billed charges,Implant Device,10.5,35,,10.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,22.2,
DEVICOR MRM4008 BREAST BX MARKERS,A4648,HCPCS,,79007224,CDM,278,RC,,,both,,,280,207.2,,,207.2,Other,150% of Medicare + 9.63% HCRA Surcharge,126,45,,126,percent of total billed charges,Critical Access Hospital RCC factor,95.2,34,,95.2,percent of total billed charges,Implant Device,95.2,34,,95.2,percent of total billed charges,Implant Device,95.2,34,,95.2,percent of total billed charges,Implant Device,95.2,34,,95.2,percent of total billed charges,Implant Device,95.2,34,,95.2,percent of total billed charges,Implant Device,138.6,,,138.6,Other,110% of Medicare,98,35,,98,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,98,35,,98,percent of total billed charges,Implant Device,98,35,,98,percent of total billed charges,Implant Device,98,35,,98,percent of total billed charges,Implant Device,98,35,,98,percent of total billed charges,Implant Device,98,35,,98,percent of total billed charges,Implant Device,112,40,,112,percent of total billed charges,Implant Device,98,70,,98,percent of total billed charges,All Other,95.2,34,,95.2,percent of total billed charges,Implant Device,95.2,34,,95.2,percent of total billed charges,Implant Device,98,35,,98,percent of total billed charges,Implant Device,98,35,,98,percent of total billed charges,Implant Device,98,35,,98,percent of total billed charges,Implant Device,98,35,,98,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,207.2,
COOK G53688 STENT & POSITIONER 5FR,C2617,HCPCS,,79007225,CDM,278,RC,,,both,,,392,290.08,,,290.08,Other,150% of Medicare + 9.63% HCRA Surcharge,176.4,45,,176.4,percent of total billed charges,Critical Access Hospital RCC factor,133.28,34,,133.28,percent of total billed charges,Implant Device,133.28,34,,133.28,percent of total billed charges,Implant Device,133.28,34,,133.28,percent of total billed charges,Implant Device,133.28,34,,133.28,percent of total billed charges,Implant Device,133.28,34,,133.28,percent of total billed charges,Implant Device,194.04,,,194.04,Other,110% of Medicare,137.2,35,,137.2,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,137.2,35,,137.2,percent of total billed charges,Implant Device,137.2,35,,137.2,percent of total billed charges,Implant Device,137.2,35,,137.2,percent of total billed charges,Implant Device,137.2,35,,137.2,percent of total billed charges,Implant Device,137.2,35,,137.2,percent of total billed charges,Implant Device,156.8,40,,156.8,percent of total billed charges,Implant Device,137.2,70,,137.2,percent of total billed charges,All Other,133.28,34,,133.28,percent of total billed charges,Implant Device,133.28,34,,133.28,percent of total billed charges,Implant Device,137.2,35,,137.2,percent of total billed charges,Implant Device,137.2,35,,137.2,percent of total billed charges,Implant Device,137.2,35,,137.2,percent of total billed charges,Implant Device,137.2,35,,137.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,290.08,
COOK G53704 STENT & POSITIONER 6FR,C2617,HCPCS,,79007226,CDM,278,RC,,,both,,,392,290.08,,,290.08,Other,150% of Medicare + 9.63% HCRA Surcharge,176.4,45,,176.4,percent of total billed charges,Critical Access Hospital RCC factor,133.28,34,,133.28,percent of total billed charges,Implant Device,133.28,34,,133.28,percent of total billed charges,Implant Device,133.28,34,,133.28,percent of total billed charges,Implant Device,133.28,34,,133.28,percent of total billed charges,Implant Device,133.28,34,,133.28,percent of total billed charges,Implant Device,194.04,,,194.04,Other,110% of Medicare,137.2,35,,137.2,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,137.2,35,,137.2,percent of total billed charges,Implant Device,137.2,35,,137.2,percent of total billed charges,Implant Device,137.2,35,,137.2,percent of total billed charges,Implant Device,137.2,35,,137.2,percent of total billed charges,Implant Device,137.2,35,,137.2,percent of total billed charges,Implant Device,156.8,40,,156.8,percent of total billed charges,Implant Device,137.2,70,,137.2,percent of total billed charges,All Other,133.28,34,,133.28,percent of total billed charges,Implant Device,133.28,34,,133.28,percent of total billed charges,Implant Device,137.2,35,,137.2,percent of total billed charges,Implant Device,137.2,35,,137.2,percent of total billed charges,Implant Device,137.2,35,,137.2,percent of total billed charges,Implant Device,137.2,35,,137.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,290.08,
STRYKER 6260-9-326 FEMORAL HD 26MM,C1776,HCPCS,,79007227,CDM,278,RC,,,both,,,3278,2425.73,,,2425.73,Other,150% of Medicare + 9.63% HCRA Surcharge,1475.1,45,,1475.1,percent of total billed charges,Critical Access Hospital RCC factor,1114.52,34,,1114.52,percent of total billed charges,Implant Device,1114.52,34,,1114.52,percent of total billed charges,Implant Device,1114.52,34,,1114.52,percent of total billed charges,Implant Device,1114.52,34,,1114.52,percent of total billed charges,Implant Device,1114.52,34,,1114.52,percent of total billed charges,Implant Device,1622.61,,,1622.61,Other,110% of Medicare,1147.3,35,,1147.3,percent of total billed charges,Implant Device,1114.52,34,"Charges > $500, x 34%",1114.52,percent of total billed charges,Implant Device,1147.3,35,,1147.3,percent of total billed charges,Implant Device,1147.3,35,,1147.3,percent of total billed charges,Implant Device,1147.3,35,,1147.3,percent of total billed charges,Implant Device,1147.3,35,,1147.3,percent of total billed charges,Implant Device,1147.3,35,,1147.3,percent of total billed charges,Implant Device,1311.2,40,,1311.2,percent of total billed charges,Implant Device,1147.3,70,,1147.3,percent of total billed charges,All Other,1114.52,34,,1114.52,percent of total billed charges,Implant Device,1114.52,34,,1114.52,percent of total billed charges,Implant Device,1147.3,35,,1147.3,percent of total billed charges,Implant Device,1147.3,35,,1147.3,percent of total billed charges,Implant Device,1147.3,35,,1147.3,percent of total billed charges,Implant Device,1147.3,35,,1147.3,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1114.52,34,"If Charge > 2,000, then 34 percent",1114.52,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2425.73,
STRYKER UH1-56-26 UHR UNI HD 56X26MM,C1776,HCPCS,,79007228,CDM,278,RC,,,both,,,1391,1029.34,,,1029.34,Other,150% of Medicare + 9.63% HCRA Surcharge,625.95,45,,625.95,percent of total billed charges,Critical Access Hospital RCC factor,472.94,34,,472.94,percent of total billed charges,Implant Device,472.94,34,,472.94,percent of total billed charges,Implant Device,472.94,34,,472.94,percent of total billed charges,Implant Device,472.94,34,,472.94,percent of total billed charges,Implant Device,472.94,34,,472.94,percent of total billed charges,Implant Device,688.55,,,688.55,Other,110% of Medicare,486.85,35,,486.85,percent of total billed charges,Implant Device,472.94,34,"Charges > $500, x 34%",472.94,percent of total billed charges,Implant Device,486.85,35,,486.85,percent of total billed charges,Implant Device,486.85,35,,486.85,percent of total billed charges,Implant Device,486.85,35,,486.85,percent of total billed charges,Implant Device,486.85,35,,486.85,percent of total billed charges,Implant Device,486.85,35,,486.85,percent of total billed charges,Implant Device,556.4,40,,556.4,percent of total billed charges,Implant Device,486.85,70,,486.85,percent of total billed charges,All Other,472.94,34,,472.94,percent of total billed charges,Implant Device,472.94,34,,472.94,percent of total billed charges,Implant Device,486.85,35,,486.85,percent of total billed charges,Implant Device,486.85,35,,486.85,percent of total billed charges,Implant Device,486.85,35,,486.85,percent of total billed charges,Implant Device,486.85,35,,486.85,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1029.34,
STRYKER 6276-1-123 REST MOD HIP 23X10MM,C1776,HCPCS,,79007229,CDM,278,RC,,,both,,,19076,14116.29,,,14116.29,Other,150% of Medicare + 9.63% HCRA Surcharge,8584.2,45,,8584.2,percent of total billed charges,Critical Access Hospital RCC factor,6485.84,34,,6485.84,percent of total billed charges,Implant Device,6485.84,34,,6485.84,percent of total billed charges,Implant Device,6485.84,34,,6485.84,percent of total billed charges,Implant Device,6485.84,34,,6485.84,percent of total billed charges,Implant Device,6485.84,34,,6485.84,percent of total billed charges,Implant Device,9442.62,,,9442.62,Other,110% of Medicare,6676.6,35,,6676.6,percent of total billed charges,Implant Device,6485.84,34,"Charges > $500, x 34%",6485.84,percent of total billed charges,Implant Device,6676.6,35,,6676.6,percent of total billed charges,Implant Device,6676.6,35,,6676.6,percent of total billed charges,Implant Device,6676.6,35,,6676.6,percent of total billed charges,Implant Device,6676.6,35,,6676.6,percent of total billed charges,Implant Device,6676.6,35,,6676.6,percent of total billed charges,Implant Device,7630.4,40,,7630.4,percent of total billed charges,Implant Device,6676.6,70,,6676.6,percent of total billed charges,All Other,6485.84,34,,6485.84,percent of total billed charges,Implant Device,6485.84,34,,6485.84,percent of total billed charges,Implant Device,6676.6,35,,6676.6,percent of total billed charges,Implant Device,6676.6,35,,6676.6,percent of total billed charges,Implant Device,6676.6,35,,6676.6,percent of total billed charges,Implant Device,6676.6,35,,6676.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,6485.84,34,"If Charge > 2,000, then 34 percent",6485.84,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,14116.29,
ACUMED 65-0110-S BONE VOID FILLER 10CC,C1713,HCPCS,,79007230,CDM,278,RC,,,both,,,9828,7272.74,,,7272.74,Other,150% of Medicare + 9.63% HCRA Surcharge,4422.6,45,,4422.6,percent of total billed charges,Critical Access Hospital RCC factor,3341.52,34,,3341.52,percent of total billed charges,Implant Device,3341.52,34,,3341.52,percent of total billed charges,Implant Device,3341.52,34,,3341.52,percent of total billed charges,Implant Device,3341.52,34,,3341.52,percent of total billed charges,Implant Device,3341.52,34,,3341.52,percent of total billed charges,Implant Device,4864.86,,,4864.86,Other,110% of Medicare,3439.8,35,,3439.8,percent of total billed charges,Implant Device,3341.52,34,"Charges > $500, x 34%",3341.52,percent of total billed charges,Implant Device,3439.8,35,,3439.8,percent of total billed charges,Implant Device,3439.8,35,,3439.8,percent of total billed charges,Implant Device,3439.8,35,,3439.8,percent of total billed charges,Implant Device,3439.8,35,,3439.8,percent of total billed charges,Implant Device,3439.8,35,,3439.8,percent of total billed charges,Implant Device,3931.2,40,,3931.2,percent of total billed charges,Implant Device,3439.8,70,,3439.8,percent of total billed charges,All Other,3341.52,34,,3341.52,percent of total billed charges,Implant Device,3341.52,34,,3341.52,percent of total billed charges,Implant Device,3439.8,35,,3439.8,percent of total billed charges,Implant Device,3439.8,35,,3439.8,percent of total billed charges,Implant Device,3439.8,35,,3439.8,percent of total billed charges,Implant Device,3439.8,35,,3439.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3341.52,34,"If Charge > 2,000, then 34 percent",3341.52,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,7272.74,
ACUMED 65-0105-S BONE VOID FILLER 5CC,C1713,HCPCS,,79007231,CDM,278,RC,,,both,,,4950,3663.01,,,3663.01,Other,150% of Medicare + 9.63% HCRA Surcharge,2227.5,45,,2227.5,percent of total billed charges,Critical Access Hospital RCC factor,1683,34,,1683,percent of total billed charges,Implant Device,1683,34,,1683,percent of total billed charges,Implant Device,1683,34,,1683,percent of total billed charges,Implant Device,1683,34,,1683,percent of total billed charges,Implant Device,1683,34,,1683,percent of total billed charges,Implant Device,2450.25,,,2450.25,Other,110% of Medicare,1732.5,35,,1732.5,percent of total billed charges,Implant Device,1683,34,"Charges > $500, x 34%",1683,percent of total billed charges,Implant Device,1732.5,35,,1732.5,percent of total billed charges,Implant Device,1732.5,35,,1732.5,percent of total billed charges,Implant Device,1732.5,35,,1732.5,percent of total billed charges,Implant Device,1732.5,35,,1732.5,percent of total billed charges,Implant Device,1732.5,35,,1732.5,percent of total billed charges,Implant Device,1980,40,,1980,percent of total billed charges,Implant Device,1732.5,70,,1732.5,percent of total billed charges,All Other,1683,34,,1683,percent of total billed charges,Implant Device,1683,34,,1683,percent of total billed charges,Implant Device,1732.5,35,,1732.5,percent of total billed charges,Implant Device,1732.5,35,,1732.5,percent of total billed charges,Implant Device,1732.5,35,,1732.5,percent of total billed charges,Implant Device,1732.5,35,,1732.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1683,34,"If Charge > 2,000, then 34 percent",1683,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3663.01,
DEPUY 458.946S TI LOCKING SCREW 5X46MM,C1713,HCPCS,,79007233,CDM,278,RC,,,both,,,456,337.44,,,337.44,Other,150% of Medicare + 9.63% HCRA Surcharge,205.2,45,,205.2,percent of total billed charges,Critical Access Hospital RCC factor,155.04,34,,155.04,percent of total billed charges,Implant Device,155.04,34,,155.04,percent of total billed charges,Implant Device,155.04,34,,155.04,percent of total billed charges,Implant Device,155.04,34,,155.04,percent of total billed charges,Implant Device,155.04,34,,155.04,percent of total billed charges,Implant Device,225.72,,,225.72,Other,110% of Medicare,159.6,35,,159.6,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,159.6,35,,159.6,percent of total billed charges,Implant Device,159.6,35,,159.6,percent of total billed charges,Implant Device,159.6,35,,159.6,percent of total billed charges,Implant Device,159.6,35,,159.6,percent of total billed charges,Implant Device,159.6,35,,159.6,percent of total billed charges,Implant Device,182.4,40,,182.4,percent of total billed charges,Implant Device,159.6,70,,159.6,percent of total billed charges,All Other,155.04,34,,155.04,percent of total billed charges,Implant Device,155.04,34,,155.04,percent of total billed charges,Implant Device,159.6,35,,159.6,percent of total billed charges,Implant Device,159.6,35,,159.6,percent of total billed charges,Implant Device,159.6,35,,159.6,percent of total billed charges,Implant Device,159.6,35,,159.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,337.44,
DEPUY 04.032.090S TI NAIL SCREW 11X90MM,C1713,HCPCS,,79007234,CDM,278,RC,,,both,,,2197,1625.79,,,1625.79,Other,150% of Medicare + 9.63% HCRA Surcharge,988.65,45,,988.65,percent of total billed charges,Critical Access Hospital RCC factor,746.98,34,,746.98,percent of total billed charges,Implant Device,746.98,34,,746.98,percent of total billed charges,Implant Device,746.98,34,,746.98,percent of total billed charges,Implant Device,746.98,34,,746.98,percent of total billed charges,Implant Device,746.98,34,,746.98,percent of total billed charges,Implant Device,1087.52,,,1087.52,Other,110% of Medicare,768.95,35,,768.95,percent of total billed charges,Implant Device,746.98,34,"Charges > $500, x 34%",746.98,percent of total billed charges,Implant Device,768.95,35,,768.95,percent of total billed charges,Implant Device,768.95,35,,768.95,percent of total billed charges,Implant Device,768.95,35,,768.95,percent of total billed charges,Implant Device,768.95,35,,768.95,percent of total billed charges,Implant Device,768.95,35,,768.95,percent of total billed charges,Implant Device,878.8,40,,878.8,percent of total billed charges,Implant Device,768.95,70,,768.95,percent of total billed charges,All Other,746.98,34,,746.98,percent of total billed charges,Implant Device,746.98,34,,746.98,percent of total billed charges,Implant Device,768.95,35,,768.95,percent of total billed charges,Implant Device,768.95,35,,768.95,percent of total billed charges,Implant Device,768.95,35,,768.95,percent of total billed charges,Implant Device,768.95,35,,768.95,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,746.98,34,"If Charge > 2,000, then 34 percent",746.98,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1625.79,
DEPUY 456.411S TI CANN NAIL LT 11X300MM,C1713,HCPCS,,79007235,CDM,278,RC,,,both,,,6692,4952.1,,,4952.1,Other,150% of Medicare + 9.63% HCRA Surcharge,3011.4,45,,3011.4,percent of total billed charges,Critical Access Hospital RCC factor,2275.28,34,,2275.28,percent of total billed charges,Implant Device,2275.28,34,,2275.28,percent of total billed charges,Implant Device,2275.28,34,,2275.28,percent of total billed charges,Implant Device,2275.28,34,,2275.28,percent of total billed charges,Implant Device,2275.28,34,,2275.28,percent of total billed charges,Implant Device,3312.54,,,3312.54,Other,110% of Medicare,2342.2,35,,2342.2,percent of total billed charges,Implant Device,2275.28,34,"Charges > $500, x 34%",2275.28,percent of total billed charges,Implant Device,2342.2,35,,2342.2,percent of total billed charges,Implant Device,2342.2,35,,2342.2,percent of total billed charges,Implant Device,2342.2,35,,2342.2,percent of total billed charges,Implant Device,2342.2,35,,2342.2,percent of total billed charges,Implant Device,2342.2,35,,2342.2,percent of total billed charges,Implant Device,2676.8,40,,2676.8,percent of total billed charges,Implant Device,2342.2,70,,2342.2,percent of total billed charges,All Other,2275.28,34,,2275.28,percent of total billed charges,Implant Device,2275.28,34,,2275.28,percent of total billed charges,Implant Device,2342.2,35,,2342.2,percent of total billed charges,Implant Device,2342.2,35,,2342.2,percent of total billed charges,Implant Device,2342.2,35,,2342.2,percent of total billed charges,Implant Device,2342.2,35,,2342.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2275.28,34,"If Charge > 2,000, then 34 percent",2275.28,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4952.1,
S&N 71420578 GENESIS PATELLAR COMP 35MM,C1776,HCPCS,,79007236,CDM,278,RC,,,both,,,1815,1343.1,,,1343.1,Other,150% of Medicare + 9.63% HCRA Surcharge,816.75,45,,816.75,percent of total billed charges,Critical Access Hospital RCC factor,617.1,34,,617.1,percent of total billed charges,Implant Device,617.1,34,,617.1,percent of total billed charges,Implant Device,617.1,34,,617.1,percent of total billed charges,Implant Device,617.1,34,,617.1,percent of total billed charges,Implant Device,617.1,34,,617.1,percent of total billed charges,Implant Device,898.43,,,898.43,Other,110% of Medicare,635.25,35,,635.25,percent of total billed charges,Implant Device,617.1,34,"Charges > $500, x 34%",617.1,percent of total billed charges,Implant Device,635.25,35,,635.25,percent of total billed charges,Implant Device,635.25,35,,635.25,percent of total billed charges,Implant Device,635.25,35,,635.25,percent of total billed charges,Implant Device,635.25,35,,635.25,percent of total billed charges,Implant Device,635.25,35,,635.25,percent of total billed charges,Implant Device,726,40,,726,percent of total billed charges,Implant Device,635.25,70,,635.25,percent of total billed charges,All Other,617.1,34,,617.1,percent of total billed charges,Implant Device,617.1,34,,617.1,percent of total billed charges,Implant Device,635.25,35,,635.25,percent of total billed charges,Implant Device,635.25,35,,635.25,percent of total billed charges,Implant Device,635.25,35,,635.25,percent of total billed charges,Implant Device,635.25,35,,635.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1343.1,
S&N 71421167 LEGION FEMORAL COMP SZ 7 LT,C1776,HCPCS,,79007237,CDM,278,RC,,,both,,,24904,18429.02,,,18429.02,Other,150% of Medicare + 9.63% HCRA Surcharge,11206.8,45,,11206.8,percent of total billed charges,Critical Access Hospital RCC factor,8467.36,34,,8467.36,percent of total billed charges,Implant Device,8467.36,34,,8467.36,percent of total billed charges,Implant Device,8467.36,34,,8467.36,percent of total billed charges,Implant Device,8467.36,34,,8467.36,percent of total billed charges,Implant Device,8467.36,34,,8467.36,percent of total billed charges,Implant Device,12327.48,,,12327.48,Other,110% of Medicare,8716.4,35,,8716.4,percent of total billed charges,Implant Device,8467.36,34,"Charges > $500, x 34%",8467.36,percent of total billed charges,Implant Device,8716.4,35,,8716.4,percent of total billed charges,Implant Device,8716.4,35,,8716.4,percent of total billed charges,Implant Device,8716.4,35,,8716.4,percent of total billed charges,Implant Device,8716.4,35,,8716.4,percent of total billed charges,Implant Device,8716.4,35,,8716.4,percent of total billed charges,Implant Device,9961.6,40,,9961.6,percent of total billed charges,Implant Device,8716.4,70,,8716.4,percent of total billed charges,All Other,8467.36,34,,8467.36,percent of total billed charges,Implant Device,8467.36,34,,8467.36,percent of total billed charges,Implant Device,8716.4,35,,8716.4,percent of total billed charges,Implant Device,8716.4,35,,8716.4,percent of total billed charges,Implant Device,8716.4,35,,8716.4,percent of total billed charges,Implant Device,8716.4,35,,8716.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,8467.36,34,"If Charge > 2,000, then 34 percent",8467.36,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,18429.02,
S&N 71424227 LEGION OFFSET COUPLER 6MM,C1776,HCPCS,,79007238,CDM,278,RC,,,both,,,4726,3497.25,,,3497.25,Other,150% of Medicare + 9.63% HCRA Surcharge,2126.7,45,,2126.7,percent of total billed charges,Critical Access Hospital RCC factor,1606.84,34,,1606.84,percent of total billed charges,Implant Device,1606.84,34,,1606.84,percent of total billed charges,Implant Device,1606.84,34,,1606.84,percent of total billed charges,Implant Device,1606.84,34,,1606.84,percent of total billed charges,Implant Device,1606.84,34,,1606.84,percent of total billed charges,Implant Device,2339.37,,,2339.37,Other,110% of Medicare,1654.1,35,,1654.1,percent of total billed charges,Implant Device,1606.84,34,"Charges > $500, x 34%",1606.84,percent of total billed charges,Implant Device,1654.1,35,,1654.1,percent of total billed charges,Implant Device,1654.1,35,,1654.1,percent of total billed charges,Implant Device,1654.1,35,,1654.1,percent of total billed charges,Implant Device,1654.1,35,,1654.1,percent of total billed charges,Implant Device,1654.1,35,,1654.1,percent of total billed charges,Implant Device,1890.4,40,,1890.4,percent of total billed charges,Implant Device,1654.1,70,,1654.1,percent of total billed charges,All Other,1606.84,34,,1606.84,percent of total billed charges,Implant Device,1606.84,34,,1606.84,percent of total billed charges,Implant Device,1654.1,35,,1654.1,percent of total billed charges,Implant Device,1654.1,35,,1654.1,percent of total billed charges,Implant Device,1654.1,35,,1654.1,percent of total billed charges,Implant Device,1654.1,35,,1654.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1606.84,34,"If Charge > 2,000, then 34 percent",1606.84,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3497.25,
S&N 71420832 GENESIS ART INS SZ 5-6 11MM,C1776,HCPCS,,79007239,CDM,278,RC,,,both,,,3044,2252.57,,,2252.57,Other,150% of Medicare + 9.63% HCRA Surcharge,1369.8,45,,1369.8,percent of total billed charges,Critical Access Hospital RCC factor,1034.96,34,,1034.96,percent of total billed charges,Implant Device,1034.96,34,,1034.96,percent of total billed charges,Implant Device,1034.96,34,,1034.96,percent of total billed charges,Implant Device,1034.96,34,,1034.96,percent of total billed charges,Implant Device,1034.96,34,,1034.96,percent of total billed charges,Implant Device,1506.78,,,1506.78,Other,110% of Medicare,1065.4,35,,1065.4,percent of total billed charges,Implant Device,1034.96,34,"Charges > $500, x 34%",1034.96,percent of total billed charges,Implant Device,1065.4,35,,1065.4,percent of total billed charges,Implant Device,1065.4,35,,1065.4,percent of total billed charges,Implant Device,1065.4,35,,1065.4,percent of total billed charges,Implant Device,1065.4,35,,1065.4,percent of total billed charges,Implant Device,1065.4,35,,1065.4,percent of total billed charges,Implant Device,1217.6,40,,1217.6,percent of total billed charges,Implant Device,1065.4,70,,1065.4,percent of total billed charges,All Other,1034.96,34,,1034.96,percent of total billed charges,Implant Device,1034.96,34,,1034.96,percent of total billed charges,Implant Device,1065.4,35,,1065.4,percent of total billed charges,Implant Device,1065.4,35,,1065.4,percent of total billed charges,Implant Device,1065.4,35,,1065.4,percent of total billed charges,Implant Device,1065.4,35,,1065.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1034.96,34,"If Charge > 2,000, then 34 percent",1034.96,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2252.57,
S&N 71420170 GENESIS TIBIAL BASEPLT SZ 6,C1776,HCPCS,,79007240,CDM,278,RC,,,both,,,4538,3358.13,,,3358.13,Other,150% of Medicare + 9.63% HCRA Surcharge,2042.1,45,,2042.1,percent of total billed charges,Critical Access Hospital RCC factor,1542.92,34,,1542.92,percent of total billed charges,Implant Device,1542.92,34,,1542.92,percent of total billed charges,Implant Device,1542.92,34,,1542.92,percent of total billed charges,Implant Device,1542.92,34,,1542.92,percent of total billed charges,Implant Device,1542.92,34,,1542.92,percent of total billed charges,Implant Device,2246.31,,,2246.31,Other,110% of Medicare,1588.3,35,,1588.3,percent of total billed charges,Implant Device,1542.92,34,"Charges > $500, x 34%",1542.92,percent of total billed charges,Implant Device,1588.3,35,,1588.3,percent of total billed charges,Implant Device,1588.3,35,,1588.3,percent of total billed charges,Implant Device,1588.3,35,,1588.3,percent of total billed charges,Implant Device,1588.3,35,,1588.3,percent of total billed charges,Implant Device,1588.3,35,,1588.3,percent of total billed charges,Implant Device,1815.2,40,,1815.2,percent of total billed charges,Implant Device,1588.3,70,,1588.3,percent of total billed charges,All Other,1542.92,34,,1542.92,percent of total billed charges,Implant Device,1542.92,34,,1542.92,percent of total billed charges,Implant Device,1588.3,35,,1588.3,percent of total billed charges,Implant Device,1588.3,35,,1588.3,percent of total billed charges,Implant Device,1588.3,35,,1588.3,percent of total billed charges,Implant Device,1588.3,35,,1588.3,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1542.92,34,"If Charge > 2,000, then 34 percent",1542.92,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3358.13,
S&N 71420650 GENESIS LONG STEM 16X150MM,C1776,HCPCS,,79007241,CDM,278,RC,,,both,,,7350,5439.02,,,5439.02,Other,150% of Medicare + 9.63% HCRA Surcharge,3307.5,45,,3307.5,percent of total billed charges,Critical Access Hospital RCC factor,2499,34,,2499,percent of total billed charges,Implant Device,2499,34,,2499,percent of total billed charges,Implant Device,2499,34,,2499,percent of total billed charges,Implant Device,2499,34,,2499,percent of total billed charges,Implant Device,2499,34,,2499,percent of total billed charges,Implant Device,3638.25,,,3638.25,Other,110% of Medicare,2572.5,35,,2572.5,percent of total billed charges,Implant Device,2499,34,"Charges > $500, x 34%",2499,percent of total billed charges,Implant Device,2572.5,35,,2572.5,percent of total billed charges,Implant Device,2572.5,35,,2572.5,percent of total billed charges,Implant Device,2572.5,35,,2572.5,percent of total billed charges,Implant Device,2572.5,35,,2572.5,percent of total billed charges,Implant Device,2572.5,35,,2572.5,percent of total billed charges,Implant Device,2940,40,,2940,percent of total billed charges,Implant Device,2572.5,70,,2572.5,percent of total billed charges,All Other,2499,34,,2499,percent of total billed charges,Implant Device,2499,34,,2499,percent of total billed charges,Implant Device,2572.5,35,,2572.5,percent of total billed charges,Implant Device,2572.5,35,,2572.5,percent of total billed charges,Implant Device,2572.5,35,,2572.5,percent of total billed charges,Implant Device,2572.5,35,,2572.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2499,34,"If Charge > 2,000, then 34 percent",2499,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5439.02,
DEPUY 02.210.118 LOCKING SCREW 2.4X18MM,C1713,HCPCS,,79007242,CDM,278,RC,,,both,,,330,244.2,,,244.2,Other,150% of Medicare + 9.63% HCRA Surcharge,148.5,45,,148.5,percent of total billed charges,Critical Access Hospital RCC factor,112.2,34,,112.2,percent of total billed charges,Implant Device,112.2,34,,112.2,percent of total billed charges,Implant Device,112.2,34,,112.2,percent of total billed charges,Implant Device,112.2,34,,112.2,percent of total billed charges,Implant Device,112.2,34,,112.2,percent of total billed charges,Implant Device,163.35,,,163.35,Other,110% of Medicare,115.5,35,,115.5,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,132,40,,132,percent of total billed charges,Implant Device,115.5,70,,115.5,percent of total billed charges,All Other,112.2,34,,112.2,percent of total billed charges,Implant Device,112.2,34,,112.2,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,244.2,
DEPUY 02.210.120 LOCKING SCREW 2.4X20MM,C1713,HCPCS,,79007243,CDM,278,RC,,,both,,,330,244.2,,,244.2,Other,150% of Medicare + 9.63% HCRA Surcharge,148.5,45,,148.5,percent of total billed charges,Critical Access Hospital RCC factor,112.2,34,,112.2,percent of total billed charges,Implant Device,112.2,34,,112.2,percent of total billed charges,Implant Device,112.2,34,,112.2,percent of total billed charges,Implant Device,112.2,34,,112.2,percent of total billed charges,Implant Device,112.2,34,,112.2,percent of total billed charges,Implant Device,163.35,,,163.35,Other,110% of Medicare,115.5,35,,115.5,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,132,40,,132,percent of total billed charges,Implant Device,115.5,70,,115.5,percent of total billed charges,All Other,112.2,34,,112.2,percent of total billed charges,Implant Device,112.2,34,,112.2,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,244.2,
DEPUY 02.111.531 RADIUS PLATE 6HOLE2.4MM,C1713,HCPCS,,79007244,CDM,278,RC,,,both,,,2323,1719.03,,,1719.03,Other,150% of Medicare + 9.63% HCRA Surcharge,1045.35,45,,1045.35,percent of total billed charges,Critical Access Hospital RCC factor,789.82,34,,789.82,percent of total billed charges,Implant Device,789.82,34,,789.82,percent of total billed charges,Implant Device,789.82,34,,789.82,percent of total billed charges,Implant Device,789.82,34,,789.82,percent of total billed charges,Implant Device,789.82,34,,789.82,percent of total billed charges,Implant Device,1149.89,,,1149.89,Other,110% of Medicare,813.05,35,,813.05,percent of total billed charges,Implant Device,789.82,34,"Charges > $500, x 34%",789.82,percent of total billed charges,Implant Device,813.05,35,,813.05,percent of total billed charges,Implant Device,813.05,35,,813.05,percent of total billed charges,Implant Device,813.05,35,,813.05,percent of total billed charges,Implant Device,813.05,35,,813.05,percent of total billed charges,Implant Device,813.05,35,,813.05,percent of total billed charges,Implant Device,929.2,40,,929.2,percent of total billed charges,Implant Device,813.05,70,,813.05,percent of total billed charges,All Other,789.82,34,,789.82,percent of total billed charges,Implant Device,789.82,34,,789.82,percent of total billed charges,Implant Device,813.05,35,,813.05,percent of total billed charges,Implant Device,813.05,35,,813.05,percent of total billed charges,Implant Device,813.05,35,,813.05,percent of total billed charges,Implant Device,813.05,35,,813.05,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,789.82,34,"If Charge > 2,000, then 34 percent",789.82,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1719.03,
DEPUY 04.004-452S CANN TIB NAIL 10X360MM,C1713,HCPCS,,79007248,CDM,278,RC,,,both,,,5640,4173.61,,,4173.61,Other,150% of Medicare + 9.63% HCRA Surcharge,2538,45,,2538,percent of total billed charges,Critical Access Hospital RCC factor,1917.6,34,,1917.6,percent of total billed charges,Implant Device,1917.6,34,,1917.6,percent of total billed charges,Implant Device,1917.6,34,,1917.6,percent of total billed charges,Implant Device,1917.6,34,,1917.6,percent of total billed charges,Implant Device,1917.6,34,,1917.6,percent of total billed charges,Implant Device,2791.8,,,2791.8,Other,110% of Medicare,1974,35,,1974,percent of total billed charges,Implant Device,1917.6,34,"Charges > $500, x 34%",1917.6,percent of total billed charges,Implant Device,1974,35,,1974,percent of total billed charges,Implant Device,1974,35,,1974,percent of total billed charges,Implant Device,1974,35,,1974,percent of total billed charges,Implant Device,1974,35,,1974,percent of total billed charges,Implant Device,1974,35,,1974,percent of total billed charges,Implant Device,2256,40,,2256,percent of total billed charges,Implant Device,1974,70,,1974,percent of total billed charges,All Other,1917.6,34,,1917.6,percent of total billed charges,Implant Device,1917.6,34,,1917.6,percent of total billed charges,Implant Device,1974,35,,1974,percent of total billed charges,Implant Device,1974,35,,1974,percent of total billed charges,Implant Device,1974,35,,1974,percent of total billed charges,Implant Device,1974,35,,1974,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1917.6,34,"If Charge > 2,000, then 34 percent",1917.6,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4173.61,
DEPUY 04.005.530S LOCKING SCREW 5X40MM,C1713,HCPCS,,79007249,CDM,278,RC,,,both,,,412,304.88,,,304.88,Other,150% of Medicare + 9.63% HCRA Surcharge,185.4,45,,185.4,percent of total billed charges,Critical Access Hospital RCC factor,140.08,34,,140.08,percent of total billed charges,Implant Device,140.08,34,,140.08,percent of total billed charges,Implant Device,140.08,34,,140.08,percent of total billed charges,Implant Device,140.08,34,,140.08,percent of total billed charges,Implant Device,140.08,34,,140.08,percent of total billed charges,Implant Device,203.94,,,203.94,Other,110% of Medicare,144.2,35,,144.2,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,144.2,35,,144.2,percent of total billed charges,Implant Device,144.2,35,,144.2,percent of total billed charges,Implant Device,144.2,35,,144.2,percent of total billed charges,Implant Device,144.2,35,,144.2,percent of total billed charges,Implant Device,144.2,35,,144.2,percent of total billed charges,Implant Device,164.8,40,,164.8,percent of total billed charges,Implant Device,144.2,70,,144.2,percent of total billed charges,All Other,140.08,34,,140.08,percent of total billed charges,Implant Device,140.08,34,,140.08,percent of total billed charges,Implant Device,144.2,35,,144.2,percent of total billed charges,Implant Device,144.2,35,,144.2,percent of total billed charges,Implant Device,144.2,35,,144.2,percent of total billed charges,Implant Device,144.2,35,,144.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,304.88,
DEPUY 04.005.534S LOCKING SCREW 5X44MM,C1713,HCPCS,,79007250,CDM,278,RC,,,both,,,412,304.88,,,304.88,Other,150% of Medicare + 9.63% HCRA Surcharge,185.4,45,,185.4,percent of total billed charges,Critical Access Hospital RCC factor,140.08,34,,140.08,percent of total billed charges,Implant Device,140.08,34,,140.08,percent of total billed charges,Implant Device,140.08,34,,140.08,percent of total billed charges,Implant Device,140.08,34,,140.08,percent of total billed charges,Implant Device,140.08,34,,140.08,percent of total billed charges,Implant Device,203.94,,,203.94,Other,110% of Medicare,144.2,35,,144.2,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,144.2,35,,144.2,percent of total billed charges,Implant Device,144.2,35,,144.2,percent of total billed charges,Implant Device,144.2,35,,144.2,percent of total billed charges,Implant Device,144.2,35,,144.2,percent of total billed charges,Implant Device,144.2,35,,144.2,percent of total billed charges,Implant Device,164.8,40,,164.8,percent of total billed charges,Implant Device,144.2,70,,144.2,percent of total billed charges,All Other,140.08,34,,140.08,percent of total billed charges,Implant Device,140.08,34,,140.08,percent of total billed charges,Implant Device,144.2,35,,144.2,percent of total billed charges,Implant Device,144.2,35,,144.2,percent of total billed charges,Implant Device,144.2,35,,144.2,percent of total billed charges,Implant Device,144.2,35,,144.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,304.88,
DEPUY 96-2365 TIBIAL INSERT TC3 SZ5 20MM,C1776,HCPCS,,79007251,CDM,278,RC,,,both,,,10896,8063.07,,,8063.07,Other,150% of Medicare + 9.63% HCRA Surcharge,4903.2,45,,4903.2,percent of total billed charges,Critical Access Hospital RCC factor,3704.64,34,,3704.64,percent of total billed charges,Implant Device,3704.64,34,,3704.64,percent of total billed charges,Implant Device,3704.64,34,,3704.64,percent of total billed charges,Implant Device,3704.64,34,,3704.64,percent of total billed charges,Implant Device,3704.64,34,,3704.64,percent of total billed charges,Implant Device,5393.52,,,5393.52,Other,110% of Medicare,3813.6,35,,3813.6,percent of total billed charges,Implant Device,3704.64,34,"Charges > $500, x 34%",3704.64,percent of total billed charges,Implant Device,3813.6,35,,3813.6,percent of total billed charges,Implant Device,3813.6,35,,3813.6,percent of total billed charges,Implant Device,3813.6,35,,3813.6,percent of total billed charges,Implant Device,3813.6,35,,3813.6,percent of total billed charges,Implant Device,3813.6,35,,3813.6,percent of total billed charges,Implant Device,4358.4,40,,4358.4,percent of total billed charges,Implant Device,3813.6,70,,3813.6,percent of total billed charges,All Other,3704.64,34,,3704.64,percent of total billed charges,Implant Device,3704.64,34,,3704.64,percent of total billed charges,Implant Device,3813.6,35,,3813.6,percent of total billed charges,Implant Device,3813.6,35,,3813.6,percent of total billed charges,Implant Device,3813.6,35,,3813.6,percent of total billed charges,Implant Device,3813.6,35,,3813.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3704.64,34,"If Charge > 2,000, then 34 percent",3704.64,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,8063.07,
DEPUY 204.844 CORTEX SCREW 3.5X44MM,C1713,HCPCS,,79007252,CDM,278,RC,,,both,,,57,42.18,,,42.18,Other,150% of Medicare + 9.63% HCRA Surcharge,25.65,45,,25.65,percent of total billed charges,Critical Access Hospital RCC factor,19.38,34,,19.38,percent of total billed charges,Implant Device,19.38,34,,19.38,percent of total billed charges,Implant Device,19.38,34,,19.38,percent of total billed charges,Implant Device,19.38,34,,19.38,percent of total billed charges,Implant Device,19.38,34,,19.38,percent of total billed charges,Implant Device,28.22,,,28.22,Other,110% of Medicare,19.95,35,,19.95,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,19.95,35,,19.95,percent of total billed charges,Implant Device,19.95,35,,19.95,percent of total billed charges,Implant Device,19.95,35,,19.95,percent of total billed charges,Implant Device,19.95,35,,19.95,percent of total billed charges,Implant Device,19.95,35,,19.95,percent of total billed charges,Implant Device,22.8,40,,22.8,percent of total billed charges,Implant Device,19.95,70,,19.95,percent of total billed charges,All Other,19.38,34,,19.38,percent of total billed charges,Implant Device,19.38,34,,19.38,percent of total billed charges,Implant Device,19.95,35,,19.95,percent of total billed charges,Implant Device,19.95,35,,19.95,percent of total billed charges,Implant Device,19.95,35,,19.95,percent of total billed charges,Implant Device,19.95,35,,19.95,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,42.18,
DEPUY 02.127.210 TIB PLATE 4HOLE 3.5X87,C1776,HCPCS,,79007253,CDM,278,RC,,,both,,,6315,4673.12,,,4673.12,Other,150% of Medicare + 9.63% HCRA Surcharge,2841.75,45,,2841.75,percent of total billed charges,Critical Access Hospital RCC factor,2147.1,34,,2147.1,percent of total billed charges,Implant Device,2147.1,34,,2147.1,percent of total billed charges,Implant Device,2147.1,34,,2147.1,percent of total billed charges,Implant Device,2147.1,34,,2147.1,percent of total billed charges,Implant Device,2147.1,34,,2147.1,percent of total billed charges,Implant Device,3125.93,,,3125.93,Other,110% of Medicare,2210.25,35,,2210.25,percent of total billed charges,Implant Device,2147.1,34,"Charges > $500, x 34%",2147.1,percent of total billed charges,Implant Device,2210.25,35,,2210.25,percent of total billed charges,Implant Device,2210.25,35,,2210.25,percent of total billed charges,Implant Device,2210.25,35,,2210.25,percent of total billed charges,Implant Device,2210.25,35,,2210.25,percent of total billed charges,Implant Device,2210.25,35,,2210.25,percent of total billed charges,Implant Device,2526,40,,2526,percent of total billed charges,Implant Device,2210.25,70,,2210.25,percent of total billed charges,All Other,2147.1,34,,2147.1,percent of total billed charges,Implant Device,2147.1,34,,2147.1,percent of total billed charges,Implant Device,2210.25,35,,2210.25,percent of total billed charges,Implant Device,2210.25,35,,2210.25,percent of total billed charges,Implant Device,2210.25,35,,2210.25,percent of total billed charges,Implant Device,2210.25,35,,2210.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2147.1,34,"If Charge > 2,000, then 34 percent",2147.1,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4673.12,
DEPUY 02.127.175 LOCK SCREW 3.5X75MM,C1713,HCPCS,,79007254,CDM,278,RC,,,both,,,414,306.36,,,306.36,Other,150% of Medicare + 9.63% HCRA Surcharge,186.3,45,,186.3,percent of total billed charges,Critical Access Hospital RCC factor,140.76,34,,140.76,percent of total billed charges,Implant Device,140.76,34,,140.76,percent of total billed charges,Implant Device,140.76,34,,140.76,percent of total billed charges,Implant Device,140.76,34,,140.76,percent of total billed charges,Implant Device,140.76,34,,140.76,percent of total billed charges,Implant Device,204.93,,,204.93,Other,110% of Medicare,144.9,35,,144.9,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,144.9,35,,144.9,percent of total billed charges,Implant Device,144.9,35,,144.9,percent of total billed charges,Implant Device,144.9,35,,144.9,percent of total billed charges,Implant Device,144.9,35,,144.9,percent of total billed charges,Implant Device,144.9,35,,144.9,percent of total billed charges,Implant Device,165.6,40,,165.6,percent of total billed charges,Implant Device,144.9,70,,144.9,percent of total billed charges,All Other,140.76,34,,140.76,percent of total billed charges,Implant Device,140.76,34,,140.76,percent of total billed charges,Implant Device,144.9,35,,144.9,percent of total billed charges,Implant Device,144.9,35,,144.9,percent of total billed charges,Implant Device,144.9,35,,144.9,percent of total billed charges,Implant Device,144.9,35,,144.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,306.36,
DEPUY 04.005.538S LOCK SCREW 5.0X48MM,C1713,HCPCS,,79007255,CDM,278,RC,,,both,,,412,304.88,,,304.88,Other,150% of Medicare + 9.63% HCRA Surcharge,185.4,45,,185.4,percent of total billed charges,Critical Access Hospital RCC factor,140.08,34,,140.08,percent of total billed charges,Implant Device,140.08,34,,140.08,percent of total billed charges,Implant Device,140.08,34,,140.08,percent of total billed charges,Implant Device,140.08,34,,140.08,percent of total billed charges,Implant Device,140.08,34,,140.08,percent of total billed charges,Implant Device,203.94,,,203.94,Other,110% of Medicare,144.2,35,,144.2,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,144.2,35,,144.2,percent of total billed charges,Implant Device,144.2,35,,144.2,percent of total billed charges,Implant Device,144.2,35,,144.2,percent of total billed charges,Implant Device,144.2,35,,144.2,percent of total billed charges,Implant Device,144.2,35,,144.2,percent of total billed charges,Implant Device,164.8,40,,164.8,percent of total billed charges,Implant Device,144.2,70,,144.2,percent of total billed charges,All Other,140.08,34,,140.08,percent of total billed charges,Implant Device,140.08,34,,140.08,percent of total billed charges,Implant Device,144.2,35,,144.2,percent of total billed charges,Implant Device,144.2,35,,144.2,percent of total billed charges,Implant Device,144.2,35,,144.2,percent of total billed charges,Implant Device,144.2,35,,144.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,304.88,
BIOMET EBI 1802-49-055 CANN SCREW 4X55MM,C1713,HCPCS,,79007256,CDM,278,RC,,,both,,,750,555,,,555,Other,150% of Medicare + 9.63% HCRA Surcharge,337.5,45,,337.5,percent of total billed charges,Critical Access Hospital RCC factor,255,34,,255,percent of total billed charges,Implant Device,255,34,,255,percent of total billed charges,Implant Device,255,34,,255,percent of total billed charges,Implant Device,255,34,,255,percent of total billed charges,Implant Device,255,34,,255,percent of total billed charges,Implant Device,371.25,,,371.25,Other,110% of Medicare,262.5,35,,262.5,percent of total billed charges,Implant Device,255,34,"Charges > $500, x 34%",255,percent of total billed charges,Implant Device,262.5,35,,262.5,percent of total billed charges,Implant Device,262.5,35,,262.5,percent of total billed charges,Implant Device,262.5,35,,262.5,percent of total billed charges,Implant Device,262.5,35,,262.5,percent of total billed charges,Implant Device,262.5,35,,262.5,percent of total billed charges,Implant Device,300,40,,300,percent of total billed charges,Implant Device,262.5,70,,262.5,percent of total billed charges,All Other,255,34,,255,percent of total billed charges,Implant Device,255,34,,255,percent of total billed charges,Implant Device,262.5,35,,262.5,percent of total billed charges,Implant Device,262.5,35,,262.5,percent of total billed charges,Implant Device,262.5,35,,262.5,percent of total billed charges,Implant Device,262.5,35,,262.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,555,
ARTHREX AR-7000-38 PT SCREW 3.75X38MM,C1713,HCPCS,,79007258,CDM,278,RC,,,both,,,858,634.92,,,634.92,Other,150% of Medicare + 9.63% HCRA Surcharge,386.1,45,,386.1,percent of total billed charges,Critical Access Hospital RCC factor,291.72,34,,291.72,percent of total billed charges,Implant Device,291.72,34,,291.72,percent of total billed charges,Implant Device,291.72,34,,291.72,percent of total billed charges,Implant Device,291.72,34,,291.72,percent of total billed charges,Implant Device,291.72,34,,291.72,percent of total billed charges,Implant Device,424.71,,,424.71,Other,110% of Medicare,300.3,35,,300.3,percent of total billed charges,Implant Device,291.72,34,"Charges > $500, x 34%",291.72,percent of total billed charges,Implant Device,300.3,35,,300.3,percent of total billed charges,Implant Device,300.3,35,,300.3,percent of total billed charges,Implant Device,300.3,35,,300.3,percent of total billed charges,Implant Device,300.3,35,,300.3,percent of total billed charges,Implant Device,300.3,35,,300.3,percent of total billed charges,Implant Device,343.2,40,,343.2,percent of total billed charges,Implant Device,300.3,70,,300.3,percent of total billed charges,All Other,291.72,34,,291.72,percent of total billed charges,Implant Device,291.72,34,,291.72,percent of total billed charges,Implant Device,300.3,35,,300.3,percent of total billed charges,Implant Device,300.3,35,,300.3,percent of total billed charges,Implant Device,300.3,35,,300.3,percent of total billed charges,Implant Device,300.3,35,,300.3,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,634.92,
STRYKER 345445 CANC FT SCREW 4X45MM,C1713,HCPCS,,79007259,CDM,278,RC,,,both,,,105,77.7,,,77.7,Other,150% of Medicare + 9.63% HCRA Surcharge,47.25,45,,47.25,percent of total billed charges,Critical Access Hospital RCC factor,35.7,34,,35.7,percent of total billed charges,Implant Device,35.7,34,,35.7,percent of total billed charges,Implant Device,35.7,34,,35.7,percent of total billed charges,Implant Device,35.7,34,,35.7,percent of total billed charges,Implant Device,35.7,34,,35.7,percent of total billed charges,Implant Device,51.98,,,51.98,Other,110% of Medicare,36.75,35,,36.75,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,36.75,35,,36.75,percent of total billed charges,Implant Device,36.75,35,,36.75,percent of total billed charges,Implant Device,36.75,35,,36.75,percent of total billed charges,Implant Device,36.75,35,,36.75,percent of total billed charges,Implant Device,36.75,35,,36.75,percent of total billed charges,Implant Device,42,40,,42,percent of total billed charges,Implant Device,36.75,70,,36.75,percent of total billed charges,All Other,35.7,34,,35.7,percent of total billed charges,Implant Device,35.7,34,,35.7,percent of total billed charges,Implant Device,36.75,35,,36.75,percent of total billed charges,Implant Device,36.75,35,,36.75,percent of total billed charges,Implant Device,36.75,35,,36.75,percent of total billed charges,Implant Device,36.75,35,,36.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,77.7,
ZIMMER 02.03263.015 PROX FEM PLATE 324MM,C1713,HCPCS,,79007260,CDM,278,RC,,,both,,,4536,3356.65,,,3356.65,Other,150% of Medicare + 9.63% HCRA Surcharge,2041.2,45,,2041.2,percent of total billed charges,Critical Access Hospital RCC factor,1542.24,34,,1542.24,percent of total billed charges,Implant Device,1542.24,34,,1542.24,percent of total billed charges,Implant Device,1542.24,34,,1542.24,percent of total billed charges,Implant Device,1542.24,34,,1542.24,percent of total billed charges,Implant Device,1542.24,34,,1542.24,percent of total billed charges,Implant Device,2245.32,,,2245.32,Other,110% of Medicare,1587.6,35,,1587.6,percent of total billed charges,Implant Device,1542.24,34,"Charges > $500, x 34%",1542.24,percent of total billed charges,Implant Device,1587.6,35,,1587.6,percent of total billed charges,Implant Device,1587.6,35,,1587.6,percent of total billed charges,Implant Device,1587.6,35,,1587.6,percent of total billed charges,Implant Device,1587.6,35,,1587.6,percent of total billed charges,Implant Device,1587.6,35,,1587.6,percent of total billed charges,Implant Device,1814.4,40,,1814.4,percent of total billed charges,Implant Device,1587.6,70,,1587.6,percent of total billed charges,All Other,1542.24,34,,1542.24,percent of total billed charges,Implant Device,1542.24,34,,1542.24,percent of total billed charges,Implant Device,1587.6,35,,1587.6,percent of total billed charges,Implant Device,1587.6,35,,1587.6,percent of total billed charges,Implant Device,1587.6,35,,1587.6,percent of total billed charges,Implant Device,1587.6,35,,1587.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1542.24,34,"If Charge > 2,000, then 34 percent",1542.24,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3356.65,
ZIMMER 02.03150.300 LOCKING SCREW CAP,C1713,HCPCS,,79007261,CDM,278,RC,,,both,,,478,353.72,,,353.72,Other,150% of Medicare + 9.63% HCRA Surcharge,215.1,45,,215.1,percent of total billed charges,Critical Access Hospital RCC factor,162.52,34,,162.52,percent of total billed charges,Implant Device,162.52,34,,162.52,percent of total billed charges,Implant Device,162.52,34,,162.52,percent of total billed charges,Implant Device,162.52,34,,162.52,percent of total billed charges,Implant Device,162.52,34,,162.52,percent of total billed charges,Implant Device,236.61,,,236.61,Other,110% of Medicare,167.3,35,,167.3,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,167.3,35,,167.3,percent of total billed charges,Implant Device,167.3,35,,167.3,percent of total billed charges,Implant Device,167.3,35,,167.3,percent of total billed charges,Implant Device,167.3,35,,167.3,percent of total billed charges,Implant Device,167.3,35,,167.3,percent of total billed charges,Implant Device,191.2,40,,191.2,percent of total billed charges,Implant Device,167.3,70,,167.3,percent of total billed charges,All Other,162.52,34,,162.52,percent of total billed charges,Implant Device,162.52,34,,162.52,percent of total billed charges,Implant Device,167.3,35,,167.3,percent of total billed charges,Implant Device,167.3,35,,167.3,percent of total billed charges,Implant Device,167.3,35,,167.3,percent of total billed charges,Implant Device,167.3,35,,167.3,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,353.72,
ZIMMER 02.03155.030 CORT SCREW 4X30MM,C1713,HCPCS,,79007262,CDM,278,RC,,,both,,,324,239.76,,,239.76,Other,150% of Medicare + 9.63% HCRA Surcharge,145.8,45,,145.8,percent of total billed charges,Critical Access Hospital RCC factor,110.16,34,,110.16,percent of total billed charges,Implant Device,110.16,34,,110.16,percent of total billed charges,Implant Device,110.16,34,,110.16,percent of total billed charges,Implant Device,110.16,34,,110.16,percent of total billed charges,Implant Device,110.16,34,,110.16,percent of total billed charges,Implant Device,160.38,,,160.38,Other,110% of Medicare,113.4,35,,113.4,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,129.6,40,,129.6,percent of total billed charges,Implant Device,113.4,70,,113.4,percent of total billed charges,All Other,110.16,34,,110.16,percent of total billed charges,Implant Device,110.16,34,,110.16,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,239.76,
ZIMMER 02.03155.036 CORT SCREW 4X36MM,C1713,HCPCS,,79007263,CDM,278,RC,,,both,,,324,239.76,,,239.76,Other,150% of Medicare + 9.63% HCRA Surcharge,145.8,45,,145.8,percent of total billed charges,Critical Access Hospital RCC factor,110.16,34,,110.16,percent of total billed charges,Implant Device,110.16,34,,110.16,percent of total billed charges,Implant Device,110.16,34,,110.16,percent of total billed charges,Implant Device,110.16,34,,110.16,percent of total billed charges,Implant Device,110.16,34,,110.16,percent of total billed charges,Implant Device,160.38,,,160.38,Other,110% of Medicare,113.4,35,,113.4,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,129.6,40,,129.6,percent of total billed charges,Implant Device,113.4,70,,113.4,percent of total billed charges,All Other,110.16,34,,110.16,percent of total billed charges,Implant Device,110.16,34,,110.16,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,239.76,
ZIMMER 02.03155.038 CORT SCREW 4X38MM,C1713,HCPCS,,79007264,CDM,278,RC,,,both,,,324,239.76,,,239.76,Other,150% of Medicare + 9.63% HCRA Surcharge,145.8,45,,145.8,percent of total billed charges,Critical Access Hospital RCC factor,110.16,34,,110.16,percent of total billed charges,Implant Device,110.16,34,,110.16,percent of total billed charges,Implant Device,110.16,34,,110.16,percent of total billed charges,Implant Device,110.16,34,,110.16,percent of total billed charges,Implant Device,110.16,34,,110.16,percent of total billed charges,Implant Device,160.38,,,160.38,Other,110% of Medicare,113.4,35,,113.4,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,129.6,40,,129.6,percent of total billed charges,Implant Device,113.4,70,,113.4,percent of total billed charges,All Other,110.16,34,,110.16,percent of total billed charges,Implant Device,110.16,34,,110.16,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,239.76,
ZIMMER 02.03155.042 CORT SCREW 4X42MM,C1713,HCPCS,,79007265,CDM,278,RC,,,both,,,324,239.76,,,239.76,Other,150% of Medicare + 9.63% HCRA Surcharge,145.8,45,,145.8,percent of total billed charges,Critical Access Hospital RCC factor,110.16,34,,110.16,percent of total billed charges,Implant Device,110.16,34,,110.16,percent of total billed charges,Implant Device,110.16,34,,110.16,percent of total billed charges,Implant Device,110.16,34,,110.16,percent of total billed charges,Implant Device,110.16,34,,110.16,percent of total billed charges,Implant Device,160.38,,,160.38,Other,110% of Medicare,113.4,35,,113.4,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,129.6,40,,129.6,percent of total billed charges,Implant Device,113.4,70,,113.4,percent of total billed charges,All Other,110.16,34,,110.16,percent of total billed charges,Implant Device,110.16,34,,110.16,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,239.76,
ZIMMER 02.03155.044 CORT SCREW 4X44MM,C1713,HCPCS,,79007266,CDM,278,RC,,,both,,,324,239.76,,,239.76,Other,150% of Medicare + 9.63% HCRA Surcharge,145.8,45,,145.8,percent of total billed charges,Critical Access Hospital RCC factor,110.16,34,,110.16,percent of total billed charges,Implant Device,110.16,34,,110.16,percent of total billed charges,Implant Device,110.16,34,,110.16,percent of total billed charges,Implant Device,110.16,34,,110.16,percent of total billed charges,Implant Device,110.16,34,,110.16,percent of total billed charges,Implant Device,160.38,,,160.38,Other,110% of Medicare,113.4,35,,113.4,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,129.6,40,,129.6,percent of total billed charges,Implant Device,113.4,70,,113.4,percent of total billed charges,All Other,110.16,34,,110.16,percent of total billed charges,Implant Device,110.16,34,,110.16,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,239.76,
ZIMMER 02.03155.050 CORT SCREW 4X50MM,C1713,HCPCS,,79007267,CDM,278,RC,,,both,,,324,239.76,,,239.76,Other,150% of Medicare + 9.63% HCRA Surcharge,145.8,45,,145.8,percent of total billed charges,Critical Access Hospital RCC factor,110.16,34,,110.16,percent of total billed charges,Implant Device,110.16,34,,110.16,percent of total billed charges,Implant Device,110.16,34,,110.16,percent of total billed charges,Implant Device,110.16,34,,110.16,percent of total billed charges,Implant Device,110.16,34,,110.16,percent of total billed charges,Implant Device,160.38,,,160.38,Other,110% of Medicare,113.4,35,,113.4,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,129.6,40,,129.6,percent of total billed charges,Implant Device,113.4,70,,113.4,percent of total billed charges,All Other,110.16,34,,110.16,percent of total billed charges,Implant Device,110.16,34,,110.16,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,239.76,
DEPUY 1221-36-154 ACETABLR LINER 36X54MM,C1776,HCPCS,,79007269,CDM,278,RC,,,both,,,2565,1898.11,,,1898.11,Other,150% of Medicare + 9.63% HCRA Surcharge,1154.25,45,,1154.25,percent of total billed charges,Critical Access Hospital RCC factor,872.1,34,,872.1,percent of total billed charges,Implant Device,872.1,34,,872.1,percent of total billed charges,Implant Device,872.1,34,,872.1,percent of total billed charges,Implant Device,872.1,34,,872.1,percent of total billed charges,Implant Device,872.1,34,,872.1,percent of total billed charges,Implant Device,1269.68,,,1269.68,Other,110% of Medicare,897.75,35,,897.75,percent of total billed charges,Implant Device,872.1,34,"Charges > $500, x 34%",872.1,percent of total billed charges,Implant Device,897.75,35,,897.75,percent of total billed charges,Implant Device,897.75,35,,897.75,percent of total billed charges,Implant Device,897.75,35,,897.75,percent of total billed charges,Implant Device,897.75,35,,897.75,percent of total billed charges,Implant Device,897.75,35,,897.75,percent of total billed charges,Implant Device,1026,40,,1026,percent of total billed charges,Implant Device,897.75,70,,897.75,percent of total billed charges,All Other,872.1,34,,872.1,percent of total billed charges,Implant Device,872.1,34,,872.1,percent of total billed charges,Implant Device,897.75,35,,897.75,percent of total billed charges,Implant Device,897.75,35,,897.75,percent of total billed charges,Implant Device,897.75,35,,897.75,percent of total billed charges,Implant Device,897.75,35,,897.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,872.1,34,"If Charge > 2,000, then 34 percent",872.1,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1898.11,
DEPUY 1365-36-230 FEM HEAD 36MM 11/13,C1776,HCPCS,,79007270,CDM,278,RC,,,both,,,5549,4106.27,,,4106.27,Other,150% of Medicare + 9.63% HCRA Surcharge,2497.05,45,,2497.05,percent of total billed charges,Critical Access Hospital RCC factor,1886.66,34,,1886.66,percent of total billed charges,Implant Device,1886.66,34,,1886.66,percent of total billed charges,Implant Device,1886.66,34,,1886.66,percent of total billed charges,Implant Device,1886.66,34,,1886.66,percent of total billed charges,Implant Device,1886.66,34,,1886.66,percent of total billed charges,Implant Device,2746.76,,,2746.76,Other,110% of Medicare,1942.15,35,,1942.15,percent of total billed charges,Implant Device,1886.66,34,"Charges > $500, x 34%",1886.66,percent of total billed charges,Implant Device,1942.15,35,,1942.15,percent of total billed charges,Implant Device,1942.15,35,,1942.15,percent of total billed charges,Implant Device,1942.15,35,,1942.15,percent of total billed charges,Implant Device,1942.15,35,,1942.15,percent of total billed charges,Implant Device,1942.15,35,,1942.15,percent of total billed charges,Implant Device,2219.6,40,,2219.6,percent of total billed charges,Implant Device,1942.15,70,,1942.15,percent of total billed charges,All Other,1886.66,34,,1886.66,percent of total billed charges,Implant Device,1886.66,34,,1886.66,percent of total billed charges,Implant Device,1942.15,35,,1942.15,percent of total billed charges,Implant Device,1942.15,35,,1942.15,percent of total billed charges,Implant Device,1942.15,35,,1942.15,percent of total billed charges,Implant Device,1942.15,35,,1942.15,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1886.66,34,"If Charge > 2,000, then 34 percent",1886.66,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4106.27,
DEPUY TOTAL KNEE WITH REVISION COMPONENT,C1776,HCPCS,,79007273,CDM,278,RC,,,both,,,24297,17979.84,,,17979.84,Other,150% of Medicare + 9.63% HCRA Surcharge,10933.65,45,,10933.65,percent of total billed charges,Critical Access Hospital RCC factor,8260.98,34,,8260.98,percent of total billed charges,Implant Device,8260.98,34,,8260.98,percent of total billed charges,Implant Device,8260.98,34,,8260.98,percent of total billed charges,Implant Device,8260.98,34,,8260.98,percent of total billed charges,Implant Device,8260.98,34,,8260.98,percent of total billed charges,Implant Device,12027.02,,,12027.02,Other,110% of Medicare,8503.95,35,,8503.95,percent of total billed charges,Implant Device,8260.98,34,"Charges > $500, x 34%",8260.98,percent of total billed charges,Implant Device,8503.95,35,,8503.95,percent of total billed charges,Implant Device,8503.95,35,,8503.95,percent of total billed charges,Implant Device,8503.95,35,,8503.95,percent of total billed charges,Implant Device,8503.95,35,,8503.95,percent of total billed charges,Implant Device,8503.95,35,,8503.95,percent of total billed charges,Implant Device,9718.8,40,,9718.8,percent of total billed charges,Implant Device,8503.95,70,,8503.95,percent of total billed charges,All Other,8260.98,34,,8260.98,percent of total billed charges,Implant Device,8260.98,34,,8260.98,percent of total billed charges,Implant Device,8503.95,35,,8503.95,percent of total billed charges,Implant Device,8503.95,35,,8503.95,percent of total billed charges,Implant Device,8503.95,35,,8503.95,percent of total billed charges,Implant Device,8503.95,35,,8503.95,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,8260.98,34,"If Charge > 2,000, then 34 percent",8260.98,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,17979.84,
GORE HH0710 GORE BIO-A TISSUE MESH,C1781,HCPCS,,79007274,CDM,278,RC,,,both,,,1864,1379.36,,,1379.36,Other,150% of Medicare + 9.63% HCRA Surcharge,838.8,45,,838.8,percent of total billed charges,Critical Access Hospital RCC factor,633.76,34,,633.76,percent of total billed charges,Implant Device,633.76,34,,633.76,percent of total billed charges,Implant Device,633.76,34,,633.76,percent of total billed charges,Implant Device,633.76,34,,633.76,percent of total billed charges,Implant Device,633.76,34,,633.76,percent of total billed charges,Implant Device,922.68,,,922.68,Other,110% of Medicare,652.4,35,,652.4,percent of total billed charges,Implant Device,633.76,34,"Charges > $500, x 34%",633.76,percent of total billed charges,Implant Device,652.4,35,,652.4,percent of total billed charges,Implant Device,652.4,35,,652.4,percent of total billed charges,Implant Device,652.4,35,,652.4,percent of total billed charges,Implant Device,652.4,35,,652.4,percent of total billed charges,Implant Device,652.4,35,,652.4,percent of total billed charges,Implant Device,745.6,40,,745.6,percent of total billed charges,Implant Device,652.4,70,,652.4,percent of total billed charges,All Other,633.76,34,,633.76,percent of total billed charges,Implant Device,633.76,34,,633.76,percent of total billed charges,Implant Device,652.4,35,,652.4,percent of total billed charges,Implant Device,652.4,35,,652.4,percent of total billed charges,Implant Device,652.4,35,,652.4,percent of total billed charges,Implant Device,652.4,35,,652.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1379.36,
ARTHREX AR-8933V-18 LOCKING SCREW 3X18MM,C1713,HCPCS,,79007275,CDM,278,RC,,,both,,,756,559.44,,,559.44,Other,150% of Medicare + 9.63% HCRA Surcharge,340.2,45,,340.2,percent of total billed charges,Critical Access Hospital RCC factor,257.04,34,,257.04,percent of total billed charges,Implant Device,257.04,34,,257.04,percent of total billed charges,Implant Device,257.04,34,,257.04,percent of total billed charges,Implant Device,257.04,34,,257.04,percent of total billed charges,Implant Device,257.04,34,,257.04,percent of total billed charges,Implant Device,374.22,,,374.22,Other,110% of Medicare,264.6,35,,264.6,percent of total billed charges,Implant Device,257.04,34,"Charges > $500, x 34%",257.04,percent of total billed charges,Implant Device,264.6,35,,264.6,percent of total billed charges,Implant Device,264.6,35,,264.6,percent of total billed charges,Implant Device,264.6,35,,264.6,percent of total billed charges,Implant Device,264.6,35,,264.6,percent of total billed charges,Implant Device,264.6,35,,264.6,percent of total billed charges,Implant Device,302.4,40,,302.4,percent of total billed charges,Implant Device,264.6,70,,264.6,percent of total billed charges,All Other,257.04,34,,257.04,percent of total billed charges,Implant Device,257.04,34,,257.04,percent of total billed charges,Implant Device,264.6,35,,264.6,percent of total billed charges,Implant Device,264.6,35,,264.6,percent of total billed charges,Implant Device,264.6,35,,264.6,percent of total billed charges,Implant Device,264.6,35,,264.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,559.44,
STABILITY BIOLOGICS 901 ACHILLES TENDON,C1713,HCPCS,,79007277,CDM,278,RC,,,both,,,5025,3718.51,,,3718.51,Other,150% of Medicare + 9.63% HCRA Surcharge,2261.25,45,,2261.25,percent of total billed charges,Critical Access Hospital RCC factor,1708.5,34,,1708.5,percent of total billed charges,Implant Device,1708.5,34,,1708.5,percent of total billed charges,Implant Device,1708.5,34,,1708.5,percent of total billed charges,Implant Device,1708.5,34,,1708.5,percent of total billed charges,Implant Device,1708.5,34,,1708.5,percent of total billed charges,Implant Device,2487.38,,,2487.38,Other,110% of Medicare,1758.75,35,,1758.75,percent of total billed charges,Implant Device,1708.5,34,"Charges > $500, x 34%",1708.5,percent of total billed charges,Implant Device,1758.75,35,,1758.75,percent of total billed charges,Implant Device,1758.75,35,,1758.75,percent of total billed charges,Implant Device,1758.75,35,,1758.75,percent of total billed charges,Implant Device,1758.75,35,,1758.75,percent of total billed charges,Implant Device,1758.75,35,,1758.75,percent of total billed charges,Implant Device,2010,40,,2010,percent of total billed charges,Implant Device,1758.75,70,,1758.75,percent of total billed charges,All Other,1708.5,34,,1708.5,percent of total billed charges,Implant Device,1708.5,34,,1708.5,percent of total billed charges,Implant Device,1758.75,35,,1758.75,percent of total billed charges,Implant Device,1758.75,35,,1758.75,percent of total billed charges,Implant Device,1758.75,35,,1758.75,percent of total billed charges,Implant Device,1758.75,35,,1758.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1708.5,34,"If Charge > 2,000, then 34 percent",1708.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3718.51,
ATLAS 1100-03-0060 ROD CONTOURED 60MM,C1713,HCPCS,,79007280,CDM,278,RC,,,both,,,840,621.6,,,621.6,Other,150% of Medicare + 9.63% HCRA Surcharge,378,45,,378,percent of total billed charges,Critical Access Hospital RCC factor,285.6,34,,285.6,percent of total billed charges,Implant Device,285.6,34,,285.6,percent of total billed charges,Implant Device,285.6,34,,285.6,percent of total billed charges,Implant Device,285.6,34,,285.6,percent of total billed charges,Implant Device,285.6,34,,285.6,percent of total billed charges,Implant Device,415.8,,,415.8,Other,110% of Medicare,294,35,,294,percent of total billed charges,Implant Device,285.6,34,"Charges > $500, x 34%",285.6,percent of total billed charges,Implant Device,294,35,,294,percent of total billed charges,Implant Device,294,35,,294,percent of total billed charges,Implant Device,294,35,,294,percent of total billed charges,Implant Device,294,35,,294,percent of total billed charges,Implant Device,294,35,,294,percent of total billed charges,Implant Device,336,40,,336,percent of total billed charges,Implant Device,294,70,,294,percent of total billed charges,All Other,285.6,34,,285.6,percent of total billed charges,Implant Device,285.6,34,,285.6,percent of total billed charges,Implant Device,294,35,,294,percent of total billed charges,Implant Device,294,35,,294,percent of total billed charges,Implant Device,294,35,,294,percent of total billed charges,Implant Device,294,35,,294,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,621.6,
P 28 P20-135-026S CANN SCREW 3.5X26MM,C1713,HCPCS,,79007284,CDM,278,RC,,,both,,,768,568.32,,,568.32,Other,150% of Medicare + 9.63% HCRA Surcharge,345.6,45,,345.6,percent of total billed charges,Critical Access Hospital RCC factor,261.12,34,,261.12,percent of total billed charges,Implant Device,261.12,34,,261.12,percent of total billed charges,Implant Device,261.12,34,,261.12,percent of total billed charges,Implant Device,261.12,34,,261.12,percent of total billed charges,Implant Device,261.12,34,,261.12,percent of total billed charges,Implant Device,380.16,,,380.16,Other,110% of Medicare,268.8,35,,268.8,percent of total billed charges,Implant Device,261.12,34,"Charges > $500, x 34%",261.12,percent of total billed charges,Implant Device,268.8,35,,268.8,percent of total billed charges,Implant Device,268.8,35,,268.8,percent of total billed charges,Implant Device,268.8,35,,268.8,percent of total billed charges,Implant Device,268.8,35,,268.8,percent of total billed charges,Implant Device,268.8,35,,268.8,percent of total billed charges,Implant Device,307.2,40,,307.2,percent of total billed charges,Implant Device,268.8,70,,268.8,percent of total billed charges,All Other,261.12,34,,261.12,percent of total billed charges,Implant Device,261.12,34,,261.12,percent of total billed charges,Implant Device,268.8,35,,268.8,percent of total billed charges,Implant Device,268.8,35,,268.8,percent of total billed charges,Implant Device,268.8,35,,268.8,percent of total billed charges,Implant Device,268.8,35,,268.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,568.32,
P 28 SE-1310 SPEED IMPLANT 13X10X10MM,C1713,HCPCS,,79007288,CDM,278,RC,,,both,,,3000,2220.01,,,2220.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1350,45,,1350,percent of total billed charges,Critical Access Hospital RCC factor,1020,34,,1020,percent of total billed charges,Implant Device,1020,34,,1020,percent of total billed charges,Implant Device,1020,34,,1020,percent of total billed charges,Implant Device,1020,34,,1020,percent of total billed charges,Implant Device,1020,34,,1020,percent of total billed charges,Implant Device,1485,,,1485,Other,110% of Medicare,1050,35,,1050,percent of total billed charges,Implant Device,1020,34,"Charges > $500, x 34%",1020,percent of total billed charges,Implant Device,1050,35,,1050,percent of total billed charges,Implant Device,1050,35,,1050,percent of total billed charges,Implant Device,1050,35,,1050,percent of total billed charges,Implant Device,1050,35,,1050,percent of total billed charges,Implant Device,1050,35,,1050,percent of total billed charges,Implant Device,1200,40,,1200,percent of total billed charges,Implant Device,1050,70,,1050,percent of total billed charges,All Other,1020,34,,1020,percent of total billed charges,Implant Device,1020,34,,1020,percent of total billed charges,Implant Device,1050,35,,1050,percent of total billed charges,Implant Device,1050,35,,1050,percent of total billed charges,Implant Device,1050,35,,1050,percent of total billed charges,Implant Device,1050,35,,1050,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1020,34,"If Charge > 2,000, then 34 percent",1020,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2220.01,
P 28 HL2M HAMMERLOCK 2 IMPLANT 15X5MM,C1713,HCPCS,,79007289,CDM,278,RC,,,both,,,3480,2575.21,,,2575.21,Other,150% of Medicare + 9.63% HCRA Surcharge,1566,45,,1566,percent of total billed charges,Critical Access Hospital RCC factor,1183.2,34,,1183.2,percent of total billed charges,Implant Device,1183.2,34,,1183.2,percent of total billed charges,Implant Device,1183.2,34,,1183.2,percent of total billed charges,Implant Device,1183.2,34,,1183.2,percent of total billed charges,Implant Device,1183.2,34,,1183.2,percent of total billed charges,Implant Device,1722.6,,,1722.6,Other,110% of Medicare,1218,35,,1218,percent of total billed charges,Implant Device,1183.2,34,"Charges > $500, x 34%",1183.2,percent of total billed charges,Implant Device,1218,35,,1218,percent of total billed charges,Implant Device,1218,35,,1218,percent of total billed charges,Implant Device,1218,35,,1218,percent of total billed charges,Implant Device,1218,35,,1218,percent of total billed charges,Implant Device,1218,35,,1218,percent of total billed charges,Implant Device,1392,40,,1392,percent of total billed charges,Implant Device,1218,70,,1218,percent of total billed charges,All Other,1183.2,34,,1183.2,percent of total billed charges,Implant Device,1183.2,34,,1183.2,percent of total billed charges,Implant Device,1218,35,,1218,percent of total billed charges,Implant Device,1218,35,,1218,percent of total billed charges,Implant Device,1218,35,,1218,percent of total billed charges,Implant Device,1218,35,,1218,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1183.2,34,"If Charge > 2,000, then 34 percent",1183.2,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2575.21,
ALPHATEC 62075-50 POLYAX SCREW 7.5X50MM,C1713,HCPCS,,79007290,CDM,278,RC,,,both,,,2550,1887.01,,,1887.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1147.5,45,,1147.5,percent of total billed charges,Critical Access Hospital RCC factor,867,34,,867,percent of total billed charges,Implant Device,867,34,,867,percent of total billed charges,Implant Device,867,34,,867,percent of total billed charges,Implant Device,867,34,,867,percent of total billed charges,Implant Device,867,34,,867,percent of total billed charges,Implant Device,1262.25,,,1262.25,Other,110% of Medicare,892.5,35,,892.5,percent of total billed charges,Implant Device,867,34,"Charges > $500, x 34%",867,percent of total billed charges,Implant Device,892.5,35,,892.5,percent of total billed charges,Implant Device,892.5,35,,892.5,percent of total billed charges,Implant Device,892.5,35,,892.5,percent of total billed charges,Implant Device,892.5,35,,892.5,percent of total billed charges,Implant Device,892.5,35,,892.5,percent of total billed charges,Implant Device,1020,40,,1020,percent of total billed charges,Implant Device,892.5,70,,892.5,percent of total billed charges,All Other,867,34,,867,percent of total billed charges,Implant Device,867,34,,867,percent of total billed charges,Implant Device,892.5,35,,892.5,percent of total billed charges,Implant Device,892.5,35,,892.5,percent of total billed charges,Implant Device,892.5,35,,892.5,percent of total billed charges,Implant Device,892.5,35,,892.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,867,34,"If Charge > 2,000, then 34 percent",867,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1887.01,
ATLAS 1208-01-2712 INTERBDY SPACER 27X12,C1713,HCPCS,,79007291,CDM,278,RC,,,both,,,9555,7070.72,,,7070.72,Other,150% of Medicare + 9.63% HCRA Surcharge,4299.75,45,,4299.75,percent of total billed charges,Critical Access Hospital RCC factor,3248.7,34,,3248.7,percent of total billed charges,Implant Device,3248.7,34,,3248.7,percent of total billed charges,Implant Device,3248.7,34,,3248.7,percent of total billed charges,Implant Device,3248.7,34,,3248.7,percent of total billed charges,Implant Device,3248.7,34,,3248.7,percent of total billed charges,Implant Device,4729.73,,,4729.73,Other,110% of Medicare,3344.25,35,,3344.25,percent of total billed charges,Implant Device,3248.7,34,"Charges > $500, x 34%",3248.7,percent of total billed charges,Implant Device,3344.25,35,,3344.25,percent of total billed charges,Implant Device,3344.25,35,,3344.25,percent of total billed charges,Implant Device,3344.25,35,,3344.25,percent of total billed charges,Implant Device,3344.25,35,,3344.25,percent of total billed charges,Implant Device,3344.25,35,,3344.25,percent of total billed charges,Implant Device,3822,40,,3822,percent of total billed charges,Implant Device,3344.25,70,,3344.25,percent of total billed charges,All Other,3248.7,34,,3248.7,percent of total billed charges,Implant Device,3248.7,34,,3248.7,percent of total billed charges,Implant Device,3344.25,35,,3344.25,percent of total billed charges,Implant Device,3344.25,35,,3344.25,percent of total billed charges,Implant Device,3344.25,35,,3344.25,percent of total billed charges,Implant Device,3344.25,35,,3344.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3248.7,34,"If Charge > 2,000, then 34 percent",3248.7,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,7070.72,
DEPUY 226.591 LCP PLATE 9 HOLE 4.5X170MM,C1713,HCPCS,,79007295,CDM,278,RC,,,both,,,1554,1149.96,,,1149.96,Other,150% of Medicare + 9.63% HCRA Surcharge,699.3,45,,699.3,percent of total billed charges,Critical Access Hospital RCC factor,528.36,34,,528.36,percent of total billed charges,Implant Device,528.36,34,,528.36,percent of total billed charges,Implant Device,528.36,34,,528.36,percent of total billed charges,Implant Device,528.36,34,,528.36,percent of total billed charges,Implant Device,528.36,34,,528.36,percent of total billed charges,Implant Device,769.23,,,769.23,Other,110% of Medicare,543.9,35,,543.9,percent of total billed charges,Implant Device,528.36,34,"Charges > $500, x 34%",528.36,percent of total billed charges,Implant Device,543.9,35,,543.9,percent of total billed charges,Implant Device,543.9,35,,543.9,percent of total billed charges,Implant Device,543.9,35,,543.9,percent of total billed charges,Implant Device,543.9,35,,543.9,percent of total billed charges,Implant Device,543.9,35,,543.9,percent of total billed charges,Implant Device,621.6,40,,621.6,percent of total billed charges,Implant Device,543.9,70,,543.9,percent of total billed charges,All Other,528.36,34,,528.36,percent of total billed charges,Implant Device,528.36,34,,528.36,percent of total billed charges,Implant Device,543.9,35,,543.9,percent of total billed charges,Implant Device,543.9,35,,543.9,percent of total billed charges,Implant Device,543.9,35,,543.9,percent of total billed charges,Implant Device,543.9,35,,543.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1149.96,
DEPUY 214.826 CORTEX SCREW 4.5X26MM,C1713,HCPCS,,79007296,CDM,278,RC,,,both,,,57,42.18,,,42.18,Other,150% of Medicare + 9.63% HCRA Surcharge,25.65,45,,25.65,percent of total billed charges,Critical Access Hospital RCC factor,19.38,34,,19.38,percent of total billed charges,Implant Device,19.38,34,,19.38,percent of total billed charges,Implant Device,19.38,34,,19.38,percent of total billed charges,Implant Device,19.38,34,,19.38,percent of total billed charges,Implant Device,19.38,34,,19.38,percent of total billed charges,Implant Device,28.22,,,28.22,Other,110% of Medicare,19.95,35,,19.95,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,19.95,35,,19.95,percent of total billed charges,Implant Device,19.95,35,,19.95,percent of total billed charges,Implant Device,19.95,35,,19.95,percent of total billed charges,Implant Device,19.95,35,,19.95,percent of total billed charges,Implant Device,19.95,35,,19.95,percent of total billed charges,Implant Device,22.8,40,,22.8,percent of total billed charges,Implant Device,19.95,70,,19.95,percent of total billed charges,All Other,19.38,34,,19.38,percent of total billed charges,Implant Device,19.38,34,,19.38,percent of total billed charges,Implant Device,19.95,35,,19.95,percent of total billed charges,Implant Device,19.95,35,,19.95,percent of total billed charges,Implant Device,19.95,35,,19.95,percent of total billed charges,Implant Device,19.95,35,,19.95,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,42.18,
DEPUY 02.221.510 LOCKING SCREW 5X10MM,C1713,HCPCS,,79007298,CDM,278,RC,,,both,,,564,417.36,,,417.36,Other,150% of Medicare + 9.63% HCRA Surcharge,253.8,45,,253.8,percent of total billed charges,Critical Access Hospital RCC factor,191.76,34,,191.76,percent of total billed charges,Implant Device,191.76,34,,191.76,percent of total billed charges,Implant Device,191.76,34,,191.76,percent of total billed charges,Implant Device,191.76,34,,191.76,percent of total billed charges,Implant Device,191.76,34,,191.76,percent of total billed charges,Implant Device,279.18,,,279.18,Other,110% of Medicare,197.4,35,,197.4,percent of total billed charges,Implant Device,191.76,34,"Charges > $500, x 34%",191.76,percent of total billed charges,Implant Device,197.4,35,,197.4,percent of total billed charges,Implant Device,197.4,35,,197.4,percent of total billed charges,Implant Device,197.4,35,,197.4,percent of total billed charges,Implant Device,197.4,35,,197.4,percent of total billed charges,Implant Device,197.4,35,,197.4,percent of total billed charges,Implant Device,225.6,40,,225.6,percent of total billed charges,Implant Device,197.4,70,,197.4,percent of total billed charges,All Other,191.76,34,,191.76,percent of total billed charges,Implant Device,191.76,34,,191.76,percent of total billed charges,Implant Device,197.4,35,,197.4,percent of total billed charges,Implant Device,197.4,35,,197.4,percent of total billed charges,Implant Device,197.4,35,,197.4,percent of total billed charges,Implant Device,197.4,35,,197.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,417.36,
DEPUY 212.209 LOCKING SCREW 5X30MM,C1713,HCPCS,,79007299,CDM,278,RC,,,both,,,567,419.58,,,419.58,Other,150% of Medicare + 9.63% HCRA Surcharge,255.15,45,,255.15,percent of total billed charges,Critical Access Hospital RCC factor,192.78,34,,192.78,percent of total billed charges,Implant Device,192.78,34,,192.78,percent of total billed charges,Implant Device,192.78,34,,192.78,percent of total billed charges,Implant Device,192.78,34,,192.78,percent of total billed charges,Implant Device,192.78,34,,192.78,percent of total billed charges,Implant Device,280.67,,,280.67,Other,110% of Medicare,198.45,35,,198.45,percent of total billed charges,Implant Device,192.78,34,"Charges > $500, x 34%",192.78,percent of total billed charges,Implant Device,198.45,35,,198.45,percent of total billed charges,Implant Device,198.45,35,,198.45,percent of total billed charges,Implant Device,198.45,35,,198.45,percent of total billed charges,Implant Device,198.45,35,,198.45,percent of total billed charges,Implant Device,198.45,35,,198.45,percent of total billed charges,Implant Device,226.8,40,,226.8,percent of total billed charges,Implant Device,198.45,70,,198.45,percent of total billed charges,All Other,192.78,34,,192.78,percent of total billed charges,Implant Device,192.78,34,,192.78,percent of total billed charges,Implant Device,198.45,35,,198.45,percent of total billed charges,Implant Device,198.45,35,,198.45,percent of total billed charges,Implant Device,198.45,35,,198.45,percent of total billed charges,Implant Device,198.45,35,,198.45,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,419.58,
DEPUY 298.803S THREAD CERCLAGE PIN 4.5MM,C1713,HCPCS,,79007300,CDM,278,RC,,,both,,,711,526.14,,,526.14,Other,150% of Medicare + 9.63% HCRA Surcharge,319.95,45,,319.95,percent of total billed charges,Critical Access Hospital RCC factor,241.74,34,,241.74,percent of total billed charges,Implant Device,241.74,34,,241.74,percent of total billed charges,Implant Device,241.74,34,,241.74,percent of total billed charges,Implant Device,241.74,34,,241.74,percent of total billed charges,Implant Device,241.74,34,,241.74,percent of total billed charges,Implant Device,351.95,,,351.95,Other,110% of Medicare,248.85,35,,248.85,percent of total billed charges,Implant Device,241.74,34,"Charges > $500, x 34%",241.74,percent of total billed charges,Implant Device,248.85,35,,248.85,percent of total billed charges,Implant Device,248.85,35,,248.85,percent of total billed charges,Implant Device,248.85,35,,248.85,percent of total billed charges,Implant Device,248.85,35,,248.85,percent of total billed charges,Implant Device,248.85,35,,248.85,percent of total billed charges,Implant Device,284.4,40,,284.4,percent of total billed charges,Implant Device,248.85,70,,248.85,percent of total billed charges,All Other,241.74,34,,241.74,percent of total billed charges,Implant Device,241.74,34,,241.74,percent of total billed charges,Implant Device,248.85,35,,248.85,percent of total billed charges,Implant Device,248.85,35,,248.85,percent of total billed charges,Implant Device,248.85,35,,248.85,percent of total billed charges,Implant Device,248.85,35,,248.85,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,526.14,
STRYKER 3910-500-512 ICONIX 1.4MM ANCHOR,C1713,HCPCS,,79007301,CDM,278,RC,,,both,,,1126,833.24,,,833.24,Other,150% of Medicare + 9.63% HCRA Surcharge,506.7,45,,506.7,percent of total billed charges,Critical Access Hospital RCC factor,382.84,34,,382.84,percent of total billed charges,Implant Device,382.84,34,,382.84,percent of total billed charges,Implant Device,382.84,34,,382.84,percent of total billed charges,Implant Device,382.84,34,,382.84,percent of total billed charges,Implant Device,382.84,34,,382.84,percent of total billed charges,Implant Device,557.37,,,557.37,Other,110% of Medicare,394.1,35,,394.1,percent of total billed charges,Implant Device,382.84,34,"Charges > $500, x 34%",382.84,percent of total billed charges,Implant Device,394.1,35,,394.1,percent of total billed charges,Implant Device,394.1,35,,394.1,percent of total billed charges,Implant Device,394.1,35,,394.1,percent of total billed charges,Implant Device,394.1,35,,394.1,percent of total billed charges,Implant Device,394.1,35,,394.1,percent of total billed charges,Implant Device,450.4,40,,450.4,percent of total billed charges,Implant Device,394.1,70,,394.1,percent of total billed charges,All Other,382.84,34,,382.84,percent of total billed charges,Implant Device,382.84,34,,382.84,percent of total billed charges,Implant Device,394.1,35,,394.1,percent of total billed charges,Implant Device,394.1,35,,394.1,percent of total billed charges,Implant Device,394.1,35,,394.1,percent of total billed charges,Implant Device,394.1,35,,394.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,833.24,
STRYKER 629223 DISTAL HUM PLATE 3HOLE,C1713,HCPCS,,79007303,CDM,278,RC,,,both,,,3884,2874.17,,,2874.17,Other,150% of Medicare + 9.63% HCRA Surcharge,1747.8,45,,1747.8,percent of total billed charges,Critical Access Hospital RCC factor,1320.56,34,,1320.56,percent of total billed charges,Implant Device,1320.56,34,,1320.56,percent of total billed charges,Implant Device,1320.56,34,,1320.56,percent of total billed charges,Implant Device,1320.56,34,,1320.56,percent of total billed charges,Implant Device,1320.56,34,,1320.56,percent of total billed charges,Implant Device,1922.58,,,1922.58,Other,110% of Medicare,1359.4,35,,1359.4,percent of total billed charges,Implant Device,1320.56,34,"Charges > $500, x 34%",1320.56,percent of total billed charges,Implant Device,1359.4,35,,1359.4,percent of total billed charges,Implant Device,1359.4,35,,1359.4,percent of total billed charges,Implant Device,1359.4,35,,1359.4,percent of total billed charges,Implant Device,1359.4,35,,1359.4,percent of total billed charges,Implant Device,1359.4,35,,1359.4,percent of total billed charges,Implant Device,1553.6,40,,1553.6,percent of total billed charges,Implant Device,1359.4,70,,1359.4,percent of total billed charges,All Other,1320.56,34,,1320.56,percent of total billed charges,Implant Device,1320.56,34,,1320.56,percent of total billed charges,Implant Device,1359.4,35,,1359.4,percent of total billed charges,Implant Device,1359.4,35,,1359.4,percent of total billed charges,Implant Device,1359.4,35,,1359.4,percent of total billed charges,Implant Device,1359.4,35,,1359.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1320.56,34,"If Charge > 2,000, then 34 percent",1320.56,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2874.17,
STRYKER 614742 NONLOCKING SCREW 2.7X42MM,C1713,HCPCS,,79007304,CDM,278,RC,,,both,,,349,258.26,,,258.26,Other,150% of Medicare + 9.63% HCRA Surcharge,157.05,45,,157.05,percent of total billed charges,Critical Access Hospital RCC factor,118.66,34,,118.66,percent of total billed charges,Implant Device,118.66,34,,118.66,percent of total billed charges,Implant Device,118.66,34,,118.66,percent of total billed charges,Implant Device,118.66,34,,118.66,percent of total billed charges,Implant Device,118.66,34,,118.66,percent of total billed charges,Implant Device,172.76,,,172.76,Other,110% of Medicare,122.15,35,,122.15,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,122.15,35,,122.15,percent of total billed charges,Implant Device,122.15,35,,122.15,percent of total billed charges,Implant Device,122.15,35,,122.15,percent of total billed charges,Implant Device,122.15,35,,122.15,percent of total billed charges,Implant Device,122.15,35,,122.15,percent of total billed charges,Implant Device,139.6,40,,139.6,percent of total billed charges,Implant Device,122.15,70,,122.15,percent of total billed charges,All Other,118.66,34,,118.66,percent of total billed charges,Implant Device,118.66,34,,118.66,percent of total billed charges,Implant Device,122.15,35,,122.15,percent of total billed charges,Implant Device,122.15,35,,122.15,percent of total billed charges,Implant Device,122.15,35,,122.15,percent of total billed charges,Implant Device,122.15,35,,122.15,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,258.26,
STRYKER 614724 NONLOCKING SCREW 2.7X24MM,C1713,HCPCS,,79007305,CDM,278,RC,,,both,,,349,258.26,,,258.26,Other,150% of Medicare + 9.63% HCRA Surcharge,157.05,45,,157.05,percent of total billed charges,Critical Access Hospital RCC factor,118.66,34,,118.66,percent of total billed charges,Implant Device,118.66,34,,118.66,percent of total billed charges,Implant Device,118.66,34,,118.66,percent of total billed charges,Implant Device,118.66,34,,118.66,percent of total billed charges,Implant Device,118.66,34,,118.66,percent of total billed charges,Implant Device,172.76,,,172.76,Other,110% of Medicare,122.15,35,,122.15,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,122.15,35,,122.15,percent of total billed charges,Implant Device,122.15,35,,122.15,percent of total billed charges,Implant Device,122.15,35,,122.15,percent of total billed charges,Implant Device,122.15,35,,122.15,percent of total billed charges,Implant Device,122.15,35,,122.15,percent of total billed charges,Implant Device,139.6,40,,139.6,percent of total billed charges,Implant Device,122.15,70,,122.15,percent of total billed charges,All Other,118.66,34,,118.66,percent of total billed charges,Implant Device,118.66,34,,118.66,percent of total billed charges,Implant Device,122.15,35,,122.15,percent of total billed charges,Implant Device,122.15,35,,122.15,percent of total billed charges,Implant Device,122.15,35,,122.15,percent of total billed charges,Implant Device,122.15,35,,122.15,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,258.26,
STRYKER 614732 NONLOCKING SCREW 2.7X32MM,C1713,HCPCS,,79007306,CDM,278,RC,,,both,,,375,277.5,,,277.5,Other,150% of Medicare + 9.63% HCRA Surcharge,168.75,45,,168.75,percent of total billed charges,Critical Access Hospital RCC factor,127.5,34,,127.5,percent of total billed charges,Implant Device,127.5,34,,127.5,percent of total billed charges,Implant Device,127.5,34,,127.5,percent of total billed charges,Implant Device,127.5,34,,127.5,percent of total billed charges,Implant Device,127.5,34,,127.5,percent of total billed charges,Implant Device,185.63,,,185.63,Other,110% of Medicare,131.25,35,,131.25,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,131.25,35,,131.25,percent of total billed charges,Implant Device,131.25,35,,131.25,percent of total billed charges,Implant Device,131.25,35,,131.25,percent of total billed charges,Implant Device,131.25,35,,131.25,percent of total billed charges,Implant Device,131.25,35,,131.25,percent of total billed charges,Implant Device,150,40,,150,percent of total billed charges,Implant Device,131.25,70,,131.25,percent of total billed charges,All Other,127.5,34,,127.5,percent of total billed charges,Implant Device,127.5,34,,127.5,percent of total billed charges,Implant Device,131.25,35,,131.25,percent of total billed charges,Implant Device,131.25,35,,131.25,percent of total billed charges,Implant Device,131.25,35,,131.25,percent of total billed charges,Implant Device,131.25,35,,131.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,277.5,
STRYKER 614528 LOCKING SCREW 2.7X28MM,C1713,HCPCS,,79007307,CDM,278,RC,,,both,,,671,496.54,,,496.54,Other,150% of Medicare + 9.63% HCRA Surcharge,301.95,45,,301.95,percent of total billed charges,Critical Access Hospital RCC factor,228.14,34,,228.14,percent of total billed charges,Implant Device,228.14,34,,228.14,percent of total billed charges,Implant Device,228.14,34,,228.14,percent of total billed charges,Implant Device,228.14,34,,228.14,percent of total billed charges,Implant Device,228.14,34,,228.14,percent of total billed charges,Implant Device,332.15,,,332.15,Other,110% of Medicare,234.85,35,,234.85,percent of total billed charges,Implant Device,228.14,34,"Charges > $500, x 34%",228.14,percent of total billed charges,Implant Device,234.85,35,,234.85,percent of total billed charges,Implant Device,234.85,35,,234.85,percent of total billed charges,Implant Device,234.85,35,,234.85,percent of total billed charges,Implant Device,234.85,35,,234.85,percent of total billed charges,Implant Device,234.85,35,,234.85,percent of total billed charges,Implant Device,268.4,40,,268.4,percent of total billed charges,Implant Device,234.85,70,,234.85,percent of total billed charges,All Other,228.14,34,,228.14,percent of total billed charges,Implant Device,228.14,34,,228.14,percent of total billed charges,Implant Device,234.85,35,,234.85,percent of total billed charges,Implant Device,234.85,35,,234.85,percent of total billed charges,Implant Device,234.85,35,,234.85,percent of total billed charges,Implant Device,234.85,35,,234.85,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,496.54,
GORE PLC271000 EXCLUDER ENDOPROS GRAFT,C1874,HCPCS,,79007311,CDM,278,RC,,,both,,,14571,10782.58,,,10782.58,Other,150% of Medicare + 9.63% HCRA Surcharge,6556.95,45,,6556.95,percent of total billed charges,Critical Access Hospital RCC factor,4954.14,34,,4954.14,percent of total billed charges,Implant Device,4954.14,34,,4954.14,percent of total billed charges,Implant Device,4954.14,34,,4954.14,percent of total billed charges,Implant Device,4954.14,34,,4954.14,percent of total billed charges,Implant Device,4954.14,34,,4954.14,percent of total billed charges,Implant Device,7212.65,,,7212.65,Other,110% of Medicare,5099.85,35,,5099.85,percent of total billed charges,Implant Device,4954.14,34,"Charges > $500, x 34%",4954.14,percent of total billed charges,Implant Device,5099.85,35,,5099.85,percent of total billed charges,Implant Device,5099.85,35,,5099.85,percent of total billed charges,Implant Device,5099.85,35,,5099.85,percent of total billed charges,Implant Device,5099.85,35,,5099.85,percent of total billed charges,Implant Device,5099.85,35,,5099.85,percent of total billed charges,Implant Device,5828.4,40,,5828.4,percent of total billed charges,Implant Device,5099.85,70,,5099.85,percent of total billed charges,All Other,4954.14,34,,4954.14,percent of total billed charges,Implant Device,4954.14,34,,4954.14,percent of total billed charges,Implant Device,5099.85,35,,5099.85,percent of total billed charges,Implant Device,5099.85,35,,5099.85,percent of total billed charges,Implant Device,5099.85,35,,5099.85,percent of total billed charges,Implant Device,5099.85,35,,5099.85,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,4954.14,34,"If Charge > 2,000, then 34 percent",4954.14,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,10782.58,
STRYKER 40-20222S 2X22MM CANN SCREW,C1713,HCPCS,,79007329,CDM,278,RC,,,both,,,773,572.02,,,572.02,Other,150% of Medicare + 9.63% HCRA Surcharge,347.85,45,,347.85,percent of total billed charges,Critical Access Hospital RCC factor,262.82,34,,262.82,percent of total billed charges,Implant Device,262.82,34,,262.82,percent of total billed charges,Implant Device,262.82,34,,262.82,percent of total billed charges,Implant Device,262.82,34,,262.82,percent of total billed charges,Implant Device,262.82,34,,262.82,percent of total billed charges,Implant Device,382.64,,,382.64,Other,110% of Medicare,270.55,35,,270.55,percent of total billed charges,Implant Device,262.82,34,"Charges > $500, x 34%",262.82,percent of total billed charges,Implant Device,270.55,35,,270.55,percent of total billed charges,Implant Device,270.55,35,,270.55,percent of total billed charges,Implant Device,270.55,35,,270.55,percent of total billed charges,Implant Device,270.55,35,,270.55,percent of total billed charges,Implant Device,270.55,35,,270.55,percent of total billed charges,Implant Device,309.2,40,,309.2,percent of total billed charges,Implant Device,270.55,70,,270.55,percent of total billed charges,All Other,262.82,34,,262.82,percent of total billed charges,Implant Device,262.82,34,,262.82,percent of total billed charges,Implant Device,270.55,35,,270.55,percent of total billed charges,Implant Device,270.55,35,,270.55,percent of total billed charges,Implant Device,270.55,35,,270.55,percent of total billed charges,Implant Device,270.55,35,,270.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,572.02,
DEPUY 1987-13-111 LPS DIST FEM COMPONENT,C1776,HCPCS,,79007330,CDM,278,RC,,,both,,,41585,30773,,,30773,Other,150% of Medicare + 9.63% HCRA Surcharge,18713.25,45,,18713.25,percent of total billed charges,Critical Access Hospital RCC factor,14138.9,34,,14138.9,percent of total billed charges,Implant Device,14138.9,34,,14138.9,percent of total billed charges,Implant Device,14138.9,34,,14138.9,percent of total billed charges,Implant Device,14138.9,34,,14138.9,percent of total billed charges,Implant Device,14138.9,34,,14138.9,percent of total billed charges,Implant Device,20584.58,,,20584.58,Other,110% of Medicare,14554.75,35,,14554.75,percent of total billed charges,Implant Device,14138.9,34,"Charges > $500, x 34%",14138.9,percent of total billed charges,Implant Device,14554.75,35,,14554.75,percent of total billed charges,Implant Device,14554.75,35,,14554.75,percent of total billed charges,Implant Device,14554.75,35,,14554.75,percent of total billed charges,Implant Device,14554.75,35,,14554.75,percent of total billed charges,Implant Device,14554.75,35,,14554.75,percent of total billed charges,Implant Device,16634,40,,16634,percent of total billed charges,Implant Device,14554.75,70,,14554.75,percent of total billed charges,All Other,14138.9,34,,14138.9,percent of total billed charges,Implant Device,14138.9,34,,14138.9,percent of total billed charges,Implant Device,14554.75,35,,14554.75,percent of total billed charges,Implant Device,14554.75,35,,14554.75,percent of total billed charges,Implant Device,14554.75,35,,14554.75,percent of total billed charges,Implant Device,14554.75,35,,14554.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,14138.9,34,"If Charge > 2,000, then 34 percent",14138.9,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,30773,
DEPUY 1987-27-016 LPS TIBIAL INSERT 16MM,C1776,HCPCS,,79007331,CDM,278,RC,,,both,,,14280,10567.24,,,10567.24,Other,150% of Medicare + 9.63% HCRA Surcharge,6426,45,,6426,percent of total billed charges,Critical Access Hospital RCC factor,4855.2,34,,4855.2,percent of total billed charges,Implant Device,4855.2,34,,4855.2,percent of total billed charges,Implant Device,4855.2,34,,4855.2,percent of total billed charges,Implant Device,4855.2,34,,4855.2,percent of total billed charges,Implant Device,4855.2,34,,4855.2,percent of total billed charges,Implant Device,7068.6,,,7068.6,Other,110% of Medicare,4998,35,,4998,percent of total billed charges,Implant Device,4855.2,34,"Charges > $500, x 34%",4855.2,percent of total billed charges,Implant Device,4998,35,,4998,percent of total billed charges,Implant Device,4998,35,,4998,percent of total billed charges,Implant Device,4998,35,,4998,percent of total billed charges,Implant Device,4998,35,,4998,percent of total billed charges,Implant Device,4998,35,,4998,percent of total billed charges,Implant Device,5712,40,,5712,percent of total billed charges,Implant Device,4998,70,,4998,percent of total billed charges,All Other,4855.2,34,,4855.2,percent of total billed charges,Implant Device,4855.2,34,,4855.2,percent of total billed charges,Implant Device,4998,35,,4998,percent of total billed charges,Implant Device,4998,35,,4998,percent of total billed charges,Implant Device,4998,35,,4998,percent of total billed charges,Implant Device,4998,35,,4998,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,4855.2,34,"If Charge > 2,000, then 34 percent",4855.2,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,10567.24,
DEPUY 86-7414 UNI STEM 75X14MM FLUTED,C1776,HCPCS,,79007332,CDM,278,RC,,,both,,,6144,4546.58,,,4546.58,Other,150% of Medicare + 9.63% HCRA Surcharge,2764.8,45,,2764.8,percent of total billed charges,Critical Access Hospital RCC factor,2088.96,34,,2088.96,percent of total billed charges,Implant Device,2088.96,34,,2088.96,percent of total billed charges,Implant Device,2088.96,34,,2088.96,percent of total billed charges,Implant Device,2088.96,34,,2088.96,percent of total billed charges,Implant Device,2088.96,34,,2088.96,percent of total billed charges,Implant Device,3041.28,,,3041.28,Other,110% of Medicare,2150.4,35,,2150.4,percent of total billed charges,Implant Device,2088.96,34,"Charges > $500, x 34%",2088.96,percent of total billed charges,Implant Device,2150.4,35,,2150.4,percent of total billed charges,Implant Device,2150.4,35,,2150.4,percent of total billed charges,Implant Device,2150.4,35,,2150.4,percent of total billed charges,Implant Device,2150.4,35,,2150.4,percent of total billed charges,Implant Device,2150.4,35,,2150.4,percent of total billed charges,Implant Device,2457.6,40,,2457.6,percent of total billed charges,Implant Device,2150.4,70,,2150.4,percent of total billed charges,All Other,2088.96,34,,2088.96,percent of total billed charges,Implant Device,2088.96,34,,2088.96,percent of total billed charges,Implant Device,2150.4,35,,2150.4,percent of total billed charges,Implant Device,2150.4,35,,2150.4,percent of total billed charges,Implant Device,2150.4,35,,2150.4,percent of total billed charges,Implant Device,2150.4,35,,2150.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2088.96,34,"If Charge > 2,000, then 34 percent",2088.96,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4546.58,
DEPUY 207.010 CANCELLOUS SCREW 4X10MM,C1713,HCPCS,,79007337,CDM,278,RC,,,both,,,85,62.9,,,62.9,Other,150% of Medicare + 9.63% HCRA Surcharge,38.25,45,,38.25,percent of total billed charges,Critical Access Hospital RCC factor,28.9,34,,28.9,percent of total billed charges,Implant Device,28.9,34,,28.9,percent of total billed charges,Implant Device,28.9,34,,28.9,percent of total billed charges,Implant Device,28.9,34,,28.9,percent of total billed charges,Implant Device,28.9,34,,28.9,percent of total billed charges,Implant Device,42.08,,,42.08,Other,110% of Medicare,29.75,35,,29.75,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,29.75,35,,29.75,percent of total billed charges,Implant Device,29.75,35,,29.75,percent of total billed charges,Implant Device,29.75,35,,29.75,percent of total billed charges,Implant Device,29.75,35,,29.75,percent of total billed charges,Implant Device,29.75,35,,29.75,percent of total billed charges,Implant Device,34,40,,34,percent of total billed charges,Implant Device,29.75,70,,29.75,percent of total billed charges,All Other,28.9,34,,28.9,percent of total billed charges,Implant Device,28.9,34,,28.9,percent of total billed charges,Implant Device,29.75,35,,29.75,percent of total billed charges,Implant Device,29.75,35,,29.75,percent of total billed charges,Implant Device,29.75,35,,29.75,percent of total billed charges,Implant Device,29.75,35,,29.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,62.9,
DEPUY 02.110.151 LCP WRIST FUSION PLATE,C1713,HCPCS,,79007339,CDM,278,RC,,,both,,,6503,4812.24,,,4812.24,Other,150% of Medicare + 9.63% HCRA Surcharge,2926.35,45,,2926.35,percent of total billed charges,Critical Access Hospital RCC factor,2211.02,34,,2211.02,percent of total billed charges,Implant Device,2211.02,34,,2211.02,percent of total billed charges,Implant Device,2211.02,34,,2211.02,percent of total billed charges,Implant Device,2211.02,34,,2211.02,percent of total billed charges,Implant Device,2211.02,34,,2211.02,percent of total billed charges,Implant Device,3218.99,,,3218.99,Other,110% of Medicare,2276.05,35,,2276.05,percent of total billed charges,Implant Device,2211.02,34,"Charges > $500, x 34%",2211.02,percent of total billed charges,Implant Device,2276.05,35,,2276.05,percent of total billed charges,Implant Device,2276.05,35,,2276.05,percent of total billed charges,Implant Device,2276.05,35,,2276.05,percent of total billed charges,Implant Device,2276.05,35,,2276.05,percent of total billed charges,Implant Device,2276.05,35,,2276.05,percent of total billed charges,Implant Device,2601.2,40,,2601.2,percent of total billed charges,Implant Device,2276.05,70,,2276.05,percent of total billed charges,All Other,2211.02,34,,2211.02,percent of total billed charges,Implant Device,2211.02,34,,2211.02,percent of total billed charges,Implant Device,2276.05,35,,2276.05,percent of total billed charges,Implant Device,2276.05,35,,2276.05,percent of total billed charges,Implant Device,2276.05,35,,2276.05,percent of total billed charges,Implant Device,2276.05,35,,2276.05,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2211.02,34,"If Charge > 2,000, then 34 percent",2211.02,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4812.24,
DEPUY 202.220 LOCK SCREW SELF TAP 2.7X20,C1713,HCPCS,,79007340,CDM,278,RC,,,both,,,311,230.14,,,230.14,Other,150% of Medicare + 9.63% HCRA Surcharge,139.95,45,,139.95,percent of total billed charges,Critical Access Hospital RCC factor,105.74,34,,105.74,percent of total billed charges,Implant Device,105.74,34,,105.74,percent of total billed charges,Implant Device,105.74,34,,105.74,percent of total billed charges,Implant Device,105.74,34,,105.74,percent of total billed charges,Implant Device,105.74,34,,105.74,percent of total billed charges,Implant Device,153.95,,,153.95,Other,110% of Medicare,108.85,35,,108.85,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,108.85,35,,108.85,percent of total billed charges,Implant Device,108.85,35,,108.85,percent of total billed charges,Implant Device,108.85,35,,108.85,percent of total billed charges,Implant Device,108.85,35,,108.85,percent of total billed charges,Implant Device,108.85,35,,108.85,percent of total billed charges,Implant Device,124.4,40,,124.4,percent of total billed charges,Implant Device,108.85,70,,108.85,percent of total billed charges,All Other,105.74,34,,105.74,percent of total billed charges,Implant Device,105.74,34,,105.74,percent of total billed charges,Implant Device,108.85,35,,108.85,percent of total billed charges,Implant Device,108.85,35,,108.85,percent of total billed charges,Implant Device,108.85,35,,108.85,percent of total billed charges,Implant Device,108.85,35,,108.85,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,230.14,
DEPUY 202.210 LOCK SCREW SELF TAP 2.7X10,C1713,HCPCS,,79007341,CDM,278,RC,,,both,,,300,222,,,222,Other,150% of Medicare + 9.63% HCRA Surcharge,135,45,,135,percent of total billed charges,Critical Access Hospital RCC factor,102,34,,102,percent of total billed charges,Implant Device,102,34,,102,percent of total billed charges,Implant Device,102,34,,102,percent of total billed charges,Implant Device,102,34,,102,percent of total billed charges,Implant Device,102,34,,102,percent of total billed charges,Implant Device,148.5,,,148.5,Other,110% of Medicare,105,35,,105,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,105,35,,105,percent of total billed charges,Implant Device,105,35,,105,percent of total billed charges,Implant Device,105,35,,105,percent of total billed charges,Implant Device,105,35,,105,percent of total billed charges,Implant Device,105,35,,105,percent of total billed charges,Implant Device,120,40,,120,percent of total billed charges,Implant Device,105,70,,105,percent of total billed charges,All Other,102,34,,102,percent of total billed charges,Implant Device,102,34,,102,percent of total billed charges,Implant Device,105,35,,105,percent of total billed charges,Implant Device,105,35,,105,percent of total billed charges,Implant Device,105,35,,105,percent of total billed charges,Implant Device,105,35,,105,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,222,
STRYKER 1828-1334S FEMORAL NAIL 13X340MM,C1713,HCPCS,,79007342,CDM,278,RC,,,both,,,7030,5202.22,,,5202.22,Other,150% of Medicare + 9.63% HCRA Surcharge,3163.5,45,,3163.5,percent of total billed charges,Critical Access Hospital RCC factor,2390.2,34,,2390.2,percent of total billed charges,Implant Device,2390.2,34,,2390.2,percent of total billed charges,Implant Device,2390.2,34,,2390.2,percent of total billed charges,Implant Device,2390.2,34,,2390.2,percent of total billed charges,Implant Device,2390.2,34,,2390.2,percent of total billed charges,Implant Device,3479.85,,,3479.85,Other,110% of Medicare,2460.5,35,,2460.5,percent of total billed charges,Implant Device,2390.2,34,"Charges > $500, x 34%",2390.2,percent of total billed charges,Implant Device,2460.5,35,,2460.5,percent of total billed charges,Implant Device,2460.5,35,,2460.5,percent of total billed charges,Implant Device,2460.5,35,,2460.5,percent of total billed charges,Implant Device,2460.5,35,,2460.5,percent of total billed charges,Implant Device,2460.5,35,,2460.5,percent of total billed charges,Implant Device,2812,40,,2812,percent of total billed charges,Implant Device,2460.5,70,,2460.5,percent of total billed charges,All Other,2390.2,34,,2390.2,percent of total billed charges,Implant Device,2390.2,34,,2390.2,percent of total billed charges,Implant Device,2460.5,35,,2460.5,percent of total billed charges,Implant Device,2460.5,35,,2460.5,percent of total billed charges,Implant Device,2460.5,35,,2460.5,percent of total billed charges,Implant Device,2460.5,35,,2460.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2390.2,34,"If Charge > 2,000, then 34 percent",2390.2,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5202.22,
DEPUY 212.108 LOCK SCREW SELF TAP 3.5X24,C1713,HCPCS,,79007343,CDM,278,RC,,,both,,,488,361.12,,,361.12,Other,150% of Medicare + 9.63% HCRA Surcharge,219.6,45,,219.6,percent of total billed charges,Critical Access Hospital RCC factor,165.92,34,,165.92,percent of total billed charges,Implant Device,165.92,34,,165.92,percent of total billed charges,Implant Device,165.92,34,,165.92,percent of total billed charges,Implant Device,165.92,34,,165.92,percent of total billed charges,Implant Device,165.92,34,,165.92,percent of total billed charges,Implant Device,241.56,,,241.56,Other,110% of Medicare,170.8,35,,170.8,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,170.8,35,,170.8,percent of total billed charges,Implant Device,170.8,35,,170.8,percent of total billed charges,Implant Device,170.8,35,,170.8,percent of total billed charges,Implant Device,170.8,35,,170.8,percent of total billed charges,Implant Device,170.8,35,,170.8,percent of total billed charges,Implant Device,195.2,40,,195.2,percent of total billed charges,Implant Device,170.8,70,,170.8,percent of total billed charges,All Other,165.92,34,,165.92,percent of total billed charges,Implant Device,165.92,34,,165.92,percent of total billed charges,Implant Device,170.8,35,,170.8,percent of total billed charges,Implant Device,170.8,35,,170.8,percent of total billed charges,Implant Device,170.8,35,,170.8,percent of total billed charges,Implant Device,170.8,35,,170.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,361.12,
STRYKER 1896-5075S LOCKING SCREW 5X75,C1713,HCPCS,,79007344,CDM,278,RC,,,both,,,788,583.12,,,583.12,Other,150% of Medicare + 9.63% HCRA Surcharge,354.6,45,,354.6,percent of total billed charges,Critical Access Hospital RCC factor,267.92,34,,267.92,percent of total billed charges,Implant Device,267.92,34,,267.92,percent of total billed charges,Implant Device,267.92,34,,267.92,percent of total billed charges,Implant Device,267.92,34,,267.92,percent of total billed charges,Implant Device,267.92,34,,267.92,percent of total billed charges,Implant Device,390.06,,,390.06,Other,110% of Medicare,275.8,35,,275.8,percent of total billed charges,Implant Device,267.92,34,"Charges > $500, x 34%",267.92,percent of total billed charges,Implant Device,275.8,35,,275.8,percent of total billed charges,Implant Device,275.8,35,,275.8,percent of total billed charges,Implant Device,275.8,35,,275.8,percent of total billed charges,Implant Device,275.8,35,,275.8,percent of total billed charges,Implant Device,275.8,35,,275.8,percent of total billed charges,Implant Device,315.2,40,,315.2,percent of total billed charges,Implant Device,275.8,70,,275.8,percent of total billed charges,All Other,267.92,34,,267.92,percent of total billed charges,Implant Device,267.92,34,,267.92,percent of total billed charges,Implant Device,275.8,35,,275.8,percent of total billed charges,Implant Device,275.8,35,,275.8,percent of total billed charges,Implant Device,275.8,35,,275.8,percent of total billed charges,Implant Device,275.8,35,,275.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,583.12,
STRYKER 6704-0-420 CABLE/SLEEVE SET 1.6,C1713,HCPCS,,79007345,CDM,278,RC,,,both,,,963,712.62,,,712.62,Other,150% of Medicare + 9.63% HCRA Surcharge,433.35,45,,433.35,percent of total billed charges,Critical Access Hospital RCC factor,327.42,34,,327.42,percent of total billed charges,Implant Device,327.42,34,,327.42,percent of total billed charges,Implant Device,327.42,34,,327.42,percent of total billed charges,Implant Device,327.42,34,,327.42,percent of total billed charges,Implant Device,327.42,34,,327.42,percent of total billed charges,Implant Device,476.69,,,476.69,Other,110% of Medicare,337.05,35,,337.05,percent of total billed charges,Implant Device,327.42,34,"Charges > $500, x 34%",327.42,percent of total billed charges,Implant Device,337.05,35,,337.05,percent of total billed charges,Implant Device,337.05,35,,337.05,percent of total billed charges,Implant Device,337.05,35,,337.05,percent of total billed charges,Implant Device,337.05,35,,337.05,percent of total billed charges,Implant Device,337.05,35,,337.05,percent of total billed charges,Implant Device,385.2,40,,385.2,percent of total billed charges,Implant Device,337.05,70,,337.05,percent of total billed charges,All Other,327.42,34,,327.42,percent of total billed charges,Implant Device,327.42,34,,327.42,percent of total billed charges,Implant Device,337.05,35,,337.05,percent of total billed charges,Implant Device,337.05,35,,337.05,percent of total billed charges,Implant Device,337.05,35,,337.05,percent of total billed charges,Implant Device,337.05,35,,337.05,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,712.62,
BOST SCI 39200-08407 8X41X75 EPIC STENT,C1876,HCPCS,,79007346,CDM,278,RC,,,both,,,2550,1887.01,,,1887.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1147.5,45,,1147.5,percent of total billed charges,Critical Access Hospital RCC factor,867,34,,867,percent of total billed charges,Implant Device,867,34,,867,percent of total billed charges,Implant Device,867,34,,867,percent of total billed charges,Implant Device,867,34,,867,percent of total billed charges,Implant Device,867,34,,867,percent of total billed charges,Implant Device,1262.25,,,1262.25,Other,110% of Medicare,892.5,35,,892.5,percent of total billed charges,Implant Device,867,34,"Charges > $500, x 34%",867,percent of total billed charges,Implant Device,892.5,35,,892.5,percent of total billed charges,Implant Device,892.5,35,,892.5,percent of total billed charges,Implant Device,892.5,35,,892.5,percent of total billed charges,Implant Device,892.5,35,,892.5,percent of total billed charges,Implant Device,892.5,35,,892.5,percent of total billed charges,Implant Device,1020,40,,1020,percent of total billed charges,Implant Device,892.5,70,,892.5,percent of total billed charges,All Other,867,34,,867,percent of total billed charges,Implant Device,867,34,,867,percent of total billed charges,Implant Device,892.5,35,,892.5,percent of total billed charges,Implant Device,892.5,35,,892.5,percent of total billed charges,Implant Device,892.5,35,,892.5,percent of total billed charges,Implant Device,892.5,35,,892.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,867,34,"If Charge > 2,000, then 34 percent",867,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1887.01,
PHOENIX 400-651 SPINAL CABLE SYS 4-CRIMP,C1713,HCPCS,,79007347,CDM,278,RC,,,both,,,5550,4107.01,,,4107.01,Other,150% of Medicare + 9.63% HCRA Surcharge,2497.5,45,,2497.5,percent of total billed charges,Critical Access Hospital RCC factor,1887,34,,1887,percent of total billed charges,Implant Device,1887,34,,1887,percent of total billed charges,Implant Device,1887,34,,1887,percent of total billed charges,Implant Device,1887,34,,1887,percent of total billed charges,Implant Device,1887,34,,1887,percent of total billed charges,Implant Device,2747.25,,,2747.25,Other,110% of Medicare,1942.5,35,,1942.5,percent of total billed charges,Implant Device,1887,34,"Charges > $500, x 34%",1887,percent of total billed charges,Implant Device,1942.5,35,,1942.5,percent of total billed charges,Implant Device,1942.5,35,,1942.5,percent of total billed charges,Implant Device,1942.5,35,,1942.5,percent of total billed charges,Implant Device,1942.5,35,,1942.5,percent of total billed charges,Implant Device,1942.5,35,,1942.5,percent of total billed charges,Implant Device,2220,40,,2220,percent of total billed charges,Implant Device,1942.5,70,,1942.5,percent of total billed charges,All Other,1887,34,,1887,percent of total billed charges,Implant Device,1887,34,,1887,percent of total billed charges,Implant Device,1942.5,35,,1942.5,percent of total billed charges,Implant Device,1942.5,35,,1942.5,percent of total billed charges,Implant Device,1942.5,35,,1942.5,percent of total billed charges,Implant Device,1942.5,35,,1942.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1887,34,"If Charge > 2,000, then 34 percent",1887,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4107.01,
PHOENIX 90-300-25508 BONE VOID FILL 10CC,C1713,HCPCS,,79007348,CDM,278,RC,,,both,,,8625,6382.52,,,6382.52,Other,150% of Medicare + 9.63% HCRA Surcharge,3881.25,45,,3881.25,percent of total billed charges,Critical Access Hospital RCC factor,2932.5,34,,2932.5,percent of total billed charges,Implant Device,2932.5,34,,2932.5,percent of total billed charges,Implant Device,2932.5,34,,2932.5,percent of total billed charges,Implant Device,2932.5,34,,2932.5,percent of total billed charges,Implant Device,2932.5,34,,2932.5,percent of total billed charges,Implant Device,4269.38,,,4269.38,Other,110% of Medicare,3018.75,35,,3018.75,percent of total billed charges,Implant Device,2932.5,34,"Charges > $500, x 34%",2932.5,percent of total billed charges,Implant Device,3018.75,35,,3018.75,percent of total billed charges,Implant Device,3018.75,35,,3018.75,percent of total billed charges,Implant Device,3018.75,35,,3018.75,percent of total billed charges,Implant Device,3018.75,35,,3018.75,percent of total billed charges,Implant Device,3018.75,35,,3018.75,percent of total billed charges,Implant Device,3450,40,,3450,percent of total billed charges,Implant Device,3018.75,70,,3018.75,percent of total billed charges,All Other,2932.5,34,,2932.5,percent of total billed charges,Implant Device,2932.5,34,,2932.5,percent of total billed charges,Implant Device,3018.75,35,,3018.75,percent of total billed charges,Implant Device,3018.75,35,,3018.75,percent of total billed charges,Implant Device,3018.75,35,,3018.75,percent of total billed charges,Implant Device,3018.75,35,,3018.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2932.5,34,"If Charge > 2,000, then 34 percent",2932.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,6382.52,
PHOENIX 90-200-10 BONE VOID FILLER 10CC,C1713,HCPCS,,79007349,CDM,278,RC,,,both,,,8625,6382.52,,,6382.52,Other,150% of Medicare + 9.63% HCRA Surcharge,3881.25,45,,3881.25,percent of total billed charges,Critical Access Hospital RCC factor,2932.5,34,,2932.5,percent of total billed charges,Implant Device,2932.5,34,,2932.5,percent of total billed charges,Implant Device,2932.5,34,,2932.5,percent of total billed charges,Implant Device,2932.5,34,,2932.5,percent of total billed charges,Implant Device,2932.5,34,,2932.5,percent of total billed charges,Implant Device,4269.38,,,4269.38,Other,110% of Medicare,3018.75,35,,3018.75,percent of total billed charges,Implant Device,2932.5,34,"Charges > $500, x 34%",2932.5,percent of total billed charges,Implant Device,3018.75,35,,3018.75,percent of total billed charges,Implant Device,3018.75,35,,3018.75,percent of total billed charges,Implant Device,3018.75,35,,3018.75,percent of total billed charges,Implant Device,3018.75,35,,3018.75,percent of total billed charges,Implant Device,3018.75,35,,3018.75,percent of total billed charges,Implant Device,3450,40,,3450,percent of total billed charges,Implant Device,3018.75,70,,3018.75,percent of total billed charges,All Other,2932.5,34,,2932.5,percent of total billed charges,Implant Device,2932.5,34,,2932.5,percent of total billed charges,Implant Device,3018.75,35,,3018.75,percent of total billed charges,Implant Device,3018.75,35,,3018.75,percent of total billed charges,Implant Device,3018.75,35,,3018.75,percent of total billed charges,Implant Device,3018.75,35,,3018.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2932.5,34,"If Charge > 2,000, then 34 percent",2932.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,6382.52,
ZIMMER 00-5852-050-11 STEM EXT 11X130MM,C1713,HCPCS,,79007352,CDM,278,RC,,,both,,,11453,8475.25,,,8475.25,Other,150% of Medicare + 9.63% HCRA Surcharge,5153.85,45,,5153.85,percent of total billed charges,Critical Access Hospital RCC factor,3894.02,34,,3894.02,percent of total billed charges,Implant Device,3894.02,34,,3894.02,percent of total billed charges,Implant Device,3894.02,34,,3894.02,percent of total billed charges,Implant Device,3894.02,34,,3894.02,percent of total billed charges,Implant Device,3894.02,34,,3894.02,percent of total billed charges,Implant Device,5669.24,,,5669.24,Other,110% of Medicare,4008.55,35,,4008.55,percent of total billed charges,Implant Device,3894.02,34,"Charges > $500, x 34%",3894.02,percent of total billed charges,Implant Device,4008.55,35,,4008.55,percent of total billed charges,Implant Device,4008.55,35,,4008.55,percent of total billed charges,Implant Device,4008.55,35,,4008.55,percent of total billed charges,Implant Device,4008.55,35,,4008.55,percent of total billed charges,Implant Device,4008.55,35,,4008.55,percent of total billed charges,Implant Device,4581.2,40,,4581.2,percent of total billed charges,Implant Device,4008.55,70,,4008.55,percent of total billed charges,All Other,3894.02,34,,3894.02,percent of total billed charges,Implant Device,3894.02,34,,3894.02,percent of total billed charges,Implant Device,4008.55,35,,4008.55,percent of total billed charges,Implant Device,4008.55,35,,4008.55,percent of total billed charges,Implant Device,4008.55,35,,4008.55,percent of total billed charges,Implant Device,4008.55,35,,4008.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3894.02,34,"If Charge > 2,000, then 34 percent",3894.02,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,8475.25,
ZIMMER 00-5850-046-03 SEGMENT 30MM,C1713,HCPCS,,79007353,CDM,278,RC,,,both,,,11302,8363.51,,,8363.51,Other,150% of Medicare + 9.63% HCRA Surcharge,5085.9,45,,5085.9,percent of total billed charges,Critical Access Hospital RCC factor,3842.68,34,,3842.68,percent of total billed charges,Implant Device,3842.68,34,,3842.68,percent of total billed charges,Implant Device,3842.68,34,,3842.68,percent of total billed charges,Implant Device,3842.68,34,,3842.68,percent of total billed charges,Implant Device,3842.68,34,,3842.68,percent of total billed charges,Implant Device,5594.49,,,5594.49,Other,110% of Medicare,3955.7,35,,3955.7,percent of total billed charges,Implant Device,3842.68,34,"Charges > $500, x 34%",3842.68,percent of total billed charges,Implant Device,3955.7,35,,3955.7,percent of total billed charges,Implant Device,3955.7,35,,3955.7,percent of total billed charges,Implant Device,3955.7,35,,3955.7,percent of total billed charges,Implant Device,3955.7,35,,3955.7,percent of total billed charges,Implant Device,3955.7,35,,3955.7,percent of total billed charges,Implant Device,4520.8,40,,4520.8,percent of total billed charges,Implant Device,3955.7,70,,3955.7,percent of total billed charges,All Other,3842.68,34,,3842.68,percent of total billed charges,Implant Device,3842.68,34,,3842.68,percent of total billed charges,Implant Device,3955.7,35,,3955.7,percent of total billed charges,Implant Device,3955.7,35,,3955.7,percent of total billed charges,Implant Device,3955.7,35,,3955.7,percent of total billed charges,Implant Device,3955.7,35,,3955.7,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3842.68,34,"If Charge > 2,000, then 34 percent",3842.68,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,8363.51,
ZIMMER 00-5852-040-25 STEM COLLAR 25MM,C1713,HCPCS,,79007354,CDM,278,RC,,,both,,,7178,5311.74,,,5311.74,Other,150% of Medicare + 9.63% HCRA Surcharge,3230.1,45,,3230.1,percent of total billed charges,Critical Access Hospital RCC factor,2440.52,34,,2440.52,percent of total billed charges,Implant Device,2440.52,34,,2440.52,percent of total billed charges,Implant Device,2440.52,34,,2440.52,percent of total billed charges,Implant Device,2440.52,34,,2440.52,percent of total billed charges,Implant Device,2440.52,34,,2440.52,percent of total billed charges,Implant Device,3553.11,,,3553.11,Other,110% of Medicare,2512.3,35,,2512.3,percent of total billed charges,Implant Device,2440.52,34,"Charges > $500, x 34%",2440.52,percent of total billed charges,Implant Device,2512.3,35,,2512.3,percent of total billed charges,Implant Device,2512.3,35,,2512.3,percent of total billed charges,Implant Device,2512.3,35,,2512.3,percent of total billed charges,Implant Device,2512.3,35,,2512.3,percent of total billed charges,Implant Device,2512.3,35,,2512.3,percent of total billed charges,Implant Device,2871.2,40,,2871.2,percent of total billed charges,Implant Device,2512.3,70,,2512.3,percent of total billed charges,All Other,2440.52,34,,2440.52,percent of total billed charges,Implant Device,2440.52,34,,2440.52,percent of total billed charges,Implant Device,2512.3,35,,2512.3,percent of total billed charges,Implant Device,2512.3,35,,2512.3,percent of total billed charges,Implant Device,2512.3,35,,2512.3,percent of total billed charges,Implant Device,2512.3,35,,2512.3,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2440.52,34,"If Charge > 2,000, then 34 percent",2440.52,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5311.74,
STRYKER 6276-7-221 MODULAR HIP 195X21MM,C1776,HCPCS,,79007355,CDM,278,RC,,,both,,,15277,11305.02,,,11305.02,Other,150% of Medicare + 9.63% HCRA Surcharge,6874.65,45,,6874.65,percent of total billed charges,Critical Access Hospital RCC factor,5194.18,34,,5194.18,percent of total billed charges,Implant Device,5194.18,34,,5194.18,percent of total billed charges,Implant Device,5194.18,34,,5194.18,percent of total billed charges,Implant Device,5194.18,34,,5194.18,percent of total billed charges,Implant Device,5194.18,34,,5194.18,percent of total billed charges,Implant Device,7562.12,,,7562.12,Other,110% of Medicare,5346.95,35,,5346.95,percent of total billed charges,Implant Device,5194.18,34,"Charges > $500, x 34%",5194.18,percent of total billed charges,Implant Device,5346.95,35,,5346.95,percent of total billed charges,Implant Device,5346.95,35,,5346.95,percent of total billed charges,Implant Device,5346.95,35,,5346.95,percent of total billed charges,Implant Device,5346.95,35,,5346.95,percent of total billed charges,Implant Device,5346.95,35,,5346.95,percent of total billed charges,Implant Device,6110.8,40,,6110.8,percent of total billed charges,Implant Device,5346.95,70,,5346.95,percent of total billed charges,All Other,5194.18,34,,5194.18,percent of total billed charges,Implant Device,5194.18,34,,5194.18,percent of total billed charges,Implant Device,5346.95,35,,5346.95,percent of total billed charges,Implant Device,5346.95,35,,5346.95,percent of total billed charges,Implant Device,5346.95,35,,5346.95,percent of total billed charges,Implant Device,5346.95,35,,5346.95,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,5194.18,34,"If Charge > 2,000, then 34 percent",5194.18,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,11305.02,
S&N 71453254 ARTICULAR INSERT SZ5-6 13MM,C1776,HCPCS,,79007359,CDM,278,RC,,,both,,,5528,4090.73,,,4090.73,Other,150% of Medicare + 9.63% HCRA Surcharge,2487.6,45,,2487.6,percent of total billed charges,Critical Access Hospital RCC factor,1879.52,34,,1879.52,percent of total billed charges,Implant Device,1879.52,34,,1879.52,percent of total billed charges,Implant Device,1879.52,34,,1879.52,percent of total billed charges,Implant Device,1879.52,34,,1879.52,percent of total billed charges,Implant Device,1879.52,34,,1879.52,percent of total billed charges,Implant Device,2736.36,,,2736.36,Other,110% of Medicare,1934.8,35,,1934.8,percent of total billed charges,Implant Device,1879.52,34,"Charges > $500, x 34%",1879.52,percent of total billed charges,Implant Device,1934.8,35,,1934.8,percent of total billed charges,Implant Device,1934.8,35,,1934.8,percent of total billed charges,Implant Device,1934.8,35,,1934.8,percent of total billed charges,Implant Device,1934.8,35,,1934.8,percent of total billed charges,Implant Device,1934.8,35,,1934.8,percent of total billed charges,Implant Device,2211.2,40,,2211.2,percent of total billed charges,Implant Device,1934.8,70,,1934.8,percent of total billed charges,All Other,1879.52,34,,1879.52,percent of total billed charges,Implant Device,1879.52,34,,1879.52,percent of total billed charges,Implant Device,1934.8,35,,1934.8,percent of total billed charges,Implant Device,1934.8,35,,1934.8,percent of total billed charges,Implant Device,1934.8,35,,1934.8,percent of total billed charges,Implant Device,1934.8,35,,1934.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1879.52,34,"If Charge > 2,000, then 34 percent",1879.52,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4090.73,
IN2BONES S22 ST010 SCREW 2.2X10MM,C1713,HCPCS,,79007360,CDM,278,RC,,,both,,,675,499.5,,,499.5,Other,150% of Medicare + 9.63% HCRA Surcharge,303.75,45,,303.75,percent of total billed charges,Critical Access Hospital RCC factor,229.5,34,,229.5,percent of total billed charges,Implant Device,229.5,34,,229.5,percent of total billed charges,Implant Device,229.5,34,,229.5,percent of total billed charges,Implant Device,229.5,34,,229.5,percent of total billed charges,Implant Device,229.5,34,,229.5,percent of total billed charges,Implant Device,334.13,,,334.13,Other,110% of Medicare,236.25,35,,236.25,percent of total billed charges,Implant Device,229.5,34,"Charges > $500, x 34%",229.5,percent of total billed charges,Implant Device,236.25,35,,236.25,percent of total billed charges,Implant Device,236.25,35,,236.25,percent of total billed charges,Implant Device,236.25,35,,236.25,percent of total billed charges,Implant Device,236.25,35,,236.25,percent of total billed charges,Implant Device,236.25,35,,236.25,percent of total billed charges,Implant Device,270,40,,270,percent of total billed charges,Implant Device,236.25,70,,236.25,percent of total billed charges,All Other,229.5,34,,229.5,percent of total billed charges,Implant Device,229.5,34,,229.5,percent of total billed charges,Implant Device,236.25,35,,236.25,percent of total billed charges,Implant Device,236.25,35,,236.25,percent of total billed charges,Implant Device,236.25,35,,236.25,percent of total billed charges,Implant Device,236.25,35,,236.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,499.5,
DEPUY 1024-08-300 FEMORAL INS SZ 3 RM/LL,C1776,HCPCS,,79007361,CDM,278,RC,,,both,,,4200,3108.01,,,3108.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1890,45,,1890,percent of total billed charges,Critical Access Hospital RCC factor,1428,34,,1428,percent of total billed charges,Implant Device,1428,34,,1428,percent of total billed charges,Implant Device,1428,34,,1428,percent of total billed charges,Implant Device,1428,34,,1428,percent of total billed charges,Implant Device,1428,34,,1428,percent of total billed charges,Implant Device,2079,,,2079,Other,110% of Medicare,1470,35,,1470,percent of total billed charges,Implant Device,1428,34,"Charges > $500, x 34%",1428,percent of total billed charges,Implant Device,1470,35,,1470,percent of total billed charges,Implant Device,1470,35,,1470,percent of total billed charges,Implant Device,1470,35,,1470,percent of total billed charges,Implant Device,1470,35,,1470,percent of total billed charges,Implant Device,1470,35,,1470,percent of total billed charges,Implant Device,1680,40,,1680,percent of total billed charges,Implant Device,1470,70,,1470,percent of total billed charges,All Other,1428,34,,1428,percent of total billed charges,Implant Device,1428,34,,1428,percent of total billed charges,Implant Device,1470,35,,1470,percent of total billed charges,Implant Device,1470,35,,1470,percent of total billed charges,Implant Device,1470,35,,1470,percent of total billed charges,Implant Device,1470,35,,1470,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1428,34,"If Charge > 2,000, then 34 percent",1428,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3108.01,
STRYKER 627438 8 HOLE PLATE RT DIST MED,C1713,HCPCS,,79007362,CDM,278,RC,,,both,,,7635,5649.92,,,5649.92,Other,150% of Medicare + 9.63% HCRA Surcharge,3435.75,45,,3435.75,percent of total billed charges,Critical Access Hospital RCC factor,2595.9,34,,2595.9,percent of total billed charges,Implant Device,2595.9,34,,2595.9,percent of total billed charges,Implant Device,2595.9,34,,2595.9,percent of total billed charges,Implant Device,2595.9,34,,2595.9,percent of total billed charges,Implant Device,2595.9,34,,2595.9,percent of total billed charges,Implant Device,3779.33,,,3779.33,Other,110% of Medicare,2672.25,35,,2672.25,percent of total billed charges,Implant Device,2595.9,34,"Charges > $500, x 34%",2595.9,percent of total billed charges,Implant Device,2672.25,35,,2672.25,percent of total billed charges,Implant Device,2672.25,35,,2672.25,percent of total billed charges,Implant Device,2672.25,35,,2672.25,percent of total billed charges,Implant Device,2672.25,35,,2672.25,percent of total billed charges,Implant Device,2672.25,35,,2672.25,percent of total billed charges,Implant Device,3054,40,,3054,percent of total billed charges,Implant Device,2672.25,70,,2672.25,percent of total billed charges,All Other,2595.9,34,,2595.9,percent of total billed charges,Implant Device,2595.9,34,,2595.9,percent of total billed charges,Implant Device,2672.25,35,,2672.25,percent of total billed charges,Implant Device,2672.25,35,,2672.25,percent of total billed charges,Implant Device,2672.25,35,,2672.25,percent of total billed charges,Implant Device,2672.25,35,,2672.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2595.9,34,"If Charge > 2,000, then 34 percent",2595.9,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5649.92,
STRYKER 661050 4.5X50MM LOCKING SCREW,C1713,HCPCS,,79007363,CDM,278,RC,,,both,,,583,431.42,,,431.42,Other,150% of Medicare + 9.63% HCRA Surcharge,262.35,45,,262.35,percent of total billed charges,Critical Access Hospital RCC factor,198.22,34,,198.22,percent of total billed charges,Implant Device,198.22,34,,198.22,percent of total billed charges,Implant Device,198.22,34,,198.22,percent of total billed charges,Implant Device,198.22,34,,198.22,percent of total billed charges,Implant Device,198.22,34,,198.22,percent of total billed charges,Implant Device,288.59,,,288.59,Other,110% of Medicare,204.05,35,,204.05,percent of total billed charges,Implant Device,198.22,34,"Charges > $500, x 34%",198.22,percent of total billed charges,Implant Device,204.05,35,,204.05,percent of total billed charges,Implant Device,204.05,35,,204.05,percent of total billed charges,Implant Device,204.05,35,,204.05,percent of total billed charges,Implant Device,204.05,35,,204.05,percent of total billed charges,Implant Device,204.05,35,,204.05,percent of total billed charges,Implant Device,233.2,40,,233.2,percent of total billed charges,Implant Device,204.05,70,,204.05,percent of total billed charges,All Other,198.22,34,,198.22,percent of total billed charges,Implant Device,198.22,34,,198.22,percent of total billed charges,Implant Device,204.05,35,,204.05,percent of total billed charges,Implant Device,204.05,35,,204.05,percent of total billed charges,Implant Device,204.05,35,,204.05,percent of total billed charges,Implant Device,204.05,35,,204.05,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,431.42,
STRYKER 661046 4.5X46MM LOCKING SCREW,C1713,HCPCS,,79007364,CDM,278,RC,,,both,,,583,431.42,,,431.42,Other,150% of Medicare + 9.63% HCRA Surcharge,262.35,45,,262.35,percent of total billed charges,Critical Access Hospital RCC factor,198.22,34,,198.22,percent of total billed charges,Implant Device,198.22,34,,198.22,percent of total billed charges,Implant Device,198.22,34,,198.22,percent of total billed charges,Implant Device,198.22,34,,198.22,percent of total billed charges,Implant Device,198.22,34,,198.22,percent of total billed charges,Implant Device,288.59,,,288.59,Other,110% of Medicare,204.05,35,,204.05,percent of total billed charges,Implant Device,198.22,34,"Charges > $500, x 34%",198.22,percent of total billed charges,Implant Device,204.05,35,,204.05,percent of total billed charges,Implant Device,204.05,35,,204.05,percent of total billed charges,Implant Device,204.05,35,,204.05,percent of total billed charges,Implant Device,204.05,35,,204.05,percent of total billed charges,Implant Device,204.05,35,,204.05,percent of total billed charges,Implant Device,233.2,40,,233.2,percent of total billed charges,Implant Device,204.05,70,,204.05,percent of total billed charges,All Other,198.22,34,,198.22,percent of total billed charges,Implant Device,198.22,34,,198.22,percent of total billed charges,Implant Device,204.05,35,,204.05,percent of total billed charges,Implant Device,204.05,35,,204.05,percent of total billed charges,Implant Device,204.05,35,,204.05,percent of total billed charges,Implant Device,204.05,35,,204.05,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,431.42,
STRYKER 661018 4.5X18MM LOCKING SCREW,C1713,HCPCS,,79007365,CDM,278,RC,,,both,,,753,557.22,,,557.22,Other,150% of Medicare + 9.63% HCRA Surcharge,338.85,45,,338.85,percent of total billed charges,Critical Access Hospital RCC factor,256.02,34,,256.02,percent of total billed charges,Implant Device,256.02,34,,256.02,percent of total billed charges,Implant Device,256.02,34,,256.02,percent of total billed charges,Implant Device,256.02,34,,256.02,percent of total billed charges,Implant Device,256.02,34,,256.02,percent of total billed charges,Implant Device,372.74,,,372.74,Other,110% of Medicare,263.55,35,,263.55,percent of total billed charges,Implant Device,256.02,34,"Charges > $500, x 34%",256.02,percent of total billed charges,Implant Device,263.55,35,,263.55,percent of total billed charges,Implant Device,263.55,35,,263.55,percent of total billed charges,Implant Device,263.55,35,,263.55,percent of total billed charges,Implant Device,263.55,35,,263.55,percent of total billed charges,Implant Device,263.55,35,,263.55,percent of total billed charges,Implant Device,301.2,40,,301.2,percent of total billed charges,Implant Device,263.55,70,,263.55,percent of total billed charges,All Other,256.02,34,,256.02,percent of total billed charges,Implant Device,256.02,34,,256.02,percent of total billed charges,Implant Device,263.55,35,,263.55,percent of total billed charges,Implant Device,263.55,35,,263.55,percent of total billed charges,Implant Device,263.55,35,,263.55,percent of total billed charges,Implant Device,263.55,35,,263.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,557.22,
STRYKER 661024 4.5X24MM LOCKING SCREW,C1713,HCPCS,,79007366,CDM,278,RC,,,both,,,583,431.42,,,431.42,Other,150% of Medicare + 9.63% HCRA Surcharge,262.35,45,,262.35,percent of total billed charges,Critical Access Hospital RCC factor,198.22,34,,198.22,percent of total billed charges,Implant Device,198.22,34,,198.22,percent of total billed charges,Implant Device,198.22,34,,198.22,percent of total billed charges,Implant Device,198.22,34,,198.22,percent of total billed charges,Implant Device,198.22,34,,198.22,percent of total billed charges,Implant Device,288.59,,,288.59,Other,110% of Medicare,204.05,35,,204.05,percent of total billed charges,Implant Device,198.22,34,"Charges > $500, x 34%",198.22,percent of total billed charges,Implant Device,204.05,35,,204.05,percent of total billed charges,Implant Device,204.05,35,,204.05,percent of total billed charges,Implant Device,204.05,35,,204.05,percent of total billed charges,Implant Device,204.05,35,,204.05,percent of total billed charges,Implant Device,204.05,35,,204.05,percent of total billed charges,Implant Device,233.2,40,,233.2,percent of total billed charges,Implant Device,204.05,70,,204.05,percent of total billed charges,All Other,198.22,34,,198.22,percent of total billed charges,Implant Device,198.22,34,,198.22,percent of total billed charges,Implant Device,204.05,35,,204.05,percent of total billed charges,Implant Device,204.05,35,,204.05,percent of total billed charges,Implant Device,204.05,35,,204.05,percent of total billed charges,Implant Device,204.05,35,,204.05,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,431.42,
STRYKER 661026 4.5X26MM LOCKING SCREW,C1713,HCPCS,,79007367,CDM,278,RC,,,both,,,630,466.2,,,466.2,Other,150% of Medicare + 9.63% HCRA Surcharge,283.5,45,,283.5,percent of total billed charges,Critical Access Hospital RCC factor,214.2,34,,214.2,percent of total billed charges,Implant Device,214.2,34,,214.2,percent of total billed charges,Implant Device,214.2,34,,214.2,percent of total billed charges,Implant Device,214.2,34,,214.2,percent of total billed charges,Implant Device,214.2,34,,214.2,percent of total billed charges,Implant Device,311.85,,,311.85,Other,110% of Medicare,220.5,35,,220.5,percent of total billed charges,Implant Device,214.2,34,"Charges > $500, x 34%",214.2,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,252,40,,252,percent of total billed charges,Implant Device,220.5,70,,220.5,percent of total billed charges,All Other,214.2,34,,214.2,percent of total billed charges,Implant Device,214.2,34,,214.2,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,466.2,
STRYKER 661450 3.5X50MM CORTICAL SCREW,C1713,HCPCS,,79007368,CDM,278,RC,,,both,,,120,88.8,,,88.8,Other,150% of Medicare + 9.63% HCRA Surcharge,54,45,,54,percent of total billed charges,Critical Access Hospital RCC factor,40.8,34,,40.8,percent of total billed charges,Implant Device,40.8,34,,40.8,percent of total billed charges,Implant Device,40.8,34,,40.8,percent of total billed charges,Implant Device,40.8,34,,40.8,percent of total billed charges,Implant Device,40.8,34,,40.8,percent of total billed charges,Implant Device,59.4,,,59.4,Other,110% of Medicare,42,35,,42,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,42,35,,42,percent of total billed charges,Implant Device,42,35,,42,percent of total billed charges,Implant Device,42,35,,42,percent of total billed charges,Implant Device,42,35,,42,percent of total billed charges,Implant Device,42,35,,42,percent of total billed charges,Implant Device,48,40,,48,percent of total billed charges,Implant Device,42,70,,42,percent of total billed charges,All Other,40.8,34,,40.8,percent of total billed charges,Implant Device,40.8,34,,40.8,percent of total billed charges,Implant Device,42,35,,42,percent of total billed charges,Implant Device,42,35,,42,percent of total billed charges,Implant Device,42,35,,42,percent of total billed charges,Implant Device,42,35,,42,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,88.8,
STRYKER 661440 3.5X40MM CORTICAL SCREW,C1713,HCPCS,,79007369,CDM,278,RC,,,both,,,132,97.68,,,97.68,Other,150% of Medicare + 9.63% HCRA Surcharge,59.4,45,,59.4,percent of total billed charges,Critical Access Hospital RCC factor,44.88,34,,44.88,percent of total billed charges,Implant Device,44.88,34,,44.88,percent of total billed charges,Implant Device,44.88,34,,44.88,percent of total billed charges,Implant Device,44.88,34,,44.88,percent of total billed charges,Implant Device,44.88,34,,44.88,percent of total billed charges,Implant Device,65.34,,,65.34,Other,110% of Medicare,46.2,35,,46.2,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,46.2,35,,46.2,percent of total billed charges,Implant Device,46.2,35,,46.2,percent of total billed charges,Implant Device,46.2,35,,46.2,percent of total billed charges,Implant Device,46.2,35,,46.2,percent of total billed charges,Implant Device,46.2,35,,46.2,percent of total billed charges,Implant Device,52.8,40,,52.8,percent of total billed charges,Implant Device,46.2,70,,46.2,percent of total billed charges,All Other,44.88,34,,44.88,percent of total billed charges,Implant Device,44.88,34,,44.88,percent of total billed charges,Implant Device,46.2,35,,46.2,percent of total billed charges,Implant Device,46.2,35,,46.2,percent of total billed charges,Implant Device,46.2,35,,46.2,percent of total billed charges,Implant Device,46.2,35,,46.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,97.68,
STRYKER 661430 3.5X30MM CORTICAL SCREW,C1713,HCPCS,,79007370,CDM,278,RC,,,both,,,132,97.68,,,97.68,Other,150% of Medicare + 9.63% HCRA Surcharge,59.4,45,,59.4,percent of total billed charges,Critical Access Hospital RCC factor,44.88,34,,44.88,percent of total billed charges,Implant Device,44.88,34,,44.88,percent of total billed charges,Implant Device,44.88,34,,44.88,percent of total billed charges,Implant Device,44.88,34,,44.88,percent of total billed charges,Implant Device,44.88,34,,44.88,percent of total billed charges,Implant Device,65.34,,,65.34,Other,110% of Medicare,46.2,35,,46.2,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,46.2,35,,46.2,percent of total billed charges,Implant Device,46.2,35,,46.2,percent of total billed charges,Implant Device,46.2,35,,46.2,percent of total billed charges,Implant Device,46.2,35,,46.2,percent of total billed charges,Implant Device,46.2,35,,46.2,percent of total billed charges,Implant Device,52.8,40,,52.8,percent of total billed charges,Implant Device,46.2,70,,46.2,percent of total billed charges,All Other,44.88,34,,44.88,percent of total billed charges,Implant Device,44.88,34,,44.88,percent of total billed charges,Implant Device,46.2,35,,46.2,percent of total billed charges,Implant Device,46.2,35,,46.2,percent of total billed charges,Implant Device,46.2,35,,46.2,percent of total billed charges,Implant Device,46.2,35,,46.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,97.68,
STRYKER 661428 3.5X28MM CORTICAL SCREW,C1713,HCPCS,,79007371,CDM,278,RC,,,both,,,132,97.68,,,97.68,Other,150% of Medicare + 9.63% HCRA Surcharge,59.4,45,,59.4,percent of total billed charges,Critical Access Hospital RCC factor,44.88,34,,44.88,percent of total billed charges,Implant Device,44.88,34,,44.88,percent of total billed charges,Implant Device,44.88,34,,44.88,percent of total billed charges,Implant Device,44.88,34,,44.88,percent of total billed charges,Implant Device,44.88,34,,44.88,percent of total billed charges,Implant Device,65.34,,,65.34,Other,110% of Medicare,46.2,35,,46.2,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,46.2,35,,46.2,percent of total billed charges,Implant Device,46.2,35,,46.2,percent of total billed charges,Implant Device,46.2,35,,46.2,percent of total billed charges,Implant Device,46.2,35,,46.2,percent of total billed charges,Implant Device,46.2,35,,46.2,percent of total billed charges,Implant Device,52.8,40,,52.8,percent of total billed charges,Implant Device,46.2,70,,46.2,percent of total billed charges,All Other,44.88,34,,44.88,percent of total billed charges,Implant Device,44.88,34,,44.88,percent of total billed charges,Implant Device,46.2,35,,46.2,percent of total billed charges,Implant Device,46.2,35,,46.2,percent of total billed charges,Implant Device,46.2,35,,46.2,percent of total billed charges,Implant Device,46.2,35,,46.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,97.68,
ZIMMER 00-5001-048-00 BIPOLAR SHELL 48MM,C1776,HCPCS,,79007373,CDM,278,RC,,,both,,,960,710.4,,,710.4,Other,150% of Medicare + 9.63% HCRA Surcharge,432,45,,432,percent of total billed charges,Critical Access Hospital RCC factor,326.4,34,,326.4,percent of total billed charges,Implant Device,326.4,34,,326.4,percent of total billed charges,Implant Device,326.4,34,,326.4,percent of total billed charges,Implant Device,326.4,34,,326.4,percent of total billed charges,Implant Device,326.4,34,,326.4,percent of total billed charges,Implant Device,475.2,,,475.2,Other,110% of Medicare,336,35,,336,percent of total billed charges,Implant Device,326.4,34,"Charges > $500, x 34%",326.4,percent of total billed charges,Implant Device,336,35,,336,percent of total billed charges,Implant Device,336,35,,336,percent of total billed charges,Implant Device,336,35,,336,percent of total billed charges,Implant Device,336,35,,336,percent of total billed charges,Implant Device,336,35,,336,percent of total billed charges,Implant Device,384,40,,384,percent of total billed charges,Implant Device,336,70,,336,percent of total billed charges,All Other,326.4,34,,326.4,percent of total billed charges,Implant Device,326.4,34,,326.4,percent of total billed charges,Implant Device,336,35,,336,percent of total billed charges,Implant Device,336,35,,336,percent of total billed charges,Implant Device,336,35,,336,percent of total billed charges,Implant Device,336,35,,336,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,710.4,
ARROW ACS-15192-VF VECTORFLOW 19CM CATH,C1750,HCPCS,,79007376,CDM,278,RC,,,both,,,858,634.92,,,634.92,Other,150% of Medicare + 9.63% HCRA Surcharge,386.1,45,,386.1,percent of total billed charges,Critical Access Hospital RCC factor,291.72,34,,291.72,percent of total billed charges,Implant Device,291.72,34,,291.72,percent of total billed charges,Implant Device,291.72,34,,291.72,percent of total billed charges,Implant Device,291.72,34,,291.72,percent of total billed charges,Implant Device,291.72,34,,291.72,percent of total billed charges,Implant Device,424.71,,,424.71,Other,110% of Medicare,300.3,35,,300.3,percent of total billed charges,Implant Device,291.72,34,"Charges > $500, x 34%",291.72,percent of total billed charges,Implant Device,300.3,35,,300.3,percent of total billed charges,Implant Device,300.3,35,,300.3,percent of total billed charges,Implant Device,300.3,35,,300.3,percent of total billed charges,Implant Device,300.3,35,,300.3,percent of total billed charges,Implant Device,300.3,35,,300.3,percent of total billed charges,Implant Device,343.2,40,,343.2,percent of total billed charges,Implant Device,300.3,70,,300.3,percent of total billed charges,All Other,291.72,34,,291.72,percent of total billed charges,Implant Device,291.72,34,,291.72,percent of total billed charges,Implant Device,300.3,35,,300.3,percent of total billed charges,Implant Device,300.3,35,,300.3,percent of total billed charges,Implant Device,300.3,35,,300.3,percent of total billed charges,Implant Device,300.3,35,,300.3,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,634.92,
ARROW ACS-15232-VF VECTORFLOW 23CM CATH,C1750,HCPCS,,79007377,CDM,278,RC,,,both,,,932,689.68,,,689.68,Other,150% of Medicare + 9.63% HCRA Surcharge,419.4,45,,419.4,percent of total billed charges,Critical Access Hospital RCC factor,316.88,34,,316.88,percent of total billed charges,Implant Device,316.88,34,,316.88,percent of total billed charges,Implant Device,316.88,34,,316.88,percent of total billed charges,Implant Device,316.88,34,,316.88,percent of total billed charges,Implant Device,316.88,34,,316.88,percent of total billed charges,Implant Device,461.34,,,461.34,Other,110% of Medicare,326.2,35,,326.2,percent of total billed charges,Implant Device,316.88,34,"Charges > $500, x 34%",316.88,percent of total billed charges,Implant Device,326.2,35,,326.2,percent of total billed charges,Implant Device,326.2,35,,326.2,percent of total billed charges,Implant Device,326.2,35,,326.2,percent of total billed charges,Implant Device,326.2,35,,326.2,percent of total billed charges,Implant Device,326.2,35,,326.2,percent of total billed charges,Implant Device,372.8,40,,372.8,percent of total billed charges,Implant Device,326.2,70,,326.2,percent of total billed charges,All Other,316.88,34,,316.88,percent of total billed charges,Implant Device,316.88,34,,316.88,percent of total billed charges,Implant Device,326.2,35,,326.2,percent of total billed charges,Implant Device,326.2,35,,326.2,percent of total billed charges,Implant Device,326.2,35,,326.2,percent of total billed charges,Implant Device,326.2,35,,326.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,689.68,
ARROW ACS-15272-VF VECTORFLOW 27CM CATH,C1750,HCPCS,,79007378,CDM,278,RC,,,both,,,858,634.92,,,634.92,Other,150% of Medicare + 9.63% HCRA Surcharge,386.1,45,,386.1,percent of total billed charges,Critical Access Hospital RCC factor,291.72,34,,291.72,percent of total billed charges,Implant Device,291.72,34,,291.72,percent of total billed charges,Implant Device,291.72,34,,291.72,percent of total billed charges,Implant Device,291.72,34,,291.72,percent of total billed charges,Implant Device,291.72,34,,291.72,percent of total billed charges,Implant Device,424.71,,,424.71,Other,110% of Medicare,300.3,35,,300.3,percent of total billed charges,Implant Device,291.72,34,"Charges > $500, x 34%",291.72,percent of total billed charges,Implant Device,300.3,35,,300.3,percent of total billed charges,Implant Device,300.3,35,,300.3,percent of total billed charges,Implant Device,300.3,35,,300.3,percent of total billed charges,Implant Device,300.3,35,,300.3,percent of total billed charges,Implant Device,300.3,35,,300.3,percent of total billed charges,Implant Device,343.2,40,,343.2,percent of total billed charges,Implant Device,300.3,70,,300.3,percent of total billed charges,All Other,291.72,34,,291.72,percent of total billed charges,Implant Device,291.72,34,,291.72,percent of total billed charges,Implant Device,300.3,35,,300.3,percent of total billed charges,Implant Device,300.3,35,,300.3,percent of total billed charges,Implant Device,300.3,35,,300.3,percent of total billed charges,Implant Device,300.3,35,,300.3,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,634.92,
ARROW ACS-15312-VF VECTORFLOW 31CM CATH,C1750,HCPCS,,79007379,CDM,278,RC,,,both,,,858,634.92,,,634.92,Other,150% of Medicare + 9.63% HCRA Surcharge,386.1,45,,386.1,percent of total billed charges,Critical Access Hospital RCC factor,291.72,34,,291.72,percent of total billed charges,Implant Device,291.72,34,,291.72,percent of total billed charges,Implant Device,291.72,34,,291.72,percent of total billed charges,Implant Device,291.72,34,,291.72,percent of total billed charges,Implant Device,291.72,34,,291.72,percent of total billed charges,Implant Device,424.71,,,424.71,Other,110% of Medicare,300.3,35,,300.3,percent of total billed charges,Implant Device,291.72,34,"Charges > $500, x 34%",291.72,percent of total billed charges,Implant Device,300.3,35,,300.3,percent of total billed charges,Implant Device,300.3,35,,300.3,percent of total billed charges,Implant Device,300.3,35,,300.3,percent of total billed charges,Implant Device,300.3,35,,300.3,percent of total billed charges,Implant Device,300.3,35,,300.3,percent of total billed charges,Implant Device,343.2,40,,343.2,percent of total billed charges,Implant Device,300.3,70,,300.3,percent of total billed charges,All Other,291.72,34,,291.72,percent of total billed charges,Implant Device,291.72,34,,291.72,percent of total billed charges,Implant Device,300.3,35,,300.3,percent of total billed charges,Implant Device,300.3,35,,300.3,percent of total billed charges,Implant Device,300.3,35,,300.3,percent of total billed charges,Implant Device,300.3,35,,300.3,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,634.92,
ARROW ACS-15422-VF VECTORFLOW 42CM CATH,C1750,HCPCS,,79007380,CDM,278,RC,,,both,,,932,689.68,,,689.68,Other,150% of Medicare + 9.63% HCRA Surcharge,419.4,45,,419.4,percent of total billed charges,Critical Access Hospital RCC factor,316.88,34,,316.88,percent of total billed charges,Implant Device,316.88,34,,316.88,percent of total billed charges,Implant Device,316.88,34,,316.88,percent of total billed charges,Implant Device,316.88,34,,316.88,percent of total billed charges,Implant Device,316.88,34,,316.88,percent of total billed charges,Implant Device,461.34,,,461.34,Other,110% of Medicare,326.2,35,,326.2,percent of total billed charges,Implant Device,316.88,34,"Charges > $500, x 34%",316.88,percent of total billed charges,Implant Device,326.2,35,,326.2,percent of total billed charges,Implant Device,326.2,35,,326.2,percent of total billed charges,Implant Device,326.2,35,,326.2,percent of total billed charges,Implant Device,326.2,35,,326.2,percent of total billed charges,Implant Device,326.2,35,,326.2,percent of total billed charges,Implant Device,372.8,40,,372.8,percent of total billed charges,Implant Device,326.2,70,,326.2,percent of total billed charges,All Other,316.88,34,,316.88,percent of total billed charges,Implant Device,316.88,34,,316.88,percent of total billed charges,Implant Device,326.2,35,,326.2,percent of total billed charges,Implant Device,326.2,35,,326.2,percent of total billed charges,Implant Device,326.2,35,,326.2,percent of total billed charges,Implant Device,326.2,35,,326.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,689.68,
ARROW ACS-15552-VF VECTORFLOW 55CM CATH,C1750,HCPCS,,79007381,CDM,278,RC,,,both,,,858,634.92,,,634.92,Other,150% of Medicare + 9.63% HCRA Surcharge,386.1,45,,386.1,percent of total billed charges,Critical Access Hospital RCC factor,291.72,34,,291.72,percent of total billed charges,Implant Device,291.72,34,,291.72,percent of total billed charges,Implant Device,291.72,34,,291.72,percent of total billed charges,Implant Device,291.72,34,,291.72,percent of total billed charges,Implant Device,291.72,34,,291.72,percent of total billed charges,Implant Device,424.71,,,424.71,Other,110% of Medicare,300.3,35,,300.3,percent of total billed charges,Implant Device,291.72,34,"Charges > $500, x 34%",291.72,percent of total billed charges,Implant Device,300.3,35,,300.3,percent of total billed charges,Implant Device,300.3,35,,300.3,percent of total billed charges,Implant Device,300.3,35,,300.3,percent of total billed charges,Implant Device,300.3,35,,300.3,percent of total billed charges,Implant Device,300.3,35,,300.3,percent of total billed charges,Implant Device,343.2,40,,343.2,percent of total billed charges,Implant Device,300.3,70,,300.3,percent of total billed charges,All Other,291.72,34,,291.72,percent of total billed charges,Implant Device,291.72,34,,291.72,percent of total billed charges,Implant Device,300.3,35,,300.3,percent of total billed charges,Implant Device,300.3,35,,300.3,percent of total billed charges,Implant Device,300.3,35,,300.3,percent of total billed charges,Implant Device,300.3,35,,300.3,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,634.92,
ARROW ACS-15192-VFI VECTORFLOW 19CM CATH,C1750,HCPCS,,79007382,CDM,278,RC,,,both,,,932,689.68,,,689.68,Other,150% of Medicare + 9.63% HCRA Surcharge,419.4,45,,419.4,percent of total billed charges,Critical Access Hospital RCC factor,316.88,34,,316.88,percent of total billed charges,Implant Device,316.88,34,,316.88,percent of total billed charges,Implant Device,316.88,34,,316.88,percent of total billed charges,Implant Device,316.88,34,,316.88,percent of total billed charges,Implant Device,316.88,34,,316.88,percent of total billed charges,Implant Device,461.34,,,461.34,Other,110% of Medicare,326.2,35,,326.2,percent of total billed charges,Implant Device,316.88,34,"Charges > $500, x 34%",316.88,percent of total billed charges,Implant Device,326.2,35,,326.2,percent of total billed charges,Implant Device,326.2,35,,326.2,percent of total billed charges,Implant Device,326.2,35,,326.2,percent of total billed charges,Implant Device,326.2,35,,326.2,percent of total billed charges,Implant Device,326.2,35,,326.2,percent of total billed charges,Implant Device,372.8,40,,372.8,percent of total billed charges,Implant Device,326.2,70,,326.2,percent of total billed charges,All Other,316.88,34,,316.88,percent of total billed charges,Implant Device,316.88,34,,316.88,percent of total billed charges,Implant Device,326.2,35,,326.2,percent of total billed charges,Implant Device,326.2,35,,326.2,percent of total billed charges,Implant Device,326.2,35,,326.2,percent of total billed charges,Implant Device,326.2,35,,326.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,689.68,
ARROW ACS-15232-VFI VECTORFLOW 23CM CATH,C1750,HCPCS,,79007383,CDM,278,RC,,,both,,,798,590.52,,,590.52,Other,150% of Medicare + 9.63% HCRA Surcharge,359.1,45,,359.1,percent of total billed charges,Critical Access Hospital RCC factor,271.32,34,,271.32,percent of total billed charges,Implant Device,271.32,34,,271.32,percent of total billed charges,Implant Device,271.32,34,,271.32,percent of total billed charges,Implant Device,271.32,34,,271.32,percent of total billed charges,Implant Device,271.32,34,,271.32,percent of total billed charges,Implant Device,395.01,,,395.01,Other,110% of Medicare,279.3,35,,279.3,percent of total billed charges,Implant Device,271.32,34,"Charges > $500, x 34%",271.32,percent of total billed charges,Implant Device,279.3,35,,279.3,percent of total billed charges,Implant Device,279.3,35,,279.3,percent of total billed charges,Implant Device,279.3,35,,279.3,percent of total billed charges,Implant Device,279.3,35,,279.3,percent of total billed charges,Implant Device,279.3,35,,279.3,percent of total billed charges,Implant Device,319.2,40,,319.2,percent of total billed charges,Implant Device,279.3,70,,279.3,percent of total billed charges,All Other,271.32,34,,271.32,percent of total billed charges,Implant Device,271.32,34,,271.32,percent of total billed charges,Implant Device,279.3,35,,279.3,percent of total billed charges,Implant Device,279.3,35,,279.3,percent of total billed charges,Implant Device,279.3,35,,279.3,percent of total billed charges,Implant Device,279.3,35,,279.3,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,590.52,
ARROW ACS-15272-VFI VECTORFLOW 27CM CATH,C1750,HCPCS,,79007384,CDM,278,RC,,,both,,,858,634.92,,,634.92,Other,150% of Medicare + 9.63% HCRA Surcharge,386.1,45,,386.1,percent of total billed charges,Critical Access Hospital RCC factor,291.72,34,,291.72,percent of total billed charges,Implant Device,291.72,34,,291.72,percent of total billed charges,Implant Device,291.72,34,,291.72,percent of total billed charges,Implant Device,291.72,34,,291.72,percent of total billed charges,Implant Device,291.72,34,,291.72,percent of total billed charges,Implant Device,424.71,,,424.71,Other,110% of Medicare,300.3,35,,300.3,percent of total billed charges,Implant Device,291.72,34,"Charges > $500, x 34%",291.72,percent of total billed charges,Implant Device,300.3,35,,300.3,percent of total billed charges,Implant Device,300.3,35,,300.3,percent of total billed charges,Implant Device,300.3,35,,300.3,percent of total billed charges,Implant Device,300.3,35,,300.3,percent of total billed charges,Implant Device,300.3,35,,300.3,percent of total billed charges,Implant Device,343.2,40,,343.2,percent of total billed charges,Implant Device,300.3,70,,300.3,percent of total billed charges,All Other,291.72,34,,291.72,percent of total billed charges,Implant Device,291.72,34,,291.72,percent of total billed charges,Implant Device,300.3,35,,300.3,percent of total billed charges,Implant Device,300.3,35,,300.3,percent of total billed charges,Implant Device,300.3,35,,300.3,percent of total billed charges,Implant Device,300.3,35,,300.3,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,634.92,
STRYKER 5030-4-300 TRANSFIX PIN 4/5X300,C1713,HCPCS,,79007404,CDM,278,RC,,,both,,,234,173.16,,,173.16,Other,150% of Medicare + 9.63% HCRA Surcharge,105.3,45,,105.3,percent of total billed charges,Critical Access Hospital RCC factor,79.56,34,,79.56,percent of total billed charges,Implant Device,79.56,34,,79.56,percent of total billed charges,Implant Device,79.56,34,,79.56,percent of total billed charges,Implant Device,79.56,34,,79.56,percent of total billed charges,Implant Device,79.56,34,,79.56,percent of total billed charges,Implant Device,115.83,,,115.83,Other,110% of Medicare,81.9,35,,81.9,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,81.9,35,,81.9,percent of total billed charges,Implant Device,81.9,35,,81.9,percent of total billed charges,Implant Device,81.9,35,,81.9,percent of total billed charges,Implant Device,81.9,35,,81.9,percent of total billed charges,Implant Device,81.9,35,,81.9,percent of total billed charges,Implant Device,93.6,40,,93.6,percent of total billed charges,Implant Device,81.9,70,,81.9,percent of total billed charges,All Other,79.56,34,,79.56,percent of total billed charges,Implant Device,79.56,34,,79.56,percent of total billed charges,Implant Device,81.9,35,,81.9,percent of total billed charges,Implant Device,81.9,35,,81.9,percent of total billed charges,Implant Device,81.9,35,,81.9,percent of total billed charges,Implant Device,81.9,35,,81.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,173.16,
STRYKER 5610-F-302 FEMORAL COMPNENT SZ 3,C1776,HCPCS,,79007405,CDM,278,RC,,,both,,,8352,6180.5,,,6180.5,Other,150% of Medicare + 9.63% HCRA Surcharge,3758.4,45,,3758.4,percent of total billed charges,Critical Access Hospital RCC factor,2839.68,34,,2839.68,percent of total billed charges,Implant Device,2839.68,34,,2839.68,percent of total billed charges,Implant Device,2839.68,34,,2839.68,percent of total billed charges,Implant Device,2839.68,34,,2839.68,percent of total billed charges,Implant Device,2839.68,34,,2839.68,percent of total billed charges,Implant Device,4134.24,,,4134.24,Other,110% of Medicare,2923.2,35,,2923.2,percent of total billed charges,Implant Device,2839.68,34,"Charges > $500, x 34%",2839.68,percent of total billed charges,Implant Device,2923.2,35,,2923.2,percent of total billed charges,Implant Device,2923.2,35,,2923.2,percent of total billed charges,Implant Device,2923.2,35,,2923.2,percent of total billed charges,Implant Device,2923.2,35,,2923.2,percent of total billed charges,Implant Device,2923.2,35,,2923.2,percent of total billed charges,Implant Device,3340.8,40,,3340.8,percent of total billed charges,Implant Device,2923.2,70,,2923.2,percent of total billed charges,All Other,2839.68,34,,2839.68,percent of total billed charges,Implant Device,2839.68,34,,2839.68,percent of total billed charges,Implant Device,2923.2,35,,2923.2,percent of total billed charges,Implant Device,2923.2,35,,2923.2,percent of total billed charges,Implant Device,2923.2,35,,2923.2,percent of total billed charges,Implant Device,2923.2,35,,2923.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2839.68,34,"If Charge > 2,000, then 34 percent",2839.68,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,6180.5,
J&J 466F230BJ OPTEASE VENA CAVA FILTER,C1880,HCPCS,,79007406,CDM,278,RC,,,both,,,3111,2302.15,,,2302.15,Other,150% of Medicare + 9.63% HCRA Surcharge,1399.95,45,,1399.95,percent of total billed charges,Critical Access Hospital RCC factor,1057.74,34,,1057.74,percent of total billed charges,Implant Device,1057.74,34,,1057.74,percent of total billed charges,Implant Device,1057.74,34,,1057.74,percent of total billed charges,Implant Device,1057.74,34,,1057.74,percent of total billed charges,Implant Device,1057.74,34,,1057.74,percent of total billed charges,Implant Device,1539.95,,,1539.95,Other,110% of Medicare,1088.85,35,,1088.85,percent of total billed charges,Implant Device,1057.74,34,"Charges > $500, x 34%",1057.74,percent of total billed charges,Implant Device,1088.85,35,,1088.85,percent of total billed charges,Implant Device,1088.85,35,,1088.85,percent of total billed charges,Implant Device,1088.85,35,,1088.85,percent of total billed charges,Implant Device,1088.85,35,,1088.85,percent of total billed charges,Implant Device,1088.85,35,,1088.85,percent of total billed charges,Implant Device,1244.4,40,,1244.4,percent of total billed charges,Implant Device,1088.85,70,,1088.85,percent of total billed charges,All Other,1057.74,34,,1057.74,percent of total billed charges,Implant Device,1057.74,34,,1057.74,percent of total billed charges,Implant Device,1088.85,35,,1088.85,percent of total billed charges,Implant Device,1088.85,35,,1088.85,percent of total billed charges,Implant Device,1088.85,35,,1088.85,percent of total billed charges,Implant Device,1088.85,35,,1088.85,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1057.74,34,"If Charge > 2,000, then 34 percent",1057.74,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2302.15,
ZIMMER 00-5990-034-20 FEM AUG BLOCK SZ D,C1776,HCPCS,,79007407,CDM,278,RC,,,both,,,2993,2214.83,,,2214.83,Other,150% of Medicare + 9.63% HCRA Surcharge,1346.85,45,,1346.85,percent of total billed charges,Critical Access Hospital RCC factor,1017.62,34,,1017.62,percent of total billed charges,Implant Device,1017.62,34,,1017.62,percent of total billed charges,Implant Device,1017.62,34,,1017.62,percent of total billed charges,Implant Device,1017.62,34,,1017.62,percent of total billed charges,Implant Device,1017.62,34,,1017.62,percent of total billed charges,Implant Device,1481.54,,,1481.54,Other,110% of Medicare,1047.55,35,,1047.55,percent of total billed charges,Implant Device,1017.62,34,"Charges > $500, x 34%",1017.62,percent of total billed charges,Implant Device,1047.55,35,,1047.55,percent of total billed charges,Implant Device,1047.55,35,,1047.55,percent of total billed charges,Implant Device,1047.55,35,,1047.55,percent of total billed charges,Implant Device,1047.55,35,,1047.55,percent of total billed charges,Implant Device,1047.55,35,,1047.55,percent of total billed charges,Implant Device,1197.2,40,,1197.2,percent of total billed charges,Implant Device,1047.55,70,,1047.55,percent of total billed charges,All Other,1017.62,34,,1017.62,percent of total billed charges,Implant Device,1017.62,34,,1017.62,percent of total billed charges,Implant Device,1047.55,35,,1047.55,percent of total billed charges,Implant Device,1047.55,35,,1047.55,percent of total billed charges,Implant Device,1047.55,35,,1047.55,percent of total billed charges,Implant Device,1047.55,35,,1047.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1017.62,34,"If Charge > 2,000, then 34 percent",1017.62,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2214.83,
ZIMMER 00-5994-041-14 ART SURF SZ C D,C1776,HCPCS,,79007408,CDM,278,RC,,,both,,,6773,5012.04,,,5012.04,Other,150% of Medicare + 9.63% HCRA Surcharge,3047.85,45,,3047.85,percent of total billed charges,Critical Access Hospital RCC factor,2302.82,34,,2302.82,percent of total billed charges,Implant Device,2302.82,34,,2302.82,percent of total billed charges,Implant Device,2302.82,34,,2302.82,percent of total billed charges,Implant Device,2302.82,34,,2302.82,percent of total billed charges,Implant Device,2302.82,34,,2302.82,percent of total billed charges,Implant Device,3352.64,,,3352.64,Other,110% of Medicare,2370.55,35,,2370.55,percent of total billed charges,Implant Device,2302.82,34,"Charges > $500, x 34%",2302.82,percent of total billed charges,Implant Device,2370.55,35,,2370.55,percent of total billed charges,Implant Device,2370.55,35,,2370.55,percent of total billed charges,Implant Device,2370.55,35,,2370.55,percent of total billed charges,Implant Device,2370.55,35,,2370.55,percent of total billed charges,Implant Device,2370.55,35,,2370.55,percent of total billed charges,Implant Device,2709.2,40,,2709.2,percent of total billed charges,Implant Device,2370.55,70,,2370.55,percent of total billed charges,All Other,2302.82,34,,2302.82,percent of total billed charges,Implant Device,2302.82,34,,2302.82,percent of total billed charges,Implant Device,2370.55,35,,2370.55,percent of total billed charges,Implant Device,2370.55,35,,2370.55,percent of total billed charges,Implant Device,2370.55,35,,2370.55,percent of total billed charges,Implant Device,2370.55,35,,2370.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2302.82,34,"If Charge > 2,000, then 34 percent",2302.82,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5012.04,
DEPUY 456.322S FIXATION NAIL 12X170MM,C1713,HCPCS,,79007409,CDM,278,RC,,,both,,,5240,3877.61,,,3877.61,Other,150% of Medicare + 9.63% HCRA Surcharge,2358,45,,2358,percent of total billed charges,Critical Access Hospital RCC factor,1781.6,34,,1781.6,percent of total billed charges,Implant Device,1781.6,34,,1781.6,percent of total billed charges,Implant Device,1781.6,34,,1781.6,percent of total billed charges,Implant Device,1781.6,34,,1781.6,percent of total billed charges,Implant Device,1781.6,34,,1781.6,percent of total billed charges,Implant Device,2593.8,,,2593.8,Other,110% of Medicare,1834,35,,1834,percent of total billed charges,Implant Device,1781.6,34,"Charges > $500, x 34%",1781.6,percent of total billed charges,Implant Device,1834,35,,1834,percent of total billed charges,Implant Device,1834,35,,1834,percent of total billed charges,Implant Device,1834,35,,1834,percent of total billed charges,Implant Device,1834,35,,1834,percent of total billed charges,Implant Device,1834,35,,1834,percent of total billed charges,Implant Device,2096,40,,2096,percent of total billed charges,Implant Device,1834,70,,1834,percent of total billed charges,All Other,1781.6,34,,1781.6,percent of total billed charges,Implant Device,1781.6,34,,1781.6,percent of total billed charges,Implant Device,1834,35,,1834,percent of total billed charges,Implant Device,1834,35,,1834,percent of total billed charges,Implant Device,1834,35,,1834,percent of total billed charges,Implant Device,1834,35,,1834,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1781.6,34,"If Charge > 2,000, then 34 percent",1781.6,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3877.61,
DEPUY 212.119 LOCKING SCREW 3.5X45MM,C1713,HCPCS,,79007410,CDM,278,RC,,,both,,,327,241.98,,,241.98,Other,150% of Medicare + 9.63% HCRA Surcharge,147.15,45,,147.15,percent of total billed charges,Critical Access Hospital RCC factor,111.18,34,,111.18,percent of total billed charges,Implant Device,111.18,34,,111.18,percent of total billed charges,Implant Device,111.18,34,,111.18,percent of total billed charges,Implant Device,111.18,34,,111.18,percent of total billed charges,Implant Device,111.18,34,,111.18,percent of total billed charges,Implant Device,161.87,,,161.87,Other,110% of Medicare,114.45,35,,114.45,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,114.45,35,,114.45,percent of total billed charges,Implant Device,114.45,35,,114.45,percent of total billed charges,Implant Device,114.45,35,,114.45,percent of total billed charges,Implant Device,114.45,35,,114.45,percent of total billed charges,Implant Device,114.45,35,,114.45,percent of total billed charges,Implant Device,130.8,40,,130.8,percent of total billed charges,Implant Device,114.45,70,,114.45,percent of total billed charges,All Other,111.18,34,,111.18,percent of total billed charges,Implant Device,111.18,34,,111.18,percent of total billed charges,Implant Device,114.45,35,,114.45,percent of total billed charges,Implant Device,114.45,35,,114.45,percent of total billed charges,Implant Device,114.45,35,,114.45,percent of total billed charges,Implant Device,114.45,35,,114.45,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,241.98,
DEPUY 239.916S TIBIAL PLATE 3.5X220,C1713,HCPCS,,79007411,CDM,278,RC,,,both,,,6657,4926.2,,,4926.2,Other,150% of Medicare + 9.63% HCRA Surcharge,2995.65,45,,2995.65,percent of total billed charges,Critical Access Hospital RCC factor,2263.38,34,,2263.38,percent of total billed charges,Implant Device,2263.38,34,,2263.38,percent of total billed charges,Implant Device,2263.38,34,,2263.38,percent of total billed charges,Implant Device,2263.38,34,,2263.38,percent of total billed charges,Implant Device,2263.38,34,,2263.38,percent of total billed charges,Implant Device,3295.22,,,3295.22,Other,110% of Medicare,2329.95,35,,2329.95,percent of total billed charges,Implant Device,2263.38,34,"Charges > $500, x 34%",2263.38,percent of total billed charges,Implant Device,2329.95,35,,2329.95,percent of total billed charges,Implant Device,2329.95,35,,2329.95,percent of total billed charges,Implant Device,2329.95,35,,2329.95,percent of total billed charges,Implant Device,2329.95,35,,2329.95,percent of total billed charges,Implant Device,2329.95,35,,2329.95,percent of total billed charges,Implant Device,2662.8,40,,2662.8,percent of total billed charges,Implant Device,2329.95,70,,2329.95,percent of total billed charges,All Other,2263.38,34,,2263.38,percent of total billed charges,Implant Device,2263.38,34,,2263.38,percent of total billed charges,Implant Device,2329.95,35,,2329.95,percent of total billed charges,Implant Device,2329.95,35,,2329.95,percent of total billed charges,Implant Device,2329.95,35,,2329.95,percent of total billed charges,Implant Device,2329.95,35,,2329.95,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2263.38,34,"If Charge > 2,000, then 34 percent",2263.38,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4926.2,
STRYKER 1828-1244S FEMORAL NAIL 12X440MM,C1713,HCPCS,,79007412,CDM,278,RC,,,both,,,7030,5202.22,,,5202.22,Other,150% of Medicare + 9.63% HCRA Surcharge,3163.5,45,,3163.5,percent of total billed charges,Critical Access Hospital RCC factor,2390.2,34,,2390.2,percent of total billed charges,Implant Device,2390.2,34,,2390.2,percent of total billed charges,Implant Device,2390.2,34,,2390.2,percent of total billed charges,Implant Device,2390.2,34,,2390.2,percent of total billed charges,Implant Device,2390.2,34,,2390.2,percent of total billed charges,Implant Device,3479.85,,,3479.85,Other,110% of Medicare,2460.5,35,,2460.5,percent of total billed charges,Implant Device,2390.2,34,"Charges > $500, x 34%",2390.2,percent of total billed charges,Implant Device,2460.5,35,,2460.5,percent of total billed charges,Implant Device,2460.5,35,,2460.5,percent of total billed charges,Implant Device,2460.5,35,,2460.5,percent of total billed charges,Implant Device,2460.5,35,,2460.5,percent of total billed charges,Implant Device,2460.5,35,,2460.5,percent of total billed charges,Implant Device,2812,40,,2812,percent of total billed charges,Implant Device,2460.5,70,,2460.5,percent of total billed charges,All Other,2390.2,34,,2390.2,percent of total billed charges,Implant Device,2390.2,34,,2390.2,percent of total billed charges,Implant Device,2460.5,35,,2460.5,percent of total billed charges,Implant Device,2460.5,35,,2460.5,percent of total billed charges,Implant Device,2460.5,35,,2460.5,percent of total billed charges,Implant Device,2460.5,35,,2460.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2390.2,34,"If Charge > 2,000, then 34 percent",2390.2,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5202.22,
STRYKER 1896-5080S LOCKING SCREW 5X80MM,C1713,HCPCS,,79007413,CDM,278,RC,,,both,,,441,326.34,,,326.34,Other,150% of Medicare + 9.63% HCRA Surcharge,198.45,45,,198.45,percent of total billed charges,Critical Access Hospital RCC factor,149.94,34,,149.94,percent of total billed charges,Implant Device,149.94,34,,149.94,percent of total billed charges,Implant Device,149.94,34,,149.94,percent of total billed charges,Implant Device,149.94,34,,149.94,percent of total billed charges,Implant Device,149.94,34,,149.94,percent of total billed charges,Implant Device,218.3,,,218.3,Other,110% of Medicare,154.35,35,,154.35,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,154.35,35,,154.35,percent of total billed charges,Implant Device,154.35,35,,154.35,percent of total billed charges,Implant Device,154.35,35,,154.35,percent of total billed charges,Implant Device,154.35,35,,154.35,percent of total billed charges,Implant Device,154.35,35,,154.35,percent of total billed charges,Implant Device,176.4,40,,176.4,percent of total billed charges,Implant Device,154.35,70,,154.35,percent of total billed charges,All Other,149.94,34,,149.94,percent of total billed charges,Implant Device,149.94,34,,149.94,percent of total billed charges,Implant Device,154.35,35,,154.35,percent of total billed charges,Implant Device,154.35,35,,154.35,percent of total billed charges,Implant Device,154.35,35,,154.35,percent of total billed charges,Implant Device,154.35,35,,154.35,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,326.34,
DEPUY 204.838 CORTEX SCREW 3.5X38MM,C1713,HCPCS,,79007414,CDM,278,RC,,,both,,,82,60.68,,,60.68,Other,150% of Medicare + 9.63% HCRA Surcharge,36.9,45,,36.9,percent of total billed charges,Critical Access Hospital RCC factor,27.88,34,,27.88,percent of total billed charges,Implant Device,27.88,34,,27.88,percent of total billed charges,Implant Device,27.88,34,,27.88,percent of total billed charges,Implant Device,27.88,34,,27.88,percent of total billed charges,Implant Device,27.88,34,,27.88,percent of total billed charges,Implant Device,40.59,,,40.59,Other,110% of Medicare,28.7,35,,28.7,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,28.7,35,,28.7,percent of total billed charges,Implant Device,28.7,35,,28.7,percent of total billed charges,Implant Device,28.7,35,,28.7,percent of total billed charges,Implant Device,28.7,35,,28.7,percent of total billed charges,Implant Device,28.7,35,,28.7,percent of total billed charges,Implant Device,32.8,40,,32.8,percent of total billed charges,Implant Device,28.7,70,,28.7,percent of total billed charges,All Other,27.88,34,,27.88,percent of total billed charges,Implant Device,27.88,34,,27.88,percent of total billed charges,Implant Device,28.7,35,,28.7,percent of total billed charges,Implant Device,28.7,35,,28.7,percent of total billed charges,Implant Device,28.7,35,,28.7,percent of total billed charges,Implant Device,28.7,35,,28.7,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,60.68,
P28 P50-053-2713 TUFFNEK SCREW 2.7X13MM,C1713,HCPCS,,79007416,CDM,278,RC,,,both,,,667,493.58,,,493.58,Other,150% of Medicare + 9.63% HCRA Surcharge,300.15,45,,300.15,percent of total billed charges,Critical Access Hospital RCC factor,226.78,34,,226.78,percent of total billed charges,Implant Device,226.78,34,,226.78,percent of total billed charges,Implant Device,226.78,34,,226.78,percent of total billed charges,Implant Device,226.78,34,,226.78,percent of total billed charges,Implant Device,226.78,34,,226.78,percent of total billed charges,Implant Device,330.17,,,330.17,Other,110% of Medicare,233.45,35,,233.45,percent of total billed charges,Implant Device,226.78,34,"Charges > $500, x 34%",226.78,percent of total billed charges,Implant Device,233.45,35,,233.45,percent of total billed charges,Implant Device,233.45,35,,233.45,percent of total billed charges,Implant Device,233.45,35,,233.45,percent of total billed charges,Implant Device,233.45,35,,233.45,percent of total billed charges,Implant Device,233.45,35,,233.45,percent of total billed charges,Implant Device,266.8,40,,266.8,percent of total billed charges,Implant Device,233.45,70,,233.45,percent of total billed charges,All Other,226.78,34,,226.78,percent of total billed charges,Implant Device,226.78,34,,226.78,percent of total billed charges,Implant Device,233.45,35,,233.45,percent of total billed charges,Implant Device,233.45,35,,233.45,percent of total billed charges,Implant Device,233.45,35,,233.45,percent of total billed charges,Implant Device,233.45,35,,233.45,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,493.58,
P28 P53-101-2011 PLATE 2 HOLE 1.1X15MM,C1713,HCPCS,,79007417,CDM,278,RC,,,both,,,3590,2656.61,,,2656.61,Other,150% of Medicare + 9.63% HCRA Surcharge,1615.5,45,,1615.5,percent of total billed charges,Critical Access Hospital RCC factor,1220.6,34,,1220.6,percent of total billed charges,Implant Device,1220.6,34,,1220.6,percent of total billed charges,Implant Device,1220.6,34,,1220.6,percent of total billed charges,Implant Device,1220.6,34,,1220.6,percent of total billed charges,Implant Device,1220.6,34,,1220.6,percent of total billed charges,Implant Device,1777.05,,,1777.05,Other,110% of Medicare,1256.5,35,,1256.5,percent of total billed charges,Implant Device,1220.6,34,"Charges > $500, x 34%",1220.6,percent of total billed charges,Implant Device,1256.5,35,,1256.5,percent of total billed charges,Implant Device,1256.5,35,,1256.5,percent of total billed charges,Implant Device,1256.5,35,,1256.5,percent of total billed charges,Implant Device,1256.5,35,,1256.5,percent of total billed charges,Implant Device,1256.5,35,,1256.5,percent of total billed charges,Implant Device,1436,40,,1436,percent of total billed charges,Implant Device,1256.5,70,,1256.5,percent of total billed charges,All Other,1220.6,34,,1220.6,percent of total billed charges,Implant Device,1220.6,34,,1220.6,percent of total billed charges,Implant Device,1256.5,35,,1256.5,percent of total billed charges,Implant Device,1256.5,35,,1256.5,percent of total billed charges,Implant Device,1256.5,35,,1256.5,percent of total billed charges,Implant Device,1256.5,35,,1256.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1220.6,34,"If Charge > 2,000, then 34 percent",1220.6,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2656.61,
P28 P53-105-R003 HEVANS PLATE LG RT 24MM,C1713,HCPCS,,79007418,CDM,278,RC,,,both,,,4851,3589.75,,,3589.75,Other,150% of Medicare + 9.63% HCRA Surcharge,2182.95,45,,2182.95,percent of total billed charges,Critical Access Hospital RCC factor,1649.34,34,,1649.34,percent of total billed charges,Implant Device,1649.34,34,,1649.34,percent of total billed charges,Implant Device,1649.34,34,,1649.34,percent of total billed charges,Implant Device,1649.34,34,,1649.34,percent of total billed charges,Implant Device,1649.34,34,,1649.34,percent of total billed charges,Implant Device,2401.25,,,2401.25,Other,110% of Medicare,1697.85,35,,1697.85,percent of total billed charges,Implant Device,1649.34,34,"Charges > $500, x 34%",1649.34,percent of total billed charges,Implant Device,1697.85,35,,1697.85,percent of total billed charges,Implant Device,1697.85,35,,1697.85,percent of total billed charges,Implant Device,1697.85,35,,1697.85,percent of total billed charges,Implant Device,1697.85,35,,1697.85,percent of total billed charges,Implant Device,1697.85,35,,1697.85,percent of total billed charges,Implant Device,1940.4,40,,1940.4,percent of total billed charges,Implant Device,1697.85,70,,1697.85,percent of total billed charges,All Other,1649.34,34,,1649.34,percent of total billed charges,Implant Device,1649.34,34,,1649.34,percent of total billed charges,Implant Device,1697.85,35,,1697.85,percent of total billed charges,Implant Device,1697.85,35,,1697.85,percent of total billed charges,Implant Device,1697.85,35,,1697.85,percent of total billed charges,Implant Device,1697.85,35,,1697.85,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1649.34,34,"If Charge > 2,000, then 34 percent",1649.34,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3589.75,
P28 PCOT-181406 COTTON WEDGE 6MM,C1713,HCPCS,,79007420,CDM,278,RC,,,both,,,5198,3846.53,,,3846.53,Other,150% of Medicare + 9.63% HCRA Surcharge,2339.1,45,,2339.1,percent of total billed charges,Critical Access Hospital RCC factor,1767.32,34,,1767.32,percent of total billed charges,Implant Device,1767.32,34,,1767.32,percent of total billed charges,Implant Device,1767.32,34,,1767.32,percent of total billed charges,Implant Device,1767.32,34,,1767.32,percent of total billed charges,Implant Device,1767.32,34,,1767.32,percent of total billed charges,Implant Device,2573.01,,,2573.01,Other,110% of Medicare,1819.3,35,,1819.3,percent of total billed charges,Implant Device,1767.32,34,"Charges > $500, x 34%",1767.32,percent of total billed charges,Implant Device,1819.3,35,,1819.3,percent of total billed charges,Implant Device,1819.3,35,,1819.3,percent of total billed charges,Implant Device,1819.3,35,,1819.3,percent of total billed charges,Implant Device,1819.3,35,,1819.3,percent of total billed charges,Implant Device,1819.3,35,,1819.3,percent of total billed charges,Implant Device,2079.2,40,,2079.2,percent of total billed charges,Implant Device,1819.3,70,,1819.3,percent of total billed charges,All Other,1767.32,34,,1767.32,percent of total billed charges,Implant Device,1767.32,34,,1767.32,percent of total billed charges,Implant Device,1819.3,35,,1819.3,percent of total billed charges,Implant Device,1819.3,35,,1819.3,percent of total billed charges,Implant Device,1819.3,35,,1819.3,percent of total billed charges,Implant Device,1819.3,35,,1819.3,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1767.32,34,"If Charge > 2,000, then 34 percent",1767.32,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3846.53,
P28 PLCL-25010 EVANS WEDGE 10MM,C1713,HCPCS,,79007421,CDM,278,RC,,,both,,,5985,4428.91,,,4428.91,Other,150% of Medicare + 9.63% HCRA Surcharge,2693.25,45,,2693.25,percent of total billed charges,Critical Access Hospital RCC factor,2034.9,34,,2034.9,percent of total billed charges,Implant Device,2034.9,34,,2034.9,percent of total billed charges,Implant Device,2034.9,34,,2034.9,percent of total billed charges,Implant Device,2034.9,34,,2034.9,percent of total billed charges,Implant Device,2034.9,34,,2034.9,percent of total billed charges,Implant Device,2962.58,,,2962.58,Other,110% of Medicare,2094.75,35,,2094.75,percent of total billed charges,Implant Device,2034.9,34,"Charges > $500, x 34%",2034.9,percent of total billed charges,Implant Device,2094.75,35,,2094.75,percent of total billed charges,Implant Device,2094.75,35,,2094.75,percent of total billed charges,Implant Device,2094.75,35,,2094.75,percent of total billed charges,Implant Device,2094.75,35,,2094.75,percent of total billed charges,Implant Device,2094.75,35,,2094.75,percent of total billed charges,Implant Device,2394,40,,2394,percent of total billed charges,Implant Device,2094.75,70,,2094.75,percent of total billed charges,All Other,2034.9,34,,2034.9,percent of total billed charges,Implant Device,2034.9,34,,2034.9,percent of total billed charges,Implant Device,2094.75,35,,2094.75,percent of total billed charges,Implant Device,2094.75,35,,2094.75,percent of total billed charges,Implant Device,2094.75,35,,2094.75,percent of total billed charges,Implant Device,2094.75,35,,2094.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2034.9,34,"If Charge > 2,000, then 34 percent",2034.9,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4428.91,
LIFENET AFLEX103 DERMIS PATCH 50X90MM,C1762,HCPCS,,79007422,CDM,278,RC,,,both,,,10395,7692.33,,,7692.33,Other,150% of Medicare + 9.63% HCRA Surcharge,4677.75,45,,4677.75,percent of total billed charges,Critical Access Hospital RCC factor,3534.3,34,,3534.3,percent of total billed charges,Implant Device,3534.3,34,,3534.3,percent of total billed charges,Implant Device,3534.3,34,,3534.3,percent of total billed charges,Implant Device,3534.3,34,,3534.3,percent of total billed charges,Implant Device,3534.3,34,,3534.3,percent of total billed charges,Implant Device,5145.53,,,5145.53,Other,110% of Medicare,3638.25,35,,3638.25,percent of total billed charges,Implant Device,3534.3,34,"Charges > $500, x 34%",3534.3,percent of total billed charges,Implant Device,3638.25,35,,3638.25,percent of total billed charges,Implant Device,3638.25,35,,3638.25,percent of total billed charges,Implant Device,3638.25,35,,3638.25,percent of total billed charges,Implant Device,3638.25,35,,3638.25,percent of total billed charges,Implant Device,3638.25,35,,3638.25,percent of total billed charges,Implant Device,4158,40,,4158,percent of total billed charges,Implant Device,3638.25,70,,3638.25,percent of total billed charges,All Other,3534.3,34,,3534.3,percent of total billed charges,Implant Device,3534.3,34,,3534.3,percent of total billed charges,Implant Device,3638.25,35,,3638.25,percent of total billed charges,Implant Device,3638.25,35,,3638.25,percent of total billed charges,Implant Device,3638.25,35,,3638.25,percent of total billed charges,Implant Device,3638.25,35,,3638.25,percent of total billed charges,Implant Device,976.07,,,976.07,Other,100% of Medicaid,976.07,,,976.07,Other,100% of Medicaid,976.07,,,976.07,Other,100% of Medicaid,976.07,,,976.07,Other,100% of Medicaid,2196.16,,,2196.16,Other,225% of Medicaid,1493.39,,,1493.39,Other,153% of Medicaid,2196.16,,,2196.16,Other,225% of Medicaid,1366.5,,,1366.5,Other,140% of Medicaid,3534.3,34,"If Charge > 2,000, then 34 percent",3534.3,percent of total billed charges,Implants,2537.78,,,2537.78,Other,260% of Medicaid,3162.47,,,3162.47,Other,324% of Medicaid,2098.55,,,2098.55,Other,215% of Medicaid,2098.55,,,2098.55,Other,215% of Medicaid,1220.09,,,1220.09,Other,125% of Medicaid,976.07,7692.33,
RTI SURGICAL DL0407 ELEMAX SPACER 7MM,C1713,HCPCS,,79007423,CDM,278,RC,,,both,,,2850,2109.01,,,2109.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1282.5,45,,1282.5,percent of total billed charges,Critical Access Hospital RCC factor,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,1410.75,,,1410.75,Other,110% of Medicare,997.5,35,,997.5,percent of total billed charges,Implant Device,969,34,"Charges > $500, x 34%",969,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,1140,40,,1140,percent of total billed charges,Implant Device,997.5,70,,997.5,percent of total billed charges,All Other,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,969,34,"If Charge > 2,000, then 34 percent",969,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2109.01,
RTI SURGICAL DL0406 ELEMAX SPACER 6MM,C1713,HCPCS,,79007424,CDM,278,RC,,,both,,,2850,2109.01,,,2109.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1282.5,45,,1282.5,percent of total billed charges,Critical Access Hospital RCC factor,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,1410.75,,,1410.75,Other,110% of Medicare,997.5,35,,997.5,percent of total billed charges,Implant Device,969,34,"Charges > $500, x 34%",969,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,1140,40,,1140,percent of total billed charges,Implant Device,997.5,70,,997.5,percent of total billed charges,All Other,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,969,34,"If Charge > 2,000, then 34 percent",969,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2109.01,
ALPHATEC 71003-048 TRESTLE LUXE PLATE 48,C1713,HCPCS,,79007425,CDM,278,RC,,,both,,,3135,2319.91,,,2319.91,Other,150% of Medicare + 9.63% HCRA Surcharge,1410.75,45,,1410.75,percent of total billed charges,Critical Access Hospital RCC factor,1065.9,34,,1065.9,percent of total billed charges,Implant Device,1065.9,34,,1065.9,percent of total billed charges,Implant Device,1065.9,34,,1065.9,percent of total billed charges,Implant Device,1065.9,34,,1065.9,percent of total billed charges,Implant Device,1065.9,34,,1065.9,percent of total billed charges,Implant Device,1551.83,,,1551.83,Other,110% of Medicare,1097.25,35,,1097.25,percent of total billed charges,Implant Device,1065.9,34,"Charges > $500, x 34%",1065.9,percent of total billed charges,Implant Device,1097.25,35,,1097.25,percent of total billed charges,Implant Device,1097.25,35,,1097.25,percent of total billed charges,Implant Device,1097.25,35,,1097.25,percent of total billed charges,Implant Device,1097.25,35,,1097.25,percent of total billed charges,Implant Device,1097.25,35,,1097.25,percent of total billed charges,Implant Device,1254,40,,1254,percent of total billed charges,Implant Device,1097.25,70,,1097.25,percent of total billed charges,All Other,1065.9,34,,1065.9,percent of total billed charges,Implant Device,1065.9,34,,1065.9,percent of total billed charges,Implant Device,1097.25,35,,1097.25,percent of total billed charges,Implant Device,1097.25,35,,1097.25,percent of total billed charges,Implant Device,1097.25,35,,1097.25,percent of total billed charges,Implant Device,1097.25,35,,1097.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1065.9,34,"If Charge > 2,000, then 34 percent",1065.9,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2319.91,
DEPUY 1541-23-000 HIP STEM SZ 3 200MM LT,C1776,HCPCS,,79007429,CDM,278,RC,,,both,,,14227,10528.02,,,10528.02,Other,150% of Medicare + 9.63% HCRA Surcharge,6402.15,45,,6402.15,percent of total billed charges,Critical Access Hospital RCC factor,4837.18,34,,4837.18,percent of total billed charges,Implant Device,4837.18,34,,4837.18,percent of total billed charges,Implant Device,4837.18,34,,4837.18,percent of total billed charges,Implant Device,4837.18,34,,4837.18,percent of total billed charges,Implant Device,4837.18,34,,4837.18,percent of total billed charges,Implant Device,7042.37,,,7042.37,Other,110% of Medicare,4979.45,35,,4979.45,percent of total billed charges,Implant Device,4837.18,34,"Charges > $500, x 34%",4837.18,percent of total billed charges,Implant Device,4979.45,35,,4979.45,percent of total billed charges,Implant Device,4979.45,35,,4979.45,percent of total billed charges,Implant Device,4979.45,35,,4979.45,percent of total billed charges,Implant Device,4979.45,35,,4979.45,percent of total billed charges,Implant Device,4979.45,35,,4979.45,percent of total billed charges,Implant Device,5690.8,40,,5690.8,percent of total billed charges,Implant Device,4979.45,70,,4979.45,percent of total billed charges,All Other,4837.18,34,,4837.18,percent of total billed charges,Implant Device,4837.18,34,,4837.18,percent of total billed charges,Implant Device,4979.45,35,,4979.45,percent of total billed charges,Implant Device,4979.45,35,,4979.45,percent of total billed charges,Implant Device,4979.45,35,,4979.45,percent of total billed charges,Implant Device,4979.45,35,,4979.45,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,4837.18,34,"If Charge > 2,000, then 34 percent",4837.18,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,10528.02,
GORE TGU454510 THORACIC ENDOPRS 45X45X10,C1768,HCPCS,,79007432,CDM,278,RC,,,both,,,47625,35242.62,,,35242.62,Other,150% of Medicare + 9.63% HCRA Surcharge,21431.25,45,,21431.25,percent of total billed charges,Critical Access Hospital RCC factor,16192.5,34,,16192.5,percent of total billed charges,Implant Device,16192.5,34,,16192.5,percent of total billed charges,Implant Device,16192.5,34,,16192.5,percent of total billed charges,Implant Device,16192.5,34,,16192.5,percent of total billed charges,Implant Device,16192.5,34,,16192.5,percent of total billed charges,Implant Device,23574.38,,,23574.38,Other,110% of Medicare,16668.75,35,,16668.75,percent of total billed charges,Implant Device,16192.5,34,"Charges > $500, x 34%",16192.5,percent of total billed charges,Implant Device,16668.75,35,,16668.75,percent of total billed charges,Implant Device,16668.75,35,,16668.75,percent of total billed charges,Implant Device,16668.75,35,,16668.75,percent of total billed charges,Implant Device,16668.75,35,,16668.75,percent of total billed charges,Implant Device,16668.75,35,,16668.75,percent of total billed charges,Implant Device,19050,40,,19050,percent of total billed charges,Implant Device,16668.75,70,,16668.75,percent of total billed charges,All Other,16192.5,34,,16192.5,percent of total billed charges,Implant Device,16192.5,34,,16192.5,percent of total billed charges,Implant Device,16668.75,35,,16668.75,percent of total billed charges,Implant Device,16668.75,35,,16668.75,percent of total billed charges,Implant Device,16668.75,35,,16668.75,percent of total billed charges,Implant Device,16668.75,35,,16668.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,16192.5,34,"If Charge > 2,000, then 34 percent",16192.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,35242.62,
GORE RLT281412 EXCLUDER ENDOPROS GRAFT,C1768,HCPCS,,79007433,CDM,278,RC,,,both,,,35538,26298.21,,,26298.21,Other,150% of Medicare + 9.63% HCRA Surcharge,15992.1,45,,15992.1,percent of total billed charges,Critical Access Hospital RCC factor,12082.92,34,,12082.92,percent of total billed charges,Implant Device,12082.92,34,,12082.92,percent of total billed charges,Implant Device,12082.92,34,,12082.92,percent of total billed charges,Implant Device,12082.92,34,,12082.92,percent of total billed charges,Implant Device,12082.92,34,,12082.92,percent of total billed charges,Implant Device,17591.31,,,17591.31,Other,110% of Medicare,12438.3,35,,12438.3,percent of total billed charges,Implant Device,12082.92,34,"Charges > $500, x 34%",12082.92,percent of total billed charges,Implant Device,12438.3,35,,12438.3,percent of total billed charges,Implant Device,12438.3,35,,12438.3,percent of total billed charges,Implant Device,12438.3,35,,12438.3,percent of total billed charges,Implant Device,12438.3,35,,12438.3,percent of total billed charges,Implant Device,12438.3,35,,12438.3,percent of total billed charges,Implant Device,14215.2,40,,14215.2,percent of total billed charges,Implant Device,12438.3,70,,12438.3,percent of total billed charges,All Other,12082.92,34,,12082.92,percent of total billed charges,Implant Device,12082.92,34,,12082.92,percent of total billed charges,Implant Device,12438.3,35,,12438.3,percent of total billed charges,Implant Device,12438.3,35,,12438.3,percent of total billed charges,Implant Device,12438.3,35,,12438.3,percent of total billed charges,Implant Device,12438.3,35,,12438.3,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,12082.92,34,"If Charge > 2,000, then 34 percent",12082.92,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,26298.21,
GORE VBJ081002 VIABAHN 8X10 COVERD STENT,C1874,HCPCS,,79007435,CDM,278,RC,,,both,,,10485,7758.93,,,7758.93,Other,150% of Medicare + 9.63% HCRA Surcharge,4718.25,45,,4718.25,percent of total billed charges,Critical Access Hospital RCC factor,3564.9,34,,3564.9,percent of total billed charges,Implant Device,3564.9,34,,3564.9,percent of total billed charges,Implant Device,3564.9,34,,3564.9,percent of total billed charges,Implant Device,3564.9,34,,3564.9,percent of total billed charges,Implant Device,3564.9,34,,3564.9,percent of total billed charges,Implant Device,5190.08,,,5190.08,Other,110% of Medicare,3669.75,35,,3669.75,percent of total billed charges,Implant Device,3564.9,34,"Charges > $500, x 34%",3564.9,percent of total billed charges,Implant Device,3669.75,35,,3669.75,percent of total billed charges,Implant Device,3669.75,35,,3669.75,percent of total billed charges,Implant Device,3669.75,35,,3669.75,percent of total billed charges,Implant Device,3669.75,35,,3669.75,percent of total billed charges,Implant Device,3669.75,35,,3669.75,percent of total billed charges,Implant Device,4194,40,,4194,percent of total billed charges,Implant Device,3669.75,70,,3669.75,percent of total billed charges,All Other,3564.9,34,,3564.9,percent of total billed charges,Implant Device,3564.9,34,,3564.9,percent of total billed charges,Implant Device,3669.75,35,,3669.75,percent of total billed charges,Implant Device,3669.75,35,,3669.75,percent of total billed charges,Implant Device,3669.75,35,,3669.75,percent of total billed charges,Implant Device,3669.75,35,,3669.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3564.9,34,"If Charge > 2,000, then 34 percent",3564.9,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,7758.93,
GORE VBJR081502A VIABAHN 8X15 STENT,C1874,HCPCS,,79007436,CDM,278,RC,,,both,,,11685,8646.93,,,8646.93,Other,150% of Medicare + 9.63% HCRA Surcharge,5258.25,45,,5258.25,percent of total billed charges,Critical Access Hospital RCC factor,3972.9,34,,3972.9,percent of total billed charges,Implant Device,3972.9,34,,3972.9,percent of total billed charges,Implant Device,3972.9,34,,3972.9,percent of total billed charges,Implant Device,3972.9,34,,3972.9,percent of total billed charges,Implant Device,3972.9,34,,3972.9,percent of total billed charges,Implant Device,5784.08,,,5784.08,Other,110% of Medicare,4089.75,35,,4089.75,percent of total billed charges,Implant Device,3972.9,34,"Charges > $500, x 34%",3972.9,percent of total billed charges,Implant Device,4089.75,35,,4089.75,percent of total billed charges,Implant Device,4089.75,35,,4089.75,percent of total billed charges,Implant Device,4089.75,35,,4089.75,percent of total billed charges,Implant Device,4089.75,35,,4089.75,percent of total billed charges,Implant Device,4089.75,35,,4089.75,percent of total billed charges,Implant Device,4674,40,,4674,percent of total billed charges,Implant Device,4089.75,70,,4089.75,percent of total billed charges,All Other,3972.9,34,,3972.9,percent of total billed charges,Implant Device,3972.9,34,,3972.9,percent of total billed charges,Implant Device,4089.75,35,,4089.75,percent of total billed charges,Implant Device,4089.75,35,,4089.75,percent of total billed charges,Implant Device,4089.75,35,,4089.75,percent of total billed charges,Implant Device,4089.75,35,,4089.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3972.9,34,"If Charge > 2,000, then 34 percent",3972.9,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,8646.93,
GORE VBJR082502A VIABAHN 8X25 STENT,C1874,HCPCS,,79007437,CDM,278,RC,,,both,,,19186,14197.69,,,14197.69,Other,150% of Medicare + 9.63% HCRA Surcharge,8633.7,45,,8633.7,percent of total billed charges,Critical Access Hospital RCC factor,6523.24,34,,6523.24,percent of total billed charges,Implant Device,6523.24,34,,6523.24,percent of total billed charges,Implant Device,6523.24,34,,6523.24,percent of total billed charges,Implant Device,6523.24,34,,6523.24,percent of total billed charges,Implant Device,6523.24,34,,6523.24,percent of total billed charges,Implant Device,9497.07,,,9497.07,Other,110% of Medicare,6715.1,35,,6715.1,percent of total billed charges,Implant Device,6523.24,34,"Charges > $500, x 34%",6523.24,percent of total billed charges,Implant Device,6715.1,35,,6715.1,percent of total billed charges,Implant Device,6715.1,35,,6715.1,percent of total billed charges,Implant Device,6715.1,35,,6715.1,percent of total billed charges,Implant Device,6715.1,35,,6715.1,percent of total billed charges,Implant Device,6715.1,35,,6715.1,percent of total billed charges,Implant Device,7674.4,40,,7674.4,percent of total billed charges,Implant Device,6715.1,70,,6715.1,percent of total billed charges,All Other,6523.24,34,,6523.24,percent of total billed charges,Implant Device,6523.24,34,,6523.24,percent of total billed charges,Implant Device,6715.1,35,,6715.1,percent of total billed charges,Implant Device,6715.1,35,,6715.1,percent of total billed charges,Implant Device,6715.1,35,,6715.1,percent of total billed charges,Implant Device,6715.1,35,,6715.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,6523.24,34,"If Charge > 2,000, then 34 percent",6523.24,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,14197.69,
GORE VBJR080502A VIABAHN 8X5 STENT,C1874,HCPCS,,79007438,CDM,278,RC,,,both,,,10311,7630.17,,,7630.17,Other,150% of Medicare + 9.63% HCRA Surcharge,4639.95,45,,4639.95,percent of total billed charges,Critical Access Hospital RCC factor,3505.74,34,,3505.74,percent of total billed charges,Implant Device,3505.74,34,,3505.74,percent of total billed charges,Implant Device,3505.74,34,,3505.74,percent of total billed charges,Implant Device,3505.74,34,,3505.74,percent of total billed charges,Implant Device,3505.74,34,,3505.74,percent of total billed charges,Implant Device,5103.95,,,5103.95,Other,110% of Medicare,3608.85,35,,3608.85,percent of total billed charges,Implant Device,3505.74,34,"Charges > $500, x 34%",3505.74,percent of total billed charges,Implant Device,3608.85,35,,3608.85,percent of total billed charges,Implant Device,3608.85,35,,3608.85,percent of total billed charges,Implant Device,3608.85,35,,3608.85,percent of total billed charges,Implant Device,3608.85,35,,3608.85,percent of total billed charges,Implant Device,3608.85,35,,3608.85,percent of total billed charges,Implant Device,4124.4,40,,4124.4,percent of total billed charges,Implant Device,3608.85,70,,3608.85,percent of total billed charges,All Other,3505.74,34,,3505.74,percent of total billed charges,Implant Device,3505.74,34,,3505.74,percent of total billed charges,Implant Device,3608.85,35,,3608.85,percent of total billed charges,Implant Device,3608.85,35,,3608.85,percent of total billed charges,Implant Device,3608.85,35,,3608.85,percent of total billed charges,Implant Device,3608.85,35,,3608.85,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3505.74,34,"If Charge > 2,000, then 34 percent",3505.74,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,7630.17,
ARTHREX AR-8967-1870 CANN SCREW 6.7X70MM,C1713,HCPCS,,79007440,CDM,278,RC,,,both,,,1074,794.76,,,794.76,Other,150% of Medicare + 9.63% HCRA Surcharge,483.3,45,,483.3,percent of total billed charges,Critical Access Hospital RCC factor,365.16,34,,365.16,percent of total billed charges,Implant Device,365.16,34,,365.16,percent of total billed charges,Implant Device,365.16,34,,365.16,percent of total billed charges,Implant Device,365.16,34,,365.16,percent of total billed charges,Implant Device,365.16,34,,365.16,percent of total billed charges,Implant Device,531.63,,,531.63,Other,110% of Medicare,375.9,35,,375.9,percent of total billed charges,Implant Device,365.16,34,"Charges > $500, x 34%",365.16,percent of total billed charges,Implant Device,375.9,35,,375.9,percent of total billed charges,Implant Device,375.9,35,,375.9,percent of total billed charges,Implant Device,375.9,35,,375.9,percent of total billed charges,Implant Device,375.9,35,,375.9,percent of total billed charges,Implant Device,375.9,35,,375.9,percent of total billed charges,Implant Device,429.6,40,,429.6,percent of total billed charges,Implant Device,375.9,70,,375.9,percent of total billed charges,All Other,365.16,34,,365.16,percent of total billed charges,Implant Device,365.16,34,,365.16,percent of total billed charges,Implant Device,375.9,35,,375.9,percent of total billed charges,Implant Device,375.9,35,,375.9,percent of total billed charges,Implant Device,375.9,35,,375.9,percent of total billed charges,Implant Device,375.9,35,,375.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,794.76,
ARTHREX AR-8967-1865 CANN SCREW 6.7X65MM,C1713,HCPCS,,79007441,CDM,278,RC,,,both,,,1074,794.76,,,794.76,Other,150% of Medicare + 9.63% HCRA Surcharge,483.3,45,,483.3,percent of total billed charges,Critical Access Hospital RCC factor,365.16,34,,365.16,percent of total billed charges,Implant Device,365.16,34,,365.16,percent of total billed charges,Implant Device,365.16,34,,365.16,percent of total billed charges,Implant Device,365.16,34,,365.16,percent of total billed charges,Implant Device,365.16,34,,365.16,percent of total billed charges,Implant Device,531.63,,,531.63,Other,110% of Medicare,375.9,35,,375.9,percent of total billed charges,Implant Device,365.16,34,"Charges > $500, x 34%",365.16,percent of total billed charges,Implant Device,375.9,35,,375.9,percent of total billed charges,Implant Device,375.9,35,,375.9,percent of total billed charges,Implant Device,375.9,35,,375.9,percent of total billed charges,Implant Device,375.9,35,,375.9,percent of total billed charges,Implant Device,375.9,35,,375.9,percent of total billed charges,Implant Device,429.6,40,,429.6,percent of total billed charges,Implant Device,375.9,70,,375.9,percent of total billed charges,All Other,365.16,34,,365.16,percent of total billed charges,Implant Device,365.16,34,,365.16,percent of total billed charges,Implant Device,375.9,35,,375.9,percent of total billed charges,Implant Device,375.9,35,,375.9,percent of total billed charges,Implant Device,375.9,35,,375.9,percent of total billed charges,Implant Device,375.9,35,,375.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,794.76,
ARTHREX AR-8967W WASHER 6.7MM,C1713,HCPCS,,79007442,CDM,278,RC,,,both,,,240,177.6,,,177.6,Other,150% of Medicare + 9.63% HCRA Surcharge,108,45,,108,percent of total billed charges,Critical Access Hospital RCC factor,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,118.8,,,118.8,Other,110% of Medicare,84,35,,84,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,96,40,,96,percent of total billed charges,Implant Device,84,70,,84,percent of total billed charges,All Other,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,177.6,
ARTHREX AR-8005-20 COMP STAPLE 20X20MM,C1713,HCPCS,,79007443,CDM,278,RC,,,both,,,1824,1349.76,,,1349.76,Other,150% of Medicare + 9.63% HCRA Surcharge,820.8,45,,820.8,percent of total billed charges,Critical Access Hospital RCC factor,620.16,34,,620.16,percent of total billed charges,Implant Device,620.16,34,,620.16,percent of total billed charges,Implant Device,620.16,34,,620.16,percent of total billed charges,Implant Device,620.16,34,,620.16,percent of total billed charges,Implant Device,620.16,34,,620.16,percent of total billed charges,Implant Device,902.88,,,902.88,Other,110% of Medicare,638.4,35,,638.4,percent of total billed charges,Implant Device,620.16,34,"Charges > $500, x 34%",620.16,percent of total billed charges,Implant Device,638.4,35,,638.4,percent of total billed charges,Implant Device,638.4,35,,638.4,percent of total billed charges,Implant Device,638.4,35,,638.4,percent of total billed charges,Implant Device,638.4,35,,638.4,percent of total billed charges,Implant Device,638.4,35,,638.4,percent of total billed charges,Implant Device,729.6,40,,729.6,percent of total billed charges,Implant Device,638.4,70,,638.4,percent of total billed charges,All Other,620.16,34,,620.16,percent of total billed charges,Implant Device,620.16,34,,620.16,percent of total billed charges,Implant Device,638.4,35,,638.4,percent of total billed charges,Implant Device,638.4,35,,638.4,percent of total billed charges,Implant Device,638.4,35,,638.4,percent of total billed charges,Implant Device,638.4,35,,638.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1349.76,
ZIMMER 00-8757-066-01 TRAB SHELL 66MM,C1776,HCPCS,,79007447,CDM,278,RC,,,both,,,3450,2553.01,,,2553.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1552.5,45,,1552.5,percent of total billed charges,Critical Access Hospital RCC factor,1173,34,,1173,percent of total billed charges,Implant Device,1173,34,,1173,percent of total billed charges,Implant Device,1173,34,,1173,percent of total billed charges,Implant Device,1173,34,,1173,percent of total billed charges,Implant Device,1173,34,,1173,percent of total billed charges,Implant Device,1707.75,,,1707.75,Other,110% of Medicare,1207.5,35,,1207.5,percent of total billed charges,Implant Device,1173,34,"Charges > $500, x 34%",1173,percent of total billed charges,Implant Device,1207.5,35,,1207.5,percent of total billed charges,Implant Device,1207.5,35,,1207.5,percent of total billed charges,Implant Device,1207.5,35,,1207.5,percent of total billed charges,Implant Device,1207.5,35,,1207.5,percent of total billed charges,Implant Device,1207.5,35,,1207.5,percent of total billed charges,Implant Device,1380,40,,1380,percent of total billed charges,Implant Device,1207.5,70,,1207.5,percent of total billed charges,All Other,1173,34,,1173,percent of total billed charges,Implant Device,1173,34,,1173,percent of total billed charges,Implant Device,1207.5,35,,1207.5,percent of total billed charges,Implant Device,1207.5,35,,1207.5,percent of total billed charges,Implant Device,1207.5,35,,1207.5,percent of total billed charges,Implant Device,1207.5,35,,1207.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1173,34,"If Charge > 2,000, then 34 percent",1173,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2553.01,
ZIMMER 00-8852-017-36 ELE RIM LINER 36MM,C1776,HCPCS,,79007448,CDM,278,RC,,,both,,,3456,2557.45,,,2557.45,Other,150% of Medicare + 9.63% HCRA Surcharge,1555.2,45,,1555.2,percent of total billed charges,Critical Access Hospital RCC factor,1175.04,34,,1175.04,percent of total billed charges,Implant Device,1175.04,34,,1175.04,percent of total billed charges,Implant Device,1175.04,34,,1175.04,percent of total billed charges,Implant Device,1175.04,34,,1175.04,percent of total billed charges,Implant Device,1175.04,34,,1175.04,percent of total billed charges,Implant Device,1710.72,,,1710.72,Other,110% of Medicare,1209.6,35,,1209.6,percent of total billed charges,Implant Device,1175.04,34,"Charges > $500, x 34%",1175.04,percent of total billed charges,Implant Device,1209.6,35,,1209.6,percent of total billed charges,Implant Device,1209.6,35,,1209.6,percent of total billed charges,Implant Device,1209.6,35,,1209.6,percent of total billed charges,Implant Device,1209.6,35,,1209.6,percent of total billed charges,Implant Device,1209.6,35,,1209.6,percent of total billed charges,Implant Device,1382.4,40,,1382.4,percent of total billed charges,Implant Device,1209.6,70,,1209.6,percent of total billed charges,All Other,1175.04,34,,1175.04,percent of total billed charges,Implant Device,1175.04,34,,1175.04,percent of total billed charges,Implant Device,1209.6,35,,1209.6,percent of total billed charges,Implant Device,1209.6,35,,1209.6,percent of total billed charges,Implant Device,1209.6,35,,1209.6,percent of total billed charges,Implant Device,1209.6,35,,1209.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1175.04,34,"If Charge > 2,000, then 34 percent",1175.04,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2557.45,
ZIMMER 00-8757-064-01 TRAB SHELL 64MM,C1776,HCPCS,,79007449,CDM,278,RC,,,both,,,3450,2553.01,,,2553.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1552.5,45,,1552.5,percent of total billed charges,Critical Access Hospital RCC factor,1173,34,,1173,percent of total billed charges,Implant Device,1173,34,,1173,percent of total billed charges,Implant Device,1173,34,,1173,percent of total billed charges,Implant Device,1173,34,,1173,percent of total billed charges,Implant Device,1173,34,,1173,percent of total billed charges,Implant Device,1707.75,,,1707.75,Other,110% of Medicare,1207.5,35,,1207.5,percent of total billed charges,Implant Device,1173,34,"Charges > $500, x 34%",1173,percent of total billed charges,Implant Device,1207.5,35,,1207.5,percent of total billed charges,Implant Device,1207.5,35,,1207.5,percent of total billed charges,Implant Device,1207.5,35,,1207.5,percent of total billed charges,Implant Device,1207.5,35,,1207.5,percent of total billed charges,Implant Device,1207.5,35,,1207.5,percent of total billed charges,Implant Device,1380,40,,1380,percent of total billed charges,Implant Device,1207.5,70,,1207.5,percent of total billed charges,All Other,1173,34,,1173,percent of total billed charges,Implant Device,1173,34,,1173,percent of total billed charges,Implant Device,1207.5,35,,1207.5,percent of total billed charges,Implant Device,1207.5,35,,1207.5,percent of total billed charges,Implant Device,1207.5,35,,1207.5,percent of total billed charges,Implant Device,1207.5,35,,1207.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1173,34,"If Charge > 2,000, then 34 percent",1173,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2553.01,
ZIMMER 00-5850-048-09 SEGMT FEM/TIB 90MM,C1776,HCPCS,,79007450,CDM,278,RC,,,both,,,10305,7625.73,,,7625.73,Other,150% of Medicare + 9.63% HCRA Surcharge,4637.25,45,,4637.25,percent of total billed charges,Critical Access Hospital RCC factor,3503.7,34,,3503.7,percent of total billed charges,Implant Device,3503.7,34,,3503.7,percent of total billed charges,Implant Device,3503.7,34,,3503.7,percent of total billed charges,Implant Device,3503.7,34,,3503.7,percent of total billed charges,Implant Device,3503.7,34,,3503.7,percent of total billed charges,Implant Device,5100.98,,,5100.98,Other,110% of Medicare,3606.75,35,,3606.75,percent of total billed charges,Implant Device,3503.7,34,"Charges > $500, x 34%",3503.7,percent of total billed charges,Implant Device,3606.75,35,,3606.75,percent of total billed charges,Implant Device,3606.75,35,,3606.75,percent of total billed charges,Implant Device,3606.75,35,,3606.75,percent of total billed charges,Implant Device,3606.75,35,,3606.75,percent of total billed charges,Implant Device,3606.75,35,,3606.75,percent of total billed charges,Implant Device,4122,40,,4122,percent of total billed charges,Implant Device,3606.75,70,,3606.75,percent of total billed charges,All Other,3503.7,34,,3503.7,percent of total billed charges,Implant Device,3503.7,34,,3503.7,percent of total billed charges,Implant Device,3606.75,35,,3606.75,percent of total billed charges,Implant Device,3606.75,35,,3606.75,percent of total billed charges,Implant Device,3606.75,35,,3606.75,percent of total billed charges,Implant Device,3606.75,35,,3606.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3503.7,34,"If Charge > 2,000, then 34 percent",3503.7,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,7625.73,
ZIMMER 00-5850-032-46 TRAB FEM COMP 46MM,C1776,HCPCS,,79007451,CDM,278,RC,,,both,,,32319,23916.14,,,23916.14,Other,150% of Medicare + 9.63% HCRA Surcharge,14543.55,45,,14543.55,percent of total billed charges,Critical Access Hospital RCC factor,10988.46,34,,10988.46,percent of total billed charges,Implant Device,10988.46,34,,10988.46,percent of total billed charges,Implant Device,10988.46,34,,10988.46,percent of total billed charges,Implant Device,10988.46,34,,10988.46,percent of total billed charges,Implant Device,10988.46,34,,10988.46,percent of total billed charges,Implant Device,15997.91,,,15997.91,Other,110% of Medicare,11311.65,35,,11311.65,percent of total billed charges,Implant Device,10988.46,34,"Charges > $500, x 34%",10988.46,percent of total billed charges,Implant Device,11311.65,35,,11311.65,percent of total billed charges,Implant Device,11311.65,35,,11311.65,percent of total billed charges,Implant Device,11311.65,35,,11311.65,percent of total billed charges,Implant Device,11311.65,35,,11311.65,percent of total billed charges,Implant Device,11311.65,35,,11311.65,percent of total billed charges,Implant Device,12927.6,40,,12927.6,percent of total billed charges,Implant Device,11311.65,70,,11311.65,percent of total billed charges,All Other,10988.46,34,,10988.46,percent of total billed charges,Implant Device,10988.46,34,,10988.46,percent of total billed charges,Implant Device,11311.65,35,,11311.65,percent of total billed charges,Implant Device,11311.65,35,,11311.65,percent of total billed charges,Implant Device,11311.65,35,,11311.65,percent of total billed charges,Implant Device,11311.65,35,,11311.65,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,10988.46,34,"If Charge > 2,000, then 34 percent",10988.46,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,23916.14,
ZIMMER 00-5850-032-17 TISSUE ATTACH 7MM,C1713,HCPCS,,79007452,CDM,278,RC,,,both,,,6633,4908.44,,,4908.44,Other,150% of Medicare + 9.63% HCRA Surcharge,2984.85,45,,2984.85,percent of total billed charges,Critical Access Hospital RCC factor,2255.22,34,,2255.22,percent of total billed charges,Implant Device,2255.22,34,,2255.22,percent of total billed charges,Implant Device,2255.22,34,,2255.22,percent of total billed charges,Implant Device,2255.22,34,,2255.22,percent of total billed charges,Implant Device,2255.22,34,,2255.22,percent of total billed charges,Implant Device,3283.34,,,3283.34,Other,110% of Medicare,2321.55,35,,2321.55,percent of total billed charges,Implant Device,2255.22,34,"Charges > $500, x 34%",2255.22,percent of total billed charges,Implant Device,2321.55,35,,2321.55,percent of total billed charges,Implant Device,2321.55,35,,2321.55,percent of total billed charges,Implant Device,2321.55,35,,2321.55,percent of total billed charges,Implant Device,2321.55,35,,2321.55,percent of total billed charges,Implant Device,2321.55,35,,2321.55,percent of total billed charges,Implant Device,2653.2,40,,2653.2,percent of total billed charges,Implant Device,2321.55,70,,2321.55,percent of total billed charges,All Other,2255.22,34,,2255.22,percent of total billed charges,Implant Device,2255.22,34,,2255.22,percent of total billed charges,Implant Device,2321.55,35,,2321.55,percent of total billed charges,Implant Device,2321.55,35,,2321.55,percent of total billed charges,Implant Device,2321.55,35,,2321.55,percent of total billed charges,Implant Device,2321.55,35,,2321.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2255.22,34,"If Charge > 2,000, then 34 percent",2255.22,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4908.44,
ZIMMER 00-5850-046-16 SEGMENT 160MM,C1776,HCPCS,,79007453,CDM,278,RC,,,both,,,10305,7625.73,,,7625.73,Other,150% of Medicare + 9.63% HCRA Surcharge,4637.25,45,,4637.25,percent of total billed charges,Critical Access Hospital RCC factor,3503.7,34,,3503.7,percent of total billed charges,Implant Device,3503.7,34,,3503.7,percent of total billed charges,Implant Device,3503.7,34,,3503.7,percent of total billed charges,Implant Device,3503.7,34,,3503.7,percent of total billed charges,Implant Device,3503.7,34,,3503.7,percent of total billed charges,Implant Device,5100.98,,,5100.98,Other,110% of Medicare,3606.75,35,,3606.75,percent of total billed charges,Implant Device,3503.7,34,"Charges > $500, x 34%",3503.7,percent of total billed charges,Implant Device,3606.75,35,,3606.75,percent of total billed charges,Implant Device,3606.75,35,,3606.75,percent of total billed charges,Implant Device,3606.75,35,,3606.75,percent of total billed charges,Implant Device,3606.75,35,,3606.75,percent of total billed charges,Implant Device,3606.75,35,,3606.75,percent of total billed charges,Implant Device,4122,40,,4122,percent of total billed charges,Implant Device,3606.75,70,,3606.75,percent of total billed charges,All Other,3503.7,34,,3503.7,percent of total billed charges,Implant Device,3503.7,34,,3503.7,percent of total billed charges,Implant Device,3606.75,35,,3606.75,percent of total billed charges,Implant Device,3606.75,35,,3606.75,percent of total billed charges,Implant Device,3606.75,35,,3606.75,percent of total billed charges,Implant Device,3606.75,35,,3606.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3503.7,34,"If Charge > 2,000, then 34 percent",3503.7,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,7625.73,
DEPUY 09.402.220S COCR RADIAL HD 20X14MM,C1776,HCPCS,,79007455,CDM,278,RC,,,both,,,7443,5507.84,,,5507.84,Other,150% of Medicare + 9.63% HCRA Surcharge,3349.35,45,,3349.35,percent of total billed charges,Critical Access Hospital RCC factor,2530.62,34,,2530.62,percent of total billed charges,Implant Device,2530.62,34,,2530.62,percent of total billed charges,Implant Device,2530.62,34,,2530.62,percent of total billed charges,Implant Device,2530.62,34,,2530.62,percent of total billed charges,Implant Device,2530.62,34,,2530.62,percent of total billed charges,Implant Device,3684.29,,,3684.29,Other,110% of Medicare,2605.05,35,,2605.05,percent of total billed charges,Implant Device,2530.62,34,"Charges > $500, x 34%",2530.62,percent of total billed charges,Implant Device,2605.05,35,,2605.05,percent of total billed charges,Implant Device,2605.05,35,,2605.05,percent of total billed charges,Implant Device,2605.05,35,,2605.05,percent of total billed charges,Implant Device,2605.05,35,,2605.05,percent of total billed charges,Implant Device,2605.05,35,,2605.05,percent of total billed charges,Implant Device,2977.2,40,,2977.2,percent of total billed charges,Implant Device,2605.05,70,,2605.05,percent of total billed charges,All Other,2530.62,34,,2530.62,percent of total billed charges,Implant Device,2530.62,34,,2530.62,percent of total billed charges,Implant Device,2605.05,35,,2605.05,percent of total billed charges,Implant Device,2605.05,35,,2605.05,percent of total billed charges,Implant Device,2605.05,35,,2605.05,percent of total billed charges,Implant Device,2605.05,35,,2605.05,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2530.62,34,"If Charge > 2,000, then 34 percent",2530.62,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5507.84,
DEPUY 04.402.007S STR RADIAL STEM 7X26MM,C1776,HCPCS,,79007456,CDM,278,RC,,,both,,,7443,5507.84,,,5507.84,Other,150% of Medicare + 9.63% HCRA Surcharge,3349.35,45,,3349.35,percent of total billed charges,Critical Access Hospital RCC factor,2530.62,34,,2530.62,percent of total billed charges,Implant Device,2530.62,34,,2530.62,percent of total billed charges,Implant Device,2530.62,34,,2530.62,percent of total billed charges,Implant Device,2530.62,34,,2530.62,percent of total billed charges,Implant Device,2530.62,34,,2530.62,percent of total billed charges,Implant Device,3684.29,,,3684.29,Other,110% of Medicare,2605.05,35,,2605.05,percent of total billed charges,Implant Device,2530.62,34,"Charges > $500, x 34%",2530.62,percent of total billed charges,Implant Device,2605.05,35,,2605.05,percent of total billed charges,Implant Device,2605.05,35,,2605.05,percent of total billed charges,Implant Device,2605.05,35,,2605.05,percent of total billed charges,Implant Device,2605.05,35,,2605.05,percent of total billed charges,Implant Device,2605.05,35,,2605.05,percent of total billed charges,Implant Device,2977.2,40,,2977.2,percent of total billed charges,Implant Device,2605.05,70,,2605.05,percent of total billed charges,All Other,2530.62,34,,2530.62,percent of total billed charges,Implant Device,2530.62,34,,2530.62,percent of total billed charges,Implant Device,2605.05,35,,2605.05,percent of total billed charges,Implant Device,2605.05,35,,2605.05,percent of total billed charges,Implant Device,2605.05,35,,2605.05,percent of total billed charges,Implant Device,2605.05,35,,2605.05,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2530.62,34,"If Charge > 2,000, then 34 percent",2530.62,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5507.84,
DEPUY 239.987 MED PROX TIB PLATE 6HOLE,C1713,HCPCS,,79007457,CDM,278,RC,,,both,,,5931,4388.95,,,4388.95,Other,150% of Medicare + 9.63% HCRA Surcharge,2668.95,45,,2668.95,percent of total billed charges,Critical Access Hospital RCC factor,2016.54,34,,2016.54,percent of total billed charges,Implant Device,2016.54,34,,2016.54,percent of total billed charges,Implant Device,2016.54,34,,2016.54,percent of total billed charges,Implant Device,2016.54,34,,2016.54,percent of total billed charges,Implant Device,2016.54,34,,2016.54,percent of total billed charges,Implant Device,2935.85,,,2935.85,Other,110% of Medicare,2075.85,35,,2075.85,percent of total billed charges,Implant Device,2016.54,34,"Charges > $500, x 34%",2016.54,percent of total billed charges,Implant Device,2075.85,35,,2075.85,percent of total billed charges,Implant Device,2075.85,35,,2075.85,percent of total billed charges,Implant Device,2075.85,35,,2075.85,percent of total billed charges,Implant Device,2075.85,35,,2075.85,percent of total billed charges,Implant Device,2075.85,35,,2075.85,percent of total billed charges,Implant Device,2372.4,40,,2372.4,percent of total billed charges,Implant Device,2075.85,70,,2075.85,percent of total billed charges,All Other,2016.54,34,,2016.54,percent of total billed charges,Implant Device,2016.54,34,,2016.54,percent of total billed charges,Implant Device,2075.85,35,,2075.85,percent of total billed charges,Implant Device,2075.85,35,,2075.85,percent of total billed charges,Implant Device,2075.85,35,,2075.85,percent of total billed charges,Implant Device,2075.85,35,,2075.85,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2016.54,34,"If Charge > 2,000, then 34 percent",2016.54,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4388.95,
DEPUY 02.205.050 CANN LOCK SCREW 5X50MM,C1713,HCPCS,,79007459,CDM,278,RC,,,both,,,868,642.32,,,642.32,Other,150% of Medicare + 9.63% HCRA Surcharge,390.6,45,,390.6,percent of total billed charges,Critical Access Hospital RCC factor,295.12,34,,295.12,percent of total billed charges,Implant Device,295.12,34,,295.12,percent of total billed charges,Implant Device,295.12,34,,295.12,percent of total billed charges,Implant Device,295.12,34,,295.12,percent of total billed charges,Implant Device,295.12,34,,295.12,percent of total billed charges,Implant Device,429.66,,,429.66,Other,110% of Medicare,303.8,35,,303.8,percent of total billed charges,Implant Device,295.12,34,"Charges > $500, x 34%",295.12,percent of total billed charges,Implant Device,303.8,35,,303.8,percent of total billed charges,Implant Device,303.8,35,,303.8,percent of total billed charges,Implant Device,303.8,35,,303.8,percent of total billed charges,Implant Device,303.8,35,,303.8,percent of total billed charges,Implant Device,303.8,35,,303.8,percent of total billed charges,Implant Device,347.2,40,,347.2,percent of total billed charges,Implant Device,303.8,70,,303.8,percent of total billed charges,All Other,295.12,34,,295.12,percent of total billed charges,Implant Device,295.12,34,,295.12,percent of total billed charges,Implant Device,303.8,35,,303.8,percent of total billed charges,Implant Device,303.8,35,,303.8,percent of total billed charges,Implant Device,303.8,35,,303.8,percent of total billed charges,Implant Device,303.8,35,,303.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,642.32,
DEPUY 02.205.040 CANN LOCK SCREW 5X40MM,C1713,HCPCS,,79007460,CDM,278,RC,,,both,,,810,599.4,,,599.4,Other,150% of Medicare + 9.63% HCRA Surcharge,364.5,45,,364.5,percent of total billed charges,Critical Access Hospital RCC factor,275.4,34,,275.4,percent of total billed charges,Implant Device,275.4,34,,275.4,percent of total billed charges,Implant Device,275.4,34,,275.4,percent of total billed charges,Implant Device,275.4,34,,275.4,percent of total billed charges,Implant Device,275.4,34,,275.4,percent of total billed charges,Implant Device,400.95,,,400.95,Other,110% of Medicare,283.5,35,,283.5,percent of total billed charges,Implant Device,275.4,34,"Charges > $500, x 34%",275.4,percent of total billed charges,Implant Device,283.5,35,,283.5,percent of total billed charges,Implant Device,283.5,35,,283.5,percent of total billed charges,Implant Device,283.5,35,,283.5,percent of total billed charges,Implant Device,283.5,35,,283.5,percent of total billed charges,Implant Device,283.5,35,,283.5,percent of total billed charges,Implant Device,324,40,,324,percent of total billed charges,Implant Device,283.5,70,,283.5,percent of total billed charges,All Other,275.4,34,,275.4,percent of total billed charges,Implant Device,275.4,34,,275.4,percent of total billed charges,Implant Device,283.5,35,,283.5,percent of total billed charges,Implant Device,283.5,35,,283.5,percent of total billed charges,Implant Device,283.5,35,,283.5,percent of total billed charges,Implant Device,283.5,35,,283.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,599.4,
DEPUY 214.866 CORTEX SCREW 4.5X66MM,C1713,HCPCS,,79007462,CDM,278,RC,,,both,,,99,73.26,,,73.26,Other,150% of Medicare + 9.63% HCRA Surcharge,44.55,45,,44.55,percent of total billed charges,Critical Access Hospital RCC factor,33.66,34,,33.66,percent of total billed charges,Implant Device,33.66,34,,33.66,percent of total billed charges,Implant Device,33.66,34,,33.66,percent of total billed charges,Implant Device,33.66,34,,33.66,percent of total billed charges,Implant Device,33.66,34,,33.66,percent of total billed charges,Implant Device,49.01,,,49.01,Other,110% of Medicare,34.65,35,,34.65,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,34.65,35,,34.65,percent of total billed charges,Implant Device,34.65,35,,34.65,percent of total billed charges,Implant Device,34.65,35,,34.65,percent of total billed charges,Implant Device,34.65,35,,34.65,percent of total billed charges,Implant Device,34.65,35,,34.65,percent of total billed charges,Implant Device,39.6,40,,39.6,percent of total billed charges,Implant Device,34.65,70,,34.65,percent of total billed charges,All Other,33.66,34,,33.66,percent of total billed charges,Implant Device,33.66,34,,33.66,percent of total billed charges,Implant Device,34.65,35,,34.65,percent of total billed charges,Implant Device,34.65,35,,34.65,percent of total billed charges,Implant Device,34.65,35,,34.65,percent of total billed charges,Implant Device,34.65,35,,34.65,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,73.26,
GORE RLT261414 EXCLUDER ENDOPROS GRAFT,C1768,HCPCS,,79007464,CDM,278,RC,,,both,,,33825,25030.58,,,25030.58,Other,150% of Medicare + 9.63% HCRA Surcharge,15221.25,45,,15221.25,percent of total billed charges,Critical Access Hospital RCC factor,11500.5,34,,11500.5,percent of total billed charges,Implant Device,11500.5,34,,11500.5,percent of total billed charges,Implant Device,11500.5,34,,11500.5,percent of total billed charges,Implant Device,11500.5,34,,11500.5,percent of total billed charges,Implant Device,11500.5,34,,11500.5,percent of total billed charges,Implant Device,16743.38,,,16743.38,Other,110% of Medicare,11838.75,35,,11838.75,percent of total billed charges,Implant Device,11500.5,34,"Charges > $500, x 34%",11500.5,percent of total billed charges,Implant Device,11838.75,35,,11838.75,percent of total billed charges,Implant Device,11838.75,35,,11838.75,percent of total billed charges,Implant Device,11838.75,35,,11838.75,percent of total billed charges,Implant Device,11838.75,35,,11838.75,percent of total billed charges,Implant Device,11838.75,35,,11838.75,percent of total billed charges,Implant Device,13530,40,,13530,percent of total billed charges,Implant Device,11838.75,70,,11838.75,percent of total billed charges,All Other,11500.5,34,,11500.5,percent of total billed charges,Implant Device,11500.5,34,,11500.5,percent of total billed charges,Implant Device,11838.75,35,,11838.75,percent of total billed charges,Implant Device,11838.75,35,,11838.75,percent of total billed charges,Implant Device,11838.75,35,,11838.75,percent of total billed charges,Implant Device,11838.75,35,,11838.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,11500.5,34,"If Charge > 2,000, then 34 percent",11500.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,25030.58,
DEPUY 02.118.514 MATAPHYSEAL SCRW 2.7X14,C1713,HCPCS,,79007465,CDM,278,RC,,,both,,,178,131.72,,,131.72,Other,150% of Medicare + 9.63% HCRA Surcharge,80.1,45,,80.1,percent of total billed charges,Critical Access Hospital RCC factor,60.52,34,,60.52,percent of total billed charges,Implant Device,60.52,34,,60.52,percent of total billed charges,Implant Device,60.52,34,,60.52,percent of total billed charges,Implant Device,60.52,34,,60.52,percent of total billed charges,Implant Device,60.52,34,,60.52,percent of total billed charges,Implant Device,88.11,,,88.11,Other,110% of Medicare,62.3,35,,62.3,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,62.3,35,,62.3,percent of total billed charges,Implant Device,62.3,35,,62.3,percent of total billed charges,Implant Device,62.3,35,,62.3,percent of total billed charges,Implant Device,62.3,35,,62.3,percent of total billed charges,Implant Device,62.3,35,,62.3,percent of total billed charges,Implant Device,71.2,40,,71.2,percent of total billed charges,Implant Device,62.3,70,,62.3,percent of total billed charges,All Other,60.52,34,,60.52,percent of total billed charges,Implant Device,60.52,34,,60.52,percent of total billed charges,Implant Device,62.3,35,,62.3,percent of total billed charges,Implant Device,62.3,35,,62.3,percent of total billed charges,Implant Device,62.3,35,,62.3,percent of total billed charges,Implant Device,62.3,35,,62.3,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,131.72,
DEPUY 02.211.014 LOCKING SCREW 2.7X14MM,C1713,HCPCS,,79007466,CDM,278,RC,,,both,,,343,253.82,,,253.82,Other,150% of Medicare + 9.63% HCRA Surcharge,154.35,45,,154.35,percent of total billed charges,Critical Access Hospital RCC factor,116.62,34,,116.62,percent of total billed charges,Implant Device,116.62,34,,116.62,percent of total billed charges,Implant Device,116.62,34,,116.62,percent of total billed charges,Implant Device,116.62,34,,116.62,percent of total billed charges,Implant Device,116.62,34,,116.62,percent of total billed charges,Implant Device,169.79,,,169.79,Other,110% of Medicare,120.05,35,,120.05,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,120.05,35,,120.05,percent of total billed charges,Implant Device,120.05,35,,120.05,percent of total billed charges,Implant Device,120.05,35,,120.05,percent of total billed charges,Implant Device,120.05,35,,120.05,percent of total billed charges,Implant Device,120.05,35,,120.05,percent of total billed charges,Implant Device,137.2,40,,137.2,percent of total billed charges,Implant Device,120.05,70,,120.05,percent of total billed charges,All Other,116.62,34,,116.62,percent of total billed charges,Implant Device,116.62,34,,116.62,percent of total billed charges,Implant Device,120.05,35,,120.05,percent of total billed charges,Implant Device,120.05,35,,120.05,percent of total billed charges,Implant Device,120.05,35,,120.05,percent of total billed charges,Implant Device,120.05,35,,120.05,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,253.82,
DEPUY 02.211.010 LOCKING SCREW 2.7X10MM,C1713,HCPCS,,79007467,CDM,278,RC,,,both,,,357,264.18,,,264.18,Other,150% of Medicare + 9.63% HCRA Surcharge,160.65,45,,160.65,percent of total billed charges,Critical Access Hospital RCC factor,121.38,34,,121.38,percent of total billed charges,Implant Device,121.38,34,,121.38,percent of total billed charges,Implant Device,121.38,34,,121.38,percent of total billed charges,Implant Device,121.38,34,,121.38,percent of total billed charges,Implant Device,121.38,34,,121.38,percent of total billed charges,Implant Device,176.72,,,176.72,Other,110% of Medicare,124.95,35,,124.95,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,124.95,35,,124.95,percent of total billed charges,Implant Device,124.95,35,,124.95,percent of total billed charges,Implant Device,124.95,35,,124.95,percent of total billed charges,Implant Device,124.95,35,,124.95,percent of total billed charges,Implant Device,124.95,35,,124.95,percent of total billed charges,Implant Device,142.8,40,,142.8,percent of total billed charges,Implant Device,124.95,70,,124.95,percent of total billed charges,All Other,121.38,34,,121.38,percent of total billed charges,Implant Device,121.38,34,,121.38,percent of total billed charges,Implant Device,124.95,35,,124.95,percent of total billed charges,Implant Device,124.95,35,,124.95,percent of total billed charges,Implant Device,124.95,35,,124.95,percent of total billed charges,Implant Device,124.95,35,,124.95,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,264.18,
STRYKER 6704-3-080 TROCHANTERIC GRIP 2/2,C1713,HCPCS,,79007468,CDM,278,RC,,,both,,,3315,2453.11,,,2453.11,Other,150% of Medicare + 9.63% HCRA Surcharge,1491.75,45,,1491.75,percent of total billed charges,Critical Access Hospital RCC factor,1127.1,34,,1127.1,percent of total billed charges,Implant Device,1127.1,34,,1127.1,percent of total billed charges,Implant Device,1127.1,34,,1127.1,percent of total billed charges,Implant Device,1127.1,34,,1127.1,percent of total billed charges,Implant Device,1127.1,34,,1127.1,percent of total billed charges,Implant Device,1640.93,,,1640.93,Other,110% of Medicare,1160.25,35,,1160.25,percent of total billed charges,Implant Device,1127.1,34,"Charges > $500, x 34%",1127.1,percent of total billed charges,Implant Device,1160.25,35,,1160.25,percent of total billed charges,Implant Device,1160.25,35,,1160.25,percent of total billed charges,Implant Device,1160.25,35,,1160.25,percent of total billed charges,Implant Device,1160.25,35,,1160.25,percent of total billed charges,Implant Device,1160.25,35,,1160.25,percent of total billed charges,Implant Device,1326,40,,1326,percent of total billed charges,Implant Device,1160.25,70,,1160.25,percent of total billed charges,All Other,1127.1,34,,1127.1,percent of total billed charges,Implant Device,1127.1,34,,1127.1,percent of total billed charges,Implant Device,1160.25,35,,1160.25,percent of total billed charges,Implant Device,1160.25,35,,1160.25,percent of total billed charges,Implant Device,1160.25,35,,1160.25,percent of total billed charges,Implant Device,1160.25,35,,1160.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1127.1,34,"If Charge > 2,000, then 34 percent",1127.1,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2453.11,
ARTHREX AR-1319FT ANCHOR BONE K-WIRE,C1713,HCPCS,,79007469,CDM,278,RC,,,both,,,171,126.54,,,126.54,Other,150% of Medicare + 9.63% HCRA Surcharge,76.95,45,,76.95,percent of total billed charges,Critical Access Hospital RCC factor,58.14,34,,58.14,percent of total billed charges,Implant Device,58.14,34,,58.14,percent of total billed charges,Implant Device,58.14,34,,58.14,percent of total billed charges,Implant Device,58.14,34,,58.14,percent of total billed charges,Implant Device,58.14,34,,58.14,percent of total billed charges,Implant Device,84.65,,,84.65,Other,110% of Medicare,59.85,35,,59.85,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,59.85,35,,59.85,percent of total billed charges,Implant Device,59.85,35,,59.85,percent of total billed charges,Implant Device,59.85,35,,59.85,percent of total billed charges,Implant Device,59.85,35,,59.85,percent of total billed charges,Implant Device,59.85,35,,59.85,percent of total billed charges,Implant Device,68.4,40,,68.4,percent of total billed charges,Implant Device,59.85,70,,59.85,percent of total billed charges,All Other,58.14,34,,58.14,percent of total billed charges,Implant Device,58.14,34,,58.14,percent of total billed charges,Implant Device,59.85,35,,59.85,percent of total billed charges,Implant Device,59.85,35,,59.85,percent of total billed charges,Implant Device,59.85,35,,59.85,percent of total billed charges,Implant Device,59.85,35,,59.85,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,126.54,
STRYKER 40-35900 WASHER FOR 3.5MM SCREW,C1713,HCPCS,,79007470,CDM,278,RC,,,both,,,362,267.88,,,267.88,Other,150% of Medicare + 9.63% HCRA Surcharge,162.9,45,,162.9,percent of total billed charges,Critical Access Hospital RCC factor,123.08,34,,123.08,percent of total billed charges,Implant Device,123.08,34,,123.08,percent of total billed charges,Implant Device,123.08,34,,123.08,percent of total billed charges,Implant Device,123.08,34,,123.08,percent of total billed charges,Implant Device,123.08,34,,123.08,percent of total billed charges,Implant Device,179.19,,,179.19,Other,110% of Medicare,126.7,35,,126.7,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,126.7,35,,126.7,percent of total billed charges,Implant Device,126.7,35,,126.7,percent of total billed charges,Implant Device,126.7,35,,126.7,percent of total billed charges,Implant Device,126.7,35,,126.7,percent of total billed charges,Implant Device,126.7,35,,126.7,percent of total billed charges,Implant Device,144.8,40,,144.8,percent of total billed charges,Implant Device,126.7,70,,126.7,percent of total billed charges,All Other,123.08,34,,123.08,percent of total billed charges,Implant Device,123.08,34,,123.08,percent of total billed charges,Implant Device,126.7,35,,126.7,percent of total billed charges,Implant Device,126.7,35,,126.7,percent of total billed charges,Implant Device,126.7,35,,126.7,percent of total billed charges,Implant Device,126.7,35,,126.7,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,267.88,
STRYKER 5630-G-510 TIBIAL INSRT SZ5 10MM,C1776,HCPCS,,79007471,CDM,278,RC,,,both,,,3232,2391.69,,,2391.69,Other,150% of Medicare + 9.63% HCRA Surcharge,1454.4,45,,1454.4,percent of total billed charges,Critical Access Hospital RCC factor,1098.88,34,,1098.88,percent of total billed charges,Implant Device,1098.88,34,,1098.88,percent of total billed charges,Implant Device,1098.88,34,,1098.88,percent of total billed charges,Implant Device,1098.88,34,,1098.88,percent of total billed charges,Implant Device,1098.88,34,,1098.88,percent of total billed charges,Implant Device,1599.84,,,1599.84,Other,110% of Medicare,1131.2,35,,1131.2,percent of total billed charges,Implant Device,1098.88,34,"Charges > $500, x 34%",1098.88,percent of total billed charges,Implant Device,1131.2,35,,1131.2,percent of total billed charges,Implant Device,1131.2,35,,1131.2,percent of total billed charges,Implant Device,1131.2,35,,1131.2,percent of total billed charges,Implant Device,1131.2,35,,1131.2,percent of total billed charges,Implant Device,1131.2,35,,1131.2,percent of total billed charges,Implant Device,1292.8,40,,1292.8,percent of total billed charges,Implant Device,1131.2,70,,1131.2,percent of total billed charges,All Other,1098.88,34,,1098.88,percent of total billed charges,Implant Device,1098.88,34,,1098.88,percent of total billed charges,Implant Device,1131.2,35,,1131.2,percent of total billed charges,Implant Device,1131.2,35,,1131.2,percent of total billed charges,Implant Device,1131.2,35,,1131.2,percent of total billed charges,Implant Device,1131.2,35,,1131.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1098.88,34,"If Charge > 2,000, then 34 percent",1098.88,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2391.69,
STRYKER 40-20810 VARIAX LOCK PLATE 10 HL,C1713,HCPCS,,79007472,CDM,278,RC,,,both,,,2205,1631.71,,,1631.71,Other,150% of Medicare + 9.63% HCRA Surcharge,992.25,45,,992.25,percent of total billed charges,Critical Access Hospital RCC factor,749.7,34,,749.7,percent of total billed charges,Implant Device,749.7,34,,749.7,percent of total billed charges,Implant Device,749.7,34,,749.7,percent of total billed charges,Implant Device,749.7,34,,749.7,percent of total billed charges,Implant Device,749.7,34,,749.7,percent of total billed charges,Implant Device,1091.48,,,1091.48,Other,110% of Medicare,771.75,35,,771.75,percent of total billed charges,Implant Device,749.7,34,"Charges > $500, x 34%",749.7,percent of total billed charges,Implant Device,771.75,35,,771.75,percent of total billed charges,Implant Device,771.75,35,,771.75,percent of total billed charges,Implant Device,771.75,35,,771.75,percent of total billed charges,Implant Device,771.75,35,,771.75,percent of total billed charges,Implant Device,771.75,35,,771.75,percent of total billed charges,Implant Device,882,40,,882,percent of total billed charges,Implant Device,771.75,70,,771.75,percent of total billed charges,All Other,749.7,34,,749.7,percent of total billed charges,Implant Device,749.7,34,,749.7,percent of total billed charges,Implant Device,771.75,35,,771.75,percent of total billed charges,Implant Device,771.75,35,,771.75,percent of total billed charges,Implant Device,771.75,35,,771.75,percent of total billed charges,Implant Device,771.75,35,,771.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,749.7,34,"If Charge > 2,000, then 34 percent",749.7,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1631.71,
ARTHREX AR-8725-14H CANN SCREW 2.5X14MM,C1713,HCPCS,,79007475,CDM,278,RC,,,both,,,1266,936.84,,,936.84,Other,150% of Medicare + 9.63% HCRA Surcharge,569.7,45,,569.7,percent of total billed charges,Critical Access Hospital RCC factor,430.44,34,,430.44,percent of total billed charges,Implant Device,430.44,34,,430.44,percent of total billed charges,Implant Device,430.44,34,,430.44,percent of total billed charges,Implant Device,430.44,34,,430.44,percent of total billed charges,Implant Device,430.44,34,,430.44,percent of total billed charges,Implant Device,626.67,,,626.67,Other,110% of Medicare,443.1,35,,443.1,percent of total billed charges,Implant Device,430.44,34,"Charges > $500, x 34%",430.44,percent of total billed charges,Implant Device,443.1,35,,443.1,percent of total billed charges,Implant Device,443.1,35,,443.1,percent of total billed charges,Implant Device,443.1,35,,443.1,percent of total billed charges,Implant Device,443.1,35,,443.1,percent of total billed charges,Implant Device,443.1,35,,443.1,percent of total billed charges,Implant Device,506.4,40,,506.4,percent of total billed charges,Implant Device,443.1,70,,443.1,percent of total billed charges,All Other,430.44,34,,430.44,percent of total billed charges,Implant Device,430.44,34,,430.44,percent of total billed charges,Implant Device,443.1,35,,443.1,percent of total billed charges,Implant Device,443.1,35,,443.1,percent of total billed charges,Implant Device,443.1,35,,443.1,percent of total billed charges,Implant Device,443.1,35,,443.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,936.84,
ARTHREX AR-8725-16H CANN SCREW 2.5X16MM,C1713,HCPCS,,79007476,CDM,278,RC,,,both,,,885,654.9,,,654.9,Other,150% of Medicare + 9.63% HCRA Surcharge,398.25,45,,398.25,percent of total billed charges,Critical Access Hospital RCC factor,300.9,34,,300.9,percent of total billed charges,Implant Device,300.9,34,,300.9,percent of total billed charges,Implant Device,300.9,34,,300.9,percent of total billed charges,Implant Device,300.9,34,,300.9,percent of total billed charges,Implant Device,300.9,34,,300.9,percent of total billed charges,Implant Device,438.08,,,438.08,Other,110% of Medicare,309.75,35,,309.75,percent of total billed charges,Implant Device,300.9,34,"Charges > $500, x 34%",300.9,percent of total billed charges,Implant Device,309.75,35,,309.75,percent of total billed charges,Implant Device,309.75,35,,309.75,percent of total billed charges,Implant Device,309.75,35,,309.75,percent of total billed charges,Implant Device,309.75,35,,309.75,percent of total billed charges,Implant Device,309.75,35,,309.75,percent of total billed charges,Implant Device,354,40,,354,percent of total billed charges,Implant Device,309.75,70,,309.75,percent of total billed charges,All Other,300.9,34,,300.9,percent of total billed charges,Implant Device,300.9,34,,300.9,percent of total billed charges,Implant Device,309.75,35,,309.75,percent of total billed charges,Implant Device,309.75,35,,309.75,percent of total billed charges,Implant Device,309.75,35,,309.75,percent of total billed charges,Implant Device,309.75,35,,309.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,654.9,
STRYKER 629508 8 HOLE NARROW COMP PLATE,C1713,HCPCS,,79007479,CDM,278,RC,,,both,,,1873,1386.02,,,1386.02,Other,150% of Medicare + 9.63% HCRA Surcharge,842.85,45,,842.85,percent of total billed charges,Critical Access Hospital RCC factor,636.82,34,,636.82,percent of total billed charges,Implant Device,636.82,34,,636.82,percent of total billed charges,Implant Device,636.82,34,,636.82,percent of total billed charges,Implant Device,636.82,34,,636.82,percent of total billed charges,Implant Device,636.82,34,,636.82,percent of total billed charges,Implant Device,927.14,,,927.14,Other,110% of Medicare,655.55,35,,655.55,percent of total billed charges,Implant Device,636.82,34,"Charges > $500, x 34%",636.82,percent of total billed charges,Implant Device,655.55,35,,655.55,percent of total billed charges,Implant Device,655.55,35,,655.55,percent of total billed charges,Implant Device,655.55,35,,655.55,percent of total billed charges,Implant Device,655.55,35,,655.55,percent of total billed charges,Implant Device,655.55,35,,655.55,percent of total billed charges,Implant Device,749.2,40,,749.2,percent of total billed charges,Implant Device,655.55,70,,655.55,percent of total billed charges,All Other,636.82,34,,636.82,percent of total billed charges,Implant Device,636.82,34,,636.82,percent of total billed charges,Implant Device,655.55,35,,655.55,percent of total billed charges,Implant Device,655.55,35,,655.55,percent of total billed charges,Implant Device,655.55,35,,655.55,percent of total billed charges,Implant Device,655.55,35,,655.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1386.02,
STRYKER 657412 3.5X12MM NONLOCK SCREW,C1713,HCPCS,,79007480,CDM,278,RC,,,both,,,294,217.56,,,217.56,Other,150% of Medicare + 9.63% HCRA Surcharge,132.3,45,,132.3,percent of total billed charges,Critical Access Hospital RCC factor,99.96,34,,99.96,percent of total billed charges,Implant Device,99.96,34,,99.96,percent of total billed charges,Implant Device,99.96,34,,99.96,percent of total billed charges,Implant Device,99.96,34,,99.96,percent of total billed charges,Implant Device,99.96,34,,99.96,percent of total billed charges,Implant Device,145.53,,,145.53,Other,110% of Medicare,102.9,35,,102.9,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,102.9,35,,102.9,percent of total billed charges,Implant Device,102.9,35,,102.9,percent of total billed charges,Implant Device,102.9,35,,102.9,percent of total billed charges,Implant Device,102.9,35,,102.9,percent of total billed charges,Implant Device,102.9,35,,102.9,percent of total billed charges,Implant Device,117.6,40,,117.6,percent of total billed charges,Implant Device,102.9,70,,102.9,percent of total billed charges,All Other,99.96,34,,99.96,percent of total billed charges,Implant Device,99.96,34,,99.96,percent of total billed charges,Implant Device,102.9,35,,102.9,percent of total billed charges,Implant Device,102.9,35,,102.9,percent of total billed charges,Implant Device,102.9,35,,102.9,percent of total billed charges,Implant Device,102.9,35,,102.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,217.56,
STRYKER 657414 3.5X14MM NONLOCK SCREW,C1713,HCPCS,,79007481,CDM,278,RC,,,both,,,294,217.56,,,217.56,Other,150% of Medicare + 9.63% HCRA Surcharge,132.3,45,,132.3,percent of total billed charges,Critical Access Hospital RCC factor,99.96,34,,99.96,percent of total billed charges,Implant Device,99.96,34,,99.96,percent of total billed charges,Implant Device,99.96,34,,99.96,percent of total billed charges,Implant Device,99.96,34,,99.96,percent of total billed charges,Implant Device,99.96,34,,99.96,percent of total billed charges,Implant Device,145.53,,,145.53,Other,110% of Medicare,102.9,35,,102.9,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,102.9,35,,102.9,percent of total billed charges,Implant Device,102.9,35,,102.9,percent of total billed charges,Implant Device,102.9,35,,102.9,percent of total billed charges,Implant Device,102.9,35,,102.9,percent of total billed charges,Implant Device,102.9,35,,102.9,percent of total billed charges,Implant Device,117.6,40,,117.6,percent of total billed charges,Implant Device,102.9,70,,102.9,percent of total billed charges,All Other,99.96,34,,99.96,percent of total billed charges,Implant Device,99.96,34,,99.96,percent of total billed charges,Implant Device,102.9,35,,102.9,percent of total billed charges,Implant Device,102.9,35,,102.9,percent of total billed charges,Implant Device,102.9,35,,102.9,percent of total billed charges,Implant Device,102.9,35,,102.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,217.56,
STRYKER 657416 3.5X16MM NONLOCK SCREW,C1713,HCPCS,,79007482,CDM,278,RC,,,both,,,294,217.56,,,217.56,Other,150% of Medicare + 9.63% HCRA Surcharge,132.3,45,,132.3,percent of total billed charges,Critical Access Hospital RCC factor,99.96,34,,99.96,percent of total billed charges,Implant Device,99.96,34,,99.96,percent of total billed charges,Implant Device,99.96,34,,99.96,percent of total billed charges,Implant Device,99.96,34,,99.96,percent of total billed charges,Implant Device,99.96,34,,99.96,percent of total billed charges,Implant Device,145.53,,,145.53,Other,110% of Medicare,102.9,35,,102.9,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,102.9,35,,102.9,percent of total billed charges,Implant Device,102.9,35,,102.9,percent of total billed charges,Implant Device,102.9,35,,102.9,percent of total billed charges,Implant Device,102.9,35,,102.9,percent of total billed charges,Implant Device,102.9,35,,102.9,percent of total billed charges,Implant Device,117.6,40,,117.6,percent of total billed charges,Implant Device,102.9,70,,102.9,percent of total billed charges,All Other,99.96,34,,99.96,percent of total billed charges,Implant Device,99.96,34,,99.96,percent of total billed charges,Implant Device,102.9,35,,102.9,percent of total billed charges,Implant Device,102.9,35,,102.9,percent of total billed charges,Implant Device,102.9,35,,102.9,percent of total billed charges,Implant Device,102.9,35,,102.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,217.56,
IN2BONES S22 ST012 SNPOFF SCREW 2.2X12MM,C1713,HCPCS,,79007484,CDM,278,RC,,,both,,,1275,943.5,,,943.5,Other,150% of Medicare + 9.63% HCRA Surcharge,573.75,45,,573.75,percent of total billed charges,Critical Access Hospital RCC factor,433.5,34,,433.5,percent of total billed charges,Implant Device,433.5,34,,433.5,percent of total billed charges,Implant Device,433.5,34,,433.5,percent of total billed charges,Implant Device,433.5,34,,433.5,percent of total billed charges,Implant Device,433.5,34,,433.5,percent of total billed charges,Implant Device,631.13,,,631.13,Other,110% of Medicare,446.25,35,,446.25,percent of total billed charges,Implant Device,433.5,34,"Charges > $500, x 34%",433.5,percent of total billed charges,Implant Device,446.25,35,,446.25,percent of total billed charges,Implant Device,446.25,35,,446.25,percent of total billed charges,Implant Device,446.25,35,,446.25,percent of total billed charges,Implant Device,446.25,35,,446.25,percent of total billed charges,Implant Device,446.25,35,,446.25,percent of total billed charges,Implant Device,510,40,,510,percent of total billed charges,Implant Device,446.25,70,,446.25,percent of total billed charges,All Other,433.5,34,,433.5,percent of total billed charges,Implant Device,433.5,34,,433.5,percent of total billed charges,Implant Device,446.25,35,,446.25,percent of total billed charges,Implant Device,446.25,35,,446.25,percent of total billed charges,Implant Device,446.25,35,,446.25,percent of total billed charges,Implant Device,446.25,35,,446.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,943.5,
BOST SCI M0053750 5FRX3CM STENT NO BARB,C2625,HCPCS,,79007485,CDM,278,RC,,,both,,,630,466.2,,,466.2,Other,150% of Medicare + 9.63% HCRA Surcharge,283.5,45,,283.5,percent of total billed charges,Critical Access Hospital RCC factor,214.2,34,,214.2,percent of total billed charges,Implant Device,214.2,34,,214.2,percent of total billed charges,Implant Device,214.2,34,,214.2,percent of total billed charges,Implant Device,214.2,34,,214.2,percent of total billed charges,Implant Device,214.2,34,,214.2,percent of total billed charges,Implant Device,311.85,,,311.85,Other,110% of Medicare,220.5,35,,220.5,percent of total billed charges,Implant Device,214.2,34,"Charges > $500, x 34%",214.2,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,252,40,,252,percent of total billed charges,Implant Device,220.5,70,,220.5,percent of total billed charges,All Other,214.2,34,,214.2,percent of total billed charges,Implant Device,214.2,34,,214.2,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,466.2,
ZIMMER 00-5990-036-01 FEM AUG BLOCK SZ F,C1776,HCPCS,,79007486,CDM,278,RC,,,both,,,3061,2265.15,,,2265.15,Other,150% of Medicare + 9.63% HCRA Surcharge,1377.45,45,,1377.45,percent of total billed charges,Critical Access Hospital RCC factor,1040.74,34,,1040.74,percent of total billed charges,Implant Device,1040.74,34,,1040.74,percent of total billed charges,Implant Device,1040.74,34,,1040.74,percent of total billed charges,Implant Device,1040.74,34,,1040.74,percent of total billed charges,Implant Device,1040.74,34,,1040.74,percent of total billed charges,Implant Device,1515.2,,,1515.2,Other,110% of Medicare,1071.35,35,,1071.35,percent of total billed charges,Implant Device,1040.74,34,"Charges > $500, x 34%",1040.74,percent of total billed charges,Implant Device,1071.35,35,,1071.35,percent of total billed charges,Implant Device,1071.35,35,,1071.35,percent of total billed charges,Implant Device,1071.35,35,,1071.35,percent of total billed charges,Implant Device,1071.35,35,,1071.35,percent of total billed charges,Implant Device,1071.35,35,,1071.35,percent of total billed charges,Implant Device,1224.4,40,,1224.4,percent of total billed charges,Implant Device,1071.35,70,,1071.35,percent of total billed charges,All Other,1040.74,34,,1040.74,percent of total billed charges,Implant Device,1040.74,34,,1040.74,percent of total billed charges,Implant Device,1071.35,35,,1071.35,percent of total billed charges,Implant Device,1071.35,35,,1071.35,percent of total billed charges,Implant Device,1071.35,35,,1071.35,percent of total billed charges,Implant Device,1071.35,35,,1071.35,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1040.74,34,"If Charge > 2,000, then 34 percent",1040.74,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2265.15,
ZIMMER 00-5990-036-21 FEM AUG BLOCK SZ F,C1776,HCPCS,,79007487,CDM,278,RC,,,both,,,3240,2397.61,,,2397.61,Other,150% of Medicare + 9.63% HCRA Surcharge,1458,45,,1458,percent of total billed charges,Critical Access Hospital RCC factor,1101.6,34,,1101.6,percent of total billed charges,Implant Device,1101.6,34,,1101.6,percent of total billed charges,Implant Device,1101.6,34,,1101.6,percent of total billed charges,Implant Device,1101.6,34,,1101.6,percent of total billed charges,Implant Device,1101.6,34,,1101.6,percent of total billed charges,Implant Device,1603.8,,,1603.8,Other,110% of Medicare,1134,35,,1134,percent of total billed charges,Implant Device,1101.6,34,"Charges > $500, x 34%",1101.6,percent of total billed charges,Implant Device,1134,35,,1134,percent of total billed charges,Implant Device,1134,35,,1134,percent of total billed charges,Implant Device,1134,35,,1134,percent of total billed charges,Implant Device,1134,35,,1134,percent of total billed charges,Implant Device,1134,35,,1134,percent of total billed charges,Implant Device,1296,40,,1296,percent of total billed charges,Implant Device,1134,70,,1134,percent of total billed charges,All Other,1101.6,34,,1101.6,percent of total billed charges,Implant Device,1101.6,34,,1101.6,percent of total billed charges,Implant Device,1134,35,,1134,percent of total billed charges,Implant Device,1134,35,,1134,percent of total billed charges,Implant Device,1134,35,,1134,percent of total billed charges,Implant Device,1134,35,,1134,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1101.6,34,"If Charge > 2,000, then 34 percent",1101.6,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2397.61,
ZIMMER 00-5988-011-18 STEM EXT 18X155MM,C1776,HCPCS,,79007488,CDM,278,RC,,,both,,,3358,2484.93,,,2484.93,Other,150% of Medicare + 9.63% HCRA Surcharge,1511.1,45,,1511.1,percent of total billed charges,Critical Access Hospital RCC factor,1141.72,34,,1141.72,percent of total billed charges,Implant Device,1141.72,34,,1141.72,percent of total billed charges,Implant Device,1141.72,34,,1141.72,percent of total billed charges,Implant Device,1141.72,34,,1141.72,percent of total billed charges,Implant Device,1141.72,34,,1141.72,percent of total billed charges,Implant Device,1662.21,,,1662.21,Other,110% of Medicare,1175.3,35,,1175.3,percent of total billed charges,Implant Device,1141.72,34,"Charges > $500, x 34%",1141.72,percent of total billed charges,Implant Device,1175.3,35,,1175.3,percent of total billed charges,Implant Device,1175.3,35,,1175.3,percent of total billed charges,Implant Device,1175.3,35,,1175.3,percent of total billed charges,Implant Device,1175.3,35,,1175.3,percent of total billed charges,Implant Device,1175.3,35,,1175.3,percent of total billed charges,Implant Device,1343.2,40,,1343.2,percent of total billed charges,Implant Device,1175.3,70,,1175.3,percent of total billed charges,All Other,1141.72,34,,1141.72,percent of total billed charges,Implant Device,1141.72,34,,1141.72,percent of total billed charges,Implant Device,1175.3,35,,1175.3,percent of total billed charges,Implant Device,1175.3,35,,1175.3,percent of total billed charges,Implant Device,1175.3,35,,1175.3,percent of total billed charges,Implant Device,1175.3,35,,1175.3,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1141.72,34,"If Charge > 2,000, then 34 percent",1141.72,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2484.93,
STRYKER 53-23212E BONE SCREW T7 2.3X12,C1713,HCPCS,,79007489,CDM,278,RC,,,both,,,362,267.88,,,267.88,Other,150% of Medicare + 9.63% HCRA Surcharge,162.9,45,,162.9,percent of total billed charges,Critical Access Hospital RCC factor,123.08,34,,123.08,percent of total billed charges,Implant Device,123.08,34,,123.08,percent of total billed charges,Implant Device,123.08,34,,123.08,percent of total billed charges,Implant Device,123.08,34,,123.08,percent of total billed charges,Implant Device,123.08,34,,123.08,percent of total billed charges,Implant Device,179.19,,,179.19,Other,110% of Medicare,126.7,35,,126.7,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,126.7,35,,126.7,percent of total billed charges,Implant Device,126.7,35,,126.7,percent of total billed charges,Implant Device,126.7,35,,126.7,percent of total billed charges,Implant Device,126.7,35,,126.7,percent of total billed charges,Implant Device,126.7,35,,126.7,percent of total billed charges,Implant Device,144.8,40,,144.8,percent of total billed charges,Implant Device,126.7,70,,126.7,percent of total billed charges,All Other,123.08,34,,123.08,percent of total billed charges,Implant Device,123.08,34,,123.08,percent of total billed charges,Implant Device,126.7,35,,126.7,percent of total billed charges,Implant Device,126.7,35,,126.7,percent of total billed charges,Implant Device,126.7,35,,126.7,percent of total billed charges,Implant Device,126.7,35,,126.7,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,267.88,
DEPUY 02.123.040 3.5MM PROX HUM PLATE 3H,C1713,HCPCS,,79007490,CDM,278,RC,,,both,,,3987,2950.39,,,2950.39,Other,150% of Medicare + 9.63% HCRA Surcharge,1794.15,45,,1794.15,percent of total billed charges,Critical Access Hospital RCC factor,1355.58,34,,1355.58,percent of total billed charges,Implant Device,1355.58,34,,1355.58,percent of total billed charges,Implant Device,1355.58,34,,1355.58,percent of total billed charges,Implant Device,1355.58,34,,1355.58,percent of total billed charges,Implant Device,1355.58,34,,1355.58,percent of total billed charges,Implant Device,1973.57,,,1973.57,Other,110% of Medicare,1395.45,35,,1395.45,percent of total billed charges,Implant Device,1355.58,34,"Charges > $500, x 34%",1355.58,percent of total billed charges,Implant Device,1395.45,35,,1395.45,percent of total billed charges,Implant Device,1395.45,35,,1395.45,percent of total billed charges,Implant Device,1395.45,35,,1395.45,percent of total billed charges,Implant Device,1395.45,35,,1395.45,percent of total billed charges,Implant Device,1395.45,35,,1395.45,percent of total billed charges,Implant Device,1594.8,40,,1594.8,percent of total billed charges,Implant Device,1395.45,70,,1395.45,percent of total billed charges,All Other,1355.58,34,,1355.58,percent of total billed charges,Implant Device,1355.58,34,,1355.58,percent of total billed charges,Implant Device,1395.45,35,,1395.45,percent of total billed charges,Implant Device,1395.45,35,,1395.45,percent of total billed charges,Implant Device,1395.45,35,,1395.45,percent of total billed charges,Implant Device,1395.45,35,,1395.45,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1355.58,34,"If Charge > 2,000, then 34 percent",1355.58,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2950.39,
ATLAS SPINE 1106-01-6540 SCREW 6.5X40MM,C1713,HCPCS,,79007492,CDM,278,RC,,,both,,,630,466.2,,,466.2,Other,150% of Medicare + 9.63% HCRA Surcharge,283.5,45,,283.5,percent of total billed charges,Critical Access Hospital RCC factor,214.2,34,,214.2,percent of total billed charges,Implant Device,214.2,34,,214.2,percent of total billed charges,Implant Device,214.2,34,,214.2,percent of total billed charges,Implant Device,214.2,34,,214.2,percent of total billed charges,Implant Device,214.2,34,,214.2,percent of total billed charges,Implant Device,311.85,,,311.85,Other,110% of Medicare,220.5,35,,220.5,percent of total billed charges,Implant Device,214.2,34,"Charges > $500, x 34%",214.2,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,252,40,,252,percent of total billed charges,Implant Device,220.5,70,,220.5,percent of total billed charges,All Other,214.2,34,,214.2,percent of total billed charges,Implant Device,214.2,34,,214.2,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,466.2,
ATLAS SPINE 1106-01-6545 SCREW 6/5X45MM,C1713,HCPCS,,79007493,CDM,278,RC,,,both,,,630,466.2,,,466.2,Other,150% of Medicare + 9.63% HCRA Surcharge,283.5,45,,283.5,percent of total billed charges,Critical Access Hospital RCC factor,214.2,34,,214.2,percent of total billed charges,Implant Device,214.2,34,,214.2,percent of total billed charges,Implant Device,214.2,34,,214.2,percent of total billed charges,Implant Device,214.2,34,,214.2,percent of total billed charges,Implant Device,214.2,34,,214.2,percent of total billed charges,Implant Device,311.85,,,311.85,Other,110% of Medicare,220.5,35,,220.5,percent of total billed charges,Implant Device,214.2,34,"Charges > $500, x 34%",214.2,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,252,40,,252,percent of total billed charges,Implant Device,220.5,70,,220.5,percent of total billed charges,All Other,214.2,34,,214.2,percent of total billed charges,Implant Device,214.2,34,,214.2,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,466.2,
ATLAS SPINE 1100-03-0095 ROD 60MM,C1713,HCPCS,,79007494,CDM,278,RC,,,both,,,840,621.6,,,621.6,Other,150% of Medicare + 9.63% HCRA Surcharge,378,45,,378,percent of total billed charges,Critical Access Hospital RCC factor,285.6,34,,285.6,percent of total billed charges,Implant Device,285.6,34,,285.6,percent of total billed charges,Implant Device,285.6,34,,285.6,percent of total billed charges,Implant Device,285.6,34,,285.6,percent of total billed charges,Implant Device,285.6,34,,285.6,percent of total billed charges,Implant Device,415.8,,,415.8,Other,110% of Medicare,294,35,,294,percent of total billed charges,Implant Device,285.6,34,"Charges > $500, x 34%",285.6,percent of total billed charges,Implant Device,294,35,,294,percent of total billed charges,Implant Device,294,35,,294,percent of total billed charges,Implant Device,294,35,,294,percent of total billed charges,Implant Device,294,35,,294,percent of total billed charges,Implant Device,294,35,,294,percent of total billed charges,Implant Device,336,40,,336,percent of total billed charges,Implant Device,294,70,,294,percent of total billed charges,All Other,285.6,34,,285.6,percent of total billed charges,Implant Device,285.6,34,,285.6,percent of total billed charges,Implant Device,294,35,,294,percent of total billed charges,Implant Device,294,35,,294,percent of total billed charges,Implant Device,294,35,,294,percent of total billed charges,Implant Device,294,35,,294,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,621.6,
ATLAS SPINE 1106-01-6540 SCREW 6.5X40MM,C1713,HCPCS,,79007495,CDM,278,RC,,,both,,,316,233.84,,,233.84,Other,150% of Medicare + 9.63% HCRA Surcharge,142.2,45,,142.2,percent of total billed charges,Critical Access Hospital RCC factor,107.44,34,,107.44,percent of total billed charges,Implant Device,107.44,34,,107.44,percent of total billed charges,Implant Device,107.44,34,,107.44,percent of total billed charges,Implant Device,107.44,34,,107.44,percent of total billed charges,Implant Device,107.44,34,,107.44,percent of total billed charges,Implant Device,156.42,,,156.42,Other,110% of Medicare,110.6,35,,110.6,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,110.6,35,,110.6,percent of total billed charges,Implant Device,110.6,35,,110.6,percent of total billed charges,Implant Device,110.6,35,,110.6,percent of total billed charges,Implant Device,110.6,35,,110.6,percent of total billed charges,Implant Device,110.6,35,,110.6,percent of total billed charges,Implant Device,126.4,40,,126.4,percent of total billed charges,Implant Device,110.6,70,,110.6,percent of total billed charges,All Other,107.44,34,,107.44,percent of total billed charges,Implant Device,107.44,34,,107.44,percent of total billed charges,Implant Device,110.6,35,,110.6,percent of total billed charges,Implant Device,110.6,35,,110.6,percent of total billed charges,Implant Device,110.6,35,,110.6,percent of total billed charges,Implant Device,110.6,35,,110.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,233.84,
DEPUY 206.012 CANCELLOUS SCREW 4X12MM,C1713,HCPCS,,79007497,CDM,278,RC,,,both,,,86,63.64,,,63.64,Other,150% of Medicare + 9.63% HCRA Surcharge,38.7,45,,38.7,percent of total billed charges,Critical Access Hospital RCC factor,29.24,34,,29.24,percent of total billed charges,Implant Device,29.24,34,,29.24,percent of total billed charges,Implant Device,29.24,34,,29.24,percent of total billed charges,Implant Device,29.24,34,,29.24,percent of total billed charges,Implant Device,29.24,34,,29.24,percent of total billed charges,Implant Device,42.57,,,42.57,Other,110% of Medicare,30.1,35,,30.1,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,30.1,35,,30.1,percent of total billed charges,Implant Device,30.1,35,,30.1,percent of total billed charges,Implant Device,30.1,35,,30.1,percent of total billed charges,Implant Device,30.1,35,,30.1,percent of total billed charges,Implant Device,30.1,35,,30.1,percent of total billed charges,Implant Device,34.4,40,,34.4,percent of total billed charges,Implant Device,30.1,70,,30.1,percent of total billed charges,All Other,29.24,34,,29.24,percent of total billed charges,Implant Device,29.24,34,,29.24,percent of total billed charges,Implant Device,30.1,35,,30.1,percent of total billed charges,Implant Device,30.1,35,,30.1,percent of total billed charges,Implant Device,30.1,35,,30.1,percent of total billed charges,Implant Device,30.1,35,,30.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,63.64,
WRIGHT G4260004 SWANSON SZ 4 TOE IMPLANT,C1776,HCPCS,,79007498,CDM,278,RC,,,both,,,3966,2934.85,,,2934.85,Other,150% of Medicare + 9.63% HCRA Surcharge,1784.7,45,,1784.7,percent of total billed charges,Critical Access Hospital RCC factor,1348.44,34,,1348.44,percent of total billed charges,Implant Device,1348.44,34,,1348.44,percent of total billed charges,Implant Device,1348.44,34,,1348.44,percent of total billed charges,Implant Device,1348.44,34,,1348.44,percent of total billed charges,Implant Device,1348.44,34,,1348.44,percent of total billed charges,Implant Device,1963.17,,,1963.17,Other,110% of Medicare,1388.1,35,,1388.1,percent of total billed charges,Implant Device,1348.44,34,"Charges > $500, x 34%",1348.44,percent of total billed charges,Implant Device,1388.1,35,,1388.1,percent of total billed charges,Implant Device,1388.1,35,,1388.1,percent of total billed charges,Implant Device,1388.1,35,,1388.1,percent of total billed charges,Implant Device,1388.1,35,,1388.1,percent of total billed charges,Implant Device,1388.1,35,,1388.1,percent of total billed charges,Implant Device,1586.4,40,,1586.4,percent of total billed charges,Implant Device,1388.1,70,,1388.1,percent of total billed charges,All Other,1348.44,34,,1348.44,percent of total billed charges,Implant Device,1348.44,34,,1348.44,percent of total billed charges,Implant Device,1388.1,35,,1388.1,percent of total billed charges,Implant Device,1388.1,35,,1388.1,percent of total billed charges,Implant Device,1388.1,35,,1388.1,percent of total billed charges,Implant Device,1388.1,35,,1388.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1348.44,34,"If Charge > 2,000, then 34 percent",1348.44,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2934.85,
DEPUY 04.037.155S NAIL 11X340MM 130DG LT,C1713,HCPCS,,79007499,CDM,278,RC,,,both,,,9372,6935.3,,,6935.3,Other,150% of Medicare + 9.63% HCRA Surcharge,4217.4,45,,4217.4,percent of total billed charges,Critical Access Hospital RCC factor,3186.48,34,,3186.48,percent of total billed charges,Implant Device,3186.48,34,,3186.48,percent of total billed charges,Implant Device,3186.48,34,,3186.48,percent of total billed charges,Implant Device,3186.48,34,,3186.48,percent of total billed charges,Implant Device,3186.48,34,,3186.48,percent of total billed charges,Implant Device,4639.14,,,4639.14,Other,110% of Medicare,3280.2,35,,3280.2,percent of total billed charges,Implant Device,3186.48,34,"Charges > $500, x 34%",3186.48,percent of total billed charges,Implant Device,3280.2,35,,3280.2,percent of total billed charges,Implant Device,3280.2,35,,3280.2,percent of total billed charges,Implant Device,3280.2,35,,3280.2,percent of total billed charges,Implant Device,3280.2,35,,3280.2,percent of total billed charges,Implant Device,3280.2,35,,3280.2,percent of total billed charges,Implant Device,3748.8,40,,3748.8,percent of total billed charges,Implant Device,3280.2,70,,3280.2,percent of total billed charges,All Other,3186.48,34,,3186.48,percent of total billed charges,Implant Device,3186.48,34,,3186.48,percent of total billed charges,Implant Device,3280.2,35,,3280.2,percent of total billed charges,Implant Device,3280.2,35,,3280.2,percent of total billed charges,Implant Device,3280.2,35,,3280.2,percent of total billed charges,Implant Device,3280.2,35,,3280.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3186.48,34,"If Charge > 2,000, then 34 percent",3186.48,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,6935.3,
DEPUY 04.038.295S TFN HELICAL BLADE 95MM,C1713,HCPCS,,79007500,CDM,278,RC,,,both,,,3195,2364.31,,,2364.31,Other,150% of Medicare + 9.63% HCRA Surcharge,1437.75,45,,1437.75,percent of total billed charges,Critical Access Hospital RCC factor,1086.3,34,,1086.3,percent of total billed charges,Implant Device,1086.3,34,,1086.3,percent of total billed charges,Implant Device,1086.3,34,,1086.3,percent of total billed charges,Implant Device,1086.3,34,,1086.3,percent of total billed charges,Implant Device,1086.3,34,,1086.3,percent of total billed charges,Implant Device,1581.53,,,1581.53,Other,110% of Medicare,1118.25,35,,1118.25,percent of total billed charges,Implant Device,1086.3,34,"Charges > $500, x 34%",1086.3,percent of total billed charges,Implant Device,1118.25,35,,1118.25,percent of total billed charges,Implant Device,1118.25,35,,1118.25,percent of total billed charges,Implant Device,1118.25,35,,1118.25,percent of total billed charges,Implant Device,1118.25,35,,1118.25,percent of total billed charges,Implant Device,1118.25,35,,1118.25,percent of total billed charges,Implant Device,1278,40,,1278,percent of total billed charges,Implant Device,1118.25,70,,1118.25,percent of total billed charges,All Other,1086.3,34,,1086.3,percent of total billed charges,Implant Device,1086.3,34,,1086.3,percent of total billed charges,Implant Device,1118.25,35,,1118.25,percent of total billed charges,Implant Device,1118.25,35,,1118.25,percent of total billed charges,Implant Device,1118.25,35,,1118.25,percent of total billed charges,Implant Device,1118.25,35,,1118.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1086.3,34,"If Charge > 2,000, then 34 percent",1086.3,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2364.31,
P28 P20-140-032S CANN SHORT SCREW 4X32MM,C1713,HCPCS,,79007501,CDM,278,RC,,,both,,,794,587.56,,,587.56,Other,150% of Medicare + 9.63% HCRA Surcharge,357.3,45,,357.3,percent of total billed charges,Critical Access Hospital RCC factor,269.96,34,,269.96,percent of total billed charges,Implant Device,269.96,34,,269.96,percent of total billed charges,Implant Device,269.96,34,,269.96,percent of total billed charges,Implant Device,269.96,34,,269.96,percent of total billed charges,Implant Device,269.96,34,,269.96,percent of total billed charges,Implant Device,393.03,,,393.03,Other,110% of Medicare,277.9,35,,277.9,percent of total billed charges,Implant Device,269.96,34,"Charges > $500, x 34%",269.96,percent of total billed charges,Implant Device,277.9,35,,277.9,percent of total billed charges,Implant Device,277.9,35,,277.9,percent of total billed charges,Implant Device,277.9,35,,277.9,percent of total billed charges,Implant Device,277.9,35,,277.9,percent of total billed charges,Implant Device,277.9,35,,277.9,percent of total billed charges,Implant Device,317.6,40,,317.6,percent of total billed charges,Implant Device,277.9,70,,277.9,percent of total billed charges,All Other,269.96,34,,269.96,percent of total billed charges,Implant Device,269.96,34,,269.96,percent of total billed charges,Implant Device,277.9,35,,277.9,percent of total billed charges,Implant Device,277.9,35,,277.9,percent of total billed charges,Implant Device,277.9,35,,277.9,percent of total billed charges,Implant Device,277.9,35,,277.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,587.56,
P28 P53-101-2021 PLATE 15X1.5MM  2 HOLE,C1713,HCPCS,,79007505,CDM,278,RC,,,both,,,3590,2656.61,,,2656.61,Other,150% of Medicare + 9.63% HCRA Surcharge,1615.5,45,,1615.5,percent of total billed charges,Critical Access Hospital RCC factor,1220.6,34,,1220.6,percent of total billed charges,Implant Device,1220.6,34,,1220.6,percent of total billed charges,Implant Device,1220.6,34,,1220.6,percent of total billed charges,Implant Device,1220.6,34,,1220.6,percent of total billed charges,Implant Device,1220.6,34,,1220.6,percent of total billed charges,Implant Device,1777.05,,,1777.05,Other,110% of Medicare,1256.5,35,,1256.5,percent of total billed charges,Implant Device,1220.6,34,"Charges > $500, x 34%",1220.6,percent of total billed charges,Implant Device,1256.5,35,,1256.5,percent of total billed charges,Implant Device,1256.5,35,,1256.5,percent of total billed charges,Implant Device,1256.5,35,,1256.5,percent of total billed charges,Implant Device,1256.5,35,,1256.5,percent of total billed charges,Implant Device,1256.5,35,,1256.5,percent of total billed charges,Implant Device,1436,40,,1436,percent of total billed charges,Implant Device,1256.5,70,,1256.5,percent of total billed charges,All Other,1220.6,34,,1220.6,percent of total billed charges,Implant Device,1220.6,34,,1220.6,percent of total billed charges,Implant Device,1256.5,35,,1256.5,percent of total billed charges,Implant Device,1256.5,35,,1256.5,percent of total billed charges,Implant Device,1256.5,35,,1256.5,percent of total billed charges,Implant Device,1256.5,35,,1256.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1220.6,34,"If Charge > 2,000, then 34 percent",1220.6,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2656.61,
STRYKER 627332 PROX TIBIAL PLATE 2 HOLE,C1713,HCPCS,,79007506,CDM,278,RC,,,both,,,5922,4382.29,,,4382.29,Other,150% of Medicare + 9.63% HCRA Surcharge,2664.9,45,,2664.9,percent of total billed charges,Critical Access Hospital RCC factor,2013.48,34,,2013.48,percent of total billed charges,Implant Device,2013.48,34,,2013.48,percent of total billed charges,Implant Device,2013.48,34,,2013.48,percent of total billed charges,Implant Device,2013.48,34,,2013.48,percent of total billed charges,Implant Device,2013.48,34,,2013.48,percent of total billed charges,Implant Device,2931.39,,,2931.39,Other,110% of Medicare,2072.7,35,,2072.7,percent of total billed charges,Implant Device,2013.48,34,"Charges > $500, x 34%",2013.48,percent of total billed charges,Implant Device,2072.7,35,,2072.7,percent of total billed charges,Implant Device,2072.7,35,,2072.7,percent of total billed charges,Implant Device,2072.7,35,,2072.7,percent of total billed charges,Implant Device,2072.7,35,,2072.7,percent of total billed charges,Implant Device,2072.7,35,,2072.7,percent of total billed charges,Implant Device,2368.8,40,,2368.8,percent of total billed charges,Implant Device,2072.7,70,,2072.7,percent of total billed charges,All Other,2013.48,34,,2013.48,percent of total billed charges,Implant Device,2013.48,34,,2013.48,percent of total billed charges,Implant Device,2072.7,35,,2072.7,percent of total billed charges,Implant Device,2072.7,35,,2072.7,percent of total billed charges,Implant Device,2072.7,35,,2072.7,percent of total billed charges,Implant Device,2072.7,35,,2072.7,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2013.48,34,"If Charge > 2,000, then 34 percent",2013.48,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4382.29,
STRYKER 607365 4.0X65MM CANCELLOUS CREW,C1713,HCPCS,,79007507,CDM,278,RC,,,both,,,133,98.42,,,98.42,Other,150% of Medicare + 9.63% HCRA Surcharge,59.85,45,,59.85,percent of total billed charges,Critical Access Hospital RCC factor,45.22,34,,45.22,percent of total billed charges,Implant Device,45.22,34,,45.22,percent of total billed charges,Implant Device,45.22,34,,45.22,percent of total billed charges,Implant Device,45.22,34,,45.22,percent of total billed charges,Implant Device,45.22,34,,45.22,percent of total billed charges,Implant Device,65.84,,,65.84,Other,110% of Medicare,46.55,35,,46.55,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,46.55,35,,46.55,percent of total billed charges,Implant Device,46.55,35,,46.55,percent of total billed charges,Implant Device,46.55,35,,46.55,percent of total billed charges,Implant Device,46.55,35,,46.55,percent of total billed charges,Implant Device,46.55,35,,46.55,percent of total billed charges,Implant Device,53.2,40,,53.2,percent of total billed charges,Implant Device,46.55,70,,46.55,percent of total billed charges,All Other,45.22,34,,45.22,percent of total billed charges,Implant Device,45.22,34,,45.22,percent of total billed charges,Implant Device,46.55,35,,46.55,percent of total billed charges,Implant Device,46.55,35,,46.55,percent of total billed charges,Implant Device,46.55,35,,46.55,percent of total billed charges,Implant Device,46.55,35,,46.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,98.42,
STRYKER 661438 3.5X38MM CORTICAL SCREW,C1713,HCPCS,,79007508,CDM,278,RC,,,both,,,122,90.28,,,90.28,Other,150% of Medicare + 9.63% HCRA Surcharge,54.9,45,,54.9,percent of total billed charges,Critical Access Hospital RCC factor,41.48,34,,41.48,percent of total billed charges,Implant Device,41.48,34,,41.48,percent of total billed charges,Implant Device,41.48,34,,41.48,percent of total billed charges,Implant Device,41.48,34,,41.48,percent of total billed charges,Implant Device,41.48,34,,41.48,percent of total billed charges,Implant Device,60.39,,,60.39,Other,110% of Medicare,42.7,35,,42.7,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,42.7,35,,42.7,percent of total billed charges,Implant Device,42.7,35,,42.7,percent of total billed charges,Implant Device,42.7,35,,42.7,percent of total billed charges,Implant Device,42.7,35,,42.7,percent of total billed charges,Implant Device,42.7,35,,42.7,percent of total billed charges,Implant Device,48.8,40,,48.8,percent of total billed charges,Implant Device,42.7,70,,42.7,percent of total billed charges,All Other,41.48,34,,41.48,percent of total billed charges,Implant Device,41.48,34,,41.48,percent of total billed charges,Implant Device,42.7,35,,42.7,percent of total billed charges,Implant Device,42.7,35,,42.7,percent of total billed charges,Implant Device,42.7,35,,42.7,percent of total billed charges,Implant Device,42.7,35,,42.7,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,90.28,
STRYKER 661085 4.0X85MM LOCKING SCREW,C1713,HCPCS,,79007509,CDM,278,RC,,,both,,,816,603.84,,,603.84,Other,150% of Medicare + 9.63% HCRA Surcharge,367.2,45,,367.2,percent of total billed charges,Critical Access Hospital RCC factor,277.44,34,,277.44,percent of total billed charges,Implant Device,277.44,34,,277.44,percent of total billed charges,Implant Device,277.44,34,,277.44,percent of total billed charges,Implant Device,277.44,34,,277.44,percent of total billed charges,Implant Device,277.44,34,,277.44,percent of total billed charges,Implant Device,403.92,,,403.92,Other,110% of Medicare,285.6,35,,285.6,percent of total billed charges,Implant Device,277.44,34,"Charges > $500, x 34%",277.44,percent of total billed charges,Implant Device,285.6,35,,285.6,percent of total billed charges,Implant Device,285.6,35,,285.6,percent of total billed charges,Implant Device,285.6,35,,285.6,percent of total billed charges,Implant Device,285.6,35,,285.6,percent of total billed charges,Implant Device,285.6,35,,285.6,percent of total billed charges,Implant Device,326.4,40,,326.4,percent of total billed charges,Implant Device,285.6,70,,285.6,percent of total billed charges,All Other,277.44,34,,277.44,percent of total billed charges,Implant Device,277.44,34,,277.44,percent of total billed charges,Implant Device,285.6,35,,285.6,percent of total billed charges,Implant Device,285.6,35,,285.6,percent of total billed charges,Implant Device,285.6,35,,285.6,percent of total billed charges,Implant Device,285.6,35,,285.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,603.84,
STRYKER 661032 4.0 X 32MM LOCKING SCREW,C1713,HCPCS,,79007511,CDM,278,RC,,,both,,,630,466.2,,,466.2,Other,150% of Medicare + 9.63% HCRA Surcharge,283.5,45,,283.5,percent of total billed charges,Critical Access Hospital RCC factor,214.2,34,,214.2,percent of total billed charges,Implant Device,214.2,34,,214.2,percent of total billed charges,Implant Device,214.2,34,,214.2,percent of total billed charges,Implant Device,214.2,34,,214.2,percent of total billed charges,Implant Device,214.2,34,,214.2,percent of total billed charges,Implant Device,311.85,,,311.85,Other,110% of Medicare,220.5,35,,220.5,percent of total billed charges,Implant Device,214.2,34,"Charges > $500, x 34%",214.2,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,252,40,,252,percent of total billed charges,Implant Device,220.5,70,,220.5,percent of total billed charges,All Other,214.2,34,,214.2,percent of total billed charges,Implant Device,214.2,34,,214.2,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,466.2,
STRYKER 5552-E-4821 HUMERAL HEAD 48X21MM,C1776,HCPCS,,79007512,CDM,278,RC,,,both,,,10713,7927.65,,,7927.65,Other,150% of Medicare + 9.63% HCRA Surcharge,4820.85,45,,4820.85,percent of total billed charges,Critical Access Hospital RCC factor,3642.42,34,,3642.42,percent of total billed charges,Implant Device,3642.42,34,,3642.42,percent of total billed charges,Implant Device,3642.42,34,,3642.42,percent of total billed charges,Implant Device,3642.42,34,,3642.42,percent of total billed charges,Implant Device,3642.42,34,,3642.42,percent of total billed charges,Implant Device,5302.94,,,5302.94,Other,110% of Medicare,3749.55,35,,3749.55,percent of total billed charges,Implant Device,3642.42,34,"Charges > $500, x 34%",3642.42,percent of total billed charges,Implant Device,3749.55,35,,3749.55,percent of total billed charges,Implant Device,3749.55,35,,3749.55,percent of total billed charges,Implant Device,3749.55,35,,3749.55,percent of total billed charges,Implant Device,3749.55,35,,3749.55,percent of total billed charges,Implant Device,3749.55,35,,3749.55,percent of total billed charges,Implant Device,4285.2,40,,4285.2,percent of total billed charges,Implant Device,3749.55,70,,3749.55,percent of total billed charges,All Other,3642.42,34,,3642.42,percent of total billed charges,Implant Device,3642.42,34,,3642.42,percent of total billed charges,Implant Device,3749.55,35,,3749.55,percent of total billed charges,Implant Device,3749.55,35,,3749.55,percent of total billed charges,Implant Device,3749.55,35,,3749.55,percent of total billed charges,Implant Device,3749.55,35,,3749.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3642.42,34,"If Charge > 2,000, then 34 percent",3642.42,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,7927.65,
STRYKER 5569-P-2015 HUMRAL STEM 14X133MM,C1776,HCPCS,,79007513,CDM,278,RC,,,both,,,15293,11316.86,,,11316.86,Other,150% of Medicare + 9.63% HCRA Surcharge,6881.85,45,,6881.85,percent of total billed charges,Critical Access Hospital RCC factor,5199.62,34,,5199.62,percent of total billed charges,Implant Device,5199.62,34,,5199.62,percent of total billed charges,Implant Device,5199.62,34,,5199.62,percent of total billed charges,Implant Device,5199.62,34,,5199.62,percent of total billed charges,Implant Device,5199.62,34,,5199.62,percent of total billed charges,Implant Device,7570.04,,,7570.04,Other,110% of Medicare,5352.55,35,,5352.55,percent of total billed charges,Implant Device,5199.62,34,"Charges > $500, x 34%",5199.62,percent of total billed charges,Implant Device,5352.55,35,,5352.55,percent of total billed charges,Implant Device,5352.55,35,,5352.55,percent of total billed charges,Implant Device,5352.55,35,,5352.55,percent of total billed charges,Implant Device,5352.55,35,,5352.55,percent of total billed charges,Implant Device,5352.55,35,,5352.55,percent of total billed charges,Implant Device,6117.2,40,,6117.2,percent of total billed charges,Implant Device,5352.55,70,,5352.55,percent of total billed charges,All Other,5199.62,34,,5199.62,percent of total billed charges,Implant Device,5199.62,34,,5199.62,percent of total billed charges,Implant Device,5352.55,35,,5352.55,percent of total billed charges,Implant Device,5352.55,35,,5352.55,percent of total billed charges,Implant Device,5352.55,35,,5352.55,percent of total billed charges,Implant Device,5352.55,35,,5352.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,5199.62,34,"If Charge > 2,000, then 34 percent",5199.62,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,11316.86,
ARTHREX AR-8954PL-M CALCANEAL PLATE MED,C1713,HCPCS,,79007524,CDM,278,RC,,,both,,,4695,3474.31,,,3474.31,Other,150% of Medicare + 9.63% HCRA Surcharge,2112.75,45,,2112.75,percent of total billed charges,Critical Access Hospital RCC factor,1596.3,34,,1596.3,percent of total billed charges,Implant Device,1596.3,34,,1596.3,percent of total billed charges,Implant Device,1596.3,34,,1596.3,percent of total billed charges,Implant Device,1596.3,34,,1596.3,percent of total billed charges,Implant Device,1596.3,34,,1596.3,percent of total billed charges,Implant Device,2324.03,,,2324.03,Other,110% of Medicare,1643.25,35,,1643.25,percent of total billed charges,Implant Device,1596.3,34,"Charges > $500, x 34%",1596.3,percent of total billed charges,Implant Device,1643.25,35,,1643.25,percent of total billed charges,Implant Device,1643.25,35,,1643.25,percent of total billed charges,Implant Device,1643.25,35,,1643.25,percent of total billed charges,Implant Device,1643.25,35,,1643.25,percent of total billed charges,Implant Device,1643.25,35,,1643.25,percent of total billed charges,Implant Device,1878,40,,1878,percent of total billed charges,Implant Device,1643.25,70,,1643.25,percent of total billed charges,All Other,1596.3,34,,1596.3,percent of total billed charges,Implant Device,1596.3,34,,1596.3,percent of total billed charges,Implant Device,1643.25,35,,1643.25,percent of total billed charges,Implant Device,1643.25,35,,1643.25,percent of total billed charges,Implant Device,1643.25,35,,1643.25,percent of total billed charges,Implant Device,1643.25,35,,1643.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1596.3,34,"If Charge > 2,000, then 34 percent",1596.3,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3474.31,
ARTHREX AR-8935L-38 LOCKING SCREW 3.5X38,C1713,HCPCS,,79007525,CDM,278,RC,,,both,,,366,270.84,,,270.84,Other,150% of Medicare + 9.63% HCRA Surcharge,164.7,45,,164.7,percent of total billed charges,Critical Access Hospital RCC factor,124.44,34,,124.44,percent of total billed charges,Implant Device,124.44,34,,124.44,percent of total billed charges,Implant Device,124.44,34,,124.44,percent of total billed charges,Implant Device,124.44,34,,124.44,percent of total billed charges,Implant Device,124.44,34,,124.44,percent of total billed charges,Implant Device,181.17,,,181.17,Other,110% of Medicare,128.1,35,,128.1,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,128.1,35,,128.1,percent of total billed charges,Implant Device,128.1,35,,128.1,percent of total billed charges,Implant Device,128.1,35,,128.1,percent of total billed charges,Implant Device,128.1,35,,128.1,percent of total billed charges,Implant Device,128.1,35,,128.1,percent of total billed charges,Implant Device,146.4,40,,146.4,percent of total billed charges,Implant Device,128.1,70,,128.1,percent of total billed charges,All Other,124.44,34,,124.44,percent of total billed charges,Implant Device,124.44,34,,124.44,percent of total billed charges,Implant Device,128.1,35,,128.1,percent of total billed charges,Implant Device,128.1,35,,128.1,percent of total billed charges,Implant Device,128.1,35,,128.1,percent of total billed charges,Implant Device,128.1,35,,128.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,270.84,
ARTHREX AR-8933-24 CORT SCREW 3.0X24MM,C1713,HCPCS,,79007526,CDM,278,RC,,,both,,,474,350.76,,,350.76,Other,150% of Medicare + 9.63% HCRA Surcharge,213.3,45,,213.3,percent of total billed charges,Critical Access Hospital RCC factor,161.16,34,,161.16,percent of total billed charges,Implant Device,161.16,34,,161.16,percent of total billed charges,Implant Device,161.16,34,,161.16,percent of total billed charges,Implant Device,161.16,34,,161.16,percent of total billed charges,Implant Device,161.16,34,,161.16,percent of total billed charges,Implant Device,234.63,,,234.63,Other,110% of Medicare,165.9,35,,165.9,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,165.9,35,,165.9,percent of total billed charges,Implant Device,165.9,35,,165.9,percent of total billed charges,Implant Device,165.9,35,,165.9,percent of total billed charges,Implant Device,165.9,35,,165.9,percent of total billed charges,Implant Device,165.9,35,,165.9,percent of total billed charges,Implant Device,189.6,40,,189.6,percent of total billed charges,Implant Device,165.9,70,,165.9,percent of total billed charges,All Other,161.16,34,,161.16,percent of total billed charges,Implant Device,161.16,34,,161.16,percent of total billed charges,Implant Device,165.9,35,,165.9,percent of total billed charges,Implant Device,165.9,35,,165.9,percent of total billed charges,Implant Device,165.9,35,,165.9,percent of total billed charges,Implant Device,165.9,35,,165.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,350.76,
ARTHREX AR-8933L-24 LOCKING SCREW 3X24MM,C1713,HCPCS,,79007527,CDM,278,RC,,,both,,,474,350.76,,,350.76,Other,150% of Medicare + 9.63% HCRA Surcharge,213.3,45,,213.3,percent of total billed charges,Critical Access Hospital RCC factor,161.16,34,,161.16,percent of total billed charges,Implant Device,161.16,34,,161.16,percent of total billed charges,Implant Device,161.16,34,,161.16,percent of total billed charges,Implant Device,161.16,34,,161.16,percent of total billed charges,Implant Device,161.16,34,,161.16,percent of total billed charges,Implant Device,234.63,,,234.63,Other,110% of Medicare,165.9,35,,165.9,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,165.9,35,,165.9,percent of total billed charges,Implant Device,165.9,35,,165.9,percent of total billed charges,Implant Device,165.9,35,,165.9,percent of total billed charges,Implant Device,165.9,35,,165.9,percent of total billed charges,Implant Device,165.9,35,,165.9,percent of total billed charges,Implant Device,189.6,40,,189.6,percent of total billed charges,Implant Device,165.9,70,,165.9,percent of total billed charges,All Other,161.16,34,,161.16,percent of total billed charges,Implant Device,161.16,34,,161.16,percent of total billed charges,Implant Device,165.9,35,,165.9,percent of total billed charges,Implant Device,165.9,35,,165.9,percent of total billed charges,Implant Device,165.9,35,,165.9,percent of total billed charges,Implant Device,165.9,35,,165.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,350.76,
ARTHREX AR-8970TT TIB TALAR ANKLE PLATE,C1713,HCPCS,,79007528,CDM,278,RC,,,both,,,8895,6582.32,,,6582.32,Other,150% of Medicare + 9.63% HCRA Surcharge,4002.75,45,,4002.75,percent of total billed charges,Critical Access Hospital RCC factor,3024.3,34,,3024.3,percent of total billed charges,Implant Device,3024.3,34,,3024.3,percent of total billed charges,Implant Device,3024.3,34,,3024.3,percent of total billed charges,Implant Device,3024.3,34,,3024.3,percent of total billed charges,Implant Device,3024.3,34,,3024.3,percent of total billed charges,Implant Device,4403.03,,,4403.03,Other,110% of Medicare,3113.25,35,,3113.25,percent of total billed charges,Implant Device,3024.3,34,"Charges > $500, x 34%",3024.3,percent of total billed charges,Implant Device,3113.25,35,,3113.25,percent of total billed charges,Implant Device,3113.25,35,,3113.25,percent of total billed charges,Implant Device,3113.25,35,,3113.25,percent of total billed charges,Implant Device,3113.25,35,,3113.25,percent of total billed charges,Implant Device,3113.25,35,,3113.25,percent of total billed charges,Implant Device,3558,40,,3558,percent of total billed charges,Implant Device,3113.25,70,,3113.25,percent of total billed charges,All Other,3024.3,34,,3024.3,percent of total billed charges,Implant Device,3024.3,34,,3024.3,percent of total billed charges,Implant Device,3113.25,35,,3113.25,percent of total billed charges,Implant Device,3113.25,35,,3113.25,percent of total billed charges,Implant Device,3113.25,35,,3113.25,percent of total billed charges,Implant Device,3113.25,35,,3113.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3024.3,34,"If Charge > 2,000, then 34 percent",3024.3,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,6582.32,
ARTHREX AR-8545L-32 LOCKING SCREW 4.5X32,C1713,HCPCS,,79007529,CDM,278,RC,,,both,,,837,619.38,,,619.38,Other,150% of Medicare + 9.63% HCRA Surcharge,376.65,45,,376.65,percent of total billed charges,Critical Access Hospital RCC factor,284.58,34,,284.58,percent of total billed charges,Implant Device,284.58,34,,284.58,percent of total billed charges,Implant Device,284.58,34,,284.58,percent of total billed charges,Implant Device,284.58,34,,284.58,percent of total billed charges,Implant Device,284.58,34,,284.58,percent of total billed charges,Implant Device,414.32,,,414.32,Other,110% of Medicare,292.95,35,,292.95,percent of total billed charges,Implant Device,284.58,34,"Charges > $500, x 34%",284.58,percent of total billed charges,Implant Device,292.95,35,,292.95,percent of total billed charges,Implant Device,292.95,35,,292.95,percent of total billed charges,Implant Device,292.95,35,,292.95,percent of total billed charges,Implant Device,292.95,35,,292.95,percent of total billed charges,Implant Device,292.95,35,,292.95,percent of total billed charges,Implant Device,334.8,40,,334.8,percent of total billed charges,Implant Device,292.95,70,,292.95,percent of total billed charges,All Other,284.58,34,,284.58,percent of total billed charges,Implant Device,284.58,34,,284.58,percent of total billed charges,Implant Device,292.95,35,,292.95,percent of total billed charges,Implant Device,292.95,35,,292.95,percent of total billed charges,Implant Device,292.95,35,,292.95,percent of total billed charges,Implant Device,292.95,35,,292.95,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,619.38,
ARTHREX AR-8545L-34 LOCKING SCREW 4.5X34,C1713,HCPCS,,79007530,CDM,278,RC,,,both,,,837,619.38,,,619.38,Other,150% of Medicare + 9.63% HCRA Surcharge,376.65,45,,376.65,percent of total billed charges,Critical Access Hospital RCC factor,284.58,34,,284.58,percent of total billed charges,Implant Device,284.58,34,,284.58,percent of total billed charges,Implant Device,284.58,34,,284.58,percent of total billed charges,Implant Device,284.58,34,,284.58,percent of total billed charges,Implant Device,284.58,34,,284.58,percent of total billed charges,Implant Device,414.32,,,414.32,Other,110% of Medicare,292.95,35,,292.95,percent of total billed charges,Implant Device,284.58,34,"Charges > $500, x 34%",284.58,percent of total billed charges,Implant Device,292.95,35,,292.95,percent of total billed charges,Implant Device,292.95,35,,292.95,percent of total billed charges,Implant Device,292.95,35,,292.95,percent of total billed charges,Implant Device,292.95,35,,292.95,percent of total billed charges,Implant Device,292.95,35,,292.95,percent of total billed charges,Implant Device,334.8,40,,334.8,percent of total billed charges,Implant Device,292.95,70,,292.95,percent of total billed charges,All Other,284.58,34,,284.58,percent of total billed charges,Implant Device,284.58,34,,284.58,percent of total billed charges,Implant Device,292.95,35,,292.95,percent of total billed charges,Implant Device,292.95,35,,292.95,percent of total billed charges,Implant Device,292.95,35,,292.95,percent of total billed charges,Implant Device,292.95,35,,292.95,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,619.38,
ARTHREX AR-8545L-36 LOCKING SCREW 4.5X36,C1713,HCPCS,,79007531,CDM,278,RC,,,both,,,585,432.9,,,432.9,Other,150% of Medicare + 9.63% HCRA Surcharge,263.25,45,,263.25,percent of total billed charges,Critical Access Hospital RCC factor,198.9,34,,198.9,percent of total billed charges,Implant Device,198.9,34,,198.9,percent of total billed charges,Implant Device,198.9,34,,198.9,percent of total billed charges,Implant Device,198.9,34,,198.9,percent of total billed charges,Implant Device,198.9,34,,198.9,percent of total billed charges,Implant Device,289.58,,,289.58,Other,110% of Medicare,204.75,35,,204.75,percent of total billed charges,Implant Device,198.9,34,"Charges > $500, x 34%",198.9,percent of total billed charges,Implant Device,204.75,35,,204.75,percent of total billed charges,Implant Device,204.75,35,,204.75,percent of total billed charges,Implant Device,204.75,35,,204.75,percent of total billed charges,Implant Device,204.75,35,,204.75,percent of total billed charges,Implant Device,204.75,35,,204.75,percent of total billed charges,Implant Device,234,40,,234,percent of total billed charges,Implant Device,204.75,70,,204.75,percent of total billed charges,All Other,198.9,34,,198.9,percent of total billed charges,Implant Device,198.9,34,,198.9,percent of total billed charges,Implant Device,204.75,35,,204.75,percent of total billed charges,Implant Device,204.75,35,,204.75,percent of total billed charges,Implant Device,204.75,35,,204.75,percent of total billed charges,Implant Device,204.75,35,,204.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,432.9,
ARTHREX AR-8545L-38 LOCKING SCREW 4.5X28,C1713,HCPCS,,79007532,CDM,278,RC,,,both,,,540,399.6,,,399.6,Other,150% of Medicare + 9.63% HCRA Surcharge,243,45,,243,percent of total billed charges,Critical Access Hospital RCC factor,183.6,34,,183.6,percent of total billed charges,Implant Device,183.6,34,,183.6,percent of total billed charges,Implant Device,183.6,34,,183.6,percent of total billed charges,Implant Device,183.6,34,,183.6,percent of total billed charges,Implant Device,183.6,34,,183.6,percent of total billed charges,Implant Device,267.3,,,267.3,Other,110% of Medicare,189,35,,189,percent of total billed charges,Implant Device,183.6,34,"Charges > $500, x 34%",183.6,percent of total billed charges,Implant Device,189,35,,189,percent of total billed charges,Implant Device,189,35,,189,percent of total billed charges,Implant Device,189,35,,189,percent of total billed charges,Implant Device,189,35,,189,percent of total billed charges,Implant Device,189,35,,189,percent of total billed charges,Implant Device,216,40,,216,percent of total billed charges,Implant Device,189,70,,189,percent of total billed charges,All Other,183.6,34,,183.6,percent of total billed charges,Implant Device,183.6,34,,183.6,percent of total billed charges,Implant Device,189,35,,189,percent of total billed charges,Implant Device,189,35,,189,percent of total billed charges,Implant Device,189,35,,189,percent of total billed charges,Implant Device,189,35,,189,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,399.6,
ARTHREX AR-8545-36 CORTICAL SCREW 4.5X36,C1713,HCPCS,,79007533,CDM,278,RC,,,both,,,225,166.5,,,166.5,Other,150% of Medicare + 9.63% HCRA Surcharge,101.25,45,,101.25,percent of total billed charges,Critical Access Hospital RCC factor,76.5,34,,76.5,percent of total billed charges,Implant Device,76.5,34,,76.5,percent of total billed charges,Implant Device,76.5,34,,76.5,percent of total billed charges,Implant Device,76.5,34,,76.5,percent of total billed charges,Implant Device,76.5,34,,76.5,percent of total billed charges,Implant Device,111.38,,,111.38,Other,110% of Medicare,78.75,35,,78.75,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,78.75,35,,78.75,percent of total billed charges,Implant Device,78.75,35,,78.75,percent of total billed charges,Implant Device,78.75,35,,78.75,percent of total billed charges,Implant Device,78.75,35,,78.75,percent of total billed charges,Implant Device,78.75,35,,78.75,percent of total billed charges,Implant Device,90,40,,90,percent of total billed charges,Implant Device,78.75,70,,78.75,percent of total billed charges,All Other,76.5,34,,76.5,percent of total billed charges,Implant Device,76.5,34,,76.5,percent of total billed charges,Implant Device,78.75,35,,78.75,percent of total billed charges,Implant Device,78.75,35,,78.75,percent of total billed charges,Implant Device,78.75,35,,78.75,percent of total billed charges,Implant Device,78.75,35,,78.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,166.5,
ARTHREX AR-8967-28100 CANN SCREW 6.7X100,C1713,HCPCS,,79007534,CDM,278,RC,,,both,,,750,555,,,555,Other,150% of Medicare + 9.63% HCRA Surcharge,337.5,45,,337.5,percent of total billed charges,Critical Access Hospital RCC factor,255,34,,255,percent of total billed charges,Implant Device,255,34,,255,percent of total billed charges,Implant Device,255,34,,255,percent of total billed charges,Implant Device,255,34,,255,percent of total billed charges,Implant Device,255,34,,255,percent of total billed charges,Implant Device,371.25,,,371.25,Other,110% of Medicare,262.5,35,,262.5,percent of total billed charges,Implant Device,255,34,"Charges > $500, x 34%",255,percent of total billed charges,Implant Device,262.5,35,,262.5,percent of total billed charges,Implant Device,262.5,35,,262.5,percent of total billed charges,Implant Device,262.5,35,,262.5,percent of total billed charges,Implant Device,262.5,35,,262.5,percent of total billed charges,Implant Device,262.5,35,,262.5,percent of total billed charges,Implant Device,300,40,,300,percent of total billed charges,Implant Device,262.5,70,,262.5,percent of total billed charges,All Other,255,34,,255,percent of total billed charges,Implant Device,255,34,,255,percent of total billed charges,Implant Device,262.5,35,,262.5,percent of total billed charges,Implant Device,262.5,35,,262.5,percent of total billed charges,Implant Device,262.5,35,,262.5,percent of total billed charges,Implant Device,262.5,35,,262.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,555,
ARTHREX AR-8967-1895 CANN SCREW 6.7X95,C1713,HCPCS,,79007535,CDM,278,RC,,,both,,,1074,794.76,,,794.76,Other,150% of Medicare + 9.63% HCRA Surcharge,483.3,45,,483.3,percent of total billed charges,Critical Access Hospital RCC factor,365.16,34,,365.16,percent of total billed charges,Implant Device,365.16,34,,365.16,percent of total billed charges,Implant Device,365.16,34,,365.16,percent of total billed charges,Implant Device,365.16,34,,365.16,percent of total billed charges,Implant Device,365.16,34,,365.16,percent of total billed charges,Implant Device,531.63,,,531.63,Other,110% of Medicare,375.9,35,,375.9,percent of total billed charges,Implant Device,365.16,34,"Charges > $500, x 34%",365.16,percent of total billed charges,Implant Device,375.9,35,,375.9,percent of total billed charges,Implant Device,375.9,35,,375.9,percent of total billed charges,Implant Device,375.9,35,,375.9,percent of total billed charges,Implant Device,375.9,35,,375.9,percent of total billed charges,Implant Device,375.9,35,,375.9,percent of total billed charges,Implant Device,429.6,40,,429.6,percent of total billed charges,Implant Device,375.9,70,,375.9,percent of total billed charges,All Other,365.16,34,,365.16,percent of total billed charges,Implant Device,365.16,34,,365.16,percent of total billed charges,Implant Device,375.9,35,,375.9,percent of total billed charges,Implant Device,375.9,35,,375.9,percent of total billed charges,Implant Device,375.9,35,,375.9,percent of total billed charges,Implant Device,375.9,35,,375.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,794.76,
ARTHREX AR-8970-09T BB-TAK LG THREADED,C1713,HCPCS,,79007537,CDM,278,RC,,,both,,,450,333,,,333,Other,150% of Medicare + 9.63% HCRA Surcharge,202.5,45,,202.5,percent of total billed charges,Critical Access Hospital RCC factor,153,34,,153,percent of total billed charges,Implant Device,153,34,,153,percent of total billed charges,Implant Device,153,34,,153,percent of total billed charges,Implant Device,153,34,,153,percent of total billed charges,Implant Device,153,34,,153,percent of total billed charges,Implant Device,222.75,,,222.75,Other,110% of Medicare,157.5,35,,157.5,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,157.5,35,,157.5,percent of total billed charges,Implant Device,157.5,35,,157.5,percent of total billed charges,Implant Device,157.5,35,,157.5,percent of total billed charges,Implant Device,157.5,35,,157.5,percent of total billed charges,Implant Device,157.5,35,,157.5,percent of total billed charges,Implant Device,180,40,,180,percent of total billed charges,Implant Device,157.5,70,,157.5,percent of total billed charges,All Other,153,34,,153,percent of total billed charges,Implant Device,153,34,,153,percent of total billed charges,Implant Device,157.5,35,,157.5,percent of total billed charges,Implant Device,157.5,35,,157.5,percent of total billed charges,Implant Device,157.5,35,,157.5,percent of total billed charges,Implant Device,157.5,35,,157.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,333,
DEPUY 02.240.244 CANN SCREW 3.7X44MM,C1713,HCPCS,,79007540,CDM,278,RC,,,both,,,690,510.6,,,510.6,Other,150% of Medicare + 9.63% HCRA Surcharge,310.5,45,,310.5,percent of total billed charges,Critical Access Hospital RCC factor,234.6,34,,234.6,percent of total billed charges,Implant Device,234.6,34,,234.6,percent of total billed charges,Implant Device,234.6,34,,234.6,percent of total billed charges,Implant Device,234.6,34,,234.6,percent of total billed charges,Implant Device,234.6,34,,234.6,percent of total billed charges,Implant Device,341.55,,,341.55,Other,110% of Medicare,241.5,35,,241.5,percent of total billed charges,Implant Device,234.6,34,"Charges > $500, x 34%",234.6,percent of total billed charges,Implant Device,241.5,35,,241.5,percent of total billed charges,Implant Device,241.5,35,,241.5,percent of total billed charges,Implant Device,241.5,35,,241.5,percent of total billed charges,Implant Device,241.5,35,,241.5,percent of total billed charges,Implant Device,241.5,35,,241.5,percent of total billed charges,Implant Device,276,40,,276,percent of total billed charges,Implant Device,241.5,70,,241.5,percent of total billed charges,All Other,234.6,34,,234.6,percent of total billed charges,Implant Device,234.6,34,,234.6,percent of total billed charges,Implant Device,241.5,35,,241.5,percent of total billed charges,Implant Device,241.5,35,,241.5,percent of total billed charges,Implant Device,241.5,35,,241.5,percent of total billed charges,Implant Device,241.5,35,,241.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,510.6,
ARTHREX ABS-3008 QUICKSET KIT CA PO,C1713,HCPCS,,79007541,CDM,278,RC,,,both,,,5985,4428.91,,,4428.91,Other,150% of Medicare + 9.63% HCRA Surcharge,2693.25,45,,2693.25,percent of total billed charges,Critical Access Hospital RCC factor,2034.9,34,,2034.9,percent of total billed charges,Implant Device,2034.9,34,,2034.9,percent of total billed charges,Implant Device,2034.9,34,,2034.9,percent of total billed charges,Implant Device,2034.9,34,,2034.9,percent of total billed charges,Implant Device,2034.9,34,,2034.9,percent of total billed charges,Implant Device,2962.58,,,2962.58,Other,110% of Medicare,2094.75,35,,2094.75,percent of total billed charges,Implant Device,2034.9,34,"Charges > $500, x 34%",2034.9,percent of total billed charges,Implant Device,2094.75,35,,2094.75,percent of total billed charges,Implant Device,2094.75,35,,2094.75,percent of total billed charges,Implant Device,2094.75,35,,2094.75,percent of total billed charges,Implant Device,2094.75,35,,2094.75,percent of total billed charges,Implant Device,2094.75,35,,2094.75,percent of total billed charges,Implant Device,2394,40,,2394,percent of total billed charges,Implant Device,2094.75,70,,2094.75,percent of total billed charges,All Other,2034.9,34,,2034.9,percent of total billed charges,Implant Device,2034.9,34,,2034.9,percent of total billed charges,Implant Device,2094.75,35,,2094.75,percent of total billed charges,Implant Device,2094.75,35,,2094.75,percent of total billed charges,Implant Device,2094.75,35,,2094.75,percent of total billed charges,Implant Device,2094.75,35,,2094.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2034.9,34,"If Charge > 2,000, then 34 percent",2034.9,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4428.91,
DEPUY 1035-47-000 BIPOLAR HEAD 28X47MM,C1776,HCPCS,,79007542,CDM,278,RC,,,both,,,1733,1282.42,,,1282.42,Other,150% of Medicare + 9.63% HCRA Surcharge,779.85,45,,779.85,percent of total billed charges,Critical Access Hospital RCC factor,589.22,34,,589.22,percent of total billed charges,Implant Device,589.22,34,,589.22,percent of total billed charges,Implant Device,589.22,34,,589.22,percent of total billed charges,Implant Device,589.22,34,,589.22,percent of total billed charges,Implant Device,589.22,34,,589.22,percent of total billed charges,Implant Device,857.84,,,857.84,Other,110% of Medicare,606.55,35,,606.55,percent of total billed charges,Implant Device,589.22,34,"Charges > $500, x 34%",589.22,percent of total billed charges,Implant Device,606.55,35,,606.55,percent of total billed charges,Implant Device,606.55,35,,606.55,percent of total billed charges,Implant Device,606.55,35,,606.55,percent of total billed charges,Implant Device,606.55,35,,606.55,percent of total billed charges,Implant Device,606.55,35,,606.55,percent of total billed charges,Implant Device,693.2,40,,693.2,percent of total billed charges,Implant Device,606.55,70,,606.55,percent of total billed charges,All Other,589.22,34,,589.22,percent of total billed charges,Implant Device,589.22,34,,589.22,percent of total billed charges,Implant Device,606.55,35,,606.55,percent of total billed charges,Implant Device,606.55,35,,606.55,percent of total billed charges,Implant Device,606.55,35,,606.55,percent of total billed charges,Implant Device,606.55,35,,606.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1282.42,
BIOTRONIK 350974 SETROX S 53 LEAD,C1898,HCPCS,,79007543,CDM,278,RC,,,both,,,1800,1332,,,1332,Other,150% of Medicare + 9.63% HCRA Surcharge,810,45,,810,percent of total billed charges,Critical Access Hospital RCC factor,612,34,,612,percent of total billed charges,Implant Device,612,34,,612,percent of total billed charges,Implant Device,612,34,,612,percent of total billed charges,Implant Device,612,34,,612,percent of total billed charges,Implant Device,612,34,,612,percent of total billed charges,Implant Device,891,,,891,Other,110% of Medicare,630,35,,630,percent of total billed charges,Implant Device,612,34,"Charges > $500, x 34%",612,percent of total billed charges,Implant Device,630,35,,630,percent of total billed charges,Implant Device,630,35,,630,percent of total billed charges,Implant Device,630,35,,630,percent of total billed charges,Implant Device,630,35,,630,percent of total billed charges,Implant Device,630,35,,630,percent of total billed charges,Implant Device,720,40,,720,percent of total billed charges,Implant Device,630,70,,630,percent of total billed charges,All Other,612,34,,612,percent of total billed charges,Implant Device,612,34,,612,percent of total billed charges,Implant Device,630,35,,630,percent of total billed charges,Implant Device,630,35,,630,percent of total billed charges,Implant Device,630,35,,630,percent of total billed charges,Implant Device,630,35,,630,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1332,
MICROAIRE 1620-509 PIN 2.0X5X64 SMOOTH,C1713,HCPCS,,79007545,CDM,278,RC,,,both,,,10,7.4,,,7.4,Other,150% of Medicare + 9.63% HCRA Surcharge,4.5,45,,4.5,percent of total billed charges,Critical Access Hospital RCC factor,3.4,34,,3.4,percent of total billed charges,Implant Device,3.4,34,,3.4,percent of total billed charges,Implant Device,3.4,34,,3.4,percent of total billed charges,Implant Device,3.4,34,,3.4,percent of total billed charges,Implant Device,3.4,34,,3.4,percent of total billed charges,Implant Device,4.95,,,4.95,Other,110% of Medicare,3.5,35,,3.5,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,3.5,35,,3.5,percent of total billed charges,Implant Device,3.5,35,,3.5,percent of total billed charges,Implant Device,3.5,35,,3.5,percent of total billed charges,Implant Device,3.5,35,,3.5,percent of total billed charges,Implant Device,3.5,35,,3.5,percent of total billed charges,Implant Device,4,40,,4,percent of total billed charges,Implant Device,3.5,70,,3.5,percent of total billed charges,All Other,3.4,34,,3.4,percent of total billed charges,Implant Device,3.4,34,,3.4,percent of total billed charges,Implant Device,3.5,35,,3.5,percent of total billed charges,Implant Device,3.5,35,,3.5,percent of total billed charges,Implant Device,3.5,35,,3.5,percent of total billed charges,Implant Device,3.5,35,,3.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,7.4,
MICROAIRE 1620-509T PIN 2.0X5X64 THREAD,C1713,HCPCS,,79007546,CDM,278,RC,,,both,,,25,18.5,,,18.5,Other,150% of Medicare + 9.63% HCRA Surcharge,11.25,45,,11.25,percent of total billed charges,Critical Access Hospital RCC factor,8.5,34,,8.5,percent of total billed charges,Implant Device,8.5,34,,8.5,percent of total billed charges,Implant Device,8.5,34,,8.5,percent of total billed charges,Implant Device,8.5,34,,8.5,percent of total billed charges,Implant Device,8.5,34,,8.5,percent of total billed charges,Implant Device,12.38,,,12.38,Other,110% of Medicare,8.75,35,,8.75,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,8.75,35,,8.75,percent of total billed charges,Implant Device,8.75,35,,8.75,percent of total billed charges,Implant Device,8.75,35,,8.75,percent of total billed charges,Implant Device,8.75,35,,8.75,percent of total billed charges,Implant Device,8.75,35,,8.75,percent of total billed charges,Implant Device,10,40,,10,percent of total billed charges,Implant Device,8.75,70,,8.75,percent of total billed charges,All Other,8.5,34,,8.5,percent of total billed charges,Implant Device,8.5,34,,8.5,percent of total billed charges,Implant Device,8.75,35,,8.75,percent of total billed charges,Implant Device,8.75,35,,8.75,percent of total billed charges,Implant Device,8.75,35,,8.75,percent of total billed charges,Implant Device,8.75,35,,8.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,18.5,
MICROAIRE 1624-509 PIN 2.4X3X32 SMOOTH,C1713,HCPCS,,79007547,CDM,278,RC,,,both,,,12,8.88,,,8.88,Other,150% of Medicare + 9.63% HCRA Surcharge,5.4,45,,5.4,percent of total billed charges,Critical Access Hospital RCC factor,4.08,34,,4.08,percent of total billed charges,Implant Device,4.08,34,,4.08,percent of total billed charges,Implant Device,4.08,34,,4.08,percent of total billed charges,Implant Device,4.08,34,,4.08,percent of total billed charges,Implant Device,4.08,34,,4.08,percent of total billed charges,Implant Device,5.94,,,5.94,Other,110% of Medicare,4.2,35,,4.2,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,4.2,35,,4.2,percent of total billed charges,Implant Device,4.2,35,,4.2,percent of total billed charges,Implant Device,4.2,35,,4.2,percent of total billed charges,Implant Device,4.2,35,,4.2,percent of total billed charges,Implant Device,4.2,35,,4.2,percent of total billed charges,Implant Device,4.8,40,,4.8,percent of total billed charges,Implant Device,4.2,70,,4.2,percent of total billed charges,All Other,4.08,34,,4.08,percent of total billed charges,Implant Device,4.08,34,,4.08,percent of total billed charges,Implant Device,4.2,35,,4.2,percent of total billed charges,Implant Device,4.2,35,,4.2,percent of total billed charges,Implant Device,4.2,35,,4.2,percent of total billed charges,Implant Device,4.2,35,,4.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,8.88,
MICORAIRE 1624-509T PIN 2.4X3X32 THREAD,C1713,HCPCS,,79007548,CDM,278,RC,,,both,,,25,18.5,,,18.5,Other,150% of Medicare + 9.63% HCRA Surcharge,11.25,45,,11.25,percent of total billed charges,Critical Access Hospital RCC factor,8.5,34,,8.5,percent of total billed charges,Implant Device,8.5,34,,8.5,percent of total billed charges,Implant Device,8.5,34,,8.5,percent of total billed charges,Implant Device,8.5,34,,8.5,percent of total billed charges,Implant Device,8.5,34,,8.5,percent of total billed charges,Implant Device,12.38,,,12.38,Other,110% of Medicare,8.75,35,,8.75,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,8.75,35,,8.75,percent of total billed charges,Implant Device,8.75,35,,8.75,percent of total billed charges,Implant Device,8.75,35,,8.75,percent of total billed charges,Implant Device,8.75,35,,8.75,percent of total billed charges,Implant Device,8.75,35,,8.75,percent of total billed charges,Implant Device,10,40,,10,percent of total billed charges,Implant Device,8.75,70,,8.75,percent of total billed charges,All Other,8.5,34,,8.5,percent of total billed charges,Implant Device,8.5,34,,8.5,percent of total billed charges,Implant Device,8.75,35,,8.75,percent of total billed charges,Implant Device,8.75,35,,8.75,percent of total billed charges,Implant Device,8.75,35,,8.75,percent of total billed charges,Implant Device,8.75,35,,8.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,18.5,
MICROAIRE 1628-509 PIN 2.8X7X64 SMOOTH,C1713,HCPCS,,79007549,CDM,278,RC,,,both,,,12,8.88,,,8.88,Other,150% of Medicare + 9.63% HCRA Surcharge,5.4,45,,5.4,percent of total billed charges,Critical Access Hospital RCC factor,4.08,34,,4.08,percent of total billed charges,Implant Device,4.08,34,,4.08,percent of total billed charges,Implant Device,4.08,34,,4.08,percent of total billed charges,Implant Device,4.08,34,,4.08,percent of total billed charges,Implant Device,4.08,34,,4.08,percent of total billed charges,Implant Device,5.94,,,5.94,Other,110% of Medicare,4.2,35,,4.2,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,4.2,35,,4.2,percent of total billed charges,Implant Device,4.2,35,,4.2,percent of total billed charges,Implant Device,4.2,35,,4.2,percent of total billed charges,Implant Device,4.2,35,,4.2,percent of total billed charges,Implant Device,4.2,35,,4.2,percent of total billed charges,Implant Device,4.8,40,,4.8,percent of total billed charges,Implant Device,4.2,70,,4.2,percent of total billed charges,All Other,4.08,34,,4.08,percent of total billed charges,Implant Device,4.08,34,,4.08,percent of total billed charges,Implant Device,4.2,35,,4.2,percent of total billed charges,Implant Device,4.2,35,,4.2,percent of total billed charges,Implant Device,4.2,35,,4.2,percent of total billed charges,Implant Device,4.2,35,,4.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,8.88,
MICROAIRE 1628-509T PIN 2.8X7X64 THREAD,C1713,HCPCS,,79007550,CDM,278,RC,,,both,,,25,18.5,,,18.5,Other,150% of Medicare + 9.63% HCRA Surcharge,11.25,45,,11.25,percent of total billed charges,Critical Access Hospital RCC factor,8.5,34,,8.5,percent of total billed charges,Implant Device,8.5,34,,8.5,percent of total billed charges,Implant Device,8.5,34,,8.5,percent of total billed charges,Implant Device,8.5,34,,8.5,percent of total billed charges,Implant Device,8.5,34,,8.5,percent of total billed charges,Implant Device,12.38,,,12.38,Other,110% of Medicare,8.75,35,,8.75,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,8.75,35,,8.75,percent of total billed charges,Implant Device,8.75,35,,8.75,percent of total billed charges,Implant Device,8.75,35,,8.75,percent of total billed charges,Implant Device,8.75,35,,8.75,percent of total billed charges,Implant Device,8.75,35,,8.75,percent of total billed charges,Implant Device,10,40,,10,percent of total billed charges,Implant Device,8.75,70,,8.75,percent of total billed charges,All Other,8.5,34,,8.5,percent of total billed charges,Implant Device,8.5,34,,8.5,percent of total billed charges,Implant Device,8.75,35,,8.75,percent of total billed charges,Implant Device,8.75,35,,8.75,percent of total billed charges,Implant Device,8.75,35,,8.75,percent of total billed charges,Implant Device,8.75,35,,8.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,18.5,
MICROAIRE 1632-509 PIN 3.2X1X8 SMOOTH,C1713,HCPCS,,79007551,CDM,278,RC,,,both,,,12,8.88,,,8.88,Other,150% of Medicare + 9.63% HCRA Surcharge,5.4,45,,5.4,percent of total billed charges,Critical Access Hospital RCC factor,4.08,34,,4.08,percent of total billed charges,Implant Device,4.08,34,,4.08,percent of total billed charges,Implant Device,4.08,34,,4.08,percent of total billed charges,Implant Device,4.08,34,,4.08,percent of total billed charges,Implant Device,4.08,34,,4.08,percent of total billed charges,Implant Device,5.94,,,5.94,Other,110% of Medicare,4.2,35,,4.2,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,4.2,35,,4.2,percent of total billed charges,Implant Device,4.2,35,,4.2,percent of total billed charges,Implant Device,4.2,35,,4.2,percent of total billed charges,Implant Device,4.2,35,,4.2,percent of total billed charges,Implant Device,4.2,35,,4.2,percent of total billed charges,Implant Device,4.8,40,,4.8,percent of total billed charges,Implant Device,4.2,70,,4.2,percent of total billed charges,All Other,4.08,34,,4.08,percent of total billed charges,Implant Device,4.08,34,,4.08,percent of total billed charges,Implant Device,4.2,35,,4.2,percent of total billed charges,Implant Device,4.2,35,,4.2,percent of total billed charges,Implant Device,4.2,35,,4.2,percent of total billed charges,Implant Device,4.2,35,,4.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,8.88,
MICROAIRE 1632-509T PIN 3.2X1X8 THREAD,C1713,HCPCS,,79007552,CDM,278,RC,,,both,,,25,18.5,,,18.5,Other,150% of Medicare + 9.63% HCRA Surcharge,11.25,45,,11.25,percent of total billed charges,Critical Access Hospital RCC factor,8.5,34,,8.5,percent of total billed charges,Implant Device,8.5,34,,8.5,percent of total billed charges,Implant Device,8.5,34,,8.5,percent of total billed charges,Implant Device,8.5,34,,8.5,percent of total billed charges,Implant Device,8.5,34,,8.5,percent of total billed charges,Implant Device,12.38,,,12.38,Other,110% of Medicare,8.75,35,,8.75,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,8.75,35,,8.75,percent of total billed charges,Implant Device,8.75,35,,8.75,percent of total billed charges,Implant Device,8.75,35,,8.75,percent of total billed charges,Implant Device,8.75,35,,8.75,percent of total billed charges,Implant Device,8.75,35,,8.75,percent of total billed charges,Implant Device,10,40,,10,percent of total billed charges,Implant Device,8.75,70,,8.75,percent of total billed charges,All Other,8.5,34,,8.5,percent of total billed charges,Implant Device,8.5,34,,8.5,percent of total billed charges,Implant Device,8.75,35,,8.75,percent of total billed charges,Implant Device,8.75,35,,8.75,percent of total billed charges,Implant Device,8.75,35,,8.75,percent of total billed charges,Implant Device,8.75,35,,8.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,18.5,
MICROAIRE 1636-509 PIN 3.6X9X64 SMOOTH,C1713,HCPCS,,79007553,CDM,278,RC,,,both,,,12,8.88,,,8.88,Other,150% of Medicare + 9.63% HCRA Surcharge,5.4,45,,5.4,percent of total billed charges,Critical Access Hospital RCC factor,4.08,34,,4.08,percent of total billed charges,Implant Device,4.08,34,,4.08,percent of total billed charges,Implant Device,4.08,34,,4.08,percent of total billed charges,Implant Device,4.08,34,,4.08,percent of total billed charges,Implant Device,4.08,34,,4.08,percent of total billed charges,Implant Device,5.94,,,5.94,Other,110% of Medicare,4.2,35,,4.2,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,4.2,35,,4.2,percent of total billed charges,Implant Device,4.2,35,,4.2,percent of total billed charges,Implant Device,4.2,35,,4.2,percent of total billed charges,Implant Device,4.2,35,,4.2,percent of total billed charges,Implant Device,4.2,35,,4.2,percent of total billed charges,Implant Device,4.8,40,,4.8,percent of total billed charges,Implant Device,4.2,70,,4.2,percent of total billed charges,All Other,4.08,34,,4.08,percent of total billed charges,Implant Device,4.08,34,,4.08,percent of total billed charges,Implant Device,4.2,35,,4.2,percent of total billed charges,Implant Device,4.2,35,,4.2,percent of total billed charges,Implant Device,4.2,35,,4.2,percent of total billed charges,Implant Device,4.2,35,,4.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,8.88,
MICROAIRE 1636-509T PIN 3.6X9X64 THREAD,C1713,HCPCS,,79007554,CDM,278,RC,,,both,,,25,18.5,,,18.5,Other,150% of Medicare + 9.63% HCRA Surcharge,11.25,45,,11.25,percent of total billed charges,Critical Access Hospital RCC factor,8.5,34,,8.5,percent of total billed charges,Implant Device,8.5,34,,8.5,percent of total billed charges,Implant Device,8.5,34,,8.5,percent of total billed charges,Implant Device,8.5,34,,8.5,percent of total billed charges,Implant Device,8.5,34,,8.5,percent of total billed charges,Implant Device,12.38,,,12.38,Other,110% of Medicare,8.75,35,,8.75,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,8.75,35,,8.75,percent of total billed charges,Implant Device,8.75,35,,8.75,percent of total billed charges,Implant Device,8.75,35,,8.75,percent of total billed charges,Implant Device,8.75,35,,8.75,percent of total billed charges,Implant Device,8.75,35,,8.75,percent of total billed charges,Implant Device,10,40,,10,percent of total billed charges,Implant Device,8.75,70,,8.75,percent of total billed charges,All Other,8.5,34,,8.5,percent of total billed charges,Implant Device,8.5,34,,8.5,percent of total billed charges,Implant Device,8.75,35,,8.75,percent of total billed charges,Implant Device,8.75,35,,8.75,percent of total billed charges,Implant Device,8.75,35,,8.75,percent of total billed charges,Implant Device,8.75,35,,8.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,18.5,
MICROAIRE 1640-509 PIN 4.0X5X32 SMOOTH,C1713,HCPCS,,79007555,CDM,278,RC,,,both,,,41,30.34,,,30.34,Other,150% of Medicare + 9.63% HCRA Surcharge,18.45,45,,18.45,percent of total billed charges,Critical Access Hospital RCC factor,13.94,34,,13.94,percent of total billed charges,Implant Device,13.94,34,,13.94,percent of total billed charges,Implant Device,13.94,34,,13.94,percent of total billed charges,Implant Device,13.94,34,,13.94,percent of total billed charges,Implant Device,13.94,34,,13.94,percent of total billed charges,Implant Device,20.3,,,20.3,Other,110% of Medicare,14.35,35,,14.35,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,14.35,35,,14.35,percent of total billed charges,Implant Device,14.35,35,,14.35,percent of total billed charges,Implant Device,14.35,35,,14.35,percent of total billed charges,Implant Device,14.35,35,,14.35,percent of total billed charges,Implant Device,14.35,35,,14.35,percent of total billed charges,Implant Device,16.4,40,,16.4,percent of total billed charges,Implant Device,14.35,70,,14.35,percent of total billed charges,All Other,13.94,34,,13.94,percent of total billed charges,Implant Device,13.94,34,,13.94,percent of total billed charges,Implant Device,14.35,35,,14.35,percent of total billed charges,Implant Device,14.35,35,,14.35,percent of total billed charges,Implant Device,14.35,35,,14.35,percent of total billed charges,Implant Device,14.35,35,,14.35,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,30.34,
MICROAIRE 1640-509T PIN 4.0X5X32 THREAD,C1713,HCPCS,,79007556,CDM,278,RC,,,both,,,25,18.5,,,18.5,Other,150% of Medicare + 9.63% HCRA Surcharge,11.25,45,,11.25,percent of total billed charges,Critical Access Hospital RCC factor,8.5,34,,8.5,percent of total billed charges,Implant Device,8.5,34,,8.5,percent of total billed charges,Implant Device,8.5,34,,8.5,percent of total billed charges,Implant Device,8.5,34,,8.5,percent of total billed charges,Implant Device,8.5,34,,8.5,percent of total billed charges,Implant Device,12.38,,,12.38,Other,110% of Medicare,8.75,35,,8.75,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,8.75,35,,8.75,percent of total billed charges,Implant Device,8.75,35,,8.75,percent of total billed charges,Implant Device,8.75,35,,8.75,percent of total billed charges,Implant Device,8.75,35,,8.75,percent of total billed charges,Implant Device,8.75,35,,8.75,percent of total billed charges,Implant Device,10,40,,10,percent of total billed charges,Implant Device,8.75,70,,8.75,percent of total billed charges,All Other,8.5,34,,8.5,percent of total billed charges,Implant Device,8.5,34,,8.5,percent of total billed charges,Implant Device,8.75,35,,8.75,percent of total billed charges,Implant Device,8.75,35,,8.75,percent of total billed charges,Implant Device,8.75,35,,8.75,percent of total billed charges,Implant Device,8.75,35,,8.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,18.5,
MICORAIRE 1648-509 PIN 4.8X3X16 SMOOTH,C1713,HCPCS,,79007557,CDM,278,RC,,,both,,,13,9.62,,,9.62,Other,150% of Medicare + 9.63% HCRA Surcharge,5.85,45,,5.85,percent of total billed charges,Critical Access Hospital RCC factor,4.42,34,,4.42,percent of total billed charges,Implant Device,4.42,34,,4.42,percent of total billed charges,Implant Device,4.42,34,,4.42,percent of total billed charges,Implant Device,4.42,34,,4.42,percent of total billed charges,Implant Device,4.42,34,,4.42,percent of total billed charges,Implant Device,6.44,,,6.44,Other,110% of Medicare,4.55,35,,4.55,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,4.55,35,,4.55,percent of total billed charges,Implant Device,4.55,35,,4.55,percent of total billed charges,Implant Device,4.55,35,,4.55,percent of total billed charges,Implant Device,4.55,35,,4.55,percent of total billed charges,Implant Device,4.55,35,,4.55,percent of total billed charges,Implant Device,5.2,40,,5.2,percent of total billed charges,Implant Device,4.55,70,,4.55,percent of total billed charges,All Other,4.42,34,,4.42,percent of total billed charges,Implant Device,4.42,34,,4.42,percent of total billed charges,Implant Device,4.55,35,,4.55,percent of total billed charges,Implant Device,4.55,35,,4.55,percent of total billed charges,Implant Device,4.55,35,,4.55,percent of total billed charges,Implant Device,4.55,35,,4.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,9.62,
MICROAIRE 1648-509T PIN 4.8X3X16 THREAD,C1713,HCPCS,,79007558,CDM,278,RC,,,both,,,70,51.8,,,51.8,Other,150% of Medicare + 9.63% HCRA Surcharge,31.5,45,,31.5,percent of total billed charges,Critical Access Hospital RCC factor,23.8,34,,23.8,percent of total billed charges,Implant Device,23.8,34,,23.8,percent of total billed charges,Implant Device,23.8,34,,23.8,percent of total billed charges,Implant Device,23.8,34,,23.8,percent of total billed charges,Implant Device,23.8,34,,23.8,percent of total billed charges,Implant Device,34.65,,,34.65,Other,110% of Medicare,24.5,35,,24.5,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,24.5,35,,24.5,percent of total billed charges,Implant Device,24.5,35,,24.5,percent of total billed charges,Implant Device,24.5,35,,24.5,percent of total billed charges,Implant Device,24.5,35,,24.5,percent of total billed charges,Implant Device,24.5,35,,24.5,percent of total billed charges,Implant Device,28,40,,28,percent of total billed charges,Implant Device,24.5,70,,24.5,percent of total billed charges,All Other,23.8,34,,23.8,percent of total billed charges,Implant Device,23.8,34,,23.8,percent of total billed charges,Implant Device,24.5,35,,24.5,percent of total billed charges,Implant Device,24.5,35,,24.5,percent of total billed charges,Implant Device,24.5,35,,24.5,percent of total billed charges,Implant Device,24.5,35,,24.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,51.8,
STRYKER 54-25573 PLATE LEFT NARROW,C1713,HCPCS,,79007560,CDM,278,RC,,,both,,,5208,3853.93,,,3853.93,Other,150% of Medicare + 9.63% HCRA Surcharge,2343.6,45,,2343.6,percent of total billed charges,Critical Access Hospital RCC factor,1770.72,34,,1770.72,percent of total billed charges,Implant Device,1770.72,34,,1770.72,percent of total billed charges,Implant Device,1770.72,34,,1770.72,percent of total billed charges,Implant Device,1770.72,34,,1770.72,percent of total billed charges,Implant Device,1770.72,34,,1770.72,percent of total billed charges,Implant Device,2577.96,,,2577.96,Other,110% of Medicare,1822.8,35,,1822.8,percent of total billed charges,Implant Device,1770.72,34,"Charges > $500, x 34%",1770.72,percent of total billed charges,Implant Device,1822.8,35,,1822.8,percent of total billed charges,Implant Device,1822.8,35,,1822.8,percent of total billed charges,Implant Device,1822.8,35,,1822.8,percent of total billed charges,Implant Device,1822.8,35,,1822.8,percent of total billed charges,Implant Device,1822.8,35,,1822.8,percent of total billed charges,Implant Device,2083.2,40,,2083.2,percent of total billed charges,Implant Device,1822.8,70,,1822.8,percent of total billed charges,All Other,1770.72,34,,1770.72,percent of total billed charges,Implant Device,1770.72,34,,1770.72,percent of total billed charges,Implant Device,1822.8,35,,1822.8,percent of total billed charges,Implant Device,1822.8,35,,1822.8,percent of total billed charges,Implant Device,1822.8,35,,1822.8,percent of total billed charges,Implant Device,1822.8,35,,1822.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1770.72,34,"If Charge > 2,000, then 34 percent",1770.72,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3853.93,
STRYKER 6276-7-315 MOD HIP SYS 235X15MM,C1776,HCPCS,,79007561,CDM,278,RC,,,both,,,16079,11898.5,,,11898.5,Other,150% of Medicare + 9.63% HCRA Surcharge,7235.55,45,,7235.55,percent of total billed charges,Critical Access Hospital RCC factor,5466.86,34,,5466.86,percent of total billed charges,Implant Device,5466.86,34,,5466.86,percent of total billed charges,Implant Device,5466.86,34,,5466.86,percent of total billed charges,Implant Device,5466.86,34,,5466.86,percent of total billed charges,Implant Device,5466.86,34,,5466.86,percent of total billed charges,Implant Device,7959.11,,,7959.11,Other,110% of Medicare,5627.65,35,,5627.65,percent of total billed charges,Implant Device,5466.86,34,"Charges > $500, x 34%",5466.86,percent of total billed charges,Implant Device,5627.65,35,,5627.65,percent of total billed charges,Implant Device,5627.65,35,,5627.65,percent of total billed charges,Implant Device,5627.65,35,,5627.65,percent of total billed charges,Implant Device,5627.65,35,,5627.65,percent of total billed charges,Implant Device,5627.65,35,,5627.65,percent of total billed charges,Implant Device,6431.6,40,,6431.6,percent of total billed charges,Implant Device,5627.65,70,,5627.65,percent of total billed charges,All Other,5466.86,34,,5466.86,percent of total billed charges,Implant Device,5466.86,34,,5466.86,percent of total billed charges,Implant Device,5627.65,35,,5627.65,percent of total billed charges,Implant Device,5627.65,35,,5627.65,percent of total billed charges,Implant Device,5627.65,35,,5627.65,percent of total billed charges,Implant Device,5627.65,35,,5627.65,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,5466.86,34,"If Charge > 2,000, then 34 percent",5466.86,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,11898.5,
STRYKER UH1-51-26 BIPOLAR COMP 51X26MM,C1776,HCPCS,,79007562,CDM,278,RC,,,both,,,1391,1029.34,,,1029.34,Other,150% of Medicare + 9.63% HCRA Surcharge,625.95,45,,625.95,percent of total billed charges,Critical Access Hospital RCC factor,472.94,34,,472.94,percent of total billed charges,Implant Device,472.94,34,,472.94,percent of total billed charges,Implant Device,472.94,34,,472.94,percent of total billed charges,Implant Device,472.94,34,,472.94,percent of total billed charges,Implant Device,472.94,34,,472.94,percent of total billed charges,Implant Device,688.55,,,688.55,Other,110% of Medicare,486.85,35,,486.85,percent of total billed charges,Implant Device,472.94,34,"Charges > $500, x 34%",472.94,percent of total billed charges,Implant Device,486.85,35,,486.85,percent of total billed charges,Implant Device,486.85,35,,486.85,percent of total billed charges,Implant Device,486.85,35,,486.85,percent of total billed charges,Implant Device,486.85,35,,486.85,percent of total billed charges,Implant Device,486.85,35,,486.85,percent of total billed charges,Implant Device,556.4,40,,556.4,percent of total billed charges,Implant Device,486.85,70,,486.85,percent of total billed charges,All Other,472.94,34,,472.94,percent of total billed charges,Implant Device,472.94,34,,472.94,percent of total billed charges,Implant Device,486.85,35,,486.85,percent of total billed charges,Implant Device,486.85,35,,486.85,percent of total billed charges,Implant Device,486.85,35,,486.85,percent of total billed charges,Implant Device,486.85,35,,486.85,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1029.34,
STRYKER 57-15385 5 HOLE PLATE 2.3 ROTATN,C1713,HCPCS,,79007566,CDM,278,RC,,,both,,,1877,1388.98,,,1388.98,Other,150% of Medicare + 9.63% HCRA Surcharge,844.65,45,,844.65,percent of total billed charges,Critical Access Hospital RCC factor,638.18,34,,638.18,percent of total billed charges,Implant Device,638.18,34,,638.18,percent of total billed charges,Implant Device,638.18,34,,638.18,percent of total billed charges,Implant Device,638.18,34,,638.18,percent of total billed charges,Implant Device,638.18,34,,638.18,percent of total billed charges,Implant Device,929.12,,,929.12,Other,110% of Medicare,656.95,35,,656.95,percent of total billed charges,Implant Device,638.18,34,"Charges > $500, x 34%",638.18,percent of total billed charges,Implant Device,656.95,35,,656.95,percent of total billed charges,Implant Device,656.95,35,,656.95,percent of total billed charges,Implant Device,656.95,35,,656.95,percent of total billed charges,Implant Device,656.95,35,,656.95,percent of total billed charges,Implant Device,656.95,35,,656.95,percent of total billed charges,Implant Device,750.8,40,,750.8,percent of total billed charges,Implant Device,656.95,70,,656.95,percent of total billed charges,All Other,638.18,34,,638.18,percent of total billed charges,Implant Device,638.18,34,,638.18,percent of total billed charges,Implant Device,656.95,35,,656.95,percent of total billed charges,Implant Device,656.95,35,,656.95,percent of total billed charges,Implant Device,656.95,35,,656.95,percent of total billed charges,Implant Device,656.95,35,,656.95,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1388.98,
ALPHATEC SPINE 71001-16 PLATE 16MM,C1713,HCPCS,,79007575,CDM,278,RC,,,both,,,2280,1687.21,,,1687.21,Other,150% of Medicare + 9.63% HCRA Surcharge,1026,45,,1026,percent of total billed charges,Critical Access Hospital RCC factor,775.2,34,,775.2,percent of total billed charges,Implant Device,775.2,34,,775.2,percent of total billed charges,Implant Device,775.2,34,,775.2,percent of total billed charges,Implant Device,775.2,34,,775.2,percent of total billed charges,Implant Device,775.2,34,,775.2,percent of total billed charges,Implant Device,1128.6,,,1128.6,Other,110% of Medicare,798,35,,798,percent of total billed charges,Implant Device,775.2,34,"Charges > $500, x 34%",775.2,percent of total billed charges,Implant Device,798,35,,798,percent of total billed charges,Implant Device,798,35,,798,percent of total billed charges,Implant Device,798,35,,798,percent of total billed charges,Implant Device,798,35,,798,percent of total billed charges,Implant Device,798,35,,798,percent of total billed charges,Implant Device,912,40,,912,percent of total billed charges,Implant Device,798,70,,798,percent of total billed charges,All Other,775.2,34,,775.2,percent of total billed charges,Implant Device,775.2,34,,775.2,percent of total billed charges,Implant Device,798,35,,798,percent of total billed charges,Implant Device,798,35,,798,percent of total billed charges,Implant Device,798,35,,798,percent of total billed charges,Implant Device,798,35,,798,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,775.2,34,"If Charge > 2,000, then 34 percent",775.2,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1687.21,
ARTHREX AR-8740-28PTS CANN SCREW 4X28MM,C1713,HCPCS,,79007576,CDM,278,RC,,,both,,,708,523.92,,,523.92,Other,150% of Medicare + 9.63% HCRA Surcharge,318.6,45,,318.6,percent of total billed charges,Critical Access Hospital RCC factor,240.72,34,,240.72,percent of total billed charges,Implant Device,240.72,34,,240.72,percent of total billed charges,Implant Device,240.72,34,,240.72,percent of total billed charges,Implant Device,240.72,34,,240.72,percent of total billed charges,Implant Device,240.72,34,,240.72,percent of total billed charges,Implant Device,350.46,,,350.46,Other,110% of Medicare,247.8,35,,247.8,percent of total billed charges,Implant Device,240.72,34,"Charges > $500, x 34%",240.72,percent of total billed charges,Implant Device,247.8,35,,247.8,percent of total billed charges,Implant Device,247.8,35,,247.8,percent of total billed charges,Implant Device,247.8,35,,247.8,percent of total billed charges,Implant Device,247.8,35,,247.8,percent of total billed charges,Implant Device,247.8,35,,247.8,percent of total billed charges,Implant Device,283.2,40,,283.2,percent of total billed charges,Implant Device,247.8,70,,247.8,percent of total billed charges,All Other,240.72,34,,240.72,percent of total billed charges,Implant Device,240.72,34,,240.72,percent of total billed charges,Implant Device,247.8,35,,247.8,percent of total billed charges,Implant Device,247.8,35,,247.8,percent of total billed charges,Implant Device,247.8,35,,247.8,percent of total billed charges,Implant Device,247.8,35,,247.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,523.92,
ARTHREX AR-8004-15 COMP STAPLE 15X15MM,C1713,HCPCS,,79007577,CDM,278,RC,,,both,,,1824,1349.76,,,1349.76,Other,150% of Medicare + 9.63% HCRA Surcharge,820.8,45,,820.8,percent of total billed charges,Critical Access Hospital RCC factor,620.16,34,,620.16,percent of total billed charges,Implant Device,620.16,34,,620.16,percent of total billed charges,Implant Device,620.16,34,,620.16,percent of total billed charges,Implant Device,620.16,34,,620.16,percent of total billed charges,Implant Device,620.16,34,,620.16,percent of total billed charges,Implant Device,902.88,,,902.88,Other,110% of Medicare,638.4,35,,638.4,percent of total billed charges,Implant Device,620.16,34,"Charges > $500, x 34%",620.16,percent of total billed charges,Implant Device,638.4,35,,638.4,percent of total billed charges,Implant Device,638.4,35,,638.4,percent of total billed charges,Implant Device,638.4,35,,638.4,percent of total billed charges,Implant Device,638.4,35,,638.4,percent of total billed charges,Implant Device,638.4,35,,638.4,percent of total billed charges,Implant Device,729.6,40,,729.6,percent of total billed charges,Implant Device,638.4,70,,638.4,percent of total billed charges,All Other,620.16,34,,620.16,percent of total billed charges,Implant Device,620.16,34,,620.16,percent of total billed charges,Implant Device,638.4,35,,638.4,percent of total billed charges,Implant Device,638.4,35,,638.4,percent of total billed charges,Implant Device,638.4,35,,638.4,percent of total billed charges,Implant Device,638.4,35,,638.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1349.76,
DEPUY 02.112.081 CLAVICLE PLATE 3.5X85MM,C1713,HCPCS,,79007579,CDM,278,RC,,,both,,,2397,1773.79,,,1773.79,Other,150% of Medicare + 9.63% HCRA Surcharge,1078.65,45,,1078.65,percent of total billed charges,Critical Access Hospital RCC factor,814.98,34,,814.98,percent of total billed charges,Implant Device,814.98,34,,814.98,percent of total billed charges,Implant Device,814.98,34,,814.98,percent of total billed charges,Implant Device,814.98,34,,814.98,percent of total billed charges,Implant Device,814.98,34,,814.98,percent of total billed charges,Implant Device,1186.52,,,1186.52,Other,110% of Medicare,838.95,35,,838.95,percent of total billed charges,Implant Device,814.98,34,"Charges > $500, x 34%",814.98,percent of total billed charges,Implant Device,838.95,35,,838.95,percent of total billed charges,Implant Device,838.95,35,,838.95,percent of total billed charges,Implant Device,838.95,35,,838.95,percent of total billed charges,Implant Device,838.95,35,,838.95,percent of total billed charges,Implant Device,838.95,35,,838.95,percent of total billed charges,Implant Device,958.8,40,,958.8,percent of total billed charges,Implant Device,838.95,70,,838.95,percent of total billed charges,All Other,814.98,34,,814.98,percent of total billed charges,Implant Device,814.98,34,,814.98,percent of total billed charges,Implant Device,838.95,35,,838.95,percent of total billed charges,Implant Device,838.95,35,,838.95,percent of total billed charges,Implant Device,838.95,35,,838.95,percent of total billed charges,Implant Device,838.95,35,,838.95,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,814.98,34,"If Charge > 2,000, then 34 percent",814.98,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1773.79,
DEPUY 202.820 CORTEX SCREW 2.7X20MM,C1713,HCPCS,,79007580,CDM,278,RC,,,both,,,85,62.9,,,62.9,Other,150% of Medicare + 9.63% HCRA Surcharge,38.25,45,,38.25,percent of total billed charges,Critical Access Hospital RCC factor,28.9,34,,28.9,percent of total billed charges,Implant Device,28.9,34,,28.9,percent of total billed charges,Implant Device,28.9,34,,28.9,percent of total billed charges,Implant Device,28.9,34,,28.9,percent of total billed charges,Implant Device,28.9,34,,28.9,percent of total billed charges,Implant Device,42.08,,,42.08,Other,110% of Medicare,29.75,35,,29.75,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,29.75,35,,29.75,percent of total billed charges,Implant Device,29.75,35,,29.75,percent of total billed charges,Implant Device,29.75,35,,29.75,percent of total billed charges,Implant Device,29.75,35,,29.75,percent of total billed charges,Implant Device,29.75,35,,29.75,percent of total billed charges,Implant Device,34,40,,34,percent of total billed charges,Implant Device,29.75,70,,29.75,percent of total billed charges,All Other,28.9,34,,28.9,percent of total billed charges,Implant Device,28.9,34,,28.9,percent of total billed charges,Implant Device,29.75,35,,29.75,percent of total billed charges,Implant Device,29.75,35,,29.75,percent of total billed charges,Implant Device,29.75,35,,29.75,percent of total billed charges,Implant Device,29.75,35,,29.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,62.9,
DEPUY 02.240.240 CANN SCREW 3.7X25MM,C1713,HCPCS,,79007581,CDM,278,RC,,,both,,,690,510.6,,,510.6,Other,150% of Medicare + 9.63% HCRA Surcharge,310.5,45,,310.5,percent of total billed charges,Critical Access Hospital RCC factor,234.6,34,,234.6,percent of total billed charges,Implant Device,234.6,34,,234.6,percent of total billed charges,Implant Device,234.6,34,,234.6,percent of total billed charges,Implant Device,234.6,34,,234.6,percent of total billed charges,Implant Device,234.6,34,,234.6,percent of total billed charges,Implant Device,341.55,,,341.55,Other,110% of Medicare,241.5,35,,241.5,percent of total billed charges,Implant Device,234.6,34,"Charges > $500, x 34%",234.6,percent of total billed charges,Implant Device,241.5,35,,241.5,percent of total billed charges,Implant Device,241.5,35,,241.5,percent of total billed charges,Implant Device,241.5,35,,241.5,percent of total billed charges,Implant Device,241.5,35,,241.5,percent of total billed charges,Implant Device,241.5,35,,241.5,percent of total billed charges,Implant Device,276,40,,276,percent of total billed charges,Implant Device,241.5,70,,241.5,percent of total billed charges,All Other,234.6,34,,234.6,percent of total billed charges,Implant Device,234.6,34,,234.6,percent of total billed charges,Implant Device,241.5,35,,241.5,percent of total billed charges,Implant Device,241.5,35,,241.5,percent of total billed charges,Implant Device,241.5,35,,241.5,percent of total billed charges,Implant Device,241.5,35,,241.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,510.6,
WRIGHT 4700001 FINGER JOINT IMPLANT SZ 1,C1776,HCPCS,,79007582,CDM,278,RC,,,both,,,4140,3063.61,,,3063.61,Other,150% of Medicare + 9.63% HCRA Surcharge,1863,45,,1863,percent of total billed charges,Critical Access Hospital RCC factor,1407.6,34,,1407.6,percent of total billed charges,Implant Device,1407.6,34,,1407.6,percent of total billed charges,Implant Device,1407.6,34,,1407.6,percent of total billed charges,Implant Device,1407.6,34,,1407.6,percent of total billed charges,Implant Device,1407.6,34,,1407.6,percent of total billed charges,Implant Device,2049.3,,,2049.3,Other,110% of Medicare,1449,35,,1449,percent of total billed charges,Implant Device,1407.6,34,"Charges > $500, x 34%",1407.6,percent of total billed charges,Implant Device,1449,35,,1449,percent of total billed charges,Implant Device,1449,35,,1449,percent of total billed charges,Implant Device,1449,35,,1449,percent of total billed charges,Implant Device,1449,35,,1449,percent of total billed charges,Implant Device,1449,35,,1449,percent of total billed charges,Implant Device,1656,40,,1656,percent of total billed charges,Implant Device,1449,70,,1449,percent of total billed charges,All Other,1407.6,34,,1407.6,percent of total billed charges,Implant Device,1407.6,34,,1407.6,percent of total billed charges,Implant Device,1449,35,,1449,percent of total billed charges,Implant Device,1449,35,,1449,percent of total billed charges,Implant Device,1449,35,,1449,percent of total billed charges,Implant Device,1449,35,,1449,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1407.6,34,"If Charge > 2,000, then 34 percent",1407.6,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3063.61,
ST JUDE 2088TC/46 TENDRIL LEAD 46CM,C1898,HCPCS,,79007583,CDM,278,RC,,,both,,,1650,1221,,,1221,Other,150% of Medicare + 9.63% HCRA Surcharge,742.5,45,,742.5,percent of total billed charges,Critical Access Hospital RCC factor,561,34,,561,percent of total billed charges,Implant Device,561,34,,561,percent of total billed charges,Implant Device,561,34,,561,percent of total billed charges,Implant Device,561,34,,561,percent of total billed charges,Implant Device,561,34,,561,percent of total billed charges,Implant Device,816.75,,,816.75,Other,110% of Medicare,577.5,35,,577.5,percent of total billed charges,Implant Device,561,34,"Charges > $500, x 34%",561,percent of total billed charges,Implant Device,577.5,35,,577.5,percent of total billed charges,Implant Device,577.5,35,,577.5,percent of total billed charges,Implant Device,577.5,35,,577.5,percent of total billed charges,Implant Device,577.5,35,,577.5,percent of total billed charges,Implant Device,577.5,35,,577.5,percent of total billed charges,Implant Device,660,40,,660,percent of total billed charges,Implant Device,577.5,70,,577.5,percent of total billed charges,All Other,561,34,,561,percent of total billed charges,Implant Device,561,34,,561,percent of total billed charges,Implant Device,577.5,35,,577.5,percent of total billed charges,Implant Device,577.5,35,,577.5,percent of total billed charges,Implant Device,577.5,35,,577.5,percent of total billed charges,Implant Device,577.5,35,,577.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1221,
ST JUDE 2088TC/52 TENDRIL STS LEAD 52CM,C1898,HCPCS,,79007584,CDM,278,RC,,,both,,,1650,1221,,,1221,Other,150% of Medicare + 9.63% HCRA Surcharge,742.5,45,,742.5,percent of total billed charges,Critical Access Hospital RCC factor,561,34,,561,percent of total billed charges,Implant Device,561,34,,561,percent of total billed charges,Implant Device,561,34,,561,percent of total billed charges,Implant Device,561,34,,561,percent of total billed charges,Implant Device,561,34,,561,percent of total billed charges,Implant Device,816.75,,,816.75,Other,110% of Medicare,577.5,35,,577.5,percent of total billed charges,Implant Device,561,34,"Charges > $500, x 34%",561,percent of total billed charges,Implant Device,577.5,35,,577.5,percent of total billed charges,Implant Device,577.5,35,,577.5,percent of total billed charges,Implant Device,577.5,35,,577.5,percent of total billed charges,Implant Device,577.5,35,,577.5,percent of total billed charges,Implant Device,577.5,35,,577.5,percent of total billed charges,Implant Device,660,40,,660,percent of total billed charges,Implant Device,577.5,70,,577.5,percent of total billed charges,All Other,561,34,,561,percent of total billed charges,Implant Device,561,34,,561,percent of total billed charges,Implant Device,577.5,35,,577.5,percent of total billed charges,Implant Device,577.5,35,,577.5,percent of total billed charges,Implant Device,577.5,35,,577.5,percent of total billed charges,Implant Device,577.5,35,,577.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1221,
S&N 71453252 ARTICULAR INSERT SZ 5 9MM,C1713,HCPCS,,79007591,CDM,278,RC,,,both,,,5528,4090.73,,,4090.73,Other,150% of Medicare + 9.63% HCRA Surcharge,2487.6,45,,2487.6,percent of total billed charges,Critical Access Hospital RCC factor,1879.52,34,,1879.52,percent of total billed charges,Implant Device,1879.52,34,,1879.52,percent of total billed charges,Implant Device,1879.52,34,,1879.52,percent of total billed charges,Implant Device,1879.52,34,,1879.52,percent of total billed charges,Implant Device,1879.52,34,,1879.52,percent of total billed charges,Implant Device,2736.36,,,2736.36,Other,110% of Medicare,1934.8,35,,1934.8,percent of total billed charges,Implant Device,1879.52,34,"Charges > $500, x 34%",1879.52,percent of total billed charges,Implant Device,1934.8,35,,1934.8,percent of total billed charges,Implant Device,1934.8,35,,1934.8,percent of total billed charges,Implant Device,1934.8,35,,1934.8,percent of total billed charges,Implant Device,1934.8,35,,1934.8,percent of total billed charges,Implant Device,1934.8,35,,1934.8,percent of total billed charges,Implant Device,2211.2,40,,2211.2,percent of total billed charges,Implant Device,1934.8,70,,1934.8,percent of total billed charges,All Other,1879.52,34,,1879.52,percent of total billed charges,Implant Device,1879.52,34,,1879.52,percent of total billed charges,Implant Device,1934.8,35,,1934.8,percent of total billed charges,Implant Device,1934.8,35,,1934.8,percent of total billed charges,Implant Device,1934.8,35,,1934.8,percent of total billed charges,Implant Device,1934.8,35,,1934.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1879.52,34,"If Charge > 2,000, then 34 percent",1879.52,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4090.73,
DEPUY 1294-35-140 TIBIAL TRAY PLTFRM SZ4,C1713,HCPCS,,79007592,CDM,278,RC,,,both,,,19157,14176.23,,,14176.23,Other,150% of Medicare + 9.63% HCRA Surcharge,8620.65,45,,8620.65,percent of total billed charges,Critical Access Hospital RCC factor,6513.38,34,,6513.38,percent of total billed charges,Implant Device,6513.38,34,,6513.38,percent of total billed charges,Implant Device,6513.38,34,,6513.38,percent of total billed charges,Implant Device,6513.38,34,,6513.38,percent of total billed charges,Implant Device,6513.38,34,,6513.38,percent of total billed charges,Implant Device,9482.72,,,9482.72,Other,110% of Medicare,6704.95,35,,6704.95,percent of total billed charges,Implant Device,6513.38,34,"Charges > $500, x 34%",6513.38,percent of total billed charges,Implant Device,6704.95,35,,6704.95,percent of total billed charges,Implant Device,6704.95,35,,6704.95,percent of total billed charges,Implant Device,6704.95,35,,6704.95,percent of total billed charges,Implant Device,6704.95,35,,6704.95,percent of total billed charges,Implant Device,6704.95,35,,6704.95,percent of total billed charges,Implant Device,7662.8,40,,7662.8,percent of total billed charges,Implant Device,6704.95,70,,6704.95,percent of total billed charges,All Other,6513.38,34,,6513.38,percent of total billed charges,Implant Device,6513.38,34,,6513.38,percent of total billed charges,Implant Device,6704.95,35,,6704.95,percent of total billed charges,Implant Device,6704.95,35,,6704.95,percent of total billed charges,Implant Device,6704.95,35,,6704.95,percent of total billed charges,Implant Device,6704.95,35,,6704.95,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,6513.38,34,"If Charge > 2,000, then 34 percent",6513.38,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,14176.23,
DEPUY 1987-07-030 LPS SEG COMPONENT 30MM,C1713,HCPCS,,79007593,CDM,278,RC,,,both,,,5969,4417.07,,,4417.07,Other,150% of Medicare + 9.63% HCRA Surcharge,2686.05,45,,2686.05,percent of total billed charges,Critical Access Hospital RCC factor,2029.46,34,,2029.46,percent of total billed charges,Implant Device,2029.46,34,,2029.46,percent of total billed charges,Implant Device,2029.46,34,,2029.46,percent of total billed charges,Implant Device,2029.46,34,,2029.46,percent of total billed charges,Implant Device,2029.46,34,,2029.46,percent of total billed charges,Implant Device,2954.66,,,2954.66,Other,110% of Medicare,2089.15,35,,2089.15,percent of total billed charges,Implant Device,2029.46,34,"Charges > $500, x 34%",2029.46,percent of total billed charges,Implant Device,2089.15,35,,2089.15,percent of total billed charges,Implant Device,2089.15,35,,2089.15,percent of total billed charges,Implant Device,2089.15,35,,2089.15,percent of total billed charges,Implant Device,2089.15,35,,2089.15,percent of total billed charges,Implant Device,2089.15,35,,2089.15,percent of total billed charges,Implant Device,2387.6,40,,2387.6,percent of total billed charges,Implant Device,2089.15,70,,2089.15,percent of total billed charges,All Other,2029.46,34,,2029.46,percent of total billed charges,Implant Device,2029.46,34,,2029.46,percent of total billed charges,Implant Device,2089.15,35,,2089.15,percent of total billed charges,Implant Device,2089.15,35,,2089.15,percent of total billed charges,Implant Device,2089.15,35,,2089.15,percent of total billed charges,Implant Device,2089.15,35,,2089.15,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2029.46,34,"If Charge > 2,000, then 34 percent",2029.46,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4417.07,
DEPUY 1987-15-214 FEMORAL STEM 14X150MM,C1713,HCPCS,,79007594,CDM,278,RC,,,both,,,14302,10583.52,,,10583.52,Other,150% of Medicare + 9.63% HCRA Surcharge,6435.9,45,,6435.9,percent of total billed charges,Critical Access Hospital RCC factor,4862.68,34,,4862.68,percent of total billed charges,Implant Device,4862.68,34,,4862.68,percent of total billed charges,Implant Device,4862.68,34,,4862.68,percent of total billed charges,Implant Device,4862.68,34,,4862.68,percent of total billed charges,Implant Device,4862.68,34,,4862.68,percent of total billed charges,Implant Device,7079.49,,,7079.49,Other,110% of Medicare,5005.7,35,,5005.7,percent of total billed charges,Implant Device,4862.68,34,"Charges > $500, x 34%",4862.68,percent of total billed charges,Implant Device,5005.7,35,,5005.7,percent of total billed charges,Implant Device,5005.7,35,,5005.7,percent of total billed charges,Implant Device,5005.7,35,,5005.7,percent of total billed charges,Implant Device,5005.7,35,,5005.7,percent of total billed charges,Implant Device,5005.7,35,,5005.7,percent of total billed charges,Implant Device,5720.8,40,,5720.8,percent of total billed charges,Implant Device,5005.7,70,,5005.7,percent of total billed charges,All Other,4862.68,34,,4862.68,percent of total billed charges,Implant Device,4862.68,34,,4862.68,percent of total billed charges,Implant Device,5005.7,35,,5005.7,percent of total billed charges,Implant Device,5005.7,35,,5005.7,percent of total billed charges,Implant Device,5005.7,35,,5005.7,percent of total billed charges,Implant Device,5005.7,35,,5005.7,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,4862.68,34,"If Charge > 2,000, then 34 percent",4862.68,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,10583.52,
STRYKER 1828-0934S T2 FEM NAIL 9X430MM,C1713,HCPCS,,79007595,CDM,278,RC,,,both,,,7030,5202.22,,,5202.22,Other,150% of Medicare + 9.63% HCRA Surcharge,3163.5,45,,3163.5,percent of total billed charges,Critical Access Hospital RCC factor,2390.2,34,,2390.2,percent of total billed charges,Implant Device,2390.2,34,,2390.2,percent of total billed charges,Implant Device,2390.2,34,,2390.2,percent of total billed charges,Implant Device,2390.2,34,,2390.2,percent of total billed charges,Implant Device,2390.2,34,,2390.2,percent of total billed charges,Implant Device,3479.85,,,3479.85,Other,110% of Medicare,2460.5,35,,2460.5,percent of total billed charges,Implant Device,2390.2,34,"Charges > $500, x 34%",2390.2,percent of total billed charges,Implant Device,2460.5,35,,2460.5,percent of total billed charges,Implant Device,2460.5,35,,2460.5,percent of total billed charges,Implant Device,2460.5,35,,2460.5,percent of total billed charges,Implant Device,2460.5,35,,2460.5,percent of total billed charges,Implant Device,2460.5,35,,2460.5,percent of total billed charges,Implant Device,2812,40,,2812,percent of total billed charges,Implant Device,2460.5,70,,2460.5,percent of total billed charges,All Other,2390.2,34,,2390.2,percent of total billed charges,Implant Device,2390.2,34,,2390.2,percent of total billed charges,Implant Device,2460.5,35,,2460.5,percent of total billed charges,Implant Device,2460.5,35,,2460.5,percent of total billed charges,Implant Device,2460.5,35,,2460.5,percent of total billed charges,Implant Device,2460.5,35,,2460.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2390.2,34,"If Charge > 2,000, then 34 percent",2390.2,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5202.22,
BARD FEM07060 FLUENCY 7X60X80 COVD STENT,C1874,HCPCS,,79007596,CDM,278,RC,,,both,,,10917,8078.61,,,8078.61,Other,150% of Medicare + 9.63% HCRA Surcharge,4912.65,45,,4912.65,percent of total billed charges,Critical Access Hospital RCC factor,3711.78,34,,3711.78,percent of total billed charges,Implant Device,3711.78,34,,3711.78,percent of total billed charges,Implant Device,3711.78,34,,3711.78,percent of total billed charges,Implant Device,3711.78,34,,3711.78,percent of total billed charges,Implant Device,3711.78,34,,3711.78,percent of total billed charges,Implant Device,5403.92,,,5403.92,Other,110% of Medicare,3820.95,35,,3820.95,percent of total billed charges,Implant Device,3711.78,34,"Charges > $500, x 34%",3711.78,percent of total billed charges,Implant Device,3820.95,35,,3820.95,percent of total billed charges,Implant Device,3820.95,35,,3820.95,percent of total billed charges,Implant Device,3820.95,35,,3820.95,percent of total billed charges,Implant Device,3820.95,35,,3820.95,percent of total billed charges,Implant Device,3820.95,35,,3820.95,percent of total billed charges,Implant Device,4366.8,40,,4366.8,percent of total billed charges,Implant Device,3820.95,70,,3820.95,percent of total billed charges,All Other,3711.78,34,,3711.78,percent of total billed charges,Implant Device,3711.78,34,,3711.78,percent of total billed charges,Implant Device,3820.95,35,,3820.95,percent of total billed charges,Implant Device,3820.95,35,,3820.95,percent of total billed charges,Implant Device,3820.95,35,,3820.95,percent of total billed charges,Implant Device,3820.95,35,,3820.95,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3711.78,34,"If Charge > 2,000, then 34 percent",3711.78,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,8078.61,
BARD FEM06060 FLUENCY 6X60X80 COVD STENT,C1874,HCPCS,,79007597,CDM,278,RC,,,both,,,10398,7694.55,,,7694.55,Other,150% of Medicare + 9.63% HCRA Surcharge,4679.1,45,,4679.1,percent of total billed charges,Critical Access Hospital RCC factor,3535.32,34,,3535.32,percent of total billed charges,Implant Device,3535.32,34,,3535.32,percent of total billed charges,Implant Device,3535.32,34,,3535.32,percent of total billed charges,Implant Device,3535.32,34,,3535.32,percent of total billed charges,Implant Device,3535.32,34,,3535.32,percent of total billed charges,Implant Device,5147.01,,,5147.01,Other,110% of Medicare,3639.3,35,,3639.3,percent of total billed charges,Implant Device,3535.32,34,"Charges > $500, x 34%",3535.32,percent of total billed charges,Implant Device,3639.3,35,,3639.3,percent of total billed charges,Implant Device,3639.3,35,,3639.3,percent of total billed charges,Implant Device,3639.3,35,,3639.3,percent of total billed charges,Implant Device,3639.3,35,,3639.3,percent of total billed charges,Implant Device,3639.3,35,,3639.3,percent of total billed charges,Implant Device,4159.2,40,,4159.2,percent of total billed charges,Implant Device,3639.3,70,,3639.3,percent of total billed charges,All Other,3535.32,34,,3535.32,percent of total billed charges,Implant Device,3535.32,34,,3535.32,percent of total billed charges,Implant Device,3639.3,35,,3639.3,percent of total billed charges,Implant Device,3639.3,35,,3639.3,percent of total billed charges,Implant Device,3639.3,35,,3639.3,percent of total billed charges,Implant Device,3639.3,35,,3639.3,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3535.32,34,"If Charge > 2,000, then 34 percent",3535.32,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,7694.55,
IN2BONES A06 SP003 DUAFIT PIP SZ3 IMPLNT,C1713,HCPCS,,79007598,CDM,278,RC,,,both,,,3525,2608.51,,,2608.51,Other,150% of Medicare + 9.63% HCRA Surcharge,1586.25,45,,1586.25,percent of total billed charges,Critical Access Hospital RCC factor,1198.5,34,,1198.5,percent of total billed charges,Implant Device,1198.5,34,,1198.5,percent of total billed charges,Implant Device,1198.5,34,,1198.5,percent of total billed charges,Implant Device,1198.5,34,,1198.5,percent of total billed charges,Implant Device,1198.5,34,,1198.5,percent of total billed charges,Implant Device,1744.88,,,1744.88,Other,110% of Medicare,1233.75,35,,1233.75,percent of total billed charges,Implant Device,1198.5,34,"Charges > $500, x 34%",1198.5,percent of total billed charges,Implant Device,1233.75,35,,1233.75,percent of total billed charges,Implant Device,1233.75,35,,1233.75,percent of total billed charges,Implant Device,1233.75,35,,1233.75,percent of total billed charges,Implant Device,1233.75,35,,1233.75,percent of total billed charges,Implant Device,1233.75,35,,1233.75,percent of total billed charges,Implant Device,1410,40,,1410,percent of total billed charges,Implant Device,1233.75,70,,1233.75,percent of total billed charges,All Other,1198.5,34,,1198.5,percent of total billed charges,Implant Device,1198.5,34,,1198.5,percent of total billed charges,Implant Device,1233.75,35,,1233.75,percent of total billed charges,Implant Device,1233.75,35,,1233.75,percent of total billed charges,Implant Device,1233.75,35,,1233.75,percent of total billed charges,Implant Device,1233.75,35,,1233.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1198.5,34,"If Charge > 2,000, then 34 percent",1198.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2608.51,
LIFENET AFLEX 301 DECELL DERMIS 40X70X3,C1713,HCPCS,,79007599,CDM,278,RC,,,both,,,11317,8374.61,,,8374.61,Other,150% of Medicare + 9.63% HCRA Surcharge,5092.65,45,,5092.65,percent of total billed charges,Critical Access Hospital RCC factor,3847.78,34,,3847.78,percent of total billed charges,Implant Device,3847.78,34,,3847.78,percent of total billed charges,Implant Device,3847.78,34,,3847.78,percent of total billed charges,Implant Device,3847.78,34,,3847.78,percent of total billed charges,Implant Device,3847.78,34,,3847.78,percent of total billed charges,Implant Device,5601.92,,,5601.92,Other,110% of Medicare,3960.95,35,,3960.95,percent of total billed charges,Implant Device,3847.78,34,"Charges > $500, x 34%",3847.78,percent of total billed charges,Implant Device,3960.95,35,,3960.95,percent of total billed charges,Implant Device,3960.95,35,,3960.95,percent of total billed charges,Implant Device,3960.95,35,,3960.95,percent of total billed charges,Implant Device,3960.95,35,,3960.95,percent of total billed charges,Implant Device,3960.95,35,,3960.95,percent of total billed charges,Implant Device,4526.8,40,,4526.8,percent of total billed charges,Implant Device,3960.95,70,,3960.95,percent of total billed charges,All Other,3847.78,34,,3847.78,percent of total billed charges,Implant Device,3847.78,34,,3847.78,percent of total billed charges,Implant Device,3960.95,35,,3960.95,percent of total billed charges,Implant Device,3960.95,35,,3960.95,percent of total billed charges,Implant Device,3960.95,35,,3960.95,percent of total billed charges,Implant Device,3960.95,35,,3960.95,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3847.78,34,"If Charge > 2,000, then 34 percent",3847.78,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,8374.61,
STRYKER 1822-0931S TIBIAL NAIL STD 9X315,C1713,HCPCS,,79007600,CDM,278,RC,,,both,,,3529,2611.47,,,2611.47,Other,150% of Medicare + 9.63% HCRA Surcharge,1588.05,45,,1588.05,percent of total billed charges,Critical Access Hospital RCC factor,1199.86,34,,1199.86,percent of total billed charges,Implant Device,1199.86,34,,1199.86,percent of total billed charges,Implant Device,1199.86,34,,1199.86,percent of total billed charges,Implant Device,1199.86,34,,1199.86,percent of total billed charges,Implant Device,1199.86,34,,1199.86,percent of total billed charges,Implant Device,1746.86,,,1746.86,Other,110% of Medicare,1235.15,35,,1235.15,percent of total billed charges,Implant Device,1199.86,34,"Charges > $500, x 34%",1199.86,percent of total billed charges,Implant Device,1235.15,35,,1235.15,percent of total billed charges,Implant Device,1235.15,35,,1235.15,percent of total billed charges,Implant Device,1235.15,35,,1235.15,percent of total billed charges,Implant Device,1235.15,35,,1235.15,percent of total billed charges,Implant Device,1235.15,35,,1235.15,percent of total billed charges,Implant Device,1411.6,40,,1411.6,percent of total billed charges,Implant Device,1235.15,70,,1235.15,percent of total billed charges,All Other,1199.86,34,,1199.86,percent of total billed charges,Implant Device,1199.86,34,,1199.86,percent of total billed charges,Implant Device,1235.15,35,,1235.15,percent of total billed charges,Implant Device,1235.15,35,,1235.15,percent of total billed charges,Implant Device,1235.15,35,,1235.15,percent of total billed charges,Implant Device,1235.15,35,,1235.15,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1199.86,34,"If Charge > 2,000, then 34 percent",1199.86,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2611.47,
BOST SCI M00516700  8X103 ESOPH STENT,C1874,HCPCS,,79007601,CDM,278,RC,,,both,,,7409,5482.68,,,5482.68,Other,150% of Medicare + 9.63% HCRA Surcharge,3334.05,45,,3334.05,percent of total billed charges,Critical Access Hospital RCC factor,2519.06,34,,2519.06,percent of total billed charges,Implant Device,2519.06,34,,2519.06,percent of total billed charges,Implant Device,2519.06,34,,2519.06,percent of total billed charges,Implant Device,2519.06,34,,2519.06,percent of total billed charges,Implant Device,2519.06,34,,2519.06,percent of total billed charges,Implant Device,3667.46,,,3667.46,Other,110% of Medicare,2593.15,35,,2593.15,percent of total billed charges,Implant Device,2519.06,34,"Charges > $500, x 34%",2519.06,percent of total billed charges,Implant Device,2593.15,35,,2593.15,percent of total billed charges,Implant Device,2593.15,35,,2593.15,percent of total billed charges,Implant Device,2593.15,35,,2593.15,percent of total billed charges,Implant Device,2593.15,35,,2593.15,percent of total billed charges,Implant Device,2593.15,35,,2593.15,percent of total billed charges,Implant Device,2963.6,40,,2963.6,percent of total billed charges,Implant Device,2593.15,70,,2593.15,percent of total billed charges,All Other,2519.06,34,,2519.06,percent of total billed charges,Implant Device,2519.06,34,,2519.06,percent of total billed charges,Implant Device,2593.15,35,,2593.15,percent of total billed charges,Implant Device,2593.15,35,,2593.15,percent of total billed charges,Implant Device,2593.15,35,,2593.15,percent of total billed charges,Implant Device,2593.15,35,,2593.15,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2519.06,34,"If Charge > 2,000, then 34 percent",2519.06,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5482.68,
ZIMMER 8018-028-05 COCR FEM HEAD 28+10.5,C1776,HCPCS,,79007602,CDM,278,RC,,,both,,,2543,1881.83,,,1881.83,Other,150% of Medicare + 9.63% HCRA Surcharge,1144.35,45,,1144.35,percent of total billed charges,Critical Access Hospital RCC factor,864.62,34,,864.62,percent of total billed charges,Implant Device,864.62,34,,864.62,percent of total billed charges,Implant Device,864.62,34,,864.62,percent of total billed charges,Implant Device,864.62,34,,864.62,percent of total billed charges,Implant Device,864.62,34,,864.62,percent of total billed charges,Implant Device,1258.79,,,1258.79,Other,110% of Medicare,890.05,35,,890.05,percent of total billed charges,Implant Device,864.62,34,"Charges > $500, x 34%",864.62,percent of total billed charges,Implant Device,890.05,35,,890.05,percent of total billed charges,Implant Device,890.05,35,,890.05,percent of total billed charges,Implant Device,890.05,35,,890.05,percent of total billed charges,Implant Device,890.05,35,,890.05,percent of total billed charges,Implant Device,890.05,35,,890.05,percent of total billed charges,Implant Device,1017.2,40,,1017.2,percent of total billed charges,Implant Device,890.05,70,,890.05,percent of total billed charges,All Other,864.62,34,,864.62,percent of total billed charges,Implant Device,864.62,34,,864.62,percent of total billed charges,Implant Device,890.05,35,,890.05,percent of total billed charges,Implant Device,890.05,35,,890.05,percent of total billed charges,Implant Device,890.05,35,,890.05,percent of total billed charges,Implant Device,890.05,35,,890.05,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,864.62,34,"If Charge > 2,000, then 34 percent",864.62,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1881.83,
J&J SF06100MB SMART FLEX 6X100MM STENT,C1876,HCPCS,,79007603,CDM,278,RC,,,both,,,2100,1554.01,,,1554.01,Other,150% of Medicare + 9.63% HCRA Surcharge,945,45,,945,percent of total billed charges,Critical Access Hospital RCC factor,714,34,,714,percent of total billed charges,Implant Device,714,34,,714,percent of total billed charges,Implant Device,714,34,,714,percent of total billed charges,Implant Device,714,34,,714,percent of total billed charges,Implant Device,714,34,,714,percent of total billed charges,Implant Device,1039.5,,,1039.5,Other,110% of Medicare,735,35,,735,percent of total billed charges,Implant Device,714,34,"Charges > $500, x 34%",714,percent of total billed charges,Implant Device,735,35,,735,percent of total billed charges,Implant Device,735,35,,735,percent of total billed charges,Implant Device,735,35,,735,percent of total billed charges,Implant Device,735,35,,735,percent of total billed charges,Implant Device,735,35,,735,percent of total billed charges,Implant Device,840,40,,840,percent of total billed charges,Implant Device,735,70,,735,percent of total billed charges,All Other,714,34,,714,percent of total billed charges,Implant Device,714,34,,714,percent of total billed charges,Implant Device,735,35,,735,percent of total billed charges,Implant Device,735,35,,735,percent of total billed charges,Implant Device,735,35,,735,percent of total billed charges,Implant Device,735,35,,735,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,714,34,"If Charge > 2,000, then 34 percent",714,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1554.01,
ARTHREX ABS-1007-BC BIOCARTLIDGE .75CC,C1713,HCPCS,,79007608,CDM,278,RC,,,both,,,2250,1665.01,,,1665.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1012.5,45,,1012.5,percent of total billed charges,Critical Access Hospital RCC factor,765,34,,765,percent of total billed charges,Implant Device,765,34,,765,percent of total billed charges,Implant Device,765,34,,765,percent of total billed charges,Implant Device,765,34,,765,percent of total billed charges,Implant Device,765,34,,765,percent of total billed charges,Implant Device,1113.75,,,1113.75,Other,110% of Medicare,787.5,35,,787.5,percent of total billed charges,Implant Device,765,34,"Charges > $500, x 34%",765,percent of total billed charges,Implant Device,787.5,35,,787.5,percent of total billed charges,Implant Device,787.5,35,,787.5,percent of total billed charges,Implant Device,787.5,35,,787.5,percent of total billed charges,Implant Device,787.5,35,,787.5,percent of total billed charges,Implant Device,787.5,35,,787.5,percent of total billed charges,Implant Device,900,40,,900,percent of total billed charges,Implant Device,787.5,70,,787.5,percent of total billed charges,All Other,765,34,,765,percent of total billed charges,Implant Device,765,34,,765,percent of total billed charges,Implant Device,787.5,35,,787.5,percent of total billed charges,Implant Device,787.5,35,,787.5,percent of total billed charges,Implant Device,787.5,35,,787.5,percent of total billed charges,Implant Device,787.5,35,,787.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,765,34,"If Charge > 2,000, then 34 percent",765,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1665.01,
ARTRHEX ABS-1010-BC BIOCARTLIDGE 1CC,C1713,HCPCS,,79007609,CDM,278,RC,,,both,,,2940,2175.61,,,2175.61,Other,150% of Medicare + 9.63% HCRA Surcharge,1323,45,,1323,percent of total billed charges,Critical Access Hospital RCC factor,999.6,34,,999.6,percent of total billed charges,Implant Device,999.6,34,,999.6,percent of total billed charges,Implant Device,999.6,34,,999.6,percent of total billed charges,Implant Device,999.6,34,,999.6,percent of total billed charges,Implant Device,999.6,34,,999.6,percent of total billed charges,Implant Device,1455.3,,,1455.3,Other,110% of Medicare,1029,35,,1029,percent of total billed charges,Implant Device,999.6,34,"Charges > $500, x 34%",999.6,percent of total billed charges,Implant Device,1029,35,,1029,percent of total billed charges,Implant Device,1029,35,,1029,percent of total billed charges,Implant Device,1029,35,,1029,percent of total billed charges,Implant Device,1029,35,,1029,percent of total billed charges,Implant Device,1029,35,,1029,percent of total billed charges,Implant Device,1176,40,,1176,percent of total billed charges,Implant Device,1029,70,,1029,percent of total billed charges,All Other,999.6,34,,999.6,percent of total billed charges,Implant Device,999.6,34,,999.6,percent of total billed charges,Implant Device,1029,35,,1029,percent of total billed charges,Implant Device,1029,35,,1029,percent of total billed charges,Implant Device,1029,35,,1029,percent of total billed charges,Implant Device,1029,35,,1029,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,999.6,34,"If Charge > 2,000, then 34 percent",999.6,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2175.61,
ZIMMER 5962-050-12 ART SURFCE 7 10 12MM,C1713,HCPCS,,79007611,CDM,278,RC,,,both,,,5130,3796.21,,,3796.21,Other,150% of Medicare + 9.63% HCRA Surcharge,2308.5,45,,2308.5,percent of total billed charges,Critical Access Hospital RCC factor,1744.2,34,,1744.2,percent of total billed charges,Implant Device,1744.2,34,,1744.2,percent of total billed charges,Implant Device,1744.2,34,,1744.2,percent of total billed charges,Implant Device,1744.2,34,,1744.2,percent of total billed charges,Implant Device,1744.2,34,,1744.2,percent of total billed charges,Implant Device,2539.35,,,2539.35,Other,110% of Medicare,1795.5,35,,1795.5,percent of total billed charges,Implant Device,1744.2,34,"Charges > $500, x 34%",1744.2,percent of total billed charges,Implant Device,1795.5,35,,1795.5,percent of total billed charges,Implant Device,1795.5,35,,1795.5,percent of total billed charges,Implant Device,1795.5,35,,1795.5,percent of total billed charges,Implant Device,1795.5,35,,1795.5,percent of total billed charges,Implant Device,1795.5,35,,1795.5,percent of total billed charges,Implant Device,2052,40,,2052,percent of total billed charges,Implant Device,1795.5,70,,1795.5,percent of total billed charges,All Other,1744.2,34,,1744.2,percent of total billed charges,Implant Device,1744.2,34,,1744.2,percent of total billed charges,Implant Device,1795.5,35,,1795.5,percent of total billed charges,Implant Device,1795.5,35,,1795.5,percent of total billed charges,Implant Device,1795.5,35,,1795.5,percent of total billed charges,Implant Device,1795.5,35,,1795.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1744.2,34,"If Charge > 2,000, then 34 percent",1744.2,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3796.21,
STRYKER 5038-2-080 APEX PIN 3X80MM,C1713,HCPCS,,79007612,CDM,278,RC,,,both,,,337,249.38,,,249.38,Other,150% of Medicare + 9.63% HCRA Surcharge,151.65,45,,151.65,percent of total billed charges,Critical Access Hospital RCC factor,114.58,34,,114.58,percent of total billed charges,Implant Device,114.58,34,,114.58,percent of total billed charges,Implant Device,114.58,34,,114.58,percent of total billed charges,Implant Device,114.58,34,,114.58,percent of total billed charges,Implant Device,114.58,34,,114.58,percent of total billed charges,Implant Device,166.82,,,166.82,Other,110% of Medicare,117.95,35,,117.95,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,117.95,35,,117.95,percent of total billed charges,Implant Device,117.95,35,,117.95,percent of total billed charges,Implant Device,117.95,35,,117.95,percent of total billed charges,Implant Device,117.95,35,,117.95,percent of total billed charges,Implant Device,117.95,35,,117.95,percent of total billed charges,Implant Device,134.8,40,,134.8,percent of total billed charges,Implant Device,117.95,70,,117.95,percent of total billed charges,All Other,114.58,34,,114.58,percent of total billed charges,Implant Device,114.58,34,,114.58,percent of total billed charges,Implant Device,117.95,35,,117.95,percent of total billed charges,Implant Device,117.95,35,,117.95,percent of total billed charges,Implant Device,117.95,35,,117.95,percent of total billed charges,Implant Device,117.95,35,,117.95,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,249.38,
STRYKER 5023-2-090 APEX PIN 4X90MM,C1713,HCPCS,,79007613,CDM,278,RC,,,both,,,464,343.36,,,343.36,Other,150% of Medicare + 9.63% HCRA Surcharge,208.8,45,,208.8,percent of total billed charges,Critical Access Hospital RCC factor,157.76,34,,157.76,percent of total billed charges,Implant Device,157.76,34,,157.76,percent of total billed charges,Implant Device,157.76,34,,157.76,percent of total billed charges,Implant Device,157.76,34,,157.76,percent of total billed charges,Implant Device,157.76,34,,157.76,percent of total billed charges,Implant Device,229.68,,,229.68,Other,110% of Medicare,162.4,35,,162.4,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,162.4,35,,162.4,percent of total billed charges,Implant Device,162.4,35,,162.4,percent of total billed charges,Implant Device,162.4,35,,162.4,percent of total billed charges,Implant Device,162.4,35,,162.4,percent of total billed charges,Implant Device,162.4,35,,162.4,percent of total billed charges,Implant Device,185.6,40,,185.6,percent of total billed charges,Implant Device,162.4,70,,162.4,percent of total billed charges,All Other,157.76,34,,157.76,percent of total billed charges,Implant Device,157.76,34,,157.76,percent of total billed charges,Implant Device,162.4,35,,162.4,percent of total billed charges,Implant Device,162.4,35,,162.4,percent of total billed charges,Implant Device,162.4,35,,162.4,percent of total billed charges,Implant Device,162.4,35,,162.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,343.36,
STRYKER 5630-G-309 TIB INSERT SZ 3 9MM,C1776,HCPCS,,79007616,CDM,278,RC,,,both,,,3232,2391.69,,,2391.69,Other,150% of Medicare + 9.63% HCRA Surcharge,1454.4,45,,1454.4,percent of total billed charges,Critical Access Hospital RCC factor,1098.88,34,,1098.88,percent of total billed charges,Implant Device,1098.88,34,,1098.88,percent of total billed charges,Implant Device,1098.88,34,,1098.88,percent of total billed charges,Implant Device,1098.88,34,,1098.88,percent of total billed charges,Implant Device,1098.88,34,,1098.88,percent of total billed charges,Implant Device,1599.84,,,1599.84,Other,110% of Medicare,1131.2,35,,1131.2,percent of total billed charges,Implant Device,1098.88,34,"Charges > $500, x 34%",1098.88,percent of total billed charges,Implant Device,1131.2,35,,1131.2,percent of total billed charges,Implant Device,1131.2,35,,1131.2,percent of total billed charges,Implant Device,1131.2,35,,1131.2,percent of total billed charges,Implant Device,1131.2,35,,1131.2,percent of total billed charges,Implant Device,1131.2,35,,1131.2,percent of total billed charges,Implant Device,1292.8,40,,1292.8,percent of total billed charges,Implant Device,1131.2,70,,1131.2,percent of total billed charges,All Other,1098.88,34,,1098.88,percent of total billed charges,Implant Device,1098.88,34,,1098.88,percent of total billed charges,Implant Device,1131.2,35,,1131.2,percent of total billed charges,Implant Device,1131.2,35,,1131.2,percent of total billed charges,Implant Device,1131.2,35,,1131.2,percent of total billed charges,Implant Device,1131.2,35,,1131.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1098.88,34,"If Charge > 2,000, then 34 percent",1098.88,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2391.69,
GORE RLT261416 EXCLUDER ENDOPROSTHESIS,C1874,HCPCS,,79007622,CDM,278,RC,,,both,,,32250,23865.08,,,23865.08,Other,150% of Medicare + 9.63% HCRA Surcharge,14512.5,45,,14512.5,percent of total billed charges,Critical Access Hospital RCC factor,10965,34,,10965,percent of total billed charges,Implant Device,10965,34,,10965,percent of total billed charges,Implant Device,10965,34,,10965,percent of total billed charges,Implant Device,10965,34,,10965,percent of total billed charges,Implant Device,10965,34,,10965,percent of total billed charges,Implant Device,15963.75,,,15963.75,Other,110% of Medicare,11287.5,35,,11287.5,percent of total billed charges,Implant Device,10965,34,"Charges > $500, x 34%",10965,percent of total billed charges,Implant Device,11287.5,35,,11287.5,percent of total billed charges,Implant Device,11287.5,35,,11287.5,percent of total billed charges,Implant Device,11287.5,35,,11287.5,percent of total billed charges,Implant Device,11287.5,35,,11287.5,percent of total billed charges,Implant Device,11287.5,35,,11287.5,percent of total billed charges,Implant Device,12900,40,,12900,percent of total billed charges,Implant Device,11287.5,70,,11287.5,percent of total billed charges,All Other,10965,34,,10965,percent of total billed charges,Implant Device,10965,34,,10965,percent of total billed charges,Implant Device,11287.5,35,,11287.5,percent of total billed charges,Implant Device,11287.5,35,,11287.5,percent of total billed charges,Implant Device,11287.5,35,,11287.5,percent of total billed charges,Implant Device,11287.5,35,,11287.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,10965,34,"If Charge > 2,000, then 34 percent",10965,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,23865.08,
STRYKER 1822-1030S TIB NAIL STD 10X300M,C1713,HCPCS,,79007623,CDM,278,RC,,,both,,,6110,4521.42,,,4521.42,Other,150% of Medicare + 9.63% HCRA Surcharge,2749.5,45,,2749.5,percent of total billed charges,Critical Access Hospital RCC factor,2077.4,34,,2077.4,percent of total billed charges,Implant Device,2077.4,34,,2077.4,percent of total billed charges,Implant Device,2077.4,34,,2077.4,percent of total billed charges,Implant Device,2077.4,34,,2077.4,percent of total billed charges,Implant Device,2077.4,34,,2077.4,percent of total billed charges,Implant Device,3024.45,,,3024.45,Other,110% of Medicare,2138.5,35,,2138.5,percent of total billed charges,Implant Device,2077.4,34,"Charges > $500, x 34%",2077.4,percent of total billed charges,Implant Device,2138.5,35,,2138.5,percent of total billed charges,Implant Device,2138.5,35,,2138.5,percent of total billed charges,Implant Device,2138.5,35,,2138.5,percent of total billed charges,Implant Device,2138.5,35,,2138.5,percent of total billed charges,Implant Device,2138.5,35,,2138.5,percent of total billed charges,Implant Device,2444,40,,2444,percent of total billed charges,Implant Device,2138.5,70,,2138.5,percent of total billed charges,All Other,2077.4,34,,2077.4,percent of total billed charges,Implant Device,2077.4,34,,2077.4,percent of total billed charges,Implant Device,2138.5,35,,2138.5,percent of total billed charges,Implant Device,2138.5,35,,2138.5,percent of total billed charges,Implant Device,2138.5,35,,2138.5,percent of total billed charges,Implant Device,2138.5,35,,2138.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2077.4,34,"If Charge > 2,000, then 34 percent",2077.4,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4521.42,
STRYKER 661426 NON LOCK SCREW 3.5X26MM,C1713,HCPCS,,79007624,CDM,278,RC,,,both,,,132,97.68,,,97.68,Other,150% of Medicare + 9.63% HCRA Surcharge,59.4,45,,59.4,percent of total billed charges,Critical Access Hospital RCC factor,44.88,34,,44.88,percent of total billed charges,Implant Device,44.88,34,,44.88,percent of total billed charges,Implant Device,44.88,34,,44.88,percent of total billed charges,Implant Device,44.88,34,,44.88,percent of total billed charges,Implant Device,44.88,34,,44.88,percent of total billed charges,Implant Device,65.34,,,65.34,Other,110% of Medicare,46.2,35,,46.2,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,46.2,35,,46.2,percent of total billed charges,Implant Device,46.2,35,,46.2,percent of total billed charges,Implant Device,46.2,35,,46.2,percent of total billed charges,Implant Device,46.2,35,,46.2,percent of total billed charges,Implant Device,46.2,35,,46.2,percent of total billed charges,Implant Device,52.8,40,,52.8,percent of total billed charges,Implant Device,46.2,70,,46.2,percent of total billed charges,All Other,44.88,34,,44.88,percent of total billed charges,Implant Device,44.88,34,,44.88,percent of total billed charges,Implant Device,46.2,35,,46.2,percent of total billed charges,Implant Device,46.2,35,,46.2,percent of total billed charges,Implant Device,46.2,35,,46.2,percent of total billed charges,Implant Device,46.2,35,,46.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,97.68,
STRYKER 661022 LOCK SCREW 4X22MM,C1713,HCPCS,,79007625,CDM,278,RC,,,both,,,630,466.2,,,466.2,Other,150% of Medicare + 9.63% HCRA Surcharge,283.5,45,,283.5,percent of total billed charges,Critical Access Hospital RCC factor,214.2,34,,214.2,percent of total billed charges,Implant Device,214.2,34,,214.2,percent of total billed charges,Implant Device,214.2,34,,214.2,percent of total billed charges,Implant Device,214.2,34,,214.2,percent of total billed charges,Implant Device,214.2,34,,214.2,percent of total billed charges,Implant Device,311.85,,,311.85,Other,110% of Medicare,220.5,35,,220.5,percent of total billed charges,Implant Device,214.2,34,"Charges > $500, x 34%",214.2,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,252,40,,252,percent of total billed charges,Implant Device,220.5,70,,220.5,percent of total billed charges,All Other,214.2,34,,214.2,percent of total billed charges,Implant Device,214.2,34,,214.2,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,466.2,
DEPUY 214.040 4.5MM CORTEX SCREW 40MM,C1713,HCPCS,,79007627,CDM,278,RC,,,both,,,80,59.2,,,59.2,Other,150% of Medicare + 9.63% HCRA Surcharge,36,45,,36,percent of total billed charges,Critical Access Hospital RCC factor,27.2,34,,27.2,percent of total billed charges,Implant Device,27.2,34,,27.2,percent of total billed charges,Implant Device,27.2,34,,27.2,percent of total billed charges,Implant Device,27.2,34,,27.2,percent of total billed charges,Implant Device,27.2,34,,27.2,percent of total billed charges,Implant Device,39.6,,,39.6,Other,110% of Medicare,28,35,,28,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,28,35,,28,percent of total billed charges,Implant Device,28,35,,28,percent of total billed charges,Implant Device,28,35,,28,percent of total billed charges,Implant Device,28,35,,28,percent of total billed charges,Implant Device,28,35,,28,percent of total billed charges,Implant Device,32,40,,32,percent of total billed charges,Implant Device,28,70,,28,percent of total billed charges,All Other,27.2,34,,27.2,percent of total billed charges,Implant Device,27.2,34,,27.2,percent of total billed charges,Implant Device,28,35,,28,percent of total billed charges,Implant Device,28,35,,28,percent of total billed charges,Implant Device,28,35,,28,percent of total billed charges,Implant Device,28,35,,28,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,59.2,
DEPUY 214.048 4.5MM CORTEX SCREW 48MM,C1713,HCPCS,,79007628,CDM,278,RC,,,both,,,80,59.2,,,59.2,Other,150% of Medicare + 9.63% HCRA Surcharge,36,45,,36,percent of total billed charges,Critical Access Hospital RCC factor,27.2,34,,27.2,percent of total billed charges,Implant Device,27.2,34,,27.2,percent of total billed charges,Implant Device,27.2,34,,27.2,percent of total billed charges,Implant Device,27.2,34,,27.2,percent of total billed charges,Implant Device,27.2,34,,27.2,percent of total billed charges,Implant Device,39.6,,,39.6,Other,110% of Medicare,28,35,,28,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,28,35,,28,percent of total billed charges,Implant Device,28,35,,28,percent of total billed charges,Implant Device,28,35,,28,percent of total billed charges,Implant Device,28,35,,28,percent of total billed charges,Implant Device,28,35,,28,percent of total billed charges,Implant Device,32,40,,32,percent of total billed charges,Implant Device,28,70,,28,percent of total billed charges,All Other,27.2,34,,27.2,percent of total billed charges,Implant Device,27.2,34,,27.2,percent of total billed charges,Implant Device,28,35,,28,percent of total billed charges,Implant Device,28,35,,28,percent of total billed charges,Implant Device,28,35,,28,percent of total billed charges,Implant Device,28,35,,28,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,59.2,
DEPUY 02.112.093 CLAVICLE PLATE 3.5X120,C1713,HCPCS,,79007629,CDM,278,RC,,,both,,,2459,1819.67,,,1819.67,Other,150% of Medicare + 9.63% HCRA Surcharge,1106.55,45,,1106.55,percent of total billed charges,Critical Access Hospital RCC factor,836.06,34,,836.06,percent of total billed charges,Implant Device,836.06,34,,836.06,percent of total billed charges,Implant Device,836.06,34,,836.06,percent of total billed charges,Implant Device,836.06,34,,836.06,percent of total billed charges,Implant Device,836.06,34,,836.06,percent of total billed charges,Implant Device,1217.21,,,1217.21,Other,110% of Medicare,860.65,35,,860.65,percent of total billed charges,Implant Device,836.06,34,"Charges > $500, x 34%",836.06,percent of total billed charges,Implant Device,860.65,35,,860.65,percent of total billed charges,Implant Device,860.65,35,,860.65,percent of total billed charges,Implant Device,860.65,35,,860.65,percent of total billed charges,Implant Device,860.65,35,,860.65,percent of total billed charges,Implant Device,860.65,35,,860.65,percent of total billed charges,Implant Device,983.6,40,,983.6,percent of total billed charges,Implant Device,860.65,70,,860.65,percent of total billed charges,All Other,836.06,34,,836.06,percent of total billed charges,Implant Device,836.06,34,,836.06,percent of total billed charges,Implant Device,860.65,35,,860.65,percent of total billed charges,Implant Device,860.65,35,,860.65,percent of total billed charges,Implant Device,860.65,35,,860.65,percent of total billed charges,Implant Device,860.65,35,,860.65,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,836.06,34,"If Charge > 2,000, then 34 percent",836.06,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1819.67,
DEPUY 202.214 LOCKING SCREW 2.7X14MM,C1713,HCPCS,,79007631,CDM,278,RC,,,both,,,300,222,,,222,Other,150% of Medicare + 9.63% HCRA Surcharge,135,45,,135,percent of total billed charges,Critical Access Hospital RCC factor,102,34,,102,percent of total billed charges,Implant Device,102,34,,102,percent of total billed charges,Implant Device,102,34,,102,percent of total billed charges,Implant Device,102,34,,102,percent of total billed charges,Implant Device,102,34,,102,percent of total billed charges,Implant Device,148.5,,,148.5,Other,110% of Medicare,105,35,,105,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,105,35,,105,percent of total billed charges,Implant Device,105,35,,105,percent of total billed charges,Implant Device,105,35,,105,percent of total billed charges,Implant Device,105,35,,105,percent of total billed charges,Implant Device,105,35,,105,percent of total billed charges,Implant Device,120,40,,120,percent of total billed charges,Implant Device,105,70,,105,percent of total billed charges,All Other,102,34,,102,percent of total billed charges,Implant Device,102,34,,102,percent of total billed charges,Implant Device,105,35,,105,percent of total billed charges,Implant Device,105,35,,105,percent of total billed charges,Implant Device,105,35,,105,percent of total billed charges,Implant Device,105,35,,105,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,222,
DEPUY 201.768 CORTEX SCREW 2.4X18MM,C1713,HCPCS,,79007632,CDM,278,RC,,,both,,,130,96.2,,,96.2,Other,150% of Medicare + 9.63% HCRA Surcharge,58.5,45,,58.5,percent of total billed charges,Critical Access Hospital RCC factor,44.2,34,,44.2,percent of total billed charges,Implant Device,44.2,34,,44.2,percent of total billed charges,Implant Device,44.2,34,,44.2,percent of total billed charges,Implant Device,44.2,34,,44.2,percent of total billed charges,Implant Device,44.2,34,,44.2,percent of total billed charges,Implant Device,64.35,,,64.35,Other,110% of Medicare,45.5,35,,45.5,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,45.5,35,,45.5,percent of total billed charges,Implant Device,45.5,35,,45.5,percent of total billed charges,Implant Device,45.5,35,,45.5,percent of total billed charges,Implant Device,45.5,35,,45.5,percent of total billed charges,Implant Device,45.5,35,,45.5,percent of total billed charges,Implant Device,52,40,,52,percent of total billed charges,Implant Device,45.5,70,,45.5,percent of total billed charges,All Other,44.2,34,,44.2,percent of total billed charges,Implant Device,44.2,34,,44.2,percent of total billed charges,Implant Device,45.5,35,,45.5,percent of total billed charges,Implant Device,45.5,35,,45.5,percent of total billed charges,Implant Device,45.5,35,,45.5,percent of total billed charges,Implant Device,45.5,35,,45.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,96.2,
STRYKER 1832-2828S HUMERAL NAIL 8X280,C1713,HCPCS,,79007635,CDM,278,RC,,,both,,,7492,5544.1,,,5544.1,Other,150% of Medicare + 9.63% HCRA Surcharge,3371.4,45,,3371.4,percent of total billed charges,Critical Access Hospital RCC factor,2547.28,34,,2547.28,percent of total billed charges,Implant Device,2547.28,34,,2547.28,percent of total billed charges,Implant Device,2547.28,34,,2547.28,percent of total billed charges,Implant Device,2547.28,34,,2547.28,percent of total billed charges,Implant Device,2547.28,34,,2547.28,percent of total billed charges,Implant Device,3708.54,,,3708.54,Other,110% of Medicare,2622.2,35,,2622.2,percent of total billed charges,Implant Device,2547.28,34,"Charges > $500, x 34%",2547.28,percent of total billed charges,Implant Device,2622.2,35,,2622.2,percent of total billed charges,Implant Device,2622.2,35,,2622.2,percent of total billed charges,Implant Device,2622.2,35,,2622.2,percent of total billed charges,Implant Device,2622.2,35,,2622.2,percent of total billed charges,Implant Device,2622.2,35,,2622.2,percent of total billed charges,Implant Device,2996.8,40,,2996.8,percent of total billed charges,Implant Device,2622.2,70,,2622.2,percent of total billed charges,All Other,2547.28,34,,2547.28,percent of total billed charges,Implant Device,2547.28,34,,2547.28,percent of total billed charges,Implant Device,2622.2,35,,2622.2,percent of total billed charges,Implant Device,2622.2,35,,2622.2,percent of total billed charges,Implant Device,2622.2,35,,2622.2,percent of total billed charges,Implant Device,2622.2,35,,2622.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2547.28,34,"If Charge > 2,000, then 34 percent",2547.28,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5544.1,
DEPUY 02.107.002 PLATE 2 HOLE 2.7/3.5X73,C1713,HCPCS,,79007637,CDM,278,RC,,,both,,,2513,1859.63,,,1859.63,Other,150% of Medicare + 9.63% HCRA Surcharge,1130.85,45,,1130.85,percent of total billed charges,Critical Access Hospital RCC factor,854.42,34,,854.42,percent of total billed charges,Implant Device,854.42,34,,854.42,percent of total billed charges,Implant Device,854.42,34,,854.42,percent of total billed charges,Implant Device,854.42,34,,854.42,percent of total billed charges,Implant Device,854.42,34,,854.42,percent of total billed charges,Implant Device,1243.94,,,1243.94,Other,110% of Medicare,879.55,35,,879.55,percent of total billed charges,Implant Device,854.42,34,"Charges > $500, x 34%",854.42,percent of total billed charges,Implant Device,879.55,35,,879.55,percent of total billed charges,Implant Device,879.55,35,,879.55,percent of total billed charges,Implant Device,879.55,35,,879.55,percent of total billed charges,Implant Device,879.55,35,,879.55,percent of total billed charges,Implant Device,879.55,35,,879.55,percent of total billed charges,Implant Device,1005.2,40,,1005.2,percent of total billed charges,Implant Device,879.55,70,,879.55,percent of total billed charges,All Other,854.42,34,,854.42,percent of total billed charges,Implant Device,854.42,34,,854.42,percent of total billed charges,Implant Device,879.55,35,,879.55,percent of total billed charges,Implant Device,879.55,35,,879.55,percent of total billed charges,Implant Device,879.55,35,,879.55,percent of total billed charges,Implant Device,879.55,35,,879.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,854.42,34,"If Charge > 2,000, then 34 percent",854.42,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1859.63,
DEPUY 02.211.050 LOCK SCREW 2.7X50,C1713,HCPCS,,79007638,CDM,278,RC,,,both,,,343,253.82,,,253.82,Other,150% of Medicare + 9.63% HCRA Surcharge,154.35,45,,154.35,percent of total billed charges,Critical Access Hospital RCC factor,116.62,34,,116.62,percent of total billed charges,Implant Device,116.62,34,,116.62,percent of total billed charges,Implant Device,116.62,34,,116.62,percent of total billed charges,Implant Device,116.62,34,,116.62,percent of total billed charges,Implant Device,116.62,34,,116.62,percent of total billed charges,Implant Device,169.79,,,169.79,Other,110% of Medicare,120.05,35,,120.05,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,120.05,35,,120.05,percent of total billed charges,Implant Device,120.05,35,,120.05,percent of total billed charges,Implant Device,120.05,35,,120.05,percent of total billed charges,Implant Device,120.05,35,,120.05,percent of total billed charges,Implant Device,120.05,35,,120.05,percent of total billed charges,Implant Device,137.2,40,,137.2,percent of total billed charges,Implant Device,120.05,70,,120.05,percent of total billed charges,All Other,116.62,34,,116.62,percent of total billed charges,Implant Device,116.62,34,,116.62,percent of total billed charges,Implant Device,120.05,35,,120.05,percent of total billed charges,Implant Device,120.05,35,,120.05,percent of total billed charges,Implant Device,120.05,35,,120.05,percent of total billed charges,Implant Device,120.05,35,,120.05,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,253.82,
P28 P20-135-024F CANN SCREW 3.5X24MM,C1713,HCPCS,,79007642,CDM,278,RC,,,both,,,768,568.32,,,568.32,Other,150% of Medicare + 9.63% HCRA Surcharge,345.6,45,,345.6,percent of total billed charges,Critical Access Hospital RCC factor,261.12,34,,261.12,percent of total billed charges,Implant Device,261.12,34,,261.12,percent of total billed charges,Implant Device,261.12,34,,261.12,percent of total billed charges,Implant Device,261.12,34,,261.12,percent of total billed charges,Implant Device,261.12,34,,261.12,percent of total billed charges,Implant Device,380.16,,,380.16,Other,110% of Medicare,268.8,35,,268.8,percent of total billed charges,Implant Device,261.12,34,"Charges > $500, x 34%",261.12,percent of total billed charges,Implant Device,268.8,35,,268.8,percent of total billed charges,Implant Device,268.8,35,,268.8,percent of total billed charges,Implant Device,268.8,35,,268.8,percent of total billed charges,Implant Device,268.8,35,,268.8,percent of total billed charges,Implant Device,268.8,35,,268.8,percent of total billed charges,Implant Device,307.2,40,,307.2,percent of total billed charges,Implant Device,268.8,70,,268.8,percent of total billed charges,All Other,261.12,34,,261.12,percent of total billed charges,Implant Device,261.12,34,,261.12,percent of total billed charges,Implant Device,268.8,35,,268.8,percent of total billed charges,Implant Device,268.8,35,,268.8,percent of total billed charges,Implant Device,268.8,35,,268.8,percent of total billed charges,Implant Device,268.8,35,,268.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,568.32,
P28 P50-053-2708 LOCKING SCREW 2.7X08MM,C1713,HCPCS,,79007644,CDM,278,RC,,,both,,,667,493.58,,,493.58,Other,150% of Medicare + 9.63% HCRA Surcharge,300.15,45,,300.15,percent of total billed charges,Critical Access Hospital RCC factor,226.78,34,,226.78,percent of total billed charges,Implant Device,226.78,34,,226.78,percent of total billed charges,Implant Device,226.78,34,,226.78,percent of total billed charges,Implant Device,226.78,34,,226.78,percent of total billed charges,Implant Device,226.78,34,,226.78,percent of total billed charges,Implant Device,330.17,,,330.17,Other,110% of Medicare,233.45,35,,233.45,percent of total billed charges,Implant Device,226.78,34,"Charges > $500, x 34%",226.78,percent of total billed charges,Implant Device,233.45,35,,233.45,percent of total billed charges,Implant Device,233.45,35,,233.45,percent of total billed charges,Implant Device,233.45,35,,233.45,percent of total billed charges,Implant Device,233.45,35,,233.45,percent of total billed charges,Implant Device,233.45,35,,233.45,percent of total billed charges,Implant Device,266.8,40,,266.8,percent of total billed charges,Implant Device,233.45,70,,233.45,percent of total billed charges,All Other,226.78,34,,226.78,percent of total billed charges,Implant Device,226.78,34,,226.78,percent of total billed charges,Implant Device,233.45,35,,233.45,percent of total billed charges,Implant Device,233.45,35,,233.45,percent of total billed charges,Implant Device,233.45,35,,233.45,percent of total billed charges,Implant Device,233.45,35,,233.45,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,493.58,
P28 P50-053-2712 LOCKING SCREW 2.7X12MM,C1713,HCPCS,,79007645,CDM,278,RC,,,both,,,667,493.58,,,493.58,Other,150% of Medicare + 9.63% HCRA Surcharge,300.15,45,,300.15,percent of total billed charges,Critical Access Hospital RCC factor,226.78,34,,226.78,percent of total billed charges,Implant Device,226.78,34,,226.78,percent of total billed charges,Implant Device,226.78,34,,226.78,percent of total billed charges,Implant Device,226.78,34,,226.78,percent of total billed charges,Implant Device,226.78,34,,226.78,percent of total billed charges,Implant Device,330.17,,,330.17,Other,110% of Medicare,233.45,35,,233.45,percent of total billed charges,Implant Device,226.78,34,"Charges > $500, x 34%",226.78,percent of total billed charges,Implant Device,233.45,35,,233.45,percent of total billed charges,Implant Device,233.45,35,,233.45,percent of total billed charges,Implant Device,233.45,35,,233.45,percent of total billed charges,Implant Device,233.45,35,,233.45,percent of total billed charges,Implant Device,233.45,35,,233.45,percent of total billed charges,Implant Device,266.8,40,,266.8,percent of total billed charges,Implant Device,233.45,70,,233.45,percent of total billed charges,All Other,226.78,34,,226.78,percent of total billed charges,Implant Device,226.78,34,,226.78,percent of total billed charges,Implant Device,233.45,35,,233.45,percent of total billed charges,Implant Device,233.45,35,,233.45,percent of total billed charges,Implant Device,233.45,35,,233.45,percent of total billed charges,Implant Device,233.45,35,,233.45,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,493.58,
P28 P50-053-3512 LOCKING SCREW 3.5X12MM,C1713,HCPCS,,79007646,CDM,278,RC,,,both,,,694,513.56,,,513.56,Other,150% of Medicare + 9.63% HCRA Surcharge,312.3,45,,312.3,percent of total billed charges,Critical Access Hospital RCC factor,235.96,34,,235.96,percent of total billed charges,Implant Device,235.96,34,,235.96,percent of total billed charges,Implant Device,235.96,34,,235.96,percent of total billed charges,Implant Device,235.96,34,,235.96,percent of total billed charges,Implant Device,235.96,34,,235.96,percent of total billed charges,Implant Device,343.53,,,343.53,Other,110% of Medicare,242.9,35,,242.9,percent of total billed charges,Implant Device,235.96,34,"Charges > $500, x 34%",235.96,percent of total billed charges,Implant Device,242.9,35,,242.9,percent of total billed charges,Implant Device,242.9,35,,242.9,percent of total billed charges,Implant Device,242.9,35,,242.9,percent of total billed charges,Implant Device,242.9,35,,242.9,percent of total billed charges,Implant Device,242.9,35,,242.9,percent of total billed charges,Implant Device,277.6,40,,277.6,percent of total billed charges,Implant Device,242.9,70,,242.9,percent of total billed charges,All Other,235.96,34,,235.96,percent of total billed charges,Implant Device,235.96,34,,235.96,percent of total billed charges,Implant Device,242.9,35,,242.9,percent of total billed charges,Implant Device,242.9,35,,242.9,percent of total billed charges,Implant Device,242.9,35,,242.9,percent of total billed charges,Implant Device,242.9,35,,242.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,513.56,
P28 P50-053-3514 LOCKING SCREW 3.5X14MM,C1713,HCPCS,,79007647,CDM,278,RC,,,both,,,880,651.2,,,651.2,Other,150% of Medicare + 9.63% HCRA Surcharge,396,45,,396,percent of total billed charges,Critical Access Hospital RCC factor,299.2,34,,299.2,percent of total billed charges,Implant Device,299.2,34,,299.2,percent of total billed charges,Implant Device,299.2,34,,299.2,percent of total billed charges,Implant Device,299.2,34,,299.2,percent of total billed charges,Implant Device,299.2,34,,299.2,percent of total billed charges,Implant Device,435.6,,,435.6,Other,110% of Medicare,308,35,,308,percent of total billed charges,Implant Device,299.2,34,"Charges > $500, x 34%",299.2,percent of total billed charges,Implant Device,308,35,,308,percent of total billed charges,Implant Device,308,35,,308,percent of total billed charges,Implant Device,308,35,,308,percent of total billed charges,Implant Device,308,35,,308,percent of total billed charges,Implant Device,308,35,,308,percent of total billed charges,Implant Device,352,40,,352,percent of total billed charges,Implant Device,308,70,,308,percent of total billed charges,All Other,299.2,34,,299.2,percent of total billed charges,Implant Device,299.2,34,,299.2,percent of total billed charges,Implant Device,308,35,,308,percent of total billed charges,Implant Device,308,35,,308,percent of total billed charges,Implant Device,308,35,,308,percent of total billed charges,Implant Device,308,35,,308,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,651.2,
P28 P53-103-L053 MTP PLATE 5HOLE LONG LT,C1713,HCPCS,,79007648,CDM,278,RC,,,both,,,5688,4209.13,,,4209.13,Other,150% of Medicare + 9.63% HCRA Surcharge,2559.6,45,,2559.6,percent of total billed charges,Critical Access Hospital RCC factor,1933.92,34,,1933.92,percent of total billed charges,Implant Device,1933.92,34,,1933.92,percent of total billed charges,Implant Device,1933.92,34,,1933.92,percent of total billed charges,Implant Device,1933.92,34,,1933.92,percent of total billed charges,Implant Device,1933.92,34,,1933.92,percent of total billed charges,Implant Device,2815.56,,,2815.56,Other,110% of Medicare,1990.8,35,,1990.8,percent of total billed charges,Implant Device,1933.92,34,"Charges > $500, x 34%",1933.92,percent of total billed charges,Implant Device,1990.8,35,,1990.8,percent of total billed charges,Implant Device,1990.8,35,,1990.8,percent of total billed charges,Implant Device,1990.8,35,,1990.8,percent of total billed charges,Implant Device,1990.8,35,,1990.8,percent of total billed charges,Implant Device,1990.8,35,,1990.8,percent of total billed charges,Implant Device,2275.2,40,,2275.2,percent of total billed charges,Implant Device,1990.8,70,,1990.8,percent of total billed charges,All Other,1933.92,34,,1933.92,percent of total billed charges,Implant Device,1933.92,34,,1933.92,percent of total billed charges,Implant Device,1990.8,35,,1990.8,percent of total billed charges,Implant Device,1990.8,35,,1990.8,percent of total billed charges,Implant Device,1990.8,35,,1990.8,percent of total billed charges,Implant Device,1990.8,35,,1990.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1933.92,34,"If Charge > 2,000, then 34 percent",1933.92,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4209.13,
STRYKER 5542-P-0040 TSA GLENOID SZ 40,C1776,HCPCS,,79007651,CDM,278,RC,,,both,,,3675,2719.51,,,2719.51,Other,150% of Medicare + 9.63% HCRA Surcharge,1653.75,45,,1653.75,percent of total billed charges,Critical Access Hospital RCC factor,1249.5,34,,1249.5,percent of total billed charges,Implant Device,1249.5,34,,1249.5,percent of total billed charges,Implant Device,1249.5,34,,1249.5,percent of total billed charges,Implant Device,1249.5,34,,1249.5,percent of total billed charges,Implant Device,1249.5,34,,1249.5,percent of total billed charges,Implant Device,1819.13,,,1819.13,Other,110% of Medicare,1286.25,35,,1286.25,percent of total billed charges,Implant Device,1249.5,34,"Charges > $500, x 34%",1249.5,percent of total billed charges,Implant Device,1286.25,35,,1286.25,percent of total billed charges,Implant Device,1286.25,35,,1286.25,percent of total billed charges,Implant Device,1286.25,35,,1286.25,percent of total billed charges,Implant Device,1286.25,35,,1286.25,percent of total billed charges,Implant Device,1286.25,35,,1286.25,percent of total billed charges,Implant Device,1470,40,,1470,percent of total billed charges,Implant Device,1286.25,70,,1286.25,percent of total billed charges,All Other,1249.5,34,,1249.5,percent of total billed charges,Implant Device,1249.5,34,,1249.5,percent of total billed charges,Implant Device,1286.25,35,,1286.25,percent of total billed charges,Implant Device,1286.25,35,,1286.25,percent of total billed charges,Implant Device,1286.25,35,,1286.25,percent of total billed charges,Implant Device,1286.25,35,,1286.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1249.5,34,"If Charge > 2,000, then 34 percent",1249.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2719.51,
STRYKER 5552-E-4419 HUMERAL HEAD 44X19MM,C1776,HCPCS,,79007652,CDM,278,RC,,,both,,,5355,3962.71,,,3962.71,Other,150% of Medicare + 9.63% HCRA Surcharge,2409.75,45,,2409.75,percent of total billed charges,Critical Access Hospital RCC factor,1820.7,34,,1820.7,percent of total billed charges,Implant Device,1820.7,34,,1820.7,percent of total billed charges,Implant Device,1820.7,34,,1820.7,percent of total billed charges,Implant Device,1820.7,34,,1820.7,percent of total billed charges,Implant Device,1820.7,34,,1820.7,percent of total billed charges,Implant Device,2650.73,,,2650.73,Other,110% of Medicare,1874.25,35,,1874.25,percent of total billed charges,Implant Device,1820.7,34,"Charges > $500, x 34%",1820.7,percent of total billed charges,Implant Device,1874.25,35,,1874.25,percent of total billed charges,Implant Device,1874.25,35,,1874.25,percent of total billed charges,Implant Device,1874.25,35,,1874.25,percent of total billed charges,Implant Device,1874.25,35,,1874.25,percent of total billed charges,Implant Device,1874.25,35,,1874.25,percent of total billed charges,Implant Device,2142,40,,2142,percent of total billed charges,Implant Device,1874.25,70,,1874.25,percent of total billed charges,All Other,1820.7,34,,1820.7,percent of total billed charges,Implant Device,1820.7,34,,1820.7,percent of total billed charges,Implant Device,1874.25,35,,1874.25,percent of total billed charges,Implant Device,1874.25,35,,1874.25,percent of total billed charges,Implant Device,1874.25,35,,1874.25,percent of total billed charges,Implant Device,1874.25,35,,1874.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1820.7,34,"If Charge > 2,000, then 34 percent",1820.7,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3962.71,
STRYKER 5569-P-2012 HUMERAL STEM 12X128,C1776,HCPCS,,79007653,CDM,278,RC,,,both,,,22716,16809.9,,,16809.9,Other,150% of Medicare + 9.63% HCRA Surcharge,10222.2,45,,10222.2,percent of total billed charges,Critical Access Hospital RCC factor,7723.44,34,,7723.44,percent of total billed charges,Implant Device,7723.44,34,,7723.44,percent of total billed charges,Implant Device,7723.44,34,,7723.44,percent of total billed charges,Implant Device,7723.44,34,,7723.44,percent of total billed charges,Implant Device,7723.44,34,,7723.44,percent of total billed charges,Implant Device,11244.42,,,11244.42,Other,110% of Medicare,7950.6,35,,7950.6,percent of total billed charges,Implant Device,7723.44,34,"Charges > $500, x 34%",7723.44,percent of total billed charges,Implant Device,7950.6,35,,7950.6,percent of total billed charges,Implant Device,7950.6,35,,7950.6,percent of total billed charges,Implant Device,7950.6,35,,7950.6,percent of total billed charges,Implant Device,7950.6,35,,7950.6,percent of total billed charges,Implant Device,7950.6,35,,7950.6,percent of total billed charges,Implant Device,9086.4,40,,9086.4,percent of total billed charges,Implant Device,7950.6,70,,7950.6,percent of total billed charges,All Other,7723.44,34,,7723.44,percent of total billed charges,Implant Device,7723.44,34,,7723.44,percent of total billed charges,Implant Device,7950.6,35,,7950.6,percent of total billed charges,Implant Device,7950.6,35,,7950.6,percent of total billed charges,Implant Device,7950.6,35,,7950.6,percent of total billed charges,Implant Device,7950.6,35,,7950.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,7723.44,34,"If Charge > 2,000, then 34 percent",7723.44,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,16809.9,
DEPUY 207.040 CANCELLOUS BONE SCREW 4X40,C1713,HCPCS,,79007655,CDM,278,RC,,,both,,,78,57.72,,,57.72,Other,150% of Medicare + 9.63% HCRA Surcharge,35.1,45,,35.1,percent of total billed charges,Critical Access Hospital RCC factor,26.52,34,,26.52,percent of total billed charges,Implant Device,26.52,34,,26.52,percent of total billed charges,Implant Device,26.52,34,,26.52,percent of total billed charges,Implant Device,26.52,34,,26.52,percent of total billed charges,Implant Device,26.52,34,,26.52,percent of total billed charges,Implant Device,38.61,,,38.61,Other,110% of Medicare,27.3,35,,27.3,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,27.3,35,,27.3,percent of total billed charges,Implant Device,27.3,35,,27.3,percent of total billed charges,Implant Device,27.3,35,,27.3,percent of total billed charges,Implant Device,27.3,35,,27.3,percent of total billed charges,Implant Device,27.3,35,,27.3,percent of total billed charges,Implant Device,31.2,40,,31.2,percent of total billed charges,Implant Device,27.3,70,,27.3,percent of total billed charges,All Other,26.52,34,,26.52,percent of total billed charges,Implant Device,26.52,34,,26.52,percent of total billed charges,Implant Device,27.3,35,,27.3,percent of total billed charges,Implant Device,27.3,35,,27.3,percent of total billed charges,Implant Device,27.3,35,,27.3,percent of total billed charges,Implant Device,27.3,35,,27.3,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,57.72,
STRYKER 1828-1326S FEMORAL NAIL 13X260MM,C1713,HCPCS,,79007658,CDM,278,RC,,,both,,,7030,5202.22,,,5202.22,Other,150% of Medicare + 9.63% HCRA Surcharge,3163.5,45,,3163.5,percent of total billed charges,Critical Access Hospital RCC factor,2390.2,34,,2390.2,percent of total billed charges,Implant Device,2390.2,34,,2390.2,percent of total billed charges,Implant Device,2390.2,34,,2390.2,percent of total billed charges,Implant Device,2390.2,34,,2390.2,percent of total billed charges,Implant Device,2390.2,34,,2390.2,percent of total billed charges,Implant Device,3479.85,,,3479.85,Other,110% of Medicare,2460.5,35,,2460.5,percent of total billed charges,Implant Device,2390.2,34,"Charges > $500, x 34%",2390.2,percent of total billed charges,Implant Device,2460.5,35,,2460.5,percent of total billed charges,Implant Device,2460.5,35,,2460.5,percent of total billed charges,Implant Device,2460.5,35,,2460.5,percent of total billed charges,Implant Device,2460.5,35,,2460.5,percent of total billed charges,Implant Device,2460.5,35,,2460.5,percent of total billed charges,Implant Device,2812,40,,2812,percent of total billed charges,Implant Device,2460.5,70,,2460.5,percent of total billed charges,All Other,2390.2,34,,2390.2,percent of total billed charges,Implant Device,2390.2,34,,2390.2,percent of total billed charges,Implant Device,2460.5,35,,2460.5,percent of total billed charges,Implant Device,2460.5,35,,2460.5,percent of total billed charges,Implant Device,2460.5,35,,2460.5,percent of total billed charges,Implant Device,2460.5,35,,2460.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2390.2,34,"If Charge > 2,000, then 34 percent",2390.2,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5202.22,
ZIMMER 00-5952-030-12 ARTICULR SURF 12MM,C1776,HCPCS,,79007659,CDM,278,RC,,,both,,,2496,1847.05,,,1847.05,Other,150% of Medicare + 9.63% HCRA Surcharge,1123.2,45,,1123.2,percent of total billed charges,Critical Access Hospital RCC factor,848.64,34,,848.64,percent of total billed charges,Implant Device,848.64,34,,848.64,percent of total billed charges,Implant Device,848.64,34,,848.64,percent of total billed charges,Implant Device,848.64,34,,848.64,percent of total billed charges,Implant Device,848.64,34,,848.64,percent of total billed charges,Implant Device,1235.52,,,1235.52,Other,110% of Medicare,873.6,35,,873.6,percent of total billed charges,Implant Device,848.64,34,"Charges > $500, x 34%",848.64,percent of total billed charges,Implant Device,873.6,35,,873.6,percent of total billed charges,Implant Device,873.6,35,,873.6,percent of total billed charges,Implant Device,873.6,35,,873.6,percent of total billed charges,Implant Device,873.6,35,,873.6,percent of total billed charges,Implant Device,873.6,35,,873.6,percent of total billed charges,Implant Device,998.4,40,,998.4,percent of total billed charges,Implant Device,873.6,70,,873.6,percent of total billed charges,All Other,848.64,34,,848.64,percent of total billed charges,Implant Device,848.64,34,,848.64,percent of total billed charges,Implant Device,873.6,35,,873.6,percent of total billed charges,Implant Device,873.6,35,,873.6,percent of total billed charges,Implant Device,873.6,35,,873.6,percent of total billed charges,Implant Device,873.6,35,,873.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,848.64,34,"If Charge > 2,000, then 34 percent",848.64,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1847.05,
ARTHREX AR-5028P-08 DELTA SCREW 8X28MM,C1713,HCPCS,,79007660,CDM,278,RC,,,both,,,1074,794.76,,,794.76,Other,150% of Medicare + 9.63% HCRA Surcharge,483.3,45,,483.3,percent of total billed charges,Critical Access Hospital RCC factor,365.16,34,,365.16,percent of total billed charges,Implant Device,365.16,34,,365.16,percent of total billed charges,Implant Device,365.16,34,,365.16,percent of total billed charges,Implant Device,365.16,34,,365.16,percent of total billed charges,Implant Device,365.16,34,,365.16,percent of total billed charges,Implant Device,531.63,,,531.63,Other,110% of Medicare,375.9,35,,375.9,percent of total billed charges,Implant Device,365.16,34,"Charges > $500, x 34%",365.16,percent of total billed charges,Implant Device,375.9,35,,375.9,percent of total billed charges,Implant Device,375.9,35,,375.9,percent of total billed charges,Implant Device,375.9,35,,375.9,percent of total billed charges,Implant Device,375.9,35,,375.9,percent of total billed charges,Implant Device,375.9,35,,375.9,percent of total billed charges,Implant Device,429.6,40,,429.6,percent of total billed charges,Implant Device,375.9,70,,375.9,percent of total billed charges,All Other,365.16,34,,365.16,percent of total billed charges,Implant Device,365.16,34,,365.16,percent of total billed charges,Implant Device,375.9,35,,375.9,percent of total billed charges,Implant Device,375.9,35,,375.9,percent of total billed charges,Implant Device,375.9,35,,375.9,percent of total billed charges,Implant Device,375.9,35,,375.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,794.76,
ARTHREX AR-1380P PEEK INTER SCREW 8X23MM,C1713,HCPCS,,79007661,CDM,278,RC,,,both,,,1074,794.76,,,794.76,Other,150% of Medicare + 9.63% HCRA Surcharge,483.3,45,,483.3,percent of total billed charges,Critical Access Hospital RCC factor,365.16,34,,365.16,percent of total billed charges,Implant Device,365.16,34,,365.16,percent of total billed charges,Implant Device,365.16,34,,365.16,percent of total billed charges,Implant Device,365.16,34,,365.16,percent of total billed charges,Implant Device,365.16,34,,365.16,percent of total billed charges,Implant Device,531.63,,,531.63,Other,110% of Medicare,375.9,35,,375.9,percent of total billed charges,Implant Device,365.16,34,"Charges > $500, x 34%",365.16,percent of total billed charges,Implant Device,375.9,35,,375.9,percent of total billed charges,Implant Device,375.9,35,,375.9,percent of total billed charges,Implant Device,375.9,35,,375.9,percent of total billed charges,Implant Device,375.9,35,,375.9,percent of total billed charges,Implant Device,375.9,35,,375.9,percent of total billed charges,Implant Device,429.6,40,,429.6,percent of total billed charges,Implant Device,375.9,70,,375.9,percent of total billed charges,All Other,365.16,34,,365.16,percent of total billed charges,Implant Device,365.16,34,,365.16,percent of total billed charges,Implant Device,375.9,35,,375.9,percent of total billed charges,Implant Device,375.9,35,,375.9,percent of total billed charges,Implant Device,375.9,35,,375.9,percent of total billed charges,Implant Device,375.9,35,,375.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,794.76,
ARTHREX AR-8935-24 CORTICAL SCREW 3.5X24,C1713,HCPCS,,79007662,CDM,278,RC,,,both,,,258,190.92,,,190.92,Other,150% of Medicare + 9.63% HCRA Surcharge,116.1,45,,116.1,percent of total billed charges,Critical Access Hospital RCC factor,87.72,34,,87.72,percent of total billed charges,Implant Device,87.72,34,,87.72,percent of total billed charges,Implant Device,87.72,34,,87.72,percent of total billed charges,Implant Device,87.72,34,,87.72,percent of total billed charges,Implant Device,87.72,34,,87.72,percent of total billed charges,Implant Device,127.71,,,127.71,Other,110% of Medicare,90.3,35,,90.3,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,90.3,35,,90.3,percent of total billed charges,Implant Device,90.3,35,,90.3,percent of total billed charges,Implant Device,90.3,35,,90.3,percent of total billed charges,Implant Device,90.3,35,,90.3,percent of total billed charges,Implant Device,90.3,35,,90.3,percent of total billed charges,Implant Device,103.2,40,,103.2,percent of total billed charges,Implant Device,90.3,70,,90.3,percent of total billed charges,All Other,87.72,34,,87.72,percent of total billed charges,Implant Device,87.72,34,,87.72,percent of total billed charges,Implant Device,90.3,35,,90.3,percent of total billed charges,Implant Device,90.3,35,,90.3,percent of total billed charges,Implant Device,90.3,35,,90.3,percent of total billed charges,Implant Device,90.3,35,,90.3,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,190.92,
ACUMED CO-N2314 NON LOCKING SCREW 2.3X14,C1713,HCPCS,,79007663,CDM,278,RC,,,both,,,315,233.1,,,233.1,Other,150% of Medicare + 9.63% HCRA Surcharge,141.75,45,,141.75,percent of total billed charges,Critical Access Hospital RCC factor,107.1,34,,107.1,percent of total billed charges,Implant Device,107.1,34,,107.1,percent of total billed charges,Implant Device,107.1,34,,107.1,percent of total billed charges,Implant Device,107.1,34,,107.1,percent of total billed charges,Implant Device,107.1,34,,107.1,percent of total billed charges,Implant Device,155.93,,,155.93,Other,110% of Medicare,110.25,35,,110.25,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,110.25,35,,110.25,percent of total billed charges,Implant Device,110.25,35,,110.25,percent of total billed charges,Implant Device,110.25,35,,110.25,percent of total billed charges,Implant Device,110.25,35,,110.25,percent of total billed charges,Implant Device,110.25,35,,110.25,percent of total billed charges,Implant Device,126,40,,126,percent of total billed charges,Implant Device,110.25,70,,110.25,percent of total billed charges,All Other,107.1,34,,107.1,percent of total billed charges,Implant Device,107.1,34,,107.1,percent of total billed charges,Implant Device,110.25,35,,110.25,percent of total billed charges,Implant Device,110.25,35,,110.25,percent of total billed charges,Implant Device,110.25,35,,110.25,percent of total billed charges,Implant Device,110.25,35,,110.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,233.1,
ACUMED CO-N2312 NON LOCKING SCREW 2.3X12,C1713,HCPCS,,79007664,CDM,278,RC,,,both,,,315,233.1,,,233.1,Other,150% of Medicare + 9.63% HCRA Surcharge,141.75,45,,141.75,percent of total billed charges,Critical Access Hospital RCC factor,107.1,34,,107.1,percent of total billed charges,Implant Device,107.1,34,,107.1,percent of total billed charges,Implant Device,107.1,34,,107.1,percent of total billed charges,Implant Device,107.1,34,,107.1,percent of total billed charges,Implant Device,107.1,34,,107.1,percent of total billed charges,Implant Device,155.93,,,155.93,Other,110% of Medicare,110.25,35,,110.25,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,110.25,35,,110.25,percent of total billed charges,Implant Device,110.25,35,,110.25,percent of total billed charges,Implant Device,110.25,35,,110.25,percent of total billed charges,Implant Device,110.25,35,,110.25,percent of total billed charges,Implant Device,110.25,35,,110.25,percent of total billed charges,Implant Device,126,40,,126,percent of total billed charges,Implant Device,110.25,70,,110.25,percent of total billed charges,All Other,107.1,34,,107.1,percent of total billed charges,Implant Device,107.1,34,,107.1,percent of total billed charges,Implant Device,110.25,35,,110.25,percent of total billed charges,Implant Device,110.25,35,,110.25,percent of total billed charges,Implant Device,110.25,35,,110.25,percent of total billed charges,Implant Device,110.25,35,,110.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,233.1,
STRYKER 6276-7-214 MOD HIP SYSTEM 195X14,C1776,HCPCS,,79007665,CDM,278,RC,,,both,,,15277,11305.02,,,11305.02,Other,150% of Medicare + 9.63% HCRA Surcharge,6874.65,45,,6874.65,percent of total billed charges,Critical Access Hospital RCC factor,5194.18,34,,5194.18,percent of total billed charges,Implant Device,5194.18,34,,5194.18,percent of total billed charges,Implant Device,5194.18,34,,5194.18,percent of total billed charges,Implant Device,5194.18,34,,5194.18,percent of total billed charges,Implant Device,5194.18,34,,5194.18,percent of total billed charges,Implant Device,7562.12,,,7562.12,Other,110% of Medicare,5346.95,35,,5346.95,percent of total billed charges,Implant Device,5194.18,34,"Charges > $500, x 34%",5194.18,percent of total billed charges,Implant Device,5346.95,35,,5346.95,percent of total billed charges,Implant Device,5346.95,35,,5346.95,percent of total billed charges,Implant Device,5346.95,35,,5346.95,percent of total billed charges,Implant Device,5346.95,35,,5346.95,percent of total billed charges,Implant Device,5346.95,35,,5346.95,percent of total billed charges,Implant Device,6110.8,40,,6110.8,percent of total billed charges,Implant Device,5346.95,70,,5346.95,percent of total billed charges,All Other,5194.18,34,,5194.18,percent of total billed charges,Implant Device,5194.18,34,,5194.18,percent of total billed charges,Implant Device,5346.95,35,,5346.95,percent of total billed charges,Implant Device,5346.95,35,,5346.95,percent of total billed charges,Implant Device,5346.95,35,,5346.95,percent of total billed charges,Implant Device,5346.95,35,,5346.95,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,5194.18,34,"If Charge > 2,000, then 34 percent",5194.18,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,11305.02,
STRYKER 1830-0930S HUMERAL NAIL 09X300MM,C1713,HCPCS,,79007666,CDM,278,RC,,,both,,,6161,4559.16,,,4559.16,Other,150% of Medicare + 9.63% HCRA Surcharge,2772.45,45,,2772.45,percent of total billed charges,Critical Access Hospital RCC factor,2094.74,34,,2094.74,percent of total billed charges,Implant Device,2094.74,34,,2094.74,percent of total billed charges,Implant Device,2094.74,34,,2094.74,percent of total billed charges,Implant Device,2094.74,34,,2094.74,percent of total billed charges,Implant Device,2094.74,34,,2094.74,percent of total billed charges,Implant Device,3049.7,,,3049.7,Other,110% of Medicare,2156.35,35,,2156.35,percent of total billed charges,Implant Device,2094.74,34,"Charges > $500, x 34%",2094.74,percent of total billed charges,Implant Device,2156.35,35,,2156.35,percent of total billed charges,Implant Device,2156.35,35,,2156.35,percent of total billed charges,Implant Device,2156.35,35,,2156.35,percent of total billed charges,Implant Device,2156.35,35,,2156.35,percent of total billed charges,Implant Device,2156.35,35,,2156.35,percent of total billed charges,Implant Device,2464.4,40,,2464.4,percent of total billed charges,Implant Device,2156.35,70,,2156.35,percent of total billed charges,All Other,2094.74,34,,2094.74,percent of total billed charges,Implant Device,2094.74,34,,2094.74,percent of total billed charges,Implant Device,2156.35,35,,2156.35,percent of total billed charges,Implant Device,2156.35,35,,2156.35,percent of total billed charges,Implant Device,2156.35,35,,2156.35,percent of total billed charges,Implant Device,2156.35,35,,2156.35,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2094.74,34,"If Charge > 2,000, then 34 percent",2094.74,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4559.16,
DEPUY 202.872 CORTEX SCREW 2.7X12MM,C1713,HCPCS,,79007667,CDM,278,RC,,,both,,,88,65.12,,,65.12,Other,150% of Medicare + 9.63% HCRA Surcharge,39.6,45,,39.6,percent of total billed charges,Critical Access Hospital RCC factor,29.92,34,,29.92,percent of total billed charges,Implant Device,29.92,34,,29.92,percent of total billed charges,Implant Device,29.92,34,,29.92,percent of total billed charges,Implant Device,29.92,34,,29.92,percent of total billed charges,Implant Device,29.92,34,,29.92,percent of total billed charges,Implant Device,43.56,,,43.56,Other,110% of Medicare,30.8,35,,30.8,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,30.8,35,,30.8,percent of total billed charges,Implant Device,30.8,35,,30.8,percent of total billed charges,Implant Device,30.8,35,,30.8,percent of total billed charges,Implant Device,30.8,35,,30.8,percent of total billed charges,Implant Device,30.8,35,,30.8,percent of total billed charges,Implant Device,35.2,40,,35.2,percent of total billed charges,Implant Device,30.8,70,,30.8,percent of total billed charges,All Other,29.92,34,,29.92,percent of total billed charges,Implant Device,29.92,34,,29.92,percent of total billed charges,Implant Device,30.8,35,,30.8,percent of total billed charges,Implant Device,30.8,35,,30.8,percent of total billed charges,Implant Device,30.8,35,,30.8,percent of total billed charges,Implant Device,30.8,35,,30.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,65.12,
DEPUY 02.111.640 DIST RADIUS PLATE 2.4MM,C1713,HCPCS,,79007668,CDM,278,RC,,,both,,,2410,1783.41,,,1783.41,Other,150% of Medicare + 9.63% HCRA Surcharge,1084.5,45,,1084.5,percent of total billed charges,Critical Access Hospital RCC factor,819.4,34,,819.4,percent of total billed charges,Implant Device,819.4,34,,819.4,percent of total billed charges,Implant Device,819.4,34,,819.4,percent of total billed charges,Implant Device,819.4,34,,819.4,percent of total billed charges,Implant Device,819.4,34,,819.4,percent of total billed charges,Implant Device,1192.95,,,1192.95,Other,110% of Medicare,843.5,35,,843.5,percent of total billed charges,Implant Device,819.4,34,"Charges > $500, x 34%",819.4,percent of total billed charges,Implant Device,843.5,35,,843.5,percent of total billed charges,Implant Device,843.5,35,,843.5,percent of total billed charges,Implant Device,843.5,35,,843.5,percent of total billed charges,Implant Device,843.5,35,,843.5,percent of total billed charges,Implant Device,843.5,35,,843.5,percent of total billed charges,Implant Device,964,40,,964,percent of total billed charges,Implant Device,843.5,70,,843.5,percent of total billed charges,All Other,819.4,34,,819.4,percent of total billed charges,Implant Device,819.4,34,,819.4,percent of total billed charges,Implant Device,843.5,35,,843.5,percent of total billed charges,Implant Device,843.5,35,,843.5,percent of total billed charges,Implant Device,843.5,35,,843.5,percent of total billed charges,Implant Device,843.5,35,,843.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,819.4,34,"If Charge > 2,000, then 34 percent",819.4,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1783.41,
DEPUY 201.772 CORTEX SCREW 2.4X22MM,C1713,HCPCS,,79007669,CDM,278,RC,,,both,,,130,96.2,,,96.2,Other,150% of Medicare + 9.63% HCRA Surcharge,58.5,45,,58.5,percent of total billed charges,Critical Access Hospital RCC factor,44.2,34,,44.2,percent of total billed charges,Implant Device,44.2,34,,44.2,percent of total billed charges,Implant Device,44.2,34,,44.2,percent of total billed charges,Implant Device,44.2,34,,44.2,percent of total billed charges,Implant Device,44.2,34,,44.2,percent of total billed charges,Implant Device,64.35,,,64.35,Other,110% of Medicare,45.5,35,,45.5,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,45.5,35,,45.5,percent of total billed charges,Implant Device,45.5,35,,45.5,percent of total billed charges,Implant Device,45.5,35,,45.5,percent of total billed charges,Implant Device,45.5,35,,45.5,percent of total billed charges,Implant Device,45.5,35,,45.5,percent of total billed charges,Implant Device,52,40,,52,percent of total billed charges,Implant Device,45.5,70,,45.5,percent of total billed charges,All Other,44.2,34,,44.2,percent of total billed charges,Implant Device,44.2,34,,44.2,percent of total billed charges,Implant Device,45.5,35,,45.5,percent of total billed charges,Implant Device,45.5,35,,45.5,percent of total billed charges,Implant Device,45.5,35,,45.5,percent of total billed charges,Implant Device,45.5,35,,45.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,96.2,
DEPUY 201.774 CORTEX SCREW 2.4X24MM,C1713,HCPCS,,79007670,CDM,278,RC,,,both,,,233,172.42,,,172.42,Other,150% of Medicare + 9.63% HCRA Surcharge,104.85,45,,104.85,percent of total billed charges,Critical Access Hospital RCC factor,79.22,34,,79.22,percent of total billed charges,Implant Device,79.22,34,,79.22,percent of total billed charges,Implant Device,79.22,34,,79.22,percent of total billed charges,Implant Device,79.22,34,,79.22,percent of total billed charges,Implant Device,79.22,34,,79.22,percent of total billed charges,Implant Device,115.34,,,115.34,Other,110% of Medicare,81.55,35,,81.55,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,81.55,35,,81.55,percent of total billed charges,Implant Device,81.55,35,,81.55,percent of total billed charges,Implant Device,81.55,35,,81.55,percent of total billed charges,Implant Device,81.55,35,,81.55,percent of total billed charges,Implant Device,81.55,35,,81.55,percent of total billed charges,Implant Device,93.2,40,,93.2,percent of total billed charges,Implant Device,81.55,70,,81.55,percent of total billed charges,All Other,79.22,34,,79.22,percent of total billed charges,Implant Device,79.22,34,,79.22,percent of total billed charges,Implant Device,81.55,35,,81.55,percent of total billed charges,Implant Device,81.55,35,,81.55,percent of total billed charges,Implant Device,81.55,35,,81.55,percent of total billed charges,Implant Device,81.55,35,,81.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,172.42,
DEPUY 02.210.112 LOCKING SCREW 2.4X12MM,C1713,HCPCS,,79007671,CDM,278,RC,,,both,,,330,244.2,,,244.2,Other,150% of Medicare + 9.63% HCRA Surcharge,148.5,45,,148.5,percent of total billed charges,Critical Access Hospital RCC factor,112.2,34,,112.2,percent of total billed charges,Implant Device,112.2,34,,112.2,percent of total billed charges,Implant Device,112.2,34,,112.2,percent of total billed charges,Implant Device,112.2,34,,112.2,percent of total billed charges,Implant Device,112.2,34,,112.2,percent of total billed charges,Implant Device,163.35,,,163.35,Other,110% of Medicare,115.5,35,,115.5,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,132,40,,132,percent of total billed charges,Implant Device,115.5,70,,115.5,percent of total billed charges,All Other,112.2,34,,112.2,percent of total billed charges,Implant Device,112.2,34,,112.2,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,244.2,
DEPUY 02.210.122 LOCKING SCREW 2.4X22MM,C1713,HCPCS,,79007672,CDM,278,RC,,,both,,,330,244.2,,,244.2,Other,150% of Medicare + 9.63% HCRA Surcharge,148.5,45,,148.5,percent of total billed charges,Critical Access Hospital RCC factor,112.2,34,,112.2,percent of total billed charges,Implant Device,112.2,34,,112.2,percent of total billed charges,Implant Device,112.2,34,,112.2,percent of total billed charges,Implant Device,112.2,34,,112.2,percent of total billed charges,Implant Device,112.2,34,,112.2,percent of total billed charges,Implant Device,163.35,,,163.35,Other,110% of Medicare,115.5,35,,115.5,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,132,40,,132,percent of total billed charges,Implant Device,115.5,70,,115.5,percent of total billed charges,All Other,112.2,34,,112.2,percent of total billed charges,Implant Device,112.2,34,,112.2,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,244.2,
DEPUY 02.210.116 LOCKING SCREW 2.4X16MM,C1713,HCPCS,,79007673,CDM,278,RC,,,both,,,330,244.2,,,244.2,Other,150% of Medicare + 9.63% HCRA Surcharge,148.5,45,,148.5,percent of total billed charges,Critical Access Hospital RCC factor,112.2,34,,112.2,percent of total billed charges,Implant Device,112.2,34,,112.2,percent of total billed charges,Implant Device,112.2,34,,112.2,percent of total billed charges,Implant Device,112.2,34,,112.2,percent of total billed charges,Implant Device,112.2,34,,112.2,percent of total billed charges,Implant Device,163.35,,,163.35,Other,110% of Medicare,115.5,35,,115.5,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,132,40,,132,percent of total billed charges,Implant Device,115.5,70,,115.5,percent of total billed charges,All Other,112.2,34,,112.2,percent of total billed charges,Implant Device,112.2,34,,112.2,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,244.2,
DEPUY 02.210.126 LOCKING SCREW 2.4X26MM,C1713,HCPCS,,79007674,CDM,278,RC,,,both,,,562,415.88,,,415.88,Other,150% of Medicare + 9.63% HCRA Surcharge,252.9,45,,252.9,percent of total billed charges,Critical Access Hospital RCC factor,191.08,34,,191.08,percent of total billed charges,Implant Device,191.08,34,,191.08,percent of total billed charges,Implant Device,191.08,34,,191.08,percent of total billed charges,Implant Device,191.08,34,,191.08,percent of total billed charges,Implant Device,191.08,34,,191.08,percent of total billed charges,Implant Device,278.19,,,278.19,Other,110% of Medicare,196.7,35,,196.7,percent of total billed charges,Implant Device,191.08,34,"Charges > $500, x 34%",191.08,percent of total billed charges,Implant Device,196.7,35,,196.7,percent of total billed charges,Implant Device,196.7,35,,196.7,percent of total billed charges,Implant Device,196.7,35,,196.7,percent of total billed charges,Implant Device,196.7,35,,196.7,percent of total billed charges,Implant Device,196.7,35,,196.7,percent of total billed charges,Implant Device,224.8,40,,224.8,percent of total billed charges,Implant Device,196.7,70,,196.7,percent of total billed charges,All Other,191.08,34,,191.08,percent of total billed charges,Implant Device,191.08,34,,191.08,percent of total billed charges,Implant Device,196.7,35,,196.7,percent of total billed charges,Implant Device,196.7,35,,196.7,percent of total billed charges,Implant Device,196.7,35,,196.7,percent of total billed charges,Implant Device,196.7,35,,196.7,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,415.88,
DEPUY 1035-53-000 BI-POLAR HEAD 23X53MM,C1713,HCPCS,,79007675,CDM,278,RC,,,both,,,4030,2982.21,,,2982.21,Other,150% of Medicare + 9.63% HCRA Surcharge,1813.5,45,,1813.5,percent of total billed charges,Critical Access Hospital RCC factor,1370.2,34,,1370.2,percent of total billed charges,Implant Device,1370.2,34,,1370.2,percent of total billed charges,Implant Device,1370.2,34,,1370.2,percent of total billed charges,Implant Device,1370.2,34,,1370.2,percent of total billed charges,Implant Device,1370.2,34,,1370.2,percent of total billed charges,Implant Device,1994.85,,,1994.85,Other,110% of Medicare,1410.5,35,,1410.5,percent of total billed charges,Implant Device,1370.2,34,"Charges > $500, x 34%",1370.2,percent of total billed charges,Implant Device,1410.5,35,,1410.5,percent of total billed charges,Implant Device,1410.5,35,,1410.5,percent of total billed charges,Implant Device,1410.5,35,,1410.5,percent of total billed charges,Implant Device,1410.5,35,,1410.5,percent of total billed charges,Implant Device,1410.5,35,,1410.5,percent of total billed charges,Implant Device,1612,40,,1612,percent of total billed charges,Implant Device,1410.5,70,,1410.5,percent of total billed charges,All Other,1370.2,34,,1370.2,percent of total billed charges,Implant Device,1370.2,34,,1370.2,percent of total billed charges,Implant Device,1410.5,35,,1410.5,percent of total billed charges,Implant Device,1410.5,35,,1410.5,percent of total billed charges,Implant Device,1410.5,35,,1410.5,percent of total billed charges,Implant Device,1410.5,35,,1410.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1370.2,34,"If Charge > 2,000, then 34 percent",1370.2,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2982.21,
DEPUY 1516-30-407 ROTATING PLATFORM SZ 4,C1776,HCPCS,,79007676,CDM,278,RC,,,both,,,5400,3996.01,,,3996.01,Other,150% of Medicare + 9.63% HCRA Surcharge,2430,45,,2430,percent of total billed charges,Critical Access Hospital RCC factor,1836,34,,1836,percent of total billed charges,Implant Device,1836,34,,1836,percent of total billed charges,Implant Device,1836,34,,1836,percent of total billed charges,Implant Device,1836,34,,1836,percent of total billed charges,Implant Device,1836,34,,1836,percent of total billed charges,Implant Device,2673,,,2673,Other,110% of Medicare,1890,35,,1890,percent of total billed charges,Implant Device,1836,34,"Charges > $500, x 34%",1836,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,2160,40,,2160,percent of total billed charges,Implant Device,1890,70,,1890,percent of total billed charges,All Other,1836,34,,1836,percent of total billed charges,Implant Device,1836,34,,1836,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1836,34,"If Charge > 2,000, then 34 percent",1836,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3996.01,
DEPUY 02.111.621 DISTAL RAD PLATE 2.4MM,C1713,HCPCS,,79007677,CDM,278,RC,,,both,,,3963,2932.63,,,2932.63,Other,150% of Medicare + 9.63% HCRA Surcharge,1783.35,45,,1783.35,percent of total billed charges,Critical Access Hospital RCC factor,1347.42,34,,1347.42,percent of total billed charges,Implant Device,1347.42,34,,1347.42,percent of total billed charges,Implant Device,1347.42,34,,1347.42,percent of total billed charges,Implant Device,1347.42,34,,1347.42,percent of total billed charges,Implant Device,1347.42,34,,1347.42,percent of total billed charges,Implant Device,1961.69,,,1961.69,Other,110% of Medicare,1387.05,35,,1387.05,percent of total billed charges,Implant Device,1347.42,34,"Charges > $500, x 34%",1347.42,percent of total billed charges,Implant Device,1387.05,35,,1387.05,percent of total billed charges,Implant Device,1387.05,35,,1387.05,percent of total billed charges,Implant Device,1387.05,35,,1387.05,percent of total billed charges,Implant Device,1387.05,35,,1387.05,percent of total billed charges,Implant Device,1387.05,35,,1387.05,percent of total billed charges,Implant Device,1585.2,40,,1585.2,percent of total billed charges,Implant Device,1387.05,70,,1387.05,percent of total billed charges,All Other,1347.42,34,,1347.42,percent of total billed charges,Implant Device,1347.42,34,,1347.42,percent of total billed charges,Implant Device,1387.05,35,,1387.05,percent of total billed charges,Implant Device,1387.05,35,,1387.05,percent of total billed charges,Implant Device,1387.05,35,,1387.05,percent of total billed charges,Implant Device,1387.05,35,,1387.05,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1347.42,34,"If Charge > 2,000, then 34 percent",1347.42,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2932.63,
DEPUY 02.210.114 LOCKING SCEW 2.4X14MM,C1713,HCPCS,,79007678,CDM,278,RC,,,both,,,330,244.2,,,244.2,Other,150% of Medicare + 9.63% HCRA Surcharge,148.5,45,,148.5,percent of total billed charges,Critical Access Hospital RCC factor,112.2,34,,112.2,percent of total billed charges,Implant Device,112.2,34,,112.2,percent of total billed charges,Implant Device,112.2,34,,112.2,percent of total billed charges,Implant Device,112.2,34,,112.2,percent of total billed charges,Implant Device,112.2,34,,112.2,percent of total billed charges,Implant Device,163.35,,,163.35,Other,110% of Medicare,115.5,35,,115.5,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,132,40,,132,percent of total billed charges,Implant Device,115.5,70,,115.5,percent of total billed charges,All Other,112.2,34,,112.2,percent of total billed charges,Implant Device,112.2,34,,112.2,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,244.2,
STRYKER 5630-G-509 TIBIAL INS SZ 5 9MM,C1776,HCPCS,,79007680,CDM,278,RC,,,both,,,3232,2391.69,,,2391.69,Other,150% of Medicare + 9.63% HCRA Surcharge,1454.4,45,,1454.4,percent of total billed charges,Critical Access Hospital RCC factor,1098.88,34,,1098.88,percent of total billed charges,Implant Device,1098.88,34,,1098.88,percent of total billed charges,Implant Device,1098.88,34,,1098.88,percent of total billed charges,Implant Device,1098.88,34,,1098.88,percent of total billed charges,Implant Device,1098.88,34,,1098.88,percent of total billed charges,Implant Device,1599.84,,,1599.84,Other,110% of Medicare,1131.2,35,,1131.2,percent of total billed charges,Implant Device,1098.88,34,"Charges > $500, x 34%",1098.88,percent of total billed charges,Implant Device,1131.2,35,,1131.2,percent of total billed charges,Implant Device,1131.2,35,,1131.2,percent of total billed charges,Implant Device,1131.2,35,,1131.2,percent of total billed charges,Implant Device,1131.2,35,,1131.2,percent of total billed charges,Implant Device,1131.2,35,,1131.2,percent of total billed charges,Implant Device,1292.8,40,,1292.8,percent of total billed charges,Implant Device,1131.2,70,,1131.2,percent of total billed charges,All Other,1098.88,34,,1098.88,percent of total billed charges,Implant Device,1098.88,34,,1098.88,percent of total billed charges,Implant Device,1131.2,35,,1131.2,percent of total billed charges,Implant Device,1131.2,35,,1131.2,percent of total billed charges,Implant Device,1131.2,35,,1131.2,percent of total billed charges,Implant Device,1131.2,35,,1131.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1098.88,34,"If Charge > 2,000, then 34 percent",1098.88,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2391.69,
DEPUY 202.006 2.7X16MM CORTEX  SCREW,C1713,HCPCS,,79007682,CDM,278,RC,,,both,,,122,90.28,,,90.28,Other,150% of Medicare + 9.63% HCRA Surcharge,54.9,45,,54.9,percent of total billed charges,Critical Access Hospital RCC factor,41.48,34,,41.48,percent of total billed charges,Implant Device,41.48,34,,41.48,percent of total billed charges,Implant Device,41.48,34,,41.48,percent of total billed charges,Implant Device,41.48,34,,41.48,percent of total billed charges,Implant Device,41.48,34,,41.48,percent of total billed charges,Implant Device,60.39,,,60.39,Other,110% of Medicare,42.7,35,,42.7,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,42.7,35,,42.7,percent of total billed charges,Implant Device,42.7,35,,42.7,percent of total billed charges,Implant Device,42.7,35,,42.7,percent of total billed charges,Implant Device,42.7,35,,42.7,percent of total billed charges,Implant Device,42.7,35,,42.7,percent of total billed charges,Implant Device,48.8,40,,48.8,percent of total billed charges,Implant Device,42.7,70,,42.7,percent of total billed charges,All Other,41.48,34,,41.48,percent of total billed charges,Implant Device,41.48,34,,41.48,percent of total billed charges,Implant Device,42.7,35,,42.7,percent of total billed charges,Implant Device,42.7,35,,42.7,percent of total billed charges,Implant Device,42.7,35,,42.7,percent of total billed charges,Implant Device,42.7,35,,42.7,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,90.28,
STRYKER 608085 6.5X85MM CANCELLOUS SCREW,C1713,HCPCS,,79007683,CDM,278,RC,,,both,,,155,114.7,,,114.7,Other,150% of Medicare + 9.63% HCRA Surcharge,69.75,45,,69.75,percent of total billed charges,Critical Access Hospital RCC factor,52.7,34,,52.7,percent of total billed charges,Implant Device,52.7,34,,52.7,percent of total billed charges,Implant Device,52.7,34,,52.7,percent of total billed charges,Implant Device,52.7,34,,52.7,percent of total billed charges,Implant Device,52.7,34,,52.7,percent of total billed charges,Implant Device,76.73,,,76.73,Other,110% of Medicare,54.25,35,,54.25,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,54.25,35,,54.25,percent of total billed charges,Implant Device,54.25,35,,54.25,percent of total billed charges,Implant Device,54.25,35,,54.25,percent of total billed charges,Implant Device,54.25,35,,54.25,percent of total billed charges,Implant Device,54.25,35,,54.25,percent of total billed charges,Implant Device,62,40,,62,percent of total billed charges,Implant Device,54.25,70,,54.25,percent of total billed charges,All Other,52.7,34,,52.7,percent of total billed charges,Implant Device,52.7,34,,52.7,percent of total billed charges,Implant Device,54.25,35,,54.25,percent of total billed charges,Implant Device,54.25,35,,54.25,percent of total billed charges,Implant Device,54.25,35,,54.25,percent of total billed charges,Implant Device,54.25,35,,54.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,114.7,
STRYKER 661744 4.5X44MM CORTICAL SCREW,C1713,HCPCS,,79007684,CDM,278,RC,,,both,,,138,102.12,,,102.12,Other,150% of Medicare + 9.63% HCRA Surcharge,62.1,45,,62.1,percent of total billed charges,Critical Access Hospital RCC factor,46.92,34,,46.92,percent of total billed charges,Implant Device,46.92,34,,46.92,percent of total billed charges,Implant Device,46.92,34,,46.92,percent of total billed charges,Implant Device,46.92,34,,46.92,percent of total billed charges,Implant Device,46.92,34,,46.92,percent of total billed charges,Implant Device,68.31,,,68.31,Other,110% of Medicare,48.3,35,,48.3,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,48.3,35,,48.3,percent of total billed charges,Implant Device,48.3,35,,48.3,percent of total billed charges,Implant Device,48.3,35,,48.3,percent of total billed charges,Implant Device,48.3,35,,48.3,percent of total billed charges,Implant Device,48.3,35,,48.3,percent of total billed charges,Implant Device,55.2,40,,55.2,percent of total billed charges,Implant Device,48.3,70,,48.3,percent of total billed charges,All Other,46.92,34,,46.92,percent of total billed charges,Implant Device,46.92,34,,46.92,percent of total billed charges,Implant Device,48.3,35,,48.3,percent of total billed charges,Implant Device,48.3,35,,48.3,percent of total billed charges,Implant Device,48.3,35,,48.3,percent of total billed charges,Implant Device,48.3,35,,48.3,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,102.12,
STRYKER 608075 6.5X75MM CANCELLOUS SCREW,C1713,HCPCS,,79007685,CDM,278,RC,,,both,,,155,114.7,,,114.7,Other,150% of Medicare + 9.63% HCRA Surcharge,69.75,45,,69.75,percent of total billed charges,Critical Access Hospital RCC factor,52.7,34,,52.7,percent of total billed charges,Implant Device,52.7,34,,52.7,percent of total billed charges,Implant Device,52.7,34,,52.7,percent of total billed charges,Implant Device,52.7,34,,52.7,percent of total billed charges,Implant Device,52.7,34,,52.7,percent of total billed charges,Implant Device,76.73,,,76.73,Other,110% of Medicare,54.25,35,,54.25,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,54.25,35,,54.25,percent of total billed charges,Implant Device,54.25,35,,54.25,percent of total billed charges,Implant Device,54.25,35,,54.25,percent of total billed charges,Implant Device,54.25,35,,54.25,percent of total billed charges,Implant Device,54.25,35,,54.25,percent of total billed charges,Implant Device,62,40,,62,percent of total billed charges,Implant Device,54.25,70,,54.25,percent of total billed charges,All Other,52.7,34,,52.7,percent of total billed charges,Implant Device,52.7,34,,52.7,percent of total billed charges,Implant Device,54.25,35,,54.25,percent of total billed charges,Implant Device,54.25,35,,54.25,percent of total billed charges,Implant Device,54.25,35,,54.25,percent of total billed charges,Implant Device,54.25,35,,54.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,114.7,
STRYKER 627604 DIST FEM PLATE 4HOL 130MM,C1713,HCPCS,,79007686,CDM,278,RC,,,both,,,9654,7143.98,,,7143.98,Other,150% of Medicare + 9.63% HCRA Surcharge,4344.3,45,,4344.3,percent of total billed charges,Critical Access Hospital RCC factor,3282.36,34,,3282.36,percent of total billed charges,Implant Device,3282.36,34,,3282.36,percent of total billed charges,Implant Device,3282.36,34,,3282.36,percent of total billed charges,Implant Device,3282.36,34,,3282.36,percent of total billed charges,Implant Device,3282.36,34,,3282.36,percent of total billed charges,Implant Device,4778.73,,,4778.73,Other,110% of Medicare,3378.9,35,,3378.9,percent of total billed charges,Implant Device,3282.36,34,"Charges > $500, x 34%",3282.36,percent of total billed charges,Implant Device,3378.9,35,,3378.9,percent of total billed charges,Implant Device,3378.9,35,,3378.9,percent of total billed charges,Implant Device,3378.9,35,,3378.9,percent of total billed charges,Implant Device,3378.9,35,,3378.9,percent of total billed charges,Implant Device,3378.9,35,,3378.9,percent of total billed charges,Implant Device,3861.6,40,,3861.6,percent of total billed charges,Implant Device,3378.9,70,,3378.9,percent of total billed charges,All Other,3282.36,34,,3282.36,percent of total billed charges,Implant Device,3282.36,34,,3282.36,percent of total billed charges,Implant Device,3378.9,35,,3378.9,percent of total billed charges,Implant Device,3378.9,35,,3378.9,percent of total billed charges,Implant Device,3378.9,35,,3378.9,percent of total billed charges,Implant Device,3378.9,35,,3378.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3282.36,34,"If Charge > 2,000, then 34 percent",3282.36,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,7143.98,
STRYKER 661175 5X75MM LOCKING SCREW,C1713,HCPCS,,79007687,CDM,278,RC,,,both,,,616,455.84,,,455.84,Other,150% of Medicare + 9.63% HCRA Surcharge,277.2,45,,277.2,percent of total billed charges,Critical Access Hospital RCC factor,209.44,34,,209.44,percent of total billed charges,Implant Device,209.44,34,,209.44,percent of total billed charges,Implant Device,209.44,34,,209.44,percent of total billed charges,Implant Device,209.44,34,,209.44,percent of total billed charges,Implant Device,209.44,34,,209.44,percent of total billed charges,Implant Device,304.92,,,304.92,Other,110% of Medicare,215.6,35,,215.6,percent of total billed charges,Implant Device,209.44,34,"Charges > $500, x 34%",209.44,percent of total billed charges,Implant Device,215.6,35,,215.6,percent of total billed charges,Implant Device,215.6,35,,215.6,percent of total billed charges,Implant Device,215.6,35,,215.6,percent of total billed charges,Implant Device,215.6,35,,215.6,percent of total billed charges,Implant Device,215.6,35,,215.6,percent of total billed charges,Implant Device,246.4,40,,246.4,percent of total billed charges,Implant Device,215.6,70,,215.6,percent of total billed charges,All Other,209.44,34,,209.44,percent of total billed charges,Implant Device,209.44,34,,209.44,percent of total billed charges,Implant Device,215.6,35,,215.6,percent of total billed charges,Implant Device,215.6,35,,215.6,percent of total billed charges,Implant Device,215.6,35,,215.6,percent of total billed charges,Implant Device,215.6,35,,215.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,455.84,
STRYKER 661140 5X40MM LOCKING SCREW,C1713,HCPCS,,79007688,CDM,278,RC,,,both,,,801,592.74,,,592.74,Other,150% of Medicare + 9.63% HCRA Surcharge,360.45,45,,360.45,percent of total billed charges,Critical Access Hospital RCC factor,272.34,34,,272.34,percent of total billed charges,Implant Device,272.34,34,,272.34,percent of total billed charges,Implant Device,272.34,34,,272.34,percent of total billed charges,Implant Device,272.34,34,,272.34,percent of total billed charges,Implant Device,272.34,34,,272.34,percent of total billed charges,Implant Device,396.5,,,396.5,Other,110% of Medicare,280.35,35,,280.35,percent of total billed charges,Implant Device,272.34,34,"Charges > $500, x 34%",272.34,percent of total billed charges,Implant Device,280.35,35,,280.35,percent of total billed charges,Implant Device,280.35,35,,280.35,percent of total billed charges,Implant Device,280.35,35,,280.35,percent of total billed charges,Implant Device,280.35,35,,280.35,percent of total billed charges,Implant Device,280.35,35,,280.35,percent of total billed charges,Implant Device,320.4,40,,320.4,percent of total billed charges,Implant Device,280.35,70,,280.35,percent of total billed charges,All Other,272.34,34,,272.34,percent of total billed charges,Implant Device,272.34,34,,272.34,percent of total billed charges,Implant Device,280.35,35,,280.35,percent of total billed charges,Implant Device,280.35,35,,280.35,percent of total billed charges,Implant Device,280.35,35,,280.35,percent of total billed charges,Implant Device,280.35,35,,280.35,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,592.74,
J&J 212035 MINI QUICKANCHOR 2/0 SUTURE,C1713,HCPCS,,79007693,CDM,278,RC,,,both,,,1401,1036.74,,,1036.74,Other,150% of Medicare + 9.63% HCRA Surcharge,630.45,45,,630.45,percent of total billed charges,Critical Access Hospital RCC factor,476.34,34,,476.34,percent of total billed charges,Implant Device,476.34,34,,476.34,percent of total billed charges,Implant Device,476.34,34,,476.34,percent of total billed charges,Implant Device,476.34,34,,476.34,percent of total billed charges,Implant Device,476.34,34,,476.34,percent of total billed charges,Implant Device,693.5,,,693.5,Other,110% of Medicare,490.35,35,,490.35,percent of total billed charges,Implant Device,476.34,34,"Charges > $500, x 34%",476.34,percent of total billed charges,Implant Device,490.35,35,,490.35,percent of total billed charges,Implant Device,490.35,35,,490.35,percent of total billed charges,Implant Device,490.35,35,,490.35,percent of total billed charges,Implant Device,490.35,35,,490.35,percent of total billed charges,Implant Device,490.35,35,,490.35,percent of total billed charges,Implant Device,560.4,40,,560.4,percent of total billed charges,Implant Device,490.35,70,,490.35,percent of total billed charges,All Other,476.34,34,,476.34,percent of total billed charges,Implant Device,476.34,34,,476.34,percent of total billed charges,Implant Device,490.35,35,,490.35,percent of total billed charges,Implant Device,490.35,35,,490.35,percent of total billed charges,Implant Device,490.35,35,,490.35,percent of total billed charges,Implant Device,490.35,35,,490.35,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1036.74,
J&J 212843 MINI QUICKANCHOR 3/0 SUTURE,C1713,HCPCS,,79007694,CDM,278,RC,,,both,,,1362,1007.88,,,1007.88,Other,150% of Medicare + 9.63% HCRA Surcharge,612.9,45,,612.9,percent of total billed charges,Critical Access Hospital RCC factor,463.08,34,,463.08,percent of total billed charges,Implant Device,463.08,34,,463.08,percent of total billed charges,Implant Device,463.08,34,,463.08,percent of total billed charges,Implant Device,463.08,34,,463.08,percent of total billed charges,Implant Device,463.08,34,,463.08,percent of total billed charges,Implant Device,674.19,,,674.19,Other,110% of Medicare,476.7,35,,476.7,percent of total billed charges,Implant Device,463.08,34,"Charges > $500, x 34%",463.08,percent of total billed charges,Implant Device,476.7,35,,476.7,percent of total billed charges,Implant Device,476.7,35,,476.7,percent of total billed charges,Implant Device,476.7,35,,476.7,percent of total billed charges,Implant Device,476.7,35,,476.7,percent of total billed charges,Implant Device,476.7,35,,476.7,percent of total billed charges,Implant Device,544.8,40,,544.8,percent of total billed charges,Implant Device,476.7,70,,476.7,percent of total billed charges,All Other,463.08,34,,463.08,percent of total billed charges,Implant Device,463.08,34,,463.08,percent of total billed charges,Implant Device,476.7,35,,476.7,percent of total billed charges,Implant Device,476.7,35,,476.7,percent of total billed charges,Implant Device,476.7,35,,476.7,percent of total billed charges,Implant Device,476.7,35,,476.7,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1007.88,
ZIMMER 00-5994-040-12 ARTSURF GREEN 12MM,C1776,HCPCS,,79007696,CDM,278,RC,,,both,,,6257,4630.2,,,4630.2,Other,150% of Medicare + 9.63% HCRA Surcharge,2815.65,45,,2815.65,percent of total billed charges,Critical Access Hospital RCC factor,2127.38,34,,2127.38,percent of total billed charges,Implant Device,2127.38,34,,2127.38,percent of total billed charges,Implant Device,2127.38,34,,2127.38,percent of total billed charges,Implant Device,2127.38,34,,2127.38,percent of total billed charges,Implant Device,2127.38,34,,2127.38,percent of total billed charges,Implant Device,3097.22,,,3097.22,Other,110% of Medicare,2189.95,35,,2189.95,percent of total billed charges,Implant Device,2127.38,34,"Charges > $500, x 34%",2127.38,percent of total billed charges,Implant Device,2189.95,35,,2189.95,percent of total billed charges,Implant Device,2189.95,35,,2189.95,percent of total billed charges,Implant Device,2189.95,35,,2189.95,percent of total billed charges,Implant Device,2189.95,35,,2189.95,percent of total billed charges,Implant Device,2189.95,35,,2189.95,percent of total billed charges,Implant Device,2502.8,40,,2502.8,percent of total billed charges,Implant Device,2189.95,70,,2189.95,percent of total billed charges,All Other,2127.38,34,,2127.38,percent of total billed charges,Implant Device,2127.38,34,,2127.38,percent of total billed charges,Implant Device,2189.95,35,,2189.95,percent of total billed charges,Implant Device,2189.95,35,,2189.95,percent of total billed charges,Implant Device,2189.95,35,,2189.95,percent of total billed charges,Implant Device,2189.95,35,,2189.95,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2127.38,34,"If Charge > 2,000, then 34 percent",2127.38,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4630.2,
STRYKER 628224 PLATE 4 HOLE SUPR LATERAL,C1713,HCPCS,,79007698,CDM,278,RC,,,both,,,5010,3707.41,,,3707.41,Other,150% of Medicare + 9.63% HCRA Surcharge,2254.5,45,,2254.5,percent of total billed charges,Critical Access Hospital RCC factor,1703.4,34,,1703.4,percent of total billed charges,Implant Device,1703.4,34,,1703.4,percent of total billed charges,Implant Device,1703.4,34,,1703.4,percent of total billed charges,Implant Device,1703.4,34,,1703.4,percent of total billed charges,Implant Device,1703.4,34,,1703.4,percent of total billed charges,Implant Device,2479.95,,,2479.95,Other,110% of Medicare,1753.5,35,,1753.5,percent of total billed charges,Implant Device,1703.4,34,"Charges > $500, x 34%",1703.4,percent of total billed charges,Implant Device,1753.5,35,,1753.5,percent of total billed charges,Implant Device,1753.5,35,,1753.5,percent of total billed charges,Implant Device,1753.5,35,,1753.5,percent of total billed charges,Implant Device,1753.5,35,,1753.5,percent of total billed charges,Implant Device,1753.5,35,,1753.5,percent of total billed charges,Implant Device,2004,40,,2004,percent of total billed charges,Implant Device,1753.5,70,,1753.5,percent of total billed charges,All Other,1703.4,34,,1703.4,percent of total billed charges,Implant Device,1703.4,34,,1703.4,percent of total billed charges,Implant Device,1753.5,35,,1753.5,percent of total billed charges,Implant Device,1753.5,35,,1753.5,percent of total billed charges,Implant Device,1753.5,35,,1753.5,percent of total billed charges,Implant Device,1753.5,35,,1753.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1703.4,34,"If Charge > 2,000, then 34 percent",1703.4,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3707.41,
STRYKER 614720 NON LOCK SCREW 2.7X20MM,C1713,HCPCS,,79007699,CDM,278,RC,,,both,,,375,277.5,,,277.5,Other,150% of Medicare + 9.63% HCRA Surcharge,168.75,45,,168.75,percent of total billed charges,Critical Access Hospital RCC factor,127.5,34,,127.5,percent of total billed charges,Implant Device,127.5,34,,127.5,percent of total billed charges,Implant Device,127.5,34,,127.5,percent of total billed charges,Implant Device,127.5,34,,127.5,percent of total billed charges,Implant Device,127.5,34,,127.5,percent of total billed charges,Implant Device,185.63,,,185.63,Other,110% of Medicare,131.25,35,,131.25,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,131.25,35,,131.25,percent of total billed charges,Implant Device,131.25,35,,131.25,percent of total billed charges,Implant Device,131.25,35,,131.25,percent of total billed charges,Implant Device,131.25,35,,131.25,percent of total billed charges,Implant Device,131.25,35,,131.25,percent of total billed charges,Implant Device,150,40,,150,percent of total billed charges,Implant Device,131.25,70,,131.25,percent of total billed charges,All Other,127.5,34,,127.5,percent of total billed charges,Implant Device,127.5,34,,127.5,percent of total billed charges,Implant Device,131.25,35,,131.25,percent of total billed charges,Implant Device,131.25,35,,131.25,percent of total billed charges,Implant Device,131.25,35,,131.25,percent of total billed charges,Implant Device,131.25,35,,131.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,277.5,
ARTHREX AR-8945-40PT SCREW 4.5X40MM,C1713,HCPCS,,79007703,CDM,278,RC,,,both,,,750,555,,,555,Other,150% of Medicare + 9.63% HCRA Surcharge,337.5,45,,337.5,percent of total billed charges,Critical Access Hospital RCC factor,255,34,,255,percent of total billed charges,Implant Device,255,34,,255,percent of total billed charges,Implant Device,255,34,,255,percent of total billed charges,Implant Device,255,34,,255,percent of total billed charges,Implant Device,255,34,,255,percent of total billed charges,Implant Device,371.25,,,371.25,Other,110% of Medicare,262.5,35,,262.5,percent of total billed charges,Implant Device,255,34,"Charges > $500, x 34%",255,percent of total billed charges,Implant Device,262.5,35,,262.5,percent of total billed charges,Implant Device,262.5,35,,262.5,percent of total billed charges,Implant Device,262.5,35,,262.5,percent of total billed charges,Implant Device,262.5,35,,262.5,percent of total billed charges,Implant Device,262.5,35,,262.5,percent of total billed charges,Implant Device,300,40,,300,percent of total billed charges,Implant Device,262.5,70,,262.5,percent of total billed charges,All Other,255,34,,255,percent of total billed charges,Implant Device,255,34,,255,percent of total billed charges,Implant Device,262.5,35,,262.5,percent of total billed charges,Implant Device,262.5,35,,262.5,percent of total billed charges,Implant Device,262.5,35,,262.5,percent of total billed charges,Implant Device,262.5,35,,262.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,555,
WRIGHT MEDICAL MD102 MDI IMPLANT SIZE 2,C1776,HCPCS,,79007704,CDM,278,RC,,,both,,,14817,10964.62,,,10964.62,Other,150% of Medicare + 9.63% HCRA Surcharge,6667.65,45,,6667.65,percent of total billed charges,Critical Access Hospital RCC factor,5037.78,34,,5037.78,percent of total billed charges,Implant Device,5037.78,34,,5037.78,percent of total billed charges,Implant Device,5037.78,34,,5037.78,percent of total billed charges,Implant Device,5037.78,34,,5037.78,percent of total billed charges,Implant Device,5037.78,34,,5037.78,percent of total billed charges,Implant Device,7334.42,,,7334.42,Other,110% of Medicare,5185.95,35,,5185.95,percent of total billed charges,Implant Device,5037.78,34,"Charges > $500, x 34%",5037.78,percent of total billed charges,Implant Device,5185.95,35,,5185.95,percent of total billed charges,Implant Device,5185.95,35,,5185.95,percent of total billed charges,Implant Device,5185.95,35,,5185.95,percent of total billed charges,Implant Device,5185.95,35,,5185.95,percent of total billed charges,Implant Device,5185.95,35,,5185.95,percent of total billed charges,Implant Device,5926.8,40,,5926.8,percent of total billed charges,Implant Device,5185.95,70,,5185.95,percent of total billed charges,All Other,5037.78,34,,5037.78,percent of total billed charges,Implant Device,5037.78,34,,5037.78,percent of total billed charges,Implant Device,5185.95,35,,5185.95,percent of total billed charges,Implant Device,5185.95,35,,5185.95,percent of total billed charges,Implant Device,5185.95,35,,5185.95,percent of total billed charges,Implant Device,5185.95,35,,5185.95,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,5037.78,34,"If Charge > 2,000, then 34 percent",5037.78,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,10964.62,
DEPUY 1570-01-100 FEM STEM 12/14 TAPER,C1776,HCPCS,,79007705,CDM,278,RC,,,both,,,11331,8384.97,,,8384.97,Other,150% of Medicare + 9.63% HCRA Surcharge,5098.95,45,,5098.95,percent of total billed charges,Critical Access Hospital RCC factor,3852.54,34,,3852.54,percent of total billed charges,Implant Device,3852.54,34,,3852.54,percent of total billed charges,Implant Device,3852.54,34,,3852.54,percent of total billed charges,Implant Device,3852.54,34,,3852.54,percent of total billed charges,Implant Device,3852.54,34,,3852.54,percent of total billed charges,Implant Device,5608.85,,,5608.85,Other,110% of Medicare,3965.85,35,,3965.85,percent of total billed charges,Implant Device,3852.54,34,"Charges > $500, x 34%",3852.54,percent of total billed charges,Implant Device,3965.85,35,,3965.85,percent of total billed charges,Implant Device,3965.85,35,,3965.85,percent of total billed charges,Implant Device,3965.85,35,,3965.85,percent of total billed charges,Implant Device,3965.85,35,,3965.85,percent of total billed charges,Implant Device,3965.85,35,,3965.85,percent of total billed charges,Implant Device,4532.4,40,,4532.4,percent of total billed charges,Implant Device,3965.85,70,,3965.85,percent of total billed charges,All Other,3852.54,34,,3852.54,percent of total billed charges,Implant Device,3852.54,34,,3852.54,percent of total billed charges,Implant Device,3965.85,35,,3965.85,percent of total billed charges,Implant Device,3965.85,35,,3965.85,percent of total billed charges,Implant Device,3965.85,35,,3965.85,percent of total billed charges,Implant Device,3965.85,35,,3965.85,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3852.54,34,"If Charge > 2,000, then 34 percent",3852.54,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,8384.97,
STRYKER 54-25783 PLATE RT STD X SHORT,C1713,HCPCS,,79007706,CDM,278,RC,,,both,,,2604,1926.97,,,1926.97,Other,150% of Medicare + 9.63% HCRA Surcharge,1171.8,45,,1171.8,percent of total billed charges,Critical Access Hospital RCC factor,885.36,34,,885.36,percent of total billed charges,Implant Device,885.36,34,,885.36,percent of total billed charges,Implant Device,885.36,34,,885.36,percent of total billed charges,Implant Device,885.36,34,,885.36,percent of total billed charges,Implant Device,885.36,34,,885.36,percent of total billed charges,Implant Device,1288.98,,,1288.98,Other,110% of Medicare,911.4,35,,911.4,percent of total billed charges,Implant Device,885.36,34,"Charges > $500, x 34%",885.36,percent of total billed charges,Implant Device,911.4,35,,911.4,percent of total billed charges,Implant Device,911.4,35,,911.4,percent of total billed charges,Implant Device,911.4,35,,911.4,percent of total billed charges,Implant Device,911.4,35,,911.4,percent of total billed charges,Implant Device,911.4,35,,911.4,percent of total billed charges,Implant Device,1041.6,40,,1041.6,percent of total billed charges,Implant Device,911.4,70,,911.4,percent of total billed charges,All Other,885.36,34,,885.36,percent of total billed charges,Implant Device,885.36,34,,885.36,percent of total billed charges,Implant Device,911.4,35,,911.4,percent of total billed charges,Implant Device,911.4,35,,911.4,percent of total billed charges,Implant Device,911.4,35,,911.4,percent of total billed charges,Implant Device,911.4,35,,911.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,885.36,34,"If Charge > 2,000, then 34 percent",885.36,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1926.97,
STRYKER 656416 NON LOCK SCREW 2.7X16MM,C1713,HCPCS,,79007707,CDM,278,RC,,,both,,,282,208.68,,,208.68,Other,150% of Medicare + 9.63% HCRA Surcharge,126.9,45,,126.9,percent of total billed charges,Critical Access Hospital RCC factor,95.88,34,,95.88,percent of total billed charges,Implant Device,95.88,34,,95.88,percent of total billed charges,Implant Device,95.88,34,,95.88,percent of total billed charges,Implant Device,95.88,34,,95.88,percent of total billed charges,Implant Device,95.88,34,,95.88,percent of total billed charges,Implant Device,139.59,,,139.59,Other,110% of Medicare,98.7,35,,98.7,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,98.7,35,,98.7,percent of total billed charges,Implant Device,98.7,35,,98.7,percent of total billed charges,Implant Device,98.7,35,,98.7,percent of total billed charges,Implant Device,98.7,35,,98.7,percent of total billed charges,Implant Device,98.7,35,,98.7,percent of total billed charges,Implant Device,112.8,40,,112.8,percent of total billed charges,Implant Device,98.7,70,,98.7,percent of total billed charges,All Other,95.88,34,,95.88,percent of total billed charges,Implant Device,95.88,34,,95.88,percent of total billed charges,Implant Device,98.7,35,,98.7,percent of total billed charges,Implant Device,98.7,35,,98.7,percent of total billed charges,Implant Device,98.7,35,,98.7,percent of total billed charges,Implant Device,98.7,35,,98.7,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,208.68,
STRYKER 656418 NON LOCK SCREW 2.7X18MM,C1713,HCPCS,,79007708,CDM,278,RC,,,both,,,258,190.92,,,190.92,Other,150% of Medicare + 9.63% HCRA Surcharge,116.1,45,,116.1,percent of total billed charges,Critical Access Hospital RCC factor,87.72,34,,87.72,percent of total billed charges,Implant Device,87.72,34,,87.72,percent of total billed charges,Implant Device,87.72,34,,87.72,percent of total billed charges,Implant Device,87.72,34,,87.72,percent of total billed charges,Implant Device,87.72,34,,87.72,percent of total billed charges,Implant Device,127.71,,,127.71,Other,110% of Medicare,90.3,35,,90.3,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,90.3,35,,90.3,percent of total billed charges,Implant Device,90.3,35,,90.3,percent of total billed charges,Implant Device,90.3,35,,90.3,percent of total billed charges,Implant Device,90.3,35,,90.3,percent of total billed charges,Implant Device,90.3,35,,90.3,percent of total billed charges,Implant Device,103.2,40,,103.2,percent of total billed charges,Implant Device,90.3,70,,90.3,percent of total billed charges,All Other,87.72,34,,87.72,percent of total billed charges,Implant Device,87.72,34,,87.72,percent of total billed charges,Implant Device,90.3,35,,90.3,percent of total billed charges,Implant Device,90.3,35,,90.3,percent of total billed charges,Implant Device,90.3,35,,90.3,percent of total billed charges,Implant Device,90.3,35,,90.3,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,190.92,
STRYKER 656420 NON LOCK SCREW 2.7X20MM,C1713,HCPCS,,79007709,CDM,278,RC,,,both,,,258,190.92,,,190.92,Other,150% of Medicare + 9.63% HCRA Surcharge,116.1,45,,116.1,percent of total billed charges,Critical Access Hospital RCC factor,87.72,34,,87.72,percent of total billed charges,Implant Device,87.72,34,,87.72,percent of total billed charges,Implant Device,87.72,34,,87.72,percent of total billed charges,Implant Device,87.72,34,,87.72,percent of total billed charges,Implant Device,87.72,34,,87.72,percent of total billed charges,Implant Device,127.71,,,127.71,Other,110% of Medicare,90.3,35,,90.3,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,90.3,35,,90.3,percent of total billed charges,Implant Device,90.3,35,,90.3,percent of total billed charges,Implant Device,90.3,35,,90.3,percent of total billed charges,Implant Device,90.3,35,,90.3,percent of total billed charges,Implant Device,90.3,35,,90.3,percent of total billed charges,Implant Device,103.2,40,,103.2,percent of total billed charges,Implant Device,90.3,70,,90.3,percent of total billed charges,All Other,87.72,34,,87.72,percent of total billed charges,Implant Device,87.72,34,,87.72,percent of total billed charges,Implant Device,90.3,35,,90.3,percent of total billed charges,Implant Device,90.3,35,,90.3,percent of total billed charges,Implant Device,90.3,35,,90.3,percent of total billed charges,Implant Device,90.3,35,,90.3,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,190.92,
STRYKER 656026 LOCKING SCREW 2.4X26MM,C1713,HCPCS,,79007710,CDM,278,RC,,,both,,,480,355.2,,,355.2,Other,150% of Medicare + 9.63% HCRA Surcharge,216,45,,216,percent of total billed charges,Critical Access Hospital RCC factor,163.2,34,,163.2,percent of total billed charges,Implant Device,163.2,34,,163.2,percent of total billed charges,Implant Device,163.2,34,,163.2,percent of total billed charges,Implant Device,163.2,34,,163.2,percent of total billed charges,Implant Device,163.2,34,,163.2,percent of total billed charges,Implant Device,237.6,,,237.6,Other,110% of Medicare,168,35,,168,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,192,40,,192,percent of total billed charges,Implant Device,168,70,,168,percent of total billed charges,All Other,163.2,34,,163.2,percent of total billed charges,Implant Device,163.2,34,,163.2,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,355.2,
STRYKER 656020 LOCKING SCREW 2.4X20MM,C1713,HCPCS,,79007711,CDM,278,RC,,,both,,,480,355.2,,,355.2,Other,150% of Medicare + 9.63% HCRA Surcharge,216,45,,216,percent of total billed charges,Critical Access Hospital RCC factor,163.2,34,,163.2,percent of total billed charges,Implant Device,163.2,34,,163.2,percent of total billed charges,Implant Device,163.2,34,,163.2,percent of total billed charges,Implant Device,163.2,34,,163.2,percent of total billed charges,Implant Device,163.2,34,,163.2,percent of total billed charges,Implant Device,237.6,,,237.6,Other,110% of Medicare,168,35,,168,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,192,40,,192,percent of total billed charges,Implant Device,168,70,,168,percent of total billed charges,All Other,163.2,34,,163.2,percent of total billed charges,Implant Device,163.2,34,,163.2,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,355.2,
STRYKER 628027 CLAVICLE PLATE 7 HOLE RT,C1713,HCPCS,,79007713,CDM,278,RC,,,both,,,2762,2043.89,,,2043.89,Other,150% of Medicare + 9.63% HCRA Surcharge,1242.9,45,,1242.9,percent of total billed charges,Critical Access Hospital RCC factor,939.08,34,,939.08,percent of total billed charges,Implant Device,939.08,34,,939.08,percent of total billed charges,Implant Device,939.08,34,,939.08,percent of total billed charges,Implant Device,939.08,34,,939.08,percent of total billed charges,Implant Device,939.08,34,,939.08,percent of total billed charges,Implant Device,1367.19,,,1367.19,Other,110% of Medicare,966.7,35,,966.7,percent of total billed charges,Implant Device,939.08,34,"Charges > $500, x 34%",939.08,percent of total billed charges,Implant Device,966.7,35,,966.7,percent of total billed charges,Implant Device,966.7,35,,966.7,percent of total billed charges,Implant Device,966.7,35,,966.7,percent of total billed charges,Implant Device,966.7,35,,966.7,percent of total billed charges,Implant Device,966.7,35,,966.7,percent of total billed charges,Implant Device,1104.8,40,,1104.8,percent of total billed charges,Implant Device,966.7,70,,966.7,percent of total billed charges,All Other,939.08,34,,939.08,percent of total billed charges,Implant Device,939.08,34,,939.08,percent of total billed charges,Implant Device,966.7,35,,966.7,percent of total billed charges,Implant Device,966.7,35,,966.7,percent of total billed charges,Implant Device,966.7,35,,966.7,percent of total billed charges,Implant Device,966.7,35,,966.7,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,939.08,34,"If Charge > 2,000, then 34 percent",939.08,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2043.89,
STRYKER 614710 NON LOCK SCREW 2.7X10MM,C1713,HCPCS,,79007714,CDM,278,RC,,,both,,,349,258.26,,,258.26,Other,150% of Medicare + 9.63% HCRA Surcharge,157.05,45,,157.05,percent of total billed charges,Critical Access Hospital RCC factor,118.66,34,,118.66,percent of total billed charges,Implant Device,118.66,34,,118.66,percent of total billed charges,Implant Device,118.66,34,,118.66,percent of total billed charges,Implant Device,118.66,34,,118.66,percent of total billed charges,Implant Device,118.66,34,,118.66,percent of total billed charges,Implant Device,172.76,,,172.76,Other,110% of Medicare,122.15,35,,122.15,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,122.15,35,,122.15,percent of total billed charges,Implant Device,122.15,35,,122.15,percent of total billed charges,Implant Device,122.15,35,,122.15,percent of total billed charges,Implant Device,122.15,35,,122.15,percent of total billed charges,Implant Device,122.15,35,,122.15,percent of total billed charges,Implant Device,139.6,40,,139.6,percent of total billed charges,Implant Device,122.15,70,,122.15,percent of total billed charges,All Other,118.66,34,,118.66,percent of total billed charges,Implant Device,118.66,34,,118.66,percent of total billed charges,Implant Device,122.15,35,,122.15,percent of total billed charges,Implant Device,122.15,35,,122.15,percent of total billed charges,Implant Device,122.15,35,,122.15,percent of total billed charges,Implant Device,122.15,35,,122.15,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,258.26,
STRYKER 614712 NON LOCK SCREW 2.7X12MM,C1713,HCPCS,,79007715,CDM,278,RC,,,both,,,349,258.26,,,258.26,Other,150% of Medicare + 9.63% HCRA Surcharge,157.05,45,,157.05,percent of total billed charges,Critical Access Hospital RCC factor,118.66,34,,118.66,percent of total billed charges,Implant Device,118.66,34,,118.66,percent of total billed charges,Implant Device,118.66,34,,118.66,percent of total billed charges,Implant Device,118.66,34,,118.66,percent of total billed charges,Implant Device,118.66,34,,118.66,percent of total billed charges,Implant Device,172.76,,,172.76,Other,110% of Medicare,122.15,35,,122.15,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,122.15,35,,122.15,percent of total billed charges,Implant Device,122.15,35,,122.15,percent of total billed charges,Implant Device,122.15,35,,122.15,percent of total billed charges,Implant Device,122.15,35,,122.15,percent of total billed charges,Implant Device,122.15,35,,122.15,percent of total billed charges,Implant Device,139.6,40,,139.6,percent of total billed charges,Implant Device,122.15,70,,122.15,percent of total billed charges,All Other,118.66,34,,118.66,percent of total billed charges,Implant Device,118.66,34,,118.66,percent of total billed charges,Implant Device,122.15,35,,122.15,percent of total billed charges,Implant Device,122.15,35,,122.15,percent of total billed charges,Implant Device,122.15,35,,122.15,percent of total billed charges,Implant Device,122.15,35,,122.15,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,258.26,
STRYKER 614714 NON LOCK SCREW 2.7X14MM,C1713,HCPCS,,79007716,CDM,278,RC,,,both,,,375,277.5,,,277.5,Other,150% of Medicare + 9.63% HCRA Surcharge,168.75,45,,168.75,percent of total billed charges,Critical Access Hospital RCC factor,127.5,34,,127.5,percent of total billed charges,Implant Device,127.5,34,,127.5,percent of total billed charges,Implant Device,127.5,34,,127.5,percent of total billed charges,Implant Device,127.5,34,,127.5,percent of total billed charges,Implant Device,127.5,34,,127.5,percent of total billed charges,Implant Device,185.63,,,185.63,Other,110% of Medicare,131.25,35,,131.25,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,131.25,35,,131.25,percent of total billed charges,Implant Device,131.25,35,,131.25,percent of total billed charges,Implant Device,131.25,35,,131.25,percent of total billed charges,Implant Device,131.25,35,,131.25,percent of total billed charges,Implant Device,131.25,35,,131.25,percent of total billed charges,Implant Device,150,40,,150,percent of total billed charges,Implant Device,131.25,70,,131.25,percent of total billed charges,All Other,127.5,34,,127.5,percent of total billed charges,Implant Device,127.5,34,,127.5,percent of total billed charges,Implant Device,131.25,35,,131.25,percent of total billed charges,Implant Device,131.25,35,,131.25,percent of total billed charges,Implant Device,131.25,35,,131.25,percent of total billed charges,Implant Device,131.25,35,,131.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,277.5,
STRYKER 614508 LOCKING SCREW 2.7X8MM,C1713,HCPCS,,79007717,CDM,278,RC,,,both,,,671,496.54,,,496.54,Other,150% of Medicare + 9.63% HCRA Surcharge,301.95,45,,301.95,percent of total billed charges,Critical Access Hospital RCC factor,228.14,34,,228.14,percent of total billed charges,Implant Device,228.14,34,,228.14,percent of total billed charges,Implant Device,228.14,34,,228.14,percent of total billed charges,Implant Device,228.14,34,,228.14,percent of total billed charges,Implant Device,228.14,34,,228.14,percent of total billed charges,Implant Device,332.15,,,332.15,Other,110% of Medicare,234.85,35,,234.85,percent of total billed charges,Implant Device,228.14,34,"Charges > $500, x 34%",228.14,percent of total billed charges,Implant Device,234.85,35,,234.85,percent of total billed charges,Implant Device,234.85,35,,234.85,percent of total billed charges,Implant Device,234.85,35,,234.85,percent of total billed charges,Implant Device,234.85,35,,234.85,percent of total billed charges,Implant Device,234.85,35,,234.85,percent of total billed charges,Implant Device,268.4,40,,268.4,percent of total billed charges,Implant Device,234.85,70,,234.85,percent of total billed charges,All Other,228.14,34,,228.14,percent of total billed charges,Implant Device,228.14,34,,228.14,percent of total billed charges,Implant Device,234.85,35,,234.85,percent of total billed charges,Implant Device,234.85,35,,234.85,percent of total billed charges,Implant Device,234.85,35,,234.85,percent of total billed charges,Implant Device,234.85,35,,234.85,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,496.54,
STRYKER 614510 LOCKING SCREW 2.7X10MM,C1713,HCPCS,,79007718,CDM,278,RC,,,both,,,727,537.98,,,537.98,Other,150% of Medicare + 9.63% HCRA Surcharge,327.15,45,,327.15,percent of total billed charges,Critical Access Hospital RCC factor,247.18,34,,247.18,percent of total billed charges,Implant Device,247.18,34,,247.18,percent of total billed charges,Implant Device,247.18,34,,247.18,percent of total billed charges,Implant Device,247.18,34,,247.18,percent of total billed charges,Implant Device,247.18,34,,247.18,percent of total billed charges,Implant Device,359.87,,,359.87,Other,110% of Medicare,254.45,35,,254.45,percent of total billed charges,Implant Device,247.18,34,"Charges > $500, x 34%",247.18,percent of total billed charges,Implant Device,254.45,35,,254.45,percent of total billed charges,Implant Device,254.45,35,,254.45,percent of total billed charges,Implant Device,254.45,35,,254.45,percent of total billed charges,Implant Device,254.45,35,,254.45,percent of total billed charges,Implant Device,254.45,35,,254.45,percent of total billed charges,Implant Device,290.8,40,,290.8,percent of total billed charges,Implant Device,254.45,70,,254.45,percent of total billed charges,All Other,247.18,34,,247.18,percent of total billed charges,Implant Device,247.18,34,,247.18,percent of total billed charges,Implant Device,254.45,35,,254.45,percent of total billed charges,Implant Device,254.45,35,,254.45,percent of total billed charges,Implant Device,254.45,35,,254.45,percent of total billed charges,Implant Device,254.45,35,,254.45,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,537.98,
ARTHREX AR-8930-13 SNAP OFF SCREW 2X13MM,C1713,HCPCS,,79007720,CDM,278,RC,,,both,,,720,532.8,,,532.8,Other,150% of Medicare + 9.63% HCRA Surcharge,324,45,,324,percent of total billed charges,Critical Access Hospital RCC factor,244.8,34,,244.8,percent of total billed charges,Implant Device,244.8,34,,244.8,percent of total billed charges,Implant Device,244.8,34,,244.8,percent of total billed charges,Implant Device,244.8,34,,244.8,percent of total billed charges,Implant Device,244.8,34,,244.8,percent of total billed charges,Implant Device,356.4,,,356.4,Other,110% of Medicare,252,35,,252,percent of total billed charges,Implant Device,244.8,34,"Charges > $500, x 34%",244.8,percent of total billed charges,Implant Device,252,35,,252,percent of total billed charges,Implant Device,252,35,,252,percent of total billed charges,Implant Device,252,35,,252,percent of total billed charges,Implant Device,252,35,,252,percent of total billed charges,Implant Device,252,35,,252,percent of total billed charges,Implant Device,288,40,,288,percent of total billed charges,Implant Device,252,70,,252,percent of total billed charges,All Other,244.8,34,,244.8,percent of total billed charges,Implant Device,244.8,34,,244.8,percent of total billed charges,Implant Device,252,35,,252,percent of total billed charges,Implant Device,252,35,,252,percent of total billed charges,Implant Device,252,35,,252,percent of total billed charges,Implant Device,252,35,,252,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,532.8,
STRYKER 40-35046 NONLOCK SCREW 3.5X46MM,C1713,HCPCS,,79007721,CDM,278,RC,,,both,,,352,260.48,,,260.48,Other,150% of Medicare + 9.63% HCRA Surcharge,158.4,45,,158.4,percent of total billed charges,Critical Access Hospital RCC factor,119.68,34,,119.68,percent of total billed charges,Implant Device,119.68,34,,119.68,percent of total billed charges,Implant Device,119.68,34,,119.68,percent of total billed charges,Implant Device,119.68,34,,119.68,percent of total billed charges,Implant Device,119.68,34,,119.68,percent of total billed charges,Implant Device,174.24,,,174.24,Other,110% of Medicare,123.2,35,,123.2,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,123.2,35,,123.2,percent of total billed charges,Implant Device,123.2,35,,123.2,percent of total billed charges,Implant Device,123.2,35,,123.2,percent of total billed charges,Implant Device,123.2,35,,123.2,percent of total billed charges,Implant Device,123.2,35,,123.2,percent of total billed charges,Implant Device,140.8,40,,140.8,percent of total billed charges,Implant Device,123.2,70,,123.2,percent of total billed charges,All Other,119.68,34,,119.68,percent of total billed charges,Implant Device,119.68,34,,119.68,percent of total billed charges,Implant Device,123.2,35,,123.2,percent of total billed charges,Implant Device,123.2,35,,123.2,percent of total billed charges,Implant Device,123.2,35,,123.2,percent of total billed charges,Implant Device,123.2,35,,123.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,260.48,
SMITH & NEPHEW TOTAL KNEE NARROW CAP,C1776,HCPCS,,79007722,CDM,278,RC,,,both,,,17700,13098.04,,,13098.04,Other,150% of Medicare + 9.63% HCRA Surcharge,7965,45,,7965,percent of total billed charges,Critical Access Hospital RCC factor,6018,34,,6018,percent of total billed charges,Implant Device,6018,34,,6018,percent of total billed charges,Implant Device,6018,34,,6018,percent of total billed charges,Implant Device,6018,34,,6018,percent of total billed charges,Implant Device,6018,34,,6018,percent of total billed charges,Implant Device,8761.5,,,8761.5,Other,110% of Medicare,6195,35,,6195,percent of total billed charges,Implant Device,6018,34,"Charges > $500, x 34%",6018,percent of total billed charges,Implant Device,6195,35,,6195,percent of total billed charges,Implant Device,6195,35,,6195,percent of total billed charges,Implant Device,6195,35,,6195,percent of total billed charges,Implant Device,6195,35,,6195,percent of total billed charges,Implant Device,6195,35,,6195,percent of total billed charges,Implant Device,7080,40,,7080,percent of total billed charges,Implant Device,6195,70,,6195,percent of total billed charges,All Other,6018,34,,6018,percent of total billed charges,Implant Device,6018,34,,6018,percent of total billed charges,Implant Device,6195,35,,6195,percent of total billed charges,Implant Device,6195,35,,6195,percent of total billed charges,Implant Device,6195,35,,6195,percent of total billed charges,Implant Device,6195,35,,6195,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,6018,34,"If Charge > 2,000, then 34 percent",6018,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,13098.04,
DEPUY 04.005.536S 46X5.0MM TI LOCK SCREW,C1713,HCPCS,,79007724,CDM,278,RC,,,both,,,939,694.86,,,694.86,Other,150% of Medicare + 9.63% HCRA Surcharge,422.55,45,,422.55,percent of total billed charges,Critical Access Hospital RCC factor,319.26,34,,319.26,percent of total billed charges,Implant Device,319.26,34,,319.26,percent of total billed charges,Implant Device,319.26,34,,319.26,percent of total billed charges,Implant Device,319.26,34,,319.26,percent of total billed charges,Implant Device,319.26,34,,319.26,percent of total billed charges,Implant Device,464.81,,,464.81,Other,110% of Medicare,328.65,35,,328.65,percent of total billed charges,Implant Device,319.26,34,"Charges > $500, x 34%",319.26,percent of total billed charges,Implant Device,328.65,35,,328.65,percent of total billed charges,Implant Device,328.65,35,,328.65,percent of total billed charges,Implant Device,328.65,35,,328.65,percent of total billed charges,Implant Device,328.65,35,,328.65,percent of total billed charges,Implant Device,328.65,35,,328.65,percent of total billed charges,Implant Device,375.6,40,,375.6,percent of total billed charges,Implant Device,328.65,70,,328.65,percent of total billed charges,All Other,319.26,34,,319.26,percent of total billed charges,Implant Device,319.26,34,,319.26,percent of total billed charges,Implant Device,328.65,35,,328.65,percent of total billed charges,Implant Device,328.65,35,,328.65,percent of total billed charges,Implant Device,328.65,35,,328.65,percent of total billed charges,Implant Device,328.65,35,,328.65,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,694.86,
DEPUY 04.005.528S 28X5.0MM TI LOCK SCREW,C1713,HCPCS,,79007725,CDM,278,RC,,,both,,,412,304.88,,,304.88,Other,150% of Medicare + 9.63% HCRA Surcharge,185.4,45,,185.4,percent of total billed charges,Critical Access Hospital RCC factor,140.08,34,,140.08,percent of total billed charges,Implant Device,140.08,34,,140.08,percent of total billed charges,Implant Device,140.08,34,,140.08,percent of total billed charges,Implant Device,140.08,34,,140.08,percent of total billed charges,Implant Device,140.08,34,,140.08,percent of total billed charges,Implant Device,203.94,,,203.94,Other,110% of Medicare,144.2,35,,144.2,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,144.2,35,,144.2,percent of total billed charges,Implant Device,144.2,35,,144.2,percent of total billed charges,Implant Device,144.2,35,,144.2,percent of total billed charges,Implant Device,144.2,35,,144.2,percent of total billed charges,Implant Device,144.2,35,,144.2,percent of total billed charges,Implant Device,164.8,40,,164.8,percent of total billed charges,Implant Device,144.2,70,,144.2,percent of total billed charges,All Other,140.08,34,,140.08,percent of total billed charges,Implant Device,140.08,34,,140.08,percent of total billed charges,Implant Device,144.2,35,,144.2,percent of total billed charges,Implant Device,144.2,35,,144.2,percent of total billed charges,Implant Device,144.2,35,,144.2,percent of total billed charges,Implant Device,144.2,35,,144.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,304.88,
DEPUY 04.005.532S 32X5.0MM TI LOCK SCREW,C1713,HCPCS,,79007726,CDM,278,RC,,,both,,,412,304.88,,,304.88,Other,150% of Medicare + 9.63% HCRA Surcharge,185.4,45,,185.4,percent of total billed charges,Critical Access Hospital RCC factor,140.08,34,,140.08,percent of total billed charges,Implant Device,140.08,34,,140.08,percent of total billed charges,Implant Device,140.08,34,,140.08,percent of total billed charges,Implant Device,140.08,34,,140.08,percent of total billed charges,Implant Device,140.08,34,,140.08,percent of total billed charges,Implant Device,203.94,,,203.94,Other,110% of Medicare,144.2,35,,144.2,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,144.2,35,,144.2,percent of total billed charges,Implant Device,144.2,35,,144.2,percent of total billed charges,Implant Device,144.2,35,,144.2,percent of total billed charges,Implant Device,144.2,35,,144.2,percent of total billed charges,Implant Device,144.2,35,,144.2,percent of total billed charges,Implant Device,164.8,40,,164.8,percent of total billed charges,Implant Device,144.2,70,,144.2,percent of total billed charges,All Other,140.08,34,,140.08,percent of total billed charges,Implant Device,140.08,34,,140.08,percent of total billed charges,Implant Device,144.2,35,,144.2,percent of total billed charges,Implant Device,144.2,35,,144.2,percent of total billed charges,Implant Device,144.2,35,,144.2,percent of total billed charges,Implant Device,144.2,35,,144.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,304.88,
DEPUY 04.004.455S 10X375 CANNULATED NAIL,C1713,HCPCS,,79007727,CDM,278,RC,,,both,,,6035,4465.92,,,4465.92,Other,150% of Medicare + 9.63% HCRA Surcharge,2715.75,45,,2715.75,percent of total billed charges,Critical Access Hospital RCC factor,2051.9,34,,2051.9,percent of total billed charges,Implant Device,2051.9,34,,2051.9,percent of total billed charges,Implant Device,2051.9,34,,2051.9,percent of total billed charges,Implant Device,2051.9,34,,2051.9,percent of total billed charges,Implant Device,2051.9,34,,2051.9,percent of total billed charges,Implant Device,2987.33,,,2987.33,Other,110% of Medicare,2112.25,35,,2112.25,percent of total billed charges,Implant Device,2051.9,34,"Charges > $500, x 34%",2051.9,percent of total billed charges,Implant Device,2112.25,35,,2112.25,percent of total billed charges,Implant Device,2112.25,35,,2112.25,percent of total billed charges,Implant Device,2112.25,35,,2112.25,percent of total billed charges,Implant Device,2112.25,35,,2112.25,percent of total billed charges,Implant Device,2112.25,35,,2112.25,percent of total billed charges,Implant Device,2414,40,,2414,percent of total billed charges,Implant Device,2112.25,70,,2112.25,percent of total billed charges,All Other,2051.9,34,,2051.9,percent of total billed charges,Implant Device,2051.9,34,,2051.9,percent of total billed charges,Implant Device,2112.25,35,,2112.25,percent of total billed charges,Implant Device,2112.25,35,,2112.25,percent of total billed charges,Implant Device,2112.25,35,,2112.25,percent of total billed charges,Implant Device,2112.25,35,,2112.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2051.9,34,"If Charge > 2,000, then 34 percent",2051.9,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4465.92,
WRIGHT TFF-2015 TENFUSE PIP ALLOGRAFT,C1713,HCPCS,,79007728,CDM,278,RC,,,both,,,3557,2632.19,,,2632.19,Other,150% of Medicare + 9.63% HCRA Surcharge,1600.65,45,,1600.65,percent of total billed charges,Critical Access Hospital RCC factor,1209.38,34,,1209.38,percent of total billed charges,Implant Device,1209.38,34,,1209.38,percent of total billed charges,Implant Device,1209.38,34,,1209.38,percent of total billed charges,Implant Device,1209.38,34,,1209.38,percent of total billed charges,Implant Device,1209.38,34,,1209.38,percent of total billed charges,Implant Device,1760.72,,,1760.72,Other,110% of Medicare,1244.95,35,,1244.95,percent of total billed charges,Implant Device,1209.38,34,"Charges > $500, x 34%",1209.38,percent of total billed charges,Implant Device,1244.95,35,,1244.95,percent of total billed charges,Implant Device,1244.95,35,,1244.95,percent of total billed charges,Implant Device,1244.95,35,,1244.95,percent of total billed charges,Implant Device,1244.95,35,,1244.95,percent of total billed charges,Implant Device,1244.95,35,,1244.95,percent of total billed charges,Implant Device,1422.8,40,,1422.8,percent of total billed charges,Implant Device,1244.95,70,,1244.95,percent of total billed charges,All Other,1209.38,34,,1209.38,percent of total billed charges,Implant Device,1209.38,34,,1209.38,percent of total billed charges,Implant Device,1244.95,35,,1244.95,percent of total billed charges,Implant Device,1244.95,35,,1244.95,percent of total billed charges,Implant Device,1244.95,35,,1244.95,percent of total billed charges,Implant Device,1244.95,35,,1244.95,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1209.38,34,"If Charge > 2,000, then 34 percent",1209.38,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2632.19,
STRYKER 40-20905 DISTAL FIB PLATE 5 HOLE,C1713,HCPCS,,79007729,CDM,278,RC,,,both,,,2644,1956.57,,,1956.57,Other,150% of Medicare + 9.63% HCRA Surcharge,1189.8,45,,1189.8,percent of total billed charges,Critical Access Hospital RCC factor,898.96,34,,898.96,percent of total billed charges,Implant Device,898.96,34,,898.96,percent of total billed charges,Implant Device,898.96,34,,898.96,percent of total billed charges,Implant Device,898.96,34,,898.96,percent of total billed charges,Implant Device,898.96,34,,898.96,percent of total billed charges,Implant Device,1308.78,,,1308.78,Other,110% of Medicare,925.4,35,,925.4,percent of total billed charges,Implant Device,898.96,34,"Charges > $500, x 34%",898.96,percent of total billed charges,Implant Device,925.4,35,,925.4,percent of total billed charges,Implant Device,925.4,35,,925.4,percent of total billed charges,Implant Device,925.4,35,,925.4,percent of total billed charges,Implant Device,925.4,35,,925.4,percent of total billed charges,Implant Device,925.4,35,,925.4,percent of total billed charges,Implant Device,1057.6,40,,1057.6,percent of total billed charges,Implant Device,925.4,70,,925.4,percent of total billed charges,All Other,898.96,34,,898.96,percent of total billed charges,Implant Device,898.96,34,,898.96,percent of total billed charges,Implant Device,925.4,35,,925.4,percent of total billed charges,Implant Device,925.4,35,,925.4,percent of total billed charges,Implant Device,925.4,35,,925.4,percent of total billed charges,Implant Device,925.4,35,,925.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,898.96,34,"If Charge > 2,000, then 34 percent",898.96,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1956.57,
STRYKER 40-35042 NONLCK BONE SCRW 3.5X42,C1713,HCPCS,,79007730,CDM,278,RC,,,both,,,216,159.84,,,159.84,Other,150% of Medicare + 9.63% HCRA Surcharge,97.2,45,,97.2,percent of total billed charges,Critical Access Hospital RCC factor,73.44,34,,73.44,percent of total billed charges,Implant Device,73.44,34,,73.44,percent of total billed charges,Implant Device,73.44,34,,73.44,percent of total billed charges,Implant Device,73.44,34,,73.44,percent of total billed charges,Implant Device,73.44,34,,73.44,percent of total billed charges,Implant Device,106.92,,,106.92,Other,110% of Medicare,75.6,35,,75.6,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,75.6,35,,75.6,percent of total billed charges,Implant Device,75.6,35,,75.6,percent of total billed charges,Implant Device,75.6,35,,75.6,percent of total billed charges,Implant Device,75.6,35,,75.6,percent of total billed charges,Implant Device,75.6,35,,75.6,percent of total billed charges,Implant Device,86.4,40,,86.4,percent of total billed charges,Implant Device,75.6,70,,75.6,percent of total billed charges,All Other,73.44,34,,73.44,percent of total billed charges,Implant Device,73.44,34,,73.44,percent of total billed charges,Implant Device,75.6,35,,75.6,percent of total billed charges,Implant Device,75.6,35,,75.6,percent of total billed charges,Implant Device,75.6,35,,75.6,percent of total billed charges,Implant Device,75.6,35,,75.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,159.84,
ARTHREX AR-8967-1840 CANN SCREW 6.7X40MM,C1713,HCPCS,,79007731,CDM,278,RC,,,both,,,1074,794.76,,,794.76,Other,150% of Medicare + 9.63% HCRA Surcharge,483.3,45,,483.3,percent of total billed charges,Critical Access Hospital RCC factor,365.16,34,,365.16,percent of total billed charges,Implant Device,365.16,34,,365.16,percent of total billed charges,Implant Device,365.16,34,,365.16,percent of total billed charges,Implant Device,365.16,34,,365.16,percent of total billed charges,Implant Device,365.16,34,,365.16,percent of total billed charges,Implant Device,531.63,,,531.63,Other,110% of Medicare,375.9,35,,375.9,percent of total billed charges,Implant Device,365.16,34,"Charges > $500, x 34%",365.16,percent of total billed charges,Implant Device,375.9,35,,375.9,percent of total billed charges,Implant Device,375.9,35,,375.9,percent of total billed charges,Implant Device,375.9,35,,375.9,percent of total billed charges,Implant Device,375.9,35,,375.9,percent of total billed charges,Implant Device,375.9,35,,375.9,percent of total billed charges,Implant Device,429.6,40,,429.6,percent of total billed charges,Implant Device,375.9,70,,375.9,percent of total billed charges,All Other,365.16,34,,365.16,percent of total billed charges,Implant Device,365.16,34,,365.16,percent of total billed charges,Implant Device,375.9,35,,375.9,percent of total billed charges,Implant Device,375.9,35,,375.9,percent of total billed charges,Implant Device,375.9,35,,375.9,percent of total billed charges,Implant Device,375.9,35,,375.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,794.76,
LIFE CELL CM1520P ALLODERM RTM 9.6X19.3,C1781,HCPCS,,79007733,CDM,278,RC,,,both,,,17706,13102.48,,,13102.48,Other,150% of Medicare + 9.63% HCRA Surcharge,7967.7,45,,7967.7,percent of total billed charges,Critical Access Hospital RCC factor,6020.04,34,,6020.04,percent of total billed charges,Implant Device,6020.04,34,,6020.04,percent of total billed charges,Implant Device,6020.04,34,,6020.04,percent of total billed charges,Implant Device,6020.04,34,,6020.04,percent of total billed charges,Implant Device,6020.04,34,,6020.04,percent of total billed charges,Implant Device,8764.47,,,8764.47,Other,110% of Medicare,6197.1,35,,6197.1,percent of total billed charges,Implant Device,6020.04,34,"Charges > $500, x 34%",6020.04,percent of total billed charges,Implant Device,6197.1,35,,6197.1,percent of total billed charges,Implant Device,6197.1,35,,6197.1,percent of total billed charges,Implant Device,6197.1,35,,6197.1,percent of total billed charges,Implant Device,6197.1,35,,6197.1,percent of total billed charges,Implant Device,6197.1,35,,6197.1,percent of total billed charges,Implant Device,7082.4,40,,7082.4,percent of total billed charges,Implant Device,6197.1,70,,6197.1,percent of total billed charges,All Other,6020.04,34,,6020.04,percent of total billed charges,Implant Device,6020.04,34,,6020.04,percent of total billed charges,Implant Device,6197.1,35,,6197.1,percent of total billed charges,Implant Device,6197.1,35,,6197.1,percent of total billed charges,Implant Device,6197.1,35,,6197.1,percent of total billed charges,Implant Device,6197.1,35,,6197.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,6020.04,34,"If Charge > 2,000, then 34 percent",6020.04,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,13102.48,
ZIMMER 201.050 KNEE CREATIONS BONE SUBST,C1713,HCPCS,,79007734,CDM,278,RC,,,both,,,8850,6549.02,,,6549.02,Other,150% of Medicare + 9.63% HCRA Surcharge,3982.5,45,,3982.5,percent of total billed charges,Critical Access Hospital RCC factor,3009,34,,3009,percent of total billed charges,Implant Device,3009,34,,3009,percent of total billed charges,Implant Device,3009,34,,3009,percent of total billed charges,Implant Device,3009,34,,3009,percent of total billed charges,Implant Device,3009,34,,3009,percent of total billed charges,Implant Device,4380.75,,,4380.75,Other,110% of Medicare,3097.5,35,,3097.5,percent of total billed charges,Implant Device,3009,34,"Charges > $500, x 34%",3009,percent of total billed charges,Implant Device,3097.5,35,,3097.5,percent of total billed charges,Implant Device,3097.5,35,,3097.5,percent of total billed charges,Implant Device,3097.5,35,,3097.5,percent of total billed charges,Implant Device,3097.5,35,,3097.5,percent of total billed charges,Implant Device,3097.5,35,,3097.5,percent of total billed charges,Implant Device,3540,40,,3540,percent of total billed charges,Implant Device,3097.5,70,,3097.5,percent of total billed charges,All Other,3009,34,,3009,percent of total billed charges,Implant Device,3009,34,,3009,percent of total billed charges,Implant Device,3097.5,35,,3097.5,percent of total billed charges,Implant Device,3097.5,35,,3097.5,percent of total billed charges,Implant Device,3097.5,35,,3097.5,percent of total billed charges,Implant Device,3097.5,35,,3097.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3009,34,"If Charge > 2,000, then 34 percent",3009,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,6549.02,
ZIMMER 00-8852-014-36 RIM LINER 36X60MM,C1776,HCPCS,,79007735,CDM,278,RC,,,both,,,4403,3258.23,,,3258.23,Other,150% of Medicare + 9.63% HCRA Surcharge,1981.35,45,,1981.35,percent of total billed charges,Critical Access Hospital RCC factor,1497.02,34,,1497.02,percent of total billed charges,Implant Device,1497.02,34,,1497.02,percent of total billed charges,Implant Device,1497.02,34,,1497.02,percent of total billed charges,Implant Device,1497.02,34,,1497.02,percent of total billed charges,Implant Device,1497.02,34,,1497.02,percent of total billed charges,Implant Device,2179.49,,,2179.49,Other,110% of Medicare,1541.05,35,,1541.05,percent of total billed charges,Implant Device,1497.02,34,"Charges > $500, x 34%",1497.02,percent of total billed charges,Implant Device,1541.05,35,,1541.05,percent of total billed charges,Implant Device,1541.05,35,,1541.05,percent of total billed charges,Implant Device,1541.05,35,,1541.05,percent of total billed charges,Implant Device,1541.05,35,,1541.05,percent of total billed charges,Implant Device,1541.05,35,,1541.05,percent of total billed charges,Implant Device,1761.2,40,,1761.2,percent of total billed charges,Implant Device,1541.05,70,,1541.05,percent of total billed charges,All Other,1497.02,34,,1497.02,percent of total billed charges,Implant Device,1497.02,34,,1497.02,percent of total billed charges,Implant Device,1541.05,35,,1541.05,percent of total billed charges,Implant Device,1541.05,35,,1541.05,percent of total billed charges,Implant Device,1541.05,35,,1541.05,percent of total billed charges,Implant Device,1541.05,35,,1541.05,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1497.02,34,"If Charge > 2,000, then 34 percent",1497.02,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3258.23,
STRYKER 58-19005 EMERGENCY SCREW 1.9X5MM,C1713,HCPCS,,79007737,CDM,278,RC,,,both,,,367,271.58,,,271.58,Other,150% of Medicare + 9.63% HCRA Surcharge,165.15,45,,165.15,percent of total billed charges,Critical Access Hospital RCC factor,124.78,34,,124.78,percent of total billed charges,Implant Device,124.78,34,,124.78,percent of total billed charges,Implant Device,124.78,34,,124.78,percent of total billed charges,Implant Device,124.78,34,,124.78,percent of total billed charges,Implant Device,124.78,34,,124.78,percent of total billed charges,Implant Device,181.67,,,181.67,Other,110% of Medicare,128.45,35,,128.45,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,128.45,35,,128.45,percent of total billed charges,Implant Device,128.45,35,,128.45,percent of total billed charges,Implant Device,128.45,35,,128.45,percent of total billed charges,Implant Device,128.45,35,,128.45,percent of total billed charges,Implant Device,128.45,35,,128.45,percent of total billed charges,Implant Device,146.8,40,,146.8,percent of total billed charges,Implant Device,128.45,70,,128.45,percent of total billed charges,All Other,124.78,34,,124.78,percent of total billed charges,Implant Device,124.78,34,,124.78,percent of total billed charges,Implant Device,128.45,35,,128.45,percent of total billed charges,Implant Device,128.45,35,,128.45,percent of total billed charges,Implant Device,128.45,35,,128.45,percent of total billed charges,Implant Device,128.45,35,,128.45,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,271.58,
WRIGHT DIN40040S CANNULATED SCREW 4X40MM,C1713,HCPCS,,79007738,CDM,278,RC,,,both,,,1125,832.5,,,832.5,Other,150% of Medicare + 9.63% HCRA Surcharge,506.25,45,,506.25,percent of total billed charges,Critical Access Hospital RCC factor,382.5,34,,382.5,percent of total billed charges,Implant Device,382.5,34,,382.5,percent of total billed charges,Implant Device,382.5,34,,382.5,percent of total billed charges,Implant Device,382.5,34,,382.5,percent of total billed charges,Implant Device,382.5,34,,382.5,percent of total billed charges,Implant Device,556.88,,,556.88,Other,110% of Medicare,393.75,35,,393.75,percent of total billed charges,Implant Device,382.5,34,"Charges > $500, x 34%",382.5,percent of total billed charges,Implant Device,393.75,35,,393.75,percent of total billed charges,Implant Device,393.75,35,,393.75,percent of total billed charges,Implant Device,393.75,35,,393.75,percent of total billed charges,Implant Device,393.75,35,,393.75,percent of total billed charges,Implant Device,393.75,35,,393.75,percent of total billed charges,Implant Device,450,40,,450,percent of total billed charges,Implant Device,393.75,70,,393.75,percent of total billed charges,All Other,382.5,34,,382.5,percent of total billed charges,Implant Device,382.5,34,,382.5,percent of total billed charges,Implant Device,393.75,35,,393.75,percent of total billed charges,Implant Device,393.75,35,,393.75,percent of total billed charges,Implant Device,393.75,35,,393.75,percent of total billed charges,Implant Device,393.75,35,,393.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,832.5,
WRIGHT DIN40036S CANNULATED SCREW 4X36MM,C1713,HCPCS,,79007739,CDM,278,RC,,,both,,,1125,832.5,,,832.5,Other,150% of Medicare + 9.63% HCRA Surcharge,506.25,45,,506.25,percent of total billed charges,Critical Access Hospital RCC factor,382.5,34,,382.5,percent of total billed charges,Implant Device,382.5,34,,382.5,percent of total billed charges,Implant Device,382.5,34,,382.5,percent of total billed charges,Implant Device,382.5,34,,382.5,percent of total billed charges,Implant Device,382.5,34,,382.5,percent of total billed charges,Implant Device,556.88,,,556.88,Other,110% of Medicare,393.75,35,,393.75,percent of total billed charges,Implant Device,382.5,34,"Charges > $500, x 34%",382.5,percent of total billed charges,Implant Device,393.75,35,,393.75,percent of total billed charges,Implant Device,393.75,35,,393.75,percent of total billed charges,Implant Device,393.75,35,,393.75,percent of total billed charges,Implant Device,393.75,35,,393.75,percent of total billed charges,Implant Device,393.75,35,,393.75,percent of total billed charges,Implant Device,450,40,,450,percent of total billed charges,Implant Device,393.75,70,,393.75,percent of total billed charges,All Other,382.5,34,,382.5,percent of total billed charges,Implant Device,382.5,34,,382.5,percent of total billed charges,Implant Device,393.75,35,,393.75,percent of total billed charges,Implant Device,393.75,35,,393.75,percent of total billed charges,Implant Device,393.75,35,,393.75,percent of total billed charges,Implant Device,393.75,35,,393.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,832.5,
WRIGHT DIN20020S CANNULATED SCREW 2X20MM,C1713,HCPCS,,79007740,CDM,278,RC,,,both,,,856,633.44,,,633.44,Other,150% of Medicare + 9.63% HCRA Surcharge,385.2,45,,385.2,percent of total billed charges,Critical Access Hospital RCC factor,291.04,34,,291.04,percent of total billed charges,Implant Device,291.04,34,,291.04,percent of total billed charges,Implant Device,291.04,34,,291.04,percent of total billed charges,Implant Device,291.04,34,,291.04,percent of total billed charges,Implant Device,291.04,34,,291.04,percent of total billed charges,Implant Device,423.72,,,423.72,Other,110% of Medicare,299.6,35,,299.6,percent of total billed charges,Implant Device,291.04,34,"Charges > $500, x 34%",291.04,percent of total billed charges,Implant Device,299.6,35,,299.6,percent of total billed charges,Implant Device,299.6,35,,299.6,percent of total billed charges,Implant Device,299.6,35,,299.6,percent of total billed charges,Implant Device,299.6,35,,299.6,percent of total billed charges,Implant Device,299.6,35,,299.6,percent of total billed charges,Implant Device,342.4,40,,342.4,percent of total billed charges,Implant Device,299.6,70,,299.6,percent of total billed charges,All Other,291.04,34,,291.04,percent of total billed charges,Implant Device,291.04,34,,291.04,percent of total billed charges,Implant Device,299.6,35,,299.6,percent of total billed charges,Implant Device,299.6,35,,299.6,percent of total billed charges,Implant Device,299.6,35,,299.6,percent of total billed charges,Implant Device,299.6,35,,299.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,633.44,
S&N 71453214 ARTICULAR INSRT SZ 3-4 15MM,C1776,HCPCS,,79007773,CDM,278,RC,,,both,,,5212,3856.89,,,3856.89,Other,150% of Medicare + 9.63% HCRA Surcharge,2345.4,45,,2345.4,percent of total billed charges,Critical Access Hospital RCC factor,1772.08,34,,1772.08,percent of total billed charges,Implant Device,1772.08,34,,1772.08,percent of total billed charges,Implant Device,1772.08,34,,1772.08,percent of total billed charges,Implant Device,1772.08,34,,1772.08,percent of total billed charges,Implant Device,1772.08,34,,1772.08,percent of total billed charges,Implant Device,2579.94,,,2579.94,Other,110% of Medicare,1824.2,35,,1824.2,percent of total billed charges,Implant Device,1772.08,34,"Charges > $500, x 34%",1772.08,percent of total billed charges,Implant Device,1824.2,35,,1824.2,percent of total billed charges,Implant Device,1824.2,35,,1824.2,percent of total billed charges,Implant Device,1824.2,35,,1824.2,percent of total billed charges,Implant Device,1824.2,35,,1824.2,percent of total billed charges,Implant Device,1824.2,35,,1824.2,percent of total billed charges,Implant Device,2084.8,40,,2084.8,percent of total billed charges,Implant Device,1824.2,70,,1824.2,percent of total billed charges,All Other,1772.08,34,,1772.08,percent of total billed charges,Implant Device,1772.08,34,,1772.08,percent of total billed charges,Implant Device,1824.2,35,,1824.2,percent of total billed charges,Implant Device,1824.2,35,,1824.2,percent of total billed charges,Implant Device,1824.2,35,,1824.2,percent of total billed charges,Implant Device,1824.2,35,,1824.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1772.08,34,"If Charge > 2,000, then 34 percent",1772.08,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3856.89,
BOST SCI M00570630 BILARY STENT 8X100MM,C1874,HCPCS,,79007774,CDM,278,RC,,,both,,,5550,4107.01,,,4107.01,Other,150% of Medicare + 9.63% HCRA Surcharge,2497.5,45,,2497.5,percent of total billed charges,Critical Access Hospital RCC factor,1887,34,,1887,percent of total billed charges,Implant Device,1887,34,,1887,percent of total billed charges,Implant Device,1887,34,,1887,percent of total billed charges,Implant Device,1887,34,,1887,percent of total billed charges,Implant Device,1887,34,,1887,percent of total billed charges,Implant Device,2747.25,,,2747.25,Other,110% of Medicare,1942.5,35,,1942.5,percent of total billed charges,Implant Device,1887,34,"Charges > $500, x 34%",1887,percent of total billed charges,Implant Device,1942.5,35,,1942.5,percent of total billed charges,Implant Device,1942.5,35,,1942.5,percent of total billed charges,Implant Device,1942.5,35,,1942.5,percent of total billed charges,Implant Device,1942.5,35,,1942.5,percent of total billed charges,Implant Device,1942.5,35,,1942.5,percent of total billed charges,Implant Device,2220,40,,2220,percent of total billed charges,Implant Device,1942.5,70,,1942.5,percent of total billed charges,All Other,1887,34,,1887,percent of total billed charges,Implant Device,1887,34,,1887,percent of total billed charges,Implant Device,1942.5,35,,1942.5,percent of total billed charges,Implant Device,1942.5,35,,1942.5,percent of total billed charges,Implant Device,1942.5,35,,1942.5,percent of total billed charges,Implant Device,1942.5,35,,1942.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1887,34,"If Charge > 2,000, then 34 percent",1887,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4107.01,
ZIMMER 00-2347-023-32 4.5X32MM SCREW,C1713,HCPCS,,79007775,CDM,278,RC,,,both,,,109,80.66,,,80.66,Other,150% of Medicare + 9.63% HCRA Surcharge,49.05,45,,49.05,percent of total billed charges,Critical Access Hospital RCC factor,37.06,34,,37.06,percent of total billed charges,Implant Device,37.06,34,,37.06,percent of total billed charges,Implant Device,37.06,34,,37.06,percent of total billed charges,Implant Device,37.06,34,,37.06,percent of total billed charges,Implant Device,37.06,34,,37.06,percent of total billed charges,Implant Device,53.96,,,53.96,Other,110% of Medicare,38.15,35,,38.15,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,38.15,35,,38.15,percent of total billed charges,Implant Device,38.15,35,,38.15,percent of total billed charges,Implant Device,38.15,35,,38.15,percent of total billed charges,Implant Device,38.15,35,,38.15,percent of total billed charges,Implant Device,38.15,35,,38.15,percent of total billed charges,Implant Device,43.6,40,,43.6,percent of total billed charges,Implant Device,38.15,70,,38.15,percent of total billed charges,All Other,37.06,34,,37.06,percent of total billed charges,Implant Device,37.06,34,,37.06,percent of total billed charges,Implant Device,38.15,35,,38.15,percent of total billed charges,Implant Device,38.15,35,,38.15,percent of total billed charges,Implant Device,38.15,35,,38.15,percent of total billed charges,Implant Device,38.15,35,,38.15,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,80.66,
ZIMMER 00-2357-102-14 FEM LOCK PLATE 14H,C1713,HCPCS,,79007776,CDM,278,RC,,,both,,,4872,3605.29,,,3605.29,Other,150% of Medicare + 9.63% HCRA Surcharge,2192.4,45,,2192.4,percent of total billed charges,Critical Access Hospital RCC factor,1656.48,34,,1656.48,percent of total billed charges,Implant Device,1656.48,34,,1656.48,percent of total billed charges,Implant Device,1656.48,34,,1656.48,percent of total billed charges,Implant Device,1656.48,34,,1656.48,percent of total billed charges,Implant Device,1656.48,34,,1656.48,percent of total billed charges,Implant Device,2411.64,,,2411.64,Other,110% of Medicare,1705.2,35,,1705.2,percent of total billed charges,Implant Device,1656.48,34,"Charges > $500, x 34%",1656.48,percent of total billed charges,Implant Device,1705.2,35,,1705.2,percent of total billed charges,Implant Device,1705.2,35,,1705.2,percent of total billed charges,Implant Device,1705.2,35,,1705.2,percent of total billed charges,Implant Device,1705.2,35,,1705.2,percent of total billed charges,Implant Device,1705.2,35,,1705.2,percent of total billed charges,Implant Device,1948.8,40,,1948.8,percent of total billed charges,Implant Device,1705.2,70,,1705.2,percent of total billed charges,All Other,1656.48,34,,1656.48,percent of total billed charges,Implant Device,1656.48,34,,1656.48,percent of total billed charges,Implant Device,1705.2,35,,1705.2,percent of total billed charges,Implant Device,1705.2,35,,1705.2,percent of total billed charges,Implant Device,1705.2,35,,1705.2,percent of total billed charges,Implant Device,1705.2,35,,1705.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1656.48,34,"If Charge > 2,000, then 34 percent",1656.48,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3605.29,
ZIMMER 00-2359-060-55 5.5X60MM SCREW,C1713,HCPCS,,79007777,CDM,278,RC,,,both,,,578,427.72,,,427.72,Other,150% of Medicare + 9.63% HCRA Surcharge,260.1,45,,260.1,percent of total billed charges,Critical Access Hospital RCC factor,196.52,34,,196.52,percent of total billed charges,Implant Device,196.52,34,,196.52,percent of total billed charges,Implant Device,196.52,34,,196.52,percent of total billed charges,Implant Device,196.52,34,,196.52,percent of total billed charges,Implant Device,196.52,34,,196.52,percent of total billed charges,Implant Device,286.11,,,286.11,Other,110% of Medicare,202.3,35,,202.3,percent of total billed charges,Implant Device,196.52,34,"Charges > $500, x 34%",196.52,percent of total billed charges,Implant Device,202.3,35,,202.3,percent of total billed charges,Implant Device,202.3,35,,202.3,percent of total billed charges,Implant Device,202.3,35,,202.3,percent of total billed charges,Implant Device,202.3,35,,202.3,percent of total billed charges,Implant Device,202.3,35,,202.3,percent of total billed charges,Implant Device,231.2,40,,231.2,percent of total billed charges,Implant Device,202.3,70,,202.3,percent of total billed charges,All Other,196.52,34,,196.52,percent of total billed charges,Implant Device,196.52,34,,196.52,percent of total billed charges,Implant Device,202.3,35,,202.3,percent of total billed charges,Implant Device,202.3,35,,202.3,percent of total billed charges,Implant Device,202.3,35,,202.3,percent of total billed charges,Implant Device,202.3,35,,202.3,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,427.72,
ZIMMER 00-2359-065-55 5.5X65MM SCREW,C1713,HCPCS,,79007778,CDM,278,RC,,,both,,,578,427.72,,,427.72,Other,150% of Medicare + 9.63% HCRA Surcharge,260.1,45,,260.1,percent of total billed charges,Critical Access Hospital RCC factor,196.52,34,,196.52,percent of total billed charges,Implant Device,196.52,34,,196.52,percent of total billed charges,Implant Device,196.52,34,,196.52,percent of total billed charges,Implant Device,196.52,34,,196.52,percent of total billed charges,Implant Device,196.52,34,,196.52,percent of total billed charges,Implant Device,286.11,,,286.11,Other,110% of Medicare,202.3,35,,202.3,percent of total billed charges,Implant Device,196.52,34,"Charges > $500, x 34%",196.52,percent of total billed charges,Implant Device,202.3,35,,202.3,percent of total billed charges,Implant Device,202.3,35,,202.3,percent of total billed charges,Implant Device,202.3,35,,202.3,percent of total billed charges,Implant Device,202.3,35,,202.3,percent of total billed charges,Implant Device,202.3,35,,202.3,percent of total billed charges,Implant Device,231.2,40,,231.2,percent of total billed charges,Implant Device,202.3,70,,202.3,percent of total billed charges,All Other,196.52,34,,196.52,percent of total billed charges,Implant Device,196.52,34,,196.52,percent of total billed charges,Implant Device,202.3,35,,202.3,percent of total billed charges,Implant Device,202.3,35,,202.3,percent of total billed charges,Implant Device,202.3,35,,202.3,percent of total billed charges,Implant Device,202.3,35,,202.3,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,427.72,
ZIMMER 00-2359-070-55 5.5X70MM SCREW,C1713,HCPCS,,79007779,CDM,278,RC,,,both,,,578,427.72,,,427.72,Other,150% of Medicare + 9.63% HCRA Surcharge,260.1,45,,260.1,percent of total billed charges,Critical Access Hospital RCC factor,196.52,34,,196.52,percent of total billed charges,Implant Device,196.52,34,,196.52,percent of total billed charges,Implant Device,196.52,34,,196.52,percent of total billed charges,Implant Device,196.52,34,,196.52,percent of total billed charges,Implant Device,196.52,34,,196.52,percent of total billed charges,Implant Device,286.11,,,286.11,Other,110% of Medicare,202.3,35,,202.3,percent of total billed charges,Implant Device,196.52,34,"Charges > $500, x 34%",196.52,percent of total billed charges,Implant Device,202.3,35,,202.3,percent of total billed charges,Implant Device,202.3,35,,202.3,percent of total billed charges,Implant Device,202.3,35,,202.3,percent of total billed charges,Implant Device,202.3,35,,202.3,percent of total billed charges,Implant Device,202.3,35,,202.3,percent of total billed charges,Implant Device,231.2,40,,231.2,percent of total billed charges,Implant Device,202.3,70,,202.3,percent of total billed charges,All Other,196.52,34,,196.52,percent of total billed charges,Implant Device,196.52,34,,196.52,percent of total billed charges,Implant Device,202.3,35,,202.3,percent of total billed charges,Implant Device,202.3,35,,202.3,percent of total billed charges,Implant Device,202.3,35,,202.3,percent of total billed charges,Implant Device,202.3,35,,202.3,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,427.72,
ZIMMER 00-5994-050-12 ART SURF 7-10 12MM,C1776,HCPCS,,79007780,CDM,278,RC,,,both,,,6773,5012.04,,,5012.04,Other,150% of Medicare + 9.63% HCRA Surcharge,3047.85,45,,3047.85,percent of total billed charges,Critical Access Hospital RCC factor,2302.82,34,,2302.82,percent of total billed charges,Implant Device,2302.82,34,,2302.82,percent of total billed charges,Implant Device,2302.82,34,,2302.82,percent of total billed charges,Implant Device,2302.82,34,,2302.82,percent of total billed charges,Implant Device,2302.82,34,,2302.82,percent of total billed charges,Implant Device,3352.64,,,3352.64,Other,110% of Medicare,2370.55,35,,2370.55,percent of total billed charges,Implant Device,2302.82,34,"Charges > $500, x 34%",2302.82,percent of total billed charges,Implant Device,2370.55,35,,2370.55,percent of total billed charges,Implant Device,2370.55,35,,2370.55,percent of total billed charges,Implant Device,2370.55,35,,2370.55,percent of total billed charges,Implant Device,2370.55,35,,2370.55,percent of total billed charges,Implant Device,2370.55,35,,2370.55,percent of total billed charges,Implant Device,2709.2,40,,2709.2,percent of total billed charges,Implant Device,2370.55,70,,2370.55,percent of total billed charges,All Other,2302.82,34,,2302.82,percent of total billed charges,Implant Device,2302.82,34,,2302.82,percent of total billed charges,Implant Device,2370.55,35,,2370.55,percent of total billed charges,Implant Device,2370.55,35,,2370.55,percent of total billed charges,Implant Device,2370.55,35,,2370.55,percent of total billed charges,Implant Device,2370.55,35,,2370.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2302.82,34,"If Charge > 2,000, then 34 percent",2302.82,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5012.04,
DEPUY 212.101 LOCKING SCREW 3.5X10MM,C1713,HCPCS,,79007781,CDM,278,RC,,,both,,,488,361.12,,,361.12,Other,150% of Medicare + 9.63% HCRA Surcharge,219.6,45,,219.6,percent of total billed charges,Critical Access Hospital RCC factor,165.92,34,,165.92,percent of total billed charges,Implant Device,165.92,34,,165.92,percent of total billed charges,Implant Device,165.92,34,,165.92,percent of total billed charges,Implant Device,165.92,34,,165.92,percent of total billed charges,Implant Device,165.92,34,,165.92,percent of total billed charges,Implant Device,241.56,,,241.56,Other,110% of Medicare,170.8,35,,170.8,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,170.8,35,,170.8,percent of total billed charges,Implant Device,170.8,35,,170.8,percent of total billed charges,Implant Device,170.8,35,,170.8,percent of total billed charges,Implant Device,170.8,35,,170.8,percent of total billed charges,Implant Device,170.8,35,,170.8,percent of total billed charges,Implant Device,195.2,40,,195.2,percent of total billed charges,Implant Device,170.8,70,,170.8,percent of total billed charges,All Other,165.92,34,,165.92,percent of total billed charges,Implant Device,165.92,34,,165.92,percent of total billed charges,Implant Device,170.8,35,,170.8,percent of total billed charges,Implant Device,170.8,35,,170.8,percent of total billed charges,Implant Device,170.8,35,,170.8,percent of total billed charges,Implant Device,170.8,35,,170.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,361.12,
GORE PLC201000 EXCLUDER ENDOPROS 20X9.5,C1874,HCPCS,,79007782,CDM,278,RC,,,both,,,13200,9768.03,,,9768.03,Other,150% of Medicare + 9.63% HCRA Surcharge,5940,45,,5940,percent of total billed charges,Critical Access Hospital RCC factor,4488,34,,4488,percent of total billed charges,Implant Device,4488,34,,4488,percent of total billed charges,Implant Device,4488,34,,4488,percent of total billed charges,Implant Device,4488,34,,4488,percent of total billed charges,Implant Device,4488,34,,4488,percent of total billed charges,Implant Device,6534,,,6534,Other,110% of Medicare,4620,35,,4620,percent of total billed charges,Implant Device,4488,34,"Charges > $500, x 34%",4488,percent of total billed charges,Implant Device,4620,35,,4620,percent of total billed charges,Implant Device,4620,35,,4620,percent of total billed charges,Implant Device,4620,35,,4620,percent of total billed charges,Implant Device,4620,35,,4620,percent of total billed charges,Implant Device,4620,35,,4620,percent of total billed charges,Implant Device,5280,40,,5280,percent of total billed charges,Implant Device,4620,70,,4620,percent of total billed charges,All Other,4488,34,,4488,percent of total billed charges,Implant Device,4488,34,,4488,percent of total billed charges,Implant Device,4620,35,,4620,percent of total billed charges,Implant Device,4620,35,,4620,percent of total billed charges,Implant Device,4620,35,,4620,percent of total billed charges,Implant Device,4620,35,,4620,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,4488,34,"If Charge > 2,000, then 34 percent",4488,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,9768.03,
P28 P50-053-3524 LOCK PLATE SCREW 3.5X24,C1713,HCPCS,,79007783,CDM,278,RC,,,both,,,694,513.56,,,513.56,Other,150% of Medicare + 9.63% HCRA Surcharge,312.3,45,,312.3,percent of total billed charges,Critical Access Hospital RCC factor,235.96,34,,235.96,percent of total billed charges,Implant Device,235.96,34,,235.96,percent of total billed charges,Implant Device,235.96,34,,235.96,percent of total billed charges,Implant Device,235.96,34,,235.96,percent of total billed charges,Implant Device,235.96,34,,235.96,percent of total billed charges,Implant Device,343.53,,,343.53,Other,110% of Medicare,242.9,35,,242.9,percent of total billed charges,Implant Device,235.96,34,"Charges > $500, x 34%",235.96,percent of total billed charges,Implant Device,242.9,35,,242.9,percent of total billed charges,Implant Device,242.9,35,,242.9,percent of total billed charges,Implant Device,242.9,35,,242.9,percent of total billed charges,Implant Device,242.9,35,,242.9,percent of total billed charges,Implant Device,242.9,35,,242.9,percent of total billed charges,Implant Device,277.6,40,,277.6,percent of total billed charges,Implant Device,242.9,70,,242.9,percent of total billed charges,All Other,235.96,34,,235.96,percent of total billed charges,Implant Device,235.96,34,,235.96,percent of total billed charges,Implant Device,242.9,35,,242.9,percent of total billed charges,Implant Device,242.9,35,,242.9,percent of total billed charges,Implant Device,242.9,35,,242.9,percent of total billed charges,Implant Device,242.9,35,,242.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,513.56,
P28 P50-053-3526 LOCK PLATE SCREW 3.5X26,C1713,HCPCS,,79007784,CDM,278,RC,,,both,,,829,613.46,,,613.46,Other,150% of Medicare + 9.63% HCRA Surcharge,373.05,45,,373.05,percent of total billed charges,Critical Access Hospital RCC factor,281.86,34,,281.86,percent of total billed charges,Implant Device,281.86,34,,281.86,percent of total billed charges,Implant Device,281.86,34,,281.86,percent of total billed charges,Implant Device,281.86,34,,281.86,percent of total billed charges,Implant Device,281.86,34,,281.86,percent of total billed charges,Implant Device,410.36,,,410.36,Other,110% of Medicare,290.15,35,,290.15,percent of total billed charges,Implant Device,281.86,34,"Charges > $500, x 34%",281.86,percent of total billed charges,Implant Device,290.15,35,,290.15,percent of total billed charges,Implant Device,290.15,35,,290.15,percent of total billed charges,Implant Device,290.15,35,,290.15,percent of total billed charges,Implant Device,290.15,35,,290.15,percent of total billed charges,Implant Device,290.15,35,,290.15,percent of total billed charges,Implant Device,331.6,40,,331.6,percent of total billed charges,Implant Device,290.15,70,,290.15,percent of total billed charges,All Other,281.86,34,,281.86,percent of total billed charges,Implant Device,281.86,34,,281.86,percent of total billed charges,Implant Device,290.15,35,,290.15,percent of total billed charges,Implant Device,290.15,35,,290.15,percent of total billed charges,Implant Device,290.15,35,,290.15,percent of total billed charges,Implant Device,290.15,35,,290.15,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,613.46,
P28 P50-053-3528 LOCK PLATE SCREW 3.5X28,C1713,HCPCS,,79007785,CDM,278,RC,,,both,,,880,651.2,,,651.2,Other,150% of Medicare + 9.63% HCRA Surcharge,396,45,,396,percent of total billed charges,Critical Access Hospital RCC factor,299.2,34,,299.2,percent of total billed charges,Implant Device,299.2,34,,299.2,percent of total billed charges,Implant Device,299.2,34,,299.2,percent of total billed charges,Implant Device,299.2,34,,299.2,percent of total billed charges,Implant Device,299.2,34,,299.2,percent of total billed charges,Implant Device,435.6,,,435.6,Other,110% of Medicare,308,35,,308,percent of total billed charges,Implant Device,299.2,34,"Charges > $500, x 34%",299.2,percent of total billed charges,Implant Device,308,35,,308,percent of total billed charges,Implant Device,308,35,,308,percent of total billed charges,Implant Device,308,35,,308,percent of total billed charges,Implant Device,308,35,,308,percent of total billed charges,Implant Device,308,35,,308,percent of total billed charges,Implant Device,352,40,,352,percent of total billed charges,Implant Device,308,70,,308,percent of total billed charges,All Other,299.2,34,,299.2,percent of total billed charges,Implant Device,299.2,34,,299.2,percent of total billed charges,Implant Device,308,35,,308,percent of total billed charges,Implant Device,308,35,,308,percent of total billed charges,Implant Device,308,35,,308,percent of total billed charges,Implant Device,308,35,,308,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,651.2,
P28 P50-053-3538 LOCK PLATE SCREW 3.5X38,C1713,HCPCS,,79007786,CDM,278,RC,,,both,,,694,513.56,,,513.56,Other,150% of Medicare + 9.63% HCRA Surcharge,312.3,45,,312.3,percent of total billed charges,Critical Access Hospital RCC factor,235.96,34,,235.96,percent of total billed charges,Implant Device,235.96,34,,235.96,percent of total billed charges,Implant Device,235.96,34,,235.96,percent of total billed charges,Implant Device,235.96,34,,235.96,percent of total billed charges,Implant Device,235.96,34,,235.96,percent of total billed charges,Implant Device,343.53,,,343.53,Other,110% of Medicare,242.9,35,,242.9,percent of total billed charges,Implant Device,235.96,34,"Charges > $500, x 34%",235.96,percent of total billed charges,Implant Device,242.9,35,,242.9,percent of total billed charges,Implant Device,242.9,35,,242.9,percent of total billed charges,Implant Device,242.9,35,,242.9,percent of total billed charges,Implant Device,242.9,35,,242.9,percent of total billed charges,Implant Device,242.9,35,,242.9,percent of total billed charges,Implant Device,277.6,40,,277.6,percent of total billed charges,Implant Device,242.9,70,,242.9,percent of total billed charges,All Other,235.96,34,,235.96,percent of total billed charges,Implant Device,235.96,34,,235.96,percent of total billed charges,Implant Device,242.9,35,,242.9,percent of total billed charges,Implant Device,242.9,35,,242.9,percent of total billed charges,Implant Device,242.9,35,,242.9,percent of total billed charges,Implant Device,242.9,35,,242.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,513.56,
P28 P50-053-3542 LOCK PLATE SCREW 3.5X42,C1713,HCPCS,,79007787,CDM,278,RC,,,both,,,694,513.56,,,513.56,Other,150% of Medicare + 9.63% HCRA Surcharge,312.3,45,,312.3,percent of total billed charges,Critical Access Hospital RCC factor,235.96,34,,235.96,percent of total billed charges,Implant Device,235.96,34,,235.96,percent of total billed charges,Implant Device,235.96,34,,235.96,percent of total billed charges,Implant Device,235.96,34,,235.96,percent of total billed charges,Implant Device,235.96,34,,235.96,percent of total billed charges,Implant Device,343.53,,,343.53,Other,110% of Medicare,242.9,35,,242.9,percent of total billed charges,Implant Device,235.96,34,"Charges > $500, x 34%",235.96,percent of total billed charges,Implant Device,242.9,35,,242.9,percent of total billed charges,Implant Device,242.9,35,,242.9,percent of total billed charges,Implant Device,242.9,35,,242.9,percent of total billed charges,Implant Device,242.9,35,,242.9,percent of total billed charges,Implant Device,242.9,35,,242.9,percent of total billed charges,Implant Device,277.6,40,,277.6,percent of total billed charges,Implant Device,242.9,70,,242.9,percent of total billed charges,All Other,235.96,34,,235.96,percent of total billed charges,Implant Device,235.96,34,,235.96,percent of total billed charges,Implant Device,242.9,35,,242.9,percent of total billed charges,Implant Device,242.9,35,,242.9,percent of total billed charges,Implant Device,242.9,35,,242.9,percent of total billed charges,Implant Device,242.9,35,,242.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,513.56,
P28 P53-107-2015 BEAVER PLATE MED SLIDE,C1713,HCPCS,,79007788,CDM,278,RC,,,both,,,6872,5085.3,,,5085.3,Other,150% of Medicare + 9.63% HCRA Surcharge,3092.4,45,,3092.4,percent of total billed charges,Critical Access Hospital RCC factor,2336.48,34,,2336.48,percent of total billed charges,Implant Device,2336.48,34,,2336.48,percent of total billed charges,Implant Device,2336.48,34,,2336.48,percent of total billed charges,Implant Device,2336.48,34,,2336.48,percent of total billed charges,Implant Device,2336.48,34,,2336.48,percent of total billed charges,Implant Device,3401.64,,,3401.64,Other,110% of Medicare,2405.2,35,,2405.2,percent of total billed charges,Implant Device,2336.48,34,"Charges > $500, x 34%",2336.48,percent of total billed charges,Implant Device,2405.2,35,,2405.2,percent of total billed charges,Implant Device,2405.2,35,,2405.2,percent of total billed charges,Implant Device,2405.2,35,,2405.2,percent of total billed charges,Implant Device,2405.2,35,,2405.2,percent of total billed charges,Implant Device,2405.2,35,,2405.2,percent of total billed charges,Implant Device,2748.8,40,,2748.8,percent of total billed charges,Implant Device,2405.2,70,,2405.2,percent of total billed charges,All Other,2336.48,34,,2336.48,percent of total billed charges,Implant Device,2336.48,34,,2336.48,percent of total billed charges,Implant Device,2405.2,35,,2405.2,percent of total billed charges,Implant Device,2405.2,35,,2405.2,percent of total billed charges,Implant Device,2405.2,35,,2405.2,percent of total billed charges,Implant Device,2405.2,35,,2405.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2336.48,34,"If Charge > 2,000, then 34 percent",2336.48,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5085.3,
P28 P50-053-4228 LOCK PLATE SCREW 4.2X28,C1713,HCPCS,,79007790,CDM,278,RC,,,both,,,718,531.32,,,531.32,Other,150% of Medicare + 9.63% HCRA Surcharge,323.1,45,,323.1,percent of total billed charges,Critical Access Hospital RCC factor,244.12,34,,244.12,percent of total billed charges,Implant Device,244.12,34,,244.12,percent of total billed charges,Implant Device,244.12,34,,244.12,percent of total billed charges,Implant Device,244.12,34,,244.12,percent of total billed charges,Implant Device,244.12,34,,244.12,percent of total billed charges,Implant Device,355.41,,,355.41,Other,110% of Medicare,251.3,35,,251.3,percent of total billed charges,Implant Device,244.12,34,"Charges > $500, x 34%",244.12,percent of total billed charges,Implant Device,251.3,35,,251.3,percent of total billed charges,Implant Device,251.3,35,,251.3,percent of total billed charges,Implant Device,251.3,35,,251.3,percent of total billed charges,Implant Device,251.3,35,,251.3,percent of total billed charges,Implant Device,251.3,35,,251.3,percent of total billed charges,Implant Device,287.2,40,,287.2,percent of total billed charges,Implant Device,251.3,70,,251.3,percent of total billed charges,All Other,244.12,34,,244.12,percent of total billed charges,Implant Device,244.12,34,,244.12,percent of total billed charges,Implant Device,251.3,35,,251.3,percent of total billed charges,Implant Device,251.3,35,,251.3,percent of total billed charges,Implant Device,251.3,35,,251.3,percent of total billed charges,Implant Device,251.3,35,,251.3,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,531.32,
ZIMMER 00-8851-011-36 NEUTRAL LINR 36X54,C1776,HCPCS,,79007792,CDM,278,RC,,,both,,,4403,3258.23,,,3258.23,Other,150% of Medicare + 9.63% HCRA Surcharge,1981.35,45,,1981.35,percent of total billed charges,Critical Access Hospital RCC factor,1497.02,34,,1497.02,percent of total billed charges,Implant Device,1497.02,34,,1497.02,percent of total billed charges,Implant Device,1497.02,34,,1497.02,percent of total billed charges,Implant Device,1497.02,34,,1497.02,percent of total billed charges,Implant Device,1497.02,34,,1497.02,percent of total billed charges,Implant Device,2179.49,,,2179.49,Other,110% of Medicare,1541.05,35,,1541.05,percent of total billed charges,Implant Device,1497.02,34,"Charges > $500, x 34%",1497.02,percent of total billed charges,Implant Device,1541.05,35,,1541.05,percent of total billed charges,Implant Device,1541.05,35,,1541.05,percent of total billed charges,Implant Device,1541.05,35,,1541.05,percent of total billed charges,Implant Device,1541.05,35,,1541.05,percent of total billed charges,Implant Device,1541.05,35,,1541.05,percent of total billed charges,Implant Device,1761.2,40,,1761.2,percent of total billed charges,Implant Device,1541.05,70,,1541.05,percent of total billed charges,All Other,1497.02,34,,1497.02,percent of total billed charges,Implant Device,1497.02,34,,1497.02,percent of total billed charges,Implant Device,1541.05,35,,1541.05,percent of total billed charges,Implant Device,1541.05,35,,1541.05,percent of total billed charges,Implant Device,1541.05,35,,1541.05,percent of total billed charges,Implant Device,1541.05,35,,1541.05,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1497.02,34,"If Charge > 2,000, then 34 percent",1497.02,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3258.23,
STRYKER 3325-0400S NAIL KIT LT 11X400MM,C1713,HCPCS,,79007793,CDM,278,RC,,,both,,,8879,6570.48,,,6570.48,Other,150% of Medicare + 9.63% HCRA Surcharge,3995.55,45,,3995.55,percent of total billed charges,Critical Access Hospital RCC factor,3018.86,34,,3018.86,percent of total billed charges,Implant Device,3018.86,34,,3018.86,percent of total billed charges,Implant Device,3018.86,34,,3018.86,percent of total billed charges,Implant Device,3018.86,34,,3018.86,percent of total billed charges,Implant Device,3018.86,34,,3018.86,percent of total billed charges,Implant Device,4395.11,,,4395.11,Other,110% of Medicare,3107.65,35,,3107.65,percent of total billed charges,Implant Device,3018.86,34,"Charges > $500, x 34%",3018.86,percent of total billed charges,Implant Device,3107.65,35,,3107.65,percent of total billed charges,Implant Device,3107.65,35,,3107.65,percent of total billed charges,Implant Device,3107.65,35,,3107.65,percent of total billed charges,Implant Device,3107.65,35,,3107.65,percent of total billed charges,Implant Device,3107.65,35,,3107.65,percent of total billed charges,Implant Device,3551.6,40,,3551.6,percent of total billed charges,Implant Device,3107.65,70,,3107.65,percent of total billed charges,All Other,3018.86,34,,3018.86,percent of total billed charges,Implant Device,3018.86,34,,3018.86,percent of total billed charges,Implant Device,3107.65,35,,3107.65,percent of total billed charges,Implant Device,3107.65,35,,3107.65,percent of total billed charges,Implant Device,3107.65,35,,3107.65,percent of total billed charges,Implant Device,3107.65,35,,3107.65,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3018.86,34,"If Charge > 2,000, then 34 percent",3018.86,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,6570.48,
IN2BONES A60 SP103 DUAFIT PIP 10DEG SZ 3,C1713,HCPCS,,79007794,CDM,278,RC,,,both,,,3525,2608.51,,,2608.51,Other,150% of Medicare + 9.63% HCRA Surcharge,1586.25,45,,1586.25,percent of total billed charges,Critical Access Hospital RCC factor,1198.5,34,,1198.5,percent of total billed charges,Implant Device,1198.5,34,,1198.5,percent of total billed charges,Implant Device,1198.5,34,,1198.5,percent of total billed charges,Implant Device,1198.5,34,,1198.5,percent of total billed charges,Implant Device,1198.5,34,,1198.5,percent of total billed charges,Implant Device,1744.88,,,1744.88,Other,110% of Medicare,1233.75,35,,1233.75,percent of total billed charges,Implant Device,1198.5,34,"Charges > $500, x 34%",1198.5,percent of total billed charges,Implant Device,1233.75,35,,1233.75,percent of total billed charges,Implant Device,1233.75,35,,1233.75,percent of total billed charges,Implant Device,1233.75,35,,1233.75,percent of total billed charges,Implant Device,1233.75,35,,1233.75,percent of total billed charges,Implant Device,1233.75,35,,1233.75,percent of total billed charges,Implant Device,1410,40,,1410,percent of total billed charges,Implant Device,1233.75,70,,1233.75,percent of total billed charges,All Other,1198.5,34,,1198.5,percent of total billed charges,Implant Device,1198.5,34,,1198.5,percent of total billed charges,Implant Device,1233.75,35,,1233.75,percent of total billed charges,Implant Device,1233.75,35,,1233.75,percent of total billed charges,Implant Device,1233.75,35,,1233.75,percent of total billed charges,Implant Device,1233.75,35,,1233.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1198.5,34,"If Charge > 2,000, then 34 percent",1198.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2608.51,
STRYKER 656412 NON LOCK SCREW 2.7X12MM,C1713,HCPCS,,79007795,CDM,278,RC,,,both,,,282,208.68,,,208.68,Other,150% of Medicare + 9.63% HCRA Surcharge,126.9,45,,126.9,percent of total billed charges,Critical Access Hospital RCC factor,95.88,34,,95.88,percent of total billed charges,Implant Device,95.88,34,,95.88,percent of total billed charges,Implant Device,95.88,34,,95.88,percent of total billed charges,Implant Device,95.88,34,,95.88,percent of total billed charges,Implant Device,95.88,34,,95.88,percent of total billed charges,Implant Device,139.59,,,139.59,Other,110% of Medicare,98.7,35,,98.7,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,98.7,35,,98.7,percent of total billed charges,Implant Device,98.7,35,,98.7,percent of total billed charges,Implant Device,98.7,35,,98.7,percent of total billed charges,Implant Device,98.7,35,,98.7,percent of total billed charges,Implant Device,98.7,35,,98.7,percent of total billed charges,Implant Device,112.8,40,,112.8,percent of total billed charges,Implant Device,98.7,70,,98.7,percent of total billed charges,All Other,95.88,34,,95.88,percent of total billed charges,Implant Device,95.88,34,,95.88,percent of total billed charges,Implant Device,98.7,35,,98.7,percent of total billed charges,Implant Device,98.7,35,,98.7,percent of total billed charges,Implant Device,98.7,35,,98.7,percent of total billed charges,Implant Device,98.7,35,,98.7,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,208.68,
STRYKER 656016 LOCK SCREW 2.4X16MM,C1713,HCPCS,,79007796,CDM,278,RC,,,both,,,480,355.2,,,355.2,Other,150% of Medicare + 9.63% HCRA Surcharge,216,45,,216,percent of total billed charges,Critical Access Hospital RCC factor,163.2,34,,163.2,percent of total billed charges,Implant Device,163.2,34,,163.2,percent of total billed charges,Implant Device,163.2,34,,163.2,percent of total billed charges,Implant Device,163.2,34,,163.2,percent of total billed charges,Implant Device,163.2,34,,163.2,percent of total billed charges,Implant Device,237.6,,,237.6,Other,110% of Medicare,168,35,,168,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,192,40,,192,percent of total billed charges,Implant Device,168,70,,168,percent of total billed charges,All Other,163.2,34,,163.2,percent of total billed charges,Implant Device,163.2,34,,163.2,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,355.2,
TRILLIANT 200-24-014 14X2.4MM CORT SCREW,C1713,HCPCS,,79007797,CDM,278,RC,,,both,,,525,388.5,,,388.5,Other,150% of Medicare + 9.63% HCRA Surcharge,236.25,45,,236.25,percent of total billed charges,Critical Access Hospital RCC factor,178.5,34,,178.5,percent of total billed charges,Implant Device,178.5,34,,178.5,percent of total billed charges,Implant Device,178.5,34,,178.5,percent of total billed charges,Implant Device,178.5,34,,178.5,percent of total billed charges,Implant Device,178.5,34,,178.5,percent of total billed charges,Implant Device,259.88,,,259.88,Other,110% of Medicare,183.75,35,,183.75,percent of total billed charges,Implant Device,178.5,34,"Charges > $500, x 34%",178.5,percent of total billed charges,Implant Device,183.75,35,,183.75,percent of total billed charges,Implant Device,183.75,35,,183.75,percent of total billed charges,Implant Device,183.75,35,,183.75,percent of total billed charges,Implant Device,183.75,35,,183.75,percent of total billed charges,Implant Device,183.75,35,,183.75,percent of total billed charges,Implant Device,210,40,,210,percent of total billed charges,Implant Device,183.75,70,,183.75,percent of total billed charges,All Other,178.5,34,,178.5,percent of total billed charges,Implant Device,178.5,34,,178.5,percent of total billed charges,Implant Device,183.75,35,,183.75,percent of total billed charges,Implant Device,183.75,35,,183.75,percent of total billed charges,Implant Device,183.75,35,,183.75,percent of total billed charges,Implant Device,183.75,35,,183.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,388.5,
TRILLIANT 200-24-016 16X2.4MM CORT SCREW,C1713,HCPCS,,79007798,CDM,278,RC,,,both,,,525,388.5,,,388.5,Other,150% of Medicare + 9.63% HCRA Surcharge,236.25,45,,236.25,percent of total billed charges,Critical Access Hospital RCC factor,178.5,34,,178.5,percent of total billed charges,Implant Device,178.5,34,,178.5,percent of total billed charges,Implant Device,178.5,34,,178.5,percent of total billed charges,Implant Device,178.5,34,,178.5,percent of total billed charges,Implant Device,178.5,34,,178.5,percent of total billed charges,Implant Device,259.88,,,259.88,Other,110% of Medicare,183.75,35,,183.75,percent of total billed charges,Implant Device,178.5,34,"Charges > $500, x 34%",178.5,percent of total billed charges,Implant Device,183.75,35,,183.75,percent of total billed charges,Implant Device,183.75,35,,183.75,percent of total billed charges,Implant Device,183.75,35,,183.75,percent of total billed charges,Implant Device,183.75,35,,183.75,percent of total billed charges,Implant Device,183.75,35,,183.75,percent of total billed charges,Implant Device,210,40,,210,percent of total billed charges,Implant Device,183.75,70,,183.75,percent of total billed charges,All Other,178.5,34,,178.5,percent of total billed charges,Implant Device,178.5,34,,178.5,percent of total billed charges,Implant Device,183.75,35,,183.75,percent of total billed charges,Implant Device,183.75,35,,183.75,percent of total billed charges,Implant Device,183.75,35,,183.75,percent of total billed charges,Implant Device,183.75,35,,183.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,388.5,
ARTHREX AR-1562BC TENOD SCREW 6.25X15MM,C1713,HCPCS,,79007802,CDM,278,RC,,,both,,,1036,766.64,,,766.64,Other,150% of Medicare + 9.63% HCRA Surcharge,466.2,45,,466.2,percent of total billed charges,Critical Access Hospital RCC factor,352.24,34,,352.24,percent of total billed charges,Implant Device,352.24,34,,352.24,percent of total billed charges,Implant Device,352.24,34,,352.24,percent of total billed charges,Implant Device,352.24,34,,352.24,percent of total billed charges,Implant Device,352.24,34,,352.24,percent of total billed charges,Implant Device,512.82,,,512.82,Other,110% of Medicare,362.6,35,,362.6,percent of total billed charges,Implant Device,352.24,34,"Charges > $500, x 34%",352.24,percent of total billed charges,Implant Device,362.6,35,,362.6,percent of total billed charges,Implant Device,362.6,35,,362.6,percent of total billed charges,Implant Device,362.6,35,,362.6,percent of total billed charges,Implant Device,362.6,35,,362.6,percent of total billed charges,Implant Device,362.6,35,,362.6,percent of total billed charges,Implant Device,414.4,40,,414.4,percent of total billed charges,Implant Device,362.6,70,,362.6,percent of total billed charges,All Other,352.24,34,,352.24,percent of total billed charges,Implant Device,352.24,34,,352.24,percent of total billed charges,Implant Device,362.6,35,,362.6,percent of total billed charges,Implant Device,362.6,35,,362.6,percent of total billed charges,Implant Device,362.6,35,,362.6,percent of total billed charges,Implant Device,362.6,35,,362.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,766.64,
STABILITY BIO 447-10201 ACHILLES TENDON,C1713,HCPCS,,79007803,CDM,278,RC,,,both,,,4200,3108.01,,,3108.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1890,45,,1890,percent of total billed charges,Critical Access Hospital RCC factor,1428,34,,1428,percent of total billed charges,Implant Device,1428,34,,1428,percent of total billed charges,Implant Device,1428,34,,1428,percent of total billed charges,Implant Device,1428,34,,1428,percent of total billed charges,Implant Device,1428,34,,1428,percent of total billed charges,Implant Device,2079,,,2079,Other,110% of Medicare,1470,35,,1470,percent of total billed charges,Implant Device,1428,34,"Charges > $500, x 34%",1428,percent of total billed charges,Implant Device,1470,35,,1470,percent of total billed charges,Implant Device,1470,35,,1470,percent of total billed charges,Implant Device,1470,35,,1470,percent of total billed charges,Implant Device,1470,35,,1470,percent of total billed charges,Implant Device,1470,35,,1470,percent of total billed charges,Implant Device,1680,40,,1680,percent of total billed charges,Implant Device,1470,70,,1470,percent of total billed charges,All Other,1428,34,,1428,percent of total billed charges,Implant Device,1428,34,,1428,percent of total billed charges,Implant Device,1470,35,,1470,percent of total billed charges,Implant Device,1470,35,,1470,percent of total billed charges,Implant Device,1470,35,,1470,percent of total billed charges,Implant Device,1470,35,,1470,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1428,34,"If Charge > 2,000, then 34 percent",1428,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3108.01,
DEPUY 86-6402 MODULAR STEM 13X60MM,C1776,HCPCS,,79007804,CDM,278,RC,,,both,,,3900,2886.01,,,2886.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1755,45,,1755,percent of total billed charges,Critical Access Hospital RCC factor,1326,34,,1326,percent of total billed charges,Implant Device,1326,34,,1326,percent of total billed charges,Implant Device,1326,34,,1326,percent of total billed charges,Implant Device,1326,34,,1326,percent of total billed charges,Implant Device,1326,34,,1326,percent of total billed charges,Implant Device,1930.5,,,1930.5,Other,110% of Medicare,1365,35,,1365,percent of total billed charges,Implant Device,1326,34,"Charges > $500, x 34%",1326,percent of total billed charges,Implant Device,1365,35,,1365,percent of total billed charges,Implant Device,1365,35,,1365,percent of total billed charges,Implant Device,1365,35,,1365,percent of total billed charges,Implant Device,1365,35,,1365,percent of total billed charges,Implant Device,1365,35,,1365,percent of total billed charges,Implant Device,1560,40,,1560,percent of total billed charges,Implant Device,1365,70,,1365,percent of total billed charges,All Other,1326,34,,1326,percent of total billed charges,Implant Device,1326,34,,1326,percent of total billed charges,Implant Device,1365,35,,1365,percent of total billed charges,Implant Device,1365,35,,1365,percent of total billed charges,Implant Device,1365,35,,1365,percent of total billed charges,Implant Device,1365,35,,1365,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1326,34,"If Charge > 2,000, then 34 percent",1326,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2886.01,
DEPUY 96-0081 FEMORAL CEMENTED LEFT SZ 2,C1776,HCPCS,,79007805,CDM,278,RC,,,both,,,23138,17122.18,,,17122.18,Other,150% of Medicare + 9.63% HCRA Surcharge,10412.1,45,,10412.1,percent of total billed charges,Critical Access Hospital RCC factor,7866.92,34,,7866.92,percent of total billed charges,Implant Device,7866.92,34,,7866.92,percent of total billed charges,Implant Device,7866.92,34,,7866.92,percent of total billed charges,Implant Device,7866.92,34,,7866.92,percent of total billed charges,Implant Device,7866.92,34,,7866.92,percent of total billed charges,Implant Device,11453.31,,,11453.31,Other,110% of Medicare,8098.3,35,,8098.3,percent of total billed charges,Implant Device,7866.92,34,"Charges > $500, x 34%",7866.92,percent of total billed charges,Implant Device,8098.3,35,,8098.3,percent of total billed charges,Implant Device,8098.3,35,,8098.3,percent of total billed charges,Implant Device,8098.3,35,,8098.3,percent of total billed charges,Implant Device,8098.3,35,,8098.3,percent of total billed charges,Implant Device,8098.3,35,,8098.3,percent of total billed charges,Implant Device,9255.2,40,,9255.2,percent of total billed charges,Implant Device,8098.3,70,,8098.3,percent of total billed charges,All Other,7866.92,34,,7866.92,percent of total billed charges,Implant Device,7866.92,34,,7866.92,percent of total billed charges,Implant Device,8098.3,35,,8098.3,percent of total billed charges,Implant Device,8098.3,35,,8098.3,percent of total billed charges,Implant Device,8098.3,35,,8098.3,percent of total billed charges,Implant Device,8098.3,35,,8098.3,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,7866.92,34,"If Charge > 2,000, then 34 percent",7866.92,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,17122.18,
DEPUY 96-0820 DISTAL AUGMENT SZ 2 4MM LT,C1776,HCPCS,,79007806,CDM,278,RC,,,both,,,3929,2907.47,,,2907.47,Other,150% of Medicare + 9.63% HCRA Surcharge,1768.05,45,,1768.05,percent of total billed charges,Critical Access Hospital RCC factor,1335.86,34,,1335.86,percent of total billed charges,Implant Device,1335.86,34,,1335.86,percent of total billed charges,Implant Device,1335.86,34,,1335.86,percent of total billed charges,Implant Device,1335.86,34,,1335.86,percent of total billed charges,Implant Device,1335.86,34,,1335.86,percent of total billed charges,Implant Device,1944.86,,,1944.86,Other,110% of Medicare,1375.15,35,,1375.15,percent of total billed charges,Implant Device,1335.86,34,"Charges > $500, x 34%",1335.86,percent of total billed charges,Implant Device,1375.15,35,,1375.15,percent of total billed charges,Implant Device,1375.15,35,,1375.15,percent of total billed charges,Implant Device,1375.15,35,,1375.15,percent of total billed charges,Implant Device,1375.15,35,,1375.15,percent of total billed charges,Implant Device,1375.15,35,,1375.15,percent of total billed charges,Implant Device,1571.6,40,,1571.6,percent of total billed charges,Implant Device,1375.15,70,,1375.15,percent of total billed charges,All Other,1335.86,34,,1335.86,percent of total billed charges,Implant Device,1335.86,34,,1335.86,percent of total billed charges,Implant Device,1375.15,35,,1375.15,percent of total billed charges,Implant Device,1375.15,35,,1375.15,percent of total billed charges,Implant Device,1375.15,35,,1375.15,percent of total billed charges,Implant Device,1375.15,35,,1375.15,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1335.86,34,"If Charge > 2,000, then 34 percent",1335.86,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2907.47,
DEPUY 96-2325 TIBIAL INSERT SZ 2 20MM,C1776,HCPCS,,79007807,CDM,278,RC,,,both,,,10896,8063.07,,,8063.07,Other,150% of Medicare + 9.63% HCRA Surcharge,4903.2,45,,4903.2,percent of total billed charges,Critical Access Hospital RCC factor,3704.64,34,,3704.64,percent of total billed charges,Implant Device,3704.64,34,,3704.64,percent of total billed charges,Implant Device,3704.64,34,,3704.64,percent of total billed charges,Implant Device,3704.64,34,,3704.64,percent of total billed charges,Implant Device,3704.64,34,,3704.64,percent of total billed charges,Implant Device,5393.52,,,5393.52,Other,110% of Medicare,3813.6,35,,3813.6,percent of total billed charges,Implant Device,3704.64,34,"Charges > $500, x 34%",3704.64,percent of total billed charges,Implant Device,3813.6,35,,3813.6,percent of total billed charges,Implant Device,3813.6,35,,3813.6,percent of total billed charges,Implant Device,3813.6,35,,3813.6,percent of total billed charges,Implant Device,3813.6,35,,3813.6,percent of total billed charges,Implant Device,3813.6,35,,3813.6,percent of total billed charges,Implant Device,4358.4,40,,4358.4,percent of total billed charges,Implant Device,3813.6,70,,3813.6,percent of total billed charges,All Other,3704.64,34,,3704.64,percent of total billed charges,Implant Device,3704.64,34,,3704.64,percent of total billed charges,Implant Device,3813.6,35,,3813.6,percent of total billed charges,Implant Device,3813.6,35,,3813.6,percent of total billed charges,Implant Device,3813.6,35,,3813.6,percent of total billed charges,Implant Device,3813.6,35,,3813.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3704.64,34,"If Charge > 2,000, then 34 percent",3704.64,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,8063.07,
DEPUY 462.642 TI SPIRAL BLADE SCREW 42MM,C1713,HCPCS,,79007812,CDM,278,RC,,,both,,,1189,879.86,,,879.86,Other,150% of Medicare + 9.63% HCRA Surcharge,535.05,45,,535.05,percent of total billed charges,Critical Access Hospital RCC factor,404.26,34,,404.26,percent of total billed charges,Implant Device,404.26,34,,404.26,percent of total billed charges,Implant Device,404.26,34,,404.26,percent of total billed charges,Implant Device,404.26,34,,404.26,percent of total billed charges,Implant Device,404.26,34,,404.26,percent of total billed charges,Implant Device,588.56,,,588.56,Other,110% of Medicare,416.15,35,,416.15,percent of total billed charges,Implant Device,404.26,34,"Charges > $500, x 34%",404.26,percent of total billed charges,Implant Device,416.15,35,,416.15,percent of total billed charges,Implant Device,416.15,35,,416.15,percent of total billed charges,Implant Device,416.15,35,,416.15,percent of total billed charges,Implant Device,416.15,35,,416.15,percent of total billed charges,Implant Device,416.15,35,,416.15,percent of total billed charges,Implant Device,475.6,40,,475.6,percent of total billed charges,Implant Device,416.15,70,,416.15,percent of total billed charges,All Other,404.26,34,,404.26,percent of total billed charges,Implant Device,404.26,34,,404.26,percent of total billed charges,Implant Device,416.15,35,,416.15,percent of total billed charges,Implant Device,416.15,35,,416.15,percent of total billed charges,Implant Device,416.15,35,,416.15,percent of total billed charges,Implant Device,416.15,35,,416.15,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,879.86,
DEPUY 04.005.416 4.0X26MM LOCKING SCREW,C1713,HCPCS,,79007813,CDM,278,RC,,,both,,,364,269.36,,,269.36,Other,150% of Medicare + 9.63% HCRA Surcharge,163.8,45,,163.8,percent of total billed charges,Critical Access Hospital RCC factor,123.76,34,,123.76,percent of total billed charges,Implant Device,123.76,34,,123.76,percent of total billed charges,Implant Device,123.76,34,,123.76,percent of total billed charges,Implant Device,123.76,34,,123.76,percent of total billed charges,Implant Device,123.76,34,,123.76,percent of total billed charges,Implant Device,180.18,,,180.18,Other,110% of Medicare,127.4,35,,127.4,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,127.4,35,,127.4,percent of total billed charges,Implant Device,127.4,35,,127.4,percent of total billed charges,Implant Device,127.4,35,,127.4,percent of total billed charges,Implant Device,127.4,35,,127.4,percent of total billed charges,Implant Device,127.4,35,,127.4,percent of total billed charges,Implant Device,145.6,40,,145.6,percent of total billed charges,Implant Device,127.4,70,,127.4,percent of total billed charges,All Other,123.76,34,,123.76,percent of total billed charges,Implant Device,123.76,34,,123.76,percent of total billed charges,Implant Device,127.4,35,,127.4,percent of total billed charges,Implant Device,127.4,35,,127.4,percent of total billed charges,Implant Device,127.4,35,,127.4,percent of total billed charges,Implant Device,127.4,35,,127.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,269.36,
DEPUY 04.005.418 4.0X28MM LOCKING SCREW,C1713,HCPCS,,79007814,CDM,278,RC,,,both,,,449,332.26,,,332.26,Other,150% of Medicare + 9.63% HCRA Surcharge,202.05,45,,202.05,percent of total billed charges,Critical Access Hospital RCC factor,152.66,34,,152.66,percent of total billed charges,Implant Device,152.66,34,,152.66,percent of total billed charges,Implant Device,152.66,34,,152.66,percent of total billed charges,Implant Device,152.66,34,,152.66,percent of total billed charges,Implant Device,152.66,34,,152.66,percent of total billed charges,Implant Device,222.26,,,222.26,Other,110% of Medicare,157.15,35,,157.15,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,157.15,35,,157.15,percent of total billed charges,Implant Device,157.15,35,,157.15,percent of total billed charges,Implant Device,157.15,35,,157.15,percent of total billed charges,Implant Device,157.15,35,,157.15,percent of total billed charges,Implant Device,157.15,35,,157.15,percent of total billed charges,Implant Device,179.6,40,,179.6,percent of total billed charges,Implant Device,157.15,70,,157.15,percent of total billed charges,All Other,152.66,34,,152.66,percent of total billed charges,Implant Device,152.66,34,,152.66,percent of total billed charges,Implant Device,157.15,35,,157.15,percent of total billed charges,Implant Device,157.15,35,,157.15,percent of total billed charges,Implant Device,157.15,35,,157.15,percent of total billed charges,Implant Device,157.15,35,,157.15,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,332.26,
DEPUY 04.001.000S END CAP HUMERAL NAIL,C1713,HCPCS,,79007815,CDM,278,RC,,,both,,,396,293.04,,,293.04,Other,150% of Medicare + 9.63% HCRA Surcharge,178.2,45,,178.2,percent of total billed charges,Critical Access Hospital RCC factor,134.64,34,,134.64,percent of total billed charges,Implant Device,134.64,34,,134.64,percent of total billed charges,Implant Device,134.64,34,,134.64,percent of total billed charges,Implant Device,134.64,34,,134.64,percent of total billed charges,Implant Device,134.64,34,,134.64,percent of total billed charges,Implant Device,196.02,,,196.02,Other,110% of Medicare,138.6,35,,138.6,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,138.6,35,,138.6,percent of total billed charges,Implant Device,138.6,35,,138.6,percent of total billed charges,Implant Device,138.6,35,,138.6,percent of total billed charges,Implant Device,138.6,35,,138.6,percent of total billed charges,Implant Device,138.6,35,,138.6,percent of total billed charges,Implant Device,158.4,40,,158.4,percent of total billed charges,Implant Device,138.6,70,,138.6,percent of total billed charges,All Other,134.64,34,,134.64,percent of total billed charges,Implant Device,134.64,34,,134.64,percent of total billed charges,Implant Device,138.6,35,,138.6,percent of total billed charges,Implant Device,138.6,35,,138.6,percent of total billed charges,Implant Device,138.6,35,,138.6,percent of total billed charges,Implant Device,138.6,35,,138.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,293.04,
DEPUY 04.001.210S 7X150 CANN HUMRL NAIL,C1713,HCPCS,,79007816,CDM,278,RC,,,both,,,6940,5135.62,,,5135.62,Other,150% of Medicare + 9.63% HCRA Surcharge,3123,45,,3123,percent of total billed charges,Critical Access Hospital RCC factor,2359.6,34,,2359.6,percent of total billed charges,Implant Device,2359.6,34,,2359.6,percent of total billed charges,Implant Device,2359.6,34,,2359.6,percent of total billed charges,Implant Device,2359.6,34,,2359.6,percent of total billed charges,Implant Device,2359.6,34,,2359.6,percent of total billed charges,Implant Device,3435.3,,,3435.3,Other,110% of Medicare,2429,35,,2429,percent of total billed charges,Implant Device,2359.6,34,"Charges > $500, x 34%",2359.6,percent of total billed charges,Implant Device,2429,35,,2429,percent of total billed charges,Implant Device,2429,35,,2429,percent of total billed charges,Implant Device,2429,35,,2429,percent of total billed charges,Implant Device,2429,35,,2429,percent of total billed charges,Implant Device,2429,35,,2429,percent of total billed charges,Implant Device,2776,40,,2776,percent of total billed charges,Implant Device,2429,70,,2429,percent of total billed charges,All Other,2359.6,34,,2359.6,percent of total billed charges,Implant Device,2359.6,34,,2359.6,percent of total billed charges,Implant Device,2429,35,,2429,percent of total billed charges,Implant Device,2429,35,,2429,percent of total billed charges,Implant Device,2429,35,,2429,percent of total billed charges,Implant Device,2429,35,,2429,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2359.6,34,"If Charge > 2,000, then 34 percent",2359.6,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5135.62,
DEPUY 456.327S 11X235MM TI CANN FEM NAIL,C1713,HCPCS,,79007817,CDM,278,RC,,,both,,,2738,2026.13,,,2026.13,Other,150% of Medicare + 9.63% HCRA Surcharge,1232.1,45,,1232.1,percent of total billed charges,Critical Access Hospital RCC factor,930.92,34,,930.92,percent of total billed charges,Implant Device,930.92,34,,930.92,percent of total billed charges,Implant Device,930.92,34,,930.92,percent of total billed charges,Implant Device,930.92,34,,930.92,percent of total billed charges,Implant Device,930.92,34,,930.92,percent of total billed charges,Implant Device,1355.31,,,1355.31,Other,110% of Medicare,958.3,35,,958.3,percent of total billed charges,Implant Device,930.92,34,"Charges > $500, x 34%",930.92,percent of total billed charges,Implant Device,958.3,35,,958.3,percent of total billed charges,Implant Device,958.3,35,,958.3,percent of total billed charges,Implant Device,958.3,35,,958.3,percent of total billed charges,Implant Device,958.3,35,,958.3,percent of total billed charges,Implant Device,958.3,35,,958.3,percent of total billed charges,Implant Device,1095.2,40,,1095.2,percent of total billed charges,Implant Device,958.3,70,,958.3,percent of total billed charges,All Other,930.92,34,,930.92,percent of total billed charges,Implant Device,930.92,34,,930.92,percent of total billed charges,Implant Device,958.3,35,,958.3,percent of total billed charges,Implant Device,958.3,35,,958.3,percent of total billed charges,Implant Device,958.3,35,,958.3,percent of total billed charges,Implant Device,958.3,35,,958.3,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,930.92,34,"If Charge > 2,000, then 34 percent",930.92,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2026.13,
DEPUY 456.303S 11X90MM TI HELOCAL BLADE,C1713,HCPCS,,79007818,CDM,278,RC,,,both,,,1301,962.74,,,962.74,Other,150% of Medicare + 9.63% HCRA Surcharge,585.45,45,,585.45,percent of total billed charges,Critical Access Hospital RCC factor,442.34,34,,442.34,percent of total billed charges,Implant Device,442.34,34,,442.34,percent of total billed charges,Implant Device,442.34,34,,442.34,percent of total billed charges,Implant Device,442.34,34,,442.34,percent of total billed charges,Implant Device,442.34,34,,442.34,percent of total billed charges,Implant Device,644,,,644,Other,110% of Medicare,455.35,35,,455.35,percent of total billed charges,Implant Device,442.34,34,"Charges > $500, x 34%",442.34,percent of total billed charges,Implant Device,455.35,35,,455.35,percent of total billed charges,Implant Device,455.35,35,,455.35,percent of total billed charges,Implant Device,455.35,35,,455.35,percent of total billed charges,Implant Device,455.35,35,,455.35,percent of total billed charges,Implant Device,455.35,35,,455.35,percent of total billed charges,Implant Device,520.4,40,,520.4,percent of total billed charges,Implant Device,455.35,70,,455.35,percent of total billed charges,All Other,442.34,34,,442.34,percent of total billed charges,Implant Device,442.34,34,,442.34,percent of total billed charges,Implant Device,455.35,35,,455.35,percent of total billed charges,Implant Device,455.35,35,,455.35,percent of total billed charges,Implant Device,455.35,35,,455.35,percent of total billed charges,Implant Device,455.35,35,,455.35,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,962.74,
MEDLINE PCO15X PARIETEX MESH 15CM ROUND,C1713,HCPCS,,79007820,CDM,278,RC,,,both,,,2309,1708.67,,,1708.67,Other,150% of Medicare + 9.63% HCRA Surcharge,1039.05,45,,1039.05,percent of total billed charges,Critical Access Hospital RCC factor,785.06,34,,785.06,percent of total billed charges,Implant Device,785.06,34,,785.06,percent of total billed charges,Implant Device,785.06,34,,785.06,percent of total billed charges,Implant Device,785.06,34,,785.06,percent of total billed charges,Implant Device,785.06,34,,785.06,percent of total billed charges,Implant Device,1142.96,,,1142.96,Other,110% of Medicare,808.15,35,,808.15,percent of total billed charges,Implant Device,785.06,34,"Charges > $500, x 34%",785.06,percent of total billed charges,Implant Device,808.15,35,,808.15,percent of total billed charges,Implant Device,808.15,35,,808.15,percent of total billed charges,Implant Device,808.15,35,,808.15,percent of total billed charges,Implant Device,808.15,35,,808.15,percent of total billed charges,Implant Device,808.15,35,,808.15,percent of total billed charges,Implant Device,923.6,40,,923.6,percent of total billed charges,Implant Device,808.15,70,,808.15,percent of total billed charges,All Other,785.06,34,,785.06,percent of total billed charges,Implant Device,785.06,34,,785.06,percent of total billed charges,Implant Device,808.15,35,,808.15,percent of total billed charges,Implant Device,808.15,35,,808.15,percent of total billed charges,Implant Device,808.15,35,,808.15,percent of total billed charges,Implant Device,808.15,35,,808.15,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,785.06,34,"If Charge > 2,000, then 34 percent",785.06,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1708.67,
STRYKER 628048 PLATE 8 HOLE LEFT,C1713,HCPCS,,79007822,CDM,278,RC,,,both,,,6747,4992.8,,,4992.8,Other,150% of Medicare + 9.63% HCRA Surcharge,3036.15,45,,3036.15,percent of total billed charges,Critical Access Hospital RCC factor,2293.98,34,,2293.98,percent of total billed charges,Implant Device,2293.98,34,,2293.98,percent of total billed charges,Implant Device,2293.98,34,,2293.98,percent of total billed charges,Implant Device,2293.98,34,,2293.98,percent of total billed charges,Implant Device,2293.98,34,,2293.98,percent of total billed charges,Implant Device,3339.77,,,3339.77,Other,110% of Medicare,2361.45,35,,2361.45,percent of total billed charges,Implant Device,2293.98,34,"Charges > $500, x 34%",2293.98,percent of total billed charges,Implant Device,2361.45,35,,2361.45,percent of total billed charges,Implant Device,2361.45,35,,2361.45,percent of total billed charges,Implant Device,2361.45,35,,2361.45,percent of total billed charges,Implant Device,2361.45,35,,2361.45,percent of total billed charges,Implant Device,2361.45,35,,2361.45,percent of total billed charges,Implant Device,2698.8,40,,2698.8,percent of total billed charges,Implant Device,2361.45,70,,2361.45,percent of total billed charges,All Other,2293.98,34,,2293.98,percent of total billed charges,Implant Device,2293.98,34,,2293.98,percent of total billed charges,Implant Device,2361.45,35,,2361.45,percent of total billed charges,Implant Device,2361.45,35,,2361.45,percent of total billed charges,Implant Device,2361.45,35,,2361.45,percent of total billed charges,Implant Device,2361.45,35,,2361.45,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2293.98,34,"If Charge > 2,000, then 34 percent",2293.98,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4992.8,
STRYKER 614718 NON LOCK SCREW 2.7X18MM,C1713,HCPCS,,79007823,CDM,278,RC,,,both,,,375,277.5,,,277.5,Other,150% of Medicare + 9.63% HCRA Surcharge,168.75,45,,168.75,percent of total billed charges,Critical Access Hospital RCC factor,127.5,34,,127.5,percent of total billed charges,Implant Device,127.5,34,,127.5,percent of total billed charges,Implant Device,127.5,34,,127.5,percent of total billed charges,Implant Device,127.5,34,,127.5,percent of total billed charges,Implant Device,127.5,34,,127.5,percent of total billed charges,Implant Device,185.63,,,185.63,Other,110% of Medicare,131.25,35,,131.25,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,131.25,35,,131.25,percent of total billed charges,Implant Device,131.25,35,,131.25,percent of total billed charges,Implant Device,131.25,35,,131.25,percent of total billed charges,Implant Device,131.25,35,,131.25,percent of total billed charges,Implant Device,131.25,35,,131.25,percent of total billed charges,Implant Device,150,40,,150,percent of total billed charges,Implant Device,131.25,70,,131.25,percent of total billed charges,All Other,127.5,34,,127.5,percent of total billed charges,Implant Device,127.5,34,,127.5,percent of total billed charges,Implant Device,131.25,35,,131.25,percent of total billed charges,Implant Device,131.25,35,,131.25,percent of total billed charges,Implant Device,131.25,35,,131.25,percent of total billed charges,Implant Device,131.25,35,,131.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,277.5,
STRYKER 614716 NON LOCK SCREW 2.7X16MM,C1713,HCPCS,,79007824,CDM,278,RC,,,both,,,375,277.5,,,277.5,Other,150% of Medicare + 9.63% HCRA Surcharge,168.75,45,,168.75,percent of total billed charges,Critical Access Hospital RCC factor,127.5,34,,127.5,percent of total billed charges,Implant Device,127.5,34,,127.5,percent of total billed charges,Implant Device,127.5,34,,127.5,percent of total billed charges,Implant Device,127.5,34,,127.5,percent of total billed charges,Implant Device,127.5,34,,127.5,percent of total billed charges,Implant Device,185.63,,,185.63,Other,110% of Medicare,131.25,35,,131.25,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,131.25,35,,131.25,percent of total billed charges,Implant Device,131.25,35,,131.25,percent of total billed charges,Implant Device,131.25,35,,131.25,percent of total billed charges,Implant Device,131.25,35,,131.25,percent of total billed charges,Implant Device,131.25,35,,131.25,percent of total billed charges,Implant Device,150,40,,150,percent of total billed charges,Implant Device,131.25,70,,131.25,percent of total billed charges,All Other,127.5,34,,127.5,percent of total billed charges,Implant Device,127.5,34,,127.5,percent of total billed charges,Implant Device,131.25,35,,131.25,percent of total billed charges,Implant Device,131.25,35,,131.25,percent of total billed charges,Implant Device,131.25,35,,131.25,percent of total billed charges,Implant Device,131.25,35,,131.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,277.5,
STRYKER 614810 NON LOCK SCREW 3.5X10MM,C1713,HCPCS,,79007825,CDM,278,RC,,,both,,,375,277.5,,,277.5,Other,150% of Medicare + 9.63% HCRA Surcharge,168.75,45,,168.75,percent of total billed charges,Critical Access Hospital RCC factor,127.5,34,,127.5,percent of total billed charges,Implant Device,127.5,34,,127.5,percent of total billed charges,Implant Device,127.5,34,,127.5,percent of total billed charges,Implant Device,127.5,34,,127.5,percent of total billed charges,Implant Device,127.5,34,,127.5,percent of total billed charges,Implant Device,185.63,,,185.63,Other,110% of Medicare,131.25,35,,131.25,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,131.25,35,,131.25,percent of total billed charges,Implant Device,131.25,35,,131.25,percent of total billed charges,Implant Device,131.25,35,,131.25,percent of total billed charges,Implant Device,131.25,35,,131.25,percent of total billed charges,Implant Device,131.25,35,,131.25,percent of total billed charges,Implant Device,150,40,,150,percent of total billed charges,Implant Device,131.25,70,,131.25,percent of total billed charges,All Other,127.5,34,,127.5,percent of total billed charges,Implant Device,127.5,34,,127.5,percent of total billed charges,Implant Device,131.25,35,,131.25,percent of total billed charges,Implant Device,131.25,35,,131.25,percent of total billed charges,Implant Device,131.25,35,,131.25,percent of total billed charges,Implant Device,131.25,35,,131.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,277.5,
DEPUY 202.640 CANNULATED SCREW 3.0X40MM,C1713,HCPCS,,79007826,CDM,278,RC,,,both,,,770,569.8,,,569.8,Other,150% of Medicare + 9.63% HCRA Surcharge,346.5,45,,346.5,percent of total billed charges,Critical Access Hospital RCC factor,261.8,34,,261.8,percent of total billed charges,Implant Device,261.8,34,,261.8,percent of total billed charges,Implant Device,261.8,34,,261.8,percent of total billed charges,Implant Device,261.8,34,,261.8,percent of total billed charges,Implant Device,261.8,34,,261.8,percent of total billed charges,Implant Device,381.15,,,381.15,Other,110% of Medicare,269.5,35,,269.5,percent of total billed charges,Implant Device,261.8,34,"Charges > $500, x 34%",261.8,percent of total billed charges,Implant Device,269.5,35,,269.5,percent of total billed charges,Implant Device,269.5,35,,269.5,percent of total billed charges,Implant Device,269.5,35,,269.5,percent of total billed charges,Implant Device,269.5,35,,269.5,percent of total billed charges,Implant Device,269.5,35,,269.5,percent of total billed charges,Implant Device,308,40,,308,percent of total billed charges,Implant Device,269.5,70,,269.5,percent of total billed charges,All Other,261.8,34,,261.8,percent of total billed charges,Implant Device,261.8,34,,261.8,percent of total billed charges,Implant Device,269.5,35,,269.5,percent of total billed charges,Implant Device,269.5,35,,269.5,percent of total billed charges,Implant Device,269.5,35,,269.5,percent of total billed charges,Implant Device,269.5,35,,269.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,569.8,
ST JUDE CM2000 CARDIOMEMS WIRELESS SENSR,C2624,HCPCS,,79007836,CDM,278,RC,,,both,,,67500,49950.17,,,49950.17,Other,150% of Medicare + 9.63% HCRA Surcharge,30375,45,,30375,percent of total billed charges,Critical Access Hospital RCC factor,22950,34,,22950,percent of total billed charges,Implant Device,22950,34,,22950,percent of total billed charges,Implant Device,22950,34,,22950,percent of total billed charges,Implant Device,22950,34,,22950,percent of total billed charges,Implant Device,22950,34,,22950,percent of total billed charges,Implant Device,33412.5,,,33412.5,Other,110% of Medicare,23625,35,,23625,percent of total billed charges,Implant Device,22950,34,"Charges > $500, x 34%",22950,percent of total billed charges,Implant Device,23625,35,,23625,percent of total billed charges,Implant Device,23625,35,,23625,percent of total billed charges,Implant Device,23625,35,,23625,percent of total billed charges,Implant Device,23625,35,,23625,percent of total billed charges,Implant Device,23625,35,,23625,percent of total billed charges,Implant Device,27000,40,,27000,percent of total billed charges,Implant Device,23625,70,,23625,percent of total billed charges,All Other,22950,34,,22950,percent of total billed charges,Implant Device,22950,34,,22950,percent of total billed charges,Implant Device,23625,35,,23625,percent of total billed charges,Implant Device,23625,35,,23625,percent of total billed charges,Implant Device,23625,35,,23625,percent of total billed charges,Implant Device,23625,35,,23625,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,22950,34,"If Charge > 2,000, then 34 percent",22950,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,49950.17,
STRYKER 5569-P-2011 HUMERAL STEM SZ 11,C1776,HCPCS,,79007843,CDM,278,RC,,,both,,,10500,7770.03,,,7770.03,Other,150% of Medicare + 9.63% HCRA Surcharge,4725,45,,4725,percent of total billed charges,Critical Access Hospital RCC factor,3570,34,,3570,percent of total billed charges,Implant Device,3570,34,,3570,percent of total billed charges,Implant Device,3570,34,,3570,percent of total billed charges,Implant Device,3570,34,,3570,percent of total billed charges,Implant Device,3570,34,,3570,percent of total billed charges,Implant Device,5197.5,,,5197.5,Other,110% of Medicare,3675,35,,3675,percent of total billed charges,Implant Device,3570,34,"Charges > $500, x 34%",3570,percent of total billed charges,Implant Device,3675,35,,3675,percent of total billed charges,Implant Device,3675,35,,3675,percent of total billed charges,Implant Device,3675,35,,3675,percent of total billed charges,Implant Device,3675,35,,3675,percent of total billed charges,Implant Device,3675,35,,3675,percent of total billed charges,Implant Device,4200,40,,4200,percent of total billed charges,Implant Device,3675,70,,3675,percent of total billed charges,All Other,3570,34,,3570,percent of total billed charges,Implant Device,3570,34,,3570,percent of total billed charges,Implant Device,3675,35,,3675,percent of total billed charges,Implant Device,3675,35,,3675,percent of total billed charges,Implant Device,3675,35,,3675,percent of total billed charges,Implant Device,3675,35,,3675,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3570,34,"If Charge > 2,000, then 34 percent",3570,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,7770.03,
MEDLINE PCO2015X PARIETEX MESH 20X15CM,C1781,HCPCS,,79007845,CDM,278,RC,,,both,,,2971,2198.55,,,2198.55,Other,150% of Medicare + 9.63% HCRA Surcharge,1336.95,45,,1336.95,percent of total billed charges,Critical Access Hospital RCC factor,1010.14,34,,1010.14,percent of total billed charges,Implant Device,1010.14,34,,1010.14,percent of total billed charges,Implant Device,1010.14,34,,1010.14,percent of total billed charges,Implant Device,1010.14,34,,1010.14,percent of total billed charges,Implant Device,1010.14,34,,1010.14,percent of total billed charges,Implant Device,1470.65,,,1470.65,Other,110% of Medicare,1039.85,35,,1039.85,percent of total billed charges,Implant Device,1010.14,34,"Charges > $500, x 34%",1010.14,percent of total billed charges,Implant Device,1039.85,35,,1039.85,percent of total billed charges,Implant Device,1039.85,35,,1039.85,percent of total billed charges,Implant Device,1039.85,35,,1039.85,percent of total billed charges,Implant Device,1039.85,35,,1039.85,percent of total billed charges,Implant Device,1039.85,35,,1039.85,percent of total billed charges,Implant Device,1188.4,40,,1188.4,percent of total billed charges,Implant Device,1039.85,70,,1039.85,percent of total billed charges,All Other,1010.14,34,,1010.14,percent of total billed charges,Implant Device,1010.14,34,,1010.14,percent of total billed charges,Implant Device,1039.85,35,,1039.85,percent of total billed charges,Implant Device,1039.85,35,,1039.85,percent of total billed charges,Implant Device,1039.85,35,,1039.85,percent of total billed charges,Implant Device,1039.85,35,,1039.85,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1010.14,34,"If Charge > 2,000, then 34 percent",1010.14,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2198.55,
ATLAS 1208-01-3010 INTERBODY SPACR 30X10,C1713,HCPCS,,79007846,CDM,278,RC,,,both,,,9555,7070.72,,,7070.72,Other,150% of Medicare + 9.63% HCRA Surcharge,4299.75,45,,4299.75,percent of total billed charges,Critical Access Hospital RCC factor,3248.7,34,,3248.7,percent of total billed charges,Implant Device,3248.7,34,,3248.7,percent of total billed charges,Implant Device,3248.7,34,,3248.7,percent of total billed charges,Implant Device,3248.7,34,,3248.7,percent of total billed charges,Implant Device,3248.7,34,,3248.7,percent of total billed charges,Implant Device,4729.73,,,4729.73,Other,110% of Medicare,3344.25,35,,3344.25,percent of total billed charges,Implant Device,3248.7,34,"Charges > $500, x 34%",3248.7,percent of total billed charges,Implant Device,3344.25,35,,3344.25,percent of total billed charges,Implant Device,3344.25,35,,3344.25,percent of total billed charges,Implant Device,3344.25,35,,3344.25,percent of total billed charges,Implant Device,3344.25,35,,3344.25,percent of total billed charges,Implant Device,3344.25,35,,3344.25,percent of total billed charges,Implant Device,3822,40,,3822,percent of total billed charges,Implant Device,3344.25,70,,3344.25,percent of total billed charges,All Other,3248.7,34,,3248.7,percent of total billed charges,Implant Device,3248.7,34,,3248.7,percent of total billed charges,Implant Device,3344.25,35,,3344.25,percent of total billed charges,Implant Device,3344.25,35,,3344.25,percent of total billed charges,Implant Device,3344.25,35,,3344.25,percent of total billed charges,Implant Device,3344.25,35,,3344.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3248.7,34,"If Charge > 2,000, then 34 percent",3248.7,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,7070.72,
DEPUY 1035-57-000 SELF CNT HIP 57X28MM,C1776,HCPCS,,79007852,CDM,278,RC,,,both,,,4030,2982.21,,,2982.21,Other,150% of Medicare + 9.63% HCRA Surcharge,1813.5,45,,1813.5,percent of total billed charges,Critical Access Hospital RCC factor,1370.2,34,,1370.2,percent of total billed charges,Implant Device,1370.2,34,,1370.2,percent of total billed charges,Implant Device,1370.2,34,,1370.2,percent of total billed charges,Implant Device,1370.2,34,,1370.2,percent of total billed charges,Implant Device,1370.2,34,,1370.2,percent of total billed charges,Implant Device,1994.85,,,1994.85,Other,110% of Medicare,1410.5,35,,1410.5,percent of total billed charges,Implant Device,1370.2,34,"Charges > $500, x 34%",1370.2,percent of total billed charges,Implant Device,1410.5,35,,1410.5,percent of total billed charges,Implant Device,1410.5,35,,1410.5,percent of total billed charges,Implant Device,1410.5,35,,1410.5,percent of total billed charges,Implant Device,1410.5,35,,1410.5,percent of total billed charges,Implant Device,1410.5,35,,1410.5,percent of total billed charges,Implant Device,1612,40,,1612,percent of total billed charges,Implant Device,1410.5,70,,1410.5,percent of total billed charges,All Other,1370.2,34,,1370.2,percent of total billed charges,Implant Device,1370.2,34,,1370.2,percent of total billed charges,Implant Device,1410.5,35,,1410.5,percent of total billed charges,Implant Device,1410.5,35,,1410.5,percent of total billed charges,Implant Device,1410.5,35,,1410.5,percent of total billed charges,Implant Device,1410.5,35,,1410.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1370.2,34,"If Charge > 2,000, then 34 percent",1370.2,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2982.21,
DEPUY 3L92505 CORAIL FEMORAL STEM SZ 15,C1776,HCPCS,,79007853,CDM,278,RC,,,both,,,13446,9950.07,,,9950.07,Other,150% of Medicare + 9.63% HCRA Surcharge,6050.7,45,,6050.7,percent of total billed charges,Critical Access Hospital RCC factor,4571.64,34,,4571.64,percent of total billed charges,Implant Device,4571.64,34,,4571.64,percent of total billed charges,Implant Device,4571.64,34,,4571.64,percent of total billed charges,Implant Device,4571.64,34,,4571.64,percent of total billed charges,Implant Device,4571.64,34,,4571.64,percent of total billed charges,Implant Device,6655.77,,,6655.77,Other,110% of Medicare,4706.1,35,,4706.1,percent of total billed charges,Implant Device,4571.64,34,"Charges > $500, x 34%",4571.64,percent of total billed charges,Implant Device,4706.1,35,,4706.1,percent of total billed charges,Implant Device,4706.1,35,,4706.1,percent of total billed charges,Implant Device,4706.1,35,,4706.1,percent of total billed charges,Implant Device,4706.1,35,,4706.1,percent of total billed charges,Implant Device,4706.1,35,,4706.1,percent of total billed charges,Implant Device,5378.4,40,,5378.4,percent of total billed charges,Implant Device,4706.1,70,,4706.1,percent of total billed charges,All Other,4571.64,34,,4571.64,percent of total billed charges,Implant Device,4571.64,34,,4571.64,percent of total billed charges,Implant Device,4706.1,35,,4706.1,percent of total billed charges,Implant Device,4706.1,35,,4706.1,percent of total billed charges,Implant Device,4706.1,35,,4706.1,percent of total billed charges,Implant Device,4706.1,35,,4706.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,4571.64,34,"If Charge > 2,000, then 34 percent",4571.64,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,9950.07,
STRYKER 5630-G-429 TIBIAL INSRT SZ 4X9MM,C1776,HCPCS,,79007854,CDM,278,RC,,,both,,,3232,2391.69,,,2391.69,Other,150% of Medicare + 9.63% HCRA Surcharge,1454.4,45,,1454.4,percent of total billed charges,Critical Access Hospital RCC factor,1098.88,34,,1098.88,percent of total billed charges,Implant Device,1098.88,34,,1098.88,percent of total billed charges,Implant Device,1098.88,34,,1098.88,percent of total billed charges,Implant Device,1098.88,34,,1098.88,percent of total billed charges,Implant Device,1098.88,34,,1098.88,percent of total billed charges,Implant Device,1599.84,,,1599.84,Other,110% of Medicare,1131.2,35,,1131.2,percent of total billed charges,Implant Device,1098.88,34,"Charges > $500, x 34%",1098.88,percent of total billed charges,Implant Device,1131.2,35,,1131.2,percent of total billed charges,Implant Device,1131.2,35,,1131.2,percent of total billed charges,Implant Device,1131.2,35,,1131.2,percent of total billed charges,Implant Device,1131.2,35,,1131.2,percent of total billed charges,Implant Device,1131.2,35,,1131.2,percent of total billed charges,Implant Device,1292.8,40,,1292.8,percent of total billed charges,Implant Device,1131.2,70,,1131.2,percent of total billed charges,All Other,1098.88,34,,1098.88,percent of total billed charges,Implant Device,1098.88,34,,1098.88,percent of total billed charges,Implant Device,1131.2,35,,1131.2,percent of total billed charges,Implant Device,1131.2,35,,1131.2,percent of total billed charges,Implant Device,1131.2,35,,1131.2,percent of total billed charges,Implant Device,1131.2,35,,1131.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1098.88,34,"If Charge > 2,000, then 34 percent",1098.88,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2391.69,
STABILITY BIO SB 692 FEM HEAD ALLOGRAFT,C1713,HCPCS,,79007855,CDM,278,RC,,,both,,,4186,3097.65,,,3097.65,Other,150% of Medicare + 9.63% HCRA Surcharge,1883.7,45,,1883.7,percent of total billed charges,Critical Access Hospital RCC factor,1423.24,34,,1423.24,percent of total billed charges,Implant Device,1423.24,34,,1423.24,percent of total billed charges,Implant Device,1423.24,34,,1423.24,percent of total billed charges,Implant Device,1423.24,34,,1423.24,percent of total billed charges,Implant Device,1423.24,34,,1423.24,percent of total billed charges,Implant Device,2072.07,,,2072.07,Other,110% of Medicare,1465.1,35,,1465.1,percent of total billed charges,Implant Device,1423.24,34,"Charges > $500, x 34%",1423.24,percent of total billed charges,Implant Device,1465.1,35,,1465.1,percent of total billed charges,Implant Device,1465.1,35,,1465.1,percent of total billed charges,Implant Device,1465.1,35,,1465.1,percent of total billed charges,Implant Device,1465.1,35,,1465.1,percent of total billed charges,Implant Device,1465.1,35,,1465.1,percent of total billed charges,Implant Device,1674.4,40,,1674.4,percent of total billed charges,Implant Device,1465.1,70,,1465.1,percent of total billed charges,All Other,1423.24,34,,1423.24,percent of total billed charges,Implant Device,1423.24,34,,1423.24,percent of total billed charges,Implant Device,1465.1,35,,1465.1,percent of total billed charges,Implant Device,1465.1,35,,1465.1,percent of total billed charges,Implant Device,1465.1,35,,1465.1,percent of total billed charges,Implant Device,1465.1,35,,1465.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1423.24,34,"If Charge > 2,000, then 34 percent",1423.24,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3097.65,
STRYKER 180-0824S HUMERAL NAIL 8X240MM,C1713,HCPCS,,79007864,CDM,278,RC,,,both,,,6344,4694.58,,,4694.58,Other,150% of Medicare + 9.63% HCRA Surcharge,2854.8,45,,2854.8,percent of total billed charges,Critical Access Hospital RCC factor,2156.96,34,,2156.96,percent of total billed charges,Implant Device,2156.96,34,,2156.96,percent of total billed charges,Implant Device,2156.96,34,,2156.96,percent of total billed charges,Implant Device,2156.96,34,,2156.96,percent of total billed charges,Implant Device,2156.96,34,,2156.96,percent of total billed charges,Implant Device,3140.28,,,3140.28,Other,110% of Medicare,2220.4,35,,2220.4,percent of total billed charges,Implant Device,2156.96,34,"Charges > $500, x 34%",2156.96,percent of total billed charges,Implant Device,2220.4,35,,2220.4,percent of total billed charges,Implant Device,2220.4,35,,2220.4,percent of total billed charges,Implant Device,2220.4,35,,2220.4,percent of total billed charges,Implant Device,2220.4,35,,2220.4,percent of total billed charges,Implant Device,2220.4,35,,2220.4,percent of total billed charges,Implant Device,2537.6,40,,2537.6,percent of total billed charges,Implant Device,2220.4,70,,2220.4,percent of total billed charges,All Other,2156.96,34,,2156.96,percent of total billed charges,Implant Device,2156.96,34,,2156.96,percent of total billed charges,Implant Device,2220.4,35,,2220.4,percent of total billed charges,Implant Device,2220.4,35,,2220.4,percent of total billed charges,Implant Device,2220.4,35,,2220.4,percent of total billed charges,Implant Device,2220.4,35,,2220.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2156.96,34,"If Charge > 2,000, then 34 percent",2156.96,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4694.58,
WRIGHT CCP-N3012 LOCKING SCREW 3X12MM,C1713,HCPCS,,79007865,CDM,278,RC,,,both,,,957,708.18,,,708.18,Other,150% of Medicare + 9.63% HCRA Surcharge,430.65,45,,430.65,percent of total billed charges,Critical Access Hospital RCC factor,325.38,34,,325.38,percent of total billed charges,Implant Device,325.38,34,,325.38,percent of total billed charges,Implant Device,325.38,34,,325.38,percent of total billed charges,Implant Device,325.38,34,,325.38,percent of total billed charges,Implant Device,325.38,34,,325.38,percent of total billed charges,Implant Device,473.72,,,473.72,Other,110% of Medicare,334.95,35,,334.95,percent of total billed charges,Implant Device,325.38,34,"Charges > $500, x 34%",325.38,percent of total billed charges,Implant Device,334.95,35,,334.95,percent of total billed charges,Implant Device,334.95,35,,334.95,percent of total billed charges,Implant Device,334.95,35,,334.95,percent of total billed charges,Implant Device,334.95,35,,334.95,percent of total billed charges,Implant Device,334.95,35,,334.95,percent of total billed charges,Implant Device,382.8,40,,382.8,percent of total billed charges,Implant Device,334.95,70,,334.95,percent of total billed charges,All Other,325.38,34,,325.38,percent of total billed charges,Implant Device,325.38,34,,325.38,percent of total billed charges,Implant Device,334.95,35,,334.95,percent of total billed charges,Implant Device,334.95,35,,334.95,percent of total billed charges,Implant Device,334.95,35,,334.95,percent of total billed charges,Implant Device,334.95,35,,334.95,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,708.18,
STRYKER 6704-0-110 BEADED CABLE 1.6MM,C1713,HCPCS,,79007866,CDM,278,RC,,,both,,,2858,2114.93,,,2114.93,Other,150% of Medicare + 9.63% HCRA Surcharge,1286.1,45,,1286.1,percent of total billed charges,Critical Access Hospital RCC factor,971.72,34,,971.72,percent of total billed charges,Implant Device,971.72,34,,971.72,percent of total billed charges,Implant Device,971.72,34,,971.72,percent of total billed charges,Implant Device,971.72,34,,971.72,percent of total billed charges,Implant Device,971.72,34,,971.72,percent of total billed charges,Implant Device,1414.71,,,1414.71,Other,110% of Medicare,1000.3,35,,1000.3,percent of total billed charges,Implant Device,971.72,34,"Charges > $500, x 34%",971.72,percent of total billed charges,Implant Device,1000.3,35,,1000.3,percent of total billed charges,Implant Device,1000.3,35,,1000.3,percent of total billed charges,Implant Device,1000.3,35,,1000.3,percent of total billed charges,Implant Device,1000.3,35,,1000.3,percent of total billed charges,Implant Device,1000.3,35,,1000.3,percent of total billed charges,Implant Device,1143.2,40,,1143.2,percent of total billed charges,Implant Device,1000.3,70,,1000.3,percent of total billed charges,All Other,971.72,34,,971.72,percent of total billed charges,Implant Device,971.72,34,,971.72,percent of total billed charges,Implant Device,1000.3,35,,1000.3,percent of total billed charges,Implant Device,1000.3,35,,1000.3,percent of total billed charges,Implant Device,1000.3,35,,1000.3,percent of total billed charges,Implant Device,1000.3,35,,1000.3,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,971.72,34,"If Charge > 2,000, then 34 percent",971.72,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2114.93,
STABILITY BIOLOGICS 1005-14 FEMORAL HEAD,C1713,HCPCS,,79007867,CDM,278,RC,,,both,,,2850,2109.01,,,2109.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1282.5,45,,1282.5,percent of total billed charges,Critical Access Hospital RCC factor,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,1410.75,,,1410.75,Other,110% of Medicare,997.5,35,,997.5,percent of total billed charges,Implant Device,969,34,"Charges > $500, x 34%",969,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,1140,40,,1140,percent of total billed charges,Implant Device,997.5,70,,997.5,percent of total billed charges,All Other,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,969,34,"If Charge > 2,000, then 34 percent",969,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2109.01,
WRIGHT CCP-3528 LAG SCREW 3.5X26MM,C1713,HCPCS,,79007868,CDM,278,RC,,,both,,,1125,832.5,,,832.5,Other,150% of Medicare + 9.63% HCRA Surcharge,506.25,45,,506.25,percent of total billed charges,Critical Access Hospital RCC factor,382.5,34,,382.5,percent of total billed charges,Implant Device,382.5,34,,382.5,percent of total billed charges,Implant Device,382.5,34,,382.5,percent of total billed charges,Implant Device,382.5,34,,382.5,percent of total billed charges,Implant Device,382.5,34,,382.5,percent of total billed charges,Implant Device,556.88,,,556.88,Other,110% of Medicare,393.75,35,,393.75,percent of total billed charges,Implant Device,382.5,34,"Charges > $500, x 34%",382.5,percent of total billed charges,Implant Device,393.75,35,,393.75,percent of total billed charges,Implant Device,393.75,35,,393.75,percent of total billed charges,Implant Device,393.75,35,,393.75,percent of total billed charges,Implant Device,393.75,35,,393.75,percent of total billed charges,Implant Device,393.75,35,,393.75,percent of total billed charges,Implant Device,450,40,,450,percent of total billed charges,Implant Device,393.75,70,,393.75,percent of total billed charges,All Other,382.5,34,,382.5,percent of total billed charges,Implant Device,382.5,34,,382.5,percent of total billed charges,Implant Device,393.75,35,,393.75,percent of total billed charges,Implant Device,393.75,35,,393.75,percent of total billed charges,Implant Device,393.75,35,,393.75,percent of total billed charges,Implant Device,393.75,35,,393.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,832.5,
SYNTHES 201.816 2.0 CORTEX SCREW 10MM,C1713,HCPCS,,79007869,CDM,278,RC,,,both,,,83,61.42,,,61.42,Other,150% of Medicare + 9.63% HCRA Surcharge,37.35,45,,37.35,percent of total billed charges,Critical Access Hospital RCC factor,28.22,34,,28.22,percent of total billed charges,Implant Device,28.22,34,,28.22,percent of total billed charges,Implant Device,28.22,34,,28.22,percent of total billed charges,Implant Device,28.22,34,,28.22,percent of total billed charges,Implant Device,28.22,34,,28.22,percent of total billed charges,Implant Device,41.09,,,41.09,Other,110% of Medicare,29.05,35,,29.05,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,29.05,35,,29.05,percent of total billed charges,Implant Device,29.05,35,,29.05,percent of total billed charges,Implant Device,29.05,35,,29.05,percent of total billed charges,Implant Device,29.05,35,,29.05,percent of total billed charges,Implant Device,29.05,35,,29.05,percent of total billed charges,Implant Device,33.2,40,,33.2,percent of total billed charges,Implant Device,29.05,70,,29.05,percent of total billed charges,All Other,28.22,34,,28.22,percent of total billed charges,Implant Device,28.22,34,,28.22,percent of total billed charges,Implant Device,29.05,35,,29.05,percent of total billed charges,Implant Device,29.05,35,,29.05,percent of total billed charges,Implant Device,29.05,35,,29.05,percent of total billed charges,Implant Device,29.05,35,,29.05,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,61.42,
MAQUET PPBF1015 VITAMESH BLUE 4X6,C1781,HCPCS,,79007870,CDM,278,RC,,,both,,,166,122.84,,,122.84,Other,150% of Medicare + 9.63% HCRA Surcharge,74.7,45,,74.7,percent of total billed charges,Critical Access Hospital RCC factor,56.44,34,,56.44,percent of total billed charges,Implant Device,56.44,34,,56.44,percent of total billed charges,Implant Device,56.44,34,,56.44,percent of total billed charges,Implant Device,56.44,34,,56.44,percent of total billed charges,Implant Device,56.44,34,,56.44,percent of total billed charges,Implant Device,82.17,,,82.17,Other,110% of Medicare,58.1,35,,58.1,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,58.1,35,,58.1,percent of total billed charges,Implant Device,58.1,35,,58.1,percent of total billed charges,Implant Device,58.1,35,,58.1,percent of total billed charges,Implant Device,58.1,35,,58.1,percent of total billed charges,Implant Device,58.1,35,,58.1,percent of total billed charges,Implant Device,66.4,40,,66.4,percent of total billed charges,Implant Device,58.1,70,,58.1,percent of total billed charges,All Other,56.44,34,,56.44,percent of total billed charges,Implant Device,56.44,34,,56.44,percent of total billed charges,Implant Device,58.1,35,,58.1,percent of total billed charges,Implant Device,58.1,35,,58.1,percent of total billed charges,Implant Device,58.1,35,,58.1,percent of total billed charges,Implant Device,58.1,35,,58.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,122.84,
MEDTRONIC CMRM6133US-S ICD ANTIBAC ENVLP,C1781,HCPCS,,79007872,CDM,278,RC,,,both,,,2986,2209.65,,,2209.65,Other,150% of Medicare + 9.63% HCRA Surcharge,1343.7,45,,1343.7,percent of total billed charges,Critical Access Hospital RCC factor,1015.24,34,,1015.24,percent of total billed charges,Implant Device,1015.24,34,,1015.24,percent of total billed charges,Implant Device,1015.24,34,,1015.24,percent of total billed charges,Implant Device,1015.24,34,,1015.24,percent of total billed charges,Implant Device,1015.24,34,,1015.24,percent of total billed charges,Implant Device,1478.07,,,1478.07,Other,110% of Medicare,1045.1,35,,1045.1,percent of total billed charges,Implant Device,1015.24,34,"Charges > $500, x 34%",1015.24,percent of total billed charges,Implant Device,1045.1,35,,1045.1,percent of total billed charges,Implant Device,1045.1,35,,1045.1,percent of total billed charges,Implant Device,1045.1,35,,1045.1,percent of total billed charges,Implant Device,1045.1,35,,1045.1,percent of total billed charges,Implant Device,1045.1,35,,1045.1,percent of total billed charges,Implant Device,1194.4,40,,1194.4,percent of total billed charges,Implant Device,1045.1,70,,1045.1,percent of total billed charges,All Other,1015.24,34,,1015.24,percent of total billed charges,Implant Device,1015.24,34,,1015.24,percent of total billed charges,Implant Device,1045.1,35,,1045.1,percent of total billed charges,Implant Device,1045.1,35,,1045.1,percent of total billed charges,Implant Device,1045.1,35,,1045.1,percent of total billed charges,Implant Device,1045.1,35,,1045.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1015.24,34,"If Charge > 2,000, then 34 percent",1015.24,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2209.65,
DEPUY 02.111.631 DIST RAD PLATE 2.4MM 6H,C1713,HCPCS,,79007873,CDM,278,RC,,,both,,,2323,1719.03,,,1719.03,Other,150% of Medicare + 9.63% HCRA Surcharge,1045.35,45,,1045.35,percent of total billed charges,Critical Access Hospital RCC factor,789.82,34,,789.82,percent of total billed charges,Implant Device,789.82,34,,789.82,percent of total billed charges,Implant Device,789.82,34,,789.82,percent of total billed charges,Implant Device,789.82,34,,789.82,percent of total billed charges,Implant Device,789.82,34,,789.82,percent of total billed charges,Implant Device,1149.89,,,1149.89,Other,110% of Medicare,813.05,35,,813.05,percent of total billed charges,Implant Device,789.82,34,"Charges > $500, x 34%",789.82,percent of total billed charges,Implant Device,813.05,35,,813.05,percent of total billed charges,Implant Device,813.05,35,,813.05,percent of total billed charges,Implant Device,813.05,35,,813.05,percent of total billed charges,Implant Device,813.05,35,,813.05,percent of total billed charges,Implant Device,813.05,35,,813.05,percent of total billed charges,Implant Device,929.2,40,,929.2,percent of total billed charges,Implant Device,813.05,70,,813.05,percent of total billed charges,All Other,789.82,34,,789.82,percent of total billed charges,Implant Device,789.82,34,,789.82,percent of total billed charges,Implant Device,813.05,35,,813.05,percent of total billed charges,Implant Device,813.05,35,,813.05,percent of total billed charges,Implant Device,813.05,35,,813.05,percent of total billed charges,Implant Device,813.05,35,,813.05,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,789.82,34,"If Charge > 2,000, then 34 percent",789.82,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1719.03,
PARAGON 28 P20-155-065S SCREW 5.5X65MM,C1713,HCPCS,,79007874,CDM,278,RC,,,both,,,1236,914.64,,,914.64,Other,150% of Medicare + 9.63% HCRA Surcharge,556.2,45,,556.2,percent of total billed charges,Critical Access Hospital RCC factor,420.24,34,,420.24,percent of total billed charges,Implant Device,420.24,34,,420.24,percent of total billed charges,Implant Device,420.24,34,,420.24,percent of total billed charges,Implant Device,420.24,34,,420.24,percent of total billed charges,Implant Device,420.24,34,,420.24,percent of total billed charges,Implant Device,611.82,,,611.82,Other,110% of Medicare,432.6,35,,432.6,percent of total billed charges,Implant Device,420.24,34,"Charges > $500, x 34%",420.24,percent of total billed charges,Implant Device,432.6,35,,432.6,percent of total billed charges,Implant Device,432.6,35,,432.6,percent of total billed charges,Implant Device,432.6,35,,432.6,percent of total billed charges,Implant Device,432.6,35,,432.6,percent of total billed charges,Implant Device,432.6,35,,432.6,percent of total billed charges,Implant Device,494.4,40,,494.4,percent of total billed charges,Implant Device,432.6,70,,432.6,percent of total billed charges,All Other,420.24,34,,420.24,percent of total billed charges,Implant Device,420.24,34,,420.24,percent of total billed charges,Implant Device,432.6,35,,432.6,percent of total billed charges,Implant Device,432.6,35,,432.6,percent of total billed charges,Implant Device,432.6,35,,432.6,percent of total billed charges,Implant Device,432.6,35,,432.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,914.64,
PARAGON 28 P20-170-076F SCREW 7.0X76MM,C1713,HCPCS,,79007875,CDM,278,RC,,,both,,,1697,1255.78,,,1255.78,Other,150% of Medicare + 9.63% HCRA Surcharge,763.65,45,,763.65,percent of total billed charges,Critical Access Hospital RCC factor,576.98,34,,576.98,percent of total billed charges,Implant Device,576.98,34,,576.98,percent of total billed charges,Implant Device,576.98,34,,576.98,percent of total billed charges,Implant Device,576.98,34,,576.98,percent of total billed charges,Implant Device,576.98,34,,576.98,percent of total billed charges,Implant Device,840.02,,,840.02,Other,110% of Medicare,593.95,35,,593.95,percent of total billed charges,Implant Device,576.98,34,"Charges > $500, x 34%",576.98,percent of total billed charges,Implant Device,593.95,35,,593.95,percent of total billed charges,Implant Device,593.95,35,,593.95,percent of total billed charges,Implant Device,593.95,35,,593.95,percent of total billed charges,Implant Device,593.95,35,,593.95,percent of total billed charges,Implant Device,593.95,35,,593.95,percent of total billed charges,Implant Device,678.8,40,,678.8,percent of total billed charges,Implant Device,593.95,70,,593.95,percent of total billed charges,All Other,576.98,34,,576.98,percent of total billed charges,Implant Device,576.98,34,,576.98,percent of total billed charges,Implant Device,593.95,35,,593.95,percent of total billed charges,Implant Device,593.95,35,,593.95,percent of total billed charges,Implant Device,593.95,35,,593.95,percent of total billed charges,Implant Device,593.95,35,,593.95,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1255.78,
PARAGON 28 PSBT-1608 ARTHROD WEDGE 16MM,C1713,HCPCS,,79007876,CDM,278,RC,,,both,,,8520,6304.82,,,6304.82,Other,150% of Medicare + 9.63% HCRA Surcharge,3834,45,,3834,percent of total billed charges,Critical Access Hospital RCC factor,2896.8,34,,2896.8,percent of total billed charges,Implant Device,2896.8,34,,2896.8,percent of total billed charges,Implant Device,2896.8,34,,2896.8,percent of total billed charges,Implant Device,2896.8,34,,2896.8,percent of total billed charges,Implant Device,2896.8,34,,2896.8,percent of total billed charges,Implant Device,4217.4,,,4217.4,Other,110% of Medicare,2982,35,,2982,percent of total billed charges,Implant Device,2896.8,34,"Charges > $500, x 34%",2896.8,percent of total billed charges,Implant Device,2982,35,,2982,percent of total billed charges,Implant Device,2982,35,,2982,percent of total billed charges,Implant Device,2982,35,,2982,percent of total billed charges,Implant Device,2982,35,,2982,percent of total billed charges,Implant Device,2982,35,,2982,percent of total billed charges,Implant Device,3408,40,,3408,percent of total billed charges,Implant Device,2982,70,,2982,percent of total billed charges,All Other,2896.8,34,,2896.8,percent of total billed charges,Implant Device,2896.8,34,,2896.8,percent of total billed charges,Implant Device,2982,35,,2982,percent of total billed charges,Implant Device,2982,35,,2982,percent of total billed charges,Implant Device,2982,35,,2982,percent of total billed charges,Implant Device,2982,35,,2982,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2896.8,34,"If Charge > 2,000, then 34 percent",2896.8,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,6304.82,
ARTHREX AR-8724-16 SCREW 2.4X16MM,C1713,HCPCS,,79007877,CDM,278,RC,,,both,,,474,350.76,,,350.76,Other,150% of Medicare + 9.63% HCRA Surcharge,213.3,45,,213.3,percent of total billed charges,Critical Access Hospital RCC factor,161.16,34,,161.16,percent of total billed charges,Implant Device,161.16,34,,161.16,percent of total billed charges,Implant Device,161.16,34,,161.16,percent of total billed charges,Implant Device,161.16,34,,161.16,percent of total billed charges,Implant Device,161.16,34,,161.16,percent of total billed charges,Implant Device,234.63,,,234.63,Other,110% of Medicare,165.9,35,,165.9,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,165.9,35,,165.9,percent of total billed charges,Implant Device,165.9,35,,165.9,percent of total billed charges,Implant Device,165.9,35,,165.9,percent of total billed charges,Implant Device,165.9,35,,165.9,percent of total billed charges,Implant Device,165.9,35,,165.9,percent of total billed charges,Implant Device,189.6,40,,189.6,percent of total billed charges,Implant Device,165.9,70,,165.9,percent of total billed charges,All Other,161.16,34,,161.16,percent of total billed charges,Implant Device,161.16,34,,161.16,percent of total billed charges,Implant Device,165.9,35,,165.9,percent of total billed charges,Implant Device,165.9,35,,165.9,percent of total billed charges,Implant Device,165.9,35,,165.9,percent of total billed charges,Implant Device,165.9,35,,165.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,350.76,
STRYKER 614730 2.7X30MM BONE SCREW,C1713,HCPCS,,79007881,CDM,278,RC,,,both,,,375,277.5,,,277.5,Other,150% of Medicare + 9.63% HCRA Surcharge,168.75,45,,168.75,percent of total billed charges,Critical Access Hospital RCC factor,127.5,34,,127.5,percent of total billed charges,Implant Device,127.5,34,,127.5,percent of total billed charges,Implant Device,127.5,34,,127.5,percent of total billed charges,Implant Device,127.5,34,,127.5,percent of total billed charges,Implant Device,127.5,34,,127.5,percent of total billed charges,Implant Device,185.63,,,185.63,Other,110% of Medicare,131.25,35,,131.25,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,131.25,35,,131.25,percent of total billed charges,Implant Device,131.25,35,,131.25,percent of total billed charges,Implant Device,131.25,35,,131.25,percent of total billed charges,Implant Device,131.25,35,,131.25,percent of total billed charges,Implant Device,131.25,35,,131.25,percent of total billed charges,Implant Device,150,40,,150,percent of total billed charges,Implant Device,131.25,70,,131.25,percent of total billed charges,All Other,127.5,34,,127.5,percent of total billed charges,Implant Device,127.5,34,,127.5,percent of total billed charges,Implant Device,131.25,35,,131.25,percent of total billed charges,Implant Device,131.25,35,,131.25,percent of total billed charges,Implant Device,131.25,35,,131.25,percent of total billed charges,Implant Device,131.25,35,,131.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,277.5,
STRYKER 614750 2.7X50MM BONE SCREW,C1713,HCPCS,,79007882,CDM,278,RC,,,both,,,375,277.5,,,277.5,Other,150% of Medicare + 9.63% HCRA Surcharge,168.75,45,,168.75,percent of total billed charges,Critical Access Hospital RCC factor,127.5,34,,127.5,percent of total billed charges,Implant Device,127.5,34,,127.5,percent of total billed charges,Implant Device,127.5,34,,127.5,percent of total billed charges,Implant Device,127.5,34,,127.5,percent of total billed charges,Implant Device,127.5,34,,127.5,percent of total billed charges,Implant Device,185.63,,,185.63,Other,110% of Medicare,131.25,35,,131.25,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,131.25,35,,131.25,percent of total billed charges,Implant Device,131.25,35,,131.25,percent of total billed charges,Implant Device,131.25,35,,131.25,percent of total billed charges,Implant Device,131.25,35,,131.25,percent of total billed charges,Implant Device,131.25,35,,131.25,percent of total billed charges,Implant Device,150,40,,150,percent of total billed charges,Implant Device,131.25,70,,131.25,percent of total billed charges,All Other,127.5,34,,127.5,percent of total billed charges,Implant Device,127.5,34,,127.5,percent of total billed charges,Implant Device,131.25,35,,131.25,percent of total billed charges,Implant Device,131.25,35,,131.25,percent of total billed charges,Implant Device,131.25,35,,131.25,percent of total billed charges,Implant Device,131.25,35,,131.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,277.5,
STRYKER 629224 4 HOLE LATERAL PLATE,C1713,HCPCS,,79007883,CDM,278,RC,,,both,,,4281,3167.95,,,3167.95,Other,150% of Medicare + 9.63% HCRA Surcharge,1926.45,45,,1926.45,percent of total billed charges,Critical Access Hospital RCC factor,1455.54,34,,1455.54,percent of total billed charges,Implant Device,1455.54,34,,1455.54,percent of total billed charges,Implant Device,1455.54,34,,1455.54,percent of total billed charges,Implant Device,1455.54,34,,1455.54,percent of total billed charges,Implant Device,1455.54,34,,1455.54,percent of total billed charges,Implant Device,2119.1,,,2119.1,Other,110% of Medicare,1498.35,35,,1498.35,percent of total billed charges,Implant Device,1455.54,34,"Charges > $500, x 34%",1455.54,percent of total billed charges,Implant Device,1498.35,35,,1498.35,percent of total billed charges,Implant Device,1498.35,35,,1498.35,percent of total billed charges,Implant Device,1498.35,35,,1498.35,percent of total billed charges,Implant Device,1498.35,35,,1498.35,percent of total billed charges,Implant Device,1498.35,35,,1498.35,percent of total billed charges,Implant Device,1712.4,40,,1712.4,percent of total billed charges,Implant Device,1498.35,70,,1498.35,percent of total billed charges,All Other,1455.54,34,,1455.54,percent of total billed charges,Implant Device,1455.54,34,,1455.54,percent of total billed charges,Implant Device,1498.35,35,,1498.35,percent of total billed charges,Implant Device,1498.35,35,,1498.35,percent of total billed charges,Implant Device,1498.35,35,,1498.35,percent of total billed charges,Implant Device,1498.35,35,,1498.35,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1455.54,34,"If Charge > 2,000, then 34 percent",1455.54,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3167.95,
STRYKER 614738 2.7X38MM BONE SCREW,C1713,HCPCS,,79007884,CDM,278,RC,,,both,,,375,277.5,,,277.5,Other,150% of Medicare + 9.63% HCRA Surcharge,168.75,45,,168.75,percent of total billed charges,Critical Access Hospital RCC factor,127.5,34,,127.5,percent of total billed charges,Implant Device,127.5,34,,127.5,percent of total billed charges,Implant Device,127.5,34,,127.5,percent of total billed charges,Implant Device,127.5,34,,127.5,percent of total billed charges,Implant Device,127.5,34,,127.5,percent of total billed charges,Implant Device,185.63,,,185.63,Other,110% of Medicare,131.25,35,,131.25,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,131.25,35,,131.25,percent of total billed charges,Implant Device,131.25,35,,131.25,percent of total billed charges,Implant Device,131.25,35,,131.25,percent of total billed charges,Implant Device,131.25,35,,131.25,percent of total billed charges,Implant Device,131.25,35,,131.25,percent of total billed charges,Implant Device,150,40,,150,percent of total billed charges,Implant Device,131.25,70,,131.25,percent of total billed charges,All Other,127.5,34,,127.5,percent of total billed charges,Implant Device,127.5,34,,127.5,percent of total billed charges,Implant Device,131.25,35,,131.25,percent of total billed charges,Implant Device,131.25,35,,131.25,percent of total billed charges,Implant Device,131.25,35,,131.25,percent of total billed charges,Implant Device,131.25,35,,131.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,277.5,
STRYKER 629384 4 HOLE MEDIVAL PLATE,C1713,HCPCS,,79007885,CDM,278,RC,,,both,,,2804,2074.97,,,2074.97,Other,150% of Medicare + 9.63% HCRA Surcharge,1261.8,45,,1261.8,percent of total billed charges,Critical Access Hospital RCC factor,953.36,34,,953.36,percent of total billed charges,Implant Device,953.36,34,,953.36,percent of total billed charges,Implant Device,953.36,34,,953.36,percent of total billed charges,Implant Device,953.36,34,,953.36,percent of total billed charges,Implant Device,953.36,34,,953.36,percent of total billed charges,Implant Device,1387.98,,,1387.98,Other,110% of Medicare,981.4,35,,981.4,percent of total billed charges,Implant Device,953.36,34,"Charges > $500, x 34%",953.36,percent of total billed charges,Implant Device,981.4,35,,981.4,percent of total billed charges,Implant Device,981.4,35,,981.4,percent of total billed charges,Implant Device,981.4,35,,981.4,percent of total billed charges,Implant Device,981.4,35,,981.4,percent of total billed charges,Implant Device,981.4,35,,981.4,percent of total billed charges,Implant Device,1121.6,40,,1121.6,percent of total billed charges,Implant Device,981.4,70,,981.4,percent of total billed charges,All Other,953.36,34,,953.36,percent of total billed charges,Implant Device,953.36,34,,953.36,percent of total billed charges,Implant Device,981.4,35,,981.4,percent of total billed charges,Implant Device,981.4,35,,981.4,percent of total billed charges,Implant Device,981.4,35,,981.4,percent of total billed charges,Implant Device,981.4,35,,981.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,953.36,34,"If Charge > 2,000, then 34 percent",953.36,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2074.97,
STRYKER 614522 2.7X22MM LOCK SCREW,C1713,HCPCS,,79007886,CDM,278,RC,,,both,,,727,537.98,,,537.98,Other,150% of Medicare + 9.63% HCRA Surcharge,327.15,45,,327.15,percent of total billed charges,Critical Access Hospital RCC factor,247.18,34,,247.18,percent of total billed charges,Implant Device,247.18,34,,247.18,percent of total billed charges,Implant Device,247.18,34,,247.18,percent of total billed charges,Implant Device,247.18,34,,247.18,percent of total billed charges,Implant Device,247.18,34,,247.18,percent of total billed charges,Implant Device,359.87,,,359.87,Other,110% of Medicare,254.45,35,,254.45,percent of total billed charges,Implant Device,247.18,34,"Charges > $500, x 34%",247.18,percent of total billed charges,Implant Device,254.45,35,,254.45,percent of total billed charges,Implant Device,254.45,35,,254.45,percent of total billed charges,Implant Device,254.45,35,,254.45,percent of total billed charges,Implant Device,254.45,35,,254.45,percent of total billed charges,Implant Device,254.45,35,,254.45,percent of total billed charges,Implant Device,290.8,40,,290.8,percent of total billed charges,Implant Device,254.45,70,,254.45,percent of total billed charges,All Other,247.18,34,,247.18,percent of total billed charges,Implant Device,247.18,34,,247.18,percent of total billed charges,Implant Device,254.45,35,,254.45,percent of total billed charges,Implant Device,254.45,35,,254.45,percent of total billed charges,Implant Device,254.45,35,,254.45,percent of total billed charges,Implant Device,254.45,35,,254.45,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,537.98,
STRYKER 614830 3.5X30MM BONE SCREW,C1713,HCPCS,,79007887,CDM,278,RC,,,both,,,375,277.5,,,277.5,Other,150% of Medicare + 9.63% HCRA Surcharge,168.75,45,,168.75,percent of total billed charges,Critical Access Hospital RCC factor,127.5,34,,127.5,percent of total billed charges,Implant Device,127.5,34,,127.5,percent of total billed charges,Implant Device,127.5,34,,127.5,percent of total billed charges,Implant Device,127.5,34,,127.5,percent of total billed charges,Implant Device,127.5,34,,127.5,percent of total billed charges,Implant Device,185.63,,,185.63,Other,110% of Medicare,131.25,35,,131.25,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,131.25,35,,131.25,percent of total billed charges,Implant Device,131.25,35,,131.25,percent of total billed charges,Implant Device,131.25,35,,131.25,percent of total billed charges,Implant Device,131.25,35,,131.25,percent of total billed charges,Implant Device,131.25,35,,131.25,percent of total billed charges,Implant Device,150,40,,150,percent of total billed charges,Implant Device,131.25,70,,131.25,percent of total billed charges,All Other,127.5,34,,127.5,percent of total billed charges,Implant Device,127.5,34,,127.5,percent of total billed charges,Implant Device,131.25,35,,131.25,percent of total billed charges,Implant Device,131.25,35,,131.25,percent of total billed charges,Implant Device,131.25,35,,131.25,percent of total billed charges,Implant Device,131.25,35,,131.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,277.5,
STRYKER 614760 2.7X60MM BONE SCREW,C1713,HCPCS,,79007888,CDM,278,RC,,,both,,,375,277.5,,,277.5,Other,150% of Medicare + 9.63% HCRA Surcharge,168.75,45,,168.75,percent of total billed charges,Critical Access Hospital RCC factor,127.5,34,,127.5,percent of total billed charges,Implant Device,127.5,34,,127.5,percent of total billed charges,Implant Device,127.5,34,,127.5,percent of total billed charges,Implant Device,127.5,34,,127.5,percent of total billed charges,Implant Device,127.5,34,,127.5,percent of total billed charges,Implant Device,185.63,,,185.63,Other,110% of Medicare,131.25,35,,131.25,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,131.25,35,,131.25,percent of total billed charges,Implant Device,131.25,35,,131.25,percent of total billed charges,Implant Device,131.25,35,,131.25,percent of total billed charges,Implant Device,131.25,35,,131.25,percent of total billed charges,Implant Device,131.25,35,,131.25,percent of total billed charges,Implant Device,150,40,,150,percent of total billed charges,Implant Device,131.25,70,,131.25,percent of total billed charges,All Other,127.5,34,,127.5,percent of total billed charges,Implant Device,127.5,34,,127.5,percent of total billed charges,Implant Device,131.25,35,,131.25,percent of total billed charges,Implant Device,131.25,35,,131.25,percent of total billed charges,Implant Device,131.25,35,,131.25,percent of total billed charges,Implant Device,131.25,35,,131.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,277.5,
STRYKER 614832 3.5X32MM BONE SCREW,C1713,HCPCS,,79007889,CDM,278,RC,,,both,,,390,288.6,,,288.6,Other,150% of Medicare + 9.63% HCRA Surcharge,175.5,45,,175.5,percent of total billed charges,Critical Access Hospital RCC factor,132.6,34,,132.6,percent of total billed charges,Implant Device,132.6,34,,132.6,percent of total billed charges,Implant Device,132.6,34,,132.6,percent of total billed charges,Implant Device,132.6,34,,132.6,percent of total billed charges,Implant Device,132.6,34,,132.6,percent of total billed charges,Implant Device,193.05,,,193.05,Other,110% of Medicare,136.5,35,,136.5,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,136.5,35,,136.5,percent of total billed charges,Implant Device,136.5,35,,136.5,percent of total billed charges,Implant Device,136.5,35,,136.5,percent of total billed charges,Implant Device,136.5,35,,136.5,percent of total billed charges,Implant Device,136.5,35,,136.5,percent of total billed charges,Implant Device,156,40,,156,percent of total billed charges,Implant Device,136.5,70,,136.5,percent of total billed charges,All Other,132.6,34,,132.6,percent of total billed charges,Implant Device,132.6,34,,132.6,percent of total billed charges,Implant Device,136.5,35,,136.5,percent of total billed charges,Implant Device,136.5,35,,136.5,percent of total billed charges,Implant Device,136.5,35,,136.5,percent of total billed charges,Implant Device,136.5,35,,136.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,288.6,
ALLERGAN LM-410320 SILICONE IMPLANT,C1789,HCPCS,,79007890,CDM,278,RC,,,both,,,3976,2942.25,,,2942.25,Other,150% of Medicare + 9.63% HCRA Surcharge,1789.2,45,,1789.2,percent of total billed charges,Critical Access Hospital RCC factor,1351.84,34,,1351.84,percent of total billed charges,Implant Device,1351.84,34,,1351.84,percent of total billed charges,Implant Device,1351.84,34,,1351.84,percent of total billed charges,Implant Device,1351.84,34,,1351.84,percent of total billed charges,Implant Device,1351.84,34,,1351.84,percent of total billed charges,Implant Device,1968.12,,,1968.12,Other,110% of Medicare,1391.6,35,,1391.6,percent of total billed charges,Implant Device,1351.84,34,"Charges > $500, x 34%",1351.84,percent of total billed charges,Implant Device,1391.6,35,,1391.6,percent of total billed charges,Implant Device,1391.6,35,,1391.6,percent of total billed charges,Implant Device,1391.6,35,,1391.6,percent of total billed charges,Implant Device,1391.6,35,,1391.6,percent of total billed charges,Implant Device,1391.6,35,,1391.6,percent of total billed charges,Implant Device,1590.4,40,,1590.4,percent of total billed charges,Implant Device,1391.6,70,,1391.6,percent of total billed charges,All Other,1351.84,34,,1351.84,percent of total billed charges,Implant Device,1351.84,34,,1351.84,percent of total billed charges,Implant Device,1391.6,35,,1391.6,percent of total billed charges,Implant Device,1391.6,35,,1391.6,percent of total billed charges,Implant Device,1391.6,35,,1391.6,percent of total billed charges,Implant Device,1391.6,35,,1391.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1351.84,34,"If Charge > 2,000, then 34 percent",1351.84,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2942.25,
LIFE CELL CL1520P ALLODERM PREFORATED,Q4116,HCPCS,,79007892,CDM,278,RC,,,both,,,21996,16277.09,,,16277.09,Other,150% of Medicare + 9.63% HCRA Surcharge,9898.2,45,,9898.2,percent of total billed charges,Critical Access Hospital RCC factor,7478.64,34,,7478.64,percent of total billed charges,Implant Device,7478.64,34,,7478.64,percent of total billed charges,Implant Device,7478.64,34,,7478.64,percent of total billed charges,Implant Device,7478.64,34,,7478.64,percent of total billed charges,Implant Device,7478.64,34,,7478.64,percent of total billed charges,Implant Device,10888.02,,,10888.02,Other,110% of Medicare,7698.6,35,,7698.6,percent of total billed charges,Implant Device,7478.64,34,"Charges > $500, x 34%",7478.64,percent of total billed charges,Implant Device,7698.6,35,,7698.6,percent of total billed charges,Implant Device,7698.6,35,,7698.6,percent of total billed charges,Implant Device,7698.6,35,,7698.6,percent of total billed charges,Implant Device,7698.6,35,,7698.6,percent of total billed charges,Implant Device,7698.6,35,,7698.6,percent of total billed charges,Implant Device,8798.4,40,,8798.4,percent of total billed charges,Implant Device,7698.6,70,,7698.6,percent of total billed charges,All Other,7478.64,34,,7478.64,percent of total billed charges,Implant Device,7478.64,34,,7478.64,percent of total billed charges,Implant Device,7698.6,35,,7698.6,percent of total billed charges,Implant Device,7698.6,35,,7698.6,percent of total billed charges,Implant Device,7698.6,35,,7698.6,percent of total billed charges,Implant Device,7698.6,35,,7698.6,percent of total billed charges,Implant Device,976.07,,,976.07,Other,100% of Medicaid,976.07,,,976.07,Other,100% of Medicaid,976.07,,,976.07,Other,100% of Medicaid,976.07,,,976.07,Other,100% of Medicaid,2196.15,,,2196.15,Other,225% of Medicaid,1493.38,,,1493.38,Other,153% of Medicaid,2196.15,,,2196.15,Other,225% of Medicaid,1366.49,,,1366.49,Other,140% of Medicaid,7478.64,34,"If Charge > 2,000, then 34 percent",7478.64,percent of total billed charges,Implants,2537.77,,,2537.77,Other,260% of Medicaid,3162.45,,,3162.45,Other,324% of Medicaid,2098.54,,,2098.54,Other,215% of Medicaid,2098.54,,,2098.54,Other,215% of Medicaid,1220.08,,,1220.08,Other,125% of Medicaid,976.07,16277.09,
STRYKER 0194-2000S FLEXIBLE NAIL 2.0MM,C1713,HCPCS,,79007893,CDM,278,RC,,,both,,,1089,805.86,,,805.86,Other,150% of Medicare + 9.63% HCRA Surcharge,490.05,45,,490.05,percent of total billed charges,Critical Access Hospital RCC factor,370.26,34,,370.26,percent of total billed charges,Implant Device,370.26,34,,370.26,percent of total billed charges,Implant Device,370.26,34,,370.26,percent of total billed charges,Implant Device,370.26,34,,370.26,percent of total billed charges,Implant Device,370.26,34,,370.26,percent of total billed charges,Implant Device,539.06,,,539.06,Other,110% of Medicare,381.15,35,,381.15,percent of total billed charges,Implant Device,370.26,34,"Charges > $500, x 34%",370.26,percent of total billed charges,Implant Device,381.15,35,,381.15,percent of total billed charges,Implant Device,381.15,35,,381.15,percent of total billed charges,Implant Device,381.15,35,,381.15,percent of total billed charges,Implant Device,381.15,35,,381.15,percent of total billed charges,Implant Device,381.15,35,,381.15,percent of total billed charges,Implant Device,435.6,40,,435.6,percent of total billed charges,Implant Device,381.15,70,,381.15,percent of total billed charges,All Other,370.26,34,,370.26,percent of total billed charges,Implant Device,370.26,34,,370.26,percent of total billed charges,Implant Device,381.15,35,,381.15,percent of total billed charges,Implant Device,381.15,35,,381.15,percent of total billed charges,Implant Device,381.15,35,,381.15,percent of total billed charges,Implant Device,381.15,35,,381.15,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,805.86,
STRYKER 53-05216 DOG BONE PLATE,C1713,HCPCS,,79007894,CDM,278,RC,,,both,,,409,302.66,,,302.66,Other,150% of Medicare + 9.63% HCRA Surcharge,184.05,45,,184.05,percent of total billed charges,Critical Access Hospital RCC factor,139.06,34,,139.06,percent of total billed charges,Implant Device,139.06,34,,139.06,percent of total billed charges,Implant Device,139.06,34,,139.06,percent of total billed charges,Implant Device,139.06,34,,139.06,percent of total billed charges,Implant Device,139.06,34,,139.06,percent of total billed charges,Implant Device,202.46,,,202.46,Other,110% of Medicare,143.15,35,,143.15,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,143.15,35,,143.15,percent of total billed charges,Implant Device,143.15,35,,143.15,percent of total billed charges,Implant Device,143.15,35,,143.15,percent of total billed charges,Implant Device,143.15,35,,143.15,percent of total billed charges,Implant Device,143.15,35,,143.15,percent of total billed charges,Implant Device,163.6,40,,163.6,percent of total billed charges,Implant Device,143.15,70,,143.15,percent of total billed charges,All Other,139.06,34,,139.06,percent of total billed charges,Implant Device,139.06,34,,139.06,percent of total billed charges,Implant Device,143.15,35,,143.15,percent of total billed charges,Implant Device,143.15,35,,143.15,percent of total billed charges,Implant Device,143.15,35,,143.15,percent of total billed charges,Implant Device,143.15,35,,143.15,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,302.66,
STRYKER 53-05228 SQUARE PLATE 4 HOLE,C1713,HCPCS,,79007895,CDM,278,RC,,,both,,,511,378.14,,,378.14,Other,150% of Medicare + 9.63% HCRA Surcharge,229.95,45,,229.95,percent of total billed charges,Critical Access Hospital RCC factor,173.74,34,,173.74,percent of total billed charges,Implant Device,173.74,34,,173.74,percent of total billed charges,Implant Device,173.74,34,,173.74,percent of total billed charges,Implant Device,173.74,34,,173.74,percent of total billed charges,Implant Device,173.74,34,,173.74,percent of total billed charges,Implant Device,252.95,,,252.95,Other,110% of Medicare,178.85,35,,178.85,percent of total billed charges,Implant Device,173.74,34,"Charges > $500, x 34%",173.74,percent of total billed charges,Implant Device,178.85,35,,178.85,percent of total billed charges,Implant Device,178.85,35,,178.85,percent of total billed charges,Implant Device,178.85,35,,178.85,percent of total billed charges,Implant Device,178.85,35,,178.85,percent of total billed charges,Implant Device,178.85,35,,178.85,percent of total billed charges,Implant Device,204.4,40,,204.4,percent of total billed charges,Implant Device,178.85,70,,178.85,percent of total billed charges,All Other,173.74,34,,173.74,percent of total billed charges,Implant Device,173.74,34,,173.74,percent of total billed charges,Implant Device,178.85,35,,178.85,percent of total billed charges,Implant Device,178.85,35,,178.85,percent of total billed charges,Implant Device,178.85,35,,178.85,percent of total billed charges,Implant Device,178.85,35,,178.85,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,378.14,
DEPUY 3L92502 FEMORAL STEM STD SZ 12,C1776,HCPCS,,79007906,CDM,278,RC,,,both,,,13446,9950.07,,,9950.07,Other,150% of Medicare + 9.63% HCRA Surcharge,6050.7,45,,6050.7,percent of total billed charges,Critical Access Hospital RCC factor,4571.64,34,,4571.64,percent of total billed charges,Implant Device,4571.64,34,,4571.64,percent of total billed charges,Implant Device,4571.64,34,,4571.64,percent of total billed charges,Implant Device,4571.64,34,,4571.64,percent of total billed charges,Implant Device,4571.64,34,,4571.64,percent of total billed charges,Implant Device,6655.77,,,6655.77,Other,110% of Medicare,4706.1,35,,4706.1,percent of total billed charges,Implant Device,4571.64,34,"Charges > $500, x 34%",4571.64,percent of total billed charges,Implant Device,4706.1,35,,4706.1,percent of total billed charges,Implant Device,4706.1,35,,4706.1,percent of total billed charges,Implant Device,4706.1,35,,4706.1,percent of total billed charges,Implant Device,4706.1,35,,4706.1,percent of total billed charges,Implant Device,4706.1,35,,4706.1,percent of total billed charges,Implant Device,5378.4,40,,5378.4,percent of total billed charges,Implant Device,4706.1,70,,4706.1,percent of total billed charges,All Other,4571.64,34,,4571.64,percent of total billed charges,Implant Device,4571.64,34,,4571.64,percent of total billed charges,Implant Device,4706.1,35,,4706.1,percent of total billed charges,Implant Device,4706.1,35,,4706.1,percent of total billed charges,Implant Device,4706.1,35,,4706.1,percent of total billed charges,Implant Device,4706.1,35,,4706.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,4571.64,34,"If Charge > 2,000, then 34 percent",4571.64,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,9950.07,
P28 P50-053-2710 LOCK PLATE SCREW 27X10,C1713,HCPCS,,79007907,CDM,278,RC,,,both,,,667,493.58,,,493.58,Other,150% of Medicare + 9.63% HCRA Surcharge,300.15,45,,300.15,percent of total billed charges,Critical Access Hospital RCC factor,226.78,34,,226.78,percent of total billed charges,Implant Device,226.78,34,,226.78,percent of total billed charges,Implant Device,226.78,34,,226.78,percent of total billed charges,Implant Device,226.78,34,,226.78,percent of total billed charges,Implant Device,226.78,34,,226.78,percent of total billed charges,Implant Device,330.17,,,330.17,Other,110% of Medicare,233.45,35,,233.45,percent of total billed charges,Implant Device,226.78,34,"Charges > $500, x 34%",226.78,percent of total billed charges,Implant Device,233.45,35,,233.45,percent of total billed charges,Implant Device,233.45,35,,233.45,percent of total billed charges,Implant Device,233.45,35,,233.45,percent of total billed charges,Implant Device,233.45,35,,233.45,percent of total billed charges,Implant Device,233.45,35,,233.45,percent of total billed charges,Implant Device,266.8,40,,266.8,percent of total billed charges,Implant Device,233.45,70,,233.45,percent of total billed charges,All Other,226.78,34,,226.78,percent of total billed charges,Implant Device,226.78,34,,226.78,percent of total billed charges,Implant Device,233.45,35,,233.45,percent of total billed charges,Implant Device,233.45,35,,233.45,percent of total billed charges,Implant Device,233.45,35,,233.45,percent of total billed charges,Implant Device,233.45,35,,233.45,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,493.58,
P28 P50-153-2710 NONLOCK SCREW 2.7X10,C1713,HCPCS,,79007908,CDM,278,RC,,,both,,,542,401.08,,,401.08,Other,150% of Medicare + 9.63% HCRA Surcharge,243.9,45,,243.9,percent of total billed charges,Critical Access Hospital RCC factor,184.28,34,,184.28,percent of total billed charges,Implant Device,184.28,34,,184.28,percent of total billed charges,Implant Device,184.28,34,,184.28,percent of total billed charges,Implant Device,184.28,34,,184.28,percent of total billed charges,Implant Device,184.28,34,,184.28,percent of total billed charges,Implant Device,268.29,,,268.29,Other,110% of Medicare,189.7,35,,189.7,percent of total billed charges,Implant Device,184.28,34,"Charges > $500, x 34%",184.28,percent of total billed charges,Implant Device,189.7,35,,189.7,percent of total billed charges,Implant Device,189.7,35,,189.7,percent of total billed charges,Implant Device,189.7,35,,189.7,percent of total billed charges,Implant Device,189.7,35,,189.7,percent of total billed charges,Implant Device,189.7,35,,189.7,percent of total billed charges,Implant Device,216.8,40,,216.8,percent of total billed charges,Implant Device,189.7,70,,189.7,percent of total billed charges,All Other,184.28,34,,184.28,percent of total billed charges,Implant Device,184.28,34,,184.28,percent of total billed charges,Implant Device,189.7,35,,189.7,percent of total billed charges,Implant Device,189.7,35,,189.7,percent of total billed charges,Implant Device,189.7,35,,189.7,percent of total billed charges,Implant Device,189.7,35,,189.7,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,401.08,
P28 P50-153-3514 NONLOCK SCREW 3.5X14,C1713,HCPCS,,79007909,CDM,278,RC,,,both,,,566,418.84,,,418.84,Other,150% of Medicare + 9.63% HCRA Surcharge,254.7,45,,254.7,percent of total billed charges,Critical Access Hospital RCC factor,192.44,34,,192.44,percent of total billed charges,Implant Device,192.44,34,,192.44,percent of total billed charges,Implant Device,192.44,34,,192.44,percent of total billed charges,Implant Device,192.44,34,,192.44,percent of total billed charges,Implant Device,192.44,34,,192.44,percent of total billed charges,Implant Device,280.17,,,280.17,Other,110% of Medicare,198.1,35,,198.1,percent of total billed charges,Implant Device,192.44,34,"Charges > $500, x 34%",192.44,percent of total billed charges,Implant Device,198.1,35,,198.1,percent of total billed charges,Implant Device,198.1,35,,198.1,percent of total billed charges,Implant Device,198.1,35,,198.1,percent of total billed charges,Implant Device,198.1,35,,198.1,percent of total billed charges,Implant Device,198.1,35,,198.1,percent of total billed charges,Implant Device,226.4,40,,226.4,percent of total billed charges,Implant Device,198.1,70,,198.1,percent of total billed charges,All Other,192.44,34,,192.44,percent of total billed charges,Implant Device,192.44,34,,192.44,percent of total billed charges,Implant Device,198.1,35,,198.1,percent of total billed charges,Implant Device,198.1,35,,198.1,percent of total billed charges,Implant Device,198.1,35,,198.1,percent of total billed charges,Implant Device,198.1,35,,198.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,418.84,
P28 P53-103-L002 MTP PLATE O MD LT,C1713,HCPCS,,79007910,CDM,278,RC,,,both,,,5155,3814.71,,,3814.71,Other,150% of Medicare + 9.63% HCRA Surcharge,2319.75,45,,2319.75,percent of total billed charges,Critical Access Hospital RCC factor,1752.7,34,,1752.7,percent of total billed charges,Implant Device,1752.7,34,,1752.7,percent of total billed charges,Implant Device,1752.7,34,,1752.7,percent of total billed charges,Implant Device,1752.7,34,,1752.7,percent of total billed charges,Implant Device,1752.7,34,,1752.7,percent of total billed charges,Implant Device,2551.73,,,2551.73,Other,110% of Medicare,1804.25,35,,1804.25,percent of total billed charges,Implant Device,1752.7,34,"Charges > $500, x 34%",1752.7,percent of total billed charges,Implant Device,1804.25,35,,1804.25,percent of total billed charges,Implant Device,1804.25,35,,1804.25,percent of total billed charges,Implant Device,1804.25,35,,1804.25,percent of total billed charges,Implant Device,1804.25,35,,1804.25,percent of total billed charges,Implant Device,1804.25,35,,1804.25,percent of total billed charges,Implant Device,2062,40,,2062,percent of total billed charges,Implant Device,1804.25,70,,1804.25,percent of total billed charges,All Other,1752.7,34,,1752.7,percent of total billed charges,Implant Device,1752.7,34,,1752.7,percent of total billed charges,Implant Device,1804.25,35,,1804.25,percent of total billed charges,Implant Device,1804.25,35,,1804.25,percent of total billed charges,Implant Device,1804.25,35,,1804.25,percent of total billed charges,Implant Device,1804.25,35,,1804.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1752.7,34,"If Charge > 2,000, then 34 percent",1752.7,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3814.71,
DEPUY 206.024 CANCELLOUS SCREW 4X24MM,C1713,HCPCS,,79007911,CDM,278,RC,,,both,,,92,68.08,,,68.08,Other,150% of Medicare + 9.63% HCRA Surcharge,41.4,45,,41.4,percent of total billed charges,Critical Access Hospital RCC factor,31.28,34,,31.28,percent of total billed charges,Implant Device,31.28,34,,31.28,percent of total billed charges,Implant Device,31.28,34,,31.28,percent of total billed charges,Implant Device,31.28,34,,31.28,percent of total billed charges,Implant Device,31.28,34,,31.28,percent of total billed charges,Implant Device,45.54,,,45.54,Other,110% of Medicare,32.2,35,,32.2,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,32.2,35,,32.2,percent of total billed charges,Implant Device,32.2,35,,32.2,percent of total billed charges,Implant Device,32.2,35,,32.2,percent of total billed charges,Implant Device,32.2,35,,32.2,percent of total billed charges,Implant Device,32.2,35,,32.2,percent of total billed charges,Implant Device,36.8,40,,36.8,percent of total billed charges,Implant Device,32.2,70,,32.2,percent of total billed charges,All Other,31.28,34,,31.28,percent of total billed charges,Implant Device,31.28,34,,31.28,percent of total billed charges,Implant Device,32.2,35,,32.2,percent of total billed charges,Implant Device,32.2,35,,32.2,percent of total billed charges,Implant Device,32.2,35,,32.2,percent of total billed charges,Implant Device,32.2,35,,32.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,68.08,
S&N 71424004 TIBIAL BASEPLATE SZ 4 LEFT,C1776,HCPCS,,79007912,CDM,278,RC,,,both,,,9954,7365.98,,,7365.98,Other,150% of Medicare + 9.63% HCRA Surcharge,4479.3,45,,4479.3,percent of total billed charges,Critical Access Hospital RCC factor,3384.36,34,,3384.36,percent of total billed charges,Implant Device,3384.36,34,,3384.36,percent of total billed charges,Implant Device,3384.36,34,,3384.36,percent of total billed charges,Implant Device,3384.36,34,,3384.36,percent of total billed charges,Implant Device,3384.36,34,,3384.36,percent of total billed charges,Implant Device,4927.23,,,4927.23,Other,110% of Medicare,3483.9,35,,3483.9,percent of total billed charges,Implant Device,3384.36,34,"Charges > $500, x 34%",3384.36,percent of total billed charges,Implant Device,3483.9,35,,3483.9,percent of total billed charges,Implant Device,3483.9,35,,3483.9,percent of total billed charges,Implant Device,3483.9,35,,3483.9,percent of total billed charges,Implant Device,3483.9,35,,3483.9,percent of total billed charges,Implant Device,3483.9,35,,3483.9,percent of total billed charges,Implant Device,3981.6,40,,3981.6,percent of total billed charges,Implant Device,3483.9,70,,3483.9,percent of total billed charges,All Other,3384.36,34,,3384.36,percent of total billed charges,Implant Device,3384.36,34,,3384.36,percent of total billed charges,Implant Device,3483.9,35,,3483.9,percent of total billed charges,Implant Device,3483.9,35,,3483.9,percent of total billed charges,Implant Device,3483.9,35,,3483.9,percent of total billed charges,Implant Device,3483.9,35,,3483.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3384.36,34,"If Charge > 2,000, then 34 percent",3384.36,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,7365.98,
S&N 71424225 OFFSET COUPLER 4MM,C1776,HCPCS,,79007913,CDM,278,RC,,,both,,,4725,3496.51,,,3496.51,Other,150% of Medicare + 9.63% HCRA Surcharge,2126.25,45,,2126.25,percent of total billed charges,Critical Access Hospital RCC factor,1606.5,34,,1606.5,percent of total billed charges,Implant Device,1606.5,34,,1606.5,percent of total billed charges,Implant Device,1606.5,34,,1606.5,percent of total billed charges,Implant Device,1606.5,34,,1606.5,percent of total billed charges,Implant Device,1606.5,34,,1606.5,percent of total billed charges,Implant Device,2338.88,,,2338.88,Other,110% of Medicare,1653.75,35,,1653.75,percent of total billed charges,Implant Device,1606.5,34,"Charges > $500, x 34%",1606.5,percent of total billed charges,Implant Device,1653.75,35,,1653.75,percent of total billed charges,Implant Device,1653.75,35,,1653.75,percent of total billed charges,Implant Device,1653.75,35,,1653.75,percent of total billed charges,Implant Device,1653.75,35,,1653.75,percent of total billed charges,Implant Device,1653.75,35,,1653.75,percent of total billed charges,Implant Device,1890,40,,1890,percent of total billed charges,Implant Device,1653.75,70,,1653.75,percent of total billed charges,All Other,1606.5,34,,1606.5,percent of total billed charges,Implant Device,1606.5,34,,1606.5,percent of total billed charges,Implant Device,1653.75,35,,1653.75,percent of total billed charges,Implant Device,1653.75,35,,1653.75,percent of total billed charges,Implant Device,1653.75,35,,1653.75,percent of total billed charges,Implant Device,1653.75,35,,1653.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1606.5,34,"If Charge > 2,000, then 34 percent",1606.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3496.51,
S&N 71424029 STEM STRAIGHT 16X120MM,C1713,HCPCS,,79007914,CDM,278,RC,,,both,,,4608,3409.93,,,3409.93,Other,150% of Medicare + 9.63% HCRA Surcharge,2073.6,45,,2073.6,percent of total billed charges,Critical Access Hospital RCC factor,1566.72,34,,1566.72,percent of total billed charges,Implant Device,1566.72,34,,1566.72,percent of total billed charges,Implant Device,1566.72,34,,1566.72,percent of total billed charges,Implant Device,1566.72,34,,1566.72,percent of total billed charges,Implant Device,1566.72,34,,1566.72,percent of total billed charges,Implant Device,2280.96,,,2280.96,Other,110% of Medicare,1612.8,35,,1612.8,percent of total billed charges,Implant Device,1566.72,34,"Charges > $500, x 34%",1566.72,percent of total billed charges,Implant Device,1612.8,35,,1612.8,percent of total billed charges,Implant Device,1612.8,35,,1612.8,percent of total billed charges,Implant Device,1612.8,35,,1612.8,percent of total billed charges,Implant Device,1612.8,35,,1612.8,percent of total billed charges,Implant Device,1612.8,35,,1612.8,percent of total billed charges,Implant Device,1843.2,40,,1843.2,percent of total billed charges,Implant Device,1612.8,70,,1612.8,percent of total billed charges,All Other,1566.72,34,,1566.72,percent of total billed charges,Implant Device,1566.72,34,,1566.72,percent of total billed charges,Implant Device,1612.8,35,,1612.8,percent of total billed charges,Implant Device,1612.8,35,,1612.8,percent of total billed charges,Implant Device,1612.8,35,,1612.8,percent of total billed charges,Implant Device,1612.8,35,,1612.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1566.72,34,"If Charge > 2,000, then 34 percent",1566.72,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3409.93,
S&N 71421514 ARTICULAR INSERT 25MM,C1713,HCPCS,,79007915,CDM,278,RC,,,both,,,3292,2436.09,,,2436.09,Other,150% of Medicare + 9.63% HCRA Surcharge,1481.4,45,,1481.4,percent of total billed charges,Critical Access Hospital RCC factor,1119.28,34,,1119.28,percent of total billed charges,Implant Device,1119.28,34,,1119.28,percent of total billed charges,Implant Device,1119.28,34,,1119.28,percent of total billed charges,Implant Device,1119.28,34,,1119.28,percent of total billed charges,Implant Device,1119.28,34,,1119.28,percent of total billed charges,Implant Device,1629.54,,,1629.54,Other,110% of Medicare,1152.2,35,,1152.2,percent of total billed charges,Implant Device,1119.28,34,"Charges > $500, x 34%",1119.28,percent of total billed charges,Implant Device,1152.2,35,,1152.2,percent of total billed charges,Implant Device,1152.2,35,,1152.2,percent of total billed charges,Implant Device,1152.2,35,,1152.2,percent of total billed charges,Implant Device,1152.2,35,,1152.2,percent of total billed charges,Implant Device,1152.2,35,,1152.2,percent of total billed charges,Implant Device,1316.8,40,,1316.8,percent of total billed charges,Implant Device,1152.2,70,,1152.2,percent of total billed charges,All Other,1119.28,34,,1119.28,percent of total billed charges,Implant Device,1119.28,34,,1119.28,percent of total billed charges,Implant Device,1152.2,35,,1152.2,percent of total billed charges,Implant Device,1152.2,35,,1152.2,percent of total billed charges,Implant Device,1152.2,35,,1152.2,percent of total billed charges,Implant Device,1152.2,35,,1152.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1119.28,34,"If Charge > 2,000, then 34 percent",1119.28,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2436.09,
IN2BONES S25 ST014 COMP SCREW 2.5X14MM,C1713,HCPCS,,79007917,CDM,278,RC,,,both,,,1050,777,,,777,Other,150% of Medicare + 9.63% HCRA Surcharge,472.5,45,,472.5,percent of total billed charges,Critical Access Hospital RCC factor,357,34,,357,percent of total billed charges,Implant Device,357,34,,357,percent of total billed charges,Implant Device,357,34,,357,percent of total billed charges,Implant Device,357,34,,357,percent of total billed charges,Implant Device,357,34,,357,percent of total billed charges,Implant Device,519.75,,,519.75,Other,110% of Medicare,367.5,35,,367.5,percent of total billed charges,Implant Device,357,34,"Charges > $500, x 34%",357,percent of total billed charges,Implant Device,367.5,35,,367.5,percent of total billed charges,Implant Device,367.5,35,,367.5,percent of total billed charges,Implant Device,367.5,35,,367.5,percent of total billed charges,Implant Device,367.5,35,,367.5,percent of total billed charges,Implant Device,367.5,35,,367.5,percent of total billed charges,Implant Device,420,40,,420,percent of total billed charges,Implant Device,367.5,70,,367.5,percent of total billed charges,All Other,357,34,,357,percent of total billed charges,Implant Device,357,34,,357,percent of total billed charges,Implant Device,367.5,35,,367.5,percent of total billed charges,Implant Device,367.5,35,,367.5,percent of total billed charges,Implant Device,367.5,35,,367.5,percent of total billed charges,Implant Device,367.5,35,,367.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,777,
WRIGHT CCP-L3512 LOCKING SCREW 3.5X12MM,C1713,HCPCS,,79007919,CDM,278,RC,,,both,,,1125,832.5,,,832.5,Other,150% of Medicare + 9.63% HCRA Surcharge,506.25,45,,506.25,percent of total billed charges,Critical Access Hospital RCC factor,382.5,34,,382.5,percent of total billed charges,Implant Device,382.5,34,,382.5,percent of total billed charges,Implant Device,382.5,34,,382.5,percent of total billed charges,Implant Device,382.5,34,,382.5,percent of total billed charges,Implant Device,382.5,34,,382.5,percent of total billed charges,Implant Device,556.88,,,556.88,Other,110% of Medicare,393.75,35,,393.75,percent of total billed charges,Implant Device,382.5,34,"Charges > $500, x 34%",382.5,percent of total billed charges,Implant Device,393.75,35,,393.75,percent of total billed charges,Implant Device,393.75,35,,393.75,percent of total billed charges,Implant Device,393.75,35,,393.75,percent of total billed charges,Implant Device,393.75,35,,393.75,percent of total billed charges,Implant Device,393.75,35,,393.75,percent of total billed charges,Implant Device,450,40,,450,percent of total billed charges,Implant Device,393.75,70,,393.75,percent of total billed charges,All Other,382.5,34,,382.5,percent of total billed charges,Implant Device,382.5,34,,382.5,percent of total billed charges,Implant Device,393.75,35,,393.75,percent of total billed charges,Implant Device,393.75,35,,393.75,percent of total billed charges,Implant Device,393.75,35,,393.75,percent of total billed charges,Implant Device,393.75,35,,393.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,832.5,
BME SE-2015 SPEED IMPLANT 20X15X15MM,C1713,HCPCS,,79007920,CDM,278,RC,,,both,,,5160,3818.41,,,3818.41,Other,150% of Medicare + 9.63% HCRA Surcharge,2322,45,,2322,percent of total billed charges,Critical Access Hospital RCC factor,1754.4,34,,1754.4,percent of total billed charges,Implant Device,1754.4,34,,1754.4,percent of total billed charges,Implant Device,1754.4,34,,1754.4,percent of total billed charges,Implant Device,1754.4,34,,1754.4,percent of total billed charges,Implant Device,1754.4,34,,1754.4,percent of total billed charges,Implant Device,2554.2,,,2554.2,Other,110% of Medicare,1806,35,,1806,percent of total billed charges,Implant Device,1754.4,34,"Charges > $500, x 34%",1754.4,percent of total billed charges,Implant Device,1806,35,,1806,percent of total billed charges,Implant Device,1806,35,,1806,percent of total billed charges,Implant Device,1806,35,,1806,percent of total billed charges,Implant Device,1806,35,,1806,percent of total billed charges,Implant Device,1806,35,,1806,percent of total billed charges,Implant Device,2064,40,,2064,percent of total billed charges,Implant Device,1806,70,,1806,percent of total billed charges,All Other,1754.4,34,,1754.4,percent of total billed charges,Implant Device,1754.4,34,,1754.4,percent of total billed charges,Implant Device,1806,35,,1806,percent of total billed charges,Implant Device,1806,35,,1806,percent of total billed charges,Implant Device,1806,35,,1806,percent of total billed charges,Implant Device,1806,35,,1806,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1754.4,34,"If Charge > 2,000, then 34 percent",1754.4,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3818.41,
ZIMMER 14376-38 CANNULATED SCREW 4X38MM,C1713,HCPCS,,79007921,CDM,278,RC,,,both,,,514,380.36,,,380.36,Other,150% of Medicare + 9.63% HCRA Surcharge,231.3,45,,231.3,percent of total billed charges,Critical Access Hospital RCC factor,174.76,34,,174.76,percent of total billed charges,Implant Device,174.76,34,,174.76,percent of total billed charges,Implant Device,174.76,34,,174.76,percent of total billed charges,Implant Device,174.76,34,,174.76,percent of total billed charges,Implant Device,174.76,34,,174.76,percent of total billed charges,Implant Device,254.43,,,254.43,Other,110% of Medicare,179.9,35,,179.9,percent of total billed charges,Implant Device,174.76,34,"Charges > $500, x 34%",174.76,percent of total billed charges,Implant Device,179.9,35,,179.9,percent of total billed charges,Implant Device,179.9,35,,179.9,percent of total billed charges,Implant Device,179.9,35,,179.9,percent of total billed charges,Implant Device,179.9,35,,179.9,percent of total billed charges,Implant Device,179.9,35,,179.9,percent of total billed charges,Implant Device,205.6,40,,205.6,percent of total billed charges,Implant Device,179.9,70,,179.9,percent of total billed charges,All Other,174.76,34,,174.76,percent of total billed charges,Implant Device,174.76,34,,174.76,percent of total billed charges,Implant Device,179.9,35,,179.9,percent of total billed charges,Implant Device,179.9,35,,179.9,percent of total billed charges,Implant Device,179.9,35,,179.9,percent of total billed charges,Implant Device,179.9,35,,179.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,380.36,
DEPUY 204.822 CORTEX SCREW ST 3.5X22MM,C1713,HCPCS,,79007922,CDM,278,RC,,,both,,,57,42.18,,,42.18,Other,150% of Medicare + 9.63% HCRA Surcharge,25.65,45,,25.65,percent of total billed charges,Critical Access Hospital RCC factor,19.38,34,,19.38,percent of total billed charges,Implant Device,19.38,34,,19.38,percent of total billed charges,Implant Device,19.38,34,,19.38,percent of total billed charges,Implant Device,19.38,34,,19.38,percent of total billed charges,Implant Device,19.38,34,,19.38,percent of total billed charges,Implant Device,28.22,,,28.22,Other,110% of Medicare,19.95,35,,19.95,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,19.95,35,,19.95,percent of total billed charges,Implant Device,19.95,35,,19.95,percent of total billed charges,Implant Device,19.95,35,,19.95,percent of total billed charges,Implant Device,19.95,35,,19.95,percent of total billed charges,Implant Device,19.95,35,,19.95,percent of total billed charges,Implant Device,22.8,40,,22.8,percent of total billed charges,Implant Device,19.95,70,,19.95,percent of total billed charges,All Other,19.38,34,,19.38,percent of total billed charges,Implant Device,19.38,34,,19.38,percent of total billed charges,Implant Device,19.95,35,,19.95,percent of total billed charges,Implant Device,19.95,35,,19.95,percent of total billed charges,Implant Device,19.95,35,,19.95,percent of total billed charges,Implant Device,19.95,35,,19.95,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,42.18,
DEPUY 206.022 CANCELLOUS SCREW 4X22MM,C1713,HCPCS,,79007923,CDM,278,RC,,,both,,,59,43.66,,,43.66,Other,150% of Medicare + 9.63% HCRA Surcharge,26.55,45,,26.55,percent of total billed charges,Critical Access Hospital RCC factor,20.06,34,,20.06,percent of total billed charges,Implant Device,20.06,34,,20.06,percent of total billed charges,Implant Device,20.06,34,,20.06,percent of total billed charges,Implant Device,20.06,34,,20.06,percent of total billed charges,Implant Device,20.06,34,,20.06,percent of total billed charges,Implant Device,29.21,,,29.21,Other,110% of Medicare,20.65,35,,20.65,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,20.65,35,,20.65,percent of total billed charges,Implant Device,20.65,35,,20.65,percent of total billed charges,Implant Device,20.65,35,,20.65,percent of total billed charges,Implant Device,20.65,35,,20.65,percent of total billed charges,Implant Device,20.65,35,,20.65,percent of total billed charges,Implant Device,23.6,40,,23.6,percent of total billed charges,Implant Device,20.65,70,,20.65,percent of total billed charges,All Other,20.06,34,,20.06,percent of total billed charges,Implant Device,20.06,34,,20.06,percent of total billed charges,Implant Device,20.65,35,,20.65,percent of total billed charges,Implant Device,20.65,35,,20.65,percent of total billed charges,Implant Device,20.65,35,,20.65,percent of total billed charges,Implant Device,20.65,35,,20.65,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,43.66,
SUT EXP PC012X PARIETEX COMP MESH 12CM,C1713,HCPCS,,79007924,CDM,278,RC,,,both,,,1857,1374.18,,,1374.18,Other,150% of Medicare + 9.63% HCRA Surcharge,835.65,45,,835.65,percent of total billed charges,Critical Access Hospital RCC factor,631.38,34,,631.38,percent of total billed charges,Implant Device,631.38,34,,631.38,percent of total billed charges,Implant Device,631.38,34,,631.38,percent of total billed charges,Implant Device,631.38,34,,631.38,percent of total billed charges,Implant Device,631.38,34,,631.38,percent of total billed charges,Implant Device,919.22,,,919.22,Other,110% of Medicare,649.95,35,,649.95,percent of total billed charges,Implant Device,631.38,34,"Charges > $500, x 34%",631.38,percent of total billed charges,Implant Device,649.95,35,,649.95,percent of total billed charges,Implant Device,649.95,35,,649.95,percent of total billed charges,Implant Device,649.95,35,,649.95,percent of total billed charges,Implant Device,649.95,35,,649.95,percent of total billed charges,Implant Device,649.95,35,,649.95,percent of total billed charges,Implant Device,742.8,40,,742.8,percent of total billed charges,Implant Device,649.95,70,,649.95,percent of total billed charges,All Other,631.38,34,,631.38,percent of total billed charges,Implant Device,631.38,34,,631.38,percent of total billed charges,Implant Device,649.95,35,,649.95,percent of total billed charges,Implant Device,649.95,35,,649.95,percent of total billed charges,Implant Device,649.95,35,,649.95,percent of total billed charges,Implant Device,649.95,35,,649.95,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1374.18,
P28 P50-053-2730 LOCK PLATE SCREW 2.7X30,C1713,HCPCS,,79007925,CDM,278,RC,,,both,,,880,651.2,,,651.2,Other,150% of Medicare + 9.63% HCRA Surcharge,396,45,,396,percent of total billed charges,Critical Access Hospital RCC factor,299.2,34,,299.2,percent of total billed charges,Implant Device,299.2,34,,299.2,percent of total billed charges,Implant Device,299.2,34,,299.2,percent of total billed charges,Implant Device,299.2,34,,299.2,percent of total billed charges,Implant Device,299.2,34,,299.2,percent of total billed charges,Implant Device,435.6,,,435.6,Other,110% of Medicare,308,35,,308,percent of total billed charges,Implant Device,299.2,34,"Charges > $500, x 34%",299.2,percent of total billed charges,Implant Device,308,35,,308,percent of total billed charges,Implant Device,308,35,,308,percent of total billed charges,Implant Device,308,35,,308,percent of total billed charges,Implant Device,308,35,,308,percent of total billed charges,Implant Device,308,35,,308,percent of total billed charges,Implant Device,352,40,,352,percent of total billed charges,Implant Device,308,70,,308,percent of total billed charges,All Other,299.2,34,,299.2,percent of total billed charges,Implant Device,299.2,34,,299.2,percent of total billed charges,Implant Device,308,35,,308,percent of total billed charges,Implant Device,308,35,,308,percent of total billed charges,Implant Device,308,35,,308,percent of total billed charges,Implant Device,308,35,,308,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,651.2,
P28 P50-053-3534 LOCK PLATE SCREW 3.5X24,C1713,HCPCS,,79007926,CDM,278,RC,,,both,,,694,513.56,,,513.56,Other,150% of Medicare + 9.63% HCRA Surcharge,312.3,45,,312.3,percent of total billed charges,Critical Access Hospital RCC factor,235.96,34,,235.96,percent of total billed charges,Implant Device,235.96,34,,235.96,percent of total billed charges,Implant Device,235.96,34,,235.96,percent of total billed charges,Implant Device,235.96,34,,235.96,percent of total billed charges,Implant Device,235.96,34,,235.96,percent of total billed charges,Implant Device,343.53,,,343.53,Other,110% of Medicare,242.9,35,,242.9,percent of total billed charges,Implant Device,235.96,34,"Charges > $500, x 34%",235.96,percent of total billed charges,Implant Device,242.9,35,,242.9,percent of total billed charges,Implant Device,242.9,35,,242.9,percent of total billed charges,Implant Device,242.9,35,,242.9,percent of total billed charges,Implant Device,242.9,35,,242.9,percent of total billed charges,Implant Device,242.9,35,,242.9,percent of total billed charges,Implant Device,277.6,40,,277.6,percent of total billed charges,Implant Device,242.9,70,,242.9,percent of total billed charges,All Other,235.96,34,,235.96,percent of total billed charges,Implant Device,235.96,34,,235.96,percent of total billed charges,Implant Device,242.9,35,,242.9,percent of total billed charges,Implant Device,242.9,35,,242.9,percent of total billed charges,Implant Device,242.9,35,,242.9,percent of total billed charges,Implant Device,242.9,35,,242.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,513.56,
P28 P50-053-4232 LOCK PLATE SCREW 4.2X32,C1713,HCPCS,,79007927,CDM,278,RC,,,both,,,854,631.96,,,631.96,Other,150% of Medicare + 9.63% HCRA Surcharge,384.3,45,,384.3,percent of total billed charges,Critical Access Hospital RCC factor,290.36,34,,290.36,percent of total billed charges,Implant Device,290.36,34,,290.36,percent of total billed charges,Implant Device,290.36,34,,290.36,percent of total billed charges,Implant Device,290.36,34,,290.36,percent of total billed charges,Implant Device,290.36,34,,290.36,percent of total billed charges,Implant Device,422.73,,,422.73,Other,110% of Medicare,298.9,35,,298.9,percent of total billed charges,Implant Device,290.36,34,"Charges > $500, x 34%",290.36,percent of total billed charges,Implant Device,298.9,35,,298.9,percent of total billed charges,Implant Device,298.9,35,,298.9,percent of total billed charges,Implant Device,298.9,35,,298.9,percent of total billed charges,Implant Device,298.9,35,,298.9,percent of total billed charges,Implant Device,298.9,35,,298.9,percent of total billed charges,Implant Device,341.6,40,,341.6,percent of total billed charges,Implant Device,298.9,70,,298.9,percent of total billed charges,All Other,290.36,34,,290.36,percent of total billed charges,Implant Device,290.36,34,,290.36,percent of total billed charges,Implant Device,298.9,35,,298.9,percent of total billed charges,Implant Device,298.9,35,,298.9,percent of total billed charges,Implant Device,298.9,35,,298.9,percent of total billed charges,Implant Device,298.9,35,,298.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,631.96,
P28 P53-105-L003 PLATE LONG LEFT 24MM,C1713,HCPCS,,79007928,CDM,278,RC,,,both,,,4851,3589.75,,,3589.75,Other,150% of Medicare + 9.63% HCRA Surcharge,2182.95,45,,2182.95,percent of total billed charges,Critical Access Hospital RCC factor,1649.34,34,,1649.34,percent of total billed charges,Implant Device,1649.34,34,,1649.34,percent of total billed charges,Implant Device,1649.34,34,,1649.34,percent of total billed charges,Implant Device,1649.34,34,,1649.34,percent of total billed charges,Implant Device,1649.34,34,,1649.34,percent of total billed charges,Implant Device,2401.25,,,2401.25,Other,110% of Medicare,1697.85,35,,1697.85,percent of total billed charges,Implant Device,1649.34,34,"Charges > $500, x 34%",1649.34,percent of total billed charges,Implant Device,1697.85,35,,1697.85,percent of total billed charges,Implant Device,1697.85,35,,1697.85,percent of total billed charges,Implant Device,1697.85,35,,1697.85,percent of total billed charges,Implant Device,1697.85,35,,1697.85,percent of total billed charges,Implant Device,1697.85,35,,1697.85,percent of total billed charges,Implant Device,1940.4,40,,1940.4,percent of total billed charges,Implant Device,1697.85,70,,1697.85,percent of total billed charges,All Other,1649.34,34,,1649.34,percent of total billed charges,Implant Device,1649.34,34,,1649.34,percent of total billed charges,Implant Device,1697.85,35,,1697.85,percent of total billed charges,Implant Device,1697.85,35,,1697.85,percent of total billed charges,Implant Device,1697.85,35,,1697.85,percent of total billed charges,Implant Device,1697.85,35,,1697.85,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1649.34,34,"If Charge > 2,000, then 34 percent",1649.34,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3589.75,
ARROW CS-15312-VF VECTORFLOW 31CM CATH,C1750,HCPCS,,79007929,CDM,278,RC,,,both,,,995,736.3,,,736.3,Other,150% of Medicare + 9.63% HCRA Surcharge,447.75,45,,447.75,percent of total billed charges,Critical Access Hospital RCC factor,338.3,34,,338.3,percent of total billed charges,Implant Device,338.3,34,,338.3,percent of total billed charges,Implant Device,338.3,34,,338.3,percent of total billed charges,Implant Device,338.3,34,,338.3,percent of total billed charges,Implant Device,338.3,34,,338.3,percent of total billed charges,Implant Device,492.53,,,492.53,Other,110% of Medicare,348.25,35,,348.25,percent of total billed charges,Implant Device,338.3,34,"Charges > $500, x 34%",338.3,percent of total billed charges,Implant Device,348.25,35,,348.25,percent of total billed charges,Implant Device,348.25,35,,348.25,percent of total billed charges,Implant Device,348.25,35,,348.25,percent of total billed charges,Implant Device,348.25,35,,348.25,percent of total billed charges,Implant Device,348.25,35,,348.25,percent of total billed charges,Implant Device,398,40,,398,percent of total billed charges,Implant Device,348.25,70,,348.25,percent of total billed charges,All Other,338.3,34,,338.3,percent of total billed charges,Implant Device,338.3,34,,338.3,percent of total billed charges,Implant Device,348.25,35,,348.25,percent of total billed charges,Implant Device,348.25,35,,348.25,percent of total billed charges,Implant Device,348.25,35,,348.25,percent of total billed charges,Implant Device,348.25,35,,348.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,736.3,
ARROW CS-15552-VF VECTORFLOW 55CM CATH,C1750,HCPCS,,79007930,CDM,278,RC,,,both,,,994,735.56,,,735.56,Other,150% of Medicare + 9.63% HCRA Surcharge,447.3,45,,447.3,percent of total billed charges,Critical Access Hospital RCC factor,337.96,34,,337.96,percent of total billed charges,Implant Device,337.96,34,,337.96,percent of total billed charges,Implant Device,337.96,34,,337.96,percent of total billed charges,Implant Device,337.96,34,,337.96,percent of total billed charges,Implant Device,337.96,34,,337.96,percent of total billed charges,Implant Device,492.03,,,492.03,Other,110% of Medicare,347.9,35,,347.9,percent of total billed charges,Implant Device,337.96,34,"Charges > $500, x 34%",337.96,percent of total billed charges,Implant Device,347.9,35,,347.9,percent of total billed charges,Implant Device,347.9,35,,347.9,percent of total billed charges,Implant Device,347.9,35,,347.9,percent of total billed charges,Implant Device,347.9,35,,347.9,percent of total billed charges,Implant Device,347.9,35,,347.9,percent of total billed charges,Implant Device,397.6,40,,397.6,percent of total billed charges,Implant Device,347.9,70,,347.9,percent of total billed charges,All Other,337.96,34,,337.96,percent of total billed charges,Implant Device,337.96,34,,337.96,percent of total billed charges,Implant Device,347.9,35,,347.9,percent of total billed charges,Implant Device,347.9,35,,347.9,percent of total billed charges,Implant Device,347.9,35,,347.9,percent of total billed charges,Implant Device,347.9,35,,347.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,735.56,
S&N 71335552 SHELL 3 HOLE 52MM,C1713,HCPCS,,79007931,CDM,278,RC,,,both,,,3801,2812.75,,,2812.75,Other,150% of Medicare + 9.63% HCRA Surcharge,1710.45,45,,1710.45,percent of total billed charges,Critical Access Hospital RCC factor,1292.34,34,,1292.34,percent of total billed charges,Implant Device,1292.34,34,,1292.34,percent of total billed charges,Implant Device,1292.34,34,,1292.34,percent of total billed charges,Implant Device,1292.34,34,,1292.34,percent of total billed charges,Implant Device,1292.34,34,,1292.34,percent of total billed charges,Implant Device,1881.5,,,1881.5,Other,110% of Medicare,1330.35,35,,1330.35,percent of total billed charges,Implant Device,1292.34,34,"Charges > $500, x 34%",1292.34,percent of total billed charges,Implant Device,1330.35,35,,1330.35,percent of total billed charges,Implant Device,1330.35,35,,1330.35,percent of total billed charges,Implant Device,1330.35,35,,1330.35,percent of total billed charges,Implant Device,1330.35,35,,1330.35,percent of total billed charges,Implant Device,1330.35,35,,1330.35,percent of total billed charges,Implant Device,1520.4,40,,1520.4,percent of total billed charges,Implant Device,1330.35,70,,1330.35,percent of total billed charges,All Other,1292.34,34,,1292.34,percent of total billed charges,Implant Device,1292.34,34,,1292.34,percent of total billed charges,Implant Device,1330.35,35,,1330.35,percent of total billed charges,Implant Device,1330.35,35,,1330.35,percent of total billed charges,Implant Device,1330.35,35,,1330.35,percent of total billed charges,Implant Device,1330.35,35,,1330.35,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1292.34,34,"If Charge > 2,000, then 34 percent",1292.34,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2812.75,
S&N 71306612 FEMORAL COMPONENT SIZE 12,C1713,HCPCS,,79007932,CDM,278,RC,,,both,,,9135,6759.92,,,6759.92,Other,150% of Medicare + 9.63% HCRA Surcharge,4110.75,45,,4110.75,percent of total billed charges,Critical Access Hospital RCC factor,3105.9,34,,3105.9,percent of total billed charges,Implant Device,3105.9,34,,3105.9,percent of total billed charges,Implant Device,3105.9,34,,3105.9,percent of total billed charges,Implant Device,3105.9,34,,3105.9,percent of total billed charges,Implant Device,3105.9,34,,3105.9,percent of total billed charges,Implant Device,4521.83,,,4521.83,Other,110% of Medicare,3197.25,35,,3197.25,percent of total billed charges,Implant Device,3105.9,34,"Charges > $500, x 34%",3105.9,percent of total billed charges,Implant Device,3197.25,35,,3197.25,percent of total billed charges,Implant Device,3197.25,35,,3197.25,percent of total billed charges,Implant Device,3197.25,35,,3197.25,percent of total billed charges,Implant Device,3197.25,35,,3197.25,percent of total billed charges,Implant Device,3197.25,35,,3197.25,percent of total billed charges,Implant Device,3654,40,,3654,percent of total billed charges,Implant Device,3197.25,70,,3197.25,percent of total billed charges,All Other,3105.9,34,,3105.9,percent of total billed charges,Implant Device,3105.9,34,,3105.9,percent of total billed charges,Implant Device,3197.25,35,,3197.25,percent of total billed charges,Implant Device,3197.25,35,,3197.25,percent of total billed charges,Implant Device,3197.25,35,,3197.25,percent of total billed charges,Implant Device,3197.25,35,,3197.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3105.9,34,"If Charge > 2,000, then 34 percent",3105.9,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,6759.92,
S&N 71332520 CANC HEAD SCREW 6.5X20MM,C1713,HCPCS,,79007933,CDM,278,RC,,,both,,,273,202.02,,,202.02,Other,150% of Medicare + 9.63% HCRA Surcharge,122.85,45,,122.85,percent of total billed charges,Critical Access Hospital RCC factor,92.82,34,,92.82,percent of total billed charges,Implant Device,92.82,34,,92.82,percent of total billed charges,Implant Device,92.82,34,,92.82,percent of total billed charges,Implant Device,92.82,34,,92.82,percent of total billed charges,Implant Device,92.82,34,,92.82,percent of total billed charges,Implant Device,135.14,,,135.14,Other,110% of Medicare,95.55,35,,95.55,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,95.55,35,,95.55,percent of total billed charges,Implant Device,95.55,35,,95.55,percent of total billed charges,Implant Device,95.55,35,,95.55,percent of total billed charges,Implant Device,95.55,35,,95.55,percent of total billed charges,Implant Device,95.55,35,,95.55,percent of total billed charges,Implant Device,109.2,40,,109.2,percent of total billed charges,Implant Device,95.55,70,,95.55,percent of total billed charges,All Other,92.82,34,,92.82,percent of total billed charges,Implant Device,92.82,34,,92.82,percent of total billed charges,Implant Device,95.55,35,,95.55,percent of total billed charges,Implant Device,95.55,35,,95.55,percent of total billed charges,Implant Device,95.55,35,,95.55,percent of total billed charges,Implant Device,95.55,35,,95.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,202.02,
S&N 71343603 FEM HEAD 12/14 TAPER 36MM,C1713,HCPCS,,79007934,CDM,278,RC,,,both,,,3969,2937.07,,,2937.07,Other,150% of Medicare + 9.63% HCRA Surcharge,1786.05,45,,1786.05,percent of total billed charges,Critical Access Hospital RCC factor,1349.46,34,,1349.46,percent of total billed charges,Implant Device,1349.46,34,,1349.46,percent of total billed charges,Implant Device,1349.46,34,,1349.46,percent of total billed charges,Implant Device,1349.46,34,,1349.46,percent of total billed charges,Implant Device,1349.46,34,,1349.46,percent of total billed charges,Implant Device,1964.66,,,1964.66,Other,110% of Medicare,1389.15,35,,1389.15,percent of total billed charges,Implant Device,1349.46,34,"Charges > $500, x 34%",1349.46,percent of total billed charges,Implant Device,1389.15,35,,1389.15,percent of total billed charges,Implant Device,1389.15,35,,1389.15,percent of total billed charges,Implant Device,1389.15,35,,1389.15,percent of total billed charges,Implant Device,1389.15,35,,1389.15,percent of total billed charges,Implant Device,1389.15,35,,1389.15,percent of total billed charges,Implant Device,1587.6,40,,1587.6,percent of total billed charges,Implant Device,1389.15,70,,1389.15,percent of total billed charges,All Other,1349.46,34,,1349.46,percent of total billed charges,Implant Device,1349.46,34,,1349.46,percent of total billed charges,Implant Device,1389.15,35,,1389.15,percent of total billed charges,Implant Device,1389.15,35,,1389.15,percent of total billed charges,Implant Device,1389.15,35,,1389.15,percent of total billed charges,Implant Device,1389.15,35,,1389.15,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1349.46,34,"If Charge > 2,000, then 34 percent",1349.46,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2937.07,
S&N 71335752 ACETABULAR LINER 36X52MM,C1713,HCPCS,,79007935,CDM,278,RC,,,both,,,3003,2222.23,,,2222.23,Other,150% of Medicare + 9.63% HCRA Surcharge,1351.35,45,,1351.35,percent of total billed charges,Critical Access Hospital RCC factor,1021.02,34,,1021.02,percent of total billed charges,Implant Device,1021.02,34,,1021.02,percent of total billed charges,Implant Device,1021.02,34,,1021.02,percent of total billed charges,Implant Device,1021.02,34,,1021.02,percent of total billed charges,Implant Device,1021.02,34,,1021.02,percent of total billed charges,Implant Device,1486.49,,,1486.49,Other,110% of Medicare,1051.05,35,,1051.05,percent of total billed charges,Implant Device,1021.02,34,"Charges > $500, x 34%",1021.02,percent of total billed charges,Implant Device,1051.05,35,,1051.05,percent of total billed charges,Implant Device,1051.05,35,,1051.05,percent of total billed charges,Implant Device,1051.05,35,,1051.05,percent of total billed charges,Implant Device,1051.05,35,,1051.05,percent of total billed charges,Implant Device,1051.05,35,,1051.05,percent of total billed charges,Implant Device,1201.2,40,,1201.2,percent of total billed charges,Implant Device,1051.05,70,,1051.05,percent of total billed charges,All Other,1021.02,34,,1021.02,percent of total billed charges,Implant Device,1021.02,34,,1021.02,percent of total billed charges,Implant Device,1051.05,35,,1051.05,percent of total billed charges,Implant Device,1051.05,35,,1051.05,percent of total billed charges,Implant Device,1051.05,35,,1051.05,percent of total billed charges,Implant Device,1051.05,35,,1051.05,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1021.02,34,"If Charge > 2,000, then 34 percent",1021.02,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2222.23,
S&N 71332525 CANC HEAD SCREW 6.5X25MM,C1713,HCPCS,,79007936,CDM,278,RC,,,both,,,273,202.02,,,202.02,Other,150% of Medicare + 9.63% HCRA Surcharge,122.85,45,,122.85,percent of total billed charges,Critical Access Hospital RCC factor,92.82,34,,92.82,percent of total billed charges,Implant Device,92.82,34,,92.82,percent of total billed charges,Implant Device,92.82,34,,92.82,percent of total billed charges,Implant Device,92.82,34,,92.82,percent of total billed charges,Implant Device,92.82,34,,92.82,percent of total billed charges,Implant Device,135.14,,,135.14,Other,110% of Medicare,95.55,35,,95.55,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,95.55,35,,95.55,percent of total billed charges,Implant Device,95.55,35,,95.55,percent of total billed charges,Implant Device,95.55,35,,95.55,percent of total billed charges,Implant Device,95.55,35,,95.55,percent of total billed charges,Implant Device,95.55,35,,95.55,percent of total billed charges,Implant Device,109.2,40,,109.2,percent of total billed charges,Implant Device,95.55,70,,95.55,percent of total billed charges,All Other,92.82,34,,92.82,percent of total billed charges,Implant Device,92.82,34,,92.82,percent of total billed charges,Implant Device,95.55,35,,95.55,percent of total billed charges,Implant Device,95.55,35,,95.55,percent of total billed charges,Implant Device,95.55,35,,95.55,percent of total billed charges,Implant Device,95.55,35,,95.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,202.02,
S&N 71336500 CENTRAL HOLE COVER,C1713,HCPCS,,79007937,CDM,278,RC,,,both,,,210,155.4,,,155.4,Other,150% of Medicare + 9.63% HCRA Surcharge,94.5,45,,94.5,percent of total billed charges,Critical Access Hospital RCC factor,71.4,34,,71.4,percent of total billed charges,Implant Device,71.4,34,,71.4,percent of total billed charges,Implant Device,71.4,34,,71.4,percent of total billed charges,Implant Device,71.4,34,,71.4,percent of total billed charges,Implant Device,71.4,34,,71.4,percent of total billed charges,Implant Device,103.95,,,103.95,Other,110% of Medicare,73.5,35,,73.5,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,73.5,35,,73.5,percent of total billed charges,Implant Device,73.5,35,,73.5,percent of total billed charges,Implant Device,73.5,35,,73.5,percent of total billed charges,Implant Device,73.5,35,,73.5,percent of total billed charges,Implant Device,73.5,35,,73.5,percent of total billed charges,Implant Device,84,40,,84,percent of total billed charges,Implant Device,73.5,70,,73.5,percent of total billed charges,All Other,71.4,34,,71.4,percent of total billed charges,Implant Device,71.4,34,,71.4,percent of total billed charges,Implant Device,73.5,35,,73.5,percent of total billed charges,Implant Device,73.5,35,,73.5,percent of total billed charges,Implant Device,73.5,35,,73.5,percent of total billed charges,Implant Device,73.5,35,,73.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,155.4,
STRYKER 3425-1420S 11X120MM LONG NAIL,C1713,HCPCS,,79007938,CDM,278,RC,,,both,,,11742,8689.11,,,8689.11,Other,150% of Medicare + 9.63% HCRA Surcharge,5283.9,45,,5283.9,percent of total billed charges,Critical Access Hospital RCC factor,3992.28,34,,3992.28,percent of total billed charges,Implant Device,3992.28,34,,3992.28,percent of total billed charges,Implant Device,3992.28,34,,3992.28,percent of total billed charges,Implant Device,3992.28,34,,3992.28,percent of total billed charges,Implant Device,3992.28,34,,3992.28,percent of total billed charges,Implant Device,5812.29,,,5812.29,Other,110% of Medicare,4109.7,35,,4109.7,percent of total billed charges,Implant Device,3992.28,34,"Charges > $500, x 34%",3992.28,percent of total billed charges,Implant Device,4109.7,35,,4109.7,percent of total billed charges,Implant Device,4109.7,35,,4109.7,percent of total billed charges,Implant Device,4109.7,35,,4109.7,percent of total billed charges,Implant Device,4109.7,35,,4109.7,percent of total billed charges,Implant Device,4109.7,35,,4109.7,percent of total billed charges,Implant Device,4696.8,40,,4696.8,percent of total billed charges,Implant Device,4109.7,70,,4109.7,percent of total billed charges,All Other,3992.28,34,,3992.28,percent of total billed charges,Implant Device,3992.28,34,,3992.28,percent of total billed charges,Implant Device,4109.7,35,,4109.7,percent of total billed charges,Implant Device,4109.7,35,,4109.7,percent of total billed charges,Implant Device,4109.7,35,,4109.7,percent of total billed charges,Implant Device,4109.7,35,,4109.7,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3992.28,34,"If Charge > 2,000, then 34 percent",3992.28,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,8689.11,
ARTHREX AR-1588TP PCL TIGHTROPE,C1713,HCPCS,,79007942,CDM,278,RC,,,both,,,1497,1107.78,,,1107.78,Other,150% of Medicare + 9.63% HCRA Surcharge,673.65,45,,673.65,percent of total billed charges,Critical Access Hospital RCC factor,508.98,34,,508.98,percent of total billed charges,Implant Device,508.98,34,,508.98,percent of total billed charges,Implant Device,508.98,34,,508.98,percent of total billed charges,Implant Device,508.98,34,,508.98,percent of total billed charges,Implant Device,508.98,34,,508.98,percent of total billed charges,Implant Device,741.02,,,741.02,Other,110% of Medicare,523.95,35,,523.95,percent of total billed charges,Implant Device,508.98,34,"Charges > $500, x 34%",508.98,percent of total billed charges,Implant Device,523.95,35,,523.95,percent of total billed charges,Implant Device,523.95,35,,523.95,percent of total billed charges,Implant Device,523.95,35,,523.95,percent of total billed charges,Implant Device,523.95,35,,523.95,percent of total billed charges,Implant Device,523.95,35,,523.95,percent of total billed charges,Implant Device,598.8,40,,598.8,percent of total billed charges,Implant Device,523.95,70,,523.95,percent of total billed charges,All Other,508.98,34,,508.98,percent of total billed charges,Implant Device,508.98,34,,508.98,percent of total billed charges,Implant Device,523.95,35,,523.95,percent of total billed charges,Implant Device,523.95,35,,523.95,percent of total billed charges,Implant Device,523.95,35,,523.95,percent of total billed charges,Implant Device,523.95,35,,523.95,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1107.78,
IN2BONES S30-ST134 IBS 3X34MM COMP SCRW,C1713,HCPCS,,79007945,CDM,278,RC,,,both,,,1050,777,,,777,Other,150% of Medicare + 9.63% HCRA Surcharge,472.5,45,,472.5,percent of total billed charges,Critical Access Hospital RCC factor,357,34,,357,percent of total billed charges,Implant Device,357,34,,357,percent of total billed charges,Implant Device,357,34,,357,percent of total billed charges,Implant Device,357,34,,357,percent of total billed charges,Implant Device,357,34,,357,percent of total billed charges,Implant Device,519.75,,,519.75,Other,110% of Medicare,367.5,35,,367.5,percent of total billed charges,Implant Device,357,34,"Charges > $500, x 34%",357,percent of total billed charges,Implant Device,367.5,35,,367.5,percent of total billed charges,Implant Device,367.5,35,,367.5,percent of total billed charges,Implant Device,367.5,35,,367.5,percent of total billed charges,Implant Device,367.5,35,,367.5,percent of total billed charges,Implant Device,367.5,35,,367.5,percent of total billed charges,Implant Device,420,40,,420,percent of total billed charges,Implant Device,367.5,70,,367.5,percent of total billed charges,All Other,357,34,,357,percent of total billed charges,Implant Device,357,34,,357,percent of total billed charges,Implant Device,367.5,35,,367.5,percent of total billed charges,Implant Device,367.5,35,,367.5,percent of total billed charges,Implant Device,367.5,35,,367.5,percent of total billed charges,Implant Device,367.5,35,,367.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,777,
DEPUY 02.0206.222 CORTEX SCREW 3.5X22MM,C1713,HCPCS,,79007946,CDM,278,RC,,,both,,,135,99.9,,,99.9,Other,150% of Medicare + 9.63% HCRA Surcharge,60.75,45,,60.75,percent of total billed charges,Critical Access Hospital RCC factor,45.9,34,,45.9,percent of total billed charges,Implant Device,45.9,34,,45.9,percent of total billed charges,Implant Device,45.9,34,,45.9,percent of total billed charges,Implant Device,45.9,34,,45.9,percent of total billed charges,Implant Device,45.9,34,,45.9,percent of total billed charges,Implant Device,66.83,,,66.83,Other,110% of Medicare,47.25,35,,47.25,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,47.25,35,,47.25,percent of total billed charges,Implant Device,47.25,35,,47.25,percent of total billed charges,Implant Device,47.25,35,,47.25,percent of total billed charges,Implant Device,47.25,35,,47.25,percent of total billed charges,Implant Device,47.25,35,,47.25,percent of total billed charges,Implant Device,54,40,,54,percent of total billed charges,Implant Device,47.25,70,,47.25,percent of total billed charges,All Other,45.9,34,,45.9,percent of total billed charges,Implant Device,45.9,34,,45.9,percent of total billed charges,Implant Device,47.25,35,,47.25,percent of total billed charges,Implant Device,47.25,35,,47.25,percent of total billed charges,Implant Device,47.25,35,,47.25,percent of total billed charges,Implant Device,47.25,35,,47.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,99.9,
DEPUY 02.0206.226 CORTEX SCREW 3.5X26MM,C1713,HCPCS,,79007947,CDM,278,RC,,,both,,,135,99.9,,,99.9,Other,150% of Medicare + 9.63% HCRA Surcharge,60.75,45,,60.75,percent of total billed charges,Critical Access Hospital RCC factor,45.9,34,,45.9,percent of total billed charges,Implant Device,45.9,34,,45.9,percent of total billed charges,Implant Device,45.9,34,,45.9,percent of total billed charges,Implant Device,45.9,34,,45.9,percent of total billed charges,Implant Device,45.9,34,,45.9,percent of total billed charges,Implant Device,66.83,,,66.83,Other,110% of Medicare,47.25,35,,47.25,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,47.25,35,,47.25,percent of total billed charges,Implant Device,47.25,35,,47.25,percent of total billed charges,Implant Device,47.25,35,,47.25,percent of total billed charges,Implant Device,47.25,35,,47.25,percent of total billed charges,Implant Device,47.25,35,,47.25,percent of total billed charges,Implant Device,54,40,,54,percent of total billed charges,Implant Device,47.25,70,,47.25,percent of total billed charges,All Other,45.9,34,,45.9,percent of total billed charges,Implant Device,45.9,34,,45.9,percent of total billed charges,Implant Device,47.25,35,,47.25,percent of total billed charges,Implant Device,47.25,35,,47.25,percent of total billed charges,Implant Device,47.25,35,,47.25,percent of total billed charges,Implant Device,47.25,35,,47.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,99.9,
DEPUY 02.206.222 CORTEX SCREW 3.5X22MM,C1713,HCPCS,,79007957,CDM,278,RC,,,both,,,135,99.9,,,99.9,Other,150% of Medicare + 9.63% HCRA Surcharge,60.75,45,,60.75,percent of total billed charges,Critical Access Hospital RCC factor,45.9,34,,45.9,percent of total billed charges,Implant Device,45.9,34,,45.9,percent of total billed charges,Implant Device,45.9,34,,45.9,percent of total billed charges,Implant Device,45.9,34,,45.9,percent of total billed charges,Implant Device,45.9,34,,45.9,percent of total billed charges,Implant Device,66.83,,,66.83,Other,110% of Medicare,47.25,35,,47.25,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,47.25,35,,47.25,percent of total billed charges,Implant Device,47.25,35,,47.25,percent of total billed charges,Implant Device,47.25,35,,47.25,percent of total billed charges,Implant Device,47.25,35,,47.25,percent of total billed charges,Implant Device,47.25,35,,47.25,percent of total billed charges,Implant Device,54,40,,54,percent of total billed charges,Implant Device,47.25,70,,47.25,percent of total billed charges,All Other,45.9,34,,45.9,percent of total billed charges,Implant Device,45.9,34,,45.9,percent of total billed charges,Implant Device,47.25,35,,47.25,percent of total billed charges,Implant Device,47.25,35,,47.25,percent of total billed charges,Implant Device,47.25,35,,47.25,percent of total billed charges,Implant Device,47.25,35,,47.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,99.9,
CARDINAL SF06060MB SMART FLEX 6X60 STENT,C1876,HCPCS,,79007958,CDM,278,RC,,,both,,,2100,1554.01,,,1554.01,Other,150% of Medicare + 9.63% HCRA Surcharge,945,45,,945,percent of total billed charges,Critical Access Hospital RCC factor,714,34,,714,percent of total billed charges,Implant Device,714,34,,714,percent of total billed charges,Implant Device,714,34,,714,percent of total billed charges,Implant Device,714,34,,714,percent of total billed charges,Implant Device,714,34,,714,percent of total billed charges,Implant Device,1039.5,,,1039.5,Other,110% of Medicare,735,35,,735,percent of total billed charges,Implant Device,714,34,"Charges > $500, x 34%",714,percent of total billed charges,Implant Device,735,35,,735,percent of total billed charges,Implant Device,735,35,,735,percent of total billed charges,Implant Device,735,35,,735,percent of total billed charges,Implant Device,735,35,,735,percent of total billed charges,Implant Device,735,35,,735,percent of total billed charges,Implant Device,840,40,,840,percent of total billed charges,Implant Device,735,70,,735,percent of total billed charges,All Other,714,34,,714,percent of total billed charges,Implant Device,714,34,,714,percent of total billed charges,Implant Device,735,35,,735,percent of total billed charges,Implant Device,735,35,,735,percent of total billed charges,Implant Device,735,35,,735,percent of total billed charges,Implant Device,735,35,,735,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,714,34,"If Charge > 2,000, then 34 percent",714,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1554.01,
ZIMMER 00-8851-015-36 NEUTRAL LINER 36MM,C1776,HCPCS,,79007960,CDM,278,RC,,,both,,,3456,2557.45,,,2557.45,Other,150% of Medicare + 9.63% HCRA Surcharge,1555.2,45,,1555.2,percent of total billed charges,Critical Access Hospital RCC factor,1175.04,34,,1175.04,percent of total billed charges,Implant Device,1175.04,34,,1175.04,percent of total billed charges,Implant Device,1175.04,34,,1175.04,percent of total billed charges,Implant Device,1175.04,34,,1175.04,percent of total billed charges,Implant Device,1175.04,34,,1175.04,percent of total billed charges,Implant Device,1710.72,,,1710.72,Other,110% of Medicare,1209.6,35,,1209.6,percent of total billed charges,Implant Device,1175.04,34,"Charges > $500, x 34%",1175.04,percent of total billed charges,Implant Device,1209.6,35,,1209.6,percent of total billed charges,Implant Device,1209.6,35,,1209.6,percent of total billed charges,Implant Device,1209.6,35,,1209.6,percent of total billed charges,Implant Device,1209.6,35,,1209.6,percent of total billed charges,Implant Device,1209.6,35,,1209.6,percent of total billed charges,Implant Device,1382.4,40,,1382.4,percent of total billed charges,Implant Device,1209.6,70,,1209.6,percent of total billed charges,All Other,1175.04,34,,1175.04,percent of total billed charges,Implant Device,1175.04,34,,1175.04,percent of total billed charges,Implant Device,1209.6,35,,1209.6,percent of total billed charges,Implant Device,1209.6,35,,1209.6,percent of total billed charges,Implant Device,1209.6,35,,1209.6,percent of total billed charges,Implant Device,1209.6,35,,1209.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1175.04,34,"If Charge > 2,000, then 34 percent",1175.04,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2557.45,
ZIMMER 0-8018-028-03 FEMORAL HD 3.5X28,C1776,HCPCS,,79007961,CDM,278,RC,,,both,,,2543,1881.83,,,1881.83,Other,150% of Medicare + 9.63% HCRA Surcharge,1144.35,45,,1144.35,percent of total billed charges,Critical Access Hospital RCC factor,864.62,34,,864.62,percent of total billed charges,Implant Device,864.62,34,,864.62,percent of total billed charges,Implant Device,864.62,34,,864.62,percent of total billed charges,Implant Device,864.62,34,,864.62,percent of total billed charges,Implant Device,864.62,34,,864.62,percent of total billed charges,Implant Device,1258.79,,,1258.79,Other,110% of Medicare,890.05,35,,890.05,percent of total billed charges,Implant Device,864.62,34,"Charges > $500, x 34%",864.62,percent of total billed charges,Implant Device,890.05,35,,890.05,percent of total billed charges,Implant Device,890.05,35,,890.05,percent of total billed charges,Implant Device,890.05,35,,890.05,percent of total billed charges,Implant Device,890.05,35,,890.05,percent of total billed charges,Implant Device,890.05,35,,890.05,percent of total billed charges,Implant Device,1017.2,40,,1017.2,percent of total billed charges,Implant Device,890.05,70,,890.05,percent of total billed charges,All Other,864.62,34,,864.62,percent of total billed charges,Implant Device,864.62,34,,864.62,percent of total billed charges,Implant Device,890.05,35,,890.05,percent of total billed charges,Implant Device,890.05,35,,890.05,percent of total billed charges,Implant Device,890.05,35,,890.05,percent of total billed charges,Implant Device,890.05,35,,890.05,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,864.62,34,"If Charge > 2,000, then 34 percent",864.62,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1881.83,
STRYKER 40-20808 PLATE 8 HOLE STRAIGHT,C1713,HCPCS,,79007962,CDM,278,RC,,,both,,,2229,1649.47,,,1649.47,Other,150% of Medicare + 9.63% HCRA Surcharge,1003.05,45,,1003.05,percent of total billed charges,Critical Access Hospital RCC factor,757.86,34,,757.86,percent of total billed charges,Implant Device,757.86,34,,757.86,percent of total billed charges,Implant Device,757.86,34,,757.86,percent of total billed charges,Implant Device,757.86,34,,757.86,percent of total billed charges,Implant Device,757.86,34,,757.86,percent of total billed charges,Implant Device,1103.36,,,1103.36,Other,110% of Medicare,780.15,35,,780.15,percent of total billed charges,Implant Device,757.86,34,"Charges > $500, x 34%",757.86,percent of total billed charges,Implant Device,780.15,35,,780.15,percent of total billed charges,Implant Device,780.15,35,,780.15,percent of total billed charges,Implant Device,780.15,35,,780.15,percent of total billed charges,Implant Device,780.15,35,,780.15,percent of total billed charges,Implant Device,780.15,35,,780.15,percent of total billed charges,Implant Device,891.6,40,,891.6,percent of total billed charges,Implant Device,780.15,70,,780.15,percent of total billed charges,All Other,757.86,34,,757.86,percent of total billed charges,Implant Device,757.86,34,,757.86,percent of total billed charges,Implant Device,780.15,35,,780.15,percent of total billed charges,Implant Device,780.15,35,,780.15,percent of total billed charges,Implant Device,780.15,35,,780.15,percent of total billed charges,Implant Device,780.15,35,,780.15,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,757.86,34,"If Charge > 2,000, then 34 percent",757.86,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1649.47,
ARTHROSURFACE 8H02-5248 ART COMP 52X48MM,C1776,HCPCS,,79007970,CDM,278,RC,,,both,,,17436,12902.68,,,12902.68,Other,150% of Medicare + 9.63% HCRA Surcharge,7846.2,45,,7846.2,percent of total billed charges,Critical Access Hospital RCC factor,5928.24,34,,5928.24,percent of total billed charges,Implant Device,5928.24,34,,5928.24,percent of total billed charges,Implant Device,5928.24,34,,5928.24,percent of total billed charges,Implant Device,5928.24,34,,5928.24,percent of total billed charges,Implant Device,5928.24,34,,5928.24,percent of total billed charges,Implant Device,8630.82,,,8630.82,Other,110% of Medicare,6102.6,35,,6102.6,percent of total billed charges,Implant Device,5928.24,34,"Charges > $500, x 34%",5928.24,percent of total billed charges,Implant Device,6102.6,35,,6102.6,percent of total billed charges,Implant Device,6102.6,35,,6102.6,percent of total billed charges,Implant Device,6102.6,35,,6102.6,percent of total billed charges,Implant Device,6102.6,35,,6102.6,percent of total billed charges,Implant Device,6102.6,35,,6102.6,percent of total billed charges,Implant Device,6974.4,40,,6974.4,percent of total billed charges,Implant Device,6102.6,70,,6102.6,percent of total billed charges,All Other,5928.24,34,,5928.24,percent of total billed charges,Implant Device,5928.24,34,,5928.24,percent of total billed charges,Implant Device,6102.6,35,,6102.6,percent of total billed charges,Implant Device,6102.6,35,,6102.6,percent of total billed charges,Implant Device,6102.6,35,,6102.6,percent of total billed charges,Implant Device,6102.6,35,,6102.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,5928.24,34,"If Charge > 2,000, then 34 percent",5928.24,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,12902.68,
IN2BONES S25 ST012 COMP SCREW 2.5X12MM,C1713,HCPCS,,79007972,CDM,278,RC,,,both,,,1050,777,,,777,Other,150% of Medicare + 9.63% HCRA Surcharge,472.5,45,,472.5,percent of total billed charges,Critical Access Hospital RCC factor,357,34,,357,percent of total billed charges,Implant Device,357,34,,357,percent of total billed charges,Implant Device,357,34,,357,percent of total billed charges,Implant Device,357,34,,357,percent of total billed charges,Implant Device,357,34,,357,percent of total billed charges,Implant Device,519.75,,,519.75,Other,110% of Medicare,367.5,35,,367.5,percent of total billed charges,Implant Device,357,34,"Charges > $500, x 34%",357,percent of total billed charges,Implant Device,367.5,35,,367.5,percent of total billed charges,Implant Device,367.5,35,,367.5,percent of total billed charges,Implant Device,367.5,35,,367.5,percent of total billed charges,Implant Device,367.5,35,,367.5,percent of total billed charges,Implant Device,367.5,35,,367.5,percent of total billed charges,Implant Device,420,40,,420,percent of total billed charges,Implant Device,367.5,70,,367.5,percent of total billed charges,All Other,357,34,,357,percent of total billed charges,Implant Device,357,34,,357,percent of total billed charges,Implant Device,367.5,35,,367.5,percent of total billed charges,Implant Device,367.5,35,,367.5,percent of total billed charges,Implant Device,367.5,35,,367.5,percent of total billed charges,Implant Device,367.5,35,,367.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,777,
BARD-DAVOL 0115311 3D MAX MESH LG LT,C1781,HCPCS,,79007976,CDM,278,RC,,,both,,,743,549.82,,,549.82,Other,150% of Medicare + 9.63% HCRA Surcharge,334.35,45,,334.35,percent of total billed charges,Critical Access Hospital RCC factor,252.62,34,,252.62,percent of total billed charges,Implant Device,252.62,34,,252.62,percent of total billed charges,Implant Device,252.62,34,,252.62,percent of total billed charges,Implant Device,252.62,34,,252.62,percent of total billed charges,Implant Device,252.62,34,,252.62,percent of total billed charges,Implant Device,367.79,,,367.79,Other,110% of Medicare,260.05,35,,260.05,percent of total billed charges,Implant Device,252.62,34,"Charges > $500, x 34%",252.62,percent of total billed charges,Implant Device,260.05,35,,260.05,percent of total billed charges,Implant Device,260.05,35,,260.05,percent of total billed charges,Implant Device,260.05,35,,260.05,percent of total billed charges,Implant Device,260.05,35,,260.05,percent of total billed charges,Implant Device,260.05,35,,260.05,percent of total billed charges,Implant Device,297.2,40,,297.2,percent of total billed charges,Implant Device,260.05,70,,260.05,percent of total billed charges,All Other,252.62,34,,252.62,percent of total billed charges,Implant Device,252.62,34,,252.62,percent of total billed charges,Implant Device,260.05,35,,260.05,percent of total billed charges,Implant Device,260.05,35,,260.05,percent of total billed charges,Implant Device,260.05,35,,260.05,percent of total billed charges,Implant Device,260.05,35,,260.05,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,549.82,
BARD-DAVOL 0115312 3D MAX MESH XL LT,C1781,HCPCS,,79007977,CDM,278,RC,,,both,,,773,572.02,,,572.02,Other,150% of Medicare + 9.63% HCRA Surcharge,347.85,45,,347.85,percent of total billed charges,Critical Access Hospital RCC factor,262.82,34,,262.82,percent of total billed charges,Implant Device,262.82,34,,262.82,percent of total billed charges,Implant Device,262.82,34,,262.82,percent of total billed charges,Implant Device,262.82,34,,262.82,percent of total billed charges,Implant Device,262.82,34,,262.82,percent of total billed charges,Implant Device,382.64,,,382.64,Other,110% of Medicare,270.55,35,,270.55,percent of total billed charges,Implant Device,262.82,34,"Charges > $500, x 34%",262.82,percent of total billed charges,Implant Device,270.55,35,,270.55,percent of total billed charges,Implant Device,270.55,35,,270.55,percent of total billed charges,Implant Device,270.55,35,,270.55,percent of total billed charges,Implant Device,270.55,35,,270.55,percent of total billed charges,Implant Device,270.55,35,,270.55,percent of total billed charges,Implant Device,309.2,40,,309.2,percent of total billed charges,Implant Device,270.55,70,,270.55,percent of total billed charges,All Other,262.82,34,,262.82,percent of total billed charges,Implant Device,262.82,34,,262.82,percent of total billed charges,Implant Device,270.55,35,,270.55,percent of total billed charges,Implant Device,270.55,35,,270.55,percent of total billed charges,Implant Device,270.55,35,,270.55,percent of total billed charges,Implant Device,270.55,35,,270.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,572.02,
BARD-DAVOL 0115321 3D MAX MESH LG RT,C1781,HCPCS,,79007978,CDM,278,RC,,,both,,,510,377.4,,,377.4,Other,150% of Medicare + 9.63% HCRA Surcharge,229.5,45,,229.5,percent of total billed charges,Critical Access Hospital RCC factor,173.4,34,,173.4,percent of total billed charges,Implant Device,173.4,34,,173.4,percent of total billed charges,Implant Device,173.4,34,,173.4,percent of total billed charges,Implant Device,173.4,34,,173.4,percent of total billed charges,Implant Device,173.4,34,,173.4,percent of total billed charges,Implant Device,252.45,,,252.45,Other,110% of Medicare,178.5,35,,178.5,percent of total billed charges,Implant Device,173.4,34,"Charges > $500, x 34%",173.4,percent of total billed charges,Implant Device,178.5,35,,178.5,percent of total billed charges,Implant Device,178.5,35,,178.5,percent of total billed charges,Implant Device,178.5,35,,178.5,percent of total billed charges,Implant Device,178.5,35,,178.5,percent of total billed charges,Implant Device,178.5,35,,178.5,percent of total billed charges,Implant Device,204,40,,204,percent of total billed charges,Implant Device,178.5,70,,178.5,percent of total billed charges,All Other,173.4,34,,173.4,percent of total billed charges,Implant Device,173.4,34,,173.4,percent of total billed charges,Implant Device,178.5,35,,178.5,percent of total billed charges,Implant Device,178.5,35,,178.5,percent of total billed charges,Implant Device,178.5,35,,178.5,percent of total billed charges,Implant Device,178.5,35,,178.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,377.4,
BARD-DAVOL 0115322 3D MAX MESH XL RT,C1781,HCPCS,,79007979,CDM,278,RC,,,both,,,773,572.02,,,572.02,Other,150% of Medicare + 9.63% HCRA Surcharge,347.85,45,,347.85,percent of total billed charges,Critical Access Hospital RCC factor,262.82,34,,262.82,percent of total billed charges,Implant Device,262.82,34,,262.82,percent of total billed charges,Implant Device,262.82,34,,262.82,percent of total billed charges,Implant Device,262.82,34,,262.82,percent of total billed charges,Implant Device,262.82,34,,262.82,percent of total billed charges,Implant Device,382.64,,,382.64,Other,110% of Medicare,270.55,35,,270.55,percent of total billed charges,Implant Device,262.82,34,"Charges > $500, x 34%",262.82,percent of total billed charges,Implant Device,270.55,35,,270.55,percent of total billed charges,Implant Device,270.55,35,,270.55,percent of total billed charges,Implant Device,270.55,35,,270.55,percent of total billed charges,Implant Device,270.55,35,,270.55,percent of total billed charges,Implant Device,270.55,35,,270.55,percent of total billed charges,Implant Device,309.2,40,,309.2,percent of total billed charges,Implant Device,270.55,70,,270.55,percent of total billed charges,All Other,262.82,34,,262.82,percent of total billed charges,Implant Device,262.82,34,,262.82,percent of total billed charges,Implant Device,270.55,35,,270.55,percent of total billed charges,Implant Device,270.55,35,,270.55,percent of total billed charges,Implant Device,270.55,35,,270.55,percent of total billed charges,Implant Device,270.55,35,,270.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,572.02,
J&J 212029 KNOTLESS SUTURE ANCHOR,C1713,HCPCS,,79007983,CDM,278,RC,,,both,,,1080,799.2,,,799.2,Other,150% of Medicare + 9.63% HCRA Surcharge,486,45,,486,percent of total billed charges,Critical Access Hospital RCC factor,367.2,34,,367.2,percent of total billed charges,Implant Device,367.2,34,,367.2,percent of total billed charges,Implant Device,367.2,34,,367.2,percent of total billed charges,Implant Device,367.2,34,,367.2,percent of total billed charges,Implant Device,367.2,34,,367.2,percent of total billed charges,Implant Device,534.6,,,534.6,Other,110% of Medicare,378,35,,378,percent of total billed charges,Implant Device,367.2,34,"Charges > $500, x 34%",367.2,percent of total billed charges,Implant Device,378,35,,378,percent of total billed charges,Implant Device,378,35,,378,percent of total billed charges,Implant Device,378,35,,378,percent of total billed charges,Implant Device,378,35,,378,percent of total billed charges,Implant Device,378,35,,378,percent of total billed charges,Implant Device,432,40,,432,percent of total billed charges,Implant Device,378,70,,378,percent of total billed charges,All Other,367.2,34,,367.2,percent of total billed charges,Implant Device,367.2,34,,367.2,percent of total billed charges,Implant Device,378,35,,378,percent of total billed charges,Implant Device,378,35,,378,percent of total billed charges,Implant Device,378,35,,378,percent of total billed charges,Implant Device,378,35,,378,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,799.2,
J&J 212032 GII SUPER QUICK ANCHOR,C1713,HCPCS,,79007984,CDM,278,RC,,,both,,,1042,771.08,,,771.08,Other,150% of Medicare + 9.63% HCRA Surcharge,468.9,45,,468.9,percent of total billed charges,Critical Access Hospital RCC factor,354.28,34,,354.28,percent of total billed charges,Implant Device,354.28,34,,354.28,percent of total billed charges,Implant Device,354.28,34,,354.28,percent of total billed charges,Implant Device,354.28,34,,354.28,percent of total billed charges,Implant Device,354.28,34,,354.28,percent of total billed charges,Implant Device,515.79,,,515.79,Other,110% of Medicare,364.7,35,,364.7,percent of total billed charges,Implant Device,354.28,34,"Charges > $500, x 34%",354.28,percent of total billed charges,Implant Device,364.7,35,,364.7,percent of total billed charges,Implant Device,364.7,35,,364.7,percent of total billed charges,Implant Device,364.7,35,,364.7,percent of total billed charges,Implant Device,364.7,35,,364.7,percent of total billed charges,Implant Device,364.7,35,,364.7,percent of total billed charges,Implant Device,416.8,40,,416.8,percent of total billed charges,Implant Device,364.7,70,,364.7,percent of total billed charges,All Other,354.28,34,,354.28,percent of total billed charges,Implant Device,354.28,34,,354.28,percent of total billed charges,Implant Device,364.7,35,,364.7,percent of total billed charges,Implant Device,364.7,35,,364.7,percent of total billed charges,Implant Device,364.7,35,,364.7,percent of total billed charges,Implant Device,364.7,35,,364.7,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,771.08,
J&J 212134 GII QUICK ANCHOR PLUS PANNERY,C1713,HCPCS,,79007985,CDM,278,RC,,,both,,,664,491.36,,,491.36,Other,150% of Medicare + 9.63% HCRA Surcharge,298.8,45,,298.8,percent of total billed charges,Critical Access Hospital RCC factor,225.76,34,,225.76,percent of total billed charges,Implant Device,225.76,34,,225.76,percent of total billed charges,Implant Device,225.76,34,,225.76,percent of total billed charges,Implant Device,225.76,34,,225.76,percent of total billed charges,Implant Device,225.76,34,,225.76,percent of total billed charges,Implant Device,328.68,,,328.68,Other,110% of Medicare,232.4,35,,232.4,percent of total billed charges,Implant Device,225.76,34,"Charges > $500, x 34%",225.76,percent of total billed charges,Implant Device,232.4,35,,232.4,percent of total billed charges,Implant Device,232.4,35,,232.4,percent of total billed charges,Implant Device,232.4,35,,232.4,percent of total billed charges,Implant Device,232.4,35,,232.4,percent of total billed charges,Implant Device,232.4,35,,232.4,percent of total billed charges,Implant Device,265.6,40,,265.6,percent of total billed charges,Implant Device,232.4,70,,232.4,percent of total billed charges,All Other,225.76,34,,225.76,percent of total billed charges,Implant Device,225.76,34,,225.76,percent of total billed charges,Implant Device,232.4,35,,232.4,percent of total billed charges,Implant Device,232.4,35,,232.4,percent of total billed charges,Implant Device,232.4,35,,232.4,percent of total billed charges,Implant Device,232.4,35,,232.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,491.36,
J&J 212450 GII EASY ARTHROSCOPE,C1713,HCPCS,,79007986,CDM,278,RC,,,both,,,1024,757.76,,,757.76,Other,150% of Medicare + 9.63% HCRA Surcharge,460.8,45,,460.8,percent of total billed charges,Critical Access Hospital RCC factor,348.16,34,,348.16,percent of total billed charges,Implant Device,348.16,34,,348.16,percent of total billed charges,Implant Device,348.16,34,,348.16,percent of total billed charges,Implant Device,348.16,34,,348.16,percent of total billed charges,Implant Device,348.16,34,,348.16,percent of total billed charges,Implant Device,506.88,,,506.88,Other,110% of Medicare,358.4,35,,358.4,percent of total billed charges,Implant Device,348.16,34,"Charges > $500, x 34%",348.16,percent of total billed charges,Implant Device,358.4,35,,358.4,percent of total billed charges,Implant Device,358.4,35,,358.4,percent of total billed charges,Implant Device,358.4,35,,358.4,percent of total billed charges,Implant Device,358.4,35,,358.4,percent of total billed charges,Implant Device,358.4,35,,358.4,percent of total billed charges,Implant Device,409.6,40,,409.6,percent of total billed charges,Implant Device,358.4,70,,358.4,percent of total billed charges,All Other,348.16,34,,348.16,percent of total billed charges,Implant Device,348.16,34,,348.16,percent of total billed charges,Implant Device,358.4,35,,358.4,percent of total billed charges,Implant Device,358.4,35,,358.4,percent of total billed charges,Implant Device,358.4,35,,358.4,percent of total billed charges,Implant Device,358.4,35,,358.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,757.76,
J&J 212725 KNOTLESS ANCHOR,C1713,HCPCS,,79007987,CDM,278,RC,,,both,,,1126,833.24,,,833.24,Other,150% of Medicare + 9.63% HCRA Surcharge,506.7,45,,506.7,percent of total billed charges,Critical Access Hospital RCC factor,382.84,34,,382.84,percent of total billed charges,Implant Device,382.84,34,,382.84,percent of total billed charges,Implant Device,382.84,34,,382.84,percent of total billed charges,Implant Device,382.84,34,,382.84,percent of total billed charges,Implant Device,382.84,34,,382.84,percent of total billed charges,Implant Device,557.37,,,557.37,Other,110% of Medicare,394.1,35,,394.1,percent of total billed charges,Implant Device,382.84,34,"Charges > $500, x 34%",382.84,percent of total billed charges,Implant Device,394.1,35,,394.1,percent of total billed charges,Implant Device,394.1,35,,394.1,percent of total billed charges,Implant Device,394.1,35,,394.1,percent of total billed charges,Implant Device,394.1,35,,394.1,percent of total billed charges,Implant Device,394.1,35,,394.1,percent of total billed charges,Implant Device,450.4,40,,450.4,percent of total billed charges,Implant Device,394.1,70,,394.1,percent of total billed charges,All Other,382.84,34,,382.84,percent of total billed charges,Implant Device,382.84,34,,382.84,percent of total billed charges,Implant Device,394.1,35,,394.1,percent of total billed charges,Implant Device,394.1,35,,394.1,percent of total billed charges,Implant Device,394.1,35,,394.1,percent of total billed charges,Implant Device,394.1,35,,394.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,833.24,
ZIMMER 00-5880-050-12 ART SURF SZ 3 12MM,C1776,HCPCS,,79008017,CDM,278,RC,,,both,,,5765,4266.11,,,4266.11,Other,150% of Medicare + 9.63% HCRA Surcharge,2594.25,45,,2594.25,percent of total billed charges,Critical Access Hospital RCC factor,1960.1,34,,1960.1,percent of total billed charges,Implant Device,1960.1,34,,1960.1,percent of total billed charges,Implant Device,1960.1,34,,1960.1,percent of total billed charges,Implant Device,1960.1,34,,1960.1,percent of total billed charges,Implant Device,1960.1,34,,1960.1,percent of total billed charges,Implant Device,2853.68,,,2853.68,Other,110% of Medicare,2017.75,35,,2017.75,percent of total billed charges,Implant Device,1960.1,34,"Charges > $500, x 34%",1960.1,percent of total billed charges,Implant Device,2017.75,35,,2017.75,percent of total billed charges,Implant Device,2017.75,35,,2017.75,percent of total billed charges,Implant Device,2017.75,35,,2017.75,percent of total billed charges,Implant Device,2017.75,35,,2017.75,percent of total billed charges,Implant Device,2017.75,35,,2017.75,percent of total billed charges,Implant Device,2306,40,,2306,percent of total billed charges,Implant Device,2017.75,70,,2017.75,percent of total billed charges,All Other,1960.1,34,,1960.1,percent of total billed charges,Implant Device,1960.1,34,,1960.1,percent of total billed charges,Implant Device,2017.75,35,,2017.75,percent of total billed charges,Implant Device,2017.75,35,,2017.75,percent of total billed charges,Implant Device,2017.75,35,,2017.75,percent of total billed charges,Implant Device,2017.75,35,,2017.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1960.1,34,"If Charge > 2,000, then 34 percent",1960.1,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4266.11,
GORE VBJR060502A VIABAHN 6MMX5CM STENT,C1874,HCPCS,,79008018,CDM,278,RC,,,both,,,10065,7448.13,,,7448.13,Other,150% of Medicare + 9.63% HCRA Surcharge,4529.25,45,,4529.25,percent of total billed charges,Critical Access Hospital RCC factor,3422.1,34,,3422.1,percent of total billed charges,Implant Device,3422.1,34,,3422.1,percent of total billed charges,Implant Device,3422.1,34,,3422.1,percent of total billed charges,Implant Device,3422.1,34,,3422.1,percent of total billed charges,Implant Device,3422.1,34,,3422.1,percent of total billed charges,Implant Device,4982.18,,,4982.18,Other,110% of Medicare,3522.75,35,,3522.75,percent of total billed charges,Implant Device,3422.1,34,"Charges > $500, x 34%",3422.1,percent of total billed charges,Implant Device,3522.75,35,,3522.75,percent of total billed charges,Implant Device,3522.75,35,,3522.75,percent of total billed charges,Implant Device,3522.75,35,,3522.75,percent of total billed charges,Implant Device,3522.75,35,,3522.75,percent of total billed charges,Implant Device,3522.75,35,,3522.75,percent of total billed charges,Implant Device,4026,40,,4026,percent of total billed charges,Implant Device,3522.75,70,,3522.75,percent of total billed charges,All Other,3422.1,34,,3422.1,percent of total billed charges,Implant Device,3422.1,34,,3422.1,percent of total billed charges,Implant Device,3522.75,35,,3522.75,percent of total billed charges,Implant Device,3522.75,35,,3522.75,percent of total billed charges,Implant Device,3522.75,35,,3522.75,percent of total billed charges,Implant Device,3522.75,35,,3522.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3422.1,34,"If Charge > 2,000, then 34 percent",3422.1,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,7448.13,
EXACTECH 320-42-10 HUMERAL LINER 42X+0MM,C1776,HCPCS,,79008020,CDM,278,RC,,,both,,,2835,2097.91,,,2097.91,Other,150% of Medicare + 9.63% HCRA Surcharge,1275.75,45,,1275.75,percent of total billed charges,Critical Access Hospital RCC factor,963.9,34,,963.9,percent of total billed charges,Implant Device,963.9,34,,963.9,percent of total billed charges,Implant Device,963.9,34,,963.9,percent of total billed charges,Implant Device,963.9,34,,963.9,percent of total billed charges,Implant Device,963.9,34,,963.9,percent of total billed charges,Implant Device,1403.33,,,1403.33,Other,110% of Medicare,992.25,35,,992.25,percent of total billed charges,Implant Device,963.9,34,"Charges > $500, x 34%",963.9,percent of total billed charges,Implant Device,992.25,35,,992.25,percent of total billed charges,Implant Device,992.25,35,,992.25,percent of total billed charges,Implant Device,992.25,35,,992.25,percent of total billed charges,Implant Device,992.25,35,,992.25,percent of total billed charges,Implant Device,992.25,35,,992.25,percent of total billed charges,Implant Device,1134,40,,1134,percent of total billed charges,Implant Device,992.25,70,,992.25,percent of total billed charges,All Other,963.9,34,,963.9,percent of total billed charges,Implant Device,963.9,34,,963.9,percent of total billed charges,Implant Device,992.25,35,,992.25,percent of total billed charges,Implant Device,992.25,35,,992.25,percent of total billed charges,Implant Device,992.25,35,,992.25,percent of total billed charges,Implant Device,992.25,35,,992.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,963.9,34,"If Charge > 2,000, then 34 percent",963.9,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2097.91,
DEPUY 208.434 CANN SCREW 6.5X32X60MM,C1713,HCPCS,,79008021,CDM,278,RC,,,both,,,1200,888,,,888,Other,150% of Medicare + 9.63% HCRA Surcharge,540,45,,540,percent of total billed charges,Critical Access Hospital RCC factor,408,34,,408,percent of total billed charges,Implant Device,408,34,,408,percent of total billed charges,Implant Device,408,34,,408,percent of total billed charges,Implant Device,408,34,,408,percent of total billed charges,Implant Device,408,34,,408,percent of total billed charges,Implant Device,594,,,594,Other,110% of Medicare,420,35,,420,percent of total billed charges,Implant Device,408,34,"Charges > $500, x 34%",408,percent of total billed charges,Implant Device,420,35,,420,percent of total billed charges,Implant Device,420,35,,420,percent of total billed charges,Implant Device,420,35,,420,percent of total billed charges,Implant Device,420,35,,420,percent of total billed charges,Implant Device,420,35,,420,percent of total billed charges,Implant Device,480,40,,480,percent of total billed charges,Implant Device,420,70,,420,percent of total billed charges,All Other,408,34,,408,percent of total billed charges,Implant Device,408,34,,408,percent of total billed charges,Implant Device,420,35,,420,percent of total billed charges,Implant Device,420,35,,420,percent of total billed charges,Implant Device,420,35,,420,percent of total billed charges,Implant Device,420,35,,420,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,888,
DEPUY 208.436 CANN SCREW 6.5X32X70MM,C1713,HCPCS,,79008022,CDM,278,RC,,,both,,,1200,888,,,888,Other,150% of Medicare + 9.63% HCRA Surcharge,540,45,,540,percent of total billed charges,Critical Access Hospital RCC factor,408,34,,408,percent of total billed charges,Implant Device,408,34,,408,percent of total billed charges,Implant Device,408,34,,408,percent of total billed charges,Implant Device,408,34,,408,percent of total billed charges,Implant Device,408,34,,408,percent of total billed charges,Implant Device,594,,,594,Other,110% of Medicare,420,35,,420,percent of total billed charges,Implant Device,408,34,"Charges > $500, x 34%",408,percent of total billed charges,Implant Device,420,35,,420,percent of total billed charges,Implant Device,420,35,,420,percent of total billed charges,Implant Device,420,35,,420,percent of total billed charges,Implant Device,420,35,,420,percent of total billed charges,Implant Device,420,35,,420,percent of total billed charges,Implant Device,480,40,,480,percent of total billed charges,Implant Device,420,70,,420,percent of total billed charges,All Other,408,34,,408,percent of total billed charges,Implant Device,408,34,,408,percent of total billed charges,Implant Device,420,35,,420,percent of total billed charges,Implant Device,420,35,,420,percent of total billed charges,Implant Device,420,35,,420,percent of total billed charges,Implant Device,420,35,,420,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,888,
ATLAS SPINE 1106-01-7545 SHAFT 7.5X45MM,C1713,HCPCS,,79008023,CDM,278,RC,,,both,,,630,466.2,,,466.2,Other,150% of Medicare + 9.63% HCRA Surcharge,283.5,45,,283.5,percent of total billed charges,Critical Access Hospital RCC factor,214.2,34,,214.2,percent of total billed charges,Implant Device,214.2,34,,214.2,percent of total billed charges,Implant Device,214.2,34,,214.2,percent of total billed charges,Implant Device,214.2,34,,214.2,percent of total billed charges,Implant Device,214.2,34,,214.2,percent of total billed charges,Implant Device,311.85,,,311.85,Other,110% of Medicare,220.5,35,,220.5,percent of total billed charges,Implant Device,214.2,34,"Charges > $500, x 34%",214.2,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,252,40,,252,percent of total billed charges,Implant Device,220.5,70,,220.5,percent of total billed charges,All Other,214.2,34,,214.2,percent of total billed charges,Implant Device,214.2,34,,214.2,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,466.2,
ATLAS SPINE 1100-03-0040 ROD 40MM,C1713,HCPCS,,79008024,CDM,278,RC,,,both,,,840,621.6,,,621.6,Other,150% of Medicare + 9.63% HCRA Surcharge,378,45,,378,percent of total billed charges,Critical Access Hospital RCC factor,285.6,34,,285.6,percent of total billed charges,Implant Device,285.6,34,,285.6,percent of total billed charges,Implant Device,285.6,34,,285.6,percent of total billed charges,Implant Device,285.6,34,,285.6,percent of total billed charges,Implant Device,285.6,34,,285.6,percent of total billed charges,Implant Device,415.8,,,415.8,Other,110% of Medicare,294,35,,294,percent of total billed charges,Implant Device,285.6,34,"Charges > $500, x 34%",285.6,percent of total billed charges,Implant Device,294,35,,294,percent of total billed charges,Implant Device,294,35,,294,percent of total billed charges,Implant Device,294,35,,294,percent of total billed charges,Implant Device,294,35,,294,percent of total billed charges,Implant Device,294,35,,294,percent of total billed charges,Implant Device,336,40,,336,percent of total billed charges,Implant Device,294,70,,294,percent of total billed charges,All Other,285.6,34,,285.6,percent of total billed charges,Implant Device,285.6,34,,285.6,percent of total billed charges,Implant Device,294,35,,294,percent of total billed charges,Implant Device,294,35,,294,percent of total billed charges,Implant Device,294,35,,294,percent of total billed charges,Implant Device,294,35,,294,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,621.6,
ATLAS 1208-01-2709 TRUE POS CAGE 27X9MM,C1713,HCPCS,,79008025,CDM,278,RC,,,both,,,9555,7070.72,,,7070.72,Other,150% of Medicare + 9.63% HCRA Surcharge,4299.75,45,,4299.75,percent of total billed charges,Critical Access Hospital RCC factor,3248.7,34,,3248.7,percent of total billed charges,Implant Device,3248.7,34,,3248.7,percent of total billed charges,Implant Device,3248.7,34,,3248.7,percent of total billed charges,Implant Device,3248.7,34,,3248.7,percent of total billed charges,Implant Device,3248.7,34,,3248.7,percent of total billed charges,Implant Device,4729.73,,,4729.73,Other,110% of Medicare,3344.25,35,,3344.25,percent of total billed charges,Implant Device,3248.7,34,"Charges > $500, x 34%",3248.7,percent of total billed charges,Implant Device,3344.25,35,,3344.25,percent of total billed charges,Implant Device,3344.25,35,,3344.25,percent of total billed charges,Implant Device,3344.25,35,,3344.25,percent of total billed charges,Implant Device,3344.25,35,,3344.25,percent of total billed charges,Implant Device,3344.25,35,,3344.25,percent of total billed charges,Implant Device,3822,40,,3822,percent of total billed charges,Implant Device,3344.25,70,,3344.25,percent of total billed charges,All Other,3248.7,34,,3248.7,percent of total billed charges,Implant Device,3248.7,34,,3248.7,percent of total billed charges,Implant Device,3344.25,35,,3344.25,percent of total billed charges,Implant Device,3344.25,35,,3344.25,percent of total billed charges,Implant Device,3344.25,35,,3344.25,percent of total billed charges,Implant Device,3344.25,35,,3344.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3248.7,34,"If Charge > 2,000, then 34 percent",3248.7,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,7070.72,
P28 P50-053-3522 LOCKING SCREW 3.5X22MM,C1713,HCPCS,,79008027,CDM,278,RC,,,both,,,694,513.56,,,513.56,Other,150% of Medicare + 9.63% HCRA Surcharge,312.3,45,,312.3,percent of total billed charges,Critical Access Hospital RCC factor,235.96,34,,235.96,percent of total billed charges,Implant Device,235.96,34,,235.96,percent of total billed charges,Implant Device,235.96,34,,235.96,percent of total billed charges,Implant Device,235.96,34,,235.96,percent of total billed charges,Implant Device,235.96,34,,235.96,percent of total billed charges,Implant Device,343.53,,,343.53,Other,110% of Medicare,242.9,35,,242.9,percent of total billed charges,Implant Device,235.96,34,"Charges > $500, x 34%",235.96,percent of total billed charges,Implant Device,242.9,35,,242.9,percent of total billed charges,Implant Device,242.9,35,,242.9,percent of total billed charges,Implant Device,242.9,35,,242.9,percent of total billed charges,Implant Device,242.9,35,,242.9,percent of total billed charges,Implant Device,242.9,35,,242.9,percent of total billed charges,Implant Device,277.6,40,,277.6,percent of total billed charges,Implant Device,242.9,70,,242.9,percent of total billed charges,All Other,235.96,34,,235.96,percent of total billed charges,Implant Device,235.96,34,,235.96,percent of total billed charges,Implant Device,242.9,35,,242.9,percent of total billed charges,Implant Device,242.9,35,,242.9,percent of total billed charges,Implant Device,242.9,35,,242.9,percent of total billed charges,Implant Device,242.9,35,,242.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,513.56,
P28 P50-053-4226 LOCKING SCREW 4.2X26MM,C1713,HCPCS,,79008028,CDM,278,RC,,,both,,,718,531.32,,,531.32,Other,150% of Medicare + 9.63% HCRA Surcharge,323.1,45,,323.1,percent of total billed charges,Critical Access Hospital RCC factor,244.12,34,,244.12,percent of total billed charges,Implant Device,244.12,34,,244.12,percent of total billed charges,Implant Device,244.12,34,,244.12,percent of total billed charges,Implant Device,244.12,34,,244.12,percent of total billed charges,Implant Device,244.12,34,,244.12,percent of total billed charges,Implant Device,355.41,,,355.41,Other,110% of Medicare,251.3,35,,251.3,percent of total billed charges,Implant Device,244.12,34,"Charges > $500, x 34%",244.12,percent of total billed charges,Implant Device,251.3,35,,251.3,percent of total billed charges,Implant Device,251.3,35,,251.3,percent of total billed charges,Implant Device,251.3,35,,251.3,percent of total billed charges,Implant Device,251.3,35,,251.3,percent of total billed charges,Implant Device,251.3,35,,251.3,percent of total billed charges,Implant Device,287.2,40,,287.2,percent of total billed charges,Implant Device,251.3,70,,251.3,percent of total billed charges,All Other,244.12,34,,244.12,percent of total billed charges,Implant Device,244.12,34,,244.12,percent of total billed charges,Implant Device,251.3,35,,251.3,percent of total billed charges,Implant Device,251.3,35,,251.3,percent of total billed charges,Implant Device,251.3,35,,251.3,percent of total billed charges,Implant Device,251.3,35,,251.3,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,531.32,
P28 P53-104-0210 EVANS WEDGE PLATE 10MM,C1713,HCPCS,,79008029,CDM,278,RC,,,both,,,5784,4280.17,,,4280.17,Other,150% of Medicare + 9.63% HCRA Surcharge,2602.8,45,,2602.8,percent of total billed charges,Critical Access Hospital RCC factor,1966.56,34,,1966.56,percent of total billed charges,Implant Device,1966.56,34,,1966.56,percent of total billed charges,Implant Device,1966.56,34,,1966.56,percent of total billed charges,Implant Device,1966.56,34,,1966.56,percent of total billed charges,Implant Device,1966.56,34,,1966.56,percent of total billed charges,Implant Device,2863.08,,,2863.08,Other,110% of Medicare,2024.4,35,,2024.4,percent of total billed charges,Implant Device,1966.56,34,"Charges > $500, x 34%",1966.56,percent of total billed charges,Implant Device,2024.4,35,,2024.4,percent of total billed charges,Implant Device,2024.4,35,,2024.4,percent of total billed charges,Implant Device,2024.4,35,,2024.4,percent of total billed charges,Implant Device,2024.4,35,,2024.4,percent of total billed charges,Implant Device,2024.4,35,,2024.4,percent of total billed charges,Implant Device,2313.6,40,,2313.6,percent of total billed charges,Implant Device,2024.4,70,,2024.4,percent of total billed charges,All Other,1966.56,34,,1966.56,percent of total billed charges,Implant Device,1966.56,34,,1966.56,percent of total billed charges,Implant Device,2024.4,35,,2024.4,percent of total billed charges,Implant Device,2024.4,35,,2024.4,percent of total billed charges,Implant Device,2024.4,35,,2024.4,percent of total billed charges,Implant Device,2024.4,35,,2024.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1966.56,34,"If Charge > 2,000, then 34 percent",1966.56,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4280.17,
P28 PLCL-30012 EVANS WEDGE 12MM,C1713,HCPCS,,79008030,CDM,278,RC,,,both,,,4485,3318.91,,,3318.91,Other,150% of Medicare + 9.63% HCRA Surcharge,2018.25,45,,2018.25,percent of total billed charges,Critical Access Hospital RCC factor,1524.9,34,,1524.9,percent of total billed charges,Implant Device,1524.9,34,,1524.9,percent of total billed charges,Implant Device,1524.9,34,,1524.9,percent of total billed charges,Implant Device,1524.9,34,,1524.9,percent of total billed charges,Implant Device,1524.9,34,,1524.9,percent of total billed charges,Implant Device,2220.08,,,2220.08,Other,110% of Medicare,1569.75,35,,1569.75,percent of total billed charges,Implant Device,1524.9,34,"Charges > $500, x 34%",1524.9,percent of total billed charges,Implant Device,1569.75,35,,1569.75,percent of total billed charges,Implant Device,1569.75,35,,1569.75,percent of total billed charges,Implant Device,1569.75,35,,1569.75,percent of total billed charges,Implant Device,1569.75,35,,1569.75,percent of total billed charges,Implant Device,1569.75,35,,1569.75,percent of total billed charges,Implant Device,1794,40,,1794,percent of total billed charges,Implant Device,1569.75,70,,1569.75,percent of total billed charges,All Other,1524.9,34,,1524.9,percent of total billed charges,Implant Device,1524.9,34,,1524.9,percent of total billed charges,Implant Device,1569.75,35,,1569.75,percent of total billed charges,Implant Device,1569.75,35,,1569.75,percent of total billed charges,Implant Device,1569.75,35,,1569.75,percent of total billed charges,Implant Device,1569.75,35,,1569.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1524.9,34,"If Charge > 2,000, then 34 percent",1524.9,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3318.91,
BME SE-1818TI SPEED TITAN IMPL 18X18X18,C1713,HCPCS,,79008031,CDM,278,RC,,,both,,,3612,2672.89,,,2672.89,Other,150% of Medicare + 9.63% HCRA Surcharge,1625.4,45,,1625.4,percent of total billed charges,Critical Access Hospital RCC factor,1228.08,34,,1228.08,percent of total billed charges,Implant Device,1228.08,34,,1228.08,percent of total billed charges,Implant Device,1228.08,34,,1228.08,percent of total billed charges,Implant Device,1228.08,34,,1228.08,percent of total billed charges,Implant Device,1228.08,34,,1228.08,percent of total billed charges,Implant Device,1787.94,,,1787.94,Other,110% of Medicare,1264.2,35,,1264.2,percent of total billed charges,Implant Device,1228.08,34,"Charges > $500, x 34%",1228.08,percent of total billed charges,Implant Device,1264.2,35,,1264.2,percent of total billed charges,Implant Device,1264.2,35,,1264.2,percent of total billed charges,Implant Device,1264.2,35,,1264.2,percent of total billed charges,Implant Device,1264.2,35,,1264.2,percent of total billed charges,Implant Device,1264.2,35,,1264.2,percent of total billed charges,Implant Device,1444.8,40,,1444.8,percent of total billed charges,Implant Device,1264.2,70,,1264.2,percent of total billed charges,All Other,1228.08,34,,1228.08,percent of total billed charges,Implant Device,1228.08,34,,1228.08,percent of total billed charges,Implant Device,1264.2,35,,1264.2,percent of total billed charges,Implant Device,1264.2,35,,1264.2,percent of total billed charges,Implant Device,1264.2,35,,1264.2,percent of total billed charges,Implant Device,1264.2,35,,1264.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1228.08,34,"If Charge > 2,000, then 34 percent",1228.08,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2672.89,
DEPUY 456.321S 12X125 CANN FIXATION NAIL,C1713,HCPCS,,79008032,CDM,278,RC,,,both,,,2738,2026.13,,,2026.13,Other,150% of Medicare + 9.63% HCRA Surcharge,1232.1,45,,1232.1,percent of total billed charges,Critical Access Hospital RCC factor,930.92,34,,930.92,percent of total billed charges,Implant Device,930.92,34,,930.92,percent of total billed charges,Implant Device,930.92,34,,930.92,percent of total billed charges,Implant Device,930.92,34,,930.92,percent of total billed charges,Implant Device,930.92,34,,930.92,percent of total billed charges,Implant Device,1355.31,,,1355.31,Other,110% of Medicare,958.3,35,,958.3,percent of total billed charges,Implant Device,930.92,34,"Charges > $500, x 34%",930.92,percent of total billed charges,Implant Device,958.3,35,,958.3,percent of total billed charges,Implant Device,958.3,35,,958.3,percent of total billed charges,Implant Device,958.3,35,,958.3,percent of total billed charges,Implant Device,958.3,35,,958.3,percent of total billed charges,Implant Device,958.3,35,,958.3,percent of total billed charges,Implant Device,1095.2,40,,1095.2,percent of total billed charges,Implant Device,958.3,70,,958.3,percent of total billed charges,All Other,930.92,34,,930.92,percent of total billed charges,Implant Device,930.92,34,,930.92,percent of total billed charges,Implant Device,958.3,35,,958.3,percent of total billed charges,Implant Device,958.3,35,,958.3,percent of total billed charges,Implant Device,958.3,35,,958.3,percent of total billed charges,Implant Device,958.3,35,,958.3,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,930.92,34,"If Charge > 2,000, then 34 percent",930.92,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2026.13,
ATLAS SPINE 1106-04-0000 STD LOCK COLLAR,C1713,HCPCS,,79008034,CDM,278,RC,,,both,,,662,489.88,,,489.88,Other,150% of Medicare + 9.63% HCRA Surcharge,297.9,45,,297.9,percent of total billed charges,Critical Access Hospital RCC factor,225.08,34,,225.08,percent of total billed charges,Implant Device,225.08,34,,225.08,percent of total billed charges,Implant Device,225.08,34,,225.08,percent of total billed charges,Implant Device,225.08,34,,225.08,percent of total billed charges,Implant Device,225.08,34,,225.08,percent of total billed charges,Implant Device,327.69,,,327.69,Other,110% of Medicare,231.7,35,,231.7,percent of total billed charges,Implant Device,225.08,34,"Charges > $500, x 34%",225.08,percent of total billed charges,Implant Device,231.7,35,,231.7,percent of total billed charges,Implant Device,231.7,35,,231.7,percent of total billed charges,Implant Device,231.7,35,,231.7,percent of total billed charges,Implant Device,231.7,35,,231.7,percent of total billed charges,Implant Device,231.7,35,,231.7,percent of total billed charges,Implant Device,264.8,40,,264.8,percent of total billed charges,Implant Device,231.7,70,,231.7,percent of total billed charges,All Other,225.08,34,,225.08,percent of total billed charges,Implant Device,225.08,34,,225.08,percent of total billed charges,Implant Device,231.7,35,,231.7,percent of total billed charges,Implant Device,231.7,35,,231.7,percent of total billed charges,Implant Device,231.7,35,,231.7,percent of total billed charges,Implant Device,231.7,35,,231.7,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,489.88,
EXACTECH 314-13-23 GLENOID CAGE LT MED,C1713,HCPCS,,79008035,CDM,278,RC,,,both,,,4725,3496.51,,,3496.51,Other,150% of Medicare + 9.63% HCRA Surcharge,2126.25,45,,2126.25,percent of total billed charges,Critical Access Hospital RCC factor,1606.5,34,,1606.5,percent of total billed charges,Implant Device,1606.5,34,,1606.5,percent of total billed charges,Implant Device,1606.5,34,,1606.5,percent of total billed charges,Implant Device,1606.5,34,,1606.5,percent of total billed charges,Implant Device,1606.5,34,,1606.5,percent of total billed charges,Implant Device,2338.88,,,2338.88,Other,110% of Medicare,1653.75,35,,1653.75,percent of total billed charges,Implant Device,1606.5,34,"Charges > $500, x 34%",1606.5,percent of total billed charges,Implant Device,1653.75,35,,1653.75,percent of total billed charges,Implant Device,1653.75,35,,1653.75,percent of total billed charges,Implant Device,1653.75,35,,1653.75,percent of total billed charges,Implant Device,1653.75,35,,1653.75,percent of total billed charges,Implant Device,1653.75,35,,1653.75,percent of total billed charges,Implant Device,1890,40,,1890,percent of total billed charges,Implant Device,1653.75,70,,1653.75,percent of total billed charges,All Other,1606.5,34,,1606.5,percent of total billed charges,Implant Device,1606.5,34,,1606.5,percent of total billed charges,Implant Device,1653.75,35,,1653.75,percent of total billed charges,Implant Device,1653.75,35,,1653.75,percent of total billed charges,Implant Device,1653.75,35,,1653.75,percent of total billed charges,Implant Device,1653.75,35,,1653.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1606.5,34,"If Charge > 2,000, then 34 percent",1606.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3496.51,
DEPUY 3L93710 CORAIL FEMORAL STEM SZ10,C1776,HCPCS,,79008036,CDM,278,RC,,,both,,,12861,9517.17,,,9517.17,Other,150% of Medicare + 9.63% HCRA Surcharge,5787.45,45,,5787.45,percent of total billed charges,Critical Access Hospital RCC factor,4372.74,34,,4372.74,percent of total billed charges,Implant Device,4372.74,34,,4372.74,percent of total billed charges,Implant Device,4372.74,34,,4372.74,percent of total billed charges,Implant Device,4372.74,34,,4372.74,percent of total billed charges,Implant Device,4372.74,34,,4372.74,percent of total billed charges,Implant Device,6366.2,,,6366.2,Other,110% of Medicare,4501.35,35,,4501.35,percent of total billed charges,Implant Device,4372.74,34,"Charges > $500, x 34%",4372.74,percent of total billed charges,Implant Device,4501.35,35,,4501.35,percent of total billed charges,Implant Device,4501.35,35,,4501.35,percent of total billed charges,Implant Device,4501.35,35,,4501.35,percent of total billed charges,Implant Device,4501.35,35,,4501.35,percent of total billed charges,Implant Device,4501.35,35,,4501.35,percent of total billed charges,Implant Device,5144.4,40,,5144.4,percent of total billed charges,Implant Device,4501.35,70,,4501.35,percent of total billed charges,All Other,4372.74,34,,4372.74,percent of total billed charges,Implant Device,4372.74,34,,4372.74,percent of total billed charges,Implant Device,4501.35,35,,4501.35,percent of total billed charges,Implant Device,4501.35,35,,4501.35,percent of total billed charges,Implant Device,4501.35,35,,4501.35,percent of total billed charges,Implant Device,4501.35,35,,4501.35,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,4372.74,34,"If Charge > 2,000, then 34 percent",4372.74,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,9517.17,
STRYKER 59-23011 BONE SCREW 2.3X11MM,C1713,HCPCS,,79008037,CDM,278,RC,,,both,,,380,281.2,,,281.2,Other,150% of Medicare + 9.63% HCRA Surcharge,171,45,,171,percent of total billed charges,Critical Access Hospital RCC factor,129.2,34,,129.2,percent of total billed charges,Implant Device,129.2,34,,129.2,percent of total billed charges,Implant Device,129.2,34,,129.2,percent of total billed charges,Implant Device,129.2,34,,129.2,percent of total billed charges,Implant Device,129.2,34,,129.2,percent of total billed charges,Implant Device,188.1,,,188.1,Other,110% of Medicare,133,35,,133,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,133,35,,133,percent of total billed charges,Implant Device,133,35,,133,percent of total billed charges,Implant Device,133,35,,133,percent of total billed charges,Implant Device,133,35,,133,percent of total billed charges,Implant Device,133,35,,133,percent of total billed charges,Implant Device,152,40,,152,percent of total billed charges,Implant Device,133,70,,133,percent of total billed charges,All Other,129.2,34,,129.2,percent of total billed charges,Implant Device,129.2,34,,129.2,percent of total billed charges,Implant Device,133,35,,133,percent of total billed charges,Implant Device,133,35,,133,percent of total billed charges,Implant Device,133,35,,133,percent of total billed charges,Implant Device,133,35,,133,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,281.2,
STRYKER 57-10101 PLATE STRT 4 HOLE 2.3MM,C1713,HCPCS,,79008038,CDM,278,RC,,,both,,,959,709.66,,,709.66,Other,150% of Medicare + 9.63% HCRA Surcharge,431.55,45,,431.55,percent of total billed charges,Critical Access Hospital RCC factor,326.06,34,,326.06,percent of total billed charges,Implant Device,326.06,34,,326.06,percent of total billed charges,Implant Device,326.06,34,,326.06,percent of total billed charges,Implant Device,326.06,34,,326.06,percent of total billed charges,Implant Device,326.06,34,,326.06,percent of total billed charges,Implant Device,474.71,,,474.71,Other,110% of Medicare,335.65,35,,335.65,percent of total billed charges,Implant Device,326.06,34,"Charges > $500, x 34%",326.06,percent of total billed charges,Implant Device,335.65,35,,335.65,percent of total billed charges,Implant Device,335.65,35,,335.65,percent of total billed charges,Implant Device,335.65,35,,335.65,percent of total billed charges,Implant Device,335.65,35,,335.65,percent of total billed charges,Implant Device,335.65,35,,335.65,percent of total billed charges,Implant Device,383.6,40,,383.6,percent of total billed charges,Implant Device,335.65,70,,335.65,percent of total billed charges,All Other,326.06,34,,326.06,percent of total billed charges,Implant Device,326.06,34,,326.06,percent of total billed charges,Implant Device,335.65,35,,335.65,percent of total billed charges,Implant Device,335.65,35,,335.65,percent of total billed charges,Implant Device,335.65,35,,335.65,percent of total billed charges,Implant Device,335.65,35,,335.65,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,709.66,
ALLERGAN MF410470 SILICONE IMPLANT,C1789,HCPCS,,79008041,CDM,278,RC,,,both,,,3976,2942.25,,,2942.25,Other,150% of Medicare + 9.63% HCRA Surcharge,1789.2,45,,1789.2,percent of total billed charges,Critical Access Hospital RCC factor,1351.84,34,,1351.84,percent of total billed charges,Implant Device,1351.84,34,,1351.84,percent of total billed charges,Implant Device,1351.84,34,,1351.84,percent of total billed charges,Implant Device,1351.84,34,,1351.84,percent of total billed charges,Implant Device,1351.84,34,,1351.84,percent of total billed charges,Implant Device,1968.12,,,1968.12,Other,110% of Medicare,1391.6,35,,1391.6,percent of total billed charges,Implant Device,1351.84,34,"Charges > $500, x 34%",1351.84,percent of total billed charges,Implant Device,1391.6,35,,1391.6,percent of total billed charges,Implant Device,1391.6,35,,1391.6,percent of total billed charges,Implant Device,1391.6,35,,1391.6,percent of total billed charges,Implant Device,1391.6,35,,1391.6,percent of total billed charges,Implant Device,1391.6,35,,1391.6,percent of total billed charges,Implant Device,1590.4,40,,1590.4,percent of total billed charges,Implant Device,1391.6,70,,1391.6,percent of total billed charges,All Other,1351.84,34,,1351.84,percent of total billed charges,Implant Device,1351.84,34,,1351.84,percent of total billed charges,Implant Device,1391.6,35,,1391.6,percent of total billed charges,Implant Device,1391.6,35,,1391.6,percent of total billed charges,Implant Device,1391.6,35,,1391.6,percent of total billed charges,Implant Device,1391.6,35,,1391.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1351.84,34,"If Charge > 2,000, then 34 percent",1351.84,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2942.25,
STRYKER 602875 3.5X75MM CANNULATED SCREW,C1713,HCPCS,,79008043,CDM,278,RC,,,both,,,1145,847.3,,,847.3,Other,150% of Medicare + 9.63% HCRA Surcharge,515.25,45,,515.25,percent of total billed charges,Critical Access Hospital RCC factor,389.3,34,,389.3,percent of total billed charges,Implant Device,389.3,34,,389.3,percent of total billed charges,Implant Device,389.3,34,,389.3,percent of total billed charges,Implant Device,389.3,34,,389.3,percent of total billed charges,Implant Device,389.3,34,,389.3,percent of total billed charges,Implant Device,566.78,,,566.78,Other,110% of Medicare,400.75,35,,400.75,percent of total billed charges,Implant Device,389.3,34,"Charges > $500, x 34%",389.3,percent of total billed charges,Implant Device,400.75,35,,400.75,percent of total billed charges,Implant Device,400.75,35,,400.75,percent of total billed charges,Implant Device,400.75,35,,400.75,percent of total billed charges,Implant Device,400.75,35,,400.75,percent of total billed charges,Implant Device,400.75,35,,400.75,percent of total billed charges,Implant Device,458,40,,458,percent of total billed charges,Implant Device,400.75,70,,400.75,percent of total billed charges,All Other,389.3,34,,389.3,percent of total billed charges,Implant Device,389.3,34,,389.3,percent of total billed charges,Implant Device,400.75,35,,400.75,percent of total billed charges,Implant Device,400.75,35,,400.75,percent of total billed charges,Implant Device,400.75,35,,400.75,percent of total billed charges,Implant Device,400.75,35,,400.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,847.3,
STRYKER 602885 3.5X80MM CANNULATED SCREW,C1713,HCPCS,,79008044,CDM,278,RC,,,both,,,696,515.04,,,515.04,Other,150% of Medicare + 9.63% HCRA Surcharge,313.2,45,,313.2,percent of total billed charges,Critical Access Hospital RCC factor,236.64,34,,236.64,percent of total billed charges,Implant Device,236.64,34,,236.64,percent of total billed charges,Implant Device,236.64,34,,236.64,percent of total billed charges,Implant Device,236.64,34,,236.64,percent of total billed charges,Implant Device,236.64,34,,236.64,percent of total billed charges,Implant Device,344.52,,,344.52,Other,110% of Medicare,243.6,35,,243.6,percent of total billed charges,Implant Device,236.64,34,"Charges > $500, x 34%",236.64,percent of total billed charges,Implant Device,243.6,35,,243.6,percent of total billed charges,Implant Device,243.6,35,,243.6,percent of total billed charges,Implant Device,243.6,35,,243.6,percent of total billed charges,Implant Device,243.6,35,,243.6,percent of total billed charges,Implant Device,243.6,35,,243.6,percent of total billed charges,Implant Device,278.4,40,,278.4,percent of total billed charges,Implant Device,243.6,70,,243.6,percent of total billed charges,All Other,236.64,34,,236.64,percent of total billed charges,Implant Device,236.64,34,,236.64,percent of total billed charges,Implant Device,243.6,35,,243.6,percent of total billed charges,Implant Device,243.6,35,,243.6,percent of total billed charges,Implant Device,243.6,35,,243.6,percent of total billed charges,Implant Device,243.6,35,,243.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,515.04,
STRYKER 326090 ASNIS CANN SCREW 6.5X90MM,C1713,HCPCS,,79008045,CDM,278,RC,,,both,,,765,566.1,,,566.1,Other,150% of Medicare + 9.63% HCRA Surcharge,344.25,45,,344.25,percent of total billed charges,Critical Access Hospital RCC factor,260.1,34,,260.1,percent of total billed charges,Implant Device,260.1,34,,260.1,percent of total billed charges,Implant Device,260.1,34,,260.1,percent of total billed charges,Implant Device,260.1,34,,260.1,percent of total billed charges,Implant Device,260.1,34,,260.1,percent of total billed charges,Implant Device,378.68,,,378.68,Other,110% of Medicare,267.75,35,,267.75,percent of total billed charges,Implant Device,260.1,34,"Charges > $500, x 34%",260.1,percent of total billed charges,Implant Device,267.75,35,,267.75,percent of total billed charges,Implant Device,267.75,35,,267.75,percent of total billed charges,Implant Device,267.75,35,,267.75,percent of total billed charges,Implant Device,267.75,35,,267.75,percent of total billed charges,Implant Device,267.75,35,,267.75,percent of total billed charges,Implant Device,306,40,,306,percent of total billed charges,Implant Device,267.75,70,,267.75,percent of total billed charges,All Other,260.1,34,,260.1,percent of total billed charges,Implant Device,260.1,34,,260.1,percent of total billed charges,Implant Device,267.75,35,,267.75,percent of total billed charges,Implant Device,267.75,35,,267.75,percent of total billed charges,Implant Device,267.75,35,,267.75,percent of total billed charges,Implant Device,267.75,35,,267.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,566.1,
LIFENET FGL GRAFTLINK ALLOGRAFT PREMADE,C1713,HCPCS,,79008046,CDM,278,RC,,,both,,,6886,5095.66,,,5095.66,Other,150% of Medicare + 9.63% HCRA Surcharge,3098.7,45,,3098.7,percent of total billed charges,Critical Access Hospital RCC factor,2341.24,34,,2341.24,percent of total billed charges,Implant Device,2341.24,34,,2341.24,percent of total billed charges,Implant Device,2341.24,34,,2341.24,percent of total billed charges,Implant Device,2341.24,34,,2341.24,percent of total billed charges,Implant Device,2341.24,34,,2341.24,percent of total billed charges,Implant Device,3408.57,,,3408.57,Other,110% of Medicare,2410.1,35,,2410.1,percent of total billed charges,Implant Device,2341.24,34,"Charges > $500, x 34%",2341.24,percent of total billed charges,Implant Device,2410.1,35,,2410.1,percent of total billed charges,Implant Device,2410.1,35,,2410.1,percent of total billed charges,Implant Device,2410.1,35,,2410.1,percent of total billed charges,Implant Device,2410.1,35,,2410.1,percent of total billed charges,Implant Device,2410.1,35,,2410.1,percent of total billed charges,Implant Device,2754.4,40,,2754.4,percent of total billed charges,Implant Device,2410.1,70,,2410.1,percent of total billed charges,All Other,2341.24,34,,2341.24,percent of total billed charges,Implant Device,2341.24,34,,2341.24,percent of total billed charges,Implant Device,2410.1,35,,2410.1,percent of total billed charges,Implant Device,2410.1,35,,2410.1,percent of total billed charges,Implant Device,2410.1,35,,2410.1,percent of total billed charges,Implant Device,2410.1,35,,2410.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2341.24,34,"If Charge > 2,000, then 34 percent",2341.24,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5095.66,
ARTHREX AR-1588TN-1 OPEN TBS TIGHTROPE,C1713,HCPCS,,79008047,CDM,278,RC,,,both,,,582,430.68,,,430.68,Other,150% of Medicare + 9.63% HCRA Surcharge,261.9,45,,261.9,percent of total billed charges,Critical Access Hospital RCC factor,197.88,34,,197.88,percent of total billed charges,Implant Device,197.88,34,,197.88,percent of total billed charges,Implant Device,197.88,34,,197.88,percent of total billed charges,Implant Device,197.88,34,,197.88,percent of total billed charges,Implant Device,197.88,34,,197.88,percent of total billed charges,Implant Device,288.09,,,288.09,Other,110% of Medicare,203.7,35,,203.7,percent of total billed charges,Implant Device,197.88,34,"Charges > $500, x 34%",197.88,percent of total billed charges,Implant Device,203.7,35,,203.7,percent of total billed charges,Implant Device,203.7,35,,203.7,percent of total billed charges,Implant Device,203.7,35,,203.7,percent of total billed charges,Implant Device,203.7,35,,203.7,percent of total billed charges,Implant Device,203.7,35,,203.7,percent of total billed charges,Implant Device,232.8,40,,232.8,percent of total billed charges,Implant Device,203.7,70,,203.7,percent of total billed charges,All Other,197.88,34,,197.88,percent of total billed charges,Implant Device,197.88,34,,197.88,percent of total billed charges,Implant Device,203.7,35,,203.7,percent of total billed charges,Implant Device,203.7,35,,203.7,percent of total billed charges,Implant Device,203.7,35,,203.7,percent of total billed charges,Implant Device,203.7,35,,203.7,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,430.68,
ARTHREX AR-1588TB BUTTON 8/X12,C1713,HCPCS,,79008048,CDM,278,RC,,,both,,,616,455.84,,,455.84,Other,150% of Medicare + 9.63% HCRA Surcharge,277.2,45,,277.2,percent of total billed charges,Critical Access Hospital RCC factor,209.44,34,,209.44,percent of total billed charges,Implant Device,209.44,34,,209.44,percent of total billed charges,Implant Device,209.44,34,,209.44,percent of total billed charges,Implant Device,209.44,34,,209.44,percent of total billed charges,Implant Device,209.44,34,,209.44,percent of total billed charges,Implant Device,304.92,,,304.92,Other,110% of Medicare,215.6,35,,215.6,percent of total billed charges,Implant Device,209.44,34,"Charges > $500, x 34%",209.44,percent of total billed charges,Implant Device,215.6,35,,215.6,percent of total billed charges,Implant Device,215.6,35,,215.6,percent of total billed charges,Implant Device,215.6,35,,215.6,percent of total billed charges,Implant Device,215.6,35,,215.6,percent of total billed charges,Implant Device,215.6,35,,215.6,percent of total billed charges,Implant Device,246.4,40,,246.4,percent of total billed charges,Implant Device,215.6,70,,215.6,percent of total billed charges,All Other,209.44,34,,209.44,percent of total billed charges,Implant Device,209.44,34,,209.44,percent of total billed charges,Implant Device,215.6,35,,215.6,percent of total billed charges,Implant Device,215.6,35,,215.6,percent of total billed charges,Implant Device,215.6,35,,215.6,percent of total billed charges,Implant Device,215.6,35,,215.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,455.84,
STRYKER 3225-0440S LONG NAIL TI 11X440MM,C1713,HCPCS,,79008050,CDM,278,RC,,,both,,,8879,6570.48,,,6570.48,Other,150% of Medicare + 9.63% HCRA Surcharge,3995.55,45,,3995.55,percent of total billed charges,Critical Access Hospital RCC factor,3018.86,34,,3018.86,percent of total billed charges,Implant Device,3018.86,34,,3018.86,percent of total billed charges,Implant Device,3018.86,34,,3018.86,percent of total billed charges,Implant Device,3018.86,34,,3018.86,percent of total billed charges,Implant Device,3018.86,34,,3018.86,percent of total billed charges,Implant Device,4395.11,,,4395.11,Other,110% of Medicare,3107.65,35,,3107.65,percent of total billed charges,Implant Device,3018.86,34,"Charges > $500, x 34%",3018.86,percent of total billed charges,Implant Device,3107.65,35,,3107.65,percent of total billed charges,Implant Device,3107.65,35,,3107.65,percent of total billed charges,Implant Device,3107.65,35,,3107.65,percent of total billed charges,Implant Device,3107.65,35,,3107.65,percent of total billed charges,Implant Device,3107.65,35,,3107.65,percent of total billed charges,Implant Device,3551.6,40,,3551.6,percent of total billed charges,Implant Device,3107.65,70,,3107.65,percent of total billed charges,All Other,3018.86,34,,3018.86,percent of total billed charges,Implant Device,3018.86,34,,3018.86,percent of total billed charges,Implant Device,3107.65,35,,3107.65,percent of total billed charges,Implant Device,3107.65,35,,3107.65,percent of total billed charges,Implant Device,3107.65,35,,3107.65,percent of total billed charges,Implant Device,3107.65,35,,3107.65,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3018.86,34,"If Charge > 2,000, then 34 percent",3018.86,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,6570.48,
DEPUY 240.039 PROXTIB PLATE 6H 4.5X118MM,C1713,HCPCS,,79008051,CDM,278,RC,,,both,,,6351,4699.76,,,4699.76,Other,150% of Medicare + 9.63% HCRA Surcharge,2857.95,45,,2857.95,percent of total billed charges,Critical Access Hospital RCC factor,2159.34,34,,2159.34,percent of total billed charges,Implant Device,2159.34,34,,2159.34,percent of total billed charges,Implant Device,2159.34,34,,2159.34,percent of total billed charges,Implant Device,2159.34,34,,2159.34,percent of total billed charges,Implant Device,2159.34,34,,2159.34,percent of total billed charges,Implant Device,3143.75,,,3143.75,Other,110% of Medicare,2222.85,35,,2222.85,percent of total billed charges,Implant Device,2159.34,34,"Charges > $500, x 34%",2159.34,percent of total billed charges,Implant Device,2222.85,35,,2222.85,percent of total billed charges,Implant Device,2222.85,35,,2222.85,percent of total billed charges,Implant Device,2222.85,35,,2222.85,percent of total billed charges,Implant Device,2222.85,35,,2222.85,percent of total billed charges,Implant Device,2222.85,35,,2222.85,percent of total billed charges,Implant Device,2540.4,40,,2540.4,percent of total billed charges,Implant Device,2222.85,70,,2222.85,percent of total billed charges,All Other,2159.34,34,,2159.34,percent of total billed charges,Implant Device,2159.34,34,,2159.34,percent of total billed charges,Implant Device,2222.85,35,,2222.85,percent of total billed charges,Implant Device,2222.85,35,,2222.85,percent of total billed charges,Implant Device,2222.85,35,,2222.85,percent of total billed charges,Implant Device,2222.85,35,,2222.85,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2159.34,34,"If Charge > 2,000, then 34 percent",2159.34,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4699.76,
DEPUY 214.846 CORTEX SCREW 4.5X46MM,C1713,HCPCS,,79008052,CDM,278,RC,,,both,,,57,42.18,,,42.18,Other,150% of Medicare + 9.63% HCRA Surcharge,25.65,45,,25.65,percent of total billed charges,Critical Access Hospital RCC factor,19.38,34,,19.38,percent of total billed charges,Implant Device,19.38,34,,19.38,percent of total billed charges,Implant Device,19.38,34,,19.38,percent of total billed charges,Implant Device,19.38,34,,19.38,percent of total billed charges,Implant Device,19.38,34,,19.38,percent of total billed charges,Implant Device,28.22,,,28.22,Other,110% of Medicare,19.95,35,,19.95,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,19.95,35,,19.95,percent of total billed charges,Implant Device,19.95,35,,19.95,percent of total billed charges,Implant Device,19.95,35,,19.95,percent of total billed charges,Implant Device,19.95,35,,19.95,percent of total billed charges,Implant Device,19.95,35,,19.95,percent of total billed charges,Implant Device,22.8,40,,22.8,percent of total billed charges,Implant Device,19.95,70,,19.95,percent of total billed charges,All Other,19.38,34,,19.38,percent of total billed charges,Implant Device,19.38,34,,19.38,percent of total billed charges,Implant Device,19.95,35,,19.95,percent of total billed charges,Implant Device,19.95,35,,19.95,percent of total billed charges,Implant Device,19.95,35,,19.95,percent of total billed charges,Implant Device,19.95,35,,19.95,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,42.18,
DEPUY 214.836 CORTEX SCREW 4.5X36MM,C1713,HCPCS,,79008053,CDM,278,RC,,,both,,,57,42.18,,,42.18,Other,150% of Medicare + 9.63% HCRA Surcharge,25.65,45,,25.65,percent of total billed charges,Critical Access Hospital RCC factor,19.38,34,,19.38,percent of total billed charges,Implant Device,19.38,34,,19.38,percent of total billed charges,Implant Device,19.38,34,,19.38,percent of total billed charges,Implant Device,19.38,34,,19.38,percent of total billed charges,Implant Device,19.38,34,,19.38,percent of total billed charges,Implant Device,28.22,,,28.22,Other,110% of Medicare,19.95,35,,19.95,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,19.95,35,,19.95,percent of total billed charges,Implant Device,19.95,35,,19.95,percent of total billed charges,Implant Device,19.95,35,,19.95,percent of total billed charges,Implant Device,19.95,35,,19.95,percent of total billed charges,Implant Device,19.95,35,,19.95,percent of total billed charges,Implant Device,22.8,40,,22.8,percent of total billed charges,Implant Device,19.95,70,,19.95,percent of total billed charges,All Other,19.38,34,,19.38,percent of total billed charges,Implant Device,19.38,34,,19.38,percent of total billed charges,Implant Device,19.95,35,,19.95,percent of total billed charges,Implant Device,19.95,35,,19.95,percent of total billed charges,Implant Device,19.95,35,,19.95,percent of total billed charges,Implant Device,19.95,35,,19.95,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,42.18,
DEPUY 02.205.070 CANN LOCK SCREW 5X70MM,C1713,HCPCS,,79008054,CDM,278,RC,,,both,,,867,641.58,,,641.58,Other,150% of Medicare + 9.63% HCRA Surcharge,390.15,45,,390.15,percent of total billed charges,Critical Access Hospital RCC factor,294.78,34,,294.78,percent of total billed charges,Implant Device,294.78,34,,294.78,percent of total billed charges,Implant Device,294.78,34,,294.78,percent of total billed charges,Implant Device,294.78,34,,294.78,percent of total billed charges,Implant Device,294.78,34,,294.78,percent of total billed charges,Implant Device,429.17,,,429.17,Other,110% of Medicare,303.45,35,,303.45,percent of total billed charges,Implant Device,294.78,34,"Charges > $500, x 34%",294.78,percent of total billed charges,Implant Device,303.45,35,,303.45,percent of total billed charges,Implant Device,303.45,35,,303.45,percent of total billed charges,Implant Device,303.45,35,,303.45,percent of total billed charges,Implant Device,303.45,35,,303.45,percent of total billed charges,Implant Device,303.45,35,,303.45,percent of total billed charges,Implant Device,346.8,40,,346.8,percent of total billed charges,Implant Device,303.45,70,,303.45,percent of total billed charges,All Other,294.78,34,,294.78,percent of total billed charges,Implant Device,294.78,34,,294.78,percent of total billed charges,Implant Device,303.45,35,,303.45,percent of total billed charges,Implant Device,303.45,35,,303.45,percent of total billed charges,Implant Device,303.45,35,,303.45,percent of total billed charges,Implant Device,303.45,35,,303.45,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,641.58,
DEPUY 02.205.075 CANN LOCK SCREW 5X75MM,C1713,HCPCS,,79008055,CDM,278,RC,,,both,,,867,641.58,,,641.58,Other,150% of Medicare + 9.63% HCRA Surcharge,390.15,45,,390.15,percent of total billed charges,Critical Access Hospital RCC factor,294.78,34,,294.78,percent of total billed charges,Implant Device,294.78,34,,294.78,percent of total billed charges,Implant Device,294.78,34,,294.78,percent of total billed charges,Implant Device,294.78,34,,294.78,percent of total billed charges,Implant Device,294.78,34,,294.78,percent of total billed charges,Implant Device,429.17,,,429.17,Other,110% of Medicare,303.45,35,,303.45,percent of total billed charges,Implant Device,294.78,34,"Charges > $500, x 34%",294.78,percent of total billed charges,Implant Device,303.45,35,,303.45,percent of total billed charges,Implant Device,303.45,35,,303.45,percent of total billed charges,Implant Device,303.45,35,,303.45,percent of total billed charges,Implant Device,303.45,35,,303.45,percent of total billed charges,Implant Device,303.45,35,,303.45,percent of total billed charges,Implant Device,346.8,40,,346.8,percent of total billed charges,Implant Device,303.45,70,,303.45,percent of total billed charges,All Other,294.78,34,,294.78,percent of total billed charges,Implant Device,294.78,34,,294.78,percent of total billed charges,Implant Device,303.45,35,,303.45,percent of total billed charges,Implant Device,303.45,35,,303.45,percent of total billed charges,Implant Device,303.45,35,,303.45,percent of total billed charges,Implant Device,303.45,35,,303.45,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,641.58,
DEPUY 214.870 CORTEX SCREW 4.5X70MM,C1713,HCPCS,,79008056,CDM,278,RC,,,both,,,83,61.42,,,61.42,Other,150% of Medicare + 9.63% HCRA Surcharge,37.35,45,,37.35,percent of total billed charges,Critical Access Hospital RCC factor,28.22,34,,28.22,percent of total billed charges,Implant Device,28.22,34,,28.22,percent of total billed charges,Implant Device,28.22,34,,28.22,percent of total billed charges,Implant Device,28.22,34,,28.22,percent of total billed charges,Implant Device,28.22,34,,28.22,percent of total billed charges,Implant Device,41.09,,,41.09,Other,110% of Medicare,29.05,35,,29.05,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,29.05,35,,29.05,percent of total billed charges,Implant Device,29.05,35,,29.05,percent of total billed charges,Implant Device,29.05,35,,29.05,percent of total billed charges,Implant Device,29.05,35,,29.05,percent of total billed charges,Implant Device,29.05,35,,29.05,percent of total billed charges,Implant Device,33.2,40,,33.2,percent of total billed charges,Implant Device,29.05,70,,29.05,percent of total billed charges,All Other,28.22,34,,28.22,percent of total billed charges,Implant Device,28.22,34,,28.22,percent of total billed charges,Implant Device,29.05,35,,29.05,percent of total billed charges,Implant Device,29.05,35,,29.05,percent of total billed charges,Implant Device,29.05,35,,29.05,percent of total billed charges,Implant Device,29.05,35,,29.05,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,61.42,
DEPUY 02.240.234 CANN CONCL SCREW 3.7X25,C1713,HCPCS,,79008058,CDM,278,RC,,,both,,,741,548.34,,,548.34,Other,150% of Medicare + 9.63% HCRA Surcharge,333.45,45,,333.45,percent of total billed charges,Critical Access Hospital RCC factor,251.94,34,,251.94,percent of total billed charges,Implant Device,251.94,34,,251.94,percent of total billed charges,Implant Device,251.94,34,,251.94,percent of total billed charges,Implant Device,251.94,34,,251.94,percent of total billed charges,Implant Device,251.94,34,,251.94,percent of total billed charges,Implant Device,366.8,,,366.8,Other,110% of Medicare,259.35,35,,259.35,percent of total billed charges,Implant Device,251.94,34,"Charges > $500, x 34%",251.94,percent of total billed charges,Implant Device,259.35,35,,259.35,percent of total billed charges,Implant Device,259.35,35,,259.35,percent of total billed charges,Implant Device,259.35,35,,259.35,percent of total billed charges,Implant Device,259.35,35,,259.35,percent of total billed charges,Implant Device,259.35,35,,259.35,percent of total billed charges,Implant Device,296.4,40,,296.4,percent of total billed charges,Implant Device,259.35,70,,259.35,percent of total billed charges,All Other,251.94,34,,251.94,percent of total billed charges,Implant Device,251.94,34,,251.94,percent of total billed charges,Implant Device,259.35,35,,259.35,percent of total billed charges,Implant Device,259.35,35,,259.35,percent of total billed charges,Implant Device,259.35,35,,259.35,percent of total billed charges,Implant Device,259.35,35,,259.35,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,548.34,
DEPUY SYNTHES 217.075 CANC SCREW 6.5X75,C1713,HCPCS,,79008059,CDM,278,RC,,,both,,,173,128.02,,,128.02,Other,150% of Medicare + 9.63% HCRA Surcharge,77.85,45,,77.85,percent of total billed charges,Critical Access Hospital RCC factor,58.82,34,,58.82,percent of total billed charges,Implant Device,58.82,34,,58.82,percent of total billed charges,Implant Device,58.82,34,,58.82,percent of total billed charges,Implant Device,58.82,34,,58.82,percent of total billed charges,Implant Device,58.82,34,,58.82,percent of total billed charges,Implant Device,85.64,,,85.64,Other,110% of Medicare,60.55,35,,60.55,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,60.55,35,,60.55,percent of total billed charges,Implant Device,60.55,35,,60.55,percent of total billed charges,Implant Device,60.55,35,,60.55,percent of total billed charges,Implant Device,60.55,35,,60.55,percent of total billed charges,Implant Device,60.55,35,,60.55,percent of total billed charges,Implant Device,69.2,40,,69.2,percent of total billed charges,Implant Device,60.55,70,,60.55,percent of total billed charges,All Other,58.82,34,,58.82,percent of total billed charges,Implant Device,58.82,34,,58.82,percent of total billed charges,Implant Device,60.55,35,,60.55,percent of total billed charges,Implant Device,60.55,35,,60.55,percent of total billed charges,Implant Device,60.55,35,,60.55,percent of total billed charges,Implant Device,60.55,35,,60.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,128.02,
DEPUY SYNTHES 245.081 PLATE 8 HOLE,C1713,HCPCS,,79008060,CDM,278,RC,,,both,,,2412,1784.89,,,1784.89,Other,150% of Medicare + 9.63% HCRA Surcharge,1085.4,45,,1085.4,percent of total billed charges,Critical Access Hospital RCC factor,820.08,34,,820.08,percent of total billed charges,Implant Device,820.08,34,,820.08,percent of total billed charges,Implant Device,820.08,34,,820.08,percent of total billed charges,Implant Device,820.08,34,,820.08,percent of total billed charges,Implant Device,820.08,34,,820.08,percent of total billed charges,Implant Device,1193.94,,,1193.94,Other,110% of Medicare,844.2,35,,844.2,percent of total billed charges,Implant Device,820.08,34,"Charges > $500, x 34%",820.08,percent of total billed charges,Implant Device,844.2,35,,844.2,percent of total billed charges,Implant Device,844.2,35,,844.2,percent of total billed charges,Implant Device,844.2,35,,844.2,percent of total billed charges,Implant Device,844.2,35,,844.2,percent of total billed charges,Implant Device,844.2,35,,844.2,percent of total billed charges,Implant Device,964.8,40,,964.8,percent of total billed charges,Implant Device,844.2,70,,844.2,percent of total billed charges,All Other,820.08,34,,820.08,percent of total billed charges,Implant Device,820.08,34,,820.08,percent of total billed charges,Implant Device,844.2,35,,844.2,percent of total billed charges,Implant Device,844.2,35,,844.2,percent of total billed charges,Implant Device,844.2,35,,844.2,percent of total billed charges,Implant Device,844.2,35,,844.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,820.08,34,"If Charge > 2,000, then 34 percent",820.08,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1784.89,
STRYKER 53-23014E 2.3X12MM LOCK SCREW,C1713,HCPCS,,79008061,CDM,278,RC,,,both,,,426,315.24,,,315.24,Other,150% of Medicare + 9.63% HCRA Surcharge,191.7,45,,191.7,percent of total billed charges,Critical Access Hospital RCC factor,144.84,34,,144.84,percent of total billed charges,Implant Device,144.84,34,,144.84,percent of total billed charges,Implant Device,144.84,34,,144.84,percent of total billed charges,Implant Device,144.84,34,,144.84,percent of total billed charges,Implant Device,144.84,34,,144.84,percent of total billed charges,Implant Device,210.87,,,210.87,Other,110% of Medicare,149.1,35,,149.1,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,149.1,35,,149.1,percent of total billed charges,Implant Device,149.1,35,,149.1,percent of total billed charges,Implant Device,149.1,35,,149.1,percent of total billed charges,Implant Device,149.1,35,,149.1,percent of total billed charges,Implant Device,149.1,35,,149.1,percent of total billed charges,Implant Device,170.4,40,,170.4,percent of total billed charges,Implant Device,149.1,70,,149.1,percent of total billed charges,All Other,144.84,34,,144.84,percent of total billed charges,Implant Device,144.84,34,,144.84,percent of total billed charges,Implant Device,149.1,35,,149.1,percent of total billed charges,Implant Device,149.1,35,,149.1,percent of total billed charges,Implant Device,149.1,35,,149.1,percent of total billed charges,Implant Device,149.1,35,,149.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,315.24,
ZIMMER 00-5990-035-24 FEM AUG BLOCK E 20,C1776,HCPCS,,79008062,CDM,278,RC,,,both,,,3488,2581.13,,,2581.13,Other,150% of Medicare + 9.63% HCRA Surcharge,1569.6,45,,1569.6,percent of total billed charges,Critical Access Hospital RCC factor,1185.92,34,,1185.92,percent of total billed charges,Implant Device,1185.92,34,,1185.92,percent of total billed charges,Implant Device,1185.92,34,,1185.92,percent of total billed charges,Implant Device,1185.92,34,,1185.92,percent of total billed charges,Implant Device,1185.92,34,,1185.92,percent of total billed charges,Implant Device,1726.56,,,1726.56,Other,110% of Medicare,1220.8,35,,1220.8,percent of total billed charges,Implant Device,1185.92,34,"Charges > $500, x 34%",1185.92,percent of total billed charges,Implant Device,1220.8,35,,1220.8,percent of total billed charges,Implant Device,1220.8,35,,1220.8,percent of total billed charges,Implant Device,1220.8,35,,1220.8,percent of total billed charges,Implant Device,1220.8,35,,1220.8,percent of total billed charges,Implant Device,1220.8,35,,1220.8,percent of total billed charges,Implant Device,1395.2,40,,1395.2,percent of total billed charges,Implant Device,1220.8,70,,1220.8,percent of total billed charges,All Other,1185.92,34,,1185.92,percent of total billed charges,Implant Device,1185.92,34,,1185.92,percent of total billed charges,Implant Device,1220.8,35,,1220.8,percent of total billed charges,Implant Device,1220.8,35,,1220.8,percent of total billed charges,Implant Device,1220.8,35,,1220.8,percent of total billed charges,Implant Device,1220.8,35,,1220.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1185.92,34,"If Charge > 2,000, then 34 percent",1185.92,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2581.13,
WRIGHT K20003010 AUGMENT BONE GRAFT 3CC,C1713,HCPCS,,79008066,CDM,278,RC,,,both,,,10485,7758.93,,,7758.93,Other,150% of Medicare + 9.63% HCRA Surcharge,4718.25,45,,4718.25,percent of total billed charges,Critical Access Hospital RCC factor,3564.9,34,,3564.9,percent of total billed charges,Implant Device,3564.9,34,,3564.9,percent of total billed charges,Implant Device,3564.9,34,,3564.9,percent of total billed charges,Implant Device,3564.9,34,,3564.9,percent of total billed charges,Implant Device,3564.9,34,,3564.9,percent of total billed charges,Implant Device,5190.08,,,5190.08,Other,110% of Medicare,3669.75,35,,3669.75,percent of total billed charges,Implant Device,3564.9,34,"Charges > $500, x 34%",3564.9,percent of total billed charges,Implant Device,3669.75,35,,3669.75,percent of total billed charges,Implant Device,3669.75,35,,3669.75,percent of total billed charges,Implant Device,3669.75,35,,3669.75,percent of total billed charges,Implant Device,3669.75,35,,3669.75,percent of total billed charges,Implant Device,3669.75,35,,3669.75,percent of total billed charges,Implant Device,4194,40,,4194,percent of total billed charges,Implant Device,3669.75,70,,3669.75,percent of total billed charges,All Other,3564.9,34,,3564.9,percent of total billed charges,Implant Device,3564.9,34,,3564.9,percent of total billed charges,Implant Device,3669.75,35,,3669.75,percent of total billed charges,Implant Device,3669.75,35,,3669.75,percent of total billed charges,Implant Device,3669.75,35,,3669.75,percent of total billed charges,Implant Device,3669.75,35,,3669.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3564.9,34,"If Charge > 2,000, then 34 percent",3564.9,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,7758.93,
ZIMMER 00-2359-014-45 LOCK SCREW 4.5X14,C1713,HCPCS,,79008068,CDM,278,RC,,,both,,,445,329.3,,,329.3,Other,150% of Medicare + 9.63% HCRA Surcharge,200.25,45,,200.25,percent of total billed charges,Critical Access Hospital RCC factor,151.3,34,,151.3,percent of total billed charges,Implant Device,151.3,34,,151.3,percent of total billed charges,Implant Device,151.3,34,,151.3,percent of total billed charges,Implant Device,151.3,34,,151.3,percent of total billed charges,Implant Device,151.3,34,,151.3,percent of total billed charges,Implant Device,220.28,,,220.28,Other,110% of Medicare,155.75,35,,155.75,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,155.75,35,,155.75,percent of total billed charges,Implant Device,155.75,35,,155.75,percent of total billed charges,Implant Device,155.75,35,,155.75,percent of total billed charges,Implant Device,155.75,35,,155.75,percent of total billed charges,Implant Device,155.75,35,,155.75,percent of total billed charges,Implant Device,178,40,,178,percent of total billed charges,Implant Device,155.75,70,,155.75,percent of total billed charges,All Other,151.3,34,,151.3,percent of total billed charges,Implant Device,151.3,34,,151.3,percent of total billed charges,Implant Device,155.75,35,,155.75,percent of total billed charges,Implant Device,155.75,35,,155.75,percent of total billed charges,Implant Device,155.75,35,,155.75,percent of total billed charges,Implant Device,155.75,35,,155.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,329.3,
ZIMMER 00-2359-044-45 LOCK SCREW 4.5X44,C1713,HCPCS,,79008069,CDM,278,RC,,,both,,,445,329.3,,,329.3,Other,150% of Medicare + 9.63% HCRA Surcharge,200.25,45,,200.25,percent of total billed charges,Critical Access Hospital RCC factor,151.3,34,,151.3,percent of total billed charges,Implant Device,151.3,34,,151.3,percent of total billed charges,Implant Device,151.3,34,,151.3,percent of total billed charges,Implant Device,151.3,34,,151.3,percent of total billed charges,Implant Device,151.3,34,,151.3,percent of total billed charges,Implant Device,220.28,,,220.28,Other,110% of Medicare,155.75,35,,155.75,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,155.75,35,,155.75,percent of total billed charges,Implant Device,155.75,35,,155.75,percent of total billed charges,Implant Device,155.75,35,,155.75,percent of total billed charges,Implant Device,155.75,35,,155.75,percent of total billed charges,Implant Device,155.75,35,,155.75,percent of total billed charges,Implant Device,178,40,,178,percent of total billed charges,Implant Device,155.75,70,,155.75,percent of total billed charges,All Other,151.3,34,,151.3,percent of total billed charges,Implant Device,151.3,34,,151.3,percent of total billed charges,Implant Device,155.75,35,,155.75,percent of total billed charges,Implant Device,155.75,35,,155.75,percent of total billed charges,Implant Device,155.75,35,,155.75,percent of total billed charges,Implant Device,155.75,35,,155.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,329.3,
ZIMMER 00-2359-090-55 CANN SCREW 5.5X90,C1713,HCPCS,,79008070,CDM,278,RC,,,both,,,578,427.72,,,427.72,Other,150% of Medicare + 9.63% HCRA Surcharge,260.1,45,,260.1,percent of total billed charges,Critical Access Hospital RCC factor,196.52,34,,196.52,percent of total billed charges,Implant Device,196.52,34,,196.52,percent of total billed charges,Implant Device,196.52,34,,196.52,percent of total billed charges,Implant Device,196.52,34,,196.52,percent of total billed charges,Implant Device,196.52,34,,196.52,percent of total billed charges,Implant Device,286.11,,,286.11,Other,110% of Medicare,202.3,35,,202.3,percent of total billed charges,Implant Device,196.52,34,"Charges > $500, x 34%",196.52,percent of total billed charges,Implant Device,202.3,35,,202.3,percent of total billed charges,Implant Device,202.3,35,,202.3,percent of total billed charges,Implant Device,202.3,35,,202.3,percent of total billed charges,Implant Device,202.3,35,,202.3,percent of total billed charges,Implant Device,202.3,35,,202.3,percent of total billed charges,Implant Device,231.2,40,,231.2,percent of total billed charges,Implant Device,202.3,70,,202.3,percent of total billed charges,All Other,196.52,34,,196.52,percent of total billed charges,Implant Device,196.52,34,,196.52,percent of total billed charges,Implant Device,202.3,35,,202.3,percent of total billed charges,Implant Device,202.3,35,,202.3,percent of total billed charges,Implant Device,202.3,35,,202.3,percent of total billed charges,Implant Device,202.3,35,,202.3,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,427.72,
ZIMMER 00-2359-095-55 CANN SCREW 5.5X95,C1713,HCPCS,,79008071,CDM,278,RC,,,both,,,578,427.72,,,427.72,Other,150% of Medicare + 9.63% HCRA Surcharge,260.1,45,,260.1,percent of total billed charges,Critical Access Hospital RCC factor,196.52,34,,196.52,percent of total billed charges,Implant Device,196.52,34,,196.52,percent of total billed charges,Implant Device,196.52,34,,196.52,percent of total billed charges,Implant Device,196.52,34,,196.52,percent of total billed charges,Implant Device,196.52,34,,196.52,percent of total billed charges,Implant Device,286.11,,,286.11,Other,110% of Medicare,202.3,35,,202.3,percent of total billed charges,Implant Device,196.52,34,"Charges > $500, x 34%",196.52,percent of total billed charges,Implant Device,202.3,35,,202.3,percent of total billed charges,Implant Device,202.3,35,,202.3,percent of total billed charges,Implant Device,202.3,35,,202.3,percent of total billed charges,Implant Device,202.3,35,,202.3,percent of total billed charges,Implant Device,202.3,35,,202.3,percent of total billed charges,Implant Device,231.2,40,,231.2,percent of total billed charges,Implant Device,202.3,70,,202.3,percent of total billed charges,All Other,196.52,34,,196.52,percent of total billed charges,Implant Device,196.52,34,,196.52,percent of total billed charges,Implant Device,202.3,35,,202.3,percent of total billed charges,Implant Device,202.3,35,,202.3,percent of total billed charges,Implant Device,202.3,35,,202.3,percent of total billed charges,Implant Device,202.3,35,,202.3,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,427.72,
ZIMMER 00-2347-023-38 PERI SCREW 4.5X38,C1713,HCPCS,,79008072,CDM,278,RC,,,both,,,109,80.66,,,80.66,Other,150% of Medicare + 9.63% HCRA Surcharge,49.05,45,,49.05,percent of total billed charges,Critical Access Hospital RCC factor,37.06,34,,37.06,percent of total billed charges,Implant Device,37.06,34,,37.06,percent of total billed charges,Implant Device,37.06,34,,37.06,percent of total billed charges,Implant Device,37.06,34,,37.06,percent of total billed charges,Implant Device,37.06,34,,37.06,percent of total billed charges,Implant Device,53.96,,,53.96,Other,110% of Medicare,38.15,35,,38.15,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,38.15,35,,38.15,percent of total billed charges,Implant Device,38.15,35,,38.15,percent of total billed charges,Implant Device,38.15,35,,38.15,percent of total billed charges,Implant Device,38.15,35,,38.15,percent of total billed charges,Implant Device,38.15,35,,38.15,percent of total billed charges,Implant Device,43.6,40,,43.6,percent of total billed charges,Implant Device,38.15,70,,38.15,percent of total billed charges,All Other,37.06,34,,37.06,percent of total billed charges,Implant Device,37.06,34,,37.06,percent of total billed charges,Implant Device,38.15,35,,38.15,percent of total billed charges,Implant Device,38.15,35,,38.15,percent of total billed charges,Implant Device,38.15,35,,38.15,percent of total billed charges,Implant Device,38.15,35,,38.15,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,80.66,
GORE RLT231412 EXCLUDER ENDOPROS GRAFT,C1768,HCPCS,,79008073,CDM,278,RC,,,both,,,33000,24420.08,,,24420.08,Other,150% of Medicare + 9.63% HCRA Surcharge,14850,45,,14850,percent of total billed charges,Critical Access Hospital RCC factor,11220,34,,11220,percent of total billed charges,Implant Device,11220,34,,11220,percent of total billed charges,Implant Device,11220,34,,11220,percent of total billed charges,Implant Device,11220,34,,11220,percent of total billed charges,Implant Device,11220,34,,11220,percent of total billed charges,Implant Device,16335,,,16335,Other,110% of Medicare,11550,35,,11550,percent of total billed charges,Implant Device,11220,34,"Charges > $500, x 34%",11220,percent of total billed charges,Implant Device,11550,35,,11550,percent of total billed charges,Implant Device,11550,35,,11550,percent of total billed charges,Implant Device,11550,35,,11550,percent of total billed charges,Implant Device,11550,35,,11550,percent of total billed charges,Implant Device,11550,35,,11550,percent of total billed charges,Implant Device,13200,40,,13200,percent of total billed charges,Implant Device,11550,70,,11550,percent of total billed charges,All Other,11220,34,,11220,percent of total billed charges,Implant Device,11220,34,,11220,percent of total billed charges,Implant Device,11550,35,,11550,percent of total billed charges,Implant Device,11550,35,,11550,percent of total billed charges,Implant Device,11550,35,,11550,percent of total billed charges,Implant Device,11550,35,,11550,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,11220,34,"If Charge > 2,000, then 34 percent",11220,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,24420.08,
GORE PLC161400 EXCL ENDOPROSTHESIS GRAFT,C1874,HCPCS,,79008074,CDM,278,RC,,,both,,,14571,10782.58,,,10782.58,Other,150% of Medicare + 9.63% HCRA Surcharge,6556.95,45,,6556.95,percent of total billed charges,Critical Access Hospital RCC factor,4954.14,34,,4954.14,percent of total billed charges,Implant Device,4954.14,34,,4954.14,percent of total billed charges,Implant Device,4954.14,34,,4954.14,percent of total billed charges,Implant Device,4954.14,34,,4954.14,percent of total billed charges,Implant Device,4954.14,34,,4954.14,percent of total billed charges,Implant Device,7212.65,,,7212.65,Other,110% of Medicare,5099.85,35,,5099.85,percent of total billed charges,Implant Device,4954.14,34,"Charges > $500, x 34%",4954.14,percent of total billed charges,Implant Device,5099.85,35,,5099.85,percent of total billed charges,Implant Device,5099.85,35,,5099.85,percent of total billed charges,Implant Device,5099.85,35,,5099.85,percent of total billed charges,Implant Device,5099.85,35,,5099.85,percent of total billed charges,Implant Device,5099.85,35,,5099.85,percent of total billed charges,Implant Device,5828.4,40,,5828.4,percent of total billed charges,Implant Device,5099.85,70,,5099.85,percent of total billed charges,All Other,4954.14,34,,4954.14,percent of total billed charges,Implant Device,4954.14,34,,4954.14,percent of total billed charges,Implant Device,5099.85,35,,5099.85,percent of total billed charges,Implant Device,5099.85,35,,5099.85,percent of total billed charges,Implant Device,5099.85,35,,5099.85,percent of total billed charges,Implant Device,5099.85,35,,5099.85,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,4954.14,34,"If Charge > 2,000, then 34 percent",4954.14,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,10782.58,
DEPUY 1365-36-320 FEMORAL HEAD 36MM,C1776,HCPCS,,79008075,CDM,278,RC,,,both,,,2636,1950.65,,,1950.65,Other,150% of Medicare + 9.63% HCRA Surcharge,1186.2,45,,1186.2,percent of total billed charges,Critical Access Hospital RCC factor,896.24,34,,896.24,percent of total billed charges,Implant Device,896.24,34,,896.24,percent of total billed charges,Implant Device,896.24,34,,896.24,percent of total billed charges,Implant Device,896.24,34,,896.24,percent of total billed charges,Implant Device,896.24,34,,896.24,percent of total billed charges,Implant Device,1304.82,,,1304.82,Other,110% of Medicare,922.6,35,,922.6,percent of total billed charges,Implant Device,896.24,34,"Charges > $500, x 34%",896.24,percent of total billed charges,Implant Device,922.6,35,,922.6,percent of total billed charges,Implant Device,922.6,35,,922.6,percent of total billed charges,Implant Device,922.6,35,,922.6,percent of total billed charges,Implant Device,922.6,35,,922.6,percent of total billed charges,Implant Device,922.6,35,,922.6,percent of total billed charges,Implant Device,1054.4,40,,1054.4,percent of total billed charges,Implant Device,922.6,70,,922.6,percent of total billed charges,All Other,896.24,34,,896.24,percent of total billed charges,Implant Device,896.24,34,,896.24,percent of total billed charges,Implant Device,922.6,35,,922.6,percent of total billed charges,Implant Device,922.6,35,,922.6,percent of total billed charges,Implant Device,922.6,35,,922.6,percent of total billed charges,Implant Device,922.6,35,,922.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,896.24,34,"If Charge > 2,000, then 34 percent",896.24,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1950.65,
ACUMED 30-0246 LOCKING SCREW 3.5X36MM,C1713,HCPCS,,79008076,CDM,278,RC,,,both,,,450,333,,,333,Other,150% of Medicare + 9.63% HCRA Surcharge,202.5,45,,202.5,percent of total billed charges,Critical Access Hospital RCC factor,153,34,,153,percent of total billed charges,Implant Device,153,34,,153,percent of total billed charges,Implant Device,153,34,,153,percent of total billed charges,Implant Device,153,34,,153,percent of total billed charges,Implant Device,153,34,,153,percent of total billed charges,Implant Device,222.75,,,222.75,Other,110% of Medicare,157.5,35,,157.5,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,157.5,35,,157.5,percent of total billed charges,Implant Device,157.5,35,,157.5,percent of total billed charges,Implant Device,157.5,35,,157.5,percent of total billed charges,Implant Device,157.5,35,,157.5,percent of total billed charges,Implant Device,157.5,35,,157.5,percent of total billed charges,Implant Device,180,40,,180,percent of total billed charges,Implant Device,157.5,70,,157.5,percent of total billed charges,All Other,153,34,,153,percent of total billed charges,Implant Device,153,34,,153,percent of total billed charges,Implant Device,157.5,35,,157.5,percent of total billed charges,Implant Device,157.5,35,,157.5,percent of total billed charges,Implant Device,157.5,35,,157.5,percent of total billed charges,Implant Device,157.5,35,,157.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,333,
ACUMED 70-0314 OLECRANON PLATE LT 9 HOLE,C1713,HCPCS,,79008077,CDM,278,RC,,,both,,,4128,3054.73,,,3054.73,Other,150% of Medicare + 9.63% HCRA Surcharge,1857.6,45,,1857.6,percent of total billed charges,Critical Access Hospital RCC factor,1403.52,34,,1403.52,percent of total billed charges,Implant Device,1403.52,34,,1403.52,percent of total billed charges,Implant Device,1403.52,34,,1403.52,percent of total billed charges,Implant Device,1403.52,34,,1403.52,percent of total billed charges,Implant Device,1403.52,34,,1403.52,percent of total billed charges,Implant Device,2043.36,,,2043.36,Other,110% of Medicare,1444.8,35,,1444.8,percent of total billed charges,Implant Device,1403.52,34,"Charges > $500, x 34%",1403.52,percent of total billed charges,Implant Device,1444.8,35,,1444.8,percent of total billed charges,Implant Device,1444.8,35,,1444.8,percent of total billed charges,Implant Device,1444.8,35,,1444.8,percent of total billed charges,Implant Device,1444.8,35,,1444.8,percent of total billed charges,Implant Device,1444.8,35,,1444.8,percent of total billed charges,Implant Device,1651.2,40,,1651.2,percent of total billed charges,Implant Device,1444.8,70,,1444.8,percent of total billed charges,All Other,1403.52,34,,1403.52,percent of total billed charges,Implant Device,1403.52,34,,1403.52,percent of total billed charges,Implant Device,1444.8,35,,1444.8,percent of total billed charges,Implant Device,1444.8,35,,1444.8,percent of total billed charges,Implant Device,1444.8,35,,1444.8,percent of total billed charges,Implant Device,1444.8,35,,1444.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1403.52,34,"If Charge > 2,000, then 34 percent",1403.52,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3054.73,
ACUMED 30-0306 NON LOCKING SCREW 3X18MM,C1713,HCPCS,,79008078,CDM,278,RC,,,both,,,270,199.8,,,199.8,Other,150% of Medicare + 9.63% HCRA Surcharge,121.5,45,,121.5,percent of total billed charges,Critical Access Hospital RCC factor,91.8,34,,91.8,percent of total billed charges,Implant Device,91.8,34,,91.8,percent of total billed charges,Implant Device,91.8,34,,91.8,percent of total billed charges,Implant Device,91.8,34,,91.8,percent of total billed charges,Implant Device,91.8,34,,91.8,percent of total billed charges,Implant Device,133.65,,,133.65,Other,110% of Medicare,94.5,35,,94.5,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,94.5,35,,94.5,percent of total billed charges,Implant Device,94.5,35,,94.5,percent of total billed charges,Implant Device,94.5,35,,94.5,percent of total billed charges,Implant Device,94.5,35,,94.5,percent of total billed charges,Implant Device,94.5,35,,94.5,percent of total billed charges,Implant Device,108,40,,108,percent of total billed charges,Implant Device,94.5,70,,94.5,percent of total billed charges,All Other,91.8,34,,91.8,percent of total billed charges,Implant Device,91.8,34,,91.8,percent of total billed charges,Implant Device,94.5,35,,94.5,percent of total billed charges,Implant Device,94.5,35,,94.5,percent of total billed charges,Implant Device,94.5,35,,94.5,percent of total billed charges,Implant Device,94.5,35,,94.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,199.8,
ACUMED TR-S0804-S STEM 8.0X4.0MM,C1776,HCPCS,,79008079,CDM,278,RC,,,both,,,6069,4491.08,,,4491.08,Other,150% of Medicare + 9.63% HCRA Surcharge,2731.05,45,,2731.05,percent of total billed charges,Critical Access Hospital RCC factor,2063.46,34,,2063.46,percent of total billed charges,Implant Device,2063.46,34,,2063.46,percent of total billed charges,Implant Device,2063.46,34,,2063.46,percent of total billed charges,Implant Device,2063.46,34,,2063.46,percent of total billed charges,Implant Device,2063.46,34,,2063.46,percent of total billed charges,Implant Device,3004.16,,,3004.16,Other,110% of Medicare,2124.15,35,,2124.15,percent of total billed charges,Implant Device,2063.46,34,"Charges > $500, x 34%",2063.46,percent of total billed charges,Implant Device,2124.15,35,,2124.15,percent of total billed charges,Implant Device,2124.15,35,,2124.15,percent of total billed charges,Implant Device,2124.15,35,,2124.15,percent of total billed charges,Implant Device,2124.15,35,,2124.15,percent of total billed charges,Implant Device,2124.15,35,,2124.15,percent of total billed charges,Implant Device,2427.6,40,,2427.6,percent of total billed charges,Implant Device,2124.15,70,,2124.15,percent of total billed charges,All Other,2063.46,34,,2063.46,percent of total billed charges,Implant Device,2063.46,34,,2063.46,percent of total billed charges,Implant Device,2124.15,35,,2124.15,percent of total billed charges,Implant Device,2124.15,35,,2124.15,percent of total billed charges,Implant Device,2124.15,35,,2124.15,percent of total billed charges,Implant Device,2124.15,35,,2124.15,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2063.46,34,"If Charge > 2,000, then 34 percent",2063.46,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4491.08,
ACUMED TR-H220L-S RADIAL HEAD 22MM LEFT,C1776,HCPCS,,79008080,CDM,278,RC,,,both,,,9966,7374.86,,,7374.86,Other,150% of Medicare + 9.63% HCRA Surcharge,4484.7,45,,4484.7,percent of total billed charges,Critical Access Hospital RCC factor,3388.44,34,,3388.44,percent of total billed charges,Implant Device,3388.44,34,,3388.44,percent of total billed charges,Implant Device,3388.44,34,,3388.44,percent of total billed charges,Implant Device,3388.44,34,,3388.44,percent of total billed charges,Implant Device,3388.44,34,,3388.44,percent of total billed charges,Implant Device,4933.17,,,4933.17,Other,110% of Medicare,3488.1,35,,3488.1,percent of total billed charges,Implant Device,3388.44,34,"Charges > $500, x 34%",3388.44,percent of total billed charges,Implant Device,3488.1,35,,3488.1,percent of total billed charges,Implant Device,3488.1,35,,3488.1,percent of total billed charges,Implant Device,3488.1,35,,3488.1,percent of total billed charges,Implant Device,3488.1,35,,3488.1,percent of total billed charges,Implant Device,3488.1,35,,3488.1,percent of total billed charges,Implant Device,3986.4,40,,3986.4,percent of total billed charges,Implant Device,3488.1,70,,3488.1,percent of total billed charges,All Other,3388.44,34,,3388.44,percent of total billed charges,Implant Device,3388.44,34,,3388.44,percent of total billed charges,Implant Device,3488.1,35,,3488.1,percent of total billed charges,Implant Device,3488.1,35,,3488.1,percent of total billed charges,Implant Device,3488.1,35,,3488.1,percent of total billed charges,Implant Device,3488.1,35,,3488.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3388.44,34,"If Charge > 2,000, then 34 percent",3388.44,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,7374.86,
STRYKER 53-23228E NONLOCK SCREW 2.3X28MM,C1713,HCPCS,,79008081,CDM,278,RC,,,both,,,375,277.5,,,277.5,Other,150% of Medicare + 9.63% HCRA Surcharge,168.75,45,,168.75,percent of total billed charges,Critical Access Hospital RCC factor,127.5,34,,127.5,percent of total billed charges,Implant Device,127.5,34,,127.5,percent of total billed charges,Implant Device,127.5,34,,127.5,percent of total billed charges,Implant Device,127.5,34,,127.5,percent of total billed charges,Implant Device,127.5,34,,127.5,percent of total billed charges,Implant Device,185.63,,,185.63,Other,110% of Medicare,131.25,35,,131.25,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,131.25,35,,131.25,percent of total billed charges,Implant Device,131.25,35,,131.25,percent of total billed charges,Implant Device,131.25,35,,131.25,percent of total billed charges,Implant Device,131.25,35,,131.25,percent of total billed charges,Implant Device,131.25,35,,131.25,percent of total billed charges,Implant Device,150,40,,150,percent of total billed charges,Implant Device,131.25,70,,131.25,percent of total billed charges,All Other,127.5,34,,127.5,percent of total billed charges,Implant Device,127.5,34,,127.5,percent of total billed charges,Implant Device,131.25,35,,131.25,percent of total billed charges,Implant Device,131.25,35,,131.25,percent of total billed charges,Implant Device,131.25,35,,131.25,percent of total billed charges,Implant Device,131.25,35,,131.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,277.5,
INTEGRA 606-200-006 10X15 SURGIMEND MESH,C1781,HCPCS,,79008084,CDM,278,RC,,,both,,,8550,6327.02,,,6327.02,Other,150% of Medicare + 9.63% HCRA Surcharge,3847.5,45,,3847.5,percent of total billed charges,Critical Access Hospital RCC factor,2907,34,,2907,percent of total billed charges,Implant Device,2907,34,,2907,percent of total billed charges,Implant Device,2907,34,,2907,percent of total billed charges,Implant Device,2907,34,,2907,percent of total billed charges,Implant Device,2907,34,,2907,percent of total billed charges,Implant Device,4232.25,,,4232.25,Other,110% of Medicare,2992.5,35,,2992.5,percent of total billed charges,Implant Device,2907,34,"Charges > $500, x 34%",2907,percent of total billed charges,Implant Device,2992.5,35,,2992.5,percent of total billed charges,Implant Device,2992.5,35,,2992.5,percent of total billed charges,Implant Device,2992.5,35,,2992.5,percent of total billed charges,Implant Device,2992.5,35,,2992.5,percent of total billed charges,Implant Device,2992.5,35,,2992.5,percent of total billed charges,Implant Device,3420,40,,3420,percent of total billed charges,Implant Device,2992.5,70,,2992.5,percent of total billed charges,All Other,2907,34,,2907,percent of total billed charges,Implant Device,2907,34,,2907,percent of total billed charges,Implant Device,2992.5,35,,2992.5,percent of total billed charges,Implant Device,2992.5,35,,2992.5,percent of total billed charges,Implant Device,2992.5,35,,2992.5,percent of total billed charges,Implant Device,2992.5,35,,2992.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2907,34,"If Charge > 2,000, then 34 percent",2907,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,6327.02,
INTEGRA 606-200-008 16X20 SURGIMEND MESH,C1781,HCPCS,,79008085,CDM,278,RC,,,both,,,18240,13497.65,,,13497.65,Other,150% of Medicare + 9.63% HCRA Surcharge,8208,45,,8208,percent of total billed charges,Critical Access Hospital RCC factor,6201.6,34,,6201.6,percent of total billed charges,Implant Device,6201.6,34,,6201.6,percent of total billed charges,Implant Device,6201.6,34,,6201.6,percent of total billed charges,Implant Device,6201.6,34,,6201.6,percent of total billed charges,Implant Device,6201.6,34,,6201.6,percent of total billed charges,Implant Device,9028.8,,,9028.8,Other,110% of Medicare,6384,35,,6384,percent of total billed charges,Implant Device,6201.6,34,"Charges > $500, x 34%",6201.6,percent of total billed charges,Implant Device,6384,35,,6384,percent of total billed charges,Implant Device,6384,35,,6384,percent of total billed charges,Implant Device,6384,35,,6384,percent of total billed charges,Implant Device,6384,35,,6384,percent of total billed charges,Implant Device,6384,35,,6384,percent of total billed charges,Implant Device,7296,40,,7296,percent of total billed charges,Implant Device,6384,70,,6384,percent of total billed charges,All Other,6201.6,34,,6201.6,percent of total billed charges,Implant Device,6201.6,34,,6201.6,percent of total billed charges,Implant Device,6384,35,,6384,percent of total billed charges,Implant Device,6384,35,,6384,percent of total billed charges,Implant Device,6384,35,,6384,percent of total billed charges,Implant Device,6384,35,,6384,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,6201.6,34,"If Charge > 2,000, then 34 percent",6201.6,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,13497.65,
INTEGRA 606-200-009 13X25 SURGIMEND MESH,C1781,HCPCS,,79008086,CDM,278,RC,,,both,,,18525,13708.55,,,13708.55,Other,150% of Medicare + 9.63% HCRA Surcharge,8336.25,45,,8336.25,percent of total billed charges,Critical Access Hospital RCC factor,6298.5,34,,6298.5,percent of total billed charges,Implant Device,6298.5,34,,6298.5,percent of total billed charges,Implant Device,6298.5,34,,6298.5,percent of total billed charges,Implant Device,6298.5,34,,6298.5,percent of total billed charges,Implant Device,6298.5,34,,6298.5,percent of total billed charges,Implant Device,9169.88,,,9169.88,Other,110% of Medicare,6483.75,35,,6483.75,percent of total billed charges,Implant Device,6298.5,34,"Charges > $500, x 34%",6298.5,percent of total billed charges,Implant Device,6483.75,35,,6483.75,percent of total billed charges,Implant Device,6483.75,35,,6483.75,percent of total billed charges,Implant Device,6483.75,35,,6483.75,percent of total billed charges,Implant Device,6483.75,35,,6483.75,percent of total billed charges,Implant Device,6483.75,35,,6483.75,percent of total billed charges,Implant Device,7410,40,,7410,percent of total billed charges,Implant Device,6483.75,70,,6483.75,percent of total billed charges,All Other,6298.5,34,,6298.5,percent of total billed charges,Implant Device,6298.5,34,,6298.5,percent of total billed charges,Implant Device,6483.75,35,,6483.75,percent of total billed charges,Implant Device,6483.75,35,,6483.75,percent of total billed charges,Implant Device,6483.75,35,,6483.75,percent of total billed charges,Implant Device,6483.75,35,,6483.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,6298.5,34,"If Charge > 2,000, then 34 percent",6298.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,13708.55,
INTEGRA 606-200-017 20X30 SURGIMEND MESH,C1781,HCPCS,,79008087,CDM,278,RC,,,both,,,34200,25308.09,,,25308.09,Other,150% of Medicare + 9.63% HCRA Surcharge,15390,45,,15390,percent of total billed charges,Critical Access Hospital RCC factor,11628,34,,11628,percent of total billed charges,Implant Device,11628,34,,11628,percent of total billed charges,Implant Device,11628,34,,11628,percent of total billed charges,Implant Device,11628,34,,11628,percent of total billed charges,Implant Device,11628,34,,11628,percent of total billed charges,Implant Device,16929,,,16929,Other,110% of Medicare,11970,35,,11970,percent of total billed charges,Implant Device,11628,34,"Charges > $500, x 34%",11628,percent of total billed charges,Implant Device,11970,35,,11970,percent of total billed charges,Implant Device,11970,35,,11970,percent of total billed charges,Implant Device,11970,35,,11970,percent of total billed charges,Implant Device,11970,35,,11970,percent of total billed charges,Implant Device,11970,35,,11970,percent of total billed charges,Implant Device,13680,40,,13680,percent of total billed charges,Implant Device,11970,70,,11970,percent of total billed charges,All Other,11628,34,,11628,percent of total billed charges,Implant Device,11628,34,,11628,percent of total billed charges,Implant Device,11970,35,,11970,percent of total billed charges,Implant Device,11970,35,,11970,percent of total billed charges,Implant Device,11970,35,,11970,percent of total billed charges,Implant Device,11970,35,,11970,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,11628,34,"If Charge > 2,000, then 34 percent",11628,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,25308.09,
IN2BONES S25 ST016 COMP SCREW 2.5X14MM,C1713,HCPCS,,79008094,CDM,278,RC,,,both,,,1050,777,,,777,Other,150% of Medicare + 9.63% HCRA Surcharge,472.5,45,,472.5,percent of total billed charges,Critical Access Hospital RCC factor,357,34,,357,percent of total billed charges,Implant Device,357,34,,357,percent of total billed charges,Implant Device,357,34,,357,percent of total billed charges,Implant Device,357,34,,357,percent of total billed charges,Implant Device,357,34,,357,percent of total billed charges,Implant Device,519.75,,,519.75,Other,110% of Medicare,367.5,35,,367.5,percent of total billed charges,Implant Device,357,34,"Charges > $500, x 34%",357,percent of total billed charges,Implant Device,367.5,35,,367.5,percent of total billed charges,Implant Device,367.5,35,,367.5,percent of total billed charges,Implant Device,367.5,35,,367.5,percent of total billed charges,Implant Device,367.5,35,,367.5,percent of total billed charges,Implant Device,367.5,35,,367.5,percent of total billed charges,Implant Device,420,40,,420,percent of total billed charges,Implant Device,367.5,70,,367.5,percent of total billed charges,All Other,357,34,,357,percent of total billed charges,Implant Device,357,34,,357,percent of total billed charges,Implant Device,367.5,35,,367.5,percent of total billed charges,Implant Device,367.5,35,,367.5,percent of total billed charges,Implant Device,367.5,35,,367.5,percent of total billed charges,Implant Device,367.5,35,,367.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,777,
EXACTECH 300-10-00 HUMERAL ADAPT TRAY +0,C1713,HCPCS,,79008095,CDM,278,RC,,,both,,,6480,4795.22,,,4795.22,Other,150% of Medicare + 9.63% HCRA Surcharge,2916,45,,2916,percent of total billed charges,Critical Access Hospital RCC factor,2203.2,34,,2203.2,percent of total billed charges,Implant Device,2203.2,34,,2203.2,percent of total billed charges,Implant Device,2203.2,34,,2203.2,percent of total billed charges,Implant Device,2203.2,34,,2203.2,percent of total billed charges,Implant Device,2203.2,34,,2203.2,percent of total billed charges,Implant Device,3207.6,,,3207.6,Other,110% of Medicare,2268,35,,2268,percent of total billed charges,Implant Device,2203.2,34,"Charges > $500, x 34%",2203.2,percent of total billed charges,Implant Device,2268,35,,2268,percent of total billed charges,Implant Device,2268,35,,2268,percent of total billed charges,Implant Device,2268,35,,2268,percent of total billed charges,Implant Device,2268,35,,2268,percent of total billed charges,Implant Device,2268,35,,2268,percent of total billed charges,Implant Device,2592,40,,2592,percent of total billed charges,Implant Device,2268,70,,2268,percent of total billed charges,All Other,2203.2,34,,2203.2,percent of total billed charges,Implant Device,2203.2,34,,2203.2,percent of total billed charges,Implant Device,2268,35,,2268,percent of total billed charges,Implant Device,2268,35,,2268,percent of total billed charges,Implant Device,2268,35,,2268,percent of total billed charges,Implant Device,2268,35,,2268,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2203.2,34,"If Charge > 2,000, then 34 percent",2203.2,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4795.22,
STRYKER EZ20-16-16 EASYCLIP,C1713,HCPCS,,79008096,CDM,278,RC,,,both,,,7503,5552.24,,,5552.24,Other,150% of Medicare + 9.63% HCRA Surcharge,3376.35,45,,3376.35,percent of total billed charges,Critical Access Hospital RCC factor,2551.02,34,,2551.02,percent of total billed charges,Implant Device,2551.02,34,,2551.02,percent of total billed charges,Implant Device,2551.02,34,,2551.02,percent of total billed charges,Implant Device,2551.02,34,,2551.02,percent of total billed charges,Implant Device,2551.02,34,,2551.02,percent of total billed charges,Implant Device,3713.99,,,3713.99,Other,110% of Medicare,2626.05,35,,2626.05,percent of total billed charges,Implant Device,2551.02,34,"Charges > $500, x 34%",2551.02,percent of total billed charges,Implant Device,2626.05,35,,2626.05,percent of total billed charges,Implant Device,2626.05,35,,2626.05,percent of total billed charges,Implant Device,2626.05,35,,2626.05,percent of total billed charges,Implant Device,2626.05,35,,2626.05,percent of total billed charges,Implant Device,2626.05,35,,2626.05,percent of total billed charges,Implant Device,3001.2,40,,3001.2,percent of total billed charges,Implant Device,2626.05,70,,2626.05,percent of total billed charges,All Other,2551.02,34,,2551.02,percent of total billed charges,Implant Device,2551.02,34,,2551.02,percent of total billed charges,Implant Device,2626.05,35,,2626.05,percent of total billed charges,Implant Device,2626.05,35,,2626.05,percent of total billed charges,Implant Device,2626.05,35,,2626.05,percent of total billed charges,Implant Device,2626.05,35,,2626.05,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2551.02,34,"If Charge > 2,000, then 34 percent",2551.02,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5552.24,
DEPUY 02.118.403 PLATE 2.7 4 HOLE LEFT,C1713,HCPCS,,79008099,CDM,278,RC,,,both,,,3266,2416.85,,,2416.85,Other,150% of Medicare + 9.63% HCRA Surcharge,1469.7,45,,1469.7,percent of total billed charges,Critical Access Hospital RCC factor,1110.44,34,,1110.44,percent of total billed charges,Implant Device,1110.44,34,,1110.44,percent of total billed charges,Implant Device,1110.44,34,,1110.44,percent of total billed charges,Implant Device,1110.44,34,,1110.44,percent of total billed charges,Implant Device,1110.44,34,,1110.44,percent of total billed charges,Implant Device,1616.67,,,1616.67,Other,110% of Medicare,1143.1,35,,1143.1,percent of total billed charges,Implant Device,1110.44,34,"Charges > $500, x 34%",1110.44,percent of total billed charges,Implant Device,1143.1,35,,1143.1,percent of total billed charges,Implant Device,1143.1,35,,1143.1,percent of total billed charges,Implant Device,1143.1,35,,1143.1,percent of total billed charges,Implant Device,1143.1,35,,1143.1,percent of total billed charges,Implant Device,1143.1,35,,1143.1,percent of total billed charges,Implant Device,1306.4,40,,1306.4,percent of total billed charges,Implant Device,1143.1,70,,1143.1,percent of total billed charges,All Other,1110.44,34,,1110.44,percent of total billed charges,Implant Device,1110.44,34,,1110.44,percent of total billed charges,Implant Device,1143.1,35,,1143.1,percent of total billed charges,Implant Device,1143.1,35,,1143.1,percent of total billed charges,Implant Device,1143.1,35,,1143.1,percent of total billed charges,Implant Device,1143.1,35,,1143.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1110.44,34,"If Charge > 2,000, then 34 percent",1110.44,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2416.85,
DEPUY 02.118.512 SELF TAP SCREW 2.7X12MM,C1713,HCPCS,,79008100,CDM,278,RC,,,both,,,203,150.22,,,150.22,Other,150% of Medicare + 9.63% HCRA Surcharge,91.35,45,,91.35,percent of total billed charges,Critical Access Hospital RCC factor,69.02,34,,69.02,percent of total billed charges,Implant Device,69.02,34,,69.02,percent of total billed charges,Implant Device,69.02,34,,69.02,percent of total billed charges,Implant Device,69.02,34,,69.02,percent of total billed charges,Implant Device,69.02,34,,69.02,percent of total billed charges,Implant Device,100.49,,,100.49,Other,110% of Medicare,71.05,35,,71.05,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,71.05,35,,71.05,percent of total billed charges,Implant Device,71.05,35,,71.05,percent of total billed charges,Implant Device,71.05,35,,71.05,percent of total billed charges,Implant Device,71.05,35,,71.05,percent of total billed charges,Implant Device,71.05,35,,71.05,percent of total billed charges,Implant Device,81.2,40,,81.2,percent of total billed charges,Implant Device,71.05,70,,71.05,percent of total billed charges,All Other,69.02,34,,69.02,percent of total billed charges,Implant Device,69.02,34,,69.02,percent of total billed charges,Implant Device,71.05,35,,71.05,percent of total billed charges,Implant Device,71.05,35,,71.05,percent of total billed charges,Implant Device,71.05,35,,71.05,percent of total billed charges,Implant Device,71.05,35,,71.05,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,150.22,
STRYKER 5028-6-150 5X150MM APEX PIN,C1713,HCPCS,,79008101,CDM,278,RC,,,both,,,622,460.28,,,460.28,Other,150% of Medicare + 9.63% HCRA Surcharge,279.9,45,,279.9,percent of total billed charges,Critical Access Hospital RCC factor,211.48,34,,211.48,percent of total billed charges,Implant Device,211.48,34,,211.48,percent of total billed charges,Implant Device,211.48,34,,211.48,percent of total billed charges,Implant Device,211.48,34,,211.48,percent of total billed charges,Implant Device,211.48,34,,211.48,percent of total billed charges,Implant Device,307.89,,,307.89,Other,110% of Medicare,217.7,35,,217.7,percent of total billed charges,Implant Device,211.48,34,"Charges > $500, x 34%",211.48,percent of total billed charges,Implant Device,217.7,35,,217.7,percent of total billed charges,Implant Device,217.7,35,,217.7,percent of total billed charges,Implant Device,217.7,35,,217.7,percent of total billed charges,Implant Device,217.7,35,,217.7,percent of total billed charges,Implant Device,217.7,35,,217.7,percent of total billed charges,Implant Device,248.8,40,,248.8,percent of total billed charges,Implant Device,217.7,70,,217.7,percent of total billed charges,All Other,211.48,34,,211.48,percent of total billed charges,Implant Device,211.48,34,,211.48,percent of total billed charges,Implant Device,217.7,35,,217.7,percent of total billed charges,Implant Device,217.7,35,,217.7,percent of total billed charges,Implant Device,217.7,35,,217.7,percent of total billed charges,Implant Device,217.7,35,,217.7,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,460.28,
ARTHREX AR-8952MT-04 METATARSAL PLATE 4H,C1713,HCPCS,,79008105,CDM,278,RC,,,both,,,2979,2204.47,,,2204.47,Other,150% of Medicare + 9.63% HCRA Surcharge,1340.55,45,,1340.55,percent of total billed charges,Critical Access Hospital RCC factor,1012.86,34,,1012.86,percent of total billed charges,Implant Device,1012.86,34,,1012.86,percent of total billed charges,Implant Device,1012.86,34,,1012.86,percent of total billed charges,Implant Device,1012.86,34,,1012.86,percent of total billed charges,Implant Device,1012.86,34,,1012.86,percent of total billed charges,Implant Device,1474.61,,,1474.61,Other,110% of Medicare,1042.65,35,,1042.65,percent of total billed charges,Implant Device,1012.86,34,"Charges > $500, x 34%",1012.86,percent of total billed charges,Implant Device,1042.65,35,,1042.65,percent of total billed charges,Implant Device,1042.65,35,,1042.65,percent of total billed charges,Implant Device,1042.65,35,,1042.65,percent of total billed charges,Implant Device,1042.65,35,,1042.65,percent of total billed charges,Implant Device,1042.65,35,,1042.65,percent of total billed charges,Implant Device,1191.6,40,,1191.6,percent of total billed charges,Implant Device,1042.65,70,,1042.65,percent of total billed charges,All Other,1012.86,34,,1012.86,percent of total billed charges,Implant Device,1012.86,34,,1012.86,percent of total billed charges,Implant Device,1042.65,35,,1042.65,percent of total billed charges,Implant Device,1042.65,35,,1042.65,percent of total billed charges,Implant Device,1042.65,35,,1042.65,percent of total billed charges,Implant Device,1042.65,35,,1042.65,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1012.86,34,"If Charge > 2,000, then 34 percent",1012.86,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2204.47,
ARTHREX AR-8724V-14 LOCK SCREW 2.4X14MM,C1713,HCPCS,,79008106,CDM,278,RC,,,both,,,600,444,,,444,Other,150% of Medicare + 9.63% HCRA Surcharge,270,45,,270,percent of total billed charges,Critical Access Hospital RCC factor,204,34,,204,percent of total billed charges,Implant Device,204,34,,204,percent of total billed charges,Implant Device,204,34,,204,percent of total billed charges,Implant Device,204,34,,204,percent of total billed charges,Implant Device,204,34,,204,percent of total billed charges,Implant Device,297,,,297,Other,110% of Medicare,210,35,,210,percent of total billed charges,Implant Device,204,34,"Charges > $500, x 34%",204,percent of total billed charges,Implant Device,210,35,,210,percent of total billed charges,Implant Device,210,35,,210,percent of total billed charges,Implant Device,210,35,,210,percent of total billed charges,Implant Device,210,35,,210,percent of total billed charges,Implant Device,210,35,,210,percent of total billed charges,Implant Device,240,40,,240,percent of total billed charges,Implant Device,210,70,,210,percent of total billed charges,All Other,204,34,,204,percent of total billed charges,Implant Device,204,34,,204,percent of total billed charges,Implant Device,210,35,,210,percent of total billed charges,Implant Device,210,35,,210,percent of total billed charges,Implant Device,210,35,,210,percent of total billed charges,Implant Device,210,35,,210,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,444,
EXACTECH 314-13-33 CAGE GLENOID POST AUG,C1713,HCPCS,,79008107,CDM,278,RC,,,both,,,4725,3496.51,,,3496.51,Other,150% of Medicare + 9.63% HCRA Surcharge,2126.25,45,,2126.25,percent of total billed charges,Critical Access Hospital RCC factor,1606.5,34,,1606.5,percent of total billed charges,Implant Device,1606.5,34,,1606.5,percent of total billed charges,Implant Device,1606.5,34,,1606.5,percent of total billed charges,Implant Device,1606.5,34,,1606.5,percent of total billed charges,Implant Device,1606.5,34,,1606.5,percent of total billed charges,Implant Device,2338.88,,,2338.88,Other,110% of Medicare,1653.75,35,,1653.75,percent of total billed charges,Implant Device,1606.5,34,"Charges > $500, x 34%",1606.5,percent of total billed charges,Implant Device,1653.75,35,,1653.75,percent of total billed charges,Implant Device,1653.75,35,,1653.75,percent of total billed charges,Implant Device,1653.75,35,,1653.75,percent of total billed charges,Implant Device,1653.75,35,,1653.75,percent of total billed charges,Implant Device,1653.75,35,,1653.75,percent of total billed charges,Implant Device,1890,40,,1890,percent of total billed charges,Implant Device,1653.75,70,,1653.75,percent of total billed charges,All Other,1606.5,34,,1606.5,percent of total billed charges,Implant Device,1606.5,34,,1606.5,percent of total billed charges,Implant Device,1653.75,35,,1653.75,percent of total billed charges,Implant Device,1653.75,35,,1653.75,percent of total billed charges,Implant Device,1653.75,35,,1653.75,percent of total billed charges,Implant Device,1653.75,35,,1653.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1606.5,34,"If Charge > 2,000, then 34 percent",1606.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3496.51,
DEPUY 1376-22-000 STEM CENTRALIZER 13MM,C1776,HCPCS,,79008108,CDM,278,RC,,,both,,,305,225.7,,,225.7,Other,150% of Medicare + 9.63% HCRA Surcharge,137.25,45,,137.25,percent of total billed charges,Critical Access Hospital RCC factor,103.7,34,,103.7,percent of total billed charges,Implant Device,103.7,34,,103.7,percent of total billed charges,Implant Device,103.7,34,,103.7,percent of total billed charges,Implant Device,103.7,34,,103.7,percent of total billed charges,Implant Device,103.7,34,,103.7,percent of total billed charges,Implant Device,150.98,,,150.98,Other,110% of Medicare,106.75,35,,106.75,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,106.75,35,,106.75,percent of total billed charges,Implant Device,106.75,35,,106.75,percent of total billed charges,Implant Device,106.75,35,,106.75,percent of total billed charges,Implant Device,106.75,35,,106.75,percent of total billed charges,Implant Device,106.75,35,,106.75,percent of total billed charges,Implant Device,122,40,,122,percent of total billed charges,Implant Device,106.75,70,,106.75,percent of total billed charges,All Other,103.7,34,,103.7,percent of total billed charges,Implant Device,103.7,34,,103.7,percent of total billed charges,Implant Device,106.75,35,,106.75,percent of total billed charges,Implant Device,106.75,35,,106.75,percent of total billed charges,Implant Device,106.75,35,,106.75,percent of total billed charges,Implant Device,106.75,35,,106.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,225.7,
DEPUY 1570-06-135 FEMORAL STEM S7 133MM,C1776,HCPCS,,79008109,CDM,278,RC,,,both,,,5575,4125.51,,,4125.51,Other,150% of Medicare + 9.63% HCRA Surcharge,2508.75,45,,2508.75,percent of total billed charges,Critical Access Hospital RCC factor,1895.5,34,,1895.5,percent of total billed charges,Implant Device,1895.5,34,,1895.5,percent of total billed charges,Implant Device,1895.5,34,,1895.5,percent of total billed charges,Implant Device,1895.5,34,,1895.5,percent of total billed charges,Implant Device,1895.5,34,,1895.5,percent of total billed charges,Implant Device,2759.63,,,2759.63,Other,110% of Medicare,1951.25,35,,1951.25,percent of total billed charges,Implant Device,1895.5,34,"Charges > $500, x 34%",1895.5,percent of total billed charges,Implant Device,1951.25,35,,1951.25,percent of total billed charges,Implant Device,1951.25,35,,1951.25,percent of total billed charges,Implant Device,1951.25,35,,1951.25,percent of total billed charges,Implant Device,1951.25,35,,1951.25,percent of total billed charges,Implant Device,1951.25,35,,1951.25,percent of total billed charges,Implant Device,2230,40,,2230,percent of total billed charges,Implant Device,1951.25,70,,1951.25,percent of total billed charges,All Other,1895.5,34,,1895.5,percent of total billed charges,Implant Device,1895.5,34,,1895.5,percent of total billed charges,Implant Device,1951.25,35,,1951.25,percent of total billed charges,Implant Device,1951.25,35,,1951.25,percent of total billed charges,Implant Device,1951.25,35,,1951.25,percent of total billed charges,Implant Device,1951.25,35,,1951.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1895.5,34,"If Charge > 2,000, then 34 percent",1895.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4125.51,
STRYKER ST0A-15P SMART TOE 15MM ANGLED,C1776,HCPCS,,79008110,CDM,278,RC,,,both,,,4395,3252.31,,,3252.31,Other,150% of Medicare + 9.63% HCRA Surcharge,1977.75,45,,1977.75,percent of total billed charges,Critical Access Hospital RCC factor,1494.3,34,,1494.3,percent of total billed charges,Implant Device,1494.3,34,,1494.3,percent of total billed charges,Implant Device,1494.3,34,,1494.3,percent of total billed charges,Implant Device,1494.3,34,,1494.3,percent of total billed charges,Implant Device,1494.3,34,,1494.3,percent of total billed charges,Implant Device,2175.53,,,2175.53,Other,110% of Medicare,1538.25,35,,1538.25,percent of total billed charges,Implant Device,1494.3,34,"Charges > $500, x 34%",1494.3,percent of total billed charges,Implant Device,1538.25,35,,1538.25,percent of total billed charges,Implant Device,1538.25,35,,1538.25,percent of total billed charges,Implant Device,1538.25,35,,1538.25,percent of total billed charges,Implant Device,1538.25,35,,1538.25,percent of total billed charges,Implant Device,1538.25,35,,1538.25,percent of total billed charges,Implant Device,1758,40,,1758,percent of total billed charges,Implant Device,1538.25,70,,1538.25,percent of total billed charges,All Other,1494.3,34,,1494.3,percent of total billed charges,Implant Device,1494.3,34,,1494.3,percent of total billed charges,Implant Device,1538.25,35,,1538.25,percent of total billed charges,Implant Device,1538.25,35,,1538.25,percent of total billed charges,Implant Device,1538.25,35,,1538.25,percent of total billed charges,Implant Device,1538.25,35,,1538.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1494.3,34,"If Charge > 2,000, then 34 percent",1494.3,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3252.31,
ARTHREX AR-8724V-16 LOCK SCREW 2.4X16MM,C1713,HCPCS,,79008111,CDM,278,RC,,,both,,,420,310.8,,,310.8,Other,150% of Medicare + 9.63% HCRA Surcharge,189,45,,189,percent of total billed charges,Critical Access Hospital RCC factor,142.8,34,,142.8,percent of total billed charges,Implant Device,142.8,34,,142.8,percent of total billed charges,Implant Device,142.8,34,,142.8,percent of total billed charges,Implant Device,142.8,34,,142.8,percent of total billed charges,Implant Device,142.8,34,,142.8,percent of total billed charges,Implant Device,207.9,,,207.9,Other,110% of Medicare,147,35,,147,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,147,35,,147,percent of total billed charges,Implant Device,147,35,,147,percent of total billed charges,Implant Device,147,35,,147,percent of total billed charges,Implant Device,147,35,,147,percent of total billed charges,Implant Device,147,35,,147,percent of total billed charges,Implant Device,168,40,,168,percent of total billed charges,Implant Device,147,70,,147,percent of total billed charges,All Other,142.8,34,,142.8,percent of total billed charges,Implant Device,142.8,34,,142.8,percent of total billed charges,Implant Device,147,35,,147,percent of total billed charges,Implant Device,147,35,,147,percent of total billed charges,Implant Device,147,35,,147,percent of total billed charges,Implant Device,147,35,,147,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,310.8,
DEPUY 02.200.026 3.5X26MM CORTEX SCREW,C1713,HCPCS,,79008112,CDM,278,RC,,,both,,,99,73.26,,,73.26,Other,150% of Medicare + 9.63% HCRA Surcharge,44.55,45,,44.55,percent of total billed charges,Critical Access Hospital RCC factor,33.66,34,,33.66,percent of total billed charges,Implant Device,33.66,34,,33.66,percent of total billed charges,Implant Device,33.66,34,,33.66,percent of total billed charges,Implant Device,33.66,34,,33.66,percent of total billed charges,Implant Device,33.66,34,,33.66,percent of total billed charges,Implant Device,49.01,,,49.01,Other,110% of Medicare,34.65,35,,34.65,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,34.65,35,,34.65,percent of total billed charges,Implant Device,34.65,35,,34.65,percent of total billed charges,Implant Device,34.65,35,,34.65,percent of total billed charges,Implant Device,34.65,35,,34.65,percent of total billed charges,Implant Device,34.65,35,,34.65,percent of total billed charges,Implant Device,39.6,40,,39.6,percent of total billed charges,Implant Device,34.65,70,,34.65,percent of total billed charges,All Other,33.66,34,,33.66,percent of total billed charges,Implant Device,33.66,34,,33.66,percent of total billed charges,Implant Device,34.65,35,,34.65,percent of total billed charges,Implant Device,34.65,35,,34.65,percent of total billed charges,Implant Device,34.65,35,,34.65,percent of total billed charges,Implant Device,34.65,35,,34.65,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,73.26,
DEPUY 02.200.022 3.5X22MM CORTEX SCREW,C1713,HCPCS,,79008113,CDM,278,RC,,,both,,,99,73.26,,,73.26,Other,150% of Medicare + 9.63% HCRA Surcharge,44.55,45,,44.55,percent of total billed charges,Critical Access Hospital RCC factor,33.66,34,,33.66,percent of total billed charges,Implant Device,33.66,34,,33.66,percent of total billed charges,Implant Device,33.66,34,,33.66,percent of total billed charges,Implant Device,33.66,34,,33.66,percent of total billed charges,Implant Device,33.66,34,,33.66,percent of total billed charges,Implant Device,49.01,,,49.01,Other,110% of Medicare,34.65,35,,34.65,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,34.65,35,,34.65,percent of total billed charges,Implant Device,34.65,35,,34.65,percent of total billed charges,Implant Device,34.65,35,,34.65,percent of total billed charges,Implant Device,34.65,35,,34.65,percent of total billed charges,Implant Device,34.65,35,,34.65,percent of total billed charges,Implant Device,39.6,40,,39.6,percent of total billed charges,Implant Device,34.65,70,,34.65,percent of total billed charges,All Other,33.66,34,,33.66,percent of total billed charges,Implant Device,33.66,34,,33.66,percent of total billed charges,Implant Device,34.65,35,,34.65,percent of total billed charges,Implant Device,34.65,35,,34.65,percent of total billed charges,Implant Device,34.65,35,,34.65,percent of total billed charges,Implant Device,34.65,35,,34.65,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,73.26,
DEPUY 212.102 3.5X12MM LOCKING SCREW,C1713,HCPCS,,79008114,CDM,278,RC,,,both,,,327,241.98,,,241.98,Other,150% of Medicare + 9.63% HCRA Surcharge,147.15,45,,147.15,percent of total billed charges,Critical Access Hospital RCC factor,111.18,34,,111.18,percent of total billed charges,Implant Device,111.18,34,,111.18,percent of total billed charges,Implant Device,111.18,34,,111.18,percent of total billed charges,Implant Device,111.18,34,,111.18,percent of total billed charges,Implant Device,111.18,34,,111.18,percent of total billed charges,Implant Device,161.87,,,161.87,Other,110% of Medicare,114.45,35,,114.45,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,114.45,35,,114.45,percent of total billed charges,Implant Device,114.45,35,,114.45,percent of total billed charges,Implant Device,114.45,35,,114.45,percent of total billed charges,Implant Device,114.45,35,,114.45,percent of total billed charges,Implant Device,114.45,35,,114.45,percent of total billed charges,Implant Device,130.8,40,,130.8,percent of total billed charges,Implant Device,114.45,70,,114.45,percent of total billed charges,All Other,111.18,34,,111.18,percent of total billed charges,Implant Device,111.18,34,,111.18,percent of total billed charges,Implant Device,114.45,35,,114.45,percent of total billed charges,Implant Device,114.45,35,,114.45,percent of total billed charges,Implant Device,114.45,35,,114.45,percent of total billed charges,Implant Device,114.45,35,,114.45,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,241.98,
STRYKER 4933-8-040 2.0 OLIVE WIRE,C1713,HCPCS,,79008115,CDM,278,RC,,,both,,,441,326.34,,,326.34,Other,150% of Medicare + 9.63% HCRA Surcharge,198.45,45,,198.45,percent of total billed charges,Critical Access Hospital RCC factor,149.94,34,,149.94,percent of total billed charges,Implant Device,149.94,34,,149.94,percent of total billed charges,Implant Device,149.94,34,,149.94,percent of total billed charges,Implant Device,149.94,34,,149.94,percent of total billed charges,Implant Device,149.94,34,,149.94,percent of total billed charges,Implant Device,218.3,,,218.3,Other,110% of Medicare,154.35,35,,154.35,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,154.35,35,,154.35,percent of total billed charges,Implant Device,154.35,35,,154.35,percent of total billed charges,Implant Device,154.35,35,,154.35,percent of total billed charges,Implant Device,154.35,35,,154.35,percent of total billed charges,Implant Device,154.35,35,,154.35,percent of total billed charges,Implant Device,176.4,40,,176.4,percent of total billed charges,Implant Device,154.35,70,,154.35,percent of total billed charges,All Other,149.94,34,,149.94,percent of total billed charges,Implant Device,149.94,34,,149.94,percent of total billed charges,Implant Device,154.35,35,,154.35,percent of total billed charges,Implant Device,154.35,35,,154.35,percent of total billed charges,Implant Device,154.35,35,,154.35,percent of total billed charges,Implant Device,154.35,35,,154.35,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,326.34,
STRYKER 5014-4-200S APEX PIN 6X200X40MM,C1713,HCPCS,,79008118,CDM,278,RC,,,both,,,701,518.74,,,518.74,Other,150% of Medicare + 9.63% HCRA Surcharge,315.45,45,,315.45,percent of total billed charges,Critical Access Hospital RCC factor,238.34,34,,238.34,percent of total billed charges,Implant Device,238.34,34,,238.34,percent of total billed charges,Implant Device,238.34,34,,238.34,percent of total billed charges,Implant Device,238.34,34,,238.34,percent of total billed charges,Implant Device,238.34,34,,238.34,percent of total billed charges,Implant Device,347,,,347,Other,110% of Medicare,245.35,35,,245.35,percent of total billed charges,Implant Device,238.34,34,"Charges > $500, x 34%",238.34,percent of total billed charges,Implant Device,245.35,35,,245.35,percent of total billed charges,Implant Device,245.35,35,,245.35,percent of total billed charges,Implant Device,245.35,35,,245.35,percent of total billed charges,Implant Device,245.35,35,,245.35,percent of total billed charges,Implant Device,245.35,35,,245.35,percent of total billed charges,Implant Device,280.4,40,,280.4,percent of total billed charges,Implant Device,245.35,70,,245.35,percent of total billed charges,All Other,238.34,34,,238.34,percent of total billed charges,Implant Device,238.34,34,,238.34,percent of total billed charges,Implant Device,245.35,35,,245.35,percent of total billed charges,Implant Device,245.35,35,,245.35,percent of total billed charges,Implant Device,245.35,35,,245.35,percent of total billed charges,Implant Device,245.35,35,,245.35,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,518.74,
S&N 71204532 ARTICULAR INSERT XLG 8MM,C1776,HCPCS,,79008119,CDM,278,RC,,,both,,,6270,4639.82,,,4639.82,Other,150% of Medicare + 9.63% HCRA Surcharge,2821.5,45,,2821.5,percent of total billed charges,Critical Access Hospital RCC factor,2131.8,34,,2131.8,percent of total billed charges,Implant Device,2131.8,34,,2131.8,percent of total billed charges,Implant Device,2131.8,34,,2131.8,percent of total billed charges,Implant Device,2131.8,34,,2131.8,percent of total billed charges,Implant Device,2131.8,34,,2131.8,percent of total billed charges,Implant Device,3103.65,,,3103.65,Other,110% of Medicare,2194.5,35,,2194.5,percent of total billed charges,Implant Device,2131.8,34,"Charges > $500, x 34%",2131.8,percent of total billed charges,Implant Device,2194.5,35,,2194.5,percent of total billed charges,Implant Device,2194.5,35,,2194.5,percent of total billed charges,Implant Device,2194.5,35,,2194.5,percent of total billed charges,Implant Device,2194.5,35,,2194.5,percent of total billed charges,Implant Device,2194.5,35,,2194.5,percent of total billed charges,Implant Device,2508,40,,2508,percent of total billed charges,Implant Device,2194.5,70,,2194.5,percent of total billed charges,All Other,2131.8,34,,2131.8,percent of total billed charges,Implant Device,2131.8,34,,2131.8,percent of total billed charges,Implant Device,2194.5,35,,2194.5,percent of total billed charges,Implant Device,2194.5,35,,2194.5,percent of total billed charges,Implant Device,2194.5,35,,2194.5,percent of total billed charges,Implant Device,2194.5,35,,2194.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2131.8,34,"If Charge > 2,000, then 34 percent",2131.8,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4639.82,
DEPUY 1506-10-005 ATTUNE TIBIAL BASE SZ5,C1776,HCPCS,,79008120,CDM,278,RC,,,both,,,6675,4939.52,,,4939.52,Other,150% of Medicare + 9.63% HCRA Surcharge,3003.75,45,,3003.75,percent of total billed charges,Critical Access Hospital RCC factor,2269.5,34,,2269.5,percent of total billed charges,Implant Device,2269.5,34,,2269.5,percent of total billed charges,Implant Device,2269.5,34,,2269.5,percent of total billed charges,Implant Device,2269.5,34,,2269.5,percent of total billed charges,Implant Device,2269.5,34,,2269.5,percent of total billed charges,Implant Device,3304.13,,,3304.13,Other,110% of Medicare,2336.25,35,,2336.25,percent of total billed charges,Implant Device,2269.5,34,"Charges > $500, x 34%",2269.5,percent of total billed charges,Implant Device,2336.25,35,,2336.25,percent of total billed charges,Implant Device,2336.25,35,,2336.25,percent of total billed charges,Implant Device,2336.25,35,,2336.25,percent of total billed charges,Implant Device,2336.25,35,,2336.25,percent of total billed charges,Implant Device,2336.25,35,,2336.25,percent of total billed charges,Implant Device,2670,40,,2670,percent of total billed charges,Implant Device,2336.25,70,,2336.25,percent of total billed charges,All Other,2269.5,34,,2269.5,percent of total billed charges,Implant Device,2269.5,34,,2269.5,percent of total billed charges,Implant Device,2336.25,35,,2336.25,percent of total billed charges,Implant Device,2336.25,35,,2336.25,percent of total billed charges,Implant Device,2336.25,35,,2336.25,percent of total billed charges,Implant Device,2336.25,35,,2336.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2269.5,34,"If Charge > 2,000, then 34 percent",2269.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4939.52,
DEPUY 1516-30-610 ATTUNE TIBIAL INS SZ6,C1776,HCPCS,,79008121,CDM,278,RC,,,both,,,5250,3885.01,,,3885.01,Other,150% of Medicare + 9.63% HCRA Surcharge,2362.5,45,,2362.5,percent of total billed charges,Critical Access Hospital RCC factor,1785,34,,1785,percent of total billed charges,Implant Device,1785,34,,1785,percent of total billed charges,Implant Device,1785,34,,1785,percent of total billed charges,Implant Device,1785,34,,1785,percent of total billed charges,Implant Device,1785,34,,1785,percent of total billed charges,Implant Device,2598.75,,,2598.75,Other,110% of Medicare,1837.5,35,,1837.5,percent of total billed charges,Implant Device,1785,34,"Charges > $500, x 34%",1785,percent of total billed charges,Implant Device,1837.5,35,,1837.5,percent of total billed charges,Implant Device,1837.5,35,,1837.5,percent of total billed charges,Implant Device,1837.5,35,,1837.5,percent of total billed charges,Implant Device,1837.5,35,,1837.5,percent of total billed charges,Implant Device,1837.5,35,,1837.5,percent of total billed charges,Implant Device,2100,40,,2100,percent of total billed charges,Implant Device,1837.5,70,,1837.5,percent of total billed charges,All Other,1785,34,,1785,percent of total billed charges,Implant Device,1785,34,,1785,percent of total billed charges,Implant Device,1837.5,35,,1837.5,percent of total billed charges,Implant Device,1837.5,35,,1837.5,percent of total billed charges,Implant Device,1837.5,35,,1837.5,percent of total billed charges,Implant Device,1837.5,35,,1837.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1785,34,"If Charge > 2,000, then 34 percent",1785,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3885.01,
X-SPINE X090-0015-PT5CC DBM PUTTY 5CC,C1713,HCPCS,,79008122,CDM,278,RC,,,both,,,1500,1110,,,1110,Other,150% of Medicare + 9.63% HCRA Surcharge,675,45,,675,percent of total billed charges,Critical Access Hospital RCC factor,510,34,,510,percent of total billed charges,Implant Device,510,34,,510,percent of total billed charges,Implant Device,510,34,,510,percent of total billed charges,Implant Device,510,34,,510,percent of total billed charges,Implant Device,510,34,,510,percent of total billed charges,Implant Device,742.5,,,742.5,Other,110% of Medicare,525,35,,525,percent of total billed charges,Implant Device,510,34,"Charges > $500, x 34%",510,percent of total billed charges,Implant Device,525,35,,525,percent of total billed charges,Implant Device,525,35,,525,percent of total billed charges,Implant Device,525,35,,525,percent of total billed charges,Implant Device,525,35,,525,percent of total billed charges,Implant Device,525,35,,525,percent of total billed charges,Implant Device,600,40,,600,percent of total billed charges,Implant Device,525,70,,525,percent of total billed charges,All Other,510,34,,510,percent of total billed charges,Implant Device,510,34,,510,percent of total billed charges,Implant Device,525,35,,525,percent of total billed charges,Implant Device,525,35,,525,percent of total billed charges,Implant Device,525,35,,525,percent of total billed charges,Implant Device,525,35,,525,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1110,
X-SPINE 109640 OSTEOSPONGE STRIP 40X15X5,C1713,HCPCS,,79008123,CDM,278,RC,,,both,,,4590,3396.61,,,3396.61,Other,150% of Medicare + 9.63% HCRA Surcharge,2065.5,45,,2065.5,percent of total billed charges,Critical Access Hospital RCC factor,1560.6,34,,1560.6,percent of total billed charges,Implant Device,1560.6,34,,1560.6,percent of total billed charges,Implant Device,1560.6,34,,1560.6,percent of total billed charges,Implant Device,1560.6,34,,1560.6,percent of total billed charges,Implant Device,1560.6,34,,1560.6,percent of total billed charges,Implant Device,2272.05,,,2272.05,Other,110% of Medicare,1606.5,35,,1606.5,percent of total billed charges,Implant Device,1560.6,34,"Charges > $500, x 34%",1560.6,percent of total billed charges,Implant Device,1606.5,35,,1606.5,percent of total billed charges,Implant Device,1606.5,35,,1606.5,percent of total billed charges,Implant Device,1606.5,35,,1606.5,percent of total billed charges,Implant Device,1606.5,35,,1606.5,percent of total billed charges,Implant Device,1606.5,35,,1606.5,percent of total billed charges,Implant Device,1836,40,,1836,percent of total billed charges,Implant Device,1606.5,70,,1606.5,percent of total billed charges,All Other,1560.6,34,,1560.6,percent of total billed charges,Implant Device,1560.6,34,,1560.6,percent of total billed charges,Implant Device,1606.5,35,,1606.5,percent of total billed charges,Implant Device,1606.5,35,,1606.5,percent of total billed charges,Implant Device,1606.5,35,,1606.5,percent of total billed charges,Implant Device,1606.5,35,,1606.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1560.6,34,"If Charge > 2,000, then 34 percent",1560.6,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3396.61,
PROVIDENCE DX-22-100 DTRAX SPINAL SYSTEM,C1713,HCPCS,,79008124,CDM,278,RC,,,both,,,6000,4440.02,,,4440.02,Other,150% of Medicare + 9.63% HCRA Surcharge,2700,45,,2700,percent of total billed charges,Critical Access Hospital RCC factor,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2970,,,2970,Other,110% of Medicare,2100,35,,2100,percent of total billed charges,Implant Device,2040,34,"Charges > $500, x 34%",2040,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2400,40,,2400,percent of total billed charges,Implant Device,2100,70,,2100,percent of total billed charges,All Other,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2040,34,"If Charge > 2,000, then 34 percent",2040,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4440.02,
PROVIDENCE PD-31-100 CERVICAL CAGE-T,C1713,HCPCS,,79008125,CDM,278,RC,,,both,,,9600,7104.02,,,7104.02,Other,150% of Medicare + 9.63% HCRA Surcharge,4320,45,,4320,percent of total billed charges,Critical Access Hospital RCC factor,3264,34,,3264,percent of total billed charges,Implant Device,3264,34,,3264,percent of total billed charges,Implant Device,3264,34,,3264,percent of total billed charges,Implant Device,3264,34,,3264,percent of total billed charges,Implant Device,3264,34,,3264,percent of total billed charges,Implant Device,4752,,,4752,Other,110% of Medicare,3360,35,,3360,percent of total billed charges,Implant Device,3264,34,"Charges > $500, x 34%",3264,percent of total billed charges,Implant Device,3360,35,,3360,percent of total billed charges,Implant Device,3360,35,,3360,percent of total billed charges,Implant Device,3360,35,,3360,percent of total billed charges,Implant Device,3360,35,,3360,percent of total billed charges,Implant Device,3360,35,,3360,percent of total billed charges,Implant Device,3840,40,,3840,percent of total billed charges,Implant Device,3360,70,,3360,percent of total billed charges,All Other,3264,34,,3264,percent of total billed charges,Implant Device,3264,34,,3264,percent of total billed charges,Implant Device,3360,35,,3360,percent of total billed charges,Implant Device,3360,35,,3360,percent of total billed charges,Implant Device,3360,35,,3360,percent of total billed charges,Implant Device,3360,35,,3360,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3264,34,"If Charge > 2,000, then 34 percent",3264,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,7104.02,
STRYKER ST0-15P SMART TOE 15MM,C1776,HCPCS,,79008126,CDM,278,RC,,,both,,,4704,3480.97,,,3480.97,Other,150% of Medicare + 9.63% HCRA Surcharge,2116.8,45,,2116.8,percent of total billed charges,Critical Access Hospital RCC factor,1599.36,34,,1599.36,percent of total billed charges,Implant Device,1599.36,34,,1599.36,percent of total billed charges,Implant Device,1599.36,34,,1599.36,percent of total billed charges,Implant Device,1599.36,34,,1599.36,percent of total billed charges,Implant Device,1599.36,34,,1599.36,percent of total billed charges,Implant Device,2328.48,,,2328.48,Other,110% of Medicare,1646.4,35,,1646.4,percent of total billed charges,Implant Device,1599.36,34,"Charges > $500, x 34%",1599.36,percent of total billed charges,Implant Device,1646.4,35,,1646.4,percent of total billed charges,Implant Device,1646.4,35,,1646.4,percent of total billed charges,Implant Device,1646.4,35,,1646.4,percent of total billed charges,Implant Device,1646.4,35,,1646.4,percent of total billed charges,Implant Device,1646.4,35,,1646.4,percent of total billed charges,Implant Device,1881.6,40,,1881.6,percent of total billed charges,Implant Device,1646.4,70,,1646.4,percent of total billed charges,All Other,1599.36,34,,1599.36,percent of total billed charges,Implant Device,1599.36,34,,1599.36,percent of total billed charges,Implant Device,1646.4,35,,1646.4,percent of total billed charges,Implant Device,1646.4,35,,1646.4,percent of total billed charges,Implant Device,1646.4,35,,1646.4,percent of total billed charges,Implant Device,1646.4,35,,1646.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1599.36,34,"If Charge > 2,000, then 34 percent",1599.36,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3480.97,
ZIMMER 431184 60MM HEAD HIP MOLD W/INS,C1776,HCPCS,,79008128,CDM,278,RC,,,both,,,5250,3885.01,,,3885.01,Other,150% of Medicare + 9.63% HCRA Surcharge,2362.5,45,,2362.5,percent of total billed charges,Critical Access Hospital RCC factor,1785,34,,1785,percent of total billed charges,Implant Device,1785,34,,1785,percent of total billed charges,Implant Device,1785,34,,1785,percent of total billed charges,Implant Device,1785,34,,1785,percent of total billed charges,Implant Device,1785,34,,1785,percent of total billed charges,Implant Device,2598.75,,,2598.75,Other,110% of Medicare,1837.5,35,,1837.5,percent of total billed charges,Implant Device,1785,34,"Charges > $500, x 34%",1785,percent of total billed charges,Implant Device,1837.5,35,,1837.5,percent of total billed charges,Implant Device,1837.5,35,,1837.5,percent of total billed charges,Implant Device,1837.5,35,,1837.5,percent of total billed charges,Implant Device,1837.5,35,,1837.5,percent of total billed charges,Implant Device,1837.5,35,,1837.5,percent of total billed charges,Implant Device,2100,40,,2100,percent of total billed charges,Implant Device,1837.5,70,,1837.5,percent of total billed charges,All Other,1785,34,,1785,percent of total billed charges,Implant Device,1785,34,,1785,percent of total billed charges,Implant Device,1837.5,35,,1837.5,percent of total billed charges,Implant Device,1837.5,35,,1837.5,percent of total billed charges,Implant Device,1837.5,35,,1837.5,percent of total billed charges,Implant Device,1837.5,35,,1837.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1785,34,"If Charge > 2,000, then 34 percent",1785,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3885.01,
ZIMMER 431187 HIP NECK LENGTH ADPTR +6MM,C1776,HCPCS,,79008129,CDM,278,RC,,,both,,,1320,976.8,,,976.8,Other,150% of Medicare + 9.63% HCRA Surcharge,594,45,,594,percent of total billed charges,Critical Access Hospital RCC factor,448.8,34,,448.8,percent of total billed charges,Implant Device,448.8,34,,448.8,percent of total billed charges,Implant Device,448.8,34,,448.8,percent of total billed charges,Implant Device,448.8,34,,448.8,percent of total billed charges,Implant Device,448.8,34,,448.8,percent of total billed charges,Implant Device,653.4,,,653.4,Other,110% of Medicare,462,35,,462,percent of total billed charges,Implant Device,448.8,34,"Charges > $500, x 34%",448.8,percent of total billed charges,Implant Device,462,35,,462,percent of total billed charges,Implant Device,462,35,,462,percent of total billed charges,Implant Device,462,35,,462,percent of total billed charges,Implant Device,462,35,,462,percent of total billed charges,Implant Device,462,35,,462,percent of total billed charges,Implant Device,528,40,,528,percent of total billed charges,Implant Device,462,70,,462,percent of total billed charges,All Other,448.8,34,,448.8,percent of total billed charges,Implant Device,448.8,34,,448.8,percent of total billed charges,Implant Device,462,35,,462,percent of total billed charges,Implant Device,462,35,,462,percent of total billed charges,Implant Device,462,35,,462,percent of total billed charges,Implant Device,462,35,,462,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,976.8,
ZIMMER 431194 HIP MOLD STEM 17X165,C1776,HCPCS,,79008130,CDM,278,RC,,,both,,,6570,4861.82,,,4861.82,Other,150% of Medicare + 9.63% HCRA Surcharge,2956.5,45,,2956.5,percent of total billed charges,Critical Access Hospital RCC factor,2233.8,34,,2233.8,percent of total billed charges,Implant Device,2233.8,34,,2233.8,percent of total billed charges,Implant Device,2233.8,34,,2233.8,percent of total billed charges,Implant Device,2233.8,34,,2233.8,percent of total billed charges,Implant Device,2233.8,34,,2233.8,percent of total billed charges,Implant Device,3252.15,,,3252.15,Other,110% of Medicare,2299.5,35,,2299.5,percent of total billed charges,Implant Device,2233.8,34,"Charges > $500, x 34%",2233.8,percent of total billed charges,Implant Device,2299.5,35,,2299.5,percent of total billed charges,Implant Device,2299.5,35,,2299.5,percent of total billed charges,Implant Device,2299.5,35,,2299.5,percent of total billed charges,Implant Device,2299.5,35,,2299.5,percent of total billed charges,Implant Device,2299.5,35,,2299.5,percent of total billed charges,Implant Device,2628,40,,2628,percent of total billed charges,Implant Device,2299.5,70,,2299.5,percent of total billed charges,All Other,2233.8,34,,2233.8,percent of total billed charges,Implant Device,2233.8,34,,2233.8,percent of total billed charges,Implant Device,2299.5,35,,2299.5,percent of total billed charges,Implant Device,2299.5,35,,2299.5,percent of total billed charges,Implant Device,2299.5,35,,2299.5,percent of total billed charges,Implant Device,2299.5,35,,2299.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2233.8,34,"If Charge > 2,000, then 34 percent",2233.8,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4861.82,
BIOMET 11-300917 ARCOS 17X190MM SPL TPR,C1776,HCPCS,,79008131,CDM,278,RC,,,both,,,10199,7547.29,,,7547.29,Other,150% of Medicare + 9.63% HCRA Surcharge,4589.55,45,,4589.55,percent of total billed charges,Critical Access Hospital RCC factor,3467.66,34,,3467.66,percent of total billed charges,Implant Device,3467.66,34,,3467.66,percent of total billed charges,Implant Device,3467.66,34,,3467.66,percent of total billed charges,Implant Device,3467.66,34,,3467.66,percent of total billed charges,Implant Device,3467.66,34,,3467.66,percent of total billed charges,Implant Device,5048.51,,,5048.51,Other,110% of Medicare,3569.65,35,,3569.65,percent of total billed charges,Implant Device,3467.66,34,"Charges > $500, x 34%",3467.66,percent of total billed charges,Implant Device,3569.65,35,,3569.65,percent of total billed charges,Implant Device,3569.65,35,,3569.65,percent of total billed charges,Implant Device,3569.65,35,,3569.65,percent of total billed charges,Implant Device,3569.65,35,,3569.65,percent of total billed charges,Implant Device,3569.65,35,,3569.65,percent of total billed charges,Implant Device,4079.6,40,,4079.6,percent of total billed charges,Implant Device,3569.65,70,,3569.65,percent of total billed charges,All Other,3467.66,34,,3467.66,percent of total billed charges,Implant Device,3467.66,34,,3467.66,percent of total billed charges,Implant Device,3569.65,35,,3569.65,percent of total billed charges,Implant Device,3569.65,35,,3569.65,percent of total billed charges,Implant Device,3569.65,35,,3569.65,percent of total billed charges,Implant Device,3569.65,35,,3569.65,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3467.66,34,"If Charge > 2,000, then 34 percent",3467.66,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,7547.29,
BIOMET 11-301332 ARCOS CPMS SZ B HI 70MM,C1776,HCPCS,,79008132,CDM,278,RC,,,both,,,19784,14640.21,,,14640.21,Other,150% of Medicare + 9.63% HCRA Surcharge,8902.8,45,,8902.8,percent of total billed charges,Critical Access Hospital RCC factor,6726.56,34,,6726.56,percent of total billed charges,Implant Device,6726.56,34,,6726.56,percent of total billed charges,Implant Device,6726.56,34,,6726.56,percent of total billed charges,Implant Device,6726.56,34,,6726.56,percent of total billed charges,Implant Device,6726.56,34,,6726.56,percent of total billed charges,Implant Device,9793.08,,,9793.08,Other,110% of Medicare,6924.4,35,,6924.4,percent of total billed charges,Implant Device,6726.56,34,"Charges > $500, x 34%",6726.56,percent of total billed charges,Implant Device,6924.4,35,,6924.4,percent of total billed charges,Implant Device,6924.4,35,,6924.4,percent of total billed charges,Implant Device,6924.4,35,,6924.4,percent of total billed charges,Implant Device,6924.4,35,,6924.4,percent of total billed charges,Implant Device,6924.4,35,,6924.4,percent of total billed charges,Implant Device,7913.6,40,,7913.6,percent of total billed charges,Implant Device,6924.4,70,,6924.4,percent of total billed charges,All Other,6726.56,34,,6726.56,percent of total billed charges,Implant Device,6726.56,34,,6726.56,percent of total billed charges,Implant Device,6924.4,35,,6924.4,percent of total billed charges,Implant Device,6924.4,35,,6924.4,percent of total billed charges,Implant Device,6924.4,35,,6924.4,percent of total billed charges,Implant Device,6924.4,35,,6924.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,6726.56,34,"If Charge > 2,000, then 34 percent",6726.56,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,14640.21,
BIOMET 163638 28MM COCR MOD HEAD +6MM,C1776,HCPCS,,79008133,CDM,278,RC,,,both,,,4830,3574.21,,,3574.21,Other,150% of Medicare + 9.63% HCRA Surcharge,2173.5,45,,2173.5,percent of total billed charges,Critical Access Hospital RCC factor,1642.2,34,,1642.2,percent of total billed charges,Implant Device,1642.2,34,,1642.2,percent of total billed charges,Implant Device,1642.2,34,,1642.2,percent of total billed charges,Implant Device,1642.2,34,,1642.2,percent of total billed charges,Implant Device,1642.2,34,,1642.2,percent of total billed charges,Implant Device,2390.85,,,2390.85,Other,110% of Medicare,1690.5,35,,1690.5,percent of total billed charges,Implant Device,1642.2,34,"Charges > $500, x 34%",1642.2,percent of total billed charges,Implant Device,1690.5,35,,1690.5,percent of total billed charges,Implant Device,1690.5,35,,1690.5,percent of total billed charges,Implant Device,1690.5,35,,1690.5,percent of total billed charges,Implant Device,1690.5,35,,1690.5,percent of total billed charges,Implant Device,1690.5,35,,1690.5,percent of total billed charges,Implant Device,1932,40,,1932,percent of total billed charges,Implant Device,1690.5,70,,1690.5,percent of total billed charges,All Other,1642.2,34,,1642.2,percent of total billed charges,Implant Device,1642.2,34,,1642.2,percent of total billed charges,Implant Device,1690.5,35,,1690.5,percent of total billed charges,Implant Device,1690.5,35,,1690.5,percent of total billed charges,Implant Device,1690.5,35,,1690.5,percent of total billed charges,Implant Device,1690.5,35,,1690.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1642.2,34,"If Charge > 2,000, then 34 percent",1642.2,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3574.21,
BIOMET 11-300916 ARCOS STS STEM 16X190MM,C1776,HCPCS,,79008135,CDM,278,RC,,,both,,,10199,7547.29,,,7547.29,Other,150% of Medicare + 9.63% HCRA Surcharge,4589.55,45,,4589.55,percent of total billed charges,Critical Access Hospital RCC factor,3467.66,34,,3467.66,percent of total billed charges,Implant Device,3467.66,34,,3467.66,percent of total billed charges,Implant Device,3467.66,34,,3467.66,percent of total billed charges,Implant Device,3467.66,34,,3467.66,percent of total billed charges,Implant Device,3467.66,34,,3467.66,percent of total billed charges,Implant Device,5048.51,,,5048.51,Other,110% of Medicare,3569.65,35,,3569.65,percent of total billed charges,Implant Device,3467.66,34,"Charges > $500, x 34%",3467.66,percent of total billed charges,Implant Device,3569.65,35,,3569.65,percent of total billed charges,Implant Device,3569.65,35,,3569.65,percent of total billed charges,Implant Device,3569.65,35,,3569.65,percent of total billed charges,Implant Device,3569.65,35,,3569.65,percent of total billed charges,Implant Device,3569.65,35,,3569.65,percent of total billed charges,Implant Device,4079.6,40,,4079.6,percent of total billed charges,Implant Device,3569.65,70,,3569.65,percent of total billed charges,All Other,3467.66,34,,3467.66,percent of total billed charges,Implant Device,3467.66,34,,3467.66,percent of total billed charges,Implant Device,3569.65,35,,3569.65,percent of total billed charges,Implant Device,3569.65,35,,3569.65,percent of total billed charges,Implant Device,3569.65,35,,3569.65,percent of total billed charges,Implant Device,3569.65,35,,3569.65,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3467.66,34,"If Charge > 2,000, then 34 percent",3467.66,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,7547.29,
BIOMET 11-301302 ARCOS STAND CONE SZB 60,C1776,HCPCS,,79008136,CDM,278,RC,,,both,,,19784,14640.21,,,14640.21,Other,150% of Medicare + 9.63% HCRA Surcharge,8902.8,45,,8902.8,percent of total billed charges,Critical Access Hospital RCC factor,6726.56,34,,6726.56,percent of total billed charges,Implant Device,6726.56,34,,6726.56,percent of total billed charges,Implant Device,6726.56,34,,6726.56,percent of total billed charges,Implant Device,6726.56,34,,6726.56,percent of total billed charges,Implant Device,6726.56,34,,6726.56,percent of total billed charges,Implant Device,9793.08,,,9793.08,Other,110% of Medicare,6924.4,35,,6924.4,percent of total billed charges,Implant Device,6726.56,34,"Charges > $500, x 34%",6726.56,percent of total billed charges,Implant Device,6924.4,35,,6924.4,percent of total billed charges,Implant Device,6924.4,35,,6924.4,percent of total billed charges,Implant Device,6924.4,35,,6924.4,percent of total billed charges,Implant Device,6924.4,35,,6924.4,percent of total billed charges,Implant Device,6924.4,35,,6924.4,percent of total billed charges,Implant Device,7913.6,40,,7913.6,percent of total billed charges,Implant Device,6924.4,70,,6924.4,percent of total billed charges,All Other,6726.56,34,,6726.56,percent of total billed charges,Implant Device,6726.56,34,,6726.56,percent of total billed charges,Implant Device,6924.4,35,,6924.4,percent of total billed charges,Implant Device,6924.4,35,,6924.4,percent of total billed charges,Implant Device,6924.4,35,,6924.4,percent of total billed charges,Implant Device,6924.4,35,,6924.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,6726.56,34,"If Charge > 2,000, then 34 percent",6726.56,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,14640.21,
BIOMET 8143-11-180 HIP NAIL 125DG 11X180,C1713,HCPCS,,79008137,CDM,278,RC,,,both,,,4464,3303.37,,,3303.37,Other,150% of Medicare + 9.63% HCRA Surcharge,2008.8,45,,2008.8,percent of total billed charges,Critical Access Hospital RCC factor,1517.76,34,,1517.76,percent of total billed charges,Implant Device,1517.76,34,,1517.76,percent of total billed charges,Implant Device,1517.76,34,,1517.76,percent of total billed charges,Implant Device,1517.76,34,,1517.76,percent of total billed charges,Implant Device,1517.76,34,,1517.76,percent of total billed charges,Implant Device,2209.68,,,2209.68,Other,110% of Medicare,1562.4,35,,1562.4,percent of total billed charges,Implant Device,1517.76,34,"Charges > $500, x 34%",1517.76,percent of total billed charges,Implant Device,1562.4,35,,1562.4,percent of total billed charges,Implant Device,1562.4,35,,1562.4,percent of total billed charges,Implant Device,1562.4,35,,1562.4,percent of total billed charges,Implant Device,1562.4,35,,1562.4,percent of total billed charges,Implant Device,1562.4,35,,1562.4,percent of total billed charges,Implant Device,1785.6,40,,1785.6,percent of total billed charges,Implant Device,1562.4,70,,1562.4,percent of total billed charges,All Other,1517.76,34,,1517.76,percent of total billed charges,Implant Device,1517.76,34,,1517.76,percent of total billed charges,Implant Device,1562.4,35,,1562.4,percent of total billed charges,Implant Device,1562.4,35,,1562.4,percent of total billed charges,Implant Device,1562.4,35,,1562.4,percent of total billed charges,Implant Device,1562.4,35,,1562.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1517.76,34,"If Charge > 2,000, then 34 percent",1517.76,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3303.37,
BIOMET 8145-10-100 HIP SCREW 10.5X100,C1713,HCPCS,,79008138,CDM,278,RC,,,both,,,1786,1321.64,,,1321.64,Other,150% of Medicare + 9.63% HCRA Surcharge,803.7,45,,803.7,percent of total billed charges,Critical Access Hospital RCC factor,607.24,34,,607.24,percent of total billed charges,Implant Device,607.24,34,,607.24,percent of total billed charges,Implant Device,607.24,34,,607.24,percent of total billed charges,Implant Device,607.24,34,,607.24,percent of total billed charges,Implant Device,607.24,34,,607.24,percent of total billed charges,Implant Device,884.07,,,884.07,Other,110% of Medicare,625.1,35,,625.1,percent of total billed charges,Implant Device,607.24,34,"Charges > $500, x 34%",607.24,percent of total billed charges,Implant Device,625.1,35,,625.1,percent of total billed charges,Implant Device,625.1,35,,625.1,percent of total billed charges,Implant Device,625.1,35,,625.1,percent of total billed charges,Implant Device,625.1,35,,625.1,percent of total billed charges,Implant Device,625.1,35,,625.1,percent of total billed charges,Implant Device,714.4,40,,714.4,percent of total billed charges,Implant Device,625.1,70,,625.1,percent of total billed charges,All Other,607.24,34,,607.24,percent of total billed charges,Implant Device,607.24,34,,607.24,percent of total billed charges,Implant Device,625.1,35,,625.1,percent of total billed charges,Implant Device,625.1,35,,625.1,percent of total billed charges,Implant Device,625.1,35,,625.1,percent of total billed charges,Implant Device,625.1,35,,625.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1321.64,
WRIGHT G4700005 FINGER JOINT IMPLNT SZ 5,C1776,HCPCS,,79008139,CDM,278,RC,,,both,,,4140,3063.61,,,3063.61,Other,150% of Medicare + 9.63% HCRA Surcharge,1863,45,,1863,percent of total billed charges,Critical Access Hospital RCC factor,1407.6,34,,1407.6,percent of total billed charges,Implant Device,1407.6,34,,1407.6,percent of total billed charges,Implant Device,1407.6,34,,1407.6,percent of total billed charges,Implant Device,1407.6,34,,1407.6,percent of total billed charges,Implant Device,1407.6,34,,1407.6,percent of total billed charges,Implant Device,2049.3,,,2049.3,Other,110% of Medicare,1449,35,,1449,percent of total billed charges,Implant Device,1407.6,34,"Charges > $500, x 34%",1407.6,percent of total billed charges,Implant Device,1449,35,,1449,percent of total billed charges,Implant Device,1449,35,,1449,percent of total billed charges,Implant Device,1449,35,,1449,percent of total billed charges,Implant Device,1449,35,,1449,percent of total billed charges,Implant Device,1449,35,,1449,percent of total billed charges,Implant Device,1656,40,,1656,percent of total billed charges,Implant Device,1449,70,,1449,percent of total billed charges,All Other,1407.6,34,,1407.6,percent of total billed charges,Implant Device,1407.6,34,,1407.6,percent of total billed charges,Implant Device,1449,35,,1449,percent of total billed charges,Implant Device,1449,35,,1449,percent of total billed charges,Implant Device,1449,35,,1449,percent of total billed charges,Implant Device,1449,35,,1449,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1407.6,34,"If Charge > 2,000, then 34 percent",1407.6,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3063.61,
STRYKER 40-35038 3.5X38MM NONLOCK SCREW,C1713,HCPCS,,79008141,CDM,278,RC,,,both,,,352,260.48,,,260.48,Other,150% of Medicare + 9.63% HCRA Surcharge,158.4,45,,158.4,percent of total billed charges,Critical Access Hospital RCC factor,119.68,34,,119.68,percent of total billed charges,Implant Device,119.68,34,,119.68,percent of total billed charges,Implant Device,119.68,34,,119.68,percent of total billed charges,Implant Device,119.68,34,,119.68,percent of total billed charges,Implant Device,119.68,34,,119.68,percent of total billed charges,Implant Device,174.24,,,174.24,Other,110% of Medicare,123.2,35,,123.2,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,123.2,35,,123.2,percent of total billed charges,Implant Device,123.2,35,,123.2,percent of total billed charges,Implant Device,123.2,35,,123.2,percent of total billed charges,Implant Device,123.2,35,,123.2,percent of total billed charges,Implant Device,123.2,35,,123.2,percent of total billed charges,Implant Device,140.8,40,,140.8,percent of total billed charges,Implant Device,123.2,70,,123.2,percent of total billed charges,All Other,119.68,34,,119.68,percent of total billed charges,Implant Device,119.68,34,,119.68,percent of total billed charges,Implant Device,123.2,35,,123.2,percent of total billed charges,Implant Device,123.2,35,,123.2,percent of total billed charges,Implant Device,123.2,35,,123.2,percent of total billed charges,Implant Device,123.2,35,,123.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,260.48,
STRYKER 40-35032 3.5X32MM NONLOCK SCREW,C1713,HCPCS,,79008142,CDM,278,RC,,,both,,,408,301.92,,,301.92,Other,150% of Medicare + 9.63% HCRA Surcharge,183.6,45,,183.6,percent of total billed charges,Critical Access Hospital RCC factor,138.72,34,,138.72,percent of total billed charges,Implant Device,138.72,34,,138.72,percent of total billed charges,Implant Device,138.72,34,,138.72,percent of total billed charges,Implant Device,138.72,34,,138.72,percent of total billed charges,Implant Device,138.72,34,,138.72,percent of total billed charges,Implant Device,201.96,,,201.96,Other,110% of Medicare,142.8,35,,142.8,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,142.8,35,,142.8,percent of total billed charges,Implant Device,142.8,35,,142.8,percent of total billed charges,Implant Device,142.8,35,,142.8,percent of total billed charges,Implant Device,142.8,35,,142.8,percent of total billed charges,Implant Device,142.8,35,,142.8,percent of total billed charges,Implant Device,163.2,40,,163.2,percent of total billed charges,Implant Device,142.8,70,,142.8,percent of total billed charges,All Other,138.72,34,,138.72,percent of total billed charges,Implant Device,138.72,34,,138.72,percent of total billed charges,Implant Device,142.8,35,,142.8,percent of total billed charges,Implant Device,142.8,35,,142.8,percent of total billed charges,Implant Device,142.8,35,,142.8,percent of total billed charges,Implant Device,142.8,35,,142.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,301.92,
ALPHATEC SPINE 62004-80 ROD 80MM,C1713,HCPCS,,79008145,CDM,278,RC,,,both,,,600,444,,,444,Other,150% of Medicare + 9.63% HCRA Surcharge,270,45,,270,percent of total billed charges,Critical Access Hospital RCC factor,204,34,,204,percent of total billed charges,Implant Device,204,34,,204,percent of total billed charges,Implant Device,204,34,,204,percent of total billed charges,Implant Device,204,34,,204,percent of total billed charges,Implant Device,204,34,,204,percent of total billed charges,Implant Device,297,,,297,Other,110% of Medicare,210,35,,210,percent of total billed charges,Implant Device,204,34,"Charges > $500, x 34%",204,percent of total billed charges,Implant Device,210,35,,210,percent of total billed charges,Implant Device,210,35,,210,percent of total billed charges,Implant Device,210,35,,210,percent of total billed charges,Implant Device,210,35,,210,percent of total billed charges,Implant Device,210,35,,210,percent of total billed charges,Implant Device,240,40,,240,percent of total billed charges,Implant Device,210,70,,210,percent of total billed charges,All Other,204,34,,204,percent of total billed charges,Implant Device,204,34,,204,percent of total billed charges,Implant Device,210,35,,210,percent of total billed charges,Implant Device,210,35,,210,percent of total billed charges,Implant Device,210,35,,210,percent of total billed charges,Implant Device,210,35,,210,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,444,
STRYKER 1822-0925S 9X255MM TIBIAL NAIL,C1713,HCPCS,,79008147,CDM,278,RC,,,both,,,6416,4747.86,,,4747.86,Other,150% of Medicare + 9.63% HCRA Surcharge,2887.2,45,,2887.2,percent of total billed charges,Critical Access Hospital RCC factor,2181.44,34,,2181.44,percent of total billed charges,Implant Device,2181.44,34,,2181.44,percent of total billed charges,Implant Device,2181.44,34,,2181.44,percent of total billed charges,Implant Device,2181.44,34,,2181.44,percent of total billed charges,Implant Device,2181.44,34,,2181.44,percent of total billed charges,Implant Device,3175.92,,,3175.92,Other,110% of Medicare,2245.6,35,,2245.6,percent of total billed charges,Implant Device,2181.44,34,"Charges > $500, x 34%",2181.44,percent of total billed charges,Implant Device,2245.6,35,,2245.6,percent of total billed charges,Implant Device,2245.6,35,,2245.6,percent of total billed charges,Implant Device,2245.6,35,,2245.6,percent of total billed charges,Implant Device,2245.6,35,,2245.6,percent of total billed charges,Implant Device,2245.6,35,,2245.6,percent of total billed charges,Implant Device,2566.4,40,,2566.4,percent of total billed charges,Implant Device,2245.6,70,,2245.6,percent of total billed charges,All Other,2181.44,34,,2181.44,percent of total billed charges,Implant Device,2181.44,34,,2181.44,percent of total billed charges,Implant Device,2245.6,35,,2245.6,percent of total billed charges,Implant Device,2245.6,35,,2245.6,percent of total billed charges,Implant Device,2245.6,35,,2245.6,percent of total billed charges,Implant Device,2245.6,35,,2245.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2181.44,34,"If Charge > 2,000, then 34 percent",2181.44,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4747.86,
STRYKER 1896-5027S 5X27 5MM LOCK SCREW,C1713,HCPCS,,79008148,CDM,278,RC,,,both,,,826,611.24,,,611.24,Other,150% of Medicare + 9.63% HCRA Surcharge,371.7,45,,371.7,percent of total billed charges,Critical Access Hospital RCC factor,280.84,34,,280.84,percent of total billed charges,Implant Device,280.84,34,,280.84,percent of total billed charges,Implant Device,280.84,34,,280.84,percent of total billed charges,Implant Device,280.84,34,,280.84,percent of total billed charges,Implant Device,280.84,34,,280.84,percent of total billed charges,Implant Device,408.87,,,408.87,Other,110% of Medicare,289.1,35,,289.1,percent of total billed charges,Implant Device,280.84,34,"Charges > $500, x 34%",280.84,percent of total billed charges,Implant Device,289.1,35,,289.1,percent of total billed charges,Implant Device,289.1,35,,289.1,percent of total billed charges,Implant Device,289.1,35,,289.1,percent of total billed charges,Implant Device,289.1,35,,289.1,percent of total billed charges,Implant Device,289.1,35,,289.1,percent of total billed charges,Implant Device,330.4,40,,330.4,percent of total billed charges,Implant Device,289.1,70,,289.1,percent of total billed charges,All Other,280.84,34,,280.84,percent of total billed charges,Implant Device,280.84,34,,280.84,percent of total billed charges,Implant Device,289.1,35,,289.1,percent of total billed charges,Implant Device,289.1,35,,289.1,percent of total billed charges,Implant Device,289.1,35,,289.1,percent of total billed charges,Implant Device,289.1,35,,289.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,611.24,
BARD 5955450 VENTRALIGHT MESH ECHO 4.5,C1781,HCPCS,,79008149,CDM,278,RC,,,both,,,3420,2530.81,,,2530.81,Other,150% of Medicare + 9.63% HCRA Surcharge,1539,45,,1539,percent of total billed charges,Critical Access Hospital RCC factor,1162.8,34,,1162.8,percent of total billed charges,Implant Device,1162.8,34,,1162.8,percent of total billed charges,Implant Device,1162.8,34,,1162.8,percent of total billed charges,Implant Device,1162.8,34,,1162.8,percent of total billed charges,Implant Device,1162.8,34,,1162.8,percent of total billed charges,Implant Device,1692.9,,,1692.9,Other,110% of Medicare,1197,35,,1197,percent of total billed charges,Implant Device,1162.8,34,"Charges > $500, x 34%",1162.8,percent of total billed charges,Implant Device,1197,35,,1197,percent of total billed charges,Implant Device,1197,35,,1197,percent of total billed charges,Implant Device,1197,35,,1197,percent of total billed charges,Implant Device,1197,35,,1197,percent of total billed charges,Implant Device,1197,35,,1197,percent of total billed charges,Implant Device,1368,40,,1368,percent of total billed charges,Implant Device,1197,70,,1197,percent of total billed charges,All Other,1162.8,34,,1162.8,percent of total billed charges,Implant Device,1162.8,34,,1162.8,percent of total billed charges,Implant Device,1197,35,,1197,percent of total billed charges,Implant Device,1197,35,,1197,percent of total billed charges,Implant Device,1197,35,,1197,percent of total billed charges,Implant Device,1197,35,,1197,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1162.8,34,"If Charge > 2,000, then 34 percent",1162.8,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2530.81,
BME SE-1515TI SPEED TITAN IMP 15X15X15,C1713,HCPCS,,79008150,CDM,278,RC,,,both,,,3612,2672.89,,,2672.89,Other,150% of Medicare + 9.63% HCRA Surcharge,1625.4,45,,1625.4,percent of total billed charges,Critical Access Hospital RCC factor,1228.08,34,,1228.08,percent of total billed charges,Implant Device,1228.08,34,,1228.08,percent of total billed charges,Implant Device,1228.08,34,,1228.08,percent of total billed charges,Implant Device,1228.08,34,,1228.08,percent of total billed charges,Implant Device,1228.08,34,,1228.08,percent of total billed charges,Implant Device,1787.94,,,1787.94,Other,110% of Medicare,1264.2,35,,1264.2,percent of total billed charges,Implant Device,1228.08,34,"Charges > $500, x 34%",1228.08,percent of total billed charges,Implant Device,1264.2,35,,1264.2,percent of total billed charges,Implant Device,1264.2,35,,1264.2,percent of total billed charges,Implant Device,1264.2,35,,1264.2,percent of total billed charges,Implant Device,1264.2,35,,1264.2,percent of total billed charges,Implant Device,1264.2,35,,1264.2,percent of total billed charges,Implant Device,1444.8,40,,1444.8,percent of total billed charges,Implant Device,1264.2,70,,1264.2,percent of total billed charges,All Other,1228.08,34,,1228.08,percent of total billed charges,Implant Device,1228.08,34,,1228.08,percent of total billed charges,Implant Device,1264.2,35,,1264.2,percent of total billed charges,Implant Device,1264.2,35,,1264.2,percent of total billed charges,Implant Device,1264.2,35,,1264.2,percent of total billed charges,Implant Device,1264.2,35,,1264.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1228.08,34,"If Charge > 2,000, then 34 percent",1228.08,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2672.89,
DEPUY 02.206.212 CORTEX SCREW 3.5X12MM,C1713,HCPCS,,79008152,CDM,278,RC,,,both,,,140,103.6,,,103.6,Other,150% of Medicare + 9.63% HCRA Surcharge,63,45,,63,percent of total billed charges,Critical Access Hospital RCC factor,47.6,34,,47.6,percent of total billed charges,Implant Device,47.6,34,,47.6,percent of total billed charges,Implant Device,47.6,34,,47.6,percent of total billed charges,Implant Device,47.6,34,,47.6,percent of total billed charges,Implant Device,47.6,34,,47.6,percent of total billed charges,Implant Device,69.3,,,69.3,Other,110% of Medicare,49,35,,49,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,49,35,,49,percent of total billed charges,Implant Device,49,35,,49,percent of total billed charges,Implant Device,49,35,,49,percent of total billed charges,Implant Device,49,35,,49,percent of total billed charges,Implant Device,49,35,,49,percent of total billed charges,Implant Device,56,40,,56,percent of total billed charges,Implant Device,49,70,,49,percent of total billed charges,All Other,47.6,34,,47.6,percent of total billed charges,Implant Device,47.6,34,,47.6,percent of total billed charges,Implant Device,49,35,,49,percent of total billed charges,Implant Device,49,35,,49,percent of total billed charges,Implant Device,49,35,,49,percent of total billed charges,Implant Device,49,35,,49,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,103.6,
DEPUY 02.206.228 CORTEX SCREW 3.5X28MM,C1713,HCPCS,,79008153,CDM,278,RC,,,both,,,79,58.46,,,58.46,Other,150% of Medicare + 9.63% HCRA Surcharge,35.55,45,,35.55,percent of total billed charges,Critical Access Hospital RCC factor,26.86,34,,26.86,percent of total billed charges,Implant Device,26.86,34,,26.86,percent of total billed charges,Implant Device,26.86,34,,26.86,percent of total billed charges,Implant Device,26.86,34,,26.86,percent of total billed charges,Implant Device,26.86,34,,26.86,percent of total billed charges,Implant Device,39.11,,,39.11,Other,110% of Medicare,27.65,35,,27.65,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,27.65,35,,27.65,percent of total billed charges,Implant Device,27.65,35,,27.65,percent of total billed charges,Implant Device,27.65,35,,27.65,percent of total billed charges,Implant Device,27.65,35,,27.65,percent of total billed charges,Implant Device,27.65,35,,27.65,percent of total billed charges,Implant Device,31.6,40,,31.6,percent of total billed charges,Implant Device,27.65,70,,27.65,percent of total billed charges,All Other,26.86,34,,26.86,percent of total billed charges,Implant Device,26.86,34,,26.86,percent of total billed charges,Implant Device,27.65,35,,27.65,percent of total billed charges,Implant Device,27.65,35,,27.65,percent of total billed charges,Implant Device,27.65,35,,27.65,percent of total billed charges,Implant Device,27.65,35,,27.65,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,58.46,
DEPUY 02.206.226 CORTEX SCREW 3.5X26MM,C1713,HCPCS,,79008154,CDM,278,RC,,,both,,,79,58.46,,,58.46,Other,150% of Medicare + 9.63% HCRA Surcharge,35.55,45,,35.55,percent of total billed charges,Critical Access Hospital RCC factor,26.86,34,,26.86,percent of total billed charges,Implant Device,26.86,34,,26.86,percent of total billed charges,Implant Device,26.86,34,,26.86,percent of total billed charges,Implant Device,26.86,34,,26.86,percent of total billed charges,Implant Device,26.86,34,,26.86,percent of total billed charges,Implant Device,39.11,,,39.11,Other,110% of Medicare,27.65,35,,27.65,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,27.65,35,,27.65,percent of total billed charges,Implant Device,27.65,35,,27.65,percent of total billed charges,Implant Device,27.65,35,,27.65,percent of total billed charges,Implant Device,27.65,35,,27.65,percent of total billed charges,Implant Device,27.65,35,,27.65,percent of total billed charges,Implant Device,31.6,40,,31.6,percent of total billed charges,Implant Device,27.65,70,,27.65,percent of total billed charges,All Other,26.86,34,,26.86,percent of total billed charges,Implant Device,26.86,34,,26.86,percent of total billed charges,Implant Device,27.65,35,,27.65,percent of total billed charges,Implant Device,27.65,35,,27.65,percent of total billed charges,Implant Device,27.65,35,,27.65,percent of total billed charges,Implant Device,27.65,35,,27.65,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,58.46,
STRYKER 1832-1045S HUMERAL NAIL 8X150MM,C1713,HCPCS,,79008155,CDM,278,RC,,,both,,,4760,3522.41,,,3522.41,Other,150% of Medicare + 9.63% HCRA Surcharge,2142,45,,2142,percent of total billed charges,Critical Access Hospital RCC factor,1618.4,34,,1618.4,percent of total billed charges,Implant Device,1618.4,34,,1618.4,percent of total billed charges,Implant Device,1618.4,34,,1618.4,percent of total billed charges,Implant Device,1618.4,34,,1618.4,percent of total billed charges,Implant Device,1618.4,34,,1618.4,percent of total billed charges,Implant Device,2356.2,,,2356.2,Other,110% of Medicare,1666,35,,1666,percent of total billed charges,Implant Device,1618.4,34,"Charges > $500, x 34%",1618.4,percent of total billed charges,Implant Device,1666,35,,1666,percent of total billed charges,Implant Device,1666,35,,1666,percent of total billed charges,Implant Device,1666,35,,1666,percent of total billed charges,Implant Device,1666,35,,1666,percent of total billed charges,Implant Device,1666,35,,1666,percent of total billed charges,Implant Device,1904,40,,1904,percent of total billed charges,Implant Device,1666,70,,1666,percent of total billed charges,All Other,1618.4,34,,1618.4,percent of total billed charges,Implant Device,1618.4,34,,1618.4,percent of total billed charges,Implant Device,1666,35,,1666,percent of total billed charges,Implant Device,1666,35,,1666,percent of total billed charges,Implant Device,1666,35,,1666,percent of total billed charges,Implant Device,1666,35,,1666,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1618.4,34,"If Charge > 2,000, then 34 percent",1618.4,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3522.41,
STRYKER 1896-4034S LOCKING SCREW 4X34MM,C1713,HCPCS,,79008156,CDM,278,RC,,,both,,,773,572.02,,,572.02,Other,150% of Medicare + 9.63% HCRA Surcharge,347.85,45,,347.85,percent of total billed charges,Critical Access Hospital RCC factor,262.82,34,,262.82,percent of total billed charges,Implant Device,262.82,34,,262.82,percent of total billed charges,Implant Device,262.82,34,,262.82,percent of total billed charges,Implant Device,262.82,34,,262.82,percent of total billed charges,Implant Device,262.82,34,,262.82,percent of total billed charges,Implant Device,382.64,,,382.64,Other,110% of Medicare,270.55,35,,270.55,percent of total billed charges,Implant Device,262.82,34,"Charges > $500, x 34%",262.82,percent of total billed charges,Implant Device,270.55,35,,270.55,percent of total billed charges,Implant Device,270.55,35,,270.55,percent of total billed charges,Implant Device,270.55,35,,270.55,percent of total billed charges,Implant Device,270.55,35,,270.55,percent of total billed charges,Implant Device,270.55,35,,270.55,percent of total billed charges,Implant Device,309.2,40,,309.2,percent of total billed charges,Implant Device,270.55,70,,270.55,percent of total billed charges,All Other,262.82,34,,262.82,percent of total billed charges,Implant Device,262.82,34,,262.82,percent of total billed charges,Implant Device,270.55,35,,270.55,percent of total billed charges,Implant Device,270.55,35,,270.55,percent of total billed charges,Implant Device,270.55,35,,270.55,percent of total billed charges,Implant Device,270.55,35,,270.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,572.02,
DEPUY 241.371 TUBULAR PLATE 7 HOLE,C1713,HCPCS,,79008157,CDM,278,RC,,,both,,,668,494.32,,,494.32,Other,150% of Medicare + 9.63% HCRA Surcharge,300.6,45,,300.6,percent of total billed charges,Critical Access Hospital RCC factor,227.12,34,,227.12,percent of total billed charges,Implant Device,227.12,34,,227.12,percent of total billed charges,Implant Device,227.12,34,,227.12,percent of total billed charges,Implant Device,227.12,34,,227.12,percent of total billed charges,Implant Device,227.12,34,,227.12,percent of total billed charges,Implant Device,330.66,,,330.66,Other,110% of Medicare,233.8,35,,233.8,percent of total billed charges,Implant Device,227.12,34,"Charges > $500, x 34%",227.12,percent of total billed charges,Implant Device,233.8,35,,233.8,percent of total billed charges,Implant Device,233.8,35,,233.8,percent of total billed charges,Implant Device,233.8,35,,233.8,percent of total billed charges,Implant Device,233.8,35,,233.8,percent of total billed charges,Implant Device,233.8,35,,233.8,percent of total billed charges,Implant Device,267.2,40,,267.2,percent of total billed charges,Implant Device,233.8,70,,233.8,percent of total billed charges,All Other,227.12,34,,227.12,percent of total billed charges,Implant Device,227.12,34,,227.12,percent of total billed charges,Implant Device,233.8,35,,233.8,percent of total billed charges,Implant Device,233.8,35,,233.8,percent of total billed charges,Implant Device,233.8,35,,233.8,percent of total billed charges,Implant Device,233.8,35,,233.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,494.32,
DEPUY 02.206.218 CORTEX SCREW 3.5X18MM,C1713,HCPCS,,79008158,CDM,278,RC,,,both,,,140,103.6,,,103.6,Other,150% of Medicare + 9.63% HCRA Surcharge,63,45,,63,percent of total billed charges,Critical Access Hospital RCC factor,47.6,34,,47.6,percent of total billed charges,Implant Device,47.6,34,,47.6,percent of total billed charges,Implant Device,47.6,34,,47.6,percent of total billed charges,Implant Device,47.6,34,,47.6,percent of total billed charges,Implant Device,47.6,34,,47.6,percent of total billed charges,Implant Device,69.3,,,69.3,Other,110% of Medicare,49,35,,49,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,49,35,,49,percent of total billed charges,Implant Device,49,35,,49,percent of total billed charges,Implant Device,49,35,,49,percent of total billed charges,Implant Device,49,35,,49,percent of total billed charges,Implant Device,49,35,,49,percent of total billed charges,Implant Device,56,40,,56,percent of total billed charges,Implant Device,49,70,,49,percent of total billed charges,All Other,47.6,34,,47.6,percent of total billed charges,Implant Device,47.6,34,,47.6,percent of total billed charges,Implant Device,49,35,,49,percent of total billed charges,Implant Device,49,35,,49,percent of total billed charges,Implant Device,49,35,,49,percent of total billed charges,Implant Device,49,35,,49,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,103.6,
MENTOR 350-5800BC BREAST IMPLANT,C1789,HCPCS,,79008159,CDM,278,RC,,,both,,,3015,2231.11,,,2231.11,Other,150% of Medicare + 9.63% HCRA Surcharge,1356.75,45,,1356.75,percent of total billed charges,Critical Access Hospital RCC factor,1025.1,34,,1025.1,percent of total billed charges,Implant Device,1025.1,34,,1025.1,percent of total billed charges,Implant Device,1025.1,34,,1025.1,percent of total billed charges,Implant Device,1025.1,34,,1025.1,percent of total billed charges,Implant Device,1025.1,34,,1025.1,percent of total billed charges,Implant Device,1492.43,,,1492.43,Other,110% of Medicare,1055.25,35,,1055.25,percent of total billed charges,Implant Device,1025.1,34,"Charges > $500, x 34%",1025.1,percent of total billed charges,Implant Device,1055.25,35,,1055.25,percent of total billed charges,Implant Device,1055.25,35,,1055.25,percent of total billed charges,Implant Device,1055.25,35,,1055.25,percent of total billed charges,Implant Device,1055.25,35,,1055.25,percent of total billed charges,Implant Device,1055.25,35,,1055.25,percent of total billed charges,Implant Device,1206,40,,1206,percent of total billed charges,Implant Device,1055.25,70,,1055.25,percent of total billed charges,All Other,1025.1,34,,1025.1,percent of total billed charges,Implant Device,1025.1,34,,1025.1,percent of total billed charges,Implant Device,1055.25,35,,1055.25,percent of total billed charges,Implant Device,1055.25,35,,1055.25,percent of total billed charges,Implant Device,1055.25,35,,1055.25,percent of total billed charges,Implant Device,1055.25,35,,1055.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1025.1,34,"If Charge > 2,000, then 34 percent",1025.1,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2231.11,
ARTHREX AR-8740-44H 4X44MM FT COMP SCREW,C1713,HCPCS,,79008160,CDM,278,RC,,,both,,,1266,936.84,,,936.84,Other,150% of Medicare + 9.63% HCRA Surcharge,569.7,45,,569.7,percent of total billed charges,Critical Access Hospital RCC factor,430.44,34,,430.44,percent of total billed charges,Implant Device,430.44,34,,430.44,percent of total billed charges,Implant Device,430.44,34,,430.44,percent of total billed charges,Implant Device,430.44,34,,430.44,percent of total billed charges,Implant Device,430.44,34,,430.44,percent of total billed charges,Implant Device,626.67,,,626.67,Other,110% of Medicare,443.1,35,,443.1,percent of total billed charges,Implant Device,430.44,34,"Charges > $500, x 34%",430.44,percent of total billed charges,Implant Device,443.1,35,,443.1,percent of total billed charges,Implant Device,443.1,35,,443.1,percent of total billed charges,Implant Device,443.1,35,,443.1,percent of total billed charges,Implant Device,443.1,35,,443.1,percent of total billed charges,Implant Device,443.1,35,,443.1,percent of total billed charges,Implant Device,506.4,40,,506.4,percent of total billed charges,Implant Device,443.1,70,,443.1,percent of total billed charges,All Other,430.44,34,,430.44,percent of total billed charges,Implant Device,430.44,34,,430.44,percent of total billed charges,Implant Device,443.1,35,,443.1,percent of total billed charges,Implant Device,443.1,35,,443.1,percent of total billed charges,Implant Device,443.1,35,,443.1,percent of total billed charges,Implant Device,443.1,35,,443.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,936.84,
ARTHREX AR-8740-30H 4X30MM FT COMP SCREW,C1713,HCPCS,,79008161,CDM,278,RC,,,both,,,1266,936.84,,,936.84,Other,150% of Medicare + 9.63% HCRA Surcharge,569.7,45,,569.7,percent of total billed charges,Critical Access Hospital RCC factor,430.44,34,,430.44,percent of total billed charges,Implant Device,430.44,34,,430.44,percent of total billed charges,Implant Device,430.44,34,,430.44,percent of total billed charges,Implant Device,430.44,34,,430.44,percent of total billed charges,Implant Device,430.44,34,,430.44,percent of total billed charges,Implant Device,626.67,,,626.67,Other,110% of Medicare,443.1,35,,443.1,percent of total billed charges,Implant Device,430.44,34,"Charges > $500, x 34%",430.44,percent of total billed charges,Implant Device,443.1,35,,443.1,percent of total billed charges,Implant Device,443.1,35,,443.1,percent of total billed charges,Implant Device,443.1,35,,443.1,percent of total billed charges,Implant Device,443.1,35,,443.1,percent of total billed charges,Implant Device,443.1,35,,443.1,percent of total billed charges,Implant Device,506.4,40,,506.4,percent of total billed charges,Implant Device,443.1,70,,443.1,percent of total billed charges,All Other,430.44,34,,430.44,percent of total billed charges,Implant Device,430.44,34,,430.44,percent of total billed charges,Implant Device,443.1,35,,443.1,percent of total billed charges,Implant Device,443.1,35,,443.1,percent of total billed charges,Implant Device,443.1,35,,443.1,percent of total billed charges,Implant Device,443.1,35,,443.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,936.84,
GORE RLT281414 EXCLUDER ENDO VASC GRAFT,C1768,HCPCS,,79008163,CDM,278,RC,,,both,,,33000,24420.08,,,24420.08,Other,150% of Medicare + 9.63% HCRA Surcharge,14850,45,,14850,percent of total billed charges,Critical Access Hospital RCC factor,11220,34,,11220,percent of total billed charges,Implant Device,11220,34,,11220,percent of total billed charges,Implant Device,11220,34,,11220,percent of total billed charges,Implant Device,11220,34,,11220,percent of total billed charges,Implant Device,11220,34,,11220,percent of total billed charges,Implant Device,16335,,,16335,Other,110% of Medicare,11550,35,,11550,percent of total billed charges,Implant Device,11220,34,"Charges > $500, x 34%",11220,percent of total billed charges,Implant Device,11550,35,,11550,percent of total billed charges,Implant Device,11550,35,,11550,percent of total billed charges,Implant Device,11550,35,,11550,percent of total billed charges,Implant Device,11550,35,,11550,percent of total billed charges,Implant Device,11550,35,,11550,percent of total billed charges,Implant Device,13200,40,,13200,percent of total billed charges,Implant Device,11550,70,,11550,percent of total billed charges,All Other,11220,34,,11220,percent of total billed charges,Implant Device,11220,34,,11220,percent of total billed charges,Implant Device,11550,35,,11550,percent of total billed charges,Implant Device,11550,35,,11550,percent of total billed charges,Implant Device,11550,35,,11550,percent of total billed charges,Implant Device,11550,35,,11550,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,11220,34,"If Charge > 2,000, then 34 percent",11220,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,24420.08,
P28 P50-053-2720 LOCK PLATE SCREW 2.7X20,C1713,HCPCS,,79008164,CDM,278,RC,,,both,,,488,361.12,,,361.12,Other,150% of Medicare + 9.63% HCRA Surcharge,219.6,45,,219.6,percent of total billed charges,Critical Access Hospital RCC factor,165.92,34,,165.92,percent of total billed charges,Implant Device,165.92,34,,165.92,percent of total billed charges,Implant Device,165.92,34,,165.92,percent of total billed charges,Implant Device,165.92,34,,165.92,percent of total billed charges,Implant Device,165.92,34,,165.92,percent of total billed charges,Implant Device,241.56,,,241.56,Other,110% of Medicare,170.8,35,,170.8,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,170.8,35,,170.8,percent of total billed charges,Implant Device,170.8,35,,170.8,percent of total billed charges,Implant Device,170.8,35,,170.8,percent of total billed charges,Implant Device,170.8,35,,170.8,percent of total billed charges,Implant Device,170.8,35,,170.8,percent of total billed charges,Implant Device,195.2,40,,195.2,percent of total billed charges,Implant Device,170.8,70,,170.8,percent of total billed charges,All Other,165.92,34,,165.92,percent of total billed charges,Implant Device,165.92,34,,165.92,percent of total billed charges,Implant Device,170.8,35,,170.8,percent of total billed charges,Implant Device,170.8,35,,170.8,percent of total billed charges,Implant Device,170.8,35,,170.8,percent of total billed charges,Implant Device,170.8,35,,170.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,361.12,
P28 P53-105-L002 PLATE MEDIUM LEFT 20MM,C1713,HCPCS,,79008165,CDM,278,RC,,,both,,,5610,4151.41,,,4151.41,Other,150% of Medicare + 9.63% HCRA Surcharge,2524.5,45,,2524.5,percent of total billed charges,Critical Access Hospital RCC factor,1907.4,34,,1907.4,percent of total billed charges,Implant Device,1907.4,34,,1907.4,percent of total billed charges,Implant Device,1907.4,34,,1907.4,percent of total billed charges,Implant Device,1907.4,34,,1907.4,percent of total billed charges,Implant Device,1907.4,34,,1907.4,percent of total billed charges,Implant Device,2776.95,,,2776.95,Other,110% of Medicare,1963.5,35,,1963.5,percent of total billed charges,Implant Device,1907.4,34,"Charges > $500, x 34%",1907.4,percent of total billed charges,Implant Device,1963.5,35,,1963.5,percent of total billed charges,Implant Device,1963.5,35,,1963.5,percent of total billed charges,Implant Device,1963.5,35,,1963.5,percent of total billed charges,Implant Device,1963.5,35,,1963.5,percent of total billed charges,Implant Device,1963.5,35,,1963.5,percent of total billed charges,Implant Device,2244,40,,2244,percent of total billed charges,Implant Device,1963.5,70,,1963.5,percent of total billed charges,All Other,1907.4,34,,1907.4,percent of total billed charges,Implant Device,1907.4,34,,1907.4,percent of total billed charges,Implant Device,1963.5,35,,1963.5,percent of total billed charges,Implant Device,1963.5,35,,1963.5,percent of total billed charges,Implant Device,1963.5,35,,1963.5,percent of total billed charges,Implant Device,1963.5,35,,1963.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1907.4,34,"If Charge > 2,000, then 34 percent",1907.4,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4151.41,
P28 PCOT-181405 COTTON WEDGE 5MM,C1713,HCPCS,,79008166,CDM,278,RC,,,both,,,5993,4434.83,,,4434.83,Other,150% of Medicare + 9.63% HCRA Surcharge,2696.85,45,,2696.85,percent of total billed charges,Critical Access Hospital RCC factor,2037.62,34,,2037.62,percent of total billed charges,Implant Device,2037.62,34,,2037.62,percent of total billed charges,Implant Device,2037.62,34,,2037.62,percent of total billed charges,Implant Device,2037.62,34,,2037.62,percent of total billed charges,Implant Device,2037.62,34,,2037.62,percent of total billed charges,Implant Device,2966.54,,,2966.54,Other,110% of Medicare,2097.55,35,,2097.55,percent of total billed charges,Implant Device,2037.62,34,"Charges > $500, x 34%",2037.62,percent of total billed charges,Implant Device,2097.55,35,,2097.55,percent of total billed charges,Implant Device,2097.55,35,,2097.55,percent of total billed charges,Implant Device,2097.55,35,,2097.55,percent of total billed charges,Implant Device,2097.55,35,,2097.55,percent of total billed charges,Implant Device,2097.55,35,,2097.55,percent of total billed charges,Implant Device,2397.2,40,,2397.2,percent of total billed charges,Implant Device,2097.55,70,,2097.55,percent of total billed charges,All Other,2037.62,34,,2037.62,percent of total billed charges,Implant Device,2037.62,34,,2037.62,percent of total billed charges,Implant Device,2097.55,35,,2097.55,percent of total billed charges,Implant Device,2097.55,35,,2097.55,percent of total billed charges,Implant Device,2097.55,35,,2097.55,percent of total billed charges,Implant Device,2097.55,35,,2097.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2037.62,34,"If Charge > 2,000, then 34 percent",2037.62,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4434.83,
P28 PLCL-20008 EVANS WWEDGE 8MM,C1713,HCPCS,,79008167,CDM,278,RC,,,both,,,5610,4151.41,,,4151.41,Other,150% of Medicare + 9.63% HCRA Surcharge,2524.5,45,,2524.5,percent of total billed charges,Critical Access Hospital RCC factor,1907.4,34,,1907.4,percent of total billed charges,Implant Device,1907.4,34,,1907.4,percent of total billed charges,Implant Device,1907.4,34,,1907.4,percent of total billed charges,Implant Device,1907.4,34,,1907.4,percent of total billed charges,Implant Device,1907.4,34,,1907.4,percent of total billed charges,Implant Device,2776.95,,,2776.95,Other,110% of Medicare,1963.5,35,,1963.5,percent of total billed charges,Implant Device,1907.4,34,"Charges > $500, x 34%",1907.4,percent of total billed charges,Implant Device,1963.5,35,,1963.5,percent of total billed charges,Implant Device,1963.5,35,,1963.5,percent of total billed charges,Implant Device,1963.5,35,,1963.5,percent of total billed charges,Implant Device,1963.5,35,,1963.5,percent of total billed charges,Implant Device,1963.5,35,,1963.5,percent of total billed charges,Implant Device,2244,40,,2244,percent of total billed charges,Implant Device,1963.5,70,,1963.5,percent of total billed charges,All Other,1907.4,34,,1907.4,percent of total billed charges,Implant Device,1907.4,34,,1907.4,percent of total billed charges,Implant Device,1963.5,35,,1963.5,percent of total billed charges,Implant Device,1963.5,35,,1963.5,percent of total billed charges,Implant Device,1963.5,35,,1963.5,percent of total billed charges,Implant Device,1963.5,35,,1963.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1907.4,34,"If Charge > 2,000, then 34 percent",1907.4,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4151.41,
ARTHREX AR-4154P-3010 PIP DART 30 BEND,C1713,HCPCS,,79008168,CDM,278,RC,,,both,,,2550,1887.01,,,1887.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1147.5,45,,1147.5,percent of total billed charges,Critical Access Hospital RCC factor,867,34,,867,percent of total billed charges,Implant Device,867,34,,867,percent of total billed charges,Implant Device,867,34,,867,percent of total billed charges,Implant Device,867,34,,867,percent of total billed charges,Implant Device,867,34,,867,percent of total billed charges,Implant Device,1262.25,,,1262.25,Other,110% of Medicare,892.5,35,,892.5,percent of total billed charges,Implant Device,867,34,"Charges > $500, x 34%",867,percent of total billed charges,Implant Device,892.5,35,,892.5,percent of total billed charges,Implant Device,892.5,35,,892.5,percent of total billed charges,Implant Device,892.5,35,,892.5,percent of total billed charges,Implant Device,892.5,35,,892.5,percent of total billed charges,Implant Device,892.5,35,,892.5,percent of total billed charges,Implant Device,1020,40,,1020,percent of total billed charges,Implant Device,892.5,70,,892.5,percent of total billed charges,All Other,867,34,,867,percent of total billed charges,Implant Device,867,34,,867,percent of total billed charges,Implant Device,892.5,35,,892.5,percent of total billed charges,Implant Device,892.5,35,,892.5,percent of total billed charges,Implant Device,892.5,35,,892.5,percent of total billed charges,Implant Device,892.5,35,,892.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,867,34,"If Charge > 2,000, then 34 percent",867,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1887.01,
DEPUY 202.216 LOCKING SCREW 2.7X16MM,C1713,HCPCS,,79008169,CDM,278,RC,,,both,,,300,222,,,222,Other,150% of Medicare + 9.63% HCRA Surcharge,135,45,,135,percent of total billed charges,Critical Access Hospital RCC factor,102,34,,102,percent of total billed charges,Implant Device,102,34,,102,percent of total billed charges,Implant Device,102,34,,102,percent of total billed charges,Implant Device,102,34,,102,percent of total billed charges,Implant Device,102,34,,102,percent of total billed charges,Implant Device,148.5,,,148.5,Other,110% of Medicare,105,35,,105,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,105,35,,105,percent of total billed charges,Implant Device,105,35,,105,percent of total billed charges,Implant Device,105,35,,105,percent of total billed charges,Implant Device,105,35,,105,percent of total billed charges,Implant Device,105,35,,105,percent of total billed charges,Implant Device,120,40,,120,percent of total billed charges,Implant Device,105,70,,105,percent of total billed charges,All Other,102,34,,102,percent of total billed charges,Implant Device,102,34,,102,percent of total billed charges,Implant Device,105,35,,105,percent of total billed charges,Implant Device,105,35,,105,percent of total billed charges,Implant Device,105,35,,105,percent of total billed charges,Implant Device,105,35,,105,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,222,
STRYKER MV32A 4X32MM FIXOS,C1713,HCPCS,,79008170,CDM,278,RC,,,both,,,1413,1045.62,,,1045.62,Other,150% of Medicare + 9.63% HCRA Surcharge,635.85,45,,635.85,percent of total billed charges,Critical Access Hospital RCC factor,480.42,34,,480.42,percent of total billed charges,Implant Device,480.42,34,,480.42,percent of total billed charges,Implant Device,480.42,34,,480.42,percent of total billed charges,Implant Device,480.42,34,,480.42,percent of total billed charges,Implant Device,480.42,34,,480.42,percent of total billed charges,Implant Device,699.44,,,699.44,Other,110% of Medicare,494.55,35,,494.55,percent of total billed charges,Implant Device,480.42,34,"Charges > $500, x 34%",480.42,percent of total billed charges,Implant Device,494.55,35,,494.55,percent of total billed charges,Implant Device,494.55,35,,494.55,percent of total billed charges,Implant Device,494.55,35,,494.55,percent of total billed charges,Implant Device,494.55,35,,494.55,percent of total billed charges,Implant Device,494.55,35,,494.55,percent of total billed charges,Implant Device,565.2,40,,565.2,percent of total billed charges,Implant Device,494.55,70,,494.55,percent of total billed charges,All Other,480.42,34,,480.42,percent of total billed charges,Implant Device,480.42,34,,480.42,percent of total billed charges,Implant Device,494.55,35,,494.55,percent of total billed charges,Implant Device,494.55,35,,494.55,percent of total billed charges,Implant Device,494.55,35,,494.55,percent of total billed charges,Implant Device,494.55,35,,494.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1045.62,
STRYKER MV28A 4X28MM FIXOS,C1713,HCPCS,,79008171,CDM,278,RC,,,both,,,1413,1045.62,,,1045.62,Other,150% of Medicare + 9.63% HCRA Surcharge,635.85,45,,635.85,percent of total billed charges,Critical Access Hospital RCC factor,480.42,34,,480.42,percent of total billed charges,Implant Device,480.42,34,,480.42,percent of total billed charges,Implant Device,480.42,34,,480.42,percent of total billed charges,Implant Device,480.42,34,,480.42,percent of total billed charges,Implant Device,480.42,34,,480.42,percent of total billed charges,Implant Device,699.44,,,699.44,Other,110% of Medicare,494.55,35,,494.55,percent of total billed charges,Implant Device,480.42,34,"Charges > $500, x 34%",480.42,percent of total billed charges,Implant Device,494.55,35,,494.55,percent of total billed charges,Implant Device,494.55,35,,494.55,percent of total billed charges,Implant Device,494.55,35,,494.55,percent of total billed charges,Implant Device,494.55,35,,494.55,percent of total billed charges,Implant Device,494.55,35,,494.55,percent of total billed charges,Implant Device,565.2,40,,565.2,percent of total billed charges,Implant Device,494.55,70,,494.55,percent of total billed charges,All Other,480.42,34,,480.42,percent of total billed charges,Implant Device,480.42,34,,480.42,percent of total billed charges,Implant Device,494.55,35,,494.55,percent of total billed charges,Implant Device,494.55,35,,494.55,percent of total billed charges,Implant Device,494.55,35,,494.55,percent of total billed charges,Implant Device,494.55,35,,494.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1045.62,
BIOMET TP16000 PEG PARTIAL THREAD 2.5X16,C1713,HCPCS,,79008174,CDM,278,RC,,,both,,,288,213.12,,,213.12,Other,150% of Medicare + 9.63% HCRA Surcharge,129.6,45,,129.6,percent of total billed charges,Critical Access Hospital RCC factor,97.92,34,,97.92,percent of total billed charges,Implant Device,97.92,34,,97.92,percent of total billed charges,Implant Device,97.92,34,,97.92,percent of total billed charges,Implant Device,97.92,34,,97.92,percent of total billed charges,Implant Device,97.92,34,,97.92,percent of total billed charges,Implant Device,142.56,,,142.56,Other,110% of Medicare,100.8,35,,100.8,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,100.8,35,,100.8,percent of total billed charges,Implant Device,100.8,35,,100.8,percent of total billed charges,Implant Device,100.8,35,,100.8,percent of total billed charges,Implant Device,100.8,35,,100.8,percent of total billed charges,Implant Device,100.8,35,,100.8,percent of total billed charges,Implant Device,115.2,40,,115.2,percent of total billed charges,Implant Device,100.8,70,,100.8,percent of total billed charges,All Other,97.92,34,,97.92,percent of total billed charges,Implant Device,97.92,34,,97.92,percent of total billed charges,Implant Device,100.8,35,,100.8,percent of total billed charges,Implant Device,100.8,35,,100.8,percent of total billed charges,Implant Device,100.8,35,,100.8,percent of total billed charges,Implant Device,100.8,35,,100.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,213.12,
BIOMET TP22000 PEG PARTIAL THREAD 2.5X22,C1713,HCPCS,,79008175,CDM,278,RC,,,both,,,420,310.8,,,310.8,Other,150% of Medicare + 9.63% HCRA Surcharge,189,45,,189,percent of total billed charges,Critical Access Hospital RCC factor,142.8,34,,142.8,percent of total billed charges,Implant Device,142.8,34,,142.8,percent of total billed charges,Implant Device,142.8,34,,142.8,percent of total billed charges,Implant Device,142.8,34,,142.8,percent of total billed charges,Implant Device,142.8,34,,142.8,percent of total billed charges,Implant Device,207.9,,,207.9,Other,110% of Medicare,147,35,,147,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,147,35,,147,percent of total billed charges,Implant Device,147,35,,147,percent of total billed charges,Implant Device,147,35,,147,percent of total billed charges,Implant Device,147,35,,147,percent of total billed charges,Implant Device,147,35,,147,percent of total billed charges,Implant Device,168,40,,168,percent of total billed charges,Implant Device,147,70,,147,percent of total billed charges,All Other,142.8,34,,142.8,percent of total billed charges,Implant Device,142.8,34,,142.8,percent of total billed charges,Implant Device,147,35,,147,percent of total billed charges,Implant Device,147,35,,147,percent of total billed charges,Implant Device,147,35,,147,percent of total billed charges,Implant Device,147,35,,147,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,310.8,
STABILITY BIO SB 1152-14 HUMERUS SHAFT,C1713,HCPCS,,79008176,CDM,278,RC,,,both,,,2475,1831.51,,,1831.51,Other,150% of Medicare + 9.63% HCRA Surcharge,1113.75,45,,1113.75,percent of total billed charges,Critical Access Hospital RCC factor,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,1225.13,,,1225.13,Other,110% of Medicare,866.25,35,,866.25,percent of total billed charges,Implant Device,841.5,34,"Charges > $500, x 34%",841.5,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,990,40,,990,percent of total billed charges,Implant Device,866.25,70,,866.25,percent of total billed charges,All Other,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,841.5,34,"If Charge > 2,000, then 34 percent",841.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1831.51,
ZIMMER 00-2359-020-38 LOCK SCREW 3.5X30,C1713,HCPCS,,79008178,CDM,278,RC,,,both,,,323,239.02,,,239.02,Other,150% of Medicare + 9.63% HCRA Surcharge,145.35,45,,145.35,percent of total billed charges,Critical Access Hospital RCC factor,109.82,34,,109.82,percent of total billed charges,Implant Device,109.82,34,,109.82,percent of total billed charges,Implant Device,109.82,34,,109.82,percent of total billed charges,Implant Device,109.82,34,,109.82,percent of total billed charges,Implant Device,109.82,34,,109.82,percent of total billed charges,Implant Device,159.89,,,159.89,Other,110% of Medicare,113.05,35,,113.05,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,113.05,35,,113.05,percent of total billed charges,Implant Device,113.05,35,,113.05,percent of total billed charges,Implant Device,113.05,35,,113.05,percent of total billed charges,Implant Device,113.05,35,,113.05,percent of total billed charges,Implant Device,113.05,35,,113.05,percent of total billed charges,Implant Device,129.2,40,,129.2,percent of total billed charges,Implant Device,113.05,70,,113.05,percent of total billed charges,All Other,109.82,34,,109.82,percent of total billed charges,Implant Device,109.82,34,,109.82,percent of total billed charges,Implant Device,113.05,35,,113.05,percent of total billed charges,Implant Device,113.05,35,,113.05,percent of total billed charges,Implant Device,113.05,35,,113.05,percent of total billed charges,Implant Device,113.05,35,,113.05,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,239.02,
STRYKER 5630-G-310 TIBIAL INS SZ 3 10MM,C1776,HCPCS,,79008179,CDM,278,RC,,,both,,,3232,2391.69,,,2391.69,Other,150% of Medicare + 9.63% HCRA Surcharge,1454.4,45,,1454.4,percent of total billed charges,Critical Access Hospital RCC factor,1098.88,34,,1098.88,percent of total billed charges,Implant Device,1098.88,34,,1098.88,percent of total billed charges,Implant Device,1098.88,34,,1098.88,percent of total billed charges,Implant Device,1098.88,34,,1098.88,percent of total billed charges,Implant Device,1098.88,34,,1098.88,percent of total billed charges,Implant Device,1599.84,,,1599.84,Other,110% of Medicare,1131.2,35,,1131.2,percent of total billed charges,Implant Device,1098.88,34,"Charges > $500, x 34%",1098.88,percent of total billed charges,Implant Device,1131.2,35,,1131.2,percent of total billed charges,Implant Device,1131.2,35,,1131.2,percent of total billed charges,Implant Device,1131.2,35,,1131.2,percent of total billed charges,Implant Device,1131.2,35,,1131.2,percent of total billed charges,Implant Device,1131.2,35,,1131.2,percent of total billed charges,Implant Device,1292.8,40,,1292.8,percent of total billed charges,Implant Device,1131.2,70,,1131.2,percent of total billed charges,All Other,1098.88,34,,1098.88,percent of total billed charges,Implant Device,1098.88,34,,1098.88,percent of total billed charges,Implant Device,1131.2,35,,1131.2,percent of total billed charges,Implant Device,1131.2,35,,1131.2,percent of total billed charges,Implant Device,1131.2,35,,1131.2,percent of total billed charges,Implant Device,1131.2,35,,1131.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1098.88,34,"If Charge > 2,000, then 34 percent",1098.88,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2391.69,
DEPUY 02.113.103S LCP HOOK PLATE 3H 3.5,C1713,HCPCS,,79008180,CDM,278,RC,,,both,,,2295,1698.31,,,1698.31,Other,150% of Medicare + 9.63% HCRA Surcharge,1032.75,45,,1032.75,percent of total billed charges,Critical Access Hospital RCC factor,780.3,34,,780.3,percent of total billed charges,Implant Device,780.3,34,,780.3,percent of total billed charges,Implant Device,780.3,34,,780.3,percent of total billed charges,Implant Device,780.3,34,,780.3,percent of total billed charges,Implant Device,780.3,34,,780.3,percent of total billed charges,Implant Device,1136.03,,,1136.03,Other,110% of Medicare,803.25,35,,803.25,percent of total billed charges,Implant Device,780.3,34,"Charges > $500, x 34%",780.3,percent of total billed charges,Implant Device,803.25,35,,803.25,percent of total billed charges,Implant Device,803.25,35,,803.25,percent of total billed charges,Implant Device,803.25,35,,803.25,percent of total billed charges,Implant Device,803.25,35,,803.25,percent of total billed charges,Implant Device,803.25,35,,803.25,percent of total billed charges,Implant Device,918,40,,918,percent of total billed charges,Implant Device,803.25,70,,803.25,percent of total billed charges,All Other,780.3,34,,780.3,percent of total billed charges,Implant Device,780.3,34,,780.3,percent of total billed charges,Implant Device,803.25,35,,803.25,percent of total billed charges,Implant Device,803.25,35,,803.25,percent of total billed charges,Implant Device,803.25,35,,803.25,percent of total billed charges,Implant Device,803.25,35,,803.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,780.3,34,"If Charge > 2,000, then 34 percent",780.3,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1698.31,
WRIGHT CCP-LPXOR LAPIDUS PLATE RIGHT,C1713,HCPCS,,79008181,CDM,278,RC,,,both,,,7245,5361.32,,,5361.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3260.25,45,,3260.25,percent of total billed charges,Critical Access Hospital RCC factor,2463.3,34,,2463.3,percent of total billed charges,Implant Device,2463.3,34,,2463.3,percent of total billed charges,Implant Device,2463.3,34,,2463.3,percent of total billed charges,Implant Device,2463.3,34,,2463.3,percent of total billed charges,Implant Device,2463.3,34,,2463.3,percent of total billed charges,Implant Device,3586.28,,,3586.28,Other,110% of Medicare,2535.75,35,,2535.75,percent of total billed charges,Implant Device,2463.3,34,"Charges > $500, x 34%",2463.3,percent of total billed charges,Implant Device,2535.75,35,,2535.75,percent of total billed charges,Implant Device,2535.75,35,,2535.75,percent of total billed charges,Implant Device,2535.75,35,,2535.75,percent of total billed charges,Implant Device,2535.75,35,,2535.75,percent of total billed charges,Implant Device,2535.75,35,,2535.75,percent of total billed charges,Implant Device,2898,40,,2898,percent of total billed charges,Implant Device,2535.75,70,,2535.75,percent of total billed charges,All Other,2463.3,34,,2463.3,percent of total billed charges,Implant Device,2463.3,34,,2463.3,percent of total billed charges,Implant Device,2535.75,35,,2535.75,percent of total billed charges,Implant Device,2535.75,35,,2535.75,percent of total billed charges,Implant Device,2535.75,35,,2535.75,percent of total billed charges,Implant Device,2535.75,35,,2535.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2463.3,34,"If Charge > 2,000, then 34 percent",2463.3,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5361.32,
WRIGHT CCP-X3534 LAG SCREW 3.5X34MM,C1713,HCPCS,,79008182,CDM,278,RC,,,both,,,1125,832.5,,,832.5,Other,150% of Medicare + 9.63% HCRA Surcharge,506.25,45,,506.25,percent of total billed charges,Critical Access Hospital RCC factor,382.5,34,,382.5,percent of total billed charges,Implant Device,382.5,34,,382.5,percent of total billed charges,Implant Device,382.5,34,,382.5,percent of total billed charges,Implant Device,382.5,34,,382.5,percent of total billed charges,Implant Device,382.5,34,,382.5,percent of total billed charges,Implant Device,556.88,,,556.88,Other,110% of Medicare,393.75,35,,393.75,percent of total billed charges,Implant Device,382.5,34,"Charges > $500, x 34%",382.5,percent of total billed charges,Implant Device,393.75,35,,393.75,percent of total billed charges,Implant Device,393.75,35,,393.75,percent of total billed charges,Implant Device,393.75,35,,393.75,percent of total billed charges,Implant Device,393.75,35,,393.75,percent of total billed charges,Implant Device,393.75,35,,393.75,percent of total billed charges,Implant Device,450,40,,450,percent of total billed charges,Implant Device,393.75,70,,393.75,percent of total billed charges,All Other,382.5,34,,382.5,percent of total billed charges,Implant Device,382.5,34,,382.5,percent of total billed charges,Implant Device,393.75,35,,393.75,percent of total billed charges,Implant Device,393.75,35,,393.75,percent of total billed charges,Implant Device,393.75,35,,393.75,percent of total billed charges,Implant Device,393.75,35,,393.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,832.5,
WRIGHT CCP-L3528 LOCKING SCREW 3.5X28MM,C1713,HCPCS,,79008183,CDM,278,RC,,,both,,,1125,832.5,,,832.5,Other,150% of Medicare + 9.63% HCRA Surcharge,506.25,45,,506.25,percent of total billed charges,Critical Access Hospital RCC factor,382.5,34,,382.5,percent of total billed charges,Implant Device,382.5,34,,382.5,percent of total billed charges,Implant Device,382.5,34,,382.5,percent of total billed charges,Implant Device,382.5,34,,382.5,percent of total billed charges,Implant Device,382.5,34,,382.5,percent of total billed charges,Implant Device,556.88,,,556.88,Other,110% of Medicare,393.75,35,,393.75,percent of total billed charges,Implant Device,382.5,34,"Charges > $500, x 34%",382.5,percent of total billed charges,Implant Device,393.75,35,,393.75,percent of total billed charges,Implant Device,393.75,35,,393.75,percent of total billed charges,Implant Device,393.75,35,,393.75,percent of total billed charges,Implant Device,393.75,35,,393.75,percent of total billed charges,Implant Device,393.75,35,,393.75,percent of total billed charges,Implant Device,450,40,,450,percent of total billed charges,Implant Device,393.75,70,,393.75,percent of total billed charges,All Other,382.5,34,,382.5,percent of total billed charges,Implant Device,382.5,34,,382.5,percent of total billed charges,Implant Device,393.75,35,,393.75,percent of total billed charges,Implant Device,393.75,35,,393.75,percent of total billed charges,Implant Device,393.75,35,,393.75,percent of total billed charges,Implant Device,393.75,35,,393.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,832.5,
WRIGHT CCP-L3526 LOCKING SCREW 3.5X26MM,C1713,HCPCS,,79008184,CDM,278,RC,,,both,,,1125,832.5,,,832.5,Other,150% of Medicare + 9.63% HCRA Surcharge,506.25,45,,506.25,percent of total billed charges,Critical Access Hospital RCC factor,382.5,34,,382.5,percent of total billed charges,Implant Device,382.5,34,,382.5,percent of total billed charges,Implant Device,382.5,34,,382.5,percent of total billed charges,Implant Device,382.5,34,,382.5,percent of total billed charges,Implant Device,382.5,34,,382.5,percent of total billed charges,Implant Device,556.88,,,556.88,Other,110% of Medicare,393.75,35,,393.75,percent of total billed charges,Implant Device,382.5,34,"Charges > $500, x 34%",382.5,percent of total billed charges,Implant Device,393.75,35,,393.75,percent of total billed charges,Implant Device,393.75,35,,393.75,percent of total billed charges,Implant Device,393.75,35,,393.75,percent of total billed charges,Implant Device,393.75,35,,393.75,percent of total billed charges,Implant Device,393.75,35,,393.75,percent of total billed charges,Implant Device,450,40,,450,percent of total billed charges,Implant Device,393.75,70,,393.75,percent of total billed charges,All Other,382.5,34,,382.5,percent of total billed charges,Implant Device,382.5,34,,382.5,percent of total billed charges,Implant Device,393.75,35,,393.75,percent of total billed charges,Implant Device,393.75,35,,393.75,percent of total billed charges,Implant Device,393.75,35,,393.75,percent of total billed charges,Implant Device,393.75,35,,393.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,832.5,
BME EL-1818S2 ELITE STR BRIDGE 18X18X18,C1713,HCPCS,,79008187,CDM,278,RC,,,both,,,5160,3818.41,,,3818.41,Other,150% of Medicare + 9.63% HCRA Surcharge,2322,45,,2322,percent of total billed charges,Critical Access Hospital RCC factor,1754.4,34,,1754.4,percent of total billed charges,Implant Device,1754.4,34,,1754.4,percent of total billed charges,Implant Device,1754.4,34,,1754.4,percent of total billed charges,Implant Device,1754.4,34,,1754.4,percent of total billed charges,Implant Device,1754.4,34,,1754.4,percent of total billed charges,Implant Device,2554.2,,,2554.2,Other,110% of Medicare,1806,35,,1806,percent of total billed charges,Implant Device,1754.4,34,"Charges > $500, x 34%",1754.4,percent of total billed charges,Implant Device,1806,35,,1806,percent of total billed charges,Implant Device,1806,35,,1806,percent of total billed charges,Implant Device,1806,35,,1806,percent of total billed charges,Implant Device,1806,35,,1806,percent of total billed charges,Implant Device,1806,35,,1806,percent of total billed charges,Implant Device,2064,40,,2064,percent of total billed charges,Implant Device,1806,70,,1806,percent of total billed charges,All Other,1754.4,34,,1754.4,percent of total billed charges,Implant Device,1754.4,34,,1754.4,percent of total billed charges,Implant Device,1806,35,,1806,percent of total billed charges,Implant Device,1806,35,,1806,percent of total billed charges,Implant Device,1806,35,,1806,percent of total billed charges,Implant Device,1806,35,,1806,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1754.4,34,"If Charge > 2,000, then 34 percent",1754.4,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3818.41,
BME EL-2020S2 ELITE STR BRIDGE 20X20X20,C1713,HCPCS,,79008188,CDM,278,RC,,,both,,,5160,3818.41,,,3818.41,Other,150% of Medicare + 9.63% HCRA Surcharge,2322,45,,2322,percent of total billed charges,Critical Access Hospital RCC factor,1754.4,34,,1754.4,percent of total billed charges,Implant Device,1754.4,34,,1754.4,percent of total billed charges,Implant Device,1754.4,34,,1754.4,percent of total billed charges,Implant Device,1754.4,34,,1754.4,percent of total billed charges,Implant Device,1754.4,34,,1754.4,percent of total billed charges,Implant Device,2554.2,,,2554.2,Other,110% of Medicare,1806,35,,1806,percent of total billed charges,Implant Device,1754.4,34,"Charges > $500, x 34%",1754.4,percent of total billed charges,Implant Device,1806,35,,1806,percent of total billed charges,Implant Device,1806,35,,1806,percent of total billed charges,Implant Device,1806,35,,1806,percent of total billed charges,Implant Device,1806,35,,1806,percent of total billed charges,Implant Device,1806,35,,1806,percent of total billed charges,Implant Device,2064,40,,2064,percent of total billed charges,Implant Device,1806,70,,1806,percent of total billed charges,All Other,1754.4,34,,1754.4,percent of total billed charges,Implant Device,1754.4,34,,1754.4,percent of total billed charges,Implant Device,1806,35,,1806,percent of total billed charges,Implant Device,1806,35,,1806,percent of total billed charges,Implant Device,1806,35,,1806,percent of total billed charges,Implant Device,1806,35,,1806,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1754.4,34,"If Charge > 2,000, then 34 percent",1754.4,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3818.41,
BME SE-2520T1 SPEED TITAN IMPL 25X20X20,C1713,HCPCS,,79008189,CDM,278,RC,,,both,,,5640,4173.61,,,4173.61,Other,150% of Medicare + 9.63% HCRA Surcharge,2538,45,,2538,percent of total billed charges,Critical Access Hospital RCC factor,1917.6,34,,1917.6,percent of total billed charges,Implant Device,1917.6,34,,1917.6,percent of total billed charges,Implant Device,1917.6,34,,1917.6,percent of total billed charges,Implant Device,1917.6,34,,1917.6,percent of total billed charges,Implant Device,1917.6,34,,1917.6,percent of total billed charges,Implant Device,2791.8,,,2791.8,Other,110% of Medicare,1974,35,,1974,percent of total billed charges,Implant Device,1917.6,34,"Charges > $500, x 34%",1917.6,percent of total billed charges,Implant Device,1974,35,,1974,percent of total billed charges,Implant Device,1974,35,,1974,percent of total billed charges,Implant Device,1974,35,,1974,percent of total billed charges,Implant Device,1974,35,,1974,percent of total billed charges,Implant Device,1974,35,,1974,percent of total billed charges,Implant Device,2256,40,,2256,percent of total billed charges,Implant Device,1974,70,,1974,percent of total billed charges,All Other,1917.6,34,,1917.6,percent of total billed charges,Implant Device,1917.6,34,,1917.6,percent of total billed charges,Implant Device,1974,35,,1974,percent of total billed charges,Implant Device,1974,35,,1974,percent of total billed charges,Implant Device,1974,35,,1974,percent of total billed charges,Implant Device,1974,35,,1974,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1917.6,34,"If Charge > 2,000, then 34 percent",1917.6,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4173.61,
P 28 PCCC-0804 CALCANEAL JOINT WEDGE 8MM,C1713,HCPCS,,79008192,CDM,278,RC,,,both,,,5993,4434.83,,,4434.83,Other,150% of Medicare + 9.63% HCRA Surcharge,2696.85,45,,2696.85,percent of total billed charges,Critical Access Hospital RCC factor,2037.62,34,,2037.62,percent of total billed charges,Implant Device,2037.62,34,,2037.62,percent of total billed charges,Implant Device,2037.62,34,,2037.62,percent of total billed charges,Implant Device,2037.62,34,,2037.62,percent of total billed charges,Implant Device,2037.62,34,,2037.62,percent of total billed charges,Implant Device,2966.54,,,2966.54,Other,110% of Medicare,2097.55,35,,2097.55,percent of total billed charges,Implant Device,2037.62,34,"Charges > $500, x 34%",2037.62,percent of total billed charges,Implant Device,2097.55,35,,2097.55,percent of total billed charges,Implant Device,2097.55,35,,2097.55,percent of total billed charges,Implant Device,2097.55,35,,2097.55,percent of total billed charges,Implant Device,2097.55,35,,2097.55,percent of total billed charges,Implant Device,2097.55,35,,2097.55,percent of total billed charges,Implant Device,2397.2,40,,2397.2,percent of total billed charges,Implant Device,2097.55,70,,2097.55,percent of total billed charges,All Other,2037.62,34,,2037.62,percent of total billed charges,Implant Device,2037.62,34,,2037.62,percent of total billed charges,Implant Device,2097.55,35,,2097.55,percent of total billed charges,Implant Device,2097.55,35,,2097.55,percent of total billed charges,Implant Device,2097.55,35,,2097.55,percent of total billed charges,Implant Device,2097.55,35,,2097.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2037.62,34,"If Charge > 2,000, then 34 percent",2037.62,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4434.83,
P 28 PLP-3008 LAPIDUS WEDGE 8MM,C1713,HCPCS,,79008193,CDM,278,RC,,,both,,,6064,4487.38,,,4487.38,Other,150% of Medicare + 9.63% HCRA Surcharge,2728.8,45,,2728.8,percent of total billed charges,Critical Access Hospital RCC factor,2061.76,34,,2061.76,percent of total billed charges,Implant Device,2061.76,34,,2061.76,percent of total billed charges,Implant Device,2061.76,34,,2061.76,percent of total billed charges,Implant Device,2061.76,34,,2061.76,percent of total billed charges,Implant Device,2061.76,34,,2061.76,percent of total billed charges,Implant Device,3001.68,,,3001.68,Other,110% of Medicare,2122.4,35,,2122.4,percent of total billed charges,Implant Device,2061.76,34,"Charges > $500, x 34%",2061.76,percent of total billed charges,Implant Device,2122.4,35,,2122.4,percent of total billed charges,Implant Device,2122.4,35,,2122.4,percent of total billed charges,Implant Device,2122.4,35,,2122.4,percent of total billed charges,Implant Device,2122.4,35,,2122.4,percent of total billed charges,Implant Device,2122.4,35,,2122.4,percent of total billed charges,Implant Device,2425.6,40,,2425.6,percent of total billed charges,Implant Device,2122.4,70,,2122.4,percent of total billed charges,All Other,2061.76,34,,2061.76,percent of total billed charges,Implant Device,2061.76,34,,2061.76,percent of total billed charges,Implant Device,2122.4,35,,2122.4,percent of total billed charges,Implant Device,2122.4,35,,2122.4,percent of total billed charges,Implant Device,2122.4,35,,2122.4,percent of total billed charges,Implant Device,2122.4,35,,2122.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2061.76,34,"If Charge > 2,000, then 34 percent",2061.76,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4487.38,
P 28 PLP-3012 LAPIDUS WEDGE 12MM,C1713,HCPCS,,79008194,CDM,278,RC,,,both,,,6064,4487.38,,,4487.38,Other,150% of Medicare + 9.63% HCRA Surcharge,2728.8,45,,2728.8,percent of total billed charges,Critical Access Hospital RCC factor,2061.76,34,,2061.76,percent of total billed charges,Implant Device,2061.76,34,,2061.76,percent of total billed charges,Implant Device,2061.76,34,,2061.76,percent of total billed charges,Implant Device,2061.76,34,,2061.76,percent of total billed charges,Implant Device,2061.76,34,,2061.76,percent of total billed charges,Implant Device,3001.68,,,3001.68,Other,110% of Medicare,2122.4,35,,2122.4,percent of total billed charges,Implant Device,2061.76,34,"Charges > $500, x 34%",2061.76,percent of total billed charges,Implant Device,2122.4,35,,2122.4,percent of total billed charges,Implant Device,2122.4,35,,2122.4,percent of total billed charges,Implant Device,2122.4,35,,2122.4,percent of total billed charges,Implant Device,2122.4,35,,2122.4,percent of total billed charges,Implant Device,2122.4,35,,2122.4,percent of total billed charges,Implant Device,2425.6,40,,2425.6,percent of total billed charges,Implant Device,2122.4,70,,2122.4,percent of total billed charges,All Other,2061.76,34,,2061.76,percent of total billed charges,Implant Device,2061.76,34,,2061.76,percent of total billed charges,Implant Device,2122.4,35,,2122.4,percent of total billed charges,Implant Device,2122.4,35,,2122.4,percent of total billed charges,Implant Device,2122.4,35,,2122.4,percent of total billed charges,Implant Device,2122.4,35,,2122.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2061.76,34,"If Charge > 2,000, then 34 percent",2061.76,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4487.38,
MENTOR  350-2400 SALINE BREAST IMPLANTS,C1789,HCPCS,,79008195,CDM,278,RC,,,both,,,2010,1487.41,,,1487.41,Other,150% of Medicare + 9.63% HCRA Surcharge,904.5,45,,904.5,percent of total billed charges,Critical Access Hospital RCC factor,683.4,34,,683.4,percent of total billed charges,Implant Device,683.4,34,,683.4,percent of total billed charges,Implant Device,683.4,34,,683.4,percent of total billed charges,Implant Device,683.4,34,,683.4,percent of total billed charges,Implant Device,683.4,34,,683.4,percent of total billed charges,Implant Device,994.95,,,994.95,Other,110% of Medicare,703.5,35,,703.5,percent of total billed charges,Implant Device,683.4,34,"Charges > $500, x 34%",683.4,percent of total billed charges,Implant Device,703.5,35,,703.5,percent of total billed charges,Implant Device,703.5,35,,703.5,percent of total billed charges,Implant Device,703.5,35,,703.5,percent of total billed charges,Implant Device,703.5,35,,703.5,percent of total billed charges,Implant Device,703.5,35,,703.5,percent of total billed charges,Implant Device,804,40,,804,percent of total billed charges,Implant Device,703.5,70,,703.5,percent of total billed charges,All Other,683.4,34,,683.4,percent of total billed charges,Implant Device,683.4,34,,683.4,percent of total billed charges,Implant Device,703.5,35,,703.5,percent of total billed charges,Implant Device,703.5,35,,703.5,percent of total billed charges,Implant Device,703.5,35,,703.5,percent of total billed charges,Implant Device,703.5,35,,703.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,683.4,34,"If Charge > 2,000, then 34 percent",683.4,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1487.41,
DEPUY 224.581 LCP PLATE 8 HOLE 4.5X152MM,C1713,HCPCS,,79008196,CDM,278,RC,,,both,,,1222,904.28,,,904.28,Other,150% of Medicare + 9.63% HCRA Surcharge,549.9,45,,549.9,percent of total billed charges,Critical Access Hospital RCC factor,415.48,34,,415.48,percent of total billed charges,Implant Device,415.48,34,,415.48,percent of total billed charges,Implant Device,415.48,34,,415.48,percent of total billed charges,Implant Device,415.48,34,,415.48,percent of total billed charges,Implant Device,415.48,34,,415.48,percent of total billed charges,Implant Device,604.89,,,604.89,Other,110% of Medicare,427.7,35,,427.7,percent of total billed charges,Implant Device,415.48,34,"Charges > $500, x 34%",415.48,percent of total billed charges,Implant Device,427.7,35,,427.7,percent of total billed charges,Implant Device,427.7,35,,427.7,percent of total billed charges,Implant Device,427.7,35,,427.7,percent of total billed charges,Implant Device,427.7,35,,427.7,percent of total billed charges,Implant Device,427.7,35,,427.7,percent of total billed charges,Implant Device,488.8,40,,488.8,percent of total billed charges,Implant Device,427.7,70,,427.7,percent of total billed charges,All Other,415.48,34,,415.48,percent of total billed charges,Implant Device,415.48,34,,415.48,percent of total billed charges,Implant Device,427.7,35,,427.7,percent of total billed charges,Implant Device,427.7,35,,427.7,percent of total billed charges,Implant Device,427.7,35,,427.7,percent of total billed charges,Implant Device,427.7,35,,427.7,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,904.28,
DEPUY 214.824 CORTEX SCREW 4.5X24MM,C1713,HCPCS,,79008197,CDM,278,RC,,,both,,,57,42.18,,,42.18,Other,150% of Medicare + 9.63% HCRA Surcharge,25.65,45,,25.65,percent of total billed charges,Critical Access Hospital RCC factor,19.38,34,,19.38,percent of total billed charges,Implant Device,19.38,34,,19.38,percent of total billed charges,Implant Device,19.38,34,,19.38,percent of total billed charges,Implant Device,19.38,34,,19.38,percent of total billed charges,Implant Device,19.38,34,,19.38,percent of total billed charges,Implant Device,28.22,,,28.22,Other,110% of Medicare,19.95,35,,19.95,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,19.95,35,,19.95,percent of total billed charges,Implant Device,19.95,35,,19.95,percent of total billed charges,Implant Device,19.95,35,,19.95,percent of total billed charges,Implant Device,19.95,35,,19.95,percent of total billed charges,Implant Device,19.95,35,,19.95,percent of total billed charges,Implant Device,22.8,40,,22.8,percent of total billed charges,Implant Device,19.95,70,,19.95,percent of total billed charges,All Other,19.38,34,,19.38,percent of total billed charges,Implant Device,19.38,34,,19.38,percent of total billed charges,Implant Device,19.95,35,,19.95,percent of total billed charges,Implant Device,19.95,35,,19.95,percent of total billed charges,Implant Device,19.95,35,,19.95,percent of total billed charges,Implant Device,19.95,35,,19.95,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,42.18,
BIOMET 110007658 CANN SCREW 5X55MM,C1713,HCPCS,,79008198,CDM,278,RC,,,both,,,870,643.8,,,643.8,Other,150% of Medicare + 9.63% HCRA Surcharge,391.5,45,,391.5,percent of total billed charges,Critical Access Hospital RCC factor,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,430.65,,,430.65,Other,110% of Medicare,304.5,35,,304.5,percent of total billed charges,Implant Device,295.8,34,"Charges > $500, x 34%",295.8,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,348,40,,348,percent of total billed charges,Implant Device,304.5,70,,304.5,percent of total billed charges,All Other,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,643.8,
BIOMET 110007747 CANN SCREW 6.5X16MM,C1713,HCPCS,,79008199,CDM,278,RC,,,both,,,1320,976.8,,,976.8,Other,150% of Medicare + 9.63% HCRA Surcharge,594,45,,594,percent of total billed charges,Critical Access Hospital RCC factor,448.8,34,,448.8,percent of total billed charges,Implant Device,448.8,34,,448.8,percent of total billed charges,Implant Device,448.8,34,,448.8,percent of total billed charges,Implant Device,448.8,34,,448.8,percent of total billed charges,Implant Device,448.8,34,,448.8,percent of total billed charges,Implant Device,653.4,,,653.4,Other,110% of Medicare,462,35,,462,percent of total billed charges,Implant Device,448.8,34,"Charges > $500, x 34%",448.8,percent of total billed charges,Implant Device,462,35,,462,percent of total billed charges,Implant Device,462,35,,462,percent of total billed charges,Implant Device,462,35,,462,percent of total billed charges,Implant Device,462,35,,462,percent of total billed charges,Implant Device,462,35,,462,percent of total billed charges,Implant Device,528,40,,528,percent of total billed charges,Implant Device,462,70,,462,percent of total billed charges,All Other,448.8,34,,448.8,percent of total billed charges,Implant Device,448.8,34,,448.8,percent of total billed charges,Implant Device,462,35,,462,percent of total billed charges,Implant Device,462,35,,462,percent of total billed charges,Implant Device,462,35,,462,percent of total billed charges,Implant Device,462,35,,462,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,976.8,
BIOMET 8240-77-022 FUSION PLATE LARGE,C1713,HCPCS,,79008204,CDM,278,RC,,,both,,,4710,3485.41,,,3485.41,Other,150% of Medicare + 9.63% HCRA Surcharge,2119.5,45,,2119.5,percent of total billed charges,Critical Access Hospital RCC factor,1601.4,34,,1601.4,percent of total billed charges,Implant Device,1601.4,34,,1601.4,percent of total billed charges,Implant Device,1601.4,34,,1601.4,percent of total billed charges,Implant Device,1601.4,34,,1601.4,percent of total billed charges,Implant Device,1601.4,34,,1601.4,percent of total billed charges,Implant Device,2331.45,,,2331.45,Other,110% of Medicare,1648.5,35,,1648.5,percent of total billed charges,Implant Device,1601.4,34,"Charges > $500, x 34%",1601.4,percent of total billed charges,Implant Device,1648.5,35,,1648.5,percent of total billed charges,Implant Device,1648.5,35,,1648.5,percent of total billed charges,Implant Device,1648.5,35,,1648.5,percent of total billed charges,Implant Device,1648.5,35,,1648.5,percent of total billed charges,Implant Device,1648.5,35,,1648.5,percent of total billed charges,Implant Device,1884,40,,1884,percent of total billed charges,Implant Device,1648.5,70,,1648.5,percent of total billed charges,All Other,1601.4,34,,1601.4,percent of total billed charges,Implant Device,1601.4,34,,1601.4,percent of total billed charges,Implant Device,1648.5,35,,1648.5,percent of total billed charges,Implant Device,1648.5,35,,1648.5,percent of total billed charges,Implant Device,1648.5,35,,1648.5,percent of total billed charges,Implant Device,1648.5,35,,1648.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1601.4,34,"If Charge > 2,000, then 34 percent",1601.4,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3485.41,
BIOMET 8163-35-028 MULTI SCREW 3.5X28MM,C1713,HCPCS,,79008205,CDM,278,RC,,,both,,,930,688.2,,,688.2,Other,150% of Medicare + 9.63% HCRA Surcharge,418.5,45,,418.5,percent of total billed charges,Critical Access Hospital RCC factor,316.2,34,,316.2,percent of total billed charges,Implant Device,316.2,34,,316.2,percent of total billed charges,Implant Device,316.2,34,,316.2,percent of total billed charges,Implant Device,316.2,34,,316.2,percent of total billed charges,Implant Device,316.2,34,,316.2,percent of total billed charges,Implant Device,460.35,,,460.35,Other,110% of Medicare,325.5,35,,325.5,percent of total billed charges,Implant Device,316.2,34,"Charges > $500, x 34%",316.2,percent of total billed charges,Implant Device,325.5,35,,325.5,percent of total billed charges,Implant Device,325.5,35,,325.5,percent of total billed charges,Implant Device,325.5,35,,325.5,percent of total billed charges,Implant Device,325.5,35,,325.5,percent of total billed charges,Implant Device,325.5,35,,325.5,percent of total billed charges,Implant Device,372,40,,372,percent of total billed charges,Implant Device,325.5,70,,325.5,percent of total billed charges,All Other,316.2,34,,316.2,percent of total billed charges,Implant Device,316.2,34,,316.2,percent of total billed charges,Implant Device,325.5,35,,325.5,percent of total billed charges,Implant Device,325.5,35,,325.5,percent of total billed charges,Implant Device,325.5,35,,325.5,percent of total billed charges,Implant Device,325.5,35,,325.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,688.2,
BIOMET 8163-35-030 MULTI SCREW 3.5X30MM,C1713,HCPCS,,79008206,CDM,278,RC,,,both,,,930,688.2,,,688.2,Other,150% of Medicare + 9.63% HCRA Surcharge,418.5,45,,418.5,percent of total billed charges,Critical Access Hospital RCC factor,316.2,34,,316.2,percent of total billed charges,Implant Device,316.2,34,,316.2,percent of total billed charges,Implant Device,316.2,34,,316.2,percent of total billed charges,Implant Device,316.2,34,,316.2,percent of total billed charges,Implant Device,316.2,34,,316.2,percent of total billed charges,Implant Device,460.35,,,460.35,Other,110% of Medicare,325.5,35,,325.5,percent of total billed charges,Implant Device,316.2,34,"Charges > $500, x 34%",316.2,percent of total billed charges,Implant Device,325.5,35,,325.5,percent of total billed charges,Implant Device,325.5,35,,325.5,percent of total billed charges,Implant Device,325.5,35,,325.5,percent of total billed charges,Implant Device,325.5,35,,325.5,percent of total billed charges,Implant Device,325.5,35,,325.5,percent of total billed charges,Implant Device,372,40,,372,percent of total billed charges,Implant Device,325.5,70,,325.5,percent of total billed charges,All Other,316.2,34,,316.2,percent of total billed charges,Implant Device,316.2,34,,316.2,percent of total billed charges,Implant Device,325.5,35,,325.5,percent of total billed charges,Implant Device,325.5,35,,325.5,percent of total billed charges,Implant Device,325.5,35,,325.5,percent of total billed charges,Implant Device,325.5,35,,325.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,688.2,
BIOMET 8161-35-028 CORT SCREW 3.5X28MM,C1713,HCPCS,,79008207,CDM,278,RC,,,both,,,660,488.4,,,488.4,Other,150% of Medicare + 9.63% HCRA Surcharge,297,45,,297,percent of total billed charges,Critical Access Hospital RCC factor,224.4,34,,224.4,percent of total billed charges,Implant Device,224.4,34,,224.4,percent of total billed charges,Implant Device,224.4,34,,224.4,percent of total billed charges,Implant Device,224.4,34,,224.4,percent of total billed charges,Implant Device,224.4,34,,224.4,percent of total billed charges,Implant Device,326.7,,,326.7,Other,110% of Medicare,231,35,,231,percent of total billed charges,Implant Device,224.4,34,"Charges > $500, x 34%",224.4,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,264,40,,264,percent of total billed charges,Implant Device,231,70,,231,percent of total billed charges,All Other,224.4,34,,224.4,percent of total billed charges,Implant Device,224.4,34,,224.4,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,231,35,,231,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,488.4,
BIOMET 110007745 CANN SCREW 6.5X60X16MM,C1713,HCPCS,,79008208,CDM,278,RC,,,both,,,1320,976.8,,,976.8,Other,150% of Medicare + 9.63% HCRA Surcharge,594,45,,594,percent of total billed charges,Critical Access Hospital RCC factor,448.8,34,,448.8,percent of total billed charges,Implant Device,448.8,34,,448.8,percent of total billed charges,Implant Device,448.8,34,,448.8,percent of total billed charges,Implant Device,448.8,34,,448.8,percent of total billed charges,Implant Device,448.8,34,,448.8,percent of total billed charges,Implant Device,653.4,,,653.4,Other,110% of Medicare,462,35,,462,percent of total billed charges,Implant Device,448.8,34,"Charges > $500, x 34%",448.8,percent of total billed charges,Implant Device,462,35,,462,percent of total billed charges,Implant Device,462,35,,462,percent of total billed charges,Implant Device,462,35,,462,percent of total billed charges,Implant Device,462,35,,462,percent of total billed charges,Implant Device,462,35,,462,percent of total billed charges,Implant Device,528,40,,528,percent of total billed charges,Implant Device,462,70,,462,percent of total billed charges,All Other,448.8,34,,448.8,percent of total billed charges,Implant Device,448.8,34,,448.8,percent of total billed charges,Implant Device,462,35,,462,percent of total billed charges,Implant Device,462,35,,462,percent of total billed charges,Implant Device,462,35,,462,percent of total billed charges,Implant Device,462,35,,462,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,976.8,
STRYKER 6195-1-001 SIMPLEX CEMENT W/GENT,C1713,HCPCS,,79008210,CDM,278,RC,,,both,,,833,616.42,,,616.42,Other,150% of Medicare + 9.63% HCRA Surcharge,374.85,45,,374.85,percent of total billed charges,Critical Access Hospital RCC factor,283.22,34,,283.22,percent of total billed charges,Implant Device,283.22,34,,283.22,percent of total billed charges,Implant Device,283.22,34,,283.22,percent of total billed charges,Implant Device,283.22,34,,283.22,percent of total billed charges,Implant Device,283.22,34,,283.22,percent of total billed charges,Implant Device,412.34,,,412.34,Other,110% of Medicare,291.55,35,,291.55,percent of total billed charges,Implant Device,283.22,34,"Charges > $500, x 34%",283.22,percent of total billed charges,Implant Device,291.55,35,,291.55,percent of total billed charges,Implant Device,291.55,35,,291.55,percent of total billed charges,Implant Device,291.55,35,,291.55,percent of total billed charges,Implant Device,291.55,35,,291.55,percent of total billed charges,Implant Device,291.55,35,,291.55,percent of total billed charges,Implant Device,333.2,40,,333.2,percent of total billed charges,Implant Device,291.55,70,,291.55,percent of total billed charges,All Other,283.22,34,,283.22,percent of total billed charges,Implant Device,283.22,34,,283.22,percent of total billed charges,Implant Device,291.55,35,,291.55,percent of total billed charges,Implant Device,291.55,35,,291.55,percent of total billed charges,Implant Device,291.55,35,,291.55,percent of total billed charges,Implant Device,291.55,35,,291.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,616.42,
BIOMET 12-115122 MODULAR HEAD 36MM,C1776,HCPCS,,79008211,CDM,278,RC,,,both,,,2880,2131.21,,,2131.21,Other,150% of Medicare + 9.63% HCRA Surcharge,1296,45,,1296,percent of total billed charges,Critical Access Hospital RCC factor,979.2,34,,979.2,percent of total billed charges,Implant Device,979.2,34,,979.2,percent of total billed charges,Implant Device,979.2,34,,979.2,percent of total billed charges,Implant Device,979.2,34,,979.2,percent of total billed charges,Implant Device,979.2,34,,979.2,percent of total billed charges,Implant Device,1425.6,,,1425.6,Other,110% of Medicare,1008,35,,1008,percent of total billed charges,Implant Device,979.2,34,"Charges > $500, x 34%",979.2,percent of total billed charges,Implant Device,1008,35,,1008,percent of total billed charges,Implant Device,1008,35,,1008,percent of total billed charges,Implant Device,1008,35,,1008,percent of total billed charges,Implant Device,1008,35,,1008,percent of total billed charges,Implant Device,1008,35,,1008,percent of total billed charges,Implant Device,1152,40,,1152,percent of total billed charges,Implant Device,1008,70,,1008,percent of total billed charges,All Other,979.2,34,,979.2,percent of total billed charges,Implant Device,979.2,34,,979.2,percent of total billed charges,Implant Device,1008,35,,1008,percent of total billed charges,Implant Device,1008,35,,1008,percent of total billed charges,Implant Device,1008,35,,1008,percent of total billed charges,Implant Device,1008,35,,1008,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,979.2,34,"If Charge > 2,000, then 34 percent",979.2,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2131.21,
ZIMMER 00-8852-013-36 LINER 36MM SZ LL,C1776,HCPCS,,79008212,CDM,278,RC,,,both,,,4403,3258.23,,,3258.23,Other,150% of Medicare + 9.63% HCRA Surcharge,1981.35,45,,1981.35,percent of total billed charges,Critical Access Hospital RCC factor,1497.02,34,,1497.02,percent of total billed charges,Implant Device,1497.02,34,,1497.02,percent of total billed charges,Implant Device,1497.02,34,,1497.02,percent of total billed charges,Implant Device,1497.02,34,,1497.02,percent of total billed charges,Implant Device,1497.02,34,,1497.02,percent of total billed charges,Implant Device,2179.49,,,2179.49,Other,110% of Medicare,1541.05,35,,1541.05,percent of total billed charges,Implant Device,1497.02,34,"Charges > $500, x 34%",1497.02,percent of total billed charges,Implant Device,1541.05,35,,1541.05,percent of total billed charges,Implant Device,1541.05,35,,1541.05,percent of total billed charges,Implant Device,1541.05,35,,1541.05,percent of total billed charges,Implant Device,1541.05,35,,1541.05,percent of total billed charges,Implant Device,1541.05,35,,1541.05,percent of total billed charges,Implant Device,1761.2,40,,1761.2,percent of total billed charges,Implant Device,1541.05,70,,1541.05,percent of total billed charges,All Other,1497.02,34,,1497.02,percent of total billed charges,Implant Device,1497.02,34,,1497.02,percent of total billed charges,Implant Device,1541.05,35,,1541.05,percent of total billed charges,Implant Device,1541.05,35,,1541.05,percent of total billed charges,Implant Device,1541.05,35,,1541.05,percent of total billed charges,Implant Device,1541.05,35,,1541.05,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1497.02,34,"If Charge > 2,000, then 34 percent",1497.02,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3258.23,
ARTHREX AR-1588RT-J ACL TIGHTROPE KIT,C1713,HCPCS,,79008213,CDM,278,RC,,,both,,,1110,821.4,,,821.4,Other,150% of Medicare + 9.63% HCRA Surcharge,499.5,45,,499.5,percent of total billed charges,Critical Access Hospital RCC factor,377.4,34,,377.4,percent of total billed charges,Implant Device,377.4,34,,377.4,percent of total billed charges,Implant Device,377.4,34,,377.4,percent of total billed charges,Implant Device,377.4,34,,377.4,percent of total billed charges,Implant Device,377.4,34,,377.4,percent of total billed charges,Implant Device,549.45,,,549.45,Other,110% of Medicare,388.5,35,,388.5,percent of total billed charges,Implant Device,377.4,34,"Charges > $500, x 34%",377.4,percent of total billed charges,Implant Device,388.5,35,,388.5,percent of total billed charges,Implant Device,388.5,35,,388.5,percent of total billed charges,Implant Device,388.5,35,,388.5,percent of total billed charges,Implant Device,388.5,35,,388.5,percent of total billed charges,Implant Device,388.5,35,,388.5,percent of total billed charges,Implant Device,444,40,,444,percent of total billed charges,Implant Device,388.5,70,,388.5,percent of total billed charges,All Other,377.4,34,,377.4,percent of total billed charges,Implant Device,377.4,34,,377.4,percent of total billed charges,Implant Device,388.5,35,,388.5,percent of total billed charges,Implant Device,388.5,35,,388.5,percent of total billed charges,Implant Device,388.5,35,,388.5,percent of total billed charges,Implant Device,388.5,35,,388.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,821.4,
MENTOR 354-2911 BREAST IMPLANT-SALINE,C1789,HCPCS,,79008218,CDM,278,RC,,,both,,,2550,1887.01,,,1887.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1147.5,45,,1147.5,percent of total billed charges,Critical Access Hospital RCC factor,867,34,,867,percent of total billed charges,Implant Device,867,34,,867,percent of total billed charges,Implant Device,867,34,,867,percent of total billed charges,Implant Device,867,34,,867,percent of total billed charges,Implant Device,867,34,,867,percent of total billed charges,Implant Device,1262.25,,,1262.25,Other,110% of Medicare,892.5,35,,892.5,percent of total billed charges,Implant Device,867,34,"Charges > $500, x 34%",867,percent of total billed charges,Implant Device,892.5,35,,892.5,percent of total billed charges,Implant Device,892.5,35,,892.5,percent of total billed charges,Implant Device,892.5,35,,892.5,percent of total billed charges,Implant Device,892.5,35,,892.5,percent of total billed charges,Implant Device,892.5,35,,892.5,percent of total billed charges,Implant Device,1020,40,,1020,percent of total billed charges,Implant Device,892.5,70,,892.5,percent of total billed charges,All Other,867,34,,867,percent of total billed charges,Implant Device,867,34,,867,percent of total billed charges,Implant Device,892.5,35,,892.5,percent of total billed charges,Implant Device,892.5,35,,892.5,percent of total billed charges,Implant Device,892.5,35,,892.5,percent of total billed charges,Implant Device,892.5,35,,892.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,867,34,"If Charge > 2,000, then 34 percent",867,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1887.01,
STRYKER ST0A-19P SMART TOE 19MM,C1776,HCPCS,,79008221,CDM,278,RC,,,both,,,3582,2650.69,,,2650.69,Other,150% of Medicare + 9.63% HCRA Surcharge,1611.9,45,,1611.9,percent of total billed charges,Critical Access Hospital RCC factor,1217.88,34,,1217.88,percent of total billed charges,Implant Device,1217.88,34,,1217.88,percent of total billed charges,Implant Device,1217.88,34,,1217.88,percent of total billed charges,Implant Device,1217.88,34,,1217.88,percent of total billed charges,Implant Device,1217.88,34,,1217.88,percent of total billed charges,Implant Device,1773.09,,,1773.09,Other,110% of Medicare,1253.7,35,,1253.7,percent of total billed charges,Implant Device,1217.88,34,"Charges > $500, x 34%",1217.88,percent of total billed charges,Implant Device,1253.7,35,,1253.7,percent of total billed charges,Implant Device,1253.7,35,,1253.7,percent of total billed charges,Implant Device,1253.7,35,,1253.7,percent of total billed charges,Implant Device,1253.7,35,,1253.7,percent of total billed charges,Implant Device,1253.7,35,,1253.7,percent of total billed charges,Implant Device,1432.8,40,,1432.8,percent of total billed charges,Implant Device,1253.7,70,,1253.7,percent of total billed charges,All Other,1217.88,34,,1217.88,percent of total billed charges,Implant Device,1217.88,34,,1217.88,percent of total billed charges,Implant Device,1253.7,35,,1253.7,percent of total billed charges,Implant Device,1253.7,35,,1253.7,percent of total billed charges,Implant Device,1253.7,35,,1253.7,percent of total billed charges,Implant Device,1253.7,35,,1253.7,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1217.88,34,"If Charge > 2,000, then 34 percent",1217.88,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2650.69,
ARTHREX AR-8970AR ANKLE FUSION PLATE RT,C1713,HCPCS,,79008222,CDM,278,RC,,,both,,,8896,6583.06,,,6583.06,Other,150% of Medicare + 9.63% HCRA Surcharge,4003.2,45,,4003.2,percent of total billed charges,Critical Access Hospital RCC factor,3024.64,34,,3024.64,percent of total billed charges,Implant Device,3024.64,34,,3024.64,percent of total billed charges,Implant Device,3024.64,34,,3024.64,percent of total billed charges,Implant Device,3024.64,34,,3024.64,percent of total billed charges,Implant Device,3024.64,34,,3024.64,percent of total billed charges,Implant Device,4403.52,,,4403.52,Other,110% of Medicare,3113.6,35,,3113.6,percent of total billed charges,Implant Device,3024.64,34,"Charges > $500, x 34%",3024.64,percent of total billed charges,Implant Device,3113.6,35,,3113.6,percent of total billed charges,Implant Device,3113.6,35,,3113.6,percent of total billed charges,Implant Device,3113.6,35,,3113.6,percent of total billed charges,Implant Device,3113.6,35,,3113.6,percent of total billed charges,Implant Device,3113.6,35,,3113.6,percent of total billed charges,Implant Device,3558.4,40,,3558.4,percent of total billed charges,Implant Device,3113.6,70,,3113.6,percent of total billed charges,All Other,3024.64,34,,3024.64,percent of total billed charges,Implant Device,3024.64,34,,3024.64,percent of total billed charges,Implant Device,3113.6,35,,3113.6,percent of total billed charges,Implant Device,3113.6,35,,3113.6,percent of total billed charges,Implant Device,3113.6,35,,3113.6,percent of total billed charges,Implant Device,3113.6,35,,3113.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3024.64,34,"If Charge > 2,000, then 34 percent",3024.64,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,6583.06,
ARTHREX AR-8545L-24 LOCK SCREW 4.5X24MM,C1713,HCPCS,,79008223,CDM,278,RC,,,both,,,837,619.38,,,619.38,Other,150% of Medicare + 9.63% HCRA Surcharge,376.65,45,,376.65,percent of total billed charges,Critical Access Hospital RCC factor,284.58,34,,284.58,percent of total billed charges,Implant Device,284.58,34,,284.58,percent of total billed charges,Implant Device,284.58,34,,284.58,percent of total billed charges,Implant Device,284.58,34,,284.58,percent of total billed charges,Implant Device,284.58,34,,284.58,percent of total billed charges,Implant Device,414.32,,,414.32,Other,110% of Medicare,292.95,35,,292.95,percent of total billed charges,Implant Device,284.58,34,"Charges > $500, x 34%",284.58,percent of total billed charges,Implant Device,292.95,35,,292.95,percent of total billed charges,Implant Device,292.95,35,,292.95,percent of total billed charges,Implant Device,292.95,35,,292.95,percent of total billed charges,Implant Device,292.95,35,,292.95,percent of total billed charges,Implant Device,292.95,35,,292.95,percent of total billed charges,Implant Device,334.8,40,,334.8,percent of total billed charges,Implant Device,292.95,70,,292.95,percent of total billed charges,All Other,284.58,34,,284.58,percent of total billed charges,Implant Device,284.58,34,,284.58,percent of total billed charges,Implant Device,292.95,35,,292.95,percent of total billed charges,Implant Device,292.95,35,,292.95,percent of total billed charges,Implant Device,292.95,35,,292.95,percent of total billed charges,Implant Device,292.95,35,,292.95,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,619.38,
ARTHREX AR-8545L-28 LOCK SCREW 4.5X28MM,C1713,HCPCS,,79008224,CDM,278,RC,,,both,,,837,619.38,,,619.38,Other,150% of Medicare + 9.63% HCRA Surcharge,376.65,45,,376.65,percent of total billed charges,Critical Access Hospital RCC factor,284.58,34,,284.58,percent of total billed charges,Implant Device,284.58,34,,284.58,percent of total billed charges,Implant Device,284.58,34,,284.58,percent of total billed charges,Implant Device,284.58,34,,284.58,percent of total billed charges,Implant Device,284.58,34,,284.58,percent of total billed charges,Implant Device,414.32,,,414.32,Other,110% of Medicare,292.95,35,,292.95,percent of total billed charges,Implant Device,284.58,34,"Charges > $500, x 34%",284.58,percent of total billed charges,Implant Device,292.95,35,,292.95,percent of total billed charges,Implant Device,292.95,35,,292.95,percent of total billed charges,Implant Device,292.95,35,,292.95,percent of total billed charges,Implant Device,292.95,35,,292.95,percent of total billed charges,Implant Device,292.95,35,,292.95,percent of total billed charges,Implant Device,334.8,40,,334.8,percent of total billed charges,Implant Device,292.95,70,,292.95,percent of total billed charges,All Other,284.58,34,,284.58,percent of total billed charges,Implant Device,284.58,34,,284.58,percent of total billed charges,Implant Device,292.95,35,,292.95,percent of total billed charges,Implant Device,292.95,35,,292.95,percent of total billed charges,Implant Device,292.95,35,,292.95,percent of total billed charges,Implant Device,292.95,35,,292.95,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,619.38,
ARTHREX AR-8545L-30 LOCK SCREW 4.5X30MM,C1713,HCPCS,,79008225,CDM,278,RC,,,both,,,837,619.38,,,619.38,Other,150% of Medicare + 9.63% HCRA Surcharge,376.65,45,,376.65,percent of total billed charges,Critical Access Hospital RCC factor,284.58,34,,284.58,percent of total billed charges,Implant Device,284.58,34,,284.58,percent of total billed charges,Implant Device,284.58,34,,284.58,percent of total billed charges,Implant Device,284.58,34,,284.58,percent of total billed charges,Implant Device,284.58,34,,284.58,percent of total billed charges,Implant Device,414.32,,,414.32,Other,110% of Medicare,292.95,35,,292.95,percent of total billed charges,Implant Device,284.58,34,"Charges > $500, x 34%",284.58,percent of total billed charges,Implant Device,292.95,35,,292.95,percent of total billed charges,Implant Device,292.95,35,,292.95,percent of total billed charges,Implant Device,292.95,35,,292.95,percent of total billed charges,Implant Device,292.95,35,,292.95,percent of total billed charges,Implant Device,292.95,35,,292.95,percent of total billed charges,Implant Device,334.8,40,,334.8,percent of total billed charges,Implant Device,292.95,70,,292.95,percent of total billed charges,All Other,284.58,34,,284.58,percent of total billed charges,Implant Device,284.58,34,,284.58,percent of total billed charges,Implant Device,292.95,35,,292.95,percent of total billed charges,Implant Device,292.95,35,,292.95,percent of total billed charges,Implant Device,292.95,35,,292.95,percent of total billed charges,Implant Device,292.95,35,,292.95,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,619.38,
ARTHREX AR-8545L-40 LOCK SCREW 4.5X40MM,C1713,HCPCS,,79008226,CDM,278,RC,,,both,,,837,619.38,,,619.38,Other,150% of Medicare + 9.63% HCRA Surcharge,376.65,45,,376.65,percent of total billed charges,Critical Access Hospital RCC factor,284.58,34,,284.58,percent of total billed charges,Implant Device,284.58,34,,284.58,percent of total billed charges,Implant Device,284.58,34,,284.58,percent of total billed charges,Implant Device,284.58,34,,284.58,percent of total billed charges,Implant Device,284.58,34,,284.58,percent of total billed charges,Implant Device,414.32,,,414.32,Other,110% of Medicare,292.95,35,,292.95,percent of total billed charges,Implant Device,284.58,34,"Charges > $500, x 34%",284.58,percent of total billed charges,Implant Device,292.95,35,,292.95,percent of total billed charges,Implant Device,292.95,35,,292.95,percent of total billed charges,Implant Device,292.95,35,,292.95,percent of total billed charges,Implant Device,292.95,35,,292.95,percent of total billed charges,Implant Device,292.95,35,,292.95,percent of total billed charges,Implant Device,334.8,40,,334.8,percent of total billed charges,Implant Device,292.95,70,,292.95,percent of total billed charges,All Other,284.58,34,,284.58,percent of total billed charges,Implant Device,284.58,34,,284.58,percent of total billed charges,Implant Device,292.95,35,,292.95,percent of total billed charges,Implant Device,292.95,35,,292.95,percent of total billed charges,Implant Device,292.95,35,,292.95,percent of total billed charges,Implant Device,292.95,35,,292.95,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,619.38,
ARTHREX AR-8545-30 CORT SCREW 4.5X30MM,C1713,HCPCS,,79008227,CDM,278,RC,,,both,,,225,166.5,,,166.5,Other,150% of Medicare + 9.63% HCRA Surcharge,101.25,45,,101.25,percent of total billed charges,Critical Access Hospital RCC factor,76.5,34,,76.5,percent of total billed charges,Implant Device,76.5,34,,76.5,percent of total billed charges,Implant Device,76.5,34,,76.5,percent of total billed charges,Implant Device,76.5,34,,76.5,percent of total billed charges,Implant Device,76.5,34,,76.5,percent of total billed charges,Implant Device,111.38,,,111.38,Other,110% of Medicare,78.75,35,,78.75,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,78.75,35,,78.75,percent of total billed charges,Implant Device,78.75,35,,78.75,percent of total billed charges,Implant Device,78.75,35,,78.75,percent of total billed charges,Implant Device,78.75,35,,78.75,percent of total billed charges,Implant Device,78.75,35,,78.75,percent of total billed charges,Implant Device,90,40,,90,percent of total billed charges,Implant Device,78.75,70,,78.75,percent of total billed charges,All Other,76.5,34,,76.5,percent of total billed charges,Implant Device,76.5,34,,76.5,percent of total billed charges,Implant Device,78.75,35,,78.75,percent of total billed charges,Implant Device,78.75,35,,78.75,percent of total billed charges,Implant Device,78.75,35,,78.75,percent of total billed charges,Implant Device,78.75,35,,78.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,166.5,
ARTHREX AR-8967-2860 CANN SCREW 6.7X60MM,C1713,HCPCS,,79008228,CDM,278,RC,,,both,,,750,555,,,555,Other,150% of Medicare + 9.63% HCRA Surcharge,337.5,45,,337.5,percent of total billed charges,Critical Access Hospital RCC factor,255,34,,255,percent of total billed charges,Implant Device,255,34,,255,percent of total billed charges,Implant Device,255,34,,255,percent of total billed charges,Implant Device,255,34,,255,percent of total billed charges,Implant Device,255,34,,255,percent of total billed charges,Implant Device,371.25,,,371.25,Other,110% of Medicare,262.5,35,,262.5,percent of total billed charges,Implant Device,255,34,"Charges > $500, x 34%",255,percent of total billed charges,Implant Device,262.5,35,,262.5,percent of total billed charges,Implant Device,262.5,35,,262.5,percent of total billed charges,Implant Device,262.5,35,,262.5,percent of total billed charges,Implant Device,262.5,35,,262.5,percent of total billed charges,Implant Device,262.5,35,,262.5,percent of total billed charges,Implant Device,300,40,,300,percent of total billed charges,Implant Device,262.5,70,,262.5,percent of total billed charges,All Other,255,34,,255,percent of total billed charges,Implant Device,255,34,,255,percent of total billed charges,Implant Device,262.5,35,,262.5,percent of total billed charges,Implant Device,262.5,35,,262.5,percent of total billed charges,Implant Device,262.5,35,,262.5,percent of total billed charges,Implant Device,262.5,35,,262.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,555,
ARTHREX AR-8555-55 CANC SCREW 5.5X55MM,C1713,HCPCS,,79008230,CDM,278,RC,,,both,,,225,166.5,,,166.5,Other,150% of Medicare + 9.63% HCRA Surcharge,101.25,45,,101.25,percent of total billed charges,Critical Access Hospital RCC factor,76.5,34,,76.5,percent of total billed charges,Implant Device,76.5,34,,76.5,percent of total billed charges,Implant Device,76.5,34,,76.5,percent of total billed charges,Implant Device,76.5,34,,76.5,percent of total billed charges,Implant Device,76.5,34,,76.5,percent of total billed charges,Implant Device,111.38,,,111.38,Other,110% of Medicare,78.75,35,,78.75,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,78.75,35,,78.75,percent of total billed charges,Implant Device,78.75,35,,78.75,percent of total billed charges,Implant Device,78.75,35,,78.75,percent of total billed charges,Implant Device,78.75,35,,78.75,percent of total billed charges,Implant Device,78.75,35,,78.75,percent of total billed charges,Implant Device,90,40,,90,percent of total billed charges,Implant Device,78.75,70,,78.75,percent of total billed charges,All Other,76.5,34,,76.5,percent of total billed charges,Implant Device,76.5,34,,76.5,percent of total billed charges,Implant Device,78.75,35,,78.75,percent of total billed charges,Implant Device,78.75,35,,78.75,percent of total billed charges,Implant Device,78.75,35,,78.75,percent of total billed charges,Implant Device,78.75,35,,78.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,166.5,
ARTHREX AR-8930-14 2X14MM SNAP OFF SCREW,C1713,HCPCS,,79008232,CDM,278,RC,,,both,,,720,532.8,,,532.8,Other,150% of Medicare + 9.63% HCRA Surcharge,324,45,,324,percent of total billed charges,Critical Access Hospital RCC factor,244.8,34,,244.8,percent of total billed charges,Implant Device,244.8,34,,244.8,percent of total billed charges,Implant Device,244.8,34,,244.8,percent of total billed charges,Implant Device,244.8,34,,244.8,percent of total billed charges,Implant Device,244.8,34,,244.8,percent of total billed charges,Implant Device,356.4,,,356.4,Other,110% of Medicare,252,35,,252,percent of total billed charges,Implant Device,244.8,34,"Charges > $500, x 34%",244.8,percent of total billed charges,Implant Device,252,35,,252,percent of total billed charges,Implant Device,252,35,,252,percent of total billed charges,Implant Device,252,35,,252,percent of total billed charges,Implant Device,252,35,,252,percent of total billed charges,Implant Device,252,35,,252,percent of total billed charges,Implant Device,288,40,,288,percent of total billed charges,Implant Device,252,70,,252,percent of total billed charges,All Other,244.8,34,,244.8,percent of total billed charges,Implant Device,244.8,34,,244.8,percent of total billed charges,Implant Device,252,35,,252,percent of total billed charges,Implant Device,252,35,,252,percent of total billed charges,Implant Device,252,35,,252,percent of total billed charges,Implant Device,252,35,,252,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,532.8,
ARTHREX AR-4154P-3000 PIP DART 2.5X30MM,C1713,HCPCS,,79008234,CDM,278,RC,,,both,,,1785,1320.9,,,1320.9,Other,150% of Medicare + 9.63% HCRA Surcharge,803.25,45,,803.25,percent of total billed charges,Critical Access Hospital RCC factor,606.9,34,,606.9,percent of total billed charges,Implant Device,606.9,34,,606.9,percent of total billed charges,Implant Device,606.9,34,,606.9,percent of total billed charges,Implant Device,606.9,34,,606.9,percent of total billed charges,Implant Device,606.9,34,,606.9,percent of total billed charges,Implant Device,883.58,,,883.58,Other,110% of Medicare,624.75,35,,624.75,percent of total billed charges,Implant Device,606.9,34,"Charges > $500, x 34%",606.9,percent of total billed charges,Implant Device,624.75,35,,624.75,percent of total billed charges,Implant Device,624.75,35,,624.75,percent of total billed charges,Implant Device,624.75,35,,624.75,percent of total billed charges,Implant Device,624.75,35,,624.75,percent of total billed charges,Implant Device,624.75,35,,624.75,percent of total billed charges,Implant Device,714,40,,714,percent of total billed charges,Implant Device,624.75,70,,624.75,percent of total billed charges,All Other,606.9,34,,606.9,percent of total billed charges,Implant Device,606.9,34,,606.9,percent of total billed charges,Implant Device,624.75,35,,624.75,percent of total billed charges,Implant Device,624.75,35,,624.75,percent of total billed charges,Implant Device,624.75,35,,624.75,percent of total billed charges,Implant Device,624.75,35,,624.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1320.9,
ZIMMER 00-4827-014-01 CORT SCREW 2.7X14,C1713,HCPCS,,79008235,CDM,278,RC,,,both,,,71,52.54,,,52.54,Other,150% of Medicare + 9.63% HCRA Surcharge,31.95,45,,31.95,percent of total billed charges,Critical Access Hospital RCC factor,24.14,34,,24.14,percent of total billed charges,Implant Device,24.14,34,,24.14,percent of total billed charges,Implant Device,24.14,34,,24.14,percent of total billed charges,Implant Device,24.14,34,,24.14,percent of total billed charges,Implant Device,24.14,34,,24.14,percent of total billed charges,Implant Device,35.15,,,35.15,Other,110% of Medicare,24.85,35,,24.85,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,24.85,35,,24.85,percent of total billed charges,Implant Device,24.85,35,,24.85,percent of total billed charges,Implant Device,24.85,35,,24.85,percent of total billed charges,Implant Device,24.85,35,,24.85,percent of total billed charges,Implant Device,24.85,35,,24.85,percent of total billed charges,Implant Device,28.4,40,,28.4,percent of total billed charges,Implant Device,24.85,70,,24.85,percent of total billed charges,All Other,24.14,34,,24.14,percent of total billed charges,Implant Device,24.14,34,,24.14,percent of total billed charges,Implant Device,24.85,35,,24.85,percent of total billed charges,Implant Device,24.85,35,,24.85,percent of total billed charges,Implant Device,24.85,35,,24.85,percent of total billed charges,Implant Device,24.85,35,,24.85,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,52.54,
STRYKER 627735 PROX MED PLATE RT 5 HOLE,C1713,HCPCS,,79008236,CDM,278,RC,,,both,,,7191,5321.36,,,5321.36,Other,150% of Medicare + 9.63% HCRA Surcharge,3235.95,45,,3235.95,percent of total billed charges,Critical Access Hospital RCC factor,2444.94,34,,2444.94,percent of total billed charges,Implant Device,2444.94,34,,2444.94,percent of total billed charges,Implant Device,2444.94,34,,2444.94,percent of total billed charges,Implant Device,2444.94,34,,2444.94,percent of total billed charges,Implant Device,2444.94,34,,2444.94,percent of total billed charges,Implant Device,3559.55,,,3559.55,Other,110% of Medicare,2516.85,35,,2516.85,percent of total billed charges,Implant Device,2444.94,34,"Charges > $500, x 34%",2444.94,percent of total billed charges,Implant Device,2516.85,35,,2516.85,percent of total billed charges,Implant Device,2516.85,35,,2516.85,percent of total billed charges,Implant Device,2516.85,35,,2516.85,percent of total billed charges,Implant Device,2516.85,35,,2516.85,percent of total billed charges,Implant Device,2516.85,35,,2516.85,percent of total billed charges,Implant Device,2876.4,40,,2876.4,percent of total billed charges,Implant Device,2516.85,70,,2516.85,percent of total billed charges,All Other,2444.94,34,,2444.94,percent of total billed charges,Implant Device,2444.94,34,,2444.94,percent of total billed charges,Implant Device,2516.85,35,,2516.85,percent of total billed charges,Implant Device,2516.85,35,,2516.85,percent of total billed charges,Implant Device,2516.85,35,,2516.85,percent of total billed charges,Implant Device,2516.85,35,,2516.85,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2444.94,34,"If Charge > 2,000, then 34 percent",2444.94,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5321.36,
STRYKER 627336 PROX LAT PLATE RT 6 HOLE,C1713,HCPCS,,79008237,CDM,278,RC,,,both,,,8352,6180.5,,,6180.5,Other,150% of Medicare + 9.63% HCRA Surcharge,3758.4,45,,3758.4,percent of total billed charges,Critical Access Hospital RCC factor,2839.68,34,,2839.68,percent of total billed charges,Implant Device,2839.68,34,,2839.68,percent of total billed charges,Implant Device,2839.68,34,,2839.68,percent of total billed charges,Implant Device,2839.68,34,,2839.68,percent of total billed charges,Implant Device,2839.68,34,,2839.68,percent of total billed charges,Implant Device,4134.24,,,4134.24,Other,110% of Medicare,2923.2,35,,2923.2,percent of total billed charges,Implant Device,2839.68,34,"Charges > $500, x 34%",2839.68,percent of total billed charges,Implant Device,2923.2,35,,2923.2,percent of total billed charges,Implant Device,2923.2,35,,2923.2,percent of total billed charges,Implant Device,2923.2,35,,2923.2,percent of total billed charges,Implant Device,2923.2,35,,2923.2,percent of total billed charges,Implant Device,2923.2,35,,2923.2,percent of total billed charges,Implant Device,3340.8,40,,3340.8,percent of total billed charges,Implant Device,2923.2,70,,2923.2,percent of total billed charges,All Other,2839.68,34,,2839.68,percent of total billed charges,Implant Device,2839.68,34,,2839.68,percent of total billed charges,Implant Device,2923.2,35,,2923.2,percent of total billed charges,Implant Device,2923.2,35,,2923.2,percent of total billed charges,Implant Device,2923.2,35,,2923.2,percent of total billed charges,Implant Device,2923.2,35,,2923.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2839.68,34,"If Charge > 2,000, then 34 percent",2839.68,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,6180.5,
STRYKER 661448 NON LOCK SCREW 3.5X48MM,C1713,HCPCS,,79008238,CDM,278,RC,,,both,,,122,90.28,,,90.28,Other,150% of Medicare + 9.63% HCRA Surcharge,54.9,45,,54.9,percent of total billed charges,Critical Access Hospital RCC factor,41.48,34,,41.48,percent of total billed charges,Implant Device,41.48,34,,41.48,percent of total billed charges,Implant Device,41.48,34,,41.48,percent of total billed charges,Implant Device,41.48,34,,41.48,percent of total billed charges,Implant Device,41.48,34,,41.48,percent of total billed charges,Implant Device,60.39,,,60.39,Other,110% of Medicare,42.7,35,,42.7,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,42.7,35,,42.7,percent of total billed charges,Implant Device,42.7,35,,42.7,percent of total billed charges,Implant Device,42.7,35,,42.7,percent of total billed charges,Implant Device,42.7,35,,42.7,percent of total billed charges,Implant Device,42.7,35,,42.7,percent of total billed charges,Implant Device,48.8,40,,48.8,percent of total billed charges,Implant Device,42.7,70,,42.7,percent of total billed charges,All Other,41.48,34,,41.48,percent of total billed charges,Implant Device,41.48,34,,41.48,percent of total billed charges,Implant Device,42.7,35,,42.7,percent of total billed charges,Implant Device,42.7,35,,42.7,percent of total billed charges,Implant Device,42.7,35,,42.7,percent of total billed charges,Implant Device,42.7,35,,42.7,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,90.28,
STRYKER 661432 NON LOCK SCREW 3.5X32MM,C1713,HCPCS,,79008239,CDM,278,RC,,,both,,,132,97.68,,,97.68,Other,150% of Medicare + 9.63% HCRA Surcharge,59.4,45,,59.4,percent of total billed charges,Critical Access Hospital RCC factor,44.88,34,,44.88,percent of total billed charges,Implant Device,44.88,34,,44.88,percent of total billed charges,Implant Device,44.88,34,,44.88,percent of total billed charges,Implant Device,44.88,34,,44.88,percent of total billed charges,Implant Device,44.88,34,,44.88,percent of total billed charges,Implant Device,65.34,,,65.34,Other,110% of Medicare,46.2,35,,46.2,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,46.2,35,,46.2,percent of total billed charges,Implant Device,46.2,35,,46.2,percent of total billed charges,Implant Device,46.2,35,,46.2,percent of total billed charges,Implant Device,46.2,35,,46.2,percent of total billed charges,Implant Device,46.2,35,,46.2,percent of total billed charges,Implant Device,52.8,40,,52.8,percent of total billed charges,Implant Device,46.2,70,,46.2,percent of total billed charges,All Other,44.88,34,,44.88,percent of total billed charges,Implant Device,44.88,34,,44.88,percent of total billed charges,Implant Device,46.2,35,,46.2,percent of total billed charges,Implant Device,46.2,35,,46.2,percent of total billed charges,Implant Device,46.2,35,,46.2,percent of total billed charges,Implant Device,46.2,35,,46.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,97.68,
STRYKER 661020 LOCKING SCREW 4.0X20MM,C1713,HCPCS,,79008240,CDM,278,RC,,,both,,,583,431.42,,,431.42,Other,150% of Medicare + 9.63% HCRA Surcharge,262.35,45,,262.35,percent of total billed charges,Critical Access Hospital RCC factor,198.22,34,,198.22,percent of total billed charges,Implant Device,198.22,34,,198.22,percent of total billed charges,Implant Device,198.22,34,,198.22,percent of total billed charges,Implant Device,198.22,34,,198.22,percent of total billed charges,Implant Device,198.22,34,,198.22,percent of total billed charges,Implant Device,288.59,,,288.59,Other,110% of Medicare,204.05,35,,204.05,percent of total billed charges,Implant Device,198.22,34,"Charges > $500, x 34%",198.22,percent of total billed charges,Implant Device,204.05,35,,204.05,percent of total billed charges,Implant Device,204.05,35,,204.05,percent of total billed charges,Implant Device,204.05,35,,204.05,percent of total billed charges,Implant Device,204.05,35,,204.05,percent of total billed charges,Implant Device,204.05,35,,204.05,percent of total billed charges,Implant Device,233.2,40,,233.2,percent of total billed charges,Implant Device,204.05,70,,204.05,percent of total billed charges,All Other,198.22,34,,198.22,percent of total billed charges,Implant Device,198.22,34,,198.22,percent of total billed charges,Implant Device,204.05,35,,204.05,percent of total billed charges,Implant Device,204.05,35,,204.05,percent of total billed charges,Implant Device,204.05,35,,204.05,percent of total billed charges,Implant Device,204.05,35,,204.05,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,431.42,
STRYKER 661034 LOCKING SCREW 4.0X34MM,C1713,HCPCS,,79008241,CDM,278,RC,,,both,,,630,466.2,,,466.2,Other,150% of Medicare + 9.63% HCRA Surcharge,283.5,45,,283.5,percent of total billed charges,Critical Access Hospital RCC factor,214.2,34,,214.2,percent of total billed charges,Implant Device,214.2,34,,214.2,percent of total billed charges,Implant Device,214.2,34,,214.2,percent of total billed charges,Implant Device,214.2,34,,214.2,percent of total billed charges,Implant Device,214.2,34,,214.2,percent of total billed charges,Implant Device,311.85,,,311.85,Other,110% of Medicare,220.5,35,,220.5,percent of total billed charges,Implant Device,214.2,34,"Charges > $500, x 34%",214.2,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,252,40,,252,percent of total billed charges,Implant Device,220.5,70,,220.5,percent of total billed charges,All Other,214.2,34,,214.2,percent of total billed charges,Implant Device,214.2,34,,214.2,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,466.2,
STRYKER 661028 LOCKING SCREW 4.0X28MM,C1713,HCPCS,,79008242,CDM,278,RC,,,both,,,583,431.42,,,431.42,Other,150% of Medicare + 9.63% HCRA Surcharge,262.35,45,,262.35,percent of total billed charges,Critical Access Hospital RCC factor,198.22,34,,198.22,percent of total billed charges,Implant Device,198.22,34,,198.22,percent of total billed charges,Implant Device,198.22,34,,198.22,percent of total billed charges,Implant Device,198.22,34,,198.22,percent of total billed charges,Implant Device,198.22,34,,198.22,percent of total billed charges,Implant Device,288.59,,,288.59,Other,110% of Medicare,204.05,35,,204.05,percent of total billed charges,Implant Device,198.22,34,"Charges > $500, x 34%",198.22,percent of total billed charges,Implant Device,204.05,35,,204.05,percent of total billed charges,Implant Device,204.05,35,,204.05,percent of total billed charges,Implant Device,204.05,35,,204.05,percent of total billed charges,Implant Device,204.05,35,,204.05,percent of total billed charges,Implant Device,204.05,35,,204.05,percent of total billed charges,Implant Device,233.2,40,,233.2,percent of total billed charges,Implant Device,204.05,70,,204.05,percent of total billed charges,All Other,198.22,34,,198.22,percent of total billed charges,Implant Device,198.22,34,,198.22,percent of total billed charges,Implant Device,204.05,35,,204.05,percent of total billed charges,Implant Device,204.05,35,,204.05,percent of total billed charges,Implant Device,204.05,35,,204.05,percent of total billed charges,Implant Device,204.05,35,,204.05,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,431.42,
P28 P50-053-2718 LOCK PLATE SCREW 2.7X18,C1713,HCPCS,,79008244,CDM,278,RC,,,both,,,488,361.12,,,361.12,Other,150% of Medicare + 9.63% HCRA Surcharge,219.6,45,,219.6,percent of total billed charges,Critical Access Hospital RCC factor,165.92,34,,165.92,percent of total billed charges,Implant Device,165.92,34,,165.92,percent of total billed charges,Implant Device,165.92,34,,165.92,percent of total billed charges,Implant Device,165.92,34,,165.92,percent of total billed charges,Implant Device,165.92,34,,165.92,percent of total billed charges,Implant Device,241.56,,,241.56,Other,110% of Medicare,170.8,35,,170.8,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,170.8,35,,170.8,percent of total billed charges,Implant Device,170.8,35,,170.8,percent of total billed charges,Implant Device,170.8,35,,170.8,percent of total billed charges,Implant Device,170.8,35,,170.8,percent of total billed charges,Implant Device,170.8,35,,170.8,percent of total billed charges,Implant Device,195.2,40,,195.2,percent of total billed charges,Implant Device,170.8,70,,170.8,percent of total billed charges,All Other,165.92,34,,165.92,percent of total billed charges,Implant Device,165.92,34,,165.92,percent of total billed charges,Implant Device,170.8,35,,170.8,percent of total billed charges,Implant Device,170.8,35,,170.8,percent of total billed charges,Implant Device,170.8,35,,170.8,percent of total billed charges,Implant Device,170.8,35,,170.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,361.12,
P28 P50-053-2726 LOCK PLATE SCREW 2.7X26,C1713,HCPCS,,79008245,CDM,278,RC,,,both,,,829,613.46,,,613.46,Other,150% of Medicare + 9.63% HCRA Surcharge,373.05,45,,373.05,percent of total billed charges,Critical Access Hospital RCC factor,281.86,34,,281.86,percent of total billed charges,Implant Device,281.86,34,,281.86,percent of total billed charges,Implant Device,281.86,34,,281.86,percent of total billed charges,Implant Device,281.86,34,,281.86,percent of total billed charges,Implant Device,281.86,34,,281.86,percent of total billed charges,Implant Device,410.36,,,410.36,Other,110% of Medicare,290.15,35,,290.15,percent of total billed charges,Implant Device,281.86,34,"Charges > $500, x 34%",281.86,percent of total billed charges,Implant Device,290.15,35,,290.15,percent of total billed charges,Implant Device,290.15,35,,290.15,percent of total billed charges,Implant Device,290.15,35,,290.15,percent of total billed charges,Implant Device,290.15,35,,290.15,percent of total billed charges,Implant Device,290.15,35,,290.15,percent of total billed charges,Implant Device,331.6,40,,331.6,percent of total billed charges,Implant Device,290.15,70,,290.15,percent of total billed charges,All Other,281.86,34,,281.86,percent of total billed charges,Implant Device,281.86,34,,281.86,percent of total billed charges,Implant Device,290.15,35,,290.15,percent of total billed charges,Implant Device,290.15,35,,290.15,percent of total billed charges,Implant Device,290.15,35,,290.15,percent of total billed charges,Implant Device,290.15,35,,290.15,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,613.46,
BIOMET 11-300919 TAPER DIST STEM 19X190,C1776,HCPCS,,79008247,CDM,278,RC,,,both,,,13543,10021.85,,,10021.85,Other,150% of Medicare + 9.63% HCRA Surcharge,6094.35,45,,6094.35,percent of total billed charges,Critical Access Hospital RCC factor,4604.62,34,,4604.62,percent of total billed charges,Implant Device,4604.62,34,,4604.62,percent of total billed charges,Implant Device,4604.62,34,,4604.62,percent of total billed charges,Implant Device,4604.62,34,,4604.62,percent of total billed charges,Implant Device,4604.62,34,,4604.62,percent of total billed charges,Implant Device,6703.79,,,6703.79,Other,110% of Medicare,4740.05,35,,4740.05,percent of total billed charges,Implant Device,4604.62,34,"Charges > $500, x 34%",4604.62,percent of total billed charges,Implant Device,4740.05,35,,4740.05,percent of total billed charges,Implant Device,4740.05,35,,4740.05,percent of total billed charges,Implant Device,4740.05,35,,4740.05,percent of total billed charges,Implant Device,4740.05,35,,4740.05,percent of total billed charges,Implant Device,4740.05,35,,4740.05,percent of total billed charges,Implant Device,5417.2,40,,5417.2,percent of total billed charges,Implant Device,4740.05,70,,4740.05,percent of total billed charges,All Other,4604.62,34,,4604.62,percent of total billed charges,Implant Device,4604.62,34,,4604.62,percent of total billed charges,Implant Device,4740.05,35,,4740.05,percent of total billed charges,Implant Device,4740.05,35,,4740.05,percent of total billed charges,Implant Device,4740.05,35,,4740.05,percent of total billed charges,Implant Device,4740.05,35,,4740.05,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,4604.62,34,"If Charge > 2,000, then 34 percent",4604.62,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,10021.85,
BIOMET 11-301304 CONE PROXIMAL BODY 60MM,C1776,HCPCS,,79008248,CDM,278,RC,,,both,,,19784,14640.21,,,14640.21,Other,150% of Medicare + 9.63% HCRA Surcharge,8902.8,45,,8902.8,percent of total billed charges,Critical Access Hospital RCC factor,6726.56,34,,6726.56,percent of total billed charges,Implant Device,6726.56,34,,6726.56,percent of total billed charges,Implant Device,6726.56,34,,6726.56,percent of total billed charges,Implant Device,6726.56,34,,6726.56,percent of total billed charges,Implant Device,6726.56,34,,6726.56,percent of total billed charges,Implant Device,9793.08,,,9793.08,Other,110% of Medicare,6924.4,35,,6924.4,percent of total billed charges,Implant Device,6726.56,34,"Charges > $500, x 34%",6726.56,percent of total billed charges,Implant Device,6924.4,35,,6924.4,percent of total billed charges,Implant Device,6924.4,35,,6924.4,percent of total billed charges,Implant Device,6924.4,35,,6924.4,percent of total billed charges,Implant Device,6924.4,35,,6924.4,percent of total billed charges,Implant Device,6924.4,35,,6924.4,percent of total billed charges,Implant Device,7913.6,40,,7913.6,percent of total billed charges,Implant Device,6924.4,70,,6924.4,percent of total billed charges,All Other,6726.56,34,,6726.56,percent of total billed charges,Implant Device,6726.56,34,,6726.56,percent of total billed charges,Implant Device,6924.4,35,,6924.4,percent of total billed charges,Implant Device,6924.4,35,,6924.4,percent of total billed charges,Implant Device,6924.4,35,,6924.4,percent of total billed charges,Implant Device,6924.4,35,,6924.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,6726.56,34,"If Charge > 2,000, then 34 percent",6726.56,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,14640.21,
BIOMET 12-115121 MOD CERAMIC HEAD 36MM,C1776,HCPCS,,79008249,CDM,278,RC,,,both,,,3083,2281.43,,,2281.43,Other,150% of Medicare + 9.63% HCRA Surcharge,1387.35,45,,1387.35,percent of total billed charges,Critical Access Hospital RCC factor,1048.22,34,,1048.22,percent of total billed charges,Implant Device,1048.22,34,,1048.22,percent of total billed charges,Implant Device,1048.22,34,,1048.22,percent of total billed charges,Implant Device,1048.22,34,,1048.22,percent of total billed charges,Implant Device,1048.22,34,,1048.22,percent of total billed charges,Implant Device,1526.09,,,1526.09,Other,110% of Medicare,1079.05,35,,1079.05,percent of total billed charges,Implant Device,1048.22,34,"Charges > $500, x 34%",1048.22,percent of total billed charges,Implant Device,1079.05,35,,1079.05,percent of total billed charges,Implant Device,1079.05,35,,1079.05,percent of total billed charges,Implant Device,1079.05,35,,1079.05,percent of total billed charges,Implant Device,1079.05,35,,1079.05,percent of total billed charges,Implant Device,1079.05,35,,1079.05,percent of total billed charges,Implant Device,1233.2,40,,1233.2,percent of total billed charges,Implant Device,1079.05,70,,1079.05,percent of total billed charges,All Other,1048.22,34,,1048.22,percent of total billed charges,Implant Device,1048.22,34,,1048.22,percent of total billed charges,Implant Device,1079.05,35,,1079.05,percent of total billed charges,Implant Device,1079.05,35,,1079.05,percent of total billed charges,Implant Device,1079.05,35,,1079.05,percent of total billed charges,Implant Device,1079.05,35,,1079.05,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1048.22,34,"If Charge > 2,000, then 34 percent",1048.22,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2281.43,
ARTHREX AR-9045-50PT SCREW 4.5X50,C1713,HCPCS,,79008250,CDM,278,RC,,,both,,,2385,1764.91,,,1764.91,Other,150% of Medicare + 9.63% HCRA Surcharge,1073.25,45,,1073.25,percent of total billed charges,Critical Access Hospital RCC factor,810.9,34,,810.9,percent of total billed charges,Implant Device,810.9,34,,810.9,percent of total billed charges,Implant Device,810.9,34,,810.9,percent of total billed charges,Implant Device,810.9,34,,810.9,percent of total billed charges,Implant Device,810.9,34,,810.9,percent of total billed charges,Implant Device,1180.58,,,1180.58,Other,110% of Medicare,834.75,35,,834.75,percent of total billed charges,Implant Device,810.9,34,"Charges > $500, x 34%",810.9,percent of total billed charges,Implant Device,834.75,35,,834.75,percent of total billed charges,Implant Device,834.75,35,,834.75,percent of total billed charges,Implant Device,834.75,35,,834.75,percent of total billed charges,Implant Device,834.75,35,,834.75,percent of total billed charges,Implant Device,834.75,35,,834.75,percent of total billed charges,Implant Device,954,40,,954,percent of total billed charges,Implant Device,834.75,70,,834.75,percent of total billed charges,All Other,810.9,34,,810.9,percent of total billed charges,Implant Device,810.9,34,,810.9,percent of total billed charges,Implant Device,834.75,35,,834.75,percent of total billed charges,Implant Device,834.75,35,,834.75,percent of total billed charges,Implant Device,834.75,35,,834.75,percent of total billed charges,Implant Device,834.75,35,,834.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,810.9,34,"If Charge > 2,000, then 34 percent",810.9,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1764.91,
MENTOR TEXP110RH TISSUE EXPANDER 300CC,C1789,HCPCS,,79008253,CDM,278,RC,,,both,,,6375,4717.52,,,4717.52,Other,150% of Medicare + 9.63% HCRA Surcharge,2868.75,45,,2868.75,percent of total billed charges,Critical Access Hospital RCC factor,2167.5,34,,2167.5,percent of total billed charges,Implant Device,2167.5,34,,2167.5,percent of total billed charges,Implant Device,2167.5,34,,2167.5,percent of total billed charges,Implant Device,2167.5,34,,2167.5,percent of total billed charges,Implant Device,2167.5,34,,2167.5,percent of total billed charges,Implant Device,3155.63,,,3155.63,Other,110% of Medicare,2231.25,35,,2231.25,percent of total billed charges,Implant Device,2167.5,34,"Charges > $500, x 34%",2167.5,percent of total billed charges,Implant Device,2231.25,35,,2231.25,percent of total billed charges,Implant Device,2231.25,35,,2231.25,percent of total billed charges,Implant Device,2231.25,35,,2231.25,percent of total billed charges,Implant Device,2231.25,35,,2231.25,percent of total billed charges,Implant Device,2231.25,35,,2231.25,percent of total billed charges,Implant Device,2550,40,,2550,percent of total billed charges,Implant Device,2231.25,70,,2231.25,percent of total billed charges,All Other,2167.5,34,,2167.5,percent of total billed charges,Implant Device,2167.5,34,,2167.5,percent of total billed charges,Implant Device,2231.25,35,,2231.25,percent of total billed charges,Implant Device,2231.25,35,,2231.25,percent of total billed charges,Implant Device,2231.25,35,,2231.25,percent of total billed charges,Implant Device,2231.25,35,,2231.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2167.5,34,"If Charge > 2,000, then 34 percent",2167.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4717.52,
MENTOR TEXP120RH TISSUE EXPANDER 375CC,C1789,HCPCS,,79008254,CDM,278,RC,,,both,,,6375,4717.52,,,4717.52,Other,150% of Medicare + 9.63% HCRA Surcharge,2868.75,45,,2868.75,percent of total billed charges,Critical Access Hospital RCC factor,2167.5,34,,2167.5,percent of total billed charges,Implant Device,2167.5,34,,2167.5,percent of total billed charges,Implant Device,2167.5,34,,2167.5,percent of total billed charges,Implant Device,2167.5,34,,2167.5,percent of total billed charges,Implant Device,2167.5,34,,2167.5,percent of total billed charges,Implant Device,3155.63,,,3155.63,Other,110% of Medicare,2231.25,35,,2231.25,percent of total billed charges,Implant Device,2167.5,34,"Charges > $500, x 34%",2167.5,percent of total billed charges,Implant Device,2231.25,35,,2231.25,percent of total billed charges,Implant Device,2231.25,35,,2231.25,percent of total billed charges,Implant Device,2231.25,35,,2231.25,percent of total billed charges,Implant Device,2231.25,35,,2231.25,percent of total billed charges,Implant Device,2231.25,35,,2231.25,percent of total billed charges,Implant Device,2550,40,,2550,percent of total billed charges,Implant Device,2231.25,70,,2231.25,percent of total billed charges,All Other,2167.5,34,,2167.5,percent of total billed charges,Implant Device,2167.5,34,,2167.5,percent of total billed charges,Implant Device,2231.25,35,,2231.25,percent of total billed charges,Implant Device,2231.25,35,,2231.25,percent of total billed charges,Implant Device,2231.25,35,,2231.25,percent of total billed charges,Implant Device,2231.25,35,,2231.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2167.5,34,"If Charge > 2,000, then 34 percent",2167.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4717.52,
MENTOR TEXP130RH TISSUE EXPANDER 475CC,C1789,HCPCS,,79008255,CDM,278,RC,,,both,,,6375,4717.52,,,4717.52,Other,150% of Medicare + 9.63% HCRA Surcharge,2868.75,45,,2868.75,percent of total billed charges,Critical Access Hospital RCC factor,2167.5,34,,2167.5,percent of total billed charges,Implant Device,2167.5,34,,2167.5,percent of total billed charges,Implant Device,2167.5,34,,2167.5,percent of total billed charges,Implant Device,2167.5,34,,2167.5,percent of total billed charges,Implant Device,2167.5,34,,2167.5,percent of total billed charges,Implant Device,3155.63,,,3155.63,Other,110% of Medicare,2231.25,35,,2231.25,percent of total billed charges,Implant Device,2167.5,34,"Charges > $500, x 34%",2167.5,percent of total billed charges,Implant Device,2231.25,35,,2231.25,percent of total billed charges,Implant Device,2231.25,35,,2231.25,percent of total billed charges,Implant Device,2231.25,35,,2231.25,percent of total billed charges,Implant Device,2231.25,35,,2231.25,percent of total billed charges,Implant Device,2231.25,35,,2231.25,percent of total billed charges,Implant Device,2550,40,,2550,percent of total billed charges,Implant Device,2231.25,70,,2231.25,percent of total billed charges,All Other,2167.5,34,,2167.5,percent of total billed charges,Implant Device,2167.5,34,,2167.5,percent of total billed charges,Implant Device,2231.25,35,,2231.25,percent of total billed charges,Implant Device,2231.25,35,,2231.25,percent of total billed charges,Implant Device,2231.25,35,,2231.25,percent of total billed charges,Implant Device,2231.25,35,,2231.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2167.5,34,"If Charge > 2,000, then 34 percent",2167.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4717.52,
LIFE CELL CS1520P ALLODERM RTU SMALL,Q4116,HCPCS,,79008256,CDM,278,RC,,,both,,,10332,7645.71,,,7645.71,Other,150% of Medicare + 9.63% HCRA Surcharge,4649.4,45,,4649.4,percent of total billed charges,Critical Access Hospital RCC factor,3512.88,34,,3512.88,percent of total billed charges,Implant Device,3512.88,34,,3512.88,percent of total billed charges,Implant Device,3512.88,34,,3512.88,percent of total billed charges,Implant Device,3512.88,34,,3512.88,percent of total billed charges,Implant Device,3512.88,34,,3512.88,percent of total billed charges,Implant Device,5114.34,,,5114.34,Other,110% of Medicare,3616.2,35,,3616.2,percent of total billed charges,Implant Device,3512.88,34,"Charges > $500, x 34%",3512.88,percent of total billed charges,Implant Device,3616.2,35,,3616.2,percent of total billed charges,Implant Device,3616.2,35,,3616.2,percent of total billed charges,Implant Device,3616.2,35,,3616.2,percent of total billed charges,Implant Device,3616.2,35,,3616.2,percent of total billed charges,Implant Device,3616.2,35,,3616.2,percent of total billed charges,Implant Device,4132.8,40,,4132.8,percent of total billed charges,Implant Device,3616.2,70,,3616.2,percent of total billed charges,All Other,3512.88,34,,3512.88,percent of total billed charges,Implant Device,3512.88,34,,3512.88,percent of total billed charges,Implant Device,3616.2,35,,3616.2,percent of total billed charges,Implant Device,3616.2,35,,3616.2,percent of total billed charges,Implant Device,3616.2,35,,3616.2,percent of total billed charges,Implant Device,3616.2,35,,3616.2,percent of total billed charges,Implant Device,976.07,,,976.07,Other,100% of Medicaid,976.07,,,976.07,Other,100% of Medicaid,976.07,,,976.07,Other,100% of Medicaid,976.07,,,976.07,Other,100% of Medicaid,2196.15,,,2196.15,Other,225% of Medicaid,1493.38,,,1493.38,Other,153% of Medicaid,2196.15,,,2196.15,Other,225% of Medicaid,1366.49,,,1366.49,Other,140% of Medicaid,3512.88,34,"If Charge > 2,000, then 34 percent",3512.88,percent of total billed charges,Implants,2537.77,,,2537.77,Other,260% of Medicaid,3162.45,,,3162.45,Other,324% of Medicaid,2098.54,,,2098.54,Other,215% of Medicaid,2098.54,,,2098.54,Other,215% of Medicaid,1220.08,,,1220.08,Other,125% of Medicaid,976.07,7645.71,
MTF 400405 ILIAC CREST WEDGE 13-15MM,C1762,HCPCS,,79008257,CDM,278,RC,,,both,,,2740,2027.61,,,2027.61,Other,150% of Medicare + 9.63% HCRA Surcharge,1233,45,,1233,percent of total billed charges,Critical Access Hospital RCC factor,931.6,34,,931.6,percent of total billed charges,Implant Device,931.6,34,,931.6,percent of total billed charges,Implant Device,931.6,34,,931.6,percent of total billed charges,Implant Device,931.6,34,,931.6,percent of total billed charges,Implant Device,931.6,34,,931.6,percent of total billed charges,Implant Device,1356.3,,,1356.3,Other,110% of Medicare,959,35,,959,percent of total billed charges,Implant Device,931.6,34,"Charges > $500, x 34%",931.6,percent of total billed charges,Implant Device,959,35,,959,percent of total billed charges,Implant Device,959,35,,959,percent of total billed charges,Implant Device,959,35,,959,percent of total billed charges,Implant Device,959,35,,959,percent of total billed charges,Implant Device,959,35,,959,percent of total billed charges,Implant Device,1096,40,,1096,percent of total billed charges,Implant Device,959,70,,959,percent of total billed charges,All Other,931.6,34,,931.6,percent of total billed charges,Implant Device,931.6,34,,931.6,percent of total billed charges,Implant Device,959,35,,959,percent of total billed charges,Implant Device,959,35,,959,percent of total billed charges,Implant Device,959,35,,959,percent of total billed charges,Implant Device,959,35,,959,percent of total billed charges,Implant Device,976.07,,,976.07,Other,100% of Medicaid,976.07,,,976.07,Other,100% of Medicaid,976.07,,,976.07,Other,100% of Medicaid,976.07,,,976.07,Other,100% of Medicaid,2196.16,,,2196.16,Other,225% of Medicaid,1493.39,,,1493.39,Other,153% of Medicaid,2196.16,,,2196.16,Other,225% of Medicaid,1366.5,,,1366.5,Other,140% of Medicaid,931.6,34,"If Charge > 2,000, then 34 percent",931.6,percent of total billed charges,Implants,2537.78,,,2537.78,Other,260% of Medicaid,3162.47,,,3162.47,Other,324% of Medicaid,2098.55,,,2098.55,Other,215% of Medicaid,2098.55,,,2098.55,Other,215% of Medicaid,1220.09,,,1220.09,Other,125% of Medicaid,931.6,3162.47,
ZIMMER 00-8852-016-36 RIM LINER 36MM,C1776,HCPCS,,79008258,CDM,278,RC,,,both,,,3456,2557.45,,,2557.45,Other,150% of Medicare + 9.63% HCRA Surcharge,1555.2,45,,1555.2,percent of total billed charges,Critical Access Hospital RCC factor,1175.04,34,,1175.04,percent of total billed charges,Implant Device,1175.04,34,,1175.04,percent of total billed charges,Implant Device,1175.04,34,,1175.04,percent of total billed charges,Implant Device,1175.04,34,,1175.04,percent of total billed charges,Implant Device,1175.04,34,,1175.04,percent of total billed charges,Implant Device,1710.72,,,1710.72,Other,110% of Medicare,1209.6,35,,1209.6,percent of total billed charges,Implant Device,1175.04,34,"Charges > $500, x 34%",1175.04,percent of total billed charges,Implant Device,1209.6,35,,1209.6,percent of total billed charges,Implant Device,1209.6,35,,1209.6,percent of total billed charges,Implant Device,1209.6,35,,1209.6,percent of total billed charges,Implant Device,1209.6,35,,1209.6,percent of total billed charges,Implant Device,1209.6,35,,1209.6,percent of total billed charges,Implant Device,1382.4,40,,1382.4,percent of total billed charges,Implant Device,1209.6,70,,1209.6,percent of total billed charges,All Other,1175.04,34,,1175.04,percent of total billed charges,Implant Device,1175.04,34,,1175.04,percent of total billed charges,Implant Device,1209.6,35,,1209.6,percent of total billed charges,Implant Device,1209.6,35,,1209.6,percent of total billed charges,Implant Device,1209.6,35,,1209.6,percent of total billed charges,Implant Device,1209.6,35,,1209.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1175.04,34,"If Charge > 2,000, then 34 percent",1175.04,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2557.45,
BIOMET 11-300921 ST5 DISTL STEM 21X190MM,C1776,HCPCS,,79008259,CDM,278,RC,,,both,,,10199,7547.29,,,7547.29,Other,150% of Medicare + 9.63% HCRA Surcharge,4589.55,45,,4589.55,percent of total billed charges,Critical Access Hospital RCC factor,3467.66,34,,3467.66,percent of total billed charges,Implant Device,3467.66,34,,3467.66,percent of total billed charges,Implant Device,3467.66,34,,3467.66,percent of total billed charges,Implant Device,3467.66,34,,3467.66,percent of total billed charges,Implant Device,3467.66,34,,3467.66,percent of total billed charges,Implant Device,5048.51,,,5048.51,Other,110% of Medicare,3569.65,35,,3569.65,percent of total billed charges,Implant Device,3467.66,34,"Charges > $500, x 34%",3467.66,percent of total billed charges,Implant Device,3569.65,35,,3569.65,percent of total billed charges,Implant Device,3569.65,35,,3569.65,percent of total billed charges,Implant Device,3569.65,35,,3569.65,percent of total billed charges,Implant Device,3569.65,35,,3569.65,percent of total billed charges,Implant Device,3569.65,35,,3569.65,percent of total billed charges,Implant Device,4079.6,40,,4079.6,percent of total billed charges,Implant Device,3569.65,70,,3569.65,percent of total billed charges,All Other,3467.66,34,,3467.66,percent of total billed charges,Implant Device,3467.66,34,,3467.66,percent of total billed charges,Implant Device,3569.65,35,,3569.65,percent of total billed charges,Implant Device,3569.65,35,,3569.65,percent of total billed charges,Implant Device,3569.65,35,,3569.65,percent of total billed charges,Implant Device,3569.65,35,,3569.65,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3467.66,34,"If Charge > 2,000, then 34 percent",3467.66,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,7547.29,
BIOMET 11-301335 CONE PROXIMAL SZ E 70MM,C1776,HCPCS,,79008260,CDM,278,RC,,,both,,,36210,26795.49,,,26795.49,Other,150% of Medicare + 9.63% HCRA Surcharge,16294.5,45,,16294.5,percent of total billed charges,Critical Access Hospital RCC factor,12311.4,34,,12311.4,percent of total billed charges,Implant Device,12311.4,34,,12311.4,percent of total billed charges,Implant Device,12311.4,34,,12311.4,percent of total billed charges,Implant Device,12311.4,34,,12311.4,percent of total billed charges,Implant Device,12311.4,34,,12311.4,percent of total billed charges,Implant Device,17923.95,,,17923.95,Other,110% of Medicare,12673.5,35,,12673.5,percent of total billed charges,Implant Device,12311.4,34,"Charges > $500, x 34%",12311.4,percent of total billed charges,Implant Device,12673.5,35,,12673.5,percent of total billed charges,Implant Device,12673.5,35,,12673.5,percent of total billed charges,Implant Device,12673.5,35,,12673.5,percent of total billed charges,Implant Device,12673.5,35,,12673.5,percent of total billed charges,Implant Device,12673.5,35,,12673.5,percent of total billed charges,Implant Device,14484,40,,14484,percent of total billed charges,Implant Device,12673.5,70,,12673.5,percent of total billed charges,All Other,12311.4,34,,12311.4,percent of total billed charges,Implant Device,12311.4,34,,12311.4,percent of total billed charges,Implant Device,12673.5,35,,12673.5,percent of total billed charges,Implant Device,12673.5,35,,12673.5,percent of total billed charges,Implant Device,12673.5,35,,12673.5,percent of total billed charges,Implant Device,12673.5,35,,12673.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,12311.4,34,"If Charge > 2,000, then 34 percent",12311.4,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,26795.49,
EXACTECH 306-02-08 HUMERAL STEM 8X215MM,C1776,HCPCS,,79008261,CDM,278,RC,,,both,,,12852,9510.51,,,9510.51,Other,150% of Medicare + 9.63% HCRA Surcharge,5783.4,45,,5783.4,percent of total billed charges,Critical Access Hospital RCC factor,4369.68,34,,4369.68,percent of total billed charges,Implant Device,4369.68,34,,4369.68,percent of total billed charges,Implant Device,4369.68,34,,4369.68,percent of total billed charges,Implant Device,4369.68,34,,4369.68,percent of total billed charges,Implant Device,4369.68,34,,4369.68,percent of total billed charges,Implant Device,6361.74,,,6361.74,Other,110% of Medicare,4498.2,35,,4498.2,percent of total billed charges,Implant Device,4369.68,34,"Charges > $500, x 34%",4369.68,percent of total billed charges,Implant Device,4498.2,35,,4498.2,percent of total billed charges,Implant Device,4498.2,35,,4498.2,percent of total billed charges,Implant Device,4498.2,35,,4498.2,percent of total billed charges,Implant Device,4498.2,35,,4498.2,percent of total billed charges,Implant Device,4498.2,35,,4498.2,percent of total billed charges,Implant Device,5140.8,40,,5140.8,percent of total billed charges,Implant Device,4498.2,70,,4498.2,percent of total billed charges,All Other,4369.68,34,,4369.68,percent of total billed charges,Implant Device,4369.68,34,,4369.68,percent of total billed charges,Implant Device,4498.2,35,,4498.2,percent of total billed charges,Implant Device,4498.2,35,,4498.2,percent of total billed charges,Implant Device,4498.2,35,,4498.2,percent of total billed charges,Implant Device,4498.2,35,,4498.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,4369.68,34,"If Charge > 2,000, then 34 percent",4369.68,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,9510.51,
S&N 74023247 ART SURF 27MM SZ 3-4 LEFT,C1776,HCPCS,,79008265,CDM,278,RC,,,both,,,5625,4162.51,,,4162.51,Other,150% of Medicare + 9.63% HCRA Surcharge,2531.25,45,,2531.25,percent of total billed charges,Critical Access Hospital RCC factor,1912.5,34,,1912.5,percent of total billed charges,Implant Device,1912.5,34,,1912.5,percent of total billed charges,Implant Device,1912.5,34,,1912.5,percent of total billed charges,Implant Device,1912.5,34,,1912.5,percent of total billed charges,Implant Device,1912.5,34,,1912.5,percent of total billed charges,Implant Device,2784.38,,,2784.38,Other,110% of Medicare,1968.75,35,,1968.75,percent of total billed charges,Implant Device,1912.5,34,"Charges > $500, x 34%",1912.5,percent of total billed charges,Implant Device,1968.75,35,,1968.75,percent of total billed charges,Implant Device,1968.75,35,,1968.75,percent of total billed charges,Implant Device,1968.75,35,,1968.75,percent of total billed charges,Implant Device,1968.75,35,,1968.75,percent of total billed charges,Implant Device,1968.75,35,,1968.75,percent of total billed charges,Implant Device,2250,40,,2250,percent of total billed charges,Implant Device,1968.75,70,,1968.75,percent of total billed charges,All Other,1912.5,34,,1912.5,percent of total billed charges,Implant Device,1912.5,34,,1912.5,percent of total billed charges,Implant Device,1968.75,35,,1968.75,percent of total billed charges,Implant Device,1968.75,35,,1968.75,percent of total billed charges,Implant Device,1968.75,35,,1968.75,percent of total billed charges,Implant Device,1968.75,35,,1968.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1912.5,34,"If Charge > 2,000, then 34 percent",1912.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4162.51,
STRYKER 57-10304 1.7MM 4 HOLE LOCK PLATE,C1713,HCPCS,,79008266,CDM,278,RC,,,both,,,1506,1114.44,,,1114.44,Other,150% of Medicare + 9.63% HCRA Surcharge,677.7,45,,677.7,percent of total billed charges,Critical Access Hospital RCC factor,512.04,34,,512.04,percent of total billed charges,Implant Device,512.04,34,,512.04,percent of total billed charges,Implant Device,512.04,34,,512.04,percent of total billed charges,Implant Device,512.04,34,,512.04,percent of total billed charges,Implant Device,512.04,34,,512.04,percent of total billed charges,Implant Device,745.47,,,745.47,Other,110% of Medicare,527.1,35,,527.1,percent of total billed charges,Implant Device,512.04,34,"Charges > $500, x 34%",512.04,percent of total billed charges,Implant Device,527.1,35,,527.1,percent of total billed charges,Implant Device,527.1,35,,527.1,percent of total billed charges,Implant Device,527.1,35,,527.1,percent of total billed charges,Implant Device,527.1,35,,527.1,percent of total billed charges,Implant Device,527.1,35,,527.1,percent of total billed charges,Implant Device,602.4,40,,602.4,percent of total billed charges,Implant Device,527.1,70,,527.1,percent of total billed charges,All Other,512.04,34,,512.04,percent of total billed charges,Implant Device,512.04,34,,512.04,percent of total billed charges,Implant Device,527.1,35,,527.1,percent of total billed charges,Implant Device,527.1,35,,527.1,percent of total billed charges,Implant Device,527.1,35,,527.1,percent of total billed charges,Implant Device,527.1,35,,527.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1114.44,
STRYKER 53-17005E 1.7X5MM LOCKING SCREWS,C1713,HCPCS,,79008267,CDM,278,RC,,,both,,,423,313.02,,,313.02,Other,150% of Medicare + 9.63% HCRA Surcharge,190.35,45,,190.35,percent of total billed charges,Critical Access Hospital RCC factor,143.82,34,,143.82,percent of total billed charges,Implant Device,143.82,34,,143.82,percent of total billed charges,Implant Device,143.82,34,,143.82,percent of total billed charges,Implant Device,143.82,34,,143.82,percent of total billed charges,Implant Device,143.82,34,,143.82,percent of total billed charges,Implant Device,209.39,,,209.39,Other,110% of Medicare,148.05,35,,148.05,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,148.05,35,,148.05,percent of total billed charges,Implant Device,148.05,35,,148.05,percent of total billed charges,Implant Device,148.05,35,,148.05,percent of total billed charges,Implant Device,148.05,35,,148.05,percent of total billed charges,Implant Device,148.05,35,,148.05,percent of total billed charges,Implant Device,169.2,40,,169.2,percent of total billed charges,Implant Device,148.05,70,,148.05,percent of total billed charges,All Other,143.82,34,,143.82,percent of total billed charges,Implant Device,143.82,34,,143.82,percent of total billed charges,Implant Device,148.05,35,,148.05,percent of total billed charges,Implant Device,148.05,35,,148.05,percent of total billed charges,Implant Device,148.05,35,,148.05,percent of total billed charges,Implant Device,148.05,35,,148.05,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,313.02,
STRYKER 53-17007E 1.7X7MM LOCKING SCREWS,C1713,HCPCS,,79008268,CDM,278,RC,,,both,,,241,178.34,,,178.34,Other,150% of Medicare + 9.63% HCRA Surcharge,108.45,45,,108.45,percent of total billed charges,Critical Access Hospital RCC factor,81.94,34,,81.94,percent of total billed charges,Implant Device,81.94,34,,81.94,percent of total billed charges,Implant Device,81.94,34,,81.94,percent of total billed charges,Implant Device,81.94,34,,81.94,percent of total billed charges,Implant Device,81.94,34,,81.94,percent of total billed charges,Implant Device,119.3,,,119.3,Other,110% of Medicare,84.35,35,,84.35,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,84.35,35,,84.35,percent of total billed charges,Implant Device,84.35,35,,84.35,percent of total billed charges,Implant Device,84.35,35,,84.35,percent of total billed charges,Implant Device,84.35,35,,84.35,percent of total billed charges,Implant Device,84.35,35,,84.35,percent of total billed charges,Implant Device,96.4,40,,96.4,percent of total billed charges,Implant Device,84.35,70,,84.35,percent of total billed charges,All Other,81.94,34,,81.94,percent of total billed charges,Implant Device,81.94,34,,81.94,percent of total billed charges,Implant Device,84.35,35,,84.35,percent of total billed charges,Implant Device,84.35,35,,84.35,percent of total billed charges,Implant Device,84.35,35,,84.35,percent of total billed charges,Implant Device,84.35,35,,84.35,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,178.34,
STRYKER 54-25684 VDR PLATE RIGHT SHORT,C1713,HCPCS,,79008269,CDM,278,RC,,,both,,,2604,1926.97,,,1926.97,Other,150% of Medicare + 9.63% HCRA Surcharge,1171.8,45,,1171.8,percent of total billed charges,Critical Access Hospital RCC factor,885.36,34,,885.36,percent of total billed charges,Implant Device,885.36,34,,885.36,percent of total billed charges,Implant Device,885.36,34,,885.36,percent of total billed charges,Implant Device,885.36,34,,885.36,percent of total billed charges,Implant Device,885.36,34,,885.36,percent of total billed charges,Implant Device,1288.98,,,1288.98,Other,110% of Medicare,911.4,35,,911.4,percent of total billed charges,Implant Device,885.36,34,"Charges > $500, x 34%",885.36,percent of total billed charges,Implant Device,911.4,35,,911.4,percent of total billed charges,Implant Device,911.4,35,,911.4,percent of total billed charges,Implant Device,911.4,35,,911.4,percent of total billed charges,Implant Device,911.4,35,,911.4,percent of total billed charges,Implant Device,911.4,35,,911.4,percent of total billed charges,Implant Device,1041.6,40,,1041.6,percent of total billed charges,Implant Device,911.4,70,,911.4,percent of total billed charges,All Other,885.36,34,,885.36,percent of total billed charges,Implant Device,885.36,34,,885.36,percent of total billed charges,Implant Device,911.4,35,,911.4,percent of total billed charges,Implant Device,911.4,35,,911.4,percent of total billed charges,Implant Device,911.4,35,,911.4,percent of total billed charges,Implant Device,911.4,35,,911.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,885.36,34,"If Charge > 2,000, then 34 percent",885.36,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1926.97,
STRYKER 656114 NONLOCKING SCREW 2.4X14MM,C1713,HCPCS,,79008270,CDM,278,RC,,,both,,,282,208.68,,,208.68,Other,150% of Medicare + 9.63% HCRA Surcharge,126.9,45,,126.9,percent of total billed charges,Critical Access Hospital RCC factor,95.88,34,,95.88,percent of total billed charges,Implant Device,95.88,34,,95.88,percent of total billed charges,Implant Device,95.88,34,,95.88,percent of total billed charges,Implant Device,95.88,34,,95.88,percent of total billed charges,Implant Device,95.88,34,,95.88,percent of total billed charges,Implant Device,139.59,,,139.59,Other,110% of Medicare,98.7,35,,98.7,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,98.7,35,,98.7,percent of total billed charges,Implant Device,98.7,35,,98.7,percent of total billed charges,Implant Device,98.7,35,,98.7,percent of total billed charges,Implant Device,98.7,35,,98.7,percent of total billed charges,Implant Device,98.7,35,,98.7,percent of total billed charges,Implant Device,112.8,40,,112.8,percent of total billed charges,Implant Device,98.7,70,,98.7,percent of total billed charges,All Other,95.88,34,,95.88,percent of total billed charges,Implant Device,95.88,34,,95.88,percent of total billed charges,Implant Device,98.7,35,,98.7,percent of total billed charges,Implant Device,98.7,35,,98.7,percent of total billed charges,Implant Device,98.7,35,,98.7,percent of total billed charges,Implant Device,98.7,35,,98.7,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,208.68,
EXACTECH 308-02-09 HUM DIST STEM 9X120MM,C1776,HCPCS,,79008274,CDM,278,RC,,,both,,,16020,11854.84,,,11854.84,Other,150% of Medicare + 9.63% HCRA Surcharge,7209,45,,7209,percent of total billed charges,Critical Access Hospital RCC factor,5446.8,34,,5446.8,percent of total billed charges,Implant Device,5446.8,34,,5446.8,percent of total billed charges,Implant Device,5446.8,34,,5446.8,percent of total billed charges,Implant Device,5446.8,34,,5446.8,percent of total billed charges,Implant Device,5446.8,34,,5446.8,percent of total billed charges,Implant Device,7929.9,,,7929.9,Other,110% of Medicare,5607,35,,5607,percent of total billed charges,Implant Device,5446.8,34,"Charges > $500, x 34%",5446.8,percent of total billed charges,Implant Device,5607,35,,5607,percent of total billed charges,Implant Device,5607,35,,5607,percent of total billed charges,Implant Device,5607,35,,5607,percent of total billed charges,Implant Device,5607,35,,5607,percent of total billed charges,Implant Device,5607,35,,5607,percent of total billed charges,Implant Device,6408,40,,6408,percent of total billed charges,Implant Device,5607,70,,5607,percent of total billed charges,All Other,5446.8,34,,5446.8,percent of total billed charges,Implant Device,5446.8,34,,5446.8,percent of total billed charges,Implant Device,5607,35,,5607,percent of total billed charges,Implant Device,5607,35,,5607,percent of total billed charges,Implant Device,5607,35,,5607,percent of total billed charges,Implant Device,5607,35,,5607,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,5446.8,34,"If Charge > 2,000, then 34 percent",5446.8,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,11854.84,
EXACTECH 308-05-18 HUM FIXTN RING 18.5MM,C1776,HCPCS,,79008275,CDM,278,RC,,,both,,,5145,3807.31,,,3807.31,Other,150% of Medicare + 9.63% HCRA Surcharge,2315.25,45,,2315.25,percent of total billed charges,Critical Access Hospital RCC factor,1749.3,34,,1749.3,percent of total billed charges,Implant Device,1749.3,34,,1749.3,percent of total billed charges,Implant Device,1749.3,34,,1749.3,percent of total billed charges,Implant Device,1749.3,34,,1749.3,percent of total billed charges,Implant Device,1749.3,34,,1749.3,percent of total billed charges,Implant Device,2546.78,,,2546.78,Other,110% of Medicare,1800.75,35,,1800.75,percent of total billed charges,Implant Device,1749.3,34,"Charges > $500, x 34%",1749.3,percent of total billed charges,Implant Device,1800.75,35,,1800.75,percent of total billed charges,Implant Device,1800.75,35,,1800.75,percent of total billed charges,Implant Device,1800.75,35,,1800.75,percent of total billed charges,Implant Device,1800.75,35,,1800.75,percent of total billed charges,Implant Device,1800.75,35,,1800.75,percent of total billed charges,Implant Device,2058,40,,2058,percent of total billed charges,Implant Device,1800.75,70,,1800.75,percent of total billed charges,All Other,1749.3,34,,1749.3,percent of total billed charges,Implant Device,1749.3,34,,1749.3,percent of total billed charges,Implant Device,1800.75,35,,1800.75,percent of total billed charges,Implant Device,1800.75,35,,1800.75,percent of total billed charges,Implant Device,1800.75,35,,1800.75,percent of total billed charges,Implant Device,1800.75,35,,1800.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1749.3,34,"If Charge > 2,000, then 34 percent",1749.3,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3807.31,
EXACTECH 308-10-50 HUM MID SEGMENT 50MM,C1776,HCPCS,,79008276,CDM,278,RC,,,both,,,30210,22355.48,,,22355.48,Other,150% of Medicare + 9.63% HCRA Surcharge,13594.5,45,,13594.5,percent of total billed charges,Critical Access Hospital RCC factor,10271.4,34,,10271.4,percent of total billed charges,Implant Device,10271.4,34,,10271.4,percent of total billed charges,Implant Device,10271.4,34,,10271.4,percent of total billed charges,Implant Device,10271.4,34,,10271.4,percent of total billed charges,Implant Device,10271.4,34,,10271.4,percent of total billed charges,Implant Device,14953.95,,,14953.95,Other,110% of Medicare,10573.5,35,,10573.5,percent of total billed charges,Implant Device,10271.4,34,"Charges > $500, x 34%",10271.4,percent of total billed charges,Implant Device,10573.5,35,,10573.5,percent of total billed charges,Implant Device,10573.5,35,,10573.5,percent of total billed charges,Implant Device,10573.5,35,,10573.5,percent of total billed charges,Implant Device,10573.5,35,,10573.5,percent of total billed charges,Implant Device,10573.5,35,,10573.5,percent of total billed charges,Implant Device,12084,40,,12084,percent of total billed charges,Implant Device,10573.5,70,,10573.5,percent of total billed charges,All Other,10271.4,34,,10271.4,percent of total billed charges,Implant Device,10271.4,34,,10271.4,percent of total billed charges,Implant Device,10573.5,35,,10573.5,percent of total billed charges,Implant Device,10573.5,35,,10573.5,percent of total billed charges,Implant Device,10573.5,35,,10573.5,percent of total billed charges,Implant Device,10573.5,35,,10573.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,10271.4,34,"If Charge > 2,000, then 34 percent",10271.4,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,22355.48,
EXACTECH 308-09-00 HUM PROX BODY SM +0MM,C1776,HCPCS,,79008277,CDM,278,RC,,,both,,,16725,12376.54,,,12376.54,Other,150% of Medicare + 9.63% HCRA Surcharge,7526.25,45,,7526.25,percent of total billed charges,Critical Access Hospital RCC factor,5686.5,34,,5686.5,percent of total billed charges,Implant Device,5686.5,34,,5686.5,percent of total billed charges,Implant Device,5686.5,34,,5686.5,percent of total billed charges,Implant Device,5686.5,34,,5686.5,percent of total billed charges,Implant Device,5686.5,34,,5686.5,percent of total billed charges,Implant Device,8278.88,,,8278.88,Other,110% of Medicare,5853.75,35,,5853.75,percent of total billed charges,Implant Device,5686.5,34,"Charges > $500, x 34%",5686.5,percent of total billed charges,Implant Device,5853.75,35,,5853.75,percent of total billed charges,Implant Device,5853.75,35,,5853.75,percent of total billed charges,Implant Device,5853.75,35,,5853.75,percent of total billed charges,Implant Device,5853.75,35,,5853.75,percent of total billed charges,Implant Device,5853.75,35,,5853.75,percent of total billed charges,Implant Device,6690,40,,6690,percent of total billed charges,Implant Device,5853.75,70,,5853.75,percent of total billed charges,All Other,5686.5,34,,5686.5,percent of total billed charges,Implant Device,5686.5,34,,5686.5,percent of total billed charges,Implant Device,5853.75,35,,5853.75,percent of total billed charges,Implant Device,5853.75,35,,5853.75,percent of total billed charges,Implant Device,5853.75,35,,5853.75,percent of total billed charges,Implant Device,5853.75,35,,5853.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,5686.5,34,"If Charge > 2,000, then 34 percent",5686.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,12376.54,
EXACTECH 308-15-50 HUM LOCK SCREW SZ 50,C1713,HCPCS,,79008278,CDM,278,RC,,,both,,,1701,1258.74,,,1258.74,Other,150% of Medicare + 9.63% HCRA Surcharge,765.45,45,,765.45,percent of total billed charges,Critical Access Hospital RCC factor,578.34,34,,578.34,percent of total billed charges,Implant Device,578.34,34,,578.34,percent of total billed charges,Implant Device,578.34,34,,578.34,percent of total billed charges,Implant Device,578.34,34,,578.34,percent of total billed charges,Implant Device,578.34,34,,578.34,percent of total billed charges,Implant Device,842,,,842,Other,110% of Medicare,595.35,35,,595.35,percent of total billed charges,Implant Device,578.34,34,"Charges > $500, x 34%",578.34,percent of total billed charges,Implant Device,595.35,35,,595.35,percent of total billed charges,Implant Device,595.35,35,,595.35,percent of total billed charges,Implant Device,595.35,35,,595.35,percent of total billed charges,Implant Device,595.35,35,,595.35,percent of total billed charges,Implant Device,595.35,35,,595.35,percent of total billed charges,Implant Device,680.4,40,,680.4,percent of total billed charges,Implant Device,595.35,70,,595.35,percent of total billed charges,All Other,578.34,34,,578.34,percent of total billed charges,Implant Device,578.34,34,,578.34,percent of total billed charges,Implant Device,595.35,35,,595.35,percent of total billed charges,Implant Device,595.35,35,,595.35,percent of total billed charges,Implant Device,595.35,35,,595.35,percent of total billed charges,Implant Device,595.35,35,,595.35,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1258.74,
EXACTECH 320-38-10 HUMERAL LINER 38MM +0,C1776,HCPCS,,79008279,CDM,278,RC,,,both,,,2835,2097.91,,,2097.91,Other,150% of Medicare + 9.63% HCRA Surcharge,1275.75,45,,1275.75,percent of total billed charges,Critical Access Hospital RCC factor,963.9,34,,963.9,percent of total billed charges,Implant Device,963.9,34,,963.9,percent of total billed charges,Implant Device,963.9,34,,963.9,percent of total billed charges,Implant Device,963.9,34,,963.9,percent of total billed charges,Implant Device,963.9,34,,963.9,percent of total billed charges,Implant Device,1403.33,,,1403.33,Other,110% of Medicare,992.25,35,,992.25,percent of total billed charges,Implant Device,963.9,34,"Charges > $500, x 34%",963.9,percent of total billed charges,Implant Device,992.25,35,,992.25,percent of total billed charges,Implant Device,992.25,35,,992.25,percent of total billed charges,Implant Device,992.25,35,,992.25,percent of total billed charges,Implant Device,992.25,35,,992.25,percent of total billed charges,Implant Device,992.25,35,,992.25,percent of total billed charges,Implant Device,1134,40,,1134,percent of total billed charges,Implant Device,992.25,70,,992.25,percent of total billed charges,All Other,963.9,34,,963.9,percent of total billed charges,Implant Device,963.9,34,,963.9,percent of total billed charges,Implant Device,992.25,35,,992.25,percent of total billed charges,Implant Device,992.25,35,,992.25,percent of total billed charges,Implant Device,992.25,35,,992.25,percent of total billed charges,Implant Device,992.25,35,,992.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,963.9,34,"If Charge > 2,000, then 34 percent",963.9,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2097.91,
STRYKER 40-35048 3.5X48MM CORTICAL SCREW,C1713,HCPCS,,79008285,CDM,278,RC,,,both,,,192,142.08,,,142.08,Other,150% of Medicare + 9.63% HCRA Surcharge,86.4,45,,86.4,percent of total billed charges,Critical Access Hospital RCC factor,65.28,34,,65.28,percent of total billed charges,Implant Device,65.28,34,,65.28,percent of total billed charges,Implant Device,65.28,34,,65.28,percent of total billed charges,Implant Device,65.28,34,,65.28,percent of total billed charges,Implant Device,65.28,34,,65.28,percent of total billed charges,Implant Device,95.04,,,95.04,Other,110% of Medicare,67.2,35,,67.2,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,67.2,35,,67.2,percent of total billed charges,Implant Device,67.2,35,,67.2,percent of total billed charges,Implant Device,67.2,35,,67.2,percent of total billed charges,Implant Device,67.2,35,,67.2,percent of total billed charges,Implant Device,67.2,35,,67.2,percent of total billed charges,Implant Device,76.8,40,,76.8,percent of total billed charges,Implant Device,67.2,70,,67.2,percent of total billed charges,All Other,65.28,34,,65.28,percent of total billed charges,Implant Device,65.28,34,,65.28,percent of total billed charges,Implant Device,67.2,35,,67.2,percent of total billed charges,Implant Device,67.2,35,,67.2,percent of total billed charges,Implant Device,67.2,35,,67.2,percent of total billed charges,Implant Device,67.2,35,,67.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,142.08,
STRYKER 40-35048 3.5X48MM CORTICAL SCREW,C1713,HCPCS,,79008286,CDM,278,RC,,,both,,,354,261.96,,,261.96,Other,150% of Medicare + 9.63% HCRA Surcharge,159.3,45,,159.3,percent of total billed charges,Critical Access Hospital RCC factor,120.36,34,,120.36,percent of total billed charges,Implant Device,120.36,34,,120.36,percent of total billed charges,Implant Device,120.36,34,,120.36,percent of total billed charges,Implant Device,120.36,34,,120.36,percent of total billed charges,Implant Device,120.36,34,,120.36,percent of total billed charges,Implant Device,175.23,,,175.23,Other,110% of Medicare,123.9,35,,123.9,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,123.9,35,,123.9,percent of total billed charges,Implant Device,123.9,35,,123.9,percent of total billed charges,Implant Device,123.9,35,,123.9,percent of total billed charges,Implant Device,123.9,35,,123.9,percent of total billed charges,Implant Device,123.9,35,,123.9,percent of total billed charges,Implant Device,141.6,40,,141.6,percent of total billed charges,Implant Device,123.9,70,,123.9,percent of total billed charges,All Other,120.36,34,,120.36,percent of total billed charges,Implant Device,120.36,34,,120.36,percent of total billed charges,Implant Device,123.9,35,,123.9,percent of total billed charges,Implant Device,123.9,35,,123.9,percent of total billed charges,Implant Device,123.9,35,,123.9,percent of total billed charges,Implant Device,123.9,35,,123.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,261.96,
BIOMET 01-7100 PLATE 5 HOLE Y REGULAR,C1713,HCPCS,,79008287,CDM,278,RC,,,both,,,912,674.88,,,674.88,Other,150% of Medicare + 9.63% HCRA Surcharge,410.4,45,,410.4,percent of total billed charges,Critical Access Hospital RCC factor,310.08,34,,310.08,percent of total billed charges,Implant Device,310.08,34,,310.08,percent of total billed charges,Implant Device,310.08,34,,310.08,percent of total billed charges,Implant Device,310.08,34,,310.08,percent of total billed charges,Implant Device,310.08,34,,310.08,percent of total billed charges,Implant Device,451.44,,,451.44,Other,110% of Medicare,319.2,35,,319.2,percent of total billed charges,Implant Device,310.08,34,"Charges > $500, x 34%",310.08,percent of total billed charges,Implant Device,319.2,35,,319.2,percent of total billed charges,Implant Device,319.2,35,,319.2,percent of total billed charges,Implant Device,319.2,35,,319.2,percent of total billed charges,Implant Device,319.2,35,,319.2,percent of total billed charges,Implant Device,319.2,35,,319.2,percent of total billed charges,Implant Device,364.8,40,,364.8,percent of total billed charges,Implant Device,319.2,70,,319.2,percent of total billed charges,All Other,310.08,34,,310.08,percent of total billed charges,Implant Device,310.08,34,,310.08,percent of total billed charges,Implant Device,319.2,35,,319.2,percent of total billed charges,Implant Device,319.2,35,,319.2,percent of total billed charges,Implant Device,319.2,35,,319.2,percent of total billed charges,Implant Device,319.2,35,,319.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,674.88,
BIOMET 91-1506 SCREW 1.5X6MM,C1713,HCPCS,,79008288,CDM,278,RC,,,both,,,285,210.9,,,210.9,Other,150% of Medicare + 9.63% HCRA Surcharge,128.25,45,,128.25,percent of total billed charges,Critical Access Hospital RCC factor,96.9,34,,96.9,percent of total billed charges,Implant Device,96.9,34,,96.9,percent of total billed charges,Implant Device,96.9,34,,96.9,percent of total billed charges,Implant Device,96.9,34,,96.9,percent of total billed charges,Implant Device,96.9,34,,96.9,percent of total billed charges,Implant Device,141.08,,,141.08,Other,110% of Medicare,99.75,35,,99.75,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,99.75,35,,99.75,percent of total billed charges,Implant Device,99.75,35,,99.75,percent of total billed charges,Implant Device,99.75,35,,99.75,percent of total billed charges,Implant Device,99.75,35,,99.75,percent of total billed charges,Implant Device,99.75,35,,99.75,percent of total billed charges,Implant Device,114,40,,114,percent of total billed charges,Implant Device,99.75,70,,99.75,percent of total billed charges,All Other,96.9,34,,96.9,percent of total billed charges,Implant Device,96.9,34,,96.9,percent of total billed charges,Implant Device,99.75,35,,99.75,percent of total billed charges,Implant Device,99.75,35,,99.75,percent of total billed charges,Implant Device,99.75,35,,99.75,percent of total billed charges,Implant Device,99.75,35,,99.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,210.9,
BIOMET 91-1504 SCREW 1.5X4MM,C1713,HCPCS,,79008289,CDM,278,RC,,,both,,,285,210.9,,,210.9,Other,150% of Medicare + 9.63% HCRA Surcharge,128.25,45,,128.25,percent of total billed charges,Critical Access Hospital RCC factor,96.9,34,,96.9,percent of total billed charges,Implant Device,96.9,34,,96.9,percent of total billed charges,Implant Device,96.9,34,,96.9,percent of total billed charges,Implant Device,96.9,34,,96.9,percent of total billed charges,Implant Device,96.9,34,,96.9,percent of total billed charges,Implant Device,141.08,,,141.08,Other,110% of Medicare,99.75,35,,99.75,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,99.75,35,,99.75,percent of total billed charges,Implant Device,99.75,35,,99.75,percent of total billed charges,Implant Device,99.75,35,,99.75,percent of total billed charges,Implant Device,99.75,35,,99.75,percent of total billed charges,Implant Device,99.75,35,,99.75,percent of total billed charges,Implant Device,114,40,,114,percent of total billed charges,Implant Device,99.75,70,,99.75,percent of total billed charges,All Other,96.9,34,,96.9,percent of total billed charges,Implant Device,96.9,34,,96.9,percent of total billed charges,Implant Device,99.75,35,,99.75,percent of total billed charges,Implant Device,99.75,35,,99.75,percent of total billed charges,Implant Device,99.75,35,,99.75,percent of total billed charges,Implant Device,99.75,35,,99.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,210.9,
DEPUY 09.402.422S RADIAL HEAD 22X4X16.5,C1776,HCPCS,,79008291,CDM,278,RC,,,both,,,6996,5177.06,,,5177.06,Other,150% of Medicare + 9.63% HCRA Surcharge,3148.2,45,,3148.2,percent of total billed charges,Critical Access Hospital RCC factor,2378.64,34,,2378.64,percent of total billed charges,Implant Device,2378.64,34,,2378.64,percent of total billed charges,Implant Device,2378.64,34,,2378.64,percent of total billed charges,Implant Device,2378.64,34,,2378.64,percent of total billed charges,Implant Device,2378.64,34,,2378.64,percent of total billed charges,Implant Device,3463.02,,,3463.02,Other,110% of Medicare,2448.6,35,,2448.6,percent of total billed charges,Implant Device,2378.64,34,"Charges > $500, x 34%",2378.64,percent of total billed charges,Implant Device,2448.6,35,,2448.6,percent of total billed charges,Implant Device,2448.6,35,,2448.6,percent of total billed charges,Implant Device,2448.6,35,,2448.6,percent of total billed charges,Implant Device,2448.6,35,,2448.6,percent of total billed charges,Implant Device,2448.6,35,,2448.6,percent of total billed charges,Implant Device,2798.4,40,,2798.4,percent of total billed charges,Implant Device,2448.6,70,,2448.6,percent of total billed charges,All Other,2378.64,34,,2378.64,percent of total billed charges,Implant Device,2378.64,34,,2378.64,percent of total billed charges,Implant Device,2448.6,35,,2448.6,percent of total billed charges,Implant Device,2448.6,35,,2448.6,percent of total billed charges,Implant Device,2448.6,35,,2448.6,percent of total billed charges,Implant Device,2448.6,35,,2448.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2378.64,34,"If Charge > 2,000, then 34 percent",2378.64,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5177.06,
DEPUY 04.402.009S RADIAL STEM 9X30MM,C1776,HCPCS,,79008292,CDM,278,RC,,,both,,,6996,5177.06,,,5177.06,Other,150% of Medicare + 9.63% HCRA Surcharge,3148.2,45,,3148.2,percent of total billed charges,Critical Access Hospital RCC factor,2378.64,34,,2378.64,percent of total billed charges,Implant Device,2378.64,34,,2378.64,percent of total billed charges,Implant Device,2378.64,34,,2378.64,percent of total billed charges,Implant Device,2378.64,34,,2378.64,percent of total billed charges,Implant Device,2378.64,34,,2378.64,percent of total billed charges,Implant Device,3463.02,,,3463.02,Other,110% of Medicare,2448.6,35,,2448.6,percent of total billed charges,Implant Device,2378.64,34,"Charges > $500, x 34%",2378.64,percent of total billed charges,Implant Device,2448.6,35,,2448.6,percent of total billed charges,Implant Device,2448.6,35,,2448.6,percent of total billed charges,Implant Device,2448.6,35,,2448.6,percent of total billed charges,Implant Device,2448.6,35,,2448.6,percent of total billed charges,Implant Device,2448.6,35,,2448.6,percent of total billed charges,Implant Device,2798.4,40,,2798.4,percent of total billed charges,Implant Device,2448.6,70,,2448.6,percent of total billed charges,All Other,2378.64,34,,2378.64,percent of total billed charges,Implant Device,2378.64,34,,2378.64,percent of total billed charges,Implant Device,2448.6,35,,2448.6,percent of total billed charges,Implant Device,2448.6,35,,2448.6,percent of total billed charges,Implant Device,2448.6,35,,2448.6,percent of total billed charges,Implant Device,2448.6,35,,2448.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2378.64,34,"If Charge > 2,000, then 34 percent",2378.64,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5177.06,
DEPUY 02.111.530 PLATE 2.4MM 6 HOLE RT,C1713,HCPCS,,79008293,CDM,278,RC,,,both,,,2323,1719.03,,,1719.03,Other,150% of Medicare + 9.63% HCRA Surcharge,1045.35,45,,1045.35,percent of total billed charges,Critical Access Hospital RCC factor,789.82,34,,789.82,percent of total billed charges,Implant Device,789.82,34,,789.82,percent of total billed charges,Implant Device,789.82,34,,789.82,percent of total billed charges,Implant Device,789.82,34,,789.82,percent of total billed charges,Implant Device,789.82,34,,789.82,percent of total billed charges,Implant Device,1149.89,,,1149.89,Other,110% of Medicare,813.05,35,,813.05,percent of total billed charges,Implant Device,789.82,34,"Charges > $500, x 34%",789.82,percent of total billed charges,Implant Device,813.05,35,,813.05,percent of total billed charges,Implant Device,813.05,35,,813.05,percent of total billed charges,Implant Device,813.05,35,,813.05,percent of total billed charges,Implant Device,813.05,35,,813.05,percent of total billed charges,Implant Device,813.05,35,,813.05,percent of total billed charges,Implant Device,929.2,40,,929.2,percent of total billed charges,Implant Device,813.05,70,,813.05,percent of total billed charges,All Other,789.82,34,,789.82,percent of total billed charges,Implant Device,789.82,34,,789.82,percent of total billed charges,Implant Device,813.05,35,,813.05,percent of total billed charges,Implant Device,813.05,35,,813.05,percent of total billed charges,Implant Device,813.05,35,,813.05,percent of total billed charges,Implant Device,813.05,35,,813.05,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,789.82,34,"If Charge > 2,000, then 34 percent",789.82,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1719.03,
BOST SCI 22-140 NEPHRO STENT 10FRX22CM,C2617,HCPCS,,79008297,CDM,278,RC,,,both,,,316,233.84,,,233.84,Other,150% of Medicare + 9.63% HCRA Surcharge,142.2,45,,142.2,percent of total billed charges,Critical Access Hospital RCC factor,107.44,34,,107.44,percent of total billed charges,Implant Device,107.44,34,,107.44,percent of total billed charges,Implant Device,107.44,34,,107.44,percent of total billed charges,Implant Device,107.44,34,,107.44,percent of total billed charges,Implant Device,107.44,34,,107.44,percent of total billed charges,Implant Device,156.42,,,156.42,Other,110% of Medicare,110.6,35,,110.6,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,110.6,35,,110.6,percent of total billed charges,Implant Device,110.6,35,,110.6,percent of total billed charges,Implant Device,110.6,35,,110.6,percent of total billed charges,Implant Device,110.6,35,,110.6,percent of total billed charges,Implant Device,110.6,35,,110.6,percent of total billed charges,Implant Device,126.4,40,,126.4,percent of total billed charges,Implant Device,110.6,70,,110.6,percent of total billed charges,All Other,107.44,34,,107.44,percent of total billed charges,Implant Device,107.44,34,,107.44,percent of total billed charges,Implant Device,110.6,35,,110.6,percent of total billed charges,Implant Device,110.6,35,,110.6,percent of total billed charges,Implant Device,110.6,35,,110.6,percent of total billed charges,Implant Device,110.6,35,,110.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,233.84,
ALAMO PS290FD ACHILLES TENDON,C1762,HCPCS,,79008298,CDM,278,RC,,,both,,,6900,5106.02,,,5106.02,Other,150% of Medicare + 9.63% HCRA Surcharge,3105,45,,3105,percent of total billed charges,Critical Access Hospital RCC factor,2346,34,,2346,percent of total billed charges,Implant Device,2346,34,,2346,percent of total billed charges,Implant Device,2346,34,,2346,percent of total billed charges,Implant Device,2346,34,,2346,percent of total billed charges,Implant Device,2346,34,,2346,percent of total billed charges,Implant Device,3415.5,,,3415.5,Other,110% of Medicare,2415,35,,2415,percent of total billed charges,Implant Device,2346,34,"Charges > $500, x 34%",2346,percent of total billed charges,Implant Device,2415,35,,2415,percent of total billed charges,Implant Device,2415,35,,2415,percent of total billed charges,Implant Device,2415,35,,2415,percent of total billed charges,Implant Device,2415,35,,2415,percent of total billed charges,Implant Device,2415,35,,2415,percent of total billed charges,Implant Device,2760,40,,2760,percent of total billed charges,Implant Device,2415,70,,2415,percent of total billed charges,All Other,2346,34,,2346,percent of total billed charges,Implant Device,2346,34,,2346,percent of total billed charges,Implant Device,2415,35,,2415,percent of total billed charges,Implant Device,2415,35,,2415,percent of total billed charges,Implant Device,2415,35,,2415,percent of total billed charges,Implant Device,2415,35,,2415,percent of total billed charges,Implant Device,976.07,,,976.07,Other,100% of Medicaid,976.07,,,976.07,Other,100% of Medicaid,976.07,,,976.07,Other,100% of Medicaid,976.07,,,976.07,Other,100% of Medicaid,2196.16,,,2196.16,Other,225% of Medicaid,1493.39,,,1493.39,Other,153% of Medicaid,2196.16,,,2196.16,Other,225% of Medicaid,1366.5,,,1366.5,Other,140% of Medicaid,2346,34,"If Charge > 2,000, then 34 percent",2346,percent of total billed charges,Implants,2537.78,,,2537.78,Other,260% of Medicaid,3162.47,,,3162.47,Other,324% of Medicaid,2098.55,,,2098.55,Other,215% of Medicaid,2098.55,,,2098.55,Other,215% of Medicaid,1220.09,,,1220.09,Other,125% of Medicaid,976.07,5106.02,
DEPUY 1221-36-162 ACET LINER 36X62MM,C1776,HCPCS,,79008302,CDM,278,RC,,,both,,,4743,3509.83,,,3509.83,Other,150% of Medicare + 9.63% HCRA Surcharge,2134.35,45,,2134.35,percent of total billed charges,Critical Access Hospital RCC factor,1612.62,34,,1612.62,percent of total billed charges,Implant Device,1612.62,34,,1612.62,percent of total billed charges,Implant Device,1612.62,34,,1612.62,percent of total billed charges,Implant Device,1612.62,34,,1612.62,percent of total billed charges,Implant Device,1612.62,34,,1612.62,percent of total billed charges,Implant Device,2347.79,,,2347.79,Other,110% of Medicare,1660.05,35,,1660.05,percent of total billed charges,Implant Device,1612.62,34,"Charges > $500, x 34%",1612.62,percent of total billed charges,Implant Device,1660.05,35,,1660.05,percent of total billed charges,Implant Device,1660.05,35,,1660.05,percent of total billed charges,Implant Device,1660.05,35,,1660.05,percent of total billed charges,Implant Device,1660.05,35,,1660.05,percent of total billed charges,Implant Device,1660.05,35,,1660.05,percent of total billed charges,Implant Device,1897.2,40,,1897.2,percent of total billed charges,Implant Device,1660.05,70,,1660.05,percent of total billed charges,All Other,1612.62,34,,1612.62,percent of total billed charges,Implant Device,1612.62,34,,1612.62,percent of total billed charges,Implant Device,1660.05,35,,1660.05,percent of total billed charges,Implant Device,1660.05,35,,1660.05,percent of total billed charges,Implant Device,1660.05,35,,1660.05,percent of total billed charges,Implant Device,1660.05,35,,1660.05,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1612.62,34,"If Charge > 2,000, then 34 percent",1612.62,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3509.83,
BIMET 11-301315 CONE PRX BODY SZ E 60MM,C1776,HCPCS,,79008303,CDM,278,RC,,,both,,,36210,26795.49,,,26795.49,Other,150% of Medicare + 9.63% HCRA Surcharge,16294.5,45,,16294.5,percent of total billed charges,Critical Access Hospital RCC factor,12311.4,34,,12311.4,percent of total billed charges,Implant Device,12311.4,34,,12311.4,percent of total billed charges,Implant Device,12311.4,34,,12311.4,percent of total billed charges,Implant Device,12311.4,34,,12311.4,percent of total billed charges,Implant Device,12311.4,34,,12311.4,percent of total billed charges,Implant Device,17923.95,,,17923.95,Other,110% of Medicare,12673.5,35,,12673.5,percent of total billed charges,Implant Device,12311.4,34,"Charges > $500, x 34%",12311.4,percent of total billed charges,Implant Device,12673.5,35,,12673.5,percent of total billed charges,Implant Device,12673.5,35,,12673.5,percent of total billed charges,Implant Device,12673.5,35,,12673.5,percent of total billed charges,Implant Device,12673.5,35,,12673.5,percent of total billed charges,Implant Device,12673.5,35,,12673.5,percent of total billed charges,Implant Device,14484,40,,14484,percent of total billed charges,Implant Device,12673.5,70,,12673.5,percent of total billed charges,All Other,12311.4,34,,12311.4,percent of total billed charges,Implant Device,12311.4,34,,12311.4,percent of total billed charges,Implant Device,12673.5,35,,12673.5,percent of total billed charges,Implant Device,12673.5,35,,12673.5,percent of total billed charges,Implant Device,12673.5,35,,12673.5,percent of total billed charges,Implant Device,12673.5,35,,12673.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,12311.4,34,"If Charge > 2,000, then 34 percent",12311.4,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,26795.49,
BIOMET 8145-10-110 LAG SCREW 10.5X110MM,C1713,HCPCS,,79008304,CDM,278,RC,,,both,,,2052,1518.49,,,1518.49,Other,150% of Medicare + 9.63% HCRA Surcharge,923.4,45,,923.4,percent of total billed charges,Critical Access Hospital RCC factor,697.68,34,,697.68,percent of total billed charges,Implant Device,697.68,34,,697.68,percent of total billed charges,Implant Device,697.68,34,,697.68,percent of total billed charges,Implant Device,697.68,34,,697.68,percent of total billed charges,Implant Device,697.68,34,,697.68,percent of total billed charges,Implant Device,1015.74,,,1015.74,Other,110% of Medicare,718.2,35,,718.2,percent of total billed charges,Implant Device,697.68,34,"Charges > $500, x 34%",697.68,percent of total billed charges,Implant Device,718.2,35,,718.2,percent of total billed charges,Implant Device,718.2,35,,718.2,percent of total billed charges,Implant Device,718.2,35,,718.2,percent of total billed charges,Implant Device,718.2,35,,718.2,percent of total billed charges,Implant Device,718.2,35,,718.2,percent of total billed charges,Implant Device,820.8,40,,820.8,percent of total billed charges,Implant Device,718.2,70,,718.2,percent of total billed charges,All Other,697.68,34,,697.68,percent of total billed charges,Implant Device,697.68,34,,697.68,percent of total billed charges,Implant Device,718.2,35,,718.2,percent of total billed charges,Implant Device,718.2,35,,718.2,percent of total billed charges,Implant Device,718.2,35,,718.2,percent of total billed charges,Implant Device,718.2,35,,718.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,697.68,34,"If Charge > 2,000, then 34 percent",697.68,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1518.49,
BOIMET 8145-50-038 CORT BONE SCREW 5X38,C1713,HCPCS,,79008305,CDM,278,RC,,,both,,,594,439.56,,,439.56,Other,150% of Medicare + 9.63% HCRA Surcharge,267.3,45,,267.3,percent of total billed charges,Critical Access Hospital RCC factor,201.96,34,,201.96,percent of total billed charges,Implant Device,201.96,34,,201.96,percent of total billed charges,Implant Device,201.96,34,,201.96,percent of total billed charges,Implant Device,201.96,34,,201.96,percent of total billed charges,Implant Device,201.96,34,,201.96,percent of total billed charges,Implant Device,294.03,,,294.03,Other,110% of Medicare,207.9,35,,207.9,percent of total billed charges,Implant Device,201.96,34,"Charges > $500, x 34%",201.96,percent of total billed charges,Implant Device,207.9,35,,207.9,percent of total billed charges,Implant Device,207.9,35,,207.9,percent of total billed charges,Implant Device,207.9,35,,207.9,percent of total billed charges,Implant Device,207.9,35,,207.9,percent of total billed charges,Implant Device,207.9,35,,207.9,percent of total billed charges,Implant Device,237.6,40,,237.6,percent of total billed charges,Implant Device,207.9,70,,207.9,percent of total billed charges,All Other,201.96,34,,201.96,percent of total billed charges,Implant Device,201.96,34,,201.96,percent of total billed charges,Implant Device,207.9,35,,207.9,percent of total billed charges,Implant Device,207.9,35,,207.9,percent of total billed charges,Implant Device,207.9,35,,207.9,percent of total billed charges,Implant Device,207.9,35,,207.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,439.56,
DEPUY 02.240.026 CANNLOCK SCREW 3.7X26MM,C1713,HCPCS,,79008306,CDM,278,RC,,,both,,,476,352.24,,,352.24,Other,150% of Medicare + 9.63% HCRA Surcharge,214.2,45,,214.2,percent of total billed charges,Critical Access Hospital RCC factor,161.84,34,,161.84,percent of total billed charges,Implant Device,161.84,34,,161.84,percent of total billed charges,Implant Device,161.84,34,,161.84,percent of total billed charges,Implant Device,161.84,34,,161.84,percent of total billed charges,Implant Device,161.84,34,,161.84,percent of total billed charges,Implant Device,235.62,,,235.62,Other,110% of Medicare,166.6,35,,166.6,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,166.6,35,,166.6,percent of total billed charges,Implant Device,166.6,35,,166.6,percent of total billed charges,Implant Device,166.6,35,,166.6,percent of total billed charges,Implant Device,166.6,35,,166.6,percent of total billed charges,Implant Device,166.6,35,,166.6,percent of total billed charges,Implant Device,190.4,40,,190.4,percent of total billed charges,Implant Device,166.6,70,,166.6,percent of total billed charges,All Other,161.84,34,,161.84,percent of total billed charges,Implant Device,161.84,34,,161.84,percent of total billed charges,Implant Device,166.6,35,,166.6,percent of total billed charges,Implant Device,166.6,35,,166.6,percent of total billed charges,Implant Device,166.6,35,,166.6,percent of total billed charges,Implant Device,166.6,35,,166.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,352.24,
DEPUY 02.240.028 CANNLOCK SCREW 3.7X28MM,C1713,HCPCS,,79008307,CDM,278,RC,,,both,,,476,352.24,,,352.24,Other,150% of Medicare + 9.63% HCRA Surcharge,214.2,45,,214.2,percent of total billed charges,Critical Access Hospital RCC factor,161.84,34,,161.84,percent of total billed charges,Implant Device,161.84,34,,161.84,percent of total billed charges,Implant Device,161.84,34,,161.84,percent of total billed charges,Implant Device,161.84,34,,161.84,percent of total billed charges,Implant Device,161.84,34,,161.84,percent of total billed charges,Implant Device,235.62,,,235.62,Other,110% of Medicare,166.6,35,,166.6,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,166.6,35,,166.6,percent of total billed charges,Implant Device,166.6,35,,166.6,percent of total billed charges,Implant Device,166.6,35,,166.6,percent of total billed charges,Implant Device,166.6,35,,166.6,percent of total billed charges,Implant Device,166.6,35,,166.6,percent of total billed charges,Implant Device,190.4,40,,190.4,percent of total billed charges,Implant Device,166.6,70,,166.6,percent of total billed charges,All Other,161.84,34,,161.84,percent of total billed charges,Implant Device,161.84,34,,161.84,percent of total billed charges,Implant Device,166.6,35,,166.6,percent of total billed charges,Implant Device,166.6,35,,166.6,percent of total billed charges,Implant Device,166.6,35,,166.6,percent of total billed charges,Implant Device,166.6,35,,166.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,352.24,
STRYKER EZM12-10-10 EASYCLIP COMP SCREW,C1713,HCPCS,,79008308,CDM,278,RC,,,both,,,2132,1577.69,,,1577.69,Other,150% of Medicare + 9.63% HCRA Surcharge,959.4,45,,959.4,percent of total billed charges,Critical Access Hospital RCC factor,724.88,34,,724.88,percent of total billed charges,Implant Device,724.88,34,,724.88,percent of total billed charges,Implant Device,724.88,34,,724.88,percent of total billed charges,Implant Device,724.88,34,,724.88,percent of total billed charges,Implant Device,724.88,34,,724.88,percent of total billed charges,Implant Device,1055.34,,,1055.34,Other,110% of Medicare,746.2,35,,746.2,percent of total billed charges,Implant Device,724.88,34,"Charges > $500, x 34%",724.88,percent of total billed charges,Implant Device,746.2,35,,746.2,percent of total billed charges,Implant Device,746.2,35,,746.2,percent of total billed charges,Implant Device,746.2,35,,746.2,percent of total billed charges,Implant Device,746.2,35,,746.2,percent of total billed charges,Implant Device,746.2,35,,746.2,percent of total billed charges,Implant Device,852.8,40,,852.8,percent of total billed charges,Implant Device,746.2,70,,746.2,percent of total billed charges,All Other,724.88,34,,724.88,percent of total billed charges,Implant Device,724.88,34,,724.88,percent of total billed charges,Implant Device,746.2,35,,746.2,percent of total billed charges,Implant Device,746.2,35,,746.2,percent of total billed charges,Implant Device,746.2,35,,746.2,percent of total billed charges,Implant Device,746.2,35,,746.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,724.88,34,"If Charge > 2,000, then 34 percent",724.88,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1577.69,
ZIMMER 00-5990-037-10 AUG BLOCK GX5MM,C1776,HCPCS,,79008314,CDM,278,RC,,,both,,,2963,2192.63,,,2192.63,Other,150% of Medicare + 9.63% HCRA Surcharge,1333.35,45,,1333.35,percent of total billed charges,Critical Access Hospital RCC factor,1007.42,34,,1007.42,percent of total billed charges,Implant Device,1007.42,34,,1007.42,percent of total billed charges,Implant Device,1007.42,34,,1007.42,percent of total billed charges,Implant Device,1007.42,34,,1007.42,percent of total billed charges,Implant Device,1007.42,34,,1007.42,percent of total billed charges,Implant Device,1466.69,,,1466.69,Other,110% of Medicare,1037.05,35,,1037.05,percent of total billed charges,Implant Device,1007.42,34,"Charges > $500, x 34%",1007.42,percent of total billed charges,Implant Device,1037.05,35,,1037.05,percent of total billed charges,Implant Device,1037.05,35,,1037.05,percent of total billed charges,Implant Device,1037.05,35,,1037.05,percent of total billed charges,Implant Device,1037.05,35,,1037.05,percent of total billed charges,Implant Device,1037.05,35,,1037.05,percent of total billed charges,Implant Device,1185.2,40,,1185.2,percent of total billed charges,Implant Device,1037.05,70,,1037.05,percent of total billed charges,All Other,1007.42,34,,1007.42,percent of total billed charges,Implant Device,1007.42,34,,1007.42,percent of total billed charges,Implant Device,1037.05,35,,1037.05,percent of total billed charges,Implant Device,1037.05,35,,1037.05,percent of total billed charges,Implant Device,1037.05,35,,1037.05,percent of total billed charges,Implant Device,1037.05,35,,1037.05,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1007.42,34,"If Charge > 2,000, then 34 percent",1007.42,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2192.63,
ARTHREX AR-1370P INTERFEREN SCREW 7X23MM,C1713,HCPCS,,79008316,CDM,278,RC,,,both,,,1074,794.76,,,794.76,Other,150% of Medicare + 9.63% HCRA Surcharge,483.3,45,,483.3,percent of total billed charges,Critical Access Hospital RCC factor,365.16,34,,365.16,percent of total billed charges,Implant Device,365.16,34,,365.16,percent of total billed charges,Implant Device,365.16,34,,365.16,percent of total billed charges,Implant Device,365.16,34,,365.16,percent of total billed charges,Implant Device,365.16,34,,365.16,percent of total billed charges,Implant Device,531.63,,,531.63,Other,110% of Medicare,375.9,35,,375.9,percent of total billed charges,Implant Device,365.16,34,"Charges > $500, x 34%",365.16,percent of total billed charges,Implant Device,375.9,35,,375.9,percent of total billed charges,Implant Device,375.9,35,,375.9,percent of total billed charges,Implant Device,375.9,35,,375.9,percent of total billed charges,Implant Device,375.9,35,,375.9,percent of total billed charges,Implant Device,375.9,35,,375.9,percent of total billed charges,Implant Device,429.6,40,,429.6,percent of total billed charges,Implant Device,375.9,70,,375.9,percent of total billed charges,All Other,365.16,34,,365.16,percent of total billed charges,Implant Device,365.16,34,,365.16,percent of total billed charges,Implant Device,375.9,35,,375.9,percent of total billed charges,Implant Device,375.9,35,,375.9,percent of total billed charges,Implant Device,375.9,35,,375.9,percent of total billed charges,Implant Device,375.9,35,,375.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,794.76,
P 28 P20-535-032S 3.5X32MM CANN ST SCREW,C1713,HCPCS,,79008317,CDM,278,RC,,,both,,,1058,782.92,,,782.92,Other,150% of Medicare + 9.63% HCRA Surcharge,476.1,45,,476.1,percent of total billed charges,Critical Access Hospital RCC factor,359.72,34,,359.72,percent of total billed charges,Implant Device,359.72,34,,359.72,percent of total billed charges,Implant Device,359.72,34,,359.72,percent of total billed charges,Implant Device,359.72,34,,359.72,percent of total billed charges,Implant Device,359.72,34,,359.72,percent of total billed charges,Implant Device,523.71,,,523.71,Other,110% of Medicare,370.3,35,,370.3,percent of total billed charges,Implant Device,359.72,34,"Charges > $500, x 34%",359.72,percent of total billed charges,Implant Device,370.3,35,,370.3,percent of total billed charges,Implant Device,370.3,35,,370.3,percent of total billed charges,Implant Device,370.3,35,,370.3,percent of total billed charges,Implant Device,370.3,35,,370.3,percent of total billed charges,Implant Device,370.3,35,,370.3,percent of total billed charges,Implant Device,423.2,40,,423.2,percent of total billed charges,Implant Device,370.3,70,,370.3,percent of total billed charges,All Other,359.72,34,,359.72,percent of total billed charges,Implant Device,359.72,34,,359.72,percent of total billed charges,Implant Device,370.3,35,,370.3,percent of total billed charges,Implant Device,370.3,35,,370.3,percent of total billed charges,Implant Device,370.3,35,,370.3,percent of total billed charges,Implant Device,370.3,35,,370.3,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,782.92,
P 28 P50-053-2722 2.7X22MM LOCK SCREW,C1713,HCPCS,,79008318,CDM,278,RC,,,both,,,829,613.46,,,613.46,Other,150% of Medicare + 9.63% HCRA Surcharge,373.05,45,,373.05,percent of total billed charges,Critical Access Hospital RCC factor,281.86,34,,281.86,percent of total billed charges,Implant Device,281.86,34,,281.86,percent of total billed charges,Implant Device,281.86,34,,281.86,percent of total billed charges,Implant Device,281.86,34,,281.86,percent of total billed charges,Implant Device,281.86,34,,281.86,percent of total billed charges,Implant Device,410.36,,,410.36,Other,110% of Medicare,290.15,35,,290.15,percent of total billed charges,Implant Device,281.86,34,"Charges > $500, x 34%",281.86,percent of total billed charges,Implant Device,290.15,35,,290.15,percent of total billed charges,Implant Device,290.15,35,,290.15,percent of total billed charges,Implant Device,290.15,35,,290.15,percent of total billed charges,Implant Device,290.15,35,,290.15,percent of total billed charges,Implant Device,290.15,35,,290.15,percent of total billed charges,Implant Device,331.6,40,,331.6,percent of total billed charges,Implant Device,290.15,70,,290.15,percent of total billed charges,All Other,281.86,34,,281.86,percent of total billed charges,Implant Device,281.86,34,,281.86,percent of total billed charges,Implant Device,290.15,35,,290.15,percent of total billed charges,Implant Device,290.15,35,,290.15,percent of total billed charges,Implant Device,290.15,35,,290.15,percent of total billed charges,Implant Device,290.15,35,,290.15,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,613.46,
P 28 P50-053-2724 2.7X24MM LOCK SCREW,C1713,HCPCS,,79008319,CDM,278,RC,,,both,,,829,613.46,,,613.46,Other,150% of Medicare + 9.63% HCRA Surcharge,373.05,45,,373.05,percent of total billed charges,Critical Access Hospital RCC factor,281.86,34,,281.86,percent of total billed charges,Implant Device,281.86,34,,281.86,percent of total billed charges,Implant Device,281.86,34,,281.86,percent of total billed charges,Implant Device,281.86,34,,281.86,percent of total billed charges,Implant Device,281.86,34,,281.86,percent of total billed charges,Implant Device,410.36,,,410.36,Other,110% of Medicare,290.15,35,,290.15,percent of total billed charges,Implant Device,281.86,34,"Charges > $500, x 34%",281.86,percent of total billed charges,Implant Device,290.15,35,,290.15,percent of total billed charges,Implant Device,290.15,35,,290.15,percent of total billed charges,Implant Device,290.15,35,,290.15,percent of total billed charges,Implant Device,290.15,35,,290.15,percent of total billed charges,Implant Device,290.15,35,,290.15,percent of total billed charges,Implant Device,331.6,40,,331.6,percent of total billed charges,Implant Device,290.15,70,,290.15,percent of total billed charges,All Other,281.86,34,,281.86,percent of total billed charges,Implant Device,281.86,34,,281.86,percent of total billed charges,Implant Device,290.15,35,,290.15,percent of total billed charges,Implant Device,290.15,35,,290.15,percent of total billed charges,Implant Device,290.15,35,,290.15,percent of total billed charges,Implant Device,290.15,35,,290.15,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,613.46,
P 28 P50-153-2720 2.7X20MM NONLOCK SCREW,C1713,HCPCS,,79008320,CDM,278,RC,,,both,,,428,316.72,,,316.72,Other,150% of Medicare + 9.63% HCRA Surcharge,192.6,45,,192.6,percent of total billed charges,Critical Access Hospital RCC factor,145.52,34,,145.52,percent of total billed charges,Implant Device,145.52,34,,145.52,percent of total billed charges,Implant Device,145.52,34,,145.52,percent of total billed charges,Implant Device,145.52,34,,145.52,percent of total billed charges,Implant Device,145.52,34,,145.52,percent of total billed charges,Implant Device,211.86,,,211.86,Other,110% of Medicare,149.8,35,,149.8,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,149.8,35,,149.8,percent of total billed charges,Implant Device,149.8,35,,149.8,percent of total billed charges,Implant Device,149.8,35,,149.8,percent of total billed charges,Implant Device,149.8,35,,149.8,percent of total billed charges,Implant Device,149.8,35,,149.8,percent of total billed charges,Implant Device,171.2,40,,171.2,percent of total billed charges,Implant Device,149.8,70,,149.8,percent of total billed charges,All Other,145.52,34,,145.52,percent of total billed charges,Implant Device,145.52,34,,145.52,percent of total billed charges,Implant Device,149.8,35,,149.8,percent of total billed charges,Implant Device,149.8,35,,149.8,percent of total billed charges,Implant Device,149.8,35,,149.8,percent of total billed charges,Implant Device,149.8,35,,149.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,316.72,
P 28 P50-153-2724 2.7X24MM NONLOCK SCREW,C1713,HCPCS,,79008321,CDM,278,RC,,,both,,,428,316.72,,,316.72,Other,150% of Medicare + 9.63% HCRA Surcharge,192.6,45,,192.6,percent of total billed charges,Critical Access Hospital RCC factor,145.52,34,,145.52,percent of total billed charges,Implant Device,145.52,34,,145.52,percent of total billed charges,Implant Device,145.52,34,,145.52,percent of total billed charges,Implant Device,145.52,34,,145.52,percent of total billed charges,Implant Device,145.52,34,,145.52,percent of total billed charges,Implant Device,211.86,,,211.86,Other,110% of Medicare,149.8,35,,149.8,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,149.8,35,,149.8,percent of total billed charges,Implant Device,149.8,35,,149.8,percent of total billed charges,Implant Device,149.8,35,,149.8,percent of total billed charges,Implant Device,149.8,35,,149.8,percent of total billed charges,Implant Device,149.8,35,,149.8,percent of total billed charges,Implant Device,171.2,40,,171.2,percent of total billed charges,Implant Device,149.8,70,,149.8,percent of total billed charges,All Other,145.52,34,,145.52,percent of total billed charges,Implant Device,145.52,34,,145.52,percent of total billed charges,Implant Device,149.8,35,,149.8,percent of total billed charges,Implant Device,149.8,35,,149.8,percent of total billed charges,Implant Device,149.8,35,,149.8,percent of total billed charges,Implant Device,149.8,35,,149.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,316.72,
P 28 P53-101-2012 28 PLATE 2 H 20X1.1MM,C1713,HCPCS,,79008322,CDM,278,RC,,,both,,,4055,3000.71,,,3000.71,Other,150% of Medicare + 9.63% HCRA Surcharge,1824.75,45,,1824.75,percent of total billed charges,Critical Access Hospital RCC factor,1378.7,34,,1378.7,percent of total billed charges,Implant Device,1378.7,34,,1378.7,percent of total billed charges,Implant Device,1378.7,34,,1378.7,percent of total billed charges,Implant Device,1378.7,34,,1378.7,percent of total billed charges,Implant Device,1378.7,34,,1378.7,percent of total billed charges,Implant Device,2007.23,,,2007.23,Other,110% of Medicare,1419.25,35,,1419.25,percent of total billed charges,Implant Device,1378.7,34,"Charges > $500, x 34%",1378.7,percent of total billed charges,Implant Device,1419.25,35,,1419.25,percent of total billed charges,Implant Device,1419.25,35,,1419.25,percent of total billed charges,Implant Device,1419.25,35,,1419.25,percent of total billed charges,Implant Device,1419.25,35,,1419.25,percent of total billed charges,Implant Device,1419.25,35,,1419.25,percent of total billed charges,Implant Device,1622,40,,1622,percent of total billed charges,Implant Device,1419.25,70,,1419.25,percent of total billed charges,All Other,1378.7,34,,1378.7,percent of total billed charges,Implant Device,1378.7,34,,1378.7,percent of total billed charges,Implant Device,1419.25,35,,1419.25,percent of total billed charges,Implant Device,1419.25,35,,1419.25,percent of total billed charges,Implant Device,1419.25,35,,1419.25,percent of total billed charges,Implant Device,1419.25,35,,1419.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1378.7,34,"If Charge > 2,000, then 34 percent",1378.7,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3000.71,
ALPHATEC 71002-28 PLATE 28MM 2 LEVEL,C1713,HCPCS,,79008324,CDM,278,RC,,,both,,,2700,1998.01,,,1998.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1215,45,,1215,percent of total billed charges,Critical Access Hospital RCC factor,918,34,,918,percent of total billed charges,Implant Device,918,34,,918,percent of total billed charges,Implant Device,918,34,,918,percent of total billed charges,Implant Device,918,34,,918,percent of total billed charges,Implant Device,918,34,,918,percent of total billed charges,Implant Device,1336.5,,,1336.5,Other,110% of Medicare,945,35,,945,percent of total billed charges,Implant Device,918,34,"Charges > $500, x 34%",918,percent of total billed charges,Implant Device,945,35,,945,percent of total billed charges,Implant Device,945,35,,945,percent of total billed charges,Implant Device,945,35,,945,percent of total billed charges,Implant Device,945,35,,945,percent of total billed charges,Implant Device,945,35,,945,percent of total billed charges,Implant Device,1080,40,,1080,percent of total billed charges,Implant Device,945,70,,945,percent of total billed charges,All Other,918,34,,918,percent of total billed charges,Implant Device,918,34,,918,percent of total billed charges,Implant Device,945,35,,945,percent of total billed charges,Implant Device,945,35,,945,percent of total billed charges,Implant Device,945,35,,945,percent of total billed charges,Implant Device,945,35,,945,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,918,34,"If Charge > 2,000, then 34 percent",918,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1998.01,
STRYKER 602685 6.5X85MM CANN SCREW,C1713,HCPCS,,79008325,CDM,278,RC,,,both,,,759,561.66,,,561.66,Other,150% of Medicare + 9.63% HCRA Surcharge,341.55,45,,341.55,percent of total billed charges,Critical Access Hospital RCC factor,258.06,34,,258.06,percent of total billed charges,Implant Device,258.06,34,,258.06,percent of total billed charges,Implant Device,258.06,34,,258.06,percent of total billed charges,Implant Device,258.06,34,,258.06,percent of total billed charges,Implant Device,258.06,34,,258.06,percent of total billed charges,Implant Device,375.71,,,375.71,Other,110% of Medicare,265.65,35,,265.65,percent of total billed charges,Implant Device,258.06,34,"Charges > $500, x 34%",258.06,percent of total billed charges,Implant Device,265.65,35,,265.65,percent of total billed charges,Implant Device,265.65,35,,265.65,percent of total billed charges,Implant Device,265.65,35,,265.65,percent of total billed charges,Implant Device,265.65,35,,265.65,percent of total billed charges,Implant Device,265.65,35,,265.65,percent of total billed charges,Implant Device,303.6,40,,303.6,percent of total billed charges,Implant Device,265.65,70,,265.65,percent of total billed charges,All Other,258.06,34,,258.06,percent of total billed charges,Implant Device,258.06,34,,258.06,percent of total billed charges,Implant Device,265.65,35,,265.65,percent of total billed charges,Implant Device,265.65,35,,265.65,percent of total billed charges,Implant Device,265.65,35,,265.65,percent of total billed charges,Implant Device,265.65,35,,265.65,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,561.66,
DEPUY 09.402.024S COCR RAD HEAD 24X13MM,C1776,HCPCS,,79008326,CDM,278,RC,,,both,,,6996,5177.06,,,5177.06,Other,150% of Medicare + 9.63% HCRA Surcharge,3148.2,45,,3148.2,percent of total billed charges,Critical Access Hospital RCC factor,2378.64,34,,2378.64,percent of total billed charges,Implant Device,2378.64,34,,2378.64,percent of total billed charges,Implant Device,2378.64,34,,2378.64,percent of total billed charges,Implant Device,2378.64,34,,2378.64,percent of total billed charges,Implant Device,2378.64,34,,2378.64,percent of total billed charges,Implant Device,3463.02,,,3463.02,Other,110% of Medicare,2448.6,35,,2448.6,percent of total billed charges,Implant Device,2378.64,34,"Charges > $500, x 34%",2378.64,percent of total billed charges,Implant Device,2448.6,35,,2448.6,percent of total billed charges,Implant Device,2448.6,35,,2448.6,percent of total billed charges,Implant Device,2448.6,35,,2448.6,percent of total billed charges,Implant Device,2448.6,35,,2448.6,percent of total billed charges,Implant Device,2448.6,35,,2448.6,percent of total billed charges,Implant Device,2798.4,40,,2798.4,percent of total billed charges,Implant Device,2448.6,70,,2448.6,percent of total billed charges,All Other,2378.64,34,,2378.64,percent of total billed charges,Implant Device,2378.64,34,,2378.64,percent of total billed charges,Implant Device,2448.6,35,,2448.6,percent of total billed charges,Implant Device,2448.6,35,,2448.6,percent of total billed charges,Implant Device,2448.6,35,,2448.6,percent of total billed charges,Implant Device,2448.6,35,,2448.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2378.64,34,"If Charge > 2,000, then 34 percent",2378.64,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5177.06,
DEPUY 04.402.008S STR RADIAL STEM 8X28MM,C1776,HCPCS,,79008327,CDM,278,RC,,,both,,,6996,5177.06,,,5177.06,Other,150% of Medicare + 9.63% HCRA Surcharge,3148.2,45,,3148.2,percent of total billed charges,Critical Access Hospital RCC factor,2378.64,34,,2378.64,percent of total billed charges,Implant Device,2378.64,34,,2378.64,percent of total billed charges,Implant Device,2378.64,34,,2378.64,percent of total billed charges,Implant Device,2378.64,34,,2378.64,percent of total billed charges,Implant Device,2378.64,34,,2378.64,percent of total billed charges,Implant Device,3463.02,,,3463.02,Other,110% of Medicare,2448.6,35,,2448.6,percent of total billed charges,Implant Device,2378.64,34,"Charges > $500, x 34%",2378.64,percent of total billed charges,Implant Device,2448.6,35,,2448.6,percent of total billed charges,Implant Device,2448.6,35,,2448.6,percent of total billed charges,Implant Device,2448.6,35,,2448.6,percent of total billed charges,Implant Device,2448.6,35,,2448.6,percent of total billed charges,Implant Device,2448.6,35,,2448.6,percent of total billed charges,Implant Device,2798.4,40,,2798.4,percent of total billed charges,Implant Device,2448.6,70,,2448.6,percent of total billed charges,All Other,2378.64,34,,2378.64,percent of total billed charges,Implant Device,2378.64,34,,2378.64,percent of total billed charges,Implant Device,2448.6,35,,2448.6,percent of total billed charges,Implant Device,2448.6,35,,2448.6,percent of total billed charges,Implant Device,2448.6,35,,2448.6,percent of total billed charges,Implant Device,2448.6,35,,2448.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2378.64,34,"If Charge > 2,000, then 34 percent",2378.64,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5177.06,
DEPUY 201.644 CORTEX SCREW 2.4X14MM,C1713,HCPCS,,79008328,CDM,278,RC,,,both,,,186,137.64,,,137.64,Other,150% of Medicare + 9.63% HCRA Surcharge,83.7,45,,83.7,percent of total billed charges,Critical Access Hospital RCC factor,63.24,34,,63.24,percent of total billed charges,Implant Device,63.24,34,,63.24,percent of total billed charges,Implant Device,63.24,34,,63.24,percent of total billed charges,Implant Device,63.24,34,,63.24,percent of total billed charges,Implant Device,63.24,34,,63.24,percent of total billed charges,Implant Device,92.07,,,92.07,Other,110% of Medicare,65.1,35,,65.1,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,65.1,35,,65.1,percent of total billed charges,Implant Device,65.1,35,,65.1,percent of total billed charges,Implant Device,65.1,35,,65.1,percent of total billed charges,Implant Device,65.1,35,,65.1,percent of total billed charges,Implant Device,65.1,35,,65.1,percent of total billed charges,Implant Device,74.4,40,,74.4,percent of total billed charges,Implant Device,65.1,70,,65.1,percent of total billed charges,All Other,63.24,34,,63.24,percent of total billed charges,Implant Device,63.24,34,,63.24,percent of total billed charges,Implant Device,65.1,35,,65.1,percent of total billed charges,Implant Device,65.1,35,,65.1,percent of total billed charges,Implant Device,65.1,35,,65.1,percent of total billed charges,Implant Device,65.1,35,,65.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,137.64,
P 28 P50-053-3532 LOCKING SCREW 3.5X32MM,C1713,HCPCS,,79008329,CDM,278,RC,,,both,,,829,613.46,,,613.46,Other,150% of Medicare + 9.63% HCRA Surcharge,373.05,45,,373.05,percent of total billed charges,Critical Access Hospital RCC factor,281.86,34,,281.86,percent of total billed charges,Implant Device,281.86,34,,281.86,percent of total billed charges,Implant Device,281.86,34,,281.86,percent of total billed charges,Implant Device,281.86,34,,281.86,percent of total billed charges,Implant Device,281.86,34,,281.86,percent of total billed charges,Implant Device,410.36,,,410.36,Other,110% of Medicare,290.15,35,,290.15,percent of total billed charges,Implant Device,281.86,34,"Charges > $500, x 34%",281.86,percent of total billed charges,Implant Device,290.15,35,,290.15,percent of total billed charges,Implant Device,290.15,35,,290.15,percent of total billed charges,Implant Device,290.15,35,,290.15,percent of total billed charges,Implant Device,290.15,35,,290.15,percent of total billed charges,Implant Device,290.15,35,,290.15,percent of total billed charges,Implant Device,331.6,40,,331.6,percent of total billed charges,Implant Device,290.15,70,,290.15,percent of total billed charges,All Other,281.86,34,,281.86,percent of total billed charges,Implant Device,281.86,34,,281.86,percent of total billed charges,Implant Device,290.15,35,,290.15,percent of total billed charges,Implant Device,290.15,35,,290.15,percent of total billed charges,Implant Device,290.15,35,,290.15,percent of total billed charges,Implant Device,290.15,35,,290.15,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,613.46,
P 28 P50-053-4234 LOCKING SCREW 4.2X34MM,C1713,HCPCS,,79008330,CDM,278,RC,,,both,,,854,631.96,,,631.96,Other,150% of Medicare + 9.63% HCRA Surcharge,384.3,45,,384.3,percent of total billed charges,Critical Access Hospital RCC factor,290.36,34,,290.36,percent of total billed charges,Implant Device,290.36,34,,290.36,percent of total billed charges,Implant Device,290.36,34,,290.36,percent of total billed charges,Implant Device,290.36,34,,290.36,percent of total billed charges,Implant Device,290.36,34,,290.36,percent of total billed charges,Implant Device,422.73,,,422.73,Other,110% of Medicare,298.9,35,,298.9,percent of total billed charges,Implant Device,290.36,34,"Charges > $500, x 34%",290.36,percent of total billed charges,Implant Device,298.9,35,,298.9,percent of total billed charges,Implant Device,298.9,35,,298.9,percent of total billed charges,Implant Device,298.9,35,,298.9,percent of total billed charges,Implant Device,298.9,35,,298.9,percent of total billed charges,Implant Device,298.9,35,,298.9,percent of total billed charges,Implant Device,341.6,40,,341.6,percent of total billed charges,Implant Device,298.9,70,,298.9,percent of total billed charges,All Other,290.36,34,,290.36,percent of total billed charges,Implant Device,290.36,34,,290.36,percent of total billed charges,Implant Device,298.9,35,,298.9,percent of total billed charges,Implant Device,298.9,35,,298.9,percent of total billed charges,Implant Device,298.9,35,,298.9,percent of total billed charges,Implant Device,298.9,35,,298.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,631.96,
P 28 P50-053-4238 LOCKING SCREW 4.2X36MM,C1713,HCPCS,,79008331,CDM,278,RC,,,both,,,854,631.96,,,631.96,Other,150% of Medicare + 9.63% HCRA Surcharge,384.3,45,,384.3,percent of total billed charges,Critical Access Hospital RCC factor,290.36,34,,290.36,percent of total billed charges,Implant Device,290.36,34,,290.36,percent of total billed charges,Implant Device,290.36,34,,290.36,percent of total billed charges,Implant Device,290.36,34,,290.36,percent of total billed charges,Implant Device,290.36,34,,290.36,percent of total billed charges,Implant Device,422.73,,,422.73,Other,110% of Medicare,298.9,35,,298.9,percent of total billed charges,Implant Device,290.36,34,"Charges > $500, x 34%",290.36,percent of total billed charges,Implant Device,298.9,35,,298.9,percent of total billed charges,Implant Device,298.9,35,,298.9,percent of total billed charges,Implant Device,298.9,35,,298.9,percent of total billed charges,Implant Device,298.9,35,,298.9,percent of total billed charges,Implant Device,298.9,35,,298.9,percent of total billed charges,Implant Device,341.6,40,,341.6,percent of total billed charges,Implant Device,298.9,70,,298.9,percent of total billed charges,All Other,290.36,34,,290.36,percent of total billed charges,Implant Device,290.36,34,,290.36,percent of total billed charges,Implant Device,298.9,35,,298.9,percent of total billed charges,Implant Device,298.9,35,,298.9,percent of total billed charges,Implant Device,298.9,35,,298.9,percent of total billed charges,Implant Device,298.9,35,,298.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,631.96,
PARAGON 28 PLCL-18006 EVANS WEDGE 6MM,C1713,HCPCS,,79008332,CDM,278,RC,,,both,,,5158,3816.93,,,3816.93,Other,150% of Medicare + 9.63% HCRA Surcharge,2321.1,45,,2321.1,percent of total billed charges,Critical Access Hospital RCC factor,1753.72,34,,1753.72,percent of total billed charges,Implant Device,1753.72,34,,1753.72,percent of total billed charges,Implant Device,1753.72,34,,1753.72,percent of total billed charges,Implant Device,1753.72,34,,1753.72,percent of total billed charges,Implant Device,1753.72,34,,1753.72,percent of total billed charges,Implant Device,2553.21,,,2553.21,Other,110% of Medicare,1805.3,35,,1805.3,percent of total billed charges,Implant Device,1753.72,34,"Charges > $500, x 34%",1753.72,percent of total billed charges,Implant Device,1805.3,35,,1805.3,percent of total billed charges,Implant Device,1805.3,35,,1805.3,percent of total billed charges,Implant Device,1805.3,35,,1805.3,percent of total billed charges,Implant Device,1805.3,35,,1805.3,percent of total billed charges,Implant Device,1805.3,35,,1805.3,percent of total billed charges,Implant Device,2063.2,40,,2063.2,percent of total billed charges,Implant Device,1805.3,70,,1805.3,percent of total billed charges,All Other,1753.72,34,,1753.72,percent of total billed charges,Implant Device,1753.72,34,,1753.72,percent of total billed charges,Implant Device,1805.3,35,,1805.3,percent of total billed charges,Implant Device,1805.3,35,,1805.3,percent of total billed charges,Implant Device,1805.3,35,,1805.3,percent of total billed charges,Implant Device,1805.3,35,,1805.3,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1753.72,34,"If Charge > 2,000, then 34 percent",1753.72,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3816.93,
DEVICOR JMRM4002 10G MR BREAST MARKER,A4648,HCPCS,,79008333,CDM,278,RC,,,both,,,280,207.2,,,207.2,Other,150% of Medicare + 9.63% HCRA Surcharge,126,45,,126,percent of total billed charges,Critical Access Hospital RCC factor,95.2,34,,95.2,percent of total billed charges,Implant Device,95.2,34,,95.2,percent of total billed charges,Implant Device,95.2,34,,95.2,percent of total billed charges,Implant Device,95.2,34,,95.2,percent of total billed charges,Implant Device,95.2,34,,95.2,percent of total billed charges,Implant Device,138.6,,,138.6,Other,110% of Medicare,98,35,,98,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,98,35,,98,percent of total billed charges,Implant Device,98,35,,98,percent of total billed charges,Implant Device,98,35,,98,percent of total billed charges,Implant Device,98,35,,98,percent of total billed charges,Implant Device,98,35,,98,percent of total billed charges,Implant Device,112,40,,112,percent of total billed charges,Implant Device,98,70,,98,percent of total billed charges,All Other,95.2,34,,95.2,percent of total billed charges,Implant Device,95.2,34,,95.2,percent of total billed charges,Implant Device,98,35,,98,percent of total billed charges,Implant Device,98,35,,98,percent of total billed charges,Implant Device,98,35,,98,percent of total billed charges,Implant Device,98,35,,98,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,207.2,
STRYKER 3525-1440S LONG NAIL R1 5 TI LT,C1713,HCPCS,,79008334,CDM,278,RC,,,both,,,4969,3677.07,,,3677.07,Other,150% of Medicare + 9.63% HCRA Surcharge,2236.05,45,,2236.05,percent of total billed charges,Critical Access Hospital RCC factor,1689.46,34,,1689.46,percent of total billed charges,Implant Device,1689.46,34,,1689.46,percent of total billed charges,Implant Device,1689.46,34,,1689.46,percent of total billed charges,Implant Device,1689.46,34,,1689.46,percent of total billed charges,Implant Device,1689.46,34,,1689.46,percent of total billed charges,Implant Device,2459.66,,,2459.66,Other,110% of Medicare,1739.15,35,,1739.15,percent of total billed charges,Implant Device,1689.46,34,"Charges > $500, x 34%",1689.46,percent of total billed charges,Implant Device,1739.15,35,,1739.15,percent of total billed charges,Implant Device,1739.15,35,,1739.15,percent of total billed charges,Implant Device,1739.15,35,,1739.15,percent of total billed charges,Implant Device,1739.15,35,,1739.15,percent of total billed charges,Implant Device,1739.15,35,,1739.15,percent of total billed charges,Implant Device,1987.6,40,,1987.6,percent of total billed charges,Implant Device,1739.15,70,,1739.15,percent of total billed charges,All Other,1689.46,34,,1689.46,percent of total billed charges,Implant Device,1689.46,34,,1689.46,percent of total billed charges,Implant Device,1739.15,35,,1739.15,percent of total billed charges,Implant Device,1739.15,35,,1739.15,percent of total billed charges,Implant Device,1739.15,35,,1739.15,percent of total billed charges,Implant Device,1739.15,35,,1739.15,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1689.46,34,"If Charge > 2,000, then 34 percent",1689.46,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3677.07,
STRYKER 3425-1440S LONG NAIL R1 R TI RT,C1713,HCPCS,,79008335,CDM,278,RC,,,both,,,5438,4024.13,,,4024.13,Other,150% of Medicare + 9.63% HCRA Surcharge,2447.1,45,,2447.1,percent of total billed charges,Critical Access Hospital RCC factor,1848.92,34,,1848.92,percent of total billed charges,Implant Device,1848.92,34,,1848.92,percent of total billed charges,Implant Device,1848.92,34,,1848.92,percent of total billed charges,Implant Device,1848.92,34,,1848.92,percent of total billed charges,Implant Device,1848.92,34,,1848.92,percent of total billed charges,Implant Device,2691.81,,,2691.81,Other,110% of Medicare,1903.3,35,,1903.3,percent of total billed charges,Implant Device,1848.92,34,"Charges > $500, x 34%",1848.92,percent of total billed charges,Implant Device,1903.3,35,,1903.3,percent of total billed charges,Implant Device,1903.3,35,,1903.3,percent of total billed charges,Implant Device,1903.3,35,,1903.3,percent of total billed charges,Implant Device,1903.3,35,,1903.3,percent of total billed charges,Implant Device,1903.3,35,,1903.3,percent of total billed charges,Implant Device,2175.2,40,,2175.2,percent of total billed charges,Implant Device,1903.3,70,,1903.3,percent of total billed charges,All Other,1848.92,34,,1848.92,percent of total billed charges,Implant Device,1848.92,34,,1848.92,percent of total billed charges,Implant Device,1903.3,35,,1903.3,percent of total billed charges,Implant Device,1903.3,35,,1903.3,percent of total billed charges,Implant Device,1903.3,35,,1903.3,percent of total billed charges,Implant Device,1903.3,35,,1903.3,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1848.92,34,"If Charge > 2,000, then 34 percent",1848.92,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4024.13,
S&N 71333434 ACETAB LINER 32MM+4MM SZ E,C1776,HCPCS,,79008338,CDM,278,RC,,,both,,,15660,11588.44,,,11588.44,Other,150% of Medicare + 9.63% HCRA Surcharge,7047,45,,7047,percent of total billed charges,Critical Access Hospital RCC factor,5324.4,34,,5324.4,percent of total billed charges,Implant Device,5324.4,34,,5324.4,percent of total billed charges,Implant Device,5324.4,34,,5324.4,percent of total billed charges,Implant Device,5324.4,34,,5324.4,percent of total billed charges,Implant Device,5324.4,34,,5324.4,percent of total billed charges,Implant Device,7751.7,,,7751.7,Other,110% of Medicare,5481,35,,5481,percent of total billed charges,Implant Device,5324.4,34,"Charges > $500, x 34%",5324.4,percent of total billed charges,Implant Device,5481,35,,5481,percent of total billed charges,Implant Device,5481,35,,5481,percent of total billed charges,Implant Device,5481,35,,5481,percent of total billed charges,Implant Device,5481,35,,5481,percent of total billed charges,Implant Device,5481,35,,5481,percent of total billed charges,Implant Device,6264,40,,6264,percent of total billed charges,Implant Device,5481,70,,5481,percent of total billed charges,All Other,5324.4,34,,5324.4,percent of total billed charges,Implant Device,5324.4,34,,5324.4,percent of total billed charges,Implant Device,5481,35,,5481,percent of total billed charges,Implant Device,5481,35,,5481,percent of total billed charges,Implant Device,5481,35,,5481,percent of total billed charges,Implant Device,5481,35,,5481,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,5324.4,34,"If Charge > 2,000, then 34 percent",5324.4,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,11588.44,
S&N 71343208 FEMORAL HEAD 32MM +8 12/14,C1776,HCPCS,,79008339,CDM,278,RC,,,both,,,4851,3589.75,,,3589.75,Other,150% of Medicare + 9.63% HCRA Surcharge,2182.95,45,,2182.95,percent of total billed charges,Critical Access Hospital RCC factor,1649.34,34,,1649.34,percent of total billed charges,Implant Device,1649.34,34,,1649.34,percent of total billed charges,Implant Device,1649.34,34,,1649.34,percent of total billed charges,Implant Device,1649.34,34,,1649.34,percent of total billed charges,Implant Device,1649.34,34,,1649.34,percent of total billed charges,Implant Device,2401.25,,,2401.25,Other,110% of Medicare,1697.85,35,,1697.85,percent of total billed charges,Implant Device,1649.34,34,"Charges > $500, x 34%",1649.34,percent of total billed charges,Implant Device,1697.85,35,,1697.85,percent of total billed charges,Implant Device,1697.85,35,,1697.85,percent of total billed charges,Implant Device,1697.85,35,,1697.85,percent of total billed charges,Implant Device,1697.85,35,,1697.85,percent of total billed charges,Implant Device,1697.85,35,,1697.85,percent of total billed charges,Implant Device,1940.4,40,,1940.4,percent of total billed charges,Implant Device,1697.85,70,,1697.85,percent of total billed charges,All Other,1649.34,34,,1649.34,percent of total billed charges,Implant Device,1649.34,34,,1649.34,percent of total billed charges,Implant Device,1697.85,35,,1697.85,percent of total billed charges,Implant Device,1697.85,35,,1697.85,percent of total billed charges,Implant Device,1697.85,35,,1697.85,percent of total billed charges,Implant Device,1697.85,35,,1697.85,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1649.34,34,"If Charge > 2,000, then 34 percent",1649.34,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3589.75,
WRIGHT CCP-LPX1R LAPIDUS PLATE RT 1MM,C1713,HCPCS,,79008340,CDM,278,RC,,,both,,,7245,5361.32,,,5361.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3260.25,45,,3260.25,percent of total billed charges,Critical Access Hospital RCC factor,2463.3,34,,2463.3,percent of total billed charges,Implant Device,2463.3,34,,2463.3,percent of total billed charges,Implant Device,2463.3,34,,2463.3,percent of total billed charges,Implant Device,2463.3,34,,2463.3,percent of total billed charges,Implant Device,2463.3,34,,2463.3,percent of total billed charges,Implant Device,3586.28,,,3586.28,Other,110% of Medicare,2535.75,35,,2535.75,percent of total billed charges,Implant Device,2463.3,34,"Charges > $500, x 34%",2463.3,percent of total billed charges,Implant Device,2535.75,35,,2535.75,percent of total billed charges,Implant Device,2535.75,35,,2535.75,percent of total billed charges,Implant Device,2535.75,35,,2535.75,percent of total billed charges,Implant Device,2535.75,35,,2535.75,percent of total billed charges,Implant Device,2535.75,35,,2535.75,percent of total billed charges,Implant Device,2898,40,,2898,percent of total billed charges,Implant Device,2535.75,70,,2535.75,percent of total billed charges,All Other,2463.3,34,,2463.3,percent of total billed charges,Implant Device,2463.3,34,,2463.3,percent of total billed charges,Implant Device,2535.75,35,,2535.75,percent of total billed charges,Implant Device,2535.75,35,,2535.75,percent of total billed charges,Implant Device,2535.75,35,,2535.75,percent of total billed charges,Implant Device,2535.75,35,,2535.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2463.3,34,"If Charge > 2,000, then 34 percent",2463.3,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5361.32,
S&N 71333334 ACETAB LINER 32MM SZ E,C1776,HCPCS,,79008341,CDM,278,RC,,,both,,,3398,2514.53,,,2514.53,Other,150% of Medicare + 9.63% HCRA Surcharge,1529.1,45,,1529.1,percent of total billed charges,Critical Access Hospital RCC factor,1155.32,34,,1155.32,percent of total billed charges,Implant Device,1155.32,34,,1155.32,percent of total billed charges,Implant Device,1155.32,34,,1155.32,percent of total billed charges,Implant Device,1155.32,34,,1155.32,percent of total billed charges,Implant Device,1155.32,34,,1155.32,percent of total billed charges,Implant Device,1682.01,,,1682.01,Other,110% of Medicare,1189.3,35,,1189.3,percent of total billed charges,Implant Device,1155.32,34,"Charges > $500, x 34%",1155.32,percent of total billed charges,Implant Device,1189.3,35,,1189.3,percent of total billed charges,Implant Device,1189.3,35,,1189.3,percent of total billed charges,Implant Device,1189.3,35,,1189.3,percent of total billed charges,Implant Device,1189.3,35,,1189.3,percent of total billed charges,Implant Device,1189.3,35,,1189.3,percent of total billed charges,Implant Device,1359.2,40,,1359.2,percent of total billed charges,Implant Device,1189.3,70,,1189.3,percent of total billed charges,All Other,1155.32,34,,1155.32,percent of total billed charges,Implant Device,1155.32,34,,1155.32,percent of total billed charges,Implant Device,1189.3,35,,1189.3,percent of total billed charges,Implant Device,1189.3,35,,1189.3,percent of total billed charges,Implant Device,1189.3,35,,1189.3,percent of total billed charges,Implant Device,1189.3,35,,1189.3,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1155.32,34,"If Charge > 2,000, then 34 percent",1155.32,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2514.53,
DEPUY 294.777 DRILLING SCREW 4.0X40MM,C1713,HCPCS,,79008347,CDM,278,RC,,,both,,,272,201.28,,,201.28,Other,150% of Medicare + 9.63% HCRA Surcharge,122.4,45,,122.4,percent of total billed charges,Critical Access Hospital RCC factor,92.48,34,,92.48,percent of total billed charges,Implant Device,92.48,34,,92.48,percent of total billed charges,Implant Device,92.48,34,,92.48,percent of total billed charges,Implant Device,92.48,34,,92.48,percent of total billed charges,Implant Device,92.48,34,,92.48,percent of total billed charges,Implant Device,134.64,,,134.64,Other,110% of Medicare,95.2,35,,95.2,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,95.2,35,,95.2,percent of total billed charges,Implant Device,95.2,35,,95.2,percent of total billed charges,Implant Device,95.2,35,,95.2,percent of total billed charges,Implant Device,95.2,35,,95.2,percent of total billed charges,Implant Device,95.2,35,,95.2,percent of total billed charges,Implant Device,108.8,40,,108.8,percent of total billed charges,Implant Device,95.2,70,,95.2,percent of total billed charges,All Other,92.48,34,,92.48,percent of total billed charges,Implant Device,92.48,34,,92.48,percent of total billed charges,Implant Device,95.2,35,,95.2,percent of total billed charges,Implant Device,95.2,35,,95.2,percent of total billed charges,Implant Device,95.2,35,,95.2,percent of total billed charges,Implant Device,95.2,35,,95.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,201.28,
MEDTRONIC 7510600 INFUSE BONE GRAFT KIT,L8699,HCPCS,,79008356,CDM,278,RC,,,both,,,17205,12731.74,,,12731.74,Other,150% of Medicare + 9.63% HCRA Surcharge,7742.25,45,,7742.25,percent of total billed charges,Critical Access Hospital RCC factor,5849.7,34,,5849.7,percent of total billed charges,Implant Device,5849.7,34,,5849.7,percent of total billed charges,Implant Device,5849.7,34,,5849.7,percent of total billed charges,Implant Device,5849.7,34,,5849.7,percent of total billed charges,Implant Device,5849.7,34,,5849.7,percent of total billed charges,Implant Device,8516.48,,,8516.48,Other,110% of Medicare,6021.75,35,,6021.75,percent of total billed charges,Implant Device,5849.7,34,"Charges > $500, x 34%",5849.7,percent of total billed charges,Implant Device,6021.75,35,,6021.75,percent of total billed charges,Implant Device,6021.75,35,,6021.75,percent of total billed charges,Implant Device,6021.75,35,,6021.75,percent of total billed charges,Implant Device,6021.75,35,,6021.75,percent of total billed charges,Implant Device,6021.75,35,,6021.75,percent of total billed charges,Implant Device,6882,40,,6882,percent of total billed charges,Implant Device,6021.75,70,,6021.75,percent of total billed charges,All Other,5849.7,34,,5849.7,percent of total billed charges,Implant Device,5849.7,34,,5849.7,percent of total billed charges,Implant Device,6021.75,35,,6021.75,percent of total billed charges,Implant Device,6021.75,35,,6021.75,percent of total billed charges,Implant Device,6021.75,35,,6021.75,percent of total billed charges,Implant Device,6021.75,35,,6021.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,5849.7,34,"If Charge > 2,000, then 34 percent",5849.7,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,12731.74,
BIOMET 1802-53-042 CANN SCREW 5.0X42MM,C1713,HCPCS,,79008360,CDM,278,RC,,,both,,,870,643.8,,,643.8,Other,150% of Medicare + 9.63% HCRA Surcharge,391.5,45,,391.5,percent of total billed charges,Critical Access Hospital RCC factor,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,430.65,,,430.65,Other,110% of Medicare,304.5,35,,304.5,percent of total billed charges,Implant Device,295.8,34,"Charges > $500, x 34%",295.8,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,348,40,,348,percent of total billed charges,Implant Device,304.5,70,,304.5,percent of total billed charges,All Other,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,643.8,
BIOMET 1802-53-044 CANN SCREW 5.0X44MM,C1713,HCPCS,,79008361,CDM,278,RC,,,both,,,870,643.8,,,643.8,Other,150% of Medicare + 9.63% HCRA Surcharge,391.5,45,,391.5,percent of total billed charges,Critical Access Hospital RCC factor,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,430.65,,,430.65,Other,110% of Medicare,304.5,35,,304.5,percent of total billed charges,Implant Device,295.8,34,"Charges > $500, x 34%",295.8,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,348,40,,348,percent of total billed charges,Implant Device,304.5,70,,304.5,percent of total billed charges,All Other,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,643.8,
BIOMET 110030166 CARTRDGE THREAD ADAPTOR,C1713,HCPCS,,79008362,CDM,278,RC,,,both,,,90,66.6,,,66.6,Other,150% of Medicare + 9.63% HCRA Surcharge,40.5,45,,40.5,percent of total billed charges,Critical Access Hospital RCC factor,30.6,34,,30.6,percent of total billed charges,Implant Device,30.6,34,,30.6,percent of total billed charges,Implant Device,30.6,34,,30.6,percent of total billed charges,Implant Device,30.6,34,,30.6,percent of total billed charges,Implant Device,30.6,34,,30.6,percent of total billed charges,Implant Device,44.55,,,44.55,Other,110% of Medicare,31.5,35,,31.5,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,31.5,35,,31.5,percent of total billed charges,Implant Device,31.5,35,,31.5,percent of total billed charges,Implant Device,31.5,35,,31.5,percent of total billed charges,Implant Device,31.5,35,,31.5,percent of total billed charges,Implant Device,31.5,35,,31.5,percent of total billed charges,Implant Device,36,40,,36,percent of total billed charges,Implant Device,31.5,70,,31.5,percent of total billed charges,All Other,30.6,34,,30.6,percent of total billed charges,Implant Device,30.6,34,,30.6,percent of total billed charges,Implant Device,31.5,35,,31.5,percent of total billed charges,Implant Device,31.5,35,,31.5,percent of total billed charges,Implant Device,31.5,35,,31.5,percent of total billed charges,Implant Device,31.5,35,,31.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,66.6,
BIOMET 431185 HIP HEAD CEMENT SPACR 64MM,C1776,HCPCS,,79008363,CDM,278,RC,,,both,,,5250,3885.01,,,3885.01,Other,150% of Medicare + 9.63% HCRA Surcharge,2362.5,45,,2362.5,percent of total billed charges,Critical Access Hospital RCC factor,1785,34,,1785,percent of total billed charges,Implant Device,1785,34,,1785,percent of total billed charges,Implant Device,1785,34,,1785,percent of total billed charges,Implant Device,1785,34,,1785,percent of total billed charges,Implant Device,1785,34,,1785,percent of total billed charges,Implant Device,2598.75,,,2598.75,Other,110% of Medicare,1837.5,35,,1837.5,percent of total billed charges,Implant Device,1785,34,"Charges > $500, x 34%",1785,percent of total billed charges,Implant Device,1837.5,35,,1837.5,percent of total billed charges,Implant Device,1837.5,35,,1837.5,percent of total billed charges,Implant Device,1837.5,35,,1837.5,percent of total billed charges,Implant Device,1837.5,35,,1837.5,percent of total billed charges,Implant Device,1837.5,35,,1837.5,percent of total billed charges,Implant Device,2100,40,,2100,percent of total billed charges,Implant Device,1837.5,70,,1837.5,percent of total billed charges,All Other,1785,34,,1785,percent of total billed charges,Implant Device,1785,34,,1785,percent of total billed charges,Implant Device,1837.5,35,,1837.5,percent of total billed charges,Implant Device,1837.5,35,,1837.5,percent of total billed charges,Implant Device,1837.5,35,,1837.5,percent of total billed charges,Implant Device,1837.5,35,,1837.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1785,34,"If Charge > 2,000, then 34 percent",1785,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3885.01,
STRYKER 3525-0420S LONG NAIL 010X420X125,C1713,HCPCS,,79008364,CDM,278,RC,,,both,,,9981,7385.96,,,7385.96,Other,150% of Medicare + 9.63% HCRA Surcharge,4491.45,45,,4491.45,percent of total billed charges,Critical Access Hospital RCC factor,3393.54,34,,3393.54,percent of total billed charges,Implant Device,3393.54,34,,3393.54,percent of total billed charges,Implant Device,3393.54,34,,3393.54,percent of total billed charges,Implant Device,3393.54,34,,3393.54,percent of total billed charges,Implant Device,3393.54,34,,3393.54,percent of total billed charges,Implant Device,4940.6,,,4940.6,Other,110% of Medicare,3493.35,35,,3493.35,percent of total billed charges,Implant Device,3393.54,34,"Charges > $500, x 34%",3393.54,percent of total billed charges,Implant Device,3493.35,35,,3493.35,percent of total billed charges,Implant Device,3493.35,35,,3493.35,percent of total billed charges,Implant Device,3493.35,35,,3493.35,percent of total billed charges,Implant Device,3493.35,35,,3493.35,percent of total billed charges,Implant Device,3493.35,35,,3493.35,percent of total billed charges,Implant Device,3992.4,40,,3992.4,percent of total billed charges,Implant Device,3493.35,70,,3493.35,percent of total billed charges,All Other,3393.54,34,,3393.54,percent of total billed charges,Implant Device,3393.54,34,,3393.54,percent of total billed charges,Implant Device,3493.35,35,,3493.35,percent of total billed charges,Implant Device,3493.35,35,,3493.35,percent of total billed charges,Implant Device,3493.35,35,,3493.35,percent of total billed charges,Implant Device,3493.35,35,,3493.35,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3393.54,34,"If Charge > 2,000, then 34 percent",3393.54,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,7385.96,
ZIMMER 00-5994-051-12 ART SURF E.F 12MM,C1776,HCPCS,,79008365,CDM,278,RC,,,both,,,6465,4784.12,,,4784.12,Other,150% of Medicare + 9.63% HCRA Surcharge,2909.25,45,,2909.25,percent of total billed charges,Critical Access Hospital RCC factor,2198.1,34,,2198.1,percent of total billed charges,Implant Device,2198.1,34,,2198.1,percent of total billed charges,Implant Device,2198.1,34,,2198.1,percent of total billed charges,Implant Device,2198.1,34,,2198.1,percent of total billed charges,Implant Device,2198.1,34,,2198.1,percent of total billed charges,Implant Device,3200.18,,,3200.18,Other,110% of Medicare,2262.75,35,,2262.75,percent of total billed charges,Implant Device,2198.1,34,"Charges > $500, x 34%",2198.1,percent of total billed charges,Implant Device,2262.75,35,,2262.75,percent of total billed charges,Implant Device,2262.75,35,,2262.75,percent of total billed charges,Implant Device,2262.75,35,,2262.75,percent of total billed charges,Implant Device,2262.75,35,,2262.75,percent of total billed charges,Implant Device,2262.75,35,,2262.75,percent of total billed charges,Implant Device,2586,40,,2586,percent of total billed charges,Implant Device,2262.75,70,,2262.75,percent of total billed charges,All Other,2198.1,34,,2198.1,percent of total billed charges,Implant Device,2198.1,34,,2198.1,percent of total billed charges,Implant Device,2262.75,35,,2262.75,percent of total billed charges,Implant Device,2262.75,35,,2262.75,percent of total billed charges,Implant Device,2262.75,35,,2262.75,percent of total billed charges,Implant Device,2262.75,35,,2262.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2198.1,34,"If Charge > 2,000, then 34 percent",2198.1,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4784.12,
BIOMET 11-301300 ARCOS CONE PRX BDY 50MM,C1776,HCPCS,,79008367,CDM,278,RC,,,both,,,26253,19427.29,,,19427.29,Other,150% of Medicare + 9.63% HCRA Surcharge,11813.85,45,,11813.85,percent of total billed charges,Critical Access Hospital RCC factor,8926.02,34,,8926.02,percent of total billed charges,Implant Device,8926.02,34,,8926.02,percent of total billed charges,Implant Device,8926.02,34,,8926.02,percent of total billed charges,Implant Device,8926.02,34,,8926.02,percent of total billed charges,Implant Device,8926.02,34,,8926.02,percent of total billed charges,Implant Device,12995.24,,,12995.24,Other,110% of Medicare,9188.55,35,,9188.55,percent of total billed charges,Implant Device,8926.02,34,"Charges > $500, x 34%",8926.02,percent of total billed charges,Implant Device,9188.55,35,,9188.55,percent of total billed charges,Implant Device,9188.55,35,,9188.55,percent of total billed charges,Implant Device,9188.55,35,,9188.55,percent of total billed charges,Implant Device,9188.55,35,,9188.55,percent of total billed charges,Implant Device,9188.55,35,,9188.55,percent of total billed charges,Implant Device,10501.2,40,,10501.2,percent of total billed charges,Implant Device,9188.55,70,,9188.55,percent of total billed charges,All Other,8926.02,34,,8926.02,percent of total billed charges,Implant Device,8926.02,34,,8926.02,percent of total billed charges,Implant Device,9188.55,35,,9188.55,percent of total billed charges,Implant Device,9188.55,35,,9188.55,percent of total billed charges,Implant Device,9188.55,35,,9188.55,percent of total billed charges,Implant Device,9188.55,35,,9188.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,8926.02,34,"If Charge > 2,000, then 34 percent",8926.02,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,19427.29,
BIOMET 12-115123 MOD HEAD 36MM +6 NECK,C1776,HCPCS,,79008368,CDM,278,RC,,,both,,,3075,2275.51,,,2275.51,Other,150% of Medicare + 9.63% HCRA Surcharge,1383.75,45,,1383.75,percent of total billed charges,Critical Access Hospital RCC factor,1045.5,34,,1045.5,percent of total billed charges,Implant Device,1045.5,34,,1045.5,percent of total billed charges,Implant Device,1045.5,34,,1045.5,percent of total billed charges,Implant Device,1045.5,34,,1045.5,percent of total billed charges,Implant Device,1045.5,34,,1045.5,percent of total billed charges,Implant Device,1522.13,,,1522.13,Other,110% of Medicare,1076.25,35,,1076.25,percent of total billed charges,Implant Device,1045.5,34,"Charges > $500, x 34%",1045.5,percent of total billed charges,Implant Device,1076.25,35,,1076.25,percent of total billed charges,Implant Device,1076.25,35,,1076.25,percent of total billed charges,Implant Device,1076.25,35,,1076.25,percent of total billed charges,Implant Device,1076.25,35,,1076.25,percent of total billed charges,Implant Device,1076.25,35,,1076.25,percent of total billed charges,Implant Device,1230,40,,1230,percent of total billed charges,Implant Device,1076.25,70,,1076.25,percent of total billed charges,All Other,1045.5,34,,1045.5,percent of total billed charges,Implant Device,1045.5,34,,1045.5,percent of total billed charges,Implant Device,1076.25,35,,1076.25,percent of total billed charges,Implant Device,1076.25,35,,1076.25,percent of total billed charges,Implant Device,1076.25,35,,1076.25,percent of total billed charges,Implant Device,1076.25,35,,1076.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1045.5,34,"If Charge > 2,000, then 34 percent",1045.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2275.51,
STRYKER WS12 SNAP OFF SCREW 2 LG 12,C1713,HCPCS,,79008369,CDM,278,RC,,,both,,,1250,925,,,925,Other,150% of Medicare + 9.63% HCRA Surcharge,562.5,45,,562.5,percent of total billed charges,Critical Access Hospital RCC factor,425,34,,425,percent of total billed charges,Implant Device,425,34,,425,percent of total billed charges,Implant Device,425,34,,425,percent of total billed charges,Implant Device,425,34,,425,percent of total billed charges,Implant Device,425,34,,425,percent of total billed charges,Implant Device,618.75,,,618.75,Other,110% of Medicare,437.5,35,,437.5,percent of total billed charges,Implant Device,425,34,"Charges > $500, x 34%",425,percent of total billed charges,Implant Device,437.5,35,,437.5,percent of total billed charges,Implant Device,437.5,35,,437.5,percent of total billed charges,Implant Device,437.5,35,,437.5,percent of total billed charges,Implant Device,437.5,35,,437.5,percent of total billed charges,Implant Device,437.5,35,,437.5,percent of total billed charges,Implant Device,500,40,,500,percent of total billed charges,Implant Device,437.5,70,,437.5,percent of total billed charges,All Other,425,34,,425,percent of total billed charges,Implant Device,425,34,,425,percent of total billed charges,Implant Device,437.5,35,,437.5,percent of total billed charges,Implant Device,437.5,35,,437.5,percent of total billed charges,Implant Device,437.5,35,,437.5,percent of total billed charges,Implant Device,437.5,35,,437.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,925,
ALPHATEC 25200-112 SOLUS LUMBAR 7DEGX12M,C1773,HCPCS,,79008371,CDM,278,RC,,,both,,,24000,17760.06,,,17760.06,Other,150% of Medicare + 9.63% HCRA Surcharge,10800,45,,10800,percent of total billed charges,Critical Access Hospital RCC factor,8160,34,,8160,percent of total billed charges,Implant Device,8160,34,,8160,percent of total billed charges,Implant Device,8160,34,,8160,percent of total billed charges,Implant Device,8160,34,,8160,percent of total billed charges,Implant Device,8160,34,,8160,percent of total billed charges,Implant Device,11880,,,11880,Other,110% of Medicare,8400,35,,8400,percent of total billed charges,Implant Device,8160,34,"Charges > $500, x 34%",8160,percent of total billed charges,Implant Device,8400,35,,8400,percent of total billed charges,Implant Device,8400,35,,8400,percent of total billed charges,Implant Device,8400,35,,8400,percent of total billed charges,Implant Device,8400,35,,8400,percent of total billed charges,Implant Device,8400,35,,8400,percent of total billed charges,Implant Device,9600,40,,9600,percent of total billed charges,Implant Device,8400,70,,8400,percent of total billed charges,All Other,8160,34,,8160,percent of total billed charges,Implant Device,8160,34,,8160,percent of total billed charges,Implant Device,8400,35,,8400,percent of total billed charges,Implant Device,8400,35,,8400,percent of total billed charges,Implant Device,8400,35,,8400,percent of total billed charges,Implant Device,8400,35,,8400,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,8160,34,"If Charge > 2,000, then 34 percent",8160,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,17760.06,
ALPHATEC 64411-210 NOVEL LUMBER 7DEGX10M,C1773,HCPCS,,79008372,CDM,278,RC,,,both,,,12000,8880.03,,,8880.03,Other,150% of Medicare + 9.63% HCRA Surcharge,5400,45,,5400,percent of total billed charges,Critical Access Hospital RCC factor,4080,34,,4080,percent of total billed charges,Implant Device,4080,34,,4080,percent of total billed charges,Implant Device,4080,34,,4080,percent of total billed charges,Implant Device,4080,34,,4080,percent of total billed charges,Implant Device,4080,34,,4080,percent of total billed charges,Implant Device,5940,,,5940,Other,110% of Medicare,4200,35,,4200,percent of total billed charges,Implant Device,4080,34,"Charges > $500, x 34%",4080,percent of total billed charges,Implant Device,4200,35,,4200,percent of total billed charges,Implant Device,4200,35,,4200,percent of total billed charges,Implant Device,4200,35,,4200,percent of total billed charges,Implant Device,4200,35,,4200,percent of total billed charges,Implant Device,4200,35,,4200,percent of total billed charges,Implant Device,4800,40,,4800,percent of total billed charges,Implant Device,4200,70,,4200,percent of total billed charges,All Other,4080,34,,4080,percent of total billed charges,Implant Device,4080,34,,4080,percent of total billed charges,Implant Device,4200,35,,4200,percent of total billed charges,Implant Device,4200,35,,4200,percent of total billed charges,Implant Device,4200,35,,4200,percent of total billed charges,Implant Device,4200,35,,4200,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,4080,34,"If Charge > 2,000, then 34 percent",4080,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,8880.03,
ALPHATEC SPINE 62004-10 ROD 100MM,C1773,HCPCS,,79008374,CDM,278,RC,,,both,,,600,444,,,444,Other,150% of Medicare + 9.63% HCRA Surcharge,270,45,,270,percent of total billed charges,Critical Access Hospital RCC factor,204,34,,204,percent of total billed charges,Implant Device,204,34,,204,percent of total billed charges,Implant Device,204,34,,204,percent of total billed charges,Implant Device,204,34,,204,percent of total billed charges,Implant Device,204,34,,204,percent of total billed charges,Implant Device,297,,,297,Other,110% of Medicare,210,35,,210,percent of total billed charges,Implant Device,204,34,"Charges > $500, x 34%",204,percent of total billed charges,Implant Device,210,35,,210,percent of total billed charges,Implant Device,210,35,,210,percent of total billed charges,Implant Device,210,35,,210,percent of total billed charges,Implant Device,210,35,,210,percent of total billed charges,Implant Device,210,35,,210,percent of total billed charges,Implant Device,240,40,,240,percent of total billed charges,Implant Device,210,70,,210,percent of total billed charges,All Other,204,34,,204,percent of total billed charges,Implant Device,204,34,,204,percent of total billed charges,Implant Device,210,35,,210,percent of total billed charges,Implant Device,210,35,,210,percent of total billed charges,Implant Device,210,35,,210,percent of total billed charges,Implant Device,210,35,,210,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,444,
ARTHREX AR-8943H-03 MEDICAL HOOK PLATE 3,C1713,HCPCS,,79008375,CDM,278,RC,,,both,,,2475,1831.51,,,1831.51,Other,150% of Medicare + 9.63% HCRA Surcharge,1113.75,45,,1113.75,percent of total billed charges,Critical Access Hospital RCC factor,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,1225.13,,,1225.13,Other,110% of Medicare,866.25,35,,866.25,percent of total billed charges,Implant Device,841.5,34,"Charges > $500, x 34%",841.5,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,990,40,,990,percent of total billed charges,Implant Device,866.25,70,,866.25,percent of total billed charges,All Other,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,841.5,34,"If Charge > 2,000, then 34 percent",841.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1831.51,
ARTHREX AR-8827-44 2.7X44MM CORT SCREW,C1713,HCPCS,,79008376,CDM,278,RC,,,both,,,135,99.9,,,99.9,Other,150% of Medicare + 9.63% HCRA Surcharge,60.75,45,,60.75,percent of total billed charges,Critical Access Hospital RCC factor,45.9,34,,45.9,percent of total billed charges,Implant Device,45.9,34,,45.9,percent of total billed charges,Implant Device,45.9,34,,45.9,percent of total billed charges,Implant Device,45.9,34,,45.9,percent of total billed charges,Implant Device,45.9,34,,45.9,percent of total billed charges,Implant Device,66.83,,,66.83,Other,110% of Medicare,47.25,35,,47.25,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,47.25,35,,47.25,percent of total billed charges,Implant Device,47.25,35,,47.25,percent of total billed charges,Implant Device,47.25,35,,47.25,percent of total billed charges,Implant Device,47.25,35,,47.25,percent of total billed charges,Implant Device,47.25,35,,47.25,percent of total billed charges,Implant Device,54,40,,54,percent of total billed charges,Implant Device,47.25,70,,47.25,percent of total billed charges,All Other,45.9,34,,45.9,percent of total billed charges,Implant Device,45.9,34,,45.9,percent of total billed charges,Implant Device,47.25,35,,47.25,percent of total billed charges,Implant Device,47.25,35,,47.25,percent of total billed charges,Implant Device,47.25,35,,47.25,percent of total billed charges,Implant Device,47.25,35,,47.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,99.9,
ARTHREX AR-8827-48 2.7X48MM CORT SCREW,C1713,HCPCS,,79008377,CDM,278,RC,,,both,,,135,99.9,,,99.9,Other,150% of Medicare + 9.63% HCRA Surcharge,60.75,45,,60.75,percent of total billed charges,Critical Access Hospital RCC factor,45.9,34,,45.9,percent of total billed charges,Implant Device,45.9,34,,45.9,percent of total billed charges,Implant Device,45.9,34,,45.9,percent of total billed charges,Implant Device,45.9,34,,45.9,percent of total billed charges,Implant Device,45.9,34,,45.9,percent of total billed charges,Implant Device,66.83,,,66.83,Other,110% of Medicare,47.25,35,,47.25,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,47.25,35,,47.25,percent of total billed charges,Implant Device,47.25,35,,47.25,percent of total billed charges,Implant Device,47.25,35,,47.25,percent of total billed charges,Implant Device,47.25,35,,47.25,percent of total billed charges,Implant Device,47.25,35,,47.25,percent of total billed charges,Implant Device,54,40,,54,percent of total billed charges,Implant Device,47.25,70,,47.25,percent of total billed charges,All Other,45.9,34,,45.9,percent of total billed charges,Implant Device,45.9,34,,45.9,percent of total billed charges,Implant Device,47.25,35,,47.25,percent of total billed charges,Implant Device,47.25,35,,47.25,percent of total billed charges,Implant Device,47.25,35,,47.25,percent of total billed charges,Implant Device,47.25,35,,47.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,99.9,
ARTHREX AR-8835L-34 3.5X34MM LOCK SCREW,C1713,HCPCS,,79008378,CDM,278,RC,,,both,,,345,255.3,,,255.3,Other,150% of Medicare + 9.63% HCRA Surcharge,155.25,45,,155.25,percent of total billed charges,Critical Access Hospital RCC factor,117.3,34,,117.3,percent of total billed charges,Implant Device,117.3,34,,117.3,percent of total billed charges,Implant Device,117.3,34,,117.3,percent of total billed charges,Implant Device,117.3,34,,117.3,percent of total billed charges,Implant Device,117.3,34,,117.3,percent of total billed charges,Implant Device,170.78,,,170.78,Other,110% of Medicare,120.75,35,,120.75,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,120.75,35,,120.75,percent of total billed charges,Implant Device,120.75,35,,120.75,percent of total billed charges,Implant Device,120.75,35,,120.75,percent of total billed charges,Implant Device,120.75,35,,120.75,percent of total billed charges,Implant Device,120.75,35,,120.75,percent of total billed charges,Implant Device,138,40,,138,percent of total billed charges,Implant Device,120.75,70,,120.75,percent of total billed charges,All Other,117.3,34,,117.3,percent of total billed charges,Implant Device,117.3,34,,117.3,percent of total billed charges,Implant Device,120.75,35,,120.75,percent of total billed charges,Implant Device,120.75,35,,120.75,percent of total billed charges,Implant Device,120.75,35,,120.75,percent of total billed charges,Implant Device,120.75,35,,120.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,255.3,
ARTHREX AR-8835L-36 3.5X36MM LOCK SCREW,C1713,HCPCS,,79008379,CDM,278,RC,,,both,,,345,255.3,,,255.3,Other,150% of Medicare + 9.63% HCRA Surcharge,155.25,45,,155.25,percent of total billed charges,Critical Access Hospital RCC factor,117.3,34,,117.3,percent of total billed charges,Implant Device,117.3,34,,117.3,percent of total billed charges,Implant Device,117.3,34,,117.3,percent of total billed charges,Implant Device,117.3,34,,117.3,percent of total billed charges,Implant Device,117.3,34,,117.3,percent of total billed charges,Implant Device,170.78,,,170.78,Other,110% of Medicare,120.75,35,,120.75,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,120.75,35,,120.75,percent of total billed charges,Implant Device,120.75,35,,120.75,percent of total billed charges,Implant Device,120.75,35,,120.75,percent of total billed charges,Implant Device,120.75,35,,120.75,percent of total billed charges,Implant Device,120.75,35,,120.75,percent of total billed charges,Implant Device,138,40,,138,percent of total billed charges,Implant Device,120.75,70,,120.75,percent of total billed charges,All Other,117.3,34,,117.3,percent of total billed charges,Implant Device,117.3,34,,117.3,percent of total billed charges,Implant Device,120.75,35,,120.75,percent of total billed charges,Implant Device,120.75,35,,120.75,percent of total billed charges,Implant Device,120.75,35,,120.75,percent of total billed charges,Implant Device,120.75,35,,120.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,255.3,
DEPUY 1570-01-090 FEM STEM SZ 3 154MM,C1776,HCPCS,,79008381,CDM,278,RC,,,both,,,11846,8766.07,,,8766.07,Other,150% of Medicare + 9.63% HCRA Surcharge,5330.7,45,,5330.7,percent of total billed charges,Critical Access Hospital RCC factor,4027.64,34,,4027.64,percent of total billed charges,Implant Device,4027.64,34,,4027.64,percent of total billed charges,Implant Device,4027.64,34,,4027.64,percent of total billed charges,Implant Device,4027.64,34,,4027.64,percent of total billed charges,Implant Device,4027.64,34,,4027.64,percent of total billed charges,Implant Device,5863.77,,,5863.77,Other,110% of Medicare,4146.1,35,,4146.1,percent of total billed charges,Implant Device,4027.64,34,"Charges > $500, x 34%",4027.64,percent of total billed charges,Implant Device,4146.1,35,,4146.1,percent of total billed charges,Implant Device,4146.1,35,,4146.1,percent of total billed charges,Implant Device,4146.1,35,,4146.1,percent of total billed charges,Implant Device,4146.1,35,,4146.1,percent of total billed charges,Implant Device,4146.1,35,,4146.1,percent of total billed charges,Implant Device,4738.4,40,,4738.4,percent of total billed charges,Implant Device,4146.1,70,,4146.1,percent of total billed charges,All Other,4027.64,34,,4027.64,percent of total billed charges,Implant Device,4027.64,34,,4027.64,percent of total billed charges,Implant Device,4146.1,35,,4146.1,percent of total billed charges,Implant Device,4146.1,35,,4146.1,percent of total billed charges,Implant Device,4146.1,35,,4146.1,percent of total billed charges,Implant Device,4146.1,35,,4146.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,4027.64,34,"If Charge > 2,000, then 34 percent",4027.64,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,8766.07,
STRYKER 627408 8H LT DIS MEDIAL PLATE,C1713,HCPCS,,79008382,CDM,278,RC,,,both,,,8085,5982.92,,,5982.92,Other,150% of Medicare + 9.63% HCRA Surcharge,3638.25,45,,3638.25,percent of total billed charges,Critical Access Hospital RCC factor,2748.9,34,,2748.9,percent of total billed charges,Implant Device,2748.9,34,,2748.9,percent of total billed charges,Implant Device,2748.9,34,,2748.9,percent of total billed charges,Implant Device,2748.9,34,,2748.9,percent of total billed charges,Implant Device,2748.9,34,,2748.9,percent of total billed charges,Implant Device,4002.08,,,4002.08,Other,110% of Medicare,2829.75,35,,2829.75,percent of total billed charges,Implant Device,2748.9,34,"Charges > $500, x 34%",2748.9,percent of total billed charges,Implant Device,2829.75,35,,2829.75,percent of total billed charges,Implant Device,2829.75,35,,2829.75,percent of total billed charges,Implant Device,2829.75,35,,2829.75,percent of total billed charges,Implant Device,2829.75,35,,2829.75,percent of total billed charges,Implant Device,2829.75,35,,2829.75,percent of total billed charges,Implant Device,3234,40,,3234,percent of total billed charges,Implant Device,2829.75,70,,2829.75,percent of total billed charges,All Other,2748.9,34,,2748.9,percent of total billed charges,Implant Device,2748.9,34,,2748.9,percent of total billed charges,Implant Device,2829.75,35,,2829.75,percent of total billed charges,Implant Device,2829.75,35,,2829.75,percent of total billed charges,Implant Device,2829.75,35,,2829.75,percent of total billed charges,Implant Device,2829.75,35,,2829.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2748.9,34,"If Charge > 2,000, then 34 percent",2748.9,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5982.92,
STRYKER 661422 3.5X22MM NONLOCK SCREW,C1713,HCPCS,,79008383,CDM,278,RC,,,both,,,132,97.68,,,97.68,Other,150% of Medicare + 9.63% HCRA Surcharge,59.4,45,,59.4,percent of total billed charges,Critical Access Hospital RCC factor,44.88,34,,44.88,percent of total billed charges,Implant Device,44.88,34,,44.88,percent of total billed charges,Implant Device,44.88,34,,44.88,percent of total billed charges,Implant Device,44.88,34,,44.88,percent of total billed charges,Implant Device,44.88,34,,44.88,percent of total billed charges,Implant Device,65.34,,,65.34,Other,110% of Medicare,46.2,35,,46.2,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,46.2,35,,46.2,percent of total billed charges,Implant Device,46.2,35,,46.2,percent of total billed charges,Implant Device,46.2,35,,46.2,percent of total billed charges,Implant Device,46.2,35,,46.2,percent of total billed charges,Implant Device,46.2,35,,46.2,percent of total billed charges,Implant Device,52.8,40,,52.8,percent of total billed charges,Implant Device,46.2,70,,46.2,percent of total billed charges,All Other,44.88,34,,44.88,percent of total billed charges,Implant Device,44.88,34,,44.88,percent of total billed charges,Implant Device,46.2,35,,46.2,percent of total billed charges,Implant Device,46.2,35,,46.2,percent of total billed charges,Implant Device,46.2,35,,46.2,percent of total billed charges,Implant Device,46.2,35,,46.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,97.68,
STRYKER 661424 3.5X24MM NONLOCK SCREW,C1713,HCPCS,,79008384,CDM,278,RC,,,both,,,132,97.68,,,97.68,Other,150% of Medicare + 9.63% HCRA Surcharge,59.4,45,,59.4,percent of total billed charges,Critical Access Hospital RCC factor,44.88,34,,44.88,percent of total billed charges,Implant Device,44.88,34,,44.88,percent of total billed charges,Implant Device,44.88,34,,44.88,percent of total billed charges,Implant Device,44.88,34,,44.88,percent of total billed charges,Implant Device,44.88,34,,44.88,percent of total billed charges,Implant Device,65.34,,,65.34,Other,110% of Medicare,46.2,35,,46.2,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,46.2,35,,46.2,percent of total billed charges,Implant Device,46.2,35,,46.2,percent of total billed charges,Implant Device,46.2,35,,46.2,percent of total billed charges,Implant Device,46.2,35,,46.2,percent of total billed charges,Implant Device,46.2,35,,46.2,percent of total billed charges,Implant Device,52.8,40,,52.8,percent of total billed charges,Implant Device,46.2,70,,46.2,percent of total billed charges,All Other,44.88,34,,44.88,percent of total billed charges,Implant Device,44.88,34,,44.88,percent of total billed charges,Implant Device,46.2,35,,46.2,percent of total billed charges,Implant Device,46.2,35,,46.2,percent of total billed charges,Implant Device,46.2,35,,46.2,percent of total billed charges,Implant Device,46.2,35,,46.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,97.68,
STRYKER 661434 3.5X34MM NONLOCK SCREW,C1713,HCPCS,,79008385,CDM,278,RC,,,both,,,132,97.68,,,97.68,Other,150% of Medicare + 9.63% HCRA Surcharge,59.4,45,,59.4,percent of total billed charges,Critical Access Hospital RCC factor,44.88,34,,44.88,percent of total billed charges,Implant Device,44.88,34,,44.88,percent of total billed charges,Implant Device,44.88,34,,44.88,percent of total billed charges,Implant Device,44.88,34,,44.88,percent of total billed charges,Implant Device,44.88,34,,44.88,percent of total billed charges,Implant Device,65.34,,,65.34,Other,110% of Medicare,46.2,35,,46.2,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,46.2,35,,46.2,percent of total billed charges,Implant Device,46.2,35,,46.2,percent of total billed charges,Implant Device,46.2,35,,46.2,percent of total billed charges,Implant Device,46.2,35,,46.2,percent of total billed charges,Implant Device,46.2,35,,46.2,percent of total billed charges,Implant Device,52.8,40,,52.8,percent of total billed charges,Implant Device,46.2,70,,46.2,percent of total billed charges,All Other,44.88,34,,44.88,percent of total billed charges,Implant Device,44.88,34,,44.88,percent of total billed charges,Implant Device,46.2,35,,46.2,percent of total billed charges,Implant Device,46.2,35,,46.2,percent of total billed charges,Implant Device,46.2,35,,46.2,percent of total billed charges,Implant Device,46.2,35,,46.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,97.68,
STRYKER 661436 3.5X36MM NONLOCK SCREW,C1713,HCPCS,,79008386,CDM,278,RC,,,both,,,122,90.28,,,90.28,Other,150% of Medicare + 9.63% HCRA Surcharge,54.9,45,,54.9,percent of total billed charges,Critical Access Hospital RCC factor,41.48,34,,41.48,percent of total billed charges,Implant Device,41.48,34,,41.48,percent of total billed charges,Implant Device,41.48,34,,41.48,percent of total billed charges,Implant Device,41.48,34,,41.48,percent of total billed charges,Implant Device,41.48,34,,41.48,percent of total billed charges,Implant Device,60.39,,,60.39,Other,110% of Medicare,42.7,35,,42.7,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,42.7,35,,42.7,percent of total billed charges,Implant Device,42.7,35,,42.7,percent of total billed charges,Implant Device,42.7,35,,42.7,percent of total billed charges,Implant Device,42.7,35,,42.7,percent of total billed charges,Implant Device,42.7,35,,42.7,percent of total billed charges,Implant Device,48.8,40,,48.8,percent of total billed charges,Implant Device,42.7,70,,42.7,percent of total billed charges,All Other,41.48,34,,41.48,percent of total billed charges,Implant Device,41.48,34,,41.48,percent of total billed charges,Implant Device,42.7,35,,42.7,percent of total billed charges,Implant Device,42.7,35,,42.7,percent of total billed charges,Implant Device,42.7,35,,42.7,percent of total billed charges,Implant Device,42.7,35,,42.7,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,90.28,
STRYKER 661026 4.0X26MM LOCKING SCREW,C1713,HCPCS,,79008387,CDM,278,RC,,,both,,,792,586.08,,,586.08,Other,150% of Medicare + 9.63% HCRA Surcharge,356.4,45,,356.4,percent of total billed charges,Critical Access Hospital RCC factor,269.28,34,,269.28,percent of total billed charges,Implant Device,269.28,34,,269.28,percent of total billed charges,Implant Device,269.28,34,,269.28,percent of total billed charges,Implant Device,269.28,34,,269.28,percent of total billed charges,Implant Device,269.28,34,,269.28,percent of total billed charges,Implant Device,392.04,,,392.04,Other,110% of Medicare,277.2,35,,277.2,percent of total billed charges,Implant Device,269.28,34,"Charges > $500, x 34%",269.28,percent of total billed charges,Implant Device,277.2,35,,277.2,percent of total billed charges,Implant Device,277.2,35,,277.2,percent of total billed charges,Implant Device,277.2,35,,277.2,percent of total billed charges,Implant Device,277.2,35,,277.2,percent of total billed charges,Implant Device,277.2,35,,277.2,percent of total billed charges,Implant Device,316.8,40,,316.8,percent of total billed charges,Implant Device,277.2,70,,277.2,percent of total billed charges,All Other,269.28,34,,269.28,percent of total billed charges,Implant Device,269.28,34,,269.28,percent of total billed charges,Implant Device,277.2,35,,277.2,percent of total billed charges,Implant Device,277.2,35,,277.2,percent of total billed charges,Implant Device,277.2,35,,277.2,percent of total billed charges,Implant Device,277.2,35,,277.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,586.08,
STRYKER 661038 4.0X38MM LOCKING SCREW,C1713,HCPCS,,79008388,CDM,278,RC,,,both,,,630,466.2,,,466.2,Other,150% of Medicare + 9.63% HCRA Surcharge,283.5,45,,283.5,percent of total billed charges,Critical Access Hospital RCC factor,214.2,34,,214.2,percent of total billed charges,Implant Device,214.2,34,,214.2,percent of total billed charges,Implant Device,214.2,34,,214.2,percent of total billed charges,Implant Device,214.2,34,,214.2,percent of total billed charges,Implant Device,214.2,34,,214.2,percent of total billed charges,Implant Device,311.85,,,311.85,Other,110% of Medicare,220.5,35,,220.5,percent of total billed charges,Implant Device,214.2,34,"Charges > $500, x 34%",214.2,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,252,40,,252,percent of total billed charges,Implant Device,220.5,70,,220.5,percent of total billed charges,All Other,214.2,34,,214.2,percent of total billed charges,Implant Device,214.2,34,,214.2,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,466.2,
STRYKER 661044 4.0X44MM LOCKING SCREW,C1713,HCPCS,,79008389,CDM,278,RC,,,both,,,583,431.42,,,431.42,Other,150% of Medicare + 9.63% HCRA Surcharge,262.35,45,,262.35,percent of total billed charges,Critical Access Hospital RCC factor,198.22,34,,198.22,percent of total billed charges,Implant Device,198.22,34,,198.22,percent of total billed charges,Implant Device,198.22,34,,198.22,percent of total billed charges,Implant Device,198.22,34,,198.22,percent of total billed charges,Implant Device,198.22,34,,198.22,percent of total billed charges,Implant Device,288.59,,,288.59,Other,110% of Medicare,204.05,35,,204.05,percent of total billed charges,Implant Device,198.22,34,"Charges > $500, x 34%",198.22,percent of total billed charges,Implant Device,204.05,35,,204.05,percent of total billed charges,Implant Device,204.05,35,,204.05,percent of total billed charges,Implant Device,204.05,35,,204.05,percent of total billed charges,Implant Device,204.05,35,,204.05,percent of total billed charges,Implant Device,204.05,35,,204.05,percent of total billed charges,Implant Device,233.2,40,,233.2,percent of total billed charges,Implant Device,204.05,70,,204.05,percent of total billed charges,All Other,198.22,34,,198.22,percent of total billed charges,Implant Device,198.22,34,,198.22,percent of total billed charges,Implant Device,204.05,35,,204.05,percent of total billed charges,Implant Device,204.05,35,,204.05,percent of total billed charges,Implant Device,204.05,35,,204.05,percent of total billed charges,Implant Device,204.05,35,,204.05,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,431.42,
STRYKER 661042 4.0X42MM LOCKING SCREW,C1713,HCPCS,,79008390,CDM,278,RC,,,both,,,630,466.2,,,466.2,Other,150% of Medicare + 9.63% HCRA Surcharge,283.5,45,,283.5,percent of total billed charges,Critical Access Hospital RCC factor,214.2,34,,214.2,percent of total billed charges,Implant Device,214.2,34,,214.2,percent of total billed charges,Implant Device,214.2,34,,214.2,percent of total billed charges,Implant Device,214.2,34,,214.2,percent of total billed charges,Implant Device,214.2,34,,214.2,percent of total billed charges,Implant Device,311.85,,,311.85,Other,110% of Medicare,220.5,35,,220.5,percent of total billed charges,Implant Device,214.2,34,"Charges > $500, x 34%",214.2,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,252,40,,252,percent of total billed charges,Implant Device,220.5,70,,220.5,percent of total billed charges,All Other,214.2,34,,214.2,percent of total billed charges,Implant Device,214.2,34,,214.2,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,466.2,
STRYKER 607336 4.0X36MM CANCELLOUSSCREW,C1713,HCPCS,,79008391,CDM,278,RC,,,both,,,186,137.64,,,137.64,Other,150% of Medicare + 9.63% HCRA Surcharge,83.7,45,,83.7,percent of total billed charges,Critical Access Hospital RCC factor,63.24,34,,63.24,percent of total billed charges,Implant Device,63.24,34,,63.24,percent of total billed charges,Implant Device,63.24,34,,63.24,percent of total billed charges,Implant Device,63.24,34,,63.24,percent of total billed charges,Implant Device,63.24,34,,63.24,percent of total billed charges,Implant Device,92.07,,,92.07,Other,110% of Medicare,65.1,35,,65.1,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,65.1,35,,65.1,percent of total billed charges,Implant Device,65.1,35,,65.1,percent of total billed charges,Implant Device,65.1,35,,65.1,percent of total billed charges,Implant Device,65.1,35,,65.1,percent of total billed charges,Implant Device,65.1,35,,65.1,percent of total billed charges,Implant Device,74.4,40,,74.4,percent of total billed charges,Implant Device,65.1,70,,65.1,percent of total billed charges,All Other,63.24,34,,63.24,percent of total billed charges,Implant Device,63.24,34,,63.24,percent of total billed charges,Implant Device,65.1,35,,65.1,percent of total billed charges,Implant Device,65.1,35,,65.1,percent of total billed charges,Implant Device,65.1,35,,65.1,percent of total billed charges,Implant Device,65.1,35,,65.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,137.64,
ZIMMER 00-5988-021-18 OFFSET STEM 18X200,C1776,HCPCS,,79008392,CDM,278,RC,,,both,,,4905,3629.71,,,3629.71,Other,150% of Medicare + 9.63% HCRA Surcharge,2207.25,45,,2207.25,percent of total billed charges,Critical Access Hospital RCC factor,1667.7,34,,1667.7,percent of total billed charges,Implant Device,1667.7,34,,1667.7,percent of total billed charges,Implant Device,1667.7,34,,1667.7,percent of total billed charges,Implant Device,1667.7,34,,1667.7,percent of total billed charges,Implant Device,1667.7,34,,1667.7,percent of total billed charges,Implant Device,2427.98,,,2427.98,Other,110% of Medicare,1716.75,35,,1716.75,percent of total billed charges,Implant Device,1667.7,34,"Charges > $500, x 34%",1667.7,percent of total billed charges,Implant Device,1716.75,35,,1716.75,percent of total billed charges,Implant Device,1716.75,35,,1716.75,percent of total billed charges,Implant Device,1716.75,35,,1716.75,percent of total billed charges,Implant Device,1716.75,35,,1716.75,percent of total billed charges,Implant Device,1716.75,35,,1716.75,percent of total billed charges,Implant Device,1962,40,,1962,percent of total billed charges,Implant Device,1716.75,70,,1716.75,percent of total billed charges,All Other,1667.7,34,,1667.7,percent of total billed charges,Implant Device,1667.7,34,,1667.7,percent of total billed charges,Implant Device,1716.75,35,,1716.75,percent of total billed charges,Implant Device,1716.75,35,,1716.75,percent of total billed charges,Implant Device,1716.75,35,,1716.75,percent of total billed charges,Implant Device,1716.75,35,,1716.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1667.7,34,"If Charge > 2,000, then 34 percent",1667.7,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3629.71,
ZIMMER 00-5980-057-02 TIBIAL PLATE SZ 8,C1713,HCPCS,,79008393,CDM,278,RC,,,both,,,2304,1704.97,,,1704.97,Other,150% of Medicare + 9.63% HCRA Surcharge,1036.8,45,,1036.8,percent of total billed charges,Critical Access Hospital RCC factor,783.36,34,,783.36,percent of total billed charges,Implant Device,783.36,34,,783.36,percent of total billed charges,Implant Device,783.36,34,,783.36,percent of total billed charges,Implant Device,783.36,34,,783.36,percent of total billed charges,Implant Device,783.36,34,,783.36,percent of total billed charges,Implant Device,1140.48,,,1140.48,Other,110% of Medicare,806.4,35,,806.4,percent of total billed charges,Implant Device,783.36,34,"Charges > $500, x 34%",783.36,percent of total billed charges,Implant Device,806.4,35,,806.4,percent of total billed charges,Implant Device,806.4,35,,806.4,percent of total billed charges,Implant Device,806.4,35,,806.4,percent of total billed charges,Implant Device,806.4,35,,806.4,percent of total billed charges,Implant Device,806.4,35,,806.4,percent of total billed charges,Implant Device,921.6,40,,921.6,percent of total billed charges,Implant Device,806.4,70,,806.4,percent of total billed charges,All Other,783.36,34,,783.36,percent of total billed charges,Implant Device,783.36,34,,783.36,percent of total billed charges,Implant Device,806.4,35,,806.4,percent of total billed charges,Implant Device,806.4,35,,806.4,percent of total billed charges,Implant Device,806.4,35,,806.4,percent of total billed charges,Implant Device,806.4,35,,806.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,783.36,34,"If Charge > 2,000, then 34 percent",783.36,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1704.97,
ZIMMER 00-5988-008-10 TIB AUG 10MM SZ 8,C1776,HCPCS,,79008394,CDM,278,RC,,,both,,,3968,2936.33,,,2936.33,Other,150% of Medicare + 9.63% HCRA Surcharge,1785.6,45,,1785.6,percent of total billed charges,Critical Access Hospital RCC factor,1349.12,34,,1349.12,percent of total billed charges,Implant Device,1349.12,34,,1349.12,percent of total billed charges,Implant Device,1349.12,34,,1349.12,percent of total billed charges,Implant Device,1349.12,34,,1349.12,percent of total billed charges,Implant Device,1349.12,34,,1349.12,percent of total billed charges,Implant Device,1964.16,,,1964.16,Other,110% of Medicare,1388.8,35,,1388.8,percent of total billed charges,Implant Device,1349.12,34,"Charges > $500, x 34%",1349.12,percent of total billed charges,Implant Device,1388.8,35,,1388.8,percent of total billed charges,Implant Device,1388.8,35,,1388.8,percent of total billed charges,Implant Device,1388.8,35,,1388.8,percent of total billed charges,Implant Device,1388.8,35,,1388.8,percent of total billed charges,Implant Device,1388.8,35,,1388.8,percent of total billed charges,Implant Device,1587.2,40,,1587.2,percent of total billed charges,Implant Device,1388.8,70,,1388.8,percent of total billed charges,All Other,1349.12,34,,1349.12,percent of total billed charges,Implant Device,1349.12,34,,1349.12,percent of total billed charges,Implant Device,1388.8,35,,1388.8,percent of total billed charges,Implant Device,1388.8,35,,1388.8,percent of total billed charges,Implant Device,1388.8,35,,1388.8,percent of total billed charges,Implant Device,1388.8,35,,1388.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1349.12,34,"If Charge > 2,000, then 34 percent",1349.12,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2936.33,
DEPUY 1024-52-400 TIBIAL TRAY SZ 4 RM/LL,C1776,HCPCS,,79008395,CDM,278,RC,,,both,,,3600,2664.01,,,2664.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1620,45,,1620,percent of total billed charges,Critical Access Hospital RCC factor,1224,34,,1224,percent of total billed charges,Implant Device,1224,34,,1224,percent of total billed charges,Implant Device,1224,34,,1224,percent of total billed charges,Implant Device,1224,34,,1224,percent of total billed charges,Implant Device,1224,34,,1224,percent of total billed charges,Implant Device,1782,,,1782,Other,110% of Medicare,1260,35,,1260,percent of total billed charges,Implant Device,1224,34,"Charges > $500, x 34%",1224,percent of total billed charges,Implant Device,1260,35,,1260,percent of total billed charges,Implant Device,1260,35,,1260,percent of total billed charges,Implant Device,1260,35,,1260,percent of total billed charges,Implant Device,1260,35,,1260,percent of total billed charges,Implant Device,1260,35,,1260,percent of total billed charges,Implant Device,1440,40,,1440,percent of total billed charges,Implant Device,1260,70,,1260,percent of total billed charges,All Other,1224,34,,1224,percent of total billed charges,Implant Device,1224,34,,1224,percent of total billed charges,Implant Device,1260,35,,1260,percent of total billed charges,Implant Device,1260,35,,1260,percent of total billed charges,Implant Device,1260,35,,1260,percent of total billed charges,Implant Device,1260,35,,1260,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1224,34,"If Charge > 2,000, then 34 percent",1224,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2664.01,
DEPUY 1024-54-408 TIB INSERT SZ 4RM/LL 8,C1776,HCPCS,,79008396,CDM,278,RC,,,both,,,2495,1846.31,,,1846.31,Other,150% of Medicare + 9.63% HCRA Surcharge,1122.75,45,,1122.75,percent of total billed charges,Critical Access Hospital RCC factor,848.3,34,,848.3,percent of total billed charges,Implant Device,848.3,34,,848.3,percent of total billed charges,Implant Device,848.3,34,,848.3,percent of total billed charges,Implant Device,848.3,34,,848.3,percent of total billed charges,Implant Device,848.3,34,,848.3,percent of total billed charges,Implant Device,1235.03,,,1235.03,Other,110% of Medicare,873.25,35,,873.25,percent of total billed charges,Implant Device,848.3,34,"Charges > $500, x 34%",848.3,percent of total billed charges,Implant Device,873.25,35,,873.25,percent of total billed charges,Implant Device,873.25,35,,873.25,percent of total billed charges,Implant Device,873.25,35,,873.25,percent of total billed charges,Implant Device,873.25,35,,873.25,percent of total billed charges,Implant Device,873.25,35,,873.25,percent of total billed charges,Implant Device,998,40,,998,percent of total billed charges,Implant Device,873.25,70,,873.25,percent of total billed charges,All Other,848.3,34,,848.3,percent of total billed charges,Implant Device,848.3,34,,848.3,percent of total billed charges,Implant Device,873.25,35,,873.25,percent of total billed charges,Implant Device,873.25,35,,873.25,percent of total billed charges,Implant Device,873.25,35,,873.25,percent of total billed charges,Implant Device,873.25,35,,873.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,848.3,34,"If Charge > 2,000, then 34 percent",848.3,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1846.31,
COVIDIEN PC03020X PARIETEX MESH 20X30,C1781,HCPCS,,79008397,CDM,278,RC,,,both,,,5737,4245.39,,,4245.39,Other,150% of Medicare + 9.63% HCRA Surcharge,2581.65,45,,2581.65,percent of total billed charges,Critical Access Hospital RCC factor,1950.58,34,,1950.58,percent of total billed charges,Implant Device,1950.58,34,,1950.58,percent of total billed charges,Implant Device,1950.58,34,,1950.58,percent of total billed charges,Implant Device,1950.58,34,,1950.58,percent of total billed charges,Implant Device,1950.58,34,,1950.58,percent of total billed charges,Implant Device,2839.82,,,2839.82,Other,110% of Medicare,2007.95,35,,2007.95,percent of total billed charges,Implant Device,1950.58,34,"Charges > $500, x 34%",1950.58,percent of total billed charges,Implant Device,2007.95,35,,2007.95,percent of total billed charges,Implant Device,2007.95,35,,2007.95,percent of total billed charges,Implant Device,2007.95,35,,2007.95,percent of total billed charges,Implant Device,2007.95,35,,2007.95,percent of total billed charges,Implant Device,2007.95,35,,2007.95,percent of total billed charges,Implant Device,2294.8,40,,2294.8,percent of total billed charges,Implant Device,2007.95,70,,2007.95,percent of total billed charges,All Other,1950.58,34,,1950.58,percent of total billed charges,Implant Device,1950.58,34,,1950.58,percent of total billed charges,Implant Device,2007.95,35,,2007.95,percent of total billed charges,Implant Device,2007.95,35,,2007.95,percent of total billed charges,Implant Device,2007.95,35,,2007.95,percent of total billed charges,Implant Device,2007.95,35,,2007.95,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1950.58,34,"If Charge > 2,000, then 34 percent",1950.58,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4245.39,
STRYKER ORTHO 628203 PLATE LATERAL 3H,C1713,HCPCS,,79008398,CDM,278,RC,,,both,,,3069,2271.07,,,2271.07,Other,150% of Medicare + 9.63% HCRA Surcharge,1381.05,45,,1381.05,percent of total billed charges,Critical Access Hospital RCC factor,1043.46,34,,1043.46,percent of total billed charges,Implant Device,1043.46,34,,1043.46,percent of total billed charges,Implant Device,1043.46,34,,1043.46,percent of total billed charges,Implant Device,1043.46,34,,1043.46,percent of total billed charges,Implant Device,1043.46,34,,1043.46,percent of total billed charges,Implant Device,1519.16,,,1519.16,Other,110% of Medicare,1074.15,35,,1074.15,percent of total billed charges,Implant Device,1043.46,34,"Charges > $500, x 34%",1043.46,percent of total billed charges,Implant Device,1074.15,35,,1074.15,percent of total billed charges,Implant Device,1074.15,35,,1074.15,percent of total billed charges,Implant Device,1074.15,35,,1074.15,percent of total billed charges,Implant Device,1074.15,35,,1074.15,percent of total billed charges,Implant Device,1074.15,35,,1074.15,percent of total billed charges,Implant Device,1227.6,40,,1227.6,percent of total billed charges,Implant Device,1074.15,70,,1074.15,percent of total billed charges,All Other,1043.46,34,,1043.46,percent of total billed charges,Implant Device,1043.46,34,,1043.46,percent of total billed charges,Implant Device,1074.15,35,,1074.15,percent of total billed charges,Implant Device,1074.15,35,,1074.15,percent of total billed charges,Implant Device,1074.15,35,,1074.15,percent of total billed charges,Implant Device,1074.15,35,,1074.15,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1043.46,34,"If Charge > 2,000, then 34 percent",1043.46,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2271.07,
STRYKER 614512 LOCKING SCREW 2.7X12MM,C1713,HCPCS,,79008399,CDM,278,RC,,,both,,,727,537.98,,,537.98,Other,150% of Medicare + 9.63% HCRA Surcharge,327.15,45,,327.15,percent of total billed charges,Critical Access Hospital RCC factor,247.18,34,,247.18,percent of total billed charges,Implant Device,247.18,34,,247.18,percent of total billed charges,Implant Device,247.18,34,,247.18,percent of total billed charges,Implant Device,247.18,34,,247.18,percent of total billed charges,Implant Device,247.18,34,,247.18,percent of total billed charges,Implant Device,359.87,,,359.87,Other,110% of Medicare,254.45,35,,254.45,percent of total billed charges,Implant Device,247.18,34,"Charges > $500, x 34%",247.18,percent of total billed charges,Implant Device,254.45,35,,254.45,percent of total billed charges,Implant Device,254.45,35,,254.45,percent of total billed charges,Implant Device,254.45,35,,254.45,percent of total billed charges,Implant Device,254.45,35,,254.45,percent of total billed charges,Implant Device,254.45,35,,254.45,percent of total billed charges,Implant Device,290.8,40,,290.8,percent of total billed charges,Implant Device,254.45,70,,254.45,percent of total billed charges,All Other,247.18,34,,247.18,percent of total billed charges,Implant Device,247.18,34,,247.18,percent of total billed charges,Implant Device,254.45,35,,254.45,percent of total billed charges,Implant Device,254.45,35,,254.45,percent of total billed charges,Implant Device,254.45,35,,254.45,percent of total billed charges,Implant Device,254.45,35,,254.45,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,537.98,
STRYKER 614516 LOCKING PLATE 2.7X16MM,C1713,HCPCS,,79008400,CDM,278,RC,,,both,,,727,537.98,,,537.98,Other,150% of Medicare + 9.63% HCRA Surcharge,327.15,45,,327.15,percent of total billed charges,Critical Access Hospital RCC factor,247.18,34,,247.18,percent of total billed charges,Implant Device,247.18,34,,247.18,percent of total billed charges,Implant Device,247.18,34,,247.18,percent of total billed charges,Implant Device,247.18,34,,247.18,percent of total billed charges,Implant Device,247.18,34,,247.18,percent of total billed charges,Implant Device,359.87,,,359.87,Other,110% of Medicare,254.45,35,,254.45,percent of total billed charges,Implant Device,247.18,34,"Charges > $500, x 34%",247.18,percent of total billed charges,Implant Device,254.45,35,,254.45,percent of total billed charges,Implant Device,254.45,35,,254.45,percent of total billed charges,Implant Device,254.45,35,,254.45,percent of total billed charges,Implant Device,254.45,35,,254.45,percent of total billed charges,Implant Device,254.45,35,,254.45,percent of total billed charges,Implant Device,290.8,40,,290.8,percent of total billed charges,Implant Device,254.45,70,,254.45,percent of total billed charges,All Other,247.18,34,,247.18,percent of total billed charges,Implant Device,247.18,34,,247.18,percent of total billed charges,Implant Device,254.45,35,,254.45,percent of total billed charges,Implant Device,254.45,35,,254.45,percent of total billed charges,Implant Device,254.45,35,,254.45,percent of total billed charges,Implant Device,254.45,35,,254.45,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,537.98,
STRYKER 614514 LOCKING PLATE 2.7X14MM,C1713,HCPCS,,79008401,CDM,278,RC,,,both,,,727,537.98,,,537.98,Other,150% of Medicare + 9.63% HCRA Surcharge,327.15,45,,327.15,percent of total billed charges,Critical Access Hospital RCC factor,247.18,34,,247.18,percent of total billed charges,Implant Device,247.18,34,,247.18,percent of total billed charges,Implant Device,247.18,34,,247.18,percent of total billed charges,Implant Device,247.18,34,,247.18,percent of total billed charges,Implant Device,247.18,34,,247.18,percent of total billed charges,Implant Device,359.87,,,359.87,Other,110% of Medicare,254.45,35,,254.45,percent of total billed charges,Implant Device,247.18,34,"Charges > $500, x 34%",247.18,percent of total billed charges,Implant Device,254.45,35,,254.45,percent of total billed charges,Implant Device,254.45,35,,254.45,percent of total billed charges,Implant Device,254.45,35,,254.45,percent of total billed charges,Implant Device,254.45,35,,254.45,percent of total billed charges,Implant Device,254.45,35,,254.45,percent of total billed charges,Implant Device,290.8,40,,290.8,percent of total billed charges,Implant Device,254.45,70,,254.45,percent of total billed charges,All Other,247.18,34,,247.18,percent of total billed charges,Implant Device,247.18,34,,247.18,percent of total billed charges,Implant Device,254.45,35,,254.45,percent of total billed charges,Implant Device,254.45,35,,254.45,percent of total billed charges,Implant Device,254.45,35,,254.45,percent of total billed charges,Implant Device,254.45,35,,254.45,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,537.98,
STRYKER 54-25428S PLATE XXL VOLAR 2.7MM,C1713,HCPCS,,79008402,CDM,278,RC,,,both,,,6072,4493.3,,,4493.3,Other,150% of Medicare + 9.63% HCRA Surcharge,2732.4,45,,2732.4,percent of total billed charges,Critical Access Hospital RCC factor,2064.48,34,,2064.48,percent of total billed charges,Implant Device,2064.48,34,,2064.48,percent of total billed charges,Implant Device,2064.48,34,,2064.48,percent of total billed charges,Implant Device,2064.48,34,,2064.48,percent of total billed charges,Implant Device,2064.48,34,,2064.48,percent of total billed charges,Implant Device,3005.64,,,3005.64,Other,110% of Medicare,2125.2,35,,2125.2,percent of total billed charges,Implant Device,2064.48,34,"Charges > $500, x 34%",2064.48,percent of total billed charges,Implant Device,2125.2,35,,2125.2,percent of total billed charges,Implant Device,2125.2,35,,2125.2,percent of total billed charges,Implant Device,2125.2,35,,2125.2,percent of total billed charges,Implant Device,2125.2,35,,2125.2,percent of total billed charges,Implant Device,2125.2,35,,2125.2,percent of total billed charges,Implant Device,2428.8,40,,2428.8,percent of total billed charges,Implant Device,2125.2,70,,2125.2,percent of total billed charges,All Other,2064.48,34,,2064.48,percent of total billed charges,Implant Device,2064.48,34,,2064.48,percent of total billed charges,Implant Device,2125.2,35,,2125.2,percent of total billed charges,Implant Device,2125.2,35,,2125.2,percent of total billed charges,Implant Device,2125.2,35,,2125.2,percent of total billed charges,Implant Device,2125.2,35,,2125.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2064.48,34,"If Charge > 2,000, then 34 percent",2064.48,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4493.3,
STRYKER 656426 NON LOCKNG SCREW 2.7X26MM,C1713,HCPCS,,79008403,CDM,278,RC,,,both,,,258,190.92,,,190.92,Other,150% of Medicare + 9.63% HCRA Surcharge,116.1,45,,116.1,percent of total billed charges,Critical Access Hospital RCC factor,87.72,34,,87.72,percent of total billed charges,Implant Device,87.72,34,,87.72,percent of total billed charges,Implant Device,87.72,34,,87.72,percent of total billed charges,Implant Device,87.72,34,,87.72,percent of total billed charges,Implant Device,87.72,34,,87.72,percent of total billed charges,Implant Device,127.71,,,127.71,Other,110% of Medicare,90.3,35,,90.3,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,90.3,35,,90.3,percent of total billed charges,Implant Device,90.3,35,,90.3,percent of total billed charges,Implant Device,90.3,35,,90.3,percent of total billed charges,Implant Device,90.3,35,,90.3,percent of total billed charges,Implant Device,90.3,35,,90.3,percent of total billed charges,Implant Device,103.2,40,,103.2,percent of total billed charges,Implant Device,90.3,70,,90.3,percent of total billed charges,All Other,87.72,34,,87.72,percent of total billed charges,Implant Device,87.72,34,,87.72,percent of total billed charges,Implant Device,90.3,35,,90.3,percent of total billed charges,Implant Device,90.3,35,,90.3,percent of total billed charges,Implant Device,90.3,35,,90.3,percent of total billed charges,Implant Device,90.3,35,,90.3,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,190.92,
STRYKER 656318 LOCKING SCREW 2.7X18MM,C1713,HCPCS,,79008404,CDM,278,RC,,,both,,,480,355.2,,,355.2,Other,150% of Medicare + 9.63% HCRA Surcharge,216,45,,216,percent of total billed charges,Critical Access Hospital RCC factor,163.2,34,,163.2,percent of total billed charges,Implant Device,163.2,34,,163.2,percent of total billed charges,Implant Device,163.2,34,,163.2,percent of total billed charges,Implant Device,163.2,34,,163.2,percent of total billed charges,Implant Device,163.2,34,,163.2,percent of total billed charges,Implant Device,237.6,,,237.6,Other,110% of Medicare,168,35,,168,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,192,40,,192,percent of total billed charges,Implant Device,168,70,,168,percent of total billed charges,All Other,163.2,34,,163.2,percent of total billed charges,Implant Device,163.2,34,,163.2,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,355.2,
STRYKER 656322 LOCKING SCREW 2.7X22MM,C1713,HCPCS,,79008405,CDM,278,RC,,,both,,,480,355.2,,,355.2,Other,150% of Medicare + 9.63% HCRA Surcharge,216,45,,216,percent of total billed charges,Critical Access Hospital RCC factor,163.2,34,,163.2,percent of total billed charges,Implant Device,163.2,34,,163.2,percent of total billed charges,Implant Device,163.2,34,,163.2,percent of total billed charges,Implant Device,163.2,34,,163.2,percent of total billed charges,Implant Device,163.2,34,,163.2,percent of total billed charges,Implant Device,237.6,,,237.6,Other,110% of Medicare,168,35,,168,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,192,40,,192,percent of total billed charges,Implant Device,168,70,,168,percent of total billed charges,All Other,163.2,34,,163.2,percent of total billed charges,Implant Device,163.2,34,,163.2,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,355.2,
ARTHREX AR-7000-32PT PT SCREW 3.75X32MM,C1713,HCPCS,,79008407,CDM,278,RC,,,both,,,858,634.92,,,634.92,Other,150% of Medicare + 9.63% HCRA Surcharge,386.1,45,,386.1,percent of total billed charges,Critical Access Hospital RCC factor,291.72,34,,291.72,percent of total billed charges,Implant Device,291.72,34,,291.72,percent of total billed charges,Implant Device,291.72,34,,291.72,percent of total billed charges,Implant Device,291.72,34,,291.72,percent of total billed charges,Implant Device,291.72,34,,291.72,percent of total billed charges,Implant Device,424.71,,,424.71,Other,110% of Medicare,300.3,35,,300.3,percent of total billed charges,Implant Device,291.72,34,"Charges > $500, x 34%",291.72,percent of total billed charges,Implant Device,300.3,35,,300.3,percent of total billed charges,Implant Device,300.3,35,,300.3,percent of total billed charges,Implant Device,300.3,35,,300.3,percent of total billed charges,Implant Device,300.3,35,,300.3,percent of total billed charges,Implant Device,300.3,35,,300.3,percent of total billed charges,Implant Device,343.2,40,,343.2,percent of total billed charges,Implant Device,300.3,70,,300.3,percent of total billed charges,All Other,291.72,34,,291.72,percent of total billed charges,Implant Device,291.72,34,,291.72,percent of total billed charges,Implant Device,300.3,35,,300.3,percent of total billed charges,Implant Device,300.3,35,,300.3,percent of total billed charges,Implant Device,300.3,35,,300.3,percent of total billed charges,Implant Device,300.3,35,,300.3,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,634.92,
ARTHREX AR-7000-28PT PT SCREW 3.75X28MM,C1713,HCPCS,,79008408,CDM,278,RC,,,both,,,858,634.92,,,634.92,Other,150% of Medicare + 9.63% HCRA Surcharge,386.1,45,,386.1,percent of total billed charges,Critical Access Hospital RCC factor,291.72,34,,291.72,percent of total billed charges,Implant Device,291.72,34,,291.72,percent of total billed charges,Implant Device,291.72,34,,291.72,percent of total billed charges,Implant Device,291.72,34,,291.72,percent of total billed charges,Implant Device,291.72,34,,291.72,percent of total billed charges,Implant Device,424.71,,,424.71,Other,110% of Medicare,300.3,35,,300.3,percent of total billed charges,Implant Device,291.72,34,"Charges > $500, x 34%",291.72,percent of total billed charges,Implant Device,300.3,35,,300.3,percent of total billed charges,Implant Device,300.3,35,,300.3,percent of total billed charges,Implant Device,300.3,35,,300.3,percent of total billed charges,Implant Device,300.3,35,,300.3,percent of total billed charges,Implant Device,300.3,35,,300.3,percent of total billed charges,Implant Device,343.2,40,,343.2,percent of total billed charges,Implant Device,300.3,70,,300.3,percent of total billed charges,All Other,291.72,34,,291.72,percent of total billed charges,Implant Device,291.72,34,,291.72,percent of total billed charges,Implant Device,300.3,35,,300.3,percent of total billed charges,Implant Device,300.3,35,,300.3,percent of total billed charges,Implant Device,300.3,35,,300.3,percent of total billed charges,Implant Device,300.3,35,,300.3,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,634.92,
ALLERGAN INC 133SV-15-T TISSUE EXPANDER,C1789,HCPCS,,79008409,CDM,278,RC,,,both,,,4650,3441.01,,,3441.01,Other,150% of Medicare + 9.63% HCRA Surcharge,2092.5,45,,2092.5,percent of total billed charges,Critical Access Hospital RCC factor,1581,34,,1581,percent of total billed charges,Implant Device,1581,34,,1581,percent of total billed charges,Implant Device,1581,34,,1581,percent of total billed charges,Implant Device,1581,34,,1581,percent of total billed charges,Implant Device,1581,34,,1581,percent of total billed charges,Implant Device,2301.75,,,2301.75,Other,110% of Medicare,1627.5,35,,1627.5,percent of total billed charges,Implant Device,1581,34,"Charges > $500, x 34%",1581,percent of total billed charges,Implant Device,1627.5,35,,1627.5,percent of total billed charges,Implant Device,1627.5,35,,1627.5,percent of total billed charges,Implant Device,1627.5,35,,1627.5,percent of total billed charges,Implant Device,1627.5,35,,1627.5,percent of total billed charges,Implant Device,1627.5,35,,1627.5,percent of total billed charges,Implant Device,1860,40,,1860,percent of total billed charges,Implant Device,1627.5,70,,1627.5,percent of total billed charges,All Other,1581,34,,1581,percent of total billed charges,Implant Device,1581,34,,1581,percent of total billed charges,Implant Device,1627.5,35,,1627.5,percent of total billed charges,Implant Device,1627.5,35,,1627.5,percent of total billed charges,Implant Device,1627.5,35,,1627.5,percent of total billed charges,Implant Device,1627.5,35,,1627.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1581,34,"If Charge > 2,000, then 34 percent",1581,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3441.01,
ALLERGAN INC 133SV-16-T TISSUE EXPANDER,C1789,HCPCS,,79008410,CDM,278,RC,,,both,,,4650,3441.01,,,3441.01,Other,150% of Medicare + 9.63% HCRA Surcharge,2092.5,45,,2092.5,percent of total billed charges,Critical Access Hospital RCC factor,1581,34,,1581,percent of total billed charges,Implant Device,1581,34,,1581,percent of total billed charges,Implant Device,1581,34,,1581,percent of total billed charges,Implant Device,1581,34,,1581,percent of total billed charges,Implant Device,1581,34,,1581,percent of total billed charges,Implant Device,2301.75,,,2301.75,Other,110% of Medicare,1627.5,35,,1627.5,percent of total billed charges,Implant Device,1581,34,"Charges > $500, x 34%",1581,percent of total billed charges,Implant Device,1627.5,35,,1627.5,percent of total billed charges,Implant Device,1627.5,35,,1627.5,percent of total billed charges,Implant Device,1627.5,35,,1627.5,percent of total billed charges,Implant Device,1627.5,35,,1627.5,percent of total billed charges,Implant Device,1627.5,35,,1627.5,percent of total billed charges,Implant Device,1860,40,,1860,percent of total billed charges,Implant Device,1627.5,70,,1627.5,percent of total billed charges,All Other,1581,34,,1581,percent of total billed charges,Implant Device,1581,34,,1581,percent of total billed charges,Implant Device,1627.5,35,,1627.5,percent of total billed charges,Implant Device,1627.5,35,,1627.5,percent of total billed charges,Implant Device,1627.5,35,,1627.5,percent of total billed charges,Implant Device,1627.5,35,,1627.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1581,34,"If Charge > 2,000, then 34 percent",1581,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3441.01,
S&N 71342364 FEM HEAD 14/16 TAPER 36MM,C1776,HCPCS,,79008411,CDM,278,RC,,,both,,,5318,3935.33,,,3935.33,Other,150% of Medicare + 9.63% HCRA Surcharge,2393.1,45,,2393.1,percent of total billed charges,Critical Access Hospital RCC factor,1808.12,34,,1808.12,percent of total billed charges,Implant Device,1808.12,34,,1808.12,percent of total billed charges,Implant Device,1808.12,34,,1808.12,percent of total billed charges,Implant Device,1808.12,34,,1808.12,percent of total billed charges,Implant Device,1808.12,34,,1808.12,percent of total billed charges,Implant Device,2632.41,,,2632.41,Other,110% of Medicare,1861.3,35,,1861.3,percent of total billed charges,Implant Device,1808.12,34,"Charges > $500, x 34%",1808.12,percent of total billed charges,Implant Device,1861.3,35,,1861.3,percent of total billed charges,Implant Device,1861.3,35,,1861.3,percent of total billed charges,Implant Device,1861.3,35,,1861.3,percent of total billed charges,Implant Device,1861.3,35,,1861.3,percent of total billed charges,Implant Device,1861.3,35,,1861.3,percent of total billed charges,Implant Device,2127.2,40,,2127.2,percent of total billed charges,Implant Device,1861.3,70,,1861.3,percent of total billed charges,All Other,1808.12,34,,1808.12,percent of total billed charges,Implant Device,1808.12,34,,1808.12,percent of total billed charges,Implant Device,1861.3,35,,1861.3,percent of total billed charges,Implant Device,1861.3,35,,1861.3,percent of total billed charges,Implant Device,1861.3,35,,1861.3,percent of total billed charges,Implant Device,1861.3,35,,1861.3,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1808.12,34,"If Charge > 2,000, then 34 percent",1808.12,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3935.33,
S&N 71333586 ACETAB LINER 26MM 46-48 OD,C1776,HCPCS,,79008412,CDM,278,RC,,,both,,,3398,2514.53,,,2514.53,Other,150% of Medicare + 9.63% HCRA Surcharge,1529.1,45,,1529.1,percent of total billed charges,Critical Access Hospital RCC factor,1155.32,34,,1155.32,percent of total billed charges,Implant Device,1155.32,34,,1155.32,percent of total billed charges,Implant Device,1155.32,34,,1155.32,percent of total billed charges,Implant Device,1155.32,34,,1155.32,percent of total billed charges,Implant Device,1155.32,34,,1155.32,percent of total billed charges,Implant Device,1682.01,,,1682.01,Other,110% of Medicare,1189.3,35,,1189.3,percent of total billed charges,Implant Device,1155.32,34,"Charges > $500, x 34%",1155.32,percent of total billed charges,Implant Device,1189.3,35,,1189.3,percent of total billed charges,Implant Device,1189.3,35,,1189.3,percent of total billed charges,Implant Device,1189.3,35,,1189.3,percent of total billed charges,Implant Device,1189.3,35,,1189.3,percent of total billed charges,Implant Device,1189.3,35,,1189.3,percent of total billed charges,Implant Device,1359.2,40,,1359.2,percent of total billed charges,Implant Device,1189.3,70,,1189.3,percent of total billed charges,All Other,1155.32,34,,1155.32,percent of total billed charges,Implant Device,1155.32,34,,1155.32,percent of total billed charges,Implant Device,1189.3,35,,1189.3,percent of total billed charges,Implant Device,1189.3,35,,1189.3,percent of total billed charges,Implant Device,1189.3,35,,1189.3,percent of total billed charges,Implant Device,1189.3,35,,1189.3,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1155.32,34,"If Charge > 2,000, then 34 percent",1155.32,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2514.53,
STRYKER 661444 3.5X44MM CORTICAL SCREW,C1713,HCPCS,,79008416,CDM,278,RC,,,both,,,122,90.28,,,90.28,Other,150% of Medicare + 9.63% HCRA Surcharge,54.9,45,,54.9,percent of total billed charges,Critical Access Hospital RCC factor,41.48,34,,41.48,percent of total billed charges,Implant Device,41.48,34,,41.48,percent of total billed charges,Implant Device,41.48,34,,41.48,percent of total billed charges,Implant Device,41.48,34,,41.48,percent of total billed charges,Implant Device,41.48,34,,41.48,percent of total billed charges,Implant Device,60.39,,,60.39,Other,110% of Medicare,42.7,35,,42.7,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,42.7,35,,42.7,percent of total billed charges,Implant Device,42.7,35,,42.7,percent of total billed charges,Implant Device,42.7,35,,42.7,percent of total billed charges,Implant Device,42.7,35,,42.7,percent of total billed charges,Implant Device,42.7,35,,42.7,percent of total billed charges,Implant Device,48.8,40,,48.8,percent of total billed charges,Implant Device,42.7,70,,42.7,percent of total billed charges,All Other,41.48,34,,41.48,percent of total billed charges,Implant Device,41.48,34,,41.48,percent of total billed charges,Implant Device,42.7,35,,42.7,percent of total billed charges,Implant Device,42.7,35,,42.7,percent of total billed charges,Implant Device,42.7,35,,42.7,percent of total billed charges,Implant Device,42.7,35,,42.7,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,90.28,
STRYKER 661442 3.5X42MM CORTICAL SCREW,C1713,HCPCS,,79008418,CDM,278,RC,,,both,,,122,90.28,,,90.28,Other,150% of Medicare + 9.63% HCRA Surcharge,54.9,45,,54.9,percent of total billed charges,Critical Access Hospital RCC factor,41.48,34,,41.48,percent of total billed charges,Implant Device,41.48,34,,41.48,percent of total billed charges,Implant Device,41.48,34,,41.48,percent of total billed charges,Implant Device,41.48,34,,41.48,percent of total billed charges,Implant Device,41.48,34,,41.48,percent of total billed charges,Implant Device,60.39,,,60.39,Other,110% of Medicare,42.7,35,,42.7,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,42.7,35,,42.7,percent of total billed charges,Implant Device,42.7,35,,42.7,percent of total billed charges,Implant Device,42.7,35,,42.7,percent of total billed charges,Implant Device,42.7,35,,42.7,percent of total billed charges,Implant Device,42.7,35,,42.7,percent of total billed charges,Implant Device,48.8,40,,48.8,percent of total billed charges,Implant Device,42.7,70,,42.7,percent of total billed charges,All Other,41.48,34,,41.48,percent of total billed charges,Implant Device,41.48,34,,41.48,percent of total billed charges,Implant Device,42.7,35,,42.7,percent of total billed charges,Implant Device,42.7,35,,42.7,percent of total billed charges,Implant Device,42.7,35,,42.7,percent of total billed charges,Implant Device,42.7,35,,42.7,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,90.28,
ACUMED AT2-M18 ACCUTRAK2 MINI SCREW 18MM,C1713,HCPCS,,79008419,CDM,278,RC,,,both,,,1584,1172.16,,,1172.16,Other,150% of Medicare + 9.63% HCRA Surcharge,712.8,45,,712.8,percent of total billed charges,Critical Access Hospital RCC factor,538.56,34,,538.56,percent of total billed charges,Implant Device,538.56,34,,538.56,percent of total billed charges,Implant Device,538.56,34,,538.56,percent of total billed charges,Implant Device,538.56,34,,538.56,percent of total billed charges,Implant Device,538.56,34,,538.56,percent of total billed charges,Implant Device,784.08,,,784.08,Other,110% of Medicare,554.4,35,,554.4,percent of total billed charges,Implant Device,538.56,34,"Charges > $500, x 34%",538.56,percent of total billed charges,Implant Device,554.4,35,,554.4,percent of total billed charges,Implant Device,554.4,35,,554.4,percent of total billed charges,Implant Device,554.4,35,,554.4,percent of total billed charges,Implant Device,554.4,35,,554.4,percent of total billed charges,Implant Device,554.4,35,,554.4,percent of total billed charges,Implant Device,633.6,40,,633.6,percent of total billed charges,Implant Device,554.4,70,,554.4,percent of total billed charges,All Other,538.56,34,,538.56,percent of total billed charges,Implant Device,538.56,34,,538.56,percent of total billed charges,Implant Device,554.4,35,,554.4,percent of total billed charges,Implant Device,554.4,35,,554.4,percent of total billed charges,Implant Device,554.4,35,,554.4,percent of total billed charges,Implant Device,554.4,35,,554.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1172.16,
DEPUY 02.112.084 CLAV PLATE 3.5X115MM 8H,C1713,HCPCS,,79008420,CDM,278,RC,,,both,,,3691,2731.35,,,2731.35,Other,150% of Medicare + 9.63% HCRA Surcharge,1660.95,45,,1660.95,percent of total billed charges,Critical Access Hospital RCC factor,1254.94,34,,1254.94,percent of total billed charges,Implant Device,1254.94,34,,1254.94,percent of total billed charges,Implant Device,1254.94,34,,1254.94,percent of total billed charges,Implant Device,1254.94,34,,1254.94,percent of total billed charges,Implant Device,1254.94,34,,1254.94,percent of total billed charges,Implant Device,1827.05,,,1827.05,Other,110% of Medicare,1291.85,35,,1291.85,percent of total billed charges,Implant Device,1254.94,34,"Charges > $500, x 34%",1254.94,percent of total billed charges,Implant Device,1291.85,35,,1291.85,percent of total billed charges,Implant Device,1291.85,35,,1291.85,percent of total billed charges,Implant Device,1291.85,35,,1291.85,percent of total billed charges,Implant Device,1291.85,35,,1291.85,percent of total billed charges,Implant Device,1291.85,35,,1291.85,percent of total billed charges,Implant Device,1476.4,40,,1476.4,percent of total billed charges,Implant Device,1291.85,70,,1291.85,percent of total billed charges,All Other,1254.94,34,,1254.94,percent of total billed charges,Implant Device,1254.94,34,,1254.94,percent of total billed charges,Implant Device,1291.85,35,,1291.85,percent of total billed charges,Implant Device,1291.85,35,,1291.85,percent of total billed charges,Implant Device,1291.85,35,,1291.85,percent of total billed charges,Implant Device,1291.85,35,,1291.85,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1254.94,34,"If Charge > 2,000, then 34 percent",1254.94,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2731.35,
STRYKER 661480 LOCKING SCREW 3.5X80MM,C1713,HCPCS,,79008421,CDM,278,RC,,,both,,,171,126.54,,,126.54,Other,150% of Medicare + 9.63% HCRA Surcharge,76.95,45,,76.95,percent of total billed charges,Critical Access Hospital RCC factor,58.14,34,,58.14,percent of total billed charges,Implant Device,58.14,34,,58.14,percent of total billed charges,Implant Device,58.14,34,,58.14,percent of total billed charges,Implant Device,58.14,34,,58.14,percent of total billed charges,Implant Device,58.14,34,,58.14,percent of total billed charges,Implant Device,84.65,,,84.65,Other,110% of Medicare,59.85,35,,59.85,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,59.85,35,,59.85,percent of total billed charges,Implant Device,59.85,35,,59.85,percent of total billed charges,Implant Device,59.85,35,,59.85,percent of total billed charges,Implant Device,59.85,35,,59.85,percent of total billed charges,Implant Device,59.85,35,,59.85,percent of total billed charges,Implant Device,68.4,40,,68.4,percent of total billed charges,Implant Device,59.85,70,,59.85,percent of total billed charges,All Other,58.14,34,,58.14,percent of total billed charges,Implant Device,58.14,34,,58.14,percent of total billed charges,Implant Device,59.85,35,,59.85,percent of total billed charges,Implant Device,59.85,35,,59.85,percent of total billed charges,Implant Device,59.85,35,,59.85,percent of total billed charges,Implant Device,59.85,35,,59.85,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,126.54,
STRYKER 607360 CANCELLOUS SCREW 4.0X60MM,C1713,HCPCS,,79008422,CDM,278,RC,,,both,,,186,137.64,,,137.64,Other,150% of Medicare + 9.63% HCRA Surcharge,83.7,45,,83.7,percent of total billed charges,Critical Access Hospital RCC factor,63.24,34,,63.24,percent of total billed charges,Implant Device,63.24,34,,63.24,percent of total billed charges,Implant Device,63.24,34,,63.24,percent of total billed charges,Implant Device,63.24,34,,63.24,percent of total billed charges,Implant Device,63.24,34,,63.24,percent of total billed charges,Implant Device,92.07,,,92.07,Other,110% of Medicare,65.1,35,,65.1,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,65.1,35,,65.1,percent of total billed charges,Implant Device,65.1,35,,65.1,percent of total billed charges,Implant Device,65.1,35,,65.1,percent of total billed charges,Implant Device,65.1,35,,65.1,percent of total billed charges,Implant Device,65.1,35,,65.1,percent of total billed charges,Implant Device,74.4,40,,74.4,percent of total billed charges,Implant Device,65.1,70,,65.1,percent of total billed charges,All Other,63.24,34,,63.24,percent of total billed charges,Implant Device,63.24,34,,63.24,percent of total billed charges,Implant Device,65.1,35,,65.1,percent of total billed charges,Implant Device,65.1,35,,65.1,percent of total billed charges,Implant Device,65.1,35,,65.1,percent of total billed charges,Implant Device,65.1,35,,65.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,137.64,
STRYKER 102-2210 VITOSS BONE GRAFT 10CC,C1713,HCPCS,,79008423,CDM,278,RC,,,both,,,9955,7366.72,,,7366.72,Other,150% of Medicare + 9.63% HCRA Surcharge,4479.75,45,,4479.75,percent of total billed charges,Critical Access Hospital RCC factor,3384.7,34,,3384.7,percent of total billed charges,Implant Device,3384.7,34,,3384.7,percent of total billed charges,Implant Device,3384.7,34,,3384.7,percent of total billed charges,Implant Device,3384.7,34,,3384.7,percent of total billed charges,Implant Device,3384.7,34,,3384.7,percent of total billed charges,Implant Device,4927.73,,,4927.73,Other,110% of Medicare,3484.25,35,,3484.25,percent of total billed charges,Implant Device,3384.7,34,"Charges > $500, x 34%",3384.7,percent of total billed charges,Implant Device,3484.25,35,,3484.25,percent of total billed charges,Implant Device,3484.25,35,,3484.25,percent of total billed charges,Implant Device,3484.25,35,,3484.25,percent of total billed charges,Implant Device,3484.25,35,,3484.25,percent of total billed charges,Implant Device,3484.25,35,,3484.25,percent of total billed charges,Implant Device,3982,40,,3982,percent of total billed charges,Implant Device,3484.25,70,,3484.25,percent of total billed charges,All Other,3384.7,34,,3384.7,percent of total billed charges,Implant Device,3384.7,34,,3384.7,percent of total billed charges,Implant Device,3484.25,35,,3484.25,percent of total billed charges,Implant Device,3484.25,35,,3484.25,percent of total billed charges,Implant Device,3484.25,35,,3484.25,percent of total billed charges,Implant Device,3484.25,35,,3484.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3384.7,34,"If Charge > 2,000, then 34 percent",3384.7,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,7366.72,
BIOMET 91-1505 SELF TAPPNG SCREW 1.5X5MM,C1713,HCPCS,,79008424,CDM,278,RC,,,both,,,285,210.9,,,210.9,Other,150% of Medicare + 9.63% HCRA Surcharge,128.25,45,,128.25,percent of total billed charges,Critical Access Hospital RCC factor,96.9,34,,96.9,percent of total billed charges,Implant Device,96.9,34,,96.9,percent of total billed charges,Implant Device,96.9,34,,96.9,percent of total billed charges,Implant Device,96.9,34,,96.9,percent of total billed charges,Implant Device,96.9,34,,96.9,percent of total billed charges,Implant Device,141.08,,,141.08,Other,110% of Medicare,99.75,35,,99.75,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,99.75,35,,99.75,percent of total billed charges,Implant Device,99.75,35,,99.75,percent of total billed charges,Implant Device,99.75,35,,99.75,percent of total billed charges,Implant Device,99.75,35,,99.75,percent of total billed charges,Implant Device,99.75,35,,99.75,percent of total billed charges,Implant Device,114,40,,114,percent of total billed charges,Implant Device,99.75,70,,99.75,percent of total billed charges,All Other,96.9,34,,96.9,percent of total billed charges,Implant Device,96.9,34,,96.9,percent of total billed charges,Implant Device,99.75,35,,99.75,percent of total billed charges,Implant Device,99.75,35,,99.75,percent of total billed charges,Implant Device,99.75,35,,99.75,percent of total billed charges,Implant Device,99.75,35,,99.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,210.9,
STRYKER F&A 626892 MTP LOCKING PLATE RT,C1713,HCPCS,,79008425,CDM,278,RC,,,both,,,7500,5550.02,,,5550.02,Other,150% of Medicare + 9.63% HCRA Surcharge,3375,45,,3375,percent of total billed charges,Critical Access Hospital RCC factor,2550,34,,2550,percent of total billed charges,Implant Device,2550,34,,2550,percent of total billed charges,Implant Device,2550,34,,2550,percent of total billed charges,Implant Device,2550,34,,2550,percent of total billed charges,Implant Device,2550,34,,2550,percent of total billed charges,Implant Device,3712.5,,,3712.5,Other,110% of Medicare,2625,35,,2625,percent of total billed charges,Implant Device,2550,34,"Charges > $500, x 34%",2550,percent of total billed charges,Implant Device,2625,35,,2625,percent of total billed charges,Implant Device,2625,35,,2625,percent of total billed charges,Implant Device,2625,35,,2625,percent of total billed charges,Implant Device,2625,35,,2625,percent of total billed charges,Implant Device,2625,35,,2625,percent of total billed charges,Implant Device,3000,40,,3000,percent of total billed charges,Implant Device,2625,70,,2625,percent of total billed charges,All Other,2550,34,,2550,percent of total billed charges,Implant Device,2550,34,,2550,percent of total billed charges,Implant Device,2625,35,,2625,percent of total billed charges,Implant Device,2625,35,,2625,percent of total billed charges,Implant Device,2625,35,,2625,percent of total billed charges,Implant Device,2625,35,,2625,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2550,34,"If Charge > 2,000, then 34 percent",2550,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5550.02,
STRYKER F&A 626924 LAG SCREW 3.6X24MM,C1713,HCPCS,,79008426,CDM,278,RC,,,both,,,879,650.46,,,650.46,Other,150% of Medicare + 9.63% HCRA Surcharge,395.55,45,,395.55,percent of total billed charges,Critical Access Hospital RCC factor,298.86,34,,298.86,percent of total billed charges,Implant Device,298.86,34,,298.86,percent of total billed charges,Implant Device,298.86,34,,298.86,percent of total billed charges,Implant Device,298.86,34,,298.86,percent of total billed charges,Implant Device,298.86,34,,298.86,percent of total billed charges,Implant Device,435.11,,,435.11,Other,110% of Medicare,307.65,35,,307.65,percent of total billed charges,Implant Device,298.86,34,"Charges > $500, x 34%",298.86,percent of total billed charges,Implant Device,307.65,35,,307.65,percent of total billed charges,Implant Device,307.65,35,,307.65,percent of total billed charges,Implant Device,307.65,35,,307.65,percent of total billed charges,Implant Device,307.65,35,,307.65,percent of total billed charges,Implant Device,307.65,35,,307.65,percent of total billed charges,Implant Device,351.6,40,,351.6,percent of total billed charges,Implant Device,307.65,70,,307.65,percent of total billed charges,All Other,298.86,34,,298.86,percent of total billed charges,Implant Device,298.86,34,,298.86,percent of total billed charges,Implant Device,307.65,35,,307.65,percent of total billed charges,Implant Device,307.65,35,,307.65,percent of total billed charges,Implant Device,307.65,35,,307.65,percent of total billed charges,Implant Device,307.65,35,,307.65,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,650.46,
STRYKER F&A 656314 LOCKNG SCREW 2.7X14MM,C1713,HCPCS,,79008427,CDM,278,RC,,,both,,,480,355.2,,,355.2,Other,150% of Medicare + 9.63% HCRA Surcharge,216,45,,216,percent of total billed charges,Critical Access Hospital RCC factor,163.2,34,,163.2,percent of total billed charges,Implant Device,163.2,34,,163.2,percent of total billed charges,Implant Device,163.2,34,,163.2,percent of total billed charges,Implant Device,163.2,34,,163.2,percent of total billed charges,Implant Device,163.2,34,,163.2,percent of total billed charges,Implant Device,237.6,,,237.6,Other,110% of Medicare,168,35,,168,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,192,40,,192,percent of total billed charges,Implant Device,168,70,,168,percent of total billed charges,All Other,163.2,34,,163.2,percent of total billed charges,Implant Device,163.2,34,,163.2,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,355.2,
STRYKER F&A 656316 LOCKNG SCREW 2.7X16MM,C1713,HCPCS,,79008428,CDM,278,RC,,,both,,,480,355.2,,,355.2,Other,150% of Medicare + 9.63% HCRA Surcharge,216,45,,216,percent of total billed charges,Critical Access Hospital RCC factor,163.2,34,,163.2,percent of total billed charges,Implant Device,163.2,34,,163.2,percent of total billed charges,Implant Device,163.2,34,,163.2,percent of total billed charges,Implant Device,163.2,34,,163.2,percent of total billed charges,Implant Device,163.2,34,,163.2,percent of total billed charges,Implant Device,237.6,,,237.6,Other,110% of Medicare,168,35,,168,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,192,40,,192,percent of total billed charges,Implant Device,168,70,,168,percent of total billed charges,All Other,163.2,34,,163.2,percent of total billed charges,Implant Device,163.2,34,,163.2,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,355.2,
STRYKER F&A 656312 LOCKNG SCREW 2.7X12MM,C1713,HCPCS,,79008429,CDM,278,RC,,,both,,,443,327.82,,,327.82,Other,150% of Medicare + 9.63% HCRA Surcharge,199.35,45,,199.35,percent of total billed charges,Critical Access Hospital RCC factor,150.62,34,,150.62,percent of total billed charges,Implant Device,150.62,34,,150.62,percent of total billed charges,Implant Device,150.62,34,,150.62,percent of total billed charges,Implant Device,150.62,34,,150.62,percent of total billed charges,Implant Device,150.62,34,,150.62,percent of total billed charges,Implant Device,219.29,,,219.29,Other,110% of Medicare,155.05,35,,155.05,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,155.05,35,,155.05,percent of total billed charges,Implant Device,155.05,35,,155.05,percent of total billed charges,Implant Device,155.05,35,,155.05,percent of total billed charges,Implant Device,155.05,35,,155.05,percent of total billed charges,Implant Device,155.05,35,,155.05,percent of total billed charges,Implant Device,177.2,40,,177.2,percent of total billed charges,Implant Device,155.05,70,,155.05,percent of total billed charges,All Other,150.62,34,,150.62,percent of total billed charges,Implant Device,150.62,34,,150.62,percent of total billed charges,Implant Device,155.05,35,,155.05,percent of total billed charges,Implant Device,155.05,35,,155.05,percent of total billed charges,Implant Device,155.05,35,,155.05,percent of total billed charges,Implant Device,155.05,35,,155.05,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,327.82,
MEDLINE USUPC09X PARIETEX MESH 9CM CIRC,C1781,HCPCS,,79008431,CDM,278,RC,,,both,,,1351,999.74,,,999.74,Other,150% of Medicare + 9.63% HCRA Surcharge,607.95,45,,607.95,percent of total billed charges,Critical Access Hospital RCC factor,459.34,34,,459.34,percent of total billed charges,Implant Device,459.34,34,,459.34,percent of total billed charges,Implant Device,459.34,34,,459.34,percent of total billed charges,Implant Device,459.34,34,,459.34,percent of total billed charges,Implant Device,459.34,34,,459.34,percent of total billed charges,Implant Device,668.75,,,668.75,Other,110% of Medicare,472.85,35,,472.85,percent of total billed charges,Implant Device,459.34,34,"Charges > $500, x 34%",459.34,percent of total billed charges,Implant Device,472.85,35,,472.85,percent of total billed charges,Implant Device,472.85,35,,472.85,percent of total billed charges,Implant Device,472.85,35,,472.85,percent of total billed charges,Implant Device,472.85,35,,472.85,percent of total billed charges,Implant Device,472.85,35,,472.85,percent of total billed charges,Implant Device,540.4,40,,540.4,percent of total billed charges,Implant Device,472.85,70,,472.85,percent of total billed charges,All Other,459.34,34,,459.34,percent of total billed charges,Implant Device,459.34,34,,459.34,percent of total billed charges,Implant Device,472.85,35,,472.85,percent of total billed charges,Implant Device,472.85,35,,472.85,percent of total billed charges,Implant Device,472.85,35,,472.85,percent of total billed charges,Implant Device,472.85,35,,472.85,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,999.74,
ZIMMER 8145-50-34 5X34MM CORT BONE SCREW,C1713,HCPCS,,79008433,CDM,278,RC,,,both,,,930,688.2,,,688.2,Other,150% of Medicare + 9.63% HCRA Surcharge,418.5,45,,418.5,percent of total billed charges,Critical Access Hospital RCC factor,316.2,34,,316.2,percent of total billed charges,Implant Device,316.2,34,,316.2,percent of total billed charges,Implant Device,316.2,34,,316.2,percent of total billed charges,Implant Device,316.2,34,,316.2,percent of total billed charges,Implant Device,316.2,34,,316.2,percent of total billed charges,Implant Device,460.35,,,460.35,Other,110% of Medicare,325.5,35,,325.5,percent of total billed charges,Implant Device,316.2,34,"Charges > $500, x 34%",316.2,percent of total billed charges,Implant Device,325.5,35,,325.5,percent of total billed charges,Implant Device,325.5,35,,325.5,percent of total billed charges,Implant Device,325.5,35,,325.5,percent of total billed charges,Implant Device,325.5,35,,325.5,percent of total billed charges,Implant Device,325.5,35,,325.5,percent of total billed charges,Implant Device,372,40,,372,percent of total billed charges,Implant Device,325.5,70,,325.5,percent of total billed charges,All Other,316.2,34,,316.2,percent of total billed charges,Implant Device,316.2,34,,316.2,percent of total billed charges,Implant Device,325.5,35,,325.5,percent of total billed charges,Implant Device,325.5,35,,325.5,percent of total billed charges,Implant Device,325.5,35,,325.5,percent of total billed charges,Implant Device,325.5,35,,325.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,688.2,
IN2BONES S22 ST011 SNAP OFF SCREW 2.2X11,C1713,HCPCS,,79008434,CDM,278,RC,,,both,,,675,499.5,,,499.5,Other,150% of Medicare + 9.63% HCRA Surcharge,303.75,45,,303.75,percent of total billed charges,Critical Access Hospital RCC factor,229.5,34,,229.5,percent of total billed charges,Implant Device,229.5,34,,229.5,percent of total billed charges,Implant Device,229.5,34,,229.5,percent of total billed charges,Implant Device,229.5,34,,229.5,percent of total billed charges,Implant Device,229.5,34,,229.5,percent of total billed charges,Implant Device,334.13,,,334.13,Other,110% of Medicare,236.25,35,,236.25,percent of total billed charges,Implant Device,229.5,34,"Charges > $500, x 34%",229.5,percent of total billed charges,Implant Device,236.25,35,,236.25,percent of total billed charges,Implant Device,236.25,35,,236.25,percent of total billed charges,Implant Device,236.25,35,,236.25,percent of total billed charges,Implant Device,236.25,35,,236.25,percent of total billed charges,Implant Device,236.25,35,,236.25,percent of total billed charges,Implant Device,270,40,,270,percent of total billed charges,Implant Device,236.25,70,,236.25,percent of total billed charges,All Other,229.5,34,,229.5,percent of total billed charges,Implant Device,229.5,34,,229.5,percent of total billed charges,Implant Device,236.25,35,,236.25,percent of total billed charges,Implant Device,236.25,35,,236.25,percent of total billed charges,Implant Device,236.25,35,,236.25,percent of total billed charges,Implant Device,236.25,35,,236.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,499.5,
STRYKER 626891 LOCK MTP CROSS PLATE LEFT,C1713,HCPCS,,79008435,CDM,278,RC,,,both,,,8961,6631.16,,,6631.16,Other,150% of Medicare + 9.63% HCRA Surcharge,4032.45,45,,4032.45,percent of total billed charges,Critical Access Hospital RCC factor,3046.74,34,,3046.74,percent of total billed charges,Implant Device,3046.74,34,,3046.74,percent of total billed charges,Implant Device,3046.74,34,,3046.74,percent of total billed charges,Implant Device,3046.74,34,,3046.74,percent of total billed charges,Implant Device,3046.74,34,,3046.74,percent of total billed charges,Implant Device,4435.7,,,4435.7,Other,110% of Medicare,3136.35,35,,3136.35,percent of total billed charges,Implant Device,3046.74,34,"Charges > $500, x 34%",3046.74,percent of total billed charges,Implant Device,3136.35,35,,3136.35,percent of total billed charges,Implant Device,3136.35,35,,3136.35,percent of total billed charges,Implant Device,3136.35,35,,3136.35,percent of total billed charges,Implant Device,3136.35,35,,3136.35,percent of total billed charges,Implant Device,3136.35,35,,3136.35,percent of total billed charges,Implant Device,3584.4,40,,3584.4,percent of total billed charges,Implant Device,3136.35,70,,3136.35,percent of total billed charges,All Other,3046.74,34,,3046.74,percent of total billed charges,Implant Device,3046.74,34,,3046.74,percent of total billed charges,Implant Device,3136.35,35,,3136.35,percent of total billed charges,Implant Device,3136.35,35,,3136.35,percent of total billed charges,Implant Device,3136.35,35,,3136.35,percent of total billed charges,Implant Device,3136.35,35,,3136.35,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3046.74,34,"If Charge > 2,000, then 34 percent",3046.74,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,6631.16,
ZIMMER 00-8852-008-32 RIM LINER 32MM,C1776,HCPCS,,79008440,CDM,278,RC,,,both,,,4845,3585.31,,,3585.31,Other,150% of Medicare + 9.63% HCRA Surcharge,2180.25,45,,2180.25,percent of total billed charges,Critical Access Hospital RCC factor,1647.3,34,,1647.3,percent of total billed charges,Implant Device,1647.3,34,,1647.3,percent of total billed charges,Implant Device,1647.3,34,,1647.3,percent of total billed charges,Implant Device,1647.3,34,,1647.3,percent of total billed charges,Implant Device,1647.3,34,,1647.3,percent of total billed charges,Implant Device,2398.28,,,2398.28,Other,110% of Medicare,1695.75,35,,1695.75,percent of total billed charges,Implant Device,1647.3,34,"Charges > $500, x 34%",1647.3,percent of total billed charges,Implant Device,1695.75,35,,1695.75,percent of total billed charges,Implant Device,1695.75,35,,1695.75,percent of total billed charges,Implant Device,1695.75,35,,1695.75,percent of total billed charges,Implant Device,1695.75,35,,1695.75,percent of total billed charges,Implant Device,1695.75,35,,1695.75,percent of total billed charges,Implant Device,1938,40,,1938,percent of total billed charges,Implant Device,1695.75,70,,1695.75,percent of total billed charges,All Other,1647.3,34,,1647.3,percent of total billed charges,Implant Device,1647.3,34,,1647.3,percent of total billed charges,Implant Device,1695.75,35,,1695.75,percent of total billed charges,Implant Device,1695.75,35,,1695.75,percent of total billed charges,Implant Device,1695.75,35,,1695.75,percent of total billed charges,Implant Device,1695.75,35,,1695.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1647.3,34,"If Charge > 2,000, then 34 percent",1647.3,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3585.31,
BIOMET 12-115115 CERAMIC HEAD 32MM,C1776,HCPCS,,79008441,CDM,278,RC,,,both,,,10170,7525.83,,,7525.83,Other,150% of Medicare + 9.63% HCRA Surcharge,4576.5,45,,4576.5,percent of total billed charges,Critical Access Hospital RCC factor,3457.8,34,,3457.8,percent of total billed charges,Implant Device,3457.8,34,,3457.8,percent of total billed charges,Implant Device,3457.8,34,,3457.8,percent of total billed charges,Implant Device,3457.8,34,,3457.8,percent of total billed charges,Implant Device,3457.8,34,,3457.8,percent of total billed charges,Implant Device,5034.15,,,5034.15,Other,110% of Medicare,3559.5,35,,3559.5,percent of total billed charges,Implant Device,3457.8,34,"Charges > $500, x 34%",3457.8,percent of total billed charges,Implant Device,3559.5,35,,3559.5,percent of total billed charges,Implant Device,3559.5,35,,3559.5,percent of total billed charges,Implant Device,3559.5,35,,3559.5,percent of total billed charges,Implant Device,3559.5,35,,3559.5,percent of total billed charges,Implant Device,3559.5,35,,3559.5,percent of total billed charges,Implant Device,4068,40,,4068,percent of total billed charges,Implant Device,3559.5,70,,3559.5,percent of total billed charges,All Other,3457.8,34,,3457.8,percent of total billed charges,Implant Device,3457.8,34,,3457.8,percent of total billed charges,Implant Device,3559.5,35,,3559.5,percent of total billed charges,Implant Device,3559.5,35,,3559.5,percent of total billed charges,Implant Device,3559.5,35,,3559.5,percent of total billed charges,Implant Device,3559.5,35,,3559.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3457.8,34,"If Charge > 2,000, then 34 percent",3457.8,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,7525.83,
BIOMET 11-301016 DISTAL STEM 16X250MM,C1776,HCPCS,,79008442,CDM,278,RC,,,both,,,14559,10773.7,,,10773.7,Other,150% of Medicare + 9.63% HCRA Surcharge,6551.55,45,,6551.55,percent of total billed charges,Critical Access Hospital RCC factor,4950.06,34,,4950.06,percent of total billed charges,Implant Device,4950.06,34,,4950.06,percent of total billed charges,Implant Device,4950.06,34,,4950.06,percent of total billed charges,Implant Device,4950.06,34,,4950.06,percent of total billed charges,Implant Device,4950.06,34,,4950.06,percent of total billed charges,Implant Device,7206.71,,,7206.71,Other,110% of Medicare,5095.65,35,,5095.65,percent of total billed charges,Implant Device,4950.06,34,"Charges > $500, x 34%",4950.06,percent of total billed charges,Implant Device,5095.65,35,,5095.65,percent of total billed charges,Implant Device,5095.65,35,,5095.65,percent of total billed charges,Implant Device,5095.65,35,,5095.65,percent of total billed charges,Implant Device,5095.65,35,,5095.65,percent of total billed charges,Implant Device,5095.65,35,,5095.65,percent of total billed charges,Implant Device,5823.6,40,,5823.6,percent of total billed charges,Implant Device,5095.65,70,,5095.65,percent of total billed charges,All Other,4950.06,34,,4950.06,percent of total billed charges,Implant Device,4950.06,34,,4950.06,percent of total billed charges,Implant Device,5095.65,35,,5095.65,percent of total billed charges,Implant Device,5095.65,35,,5095.65,percent of total billed charges,Implant Device,5095.65,35,,5095.65,percent of total billed charges,Implant Device,5095.65,35,,5095.65,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,4950.06,34,"If Charge > 2,000, then 34 percent",4950.06,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,10773.7,
ZIMMER 00-2347-023-60 SCREW 4.5X38MM,C1713,HCPCS,,79008443,CDM,278,RC,,,both,,,109,80.66,,,80.66,Other,150% of Medicare + 9.63% HCRA Surcharge,49.05,45,,49.05,percent of total billed charges,Critical Access Hospital RCC factor,37.06,34,,37.06,percent of total billed charges,Implant Device,37.06,34,,37.06,percent of total billed charges,Implant Device,37.06,34,,37.06,percent of total billed charges,Implant Device,37.06,34,,37.06,percent of total billed charges,Implant Device,37.06,34,,37.06,percent of total billed charges,Implant Device,53.96,,,53.96,Other,110% of Medicare,38.15,35,,38.15,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,38.15,35,,38.15,percent of total billed charges,Implant Device,38.15,35,,38.15,percent of total billed charges,Implant Device,38.15,35,,38.15,percent of total billed charges,Implant Device,38.15,35,,38.15,percent of total billed charges,Implant Device,38.15,35,,38.15,percent of total billed charges,Implant Device,43.6,40,,43.6,percent of total billed charges,Implant Device,38.15,70,,38.15,percent of total billed charges,All Other,37.06,34,,37.06,percent of total billed charges,Implant Device,37.06,34,,37.06,percent of total billed charges,Implant Device,38.15,35,,38.15,percent of total billed charges,Implant Device,38.15,35,,38.15,percent of total billed charges,Implant Device,38.15,35,,38.15,percent of total billed charges,Implant Device,38.15,35,,38.15,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,80.66,
ZIMMER 00-2347-023-75 SCREW 4.5X75MM,C1773,HCPCS,,79008444,CDM,278,RC,,,both,,,109,80.66,,,80.66,Other,150% of Medicare + 9.63% HCRA Surcharge,49.05,45,,49.05,percent of total billed charges,Critical Access Hospital RCC factor,37.06,34,,37.06,percent of total billed charges,Implant Device,37.06,34,,37.06,percent of total billed charges,Implant Device,37.06,34,,37.06,percent of total billed charges,Implant Device,37.06,34,,37.06,percent of total billed charges,Implant Device,37.06,34,,37.06,percent of total billed charges,Implant Device,53.96,,,53.96,Other,110% of Medicare,38.15,35,,38.15,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,38.15,35,,38.15,percent of total billed charges,Implant Device,38.15,35,,38.15,percent of total billed charges,Implant Device,38.15,35,,38.15,percent of total billed charges,Implant Device,38.15,35,,38.15,percent of total billed charges,Implant Device,38.15,35,,38.15,percent of total billed charges,Implant Device,43.6,40,,43.6,percent of total billed charges,Implant Device,38.15,70,,38.15,percent of total billed charges,All Other,37.06,34,,37.06,percent of total billed charges,Implant Device,37.06,34,,37.06,percent of total billed charges,Implant Device,38.15,35,,38.15,percent of total billed charges,Implant Device,38.15,35,,38.15,percent of total billed charges,Implant Device,38.15,35,,38.15,percent of total billed charges,Implant Device,38.15,35,,38.15,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,80.66,
BIOMET 11-300923 DISTAL STEM 23X190MM,C1776,HCPCS,,79008445,CDM,278,RC,,,both,,,18660,13808.45,,,13808.45,Other,150% of Medicare + 9.63% HCRA Surcharge,8397,45,,8397,percent of total billed charges,Critical Access Hospital RCC factor,6344.4,34,,6344.4,percent of total billed charges,Implant Device,6344.4,34,,6344.4,percent of total billed charges,Implant Device,6344.4,34,,6344.4,percent of total billed charges,Implant Device,6344.4,34,,6344.4,percent of total billed charges,Implant Device,6344.4,34,,6344.4,percent of total billed charges,Implant Device,9236.7,,,9236.7,Other,110% of Medicare,6531,35,,6531,percent of total billed charges,Implant Device,6344.4,34,"Charges > $500, x 34%",6344.4,percent of total billed charges,Implant Device,6531,35,,6531,percent of total billed charges,Implant Device,6531,35,,6531,percent of total billed charges,Implant Device,6531,35,,6531,percent of total billed charges,Implant Device,6531,35,,6531,percent of total billed charges,Implant Device,6531,35,,6531,percent of total billed charges,Implant Device,7464,40,,7464,percent of total billed charges,Implant Device,6531,70,,6531,percent of total billed charges,All Other,6344.4,34,,6344.4,percent of total billed charges,Implant Device,6344.4,34,,6344.4,percent of total billed charges,Implant Device,6531,35,,6531,percent of total billed charges,Implant Device,6531,35,,6531,percent of total billed charges,Implant Device,6531,35,,6531,percent of total billed charges,Implant Device,6531,35,,6531,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,6344.4,34,"If Charge > 2,000, then 34 percent",6344.4,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,13808.45,
BIOMET 11-301301 CONE PRX BODY 60MM SZ A,C1776,HCPCS,,79008446,CDM,278,RC,,,both,,,19784,14640.21,,,14640.21,Other,150% of Medicare + 9.63% HCRA Surcharge,8902.8,45,,8902.8,percent of total billed charges,Critical Access Hospital RCC factor,6726.56,34,,6726.56,percent of total billed charges,Implant Device,6726.56,34,,6726.56,percent of total billed charges,Implant Device,6726.56,34,,6726.56,percent of total billed charges,Implant Device,6726.56,34,,6726.56,percent of total billed charges,Implant Device,6726.56,34,,6726.56,percent of total billed charges,Implant Device,9793.08,,,9793.08,Other,110% of Medicare,6924.4,35,,6924.4,percent of total billed charges,Implant Device,6726.56,34,"Charges > $500, x 34%",6726.56,percent of total billed charges,Implant Device,6924.4,35,,6924.4,percent of total billed charges,Implant Device,6924.4,35,,6924.4,percent of total billed charges,Implant Device,6924.4,35,,6924.4,percent of total billed charges,Implant Device,6924.4,35,,6924.4,percent of total billed charges,Implant Device,6924.4,35,,6924.4,percent of total billed charges,Implant Device,7913.6,40,,7913.6,percent of total billed charges,Implant Device,6924.4,70,,6924.4,percent of total billed charges,All Other,6726.56,34,,6726.56,percent of total billed charges,Implant Device,6726.56,34,,6726.56,percent of total billed charges,Implant Device,6924.4,35,,6924.4,percent of total billed charges,Implant Device,6924.4,35,,6924.4,percent of total billed charges,Implant Device,6924.4,35,,6924.4,percent of total billed charges,Implant Device,6924.4,35,,6924.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,6726.56,34,"If Charge > 2,000, then 34 percent",6726.56,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,14640.21,
BIOMET 11-363665 HEAD COMP +9 NECK 36MM,C1776,HCPCS,,79008447,CDM,278,RC,,,both,,,5370,3973.81,,,3973.81,Other,150% of Medicare + 9.63% HCRA Surcharge,2416.5,45,,2416.5,percent of total billed charges,Critical Access Hospital RCC factor,1825.8,34,,1825.8,percent of total billed charges,Implant Device,1825.8,34,,1825.8,percent of total billed charges,Implant Device,1825.8,34,,1825.8,percent of total billed charges,Implant Device,1825.8,34,,1825.8,percent of total billed charges,Implant Device,1825.8,34,,1825.8,percent of total billed charges,Implant Device,2658.15,,,2658.15,Other,110% of Medicare,1879.5,35,,1879.5,percent of total billed charges,Implant Device,1825.8,34,"Charges > $500, x 34%",1825.8,percent of total billed charges,Implant Device,1879.5,35,,1879.5,percent of total billed charges,Implant Device,1879.5,35,,1879.5,percent of total billed charges,Implant Device,1879.5,35,,1879.5,percent of total billed charges,Implant Device,1879.5,35,,1879.5,percent of total billed charges,Implant Device,1879.5,35,,1879.5,percent of total billed charges,Implant Device,2148,40,,2148,percent of total billed charges,Implant Device,1879.5,70,,1879.5,percent of total billed charges,All Other,1825.8,34,,1825.8,percent of total billed charges,Implant Device,1825.8,34,,1825.8,percent of total billed charges,Implant Device,1879.5,35,,1879.5,percent of total billed charges,Implant Device,1879.5,35,,1879.5,percent of total billed charges,Implant Device,1879.5,35,,1879.5,percent of total billed charges,Implant Device,1879.5,35,,1879.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1825.8,34,"If Charge > 2,000, then 34 percent",1825.8,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3973.81,
DEPUY 1024-08-200 FEM UNICONDLR 2 RM/LL,C1776,HCPCS,,79008448,CDM,278,RC,,,both,,,6846,5066.06,,,5066.06,Other,150% of Medicare + 9.63% HCRA Surcharge,3080.7,45,,3080.7,percent of total billed charges,Critical Access Hospital RCC factor,2327.64,34,,2327.64,percent of total billed charges,Implant Device,2327.64,34,,2327.64,percent of total billed charges,Implant Device,2327.64,34,,2327.64,percent of total billed charges,Implant Device,2327.64,34,,2327.64,percent of total billed charges,Implant Device,2327.64,34,,2327.64,percent of total billed charges,Implant Device,3388.77,,,3388.77,Other,110% of Medicare,2396.1,35,,2396.1,percent of total billed charges,Implant Device,2327.64,34,"Charges > $500, x 34%",2327.64,percent of total billed charges,Implant Device,2396.1,35,,2396.1,percent of total billed charges,Implant Device,2396.1,35,,2396.1,percent of total billed charges,Implant Device,2396.1,35,,2396.1,percent of total billed charges,Implant Device,2396.1,35,,2396.1,percent of total billed charges,Implant Device,2396.1,35,,2396.1,percent of total billed charges,Implant Device,2738.4,40,,2738.4,percent of total billed charges,Implant Device,2396.1,70,,2396.1,percent of total billed charges,All Other,2327.64,34,,2327.64,percent of total billed charges,Implant Device,2327.64,34,,2327.64,percent of total billed charges,Implant Device,2396.1,35,,2396.1,percent of total billed charges,Implant Device,2396.1,35,,2396.1,percent of total billed charges,Implant Device,2396.1,35,,2396.1,percent of total billed charges,Implant Device,2396.1,35,,2396.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2327.64,34,"If Charge > 2,000, then 34 percent",2327.64,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5066.06,
DEPUY 1024-52-200 TIBIAL TRAY SZ 2 RM/LL,C1776,HCPCS,,79008449,CDM,278,RC,,,both,,,3600,2664.01,,,2664.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1620,45,,1620,percent of total billed charges,Critical Access Hospital RCC factor,1224,34,,1224,percent of total billed charges,Implant Device,1224,34,,1224,percent of total billed charges,Implant Device,1224,34,,1224,percent of total billed charges,Implant Device,1224,34,,1224,percent of total billed charges,Implant Device,1224,34,,1224,percent of total billed charges,Implant Device,1782,,,1782,Other,110% of Medicare,1260,35,,1260,percent of total billed charges,Implant Device,1224,34,"Charges > $500, x 34%",1224,percent of total billed charges,Implant Device,1260,35,,1260,percent of total billed charges,Implant Device,1260,35,,1260,percent of total billed charges,Implant Device,1260,35,,1260,percent of total billed charges,Implant Device,1260,35,,1260,percent of total billed charges,Implant Device,1260,35,,1260,percent of total billed charges,Implant Device,1440,40,,1440,percent of total billed charges,Implant Device,1260,70,,1260,percent of total billed charges,All Other,1224,34,,1224,percent of total billed charges,Implant Device,1224,34,,1224,percent of total billed charges,Implant Device,1260,35,,1260,percent of total billed charges,Implant Device,1260,35,,1260,percent of total billed charges,Implant Device,1260,35,,1260,percent of total billed charges,Implant Device,1260,35,,1260,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1224,34,"If Charge > 2,000, then 34 percent",1224,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2664.01,
DEPUY 1024-54-207 TIBIAL INS SZ 2 RM/LL,C1776,HCPCS,,79008450,CDM,278,RC,,,both,,,2496,1847.05,,,1847.05,Other,150% of Medicare + 9.63% HCRA Surcharge,1123.2,45,,1123.2,percent of total billed charges,Critical Access Hospital RCC factor,848.64,34,,848.64,percent of total billed charges,Implant Device,848.64,34,,848.64,percent of total billed charges,Implant Device,848.64,34,,848.64,percent of total billed charges,Implant Device,848.64,34,,848.64,percent of total billed charges,Implant Device,848.64,34,,848.64,percent of total billed charges,Implant Device,1235.52,,,1235.52,Other,110% of Medicare,873.6,35,,873.6,percent of total billed charges,Implant Device,848.64,34,"Charges > $500, x 34%",848.64,percent of total billed charges,Implant Device,873.6,35,,873.6,percent of total billed charges,Implant Device,873.6,35,,873.6,percent of total billed charges,Implant Device,873.6,35,,873.6,percent of total billed charges,Implant Device,873.6,35,,873.6,percent of total billed charges,Implant Device,873.6,35,,873.6,percent of total billed charges,Implant Device,998.4,40,,998.4,percent of total billed charges,Implant Device,873.6,70,,873.6,percent of total billed charges,All Other,848.64,34,,848.64,percent of total billed charges,Implant Device,848.64,34,,848.64,percent of total billed charges,Implant Device,873.6,35,,873.6,percent of total billed charges,Implant Device,873.6,35,,873.6,percent of total billed charges,Implant Device,873.6,35,,873.6,percent of total billed charges,Implant Device,873.6,35,,873.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,848.64,34,"If Charge > 2,000, then 34 percent",848.64,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1847.05,
STABILITY SB1152-12 HUMERUS SHAFT,C1713,HCPCS,,79008451,CDM,278,RC,,,both,,,2475,1831.51,,,1831.51,Other,150% of Medicare + 9.63% HCRA Surcharge,1113.75,45,,1113.75,percent of total billed charges,Critical Access Hospital RCC factor,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,1225.13,,,1225.13,Other,110% of Medicare,866.25,35,,866.25,percent of total billed charges,Implant Device,841.5,34,"Charges > $500, x 34%",841.5,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,990,40,,990,percent of total billed charges,Implant Device,866.25,70,,866.25,percent of total billed charges,All Other,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,841.5,34,"If Charge > 2,000, then 34 percent",841.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1831.51,
ALAMO AT444FD FEMORAL SHAFT,C1713,HCPCS,,79008452,CDM,278,RC,,,both,,,4800,3552.01,,,3552.01,Other,150% of Medicare + 9.63% HCRA Surcharge,2160,45,,2160,percent of total billed charges,Critical Access Hospital RCC factor,1632,34,,1632,percent of total billed charges,Implant Device,1632,34,,1632,percent of total billed charges,Implant Device,1632,34,,1632,percent of total billed charges,Implant Device,1632,34,,1632,percent of total billed charges,Implant Device,1632,34,,1632,percent of total billed charges,Implant Device,2376,,,2376,Other,110% of Medicare,1680,35,,1680,percent of total billed charges,Implant Device,1632,34,"Charges > $500, x 34%",1632,percent of total billed charges,Implant Device,1680,35,,1680,percent of total billed charges,Implant Device,1680,35,,1680,percent of total billed charges,Implant Device,1680,35,,1680,percent of total billed charges,Implant Device,1680,35,,1680,percent of total billed charges,Implant Device,1680,35,,1680,percent of total billed charges,Implant Device,1920,40,,1920,percent of total billed charges,Implant Device,1680,70,,1680,percent of total billed charges,All Other,1632,34,,1632,percent of total billed charges,Implant Device,1632,34,,1632,percent of total billed charges,Implant Device,1680,35,,1680,percent of total billed charges,Implant Device,1680,35,,1680,percent of total billed charges,Implant Device,1680,35,,1680,percent of total billed charges,Implant Device,1680,35,,1680,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1632,34,"If Charge > 2,000, then 34 percent",1632,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3552.01,
STRYKER 58-23006 BONE SCREW 2.3X6MM,C1713,HCPCS,,79008453,CDM,278,RC,,,both,,,370,273.8,,,273.8,Other,150% of Medicare + 9.63% HCRA Surcharge,166.5,45,,166.5,percent of total billed charges,Critical Access Hospital RCC factor,125.8,34,,125.8,percent of total billed charges,Implant Device,125.8,34,,125.8,percent of total billed charges,Implant Device,125.8,34,,125.8,percent of total billed charges,Implant Device,125.8,34,,125.8,percent of total billed charges,Implant Device,125.8,34,,125.8,percent of total billed charges,Implant Device,183.15,,,183.15,Other,110% of Medicare,129.5,35,,129.5,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,129.5,35,,129.5,percent of total billed charges,Implant Device,129.5,35,,129.5,percent of total billed charges,Implant Device,129.5,35,,129.5,percent of total billed charges,Implant Device,129.5,35,,129.5,percent of total billed charges,Implant Device,129.5,35,,129.5,percent of total billed charges,Implant Device,148,40,,148,percent of total billed charges,Implant Device,129.5,70,,129.5,percent of total billed charges,All Other,125.8,34,,125.8,percent of total billed charges,Implant Device,125.8,34,,125.8,percent of total billed charges,Implant Device,129.5,35,,129.5,percent of total billed charges,Implant Device,129.5,35,,129.5,percent of total billed charges,Implant Device,129.5,35,,129.5,percent of total billed charges,Implant Device,129.5,35,,129.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,273.8,
STRYKER 1828-1036S T2 FEMUR NAIL R1500,C1713,HCPCS,,79008457,CDM,278,RC,,,both,,,7382,5462.7,,,5462.7,Other,150% of Medicare + 9.63% HCRA Surcharge,3321.9,45,,3321.9,percent of total billed charges,Critical Access Hospital RCC factor,2509.88,34,,2509.88,percent of total billed charges,Implant Device,2509.88,34,,2509.88,percent of total billed charges,Implant Device,2509.88,34,,2509.88,percent of total billed charges,Implant Device,2509.88,34,,2509.88,percent of total billed charges,Implant Device,2509.88,34,,2509.88,percent of total billed charges,Implant Device,3654.09,,,3654.09,Other,110% of Medicare,2583.7,35,,2583.7,percent of total billed charges,Implant Device,2509.88,34,"Charges > $500, x 34%",2509.88,percent of total billed charges,Implant Device,2583.7,35,,2583.7,percent of total billed charges,Implant Device,2583.7,35,,2583.7,percent of total billed charges,Implant Device,2583.7,35,,2583.7,percent of total billed charges,Implant Device,2583.7,35,,2583.7,percent of total billed charges,Implant Device,2583.7,35,,2583.7,percent of total billed charges,Implant Device,2952.8,40,,2952.8,percent of total billed charges,Implant Device,2583.7,70,,2583.7,percent of total billed charges,All Other,2509.88,34,,2509.88,percent of total billed charges,Implant Device,2509.88,34,,2509.88,percent of total billed charges,Implant Device,2583.7,35,,2583.7,percent of total billed charges,Implant Device,2583.7,35,,2583.7,percent of total billed charges,Implant Device,2583.7,35,,2583.7,percent of total billed charges,Implant Device,2583.7,35,,2583.7,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2509.88,34,"If Charge > 2,000, then 34 percent",2509.88,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5462.7,
STRYKER 1896-5085S LOCK SCREW FT 5X85MM,C1713,HCPCS,,79008458,CDM,278,RC,,,both,,,788,583.12,,,583.12,Other,150% of Medicare + 9.63% HCRA Surcharge,354.6,45,,354.6,percent of total billed charges,Critical Access Hospital RCC factor,267.92,34,,267.92,percent of total billed charges,Implant Device,267.92,34,,267.92,percent of total billed charges,Implant Device,267.92,34,,267.92,percent of total billed charges,Implant Device,267.92,34,,267.92,percent of total billed charges,Implant Device,267.92,34,,267.92,percent of total billed charges,Implant Device,390.06,,,390.06,Other,110% of Medicare,275.8,35,,275.8,percent of total billed charges,Implant Device,267.92,34,"Charges > $500, x 34%",267.92,percent of total billed charges,Implant Device,275.8,35,,275.8,percent of total billed charges,Implant Device,275.8,35,,275.8,percent of total billed charges,Implant Device,275.8,35,,275.8,percent of total billed charges,Implant Device,275.8,35,,275.8,percent of total billed charges,Implant Device,275.8,35,,275.8,percent of total billed charges,Implant Device,315.2,40,,315.2,percent of total billed charges,Implant Device,275.8,70,,275.8,percent of total billed charges,All Other,267.92,34,,267.92,percent of total billed charges,Implant Device,267.92,34,,267.92,percent of total billed charges,Implant Device,275.8,35,,275.8,percent of total billed charges,Implant Device,275.8,35,,275.8,percent of total billed charges,Implant Device,275.8,35,,275.8,percent of total billed charges,Implant Device,275.8,35,,275.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,583.12,
WRIGHT 777404022 DARCO SCREW 4.0 X 40L,C1713,HCPCS,,79008459,CDM,278,RC,,,both,,,1254,927.96,,,927.96,Other,150% of Medicare + 9.63% HCRA Surcharge,564.3,45,,564.3,percent of total billed charges,Critical Access Hospital RCC factor,426.36,34,,426.36,percent of total billed charges,Implant Device,426.36,34,,426.36,percent of total billed charges,Implant Device,426.36,34,,426.36,percent of total billed charges,Implant Device,426.36,34,,426.36,percent of total billed charges,Implant Device,426.36,34,,426.36,percent of total billed charges,Implant Device,620.73,,,620.73,Other,110% of Medicare,438.9,35,,438.9,percent of total billed charges,Implant Device,426.36,34,"Charges > $500, x 34%",426.36,percent of total billed charges,Implant Device,438.9,35,,438.9,percent of total billed charges,Implant Device,438.9,35,,438.9,percent of total billed charges,Implant Device,438.9,35,,438.9,percent of total billed charges,Implant Device,438.9,35,,438.9,percent of total billed charges,Implant Device,438.9,35,,438.9,percent of total billed charges,Implant Device,501.6,40,,501.6,percent of total billed charges,Implant Device,438.9,70,,438.9,percent of total billed charges,All Other,426.36,34,,426.36,percent of total billed charges,Implant Device,426.36,34,,426.36,percent of total billed charges,Implant Device,438.9,35,,438.9,percent of total billed charges,Implant Device,438.9,35,,438.9,percent of total billed charges,Implant Device,438.9,35,,438.9,percent of total billed charges,Implant Device,438.9,35,,438.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,927.96,
WRIGHT 777404032 DARCO SCREW 4.0 X 40S,C1713,HCPCS,,79008460,CDM,278,RC,,,both,,,1254,927.96,,,927.96,Other,150% of Medicare + 9.63% HCRA Surcharge,564.3,45,,564.3,percent of total billed charges,Critical Access Hospital RCC factor,426.36,34,,426.36,percent of total billed charges,Implant Device,426.36,34,,426.36,percent of total billed charges,Implant Device,426.36,34,,426.36,percent of total billed charges,Implant Device,426.36,34,,426.36,percent of total billed charges,Implant Device,426.36,34,,426.36,percent of total billed charges,Implant Device,620.73,,,620.73,Other,110% of Medicare,438.9,35,,438.9,percent of total billed charges,Implant Device,426.36,34,"Charges > $500, x 34%",426.36,percent of total billed charges,Implant Device,438.9,35,,438.9,percent of total billed charges,Implant Device,438.9,35,,438.9,percent of total billed charges,Implant Device,438.9,35,,438.9,percent of total billed charges,Implant Device,438.9,35,,438.9,percent of total billed charges,Implant Device,438.9,35,,438.9,percent of total billed charges,Implant Device,501.6,40,,501.6,percent of total billed charges,Implant Device,438.9,70,,438.9,percent of total billed charges,All Other,426.36,34,,426.36,percent of total billed charges,Implant Device,426.36,34,,426.36,percent of total billed charges,Implant Device,438.9,35,,438.9,percent of total billed charges,Implant Device,438.9,35,,438.9,percent of total billed charges,Implant Device,438.9,35,,438.9,percent of total billed charges,Implant Device,438.9,35,,438.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,927.96,
WRIGHT 777404432 DARCO SCREW 4.0 X 44S,C1713,HCPCS,,79008461,CDM,278,RC,,,both,,,1254,927.96,,,927.96,Other,150% of Medicare + 9.63% HCRA Surcharge,564.3,45,,564.3,percent of total billed charges,Critical Access Hospital RCC factor,426.36,34,,426.36,percent of total billed charges,Implant Device,426.36,34,,426.36,percent of total billed charges,Implant Device,426.36,34,,426.36,percent of total billed charges,Implant Device,426.36,34,,426.36,percent of total billed charges,Implant Device,426.36,34,,426.36,percent of total billed charges,Implant Device,620.73,,,620.73,Other,110% of Medicare,438.9,35,,438.9,percent of total billed charges,Implant Device,426.36,34,"Charges > $500, x 34%",426.36,percent of total billed charges,Implant Device,438.9,35,,438.9,percent of total billed charges,Implant Device,438.9,35,,438.9,percent of total billed charges,Implant Device,438.9,35,,438.9,percent of total billed charges,Implant Device,438.9,35,,438.9,percent of total billed charges,Implant Device,438.9,35,,438.9,percent of total billed charges,Implant Device,501.6,40,,501.6,percent of total billed charges,Implant Device,438.9,70,,438.9,percent of total billed charges,All Other,426.36,34,,426.36,percent of total billed charges,Implant Device,426.36,34,,426.36,percent of total billed charges,Implant Device,438.9,35,,438.9,percent of total billed charges,Implant Device,438.9,35,,438.9,percent of total billed charges,Implant Device,438.9,35,,438.9,percent of total billed charges,Implant Device,438.9,35,,438.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,927.96,
STRYKER 3102-2102 BIO4 BONE MATRIX-2.5CC,C1713,HCPCS,,79008462,CDM,278,RC,,,both,,,5100,3774.01,,,3774.01,Other,150% of Medicare + 9.63% HCRA Surcharge,2295,45,,2295,percent of total billed charges,Critical Access Hospital RCC factor,1734,34,,1734,percent of total billed charges,Implant Device,1734,34,,1734,percent of total billed charges,Implant Device,1734,34,,1734,percent of total billed charges,Implant Device,1734,34,,1734,percent of total billed charges,Implant Device,1734,34,,1734,percent of total billed charges,Implant Device,2524.5,,,2524.5,Other,110% of Medicare,1785,35,,1785,percent of total billed charges,Implant Device,1734,34,"Charges > $500, x 34%",1734,percent of total billed charges,Implant Device,1785,35,,1785,percent of total billed charges,Implant Device,1785,35,,1785,percent of total billed charges,Implant Device,1785,35,,1785,percent of total billed charges,Implant Device,1785,35,,1785,percent of total billed charges,Implant Device,1785,35,,1785,percent of total billed charges,Implant Device,2040,40,,2040,percent of total billed charges,Implant Device,1785,70,,1785,percent of total billed charges,All Other,1734,34,,1734,percent of total billed charges,Implant Device,1734,34,,1734,percent of total billed charges,Implant Device,1785,35,,1785,percent of total billed charges,Implant Device,1785,35,,1785,percent of total billed charges,Implant Device,1785,35,,1785,percent of total billed charges,Implant Device,1785,35,,1785,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1734,34,"If Charge > 2,000, then 34 percent",1734,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3774.01,
STRYKER 3102-2105 BOI4 BONE MATRIX-5CC,C1713,HCPCS,,79008463,CDM,278,RC,,,both,,,9000,6660.02,,,6660.02,Other,150% of Medicare + 9.63% HCRA Surcharge,4050,45,,4050,percent of total billed charges,Critical Access Hospital RCC factor,3060,34,,3060,percent of total billed charges,Implant Device,3060,34,,3060,percent of total billed charges,Implant Device,3060,34,,3060,percent of total billed charges,Implant Device,3060,34,,3060,percent of total billed charges,Implant Device,3060,34,,3060,percent of total billed charges,Implant Device,4455,,,4455,Other,110% of Medicare,3150,35,,3150,percent of total billed charges,Implant Device,3060,34,"Charges > $500, x 34%",3060,percent of total billed charges,Implant Device,3150,35,,3150,percent of total billed charges,Implant Device,3150,35,,3150,percent of total billed charges,Implant Device,3150,35,,3150,percent of total billed charges,Implant Device,3150,35,,3150,percent of total billed charges,Implant Device,3150,35,,3150,percent of total billed charges,Implant Device,3600,40,,3600,percent of total billed charges,Implant Device,3150,70,,3150,percent of total billed charges,All Other,3060,34,,3060,percent of total billed charges,Implant Device,3060,34,,3060,percent of total billed charges,Implant Device,3150,35,,3150,percent of total billed charges,Implant Device,3150,35,,3150,percent of total billed charges,Implant Device,3150,35,,3150,percent of total billed charges,Implant Device,3150,35,,3150,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3060,34,"If Charge > 2,000, then 34 percent",3060,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,6660.02,
STRYKER 3102-2110 BIO4 BONE MATRIX-10CC,C1713,HCPCS,,79008464,CDM,278,RC,,,both,,,15360,11366.44,,,11366.44,Other,150% of Medicare + 9.63% HCRA Surcharge,6912,45,,6912,percent of total billed charges,Critical Access Hospital RCC factor,5222.4,34,,5222.4,percent of total billed charges,Implant Device,5222.4,34,,5222.4,percent of total billed charges,Implant Device,5222.4,34,,5222.4,percent of total billed charges,Implant Device,5222.4,34,,5222.4,percent of total billed charges,Implant Device,5222.4,34,,5222.4,percent of total billed charges,Implant Device,7603.2,,,7603.2,Other,110% of Medicare,5376,35,,5376,percent of total billed charges,Implant Device,5222.4,34,"Charges > $500, x 34%",5222.4,percent of total billed charges,Implant Device,5376,35,,5376,percent of total billed charges,Implant Device,5376,35,,5376,percent of total billed charges,Implant Device,5376,35,,5376,percent of total billed charges,Implant Device,5376,35,,5376,percent of total billed charges,Implant Device,5376,35,,5376,percent of total billed charges,Implant Device,6144,40,,6144,percent of total billed charges,Implant Device,5376,70,,5376,percent of total billed charges,All Other,5222.4,34,,5222.4,percent of total billed charges,Implant Device,5222.4,34,,5222.4,percent of total billed charges,Implant Device,5376,35,,5376,percent of total billed charges,Implant Device,5376,35,,5376,percent of total billed charges,Implant Device,5376,35,,5376,percent of total billed charges,Implant Device,5376,35,,5376,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,5222.4,34,"If Charge > 2,000, then 34 percent",5222.4,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,11366.44,
STRYKER 40-20908 VARIAX FIB PLATE 8 HOLE,C1713,HCPCS,,79008465,CDM,278,RC,,,both,,,1932,1429.68,,,1429.68,Other,150% of Medicare + 9.63% HCRA Surcharge,869.4,45,,869.4,percent of total billed charges,Critical Access Hospital RCC factor,656.88,34,,656.88,percent of total billed charges,Implant Device,656.88,34,,656.88,percent of total billed charges,Implant Device,656.88,34,,656.88,percent of total billed charges,Implant Device,656.88,34,,656.88,percent of total billed charges,Implant Device,656.88,34,,656.88,percent of total billed charges,Implant Device,956.34,,,956.34,Other,110% of Medicare,676.2,35,,676.2,percent of total billed charges,Implant Device,656.88,34,"Charges > $500, x 34%",656.88,percent of total billed charges,Implant Device,676.2,35,,676.2,percent of total billed charges,Implant Device,676.2,35,,676.2,percent of total billed charges,Implant Device,676.2,35,,676.2,percent of total billed charges,Implant Device,676.2,35,,676.2,percent of total billed charges,Implant Device,676.2,35,,676.2,percent of total billed charges,Implant Device,772.8,40,,772.8,percent of total billed charges,Implant Device,676.2,70,,676.2,percent of total billed charges,All Other,656.88,34,,656.88,percent of total billed charges,Implant Device,656.88,34,,656.88,percent of total billed charges,Implant Device,676.2,35,,676.2,percent of total billed charges,Implant Device,676.2,35,,676.2,percent of total billed charges,Implant Device,676.2,35,,676.2,percent of total billed charges,Implant Device,676.2,35,,676.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1429.68,
STRYKER 629507 COMP PLATE NARROW 7 HOLE,C1713,HCPCS,,79008470,CDM,278,RC,,,both,,,2085,1542.91,,,1542.91,Other,150% of Medicare + 9.63% HCRA Surcharge,938.25,45,,938.25,percent of total billed charges,Critical Access Hospital RCC factor,708.9,34,,708.9,percent of total billed charges,Implant Device,708.9,34,,708.9,percent of total billed charges,Implant Device,708.9,34,,708.9,percent of total billed charges,Implant Device,708.9,34,,708.9,percent of total billed charges,Implant Device,708.9,34,,708.9,percent of total billed charges,Implant Device,1032.08,,,1032.08,Other,110% of Medicare,729.75,35,,729.75,percent of total billed charges,Implant Device,708.9,34,"Charges > $500, x 34%",708.9,percent of total billed charges,Implant Device,729.75,35,,729.75,percent of total billed charges,Implant Device,729.75,35,,729.75,percent of total billed charges,Implant Device,729.75,35,,729.75,percent of total billed charges,Implant Device,729.75,35,,729.75,percent of total billed charges,Implant Device,729.75,35,,729.75,percent of total billed charges,Implant Device,834,40,,834,percent of total billed charges,Implant Device,729.75,70,,729.75,percent of total billed charges,All Other,708.9,34,,708.9,percent of total billed charges,Implant Device,708.9,34,,708.9,percent of total billed charges,Implant Device,729.75,35,,729.75,percent of total billed charges,Implant Device,729.75,35,,729.75,percent of total billed charges,Implant Device,729.75,35,,729.75,percent of total billed charges,Implant Device,729.75,35,,729.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,708.9,34,"If Charge > 2,000, then 34 percent",708.9,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1542.91,
STRYKER 657418 NON LOCK SCREW 3.5X18MM,C1713,HCPCS,,79008471,CDM,278,RC,,,both,,,294,217.56,,,217.56,Other,150% of Medicare + 9.63% HCRA Surcharge,132.3,45,,132.3,percent of total billed charges,Critical Access Hospital RCC factor,99.96,34,,99.96,percent of total billed charges,Implant Device,99.96,34,,99.96,percent of total billed charges,Implant Device,99.96,34,,99.96,percent of total billed charges,Implant Device,99.96,34,,99.96,percent of total billed charges,Implant Device,99.96,34,,99.96,percent of total billed charges,Implant Device,145.53,,,145.53,Other,110% of Medicare,102.9,35,,102.9,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,102.9,35,,102.9,percent of total billed charges,Implant Device,102.9,35,,102.9,percent of total billed charges,Implant Device,102.9,35,,102.9,percent of total billed charges,Implant Device,102.9,35,,102.9,percent of total billed charges,Implant Device,102.9,35,,102.9,percent of total billed charges,Implant Device,117.6,40,,117.6,percent of total billed charges,Implant Device,102.9,70,,102.9,percent of total billed charges,All Other,99.96,34,,99.96,percent of total billed charges,Implant Device,99.96,34,,99.96,percent of total billed charges,Implant Device,102.9,35,,102.9,percent of total billed charges,Implant Device,102.9,35,,102.9,percent of total billed charges,Implant Device,102.9,35,,102.9,percent of total billed charges,Implant Device,102.9,35,,102.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,217.56,
STRYKER 657314 LOCKING SCREW 3.5X14MM,C1713,HCPCS,,79008472,CDM,278,RC,,,both,,,539,398.86,,,398.86,Other,150% of Medicare + 9.63% HCRA Surcharge,242.55,45,,242.55,percent of total billed charges,Critical Access Hospital RCC factor,183.26,34,,183.26,percent of total billed charges,Implant Device,183.26,34,,183.26,percent of total billed charges,Implant Device,183.26,34,,183.26,percent of total billed charges,Implant Device,183.26,34,,183.26,percent of total billed charges,Implant Device,183.26,34,,183.26,percent of total billed charges,Implant Device,266.81,,,266.81,Other,110% of Medicare,188.65,35,,188.65,percent of total billed charges,Implant Device,183.26,34,"Charges > $500, x 34%",183.26,percent of total billed charges,Implant Device,188.65,35,,188.65,percent of total billed charges,Implant Device,188.65,35,,188.65,percent of total billed charges,Implant Device,188.65,35,,188.65,percent of total billed charges,Implant Device,188.65,35,,188.65,percent of total billed charges,Implant Device,188.65,35,,188.65,percent of total billed charges,Implant Device,215.6,40,,215.6,percent of total billed charges,Implant Device,188.65,70,,188.65,percent of total billed charges,All Other,183.26,34,,183.26,percent of total billed charges,Implant Device,183.26,34,,183.26,percent of total billed charges,Implant Device,188.65,35,,188.65,percent of total billed charges,Implant Device,188.65,35,,188.65,percent of total billed charges,Implant Device,188.65,35,,188.65,percent of total billed charges,Implant Device,188.65,35,,188.65,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,398.86,
STRYKER 657318 LOCKING SCREW 3.5X18MM,C1713,HCPCS,,79008473,CDM,278,RC,,,both,,,539,398.86,,,398.86,Other,150% of Medicare + 9.63% HCRA Surcharge,242.55,45,,242.55,percent of total billed charges,Critical Access Hospital RCC factor,183.26,34,,183.26,percent of total billed charges,Implant Device,183.26,34,,183.26,percent of total billed charges,Implant Device,183.26,34,,183.26,percent of total billed charges,Implant Device,183.26,34,,183.26,percent of total billed charges,Implant Device,183.26,34,,183.26,percent of total billed charges,Implant Device,266.81,,,266.81,Other,110% of Medicare,188.65,35,,188.65,percent of total billed charges,Implant Device,183.26,34,"Charges > $500, x 34%",183.26,percent of total billed charges,Implant Device,188.65,35,,188.65,percent of total billed charges,Implant Device,188.65,35,,188.65,percent of total billed charges,Implant Device,188.65,35,,188.65,percent of total billed charges,Implant Device,188.65,35,,188.65,percent of total billed charges,Implant Device,188.65,35,,188.65,percent of total billed charges,Implant Device,215.6,40,,215.6,percent of total billed charges,Implant Device,188.65,70,,188.65,percent of total billed charges,All Other,183.26,34,,183.26,percent of total billed charges,Implant Device,183.26,34,,183.26,percent of total billed charges,Implant Device,188.65,35,,188.65,percent of total billed charges,Implant Device,188.65,35,,188.65,percent of total billed charges,Implant Device,188.65,35,,188.65,percent of total billed charges,Implant Device,188.65,35,,188.65,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,398.86,
STRYKER 626920 LAG SCREW 3.6X20MM,C1713,HCPCS,,79008474,CDM,278,RC,,,both,,,879,650.46,,,650.46,Other,150% of Medicare + 9.63% HCRA Surcharge,395.55,45,,395.55,percent of total billed charges,Critical Access Hospital RCC factor,298.86,34,,298.86,percent of total billed charges,Implant Device,298.86,34,,298.86,percent of total billed charges,Implant Device,298.86,34,,298.86,percent of total billed charges,Implant Device,298.86,34,,298.86,percent of total billed charges,Implant Device,298.86,34,,298.86,percent of total billed charges,Implant Device,435.11,,,435.11,Other,110% of Medicare,307.65,35,,307.65,percent of total billed charges,Implant Device,298.86,34,"Charges > $500, x 34%",298.86,percent of total billed charges,Implant Device,307.65,35,,307.65,percent of total billed charges,Implant Device,307.65,35,,307.65,percent of total billed charges,Implant Device,307.65,35,,307.65,percent of total billed charges,Implant Device,307.65,35,,307.65,percent of total billed charges,Implant Device,307.65,35,,307.65,percent of total billed charges,Implant Device,351.6,40,,351.6,percent of total billed charges,Implant Device,307.65,70,,307.65,percent of total billed charges,All Other,298.86,34,,298.86,percent of total billed charges,Implant Device,298.86,34,,298.86,percent of total billed charges,Implant Device,307.65,35,,307.65,percent of total billed charges,Implant Device,307.65,35,,307.65,percent of total billed charges,Implant Device,307.65,35,,307.65,percent of total billed charges,Implant Device,307.65,35,,307.65,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,650.46,
STRYKER 626922 LAG SCREW 3.6X22MM,C1713,HCPCS,,79008475,CDM,278,RC,,,both,,,879,650.46,,,650.46,Other,150% of Medicare + 9.63% HCRA Surcharge,395.55,45,,395.55,percent of total billed charges,Critical Access Hospital RCC factor,298.86,34,,298.86,percent of total billed charges,Implant Device,298.86,34,,298.86,percent of total billed charges,Implant Device,298.86,34,,298.86,percent of total billed charges,Implant Device,298.86,34,,298.86,percent of total billed charges,Implant Device,298.86,34,,298.86,percent of total billed charges,Implant Device,435.11,,,435.11,Other,110% of Medicare,307.65,35,,307.65,percent of total billed charges,Implant Device,298.86,34,"Charges > $500, x 34%",298.86,percent of total billed charges,Implant Device,307.65,35,,307.65,percent of total billed charges,Implant Device,307.65,35,,307.65,percent of total billed charges,Implant Device,307.65,35,,307.65,percent of total billed charges,Implant Device,307.65,35,,307.65,percent of total billed charges,Implant Device,307.65,35,,307.65,percent of total billed charges,Implant Device,351.6,40,,351.6,percent of total billed charges,Implant Device,307.65,70,,307.65,percent of total billed charges,All Other,298.86,34,,298.86,percent of total billed charges,Implant Device,298.86,34,,298.86,percent of total billed charges,Implant Device,307.65,35,,307.65,percent of total billed charges,Implant Device,307.65,35,,307.65,percent of total billed charges,Implant Device,307.65,35,,307.65,percent of total billed charges,Implant Device,307.65,35,,307.65,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,650.46,
STRYKER 656310 LOCKING SCREW 2.7X1.10MM,C1713,HCPCS,,79008476,CDM,278,RC,,,both,,,636,470.64,,,470.64,Other,150% of Medicare + 9.63% HCRA Surcharge,286.2,45,,286.2,percent of total billed charges,Critical Access Hospital RCC factor,216.24,34,,216.24,percent of total billed charges,Implant Device,216.24,34,,216.24,percent of total billed charges,Implant Device,216.24,34,,216.24,percent of total billed charges,Implant Device,216.24,34,,216.24,percent of total billed charges,Implant Device,216.24,34,,216.24,percent of total billed charges,Implant Device,314.82,,,314.82,Other,110% of Medicare,222.6,35,,222.6,percent of total billed charges,Implant Device,216.24,34,"Charges > $500, x 34%",216.24,percent of total billed charges,Implant Device,222.6,35,,222.6,percent of total billed charges,Implant Device,222.6,35,,222.6,percent of total billed charges,Implant Device,222.6,35,,222.6,percent of total billed charges,Implant Device,222.6,35,,222.6,percent of total billed charges,Implant Device,222.6,35,,222.6,percent of total billed charges,Implant Device,254.4,40,,254.4,percent of total billed charges,Implant Device,222.6,70,,222.6,percent of total billed charges,All Other,216.24,34,,216.24,percent of total billed charges,Implant Device,216.24,34,,216.24,percent of total billed charges,Implant Device,222.6,35,,222.6,percent of total billed charges,Implant Device,222.6,35,,222.6,percent of total billed charges,Implant Device,222.6,35,,222.6,percent of total billed charges,Implant Device,222.6,35,,222.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,470.64,
ARROW CS-15122-F 12FRX20CM VENOUS CATH,C1752,HCPCS,,79008478,CDM,278,RC,,,both,,,177,130.98,,,130.98,Other,150% of Medicare + 9.63% HCRA Surcharge,79.65,45,,79.65,percent of total billed charges,Critical Access Hospital RCC factor,60.18,34,,60.18,percent of total billed charges,Implant Device,60.18,34,,60.18,percent of total billed charges,Implant Device,60.18,34,,60.18,percent of total billed charges,Implant Device,60.18,34,,60.18,percent of total billed charges,Implant Device,60.18,34,,60.18,percent of total billed charges,Implant Device,87.62,,,87.62,Other,110% of Medicare,61.95,35,,61.95,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,61.95,35,,61.95,percent of total billed charges,Implant Device,61.95,35,,61.95,percent of total billed charges,Implant Device,61.95,35,,61.95,percent of total billed charges,Implant Device,61.95,35,,61.95,percent of total billed charges,Implant Device,61.95,35,,61.95,percent of total billed charges,Implant Device,70.8,40,,70.8,percent of total billed charges,Implant Device,61.95,70,,61.95,percent of total billed charges,All Other,60.18,34,,60.18,percent of total billed charges,Implant Device,60.18,34,,60.18,percent of total billed charges,Implant Device,61.95,35,,61.95,percent of total billed charges,Implant Device,61.95,35,,61.95,percent of total billed charges,Implant Device,61.95,35,,61.95,percent of total billed charges,Implant Device,61.95,35,,61.95,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,130.98,
DEPUY 458.950S 5.0X50MM TI LOCKNG SCREW,C1713,HCPCS,,79008479,CDM,278,RC,,,both,,,456,337.44,,,337.44,Other,150% of Medicare + 9.63% HCRA Surcharge,205.2,45,,205.2,percent of total billed charges,Critical Access Hospital RCC factor,155.04,34,,155.04,percent of total billed charges,Implant Device,155.04,34,,155.04,percent of total billed charges,Implant Device,155.04,34,,155.04,percent of total billed charges,Implant Device,155.04,34,,155.04,percent of total billed charges,Implant Device,155.04,34,,155.04,percent of total billed charges,Implant Device,225.72,,,225.72,Other,110% of Medicare,159.6,35,,159.6,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,159.6,35,,159.6,percent of total billed charges,Implant Device,159.6,35,,159.6,percent of total billed charges,Implant Device,159.6,35,,159.6,percent of total billed charges,Implant Device,159.6,35,,159.6,percent of total billed charges,Implant Device,159.6,35,,159.6,percent of total billed charges,Implant Device,182.4,40,,182.4,percent of total billed charges,Implant Device,159.6,70,,159.6,percent of total billed charges,All Other,155.04,34,,155.04,percent of total billed charges,Implant Device,155.04,34,,155.04,percent of total billed charges,Implant Device,159.6,35,,159.6,percent of total billed charges,Implant Device,159.6,35,,159.6,percent of total billed charges,Implant Device,159.6,35,,159.6,percent of total billed charges,Implant Device,159.6,35,,159.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,337.44,
DEPUY 456.416S 11MM/130DEG NAIL 360MM/R,C1713,HCPCS,,79008480,CDM,278,RC,,,both,,,6895,5102.32,,,5102.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3102.75,45,,3102.75,percent of total billed charges,Critical Access Hospital RCC factor,2344.3,34,,2344.3,percent of total billed charges,Implant Device,2344.3,34,,2344.3,percent of total billed charges,Implant Device,2344.3,34,,2344.3,percent of total billed charges,Implant Device,2344.3,34,,2344.3,percent of total billed charges,Implant Device,2344.3,34,,2344.3,percent of total billed charges,Implant Device,3413.03,,,3413.03,Other,110% of Medicare,2413.25,35,,2413.25,percent of total billed charges,Implant Device,2344.3,34,"Charges > $500, x 34%",2344.3,percent of total billed charges,Implant Device,2413.25,35,,2413.25,percent of total billed charges,Implant Device,2413.25,35,,2413.25,percent of total billed charges,Implant Device,2413.25,35,,2413.25,percent of total billed charges,Implant Device,2413.25,35,,2413.25,percent of total billed charges,Implant Device,2413.25,35,,2413.25,percent of total billed charges,Implant Device,2758,40,,2758,percent of total billed charges,Implant Device,2413.25,70,,2413.25,percent of total billed charges,All Other,2344.3,34,,2344.3,percent of total billed charges,Implant Device,2344.3,34,,2344.3,percent of total billed charges,Implant Device,2413.25,35,,2413.25,percent of total billed charges,Implant Device,2413.25,35,,2413.25,percent of total billed charges,Implant Device,2413.25,35,,2413.25,percent of total billed charges,Implant Device,2413.25,35,,2413.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2344.3,34,"If Charge > 2,000, then 34 percent",2344.3,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5102.32,
STRYKER 40-20907 DISTL FIB PLATE 7 HOLE,C1776,HCPCS,,79008483,CDM,278,RC,,,both,,,1836,1358.64,,,1358.64,Other,150% of Medicare + 9.63% HCRA Surcharge,826.2,45,,826.2,percent of total billed charges,Critical Access Hospital RCC factor,624.24,34,,624.24,percent of total billed charges,Implant Device,624.24,34,,624.24,percent of total billed charges,Implant Device,624.24,34,,624.24,percent of total billed charges,Implant Device,624.24,34,,624.24,percent of total billed charges,Implant Device,624.24,34,,624.24,percent of total billed charges,Implant Device,908.82,,,908.82,Other,110% of Medicare,642.6,35,,642.6,percent of total billed charges,Implant Device,624.24,34,"Charges > $500, x 34%",624.24,percent of total billed charges,Implant Device,642.6,35,,642.6,percent of total billed charges,Implant Device,642.6,35,,642.6,percent of total billed charges,Implant Device,642.6,35,,642.6,percent of total billed charges,Implant Device,642.6,35,,642.6,percent of total billed charges,Implant Device,642.6,35,,642.6,percent of total billed charges,Implant Device,734.4,40,,734.4,percent of total billed charges,Implant Device,642.6,70,,642.6,percent of total billed charges,All Other,624.24,34,,624.24,percent of total billed charges,Implant Device,624.24,34,,624.24,percent of total billed charges,Implant Device,642.6,35,,642.6,percent of total billed charges,Implant Device,642.6,35,,642.6,percent of total billed charges,Implant Device,642.6,35,,642.6,percent of total billed charges,Implant Device,642.6,35,,642.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1358.64,
STABILITY 1148-14 DISTAL HEAD HUM SHAFT,C1776,HCPCS,,79008484,CDM,278,RC,,,both,,,3300,2442.01,,,2442.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1485,45,,1485,percent of total billed charges,Critical Access Hospital RCC factor,1122,34,,1122,percent of total billed charges,Implant Device,1122,34,,1122,percent of total billed charges,Implant Device,1122,34,,1122,percent of total billed charges,Implant Device,1122,34,,1122,percent of total billed charges,Implant Device,1122,34,,1122,percent of total billed charges,Implant Device,1633.5,,,1633.5,Other,110% of Medicare,1155,35,,1155,percent of total billed charges,Implant Device,1122,34,"Charges > $500, x 34%",1122,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,1320,40,,1320,percent of total billed charges,Implant Device,1155,70,,1155,percent of total billed charges,All Other,1122,34,,1122,percent of total billed charges,Implant Device,1122,34,,1122,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1122,34,"If Charge > 2,000, then 34 percent",1122,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2442.01,
DEPUY 237.24 CONDYLAR PLATE 70X204MM,C1713,HCPCS,,79008485,CDM,278,RC,,,both,,,2507,1855.19,,,1855.19,Other,150% of Medicare + 9.63% HCRA Surcharge,1128.15,45,,1128.15,percent of total billed charges,Critical Access Hospital RCC factor,852.38,34,,852.38,percent of total billed charges,Implant Device,852.38,34,,852.38,percent of total billed charges,Implant Device,852.38,34,,852.38,percent of total billed charges,Implant Device,852.38,34,,852.38,percent of total billed charges,Implant Device,852.38,34,,852.38,percent of total billed charges,Implant Device,1240.97,,,1240.97,Other,110% of Medicare,877.45,35,,877.45,percent of total billed charges,Implant Device,852.38,34,"Charges > $500, x 34%",852.38,percent of total billed charges,Implant Device,877.45,35,,877.45,percent of total billed charges,Implant Device,877.45,35,,877.45,percent of total billed charges,Implant Device,877.45,35,,877.45,percent of total billed charges,Implant Device,877.45,35,,877.45,percent of total billed charges,Implant Device,877.45,35,,877.45,percent of total billed charges,Implant Device,1002.8,40,,1002.8,percent of total billed charges,Implant Device,877.45,70,,877.45,percent of total billed charges,All Other,852.38,34,,852.38,percent of total billed charges,Implant Device,852.38,34,,852.38,percent of total billed charges,Implant Device,877.45,35,,877.45,percent of total billed charges,Implant Device,877.45,35,,877.45,percent of total billed charges,Implant Device,877.45,35,,877.45,percent of total billed charges,Implant Device,877.45,35,,877.45,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,852.38,34,"If Charge > 2,000, then 34 percent",852.38,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1855.19,
DEPUY 214.856 CORTEX SCREW 4.5X56MM,C1713,HCPCS,,79008486,CDM,278,RC,,,both,,,83,61.42,,,61.42,Other,150% of Medicare + 9.63% HCRA Surcharge,37.35,45,,37.35,percent of total billed charges,Critical Access Hospital RCC factor,28.22,34,,28.22,percent of total billed charges,Implant Device,28.22,34,,28.22,percent of total billed charges,Implant Device,28.22,34,,28.22,percent of total billed charges,Implant Device,28.22,34,,28.22,percent of total billed charges,Implant Device,28.22,34,,28.22,percent of total billed charges,Implant Device,41.09,,,41.09,Other,110% of Medicare,29.05,35,,29.05,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,29.05,35,,29.05,percent of total billed charges,Implant Device,29.05,35,,29.05,percent of total billed charges,Implant Device,29.05,35,,29.05,percent of total billed charges,Implant Device,29.05,35,,29.05,percent of total billed charges,Implant Device,29.05,35,,29.05,percent of total billed charges,Implant Device,33.2,40,,33.2,percent of total billed charges,Implant Device,29.05,70,,29.05,percent of total billed charges,All Other,28.22,34,,28.22,percent of total billed charges,Implant Device,28.22,34,,28.22,percent of total billed charges,Implant Device,29.05,35,,29.05,percent of total billed charges,Implant Device,29.05,35,,29.05,percent of total billed charges,Implant Device,29.05,35,,29.05,percent of total billed charges,Implant Device,29.05,35,,29.05,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,61.42,
DEPUY 214.840 CORTEX SCREW 4.5X40MM,C1713,HCPCS,,79008487,CDM,278,RC,,,both,,,57,42.18,,,42.18,Other,150% of Medicare + 9.63% HCRA Surcharge,25.65,45,,25.65,percent of total billed charges,Critical Access Hospital RCC factor,19.38,34,,19.38,percent of total billed charges,Implant Device,19.38,34,,19.38,percent of total billed charges,Implant Device,19.38,34,,19.38,percent of total billed charges,Implant Device,19.38,34,,19.38,percent of total billed charges,Implant Device,19.38,34,,19.38,percent of total billed charges,Implant Device,28.22,,,28.22,Other,110% of Medicare,19.95,35,,19.95,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,19.95,35,,19.95,percent of total billed charges,Implant Device,19.95,35,,19.95,percent of total billed charges,Implant Device,19.95,35,,19.95,percent of total billed charges,Implant Device,19.95,35,,19.95,percent of total billed charges,Implant Device,19.95,35,,19.95,percent of total billed charges,Implant Device,22.8,40,,22.8,percent of total billed charges,Implant Device,19.95,70,,19.95,percent of total billed charges,All Other,19.38,34,,19.38,percent of total billed charges,Implant Device,19.38,34,,19.38,percent of total billed charges,Implant Device,19.95,35,,19.95,percent of total billed charges,Implant Device,19.95,35,,19.95,percent of total billed charges,Implant Device,19.95,35,,19.95,percent of total billed charges,Implant Device,19.95,35,,19.95,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,42.18,
STABILITY SB1153-14 HUM W/ DIS AND PROX,C1776,HCPCS,,79008488,CDM,278,RC,,,both,,,4485,3318.91,,,3318.91,Other,150% of Medicare + 9.63% HCRA Surcharge,2018.25,45,,2018.25,percent of total billed charges,Critical Access Hospital RCC factor,1524.9,34,,1524.9,percent of total billed charges,Implant Device,1524.9,34,,1524.9,percent of total billed charges,Implant Device,1524.9,34,,1524.9,percent of total billed charges,Implant Device,1524.9,34,,1524.9,percent of total billed charges,Implant Device,1524.9,34,,1524.9,percent of total billed charges,Implant Device,2220.08,,,2220.08,Other,110% of Medicare,1569.75,35,,1569.75,percent of total billed charges,Implant Device,1524.9,34,"Charges > $500, x 34%",1524.9,percent of total billed charges,Implant Device,1569.75,35,,1569.75,percent of total billed charges,Implant Device,1569.75,35,,1569.75,percent of total billed charges,Implant Device,1569.75,35,,1569.75,percent of total billed charges,Implant Device,1569.75,35,,1569.75,percent of total billed charges,Implant Device,1569.75,35,,1569.75,percent of total billed charges,Implant Device,1794,40,,1794,percent of total billed charges,Implant Device,1569.75,70,,1569.75,percent of total billed charges,All Other,1524.9,34,,1524.9,percent of total billed charges,Implant Device,1524.9,34,,1524.9,percent of total billed charges,Implant Device,1569.75,35,,1569.75,percent of total billed charges,Implant Device,1569.75,35,,1569.75,percent of total billed charges,Implant Device,1569.75,35,,1569.75,percent of total billed charges,Implant Device,1569.75,35,,1569.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1524.9,34,"If Charge > 2,000, then 34 percent",1524.9,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3318.91,
ALPHATEC SPINE 62004-04 ROD 40MM,C1773,HCPCS,,79008489,CDM,278,RC,,,both,,,600,444,,,444,Other,150% of Medicare + 9.63% HCRA Surcharge,270,45,,270,percent of total billed charges,Critical Access Hospital RCC factor,204,34,,204,percent of total billed charges,Implant Device,204,34,,204,percent of total billed charges,Implant Device,204,34,,204,percent of total billed charges,Implant Device,204,34,,204,percent of total billed charges,Implant Device,204,34,,204,percent of total billed charges,Implant Device,297,,,297,Other,110% of Medicare,210,35,,210,percent of total billed charges,Implant Device,204,34,"Charges > $500, x 34%",204,percent of total billed charges,Implant Device,210,35,,210,percent of total billed charges,Implant Device,210,35,,210,percent of total billed charges,Implant Device,210,35,,210,percent of total billed charges,Implant Device,210,35,,210,percent of total billed charges,Implant Device,210,35,,210,percent of total billed charges,Implant Device,240,40,,240,percent of total billed charges,Implant Device,210,70,,210,percent of total billed charges,All Other,204,34,,204,percent of total billed charges,Implant Device,204,34,,204,percent of total billed charges,Implant Device,210,35,,210,percent of total billed charges,Implant Device,210,35,,210,percent of total billed charges,Implant Device,210,35,,210,percent of total billed charges,Implant Device,210,35,,210,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,444,
ZIMMER 00-8754-012-36 OFFSET LINER 36X56,C1776,HCPCS,,79008490,CDM,278,RC,,,both,,,2250,1665.01,,,1665.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1012.5,45,,1012.5,percent of total billed charges,Critical Access Hospital RCC factor,765,34,,765,percent of total billed charges,Implant Device,765,34,,765,percent of total billed charges,Implant Device,765,34,,765,percent of total billed charges,Implant Device,765,34,,765,percent of total billed charges,Implant Device,765,34,,765,percent of total billed charges,Implant Device,1113.75,,,1113.75,Other,110% of Medicare,787.5,35,,787.5,percent of total billed charges,Implant Device,765,34,"Charges > $500, x 34%",765,percent of total billed charges,Implant Device,787.5,35,,787.5,percent of total billed charges,Implant Device,787.5,35,,787.5,percent of total billed charges,Implant Device,787.5,35,,787.5,percent of total billed charges,Implant Device,787.5,35,,787.5,percent of total billed charges,Implant Device,787.5,35,,787.5,percent of total billed charges,Implant Device,900,40,,900,percent of total billed charges,Implant Device,787.5,70,,787.5,percent of total billed charges,All Other,765,34,,765,percent of total billed charges,Implant Device,765,34,,765,percent of total billed charges,Implant Device,787.5,35,,787.5,percent of total billed charges,Implant Device,787.5,35,,787.5,percent of total billed charges,Implant Device,787.5,35,,787.5,percent of total billed charges,Implant Device,787.5,35,,787.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,765,34,"If Charge > 2,000, then 34 percent",765,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1665.01,
STRYKER 5571-S-3604 HUMERAL INSRT 36X4MM,C1776,HCPCS,,79008492,CDM,278,RC,,,both,,,3525,2608.51,,,2608.51,Other,150% of Medicare + 9.63% HCRA Surcharge,1586.25,45,,1586.25,percent of total billed charges,Critical Access Hospital RCC factor,1198.5,34,,1198.5,percent of total billed charges,Implant Device,1198.5,34,,1198.5,percent of total billed charges,Implant Device,1198.5,34,,1198.5,percent of total billed charges,Implant Device,1198.5,34,,1198.5,percent of total billed charges,Implant Device,1198.5,34,,1198.5,percent of total billed charges,Implant Device,1744.88,,,1744.88,Other,110% of Medicare,1233.75,35,,1233.75,percent of total billed charges,Implant Device,1198.5,34,"Charges > $500, x 34%",1198.5,percent of total billed charges,Implant Device,1233.75,35,,1233.75,percent of total billed charges,Implant Device,1233.75,35,,1233.75,percent of total billed charges,Implant Device,1233.75,35,,1233.75,percent of total billed charges,Implant Device,1233.75,35,,1233.75,percent of total billed charges,Implant Device,1233.75,35,,1233.75,percent of total billed charges,Implant Device,1410,40,,1410,percent of total billed charges,Implant Device,1233.75,70,,1233.75,percent of total billed charges,All Other,1198.5,34,,1198.5,percent of total billed charges,Implant Device,1198.5,34,,1198.5,percent of total billed charges,Implant Device,1233.75,35,,1233.75,percent of total billed charges,Implant Device,1233.75,35,,1233.75,percent of total billed charges,Implant Device,1233.75,35,,1233.75,percent of total billed charges,Implant Device,1233.75,35,,1233.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1198.5,34,"If Charge > 2,000, then 34 percent",1198.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2608.51,
STRYKER 5572-4528 PERPHRL SCREW 4.5X28MM,C1713,HCPCS,,79008493,CDM,278,RC,,,both,,,600,444,,,444,Other,150% of Medicare + 9.63% HCRA Surcharge,270,45,,270,percent of total billed charges,Critical Access Hospital RCC factor,204,34,,204,percent of total billed charges,Implant Device,204,34,,204,percent of total billed charges,Implant Device,204,34,,204,percent of total billed charges,Implant Device,204,34,,204,percent of total billed charges,Implant Device,204,34,,204,percent of total billed charges,Implant Device,297,,,297,Other,110% of Medicare,210,35,,210,percent of total billed charges,Implant Device,204,34,"Charges > $500, x 34%",204,percent of total billed charges,Implant Device,210,35,,210,percent of total billed charges,Implant Device,210,35,,210,percent of total billed charges,Implant Device,210,35,,210,percent of total billed charges,Implant Device,210,35,,210,percent of total billed charges,Implant Device,210,35,,210,percent of total billed charges,Implant Device,240,40,,240,percent of total billed charges,Implant Device,210,70,,210,percent of total billed charges,All Other,204,34,,204,percent of total billed charges,Implant Device,204,34,,204,percent of total billed charges,Implant Device,210,35,,210,percent of total billed charges,Implant Device,210,35,,210,percent of total billed charges,Implant Device,210,35,,210,percent of total billed charges,Implant Device,210,35,,210,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,444,
STRYKER 5572-2800 GLENOID BASEPLATE 28MM,C1776,HCPCS,,79008494,CDM,278,RC,,,both,,,4125,3052.51,,,3052.51,Other,150% of Medicare + 9.63% HCRA Surcharge,1856.25,45,,1856.25,percent of total billed charges,Critical Access Hospital RCC factor,1402.5,34,,1402.5,percent of total billed charges,Implant Device,1402.5,34,,1402.5,percent of total billed charges,Implant Device,1402.5,34,,1402.5,percent of total billed charges,Implant Device,1402.5,34,,1402.5,percent of total billed charges,Implant Device,1402.5,34,,1402.5,percent of total billed charges,Implant Device,2041.88,,,2041.88,Other,110% of Medicare,1443.75,35,,1443.75,percent of total billed charges,Implant Device,1402.5,34,"Charges > $500, x 34%",1402.5,percent of total billed charges,Implant Device,1443.75,35,,1443.75,percent of total billed charges,Implant Device,1443.75,35,,1443.75,percent of total billed charges,Implant Device,1443.75,35,,1443.75,percent of total billed charges,Implant Device,1443.75,35,,1443.75,percent of total billed charges,Implant Device,1443.75,35,,1443.75,percent of total billed charges,Implant Device,1650,40,,1650,percent of total billed charges,Implant Device,1443.75,70,,1443.75,percent of total billed charges,All Other,1402.5,34,,1402.5,percent of total billed charges,Implant Device,1402.5,34,,1402.5,percent of total billed charges,Implant Device,1443.75,35,,1443.75,percent of total billed charges,Implant Device,1443.75,35,,1443.75,percent of total billed charges,Implant Device,1443.75,35,,1443.75,percent of total billed charges,Implant Device,1443.75,35,,1443.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1402.5,34,"If Charge > 2,000, then 34 percent",1402.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3052.51,
STRYKER 5570-3604 HUMERAL CUP 36X4MM,C1776,HCPCS,,79008495,CDM,278,RC,,,both,,,4125,3052.51,,,3052.51,Other,150% of Medicare + 9.63% HCRA Surcharge,1856.25,45,,1856.25,percent of total billed charges,Critical Access Hospital RCC factor,1402.5,34,,1402.5,percent of total billed charges,Implant Device,1402.5,34,,1402.5,percent of total billed charges,Implant Device,1402.5,34,,1402.5,percent of total billed charges,Implant Device,1402.5,34,,1402.5,percent of total billed charges,Implant Device,1402.5,34,,1402.5,percent of total billed charges,Implant Device,2041.88,,,2041.88,Other,110% of Medicare,1443.75,35,,1443.75,percent of total billed charges,Implant Device,1402.5,34,"Charges > $500, x 34%",1402.5,percent of total billed charges,Implant Device,1443.75,35,,1443.75,percent of total billed charges,Implant Device,1443.75,35,,1443.75,percent of total billed charges,Implant Device,1443.75,35,,1443.75,percent of total billed charges,Implant Device,1443.75,35,,1443.75,percent of total billed charges,Implant Device,1443.75,35,,1443.75,percent of total billed charges,Implant Device,1650,40,,1650,percent of total billed charges,Implant Device,1443.75,70,,1443.75,percent of total billed charges,All Other,1402.5,34,,1402.5,percent of total billed charges,Implant Device,1402.5,34,,1402.5,percent of total billed charges,Implant Device,1443.75,35,,1443.75,percent of total billed charges,Implant Device,1443.75,35,,1443.75,percent of total billed charges,Implant Device,1443.75,35,,1443.75,percent of total billed charges,Implant Device,1443.75,35,,1443.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1402.5,34,"If Charge > 2,000, then 34 percent",1402.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3052.51,
STRYKER 5572-4520 PERPHRL SCREW 4.5X20MM,C1713,HCPCS,,79008496,CDM,278,RC,,,both,,,150,111,,,111,Other,150% of Medicare + 9.63% HCRA Surcharge,67.5,45,,67.5,percent of total billed charges,Critical Access Hospital RCC factor,51,34,,51,percent of total billed charges,Implant Device,51,34,,51,percent of total billed charges,Implant Device,51,34,,51,percent of total billed charges,Implant Device,51,34,,51,percent of total billed charges,Implant Device,51,34,,51,percent of total billed charges,Implant Device,74.25,,,74.25,Other,110% of Medicare,52.5,35,,52.5,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,52.5,35,,52.5,percent of total billed charges,Implant Device,52.5,35,,52.5,percent of total billed charges,Implant Device,52.5,35,,52.5,percent of total billed charges,Implant Device,52.5,35,,52.5,percent of total billed charges,Implant Device,52.5,35,,52.5,percent of total billed charges,Implant Device,60,40,,60,percent of total billed charges,Implant Device,52.5,70,,52.5,percent of total billed charges,All Other,51,34,,51,percent of total billed charges,Implant Device,51,34,,51,percent of total billed charges,Implant Device,52.5,35,,52.5,percent of total billed charges,Implant Device,52.5,35,,52.5,percent of total billed charges,Implant Device,52.5,35,,52.5,percent of total billed charges,Implant Device,52.5,35,,52.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,111,
STRYKER 5573-6524 CTR SCREW 6.5X24MM,C1713,HCPCS,,79008497,CDM,278,RC,,,both,,,150,111,,,111,Other,150% of Medicare + 9.63% HCRA Surcharge,67.5,45,,67.5,percent of total billed charges,Critical Access Hospital RCC factor,51,34,,51,percent of total billed charges,Implant Device,51,34,,51,percent of total billed charges,Implant Device,51,34,,51,percent of total billed charges,Implant Device,51,34,,51,percent of total billed charges,Implant Device,51,34,,51,percent of total billed charges,Implant Device,74.25,,,74.25,Other,110% of Medicare,52.5,35,,52.5,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,52.5,35,,52.5,percent of total billed charges,Implant Device,52.5,35,,52.5,percent of total billed charges,Implant Device,52.5,35,,52.5,percent of total billed charges,Implant Device,52.5,35,,52.5,percent of total billed charges,Implant Device,52.5,35,,52.5,percent of total billed charges,Implant Device,60,40,,60,percent of total billed charges,Implant Device,52.5,70,,52.5,percent of total billed charges,All Other,51,34,,51,percent of total billed charges,Implant Device,51,34,,51,percent of total billed charges,Implant Device,52.5,35,,52.5,percent of total billed charges,Implant Device,52.5,35,,52.5,percent of total billed charges,Implant Device,52.5,35,,52.5,percent of total billed charges,Implant Device,52.5,35,,52.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,111,
STRYKER 5573-2E-3602 GELNOSPHERE 36X2MM,C1776,HCPCS,,79008499,CDM,278,RC,,,both,,,4125,3052.51,,,3052.51,Other,150% of Medicare + 9.63% HCRA Surcharge,1856.25,45,,1856.25,percent of total billed charges,Critical Access Hospital RCC factor,1402.5,34,,1402.5,percent of total billed charges,Implant Device,1402.5,34,,1402.5,percent of total billed charges,Implant Device,1402.5,34,,1402.5,percent of total billed charges,Implant Device,1402.5,34,,1402.5,percent of total billed charges,Implant Device,1402.5,34,,1402.5,percent of total billed charges,Implant Device,2041.88,,,2041.88,Other,110% of Medicare,1443.75,35,,1443.75,percent of total billed charges,Implant Device,1402.5,34,"Charges > $500, x 34%",1402.5,percent of total billed charges,Implant Device,1443.75,35,,1443.75,percent of total billed charges,Implant Device,1443.75,35,,1443.75,percent of total billed charges,Implant Device,1443.75,35,,1443.75,percent of total billed charges,Implant Device,1443.75,35,,1443.75,percent of total billed charges,Implant Device,1443.75,35,,1443.75,percent of total billed charges,Implant Device,1650,40,,1650,percent of total billed charges,Implant Device,1443.75,70,,1443.75,percent of total billed charges,All Other,1402.5,34,,1402.5,percent of total billed charges,Implant Device,1402.5,34,,1402.5,percent of total billed charges,Implant Device,1443.75,35,,1443.75,percent of total billed charges,Implant Device,1443.75,35,,1443.75,percent of total billed charges,Implant Device,1443.75,35,,1443.75,percent of total billed charges,Implant Device,1443.75,35,,1443.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1402.5,34,"If Charge > 2,000, then 34 percent",1402.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3052.51,
STRYKER 40-35050 3.5X50MM NON LOCK SCREW,C1713,HCPCS,,79008501,CDM,278,RC,,,both,,,408,301.92,,,301.92,Other,150% of Medicare + 9.63% HCRA Surcharge,183.6,45,,183.6,percent of total billed charges,Critical Access Hospital RCC factor,138.72,34,,138.72,percent of total billed charges,Implant Device,138.72,34,,138.72,percent of total billed charges,Implant Device,138.72,34,,138.72,percent of total billed charges,Implant Device,138.72,34,,138.72,percent of total billed charges,Implant Device,138.72,34,,138.72,percent of total billed charges,Implant Device,201.96,,,201.96,Other,110% of Medicare,142.8,35,,142.8,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,142.8,35,,142.8,percent of total billed charges,Implant Device,142.8,35,,142.8,percent of total billed charges,Implant Device,142.8,35,,142.8,percent of total billed charges,Implant Device,142.8,35,,142.8,percent of total billed charges,Implant Device,142.8,35,,142.8,percent of total billed charges,Implant Device,163.2,40,,163.2,percent of total billed charges,Implant Device,142.8,70,,142.8,percent of total billed charges,All Other,138.72,34,,138.72,percent of total billed charges,Implant Device,138.72,34,,138.72,percent of total billed charges,Implant Device,142.8,35,,142.8,percent of total billed charges,Implant Device,142.8,35,,142.8,percent of total billed charges,Implant Device,142.8,35,,142.8,percent of total billed charges,Implant Device,142.8,35,,142.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,301.92,
DEPUY 02.118.401 DIS FIB PLATE 3 HOLES,C1713,HCPCS,,79008502,CDM,278,RC,,,both,,,3125,2312.51,,,2312.51,Other,150% of Medicare + 9.63% HCRA Surcharge,1406.25,45,,1406.25,percent of total billed charges,Critical Access Hospital RCC factor,1062.5,34,,1062.5,percent of total billed charges,Implant Device,1062.5,34,,1062.5,percent of total billed charges,Implant Device,1062.5,34,,1062.5,percent of total billed charges,Implant Device,1062.5,34,,1062.5,percent of total billed charges,Implant Device,1062.5,34,,1062.5,percent of total billed charges,Implant Device,1546.88,,,1546.88,Other,110% of Medicare,1093.75,35,,1093.75,percent of total billed charges,Implant Device,1062.5,34,"Charges > $500, x 34%",1062.5,percent of total billed charges,Implant Device,1093.75,35,,1093.75,percent of total billed charges,Implant Device,1093.75,35,,1093.75,percent of total billed charges,Implant Device,1093.75,35,,1093.75,percent of total billed charges,Implant Device,1093.75,35,,1093.75,percent of total billed charges,Implant Device,1093.75,35,,1093.75,percent of total billed charges,Implant Device,1250,40,,1250,percent of total billed charges,Implant Device,1093.75,70,,1093.75,percent of total billed charges,All Other,1062.5,34,,1062.5,percent of total billed charges,Implant Device,1062.5,34,,1062.5,percent of total billed charges,Implant Device,1093.75,35,,1093.75,percent of total billed charges,Implant Device,1093.75,35,,1093.75,percent of total billed charges,Implant Device,1093.75,35,,1093.75,percent of total billed charges,Implant Device,1093.75,35,,1093.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1062.5,34,"If Charge > 2,000, then 34 percent",1062.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2312.51,
ZIMMER 32-8105-038-00 PLUG W/NOZ 16X25MM,C1713,HCPCS,,79008503,CDM,278,RC,,,both,,,581,429.94,,,429.94,Other,150% of Medicare + 9.63% HCRA Surcharge,261.45,45,,261.45,percent of total billed charges,Critical Access Hospital RCC factor,197.54,34,,197.54,percent of total billed charges,Implant Device,197.54,34,,197.54,percent of total billed charges,Implant Device,197.54,34,,197.54,percent of total billed charges,Implant Device,197.54,34,,197.54,percent of total billed charges,Implant Device,197.54,34,,197.54,percent of total billed charges,Implant Device,287.6,,,287.6,Other,110% of Medicare,203.35,35,,203.35,percent of total billed charges,Implant Device,197.54,34,"Charges > $500, x 34%",197.54,percent of total billed charges,Implant Device,203.35,35,,203.35,percent of total billed charges,Implant Device,203.35,35,,203.35,percent of total billed charges,Implant Device,203.35,35,,203.35,percent of total billed charges,Implant Device,203.35,35,,203.35,percent of total billed charges,Implant Device,203.35,35,,203.35,percent of total billed charges,Implant Device,232.4,40,,232.4,percent of total billed charges,Implant Device,203.35,70,,203.35,percent of total billed charges,All Other,197.54,34,,197.54,percent of total billed charges,Implant Device,197.54,34,,197.54,percent of total billed charges,Implant Device,203.35,35,,203.35,percent of total billed charges,Implant Device,203.35,35,,203.35,percent of total billed charges,Implant Device,203.35,35,,203.35,percent of total billed charges,Implant Device,203.35,35,,203.35,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,429.94,
"ZIMMER 32-8105-035-08 HUMERAL ASSY 8""",C1713,HCPCS,,79008504,CDM,278,RC,,,both,,,16500,12210.04,,,12210.04,Other,150% of Medicare + 9.63% HCRA Surcharge,7425,45,,7425,percent of total billed charges,Critical Access Hospital RCC factor,5610,34,,5610,percent of total billed charges,Implant Device,5610,34,,5610,percent of total billed charges,Implant Device,5610,34,,5610,percent of total billed charges,Implant Device,5610,34,,5610,percent of total billed charges,Implant Device,5610,34,,5610,percent of total billed charges,Implant Device,8167.5,,,8167.5,Other,110% of Medicare,5775,35,,5775,percent of total billed charges,Implant Device,5610,34,"Charges > $500, x 34%",5610,percent of total billed charges,Implant Device,5775,35,,5775,percent of total billed charges,Implant Device,5775,35,,5775,percent of total billed charges,Implant Device,5775,35,,5775,percent of total billed charges,Implant Device,5775,35,,5775,percent of total billed charges,Implant Device,5775,35,,5775,percent of total billed charges,Implant Device,6600,40,,6600,percent of total billed charges,Implant Device,5775,70,,5775,percent of total billed charges,All Other,5610,34,,5610,percent of total billed charges,Implant Device,5610,34,,5610,percent of total billed charges,Implant Device,5775,35,,5775,percent of total billed charges,Implant Device,5775,35,,5775,percent of total billed charges,Implant Device,5775,35,,5775,percent of total billed charges,Implant Device,5775,35,,5775,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,5610,34,"If Charge > 2,000, then 34 percent",5610,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,12210.04,
CH 07120ML SMART STENT 7X120X120CM,C1876,HCPCS,,79008505,CDM,278,RC,,,both,,,3300,2442.01,,,2442.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1485,45,,1485,percent of total billed charges,Critical Access Hospital RCC factor,1122,34,,1122,percent of total billed charges,Implant Device,1122,34,,1122,percent of total billed charges,Implant Device,1122,34,,1122,percent of total billed charges,Implant Device,1122,34,,1122,percent of total billed charges,Implant Device,1122,34,,1122,percent of total billed charges,Implant Device,1633.5,,,1633.5,Other,110% of Medicare,1155,35,,1155,percent of total billed charges,Implant Device,1122,34,"Charges > $500, x 34%",1122,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,1320,40,,1320,percent of total billed charges,Implant Device,1155,70,,1155,percent of total billed charges,All Other,1122,34,,1122,percent of total billed charges,Implant Device,1122,34,,1122,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1122,34,"If Charge > 2,000, then 34 percent",1122,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2442.01,
STRYKER 629368 OLECRANON PLATE R 8 HOLE,C1713,HCPCS,,79008507,CDM,278,RC,,,both,,,5462,4041.89,,,4041.89,Other,150% of Medicare + 9.63% HCRA Surcharge,2457.9,45,,2457.9,percent of total billed charges,Critical Access Hospital RCC factor,1857.08,34,,1857.08,percent of total billed charges,Implant Device,1857.08,34,,1857.08,percent of total billed charges,Implant Device,1857.08,34,,1857.08,percent of total billed charges,Implant Device,1857.08,34,,1857.08,percent of total billed charges,Implant Device,1857.08,34,,1857.08,percent of total billed charges,Implant Device,2703.69,,,2703.69,Other,110% of Medicare,1911.7,35,,1911.7,percent of total billed charges,Implant Device,1857.08,34,"Charges > $500, x 34%",1857.08,percent of total billed charges,Implant Device,1911.7,35,,1911.7,percent of total billed charges,Implant Device,1911.7,35,,1911.7,percent of total billed charges,Implant Device,1911.7,35,,1911.7,percent of total billed charges,Implant Device,1911.7,35,,1911.7,percent of total billed charges,Implant Device,1911.7,35,,1911.7,percent of total billed charges,Implant Device,2184.8,40,,2184.8,percent of total billed charges,Implant Device,1911.7,70,,1911.7,percent of total billed charges,All Other,1857.08,34,,1857.08,percent of total billed charges,Implant Device,1857.08,34,,1857.08,percent of total billed charges,Implant Device,1911.7,35,,1911.7,percent of total billed charges,Implant Device,1911.7,35,,1911.7,percent of total billed charges,Implant Device,1911.7,35,,1911.7,percent of total billed charges,Implant Device,1911.7,35,,1911.7,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1857.08,34,"If Charge > 2,000, then 34 percent",1857.08,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4041.89,
STRYKER 614638 3.5 X 38MM LOCKING SCREW,C1713,HCPCS,,79008508,CDM,278,RC,,,both,,,727,537.98,,,537.98,Other,150% of Medicare + 9.63% HCRA Surcharge,327.15,45,,327.15,percent of total billed charges,Critical Access Hospital RCC factor,247.18,34,,247.18,percent of total billed charges,Implant Device,247.18,34,,247.18,percent of total billed charges,Implant Device,247.18,34,,247.18,percent of total billed charges,Implant Device,247.18,34,,247.18,percent of total billed charges,Implant Device,247.18,34,,247.18,percent of total billed charges,Implant Device,359.87,,,359.87,Other,110% of Medicare,254.45,35,,254.45,percent of total billed charges,Implant Device,247.18,34,"Charges > $500, x 34%",247.18,percent of total billed charges,Implant Device,254.45,35,,254.45,percent of total billed charges,Implant Device,254.45,35,,254.45,percent of total billed charges,Implant Device,254.45,35,,254.45,percent of total billed charges,Implant Device,254.45,35,,254.45,percent of total billed charges,Implant Device,254.45,35,,254.45,percent of total billed charges,Implant Device,290.8,40,,290.8,percent of total billed charges,Implant Device,254.45,70,,254.45,percent of total billed charges,All Other,247.18,34,,247.18,percent of total billed charges,Implant Device,247.18,34,,247.18,percent of total billed charges,Implant Device,254.45,35,,254.45,percent of total billed charges,Implant Device,254.45,35,,254.45,percent of total billed charges,Implant Device,254.45,35,,254.45,percent of total billed charges,Implant Device,254.45,35,,254.45,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,537.98,
STRYKER 310-0002 RHEAD LATERAL STEM SZ 3,C1776,HCPCS,,79008509,CDM,278,RC,,,both,,,11244,8320.59,,,8320.59,Other,150% of Medicare + 9.63% HCRA Surcharge,5059.8,45,,5059.8,percent of total billed charges,Critical Access Hospital RCC factor,3822.96,34,,3822.96,percent of total billed charges,Implant Device,3822.96,34,,3822.96,percent of total billed charges,Implant Device,3822.96,34,,3822.96,percent of total billed charges,Implant Device,3822.96,34,,3822.96,percent of total billed charges,Implant Device,3822.96,34,,3822.96,percent of total billed charges,Implant Device,5565.78,,,5565.78,Other,110% of Medicare,3935.4,35,,3935.4,percent of total billed charges,Implant Device,3822.96,34,"Charges > $500, x 34%",3822.96,percent of total billed charges,Implant Device,3935.4,35,,3935.4,percent of total billed charges,Implant Device,3935.4,35,,3935.4,percent of total billed charges,Implant Device,3935.4,35,,3935.4,percent of total billed charges,Implant Device,3935.4,35,,3935.4,percent of total billed charges,Implant Device,3935.4,35,,3935.4,percent of total billed charges,Implant Device,4497.6,40,,4497.6,percent of total billed charges,Implant Device,3935.4,70,,3935.4,percent of total billed charges,All Other,3822.96,34,,3822.96,percent of total billed charges,Implant Device,3822.96,34,,3822.96,percent of total billed charges,Implant Device,3935.4,35,,3935.4,percent of total billed charges,Implant Device,3935.4,35,,3935.4,percent of total billed charges,Implant Device,3935.4,35,,3935.4,percent of total billed charges,Implant Device,3935.4,35,,3935.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3822.96,34,"If Charge > 2,000, then 34 percent",3822.96,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,8320.59,
STRYKER 310-0010 RHEAD LAT RAD HD SZ 4,C1776,HCPCS,,79008510,CDM,278,RC,,,both,,,7599,5623.28,,,5623.28,Other,150% of Medicare + 9.63% HCRA Surcharge,3419.55,45,,3419.55,percent of total billed charges,Critical Access Hospital RCC factor,2583.66,34,,2583.66,percent of total billed charges,Implant Device,2583.66,34,,2583.66,percent of total billed charges,Implant Device,2583.66,34,,2583.66,percent of total billed charges,Implant Device,2583.66,34,,2583.66,percent of total billed charges,Implant Device,2583.66,34,,2583.66,percent of total billed charges,Implant Device,3761.51,,,3761.51,Other,110% of Medicare,2659.65,35,,2659.65,percent of total billed charges,Implant Device,2583.66,34,"Charges > $500, x 34%",2583.66,percent of total billed charges,Implant Device,2659.65,35,,2659.65,percent of total billed charges,Implant Device,2659.65,35,,2659.65,percent of total billed charges,Implant Device,2659.65,35,,2659.65,percent of total billed charges,Implant Device,2659.65,35,,2659.65,percent of total billed charges,Implant Device,2659.65,35,,2659.65,percent of total billed charges,Implant Device,3039.6,40,,3039.6,percent of total billed charges,Implant Device,2659.65,70,,2659.65,percent of total billed charges,All Other,2583.66,34,,2583.66,percent of total billed charges,Implant Device,2583.66,34,,2583.66,percent of total billed charges,Implant Device,2659.65,35,,2659.65,percent of total billed charges,Implant Device,2659.65,35,,2659.65,percent of total billed charges,Implant Device,2659.65,35,,2659.65,percent of total billed charges,Implant Device,2659.65,35,,2659.65,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2583.66,34,"If Charge > 2,000, then 34 percent",2583.66,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5623.28,
ZIMMER 00-5994-050-14 ART SURF SZ 14MM,C1776,HCPCS,,79008511,CDM,278,RC,,,both,,,6465,4784.12,,,4784.12,Other,150% of Medicare + 9.63% HCRA Surcharge,2909.25,45,,2909.25,percent of total billed charges,Critical Access Hospital RCC factor,2198.1,34,,2198.1,percent of total billed charges,Implant Device,2198.1,34,,2198.1,percent of total billed charges,Implant Device,2198.1,34,,2198.1,percent of total billed charges,Implant Device,2198.1,34,,2198.1,percent of total billed charges,Implant Device,2198.1,34,,2198.1,percent of total billed charges,Implant Device,3200.18,,,3200.18,Other,110% of Medicare,2262.75,35,,2262.75,percent of total billed charges,Implant Device,2198.1,34,"Charges > $500, x 34%",2198.1,percent of total billed charges,Implant Device,2262.75,35,,2262.75,percent of total billed charges,Implant Device,2262.75,35,,2262.75,percent of total billed charges,Implant Device,2262.75,35,,2262.75,percent of total billed charges,Implant Device,2262.75,35,,2262.75,percent of total billed charges,Implant Device,2262.75,35,,2262.75,percent of total billed charges,Implant Device,2586,40,,2586,percent of total billed charges,Implant Device,2262.75,70,,2262.75,percent of total billed charges,All Other,2198.1,34,,2198.1,percent of total billed charges,Implant Device,2198.1,34,,2198.1,percent of total billed charges,Implant Device,2262.75,35,,2262.75,percent of total billed charges,Implant Device,2262.75,35,,2262.75,percent of total billed charges,Implant Device,2262.75,35,,2262.75,percent of total billed charges,Implant Device,2262.75,35,,2262.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2198.1,34,"If Charge > 2,000, then 34 percent",2198.1,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4784.12,
ACUMED PL-SA06L LT 6-H ANROMIOIN PLATE,C1713,HCPCS,,79008512,CDM,278,RC,,,both,,,5082,3760.69,,,3760.69,Other,150% of Medicare + 9.63% HCRA Surcharge,2286.9,45,,2286.9,percent of total billed charges,Critical Access Hospital RCC factor,1727.88,34,,1727.88,percent of total billed charges,Implant Device,1727.88,34,,1727.88,percent of total billed charges,Implant Device,1727.88,34,,1727.88,percent of total billed charges,Implant Device,1727.88,34,,1727.88,percent of total billed charges,Implant Device,1727.88,34,,1727.88,percent of total billed charges,Implant Device,2515.59,,,2515.59,Other,110% of Medicare,1778.7,35,,1778.7,percent of total billed charges,Implant Device,1727.88,34,"Charges > $500, x 34%",1727.88,percent of total billed charges,Implant Device,1778.7,35,,1778.7,percent of total billed charges,Implant Device,1778.7,35,,1778.7,percent of total billed charges,Implant Device,1778.7,35,,1778.7,percent of total billed charges,Implant Device,1778.7,35,,1778.7,percent of total billed charges,Implant Device,1778.7,35,,1778.7,percent of total billed charges,Implant Device,2032.8,40,,2032.8,percent of total billed charges,Implant Device,1778.7,70,,1778.7,percent of total billed charges,All Other,1727.88,34,,1727.88,percent of total billed charges,Implant Device,1727.88,34,,1727.88,percent of total billed charges,Implant Device,1778.7,35,,1778.7,percent of total billed charges,Implant Device,1778.7,35,,1778.7,percent of total billed charges,Implant Device,1778.7,35,,1778.7,percent of total billed charges,Implant Device,1778.7,35,,1778.7,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1727.88,34,"If Charge > 2,000, then 34 percent",1727.88,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3760.69,
ACUMED CA-4260 40 X 26MM CAN SCREW,C1713,HCPCS,,79008513,CDM,278,RC,,,both,,,270,199.8,,,199.8,Other,150% of Medicare + 9.63% HCRA Surcharge,121.5,45,,121.5,percent of total billed charges,Critical Access Hospital RCC factor,91.8,34,,91.8,percent of total billed charges,Implant Device,91.8,34,,91.8,percent of total billed charges,Implant Device,91.8,34,,91.8,percent of total billed charges,Implant Device,91.8,34,,91.8,percent of total billed charges,Implant Device,91.8,34,,91.8,percent of total billed charges,Implant Device,133.65,,,133.65,Other,110% of Medicare,94.5,35,,94.5,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,94.5,35,,94.5,percent of total billed charges,Implant Device,94.5,35,,94.5,percent of total billed charges,Implant Device,94.5,35,,94.5,percent of total billed charges,Implant Device,94.5,35,,94.5,percent of total billed charges,Implant Device,94.5,35,,94.5,percent of total billed charges,Implant Device,108,40,,108,percent of total billed charges,Implant Device,94.5,70,,94.5,percent of total billed charges,All Other,91.8,34,,91.8,percent of total billed charges,Implant Device,91.8,34,,91.8,percent of total billed charges,Implant Device,94.5,35,,94.5,percent of total billed charges,Implant Device,94.5,35,,94.5,percent of total billed charges,Implant Device,94.5,35,,94.5,percent of total billed charges,Implant Device,94.5,35,,94.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,199.8,
ACUMED 30-0256 3.5 X 10MM NON-LOCK SCREW,C1713,HCPCS,,79008514,CDM,278,RC,,,both,,,270,199.8,,,199.8,Other,150% of Medicare + 9.63% HCRA Surcharge,121.5,45,,121.5,percent of total billed charges,Critical Access Hospital RCC factor,91.8,34,,91.8,percent of total billed charges,Implant Device,91.8,34,,91.8,percent of total billed charges,Implant Device,91.8,34,,91.8,percent of total billed charges,Implant Device,91.8,34,,91.8,percent of total billed charges,Implant Device,91.8,34,,91.8,percent of total billed charges,Implant Device,133.65,,,133.65,Other,110% of Medicare,94.5,35,,94.5,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,94.5,35,,94.5,percent of total billed charges,Implant Device,94.5,35,,94.5,percent of total billed charges,Implant Device,94.5,35,,94.5,percent of total billed charges,Implant Device,94.5,35,,94.5,percent of total billed charges,Implant Device,94.5,35,,94.5,percent of total billed charges,Implant Device,108,40,,108,percent of total billed charges,Implant Device,94.5,70,,94.5,percent of total billed charges,All Other,91.8,34,,91.8,percent of total billed charges,Implant Device,91.8,34,,91.8,percent of total billed charges,Implant Device,94.5,35,,94.5,percent of total billed charges,Implant Device,94.5,35,,94.5,percent of total billed charges,Implant Device,94.5,35,,94.5,percent of total billed charges,Implant Device,94.5,35,,94.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,199.8,
ACUMED 30-0232 3.5 X 8MM LOCK SCREW,C1713,HCPCS,,79008515,CDM,278,RC,,,both,,,450,333,,,333,Other,150% of Medicare + 9.63% HCRA Surcharge,202.5,45,,202.5,percent of total billed charges,Critical Access Hospital RCC factor,153,34,,153,percent of total billed charges,Implant Device,153,34,,153,percent of total billed charges,Implant Device,153,34,,153,percent of total billed charges,Implant Device,153,34,,153,percent of total billed charges,Implant Device,153,34,,153,percent of total billed charges,Implant Device,222.75,,,222.75,Other,110% of Medicare,157.5,35,,157.5,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,157.5,35,,157.5,percent of total billed charges,Implant Device,157.5,35,,157.5,percent of total billed charges,Implant Device,157.5,35,,157.5,percent of total billed charges,Implant Device,157.5,35,,157.5,percent of total billed charges,Implant Device,157.5,35,,157.5,percent of total billed charges,Implant Device,180,40,,180,percent of total billed charges,Implant Device,157.5,70,,157.5,percent of total billed charges,All Other,153,34,,153,percent of total billed charges,Implant Device,153,34,,153,percent of total billed charges,Implant Device,157.5,35,,157.5,percent of total billed charges,Implant Device,157.5,35,,157.5,percent of total billed charges,Implant Device,157.5,35,,157.5,percent of total billed charges,Implant Device,157.5,35,,157.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,333,
ZIMMER 00-8755-011-36 OBLIQUE LINER 36MM,C1776,HCPCS,,79008517,CDM,278,RC,,,both,,,4973,3680.03,,,3680.03,Other,150% of Medicare + 9.63% HCRA Surcharge,2237.85,45,,2237.85,percent of total billed charges,Critical Access Hospital RCC factor,1690.82,34,,1690.82,percent of total billed charges,Implant Device,1690.82,34,,1690.82,percent of total billed charges,Implant Device,1690.82,34,,1690.82,percent of total billed charges,Implant Device,1690.82,34,,1690.82,percent of total billed charges,Implant Device,1690.82,34,,1690.82,percent of total billed charges,Implant Device,2461.64,,,2461.64,Other,110% of Medicare,1740.55,35,,1740.55,percent of total billed charges,Implant Device,1690.82,34,"Charges > $500, x 34%",1690.82,percent of total billed charges,Implant Device,1740.55,35,,1740.55,percent of total billed charges,Implant Device,1740.55,35,,1740.55,percent of total billed charges,Implant Device,1740.55,35,,1740.55,percent of total billed charges,Implant Device,1740.55,35,,1740.55,percent of total billed charges,Implant Device,1740.55,35,,1740.55,percent of total billed charges,Implant Device,1989.2,40,,1989.2,percent of total billed charges,Implant Device,1740.55,70,,1740.55,percent of total billed charges,All Other,1690.82,34,,1690.82,percent of total billed charges,Implant Device,1690.82,34,,1690.82,percent of total billed charges,Implant Device,1740.55,35,,1740.55,percent of total billed charges,Implant Device,1740.55,35,,1740.55,percent of total billed charges,Implant Device,1740.55,35,,1740.55,percent of total billed charges,Implant Device,1740.55,35,,1740.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1690.82,34,"If Charge > 2,000, then 34 percent",1690.82,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3680.03,
ZIMMER 00-8018-036-05 FEMORAL HEAD 36X54,C1776,HCPCS,,79008518,CDM,278,RC,,,both,,,3150,2331.01,,,2331.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1417.5,45,,1417.5,percent of total billed charges,Critical Access Hospital RCC factor,1071,34,,1071,percent of total billed charges,Implant Device,1071,34,,1071,percent of total billed charges,Implant Device,1071,34,,1071,percent of total billed charges,Implant Device,1071,34,,1071,percent of total billed charges,Implant Device,1071,34,,1071,percent of total billed charges,Implant Device,1559.25,,,1559.25,Other,110% of Medicare,1102.5,35,,1102.5,percent of total billed charges,Implant Device,1071,34,"Charges > $500, x 34%",1071,percent of total billed charges,Implant Device,1102.5,35,,1102.5,percent of total billed charges,Implant Device,1102.5,35,,1102.5,percent of total billed charges,Implant Device,1102.5,35,,1102.5,percent of total billed charges,Implant Device,1102.5,35,,1102.5,percent of total billed charges,Implant Device,1102.5,35,,1102.5,percent of total billed charges,Implant Device,1260,40,,1260,percent of total billed charges,Implant Device,1102.5,70,,1102.5,percent of total billed charges,All Other,1071,34,,1071,percent of total billed charges,Implant Device,1071,34,,1071,percent of total billed charges,Implant Device,1102.5,35,,1102.5,percent of total billed charges,Implant Device,1102.5,35,,1102.5,percent of total billed charges,Implant Device,1102.5,35,,1102.5,percent of total billed charges,Implant Device,1102.5,35,,1102.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1071,34,"If Charge > 2,000, then 34 percent",1071,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2331.01,
ZIMMER 00-5850-030-17 ART SURF 17MM SZ C,C1776,HCPCS,,79008519,CDM,278,RC,,,both,,,6546,4844.06,,,4844.06,Other,150% of Medicare + 9.63% HCRA Surcharge,2945.7,45,,2945.7,percent of total billed charges,Critical Access Hospital RCC factor,2225.64,34,,2225.64,percent of total billed charges,Implant Device,2225.64,34,,2225.64,percent of total billed charges,Implant Device,2225.64,34,,2225.64,percent of total billed charges,Implant Device,2225.64,34,,2225.64,percent of total billed charges,Implant Device,2225.64,34,,2225.64,percent of total billed charges,Implant Device,3240.27,,,3240.27,Other,110% of Medicare,2291.1,35,,2291.1,percent of total billed charges,Implant Device,2225.64,34,"Charges > $500, x 34%",2225.64,percent of total billed charges,Implant Device,2291.1,35,,2291.1,percent of total billed charges,Implant Device,2291.1,35,,2291.1,percent of total billed charges,Implant Device,2291.1,35,,2291.1,percent of total billed charges,Implant Device,2291.1,35,,2291.1,percent of total billed charges,Implant Device,2291.1,35,,2291.1,percent of total billed charges,Implant Device,2618.4,40,,2618.4,percent of total billed charges,Implant Device,2291.1,70,,2291.1,percent of total billed charges,All Other,2225.64,34,,2225.64,percent of total billed charges,Implant Device,2225.64,34,,2225.64,percent of total billed charges,Implant Device,2291.1,35,,2291.1,percent of total billed charges,Implant Device,2291.1,35,,2291.1,percent of total billed charges,Implant Device,2291.1,35,,2291.1,percent of total billed charges,Implant Device,2291.1,35,,2291.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2225.64,34,"If Charge > 2,000, then 34 percent",2225.64,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4844.06,
ZIMMER 00-5850-013-01 DIS FEM COMP SZ C,C1776,HCPCS,,79008520,CDM,278,RC,,,both,,,24705,18281.76,,,18281.76,Other,150% of Medicare + 9.63% HCRA Surcharge,11117.25,45,,11117.25,percent of total billed charges,Critical Access Hospital RCC factor,8399.7,34,,8399.7,percent of total billed charges,Implant Device,8399.7,34,,8399.7,percent of total billed charges,Implant Device,8399.7,34,,8399.7,percent of total billed charges,Implant Device,8399.7,34,,8399.7,percent of total billed charges,Implant Device,8399.7,34,,8399.7,percent of total billed charges,Implant Device,12228.98,,,12228.98,Other,110% of Medicare,8646.75,35,,8646.75,percent of total billed charges,Implant Device,8399.7,34,"Charges > $500, x 34%",8399.7,percent of total billed charges,Implant Device,8646.75,35,,8646.75,percent of total billed charges,Implant Device,8646.75,35,,8646.75,percent of total billed charges,Implant Device,8646.75,35,,8646.75,percent of total billed charges,Implant Device,8646.75,35,,8646.75,percent of total billed charges,Implant Device,8646.75,35,,8646.75,percent of total billed charges,Implant Device,9882,40,,9882,percent of total billed charges,Implant Device,8646.75,70,,8646.75,percent of total billed charges,All Other,8399.7,34,,8399.7,percent of total billed charges,Implant Device,8399.7,34,,8399.7,percent of total billed charges,Implant Device,8646.75,35,,8646.75,percent of total billed charges,Implant Device,8646.75,35,,8646.75,percent of total billed charges,Implant Device,8646.75,35,,8646.75,percent of total billed charges,Implant Device,8646.75,35,,8646.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,8399.7,34,"If Charge > 2,000, then 34 percent",8399.7,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,18281.76,
ZIMMER 00-5850-030-26 ART SURF 26MM SZ C,C1776,HCPCS,,79008521,CDM,278,RC,,,both,,,5603,4146.23,,,4146.23,Other,150% of Medicare + 9.63% HCRA Surcharge,2521.35,45,,2521.35,percent of total billed charges,Critical Access Hospital RCC factor,1905.02,34,,1905.02,percent of total billed charges,Implant Device,1905.02,34,,1905.02,percent of total billed charges,Implant Device,1905.02,34,,1905.02,percent of total billed charges,Implant Device,1905.02,34,,1905.02,percent of total billed charges,Implant Device,1905.02,34,,1905.02,percent of total billed charges,Implant Device,2773.49,,,2773.49,Other,110% of Medicare,1961.05,35,,1961.05,percent of total billed charges,Implant Device,1905.02,34,"Charges > $500, x 34%",1905.02,percent of total billed charges,Implant Device,1961.05,35,,1961.05,percent of total billed charges,Implant Device,1961.05,35,,1961.05,percent of total billed charges,Implant Device,1961.05,35,,1961.05,percent of total billed charges,Implant Device,1961.05,35,,1961.05,percent of total billed charges,Implant Device,1961.05,35,,1961.05,percent of total billed charges,Implant Device,2241.2,40,,2241.2,percent of total billed charges,Implant Device,1961.05,70,,1961.05,percent of total billed charges,All Other,1905.02,34,,1905.02,percent of total billed charges,Implant Device,1905.02,34,,1905.02,percent of total billed charges,Implant Device,1961.05,35,,1961.05,percent of total billed charges,Implant Device,1961.05,35,,1961.05,percent of total billed charges,Implant Device,1961.05,35,,1961.05,percent of total billed charges,Implant Device,1961.05,35,,1961.05,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1905.02,34,"If Charge > 2,000, then 34 percent",1905.02,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4146.23,
DEPUY 96-0083 FEMORAL TC3 CEMENTED SZ 4,C1776,HCPCS,,79008522,CDM,278,RC,,,both,,,23138,17122.18,,,17122.18,Other,150% of Medicare + 9.63% HCRA Surcharge,10412.1,45,,10412.1,percent of total billed charges,Critical Access Hospital RCC factor,7866.92,34,,7866.92,percent of total billed charges,Implant Device,7866.92,34,,7866.92,percent of total billed charges,Implant Device,7866.92,34,,7866.92,percent of total billed charges,Implant Device,7866.92,34,,7866.92,percent of total billed charges,Implant Device,7866.92,34,,7866.92,percent of total billed charges,Implant Device,11453.31,,,11453.31,Other,110% of Medicare,8098.3,35,,8098.3,percent of total billed charges,Implant Device,7866.92,34,"Charges > $500, x 34%",7866.92,percent of total billed charges,Implant Device,8098.3,35,,8098.3,percent of total billed charges,Implant Device,8098.3,35,,8098.3,percent of total billed charges,Implant Device,8098.3,35,,8098.3,percent of total billed charges,Implant Device,8098.3,35,,8098.3,percent of total billed charges,Implant Device,8098.3,35,,8098.3,percent of total billed charges,Implant Device,9255.2,40,,9255.2,percent of total billed charges,Implant Device,8098.3,70,,8098.3,percent of total billed charges,All Other,7866.92,34,,7866.92,percent of total billed charges,Implant Device,7866.92,34,,7866.92,percent of total billed charges,Implant Device,8098.3,35,,8098.3,percent of total billed charges,Implant Device,8098.3,35,,8098.3,percent of total billed charges,Implant Device,8098.3,35,,8098.3,percent of total billed charges,Implant Device,8098.3,35,,8098.3,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,7866.92,34,"If Charge > 2,000, then 34 percent",7866.92,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,17122.18,
DEPUY 96-0880 DISTAL AUGMENT 4MM SIZE 4,C1776,HCPCS,,79008523,CDM,278,RC,,,both,,,3929,2907.47,,,2907.47,Other,150% of Medicare + 9.63% HCRA Surcharge,1768.05,45,,1768.05,percent of total billed charges,Critical Access Hospital RCC factor,1335.86,34,,1335.86,percent of total billed charges,Implant Device,1335.86,34,,1335.86,percent of total billed charges,Implant Device,1335.86,34,,1335.86,percent of total billed charges,Implant Device,1335.86,34,,1335.86,percent of total billed charges,Implant Device,1335.86,34,,1335.86,percent of total billed charges,Implant Device,1944.86,,,1944.86,Other,110% of Medicare,1375.15,35,,1375.15,percent of total billed charges,Implant Device,1335.86,34,"Charges > $500, x 34%",1335.86,percent of total billed charges,Implant Device,1375.15,35,,1375.15,percent of total billed charges,Implant Device,1375.15,35,,1375.15,percent of total billed charges,Implant Device,1375.15,35,,1375.15,percent of total billed charges,Implant Device,1375.15,35,,1375.15,percent of total billed charges,Implant Device,1375.15,35,,1375.15,percent of total billed charges,Implant Device,1571.6,40,,1571.6,percent of total billed charges,Implant Device,1375.15,70,,1375.15,percent of total billed charges,All Other,1335.86,34,,1335.86,percent of total billed charges,Implant Device,1335.86,34,,1335.86,percent of total billed charges,Implant Device,1375.15,35,,1375.15,percent of total billed charges,Implant Device,1375.15,35,,1375.15,percent of total billed charges,Implant Device,1375.15,35,,1375.15,percent of total billed charges,Implant Device,1375.15,35,,1375.15,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1335.86,34,"If Charge > 2,000, then 34 percent",1335.86,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2907.47,
DEPUY 96-2353 TIBIAL INSERT 15MM SIZE 4,C1776,HCPCS,,79008524,CDM,278,RC,,,both,,,10896,8063.07,,,8063.07,Other,150% of Medicare + 9.63% HCRA Surcharge,4903.2,45,,4903.2,percent of total billed charges,Critical Access Hospital RCC factor,3704.64,34,,3704.64,percent of total billed charges,Implant Device,3704.64,34,,3704.64,percent of total billed charges,Implant Device,3704.64,34,,3704.64,percent of total billed charges,Implant Device,3704.64,34,,3704.64,percent of total billed charges,Implant Device,3704.64,34,,3704.64,percent of total billed charges,Implant Device,5393.52,,,5393.52,Other,110% of Medicare,3813.6,35,,3813.6,percent of total billed charges,Implant Device,3704.64,34,"Charges > $500, x 34%",3704.64,percent of total billed charges,Implant Device,3813.6,35,,3813.6,percent of total billed charges,Implant Device,3813.6,35,,3813.6,percent of total billed charges,Implant Device,3813.6,35,,3813.6,percent of total billed charges,Implant Device,3813.6,35,,3813.6,percent of total billed charges,Implant Device,3813.6,35,,3813.6,percent of total billed charges,Implant Device,4358.4,40,,4358.4,percent of total billed charges,Implant Device,3813.6,70,,3813.6,percent of total billed charges,All Other,3704.64,34,,3704.64,percent of total billed charges,Implant Device,3704.64,34,,3704.64,percent of total billed charges,Implant Device,3813.6,35,,3813.6,percent of total billed charges,Implant Device,3813.6,35,,3813.6,percent of total billed charges,Implant Device,3813.6,35,,3813.6,percent of total billed charges,Implant Device,3813.6,35,,3813.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3704.64,34,"If Charge > 2,000, then 34 percent",3704.64,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,8063.07,
DEPUY 200.011 CORTEX SCREW 1.5X11MM,C1713,HCPCS,,79008525,CDM,278,RC,,,both,,,113,83.62,,,83.62,Other,150% of Medicare + 9.63% HCRA Surcharge,50.85,45,,50.85,percent of total billed charges,Critical Access Hospital RCC factor,38.42,34,,38.42,percent of total billed charges,Implant Device,38.42,34,,38.42,percent of total billed charges,Implant Device,38.42,34,,38.42,percent of total billed charges,Implant Device,38.42,34,,38.42,percent of total billed charges,Implant Device,38.42,34,,38.42,percent of total billed charges,Implant Device,55.94,,,55.94,Other,110% of Medicare,39.55,35,,39.55,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,39.55,35,,39.55,percent of total billed charges,Implant Device,39.55,35,,39.55,percent of total billed charges,Implant Device,39.55,35,,39.55,percent of total billed charges,Implant Device,39.55,35,,39.55,percent of total billed charges,Implant Device,39.55,35,,39.55,percent of total billed charges,Implant Device,45.2,40,,45.2,percent of total billed charges,Implant Device,39.55,70,,39.55,percent of total billed charges,All Other,38.42,34,,38.42,percent of total billed charges,Implant Device,38.42,34,,38.42,percent of total billed charges,Implant Device,39.55,35,,39.55,percent of total billed charges,Implant Device,39.55,35,,39.55,percent of total billed charges,Implant Device,39.55,35,,39.55,percent of total billed charges,Implant Device,39.55,35,,39.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,83.62,
STRYKER 1822-1034S TIBIAL NAIL 10X345MM,C1713,HCPCS,,79008526,CDM,278,RC,,,both,,,3529,2611.47,,,2611.47,Other,150% of Medicare + 9.63% HCRA Surcharge,1588.05,45,,1588.05,percent of total billed charges,Critical Access Hospital RCC factor,1199.86,34,,1199.86,percent of total billed charges,Implant Device,1199.86,34,,1199.86,percent of total billed charges,Implant Device,1199.86,34,,1199.86,percent of total billed charges,Implant Device,1199.86,34,,1199.86,percent of total billed charges,Implant Device,1199.86,34,,1199.86,percent of total billed charges,Implant Device,1746.86,,,1746.86,Other,110% of Medicare,1235.15,35,,1235.15,percent of total billed charges,Implant Device,1199.86,34,"Charges > $500, x 34%",1199.86,percent of total billed charges,Implant Device,1235.15,35,,1235.15,percent of total billed charges,Implant Device,1235.15,35,,1235.15,percent of total billed charges,Implant Device,1235.15,35,,1235.15,percent of total billed charges,Implant Device,1235.15,35,,1235.15,percent of total billed charges,Implant Device,1235.15,35,,1235.15,percent of total billed charges,Implant Device,1411.6,40,,1411.6,percent of total billed charges,Implant Device,1235.15,70,,1235.15,percent of total billed charges,All Other,1199.86,34,,1199.86,percent of total billed charges,Implant Device,1199.86,34,,1199.86,percent of total billed charges,Implant Device,1235.15,35,,1235.15,percent of total billed charges,Implant Device,1235.15,35,,1235.15,percent of total billed charges,Implant Device,1235.15,35,,1235.15,percent of total billed charges,Implant Device,1235.15,35,,1235.15,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1199.86,34,"If Charge > 2,000, then 34 percent",1199.86,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2611.47,
DEPUY 1961-92-152 TIBIAL INSERT SZ 6,C1776,HCPCS,,79008527,CDM,278,RC,,,both,,,5568,4120.33,,,4120.33,Other,150% of Medicare + 9.63% HCRA Surcharge,2505.6,45,,2505.6,percent of total billed charges,Critical Access Hospital RCC factor,1893.12,34,,1893.12,percent of total billed charges,Implant Device,1893.12,34,,1893.12,percent of total billed charges,Implant Device,1893.12,34,,1893.12,percent of total billed charges,Implant Device,1893.12,34,,1893.12,percent of total billed charges,Implant Device,1893.12,34,,1893.12,percent of total billed charges,Implant Device,2756.16,,,2756.16,Other,110% of Medicare,1948.8,35,,1948.8,percent of total billed charges,Implant Device,1893.12,34,"Charges > $500, x 34%",1893.12,percent of total billed charges,Implant Device,1948.8,35,,1948.8,percent of total billed charges,Implant Device,1948.8,35,,1948.8,percent of total billed charges,Implant Device,1948.8,35,,1948.8,percent of total billed charges,Implant Device,1948.8,35,,1948.8,percent of total billed charges,Implant Device,1948.8,35,,1948.8,percent of total billed charges,Implant Device,2227.2,40,,2227.2,percent of total billed charges,Implant Device,1948.8,70,,1948.8,percent of total billed charges,All Other,1893.12,34,,1893.12,percent of total billed charges,Implant Device,1893.12,34,,1893.12,percent of total billed charges,Implant Device,1948.8,35,,1948.8,percent of total billed charges,Implant Device,1948.8,35,,1948.8,percent of total billed charges,Implant Device,1948.8,35,,1948.8,percent of total billed charges,Implant Device,1948.8,35,,1948.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1893.12,34,"If Charge > 2,000, then 34 percent",1893.12,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4120.33,
"LIFE SPINE 132-2308-1 AILERON CORE,SMALL",C1713,HCPCS,,79008528,CDM,278,RC,,,both,,,20520,15184.85,,,15184.85,Other,150% of Medicare + 9.63% HCRA Surcharge,9234,45,,9234,percent of total billed charges,Critical Access Hospital RCC factor,6976.8,34,,6976.8,percent of total billed charges,Implant Device,6976.8,34,,6976.8,percent of total billed charges,Implant Device,6976.8,34,,6976.8,percent of total billed charges,Implant Device,6976.8,34,,6976.8,percent of total billed charges,Implant Device,6976.8,34,,6976.8,percent of total billed charges,Implant Device,10157.4,,,10157.4,Other,110% of Medicare,7182,35,,7182,percent of total billed charges,Implant Device,6976.8,34,"Charges > $500, x 34%",6976.8,percent of total billed charges,Implant Device,7182,35,,7182,percent of total billed charges,Implant Device,7182,35,,7182,percent of total billed charges,Implant Device,7182,35,,7182,percent of total billed charges,Implant Device,7182,35,,7182,percent of total billed charges,Implant Device,7182,35,,7182,percent of total billed charges,Implant Device,8208,40,,8208,percent of total billed charges,Implant Device,7182,70,,7182,percent of total billed charges,All Other,6976.8,34,,6976.8,percent of total billed charges,Implant Device,6976.8,34,,6976.8,percent of total billed charges,Implant Device,7182,35,,7182,percent of total billed charges,Implant Device,7182,35,,7182,percent of total billed charges,Implant Device,7182,35,,7182,percent of total billed charges,Implant Device,7182,35,,7182,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,6976.8,34,"If Charge > 2,000, then 34 percent",6976.8,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,15184.85,
"LIFE SPINE 132-2308-2 AILERON PLT, SMALL",C1713,HCPCS,,79008529,CDM,278,RC,,,both,,,13680,10123.23,,,10123.23,Other,150% of Medicare + 9.63% HCRA Surcharge,6156,45,,6156,percent of total billed charges,Critical Access Hospital RCC factor,4651.2,34,,4651.2,percent of total billed charges,Implant Device,4651.2,34,,4651.2,percent of total billed charges,Implant Device,4651.2,34,,4651.2,percent of total billed charges,Implant Device,4651.2,34,,4651.2,percent of total billed charges,Implant Device,4651.2,34,,4651.2,percent of total billed charges,Implant Device,6771.6,,,6771.6,Other,110% of Medicare,4788,35,,4788,percent of total billed charges,Implant Device,4651.2,34,"Charges > $500, x 34%",4651.2,percent of total billed charges,Implant Device,4788,35,,4788,percent of total billed charges,Implant Device,4788,35,,4788,percent of total billed charges,Implant Device,4788,35,,4788,percent of total billed charges,Implant Device,4788,35,,4788,percent of total billed charges,Implant Device,4788,35,,4788,percent of total billed charges,Implant Device,5472,40,,5472,percent of total billed charges,Implant Device,4788,70,,4788,percent of total billed charges,All Other,4651.2,34,,4651.2,percent of total billed charges,Implant Device,4651.2,34,,4651.2,percent of total billed charges,Implant Device,4788,35,,4788,percent of total billed charges,Implant Device,4788,35,,4788,percent of total billed charges,Implant Device,4788,35,,4788,percent of total billed charges,Implant Device,4788,35,,4788,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,4651.2,34,"If Charge > 2,000, then 34 percent",4651.2,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,10123.23,
STRYKER 3102-2101 BIO4 BONE MATRIX 1CC,C1713,HCPCS,,79008530,CDM,278,RC,,,both,,,2340,1731.61,,,1731.61,Other,150% of Medicare + 9.63% HCRA Surcharge,1053,45,,1053,percent of total billed charges,Critical Access Hospital RCC factor,795.6,34,,795.6,percent of total billed charges,Implant Device,795.6,34,,795.6,percent of total billed charges,Implant Device,795.6,34,,795.6,percent of total billed charges,Implant Device,795.6,34,,795.6,percent of total billed charges,Implant Device,795.6,34,,795.6,percent of total billed charges,Implant Device,1158.3,,,1158.3,Other,110% of Medicare,819,35,,819,percent of total billed charges,Implant Device,795.6,34,"Charges > $500, x 34%",795.6,percent of total billed charges,Implant Device,819,35,,819,percent of total billed charges,Implant Device,819,35,,819,percent of total billed charges,Implant Device,819,35,,819,percent of total billed charges,Implant Device,819,35,,819,percent of total billed charges,Implant Device,819,35,,819,percent of total billed charges,Implant Device,936,40,,936,percent of total billed charges,Implant Device,819,70,,819,percent of total billed charges,All Other,795.6,34,,795.6,percent of total billed charges,Implant Device,795.6,34,,795.6,percent of total billed charges,Implant Device,819,35,,819,percent of total billed charges,Implant Device,819,35,,819,percent of total billed charges,Implant Device,819,35,,819,percent of total billed charges,Implant Device,819,35,,819,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,795.6,34,"If Charge > 2,000, then 34 percent",795.6,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1731.61,
ARTHREX AR-13200M-07L PLATE WEDGE 7MM,C1713,HCPCS,,79008531,CDM,278,RC,,,both,,,2385,1764.91,,,1764.91,Other,150% of Medicare + 9.63% HCRA Surcharge,1073.25,45,,1073.25,percent of total billed charges,Critical Access Hospital RCC factor,810.9,34,,810.9,percent of total billed charges,Implant Device,810.9,34,,810.9,percent of total billed charges,Implant Device,810.9,34,,810.9,percent of total billed charges,Implant Device,810.9,34,,810.9,percent of total billed charges,Implant Device,810.9,34,,810.9,percent of total billed charges,Implant Device,1180.58,,,1180.58,Other,110% of Medicare,834.75,35,,834.75,percent of total billed charges,Implant Device,810.9,34,"Charges > $500, x 34%",810.9,percent of total billed charges,Implant Device,834.75,35,,834.75,percent of total billed charges,Implant Device,834.75,35,,834.75,percent of total billed charges,Implant Device,834.75,35,,834.75,percent of total billed charges,Implant Device,834.75,35,,834.75,percent of total billed charges,Implant Device,834.75,35,,834.75,percent of total billed charges,Implant Device,954,40,,954,percent of total billed charges,Implant Device,834.75,70,,834.75,percent of total billed charges,All Other,810.9,34,,810.9,percent of total billed charges,Implant Device,810.9,34,,810.9,percent of total billed charges,Implant Device,834.75,35,,834.75,percent of total billed charges,Implant Device,834.75,35,,834.75,percent of total billed charges,Implant Device,834.75,35,,834.75,percent of total billed charges,Implant Device,834.75,35,,834.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,810.9,34,"If Charge > 2,000, then 34 percent",810.9,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1764.91,
IN2BONES 100-0044 VITRIUM EVANS WEDGE,C1713,HCPCS,,79008532,CDM,278,RC,,,both,,,9450,6993.02,,,6993.02,Other,150% of Medicare + 9.63% HCRA Surcharge,4252.5,45,,4252.5,percent of total billed charges,Critical Access Hospital RCC factor,3213,34,,3213,percent of total billed charges,Implant Device,3213,34,,3213,percent of total billed charges,Implant Device,3213,34,,3213,percent of total billed charges,Implant Device,3213,34,,3213,percent of total billed charges,Implant Device,3213,34,,3213,percent of total billed charges,Implant Device,4677.75,,,4677.75,Other,110% of Medicare,3307.5,35,,3307.5,percent of total billed charges,Implant Device,3213,34,"Charges > $500, x 34%",3213,percent of total billed charges,Implant Device,3307.5,35,,3307.5,percent of total billed charges,Implant Device,3307.5,35,,3307.5,percent of total billed charges,Implant Device,3307.5,35,,3307.5,percent of total billed charges,Implant Device,3307.5,35,,3307.5,percent of total billed charges,Implant Device,3307.5,35,,3307.5,percent of total billed charges,Implant Device,3780,40,,3780,percent of total billed charges,Implant Device,3307.5,70,,3307.5,percent of total billed charges,All Other,3213,34,,3213,percent of total billed charges,Implant Device,3213,34,,3213,percent of total billed charges,Implant Device,3307.5,35,,3307.5,percent of total billed charges,Implant Device,3307.5,35,,3307.5,percent of total billed charges,Implant Device,3307.5,35,,3307.5,percent of total billed charges,Implant Device,3307.5,35,,3307.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3213,34,"If Charge > 2,000, then 34 percent",3213,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,6993.02,
IN2BONES USA S35 ST128 SCREW 3.5X28MM,C1713,HCPCS,,79008533,CDM,278,RC,,,both,,,1350,999,,,999,Other,150% of Medicare + 9.63% HCRA Surcharge,607.5,45,,607.5,percent of total billed charges,Critical Access Hospital RCC factor,459,34,,459,percent of total billed charges,Implant Device,459,34,,459,percent of total billed charges,Implant Device,459,34,,459,percent of total billed charges,Implant Device,459,34,,459,percent of total billed charges,Implant Device,459,34,,459,percent of total billed charges,Implant Device,668.25,,,668.25,Other,110% of Medicare,472.5,35,,472.5,percent of total billed charges,Implant Device,459,34,"Charges > $500, x 34%",459,percent of total billed charges,Implant Device,472.5,35,,472.5,percent of total billed charges,Implant Device,472.5,35,,472.5,percent of total billed charges,Implant Device,472.5,35,,472.5,percent of total billed charges,Implant Device,472.5,35,,472.5,percent of total billed charges,Implant Device,472.5,35,,472.5,percent of total billed charges,Implant Device,540,40,,540,percent of total billed charges,Implant Device,472.5,70,,472.5,percent of total billed charges,All Other,459,34,,459,percent of total billed charges,Implant Device,459,34,,459,percent of total billed charges,Implant Device,472.5,35,,472.5,percent of total billed charges,Implant Device,472.5,35,,472.5,percent of total billed charges,Implant Device,472.5,35,,472.5,percent of total billed charges,Implant Device,472.5,35,,472.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,999,
STRYKER 5630-G-212 TIBIAL INSERT SIZE 2,C1776,HCPCS,,79008535,CDM,278,RC,,,both,,,3232,2391.69,,,2391.69,Other,150% of Medicare + 9.63% HCRA Surcharge,1454.4,45,,1454.4,percent of total billed charges,Critical Access Hospital RCC factor,1098.88,34,,1098.88,percent of total billed charges,Implant Device,1098.88,34,,1098.88,percent of total billed charges,Implant Device,1098.88,34,,1098.88,percent of total billed charges,Implant Device,1098.88,34,,1098.88,percent of total billed charges,Implant Device,1098.88,34,,1098.88,percent of total billed charges,Implant Device,1599.84,,,1599.84,Other,110% of Medicare,1131.2,35,,1131.2,percent of total billed charges,Implant Device,1098.88,34,"Charges > $500, x 34%",1098.88,percent of total billed charges,Implant Device,1131.2,35,,1131.2,percent of total billed charges,Implant Device,1131.2,35,,1131.2,percent of total billed charges,Implant Device,1131.2,35,,1131.2,percent of total billed charges,Implant Device,1131.2,35,,1131.2,percent of total billed charges,Implant Device,1131.2,35,,1131.2,percent of total billed charges,Implant Device,1292.8,40,,1292.8,percent of total billed charges,Implant Device,1131.2,70,,1131.2,percent of total billed charges,All Other,1098.88,34,,1098.88,percent of total billed charges,Implant Device,1098.88,34,,1098.88,percent of total billed charges,Implant Device,1131.2,35,,1131.2,percent of total billed charges,Implant Device,1131.2,35,,1131.2,percent of total billed charges,Implant Device,1131.2,35,,1131.2,percent of total billed charges,Implant Device,1131.2,35,,1131.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1098.88,34,"If Charge > 2,000, then 34 percent",1098.88,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2391.69,
BIOMET 11-301321 ARCOS CONE PROX SZ 1,C1776,HCPCS,,79008538,CDM,278,RC,,,both,,,20382,15082.73,,,15082.73,Other,150% of Medicare + 9.63% HCRA Surcharge,9171.9,45,,9171.9,percent of total billed charges,Critical Access Hospital RCC factor,6929.88,34,,6929.88,percent of total billed charges,Implant Device,6929.88,34,,6929.88,percent of total billed charges,Implant Device,6929.88,34,,6929.88,percent of total billed charges,Implant Device,6929.88,34,,6929.88,percent of total billed charges,Implant Device,6929.88,34,,6929.88,percent of total billed charges,Implant Device,10089.09,,,10089.09,Other,110% of Medicare,7133.7,35,,7133.7,percent of total billed charges,Implant Device,6929.88,34,"Charges > $500, x 34%",6929.88,percent of total billed charges,Implant Device,7133.7,35,,7133.7,percent of total billed charges,Implant Device,7133.7,35,,7133.7,percent of total billed charges,Implant Device,7133.7,35,,7133.7,percent of total billed charges,Implant Device,7133.7,35,,7133.7,percent of total billed charges,Implant Device,7133.7,35,,7133.7,percent of total billed charges,Implant Device,8152.8,40,,8152.8,percent of total billed charges,Implant Device,7133.7,70,,7133.7,percent of total billed charges,All Other,6929.88,34,,6929.88,percent of total billed charges,Implant Device,6929.88,34,,6929.88,percent of total billed charges,Implant Device,7133.7,35,,7133.7,percent of total billed charges,Implant Device,7133.7,35,,7133.7,percent of total billed charges,Implant Device,7133.7,35,,7133.7,percent of total billed charges,Implant Device,7133.7,35,,7133.7,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,6929.88,34,"If Charge > 2,000, then 34 percent",6929.88,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,15082.73,
ARTHREX AR-5026B-24 COMP SCREW 3.5X24MM,C1713,HCPCS,,79008539,CDM,278,RC,,,both,,,1695,1254.3,,,1254.3,Other,150% of Medicare + 9.63% HCRA Surcharge,762.75,45,,762.75,percent of total billed charges,Critical Access Hospital RCC factor,576.3,34,,576.3,percent of total billed charges,Implant Device,576.3,34,,576.3,percent of total billed charges,Implant Device,576.3,34,,576.3,percent of total billed charges,Implant Device,576.3,34,,576.3,percent of total billed charges,Implant Device,576.3,34,,576.3,percent of total billed charges,Implant Device,839.03,,,839.03,Other,110% of Medicare,593.25,35,,593.25,percent of total billed charges,Implant Device,576.3,34,"Charges > $500, x 34%",576.3,percent of total billed charges,Implant Device,593.25,35,,593.25,percent of total billed charges,Implant Device,593.25,35,,593.25,percent of total billed charges,Implant Device,593.25,35,,593.25,percent of total billed charges,Implant Device,593.25,35,,593.25,percent of total billed charges,Implant Device,593.25,35,,593.25,percent of total billed charges,Implant Device,678,40,,678,percent of total billed charges,Implant Device,593.25,70,,593.25,percent of total billed charges,All Other,576.3,34,,576.3,percent of total billed charges,Implant Device,576.3,34,,576.3,percent of total billed charges,Implant Device,593.25,35,,593.25,percent of total billed charges,Implant Device,593.25,35,,593.25,percent of total billed charges,Implant Device,593.25,35,,593.25,percent of total billed charges,Implant Device,593.25,35,,593.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1254.3,
ARTHREX AR-5026B-26 COMP SCREW 3.5X26MM,C1713,HCPCS,,79008540,CDM,278,RC,,,both,,,1695,1254.3,,,1254.3,Other,150% of Medicare + 9.63% HCRA Surcharge,762.75,45,,762.75,percent of total billed charges,Critical Access Hospital RCC factor,576.3,34,,576.3,percent of total billed charges,Implant Device,576.3,34,,576.3,percent of total billed charges,Implant Device,576.3,34,,576.3,percent of total billed charges,Implant Device,576.3,34,,576.3,percent of total billed charges,Implant Device,576.3,34,,576.3,percent of total billed charges,Implant Device,839.03,,,839.03,Other,110% of Medicare,593.25,35,,593.25,percent of total billed charges,Implant Device,576.3,34,"Charges > $500, x 34%",576.3,percent of total billed charges,Implant Device,593.25,35,,593.25,percent of total billed charges,Implant Device,593.25,35,,593.25,percent of total billed charges,Implant Device,593.25,35,,593.25,percent of total billed charges,Implant Device,593.25,35,,593.25,percent of total billed charges,Implant Device,593.25,35,,593.25,percent of total billed charges,Implant Device,678,40,,678,percent of total billed charges,Implant Device,593.25,70,,593.25,percent of total billed charges,All Other,576.3,34,,576.3,percent of total billed charges,Implant Device,576.3,34,,576.3,percent of total billed charges,Implant Device,593.25,35,,593.25,percent of total billed charges,Implant Device,593.25,35,,593.25,percent of total billed charges,Implant Device,593.25,35,,593.25,percent of total billed charges,Implant Device,593.25,35,,593.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1254.3,
ARTHREX AR-5026B-28 COMP SCREW 3.5X28MM,C1713,HCPCS,,79008541,CDM,278,RC,,,both,,,1695,1254.3,,,1254.3,Other,150% of Medicare + 9.63% HCRA Surcharge,762.75,45,,762.75,percent of total billed charges,Critical Access Hospital RCC factor,576.3,34,,576.3,percent of total billed charges,Implant Device,576.3,34,,576.3,percent of total billed charges,Implant Device,576.3,34,,576.3,percent of total billed charges,Implant Device,576.3,34,,576.3,percent of total billed charges,Implant Device,576.3,34,,576.3,percent of total billed charges,Implant Device,839.03,,,839.03,Other,110% of Medicare,593.25,35,,593.25,percent of total billed charges,Implant Device,576.3,34,"Charges > $500, x 34%",576.3,percent of total billed charges,Implant Device,593.25,35,,593.25,percent of total billed charges,Implant Device,593.25,35,,593.25,percent of total billed charges,Implant Device,593.25,35,,593.25,percent of total billed charges,Implant Device,593.25,35,,593.25,percent of total billed charges,Implant Device,593.25,35,,593.25,percent of total billed charges,Implant Device,678,40,,678,percent of total billed charges,Implant Device,593.25,70,,593.25,percent of total billed charges,All Other,576.3,34,,576.3,percent of total billed charges,Implant Device,576.3,34,,576.3,percent of total billed charges,Implant Device,593.25,35,,593.25,percent of total billed charges,Implant Device,593.25,35,,593.25,percent of total billed charges,Implant Device,593.25,35,,593.25,percent of total billed charges,Implant Device,593.25,35,,593.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1254.3,
COVIDIEN PCO1510X PARIETEX MESH 15X10MM,C1781,HCPCS,,79008542,CDM,278,RC,,,both,,,1999,1479.26,,,1479.26,Other,150% of Medicare + 9.63% HCRA Surcharge,899.55,45,,899.55,percent of total billed charges,Critical Access Hospital RCC factor,679.66,34,,679.66,percent of total billed charges,Implant Device,679.66,34,,679.66,percent of total billed charges,Implant Device,679.66,34,,679.66,percent of total billed charges,Implant Device,679.66,34,,679.66,percent of total billed charges,Implant Device,679.66,34,,679.66,percent of total billed charges,Implant Device,989.51,,,989.51,Other,110% of Medicare,699.65,35,,699.65,percent of total billed charges,Implant Device,679.66,34,"Charges > $500, x 34%",679.66,percent of total billed charges,Implant Device,699.65,35,,699.65,percent of total billed charges,Implant Device,699.65,35,,699.65,percent of total billed charges,Implant Device,699.65,35,,699.65,percent of total billed charges,Implant Device,699.65,35,,699.65,percent of total billed charges,Implant Device,699.65,35,,699.65,percent of total billed charges,Implant Device,799.6,40,,799.6,percent of total billed charges,Implant Device,699.65,70,,699.65,percent of total billed charges,All Other,679.66,34,,679.66,percent of total billed charges,Implant Device,679.66,34,,679.66,percent of total billed charges,Implant Device,699.65,35,,699.65,percent of total billed charges,Implant Device,699.65,35,,699.65,percent of total billed charges,Implant Device,699.65,35,,699.65,percent of total billed charges,Implant Device,699.65,35,,699.65,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1479.26,
STRYKER F&A 626895 POLY LOCK PLATE (T8),C1713,HCPCS,,79008543,CDM,278,RC,,,both,,,8652,6402.5,,,6402.5,Other,150% of Medicare + 9.63% HCRA Surcharge,3893.4,45,,3893.4,percent of total billed charges,Critical Access Hospital RCC factor,2941.68,34,,2941.68,percent of total billed charges,Implant Device,2941.68,34,,2941.68,percent of total billed charges,Implant Device,2941.68,34,,2941.68,percent of total billed charges,Implant Device,2941.68,34,,2941.68,percent of total billed charges,Implant Device,2941.68,34,,2941.68,percent of total billed charges,Implant Device,4282.74,,,4282.74,Other,110% of Medicare,3028.2,35,,3028.2,percent of total billed charges,Implant Device,2941.68,34,"Charges > $500, x 34%",2941.68,percent of total billed charges,Implant Device,3028.2,35,,3028.2,percent of total billed charges,Implant Device,3028.2,35,,3028.2,percent of total billed charges,Implant Device,3028.2,35,,3028.2,percent of total billed charges,Implant Device,3028.2,35,,3028.2,percent of total billed charges,Implant Device,3028.2,35,,3028.2,percent of total billed charges,Implant Device,3460.8,40,,3460.8,percent of total billed charges,Implant Device,3028.2,70,,3028.2,percent of total billed charges,All Other,2941.68,34,,2941.68,percent of total billed charges,Implant Device,2941.68,34,,2941.68,percent of total billed charges,Implant Device,3028.2,35,,3028.2,percent of total billed charges,Implant Device,3028.2,35,,3028.2,percent of total billed charges,Implant Device,3028.2,35,,3028.2,percent of total billed charges,Implant Device,3028.2,35,,3028.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2941.68,34,"If Charge > 2,000, then 34 percent",2941.68,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,6402.5,
STRYKER 661490 NON LOCKNG SCREW 3.5X90MM,C1713,HCPCS,,79008544,CDM,278,RC,,,both,,,171,126.54,,,126.54,Other,150% of Medicare + 9.63% HCRA Surcharge,76.95,45,,76.95,percent of total billed charges,Critical Access Hospital RCC factor,58.14,34,,58.14,percent of total billed charges,Implant Device,58.14,34,,58.14,percent of total billed charges,Implant Device,58.14,34,,58.14,percent of total billed charges,Implant Device,58.14,34,,58.14,percent of total billed charges,Implant Device,58.14,34,,58.14,percent of total billed charges,Implant Device,84.65,,,84.65,Other,110% of Medicare,59.85,35,,59.85,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,59.85,35,,59.85,percent of total billed charges,Implant Device,59.85,35,,59.85,percent of total billed charges,Implant Device,59.85,35,,59.85,percent of total billed charges,Implant Device,59.85,35,,59.85,percent of total billed charges,Implant Device,59.85,35,,59.85,percent of total billed charges,Implant Device,68.4,40,,68.4,percent of total billed charges,Implant Device,59.85,70,,59.85,percent of total billed charges,All Other,58.14,34,,58.14,percent of total billed charges,Implant Device,58.14,34,,58.14,percent of total billed charges,Implant Device,59.85,35,,59.85,percent of total billed charges,Implant Device,59.85,35,,59.85,percent of total billed charges,Implant Device,59.85,35,,59.85,percent of total billed charges,Implant Device,59.85,35,,59.85,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,126.54,
STRYKER SV14 S-FIX SCREW 2.5LG 14MM,C1713,HCPCS,,79008545,CDM,278,RC,,,both,,,1486,1099.64,,,1099.64,Other,150% of Medicare + 9.63% HCRA Surcharge,668.7,45,,668.7,percent of total billed charges,Critical Access Hospital RCC factor,505.24,34,,505.24,percent of total billed charges,Implant Device,505.24,34,,505.24,percent of total billed charges,Implant Device,505.24,34,,505.24,percent of total billed charges,Implant Device,505.24,34,,505.24,percent of total billed charges,Implant Device,505.24,34,,505.24,percent of total billed charges,Implant Device,735.57,,,735.57,Other,110% of Medicare,520.1,35,,520.1,percent of total billed charges,Implant Device,505.24,34,"Charges > $500, x 34%",505.24,percent of total billed charges,Implant Device,520.1,35,,520.1,percent of total billed charges,Implant Device,520.1,35,,520.1,percent of total billed charges,Implant Device,520.1,35,,520.1,percent of total billed charges,Implant Device,520.1,35,,520.1,percent of total billed charges,Implant Device,520.1,35,,520.1,percent of total billed charges,Implant Device,594.4,40,,594.4,percent of total billed charges,Implant Device,520.1,70,,520.1,percent of total billed charges,All Other,505.24,34,,505.24,percent of total billed charges,Implant Device,505.24,34,,505.24,percent of total billed charges,Implant Device,520.1,35,,520.1,percent of total billed charges,Implant Device,520.1,35,,520.1,percent of total billed charges,Implant Device,520.1,35,,520.1,percent of total billed charges,Implant Device,520.1,35,,520.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1099.64,
STRYKER 3525-0380S NAIL KIT 010X380X125,C1713,HCPCS,,79008549,CDM,278,RC,,,both,,,4920,3640.81,,,3640.81,Other,150% of Medicare + 9.63% HCRA Surcharge,2214,45,,2214,percent of total billed charges,Critical Access Hospital RCC factor,1672.8,34,,1672.8,percent of total billed charges,Implant Device,1672.8,34,,1672.8,percent of total billed charges,Implant Device,1672.8,34,,1672.8,percent of total billed charges,Implant Device,1672.8,34,,1672.8,percent of total billed charges,Implant Device,1672.8,34,,1672.8,percent of total billed charges,Implant Device,2435.4,,,2435.4,Other,110% of Medicare,1722,35,,1722,percent of total billed charges,Implant Device,1672.8,34,"Charges > $500, x 34%",1672.8,percent of total billed charges,Implant Device,1722,35,,1722,percent of total billed charges,Implant Device,1722,35,,1722,percent of total billed charges,Implant Device,1722,35,,1722,percent of total billed charges,Implant Device,1722,35,,1722,percent of total billed charges,Implant Device,1722,35,,1722,percent of total billed charges,Implant Device,1968,40,,1968,percent of total billed charges,Implant Device,1722,70,,1722,percent of total billed charges,All Other,1672.8,34,,1672.8,percent of total billed charges,Implant Device,1672.8,34,,1672.8,percent of total billed charges,Implant Device,1722,35,,1722,percent of total billed charges,Implant Device,1722,35,,1722,percent of total billed charges,Implant Device,1722,35,,1722,percent of total billed charges,Implant Device,1722,35,,1722,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1672.8,34,"If Charge > 2,000, then 34 percent",1672.8,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3640.81,
ZIMMER 00-5976-050-12 ART SURF SZ 14MM,C1776,HCPCS,,79008550,CDM,278,RC,,,both,,,1920,1420.8,,,1420.8,Other,150% of Medicare + 9.63% HCRA Surcharge,864,45,,864,percent of total billed charges,Critical Access Hospital RCC factor,652.8,34,,652.8,percent of total billed charges,Implant Device,652.8,34,,652.8,percent of total billed charges,Implant Device,652.8,34,,652.8,percent of total billed charges,Implant Device,652.8,34,,652.8,percent of total billed charges,Implant Device,652.8,34,,652.8,percent of total billed charges,Implant Device,950.4,,,950.4,Other,110% of Medicare,672,35,,672,percent of total billed charges,Implant Device,652.8,34,"Charges > $500, x 34%",652.8,percent of total billed charges,Implant Device,672,35,,672,percent of total billed charges,Implant Device,672,35,,672,percent of total billed charges,Implant Device,672,35,,672,percent of total billed charges,Implant Device,672,35,,672,percent of total billed charges,Implant Device,672,35,,672,percent of total billed charges,Implant Device,768,40,,768,percent of total billed charges,Implant Device,672,70,,672,percent of total billed charges,All Other,652.8,34,,652.8,percent of total billed charges,Implant Device,652.8,34,,652.8,percent of total billed charges,Implant Device,672,35,,672,percent of total billed charges,Implant Device,672,35,,672,percent of total billed charges,Implant Device,672,35,,672,percent of total billed charges,Implant Device,672,35,,672,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1420.8,
BIOMET 431182 HIP SPACER HEAD MOLD 52MM,C1776,HCPCS,,79008551,CDM,278,RC,,,both,,,5250,3885.01,,,3885.01,Other,150% of Medicare + 9.63% HCRA Surcharge,2362.5,45,,2362.5,percent of total billed charges,Critical Access Hospital RCC factor,1785,34,,1785,percent of total billed charges,Implant Device,1785,34,,1785,percent of total billed charges,Implant Device,1785,34,,1785,percent of total billed charges,Implant Device,1785,34,,1785,percent of total billed charges,Implant Device,1785,34,,1785,percent of total billed charges,Implant Device,2598.75,,,2598.75,Other,110% of Medicare,1837.5,35,,1837.5,percent of total billed charges,Implant Device,1785,34,"Charges > $500, x 34%",1785,percent of total billed charges,Implant Device,1837.5,35,,1837.5,percent of total billed charges,Implant Device,1837.5,35,,1837.5,percent of total billed charges,Implant Device,1837.5,35,,1837.5,percent of total billed charges,Implant Device,1837.5,35,,1837.5,percent of total billed charges,Implant Device,1837.5,35,,1837.5,percent of total billed charges,Implant Device,2100,40,,2100,percent of total billed charges,Implant Device,1837.5,70,,1837.5,percent of total billed charges,All Other,1785,34,,1785,percent of total billed charges,Implant Device,1785,34,,1785,percent of total billed charges,Implant Device,1837.5,35,,1837.5,percent of total billed charges,Implant Device,1837.5,35,,1837.5,percent of total billed charges,Implant Device,1837.5,35,,1837.5,percent of total billed charges,Implant Device,1837.5,35,,1837.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1785,34,"If Charge > 2,000, then 34 percent",1785,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3885.01,
DEPUY 02.221.512S LOCKING SCREW 5.0X12MM,C1713,HCPCS,,79008552,CDM,278,RC,,,both,,,564,417.36,,,417.36,Other,150% of Medicare + 9.63% HCRA Surcharge,253.8,45,,253.8,percent of total billed charges,Critical Access Hospital RCC factor,191.76,34,,191.76,percent of total billed charges,Implant Device,191.76,34,,191.76,percent of total billed charges,Implant Device,191.76,34,,191.76,percent of total billed charges,Implant Device,191.76,34,,191.76,percent of total billed charges,Implant Device,191.76,34,,191.76,percent of total billed charges,Implant Device,279.18,,,279.18,Other,110% of Medicare,197.4,35,,197.4,percent of total billed charges,Implant Device,191.76,34,"Charges > $500, x 34%",191.76,percent of total billed charges,Implant Device,197.4,35,,197.4,percent of total billed charges,Implant Device,197.4,35,,197.4,percent of total billed charges,Implant Device,197.4,35,,197.4,percent of total billed charges,Implant Device,197.4,35,,197.4,percent of total billed charges,Implant Device,197.4,35,,197.4,percent of total billed charges,Implant Device,225.6,40,,225.6,percent of total billed charges,Implant Device,197.4,70,,197.4,percent of total billed charges,All Other,191.76,34,,191.76,percent of total billed charges,Implant Device,191.76,34,,191.76,percent of total billed charges,Implant Device,197.4,35,,197.4,percent of total billed charges,Implant Device,197.4,35,,197.4,percent of total billed charges,Implant Device,197.4,35,,197.4,percent of total billed charges,Implant Device,197.4,35,,197.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,417.36,
STRYKER 5573-C-3602 GLENOSPHERE 36MM,C1776,HCPCS,,79008553,CDM,278,RC,,,both,,,4125,3052.51,,,3052.51,Other,150% of Medicare + 9.63% HCRA Surcharge,1856.25,45,,1856.25,percent of total billed charges,Critical Access Hospital RCC factor,1402.5,34,,1402.5,percent of total billed charges,Implant Device,1402.5,34,,1402.5,percent of total billed charges,Implant Device,1402.5,34,,1402.5,percent of total billed charges,Implant Device,1402.5,34,,1402.5,percent of total billed charges,Implant Device,1402.5,34,,1402.5,percent of total billed charges,Implant Device,2041.88,,,2041.88,Other,110% of Medicare,1443.75,35,,1443.75,percent of total billed charges,Implant Device,1402.5,34,"Charges > $500, x 34%",1402.5,percent of total billed charges,Implant Device,1443.75,35,,1443.75,percent of total billed charges,Implant Device,1443.75,35,,1443.75,percent of total billed charges,Implant Device,1443.75,35,,1443.75,percent of total billed charges,Implant Device,1443.75,35,,1443.75,percent of total billed charges,Implant Device,1443.75,35,,1443.75,percent of total billed charges,Implant Device,1650,40,,1650,percent of total billed charges,Implant Device,1443.75,70,,1443.75,percent of total billed charges,All Other,1402.5,34,,1402.5,percent of total billed charges,Implant Device,1402.5,34,,1402.5,percent of total billed charges,Implant Device,1443.75,35,,1443.75,percent of total billed charges,Implant Device,1443.75,35,,1443.75,percent of total billed charges,Implant Device,1443.75,35,,1443.75,percent of total billed charges,Implant Device,1443.75,35,,1443.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1402.5,34,"If Charge > 2,000, then 34 percent",1402.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3052.51,
STRYKER 5572-4516 PERI SCREW 4.5X16MM,C1713,HCPCS,,79008554,CDM,278,RC,,,both,,,600,444,,,444,Other,150% of Medicare + 9.63% HCRA Surcharge,270,45,,270,percent of total billed charges,Critical Access Hospital RCC factor,204,34,,204,percent of total billed charges,Implant Device,204,34,,204,percent of total billed charges,Implant Device,204,34,,204,percent of total billed charges,Implant Device,204,34,,204,percent of total billed charges,Implant Device,204,34,,204,percent of total billed charges,Implant Device,297,,,297,Other,110% of Medicare,210,35,,210,percent of total billed charges,Implant Device,204,34,"Charges > $500, x 34%",204,percent of total billed charges,Implant Device,210,35,,210,percent of total billed charges,Implant Device,210,35,,210,percent of total billed charges,Implant Device,210,35,,210,percent of total billed charges,Implant Device,210,35,,210,percent of total billed charges,Implant Device,210,35,,210,percent of total billed charges,Implant Device,240,40,,240,percent of total billed charges,Implant Device,210,70,,210,percent of total billed charges,All Other,204,34,,204,percent of total billed charges,Implant Device,204,34,,204,percent of total billed charges,Implant Device,210,35,,210,percent of total billed charges,Implant Device,210,35,,210,percent of total billed charges,Implant Device,210,35,,210,percent of total billed charges,Implant Device,210,35,,210,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,444,
STRYKER 5569-P-2010 HUM STEM SZ10 123MM,C1776,HCPCS,,79008555,CDM,278,RC,,,both,,,10500,7770.03,,,7770.03,Other,150% of Medicare + 9.63% HCRA Surcharge,4725,45,,4725,percent of total billed charges,Critical Access Hospital RCC factor,3570,34,,3570,percent of total billed charges,Implant Device,3570,34,,3570,percent of total billed charges,Implant Device,3570,34,,3570,percent of total billed charges,Implant Device,3570,34,,3570,percent of total billed charges,Implant Device,3570,34,,3570,percent of total billed charges,Implant Device,5197.5,,,5197.5,Other,110% of Medicare,3675,35,,3675,percent of total billed charges,Implant Device,3570,34,"Charges > $500, x 34%",3570,percent of total billed charges,Implant Device,3675,35,,3675,percent of total billed charges,Implant Device,3675,35,,3675,percent of total billed charges,Implant Device,3675,35,,3675,percent of total billed charges,Implant Device,3675,35,,3675,percent of total billed charges,Implant Device,3675,35,,3675,percent of total billed charges,Implant Device,4200,40,,4200,percent of total billed charges,Implant Device,3675,70,,3675,percent of total billed charges,All Other,3570,34,,3570,percent of total billed charges,Implant Device,3570,34,,3570,percent of total billed charges,Implant Device,3675,35,,3675,percent of total billed charges,Implant Device,3675,35,,3675,percent of total billed charges,Implant Device,3675,35,,3675,percent of total billed charges,Implant Device,3675,35,,3675,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3570,34,"If Charge > 2,000, then 34 percent",3570,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,7770.03,
STRYKER 5573-6528 CTR SCREW 6.5X28MM,C1713,HCPCS,,79008556,CDM,278,RC,,,both,,,150,111,,,111,Other,150% of Medicare + 9.63% HCRA Surcharge,67.5,45,,67.5,percent of total billed charges,Critical Access Hospital RCC factor,51,34,,51,percent of total billed charges,Implant Device,51,34,,51,percent of total billed charges,Implant Device,51,34,,51,percent of total billed charges,Implant Device,51,34,,51,percent of total billed charges,Implant Device,51,34,,51,percent of total billed charges,Implant Device,74.25,,,74.25,Other,110% of Medicare,52.5,35,,52.5,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,52.5,35,,52.5,percent of total billed charges,Implant Device,52.5,35,,52.5,percent of total billed charges,Implant Device,52.5,35,,52.5,percent of total billed charges,Implant Device,52.5,35,,52.5,percent of total billed charges,Implant Device,52.5,35,,52.5,percent of total billed charges,Implant Device,60,40,,60,percent of total billed charges,Implant Device,52.5,70,,52.5,percent of total billed charges,All Other,51,34,,51,percent of total billed charges,Implant Device,51,34,,51,percent of total billed charges,Implant Device,52.5,35,,52.5,percent of total billed charges,Implant Device,52.5,35,,52.5,percent of total billed charges,Implant Device,52.5,35,,52.5,percent of total billed charges,Implant Device,52.5,35,,52.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,111,
DEPUY 204.810 CORTEX SCREW 3.5X10MM,C1713,HCPCS,,79008557,CDM,278,RC,,,both,,,82,60.68,,,60.68,Other,150% of Medicare + 9.63% HCRA Surcharge,36.9,45,,36.9,percent of total billed charges,Critical Access Hospital RCC factor,27.88,34,,27.88,percent of total billed charges,Implant Device,27.88,34,,27.88,percent of total billed charges,Implant Device,27.88,34,,27.88,percent of total billed charges,Implant Device,27.88,34,,27.88,percent of total billed charges,Implant Device,27.88,34,,27.88,percent of total billed charges,Implant Device,40.59,,,40.59,Other,110% of Medicare,28.7,35,,28.7,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,28.7,35,,28.7,percent of total billed charges,Implant Device,28.7,35,,28.7,percent of total billed charges,Implant Device,28.7,35,,28.7,percent of total billed charges,Implant Device,28.7,35,,28.7,percent of total billed charges,Implant Device,28.7,35,,28.7,percent of total billed charges,Implant Device,32.8,40,,32.8,percent of total billed charges,Implant Device,28.7,70,,28.7,percent of total billed charges,All Other,27.88,34,,27.88,percent of total billed charges,Implant Device,27.88,34,,27.88,percent of total billed charges,Implant Device,28.7,35,,28.7,percent of total billed charges,Implant Device,28.7,35,,28.7,percent of total billed charges,Implant Device,28.7,35,,28.7,percent of total billed charges,Implant Device,28.7,35,,28.7,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,60.68,
BIOMET 11-301303 CONE PROX BODY 60MM,C1776,HCPCS,,79008558,CDM,278,RC,,,both,,,24006,17764.5,,,17764.5,Other,150% of Medicare + 9.63% HCRA Surcharge,10802.7,45,,10802.7,percent of total billed charges,Critical Access Hospital RCC factor,8162.04,34,,8162.04,percent of total billed charges,Implant Device,8162.04,34,,8162.04,percent of total billed charges,Implant Device,8162.04,34,,8162.04,percent of total billed charges,Implant Device,8162.04,34,,8162.04,percent of total billed charges,Implant Device,8162.04,34,,8162.04,percent of total billed charges,Implant Device,11882.97,,,11882.97,Other,110% of Medicare,8402.1,35,,8402.1,percent of total billed charges,Implant Device,8162.04,34,"Charges > $500, x 34%",8162.04,percent of total billed charges,Implant Device,8402.1,35,,8402.1,percent of total billed charges,Implant Device,8402.1,35,,8402.1,percent of total billed charges,Implant Device,8402.1,35,,8402.1,percent of total billed charges,Implant Device,8402.1,35,,8402.1,percent of total billed charges,Implant Device,8402.1,35,,8402.1,percent of total billed charges,Implant Device,9602.4,40,,9602.4,percent of total billed charges,Implant Device,8402.1,70,,8402.1,percent of total billed charges,All Other,8162.04,34,,8162.04,percent of total billed charges,Implant Device,8162.04,34,,8162.04,percent of total billed charges,Implant Device,8402.1,35,,8402.1,percent of total billed charges,Implant Device,8402.1,35,,8402.1,percent of total billed charges,Implant Device,8402.1,35,,8402.1,percent of total billed charges,Implant Device,8402.1,35,,8402.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,8162.04,34,"If Charge > 2,000, then 34 percent",8162.04,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,17764.5,
ARTHREX AR-1588BTB-J TIGHTROPE W/SUTURE,C1713,HCPCS,,79008563,CDM,278,RC,,,both,,,1335,987.9,,,987.9,Other,150% of Medicare + 9.63% HCRA Surcharge,600.75,45,,600.75,percent of total billed charges,Critical Access Hospital RCC factor,453.9,34,,453.9,percent of total billed charges,Implant Device,453.9,34,,453.9,percent of total billed charges,Implant Device,453.9,34,,453.9,percent of total billed charges,Implant Device,453.9,34,,453.9,percent of total billed charges,Implant Device,453.9,34,,453.9,percent of total billed charges,Implant Device,660.83,,,660.83,Other,110% of Medicare,467.25,35,,467.25,percent of total billed charges,Implant Device,453.9,34,"Charges > $500, x 34%",453.9,percent of total billed charges,Implant Device,467.25,35,,467.25,percent of total billed charges,Implant Device,467.25,35,,467.25,percent of total billed charges,Implant Device,467.25,35,,467.25,percent of total billed charges,Implant Device,467.25,35,,467.25,percent of total billed charges,Implant Device,467.25,35,,467.25,percent of total billed charges,Implant Device,534,40,,534,percent of total billed charges,Implant Device,467.25,70,,467.25,percent of total billed charges,All Other,453.9,34,,453.9,percent of total billed charges,Implant Device,453.9,34,,453.9,percent of total billed charges,Implant Device,467.25,35,,467.25,percent of total billed charges,Implant Device,467.25,35,,467.25,percent of total billed charges,Implant Device,467.25,35,,467.25,percent of total billed charges,Implant Device,467.25,35,,467.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,987.9,
ARTHREX AR-1588TB-4 TIGHTROPE BUTTON 14,C1713,HCPCS,,79008564,CDM,278,RC,,,both,,,672,497.28,,,497.28,Other,150% of Medicare + 9.63% HCRA Surcharge,302.4,45,,302.4,percent of total billed charges,Critical Access Hospital RCC factor,228.48,34,,228.48,percent of total billed charges,Implant Device,228.48,34,,228.48,percent of total billed charges,Implant Device,228.48,34,,228.48,percent of total billed charges,Implant Device,228.48,34,,228.48,percent of total billed charges,Implant Device,228.48,34,,228.48,percent of total billed charges,Implant Device,332.64,,,332.64,Other,110% of Medicare,235.2,35,,235.2,percent of total billed charges,Implant Device,228.48,34,"Charges > $500, x 34%",228.48,percent of total billed charges,Implant Device,235.2,35,,235.2,percent of total billed charges,Implant Device,235.2,35,,235.2,percent of total billed charges,Implant Device,235.2,35,,235.2,percent of total billed charges,Implant Device,235.2,35,,235.2,percent of total billed charges,Implant Device,235.2,35,,235.2,percent of total billed charges,Implant Device,268.8,40,,268.8,percent of total billed charges,Implant Device,235.2,70,,235.2,percent of total billed charges,All Other,228.48,34,,228.48,percent of total billed charges,Implant Device,228.48,34,,228.48,percent of total billed charges,Implant Device,235.2,35,,235.2,percent of total billed charges,Implant Device,235.2,35,,235.2,percent of total billed charges,Implant Device,235.2,35,,235.2,percent of total billed charges,Implant Device,235.2,35,,235.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,497.28,
ARTHREX AR-1588TB-5 TIGHTROPE IMP 8X12,C1713,HCPCS,,79008565,CDM,278,RC,,,both,,,672,497.28,,,497.28,Other,150% of Medicare + 9.63% HCRA Surcharge,302.4,45,,302.4,percent of total billed charges,Critical Access Hospital RCC factor,228.48,34,,228.48,percent of total billed charges,Implant Device,228.48,34,,228.48,percent of total billed charges,Implant Device,228.48,34,,228.48,percent of total billed charges,Implant Device,228.48,34,,228.48,percent of total billed charges,Implant Device,228.48,34,,228.48,percent of total billed charges,Implant Device,332.64,,,332.64,Other,110% of Medicare,235.2,35,,235.2,percent of total billed charges,Implant Device,228.48,34,"Charges > $500, x 34%",228.48,percent of total billed charges,Implant Device,235.2,35,,235.2,percent of total billed charges,Implant Device,235.2,35,,235.2,percent of total billed charges,Implant Device,235.2,35,,235.2,percent of total billed charges,Implant Device,235.2,35,,235.2,percent of total billed charges,Implant Device,235.2,35,,235.2,percent of total billed charges,Implant Device,268.8,40,,268.8,percent of total billed charges,Implant Device,235.2,70,,235.2,percent of total billed charges,All Other,228.48,34,,228.48,percent of total billed charges,Implant Device,228.48,34,,228.48,percent of total billed charges,Implant Device,235.2,35,,235.2,percent of total billed charges,Implant Device,235.2,35,,235.2,percent of total billed charges,Implant Device,235.2,35,,235.2,percent of total billed charges,Implant Device,235.2,35,,235.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,497.28,
EXACTECH 05-090-01-1407 FUSION 12X14.7MM,C1713,HCPCS,,79008566,CDM,278,RC,,,both,,,11745,8691.33,,,8691.33,Other,150% of Medicare + 9.63% HCRA Surcharge,5285.25,45,,5285.25,percent of total billed charges,Critical Access Hospital RCC factor,3993.3,34,,3993.3,percent of total billed charges,Implant Device,3993.3,34,,3993.3,percent of total billed charges,Implant Device,3993.3,34,,3993.3,percent of total billed charges,Implant Device,3993.3,34,,3993.3,percent of total billed charges,Implant Device,3993.3,34,,3993.3,percent of total billed charges,Implant Device,5813.78,,,5813.78,Other,110% of Medicare,4110.75,35,,4110.75,percent of total billed charges,Implant Device,3993.3,34,"Charges > $500, x 34%",3993.3,percent of total billed charges,Implant Device,4110.75,35,,4110.75,percent of total billed charges,Implant Device,4110.75,35,,4110.75,percent of total billed charges,Implant Device,4110.75,35,,4110.75,percent of total billed charges,Implant Device,4110.75,35,,4110.75,percent of total billed charges,Implant Device,4110.75,35,,4110.75,percent of total billed charges,Implant Device,4698,40,,4698,percent of total billed charges,Implant Device,4110.75,70,,4110.75,percent of total billed charges,All Other,3993.3,34,,3993.3,percent of total billed charges,Implant Device,3993.3,34,,3993.3,percent of total billed charges,Implant Device,4110.75,35,,4110.75,percent of total billed charges,Implant Device,4110.75,35,,4110.75,percent of total billed charges,Implant Device,4110.75,35,,4110.75,percent of total billed charges,Implant Device,4110.75,35,,4110.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3993.3,34,"If Charge > 2,000, then 34 percent",3993.3,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,8691.33,
GORE VBJR070502A 7MMX5CM COVERED STENT,C1874,HCPCS,,79008567,CDM,278,RC,,,both,,,10065,7448.13,,,7448.13,Other,150% of Medicare + 9.63% HCRA Surcharge,4529.25,45,,4529.25,percent of total billed charges,Critical Access Hospital RCC factor,3422.1,34,,3422.1,percent of total billed charges,Implant Device,3422.1,34,,3422.1,percent of total billed charges,Implant Device,3422.1,34,,3422.1,percent of total billed charges,Implant Device,3422.1,34,,3422.1,percent of total billed charges,Implant Device,3422.1,34,,3422.1,percent of total billed charges,Implant Device,4982.18,,,4982.18,Other,110% of Medicare,3522.75,35,,3522.75,percent of total billed charges,Implant Device,3422.1,34,"Charges > $500, x 34%",3422.1,percent of total billed charges,Implant Device,3522.75,35,,3522.75,percent of total billed charges,Implant Device,3522.75,35,,3522.75,percent of total billed charges,Implant Device,3522.75,35,,3522.75,percent of total billed charges,Implant Device,3522.75,35,,3522.75,percent of total billed charges,Implant Device,3522.75,35,,3522.75,percent of total billed charges,Implant Device,4026,40,,4026,percent of total billed charges,Implant Device,3522.75,70,,3522.75,percent of total billed charges,All Other,3422.1,34,,3422.1,percent of total billed charges,Implant Device,3422.1,34,,3422.1,percent of total billed charges,Implant Device,3522.75,35,,3522.75,percent of total billed charges,Implant Device,3522.75,35,,3522.75,percent of total billed charges,Implant Device,3522.75,35,,3522.75,percent of total billed charges,Implant Device,3522.75,35,,3522.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3422.1,34,"If Charge > 2,000, then 34 percent",3422.1,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,7448.13,
BIOMET 11-300915 DISTAL STEM 15X190MM,C1776,HCPCS,,79008571,CDM,278,RC,,,both,,,11059,8183.69,,,8183.69,Other,150% of Medicare + 9.63% HCRA Surcharge,4976.55,45,,4976.55,percent of total billed charges,Critical Access Hospital RCC factor,3760.06,34,,3760.06,percent of total billed charges,Implant Device,3760.06,34,,3760.06,percent of total billed charges,Implant Device,3760.06,34,,3760.06,percent of total billed charges,Implant Device,3760.06,34,,3760.06,percent of total billed charges,Implant Device,3760.06,34,,3760.06,percent of total billed charges,Implant Device,5474.21,,,5474.21,Other,110% of Medicare,3870.65,35,,3870.65,percent of total billed charges,Implant Device,3760.06,34,"Charges > $500, x 34%",3760.06,percent of total billed charges,Implant Device,3870.65,35,,3870.65,percent of total billed charges,Implant Device,3870.65,35,,3870.65,percent of total billed charges,Implant Device,3870.65,35,,3870.65,percent of total billed charges,Implant Device,3870.65,35,,3870.65,percent of total billed charges,Implant Device,3870.65,35,,3870.65,percent of total billed charges,Implant Device,4423.6,40,,4423.6,percent of total billed charges,Implant Device,3870.65,70,,3870.65,percent of total billed charges,All Other,3760.06,34,,3760.06,percent of total billed charges,Implant Device,3760.06,34,,3760.06,percent of total billed charges,Implant Device,3870.65,35,,3870.65,percent of total billed charges,Implant Device,3870.65,35,,3870.65,percent of total billed charges,Implant Device,3870.65,35,,3870.65,percent of total billed charges,Implant Device,3870.65,35,,3870.65,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3760.06,34,"If Charge > 2,000, then 34 percent",3760.06,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,8183.69,
DEPUY 243.33 2.0MML PLATES OBLIQUE LEFT,C1713,HCPCS,,79008572,CDM,278,RC,,,both,,,214,158.36,,,158.36,Other,150% of Medicare + 9.63% HCRA Surcharge,96.3,45,,96.3,percent of total billed charges,Critical Access Hospital RCC factor,72.76,34,,72.76,percent of total billed charges,Implant Device,72.76,34,,72.76,percent of total billed charges,Implant Device,72.76,34,,72.76,percent of total billed charges,Implant Device,72.76,34,,72.76,percent of total billed charges,Implant Device,72.76,34,,72.76,percent of total billed charges,Implant Device,105.93,,,105.93,Other,110% of Medicare,74.9,35,,74.9,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,74.9,35,,74.9,percent of total billed charges,Implant Device,74.9,35,,74.9,percent of total billed charges,Implant Device,74.9,35,,74.9,percent of total billed charges,Implant Device,74.9,35,,74.9,percent of total billed charges,Implant Device,74.9,35,,74.9,percent of total billed charges,Implant Device,85.6,40,,85.6,percent of total billed charges,Implant Device,74.9,70,,74.9,percent of total billed charges,All Other,72.76,34,,72.76,percent of total billed charges,Implant Device,72.76,34,,72.76,percent of total billed charges,Implant Device,74.9,35,,74.9,percent of total billed charges,Implant Device,74.9,35,,74.9,percent of total billed charges,Implant Device,74.9,35,,74.9,percent of total billed charges,Implant Device,74.9,35,,74.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,158.36,
LOCKING SCREW 3.5X34MM,C1713,HCPCS,,79008574,CDM,278,RC,,,both,,,488,361.12,,,361.12,Other,150% of Medicare + 9.63% HCRA Surcharge,219.6,45,,219.6,percent of total billed charges,Critical Access Hospital RCC factor,165.92,34,,165.92,percent of total billed charges,Implant Device,165.92,34,,165.92,percent of total billed charges,Implant Device,165.92,34,,165.92,percent of total billed charges,Implant Device,165.92,34,,165.92,percent of total billed charges,Implant Device,165.92,34,,165.92,percent of total billed charges,Implant Device,241.56,,,241.56,Other,110% of Medicare,170.8,35,,170.8,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,170.8,35,,170.8,percent of total billed charges,Implant Device,170.8,35,,170.8,percent of total billed charges,Implant Device,170.8,35,,170.8,percent of total billed charges,Implant Device,170.8,35,,170.8,percent of total billed charges,Implant Device,170.8,35,,170.8,percent of total billed charges,Implant Device,195.2,40,,195.2,percent of total billed charges,Implant Device,170.8,70,,170.8,percent of total billed charges,All Other,165.92,34,,165.92,percent of total billed charges,Implant Device,165.92,34,,165.92,percent of total billed charges,Implant Device,170.8,35,,170.8,percent of total billed charges,Implant Device,170.8,35,,170.8,percent of total billed charges,Implant Device,170.8,35,,170.8,percent of total billed charges,Implant Device,170.8,35,,170.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,361.12,
LOCKING SCREW 3.5X28MM,C1713,HCPCS,,79008575,CDM,278,RC,,,both,,,458,338.92,,,338.92,Other,150% of Medicare + 9.63% HCRA Surcharge,206.1,45,,206.1,percent of total billed charges,Critical Access Hospital RCC factor,155.72,34,,155.72,percent of total billed charges,Implant Device,155.72,34,,155.72,percent of total billed charges,Implant Device,155.72,34,,155.72,percent of total billed charges,Implant Device,155.72,34,,155.72,percent of total billed charges,Implant Device,155.72,34,,155.72,percent of total billed charges,Implant Device,226.71,,,226.71,Other,110% of Medicare,160.3,35,,160.3,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,160.3,35,,160.3,percent of total billed charges,Implant Device,160.3,35,,160.3,percent of total billed charges,Implant Device,160.3,35,,160.3,percent of total billed charges,Implant Device,160.3,35,,160.3,percent of total billed charges,Implant Device,160.3,35,,160.3,percent of total billed charges,Implant Device,183.2,40,,183.2,percent of total billed charges,Implant Device,160.3,70,,160.3,percent of total billed charges,All Other,155.72,34,,155.72,percent of total billed charges,Implant Device,155.72,34,,155.72,percent of total billed charges,Implant Device,160.3,35,,160.3,percent of total billed charges,Implant Device,160.3,35,,160.3,percent of total billed charges,Implant Device,160.3,35,,160.3,percent of total billed charges,Implant Device,160.3,35,,160.3,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,338.92,
LOCKING SCREW 3.5X30MM,C1713,HCPCS,,79008576,CDM,278,RC,,,both,,,458,338.92,,,338.92,Other,150% of Medicare + 9.63% HCRA Surcharge,206.1,45,,206.1,percent of total billed charges,Critical Access Hospital RCC factor,155.72,34,,155.72,percent of total billed charges,Implant Device,155.72,34,,155.72,percent of total billed charges,Implant Device,155.72,34,,155.72,percent of total billed charges,Implant Device,155.72,34,,155.72,percent of total billed charges,Implant Device,155.72,34,,155.72,percent of total billed charges,Implant Device,226.71,,,226.71,Other,110% of Medicare,160.3,35,,160.3,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,160.3,35,,160.3,percent of total billed charges,Implant Device,160.3,35,,160.3,percent of total billed charges,Implant Device,160.3,35,,160.3,percent of total billed charges,Implant Device,160.3,35,,160.3,percent of total billed charges,Implant Device,160.3,35,,160.3,percent of total billed charges,Implant Device,183.2,40,,183.2,percent of total billed charges,Implant Device,160.3,70,,160.3,percent of total billed charges,All Other,155.72,34,,155.72,percent of total billed charges,Implant Device,155.72,34,,155.72,percent of total billed charges,Implant Device,160.3,35,,160.3,percent of total billed charges,Implant Device,160.3,35,,160.3,percent of total billed charges,Implant Device,160.3,35,,160.3,percent of total billed charges,Implant Device,160.3,35,,160.3,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,338.92,
LOCKING SCREW 3.5X32MM,C1713,HCPCS,,79008577,CDM,278,RC,,,both,,,488,361.12,,,361.12,Other,150% of Medicare + 9.63% HCRA Surcharge,219.6,45,,219.6,percent of total billed charges,Critical Access Hospital RCC factor,165.92,34,,165.92,percent of total billed charges,Implant Device,165.92,34,,165.92,percent of total billed charges,Implant Device,165.92,34,,165.92,percent of total billed charges,Implant Device,165.92,34,,165.92,percent of total billed charges,Implant Device,165.92,34,,165.92,percent of total billed charges,Implant Device,241.56,,,241.56,Other,110% of Medicare,170.8,35,,170.8,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,170.8,35,,170.8,percent of total billed charges,Implant Device,170.8,35,,170.8,percent of total billed charges,Implant Device,170.8,35,,170.8,percent of total billed charges,Implant Device,170.8,35,,170.8,percent of total billed charges,Implant Device,170.8,35,,170.8,percent of total billed charges,Implant Device,195.2,40,,195.2,percent of total billed charges,Implant Device,170.8,70,,170.8,percent of total billed charges,All Other,165.92,34,,165.92,percent of total billed charges,Implant Device,165.92,34,,165.92,percent of total billed charges,Implant Device,170.8,35,,170.8,percent of total billed charges,Implant Device,170.8,35,,170.8,percent of total billed charges,Implant Device,170.8,35,,170.8,percent of total billed charges,Implant Device,170.8,35,,170.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,361.12,
LOCKING SCREW 3.5X34MM,C1713,HCPCS,,79008578,CDM,278,RC,,,both,,,327,241.98,,,241.98,Other,150% of Medicare + 9.63% HCRA Surcharge,147.15,45,,147.15,percent of total billed charges,Critical Access Hospital RCC factor,111.18,34,,111.18,percent of total billed charges,Implant Device,111.18,34,,111.18,percent of total billed charges,Implant Device,111.18,34,,111.18,percent of total billed charges,Implant Device,111.18,34,,111.18,percent of total billed charges,Implant Device,111.18,34,,111.18,percent of total billed charges,Implant Device,161.87,,,161.87,Other,110% of Medicare,114.45,35,,114.45,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,114.45,35,,114.45,percent of total billed charges,Implant Device,114.45,35,,114.45,percent of total billed charges,Implant Device,114.45,35,,114.45,percent of total billed charges,Implant Device,114.45,35,,114.45,percent of total billed charges,Implant Device,114.45,35,,114.45,percent of total billed charges,Implant Device,130.8,40,,130.8,percent of total billed charges,Implant Device,114.45,70,,114.45,percent of total billed charges,All Other,111.18,34,,111.18,percent of total billed charges,Implant Device,111.18,34,,111.18,percent of total billed charges,Implant Device,114.45,35,,114.45,percent of total billed charges,Implant Device,114.45,35,,114.45,percent of total billed charges,Implant Device,114.45,35,,114.45,percent of total billed charges,Implant Device,114.45,35,,114.45,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,241.98,
STRYKER F&A 955-3002 BREAK AWAY SCREW TI,C1713,HCPCS,,79008579,CDM,278,RC,,,both,,,711,526.14,,,526.14,Other,150% of Medicare + 9.63% HCRA Surcharge,319.95,45,,319.95,percent of total billed charges,Critical Access Hospital RCC factor,241.74,34,,241.74,percent of total billed charges,Implant Device,241.74,34,,241.74,percent of total billed charges,Implant Device,241.74,34,,241.74,percent of total billed charges,Implant Device,241.74,34,,241.74,percent of total billed charges,Implant Device,241.74,34,,241.74,percent of total billed charges,Implant Device,351.95,,,351.95,Other,110% of Medicare,248.85,35,,248.85,percent of total billed charges,Implant Device,241.74,34,"Charges > $500, x 34%",241.74,percent of total billed charges,Implant Device,248.85,35,,248.85,percent of total billed charges,Implant Device,248.85,35,,248.85,percent of total billed charges,Implant Device,248.85,35,,248.85,percent of total billed charges,Implant Device,248.85,35,,248.85,percent of total billed charges,Implant Device,248.85,35,,248.85,percent of total billed charges,Implant Device,284.4,40,,284.4,percent of total billed charges,Implant Device,248.85,70,,248.85,percent of total billed charges,All Other,241.74,34,,241.74,percent of total billed charges,Implant Device,241.74,34,,241.74,percent of total billed charges,Implant Device,248.85,35,,248.85,percent of total billed charges,Implant Device,248.85,35,,248.85,percent of total billed charges,Implant Device,248.85,35,,248.85,percent of total billed charges,Implant Device,248.85,35,,248.85,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,526.14,
ZIMMER 00-2357-102-18 DIST LAT PLATE 18H,C1713,HCPCS,,79008580,CDM,278,RC,,,both,,,5095,3770.31,,,3770.31,Other,150% of Medicare + 9.63% HCRA Surcharge,2292.75,45,,2292.75,percent of total billed charges,Critical Access Hospital RCC factor,1732.3,34,,1732.3,percent of total billed charges,Implant Device,1732.3,34,,1732.3,percent of total billed charges,Implant Device,1732.3,34,,1732.3,percent of total billed charges,Implant Device,1732.3,34,,1732.3,percent of total billed charges,Implant Device,1732.3,34,,1732.3,percent of total billed charges,Implant Device,2522.03,,,2522.03,Other,110% of Medicare,1783.25,35,,1783.25,percent of total billed charges,Implant Device,1732.3,34,"Charges > $500, x 34%",1732.3,percent of total billed charges,Implant Device,1783.25,35,,1783.25,percent of total billed charges,Implant Device,1783.25,35,,1783.25,percent of total billed charges,Implant Device,1783.25,35,,1783.25,percent of total billed charges,Implant Device,1783.25,35,,1783.25,percent of total billed charges,Implant Device,1783.25,35,,1783.25,percent of total billed charges,Implant Device,2038,40,,2038,percent of total billed charges,Implant Device,1783.25,70,,1783.25,percent of total billed charges,All Other,1732.3,34,,1732.3,percent of total billed charges,Implant Device,1732.3,34,,1732.3,percent of total billed charges,Implant Device,1783.25,35,,1783.25,percent of total billed charges,Implant Device,1783.25,35,,1783.25,percent of total billed charges,Implant Device,1783.25,35,,1783.25,percent of total billed charges,Implant Device,1783.25,35,,1783.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1732.3,34,"If Charge > 2,000, then 34 percent",1732.3,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3770.31,
ZIMMER 00-2347-023-46 PERI SCREW 4.5X46,C1713,HCPCS,,79008581,CDM,278,RC,,,both,,,109,80.66,,,80.66,Other,150% of Medicare + 9.63% HCRA Surcharge,49.05,45,,49.05,percent of total billed charges,Critical Access Hospital RCC factor,37.06,34,,37.06,percent of total billed charges,Implant Device,37.06,34,,37.06,percent of total billed charges,Implant Device,37.06,34,,37.06,percent of total billed charges,Implant Device,37.06,34,,37.06,percent of total billed charges,Implant Device,37.06,34,,37.06,percent of total billed charges,Implant Device,53.96,,,53.96,Other,110% of Medicare,38.15,35,,38.15,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,38.15,35,,38.15,percent of total billed charges,Implant Device,38.15,35,,38.15,percent of total billed charges,Implant Device,38.15,35,,38.15,percent of total billed charges,Implant Device,38.15,35,,38.15,percent of total billed charges,Implant Device,38.15,35,,38.15,percent of total billed charges,Implant Device,43.6,40,,43.6,percent of total billed charges,Implant Device,38.15,70,,38.15,percent of total billed charges,All Other,37.06,34,,37.06,percent of total billed charges,Implant Device,37.06,34,,37.06,percent of total billed charges,Implant Device,38.15,35,,38.15,percent of total billed charges,Implant Device,38.15,35,,38.15,percent of total billed charges,Implant Device,38.15,35,,38.15,percent of total billed charges,Implant Device,38.15,35,,38.15,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,80.66,
ZIMMER 00-2359-024-45 LOCK SCREW 4.5X24,C1713,HCPCS,,79008582,CDM,278,RC,,,both,,,445,329.3,,,329.3,Other,150% of Medicare + 9.63% HCRA Surcharge,200.25,45,,200.25,percent of total billed charges,Critical Access Hospital RCC factor,151.3,34,,151.3,percent of total billed charges,Implant Device,151.3,34,,151.3,percent of total billed charges,Implant Device,151.3,34,,151.3,percent of total billed charges,Implant Device,151.3,34,,151.3,percent of total billed charges,Implant Device,151.3,34,,151.3,percent of total billed charges,Implant Device,220.28,,,220.28,Other,110% of Medicare,155.75,35,,155.75,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,155.75,35,,155.75,percent of total billed charges,Implant Device,155.75,35,,155.75,percent of total billed charges,Implant Device,155.75,35,,155.75,percent of total billed charges,Implant Device,155.75,35,,155.75,percent of total billed charges,Implant Device,155.75,35,,155.75,percent of total billed charges,Implant Device,178,40,,178,percent of total billed charges,Implant Device,155.75,70,,155.75,percent of total billed charges,All Other,151.3,34,,151.3,percent of total billed charges,Implant Device,151.3,34,,151.3,percent of total billed charges,Implant Device,155.75,35,,155.75,percent of total billed charges,Implant Device,155.75,35,,155.75,percent of total billed charges,Implant Device,155.75,35,,155.75,percent of total billed charges,Implant Device,155.75,35,,155.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,329.3,
ZIMMER 00-2359-012-45 LOCK SCREW 4.5X12,C1713,HCPCS,,79008583,CDM,278,RC,,,both,,,445,329.3,,,329.3,Other,150% of Medicare + 9.63% HCRA Surcharge,200.25,45,,200.25,percent of total billed charges,Critical Access Hospital RCC factor,151.3,34,,151.3,percent of total billed charges,Implant Device,151.3,34,,151.3,percent of total billed charges,Implant Device,151.3,34,,151.3,percent of total billed charges,Implant Device,151.3,34,,151.3,percent of total billed charges,Implant Device,151.3,34,,151.3,percent of total billed charges,Implant Device,220.28,,,220.28,Other,110% of Medicare,155.75,35,,155.75,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,155.75,35,,155.75,percent of total billed charges,Implant Device,155.75,35,,155.75,percent of total billed charges,Implant Device,155.75,35,,155.75,percent of total billed charges,Implant Device,155.75,35,,155.75,percent of total billed charges,Implant Device,155.75,35,,155.75,percent of total billed charges,Implant Device,178,40,,178,percent of total billed charges,Implant Device,155.75,70,,155.75,percent of total billed charges,All Other,151.3,34,,151.3,percent of total billed charges,Implant Device,151.3,34,,151.3,percent of total billed charges,Implant Device,155.75,35,,155.75,percent of total billed charges,Implant Device,155.75,35,,155.75,percent of total billed charges,Implant Device,155.75,35,,155.75,percent of total billed charges,Implant Device,155.75,35,,155.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,329.3,
ZIMMER 00-2347-023-55 PERI SCREW 4.5X55,C1713,HCPCS,,79008584,CDM,278,RC,,,both,,,109,80.66,,,80.66,Other,150% of Medicare + 9.63% HCRA Surcharge,49.05,45,,49.05,percent of total billed charges,Critical Access Hospital RCC factor,37.06,34,,37.06,percent of total billed charges,Implant Device,37.06,34,,37.06,percent of total billed charges,Implant Device,37.06,34,,37.06,percent of total billed charges,Implant Device,37.06,34,,37.06,percent of total billed charges,Implant Device,37.06,34,,37.06,percent of total billed charges,Implant Device,53.96,,,53.96,Other,110% of Medicare,38.15,35,,38.15,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,38.15,35,,38.15,percent of total billed charges,Implant Device,38.15,35,,38.15,percent of total billed charges,Implant Device,38.15,35,,38.15,percent of total billed charges,Implant Device,38.15,35,,38.15,percent of total billed charges,Implant Device,38.15,35,,38.15,percent of total billed charges,Implant Device,43.6,40,,43.6,percent of total billed charges,Implant Device,38.15,70,,38.15,percent of total billed charges,All Other,37.06,34,,37.06,percent of total billed charges,Implant Device,37.06,34,,37.06,percent of total billed charges,Implant Device,38.15,35,,38.15,percent of total billed charges,Implant Device,38.15,35,,38.15,percent of total billed charges,Implant Device,38.15,35,,38.15,percent of total billed charges,Implant Device,38.15,35,,38.15,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,80.66,
MEDTRONIC 7510800 INFUSE BONE GRAFT 8ML,C1713,HCPCS,,79008585,CDM,278,RC,,,both,,,17205,12731.74,,,12731.74,Other,150% of Medicare + 9.63% HCRA Surcharge,7742.25,45,,7742.25,percent of total billed charges,Critical Access Hospital RCC factor,5849.7,34,,5849.7,percent of total billed charges,Implant Device,5849.7,34,,5849.7,percent of total billed charges,Implant Device,5849.7,34,,5849.7,percent of total billed charges,Implant Device,5849.7,34,,5849.7,percent of total billed charges,Implant Device,5849.7,34,,5849.7,percent of total billed charges,Implant Device,8516.48,,,8516.48,Other,110% of Medicare,6021.75,35,,6021.75,percent of total billed charges,Implant Device,5849.7,34,"Charges > $500, x 34%",5849.7,percent of total billed charges,Implant Device,6021.75,35,,6021.75,percent of total billed charges,Implant Device,6021.75,35,,6021.75,percent of total billed charges,Implant Device,6021.75,35,,6021.75,percent of total billed charges,Implant Device,6021.75,35,,6021.75,percent of total billed charges,Implant Device,6021.75,35,,6021.75,percent of total billed charges,Implant Device,6882,40,,6882,percent of total billed charges,Implant Device,6021.75,70,,6021.75,percent of total billed charges,All Other,5849.7,34,,5849.7,percent of total billed charges,Implant Device,5849.7,34,,5849.7,percent of total billed charges,Implant Device,6021.75,35,,6021.75,percent of total billed charges,Implant Device,6021.75,35,,6021.75,percent of total billed charges,Implant Device,6021.75,35,,6021.75,percent of total billed charges,Implant Device,6021.75,35,,6021.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,5849.7,34,"If Charge > 2,000, then 34 percent",5849.7,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,12731.74,
DEPUY 1024-54-308 TIBIAL INS SZ 3 RM/LL,C1776,HCPCS,,79008586,CDM,278,RC,,,both,,,2495,1846.31,,,1846.31,Other,150% of Medicare + 9.63% HCRA Surcharge,1122.75,45,,1122.75,percent of total billed charges,Critical Access Hospital RCC factor,848.3,34,,848.3,percent of total billed charges,Implant Device,848.3,34,,848.3,percent of total billed charges,Implant Device,848.3,34,,848.3,percent of total billed charges,Implant Device,848.3,34,,848.3,percent of total billed charges,Implant Device,848.3,34,,848.3,percent of total billed charges,Implant Device,1235.03,,,1235.03,Other,110% of Medicare,873.25,35,,873.25,percent of total billed charges,Implant Device,848.3,34,"Charges > $500, x 34%",848.3,percent of total billed charges,Implant Device,873.25,35,,873.25,percent of total billed charges,Implant Device,873.25,35,,873.25,percent of total billed charges,Implant Device,873.25,35,,873.25,percent of total billed charges,Implant Device,873.25,35,,873.25,percent of total billed charges,Implant Device,873.25,35,,873.25,percent of total billed charges,Implant Device,998,40,,998,percent of total billed charges,Implant Device,873.25,70,,873.25,percent of total billed charges,All Other,848.3,34,,848.3,percent of total billed charges,Implant Device,848.3,34,,848.3,percent of total billed charges,Implant Device,873.25,35,,873.25,percent of total billed charges,Implant Device,873.25,35,,873.25,percent of total billed charges,Implant Device,873.25,35,,873.25,percent of total billed charges,Implant Device,873.25,35,,873.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,848.3,34,"If Charge > 2,000, then 34 percent",848.3,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1846.31,
MENTOR 350-2501BC BREAST IMPLANT 250CC,C1789,HCPCS,,79008587,CDM,278,RC,,,both,,,2865,2120.11,,,2120.11,Other,150% of Medicare + 9.63% HCRA Surcharge,1289.25,45,,1289.25,percent of total billed charges,Critical Access Hospital RCC factor,974.1,34,,974.1,percent of total billed charges,Implant Device,974.1,34,,974.1,percent of total billed charges,Implant Device,974.1,34,,974.1,percent of total billed charges,Implant Device,974.1,34,,974.1,percent of total billed charges,Implant Device,974.1,34,,974.1,percent of total billed charges,Implant Device,1418.18,,,1418.18,Other,110% of Medicare,1002.75,35,,1002.75,percent of total billed charges,Implant Device,974.1,34,"Charges > $500, x 34%",974.1,percent of total billed charges,Implant Device,1002.75,35,,1002.75,percent of total billed charges,Implant Device,1002.75,35,,1002.75,percent of total billed charges,Implant Device,1002.75,35,,1002.75,percent of total billed charges,Implant Device,1002.75,35,,1002.75,percent of total billed charges,Implant Device,1002.75,35,,1002.75,percent of total billed charges,Implant Device,1146,40,,1146,percent of total billed charges,Implant Device,1002.75,70,,1002.75,percent of total billed charges,All Other,974.1,34,,974.1,percent of total billed charges,Implant Device,974.1,34,,974.1,percent of total billed charges,Implant Device,1002.75,35,,1002.75,percent of total billed charges,Implant Device,1002.75,35,,1002.75,percent of total billed charges,Implant Device,1002.75,35,,1002.75,percent of total billed charges,Implant Device,1002.75,35,,1002.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,974.1,34,"If Charge > 2,000, then 34 percent",974.1,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2120.11,
MENTOR 350-7235MC BREAST IMPLANT 235CC,C1789,HCPCS,,79008588,CDM,278,RC,,,both,,,2790,2064.61,,,2064.61,Other,150% of Medicare + 9.63% HCRA Surcharge,1255.5,45,,1255.5,percent of total billed charges,Critical Access Hospital RCC factor,948.6,34,,948.6,percent of total billed charges,Implant Device,948.6,34,,948.6,percent of total billed charges,Implant Device,948.6,34,,948.6,percent of total billed charges,Implant Device,948.6,34,,948.6,percent of total billed charges,Implant Device,948.6,34,,948.6,percent of total billed charges,Implant Device,1381.05,,,1381.05,Other,110% of Medicare,976.5,35,,976.5,percent of total billed charges,Implant Device,948.6,34,"Charges > $500, x 34%",948.6,percent of total billed charges,Implant Device,976.5,35,,976.5,percent of total billed charges,Implant Device,976.5,35,,976.5,percent of total billed charges,Implant Device,976.5,35,,976.5,percent of total billed charges,Implant Device,976.5,35,,976.5,percent of total billed charges,Implant Device,976.5,35,,976.5,percent of total billed charges,Implant Device,1116,40,,1116,percent of total billed charges,Implant Device,976.5,70,,976.5,percent of total billed charges,All Other,948.6,34,,948.6,percent of total billed charges,Implant Device,948.6,34,,948.6,percent of total billed charges,Implant Device,976.5,35,,976.5,percent of total billed charges,Implant Device,976.5,35,,976.5,percent of total billed charges,Implant Device,976.5,35,,976.5,percent of total billed charges,Implant Device,976.5,35,,976.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,948.6,34,"If Charge > 2,000, then 34 percent",948.6,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2064.61,
MENTOR 350-7255MC BREAST IMPLANT 255CC,C1789,HCPCS,,79008589,CDM,278,RC,,,both,,,2790,2064.61,,,2064.61,Other,150% of Medicare + 9.63% HCRA Surcharge,1255.5,45,,1255.5,percent of total billed charges,Critical Access Hospital RCC factor,948.6,34,,948.6,percent of total billed charges,Implant Device,948.6,34,,948.6,percent of total billed charges,Implant Device,948.6,34,,948.6,percent of total billed charges,Implant Device,948.6,34,,948.6,percent of total billed charges,Implant Device,948.6,34,,948.6,percent of total billed charges,Implant Device,1381.05,,,1381.05,Other,110% of Medicare,976.5,35,,976.5,percent of total billed charges,Implant Device,948.6,34,"Charges > $500, x 34%",948.6,percent of total billed charges,Implant Device,976.5,35,,976.5,percent of total billed charges,Implant Device,976.5,35,,976.5,percent of total billed charges,Implant Device,976.5,35,,976.5,percent of total billed charges,Implant Device,976.5,35,,976.5,percent of total billed charges,Implant Device,976.5,35,,976.5,percent of total billed charges,Implant Device,1116,40,,1116,percent of total billed charges,Implant Device,976.5,70,,976.5,percent of total billed charges,All Other,948.6,34,,948.6,percent of total billed charges,Implant Device,948.6,34,,948.6,percent of total billed charges,Implant Device,976.5,35,,976.5,percent of total billed charges,Implant Device,976.5,35,,976.5,percent of total billed charges,Implant Device,976.5,35,,976.5,percent of total billed charges,Implant Device,976.5,35,,976.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,948.6,34,"If Charge > 2,000, then 34 percent",948.6,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2064.61,
MENTOR 334-1155 BREAST IMPLANT 295CC,C1789,HCPCS,,79008590,CDM,278,RC,,,both,,,4050,2997.01,,,2997.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1822.5,45,,1822.5,percent of total billed charges,Critical Access Hospital RCC factor,1377,34,,1377,percent of total billed charges,Implant Device,1377,34,,1377,percent of total billed charges,Implant Device,1377,34,,1377,percent of total billed charges,Implant Device,1377,34,,1377,percent of total billed charges,Implant Device,1377,34,,1377,percent of total billed charges,Implant Device,2004.75,,,2004.75,Other,110% of Medicare,1417.5,35,,1417.5,percent of total billed charges,Implant Device,1377,34,"Charges > $500, x 34%",1377,percent of total billed charges,Implant Device,1417.5,35,,1417.5,percent of total billed charges,Implant Device,1417.5,35,,1417.5,percent of total billed charges,Implant Device,1417.5,35,,1417.5,percent of total billed charges,Implant Device,1417.5,35,,1417.5,percent of total billed charges,Implant Device,1417.5,35,,1417.5,percent of total billed charges,Implant Device,1620,40,,1620,percent of total billed charges,Implant Device,1417.5,70,,1417.5,percent of total billed charges,All Other,1377,34,,1377,percent of total billed charges,Implant Device,1377,34,,1377,percent of total billed charges,Implant Device,1417.5,35,,1417.5,percent of total billed charges,Implant Device,1417.5,35,,1417.5,percent of total billed charges,Implant Device,1417.5,35,,1417.5,percent of total billed charges,Implant Device,1417.5,35,,1417.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1377,34,"If Charge > 2,000, then 34 percent",1377,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2997.01,
MENTOR 334-1105 BREAST IMPLANT 255CC,C1789,HCPCS,,79008591,CDM,278,RC,,,both,,,4050,2997.01,,,2997.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1822.5,45,,1822.5,percent of total billed charges,Critical Access Hospital RCC factor,1377,34,,1377,percent of total billed charges,Implant Device,1377,34,,1377,percent of total billed charges,Implant Device,1377,34,,1377,percent of total billed charges,Implant Device,1377,34,,1377,percent of total billed charges,Implant Device,1377,34,,1377,percent of total billed charges,Implant Device,2004.75,,,2004.75,Other,110% of Medicare,1417.5,35,,1417.5,percent of total billed charges,Implant Device,1377,34,"Charges > $500, x 34%",1377,percent of total billed charges,Implant Device,1417.5,35,,1417.5,percent of total billed charges,Implant Device,1417.5,35,,1417.5,percent of total billed charges,Implant Device,1417.5,35,,1417.5,percent of total billed charges,Implant Device,1417.5,35,,1417.5,percent of total billed charges,Implant Device,1417.5,35,,1417.5,percent of total billed charges,Implant Device,1620,40,,1620,percent of total billed charges,Implant Device,1417.5,70,,1417.5,percent of total billed charges,All Other,1377,34,,1377,percent of total billed charges,Implant Device,1377,34,,1377,percent of total billed charges,Implant Device,1417.5,35,,1417.5,percent of total billed charges,Implant Device,1417.5,35,,1417.5,percent of total billed charges,Implant Device,1417.5,35,,1417.5,percent of total billed charges,Implant Device,1417.5,35,,1417.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1377,34,"If Charge > 2,000, then 34 percent",1377,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2997.01,
MENTOR 354-1158 BREAST IMPLANT 245CC,C1789,HCPCS,,79008592,CDM,278,RC,,,both,,,4050,2997.01,,,2997.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1822.5,45,,1822.5,percent of total billed charges,Critical Access Hospital RCC factor,1377,34,,1377,percent of total billed charges,Implant Device,1377,34,,1377,percent of total billed charges,Implant Device,1377,34,,1377,percent of total billed charges,Implant Device,1377,34,,1377,percent of total billed charges,Implant Device,1377,34,,1377,percent of total billed charges,Implant Device,2004.75,,,2004.75,Other,110% of Medicare,1417.5,35,,1417.5,percent of total billed charges,Implant Device,1377,34,"Charges > $500, x 34%",1377,percent of total billed charges,Implant Device,1417.5,35,,1417.5,percent of total billed charges,Implant Device,1417.5,35,,1417.5,percent of total billed charges,Implant Device,1417.5,35,,1417.5,percent of total billed charges,Implant Device,1417.5,35,,1417.5,percent of total billed charges,Implant Device,1417.5,35,,1417.5,percent of total billed charges,Implant Device,1620,40,,1620,percent of total billed charges,Implant Device,1417.5,70,,1417.5,percent of total billed charges,All Other,1377,34,,1377,percent of total billed charges,Implant Device,1377,34,,1377,percent of total billed charges,Implant Device,1417.5,35,,1417.5,percent of total billed charges,Implant Device,1417.5,35,,1417.5,percent of total billed charges,Implant Device,1417.5,35,,1417.5,percent of total billed charges,Implant Device,1417.5,35,,1417.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1377,34,"If Charge > 2,000, then 34 percent",1377,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2997.01,
MENTOR 354-1208 BREAST IMPLANT 280CC,C1789,HCPCS,,79008593,CDM,278,RC,,,both,,,4050,2997.01,,,2997.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1822.5,45,,1822.5,percent of total billed charges,Critical Access Hospital RCC factor,1377,34,,1377,percent of total billed charges,Implant Device,1377,34,,1377,percent of total billed charges,Implant Device,1377,34,,1377,percent of total billed charges,Implant Device,1377,34,,1377,percent of total billed charges,Implant Device,1377,34,,1377,percent of total billed charges,Implant Device,2004.75,,,2004.75,Other,110% of Medicare,1417.5,35,,1417.5,percent of total billed charges,Implant Device,1377,34,"Charges > $500, x 34%",1377,percent of total billed charges,Implant Device,1417.5,35,,1417.5,percent of total billed charges,Implant Device,1417.5,35,,1417.5,percent of total billed charges,Implant Device,1417.5,35,,1417.5,percent of total billed charges,Implant Device,1417.5,35,,1417.5,percent of total billed charges,Implant Device,1417.5,35,,1417.5,percent of total billed charges,Implant Device,1620,40,,1620,percent of total billed charges,Implant Device,1417.5,70,,1417.5,percent of total billed charges,All Other,1377,34,,1377,percent of total billed charges,Implant Device,1377,34,,1377,percent of total billed charges,Implant Device,1417.5,35,,1417.5,percent of total billed charges,Implant Device,1417.5,35,,1417.5,percent of total billed charges,Implant Device,1417.5,35,,1417.5,percent of total billed charges,Implant Device,1417.5,35,,1417.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1377,34,"If Charge > 2,000, then 34 percent",1377,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2997.01,
DEPUY 456.324S FIXATION NAIL 10MM/125DEG,C1713,HCPCS,,79008597,CDM,278,RC,,,both,,,2738,2026.13,,,2026.13,Other,150% of Medicare + 9.63% HCRA Surcharge,1232.1,45,,1232.1,percent of total billed charges,Critical Access Hospital RCC factor,930.92,34,,930.92,percent of total billed charges,Implant Device,930.92,34,,930.92,percent of total billed charges,Implant Device,930.92,34,,930.92,percent of total billed charges,Implant Device,930.92,34,,930.92,percent of total billed charges,Implant Device,930.92,34,,930.92,percent of total billed charges,Implant Device,1355.31,,,1355.31,Other,110% of Medicare,958.3,35,,958.3,percent of total billed charges,Implant Device,930.92,34,"Charges > $500, x 34%",930.92,percent of total billed charges,Implant Device,958.3,35,,958.3,percent of total billed charges,Implant Device,958.3,35,,958.3,percent of total billed charges,Implant Device,958.3,35,,958.3,percent of total billed charges,Implant Device,958.3,35,,958.3,percent of total billed charges,Implant Device,958.3,35,,958.3,percent of total billed charges,Implant Device,1095.2,40,,1095.2,percent of total billed charges,Implant Device,958.3,70,,958.3,percent of total billed charges,All Other,930.92,34,,930.92,percent of total billed charges,Implant Device,930.92,34,,930.92,percent of total billed charges,Implant Device,958.3,35,,958.3,percent of total billed charges,Implant Device,958.3,35,,958.3,percent of total billed charges,Implant Device,958.3,35,,958.3,percent of total billed charges,Implant Device,958.3,35,,958.3,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,930.92,34,"If Charge > 2,000, then 34 percent",930.92,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2026.13,
STRYKER 663050 CANN COMP SCREW 4.0/L50MM,C1713,HCPCS,,79008606,CDM,278,RC,,,both,,,5400,3996.01,,,3996.01,Other,150% of Medicare + 9.63% HCRA Surcharge,2430,45,,2430,percent of total billed charges,Critical Access Hospital RCC factor,1836,34,,1836,percent of total billed charges,Implant Device,1836,34,,1836,percent of total billed charges,Implant Device,1836,34,,1836,percent of total billed charges,Implant Device,1836,34,,1836,percent of total billed charges,Implant Device,1836,34,,1836,percent of total billed charges,Implant Device,2673,,,2673,Other,110% of Medicare,1890,35,,1890,percent of total billed charges,Implant Device,1836,34,"Charges > $500, x 34%",1836,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,2160,40,,2160,percent of total billed charges,Implant Device,1890,70,,1890,percent of total billed charges,All Other,1836,34,,1836,percent of total billed charges,Implant Device,1836,34,,1836,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1836,34,"If Charge > 2,000, then 34 percent",1836,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3996.01,
STRYKER 663150 CANN COMP SCREW 5.0/L50MM,C1713,HCPCS,,79008607,CDM,278,RC,,,both,,,5400,3996.01,,,3996.01,Other,150% of Medicare + 9.63% HCRA Surcharge,2430,45,,2430,percent of total billed charges,Critical Access Hospital RCC factor,1836,34,,1836,percent of total billed charges,Implant Device,1836,34,,1836,percent of total billed charges,Implant Device,1836,34,,1836,percent of total billed charges,Implant Device,1836,34,,1836,percent of total billed charges,Implant Device,1836,34,,1836,percent of total billed charges,Implant Device,2673,,,2673,Other,110% of Medicare,1890,35,,1890,percent of total billed charges,Implant Device,1836,34,"Charges > $500, x 34%",1836,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,2160,40,,2160,percent of total billed charges,Implant Device,1890,70,,1890,percent of total billed charges,All Other,1836,34,,1836,percent of total billed charges,Implant Device,1836,34,,1836,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1836,34,"If Charge > 2,000, then 34 percent",1836,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3996.01,
DEPUY 1516-30-910 TIBIAL INS SZ 9 10MM,C1776,HCPCS,,79008611,CDM,278,RC,,,both,,,5250,3885.01,,,3885.01,Other,150% of Medicare + 9.63% HCRA Surcharge,2362.5,45,,2362.5,percent of total billed charges,Critical Access Hospital RCC factor,1785,34,,1785,percent of total billed charges,Implant Device,1785,34,,1785,percent of total billed charges,Implant Device,1785,34,,1785,percent of total billed charges,Implant Device,1785,34,,1785,percent of total billed charges,Implant Device,1785,34,,1785,percent of total billed charges,Implant Device,2598.75,,,2598.75,Other,110% of Medicare,1837.5,35,,1837.5,percent of total billed charges,Implant Device,1785,34,"Charges > $500, x 34%",1785,percent of total billed charges,Implant Device,1837.5,35,,1837.5,percent of total billed charges,Implant Device,1837.5,35,,1837.5,percent of total billed charges,Implant Device,1837.5,35,,1837.5,percent of total billed charges,Implant Device,1837.5,35,,1837.5,percent of total billed charges,Implant Device,1837.5,35,,1837.5,percent of total billed charges,Implant Device,2100,40,,2100,percent of total billed charges,Implant Device,1837.5,70,,1837.5,percent of total billed charges,All Other,1785,34,,1785,percent of total billed charges,Implant Device,1785,34,,1785,percent of total billed charges,Implant Device,1837.5,35,,1837.5,percent of total billed charges,Implant Device,1837.5,35,,1837.5,percent of total billed charges,Implant Device,1837.5,35,,1837.5,percent of total billed charges,Implant Device,1837.5,35,,1837.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1785,34,"If Charge > 2,000, then 34 percent",1785,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3885.01,
ZIMMER 00-5850-013-96 INSERT XL SZ C,C1776,HCPCS,,79008613,CDM,278,RC,,,both,,,1074,794.76,,,794.76,Other,150% of Medicare + 9.63% HCRA Surcharge,483.3,45,,483.3,percent of total billed charges,Critical Access Hospital RCC factor,365.16,34,,365.16,percent of total billed charges,Implant Device,365.16,34,,365.16,percent of total billed charges,Implant Device,365.16,34,,365.16,percent of total billed charges,Implant Device,365.16,34,,365.16,percent of total billed charges,Implant Device,365.16,34,,365.16,percent of total billed charges,Implant Device,531.63,,,531.63,Other,110% of Medicare,375.9,35,,375.9,percent of total billed charges,Implant Device,365.16,34,"Charges > $500, x 34%",365.16,percent of total billed charges,Implant Device,375.9,35,,375.9,percent of total billed charges,Implant Device,375.9,35,,375.9,percent of total billed charges,Implant Device,375.9,35,,375.9,percent of total billed charges,Implant Device,375.9,35,,375.9,percent of total billed charges,Implant Device,375.9,35,,375.9,percent of total billed charges,Implant Device,429.6,40,,429.6,percent of total billed charges,Implant Device,375.9,70,,375.9,percent of total billed charges,All Other,365.16,34,,365.16,percent of total billed charges,Implant Device,365.16,34,,365.16,percent of total billed charges,Implant Device,375.9,35,,375.9,percent of total billed charges,Implant Device,375.9,35,,375.9,percent of total billed charges,Implant Device,375.9,35,,375.9,percent of total billed charges,Implant Device,375.9,35,,375.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,794.76,
ZIMMER 00-5850-043-01 DIST FEM COMP SZ C,C1776,HCPCS,,79008614,CDM,278,RC,,,both,,,25907,19171.24,,,19171.24,Other,150% of Medicare + 9.63% HCRA Surcharge,11658.15,45,,11658.15,percent of total billed charges,Critical Access Hospital RCC factor,8808.38,34,,8808.38,percent of total billed charges,Implant Device,8808.38,34,,8808.38,percent of total billed charges,Implant Device,8808.38,34,,8808.38,percent of total billed charges,Implant Device,8808.38,34,,8808.38,percent of total billed charges,Implant Device,8808.38,34,,8808.38,percent of total billed charges,Implant Device,12823.97,,,12823.97,Other,110% of Medicare,9067.45,35,,9067.45,percent of total billed charges,Implant Device,8808.38,34,"Charges > $500, x 34%",8808.38,percent of total billed charges,Implant Device,9067.45,35,,9067.45,percent of total billed charges,Implant Device,9067.45,35,,9067.45,percent of total billed charges,Implant Device,9067.45,35,,9067.45,percent of total billed charges,Implant Device,9067.45,35,,9067.45,percent of total billed charges,Implant Device,9067.45,35,,9067.45,percent of total billed charges,Implant Device,10362.8,40,,10362.8,percent of total billed charges,Implant Device,9067.45,70,,9067.45,percent of total billed charges,All Other,8808.38,34,,8808.38,percent of total billed charges,Implant Device,8808.38,34,,8808.38,percent of total billed charges,Implant Device,9067.45,35,,9067.45,percent of total billed charges,Implant Device,9067.45,35,,9067.45,percent of total billed charges,Implant Device,9067.45,35,,9067.45,percent of total billed charges,Implant Device,9067.45,35,,9067.45,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,8808.38,34,"If Charge > 2,000, then 34 percent",8808.38,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,19171.24,
STRYKER SK2710-38 CORTICAL SCREW 2.7X38,C1713,HCPCS,,79008616,CDM,278,RC,,,both,,,255,188.7,,,188.7,Other,150% of Medicare + 9.63% HCRA Surcharge,114.75,45,,114.75,percent of total billed charges,Critical Access Hospital RCC factor,86.7,34,,86.7,percent of total billed charges,Implant Device,86.7,34,,86.7,percent of total billed charges,Implant Device,86.7,34,,86.7,percent of total billed charges,Implant Device,86.7,34,,86.7,percent of total billed charges,Implant Device,86.7,34,,86.7,percent of total billed charges,Implant Device,126.23,,,126.23,Other,110% of Medicare,89.25,35,,89.25,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,89.25,35,,89.25,percent of total billed charges,Implant Device,89.25,35,,89.25,percent of total billed charges,Implant Device,89.25,35,,89.25,percent of total billed charges,Implant Device,89.25,35,,89.25,percent of total billed charges,Implant Device,89.25,35,,89.25,percent of total billed charges,Implant Device,102,40,,102,percent of total billed charges,Implant Device,89.25,70,,89.25,percent of total billed charges,All Other,86.7,34,,86.7,percent of total billed charges,Implant Device,86.7,34,,86.7,percent of total billed charges,Implant Device,89.25,35,,89.25,percent of total billed charges,Implant Device,89.25,35,,89.25,percent of total billed charges,Implant Device,89.25,35,,89.25,percent of total billed charges,Implant Device,89.25,35,,89.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,188.7,
STRYKER SK2710-22 CORTICAL SCREW 2.7X22,C1713,HCPCS,,79008617,CDM,278,RC,,,both,,,255,188.7,,,188.7,Other,150% of Medicare + 9.63% HCRA Surcharge,114.75,45,,114.75,percent of total billed charges,Critical Access Hospital RCC factor,86.7,34,,86.7,percent of total billed charges,Implant Device,86.7,34,,86.7,percent of total billed charges,Implant Device,86.7,34,,86.7,percent of total billed charges,Implant Device,86.7,34,,86.7,percent of total billed charges,Implant Device,86.7,34,,86.7,percent of total billed charges,Implant Device,126.23,,,126.23,Other,110% of Medicare,89.25,35,,89.25,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,89.25,35,,89.25,percent of total billed charges,Implant Device,89.25,35,,89.25,percent of total billed charges,Implant Device,89.25,35,,89.25,percent of total billed charges,Implant Device,89.25,35,,89.25,percent of total billed charges,Implant Device,89.25,35,,89.25,percent of total billed charges,Implant Device,102,40,,102,percent of total billed charges,Implant Device,89.25,70,,89.25,percent of total billed charges,All Other,86.7,34,,86.7,percent of total billed charges,Implant Device,86.7,34,,86.7,percent of total billed charges,Implant Device,89.25,35,,89.25,percent of total billed charges,Implant Device,89.25,35,,89.25,percent of total billed charges,Implant Device,89.25,35,,89.25,percent of total billed charges,Implant Device,89.25,35,,89.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,188.7,
STRYKER 325028 CANNULATED SCREW 4.0X28MM,C1713,HCPCS,,79008618,CDM,278,RC,,,both,,,770,569.8,,,569.8,Other,150% of Medicare + 9.63% HCRA Surcharge,346.5,45,,346.5,percent of total billed charges,Critical Access Hospital RCC factor,261.8,34,,261.8,percent of total billed charges,Implant Device,261.8,34,,261.8,percent of total billed charges,Implant Device,261.8,34,,261.8,percent of total billed charges,Implant Device,261.8,34,,261.8,percent of total billed charges,Implant Device,261.8,34,,261.8,percent of total billed charges,Implant Device,381.15,,,381.15,Other,110% of Medicare,269.5,35,,269.5,percent of total billed charges,Implant Device,261.8,34,"Charges > $500, x 34%",261.8,percent of total billed charges,Implant Device,269.5,35,,269.5,percent of total billed charges,Implant Device,269.5,35,,269.5,percent of total billed charges,Implant Device,269.5,35,,269.5,percent of total billed charges,Implant Device,269.5,35,,269.5,percent of total billed charges,Implant Device,269.5,35,,269.5,percent of total billed charges,Implant Device,308,40,,308,percent of total billed charges,Implant Device,269.5,70,,269.5,percent of total billed charges,All Other,261.8,34,,261.8,percent of total billed charges,Implant Device,261.8,34,,261.8,percent of total billed charges,Implant Device,269.5,35,,269.5,percent of total billed charges,Implant Device,269.5,35,,269.5,percent of total billed charges,Implant Device,269.5,35,,269.5,percent of total billed charges,Implant Device,269.5,35,,269.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,569.8,
STRYKER 325038 CANNULATED SCREW 4.0X38MM,C1713,HCPCS,,79008619,CDM,278,RC,,,both,,,770,569.8,,,569.8,Other,150% of Medicare + 9.63% HCRA Surcharge,346.5,45,,346.5,percent of total billed charges,Critical Access Hospital RCC factor,261.8,34,,261.8,percent of total billed charges,Implant Device,261.8,34,,261.8,percent of total billed charges,Implant Device,261.8,34,,261.8,percent of total billed charges,Implant Device,261.8,34,,261.8,percent of total billed charges,Implant Device,261.8,34,,261.8,percent of total billed charges,Implant Device,381.15,,,381.15,Other,110% of Medicare,269.5,35,,269.5,percent of total billed charges,Implant Device,261.8,34,"Charges > $500, x 34%",261.8,percent of total billed charges,Implant Device,269.5,35,,269.5,percent of total billed charges,Implant Device,269.5,35,,269.5,percent of total billed charges,Implant Device,269.5,35,,269.5,percent of total billed charges,Implant Device,269.5,35,,269.5,percent of total billed charges,Implant Device,269.5,35,,269.5,percent of total billed charges,Implant Device,308,40,,308,percent of total billed charges,Implant Device,269.5,70,,269.5,percent of total billed charges,All Other,261.8,34,,261.8,percent of total billed charges,Implant Device,261.8,34,,261.8,percent of total billed charges,Implant Device,269.5,35,,269.5,percent of total billed charges,Implant Device,269.5,35,,269.5,percent of total billed charges,Implant Device,269.5,35,,269.5,percent of total billed charges,Implant Device,269.5,35,,269.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,569.8,
STRYKER 629343 OLECRANON PLATE 3 HOLE LT,C1713,HCPCS,,79008620,CDM,278,RC,,,both,,,2543,1881.83,,,1881.83,Other,150% of Medicare + 9.63% HCRA Surcharge,1144.35,45,,1144.35,percent of total billed charges,Critical Access Hospital RCC factor,864.62,34,,864.62,percent of total billed charges,Implant Device,864.62,34,,864.62,percent of total billed charges,Implant Device,864.62,34,,864.62,percent of total billed charges,Implant Device,864.62,34,,864.62,percent of total billed charges,Implant Device,864.62,34,,864.62,percent of total billed charges,Implant Device,1258.79,,,1258.79,Other,110% of Medicare,890.05,35,,890.05,percent of total billed charges,Implant Device,864.62,34,"Charges > $500, x 34%",864.62,percent of total billed charges,Implant Device,890.05,35,,890.05,percent of total billed charges,Implant Device,890.05,35,,890.05,percent of total billed charges,Implant Device,890.05,35,,890.05,percent of total billed charges,Implant Device,890.05,35,,890.05,percent of total billed charges,Implant Device,890.05,35,,890.05,percent of total billed charges,Implant Device,1017.2,40,,1017.2,percent of total billed charges,Implant Device,890.05,70,,890.05,percent of total billed charges,All Other,864.62,34,,864.62,percent of total billed charges,Implant Device,864.62,34,,864.62,percent of total billed charges,Implant Device,890.05,35,,890.05,percent of total billed charges,Implant Device,890.05,35,,890.05,percent of total billed charges,Implant Device,890.05,35,,890.05,percent of total billed charges,Implant Device,890.05,35,,890.05,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,864.62,34,"If Charge > 2,000, then 34 percent",864.62,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1881.83,
STRYKER 614770 NON LOCKING SCREW 2.7X70,C1713,HCPCS,,79008621,CDM,278,RC,,,both,,,390,288.6,,,288.6,Other,150% of Medicare + 9.63% HCRA Surcharge,175.5,45,,175.5,percent of total billed charges,Critical Access Hospital RCC factor,132.6,34,,132.6,percent of total billed charges,Implant Device,132.6,34,,132.6,percent of total billed charges,Implant Device,132.6,34,,132.6,percent of total billed charges,Implant Device,132.6,34,,132.6,percent of total billed charges,Implant Device,132.6,34,,132.6,percent of total billed charges,Implant Device,193.05,,,193.05,Other,110% of Medicare,136.5,35,,136.5,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,136.5,35,,136.5,percent of total billed charges,Implant Device,136.5,35,,136.5,percent of total billed charges,Implant Device,136.5,35,,136.5,percent of total billed charges,Implant Device,136.5,35,,136.5,percent of total billed charges,Implant Device,136.5,35,,136.5,percent of total billed charges,Implant Device,156,40,,156,percent of total billed charges,Implant Device,136.5,70,,136.5,percent of total billed charges,All Other,132.6,34,,132.6,percent of total billed charges,Implant Device,132.6,34,,132.6,percent of total billed charges,Implant Device,136.5,35,,136.5,percent of total billed charges,Implant Device,136.5,35,,136.5,percent of total billed charges,Implant Device,136.5,35,,136.5,percent of total billed charges,Implant Device,136.5,35,,136.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,288.6,
STRYKER 614836 NON LOCKING SCREW 3.5X36,C1713,HCPCS,,79008622,CDM,278,RC,,,both,,,390,288.6,,,288.6,Other,150% of Medicare + 9.63% HCRA Surcharge,175.5,45,,175.5,percent of total billed charges,Critical Access Hospital RCC factor,132.6,34,,132.6,percent of total billed charges,Implant Device,132.6,34,,132.6,percent of total billed charges,Implant Device,132.6,34,,132.6,percent of total billed charges,Implant Device,132.6,34,,132.6,percent of total billed charges,Implant Device,132.6,34,,132.6,percent of total billed charges,Implant Device,193.05,,,193.05,Other,110% of Medicare,136.5,35,,136.5,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,136.5,35,,136.5,percent of total billed charges,Implant Device,136.5,35,,136.5,percent of total billed charges,Implant Device,136.5,35,,136.5,percent of total billed charges,Implant Device,136.5,35,,136.5,percent of total billed charges,Implant Device,136.5,35,,136.5,percent of total billed charges,Implant Device,156,40,,156,percent of total billed charges,Implant Device,136.5,70,,136.5,percent of total billed charges,All Other,132.6,34,,132.6,percent of total billed charges,Implant Device,132.6,34,,132.6,percent of total billed charges,Implant Device,136.5,35,,136.5,percent of total billed charges,Implant Device,136.5,35,,136.5,percent of total billed charges,Implant Device,136.5,35,,136.5,percent of total billed charges,Implant Device,136.5,35,,136.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,288.6,
STRYKER 614826 NON LOCKING SCREW 3.5X26,C1713,HCPCS,,79008623,CDM,278,RC,,,both,,,390,288.6,,,288.6,Other,150% of Medicare + 9.63% HCRA Surcharge,175.5,45,,175.5,percent of total billed charges,Critical Access Hospital RCC factor,132.6,34,,132.6,percent of total billed charges,Implant Device,132.6,34,,132.6,percent of total billed charges,Implant Device,132.6,34,,132.6,percent of total billed charges,Implant Device,132.6,34,,132.6,percent of total billed charges,Implant Device,132.6,34,,132.6,percent of total billed charges,Implant Device,193.05,,,193.05,Other,110% of Medicare,136.5,35,,136.5,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,136.5,35,,136.5,percent of total billed charges,Implant Device,136.5,35,,136.5,percent of total billed charges,Implant Device,136.5,35,,136.5,percent of total billed charges,Implant Device,136.5,35,,136.5,percent of total billed charges,Implant Device,136.5,35,,136.5,percent of total billed charges,Implant Device,156,40,,156,percent of total billed charges,Implant Device,136.5,70,,136.5,percent of total billed charges,All Other,132.6,34,,132.6,percent of total billed charges,Implant Device,132.6,34,,132.6,percent of total billed charges,Implant Device,136.5,35,,136.5,percent of total billed charges,Implant Device,136.5,35,,136.5,percent of total billed charges,Implant Device,136.5,35,,136.5,percent of total billed charges,Implant Device,136.5,35,,136.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,288.6,
DEPUY 223.561 LCP PLATE 3.5MM 6 HOLE,C1713,HCPCS,,79008624,CDM,278,RC,,,both,,,1210,895.4,,,895.4,Other,150% of Medicare + 9.63% HCRA Surcharge,544.5,45,,544.5,percent of total billed charges,Critical Access Hospital RCC factor,411.4,34,,411.4,percent of total billed charges,Implant Device,411.4,34,,411.4,percent of total billed charges,Implant Device,411.4,34,,411.4,percent of total billed charges,Implant Device,411.4,34,,411.4,percent of total billed charges,Implant Device,411.4,34,,411.4,percent of total billed charges,Implant Device,598.95,,,598.95,Other,110% of Medicare,423.5,35,,423.5,percent of total billed charges,Implant Device,411.4,34,"Charges > $500, x 34%",411.4,percent of total billed charges,Implant Device,423.5,35,,423.5,percent of total billed charges,Implant Device,423.5,35,,423.5,percent of total billed charges,Implant Device,423.5,35,,423.5,percent of total billed charges,Implant Device,423.5,35,,423.5,percent of total billed charges,Implant Device,423.5,35,,423.5,percent of total billed charges,Implant Device,484,40,,484,percent of total billed charges,Implant Device,423.5,70,,423.5,percent of total billed charges,All Other,411.4,34,,411.4,percent of total billed charges,Implant Device,411.4,34,,411.4,percent of total billed charges,Implant Device,423.5,35,,423.5,percent of total billed charges,Implant Device,423.5,35,,423.5,percent of total billed charges,Implant Device,423.5,35,,423.5,percent of total billed charges,Implant Device,423.5,35,,423.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,895.4,
DEPUY SYNTHES 202.808 2.7 X 8MM SCREW,C1713,HCPCS,,79008626,CDM,278,RC,,,both,,,128,94.72,,,94.72,Other,150% of Medicare + 9.63% HCRA Surcharge,57.6,45,,57.6,percent of total billed charges,Critical Access Hospital RCC factor,43.52,34,,43.52,percent of total billed charges,Implant Device,43.52,34,,43.52,percent of total billed charges,Implant Device,43.52,34,,43.52,percent of total billed charges,Implant Device,43.52,34,,43.52,percent of total billed charges,Implant Device,43.52,34,,43.52,percent of total billed charges,Implant Device,63.36,,,63.36,Other,110% of Medicare,44.8,35,,44.8,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,44.8,35,,44.8,percent of total billed charges,Implant Device,44.8,35,,44.8,percent of total billed charges,Implant Device,44.8,35,,44.8,percent of total billed charges,Implant Device,44.8,35,,44.8,percent of total billed charges,Implant Device,44.8,35,,44.8,percent of total billed charges,Implant Device,51.2,40,,51.2,percent of total billed charges,Implant Device,44.8,70,,44.8,percent of total billed charges,All Other,43.52,34,,43.52,percent of total billed charges,Implant Device,43.52,34,,43.52,percent of total billed charges,Implant Device,44.8,35,,44.8,percent of total billed charges,Implant Device,44.8,35,,44.8,percent of total billed charges,Implant Device,44.8,35,,44.8,percent of total billed charges,Implant Device,44.8,35,,44.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,94.72,
DEPUY SYNTHES 201.808 2.0 X 8MM SCREW,C1713,HCPCS,,79008627,CDM,278,RC,,,both,,,126,93.24,,,93.24,Other,150% of Medicare + 9.63% HCRA Surcharge,56.7,45,,56.7,percent of total billed charges,Critical Access Hospital RCC factor,42.84,34,,42.84,percent of total billed charges,Implant Device,42.84,34,,42.84,percent of total billed charges,Implant Device,42.84,34,,42.84,percent of total billed charges,Implant Device,42.84,34,,42.84,percent of total billed charges,Implant Device,42.84,34,,42.84,percent of total billed charges,Implant Device,62.37,,,62.37,Other,110% of Medicare,44.1,35,,44.1,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,44.1,35,,44.1,percent of total billed charges,Implant Device,44.1,35,,44.1,percent of total billed charges,Implant Device,44.1,35,,44.1,percent of total billed charges,Implant Device,44.1,35,,44.1,percent of total billed charges,Implant Device,44.1,35,,44.1,percent of total billed charges,Implant Device,50.4,40,,50.4,percent of total billed charges,Implant Device,44.1,70,,44.1,percent of total billed charges,All Other,42.84,34,,42.84,percent of total billed charges,Implant Device,42.84,34,,42.84,percent of total billed charges,Implant Device,44.1,35,,44.1,percent of total billed charges,Implant Device,44.1,35,,44.1,percent of total billed charges,Implant Device,44.1,35,,44.1,percent of total billed charges,Implant Device,44.1,35,,44.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,93.24,
VILEX CHI-3TH HEMI IMPLANT W/ COATING,C1776,HCPCS,,79008629,CDM,278,RC,,,both,,,1988,1471.12,,,1471.12,Other,150% of Medicare + 9.63% HCRA Surcharge,894.6,45,,894.6,percent of total billed charges,Critical Access Hospital RCC factor,675.92,34,,675.92,percent of total billed charges,Implant Device,675.92,34,,675.92,percent of total billed charges,Implant Device,675.92,34,,675.92,percent of total billed charges,Implant Device,675.92,34,,675.92,percent of total billed charges,Implant Device,675.92,34,,675.92,percent of total billed charges,Implant Device,984.06,,,984.06,Other,110% of Medicare,695.8,35,,695.8,percent of total billed charges,Implant Device,675.92,34,"Charges > $500, x 34%",675.92,percent of total billed charges,Implant Device,695.8,35,,695.8,percent of total billed charges,Implant Device,695.8,35,,695.8,percent of total billed charges,Implant Device,695.8,35,,695.8,percent of total billed charges,Implant Device,695.8,35,,695.8,percent of total billed charges,Implant Device,695.8,35,,695.8,percent of total billed charges,Implant Device,795.2,40,,795.2,percent of total billed charges,Implant Device,695.8,70,,695.8,percent of total billed charges,All Other,675.92,34,,675.92,percent of total billed charges,Implant Device,675.92,34,,675.92,percent of total billed charges,Implant Device,695.8,35,,695.8,percent of total billed charges,Implant Device,695.8,35,,695.8,percent of total billed charges,Implant Device,695.8,35,,695.8,percent of total billed charges,Implant Device,695.8,35,,695.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1471.12,
STRYKER 661040 4.0X40MM LOCKING SCREW,C1713,HCPCS,,79008630,CDM,278,RC,,,both,,,630,466.2,,,466.2,Other,150% of Medicare + 9.63% HCRA Surcharge,283.5,45,,283.5,percent of total billed charges,Critical Access Hospital RCC factor,214.2,34,,214.2,percent of total billed charges,Implant Device,214.2,34,,214.2,percent of total billed charges,Implant Device,214.2,34,,214.2,percent of total billed charges,Implant Device,214.2,34,,214.2,percent of total billed charges,Implant Device,214.2,34,,214.2,percent of total billed charges,Implant Device,311.85,,,311.85,Other,110% of Medicare,220.5,35,,220.5,percent of total billed charges,Implant Device,214.2,34,"Charges > $500, x 34%",214.2,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,252,40,,252,percent of total billed charges,Implant Device,220.5,70,,220.5,percent of total billed charges,All Other,214.2,34,,214.2,percent of total billed charges,Implant Device,214.2,34,,214.2,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,466.2,
STRYKER 661048 4.0X48MM LOCKING SCREW,C1713,HCPCS,,79008631,CDM,278,RC,,,both,,,583,431.42,,,431.42,Other,150% of Medicare + 9.63% HCRA Surcharge,262.35,45,,262.35,percent of total billed charges,Critical Access Hospital RCC factor,198.22,34,,198.22,percent of total billed charges,Implant Device,198.22,34,,198.22,percent of total billed charges,Implant Device,198.22,34,,198.22,percent of total billed charges,Implant Device,198.22,34,,198.22,percent of total billed charges,Implant Device,198.22,34,,198.22,percent of total billed charges,Implant Device,288.59,,,288.59,Other,110% of Medicare,204.05,35,,204.05,percent of total billed charges,Implant Device,198.22,34,"Charges > $500, x 34%",198.22,percent of total billed charges,Implant Device,204.05,35,,204.05,percent of total billed charges,Implant Device,204.05,35,,204.05,percent of total billed charges,Implant Device,204.05,35,,204.05,percent of total billed charges,Implant Device,204.05,35,,204.05,percent of total billed charges,Implant Device,204.05,35,,204.05,percent of total billed charges,Implant Device,233.2,40,,233.2,percent of total billed charges,Implant Device,204.05,70,,204.05,percent of total billed charges,All Other,198.22,34,,198.22,percent of total billed charges,Implant Device,198.22,34,,198.22,percent of total billed charges,Implant Device,204.05,35,,204.05,percent of total billed charges,Implant Device,204.05,35,,204.05,percent of total billed charges,Implant Device,204.05,35,,204.05,percent of total billed charges,Implant Device,204.05,35,,204.05,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,431.42,
STRYKER 661055 4.0X55MM LOCKING SCREW,C1713,HCPCS,,79008632,CDM,278,RC,,,both,,,630,466.2,,,466.2,Other,150% of Medicare + 9.63% HCRA Surcharge,283.5,45,,283.5,percent of total billed charges,Critical Access Hospital RCC factor,214.2,34,,214.2,percent of total billed charges,Implant Device,214.2,34,,214.2,percent of total billed charges,Implant Device,214.2,34,,214.2,percent of total billed charges,Implant Device,214.2,34,,214.2,percent of total billed charges,Implant Device,214.2,34,,214.2,percent of total billed charges,Implant Device,311.85,,,311.85,Other,110% of Medicare,220.5,35,,220.5,percent of total billed charges,Implant Device,214.2,34,"Charges > $500, x 34%",214.2,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,252,40,,252,percent of total billed charges,Implant Device,220.5,70,,220.5,percent of total billed charges,All Other,214.2,34,,214.2,percent of total billed charges,Implant Device,214.2,34,,214.2,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,466.2,
STRYKER 607355 4.0X55M CORTICAL SCREW,C1713,HCPCS,,79008633,CDM,278,RC,,,both,,,133,98.42,,,98.42,Other,150% of Medicare + 9.63% HCRA Surcharge,59.85,45,,59.85,percent of total billed charges,Critical Access Hospital RCC factor,45.22,34,,45.22,percent of total billed charges,Implant Device,45.22,34,,45.22,percent of total billed charges,Implant Device,45.22,34,,45.22,percent of total billed charges,Implant Device,45.22,34,,45.22,percent of total billed charges,Implant Device,45.22,34,,45.22,percent of total billed charges,Implant Device,65.84,,,65.84,Other,110% of Medicare,46.55,35,,46.55,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,46.55,35,,46.55,percent of total billed charges,Implant Device,46.55,35,,46.55,percent of total billed charges,Implant Device,46.55,35,,46.55,percent of total billed charges,Implant Device,46.55,35,,46.55,percent of total billed charges,Implant Device,46.55,35,,46.55,percent of total billed charges,Implant Device,53.2,40,,53.2,percent of total billed charges,Implant Device,46.55,70,,46.55,percent of total billed charges,All Other,45.22,34,,45.22,percent of total billed charges,Implant Device,45.22,34,,45.22,percent of total billed charges,Implant Device,46.55,35,,46.55,percent of total billed charges,Implant Device,46.55,35,,46.55,percent of total billed charges,Implant Device,46.55,35,,46.55,percent of total billed charges,Implant Device,46.55,35,,46.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,98.42,
DEPUY 1516-31-005 TIBIAL INSRT SZ 10 5MM,C1776,HCPCS,,79008634,CDM,278,RC,,,both,,,5250,3885.01,,,3885.01,Other,150% of Medicare + 9.63% HCRA Surcharge,2362.5,45,,2362.5,percent of total billed charges,Critical Access Hospital RCC factor,1785,34,,1785,percent of total billed charges,Implant Device,1785,34,,1785,percent of total billed charges,Implant Device,1785,34,,1785,percent of total billed charges,Implant Device,1785,34,,1785,percent of total billed charges,Implant Device,1785,34,,1785,percent of total billed charges,Implant Device,2598.75,,,2598.75,Other,110% of Medicare,1837.5,35,,1837.5,percent of total billed charges,Implant Device,1785,34,"Charges > $500, x 34%",1785,percent of total billed charges,Implant Device,1837.5,35,,1837.5,percent of total billed charges,Implant Device,1837.5,35,,1837.5,percent of total billed charges,Implant Device,1837.5,35,,1837.5,percent of total billed charges,Implant Device,1837.5,35,,1837.5,percent of total billed charges,Implant Device,1837.5,35,,1837.5,percent of total billed charges,Implant Device,2100,40,,2100,percent of total billed charges,Implant Device,1837.5,70,,1837.5,percent of total billed charges,All Other,1785,34,,1785,percent of total billed charges,Implant Device,1785,34,,1785,percent of total billed charges,Implant Device,1837.5,35,,1837.5,percent of total billed charges,Implant Device,1837.5,35,,1837.5,percent of total billed charges,Implant Device,1837.5,35,,1837.5,percent of total billed charges,Implant Device,1837.5,35,,1837.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1785,34,"If Charge > 2,000, then 34 percent",1785,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3885.01,
WRIGHT CCP-L3518 LOCKING SCREW 3.5X18MM,C1713,HCPCS,,79008636,CDM,278,RC,,,both,,,1125,832.5,,,832.5,Other,150% of Medicare + 9.63% HCRA Surcharge,506.25,45,,506.25,percent of total billed charges,Critical Access Hospital RCC factor,382.5,34,,382.5,percent of total billed charges,Implant Device,382.5,34,,382.5,percent of total billed charges,Implant Device,382.5,34,,382.5,percent of total billed charges,Implant Device,382.5,34,,382.5,percent of total billed charges,Implant Device,382.5,34,,382.5,percent of total billed charges,Implant Device,556.88,,,556.88,Other,110% of Medicare,393.75,35,,393.75,percent of total billed charges,Implant Device,382.5,34,"Charges > $500, x 34%",382.5,percent of total billed charges,Implant Device,393.75,35,,393.75,percent of total billed charges,Implant Device,393.75,35,,393.75,percent of total billed charges,Implant Device,393.75,35,,393.75,percent of total billed charges,Implant Device,393.75,35,,393.75,percent of total billed charges,Implant Device,393.75,35,,393.75,percent of total billed charges,Implant Device,450,40,,450,percent of total billed charges,Implant Device,393.75,70,,393.75,percent of total billed charges,All Other,382.5,34,,382.5,percent of total billed charges,Implant Device,382.5,34,,382.5,percent of total billed charges,Implant Device,393.75,35,,393.75,percent of total billed charges,Implant Device,393.75,35,,393.75,percent of total billed charges,Implant Device,393.75,35,,393.75,percent of total billed charges,Implant Device,393.75,35,,393.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,832.5,
DEPUY 1975-24-085 CONICL PROX BODY 24X85,C1776,HCPCS,,79008637,CDM,278,RC,,,both,,,17671,13076.58,,,13076.58,Other,150% of Medicare + 9.63% HCRA Surcharge,7951.95,45,,7951.95,percent of total billed charges,Critical Access Hospital RCC factor,6008.14,34,,6008.14,percent of total billed charges,Implant Device,6008.14,34,,6008.14,percent of total billed charges,Implant Device,6008.14,34,,6008.14,percent of total billed charges,Implant Device,6008.14,34,,6008.14,percent of total billed charges,Implant Device,6008.14,34,,6008.14,percent of total billed charges,Implant Device,8747.15,,,8747.15,Other,110% of Medicare,6184.85,35,,6184.85,percent of total billed charges,Implant Device,6008.14,34,"Charges > $500, x 34%",6008.14,percent of total billed charges,Implant Device,6184.85,35,,6184.85,percent of total billed charges,Implant Device,6184.85,35,,6184.85,percent of total billed charges,Implant Device,6184.85,35,,6184.85,percent of total billed charges,Implant Device,6184.85,35,,6184.85,percent of total billed charges,Implant Device,6184.85,35,,6184.85,percent of total billed charges,Implant Device,7068.4,40,,7068.4,percent of total billed charges,Implant Device,6184.85,70,,6184.85,percent of total billed charges,All Other,6008.14,34,,6008.14,percent of total billed charges,Implant Device,6008.14,34,,6008.14,percent of total billed charges,Implant Device,6184.85,35,,6184.85,percent of total billed charges,Implant Device,6184.85,35,,6184.85,percent of total billed charges,Implant Device,6184.85,35,,6184.85,percent of total billed charges,Implant Device,6184.85,35,,6184.85,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,6008.14,34,"If Charge > 2,000, then 34 percent",6008.14,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,13076.58,
DEPUY 1976-19-190 DIS TAPERD STEM 19X190,C1776,HCPCS,,79008638,CDM,278,RC,,,both,,,15478,11453.76,,,11453.76,Other,150% of Medicare + 9.63% HCRA Surcharge,6965.1,45,,6965.1,percent of total billed charges,Critical Access Hospital RCC factor,5262.52,34,,5262.52,percent of total billed charges,Implant Device,5262.52,34,,5262.52,percent of total billed charges,Implant Device,5262.52,34,,5262.52,percent of total billed charges,Implant Device,5262.52,34,,5262.52,percent of total billed charges,Implant Device,5262.52,34,,5262.52,percent of total billed charges,Implant Device,7661.61,,,7661.61,Other,110% of Medicare,5417.3,35,,5417.3,percent of total billed charges,Implant Device,5262.52,34,"Charges > $500, x 34%",5262.52,percent of total billed charges,Implant Device,5417.3,35,,5417.3,percent of total billed charges,Implant Device,5417.3,35,,5417.3,percent of total billed charges,Implant Device,5417.3,35,,5417.3,percent of total billed charges,Implant Device,5417.3,35,,5417.3,percent of total billed charges,Implant Device,5417.3,35,,5417.3,percent of total billed charges,Implant Device,6191.2,40,,6191.2,percent of total billed charges,Implant Device,5417.3,70,,5417.3,percent of total billed charges,All Other,5262.52,34,,5262.52,percent of total billed charges,Implant Device,5262.52,34,,5262.52,percent of total billed charges,Implant Device,5417.3,35,,5417.3,percent of total billed charges,Implant Device,5417.3,35,,5417.3,percent of total billed charges,Implant Device,5417.3,35,,5417.3,percent of total billed charges,Implant Device,5417.3,35,,5417.3,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,5262.52,34,"If Charge > 2,000, then 34 percent",5262.52,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,11453.76,
DEPUY 1739-28-000 CABLE&SLEEVE 1.8MMX24,C1713,HCPCS,,79008639,CDM,278,RC,,,both,,,1877,1388.98,,,1388.98,Other,150% of Medicare + 9.63% HCRA Surcharge,844.65,45,,844.65,percent of total billed charges,Critical Access Hospital RCC factor,638.18,34,,638.18,percent of total billed charges,Implant Device,638.18,34,,638.18,percent of total billed charges,Implant Device,638.18,34,,638.18,percent of total billed charges,Implant Device,638.18,34,,638.18,percent of total billed charges,Implant Device,638.18,34,,638.18,percent of total billed charges,Implant Device,929.12,,,929.12,Other,110% of Medicare,656.95,35,,656.95,percent of total billed charges,Implant Device,638.18,34,"Charges > $500, x 34%",638.18,percent of total billed charges,Implant Device,656.95,35,,656.95,percent of total billed charges,Implant Device,656.95,35,,656.95,percent of total billed charges,Implant Device,656.95,35,,656.95,percent of total billed charges,Implant Device,656.95,35,,656.95,percent of total billed charges,Implant Device,656.95,35,,656.95,percent of total billed charges,Implant Device,750.8,40,,750.8,percent of total billed charges,Implant Device,656.95,70,,656.95,percent of total billed charges,All Other,638.18,34,,638.18,percent of total billed charges,Implant Device,638.18,34,,638.18,percent of total billed charges,Implant Device,656.95,35,,656.95,percent of total billed charges,Implant Device,656.95,35,,656.95,percent of total billed charges,Implant Device,656.95,35,,656.95,percent of total billed charges,Implant Device,656.95,35,,656.95,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1388.98,
DEPUY 207.736 4.0X36MM CANN LONG SCREW,C1713,HCPCS,,79008640,CDM,278,RC,,,both,,,686,507.64,,,507.64,Other,150% of Medicare + 9.63% HCRA Surcharge,308.7,45,,308.7,percent of total billed charges,Critical Access Hospital RCC factor,233.24,34,,233.24,percent of total billed charges,Implant Device,233.24,34,,233.24,percent of total billed charges,Implant Device,233.24,34,,233.24,percent of total billed charges,Implant Device,233.24,34,,233.24,percent of total billed charges,Implant Device,233.24,34,,233.24,percent of total billed charges,Implant Device,339.57,,,339.57,Other,110% of Medicare,240.1,35,,240.1,percent of total billed charges,Implant Device,233.24,34,"Charges > $500, x 34%",233.24,percent of total billed charges,Implant Device,240.1,35,,240.1,percent of total billed charges,Implant Device,240.1,35,,240.1,percent of total billed charges,Implant Device,240.1,35,,240.1,percent of total billed charges,Implant Device,240.1,35,,240.1,percent of total billed charges,Implant Device,240.1,35,,240.1,percent of total billed charges,Implant Device,274.4,40,,274.4,percent of total billed charges,Implant Device,240.1,70,,240.1,percent of total billed charges,All Other,233.24,34,,233.24,percent of total billed charges,Implant Device,233.24,34,,233.24,percent of total billed charges,Implant Device,240.1,35,,240.1,percent of total billed charges,Implant Device,240.1,35,,240.1,percent of total billed charges,Implant Device,240.1,35,,240.1,percent of total billed charges,Implant Device,240.1,35,,240.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,507.64,
STRYKER PLSS3018 ANCHORAGE SCREW 3X18MM,C1713,HCPCS,,79008641,CDM,278,RC,,,both,,,675,499.5,,,499.5,Other,150% of Medicare + 9.63% HCRA Surcharge,303.75,45,,303.75,percent of total billed charges,Critical Access Hospital RCC factor,229.5,34,,229.5,percent of total billed charges,Implant Device,229.5,34,,229.5,percent of total billed charges,Implant Device,229.5,34,,229.5,percent of total billed charges,Implant Device,229.5,34,,229.5,percent of total billed charges,Implant Device,229.5,34,,229.5,percent of total billed charges,Implant Device,334.13,,,334.13,Other,110% of Medicare,236.25,35,,236.25,percent of total billed charges,Implant Device,229.5,34,"Charges > $500, x 34%",229.5,percent of total billed charges,Implant Device,236.25,35,,236.25,percent of total billed charges,Implant Device,236.25,35,,236.25,percent of total billed charges,Implant Device,236.25,35,,236.25,percent of total billed charges,Implant Device,236.25,35,,236.25,percent of total billed charges,Implant Device,236.25,35,,236.25,percent of total billed charges,Implant Device,270,40,,270,percent of total billed charges,Implant Device,236.25,70,,236.25,percent of total billed charges,All Other,229.5,34,,229.5,percent of total billed charges,Implant Device,229.5,34,,229.5,percent of total billed charges,Implant Device,236.25,35,,236.25,percent of total billed charges,Implant Device,236.25,35,,236.25,percent of total billed charges,Implant Device,236.25,35,,236.25,percent of total billed charges,Implant Device,236.25,35,,236.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,499.5,
STRYKER PLSS3020 ANCHORAGE SCREW 3X20MM,C1713,HCPCS,,79008642,CDM,278,RC,,,both,,,759,561.66,,,561.66,Other,150% of Medicare + 9.63% HCRA Surcharge,341.55,45,,341.55,percent of total billed charges,Critical Access Hospital RCC factor,258.06,34,,258.06,percent of total billed charges,Implant Device,258.06,34,,258.06,percent of total billed charges,Implant Device,258.06,34,,258.06,percent of total billed charges,Implant Device,258.06,34,,258.06,percent of total billed charges,Implant Device,258.06,34,,258.06,percent of total billed charges,Implant Device,375.71,,,375.71,Other,110% of Medicare,265.65,35,,265.65,percent of total billed charges,Implant Device,258.06,34,"Charges > $500, x 34%",258.06,percent of total billed charges,Implant Device,265.65,35,,265.65,percent of total billed charges,Implant Device,265.65,35,,265.65,percent of total billed charges,Implant Device,265.65,35,,265.65,percent of total billed charges,Implant Device,265.65,35,,265.65,percent of total billed charges,Implant Device,265.65,35,,265.65,percent of total billed charges,Implant Device,303.6,40,,303.6,percent of total billed charges,Implant Device,265.65,70,,265.65,percent of total billed charges,All Other,258.06,34,,258.06,percent of total billed charges,Implant Device,258.06,34,,258.06,percent of total billed charges,Implant Device,265.65,35,,265.65,percent of total billed charges,Implant Device,265.65,35,,265.65,percent of total billed charges,Implant Device,265.65,35,,265.65,percent of total billed charges,Implant Device,265.65,35,,265.65,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,561.66,
STRYKER 2102-2110 VITOSS FOAM STRIP,C1713,HCPCS,,79008643,CDM,278,RC,,,both,,,14412,10664.92,,,10664.92,Other,150% of Medicare + 9.63% HCRA Surcharge,6485.4,45,,6485.4,percent of total billed charges,Critical Access Hospital RCC factor,4900.08,34,,4900.08,percent of total billed charges,Implant Device,4900.08,34,,4900.08,percent of total billed charges,Implant Device,4900.08,34,,4900.08,percent of total billed charges,Implant Device,4900.08,34,,4900.08,percent of total billed charges,Implant Device,4900.08,34,,4900.08,percent of total billed charges,Implant Device,7133.94,,,7133.94,Other,110% of Medicare,5044.2,35,,5044.2,percent of total billed charges,Implant Device,4900.08,34,"Charges > $500, x 34%",4900.08,percent of total billed charges,Implant Device,5044.2,35,,5044.2,percent of total billed charges,Implant Device,5044.2,35,,5044.2,percent of total billed charges,Implant Device,5044.2,35,,5044.2,percent of total billed charges,Implant Device,5044.2,35,,5044.2,percent of total billed charges,Implant Device,5044.2,35,,5044.2,percent of total billed charges,Implant Device,5764.8,40,,5764.8,percent of total billed charges,Implant Device,5044.2,70,,5044.2,percent of total billed charges,All Other,4900.08,34,,4900.08,percent of total billed charges,Implant Device,4900.08,34,,4900.08,percent of total billed charges,Implant Device,5044.2,35,,5044.2,percent of total billed charges,Implant Device,5044.2,35,,5044.2,percent of total billed charges,Implant Device,5044.2,35,,5044.2,percent of total billed charges,Implant Device,5044.2,35,,5044.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,4900.08,34,"If Charge > 2,000, then 34 percent",4900.08,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,10664.92,
STRYKER 601665 CANNULATED SCREW 5X65MM,C1713,HCPCS,,79008644,CDM,278,RC,,,both,,,847,626.78,,,626.78,Other,150% of Medicare + 9.63% HCRA Surcharge,381.15,45,,381.15,percent of total billed charges,Critical Access Hospital RCC factor,287.98,34,,287.98,percent of total billed charges,Implant Device,287.98,34,,287.98,percent of total billed charges,Implant Device,287.98,34,,287.98,percent of total billed charges,Implant Device,287.98,34,,287.98,percent of total billed charges,Implant Device,287.98,34,,287.98,percent of total billed charges,Implant Device,419.27,,,419.27,Other,110% of Medicare,296.45,35,,296.45,percent of total billed charges,Implant Device,287.98,34,"Charges > $500, x 34%",287.98,percent of total billed charges,Implant Device,296.45,35,,296.45,percent of total billed charges,Implant Device,296.45,35,,296.45,percent of total billed charges,Implant Device,296.45,35,,296.45,percent of total billed charges,Implant Device,296.45,35,,296.45,percent of total billed charges,Implant Device,296.45,35,,296.45,percent of total billed charges,Implant Device,338.8,40,,338.8,percent of total billed charges,Implant Device,296.45,70,,296.45,percent of total billed charges,All Other,287.98,34,,287.98,percent of total billed charges,Implant Device,287.98,34,,287.98,percent of total billed charges,Implant Device,296.45,35,,296.45,percent of total billed charges,Implant Device,296.45,35,,296.45,percent of total billed charges,Implant Device,296.45,35,,296.45,percent of total billed charges,Implant Device,296.45,35,,296.45,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,626.78,
STRYKER 5017-2-150S HALF PIN 5MM 150X20,C1713,HCPCS,,79008647,CDM,278,RC,,,both,,,752,556.48,,,556.48,Other,150% of Medicare + 9.63% HCRA Surcharge,338.4,45,,338.4,percent of total billed charges,Critical Access Hospital RCC factor,255.68,34,,255.68,percent of total billed charges,Implant Device,255.68,34,,255.68,percent of total billed charges,Implant Device,255.68,34,,255.68,percent of total billed charges,Implant Device,255.68,34,,255.68,percent of total billed charges,Implant Device,255.68,34,,255.68,percent of total billed charges,Implant Device,372.24,,,372.24,Other,110% of Medicare,263.2,35,,263.2,percent of total billed charges,Implant Device,255.68,34,"Charges > $500, x 34%",255.68,percent of total billed charges,Implant Device,263.2,35,,263.2,percent of total billed charges,Implant Device,263.2,35,,263.2,percent of total billed charges,Implant Device,263.2,35,,263.2,percent of total billed charges,Implant Device,263.2,35,,263.2,percent of total billed charges,Implant Device,263.2,35,,263.2,percent of total billed charges,Implant Device,300.8,40,,300.8,percent of total billed charges,Implant Device,263.2,70,,263.2,percent of total billed charges,All Other,255.68,34,,255.68,percent of total billed charges,Implant Device,255.68,34,,255.68,percent of total billed charges,Implant Device,263.2,35,,263.2,percent of total billed charges,Implant Device,263.2,35,,263.2,percent of total billed charges,Implant Device,263.2,35,,263.2,percent of total billed charges,Implant Device,263.2,35,,263.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,556.48,
ARTHREX AR-8970TTC LATERAL CALCANEAL PLT,C1713,HCPCS,,79008652,CDM,278,RC,,,both,,,9324,6899.78,,,6899.78,Other,150% of Medicare + 9.63% HCRA Surcharge,4195.8,45,,4195.8,percent of total billed charges,Critical Access Hospital RCC factor,3170.16,34,,3170.16,percent of total billed charges,Implant Device,3170.16,34,,3170.16,percent of total billed charges,Implant Device,3170.16,34,,3170.16,percent of total billed charges,Implant Device,3170.16,34,,3170.16,percent of total billed charges,Implant Device,3170.16,34,,3170.16,percent of total billed charges,Implant Device,4615.38,,,4615.38,Other,110% of Medicare,3263.4,35,,3263.4,percent of total billed charges,Implant Device,3170.16,34,"Charges > $500, x 34%",3170.16,percent of total billed charges,Implant Device,3263.4,35,,3263.4,percent of total billed charges,Implant Device,3263.4,35,,3263.4,percent of total billed charges,Implant Device,3263.4,35,,3263.4,percent of total billed charges,Implant Device,3263.4,35,,3263.4,percent of total billed charges,Implant Device,3263.4,35,,3263.4,percent of total billed charges,Implant Device,3729.6,40,,3729.6,percent of total billed charges,Implant Device,3263.4,70,,3263.4,percent of total billed charges,All Other,3170.16,34,,3170.16,percent of total billed charges,Implant Device,3170.16,34,,3170.16,percent of total billed charges,Implant Device,3263.4,35,,3263.4,percent of total billed charges,Implant Device,3263.4,35,,3263.4,percent of total billed charges,Implant Device,3263.4,35,,3263.4,percent of total billed charges,Implant Device,3263.4,35,,3263.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3170.16,34,"If Charge > 2,000, then 34 percent",3170.16,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,6899.78,
ARTHREX AR-8545-40 CORT SCREW 4.5X40MM,C1713,HCPCS,,79008653,CDM,278,RC,,,both,,,225,166.5,,,166.5,Other,150% of Medicare + 9.63% HCRA Surcharge,101.25,45,,101.25,percent of total billed charges,Critical Access Hospital RCC factor,76.5,34,,76.5,percent of total billed charges,Implant Device,76.5,34,,76.5,percent of total billed charges,Implant Device,76.5,34,,76.5,percent of total billed charges,Implant Device,76.5,34,,76.5,percent of total billed charges,Implant Device,76.5,34,,76.5,percent of total billed charges,Implant Device,111.38,,,111.38,Other,110% of Medicare,78.75,35,,78.75,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,78.75,35,,78.75,percent of total billed charges,Implant Device,78.75,35,,78.75,percent of total billed charges,Implant Device,78.75,35,,78.75,percent of total billed charges,Implant Device,78.75,35,,78.75,percent of total billed charges,Implant Device,78.75,35,,78.75,percent of total billed charges,Implant Device,90,40,,90,percent of total billed charges,Implant Device,78.75,70,,78.75,percent of total billed charges,All Other,76.5,34,,76.5,percent of total billed charges,Implant Device,76.5,34,,76.5,percent of total billed charges,Implant Device,78.75,35,,78.75,percent of total billed charges,Implant Device,78.75,35,,78.75,percent of total billed charges,Implant Device,78.75,35,,78.75,percent of total billed charges,Implant Device,78.75,35,,78.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,166.5,
ARTHREX AR-8545-45 CORT SCREW 4.5X45MM,C1713,HCPCS,,79008654,CDM,278,RC,,,both,,,225,166.5,,,166.5,Other,150% of Medicare + 9.63% HCRA Surcharge,101.25,45,,101.25,percent of total billed charges,Critical Access Hospital RCC factor,76.5,34,,76.5,percent of total billed charges,Implant Device,76.5,34,,76.5,percent of total billed charges,Implant Device,76.5,34,,76.5,percent of total billed charges,Implant Device,76.5,34,,76.5,percent of total billed charges,Implant Device,76.5,34,,76.5,percent of total billed charges,Implant Device,111.38,,,111.38,Other,110% of Medicare,78.75,35,,78.75,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,78.75,35,,78.75,percent of total billed charges,Implant Device,78.75,35,,78.75,percent of total billed charges,Implant Device,78.75,35,,78.75,percent of total billed charges,Implant Device,78.75,35,,78.75,percent of total billed charges,Implant Device,78.75,35,,78.75,percent of total billed charges,Implant Device,90,40,,90,percent of total billed charges,Implant Device,78.75,70,,78.75,percent of total billed charges,All Other,76.5,34,,76.5,percent of total billed charges,Implant Device,76.5,34,,76.5,percent of total billed charges,Implant Device,78.75,35,,78.75,percent of total billed charges,Implant Device,78.75,35,,78.75,percent of total billed charges,Implant Device,78.75,35,,78.75,percent of total billed charges,Implant Device,78.75,35,,78.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,166.5,
ARTHREX AR-8545-50 CORT SCREW 4.5X50MM,C1713,HCPCS,,79008655,CDM,278,RC,,,both,,,225,166.5,,,166.5,Other,150% of Medicare + 9.63% HCRA Surcharge,101.25,45,,101.25,percent of total billed charges,Critical Access Hospital RCC factor,76.5,34,,76.5,percent of total billed charges,Implant Device,76.5,34,,76.5,percent of total billed charges,Implant Device,76.5,34,,76.5,percent of total billed charges,Implant Device,76.5,34,,76.5,percent of total billed charges,Implant Device,76.5,34,,76.5,percent of total billed charges,Implant Device,111.38,,,111.38,Other,110% of Medicare,78.75,35,,78.75,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,78.75,35,,78.75,percent of total billed charges,Implant Device,78.75,35,,78.75,percent of total billed charges,Implant Device,78.75,35,,78.75,percent of total billed charges,Implant Device,78.75,35,,78.75,percent of total billed charges,Implant Device,78.75,35,,78.75,percent of total billed charges,Implant Device,90,40,,90,percent of total billed charges,Implant Device,78.75,70,,78.75,percent of total billed charges,All Other,76.5,34,,76.5,percent of total billed charges,Implant Device,76.5,34,,76.5,percent of total billed charges,Implant Device,78.75,35,,78.75,percent of total billed charges,Implant Device,78.75,35,,78.75,percent of total billed charges,Implant Device,78.75,35,,78.75,percent of total billed charges,Implant Device,78.75,35,,78.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,166.5,
ARTHREX AR-8545L-45 LOCK SCREW 4.5X45MM,C1713,HCPCS,,79008656,CDM,278,RC,,,both,,,837,619.38,,,619.38,Other,150% of Medicare + 9.63% HCRA Surcharge,376.65,45,,376.65,percent of total billed charges,Critical Access Hospital RCC factor,284.58,34,,284.58,percent of total billed charges,Implant Device,284.58,34,,284.58,percent of total billed charges,Implant Device,284.58,34,,284.58,percent of total billed charges,Implant Device,284.58,34,,284.58,percent of total billed charges,Implant Device,284.58,34,,284.58,percent of total billed charges,Implant Device,414.32,,,414.32,Other,110% of Medicare,292.95,35,,292.95,percent of total billed charges,Implant Device,284.58,34,"Charges > $500, x 34%",284.58,percent of total billed charges,Implant Device,292.95,35,,292.95,percent of total billed charges,Implant Device,292.95,35,,292.95,percent of total billed charges,Implant Device,292.95,35,,292.95,percent of total billed charges,Implant Device,292.95,35,,292.95,percent of total billed charges,Implant Device,292.95,35,,292.95,percent of total billed charges,Implant Device,334.8,40,,334.8,percent of total billed charges,Implant Device,292.95,70,,292.95,percent of total billed charges,All Other,284.58,34,,284.58,percent of total billed charges,Implant Device,284.58,34,,284.58,percent of total billed charges,Implant Device,292.95,35,,292.95,percent of total billed charges,Implant Device,292.95,35,,292.95,percent of total billed charges,Implant Device,292.95,35,,292.95,percent of total billed charges,Implant Device,292.95,35,,292.95,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,619.38,
ARTHREX AR-8555-45 CANC SCREW 5.5X45MM,C1713,HCPCS,,79008657,CDM,278,RC,,,both,,,324,239.76,,,239.76,Other,150% of Medicare + 9.63% HCRA Surcharge,145.8,45,,145.8,percent of total billed charges,Critical Access Hospital RCC factor,110.16,34,,110.16,percent of total billed charges,Implant Device,110.16,34,,110.16,percent of total billed charges,Implant Device,110.16,34,,110.16,percent of total billed charges,Implant Device,110.16,34,,110.16,percent of total billed charges,Implant Device,110.16,34,,110.16,percent of total billed charges,Implant Device,160.38,,,160.38,Other,110% of Medicare,113.4,35,,113.4,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,129.6,40,,129.6,percent of total billed charges,Implant Device,113.4,70,,113.4,percent of total billed charges,All Other,110.16,34,,110.16,percent of total billed charges,Implant Device,110.16,34,,110.16,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,239.76,
ARTHREX AR-8555-50 CANC SCREW 5.5X50MM,C1713,HCPCS,,79008658,CDM,278,RC,,,both,,,324,239.76,,,239.76,Other,150% of Medicare + 9.63% HCRA Surcharge,145.8,45,,145.8,percent of total billed charges,Critical Access Hospital RCC factor,110.16,34,,110.16,percent of total billed charges,Implant Device,110.16,34,,110.16,percent of total billed charges,Implant Device,110.16,34,,110.16,percent of total billed charges,Implant Device,110.16,34,,110.16,percent of total billed charges,Implant Device,110.16,34,,110.16,percent of total billed charges,Implant Device,160.38,,,160.38,Other,110% of Medicare,113.4,35,,113.4,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,129.6,40,,129.6,percent of total billed charges,Implant Device,113.4,70,,113.4,percent of total billed charges,All Other,110.16,34,,110.16,percent of total billed charges,Implant Device,110.16,34,,110.16,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,239.76,
ARTHREX AR-8555-65 CANC SCREW 5.5X65MM,C1713,HCPCS,,79008659,CDM,278,RC,,,both,,,324,239.76,,,239.76,Other,150% of Medicare + 9.63% HCRA Surcharge,145.8,45,,145.8,percent of total billed charges,Critical Access Hospital RCC factor,110.16,34,,110.16,percent of total billed charges,Implant Device,110.16,34,,110.16,percent of total billed charges,Implant Device,110.16,34,,110.16,percent of total billed charges,Implant Device,110.16,34,,110.16,percent of total billed charges,Implant Device,110.16,34,,110.16,percent of total billed charges,Implant Device,160.38,,,160.38,Other,110% of Medicare,113.4,35,,113.4,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,129.6,40,,129.6,percent of total billed charges,Implant Device,113.4,70,,113.4,percent of total billed charges,All Other,110.16,34,,110.16,percent of total billed charges,Implant Device,110.16,34,,110.16,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,239.76,
MENTOR 350-1751BC BREAST IMPLANT 175CC,C1789,HCPCS,,79008661,CDM,278,RC,,,both,,,2865,2120.11,,,2120.11,Other,150% of Medicare + 9.63% HCRA Surcharge,1289.25,45,,1289.25,percent of total billed charges,Critical Access Hospital RCC factor,974.1,34,,974.1,percent of total billed charges,Implant Device,974.1,34,,974.1,percent of total billed charges,Implant Device,974.1,34,,974.1,percent of total billed charges,Implant Device,974.1,34,,974.1,percent of total billed charges,Implant Device,974.1,34,,974.1,percent of total billed charges,Implant Device,1418.18,,,1418.18,Other,110% of Medicare,1002.75,35,,1002.75,percent of total billed charges,Implant Device,974.1,34,"Charges > $500, x 34%",974.1,percent of total billed charges,Implant Device,1002.75,35,,1002.75,percent of total billed charges,Implant Device,1002.75,35,,1002.75,percent of total billed charges,Implant Device,1002.75,35,,1002.75,percent of total billed charges,Implant Device,1002.75,35,,1002.75,percent of total billed charges,Implant Device,1002.75,35,,1002.75,percent of total billed charges,Implant Device,1146,40,,1146,percent of total billed charges,Implant Device,1002.75,70,,1002.75,percent of total billed charges,All Other,974.1,34,,974.1,percent of total billed charges,Implant Device,974.1,34,,974.1,percent of total billed charges,Implant Device,1002.75,35,,1002.75,percent of total billed charges,Implant Device,1002.75,35,,1002.75,percent of total billed charges,Implant Device,1002.75,35,,1002.75,percent of total billed charges,Implant Device,1002.75,35,,1002.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,974.1,34,"If Charge > 2,000, then 34 percent",974.1,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2120.11,
MENTOR 350-3751BC BREAST IMPLANT 375CC,C1789,HCPCS,,79008662,CDM,278,RC,,,both,,,2865,2120.11,,,2120.11,Other,150% of Medicare + 9.63% HCRA Surcharge,1289.25,45,,1289.25,percent of total billed charges,Critical Access Hospital RCC factor,974.1,34,,974.1,percent of total billed charges,Implant Device,974.1,34,,974.1,percent of total billed charges,Implant Device,974.1,34,,974.1,percent of total billed charges,Implant Device,974.1,34,,974.1,percent of total billed charges,Implant Device,974.1,34,,974.1,percent of total billed charges,Implant Device,1418.18,,,1418.18,Other,110% of Medicare,1002.75,35,,1002.75,percent of total billed charges,Implant Device,974.1,34,"Charges > $500, x 34%",974.1,percent of total billed charges,Implant Device,1002.75,35,,1002.75,percent of total billed charges,Implant Device,1002.75,35,,1002.75,percent of total billed charges,Implant Device,1002.75,35,,1002.75,percent of total billed charges,Implant Device,1002.75,35,,1002.75,percent of total billed charges,Implant Device,1002.75,35,,1002.75,percent of total billed charges,Implant Device,1146,40,,1146,percent of total billed charges,Implant Device,1002.75,70,,1002.75,percent of total billed charges,All Other,974.1,34,,974.1,percent of total billed charges,Implant Device,974.1,34,,974.1,percent of total billed charges,Implant Device,1002.75,35,,1002.75,percent of total billed charges,Implant Device,1002.75,35,,1002.75,percent of total billed charges,Implant Device,1002.75,35,,1002.75,percent of total billed charges,Implant Device,1002.75,35,,1002.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,974.1,34,"If Charge > 2,000, then 34 percent",974.1,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2120.11,
STRYKER 657420 NON LOCK SCREW 3.5X20MM,C1713,HCPCS,,79008663,CDM,278,RC,,,both,,,294,217.56,,,217.56,Other,150% of Medicare + 9.63% HCRA Surcharge,132.3,45,,132.3,percent of total billed charges,Critical Access Hospital RCC factor,99.96,34,,99.96,percent of total billed charges,Implant Device,99.96,34,,99.96,percent of total billed charges,Implant Device,99.96,34,,99.96,percent of total billed charges,Implant Device,99.96,34,,99.96,percent of total billed charges,Implant Device,99.96,34,,99.96,percent of total billed charges,Implant Device,145.53,,,145.53,Other,110% of Medicare,102.9,35,,102.9,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,102.9,35,,102.9,percent of total billed charges,Implant Device,102.9,35,,102.9,percent of total billed charges,Implant Device,102.9,35,,102.9,percent of total billed charges,Implant Device,102.9,35,,102.9,percent of total billed charges,Implant Device,102.9,35,,102.9,percent of total billed charges,Implant Device,117.6,40,,117.6,percent of total billed charges,Implant Device,102.9,70,,102.9,percent of total billed charges,All Other,99.96,34,,99.96,percent of total billed charges,Implant Device,99.96,34,,99.96,percent of total billed charges,Implant Device,102.9,35,,102.9,percent of total billed charges,Implant Device,102.9,35,,102.9,percent of total billed charges,Implant Device,102.9,35,,102.9,percent of total billed charges,Implant Device,102.9,35,,102.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,217.56,
STRYKER 657316 LOCKING SCREW 3.5X16MM,C1713,HCPCS,,79008664,CDM,278,RC,,,both,,,539,398.86,,,398.86,Other,150% of Medicare + 9.63% HCRA Surcharge,242.55,45,,242.55,percent of total billed charges,Critical Access Hospital RCC factor,183.26,34,,183.26,percent of total billed charges,Implant Device,183.26,34,,183.26,percent of total billed charges,Implant Device,183.26,34,,183.26,percent of total billed charges,Implant Device,183.26,34,,183.26,percent of total billed charges,Implant Device,183.26,34,,183.26,percent of total billed charges,Implant Device,266.81,,,266.81,Other,110% of Medicare,188.65,35,,188.65,percent of total billed charges,Implant Device,183.26,34,"Charges > $500, x 34%",183.26,percent of total billed charges,Implant Device,188.65,35,,188.65,percent of total billed charges,Implant Device,188.65,35,,188.65,percent of total billed charges,Implant Device,188.65,35,,188.65,percent of total billed charges,Implant Device,188.65,35,,188.65,percent of total billed charges,Implant Device,188.65,35,,188.65,percent of total billed charges,Implant Device,215.6,40,,215.6,percent of total billed charges,Implant Device,188.65,70,,188.65,percent of total billed charges,All Other,183.26,34,,183.26,percent of total billed charges,Implant Device,183.26,34,,183.26,percent of total billed charges,Implant Device,188.65,35,,188.65,percent of total billed charges,Implant Device,188.65,35,,188.65,percent of total billed charges,Implant Device,188.65,35,,188.65,percent of total billed charges,Implant Device,188.65,35,,188.65,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,398.86,
MENTOR 354-9114 TISSUE EXPANDER 550CC,C1789,HCPCS,,79008665,CDM,278,RC,,,both,,,4935,3651.91,,,3651.91,Other,150% of Medicare + 9.63% HCRA Surcharge,2220.75,45,,2220.75,percent of total billed charges,Critical Access Hospital RCC factor,1677.9,34,,1677.9,percent of total billed charges,Implant Device,1677.9,34,,1677.9,percent of total billed charges,Implant Device,1677.9,34,,1677.9,percent of total billed charges,Implant Device,1677.9,34,,1677.9,percent of total billed charges,Implant Device,1677.9,34,,1677.9,percent of total billed charges,Implant Device,2442.83,,,2442.83,Other,110% of Medicare,1727.25,35,,1727.25,percent of total billed charges,Implant Device,1677.9,34,"Charges > $500, x 34%",1677.9,percent of total billed charges,Implant Device,1727.25,35,,1727.25,percent of total billed charges,Implant Device,1727.25,35,,1727.25,percent of total billed charges,Implant Device,1727.25,35,,1727.25,percent of total billed charges,Implant Device,1727.25,35,,1727.25,percent of total billed charges,Implant Device,1727.25,35,,1727.25,percent of total billed charges,Implant Device,1974,40,,1974,percent of total billed charges,Implant Device,1727.25,70,,1727.25,percent of total billed charges,All Other,1677.9,34,,1677.9,percent of total billed charges,Implant Device,1677.9,34,,1677.9,percent of total billed charges,Implant Device,1727.25,35,,1727.25,percent of total billed charges,Implant Device,1727.25,35,,1727.25,percent of total billed charges,Implant Device,1727.25,35,,1727.25,percent of total billed charges,Implant Device,1727.25,35,,1727.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1677.9,34,"If Charge > 2,000, then 34 percent",1677.9,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3651.91,
MENTOR 354-9214 TISSUE EXPANDER 550CC,C1789,HCPCS,,79008666,CDM,278,RC,,,both,,,5085,3762.91,,,3762.91,Other,150% of Medicare + 9.63% HCRA Surcharge,2288.25,45,,2288.25,percent of total billed charges,Critical Access Hospital RCC factor,1728.9,34,,1728.9,percent of total billed charges,Implant Device,1728.9,34,,1728.9,percent of total billed charges,Implant Device,1728.9,34,,1728.9,percent of total billed charges,Implant Device,1728.9,34,,1728.9,percent of total billed charges,Implant Device,1728.9,34,,1728.9,percent of total billed charges,Implant Device,2517.08,,,2517.08,Other,110% of Medicare,1779.75,35,,1779.75,percent of total billed charges,Implant Device,1728.9,34,"Charges > $500, x 34%",1728.9,percent of total billed charges,Implant Device,1779.75,35,,1779.75,percent of total billed charges,Implant Device,1779.75,35,,1779.75,percent of total billed charges,Implant Device,1779.75,35,,1779.75,percent of total billed charges,Implant Device,1779.75,35,,1779.75,percent of total billed charges,Implant Device,1779.75,35,,1779.75,percent of total billed charges,Implant Device,2034,40,,2034,percent of total billed charges,Implant Device,1779.75,70,,1779.75,percent of total billed charges,All Other,1728.9,34,,1728.9,percent of total billed charges,Implant Device,1728.9,34,,1728.9,percent of total billed charges,Implant Device,1779.75,35,,1779.75,percent of total billed charges,Implant Device,1779.75,35,,1779.75,percent of total billed charges,Implant Device,1779.75,35,,1779.75,percent of total billed charges,Implant Device,1779.75,35,,1779.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1728.9,34,"If Charge > 2,000, then 34 percent",1728.9,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3762.91,
MENTOR TEXP140RH TISSUE EXPANDER 600CC,C1789,HCPCS,,79008667,CDM,278,RC,,,both,,,6375,4717.52,,,4717.52,Other,150% of Medicare + 9.63% HCRA Surcharge,2868.75,45,,2868.75,percent of total billed charges,Critical Access Hospital RCC factor,2167.5,34,,2167.5,percent of total billed charges,Implant Device,2167.5,34,,2167.5,percent of total billed charges,Implant Device,2167.5,34,,2167.5,percent of total billed charges,Implant Device,2167.5,34,,2167.5,percent of total billed charges,Implant Device,2167.5,34,,2167.5,percent of total billed charges,Implant Device,3155.63,,,3155.63,Other,110% of Medicare,2231.25,35,,2231.25,percent of total billed charges,Implant Device,2167.5,34,"Charges > $500, x 34%",2167.5,percent of total billed charges,Implant Device,2231.25,35,,2231.25,percent of total billed charges,Implant Device,2231.25,35,,2231.25,percent of total billed charges,Implant Device,2231.25,35,,2231.25,percent of total billed charges,Implant Device,2231.25,35,,2231.25,percent of total billed charges,Implant Device,2231.25,35,,2231.25,percent of total billed charges,Implant Device,2550,40,,2550,percent of total billed charges,Implant Device,2231.25,70,,2231.25,percent of total billed charges,All Other,2167.5,34,,2167.5,percent of total billed charges,Implant Device,2167.5,34,,2167.5,percent of total billed charges,Implant Device,2231.25,35,,2231.25,percent of total billed charges,Implant Device,2231.25,35,,2231.25,percent of total billed charges,Implant Device,2231.25,35,,2231.25,percent of total billed charges,Implant Device,2231.25,35,,2231.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2167.5,34,"If Charge > 2,000, then 34 percent",2167.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4717.52,
VILEX CHI-2TH HEMI IMPLANT W/ COATING,C1776,HCPCS,,79008669,CDM,278,RC,,,both,,,1988,1471.12,,,1471.12,Other,150% of Medicare + 9.63% HCRA Surcharge,894.6,45,,894.6,percent of total billed charges,Critical Access Hospital RCC factor,675.92,34,,675.92,percent of total billed charges,Implant Device,675.92,34,,675.92,percent of total billed charges,Implant Device,675.92,34,,675.92,percent of total billed charges,Implant Device,675.92,34,,675.92,percent of total billed charges,Implant Device,675.92,34,,675.92,percent of total billed charges,Implant Device,984.06,,,984.06,Other,110% of Medicare,695.8,35,,695.8,percent of total billed charges,Implant Device,675.92,34,"Charges > $500, x 34%",675.92,percent of total billed charges,Implant Device,695.8,35,,695.8,percent of total billed charges,Implant Device,695.8,35,,695.8,percent of total billed charges,Implant Device,695.8,35,,695.8,percent of total billed charges,Implant Device,695.8,35,,695.8,percent of total billed charges,Implant Device,695.8,35,,695.8,percent of total billed charges,Implant Device,795.2,40,,795.2,percent of total billed charges,Implant Device,695.8,70,,695.8,percent of total billed charges,All Other,675.92,34,,675.92,percent of total billed charges,Implant Device,675.92,34,,675.92,percent of total billed charges,Implant Device,695.8,35,,695.8,percent of total billed charges,Implant Device,695.8,35,,695.8,percent of total billed charges,Implant Device,695.8,35,,695.8,percent of total billed charges,Implant Device,695.8,35,,695.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1471.12,
BOSTON M00516900 ESOPHAGEAL STENT 18X103,C1874,HCPCS,,79008670,CDM,278,RC,,,both,,,7222,5344.3,,,5344.3,Other,150% of Medicare + 9.63% HCRA Surcharge,3249.9,45,,3249.9,percent of total billed charges,Critical Access Hospital RCC factor,2455.48,34,,2455.48,percent of total billed charges,Implant Device,2455.48,34,,2455.48,percent of total billed charges,Implant Device,2455.48,34,,2455.48,percent of total billed charges,Implant Device,2455.48,34,,2455.48,percent of total billed charges,Implant Device,2455.48,34,,2455.48,percent of total billed charges,Implant Device,3574.89,,,3574.89,Other,110% of Medicare,2527.7,35,,2527.7,percent of total billed charges,Implant Device,2455.48,34,"Charges > $500, x 34%",2455.48,percent of total billed charges,Implant Device,2527.7,35,,2527.7,percent of total billed charges,Implant Device,2527.7,35,,2527.7,percent of total billed charges,Implant Device,2527.7,35,,2527.7,percent of total billed charges,Implant Device,2527.7,35,,2527.7,percent of total billed charges,Implant Device,2527.7,35,,2527.7,percent of total billed charges,Implant Device,2888.8,40,,2888.8,percent of total billed charges,Implant Device,2527.7,70,,2527.7,percent of total billed charges,All Other,2455.48,34,,2455.48,percent of total billed charges,Implant Device,2455.48,34,,2455.48,percent of total billed charges,Implant Device,2527.7,35,,2527.7,percent of total billed charges,Implant Device,2527.7,35,,2527.7,percent of total billed charges,Implant Device,2527.7,35,,2527.7,percent of total billed charges,Implant Device,2527.7,35,,2527.7,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2455.48,34,"If Charge > 2,000, then 34 percent",2455.48,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5344.3,
STRYKER 627203 PROX HUMERAL PLATE 3 HOLE,C1713,HCPCS,,79008672,CDM,278,RC,,,both,,,6634,4909.18,,,4909.18,Other,150% of Medicare + 9.63% HCRA Surcharge,2985.3,45,,2985.3,percent of total billed charges,Critical Access Hospital RCC factor,2255.56,34,,2255.56,percent of total billed charges,Implant Device,2255.56,34,,2255.56,percent of total billed charges,Implant Device,2255.56,34,,2255.56,percent of total billed charges,Implant Device,2255.56,34,,2255.56,percent of total billed charges,Implant Device,2255.56,34,,2255.56,percent of total billed charges,Implant Device,3283.83,,,3283.83,Other,110% of Medicare,2321.9,35,,2321.9,percent of total billed charges,Implant Device,2255.56,34,"Charges > $500, x 34%",2255.56,percent of total billed charges,Implant Device,2321.9,35,,2321.9,percent of total billed charges,Implant Device,2321.9,35,,2321.9,percent of total billed charges,Implant Device,2321.9,35,,2321.9,percent of total billed charges,Implant Device,2321.9,35,,2321.9,percent of total billed charges,Implant Device,2321.9,35,,2321.9,percent of total billed charges,Implant Device,2653.6,40,,2653.6,percent of total billed charges,Implant Device,2321.9,70,,2321.9,percent of total billed charges,All Other,2255.56,34,,2255.56,percent of total billed charges,Implant Device,2255.56,34,,2255.56,percent of total billed charges,Implant Device,2321.9,35,,2321.9,percent of total billed charges,Implant Device,2321.9,35,,2321.9,percent of total billed charges,Implant Device,2321.9,35,,2321.9,percent of total billed charges,Implant Device,2321.9,35,,2321.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2255.56,34,"If Charge > 2,000, then 34 percent",2255.56,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4909.18,
DEPUY 1024-07-400 FEM CEMENTED SIZE 4,C1776,HCPCS,,79008673,CDM,278,RC,,,both,,,4200,3108.01,,,3108.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1890,45,,1890,percent of total billed charges,Critical Access Hospital RCC factor,1428,34,,1428,percent of total billed charges,Implant Device,1428,34,,1428,percent of total billed charges,Implant Device,1428,34,,1428,percent of total billed charges,Implant Device,1428,34,,1428,percent of total billed charges,Implant Device,1428,34,,1428,percent of total billed charges,Implant Device,2079,,,2079,Other,110% of Medicare,1470,35,,1470,percent of total billed charges,Implant Device,1428,34,"Charges > $500, x 34%",1428,percent of total billed charges,Implant Device,1470,35,,1470,percent of total billed charges,Implant Device,1470,35,,1470,percent of total billed charges,Implant Device,1470,35,,1470,percent of total billed charges,Implant Device,1470,35,,1470,percent of total billed charges,Implant Device,1470,35,,1470,percent of total billed charges,Implant Device,1680,40,,1680,percent of total billed charges,Implant Device,1470,70,,1470,percent of total billed charges,All Other,1428,34,,1428,percent of total billed charges,Implant Device,1428,34,,1428,percent of total billed charges,Implant Device,1470,35,,1470,percent of total billed charges,Implant Device,1470,35,,1470,percent of total billed charges,Implant Device,1470,35,,1470,percent of total billed charges,Implant Device,1470,35,,1470,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1428,34,"If Charge > 2,000, then 34 percent",1428,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3108.01,
DEPUY 1024-53-307 TIBIAL INS SZ 3 LW/RL,C1776,HCPCS,,79008674,CDM,278,RC,,,both,,,2495,1846.31,,,1846.31,Other,150% of Medicare + 9.63% HCRA Surcharge,1122.75,45,,1122.75,percent of total billed charges,Critical Access Hospital RCC factor,848.3,34,,848.3,percent of total billed charges,Implant Device,848.3,34,,848.3,percent of total billed charges,Implant Device,848.3,34,,848.3,percent of total billed charges,Implant Device,848.3,34,,848.3,percent of total billed charges,Implant Device,848.3,34,,848.3,percent of total billed charges,Implant Device,1235.03,,,1235.03,Other,110% of Medicare,873.25,35,,873.25,percent of total billed charges,Implant Device,848.3,34,"Charges > $500, x 34%",848.3,percent of total billed charges,Implant Device,873.25,35,,873.25,percent of total billed charges,Implant Device,873.25,35,,873.25,percent of total billed charges,Implant Device,873.25,35,,873.25,percent of total billed charges,Implant Device,873.25,35,,873.25,percent of total billed charges,Implant Device,873.25,35,,873.25,percent of total billed charges,Implant Device,998,40,,998,percent of total billed charges,Implant Device,873.25,70,,873.25,percent of total billed charges,All Other,848.3,34,,848.3,percent of total billed charges,Implant Device,848.3,34,,848.3,percent of total billed charges,Implant Device,873.25,35,,873.25,percent of total billed charges,Implant Device,873.25,35,,873.25,percent of total billed charges,Implant Device,873.25,35,,873.25,percent of total billed charges,Implant Device,873.25,35,,873.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,848.3,34,"If Charge > 2,000, then 34 percent",848.3,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1846.31,
DEPUY 1024-51-300 TIBIAL TRAY SZ 3 LM.RL,C1776,HCPCS,,79008675,CDM,278,RC,,,both,,,3600,2664.01,,,2664.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1620,45,,1620,percent of total billed charges,Critical Access Hospital RCC factor,1224,34,,1224,percent of total billed charges,Implant Device,1224,34,,1224,percent of total billed charges,Implant Device,1224,34,,1224,percent of total billed charges,Implant Device,1224,34,,1224,percent of total billed charges,Implant Device,1224,34,,1224,percent of total billed charges,Implant Device,1782,,,1782,Other,110% of Medicare,1260,35,,1260,percent of total billed charges,Implant Device,1224,34,"Charges > $500, x 34%",1224,percent of total billed charges,Implant Device,1260,35,,1260,percent of total billed charges,Implant Device,1260,35,,1260,percent of total billed charges,Implant Device,1260,35,,1260,percent of total billed charges,Implant Device,1260,35,,1260,percent of total billed charges,Implant Device,1260,35,,1260,percent of total billed charges,Implant Device,1440,40,,1440,percent of total billed charges,Implant Device,1260,70,,1260,percent of total billed charges,All Other,1224,34,,1224,percent of total billed charges,Implant Device,1224,34,,1224,percent of total billed charges,Implant Device,1260,35,,1260,percent of total billed charges,Implant Device,1260,35,,1260,percent of total billed charges,Implant Device,1260,35,,1260,percent of total billed charges,Implant Device,1260,35,,1260,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1224,34,"If Charge > 2,000, then 34 percent",1224,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2664.01,
STRYKER 6495-2-040 GMRS DIST FEM COMP 65,C1776,HCPCS,,79008677,CDM,278,RC,,,both,,,18561,13735.19,,,13735.19,Other,150% of Medicare + 9.63% HCRA Surcharge,8352.45,45,,8352.45,percent of total billed charges,Critical Access Hospital RCC factor,6310.74,34,,6310.74,percent of total billed charges,Implant Device,6310.74,34,,6310.74,percent of total billed charges,Implant Device,6310.74,34,,6310.74,percent of total billed charges,Implant Device,6310.74,34,,6310.74,percent of total billed charges,Implant Device,6310.74,34,,6310.74,percent of total billed charges,Implant Device,9187.7,,,9187.7,Other,110% of Medicare,6496.35,35,,6496.35,percent of total billed charges,Implant Device,6310.74,34,"Charges > $500, x 34%",6310.74,percent of total billed charges,Implant Device,6496.35,35,,6496.35,percent of total billed charges,Implant Device,6496.35,35,,6496.35,percent of total billed charges,Implant Device,6496.35,35,,6496.35,percent of total billed charges,Implant Device,6496.35,35,,6496.35,percent of total billed charges,Implant Device,6496.35,35,,6496.35,percent of total billed charges,Implant Device,7424.4,40,,7424.4,percent of total billed charges,Implant Device,6496.35,70,,6496.35,percent of total billed charges,All Other,6310.74,34,,6310.74,percent of total billed charges,Implant Device,6310.74,34,,6310.74,percent of total billed charges,Implant Device,6496.35,35,,6496.35,percent of total billed charges,Implant Device,6496.35,35,,6496.35,percent of total billed charges,Implant Device,6496.35,35,,6496.35,percent of total billed charges,Implant Device,6496.35,35,,6496.35,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,6310.74,34,"If Charge > 2,000, then 34 percent",6310.74,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,13735.19,
STRYKER 6485-3-013 MRS STR STEM 13X127MM,C1776,HCPCS,,79008678,CDM,278,RC,,,both,,,16989,12571.9,,,12571.9,Other,150% of Medicare + 9.63% HCRA Surcharge,7645.05,45,,7645.05,percent of total billed charges,Critical Access Hospital RCC factor,5776.26,34,,5776.26,percent of total billed charges,Implant Device,5776.26,34,,5776.26,percent of total billed charges,Implant Device,5776.26,34,,5776.26,percent of total billed charges,Implant Device,5776.26,34,,5776.26,percent of total billed charges,Implant Device,5776.26,34,,5776.26,percent of total billed charges,Implant Device,8409.56,,,8409.56,Other,110% of Medicare,5946.15,35,,5946.15,percent of total billed charges,Implant Device,5776.26,34,"Charges > $500, x 34%",5776.26,percent of total billed charges,Implant Device,5946.15,35,,5946.15,percent of total billed charges,Implant Device,5946.15,35,,5946.15,percent of total billed charges,Implant Device,5946.15,35,,5946.15,percent of total billed charges,Implant Device,5946.15,35,,5946.15,percent of total billed charges,Implant Device,5946.15,35,,5946.15,percent of total billed charges,Implant Device,6795.6,40,,6795.6,percent of total billed charges,Implant Device,5946.15,70,,5946.15,percent of total billed charges,All Other,5776.26,34,,5776.26,percent of total billed charges,Implant Device,5776.26,34,,5776.26,percent of total billed charges,Implant Device,5946.15,35,,5946.15,percent of total billed charges,Implant Device,5946.15,35,,5946.15,percent of total billed charges,Implant Device,5946.15,35,,5946.15,percent of total billed charges,Implant Device,5946.15,35,,5946.15,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,5776.26,34,"If Charge > 2,000, then 34 percent",5776.26,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,12571.9,
STRYKER 6495-6-060 GMRS EX PIECE,C1776,HCPCS,,79008679,CDM,278,RC,,,both,,,8361,6187.16,,,6187.16,Other,150% of Medicare + 9.63% HCRA Surcharge,3762.45,45,,3762.45,percent of total billed charges,Critical Access Hospital RCC factor,2842.74,34,,2842.74,percent of total billed charges,Implant Device,2842.74,34,,2842.74,percent of total billed charges,Implant Device,2842.74,34,,2842.74,percent of total billed charges,Implant Device,2842.74,34,,2842.74,percent of total billed charges,Implant Device,2842.74,34,,2842.74,percent of total billed charges,Implant Device,4138.7,,,4138.7,Other,110% of Medicare,2926.35,35,,2926.35,percent of total billed charges,Implant Device,2842.74,34,"Charges > $500, x 34%",2842.74,percent of total billed charges,Implant Device,2926.35,35,,2926.35,percent of total billed charges,Implant Device,2926.35,35,,2926.35,percent of total billed charges,Implant Device,2926.35,35,,2926.35,percent of total billed charges,Implant Device,2926.35,35,,2926.35,percent of total billed charges,Implant Device,2926.35,35,,2926.35,percent of total billed charges,Implant Device,3344.4,40,,3344.4,percent of total billed charges,Implant Device,2926.35,70,,2926.35,percent of total billed charges,All Other,2842.74,34,,2842.74,percent of total billed charges,Implant Device,2842.74,34,,2842.74,percent of total billed charges,Implant Device,2926.35,35,,2926.35,percent of total billed charges,Implant Device,2926.35,35,,2926.35,percent of total billed charges,Implant Device,2926.35,35,,2926.35,percent of total billed charges,Implant Device,2926.35,35,,2926.35,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2842.74,34,"If Charge > 2,000, then 34 percent",2842.74,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,6187.16,
STRYKER 6481-2-100 MRH TIBIAL COMPONENT,C1776,HCPCS,,79008680,CDM,278,RC,,,both,,,7694,5693.58,,,5693.58,Other,150% of Medicare + 9.63% HCRA Surcharge,3462.3,45,,3462.3,percent of total billed charges,Critical Access Hospital RCC factor,2615.96,34,,2615.96,percent of total billed charges,Implant Device,2615.96,34,,2615.96,percent of total billed charges,Implant Device,2615.96,34,,2615.96,percent of total billed charges,Implant Device,2615.96,34,,2615.96,percent of total billed charges,Implant Device,2615.96,34,,2615.96,percent of total billed charges,Implant Device,3808.53,,,3808.53,Other,110% of Medicare,2692.9,35,,2692.9,percent of total billed charges,Implant Device,2615.96,34,"Charges > $500, x 34%",2615.96,percent of total billed charges,Implant Device,2692.9,35,,2692.9,percent of total billed charges,Implant Device,2692.9,35,,2692.9,percent of total billed charges,Implant Device,2692.9,35,,2692.9,percent of total billed charges,Implant Device,2692.9,35,,2692.9,percent of total billed charges,Implant Device,2692.9,35,,2692.9,percent of total billed charges,Implant Device,3077.6,40,,3077.6,percent of total billed charges,Implant Device,2692.9,70,,2692.9,percent of total billed charges,All Other,2615.96,34,,2615.96,percent of total billed charges,Implant Device,2615.96,34,,2615.96,percent of total billed charges,Implant Device,2692.9,35,,2692.9,percent of total billed charges,Implant Device,2692.9,35,,2692.9,percent of total billed charges,Implant Device,2692.9,35,,2692.9,percent of total billed charges,Implant Device,2692.9,35,,2692.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2615.96,34,"If Charge > 2,000, then 34 percent",2615.96,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5693.58,
STRYKER 6485-2-208 KINEMATIC HINGE KNEE,C1776,HCPCS,,79008681,CDM,278,RC,,,both,,,6693,4952.84,,,4952.84,Other,150% of Medicare + 9.63% HCRA Surcharge,3011.85,45,,3011.85,percent of total billed charges,Critical Access Hospital RCC factor,2275.62,34,,2275.62,percent of total billed charges,Implant Device,2275.62,34,,2275.62,percent of total billed charges,Implant Device,2275.62,34,,2275.62,percent of total billed charges,Implant Device,2275.62,34,,2275.62,percent of total billed charges,Implant Device,2275.62,34,,2275.62,percent of total billed charges,Implant Device,3313.04,,,3313.04,Other,110% of Medicare,2342.55,35,,2342.55,percent of total billed charges,Implant Device,2275.62,34,"Charges > $500, x 34%",2275.62,percent of total billed charges,Implant Device,2342.55,35,,2342.55,percent of total billed charges,Implant Device,2342.55,35,,2342.55,percent of total billed charges,Implant Device,2342.55,35,,2342.55,percent of total billed charges,Implant Device,2342.55,35,,2342.55,percent of total billed charges,Implant Device,2342.55,35,,2342.55,percent of total billed charges,Implant Device,2677.2,40,,2677.2,percent of total billed charges,Implant Device,2342.55,70,,2342.55,percent of total billed charges,All Other,2275.62,34,,2275.62,percent of total billed charges,Implant Device,2275.62,34,,2275.62,percent of total billed charges,Implant Device,2342.55,35,,2342.55,percent of total billed charges,Implant Device,2342.55,35,,2342.55,percent of total billed charges,Implant Device,2342.55,35,,2342.55,percent of total billed charges,Implant Device,2342.55,35,,2342.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2275.62,34,"If Charge > 2,000, then 34 percent",2275.62,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4952.84,
STRYKER 626773 LOCKING PLATE LEFT LONG,C1713,HCPCS,,79008682,CDM,278,RC,,,both,,,7368,5452.34,,,5452.34,Other,150% of Medicare + 9.63% HCRA Surcharge,3315.6,45,,3315.6,percent of total billed charges,Critical Access Hospital RCC factor,2505.12,34,,2505.12,percent of total billed charges,Implant Device,2505.12,34,,2505.12,percent of total billed charges,Implant Device,2505.12,34,,2505.12,percent of total billed charges,Implant Device,2505.12,34,,2505.12,percent of total billed charges,Implant Device,2505.12,34,,2505.12,percent of total billed charges,Implant Device,3647.16,,,3647.16,Other,110% of Medicare,2578.8,35,,2578.8,percent of total billed charges,Implant Device,2505.12,34,"Charges > $500, x 34%",2505.12,percent of total billed charges,Implant Device,2578.8,35,,2578.8,percent of total billed charges,Implant Device,2578.8,35,,2578.8,percent of total billed charges,Implant Device,2578.8,35,,2578.8,percent of total billed charges,Implant Device,2578.8,35,,2578.8,percent of total billed charges,Implant Device,2578.8,35,,2578.8,percent of total billed charges,Implant Device,2947.2,40,,2947.2,percent of total billed charges,Implant Device,2578.8,70,,2578.8,percent of total billed charges,All Other,2505.12,34,,2505.12,percent of total billed charges,Implant Device,2505.12,34,,2505.12,percent of total billed charges,Implant Device,2578.8,35,,2578.8,percent of total billed charges,Implant Device,2578.8,35,,2578.8,percent of total billed charges,Implant Device,2578.8,35,,2578.8,percent of total billed charges,Implant Device,2578.8,35,,2578.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2505.12,34,"If Charge > 2,000, then 34 percent",2505.12,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5452.34,
STRYKER 657324 LOCKING SCREW 3.5XL24MM,C1713,HCPCS,,79008683,CDM,278,RC,,,both,,,539,398.86,,,398.86,Other,150% of Medicare + 9.63% HCRA Surcharge,242.55,45,,242.55,percent of total billed charges,Critical Access Hospital RCC factor,183.26,34,,183.26,percent of total billed charges,Implant Device,183.26,34,,183.26,percent of total billed charges,Implant Device,183.26,34,,183.26,percent of total billed charges,Implant Device,183.26,34,,183.26,percent of total billed charges,Implant Device,183.26,34,,183.26,percent of total billed charges,Implant Device,266.81,,,266.81,Other,110% of Medicare,188.65,35,,188.65,percent of total billed charges,Implant Device,183.26,34,"Charges > $500, x 34%",183.26,percent of total billed charges,Implant Device,188.65,35,,188.65,percent of total billed charges,Implant Device,188.65,35,,188.65,percent of total billed charges,Implant Device,188.65,35,,188.65,percent of total billed charges,Implant Device,188.65,35,,188.65,percent of total billed charges,Implant Device,188.65,35,,188.65,percent of total billed charges,Implant Device,215.6,40,,215.6,percent of total billed charges,Implant Device,188.65,70,,188.65,percent of total billed charges,All Other,183.26,34,,183.26,percent of total billed charges,Implant Device,183.26,34,,183.26,percent of total billed charges,Implant Device,188.65,35,,188.65,percent of total billed charges,Implant Device,188.65,35,,188.65,percent of total billed charges,Implant Device,188.65,35,,188.65,percent of total billed charges,Implant Device,188.65,35,,188.65,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,398.86,
STRYKER 657322 LOCKING SCREW 3.5XL22MM,C1713,HCPCS,,79008684,CDM,278,RC,,,both,,,539,398.86,,,398.86,Other,150% of Medicare + 9.63% HCRA Surcharge,242.55,45,,242.55,percent of total billed charges,Critical Access Hospital RCC factor,183.26,34,,183.26,percent of total billed charges,Implant Device,183.26,34,,183.26,percent of total billed charges,Implant Device,183.26,34,,183.26,percent of total billed charges,Implant Device,183.26,34,,183.26,percent of total billed charges,Implant Device,183.26,34,,183.26,percent of total billed charges,Implant Device,266.81,,,266.81,Other,110% of Medicare,188.65,35,,188.65,percent of total billed charges,Implant Device,183.26,34,"Charges > $500, x 34%",183.26,percent of total billed charges,Implant Device,188.65,35,,188.65,percent of total billed charges,Implant Device,188.65,35,,188.65,percent of total billed charges,Implant Device,188.65,35,,188.65,percent of total billed charges,Implant Device,188.65,35,,188.65,percent of total billed charges,Implant Device,188.65,35,,188.65,percent of total billed charges,Implant Device,215.6,40,,215.6,percent of total billed charges,Implant Device,188.65,70,,188.65,percent of total billed charges,All Other,183.26,34,,183.26,percent of total billed charges,Implant Device,183.26,34,,183.26,percent of total billed charges,Implant Device,188.65,35,,188.65,percent of total billed charges,Implant Device,188.65,35,,188.65,percent of total billed charges,Implant Device,188.65,35,,188.65,percent of total billed charges,Implant Device,188.65,35,,188.65,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,398.86,
STRYKER 657428 BONE SCREW 3.5XL28MM,C1713,HCPCS,,79008685,CDM,278,RC,,,both,,,294,217.56,,,217.56,Other,150% of Medicare + 9.63% HCRA Surcharge,132.3,45,,132.3,percent of total billed charges,Critical Access Hospital RCC factor,99.96,34,,99.96,percent of total billed charges,Implant Device,99.96,34,,99.96,percent of total billed charges,Implant Device,99.96,34,,99.96,percent of total billed charges,Implant Device,99.96,34,,99.96,percent of total billed charges,Implant Device,99.96,34,,99.96,percent of total billed charges,Implant Device,145.53,,,145.53,Other,110% of Medicare,102.9,35,,102.9,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,102.9,35,,102.9,percent of total billed charges,Implant Device,102.9,35,,102.9,percent of total billed charges,Implant Device,102.9,35,,102.9,percent of total billed charges,Implant Device,102.9,35,,102.9,percent of total billed charges,Implant Device,102.9,35,,102.9,percent of total billed charges,Implant Device,117.6,40,,117.6,percent of total billed charges,Implant Device,102.9,70,,102.9,percent of total billed charges,All Other,99.96,34,,99.96,percent of total billed charges,Implant Device,99.96,34,,99.96,percent of total billed charges,Implant Device,102.9,35,,102.9,percent of total billed charges,Implant Device,102.9,35,,102.9,percent of total billed charges,Implant Device,102.9,35,,102.9,percent of total billed charges,Implant Device,102.9,35,,102.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,217.56,
STRYKER 657320 LOCKING SCREW 3.5XL20MM,C1713,HCPCS,,79008686,CDM,278,RC,,,both,,,539,398.86,,,398.86,Other,150% of Medicare + 9.63% HCRA Surcharge,242.55,45,,242.55,percent of total billed charges,Critical Access Hospital RCC factor,183.26,34,,183.26,percent of total billed charges,Implant Device,183.26,34,,183.26,percent of total billed charges,Implant Device,183.26,34,,183.26,percent of total billed charges,Implant Device,183.26,34,,183.26,percent of total billed charges,Implant Device,183.26,34,,183.26,percent of total billed charges,Implant Device,266.81,,,266.81,Other,110% of Medicare,188.65,35,,188.65,percent of total billed charges,Implant Device,183.26,34,"Charges > $500, x 34%",183.26,percent of total billed charges,Implant Device,188.65,35,,188.65,percent of total billed charges,Implant Device,188.65,35,,188.65,percent of total billed charges,Implant Device,188.65,35,,188.65,percent of total billed charges,Implant Device,188.65,35,,188.65,percent of total billed charges,Implant Device,188.65,35,,188.65,percent of total billed charges,Implant Device,215.6,40,,215.6,percent of total billed charges,Implant Device,188.65,70,,188.65,percent of total billed charges,All Other,183.26,34,,183.26,percent of total billed charges,Implant Device,183.26,34,,183.26,percent of total billed charges,Implant Device,188.65,35,,188.65,percent of total billed charges,Implant Device,188.65,35,,188.65,percent of total billed charges,Implant Device,188.65,35,,188.65,percent of total billed charges,Implant Device,188.65,35,,188.65,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,398.86,
STRYKER 657432 BONE SCREW 3.5XL32MM,C1713,HCPCS,,79008687,CDM,278,RC,,,both,,,294,217.56,,,217.56,Other,150% of Medicare + 9.63% HCRA Surcharge,132.3,45,,132.3,percent of total billed charges,Critical Access Hospital RCC factor,99.96,34,,99.96,percent of total billed charges,Implant Device,99.96,34,,99.96,percent of total billed charges,Implant Device,99.96,34,,99.96,percent of total billed charges,Implant Device,99.96,34,,99.96,percent of total billed charges,Implant Device,99.96,34,,99.96,percent of total billed charges,Implant Device,145.53,,,145.53,Other,110% of Medicare,102.9,35,,102.9,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,102.9,35,,102.9,percent of total billed charges,Implant Device,102.9,35,,102.9,percent of total billed charges,Implant Device,102.9,35,,102.9,percent of total billed charges,Implant Device,102.9,35,,102.9,percent of total billed charges,Implant Device,102.9,35,,102.9,percent of total billed charges,Implant Device,117.6,40,,117.6,percent of total billed charges,Implant Device,102.9,70,,102.9,percent of total billed charges,All Other,99.96,34,,99.96,percent of total billed charges,Implant Device,99.96,34,,99.96,percent of total billed charges,Implant Device,102.9,35,,102.9,percent of total billed charges,Implant Device,102.9,35,,102.9,percent of total billed charges,Implant Device,102.9,35,,102.9,percent of total billed charges,Implant Device,102.9,35,,102.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,217.56,
STRYKER 657436 BONE SCREW 3.5XL36MM,C1713,HCPCS,,79008688,CDM,278,RC,,,both,,,294,217.56,,,217.56,Other,150% of Medicare + 9.63% HCRA Surcharge,132.3,45,,132.3,percent of total billed charges,Critical Access Hospital RCC factor,99.96,34,,99.96,percent of total billed charges,Implant Device,99.96,34,,99.96,percent of total billed charges,Implant Device,99.96,34,,99.96,percent of total billed charges,Implant Device,99.96,34,,99.96,percent of total billed charges,Implant Device,99.96,34,,99.96,percent of total billed charges,Implant Device,145.53,,,145.53,Other,110% of Medicare,102.9,35,,102.9,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,102.9,35,,102.9,percent of total billed charges,Implant Device,102.9,35,,102.9,percent of total billed charges,Implant Device,102.9,35,,102.9,percent of total billed charges,Implant Device,102.9,35,,102.9,percent of total billed charges,Implant Device,102.9,35,,102.9,percent of total billed charges,Implant Device,117.6,40,,117.6,percent of total billed charges,Implant Device,102.9,70,,102.9,percent of total billed charges,All Other,99.96,34,,99.96,percent of total billed charges,Implant Device,99.96,34,,99.96,percent of total billed charges,Implant Device,102.9,35,,102.9,percent of total billed charges,Implant Device,102.9,35,,102.9,percent of total billed charges,Implant Device,102.9,35,,102.9,percent of total billed charges,Implant Device,102.9,35,,102.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,217.56,
RTI D00101 BIOREADY DBM PUTTY 1CC,C1713,HCPCS,,79008689,CDM,278,RC,,,both,,,489,361.86,,,361.86,Other,150% of Medicare + 9.63% HCRA Surcharge,220.05,45,,220.05,percent of total billed charges,Critical Access Hospital RCC factor,166.26,34,,166.26,percent of total billed charges,Implant Device,166.26,34,,166.26,percent of total billed charges,Implant Device,166.26,34,,166.26,percent of total billed charges,Implant Device,166.26,34,,166.26,percent of total billed charges,Implant Device,166.26,34,,166.26,percent of total billed charges,Implant Device,242.06,,,242.06,Other,110% of Medicare,171.15,35,,171.15,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,171.15,35,,171.15,percent of total billed charges,Implant Device,171.15,35,,171.15,percent of total billed charges,Implant Device,171.15,35,,171.15,percent of total billed charges,Implant Device,171.15,35,,171.15,percent of total billed charges,Implant Device,171.15,35,,171.15,percent of total billed charges,Implant Device,195.6,40,,195.6,percent of total billed charges,Implant Device,171.15,70,,171.15,percent of total billed charges,All Other,166.26,34,,166.26,percent of total billed charges,Implant Device,166.26,34,,166.26,percent of total billed charges,Implant Device,171.15,35,,171.15,percent of total billed charges,Implant Device,171.15,35,,171.15,percent of total billed charges,Implant Device,171.15,35,,171.15,percent of total billed charges,Implant Device,171.15,35,,171.15,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,361.86,
RTI D00102 BIOREADY DBM PUTTY 2CC,C1713,HCPCS,,79008690,CDM,278,RC,,,both,,,846,626.04,,,626.04,Other,150% of Medicare + 9.63% HCRA Surcharge,380.7,45,,380.7,percent of total billed charges,Critical Access Hospital RCC factor,287.64,34,,287.64,percent of total billed charges,Implant Device,287.64,34,,287.64,percent of total billed charges,Implant Device,287.64,34,,287.64,percent of total billed charges,Implant Device,287.64,34,,287.64,percent of total billed charges,Implant Device,287.64,34,,287.64,percent of total billed charges,Implant Device,418.77,,,418.77,Other,110% of Medicare,296.1,35,,296.1,percent of total billed charges,Implant Device,287.64,34,"Charges > $500, x 34%",287.64,percent of total billed charges,Implant Device,296.1,35,,296.1,percent of total billed charges,Implant Device,296.1,35,,296.1,percent of total billed charges,Implant Device,296.1,35,,296.1,percent of total billed charges,Implant Device,296.1,35,,296.1,percent of total billed charges,Implant Device,296.1,35,,296.1,percent of total billed charges,Implant Device,338.4,40,,338.4,percent of total billed charges,Implant Device,296.1,70,,296.1,percent of total billed charges,All Other,287.64,34,,287.64,percent of total billed charges,Implant Device,287.64,34,,287.64,percent of total billed charges,Implant Device,296.1,35,,296.1,percent of total billed charges,Implant Device,296.1,35,,296.1,percent of total billed charges,Implant Device,296.1,35,,296.1,percent of total billed charges,Implant Device,296.1,35,,296.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,626.04,
RTI D00105 BIOREADY DBM PUTTY 5CC,C1713,HCPCS,,79008691,CDM,278,RC,,,both,,,1761,1303.14,,,1303.14,Other,150% of Medicare + 9.63% HCRA Surcharge,792.45,45,,792.45,percent of total billed charges,Critical Access Hospital RCC factor,598.74,34,,598.74,percent of total billed charges,Implant Device,598.74,34,,598.74,percent of total billed charges,Implant Device,598.74,34,,598.74,percent of total billed charges,Implant Device,598.74,34,,598.74,percent of total billed charges,Implant Device,598.74,34,,598.74,percent of total billed charges,Implant Device,871.7,,,871.7,Other,110% of Medicare,616.35,35,,616.35,percent of total billed charges,Implant Device,598.74,34,"Charges > $500, x 34%",598.74,percent of total billed charges,Implant Device,616.35,35,,616.35,percent of total billed charges,Implant Device,616.35,35,,616.35,percent of total billed charges,Implant Device,616.35,35,,616.35,percent of total billed charges,Implant Device,616.35,35,,616.35,percent of total billed charges,Implant Device,616.35,35,,616.35,percent of total billed charges,Implant Device,704.4,40,,704.4,percent of total billed charges,Implant Device,616.35,70,,616.35,percent of total billed charges,All Other,598.74,34,,598.74,percent of total billed charges,Implant Device,598.74,34,,598.74,percent of total billed charges,Implant Device,616.35,35,,616.35,percent of total billed charges,Implant Device,616.35,35,,616.35,percent of total billed charges,Implant Device,616.35,35,,616.35,percent of total billed charges,Implant Device,616.35,35,,616.35,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1303.14,
RTI D00302 BIOREADY DBM PUTTY W/CHIPS,C1713,HCPCS,,79008692,CDM,278,RC,,,both,,,846,626.04,,,626.04,Other,150% of Medicare + 9.63% HCRA Surcharge,380.7,45,,380.7,percent of total billed charges,Critical Access Hospital RCC factor,287.64,34,,287.64,percent of total billed charges,Implant Device,287.64,34,,287.64,percent of total billed charges,Implant Device,287.64,34,,287.64,percent of total billed charges,Implant Device,287.64,34,,287.64,percent of total billed charges,Implant Device,287.64,34,,287.64,percent of total billed charges,Implant Device,418.77,,,418.77,Other,110% of Medicare,296.1,35,,296.1,percent of total billed charges,Implant Device,287.64,34,"Charges > $500, x 34%",287.64,percent of total billed charges,Implant Device,296.1,35,,296.1,percent of total billed charges,Implant Device,296.1,35,,296.1,percent of total billed charges,Implant Device,296.1,35,,296.1,percent of total billed charges,Implant Device,296.1,35,,296.1,percent of total billed charges,Implant Device,296.1,35,,296.1,percent of total billed charges,Implant Device,338.4,40,,338.4,percent of total billed charges,Implant Device,296.1,70,,296.1,percent of total billed charges,All Other,287.64,34,,287.64,percent of total billed charges,Implant Device,287.64,34,,287.64,percent of total billed charges,Implant Device,296.1,35,,296.1,percent of total billed charges,Implant Device,296.1,35,,296.1,percent of total billed charges,Implant Device,296.1,35,,296.1,percent of total billed charges,Implant Device,296.1,35,,296.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,626.04,
RTI D00305 BIOREADY DBM PUTTY W/CHIPS,C1713,HCPCS,,79008693,CDM,278,RC,,,both,,,1761,1303.14,,,1303.14,Other,150% of Medicare + 9.63% HCRA Surcharge,792.45,45,,792.45,percent of total billed charges,Critical Access Hospital RCC factor,598.74,34,,598.74,percent of total billed charges,Implant Device,598.74,34,,598.74,percent of total billed charges,Implant Device,598.74,34,,598.74,percent of total billed charges,Implant Device,598.74,34,,598.74,percent of total billed charges,Implant Device,598.74,34,,598.74,percent of total billed charges,Implant Device,871.7,,,871.7,Other,110% of Medicare,616.35,35,,616.35,percent of total billed charges,Implant Device,598.74,34,"Charges > $500, x 34%",598.74,percent of total billed charges,Implant Device,616.35,35,,616.35,percent of total billed charges,Implant Device,616.35,35,,616.35,percent of total billed charges,Implant Device,616.35,35,,616.35,percent of total billed charges,Implant Device,616.35,35,,616.35,percent of total billed charges,Implant Device,616.35,35,,616.35,percent of total billed charges,Implant Device,704.4,40,,704.4,percent of total billed charges,Implant Device,616.35,70,,616.35,percent of total billed charges,All Other,598.74,34,,598.74,percent of total billed charges,Implant Device,598.74,34,,598.74,percent of total billed charges,Implant Device,616.35,35,,616.35,percent of total billed charges,Implant Device,616.35,35,,616.35,percent of total billed charges,Implant Device,616.35,35,,616.35,percent of total billed charges,Implant Device,616.35,35,,616.35,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1303.14,
RTI 100415 CANCELLOUS CHIPS 15CC,C1713,HCPCS,,79008694,CDM,278,RC,,,both,,,825,610.5,,,610.5,Other,150% of Medicare + 9.63% HCRA Surcharge,371.25,45,,371.25,percent of total billed charges,Critical Access Hospital RCC factor,280.5,34,,280.5,percent of total billed charges,Implant Device,280.5,34,,280.5,percent of total billed charges,Implant Device,280.5,34,,280.5,percent of total billed charges,Implant Device,280.5,34,,280.5,percent of total billed charges,Implant Device,280.5,34,,280.5,percent of total billed charges,Implant Device,408.38,,,408.38,Other,110% of Medicare,288.75,35,,288.75,percent of total billed charges,Implant Device,280.5,34,"Charges > $500, x 34%",280.5,percent of total billed charges,Implant Device,288.75,35,,288.75,percent of total billed charges,Implant Device,288.75,35,,288.75,percent of total billed charges,Implant Device,288.75,35,,288.75,percent of total billed charges,Implant Device,288.75,35,,288.75,percent of total billed charges,Implant Device,288.75,35,,288.75,percent of total billed charges,Implant Device,330,40,,330,percent of total billed charges,Implant Device,288.75,70,,288.75,percent of total billed charges,All Other,280.5,34,,280.5,percent of total billed charges,Implant Device,280.5,34,,280.5,percent of total billed charges,Implant Device,288.75,35,,288.75,percent of total billed charges,Implant Device,288.75,35,,288.75,percent of total billed charges,Implant Device,288.75,35,,288.75,percent of total billed charges,Implant Device,288.75,35,,288.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,610.5,
RTI 100430 CANCELLOUS CHIPS 30CC,C1713,HCPCS,,79008695,CDM,278,RC,,,both,,,1395,1032.3,,,1032.3,Other,150% of Medicare + 9.63% HCRA Surcharge,627.75,45,,627.75,percent of total billed charges,Critical Access Hospital RCC factor,474.3,34,,474.3,percent of total billed charges,Implant Device,474.3,34,,474.3,percent of total billed charges,Implant Device,474.3,34,,474.3,percent of total billed charges,Implant Device,474.3,34,,474.3,percent of total billed charges,Implant Device,474.3,34,,474.3,percent of total billed charges,Implant Device,690.53,,,690.53,Other,110% of Medicare,488.25,35,,488.25,percent of total billed charges,Implant Device,474.3,34,"Charges > $500, x 34%",474.3,percent of total billed charges,Implant Device,488.25,35,,488.25,percent of total billed charges,Implant Device,488.25,35,,488.25,percent of total billed charges,Implant Device,488.25,35,,488.25,percent of total billed charges,Implant Device,488.25,35,,488.25,percent of total billed charges,Implant Device,488.25,35,,488.25,percent of total billed charges,Implant Device,558,40,,558,percent of total billed charges,Implant Device,488.25,70,,488.25,percent of total billed charges,All Other,474.3,34,,474.3,percent of total billed charges,Implant Device,474.3,34,,474.3,percent of total billed charges,Implant Device,488.25,35,,488.25,percent of total billed charges,Implant Device,488.25,35,,488.25,percent of total billed charges,Implant Device,488.25,35,,488.25,percent of total billed charges,Implant Device,488.25,35,,488.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1032.3,
RTI 100460 CANCELLOUS CHIPS 60CC,C1713,HCPCS,,79008696,CDM,278,RC,,,both,,,2655,1964.71,,,1964.71,Other,150% of Medicare + 9.63% HCRA Surcharge,1194.75,45,,1194.75,percent of total billed charges,Critical Access Hospital RCC factor,902.7,34,,902.7,percent of total billed charges,Implant Device,902.7,34,,902.7,percent of total billed charges,Implant Device,902.7,34,,902.7,percent of total billed charges,Implant Device,902.7,34,,902.7,percent of total billed charges,Implant Device,902.7,34,,902.7,percent of total billed charges,Implant Device,1314.23,,,1314.23,Other,110% of Medicare,929.25,35,,929.25,percent of total billed charges,Implant Device,902.7,34,"Charges > $500, x 34%",902.7,percent of total billed charges,Implant Device,929.25,35,,929.25,percent of total billed charges,Implant Device,929.25,35,,929.25,percent of total billed charges,Implant Device,929.25,35,,929.25,percent of total billed charges,Implant Device,929.25,35,,929.25,percent of total billed charges,Implant Device,929.25,35,,929.25,percent of total billed charges,Implant Device,1062,40,,1062,percent of total billed charges,Implant Device,929.25,70,,929.25,percent of total billed charges,All Other,902.7,34,,902.7,percent of total billed charges,Implant Device,902.7,34,,902.7,percent of total billed charges,Implant Device,929.25,35,,929.25,percent of total billed charges,Implant Device,929.25,35,,929.25,percent of total billed charges,Implant Device,929.25,35,,929.25,percent of total billed charges,Implant Device,929.25,35,,929.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,902.7,34,"If Charge > 2,000, then 34 percent",902.7,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1964.71,
RTI D00110 BIOREADY DBM PUTTY 10CC,C1713,HCPCS,,79008697,CDM,278,RC,,,both,,,3225,2386.51,,,2386.51,Other,150% of Medicare + 9.63% HCRA Surcharge,1451.25,45,,1451.25,percent of total billed charges,Critical Access Hospital RCC factor,1096.5,34,,1096.5,percent of total billed charges,Implant Device,1096.5,34,,1096.5,percent of total billed charges,Implant Device,1096.5,34,,1096.5,percent of total billed charges,Implant Device,1096.5,34,,1096.5,percent of total billed charges,Implant Device,1096.5,34,,1096.5,percent of total billed charges,Implant Device,1596.38,,,1596.38,Other,110% of Medicare,1128.75,35,,1128.75,percent of total billed charges,Implant Device,1096.5,34,"Charges > $500, x 34%",1096.5,percent of total billed charges,Implant Device,1128.75,35,,1128.75,percent of total billed charges,Implant Device,1128.75,35,,1128.75,percent of total billed charges,Implant Device,1128.75,35,,1128.75,percent of total billed charges,Implant Device,1128.75,35,,1128.75,percent of total billed charges,Implant Device,1128.75,35,,1128.75,percent of total billed charges,Implant Device,1290,40,,1290,percent of total billed charges,Implant Device,1128.75,70,,1128.75,percent of total billed charges,All Other,1096.5,34,,1096.5,percent of total billed charges,Implant Device,1096.5,34,,1096.5,percent of total billed charges,Implant Device,1128.75,35,,1128.75,percent of total billed charges,Implant Device,1128.75,35,,1128.75,percent of total billed charges,Implant Device,1128.75,35,,1128.75,percent of total billed charges,Implant Device,1128.75,35,,1128.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1096.5,34,"If Charge > 2,000, then 34 percent",1096.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2386.51,
RTI D03125 ILLIUM TRICORT BLOCK 25X30X14,C1713,HCPCS,,79008698,CDM,278,RC,,,both,,,2400,1776.01,,,1776.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1080,45,,1080,percent of total billed charges,Critical Access Hospital RCC factor,816,34,,816,percent of total billed charges,Implant Device,816,34,,816,percent of total billed charges,Implant Device,816,34,,816,percent of total billed charges,Implant Device,816,34,,816,percent of total billed charges,Implant Device,816,34,,816,percent of total billed charges,Implant Device,1188,,,1188,Other,110% of Medicare,840,35,,840,percent of total billed charges,Implant Device,816,34,"Charges > $500, x 34%",816,percent of total billed charges,Implant Device,840,35,,840,percent of total billed charges,Implant Device,840,35,,840,percent of total billed charges,Implant Device,840,35,,840,percent of total billed charges,Implant Device,840,35,,840,percent of total billed charges,Implant Device,840,35,,840,percent of total billed charges,Implant Device,960,40,,960,percent of total billed charges,Implant Device,840,70,,840,percent of total billed charges,All Other,816,34,,816,percent of total billed charges,Implant Device,816,34,,816,percent of total billed charges,Implant Device,840,35,,840,percent of total billed charges,Implant Device,840,35,,840,percent of total billed charges,Implant Device,840,35,,840,percent of total billed charges,Implant Device,840,35,,840,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,816,34,"If Charge > 2,000, then 34 percent",816,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1776.01,
ZIMMER 00-5976-040-14 ART SURF SZ BLUE,C1776,HCPCS,,79008699,CDM,278,RC,,,both,,,1920,1420.8,,,1420.8,Other,150% of Medicare + 9.63% HCRA Surcharge,864,45,,864,percent of total billed charges,Critical Access Hospital RCC factor,652.8,34,,652.8,percent of total billed charges,Implant Device,652.8,34,,652.8,percent of total billed charges,Implant Device,652.8,34,,652.8,percent of total billed charges,Implant Device,652.8,34,,652.8,percent of total billed charges,Implant Device,652.8,34,,652.8,percent of total billed charges,Implant Device,950.4,,,950.4,Other,110% of Medicare,672,35,,672,percent of total billed charges,Implant Device,652.8,34,"Charges > $500, x 34%",652.8,percent of total billed charges,Implant Device,672,35,,672,percent of total billed charges,Implant Device,672,35,,672,percent of total billed charges,Implant Device,672,35,,672,percent of total billed charges,Implant Device,672,35,,672,percent of total billed charges,Implant Device,672,35,,672,percent of total billed charges,Implant Device,768,40,,768,percent of total billed charges,Implant Device,672,70,,672,percent of total billed charges,All Other,652.8,34,,652.8,percent of total billed charges,Implant Device,652.8,34,,652.8,percent of total billed charges,Implant Device,672,35,,672,percent of total billed charges,Implant Device,672,35,,672,percent of total billed charges,Implant Device,672,35,,672,percent of total billed charges,Implant Device,672,35,,672,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1420.8,
ZIMMER 00-5988-006-27 TIBIAL BLOCK SZ 6,C1776,HCPCS,,79008700,CDM,278,RC,,,both,,,2993,2214.83,,,2214.83,Other,150% of Medicare + 9.63% HCRA Surcharge,1346.85,45,,1346.85,percent of total billed charges,Critical Access Hospital RCC factor,1017.62,34,,1017.62,percent of total billed charges,Implant Device,1017.62,34,,1017.62,percent of total billed charges,Implant Device,1017.62,34,,1017.62,percent of total billed charges,Implant Device,1017.62,34,,1017.62,percent of total billed charges,Implant Device,1017.62,34,,1017.62,percent of total billed charges,Implant Device,1481.54,,,1481.54,Other,110% of Medicare,1047.55,35,,1047.55,percent of total billed charges,Implant Device,1017.62,34,"Charges > $500, x 34%",1017.62,percent of total billed charges,Implant Device,1047.55,35,,1047.55,percent of total billed charges,Implant Device,1047.55,35,,1047.55,percent of total billed charges,Implant Device,1047.55,35,,1047.55,percent of total billed charges,Implant Device,1047.55,35,,1047.55,percent of total billed charges,Implant Device,1047.55,35,,1047.55,percent of total billed charges,Implant Device,1197.2,40,,1197.2,percent of total billed charges,Implant Device,1047.55,70,,1047.55,percent of total billed charges,All Other,1017.62,34,,1017.62,percent of total billed charges,Implant Device,1017.62,34,,1017.62,percent of total billed charges,Implant Device,1047.55,35,,1047.55,percent of total billed charges,Implant Device,1047.55,35,,1047.55,percent of total billed charges,Implant Device,1047.55,35,,1047.55,percent of total billed charges,Implant Device,1047.55,35,,1047.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1017.62,34,"If Charge > 2,000, then 34 percent",1017.62,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2214.83,
ZIMMER 00-5950-016-01 FEM COMPONENT SZ F,C1776,HCPCS,,79008701,CDM,278,RC,,,both,,,6300,4662.02,,,4662.02,Other,150% of Medicare + 9.63% HCRA Surcharge,2835,45,,2835,percent of total billed charges,Critical Access Hospital RCC factor,2142,34,,2142,percent of total billed charges,Implant Device,2142,34,,2142,percent of total billed charges,Implant Device,2142,34,,2142,percent of total billed charges,Implant Device,2142,34,,2142,percent of total billed charges,Implant Device,2142,34,,2142,percent of total billed charges,Implant Device,3118.5,,,3118.5,Other,110% of Medicare,2205,35,,2205,percent of total billed charges,Implant Device,2142,34,"Charges > $500, x 34%",2142,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2520,40,,2520,percent of total billed charges,Implant Device,2205,70,,2205,percent of total billed charges,All Other,2142,34,,2142,percent of total billed charges,Implant Device,2142,34,,2142,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2142,34,"If Charge > 2,000, then 34 percent",2142,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4662.02,
ZIMMER 00-8018-022-30 FEMORAL HEAD 22MM,C1776,HCPCS,,79008703,CDM,278,RC,,,both,,,1152,852.48,,,852.48,Other,150% of Medicare + 9.63% HCRA Surcharge,518.4,45,,518.4,percent of total billed charges,Critical Access Hospital RCC factor,391.68,34,,391.68,percent of total billed charges,Implant Device,391.68,34,,391.68,percent of total billed charges,Implant Device,391.68,34,,391.68,percent of total billed charges,Implant Device,391.68,34,,391.68,percent of total billed charges,Implant Device,391.68,34,,391.68,percent of total billed charges,Implant Device,570.24,,,570.24,Other,110% of Medicare,403.2,35,,403.2,percent of total billed charges,Implant Device,391.68,34,"Charges > $500, x 34%",391.68,percent of total billed charges,Implant Device,403.2,35,,403.2,percent of total billed charges,Implant Device,403.2,35,,403.2,percent of total billed charges,Implant Device,403.2,35,,403.2,percent of total billed charges,Implant Device,403.2,35,,403.2,percent of total billed charges,Implant Device,403.2,35,,403.2,percent of total billed charges,Implant Device,460.8,40,,460.8,percent of total billed charges,Implant Device,403.2,70,,403.2,percent of total billed charges,All Other,391.68,34,,391.68,percent of total billed charges,Implant Device,391.68,34,,391.68,percent of total billed charges,Implant Device,403.2,35,,403.2,percent of total billed charges,Implant Device,403.2,35,,403.2,percent of total billed charges,Implant Device,403.2,35,,403.2,percent of total billed charges,Implant Device,403.2,35,,403.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,852.48,
ZIMMER 00-7711-004-40 FEM STEM SIZE 4,C1776,HCPCS,,79008704,CDM,278,RC,,,both,,,10830,8014.23,,,8014.23,Other,150% of Medicare + 9.63% HCRA Surcharge,4873.5,45,,4873.5,percent of total billed charges,Critical Access Hospital RCC factor,3682.2,34,,3682.2,percent of total billed charges,Implant Device,3682.2,34,,3682.2,percent of total billed charges,Implant Device,3682.2,34,,3682.2,percent of total billed charges,Implant Device,3682.2,34,,3682.2,percent of total billed charges,Implant Device,3682.2,34,,3682.2,percent of total billed charges,Implant Device,5360.85,,,5360.85,Other,110% of Medicare,3790.5,35,,3790.5,percent of total billed charges,Implant Device,3682.2,34,"Charges > $500, x 34%",3682.2,percent of total billed charges,Implant Device,3790.5,35,,3790.5,percent of total billed charges,Implant Device,3790.5,35,,3790.5,percent of total billed charges,Implant Device,3790.5,35,,3790.5,percent of total billed charges,Implant Device,3790.5,35,,3790.5,percent of total billed charges,Implant Device,3790.5,35,,3790.5,percent of total billed charges,Implant Device,4332,40,,4332,percent of total billed charges,Implant Device,3790.5,70,,3790.5,percent of total billed charges,All Other,3682.2,34,,3682.2,percent of total billed charges,Implant Device,3682.2,34,,3682.2,percent of total billed charges,Implant Device,3790.5,35,,3790.5,percent of total billed charges,Implant Device,3790.5,35,,3790.5,percent of total billed charges,Implant Device,3790.5,35,,3790.5,percent of total billed charges,Implant Device,3790.5,35,,3790.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3682.2,34,"If Charge > 2,000, then 34 percent",3682.2,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,8014.23,
ZIMMER 00-5001-040-22 BI CUP LINER 22MM,C1776,HCPCS,,79008705,CDM,278,RC,,,both,,,797,589.78,,,589.78,Other,150% of Medicare + 9.63% HCRA Surcharge,358.65,45,,358.65,percent of total billed charges,Critical Access Hospital RCC factor,270.98,34,,270.98,percent of total billed charges,Implant Device,270.98,34,,270.98,percent of total billed charges,Implant Device,270.98,34,,270.98,percent of total billed charges,Implant Device,270.98,34,,270.98,percent of total billed charges,Implant Device,270.98,34,,270.98,percent of total billed charges,Implant Device,394.52,,,394.52,Other,110% of Medicare,278.95,35,,278.95,percent of total billed charges,Implant Device,270.98,34,"Charges > $500, x 34%",270.98,percent of total billed charges,Implant Device,278.95,35,,278.95,percent of total billed charges,Implant Device,278.95,35,,278.95,percent of total billed charges,Implant Device,278.95,35,,278.95,percent of total billed charges,Implant Device,278.95,35,,278.95,percent of total billed charges,Implant Device,278.95,35,,278.95,percent of total billed charges,Implant Device,318.8,40,,318.8,percent of total billed charges,Implant Device,278.95,70,,278.95,percent of total billed charges,All Other,270.98,34,,270.98,percent of total billed charges,Implant Device,270.98,34,,270.98,percent of total billed charges,Implant Device,278.95,35,,278.95,percent of total billed charges,Implant Device,278.95,35,,278.95,percent of total billed charges,Implant Device,278.95,35,,278.95,percent of total billed charges,Implant Device,278.95,35,,278.95,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,589.78,
ZIMMER 00-5001-041-00 BI CUP SHELL 41MM,C1776,HCPCS,,79008706,CDM,278,RC,,,both,,,1323,979.02,,,979.02,Other,150% of Medicare + 9.63% HCRA Surcharge,595.35,45,,595.35,percent of total billed charges,Critical Access Hospital RCC factor,449.82,34,,449.82,percent of total billed charges,Implant Device,449.82,34,,449.82,percent of total billed charges,Implant Device,449.82,34,,449.82,percent of total billed charges,Implant Device,449.82,34,,449.82,percent of total billed charges,Implant Device,449.82,34,,449.82,percent of total billed charges,Implant Device,654.89,,,654.89,Other,110% of Medicare,463.05,35,,463.05,percent of total billed charges,Implant Device,449.82,34,"Charges > $500, x 34%",449.82,percent of total billed charges,Implant Device,463.05,35,,463.05,percent of total billed charges,Implant Device,463.05,35,,463.05,percent of total billed charges,Implant Device,463.05,35,,463.05,percent of total billed charges,Implant Device,463.05,35,,463.05,percent of total billed charges,Implant Device,463.05,35,,463.05,percent of total billed charges,Implant Device,529.2,40,,529.2,percent of total billed charges,Implant Device,463.05,70,,463.05,percent of total billed charges,All Other,449.82,34,,449.82,percent of total billed charges,Implant Device,449.82,34,,449.82,percent of total billed charges,Implant Device,463.05,35,,463.05,percent of total billed charges,Implant Device,463.05,35,,463.05,percent of total billed charges,Implant Device,463.05,35,,463.05,percent of total billed charges,Implant Device,463.05,35,,463.05,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,979.02,
ARTHREX AR-13200M-07R WEDGE PLATE 7MM,C1713,HCPCS,,79008707,CDM,278,RC,,,both,,,3408,2521.93,,,2521.93,Other,150% of Medicare + 9.63% HCRA Surcharge,1533.6,45,,1533.6,percent of total billed charges,Critical Access Hospital RCC factor,1158.72,34,,1158.72,percent of total billed charges,Implant Device,1158.72,34,,1158.72,percent of total billed charges,Implant Device,1158.72,34,,1158.72,percent of total billed charges,Implant Device,1158.72,34,,1158.72,percent of total billed charges,Implant Device,1158.72,34,,1158.72,percent of total billed charges,Implant Device,1686.96,,,1686.96,Other,110% of Medicare,1192.8,35,,1192.8,percent of total billed charges,Implant Device,1158.72,34,"Charges > $500, x 34%",1158.72,percent of total billed charges,Implant Device,1192.8,35,,1192.8,percent of total billed charges,Implant Device,1192.8,35,,1192.8,percent of total billed charges,Implant Device,1192.8,35,,1192.8,percent of total billed charges,Implant Device,1192.8,35,,1192.8,percent of total billed charges,Implant Device,1192.8,35,,1192.8,percent of total billed charges,Implant Device,1363.2,40,,1363.2,percent of total billed charges,Implant Device,1192.8,70,,1192.8,percent of total billed charges,All Other,1158.72,34,,1158.72,percent of total billed charges,Implant Device,1158.72,34,,1158.72,percent of total billed charges,Implant Device,1192.8,35,,1192.8,percent of total billed charges,Implant Device,1192.8,35,,1192.8,percent of total billed charges,Implant Device,1192.8,35,,1192.8,percent of total billed charges,Implant Device,1192.8,35,,1192.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1158.72,34,"If Charge > 2,000, then 34 percent",1158.72,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2521.93,
ARTHREX AR-8935-30 CORT SCREW 3.5X30MM,C1713,HCPCS,,79008708,CDM,278,RC,,,both,,,258,190.92,,,190.92,Other,150% of Medicare + 9.63% HCRA Surcharge,116.1,45,,116.1,percent of total billed charges,Critical Access Hospital RCC factor,87.72,34,,87.72,percent of total billed charges,Implant Device,87.72,34,,87.72,percent of total billed charges,Implant Device,87.72,34,,87.72,percent of total billed charges,Implant Device,87.72,34,,87.72,percent of total billed charges,Implant Device,87.72,34,,87.72,percent of total billed charges,Implant Device,127.71,,,127.71,Other,110% of Medicare,90.3,35,,90.3,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,90.3,35,,90.3,percent of total billed charges,Implant Device,90.3,35,,90.3,percent of total billed charges,Implant Device,90.3,35,,90.3,percent of total billed charges,Implant Device,90.3,35,,90.3,percent of total billed charges,Implant Device,90.3,35,,90.3,percent of total billed charges,Implant Device,103.2,40,,103.2,percent of total billed charges,Implant Device,90.3,70,,90.3,percent of total billed charges,All Other,87.72,34,,87.72,percent of total billed charges,Implant Device,87.72,34,,87.72,percent of total billed charges,Implant Device,90.3,35,,90.3,percent of total billed charges,Implant Device,90.3,35,,90.3,percent of total billed charges,Implant Device,90.3,35,,90.3,percent of total billed charges,Implant Device,90.3,35,,90.3,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,190.92,
ARTHREX AR-8940-34 CAN SCREW 4.0X34MM,C1713,HCPCS,,79008709,CDM,278,RC,,,both,,,258,190.92,,,190.92,Other,150% of Medicare + 9.63% HCRA Surcharge,116.1,45,,116.1,percent of total billed charges,Critical Access Hospital RCC factor,87.72,34,,87.72,percent of total billed charges,Implant Device,87.72,34,,87.72,percent of total billed charges,Implant Device,87.72,34,,87.72,percent of total billed charges,Implant Device,87.72,34,,87.72,percent of total billed charges,Implant Device,87.72,34,,87.72,percent of total billed charges,Implant Device,127.71,,,127.71,Other,110% of Medicare,90.3,35,,90.3,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,90.3,35,,90.3,percent of total billed charges,Implant Device,90.3,35,,90.3,percent of total billed charges,Implant Device,90.3,35,,90.3,percent of total billed charges,Implant Device,90.3,35,,90.3,percent of total billed charges,Implant Device,90.3,35,,90.3,percent of total billed charges,Implant Device,103.2,40,,103.2,percent of total billed charges,Implant Device,90.3,70,,90.3,percent of total billed charges,All Other,87.72,34,,87.72,percent of total billed charges,Implant Device,87.72,34,,87.72,percent of total billed charges,Implant Device,90.3,35,,90.3,percent of total billed charges,Implant Device,90.3,35,,90.3,percent of total billed charges,Implant Device,90.3,35,,90.3,percent of total billed charges,Implant Device,90.3,35,,90.3,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,190.92,
STRYKER 1822-1136S TIBIAL NAIL 11X360MM,C1713,HCPCS,,79008711,CDM,278,RC,,,both,,,3529,2611.47,,,2611.47,Other,150% of Medicare + 9.63% HCRA Surcharge,1588.05,45,,1588.05,percent of total billed charges,Critical Access Hospital RCC factor,1199.86,34,,1199.86,percent of total billed charges,Implant Device,1199.86,34,,1199.86,percent of total billed charges,Implant Device,1199.86,34,,1199.86,percent of total billed charges,Implant Device,1199.86,34,,1199.86,percent of total billed charges,Implant Device,1199.86,34,,1199.86,percent of total billed charges,Implant Device,1746.86,,,1746.86,Other,110% of Medicare,1235.15,35,,1235.15,percent of total billed charges,Implant Device,1199.86,34,"Charges > $500, x 34%",1199.86,percent of total billed charges,Implant Device,1235.15,35,,1235.15,percent of total billed charges,Implant Device,1235.15,35,,1235.15,percent of total billed charges,Implant Device,1235.15,35,,1235.15,percent of total billed charges,Implant Device,1235.15,35,,1235.15,percent of total billed charges,Implant Device,1235.15,35,,1235.15,percent of total billed charges,Implant Device,1411.6,40,,1411.6,percent of total billed charges,Implant Device,1235.15,70,,1235.15,percent of total billed charges,All Other,1199.86,34,,1199.86,percent of total billed charges,Implant Device,1199.86,34,,1199.86,percent of total billed charges,Implant Device,1235.15,35,,1235.15,percent of total billed charges,Implant Device,1235.15,35,,1235.15,percent of total billed charges,Implant Device,1235.15,35,,1235.15,percent of total billed charges,Implant Device,1235.15,35,,1235.15,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1199.86,34,"If Charge > 2,000, then 34 percent",1199.86,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2611.47,
STRYKER F&A SV12 LAG SCREW 2.5X12MM,C1713,HCPCS,,79008712,CDM,278,RC,,,both,,,1761,1303.14,,,1303.14,Other,150% of Medicare + 9.63% HCRA Surcharge,792.45,45,,792.45,percent of total billed charges,Critical Access Hospital RCC factor,598.74,34,,598.74,percent of total billed charges,Implant Device,598.74,34,,598.74,percent of total billed charges,Implant Device,598.74,34,,598.74,percent of total billed charges,Implant Device,598.74,34,,598.74,percent of total billed charges,Implant Device,598.74,34,,598.74,percent of total billed charges,Implant Device,871.7,,,871.7,Other,110% of Medicare,616.35,35,,616.35,percent of total billed charges,Implant Device,598.74,34,"Charges > $500, x 34%",598.74,percent of total billed charges,Implant Device,616.35,35,,616.35,percent of total billed charges,Implant Device,616.35,35,,616.35,percent of total billed charges,Implant Device,616.35,35,,616.35,percent of total billed charges,Implant Device,616.35,35,,616.35,percent of total billed charges,Implant Device,616.35,35,,616.35,percent of total billed charges,Implant Device,704.4,40,,704.4,percent of total billed charges,Implant Device,616.35,70,,616.35,percent of total billed charges,All Other,598.74,34,,598.74,percent of total billed charges,Implant Device,598.74,34,,598.74,percent of total billed charges,Implant Device,616.35,35,,616.35,percent of total billed charges,Implant Device,616.35,35,,616.35,percent of total billed charges,Implant Device,616.35,35,,616.35,percent of total billed charges,Implant Device,616.35,35,,616.35,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1303.14,
PARAGON P50-053-2728 LOCK SCREW 2.7X28MM,C1713,HCPCS,,79008713,CDM,278,RC,,,both,,,880,651.2,,,651.2,Other,150% of Medicare + 9.63% HCRA Surcharge,396,45,,396,percent of total billed charges,Critical Access Hospital RCC factor,299.2,34,,299.2,percent of total billed charges,Implant Device,299.2,34,,299.2,percent of total billed charges,Implant Device,299.2,34,,299.2,percent of total billed charges,Implant Device,299.2,34,,299.2,percent of total billed charges,Implant Device,299.2,34,,299.2,percent of total billed charges,Implant Device,435.6,,,435.6,Other,110% of Medicare,308,35,,308,percent of total billed charges,Implant Device,299.2,34,"Charges > $500, x 34%",299.2,percent of total billed charges,Implant Device,308,35,,308,percent of total billed charges,Implant Device,308,35,,308,percent of total billed charges,Implant Device,308,35,,308,percent of total billed charges,Implant Device,308,35,,308,percent of total billed charges,Implant Device,308,35,,308,percent of total billed charges,Implant Device,352,40,,352,percent of total billed charges,Implant Device,308,70,,308,percent of total billed charges,All Other,299.2,34,,299.2,percent of total billed charges,Implant Device,299.2,34,,299.2,percent of total billed charges,Implant Device,308,35,,308,percent of total billed charges,Implant Device,308,35,,308,percent of total billed charges,Implant Device,308,35,,308,percent of total billed charges,Implant Device,308,35,,308,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,651.2,
PARAGON P50-053-4230 LOCK SCREW 4.2X30MM,C1713,HCPCS,,79008714,CDM,278,RC,,,both,,,893,660.82,,,660.82,Other,150% of Medicare + 9.63% HCRA Surcharge,401.85,45,,401.85,percent of total billed charges,Critical Access Hospital RCC factor,303.62,34,,303.62,percent of total billed charges,Implant Device,303.62,34,,303.62,percent of total billed charges,Implant Device,303.62,34,,303.62,percent of total billed charges,Implant Device,303.62,34,,303.62,percent of total billed charges,Implant Device,303.62,34,,303.62,percent of total billed charges,Implant Device,442.04,,,442.04,Other,110% of Medicare,312.55,35,,312.55,percent of total billed charges,Implant Device,303.62,34,"Charges > $500, x 34%",303.62,percent of total billed charges,Implant Device,312.55,35,,312.55,percent of total billed charges,Implant Device,312.55,35,,312.55,percent of total billed charges,Implant Device,312.55,35,,312.55,percent of total billed charges,Implant Device,312.55,35,,312.55,percent of total billed charges,Implant Device,312.55,35,,312.55,percent of total billed charges,Implant Device,357.2,40,,357.2,percent of total billed charges,Implant Device,312.55,70,,312.55,percent of total billed charges,All Other,303.62,34,,303.62,percent of total billed charges,Implant Device,303.62,34,,303.62,percent of total billed charges,Implant Device,312.55,35,,312.55,percent of total billed charges,Implant Device,312.55,35,,312.55,percent of total billed charges,Implant Device,312.55,35,,312.55,percent of total billed charges,Implant Device,312.55,35,,312.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,660.82,
STRYKER 1830-0926S HUMERAL KNEE 9X260MM,C1776,HCPCS,,79008715,CDM,278,RC,,,both,,,6661,4929.16,,,4929.16,Other,150% of Medicare + 9.63% HCRA Surcharge,2997.45,45,,2997.45,percent of total billed charges,Critical Access Hospital RCC factor,2264.74,34,,2264.74,percent of total billed charges,Implant Device,2264.74,34,,2264.74,percent of total billed charges,Implant Device,2264.74,34,,2264.74,percent of total billed charges,Implant Device,2264.74,34,,2264.74,percent of total billed charges,Implant Device,2264.74,34,,2264.74,percent of total billed charges,Implant Device,3297.2,,,3297.2,Other,110% of Medicare,2331.35,35,,2331.35,percent of total billed charges,Implant Device,2264.74,34,"Charges > $500, x 34%",2264.74,percent of total billed charges,Implant Device,2331.35,35,,2331.35,percent of total billed charges,Implant Device,2331.35,35,,2331.35,percent of total billed charges,Implant Device,2331.35,35,,2331.35,percent of total billed charges,Implant Device,2331.35,35,,2331.35,percent of total billed charges,Implant Device,2331.35,35,,2331.35,percent of total billed charges,Implant Device,2664.4,40,,2664.4,percent of total billed charges,Implant Device,2331.35,70,,2331.35,percent of total billed charges,All Other,2264.74,34,,2264.74,percent of total billed charges,Implant Device,2264.74,34,,2264.74,percent of total billed charges,Implant Device,2331.35,35,,2331.35,percent of total billed charges,Implant Device,2331.35,35,,2331.35,percent of total billed charges,Implant Device,2331.35,35,,2331.35,percent of total billed charges,Implant Device,2331.35,35,,2331.35,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2264.74,34,"If Charge > 2,000, then 34 percent",2264.74,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4929.16,
STRYKER 597030S HIP PLATE 135DEG 10 HOLE,C1713,HCPCS,,79008717,CDM,278,RC,,,both,,,2780,2057.21,,,2057.21,Other,150% of Medicare + 9.63% HCRA Surcharge,1251,45,,1251,percent of total billed charges,Critical Access Hospital RCC factor,945.2,34,,945.2,percent of total billed charges,Implant Device,945.2,34,,945.2,percent of total billed charges,Implant Device,945.2,34,,945.2,percent of total billed charges,Implant Device,945.2,34,,945.2,percent of total billed charges,Implant Device,945.2,34,,945.2,percent of total billed charges,Implant Device,1376.1,,,1376.1,Other,110% of Medicare,973,35,,973,percent of total billed charges,Implant Device,945.2,34,"Charges > $500, x 34%",945.2,percent of total billed charges,Implant Device,973,35,,973,percent of total billed charges,Implant Device,973,35,,973,percent of total billed charges,Implant Device,973,35,,973,percent of total billed charges,Implant Device,973,35,,973,percent of total billed charges,Implant Device,973,35,,973,percent of total billed charges,Implant Device,1112,40,,1112,percent of total billed charges,Implant Device,973,70,,973,percent of total billed charges,All Other,945.2,34,,945.2,percent of total billed charges,Implant Device,945.2,34,,945.2,percent of total billed charges,Implant Device,973,35,,973,percent of total billed charges,Implant Device,973,35,,973,percent of total billed charges,Implant Device,973,35,,973,percent of total billed charges,Implant Device,973,35,,973,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,945.2,34,"If Charge > 2,000, then 34 percent",945.2,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2057.21,
STRYKER 597010S HIP PLATE 130DEG 10 HOLE,C1713,HCPCS,,79008718,CDM,278,RC,,,both,,,2780,2057.21,,,2057.21,Other,150% of Medicare + 9.63% HCRA Surcharge,1251,45,,1251,percent of total billed charges,Critical Access Hospital RCC factor,945.2,34,,945.2,percent of total billed charges,Implant Device,945.2,34,,945.2,percent of total billed charges,Implant Device,945.2,34,,945.2,percent of total billed charges,Implant Device,945.2,34,,945.2,percent of total billed charges,Implant Device,945.2,34,,945.2,percent of total billed charges,Implant Device,1376.1,,,1376.1,Other,110% of Medicare,973,35,,973,percent of total billed charges,Implant Device,945.2,34,"Charges > $500, x 34%",945.2,percent of total billed charges,Implant Device,973,35,,973,percent of total billed charges,Implant Device,973,35,,973,percent of total billed charges,Implant Device,973,35,,973,percent of total billed charges,Implant Device,973,35,,973,percent of total billed charges,Implant Device,973,35,,973,percent of total billed charges,Implant Device,1112,40,,1112,percent of total billed charges,Implant Device,973,70,,973,percent of total billed charges,All Other,945.2,34,,945.2,percent of total billed charges,Implant Device,945.2,34,,945.2,percent of total billed charges,Implant Device,973,35,,973,percent of total billed charges,Implant Device,973,35,,973,percent of total billed charges,Implant Device,973,35,,973,percent of total billed charges,Implant Device,973,35,,973,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,945.2,34,"If Charge > 2,000, then 34 percent",945.2,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2057.21,
STRYKER 3362-5-105 STD LAG SCREW 105MM,C1713,HCPCS,,79008719,CDM,278,RC,,,both,,,1415,1047.1,,,1047.1,Other,150% of Medicare + 9.63% HCRA Surcharge,636.75,45,,636.75,percent of total billed charges,Critical Access Hospital RCC factor,481.1,34,,481.1,percent of total billed charges,Implant Device,481.1,34,,481.1,percent of total billed charges,Implant Device,481.1,34,,481.1,percent of total billed charges,Implant Device,481.1,34,,481.1,percent of total billed charges,Implant Device,481.1,34,,481.1,percent of total billed charges,Implant Device,700.43,,,700.43,Other,110% of Medicare,495.25,35,,495.25,percent of total billed charges,Implant Device,481.1,34,"Charges > $500, x 34%",481.1,percent of total billed charges,Implant Device,495.25,35,,495.25,percent of total billed charges,Implant Device,495.25,35,,495.25,percent of total billed charges,Implant Device,495.25,35,,495.25,percent of total billed charges,Implant Device,495.25,35,,495.25,percent of total billed charges,Implant Device,495.25,35,,495.25,percent of total billed charges,Implant Device,566,40,,566,percent of total billed charges,Implant Device,495.25,70,,495.25,percent of total billed charges,All Other,481.1,34,,481.1,percent of total billed charges,Implant Device,481.1,34,,481.1,percent of total billed charges,Implant Device,495.25,35,,495.25,percent of total billed charges,Implant Device,495.25,35,,495.25,percent of total billed charges,Implant Device,495.25,35,,495.25,percent of total billed charges,Implant Device,495.25,35,,495.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1047.1,
STRYKER 596001S COMPRESSION SCREW 32.3MM,C1713,HCPCS,,79008720,CDM,278,RC,,,both,,,354,261.96,,,261.96,Other,150% of Medicare + 9.63% HCRA Surcharge,159.3,45,,159.3,percent of total billed charges,Critical Access Hospital RCC factor,120.36,34,,120.36,percent of total billed charges,Implant Device,120.36,34,,120.36,percent of total billed charges,Implant Device,120.36,34,,120.36,percent of total billed charges,Implant Device,120.36,34,,120.36,percent of total billed charges,Implant Device,120.36,34,,120.36,percent of total billed charges,Implant Device,175.23,,,175.23,Other,110% of Medicare,123.9,35,,123.9,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,123.9,35,,123.9,percent of total billed charges,Implant Device,123.9,35,,123.9,percent of total billed charges,Implant Device,123.9,35,,123.9,percent of total billed charges,Implant Device,123.9,35,,123.9,percent of total billed charges,Implant Device,123.9,35,,123.9,percent of total billed charges,Implant Device,141.6,40,,141.6,percent of total billed charges,Implant Device,123.9,70,,123.9,percent of total billed charges,All Other,120.36,34,,120.36,percent of total billed charges,Implant Device,120.36,34,,120.36,percent of total billed charges,Implant Device,123.9,35,,123.9,percent of total billed charges,Implant Device,123.9,35,,123.9,percent of total billed charges,Implant Device,123.9,35,,123.9,percent of total billed charges,Implant Device,123.9,35,,123.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,261.96,
BIOMET 11-301310 CONE PROX BODY SZ1 50MM,C1776,HCPCS,,79008721,CDM,278,RC,,,both,,,36210,26795.49,,,26795.49,Other,150% of Medicare + 9.63% HCRA Surcharge,16294.5,45,,16294.5,percent of total billed charges,Critical Access Hospital RCC factor,12311.4,34,,12311.4,percent of total billed charges,Implant Device,12311.4,34,,12311.4,percent of total billed charges,Implant Device,12311.4,34,,12311.4,percent of total billed charges,Implant Device,12311.4,34,,12311.4,percent of total billed charges,Implant Device,12311.4,34,,12311.4,percent of total billed charges,Implant Device,17923.95,,,17923.95,Other,110% of Medicare,12673.5,35,,12673.5,percent of total billed charges,Implant Device,12311.4,34,"Charges > $500, x 34%",12311.4,percent of total billed charges,Implant Device,12673.5,35,,12673.5,percent of total billed charges,Implant Device,12673.5,35,,12673.5,percent of total billed charges,Implant Device,12673.5,35,,12673.5,percent of total billed charges,Implant Device,12673.5,35,,12673.5,percent of total billed charges,Implant Device,12673.5,35,,12673.5,percent of total billed charges,Implant Device,14484,40,,14484,percent of total billed charges,Implant Device,12673.5,70,,12673.5,percent of total billed charges,All Other,12311.4,34,,12311.4,percent of total billed charges,Implant Device,12311.4,34,,12311.4,percent of total billed charges,Implant Device,12673.5,35,,12673.5,percent of total billed charges,Implant Device,12673.5,35,,12673.5,percent of total billed charges,Implant Device,12673.5,35,,12673.5,percent of total billed charges,Implant Device,12673.5,35,,12673.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,12311.4,34,"If Charge > 2,000, then 34 percent",12311.4,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,26795.49,
BIOMET 11-300918 STS DIS STEM 18X190MM,C1776,HCPCS,,79008722,CDM,278,RC,,,both,,,10199,7547.29,,,7547.29,Other,150% of Medicare + 9.63% HCRA Surcharge,4589.55,45,,4589.55,percent of total billed charges,Critical Access Hospital RCC factor,3467.66,34,,3467.66,percent of total billed charges,Implant Device,3467.66,34,,3467.66,percent of total billed charges,Implant Device,3467.66,34,,3467.66,percent of total billed charges,Implant Device,3467.66,34,,3467.66,percent of total billed charges,Implant Device,3467.66,34,,3467.66,percent of total billed charges,Implant Device,5048.51,,,5048.51,Other,110% of Medicare,3569.65,35,,3569.65,percent of total billed charges,Implant Device,3467.66,34,"Charges > $500, x 34%",3467.66,percent of total billed charges,Implant Device,3569.65,35,,3569.65,percent of total billed charges,Implant Device,3569.65,35,,3569.65,percent of total billed charges,Implant Device,3569.65,35,,3569.65,percent of total billed charges,Implant Device,3569.65,35,,3569.65,percent of total billed charges,Implant Device,3569.65,35,,3569.65,percent of total billed charges,Implant Device,4079.6,40,,4079.6,percent of total billed charges,Implant Device,3569.65,70,,3569.65,percent of total billed charges,All Other,3467.66,34,,3467.66,percent of total billed charges,Implant Device,3467.66,34,,3467.66,percent of total billed charges,Implant Device,3569.65,35,,3569.65,percent of total billed charges,Implant Device,3569.65,35,,3569.65,percent of total billed charges,Implant Device,3569.65,35,,3569.65,percent of total billed charges,Implant Device,3569.65,35,,3569.65,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3467.66,34,"If Charge > 2,000, then 34 percent",3467.66,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,7547.29,
BIOMET 12-115120 MODULAR HEAD -3 NECK,C1776,HCPCS,,79008723,CDM,278,RC,,,both,,,3075,2275.51,,,2275.51,Other,150% of Medicare + 9.63% HCRA Surcharge,1383.75,45,,1383.75,percent of total billed charges,Critical Access Hospital RCC factor,1045.5,34,,1045.5,percent of total billed charges,Implant Device,1045.5,34,,1045.5,percent of total billed charges,Implant Device,1045.5,34,,1045.5,percent of total billed charges,Implant Device,1045.5,34,,1045.5,percent of total billed charges,Implant Device,1045.5,34,,1045.5,percent of total billed charges,Implant Device,1522.13,,,1522.13,Other,110% of Medicare,1076.25,35,,1076.25,percent of total billed charges,Implant Device,1045.5,34,"Charges > $500, x 34%",1045.5,percent of total billed charges,Implant Device,1076.25,35,,1076.25,percent of total billed charges,Implant Device,1076.25,35,,1076.25,percent of total billed charges,Implant Device,1076.25,35,,1076.25,percent of total billed charges,Implant Device,1076.25,35,,1076.25,percent of total billed charges,Implant Device,1076.25,35,,1076.25,percent of total billed charges,Implant Device,1230,40,,1230,percent of total billed charges,Implant Device,1076.25,70,,1076.25,percent of total billed charges,All Other,1045.5,34,,1045.5,percent of total billed charges,Implant Device,1045.5,34,,1045.5,percent of total billed charges,Implant Device,1076.25,35,,1076.25,percent of total billed charges,Implant Device,1076.25,35,,1076.25,percent of total billed charges,Implant Device,1076.25,35,,1076.25,percent of total billed charges,Implant Device,1076.25,35,,1076.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1045.5,34,"If Charge > 2,000, then 34 percent",1045.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2275.51,
STRYKER 623-00-36E INSERT ID 36MM CODE E,C1776,HCPCS,,79008725,CDM,278,RC,,,both,,,2503,1852.23,,,1852.23,Other,150% of Medicare + 9.63% HCRA Surcharge,1126.35,45,,1126.35,percent of total billed charges,Critical Access Hospital RCC factor,851.02,34,,851.02,percent of total billed charges,Implant Device,851.02,34,,851.02,percent of total billed charges,Implant Device,851.02,34,,851.02,percent of total billed charges,Implant Device,851.02,34,,851.02,percent of total billed charges,Implant Device,851.02,34,,851.02,percent of total billed charges,Implant Device,1238.99,,,1238.99,Other,110% of Medicare,876.05,35,,876.05,percent of total billed charges,Implant Device,851.02,34,"Charges > $500, x 34%",851.02,percent of total billed charges,Implant Device,876.05,35,,876.05,percent of total billed charges,Implant Device,876.05,35,,876.05,percent of total billed charges,Implant Device,876.05,35,,876.05,percent of total billed charges,Implant Device,876.05,35,,876.05,percent of total billed charges,Implant Device,876.05,35,,876.05,percent of total billed charges,Implant Device,1001.2,40,,1001.2,percent of total billed charges,Implant Device,876.05,70,,876.05,percent of total billed charges,All Other,851.02,34,,851.02,percent of total billed charges,Implant Device,851.02,34,,851.02,percent of total billed charges,Implant Device,876.05,35,,876.05,percent of total billed charges,Implant Device,876.05,35,,876.05,percent of total billed charges,Implant Device,876.05,35,,876.05,percent of total billed charges,Implant Device,876.05,35,,876.05,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,851.02,34,"If Charge > 2,000, then 34 percent",851.02,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1852.23,
STRYKER PLP40220 PLATE STRAIGHT 3 HOLE,C1713,HCPCS,,79008726,CDM,278,RC,,,both,,,5733,4242.43,,,4242.43,Other,150% of Medicare + 9.63% HCRA Surcharge,2579.85,45,,2579.85,percent of total billed charges,Critical Access Hospital RCC factor,1949.22,34,,1949.22,percent of total billed charges,Implant Device,1949.22,34,,1949.22,percent of total billed charges,Implant Device,1949.22,34,,1949.22,percent of total billed charges,Implant Device,1949.22,34,,1949.22,percent of total billed charges,Implant Device,1949.22,34,,1949.22,percent of total billed charges,Implant Device,2837.84,,,2837.84,Other,110% of Medicare,2006.55,35,,2006.55,percent of total billed charges,Implant Device,1949.22,34,"Charges > $500, x 34%",1949.22,percent of total billed charges,Implant Device,2006.55,35,,2006.55,percent of total billed charges,Implant Device,2006.55,35,,2006.55,percent of total billed charges,Implant Device,2006.55,35,,2006.55,percent of total billed charges,Implant Device,2006.55,35,,2006.55,percent of total billed charges,Implant Device,2006.55,35,,2006.55,percent of total billed charges,Implant Device,2293.2,40,,2293.2,percent of total billed charges,Implant Device,2006.55,70,,2006.55,percent of total billed charges,All Other,1949.22,34,,1949.22,percent of total billed charges,Implant Device,1949.22,34,,1949.22,percent of total billed charges,Implant Device,2006.55,35,,2006.55,percent of total billed charges,Implant Device,2006.55,35,,2006.55,percent of total billed charges,Implant Device,2006.55,35,,2006.55,percent of total billed charges,Implant Device,2006.55,35,,2006.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1949.22,34,"If Charge > 2,000, then 34 percent",1949.22,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4242.43,
STRYKER PLSL3018 LOCKING SCREW 3X18MM,C1713,HCPCS,,79008727,CDM,278,RC,,,both,,,1119,828.06,,,828.06,Other,150% of Medicare + 9.63% HCRA Surcharge,503.55,45,,503.55,percent of total billed charges,Critical Access Hospital RCC factor,380.46,34,,380.46,percent of total billed charges,Implant Device,380.46,34,,380.46,percent of total billed charges,Implant Device,380.46,34,,380.46,percent of total billed charges,Implant Device,380.46,34,,380.46,percent of total billed charges,Implant Device,380.46,34,,380.46,percent of total billed charges,Implant Device,553.91,,,553.91,Other,110% of Medicare,391.65,35,,391.65,percent of total billed charges,Implant Device,380.46,34,"Charges > $500, x 34%",380.46,percent of total billed charges,Implant Device,391.65,35,,391.65,percent of total billed charges,Implant Device,391.65,35,,391.65,percent of total billed charges,Implant Device,391.65,35,,391.65,percent of total billed charges,Implant Device,391.65,35,,391.65,percent of total billed charges,Implant Device,391.65,35,,391.65,percent of total billed charges,Implant Device,447.6,40,,447.6,percent of total billed charges,Implant Device,391.65,70,,391.65,percent of total billed charges,All Other,380.46,34,,380.46,percent of total billed charges,Implant Device,380.46,34,,380.46,percent of total billed charges,Implant Device,391.65,35,,391.65,percent of total billed charges,Implant Device,391.65,35,,391.65,percent of total billed charges,Implant Device,391.65,35,,391.65,percent of total billed charges,Implant Device,391.65,35,,391.65,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,828.06,
STRYKER EZM08-08-08 COMP STAPLE 8X8X8MM,C1713,HCPCS,,79008728,CDM,278,RC,,,both,,,4386,3245.65,,,3245.65,Other,150% of Medicare + 9.63% HCRA Surcharge,1973.7,45,,1973.7,percent of total billed charges,Critical Access Hospital RCC factor,1491.24,34,,1491.24,percent of total billed charges,Implant Device,1491.24,34,,1491.24,percent of total billed charges,Implant Device,1491.24,34,,1491.24,percent of total billed charges,Implant Device,1491.24,34,,1491.24,percent of total billed charges,Implant Device,1491.24,34,,1491.24,percent of total billed charges,Implant Device,2171.07,,,2171.07,Other,110% of Medicare,1535.1,35,,1535.1,percent of total billed charges,Implant Device,1491.24,34,"Charges > $500, x 34%",1491.24,percent of total billed charges,Implant Device,1535.1,35,,1535.1,percent of total billed charges,Implant Device,1535.1,35,,1535.1,percent of total billed charges,Implant Device,1535.1,35,,1535.1,percent of total billed charges,Implant Device,1535.1,35,,1535.1,percent of total billed charges,Implant Device,1535.1,35,,1535.1,percent of total billed charges,Implant Device,1754.4,40,,1754.4,percent of total billed charges,Implant Device,1535.1,70,,1535.1,percent of total billed charges,All Other,1491.24,34,,1491.24,percent of total billed charges,Implant Device,1491.24,34,,1491.24,percent of total billed charges,Implant Device,1535.1,35,,1535.1,percent of total billed charges,Implant Device,1535.1,35,,1535.1,percent of total billed charges,Implant Device,1535.1,35,,1535.1,percent of total billed charges,Implant Device,1535.1,35,,1535.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1491.24,34,"If Charge > 2,000, then 34 percent",1491.24,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3245.65,
STRYKER EZM10-10-10 COMP STAPLE 10X10X10,C1713,HCPCS,,79008729,CDM,278,RC,,,both,,,2132,1577.69,,,1577.69,Other,150% of Medicare + 9.63% HCRA Surcharge,959.4,45,,959.4,percent of total billed charges,Critical Access Hospital RCC factor,724.88,34,,724.88,percent of total billed charges,Implant Device,724.88,34,,724.88,percent of total billed charges,Implant Device,724.88,34,,724.88,percent of total billed charges,Implant Device,724.88,34,,724.88,percent of total billed charges,Implant Device,724.88,34,,724.88,percent of total billed charges,Implant Device,1055.34,,,1055.34,Other,110% of Medicare,746.2,35,,746.2,percent of total billed charges,Implant Device,724.88,34,"Charges > $500, x 34%",724.88,percent of total billed charges,Implant Device,746.2,35,,746.2,percent of total billed charges,Implant Device,746.2,35,,746.2,percent of total billed charges,Implant Device,746.2,35,,746.2,percent of total billed charges,Implant Device,746.2,35,,746.2,percent of total billed charges,Implant Device,746.2,35,,746.2,percent of total billed charges,Implant Device,852.8,40,,852.8,percent of total billed charges,Implant Device,746.2,70,,746.2,percent of total billed charges,All Other,724.88,34,,724.88,percent of total billed charges,Implant Device,724.88,34,,724.88,percent of total billed charges,Implant Device,746.2,35,,746.2,percent of total billed charges,Implant Device,746.2,35,,746.2,percent of total billed charges,Implant Device,746.2,35,,746.2,percent of total billed charges,Implant Device,746.2,35,,746.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,724.88,34,"If Charge > 2,000, then 34 percent",724.88,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1577.69,
STRYKER HT-0001 SMALL HAMMERTOE IMPLANT,C1713,HCPCS,,79008730,CDM,278,RC,,,both,,,5970,4417.81,,,4417.81,Other,150% of Medicare + 9.63% HCRA Surcharge,2686.5,45,,2686.5,percent of total billed charges,Critical Access Hospital RCC factor,2029.8,34,,2029.8,percent of total billed charges,Implant Device,2029.8,34,,2029.8,percent of total billed charges,Implant Device,2029.8,34,,2029.8,percent of total billed charges,Implant Device,2029.8,34,,2029.8,percent of total billed charges,Implant Device,2029.8,34,,2029.8,percent of total billed charges,Implant Device,2955.15,,,2955.15,Other,110% of Medicare,2089.5,35,,2089.5,percent of total billed charges,Implant Device,2029.8,34,"Charges > $500, x 34%",2029.8,percent of total billed charges,Implant Device,2089.5,35,,2089.5,percent of total billed charges,Implant Device,2089.5,35,,2089.5,percent of total billed charges,Implant Device,2089.5,35,,2089.5,percent of total billed charges,Implant Device,2089.5,35,,2089.5,percent of total billed charges,Implant Device,2089.5,35,,2089.5,percent of total billed charges,Implant Device,2388,40,,2388,percent of total billed charges,Implant Device,2089.5,70,,2089.5,percent of total billed charges,All Other,2029.8,34,,2029.8,percent of total billed charges,Implant Device,2029.8,34,,2029.8,percent of total billed charges,Implant Device,2089.5,35,,2089.5,percent of total billed charges,Implant Device,2089.5,35,,2089.5,percent of total billed charges,Implant Device,2089.5,35,,2089.5,percent of total billed charges,Implant Device,2089.5,35,,2089.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2029.8,34,"If Charge > 2,000, then 34 percent",2029.8,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4417.81,
STRYKER PLSL3016 LOCKING SCREW 3X16MM,C1713,HCPCS,,79008731,CDM,278,RC,,,both,,,978,723.72,,,723.72,Other,150% of Medicare + 9.63% HCRA Surcharge,440.1,45,,440.1,percent of total billed charges,Critical Access Hospital RCC factor,332.52,34,,332.52,percent of total billed charges,Implant Device,332.52,34,,332.52,percent of total billed charges,Implant Device,332.52,34,,332.52,percent of total billed charges,Implant Device,332.52,34,,332.52,percent of total billed charges,Implant Device,332.52,34,,332.52,percent of total billed charges,Implant Device,484.11,,,484.11,Other,110% of Medicare,342.3,35,,342.3,percent of total billed charges,Implant Device,332.52,34,"Charges > $500, x 34%",332.52,percent of total billed charges,Implant Device,342.3,35,,342.3,percent of total billed charges,Implant Device,342.3,35,,342.3,percent of total billed charges,Implant Device,342.3,35,,342.3,percent of total billed charges,Implant Device,342.3,35,,342.3,percent of total billed charges,Implant Device,342.3,35,,342.3,percent of total billed charges,Implant Device,391.2,40,,391.2,percent of total billed charges,Implant Device,342.3,70,,342.3,percent of total billed charges,All Other,332.52,34,,332.52,percent of total billed charges,Implant Device,332.52,34,,332.52,percent of total billed charges,Implant Device,342.3,35,,342.3,percent of total billed charges,Implant Device,342.3,35,,342.3,percent of total billed charges,Implant Device,342.3,35,,342.3,percent of total billed charges,Implant Device,342.3,35,,342.3,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,723.72,
STRYKER SV16 S-FIX SCREW 2.5LG 16MM,C1713,HCPCS,,79008732,CDM,278,RC,,,both,,,1761,1303.14,,,1303.14,Other,150% of Medicare + 9.63% HCRA Surcharge,792.45,45,,792.45,percent of total billed charges,Critical Access Hospital RCC factor,598.74,34,,598.74,percent of total billed charges,Implant Device,598.74,34,,598.74,percent of total billed charges,Implant Device,598.74,34,,598.74,percent of total billed charges,Implant Device,598.74,34,,598.74,percent of total billed charges,Implant Device,598.74,34,,598.74,percent of total billed charges,Implant Device,871.7,,,871.7,Other,110% of Medicare,616.35,35,,616.35,percent of total billed charges,Implant Device,598.74,34,"Charges > $500, x 34%",598.74,percent of total billed charges,Implant Device,616.35,35,,616.35,percent of total billed charges,Implant Device,616.35,35,,616.35,percent of total billed charges,Implant Device,616.35,35,,616.35,percent of total billed charges,Implant Device,616.35,35,,616.35,percent of total billed charges,Implant Device,616.35,35,,616.35,percent of total billed charges,Implant Device,704.4,40,,704.4,percent of total billed charges,Implant Device,616.35,70,,616.35,percent of total billed charges,All Other,598.74,34,,598.74,percent of total billed charges,Implant Device,598.74,34,,598.74,percent of total billed charges,Implant Device,616.35,35,,616.35,percent of total billed charges,Implant Device,616.35,35,,616.35,percent of total billed charges,Implant Device,616.35,35,,616.35,percent of total billed charges,Implant Device,616.35,35,,616.35,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1303.14,
STRYKER 626926 LAG SCREW 3.6X6MM,C1713,HCPCS,,79008737,CDM,278,RC,,,both,,,879,650.46,,,650.46,Other,150% of Medicare + 9.63% HCRA Surcharge,395.55,45,,395.55,percent of total billed charges,Critical Access Hospital RCC factor,298.86,34,,298.86,percent of total billed charges,Implant Device,298.86,34,,298.86,percent of total billed charges,Implant Device,298.86,34,,298.86,percent of total billed charges,Implant Device,298.86,34,,298.86,percent of total billed charges,Implant Device,298.86,34,,298.86,percent of total billed charges,Implant Device,435.11,,,435.11,Other,110% of Medicare,307.65,35,,307.65,percent of total billed charges,Implant Device,298.86,34,"Charges > $500, x 34%",298.86,percent of total billed charges,Implant Device,307.65,35,,307.65,percent of total billed charges,Implant Device,307.65,35,,307.65,percent of total billed charges,Implant Device,307.65,35,,307.65,percent of total billed charges,Implant Device,307.65,35,,307.65,percent of total billed charges,Implant Device,307.65,35,,307.65,percent of total billed charges,Implant Device,351.6,40,,351.6,percent of total billed charges,Implant Device,307.65,70,,307.65,percent of total billed charges,All Other,298.86,34,,298.86,percent of total billed charges,Implant Device,298.86,34,,298.86,percent of total billed charges,Implant Device,307.65,35,,307.65,percent of total billed charges,Implant Device,307.65,35,,307.65,percent of total billed charges,Implant Device,307.65,35,,307.65,percent of total billed charges,Implant Device,307.65,35,,307.65,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,650.46,
STRYKER 627644 14 HOLE DIS RT FEMUR PLT,C1713,HCPCS,,79008739,CDM,278,RC,,,both,,,11103,8216.25,,,8216.25,Other,150% of Medicare + 9.63% HCRA Surcharge,4996.35,45,,4996.35,percent of total billed charges,Critical Access Hospital RCC factor,3775.02,34,,3775.02,percent of total billed charges,Implant Device,3775.02,34,,3775.02,percent of total billed charges,Implant Device,3775.02,34,,3775.02,percent of total billed charges,Implant Device,3775.02,34,,3775.02,percent of total billed charges,Implant Device,3775.02,34,,3775.02,percent of total billed charges,Implant Device,5495.99,,,5495.99,Other,110% of Medicare,3886.05,35,,3886.05,percent of total billed charges,Implant Device,3775.02,34,"Charges > $500, x 34%",3775.02,percent of total billed charges,Implant Device,3886.05,35,,3886.05,percent of total billed charges,Implant Device,3886.05,35,,3886.05,percent of total billed charges,Implant Device,3886.05,35,,3886.05,percent of total billed charges,Implant Device,3886.05,35,,3886.05,percent of total billed charges,Implant Device,3886.05,35,,3886.05,percent of total billed charges,Implant Device,4441.2,40,,4441.2,percent of total billed charges,Implant Device,3886.05,70,,3886.05,percent of total billed charges,All Other,3775.02,34,,3775.02,percent of total billed charges,Implant Device,3775.02,34,,3775.02,percent of total billed charges,Implant Device,3886.05,35,,3886.05,percent of total billed charges,Implant Device,3886.05,35,,3886.05,percent of total billed charges,Implant Device,3886.05,35,,3886.05,percent of total billed charges,Implant Device,3886.05,35,,3886.05,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3775.02,34,"If Charge > 2,000, then 34 percent",3775.02,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,8216.25,
STRYKER 661734 4.5X34MM NON LOCK SCREW,C1713,HCPCS,,79008740,CDM,278,RC,,,both,,,139,102.86,,,102.86,Other,150% of Medicare + 9.63% HCRA Surcharge,62.55,45,,62.55,percent of total billed charges,Critical Access Hospital RCC factor,47.26,34,,47.26,percent of total billed charges,Implant Device,47.26,34,,47.26,percent of total billed charges,Implant Device,47.26,34,,47.26,percent of total billed charges,Implant Device,47.26,34,,47.26,percent of total billed charges,Implant Device,47.26,34,,47.26,percent of total billed charges,Implant Device,68.81,,,68.81,Other,110% of Medicare,48.65,35,,48.65,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,48.65,35,,48.65,percent of total billed charges,Implant Device,48.65,35,,48.65,percent of total billed charges,Implant Device,48.65,35,,48.65,percent of total billed charges,Implant Device,48.65,35,,48.65,percent of total billed charges,Implant Device,48.65,35,,48.65,percent of total billed charges,Implant Device,55.6,40,,55.6,percent of total billed charges,Implant Device,48.65,70,,48.65,percent of total billed charges,All Other,47.26,34,,47.26,percent of total billed charges,Implant Device,47.26,34,,47.26,percent of total billed charges,Implant Device,48.65,35,,48.65,percent of total billed charges,Implant Device,48.65,35,,48.65,percent of total billed charges,Implant Device,48.65,35,,48.65,percent of total billed charges,Implant Device,48.65,35,,48.65,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,102.86,
STRYKER 661732 4.5X32MM NON LOCK SCREW,C1713,HCPCS,,79008741,CDM,278,RC,,,both,,,139,102.86,,,102.86,Other,150% of Medicare + 9.63% HCRA Surcharge,62.55,45,,62.55,percent of total billed charges,Critical Access Hospital RCC factor,47.26,34,,47.26,percent of total billed charges,Implant Device,47.26,34,,47.26,percent of total billed charges,Implant Device,47.26,34,,47.26,percent of total billed charges,Implant Device,47.26,34,,47.26,percent of total billed charges,Implant Device,47.26,34,,47.26,percent of total billed charges,Implant Device,68.81,,,68.81,Other,110% of Medicare,48.65,35,,48.65,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,48.65,35,,48.65,percent of total billed charges,Implant Device,48.65,35,,48.65,percent of total billed charges,Implant Device,48.65,35,,48.65,percent of total billed charges,Implant Device,48.65,35,,48.65,percent of total billed charges,Implant Device,48.65,35,,48.65,percent of total billed charges,Implant Device,55.6,40,,55.6,percent of total billed charges,Implant Device,48.65,70,,48.65,percent of total billed charges,All Other,47.26,34,,47.26,percent of total billed charges,Implant Device,47.26,34,,47.26,percent of total billed charges,Implant Device,48.65,35,,48.65,percent of total billed charges,Implant Device,48.65,35,,48.65,percent of total billed charges,Implant Device,48.65,35,,48.65,percent of total billed charges,Implant Device,48.65,35,,48.65,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,102.86,
STRYKER 661730 4.5X30MM NON LOCK SCREW,C1713,HCPCS,,79008742,CDM,278,RC,,,both,,,139,102.86,,,102.86,Other,150% of Medicare + 9.63% HCRA Surcharge,62.55,45,,62.55,percent of total billed charges,Critical Access Hospital RCC factor,47.26,34,,47.26,percent of total billed charges,Implant Device,47.26,34,,47.26,percent of total billed charges,Implant Device,47.26,34,,47.26,percent of total billed charges,Implant Device,47.26,34,,47.26,percent of total billed charges,Implant Device,47.26,34,,47.26,percent of total billed charges,Implant Device,68.81,,,68.81,Other,110% of Medicare,48.65,35,,48.65,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,48.65,35,,48.65,percent of total billed charges,Implant Device,48.65,35,,48.65,percent of total billed charges,Implant Device,48.65,35,,48.65,percent of total billed charges,Implant Device,48.65,35,,48.65,percent of total billed charges,Implant Device,48.65,35,,48.65,percent of total billed charges,Implant Device,55.6,40,,55.6,percent of total billed charges,Implant Device,48.65,70,,48.65,percent of total billed charges,All Other,47.26,34,,47.26,percent of total billed charges,Implant Device,47.26,34,,47.26,percent of total billed charges,Implant Device,48.65,35,,48.65,percent of total billed charges,Implant Device,48.65,35,,48.65,percent of total billed charges,Implant Device,48.65,35,,48.65,percent of total billed charges,Implant Device,48.65,35,,48.65,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,102.86,
STRYKER 661738 4.5X38MM NON LOCK SCREW,C1713,HCPCS,,79008743,CDM,278,RC,,,both,,,195,144.3,,,144.3,Other,150% of Medicare + 9.63% HCRA Surcharge,87.75,45,,87.75,percent of total billed charges,Critical Access Hospital RCC factor,66.3,34,,66.3,percent of total billed charges,Implant Device,66.3,34,,66.3,percent of total billed charges,Implant Device,66.3,34,,66.3,percent of total billed charges,Implant Device,66.3,34,,66.3,percent of total billed charges,Implant Device,66.3,34,,66.3,percent of total billed charges,Implant Device,96.53,,,96.53,Other,110% of Medicare,68.25,35,,68.25,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,68.25,35,,68.25,percent of total billed charges,Implant Device,68.25,35,,68.25,percent of total billed charges,Implant Device,68.25,35,,68.25,percent of total billed charges,Implant Device,68.25,35,,68.25,percent of total billed charges,Implant Device,68.25,35,,68.25,percent of total billed charges,Implant Device,78,40,,78,percent of total billed charges,Implant Device,68.25,70,,68.25,percent of total billed charges,All Other,66.3,34,,66.3,percent of total billed charges,Implant Device,66.3,34,,66.3,percent of total billed charges,Implant Device,68.25,35,,68.25,percent of total billed charges,Implant Device,68.25,35,,68.25,percent of total billed charges,Implant Device,68.25,35,,68.25,percent of total billed charges,Implant Device,68.25,35,,68.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,144.3,
STRYKER 661728 4.5X28MM NON LOCK SCREW,C1713,HCPCS,,79008744,CDM,278,RC,,,both,,,139,102.86,,,102.86,Other,150% of Medicare + 9.63% HCRA Surcharge,62.55,45,,62.55,percent of total billed charges,Critical Access Hospital RCC factor,47.26,34,,47.26,percent of total billed charges,Implant Device,47.26,34,,47.26,percent of total billed charges,Implant Device,47.26,34,,47.26,percent of total billed charges,Implant Device,47.26,34,,47.26,percent of total billed charges,Implant Device,47.26,34,,47.26,percent of total billed charges,Implant Device,68.81,,,68.81,Other,110% of Medicare,48.65,35,,48.65,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,48.65,35,,48.65,percent of total billed charges,Implant Device,48.65,35,,48.65,percent of total billed charges,Implant Device,48.65,35,,48.65,percent of total billed charges,Implant Device,48.65,35,,48.65,percent of total billed charges,Implant Device,48.65,35,,48.65,percent of total billed charges,Implant Device,55.6,40,,55.6,percent of total billed charges,Implant Device,48.65,70,,48.65,percent of total billed charges,All Other,47.26,34,,47.26,percent of total billed charges,Implant Device,47.26,34,,47.26,percent of total billed charges,Implant Device,48.65,35,,48.65,percent of total billed charges,Implant Device,48.65,35,,48.65,percent of total billed charges,Implant Device,48.65,35,,48.65,percent of total billed charges,Implant Device,48.65,35,,48.65,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,102.86,
STRYKER 661170 5.0X70MM LOCKING SCREW,C1713,HCPCS,,79008745,CDM,278,RC,,,both,,,616,455.84,,,455.84,Other,150% of Medicare + 9.63% HCRA Surcharge,277.2,45,,277.2,percent of total billed charges,Critical Access Hospital RCC factor,209.44,34,,209.44,percent of total billed charges,Implant Device,209.44,34,,209.44,percent of total billed charges,Implant Device,209.44,34,,209.44,percent of total billed charges,Implant Device,209.44,34,,209.44,percent of total billed charges,Implant Device,209.44,34,,209.44,percent of total billed charges,Implant Device,304.92,,,304.92,Other,110% of Medicare,215.6,35,,215.6,percent of total billed charges,Implant Device,209.44,34,"Charges > $500, x 34%",209.44,percent of total billed charges,Implant Device,215.6,35,,215.6,percent of total billed charges,Implant Device,215.6,35,,215.6,percent of total billed charges,Implant Device,215.6,35,,215.6,percent of total billed charges,Implant Device,215.6,35,,215.6,percent of total billed charges,Implant Device,215.6,35,,215.6,percent of total billed charges,Implant Device,246.4,40,,246.4,percent of total billed charges,Implant Device,215.6,70,,215.6,percent of total billed charges,All Other,209.44,34,,209.44,percent of total billed charges,Implant Device,209.44,34,,209.44,percent of total billed charges,Implant Device,215.6,35,,215.6,percent of total billed charges,Implant Device,215.6,35,,215.6,percent of total billed charges,Implant Device,215.6,35,,215.6,percent of total billed charges,Implant Device,215.6,35,,215.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,455.84,
STRYKER 661165 5.0X65MM LOCKING SCREW,C1713,HCPCS,,79008746,CDM,278,RC,,,both,,,616,455.84,,,455.84,Other,150% of Medicare + 9.63% HCRA Surcharge,277.2,45,,277.2,percent of total billed charges,Critical Access Hospital RCC factor,209.44,34,,209.44,percent of total billed charges,Implant Device,209.44,34,,209.44,percent of total billed charges,Implant Device,209.44,34,,209.44,percent of total billed charges,Implant Device,209.44,34,,209.44,percent of total billed charges,Implant Device,209.44,34,,209.44,percent of total billed charges,Implant Device,304.92,,,304.92,Other,110% of Medicare,215.6,35,,215.6,percent of total billed charges,Implant Device,209.44,34,"Charges > $500, x 34%",209.44,percent of total billed charges,Implant Device,215.6,35,,215.6,percent of total billed charges,Implant Device,215.6,35,,215.6,percent of total billed charges,Implant Device,215.6,35,,215.6,percent of total billed charges,Implant Device,215.6,35,,215.6,percent of total billed charges,Implant Device,215.6,35,,215.6,percent of total billed charges,Implant Device,246.4,40,,246.4,percent of total billed charges,Implant Device,215.6,70,,215.6,percent of total billed charges,All Other,209.44,34,,209.44,percent of total billed charges,Implant Device,209.44,34,,209.44,percent of total billed charges,Implant Device,215.6,35,,215.6,percent of total billed charges,Implant Device,215.6,35,,215.6,percent of total billed charges,Implant Device,215.6,35,,215.6,percent of total billed charges,Implant Device,215.6,35,,215.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,455.84,
STRYKER 661160 5.0X60MM LOCKING SCREW,C1713,HCPCS,,79008747,CDM,278,RC,,,both,,,616,455.84,,,455.84,Other,150% of Medicare + 9.63% HCRA Surcharge,277.2,45,,277.2,percent of total billed charges,Critical Access Hospital RCC factor,209.44,34,,209.44,percent of total billed charges,Implant Device,209.44,34,,209.44,percent of total billed charges,Implant Device,209.44,34,,209.44,percent of total billed charges,Implant Device,209.44,34,,209.44,percent of total billed charges,Implant Device,209.44,34,,209.44,percent of total billed charges,Implant Device,304.92,,,304.92,Other,110% of Medicare,215.6,35,,215.6,percent of total billed charges,Implant Device,209.44,34,"Charges > $500, x 34%",209.44,percent of total billed charges,Implant Device,215.6,35,,215.6,percent of total billed charges,Implant Device,215.6,35,,215.6,percent of total billed charges,Implant Device,215.6,35,,215.6,percent of total billed charges,Implant Device,215.6,35,,215.6,percent of total billed charges,Implant Device,215.6,35,,215.6,percent of total billed charges,Implant Device,246.4,40,,246.4,percent of total billed charges,Implant Device,215.6,70,,215.6,percent of total billed charges,All Other,209.44,34,,209.44,percent of total billed charges,Implant Device,209.44,34,,209.44,percent of total billed charges,Implant Device,215.6,35,,215.6,percent of total billed charges,Implant Device,215.6,35,,215.6,percent of total billed charges,Implant Device,215.6,35,,215.6,percent of total billed charges,Implant Device,215.6,35,,215.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,455.84,
STRYKER 661136 5.0X36MM LOCKING SCREW,C1713,HCPCS,,79008748,CDM,278,RC,,,both,,,864,639.36,,,639.36,Other,150% of Medicare + 9.63% HCRA Surcharge,388.8,45,,388.8,percent of total billed charges,Critical Access Hospital RCC factor,293.76,34,,293.76,percent of total billed charges,Implant Device,293.76,34,,293.76,percent of total billed charges,Implant Device,293.76,34,,293.76,percent of total billed charges,Implant Device,293.76,34,,293.76,percent of total billed charges,Implant Device,293.76,34,,293.76,percent of total billed charges,Implant Device,427.68,,,427.68,Other,110% of Medicare,302.4,35,,302.4,percent of total billed charges,Implant Device,293.76,34,"Charges > $500, x 34%",293.76,percent of total billed charges,Implant Device,302.4,35,,302.4,percent of total billed charges,Implant Device,302.4,35,,302.4,percent of total billed charges,Implant Device,302.4,35,,302.4,percent of total billed charges,Implant Device,302.4,35,,302.4,percent of total billed charges,Implant Device,302.4,35,,302.4,percent of total billed charges,Implant Device,345.6,40,,345.6,percent of total billed charges,Implant Device,302.4,70,,302.4,percent of total billed charges,All Other,293.76,34,,293.76,percent of total billed charges,Implant Device,293.76,34,,293.76,percent of total billed charges,Implant Device,302.4,35,,302.4,percent of total billed charges,Implant Device,302.4,35,,302.4,percent of total billed charges,Implant Device,302.4,35,,302.4,percent of total billed charges,Implant Device,302.4,35,,302.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,639.36,
STRYKER 661130 5.0X30MM LOCKING SCREW,C1713,HCPCS,,79008749,CDM,278,RC,,,both,,,616,455.84,,,455.84,Other,150% of Medicare + 9.63% HCRA Surcharge,277.2,45,,277.2,percent of total billed charges,Critical Access Hospital RCC factor,209.44,34,,209.44,percent of total billed charges,Implant Device,209.44,34,,209.44,percent of total billed charges,Implant Device,209.44,34,,209.44,percent of total billed charges,Implant Device,209.44,34,,209.44,percent of total billed charges,Implant Device,209.44,34,,209.44,percent of total billed charges,Implant Device,304.92,,,304.92,Other,110% of Medicare,215.6,35,,215.6,percent of total billed charges,Implant Device,209.44,34,"Charges > $500, x 34%",209.44,percent of total billed charges,Implant Device,215.6,35,,215.6,percent of total billed charges,Implant Device,215.6,35,,215.6,percent of total billed charges,Implant Device,215.6,35,,215.6,percent of total billed charges,Implant Device,215.6,35,,215.6,percent of total billed charges,Implant Device,215.6,35,,215.6,percent of total billed charges,Implant Device,246.4,40,,246.4,percent of total billed charges,Implant Device,215.6,70,,215.6,percent of total billed charges,All Other,209.44,34,,209.44,percent of total billed charges,Implant Device,209.44,34,,209.44,percent of total billed charges,Implant Device,215.6,35,,215.6,percent of total billed charges,Implant Device,215.6,35,,215.6,percent of total billed charges,Implant Device,215.6,35,,215.6,percent of total billed charges,Implant Device,215.6,35,,215.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,455.84,
STRYKER 608040 6.5X40MM CANCELLOUS SCREW,C1713,HCPCS,,79008750,CDM,278,RC,,,both,,,216,159.84,,,159.84,Other,150% of Medicare + 9.63% HCRA Surcharge,97.2,45,,97.2,percent of total billed charges,Critical Access Hospital RCC factor,73.44,34,,73.44,percent of total billed charges,Implant Device,73.44,34,,73.44,percent of total billed charges,Implant Device,73.44,34,,73.44,percent of total billed charges,Implant Device,73.44,34,,73.44,percent of total billed charges,Implant Device,73.44,34,,73.44,percent of total billed charges,Implant Device,106.92,,,106.92,Other,110% of Medicare,75.6,35,,75.6,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,75.6,35,,75.6,percent of total billed charges,Implant Device,75.6,35,,75.6,percent of total billed charges,Implant Device,75.6,35,,75.6,percent of total billed charges,Implant Device,75.6,35,,75.6,percent of total billed charges,Implant Device,75.6,35,,75.6,percent of total billed charges,Implant Device,86.4,40,,86.4,percent of total billed charges,Implant Device,75.6,70,,75.6,percent of total billed charges,All Other,73.44,34,,73.44,percent of total billed charges,Implant Device,73.44,34,,73.44,percent of total billed charges,Implant Device,75.6,35,,75.6,percent of total billed charges,Implant Device,75.6,35,,75.6,percent of total billed charges,Implant Device,75.6,35,,75.6,percent of total billed charges,Implant Device,75.6,35,,75.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,159.84,
STRYKER 661310 5.0X10MM LOCKING SCREW,C1713,HCPCS,,79008751,CDM,278,RC,,,both,,,996,737.04,,,737.04,Other,150% of Medicare + 9.63% HCRA Surcharge,448.2,45,,448.2,percent of total billed charges,Critical Access Hospital RCC factor,338.64,34,,338.64,percent of total billed charges,Implant Device,338.64,34,,338.64,percent of total billed charges,Implant Device,338.64,34,,338.64,percent of total billed charges,Implant Device,338.64,34,,338.64,percent of total billed charges,Implant Device,338.64,34,,338.64,percent of total billed charges,Implant Device,493.02,,,493.02,Other,110% of Medicare,348.6,35,,348.6,percent of total billed charges,Implant Device,338.64,34,"Charges > $500, x 34%",338.64,percent of total billed charges,Implant Device,348.6,35,,348.6,percent of total billed charges,Implant Device,348.6,35,,348.6,percent of total billed charges,Implant Device,348.6,35,,348.6,percent of total billed charges,Implant Device,348.6,35,,348.6,percent of total billed charges,Implant Device,348.6,35,,348.6,percent of total billed charges,Implant Device,398.4,40,,398.4,percent of total billed charges,Implant Device,348.6,70,,348.6,percent of total billed charges,All Other,338.64,34,,338.64,percent of total billed charges,Implant Device,338.64,34,,338.64,percent of total billed charges,Implant Device,348.6,35,,348.6,percent of total billed charges,Implant Device,348.6,35,,348.6,percent of total billed charges,Implant Device,348.6,35,,348.6,percent of total billed charges,Implant Device,348.6,35,,348.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,737.04,
STRYKER 661308 5.0X8MM LOCKING SCREW,C1713,HCPCS,,79008752,CDM,278,RC,,,both,,,996,737.04,,,737.04,Other,150% of Medicare + 9.63% HCRA Surcharge,448.2,45,,448.2,percent of total billed charges,Critical Access Hospital RCC factor,338.64,34,,338.64,percent of total billed charges,Implant Device,338.64,34,,338.64,percent of total billed charges,Implant Device,338.64,34,,338.64,percent of total billed charges,Implant Device,338.64,34,,338.64,percent of total billed charges,Implant Device,338.64,34,,338.64,percent of total billed charges,Implant Device,493.02,,,493.02,Other,110% of Medicare,348.6,35,,348.6,percent of total billed charges,Implant Device,338.64,34,"Charges > $500, x 34%",338.64,percent of total billed charges,Implant Device,348.6,35,,348.6,percent of total billed charges,Implant Device,348.6,35,,348.6,percent of total billed charges,Implant Device,348.6,35,,348.6,percent of total billed charges,Implant Device,348.6,35,,348.6,percent of total billed charges,Implant Device,348.6,35,,348.6,percent of total billed charges,Implant Device,398.4,40,,398.4,percent of total billed charges,Implant Device,348.6,70,,348.6,percent of total billed charges,All Other,338.64,34,,338.64,percent of total billed charges,Implant Device,338.64,34,,338.64,percent of total billed charges,Implant Device,348.6,35,,348.6,percent of total billed charges,Implant Device,348.6,35,,348.6,percent of total billed charges,Implant Device,348.6,35,,348.6,percent of total billed charges,Implant Device,348.6,35,,348.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,737.04,
DEPUY VS501.024 CORTEX SCREW 5.5X24MM,C1713,HCPCS,,79008757,CDM,278,RC,,,both,,,65,48.1,,,48.1,Other,150% of Medicare + 9.63% HCRA Surcharge,29.25,45,,29.25,percent of total billed charges,Critical Access Hospital RCC factor,22.1,34,,22.1,percent of total billed charges,Implant Device,22.1,34,,22.1,percent of total billed charges,Implant Device,22.1,34,,22.1,percent of total billed charges,Implant Device,22.1,34,,22.1,percent of total billed charges,Implant Device,22.1,34,,22.1,percent of total billed charges,Implant Device,32.18,,,32.18,Other,110% of Medicare,22.75,35,,22.75,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,22.75,35,,22.75,percent of total billed charges,Implant Device,22.75,35,,22.75,percent of total billed charges,Implant Device,22.75,35,,22.75,percent of total billed charges,Implant Device,22.75,35,,22.75,percent of total billed charges,Implant Device,22.75,35,,22.75,percent of total billed charges,Implant Device,26,40,,26,percent of total billed charges,Implant Device,22.75,70,,22.75,percent of total billed charges,All Other,22.1,34,,22.1,percent of total billed charges,Implant Device,22.1,34,,22.1,percent of total billed charges,Implant Device,22.75,35,,22.75,percent of total billed charges,Implant Device,22.75,35,,22.75,percent of total billed charges,Implant Device,22.75,35,,22.75,percent of total billed charges,Implant Device,22.75,35,,22.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,48.1,
DEPUY VS501.026 CORTEX SCREW 5.5X26MM,C1713,HCPCS,,79008758,CDM,278,RC,,,both,,,65,48.1,,,48.1,Other,150% of Medicare + 9.63% HCRA Surcharge,29.25,45,,29.25,percent of total billed charges,Critical Access Hospital RCC factor,22.1,34,,22.1,percent of total billed charges,Implant Device,22.1,34,,22.1,percent of total billed charges,Implant Device,22.1,34,,22.1,percent of total billed charges,Implant Device,22.1,34,,22.1,percent of total billed charges,Implant Device,22.1,34,,22.1,percent of total billed charges,Implant Device,32.18,,,32.18,Other,110% of Medicare,22.75,35,,22.75,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,22.75,35,,22.75,percent of total billed charges,Implant Device,22.75,35,,22.75,percent of total billed charges,Implant Device,22.75,35,,22.75,percent of total billed charges,Implant Device,22.75,35,,22.75,percent of total billed charges,Implant Device,22.75,35,,22.75,percent of total billed charges,Implant Device,26,40,,26,percent of total billed charges,Implant Device,22.75,70,,22.75,percent of total billed charges,All Other,22.1,34,,22.1,percent of total billed charges,Implant Device,22.1,34,,22.1,percent of total billed charges,Implant Device,22.75,35,,22.75,percent of total billed charges,Implant Device,22.75,35,,22.75,percent of total billed charges,Implant Device,22.75,35,,22.75,percent of total billed charges,Implant Device,22.75,35,,22.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,48.1,
BIOMET 8145-50-040 CORT BONE SCRW 5X40MM,C1713,HCPCS,,79008759,CDM,278,RC,,,both,,,990,732.6,,,732.6,Other,150% of Medicare + 9.63% HCRA Surcharge,445.5,45,,445.5,percent of total billed charges,Critical Access Hospital RCC factor,336.6,34,,336.6,percent of total billed charges,Implant Device,336.6,34,,336.6,percent of total billed charges,Implant Device,336.6,34,,336.6,percent of total billed charges,Implant Device,336.6,34,,336.6,percent of total billed charges,Implant Device,336.6,34,,336.6,percent of total billed charges,Implant Device,490.05,,,490.05,Other,110% of Medicare,346.5,35,,346.5,percent of total billed charges,Implant Device,336.6,34,"Charges > $500, x 34%",336.6,percent of total billed charges,Implant Device,346.5,35,,346.5,percent of total billed charges,Implant Device,346.5,35,,346.5,percent of total billed charges,Implant Device,346.5,35,,346.5,percent of total billed charges,Implant Device,346.5,35,,346.5,percent of total billed charges,Implant Device,346.5,35,,346.5,percent of total billed charges,Implant Device,396,40,,396,percent of total billed charges,Implant Device,346.5,70,,346.5,percent of total billed charges,All Other,336.6,34,,336.6,percent of total billed charges,Implant Device,336.6,34,,336.6,percent of total billed charges,Implant Device,346.5,35,,346.5,percent of total billed charges,Implant Device,346.5,35,,346.5,percent of total billed charges,Implant Device,346.5,35,,346.5,percent of total billed charges,Implant Device,346.5,35,,346.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,732.6,
STRYKER 661060 4.0X60MM LOCKING SCREW,C1713,HCPCS,,79008760,CDM,278,RC,,,both,,,583,431.42,,,431.42,Other,150% of Medicare + 9.63% HCRA Surcharge,262.35,45,,262.35,percent of total billed charges,Critical Access Hospital RCC factor,198.22,34,,198.22,percent of total billed charges,Implant Device,198.22,34,,198.22,percent of total billed charges,Implant Device,198.22,34,,198.22,percent of total billed charges,Implant Device,198.22,34,,198.22,percent of total billed charges,Implant Device,198.22,34,,198.22,percent of total billed charges,Implant Device,288.59,,,288.59,Other,110% of Medicare,204.05,35,,204.05,percent of total billed charges,Implant Device,198.22,34,"Charges > $500, x 34%",198.22,percent of total billed charges,Implant Device,204.05,35,,204.05,percent of total billed charges,Implant Device,204.05,35,,204.05,percent of total billed charges,Implant Device,204.05,35,,204.05,percent of total billed charges,Implant Device,204.05,35,,204.05,percent of total billed charges,Implant Device,204.05,35,,204.05,percent of total billed charges,Implant Device,233.2,40,,233.2,percent of total billed charges,Implant Device,204.05,70,,204.05,percent of total billed charges,All Other,198.22,34,,198.22,percent of total billed charges,Implant Device,198.22,34,,198.22,percent of total billed charges,Implant Device,204.05,35,,204.05,percent of total billed charges,Implant Device,204.05,35,,204.05,percent of total billed charges,Implant Device,204.05,35,,204.05,percent of total billed charges,Implant Device,204.05,35,,204.05,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,431.42,
STRYKER 54-25773 VDR PLATE STANDARD LEFT,C1713,HCPCS,,79008761,CDM,278,RC,,,both,,,4866,3600.85,,,3600.85,Other,150% of Medicare + 9.63% HCRA Surcharge,2189.7,45,,2189.7,percent of total billed charges,Critical Access Hospital RCC factor,1654.44,34,,1654.44,percent of total billed charges,Implant Device,1654.44,34,,1654.44,percent of total billed charges,Implant Device,1654.44,34,,1654.44,percent of total billed charges,Implant Device,1654.44,34,,1654.44,percent of total billed charges,Implant Device,1654.44,34,,1654.44,percent of total billed charges,Implant Device,2408.67,,,2408.67,Other,110% of Medicare,1703.1,35,,1703.1,percent of total billed charges,Implant Device,1654.44,34,"Charges > $500, x 34%",1654.44,percent of total billed charges,Implant Device,1703.1,35,,1703.1,percent of total billed charges,Implant Device,1703.1,35,,1703.1,percent of total billed charges,Implant Device,1703.1,35,,1703.1,percent of total billed charges,Implant Device,1703.1,35,,1703.1,percent of total billed charges,Implant Device,1703.1,35,,1703.1,percent of total billed charges,Implant Device,1946.4,40,,1946.4,percent of total billed charges,Implant Device,1703.1,70,,1703.1,percent of total billed charges,All Other,1654.44,34,,1654.44,percent of total billed charges,Implant Device,1654.44,34,,1654.44,percent of total billed charges,Implant Device,1703.1,35,,1703.1,percent of total billed charges,Implant Device,1703.1,35,,1703.1,percent of total billed charges,Implant Device,1703.1,35,,1703.1,percent of total billed charges,Implant Device,1703.1,35,,1703.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1654.44,34,"If Charge > 2,000, then 34 percent",1654.44,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3600.85,
DEPUY 201.770 CORTEX SCREW 2.4X20MM,C1713,HCPCS,,79008763,CDM,278,RC,,,both,,,130,96.2,,,96.2,Other,150% of Medicare + 9.63% HCRA Surcharge,58.5,45,,58.5,percent of total billed charges,Critical Access Hospital RCC factor,44.2,34,,44.2,percent of total billed charges,Implant Device,44.2,34,,44.2,percent of total billed charges,Implant Device,44.2,34,,44.2,percent of total billed charges,Implant Device,44.2,34,,44.2,percent of total billed charges,Implant Device,44.2,34,,44.2,percent of total billed charges,Implant Device,64.35,,,64.35,Other,110% of Medicare,45.5,35,,45.5,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,45.5,35,,45.5,percent of total billed charges,Implant Device,45.5,35,,45.5,percent of total billed charges,Implant Device,45.5,35,,45.5,percent of total billed charges,Implant Device,45.5,35,,45.5,percent of total billed charges,Implant Device,45.5,35,,45.5,percent of total billed charges,Implant Device,52,40,,52,percent of total billed charges,Implant Device,45.5,70,,45.5,percent of total billed charges,All Other,44.2,34,,44.2,percent of total billed charges,Implant Device,44.2,34,,44.2,percent of total billed charges,Implant Device,45.5,35,,45.5,percent of total billed charges,Implant Device,45.5,35,,45.5,percent of total billed charges,Implant Device,45.5,35,,45.5,percent of total billed charges,Implant Device,45.5,35,,45.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,96.2,
DEPUY 1035-43-000 BI-POLAR HEAD 28X43MM,C1776,HCPCS,,79008764,CDM,278,RC,,,both,,,4030,2982.21,,,2982.21,Other,150% of Medicare + 9.63% HCRA Surcharge,1813.5,45,,1813.5,percent of total billed charges,Critical Access Hospital RCC factor,1370.2,34,,1370.2,percent of total billed charges,Implant Device,1370.2,34,,1370.2,percent of total billed charges,Implant Device,1370.2,34,,1370.2,percent of total billed charges,Implant Device,1370.2,34,,1370.2,percent of total billed charges,Implant Device,1370.2,34,,1370.2,percent of total billed charges,Implant Device,1994.85,,,1994.85,Other,110% of Medicare,1410.5,35,,1410.5,percent of total billed charges,Implant Device,1370.2,34,"Charges > $500, x 34%",1370.2,percent of total billed charges,Implant Device,1410.5,35,,1410.5,percent of total billed charges,Implant Device,1410.5,35,,1410.5,percent of total billed charges,Implant Device,1410.5,35,,1410.5,percent of total billed charges,Implant Device,1410.5,35,,1410.5,percent of total billed charges,Implant Device,1410.5,35,,1410.5,percent of total billed charges,Implant Device,1612,40,,1612,percent of total billed charges,Implant Device,1410.5,70,,1410.5,percent of total billed charges,All Other,1370.2,34,,1370.2,percent of total billed charges,Implant Device,1370.2,34,,1370.2,percent of total billed charges,Implant Device,1410.5,35,,1410.5,percent of total billed charges,Implant Device,1410.5,35,,1410.5,percent of total billed charges,Implant Device,1410.5,35,,1410.5,percent of total billed charges,Implant Device,1410.5,35,,1410.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1370.2,34,"If Charge > 2,000, then 34 percent",1370.2,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2982.21,
MIMEDX ES-4400 EPIFIX 4.0X4.5CM,Q4186,HCPCS,,79008765,CDM,278,RC,,,both,,,216,159.84,,,159.84,Other,150% of Medicare + 9.63% HCRA Surcharge,97.2,45,,97.2,percent of total billed charges,Critical Access Hospital RCC factor,73.44,34,,73.44,percent of total billed charges,Implant Device,73.44,34,,73.44,percent of total billed charges,Implant Device,73.44,34,,73.44,percent of total billed charges,Implant Device,73.44,34,,73.44,percent of total billed charges,Implant Device,73.44,34,,73.44,percent of total billed charges,Implant Device,106.92,,,106.92,Other,110% of Medicare,75.6,35,,75.6,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,75.6,35,,75.6,percent of total billed charges,Implant Device,75.6,35,,75.6,percent of total billed charges,Implant Device,75.6,35,,75.6,percent of total billed charges,Implant Device,75.6,35,,75.6,percent of total billed charges,Implant Device,75.6,35,,75.6,percent of total billed charges,Implant Device,86.4,40,,86.4,percent of total billed charges,Implant Device,75.6,70,,75.6,percent of total billed charges,All Other,73.44,34,,73.44,percent of total billed charges,Implant Device,73.44,34,,73.44,percent of total billed charges,Implant Device,75.6,35,,75.6,percent of total billed charges,Implant Device,75.6,35,,75.6,percent of total billed charges,Implant Device,75.6,35,,75.6,percent of total billed charges,Implant Device,75.6,35,,75.6,percent of total billed charges,Implant Device,976.07,,,976.07,Other,100% of Medicaid,976.07,,,976.07,Other,100% of Medicaid,976.07,,,976.07,Other,100% of Medicaid,976.07,,,976.07,Other,100% of Medicaid,2196.16,,,2196.16,Other,225% of Medicaid,1493.39,,,1493.39,Other,153% of Medicaid,2196.16,,,2196.16,Other,225% of Medicaid,1366.5,,,1366.5,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,2537.78,,,2537.78,Other,260% of Medicaid,3162.47,,,3162.47,Other,324% of Medicaid,2098.55,,,2098.55,Other,215% of Medicaid,2098.55,,,2098.55,Other,215% of Medicaid,1220.09,,,1220.09,Other,125% of Medicaid,0.01,3162.47,
GORE PHA060602A TIGRIS 6MMX60MM STENT,C1876,HCPCS,,79008768,CDM,278,RC,,,both,,,4485,3318.91,,,3318.91,Other,150% of Medicare + 9.63% HCRA Surcharge,2018.25,45,,2018.25,percent of total billed charges,Critical Access Hospital RCC factor,1524.9,34,,1524.9,percent of total billed charges,Implant Device,1524.9,34,,1524.9,percent of total billed charges,Implant Device,1524.9,34,,1524.9,percent of total billed charges,Implant Device,1524.9,34,,1524.9,percent of total billed charges,Implant Device,1524.9,34,,1524.9,percent of total billed charges,Implant Device,2220.08,,,2220.08,Other,110% of Medicare,1569.75,35,,1569.75,percent of total billed charges,Implant Device,1524.9,34,"Charges > $500, x 34%",1524.9,percent of total billed charges,Implant Device,1569.75,35,,1569.75,percent of total billed charges,Implant Device,1569.75,35,,1569.75,percent of total billed charges,Implant Device,1569.75,35,,1569.75,percent of total billed charges,Implant Device,1569.75,35,,1569.75,percent of total billed charges,Implant Device,1569.75,35,,1569.75,percent of total billed charges,Implant Device,1794,40,,1794,percent of total billed charges,Implant Device,1569.75,70,,1569.75,percent of total billed charges,All Other,1524.9,34,,1524.9,percent of total billed charges,Implant Device,1524.9,34,,1524.9,percent of total billed charges,Implant Device,1569.75,35,,1569.75,percent of total billed charges,Implant Device,1569.75,35,,1569.75,percent of total billed charges,Implant Device,1569.75,35,,1569.75,percent of total billed charges,Implant Device,1569.75,35,,1569.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1524.9,34,"If Charge > 2,000, then 34 percent",1524.9,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3318.91,
GORE PHA061002A TIGRIS 6MMX100MM STENT,C1876,HCPCS,,79008769,CDM,278,RC,,,both,,,4485,3318.91,,,3318.91,Other,150% of Medicare + 9.63% HCRA Surcharge,2018.25,45,,2018.25,percent of total billed charges,Critical Access Hospital RCC factor,1524.9,34,,1524.9,percent of total billed charges,Implant Device,1524.9,34,,1524.9,percent of total billed charges,Implant Device,1524.9,34,,1524.9,percent of total billed charges,Implant Device,1524.9,34,,1524.9,percent of total billed charges,Implant Device,1524.9,34,,1524.9,percent of total billed charges,Implant Device,2220.08,,,2220.08,Other,110% of Medicare,1569.75,35,,1569.75,percent of total billed charges,Implant Device,1524.9,34,"Charges > $500, x 34%",1524.9,percent of total billed charges,Implant Device,1569.75,35,,1569.75,percent of total billed charges,Implant Device,1569.75,35,,1569.75,percent of total billed charges,Implant Device,1569.75,35,,1569.75,percent of total billed charges,Implant Device,1569.75,35,,1569.75,percent of total billed charges,Implant Device,1569.75,35,,1569.75,percent of total billed charges,Implant Device,1794,40,,1794,percent of total billed charges,Implant Device,1569.75,70,,1569.75,percent of total billed charges,All Other,1524.9,34,,1524.9,percent of total billed charges,Implant Device,1524.9,34,,1524.9,percent of total billed charges,Implant Device,1569.75,35,,1569.75,percent of total billed charges,Implant Device,1569.75,35,,1569.75,percent of total billed charges,Implant Device,1569.75,35,,1569.75,percent of total billed charges,Implant Device,1569.75,35,,1569.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1524.9,34,"If Charge > 2,000, then 34 percent",1524.9,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3318.91,
GORE BXA095902A VBX VIABAHN 9X59MM STENT,C1874,HCPCS,,79008770,CDM,278,RC,,,both,,,9765,7226.12,,,7226.12,Other,150% of Medicare + 9.63% HCRA Surcharge,4394.25,45,,4394.25,percent of total billed charges,Critical Access Hospital RCC factor,3320.1,34,,3320.1,percent of total billed charges,Implant Device,3320.1,34,,3320.1,percent of total billed charges,Implant Device,3320.1,34,,3320.1,percent of total billed charges,Implant Device,3320.1,34,,3320.1,percent of total billed charges,Implant Device,3320.1,34,,3320.1,percent of total billed charges,Implant Device,4833.68,,,4833.68,Other,110% of Medicare,3417.75,35,,3417.75,percent of total billed charges,Implant Device,3320.1,34,"Charges > $500, x 34%",3320.1,percent of total billed charges,Implant Device,3417.75,35,,3417.75,percent of total billed charges,Implant Device,3417.75,35,,3417.75,percent of total billed charges,Implant Device,3417.75,35,,3417.75,percent of total billed charges,Implant Device,3417.75,35,,3417.75,percent of total billed charges,Implant Device,3417.75,35,,3417.75,percent of total billed charges,Implant Device,3906,40,,3906,percent of total billed charges,Implant Device,3417.75,70,,3417.75,percent of total billed charges,All Other,3320.1,34,,3320.1,percent of total billed charges,Implant Device,3320.1,34,,3320.1,percent of total billed charges,Implant Device,3417.75,35,,3417.75,percent of total billed charges,Implant Device,3417.75,35,,3417.75,percent of total billed charges,Implant Device,3417.75,35,,3417.75,percent of total billed charges,Implant Device,3417.75,35,,3417.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3320.1,34,"If Charge > 2,000, then 34 percent",3320.1,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,7226.12,
GORE SBT1602 BIFURCATED GRAFT 16X8MM,C1768,HCPCS,,79008771,CDM,278,RC,,,both,,,3513,2599.63,,,2599.63,Other,150% of Medicare + 9.63% HCRA Surcharge,1580.85,45,,1580.85,percent of total billed charges,Critical Access Hospital RCC factor,1194.42,34,,1194.42,percent of total billed charges,Implant Device,1194.42,34,,1194.42,percent of total billed charges,Implant Device,1194.42,34,,1194.42,percent of total billed charges,Implant Device,1194.42,34,,1194.42,percent of total billed charges,Implant Device,1194.42,34,,1194.42,percent of total billed charges,Implant Device,1738.94,,,1738.94,Other,110% of Medicare,1229.55,35,,1229.55,percent of total billed charges,Implant Device,1194.42,34,"Charges > $500, x 34%",1194.42,percent of total billed charges,Implant Device,1229.55,35,,1229.55,percent of total billed charges,Implant Device,1229.55,35,,1229.55,percent of total billed charges,Implant Device,1229.55,35,,1229.55,percent of total billed charges,Implant Device,1229.55,35,,1229.55,percent of total billed charges,Implant Device,1229.55,35,,1229.55,percent of total billed charges,Implant Device,1405.2,40,,1405.2,percent of total billed charges,Implant Device,1229.55,70,,1229.55,percent of total billed charges,All Other,1194.42,34,,1194.42,percent of total billed charges,Implant Device,1194.42,34,,1194.42,percent of total billed charges,Implant Device,1229.55,35,,1229.55,percent of total billed charges,Implant Device,1229.55,35,,1229.55,percent of total billed charges,Implant Device,1229.55,35,,1229.55,percent of total billed charges,Implant Device,1229.55,35,,1229.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1194.42,34,"If Charge > 2,000, then 34 percent",1194.42,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2599.63,
GORE SA1602 VASCULAR GRAFT 16MM 20CM,C1768,HCPCS,,79008772,CDM,278,RC,,,both,,,1164,861.36,,,861.36,Other,150% of Medicare + 9.63% HCRA Surcharge,523.8,45,,523.8,percent of total billed charges,Critical Access Hospital RCC factor,395.76,34,,395.76,percent of total billed charges,Implant Device,395.76,34,,395.76,percent of total billed charges,Implant Device,395.76,34,,395.76,percent of total billed charges,Implant Device,395.76,34,,395.76,percent of total billed charges,Implant Device,395.76,34,,395.76,percent of total billed charges,Implant Device,576.18,,,576.18,Other,110% of Medicare,407.4,35,,407.4,percent of total billed charges,Implant Device,395.76,34,"Charges > $500, x 34%",395.76,percent of total billed charges,Implant Device,407.4,35,,407.4,percent of total billed charges,Implant Device,407.4,35,,407.4,percent of total billed charges,Implant Device,407.4,35,,407.4,percent of total billed charges,Implant Device,407.4,35,,407.4,percent of total billed charges,Implant Device,407.4,35,,407.4,percent of total billed charges,Implant Device,465.6,40,,465.6,percent of total billed charges,Implant Device,407.4,70,,407.4,percent of total billed charges,All Other,395.76,34,,395.76,percent of total billed charges,Implant Device,395.76,34,,395.76,percent of total billed charges,Implant Device,407.4,35,,407.4,percent of total billed charges,Implant Device,407.4,35,,407.4,percent of total billed charges,Implant Device,407.4,35,,407.4,percent of total billed charges,Implant Device,407.4,35,,407.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,861.36,
ARTHREX AR-8935-28 NON LOCK SCREW 3.5X28,C1713,HCPCS,,79008773,CDM,278,RC,,,both,,,258,190.92,,,190.92,Other,150% of Medicare + 9.63% HCRA Surcharge,116.1,45,,116.1,percent of total billed charges,Critical Access Hospital RCC factor,87.72,34,,87.72,percent of total billed charges,Implant Device,87.72,34,,87.72,percent of total billed charges,Implant Device,87.72,34,,87.72,percent of total billed charges,Implant Device,87.72,34,,87.72,percent of total billed charges,Implant Device,87.72,34,,87.72,percent of total billed charges,Implant Device,127.71,,,127.71,Other,110% of Medicare,90.3,35,,90.3,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,90.3,35,,90.3,percent of total billed charges,Implant Device,90.3,35,,90.3,percent of total billed charges,Implant Device,90.3,35,,90.3,percent of total billed charges,Implant Device,90.3,35,,90.3,percent of total billed charges,Implant Device,90.3,35,,90.3,percent of total billed charges,Implant Device,103.2,40,,103.2,percent of total billed charges,Implant Device,90.3,70,,90.3,percent of total billed charges,All Other,87.72,34,,87.72,percent of total billed charges,Implant Device,87.72,34,,87.72,percent of total billed charges,Implant Device,90.3,35,,90.3,percent of total billed charges,Implant Device,90.3,35,,90.3,percent of total billed charges,Implant Device,90.3,35,,90.3,percent of total billed charges,Implant Device,90.3,35,,90.3,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,190.92,
ARTHREX AR-8940-30 CAN SCREW 4.0X30MM,C1713,HCPCS,,79008774,CDM,278,RC,,,both,,,258,190.92,,,190.92,Other,150% of Medicare + 9.63% HCRA Surcharge,116.1,45,,116.1,percent of total billed charges,Critical Access Hospital RCC factor,87.72,34,,87.72,percent of total billed charges,Implant Device,87.72,34,,87.72,percent of total billed charges,Implant Device,87.72,34,,87.72,percent of total billed charges,Implant Device,87.72,34,,87.72,percent of total billed charges,Implant Device,87.72,34,,87.72,percent of total billed charges,Implant Device,127.71,,,127.71,Other,110% of Medicare,90.3,35,,90.3,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,90.3,35,,90.3,percent of total billed charges,Implant Device,90.3,35,,90.3,percent of total billed charges,Implant Device,90.3,35,,90.3,percent of total billed charges,Implant Device,90.3,35,,90.3,percent of total billed charges,Implant Device,90.3,35,,90.3,percent of total billed charges,Implant Device,103.2,40,,103.2,percent of total billed charges,Implant Device,90.3,70,,90.3,percent of total billed charges,All Other,87.72,34,,87.72,percent of total billed charges,Implant Device,87.72,34,,87.72,percent of total billed charges,Implant Device,90.3,35,,90.3,percent of total billed charges,Implant Device,90.3,35,,90.3,percent of total billed charges,Implant Device,90.3,35,,90.3,percent of total billed charges,Implant Device,90.3,35,,90.3,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,190.92,
ARTHREX AR-13200M-06R WEDGE PLATE RT 6MM,C1713,HCPCS,,79008775,CDM,278,RC,,,both,,,3408,2521.93,,,2521.93,Other,150% of Medicare + 9.63% HCRA Surcharge,1533.6,45,,1533.6,percent of total billed charges,Critical Access Hospital RCC factor,1158.72,34,,1158.72,percent of total billed charges,Implant Device,1158.72,34,,1158.72,percent of total billed charges,Implant Device,1158.72,34,,1158.72,percent of total billed charges,Implant Device,1158.72,34,,1158.72,percent of total billed charges,Implant Device,1158.72,34,,1158.72,percent of total billed charges,Implant Device,1686.96,,,1686.96,Other,110% of Medicare,1192.8,35,,1192.8,percent of total billed charges,Implant Device,1158.72,34,"Charges > $500, x 34%",1158.72,percent of total billed charges,Implant Device,1192.8,35,,1192.8,percent of total billed charges,Implant Device,1192.8,35,,1192.8,percent of total billed charges,Implant Device,1192.8,35,,1192.8,percent of total billed charges,Implant Device,1192.8,35,,1192.8,percent of total billed charges,Implant Device,1192.8,35,,1192.8,percent of total billed charges,Implant Device,1363.2,40,,1363.2,percent of total billed charges,Implant Device,1192.8,70,,1192.8,percent of total billed charges,All Other,1158.72,34,,1158.72,percent of total billed charges,Implant Device,1158.72,34,,1158.72,percent of total billed charges,Implant Device,1192.8,35,,1192.8,percent of total billed charges,Implant Device,1192.8,35,,1192.8,percent of total billed charges,Implant Device,1192.8,35,,1192.8,percent of total billed charges,Implant Device,1192.8,35,,1192.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1158.72,34,"If Charge > 2,000, then 34 percent",1158.72,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2521.93,
IN2BONES S65 ST180 SCREW 6.5X80MM,C1713,HCPCS,,79008776,CDM,278,RC,,,both,,,3105,2297.71,,,2297.71,Other,150% of Medicare + 9.63% HCRA Surcharge,1397.25,45,,1397.25,percent of total billed charges,Critical Access Hospital RCC factor,1055.7,34,,1055.7,percent of total billed charges,Implant Device,1055.7,34,,1055.7,percent of total billed charges,Implant Device,1055.7,34,,1055.7,percent of total billed charges,Implant Device,1055.7,34,,1055.7,percent of total billed charges,Implant Device,1055.7,34,,1055.7,percent of total billed charges,Implant Device,1536.98,,,1536.98,Other,110% of Medicare,1086.75,35,,1086.75,percent of total billed charges,Implant Device,1055.7,34,"Charges > $500, x 34%",1055.7,percent of total billed charges,Implant Device,1086.75,35,,1086.75,percent of total billed charges,Implant Device,1086.75,35,,1086.75,percent of total billed charges,Implant Device,1086.75,35,,1086.75,percent of total billed charges,Implant Device,1086.75,35,,1086.75,percent of total billed charges,Implant Device,1086.75,35,,1086.75,percent of total billed charges,Implant Device,1242,40,,1242,percent of total billed charges,Implant Device,1086.75,70,,1086.75,percent of total billed charges,All Other,1055.7,34,,1055.7,percent of total billed charges,Implant Device,1055.7,34,,1055.7,percent of total billed charges,Implant Device,1086.75,35,,1086.75,percent of total billed charges,Implant Device,1086.75,35,,1086.75,percent of total billed charges,Implant Device,1086.75,35,,1086.75,percent of total billed charges,Implant Device,1086.75,35,,1086.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1055.7,34,"If Charge > 2,000, then 34 percent",1055.7,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2297.71,
IN2BONES S45 ST150 SCREW 4.5X50MM,C1713,HCPCS,,79008777,CDM,278,RC,,,both,,,1545,1143.3,,,1143.3,Other,150% of Medicare + 9.63% HCRA Surcharge,695.25,45,,695.25,percent of total billed charges,Critical Access Hospital RCC factor,525.3,34,,525.3,percent of total billed charges,Implant Device,525.3,34,,525.3,percent of total billed charges,Implant Device,525.3,34,,525.3,percent of total billed charges,Implant Device,525.3,34,,525.3,percent of total billed charges,Implant Device,525.3,34,,525.3,percent of total billed charges,Implant Device,764.78,,,764.78,Other,110% of Medicare,540.75,35,,540.75,percent of total billed charges,Implant Device,525.3,34,"Charges > $500, x 34%",525.3,percent of total billed charges,Implant Device,540.75,35,,540.75,percent of total billed charges,Implant Device,540.75,35,,540.75,percent of total billed charges,Implant Device,540.75,35,,540.75,percent of total billed charges,Implant Device,540.75,35,,540.75,percent of total billed charges,Implant Device,540.75,35,,540.75,percent of total billed charges,Implant Device,618,40,,618,percent of total billed charges,Implant Device,540.75,70,,540.75,percent of total billed charges,All Other,525.3,34,,525.3,percent of total billed charges,Implant Device,525.3,34,,525.3,percent of total billed charges,Implant Device,540.75,35,,540.75,percent of total billed charges,Implant Device,540.75,35,,540.75,percent of total billed charges,Implant Device,540.75,35,,540.75,percent of total billed charges,Implant Device,540.75,35,,540.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1143.3,
IN2BONES T50 SN025 COMP STAPLE 25X22X22,C1713,HCPCS,,79008778,CDM,278,RC,,,both,,,4860,3596.41,,,3596.41,Other,150% of Medicare + 9.63% HCRA Surcharge,2187,45,,2187,percent of total billed charges,Critical Access Hospital RCC factor,1652.4,34,,1652.4,percent of total billed charges,Implant Device,1652.4,34,,1652.4,percent of total billed charges,Implant Device,1652.4,34,,1652.4,percent of total billed charges,Implant Device,1652.4,34,,1652.4,percent of total billed charges,Implant Device,1652.4,34,,1652.4,percent of total billed charges,Implant Device,2405.7,,,2405.7,Other,110% of Medicare,1701,35,,1701,percent of total billed charges,Implant Device,1652.4,34,"Charges > $500, x 34%",1652.4,percent of total billed charges,Implant Device,1701,35,,1701,percent of total billed charges,Implant Device,1701,35,,1701,percent of total billed charges,Implant Device,1701,35,,1701,percent of total billed charges,Implant Device,1701,35,,1701,percent of total billed charges,Implant Device,1701,35,,1701,percent of total billed charges,Implant Device,1944,40,,1944,percent of total billed charges,Implant Device,1701,70,,1701,percent of total billed charges,All Other,1652.4,34,,1652.4,percent of total billed charges,Implant Device,1652.4,34,,1652.4,percent of total billed charges,Implant Device,1701,35,,1701,percent of total billed charges,Implant Device,1701,35,,1701,percent of total billed charges,Implant Device,1701,35,,1701,percent of total billed charges,Implant Device,1701,35,,1701,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1652.4,34,"If Charge > 2,000, then 34 percent",1652.4,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3596.41,
IN2BONES 100-0050 VITRIUM WEDGE 22X8MM,C1713,HCPCS,,79008782,CDM,278,RC,,,both,,,9450,6993.02,,,6993.02,Other,150% of Medicare + 9.63% HCRA Surcharge,4252.5,45,,4252.5,percent of total billed charges,Critical Access Hospital RCC factor,3213,34,,3213,percent of total billed charges,Implant Device,3213,34,,3213,percent of total billed charges,Implant Device,3213,34,,3213,percent of total billed charges,Implant Device,3213,34,,3213,percent of total billed charges,Implant Device,3213,34,,3213,percent of total billed charges,Implant Device,4677.75,,,4677.75,Other,110% of Medicare,3307.5,35,,3307.5,percent of total billed charges,Implant Device,3213,34,"Charges > $500, x 34%",3213,percent of total billed charges,Implant Device,3307.5,35,,3307.5,percent of total billed charges,Implant Device,3307.5,35,,3307.5,percent of total billed charges,Implant Device,3307.5,35,,3307.5,percent of total billed charges,Implant Device,3307.5,35,,3307.5,percent of total billed charges,Implant Device,3307.5,35,,3307.5,percent of total billed charges,Implant Device,3780,40,,3780,percent of total billed charges,Implant Device,3307.5,70,,3307.5,percent of total billed charges,All Other,3213,34,,3213,percent of total billed charges,Implant Device,3213,34,,3213,percent of total billed charges,Implant Device,3307.5,35,,3307.5,percent of total billed charges,Implant Device,3307.5,35,,3307.5,percent of total billed charges,Implant Device,3307.5,35,,3307.5,percent of total billed charges,Implant Device,3307.5,35,,3307.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3213,34,"If Charge > 2,000, then 34 percent",3213,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,6993.02,
IN2BONES T50 SN115 COMP STAPLE 15X15X15,C1713,HCPCS,,79008783,CDM,278,RC,,,both,,,4485,3318.91,,,3318.91,Other,150% of Medicare + 9.63% HCRA Surcharge,2018.25,45,,2018.25,percent of total billed charges,Critical Access Hospital RCC factor,1524.9,34,,1524.9,percent of total billed charges,Implant Device,1524.9,34,,1524.9,percent of total billed charges,Implant Device,1524.9,34,,1524.9,percent of total billed charges,Implant Device,1524.9,34,,1524.9,percent of total billed charges,Implant Device,1524.9,34,,1524.9,percent of total billed charges,Implant Device,2220.08,,,2220.08,Other,110% of Medicare,1569.75,35,,1569.75,percent of total billed charges,Implant Device,1524.9,34,"Charges > $500, x 34%",1524.9,percent of total billed charges,Implant Device,1569.75,35,,1569.75,percent of total billed charges,Implant Device,1569.75,35,,1569.75,percent of total billed charges,Implant Device,1569.75,35,,1569.75,percent of total billed charges,Implant Device,1569.75,35,,1569.75,percent of total billed charges,Implant Device,1569.75,35,,1569.75,percent of total billed charges,Implant Device,1794,40,,1794,percent of total billed charges,Implant Device,1569.75,70,,1569.75,percent of total billed charges,All Other,1524.9,34,,1524.9,percent of total billed charges,Implant Device,1524.9,34,,1524.9,percent of total billed charges,Implant Device,1569.75,35,,1569.75,percent of total billed charges,Implant Device,1569.75,35,,1569.75,percent of total billed charges,Implant Device,1569.75,35,,1569.75,percent of total billed charges,Implant Device,1569.75,35,,1569.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1524.9,34,"If Charge > 2,000, then 34 percent",1524.9,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3318.91,
IN2BONES T50 SN020 COMP STAPLE 20X20X20,C1713,HCPCS,,79008784,CDM,278,RC,,,both,,,4485,3318.91,,,3318.91,Other,150% of Medicare + 9.63% HCRA Surcharge,2018.25,45,,2018.25,percent of total billed charges,Critical Access Hospital RCC factor,1524.9,34,,1524.9,percent of total billed charges,Implant Device,1524.9,34,,1524.9,percent of total billed charges,Implant Device,1524.9,34,,1524.9,percent of total billed charges,Implant Device,1524.9,34,,1524.9,percent of total billed charges,Implant Device,1524.9,34,,1524.9,percent of total billed charges,Implant Device,2220.08,,,2220.08,Other,110% of Medicare,1569.75,35,,1569.75,percent of total billed charges,Implant Device,1524.9,34,"Charges > $500, x 34%",1524.9,percent of total billed charges,Implant Device,1569.75,35,,1569.75,percent of total billed charges,Implant Device,1569.75,35,,1569.75,percent of total billed charges,Implant Device,1569.75,35,,1569.75,percent of total billed charges,Implant Device,1569.75,35,,1569.75,percent of total billed charges,Implant Device,1569.75,35,,1569.75,percent of total billed charges,Implant Device,1794,40,,1794,percent of total billed charges,Implant Device,1569.75,70,,1569.75,percent of total billed charges,All Other,1524.9,34,,1524.9,percent of total billed charges,Implant Device,1524.9,34,,1524.9,percent of total billed charges,Implant Device,1569.75,35,,1569.75,percent of total billed charges,Implant Device,1569.75,35,,1569.75,percent of total billed charges,Implant Device,1569.75,35,,1569.75,percent of total billed charges,Implant Device,1569.75,35,,1569.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1524.9,34,"If Charge > 2,000, then 34 percent",1524.9,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3318.91,
IN2BONES S45 ST132 SCREW 4.5X32MM,C1713,HCPCS,,79008785,CDM,278,RC,,,both,,,1545,1143.3,,,1143.3,Other,150% of Medicare + 9.63% HCRA Surcharge,695.25,45,,695.25,percent of total billed charges,Critical Access Hospital RCC factor,525.3,34,,525.3,percent of total billed charges,Implant Device,525.3,34,,525.3,percent of total billed charges,Implant Device,525.3,34,,525.3,percent of total billed charges,Implant Device,525.3,34,,525.3,percent of total billed charges,Implant Device,525.3,34,,525.3,percent of total billed charges,Implant Device,764.78,,,764.78,Other,110% of Medicare,540.75,35,,540.75,percent of total billed charges,Implant Device,525.3,34,"Charges > $500, x 34%",525.3,percent of total billed charges,Implant Device,540.75,35,,540.75,percent of total billed charges,Implant Device,540.75,35,,540.75,percent of total billed charges,Implant Device,540.75,35,,540.75,percent of total billed charges,Implant Device,540.75,35,,540.75,percent of total billed charges,Implant Device,540.75,35,,540.75,percent of total billed charges,Implant Device,618,40,,618,percent of total billed charges,Implant Device,540.75,70,,540.75,percent of total billed charges,All Other,525.3,34,,525.3,percent of total billed charges,Implant Device,525.3,34,,525.3,percent of total billed charges,Implant Device,540.75,35,,540.75,percent of total billed charges,Implant Device,540.75,35,,540.75,percent of total billed charges,Implant Device,540.75,35,,540.75,percent of total billed charges,Implant Device,540.75,35,,540.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1143.3,
STRYKER 3325-0420S LONG NAIL KIT 11X420,C1713,HCPCS,,79008786,CDM,278,RC,,,both,,,9323,6899.04,,,6899.04,Other,150% of Medicare + 9.63% HCRA Surcharge,4195.35,45,,4195.35,percent of total billed charges,Critical Access Hospital RCC factor,3169.82,34,,3169.82,percent of total billed charges,Implant Device,3169.82,34,,3169.82,percent of total billed charges,Implant Device,3169.82,34,,3169.82,percent of total billed charges,Implant Device,3169.82,34,,3169.82,percent of total billed charges,Implant Device,3169.82,34,,3169.82,percent of total billed charges,Implant Device,4614.89,,,4614.89,Other,110% of Medicare,3263.05,35,,3263.05,percent of total billed charges,Implant Device,3169.82,34,"Charges > $500, x 34%",3169.82,percent of total billed charges,Implant Device,3263.05,35,,3263.05,percent of total billed charges,Implant Device,3263.05,35,,3263.05,percent of total billed charges,Implant Device,3263.05,35,,3263.05,percent of total billed charges,Implant Device,3263.05,35,,3263.05,percent of total billed charges,Implant Device,3263.05,35,,3263.05,percent of total billed charges,Implant Device,3729.2,40,,3729.2,percent of total billed charges,Implant Device,3263.05,70,,3263.05,percent of total billed charges,All Other,3169.82,34,,3169.82,percent of total billed charges,Implant Device,3169.82,34,,3169.82,percent of total billed charges,Implant Device,3263.05,35,,3263.05,percent of total billed charges,Implant Device,3263.05,35,,3263.05,percent of total billed charges,Implant Device,3263.05,35,,3263.05,percent of total billed charges,Implant Device,3263.05,35,,3263.05,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3169.82,34,"If Charge > 2,000, then 34 percent",3169.82,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,6899.04,
IN2BONES S65 ST145 SCREW 6.5X45MM,C1713,HCPCS,,79008789,CDM,278,RC,,,both,,,3105,2297.71,,,2297.71,Other,150% of Medicare + 9.63% HCRA Surcharge,1397.25,45,,1397.25,percent of total billed charges,Critical Access Hospital RCC factor,1055.7,34,,1055.7,percent of total billed charges,Implant Device,1055.7,34,,1055.7,percent of total billed charges,Implant Device,1055.7,34,,1055.7,percent of total billed charges,Implant Device,1055.7,34,,1055.7,percent of total billed charges,Implant Device,1055.7,34,,1055.7,percent of total billed charges,Implant Device,1536.98,,,1536.98,Other,110% of Medicare,1086.75,35,,1086.75,percent of total billed charges,Implant Device,1055.7,34,"Charges > $500, x 34%",1055.7,percent of total billed charges,Implant Device,1086.75,35,,1086.75,percent of total billed charges,Implant Device,1086.75,35,,1086.75,percent of total billed charges,Implant Device,1086.75,35,,1086.75,percent of total billed charges,Implant Device,1086.75,35,,1086.75,percent of total billed charges,Implant Device,1086.75,35,,1086.75,percent of total billed charges,Implant Device,1242,40,,1242,percent of total billed charges,Implant Device,1086.75,70,,1086.75,percent of total billed charges,All Other,1055.7,34,,1055.7,percent of total billed charges,Implant Device,1055.7,34,,1055.7,percent of total billed charges,Implant Device,1086.75,35,,1086.75,percent of total billed charges,Implant Device,1086.75,35,,1086.75,percent of total billed charges,Implant Device,1086.75,35,,1086.75,percent of total billed charges,Implant Device,1086.75,35,,1086.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1055.7,34,"If Charge > 2,000, then 34 percent",1055.7,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2297.71,
IN2BONES 100-0042 VITRIUM WEDGE 20X6MM,C1713,HCPCS,,79008790,CDM,278,RC,,,both,,,9450,6993.02,,,6993.02,Other,150% of Medicare + 9.63% HCRA Surcharge,4252.5,45,,4252.5,percent of total billed charges,Critical Access Hospital RCC factor,3213,34,,3213,percent of total billed charges,Implant Device,3213,34,,3213,percent of total billed charges,Implant Device,3213,34,,3213,percent of total billed charges,Implant Device,3213,34,,3213,percent of total billed charges,Implant Device,3213,34,,3213,percent of total billed charges,Implant Device,4677.75,,,4677.75,Other,110% of Medicare,3307.5,35,,3307.5,percent of total billed charges,Implant Device,3213,34,"Charges > $500, x 34%",3213,percent of total billed charges,Implant Device,3307.5,35,,3307.5,percent of total billed charges,Implant Device,3307.5,35,,3307.5,percent of total billed charges,Implant Device,3307.5,35,,3307.5,percent of total billed charges,Implant Device,3307.5,35,,3307.5,percent of total billed charges,Implant Device,3307.5,35,,3307.5,percent of total billed charges,Implant Device,3780,40,,3780,percent of total billed charges,Implant Device,3307.5,70,,3307.5,percent of total billed charges,All Other,3213,34,,3213,percent of total billed charges,Implant Device,3213,34,,3213,percent of total billed charges,Implant Device,3307.5,35,,3307.5,percent of total billed charges,Implant Device,3307.5,35,,3307.5,percent of total billed charges,Implant Device,3307.5,35,,3307.5,percent of total billed charges,Implant Device,3307.5,35,,3307.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3213,34,"If Charge > 2,000, then 34 percent",3213,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,6993.02,
IN2BONES PAA-050 DBM PUTTY 5CC,C1713,HCPCS,,79008791,CDM,278,RC,,,both,,,2250,1665.01,,,1665.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1012.5,45,,1012.5,percent of total billed charges,Critical Access Hospital RCC factor,765,34,,765,percent of total billed charges,Implant Device,765,34,,765,percent of total billed charges,Implant Device,765,34,,765,percent of total billed charges,Implant Device,765,34,,765,percent of total billed charges,Implant Device,765,34,,765,percent of total billed charges,Implant Device,1113.75,,,1113.75,Other,110% of Medicare,787.5,35,,787.5,percent of total billed charges,Implant Device,765,34,"Charges > $500, x 34%",765,percent of total billed charges,Implant Device,787.5,35,,787.5,percent of total billed charges,Implant Device,787.5,35,,787.5,percent of total billed charges,Implant Device,787.5,35,,787.5,percent of total billed charges,Implant Device,787.5,35,,787.5,percent of total billed charges,Implant Device,787.5,35,,787.5,percent of total billed charges,Implant Device,900,40,,900,percent of total billed charges,Implant Device,787.5,70,,787.5,percent of total billed charges,All Other,765,34,,765,percent of total billed charges,Implant Device,765,34,,765,percent of total billed charges,Implant Device,787.5,35,,787.5,percent of total billed charges,Implant Device,787.5,35,,787.5,percent of total billed charges,Implant Device,787.5,35,,787.5,percent of total billed charges,Implant Device,787.5,35,,787.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,765,34,"If Charge > 2,000, then 34 percent",765,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1665.01,
GORE BXA085902A VBX VIABAHN 8X59MM STENT,C1874,HCPCS,,79008792,CDM,278,RC,,,both,,,9765,7226.12,,,7226.12,Other,150% of Medicare + 9.63% HCRA Surcharge,4394.25,45,,4394.25,percent of total billed charges,Critical Access Hospital RCC factor,3320.1,34,,3320.1,percent of total billed charges,Implant Device,3320.1,34,,3320.1,percent of total billed charges,Implant Device,3320.1,34,,3320.1,percent of total billed charges,Implant Device,3320.1,34,,3320.1,percent of total billed charges,Implant Device,3320.1,34,,3320.1,percent of total billed charges,Implant Device,4833.68,,,4833.68,Other,110% of Medicare,3417.75,35,,3417.75,percent of total billed charges,Implant Device,3320.1,34,"Charges > $500, x 34%",3320.1,percent of total billed charges,Implant Device,3417.75,35,,3417.75,percent of total billed charges,Implant Device,3417.75,35,,3417.75,percent of total billed charges,Implant Device,3417.75,35,,3417.75,percent of total billed charges,Implant Device,3417.75,35,,3417.75,percent of total billed charges,Implant Device,3417.75,35,,3417.75,percent of total billed charges,Implant Device,3906,40,,3906,percent of total billed charges,Implant Device,3417.75,70,,3417.75,percent of total billed charges,All Other,3320.1,34,,3320.1,percent of total billed charges,Implant Device,3320.1,34,,3320.1,percent of total billed charges,Implant Device,3417.75,35,,3417.75,percent of total billed charges,Implant Device,3417.75,35,,3417.75,percent of total billed charges,Implant Device,3417.75,35,,3417.75,percent of total billed charges,Implant Device,3417.75,35,,3417.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3320.1,34,"If Charge > 2,000, then 34 percent",3320.1,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,7226.12,
GORE VBJR061002A VIABAHN 6MMX10CM STENT,C1874,HCPCS,,79008793,CDM,278,RC,,,both,,,11010,8147.43,,,8147.43,Other,150% of Medicare + 9.63% HCRA Surcharge,4954.5,45,,4954.5,percent of total billed charges,Critical Access Hospital RCC factor,3743.4,34,,3743.4,percent of total billed charges,Implant Device,3743.4,34,,3743.4,percent of total billed charges,Implant Device,3743.4,34,,3743.4,percent of total billed charges,Implant Device,3743.4,34,,3743.4,percent of total billed charges,Implant Device,3743.4,34,,3743.4,percent of total billed charges,Implant Device,5449.95,,,5449.95,Other,110% of Medicare,3853.5,35,,3853.5,percent of total billed charges,Implant Device,3743.4,34,"Charges > $500, x 34%",3743.4,percent of total billed charges,Implant Device,3853.5,35,,3853.5,percent of total billed charges,Implant Device,3853.5,35,,3853.5,percent of total billed charges,Implant Device,3853.5,35,,3853.5,percent of total billed charges,Implant Device,3853.5,35,,3853.5,percent of total billed charges,Implant Device,3853.5,35,,3853.5,percent of total billed charges,Implant Device,4404,40,,4404,percent of total billed charges,Implant Device,3853.5,70,,3853.5,percent of total billed charges,All Other,3743.4,34,,3743.4,percent of total billed charges,Implant Device,3743.4,34,,3743.4,percent of total billed charges,Implant Device,3853.5,35,,3853.5,percent of total billed charges,Implant Device,3853.5,35,,3853.5,percent of total billed charges,Implant Device,3853.5,35,,3853.5,percent of total billed charges,Implant Device,3853.5,35,,3853.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3743.4,34,"If Charge > 2,000, then 34 percent",3743.4,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,8147.43,
STRYKER 40-30116 ASNIS SCREW 3.0X16MM,C1713,HCPCS,,79008801,CDM,278,RC,,,both,,,493,364.82,,,364.82,Other,150% of Medicare + 9.63% HCRA Surcharge,221.85,45,,221.85,percent of total billed charges,Critical Access Hospital RCC factor,167.62,34,,167.62,percent of total billed charges,Implant Device,167.62,34,,167.62,percent of total billed charges,Implant Device,167.62,34,,167.62,percent of total billed charges,Implant Device,167.62,34,,167.62,percent of total billed charges,Implant Device,167.62,34,,167.62,percent of total billed charges,Implant Device,244.04,,,244.04,Other,110% of Medicare,172.55,35,,172.55,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,172.55,35,,172.55,percent of total billed charges,Implant Device,172.55,35,,172.55,percent of total billed charges,Implant Device,172.55,35,,172.55,percent of total billed charges,Implant Device,172.55,35,,172.55,percent of total billed charges,Implant Device,172.55,35,,172.55,percent of total billed charges,Implant Device,197.2,40,,197.2,percent of total billed charges,Implant Device,172.55,70,,172.55,percent of total billed charges,All Other,167.62,34,,167.62,percent of total billed charges,Implant Device,167.62,34,,167.62,percent of total billed charges,Implant Device,172.55,35,,172.55,percent of total billed charges,Implant Device,172.55,35,,172.55,percent of total billed charges,Implant Device,172.55,35,,172.55,percent of total billed charges,Implant Device,172.55,35,,172.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,364.82,
STABILITY SB 905 TENODESIS ALLOGRAFT,C1713,HCPCS,,79008802,CDM,278,RC,,,both,,,5325,3940.51,,,3940.51,Other,150% of Medicare + 9.63% HCRA Surcharge,2396.25,45,,2396.25,percent of total billed charges,Critical Access Hospital RCC factor,1810.5,34,,1810.5,percent of total billed charges,Implant Device,1810.5,34,,1810.5,percent of total billed charges,Implant Device,1810.5,34,,1810.5,percent of total billed charges,Implant Device,1810.5,34,,1810.5,percent of total billed charges,Implant Device,1810.5,34,,1810.5,percent of total billed charges,Implant Device,2635.88,,,2635.88,Other,110% of Medicare,1863.75,35,,1863.75,percent of total billed charges,Implant Device,1810.5,34,"Charges > $500, x 34%",1810.5,percent of total billed charges,Implant Device,1863.75,35,,1863.75,percent of total billed charges,Implant Device,1863.75,35,,1863.75,percent of total billed charges,Implant Device,1863.75,35,,1863.75,percent of total billed charges,Implant Device,1863.75,35,,1863.75,percent of total billed charges,Implant Device,1863.75,35,,1863.75,percent of total billed charges,Implant Device,2130,40,,2130,percent of total billed charges,Implant Device,1863.75,70,,1863.75,percent of total billed charges,All Other,1810.5,34,,1810.5,percent of total billed charges,Implant Device,1810.5,34,,1810.5,percent of total billed charges,Implant Device,1863.75,35,,1863.75,percent of total billed charges,Implant Device,1863.75,35,,1863.75,percent of total billed charges,Implant Device,1863.75,35,,1863.75,percent of total billed charges,Implant Device,1863.75,35,,1863.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1810.5,34,"If Charge > 2,000, then 34 percent",1810.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3940.51,
GORE VBJR071002A VIABAHN ENDOPROSTHESIS,C1874,HCPCS,,79008805,CDM,278,RC,,,both,,,11010,8147.43,,,8147.43,Other,150% of Medicare + 9.63% HCRA Surcharge,4954.5,45,,4954.5,percent of total billed charges,Critical Access Hospital RCC factor,3743.4,34,,3743.4,percent of total billed charges,Implant Device,3743.4,34,,3743.4,percent of total billed charges,Implant Device,3743.4,34,,3743.4,percent of total billed charges,Implant Device,3743.4,34,,3743.4,percent of total billed charges,Implant Device,3743.4,34,,3743.4,percent of total billed charges,Implant Device,5449.95,,,5449.95,Other,110% of Medicare,3853.5,35,,3853.5,percent of total billed charges,Implant Device,3743.4,34,"Charges > $500, x 34%",3743.4,percent of total billed charges,Implant Device,3853.5,35,,3853.5,percent of total billed charges,Implant Device,3853.5,35,,3853.5,percent of total billed charges,Implant Device,3853.5,35,,3853.5,percent of total billed charges,Implant Device,3853.5,35,,3853.5,percent of total billed charges,Implant Device,3853.5,35,,3853.5,percent of total billed charges,Implant Device,4404,40,,4404,percent of total billed charges,Implant Device,3853.5,70,,3853.5,percent of total billed charges,All Other,3743.4,34,,3743.4,percent of total billed charges,Implant Device,3743.4,34,,3743.4,percent of total billed charges,Implant Device,3853.5,35,,3853.5,percent of total billed charges,Implant Device,3853.5,35,,3853.5,percent of total billed charges,Implant Device,3853.5,35,,3853.5,percent of total billed charges,Implant Device,3853.5,35,,3853.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3743.4,34,"If Charge > 2,000, then 34 percent",3743.4,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,8147.43,
IN2BONES APA-001 PIP ALLOGRAFT 2.5X16MM,C1713,HCPCS,,79008806,CDM,278,RC,,,both,,,3300,2442.01,,,2442.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1485,45,,1485,percent of total billed charges,Critical Access Hospital RCC factor,1122,34,,1122,percent of total billed charges,Implant Device,1122,34,,1122,percent of total billed charges,Implant Device,1122,34,,1122,percent of total billed charges,Implant Device,1122,34,,1122,percent of total billed charges,Implant Device,1122,34,,1122,percent of total billed charges,Implant Device,1633.5,,,1633.5,Other,110% of Medicare,1155,35,,1155,percent of total billed charges,Implant Device,1122,34,"Charges > $500, x 34%",1122,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,1320,40,,1320,percent of total billed charges,Implant Device,1155,70,,1155,percent of total billed charges,All Other,1122,34,,1122,percent of total billed charges,Implant Device,1122,34,,1122,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1122,34,"If Charge > 2,000, then 34 percent",1122,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2442.01,
MENTOR 350-2450 BREAST IMPLANT 450CC,C1789,HCPCS,,79008807,CDM,278,RC,,,both,,,2010,1487.41,,,1487.41,Other,150% of Medicare + 9.63% HCRA Surcharge,904.5,45,,904.5,percent of total billed charges,Critical Access Hospital RCC factor,683.4,34,,683.4,percent of total billed charges,Implant Device,683.4,34,,683.4,percent of total billed charges,Implant Device,683.4,34,,683.4,percent of total billed charges,Implant Device,683.4,34,,683.4,percent of total billed charges,Implant Device,683.4,34,,683.4,percent of total billed charges,Implant Device,994.95,,,994.95,Other,110% of Medicare,703.5,35,,703.5,percent of total billed charges,Implant Device,683.4,34,"Charges > $500, x 34%",683.4,percent of total billed charges,Implant Device,703.5,35,,703.5,percent of total billed charges,Implant Device,703.5,35,,703.5,percent of total billed charges,Implant Device,703.5,35,,703.5,percent of total billed charges,Implant Device,703.5,35,,703.5,percent of total billed charges,Implant Device,703.5,35,,703.5,percent of total billed charges,Implant Device,804,40,,804,percent of total billed charges,Implant Device,703.5,70,,703.5,percent of total billed charges,All Other,683.4,34,,683.4,percent of total billed charges,Implant Device,683.4,34,,683.4,percent of total billed charges,Implant Device,703.5,35,,703.5,percent of total billed charges,Implant Device,703.5,35,,703.5,percent of total billed charges,Implant Device,703.5,35,,703.5,percent of total billed charges,Implant Device,703.5,35,,703.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,683.4,34,"If Charge > 2,000, then 34 percent",683.4,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1487.41,
STRYKER 604750 ASNIS CANN SCREW 4.0X50MM,C1713,HCPCS,,79008808,CDM,278,RC,,,both,,,480,355.2,,,355.2,Other,150% of Medicare + 9.63% HCRA Surcharge,216,45,,216,percent of total billed charges,Critical Access Hospital RCC factor,163.2,34,,163.2,percent of total billed charges,Implant Device,163.2,34,,163.2,percent of total billed charges,Implant Device,163.2,34,,163.2,percent of total billed charges,Implant Device,163.2,34,,163.2,percent of total billed charges,Implant Device,163.2,34,,163.2,percent of total billed charges,Implant Device,237.6,,,237.6,Other,110% of Medicare,168,35,,168,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,192,40,,192,percent of total billed charges,Implant Device,168,70,,168,percent of total billed charges,All Other,163.2,34,,163.2,percent of total billed charges,Implant Device,163.2,34,,163.2,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,355.2,
STRYKER 601670 ASNIS CANN SCREW 5.0X70MM,C1713,HCPCS,,79008809,CDM,278,RC,,,both,,,847,626.78,,,626.78,Other,150% of Medicare + 9.63% HCRA Surcharge,381.15,45,,381.15,percent of total billed charges,Critical Access Hospital RCC factor,287.98,34,,287.98,percent of total billed charges,Implant Device,287.98,34,,287.98,percent of total billed charges,Implant Device,287.98,34,,287.98,percent of total billed charges,Implant Device,287.98,34,,287.98,percent of total billed charges,Implant Device,287.98,34,,287.98,percent of total billed charges,Implant Device,419.27,,,419.27,Other,110% of Medicare,296.45,35,,296.45,percent of total billed charges,Implant Device,287.98,34,"Charges > $500, x 34%",287.98,percent of total billed charges,Implant Device,296.45,35,,296.45,percent of total billed charges,Implant Device,296.45,35,,296.45,percent of total billed charges,Implant Device,296.45,35,,296.45,percent of total billed charges,Implant Device,296.45,35,,296.45,percent of total billed charges,Implant Device,296.45,35,,296.45,percent of total billed charges,Implant Device,338.8,40,,338.8,percent of total billed charges,Implant Device,296.45,70,,296.45,percent of total billed charges,All Other,287.98,34,,287.98,percent of total billed charges,Implant Device,287.98,34,,287.98,percent of total billed charges,Implant Device,296.45,35,,296.45,percent of total billed charges,Implant Device,296.45,35,,296.45,percent of total billed charges,Implant Device,296.45,35,,296.45,percent of total billed charges,Implant Device,296.45,35,,296.45,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,626.78,
STRYKER 5023-3-120 APEX HALF PIN 4X12MM,C1713,HCPCS,,79008810,CDM,278,RC,,,both,,,203,150.22,,,150.22,Other,150% of Medicare + 9.63% HCRA Surcharge,91.35,45,,91.35,percent of total billed charges,Critical Access Hospital RCC factor,69.02,34,,69.02,percent of total billed charges,Implant Device,69.02,34,,69.02,percent of total billed charges,Implant Device,69.02,34,,69.02,percent of total billed charges,Implant Device,69.02,34,,69.02,percent of total billed charges,Implant Device,69.02,34,,69.02,percent of total billed charges,Implant Device,100.49,,,100.49,Other,110% of Medicare,71.05,35,,71.05,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,71.05,35,,71.05,percent of total billed charges,Implant Device,71.05,35,,71.05,percent of total billed charges,Implant Device,71.05,35,,71.05,percent of total billed charges,Implant Device,71.05,35,,71.05,percent of total billed charges,Implant Device,71.05,35,,71.05,percent of total billed charges,Implant Device,81.2,40,,81.2,percent of total billed charges,Implant Device,71.05,70,,71.05,percent of total billed charges,All Other,69.02,34,,69.02,percent of total billed charges,Implant Device,69.02,34,,69.02,percent of total billed charges,Implant Device,71.05,35,,71.05,percent of total billed charges,Implant Device,71.05,35,,71.05,percent of total billed charges,Implant Device,71.05,35,,71.05,percent of total billed charges,Implant Device,71.05,35,,71.05,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,150.22,
STRYKER 604744 ASNIS CANN SCREW 4.0X44MM,C1713,HCPCS,,79008811,CDM,278,RC,,,both,,,770,569.8,,,569.8,Other,150% of Medicare + 9.63% HCRA Surcharge,346.5,45,,346.5,percent of total billed charges,Critical Access Hospital RCC factor,261.8,34,,261.8,percent of total billed charges,Implant Device,261.8,34,,261.8,percent of total billed charges,Implant Device,261.8,34,,261.8,percent of total billed charges,Implant Device,261.8,34,,261.8,percent of total billed charges,Implant Device,261.8,34,,261.8,percent of total billed charges,Implant Device,381.15,,,381.15,Other,110% of Medicare,269.5,35,,269.5,percent of total billed charges,Implant Device,261.8,34,"Charges > $500, x 34%",261.8,percent of total billed charges,Implant Device,269.5,35,,269.5,percent of total billed charges,Implant Device,269.5,35,,269.5,percent of total billed charges,Implant Device,269.5,35,,269.5,percent of total billed charges,Implant Device,269.5,35,,269.5,percent of total billed charges,Implant Device,269.5,35,,269.5,percent of total billed charges,Implant Device,308,40,,308,percent of total billed charges,Implant Device,269.5,70,,269.5,percent of total billed charges,All Other,261.8,34,,261.8,percent of total billed charges,Implant Device,261.8,34,,261.8,percent of total billed charges,Implant Device,269.5,35,,269.5,percent of total billed charges,Implant Device,269.5,35,,269.5,percent of total billed charges,Implant Device,269.5,35,,269.5,percent of total billed charges,Implant Device,269.5,35,,269.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,569.8,
STRYKER FOOT & ANKLE SK988 9X8X8 STAPLE,C1713,HCPCS,,79008813,CDM,278,RC,,,both,,,4785,3540.91,,,3540.91,Other,150% of Medicare + 9.63% HCRA Surcharge,2153.25,45,,2153.25,percent of total billed charges,Critical Access Hospital RCC factor,1626.9,34,,1626.9,percent of total billed charges,Implant Device,1626.9,34,,1626.9,percent of total billed charges,Implant Device,1626.9,34,,1626.9,percent of total billed charges,Implant Device,1626.9,34,,1626.9,percent of total billed charges,Implant Device,1626.9,34,,1626.9,percent of total billed charges,Implant Device,2368.58,,,2368.58,Other,110% of Medicare,1674.75,35,,1674.75,percent of total billed charges,Implant Device,1626.9,34,"Charges > $500, x 34%",1626.9,percent of total billed charges,Implant Device,1674.75,35,,1674.75,percent of total billed charges,Implant Device,1674.75,35,,1674.75,percent of total billed charges,Implant Device,1674.75,35,,1674.75,percent of total billed charges,Implant Device,1674.75,35,,1674.75,percent of total billed charges,Implant Device,1674.75,35,,1674.75,percent of total billed charges,Implant Device,1914,40,,1914,percent of total billed charges,Implant Device,1674.75,70,,1674.75,percent of total billed charges,All Other,1626.9,34,,1626.9,percent of total billed charges,Implant Device,1626.9,34,,1626.9,percent of total billed charges,Implant Device,1674.75,35,,1674.75,percent of total billed charges,Implant Device,1674.75,35,,1674.75,percent of total billed charges,Implant Device,1674.75,35,,1674.75,percent of total billed charges,Implant Device,1674.75,35,,1674.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1626.9,34,"If Charge > 2,000, then 34 percent",1626.9,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3540.91,
ZIMMER 00-5853-050-15 FLUTED STEM 15X130,C1776,HCPCS,,79008814,CDM,278,RC,,,both,,,11878,8789.75,,,8789.75,Other,150% of Medicare + 9.63% HCRA Surcharge,5345.1,45,,5345.1,percent of total billed charges,Critical Access Hospital RCC factor,4038.52,34,,4038.52,percent of total billed charges,Implant Device,4038.52,34,,4038.52,percent of total billed charges,Implant Device,4038.52,34,,4038.52,percent of total billed charges,Implant Device,4038.52,34,,4038.52,percent of total billed charges,Implant Device,4038.52,34,,4038.52,percent of total billed charges,Implant Device,5879.61,,,5879.61,Other,110% of Medicare,4157.3,35,,4157.3,percent of total billed charges,Implant Device,4038.52,34,"Charges > $500, x 34%",4038.52,percent of total billed charges,Implant Device,4157.3,35,,4157.3,percent of total billed charges,Implant Device,4157.3,35,,4157.3,percent of total billed charges,Implant Device,4157.3,35,,4157.3,percent of total billed charges,Implant Device,4157.3,35,,4157.3,percent of total billed charges,Implant Device,4157.3,35,,4157.3,percent of total billed charges,Implant Device,4751.2,40,,4751.2,percent of total billed charges,Implant Device,4157.3,70,,4157.3,percent of total billed charges,All Other,4038.52,34,,4038.52,percent of total billed charges,Implant Device,4038.52,34,,4038.52,percent of total billed charges,Implant Device,4157.3,35,,4157.3,percent of total billed charges,Implant Device,4157.3,35,,4157.3,percent of total billed charges,Implant Device,4157.3,35,,4157.3,percent of total billed charges,Implant Device,4157.3,35,,4157.3,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,4038.52,34,"If Charge > 2,000, then 34 percent",4038.52,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,8789.75,
ZIMMER 00-5850-030-12 ART SURF SZ C 12MM,C1776,HCPCS,,79008815,CDM,278,RC,,,both,,,6200,4588.02,,,4588.02,Other,150% of Medicare + 9.63% HCRA Surcharge,2790,45,,2790,percent of total billed charges,Critical Access Hospital RCC factor,2108,34,,2108,percent of total billed charges,Implant Device,2108,34,,2108,percent of total billed charges,Implant Device,2108,34,,2108,percent of total billed charges,Implant Device,2108,34,,2108,percent of total billed charges,Implant Device,2108,34,,2108,percent of total billed charges,Implant Device,3069,,,3069,Other,110% of Medicare,2170,35,,2170,percent of total billed charges,Implant Device,2108,34,"Charges > $500, x 34%",2108,percent of total billed charges,Implant Device,2170,35,,2170,percent of total billed charges,Implant Device,2170,35,,2170,percent of total billed charges,Implant Device,2170,35,,2170,percent of total billed charges,Implant Device,2170,35,,2170,percent of total billed charges,Implant Device,2170,35,,2170,percent of total billed charges,Implant Device,2480,40,,2480,percent of total billed charges,Implant Device,2170,70,,2170,percent of total billed charges,All Other,2108,34,,2108,percent of total billed charges,Implant Device,2108,34,,2108,percent of total billed charges,Implant Device,2170,35,,2170,percent of total billed charges,Implant Device,2170,35,,2170,percent of total billed charges,Implant Device,2170,35,,2170,percent of total billed charges,Implant Device,2170,35,,2170,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2108,34,"If Charge > 2,000, then 34 percent",2108,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4588.02,
DEPUY 206.030 4.0X30MM CANCELLOUS SCREW,C1713,HCPCS,,79008816,CDM,278,RC,,,both,,,47,34.78,,,34.78,Other,150% of Medicare + 9.63% HCRA Surcharge,21.15,45,,21.15,percent of total billed charges,Critical Access Hospital RCC factor,15.98,34,,15.98,percent of total billed charges,Implant Device,15.98,34,,15.98,percent of total billed charges,Implant Device,15.98,34,,15.98,percent of total billed charges,Implant Device,15.98,34,,15.98,percent of total billed charges,Implant Device,15.98,34,,15.98,percent of total billed charges,Implant Device,23.27,,,23.27,Other,110% of Medicare,16.45,35,,16.45,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,16.45,35,,16.45,percent of total billed charges,Implant Device,16.45,35,,16.45,percent of total billed charges,Implant Device,16.45,35,,16.45,percent of total billed charges,Implant Device,16.45,35,,16.45,percent of total billed charges,Implant Device,16.45,35,,16.45,percent of total billed charges,Implant Device,18.8,40,,18.8,percent of total billed charges,Implant Device,16.45,70,,16.45,percent of total billed charges,All Other,15.98,34,,15.98,percent of total billed charges,Implant Device,15.98,34,,15.98,percent of total billed charges,Implant Device,16.45,35,,16.45,percent of total billed charges,Implant Device,16.45,35,,16.45,percent of total billed charges,Implant Device,16.45,35,,16.45,percent of total billed charges,Implant Device,16.45,35,,16.45,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,34.78,
DEPUY 202.218 2.7X18MM LOCKING SCREW,C1713,HCPCS,,79008817,CDM,278,RC,,,both,,,300,222,,,222,Other,150% of Medicare + 9.63% HCRA Surcharge,135,45,,135,percent of total billed charges,Critical Access Hospital RCC factor,102,34,,102,percent of total billed charges,Implant Device,102,34,,102,percent of total billed charges,Implant Device,102,34,,102,percent of total billed charges,Implant Device,102,34,,102,percent of total billed charges,Implant Device,102,34,,102,percent of total billed charges,Implant Device,148.5,,,148.5,Other,110% of Medicare,105,35,,105,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,105,35,,105,percent of total billed charges,Implant Device,105,35,,105,percent of total billed charges,Implant Device,105,35,,105,percent of total billed charges,Implant Device,105,35,,105,percent of total billed charges,Implant Device,105,35,,105,percent of total billed charges,Implant Device,120,40,,120,percent of total billed charges,Implant Device,105,70,,105,percent of total billed charges,All Other,102,34,,102,percent of total billed charges,Implant Device,102,34,,102,percent of total billed charges,Implant Device,105,35,,105,percent of total billed charges,Implant Device,105,35,,105,percent of total billed charges,Implant Device,105,35,,105,percent of total billed charges,Implant Device,105,35,,105,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,222,
DEPUY 02.112.143 6 HOLE DIS FIB PLATE,C1713,HCPCS,,79008818,CDM,278,RC,,,both,,,1743,1289.82,,,1289.82,Other,150% of Medicare + 9.63% HCRA Surcharge,784.35,45,,784.35,percent of total billed charges,Critical Access Hospital RCC factor,592.62,34,,592.62,percent of total billed charges,Implant Device,592.62,34,,592.62,percent of total billed charges,Implant Device,592.62,34,,592.62,percent of total billed charges,Implant Device,592.62,34,,592.62,percent of total billed charges,Implant Device,592.62,34,,592.62,percent of total billed charges,Implant Device,862.79,,,862.79,Other,110% of Medicare,610.05,35,,610.05,percent of total billed charges,Implant Device,592.62,34,"Charges > $500, x 34%",592.62,percent of total billed charges,Implant Device,610.05,35,,610.05,percent of total billed charges,Implant Device,610.05,35,,610.05,percent of total billed charges,Implant Device,610.05,35,,610.05,percent of total billed charges,Implant Device,610.05,35,,610.05,percent of total billed charges,Implant Device,610.05,35,,610.05,percent of total billed charges,Implant Device,697.2,40,,697.2,percent of total billed charges,Implant Device,610.05,70,,610.05,percent of total billed charges,All Other,592.62,34,,592.62,percent of total billed charges,Implant Device,592.62,34,,592.62,percent of total billed charges,Implant Device,610.05,35,,610.05,percent of total billed charges,Implant Device,610.05,35,,610.05,percent of total billed charges,Implant Device,610.05,35,,610.05,percent of total billed charges,Implant Device,610.05,35,,610.05,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1289.82,
ZIMMER 00-8851-013-36 NEUTRAL LINER 36MM,C1776,HCPCS,,79008820,CDM,278,RC,,,both,,,3456,2557.45,,,2557.45,Other,150% of Medicare + 9.63% HCRA Surcharge,1555.2,45,,1555.2,percent of total billed charges,Critical Access Hospital RCC factor,1175.04,34,,1175.04,percent of total billed charges,Implant Device,1175.04,34,,1175.04,percent of total billed charges,Implant Device,1175.04,34,,1175.04,percent of total billed charges,Implant Device,1175.04,34,,1175.04,percent of total billed charges,Implant Device,1175.04,34,,1175.04,percent of total billed charges,Implant Device,1710.72,,,1710.72,Other,110% of Medicare,1209.6,35,,1209.6,percent of total billed charges,Implant Device,1175.04,34,"Charges > $500, x 34%",1175.04,percent of total billed charges,Implant Device,1209.6,35,,1209.6,percent of total billed charges,Implant Device,1209.6,35,,1209.6,percent of total billed charges,Implant Device,1209.6,35,,1209.6,percent of total billed charges,Implant Device,1209.6,35,,1209.6,percent of total billed charges,Implant Device,1209.6,35,,1209.6,percent of total billed charges,Implant Device,1382.4,40,,1382.4,percent of total billed charges,Implant Device,1209.6,70,,1209.6,percent of total billed charges,All Other,1175.04,34,,1175.04,percent of total billed charges,Implant Device,1175.04,34,,1175.04,percent of total billed charges,Implant Device,1209.6,35,,1209.6,percent of total billed charges,Implant Device,1209.6,35,,1209.6,percent of total billed charges,Implant Device,1209.6,35,,1209.6,percent of total billed charges,Implant Device,1209.6,35,,1209.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1175.04,34,"If Charge > 2,000, then 34 percent",1175.04,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2557.45,
ZIMMER 00-5990-036-23 AUG BLOCK F 15MM,C1776,HCPCS,,79008821,CDM,278,RC,,,both,,,3488,2581.13,,,2581.13,Other,150% of Medicare + 9.63% HCRA Surcharge,1569.6,45,,1569.6,percent of total billed charges,Critical Access Hospital RCC factor,1185.92,34,,1185.92,percent of total billed charges,Implant Device,1185.92,34,,1185.92,percent of total billed charges,Implant Device,1185.92,34,,1185.92,percent of total billed charges,Implant Device,1185.92,34,,1185.92,percent of total billed charges,Implant Device,1185.92,34,,1185.92,percent of total billed charges,Implant Device,1726.56,,,1726.56,Other,110% of Medicare,1220.8,35,,1220.8,percent of total billed charges,Implant Device,1185.92,34,"Charges > $500, x 34%",1185.92,percent of total billed charges,Implant Device,1220.8,35,,1220.8,percent of total billed charges,Implant Device,1220.8,35,,1220.8,percent of total billed charges,Implant Device,1220.8,35,,1220.8,percent of total billed charges,Implant Device,1220.8,35,,1220.8,percent of total billed charges,Implant Device,1220.8,35,,1220.8,percent of total billed charges,Implant Device,1395.2,40,,1395.2,percent of total billed charges,Implant Device,1220.8,70,,1220.8,percent of total billed charges,All Other,1185.92,34,,1185.92,percent of total billed charges,Implant Device,1185.92,34,,1185.92,percent of total billed charges,Implant Device,1220.8,35,,1220.8,percent of total billed charges,Implant Device,1220.8,35,,1220.8,percent of total billed charges,Implant Device,1220.8,35,,1220.8,percent of total billed charges,Implant Device,1220.8,35,,1220.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1185.92,34,"If Charge > 2,000, then 34 percent",1185.92,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2581.13,
STRYKER 661090 4.0X90MM LOCKING SCREW,C1713,HCPCS,,79008824,CDM,278,RC,,,both,,,816,603.84,,,603.84,Other,150% of Medicare + 9.63% HCRA Surcharge,367.2,45,,367.2,percent of total billed charges,Critical Access Hospital RCC factor,277.44,34,,277.44,percent of total billed charges,Implant Device,277.44,34,,277.44,percent of total billed charges,Implant Device,277.44,34,,277.44,percent of total billed charges,Implant Device,277.44,34,,277.44,percent of total billed charges,Implant Device,277.44,34,,277.44,percent of total billed charges,Implant Device,403.92,,,403.92,Other,110% of Medicare,285.6,35,,285.6,percent of total billed charges,Implant Device,277.44,34,"Charges > $500, x 34%",277.44,percent of total billed charges,Implant Device,285.6,35,,285.6,percent of total billed charges,Implant Device,285.6,35,,285.6,percent of total billed charges,Implant Device,285.6,35,,285.6,percent of total billed charges,Implant Device,285.6,35,,285.6,percent of total billed charges,Implant Device,285.6,35,,285.6,percent of total billed charges,Implant Device,326.4,40,,326.4,percent of total billed charges,Implant Device,285.6,70,,285.6,percent of total billed charges,All Other,277.44,34,,277.44,percent of total billed charges,Implant Device,277.44,34,,277.44,percent of total billed charges,Implant Device,285.6,35,,285.6,percent of total billed charges,Implant Device,285.6,35,,285.6,percent of total billed charges,Implant Device,285.6,35,,285.6,percent of total billed charges,Implant Device,285.6,35,,285.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,603.84,
STRYKER 661080 4.0X80MM LOCKING SCREW,C1713,HCPCS,,79008825,CDM,278,RC,,,both,,,583,431.42,,,431.42,Other,150% of Medicare + 9.63% HCRA Surcharge,262.35,45,,262.35,percent of total billed charges,Critical Access Hospital RCC factor,198.22,34,,198.22,percent of total billed charges,Implant Device,198.22,34,,198.22,percent of total billed charges,Implant Device,198.22,34,,198.22,percent of total billed charges,Implant Device,198.22,34,,198.22,percent of total billed charges,Implant Device,198.22,34,,198.22,percent of total billed charges,Implant Device,288.59,,,288.59,Other,110% of Medicare,204.05,35,,204.05,percent of total billed charges,Implant Device,198.22,34,"Charges > $500, x 34%",198.22,percent of total billed charges,Implant Device,204.05,35,,204.05,percent of total billed charges,Implant Device,204.05,35,,204.05,percent of total billed charges,Implant Device,204.05,35,,204.05,percent of total billed charges,Implant Device,204.05,35,,204.05,percent of total billed charges,Implant Device,204.05,35,,204.05,percent of total billed charges,Implant Device,233.2,40,,233.2,percent of total billed charges,Implant Device,204.05,70,,204.05,percent of total billed charges,All Other,198.22,34,,198.22,percent of total billed charges,Implant Device,198.22,34,,198.22,percent of total billed charges,Implant Device,204.05,35,,204.05,percent of total billed charges,Implant Device,204.05,35,,204.05,percent of total billed charges,Implant Device,204.05,35,,204.05,percent of total billed charges,Implant Device,204.05,35,,204.05,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,431.42,
BAXTER 1501261 TISSEEL 2ML - FROZEN,C2615,HCPCS,,79008826,CDM,278,RC,,,both,,,374,276.76,,,276.76,Other,150% of Medicare + 9.63% HCRA Surcharge,168.3,45,,168.3,percent of total billed charges,Critical Access Hospital RCC factor,127.16,34,,127.16,percent of total billed charges,Implant Device,127.16,34,,127.16,percent of total billed charges,Implant Device,127.16,34,,127.16,percent of total billed charges,Implant Device,127.16,34,,127.16,percent of total billed charges,Implant Device,127.16,34,,127.16,percent of total billed charges,Implant Device,185.13,,,185.13,Other,110% of Medicare,130.9,35,,130.9,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,130.9,35,,130.9,percent of total billed charges,Implant Device,130.9,35,,130.9,percent of total billed charges,Implant Device,130.9,35,,130.9,percent of total billed charges,Implant Device,130.9,35,,130.9,percent of total billed charges,Implant Device,130.9,35,,130.9,percent of total billed charges,Implant Device,149.6,40,,149.6,percent of total billed charges,Implant Device,130.9,70,,130.9,percent of total billed charges,All Other,127.16,34,,127.16,percent of total billed charges,Implant Device,127.16,34,,127.16,percent of total billed charges,Implant Device,130.9,35,,130.9,percent of total billed charges,Implant Device,130.9,35,,130.9,percent of total billed charges,Implant Device,130.9,35,,130.9,percent of total billed charges,Implant Device,130.9,35,,130.9,percent of total billed charges,Implant Device,976.07,,,976.07,Other,100% of Medicaid,976.07,,,976.07,Other,100% of Medicaid,976.07,,,976.07,Other,100% of Medicaid,976.07,,,976.07,Other,100% of Medicaid,2196.15,,,2196.15,Other,225% of Medicaid,1493.38,,,1493.38,Other,153% of Medicaid,2196.15,,,2196.15,Other,225% of Medicaid,1366.49,,,1366.49,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,2537.77,,,2537.77,Other,260% of Medicaid,3162.45,,,3162.45,Other,324% of Medicaid,2098.54,,,2098.54,Other,215% of Medicaid,2098.54,,,2098.54,Other,215% of Medicaid,1220.08,,,1220.08,Other,125% of Medicaid,0.01,3162.45,
BAXTER 1501262 TISSEEL 4ML - FROZEN,C2615,HCPCS,,79008827,CDM,278,RC,,,both,,,628,464.72,,,464.72,Other,150% of Medicare + 9.63% HCRA Surcharge,282.6,45,,282.6,percent of total billed charges,Critical Access Hospital RCC factor,213.52,34,,213.52,percent of total billed charges,Implant Device,213.52,34,,213.52,percent of total billed charges,Implant Device,213.52,34,,213.52,percent of total billed charges,Implant Device,213.52,34,,213.52,percent of total billed charges,Implant Device,213.52,34,,213.52,percent of total billed charges,Implant Device,310.86,,,310.86,Other,110% of Medicare,219.8,35,,219.8,percent of total billed charges,Implant Device,213.52,34,"Charges > $500, x 34%",213.52,percent of total billed charges,Implant Device,219.8,35,,219.8,percent of total billed charges,Implant Device,219.8,35,,219.8,percent of total billed charges,Implant Device,219.8,35,,219.8,percent of total billed charges,Implant Device,219.8,35,,219.8,percent of total billed charges,Implant Device,219.8,35,,219.8,percent of total billed charges,Implant Device,251.2,40,,251.2,percent of total billed charges,Implant Device,219.8,70,,219.8,percent of total billed charges,All Other,213.52,34,,213.52,percent of total billed charges,Implant Device,213.52,34,,213.52,percent of total billed charges,Implant Device,219.8,35,,219.8,percent of total billed charges,Implant Device,219.8,35,,219.8,percent of total billed charges,Implant Device,219.8,35,,219.8,percent of total billed charges,Implant Device,219.8,35,,219.8,percent of total billed charges,Implant Device,976.07,,,976.07,Other,100% of Medicaid,976.07,,,976.07,Other,100% of Medicaid,976.07,,,976.07,Other,100% of Medicaid,976.07,,,976.07,Other,100% of Medicaid,2196.15,,,2196.15,Other,225% of Medicaid,1493.38,,,1493.38,Other,153% of Medicaid,2196.15,,,2196.15,Other,225% of Medicaid,1366.49,,,1366.49,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,2537.77,,,2537.77,Other,260% of Medicaid,3162.45,,,3162.45,Other,324% of Medicaid,2098.54,,,2098.54,Other,215% of Medicaid,2098.54,,,2098.54,Other,215% of Medicaid,1220.08,,,1220.08,Other,125% of Medicaid,0.01,3162.45,
MENTOR 354-9213 TISSUE EXPANDER 450CC,C1789,HCPCS,,79008828,CDM,278,RC,,,both,,,5085,3762.91,,,3762.91,Other,150% of Medicare + 9.63% HCRA Surcharge,2288.25,45,,2288.25,percent of total billed charges,Critical Access Hospital RCC factor,1728.9,34,,1728.9,percent of total billed charges,Implant Device,1728.9,34,,1728.9,percent of total billed charges,Implant Device,1728.9,34,,1728.9,percent of total billed charges,Implant Device,1728.9,34,,1728.9,percent of total billed charges,Implant Device,1728.9,34,,1728.9,percent of total billed charges,Implant Device,2517.08,,,2517.08,Other,110% of Medicare,1779.75,35,,1779.75,percent of total billed charges,Implant Device,1728.9,34,"Charges > $500, x 34%",1728.9,percent of total billed charges,Implant Device,1779.75,35,,1779.75,percent of total billed charges,Implant Device,1779.75,35,,1779.75,percent of total billed charges,Implant Device,1779.75,35,,1779.75,percent of total billed charges,Implant Device,1779.75,35,,1779.75,percent of total billed charges,Implant Device,1779.75,35,,1779.75,percent of total billed charges,Implant Device,2034,40,,2034,percent of total billed charges,Implant Device,1779.75,70,,1779.75,percent of total billed charges,All Other,1728.9,34,,1728.9,percent of total billed charges,Implant Device,1728.9,34,,1728.9,percent of total billed charges,Implant Device,1779.75,35,,1779.75,percent of total billed charges,Implant Device,1779.75,35,,1779.75,percent of total billed charges,Implant Device,1779.75,35,,1779.75,percent of total billed charges,Implant Device,1779.75,35,,1779.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1728.9,34,"If Charge > 2,000, then 34 percent",1728.9,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3762.91,
MTF PK1612 FLEX HD PLIABLE ACELL DERMIS,C1713,HCPCS,,79008829,CDM,278,RC,,,both,,,9786,7241.66,,,7241.66,Other,150% of Medicare + 9.63% HCRA Surcharge,4403.7,45,,4403.7,percent of total billed charges,Critical Access Hospital RCC factor,3327.24,34,,3327.24,percent of total billed charges,Implant Device,3327.24,34,,3327.24,percent of total billed charges,Implant Device,3327.24,34,,3327.24,percent of total billed charges,Implant Device,3327.24,34,,3327.24,percent of total billed charges,Implant Device,3327.24,34,,3327.24,percent of total billed charges,Implant Device,4844.07,,,4844.07,Other,110% of Medicare,3425.1,35,,3425.1,percent of total billed charges,Implant Device,3327.24,34,"Charges > $500, x 34%",3327.24,percent of total billed charges,Implant Device,3425.1,35,,3425.1,percent of total billed charges,Implant Device,3425.1,35,,3425.1,percent of total billed charges,Implant Device,3425.1,35,,3425.1,percent of total billed charges,Implant Device,3425.1,35,,3425.1,percent of total billed charges,Implant Device,3425.1,35,,3425.1,percent of total billed charges,Implant Device,3914.4,40,,3914.4,percent of total billed charges,Implant Device,3425.1,70,,3425.1,percent of total billed charges,All Other,3327.24,34,,3327.24,percent of total billed charges,Implant Device,3327.24,34,,3327.24,percent of total billed charges,Implant Device,3425.1,35,,3425.1,percent of total billed charges,Implant Device,3425.1,35,,3425.1,percent of total billed charges,Implant Device,3425.1,35,,3425.1,percent of total billed charges,Implant Device,3425.1,35,,3425.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3327.24,34,"If Charge > 2,000, then 34 percent",3327.24,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,7241.66,
MTF PK1616 FLEX HD PLIABLE ACELL DERMIS,C1713,HCPCS,,79008830,CDM,278,RC,,,both,,,15091,11167.38,,,11167.38,Other,150% of Medicare + 9.63% HCRA Surcharge,6790.95,45,,6790.95,percent of total billed charges,Critical Access Hospital RCC factor,5130.94,34,,5130.94,percent of total billed charges,Implant Device,5130.94,34,,5130.94,percent of total billed charges,Implant Device,5130.94,34,,5130.94,percent of total billed charges,Implant Device,5130.94,34,,5130.94,percent of total billed charges,Implant Device,5130.94,34,,5130.94,percent of total billed charges,Implant Device,7470.05,,,7470.05,Other,110% of Medicare,5281.85,35,,5281.85,percent of total billed charges,Implant Device,5130.94,34,"Charges > $500, x 34%",5130.94,percent of total billed charges,Implant Device,5281.85,35,,5281.85,percent of total billed charges,Implant Device,5281.85,35,,5281.85,percent of total billed charges,Implant Device,5281.85,35,,5281.85,percent of total billed charges,Implant Device,5281.85,35,,5281.85,percent of total billed charges,Implant Device,5281.85,35,,5281.85,percent of total billed charges,Implant Device,6036.4,40,,6036.4,percent of total billed charges,Implant Device,5281.85,70,,5281.85,percent of total billed charges,All Other,5130.94,34,,5130.94,percent of total billed charges,Implant Device,5130.94,34,,5130.94,percent of total billed charges,Implant Device,5281.85,35,,5281.85,percent of total billed charges,Implant Device,5281.85,35,,5281.85,percent of total billed charges,Implant Device,5281.85,35,,5281.85,percent of total billed charges,Implant Device,5281.85,35,,5281.85,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,5130.94,34,"If Charge > 2,000, then 34 percent",5130.94,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,11167.38,
ZIMMER 00-7711-012-40 M/L TAPER NECK,C1776,HCPCS,,79008831,CDM,278,RC,,,both,,,6900,5106.02,,,5106.02,Other,150% of Medicare + 9.63% HCRA Surcharge,3105,45,,3105,percent of total billed charges,Critical Access Hospital RCC factor,2346,34,,2346,percent of total billed charges,Implant Device,2346,34,,2346,percent of total billed charges,Implant Device,2346,34,,2346,percent of total billed charges,Implant Device,2346,34,,2346,percent of total billed charges,Implant Device,2346,34,,2346,percent of total billed charges,Implant Device,3415.5,,,3415.5,Other,110% of Medicare,2415,35,,2415,percent of total billed charges,Implant Device,2346,34,"Charges > $500, x 34%",2346,percent of total billed charges,Implant Device,2415,35,,2415,percent of total billed charges,Implant Device,2415,35,,2415,percent of total billed charges,Implant Device,2415,35,,2415,percent of total billed charges,Implant Device,2415,35,,2415,percent of total billed charges,Implant Device,2415,35,,2415,percent of total billed charges,Implant Device,2760,40,,2760,percent of total billed charges,Implant Device,2415,70,,2415,percent of total billed charges,All Other,2346,34,,2346,percent of total billed charges,Implant Device,2346,34,,2346,percent of total billed charges,Implant Device,2415,35,,2415,percent of total billed charges,Implant Device,2415,35,,2415,percent of total billed charges,Implant Device,2415,35,,2415,percent of total billed charges,Implant Device,2415,35,,2415,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2346,34,"If Charge > 2,000, then 34 percent",2346,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5106.02,
GORE RLT281418 ENDO GRAFT 28.5X14.5X18CM,C1768,HCPCS,,79008835,CDM,278,RC,,,both,,,33825,25030.58,,,25030.58,Other,150% of Medicare + 9.63% HCRA Surcharge,15221.25,45,,15221.25,percent of total billed charges,Critical Access Hospital RCC factor,11500.5,34,,11500.5,percent of total billed charges,Implant Device,11500.5,34,,11500.5,percent of total billed charges,Implant Device,11500.5,34,,11500.5,percent of total billed charges,Implant Device,11500.5,34,,11500.5,percent of total billed charges,Implant Device,11500.5,34,,11500.5,percent of total billed charges,Implant Device,16743.38,,,16743.38,Other,110% of Medicare,11838.75,35,,11838.75,percent of total billed charges,Implant Device,11500.5,34,"Charges > $500, x 34%",11500.5,percent of total billed charges,Implant Device,11838.75,35,,11838.75,percent of total billed charges,Implant Device,11838.75,35,,11838.75,percent of total billed charges,Implant Device,11838.75,35,,11838.75,percent of total billed charges,Implant Device,11838.75,35,,11838.75,percent of total billed charges,Implant Device,11838.75,35,,11838.75,percent of total billed charges,Implant Device,13530,40,,13530,percent of total billed charges,Implant Device,11838.75,70,,11838.75,percent of total billed charges,All Other,11500.5,34,,11500.5,percent of total billed charges,Implant Device,11500.5,34,,11500.5,percent of total billed charges,Implant Device,11838.75,35,,11838.75,percent of total billed charges,Implant Device,11838.75,35,,11838.75,percent of total billed charges,Implant Device,11838.75,35,,11838.75,percent of total billed charges,Implant Device,11838.75,35,,11838.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,11500.5,34,"If Charge > 2,000, then 34 percent",11500.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,25030.58,
CORDIS 466-F210AF OPTEASE VC FILTER KIT,C1880,HCPCS,,79008836,CDM,278,RC,,,both,,,4200,3108.01,,,3108.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1890,45,,1890,percent of total billed charges,Critical Access Hospital RCC factor,1428,34,,1428,percent of total billed charges,Implant Device,1428,34,,1428,percent of total billed charges,Implant Device,1428,34,,1428,percent of total billed charges,Implant Device,1428,34,,1428,percent of total billed charges,Implant Device,1428,34,,1428,percent of total billed charges,Implant Device,2079,,,2079,Other,110% of Medicare,1470,35,,1470,percent of total billed charges,Implant Device,1428,34,"Charges > $500, x 34%",1428,percent of total billed charges,Implant Device,1470,35,,1470,percent of total billed charges,Implant Device,1470,35,,1470,percent of total billed charges,Implant Device,1470,35,,1470,percent of total billed charges,Implant Device,1470,35,,1470,percent of total billed charges,Implant Device,1470,35,,1470,percent of total billed charges,Implant Device,1680,40,,1680,percent of total billed charges,Implant Device,1470,70,,1470,percent of total billed charges,All Other,1428,34,,1428,percent of total billed charges,Implant Device,1428,34,,1428,percent of total billed charges,Implant Device,1470,35,,1470,percent of total billed charges,Implant Device,1470,35,,1470,percent of total billed charges,Implant Device,1470,35,,1470,percent of total billed charges,Implant Device,1470,35,,1470,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1428,34,"If Charge > 2,000, then 34 percent",1428,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3108.01,
CORDIS 466-F210AJ OPTEASE VC FILTER KIT,C1880,HCPCS,,79008837,CDM,278,RC,,,both,,,4200,3108.01,,,3108.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1890,45,,1890,percent of total billed charges,Critical Access Hospital RCC factor,1428,34,,1428,percent of total billed charges,Implant Device,1428,34,,1428,percent of total billed charges,Implant Device,1428,34,,1428,percent of total billed charges,Implant Device,1428,34,,1428,percent of total billed charges,Implant Device,1428,34,,1428,percent of total billed charges,Implant Device,2079,,,2079,Other,110% of Medicare,1470,35,,1470,percent of total billed charges,Implant Device,1428,34,"Charges > $500, x 34%",1428,percent of total billed charges,Implant Device,1470,35,,1470,percent of total billed charges,Implant Device,1470,35,,1470,percent of total billed charges,Implant Device,1470,35,,1470,percent of total billed charges,Implant Device,1470,35,,1470,percent of total billed charges,Implant Device,1470,35,,1470,percent of total billed charges,Implant Device,1680,40,,1680,percent of total billed charges,Implant Device,1470,70,,1470,percent of total billed charges,All Other,1428,34,,1428,percent of total billed charges,Implant Device,1428,34,,1428,percent of total billed charges,Implant Device,1470,35,,1470,percent of total billed charges,Implant Device,1470,35,,1470,percent of total billed charges,Implant Device,1470,35,,1470,percent of total billed charges,Implant Device,1470,35,,1470,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1428,34,"If Charge > 2,000, then 34 percent",1428,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3108.01,
PARAGON P20-130-026S CANN SCREW 3.0X26MM,C1713,HCPCS,,79008838,CDM,278,RC,,,both,,,893,660.82,,,660.82,Other,150% of Medicare + 9.63% HCRA Surcharge,401.85,45,,401.85,percent of total billed charges,Critical Access Hospital RCC factor,303.62,34,,303.62,percent of total billed charges,Implant Device,303.62,34,,303.62,percent of total billed charges,Implant Device,303.62,34,,303.62,percent of total billed charges,Implant Device,303.62,34,,303.62,percent of total billed charges,Implant Device,303.62,34,,303.62,percent of total billed charges,Implant Device,442.04,,,442.04,Other,110% of Medicare,312.55,35,,312.55,percent of total billed charges,Implant Device,303.62,34,"Charges > $500, x 34%",303.62,percent of total billed charges,Implant Device,312.55,35,,312.55,percent of total billed charges,Implant Device,312.55,35,,312.55,percent of total billed charges,Implant Device,312.55,35,,312.55,percent of total billed charges,Implant Device,312.55,35,,312.55,percent of total billed charges,Implant Device,312.55,35,,312.55,percent of total billed charges,Implant Device,357.2,40,,357.2,percent of total billed charges,Implant Device,312.55,70,,312.55,percent of total billed charges,All Other,303.62,34,,303.62,percent of total billed charges,Implant Device,303.62,34,,303.62,percent of total billed charges,Implant Device,312.55,35,,312.55,percent of total billed charges,Implant Device,312.55,35,,312.55,percent of total billed charges,Implant Device,312.55,35,,312.55,percent of total billed charges,Implant Device,312.55,35,,312.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,660.82,
PARAGON P53-103-R003 MTP PLATE O LONG RT,C1713,HCPCS,,79008839,CDM,278,RC,,,both,,,6031,4462.96,,,4462.96,Other,150% of Medicare + 9.63% HCRA Surcharge,2713.95,45,,2713.95,percent of total billed charges,Critical Access Hospital RCC factor,2050.54,34,,2050.54,percent of total billed charges,Implant Device,2050.54,34,,2050.54,percent of total billed charges,Implant Device,2050.54,34,,2050.54,percent of total billed charges,Implant Device,2050.54,34,,2050.54,percent of total billed charges,Implant Device,2050.54,34,,2050.54,percent of total billed charges,Implant Device,2985.35,,,2985.35,Other,110% of Medicare,2110.85,35,,2110.85,percent of total billed charges,Implant Device,2050.54,34,"Charges > $500, x 34%",2050.54,percent of total billed charges,Implant Device,2110.85,35,,2110.85,percent of total billed charges,Implant Device,2110.85,35,,2110.85,percent of total billed charges,Implant Device,2110.85,35,,2110.85,percent of total billed charges,Implant Device,2110.85,35,,2110.85,percent of total billed charges,Implant Device,2110.85,35,,2110.85,percent of total billed charges,Implant Device,2412.4,40,,2412.4,percent of total billed charges,Implant Device,2110.85,70,,2110.85,percent of total billed charges,All Other,2050.54,34,,2050.54,percent of total billed charges,Implant Device,2050.54,34,,2050.54,percent of total billed charges,Implant Device,2110.85,35,,2110.85,percent of total billed charges,Implant Device,2110.85,35,,2110.85,percent of total billed charges,Implant Device,2110.85,35,,2110.85,percent of total billed charges,Implant Device,2110.85,35,,2110.85,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2050.54,34,"If Charge > 2,000, then 34 percent",2050.54,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4462.96,
STRYKER 1910-1272S SONICANCHOR 2.5X10MM,C1713,HCPCS,,79008847,CDM,278,RC,,,both,,,1734,1283.16,,,1283.16,Other,150% of Medicare + 9.63% HCRA Surcharge,780.3,45,,780.3,percent of total billed charges,Critical Access Hospital RCC factor,589.56,34,,589.56,percent of total billed charges,Implant Device,589.56,34,,589.56,percent of total billed charges,Implant Device,589.56,34,,589.56,percent of total billed charges,Implant Device,589.56,34,,589.56,percent of total billed charges,Implant Device,589.56,34,,589.56,percent of total billed charges,Implant Device,858.33,,,858.33,Other,110% of Medicare,606.9,35,,606.9,percent of total billed charges,Implant Device,589.56,34,"Charges > $500, x 34%",589.56,percent of total billed charges,Implant Device,606.9,35,,606.9,percent of total billed charges,Implant Device,606.9,35,,606.9,percent of total billed charges,Implant Device,606.9,35,,606.9,percent of total billed charges,Implant Device,606.9,35,,606.9,percent of total billed charges,Implant Device,606.9,35,,606.9,percent of total billed charges,Implant Device,693.6,40,,693.6,percent of total billed charges,Implant Device,606.9,70,,606.9,percent of total billed charges,All Other,589.56,34,,589.56,percent of total billed charges,Implant Device,589.56,34,,589.56,percent of total billed charges,Implant Device,606.9,35,,606.9,percent of total billed charges,Implant Device,606.9,35,,606.9,percent of total billed charges,Implant Device,606.9,35,,606.9,percent of total billed charges,Implant Device,606.9,35,,606.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1283.16,
PARAGON P50-053-3510 LOCK SCREW 3.5X10MM,C1713,HCPCS,,79008850,CDM,278,RC,,,both,,,880,651.2,,,651.2,Other,150% of Medicare + 9.63% HCRA Surcharge,396,45,,396,percent of total billed charges,Critical Access Hospital RCC factor,299.2,34,,299.2,percent of total billed charges,Implant Device,299.2,34,,299.2,percent of total billed charges,Implant Device,299.2,34,,299.2,percent of total billed charges,Implant Device,299.2,34,,299.2,percent of total billed charges,Implant Device,299.2,34,,299.2,percent of total billed charges,Implant Device,435.6,,,435.6,Other,110% of Medicare,308,35,,308,percent of total billed charges,Implant Device,299.2,34,"Charges > $500, x 34%",299.2,percent of total billed charges,Implant Device,308,35,,308,percent of total billed charges,Implant Device,308,35,,308,percent of total billed charges,Implant Device,308,35,,308,percent of total billed charges,Implant Device,308,35,,308,percent of total billed charges,Implant Device,308,35,,308,percent of total billed charges,Implant Device,352,40,,352,percent of total billed charges,Implant Device,308,70,,308,percent of total billed charges,All Other,299.2,34,,299.2,percent of total billed charges,Implant Device,299.2,34,,299.2,percent of total billed charges,Implant Device,308,35,,308,percent of total billed charges,Implant Device,308,35,,308,percent of total billed charges,Implant Device,308,35,,308,percent of total billed charges,Implant Device,308,35,,308,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,651.2,
STRYKER 657014 LOCK SCREW T10 2.7X14MM,C1713,HCPCS,,79008851,CDM,278,RC,,,both,,,539,398.86,,,398.86,Other,150% of Medicare + 9.63% HCRA Surcharge,242.55,45,,242.55,percent of total billed charges,Critical Access Hospital RCC factor,183.26,34,,183.26,percent of total billed charges,Implant Device,183.26,34,,183.26,percent of total billed charges,Implant Device,183.26,34,,183.26,percent of total billed charges,Implant Device,183.26,34,,183.26,percent of total billed charges,Implant Device,183.26,34,,183.26,percent of total billed charges,Implant Device,266.81,,,266.81,Other,110% of Medicare,188.65,35,,188.65,percent of total billed charges,Implant Device,183.26,34,"Charges > $500, x 34%",183.26,percent of total billed charges,Implant Device,188.65,35,,188.65,percent of total billed charges,Implant Device,188.65,35,,188.65,percent of total billed charges,Implant Device,188.65,35,,188.65,percent of total billed charges,Implant Device,188.65,35,,188.65,percent of total billed charges,Implant Device,188.65,35,,188.65,percent of total billed charges,Implant Device,215.6,40,,215.6,percent of total billed charges,Implant Device,188.65,70,,188.65,percent of total billed charges,All Other,183.26,34,,183.26,percent of total billed charges,Implant Device,183.26,34,,183.26,percent of total billed charges,Implant Device,188.65,35,,188.65,percent of total billed charges,Implant Device,188.65,35,,188.65,percent of total billed charges,Implant Device,188.65,35,,188.65,percent of total billed charges,Implant Device,188.65,35,,188.65,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,398.86,
STRYKER 657010 LOCK SCREW T10 2.7X10MM,C1713,HCPCS,,79008852,CDM,278,RC,,,both,,,539,398.86,,,398.86,Other,150% of Medicare + 9.63% HCRA Surcharge,242.55,45,,242.55,percent of total billed charges,Critical Access Hospital RCC factor,183.26,34,,183.26,percent of total billed charges,Implant Device,183.26,34,,183.26,percent of total billed charges,Implant Device,183.26,34,,183.26,percent of total billed charges,Implant Device,183.26,34,,183.26,percent of total billed charges,Implant Device,183.26,34,,183.26,percent of total billed charges,Implant Device,266.81,,,266.81,Other,110% of Medicare,188.65,35,,188.65,percent of total billed charges,Implant Device,183.26,34,"Charges > $500, x 34%",183.26,percent of total billed charges,Implant Device,188.65,35,,188.65,percent of total billed charges,Implant Device,188.65,35,,188.65,percent of total billed charges,Implant Device,188.65,35,,188.65,percent of total billed charges,Implant Device,188.65,35,,188.65,percent of total billed charges,Implant Device,188.65,35,,188.65,percent of total billed charges,Implant Device,215.6,40,,215.6,percent of total billed charges,Implant Device,188.65,70,,188.65,percent of total billed charges,All Other,183.26,34,,183.26,percent of total billed charges,Implant Device,183.26,34,,183.26,percent of total billed charges,Implant Device,188.65,35,,188.65,percent of total billed charges,Implant Device,188.65,35,,188.65,percent of total billed charges,Implant Device,188.65,35,,188.65,percent of total billed charges,Implant Device,188.65,35,,188.65,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,398.86,
MENTOR 354-9211 TISSUE EXPANDER 275CC,C1789,HCPCS,,79008853,CDM,278,RC,,,both,,,5085,3762.91,,,3762.91,Other,150% of Medicare + 9.63% HCRA Surcharge,2288.25,45,,2288.25,percent of total billed charges,Critical Access Hospital RCC factor,1728.9,34,,1728.9,percent of total billed charges,Implant Device,1728.9,34,,1728.9,percent of total billed charges,Implant Device,1728.9,34,,1728.9,percent of total billed charges,Implant Device,1728.9,34,,1728.9,percent of total billed charges,Implant Device,1728.9,34,,1728.9,percent of total billed charges,Implant Device,2517.08,,,2517.08,Other,110% of Medicare,1779.75,35,,1779.75,percent of total billed charges,Implant Device,1728.9,34,"Charges > $500, x 34%",1728.9,percent of total billed charges,Implant Device,1779.75,35,,1779.75,percent of total billed charges,Implant Device,1779.75,35,,1779.75,percent of total billed charges,Implant Device,1779.75,35,,1779.75,percent of total billed charges,Implant Device,1779.75,35,,1779.75,percent of total billed charges,Implant Device,1779.75,35,,1779.75,percent of total billed charges,Implant Device,2034,40,,2034,percent of total billed charges,Implant Device,1779.75,70,,1779.75,percent of total billed charges,All Other,1728.9,34,,1728.9,percent of total billed charges,Implant Device,1728.9,34,,1728.9,percent of total billed charges,Implant Device,1779.75,35,,1779.75,percent of total billed charges,Implant Device,1779.75,35,,1779.75,percent of total billed charges,Implant Device,1779.75,35,,1779.75,percent of total billed charges,Implant Device,1779.75,35,,1779.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1728.9,34,"If Charge > 2,000, then 34 percent",1728.9,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3762.91,
MTF HP1612 FLEX HD PLIABLE TISSUE-THICK,C1713,HCPCS,,79008854,CDM,278,RC,,,both,,,8343,6173.84,,,6173.84,Other,150% of Medicare + 9.63% HCRA Surcharge,3754.35,45,,3754.35,percent of total billed charges,Critical Access Hospital RCC factor,2836.62,34,,2836.62,percent of total billed charges,Implant Device,2836.62,34,,2836.62,percent of total billed charges,Implant Device,2836.62,34,,2836.62,percent of total billed charges,Implant Device,2836.62,34,,2836.62,percent of total billed charges,Implant Device,2836.62,34,,2836.62,percent of total billed charges,Implant Device,4129.79,,,4129.79,Other,110% of Medicare,2920.05,35,,2920.05,percent of total billed charges,Implant Device,2836.62,34,"Charges > $500, x 34%",2836.62,percent of total billed charges,Implant Device,2920.05,35,,2920.05,percent of total billed charges,Implant Device,2920.05,35,,2920.05,percent of total billed charges,Implant Device,2920.05,35,,2920.05,percent of total billed charges,Implant Device,2920.05,35,,2920.05,percent of total billed charges,Implant Device,2920.05,35,,2920.05,percent of total billed charges,Implant Device,3337.2,40,,3337.2,percent of total billed charges,Implant Device,2920.05,70,,2920.05,percent of total billed charges,All Other,2836.62,34,,2836.62,percent of total billed charges,Implant Device,2836.62,34,,2836.62,percent of total billed charges,Implant Device,2920.05,35,,2920.05,percent of total billed charges,Implant Device,2920.05,35,,2920.05,percent of total billed charges,Implant Device,2920.05,35,,2920.05,percent of total billed charges,Implant Device,2920.05,35,,2920.05,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2836.62,34,"If Charge > 2,000, then 34 percent",2836.62,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,6173.84,
STRYKER 657312 LOCKING SCREW 3.5X12MM,C1713,HCPCS,,79008855,CDM,278,RC,,,both,,,539,398.86,,,398.86,Other,150% of Medicare + 9.63% HCRA Surcharge,242.55,45,,242.55,percent of total billed charges,Critical Access Hospital RCC factor,183.26,34,,183.26,percent of total billed charges,Implant Device,183.26,34,,183.26,percent of total billed charges,Implant Device,183.26,34,,183.26,percent of total billed charges,Implant Device,183.26,34,,183.26,percent of total billed charges,Implant Device,183.26,34,,183.26,percent of total billed charges,Implant Device,266.81,,,266.81,Other,110% of Medicare,188.65,35,,188.65,percent of total billed charges,Implant Device,183.26,34,"Charges > $500, x 34%",183.26,percent of total billed charges,Implant Device,188.65,35,,188.65,percent of total billed charges,Implant Device,188.65,35,,188.65,percent of total billed charges,Implant Device,188.65,35,,188.65,percent of total billed charges,Implant Device,188.65,35,,188.65,percent of total billed charges,Implant Device,188.65,35,,188.65,percent of total billed charges,Implant Device,215.6,40,,215.6,percent of total billed charges,Implant Device,188.65,70,,188.65,percent of total billed charges,All Other,183.26,34,,183.26,percent of total billed charges,Implant Device,183.26,34,,183.26,percent of total billed charges,Implant Device,188.65,35,,188.65,percent of total billed charges,Implant Device,188.65,35,,188.65,percent of total billed charges,Implant Device,188.65,35,,188.65,percent of total billed charges,Implant Device,188.65,35,,188.65,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,398.86,
STRYKER 657116 NON LOCK SCREW 2.7X16MM,C1713,HCPCS,,79008856,CDM,278,RC,,,both,,,293,216.82,,,216.82,Other,150% of Medicare + 9.63% HCRA Surcharge,131.85,45,,131.85,percent of total billed charges,Critical Access Hospital RCC factor,99.62,34,,99.62,percent of total billed charges,Implant Device,99.62,34,,99.62,percent of total billed charges,Implant Device,99.62,34,,99.62,percent of total billed charges,Implant Device,99.62,34,,99.62,percent of total billed charges,Implant Device,99.62,34,,99.62,percent of total billed charges,Implant Device,145.04,,,145.04,Other,110% of Medicare,102.55,35,,102.55,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,102.55,35,,102.55,percent of total billed charges,Implant Device,102.55,35,,102.55,percent of total billed charges,Implant Device,102.55,35,,102.55,percent of total billed charges,Implant Device,102.55,35,,102.55,percent of total billed charges,Implant Device,102.55,35,,102.55,percent of total billed charges,Implant Device,117.2,40,,117.2,percent of total billed charges,Implant Device,102.55,70,,102.55,percent of total billed charges,All Other,99.62,34,,99.62,percent of total billed charges,Implant Device,99.62,34,,99.62,percent of total billed charges,Implant Device,102.55,35,,102.55,percent of total billed charges,Implant Device,102.55,35,,102.55,percent of total billed charges,Implant Device,102.55,35,,102.55,percent of total billed charges,Implant Device,102.55,35,,102.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,216.82,
STRYKER 657118 NON LOCK SCREW 2.7X18MM,C1713,HCPCS,,79008857,CDM,278,RC,,,both,,,294,217.56,,,217.56,Other,150% of Medicare + 9.63% HCRA Surcharge,132.3,45,,132.3,percent of total billed charges,Critical Access Hospital RCC factor,99.96,34,,99.96,percent of total billed charges,Implant Device,99.96,34,,99.96,percent of total billed charges,Implant Device,99.96,34,,99.96,percent of total billed charges,Implant Device,99.96,34,,99.96,percent of total billed charges,Implant Device,99.96,34,,99.96,percent of total billed charges,Implant Device,145.53,,,145.53,Other,110% of Medicare,102.9,35,,102.9,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,102.9,35,,102.9,percent of total billed charges,Implant Device,102.9,35,,102.9,percent of total billed charges,Implant Device,102.9,35,,102.9,percent of total billed charges,Implant Device,102.9,35,,102.9,percent of total billed charges,Implant Device,102.9,35,,102.9,percent of total billed charges,Implant Device,117.6,40,,117.6,percent of total billed charges,Implant Device,102.9,70,,102.9,percent of total billed charges,All Other,99.96,34,,99.96,percent of total billed charges,Implant Device,99.96,34,,99.96,percent of total billed charges,Implant Device,102.9,35,,102.9,percent of total billed charges,Implant Device,102.9,35,,102.9,percent of total billed charges,Implant Device,102.9,35,,102.9,percent of total billed charges,Implant Device,102.9,35,,102.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,217.56,
BIOMET 11-301333 MOD REV SYS SZ CX70MM,C1776,HCPCS,,79008859,CDM,278,RC,,,both,,,36210,26795.49,,,26795.49,Other,150% of Medicare + 9.63% HCRA Surcharge,16294.5,45,,16294.5,percent of total billed charges,Critical Access Hospital RCC factor,12311.4,34,,12311.4,percent of total billed charges,Implant Device,12311.4,34,,12311.4,percent of total billed charges,Implant Device,12311.4,34,,12311.4,percent of total billed charges,Implant Device,12311.4,34,,12311.4,percent of total billed charges,Implant Device,12311.4,34,,12311.4,percent of total billed charges,Implant Device,17923.95,,,17923.95,Other,110% of Medicare,12673.5,35,,12673.5,percent of total billed charges,Implant Device,12311.4,34,"Charges > $500, x 34%",12311.4,percent of total billed charges,Implant Device,12673.5,35,,12673.5,percent of total billed charges,Implant Device,12673.5,35,,12673.5,percent of total billed charges,Implant Device,12673.5,35,,12673.5,percent of total billed charges,Implant Device,12673.5,35,,12673.5,percent of total billed charges,Implant Device,12673.5,35,,12673.5,percent of total billed charges,Implant Device,14484,40,,14484,percent of total billed charges,Implant Device,12673.5,70,,12673.5,percent of total billed charges,All Other,12311.4,34,,12311.4,percent of total billed charges,Implant Device,12311.4,34,,12311.4,percent of total billed charges,Implant Device,12673.5,35,,12673.5,percent of total billed charges,Implant Device,12673.5,35,,12673.5,percent of total billed charges,Implant Device,12673.5,35,,12673.5,percent of total billed charges,Implant Device,12673.5,35,,12673.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,12311.4,34,"If Charge > 2,000, then 34 percent",12311.4,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,26795.49,
BIOMET 11-363663 MOD HEAD COMP +3MM NECK,C1776,HCPCS,,79008860,CDM,278,RC,,,both,,,5370,3973.81,,,3973.81,Other,150% of Medicare + 9.63% HCRA Surcharge,2416.5,45,,2416.5,percent of total billed charges,Critical Access Hospital RCC factor,1825.8,34,,1825.8,percent of total billed charges,Implant Device,1825.8,34,,1825.8,percent of total billed charges,Implant Device,1825.8,34,,1825.8,percent of total billed charges,Implant Device,1825.8,34,,1825.8,percent of total billed charges,Implant Device,1825.8,34,,1825.8,percent of total billed charges,Implant Device,2658.15,,,2658.15,Other,110% of Medicare,1879.5,35,,1879.5,percent of total billed charges,Implant Device,1825.8,34,"Charges > $500, x 34%",1825.8,percent of total billed charges,Implant Device,1879.5,35,,1879.5,percent of total billed charges,Implant Device,1879.5,35,,1879.5,percent of total billed charges,Implant Device,1879.5,35,,1879.5,percent of total billed charges,Implant Device,1879.5,35,,1879.5,percent of total billed charges,Implant Device,1879.5,35,,1879.5,percent of total billed charges,Implant Device,2148,40,,2148,percent of total billed charges,Implant Device,1879.5,70,,1879.5,percent of total billed charges,All Other,1825.8,34,,1825.8,percent of total billed charges,Implant Device,1825.8,34,,1825.8,percent of total billed charges,Implant Device,1879.5,35,,1879.5,percent of total billed charges,Implant Device,1879.5,35,,1879.5,percent of total billed charges,Implant Device,1879.5,35,,1879.5,percent of total billed charges,Implant Device,1879.5,35,,1879.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1825.8,34,"If Charge > 2,000, then 34 percent",1825.8,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3973.81,
BIOMET 800-4001 BONE VOID FILLER 10CC,C1713,HCPCS,,79008861,CDM,278,RC,,,both,,,13620,10078.83,,,10078.83,Other,150% of Medicare + 9.63% HCRA Surcharge,6129,45,,6129,percent of total billed charges,Critical Access Hospital RCC factor,4630.8,34,,4630.8,percent of total billed charges,Implant Device,4630.8,34,,4630.8,percent of total billed charges,Implant Device,4630.8,34,,4630.8,percent of total billed charges,Implant Device,4630.8,34,,4630.8,percent of total billed charges,Implant Device,4630.8,34,,4630.8,percent of total billed charges,Implant Device,6741.9,,,6741.9,Other,110% of Medicare,4767,35,,4767,percent of total billed charges,Implant Device,4630.8,34,"Charges > $500, x 34%",4630.8,percent of total billed charges,Implant Device,4767,35,,4767,percent of total billed charges,Implant Device,4767,35,,4767,percent of total billed charges,Implant Device,4767,35,,4767,percent of total billed charges,Implant Device,4767,35,,4767,percent of total billed charges,Implant Device,4767,35,,4767,percent of total billed charges,Implant Device,5448,40,,5448,percent of total billed charges,Implant Device,4767,70,,4767,percent of total billed charges,All Other,4630.8,34,,4630.8,percent of total billed charges,Implant Device,4630.8,34,,4630.8,percent of total billed charges,Implant Device,4767,35,,4767,percent of total billed charges,Implant Device,4767,35,,4767,percent of total billed charges,Implant Device,4767,35,,4767,percent of total billed charges,Implant Device,4767,35,,4767,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,4630.8,34,"If Charge > 2,000, then 34 percent",4630.8,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,10078.83,
BIOMET 800-4000 BONE VOID FILLER 5CC,C1713,HCPCS,,79008862,CDM,278,RC,,,both,,,6810,5039.42,,,5039.42,Other,150% of Medicare + 9.63% HCRA Surcharge,3064.5,45,,3064.5,percent of total billed charges,Critical Access Hospital RCC factor,2315.4,34,,2315.4,percent of total billed charges,Implant Device,2315.4,34,,2315.4,percent of total billed charges,Implant Device,2315.4,34,,2315.4,percent of total billed charges,Implant Device,2315.4,34,,2315.4,percent of total billed charges,Implant Device,2315.4,34,,2315.4,percent of total billed charges,Implant Device,3370.95,,,3370.95,Other,110% of Medicare,2383.5,35,,2383.5,percent of total billed charges,Implant Device,2315.4,34,"Charges > $500, x 34%",2315.4,percent of total billed charges,Implant Device,2383.5,35,,2383.5,percent of total billed charges,Implant Device,2383.5,35,,2383.5,percent of total billed charges,Implant Device,2383.5,35,,2383.5,percent of total billed charges,Implant Device,2383.5,35,,2383.5,percent of total billed charges,Implant Device,2383.5,35,,2383.5,percent of total billed charges,Implant Device,2724,40,,2724,percent of total billed charges,Implant Device,2383.5,70,,2383.5,percent of total billed charges,All Other,2315.4,34,,2315.4,percent of total billed charges,Implant Device,2315.4,34,,2315.4,percent of total billed charges,Implant Device,2383.5,35,,2383.5,percent of total billed charges,Implant Device,2383.5,35,,2383.5,percent of total billed charges,Implant Device,2383.5,35,,2383.5,percent of total billed charges,Implant Device,2383.5,35,,2383.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2315.4,34,"If Charge > 2,000, then 34 percent",2315.4,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5039.42,
BIOMET 348012 CALCIGEN-S BONE GRAFT 10GM,C1713,HCPCS,,79008865,CDM,278,RC,,,both,,,2250,1665.01,,,1665.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1012.5,45,,1012.5,percent of total billed charges,Critical Access Hospital RCC factor,765,34,,765,percent of total billed charges,Implant Device,765,34,,765,percent of total billed charges,Implant Device,765,34,,765,percent of total billed charges,Implant Device,765,34,,765,percent of total billed charges,Implant Device,765,34,,765,percent of total billed charges,Implant Device,1113.75,,,1113.75,Other,110% of Medicare,787.5,35,,787.5,percent of total billed charges,Implant Device,765,34,"Charges > $500, x 34%",765,percent of total billed charges,Implant Device,787.5,35,,787.5,percent of total billed charges,Implant Device,787.5,35,,787.5,percent of total billed charges,Implant Device,787.5,35,,787.5,percent of total billed charges,Implant Device,787.5,35,,787.5,percent of total billed charges,Implant Device,787.5,35,,787.5,percent of total billed charges,Implant Device,900,40,,900,percent of total billed charges,Implant Device,787.5,70,,787.5,percent of total billed charges,All Other,765,34,,765,percent of total billed charges,Implant Device,765,34,,765,percent of total billed charges,Implant Device,787.5,35,,787.5,percent of total billed charges,Implant Device,787.5,35,,787.5,percent of total billed charges,Implant Device,787.5,35,,787.5,percent of total billed charges,Implant Device,787.5,35,,787.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,765,34,"If Charge > 2,000, then 34 percent",765,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1665.01,
ZIMMER 00-8755-018-36 OBLIQUE LINER 36MM,C1776,HCPCS,,79008866,CDM,278,RC,,,both,,,3705,2741.71,,,2741.71,Other,150% of Medicare + 9.63% HCRA Surcharge,1667.25,45,,1667.25,percent of total billed charges,Critical Access Hospital RCC factor,1259.7,34,,1259.7,percent of total billed charges,Implant Device,1259.7,34,,1259.7,percent of total billed charges,Implant Device,1259.7,34,,1259.7,percent of total billed charges,Implant Device,1259.7,34,,1259.7,percent of total billed charges,Implant Device,1259.7,34,,1259.7,percent of total billed charges,Implant Device,1833.98,,,1833.98,Other,110% of Medicare,1296.75,35,,1296.75,percent of total billed charges,Implant Device,1259.7,34,"Charges > $500, x 34%",1259.7,percent of total billed charges,Implant Device,1296.75,35,,1296.75,percent of total billed charges,Implant Device,1296.75,35,,1296.75,percent of total billed charges,Implant Device,1296.75,35,,1296.75,percent of total billed charges,Implant Device,1296.75,35,,1296.75,percent of total billed charges,Implant Device,1296.75,35,,1296.75,percent of total billed charges,Implant Device,1482,40,,1482,percent of total billed charges,Implant Device,1296.75,70,,1296.75,percent of total billed charges,All Other,1259.7,34,,1259.7,percent of total billed charges,Implant Device,1259.7,34,,1259.7,percent of total billed charges,Implant Device,1296.75,35,,1296.75,percent of total billed charges,Implant Device,1296.75,35,,1296.75,percent of total billed charges,Implant Device,1296.75,35,,1296.75,percent of total billed charges,Implant Device,1296.75,35,,1296.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1259.7,34,"If Charge > 2,000, then 34 percent",1259.7,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2741.71,
ZIMMER 00-8757-068-01 ACETAB SHELL 68MM,C1776,HCPCS,,79008867,CDM,278,RC,,,both,,,4145,3067.31,,,3067.31,Other,150% of Medicare + 9.63% HCRA Surcharge,1865.25,45,,1865.25,percent of total billed charges,Critical Access Hospital RCC factor,1409.3,34,,1409.3,percent of total billed charges,Implant Device,1409.3,34,,1409.3,percent of total billed charges,Implant Device,1409.3,34,,1409.3,percent of total billed charges,Implant Device,1409.3,34,,1409.3,percent of total billed charges,Implant Device,1409.3,34,,1409.3,percent of total billed charges,Implant Device,2051.78,,,2051.78,Other,110% of Medicare,1450.75,35,,1450.75,percent of total billed charges,Implant Device,1409.3,34,"Charges > $500, x 34%",1409.3,percent of total billed charges,Implant Device,1450.75,35,,1450.75,percent of total billed charges,Implant Device,1450.75,35,,1450.75,percent of total billed charges,Implant Device,1450.75,35,,1450.75,percent of total billed charges,Implant Device,1450.75,35,,1450.75,percent of total billed charges,Implant Device,1450.75,35,,1450.75,percent of total billed charges,Implant Device,1658,40,,1658,percent of total billed charges,Implant Device,1450.75,70,,1450.75,percent of total billed charges,All Other,1409.3,34,,1409.3,percent of total billed charges,Implant Device,1409.3,34,,1409.3,percent of total billed charges,Implant Device,1450.75,35,,1450.75,percent of total billed charges,Implant Device,1450.75,35,,1450.75,percent of total billed charges,Implant Device,1450.75,35,,1450.75,percent of total billed charges,Implant Device,1450.75,35,,1450.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1409.3,34,"If Charge > 2,000, then 34 percent",1409.3,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3067.31,
DEPUY 1035-56-000 BIPOLAR HEAD 28MM,C1776,HCPCS,,79008869,CDM,278,RC,,,both,,,4030,2982.21,,,2982.21,Other,150% of Medicare + 9.63% HCRA Surcharge,1813.5,45,,1813.5,percent of total billed charges,Critical Access Hospital RCC factor,1370.2,34,,1370.2,percent of total billed charges,Implant Device,1370.2,34,,1370.2,percent of total billed charges,Implant Device,1370.2,34,,1370.2,percent of total billed charges,Implant Device,1370.2,34,,1370.2,percent of total billed charges,Implant Device,1370.2,34,,1370.2,percent of total billed charges,Implant Device,1994.85,,,1994.85,Other,110% of Medicare,1410.5,35,,1410.5,percent of total billed charges,Implant Device,1370.2,34,"Charges > $500, x 34%",1370.2,percent of total billed charges,Implant Device,1410.5,35,,1410.5,percent of total billed charges,Implant Device,1410.5,35,,1410.5,percent of total billed charges,Implant Device,1410.5,35,,1410.5,percent of total billed charges,Implant Device,1410.5,35,,1410.5,percent of total billed charges,Implant Device,1410.5,35,,1410.5,percent of total billed charges,Implant Device,1612,40,,1612,percent of total billed charges,Implant Device,1410.5,70,,1410.5,percent of total billed charges,All Other,1370.2,34,,1370.2,percent of total billed charges,Implant Device,1370.2,34,,1370.2,percent of total billed charges,Implant Device,1410.5,35,,1410.5,percent of total billed charges,Implant Device,1410.5,35,,1410.5,percent of total billed charges,Implant Device,1410.5,35,,1410.5,percent of total billed charges,Implant Device,1410.5,35,,1410.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1370.2,34,"If Charge > 2,000, then 34 percent",1370.2,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2982.21,
WRIGHT 5820MPXIR CROSSCHECK RT,C1713,HCPCS,,79008870,CDM,278,RC,,,both,,,9330,6904.22,,,6904.22,Other,150% of Medicare + 9.63% HCRA Surcharge,4198.5,45,,4198.5,percent of total billed charges,Critical Access Hospital RCC factor,3172.2,34,,3172.2,percent of total billed charges,Implant Device,3172.2,34,,3172.2,percent of total billed charges,Implant Device,3172.2,34,,3172.2,percent of total billed charges,Implant Device,3172.2,34,,3172.2,percent of total billed charges,Implant Device,3172.2,34,,3172.2,percent of total billed charges,Implant Device,4618.35,,,4618.35,Other,110% of Medicare,3265.5,35,,3265.5,percent of total billed charges,Implant Device,3172.2,34,"Charges > $500, x 34%",3172.2,percent of total billed charges,Implant Device,3265.5,35,,3265.5,percent of total billed charges,Implant Device,3265.5,35,,3265.5,percent of total billed charges,Implant Device,3265.5,35,,3265.5,percent of total billed charges,Implant Device,3265.5,35,,3265.5,percent of total billed charges,Implant Device,3265.5,35,,3265.5,percent of total billed charges,Implant Device,3732,40,,3732,percent of total billed charges,Implant Device,3265.5,70,,3265.5,percent of total billed charges,All Other,3172.2,34,,3172.2,percent of total billed charges,Implant Device,3172.2,34,,3172.2,percent of total billed charges,Implant Device,3265.5,35,,3265.5,percent of total billed charges,Implant Device,3265.5,35,,3265.5,percent of total billed charges,Implant Device,3265.5,35,,3265.5,percent of total billed charges,Implant Device,3265.5,35,,3265.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3172.2,34,"If Charge > 2,000, then 34 percent",3172.2,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,6904.22,
WRIGHT 588003518 SCREW 2.5LX18MM,C1713,HCPCS,,79008871,CDM,278,RC,,,both,,,1317,974.58,,,974.58,Other,150% of Medicare + 9.63% HCRA Surcharge,592.65,45,,592.65,percent of total billed charges,Critical Access Hospital RCC factor,447.78,34,,447.78,percent of total billed charges,Implant Device,447.78,34,,447.78,percent of total billed charges,Implant Device,447.78,34,,447.78,percent of total billed charges,Implant Device,447.78,34,,447.78,percent of total billed charges,Implant Device,447.78,34,,447.78,percent of total billed charges,Implant Device,651.92,,,651.92,Other,110% of Medicare,460.95,35,,460.95,percent of total billed charges,Implant Device,447.78,34,"Charges > $500, x 34%",447.78,percent of total billed charges,Implant Device,460.95,35,,460.95,percent of total billed charges,Implant Device,460.95,35,,460.95,percent of total billed charges,Implant Device,460.95,35,,460.95,percent of total billed charges,Implant Device,460.95,35,,460.95,percent of total billed charges,Implant Device,460.95,35,,460.95,percent of total billed charges,Implant Device,526.8,40,,526.8,percent of total billed charges,Implant Device,460.95,70,,460.95,percent of total billed charges,All Other,447.78,34,,447.78,percent of total billed charges,Implant Device,447.78,34,,447.78,percent of total billed charges,Implant Device,460.95,35,,460.95,percent of total billed charges,Implant Device,460.95,35,,460.95,percent of total billed charges,Implant Device,460.95,35,,460.95,percent of total billed charges,Implant Device,460.95,35,,460.95,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,974.58,
WRIGHT 5820X3526 SCREW 3.5X26MM,C1713,HCPCS,,79008872,CDM,278,RC,,,both,,,1254,927.96,,,927.96,Other,150% of Medicare + 9.63% HCRA Surcharge,564.3,45,,564.3,percent of total billed charges,Critical Access Hospital RCC factor,426.36,34,,426.36,percent of total billed charges,Implant Device,426.36,34,,426.36,percent of total billed charges,Implant Device,426.36,34,,426.36,percent of total billed charges,Implant Device,426.36,34,,426.36,percent of total billed charges,Implant Device,426.36,34,,426.36,percent of total billed charges,Implant Device,620.73,,,620.73,Other,110% of Medicare,438.9,35,,438.9,percent of total billed charges,Implant Device,426.36,34,"Charges > $500, x 34%",426.36,percent of total billed charges,Implant Device,438.9,35,,438.9,percent of total billed charges,Implant Device,438.9,35,,438.9,percent of total billed charges,Implant Device,438.9,35,,438.9,percent of total billed charges,Implant Device,438.9,35,,438.9,percent of total billed charges,Implant Device,438.9,35,,438.9,percent of total billed charges,Implant Device,501.6,40,,501.6,percent of total billed charges,Implant Device,438.9,70,,438.9,percent of total billed charges,All Other,426.36,34,,426.36,percent of total billed charges,Implant Device,426.36,34,,426.36,percent of total billed charges,Implant Device,438.9,35,,438.9,percent of total billed charges,Implant Device,438.9,35,,438.9,percent of total billed charges,Implant Device,438.9,35,,438.9,percent of total billed charges,Implant Device,438.9,35,,438.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,927.96,
STRYKER 604742 4.0X42MM ASNIS CANN SCREW,C1713,HCPCS,,79008876,CDM,278,RC,,,both,,,824,609.76,,,609.76,Other,150% of Medicare + 9.63% HCRA Surcharge,370.8,45,,370.8,percent of total billed charges,Critical Access Hospital RCC factor,280.16,34,,280.16,percent of total billed charges,Implant Device,280.16,34,,280.16,percent of total billed charges,Implant Device,280.16,34,,280.16,percent of total billed charges,Implant Device,280.16,34,,280.16,percent of total billed charges,Implant Device,280.16,34,,280.16,percent of total billed charges,Implant Device,407.88,,,407.88,Other,110% of Medicare,288.4,35,,288.4,percent of total billed charges,Implant Device,280.16,34,"Charges > $500, x 34%",280.16,percent of total billed charges,Implant Device,288.4,35,,288.4,percent of total billed charges,Implant Device,288.4,35,,288.4,percent of total billed charges,Implant Device,288.4,35,,288.4,percent of total billed charges,Implant Device,288.4,35,,288.4,percent of total billed charges,Implant Device,288.4,35,,288.4,percent of total billed charges,Implant Device,329.6,40,,329.6,percent of total billed charges,Implant Device,288.4,70,,288.4,percent of total billed charges,All Other,280.16,34,,280.16,percent of total billed charges,Implant Device,280.16,34,,280.16,percent of total billed charges,Implant Device,288.4,35,,288.4,percent of total billed charges,Implant Device,288.4,35,,288.4,percent of total billed charges,Implant Device,288.4,35,,288.4,percent of total billed charges,Implant Device,288.4,35,,288.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,609.76,
STRYKER 604746 4.0X46MM ASNIS CANN SCREW,C1713,HCPCS,,79008877,CDM,278,RC,,,both,,,824,609.76,,,609.76,Other,150% of Medicare + 9.63% HCRA Surcharge,370.8,45,,370.8,percent of total billed charges,Critical Access Hospital RCC factor,280.16,34,,280.16,percent of total billed charges,Implant Device,280.16,34,,280.16,percent of total billed charges,Implant Device,280.16,34,,280.16,percent of total billed charges,Implant Device,280.16,34,,280.16,percent of total billed charges,Implant Device,280.16,34,,280.16,percent of total billed charges,Implant Device,407.88,,,407.88,Other,110% of Medicare,288.4,35,,288.4,percent of total billed charges,Implant Device,280.16,34,"Charges > $500, x 34%",280.16,percent of total billed charges,Implant Device,288.4,35,,288.4,percent of total billed charges,Implant Device,288.4,35,,288.4,percent of total billed charges,Implant Device,288.4,35,,288.4,percent of total billed charges,Implant Device,288.4,35,,288.4,percent of total billed charges,Implant Device,288.4,35,,288.4,percent of total billed charges,Implant Device,329.6,40,,329.6,percent of total billed charges,Implant Device,288.4,70,,288.4,percent of total billed charges,All Other,280.16,34,,280.16,percent of total billed charges,Implant Device,280.16,34,,280.16,percent of total billed charges,Implant Device,288.4,35,,288.4,percent of total billed charges,Implant Device,288.4,35,,288.4,percent of total billed charges,Implant Device,288.4,35,,288.4,percent of total billed charges,Implant Device,288.4,35,,288.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,609.76,
MEDTRONIC 6950315 SET SCREW,C1713,HCPCS,,79008879,CDM,278,RC,,,both,,,230,170.2,,,170.2,Other,150% of Medicare + 9.63% HCRA Surcharge,103.5,45,,103.5,percent of total billed charges,Critical Access Hospital RCC factor,78.2,34,,78.2,percent of total billed charges,Implant Device,78.2,34,,78.2,percent of total billed charges,Implant Device,78.2,34,,78.2,percent of total billed charges,Implant Device,78.2,34,,78.2,percent of total billed charges,Implant Device,78.2,34,,78.2,percent of total billed charges,Implant Device,113.85,,,113.85,Other,110% of Medicare,80.5,35,,80.5,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,80.5,35,,80.5,percent of total billed charges,Implant Device,80.5,35,,80.5,percent of total billed charges,Implant Device,80.5,35,,80.5,percent of total billed charges,Implant Device,80.5,35,,80.5,percent of total billed charges,Implant Device,80.5,35,,80.5,percent of total billed charges,Implant Device,92,40,,92,percent of total billed charges,Implant Device,80.5,70,,80.5,percent of total billed charges,All Other,78.2,34,,78.2,percent of total billed charges,Implant Device,78.2,34,,78.2,percent of total billed charges,Implant Device,80.5,35,,80.5,percent of total billed charges,Implant Device,80.5,35,,80.5,percent of total billed charges,Implant Device,80.5,35,,80.5,percent of total billed charges,Implant Device,80.5,35,,80.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,170.2,
MEDTRONIC 7753770 70MM VENTEX ROD,C1713,HCPCS,,79008880,CDM,278,RC,,,both,,,600,444,,,444,Other,150% of Medicare + 9.63% HCRA Surcharge,270,45,,270,percent of total billed charges,Critical Access Hospital RCC factor,204,34,,204,percent of total billed charges,Implant Device,204,34,,204,percent of total billed charges,Implant Device,204,34,,204,percent of total billed charges,Implant Device,204,34,,204,percent of total billed charges,Implant Device,204,34,,204,percent of total billed charges,Implant Device,297,,,297,Other,110% of Medicare,210,35,,210,percent of total billed charges,Implant Device,204,34,"Charges > $500, x 34%",204,percent of total billed charges,Implant Device,210,35,,210,percent of total billed charges,Implant Device,210,35,,210,percent of total billed charges,Implant Device,210,35,,210,percent of total billed charges,Implant Device,210,35,,210,percent of total billed charges,Implant Device,210,35,,210,percent of total billed charges,Implant Device,240,40,,240,percent of total billed charges,Implant Device,210,70,,210,percent of total billed charges,All Other,204,34,,204,percent of total billed charges,Implant Device,204,34,,204,percent of total billed charges,Implant Device,210,35,,210,percent of total billed charges,Implant Device,210,35,,210,percent of total billed charges,Implant Device,210,35,,210,percent of total billed charges,Implant Device,210,35,,210,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,444,
MEDTRONIC 6958714 3.5X14MM SCREWS,C1713,HCPCS,,79008881,CDM,278,RC,,,both,,,1823,1349.02,,,1349.02,Other,150% of Medicare + 9.63% HCRA Surcharge,820.35,45,,820.35,percent of total billed charges,Critical Access Hospital RCC factor,619.82,34,,619.82,percent of total billed charges,Implant Device,619.82,34,,619.82,percent of total billed charges,Implant Device,619.82,34,,619.82,percent of total billed charges,Implant Device,619.82,34,,619.82,percent of total billed charges,Implant Device,619.82,34,,619.82,percent of total billed charges,Implant Device,902.39,,,902.39,Other,110% of Medicare,638.05,35,,638.05,percent of total billed charges,Implant Device,619.82,34,"Charges > $500, x 34%",619.82,percent of total billed charges,Implant Device,638.05,35,,638.05,percent of total billed charges,Implant Device,638.05,35,,638.05,percent of total billed charges,Implant Device,638.05,35,,638.05,percent of total billed charges,Implant Device,638.05,35,,638.05,percent of total billed charges,Implant Device,638.05,35,,638.05,percent of total billed charges,Implant Device,729.2,40,,729.2,percent of total billed charges,Implant Device,638.05,70,,638.05,percent of total billed charges,All Other,619.82,34,,619.82,percent of total billed charges,Implant Device,619.82,34,,619.82,percent of total billed charges,Implant Device,638.05,35,,638.05,percent of total billed charges,Implant Device,638.05,35,,638.05,percent of total billed charges,Implant Device,638.05,35,,638.05,percent of total billed charges,Implant Device,638.05,35,,638.05,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1349.02,
MEDTRONIC 7753780 80MM VENTEX ROD,C1713,HCPCS,,79008883,CDM,278,RC,,,both,,,600,444,,,444,Other,150% of Medicare + 9.63% HCRA Surcharge,270,45,,270,percent of total billed charges,Critical Access Hospital RCC factor,204,34,,204,percent of total billed charges,Implant Device,204,34,,204,percent of total billed charges,Implant Device,204,34,,204,percent of total billed charges,Implant Device,204,34,,204,percent of total billed charges,Implant Device,204,34,,204,percent of total billed charges,Implant Device,297,,,297,Other,110% of Medicare,210,35,,210,percent of total billed charges,Implant Device,204,34,"Charges > $500, x 34%",204,percent of total billed charges,Implant Device,210,35,,210,percent of total billed charges,Implant Device,210,35,,210,percent of total billed charges,Implant Device,210,35,,210,percent of total billed charges,Implant Device,210,35,,210,percent of total billed charges,Implant Device,210,35,,210,percent of total billed charges,Implant Device,240,40,,240,percent of total billed charges,Implant Device,210,70,,210,percent of total billed charges,All Other,204,34,,204,percent of total billed charges,Implant Device,204,34,,204,percent of total billed charges,Implant Device,210,35,,210,percent of total billed charges,Implant Device,210,35,,210,percent of total billed charges,Implant Device,210,35,,210,percent of total billed charges,Implant Device,210,35,,210,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,444,
MEDTRONIC 6958712 3.5X12MM SCREW,C1713,HCPCS,,79008884,CDM,278,RC,,,both,,,1823,1349.02,,,1349.02,Other,150% of Medicare + 9.63% HCRA Surcharge,820.35,45,,820.35,percent of total billed charges,Critical Access Hospital RCC factor,619.82,34,,619.82,percent of total billed charges,Implant Device,619.82,34,,619.82,percent of total billed charges,Implant Device,619.82,34,,619.82,percent of total billed charges,Implant Device,619.82,34,,619.82,percent of total billed charges,Implant Device,619.82,34,,619.82,percent of total billed charges,Implant Device,902.39,,,902.39,Other,110% of Medicare,638.05,35,,638.05,percent of total billed charges,Implant Device,619.82,34,"Charges > $500, x 34%",619.82,percent of total billed charges,Implant Device,638.05,35,,638.05,percent of total billed charges,Implant Device,638.05,35,,638.05,percent of total billed charges,Implant Device,638.05,35,,638.05,percent of total billed charges,Implant Device,638.05,35,,638.05,percent of total billed charges,Implant Device,638.05,35,,638.05,percent of total billed charges,Implant Device,729.2,40,,729.2,percent of total billed charges,Implant Device,638.05,70,,638.05,percent of total billed charges,All Other,619.82,34,,619.82,percent of total billed charges,Implant Device,619.82,34,,619.82,percent of total billed charges,Implant Device,638.05,35,,638.05,percent of total billed charges,Implant Device,638.05,35,,638.05,percent of total billed charges,Implant Device,638.05,35,,638.05,percent of total billed charges,Implant Device,638.05,35,,638.05,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1349.02,
MEDTRONIC 7752536 MD CROSSLINK,C1713,HCPCS,,79008885,CDM,278,RC,,,both,,,2100,1554.01,,,1554.01,Other,150% of Medicare + 9.63% HCRA Surcharge,945,45,,945,percent of total billed charges,Critical Access Hospital RCC factor,714,34,,714,percent of total billed charges,Implant Device,714,34,,714,percent of total billed charges,Implant Device,714,34,,714,percent of total billed charges,Implant Device,714,34,,714,percent of total billed charges,Implant Device,714,34,,714,percent of total billed charges,Implant Device,1039.5,,,1039.5,Other,110% of Medicare,735,35,,735,percent of total billed charges,Implant Device,714,34,"Charges > $500, x 34%",714,percent of total billed charges,Implant Device,735,35,,735,percent of total billed charges,Implant Device,735,35,,735,percent of total billed charges,Implant Device,735,35,,735,percent of total billed charges,Implant Device,735,35,,735,percent of total billed charges,Implant Device,735,35,,735,percent of total billed charges,Implant Device,840,40,,840,percent of total billed charges,Implant Device,735,70,,735,percent of total billed charges,All Other,714,34,,714,percent of total billed charges,Implant Device,714,34,,714,percent of total billed charges,Implant Device,735,35,,735,percent of total billed charges,Implant Device,735,35,,735,percent of total billed charges,Implant Device,735,35,,735,percent of total billed charges,Implant Device,735,35,,735,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,714,34,"If Charge > 2,000, then 34 percent",714,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1554.01,
STRYKER 40-27614 LOCKING SCREW 2.7X14MM,C1713,HCPCS,,79008886,CDM,278,RC,,,both,,,732,541.68,,,541.68,Other,150% of Medicare + 9.63% HCRA Surcharge,329.4,45,,329.4,percent of total billed charges,Critical Access Hospital RCC factor,248.88,34,,248.88,percent of total billed charges,Implant Device,248.88,34,,248.88,percent of total billed charges,Implant Device,248.88,34,,248.88,percent of total billed charges,Implant Device,248.88,34,,248.88,percent of total billed charges,Implant Device,248.88,34,,248.88,percent of total billed charges,Implant Device,362.34,,,362.34,Other,110% of Medicare,256.2,35,,256.2,percent of total billed charges,Implant Device,248.88,34,"Charges > $500, x 34%",248.88,percent of total billed charges,Implant Device,256.2,35,,256.2,percent of total billed charges,Implant Device,256.2,35,,256.2,percent of total billed charges,Implant Device,256.2,35,,256.2,percent of total billed charges,Implant Device,256.2,35,,256.2,percent of total billed charges,Implant Device,256.2,35,,256.2,percent of total billed charges,Implant Device,292.8,40,,292.8,percent of total billed charges,Implant Device,256.2,70,,256.2,percent of total billed charges,All Other,248.88,34,,248.88,percent of total billed charges,Implant Device,248.88,34,,248.88,percent of total billed charges,Implant Device,256.2,35,,256.2,percent of total billed charges,Implant Device,256.2,35,,256.2,percent of total billed charges,Implant Device,256.2,35,,256.2,percent of total billed charges,Implant Device,256.2,35,,256.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,541.68,
STRYKER 40-27610 LOCKING SCREW 2.7X10MM,C1713,HCPCS,,79008887,CDM,278,RC,,,both,,,732,541.68,,,541.68,Other,150% of Medicare + 9.63% HCRA Surcharge,329.4,45,,329.4,percent of total billed charges,Critical Access Hospital RCC factor,248.88,34,,248.88,percent of total billed charges,Implant Device,248.88,34,,248.88,percent of total billed charges,Implant Device,248.88,34,,248.88,percent of total billed charges,Implant Device,248.88,34,,248.88,percent of total billed charges,Implant Device,248.88,34,,248.88,percent of total billed charges,Implant Device,362.34,,,362.34,Other,110% of Medicare,256.2,35,,256.2,percent of total billed charges,Implant Device,248.88,34,"Charges > $500, x 34%",248.88,percent of total billed charges,Implant Device,256.2,35,,256.2,percent of total billed charges,Implant Device,256.2,35,,256.2,percent of total billed charges,Implant Device,256.2,35,,256.2,percent of total billed charges,Implant Device,256.2,35,,256.2,percent of total billed charges,Implant Device,256.2,35,,256.2,percent of total billed charges,Implant Device,292.8,40,,292.8,percent of total billed charges,Implant Device,256.2,70,,256.2,percent of total billed charges,All Other,248.88,34,,248.88,percent of total billed charges,Implant Device,248.88,34,,248.88,percent of total billed charges,Implant Device,256.2,35,,256.2,percent of total billed charges,Implant Device,256.2,35,,256.2,percent of total billed charges,Implant Device,256.2,35,,256.2,percent of total billed charges,Implant Device,256.2,35,,256.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,541.68,
STRYKER 657112 BONE SCREW 2.7X12MM,C1713,HCPCS,,79008890,CDM,278,RC,,,both,,,294,217.56,,,217.56,Other,150% of Medicare + 9.63% HCRA Surcharge,132.3,45,,132.3,percent of total billed charges,Critical Access Hospital RCC factor,99.96,34,,99.96,percent of total billed charges,Implant Device,99.96,34,,99.96,percent of total billed charges,Implant Device,99.96,34,,99.96,percent of total billed charges,Implant Device,99.96,34,,99.96,percent of total billed charges,Implant Device,99.96,34,,99.96,percent of total billed charges,Implant Device,145.53,,,145.53,Other,110% of Medicare,102.9,35,,102.9,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,102.9,35,,102.9,percent of total billed charges,Implant Device,102.9,35,,102.9,percent of total billed charges,Implant Device,102.9,35,,102.9,percent of total billed charges,Implant Device,102.9,35,,102.9,percent of total billed charges,Implant Device,102.9,35,,102.9,percent of total billed charges,Implant Device,117.6,40,,117.6,percent of total billed charges,Implant Device,102.9,70,,102.9,percent of total billed charges,All Other,99.96,34,,99.96,percent of total billed charges,Implant Device,99.96,34,,99.96,percent of total billed charges,Implant Device,102.9,35,,102.9,percent of total billed charges,Implant Device,102.9,35,,102.9,percent of total billed charges,Implant Device,102.9,35,,102.9,percent of total billed charges,Implant Device,102.9,35,,102.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,217.56,
STRYKER 657114 BONE SCREW 2.7X14MM,C1713,HCPCS,,79008891,CDM,278,RC,,,both,,,293,216.82,,,216.82,Other,150% of Medicare + 9.63% HCRA Surcharge,131.85,45,,131.85,percent of total billed charges,Critical Access Hospital RCC factor,99.62,34,,99.62,percent of total billed charges,Implant Device,99.62,34,,99.62,percent of total billed charges,Implant Device,99.62,34,,99.62,percent of total billed charges,Implant Device,99.62,34,,99.62,percent of total billed charges,Implant Device,99.62,34,,99.62,percent of total billed charges,Implant Device,145.04,,,145.04,Other,110% of Medicare,102.55,35,,102.55,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,102.55,35,,102.55,percent of total billed charges,Implant Device,102.55,35,,102.55,percent of total billed charges,Implant Device,102.55,35,,102.55,percent of total billed charges,Implant Device,102.55,35,,102.55,percent of total billed charges,Implant Device,102.55,35,,102.55,percent of total billed charges,Implant Device,117.2,40,,117.2,percent of total billed charges,Implant Device,102.55,70,,102.55,percent of total billed charges,All Other,99.62,34,,99.62,percent of total billed charges,Implant Device,99.62,34,,99.62,percent of total billed charges,Implant Device,102.55,35,,102.55,percent of total billed charges,Implant Device,102.55,35,,102.55,percent of total billed charges,Implant Device,102.55,35,,102.55,percent of total billed charges,Implant Device,102.55,35,,102.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,216.82,
STRYKER 40-20909 DISTAL FIBULA PLATE 9H,C1713,HCPCS,,79008892,CDM,278,RC,,,both,,,2102,1555.49,,,1555.49,Other,150% of Medicare + 9.63% HCRA Surcharge,945.9,45,,945.9,percent of total billed charges,Critical Access Hospital RCC factor,714.68,34,,714.68,percent of total billed charges,Implant Device,714.68,34,,714.68,percent of total billed charges,Implant Device,714.68,34,,714.68,percent of total billed charges,Implant Device,714.68,34,,714.68,percent of total billed charges,Implant Device,714.68,34,,714.68,percent of total billed charges,Implant Device,1040.49,,,1040.49,Other,110% of Medicare,735.7,35,,735.7,percent of total billed charges,Implant Device,714.68,34,"Charges > $500, x 34%",714.68,percent of total billed charges,Implant Device,735.7,35,,735.7,percent of total billed charges,Implant Device,735.7,35,,735.7,percent of total billed charges,Implant Device,735.7,35,,735.7,percent of total billed charges,Implant Device,735.7,35,,735.7,percent of total billed charges,Implant Device,735.7,35,,735.7,percent of total billed charges,Implant Device,840.8,40,,840.8,percent of total billed charges,Implant Device,735.7,70,,735.7,percent of total billed charges,All Other,714.68,34,,714.68,percent of total billed charges,Implant Device,714.68,34,,714.68,percent of total billed charges,Implant Device,735.7,35,,735.7,percent of total billed charges,Implant Device,735.7,35,,735.7,percent of total billed charges,Implant Device,735.7,35,,735.7,percent of total billed charges,Implant Device,735.7,35,,735.7,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,714.68,34,"If Charge > 2,000, then 34 percent",714.68,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1555.49,
STRYKER 657012 LOCKING SCREW 2.7X12MM,C1713,HCPCS,,79008893,CDM,278,RC,,,both,,,539,398.86,,,398.86,Other,150% of Medicare + 9.63% HCRA Surcharge,242.55,45,,242.55,percent of total billed charges,Critical Access Hospital RCC factor,183.26,34,,183.26,percent of total billed charges,Implant Device,183.26,34,,183.26,percent of total billed charges,Implant Device,183.26,34,,183.26,percent of total billed charges,Implant Device,183.26,34,,183.26,percent of total billed charges,Implant Device,183.26,34,,183.26,percent of total billed charges,Implant Device,266.81,,,266.81,Other,110% of Medicare,188.65,35,,188.65,percent of total billed charges,Implant Device,183.26,34,"Charges > $500, x 34%",183.26,percent of total billed charges,Implant Device,188.65,35,,188.65,percent of total billed charges,Implant Device,188.65,35,,188.65,percent of total billed charges,Implant Device,188.65,35,,188.65,percent of total billed charges,Implant Device,188.65,35,,188.65,percent of total billed charges,Implant Device,188.65,35,,188.65,percent of total billed charges,Implant Device,215.6,40,,215.6,percent of total billed charges,Implant Device,188.65,70,,188.65,percent of total billed charges,All Other,183.26,34,,183.26,percent of total billed charges,Implant Device,183.26,34,,183.26,percent of total billed charges,Implant Device,188.65,35,,188.65,percent of total billed charges,Implant Device,188.65,35,,188.65,percent of total billed charges,Implant Device,188.65,35,,188.65,percent of total billed charges,Implant Device,188.65,35,,188.65,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,398.86,
STRYKER 40-30140 CANN SCREW 3.0X40/8MM,C1713,HCPCS,,79008895,CDM,278,RC,,,both,,,859,635.66,,,635.66,Other,150% of Medicare + 9.63% HCRA Surcharge,386.55,45,,386.55,percent of total billed charges,Critical Access Hospital RCC factor,292.06,34,,292.06,percent of total billed charges,Implant Device,292.06,34,,292.06,percent of total billed charges,Implant Device,292.06,34,,292.06,percent of total billed charges,Implant Device,292.06,34,,292.06,percent of total billed charges,Implant Device,292.06,34,,292.06,percent of total billed charges,Implant Device,425.21,,,425.21,Other,110% of Medicare,300.65,35,,300.65,percent of total billed charges,Implant Device,292.06,34,"Charges > $500, x 34%",292.06,percent of total billed charges,Implant Device,300.65,35,,300.65,percent of total billed charges,Implant Device,300.65,35,,300.65,percent of total billed charges,Implant Device,300.65,35,,300.65,percent of total billed charges,Implant Device,300.65,35,,300.65,percent of total billed charges,Implant Device,300.65,35,,300.65,percent of total billed charges,Implant Device,343.6,40,,343.6,percent of total billed charges,Implant Device,300.65,70,,300.65,percent of total billed charges,All Other,292.06,34,,292.06,percent of total billed charges,Implant Device,292.06,34,,292.06,percent of total billed charges,Implant Device,300.65,35,,300.65,percent of total billed charges,Implant Device,300.65,35,,300.65,percent of total billed charges,Implant Device,300.65,35,,300.65,percent of total billed charges,Implant Device,300.65,35,,300.65,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,635.66,
ARTHREX AR-13120T-18 CORT SCREW 2.3X18MM,C1713,HCPCS,,79008896,CDM,278,RC,,,both,,,408,301.92,,,301.92,Other,150% of Medicare + 9.63% HCRA Surcharge,183.6,45,,183.6,percent of total billed charges,Critical Access Hospital RCC factor,138.72,34,,138.72,percent of total billed charges,Implant Device,138.72,34,,138.72,percent of total billed charges,Implant Device,138.72,34,,138.72,percent of total billed charges,Implant Device,138.72,34,,138.72,percent of total billed charges,Implant Device,138.72,34,,138.72,percent of total billed charges,Implant Device,201.96,,,201.96,Other,110% of Medicare,142.8,35,,142.8,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,142.8,35,,142.8,percent of total billed charges,Implant Device,142.8,35,,142.8,percent of total billed charges,Implant Device,142.8,35,,142.8,percent of total billed charges,Implant Device,142.8,35,,142.8,percent of total billed charges,Implant Device,142.8,35,,142.8,percent of total billed charges,Implant Device,163.2,40,,163.2,percent of total billed charges,Implant Device,142.8,70,,142.8,percent of total billed charges,All Other,138.72,34,,138.72,percent of total billed charges,Implant Device,138.72,34,,138.72,percent of total billed charges,Implant Device,142.8,35,,142.8,percent of total billed charges,Implant Device,142.8,35,,142.8,percent of total billed charges,Implant Device,142.8,35,,142.8,percent of total billed charges,Implant Device,142.8,35,,142.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,301.92,
TIDES TAH1408 AMNIOHEAL ALLOGRAFT 4X8CM,V2790,HCPCS,,79008897,CDM,278,RC,,,both,,,14993,11094.86,,,11094.86,Other,150% of Medicare + 9.63% HCRA Surcharge,6746.85,45,,6746.85,percent of total billed charges,Critical Access Hospital RCC factor,5097.62,34,,5097.62,percent of total billed charges,Implant Device,5097.62,34,,5097.62,percent of total billed charges,Implant Device,5097.62,34,,5097.62,percent of total billed charges,Implant Device,5097.62,34,,5097.62,percent of total billed charges,Implant Device,5097.62,34,,5097.62,percent of total billed charges,Implant Device,7421.54,,,7421.54,Other,110% of Medicare,5247.55,35,,5247.55,percent of total billed charges,Implant Device,5097.62,34,"Charges > $500, x 34%",5097.62,percent of total billed charges,Implant Device,5247.55,35,,5247.55,percent of total billed charges,Implant Device,5247.55,35,,5247.55,percent of total billed charges,Implant Device,5247.55,35,,5247.55,percent of total billed charges,Implant Device,5247.55,35,,5247.55,percent of total billed charges,Implant Device,5247.55,35,,5247.55,percent of total billed charges,Implant Device,5997.2,40,,5997.2,percent of total billed charges,Implant Device,5247.55,70,,5247.55,percent of total billed charges,All Other,5097.62,34,,5097.62,percent of total billed charges,Implant Device,5097.62,34,,5097.62,percent of total billed charges,Implant Device,5247.55,35,,5247.55,percent of total billed charges,Implant Device,5247.55,35,,5247.55,percent of total billed charges,Implant Device,5247.55,35,,5247.55,percent of total billed charges,Implant Device,5247.55,35,,5247.55,percent of total billed charges,Implant Device,976.07,,,976.07,Other,100% of Medicaid,976.07,,,976.07,Other,100% of Medicaid,976.07,,,976.07,Other,100% of Medicaid,976.07,,,976.07,Other,100% of Medicaid,2196.15,,,2196.15,Other,225% of Medicaid,1493.38,,,1493.38,Other,153% of Medicaid,2196.15,,,2196.15,Other,225% of Medicaid,1366.49,,,1366.49,Other,140% of Medicaid,5097.62,34,"If Charge > 2,000, then 34 percent",5097.62,percent of total billed charges,Implants,2537.77,,,2537.77,Other,260% of Medicaid,3162.45,,,3162.45,Other,324% of Medicaid,2098.54,,,2098.54,Other,215% of Medicaid,2098.54,,,2098.54,Other,215% of Medicaid,1220.08,,,1220.08,Other,125% of Medicaid,976.07,11094.86,
ARTHREX AR-13120T-12 CORT SCREW 2.3X12MM,C1713,HCPCS,,79008898,CDM,278,RC,,,both,,,408,301.92,,,301.92,Other,150% of Medicare + 9.63% HCRA Surcharge,183.6,45,,183.6,percent of total billed charges,Critical Access Hospital RCC factor,138.72,34,,138.72,percent of total billed charges,Implant Device,138.72,34,,138.72,percent of total billed charges,Implant Device,138.72,34,,138.72,percent of total billed charges,Implant Device,138.72,34,,138.72,percent of total billed charges,Implant Device,138.72,34,,138.72,percent of total billed charges,Implant Device,201.96,,,201.96,Other,110% of Medicare,142.8,35,,142.8,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,142.8,35,,142.8,percent of total billed charges,Implant Device,142.8,35,,142.8,percent of total billed charges,Implant Device,142.8,35,,142.8,percent of total billed charges,Implant Device,142.8,35,,142.8,percent of total billed charges,Implant Device,142.8,35,,142.8,percent of total billed charges,Implant Device,163.2,40,,163.2,percent of total billed charges,Implant Device,142.8,70,,142.8,percent of total billed charges,All Other,138.72,34,,138.72,percent of total billed charges,Implant Device,138.72,34,,138.72,percent of total billed charges,Implant Device,142.8,35,,142.8,percent of total billed charges,Implant Device,142.8,35,,142.8,percent of total billed charges,Implant Device,142.8,35,,142.8,percent of total billed charges,Implant Device,142.8,35,,142.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,301.92,
IN2BONES 100-0061 COTTON WEDGE 6X23MM,C1713,HCPCS,,79008899,CDM,278,RC,,,both,,,8985,6648.92,,,6648.92,Other,150% of Medicare + 9.63% HCRA Surcharge,4043.25,45,,4043.25,percent of total billed charges,Critical Access Hospital RCC factor,3054.9,34,,3054.9,percent of total billed charges,Implant Device,3054.9,34,,3054.9,percent of total billed charges,Implant Device,3054.9,34,,3054.9,percent of total billed charges,Implant Device,3054.9,34,,3054.9,percent of total billed charges,Implant Device,3054.9,34,,3054.9,percent of total billed charges,Implant Device,4447.58,,,4447.58,Other,110% of Medicare,3144.75,35,,3144.75,percent of total billed charges,Implant Device,3054.9,34,"Charges > $500, x 34%",3054.9,percent of total billed charges,Implant Device,3144.75,35,,3144.75,percent of total billed charges,Implant Device,3144.75,35,,3144.75,percent of total billed charges,Implant Device,3144.75,35,,3144.75,percent of total billed charges,Implant Device,3144.75,35,,3144.75,percent of total billed charges,Implant Device,3144.75,35,,3144.75,percent of total billed charges,Implant Device,3594,40,,3594,percent of total billed charges,Implant Device,3144.75,70,,3144.75,percent of total billed charges,All Other,3054.9,34,,3054.9,percent of total billed charges,Implant Device,3054.9,34,,3054.9,percent of total billed charges,Implant Device,3144.75,35,,3144.75,percent of total billed charges,Implant Device,3144.75,35,,3144.75,percent of total billed charges,Implant Device,3144.75,35,,3144.75,percent of total billed charges,Implant Device,3144.75,35,,3144.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3054.9,34,"If Charge > 2,000, then 34 percent",3054.9,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,6648.92,
STRYKER 658036 COMP SCREW 4.0X38MM,C1713,HCPCS,,79008901,CDM,278,RC,,,both,,,1767,1307.58,,,1307.58,Other,150% of Medicare + 9.63% HCRA Surcharge,795.15,45,,795.15,percent of total billed charges,Critical Access Hospital RCC factor,600.78,34,,600.78,percent of total billed charges,Implant Device,600.78,34,,600.78,percent of total billed charges,Implant Device,600.78,34,,600.78,percent of total billed charges,Implant Device,600.78,34,,600.78,percent of total billed charges,Implant Device,600.78,34,,600.78,percent of total billed charges,Implant Device,874.67,,,874.67,Other,110% of Medicare,618.45,35,,618.45,percent of total billed charges,Implant Device,600.78,34,"Charges > $500, x 34%",600.78,percent of total billed charges,Implant Device,618.45,35,,618.45,percent of total billed charges,Implant Device,618.45,35,,618.45,percent of total billed charges,Implant Device,618.45,35,,618.45,percent of total billed charges,Implant Device,618.45,35,,618.45,percent of total billed charges,Implant Device,618.45,35,,618.45,percent of total billed charges,Implant Device,706.8,40,,706.8,percent of total billed charges,Implant Device,618.45,70,,618.45,percent of total billed charges,All Other,600.78,34,,600.78,percent of total billed charges,Implant Device,600.78,34,,600.78,percent of total billed charges,Implant Device,618.45,35,,618.45,percent of total billed charges,Implant Device,618.45,35,,618.45,percent of total billed charges,Implant Device,618.45,35,,618.45,percent of total billed charges,Implant Device,618.45,35,,618.45,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1307.58,
STRYKER PLP40280 ANCHORAGE PLT STR 4 H,C1713,HCPCS,,79008902,CDM,278,RC,,,both,,,5733,4242.43,,,4242.43,Other,150% of Medicare + 9.63% HCRA Surcharge,2579.85,45,,2579.85,percent of total billed charges,Critical Access Hospital RCC factor,1949.22,34,,1949.22,percent of total billed charges,Implant Device,1949.22,34,,1949.22,percent of total billed charges,Implant Device,1949.22,34,,1949.22,percent of total billed charges,Implant Device,1949.22,34,,1949.22,percent of total billed charges,Implant Device,1949.22,34,,1949.22,percent of total billed charges,Implant Device,2837.84,,,2837.84,Other,110% of Medicare,2006.55,35,,2006.55,percent of total billed charges,Implant Device,1949.22,34,"Charges > $500, x 34%",1949.22,percent of total billed charges,Implant Device,2006.55,35,,2006.55,percent of total billed charges,Implant Device,2006.55,35,,2006.55,percent of total billed charges,Implant Device,2006.55,35,,2006.55,percent of total billed charges,Implant Device,2006.55,35,,2006.55,percent of total billed charges,Implant Device,2006.55,35,,2006.55,percent of total billed charges,Implant Device,2293.2,40,,2293.2,percent of total billed charges,Implant Device,2006.55,70,,2006.55,percent of total billed charges,All Other,1949.22,34,,1949.22,percent of total billed charges,Implant Device,1949.22,34,,1949.22,percent of total billed charges,Implant Device,2006.55,35,,2006.55,percent of total billed charges,Implant Device,2006.55,35,,2006.55,percent of total billed charges,Implant Device,2006.55,35,,2006.55,percent of total billed charges,Implant Device,2006.55,35,,2006.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1949.22,34,"If Charge > 2,000, then 34 percent",1949.22,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4242.43,
STRYKER PLSS3016 ANCHORAGE SCREW 3X16MM,C1713,HCPCS,,79008903,CDM,278,RC,,,both,,,1767,1307.58,,,1307.58,Other,150% of Medicare + 9.63% HCRA Surcharge,795.15,45,,795.15,percent of total billed charges,Critical Access Hospital RCC factor,600.78,34,,600.78,percent of total billed charges,Implant Device,600.78,34,,600.78,percent of total billed charges,Implant Device,600.78,34,,600.78,percent of total billed charges,Implant Device,600.78,34,,600.78,percent of total billed charges,Implant Device,600.78,34,,600.78,percent of total billed charges,Implant Device,874.67,,,874.67,Other,110% of Medicare,618.45,35,,618.45,percent of total billed charges,Implant Device,600.78,34,"Charges > $500, x 34%",600.78,percent of total billed charges,Implant Device,618.45,35,,618.45,percent of total billed charges,Implant Device,618.45,35,,618.45,percent of total billed charges,Implant Device,618.45,35,,618.45,percent of total billed charges,Implant Device,618.45,35,,618.45,percent of total billed charges,Implant Device,618.45,35,,618.45,percent of total billed charges,Implant Device,706.8,40,,706.8,percent of total billed charges,Implant Device,618.45,70,,618.45,percent of total billed charges,All Other,600.78,34,,600.78,percent of total billed charges,Implant Device,600.78,34,,600.78,percent of total billed charges,Implant Device,618.45,35,,618.45,percent of total billed charges,Implant Device,618.45,35,,618.45,percent of total billed charges,Implant Device,618.45,35,,618.45,percent of total billed charges,Implant Device,618.45,35,,618.45,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1307.58,
MENTOR 350-3560 BREAST IMPLANT 560CC,C1789,HCPCS,,79008905,CDM,278,RC,,,both,,,2010,1487.41,,,1487.41,Other,150% of Medicare + 9.63% HCRA Surcharge,904.5,45,,904.5,percent of total billed charges,Critical Access Hospital RCC factor,683.4,34,,683.4,percent of total billed charges,Implant Device,683.4,34,,683.4,percent of total billed charges,Implant Device,683.4,34,,683.4,percent of total billed charges,Implant Device,683.4,34,,683.4,percent of total billed charges,Implant Device,683.4,34,,683.4,percent of total billed charges,Implant Device,994.95,,,994.95,Other,110% of Medicare,703.5,35,,703.5,percent of total billed charges,Implant Device,683.4,34,"Charges > $500, x 34%",683.4,percent of total billed charges,Implant Device,703.5,35,,703.5,percent of total billed charges,Implant Device,703.5,35,,703.5,percent of total billed charges,Implant Device,703.5,35,,703.5,percent of total billed charges,Implant Device,703.5,35,,703.5,percent of total billed charges,Implant Device,703.5,35,,703.5,percent of total billed charges,Implant Device,804,40,,804,percent of total billed charges,Implant Device,703.5,70,,703.5,percent of total billed charges,All Other,683.4,34,,683.4,percent of total billed charges,Implant Device,683.4,34,,683.4,percent of total billed charges,Implant Device,703.5,35,,703.5,percent of total billed charges,Implant Device,703.5,35,,703.5,percent of total billed charges,Implant Device,703.5,35,,703.5,percent of total billed charges,Implant Device,703.5,35,,703.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,683.4,34,"If Charge > 2,000, then 34 percent",683.4,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1487.41,
MENTOR 350-2550 BREAST IMPLANT 550CC,C1789,HCPCS,,79008906,CDM,278,RC,,,both,,,2010,1487.41,,,1487.41,Other,150% of Medicare + 9.63% HCRA Surcharge,904.5,45,,904.5,percent of total billed charges,Critical Access Hospital RCC factor,683.4,34,,683.4,percent of total billed charges,Implant Device,683.4,34,,683.4,percent of total billed charges,Implant Device,683.4,34,,683.4,percent of total billed charges,Implant Device,683.4,34,,683.4,percent of total billed charges,Implant Device,683.4,34,,683.4,percent of total billed charges,Implant Device,994.95,,,994.95,Other,110% of Medicare,703.5,35,,703.5,percent of total billed charges,Implant Device,683.4,34,"Charges > $500, x 34%",683.4,percent of total billed charges,Implant Device,703.5,35,,703.5,percent of total billed charges,Implant Device,703.5,35,,703.5,percent of total billed charges,Implant Device,703.5,35,,703.5,percent of total billed charges,Implant Device,703.5,35,,703.5,percent of total billed charges,Implant Device,703.5,35,,703.5,percent of total billed charges,Implant Device,804,40,,804,percent of total billed charges,Implant Device,703.5,70,,703.5,percent of total billed charges,All Other,683.4,34,,683.4,percent of total billed charges,Implant Device,683.4,34,,683.4,percent of total billed charges,Implant Device,703.5,35,,703.5,percent of total billed charges,Implant Device,703.5,35,,703.5,percent of total billed charges,Implant Device,703.5,35,,703.5,percent of total billed charges,Implant Device,703.5,35,,703.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,683.4,34,"If Charge > 2,000, then 34 percent",683.4,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1487.41,
ANGIODYNAMICS H965460120 4FR MIDLNE CATH,C1751,HCPCS,,79008908,CDM,278,RC,,,both,,,375,277.5,,,277.5,Other,150% of Medicare + 9.63% HCRA Surcharge,168.75,45,,168.75,percent of total billed charges,Critical Access Hospital RCC factor,127.5,34,,127.5,percent of total billed charges,Implant Device,127.5,34,,127.5,percent of total billed charges,Implant Device,127.5,34,,127.5,percent of total billed charges,Implant Device,127.5,34,,127.5,percent of total billed charges,Implant Device,127.5,34,,127.5,percent of total billed charges,Implant Device,185.63,,,185.63,Other,110% of Medicare,131.25,35,,131.25,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,131.25,35,,131.25,percent of total billed charges,Implant Device,131.25,35,,131.25,percent of total billed charges,Implant Device,131.25,35,,131.25,percent of total billed charges,Implant Device,131.25,35,,131.25,percent of total billed charges,Implant Device,131.25,35,,131.25,percent of total billed charges,Implant Device,150,40,,150,percent of total billed charges,Implant Device,131.25,70,,131.25,percent of total billed charges,All Other,127.5,34,,127.5,percent of total billed charges,Implant Device,127.5,34,,127.5,percent of total billed charges,Implant Device,131.25,35,,131.25,percent of total billed charges,Implant Device,131.25,35,,131.25,percent of total billed charges,Implant Device,131.25,35,,131.25,percent of total billed charges,Implant Device,131.25,35,,131.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,277.5,
ANGIODYNAMICS H965460161 4FR MIDLNE CATH,C1751,HCPCS,,79008909,CDM,278,RC,,,both,,,510,377.4,,,377.4,Other,150% of Medicare + 9.63% HCRA Surcharge,229.5,45,,229.5,percent of total billed charges,Critical Access Hospital RCC factor,173.4,34,,173.4,percent of total billed charges,Implant Device,173.4,34,,173.4,percent of total billed charges,Implant Device,173.4,34,,173.4,percent of total billed charges,Implant Device,173.4,34,,173.4,percent of total billed charges,Implant Device,173.4,34,,173.4,percent of total billed charges,Implant Device,252.45,,,252.45,Other,110% of Medicare,178.5,35,,178.5,percent of total billed charges,Implant Device,173.4,34,"Charges > $500, x 34%",173.4,percent of total billed charges,Implant Device,178.5,35,,178.5,percent of total billed charges,Implant Device,178.5,35,,178.5,percent of total billed charges,Implant Device,178.5,35,,178.5,percent of total billed charges,Implant Device,178.5,35,,178.5,percent of total billed charges,Implant Device,178.5,35,,178.5,percent of total billed charges,Implant Device,204,40,,204,percent of total billed charges,Implant Device,178.5,70,,178.5,percent of total billed charges,All Other,173.4,34,,173.4,percent of total billed charges,Implant Device,173.4,34,,173.4,percent of total billed charges,Implant Device,178.5,35,,178.5,percent of total billed charges,Implant Device,178.5,35,,178.5,percent of total billed charges,Implant Device,178.5,35,,178.5,percent of total billed charges,Implant Device,178.5,35,,178.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,377.4,
BIOMET 01-7126 FACIAL PLATE 8-HOLE,C1713,HCPCS,,79008910,CDM,278,RC,,,both,,,1029,761.46,,,761.46,Other,150% of Medicare + 9.63% HCRA Surcharge,463.05,45,,463.05,percent of total billed charges,Critical Access Hospital RCC factor,349.86,34,,349.86,percent of total billed charges,Implant Device,349.86,34,,349.86,percent of total billed charges,Implant Device,349.86,34,,349.86,percent of total billed charges,Implant Device,349.86,34,,349.86,percent of total billed charges,Implant Device,349.86,34,,349.86,percent of total billed charges,Implant Device,509.36,,,509.36,Other,110% of Medicare,360.15,35,,360.15,percent of total billed charges,Implant Device,349.86,34,"Charges > $500, x 34%",349.86,percent of total billed charges,Implant Device,360.15,35,,360.15,percent of total billed charges,Implant Device,360.15,35,,360.15,percent of total billed charges,Implant Device,360.15,35,,360.15,percent of total billed charges,Implant Device,360.15,35,,360.15,percent of total billed charges,Implant Device,360.15,35,,360.15,percent of total billed charges,Implant Device,411.6,40,,411.6,percent of total billed charges,Implant Device,360.15,70,,360.15,percent of total billed charges,All Other,349.86,34,,349.86,percent of total billed charges,Implant Device,349.86,34,,349.86,percent of total billed charges,Implant Device,360.15,35,,360.15,percent of total billed charges,Implant Device,360.15,35,,360.15,percent of total billed charges,Implant Device,360.15,35,,360.15,percent of total billed charges,Implant Device,360.15,35,,360.15,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,761.46,
ZIMMER 00-5880-003-10 TIBIAL AUG SZ 3,C1776,HCPCS,,79008912,CDM,278,RC,,,both,,,4756,3519.45,,,3519.45,Other,150% of Medicare + 9.63% HCRA Surcharge,2140.2,45,,2140.2,percent of total billed charges,Critical Access Hospital RCC factor,1617.04,34,,1617.04,percent of total billed charges,Implant Device,1617.04,34,,1617.04,percent of total billed charges,Implant Device,1617.04,34,,1617.04,percent of total billed charges,Implant Device,1617.04,34,,1617.04,percent of total billed charges,Implant Device,1617.04,34,,1617.04,percent of total billed charges,Implant Device,2354.22,,,2354.22,Other,110% of Medicare,1664.6,35,,1664.6,percent of total billed charges,Implant Device,1617.04,34,"Charges > $500, x 34%",1617.04,percent of total billed charges,Implant Device,1664.6,35,,1664.6,percent of total billed charges,Implant Device,1664.6,35,,1664.6,percent of total billed charges,Implant Device,1664.6,35,,1664.6,percent of total billed charges,Implant Device,1664.6,35,,1664.6,percent of total billed charges,Implant Device,1664.6,35,,1664.6,percent of total billed charges,Implant Device,1902.4,40,,1902.4,percent of total billed charges,Implant Device,1664.6,70,,1664.6,percent of total billed charges,All Other,1617.04,34,,1617.04,percent of total billed charges,Implant Device,1617.04,34,,1617.04,percent of total billed charges,Implant Device,1664.6,35,,1664.6,percent of total billed charges,Implant Device,1664.6,35,,1664.6,percent of total billed charges,Implant Device,1664.6,35,,1664.6,percent of total billed charges,Implant Device,1664.6,35,,1664.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1617.04,34,"If Charge > 2,000, then 34 percent",1617.04,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3519.45,
ZIMMER 00-5850-046-06 SEG TAPER 60MM,C1776,HCPCS,,79008913,CDM,278,RC,,,both,,,10705,7921.73,,,7921.73,Other,150% of Medicare + 9.63% HCRA Surcharge,4817.25,45,,4817.25,percent of total billed charges,Critical Access Hospital RCC factor,3639.7,34,,3639.7,percent of total billed charges,Implant Device,3639.7,34,,3639.7,percent of total billed charges,Implant Device,3639.7,34,,3639.7,percent of total billed charges,Implant Device,3639.7,34,,3639.7,percent of total billed charges,Implant Device,3639.7,34,,3639.7,percent of total billed charges,Implant Device,5298.98,,,5298.98,Other,110% of Medicare,3746.75,35,,3746.75,percent of total billed charges,Implant Device,3639.7,34,"Charges > $500, x 34%",3639.7,percent of total billed charges,Implant Device,3746.75,35,,3746.75,percent of total billed charges,Implant Device,3746.75,35,,3746.75,percent of total billed charges,Implant Device,3746.75,35,,3746.75,percent of total billed charges,Implant Device,3746.75,35,,3746.75,percent of total billed charges,Implant Device,3746.75,35,,3746.75,percent of total billed charges,Implant Device,4282,40,,4282,percent of total billed charges,Implant Device,3746.75,70,,3746.75,percent of total billed charges,All Other,3639.7,34,,3639.7,percent of total billed charges,Implant Device,3639.7,34,,3639.7,percent of total billed charges,Implant Device,3746.75,35,,3746.75,percent of total billed charges,Implant Device,3746.75,35,,3746.75,percent of total billed charges,Implant Device,3746.75,35,,3746.75,percent of total billed charges,Implant Device,3746.75,35,,3746.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3639.7,34,"If Charge > 2,000, then 34 percent",3639.7,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,7921.73,
STRYKER 661446 NON LOCK SCREW 3.5X46MM,C1713,HCPCS,,79008914,CDM,278,RC,,,both,,,122,90.28,,,90.28,Other,150% of Medicare + 9.63% HCRA Surcharge,54.9,45,,54.9,percent of total billed charges,Critical Access Hospital RCC factor,41.48,34,,41.48,percent of total billed charges,Implant Device,41.48,34,,41.48,percent of total billed charges,Implant Device,41.48,34,,41.48,percent of total billed charges,Implant Device,41.48,34,,41.48,percent of total billed charges,Implant Device,41.48,34,,41.48,percent of total billed charges,Implant Device,60.39,,,60.39,Other,110% of Medicare,42.7,35,,42.7,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,42.7,35,,42.7,percent of total billed charges,Implant Device,42.7,35,,42.7,percent of total billed charges,Implant Device,42.7,35,,42.7,percent of total billed charges,Implant Device,42.7,35,,42.7,percent of total billed charges,Implant Device,42.7,35,,42.7,percent of total billed charges,Implant Device,48.8,40,,48.8,percent of total billed charges,Implant Device,42.7,70,,42.7,percent of total billed charges,All Other,41.48,34,,41.48,percent of total billed charges,Implant Device,41.48,34,,41.48,percent of total billed charges,Implant Device,42.7,35,,42.7,percent of total billed charges,Implant Device,42.7,35,,42.7,percent of total billed charges,Implant Device,42.7,35,,42.7,percent of total billed charges,Implant Device,42.7,35,,42.7,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,90.28,
STRYKER 607348 NON LOCK CAN SCREW 4X48MM,C1713,HCPCS,,79008915,CDM,278,RC,,,both,,,133,98.42,,,98.42,Other,150% of Medicare + 9.63% HCRA Surcharge,59.85,45,,59.85,percent of total billed charges,Critical Access Hospital RCC factor,45.22,34,,45.22,percent of total billed charges,Implant Device,45.22,34,,45.22,percent of total billed charges,Implant Device,45.22,34,,45.22,percent of total billed charges,Implant Device,45.22,34,,45.22,percent of total billed charges,Implant Device,45.22,34,,45.22,percent of total billed charges,Implant Device,65.84,,,65.84,Other,110% of Medicare,46.55,35,,46.55,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,46.55,35,,46.55,percent of total billed charges,Implant Device,46.55,35,,46.55,percent of total billed charges,Implant Device,46.55,35,,46.55,percent of total billed charges,Implant Device,46.55,35,,46.55,percent of total billed charges,Implant Device,46.55,35,,46.55,percent of total billed charges,Implant Device,53.2,40,,53.2,percent of total billed charges,Implant Device,46.55,70,,46.55,percent of total billed charges,All Other,45.22,34,,45.22,percent of total billed charges,Implant Device,45.22,34,,45.22,percent of total billed charges,Implant Device,46.55,35,,46.55,percent of total billed charges,Implant Device,46.55,35,,46.55,percent of total billed charges,Implant Device,46.55,35,,46.55,percent of total billed charges,Implant Device,46.55,35,,46.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,98.42,
IN2BONES APA-003 PIP ALLOGRAFT 2.9X19MM,C1713,HCPCS,,79008916,CDM,278,RC,,,both,,,3300,2442.01,,,2442.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1485,45,,1485,percent of total billed charges,Critical Access Hospital RCC factor,1122,34,,1122,percent of total billed charges,Implant Device,1122,34,,1122,percent of total billed charges,Implant Device,1122,34,,1122,percent of total billed charges,Implant Device,1122,34,,1122,percent of total billed charges,Implant Device,1122,34,,1122,percent of total billed charges,Implant Device,1633.5,,,1633.5,Other,110% of Medicare,1155,35,,1155,percent of total billed charges,Implant Device,1122,34,"Charges > $500, x 34%",1122,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,1320,40,,1320,percent of total billed charges,Implant Device,1155,70,,1155,percent of total billed charges,All Other,1122,34,,1122,percent of total billed charges,Implant Device,1122,34,,1122,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1122,34,"If Charge > 2,000, then 34 percent",1122,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2442.01,
STRYKER 627706 PROX TIBIAL PLATE 6 H,C1713,HCPCS,,79008918,CDM,278,RC,,,both,,,5561,4115.15,,,4115.15,Other,150% of Medicare + 9.63% HCRA Surcharge,2502.45,45,,2502.45,percent of total billed charges,Critical Access Hospital RCC factor,1890.74,34,,1890.74,percent of total billed charges,Implant Device,1890.74,34,,1890.74,percent of total billed charges,Implant Device,1890.74,34,,1890.74,percent of total billed charges,Implant Device,1890.74,34,,1890.74,percent of total billed charges,Implant Device,1890.74,34,,1890.74,percent of total billed charges,Implant Device,2752.7,,,2752.7,Other,110% of Medicare,1946.35,35,,1946.35,percent of total billed charges,Implant Device,1890.74,34,"Charges > $500, x 34%",1890.74,percent of total billed charges,Implant Device,1946.35,35,,1946.35,percent of total billed charges,Implant Device,1946.35,35,,1946.35,percent of total billed charges,Implant Device,1946.35,35,,1946.35,percent of total billed charges,Implant Device,1946.35,35,,1946.35,percent of total billed charges,Implant Device,1946.35,35,,1946.35,percent of total billed charges,Implant Device,2224.4,40,,2224.4,percent of total billed charges,Implant Device,1946.35,70,,1946.35,percent of total billed charges,All Other,1890.74,34,,1890.74,percent of total billed charges,Implant Device,1890.74,34,,1890.74,percent of total billed charges,Implant Device,1946.35,35,,1946.35,percent of total billed charges,Implant Device,1946.35,35,,1946.35,percent of total billed charges,Implant Device,1946.35,35,,1946.35,percent of total billed charges,Implant Device,1946.35,35,,1946.35,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1890.74,34,"If Charge > 2,000, then 34 percent",1890.74,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4115.15,
STRYKER 40-27022 BONE SCREW 2.7X22MM,C1713,HCPCS,,79008919,CDM,278,RC,,,both,,,334,247.16,,,247.16,Other,150% of Medicare + 9.63% HCRA Surcharge,150.3,45,,150.3,percent of total billed charges,Critical Access Hospital RCC factor,113.56,34,,113.56,percent of total billed charges,Implant Device,113.56,34,,113.56,percent of total billed charges,Implant Device,113.56,34,,113.56,percent of total billed charges,Implant Device,113.56,34,,113.56,percent of total billed charges,Implant Device,113.56,34,,113.56,percent of total billed charges,Implant Device,165.33,,,165.33,Other,110% of Medicare,116.9,35,,116.9,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,116.9,35,,116.9,percent of total billed charges,Implant Device,116.9,35,,116.9,percent of total billed charges,Implant Device,116.9,35,,116.9,percent of total billed charges,Implant Device,116.9,35,,116.9,percent of total billed charges,Implant Device,116.9,35,,116.9,percent of total billed charges,Implant Device,133.6,40,,133.6,percent of total billed charges,Implant Device,116.9,70,,116.9,percent of total billed charges,All Other,113.56,34,,113.56,percent of total billed charges,Implant Device,113.56,34,,113.56,percent of total billed charges,Implant Device,116.9,35,,116.9,percent of total billed charges,Implant Device,116.9,35,,116.9,percent of total billed charges,Implant Device,116.9,35,,116.9,percent of total billed charges,Implant Device,116.9,35,,116.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,247.16,
IN2BONES P40 ST235 MTP PLATE 6 HOLE LEFT,C1713,HCPCS,,79008926,CDM,278,RC,,,both,,,6000,4440.02,,,4440.02,Other,150% of Medicare + 9.63% HCRA Surcharge,2700,45,,2700,percent of total billed charges,Critical Access Hospital RCC factor,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2970,,,2970,Other,110% of Medicare,2100,35,,2100,percent of total billed charges,Implant Device,2040,34,"Charges > $500, x 34%",2040,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2400,40,,2400,percent of total billed charges,Implant Device,2100,70,,2100,percent of total billed charges,All Other,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2040,34,"If Charge > 2,000, then 34 percent",2040,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4440.02,
IN2BONES V30 ST314 LOCKING SCREW 3X14MM,C1713,HCPCS,,79008927,CDM,278,RC,,,both,,,870,643.8,,,643.8,Other,150% of Medicare + 9.63% HCRA Surcharge,391.5,45,,391.5,percent of total billed charges,Critical Access Hospital RCC factor,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,430.65,,,430.65,Other,110% of Medicare,304.5,35,,304.5,percent of total billed charges,Implant Device,295.8,34,"Charges > $500, x 34%",295.8,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,348,40,,348,percent of total billed charges,Implant Device,304.5,70,,304.5,percent of total billed charges,All Other,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,643.8,
IN2BONES V30 ST424 TRANSVERSE SCREW 3X24,C1713,HCPCS,,79008928,CDM,278,RC,,,both,,,870,643.8,,,643.8,Other,150% of Medicare + 9.63% HCRA Surcharge,391.5,45,,391.5,percent of total billed charges,Critical Access Hospital RCC factor,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,430.65,,,430.65,Other,110% of Medicare,304.5,35,,304.5,percent of total billed charges,Implant Device,295.8,34,"Charges > $500, x 34%",295.8,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,348,40,,348,percent of total billed charges,Implant Device,304.5,70,,304.5,percent of total billed charges,All Other,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,643.8,
IN2BONES V30 ST312 LOCKING SCREW 3X12MM,C1713,HCPCS,,79008929,CDM,278,RC,,,both,,,870,643.8,,,643.8,Other,150% of Medicare + 9.63% HCRA Surcharge,391.5,45,,391.5,percent of total billed charges,Critical Access Hospital RCC factor,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,430.65,,,430.65,Other,110% of Medicare,304.5,35,,304.5,percent of total billed charges,Implant Device,295.8,34,"Charges > $500, x 34%",295.8,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,348,40,,348,percent of total billed charges,Implant Device,304.5,70,,304.5,percent of total billed charges,All Other,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,643.8,
IN2BONES V30 ST316 LOCKING SCREW 3X16MM,C1713,HCPCS,,79008930,CDM,278,RC,,,both,,,870,643.8,,,643.8,Other,150% of Medicare + 9.63% HCRA Surcharge,391.5,45,,391.5,percent of total billed charges,Critical Access Hospital RCC factor,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,430.65,,,430.65,Other,110% of Medicare,304.5,35,,304.5,percent of total billed charges,Implant Device,295.8,34,"Charges > $500, x 34%",295.8,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,348,40,,348,percent of total billed charges,Implant Device,304.5,70,,304.5,percent of total billed charges,All Other,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,643.8,
DEPUY 294.786 SCHANZ SCREW 5.0X200MM,C1713,HCPCS,,79008932,CDM,278,RC,,,both,,,305,225.7,,,225.7,Other,150% of Medicare + 9.63% HCRA Surcharge,137.25,45,,137.25,percent of total billed charges,Critical Access Hospital RCC factor,103.7,34,,103.7,percent of total billed charges,Implant Device,103.7,34,,103.7,percent of total billed charges,Implant Device,103.7,34,,103.7,percent of total billed charges,Implant Device,103.7,34,,103.7,percent of total billed charges,Implant Device,103.7,34,,103.7,percent of total billed charges,Implant Device,150.98,,,150.98,Other,110% of Medicare,106.75,35,,106.75,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,106.75,35,,106.75,percent of total billed charges,Implant Device,106.75,35,,106.75,percent of total billed charges,Implant Device,106.75,35,,106.75,percent of total billed charges,Implant Device,106.75,35,,106.75,percent of total billed charges,Implant Device,106.75,35,,106.75,percent of total billed charges,Implant Device,122,40,,122,percent of total billed charges,Implant Device,106.75,70,,106.75,percent of total billed charges,All Other,103.7,34,,103.7,percent of total billed charges,Implant Device,103.7,34,,103.7,percent of total billed charges,Implant Device,106.75,35,,106.75,percent of total billed charges,Implant Device,106.75,35,,106.75,percent of total billed charges,Implant Device,106.75,35,,106.75,percent of total billed charges,Implant Device,106.75,35,,106.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,225.7,
STRYKER 658044 HDLESS COMP SCREW 4X44MM,C1713,HCPCS,,79008938,CDM,278,RC,,,both,,,1767,1307.58,,,1307.58,Other,150% of Medicare + 9.63% HCRA Surcharge,795.15,45,,795.15,percent of total billed charges,Critical Access Hospital RCC factor,600.78,34,,600.78,percent of total billed charges,Implant Device,600.78,34,,600.78,percent of total billed charges,Implant Device,600.78,34,,600.78,percent of total billed charges,Implant Device,600.78,34,,600.78,percent of total billed charges,Implant Device,600.78,34,,600.78,percent of total billed charges,Implant Device,874.67,,,874.67,Other,110% of Medicare,618.45,35,,618.45,percent of total billed charges,Implant Device,600.78,34,"Charges > $500, x 34%",600.78,percent of total billed charges,Implant Device,618.45,35,,618.45,percent of total billed charges,Implant Device,618.45,35,,618.45,percent of total billed charges,Implant Device,618.45,35,,618.45,percent of total billed charges,Implant Device,618.45,35,,618.45,percent of total billed charges,Implant Device,618.45,35,,618.45,percent of total billed charges,Implant Device,706.8,40,,706.8,percent of total billed charges,Implant Device,618.45,70,,618.45,percent of total billed charges,All Other,600.78,34,,600.78,percent of total billed charges,Implant Device,600.78,34,,600.78,percent of total billed charges,Implant Device,618.45,35,,618.45,percent of total billed charges,Implant Device,618.45,35,,618.45,percent of total billed charges,Implant Device,618.45,35,,618.45,percent of total billed charges,Implant Device,618.45,35,,618.45,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1307.58,
STRYKER 656112 2.4X12MM BONE SCREW,C1713,HCPCS,,79008942,CDM,278,RC,,,both,,,282,208.68,,,208.68,Other,150% of Medicare + 9.63% HCRA Surcharge,126.9,45,,126.9,percent of total billed charges,Critical Access Hospital RCC factor,95.88,34,,95.88,percent of total billed charges,Implant Device,95.88,34,,95.88,percent of total billed charges,Implant Device,95.88,34,,95.88,percent of total billed charges,Implant Device,95.88,34,,95.88,percent of total billed charges,Implant Device,95.88,34,,95.88,percent of total billed charges,Implant Device,139.59,,,139.59,Other,110% of Medicare,98.7,35,,98.7,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,98.7,35,,98.7,percent of total billed charges,Implant Device,98.7,35,,98.7,percent of total billed charges,Implant Device,98.7,35,,98.7,percent of total billed charges,Implant Device,98.7,35,,98.7,percent of total billed charges,Implant Device,98.7,35,,98.7,percent of total billed charges,Implant Device,112.8,40,,112.8,percent of total billed charges,Implant Device,98.7,70,,98.7,percent of total billed charges,All Other,95.88,34,,95.88,percent of total billed charges,Implant Device,95.88,34,,95.88,percent of total billed charges,Implant Device,98.7,35,,98.7,percent of total billed charges,Implant Device,98.7,35,,98.7,percent of total billed charges,Implant Device,98.7,35,,98.7,percent of total billed charges,Implant Device,98.7,35,,98.7,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,208.68,
STRYKER 656116 2.4X16MM BONE SCREW,C1713,HCPCS,,79008943,CDM,278,RC,,,both,,,282,208.68,,,208.68,Other,150% of Medicare + 9.63% HCRA Surcharge,126.9,45,,126.9,percent of total billed charges,Critical Access Hospital RCC factor,95.88,34,,95.88,percent of total billed charges,Implant Device,95.88,34,,95.88,percent of total billed charges,Implant Device,95.88,34,,95.88,percent of total billed charges,Implant Device,95.88,34,,95.88,percent of total billed charges,Implant Device,95.88,34,,95.88,percent of total billed charges,Implant Device,139.59,,,139.59,Other,110% of Medicare,98.7,35,,98.7,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,98.7,35,,98.7,percent of total billed charges,Implant Device,98.7,35,,98.7,percent of total billed charges,Implant Device,98.7,35,,98.7,percent of total billed charges,Implant Device,98.7,35,,98.7,percent of total billed charges,Implant Device,98.7,35,,98.7,percent of total billed charges,Implant Device,112.8,40,,112.8,percent of total billed charges,Implant Device,98.7,70,,98.7,percent of total billed charges,All Other,95.88,34,,95.88,percent of total billed charges,Implant Device,95.88,34,,95.88,percent of total billed charges,Implant Device,98.7,35,,98.7,percent of total billed charges,Implant Device,98.7,35,,98.7,percent of total billed charges,Implant Device,98.7,35,,98.7,percent of total billed charges,Implant Device,98.7,35,,98.7,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,208.68,
MIMEDX AI-5020 AMNIOFIX INJECTABLE 20MG,C1713,HCPCS,,79008946,CDM,278,RC,,,both,,,992,734.08,,,734.08,Other,150% of Medicare + 9.63% HCRA Surcharge,446.4,45,,446.4,percent of total billed charges,Critical Access Hospital RCC factor,337.28,34,,337.28,percent of total billed charges,Implant Device,337.28,34,,337.28,percent of total billed charges,Implant Device,337.28,34,,337.28,percent of total billed charges,Implant Device,337.28,34,,337.28,percent of total billed charges,Implant Device,337.28,34,,337.28,percent of total billed charges,Implant Device,491.04,,,491.04,Other,110% of Medicare,347.2,35,,347.2,percent of total billed charges,Implant Device,337.28,34,"Charges > $500, x 34%",337.28,percent of total billed charges,Implant Device,347.2,35,,347.2,percent of total billed charges,Implant Device,347.2,35,,347.2,percent of total billed charges,Implant Device,347.2,35,,347.2,percent of total billed charges,Implant Device,347.2,35,,347.2,percent of total billed charges,Implant Device,347.2,35,,347.2,percent of total billed charges,Implant Device,396.8,40,,396.8,percent of total billed charges,Implant Device,347.2,70,,347.2,percent of total billed charges,All Other,337.28,34,,337.28,percent of total billed charges,Implant Device,337.28,34,,337.28,percent of total billed charges,Implant Device,347.2,35,,347.2,percent of total billed charges,Implant Device,347.2,35,,347.2,percent of total billed charges,Implant Device,347.2,35,,347.2,percent of total billed charges,Implant Device,347.2,35,,347.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,734.08,
GORE RLT261412 EXCLUDER ENDOPROS GRAFT,C1768,HCPCS,,79008947,CDM,278,RC,,,both,,,35538,26298.21,,,26298.21,Other,150% of Medicare + 9.63% HCRA Surcharge,15992.1,45,,15992.1,percent of total billed charges,Critical Access Hospital RCC factor,12082.92,34,,12082.92,percent of total billed charges,Implant Device,12082.92,34,,12082.92,percent of total billed charges,Implant Device,12082.92,34,,12082.92,percent of total billed charges,Implant Device,12082.92,34,,12082.92,percent of total billed charges,Implant Device,12082.92,34,,12082.92,percent of total billed charges,Implant Device,17591.31,,,17591.31,Other,110% of Medicare,12438.3,35,,12438.3,percent of total billed charges,Implant Device,12082.92,34,"Charges > $500, x 34%",12082.92,percent of total billed charges,Implant Device,12438.3,35,,12438.3,percent of total billed charges,Implant Device,12438.3,35,,12438.3,percent of total billed charges,Implant Device,12438.3,35,,12438.3,percent of total billed charges,Implant Device,12438.3,35,,12438.3,percent of total billed charges,Implant Device,12438.3,35,,12438.3,percent of total billed charges,Implant Device,14215.2,40,,14215.2,percent of total billed charges,Implant Device,12438.3,70,,12438.3,percent of total billed charges,All Other,12082.92,34,,12082.92,percent of total billed charges,Implant Device,12082.92,34,,12082.92,percent of total billed charges,Implant Device,12438.3,35,,12438.3,percent of total billed charges,Implant Device,12438.3,35,,12438.3,percent of total billed charges,Implant Device,12438.3,35,,12438.3,percent of total billed charges,Implant Device,12438.3,35,,12438.3,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,12082.92,34,"If Charge > 2,000, then 34 percent",12082.92,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,26298.21,
BIOMET 11-300816 DISTAL STEM 16X150MM,C1776,HCPCS,,79008949,CDM,278,RC,,,both,,,10199,7547.29,,,7547.29,Other,150% of Medicare + 9.63% HCRA Surcharge,4589.55,45,,4589.55,percent of total billed charges,Critical Access Hospital RCC factor,3467.66,34,,3467.66,percent of total billed charges,Implant Device,3467.66,34,,3467.66,percent of total billed charges,Implant Device,3467.66,34,,3467.66,percent of total billed charges,Implant Device,3467.66,34,,3467.66,percent of total billed charges,Implant Device,3467.66,34,,3467.66,percent of total billed charges,Implant Device,5048.51,,,5048.51,Other,110% of Medicare,3569.65,35,,3569.65,percent of total billed charges,Implant Device,3467.66,34,"Charges > $500, x 34%",3467.66,percent of total billed charges,Implant Device,3569.65,35,,3569.65,percent of total billed charges,Implant Device,3569.65,35,,3569.65,percent of total billed charges,Implant Device,3569.65,35,,3569.65,percent of total billed charges,Implant Device,3569.65,35,,3569.65,percent of total billed charges,Implant Device,3569.65,35,,3569.65,percent of total billed charges,Implant Device,4079.6,40,,4079.6,percent of total billed charges,Implant Device,3569.65,70,,3569.65,percent of total billed charges,All Other,3467.66,34,,3467.66,percent of total billed charges,Implant Device,3467.66,34,,3467.66,percent of total billed charges,Implant Device,3569.65,35,,3569.65,percent of total billed charges,Implant Device,3569.65,35,,3569.65,percent of total billed charges,Implant Device,3569.65,35,,3569.65,percent of total billed charges,Implant Device,3569.65,35,,3569.65,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3467.66,34,"If Charge > 2,000, then 34 percent",3467.66,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,7547.29,
S&N 71343612 FEM HEAD 12/14 TAPER 36MM,C1713,HCPCS,,79008950,CDM,278,RC,,,both,,,4851,3589.75,,,3589.75,Other,150% of Medicare + 9.63% HCRA Surcharge,2182.95,45,,2182.95,percent of total billed charges,Critical Access Hospital RCC factor,1649.34,34,,1649.34,percent of total billed charges,Implant Device,1649.34,34,,1649.34,percent of total billed charges,Implant Device,1649.34,34,,1649.34,percent of total billed charges,Implant Device,1649.34,34,,1649.34,percent of total billed charges,Implant Device,1649.34,34,,1649.34,percent of total billed charges,Implant Device,2401.25,,,2401.25,Other,110% of Medicare,1697.85,35,,1697.85,percent of total billed charges,Implant Device,1649.34,34,"Charges > $500, x 34%",1649.34,percent of total billed charges,Implant Device,1697.85,35,,1697.85,percent of total billed charges,Implant Device,1697.85,35,,1697.85,percent of total billed charges,Implant Device,1697.85,35,,1697.85,percent of total billed charges,Implant Device,1697.85,35,,1697.85,percent of total billed charges,Implant Device,1697.85,35,,1697.85,percent of total billed charges,Implant Device,1940.4,40,,1940.4,percent of total billed charges,Implant Device,1697.85,70,,1697.85,percent of total billed charges,All Other,1649.34,34,,1649.34,percent of total billed charges,Implant Device,1649.34,34,,1649.34,percent of total billed charges,Implant Device,1697.85,35,,1697.85,percent of total billed charges,Implant Device,1697.85,35,,1697.85,percent of total billed charges,Implant Device,1697.85,35,,1697.85,percent of total billed charges,Implant Device,1697.85,35,,1697.85,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1649.34,34,"If Charge > 2,000, then 34 percent",1649.34,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3589.75,
GORE PHA070802A TIGRIS 7MMX80MM STENT,C1876,HCPCS,,79008951,CDM,278,RC,,,both,,,4485,3318.91,,,3318.91,Other,150% of Medicare + 9.63% HCRA Surcharge,2018.25,45,,2018.25,percent of total billed charges,Critical Access Hospital RCC factor,1524.9,34,,1524.9,percent of total billed charges,Implant Device,1524.9,34,,1524.9,percent of total billed charges,Implant Device,1524.9,34,,1524.9,percent of total billed charges,Implant Device,1524.9,34,,1524.9,percent of total billed charges,Implant Device,1524.9,34,,1524.9,percent of total billed charges,Implant Device,2220.08,,,2220.08,Other,110% of Medicare,1569.75,35,,1569.75,percent of total billed charges,Implant Device,1524.9,34,"Charges > $500, x 34%",1524.9,percent of total billed charges,Implant Device,1569.75,35,,1569.75,percent of total billed charges,Implant Device,1569.75,35,,1569.75,percent of total billed charges,Implant Device,1569.75,35,,1569.75,percent of total billed charges,Implant Device,1569.75,35,,1569.75,percent of total billed charges,Implant Device,1569.75,35,,1569.75,percent of total billed charges,Implant Device,1794,40,,1794,percent of total billed charges,Implant Device,1569.75,70,,1569.75,percent of total billed charges,All Other,1524.9,34,,1524.9,percent of total billed charges,Implant Device,1524.9,34,,1524.9,percent of total billed charges,Implant Device,1569.75,35,,1569.75,percent of total billed charges,Implant Device,1569.75,35,,1569.75,percent of total billed charges,Implant Device,1569.75,35,,1569.75,percent of total billed charges,Implant Device,1569.75,35,,1569.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1524.9,34,"If Charge > 2,000, then 34 percent",1524.9,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3318.91,
STRYKER 604636 4.0X36MM ASNIS SCREW,C1713,HCPCS,,79008952,CDM,278,RC,,,both,,,480,355.2,,,355.2,Other,150% of Medicare + 9.63% HCRA Surcharge,216,45,,216,percent of total billed charges,Critical Access Hospital RCC factor,163.2,34,,163.2,percent of total billed charges,Implant Device,163.2,34,,163.2,percent of total billed charges,Implant Device,163.2,34,,163.2,percent of total billed charges,Implant Device,163.2,34,,163.2,percent of total billed charges,Implant Device,163.2,34,,163.2,percent of total billed charges,Implant Device,237.6,,,237.6,Other,110% of Medicare,168,35,,168,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,192,40,,192,percent of total billed charges,Implant Device,168,70,,168,percent of total billed charges,All Other,163.2,34,,163.2,percent of total billed charges,Implant Device,163.2,34,,163.2,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,355.2,
STRYKER 1830-0929S 9X290MM HUMERAL NAIL,C1713,HCPCS,,79008953,CDM,278,RC,,,both,,,6661,4929.16,,,4929.16,Other,150% of Medicare + 9.63% HCRA Surcharge,2997.45,45,,2997.45,percent of total billed charges,Critical Access Hospital RCC factor,2264.74,34,,2264.74,percent of total billed charges,Implant Device,2264.74,34,,2264.74,percent of total billed charges,Implant Device,2264.74,34,,2264.74,percent of total billed charges,Implant Device,2264.74,34,,2264.74,percent of total billed charges,Implant Device,2264.74,34,,2264.74,percent of total billed charges,Implant Device,3297.2,,,3297.2,Other,110% of Medicare,2331.35,35,,2331.35,percent of total billed charges,Implant Device,2264.74,34,"Charges > $500, x 34%",2264.74,percent of total billed charges,Implant Device,2331.35,35,,2331.35,percent of total billed charges,Implant Device,2331.35,35,,2331.35,percent of total billed charges,Implant Device,2331.35,35,,2331.35,percent of total billed charges,Implant Device,2331.35,35,,2331.35,percent of total billed charges,Implant Device,2331.35,35,,2331.35,percent of total billed charges,Implant Device,2664.4,40,,2664.4,percent of total billed charges,Implant Device,2331.35,70,,2331.35,percent of total billed charges,All Other,2264.74,34,,2264.74,percent of total billed charges,Implant Device,2264.74,34,,2264.74,percent of total billed charges,Implant Device,2331.35,35,,2331.35,percent of total billed charges,Implant Device,2331.35,35,,2331.35,percent of total billed charges,Implant Device,2331.35,35,,2331.35,percent of total billed charges,Implant Device,2331.35,35,,2331.35,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2264.74,34,"If Charge > 2,000, then 34 percent",2264.74,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4929.16,
STRYKER 1896-4060S 4X60MM LOCKING SCREW,C1713,HCPCS,,79008954,CDM,278,RC,,,both,,,836,618.64,,,618.64,Other,150% of Medicare + 9.63% HCRA Surcharge,376.2,45,,376.2,percent of total billed charges,Critical Access Hospital RCC factor,284.24,34,,284.24,percent of total billed charges,Implant Device,284.24,34,,284.24,percent of total billed charges,Implant Device,284.24,34,,284.24,percent of total billed charges,Implant Device,284.24,34,,284.24,percent of total billed charges,Implant Device,284.24,34,,284.24,percent of total billed charges,Implant Device,413.82,,,413.82,Other,110% of Medicare,292.6,35,,292.6,percent of total billed charges,Implant Device,284.24,34,"Charges > $500, x 34%",284.24,percent of total billed charges,Implant Device,292.6,35,,292.6,percent of total billed charges,Implant Device,292.6,35,,292.6,percent of total billed charges,Implant Device,292.6,35,,292.6,percent of total billed charges,Implant Device,292.6,35,,292.6,percent of total billed charges,Implant Device,292.6,35,,292.6,percent of total billed charges,Implant Device,334.4,40,,334.4,percent of total billed charges,Implant Device,292.6,70,,292.6,percent of total billed charges,All Other,284.24,34,,284.24,percent of total billed charges,Implant Device,284.24,34,,284.24,percent of total billed charges,Implant Device,292.6,35,,292.6,percent of total billed charges,Implant Device,292.6,35,,292.6,percent of total billed charges,Implant Device,292.6,35,,292.6,percent of total billed charges,Implant Device,292.6,35,,292.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,618.64,
STRYKER 1832-3822S 8X220MM HUMERAL NAIL,C1713,HCPCS,,79008955,CDM,278,RC,,,both,,,4326,3201.25,,,3201.25,Other,150% of Medicare + 9.63% HCRA Surcharge,1946.7,45,,1946.7,percent of total billed charges,Critical Access Hospital RCC factor,1470.84,34,,1470.84,percent of total billed charges,Implant Device,1470.84,34,,1470.84,percent of total billed charges,Implant Device,1470.84,34,,1470.84,percent of total billed charges,Implant Device,1470.84,34,,1470.84,percent of total billed charges,Implant Device,1470.84,34,,1470.84,percent of total billed charges,Implant Device,2141.37,,,2141.37,Other,110% of Medicare,1514.1,35,,1514.1,percent of total billed charges,Implant Device,1470.84,34,"Charges > $500, x 34%",1470.84,percent of total billed charges,Implant Device,1514.1,35,,1514.1,percent of total billed charges,Implant Device,1514.1,35,,1514.1,percent of total billed charges,Implant Device,1514.1,35,,1514.1,percent of total billed charges,Implant Device,1514.1,35,,1514.1,percent of total billed charges,Implant Device,1514.1,35,,1514.1,percent of total billed charges,Implant Device,1730.4,40,,1730.4,percent of total billed charges,Implant Device,1514.1,70,,1514.1,percent of total billed charges,All Other,1470.84,34,,1470.84,percent of total billed charges,Implant Device,1470.84,34,,1470.84,percent of total billed charges,Implant Device,1514.1,35,,1514.1,percent of total billed charges,Implant Device,1514.1,35,,1514.1,percent of total billed charges,Implant Device,1514.1,35,,1514.1,percent of total billed charges,Implant Device,1514.1,35,,1514.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1470.84,34,"If Charge > 2,000, then 34 percent",1470.84,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3201.25,
TORNIER 7122881 HUMERAL HEAD 44X18MM,C1776,HCPCS,,79008956,CDM,278,RC,,,both,,,16246,12022.08,,,12022.08,Other,150% of Medicare + 9.63% HCRA Surcharge,7310.7,45,,7310.7,percent of total billed charges,Critical Access Hospital RCC factor,5523.64,34,,5523.64,percent of total billed charges,Implant Device,5523.64,34,,5523.64,percent of total billed charges,Implant Device,5523.64,34,,5523.64,percent of total billed charges,Implant Device,5523.64,34,,5523.64,percent of total billed charges,Implant Device,5523.64,34,,5523.64,percent of total billed charges,Implant Device,8041.77,,,8041.77,Other,110% of Medicare,5686.1,35,,5686.1,percent of total billed charges,Implant Device,5523.64,34,"Charges > $500, x 34%",5523.64,percent of total billed charges,Implant Device,5686.1,35,,5686.1,percent of total billed charges,Implant Device,5686.1,35,,5686.1,percent of total billed charges,Implant Device,5686.1,35,,5686.1,percent of total billed charges,Implant Device,5686.1,35,,5686.1,percent of total billed charges,Implant Device,5686.1,35,,5686.1,percent of total billed charges,Implant Device,6498.4,40,,6498.4,percent of total billed charges,Implant Device,5686.1,70,,5686.1,percent of total billed charges,All Other,5523.64,34,,5523.64,percent of total billed charges,Implant Device,5523.64,34,,5523.64,percent of total billed charges,Implant Device,5686.1,35,,5686.1,percent of total billed charges,Implant Device,5686.1,35,,5686.1,percent of total billed charges,Implant Device,5686.1,35,,5686.1,percent of total billed charges,Implant Device,5686.1,35,,5686.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,5523.64,34,"If Charge > 2,000, then 34 percent",5523.64,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,12022.08,
TORNIER DWE403 GLENOID CORTILOC S40,C1776,HCPCS,,79008958,CDM,278,RC,,,both,,,10164,7521.39,,,7521.39,Other,150% of Medicare + 9.63% HCRA Surcharge,4573.8,45,,4573.8,percent of total billed charges,Critical Access Hospital RCC factor,3455.76,34,,3455.76,percent of total billed charges,Implant Device,3455.76,34,,3455.76,percent of total billed charges,Implant Device,3455.76,34,,3455.76,percent of total billed charges,Implant Device,3455.76,34,,3455.76,percent of total billed charges,Implant Device,3455.76,34,,3455.76,percent of total billed charges,Implant Device,5031.18,,,5031.18,Other,110% of Medicare,3557.4,35,,3557.4,percent of total billed charges,Implant Device,3455.76,34,"Charges > $500, x 34%",3455.76,percent of total billed charges,Implant Device,3557.4,35,,3557.4,percent of total billed charges,Implant Device,3557.4,35,,3557.4,percent of total billed charges,Implant Device,3557.4,35,,3557.4,percent of total billed charges,Implant Device,3557.4,35,,3557.4,percent of total billed charges,Implant Device,3557.4,35,,3557.4,percent of total billed charges,Implant Device,4065.6,40,,4065.6,percent of total billed charges,Implant Device,3557.4,70,,3557.4,percent of total billed charges,All Other,3455.76,34,,3455.76,percent of total billed charges,Implant Device,3455.76,34,,3455.76,percent of total billed charges,Implant Device,3557.4,35,,3557.4,percent of total billed charges,Implant Device,3557.4,35,,3557.4,percent of total billed charges,Implant Device,3557.4,35,,3557.4,percent of total billed charges,Implant Device,3557.4,35,,3557.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3455.76,34,"If Charge > 2,000, then 34 percent",3455.76,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,7521.39,
TORNIER DWG402 SIMPLICITI NUCLEUS SZ 2,C1776,HCPCS,,79008959,CDM,278,RC,,,both,,,20533,15194.47,,,15194.47,Other,150% of Medicare + 9.63% HCRA Surcharge,9239.85,45,,9239.85,percent of total billed charges,Critical Access Hospital RCC factor,6981.22,34,,6981.22,percent of total billed charges,Implant Device,6981.22,34,,6981.22,percent of total billed charges,Implant Device,6981.22,34,,6981.22,percent of total billed charges,Implant Device,6981.22,34,,6981.22,percent of total billed charges,Implant Device,6981.22,34,,6981.22,percent of total billed charges,Implant Device,10163.84,,,10163.84,Other,110% of Medicare,7186.55,35,,7186.55,percent of total billed charges,Implant Device,6981.22,34,"Charges > $500, x 34%",6981.22,percent of total billed charges,Implant Device,7186.55,35,,7186.55,percent of total billed charges,Implant Device,7186.55,35,,7186.55,percent of total billed charges,Implant Device,7186.55,35,,7186.55,percent of total billed charges,Implant Device,7186.55,35,,7186.55,percent of total billed charges,Implant Device,7186.55,35,,7186.55,percent of total billed charges,Implant Device,8213.2,40,,8213.2,percent of total billed charges,Implant Device,7186.55,70,,7186.55,percent of total billed charges,All Other,6981.22,34,,6981.22,percent of total billed charges,Implant Device,6981.22,34,,6981.22,percent of total billed charges,Implant Device,7186.55,35,,7186.55,percent of total billed charges,Implant Device,7186.55,35,,7186.55,percent of total billed charges,Implant Device,7186.55,35,,7186.55,percent of total billed charges,Implant Device,7186.55,35,,7186.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,6981.22,34,"If Charge > 2,000, then 34 percent",6981.22,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,15194.47,
ANGIODYNAMICS H965451830 POWER PORT 8FR,C1788,HCPCS,,79008960,CDM,278,RC,,,both,,,1575,1165.5,,,1165.5,Other,150% of Medicare + 9.63% HCRA Surcharge,708.75,45,,708.75,percent of total billed charges,Critical Access Hospital RCC factor,535.5,34,,535.5,percent of total billed charges,Implant Device,535.5,34,,535.5,percent of total billed charges,Implant Device,535.5,34,,535.5,percent of total billed charges,Implant Device,535.5,34,,535.5,percent of total billed charges,Implant Device,535.5,34,,535.5,percent of total billed charges,Implant Device,779.63,,,779.63,Other,110% of Medicare,551.25,35,,551.25,percent of total billed charges,Implant Device,535.5,34,"Charges > $500, x 34%",535.5,percent of total billed charges,Implant Device,551.25,35,,551.25,percent of total billed charges,Implant Device,551.25,35,,551.25,percent of total billed charges,Implant Device,551.25,35,,551.25,percent of total billed charges,Implant Device,551.25,35,,551.25,percent of total billed charges,Implant Device,551.25,35,,551.25,percent of total billed charges,Implant Device,630,40,,630,percent of total billed charges,Implant Device,551.25,70,,551.25,percent of total billed charges,All Other,535.5,34,,535.5,percent of total billed charges,Implant Device,535.5,34,,535.5,percent of total billed charges,Implant Device,551.25,35,,551.25,percent of total billed charges,Implant Device,551.25,35,,551.25,percent of total billed charges,Implant Device,551.25,35,,551.25,percent of total billed charges,Implant Device,551.25,35,,551.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1165.5,
IN2BONES P40 ST245 LAPIDUS PLATE STD LT,C1713,HCPCS,,79008961,CDM,278,RC,,,both,,,6000,4440.02,,,4440.02,Other,150% of Medicare + 9.63% HCRA Surcharge,2700,45,,2700,percent of total billed charges,Critical Access Hospital RCC factor,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2970,,,2970,Other,110% of Medicare,2100,35,,2100,percent of total billed charges,Implant Device,2040,34,"Charges > $500, x 34%",2040,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2400,40,,2400,percent of total billed charges,Implant Device,2100,70,,2100,percent of total billed charges,All Other,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2040,34,"If Charge > 2,000, then 34 percent",2040,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4440.02,
IN2BONES V30 ST310 PLATE SCREW 3.0X10MM,C1713,HCPCS,,79008962,CDM,278,RC,,,both,,,870,643.8,,,643.8,Other,150% of Medicare + 9.63% HCRA Surcharge,391.5,45,,391.5,percent of total billed charges,Critical Access Hospital RCC factor,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,430.65,,,430.65,Other,110% of Medicare,304.5,35,,304.5,percent of total billed charges,Implant Device,295.8,34,"Charges > $500, x 34%",295.8,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,348,40,,348,percent of total billed charges,Implant Device,304.5,70,,304.5,percent of total billed charges,All Other,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,643.8,
IN2BONES V30 ST430 TRANSVERSE SCREW 3X30,C1713,HCPCS,,79008963,CDM,278,RC,,,both,,,870,643.8,,,643.8,Other,150% of Medicare + 9.63% HCRA Surcharge,391.5,45,,391.5,percent of total billed charges,Critical Access Hospital RCC factor,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,430.65,,,430.65,Other,110% of Medicare,304.5,35,,304.5,percent of total billed charges,Implant Device,295.8,34,"Charges > $500, x 34%",295.8,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,348,40,,348,percent of total billed charges,Implant Device,304.5,70,,304.5,percent of total billed charges,All Other,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,643.8,
IN2BONES V30 ST426 TRANSVERSE SCREW 3X26,C1713,HCPCS,,79008964,CDM,278,RC,,,both,,,870,643.8,,,643.8,Other,150% of Medicare + 9.63% HCRA Surcharge,391.5,45,,391.5,percent of total billed charges,Critical Access Hospital RCC factor,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,430.65,,,430.65,Other,110% of Medicare,304.5,35,,304.5,percent of total billed charges,Implant Device,295.8,34,"Charges > $500, x 34%",295.8,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,348,40,,348,percent of total billed charges,Implant Device,304.5,70,,304.5,percent of total billed charges,All Other,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,643.8,
IN2BONES P40 ST145 LAPIDUS PLATE STD RT,C1713,HCPCS,,79008965,CDM,278,RC,,,both,,,6000,4440.02,,,4440.02,Other,150% of Medicare + 9.63% HCRA Surcharge,2700,45,,2700,percent of total billed charges,Critical Access Hospital RCC factor,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2970,,,2970,Other,110% of Medicare,2100,35,,2100,percent of total billed charges,Implant Device,2040,34,"Charges > $500, x 34%",2040,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2400,40,,2400,percent of total billed charges,Implant Device,2100,70,,2100,percent of total billed charges,All Other,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2040,34,"If Charge > 2,000, then 34 percent",2040,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4440.02,
IN2BONES V30 ST318 PLATE SCREW 3.0X18MM,C1713,HCPCS,,79008966,CDM,278,RC,,,both,,,870,643.8,,,643.8,Other,150% of Medicare + 9.63% HCRA Surcharge,391.5,45,,391.5,percent of total billed charges,Critical Access Hospital RCC factor,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,430.65,,,430.65,Other,110% of Medicare,304.5,35,,304.5,percent of total billed charges,Implant Device,295.8,34,"Charges > $500, x 34%",295.8,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,348,40,,348,percent of total billed charges,Implant Device,304.5,70,,304.5,percent of total billed charges,All Other,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,643.8,
IN2BONES V30 ST320 PLATE SCREW 3.0X20MM,C1713,HCPCS,,79008967,CDM,278,RC,,,both,,,870,643.8,,,643.8,Other,150% of Medicare + 9.63% HCRA Surcharge,391.5,45,,391.5,percent of total billed charges,Critical Access Hospital RCC factor,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,430.65,,,430.65,Other,110% of Medicare,304.5,35,,304.5,percent of total billed charges,Implant Device,295.8,34,"Charges > $500, x 34%",295.8,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,348,40,,348,percent of total billed charges,Implant Device,304.5,70,,304.5,percent of total billed charges,All Other,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,643.8,
MAQUET 1000204-01 PROLITE MESH,C1781,HCPCS,,79008968,CDM,278,RC,,,both,,,118,87.32,,,87.32,Other,150% of Medicare + 9.63% HCRA Surcharge,53.1,45,,53.1,percent of total billed charges,Critical Access Hospital RCC factor,40.12,34,,40.12,percent of total billed charges,Implant Device,40.12,34,,40.12,percent of total billed charges,Implant Device,40.12,34,,40.12,percent of total billed charges,Implant Device,40.12,34,,40.12,percent of total billed charges,Implant Device,40.12,34,,40.12,percent of total billed charges,Implant Device,58.41,,,58.41,Other,110% of Medicare,41.3,35,,41.3,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,41.3,35,,41.3,percent of total billed charges,Implant Device,41.3,35,,41.3,percent of total billed charges,Implant Device,41.3,35,,41.3,percent of total billed charges,Implant Device,41.3,35,,41.3,percent of total billed charges,Implant Device,41.3,35,,41.3,percent of total billed charges,Implant Device,47.2,40,,47.2,percent of total billed charges,Implant Device,41.3,70,,41.3,percent of total billed charges,All Other,40.12,34,,40.12,percent of total billed charges,Implant Device,40.12,34,,40.12,percent of total billed charges,Implant Device,41.3,35,,41.3,percent of total billed charges,Implant Device,41.3,35,,41.3,percent of total billed charges,Implant Device,41.3,35,,41.3,percent of total billed charges,Implant Device,41.3,35,,41.3,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,87.32,
EXACTECH SPS0121K INTERSPACE SHOULDR KIT,C1776,HCPCS,,79008971,CDM,278,RC,,,both,,,11942,8837.11,,,8837.11,Other,150% of Medicare + 9.63% HCRA Surcharge,5373.9,45,,5373.9,percent of total billed charges,Critical Access Hospital RCC factor,4060.28,34,,4060.28,percent of total billed charges,Implant Device,4060.28,34,,4060.28,percent of total billed charges,Implant Device,4060.28,34,,4060.28,percent of total billed charges,Implant Device,4060.28,34,,4060.28,percent of total billed charges,Implant Device,4060.28,34,,4060.28,percent of total billed charges,Implant Device,5911.29,,,5911.29,Other,110% of Medicare,4179.7,35,,4179.7,percent of total billed charges,Implant Device,4060.28,34,"Charges > $500, x 34%",4060.28,percent of total billed charges,Implant Device,4179.7,35,,4179.7,percent of total billed charges,Implant Device,4179.7,35,,4179.7,percent of total billed charges,Implant Device,4179.7,35,,4179.7,percent of total billed charges,Implant Device,4179.7,35,,4179.7,percent of total billed charges,Implant Device,4179.7,35,,4179.7,percent of total billed charges,Implant Device,4776.8,40,,4776.8,percent of total billed charges,Implant Device,4179.7,70,,4179.7,percent of total billed charges,All Other,4060.28,34,,4060.28,percent of total billed charges,Implant Device,4060.28,34,,4060.28,percent of total billed charges,Implant Device,4179.7,35,,4179.7,percent of total billed charges,Implant Device,4179.7,35,,4179.7,percent of total billed charges,Implant Device,4179.7,35,,4179.7,percent of total billed charges,Implant Device,4179.7,35,,4179.7,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,4060.28,34,"If Charge > 2,000, then 34 percent",4060.28,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,8837.11,
STRYKER 5030-3-2501 5/4X250 TRANSFIX PIN,C1713,HCPCS,,79008972,CDM,278,RC,,,both,,,234,173.16,,,173.16,Other,150% of Medicare + 9.63% HCRA Surcharge,105.3,45,,105.3,percent of total billed charges,Critical Access Hospital RCC factor,79.56,34,,79.56,percent of total billed charges,Implant Device,79.56,34,,79.56,percent of total billed charges,Implant Device,79.56,34,,79.56,percent of total billed charges,Implant Device,79.56,34,,79.56,percent of total billed charges,Implant Device,79.56,34,,79.56,percent of total billed charges,Implant Device,115.83,,,115.83,Other,110% of Medicare,81.9,35,,81.9,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,81.9,35,,81.9,percent of total billed charges,Implant Device,81.9,35,,81.9,percent of total billed charges,Implant Device,81.9,35,,81.9,percent of total billed charges,Implant Device,81.9,35,,81.9,percent of total billed charges,Implant Device,81.9,35,,81.9,percent of total billed charges,Implant Device,93.6,40,,93.6,percent of total billed charges,Implant Device,81.9,70,,81.9,percent of total billed charges,All Other,79.56,34,,79.56,percent of total billed charges,Implant Device,79.56,34,,79.56,percent of total billed charges,Implant Device,81.9,35,,81.9,percent of total billed charges,Implant Device,81.9,35,,81.9,percent of total billed charges,Implant Device,81.9,35,,81.9,percent of total billed charges,Implant Device,81.9,35,,81.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,173.16,
ARTHREX AR-8950-12 2X12MM QUICK FIX SCRW,C1713,HCPCS,,79008975,CDM,278,RC,,,both,,,1029,761.46,,,761.46,Other,150% of Medicare + 9.63% HCRA Surcharge,463.05,45,,463.05,percent of total billed charges,Critical Access Hospital RCC factor,349.86,34,,349.86,percent of total billed charges,Implant Device,349.86,34,,349.86,percent of total billed charges,Implant Device,349.86,34,,349.86,percent of total billed charges,Implant Device,349.86,34,,349.86,percent of total billed charges,Implant Device,349.86,34,,349.86,percent of total billed charges,Implant Device,509.36,,,509.36,Other,110% of Medicare,360.15,35,,360.15,percent of total billed charges,Implant Device,349.86,34,"Charges > $500, x 34%",349.86,percent of total billed charges,Implant Device,360.15,35,,360.15,percent of total billed charges,Implant Device,360.15,35,,360.15,percent of total billed charges,Implant Device,360.15,35,,360.15,percent of total billed charges,Implant Device,360.15,35,,360.15,percent of total billed charges,Implant Device,360.15,35,,360.15,percent of total billed charges,Implant Device,411.6,40,,411.6,percent of total billed charges,Implant Device,360.15,70,,360.15,percent of total billed charges,All Other,349.86,34,,349.86,percent of total billed charges,Implant Device,349.86,34,,349.86,percent of total billed charges,Implant Device,360.15,35,,360.15,percent of total billed charges,Implant Device,360.15,35,,360.15,percent of total billed charges,Implant Device,360.15,35,,360.15,percent of total billed charges,Implant Device,360.15,35,,360.15,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,761.46,
BIOMET 8145-10-130 10.5X130MM LAG SCREW,C1713,HCPCS,,79008977,CDM,278,RC,,,both,,,3180,2353.21,,,2353.21,Other,150% of Medicare + 9.63% HCRA Surcharge,1431,45,,1431,percent of total billed charges,Critical Access Hospital RCC factor,1081.2,34,,1081.2,percent of total billed charges,Implant Device,1081.2,34,,1081.2,percent of total billed charges,Implant Device,1081.2,34,,1081.2,percent of total billed charges,Implant Device,1081.2,34,,1081.2,percent of total billed charges,Implant Device,1081.2,34,,1081.2,percent of total billed charges,Implant Device,1574.1,,,1574.1,Other,110% of Medicare,1113,35,,1113,percent of total billed charges,Implant Device,1081.2,34,"Charges > $500, x 34%",1081.2,percent of total billed charges,Implant Device,1113,35,,1113,percent of total billed charges,Implant Device,1113,35,,1113,percent of total billed charges,Implant Device,1113,35,,1113,percent of total billed charges,Implant Device,1113,35,,1113,percent of total billed charges,Implant Device,1113,35,,1113,percent of total billed charges,Implant Device,1272,40,,1272,percent of total billed charges,Implant Device,1113,70,,1113,percent of total billed charges,All Other,1081.2,34,,1081.2,percent of total billed charges,Implant Device,1081.2,34,,1081.2,percent of total billed charges,Implant Device,1113,35,,1113,percent of total billed charges,Implant Device,1113,35,,1113,percent of total billed charges,Implant Device,1113,35,,1113,percent of total billed charges,Implant Device,1113,35,,1113,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1081.2,34,"If Charge > 2,000, then 34 percent",1081.2,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2353.21,
NUVASIVE 5016001 BONE MATRIX-SM-1CC,C1713,HCPCS,,79008979,CDM,278,RC,,,both,,,1800,1332,,,1332,Other,150% of Medicare + 9.63% HCRA Surcharge,810,45,,810,percent of total billed charges,Critical Access Hospital RCC factor,612,34,,612,percent of total billed charges,Implant Device,612,34,,612,percent of total billed charges,Implant Device,612,34,,612,percent of total billed charges,Implant Device,612,34,,612,percent of total billed charges,Implant Device,612,34,,612,percent of total billed charges,Implant Device,891,,,891,Other,110% of Medicare,630,35,,630,percent of total billed charges,Implant Device,612,34,"Charges > $500, x 34%",612,percent of total billed charges,Implant Device,630,35,,630,percent of total billed charges,Implant Device,630,35,,630,percent of total billed charges,Implant Device,630,35,,630,percent of total billed charges,Implant Device,630,35,,630,percent of total billed charges,Implant Device,630,35,,630,percent of total billed charges,Implant Device,720,40,,720,percent of total billed charges,Implant Device,630,70,,630,percent of total billed charges,All Other,612,34,,612,percent of total billed charges,Implant Device,612,34,,612,percent of total billed charges,Implant Device,630,35,,630,percent of total billed charges,Implant Device,630,35,,630,percent of total billed charges,Implant Device,630,35,,630,percent of total billed charges,Implant Device,630,35,,630,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1332,
NUVASIVE 5016005 BONE MATRIX-MED-5CC,C1713,HCPCS,,79008980,CDM,278,RC,,,both,,,7500,5550.02,,,5550.02,Other,150% of Medicare + 9.63% HCRA Surcharge,3375,45,,3375,percent of total billed charges,Critical Access Hospital RCC factor,2550,34,,2550,percent of total billed charges,Implant Device,2550,34,,2550,percent of total billed charges,Implant Device,2550,34,,2550,percent of total billed charges,Implant Device,2550,34,,2550,percent of total billed charges,Implant Device,2550,34,,2550,percent of total billed charges,Implant Device,3712.5,,,3712.5,Other,110% of Medicare,2625,35,,2625,percent of total billed charges,Implant Device,2550,34,"Charges > $500, x 34%",2550,percent of total billed charges,Implant Device,2625,35,,2625,percent of total billed charges,Implant Device,2625,35,,2625,percent of total billed charges,Implant Device,2625,35,,2625,percent of total billed charges,Implant Device,2625,35,,2625,percent of total billed charges,Implant Device,2625,35,,2625,percent of total billed charges,Implant Device,3000,40,,3000,percent of total billed charges,Implant Device,2625,70,,2625,percent of total billed charges,All Other,2550,34,,2550,percent of total billed charges,Implant Device,2550,34,,2550,percent of total billed charges,Implant Device,2625,35,,2625,percent of total billed charges,Implant Device,2625,35,,2625,percent of total billed charges,Implant Device,2625,35,,2625,percent of total billed charges,Implant Device,2625,35,,2625,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2550,34,"If Charge > 2,000, then 34 percent",2550,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5550.02,
NUVASIVE 5016010 BONE MATRIX-LRG-10CC,C1713,HCPCS,,79008981,CDM,278,RC,,,both,,,13500,9990.03,,,9990.03,Other,150% of Medicare + 9.63% HCRA Surcharge,6075,45,,6075,percent of total billed charges,Critical Access Hospital RCC factor,4590,34,,4590,percent of total billed charges,Implant Device,4590,34,,4590,percent of total billed charges,Implant Device,4590,34,,4590,percent of total billed charges,Implant Device,4590,34,,4590,percent of total billed charges,Implant Device,4590,34,,4590,percent of total billed charges,Implant Device,6682.5,,,6682.5,Other,110% of Medicare,4725,35,,4725,percent of total billed charges,Implant Device,4590,34,"Charges > $500, x 34%",4590,percent of total billed charges,Implant Device,4725,35,,4725,percent of total billed charges,Implant Device,4725,35,,4725,percent of total billed charges,Implant Device,4725,35,,4725,percent of total billed charges,Implant Device,4725,35,,4725,percent of total billed charges,Implant Device,4725,35,,4725,percent of total billed charges,Implant Device,5400,40,,5400,percent of total billed charges,Implant Device,4725,70,,4725,percent of total billed charges,All Other,4590,34,,4590,percent of total billed charges,Implant Device,4590,34,,4590,percent of total billed charges,Implant Device,4725,35,,4725,percent of total billed charges,Implant Device,4725,35,,4725,percent of total billed charges,Implant Device,4725,35,,4725,percent of total billed charges,Implant Device,4725,35,,4725,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,4590,34,"If Charge > 2,000, then 34 percent",4590,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,9990.03,
STRYKER 40-35060 3.5X60MM NON LOCK SCREW,C1713,HCPCS,,79008982,CDM,278,RC,,,both,,,370,273.8,,,273.8,Other,150% of Medicare + 9.63% HCRA Surcharge,166.5,45,,166.5,percent of total billed charges,Critical Access Hospital RCC factor,125.8,34,,125.8,percent of total billed charges,Implant Device,125.8,34,,125.8,percent of total billed charges,Implant Device,125.8,34,,125.8,percent of total billed charges,Implant Device,125.8,34,,125.8,percent of total billed charges,Implant Device,125.8,34,,125.8,percent of total billed charges,Implant Device,183.15,,,183.15,Other,110% of Medicare,129.5,35,,129.5,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,129.5,35,,129.5,percent of total billed charges,Implant Device,129.5,35,,129.5,percent of total billed charges,Implant Device,129.5,35,,129.5,percent of total billed charges,Implant Device,129.5,35,,129.5,percent of total billed charges,Implant Device,129.5,35,,129.5,percent of total billed charges,Implant Device,148,40,,148,percent of total billed charges,Implant Device,129.5,70,,129.5,percent of total billed charges,All Other,125.8,34,,125.8,percent of total billed charges,Implant Device,125.8,34,,125.8,percent of total billed charges,Implant Device,129.5,35,,129.5,percent of total billed charges,Implant Device,129.5,35,,129.5,percent of total billed charges,Implant Device,129.5,35,,129.5,percent of total billed charges,Implant Device,129.5,35,,129.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,273.8,
STRYKER 602710 6.5X110MM CANCELLOUS SCRW,C1713,HCPCS,,79008983,CDM,278,RC,,,both,,,1224,905.76,,,905.76,Other,150% of Medicare + 9.63% HCRA Surcharge,550.8,45,,550.8,percent of total billed charges,Critical Access Hospital RCC factor,416.16,34,,416.16,percent of total billed charges,Implant Device,416.16,34,,416.16,percent of total billed charges,Implant Device,416.16,34,,416.16,percent of total billed charges,Implant Device,416.16,34,,416.16,percent of total billed charges,Implant Device,416.16,34,,416.16,percent of total billed charges,Implant Device,605.88,,,605.88,Other,110% of Medicare,428.4,35,,428.4,percent of total billed charges,Implant Device,416.16,34,"Charges > $500, x 34%",416.16,percent of total billed charges,Implant Device,428.4,35,,428.4,percent of total billed charges,Implant Device,428.4,35,,428.4,percent of total billed charges,Implant Device,428.4,35,,428.4,percent of total billed charges,Implant Device,428.4,35,,428.4,percent of total billed charges,Implant Device,428.4,35,,428.4,percent of total billed charges,Implant Device,489.6,40,,489.6,percent of total billed charges,Implant Device,428.4,70,,428.4,percent of total billed charges,All Other,416.16,34,,416.16,percent of total billed charges,Implant Device,416.16,34,,416.16,percent of total billed charges,Implant Device,428.4,35,,428.4,percent of total billed charges,Implant Device,428.4,35,,428.4,percent of total billed charges,Implant Device,428.4,35,,428.4,percent of total billed charges,Implant Device,428.4,35,,428.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,905.76,
DEPUY 202.212 LOCKING SCREW 2.7X12MM,C1713,HCPCS,,79008987,CDM,278,RC,,,both,,,300,222,,,222,Other,150% of Medicare + 9.63% HCRA Surcharge,135,45,,135,percent of total billed charges,Critical Access Hospital RCC factor,102,34,,102,percent of total billed charges,Implant Device,102,34,,102,percent of total billed charges,Implant Device,102,34,,102,percent of total billed charges,Implant Device,102,34,,102,percent of total billed charges,Implant Device,102,34,,102,percent of total billed charges,Implant Device,148.5,,,148.5,Other,110% of Medicare,105,35,,105,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,105,35,,105,percent of total billed charges,Implant Device,105,35,,105,percent of total billed charges,Implant Device,105,35,,105,percent of total billed charges,Implant Device,105,35,,105,percent of total billed charges,Implant Device,105,35,,105,percent of total billed charges,Implant Device,120,40,,120,percent of total billed charges,Implant Device,105,70,,105,percent of total billed charges,All Other,102,34,,102,percent of total billed charges,Implant Device,102,34,,102,percent of total billed charges,Implant Device,105,35,,105,percent of total billed charges,Implant Device,105,35,,105,percent of total billed charges,Implant Device,105,35,,105,percent of total billed charges,Implant Device,105,35,,105,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,222,
DEPUY 02.112.137 DIS FIB PLATE 3.5X73MM,C1713,HCPCS,,79008988,CDM,278,RC,,,both,,,1618,1197.32,,,1197.32,Other,150% of Medicare + 9.63% HCRA Surcharge,728.1,45,,728.1,percent of total billed charges,Critical Access Hospital RCC factor,550.12,34,,550.12,percent of total billed charges,Implant Device,550.12,34,,550.12,percent of total billed charges,Implant Device,550.12,34,,550.12,percent of total billed charges,Implant Device,550.12,34,,550.12,percent of total billed charges,Implant Device,550.12,34,,550.12,percent of total billed charges,Implant Device,800.91,,,800.91,Other,110% of Medicare,566.3,35,,566.3,percent of total billed charges,Implant Device,550.12,34,"Charges > $500, x 34%",550.12,percent of total billed charges,Implant Device,566.3,35,,566.3,percent of total billed charges,Implant Device,566.3,35,,566.3,percent of total billed charges,Implant Device,566.3,35,,566.3,percent of total billed charges,Implant Device,566.3,35,,566.3,percent of total billed charges,Implant Device,566.3,35,,566.3,percent of total billed charges,Implant Device,647.2,40,,647.2,percent of total billed charges,Implant Device,566.3,70,,566.3,percent of total billed charges,All Other,550.12,34,,550.12,percent of total billed charges,Implant Device,550.12,34,,550.12,percent of total billed charges,Implant Device,566.3,35,,566.3,percent of total billed charges,Implant Device,566.3,35,,566.3,percent of total billed charges,Implant Device,566.3,35,,566.3,percent of total billed charges,Implant Device,566.3,35,,566.3,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1197.32,
IN2BONES V30 ST432 TRANSVERSE SCREW 3X32,C1713,HCPCS,,79008989,CDM,278,RC,,,both,,,870,643.8,,,643.8,Other,150% of Medicare + 9.63% HCRA Surcharge,391.5,45,,391.5,percent of total billed charges,Critical Access Hospital RCC factor,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,430.65,,,430.65,Other,110% of Medicare,304.5,35,,304.5,percent of total billed charges,Implant Device,295.8,34,"Charges > $500, x 34%",295.8,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,348,40,,348,percent of total billed charges,Implant Device,304.5,70,,304.5,percent of total billed charges,All Other,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,643.8,
IN2BONES S35 ST132 SCREW 3.5X32MM,C1713,HCPCS,,79008990,CDM,278,RC,,,both,,,1050,777,,,777,Other,150% of Medicare + 9.63% HCRA Surcharge,472.5,45,,472.5,percent of total billed charges,Critical Access Hospital RCC factor,357,34,,357,percent of total billed charges,Implant Device,357,34,,357,percent of total billed charges,Implant Device,357,34,,357,percent of total billed charges,Implant Device,357,34,,357,percent of total billed charges,Implant Device,357,34,,357,percent of total billed charges,Implant Device,519.75,,,519.75,Other,110% of Medicare,367.5,35,,367.5,percent of total billed charges,Implant Device,357,34,"Charges > $500, x 34%",357,percent of total billed charges,Implant Device,367.5,35,,367.5,percent of total billed charges,Implant Device,367.5,35,,367.5,percent of total billed charges,Implant Device,367.5,35,,367.5,percent of total billed charges,Implant Device,367.5,35,,367.5,percent of total billed charges,Implant Device,367.5,35,,367.5,percent of total billed charges,Implant Device,420,40,,420,percent of total billed charges,Implant Device,367.5,70,,367.5,percent of total billed charges,All Other,357,34,,357,percent of total billed charges,Implant Device,357,34,,357,percent of total billed charges,Implant Device,367.5,35,,367.5,percent of total billed charges,Implant Device,367.5,35,,367.5,percent of total billed charges,Implant Device,367.5,35,,367.5,percent of total billed charges,Implant Device,367.5,35,,367.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,777,
STRYKER 44317000 ANT TIBIALIS ALLOGRAFT,C1713,HCPCS,,79008992,CDM,278,RC,,,both,,,6420,4750.82,,,4750.82,Other,150% of Medicare + 9.63% HCRA Surcharge,2889,45,,2889,percent of total billed charges,Critical Access Hospital RCC factor,2182.8,34,,2182.8,percent of total billed charges,Implant Device,2182.8,34,,2182.8,percent of total billed charges,Implant Device,2182.8,34,,2182.8,percent of total billed charges,Implant Device,2182.8,34,,2182.8,percent of total billed charges,Implant Device,2182.8,34,,2182.8,percent of total billed charges,Implant Device,3177.9,,,3177.9,Other,110% of Medicare,2247,35,,2247,percent of total billed charges,Implant Device,2182.8,34,"Charges > $500, x 34%",2182.8,percent of total billed charges,Implant Device,2247,35,,2247,percent of total billed charges,Implant Device,2247,35,,2247,percent of total billed charges,Implant Device,2247,35,,2247,percent of total billed charges,Implant Device,2247,35,,2247,percent of total billed charges,Implant Device,2247,35,,2247,percent of total billed charges,Implant Device,2568,40,,2568,percent of total billed charges,Implant Device,2247,70,,2247,percent of total billed charges,All Other,2182.8,34,,2182.8,percent of total billed charges,Implant Device,2182.8,34,,2182.8,percent of total billed charges,Implant Device,2247,35,,2247,percent of total billed charges,Implant Device,2247,35,,2247,percent of total billed charges,Implant Device,2247,35,,2247,percent of total billed charges,Implant Device,2247,35,,2247,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2182.8,34,"If Charge > 2,000, then 34 percent",2182.8,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4750.82,
STRYKER 44317001 POST TIBIALIS ALLOGRAFT,C1713,HCPCS,,79008993,CDM,278,RC,,,both,,,3894,2881.57,,,2881.57,Other,150% of Medicare + 9.63% HCRA Surcharge,1752.3,45,,1752.3,percent of total billed charges,Critical Access Hospital RCC factor,1323.96,34,,1323.96,percent of total billed charges,Implant Device,1323.96,34,,1323.96,percent of total billed charges,Implant Device,1323.96,34,,1323.96,percent of total billed charges,Implant Device,1323.96,34,,1323.96,percent of total billed charges,Implant Device,1323.96,34,,1323.96,percent of total billed charges,Implant Device,1927.53,,,1927.53,Other,110% of Medicare,1362.9,35,,1362.9,percent of total billed charges,Implant Device,1323.96,34,"Charges > $500, x 34%",1323.96,percent of total billed charges,Implant Device,1362.9,35,,1362.9,percent of total billed charges,Implant Device,1362.9,35,,1362.9,percent of total billed charges,Implant Device,1362.9,35,,1362.9,percent of total billed charges,Implant Device,1362.9,35,,1362.9,percent of total billed charges,Implant Device,1362.9,35,,1362.9,percent of total billed charges,Implant Device,1557.6,40,,1557.6,percent of total billed charges,Implant Device,1362.9,70,,1362.9,percent of total billed charges,All Other,1323.96,34,,1323.96,percent of total billed charges,Implant Device,1323.96,34,,1323.96,percent of total billed charges,Implant Device,1362.9,35,,1362.9,percent of total billed charges,Implant Device,1362.9,35,,1362.9,percent of total billed charges,Implant Device,1362.9,35,,1362.9,percent of total billed charges,Implant Device,1362.9,35,,1362.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1323.96,34,"If Charge > 2,000, then 34 percent",1323.96,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2881.57,
STRYKER 44317003 SEMI TENODSIS ALLOGRAFT,C1713,HCPCS,,79008994,CDM,278,RC,,,both,,,3654,2703.97,,,2703.97,Other,150% of Medicare + 9.63% HCRA Surcharge,1644.3,45,,1644.3,percent of total billed charges,Critical Access Hospital RCC factor,1242.36,34,,1242.36,percent of total billed charges,Implant Device,1242.36,34,,1242.36,percent of total billed charges,Implant Device,1242.36,34,,1242.36,percent of total billed charges,Implant Device,1242.36,34,,1242.36,percent of total billed charges,Implant Device,1242.36,34,,1242.36,percent of total billed charges,Implant Device,1808.73,,,1808.73,Other,110% of Medicare,1278.9,35,,1278.9,percent of total billed charges,Implant Device,1242.36,34,"Charges > $500, x 34%",1242.36,percent of total billed charges,Implant Device,1278.9,35,,1278.9,percent of total billed charges,Implant Device,1278.9,35,,1278.9,percent of total billed charges,Implant Device,1278.9,35,,1278.9,percent of total billed charges,Implant Device,1278.9,35,,1278.9,percent of total billed charges,Implant Device,1278.9,35,,1278.9,percent of total billed charges,Implant Device,1461.6,40,,1461.6,percent of total billed charges,Implant Device,1278.9,70,,1278.9,percent of total billed charges,All Other,1242.36,34,,1242.36,percent of total billed charges,Implant Device,1242.36,34,,1242.36,percent of total billed charges,Implant Device,1278.9,35,,1278.9,percent of total billed charges,Implant Device,1278.9,35,,1278.9,percent of total billed charges,Implant Device,1278.9,35,,1278.9,percent of total billed charges,Implant Device,1278.9,35,,1278.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1242.36,34,"If Charge > 2,000, then 34 percent",1242.36,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2703.97,
ALPHATEC SPINE 62065-50 6.5 X 50MM SCREW,C1713,HCPCS,,79008995,CDM,278,RC,,,both,,,2550,1887.01,,,1887.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1147.5,45,,1147.5,percent of total billed charges,Critical Access Hospital RCC factor,867,34,,867,percent of total billed charges,Implant Device,867,34,,867,percent of total billed charges,Implant Device,867,34,,867,percent of total billed charges,Implant Device,867,34,,867,percent of total billed charges,Implant Device,867,34,,867,percent of total billed charges,Implant Device,1262.25,,,1262.25,Other,110% of Medicare,892.5,35,,892.5,percent of total billed charges,Implant Device,867,34,"Charges > $500, x 34%",867,percent of total billed charges,Implant Device,892.5,35,,892.5,percent of total billed charges,Implant Device,892.5,35,,892.5,percent of total billed charges,Implant Device,892.5,35,,892.5,percent of total billed charges,Implant Device,892.5,35,,892.5,percent of total billed charges,Implant Device,892.5,35,,892.5,percent of total billed charges,Implant Device,1020,40,,1020,percent of total billed charges,Implant Device,892.5,70,,892.5,percent of total billed charges,All Other,867,34,,867,percent of total billed charges,Implant Device,867,34,,867,percent of total billed charges,Implant Device,892.5,35,,892.5,percent of total billed charges,Implant Device,892.5,35,,892.5,percent of total billed charges,Implant Device,892.5,35,,892.5,percent of total billed charges,Implant Device,892.5,35,,892.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,867,34,"If Charge > 2,000, then 34 percent",867,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1887.01,
ZIMMER 00-2359-055-36 CANN SCREW 3.5X55,C1713,HCPCS,,79008996,CDM,278,RC,,,both,,,334,247.16,,,247.16,Other,150% of Medicare + 9.63% HCRA Surcharge,150.3,45,,150.3,percent of total billed charges,Critical Access Hospital RCC factor,113.56,34,,113.56,percent of total billed charges,Implant Device,113.56,34,,113.56,percent of total billed charges,Implant Device,113.56,34,,113.56,percent of total billed charges,Implant Device,113.56,34,,113.56,percent of total billed charges,Implant Device,113.56,34,,113.56,percent of total billed charges,Implant Device,165.33,,,165.33,Other,110% of Medicare,116.9,35,,116.9,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,116.9,35,,116.9,percent of total billed charges,Implant Device,116.9,35,,116.9,percent of total billed charges,Implant Device,116.9,35,,116.9,percent of total billed charges,Implant Device,116.9,35,,116.9,percent of total billed charges,Implant Device,116.9,35,,116.9,percent of total billed charges,Implant Device,133.6,40,,133.6,percent of total billed charges,Implant Device,116.9,70,,116.9,percent of total billed charges,All Other,113.56,34,,113.56,percent of total billed charges,Implant Device,113.56,34,,113.56,percent of total billed charges,Implant Device,116.9,35,,116.9,percent of total billed charges,Implant Device,116.9,35,,116.9,percent of total billed charges,Implant Device,116.9,35,,116.9,percent of total billed charges,Implant Device,116.9,35,,116.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,247.16,
ZIMMER 00-2347-020-38 PERI SCREW 3.5X38,C1713,HCPCS,,79008997,CDM,278,RC,,,both,,,100,74,,,74,Other,150% of Medicare + 9.63% HCRA Surcharge,45,45,,45,percent of total billed charges,Critical Access Hospital RCC factor,34,34,,34,percent of total billed charges,Implant Device,34,34,,34,percent of total billed charges,Implant Device,34,34,,34,percent of total billed charges,Implant Device,34,34,,34,percent of total billed charges,Implant Device,34,34,,34,percent of total billed charges,Implant Device,49.5,,,49.5,Other,110% of Medicare,35,35,,35,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,35,35,,35,percent of total billed charges,Implant Device,35,35,,35,percent of total billed charges,Implant Device,35,35,,35,percent of total billed charges,Implant Device,35,35,,35,percent of total billed charges,Implant Device,35,35,,35,percent of total billed charges,Implant Device,40,40,,40,percent of total billed charges,Implant Device,35,70,,35,percent of total billed charges,All Other,34,34,,34,percent of total billed charges,Implant Device,34,34,,34,percent of total billed charges,Implant Device,35,35,,35,percent of total billed charges,Implant Device,35,35,,35,percent of total billed charges,Implant Device,35,35,,35,percent of total billed charges,Implant Device,35,35,,35,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,74,
STRYKER 627704 PROX MEDIAL PLATE LT 4H,C1713,HCPCS,,79008998,CDM,278,RC,,,both,,,5222,3864.29,,,3864.29,Other,150% of Medicare + 9.63% HCRA Surcharge,2349.9,45,,2349.9,percent of total billed charges,Critical Access Hospital RCC factor,1775.48,34,,1775.48,percent of total billed charges,Implant Device,1775.48,34,,1775.48,percent of total billed charges,Implant Device,1775.48,34,,1775.48,percent of total billed charges,Implant Device,1775.48,34,,1775.48,percent of total billed charges,Implant Device,1775.48,34,,1775.48,percent of total billed charges,Implant Device,2584.89,,,2584.89,Other,110% of Medicare,1827.7,35,,1827.7,percent of total billed charges,Implant Device,1775.48,34,"Charges > $500, x 34%",1775.48,percent of total billed charges,Implant Device,1827.7,35,,1827.7,percent of total billed charges,Implant Device,1827.7,35,,1827.7,percent of total billed charges,Implant Device,1827.7,35,,1827.7,percent of total billed charges,Implant Device,1827.7,35,,1827.7,percent of total billed charges,Implant Device,1827.7,35,,1827.7,percent of total billed charges,Implant Device,2088.8,40,,2088.8,percent of total billed charges,Implant Device,1827.7,70,,1827.7,percent of total billed charges,All Other,1775.48,34,,1775.48,percent of total billed charges,Implant Device,1775.48,34,,1775.48,percent of total billed charges,Implant Device,1827.7,35,,1827.7,percent of total billed charges,Implant Device,1827.7,35,,1827.7,percent of total billed charges,Implant Device,1827.7,35,,1827.7,percent of total billed charges,Implant Device,1827.7,35,,1827.7,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1775.48,34,"If Charge > 2,000, then 34 percent",1775.48,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3864.29,
STRYKER 661030 LOCKING SCREW 4.0X30MM,C1713,HCPCS,,79008999,CDM,278,RC,,,both,,,630,466.2,,,466.2,Other,150% of Medicare + 9.63% HCRA Surcharge,283.5,45,,283.5,percent of total billed charges,Critical Access Hospital RCC factor,214.2,34,,214.2,percent of total billed charges,Implant Device,214.2,34,,214.2,percent of total billed charges,Implant Device,214.2,34,,214.2,percent of total billed charges,Implant Device,214.2,34,,214.2,percent of total billed charges,Implant Device,214.2,34,,214.2,percent of total billed charges,Implant Device,311.85,,,311.85,Other,110% of Medicare,220.5,35,,220.5,percent of total billed charges,Implant Device,214.2,34,"Charges > $500, x 34%",214.2,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,252,40,,252,percent of total billed charges,Implant Device,220.5,70,,220.5,percent of total billed charges,All Other,214.2,34,,214.2,percent of total billed charges,Implant Device,214.2,34,,214.2,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,466.2,
STRYKER 607428 CANCELLOUS SCREW 4X28MM,C1713,HCPCS,,79009000,CDM,278,RC,,,both,,,186,137.64,,,137.64,Other,150% of Medicare + 9.63% HCRA Surcharge,83.7,45,,83.7,percent of total billed charges,Critical Access Hospital RCC factor,63.24,34,,63.24,percent of total billed charges,Implant Device,63.24,34,,63.24,percent of total billed charges,Implant Device,63.24,34,,63.24,percent of total billed charges,Implant Device,63.24,34,,63.24,percent of total billed charges,Implant Device,63.24,34,,63.24,percent of total billed charges,Implant Device,92.07,,,92.07,Other,110% of Medicare,65.1,35,,65.1,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,65.1,35,,65.1,percent of total billed charges,Implant Device,65.1,35,,65.1,percent of total billed charges,Implant Device,65.1,35,,65.1,percent of total billed charges,Implant Device,65.1,35,,65.1,percent of total billed charges,Implant Device,65.1,35,,65.1,percent of total billed charges,Implant Device,74.4,40,,74.4,percent of total billed charges,Implant Device,65.1,70,,65.1,percent of total billed charges,All Other,63.24,34,,63.24,percent of total billed charges,Implant Device,63.24,34,,63.24,percent of total billed charges,Implant Device,65.1,35,,65.1,percent of total billed charges,Implant Device,65.1,35,,65.1,percent of total billed charges,Implant Device,65.1,35,,65.1,percent of total billed charges,Implant Device,65.1,35,,65.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,137.64,
STRYKER 607334 CANCELLOUS SCREW 4X34MM,C1713,HCPCS,,79009001,CDM,278,RC,,,both,,,186,137.64,,,137.64,Other,150% of Medicare + 9.63% HCRA Surcharge,83.7,45,,83.7,percent of total billed charges,Critical Access Hospital RCC factor,63.24,34,,63.24,percent of total billed charges,Implant Device,63.24,34,,63.24,percent of total billed charges,Implant Device,63.24,34,,63.24,percent of total billed charges,Implant Device,63.24,34,,63.24,percent of total billed charges,Implant Device,63.24,34,,63.24,percent of total billed charges,Implant Device,92.07,,,92.07,Other,110% of Medicare,65.1,35,,65.1,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,65.1,35,,65.1,percent of total billed charges,Implant Device,65.1,35,,65.1,percent of total billed charges,Implant Device,65.1,35,,65.1,percent of total billed charges,Implant Device,65.1,35,,65.1,percent of total billed charges,Implant Device,65.1,35,,65.1,percent of total billed charges,Implant Device,74.4,40,,74.4,percent of total billed charges,Implant Device,65.1,70,,65.1,percent of total billed charges,All Other,63.24,34,,63.24,percent of total billed charges,Implant Device,63.24,34,,63.24,percent of total billed charges,Implant Device,65.1,35,,65.1,percent of total billed charges,Implant Device,65.1,35,,65.1,percent of total billed charges,Implant Device,65.1,35,,65.1,percent of total billed charges,Implant Device,65.1,35,,65.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,137.64,
STRYKER 661475 CORTICAL SCREW 3.5X75MM,C1713,HCPCS,,79009002,CDM,278,RC,,,both,,,122,90.28,,,90.28,Other,150% of Medicare + 9.63% HCRA Surcharge,54.9,45,,54.9,percent of total billed charges,Critical Access Hospital RCC factor,41.48,34,,41.48,percent of total billed charges,Implant Device,41.48,34,,41.48,percent of total billed charges,Implant Device,41.48,34,,41.48,percent of total billed charges,Implant Device,41.48,34,,41.48,percent of total billed charges,Implant Device,41.48,34,,41.48,percent of total billed charges,Implant Device,60.39,,,60.39,Other,110% of Medicare,42.7,35,,42.7,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,42.7,35,,42.7,percent of total billed charges,Implant Device,42.7,35,,42.7,percent of total billed charges,Implant Device,42.7,35,,42.7,percent of total billed charges,Implant Device,42.7,35,,42.7,percent of total billed charges,Implant Device,42.7,35,,42.7,percent of total billed charges,Implant Device,48.8,40,,48.8,percent of total billed charges,Implant Device,42.7,70,,42.7,percent of total billed charges,All Other,41.48,34,,41.48,percent of total billed charges,Implant Device,41.48,34,,41.48,percent of total billed charges,Implant Device,42.7,35,,42.7,percent of total billed charges,Implant Device,42.7,35,,42.7,percent of total billed charges,Implant Device,42.7,35,,42.7,percent of total billed charges,Implant Device,42.7,35,,42.7,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,90.28,
STRYKER 657020 LOCKING SCREW 2.7X20MM,C1713,HCPCS,,79009003,CDM,278,RC,,,both,,,939,694.86,,,694.86,Other,150% of Medicare + 9.63% HCRA Surcharge,422.55,45,,422.55,percent of total billed charges,Critical Access Hospital RCC factor,319.26,34,,319.26,percent of total billed charges,Implant Device,319.26,34,,319.26,percent of total billed charges,Implant Device,319.26,34,,319.26,percent of total billed charges,Implant Device,319.26,34,,319.26,percent of total billed charges,Implant Device,319.26,34,,319.26,percent of total billed charges,Implant Device,464.81,,,464.81,Other,110% of Medicare,328.65,35,,328.65,percent of total billed charges,Implant Device,319.26,34,"Charges > $500, x 34%",319.26,percent of total billed charges,Implant Device,328.65,35,,328.65,percent of total billed charges,Implant Device,328.65,35,,328.65,percent of total billed charges,Implant Device,328.65,35,,328.65,percent of total billed charges,Implant Device,328.65,35,,328.65,percent of total billed charges,Implant Device,328.65,35,,328.65,percent of total billed charges,Implant Device,375.6,40,,375.6,percent of total billed charges,Implant Device,328.65,70,,328.65,percent of total billed charges,All Other,319.26,34,,319.26,percent of total billed charges,Implant Device,319.26,34,,319.26,percent of total billed charges,Implant Device,328.65,35,,328.65,percent of total billed charges,Implant Device,328.65,35,,328.65,percent of total billed charges,Implant Device,328.65,35,,328.65,percent of total billed charges,Implant Device,328.65,35,,328.65,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,694.86,
ZIMMER 8144-11-400 NAIL 125 DEG 11X400MM,C1713,HCPCS,,79009005,CDM,278,RC,,,both,,,11430,8458.23,,,8458.23,Other,150% of Medicare + 9.63% HCRA Surcharge,5143.5,45,,5143.5,percent of total billed charges,Critical Access Hospital RCC factor,3886.2,34,,3886.2,percent of total billed charges,Implant Device,3886.2,34,,3886.2,percent of total billed charges,Implant Device,3886.2,34,,3886.2,percent of total billed charges,Implant Device,3886.2,34,,3886.2,percent of total billed charges,Implant Device,3886.2,34,,3886.2,percent of total billed charges,Implant Device,5657.85,,,5657.85,Other,110% of Medicare,4000.5,35,,4000.5,percent of total billed charges,Implant Device,3886.2,34,"Charges > $500, x 34%",3886.2,percent of total billed charges,Implant Device,4000.5,35,,4000.5,percent of total billed charges,Implant Device,4000.5,35,,4000.5,percent of total billed charges,Implant Device,4000.5,35,,4000.5,percent of total billed charges,Implant Device,4000.5,35,,4000.5,percent of total billed charges,Implant Device,4000.5,35,,4000.5,percent of total billed charges,Implant Device,4572,40,,4572,percent of total billed charges,Implant Device,4000.5,70,,4000.5,percent of total billed charges,All Other,3886.2,34,,3886.2,percent of total billed charges,Implant Device,3886.2,34,,3886.2,percent of total billed charges,Implant Device,4000.5,35,,4000.5,percent of total billed charges,Implant Device,4000.5,35,,4000.5,percent of total billed charges,Implant Device,4000.5,35,,4000.5,percent of total billed charges,Implant Device,4000.5,35,,4000.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3886.2,34,"If Charge > 2,000, then 34 percent",3886.2,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,8458.23,
ZIMMER 00-7711-013-20 M/L TAPER 13.5 EXT,C1776,HCPCS,,79009006,CDM,278,RC,,,both,,,6900,5106.02,,,5106.02,Other,150% of Medicare + 9.63% HCRA Surcharge,3105,45,,3105,percent of total billed charges,Critical Access Hospital RCC factor,2346,34,,2346,percent of total billed charges,Implant Device,2346,34,,2346,percent of total billed charges,Implant Device,2346,34,,2346,percent of total billed charges,Implant Device,2346,34,,2346,percent of total billed charges,Implant Device,2346,34,,2346,percent of total billed charges,Implant Device,3415.5,,,3415.5,Other,110% of Medicare,2415,35,,2415,percent of total billed charges,Implant Device,2346,34,"Charges > $500, x 34%",2346,percent of total billed charges,Implant Device,2415,35,,2415,percent of total billed charges,Implant Device,2415,35,,2415,percent of total billed charges,Implant Device,2415,35,,2415,percent of total billed charges,Implant Device,2415,35,,2415,percent of total billed charges,Implant Device,2415,35,,2415,percent of total billed charges,Implant Device,2760,40,,2760,percent of total billed charges,Implant Device,2415,70,,2415,percent of total billed charges,All Other,2346,34,,2346,percent of total billed charges,Implant Device,2346,34,,2346,percent of total billed charges,Implant Device,2415,35,,2415,percent of total billed charges,Implant Device,2415,35,,2415,percent of total billed charges,Implant Device,2415,35,,2415,percent of total billed charges,Implant Device,2415,35,,2415,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2346,34,"If Charge > 2,000, then 34 percent",2346,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5106.02,
DEPUY 04.032.080S 11X80MM TROCH SCREW,C1713,HCPCS,,79009007,CDM,278,RC,,,both,,,2197,1625.79,,,1625.79,Other,150% of Medicare + 9.63% HCRA Surcharge,988.65,45,,988.65,percent of total billed charges,Critical Access Hospital RCC factor,746.98,34,,746.98,percent of total billed charges,Implant Device,746.98,34,,746.98,percent of total billed charges,Implant Device,746.98,34,,746.98,percent of total billed charges,Implant Device,746.98,34,,746.98,percent of total billed charges,Implant Device,746.98,34,,746.98,percent of total billed charges,Implant Device,1087.52,,,1087.52,Other,110% of Medicare,768.95,35,,768.95,percent of total billed charges,Implant Device,746.98,34,"Charges > $500, x 34%",746.98,percent of total billed charges,Implant Device,768.95,35,,768.95,percent of total billed charges,Implant Device,768.95,35,,768.95,percent of total billed charges,Implant Device,768.95,35,,768.95,percent of total billed charges,Implant Device,768.95,35,,768.95,percent of total billed charges,Implant Device,768.95,35,,768.95,percent of total billed charges,Implant Device,878.8,40,,878.8,percent of total billed charges,Implant Device,768.95,70,,768.95,percent of total billed charges,All Other,746.98,34,,746.98,percent of total billed charges,Implant Device,746.98,34,,746.98,percent of total billed charges,Implant Device,768.95,35,,768.95,percent of total billed charges,Implant Device,768.95,35,,768.95,percent of total billed charges,Implant Device,768.95,35,,768.95,percent of total billed charges,Implant Device,768.95,35,,768.95,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,746.98,34,"If Charge > 2,000, then 34 percent",746.98,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1625.79,
STRYKER 601675 ASNIS CANN SCREW 5X75MM,C1713,HCPCS,,79009008,CDM,278,RC,,,both,,,847,626.78,,,626.78,Other,150% of Medicare + 9.63% HCRA Surcharge,381.15,45,,381.15,percent of total billed charges,Critical Access Hospital RCC factor,287.98,34,,287.98,percent of total billed charges,Implant Device,287.98,34,,287.98,percent of total billed charges,Implant Device,287.98,34,,287.98,percent of total billed charges,Implant Device,287.98,34,,287.98,percent of total billed charges,Implant Device,287.98,34,,287.98,percent of total billed charges,Implant Device,419.27,,,419.27,Other,110% of Medicare,296.45,35,,296.45,percent of total billed charges,Implant Device,287.98,34,"Charges > $500, x 34%",287.98,percent of total billed charges,Implant Device,296.45,35,,296.45,percent of total billed charges,Implant Device,296.45,35,,296.45,percent of total billed charges,Implant Device,296.45,35,,296.45,percent of total billed charges,Implant Device,296.45,35,,296.45,percent of total billed charges,Implant Device,296.45,35,,296.45,percent of total billed charges,Implant Device,338.8,40,,338.8,percent of total billed charges,Implant Device,296.45,70,,296.45,percent of total billed charges,All Other,287.98,34,,287.98,percent of total billed charges,Implant Device,287.98,34,,287.98,percent of total billed charges,Implant Device,296.45,35,,296.45,percent of total billed charges,Implant Device,296.45,35,,296.45,percent of total billed charges,Implant Device,296.45,35,,296.45,percent of total billed charges,Implant Device,296.45,35,,296.45,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,626.78,
MENTOR 350-1430 IMPLANT SMOOTH ROUND 225,C1789,HCPCS,,79009010,CDM,278,RC,,,both,,,2625,1942.51,,,1942.51,Other,150% of Medicare + 9.63% HCRA Surcharge,1181.25,45,,1181.25,percent of total billed charges,Critical Access Hospital RCC factor,892.5,34,,892.5,percent of total billed charges,Implant Device,892.5,34,,892.5,percent of total billed charges,Implant Device,892.5,34,,892.5,percent of total billed charges,Implant Device,892.5,34,,892.5,percent of total billed charges,Implant Device,892.5,34,,892.5,percent of total billed charges,Implant Device,1299.38,,,1299.38,Other,110% of Medicare,918.75,35,,918.75,percent of total billed charges,Implant Device,892.5,34,"Charges > $500, x 34%",892.5,percent of total billed charges,Implant Device,918.75,35,,918.75,percent of total billed charges,Implant Device,918.75,35,,918.75,percent of total billed charges,Implant Device,918.75,35,,918.75,percent of total billed charges,Implant Device,918.75,35,,918.75,percent of total billed charges,Implant Device,918.75,35,,918.75,percent of total billed charges,Implant Device,1050,40,,1050,percent of total billed charges,Implant Device,918.75,70,,918.75,percent of total billed charges,All Other,892.5,34,,892.5,percent of total billed charges,Implant Device,892.5,34,,892.5,percent of total billed charges,Implant Device,918.75,35,,918.75,percent of total billed charges,Implant Device,918.75,35,,918.75,percent of total billed charges,Implant Device,918.75,35,,918.75,percent of total billed charges,Implant Device,918.75,35,,918.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,892.5,34,"If Charge > 2,000, then 34 percent",892.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1942.51,
STRYKER 3102-2004 ALLOWRAP DS 2X4CM,Q4150,HCPCS,,79009011,CDM,278,RC,,,both,,,7267,5377.6,,,5377.6,Other,150% of Medicare + 9.63% HCRA Surcharge,3270.15,45,,3270.15,percent of total billed charges,Critical Access Hospital RCC factor,2470.78,34,,2470.78,percent of total billed charges,Implant Device,2470.78,34,,2470.78,percent of total billed charges,Implant Device,2470.78,34,,2470.78,percent of total billed charges,Implant Device,2470.78,34,,2470.78,percent of total billed charges,Implant Device,2470.78,34,,2470.78,percent of total billed charges,Implant Device,3597.17,,,3597.17,Other,110% of Medicare,2543.45,35,,2543.45,percent of total billed charges,Implant Device,2470.78,34,"Charges > $500, x 34%",2470.78,percent of total billed charges,Implant Device,2543.45,35,,2543.45,percent of total billed charges,Implant Device,2543.45,35,,2543.45,percent of total billed charges,Implant Device,2543.45,35,,2543.45,percent of total billed charges,Implant Device,2543.45,35,,2543.45,percent of total billed charges,Implant Device,2543.45,35,,2543.45,percent of total billed charges,Implant Device,2906.8,40,,2906.8,percent of total billed charges,Implant Device,2543.45,70,,2543.45,percent of total billed charges,All Other,2470.78,34,,2470.78,percent of total billed charges,Implant Device,2470.78,34,,2470.78,percent of total billed charges,Implant Device,2543.45,35,,2543.45,percent of total billed charges,Implant Device,2543.45,35,,2543.45,percent of total billed charges,Implant Device,2543.45,35,,2543.45,percent of total billed charges,Implant Device,2543.45,35,,2543.45,percent of total billed charges,Implant Device,976.07,,,976.07,Other,100% of Medicaid,976.07,,,976.07,Other,100% of Medicaid,976.07,,,976.07,Other,100% of Medicaid,976.07,,,976.07,Other,100% of Medicaid,2196.15,,,2196.15,Other,225% of Medicaid,1493.38,,,1493.38,Other,153% of Medicaid,2196.15,,,2196.15,Other,225% of Medicaid,1366.49,,,1366.49,Other,140% of Medicaid,2470.78,34,"If Charge > 2,000, then 34 percent",2470.78,percent of total billed charges,Implants,2537.77,,,2537.77,Other,260% of Medicaid,3162.45,,,3162.45,Other,324% of Medicaid,2098.54,,,2098.54,Other,215% of Medicaid,2098.54,,,2098.54,Other,215% of Medicaid,1220.08,,,1220.08,Other,125% of Medicaid,976.07,5377.6,
DEPUY 04.005.540S 5X50MM TI LOCK SCREW,C1713,HCPCS,,79009012,CDM,278,RC,,,both,,,412,304.88,,,304.88,Other,150% of Medicare + 9.63% HCRA Surcharge,185.4,45,,185.4,percent of total billed charges,Critical Access Hospital RCC factor,140.08,34,,140.08,percent of total billed charges,Implant Device,140.08,34,,140.08,percent of total billed charges,Implant Device,140.08,34,,140.08,percent of total billed charges,Implant Device,140.08,34,,140.08,percent of total billed charges,Implant Device,140.08,34,,140.08,percent of total billed charges,Implant Device,203.94,,,203.94,Other,110% of Medicare,144.2,35,,144.2,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,144.2,35,,144.2,percent of total billed charges,Implant Device,144.2,35,,144.2,percent of total billed charges,Implant Device,144.2,35,,144.2,percent of total billed charges,Implant Device,144.2,35,,144.2,percent of total billed charges,Implant Device,144.2,35,,144.2,percent of total billed charges,Implant Device,164.8,40,,164.8,percent of total billed charges,Implant Device,144.2,70,,144.2,percent of total billed charges,All Other,140.08,34,,140.08,percent of total billed charges,Implant Device,140.08,34,,140.08,percent of total billed charges,Implant Device,144.2,35,,144.2,percent of total billed charges,Implant Device,144.2,35,,144.2,percent of total billed charges,Implant Device,144.2,35,,144.2,percent of total billed charges,Implant Device,144.2,35,,144.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,304.88,
DEPUY 04.005.544S 5X54MM TI LOCK SCREW,C1713,HCPCS,,79009013,CDM,278,RC,,,both,,,412,304.88,,,304.88,Other,150% of Medicare + 9.63% HCRA Surcharge,185.4,45,,185.4,percent of total billed charges,Critical Access Hospital RCC factor,140.08,34,,140.08,percent of total billed charges,Implant Device,140.08,34,,140.08,percent of total billed charges,Implant Device,140.08,34,,140.08,percent of total billed charges,Implant Device,140.08,34,,140.08,percent of total billed charges,Implant Device,140.08,34,,140.08,percent of total billed charges,Implant Device,203.94,,,203.94,Other,110% of Medicare,144.2,35,,144.2,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,144.2,35,,144.2,percent of total billed charges,Implant Device,144.2,35,,144.2,percent of total billed charges,Implant Device,144.2,35,,144.2,percent of total billed charges,Implant Device,144.2,35,,144.2,percent of total billed charges,Implant Device,144.2,35,,144.2,percent of total billed charges,Implant Device,164.8,40,,164.8,percent of total billed charges,Implant Device,144.2,70,,144.2,percent of total billed charges,All Other,140.08,34,,140.08,percent of total billed charges,Implant Device,140.08,34,,140.08,percent of total billed charges,Implant Device,144.2,35,,144.2,percent of total billed charges,Implant Device,144.2,35,,144.2,percent of total billed charges,Implant Device,144.2,35,,144.2,percent of total billed charges,Implant Device,144.2,35,,144.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,304.88,
DEPUY 5038-1-110 3X110MM APEX HALF PIN,C1713,HCPCS,,79009014,CDM,278,RC,,,both,,,390,288.6,,,288.6,Other,150% of Medicare + 9.63% HCRA Surcharge,175.5,45,,175.5,percent of total billed charges,Critical Access Hospital RCC factor,132.6,34,,132.6,percent of total billed charges,Implant Device,132.6,34,,132.6,percent of total billed charges,Implant Device,132.6,34,,132.6,percent of total billed charges,Implant Device,132.6,34,,132.6,percent of total billed charges,Implant Device,132.6,34,,132.6,percent of total billed charges,Implant Device,193.05,,,193.05,Other,110% of Medicare,136.5,35,,136.5,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,136.5,35,,136.5,percent of total billed charges,Implant Device,136.5,35,,136.5,percent of total billed charges,Implant Device,136.5,35,,136.5,percent of total billed charges,Implant Device,136.5,35,,136.5,percent of total billed charges,Implant Device,136.5,35,,136.5,percent of total billed charges,Implant Device,156,40,,156,percent of total billed charges,Implant Device,136.5,70,,136.5,percent of total billed charges,All Other,132.6,34,,132.6,percent of total billed charges,Implant Device,132.6,34,,132.6,percent of total billed charges,Implant Device,136.5,35,,136.5,percent of total billed charges,Implant Device,136.5,35,,136.5,percent of total billed charges,Implant Device,136.5,35,,136.5,percent of total billed charges,Implant Device,136.5,35,,136.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,288.6,
BIOMET 8145-10-095 10.5X95 HIP LAG SCREW,C1713,HCPCS,,79009015,CDM,278,RC,,,both,,,1786,1321.64,,,1321.64,Other,150% of Medicare + 9.63% HCRA Surcharge,803.7,45,,803.7,percent of total billed charges,Critical Access Hospital RCC factor,607.24,34,,607.24,percent of total billed charges,Implant Device,607.24,34,,607.24,percent of total billed charges,Implant Device,607.24,34,,607.24,percent of total billed charges,Implant Device,607.24,34,,607.24,percent of total billed charges,Implant Device,607.24,34,,607.24,percent of total billed charges,Implant Device,884.07,,,884.07,Other,110% of Medicare,625.1,35,,625.1,percent of total billed charges,Implant Device,607.24,34,"Charges > $500, x 34%",607.24,percent of total billed charges,Implant Device,625.1,35,,625.1,percent of total billed charges,Implant Device,625.1,35,,625.1,percent of total billed charges,Implant Device,625.1,35,,625.1,percent of total billed charges,Implant Device,625.1,35,,625.1,percent of total billed charges,Implant Device,625.1,35,,625.1,percent of total billed charges,Implant Device,714.4,40,,714.4,percent of total billed charges,Implant Device,625.1,70,,625.1,percent of total billed charges,All Other,607.24,34,,607.24,percent of total billed charges,Implant Device,607.24,34,,607.24,percent of total billed charges,Implant Device,625.1,35,,625.1,percent of total billed charges,Implant Device,625.1,35,,625.1,percent of total billed charges,Implant Device,625.1,35,,625.1,percent of total billed charges,Implant Device,625.1,35,,625.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1321.64,
ZIMMER 00-5988-020-15 STEM EXT 15X100MM,C1776,HCPCS,,79009016,CDM,278,RC,,,both,,,4381,3241.95,,,3241.95,Other,150% of Medicare + 9.63% HCRA Surcharge,1971.45,45,,1971.45,percent of total billed charges,Critical Access Hospital RCC factor,1489.54,34,,1489.54,percent of total billed charges,Implant Device,1489.54,34,,1489.54,percent of total billed charges,Implant Device,1489.54,34,,1489.54,percent of total billed charges,Implant Device,1489.54,34,,1489.54,percent of total billed charges,Implant Device,1489.54,34,,1489.54,percent of total billed charges,Implant Device,2168.6,,,2168.6,Other,110% of Medicare,1533.35,35,,1533.35,percent of total billed charges,Implant Device,1489.54,34,"Charges > $500, x 34%",1489.54,percent of total billed charges,Implant Device,1533.35,35,,1533.35,percent of total billed charges,Implant Device,1533.35,35,,1533.35,percent of total billed charges,Implant Device,1533.35,35,,1533.35,percent of total billed charges,Implant Device,1533.35,35,,1533.35,percent of total billed charges,Implant Device,1533.35,35,,1533.35,percent of total billed charges,Implant Device,1752.4,40,,1752.4,percent of total billed charges,Implant Device,1533.35,70,,1533.35,percent of total billed charges,All Other,1489.54,34,,1489.54,percent of total billed charges,Implant Device,1489.54,34,,1489.54,percent of total billed charges,Implant Device,1533.35,35,,1533.35,percent of total billed charges,Implant Device,1533.35,35,,1533.35,percent of total billed charges,Implant Device,1533.35,35,,1533.35,percent of total billed charges,Implant Device,1533.35,35,,1533.35,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1489.54,34,"If Charge > 2,000, then 34 percent",1489.54,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3241.95,
DEPUY 04.032.085S 11X85MM TI NAIL SCREW,C1713,HCPCS,,79009017,CDM,278,RC,,,both,,,2197,1625.79,,,1625.79,Other,150% of Medicare + 9.63% HCRA Surcharge,988.65,45,,988.65,percent of total billed charges,Critical Access Hospital RCC factor,746.98,34,,746.98,percent of total billed charges,Implant Device,746.98,34,,746.98,percent of total billed charges,Implant Device,746.98,34,,746.98,percent of total billed charges,Implant Device,746.98,34,,746.98,percent of total billed charges,Implant Device,746.98,34,,746.98,percent of total billed charges,Implant Device,1087.52,,,1087.52,Other,110% of Medicare,768.95,35,,768.95,percent of total billed charges,Implant Device,746.98,34,"Charges > $500, x 34%",746.98,percent of total billed charges,Implant Device,768.95,35,,768.95,percent of total billed charges,Implant Device,768.95,35,,768.95,percent of total billed charges,Implant Device,768.95,35,,768.95,percent of total billed charges,Implant Device,768.95,35,,768.95,percent of total billed charges,Implant Device,768.95,35,,768.95,percent of total billed charges,Implant Device,878.8,40,,878.8,percent of total billed charges,Implant Device,768.95,70,,768.95,percent of total billed charges,All Other,746.98,34,,746.98,percent of total billed charges,Implant Device,746.98,34,,746.98,percent of total billed charges,Implant Device,768.95,35,,768.95,percent of total billed charges,Implant Device,768.95,35,,768.95,percent of total billed charges,Implant Device,768.95,35,,768.95,percent of total billed charges,Implant Device,768.95,35,,768.95,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,746.98,34,"If Charge > 2,000, then 34 percent",746.98,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1625.79,
DEPUY 456.397S TI CANN NAIL 3609MM,C1713,HCPCS,,79009018,CDM,278,RC,,,both,,,6895,5102.32,,,5102.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3102.75,45,,3102.75,percent of total billed charges,Critical Access Hospital RCC factor,2344.3,34,,2344.3,percent of total billed charges,Implant Device,2344.3,34,,2344.3,percent of total billed charges,Implant Device,2344.3,34,,2344.3,percent of total billed charges,Implant Device,2344.3,34,,2344.3,percent of total billed charges,Implant Device,2344.3,34,,2344.3,percent of total billed charges,Implant Device,3413.03,,,3413.03,Other,110% of Medicare,2413.25,35,,2413.25,percent of total billed charges,Implant Device,2344.3,34,"Charges > $500, x 34%",2344.3,percent of total billed charges,Implant Device,2413.25,35,,2413.25,percent of total billed charges,Implant Device,2413.25,35,,2413.25,percent of total billed charges,Implant Device,2413.25,35,,2413.25,percent of total billed charges,Implant Device,2413.25,35,,2413.25,percent of total billed charges,Implant Device,2413.25,35,,2413.25,percent of total billed charges,Implant Device,2758,40,,2758,percent of total billed charges,Implant Device,2413.25,70,,2413.25,percent of total billed charges,All Other,2344.3,34,,2344.3,percent of total billed charges,Implant Device,2344.3,34,,2344.3,percent of total billed charges,Implant Device,2413.25,35,,2413.25,percent of total billed charges,Implant Device,2413.25,35,,2413.25,percent of total billed charges,Implant Device,2413.25,35,,2413.25,percent of total billed charges,Implant Device,2413.25,35,,2413.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2344.3,34,"If Charge > 2,000, then 34 percent",2344.3,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5102.32,
IN2BONES P40 ST135 MTP PLATE 6 HOLE LT,C1713,HCPCS,,79009019,CDM,278,RC,,,both,,,6000,4440.02,,,4440.02,Other,150% of Medicare + 9.63% HCRA Surcharge,2700,45,,2700,percent of total billed charges,Critical Access Hospital RCC factor,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2970,,,2970,Other,110% of Medicare,2100,35,,2100,percent of total billed charges,Implant Device,2040,34,"Charges > $500, x 34%",2040,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2400,40,,2400,percent of total billed charges,Implant Device,2100,70,,2100,percent of total billed charges,All Other,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2040,34,"If Charge > 2,000, then 34 percent",2040,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4440.02,
BIOMET 8143-09-180 HIP FRCTRE NAIL 9X180,C1713,HCPCS,,79009020,CDM,278,RC,,,both,,,4464,3303.37,,,3303.37,Other,150% of Medicare + 9.63% HCRA Surcharge,2008.8,45,,2008.8,percent of total billed charges,Critical Access Hospital RCC factor,1517.76,34,,1517.76,percent of total billed charges,Implant Device,1517.76,34,,1517.76,percent of total billed charges,Implant Device,1517.76,34,,1517.76,percent of total billed charges,Implant Device,1517.76,34,,1517.76,percent of total billed charges,Implant Device,1517.76,34,,1517.76,percent of total billed charges,Implant Device,2209.68,,,2209.68,Other,110% of Medicare,1562.4,35,,1562.4,percent of total billed charges,Implant Device,1517.76,34,"Charges > $500, x 34%",1517.76,percent of total billed charges,Implant Device,1562.4,35,,1562.4,percent of total billed charges,Implant Device,1562.4,35,,1562.4,percent of total billed charges,Implant Device,1562.4,35,,1562.4,percent of total billed charges,Implant Device,1562.4,35,,1562.4,percent of total billed charges,Implant Device,1562.4,35,,1562.4,percent of total billed charges,Implant Device,1785.6,40,,1785.6,percent of total billed charges,Implant Device,1562.4,70,,1562.4,percent of total billed charges,All Other,1517.76,34,,1517.76,percent of total billed charges,Implant Device,1517.76,34,,1517.76,percent of total billed charges,Implant Device,1562.4,35,,1562.4,percent of total billed charges,Implant Device,1562.4,35,,1562.4,percent of total billed charges,Implant Device,1562.4,35,,1562.4,percent of total billed charges,Implant Device,1562.4,35,,1562.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1517.76,34,"If Charge > 2,000, then 34 percent",1517.76,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3303.37,
BIOMET 8145-50-032 CORT BONE SCREW 5X32,C1713,HCPCS,,79009021,CDM,278,RC,,,both,,,533,394.42,,,394.42,Other,150% of Medicare + 9.63% HCRA Surcharge,239.85,45,,239.85,percent of total billed charges,Critical Access Hospital RCC factor,181.22,34,,181.22,percent of total billed charges,Implant Device,181.22,34,,181.22,percent of total billed charges,Implant Device,181.22,34,,181.22,percent of total billed charges,Implant Device,181.22,34,,181.22,percent of total billed charges,Implant Device,181.22,34,,181.22,percent of total billed charges,Implant Device,263.84,,,263.84,Other,110% of Medicare,186.55,35,,186.55,percent of total billed charges,Implant Device,181.22,34,"Charges > $500, x 34%",181.22,percent of total billed charges,Implant Device,186.55,35,,186.55,percent of total billed charges,Implant Device,186.55,35,,186.55,percent of total billed charges,Implant Device,186.55,35,,186.55,percent of total billed charges,Implant Device,186.55,35,,186.55,percent of total billed charges,Implant Device,186.55,35,,186.55,percent of total billed charges,Implant Device,213.2,40,,213.2,percent of total billed charges,Implant Device,186.55,70,,186.55,percent of total billed charges,All Other,181.22,34,,181.22,percent of total billed charges,Implant Device,181.22,34,,181.22,percent of total billed charges,Implant Device,186.55,35,,186.55,percent of total billed charges,Implant Device,186.55,35,,186.55,percent of total billed charges,Implant Device,186.55,35,,186.55,percent of total billed charges,Implant Device,186.55,35,,186.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,394.42,
STRYKER 626808S LOCKING PLATE T10 8MM,C1713,HCPCS,,79009022,CDM,278,RC,,,both,,,6498,4808.54,,,4808.54,Other,150% of Medicare + 9.63% HCRA Surcharge,2924.1,45,,2924.1,percent of total billed charges,Critical Access Hospital RCC factor,2209.32,34,,2209.32,percent of total billed charges,Implant Device,2209.32,34,,2209.32,percent of total billed charges,Implant Device,2209.32,34,,2209.32,percent of total billed charges,Implant Device,2209.32,34,,2209.32,percent of total billed charges,Implant Device,2209.32,34,,2209.32,percent of total billed charges,Implant Device,3216.51,,,3216.51,Other,110% of Medicare,2274.3,35,,2274.3,percent of total billed charges,Implant Device,2209.32,34,"Charges > $500, x 34%",2209.32,percent of total billed charges,Implant Device,2274.3,35,,2274.3,percent of total billed charges,Implant Device,2274.3,35,,2274.3,percent of total billed charges,Implant Device,2274.3,35,,2274.3,percent of total billed charges,Implant Device,2274.3,35,,2274.3,percent of total billed charges,Implant Device,2274.3,35,,2274.3,percent of total billed charges,Implant Device,2599.2,40,,2599.2,percent of total billed charges,Implant Device,2274.3,70,,2274.3,percent of total billed charges,All Other,2209.32,34,,2209.32,percent of total billed charges,Implant Device,2209.32,34,,2209.32,percent of total billed charges,Implant Device,2274.3,35,,2274.3,percent of total billed charges,Implant Device,2274.3,35,,2274.3,percent of total billed charges,Implant Device,2274.3,35,,2274.3,percent of total billed charges,Implant Device,2274.3,35,,2274.3,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2209.32,34,"If Charge > 2,000, then 34 percent",2209.32,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4808.54,
STRYKER 3102-1908 ALLOGRAFT 8X22X20MM,C1713,HCPCS,,79009023,CDM,278,RC,,,both,,,7929,5867.48,,,5867.48,Other,150% of Medicare + 9.63% HCRA Surcharge,3568.05,45,,3568.05,percent of total billed charges,Critical Access Hospital RCC factor,2695.86,34,,2695.86,percent of total billed charges,Implant Device,2695.86,34,,2695.86,percent of total billed charges,Implant Device,2695.86,34,,2695.86,percent of total billed charges,Implant Device,2695.86,34,,2695.86,percent of total billed charges,Implant Device,2695.86,34,,2695.86,percent of total billed charges,Implant Device,3924.86,,,3924.86,Other,110% of Medicare,2775.15,35,,2775.15,percent of total billed charges,Implant Device,2695.86,34,"Charges > $500, x 34%",2695.86,percent of total billed charges,Implant Device,2775.15,35,,2775.15,percent of total billed charges,Implant Device,2775.15,35,,2775.15,percent of total billed charges,Implant Device,2775.15,35,,2775.15,percent of total billed charges,Implant Device,2775.15,35,,2775.15,percent of total billed charges,Implant Device,2775.15,35,,2775.15,percent of total billed charges,Implant Device,3171.6,40,,3171.6,percent of total billed charges,Implant Device,2775.15,70,,2775.15,percent of total billed charges,All Other,2695.86,34,,2695.86,percent of total billed charges,Implant Device,2695.86,34,,2695.86,percent of total billed charges,Implant Device,2775.15,35,,2775.15,percent of total billed charges,Implant Device,2775.15,35,,2775.15,percent of total billed charges,Implant Device,2775.15,35,,2775.15,percent of total billed charges,Implant Device,2775.15,35,,2775.15,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2695.86,34,"If Charge > 2,000, then 34 percent",2695.86,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5867.48,
STRYKER 3102-1900 ALLOGRAFT 6X24X14MM,C1713,HCPCS,,79009024,CDM,278,RC,,,both,,,8151,6031.76,,,6031.76,Other,150% of Medicare + 9.63% HCRA Surcharge,3667.95,45,,3667.95,percent of total billed charges,Critical Access Hospital RCC factor,2771.34,34,,2771.34,percent of total billed charges,Implant Device,2771.34,34,,2771.34,percent of total billed charges,Implant Device,2771.34,34,,2771.34,percent of total billed charges,Implant Device,2771.34,34,,2771.34,percent of total billed charges,Implant Device,2771.34,34,,2771.34,percent of total billed charges,Implant Device,4034.75,,,4034.75,Other,110% of Medicare,2852.85,35,,2852.85,percent of total billed charges,Implant Device,2771.34,34,"Charges > $500, x 34%",2771.34,percent of total billed charges,Implant Device,2852.85,35,,2852.85,percent of total billed charges,Implant Device,2852.85,35,,2852.85,percent of total billed charges,Implant Device,2852.85,35,,2852.85,percent of total billed charges,Implant Device,2852.85,35,,2852.85,percent of total billed charges,Implant Device,2852.85,35,,2852.85,percent of total billed charges,Implant Device,3260.4,40,,3260.4,percent of total billed charges,Implant Device,2852.85,70,,2852.85,percent of total billed charges,All Other,2771.34,34,,2771.34,percent of total billed charges,Implant Device,2771.34,34,,2771.34,percent of total billed charges,Implant Device,2852.85,35,,2852.85,percent of total billed charges,Implant Device,2852.85,35,,2852.85,percent of total billed charges,Implant Device,2852.85,35,,2852.85,percent of total billed charges,Implant Device,2852.85,35,,2852.85,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2771.34,34,"If Charge > 2,000, then 34 percent",2771.34,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,6031.76,
STRYKER 40-35036 BONE SCREW T10 3.5X36MM,C1713,HCPCS,,79009025,CDM,278,RC,,,both,,,408,301.92,,,301.92,Other,150% of Medicare + 9.63% HCRA Surcharge,183.6,45,,183.6,percent of total billed charges,Critical Access Hospital RCC factor,138.72,34,,138.72,percent of total billed charges,Implant Device,138.72,34,,138.72,percent of total billed charges,Implant Device,138.72,34,,138.72,percent of total billed charges,Implant Device,138.72,34,,138.72,percent of total billed charges,Implant Device,138.72,34,,138.72,percent of total billed charges,Implant Device,201.96,,,201.96,Other,110% of Medicare,142.8,35,,142.8,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,142.8,35,,142.8,percent of total billed charges,Implant Device,142.8,35,,142.8,percent of total billed charges,Implant Device,142.8,35,,142.8,percent of total billed charges,Implant Device,142.8,35,,142.8,percent of total billed charges,Implant Device,142.8,35,,142.8,percent of total billed charges,Implant Device,163.2,40,,163.2,percent of total billed charges,Implant Device,142.8,70,,142.8,percent of total billed charges,All Other,138.72,34,,138.72,percent of total billed charges,Implant Device,138.72,34,,138.72,percent of total billed charges,Implant Device,142.8,35,,142.8,percent of total billed charges,Implant Device,142.8,35,,142.8,percent of total billed charges,Implant Device,142.8,35,,142.8,percent of total billed charges,Implant Device,142.8,35,,142.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,301.92,
STRYKER 626771 LOCKING PLATE LEFT SHORT,C1713,HCPCS,,79009026,CDM,278,RC,,,both,,,7368,5452.34,,,5452.34,Other,150% of Medicare + 9.63% HCRA Surcharge,3315.6,45,,3315.6,percent of total billed charges,Critical Access Hospital RCC factor,2505.12,34,,2505.12,percent of total billed charges,Implant Device,2505.12,34,,2505.12,percent of total billed charges,Implant Device,2505.12,34,,2505.12,percent of total billed charges,Implant Device,2505.12,34,,2505.12,percent of total billed charges,Implant Device,2505.12,34,,2505.12,percent of total billed charges,Implant Device,3647.16,,,3647.16,Other,110% of Medicare,2578.8,35,,2578.8,percent of total billed charges,Implant Device,2505.12,34,"Charges > $500, x 34%",2505.12,percent of total billed charges,Implant Device,2578.8,35,,2578.8,percent of total billed charges,Implant Device,2578.8,35,,2578.8,percent of total billed charges,Implant Device,2578.8,35,,2578.8,percent of total billed charges,Implant Device,2578.8,35,,2578.8,percent of total billed charges,Implant Device,2578.8,35,,2578.8,percent of total billed charges,Implant Device,2947.2,40,,2947.2,percent of total billed charges,Implant Device,2578.8,70,,2578.8,percent of total billed charges,All Other,2505.12,34,,2505.12,percent of total billed charges,Implant Device,2505.12,34,,2505.12,percent of total billed charges,Implant Device,2578.8,35,,2578.8,percent of total billed charges,Implant Device,2578.8,35,,2578.8,percent of total billed charges,Implant Device,2578.8,35,,2578.8,percent of total billed charges,Implant Device,2578.8,35,,2578.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2505.12,34,"If Charge > 2,000, then 34 percent",2505.12,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5452.34,
STRYKER 3102-2544 DERMAL MATRIX 4X4CM,Q4142,HCPCS,,79009027,CDM,278,RC,,,both,,,5400,3996.01,,,3996.01,Other,150% of Medicare + 9.63% HCRA Surcharge,2430,45,,2430,percent of total billed charges,Critical Access Hospital RCC factor,1836,34,,1836,percent of total billed charges,Implant Device,1836,34,,1836,percent of total billed charges,Implant Device,1836,34,,1836,percent of total billed charges,Implant Device,1836,34,,1836,percent of total billed charges,Implant Device,1836,34,,1836,percent of total billed charges,Implant Device,2673,,,2673,Other,110% of Medicare,1890,35,,1890,percent of total billed charges,Implant Device,1836,34,"Charges > $500, x 34%",1836,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,2160,40,,2160,percent of total billed charges,Implant Device,1890,70,,1890,percent of total billed charges,All Other,1836,34,,1836,percent of total billed charges,Implant Device,1836,34,,1836,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,976.07,,,976.07,Other,100% of Medicaid,976.07,,,976.07,Other,100% of Medicaid,976.07,,,976.07,Other,100% of Medicaid,976.07,,,976.07,Other,100% of Medicaid,2196.16,,,2196.16,Other,225% of Medicaid,1493.39,,,1493.39,Other,153% of Medicaid,2196.16,,,2196.16,Other,225% of Medicaid,1366.5,,,1366.5,Other,140% of Medicaid,1836,34,"If Charge > 2,000, then 34 percent",1836,percent of total billed charges,Implants,2537.78,,,2537.78,Other,260% of Medicaid,3162.47,,,3162.47,Other,324% of Medicaid,2098.55,,,2098.55,Other,215% of Medicaid,2098.55,,,2098.55,Other,215% of Medicaid,1220.09,,,1220.09,Other,125% of Medicaid,976.07,3996.01,
IN2BONES 100-0040 VITRIUM WEDGE 18X10,C1713,HCPCS,,79009028,CDM,278,RC,,,both,,,9450,6993.02,,,6993.02,Other,150% of Medicare + 9.63% HCRA Surcharge,4252.5,45,,4252.5,percent of total billed charges,Critical Access Hospital RCC factor,3213,34,,3213,percent of total billed charges,Implant Device,3213,34,,3213,percent of total billed charges,Implant Device,3213,34,,3213,percent of total billed charges,Implant Device,3213,34,,3213,percent of total billed charges,Implant Device,3213,34,,3213,percent of total billed charges,Implant Device,4677.75,,,4677.75,Other,110% of Medicare,3307.5,35,,3307.5,percent of total billed charges,Implant Device,3213,34,"Charges > $500, x 34%",3213,percent of total billed charges,Implant Device,3307.5,35,,3307.5,percent of total billed charges,Implant Device,3307.5,35,,3307.5,percent of total billed charges,Implant Device,3307.5,35,,3307.5,percent of total billed charges,Implant Device,3307.5,35,,3307.5,percent of total billed charges,Implant Device,3307.5,35,,3307.5,percent of total billed charges,Implant Device,3780,40,,3780,percent of total billed charges,Implant Device,3307.5,70,,3307.5,percent of total billed charges,All Other,3213,34,,3213,percent of total billed charges,Implant Device,3213,34,,3213,percent of total billed charges,Implant Device,3307.5,35,,3307.5,percent of total billed charges,Implant Device,3307.5,35,,3307.5,percent of total billed charges,Implant Device,3307.5,35,,3307.5,percent of total billed charges,Implant Device,3307.5,35,,3307.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3213,34,"If Charge > 2,000, then 34 percent",3213,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,6993.02,
STRYKER 658610 COMP SCREW 7/L110MM,C1713,HCPCS,,79009034,CDM,278,RC,,,both,,,2955,2186.71,,,2186.71,Other,150% of Medicare + 9.63% HCRA Surcharge,1329.75,45,,1329.75,percent of total billed charges,Critical Access Hospital RCC factor,1004.7,34,,1004.7,percent of total billed charges,Implant Device,1004.7,34,,1004.7,percent of total billed charges,Implant Device,1004.7,34,,1004.7,percent of total billed charges,Implant Device,1004.7,34,,1004.7,percent of total billed charges,Implant Device,1004.7,34,,1004.7,percent of total billed charges,Implant Device,1462.73,,,1462.73,Other,110% of Medicare,1034.25,35,,1034.25,percent of total billed charges,Implant Device,1004.7,34,"Charges > $500, x 34%",1004.7,percent of total billed charges,Implant Device,1034.25,35,,1034.25,percent of total billed charges,Implant Device,1034.25,35,,1034.25,percent of total billed charges,Implant Device,1034.25,35,,1034.25,percent of total billed charges,Implant Device,1034.25,35,,1034.25,percent of total billed charges,Implant Device,1034.25,35,,1034.25,percent of total billed charges,Implant Device,1182,40,,1182,percent of total billed charges,Implant Device,1034.25,70,,1034.25,percent of total billed charges,All Other,1004.7,34,,1004.7,percent of total billed charges,Implant Device,1004.7,34,,1004.7,percent of total billed charges,Implant Device,1034.25,35,,1034.25,percent of total billed charges,Implant Device,1034.25,35,,1034.25,percent of total billed charges,Implant Device,1034.25,35,,1034.25,percent of total billed charges,Implant Device,1034.25,35,,1034.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1004.7,34,"If Charge > 2,000, then 34 percent",1004.7,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2186.71,
STRYKER 602660 CANNULATED SCREW 6.5X60MM,C1713,HCPCS,,79009036,CDM,278,RC,,,both,,,1224,905.76,,,905.76,Other,150% of Medicare + 9.63% HCRA Surcharge,550.8,45,,550.8,percent of total billed charges,Critical Access Hospital RCC factor,416.16,34,,416.16,percent of total billed charges,Implant Device,416.16,34,,416.16,percent of total billed charges,Implant Device,416.16,34,,416.16,percent of total billed charges,Implant Device,416.16,34,,416.16,percent of total billed charges,Implant Device,416.16,34,,416.16,percent of total billed charges,Implant Device,605.88,,,605.88,Other,110% of Medicare,428.4,35,,428.4,percent of total billed charges,Implant Device,416.16,34,"Charges > $500, x 34%",416.16,percent of total billed charges,Implant Device,428.4,35,,428.4,percent of total billed charges,Implant Device,428.4,35,,428.4,percent of total billed charges,Implant Device,428.4,35,,428.4,percent of total billed charges,Implant Device,428.4,35,,428.4,percent of total billed charges,Implant Device,428.4,35,,428.4,percent of total billed charges,Implant Device,489.6,40,,489.6,percent of total billed charges,Implant Device,428.4,70,,428.4,percent of total billed charges,All Other,416.16,34,,416.16,percent of total billed charges,Implant Device,416.16,34,,416.16,percent of total billed charges,Implant Device,428.4,35,,428.4,percent of total billed charges,Implant Device,428.4,35,,428.4,percent of total billed charges,Implant Device,428.4,35,,428.4,percent of total billed charges,Implant Device,428.4,35,,428.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,905.76,
STRYKER 5017-8-150S HALF PIN 5X15X25MM,C1713,HCPCS,,79009039,CDM,278,RC,,,both,,,752,556.48,,,556.48,Other,150% of Medicare + 9.63% HCRA Surcharge,338.4,45,,338.4,percent of total billed charges,Critical Access Hospital RCC factor,255.68,34,,255.68,percent of total billed charges,Implant Device,255.68,34,,255.68,percent of total billed charges,Implant Device,255.68,34,,255.68,percent of total billed charges,Implant Device,255.68,34,,255.68,percent of total billed charges,Implant Device,255.68,34,,255.68,percent of total billed charges,Implant Device,372.24,,,372.24,Other,110% of Medicare,263.2,35,,263.2,percent of total billed charges,Implant Device,255.68,34,"Charges > $500, x 34%",255.68,percent of total billed charges,Implant Device,263.2,35,,263.2,percent of total billed charges,Implant Device,263.2,35,,263.2,percent of total billed charges,Implant Device,263.2,35,,263.2,percent of total billed charges,Implant Device,263.2,35,,263.2,percent of total billed charges,Implant Device,263.2,35,,263.2,percent of total billed charges,Implant Device,300.8,40,,300.8,percent of total billed charges,Implant Device,263.2,70,,263.2,percent of total billed charges,All Other,255.68,34,,255.68,percent of total billed charges,Implant Device,255.68,34,,255.68,percent of total billed charges,Implant Device,263.2,35,,263.2,percent of total billed charges,Implant Device,263.2,35,,263.2,percent of total billed charges,Implant Device,263.2,35,,263.2,percent of total billed charges,Implant Device,263.2,35,,263.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,556.48,
STRYKER 897010 HYDROSET XT 10C,C1713,HCPCS,,79009046,CDM,278,RC,,,both,,,8512,6298.9,,,6298.9,Other,150% of Medicare + 9.63% HCRA Surcharge,3830.4,45,,3830.4,percent of total billed charges,Critical Access Hospital RCC factor,2894.08,34,,2894.08,percent of total billed charges,Implant Device,2894.08,34,,2894.08,percent of total billed charges,Implant Device,2894.08,34,,2894.08,percent of total billed charges,Implant Device,2894.08,34,,2894.08,percent of total billed charges,Implant Device,2894.08,34,,2894.08,percent of total billed charges,Implant Device,4213.44,,,4213.44,Other,110% of Medicare,2979.2,35,,2979.2,percent of total billed charges,Implant Device,2894.08,34,"Charges > $500, x 34%",2894.08,percent of total billed charges,Implant Device,2979.2,35,,2979.2,percent of total billed charges,Implant Device,2979.2,35,,2979.2,percent of total billed charges,Implant Device,2979.2,35,,2979.2,percent of total billed charges,Implant Device,2979.2,35,,2979.2,percent of total billed charges,Implant Device,2979.2,35,,2979.2,percent of total billed charges,Implant Device,3404.8,40,,3404.8,percent of total billed charges,Implant Device,2979.2,70,,2979.2,percent of total billed charges,All Other,2894.08,34,,2894.08,percent of total billed charges,Implant Device,2894.08,34,,2894.08,percent of total billed charges,Implant Device,2979.2,35,,2979.2,percent of total billed charges,Implant Device,2979.2,35,,2979.2,percent of total billed charges,Implant Device,2979.2,35,,2979.2,percent of total billed charges,Implant Device,2979.2,35,,2979.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2894.08,34,"If Charge > 2,000, then 34 percent",2894.08,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,6298.9,
STRYKER 40-10114 CALCANEUS STD PLATE MED,C1713,HCPCS,,79009047,CDM,278,RC,,,both,,,3695,2734.31,,,2734.31,Other,150% of Medicare + 9.63% HCRA Surcharge,1662.75,45,,1662.75,percent of total billed charges,Critical Access Hospital RCC factor,1256.3,34,,1256.3,percent of total billed charges,Implant Device,1256.3,34,,1256.3,percent of total billed charges,Implant Device,1256.3,34,,1256.3,percent of total billed charges,Implant Device,1256.3,34,,1256.3,percent of total billed charges,Implant Device,1256.3,34,,1256.3,percent of total billed charges,Implant Device,1829.03,,,1829.03,Other,110% of Medicare,1293.25,35,,1293.25,percent of total billed charges,Implant Device,1256.3,34,"Charges > $500, x 34%",1256.3,percent of total billed charges,Implant Device,1293.25,35,,1293.25,percent of total billed charges,Implant Device,1293.25,35,,1293.25,percent of total billed charges,Implant Device,1293.25,35,,1293.25,percent of total billed charges,Implant Device,1293.25,35,,1293.25,percent of total billed charges,Implant Device,1293.25,35,,1293.25,percent of total billed charges,Implant Device,1478,40,,1478,percent of total billed charges,Implant Device,1293.25,70,,1293.25,percent of total billed charges,All Other,1256.3,34,,1256.3,percent of total billed charges,Implant Device,1256.3,34,,1256.3,percent of total billed charges,Implant Device,1293.25,35,,1293.25,percent of total billed charges,Implant Device,1293.25,35,,1293.25,percent of total billed charges,Implant Device,1293.25,35,,1293.25,percent of total billed charges,Implant Device,1293.25,35,,1293.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1256.3,34,"If Charge > 2,000, then 34 percent",1256.3,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2734.31,
STRYKER 40-10104 CALCANEUS MESH PLATE,C1713,HCPCS,,79009048,CDM,278,RC,,,both,,,2174,1608.77,,,1608.77,Other,150% of Medicare + 9.63% HCRA Surcharge,978.3,45,,978.3,percent of total billed charges,Critical Access Hospital RCC factor,739.16,34,,739.16,percent of total billed charges,Implant Device,739.16,34,,739.16,percent of total billed charges,Implant Device,739.16,34,,739.16,percent of total billed charges,Implant Device,739.16,34,,739.16,percent of total billed charges,Implant Device,739.16,34,,739.16,percent of total billed charges,Implant Device,1076.13,,,1076.13,Other,110% of Medicare,760.9,35,,760.9,percent of total billed charges,Implant Device,739.16,34,"Charges > $500, x 34%",739.16,percent of total billed charges,Implant Device,760.9,35,,760.9,percent of total billed charges,Implant Device,760.9,35,,760.9,percent of total billed charges,Implant Device,760.9,35,,760.9,percent of total billed charges,Implant Device,760.9,35,,760.9,percent of total billed charges,Implant Device,760.9,35,,760.9,percent of total billed charges,Implant Device,869.6,40,,869.6,percent of total billed charges,Implant Device,760.9,70,,760.9,percent of total billed charges,All Other,739.16,34,,739.16,percent of total billed charges,Implant Device,739.16,34,,739.16,percent of total billed charges,Implant Device,760.9,35,,760.9,percent of total billed charges,Implant Device,760.9,35,,760.9,percent of total billed charges,Implant Device,760.9,35,,760.9,percent of total billed charges,Implant Device,760.9,35,,760.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,739.16,34,"If Charge > 2,000, then 34 percent",739.16,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1608.77,
STRYKER 40-35640 LOCK SCREW T10 3.5X40MM,C1713,HCPCS,,79009049,CDM,278,RC,,,both,,,732,541.68,,,541.68,Other,150% of Medicare + 9.63% HCRA Surcharge,329.4,45,,329.4,percent of total billed charges,Critical Access Hospital RCC factor,248.88,34,,248.88,percent of total billed charges,Implant Device,248.88,34,,248.88,percent of total billed charges,Implant Device,248.88,34,,248.88,percent of total billed charges,Implant Device,248.88,34,,248.88,percent of total billed charges,Implant Device,248.88,34,,248.88,percent of total billed charges,Implant Device,362.34,,,362.34,Other,110% of Medicare,256.2,35,,256.2,percent of total billed charges,Implant Device,248.88,34,"Charges > $500, x 34%",248.88,percent of total billed charges,Implant Device,256.2,35,,256.2,percent of total billed charges,Implant Device,256.2,35,,256.2,percent of total billed charges,Implant Device,256.2,35,,256.2,percent of total billed charges,Implant Device,256.2,35,,256.2,percent of total billed charges,Implant Device,256.2,35,,256.2,percent of total billed charges,Implant Device,292.8,40,,292.8,percent of total billed charges,Implant Device,256.2,70,,256.2,percent of total billed charges,All Other,248.88,34,,248.88,percent of total billed charges,Implant Device,248.88,34,,248.88,percent of total billed charges,Implant Device,256.2,35,,256.2,percent of total billed charges,Implant Device,256.2,35,,256.2,percent of total billed charges,Implant Device,256.2,35,,256.2,percent of total billed charges,Implant Device,256.2,35,,256.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,541.68,
STRYKER 40-35638 LOCK SCREW T10 3.5X38MM,C1713,HCPCS,,79009050,CDM,278,RC,,,both,,,732,541.68,,,541.68,Other,150% of Medicare + 9.63% HCRA Surcharge,329.4,45,,329.4,percent of total billed charges,Critical Access Hospital RCC factor,248.88,34,,248.88,percent of total billed charges,Implant Device,248.88,34,,248.88,percent of total billed charges,Implant Device,248.88,34,,248.88,percent of total billed charges,Implant Device,248.88,34,,248.88,percent of total billed charges,Implant Device,248.88,34,,248.88,percent of total billed charges,Implant Device,362.34,,,362.34,Other,110% of Medicare,256.2,35,,256.2,percent of total billed charges,Implant Device,248.88,34,"Charges > $500, x 34%",248.88,percent of total billed charges,Implant Device,256.2,35,,256.2,percent of total billed charges,Implant Device,256.2,35,,256.2,percent of total billed charges,Implant Device,256.2,35,,256.2,percent of total billed charges,Implant Device,256.2,35,,256.2,percent of total billed charges,Implant Device,256.2,35,,256.2,percent of total billed charges,Implant Device,292.8,40,,292.8,percent of total billed charges,Implant Device,256.2,70,,256.2,percent of total billed charges,All Other,248.88,34,,248.88,percent of total billed charges,Implant Device,248.88,34,,248.88,percent of total billed charges,Implant Device,256.2,35,,256.2,percent of total billed charges,Implant Device,256.2,35,,256.2,percent of total billed charges,Implant Device,256.2,35,,256.2,percent of total billed charges,Implant Device,256.2,35,,256.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,541.68,
STRYKER 627540 COMPRESSION PLATE 10H 5MM,C1713,HCPCS,,79009053,CDM,278,RC,,,both,,,8235,6093.92,,,6093.92,Other,150% of Medicare + 9.63% HCRA Surcharge,3705.75,45,,3705.75,percent of total billed charges,Critical Access Hospital RCC factor,2799.9,34,,2799.9,percent of total billed charges,Implant Device,2799.9,34,,2799.9,percent of total billed charges,Implant Device,2799.9,34,,2799.9,percent of total billed charges,Implant Device,2799.9,34,,2799.9,percent of total billed charges,Implant Device,2799.9,34,,2799.9,percent of total billed charges,Implant Device,4076.33,,,4076.33,Other,110% of Medicare,2882.25,35,,2882.25,percent of total billed charges,Implant Device,2799.9,34,"Charges > $500, x 34%",2799.9,percent of total billed charges,Implant Device,2882.25,35,,2882.25,percent of total billed charges,Implant Device,2882.25,35,,2882.25,percent of total billed charges,Implant Device,2882.25,35,,2882.25,percent of total billed charges,Implant Device,2882.25,35,,2882.25,percent of total billed charges,Implant Device,2882.25,35,,2882.25,percent of total billed charges,Implant Device,3294,40,,3294,percent of total billed charges,Implant Device,2882.25,70,,2882.25,percent of total billed charges,All Other,2799.9,34,,2799.9,percent of total billed charges,Implant Device,2799.9,34,,2799.9,percent of total billed charges,Implant Device,2882.25,35,,2882.25,percent of total billed charges,Implant Device,2882.25,35,,2882.25,percent of total billed charges,Implant Device,2882.25,35,,2882.25,percent of total billed charges,Implant Device,2882.25,35,,2882.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2799.9,34,"If Charge > 2,000, then 34 percent",2799.9,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,6093.92,
STRYKER 661724 CORTICAL SCREW 4.5X24MM,C1713,HCPCS,,79009054,CDM,278,RC,,,both,,,139,102.86,,,102.86,Other,150% of Medicare + 9.63% HCRA Surcharge,62.55,45,,62.55,percent of total billed charges,Critical Access Hospital RCC factor,47.26,34,,47.26,percent of total billed charges,Implant Device,47.26,34,,47.26,percent of total billed charges,Implant Device,47.26,34,,47.26,percent of total billed charges,Implant Device,47.26,34,,47.26,percent of total billed charges,Implant Device,47.26,34,,47.26,percent of total billed charges,Implant Device,68.81,,,68.81,Other,110% of Medicare,48.65,35,,48.65,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,48.65,35,,48.65,percent of total billed charges,Implant Device,48.65,35,,48.65,percent of total billed charges,Implant Device,48.65,35,,48.65,percent of total billed charges,Implant Device,48.65,35,,48.65,percent of total billed charges,Implant Device,48.65,35,,48.65,percent of total billed charges,Implant Device,55.6,40,,55.6,percent of total billed charges,Implant Device,48.65,70,,48.65,percent of total billed charges,All Other,47.26,34,,47.26,percent of total billed charges,Implant Device,47.26,34,,47.26,percent of total billed charges,Implant Device,48.65,35,,48.65,percent of total billed charges,Implant Device,48.65,35,,48.65,percent of total billed charges,Implant Device,48.65,35,,48.65,percent of total billed charges,Implant Device,48.65,35,,48.65,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,102.86,
STRYKER 661722 CORTICAL SCREW 4.5X22MM,C1713,HCPCS,,79009055,CDM,278,RC,,,both,,,139,102.86,,,102.86,Other,150% of Medicare + 9.63% HCRA Surcharge,62.55,45,,62.55,percent of total billed charges,Critical Access Hospital RCC factor,47.26,34,,47.26,percent of total billed charges,Implant Device,47.26,34,,47.26,percent of total billed charges,Implant Device,47.26,34,,47.26,percent of total billed charges,Implant Device,47.26,34,,47.26,percent of total billed charges,Implant Device,47.26,34,,47.26,percent of total billed charges,Implant Device,68.81,,,68.81,Other,110% of Medicare,48.65,35,,48.65,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,48.65,35,,48.65,percent of total billed charges,Implant Device,48.65,35,,48.65,percent of total billed charges,Implant Device,48.65,35,,48.65,percent of total billed charges,Implant Device,48.65,35,,48.65,percent of total billed charges,Implant Device,48.65,35,,48.65,percent of total billed charges,Implant Device,55.6,40,,55.6,percent of total billed charges,Implant Device,48.65,70,,48.65,percent of total billed charges,All Other,47.26,34,,47.26,percent of total billed charges,Implant Device,47.26,34,,47.26,percent of total billed charges,Implant Device,48.65,35,,48.65,percent of total billed charges,Implant Device,48.65,35,,48.65,percent of total billed charges,Implant Device,48.65,35,,48.65,percent of total billed charges,Implant Device,48.65,35,,48.65,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,102.86,
STRYKER 661122 LOCKING SCREW 5.0X22MM,C1713,HCPCS,,79009056,CDM,278,RC,,,both,,,864,639.36,,,639.36,Other,150% of Medicare + 9.63% HCRA Surcharge,388.8,45,,388.8,percent of total billed charges,Critical Access Hospital RCC factor,293.76,34,,293.76,percent of total billed charges,Implant Device,293.76,34,,293.76,percent of total billed charges,Implant Device,293.76,34,,293.76,percent of total billed charges,Implant Device,293.76,34,,293.76,percent of total billed charges,Implant Device,293.76,34,,293.76,percent of total billed charges,Implant Device,427.68,,,427.68,Other,110% of Medicare,302.4,35,,302.4,percent of total billed charges,Implant Device,293.76,34,"Charges > $500, x 34%",293.76,percent of total billed charges,Implant Device,302.4,35,,302.4,percent of total billed charges,Implant Device,302.4,35,,302.4,percent of total billed charges,Implant Device,302.4,35,,302.4,percent of total billed charges,Implant Device,302.4,35,,302.4,percent of total billed charges,Implant Device,302.4,35,,302.4,percent of total billed charges,Implant Device,345.6,40,,345.6,percent of total billed charges,Implant Device,302.4,70,,302.4,percent of total billed charges,All Other,293.76,34,,293.76,percent of total billed charges,Implant Device,293.76,34,,293.76,percent of total billed charges,Implant Device,302.4,35,,302.4,percent of total billed charges,Implant Device,302.4,35,,302.4,percent of total billed charges,Implant Device,302.4,35,,302.4,percent of total billed charges,Implant Device,302.4,35,,302.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,639.36,
STRYKER 608025 CANCELLOUS SCREW 6.0X25MM,C1713,HCPCS,,79009057,CDM,278,RC,,,both,,,155,114.7,,,114.7,Other,150% of Medicare + 9.63% HCRA Surcharge,69.75,45,,69.75,percent of total billed charges,Critical Access Hospital RCC factor,52.7,34,,52.7,percent of total billed charges,Implant Device,52.7,34,,52.7,percent of total billed charges,Implant Device,52.7,34,,52.7,percent of total billed charges,Implant Device,52.7,34,,52.7,percent of total billed charges,Implant Device,52.7,34,,52.7,percent of total billed charges,Implant Device,76.73,,,76.73,Other,110% of Medicare,54.25,35,,54.25,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,54.25,35,,54.25,percent of total billed charges,Implant Device,54.25,35,,54.25,percent of total billed charges,Implant Device,54.25,35,,54.25,percent of total billed charges,Implant Device,54.25,35,,54.25,percent of total billed charges,Implant Device,54.25,35,,54.25,percent of total billed charges,Implant Device,62,40,,62,percent of total billed charges,Implant Device,54.25,70,,54.25,percent of total billed charges,All Other,52.7,34,,52.7,percent of total billed charges,Implant Device,52.7,34,,52.7,percent of total billed charges,Implant Device,54.25,35,,54.25,percent of total billed charges,Implant Device,54.25,35,,54.25,percent of total billed charges,Implant Device,54.25,35,,54.25,percent of total billed charges,Implant Device,54.25,35,,54.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,114.7,
STRYKER 603018 CORTICAL SCREW 3.5X18MM,C1713,HCPCS,,79009058,CDM,278,RC,,,both,,,118,87.32,,,87.32,Other,150% of Medicare + 9.63% HCRA Surcharge,53.1,45,,53.1,percent of total billed charges,Critical Access Hospital RCC factor,40.12,34,,40.12,percent of total billed charges,Implant Device,40.12,34,,40.12,percent of total billed charges,Implant Device,40.12,34,,40.12,percent of total billed charges,Implant Device,40.12,34,,40.12,percent of total billed charges,Implant Device,40.12,34,,40.12,percent of total billed charges,Implant Device,58.41,,,58.41,Other,110% of Medicare,41.3,35,,41.3,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,41.3,35,,41.3,percent of total billed charges,Implant Device,41.3,35,,41.3,percent of total billed charges,Implant Device,41.3,35,,41.3,percent of total billed charges,Implant Device,41.3,35,,41.3,percent of total billed charges,Implant Device,41.3,35,,41.3,percent of total billed charges,Implant Device,47.2,40,,47.2,percent of total billed charges,Implant Device,41.3,70,,41.3,percent of total billed charges,All Other,40.12,34,,40.12,percent of total billed charges,Implant Device,40.12,34,,40.12,percent of total billed charges,Implant Device,41.3,35,,41.3,percent of total billed charges,Implant Device,41.3,35,,41.3,percent of total billed charges,Implant Device,41.3,35,,41.3,percent of total billed charges,Implant Device,41.3,35,,41.3,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,87.32,
STRYKER 604018 CANCELLOUS SCREW 4.0X18MM,C1713,HCPCS,,79009059,CDM,278,RC,,,both,,,118,87.32,,,87.32,Other,150% of Medicare + 9.63% HCRA Surcharge,53.1,45,,53.1,percent of total billed charges,Critical Access Hospital RCC factor,40.12,34,,40.12,percent of total billed charges,Implant Device,40.12,34,,40.12,percent of total billed charges,Implant Device,40.12,34,,40.12,percent of total billed charges,Implant Device,40.12,34,,40.12,percent of total billed charges,Implant Device,40.12,34,,40.12,percent of total billed charges,Implant Device,58.41,,,58.41,Other,110% of Medicare,41.3,35,,41.3,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,41.3,35,,41.3,percent of total billed charges,Implant Device,41.3,35,,41.3,percent of total billed charges,Implant Device,41.3,35,,41.3,percent of total billed charges,Implant Device,41.3,35,,41.3,percent of total billed charges,Implant Device,41.3,35,,41.3,percent of total billed charges,Implant Device,47.2,40,,47.2,percent of total billed charges,Implant Device,41.3,70,,41.3,percent of total billed charges,All Other,40.12,34,,40.12,percent of total billed charges,Implant Device,40.12,34,,40.12,percent of total billed charges,Implant Device,41.3,35,,41.3,percent of total billed charges,Implant Device,41.3,35,,41.3,percent of total billed charges,Implant Device,41.3,35,,41.3,percent of total billed charges,Implant Device,41.3,35,,41.3,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,87.32,
STRYKER 604020 CANCELLOUS SCREW 4.0X20MM,C1713,HCPCS,,79009060,CDM,278,RC,,,both,,,115,85.1,,,85.1,Other,150% of Medicare + 9.63% HCRA Surcharge,51.75,45,,51.75,percent of total billed charges,Critical Access Hospital RCC factor,39.1,34,,39.1,percent of total billed charges,Implant Device,39.1,34,,39.1,percent of total billed charges,Implant Device,39.1,34,,39.1,percent of total billed charges,Implant Device,39.1,34,,39.1,percent of total billed charges,Implant Device,39.1,34,,39.1,percent of total billed charges,Implant Device,56.93,,,56.93,Other,110% of Medicare,40.25,35,,40.25,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,40.25,35,,40.25,percent of total billed charges,Implant Device,40.25,35,,40.25,percent of total billed charges,Implant Device,40.25,35,,40.25,percent of total billed charges,Implant Device,40.25,35,,40.25,percent of total billed charges,Implant Device,40.25,35,,40.25,percent of total billed charges,Implant Device,46,40,,46,percent of total billed charges,Implant Device,40.25,70,,40.25,percent of total billed charges,All Other,39.1,34,,39.1,percent of total billed charges,Implant Device,39.1,34,,39.1,percent of total billed charges,Implant Device,40.25,35,,40.25,percent of total billed charges,Implant Device,40.25,35,,40.25,percent of total billed charges,Implant Device,40.25,35,,40.25,percent of total billed charges,Implant Device,40.25,35,,40.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,85.1,
STRYKER 627234 PROX HUMERUS PLATE RT 4H,C1713,HCPCS,,79009061,CDM,278,RC,,,both,,,6151,4551.76,,,4551.76,Other,150% of Medicare + 9.63% HCRA Surcharge,2767.95,45,,2767.95,percent of total billed charges,Critical Access Hospital RCC factor,2091.34,34,,2091.34,percent of total billed charges,Implant Device,2091.34,34,,2091.34,percent of total billed charges,Implant Device,2091.34,34,,2091.34,percent of total billed charges,Implant Device,2091.34,34,,2091.34,percent of total billed charges,Implant Device,2091.34,34,,2091.34,percent of total billed charges,Implant Device,3044.75,,,3044.75,Other,110% of Medicare,2152.85,35,,2152.85,percent of total billed charges,Implant Device,2091.34,34,"Charges > $500, x 34%",2091.34,percent of total billed charges,Implant Device,2152.85,35,,2152.85,percent of total billed charges,Implant Device,2152.85,35,,2152.85,percent of total billed charges,Implant Device,2152.85,35,,2152.85,percent of total billed charges,Implant Device,2152.85,35,,2152.85,percent of total billed charges,Implant Device,2152.85,35,,2152.85,percent of total billed charges,Implant Device,2460.4,40,,2460.4,percent of total billed charges,Implant Device,2152.85,70,,2152.85,percent of total billed charges,All Other,2091.34,34,,2091.34,percent of total billed charges,Implant Device,2091.34,34,,2091.34,percent of total billed charges,Implant Device,2152.85,35,,2152.85,percent of total billed charges,Implant Device,2152.85,35,,2152.85,percent of total billed charges,Implant Device,2152.85,35,,2152.85,percent of total billed charges,Implant Device,2152.85,35,,2152.85,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2091.34,34,"If Charge > 2,000, then 34 percent",2091.34,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4551.76,
TIDES TAH1404 AMNIOHEAL PLUS 4X4CM,V2790,HCPCS,,79009062,CDM,278,RC,,,both,,,7493,5544.84,,,5544.84,Other,150% of Medicare + 9.63% HCRA Surcharge,3371.85,45,,3371.85,percent of total billed charges,Critical Access Hospital RCC factor,2547.62,34,,2547.62,percent of total billed charges,Implant Device,2547.62,34,,2547.62,percent of total billed charges,Implant Device,2547.62,34,,2547.62,percent of total billed charges,Implant Device,2547.62,34,,2547.62,percent of total billed charges,Implant Device,2547.62,34,,2547.62,percent of total billed charges,Implant Device,3709.04,,,3709.04,Other,110% of Medicare,2622.55,35,,2622.55,percent of total billed charges,Implant Device,2547.62,34,"Charges > $500, x 34%",2547.62,percent of total billed charges,Implant Device,2622.55,35,,2622.55,percent of total billed charges,Implant Device,2622.55,35,,2622.55,percent of total billed charges,Implant Device,2622.55,35,,2622.55,percent of total billed charges,Implant Device,2622.55,35,,2622.55,percent of total billed charges,Implant Device,2622.55,35,,2622.55,percent of total billed charges,Implant Device,2997.2,40,,2997.2,percent of total billed charges,Implant Device,2622.55,70,,2622.55,percent of total billed charges,All Other,2547.62,34,,2547.62,percent of total billed charges,Implant Device,2547.62,34,,2547.62,percent of total billed charges,Implant Device,2622.55,35,,2622.55,percent of total billed charges,Implant Device,2622.55,35,,2622.55,percent of total billed charges,Implant Device,2622.55,35,,2622.55,percent of total billed charges,Implant Device,2622.55,35,,2622.55,percent of total billed charges,Implant Device,976.07,,,976.07,Other,100% of Medicaid,976.07,,,976.07,Other,100% of Medicaid,976.07,,,976.07,Other,100% of Medicaid,976.07,,,976.07,Other,100% of Medicaid,2196.15,,,2196.15,Other,225% of Medicaid,1493.38,,,1493.38,Other,153% of Medicaid,2196.15,,,2196.15,Other,225% of Medicaid,1366.49,,,1366.49,Other,140% of Medicaid,2547.62,34,"If Charge > 2,000, then 34 percent",2547.62,percent of total billed charges,Implants,2537.77,,,2537.77,Other,260% of Medicaid,3162.45,,,3162.45,Other,324% of Medicaid,2098.54,,,2098.54,Other,215% of Medicaid,2098.54,,,2098.54,Other,215% of Medicaid,1220.08,,,1220.08,Other,125% of Medicaid,976.07,5544.84,
STRYKER 657016 LOCK SCREW F10 2.7XL16MM,C1713,HCPCS,,79009063,CDM,278,RC,,,both,,,539,398.86,,,398.86,Other,150% of Medicare + 9.63% HCRA Surcharge,242.55,45,,242.55,percent of total billed charges,Critical Access Hospital RCC factor,183.26,34,,183.26,percent of total billed charges,Implant Device,183.26,34,,183.26,percent of total billed charges,Implant Device,183.26,34,,183.26,percent of total billed charges,Implant Device,183.26,34,,183.26,percent of total billed charges,Implant Device,183.26,34,,183.26,percent of total billed charges,Implant Device,266.81,,,266.81,Other,110% of Medicare,188.65,35,,188.65,percent of total billed charges,Implant Device,183.26,34,"Charges > $500, x 34%",183.26,percent of total billed charges,Implant Device,188.65,35,,188.65,percent of total billed charges,Implant Device,188.65,35,,188.65,percent of total billed charges,Implant Device,188.65,35,,188.65,percent of total billed charges,Implant Device,188.65,35,,188.65,percent of total billed charges,Implant Device,188.65,35,,188.65,percent of total billed charges,Implant Device,215.6,40,,215.6,percent of total billed charges,Implant Device,188.65,70,,188.65,percent of total billed charges,All Other,183.26,34,,183.26,percent of total billed charges,Implant Device,183.26,34,,183.26,percent of total billed charges,Implant Device,188.65,35,,188.65,percent of total billed charges,Implant Device,188.65,35,,188.65,percent of total billed charges,Implant Device,188.65,35,,188.65,percent of total billed charges,Implant Device,188.65,35,,188.65,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,398.86,
STRYKER 657310 LOCK SCREW F10 3.5XL10MM,C1713,HCPCS,,79009064,CDM,278,RC,,,both,,,539,398.86,,,398.86,Other,150% of Medicare + 9.63% HCRA Surcharge,242.55,45,,242.55,percent of total billed charges,Critical Access Hospital RCC factor,183.26,34,,183.26,percent of total billed charges,Implant Device,183.26,34,,183.26,percent of total billed charges,Implant Device,183.26,34,,183.26,percent of total billed charges,Implant Device,183.26,34,,183.26,percent of total billed charges,Implant Device,183.26,34,,183.26,percent of total billed charges,Implant Device,266.81,,,266.81,Other,110% of Medicare,188.65,35,,188.65,percent of total billed charges,Implant Device,183.26,34,"Charges > $500, x 34%",183.26,percent of total billed charges,Implant Device,188.65,35,,188.65,percent of total billed charges,Implant Device,188.65,35,,188.65,percent of total billed charges,Implant Device,188.65,35,,188.65,percent of total billed charges,Implant Device,188.65,35,,188.65,percent of total billed charges,Implant Device,188.65,35,,188.65,percent of total billed charges,Implant Device,215.6,40,,215.6,percent of total billed charges,Implant Device,188.65,70,,188.65,percent of total billed charges,All Other,183.26,34,,183.26,percent of total billed charges,Implant Device,183.26,34,,183.26,percent of total billed charges,Implant Device,188.65,35,,188.65,percent of total billed charges,Implant Device,188.65,35,,188.65,percent of total billed charges,Implant Device,188.65,35,,188.65,percent of total billed charges,Implant Device,188.65,35,,188.65,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,398.86,
STRYKER 5018-6-150 APEX PIN 5X150MM,C1713,HCPCS,,79009065,CDM,278,RC,,,both,,,297,219.78,,,219.78,Other,150% of Medicare + 9.63% HCRA Surcharge,133.65,45,,133.65,percent of total billed charges,Critical Access Hospital RCC factor,100.98,34,,100.98,percent of total billed charges,Implant Device,100.98,34,,100.98,percent of total billed charges,Implant Device,100.98,34,,100.98,percent of total billed charges,Implant Device,100.98,34,,100.98,percent of total billed charges,Implant Device,100.98,34,,100.98,percent of total billed charges,Implant Device,147.02,,,147.02,Other,110% of Medicare,103.95,35,,103.95,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,103.95,35,,103.95,percent of total billed charges,Implant Device,103.95,35,,103.95,percent of total billed charges,Implant Device,103.95,35,,103.95,percent of total billed charges,Implant Device,103.95,35,,103.95,percent of total billed charges,Implant Device,103.95,35,,103.95,percent of total billed charges,Implant Device,118.8,40,,118.8,percent of total billed charges,Implant Device,103.95,70,,103.95,percent of total billed charges,All Other,100.98,34,,100.98,percent of total billed charges,Implant Device,100.98,34,,100.98,percent of total billed charges,Implant Device,103.95,35,,103.95,percent of total billed charges,Implant Device,103.95,35,,103.95,percent of total billed charges,Implant Device,103.95,35,,103.95,percent of total billed charges,Implant Device,103.95,35,,103.95,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,219.78,
STRYKER 619906 4.0MM WASHER,C1713,HCPCS,,79009067,CDM,278,RC,,,both,,,153,113.22,,,113.22,Other,150% of Medicare + 9.63% HCRA Surcharge,68.85,45,,68.85,percent of total billed charges,Critical Access Hospital RCC factor,52.02,34,,52.02,percent of total billed charges,Implant Device,52.02,34,,52.02,percent of total billed charges,Implant Device,52.02,34,,52.02,percent of total billed charges,Implant Device,52.02,34,,52.02,percent of total billed charges,Implant Device,52.02,34,,52.02,percent of total billed charges,Implant Device,75.74,,,75.74,Other,110% of Medicare,53.55,35,,53.55,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,53.55,35,,53.55,percent of total billed charges,Implant Device,53.55,35,,53.55,percent of total billed charges,Implant Device,53.55,35,,53.55,percent of total billed charges,Implant Device,53.55,35,,53.55,percent of total billed charges,Implant Device,53.55,35,,53.55,percent of total billed charges,Implant Device,61.2,40,,61.2,percent of total billed charges,Implant Device,53.55,70,,53.55,percent of total billed charges,All Other,52.02,34,,52.02,percent of total billed charges,Implant Device,52.02,34,,52.02,percent of total billed charges,Implant Device,53.55,35,,53.55,percent of total billed charges,Implant Device,53.55,35,,53.55,percent of total billed charges,Implant Device,53.55,35,,53.55,percent of total billed charges,Implant Device,53.55,35,,53.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,113.22,
EXACTECH 304-22-07 FRAC HUM STEM 5.6 RT,C1776,HCPCS,,79009068,CDM,278,RC,,,both,,,6225,4606.52,,,4606.52,Other,150% of Medicare + 9.63% HCRA Surcharge,2801.25,45,,2801.25,percent of total billed charges,Critical Access Hospital RCC factor,2116.5,34,,2116.5,percent of total billed charges,Implant Device,2116.5,34,,2116.5,percent of total billed charges,Implant Device,2116.5,34,,2116.5,percent of total billed charges,Implant Device,2116.5,34,,2116.5,percent of total billed charges,Implant Device,2116.5,34,,2116.5,percent of total billed charges,Implant Device,3081.38,,,3081.38,Other,110% of Medicare,2178.75,35,,2178.75,percent of total billed charges,Implant Device,2116.5,34,"Charges > $500, x 34%",2116.5,percent of total billed charges,Implant Device,2178.75,35,,2178.75,percent of total billed charges,Implant Device,2178.75,35,,2178.75,percent of total billed charges,Implant Device,2178.75,35,,2178.75,percent of total billed charges,Implant Device,2178.75,35,,2178.75,percent of total billed charges,Implant Device,2178.75,35,,2178.75,percent of total billed charges,Implant Device,2490,40,,2490,percent of total billed charges,Implant Device,2178.75,70,,2178.75,percent of total billed charges,All Other,2116.5,34,,2116.5,percent of total billed charges,Implant Device,2116.5,34,,2116.5,percent of total billed charges,Implant Device,2178.75,35,,2178.75,percent of total billed charges,Implant Device,2178.75,35,,2178.75,percent of total billed charges,Implant Device,2178.75,35,,2178.75,percent of total billed charges,Implant Device,2178.75,35,,2178.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2116.5,34,"If Charge > 2,000, then 34 percent",2116.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4606.52,
DEPUY 02-112-082 CLAV PLTE 3.5X100 7 HLE,C1713,HCPCS,,79009069,CDM,278,RC,,,both,,,2459,1819.67,,,1819.67,Other,150% of Medicare + 9.63% HCRA Surcharge,1106.55,45,,1106.55,percent of total billed charges,Critical Access Hospital RCC factor,836.06,34,,836.06,percent of total billed charges,Implant Device,836.06,34,,836.06,percent of total billed charges,Implant Device,836.06,34,,836.06,percent of total billed charges,Implant Device,836.06,34,,836.06,percent of total billed charges,Implant Device,836.06,34,,836.06,percent of total billed charges,Implant Device,1217.21,,,1217.21,Other,110% of Medicare,860.65,35,,860.65,percent of total billed charges,Implant Device,836.06,34,"Charges > $500, x 34%",836.06,percent of total billed charges,Implant Device,860.65,35,,860.65,percent of total billed charges,Implant Device,860.65,35,,860.65,percent of total billed charges,Implant Device,860.65,35,,860.65,percent of total billed charges,Implant Device,860.65,35,,860.65,percent of total billed charges,Implant Device,860.65,35,,860.65,percent of total billed charges,Implant Device,983.6,40,,983.6,percent of total billed charges,Implant Device,860.65,70,,860.65,percent of total billed charges,All Other,836.06,34,,836.06,percent of total billed charges,Implant Device,836.06,34,,836.06,percent of total billed charges,Implant Device,860.65,35,,860.65,percent of total billed charges,Implant Device,860.65,35,,860.65,percent of total billed charges,Implant Device,860.65,35,,860.65,percent of total billed charges,Implant Device,860.65,35,,860.65,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,836.06,34,"If Charge > 2,000, then 34 percent",836.06,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1819.67,
LIFE SPINE INC 4045-35-41 4.5X35MM SCREW,C1713,HCPCS,,79009070,CDM,278,RC,,,both,,,4500,3330.01,,,3330.01,Other,150% of Medicare + 9.63% HCRA Surcharge,2025,45,,2025,percent of total billed charges,Critical Access Hospital RCC factor,1530,34,,1530,percent of total billed charges,Implant Device,1530,34,,1530,percent of total billed charges,Implant Device,1530,34,,1530,percent of total billed charges,Implant Device,1530,34,,1530,percent of total billed charges,Implant Device,1530,34,,1530,percent of total billed charges,Implant Device,2227.5,,,2227.5,Other,110% of Medicare,1575,35,,1575,percent of total billed charges,Implant Device,1530,34,"Charges > $500, x 34%",1530,percent of total billed charges,Implant Device,1575,35,,1575,percent of total billed charges,Implant Device,1575,35,,1575,percent of total billed charges,Implant Device,1575,35,,1575,percent of total billed charges,Implant Device,1575,35,,1575,percent of total billed charges,Implant Device,1575,35,,1575,percent of total billed charges,Implant Device,1800,40,,1800,percent of total billed charges,Implant Device,1575,70,,1575,percent of total billed charges,All Other,1530,34,,1530,percent of total billed charges,Implant Device,1530,34,,1530,percent of total billed charges,Implant Device,1575,35,,1575,percent of total billed charges,Implant Device,1575,35,,1575,percent of total billed charges,Implant Device,1575,35,,1575,percent of total billed charges,Implant Device,1575,35,,1575,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1530,34,"If Charge > 2,000, then 34 percent",1530,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3330.01,
LIFE SPNE INC 4045-25-41 4.5X25MM SCREW,C1713,HCPCS,,79009071,CDM,278,RC,,,both,,,4500,3330.01,,,3330.01,Other,150% of Medicare + 9.63% HCRA Surcharge,2025,45,,2025,percent of total billed charges,Critical Access Hospital RCC factor,1530,34,,1530,percent of total billed charges,Implant Device,1530,34,,1530,percent of total billed charges,Implant Device,1530,34,,1530,percent of total billed charges,Implant Device,1530,34,,1530,percent of total billed charges,Implant Device,1530,34,,1530,percent of total billed charges,Implant Device,2227.5,,,2227.5,Other,110% of Medicare,1575,35,,1575,percent of total billed charges,Implant Device,1530,34,"Charges > $500, x 34%",1530,percent of total billed charges,Implant Device,1575,35,,1575,percent of total billed charges,Implant Device,1575,35,,1575,percent of total billed charges,Implant Device,1575,35,,1575,percent of total billed charges,Implant Device,1575,35,,1575,percent of total billed charges,Implant Device,1575,35,,1575,percent of total billed charges,Implant Device,1800,40,,1800,percent of total billed charges,Implant Device,1575,70,,1575,percent of total billed charges,All Other,1530,34,,1530,percent of total billed charges,Implant Device,1530,34,,1530,percent of total billed charges,Implant Device,1575,35,,1575,percent of total billed charges,Implant Device,1575,35,,1575,percent of total billed charges,Implant Device,1575,35,,1575,percent of total billed charges,Implant Device,1575,35,,1575,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1530,34,"If Charge > 2,000, then 34 percent",1530,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3330.01,
LIFE SPINE INC 6475-045 45MM RODS,C1713,HCPCS,,79009072,CDM,278,RC,,,both,,,900,666,,,666,Other,150% of Medicare + 9.63% HCRA Surcharge,405,45,,405,percent of total billed charges,Critical Access Hospital RCC factor,306,34,,306,percent of total billed charges,Implant Device,306,34,,306,percent of total billed charges,Implant Device,306,34,,306,percent of total billed charges,Implant Device,306,34,,306,percent of total billed charges,Implant Device,306,34,,306,percent of total billed charges,Implant Device,445.5,,,445.5,Other,110% of Medicare,315,35,,315,percent of total billed charges,Implant Device,306,34,"Charges > $500, x 34%",306,percent of total billed charges,Implant Device,315,35,,315,percent of total billed charges,Implant Device,315,35,,315,percent of total billed charges,Implant Device,315,35,,315,percent of total billed charges,Implant Device,315,35,,315,percent of total billed charges,Implant Device,315,35,,315,percent of total billed charges,Implant Device,360,40,,360,percent of total billed charges,Implant Device,315,70,,315,percent of total billed charges,All Other,306,34,,306,percent of total billed charges,Implant Device,306,34,,306,percent of total billed charges,Implant Device,315,35,,315,percent of total billed charges,Implant Device,315,35,,315,percent of total billed charges,Implant Device,315,35,,315,percent of total billed charges,Implant Device,315,35,,315,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,666,
LIFE SPINE INC 148-037 45MM SET CAPS,C1713,HCPCS,,79009073,CDM,278,RC,,,both,,,450,333,,,333,Other,150% of Medicare + 9.63% HCRA Surcharge,202.5,45,,202.5,percent of total billed charges,Critical Access Hospital RCC factor,153,34,,153,percent of total billed charges,Implant Device,153,34,,153,percent of total billed charges,Implant Device,153,34,,153,percent of total billed charges,Implant Device,153,34,,153,percent of total billed charges,Implant Device,153,34,,153,percent of total billed charges,Implant Device,222.75,,,222.75,Other,110% of Medicare,157.5,35,,157.5,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,157.5,35,,157.5,percent of total billed charges,Implant Device,157.5,35,,157.5,percent of total billed charges,Implant Device,157.5,35,,157.5,percent of total billed charges,Implant Device,157.5,35,,157.5,percent of total billed charges,Implant Device,157.5,35,,157.5,percent of total billed charges,Implant Device,180,40,,180,percent of total billed charges,Implant Device,157.5,70,,157.5,percent of total billed charges,All Other,153,34,,153,percent of total billed charges,Implant Device,153,34,,153,percent of total billed charges,Implant Device,157.5,35,,157.5,percent of total billed charges,Implant Device,157.5,35,,157.5,percent of total billed charges,Implant Device,157.5,35,,157.5,percent of total billed charges,Implant Device,157.5,35,,157.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,333,
LIFE SPINE 290-35-5010 50X10X7 CANC STRI,C1713,HCPCS,,79009075,CDM,278,RC,,,both,,,3000,2220.01,,,2220.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1350,45,,1350,percent of total billed charges,Critical Access Hospital RCC factor,1020,34,,1020,percent of total billed charges,Implant Device,1020,34,,1020,percent of total billed charges,Implant Device,1020,34,,1020,percent of total billed charges,Implant Device,1020,34,,1020,percent of total billed charges,Implant Device,1020,34,,1020,percent of total billed charges,Implant Device,1485,,,1485,Other,110% of Medicare,1050,35,,1050,percent of total billed charges,Implant Device,1020,34,"Charges > $500, x 34%",1020,percent of total billed charges,Implant Device,1050,35,,1050,percent of total billed charges,Implant Device,1050,35,,1050,percent of total billed charges,Implant Device,1050,35,,1050,percent of total billed charges,Implant Device,1050,35,,1050,percent of total billed charges,Implant Device,1050,35,,1050,percent of total billed charges,Implant Device,1200,40,,1200,percent of total billed charges,Implant Device,1050,70,,1050,percent of total billed charges,All Other,1020,34,,1020,percent of total billed charges,Implant Device,1020,34,,1020,percent of total billed charges,Implant Device,1050,35,,1050,percent of total billed charges,Implant Device,1050,35,,1050,percent of total billed charges,Implant Device,1050,35,,1050,percent of total billed charges,Implant Device,1050,35,,1050,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1020,34,"If Charge > 2,000, then 34 percent",1020,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2220.01,
IN2BONES V30 ST216 NON LOCK SCREW 3X16MM,C1713,HCPCS,,79009078,CDM,278,RC,,,both,,,735,543.9,,,543.9,Other,150% of Medicare + 9.63% HCRA Surcharge,330.75,45,,330.75,percent of total billed charges,Critical Access Hospital RCC factor,249.9,34,,249.9,percent of total billed charges,Implant Device,249.9,34,,249.9,percent of total billed charges,Implant Device,249.9,34,,249.9,percent of total billed charges,Implant Device,249.9,34,,249.9,percent of total billed charges,Implant Device,249.9,34,,249.9,percent of total billed charges,Implant Device,363.83,,,363.83,Other,110% of Medicare,257.25,35,,257.25,percent of total billed charges,Implant Device,249.9,34,"Charges > $500, x 34%",249.9,percent of total billed charges,Implant Device,257.25,35,,257.25,percent of total billed charges,Implant Device,257.25,35,,257.25,percent of total billed charges,Implant Device,257.25,35,,257.25,percent of total billed charges,Implant Device,257.25,35,,257.25,percent of total billed charges,Implant Device,257.25,35,,257.25,percent of total billed charges,Implant Device,294,40,,294,percent of total billed charges,Implant Device,257.25,70,,257.25,percent of total billed charges,All Other,249.9,34,,249.9,percent of total billed charges,Implant Device,249.9,34,,249.9,percent of total billed charges,Implant Device,257.25,35,,257.25,percent of total billed charges,Implant Device,257.25,35,,257.25,percent of total billed charges,Implant Device,257.25,35,,257.25,percent of total billed charges,Implant Device,257.25,35,,257.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,543.9,
IN2BONES APA-002 PIP ALLOGRAFT 2.5X16MM,C1713,HCPCS,,79009079,CDM,278,RC,,,both,,,4308,3187.93,,,3187.93,Other,150% of Medicare + 9.63% HCRA Surcharge,1938.6,45,,1938.6,percent of total billed charges,Critical Access Hospital RCC factor,1464.72,34,,1464.72,percent of total billed charges,Implant Device,1464.72,34,,1464.72,percent of total billed charges,Implant Device,1464.72,34,,1464.72,percent of total billed charges,Implant Device,1464.72,34,,1464.72,percent of total billed charges,Implant Device,1464.72,34,,1464.72,percent of total billed charges,Implant Device,2132.46,,,2132.46,Other,110% of Medicare,1507.8,35,,1507.8,percent of total billed charges,Implant Device,1464.72,34,"Charges > $500, x 34%",1464.72,percent of total billed charges,Implant Device,1507.8,35,,1507.8,percent of total billed charges,Implant Device,1507.8,35,,1507.8,percent of total billed charges,Implant Device,1507.8,35,,1507.8,percent of total billed charges,Implant Device,1507.8,35,,1507.8,percent of total billed charges,Implant Device,1507.8,35,,1507.8,percent of total billed charges,Implant Device,1723.2,40,,1723.2,percent of total billed charges,Implant Device,1507.8,70,,1507.8,percent of total billed charges,All Other,1464.72,34,,1464.72,percent of total billed charges,Implant Device,1464.72,34,,1464.72,percent of total billed charges,Implant Device,1507.8,35,,1507.8,percent of total billed charges,Implant Device,1507.8,35,,1507.8,percent of total billed charges,Implant Device,1507.8,35,,1507.8,percent of total billed charges,Implant Device,1507.8,35,,1507.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1464.72,34,"If Charge > 2,000, then 34 percent",1464.72,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3187.93,
DEPUY 02.112.007 CLAVICLE PLATE 3.5X69MM,C1713,HCPCS,,79009080,CDM,278,RC,,,both,,,2292,1696.09,,,1696.09,Other,150% of Medicare + 9.63% HCRA Surcharge,1031.4,45,,1031.4,percent of total billed charges,Critical Access Hospital RCC factor,779.28,34,,779.28,percent of total billed charges,Implant Device,779.28,34,,779.28,percent of total billed charges,Implant Device,779.28,34,,779.28,percent of total billed charges,Implant Device,779.28,34,,779.28,percent of total billed charges,Implant Device,779.28,34,,779.28,percent of total billed charges,Implant Device,1134.54,,,1134.54,Other,110% of Medicare,802.2,35,,802.2,percent of total billed charges,Implant Device,779.28,34,"Charges > $500, x 34%",779.28,percent of total billed charges,Implant Device,802.2,35,,802.2,percent of total billed charges,Implant Device,802.2,35,,802.2,percent of total billed charges,Implant Device,802.2,35,,802.2,percent of total billed charges,Implant Device,802.2,35,,802.2,percent of total billed charges,Implant Device,802.2,35,,802.2,percent of total billed charges,Implant Device,916.8,40,,916.8,percent of total billed charges,Implant Device,802.2,70,,802.2,percent of total billed charges,All Other,779.28,34,,779.28,percent of total billed charges,Implant Device,779.28,34,,779.28,percent of total billed charges,Implant Device,802.2,35,,802.2,percent of total billed charges,Implant Device,802.2,35,,802.2,percent of total billed charges,Implant Device,802.2,35,,802.2,percent of total billed charges,Implant Device,802.2,35,,802.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,779.28,34,"If Charge > 2,000, then 34 percent",779.28,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1696.09,
ARTHREX AR-7000-26 THREAD SCRW 3.75X26MM,C1713,HCPCS,,79009082,CDM,278,RC,,,both,,,600,444,,,444,Other,150% of Medicare + 9.63% HCRA Surcharge,270,45,,270,percent of total billed charges,Critical Access Hospital RCC factor,204,34,,204,percent of total billed charges,Implant Device,204,34,,204,percent of total billed charges,Implant Device,204,34,,204,percent of total billed charges,Implant Device,204,34,,204,percent of total billed charges,Implant Device,204,34,,204,percent of total billed charges,Implant Device,297,,,297,Other,110% of Medicare,210,35,,210,percent of total billed charges,Implant Device,204,34,"Charges > $500, x 34%",204,percent of total billed charges,Implant Device,210,35,,210,percent of total billed charges,Implant Device,210,35,,210,percent of total billed charges,Implant Device,210,35,,210,percent of total billed charges,Implant Device,210,35,,210,percent of total billed charges,Implant Device,210,35,,210,percent of total billed charges,Implant Device,240,40,,240,percent of total billed charges,Implant Device,210,70,,210,percent of total billed charges,All Other,204,34,,204,percent of total billed charges,Implant Device,204,34,,204,percent of total billed charges,Implant Device,210,35,,210,percent of total billed charges,Implant Device,210,35,,210,percent of total billed charges,Implant Device,210,35,,210,percent of total billed charges,Implant Device,210,35,,210,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,444,
STRYKER 5552-E-4014 HUMERAL HEAD 40X14MM,C1776,HCPCS,,79009083,CDM,278,RC,,,both,,,4500,3330.01,,,3330.01,Other,150% of Medicare + 9.63% HCRA Surcharge,2025,45,,2025,percent of total billed charges,Critical Access Hospital RCC factor,1530,34,,1530,percent of total billed charges,Implant Device,1530,34,,1530,percent of total billed charges,Implant Device,1530,34,,1530,percent of total billed charges,Implant Device,1530,34,,1530,percent of total billed charges,Implant Device,1530,34,,1530,percent of total billed charges,Implant Device,2227.5,,,2227.5,Other,110% of Medicare,1575,35,,1575,percent of total billed charges,Implant Device,1530,34,"Charges > $500, x 34%",1530,percent of total billed charges,Implant Device,1575,35,,1575,percent of total billed charges,Implant Device,1575,35,,1575,percent of total billed charges,Implant Device,1575,35,,1575,percent of total billed charges,Implant Device,1575,35,,1575,percent of total billed charges,Implant Device,1575,35,,1575,percent of total billed charges,Implant Device,1800,40,,1800,percent of total billed charges,Implant Device,1575,70,,1575,percent of total billed charges,All Other,1530,34,,1530,percent of total billed charges,Implant Device,1530,34,,1530,percent of total billed charges,Implant Device,1575,35,,1575,percent of total billed charges,Implant Device,1575,35,,1575,percent of total billed charges,Implant Device,1575,35,,1575,percent of total billed charges,Implant Device,1575,35,,1575,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1530,34,"If Charge > 2,000, then 34 percent",1530,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3330.01,
STRYKER 657326 LOCK SCREW T10 3.5X26MM,C1713,HCPCS,,79009086,CDM,278,RC,,,both,,,539,398.86,,,398.86,Other,150% of Medicare + 9.63% HCRA Surcharge,242.55,45,,242.55,percent of total billed charges,Critical Access Hospital RCC factor,183.26,34,,183.26,percent of total billed charges,Implant Device,183.26,34,,183.26,percent of total billed charges,Implant Device,183.26,34,,183.26,percent of total billed charges,Implant Device,183.26,34,,183.26,percent of total billed charges,Implant Device,183.26,34,,183.26,percent of total billed charges,Implant Device,266.81,,,266.81,Other,110% of Medicare,188.65,35,,188.65,percent of total billed charges,Implant Device,183.26,34,"Charges > $500, x 34%",183.26,percent of total billed charges,Implant Device,188.65,35,,188.65,percent of total billed charges,Implant Device,188.65,35,,188.65,percent of total billed charges,Implant Device,188.65,35,,188.65,percent of total billed charges,Implant Device,188.65,35,,188.65,percent of total billed charges,Implant Device,188.65,35,,188.65,percent of total billed charges,Implant Device,215.6,40,,215.6,percent of total billed charges,Implant Device,188.65,70,,188.65,percent of total billed charges,All Other,183.26,34,,183.26,percent of total billed charges,Implant Device,183.26,34,,183.26,percent of total billed charges,Implant Device,188.65,35,,188.65,percent of total billed charges,Implant Device,188.65,35,,188.65,percent of total billed charges,Implant Device,188.65,35,,188.65,percent of total billed charges,Implant Device,188.65,35,,188.65,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,398.86,
STRYKER 657328 LOCK SCREW T10 3.5X28MM,C1713,HCPCS,,79009087,CDM,278,RC,,,both,,,494,365.56,,,365.56,Other,150% of Medicare + 9.63% HCRA Surcharge,222.3,45,,222.3,percent of total billed charges,Critical Access Hospital RCC factor,167.96,34,,167.96,percent of total billed charges,Implant Device,167.96,34,,167.96,percent of total billed charges,Implant Device,167.96,34,,167.96,percent of total billed charges,Implant Device,167.96,34,,167.96,percent of total billed charges,Implant Device,167.96,34,,167.96,percent of total billed charges,Implant Device,244.53,,,244.53,Other,110% of Medicare,172.9,35,,172.9,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,172.9,35,,172.9,percent of total billed charges,Implant Device,172.9,35,,172.9,percent of total billed charges,Implant Device,172.9,35,,172.9,percent of total billed charges,Implant Device,172.9,35,,172.9,percent of total billed charges,Implant Device,172.9,35,,172.9,percent of total billed charges,Implant Device,197.6,40,,197.6,percent of total billed charges,Implant Device,172.9,70,,172.9,percent of total billed charges,All Other,167.96,34,,167.96,percent of total billed charges,Implant Device,167.96,34,,167.96,percent of total billed charges,Implant Device,172.9,35,,172.9,percent of total billed charges,Implant Device,172.9,35,,172.9,percent of total billed charges,Implant Device,172.9,35,,172.9,percent of total billed charges,Implant Device,172.9,35,,172.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,365.56,
STRYKER 657334 LOCK SCREW T10 3.5X34MM,C1713,HCPCS,,79009088,CDM,278,RC,,,both,,,1035,765.9,,,765.9,Other,150% of Medicare + 9.63% HCRA Surcharge,465.75,45,,465.75,percent of total billed charges,Critical Access Hospital RCC factor,351.9,34,,351.9,percent of total billed charges,Implant Device,351.9,34,,351.9,percent of total billed charges,Implant Device,351.9,34,,351.9,percent of total billed charges,Implant Device,351.9,34,,351.9,percent of total billed charges,Implant Device,351.9,34,,351.9,percent of total billed charges,Implant Device,512.33,,,512.33,Other,110% of Medicare,362.25,35,,362.25,percent of total billed charges,Implant Device,351.9,34,"Charges > $500, x 34%",351.9,percent of total billed charges,Implant Device,362.25,35,,362.25,percent of total billed charges,Implant Device,362.25,35,,362.25,percent of total billed charges,Implant Device,362.25,35,,362.25,percent of total billed charges,Implant Device,362.25,35,,362.25,percent of total billed charges,Implant Device,362.25,35,,362.25,percent of total billed charges,Implant Device,414,40,,414,percent of total billed charges,Implant Device,362.25,70,,362.25,percent of total billed charges,All Other,351.9,34,,351.9,percent of total billed charges,Implant Device,351.9,34,,351.9,percent of total billed charges,Implant Device,362.25,35,,362.25,percent of total billed charges,Implant Device,362.25,35,,362.25,percent of total billed charges,Implant Device,362.25,35,,362.25,percent of total billed charges,Implant Device,362.25,35,,362.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,765.9,
STRYKER 657434 BONE SCREW T10 3.5X34MM,C1713,HCPCS,,79009089,CDM,278,RC,,,both,,,269,199.06,,,199.06,Other,150% of Medicare + 9.63% HCRA Surcharge,121.05,45,,121.05,percent of total billed charges,Critical Access Hospital RCC factor,91.46,34,,91.46,percent of total billed charges,Implant Device,91.46,34,,91.46,percent of total billed charges,Implant Device,91.46,34,,91.46,percent of total billed charges,Implant Device,91.46,34,,91.46,percent of total billed charges,Implant Device,91.46,34,,91.46,percent of total billed charges,Implant Device,133.16,,,133.16,Other,110% of Medicare,94.15,35,,94.15,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,94.15,35,,94.15,percent of total billed charges,Implant Device,94.15,35,,94.15,percent of total billed charges,Implant Device,94.15,35,,94.15,percent of total billed charges,Implant Device,94.15,35,,94.15,percent of total billed charges,Implant Device,94.15,35,,94.15,percent of total billed charges,Implant Device,107.6,40,,107.6,percent of total billed charges,Implant Device,94.15,70,,94.15,percent of total billed charges,All Other,91.46,34,,91.46,percent of total billed charges,Implant Device,91.46,34,,91.46,percent of total billed charges,Implant Device,94.15,35,,94.15,percent of total billed charges,Implant Device,94.15,35,,94.15,percent of total billed charges,Implant Device,94.15,35,,94.15,percent of total billed charges,Implant Device,94.15,35,,94.15,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,199.06,
BIOMET 14196-110 CANN SCREW 6.5X110MM,C1713,HCPCS,,79009091,CDM,278,RC,,,both,,,1290,954.6,,,954.6,Other,150% of Medicare + 9.63% HCRA Surcharge,580.5,45,,580.5,percent of total billed charges,Critical Access Hospital RCC factor,438.6,34,,438.6,percent of total billed charges,Implant Device,438.6,34,,438.6,percent of total billed charges,Implant Device,438.6,34,,438.6,percent of total billed charges,Implant Device,438.6,34,,438.6,percent of total billed charges,Implant Device,438.6,34,,438.6,percent of total billed charges,Implant Device,638.55,,,638.55,Other,110% of Medicare,451.5,35,,451.5,percent of total billed charges,Implant Device,438.6,34,"Charges > $500, x 34%",438.6,percent of total billed charges,Implant Device,451.5,35,,451.5,percent of total billed charges,Implant Device,451.5,35,,451.5,percent of total billed charges,Implant Device,451.5,35,,451.5,percent of total billed charges,Implant Device,451.5,35,,451.5,percent of total billed charges,Implant Device,451.5,35,,451.5,percent of total billed charges,Implant Device,516,40,,516,percent of total billed charges,Implant Device,451.5,70,,451.5,percent of total billed charges,All Other,438.6,34,,438.6,percent of total billed charges,Implant Device,438.6,34,,438.6,percent of total billed charges,Implant Device,451.5,35,,451.5,percent of total billed charges,Implant Device,451.5,35,,451.5,percent of total billed charges,Implant Device,451.5,35,,451.5,percent of total billed charges,Implant Device,451.5,35,,451.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,954.6,
BARD FEM08080 FLUENCY 8X80X80 COVD STENT,C1874,HCPCS,,79009094,CDM,278,RC,,,both,,,11844,8764.59,,,8764.59,Other,150% of Medicare + 9.63% HCRA Surcharge,5329.8,45,,5329.8,percent of total billed charges,Critical Access Hospital RCC factor,4026.96,34,,4026.96,percent of total billed charges,Implant Device,4026.96,34,,4026.96,percent of total billed charges,Implant Device,4026.96,34,,4026.96,percent of total billed charges,Implant Device,4026.96,34,,4026.96,percent of total billed charges,Implant Device,4026.96,34,,4026.96,percent of total billed charges,Implant Device,5862.78,,,5862.78,Other,110% of Medicare,4145.4,35,,4145.4,percent of total billed charges,Implant Device,4026.96,34,"Charges > $500, x 34%",4026.96,percent of total billed charges,Implant Device,4145.4,35,,4145.4,percent of total billed charges,Implant Device,4145.4,35,,4145.4,percent of total billed charges,Implant Device,4145.4,35,,4145.4,percent of total billed charges,Implant Device,4145.4,35,,4145.4,percent of total billed charges,Implant Device,4145.4,35,,4145.4,percent of total billed charges,Implant Device,4737.6,40,,4737.6,percent of total billed charges,Implant Device,4145.4,70,,4145.4,percent of total billed charges,All Other,4026.96,34,,4026.96,percent of total billed charges,Implant Device,4026.96,34,,4026.96,percent of total billed charges,Implant Device,4145.4,35,,4145.4,percent of total billed charges,Implant Device,4145.4,35,,4145.4,percent of total billed charges,Implant Device,4145.4,35,,4145.4,percent of total billed charges,Implant Device,4145.4,35,,4145.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,4026.96,34,"If Charge > 2,000, then 34 percent",4026.96,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,8764.59,
DEPUY 1961-92-032 TIBIAL INSERT SZ 3 2.5,C1776,HCPCS,,79009095,CDM,278,RC,,,both,,,5735,4243.91,,,4243.91,Other,150% of Medicare + 9.63% HCRA Surcharge,2580.75,45,,2580.75,percent of total billed charges,Critical Access Hospital RCC factor,1949.9,34,,1949.9,percent of total billed charges,Implant Device,1949.9,34,,1949.9,percent of total billed charges,Implant Device,1949.9,34,,1949.9,percent of total billed charges,Implant Device,1949.9,34,,1949.9,percent of total billed charges,Implant Device,1949.9,34,,1949.9,percent of total billed charges,Implant Device,2838.83,,,2838.83,Other,110% of Medicare,2007.25,35,,2007.25,percent of total billed charges,Implant Device,1949.9,34,"Charges > $500, x 34%",1949.9,percent of total billed charges,Implant Device,2007.25,35,,2007.25,percent of total billed charges,Implant Device,2007.25,35,,2007.25,percent of total billed charges,Implant Device,2007.25,35,,2007.25,percent of total billed charges,Implant Device,2007.25,35,,2007.25,percent of total billed charges,Implant Device,2007.25,35,,2007.25,percent of total billed charges,Implant Device,2294,40,,2294,percent of total billed charges,Implant Device,2007.25,70,,2007.25,percent of total billed charges,All Other,1949.9,34,,1949.9,percent of total billed charges,Implant Device,1949.9,34,,1949.9,percent of total billed charges,Implant Device,2007.25,35,,2007.25,percent of total billed charges,Implant Device,2007.25,35,,2007.25,percent of total billed charges,Implant Device,2007.25,35,,2007.25,percent of total billed charges,Implant Device,2007.25,35,,2007.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1949.9,34,"If Charge > 2,000, then 34 percent",1949.9,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4243.91,
IN2BONES P60 ST445 FX SCREW 4.5X45MM,C1713,HCPCS,,79009096,CDM,278,RC,,,both,,,3108,2299.93,,,2299.93,Other,150% of Medicare + 9.63% HCRA Surcharge,1398.6,45,,1398.6,percent of total billed charges,Critical Access Hospital RCC factor,1056.72,34,,1056.72,percent of total billed charges,Implant Device,1056.72,34,,1056.72,percent of total billed charges,Implant Device,1056.72,34,,1056.72,percent of total billed charges,Implant Device,1056.72,34,,1056.72,percent of total billed charges,Implant Device,1056.72,34,,1056.72,percent of total billed charges,Implant Device,1538.46,,,1538.46,Other,110% of Medicare,1087.8,35,,1087.8,percent of total billed charges,Implant Device,1056.72,34,"Charges > $500, x 34%",1056.72,percent of total billed charges,Implant Device,1087.8,35,,1087.8,percent of total billed charges,Implant Device,1087.8,35,,1087.8,percent of total billed charges,Implant Device,1087.8,35,,1087.8,percent of total billed charges,Implant Device,1087.8,35,,1087.8,percent of total billed charges,Implant Device,1087.8,35,,1087.8,percent of total billed charges,Implant Device,1243.2,40,,1243.2,percent of total billed charges,Implant Device,1087.8,70,,1087.8,percent of total billed charges,All Other,1056.72,34,,1056.72,percent of total billed charges,Implant Device,1056.72,34,,1056.72,percent of total billed charges,Implant Device,1087.8,35,,1087.8,percent of total billed charges,Implant Device,1087.8,35,,1087.8,percent of total billed charges,Implant Device,1087.8,35,,1087.8,percent of total billed charges,Implant Device,1087.8,35,,1087.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1056.72,34,"If Charge > 2,000, then 34 percent",1056.72,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2299.93,
DEPUY 200.806 CORTEX SCREW 1.5X6MM,C1713,HCPCS,,79009099,CDM,278,RC,,,both,,,126,93.24,,,93.24,Other,150% of Medicare + 9.63% HCRA Surcharge,56.7,45,,56.7,percent of total billed charges,Critical Access Hospital RCC factor,42.84,34,,42.84,percent of total billed charges,Implant Device,42.84,34,,42.84,percent of total billed charges,Implant Device,42.84,34,,42.84,percent of total billed charges,Implant Device,42.84,34,,42.84,percent of total billed charges,Implant Device,42.84,34,,42.84,percent of total billed charges,Implant Device,62.37,,,62.37,Other,110% of Medicare,44.1,35,,44.1,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,44.1,35,,44.1,percent of total billed charges,Implant Device,44.1,35,,44.1,percent of total billed charges,Implant Device,44.1,35,,44.1,percent of total billed charges,Implant Device,44.1,35,,44.1,percent of total billed charges,Implant Device,44.1,35,,44.1,percent of total billed charges,Implant Device,50.4,40,,50.4,percent of total billed charges,Implant Device,44.1,70,,44.1,percent of total billed charges,All Other,42.84,34,,42.84,percent of total billed charges,Implant Device,42.84,34,,42.84,percent of total billed charges,Implant Device,44.1,35,,44.1,percent of total billed charges,Implant Device,44.1,35,,44.1,percent of total billed charges,Implant Device,44.1,35,,44.1,percent of total billed charges,Implant Device,44.1,35,,44.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,93.24,
DEPUY 200.807 CORTEX SCREW 1.5X7MM,C1713,HCPCS,,79009100,CDM,278,RC,,,both,,,126,93.24,,,93.24,Other,150% of Medicare + 9.63% HCRA Surcharge,56.7,45,,56.7,percent of total billed charges,Critical Access Hospital RCC factor,42.84,34,,42.84,percent of total billed charges,Implant Device,42.84,34,,42.84,percent of total billed charges,Implant Device,42.84,34,,42.84,percent of total billed charges,Implant Device,42.84,34,,42.84,percent of total billed charges,Implant Device,42.84,34,,42.84,percent of total billed charges,Implant Device,62.37,,,62.37,Other,110% of Medicare,44.1,35,,44.1,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,44.1,35,,44.1,percent of total billed charges,Implant Device,44.1,35,,44.1,percent of total billed charges,Implant Device,44.1,35,,44.1,percent of total billed charges,Implant Device,44.1,35,,44.1,percent of total billed charges,Implant Device,44.1,35,,44.1,percent of total billed charges,Implant Device,50.4,40,,50.4,percent of total billed charges,Implant Device,44.1,70,,44.1,percent of total billed charges,All Other,42.84,34,,42.84,percent of total billed charges,Implant Device,42.84,34,,42.84,percent of total billed charges,Implant Device,44.1,35,,44.1,percent of total billed charges,Implant Device,44.1,35,,44.1,percent of total billed charges,Implant Device,44.1,35,,44.1,percent of total billed charges,Implant Device,44.1,35,,44.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,93.24,
DEPUY 200.814 CORTEX SCREW 1.5X14MM,C1713,HCPCS,,79009101,CDM,278,RC,,,both,,,126,93.24,,,93.24,Other,150% of Medicare + 9.63% HCRA Surcharge,56.7,45,,56.7,percent of total billed charges,Critical Access Hospital RCC factor,42.84,34,,42.84,percent of total billed charges,Implant Device,42.84,34,,42.84,percent of total billed charges,Implant Device,42.84,34,,42.84,percent of total billed charges,Implant Device,42.84,34,,42.84,percent of total billed charges,Implant Device,42.84,34,,42.84,percent of total billed charges,Implant Device,62.37,,,62.37,Other,110% of Medicare,44.1,35,,44.1,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,44.1,35,,44.1,percent of total billed charges,Implant Device,44.1,35,,44.1,percent of total billed charges,Implant Device,44.1,35,,44.1,percent of total billed charges,Implant Device,44.1,35,,44.1,percent of total billed charges,Implant Device,44.1,35,,44.1,percent of total billed charges,Implant Device,50.4,40,,50.4,percent of total billed charges,Implant Device,44.1,70,,44.1,percent of total billed charges,All Other,42.84,34,,42.84,percent of total billed charges,Implant Device,42.84,34,,42.84,percent of total billed charges,Implant Device,44.1,35,,44.1,percent of total billed charges,Implant Device,44.1,35,,44.1,percent of total billed charges,Implant Device,44.1,35,,44.1,percent of total billed charges,Implant Device,44.1,35,,44.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,93.24,
DEPUY 214.550 CANNULATED SCREW 4.5X50MM,C1713,HCPCS,,79009102,CDM,278,RC,,,both,,,781,577.94,,,577.94,Other,150% of Medicare + 9.63% HCRA Surcharge,351.45,45,,351.45,percent of total billed charges,Critical Access Hospital RCC factor,265.54,34,,265.54,percent of total billed charges,Implant Device,265.54,34,,265.54,percent of total billed charges,Implant Device,265.54,34,,265.54,percent of total billed charges,Implant Device,265.54,34,,265.54,percent of total billed charges,Implant Device,265.54,34,,265.54,percent of total billed charges,Implant Device,386.6,,,386.6,Other,110% of Medicare,273.35,35,,273.35,percent of total billed charges,Implant Device,265.54,34,"Charges > $500, x 34%",265.54,percent of total billed charges,Implant Device,273.35,35,,273.35,percent of total billed charges,Implant Device,273.35,35,,273.35,percent of total billed charges,Implant Device,273.35,35,,273.35,percent of total billed charges,Implant Device,273.35,35,,273.35,percent of total billed charges,Implant Device,273.35,35,,273.35,percent of total billed charges,Implant Device,312.4,40,,312.4,percent of total billed charges,Implant Device,273.35,70,,273.35,percent of total billed charges,All Other,265.54,34,,265.54,percent of total billed charges,Implant Device,265.54,34,,265.54,percent of total billed charges,Implant Device,273.35,35,,273.35,percent of total billed charges,Implant Device,273.35,35,,273.35,percent of total billed charges,Implant Device,273.35,35,,273.35,percent of total billed charges,Implant Device,273.35,35,,273.35,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,577.94,
DEPUY 214.544 CANNULATED SCREW 4.5X44MM,C1713,HCPCS,,79009103,CDM,278,RC,,,both,,,781,577.94,,,577.94,Other,150% of Medicare + 9.63% HCRA Surcharge,351.45,45,,351.45,percent of total billed charges,Critical Access Hospital RCC factor,265.54,34,,265.54,percent of total billed charges,Implant Device,265.54,34,,265.54,percent of total billed charges,Implant Device,265.54,34,,265.54,percent of total billed charges,Implant Device,265.54,34,,265.54,percent of total billed charges,Implant Device,265.54,34,,265.54,percent of total billed charges,Implant Device,386.6,,,386.6,Other,110% of Medicare,273.35,35,,273.35,percent of total billed charges,Implant Device,265.54,34,"Charges > $500, x 34%",265.54,percent of total billed charges,Implant Device,273.35,35,,273.35,percent of total billed charges,Implant Device,273.35,35,,273.35,percent of total billed charges,Implant Device,273.35,35,,273.35,percent of total billed charges,Implant Device,273.35,35,,273.35,percent of total billed charges,Implant Device,273.35,35,,273.35,percent of total billed charges,Implant Device,312.4,40,,312.4,percent of total billed charges,Implant Device,273.35,70,,273.35,percent of total billed charges,All Other,265.54,34,,265.54,percent of total billed charges,Implant Device,265.54,34,,265.54,percent of total billed charges,Implant Device,273.35,35,,273.35,percent of total billed charges,Implant Device,273.35,35,,273.35,percent of total billed charges,Implant Device,273.35,35,,273.35,percent of total billed charges,Implant Device,273.35,35,,273.35,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,577.94,
DEPUY 219.92 WASHER 10MM,C1713,HCPCS,,79009104,CDM,278,RC,,,both,,,104,76.96,,,76.96,Other,150% of Medicare + 9.63% HCRA Surcharge,46.8,45,,46.8,percent of total billed charges,Critical Access Hospital RCC factor,35.36,34,,35.36,percent of total billed charges,Implant Device,35.36,34,,35.36,percent of total billed charges,Implant Device,35.36,34,,35.36,percent of total billed charges,Implant Device,35.36,34,,35.36,percent of total billed charges,Implant Device,35.36,34,,35.36,percent of total billed charges,Implant Device,51.48,,,51.48,Other,110% of Medicare,36.4,35,,36.4,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,36.4,35,,36.4,percent of total billed charges,Implant Device,36.4,35,,36.4,percent of total billed charges,Implant Device,36.4,35,,36.4,percent of total billed charges,Implant Device,36.4,35,,36.4,percent of total billed charges,Implant Device,36.4,35,,36.4,percent of total billed charges,Implant Device,41.6,40,,41.6,percent of total billed charges,Implant Device,36.4,70,,36.4,percent of total billed charges,All Other,35.36,34,,35.36,percent of total billed charges,Implant Device,35.36,34,,35.36,percent of total billed charges,Implant Device,36.4,35,,36.4,percent of total billed charges,Implant Device,36.4,35,,36.4,percent of total billed charges,Implant Device,36.4,35,,36.4,percent of total billed charges,Implant Device,36.4,35,,36.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,76.96,
ORTHOFIX 99-611540 X-CALIBER SCRW 150/40,C1713,HCPCS,,79009112,CDM,278,RC,,,both,,,455,336.7,,,336.7,Other,150% of Medicare + 9.63% HCRA Surcharge,204.75,45,,204.75,percent of total billed charges,Critical Access Hospital RCC factor,154.7,34,,154.7,percent of total billed charges,Implant Device,154.7,34,,154.7,percent of total billed charges,Implant Device,154.7,34,,154.7,percent of total billed charges,Implant Device,154.7,34,,154.7,percent of total billed charges,Implant Device,154.7,34,,154.7,percent of total billed charges,Implant Device,225.23,,,225.23,Other,110% of Medicare,159.25,35,,159.25,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,159.25,35,,159.25,percent of total billed charges,Implant Device,159.25,35,,159.25,percent of total billed charges,Implant Device,159.25,35,,159.25,percent of total billed charges,Implant Device,159.25,35,,159.25,percent of total billed charges,Implant Device,159.25,35,,159.25,percent of total billed charges,Implant Device,182,40,,182,percent of total billed charges,Implant Device,159.25,70,,159.25,percent of total billed charges,All Other,154.7,34,,154.7,percent of total billed charges,Implant Device,154.7,34,,154.7,percent of total billed charges,Implant Device,159.25,35,,159.25,percent of total billed charges,Implant Device,159.25,35,,159.25,percent of total billed charges,Implant Device,159.25,35,,159.25,percent of total billed charges,Implant Device,159.25,35,,159.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,336.7,
ORTHOFIX 99-611530 X-CALIBER SCRW 150/30,C1713,HCPCS,,79009113,CDM,278,RC,,,both,,,455,336.7,,,336.7,Other,150% of Medicare + 9.63% HCRA Surcharge,204.75,45,,204.75,percent of total billed charges,Critical Access Hospital RCC factor,154.7,34,,154.7,percent of total billed charges,Implant Device,154.7,34,,154.7,percent of total billed charges,Implant Device,154.7,34,,154.7,percent of total billed charges,Implant Device,154.7,34,,154.7,percent of total billed charges,Implant Device,154.7,34,,154.7,percent of total billed charges,Implant Device,225.23,,,225.23,Other,110% of Medicare,159.25,35,,159.25,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,159.25,35,,159.25,percent of total billed charges,Implant Device,159.25,35,,159.25,percent of total billed charges,Implant Device,159.25,35,,159.25,percent of total billed charges,Implant Device,159.25,35,,159.25,percent of total billed charges,Implant Device,159.25,35,,159.25,percent of total billed charges,Implant Device,182,40,,182,percent of total billed charges,Implant Device,159.25,70,,159.25,percent of total billed charges,All Other,154.7,34,,154.7,percent of total billed charges,Implant Device,154.7,34,,154.7,percent of total billed charges,Implant Device,159.25,35,,159.25,percent of total billed charges,Implant Device,159.25,35,,159.25,percent of total billed charges,Implant Device,159.25,35,,159.25,percent of total billed charges,Implant Device,159.25,35,,159.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,336.7,
BIOMET 11-300922 DIS STEM W/SCREW 22X190,C1713,HCPCS,,79009114,CDM,278,RC,,,both,,,18660,13808.45,,,13808.45,Other,150% of Medicare + 9.63% HCRA Surcharge,8397,45,,8397,percent of total billed charges,Critical Access Hospital RCC factor,6344.4,34,,6344.4,percent of total billed charges,Implant Device,6344.4,34,,6344.4,percent of total billed charges,Implant Device,6344.4,34,,6344.4,percent of total billed charges,Implant Device,6344.4,34,,6344.4,percent of total billed charges,Implant Device,6344.4,34,,6344.4,percent of total billed charges,Implant Device,9236.7,,,9236.7,Other,110% of Medicare,6531,35,,6531,percent of total billed charges,Implant Device,6344.4,34,"Charges > $500, x 34%",6344.4,percent of total billed charges,Implant Device,6531,35,,6531,percent of total billed charges,Implant Device,6531,35,,6531,percent of total billed charges,Implant Device,6531,35,,6531,percent of total billed charges,Implant Device,6531,35,,6531,percent of total billed charges,Implant Device,6531,35,,6531,percent of total billed charges,Implant Device,7464,40,,7464,percent of total billed charges,Implant Device,6531,70,,6531,percent of total billed charges,All Other,6344.4,34,,6344.4,percent of total billed charges,Implant Device,6344.4,34,,6344.4,percent of total billed charges,Implant Device,6531,35,,6531,percent of total billed charges,Implant Device,6531,35,,6531,percent of total billed charges,Implant Device,6531,35,,6531,percent of total billed charges,Implant Device,6531,35,,6531,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,6344.4,34,"If Charge > 2,000, then 34 percent",6344.4,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,13808.45,
STRYKER 5573-6532 CORTEX SCREW 6.5X32MM,C1713,HCPCS,,79009115,CDM,278,RC,,,both,,,600,444,,,444,Other,150% of Medicare + 9.63% HCRA Surcharge,270,45,,270,percent of total billed charges,Critical Access Hospital RCC factor,204,34,,204,percent of total billed charges,Implant Device,204,34,,204,percent of total billed charges,Implant Device,204,34,,204,percent of total billed charges,Implant Device,204,34,,204,percent of total billed charges,Implant Device,204,34,,204,percent of total billed charges,Implant Device,297,,,297,Other,110% of Medicare,210,35,,210,percent of total billed charges,Implant Device,204,34,"Charges > $500, x 34%",204,percent of total billed charges,Implant Device,210,35,,210,percent of total billed charges,Implant Device,210,35,,210,percent of total billed charges,Implant Device,210,35,,210,percent of total billed charges,Implant Device,210,35,,210,percent of total billed charges,Implant Device,210,35,,210,percent of total billed charges,Implant Device,240,40,,240,percent of total billed charges,Implant Device,210,70,,210,percent of total billed charges,All Other,204,34,,204,percent of total billed charges,Implant Device,204,34,,204,percent of total billed charges,Implant Device,210,35,,210,percent of total billed charges,Implant Device,210,35,,210,percent of total billed charges,Implant Device,210,35,,210,percent of total billed charges,Implant Device,210,35,,210,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,444,
STRYKER 5572-4536 PERIPH SCREW 4.5X36MM,C1713,HCPCS,,79009116,CDM,278,RC,,,both,,,150,111,,,111,Other,150% of Medicare + 9.63% HCRA Surcharge,67.5,45,,67.5,percent of total billed charges,Critical Access Hospital RCC factor,51,34,,51,percent of total billed charges,Implant Device,51,34,,51,percent of total billed charges,Implant Device,51,34,,51,percent of total billed charges,Implant Device,51,34,,51,percent of total billed charges,Implant Device,51,34,,51,percent of total billed charges,Implant Device,74.25,,,74.25,Other,110% of Medicare,52.5,35,,52.5,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,52.5,35,,52.5,percent of total billed charges,Implant Device,52.5,35,,52.5,percent of total billed charges,Implant Device,52.5,35,,52.5,percent of total billed charges,Implant Device,52.5,35,,52.5,percent of total billed charges,Implant Device,52.5,35,,52.5,percent of total billed charges,Implant Device,60,40,,60,percent of total billed charges,Implant Device,52.5,70,,52.5,percent of total billed charges,All Other,51,34,,51,percent of total billed charges,Implant Device,51,34,,51,percent of total billed charges,Implant Device,52.5,35,,52.5,percent of total billed charges,Implant Device,52.5,35,,52.5,percent of total billed charges,Implant Device,52.5,35,,52.5,percent of total billed charges,Implant Device,52.5,35,,52.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,111,
STRYKER 5572-4524 PERIPH SCREW 4.5X24MM,C1713,HCPCS,,79009117,CDM,278,RC,,,both,,,600,444,,,444,Other,150% of Medicare + 9.63% HCRA Surcharge,270,45,,270,percent of total billed charges,Critical Access Hospital RCC factor,204,34,,204,percent of total billed charges,Implant Device,204,34,,204,percent of total billed charges,Implant Device,204,34,,204,percent of total billed charges,Implant Device,204,34,,204,percent of total billed charges,Implant Device,204,34,,204,percent of total billed charges,Implant Device,297,,,297,Other,110% of Medicare,210,35,,210,percent of total billed charges,Implant Device,204,34,"Charges > $500, x 34%",204,percent of total billed charges,Implant Device,210,35,,210,percent of total billed charges,Implant Device,210,35,,210,percent of total billed charges,Implant Device,210,35,,210,percent of total billed charges,Implant Device,210,35,,210,percent of total billed charges,Implant Device,210,35,,210,percent of total billed charges,Implant Device,240,40,,240,percent of total billed charges,Implant Device,210,70,,210,percent of total billed charges,All Other,204,34,,204,percent of total billed charges,Implant Device,204,34,,204,percent of total billed charges,Implant Device,210,35,,210,percent of total billed charges,Implant Device,210,35,,210,percent of total billed charges,Implant Device,210,35,,210,percent of total billed charges,Implant Device,210,35,,210,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,444,
ARTHREX AR-8933-26 3.0X26MM CORT SCREW,C1713,HCPCS,,79009118,CDM,278,RC,,,both,,,474,350.76,,,350.76,Other,150% of Medicare + 9.63% HCRA Surcharge,213.3,45,,213.3,percent of total billed charges,Critical Access Hospital RCC factor,161.16,34,,161.16,percent of total billed charges,Implant Device,161.16,34,,161.16,percent of total billed charges,Implant Device,161.16,34,,161.16,percent of total billed charges,Implant Device,161.16,34,,161.16,percent of total billed charges,Implant Device,161.16,34,,161.16,percent of total billed charges,Implant Device,234.63,,,234.63,Other,110% of Medicare,165.9,35,,165.9,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,165.9,35,,165.9,percent of total billed charges,Implant Device,165.9,35,,165.9,percent of total billed charges,Implant Device,165.9,35,,165.9,percent of total billed charges,Implant Device,165.9,35,,165.9,percent of total billed charges,Implant Device,165.9,35,,165.9,percent of total billed charges,Implant Device,189.6,40,,189.6,percent of total billed charges,Implant Device,165.9,70,,165.9,percent of total billed charges,All Other,161.16,34,,161.16,percent of total billed charges,Implant Device,161.16,34,,161.16,percent of total billed charges,Implant Device,165.9,35,,165.9,percent of total billed charges,Implant Device,165.9,35,,165.9,percent of total billed charges,Implant Device,165.9,35,,165.9,percent of total billed charges,Implant Device,165.9,35,,165.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,350.76,
ARTHREX AR-8933-28 3.0X28MM CORT SCREW,C1713,HCPCS,,79009119,CDM,278,RC,,,both,,,474,350.76,,,350.76,Other,150% of Medicare + 9.63% HCRA Surcharge,213.3,45,,213.3,percent of total billed charges,Critical Access Hospital RCC factor,161.16,34,,161.16,percent of total billed charges,Implant Device,161.16,34,,161.16,percent of total billed charges,Implant Device,161.16,34,,161.16,percent of total billed charges,Implant Device,161.16,34,,161.16,percent of total billed charges,Implant Device,161.16,34,,161.16,percent of total billed charges,Implant Device,234.63,,,234.63,Other,110% of Medicare,165.9,35,,165.9,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,165.9,35,,165.9,percent of total billed charges,Implant Device,165.9,35,,165.9,percent of total billed charges,Implant Device,165.9,35,,165.9,percent of total billed charges,Implant Device,165.9,35,,165.9,percent of total billed charges,Implant Device,165.9,35,,165.9,percent of total billed charges,Implant Device,189.6,40,,189.6,percent of total billed charges,Implant Device,165.9,70,,165.9,percent of total billed charges,All Other,161.16,34,,161.16,percent of total billed charges,Implant Device,161.16,34,,161.16,percent of total billed charges,Implant Device,165.9,35,,165.9,percent of total billed charges,Implant Device,165.9,35,,165.9,percent of total billed charges,Implant Device,165.9,35,,165.9,percent of total billed charges,Implant Device,165.9,35,,165.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,350.76,
ARTHREX AR-8933V-12 3.0X12MM LOCK SCREW,C1713,HCPCS,,79009120,CDM,278,RC,,,both,,,525,388.5,,,388.5,Other,150% of Medicare + 9.63% HCRA Surcharge,236.25,45,,236.25,percent of total billed charges,Critical Access Hospital RCC factor,178.5,34,,178.5,percent of total billed charges,Implant Device,178.5,34,,178.5,percent of total billed charges,Implant Device,178.5,34,,178.5,percent of total billed charges,Implant Device,178.5,34,,178.5,percent of total billed charges,Implant Device,178.5,34,,178.5,percent of total billed charges,Implant Device,259.88,,,259.88,Other,110% of Medicare,183.75,35,,183.75,percent of total billed charges,Implant Device,178.5,34,"Charges > $500, x 34%",178.5,percent of total billed charges,Implant Device,183.75,35,,183.75,percent of total billed charges,Implant Device,183.75,35,,183.75,percent of total billed charges,Implant Device,183.75,35,,183.75,percent of total billed charges,Implant Device,183.75,35,,183.75,percent of total billed charges,Implant Device,183.75,35,,183.75,percent of total billed charges,Implant Device,210,40,,210,percent of total billed charges,Implant Device,183.75,70,,183.75,percent of total billed charges,All Other,178.5,34,,178.5,percent of total billed charges,Implant Device,178.5,34,,178.5,percent of total billed charges,Implant Device,183.75,35,,183.75,percent of total billed charges,Implant Device,183.75,35,,183.75,percent of total billed charges,Implant Device,183.75,35,,183.75,percent of total billed charges,Implant Device,183.75,35,,183.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,388.5,
ARTHREX AR-8933V-24 3.0X24MM LOCK SCREW,C1713,HCPCS,,79009121,CDM,278,RC,,,both,,,600,444,,,444,Other,150% of Medicare + 9.63% HCRA Surcharge,270,45,,270,percent of total billed charges,Critical Access Hospital RCC factor,204,34,,204,percent of total billed charges,Implant Device,204,34,,204,percent of total billed charges,Implant Device,204,34,,204,percent of total billed charges,Implant Device,204,34,,204,percent of total billed charges,Implant Device,204,34,,204,percent of total billed charges,Implant Device,297,,,297,Other,110% of Medicare,210,35,,210,percent of total billed charges,Implant Device,204,34,"Charges > $500, x 34%",204,percent of total billed charges,Implant Device,210,35,,210,percent of total billed charges,Implant Device,210,35,,210,percent of total billed charges,Implant Device,210,35,,210,percent of total billed charges,Implant Device,210,35,,210,percent of total billed charges,Implant Device,210,35,,210,percent of total billed charges,Implant Device,240,40,,240,percent of total billed charges,Implant Device,210,70,,210,percent of total billed charges,All Other,204,34,,204,percent of total billed charges,Implant Device,204,34,,204,percent of total billed charges,Implant Device,210,35,,210,percent of total billed charges,Implant Device,210,35,,210,percent of total billed charges,Implant Device,210,35,,210,percent of total billed charges,Implant Device,210,35,,210,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,444,
ARTHREX AR-8942W-2008 20X20X8 EVAN WEDGE,C1713,HCPCS,,79009122,CDM,278,RC,,,both,,,9408,6961.94,,,6961.94,Other,150% of Medicare + 9.63% HCRA Surcharge,4233.6,45,,4233.6,percent of total billed charges,Critical Access Hospital RCC factor,3198.72,34,,3198.72,percent of total billed charges,Implant Device,3198.72,34,,3198.72,percent of total billed charges,Implant Device,3198.72,34,,3198.72,percent of total billed charges,Implant Device,3198.72,34,,3198.72,percent of total billed charges,Implant Device,3198.72,34,,3198.72,percent of total billed charges,Implant Device,4656.96,,,4656.96,Other,110% of Medicare,3292.8,35,,3292.8,percent of total billed charges,Implant Device,3198.72,34,"Charges > $500, x 34%",3198.72,percent of total billed charges,Implant Device,3292.8,35,,3292.8,percent of total billed charges,Implant Device,3292.8,35,,3292.8,percent of total billed charges,Implant Device,3292.8,35,,3292.8,percent of total billed charges,Implant Device,3292.8,35,,3292.8,percent of total billed charges,Implant Device,3292.8,35,,3292.8,percent of total billed charges,Implant Device,3763.2,40,,3763.2,percent of total billed charges,Implant Device,3292.8,70,,3292.8,percent of total billed charges,All Other,3198.72,34,,3198.72,percent of total billed charges,Implant Device,3198.72,34,,3198.72,percent of total billed charges,Implant Device,3292.8,35,,3292.8,percent of total billed charges,Implant Device,3292.8,35,,3292.8,percent of total billed charges,Implant Device,3292.8,35,,3292.8,percent of total billed charges,Implant Device,3292.8,35,,3292.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3198.72,34,"If Charge > 2,000, then 34 percent",3198.72,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,6961.94,
ARTHREX AR-8948W-1655 16X15.5 COTT WEDGE,C1713,HCPCS,,79009123,CDM,278,RC,,,both,,,8550,6327.02,,,6327.02,Other,150% of Medicare + 9.63% HCRA Surcharge,3847.5,45,,3847.5,percent of total billed charges,Critical Access Hospital RCC factor,2907,34,,2907,percent of total billed charges,Implant Device,2907,34,,2907,percent of total billed charges,Implant Device,2907,34,,2907,percent of total billed charges,Implant Device,2907,34,,2907,percent of total billed charges,Implant Device,2907,34,,2907,percent of total billed charges,Implant Device,4232.25,,,4232.25,Other,110% of Medicare,2992.5,35,,2992.5,percent of total billed charges,Implant Device,2907,34,"Charges > $500, x 34%",2907,percent of total billed charges,Implant Device,2992.5,35,,2992.5,percent of total billed charges,Implant Device,2992.5,35,,2992.5,percent of total billed charges,Implant Device,2992.5,35,,2992.5,percent of total billed charges,Implant Device,2992.5,35,,2992.5,percent of total billed charges,Implant Device,2992.5,35,,2992.5,percent of total billed charges,Implant Device,3420,40,,3420,percent of total billed charges,Implant Device,2992.5,70,,2992.5,percent of total billed charges,All Other,2907,34,,2907,percent of total billed charges,Implant Device,2907,34,,2907,percent of total billed charges,Implant Device,2992.5,35,,2992.5,percent of total billed charges,Implant Device,2992.5,35,,2992.5,percent of total billed charges,Implant Device,2992.5,35,,2992.5,percent of total billed charges,Implant Device,2992.5,35,,2992.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2907,34,"If Charge > 2,000, then 34 percent",2907,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,6327.02,
TIDES TAH1101 AMNIOHEAL PLUS 1X1CM,V2790,HCPCS,,79009124,CDM,278,RC,,,both,,,1343,993.82,,,993.82,Other,150% of Medicare + 9.63% HCRA Surcharge,604.35,45,,604.35,percent of total billed charges,Critical Access Hospital RCC factor,456.62,34,,456.62,percent of total billed charges,Implant Device,456.62,34,,456.62,percent of total billed charges,Implant Device,456.62,34,,456.62,percent of total billed charges,Implant Device,456.62,34,,456.62,percent of total billed charges,Implant Device,456.62,34,,456.62,percent of total billed charges,Implant Device,664.79,,,664.79,Other,110% of Medicare,470.05,35,,470.05,percent of total billed charges,Implant Device,456.62,34,"Charges > $500, x 34%",456.62,percent of total billed charges,Implant Device,470.05,35,,470.05,percent of total billed charges,Implant Device,470.05,35,,470.05,percent of total billed charges,Implant Device,470.05,35,,470.05,percent of total billed charges,Implant Device,470.05,35,,470.05,percent of total billed charges,Implant Device,470.05,35,,470.05,percent of total billed charges,Implant Device,537.2,40,,537.2,percent of total billed charges,Implant Device,470.05,70,,470.05,percent of total billed charges,All Other,456.62,34,,456.62,percent of total billed charges,Implant Device,456.62,34,,456.62,percent of total billed charges,Implant Device,470.05,35,,470.05,percent of total billed charges,Implant Device,470.05,35,,470.05,percent of total billed charges,Implant Device,470.05,35,,470.05,percent of total billed charges,Implant Device,470.05,35,,470.05,percent of total billed charges,Implant Device,976.07,,,976.07,Other,100% of Medicaid,976.07,,,976.07,Other,100% of Medicaid,976.07,,,976.07,Other,100% of Medicaid,976.07,,,976.07,Other,100% of Medicaid,2196.15,,,2196.15,Other,225% of Medicaid,1493.38,,,1493.38,Other,153% of Medicaid,2196.15,,,2196.15,Other,225% of Medicaid,1366.49,,,1366.49,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,2537.77,,,2537.77,Other,260% of Medicaid,3162.45,,,3162.45,Other,324% of Medicaid,2098.54,,,2098.54,Other,215% of Medicaid,2098.54,,,2098.54,Other,215% of Medicaid,1220.08,,,1220.08,Other,125% of Medicaid,0.01,3162.45,
STRYKER 3102-2008 ALLOWRAP 4X8CM,Q4150,HCPCS,,79009125,CDM,278,RC,,,both,,,14685,10866.94,,,10866.94,Other,150% of Medicare + 9.63% HCRA Surcharge,6608.25,45,,6608.25,percent of total billed charges,Critical Access Hospital RCC factor,4992.9,34,,4992.9,percent of total billed charges,Implant Device,4992.9,34,,4992.9,percent of total billed charges,Implant Device,4992.9,34,,4992.9,percent of total billed charges,Implant Device,4992.9,34,,4992.9,percent of total billed charges,Implant Device,4992.9,34,,4992.9,percent of total billed charges,Implant Device,7269.08,,,7269.08,Other,110% of Medicare,5139.75,35,,5139.75,percent of total billed charges,Implant Device,4992.9,34,"Charges > $500, x 34%",4992.9,percent of total billed charges,Implant Device,5139.75,35,,5139.75,percent of total billed charges,Implant Device,5139.75,35,,5139.75,percent of total billed charges,Implant Device,5139.75,35,,5139.75,percent of total billed charges,Implant Device,5139.75,35,,5139.75,percent of total billed charges,Implant Device,5139.75,35,,5139.75,percent of total billed charges,Implant Device,5874,40,,5874,percent of total billed charges,Implant Device,5139.75,70,,5139.75,percent of total billed charges,All Other,4992.9,34,,4992.9,percent of total billed charges,Implant Device,4992.9,34,,4992.9,percent of total billed charges,Implant Device,5139.75,35,,5139.75,percent of total billed charges,Implant Device,5139.75,35,,5139.75,percent of total billed charges,Implant Device,5139.75,35,,5139.75,percent of total billed charges,Implant Device,5139.75,35,,5139.75,percent of total billed charges,Implant Device,976.07,,,976.07,Other,100% of Medicaid,976.07,,,976.07,Other,100% of Medicaid,976.07,,,976.07,Other,100% of Medicaid,976.07,,,976.07,Other,100% of Medicaid,2196.15,,,2196.15,Other,225% of Medicaid,1493.38,,,1493.38,Other,153% of Medicaid,2196.15,,,2196.15,Other,225% of Medicaid,1366.49,,,1366.49,Other,140% of Medicaid,4992.9,34,"If Charge > 2,000, then 34 percent",4992.9,percent of total billed charges,Implants,2537.77,,,2537.77,Other,260% of Medicaid,3162.45,,,3162.45,Other,324% of Medicaid,2098.54,,,2098.54,Other,215% of Medicaid,2098.54,,,2098.54,Other,215% of Medicaid,1220.08,,,1220.08,Other,125% of Medicaid,976.07,10866.94,
ZIMMER 00-5976-030-12 ART SURF SZ 12MM,C1776,HCPCS,,79009126,CDM,278,RC,,,both,,,1920,1420.8,,,1420.8,Other,150% of Medicare + 9.63% HCRA Surcharge,864,45,,864,percent of total billed charges,Critical Access Hospital RCC factor,652.8,34,,652.8,percent of total billed charges,Implant Device,652.8,34,,652.8,percent of total billed charges,Implant Device,652.8,34,,652.8,percent of total billed charges,Implant Device,652.8,34,,652.8,percent of total billed charges,Implant Device,652.8,34,,652.8,percent of total billed charges,Implant Device,950.4,,,950.4,Other,110% of Medicare,672,35,,672,percent of total billed charges,Implant Device,652.8,34,"Charges > $500, x 34%",652.8,percent of total billed charges,Implant Device,672,35,,672,percent of total billed charges,Implant Device,672,35,,672,percent of total billed charges,Implant Device,672,35,,672,percent of total billed charges,Implant Device,672,35,,672,percent of total billed charges,Implant Device,672,35,,672,percent of total billed charges,Implant Device,768,40,,768,percent of total billed charges,Implant Device,672,70,,672,percent of total billed charges,All Other,652.8,34,,652.8,percent of total billed charges,Implant Device,652.8,34,,652.8,percent of total billed charges,Implant Device,672,35,,672,percent of total billed charges,Implant Device,672,35,,672,percent of total billed charges,Implant Device,672,35,,672,percent of total billed charges,Implant Device,672,35,,672,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1420.8,
ZIMMER 00-5950-015-02 FEM COMP SZ E RT,C1776,HCPCS,,79009127,CDM,278,RC,,,both,,,6300,4662.02,,,4662.02,Other,150% of Medicare + 9.63% HCRA Surcharge,2835,45,,2835,percent of total billed charges,Critical Access Hospital RCC factor,2142,34,,2142,percent of total billed charges,Implant Device,2142,34,,2142,percent of total billed charges,Implant Device,2142,34,,2142,percent of total billed charges,Implant Device,2142,34,,2142,percent of total billed charges,Implant Device,2142,34,,2142,percent of total billed charges,Implant Device,3118.5,,,3118.5,Other,110% of Medicare,2205,35,,2205,percent of total billed charges,Implant Device,2142,34,"Charges > $500, x 34%",2142,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2520,40,,2520,percent of total billed charges,Implant Device,2205,70,,2205,percent of total billed charges,All Other,2142,34,,2142,percent of total billed charges,Implant Device,2142,34,,2142,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2142,34,"If Charge > 2,000, then 34 percent",2142,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4662.02,
STRYKER UH1-58-26 UHR UNIV HEAD 58X26MM,C1776,HCPCS,,79009128,CDM,278,RC,,,both,,,2667,1973.59,,,1973.59,Other,150% of Medicare + 9.63% HCRA Surcharge,1200.15,45,,1200.15,percent of total billed charges,Critical Access Hospital RCC factor,906.78,34,,906.78,percent of total billed charges,Implant Device,906.78,34,,906.78,percent of total billed charges,Implant Device,906.78,34,,906.78,percent of total billed charges,Implant Device,906.78,34,,906.78,percent of total billed charges,Implant Device,906.78,34,,906.78,percent of total billed charges,Implant Device,1320.17,,,1320.17,Other,110% of Medicare,933.45,35,,933.45,percent of total billed charges,Implant Device,906.78,34,"Charges > $500, x 34%",906.78,percent of total billed charges,Implant Device,933.45,35,,933.45,percent of total billed charges,Implant Device,933.45,35,,933.45,percent of total billed charges,Implant Device,933.45,35,,933.45,percent of total billed charges,Implant Device,933.45,35,,933.45,percent of total billed charges,Implant Device,933.45,35,,933.45,percent of total billed charges,Implant Device,1066.8,40,,1066.8,percent of total billed charges,Implant Device,933.45,70,,933.45,percent of total billed charges,All Other,906.78,34,,906.78,percent of total billed charges,Implant Device,906.78,34,,906.78,percent of total billed charges,Implant Device,933.45,35,,933.45,percent of total billed charges,Implant Device,933.45,35,,933.45,percent of total billed charges,Implant Device,933.45,35,,933.45,percent of total billed charges,Implant Device,933.45,35,,933.45,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,906.78,34,"If Charge > 2,000, then 34 percent",906.78,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1973.59,
GORE BXA105902A VBX VIABAHN 10X59 STENT,C1874,HCPCS,,79009129,CDM,278,RC,,,both,,,9765,7226.12,,,7226.12,Other,150% of Medicare + 9.63% HCRA Surcharge,4394.25,45,,4394.25,percent of total billed charges,Critical Access Hospital RCC factor,3320.1,34,,3320.1,percent of total billed charges,Implant Device,3320.1,34,,3320.1,percent of total billed charges,Implant Device,3320.1,34,,3320.1,percent of total billed charges,Implant Device,3320.1,34,,3320.1,percent of total billed charges,Implant Device,3320.1,34,,3320.1,percent of total billed charges,Implant Device,4833.68,,,4833.68,Other,110% of Medicare,3417.75,35,,3417.75,percent of total billed charges,Implant Device,3320.1,34,"Charges > $500, x 34%",3320.1,percent of total billed charges,Implant Device,3417.75,35,,3417.75,percent of total billed charges,Implant Device,3417.75,35,,3417.75,percent of total billed charges,Implant Device,3417.75,35,,3417.75,percent of total billed charges,Implant Device,3417.75,35,,3417.75,percent of total billed charges,Implant Device,3417.75,35,,3417.75,percent of total billed charges,Implant Device,3906,40,,3906,percent of total billed charges,Implant Device,3417.75,70,,3417.75,percent of total billed charges,All Other,3320.1,34,,3320.1,percent of total billed charges,Implant Device,3320.1,34,,3320.1,percent of total billed charges,Implant Device,3417.75,35,,3417.75,percent of total billed charges,Implant Device,3417.75,35,,3417.75,percent of total billed charges,Implant Device,3417.75,35,,3417.75,percent of total billed charges,Implant Device,3417.75,35,,3417.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3320.1,34,"If Charge > 2,000, then 34 percent",3320.1,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,7226.12,
GORE BXA075902A VBX VIABAHN 7X59 STENT,C1874,HCPCS,,79009130,CDM,278,RC,,,both,,,9765,7226.12,,,7226.12,Other,150% of Medicare + 9.63% HCRA Surcharge,4394.25,45,,4394.25,percent of total billed charges,Critical Access Hospital RCC factor,3320.1,34,,3320.1,percent of total billed charges,Implant Device,3320.1,34,,3320.1,percent of total billed charges,Implant Device,3320.1,34,,3320.1,percent of total billed charges,Implant Device,3320.1,34,,3320.1,percent of total billed charges,Implant Device,3320.1,34,,3320.1,percent of total billed charges,Implant Device,4833.68,,,4833.68,Other,110% of Medicare,3417.75,35,,3417.75,percent of total billed charges,Implant Device,3320.1,34,"Charges > $500, x 34%",3320.1,percent of total billed charges,Implant Device,3417.75,35,,3417.75,percent of total billed charges,Implant Device,3417.75,35,,3417.75,percent of total billed charges,Implant Device,3417.75,35,,3417.75,percent of total billed charges,Implant Device,3417.75,35,,3417.75,percent of total billed charges,Implant Device,3417.75,35,,3417.75,percent of total billed charges,Implant Device,3906,40,,3906,percent of total billed charges,Implant Device,3417.75,70,,3417.75,percent of total billed charges,All Other,3320.1,34,,3320.1,percent of total billed charges,Implant Device,3320.1,34,,3320.1,percent of total billed charges,Implant Device,3417.75,35,,3417.75,percent of total billed charges,Implant Device,3417.75,35,,3417.75,percent of total billed charges,Implant Device,3417.75,35,,3417.75,percent of total billed charges,Implant Device,3417.75,35,,3417.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3320.1,34,"If Charge > 2,000, then 34 percent",3320.1,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,7226.12,
DEPUY 1570-06-120 FEM STEM SZ 6 127MM,C1776,HCPCS,,79009131,CDM,278,RC,,,both,,,5575,4125.51,,,4125.51,Other,150% of Medicare + 9.63% HCRA Surcharge,2508.75,45,,2508.75,percent of total billed charges,Critical Access Hospital RCC factor,1895.5,34,,1895.5,percent of total billed charges,Implant Device,1895.5,34,,1895.5,percent of total billed charges,Implant Device,1895.5,34,,1895.5,percent of total billed charges,Implant Device,1895.5,34,,1895.5,percent of total billed charges,Implant Device,1895.5,34,,1895.5,percent of total billed charges,Implant Device,2759.63,,,2759.63,Other,110% of Medicare,1951.25,35,,1951.25,percent of total billed charges,Implant Device,1895.5,34,"Charges > $500, x 34%",1895.5,percent of total billed charges,Implant Device,1951.25,35,,1951.25,percent of total billed charges,Implant Device,1951.25,35,,1951.25,percent of total billed charges,Implant Device,1951.25,35,,1951.25,percent of total billed charges,Implant Device,1951.25,35,,1951.25,percent of total billed charges,Implant Device,1951.25,35,,1951.25,percent of total billed charges,Implant Device,2230,40,,2230,percent of total billed charges,Implant Device,1951.25,70,,1951.25,percent of total billed charges,All Other,1895.5,34,,1895.5,percent of total billed charges,Implant Device,1895.5,34,,1895.5,percent of total billed charges,Implant Device,1951.25,35,,1951.25,percent of total billed charges,Implant Device,1951.25,35,,1951.25,percent of total billed charges,Implant Device,1951.25,35,,1951.25,percent of total billed charges,Implant Device,1951.25,35,,1951.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1895.5,34,"If Charge > 2,000, then 34 percent",1895.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4125.51,
DEPUY 1376-38-000 STEM CENTRALIZER 10.5M,C1776,HCPCS,,79009132,CDM,278,RC,,,both,,,276,204.24,,,204.24,Other,150% of Medicare + 9.63% HCRA Surcharge,124.2,45,,124.2,percent of total billed charges,Critical Access Hospital RCC factor,93.84,34,,93.84,percent of total billed charges,Implant Device,93.84,34,,93.84,percent of total billed charges,Implant Device,93.84,34,,93.84,percent of total billed charges,Implant Device,93.84,34,,93.84,percent of total billed charges,Implant Device,93.84,34,,93.84,percent of total billed charges,Implant Device,136.62,,,136.62,Other,110% of Medicare,96.6,35,,96.6,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,96.6,35,,96.6,percent of total billed charges,Implant Device,96.6,35,,96.6,percent of total billed charges,Implant Device,96.6,35,,96.6,percent of total billed charges,Implant Device,96.6,35,,96.6,percent of total billed charges,Implant Device,96.6,35,,96.6,percent of total billed charges,Implant Device,110.4,40,,110.4,percent of total billed charges,Implant Device,96.6,70,,96.6,percent of total billed charges,All Other,93.84,34,,93.84,percent of total billed charges,Implant Device,93.84,34,,93.84,percent of total billed charges,Implant Device,96.6,35,,96.6,percent of total billed charges,Implant Device,96.6,35,,96.6,percent of total billed charges,Implant Device,96.6,35,,96.6,percent of total billed charges,Implant Device,96.6,35,,96.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,204.24,
IN2BONES APA-004 PIP ALLOGRAFT 2.9X19MM,C1713,HCPCS,,79009135,CDM,278,RC,,,both,,,4308,3187.93,,,3187.93,Other,150% of Medicare + 9.63% HCRA Surcharge,1938.6,45,,1938.6,percent of total billed charges,Critical Access Hospital RCC factor,1464.72,34,,1464.72,percent of total billed charges,Implant Device,1464.72,34,,1464.72,percent of total billed charges,Implant Device,1464.72,34,,1464.72,percent of total billed charges,Implant Device,1464.72,34,,1464.72,percent of total billed charges,Implant Device,1464.72,34,,1464.72,percent of total billed charges,Implant Device,2132.46,,,2132.46,Other,110% of Medicare,1507.8,35,,1507.8,percent of total billed charges,Implant Device,1464.72,34,"Charges > $500, x 34%",1464.72,percent of total billed charges,Implant Device,1507.8,35,,1507.8,percent of total billed charges,Implant Device,1507.8,35,,1507.8,percent of total billed charges,Implant Device,1507.8,35,,1507.8,percent of total billed charges,Implant Device,1507.8,35,,1507.8,percent of total billed charges,Implant Device,1507.8,35,,1507.8,percent of total billed charges,Implant Device,1723.2,40,,1723.2,percent of total billed charges,Implant Device,1507.8,70,,1507.8,percent of total billed charges,All Other,1464.72,34,,1464.72,percent of total billed charges,Implant Device,1464.72,34,,1464.72,percent of total billed charges,Implant Device,1507.8,35,,1507.8,percent of total billed charges,Implant Device,1507.8,35,,1507.8,percent of total billed charges,Implant Device,1507.8,35,,1507.8,percent of total billed charges,Implant Device,1507.8,35,,1507.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1464.72,34,"If Charge > 2,000, then 34 percent",1464.72,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3187.93,
S&N 71420570 PATELLAR COMPONENT 29MM,C1776,HCPCS,,79009137,CDM,278,RC,,,both,,,2030,1502.21,,,1502.21,Other,150% of Medicare + 9.63% HCRA Surcharge,913.5,45,,913.5,percent of total billed charges,Critical Access Hospital RCC factor,690.2,34,,690.2,percent of total billed charges,Implant Device,690.2,34,,690.2,percent of total billed charges,Implant Device,690.2,34,,690.2,percent of total billed charges,Implant Device,690.2,34,,690.2,percent of total billed charges,Implant Device,690.2,34,,690.2,percent of total billed charges,Implant Device,1004.85,,,1004.85,Other,110% of Medicare,710.5,35,,710.5,percent of total billed charges,Implant Device,690.2,34,"Charges > $500, x 34%",690.2,percent of total billed charges,Implant Device,710.5,35,,710.5,percent of total billed charges,Implant Device,710.5,35,,710.5,percent of total billed charges,Implant Device,710.5,35,,710.5,percent of total billed charges,Implant Device,710.5,35,,710.5,percent of total billed charges,Implant Device,710.5,35,,710.5,percent of total billed charges,Implant Device,812,40,,812,percent of total billed charges,Implant Device,710.5,70,,710.5,percent of total billed charges,All Other,690.2,34,,690.2,percent of total billed charges,Implant Device,690.2,34,,690.2,percent of total billed charges,Implant Device,710.5,35,,710.5,percent of total billed charges,Implant Device,710.5,35,,710.5,percent of total billed charges,Implant Device,710.5,35,,710.5,percent of total billed charges,Implant Device,710.5,35,,710.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,690.2,34,"If Charge > 2,000, then 34 percent",690.2,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1502.21,
DEPUY 02.111.630 DIST RAD PLT 2.4MM 3H,C1713,HCPCS,,79009138,CDM,278,RC,,,both,,,2323,1719.03,,,1719.03,Other,150% of Medicare + 9.63% HCRA Surcharge,1045.35,45,,1045.35,percent of total billed charges,Critical Access Hospital RCC factor,789.82,34,,789.82,percent of total billed charges,Implant Device,789.82,34,,789.82,percent of total billed charges,Implant Device,789.82,34,,789.82,percent of total billed charges,Implant Device,789.82,34,,789.82,percent of total billed charges,Implant Device,789.82,34,,789.82,percent of total billed charges,Implant Device,1149.89,,,1149.89,Other,110% of Medicare,813.05,35,,813.05,percent of total billed charges,Implant Device,789.82,34,"Charges > $500, x 34%",789.82,percent of total billed charges,Implant Device,813.05,35,,813.05,percent of total billed charges,Implant Device,813.05,35,,813.05,percent of total billed charges,Implant Device,813.05,35,,813.05,percent of total billed charges,Implant Device,813.05,35,,813.05,percent of total billed charges,Implant Device,813.05,35,,813.05,percent of total billed charges,Implant Device,929.2,40,,929.2,percent of total billed charges,Implant Device,813.05,70,,813.05,percent of total billed charges,All Other,789.82,34,,789.82,percent of total billed charges,Implant Device,789.82,34,,789.82,percent of total billed charges,Implant Device,813.05,35,,813.05,percent of total billed charges,Implant Device,813.05,35,,813.05,percent of total billed charges,Implant Device,813.05,35,,813.05,percent of total billed charges,Implant Device,813.05,35,,813.05,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,789.82,34,"If Charge > 2,000, then 34 percent",789.82,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1719.03,
IN2BONES V30 ST322 LOCKING SCREW 3X22MM,C1713,HCPCS,,79009139,CDM,278,RC,,,both,,,870,643.8,,,643.8,Other,150% of Medicare + 9.63% HCRA Surcharge,391.5,45,,391.5,percent of total billed charges,Critical Access Hospital RCC factor,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,430.65,,,430.65,Other,110% of Medicare,304.5,35,,304.5,percent of total billed charges,Implant Device,295.8,34,"Charges > $500, x 34%",295.8,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,348,40,,348,percent of total billed charges,Implant Device,304.5,70,,304.5,percent of total billed charges,All Other,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,643.8,
IN2BONES V30 ST436 LOCKING SCREW 3X36MM,C1713,HCPCS,,79009140,CDM,278,RC,,,both,,,870,643.8,,,643.8,Other,150% of Medicare + 9.63% HCRA Surcharge,391.5,45,,391.5,percent of total billed charges,Critical Access Hospital RCC factor,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,430.65,,,430.65,Other,110% of Medicare,304.5,35,,304.5,percent of total billed charges,Implant Device,295.8,34,"Charges > $500, x 34%",295.8,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,348,40,,348,percent of total billed charges,Implant Device,304.5,70,,304.5,percent of total billed charges,All Other,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,643.8,
IN2BONES S35 ST134 COMP SCREW 3.5X34MM,C1713,HCPCS,,79009141,CDM,278,RC,,,both,,,1350,999,,,999,Other,150% of Medicare + 9.63% HCRA Surcharge,607.5,45,,607.5,percent of total billed charges,Critical Access Hospital RCC factor,459,34,,459,percent of total billed charges,Implant Device,459,34,,459,percent of total billed charges,Implant Device,459,34,,459,percent of total billed charges,Implant Device,459,34,,459,percent of total billed charges,Implant Device,459,34,,459,percent of total billed charges,Implant Device,668.25,,,668.25,Other,110% of Medicare,472.5,35,,472.5,percent of total billed charges,Implant Device,459,34,"Charges > $500, x 34%",459,percent of total billed charges,Implant Device,472.5,35,,472.5,percent of total billed charges,Implant Device,472.5,35,,472.5,percent of total billed charges,Implant Device,472.5,35,,472.5,percent of total billed charges,Implant Device,472.5,35,,472.5,percent of total billed charges,Implant Device,472.5,35,,472.5,percent of total billed charges,Implant Device,540,40,,540,percent of total billed charges,Implant Device,472.5,70,,472.5,percent of total billed charges,All Other,459,34,,459,percent of total billed charges,Implant Device,459,34,,459,percent of total billed charges,Implant Device,472.5,35,,472.5,percent of total billed charges,Implant Device,472.5,35,,472.5,percent of total billed charges,Implant Device,472.5,35,,472.5,percent of total billed charges,Implant Device,472.5,35,,472.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,999,
STRYKER SV10 S-FIX SCREW 2.5LG 10MM,C1713,HCPCS,,79009142,CDM,278,RC,,,both,,,1866,1380.84,,,1380.84,Other,150% of Medicare + 9.63% HCRA Surcharge,839.7,45,,839.7,percent of total billed charges,Critical Access Hospital RCC factor,634.44,34,,634.44,percent of total billed charges,Implant Device,634.44,34,,634.44,percent of total billed charges,Implant Device,634.44,34,,634.44,percent of total billed charges,Implant Device,634.44,34,,634.44,percent of total billed charges,Implant Device,634.44,34,,634.44,percent of total billed charges,Implant Device,923.67,,,923.67,Other,110% of Medicare,653.1,35,,653.1,percent of total billed charges,Implant Device,634.44,34,"Charges > $500, x 34%",634.44,percent of total billed charges,Implant Device,653.1,35,,653.1,percent of total billed charges,Implant Device,653.1,35,,653.1,percent of total billed charges,Implant Device,653.1,35,,653.1,percent of total billed charges,Implant Device,653.1,35,,653.1,percent of total billed charges,Implant Device,653.1,35,,653.1,percent of total billed charges,Implant Device,746.4,40,,746.4,percent of total billed charges,Implant Device,653.1,70,,653.1,percent of total billed charges,All Other,634.44,34,,634.44,percent of total billed charges,Implant Device,634.44,34,,634.44,percent of total billed charges,Implant Device,653.1,35,,653.1,percent of total billed charges,Implant Device,653.1,35,,653.1,percent of total billed charges,Implant Device,653.1,35,,653.1,percent of total billed charges,Implant Device,653.1,35,,653.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1380.84,
TRYKER 54-25400 PLATE SHORT LATERAL,C1713,HCPCS,,79009143,CDM,278,RC,,,both,,,3086,2283.65,,,2283.65,Other,150% of Medicare + 9.63% HCRA Surcharge,1388.7,45,,1388.7,percent of total billed charges,Critical Access Hospital RCC factor,1049.24,34,,1049.24,percent of total billed charges,Implant Device,1049.24,34,,1049.24,percent of total billed charges,Implant Device,1049.24,34,,1049.24,percent of total billed charges,Implant Device,1049.24,34,,1049.24,percent of total billed charges,Implant Device,1049.24,34,,1049.24,percent of total billed charges,Implant Device,1527.57,,,1527.57,Other,110% of Medicare,1080.1,35,,1080.1,percent of total billed charges,Implant Device,1049.24,34,"Charges > $500, x 34%",1049.24,percent of total billed charges,Implant Device,1080.1,35,,1080.1,percent of total billed charges,Implant Device,1080.1,35,,1080.1,percent of total billed charges,Implant Device,1080.1,35,,1080.1,percent of total billed charges,Implant Device,1080.1,35,,1080.1,percent of total billed charges,Implant Device,1080.1,35,,1080.1,percent of total billed charges,Implant Device,1234.4,40,,1234.4,percent of total billed charges,Implant Device,1080.1,70,,1080.1,percent of total billed charges,All Other,1049.24,34,,1049.24,percent of total billed charges,Implant Device,1049.24,34,,1049.24,percent of total billed charges,Implant Device,1080.1,35,,1080.1,percent of total billed charges,Implant Device,1080.1,35,,1080.1,percent of total billed charges,Implant Device,1080.1,35,,1080.1,percent of total billed charges,Implant Device,1080.1,35,,1080.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1049.24,34,"If Charge > 2,000, then 34 percent",1049.24,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2283.65,
STRYKER 656028 LOCKING SCREW 2.4X28MM,C1713,HCPCS,,79009144,CDM,278,RC,,,both,,,885,654.9,,,654.9,Other,150% of Medicare + 9.63% HCRA Surcharge,398.25,45,,398.25,percent of total billed charges,Critical Access Hospital RCC factor,300.9,34,,300.9,percent of total billed charges,Implant Device,300.9,34,,300.9,percent of total billed charges,Implant Device,300.9,34,,300.9,percent of total billed charges,Implant Device,300.9,34,,300.9,percent of total billed charges,Implant Device,300.9,34,,300.9,percent of total billed charges,Implant Device,438.08,,,438.08,Other,110% of Medicare,309.75,35,,309.75,percent of total billed charges,Implant Device,300.9,34,"Charges > $500, x 34%",300.9,percent of total billed charges,Implant Device,309.75,35,,309.75,percent of total billed charges,Implant Device,309.75,35,,309.75,percent of total billed charges,Implant Device,309.75,35,,309.75,percent of total billed charges,Implant Device,309.75,35,,309.75,percent of total billed charges,Implant Device,309.75,35,,309.75,percent of total billed charges,Implant Device,354,40,,354,percent of total billed charges,Implant Device,309.75,70,,309.75,percent of total billed charges,All Other,300.9,34,,300.9,percent of total billed charges,Implant Device,300.9,34,,300.9,percent of total billed charges,Implant Device,309.75,35,,309.75,percent of total billed charges,Implant Device,309.75,35,,309.75,percent of total billed charges,Implant Device,309.75,35,,309.75,percent of total billed charges,Implant Device,309.75,35,,309.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,654.9,
STRYKER EZS-08 STEP STAPLE 8MM,C1713,HCPCS,,79009145,CDM,278,RC,,,both,,,7875,5827.52,,,5827.52,Other,150% of Medicare + 9.63% HCRA Surcharge,3543.75,45,,3543.75,percent of total billed charges,Critical Access Hospital RCC factor,2677.5,34,,2677.5,percent of total billed charges,Implant Device,2677.5,34,,2677.5,percent of total billed charges,Implant Device,2677.5,34,,2677.5,percent of total billed charges,Implant Device,2677.5,34,,2677.5,percent of total billed charges,Implant Device,2677.5,34,,2677.5,percent of total billed charges,Implant Device,3898.13,,,3898.13,Other,110% of Medicare,2756.25,35,,2756.25,percent of total billed charges,Implant Device,2677.5,34,"Charges > $500, x 34%",2677.5,percent of total billed charges,Implant Device,2756.25,35,,2756.25,percent of total billed charges,Implant Device,2756.25,35,,2756.25,percent of total billed charges,Implant Device,2756.25,35,,2756.25,percent of total billed charges,Implant Device,2756.25,35,,2756.25,percent of total billed charges,Implant Device,2756.25,35,,2756.25,percent of total billed charges,Implant Device,3150,40,,3150,percent of total billed charges,Implant Device,2756.25,70,,2756.25,percent of total billed charges,All Other,2677.5,34,,2677.5,percent of total billed charges,Implant Device,2677.5,34,,2677.5,percent of total billed charges,Implant Device,2756.25,35,,2756.25,percent of total billed charges,Implant Device,2756.25,35,,2756.25,percent of total billed charges,Implant Device,2756.25,35,,2756.25,percent of total billed charges,Implant Device,2756.25,35,,2756.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2677.5,34,"If Charge > 2,000, then 34 percent",2677.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5827.52,
STRYKER 5029-7-030 8MM SEMICIRCULAR ROD,C1713,HCPCS,,79009158,CDM,278,RC,,,both,,,1005,743.7,,,743.7,Other,150% of Medicare + 9.63% HCRA Surcharge,452.25,45,,452.25,percent of total billed charges,Critical Access Hospital RCC factor,341.7,34,,341.7,percent of total billed charges,Implant Device,341.7,34,,341.7,percent of total billed charges,Implant Device,341.7,34,,341.7,percent of total billed charges,Implant Device,341.7,34,,341.7,percent of total billed charges,Implant Device,341.7,34,,341.7,percent of total billed charges,Implant Device,497.48,,,497.48,Other,110% of Medicare,351.75,35,,351.75,percent of total billed charges,Implant Device,341.7,34,"Charges > $500, x 34%",341.7,percent of total billed charges,Implant Device,351.75,35,,351.75,percent of total billed charges,Implant Device,351.75,35,,351.75,percent of total billed charges,Implant Device,351.75,35,,351.75,percent of total billed charges,Implant Device,351.75,35,,351.75,percent of total billed charges,Implant Device,351.75,35,,351.75,percent of total billed charges,Implant Device,402,40,,402,percent of total billed charges,Implant Device,351.75,70,,351.75,percent of total billed charges,All Other,341.7,34,,341.7,percent of total billed charges,Implant Device,341.7,34,,341.7,percent of total billed charges,Implant Device,351.75,35,,351.75,percent of total billed charges,Implant Device,351.75,35,,351.75,percent of total billed charges,Implant Device,351.75,35,,351.75,percent of total billed charges,Implant Device,351.75,35,,351.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,743.7,
STRYKER 00-8851-010-32 LINER 32X52MM,C1776,HCPCS,,79009159,CDM,278,RC,,,both,,,4845,3585.31,,,3585.31,Other,150% of Medicare + 9.63% HCRA Surcharge,2180.25,45,,2180.25,percent of total billed charges,Critical Access Hospital RCC factor,1647.3,34,,1647.3,percent of total billed charges,Implant Device,1647.3,34,,1647.3,percent of total billed charges,Implant Device,1647.3,34,,1647.3,percent of total billed charges,Implant Device,1647.3,34,,1647.3,percent of total billed charges,Implant Device,1647.3,34,,1647.3,percent of total billed charges,Implant Device,2398.28,,,2398.28,Other,110% of Medicare,1695.75,35,,1695.75,percent of total billed charges,Implant Device,1647.3,34,"Charges > $500, x 34%",1647.3,percent of total billed charges,Implant Device,1695.75,35,,1695.75,percent of total billed charges,Implant Device,1695.75,35,,1695.75,percent of total billed charges,Implant Device,1695.75,35,,1695.75,percent of total billed charges,Implant Device,1695.75,35,,1695.75,percent of total billed charges,Implant Device,1695.75,35,,1695.75,percent of total billed charges,Implant Device,1938,40,,1938,percent of total billed charges,Implant Device,1695.75,70,,1695.75,percent of total billed charges,All Other,1647.3,34,,1647.3,percent of total billed charges,Implant Device,1647.3,34,,1647.3,percent of total billed charges,Implant Device,1695.75,35,,1695.75,percent of total billed charges,Implant Device,1695.75,35,,1695.75,percent of total billed charges,Implant Device,1695.75,35,,1695.75,percent of total billed charges,Implant Device,1695.75,35,,1695.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1647.3,34,"If Charge > 2,000, then 34 percent",1647.3,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3585.31,
ZIMMER 8144-11-380 HFN NAIL 11X380MM,C1713,HCPCS,,79009160,CDM,278,RC,,,both,,,7290,5394.62,,,5394.62,Other,150% of Medicare + 9.63% HCRA Surcharge,3280.5,45,,3280.5,percent of total billed charges,Critical Access Hospital RCC factor,2478.6,34,,2478.6,percent of total billed charges,Implant Device,2478.6,34,,2478.6,percent of total billed charges,Implant Device,2478.6,34,,2478.6,percent of total billed charges,Implant Device,2478.6,34,,2478.6,percent of total billed charges,Implant Device,2478.6,34,,2478.6,percent of total billed charges,Implant Device,3608.55,,,3608.55,Other,110% of Medicare,2551.5,35,,2551.5,percent of total billed charges,Implant Device,2478.6,34,"Charges > $500, x 34%",2478.6,percent of total billed charges,Implant Device,2551.5,35,,2551.5,percent of total billed charges,Implant Device,2551.5,35,,2551.5,percent of total billed charges,Implant Device,2551.5,35,,2551.5,percent of total billed charges,Implant Device,2551.5,35,,2551.5,percent of total billed charges,Implant Device,2551.5,35,,2551.5,percent of total billed charges,Implant Device,2916,40,,2916,percent of total billed charges,Implant Device,2551.5,70,,2551.5,percent of total billed charges,All Other,2478.6,34,,2478.6,percent of total billed charges,Implant Device,2478.6,34,,2478.6,percent of total billed charges,Implant Device,2551.5,35,,2551.5,percent of total billed charges,Implant Device,2551.5,35,,2551.5,percent of total billed charges,Implant Device,2551.5,35,,2551.5,percent of total billed charges,Implant Device,2551.5,35,,2551.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2478.6,34,"If Charge > 2,000, then 34 percent",2478.6,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5394.62,
ZIMMER 8145-50-042 CORTICAL SCREW 5X42MM,C1713,HCPCS,,79009161,CDM,278,RC,,,both,,,594,439.56,,,439.56,Other,150% of Medicare + 9.63% HCRA Surcharge,267.3,45,,267.3,percent of total billed charges,Critical Access Hospital RCC factor,201.96,34,,201.96,percent of total billed charges,Implant Device,201.96,34,,201.96,percent of total billed charges,Implant Device,201.96,34,,201.96,percent of total billed charges,Implant Device,201.96,34,,201.96,percent of total billed charges,Implant Device,201.96,34,,201.96,percent of total billed charges,Implant Device,294.03,,,294.03,Other,110% of Medicare,207.9,35,,207.9,percent of total billed charges,Implant Device,201.96,34,"Charges > $500, x 34%",201.96,percent of total billed charges,Implant Device,207.9,35,,207.9,percent of total billed charges,Implant Device,207.9,35,,207.9,percent of total billed charges,Implant Device,207.9,35,,207.9,percent of total billed charges,Implant Device,207.9,35,,207.9,percent of total billed charges,Implant Device,207.9,35,,207.9,percent of total billed charges,Implant Device,237.6,40,,237.6,percent of total billed charges,Implant Device,207.9,70,,207.9,percent of total billed charges,All Other,201.96,34,,201.96,percent of total billed charges,Implant Device,201.96,34,,201.96,percent of total billed charges,Implant Device,207.9,35,,207.9,percent of total billed charges,Implant Device,207.9,35,,207.9,percent of total billed charges,Implant Device,207.9,35,,207.9,percent of total billed charges,Implant Device,207.9,35,,207.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,439.56,
ARTHREX AR-4502 SPEEDCINCH CURVED NEEDLE,C1713,HCPCS,,79009162,CDM,278,RC,,,both,,,1185,876.9,,,876.9,Other,150% of Medicare + 9.63% HCRA Surcharge,533.25,45,,533.25,percent of total billed charges,Critical Access Hospital RCC factor,402.9,34,,402.9,percent of total billed charges,Implant Device,402.9,34,,402.9,percent of total billed charges,Implant Device,402.9,34,,402.9,percent of total billed charges,Implant Device,402.9,34,,402.9,percent of total billed charges,Implant Device,402.9,34,,402.9,percent of total billed charges,Implant Device,586.58,,,586.58,Other,110% of Medicare,414.75,35,,414.75,percent of total billed charges,Implant Device,402.9,34,"Charges > $500, x 34%",402.9,percent of total billed charges,Implant Device,414.75,35,,414.75,percent of total billed charges,Implant Device,414.75,35,,414.75,percent of total billed charges,Implant Device,414.75,35,,414.75,percent of total billed charges,Implant Device,414.75,35,,414.75,percent of total billed charges,Implant Device,414.75,35,,414.75,percent of total billed charges,Implant Device,474,40,,474,percent of total billed charges,Implant Device,414.75,70,,414.75,percent of total billed charges,All Other,402.9,34,,402.9,percent of total billed charges,Implant Device,402.9,34,,402.9,percent of total billed charges,Implant Device,414.75,35,,414.75,percent of total billed charges,Implant Device,414.75,35,,414.75,percent of total billed charges,Implant Device,414.75,35,,414.75,percent of total billed charges,Implant Device,414.75,35,,414.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,876.9,
STRYKER 1822-1234S TIBIAL NAIL 12X345MM,C1713,HCPCS,,79009165,CDM,278,RC,,,both,,,3529,2611.47,,,2611.47,Other,150% of Medicare + 9.63% HCRA Surcharge,1588.05,45,,1588.05,percent of total billed charges,Critical Access Hospital RCC factor,1199.86,34,,1199.86,percent of total billed charges,Implant Device,1199.86,34,,1199.86,percent of total billed charges,Implant Device,1199.86,34,,1199.86,percent of total billed charges,Implant Device,1199.86,34,,1199.86,percent of total billed charges,Implant Device,1199.86,34,,1199.86,percent of total billed charges,Implant Device,1746.86,,,1746.86,Other,110% of Medicare,1235.15,35,,1235.15,percent of total billed charges,Implant Device,1199.86,34,"Charges > $500, x 34%",1199.86,percent of total billed charges,Implant Device,1235.15,35,,1235.15,percent of total billed charges,Implant Device,1235.15,35,,1235.15,percent of total billed charges,Implant Device,1235.15,35,,1235.15,percent of total billed charges,Implant Device,1235.15,35,,1235.15,percent of total billed charges,Implant Device,1235.15,35,,1235.15,percent of total billed charges,Implant Device,1411.6,40,,1411.6,percent of total billed charges,Implant Device,1235.15,70,,1235.15,percent of total billed charges,All Other,1199.86,34,,1199.86,percent of total billed charges,Implant Device,1199.86,34,,1199.86,percent of total billed charges,Implant Device,1235.15,35,,1235.15,percent of total billed charges,Implant Device,1235.15,35,,1235.15,percent of total billed charges,Implant Device,1235.15,35,,1235.15,percent of total billed charges,Implant Device,1235.15,35,,1235.15,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1199.86,34,"If Charge > 2,000, then 34 percent",1199.86,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2611.47,
STRYKER 627204 PROX HUMERUS PLATE 4 HOLE,C1713,HCPCS,,79009166,CDM,278,RC,,,both,,,9045,6693.32,,,6693.32,Other,150% of Medicare + 9.63% HCRA Surcharge,4070.25,45,,4070.25,percent of total billed charges,Critical Access Hospital RCC factor,3075.3,34,,3075.3,percent of total billed charges,Implant Device,3075.3,34,,3075.3,percent of total billed charges,Implant Device,3075.3,34,,3075.3,percent of total billed charges,Implant Device,3075.3,34,,3075.3,percent of total billed charges,Implant Device,3075.3,34,,3075.3,percent of total billed charges,Implant Device,4477.28,,,4477.28,Other,110% of Medicare,3165.75,35,,3165.75,percent of total billed charges,Implant Device,3075.3,34,"Charges > $500, x 34%",3075.3,percent of total billed charges,Implant Device,3165.75,35,,3165.75,percent of total billed charges,Implant Device,3165.75,35,,3165.75,percent of total billed charges,Implant Device,3165.75,35,,3165.75,percent of total billed charges,Implant Device,3165.75,35,,3165.75,percent of total billed charges,Implant Device,3165.75,35,,3165.75,percent of total billed charges,Implant Device,3618,40,,3618,percent of total billed charges,Implant Device,3165.75,70,,3165.75,percent of total billed charges,All Other,3075.3,34,,3075.3,percent of total billed charges,Implant Device,3075.3,34,,3075.3,percent of total billed charges,Implant Device,3165.75,35,,3165.75,percent of total billed charges,Implant Device,3165.75,35,,3165.75,percent of total billed charges,Implant Device,3165.75,35,,3165.75,percent of total billed charges,Implant Device,3165.75,35,,3165.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3075.3,34,"If Charge > 2,000, then 34 percent",3075.3,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,6693.32,
STRYKER 5023-5-150 APEX PIN 4X150MM,C1713,HCPCS,,79009167,CDM,278,RC,,,both,,,576,426.24,,,426.24,Other,150% of Medicare + 9.63% HCRA Surcharge,259.2,45,,259.2,percent of total billed charges,Critical Access Hospital RCC factor,195.84,34,,195.84,percent of total billed charges,Implant Device,195.84,34,,195.84,percent of total billed charges,Implant Device,195.84,34,,195.84,percent of total billed charges,Implant Device,195.84,34,,195.84,percent of total billed charges,Implant Device,195.84,34,,195.84,percent of total billed charges,Implant Device,285.12,,,285.12,Other,110% of Medicare,201.6,35,,201.6,percent of total billed charges,Implant Device,195.84,34,"Charges > $500, x 34%",195.84,percent of total billed charges,Implant Device,201.6,35,,201.6,percent of total billed charges,Implant Device,201.6,35,,201.6,percent of total billed charges,Implant Device,201.6,35,,201.6,percent of total billed charges,Implant Device,201.6,35,,201.6,percent of total billed charges,Implant Device,201.6,35,,201.6,percent of total billed charges,Implant Device,230.4,40,,230.4,percent of total billed charges,Implant Device,201.6,70,,201.6,percent of total billed charges,All Other,195.84,34,,195.84,percent of total billed charges,Implant Device,195.84,34,,195.84,percent of total billed charges,Implant Device,201.6,35,,201.6,percent of total billed charges,Implant Device,201.6,35,,201.6,percent of total billed charges,Implant Device,201.6,35,,201.6,percent of total billed charges,Implant Device,201.6,35,,201.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,426.24,
ST JUDE DM3500 CONFIRM RX,C1764,HCPCS,,79009168,CDM,278,RC,,,both,,,13800,10212.03,,,10212.03,Other,150% of Medicare + 9.63% HCRA Surcharge,6210,45,,6210,percent of total billed charges,Critical Access Hospital RCC factor,4692,34,,4692,percent of total billed charges,Implant Device,4692,34,,4692,percent of total billed charges,Implant Device,4692,34,,4692,percent of total billed charges,Implant Device,4692,34,,4692,percent of total billed charges,Implant Device,4692,34,,4692,percent of total billed charges,Implant Device,6831,,,6831,Other,110% of Medicare,4830,35,,4830,percent of total billed charges,Implant Device,4692,34,"Charges > $500, x 34%",4692,percent of total billed charges,Implant Device,4830,35,,4830,percent of total billed charges,Implant Device,4830,35,,4830,percent of total billed charges,Implant Device,4830,35,,4830,percent of total billed charges,Implant Device,4830,35,,4830,percent of total billed charges,Implant Device,4830,35,,4830,percent of total billed charges,Implant Device,5520,40,,5520,percent of total billed charges,Implant Device,4830,70,,4830,percent of total billed charges,All Other,4692,34,,4692,percent of total billed charges,Implant Device,4692,34,,4692,percent of total billed charges,Implant Device,4830,35,,4830,percent of total billed charges,Implant Device,4830,35,,4830,percent of total billed charges,Implant Device,4830,35,,4830,percent of total billed charges,Implant Device,4830,35,,4830,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,4692,34,"If Charge > 2,000, then 34 percent",4692,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,10212.03,
GORE VBJR070702A VIABAHN ENDOPROSTHESIS,C1874,HCPCS,,79009170,CDM,278,RC,,,both,,,11010,8147.43,,,8147.43,Other,150% of Medicare + 9.63% HCRA Surcharge,4954.5,45,,4954.5,percent of total billed charges,Critical Access Hospital RCC factor,3743.4,34,,3743.4,percent of total billed charges,Implant Device,3743.4,34,,3743.4,percent of total billed charges,Implant Device,3743.4,34,,3743.4,percent of total billed charges,Implant Device,3743.4,34,,3743.4,percent of total billed charges,Implant Device,3743.4,34,,3743.4,percent of total billed charges,Implant Device,5449.95,,,5449.95,Other,110% of Medicare,3853.5,35,,3853.5,percent of total billed charges,Implant Device,3743.4,34,"Charges > $500, x 34%",3743.4,percent of total billed charges,Implant Device,3853.5,35,,3853.5,percent of total billed charges,Implant Device,3853.5,35,,3853.5,percent of total billed charges,Implant Device,3853.5,35,,3853.5,percent of total billed charges,Implant Device,3853.5,35,,3853.5,percent of total billed charges,Implant Device,3853.5,35,,3853.5,percent of total billed charges,Implant Device,4404,40,,4404,percent of total billed charges,Implant Device,3853.5,70,,3853.5,percent of total billed charges,All Other,3743.4,34,,3743.4,percent of total billed charges,Implant Device,3743.4,34,,3743.4,percent of total billed charges,Implant Device,3853.5,35,,3853.5,percent of total billed charges,Implant Device,3853.5,35,,3853.5,percent of total billed charges,Implant Device,3853.5,35,,3853.5,percent of total billed charges,Implant Device,3853.5,35,,3853.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3743.4,34,"If Charge > 2,000, then 34 percent",3743.4,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,8147.43,
IN2BONES S22 ST013 SNAP OFF SCREW 2.2X13,C1713,HCPCS,,79009172,CDM,278,RC,,,both,,,1275,943.5,,,943.5,Other,150% of Medicare + 9.63% HCRA Surcharge,573.75,45,,573.75,percent of total billed charges,Critical Access Hospital RCC factor,433.5,34,,433.5,percent of total billed charges,Implant Device,433.5,34,,433.5,percent of total billed charges,Implant Device,433.5,34,,433.5,percent of total billed charges,Implant Device,433.5,34,,433.5,percent of total billed charges,Implant Device,433.5,34,,433.5,percent of total billed charges,Implant Device,631.13,,,631.13,Other,110% of Medicare,446.25,35,,446.25,percent of total billed charges,Implant Device,433.5,34,"Charges > $500, x 34%",433.5,percent of total billed charges,Implant Device,446.25,35,,446.25,percent of total billed charges,Implant Device,446.25,35,,446.25,percent of total billed charges,Implant Device,446.25,35,,446.25,percent of total billed charges,Implant Device,446.25,35,,446.25,percent of total billed charges,Implant Device,446.25,35,,446.25,percent of total billed charges,Implant Device,510,40,,510,percent of total billed charges,Implant Device,446.25,70,,446.25,percent of total billed charges,All Other,433.5,34,,433.5,percent of total billed charges,Implant Device,433.5,34,,433.5,percent of total billed charges,Implant Device,446.25,35,,446.25,percent of total billed charges,Implant Device,446.25,35,,446.25,percent of total billed charges,Implant Device,446.25,35,,446.25,percent of total billed charges,Implant Device,446.25,35,,446.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,943.5,
ZIMMER 00-5988-006-26 TIBIAL BLOCK 6X5MM,C1776,HCPCS,,79009174,CDM,278,RC,,,both,,,2993,2214.83,,,2214.83,Other,150% of Medicare + 9.63% HCRA Surcharge,1346.85,45,,1346.85,percent of total billed charges,Critical Access Hospital RCC factor,1017.62,34,,1017.62,percent of total billed charges,Implant Device,1017.62,34,,1017.62,percent of total billed charges,Implant Device,1017.62,34,,1017.62,percent of total billed charges,Implant Device,1017.62,34,,1017.62,percent of total billed charges,Implant Device,1017.62,34,,1017.62,percent of total billed charges,Implant Device,1481.54,,,1481.54,Other,110% of Medicare,1047.55,35,,1047.55,percent of total billed charges,Implant Device,1017.62,34,"Charges > $500, x 34%",1017.62,percent of total billed charges,Implant Device,1047.55,35,,1047.55,percent of total billed charges,Implant Device,1047.55,35,,1047.55,percent of total billed charges,Implant Device,1047.55,35,,1047.55,percent of total billed charges,Implant Device,1047.55,35,,1047.55,percent of total billed charges,Implant Device,1047.55,35,,1047.55,percent of total billed charges,Implant Device,1197.2,40,,1197.2,percent of total billed charges,Implant Device,1047.55,70,,1047.55,percent of total billed charges,All Other,1017.62,34,,1017.62,percent of total billed charges,Implant Device,1017.62,34,,1017.62,percent of total billed charges,Implant Device,1047.55,35,,1047.55,percent of total billed charges,Implant Device,1047.55,35,,1047.55,percent of total billed charges,Implant Device,1047.55,35,,1047.55,percent of total billed charges,Implant Device,1047.55,35,,1047.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1017.62,34,"If Charge > 2,000, then 34 percent",1017.62,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2214.83,
ZIMMER 00-5990-037-23 FEM AUG BLOCK 15MM,C1776,HCPCS,,79009175,CDM,278,RC,,,both,,,3488,2581.13,,,2581.13,Other,150% of Medicare + 9.63% HCRA Surcharge,1569.6,45,,1569.6,percent of total billed charges,Critical Access Hospital RCC factor,1185.92,34,,1185.92,percent of total billed charges,Implant Device,1185.92,34,,1185.92,percent of total billed charges,Implant Device,1185.92,34,,1185.92,percent of total billed charges,Implant Device,1185.92,34,,1185.92,percent of total billed charges,Implant Device,1185.92,34,,1185.92,percent of total billed charges,Implant Device,1726.56,,,1726.56,Other,110% of Medicare,1220.8,35,,1220.8,percent of total billed charges,Implant Device,1185.92,34,"Charges > $500, x 34%",1185.92,percent of total billed charges,Implant Device,1220.8,35,,1220.8,percent of total billed charges,Implant Device,1220.8,35,,1220.8,percent of total billed charges,Implant Device,1220.8,35,,1220.8,percent of total billed charges,Implant Device,1220.8,35,,1220.8,percent of total billed charges,Implant Device,1220.8,35,,1220.8,percent of total billed charges,Implant Device,1395.2,40,,1395.2,percent of total billed charges,Implant Device,1220.8,70,,1220.8,percent of total billed charges,All Other,1185.92,34,,1185.92,percent of total billed charges,Implant Device,1185.92,34,,1185.92,percent of total billed charges,Implant Device,1220.8,35,,1220.8,percent of total billed charges,Implant Device,1220.8,35,,1220.8,percent of total billed charges,Implant Device,1220.8,35,,1220.8,percent of total billed charges,Implant Device,1220.8,35,,1220.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1185.92,34,"If Charge > 2,000, then 34 percent",1185.92,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2581.13,
ZIMMER 00-5994-042-12 ART SURF SZ G 12MM,C1776,HCPCS,,79009176,CDM,278,RC,,,both,,,6320,4676.82,,,4676.82,Other,150% of Medicare + 9.63% HCRA Surcharge,2844,45,,2844,percent of total billed charges,Critical Access Hospital RCC factor,2148.8,34,,2148.8,percent of total billed charges,Implant Device,2148.8,34,,2148.8,percent of total billed charges,Implant Device,2148.8,34,,2148.8,percent of total billed charges,Implant Device,2148.8,34,,2148.8,percent of total billed charges,Implant Device,2148.8,34,,2148.8,percent of total billed charges,Implant Device,3128.4,,,3128.4,Other,110% of Medicare,2212,35,,2212,percent of total billed charges,Implant Device,2148.8,34,"Charges > $500, x 34%",2148.8,percent of total billed charges,Implant Device,2212,35,,2212,percent of total billed charges,Implant Device,2212,35,,2212,percent of total billed charges,Implant Device,2212,35,,2212,percent of total billed charges,Implant Device,2212,35,,2212,percent of total billed charges,Implant Device,2212,35,,2212,percent of total billed charges,Implant Device,2528,40,,2528,percent of total billed charges,Implant Device,2212,70,,2212,percent of total billed charges,All Other,2148.8,34,,2148.8,percent of total billed charges,Implant Device,2148.8,34,,2148.8,percent of total billed charges,Implant Device,2212,35,,2212,percent of total billed charges,Implant Device,2212,35,,2212,percent of total billed charges,Implant Device,2212,35,,2212,percent of total billed charges,Implant Device,2212,35,,2212,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2148.8,34,"If Charge > 2,000, then 34 percent",2148.8,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4676.82,
STRYKER 627334 PROX LAT TIBIAL PLATE 4 H,C1713,HCPCS,,79009179,CDM,278,RC,,,both,,,8895,6582.32,,,6582.32,Other,150% of Medicare + 9.63% HCRA Surcharge,4002.75,45,,4002.75,percent of total billed charges,Critical Access Hospital RCC factor,3024.3,34,,3024.3,percent of total billed charges,Implant Device,3024.3,34,,3024.3,percent of total billed charges,Implant Device,3024.3,34,,3024.3,percent of total billed charges,Implant Device,3024.3,34,,3024.3,percent of total billed charges,Implant Device,3024.3,34,,3024.3,percent of total billed charges,Implant Device,4403.03,,,4403.03,Other,110% of Medicare,3113.25,35,,3113.25,percent of total billed charges,Implant Device,3024.3,34,"Charges > $500, x 34%",3024.3,percent of total billed charges,Implant Device,3113.25,35,,3113.25,percent of total billed charges,Implant Device,3113.25,35,,3113.25,percent of total billed charges,Implant Device,3113.25,35,,3113.25,percent of total billed charges,Implant Device,3113.25,35,,3113.25,percent of total billed charges,Implant Device,3113.25,35,,3113.25,percent of total billed charges,Implant Device,3558,40,,3558,percent of total billed charges,Implant Device,3113.25,70,,3113.25,percent of total billed charges,All Other,3024.3,34,,3024.3,percent of total billed charges,Implant Device,3024.3,34,,3024.3,percent of total billed charges,Implant Device,3113.25,35,,3113.25,percent of total billed charges,Implant Device,3113.25,35,,3113.25,percent of total billed charges,Implant Device,3113.25,35,,3113.25,percent of total billed charges,Implant Device,3113.25,35,,3113.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3024.3,34,"If Charge > 2,000, then 34 percent",3024.3,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,6582.32,
STRYKER 661460 NON LOCK SCREW 3.5X60MM,C1713,HCPCS,,79009180,CDM,278,RC,,,both,,,180,133.2,,,133.2,Other,150% of Medicare + 9.63% HCRA Surcharge,81,45,,81,percent of total billed charges,Critical Access Hospital RCC factor,61.2,34,,61.2,percent of total billed charges,Implant Device,61.2,34,,61.2,percent of total billed charges,Implant Device,61.2,34,,61.2,percent of total billed charges,Implant Device,61.2,34,,61.2,percent of total billed charges,Implant Device,61.2,34,,61.2,percent of total billed charges,Implant Device,89.1,,,89.1,Other,110% of Medicare,63,35,,63,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,63,35,,63,percent of total billed charges,Implant Device,63,35,,63,percent of total billed charges,Implant Device,63,35,,63,percent of total billed charges,Implant Device,63,35,,63,percent of total billed charges,Implant Device,63,35,,63,percent of total billed charges,Implant Device,72,40,,72,percent of total billed charges,Implant Device,63,70,,63,percent of total billed charges,All Other,61.2,34,,61.2,percent of total billed charges,Implant Device,61.2,34,,61.2,percent of total billed charges,Implant Device,63,35,,63,percent of total billed charges,Implant Device,63,35,,63,percent of total billed charges,Implant Device,63,35,,63,percent of total billed charges,Implant Device,63,35,,63,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,133.2,
STRYKER 661420 NON LOCK SCREW 3.5X20MM,C1713,HCPCS,,79009181,CDM,278,RC,,,both,,,132,97.68,,,97.68,Other,150% of Medicare + 9.63% HCRA Surcharge,59.4,45,,59.4,percent of total billed charges,Critical Access Hospital RCC factor,44.88,34,,44.88,percent of total billed charges,Implant Device,44.88,34,,44.88,percent of total billed charges,Implant Device,44.88,34,,44.88,percent of total billed charges,Implant Device,44.88,34,,44.88,percent of total billed charges,Implant Device,44.88,34,,44.88,percent of total billed charges,Implant Device,65.34,,,65.34,Other,110% of Medicare,46.2,35,,46.2,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,46.2,35,,46.2,percent of total billed charges,Implant Device,46.2,35,,46.2,percent of total billed charges,Implant Device,46.2,35,,46.2,percent of total billed charges,Implant Device,46.2,35,,46.2,percent of total billed charges,Implant Device,46.2,35,,46.2,percent of total billed charges,Implant Device,52.8,40,,52.8,percent of total billed charges,Implant Device,46.2,70,,46.2,percent of total billed charges,All Other,44.88,34,,44.88,percent of total billed charges,Implant Device,44.88,34,,44.88,percent of total billed charges,Implant Device,46.2,35,,46.2,percent of total billed charges,Implant Device,46.2,35,,46.2,percent of total billed charges,Implant Device,46.2,35,,46.2,percent of total billed charges,Implant Device,46.2,35,,46.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,97.68,
STRYKER 661418 NON LOCK SCREW 3.5X18MM,C1713,HCPCS,,79009182,CDM,278,RC,,,both,,,122,90.28,,,90.28,Other,150% of Medicare + 9.63% HCRA Surcharge,54.9,45,,54.9,percent of total billed charges,Critical Access Hospital RCC factor,41.48,34,,41.48,percent of total billed charges,Implant Device,41.48,34,,41.48,percent of total billed charges,Implant Device,41.48,34,,41.48,percent of total billed charges,Implant Device,41.48,34,,41.48,percent of total billed charges,Implant Device,41.48,34,,41.48,percent of total billed charges,Implant Device,60.39,,,60.39,Other,110% of Medicare,42.7,35,,42.7,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,42.7,35,,42.7,percent of total billed charges,Implant Device,42.7,35,,42.7,percent of total billed charges,Implant Device,42.7,35,,42.7,percent of total billed charges,Implant Device,42.7,35,,42.7,percent of total billed charges,Implant Device,42.7,35,,42.7,percent of total billed charges,Implant Device,48.8,40,,48.8,percent of total billed charges,Implant Device,42.7,70,,42.7,percent of total billed charges,All Other,41.48,34,,41.48,percent of total billed charges,Implant Device,41.48,34,,41.48,percent of total billed charges,Implant Device,42.7,35,,42.7,percent of total billed charges,Implant Device,42.7,35,,42.7,percent of total billed charges,Implant Device,42.7,35,,42.7,percent of total billed charges,Implant Device,42.7,35,,42.7,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,90.28,
STRYKER 607370 CANCELLOUS SCREW 4.0X70MM,C1713,HCPCS,,79009183,CDM,278,RC,,,both,,,133,98.42,,,98.42,Other,150% of Medicare + 9.63% HCRA Surcharge,59.85,45,,59.85,percent of total billed charges,Critical Access Hospital RCC factor,45.22,34,,45.22,percent of total billed charges,Implant Device,45.22,34,,45.22,percent of total billed charges,Implant Device,45.22,34,,45.22,percent of total billed charges,Implant Device,45.22,34,,45.22,percent of total billed charges,Implant Device,45.22,34,,45.22,percent of total billed charges,Implant Device,65.84,,,65.84,Other,110% of Medicare,46.55,35,,46.55,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,46.55,35,,46.55,percent of total billed charges,Implant Device,46.55,35,,46.55,percent of total billed charges,Implant Device,46.55,35,,46.55,percent of total billed charges,Implant Device,46.55,35,,46.55,percent of total billed charges,Implant Device,46.55,35,,46.55,percent of total billed charges,Implant Device,53.2,40,,53.2,percent of total billed charges,Implant Device,46.55,70,,46.55,percent of total billed charges,All Other,45.22,34,,45.22,percent of total billed charges,Implant Device,45.22,34,,45.22,percent of total billed charges,Implant Device,46.55,35,,46.55,percent of total billed charges,Implant Device,46.55,35,,46.55,percent of total billed charges,Implant Device,46.55,35,,46.55,percent of total billed charges,Implant Device,46.55,35,,46.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,98.42,
STRYKER 607320 CANCELLOUS SCREW 4.0X20MM,C1713,HCPCS,,79009184,CDM,278,RC,,,both,,,195,144.3,,,144.3,Other,150% of Medicare + 9.63% HCRA Surcharge,87.75,45,,87.75,percent of total billed charges,Critical Access Hospital RCC factor,66.3,34,,66.3,percent of total billed charges,Implant Device,66.3,34,,66.3,percent of total billed charges,Implant Device,66.3,34,,66.3,percent of total billed charges,Implant Device,66.3,34,,66.3,percent of total billed charges,Implant Device,66.3,34,,66.3,percent of total billed charges,Implant Device,96.53,,,96.53,Other,110% of Medicare,68.25,35,,68.25,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,68.25,35,,68.25,percent of total billed charges,Implant Device,68.25,35,,68.25,percent of total billed charges,Implant Device,68.25,35,,68.25,percent of total billed charges,Implant Device,68.25,35,,68.25,percent of total billed charges,Implant Device,68.25,35,,68.25,percent of total billed charges,Implant Device,78,40,,78,percent of total billed charges,Implant Device,68.25,70,,68.25,percent of total billed charges,All Other,66.3,34,,66.3,percent of total billed charges,Implant Device,66.3,34,,66.3,percent of total billed charges,Implant Device,68.25,35,,68.25,percent of total billed charges,Implant Device,68.25,35,,68.25,percent of total billed charges,Implant Device,68.25,35,,68.25,percent of total billed charges,Implant Device,68.25,35,,68.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,144.3,
DEPUY 1961-92-034 TIB INSERT SZ 3 17.5MM,C1776,HCPCS,,79009185,CDM,278,RC,,,both,,,5735,4243.91,,,4243.91,Other,150% of Medicare + 9.63% HCRA Surcharge,2580.75,45,,2580.75,percent of total billed charges,Critical Access Hospital RCC factor,1949.9,34,,1949.9,percent of total billed charges,Implant Device,1949.9,34,,1949.9,percent of total billed charges,Implant Device,1949.9,34,,1949.9,percent of total billed charges,Implant Device,1949.9,34,,1949.9,percent of total billed charges,Implant Device,1949.9,34,,1949.9,percent of total billed charges,Implant Device,2838.83,,,2838.83,Other,110% of Medicare,2007.25,35,,2007.25,percent of total billed charges,Implant Device,1949.9,34,"Charges > $500, x 34%",1949.9,percent of total billed charges,Implant Device,2007.25,35,,2007.25,percent of total billed charges,Implant Device,2007.25,35,,2007.25,percent of total billed charges,Implant Device,2007.25,35,,2007.25,percent of total billed charges,Implant Device,2007.25,35,,2007.25,percent of total billed charges,Implant Device,2007.25,35,,2007.25,percent of total billed charges,Implant Device,2294,40,,2294,percent of total billed charges,Implant Device,2007.25,70,,2007.25,percent of total billed charges,All Other,1949.9,34,,1949.9,percent of total billed charges,Implant Device,1949.9,34,,1949.9,percent of total billed charges,Implant Device,2007.25,35,,2007.25,percent of total billed charges,Implant Device,2007.25,35,,2007.25,percent of total billed charges,Implant Device,2007.25,35,,2007.25,percent of total billed charges,Implant Device,2007.25,35,,2007.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1949.9,34,"If Charge > 2,000, then 34 percent",1949.9,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4243.91,
LIFECELL 1516128 ALLODERM 8X16 RTU THIN,C1776,HCPCS,,79009186,CDM,278,RC,,,both,,,15309,11328.7,,,11328.7,Other,150% of Medicare + 9.63% HCRA Surcharge,6889.05,45,,6889.05,percent of total billed charges,Critical Access Hospital RCC factor,5205.06,34,,5205.06,percent of total billed charges,Implant Device,5205.06,34,,5205.06,percent of total billed charges,Implant Device,5205.06,34,,5205.06,percent of total billed charges,Implant Device,5205.06,34,,5205.06,percent of total billed charges,Implant Device,5205.06,34,,5205.06,percent of total billed charges,Implant Device,7577.96,,,7577.96,Other,110% of Medicare,5358.15,35,,5358.15,percent of total billed charges,Implant Device,5205.06,34,"Charges > $500, x 34%",5205.06,percent of total billed charges,Implant Device,5358.15,35,,5358.15,percent of total billed charges,Implant Device,5358.15,35,,5358.15,percent of total billed charges,Implant Device,5358.15,35,,5358.15,percent of total billed charges,Implant Device,5358.15,35,,5358.15,percent of total billed charges,Implant Device,5358.15,35,,5358.15,percent of total billed charges,Implant Device,6123.6,40,,6123.6,percent of total billed charges,Implant Device,5358.15,70,,5358.15,percent of total billed charges,All Other,5205.06,34,,5205.06,percent of total billed charges,Implant Device,5205.06,34,,5205.06,percent of total billed charges,Implant Device,5358.15,35,,5358.15,percent of total billed charges,Implant Device,5358.15,35,,5358.15,percent of total billed charges,Implant Device,5358.15,35,,5358.15,percent of total billed charges,Implant Device,5358.15,35,,5358.15,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,5205.06,34,"If Charge > 2,000, then 34 percent",5205.06,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,11328.7,
MENTOR 354-9215 TISSUE EXPANDER CPX4 650,C1789,HCPCS,,79009187,CDM,278,RC,,,both,,,5085,3762.91,,,3762.91,Other,150% of Medicare + 9.63% HCRA Surcharge,2288.25,45,,2288.25,percent of total billed charges,Critical Access Hospital RCC factor,1728.9,34,,1728.9,percent of total billed charges,Implant Device,1728.9,34,,1728.9,percent of total billed charges,Implant Device,1728.9,34,,1728.9,percent of total billed charges,Implant Device,1728.9,34,,1728.9,percent of total billed charges,Implant Device,1728.9,34,,1728.9,percent of total billed charges,Implant Device,2517.08,,,2517.08,Other,110% of Medicare,1779.75,35,,1779.75,percent of total billed charges,Implant Device,1728.9,34,"Charges > $500, x 34%",1728.9,percent of total billed charges,Implant Device,1779.75,35,,1779.75,percent of total billed charges,Implant Device,1779.75,35,,1779.75,percent of total billed charges,Implant Device,1779.75,35,,1779.75,percent of total billed charges,Implant Device,1779.75,35,,1779.75,percent of total billed charges,Implant Device,1779.75,35,,1779.75,percent of total billed charges,Implant Device,2034,40,,2034,percent of total billed charges,Implant Device,1779.75,70,,1779.75,percent of total billed charges,All Other,1728.9,34,,1728.9,percent of total billed charges,Implant Device,1728.9,34,,1728.9,percent of total billed charges,Implant Device,1779.75,35,,1779.75,percent of total billed charges,Implant Device,1779.75,35,,1779.75,percent of total billed charges,Implant Device,1779.75,35,,1779.75,percent of total billed charges,Implant Device,1779.75,35,,1779.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1728.9,34,"If Charge > 2,000, then 34 percent",1728.9,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3762.91,
ZIMMER 11-300818 DISTAL STEM 18X150MM,C1776,HCPCS,,79009188,CDM,278,RC,,,both,,,10199,7547.29,,,7547.29,Other,150% of Medicare + 9.63% HCRA Surcharge,4589.55,45,,4589.55,percent of total billed charges,Critical Access Hospital RCC factor,3467.66,34,,3467.66,percent of total billed charges,Implant Device,3467.66,34,,3467.66,percent of total billed charges,Implant Device,3467.66,34,,3467.66,percent of total billed charges,Implant Device,3467.66,34,,3467.66,percent of total billed charges,Implant Device,3467.66,34,,3467.66,percent of total billed charges,Implant Device,5048.51,,,5048.51,Other,110% of Medicare,3569.65,35,,3569.65,percent of total billed charges,Implant Device,3467.66,34,"Charges > $500, x 34%",3467.66,percent of total billed charges,Implant Device,3569.65,35,,3569.65,percent of total billed charges,Implant Device,3569.65,35,,3569.65,percent of total billed charges,Implant Device,3569.65,35,,3569.65,percent of total billed charges,Implant Device,3569.65,35,,3569.65,percent of total billed charges,Implant Device,3569.65,35,,3569.65,percent of total billed charges,Implant Device,4079.6,40,,4079.6,percent of total billed charges,Implant Device,3569.65,70,,3569.65,percent of total billed charges,All Other,3467.66,34,,3467.66,percent of total billed charges,Implant Device,3467.66,34,,3467.66,percent of total billed charges,Implant Device,3569.65,35,,3569.65,percent of total billed charges,Implant Device,3569.65,35,,3569.65,percent of total billed charges,Implant Device,3569.65,35,,3569.65,percent of total billed charges,Implant Device,3569.65,35,,3569.65,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3467.66,34,"If Charge > 2,000, then 34 percent",3467.66,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,7547.29,
STRYKER 627736 PROX MEDIAL TIB PLATE 6 H,C1713,HCPCS,,79009191,CDM,278,RC,,,both,,,8178,6051.74,,,6051.74,Other,150% of Medicare + 9.63% HCRA Surcharge,3680.1,45,,3680.1,percent of total billed charges,Critical Access Hospital RCC factor,2780.52,34,,2780.52,percent of total billed charges,Implant Device,2780.52,34,,2780.52,percent of total billed charges,Implant Device,2780.52,34,,2780.52,percent of total billed charges,Implant Device,2780.52,34,,2780.52,percent of total billed charges,Implant Device,2780.52,34,,2780.52,percent of total billed charges,Implant Device,4048.11,,,4048.11,Other,110% of Medicare,2862.3,35,,2862.3,percent of total billed charges,Implant Device,2780.52,34,"Charges > $500, x 34%",2780.52,percent of total billed charges,Implant Device,2862.3,35,,2862.3,percent of total billed charges,Implant Device,2862.3,35,,2862.3,percent of total billed charges,Implant Device,2862.3,35,,2862.3,percent of total billed charges,Implant Device,2862.3,35,,2862.3,percent of total billed charges,Implant Device,2862.3,35,,2862.3,percent of total billed charges,Implant Device,3271.2,40,,3271.2,percent of total billed charges,Implant Device,2862.3,70,,2862.3,percent of total billed charges,All Other,2780.52,34,,2780.52,percent of total billed charges,Implant Device,2780.52,34,,2780.52,percent of total billed charges,Implant Device,2862.3,35,,2862.3,percent of total billed charges,Implant Device,2862.3,35,,2862.3,percent of total billed charges,Implant Device,2862.3,35,,2862.3,percent of total billed charges,Implant Device,2862.3,35,,2862.3,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2780.52,34,"If Charge > 2,000, then 34 percent",2780.52,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,6051.74,
IN2BONES V30 ST422 TRANSVERSE SCREW 3X22,C1713,HCPCS,,79009192,CDM,278,RC,,,both,,,870,643.8,,,643.8,Other,150% of Medicare + 9.63% HCRA Surcharge,391.5,45,,391.5,percent of total billed charges,Critical Access Hospital RCC factor,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,430.65,,,430.65,Other,110% of Medicare,304.5,35,,304.5,percent of total billed charges,Implant Device,295.8,34,"Charges > $500, x 34%",295.8,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,348,40,,348,percent of total billed charges,Implant Device,304.5,70,,304.5,percent of total billed charges,All Other,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,643.8,
BOST SCI M00516720 ESOPH STENT 18X123MM,C1874,HCPCS,,79009193,CDM,278,RC,,,both,,,7409,5482.68,,,5482.68,Other,150% of Medicare + 9.63% HCRA Surcharge,3334.05,45,,3334.05,percent of total billed charges,Critical Access Hospital RCC factor,2519.06,34,,2519.06,percent of total billed charges,Implant Device,2519.06,34,,2519.06,percent of total billed charges,Implant Device,2519.06,34,,2519.06,percent of total billed charges,Implant Device,2519.06,34,,2519.06,percent of total billed charges,Implant Device,2519.06,34,,2519.06,percent of total billed charges,Implant Device,3667.46,,,3667.46,Other,110% of Medicare,2593.15,35,,2593.15,percent of total billed charges,Implant Device,2519.06,34,"Charges > $500, x 34%",2519.06,percent of total billed charges,Implant Device,2593.15,35,,2593.15,percent of total billed charges,Implant Device,2593.15,35,,2593.15,percent of total billed charges,Implant Device,2593.15,35,,2593.15,percent of total billed charges,Implant Device,2593.15,35,,2593.15,percent of total billed charges,Implant Device,2593.15,35,,2593.15,percent of total billed charges,Implant Device,2963.6,40,,2963.6,percent of total billed charges,Implant Device,2593.15,70,,2593.15,percent of total billed charges,All Other,2519.06,34,,2519.06,percent of total billed charges,Implant Device,2519.06,34,,2519.06,percent of total billed charges,Implant Device,2593.15,35,,2593.15,percent of total billed charges,Implant Device,2593.15,35,,2593.15,percent of total billed charges,Implant Device,2593.15,35,,2593.15,percent of total billed charges,Implant Device,2593.15,35,,2593.15,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2519.06,34,"If Charge > 2,000, then 34 percent",2519.06,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5482.68,
DEPUY 1570-06-080 FEM STEM SZ 2 97MM,C1776,HCPCS,,79009195,CDM,278,RC,,,both,,,5575,4125.51,,,4125.51,Other,150% of Medicare + 9.63% HCRA Surcharge,2508.75,45,,2508.75,percent of total billed charges,Critical Access Hospital RCC factor,1895.5,34,,1895.5,percent of total billed charges,Implant Device,1895.5,34,,1895.5,percent of total billed charges,Implant Device,1895.5,34,,1895.5,percent of total billed charges,Implant Device,1895.5,34,,1895.5,percent of total billed charges,Implant Device,1895.5,34,,1895.5,percent of total billed charges,Implant Device,2759.63,,,2759.63,Other,110% of Medicare,1951.25,35,,1951.25,percent of total billed charges,Implant Device,1895.5,34,"Charges > $500, x 34%",1895.5,percent of total billed charges,Implant Device,1951.25,35,,1951.25,percent of total billed charges,Implant Device,1951.25,35,,1951.25,percent of total billed charges,Implant Device,1951.25,35,,1951.25,percent of total billed charges,Implant Device,1951.25,35,,1951.25,percent of total billed charges,Implant Device,1951.25,35,,1951.25,percent of total billed charges,Implant Device,2230,40,,2230,percent of total billed charges,Implant Device,1951.25,70,,1951.25,percent of total billed charges,All Other,1895.5,34,,1895.5,percent of total billed charges,Implant Device,1895.5,34,,1895.5,percent of total billed charges,Implant Device,1951.25,35,,1951.25,percent of total billed charges,Implant Device,1951.25,35,,1951.25,percent of total billed charges,Implant Device,1951.25,35,,1951.25,percent of total billed charges,Implant Device,1951.25,35,,1951.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1895.5,34,"If Charge > 2,000, then 34 percent",1895.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4125.51,
DEPUY 1570-06-080 FEMORAL 26-3MM,C1776,HCPCS,,79009196,CDM,278,RC,,,both,,,2850,2109.01,,,2109.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1282.5,45,,1282.5,percent of total billed charges,Critical Access Hospital RCC factor,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,1410.75,,,1410.75,Other,110% of Medicare,997.5,35,,997.5,percent of total billed charges,Implant Device,969,34,"Charges > $500, x 34%",969,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,1140,40,,1140,percent of total billed charges,Implant Device,997.5,70,,997.5,percent of total billed charges,All Other,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,969,34,"If Charge > 2,000, then 34 percent",969,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2109.01,
BOST SCI 27-414 6FRX28CM URETERAL STENT,C2617,HCPCS,,79009197,CDM,278,RC,,,both,,,572,423.28,,,423.28,Other,150% of Medicare + 9.63% HCRA Surcharge,257.4,45,,257.4,percent of total billed charges,Critical Access Hospital RCC factor,194.48,34,,194.48,percent of total billed charges,Implant Device,194.48,34,,194.48,percent of total billed charges,Implant Device,194.48,34,,194.48,percent of total billed charges,Implant Device,194.48,34,,194.48,percent of total billed charges,Implant Device,194.48,34,,194.48,percent of total billed charges,Implant Device,283.14,,,283.14,Other,110% of Medicare,200.2,35,,200.2,percent of total billed charges,Implant Device,194.48,34,"Charges > $500, x 34%",194.48,percent of total billed charges,Implant Device,200.2,35,,200.2,percent of total billed charges,Implant Device,200.2,35,,200.2,percent of total billed charges,Implant Device,200.2,35,,200.2,percent of total billed charges,Implant Device,200.2,35,,200.2,percent of total billed charges,Implant Device,200.2,35,,200.2,percent of total billed charges,Implant Device,228.8,40,,228.8,percent of total billed charges,Implant Device,200.2,70,,200.2,percent of total billed charges,All Other,194.48,34,,194.48,percent of total billed charges,Implant Device,194.48,34,,194.48,percent of total billed charges,Implant Device,200.2,35,,200.2,percent of total billed charges,Implant Device,200.2,35,,200.2,percent of total billed charges,Implant Device,200.2,35,,200.2,percent of total billed charges,Implant Device,200.2,35,,200.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,423.28,
STRYKER 5018-3-120 5X120 APEX HALF PIN,C1713,HCPCS,,79009200,CDM,278,RC,,,both,,,711,526.14,,,526.14,Other,150% of Medicare + 9.63% HCRA Surcharge,319.95,45,,319.95,percent of total billed charges,Critical Access Hospital RCC factor,241.74,34,,241.74,percent of total billed charges,Implant Device,241.74,34,,241.74,percent of total billed charges,Implant Device,241.74,34,,241.74,percent of total billed charges,Implant Device,241.74,34,,241.74,percent of total billed charges,Implant Device,241.74,34,,241.74,percent of total billed charges,Implant Device,351.95,,,351.95,Other,110% of Medicare,248.85,35,,248.85,percent of total billed charges,Implant Device,241.74,34,"Charges > $500, x 34%",241.74,percent of total billed charges,Implant Device,248.85,35,,248.85,percent of total billed charges,Implant Device,248.85,35,,248.85,percent of total billed charges,Implant Device,248.85,35,,248.85,percent of total billed charges,Implant Device,248.85,35,,248.85,percent of total billed charges,Implant Device,248.85,35,,248.85,percent of total billed charges,Implant Device,284.4,40,,284.4,percent of total billed charges,Implant Device,248.85,70,,248.85,percent of total billed charges,All Other,241.74,34,,241.74,percent of total billed charges,Implant Device,241.74,34,,241.74,percent of total billed charges,Implant Device,248.85,35,,248.85,percent of total billed charges,Implant Device,248.85,35,,248.85,percent of total billed charges,Implant Device,248.85,35,,248.85,percent of total billed charges,Implant Device,248.85,35,,248.85,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,526.14,
STRYKER 897015 HYDROSET XT 15CC,C1713,HCPCS,,79009201,CDM,278,RC,,,both,,,21354,15802.01,,,15802.01,Other,150% of Medicare + 9.63% HCRA Surcharge,9609.3,45,,9609.3,percent of total billed charges,Critical Access Hospital RCC factor,7260.36,34,,7260.36,percent of total billed charges,Implant Device,7260.36,34,,7260.36,percent of total billed charges,Implant Device,7260.36,34,,7260.36,percent of total billed charges,Implant Device,7260.36,34,,7260.36,percent of total billed charges,Implant Device,7260.36,34,,7260.36,percent of total billed charges,Implant Device,10570.23,,,10570.23,Other,110% of Medicare,7473.9,35,,7473.9,percent of total billed charges,Implant Device,7260.36,34,"Charges > $500, x 34%",7260.36,percent of total billed charges,Implant Device,7473.9,35,,7473.9,percent of total billed charges,Implant Device,7473.9,35,,7473.9,percent of total billed charges,Implant Device,7473.9,35,,7473.9,percent of total billed charges,Implant Device,7473.9,35,,7473.9,percent of total billed charges,Implant Device,7473.9,35,,7473.9,percent of total billed charges,Implant Device,8541.6,40,,8541.6,percent of total billed charges,Implant Device,7473.9,70,,7473.9,percent of total billed charges,All Other,7260.36,34,,7260.36,percent of total billed charges,Implant Device,7260.36,34,,7260.36,percent of total billed charges,Implant Device,7473.9,35,,7473.9,percent of total billed charges,Implant Device,7473.9,35,,7473.9,percent of total billed charges,Implant Device,7473.9,35,,7473.9,percent of total billed charges,Implant Device,7473.9,35,,7473.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,7260.36,34,"If Charge > 2,000, then 34 percent",7260.36,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,15802.01,
STRYKER 40-35626 LOCK SCREW T10 3.5X26MM,C1713,HCPCS,,79009202,CDM,278,RC,,,both,,,806,596.44,,,596.44,Other,150% of Medicare + 9.63% HCRA Surcharge,362.7,45,,362.7,percent of total billed charges,Critical Access Hospital RCC factor,274.04,34,,274.04,percent of total billed charges,Implant Device,274.04,34,,274.04,percent of total billed charges,Implant Device,274.04,34,,274.04,percent of total billed charges,Implant Device,274.04,34,,274.04,percent of total billed charges,Implant Device,274.04,34,,274.04,percent of total billed charges,Implant Device,398.97,,,398.97,Other,110% of Medicare,282.1,35,,282.1,percent of total billed charges,Implant Device,274.04,34,"Charges > $500, x 34%",274.04,percent of total billed charges,Implant Device,282.1,35,,282.1,percent of total billed charges,Implant Device,282.1,35,,282.1,percent of total billed charges,Implant Device,282.1,35,,282.1,percent of total billed charges,Implant Device,282.1,35,,282.1,percent of total billed charges,Implant Device,282.1,35,,282.1,percent of total billed charges,Implant Device,322.4,40,,322.4,percent of total billed charges,Implant Device,282.1,70,,282.1,percent of total billed charges,All Other,274.04,34,,274.04,percent of total billed charges,Implant Device,274.04,34,,274.04,percent of total billed charges,Implant Device,282.1,35,,282.1,percent of total billed charges,Implant Device,282.1,35,,282.1,percent of total billed charges,Implant Device,282.1,35,,282.1,percent of total billed charges,Implant Device,282.1,35,,282.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,596.44,
AIRXPANDERS BR140-600 TISSUE EXPANDER,C1789,HCPCS,,79009203,CDM,278,RC,,,both,,,7323,5419.04,,,5419.04,Other,150% of Medicare + 9.63% HCRA Surcharge,3295.35,45,,3295.35,percent of total billed charges,Critical Access Hospital RCC factor,2489.82,34,,2489.82,percent of total billed charges,Implant Device,2489.82,34,,2489.82,percent of total billed charges,Implant Device,2489.82,34,,2489.82,percent of total billed charges,Implant Device,2489.82,34,,2489.82,percent of total billed charges,Implant Device,2489.82,34,,2489.82,percent of total billed charges,Implant Device,3624.89,,,3624.89,Other,110% of Medicare,2563.05,35,,2563.05,percent of total billed charges,Implant Device,2489.82,34,"Charges > $500, x 34%",2489.82,percent of total billed charges,Implant Device,2563.05,35,,2563.05,percent of total billed charges,Implant Device,2563.05,35,,2563.05,percent of total billed charges,Implant Device,2563.05,35,,2563.05,percent of total billed charges,Implant Device,2563.05,35,,2563.05,percent of total billed charges,Implant Device,2563.05,35,,2563.05,percent of total billed charges,Implant Device,2929.2,40,,2929.2,percent of total billed charges,Implant Device,2563.05,70,,2563.05,percent of total billed charges,All Other,2489.82,34,,2489.82,percent of total billed charges,Implant Device,2489.82,34,,2489.82,percent of total billed charges,Implant Device,2563.05,35,,2563.05,percent of total billed charges,Implant Device,2563.05,35,,2563.05,percent of total billed charges,Implant Device,2563.05,35,,2563.05,percent of total billed charges,Implant Device,2563.05,35,,2563.05,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2489.82,34,"If Charge > 2,000, then 34 percent",2489.82,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5419.04,
ARROW CS-15232-VFM RETRO 19CM PERMACATH,C1750,HCPCS,,79009205,CDM,278,RC,,,both,,,1085,802.9,,,802.9,Other,150% of Medicare + 9.63% HCRA Surcharge,488.25,45,,488.25,percent of total billed charges,Critical Access Hospital RCC factor,368.9,34,,368.9,percent of total billed charges,Implant Device,368.9,34,,368.9,percent of total billed charges,Implant Device,368.9,34,,368.9,percent of total billed charges,Implant Device,368.9,34,,368.9,percent of total billed charges,Implant Device,368.9,34,,368.9,percent of total billed charges,Implant Device,537.08,,,537.08,Other,110% of Medicare,379.75,35,,379.75,percent of total billed charges,Implant Device,368.9,34,"Charges > $500, x 34%",368.9,percent of total billed charges,Implant Device,379.75,35,,379.75,percent of total billed charges,Implant Device,379.75,35,,379.75,percent of total billed charges,Implant Device,379.75,35,,379.75,percent of total billed charges,Implant Device,379.75,35,,379.75,percent of total billed charges,Implant Device,379.75,35,,379.75,percent of total billed charges,Implant Device,434,40,,434,percent of total billed charges,Implant Device,379.75,70,,379.75,percent of total billed charges,All Other,368.9,34,,368.9,percent of total billed charges,Implant Device,368.9,34,,368.9,percent of total billed charges,Implant Device,379.75,35,,379.75,percent of total billed charges,Implant Device,379.75,35,,379.75,percent of total billed charges,Implant Device,379.75,35,,379.75,percent of total billed charges,Implant Device,379.75,35,,379.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,802.9,
STRYKER 54-25583 VDR PLATE RIGHT NARROW,C1713,HCPCS,,79009207,CDM,278,RC,,,both,,,2604,1926.97,,,1926.97,Other,150% of Medicare + 9.63% HCRA Surcharge,1171.8,45,,1171.8,percent of total billed charges,Critical Access Hospital RCC factor,885.36,34,,885.36,percent of total billed charges,Implant Device,885.36,34,,885.36,percent of total billed charges,Implant Device,885.36,34,,885.36,percent of total billed charges,Implant Device,885.36,34,,885.36,percent of total billed charges,Implant Device,885.36,34,,885.36,percent of total billed charges,Implant Device,1288.98,,,1288.98,Other,110% of Medicare,911.4,35,,911.4,percent of total billed charges,Implant Device,885.36,34,"Charges > $500, x 34%",885.36,percent of total billed charges,Implant Device,911.4,35,,911.4,percent of total billed charges,Implant Device,911.4,35,,911.4,percent of total billed charges,Implant Device,911.4,35,,911.4,percent of total billed charges,Implant Device,911.4,35,,911.4,percent of total billed charges,Implant Device,911.4,35,,911.4,percent of total billed charges,Implant Device,1041.6,40,,1041.6,percent of total billed charges,Implant Device,911.4,70,,911.4,percent of total billed charges,All Other,885.36,34,,885.36,percent of total billed charges,Implant Device,885.36,34,,885.36,percent of total billed charges,Implant Device,911.4,35,,911.4,percent of total billed charges,Implant Device,911.4,35,,911.4,percent of total billed charges,Implant Device,911.4,35,,911.4,percent of total billed charges,Implant Device,911.4,35,,911.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,885.36,34,"If Charge > 2,000, then 34 percent",885.36,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1926.97,
STRYKER 657422 NON LOCK SCREW 3.5X22MM,C1713,HCPCS,,79009208,CDM,278,RC,,,both,,,294,217.56,,,217.56,Other,150% of Medicare + 9.63% HCRA Surcharge,132.3,45,,132.3,percent of total billed charges,Critical Access Hospital RCC factor,99.96,34,,99.96,percent of total billed charges,Implant Device,99.96,34,,99.96,percent of total billed charges,Implant Device,99.96,34,,99.96,percent of total billed charges,Implant Device,99.96,34,,99.96,percent of total billed charges,Implant Device,99.96,34,,99.96,percent of total billed charges,Implant Device,145.53,,,145.53,Other,110% of Medicare,102.9,35,,102.9,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,102.9,35,,102.9,percent of total billed charges,Implant Device,102.9,35,,102.9,percent of total billed charges,Implant Device,102.9,35,,102.9,percent of total billed charges,Implant Device,102.9,35,,102.9,percent of total billed charges,Implant Device,102.9,35,,102.9,percent of total billed charges,Implant Device,117.6,40,,117.6,percent of total billed charges,Implant Device,102.9,70,,102.9,percent of total billed charges,All Other,99.96,34,,99.96,percent of total billed charges,Implant Device,99.96,34,,99.96,percent of total billed charges,Implant Device,102.9,35,,102.9,percent of total billed charges,Implant Device,102.9,35,,102.9,percent of total billed charges,Implant Device,102.9,35,,102.9,percent of total billed charges,Implant Device,102.9,35,,102.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,217.56,
STRYKER 657424 NON LOCK SCREW 3.5X24MM,C1713,HCPCS,,79009209,CDM,278,RC,,,both,,,294,217.56,,,217.56,Other,150% of Medicare + 9.63% HCRA Surcharge,132.3,45,,132.3,percent of total billed charges,Critical Access Hospital RCC factor,99.96,34,,99.96,percent of total billed charges,Implant Device,99.96,34,,99.96,percent of total billed charges,Implant Device,99.96,34,,99.96,percent of total billed charges,Implant Device,99.96,34,,99.96,percent of total billed charges,Implant Device,99.96,34,,99.96,percent of total billed charges,Implant Device,145.53,,,145.53,Other,110% of Medicare,102.9,35,,102.9,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,102.9,35,,102.9,percent of total billed charges,Implant Device,102.9,35,,102.9,percent of total billed charges,Implant Device,102.9,35,,102.9,percent of total billed charges,Implant Device,102.9,35,,102.9,percent of total billed charges,Implant Device,102.9,35,,102.9,percent of total billed charges,Implant Device,117.6,40,,117.6,percent of total billed charges,Implant Device,102.9,70,,102.9,percent of total billed charges,All Other,99.96,34,,99.96,percent of total billed charges,Implant Device,99.96,34,,99.96,percent of total billed charges,Implant Device,102.9,35,,102.9,percent of total billed charges,Implant Device,102.9,35,,102.9,percent of total billed charges,Implant Device,102.9,35,,102.9,percent of total billed charges,Implant Device,102.9,35,,102.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,217.56,
ZIMMER 514.315 KNEE CREATIONS KIT 15X3CC,C1713,HCPCS,,79009211,CDM,278,RC,,,both,,,10020,7414.83,,,7414.83,Other,150% of Medicare + 9.63% HCRA Surcharge,4509,45,,4509,percent of total billed charges,Critical Access Hospital RCC factor,3406.8,34,,3406.8,percent of total billed charges,Implant Device,3406.8,34,,3406.8,percent of total billed charges,Implant Device,3406.8,34,,3406.8,percent of total billed charges,Implant Device,3406.8,34,,3406.8,percent of total billed charges,Implant Device,3406.8,34,,3406.8,percent of total billed charges,Implant Device,4959.9,,,4959.9,Other,110% of Medicare,3507,35,,3507,percent of total billed charges,Implant Device,3406.8,34,"Charges > $500, x 34%",3406.8,percent of total billed charges,Implant Device,3507,35,,3507,percent of total billed charges,Implant Device,3507,35,,3507,percent of total billed charges,Implant Device,3507,35,,3507,percent of total billed charges,Implant Device,3507,35,,3507,percent of total billed charges,Implant Device,3507,35,,3507,percent of total billed charges,Implant Device,4008,40,,4008,percent of total billed charges,Implant Device,3507,70,,3507,percent of total billed charges,All Other,3406.8,34,,3406.8,percent of total billed charges,Implant Device,3406.8,34,,3406.8,percent of total billed charges,Implant Device,3507,35,,3507,percent of total billed charges,Implant Device,3507,35,,3507,percent of total billed charges,Implant Device,3507,35,,3507,percent of total billed charges,Implant Device,3507,35,,3507,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3406.8,34,"If Charge > 2,000, then 34 percent",3406.8,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,7414.83,
DEPUY 3L92504 CORAIL AMT COLLAR SIZE 14,C1776,HCPCS,,79009212,CDM,278,RC,,,both,,,13446,9950.07,,,9950.07,Other,150% of Medicare + 9.63% HCRA Surcharge,6050.7,45,,6050.7,percent of total billed charges,Critical Access Hospital RCC factor,4571.64,34,,4571.64,percent of total billed charges,Implant Device,4571.64,34,,4571.64,percent of total billed charges,Implant Device,4571.64,34,,4571.64,percent of total billed charges,Implant Device,4571.64,34,,4571.64,percent of total billed charges,Implant Device,4571.64,34,,4571.64,percent of total billed charges,Implant Device,6655.77,,,6655.77,Other,110% of Medicare,4706.1,35,,4706.1,percent of total billed charges,Implant Device,4571.64,34,"Charges > $500, x 34%",4571.64,percent of total billed charges,Implant Device,4706.1,35,,4706.1,percent of total billed charges,Implant Device,4706.1,35,,4706.1,percent of total billed charges,Implant Device,4706.1,35,,4706.1,percent of total billed charges,Implant Device,4706.1,35,,4706.1,percent of total billed charges,Implant Device,4706.1,35,,4706.1,percent of total billed charges,Implant Device,5378.4,40,,5378.4,percent of total billed charges,Implant Device,4706.1,70,,4706.1,percent of total billed charges,All Other,4571.64,34,,4571.64,percent of total billed charges,Implant Device,4571.64,34,,4571.64,percent of total billed charges,Implant Device,4706.1,35,,4706.1,percent of total billed charges,Implant Device,4706.1,35,,4706.1,percent of total billed charges,Implant Device,4706.1,35,,4706.1,percent of total billed charges,Implant Device,4706.1,35,,4706.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,4571.64,34,"If Charge > 2,000, then 34 percent",4571.64,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,9950.07,
GORE PLC271200 EXCLUDER ENDOPROS 27X12CM,C1874,HCPCS,,79009214,CDM,278,RC,,,both,,,14217,10520.62,,,10520.62,Other,150% of Medicare + 9.63% HCRA Surcharge,6397.65,45,,6397.65,percent of total billed charges,Critical Access Hospital RCC factor,4833.78,34,,4833.78,percent of total billed charges,Implant Device,4833.78,34,,4833.78,percent of total billed charges,Implant Device,4833.78,34,,4833.78,percent of total billed charges,Implant Device,4833.78,34,,4833.78,percent of total billed charges,Implant Device,4833.78,34,,4833.78,percent of total billed charges,Implant Device,7037.42,,,7037.42,Other,110% of Medicare,4975.95,35,,4975.95,percent of total billed charges,Implant Device,4833.78,34,"Charges > $500, x 34%",4833.78,percent of total billed charges,Implant Device,4975.95,35,,4975.95,percent of total billed charges,Implant Device,4975.95,35,,4975.95,percent of total billed charges,Implant Device,4975.95,35,,4975.95,percent of total billed charges,Implant Device,4975.95,35,,4975.95,percent of total billed charges,Implant Device,4975.95,35,,4975.95,percent of total billed charges,Implant Device,5686.8,40,,5686.8,percent of total billed charges,Implant Device,4975.95,70,,4975.95,percent of total billed charges,All Other,4833.78,34,,4833.78,percent of total billed charges,Implant Device,4833.78,34,,4833.78,percent of total billed charges,Implant Device,4975.95,35,,4975.95,percent of total billed charges,Implant Device,4975.95,35,,4975.95,percent of total billed charges,Implant Device,4975.95,35,,4975.95,percent of total billed charges,Implant Device,4975.95,35,,4975.95,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,4833.78,34,"If Charge > 2,000, then 34 percent",4833.78,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,10520.62,
GORE PLC201400 EXCLUDER ENDOPROS 20X13.5,C1874,HCPCS,,79009215,CDM,278,RC,,,both,,,14217,10520.62,,,10520.62,Other,150% of Medicare + 9.63% HCRA Surcharge,6397.65,45,,6397.65,percent of total billed charges,Critical Access Hospital RCC factor,4833.78,34,,4833.78,percent of total billed charges,Implant Device,4833.78,34,,4833.78,percent of total billed charges,Implant Device,4833.78,34,,4833.78,percent of total billed charges,Implant Device,4833.78,34,,4833.78,percent of total billed charges,Implant Device,4833.78,34,,4833.78,percent of total billed charges,Implant Device,7037.42,,,7037.42,Other,110% of Medicare,4975.95,35,,4975.95,percent of total billed charges,Implant Device,4833.78,34,"Charges > $500, x 34%",4833.78,percent of total billed charges,Implant Device,4975.95,35,,4975.95,percent of total billed charges,Implant Device,4975.95,35,,4975.95,percent of total billed charges,Implant Device,4975.95,35,,4975.95,percent of total billed charges,Implant Device,4975.95,35,,4975.95,percent of total billed charges,Implant Device,4975.95,35,,4975.95,percent of total billed charges,Implant Device,5686.8,40,,5686.8,percent of total billed charges,Implant Device,4975.95,70,,4975.95,percent of total billed charges,All Other,4833.78,34,,4833.78,percent of total billed charges,Implant Device,4833.78,34,,4833.78,percent of total billed charges,Implant Device,4975.95,35,,4975.95,percent of total billed charges,Implant Device,4975.95,35,,4975.95,percent of total billed charges,Implant Device,4975.95,35,,4975.95,percent of total billed charges,Implant Device,4975.95,35,,4975.95,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,4833.78,34,"If Charge > 2,000, then 34 percent",4833.78,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,10520.62,
GORE PLL161407 EXCLUDER ENDOPROS 14.5X7,C1874,HCPCS,,79009216,CDM,278,RC,,,both,,,10005,7403.73,,,7403.73,Other,150% of Medicare + 9.63% HCRA Surcharge,4502.25,45,,4502.25,percent of total billed charges,Critical Access Hospital RCC factor,3401.7,34,,3401.7,percent of total billed charges,Implant Device,3401.7,34,,3401.7,percent of total billed charges,Implant Device,3401.7,34,,3401.7,percent of total billed charges,Implant Device,3401.7,34,,3401.7,percent of total billed charges,Implant Device,3401.7,34,,3401.7,percent of total billed charges,Implant Device,4952.48,,,4952.48,Other,110% of Medicare,3501.75,35,,3501.75,percent of total billed charges,Implant Device,3401.7,34,"Charges > $500, x 34%",3401.7,percent of total billed charges,Implant Device,3501.75,35,,3501.75,percent of total billed charges,Implant Device,3501.75,35,,3501.75,percent of total billed charges,Implant Device,3501.75,35,,3501.75,percent of total billed charges,Implant Device,3501.75,35,,3501.75,percent of total billed charges,Implant Device,3501.75,35,,3501.75,percent of total billed charges,Implant Device,4002,40,,4002,percent of total billed charges,Implant Device,3501.75,70,,3501.75,percent of total billed charges,All Other,3401.7,34,,3401.7,percent of total billed charges,Implant Device,3401.7,34,,3401.7,percent of total billed charges,Implant Device,3501.75,35,,3501.75,percent of total billed charges,Implant Device,3501.75,35,,3501.75,percent of total billed charges,Implant Device,3501.75,35,,3501.75,percent of total billed charges,Implant Device,3501.75,35,,3501.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3401.7,34,"If Charge > 2,000, then 34 percent",3401.7,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,7403.73,
GORE PLC141400 EXCLUDER ENDOPROS 14.5X10,C1874,HCPCS,,79009217,CDM,278,RC,,,both,,,14217,10520.62,,,10520.62,Other,150% of Medicare + 9.63% HCRA Surcharge,6397.65,45,,6397.65,percent of total billed charges,Critical Access Hospital RCC factor,4833.78,34,,4833.78,percent of total billed charges,Implant Device,4833.78,34,,4833.78,percent of total billed charges,Implant Device,4833.78,34,,4833.78,percent of total billed charges,Implant Device,4833.78,34,,4833.78,percent of total billed charges,Implant Device,4833.78,34,,4833.78,percent of total billed charges,Implant Device,7037.42,,,7037.42,Other,110% of Medicare,4975.95,35,,4975.95,percent of total billed charges,Implant Device,4833.78,34,"Charges > $500, x 34%",4833.78,percent of total billed charges,Implant Device,4975.95,35,,4975.95,percent of total billed charges,Implant Device,4975.95,35,,4975.95,percent of total billed charges,Implant Device,4975.95,35,,4975.95,percent of total billed charges,Implant Device,4975.95,35,,4975.95,percent of total billed charges,Implant Device,4975.95,35,,4975.95,percent of total billed charges,Implant Device,5686.8,40,,5686.8,percent of total billed charges,Implant Device,4975.95,70,,4975.95,percent of total billed charges,All Other,4833.78,34,,4833.78,percent of total billed charges,Implant Device,4833.78,34,,4833.78,percent of total billed charges,Implant Device,4975.95,35,,4975.95,percent of total billed charges,Implant Device,4975.95,35,,4975.95,percent of total billed charges,Implant Device,4975.95,35,,4975.95,percent of total billed charges,Implant Device,4975.95,35,,4975.95,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,4833.78,34,"If Charge > 2,000, then 34 percent",4833.78,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,10520.62,
DEPUY 456.309S 11.0M HELICAL BLADE 120MM,C1713,HCPCS,,79009218,CDM,278,RC,,,both,,,2502,1851.49,,,1851.49,Other,150% of Medicare + 9.63% HCRA Surcharge,1125.9,45,,1125.9,percent of total billed charges,Critical Access Hospital RCC factor,850.68,34,,850.68,percent of total billed charges,Implant Device,850.68,34,,850.68,percent of total billed charges,Implant Device,850.68,34,,850.68,percent of total billed charges,Implant Device,850.68,34,,850.68,percent of total billed charges,Implant Device,850.68,34,,850.68,percent of total billed charges,Implant Device,1238.49,,,1238.49,Other,110% of Medicare,875.7,35,,875.7,percent of total billed charges,Implant Device,850.68,34,"Charges > $500, x 34%",850.68,percent of total billed charges,Implant Device,875.7,35,,875.7,percent of total billed charges,Implant Device,875.7,35,,875.7,percent of total billed charges,Implant Device,875.7,35,,875.7,percent of total billed charges,Implant Device,875.7,35,,875.7,percent of total billed charges,Implant Device,875.7,35,,875.7,percent of total billed charges,Implant Device,1000.8,40,,1000.8,percent of total billed charges,Implant Device,875.7,70,,875.7,percent of total billed charges,All Other,850.68,34,,850.68,percent of total billed charges,Implant Device,850.68,34,,850.68,percent of total billed charges,Implant Device,875.7,35,,875.7,percent of total billed charges,Implant Device,875.7,35,,875.7,percent of total billed charges,Implant Device,875.7,35,,875.7,percent of total billed charges,Implant Device,875.7,35,,875.7,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,850.68,34,"If Charge > 2,000, then 34 percent",850.68,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1851.49,
ORTHOFIX M317 CORT SCREW 100/30 3/2.5MM,C1713,HCPCS,,79009220,CDM,278,RC,,,both,,,276,204.24,,,204.24,Other,150% of Medicare + 9.63% HCRA Surcharge,124.2,45,,124.2,percent of total billed charges,Critical Access Hospital RCC factor,93.84,34,,93.84,percent of total billed charges,Implant Device,93.84,34,,93.84,percent of total billed charges,Implant Device,93.84,34,,93.84,percent of total billed charges,Implant Device,93.84,34,,93.84,percent of total billed charges,Implant Device,93.84,34,,93.84,percent of total billed charges,Implant Device,136.62,,,136.62,Other,110% of Medicare,96.6,35,,96.6,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,96.6,35,,96.6,percent of total billed charges,Implant Device,96.6,35,,96.6,percent of total billed charges,Implant Device,96.6,35,,96.6,percent of total billed charges,Implant Device,96.6,35,,96.6,percent of total billed charges,Implant Device,96.6,35,,96.6,percent of total billed charges,Implant Device,110.4,40,,110.4,percent of total billed charges,Implant Device,96.6,70,,96.6,percent of total billed charges,All Other,93.84,34,,93.84,percent of total billed charges,Implant Device,93.84,34,,93.84,percent of total billed charges,Implant Device,96.6,35,,96.6,percent of total billed charges,Implant Device,96.6,35,,96.6,percent of total billed charges,Implant Device,96.6,35,,96.6,percent of total billed charges,Implant Device,96.6,35,,96.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,204.24,
GORE RLT281416 EXCLUDER ENDOPROSTHESIS,C1768,HCPCS,,79009222,CDM,278,RC,,,both,,,34671,25656.63,,,25656.63,Other,150% of Medicare + 9.63% HCRA Surcharge,15601.95,45,,15601.95,percent of total billed charges,Critical Access Hospital RCC factor,11788.14,34,,11788.14,percent of total billed charges,Implant Device,11788.14,34,,11788.14,percent of total billed charges,Implant Device,11788.14,34,,11788.14,percent of total billed charges,Implant Device,11788.14,34,,11788.14,percent of total billed charges,Implant Device,11788.14,34,,11788.14,percent of total billed charges,Implant Device,17162.15,,,17162.15,Other,110% of Medicare,12134.85,35,,12134.85,percent of total billed charges,Implant Device,11788.14,34,"Charges > $500, x 34%",11788.14,percent of total billed charges,Implant Device,12134.85,35,,12134.85,percent of total billed charges,Implant Device,12134.85,35,,12134.85,percent of total billed charges,Implant Device,12134.85,35,,12134.85,percent of total billed charges,Implant Device,12134.85,35,,12134.85,percent of total billed charges,Implant Device,12134.85,35,,12134.85,percent of total billed charges,Implant Device,13868.4,40,,13868.4,percent of total billed charges,Implant Device,12134.85,70,,12134.85,percent of total billed charges,All Other,11788.14,34,,11788.14,percent of total billed charges,Implant Device,11788.14,34,,11788.14,percent of total billed charges,Implant Device,12134.85,35,,12134.85,percent of total billed charges,Implant Device,12134.85,35,,12134.85,percent of total billed charges,Implant Device,12134.85,35,,12134.85,percent of total billed charges,Implant Device,12134.85,35,,12134.85,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,11788.14,34,"If Charge > 2,000, then 34 percent",11788.14,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,25656.63,
IN2BONES P60 ST011 PLANTAR PLATE 5 HOLE,C1713,HCPCS,,79009224,CDM,278,RC,,,both,,,5748,4253.53,,,4253.53,Other,150% of Medicare + 9.63% HCRA Surcharge,2586.6,45,,2586.6,percent of total billed charges,Critical Access Hospital RCC factor,1954.32,34,,1954.32,percent of total billed charges,Implant Device,1954.32,34,,1954.32,percent of total billed charges,Implant Device,1954.32,34,,1954.32,percent of total billed charges,Implant Device,1954.32,34,,1954.32,percent of total billed charges,Implant Device,1954.32,34,,1954.32,percent of total billed charges,Implant Device,2845.26,,,2845.26,Other,110% of Medicare,2011.8,35,,2011.8,percent of total billed charges,Implant Device,1954.32,34,"Charges > $500, x 34%",1954.32,percent of total billed charges,Implant Device,2011.8,35,,2011.8,percent of total billed charges,Implant Device,2011.8,35,,2011.8,percent of total billed charges,Implant Device,2011.8,35,,2011.8,percent of total billed charges,Implant Device,2011.8,35,,2011.8,percent of total billed charges,Implant Device,2011.8,35,,2011.8,percent of total billed charges,Implant Device,2299.2,40,,2299.2,percent of total billed charges,Implant Device,2011.8,70,,2011.8,percent of total billed charges,All Other,1954.32,34,,1954.32,percent of total billed charges,Implant Device,1954.32,34,,1954.32,percent of total billed charges,Implant Device,2011.8,35,,2011.8,percent of total billed charges,Implant Device,2011.8,35,,2011.8,percent of total billed charges,Implant Device,2011.8,35,,2011.8,percent of total billed charges,Implant Device,2011.8,35,,2011.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1954.32,34,"If Charge > 2,000, then 34 percent",1954.32,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4253.53,
IN2BONES P64 ST418 LOCK SCREW 2.4X18MM,C1713,HCPCS,,79009225,CDM,278,RC,,,both,,,804,594.96,,,594.96,Other,150% of Medicare + 9.63% HCRA Surcharge,361.8,45,,361.8,percent of total billed charges,Critical Access Hospital RCC factor,273.36,34,,273.36,percent of total billed charges,Implant Device,273.36,34,,273.36,percent of total billed charges,Implant Device,273.36,34,,273.36,percent of total billed charges,Implant Device,273.36,34,,273.36,percent of total billed charges,Implant Device,273.36,34,,273.36,percent of total billed charges,Implant Device,397.98,,,397.98,Other,110% of Medicare,281.4,35,,281.4,percent of total billed charges,Implant Device,273.36,34,"Charges > $500, x 34%",273.36,percent of total billed charges,Implant Device,281.4,35,,281.4,percent of total billed charges,Implant Device,281.4,35,,281.4,percent of total billed charges,Implant Device,281.4,35,,281.4,percent of total billed charges,Implant Device,281.4,35,,281.4,percent of total billed charges,Implant Device,281.4,35,,281.4,percent of total billed charges,Implant Device,321.6,40,,321.6,percent of total billed charges,Implant Device,281.4,70,,281.4,percent of total billed charges,All Other,273.36,34,,273.36,percent of total billed charges,Implant Device,273.36,34,,273.36,percent of total billed charges,Implant Device,281.4,35,,281.4,percent of total billed charges,Implant Device,281.4,35,,281.4,percent of total billed charges,Implant Device,281.4,35,,281.4,percent of total billed charges,Implant Device,281.4,35,,281.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,594.96,
IN2BONES P64 ST414 LOCK SCREW 2.4X14MM,C1713,HCPCS,,79009226,CDM,278,RC,,,both,,,870,643.8,,,643.8,Other,150% of Medicare + 9.63% HCRA Surcharge,391.5,45,,391.5,percent of total billed charges,Critical Access Hospital RCC factor,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,430.65,,,430.65,Other,110% of Medicare,304.5,35,,304.5,percent of total billed charges,Implant Device,295.8,34,"Charges > $500, x 34%",295.8,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,348,40,,348,percent of total billed charges,Implant Device,304.5,70,,304.5,percent of total billed charges,All Other,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,643.8,
IN2BONES P64 ST710 LOCK SCREW 2.7X10MM,C1713,HCPCS,,79009227,CDM,278,RC,,,both,,,804,594.96,,,594.96,Other,150% of Medicare + 9.63% HCRA Surcharge,361.8,45,,361.8,percent of total billed charges,Critical Access Hospital RCC factor,273.36,34,,273.36,percent of total billed charges,Implant Device,273.36,34,,273.36,percent of total billed charges,Implant Device,273.36,34,,273.36,percent of total billed charges,Implant Device,273.36,34,,273.36,percent of total billed charges,Implant Device,273.36,34,,273.36,percent of total billed charges,Implant Device,397.98,,,397.98,Other,110% of Medicare,281.4,35,,281.4,percent of total billed charges,Implant Device,273.36,34,"Charges > $500, x 34%",273.36,percent of total billed charges,Implant Device,281.4,35,,281.4,percent of total billed charges,Implant Device,281.4,35,,281.4,percent of total billed charges,Implant Device,281.4,35,,281.4,percent of total billed charges,Implant Device,281.4,35,,281.4,percent of total billed charges,Implant Device,281.4,35,,281.4,percent of total billed charges,Implant Device,321.6,40,,321.6,percent of total billed charges,Implant Device,281.4,70,,281.4,percent of total billed charges,All Other,273.36,34,,273.36,percent of total billed charges,Implant Device,273.36,34,,273.36,percent of total billed charges,Implant Device,281.4,35,,281.4,percent of total billed charges,Implant Device,281.4,35,,281.4,percent of total billed charges,Implant Device,281.4,35,,281.4,percent of total billed charges,Implant Device,281.4,35,,281.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,594.96,
IN2BONES P62 ST711 NON LOCK SCREW 2.7X11,C1713,HCPCS,,79009228,CDM,278,RC,,,both,,,612,452.88,,,452.88,Other,150% of Medicare + 9.63% HCRA Surcharge,275.4,45,,275.4,percent of total billed charges,Critical Access Hospital RCC factor,208.08,34,,208.08,percent of total billed charges,Implant Device,208.08,34,,208.08,percent of total billed charges,Implant Device,208.08,34,,208.08,percent of total billed charges,Implant Device,208.08,34,,208.08,percent of total billed charges,Implant Device,208.08,34,,208.08,percent of total billed charges,Implant Device,302.94,,,302.94,Other,110% of Medicare,214.2,35,,214.2,percent of total billed charges,Implant Device,208.08,34,"Charges > $500, x 34%",208.08,percent of total billed charges,Implant Device,214.2,35,,214.2,percent of total billed charges,Implant Device,214.2,35,,214.2,percent of total billed charges,Implant Device,214.2,35,,214.2,percent of total billed charges,Implant Device,214.2,35,,214.2,percent of total billed charges,Implant Device,214.2,35,,214.2,percent of total billed charges,Implant Device,244.8,40,,244.8,percent of total billed charges,Implant Device,214.2,70,,214.2,percent of total billed charges,All Other,208.08,34,,208.08,percent of total billed charges,Implant Device,208.08,34,,208.08,percent of total billed charges,Implant Device,214.2,35,,214.2,percent of total billed charges,Implant Device,214.2,35,,214.2,percent of total billed charges,Implant Device,214.2,35,,214.2,percent of total billed charges,Implant Device,214.2,35,,214.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,452.88,
IN2BONES P62 ST714 NON LOCK SCREW 2.7X14,C1713,HCPCS,,79009229,CDM,278,RC,,,both,,,612,452.88,,,452.88,Other,150% of Medicare + 9.63% HCRA Surcharge,275.4,45,,275.4,percent of total billed charges,Critical Access Hospital RCC factor,208.08,34,,208.08,percent of total billed charges,Implant Device,208.08,34,,208.08,percent of total billed charges,Implant Device,208.08,34,,208.08,percent of total billed charges,Implant Device,208.08,34,,208.08,percent of total billed charges,Implant Device,208.08,34,,208.08,percent of total billed charges,Implant Device,302.94,,,302.94,Other,110% of Medicare,214.2,35,,214.2,percent of total billed charges,Implant Device,208.08,34,"Charges > $500, x 34%",208.08,percent of total billed charges,Implant Device,214.2,35,,214.2,percent of total billed charges,Implant Device,214.2,35,,214.2,percent of total billed charges,Implant Device,214.2,35,,214.2,percent of total billed charges,Implant Device,214.2,35,,214.2,percent of total billed charges,Implant Device,214.2,35,,214.2,percent of total billed charges,Implant Device,244.8,40,,244.8,percent of total billed charges,Implant Device,214.2,70,,214.2,percent of total billed charges,All Other,208.08,34,,208.08,percent of total billed charges,Implant Device,208.08,34,,208.08,percent of total billed charges,Implant Device,214.2,35,,214.2,percent of total billed charges,Implant Device,214.2,35,,214.2,percent of total billed charges,Implant Device,214.2,35,,214.2,percent of total billed charges,Implant Device,214.2,35,,214.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,452.88,
DEPUY 02.118.548 SELF TAP SCREW 2.7X48MM,C1713,HCPCS,,79009231,CDM,278,RC,,,both,,,178,131.72,,,131.72,Other,150% of Medicare + 9.63% HCRA Surcharge,80.1,45,,80.1,percent of total billed charges,Critical Access Hospital RCC factor,60.52,34,,60.52,percent of total billed charges,Implant Device,60.52,34,,60.52,percent of total billed charges,Implant Device,60.52,34,,60.52,percent of total billed charges,Implant Device,60.52,34,,60.52,percent of total billed charges,Implant Device,60.52,34,,60.52,percent of total billed charges,Implant Device,88.11,,,88.11,Other,110% of Medicare,62.3,35,,62.3,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,62.3,35,,62.3,percent of total billed charges,Implant Device,62.3,35,,62.3,percent of total billed charges,Implant Device,62.3,35,,62.3,percent of total billed charges,Implant Device,62.3,35,,62.3,percent of total billed charges,Implant Device,62.3,35,,62.3,percent of total billed charges,Implant Device,71.2,40,,71.2,percent of total billed charges,Implant Device,62.3,70,,62.3,percent of total billed charges,All Other,60.52,34,,60.52,percent of total billed charges,Implant Device,60.52,34,,60.52,percent of total billed charges,Implant Device,62.3,35,,62.3,percent of total billed charges,Implant Device,62.3,35,,62.3,percent of total billed charges,Implant Device,62.3,35,,62.3,percent of total billed charges,Implant Device,62.3,35,,62.3,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,131.72,
DEPUY 02.211.060 LOCKING SCREW 2.7X60MM,C1713,HCPCS,,79009232,CDM,278,RC,,,both,,,343,253.82,,,253.82,Other,150% of Medicare + 9.63% HCRA Surcharge,154.35,45,,154.35,percent of total billed charges,Critical Access Hospital RCC factor,116.62,34,,116.62,percent of total billed charges,Implant Device,116.62,34,,116.62,percent of total billed charges,Implant Device,116.62,34,,116.62,percent of total billed charges,Implant Device,116.62,34,,116.62,percent of total billed charges,Implant Device,116.62,34,,116.62,percent of total billed charges,Implant Device,169.79,,,169.79,Other,110% of Medicare,120.05,35,,120.05,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,120.05,35,,120.05,percent of total billed charges,Implant Device,120.05,35,,120.05,percent of total billed charges,Implant Device,120.05,35,,120.05,percent of total billed charges,Implant Device,120.05,35,,120.05,percent of total billed charges,Implant Device,120.05,35,,120.05,percent of total billed charges,Implant Device,137.2,40,,137.2,percent of total billed charges,Implant Device,120.05,70,,120.05,percent of total billed charges,All Other,116.62,34,,116.62,percent of total billed charges,Implant Device,116.62,34,,116.62,percent of total billed charges,Implant Device,120.05,35,,120.05,percent of total billed charges,Implant Device,120.05,35,,120.05,percent of total billed charges,Implant Device,120.05,35,,120.05,percent of total billed charges,Implant Device,120.05,35,,120.05,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,253.82,
DEPUY 02.117.501 DIS HUM PLATE 2.7X3.5MM,C1713,HCPCS,,79009233,CDM,278,RC,,,both,,,4419,3270.07,,,3270.07,Other,150% of Medicare + 9.63% HCRA Surcharge,1988.55,45,,1988.55,percent of total billed charges,Critical Access Hospital RCC factor,1502.46,34,,1502.46,percent of total billed charges,Implant Device,1502.46,34,,1502.46,percent of total billed charges,Implant Device,1502.46,34,,1502.46,percent of total billed charges,Implant Device,1502.46,34,,1502.46,percent of total billed charges,Implant Device,1502.46,34,,1502.46,percent of total billed charges,Implant Device,2187.41,,,2187.41,Other,110% of Medicare,1546.65,35,,1546.65,percent of total billed charges,Implant Device,1502.46,34,"Charges > $500, x 34%",1502.46,percent of total billed charges,Implant Device,1546.65,35,,1546.65,percent of total billed charges,Implant Device,1546.65,35,,1546.65,percent of total billed charges,Implant Device,1546.65,35,,1546.65,percent of total billed charges,Implant Device,1546.65,35,,1546.65,percent of total billed charges,Implant Device,1546.65,35,,1546.65,percent of total billed charges,Implant Device,1767.6,40,,1767.6,percent of total billed charges,Implant Device,1546.65,70,,1546.65,percent of total billed charges,All Other,1502.46,34,,1502.46,percent of total billed charges,Implant Device,1502.46,34,,1502.46,percent of total billed charges,Implant Device,1546.65,35,,1546.65,percent of total billed charges,Implant Device,1546.65,35,,1546.65,percent of total billed charges,Implant Device,1546.65,35,,1546.65,percent of total billed charges,Implant Device,1546.65,35,,1546.65,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1502.46,34,"If Charge > 2,000, then 34 percent",1502.46,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3270.07,
DEPUY 02.118.520 SELF TAP SCREW 2.7X20MM,C1713,HCPCS,,79009234,CDM,278,RC,,,both,,,178,131.72,,,131.72,Other,150% of Medicare + 9.63% HCRA Surcharge,80.1,45,,80.1,percent of total billed charges,Critical Access Hospital RCC factor,60.52,34,,60.52,percent of total billed charges,Implant Device,60.52,34,,60.52,percent of total billed charges,Implant Device,60.52,34,,60.52,percent of total billed charges,Implant Device,60.52,34,,60.52,percent of total billed charges,Implant Device,60.52,34,,60.52,percent of total billed charges,Implant Device,88.11,,,88.11,Other,110% of Medicare,62.3,35,,62.3,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,62.3,35,,62.3,percent of total billed charges,Implant Device,62.3,35,,62.3,percent of total billed charges,Implant Device,62.3,35,,62.3,percent of total billed charges,Implant Device,62.3,35,,62.3,percent of total billed charges,Implant Device,62.3,35,,62.3,percent of total billed charges,Implant Device,71.2,40,,71.2,percent of total billed charges,Implant Device,62.3,70,,62.3,percent of total billed charges,All Other,60.52,34,,60.52,percent of total billed charges,Implant Device,60.52,34,,60.52,percent of total billed charges,Implant Device,62.3,35,,62.3,percent of total billed charges,Implant Device,62.3,35,,62.3,percent of total billed charges,Implant Device,62.3,35,,62.3,percent of total billed charges,Implant Device,62.3,35,,62.3,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,131.72,
DEPUY 241.263 DIS HUM PLATE 3.5MM 3 HOLE,C1713,HCPCS,,79009235,CDM,278,RC,,,both,,,3579,2648.47,,,2648.47,Other,150% of Medicare + 9.63% HCRA Surcharge,1610.55,45,,1610.55,percent of total billed charges,Critical Access Hospital RCC factor,1216.86,34,,1216.86,percent of total billed charges,Implant Device,1216.86,34,,1216.86,percent of total billed charges,Implant Device,1216.86,34,,1216.86,percent of total billed charges,Implant Device,1216.86,34,,1216.86,percent of total billed charges,Implant Device,1216.86,34,,1216.86,percent of total billed charges,Implant Device,1771.61,,,1771.61,Other,110% of Medicare,1252.65,35,,1252.65,percent of total billed charges,Implant Device,1216.86,34,"Charges > $500, x 34%",1216.86,percent of total billed charges,Implant Device,1252.65,35,,1252.65,percent of total billed charges,Implant Device,1252.65,35,,1252.65,percent of total billed charges,Implant Device,1252.65,35,,1252.65,percent of total billed charges,Implant Device,1252.65,35,,1252.65,percent of total billed charges,Implant Device,1252.65,35,,1252.65,percent of total billed charges,Implant Device,1431.6,40,,1431.6,percent of total billed charges,Implant Device,1252.65,70,,1252.65,percent of total billed charges,All Other,1216.86,34,,1216.86,percent of total billed charges,Implant Device,1216.86,34,,1216.86,percent of total billed charges,Implant Device,1252.65,35,,1252.65,percent of total billed charges,Implant Device,1252.65,35,,1252.65,percent of total billed charges,Implant Device,1252.65,35,,1252.65,percent of total billed charges,Implant Device,1252.65,35,,1252.65,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1216.86,34,"If Charge > 2,000, then 34 percent",1216.86,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2648.47,
DEPUY 02.118.522 SELF TAP SCREW 2.7X22MM,C1713,HCPCS,,79009236,CDM,278,RC,,,both,,,178,131.72,,,131.72,Other,150% of Medicare + 9.63% HCRA Surcharge,80.1,45,,80.1,percent of total billed charges,Critical Access Hospital RCC factor,60.52,34,,60.52,percent of total billed charges,Implant Device,60.52,34,,60.52,percent of total billed charges,Implant Device,60.52,34,,60.52,percent of total billed charges,Implant Device,60.52,34,,60.52,percent of total billed charges,Implant Device,60.52,34,,60.52,percent of total billed charges,Implant Device,88.11,,,88.11,Other,110% of Medicare,62.3,35,,62.3,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,62.3,35,,62.3,percent of total billed charges,Implant Device,62.3,35,,62.3,percent of total billed charges,Implant Device,62.3,35,,62.3,percent of total billed charges,Implant Device,62.3,35,,62.3,percent of total billed charges,Implant Device,62.3,35,,62.3,percent of total billed charges,Implant Device,71.2,40,,71.2,percent of total billed charges,Implant Device,62.3,70,,62.3,percent of total billed charges,All Other,60.52,34,,60.52,percent of total billed charges,Implant Device,60.52,34,,60.52,percent of total billed charges,Implant Device,62.3,35,,62.3,percent of total billed charges,Implant Device,62.3,35,,62.3,percent of total billed charges,Implant Device,62.3,35,,62.3,percent of total billed charges,Implant Device,62.3,35,,62.3,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,131.72,
DEPUY 02.118.524 SELF TAP SCREW 2.7X24MM,C1713,HCPCS,,79009237,CDM,278,RC,,,both,,,130,96.2,,,96.2,Other,150% of Medicare + 9.63% HCRA Surcharge,58.5,45,,58.5,percent of total billed charges,Critical Access Hospital RCC factor,44.2,34,,44.2,percent of total billed charges,Implant Device,44.2,34,,44.2,percent of total billed charges,Implant Device,44.2,34,,44.2,percent of total billed charges,Implant Device,44.2,34,,44.2,percent of total billed charges,Implant Device,44.2,34,,44.2,percent of total billed charges,Implant Device,64.35,,,64.35,Other,110% of Medicare,45.5,35,,45.5,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,45.5,35,,45.5,percent of total billed charges,Implant Device,45.5,35,,45.5,percent of total billed charges,Implant Device,45.5,35,,45.5,percent of total billed charges,Implant Device,45.5,35,,45.5,percent of total billed charges,Implant Device,45.5,35,,45.5,percent of total billed charges,Implant Device,52,40,,52,percent of total billed charges,Implant Device,45.5,70,,45.5,percent of total billed charges,All Other,44.2,34,,44.2,percent of total billed charges,Implant Device,44.2,34,,44.2,percent of total billed charges,Implant Device,45.5,35,,45.5,percent of total billed charges,Implant Device,45.5,35,,45.5,percent of total billed charges,Implant Device,45.5,35,,45.5,percent of total billed charges,Implant Device,45.5,35,,45.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,96.2,
DEPUY 02.211.046 LOCKING SCREW 2.7X46MM,C1713,HCPCS,,79009238,CDM,278,RC,,,both,,,343,253.82,,,253.82,Other,150% of Medicare + 9.63% HCRA Surcharge,154.35,45,,154.35,percent of total billed charges,Critical Access Hospital RCC factor,116.62,34,,116.62,percent of total billed charges,Implant Device,116.62,34,,116.62,percent of total billed charges,Implant Device,116.62,34,,116.62,percent of total billed charges,Implant Device,116.62,34,,116.62,percent of total billed charges,Implant Device,116.62,34,,116.62,percent of total billed charges,Implant Device,169.79,,,169.79,Other,110% of Medicare,120.05,35,,120.05,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,120.05,35,,120.05,percent of total billed charges,Implant Device,120.05,35,,120.05,percent of total billed charges,Implant Device,120.05,35,,120.05,percent of total billed charges,Implant Device,120.05,35,,120.05,percent of total billed charges,Implant Device,120.05,35,,120.05,percent of total billed charges,Implant Device,137.2,40,,137.2,percent of total billed charges,Implant Device,120.05,70,,120.05,percent of total billed charges,All Other,116.62,34,,116.62,percent of total billed charges,Implant Device,116.62,34,,116.62,percent of total billed charges,Implant Device,120.05,35,,120.05,percent of total billed charges,Implant Device,120.05,35,,120.05,percent of total billed charges,Implant Device,120.05,35,,120.05,percent of total billed charges,Implant Device,120.05,35,,120.05,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,253.82,
DEPUY 02.211.032 LOCKING SCREW 2.7X32MM,C1713,HCPCS,,79009239,CDM,278,RC,,,both,,,343,253.82,,,253.82,Other,150% of Medicare + 9.63% HCRA Surcharge,154.35,45,,154.35,percent of total billed charges,Critical Access Hospital RCC factor,116.62,34,,116.62,percent of total billed charges,Implant Device,116.62,34,,116.62,percent of total billed charges,Implant Device,116.62,34,,116.62,percent of total billed charges,Implant Device,116.62,34,,116.62,percent of total billed charges,Implant Device,116.62,34,,116.62,percent of total billed charges,Implant Device,169.79,,,169.79,Other,110% of Medicare,120.05,35,,120.05,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,120.05,35,,120.05,percent of total billed charges,Implant Device,120.05,35,,120.05,percent of total billed charges,Implant Device,120.05,35,,120.05,percent of total billed charges,Implant Device,120.05,35,,120.05,percent of total billed charges,Implant Device,120.05,35,,120.05,percent of total billed charges,Implant Device,137.2,40,,137.2,percent of total billed charges,Implant Device,120.05,70,,120.05,percent of total billed charges,All Other,116.62,34,,116.62,percent of total billed charges,Implant Device,116.62,34,,116.62,percent of total billed charges,Implant Device,120.05,35,,120.05,percent of total billed charges,Implant Device,120.05,35,,120.05,percent of total billed charges,Implant Device,120.05,35,,120.05,percent of total billed charges,Implant Device,120.05,35,,120.05,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,253.82,
DEPUY 02.211.034 LOCKING SCREW 2.7X34MM,C1713,HCPCS,,79009240,CDM,278,RC,,,both,,,343,253.82,,,253.82,Other,150% of Medicare + 9.63% HCRA Surcharge,154.35,45,,154.35,percent of total billed charges,Critical Access Hospital RCC factor,116.62,34,,116.62,percent of total billed charges,Implant Device,116.62,34,,116.62,percent of total billed charges,Implant Device,116.62,34,,116.62,percent of total billed charges,Implant Device,116.62,34,,116.62,percent of total billed charges,Implant Device,116.62,34,,116.62,percent of total billed charges,Implant Device,169.79,,,169.79,Other,110% of Medicare,120.05,35,,120.05,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,120.05,35,,120.05,percent of total billed charges,Implant Device,120.05,35,,120.05,percent of total billed charges,Implant Device,120.05,35,,120.05,percent of total billed charges,Implant Device,120.05,35,,120.05,percent of total billed charges,Implant Device,120.05,35,,120.05,percent of total billed charges,Implant Device,137.2,40,,137.2,percent of total billed charges,Implant Device,120.05,70,,120.05,percent of total billed charges,All Other,116.62,34,,116.62,percent of total billed charges,Implant Device,116.62,34,,116.62,percent of total billed charges,Implant Device,120.05,35,,120.05,percent of total billed charges,Implant Device,120.05,35,,120.05,percent of total billed charges,Implant Device,120.05,35,,120.05,percent of total billed charges,Implant Device,120.05,35,,120.05,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,253.82,
DEPUY 02.107.102 OLEC PLATE 2.7X3.5MM 2H,C1713,HCPCS,,79009241,CDM,278,RC,,,both,,,2513,1859.63,,,1859.63,Other,150% of Medicare + 9.63% HCRA Surcharge,1130.85,45,,1130.85,percent of total billed charges,Critical Access Hospital RCC factor,854.42,34,,854.42,percent of total billed charges,Implant Device,854.42,34,,854.42,percent of total billed charges,Implant Device,854.42,34,,854.42,percent of total billed charges,Implant Device,854.42,34,,854.42,percent of total billed charges,Implant Device,854.42,34,,854.42,percent of total billed charges,Implant Device,1243.94,,,1243.94,Other,110% of Medicare,879.55,35,,879.55,percent of total billed charges,Implant Device,854.42,34,"Charges > $500, x 34%",854.42,percent of total billed charges,Implant Device,879.55,35,,879.55,percent of total billed charges,Implant Device,879.55,35,,879.55,percent of total billed charges,Implant Device,879.55,35,,879.55,percent of total billed charges,Implant Device,879.55,35,,879.55,percent of total billed charges,Implant Device,879.55,35,,879.55,percent of total billed charges,Implant Device,1005.2,40,,1005.2,percent of total billed charges,Implant Device,879.55,70,,879.55,percent of total billed charges,All Other,854.42,34,,854.42,percent of total billed charges,Implant Device,854.42,34,,854.42,percent of total billed charges,Implant Device,879.55,35,,879.55,percent of total billed charges,Implant Device,879.55,35,,879.55,percent of total billed charges,Implant Device,879.55,35,,879.55,percent of total billed charges,Implant Device,879.55,35,,879.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,854.42,34,"If Charge > 2,000, then 34 percent",854.42,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1859.63,
DEPUY 204.016 CORTEX SCREW 3.5X16MM,C1713,HCPCS,,79009242,CDM,278,RC,,,both,,,59,43.66,,,43.66,Other,150% of Medicare + 9.63% HCRA Surcharge,26.55,45,,26.55,percent of total billed charges,Critical Access Hospital RCC factor,20.06,34,,20.06,percent of total billed charges,Implant Device,20.06,34,,20.06,percent of total billed charges,Implant Device,20.06,34,,20.06,percent of total billed charges,Implant Device,20.06,34,,20.06,percent of total billed charges,Implant Device,20.06,34,,20.06,percent of total billed charges,Implant Device,29.21,,,29.21,Other,110% of Medicare,20.65,35,,20.65,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,20.65,35,,20.65,percent of total billed charges,Implant Device,20.65,35,,20.65,percent of total billed charges,Implant Device,20.65,35,,20.65,percent of total billed charges,Implant Device,20.65,35,,20.65,percent of total billed charges,Implant Device,20.65,35,,20.65,percent of total billed charges,Implant Device,23.6,40,,23.6,percent of total billed charges,Implant Device,20.65,70,,20.65,percent of total billed charges,All Other,20.06,34,,20.06,percent of total billed charges,Implant Device,20.06,34,,20.06,percent of total billed charges,Implant Device,20.65,35,,20.65,percent of total billed charges,Implant Device,20.65,35,,20.65,percent of total billed charges,Implant Device,20.65,35,,20.65,percent of total billed charges,Implant Device,20.65,35,,20.65,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,43.66,
DEPUY 456.302S 11X85MM TI HELICAL BLADE,C1713,HCPCS,,79009243,CDM,278,RC,,,both,,,2687,1988.39,,,1988.39,Other,150% of Medicare + 9.63% HCRA Surcharge,1209.15,45,,1209.15,percent of total billed charges,Critical Access Hospital RCC factor,913.58,34,,913.58,percent of total billed charges,Implant Device,913.58,34,,913.58,percent of total billed charges,Implant Device,913.58,34,,913.58,percent of total billed charges,Implant Device,913.58,34,,913.58,percent of total billed charges,Implant Device,913.58,34,,913.58,percent of total billed charges,Implant Device,1330.07,,,1330.07,Other,110% of Medicare,940.45,35,,940.45,percent of total billed charges,Implant Device,913.58,34,"Charges > $500, x 34%",913.58,percent of total billed charges,Implant Device,940.45,35,,940.45,percent of total billed charges,Implant Device,940.45,35,,940.45,percent of total billed charges,Implant Device,940.45,35,,940.45,percent of total billed charges,Implant Device,940.45,35,,940.45,percent of total billed charges,Implant Device,940.45,35,,940.45,percent of total billed charges,Implant Device,1074.8,40,,1074.8,percent of total billed charges,Implant Device,940.45,70,,940.45,percent of total billed charges,All Other,913.58,34,,913.58,percent of total billed charges,Implant Device,913.58,34,,913.58,percent of total billed charges,Implant Device,940.45,35,,940.45,percent of total billed charges,Implant Device,940.45,35,,940.45,percent of total billed charges,Implant Device,940.45,35,,940.45,percent of total billed charges,Implant Device,940.45,35,,940.45,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,913.58,34,"If Charge > 2,000, then 34 percent",913.58,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1988.39,
MENTOR 350-4001BC BREAST IMPLANT 400CC,C1789,HCPCS,,79009251,CDM,278,RC,,,both,,,2865,2120.11,,,2120.11,Other,150% of Medicare + 9.63% HCRA Surcharge,1289.25,45,,1289.25,percent of total billed charges,Critical Access Hospital RCC factor,974.1,34,,974.1,percent of total billed charges,Implant Device,974.1,34,,974.1,percent of total billed charges,Implant Device,974.1,34,,974.1,percent of total billed charges,Implant Device,974.1,34,,974.1,percent of total billed charges,Implant Device,974.1,34,,974.1,percent of total billed charges,Implant Device,1418.18,,,1418.18,Other,110% of Medicare,1002.75,35,,1002.75,percent of total billed charges,Implant Device,974.1,34,"Charges > $500, x 34%",974.1,percent of total billed charges,Implant Device,1002.75,35,,1002.75,percent of total billed charges,Implant Device,1002.75,35,,1002.75,percent of total billed charges,Implant Device,1002.75,35,,1002.75,percent of total billed charges,Implant Device,1002.75,35,,1002.75,percent of total billed charges,Implant Device,1002.75,35,,1002.75,percent of total billed charges,Implant Device,1146,40,,1146,percent of total billed charges,Implant Device,1002.75,70,,1002.75,percent of total billed charges,All Other,974.1,34,,974.1,percent of total billed charges,Implant Device,974.1,34,,974.1,percent of total billed charges,Implant Device,1002.75,35,,1002.75,percent of total billed charges,Implant Device,1002.75,35,,1002.75,percent of total billed charges,Implant Device,1002.75,35,,1002.75,percent of total billed charges,Implant Device,1002.75,35,,1002.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,974.1,34,"If Charge > 2,000, then 34 percent",974.1,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2120.11,
MENTOR 350-4501BC BREAST IMPLANT 450CC,C1789,HCPCS,,79009252,CDM,278,RC,,,both,,,2865,2120.11,,,2120.11,Other,150% of Medicare + 9.63% HCRA Surcharge,1289.25,45,,1289.25,percent of total billed charges,Critical Access Hospital RCC factor,974.1,34,,974.1,percent of total billed charges,Implant Device,974.1,34,,974.1,percent of total billed charges,Implant Device,974.1,34,,974.1,percent of total billed charges,Implant Device,974.1,34,,974.1,percent of total billed charges,Implant Device,974.1,34,,974.1,percent of total billed charges,Implant Device,1418.18,,,1418.18,Other,110% of Medicare,1002.75,35,,1002.75,percent of total billed charges,Implant Device,974.1,34,"Charges > $500, x 34%",974.1,percent of total billed charges,Implant Device,1002.75,35,,1002.75,percent of total billed charges,Implant Device,1002.75,35,,1002.75,percent of total billed charges,Implant Device,1002.75,35,,1002.75,percent of total billed charges,Implant Device,1002.75,35,,1002.75,percent of total billed charges,Implant Device,1002.75,35,,1002.75,percent of total billed charges,Implant Device,1146,40,,1146,percent of total billed charges,Implant Device,1002.75,70,,1002.75,percent of total billed charges,All Other,974.1,34,,974.1,percent of total billed charges,Implant Device,974.1,34,,974.1,percent of total billed charges,Implant Device,1002.75,35,,1002.75,percent of total billed charges,Implant Device,1002.75,35,,1002.75,percent of total billed charges,Implant Device,1002.75,35,,1002.75,percent of total billed charges,Implant Device,1002.75,35,,1002.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,974.1,34,"If Charge > 2,000, then 34 percent",974.1,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2120.11,
MENTOR 350-6004BC BREAST IMPLANT 600CC,C1789,HCPCS,,79009253,CDM,278,RC,,,both,,,2940,2175.61,,,2175.61,Other,150% of Medicare + 9.63% HCRA Surcharge,1323,45,,1323,percent of total billed charges,Critical Access Hospital RCC factor,999.6,34,,999.6,percent of total billed charges,Implant Device,999.6,34,,999.6,percent of total billed charges,Implant Device,999.6,34,,999.6,percent of total billed charges,Implant Device,999.6,34,,999.6,percent of total billed charges,Implant Device,999.6,34,,999.6,percent of total billed charges,Implant Device,1455.3,,,1455.3,Other,110% of Medicare,1029,35,,1029,percent of total billed charges,Implant Device,999.6,34,"Charges > $500, x 34%",999.6,percent of total billed charges,Implant Device,1029,35,,1029,percent of total billed charges,Implant Device,1029,35,,1029,percent of total billed charges,Implant Device,1029,35,,1029,percent of total billed charges,Implant Device,1029,35,,1029,percent of total billed charges,Implant Device,1029,35,,1029,percent of total billed charges,Implant Device,1176,40,,1176,percent of total billed charges,Implant Device,1029,70,,1029,percent of total billed charges,All Other,999.6,34,,999.6,percent of total billed charges,Implant Device,999.6,34,,999.6,percent of total billed charges,Implant Device,1029,35,,1029,percent of total billed charges,Implant Device,1029,35,,1029,percent of total billed charges,Implant Device,1029,35,,1029,percent of total billed charges,Implant Device,1029,35,,1029,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,999.6,34,"If Charge > 2,000, then 34 percent",999.6,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2175.61,
MENTOR 350-6001BC BREAST IMPLANT 600CC,C1789,HCPCS,,79009254,CDM,278,RC,,,both,,,2865,2120.11,,,2120.11,Other,150% of Medicare + 9.63% HCRA Surcharge,1289.25,45,,1289.25,percent of total billed charges,Critical Access Hospital RCC factor,974.1,34,,974.1,percent of total billed charges,Implant Device,974.1,34,,974.1,percent of total billed charges,Implant Device,974.1,34,,974.1,percent of total billed charges,Implant Device,974.1,34,,974.1,percent of total billed charges,Implant Device,974.1,34,,974.1,percent of total billed charges,Implant Device,1418.18,,,1418.18,Other,110% of Medicare,1002.75,35,,1002.75,percent of total billed charges,Implant Device,974.1,34,"Charges > $500, x 34%",974.1,percent of total billed charges,Implant Device,1002.75,35,,1002.75,percent of total billed charges,Implant Device,1002.75,35,,1002.75,percent of total billed charges,Implant Device,1002.75,35,,1002.75,percent of total billed charges,Implant Device,1002.75,35,,1002.75,percent of total billed charges,Implant Device,1002.75,35,,1002.75,percent of total billed charges,Implant Device,1146,40,,1146,percent of total billed charges,Implant Device,1002.75,70,,1002.75,percent of total billed charges,All Other,974.1,34,,974.1,percent of total billed charges,Implant Device,974.1,34,,974.1,percent of total billed charges,Implant Device,1002.75,35,,1002.75,percent of total billed charges,Implant Device,1002.75,35,,1002.75,percent of total billed charges,Implant Device,1002.75,35,,1002.75,percent of total billed charges,Implant Device,1002.75,35,,1002.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,974.1,34,"If Charge > 2,000, then 34 percent",974.1,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2120.11,
MENTOR 350-5501BC BREAST IMPLANT 550CC,C1789,HCPCS,,79009255,CDM,278,RC,,,both,,,2865,2120.11,,,2120.11,Other,150% of Medicare + 9.63% HCRA Surcharge,1289.25,45,,1289.25,percent of total billed charges,Critical Access Hospital RCC factor,974.1,34,,974.1,percent of total billed charges,Implant Device,974.1,34,,974.1,percent of total billed charges,Implant Device,974.1,34,,974.1,percent of total billed charges,Implant Device,974.1,34,,974.1,percent of total billed charges,Implant Device,974.1,34,,974.1,percent of total billed charges,Implant Device,1418.18,,,1418.18,Other,110% of Medicare,1002.75,35,,1002.75,percent of total billed charges,Implant Device,974.1,34,"Charges > $500, x 34%",974.1,percent of total billed charges,Implant Device,1002.75,35,,1002.75,percent of total billed charges,Implant Device,1002.75,35,,1002.75,percent of total billed charges,Implant Device,1002.75,35,,1002.75,percent of total billed charges,Implant Device,1002.75,35,,1002.75,percent of total billed charges,Implant Device,1002.75,35,,1002.75,percent of total billed charges,Implant Device,1146,40,,1146,percent of total billed charges,Implant Device,1002.75,70,,1002.75,percent of total billed charges,All Other,974.1,34,,974.1,percent of total billed charges,Implant Device,974.1,34,,974.1,percent of total billed charges,Implant Device,1002.75,35,,1002.75,percent of total billed charges,Implant Device,1002.75,35,,1002.75,percent of total billed charges,Implant Device,1002.75,35,,1002.75,percent of total billed charges,Implant Device,1002.75,35,,1002.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,974.1,34,"If Charge > 2,000, then 34 percent",974.1,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2120.11,
MENTOR 350-5751BC BREAST IMPLANT 575CC,C1789,HCPCS,,79009256,CDM,278,RC,,,both,,,2865,2120.11,,,2120.11,Other,150% of Medicare + 9.63% HCRA Surcharge,1289.25,45,,1289.25,percent of total billed charges,Critical Access Hospital RCC factor,974.1,34,,974.1,percent of total billed charges,Implant Device,974.1,34,,974.1,percent of total billed charges,Implant Device,974.1,34,,974.1,percent of total billed charges,Implant Device,974.1,34,,974.1,percent of total billed charges,Implant Device,974.1,34,,974.1,percent of total billed charges,Implant Device,1418.18,,,1418.18,Other,110% of Medicare,1002.75,35,,1002.75,percent of total billed charges,Implant Device,974.1,34,"Charges > $500, x 34%",974.1,percent of total billed charges,Implant Device,1002.75,35,,1002.75,percent of total billed charges,Implant Device,1002.75,35,,1002.75,percent of total billed charges,Implant Device,1002.75,35,,1002.75,percent of total billed charges,Implant Device,1002.75,35,,1002.75,percent of total billed charges,Implant Device,1002.75,35,,1002.75,percent of total billed charges,Implant Device,1146,40,,1146,percent of total billed charges,Implant Device,1002.75,70,,1002.75,percent of total billed charges,All Other,974.1,34,,974.1,percent of total billed charges,Implant Device,974.1,34,,974.1,percent of total billed charges,Implant Device,1002.75,35,,1002.75,percent of total billed charges,Implant Device,1002.75,35,,1002.75,percent of total billed charges,Implant Device,1002.75,35,,1002.75,percent of total billed charges,Implant Device,1002.75,35,,1002.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,974.1,34,"If Charge > 2,000, then 34 percent",974.1,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2120.11,
IN2BONES BGP001-05 BIO DBM PUTTY 5CC,C1713,HCPCS,,79009263,CDM,278,RC,,,both,,,5505,4073.71,,,4073.71,Other,150% of Medicare + 9.63% HCRA Surcharge,2477.25,45,,2477.25,percent of total billed charges,Critical Access Hospital RCC factor,1871.7,34,,1871.7,percent of total billed charges,Implant Device,1871.7,34,,1871.7,percent of total billed charges,Implant Device,1871.7,34,,1871.7,percent of total billed charges,Implant Device,1871.7,34,,1871.7,percent of total billed charges,Implant Device,1871.7,34,,1871.7,percent of total billed charges,Implant Device,2724.98,,,2724.98,Other,110% of Medicare,1926.75,35,,1926.75,percent of total billed charges,Implant Device,1871.7,34,"Charges > $500, x 34%",1871.7,percent of total billed charges,Implant Device,1926.75,35,,1926.75,percent of total billed charges,Implant Device,1926.75,35,,1926.75,percent of total billed charges,Implant Device,1926.75,35,,1926.75,percent of total billed charges,Implant Device,1926.75,35,,1926.75,percent of total billed charges,Implant Device,1926.75,35,,1926.75,percent of total billed charges,Implant Device,2202,40,,2202,percent of total billed charges,Implant Device,1926.75,70,,1926.75,percent of total billed charges,All Other,1871.7,34,,1871.7,percent of total billed charges,Implant Device,1871.7,34,,1871.7,percent of total billed charges,Implant Device,1926.75,35,,1926.75,percent of total billed charges,Implant Device,1926.75,35,,1926.75,percent of total billed charges,Implant Device,1926.75,35,,1926.75,percent of total billed charges,Implant Device,1926.75,35,,1926.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1871.7,34,"If Charge > 2,000, then 34 percent",1871.7,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4073.71,
ZIMMER 00-7711-006-00 M/L TAPER 6 STD,C1776,HCPCS,,79009265,CDM,278,RC,,,both,,,8910,6593.42,,,6593.42,Other,150% of Medicare + 9.63% HCRA Surcharge,4009.5,45,,4009.5,percent of total billed charges,Critical Access Hospital RCC factor,3029.4,34,,3029.4,percent of total billed charges,Implant Device,3029.4,34,,3029.4,percent of total billed charges,Implant Device,3029.4,34,,3029.4,percent of total billed charges,Implant Device,3029.4,34,,3029.4,percent of total billed charges,Implant Device,3029.4,34,,3029.4,percent of total billed charges,Implant Device,4410.45,,,4410.45,Other,110% of Medicare,3118.5,35,,3118.5,percent of total billed charges,Implant Device,3029.4,34,"Charges > $500, x 34%",3029.4,percent of total billed charges,Implant Device,3118.5,35,,3118.5,percent of total billed charges,Implant Device,3118.5,35,,3118.5,percent of total billed charges,Implant Device,3118.5,35,,3118.5,percent of total billed charges,Implant Device,3118.5,35,,3118.5,percent of total billed charges,Implant Device,3118.5,35,,3118.5,percent of total billed charges,Implant Device,3564,40,,3564,percent of total billed charges,Implant Device,3118.5,70,,3118.5,percent of total billed charges,All Other,3029.4,34,,3029.4,percent of total billed charges,Implant Device,3029.4,34,,3029.4,percent of total billed charges,Implant Device,3118.5,35,,3118.5,percent of total billed charges,Implant Device,3118.5,35,,3118.5,percent of total billed charges,Implant Device,3118.5,35,,3118.5,percent of total billed charges,Implant Device,3118.5,35,,3118.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3029.4,34,"If Charge > 2,000, then 34 percent",3029.4,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,6593.42,
ARTHREX AR-89443T-06 PLATE 1/3 6 HOLE,C1713,HCPCS,,79009266,CDM,278,RC,,,both,,,720,532.8,,,532.8,Other,150% of Medicare + 9.63% HCRA Surcharge,324,45,,324,percent of total billed charges,Critical Access Hospital RCC factor,244.8,34,,244.8,percent of total billed charges,Implant Device,244.8,34,,244.8,percent of total billed charges,Implant Device,244.8,34,,244.8,percent of total billed charges,Implant Device,244.8,34,,244.8,percent of total billed charges,Implant Device,244.8,34,,244.8,percent of total billed charges,Implant Device,356.4,,,356.4,Other,110% of Medicare,252,35,,252,percent of total billed charges,Implant Device,244.8,34,"Charges > $500, x 34%",244.8,percent of total billed charges,Implant Device,252,35,,252,percent of total billed charges,Implant Device,252,35,,252,percent of total billed charges,Implant Device,252,35,,252,percent of total billed charges,Implant Device,252,35,,252,percent of total billed charges,Implant Device,252,35,,252,percent of total billed charges,Implant Device,288,40,,288,percent of total billed charges,Implant Device,252,70,,252,percent of total billed charges,All Other,244.8,34,,244.8,percent of total billed charges,Implant Device,244.8,34,,244.8,percent of total billed charges,Implant Device,252,35,,252,percent of total billed charges,Implant Device,252,35,,252,percent of total billed charges,Implant Device,252,35,,252,percent of total billed charges,Implant Device,252,35,,252,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,532.8,
ZIMMER 00-7711-017-20 M/L TAPER 17.5 EXT,C1776,HCPCS,,79009267,CDM,278,RC,,,both,,,6912,5114.9,,,5114.9,Other,150% of Medicare + 9.63% HCRA Surcharge,3110.4,45,,3110.4,percent of total billed charges,Critical Access Hospital RCC factor,2350.08,34,,2350.08,percent of total billed charges,Implant Device,2350.08,34,,2350.08,percent of total billed charges,Implant Device,2350.08,34,,2350.08,percent of total billed charges,Implant Device,2350.08,34,,2350.08,percent of total billed charges,Implant Device,2350.08,34,,2350.08,percent of total billed charges,Implant Device,3421.44,,,3421.44,Other,110% of Medicare,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2350.08,34,"Charges > $500, x 34%",2350.08,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2764.8,40,,2764.8,percent of total billed charges,Implant Device,2419.2,70,,2419.2,percent of total billed charges,All Other,2350.08,34,,2350.08,percent of total billed charges,Implant Device,2350.08,34,,2350.08,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2350.08,34,"If Charge > 2,000, then 34 percent",2350.08,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5114.9,
DEPUY 3L92500 CORAIL HIP COLLAR SZ 10,C1776,HCPCS,,79009268,CDM,278,RC,,,both,,,13446,9950.07,,,9950.07,Other,150% of Medicare + 9.63% HCRA Surcharge,6050.7,45,,6050.7,percent of total billed charges,Critical Access Hospital RCC factor,4571.64,34,,4571.64,percent of total billed charges,Implant Device,4571.64,34,,4571.64,percent of total billed charges,Implant Device,4571.64,34,,4571.64,percent of total billed charges,Implant Device,4571.64,34,,4571.64,percent of total billed charges,Implant Device,4571.64,34,,4571.64,percent of total billed charges,Implant Device,6655.77,,,6655.77,Other,110% of Medicare,4706.1,35,,4706.1,percent of total billed charges,Implant Device,4571.64,34,"Charges > $500, x 34%",4571.64,percent of total billed charges,Implant Device,4706.1,35,,4706.1,percent of total billed charges,Implant Device,4706.1,35,,4706.1,percent of total billed charges,Implant Device,4706.1,35,,4706.1,percent of total billed charges,Implant Device,4706.1,35,,4706.1,percent of total billed charges,Implant Device,4706.1,35,,4706.1,percent of total billed charges,Implant Device,5378.4,40,,5378.4,percent of total billed charges,Implant Device,4706.1,70,,4706.1,percent of total billed charges,All Other,4571.64,34,,4571.64,percent of total billed charges,Implant Device,4571.64,34,,4571.64,percent of total billed charges,Implant Device,4706.1,35,,4706.1,percent of total billed charges,Implant Device,4706.1,35,,4706.1,percent of total billed charges,Implant Device,4706.1,35,,4706.1,percent of total billed charges,Implant Device,4706.1,35,,4706.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,4571.64,34,"If Charge > 2,000, then 34 percent",4571.64,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,9950.07,
STRYKER 6276-015 MODULAR HIP 155X15MM,C1776,HCPCS,,79009269,CDM,278,RC,,,both,,,15107,11179.22,,,11179.22,Other,150% of Medicare + 9.63% HCRA Surcharge,6798.15,45,,6798.15,percent of total billed charges,Critical Access Hospital RCC factor,5136.38,34,,5136.38,percent of total billed charges,Implant Device,5136.38,34,,5136.38,percent of total billed charges,Implant Device,5136.38,34,,5136.38,percent of total billed charges,Implant Device,5136.38,34,,5136.38,percent of total billed charges,Implant Device,5136.38,34,,5136.38,percent of total billed charges,Implant Device,7477.97,,,7477.97,Other,110% of Medicare,5287.45,35,,5287.45,percent of total billed charges,Implant Device,5136.38,34,"Charges > $500, x 34%",5136.38,percent of total billed charges,Implant Device,5287.45,35,,5287.45,percent of total billed charges,Implant Device,5287.45,35,,5287.45,percent of total billed charges,Implant Device,5287.45,35,,5287.45,percent of total billed charges,Implant Device,5287.45,35,,5287.45,percent of total billed charges,Implant Device,5287.45,35,,5287.45,percent of total billed charges,Implant Device,6042.8,40,,6042.8,percent of total billed charges,Implant Device,5287.45,70,,5287.45,percent of total billed charges,All Other,5136.38,34,,5136.38,percent of total billed charges,Implant Device,5136.38,34,,5136.38,percent of total billed charges,Implant Device,5287.45,35,,5287.45,percent of total billed charges,Implant Device,5287.45,35,,5287.45,percent of total billed charges,Implant Device,5287.45,35,,5287.45,percent of total billed charges,Implant Device,5287.45,35,,5287.45,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,5136.38,34,"If Charge > 2,000, then 34 percent",5136.38,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,11179.22,
ANGIODYNAMICS H965103038181 DURAMAX 19CM,C1750,HCPCS,,79009270,CDM,278,RC,,,both,,,834,617.16,,,617.16,Other,150% of Medicare + 9.63% HCRA Surcharge,375.3,45,,375.3,percent of total billed charges,Critical Access Hospital RCC factor,283.56,34,,283.56,percent of total billed charges,Implant Device,283.56,34,,283.56,percent of total billed charges,Implant Device,283.56,34,,283.56,percent of total billed charges,Implant Device,283.56,34,,283.56,percent of total billed charges,Implant Device,283.56,34,,283.56,percent of total billed charges,Implant Device,412.83,,,412.83,Other,110% of Medicare,291.9,35,,291.9,percent of total billed charges,Implant Device,283.56,34,"Charges > $500, x 34%",283.56,percent of total billed charges,Implant Device,291.9,35,,291.9,percent of total billed charges,Implant Device,291.9,35,,291.9,percent of total billed charges,Implant Device,291.9,35,,291.9,percent of total billed charges,Implant Device,291.9,35,,291.9,percent of total billed charges,Implant Device,291.9,35,,291.9,percent of total billed charges,Implant Device,333.6,40,,333.6,percent of total billed charges,Implant Device,291.9,70,,291.9,percent of total billed charges,All Other,283.56,34,,283.56,percent of total billed charges,Implant Device,283.56,34,,283.56,percent of total billed charges,Implant Device,291.9,35,,291.9,percent of total billed charges,Implant Device,291.9,35,,291.9,percent of total billed charges,Implant Device,291.9,35,,291.9,percent of total billed charges,Implant Device,291.9,35,,291.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,617.16,
ANGIODYNAMICS H965103038191 DURAMAX 23CM,C1750,HCPCS,,79009271,CDM,278,RC,,,both,,,834,617.16,,,617.16,Other,150% of Medicare + 9.63% HCRA Surcharge,375.3,45,,375.3,percent of total billed charges,Critical Access Hospital RCC factor,283.56,34,,283.56,percent of total billed charges,Implant Device,283.56,34,,283.56,percent of total billed charges,Implant Device,283.56,34,,283.56,percent of total billed charges,Implant Device,283.56,34,,283.56,percent of total billed charges,Implant Device,283.56,34,,283.56,percent of total billed charges,Implant Device,412.83,,,412.83,Other,110% of Medicare,291.9,35,,291.9,percent of total billed charges,Implant Device,283.56,34,"Charges > $500, x 34%",283.56,percent of total billed charges,Implant Device,291.9,35,,291.9,percent of total billed charges,Implant Device,291.9,35,,291.9,percent of total billed charges,Implant Device,291.9,35,,291.9,percent of total billed charges,Implant Device,291.9,35,,291.9,percent of total billed charges,Implant Device,291.9,35,,291.9,percent of total billed charges,Implant Device,333.6,40,,333.6,percent of total billed charges,Implant Device,291.9,70,,291.9,percent of total billed charges,All Other,283.56,34,,283.56,percent of total billed charges,Implant Device,283.56,34,,283.56,percent of total billed charges,Implant Device,291.9,35,,291.9,percent of total billed charges,Implant Device,291.9,35,,291.9,percent of total billed charges,Implant Device,291.9,35,,291.9,percent of total billed charges,Implant Device,291.9,35,,291.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,617.16,
ANGIODYNAMICS H965103038201 DURAMAX 27CM,C1750,HCPCS,,79009272,CDM,278,RC,,,both,,,834,617.16,,,617.16,Other,150% of Medicare + 9.63% HCRA Surcharge,375.3,45,,375.3,percent of total billed charges,Critical Access Hospital RCC factor,283.56,34,,283.56,percent of total billed charges,Implant Device,283.56,34,,283.56,percent of total billed charges,Implant Device,283.56,34,,283.56,percent of total billed charges,Implant Device,283.56,34,,283.56,percent of total billed charges,Implant Device,283.56,34,,283.56,percent of total billed charges,Implant Device,412.83,,,412.83,Other,110% of Medicare,291.9,35,,291.9,percent of total billed charges,Implant Device,283.56,34,"Charges > $500, x 34%",283.56,percent of total billed charges,Implant Device,291.9,35,,291.9,percent of total billed charges,Implant Device,291.9,35,,291.9,percent of total billed charges,Implant Device,291.9,35,,291.9,percent of total billed charges,Implant Device,291.9,35,,291.9,percent of total billed charges,Implant Device,291.9,35,,291.9,percent of total billed charges,Implant Device,333.6,40,,333.6,percent of total billed charges,Implant Device,291.9,70,,291.9,percent of total billed charges,All Other,283.56,34,,283.56,percent of total billed charges,Implant Device,283.56,34,,283.56,percent of total billed charges,Implant Device,291.9,35,,291.9,percent of total billed charges,Implant Device,291.9,35,,291.9,percent of total billed charges,Implant Device,291.9,35,,291.9,percent of total billed charges,Implant Device,291.9,35,,291.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,617.16,
ANGIODYNAMICS H787103028185 DURAMAX 19CM,C1750,HCPCS,,79009273,CDM,278,RC,,,both,,,540,399.6,,,399.6,Other,150% of Medicare + 9.63% HCRA Surcharge,243,45,,243,percent of total billed charges,Critical Access Hospital RCC factor,183.6,34,,183.6,percent of total billed charges,Implant Device,183.6,34,,183.6,percent of total billed charges,Implant Device,183.6,34,,183.6,percent of total billed charges,Implant Device,183.6,34,,183.6,percent of total billed charges,Implant Device,183.6,34,,183.6,percent of total billed charges,Implant Device,267.3,,,267.3,Other,110% of Medicare,189,35,,189,percent of total billed charges,Implant Device,183.6,34,"Charges > $500, x 34%",183.6,percent of total billed charges,Implant Device,189,35,,189,percent of total billed charges,Implant Device,189,35,,189,percent of total billed charges,Implant Device,189,35,,189,percent of total billed charges,Implant Device,189,35,,189,percent of total billed charges,Implant Device,189,35,,189,percent of total billed charges,Implant Device,216,40,,216,percent of total billed charges,Implant Device,189,70,,189,percent of total billed charges,All Other,183.6,34,,183.6,percent of total billed charges,Implant Device,183.6,34,,183.6,percent of total billed charges,Implant Device,189,35,,189,percent of total billed charges,Implant Device,189,35,,189,percent of total billed charges,Implant Device,189,35,,189,percent of total billed charges,Implant Device,189,35,,189,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,399.6,
ANGIODYNAMICS H787103028195 DURAMAX 23CM,C1750,HCPCS,,79009274,CDM,278,RC,,,both,,,540,399.6,,,399.6,Other,150% of Medicare + 9.63% HCRA Surcharge,243,45,,243,percent of total billed charges,Critical Access Hospital RCC factor,183.6,34,,183.6,percent of total billed charges,Implant Device,183.6,34,,183.6,percent of total billed charges,Implant Device,183.6,34,,183.6,percent of total billed charges,Implant Device,183.6,34,,183.6,percent of total billed charges,Implant Device,183.6,34,,183.6,percent of total billed charges,Implant Device,267.3,,,267.3,Other,110% of Medicare,189,35,,189,percent of total billed charges,Implant Device,183.6,34,"Charges > $500, x 34%",183.6,percent of total billed charges,Implant Device,189,35,,189,percent of total billed charges,Implant Device,189,35,,189,percent of total billed charges,Implant Device,189,35,,189,percent of total billed charges,Implant Device,189,35,,189,percent of total billed charges,Implant Device,189,35,,189,percent of total billed charges,Implant Device,216,40,,216,percent of total billed charges,Implant Device,189,70,,189,percent of total billed charges,All Other,183.6,34,,183.6,percent of total billed charges,Implant Device,183.6,34,,183.6,percent of total billed charges,Implant Device,189,35,,189,percent of total billed charges,Implant Device,189,35,,189,percent of total billed charges,Implant Device,189,35,,189,percent of total billed charges,Implant Device,189,35,,189,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,399.6,
ANGIODYNAMICS H787103028205 DURAMAX 27CM,C1750,HCPCS,,79009275,CDM,278,RC,,,both,,,540,399.6,,,399.6,Other,150% of Medicare + 9.63% HCRA Surcharge,243,45,,243,percent of total billed charges,Critical Access Hospital RCC factor,183.6,34,,183.6,percent of total billed charges,Implant Device,183.6,34,,183.6,percent of total billed charges,Implant Device,183.6,34,,183.6,percent of total billed charges,Implant Device,183.6,34,,183.6,percent of total billed charges,Implant Device,183.6,34,,183.6,percent of total billed charges,Implant Device,267.3,,,267.3,Other,110% of Medicare,189,35,,189,percent of total billed charges,Implant Device,183.6,34,"Charges > $500, x 34%",183.6,percent of total billed charges,Implant Device,189,35,,189,percent of total billed charges,Implant Device,189,35,,189,percent of total billed charges,Implant Device,189,35,,189,percent of total billed charges,Implant Device,189,35,,189,percent of total billed charges,Implant Device,189,35,,189,percent of total billed charges,Implant Device,216,40,,216,percent of total billed charges,Implant Device,189,70,,189,percent of total billed charges,All Other,183.6,34,,183.6,percent of total billed charges,Implant Device,183.6,34,,183.6,percent of total billed charges,Implant Device,189,35,,189,percent of total billed charges,Implant Device,189,35,,189,percent of total billed charges,Implant Device,189,35,,189,percent of total billed charges,Implant Device,189,35,,189,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,399.6,
ACUMED 30-0234 LOCKING SCREW 3.5X12MM,C1713,HCPCS,,79009279,CDM,278,RC,,,both,,,450,333,,,333,Other,150% of Medicare + 9.63% HCRA Surcharge,202.5,45,,202.5,percent of total billed charges,Critical Access Hospital RCC factor,153,34,,153,percent of total billed charges,Implant Device,153,34,,153,percent of total billed charges,Implant Device,153,34,,153,percent of total billed charges,Implant Device,153,34,,153,percent of total billed charges,Implant Device,153,34,,153,percent of total billed charges,Implant Device,222.75,,,222.75,Other,110% of Medicare,157.5,35,,157.5,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,157.5,35,,157.5,percent of total billed charges,Implant Device,157.5,35,,157.5,percent of total billed charges,Implant Device,157.5,35,,157.5,percent of total billed charges,Implant Device,157.5,35,,157.5,percent of total billed charges,Implant Device,157.5,35,,157.5,percent of total billed charges,Implant Device,180,40,,180,percent of total billed charges,Implant Device,157.5,70,,157.5,percent of total billed charges,All Other,153,34,,153,percent of total billed charges,Implant Device,153,34,,153,percent of total billed charges,Implant Device,157.5,35,,157.5,percent of total billed charges,Implant Device,157.5,35,,157.5,percent of total billed charges,Implant Device,157.5,35,,157.5,percent of total billed charges,Implant Device,157.5,35,,157.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,333,
ACUMED CO-S2314 LOCK CORT PEG 2.3X14MM,C1713,HCPCS,,79009280,CDM,278,RC,,,both,,,324,239.76,,,239.76,Other,150% of Medicare + 9.63% HCRA Surcharge,145.8,45,,145.8,percent of total billed charges,Critical Access Hospital RCC factor,110.16,34,,110.16,percent of total billed charges,Implant Device,110.16,34,,110.16,percent of total billed charges,Implant Device,110.16,34,,110.16,percent of total billed charges,Implant Device,110.16,34,,110.16,percent of total billed charges,Implant Device,110.16,34,,110.16,percent of total billed charges,Implant Device,160.38,,,160.38,Other,110% of Medicare,113.4,35,,113.4,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,129.6,40,,129.6,percent of total billed charges,Implant Device,113.4,70,,113.4,percent of total billed charges,All Other,110.16,34,,110.16,percent of total billed charges,Implant Device,110.16,34,,110.16,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,239.76,
ACUMED CO-S2316 LOCK CORT PEG 2.3X16MM,C1713,HCPCS,,79009281,CDM,278,RC,,,both,,,324,239.76,,,239.76,Other,150% of Medicare + 9.63% HCRA Surcharge,145.8,45,,145.8,percent of total billed charges,Critical Access Hospital RCC factor,110.16,34,,110.16,percent of total billed charges,Implant Device,110.16,34,,110.16,percent of total billed charges,Implant Device,110.16,34,,110.16,percent of total billed charges,Implant Device,110.16,34,,110.16,percent of total billed charges,Implant Device,110.16,34,,110.16,percent of total billed charges,Implant Device,160.38,,,160.38,Other,110% of Medicare,113.4,35,,113.4,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,129.6,40,,129.6,percent of total billed charges,Implant Device,113.4,70,,113.4,percent of total billed charges,All Other,110.16,34,,110.16,percent of total billed charges,Implant Device,110.16,34,,110.16,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,239.76,
ACUMED CO-S2318 LOCK CORT PEG 2.3X18MM,C1713,HCPCS,,79009282,CDM,278,RC,,,both,,,324,239.76,,,239.76,Other,150% of Medicare + 9.63% HCRA Surcharge,145.8,45,,145.8,percent of total billed charges,Critical Access Hospital RCC factor,110.16,34,,110.16,percent of total billed charges,Implant Device,110.16,34,,110.16,percent of total billed charges,Implant Device,110.16,34,,110.16,percent of total billed charges,Implant Device,110.16,34,,110.16,percent of total billed charges,Implant Device,110.16,34,,110.16,percent of total billed charges,Implant Device,160.38,,,160.38,Other,110% of Medicare,113.4,35,,113.4,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,129.6,40,,129.6,percent of total billed charges,Implant Device,113.4,70,,113.4,percent of total billed charges,All Other,110.16,34,,110.16,percent of total billed charges,Implant Device,110.16,34,,110.16,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,239.76,
ACUMED CO-S2320 LOCK CORT PEG 2.3X20MM,C1713,HCPCS,,79009283,CDM,278,RC,,,both,,,324,239.76,,,239.76,Other,150% of Medicare + 9.63% HCRA Surcharge,145.8,45,,145.8,percent of total billed charges,Critical Access Hospital RCC factor,110.16,34,,110.16,percent of total billed charges,Implant Device,110.16,34,,110.16,percent of total billed charges,Implant Device,110.16,34,,110.16,percent of total billed charges,Implant Device,110.16,34,,110.16,percent of total billed charges,Implant Device,110.16,34,,110.16,percent of total billed charges,Implant Device,160.38,,,160.38,Other,110% of Medicare,113.4,35,,113.4,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,129.6,40,,129.6,percent of total billed charges,Implant Device,113.4,70,,113.4,percent of total billed charges,All Other,110.16,34,,110.16,percent of total billed charges,Implant Device,110.16,34,,110.16,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,239.76,
STRYKER HT-00002  TOE TAC HAMMERTOE MED,C1713,HCPCS,,79009284,CDM,278,RC,,,both,,,6270,4639.82,,,4639.82,Other,150% of Medicare + 9.63% HCRA Surcharge,2821.5,45,,2821.5,percent of total billed charges,Critical Access Hospital RCC factor,2131.8,34,,2131.8,percent of total billed charges,Implant Device,2131.8,34,,2131.8,percent of total billed charges,Implant Device,2131.8,34,,2131.8,percent of total billed charges,Implant Device,2131.8,34,,2131.8,percent of total billed charges,Implant Device,2131.8,34,,2131.8,percent of total billed charges,Implant Device,3103.65,,,3103.65,Other,110% of Medicare,2194.5,35,,2194.5,percent of total billed charges,Implant Device,2131.8,34,"Charges > $500, x 34%",2131.8,percent of total billed charges,Implant Device,2194.5,35,,2194.5,percent of total billed charges,Implant Device,2194.5,35,,2194.5,percent of total billed charges,Implant Device,2194.5,35,,2194.5,percent of total billed charges,Implant Device,2194.5,35,,2194.5,percent of total billed charges,Implant Device,2194.5,35,,2194.5,percent of total billed charges,Implant Device,2508,40,,2508,percent of total billed charges,Implant Device,2194.5,70,,2194.5,percent of total billed charges,All Other,2131.8,34,,2131.8,percent of total billed charges,Implant Device,2131.8,34,,2131.8,percent of total billed charges,Implant Device,2194.5,35,,2194.5,percent of total billed charges,Implant Device,2194.5,35,,2194.5,percent of total billed charges,Implant Device,2194.5,35,,2194.5,percent of total billed charges,Implant Device,2194.5,35,,2194.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2131.8,34,"If Charge > 2,000, then 34 percent",2131.8,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4639.82,
DEPUY 02.226.212 2.4X12MM HEADLESS SCREW,C1713,HCPCS,,79009285,CDM,278,RC,,,both,,,1325,980.5,,,980.5,Other,150% of Medicare + 9.63% HCRA Surcharge,596.25,45,,596.25,percent of total billed charges,Critical Access Hospital RCC factor,450.5,34,,450.5,percent of total billed charges,Implant Device,450.5,34,,450.5,percent of total billed charges,Implant Device,450.5,34,,450.5,percent of total billed charges,Implant Device,450.5,34,,450.5,percent of total billed charges,Implant Device,450.5,34,,450.5,percent of total billed charges,Implant Device,655.88,,,655.88,Other,110% of Medicare,463.75,35,,463.75,percent of total billed charges,Implant Device,450.5,34,"Charges > $500, x 34%",450.5,percent of total billed charges,Implant Device,463.75,35,,463.75,percent of total billed charges,Implant Device,463.75,35,,463.75,percent of total billed charges,Implant Device,463.75,35,,463.75,percent of total billed charges,Implant Device,463.75,35,,463.75,percent of total billed charges,Implant Device,463.75,35,,463.75,percent of total billed charges,Implant Device,530,40,,530,percent of total billed charges,Implant Device,463.75,70,,463.75,percent of total billed charges,All Other,450.5,34,,450.5,percent of total billed charges,Implant Device,450.5,34,,450.5,percent of total billed charges,Implant Device,463.75,35,,463.75,percent of total billed charges,Implant Device,463.75,35,,463.75,percent of total billed charges,Implant Device,463.75,35,,463.75,percent of total billed charges,Implant Device,463.75,35,,463.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,980.5,
DEPUY 02.226.216 2.4X16MM HEADLESS SCREW,C1713,HCPCS,,79009286,CDM,278,RC,,,both,,,1325,980.5,,,980.5,Other,150% of Medicare + 9.63% HCRA Surcharge,596.25,45,,596.25,percent of total billed charges,Critical Access Hospital RCC factor,450.5,34,,450.5,percent of total billed charges,Implant Device,450.5,34,,450.5,percent of total billed charges,Implant Device,450.5,34,,450.5,percent of total billed charges,Implant Device,450.5,34,,450.5,percent of total billed charges,Implant Device,450.5,34,,450.5,percent of total billed charges,Implant Device,655.88,,,655.88,Other,110% of Medicare,463.75,35,,463.75,percent of total billed charges,Implant Device,450.5,34,"Charges > $500, x 34%",450.5,percent of total billed charges,Implant Device,463.75,35,,463.75,percent of total billed charges,Implant Device,463.75,35,,463.75,percent of total billed charges,Implant Device,463.75,35,,463.75,percent of total billed charges,Implant Device,463.75,35,,463.75,percent of total billed charges,Implant Device,463.75,35,,463.75,percent of total billed charges,Implant Device,530,40,,530,percent of total billed charges,Implant Device,463.75,70,,463.75,percent of total billed charges,All Other,450.5,34,,450.5,percent of total billed charges,Implant Device,450.5,34,,450.5,percent of total billed charges,Implant Device,463.75,35,,463.75,percent of total billed charges,Implant Device,463.75,35,,463.75,percent of total billed charges,Implant Device,463.75,35,,463.75,percent of total billed charges,Implant Device,463.75,35,,463.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,980.5,
DEPUY 02.226.116 3.0X16MM HEADLESS SCREW,C1713,HCPCS,,79009287,CDM,278,RC,,,both,,,1325,980.5,,,980.5,Other,150% of Medicare + 9.63% HCRA Surcharge,596.25,45,,596.25,percent of total billed charges,Critical Access Hospital RCC factor,450.5,34,,450.5,percent of total billed charges,Implant Device,450.5,34,,450.5,percent of total billed charges,Implant Device,450.5,34,,450.5,percent of total billed charges,Implant Device,450.5,34,,450.5,percent of total billed charges,Implant Device,450.5,34,,450.5,percent of total billed charges,Implant Device,655.88,,,655.88,Other,110% of Medicare,463.75,35,,463.75,percent of total billed charges,Implant Device,450.5,34,"Charges > $500, x 34%",450.5,percent of total billed charges,Implant Device,463.75,35,,463.75,percent of total billed charges,Implant Device,463.75,35,,463.75,percent of total billed charges,Implant Device,463.75,35,,463.75,percent of total billed charges,Implant Device,463.75,35,,463.75,percent of total billed charges,Implant Device,463.75,35,,463.75,percent of total billed charges,Implant Device,530,40,,530,percent of total billed charges,Implant Device,463.75,70,,463.75,percent of total billed charges,All Other,450.5,34,,450.5,percent of total billed charges,Implant Device,450.5,34,,450.5,percent of total billed charges,Implant Device,463.75,35,,463.75,percent of total billed charges,Implant Device,463.75,35,,463.75,percent of total billed charges,Implant Device,463.75,35,,463.75,percent of total billed charges,Implant Device,463.75,35,,463.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,980.5,
STRYKER 40-30117 3.0X17MM ASNIS SCREW,C1713,HCPCS,,79009288,CDM,278,RC,,,both,,,910,673.4,,,673.4,Other,150% of Medicare + 9.63% HCRA Surcharge,409.5,45,,409.5,percent of total billed charges,Critical Access Hospital RCC factor,309.4,34,,309.4,percent of total billed charges,Implant Device,309.4,34,,309.4,percent of total billed charges,Implant Device,309.4,34,,309.4,percent of total billed charges,Implant Device,309.4,34,,309.4,percent of total billed charges,Implant Device,309.4,34,,309.4,percent of total billed charges,Implant Device,450.45,,,450.45,Other,110% of Medicare,318.5,35,,318.5,percent of total billed charges,Implant Device,309.4,34,"Charges > $500, x 34%",309.4,percent of total billed charges,Implant Device,318.5,35,,318.5,percent of total billed charges,Implant Device,318.5,35,,318.5,percent of total billed charges,Implant Device,318.5,35,,318.5,percent of total billed charges,Implant Device,318.5,35,,318.5,percent of total billed charges,Implant Device,318.5,35,,318.5,percent of total billed charges,Implant Device,364,40,,364,percent of total billed charges,Implant Device,318.5,70,,318.5,percent of total billed charges,All Other,309.4,34,,309.4,percent of total billed charges,Implant Device,309.4,34,,309.4,percent of total billed charges,Implant Device,318.5,35,,318.5,percent of total billed charges,Implant Device,318.5,35,,318.5,percent of total billed charges,Implant Device,318.5,35,,318.5,percent of total billed charges,Implant Device,318.5,35,,318.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,673.4,
STRYKER 657450 BONE SCREW 3.5X50MM,C1713,HCPCS,,79009290,CDM,278,RC,,,both,,,294,217.56,,,217.56,Other,150% of Medicare + 9.63% HCRA Surcharge,132.3,45,,132.3,percent of total billed charges,Critical Access Hospital RCC factor,99.96,34,,99.96,percent of total billed charges,Implant Device,99.96,34,,99.96,percent of total billed charges,Implant Device,99.96,34,,99.96,percent of total billed charges,Implant Device,99.96,34,,99.96,percent of total billed charges,Implant Device,99.96,34,,99.96,percent of total billed charges,Implant Device,145.53,,,145.53,Other,110% of Medicare,102.9,35,,102.9,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,102.9,35,,102.9,percent of total billed charges,Implant Device,102.9,35,,102.9,percent of total billed charges,Implant Device,102.9,35,,102.9,percent of total billed charges,Implant Device,102.9,35,,102.9,percent of total billed charges,Implant Device,102.9,35,,102.9,percent of total billed charges,Implant Device,117.6,40,,117.6,percent of total billed charges,Implant Device,102.9,70,,102.9,percent of total billed charges,All Other,99.96,34,,99.96,percent of total billed charges,Implant Device,99.96,34,,99.96,percent of total billed charges,Implant Device,102.9,35,,102.9,percent of total billed charges,Implant Device,102.9,35,,102.9,percent of total billed charges,Implant Device,102.9,35,,102.9,percent of total billed charges,Implant Device,102.9,35,,102.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,217.56,
DEPUY 04.005.526S 5X36MM TI LOCK SCREW,C1713,HCPCS,,79009291,CDM,278,RC,,,both,,,412,304.88,,,304.88,Other,150% of Medicare + 9.63% HCRA Surcharge,185.4,45,,185.4,percent of total billed charges,Critical Access Hospital RCC factor,140.08,34,,140.08,percent of total billed charges,Implant Device,140.08,34,,140.08,percent of total billed charges,Implant Device,140.08,34,,140.08,percent of total billed charges,Implant Device,140.08,34,,140.08,percent of total billed charges,Implant Device,140.08,34,,140.08,percent of total billed charges,Implant Device,203.94,,,203.94,Other,110% of Medicare,144.2,35,,144.2,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,144.2,35,,144.2,percent of total billed charges,Implant Device,144.2,35,,144.2,percent of total billed charges,Implant Device,144.2,35,,144.2,percent of total billed charges,Implant Device,144.2,35,,144.2,percent of total billed charges,Implant Device,144.2,35,,144.2,percent of total billed charges,Implant Device,164.8,40,,164.8,percent of total billed charges,Implant Device,144.2,70,,144.2,percent of total billed charges,All Other,140.08,34,,140.08,percent of total billed charges,Implant Device,140.08,34,,140.08,percent of total billed charges,Implant Device,144.2,35,,144.2,percent of total billed charges,Implant Device,144.2,35,,144.2,percent of total billed charges,Implant Device,144.2,35,,144.2,percent of total billed charges,Implant Device,144.2,35,,144.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,304.88,
DEPUY 04.004.549S 11X345MM CAN TIB NAIL,C1713,HCPCS,,79009292,CDM,278,RC,,,both,,,6035,4465.92,,,4465.92,Other,150% of Medicare + 9.63% HCRA Surcharge,2715.75,45,,2715.75,percent of total billed charges,Critical Access Hospital RCC factor,2051.9,34,,2051.9,percent of total billed charges,Implant Device,2051.9,34,,2051.9,percent of total billed charges,Implant Device,2051.9,34,,2051.9,percent of total billed charges,Implant Device,2051.9,34,,2051.9,percent of total billed charges,Implant Device,2051.9,34,,2051.9,percent of total billed charges,Implant Device,2987.33,,,2987.33,Other,110% of Medicare,2112.25,35,,2112.25,percent of total billed charges,Implant Device,2051.9,34,"Charges > $500, x 34%",2051.9,percent of total billed charges,Implant Device,2112.25,35,,2112.25,percent of total billed charges,Implant Device,2112.25,35,,2112.25,percent of total billed charges,Implant Device,2112.25,35,,2112.25,percent of total billed charges,Implant Device,2112.25,35,,2112.25,percent of total billed charges,Implant Device,2112.25,35,,2112.25,percent of total billed charges,Implant Device,2414,40,,2414,percent of total billed charges,Implant Device,2112.25,70,,2112.25,percent of total billed charges,All Other,2051.9,34,,2051.9,percent of total billed charges,Implant Device,2051.9,34,,2051.9,percent of total billed charges,Implant Device,2112.25,35,,2112.25,percent of total billed charges,Implant Device,2112.25,35,,2112.25,percent of total billed charges,Implant Device,2112.25,35,,2112.25,percent of total billed charges,Implant Device,2112.25,35,,2112.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2051.9,34,"If Charge > 2,000, then 34 percent",2051.9,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4465.92,
DEPUY SE-181508TRR SPEED IMPLANT 18X15X8,C1713,HCPCS,,79009295,CDM,278,RC,,,both,,,4935,3651.91,,,3651.91,Other,150% of Medicare + 9.63% HCRA Surcharge,2220.75,45,,2220.75,percent of total billed charges,Critical Access Hospital RCC factor,1677.9,34,,1677.9,percent of total billed charges,Implant Device,1677.9,34,,1677.9,percent of total billed charges,Implant Device,1677.9,34,,1677.9,percent of total billed charges,Implant Device,1677.9,34,,1677.9,percent of total billed charges,Implant Device,1677.9,34,,1677.9,percent of total billed charges,Implant Device,2442.83,,,2442.83,Other,110% of Medicare,1727.25,35,,1727.25,percent of total billed charges,Implant Device,1677.9,34,"Charges > $500, x 34%",1677.9,percent of total billed charges,Implant Device,1727.25,35,,1727.25,percent of total billed charges,Implant Device,1727.25,35,,1727.25,percent of total billed charges,Implant Device,1727.25,35,,1727.25,percent of total billed charges,Implant Device,1727.25,35,,1727.25,percent of total billed charges,Implant Device,1727.25,35,,1727.25,percent of total billed charges,Implant Device,1974,40,,1974,percent of total billed charges,Implant Device,1727.25,70,,1727.25,percent of total billed charges,All Other,1677.9,34,,1677.9,percent of total billed charges,Implant Device,1677.9,34,,1677.9,percent of total billed charges,Implant Device,1727.25,35,,1727.25,percent of total billed charges,Implant Device,1727.25,35,,1727.25,percent of total billed charges,Implant Device,1727.25,35,,1727.25,percent of total billed charges,Implant Device,1727.25,35,,1727.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1677.9,34,"If Charge > 2,000, then 34 percent",1677.9,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3651.91,
ZIMMER 00-5988-003-10 TIBIAL BLOCK 10MM,C1776,HCPCS,,79009296,CDM,278,RC,,,both,,,4343,3213.83,,,3213.83,Other,150% of Medicare + 9.63% HCRA Surcharge,1954.35,45,,1954.35,percent of total billed charges,Critical Access Hospital RCC factor,1476.62,34,,1476.62,percent of total billed charges,Implant Device,1476.62,34,,1476.62,percent of total billed charges,Implant Device,1476.62,34,,1476.62,percent of total billed charges,Implant Device,1476.62,34,,1476.62,percent of total billed charges,Implant Device,1476.62,34,,1476.62,percent of total billed charges,Implant Device,2149.79,,,2149.79,Other,110% of Medicare,1520.05,35,,1520.05,percent of total billed charges,Implant Device,1476.62,34,"Charges > $500, x 34%",1476.62,percent of total billed charges,Implant Device,1520.05,35,,1520.05,percent of total billed charges,Implant Device,1520.05,35,,1520.05,percent of total billed charges,Implant Device,1520.05,35,,1520.05,percent of total billed charges,Implant Device,1520.05,35,,1520.05,percent of total billed charges,Implant Device,1520.05,35,,1520.05,percent of total billed charges,Implant Device,1737.2,40,,1737.2,percent of total billed charges,Implant Device,1520.05,70,,1520.05,percent of total billed charges,All Other,1476.62,34,,1476.62,percent of total billed charges,Implant Device,1476.62,34,,1476.62,percent of total billed charges,Implant Device,1520.05,35,,1520.05,percent of total billed charges,Implant Device,1520.05,35,,1520.05,percent of total billed charges,Implant Device,1520.05,35,,1520.05,percent of total billed charges,Implant Device,1520.05,35,,1520.05,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1476.62,34,"If Charge > 2,000, then 34 percent",1476.62,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3213.83,
ZIMMER 00-5994-032-10 ART SURFACE 10MM,C1776,HCPCS,,79009297,CDM,278,RC,,,both,,,6465,4784.12,,,4784.12,Other,150% of Medicare + 9.63% HCRA Surcharge,2909.25,45,,2909.25,percent of total billed charges,Critical Access Hospital RCC factor,2198.1,34,,2198.1,percent of total billed charges,Implant Device,2198.1,34,,2198.1,percent of total billed charges,Implant Device,2198.1,34,,2198.1,percent of total billed charges,Implant Device,2198.1,34,,2198.1,percent of total billed charges,Implant Device,2198.1,34,,2198.1,percent of total billed charges,Implant Device,3200.18,,,3200.18,Other,110% of Medicare,2262.75,35,,2262.75,percent of total billed charges,Implant Device,2198.1,34,"Charges > $500, x 34%",2198.1,percent of total billed charges,Implant Device,2262.75,35,,2262.75,percent of total billed charges,Implant Device,2262.75,35,,2262.75,percent of total billed charges,Implant Device,2262.75,35,,2262.75,percent of total billed charges,Implant Device,2262.75,35,,2262.75,percent of total billed charges,Implant Device,2262.75,35,,2262.75,percent of total billed charges,Implant Device,2586,40,,2586,percent of total billed charges,Implant Device,2262.75,70,,2262.75,percent of total billed charges,All Other,2198.1,34,,2198.1,percent of total billed charges,Implant Device,2198.1,34,,2198.1,percent of total billed charges,Implant Device,2262.75,35,,2262.75,percent of total billed charges,Implant Device,2262.75,35,,2262.75,percent of total billed charges,Implant Device,2262.75,35,,2262.75,percent of total billed charges,Implant Device,2262.75,35,,2262.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2198.1,34,"If Charge > 2,000, then 34 percent",2198.1,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4784.12,
STRYKER 656122 2.4X2MM LOCKING SCREW,C1713,HCPCS,,79009298,CDM,278,RC,,,both,,,282,208.68,,,208.68,Other,150% of Medicare + 9.63% HCRA Surcharge,126.9,45,,126.9,percent of total billed charges,Critical Access Hospital RCC factor,95.88,34,,95.88,percent of total billed charges,Implant Device,95.88,34,,95.88,percent of total billed charges,Implant Device,95.88,34,,95.88,percent of total billed charges,Implant Device,95.88,34,,95.88,percent of total billed charges,Implant Device,95.88,34,,95.88,percent of total billed charges,Implant Device,139.59,,,139.59,Other,110% of Medicare,98.7,35,,98.7,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,98.7,35,,98.7,percent of total billed charges,Implant Device,98.7,35,,98.7,percent of total billed charges,Implant Device,98.7,35,,98.7,percent of total billed charges,Implant Device,98.7,35,,98.7,percent of total billed charges,Implant Device,98.7,35,,98.7,percent of total billed charges,Implant Device,112.8,40,,112.8,percent of total billed charges,Implant Device,98.7,70,,98.7,percent of total billed charges,All Other,95.88,34,,95.88,percent of total billed charges,Implant Device,95.88,34,,95.88,percent of total billed charges,Implant Device,98.7,35,,98.7,percent of total billed charges,Implant Device,98.7,35,,98.7,percent of total billed charges,Implant Device,98.7,35,,98.7,percent of total billed charges,Implant Device,98.7,35,,98.7,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,208.68,
STRYKER 656118 2.4X18MM NON LOCK SCREW,C1713,HCPCS,,79009299,CDM,278,RC,,,both,,,282,208.68,,,208.68,Other,150% of Medicare + 9.63% HCRA Surcharge,126.9,45,,126.9,percent of total billed charges,Critical Access Hospital RCC factor,95.88,34,,95.88,percent of total billed charges,Implant Device,95.88,34,,95.88,percent of total billed charges,Implant Device,95.88,34,,95.88,percent of total billed charges,Implant Device,95.88,34,,95.88,percent of total billed charges,Implant Device,95.88,34,,95.88,percent of total billed charges,Implant Device,139.59,,,139.59,Other,110% of Medicare,98.7,35,,98.7,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,98.7,35,,98.7,percent of total billed charges,Implant Device,98.7,35,,98.7,percent of total billed charges,Implant Device,98.7,35,,98.7,percent of total billed charges,Implant Device,98.7,35,,98.7,percent of total billed charges,Implant Device,98.7,35,,98.7,percent of total billed charges,Implant Device,112.8,40,,112.8,percent of total billed charges,Implant Device,98.7,70,,98.7,percent of total billed charges,All Other,95.88,34,,95.88,percent of total billed charges,Implant Device,95.88,34,,95.88,percent of total billed charges,Implant Device,98.7,35,,98.7,percent of total billed charges,Implant Device,98.7,35,,98.7,percent of total billed charges,Implant Device,98.7,35,,98.7,percent of total billed charges,Implant Device,98.7,35,,98.7,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,208.68,
STRYKER 3425-1340S NAIL KIT 11X340MMX125,C1713,HCPCS,,79009302,CDM,278,RC,,,both,,,4969,3677.07,,,3677.07,Other,150% of Medicare + 9.63% HCRA Surcharge,2236.05,45,,2236.05,percent of total billed charges,Critical Access Hospital RCC factor,1689.46,34,,1689.46,percent of total billed charges,Implant Device,1689.46,34,,1689.46,percent of total billed charges,Implant Device,1689.46,34,,1689.46,percent of total billed charges,Implant Device,1689.46,34,,1689.46,percent of total billed charges,Implant Device,1689.46,34,,1689.46,percent of total billed charges,Implant Device,2459.66,,,2459.66,Other,110% of Medicare,1739.15,35,,1739.15,percent of total billed charges,Implant Device,1689.46,34,"Charges > $500, x 34%",1689.46,percent of total billed charges,Implant Device,1739.15,35,,1739.15,percent of total billed charges,Implant Device,1739.15,35,,1739.15,percent of total billed charges,Implant Device,1739.15,35,,1739.15,percent of total billed charges,Implant Device,1739.15,35,,1739.15,percent of total billed charges,Implant Device,1739.15,35,,1739.15,percent of total billed charges,Implant Device,1987.6,40,,1987.6,percent of total billed charges,Implant Device,1739.15,70,,1739.15,percent of total billed charges,All Other,1689.46,34,,1689.46,percent of total billed charges,Implant Device,1689.46,34,,1689.46,percent of total billed charges,Implant Device,1739.15,35,,1739.15,percent of total billed charges,Implant Device,1739.15,35,,1739.15,percent of total billed charges,Implant Device,1739.15,35,,1739.15,percent of total billed charges,Implant Device,1739.15,35,,1739.15,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1689.46,34,"If Charge > 2,000, then 34 percent",1689.46,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3677.07,
STRYKER 657444 NON-LOCK SCREW 3.5X44MM,C1713,HCPCS,,79009303,CDM,278,RC,,,both,,,294,217.56,,,217.56,Other,150% of Medicare + 9.63% HCRA Surcharge,132.3,45,,132.3,percent of total billed charges,Critical Access Hospital RCC factor,99.96,34,,99.96,percent of total billed charges,Implant Device,99.96,34,,99.96,percent of total billed charges,Implant Device,99.96,34,,99.96,percent of total billed charges,Implant Device,99.96,34,,99.96,percent of total billed charges,Implant Device,99.96,34,,99.96,percent of total billed charges,Implant Device,145.53,,,145.53,Other,110% of Medicare,102.9,35,,102.9,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,102.9,35,,102.9,percent of total billed charges,Implant Device,102.9,35,,102.9,percent of total billed charges,Implant Device,102.9,35,,102.9,percent of total billed charges,Implant Device,102.9,35,,102.9,percent of total billed charges,Implant Device,102.9,35,,102.9,percent of total billed charges,Implant Device,117.6,40,,117.6,percent of total billed charges,Implant Device,102.9,70,,102.9,percent of total billed charges,All Other,99.96,34,,99.96,percent of total billed charges,Implant Device,99.96,34,,99.96,percent of total billed charges,Implant Device,102.9,35,,102.9,percent of total billed charges,Implant Device,102.9,35,,102.9,percent of total billed charges,Implant Device,102.9,35,,102.9,percent of total billed charges,Implant Device,102.9,35,,102.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,217.56,
STRYKER 626680 TUBLAR 10 LOCKING PLATE,C1713,HCPCS,,79009305,CDM,278,RC,,,both,,,1097,811.78,,,811.78,Other,150% of Medicare + 9.63% HCRA Surcharge,493.65,45,,493.65,percent of total billed charges,Critical Access Hospital RCC factor,372.98,34,,372.98,percent of total billed charges,Implant Device,372.98,34,,372.98,percent of total billed charges,Implant Device,372.98,34,,372.98,percent of total billed charges,Implant Device,372.98,34,,372.98,percent of total billed charges,Implant Device,372.98,34,,372.98,percent of total billed charges,Implant Device,543.02,,,543.02,Other,110% of Medicare,383.95,35,,383.95,percent of total billed charges,Implant Device,372.98,34,"Charges > $500, x 34%",372.98,percent of total billed charges,Implant Device,383.95,35,,383.95,percent of total billed charges,Implant Device,383.95,35,,383.95,percent of total billed charges,Implant Device,383.95,35,,383.95,percent of total billed charges,Implant Device,383.95,35,,383.95,percent of total billed charges,Implant Device,383.95,35,,383.95,percent of total billed charges,Implant Device,438.8,40,,438.8,percent of total billed charges,Implant Device,383.95,70,,383.95,percent of total billed charges,All Other,372.98,34,,372.98,percent of total billed charges,Implant Device,372.98,34,,372.98,percent of total billed charges,Implant Device,383.95,35,,383.95,percent of total billed charges,Implant Device,383.95,35,,383.95,percent of total billed charges,Implant Device,383.95,35,,383.95,percent of total billed charges,Implant Device,383.95,35,,383.95,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,811.78,
STRYKER 58-25010 EMERG SCREW 2.5X10MM,C1713,HCPCS,,79009306,CDM,278,RC,,,both,,,423,313.02,,,313.02,Other,150% of Medicare + 9.63% HCRA Surcharge,190.35,45,,190.35,percent of total billed charges,Critical Access Hospital RCC factor,143.82,34,,143.82,percent of total billed charges,Implant Device,143.82,34,,143.82,percent of total billed charges,Implant Device,143.82,34,,143.82,percent of total billed charges,Implant Device,143.82,34,,143.82,percent of total billed charges,Implant Device,143.82,34,,143.82,percent of total billed charges,Implant Device,209.39,,,209.39,Other,110% of Medicare,148.05,35,,148.05,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,148.05,35,,148.05,percent of total billed charges,Implant Device,148.05,35,,148.05,percent of total billed charges,Implant Device,148.05,35,,148.05,percent of total billed charges,Implant Device,148.05,35,,148.05,percent of total billed charges,Implant Device,148.05,35,,148.05,percent of total billed charges,Implant Device,169.2,40,,169.2,percent of total billed charges,Implant Device,148.05,70,,148.05,percent of total billed charges,All Other,143.82,34,,143.82,percent of total billed charges,Implant Device,143.82,34,,143.82,percent of total billed charges,Implant Device,148.05,35,,148.05,percent of total billed charges,Implant Device,148.05,35,,148.05,percent of total billed charges,Implant Device,148.05,35,,148.05,percent of total billed charges,Implant Device,148.05,35,,148.05,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,313.02,
DEPUY 04.001.410S PROX HUM NAIL 9X150MM,C1713,HCPCS,,79009308,CDM,278,RC,,,both,,,3772,2791.29,,,2791.29,Other,150% of Medicare + 9.63% HCRA Surcharge,1697.4,45,,1697.4,percent of total billed charges,Critical Access Hospital RCC factor,1282.48,34,,1282.48,percent of total billed charges,Implant Device,1282.48,34,,1282.48,percent of total billed charges,Implant Device,1282.48,34,,1282.48,percent of total billed charges,Implant Device,1282.48,34,,1282.48,percent of total billed charges,Implant Device,1282.48,34,,1282.48,percent of total billed charges,Implant Device,1867.14,,,1867.14,Other,110% of Medicare,1320.2,35,,1320.2,percent of total billed charges,Implant Device,1282.48,34,"Charges > $500, x 34%",1282.48,percent of total billed charges,Implant Device,1320.2,35,,1320.2,percent of total billed charges,Implant Device,1320.2,35,,1320.2,percent of total billed charges,Implant Device,1320.2,35,,1320.2,percent of total billed charges,Implant Device,1320.2,35,,1320.2,percent of total billed charges,Implant Device,1320.2,35,,1320.2,percent of total billed charges,Implant Device,1508.8,40,,1508.8,percent of total billed charges,Implant Device,1320.2,70,,1320.2,percent of total billed charges,All Other,1282.48,34,,1282.48,percent of total billed charges,Implant Device,1282.48,34,,1282.48,percent of total billed charges,Implant Device,1320.2,35,,1320.2,percent of total billed charges,Implant Device,1320.2,35,,1320.2,percent of total billed charges,Implant Device,1320.2,35,,1320.2,percent of total billed charges,Implant Device,1320.2,35,,1320.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1282.48,34,"If Charge > 2,000, then 34 percent",1282.48,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2791.29,
DEPUY 04.005.414 TI LOCK SCREW 4X24MM,C1713,HCPCS,,79009309,CDM,278,RC,,,both,,,730,540.2,,,540.2,Other,150% of Medicare + 9.63% HCRA Surcharge,328.5,45,,328.5,percent of total billed charges,Critical Access Hospital RCC factor,248.2,34,,248.2,percent of total billed charges,Implant Device,248.2,34,,248.2,percent of total billed charges,Implant Device,248.2,34,,248.2,percent of total billed charges,Implant Device,248.2,34,,248.2,percent of total billed charges,Implant Device,248.2,34,,248.2,percent of total billed charges,Implant Device,361.35,,,361.35,Other,110% of Medicare,255.5,35,,255.5,percent of total billed charges,Implant Device,248.2,34,"Charges > $500, x 34%",248.2,percent of total billed charges,Implant Device,255.5,35,,255.5,percent of total billed charges,Implant Device,255.5,35,,255.5,percent of total billed charges,Implant Device,255.5,35,,255.5,percent of total billed charges,Implant Device,255.5,35,,255.5,percent of total billed charges,Implant Device,255.5,35,,255.5,percent of total billed charges,Implant Device,292,40,,292,percent of total billed charges,Implant Device,255.5,70,,255.5,percent of total billed charges,All Other,248.2,34,,248.2,percent of total billed charges,Implant Device,248.2,34,,248.2,percent of total billed charges,Implant Device,255.5,35,,255.5,percent of total billed charges,Implant Device,255.5,35,,255.5,percent of total billed charges,Implant Device,255.5,35,,255.5,percent of total billed charges,Implant Device,255.5,35,,255.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,540.2,
DEPUY 462.638 TI SPIRAL BLADE 38MM,C1713,HCPCS,,79009310,CDM,278,RC,,,both,,,2414,1786.37,,,1786.37,Other,150% of Medicare + 9.63% HCRA Surcharge,1086.3,45,,1086.3,percent of total billed charges,Critical Access Hospital RCC factor,820.76,34,,820.76,percent of total billed charges,Implant Device,820.76,34,,820.76,percent of total billed charges,Implant Device,820.76,34,,820.76,percent of total billed charges,Implant Device,820.76,34,,820.76,percent of total billed charges,Implant Device,820.76,34,,820.76,percent of total billed charges,Implant Device,1194.93,,,1194.93,Other,110% of Medicare,844.9,35,,844.9,percent of total billed charges,Implant Device,820.76,34,"Charges > $500, x 34%",820.76,percent of total billed charges,Implant Device,844.9,35,,844.9,percent of total billed charges,Implant Device,844.9,35,,844.9,percent of total billed charges,Implant Device,844.9,35,,844.9,percent of total billed charges,Implant Device,844.9,35,,844.9,percent of total billed charges,Implant Device,844.9,35,,844.9,percent of total billed charges,Implant Device,965.6,40,,965.6,percent of total billed charges,Implant Device,844.9,70,,844.9,percent of total billed charges,All Other,820.76,34,,820.76,percent of total billed charges,Implant Device,820.76,34,,820.76,percent of total billed charges,Implant Device,844.9,35,,844.9,percent of total billed charges,Implant Device,844.9,35,,844.9,percent of total billed charges,Implant Device,844.9,35,,844.9,percent of total billed charges,Implant Device,844.9,35,,844.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,820.76,34,"If Charge > 2,000, then 34 percent",820.76,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1786.37,
DEPUY 1035-59-000 FEM HEAD 28MM 12/14,C1713,HCPCS,,79009311,CDM,278,RC,,,both,,,4030,2982.21,,,2982.21,Other,150% of Medicare + 9.63% HCRA Surcharge,1813.5,45,,1813.5,percent of total billed charges,Critical Access Hospital RCC factor,1370.2,34,,1370.2,percent of total billed charges,Implant Device,1370.2,34,,1370.2,percent of total billed charges,Implant Device,1370.2,34,,1370.2,percent of total billed charges,Implant Device,1370.2,34,,1370.2,percent of total billed charges,Implant Device,1370.2,34,,1370.2,percent of total billed charges,Implant Device,1994.85,,,1994.85,Other,110% of Medicare,1410.5,35,,1410.5,percent of total billed charges,Implant Device,1370.2,34,"Charges > $500, x 34%",1370.2,percent of total billed charges,Implant Device,1410.5,35,,1410.5,percent of total billed charges,Implant Device,1410.5,35,,1410.5,percent of total billed charges,Implant Device,1410.5,35,,1410.5,percent of total billed charges,Implant Device,1410.5,35,,1410.5,percent of total billed charges,Implant Device,1410.5,35,,1410.5,percent of total billed charges,Implant Device,1612,40,,1612,percent of total billed charges,Implant Device,1410.5,70,,1410.5,percent of total billed charges,All Other,1370.2,34,,1370.2,percent of total billed charges,Implant Device,1370.2,34,,1370.2,percent of total billed charges,Implant Device,1410.5,35,,1410.5,percent of total billed charges,Implant Device,1410.5,35,,1410.5,percent of total billed charges,Implant Device,1410.5,35,,1410.5,percent of total billed charges,Implant Device,1410.5,35,,1410.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1370.2,34,"If Charge > 2,000, then 34 percent",1370.2,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2982.21,
IN2BONES P60 ST034 LATERALNECK PLATE 6H,C1713,HCPCS,,79009314,CDM,278,RC,,,both,,,5748,4253.53,,,4253.53,Other,150% of Medicare + 9.63% HCRA Surcharge,2586.6,45,,2586.6,percent of total billed charges,Critical Access Hospital RCC factor,1954.32,34,,1954.32,percent of total billed charges,Implant Device,1954.32,34,,1954.32,percent of total billed charges,Implant Device,1954.32,34,,1954.32,percent of total billed charges,Implant Device,1954.32,34,,1954.32,percent of total billed charges,Implant Device,1954.32,34,,1954.32,percent of total billed charges,Implant Device,2845.26,,,2845.26,Other,110% of Medicare,2011.8,35,,2011.8,percent of total billed charges,Implant Device,1954.32,34,"Charges > $500, x 34%",1954.32,percent of total billed charges,Implant Device,2011.8,35,,2011.8,percent of total billed charges,Implant Device,2011.8,35,,2011.8,percent of total billed charges,Implant Device,2011.8,35,,2011.8,percent of total billed charges,Implant Device,2011.8,35,,2011.8,percent of total billed charges,Implant Device,2011.8,35,,2011.8,percent of total billed charges,Implant Device,2299.2,40,,2299.2,percent of total billed charges,Implant Device,2011.8,70,,2011.8,percent of total billed charges,All Other,1954.32,34,,1954.32,percent of total billed charges,Implant Device,1954.32,34,,1954.32,percent of total billed charges,Implant Device,2011.8,35,,2011.8,percent of total billed charges,Implant Device,2011.8,35,,2011.8,percent of total billed charges,Implant Device,2011.8,35,,2011.8,percent of total billed charges,Implant Device,2011.8,35,,2011.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1954.32,34,"If Charge > 2,000, then 34 percent",1954.32,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4253.53,
IN2BONES P64 ST412 LOCK SCREW 2.4X12MM,C1713,HCPCS,,79009315,CDM,278,RC,,,both,,,870,643.8,,,643.8,Other,150% of Medicare + 9.63% HCRA Surcharge,391.5,45,,391.5,percent of total billed charges,Critical Access Hospital RCC factor,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,430.65,,,430.65,Other,110% of Medicare,304.5,35,,304.5,percent of total billed charges,Implant Device,295.8,34,"Charges > $500, x 34%",295.8,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,348,40,,348,percent of total billed charges,Implant Device,304.5,70,,304.5,percent of total billed charges,All Other,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,643.8,
IN2BONES P64 ST411 LOCK SCREW 2.4X11MM,C1713,HCPCS,,79009316,CDM,278,RC,,,both,,,804,594.96,,,594.96,Other,150% of Medicare + 9.63% HCRA Surcharge,361.8,45,,361.8,percent of total billed charges,Critical Access Hospital RCC factor,273.36,34,,273.36,percent of total billed charges,Implant Device,273.36,34,,273.36,percent of total billed charges,Implant Device,273.36,34,,273.36,percent of total billed charges,Implant Device,273.36,34,,273.36,percent of total billed charges,Implant Device,273.36,34,,273.36,percent of total billed charges,Implant Device,397.98,,,397.98,Other,110% of Medicare,281.4,35,,281.4,percent of total billed charges,Implant Device,273.36,34,"Charges > $500, x 34%",273.36,percent of total billed charges,Implant Device,281.4,35,,281.4,percent of total billed charges,Implant Device,281.4,35,,281.4,percent of total billed charges,Implant Device,281.4,35,,281.4,percent of total billed charges,Implant Device,281.4,35,,281.4,percent of total billed charges,Implant Device,281.4,35,,281.4,percent of total billed charges,Implant Device,321.6,40,,321.6,percent of total billed charges,Implant Device,281.4,70,,281.4,percent of total billed charges,All Other,273.36,34,,273.36,percent of total billed charges,Implant Device,273.36,34,,273.36,percent of total billed charges,Implant Device,281.4,35,,281.4,percent of total billed charges,Implant Device,281.4,35,,281.4,percent of total billed charges,Implant Device,281.4,35,,281.4,percent of total billed charges,Implant Device,281.4,35,,281.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,594.96,
IN2BONES P62 ST412 NON LOCK SCREW 2.4X12,C1713,HCPCS,,79009317,CDM,278,RC,,,both,,,735,543.9,,,543.9,Other,150% of Medicare + 9.63% HCRA Surcharge,330.75,45,,330.75,percent of total billed charges,Critical Access Hospital RCC factor,249.9,34,,249.9,percent of total billed charges,Implant Device,249.9,34,,249.9,percent of total billed charges,Implant Device,249.9,34,,249.9,percent of total billed charges,Implant Device,249.9,34,,249.9,percent of total billed charges,Implant Device,249.9,34,,249.9,percent of total billed charges,Implant Device,363.83,,,363.83,Other,110% of Medicare,257.25,35,,257.25,percent of total billed charges,Implant Device,249.9,34,"Charges > $500, x 34%",249.9,percent of total billed charges,Implant Device,257.25,35,,257.25,percent of total billed charges,Implant Device,257.25,35,,257.25,percent of total billed charges,Implant Device,257.25,35,,257.25,percent of total billed charges,Implant Device,257.25,35,,257.25,percent of total billed charges,Implant Device,257.25,35,,257.25,percent of total billed charges,Implant Device,294,40,,294,percent of total billed charges,Implant Device,257.25,70,,257.25,percent of total billed charges,All Other,249.9,34,,249.9,percent of total billed charges,Implant Device,249.9,34,,249.9,percent of total billed charges,Implant Device,257.25,35,,257.25,percent of total billed charges,Implant Device,257.25,35,,257.25,percent of total billed charges,Implant Device,257.25,35,,257.25,percent of total billed charges,Implant Device,257.25,35,,257.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,543.9,
IN2BONES P64 ST408 LOCKING SCREW 2.4X8MM,C1713,HCPCS,,79009318,CDM,278,RC,,,both,,,870,643.8,,,643.8,Other,150% of Medicare + 9.63% HCRA Surcharge,391.5,45,,391.5,percent of total billed charges,Critical Access Hospital RCC factor,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,430.65,,,430.65,Other,110% of Medicare,304.5,35,,304.5,percent of total billed charges,Implant Device,295.8,34,"Charges > $500, x 34%",295.8,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,348,40,,348,percent of total billed charges,Implant Device,304.5,70,,304.5,percent of total billed charges,All Other,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,643.8,
IN2BONES P64 ST409 LOCKING SCREW 2.4X9MM,C1713,HCPCS,,79009319,CDM,278,RC,,,both,,,870,643.8,,,643.8,Other,150% of Medicare + 9.63% HCRA Surcharge,391.5,45,,391.5,percent of total billed charges,Critical Access Hospital RCC factor,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,430.65,,,430.65,Other,110% of Medicare,304.5,35,,304.5,percent of total billed charges,Implant Device,295.8,34,"Charges > $500, x 34%",295.8,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,348,40,,348,percent of total billed charges,Implant Device,304.5,70,,304.5,percent of total billed charges,All Other,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,643.8,
STRYKER 626964 PLATE 4 HOLE,C1713,HCPCS,,79009320,CDM,278,RC,,,both,,,4173,3088.03,,,3088.03,Other,150% of Medicare + 9.63% HCRA Surcharge,1877.85,45,,1877.85,percent of total billed charges,Critical Access Hospital RCC factor,1418.82,34,,1418.82,percent of total billed charges,Implant Device,1418.82,34,,1418.82,percent of total billed charges,Implant Device,1418.82,34,,1418.82,percent of total billed charges,Implant Device,1418.82,34,,1418.82,percent of total billed charges,Implant Device,1418.82,34,,1418.82,percent of total billed charges,Implant Device,2065.64,,,2065.64,Other,110% of Medicare,1460.55,35,,1460.55,percent of total billed charges,Implant Device,1418.82,34,"Charges > $500, x 34%",1418.82,percent of total billed charges,Implant Device,1460.55,35,,1460.55,percent of total billed charges,Implant Device,1460.55,35,,1460.55,percent of total billed charges,Implant Device,1460.55,35,,1460.55,percent of total billed charges,Implant Device,1460.55,35,,1460.55,percent of total billed charges,Implant Device,1460.55,35,,1460.55,percent of total billed charges,Implant Device,1669.2,40,,1669.2,percent of total billed charges,Implant Device,1460.55,70,,1460.55,percent of total billed charges,All Other,1418.82,34,,1418.82,percent of total billed charges,Implant Device,1418.82,34,,1418.82,percent of total billed charges,Implant Device,1460.55,35,,1460.55,percent of total billed charges,Implant Device,1460.55,35,,1460.55,percent of total billed charges,Implant Device,1460.55,35,,1460.55,percent of total billed charges,Implant Device,1460.55,35,,1460.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1418.82,34,"If Charge > 2,000, then 34 percent",1418.82,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3088.03,
STRYKER 656320 LOCKING SCREW 2.7X20MM,C1713,HCPCS,,79009321,CDM,278,RC,,,both,,,480,355.2,,,355.2,Other,150% of Medicare + 9.63% HCRA Surcharge,216,45,,216,percent of total billed charges,Critical Access Hospital RCC factor,163.2,34,,163.2,percent of total billed charges,Implant Device,163.2,34,,163.2,percent of total billed charges,Implant Device,163.2,34,,163.2,percent of total billed charges,Implant Device,163.2,34,,163.2,percent of total billed charges,Implant Device,163.2,34,,163.2,percent of total billed charges,Implant Device,237.6,,,237.6,Other,110% of Medicare,168,35,,168,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,192,40,,192,percent of total billed charges,Implant Device,168,70,,168,percent of total billed charges,All Other,163.2,34,,163.2,percent of total billed charges,Implant Device,163.2,34,,163.2,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,355.2,
STRYKER 656324 LOCKING SCREW 2.7X24MM,C1713,HCPCS,,79009322,CDM,278,RC,,,both,,,480,355.2,,,355.2,Other,150% of Medicare + 9.63% HCRA Surcharge,216,45,,216,percent of total billed charges,Critical Access Hospital RCC factor,163.2,34,,163.2,percent of total billed charges,Implant Device,163.2,34,,163.2,percent of total billed charges,Implant Device,163.2,34,,163.2,percent of total billed charges,Implant Device,163.2,34,,163.2,percent of total billed charges,Implant Device,163.2,34,,163.2,percent of total billed charges,Implant Device,237.6,,,237.6,Other,110% of Medicare,168,35,,168,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,192,40,,192,percent of total billed charges,Implant Device,168,70,,168,percent of total billed charges,All Other,163.2,34,,163.2,percent of total billed charges,Implant Device,163.2,34,,163.2,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,355.2,
STRYKER 1822-1237S TIBIAL NAIL 12X375MM,C1713,HCPCS,,79009323,CDM,278,RC,,,both,,,7143,5285.84,,,5285.84,Other,150% of Medicare + 9.63% HCRA Surcharge,3214.35,45,,3214.35,percent of total billed charges,Critical Access Hospital RCC factor,2428.62,34,,2428.62,percent of total billed charges,Implant Device,2428.62,34,,2428.62,percent of total billed charges,Implant Device,2428.62,34,,2428.62,percent of total billed charges,Implant Device,2428.62,34,,2428.62,percent of total billed charges,Implant Device,2428.62,34,,2428.62,percent of total billed charges,Implant Device,3535.79,,,3535.79,Other,110% of Medicare,2500.05,35,,2500.05,percent of total billed charges,Implant Device,2428.62,34,"Charges > $500, x 34%",2428.62,percent of total billed charges,Implant Device,2500.05,35,,2500.05,percent of total billed charges,Implant Device,2500.05,35,,2500.05,percent of total billed charges,Implant Device,2500.05,35,,2500.05,percent of total billed charges,Implant Device,2500.05,35,,2500.05,percent of total billed charges,Implant Device,2500.05,35,,2500.05,percent of total billed charges,Implant Device,2857.2,40,,2857.2,percent of total billed charges,Implant Device,2500.05,70,,2500.05,percent of total billed charges,All Other,2428.62,34,,2428.62,percent of total billed charges,Implant Device,2428.62,34,,2428.62,percent of total billed charges,Implant Device,2500.05,35,,2500.05,percent of total billed charges,Implant Device,2500.05,35,,2500.05,percent of total billed charges,Implant Device,2500.05,35,,2500.05,percent of total billed charges,Implant Device,2500.05,35,,2500.05,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2428.62,34,"If Charge > 2,000, then 34 percent",2428.62,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5285.84,
IN2BONES V30 ST428 TRANS SCREW 3.0X28MM,C1713,HCPCS,,79009328,CDM,278,RC,,,both,,,870,643.8,,,643.8,Other,150% of Medicare + 9.63% HCRA Surcharge,391.5,45,,391.5,percent of total billed charges,Critical Access Hospital RCC factor,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,430.65,,,430.65,Other,110% of Medicare,304.5,35,,304.5,percent of total billed charges,Implant Device,295.8,34,"Charges > $500, x 34%",295.8,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,348,40,,348,percent of total billed charges,Implant Device,304.5,70,,304.5,percent of total billed charges,All Other,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,643.8,
IN2BONES V35 ST316 LOCK SCREW 3.5X16MM,C1713,HCPCS,,79009329,CDM,278,RC,,,both,,,870,643.8,,,643.8,Other,150% of Medicare + 9.63% HCRA Surcharge,391.5,45,,391.5,percent of total billed charges,Critical Access Hospital RCC factor,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,430.65,,,430.65,Other,110% of Medicare,304.5,35,,304.5,percent of total billed charges,Implant Device,295.8,34,"Charges > $500, x 34%",295.8,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,348,40,,348,percent of total billed charges,Implant Device,304.5,70,,304.5,percent of total billed charges,All Other,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,643.8,
DEPUY 1516-50-410 TIB INSERT SZ 4 10MM,C1776,HCPCS,,79009330,CDM,278,RC,,,both,,,5624,4161.77,,,4161.77,Other,150% of Medicare + 9.63% HCRA Surcharge,2530.8,45,,2530.8,percent of total billed charges,Critical Access Hospital RCC factor,1912.16,34,,1912.16,percent of total billed charges,Implant Device,1912.16,34,,1912.16,percent of total billed charges,Implant Device,1912.16,34,,1912.16,percent of total billed charges,Implant Device,1912.16,34,,1912.16,percent of total billed charges,Implant Device,1912.16,34,,1912.16,percent of total billed charges,Implant Device,2783.88,,,2783.88,Other,110% of Medicare,1968.4,35,,1968.4,percent of total billed charges,Implant Device,1912.16,34,"Charges > $500, x 34%",1912.16,percent of total billed charges,Implant Device,1968.4,35,,1968.4,percent of total billed charges,Implant Device,1968.4,35,,1968.4,percent of total billed charges,Implant Device,1968.4,35,,1968.4,percent of total billed charges,Implant Device,1968.4,35,,1968.4,percent of total billed charges,Implant Device,1968.4,35,,1968.4,percent of total billed charges,Implant Device,2249.6,40,,2249.6,percent of total billed charges,Implant Device,1968.4,70,,1968.4,percent of total billed charges,All Other,1912.16,34,,1912.16,percent of total billed charges,Implant Device,1912.16,34,,1912.16,percent of total billed charges,Implant Device,1968.4,35,,1968.4,percent of total billed charges,Implant Device,1968.4,35,,1968.4,percent of total billed charges,Implant Device,1968.4,35,,1968.4,percent of total billed charges,Implant Device,1968.4,35,,1968.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1912.16,34,"If Charge > 2,000, then 34 percent",1912.16,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4161.77,
ZIMMER 11-300817 DISTAL STEM 17X150MM,C1776,HCPCS,,79009331,CDM,278,RC,,,both,,,10199,7547.29,,,7547.29,Other,150% of Medicare + 9.63% HCRA Surcharge,4589.55,45,,4589.55,percent of total billed charges,Critical Access Hospital RCC factor,3467.66,34,,3467.66,percent of total billed charges,Implant Device,3467.66,34,,3467.66,percent of total billed charges,Implant Device,3467.66,34,,3467.66,percent of total billed charges,Implant Device,3467.66,34,,3467.66,percent of total billed charges,Implant Device,3467.66,34,,3467.66,percent of total billed charges,Implant Device,5048.51,,,5048.51,Other,110% of Medicare,3569.65,35,,3569.65,percent of total billed charges,Implant Device,3467.66,34,"Charges > $500, x 34%",3467.66,percent of total billed charges,Implant Device,3569.65,35,,3569.65,percent of total billed charges,Implant Device,3569.65,35,,3569.65,percent of total billed charges,Implant Device,3569.65,35,,3569.65,percent of total billed charges,Implant Device,3569.65,35,,3569.65,percent of total billed charges,Implant Device,3569.65,35,,3569.65,percent of total billed charges,Implant Device,4079.6,40,,4079.6,percent of total billed charges,Implant Device,3569.65,70,,3569.65,percent of total billed charges,All Other,3467.66,34,,3467.66,percent of total billed charges,Implant Device,3467.66,34,,3467.66,percent of total billed charges,Implant Device,3569.65,35,,3569.65,percent of total billed charges,Implant Device,3569.65,35,,3569.65,percent of total billed charges,Implant Device,3569.65,35,,3569.65,percent of total billed charges,Implant Device,3569.65,35,,3569.65,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3467.66,34,"If Charge > 2,000, then 34 percent",3467.66,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,7547.29,
ZIMMER 00-2357-003-08 TIB LOCK PLT 2.5MM,C1713,HCPCS,,79009332,CDM,278,RC,,,both,,,4183,3095.43,,,3095.43,Other,150% of Medicare + 9.63% HCRA Surcharge,1882.35,45,,1882.35,percent of total billed charges,Critical Access Hospital RCC factor,1422.22,34,,1422.22,percent of total billed charges,Implant Device,1422.22,34,,1422.22,percent of total billed charges,Implant Device,1422.22,34,,1422.22,percent of total billed charges,Implant Device,1422.22,34,,1422.22,percent of total billed charges,Implant Device,1422.22,34,,1422.22,percent of total billed charges,Implant Device,2070.59,,,2070.59,Other,110% of Medicare,1464.05,35,,1464.05,percent of total billed charges,Implant Device,1422.22,34,"Charges > $500, x 34%",1422.22,percent of total billed charges,Implant Device,1464.05,35,,1464.05,percent of total billed charges,Implant Device,1464.05,35,,1464.05,percent of total billed charges,Implant Device,1464.05,35,,1464.05,percent of total billed charges,Implant Device,1464.05,35,,1464.05,percent of total billed charges,Implant Device,1464.05,35,,1464.05,percent of total billed charges,Implant Device,1673.2,40,,1673.2,percent of total billed charges,Implant Device,1464.05,70,,1464.05,percent of total billed charges,All Other,1422.22,34,,1422.22,percent of total billed charges,Implant Device,1422.22,34,,1422.22,percent of total billed charges,Implant Device,1464.05,35,,1464.05,percent of total billed charges,Implant Device,1464.05,35,,1464.05,percent of total billed charges,Implant Device,1464.05,35,,1464.05,percent of total billed charges,Implant Device,1464.05,35,,1464.05,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1422.22,34,"If Charge > 2,000, then 34 percent",1422.22,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3095.43,
ZIMMER 00-2347-020-44 PERI SCREW 3.5X44,C1713,HCPCS,,79009333,CDM,278,RC,,,both,,,100,74,,,74,Other,150% of Medicare + 9.63% HCRA Surcharge,45,45,,45,percent of total billed charges,Critical Access Hospital RCC factor,34,34,,34,percent of total billed charges,Implant Device,34,34,,34,percent of total billed charges,Implant Device,34,34,,34,percent of total billed charges,Implant Device,34,34,,34,percent of total billed charges,Implant Device,34,34,,34,percent of total billed charges,Implant Device,49.5,,,49.5,Other,110% of Medicare,35,35,,35,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,35,35,,35,percent of total billed charges,Implant Device,35,35,,35,percent of total billed charges,Implant Device,35,35,,35,percent of total billed charges,Implant Device,35,35,,35,percent of total billed charges,Implant Device,35,35,,35,percent of total billed charges,Implant Device,40,40,,40,percent of total billed charges,Implant Device,35,70,,35,percent of total billed charges,All Other,34,34,,34,percent of total billed charges,Implant Device,34,34,,34,percent of total billed charges,Implant Device,35,35,,35,percent of total billed charges,Implant Device,35,35,,35,percent of total billed charges,Implant Device,35,35,,35,percent of total billed charges,Implant Device,35,35,,35,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,74,
ZIMMER 00-2347-020-34 PERI SCREW 3.5X34,C1713,HCPCS,,79009334,CDM,278,RC,,,both,,,100,74,,,74,Other,150% of Medicare + 9.63% HCRA Surcharge,45,45,,45,percent of total billed charges,Critical Access Hospital RCC factor,34,34,,34,percent of total billed charges,Implant Device,34,34,,34,percent of total billed charges,Implant Device,34,34,,34,percent of total billed charges,Implant Device,34,34,,34,percent of total billed charges,Implant Device,34,34,,34,percent of total billed charges,Implant Device,49.5,,,49.5,Other,110% of Medicare,35,35,,35,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,35,35,,35,percent of total billed charges,Implant Device,35,35,,35,percent of total billed charges,Implant Device,35,35,,35,percent of total billed charges,Implant Device,35,35,,35,percent of total billed charges,Implant Device,35,35,,35,percent of total billed charges,Implant Device,40,40,,40,percent of total billed charges,Implant Device,35,70,,35,percent of total billed charges,All Other,34,34,,34,percent of total billed charges,Implant Device,34,34,,34,percent of total billed charges,Implant Device,35,35,,35,percent of total billed charges,Implant Device,35,35,,35,percent of total billed charges,Implant Device,35,35,,35,percent of total billed charges,Implant Device,35,35,,35,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,74,
STRYKER 3525-1320S NAIL KIT 011X320X125',C1713,HCPCS,,79009336,CDM,278,RC,,,both,,,12948,9581.55,,,9581.55,Other,150% of Medicare + 9.63% HCRA Surcharge,5826.6,45,,5826.6,percent of total billed charges,Critical Access Hospital RCC factor,4402.32,34,,4402.32,percent of total billed charges,Implant Device,4402.32,34,,4402.32,percent of total billed charges,Implant Device,4402.32,34,,4402.32,percent of total billed charges,Implant Device,4402.32,34,,4402.32,percent of total billed charges,Implant Device,4402.32,34,,4402.32,percent of total billed charges,Implant Device,6409.26,,,6409.26,Other,110% of Medicare,4531.8,35,,4531.8,percent of total billed charges,Implant Device,4402.32,34,"Charges > $500, x 34%",4402.32,percent of total billed charges,Implant Device,4531.8,35,,4531.8,percent of total billed charges,Implant Device,4531.8,35,,4531.8,percent of total billed charges,Implant Device,4531.8,35,,4531.8,percent of total billed charges,Implant Device,4531.8,35,,4531.8,percent of total billed charges,Implant Device,4531.8,35,,4531.8,percent of total billed charges,Implant Device,5179.2,40,,5179.2,percent of total billed charges,Implant Device,4531.8,70,,4531.8,percent of total billed charges,All Other,4402.32,34,,4402.32,percent of total billed charges,Implant Device,4402.32,34,,4402.32,percent of total billed charges,Implant Device,4531.8,35,,4531.8,percent of total billed charges,Implant Device,4531.8,35,,4531.8,percent of total billed charges,Implant Device,4531.8,35,,4531.8,percent of total billed charges,Implant Device,4531.8,35,,4531.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,4402.32,34,"If Charge > 2,000, then 34 percent",4402.32,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,9581.55,
ZIMMER 8145-50-034 CORT BONE SCREW 5X34,C1713,HCPCS,,79009338,CDM,278,RC,,,both,,,353,261.22,,,261.22,Other,150% of Medicare + 9.63% HCRA Surcharge,158.85,45,,158.85,percent of total billed charges,Critical Access Hospital RCC factor,120.02,34,,120.02,percent of total billed charges,Implant Device,120.02,34,,120.02,percent of total billed charges,Implant Device,120.02,34,,120.02,percent of total billed charges,Implant Device,120.02,34,,120.02,percent of total billed charges,Implant Device,120.02,34,,120.02,percent of total billed charges,Implant Device,174.74,,,174.74,Other,110% of Medicare,123.55,35,,123.55,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,123.55,35,,123.55,percent of total billed charges,Implant Device,123.55,35,,123.55,percent of total billed charges,Implant Device,123.55,35,,123.55,percent of total billed charges,Implant Device,123.55,35,,123.55,percent of total billed charges,Implant Device,123.55,35,,123.55,percent of total billed charges,Implant Device,141.2,40,,141.2,percent of total billed charges,Implant Device,123.55,70,,123.55,percent of total billed charges,All Other,120.02,34,,120.02,percent of total billed charges,Implant Device,120.02,34,,120.02,percent of total billed charges,Implant Device,123.55,35,,123.55,percent of total billed charges,Implant Device,123.55,35,,123.55,percent of total billed charges,Implant Device,123.55,35,,123.55,percent of total billed charges,Implant Device,123.55,35,,123.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,261.22,
STRYKER 627233 PROX HUMERUS PLATE 3H RT,C1713,HCPCS,,79009339,CDM,278,RC,,,both,,,6634,4909.18,,,4909.18,Other,150% of Medicare + 9.63% HCRA Surcharge,2985.3,45,,2985.3,percent of total billed charges,Critical Access Hospital RCC factor,2255.56,34,,2255.56,percent of total billed charges,Implant Device,2255.56,34,,2255.56,percent of total billed charges,Implant Device,2255.56,34,,2255.56,percent of total billed charges,Implant Device,2255.56,34,,2255.56,percent of total billed charges,Implant Device,2255.56,34,,2255.56,percent of total billed charges,Implant Device,3283.83,,,3283.83,Other,110% of Medicare,2321.9,35,,2321.9,percent of total billed charges,Implant Device,2255.56,34,"Charges > $500, x 34%",2255.56,percent of total billed charges,Implant Device,2321.9,35,,2321.9,percent of total billed charges,Implant Device,2321.9,35,,2321.9,percent of total billed charges,Implant Device,2321.9,35,,2321.9,percent of total billed charges,Implant Device,2321.9,35,,2321.9,percent of total billed charges,Implant Device,2321.9,35,,2321.9,percent of total billed charges,Implant Device,2653.6,40,,2653.6,percent of total billed charges,Implant Device,2321.9,70,,2321.9,percent of total billed charges,All Other,2255.56,34,,2255.56,percent of total billed charges,Implant Device,2255.56,34,,2255.56,percent of total billed charges,Implant Device,2321.9,35,,2321.9,percent of total billed charges,Implant Device,2321.9,35,,2321.9,percent of total billed charges,Implant Device,2321.9,35,,2321.9,percent of total billed charges,Implant Device,2321.9,35,,2321.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2255.56,34,"If Charge > 2,000, then 34 percent",2255.56,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4909.18,
ZIMMER 00-12-115109 BIOLOZ MOD HEAD 28MM,C1776,HCPCS,,79009340,CDM,278,RC,,,both,,,5908,4371.93,,,4371.93,Other,150% of Medicare + 9.63% HCRA Surcharge,2658.6,45,,2658.6,percent of total billed charges,Critical Access Hospital RCC factor,2008.72,34,,2008.72,percent of total billed charges,Implant Device,2008.72,34,,2008.72,percent of total billed charges,Implant Device,2008.72,34,,2008.72,percent of total billed charges,Implant Device,2008.72,34,,2008.72,percent of total billed charges,Implant Device,2008.72,34,,2008.72,percent of total billed charges,Implant Device,2924.46,,,2924.46,Other,110% of Medicare,2067.8,35,,2067.8,percent of total billed charges,Implant Device,2008.72,34,"Charges > $500, x 34%",2008.72,percent of total billed charges,Implant Device,2067.8,35,,2067.8,percent of total billed charges,Implant Device,2067.8,35,,2067.8,percent of total billed charges,Implant Device,2067.8,35,,2067.8,percent of total billed charges,Implant Device,2067.8,35,,2067.8,percent of total billed charges,Implant Device,2067.8,35,,2067.8,percent of total billed charges,Implant Device,2363.2,40,,2363.2,percent of total billed charges,Implant Device,2067.8,70,,2067.8,percent of total billed charges,All Other,2008.72,34,,2008.72,percent of total billed charges,Implant Device,2008.72,34,,2008.72,percent of total billed charges,Implant Device,2067.8,35,,2067.8,percent of total billed charges,Implant Device,2067.8,35,,2067.8,percent of total billed charges,Implant Device,2067.8,35,,2067.8,percent of total billed charges,Implant Device,2067.8,35,,2067.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2008.72,34,"If Charge > 2,000, then 34 percent",2008.72,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4371.93,
ZIMMER 00-11-3000820 20X150 SPL TPR DIST,C1776,HCPCS,,79009341,CDM,278,RC,,,both,,,10506,7774.47,,,7774.47,Other,150% of Medicare + 9.63% HCRA Surcharge,4727.7,45,,4727.7,percent of total billed charges,Critical Access Hospital RCC factor,3572.04,34,,3572.04,percent of total billed charges,Implant Device,3572.04,34,,3572.04,percent of total billed charges,Implant Device,3572.04,34,,3572.04,percent of total billed charges,Implant Device,3572.04,34,,3572.04,percent of total billed charges,Implant Device,3572.04,34,,3572.04,percent of total billed charges,Implant Device,5200.47,,,5200.47,Other,110% of Medicare,3677.1,35,,3677.1,percent of total billed charges,Implant Device,3572.04,34,"Charges > $500, x 34%",3572.04,percent of total billed charges,Implant Device,3677.1,35,,3677.1,percent of total billed charges,Implant Device,3677.1,35,,3677.1,percent of total billed charges,Implant Device,3677.1,35,,3677.1,percent of total billed charges,Implant Device,3677.1,35,,3677.1,percent of total billed charges,Implant Device,3677.1,35,,3677.1,percent of total billed charges,Implant Device,4202.4,40,,4202.4,percent of total billed charges,Implant Device,3677.1,70,,3677.1,percent of total billed charges,All Other,3572.04,34,,3572.04,percent of total billed charges,Implant Device,3572.04,34,,3572.04,percent of total billed charges,Implant Device,3677.1,35,,3677.1,percent of total billed charges,Implant Device,3677.1,35,,3677.1,percent of total billed charges,Implant Device,3677.1,35,,3677.1,percent of total billed charges,Implant Device,3677.1,35,,3677.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3572.04,34,"If Charge > 2,000, then 34 percent",3572.04,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,7774.47,
EXACTECH 320-20-42 COMPR SCREW 4.5X42MM,C1713,HCPCS,,79009342,CDM,278,RC,,,both,,,300,222,,,222,Other,150% of Medicare + 9.63% HCRA Surcharge,135,45,,135,percent of total billed charges,Critical Access Hospital RCC factor,102,34,,102,percent of total billed charges,Implant Device,102,34,,102,percent of total billed charges,Implant Device,102,34,,102,percent of total billed charges,Implant Device,102,34,,102,percent of total billed charges,Implant Device,102,34,,102,percent of total billed charges,Implant Device,148.5,,,148.5,Other,110% of Medicare,105,35,,105,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,105,35,,105,percent of total billed charges,Implant Device,105,35,,105,percent of total billed charges,Implant Device,105,35,,105,percent of total billed charges,Implant Device,105,35,,105,percent of total billed charges,Implant Device,105,35,,105,percent of total billed charges,Implant Device,120,40,,120,percent of total billed charges,Implant Device,105,70,,105,percent of total billed charges,All Other,102,34,,102,percent of total billed charges,Implant Device,102,34,,102,percent of total billed charges,Implant Device,105,35,,105,percent of total billed charges,Implant Device,105,35,,105,percent of total billed charges,Implant Device,105,35,,105,percent of total billed charges,Implant Device,105,35,,105,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,222,
ARTHREX AR-2324BCT-2 SWIVELOCK 4.75X22MM,C1713,HCPCS,,79009343,CDM,278,RC,,,both,,,1275,943.5,,,943.5,Other,150% of Medicare + 9.63% HCRA Surcharge,573.75,45,,573.75,percent of total billed charges,Critical Access Hospital RCC factor,433.5,34,,433.5,percent of total billed charges,Implant Device,433.5,34,,433.5,percent of total billed charges,Implant Device,433.5,34,,433.5,percent of total billed charges,Implant Device,433.5,34,,433.5,percent of total billed charges,Implant Device,433.5,34,,433.5,percent of total billed charges,Implant Device,631.13,,,631.13,Other,110% of Medicare,446.25,35,,446.25,percent of total billed charges,Implant Device,433.5,34,"Charges > $500, x 34%",433.5,percent of total billed charges,Implant Device,446.25,35,,446.25,percent of total billed charges,Implant Device,446.25,35,,446.25,percent of total billed charges,Implant Device,446.25,35,,446.25,percent of total billed charges,Implant Device,446.25,35,,446.25,percent of total billed charges,Implant Device,446.25,35,,446.25,percent of total billed charges,Implant Device,510,40,,510,percent of total billed charges,Implant Device,446.25,70,,446.25,percent of total billed charges,All Other,433.5,34,,433.5,percent of total billed charges,Implant Device,433.5,34,,433.5,percent of total billed charges,Implant Device,446.25,35,,446.25,percent of total billed charges,Implant Device,446.25,35,,446.25,percent of total billed charges,Implant Device,446.25,35,,446.25,percent of total billed charges,Implant Device,446.25,35,,446.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,943.5,
MEDTRONIC PRB35-08-150-120 EVERFLX STENT,C1786,HCPCS,,79009344,CDM,278,RC,,,both,,,2625,1942.51,,,1942.51,Other,150% of Medicare + 9.63% HCRA Surcharge,1181.25,45,,1181.25,percent of total billed charges,Critical Access Hospital RCC factor,892.5,34,,892.5,percent of total billed charges,Implant Device,892.5,34,,892.5,percent of total billed charges,Implant Device,892.5,34,,892.5,percent of total billed charges,Implant Device,892.5,34,,892.5,percent of total billed charges,Implant Device,892.5,34,,892.5,percent of total billed charges,Implant Device,1299.38,,,1299.38,Other,110% of Medicare,918.75,35,,918.75,percent of total billed charges,Implant Device,892.5,34,"Charges > $500, x 34%",892.5,percent of total billed charges,Implant Device,918.75,35,,918.75,percent of total billed charges,Implant Device,918.75,35,,918.75,percent of total billed charges,Implant Device,918.75,35,,918.75,percent of total billed charges,Implant Device,918.75,35,,918.75,percent of total billed charges,Implant Device,918.75,35,,918.75,percent of total billed charges,Implant Device,1050,40,,1050,percent of total billed charges,Implant Device,918.75,70,,918.75,percent of total billed charges,All Other,892.5,34,,892.5,percent of total billed charges,Implant Device,892.5,34,,892.5,percent of total billed charges,Implant Device,918.75,35,,918.75,percent of total billed charges,Implant Device,918.75,35,,918.75,percent of total billed charges,Implant Device,918.75,35,,918.75,percent of total billed charges,Implant Device,918.75,35,,918.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,892.5,34,"If Charge > 2,000, then 34 percent",892.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1942.51,
INTEGRA 606-206-002 SURGIMEND MP 16X20CM,C1781,HCPCS,,79009345,CDM,278,RC,,,both,,,18240,13497.65,,,13497.65,Other,150% of Medicare + 9.63% HCRA Surcharge,8208,45,,8208,percent of total billed charges,Critical Access Hospital RCC factor,6201.6,34,,6201.6,percent of total billed charges,Implant Device,6201.6,34,,6201.6,percent of total billed charges,Implant Device,6201.6,34,,6201.6,percent of total billed charges,Implant Device,6201.6,34,,6201.6,percent of total billed charges,Implant Device,6201.6,34,,6201.6,percent of total billed charges,Implant Device,9028.8,,,9028.8,Other,110% of Medicare,6384,35,,6384,percent of total billed charges,Implant Device,6201.6,34,"Charges > $500, x 34%",6201.6,percent of total billed charges,Implant Device,6384,35,,6384,percent of total billed charges,Implant Device,6384,35,,6384,percent of total billed charges,Implant Device,6384,35,,6384,percent of total billed charges,Implant Device,6384,35,,6384,percent of total billed charges,Implant Device,6384,35,,6384,percent of total billed charges,Implant Device,7296,40,,7296,percent of total billed charges,Implant Device,6384,70,,6384,percent of total billed charges,All Other,6201.6,34,,6201.6,percent of total billed charges,Implant Device,6201.6,34,,6201.6,percent of total billed charges,Implant Device,6384,35,,6384,percent of total billed charges,Implant Device,6384,35,,6384,percent of total billed charges,Implant Device,6384,35,,6384,percent of total billed charges,Implant Device,6384,35,,6384,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,6201.6,34,"If Charge > 2,000, then 34 percent",6201.6,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,13497.65,
INTEGRA 606-206-003 SURGIMEND MP 13X25CM,C1781,HCPCS,,79009346,CDM,278,RC,,,both,,,18525,13708.55,,,13708.55,Other,150% of Medicare + 9.63% HCRA Surcharge,8336.25,45,,8336.25,percent of total billed charges,Critical Access Hospital RCC factor,6298.5,34,,6298.5,percent of total billed charges,Implant Device,6298.5,34,,6298.5,percent of total billed charges,Implant Device,6298.5,34,,6298.5,percent of total billed charges,Implant Device,6298.5,34,,6298.5,percent of total billed charges,Implant Device,6298.5,34,,6298.5,percent of total billed charges,Implant Device,9169.88,,,9169.88,Other,110% of Medicare,6483.75,35,,6483.75,percent of total billed charges,Implant Device,6298.5,34,"Charges > $500, x 34%",6298.5,percent of total billed charges,Implant Device,6483.75,35,,6483.75,percent of total billed charges,Implant Device,6483.75,35,,6483.75,percent of total billed charges,Implant Device,6483.75,35,,6483.75,percent of total billed charges,Implant Device,6483.75,35,,6483.75,percent of total billed charges,Implant Device,6483.75,35,,6483.75,percent of total billed charges,Implant Device,7410,40,,7410,percent of total billed charges,Implant Device,6483.75,70,,6483.75,percent of total billed charges,All Other,6298.5,34,,6298.5,percent of total billed charges,Implant Device,6298.5,34,,6298.5,percent of total billed charges,Implant Device,6483.75,35,,6483.75,percent of total billed charges,Implant Device,6483.75,35,,6483.75,percent of total billed charges,Implant Device,6483.75,35,,6483.75,percent of total billed charges,Implant Device,6483.75,35,,6483.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,6298.5,34,"If Charge > 2,000, then 34 percent",6298.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,13708.55,
INTEGRA 606-206-004 SURGIMEND MP 20X20CM,C1781,HCPCS,,79009347,CDM,278,RC,,,both,,,18240,13497.65,,,13497.65,Other,150% of Medicare + 9.63% HCRA Surcharge,8208,45,,8208,percent of total billed charges,Critical Access Hospital RCC factor,6201.6,34,,6201.6,percent of total billed charges,Implant Device,6201.6,34,,6201.6,percent of total billed charges,Implant Device,6201.6,34,,6201.6,percent of total billed charges,Implant Device,6201.6,34,,6201.6,percent of total billed charges,Implant Device,6201.6,34,,6201.6,percent of total billed charges,Implant Device,9028.8,,,9028.8,Other,110% of Medicare,6384,35,,6384,percent of total billed charges,Implant Device,6201.6,34,"Charges > $500, x 34%",6201.6,percent of total billed charges,Implant Device,6384,35,,6384,percent of total billed charges,Implant Device,6384,35,,6384,percent of total billed charges,Implant Device,6384,35,,6384,percent of total billed charges,Implant Device,6384,35,,6384,percent of total billed charges,Implant Device,6384,35,,6384,percent of total billed charges,Implant Device,7296,40,,7296,percent of total billed charges,Implant Device,6384,70,,6384,percent of total billed charges,All Other,6201.6,34,,6201.6,percent of total billed charges,Implant Device,6201.6,34,,6201.6,percent of total billed charges,Implant Device,6384,35,,6384,percent of total billed charges,Implant Device,6384,35,,6384,percent of total billed charges,Implant Device,6384,35,,6384,percent of total billed charges,Implant Device,6384,35,,6384,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,6201.6,34,"If Charge > 2,000, then 34 percent",6201.6,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,13497.65,
STRYKER 626996 Y PLATE,C1713,HCPCS,,79009349,CDM,278,RC,,,both,,,3489,2581.87,,,2581.87,Other,150% of Medicare + 9.63% HCRA Surcharge,1570.05,45,,1570.05,percent of total billed charges,Critical Access Hospital RCC factor,1186.26,34,,1186.26,percent of total billed charges,Implant Device,1186.26,34,,1186.26,percent of total billed charges,Implant Device,1186.26,34,,1186.26,percent of total billed charges,Implant Device,1186.26,34,,1186.26,percent of total billed charges,Implant Device,1186.26,34,,1186.26,percent of total billed charges,Implant Device,1727.06,,,1727.06,Other,110% of Medicare,1221.15,35,,1221.15,percent of total billed charges,Implant Device,1186.26,34,"Charges > $500, x 34%",1186.26,percent of total billed charges,Implant Device,1221.15,35,,1221.15,percent of total billed charges,Implant Device,1221.15,35,,1221.15,percent of total billed charges,Implant Device,1221.15,35,,1221.15,percent of total billed charges,Implant Device,1221.15,35,,1221.15,percent of total billed charges,Implant Device,1221.15,35,,1221.15,percent of total billed charges,Implant Device,1395.6,40,,1395.6,percent of total billed charges,Implant Device,1221.15,70,,1221.15,percent of total billed charges,All Other,1186.26,34,,1186.26,percent of total billed charges,Implant Device,1186.26,34,,1186.26,percent of total billed charges,Implant Device,1221.15,35,,1221.15,percent of total billed charges,Implant Device,1221.15,35,,1221.15,percent of total billed charges,Implant Device,1221.15,35,,1221.15,percent of total billed charges,Implant Device,1221.15,35,,1221.15,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1186.26,34,"If Charge > 2,000, then 34 percent",1186.26,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2581.87,
STRYKER 897005 HYDROSET XT,C1713,HCPCS,,79009352,CDM,278,RC,,,both,,,4293,3176.83,,,3176.83,Other,150% of Medicare + 9.63% HCRA Surcharge,1931.85,45,,1931.85,percent of total billed charges,Critical Access Hospital RCC factor,1459.62,34,,1459.62,percent of total billed charges,Implant Device,1459.62,34,,1459.62,percent of total billed charges,Implant Device,1459.62,34,,1459.62,percent of total billed charges,Implant Device,1459.62,34,,1459.62,percent of total billed charges,Implant Device,1459.62,34,,1459.62,percent of total billed charges,Implant Device,2125.04,,,2125.04,Other,110% of Medicare,1502.55,35,,1502.55,percent of total billed charges,Implant Device,1459.62,34,"Charges > $500, x 34%",1459.62,percent of total billed charges,Implant Device,1502.55,35,,1502.55,percent of total billed charges,Implant Device,1502.55,35,,1502.55,percent of total billed charges,Implant Device,1502.55,35,,1502.55,percent of total billed charges,Implant Device,1502.55,35,,1502.55,percent of total billed charges,Implant Device,1502.55,35,,1502.55,percent of total billed charges,Implant Device,1717.2,40,,1717.2,percent of total billed charges,Implant Device,1502.55,70,,1502.55,percent of total billed charges,All Other,1459.62,34,,1459.62,percent of total billed charges,Implant Device,1459.62,34,,1459.62,percent of total billed charges,Implant Device,1502.55,35,,1502.55,percent of total billed charges,Implant Device,1502.55,35,,1502.55,percent of total billed charges,Implant Device,1502.55,35,,1502.55,percent of total billed charges,Implant Device,1502.55,35,,1502.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1459.62,34,"If Charge > 2,000, then 34 percent",1459.62,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3176.83,
STRYKER 4922-8-450 11X450 ROD,C1713,HCPCS,,79009359,CDM,278,RC,,,both,,,1004,742.96,,,742.96,Other,150% of Medicare + 9.63% HCRA Surcharge,451.8,45,,451.8,percent of total billed charges,Critical Access Hospital RCC factor,341.36,34,,341.36,percent of total billed charges,Implant Device,341.36,34,,341.36,percent of total billed charges,Implant Device,341.36,34,,341.36,percent of total billed charges,Implant Device,341.36,34,,341.36,percent of total billed charges,Implant Device,341.36,34,,341.36,percent of total billed charges,Implant Device,496.98,,,496.98,Other,110% of Medicare,351.4,35,,351.4,percent of total billed charges,Implant Device,341.36,34,"Charges > $500, x 34%",341.36,percent of total billed charges,Implant Device,351.4,35,,351.4,percent of total billed charges,Implant Device,351.4,35,,351.4,percent of total billed charges,Implant Device,351.4,35,,351.4,percent of total billed charges,Implant Device,351.4,35,,351.4,percent of total billed charges,Implant Device,351.4,35,,351.4,percent of total billed charges,Implant Device,401.6,40,,401.6,percent of total billed charges,Implant Device,351.4,70,,351.4,percent of total billed charges,All Other,341.36,34,,341.36,percent of total billed charges,Implant Device,341.36,34,,341.36,percent of total billed charges,Implant Device,351.4,35,,351.4,percent of total billed charges,Implant Device,351.4,35,,351.4,percent of total billed charges,Implant Device,351.4,35,,351.4,percent of total billed charges,Implant Device,351.4,35,,351.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,742.96,
ZIMMER 00-5950-016-05 FEM COMP SZ F LT,C1776,HCPCS,,79009360,CDM,278,RC,,,both,,,14693,10872.86,,,10872.86,Other,150% of Medicare + 9.63% HCRA Surcharge,6611.85,45,,6611.85,percent of total billed charges,Critical Access Hospital RCC factor,4995.62,34,,4995.62,percent of total billed charges,Implant Device,4995.62,34,,4995.62,percent of total billed charges,Implant Device,4995.62,34,,4995.62,percent of total billed charges,Implant Device,4995.62,34,,4995.62,percent of total billed charges,Implant Device,4995.62,34,,4995.62,percent of total billed charges,Implant Device,7273.04,,,7273.04,Other,110% of Medicare,5142.55,35,,5142.55,percent of total billed charges,Implant Device,4995.62,34,"Charges > $500, x 34%",4995.62,percent of total billed charges,Implant Device,5142.55,35,,5142.55,percent of total billed charges,Implant Device,5142.55,35,,5142.55,percent of total billed charges,Implant Device,5142.55,35,,5142.55,percent of total billed charges,Implant Device,5142.55,35,,5142.55,percent of total billed charges,Implant Device,5142.55,35,,5142.55,percent of total billed charges,Implant Device,5877.2,40,,5877.2,percent of total billed charges,Implant Device,5142.55,70,,5142.55,percent of total billed charges,All Other,4995.62,34,,4995.62,percent of total billed charges,Implant Device,4995.62,34,,4995.62,percent of total billed charges,Implant Device,5142.55,35,,5142.55,percent of total billed charges,Implant Device,5142.55,35,,5142.55,percent of total billed charges,Implant Device,5142.55,35,,5142.55,percent of total billed charges,Implant Device,5142.55,35,,5142.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,4995.62,34,"If Charge > 2,000, then 34 percent",4995.62,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,10872.86,
STRYKER 657442 3.5X42MM BONE SCREW,C1713,HCPCS,,79009361,CDM,278,RC,,,both,,,294,217.56,,,217.56,Other,150% of Medicare + 9.63% HCRA Surcharge,132.3,45,,132.3,percent of total billed charges,Critical Access Hospital RCC factor,99.96,34,,99.96,percent of total billed charges,Implant Device,99.96,34,,99.96,percent of total billed charges,Implant Device,99.96,34,,99.96,percent of total billed charges,Implant Device,99.96,34,,99.96,percent of total billed charges,Implant Device,99.96,34,,99.96,percent of total billed charges,Implant Device,145.53,,,145.53,Other,110% of Medicare,102.9,35,,102.9,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,102.9,35,,102.9,percent of total billed charges,Implant Device,102.9,35,,102.9,percent of total billed charges,Implant Device,102.9,35,,102.9,percent of total billed charges,Implant Device,102.9,35,,102.9,percent of total billed charges,Implant Device,102.9,35,,102.9,percent of total billed charges,Implant Device,117.6,40,,117.6,percent of total billed charges,Implant Device,102.9,70,,102.9,percent of total billed charges,All Other,99.96,34,,99.96,percent of total billed charges,Implant Device,99.96,34,,99.96,percent of total billed charges,Implant Device,102.9,35,,102.9,percent of total billed charges,Implant Device,102.9,35,,102.9,percent of total billed charges,Implant Device,102.9,35,,102.9,percent of total billed charges,Implant Device,102.9,35,,102.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,217.56,
STRYKER 657338 3.5X38MM LOCKING SCREW,C1713,HCPCS,,79009362,CDM,278,RC,,,both,,,987,730.38,,,730.38,Other,150% of Medicare + 9.63% HCRA Surcharge,444.15,45,,444.15,percent of total billed charges,Critical Access Hospital RCC factor,335.58,34,,335.58,percent of total billed charges,Implant Device,335.58,34,,335.58,percent of total billed charges,Implant Device,335.58,34,,335.58,percent of total billed charges,Implant Device,335.58,34,,335.58,percent of total billed charges,Implant Device,335.58,34,,335.58,percent of total billed charges,Implant Device,488.57,,,488.57,Other,110% of Medicare,345.45,35,,345.45,percent of total billed charges,Implant Device,335.58,34,"Charges > $500, x 34%",335.58,percent of total billed charges,Implant Device,345.45,35,,345.45,percent of total billed charges,Implant Device,345.45,35,,345.45,percent of total billed charges,Implant Device,345.45,35,,345.45,percent of total billed charges,Implant Device,345.45,35,,345.45,percent of total billed charges,Implant Device,345.45,35,,345.45,percent of total billed charges,Implant Device,394.8,40,,394.8,percent of total billed charges,Implant Device,345.45,70,,345.45,percent of total billed charges,All Other,335.58,34,,335.58,percent of total billed charges,Implant Device,335.58,34,,335.58,percent of total billed charges,Implant Device,345.45,35,,345.45,percent of total billed charges,Implant Device,345.45,35,,345.45,percent of total billed charges,Implant Device,345.45,35,,345.45,percent of total billed charges,Implant Device,345.45,35,,345.45,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,730.38,
STRYKER 657330 3.5X30MM LOCKING SCREW,C1713,HCPCS,,79009363,CDM,278,RC,,,both,,,539,398.86,,,398.86,Other,150% of Medicare + 9.63% HCRA Surcharge,242.55,45,,242.55,percent of total billed charges,Critical Access Hospital RCC factor,183.26,34,,183.26,percent of total billed charges,Implant Device,183.26,34,,183.26,percent of total billed charges,Implant Device,183.26,34,,183.26,percent of total billed charges,Implant Device,183.26,34,,183.26,percent of total billed charges,Implant Device,183.26,34,,183.26,percent of total billed charges,Implant Device,266.81,,,266.81,Other,110% of Medicare,188.65,35,,188.65,percent of total billed charges,Implant Device,183.26,34,"Charges > $500, x 34%",183.26,percent of total billed charges,Implant Device,188.65,35,,188.65,percent of total billed charges,Implant Device,188.65,35,,188.65,percent of total billed charges,Implant Device,188.65,35,,188.65,percent of total billed charges,Implant Device,188.65,35,,188.65,percent of total billed charges,Implant Device,188.65,35,,188.65,percent of total billed charges,Implant Device,215.6,40,,215.6,percent of total billed charges,Implant Device,188.65,70,,188.65,percent of total billed charges,All Other,183.26,34,,183.26,percent of total billed charges,Implant Device,183.26,34,,183.26,percent of total billed charges,Implant Device,188.65,35,,188.65,percent of total billed charges,Implant Device,188.65,35,,188.65,percent of total billed charges,Implant Device,188.65,35,,188.65,percent of total billed charges,Implant Device,188.65,35,,188.65,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,398.86,
STRYKER 657332 3.5X32MM LOCKING SCREW,C1713,HCPCS,,79009364,CDM,278,RC,,,both,,,987,730.38,,,730.38,Other,150% of Medicare + 9.63% HCRA Surcharge,444.15,45,,444.15,percent of total billed charges,Critical Access Hospital RCC factor,335.58,34,,335.58,percent of total billed charges,Implant Device,335.58,34,,335.58,percent of total billed charges,Implant Device,335.58,34,,335.58,percent of total billed charges,Implant Device,335.58,34,,335.58,percent of total billed charges,Implant Device,335.58,34,,335.58,percent of total billed charges,Implant Device,488.57,,,488.57,Other,110% of Medicare,345.45,35,,345.45,percent of total billed charges,Implant Device,335.58,34,"Charges > $500, x 34%",335.58,percent of total billed charges,Implant Device,345.45,35,,345.45,percent of total billed charges,Implant Device,345.45,35,,345.45,percent of total billed charges,Implant Device,345.45,35,,345.45,percent of total billed charges,Implant Device,345.45,35,,345.45,percent of total billed charges,Implant Device,345.45,35,,345.45,percent of total billed charges,Implant Device,394.8,40,,394.8,percent of total billed charges,Implant Device,345.45,70,,345.45,percent of total billed charges,All Other,335.58,34,,335.58,percent of total billed charges,Implant Device,335.58,34,,335.58,percent of total billed charges,Implant Device,345.45,35,,345.45,percent of total billed charges,Implant Device,345.45,35,,345.45,percent of total billed charges,Implant Device,345.45,35,,345.45,percent of total billed charges,Implant Device,345.45,35,,345.45,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,730.38,
STRYKER 657446 3.5X46MM BONE SCREW,C1713,HCPCS,,79009365,CDM,278,RC,,,both,,,294,217.56,,,217.56,Other,150% of Medicare + 9.63% HCRA Surcharge,132.3,45,,132.3,percent of total billed charges,Critical Access Hospital RCC factor,99.96,34,,99.96,percent of total billed charges,Implant Device,99.96,34,,99.96,percent of total billed charges,Implant Device,99.96,34,,99.96,percent of total billed charges,Implant Device,99.96,34,,99.96,percent of total billed charges,Implant Device,99.96,34,,99.96,percent of total billed charges,Implant Device,145.53,,,145.53,Other,110% of Medicare,102.9,35,,102.9,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,102.9,35,,102.9,percent of total billed charges,Implant Device,102.9,35,,102.9,percent of total billed charges,Implant Device,102.9,35,,102.9,percent of total billed charges,Implant Device,102.9,35,,102.9,percent of total billed charges,Implant Device,102.9,35,,102.9,percent of total billed charges,Implant Device,117.6,40,,117.6,percent of total billed charges,Implant Device,102.9,70,,102.9,percent of total billed charges,All Other,99.96,34,,99.96,percent of total billed charges,Implant Device,99.96,34,,99.96,percent of total billed charges,Implant Device,102.9,35,,102.9,percent of total billed charges,Implant Device,102.9,35,,102.9,percent of total billed charges,Implant Device,102.9,35,,102.9,percent of total billed charges,Implant Device,102.9,35,,102.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,217.56,
ARTHREX AR-8943BL-04 DISTAL FIB PLATE LT,C1713,HCPCS,,79009366,CDM,278,RC,,,both,,,2358,1744.93,,,1744.93,Other,150% of Medicare + 9.63% HCRA Surcharge,1061.1,45,,1061.1,percent of total billed charges,Critical Access Hospital RCC factor,801.72,34,,801.72,percent of total billed charges,Implant Device,801.72,34,,801.72,percent of total billed charges,Implant Device,801.72,34,,801.72,percent of total billed charges,Implant Device,801.72,34,,801.72,percent of total billed charges,Implant Device,801.72,34,,801.72,percent of total billed charges,Implant Device,1167.21,,,1167.21,Other,110% of Medicare,825.3,35,,825.3,percent of total billed charges,Implant Device,801.72,34,"Charges > $500, x 34%",801.72,percent of total billed charges,Implant Device,825.3,35,,825.3,percent of total billed charges,Implant Device,825.3,35,,825.3,percent of total billed charges,Implant Device,825.3,35,,825.3,percent of total billed charges,Implant Device,825.3,35,,825.3,percent of total billed charges,Implant Device,825.3,35,,825.3,percent of total billed charges,Implant Device,943.2,40,,943.2,percent of total billed charges,Implant Device,825.3,70,,825.3,percent of total billed charges,All Other,801.72,34,,801.72,percent of total billed charges,Implant Device,801.72,34,,801.72,percent of total billed charges,Implant Device,825.3,35,,825.3,percent of total billed charges,Implant Device,825.3,35,,825.3,percent of total billed charges,Implant Device,825.3,35,,825.3,percent of total billed charges,Implant Device,825.3,35,,825.3,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,801.72,34,"If Charge > 2,000, then 34 percent",801.72,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1744.93,
ARTHREX AR-8835-30 CORT SCREW 3.5X30MM,C1713,HCPCS,,79009367,CDM,278,RC,,,both,,,150,111,,,111,Other,150% of Medicare + 9.63% HCRA Surcharge,67.5,45,,67.5,percent of total billed charges,Critical Access Hospital RCC factor,51,34,,51,percent of total billed charges,Implant Device,51,34,,51,percent of total billed charges,Implant Device,51,34,,51,percent of total billed charges,Implant Device,51,34,,51,percent of total billed charges,Implant Device,51,34,,51,percent of total billed charges,Implant Device,74.25,,,74.25,Other,110% of Medicare,52.5,35,,52.5,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,52.5,35,,52.5,percent of total billed charges,Implant Device,52.5,35,,52.5,percent of total billed charges,Implant Device,52.5,35,,52.5,percent of total billed charges,Implant Device,52.5,35,,52.5,percent of total billed charges,Implant Device,52.5,35,,52.5,percent of total billed charges,Implant Device,60,40,,60,percent of total billed charges,Implant Device,52.5,70,,52.5,percent of total billed charges,All Other,51,34,,51,percent of total billed charges,Implant Device,51,34,,51,percent of total billed charges,Implant Device,52.5,35,,52.5,percent of total billed charges,Implant Device,52.5,35,,52.5,percent of total billed charges,Implant Device,52.5,35,,52.5,percent of total billed charges,Implant Device,52.5,35,,52.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,111,
ARTHREX AR-8827-18 CORT SCREW 2.7X18MM,C1713,HCPCS,,79009368,CDM,278,RC,,,both,,,194,143.56,,,143.56,Other,150% of Medicare + 9.63% HCRA Surcharge,87.3,45,,87.3,percent of total billed charges,Critical Access Hospital RCC factor,65.96,34,,65.96,percent of total billed charges,Implant Device,65.96,34,,65.96,percent of total billed charges,Implant Device,65.96,34,,65.96,percent of total billed charges,Implant Device,65.96,34,,65.96,percent of total billed charges,Implant Device,65.96,34,,65.96,percent of total billed charges,Implant Device,96.03,,,96.03,Other,110% of Medicare,67.9,35,,67.9,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,67.9,35,,67.9,percent of total billed charges,Implant Device,67.9,35,,67.9,percent of total billed charges,Implant Device,67.9,35,,67.9,percent of total billed charges,Implant Device,67.9,35,,67.9,percent of total billed charges,Implant Device,67.9,35,,67.9,percent of total billed charges,Implant Device,77.6,40,,77.6,percent of total billed charges,Implant Device,67.9,70,,67.9,percent of total billed charges,All Other,65.96,34,,65.96,percent of total billed charges,Implant Device,65.96,34,,65.96,percent of total billed charges,Implant Device,67.9,35,,67.9,percent of total billed charges,Implant Device,67.9,35,,67.9,percent of total billed charges,Implant Device,67.9,35,,67.9,percent of total billed charges,Implant Device,67.9,35,,67.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,143.56,
ARTHREX AR-8827-24 CORT SCREW 2.7X24MM,C1713,HCPCS,,79009369,CDM,278,RC,,,both,,,135,99.9,,,99.9,Other,150% of Medicare + 9.63% HCRA Surcharge,60.75,45,,60.75,percent of total billed charges,Critical Access Hospital RCC factor,45.9,34,,45.9,percent of total billed charges,Implant Device,45.9,34,,45.9,percent of total billed charges,Implant Device,45.9,34,,45.9,percent of total billed charges,Implant Device,45.9,34,,45.9,percent of total billed charges,Implant Device,45.9,34,,45.9,percent of total billed charges,Implant Device,66.83,,,66.83,Other,110% of Medicare,47.25,35,,47.25,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,47.25,35,,47.25,percent of total billed charges,Implant Device,47.25,35,,47.25,percent of total billed charges,Implant Device,47.25,35,,47.25,percent of total billed charges,Implant Device,47.25,35,,47.25,percent of total billed charges,Implant Device,47.25,35,,47.25,percent of total billed charges,Implant Device,54,40,,54,percent of total billed charges,Implant Device,47.25,70,,47.25,percent of total billed charges,All Other,45.9,34,,45.9,percent of total billed charges,Implant Device,45.9,34,,45.9,percent of total billed charges,Implant Device,47.25,35,,47.25,percent of total billed charges,Implant Device,47.25,35,,47.25,percent of total billed charges,Implant Device,47.25,35,,47.25,percent of total billed charges,Implant Device,47.25,35,,47.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,99.9,
ARTHREX AR-8840C-30 CANN SCREW 4X30MM,C1713,HCPCS,,79009370,CDM,278,RC,,,both,,,495,366.3,,,366.3,Other,150% of Medicare + 9.63% HCRA Surcharge,222.75,45,,222.75,percent of total billed charges,Critical Access Hospital RCC factor,168.3,34,,168.3,percent of total billed charges,Implant Device,168.3,34,,168.3,percent of total billed charges,Implant Device,168.3,34,,168.3,percent of total billed charges,Implant Device,168.3,34,,168.3,percent of total billed charges,Implant Device,168.3,34,,168.3,percent of total billed charges,Implant Device,245.03,,,245.03,Other,110% of Medicare,173.25,35,,173.25,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,173.25,35,,173.25,percent of total billed charges,Implant Device,173.25,35,,173.25,percent of total billed charges,Implant Device,173.25,35,,173.25,percent of total billed charges,Implant Device,173.25,35,,173.25,percent of total billed charges,Implant Device,173.25,35,,173.25,percent of total billed charges,Implant Device,198,40,,198,percent of total billed charges,Implant Device,173.25,70,,173.25,percent of total billed charges,All Other,168.3,34,,168.3,percent of total billed charges,Implant Device,168.3,34,,168.3,percent of total billed charges,Implant Device,173.25,35,,173.25,percent of total billed charges,Implant Device,173.25,35,,173.25,percent of total billed charges,Implant Device,173.25,35,,173.25,percent of total billed charges,Implant Device,173.25,35,,173.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,366.3,
IN2BONES V30 ST308 LOCK SCREW 3X8MM,C1713,HCPCS,,79009372,CDM,278,RC,,,both,,,870,643.8,,,643.8,Other,150% of Medicare + 9.63% HCRA Surcharge,391.5,45,,391.5,percent of total billed charges,Critical Access Hospital RCC factor,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,430.65,,,430.65,Other,110% of Medicare,304.5,35,,304.5,percent of total billed charges,Implant Device,295.8,34,"Charges > $500, x 34%",295.8,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,348,40,,348,percent of total billed charges,Implant Device,304.5,70,,304.5,percent of total billed charges,All Other,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,643.8,
IN2BONES V35 ST314 LOCK SCREW 3.5X14MM,C1713,HCPCS,,79009373,CDM,278,RC,,,both,,,870,643.8,,,643.8,Other,150% of Medicare + 9.63% HCRA Surcharge,391.5,45,,391.5,percent of total billed charges,Critical Access Hospital RCC factor,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,430.65,,,430.65,Other,110% of Medicare,304.5,35,,304.5,percent of total billed charges,Implant Device,295.8,34,"Charges > $500, x 34%",295.8,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,348,40,,348,percent of total billed charges,Implant Device,304.5,70,,304.5,percent of total billed charges,All Other,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,643.8,
DEPUY SYNTHES L98014 CONRAIL REV STEM 14,C1776,HCPCS,,79009374,CDM,278,RC,,,both,,,23137,17121.44,,,17121.44,Other,150% of Medicare + 9.63% HCRA Surcharge,10411.65,45,,10411.65,percent of total billed charges,Critical Access Hospital RCC factor,7866.58,34,,7866.58,percent of total billed charges,Implant Device,7866.58,34,,7866.58,percent of total billed charges,Implant Device,7866.58,34,,7866.58,percent of total billed charges,Implant Device,7866.58,34,,7866.58,percent of total billed charges,Implant Device,7866.58,34,,7866.58,percent of total billed charges,Implant Device,11452.82,,,11452.82,Other,110% of Medicare,8097.95,35,,8097.95,percent of total billed charges,Implant Device,7866.58,34,"Charges > $500, x 34%",7866.58,percent of total billed charges,Implant Device,8097.95,35,,8097.95,percent of total billed charges,Implant Device,8097.95,35,,8097.95,percent of total billed charges,Implant Device,8097.95,35,,8097.95,percent of total billed charges,Implant Device,8097.95,35,,8097.95,percent of total billed charges,Implant Device,8097.95,35,,8097.95,percent of total billed charges,Implant Device,9254.8,40,,9254.8,percent of total billed charges,Implant Device,8097.95,70,,8097.95,percent of total billed charges,All Other,7866.58,34,,7866.58,percent of total billed charges,Implant Device,7866.58,34,,7866.58,percent of total billed charges,Implant Device,8097.95,35,,8097.95,percent of total billed charges,Implant Device,8097.95,35,,8097.95,percent of total billed charges,Implant Device,8097.95,35,,8097.95,percent of total billed charges,Implant Device,8097.95,35,,8097.95,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,7866.58,34,"If Charge > 2,000, then 34 percent",7866.58,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,17121.44,
DEPUY 1217-01-056 PINNACLE ACET CUP 56MM,C1776,HCPCS,,79009375,CDM,278,RC,,,both,,,4967,3675.59,,,3675.59,Other,150% of Medicare + 9.63% HCRA Surcharge,2235.15,45,,2235.15,percent of total billed charges,Critical Access Hospital RCC factor,1688.78,34,,1688.78,percent of total billed charges,Implant Device,1688.78,34,,1688.78,percent of total billed charges,Implant Device,1688.78,34,,1688.78,percent of total billed charges,Implant Device,1688.78,34,,1688.78,percent of total billed charges,Implant Device,1688.78,34,,1688.78,percent of total billed charges,Implant Device,2458.67,,,2458.67,Other,110% of Medicare,1738.45,35,,1738.45,percent of total billed charges,Implant Device,1688.78,34,"Charges > $500, x 34%",1688.78,percent of total billed charges,Implant Device,1738.45,35,,1738.45,percent of total billed charges,Implant Device,1738.45,35,,1738.45,percent of total billed charges,Implant Device,1738.45,35,,1738.45,percent of total billed charges,Implant Device,1738.45,35,,1738.45,percent of total billed charges,Implant Device,1738.45,35,,1738.45,percent of total billed charges,Implant Device,1986.8,40,,1986.8,percent of total billed charges,Implant Device,1738.45,70,,1738.45,percent of total billed charges,All Other,1688.78,34,,1688.78,percent of total billed charges,Implant Device,1688.78,34,,1688.78,percent of total billed charges,Implant Device,1738.45,35,,1738.45,percent of total billed charges,Implant Device,1738.45,35,,1738.45,percent of total billed charges,Implant Device,1738.45,35,,1738.45,percent of total billed charges,Implant Device,1738.45,35,,1738.45,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1688.78,34,"If Charge > 2,000, then 34 percent",1688.78,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3675.59,
DEPUY 1221-36-156 ALTRX +4 10D 36IDX560D,C1776,HCPCS,,79009376,CDM,278,RC,,,both,,,2565,1898.11,,,1898.11,Other,150% of Medicare + 9.63% HCRA Surcharge,1154.25,45,,1154.25,percent of total billed charges,Critical Access Hospital RCC factor,872.1,34,,872.1,percent of total billed charges,Implant Device,872.1,34,,872.1,percent of total billed charges,Implant Device,872.1,34,,872.1,percent of total billed charges,Implant Device,872.1,34,,872.1,percent of total billed charges,Implant Device,872.1,34,,872.1,percent of total billed charges,Implant Device,1269.68,,,1269.68,Other,110% of Medicare,897.75,35,,897.75,percent of total billed charges,Implant Device,872.1,34,"Charges > $500, x 34%",872.1,percent of total billed charges,Implant Device,897.75,35,,897.75,percent of total billed charges,Implant Device,897.75,35,,897.75,percent of total billed charges,Implant Device,897.75,35,,897.75,percent of total billed charges,Implant Device,897.75,35,,897.75,percent of total billed charges,Implant Device,897.75,35,,897.75,percent of total billed charges,Implant Device,1026,40,,1026,percent of total billed charges,Implant Device,897.75,70,,897.75,percent of total billed charges,All Other,872.1,34,,872.1,percent of total billed charges,Implant Device,872.1,34,,872.1,percent of total billed charges,Implant Device,897.75,35,,897.75,percent of total billed charges,Implant Device,897.75,35,,897.75,percent of total billed charges,Implant Device,897.75,35,,897.75,percent of total billed charges,Implant Device,897.75,35,,897.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,872.1,34,"If Charge > 2,000, then 34 percent",872.1,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1898.11,
DEPUY 04.005.524S LOCKING SCREW 5.0X34MM,C1713,HCPCS,,79009377,CDM,278,RC,,,both,,,412,304.88,,,304.88,Other,150% of Medicare + 9.63% HCRA Surcharge,185.4,45,,185.4,percent of total billed charges,Critical Access Hospital RCC factor,140.08,34,,140.08,percent of total billed charges,Implant Device,140.08,34,,140.08,percent of total billed charges,Implant Device,140.08,34,,140.08,percent of total billed charges,Implant Device,140.08,34,,140.08,percent of total billed charges,Implant Device,140.08,34,,140.08,percent of total billed charges,Implant Device,203.94,,,203.94,Other,110% of Medicare,144.2,35,,144.2,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,144.2,35,,144.2,percent of total billed charges,Implant Device,144.2,35,,144.2,percent of total billed charges,Implant Device,144.2,35,,144.2,percent of total billed charges,Implant Device,144.2,35,,144.2,percent of total billed charges,Implant Device,144.2,35,,144.2,percent of total billed charges,Implant Device,164.8,40,,164.8,percent of total billed charges,Implant Device,144.2,70,,144.2,percent of total billed charges,All Other,140.08,34,,140.08,percent of total billed charges,Implant Device,140.08,34,,140.08,percent of total billed charges,Implant Device,144.2,35,,144.2,percent of total billed charges,Implant Device,144.2,35,,144.2,percent of total billed charges,Implant Device,144.2,35,,144.2,percent of total billed charges,Implant Device,144.2,35,,144.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,304.88,
DEPUY 207.645 4.0X4MM CANNULATED SCREW,C1713,HCPCS,,79009378,CDM,278,RC,,,both,,,815,603.1,,,603.1,Other,150% of Medicare + 9.63% HCRA Surcharge,366.75,45,,366.75,percent of total billed charges,Critical Access Hospital RCC factor,277.1,34,,277.1,percent of total billed charges,Implant Device,277.1,34,,277.1,percent of total billed charges,Implant Device,277.1,34,,277.1,percent of total billed charges,Implant Device,277.1,34,,277.1,percent of total billed charges,Implant Device,277.1,34,,277.1,percent of total billed charges,Implant Device,403.43,,,403.43,Other,110% of Medicare,285.25,35,,285.25,percent of total billed charges,Implant Device,277.1,34,"Charges > $500, x 34%",277.1,percent of total billed charges,Implant Device,285.25,35,,285.25,percent of total billed charges,Implant Device,285.25,35,,285.25,percent of total billed charges,Implant Device,285.25,35,,285.25,percent of total billed charges,Implant Device,285.25,35,,285.25,percent of total billed charges,Implant Device,285.25,35,,285.25,percent of total billed charges,Implant Device,326,40,,326,percent of total billed charges,Implant Device,285.25,70,,285.25,percent of total billed charges,All Other,277.1,34,,277.1,percent of total billed charges,Implant Device,277.1,34,,277.1,percent of total billed charges,Implant Device,285.25,35,,285.25,percent of total billed charges,Implant Device,285.25,35,,285.25,percent of total billed charges,Implant Device,285.25,35,,285.25,percent of total billed charges,Implant Device,285.25,35,,285.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,603.1,
DEPUY 214.381 8 HOLE TIBIAL PLATE,C1713,HCPCS,,79009379,CDM,278,RC,,,both,,,756,559.44,,,559.44,Other,150% of Medicare + 9.63% HCRA Surcharge,340.2,45,,340.2,percent of total billed charges,Critical Access Hospital RCC factor,257.04,34,,257.04,percent of total billed charges,Implant Device,257.04,34,,257.04,percent of total billed charges,Implant Device,257.04,34,,257.04,percent of total billed charges,Implant Device,257.04,34,,257.04,percent of total billed charges,Implant Device,257.04,34,,257.04,percent of total billed charges,Implant Device,374.22,,,374.22,Other,110% of Medicare,264.6,35,,264.6,percent of total billed charges,Implant Device,257.04,34,"Charges > $500, x 34%",257.04,percent of total billed charges,Implant Device,264.6,35,,264.6,percent of total billed charges,Implant Device,264.6,35,,264.6,percent of total billed charges,Implant Device,264.6,35,,264.6,percent of total billed charges,Implant Device,264.6,35,,264.6,percent of total billed charges,Implant Device,264.6,35,,264.6,percent of total billed charges,Implant Device,302.4,40,,302.4,percent of total billed charges,Implant Device,264.6,70,,264.6,percent of total billed charges,All Other,257.04,34,,257.04,percent of total billed charges,Implant Device,257.04,34,,257.04,percent of total billed charges,Implant Device,264.6,35,,264.6,percent of total billed charges,Implant Device,264.6,35,,264.6,percent of total billed charges,Implant Device,264.6,35,,264.6,percent of total billed charges,Implant Device,264.6,35,,264.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,559.44,
DEPUY 1516-30-707 TIBIAL INSERT SZ 7 7MM,C1776,HCPCS,,79009380,CDM,278,RC,,,both,,,5400,3996.01,,,3996.01,Other,150% of Medicare + 9.63% HCRA Surcharge,2430,45,,2430,percent of total billed charges,Critical Access Hospital RCC factor,1836,34,,1836,percent of total billed charges,Implant Device,1836,34,,1836,percent of total billed charges,Implant Device,1836,34,,1836,percent of total billed charges,Implant Device,1836,34,,1836,percent of total billed charges,Implant Device,1836,34,,1836,percent of total billed charges,Implant Device,2673,,,2673,Other,110% of Medicare,1890,35,,1890,percent of total billed charges,Implant Device,1836,34,"Charges > $500, x 34%",1836,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,2160,40,,2160,percent of total billed charges,Implant Device,1890,70,,1890,percent of total billed charges,All Other,1836,34,,1836,percent of total billed charges,Implant Device,1836,34,,1836,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1836,34,"If Charge > 2,000, then 34 percent",1836,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3996.01,
WRIGHT 4260050 FLEX HINGE TOE IMP SZ 5,C1776,HCPCS,,79009382,CDM,278,RC,,,both,,,4296,3179.05,,,3179.05,Other,150% of Medicare + 9.63% HCRA Surcharge,1933.2,45,,1933.2,percent of total billed charges,Critical Access Hospital RCC factor,1460.64,34,,1460.64,percent of total billed charges,Implant Device,1460.64,34,,1460.64,percent of total billed charges,Implant Device,1460.64,34,,1460.64,percent of total billed charges,Implant Device,1460.64,34,,1460.64,percent of total billed charges,Implant Device,1460.64,34,,1460.64,percent of total billed charges,Implant Device,2126.52,,,2126.52,Other,110% of Medicare,1503.6,35,,1503.6,percent of total billed charges,Implant Device,1460.64,34,"Charges > $500, x 34%",1460.64,percent of total billed charges,Implant Device,1503.6,35,,1503.6,percent of total billed charges,Implant Device,1503.6,35,,1503.6,percent of total billed charges,Implant Device,1503.6,35,,1503.6,percent of total billed charges,Implant Device,1503.6,35,,1503.6,percent of total billed charges,Implant Device,1503.6,35,,1503.6,percent of total billed charges,Implant Device,1718.4,40,,1718.4,percent of total billed charges,Implant Device,1503.6,70,,1503.6,percent of total billed charges,All Other,1460.64,34,,1460.64,percent of total billed charges,Implant Device,1460.64,34,,1460.64,percent of total billed charges,Implant Device,1503.6,35,,1503.6,percent of total billed charges,Implant Device,1503.6,35,,1503.6,percent of total billed charges,Implant Device,1503.6,35,,1503.6,percent of total billed charges,Implant Device,1503.6,35,,1503.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1460.64,34,"If Charge > 2,000, then 34 percent",1460.64,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3179.05,
EXACTECH 300-01-10 HUMERAL STEM 10MM,C1776,HCPCS,,79009383,CDM,278,RC,,,both,,,4425,3274.51,,,3274.51,Other,150% of Medicare + 9.63% HCRA Surcharge,1991.25,45,,1991.25,percent of total billed charges,Critical Access Hospital RCC factor,1504.5,34,,1504.5,percent of total billed charges,Implant Device,1504.5,34,,1504.5,percent of total billed charges,Implant Device,1504.5,34,,1504.5,percent of total billed charges,Implant Device,1504.5,34,,1504.5,percent of total billed charges,Implant Device,1504.5,34,,1504.5,percent of total billed charges,Implant Device,2190.38,,,2190.38,Other,110% of Medicare,1548.75,35,,1548.75,percent of total billed charges,Implant Device,1504.5,34,"Charges > $500, x 34%",1504.5,percent of total billed charges,Implant Device,1548.75,35,,1548.75,percent of total billed charges,Implant Device,1548.75,35,,1548.75,percent of total billed charges,Implant Device,1548.75,35,,1548.75,percent of total billed charges,Implant Device,1548.75,35,,1548.75,percent of total billed charges,Implant Device,1548.75,35,,1548.75,percent of total billed charges,Implant Device,1770,40,,1770,percent of total billed charges,Implant Device,1548.75,70,,1548.75,percent of total billed charges,All Other,1504.5,34,,1504.5,percent of total billed charges,Implant Device,1504.5,34,,1504.5,percent of total billed charges,Implant Device,1548.75,35,,1548.75,percent of total billed charges,Implant Device,1548.75,35,,1548.75,percent of total billed charges,Implant Device,1548.75,35,,1548.75,percent of total billed charges,Implant Device,1548.75,35,,1548.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1504.5,34,"If Charge > 2,000, then 34 percent",1504.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3274.51,
ZIMMER 00-6250-65-40 BONE SCREW 6.5X40MM,C1713,HCPCS,,79009384,CDM,278,RC,,,both,,,428,316.72,,,316.72,Other,150% of Medicare + 9.63% HCRA Surcharge,192.6,45,,192.6,percent of total billed charges,Critical Access Hospital RCC factor,145.52,34,,145.52,percent of total billed charges,Implant Device,145.52,34,,145.52,percent of total billed charges,Implant Device,145.52,34,,145.52,percent of total billed charges,Implant Device,145.52,34,,145.52,percent of total billed charges,Implant Device,145.52,34,,145.52,percent of total billed charges,Implant Device,211.86,,,211.86,Other,110% of Medicare,149.8,35,,149.8,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,149.8,35,,149.8,percent of total billed charges,Implant Device,149.8,35,,149.8,percent of total billed charges,Implant Device,149.8,35,,149.8,percent of total billed charges,Implant Device,149.8,35,,149.8,percent of total billed charges,Implant Device,149.8,35,,149.8,percent of total billed charges,Implant Device,171.2,40,,171.2,percent of total billed charges,Implant Device,149.8,70,,149.8,percent of total billed charges,All Other,145.52,34,,145.52,percent of total billed charges,Implant Device,145.52,34,,145.52,percent of total billed charges,Implant Device,149.8,35,,149.8,percent of total billed charges,Implant Device,149.8,35,,149.8,percent of total billed charges,Implant Device,149.8,35,,149.8,percent of total billed charges,Implant Device,149.8,35,,149.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,316.72,
STRYKER ORTHO 897003 HYDROSET XT,C1713,HCPCS,,79009385,CDM,278,RC,,,both,,,2814,2082.37,,,2082.37,Other,150% of Medicare + 9.63% HCRA Surcharge,1266.3,45,,1266.3,percent of total billed charges,Critical Access Hospital RCC factor,956.76,34,,956.76,percent of total billed charges,Implant Device,956.76,34,,956.76,percent of total billed charges,Implant Device,956.76,34,,956.76,percent of total billed charges,Implant Device,956.76,34,,956.76,percent of total billed charges,Implant Device,956.76,34,,956.76,percent of total billed charges,Implant Device,1392.93,,,1392.93,Other,110% of Medicare,984.9,35,,984.9,percent of total billed charges,Implant Device,956.76,34,"Charges > $500, x 34%",956.76,percent of total billed charges,Implant Device,984.9,35,,984.9,percent of total billed charges,Implant Device,984.9,35,,984.9,percent of total billed charges,Implant Device,984.9,35,,984.9,percent of total billed charges,Implant Device,984.9,35,,984.9,percent of total billed charges,Implant Device,984.9,35,,984.9,percent of total billed charges,Implant Device,1125.6,40,,1125.6,percent of total billed charges,Implant Device,984.9,70,,984.9,percent of total billed charges,All Other,956.76,34,,956.76,percent of total billed charges,Implant Device,956.76,34,,956.76,percent of total billed charges,Implant Device,984.9,35,,984.9,percent of total billed charges,Implant Device,984.9,35,,984.9,percent of total billed charges,Implant Device,984.9,35,,984.9,percent of total billed charges,Implant Device,984.9,35,,984.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,956.76,34,"If Charge > 2,000, then 34 percent",956.76,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2082.37,
ARTHREX AR-8929BC-CP ACHILLES SPEEDBRDGE,C1713,HCPCS,,79009386,CDM,278,RC,,,both,,,2925,2164.51,,,2164.51,Other,150% of Medicare + 9.63% HCRA Surcharge,1316.25,45,,1316.25,percent of total billed charges,Critical Access Hospital RCC factor,994.5,34,,994.5,percent of total billed charges,Implant Device,994.5,34,,994.5,percent of total billed charges,Implant Device,994.5,34,,994.5,percent of total billed charges,Implant Device,994.5,34,,994.5,percent of total billed charges,Implant Device,994.5,34,,994.5,percent of total billed charges,Implant Device,1447.88,,,1447.88,Other,110% of Medicare,1023.75,35,,1023.75,percent of total billed charges,Implant Device,994.5,34,"Charges > $500, x 34%",994.5,percent of total billed charges,Implant Device,1023.75,35,,1023.75,percent of total billed charges,Implant Device,1023.75,35,,1023.75,percent of total billed charges,Implant Device,1023.75,35,,1023.75,percent of total billed charges,Implant Device,1023.75,35,,1023.75,percent of total billed charges,Implant Device,1023.75,35,,1023.75,percent of total billed charges,Implant Device,1170,40,,1170,percent of total billed charges,Implant Device,1023.75,70,,1023.75,percent of total billed charges,All Other,994.5,34,,994.5,percent of total billed charges,Implant Device,994.5,34,,994.5,percent of total billed charges,Implant Device,1023.75,35,,1023.75,percent of total billed charges,Implant Device,1023.75,35,,1023.75,percent of total billed charges,Implant Device,1023.75,35,,1023.75,percent of total billed charges,Implant Device,1023.75,35,,1023.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,994.5,34,"If Charge > 2,000, then 34 percent",994.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2164.51,
DEPUY 462.644 TI SPIRAL BLADE 44MM,C1713,HCPCS,,79009387,CDM,278,RC,,,both,,,1278,945.72,,,945.72,Other,150% of Medicare + 9.63% HCRA Surcharge,575.1,45,,575.1,percent of total billed charges,Critical Access Hospital RCC factor,434.52,34,,434.52,percent of total billed charges,Implant Device,434.52,34,,434.52,percent of total billed charges,Implant Device,434.52,34,,434.52,percent of total billed charges,Implant Device,434.52,34,,434.52,percent of total billed charges,Implant Device,434.52,34,,434.52,percent of total billed charges,Implant Device,632.61,,,632.61,Other,110% of Medicare,447.3,35,,447.3,percent of total billed charges,Implant Device,434.52,34,"Charges > $500, x 34%",434.52,percent of total billed charges,Implant Device,447.3,35,,447.3,percent of total billed charges,Implant Device,447.3,35,,447.3,percent of total billed charges,Implant Device,447.3,35,,447.3,percent of total billed charges,Implant Device,447.3,35,,447.3,percent of total billed charges,Implant Device,447.3,35,,447.3,percent of total billed charges,Implant Device,511.2,40,,511.2,percent of total billed charges,Implant Device,447.3,70,,447.3,percent of total billed charges,All Other,434.52,34,,434.52,percent of total billed charges,Implant Device,434.52,34,,434.52,percent of total billed charges,Implant Device,447.3,35,,447.3,percent of total billed charges,Implant Device,447.3,35,,447.3,percent of total billed charges,Implant Device,447.3,35,,447.3,percent of total billed charges,Implant Device,447.3,35,,447.3,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,945.72,
DEPUY 04.005.442 LOCKING SCREW 4.0X52MM,C1713,HCPCS,,79009388,CDM,278,RC,,,both,,,730,540.2,,,540.2,Other,150% of Medicare + 9.63% HCRA Surcharge,328.5,45,,328.5,percent of total billed charges,Critical Access Hospital RCC factor,248.2,34,,248.2,percent of total billed charges,Implant Device,248.2,34,,248.2,percent of total billed charges,Implant Device,248.2,34,,248.2,percent of total billed charges,Implant Device,248.2,34,,248.2,percent of total billed charges,Implant Device,248.2,34,,248.2,percent of total billed charges,Implant Device,361.35,,,361.35,Other,110% of Medicare,255.5,35,,255.5,percent of total billed charges,Implant Device,248.2,34,"Charges > $500, x 34%",248.2,percent of total billed charges,Implant Device,255.5,35,,255.5,percent of total billed charges,Implant Device,255.5,35,,255.5,percent of total billed charges,Implant Device,255.5,35,,255.5,percent of total billed charges,Implant Device,255.5,35,,255.5,percent of total billed charges,Implant Device,255.5,35,,255.5,percent of total billed charges,Implant Device,292,40,,292,percent of total billed charges,Implant Device,255.5,70,,255.5,percent of total billed charges,All Other,248.2,34,,248.2,percent of total billed charges,Implant Device,248.2,34,,248.2,percent of total billed charges,Implant Device,255.5,35,,255.5,percent of total billed charges,Implant Device,255.5,35,,255.5,percent of total billed charges,Implant Device,255.5,35,,255.5,percent of total billed charges,Implant Device,255.5,35,,255.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,540.2,
IN2BONES S80 ST185 IBS SCREW 8.0X85MM,C1713,HCPCS,,79009389,CDM,278,RC,,,both,,,3585,2652.91,,,2652.91,Other,150% of Medicare + 9.63% HCRA Surcharge,1613.25,45,,1613.25,percent of total billed charges,Critical Access Hospital RCC factor,1218.9,34,,1218.9,percent of total billed charges,Implant Device,1218.9,34,,1218.9,percent of total billed charges,Implant Device,1218.9,34,,1218.9,percent of total billed charges,Implant Device,1218.9,34,,1218.9,percent of total billed charges,Implant Device,1218.9,34,,1218.9,percent of total billed charges,Implant Device,1774.58,,,1774.58,Other,110% of Medicare,1254.75,35,,1254.75,percent of total billed charges,Implant Device,1218.9,34,"Charges > $500, x 34%",1218.9,percent of total billed charges,Implant Device,1254.75,35,,1254.75,percent of total billed charges,Implant Device,1254.75,35,,1254.75,percent of total billed charges,Implant Device,1254.75,35,,1254.75,percent of total billed charges,Implant Device,1254.75,35,,1254.75,percent of total billed charges,Implant Device,1254.75,35,,1254.75,percent of total billed charges,Implant Device,1434,40,,1434,percent of total billed charges,Implant Device,1254.75,70,,1254.75,percent of total billed charges,All Other,1218.9,34,,1218.9,percent of total billed charges,Implant Device,1218.9,34,,1218.9,percent of total billed charges,Implant Device,1254.75,35,,1254.75,percent of total billed charges,Implant Device,1254.75,35,,1254.75,percent of total billed charges,Implant Device,1254.75,35,,1254.75,percent of total billed charges,Implant Device,1254.75,35,,1254.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1218.9,34,"If Charge > 2,000, then 34 percent",1218.9,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2652.91,
IN2BONES BGP001-02 BIOV W/PUTTY 2CC,C1713,HCPCS,,79009390,CDM,278,RC,,,both,,,5505,4073.71,,,4073.71,Other,150% of Medicare + 9.63% HCRA Surcharge,2477.25,45,,2477.25,percent of total billed charges,Critical Access Hospital RCC factor,1871.7,34,,1871.7,percent of total billed charges,Implant Device,1871.7,34,,1871.7,percent of total billed charges,Implant Device,1871.7,34,,1871.7,percent of total billed charges,Implant Device,1871.7,34,,1871.7,percent of total billed charges,Implant Device,1871.7,34,,1871.7,percent of total billed charges,Implant Device,2724.98,,,2724.98,Other,110% of Medicare,1926.75,35,,1926.75,percent of total billed charges,Implant Device,1871.7,34,"Charges > $500, x 34%",1871.7,percent of total billed charges,Implant Device,1926.75,35,,1926.75,percent of total billed charges,Implant Device,1926.75,35,,1926.75,percent of total billed charges,Implant Device,1926.75,35,,1926.75,percent of total billed charges,Implant Device,1926.75,35,,1926.75,percent of total billed charges,Implant Device,1926.75,35,,1926.75,percent of total billed charges,Implant Device,2202,40,,2202,percent of total billed charges,Implant Device,1926.75,70,,1926.75,percent of total billed charges,All Other,1871.7,34,,1871.7,percent of total billed charges,Implant Device,1871.7,34,,1871.7,percent of total billed charges,Implant Device,1926.75,35,,1926.75,percent of total billed charges,Implant Device,1926.75,35,,1926.75,percent of total billed charges,Implant Device,1926.75,35,,1926.75,percent of total billed charges,Implant Device,1926.75,35,,1926.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1871.7,34,"If Charge > 2,000, then 34 percent",1871.7,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4073.71,
IN2BONES P65 ST685 COLAG SCREW 6.7X85MM,C1713,HCPCS,,79009393,CDM,278,RC,,,both,,,3225,2386.51,,,2386.51,Other,150% of Medicare + 9.63% HCRA Surcharge,1451.25,45,,1451.25,percent of total billed charges,Critical Access Hospital RCC factor,1096.5,34,,1096.5,percent of total billed charges,Implant Device,1096.5,34,,1096.5,percent of total billed charges,Implant Device,1096.5,34,,1096.5,percent of total billed charges,Implant Device,1096.5,34,,1096.5,percent of total billed charges,Implant Device,1096.5,34,,1096.5,percent of total billed charges,Implant Device,1596.38,,,1596.38,Other,110% of Medicare,1128.75,35,,1128.75,percent of total billed charges,Implant Device,1096.5,34,"Charges > $500, x 34%",1096.5,percent of total billed charges,Implant Device,1128.75,35,,1128.75,percent of total billed charges,Implant Device,1128.75,35,,1128.75,percent of total billed charges,Implant Device,1128.75,35,,1128.75,percent of total billed charges,Implant Device,1128.75,35,,1128.75,percent of total billed charges,Implant Device,1128.75,35,,1128.75,percent of total billed charges,Implant Device,1290,40,,1290,percent of total billed charges,Implant Device,1128.75,70,,1128.75,percent of total billed charges,All Other,1096.5,34,,1096.5,percent of total billed charges,Implant Device,1096.5,34,,1096.5,percent of total billed charges,Implant Device,1128.75,35,,1128.75,percent of total billed charges,Implant Device,1128.75,35,,1128.75,percent of total billed charges,Implant Device,1128.75,35,,1128.75,percent of total billed charges,Implant Device,1128.75,35,,1128.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1096.5,34,"If Charge > 2,000, then 34 percent",1096.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2386.51,
STRYKER 141-2522 HEADLESS SCREW 2.5X22MM,C1713,HCPCS,,79009396,CDM,278,RC,,,both,,,1557,1152.18,,,1152.18,Other,150% of Medicare + 9.63% HCRA Surcharge,700.65,45,,700.65,percent of total billed charges,Critical Access Hospital RCC factor,529.38,34,,529.38,percent of total billed charges,Implant Device,529.38,34,,529.38,percent of total billed charges,Implant Device,529.38,34,,529.38,percent of total billed charges,Implant Device,529.38,34,,529.38,percent of total billed charges,Implant Device,529.38,34,,529.38,percent of total billed charges,Implant Device,770.72,,,770.72,Other,110% of Medicare,544.95,35,,544.95,percent of total billed charges,Implant Device,529.38,34,"Charges > $500, x 34%",529.38,percent of total billed charges,Implant Device,544.95,35,,544.95,percent of total billed charges,Implant Device,544.95,35,,544.95,percent of total billed charges,Implant Device,544.95,35,,544.95,percent of total billed charges,Implant Device,544.95,35,,544.95,percent of total billed charges,Implant Device,544.95,35,,544.95,percent of total billed charges,Implant Device,622.8,40,,622.8,percent of total billed charges,Implant Device,544.95,70,,544.95,percent of total billed charges,All Other,529.38,34,,529.38,percent of total billed charges,Implant Device,529.38,34,,529.38,percent of total billed charges,Implant Device,544.95,35,,544.95,percent of total billed charges,Implant Device,544.95,35,,544.95,percent of total billed charges,Implant Device,544.95,35,,544.95,percent of total billed charges,Implant Device,544.95,35,,544.95,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1152.18,
RTI M3C005 ALLOGENEIC BONE GRAFT - 5CC,C1713,HCPCS,,79009398,CDM,278,RC,,,both,,,7500,5550.02,,,5550.02,Other,150% of Medicare + 9.63% HCRA Surcharge,3375,45,,3375,percent of total billed charges,Critical Access Hospital RCC factor,2550,34,,2550,percent of total billed charges,Implant Device,2550,34,,2550,percent of total billed charges,Implant Device,2550,34,,2550,percent of total billed charges,Implant Device,2550,34,,2550,percent of total billed charges,Implant Device,2550,34,,2550,percent of total billed charges,Implant Device,3712.5,,,3712.5,Other,110% of Medicare,2625,35,,2625,percent of total billed charges,Implant Device,2550,34,"Charges > $500, x 34%",2550,percent of total billed charges,Implant Device,2625,35,,2625,percent of total billed charges,Implant Device,2625,35,,2625,percent of total billed charges,Implant Device,2625,35,,2625,percent of total billed charges,Implant Device,2625,35,,2625,percent of total billed charges,Implant Device,2625,35,,2625,percent of total billed charges,Implant Device,3000,40,,3000,percent of total billed charges,Implant Device,2625,70,,2625,percent of total billed charges,All Other,2550,34,,2550,percent of total billed charges,Implant Device,2550,34,,2550,percent of total billed charges,Implant Device,2625,35,,2625,percent of total billed charges,Implant Device,2625,35,,2625,percent of total billed charges,Implant Device,2625,35,,2625,percent of total billed charges,Implant Device,2625,35,,2625,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2550,34,"If Charge > 2,000, then 34 percent",2550,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5550.02,
STABILITY SB 895 TENODESIS ALLOGRAFT,C1713,HCPCS,,79009402,CDM,278,RC,,,both,,,5325,3940.51,,,3940.51,Other,150% of Medicare + 9.63% HCRA Surcharge,2396.25,45,,2396.25,percent of total billed charges,Critical Access Hospital RCC factor,1810.5,34,,1810.5,percent of total billed charges,Implant Device,1810.5,34,,1810.5,percent of total billed charges,Implant Device,1810.5,34,,1810.5,percent of total billed charges,Implant Device,1810.5,34,,1810.5,percent of total billed charges,Implant Device,1810.5,34,,1810.5,percent of total billed charges,Implant Device,2635.88,,,2635.88,Other,110% of Medicare,1863.75,35,,1863.75,percent of total billed charges,Implant Device,1810.5,34,"Charges > $500, x 34%",1810.5,percent of total billed charges,Implant Device,1863.75,35,,1863.75,percent of total billed charges,Implant Device,1863.75,35,,1863.75,percent of total billed charges,Implant Device,1863.75,35,,1863.75,percent of total billed charges,Implant Device,1863.75,35,,1863.75,percent of total billed charges,Implant Device,1863.75,35,,1863.75,percent of total billed charges,Implant Device,2130,40,,2130,percent of total billed charges,Implant Device,1863.75,70,,1863.75,percent of total billed charges,All Other,1810.5,34,,1810.5,percent of total billed charges,Implant Device,1810.5,34,,1810.5,percent of total billed charges,Implant Device,1863.75,35,,1863.75,percent of total billed charges,Implant Device,1863.75,35,,1863.75,percent of total billed charges,Implant Device,1863.75,35,,1863.75,percent of total billed charges,Implant Device,1863.75,35,,1863.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1810.5,34,"If Charge > 2,000, then 34 percent",1810.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3940.51,
STRYKER 629548 8 HOLE NARROW COMP PLATE,C1713,HCPCS,,79009403,CDM,278,RC,,,both,,,1873,1386.02,,,1386.02,Other,150% of Medicare + 9.63% HCRA Surcharge,842.85,45,,842.85,percent of total billed charges,Critical Access Hospital RCC factor,636.82,34,,636.82,percent of total billed charges,Implant Device,636.82,34,,636.82,percent of total billed charges,Implant Device,636.82,34,,636.82,percent of total billed charges,Implant Device,636.82,34,,636.82,percent of total billed charges,Implant Device,636.82,34,,636.82,percent of total billed charges,Implant Device,927.14,,,927.14,Other,110% of Medicare,655.55,35,,655.55,percent of total billed charges,Implant Device,636.82,34,"Charges > $500, x 34%",636.82,percent of total billed charges,Implant Device,655.55,35,,655.55,percent of total billed charges,Implant Device,655.55,35,,655.55,percent of total billed charges,Implant Device,655.55,35,,655.55,percent of total billed charges,Implant Device,655.55,35,,655.55,percent of total billed charges,Implant Device,655.55,35,,655.55,percent of total billed charges,Implant Device,749.2,40,,749.2,percent of total billed charges,Implant Device,655.55,70,,655.55,percent of total billed charges,All Other,636.82,34,,636.82,percent of total billed charges,Implant Device,636.82,34,,636.82,percent of total billed charges,Implant Device,655.55,35,,655.55,percent of total billed charges,Implant Device,655.55,35,,655.55,percent of total billed charges,Implant Device,655.55,35,,655.55,percent of total billed charges,Implant Device,655.55,35,,655.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1386.02,
STRYKER 657410 3.5X10MM NON-LOCK SCREW,C1713,HCPCS,,79009404,CDM,278,RC,,,both,,,294,217.56,,,217.56,Other,150% of Medicare + 9.63% HCRA Surcharge,132.3,45,,132.3,percent of total billed charges,Critical Access Hospital RCC factor,99.96,34,,99.96,percent of total billed charges,Implant Device,99.96,34,,99.96,percent of total billed charges,Implant Device,99.96,34,,99.96,percent of total billed charges,Implant Device,99.96,34,,99.96,percent of total billed charges,Implant Device,99.96,34,,99.96,percent of total billed charges,Implant Device,145.53,,,145.53,Other,110% of Medicare,102.9,35,,102.9,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,102.9,35,,102.9,percent of total billed charges,Implant Device,102.9,35,,102.9,percent of total billed charges,Implant Device,102.9,35,,102.9,percent of total billed charges,Implant Device,102.9,35,,102.9,percent of total billed charges,Implant Device,102.9,35,,102.9,percent of total billed charges,Implant Device,117.6,40,,117.6,percent of total billed charges,Implant Device,102.9,70,,102.9,percent of total billed charges,All Other,99.96,34,,99.96,percent of total billed charges,Implant Device,99.96,34,,99.96,percent of total billed charges,Implant Device,102.9,35,,102.9,percent of total billed charges,Implant Device,102.9,35,,102.9,percent of total billed charges,Implant Device,102.9,35,,102.9,percent of total billed charges,Implant Device,102.9,35,,102.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,217.56,
DEPUY 1035-46-000 SELF CTR HIP 46X28,C1776,HCPCS,,79009405,CDM,278,RC,,,both,,,1733,1282.42,,,1282.42,Other,150% of Medicare + 9.63% HCRA Surcharge,779.85,45,,779.85,percent of total billed charges,Critical Access Hospital RCC factor,589.22,34,,589.22,percent of total billed charges,Implant Device,589.22,34,,589.22,percent of total billed charges,Implant Device,589.22,34,,589.22,percent of total billed charges,Implant Device,589.22,34,,589.22,percent of total billed charges,Implant Device,589.22,34,,589.22,percent of total billed charges,Implant Device,857.84,,,857.84,Other,110% of Medicare,606.55,35,,606.55,percent of total billed charges,Implant Device,589.22,34,"Charges > $500, x 34%",589.22,percent of total billed charges,Implant Device,606.55,35,,606.55,percent of total billed charges,Implant Device,606.55,35,,606.55,percent of total billed charges,Implant Device,606.55,35,,606.55,percent of total billed charges,Implant Device,606.55,35,,606.55,percent of total billed charges,Implant Device,606.55,35,,606.55,percent of total billed charges,Implant Device,693.2,40,,693.2,percent of total billed charges,Implant Device,606.55,70,,606.55,percent of total billed charges,All Other,589.22,34,,589.22,percent of total billed charges,Implant Device,589.22,34,,589.22,percent of total billed charges,Implant Device,606.55,35,,606.55,percent of total billed charges,Implant Device,606.55,35,,606.55,percent of total billed charges,Implant Device,606.55,35,,606.55,percent of total billed charges,Implant Device,606.55,35,,606.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1282.42,
ARTHREX AR-8970AL ANTERIOP FUSION PLT LT,C1713,HCPCS,,79009406,CDM,278,RC,,,both,,,8895,6582.32,,,6582.32,Other,150% of Medicare + 9.63% HCRA Surcharge,4002.75,45,,4002.75,percent of total billed charges,Critical Access Hospital RCC factor,3024.3,34,,3024.3,percent of total billed charges,Implant Device,3024.3,34,,3024.3,percent of total billed charges,Implant Device,3024.3,34,,3024.3,percent of total billed charges,Implant Device,3024.3,34,,3024.3,percent of total billed charges,Implant Device,3024.3,34,,3024.3,percent of total billed charges,Implant Device,4403.03,,,4403.03,Other,110% of Medicare,3113.25,35,,3113.25,percent of total billed charges,Implant Device,3024.3,34,"Charges > $500, x 34%",3024.3,percent of total billed charges,Implant Device,3113.25,35,,3113.25,percent of total billed charges,Implant Device,3113.25,35,,3113.25,percent of total billed charges,Implant Device,3113.25,35,,3113.25,percent of total billed charges,Implant Device,3113.25,35,,3113.25,percent of total billed charges,Implant Device,3113.25,35,,3113.25,percent of total billed charges,Implant Device,3558,40,,3558,percent of total billed charges,Implant Device,3113.25,70,,3113.25,percent of total billed charges,All Other,3024.3,34,,3024.3,percent of total billed charges,Implant Device,3024.3,34,,3024.3,percent of total billed charges,Implant Device,3113.25,35,,3113.25,percent of total billed charges,Implant Device,3113.25,35,,3113.25,percent of total billed charges,Implant Device,3113.25,35,,3113.25,percent of total billed charges,Implant Device,3113.25,35,,3113.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3024.3,34,"If Charge > 2,000, then 34 percent",3024.3,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,6582.32,
ARTHREX AR-8545-32 CORTICAL SCREW 4.5X32,C1713,HCPCS,,79009407,CDM,278,RC,,,both,,,225,166.5,,,166.5,Other,150% of Medicare + 9.63% HCRA Surcharge,101.25,45,,101.25,percent of total billed charges,Critical Access Hospital RCC factor,76.5,34,,76.5,percent of total billed charges,Implant Device,76.5,34,,76.5,percent of total billed charges,Implant Device,76.5,34,,76.5,percent of total billed charges,Implant Device,76.5,34,,76.5,percent of total billed charges,Implant Device,76.5,34,,76.5,percent of total billed charges,Implant Device,111.38,,,111.38,Other,110% of Medicare,78.75,35,,78.75,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,78.75,35,,78.75,percent of total billed charges,Implant Device,78.75,35,,78.75,percent of total billed charges,Implant Device,78.75,35,,78.75,percent of total billed charges,Implant Device,78.75,35,,78.75,percent of total billed charges,Implant Device,78.75,35,,78.75,percent of total billed charges,Implant Device,90,40,,90,percent of total billed charges,Implant Device,78.75,70,,78.75,percent of total billed charges,All Other,76.5,34,,76.5,percent of total billed charges,Implant Device,76.5,34,,76.5,percent of total billed charges,Implant Device,78.75,35,,78.75,percent of total billed charges,Implant Device,78.75,35,,78.75,percent of total billed charges,Implant Device,78.75,35,,78.75,percent of total billed charges,Implant Device,78.75,35,,78.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,166.5,
ARTHREX AR-8545-34 CORTICAL SCREW 4.5X34,C1713,HCPCS,,79009408,CDM,278,RC,,,both,,,225,166.5,,,166.5,Other,150% of Medicare + 9.63% HCRA Surcharge,101.25,45,,101.25,percent of total billed charges,Critical Access Hospital RCC factor,76.5,34,,76.5,percent of total billed charges,Implant Device,76.5,34,,76.5,percent of total billed charges,Implant Device,76.5,34,,76.5,percent of total billed charges,Implant Device,76.5,34,,76.5,percent of total billed charges,Implant Device,76.5,34,,76.5,percent of total billed charges,Implant Device,111.38,,,111.38,Other,110% of Medicare,78.75,35,,78.75,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,78.75,35,,78.75,percent of total billed charges,Implant Device,78.75,35,,78.75,percent of total billed charges,Implant Device,78.75,35,,78.75,percent of total billed charges,Implant Device,78.75,35,,78.75,percent of total billed charges,Implant Device,78.75,35,,78.75,percent of total billed charges,Implant Device,90,40,,90,percent of total billed charges,Implant Device,78.75,70,,78.75,percent of total billed charges,All Other,76.5,34,,76.5,percent of total billed charges,Implant Device,76.5,34,,76.5,percent of total billed charges,Implant Device,78.75,35,,78.75,percent of total billed charges,Implant Device,78.75,35,,78.75,percent of total billed charges,Implant Device,78.75,35,,78.75,percent of total billed charges,Implant Device,78.75,35,,78.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,166.5,
ARTHREX AR-8967-2865 CANN SCREW 6.7X65MM,C1713,HCPCS,,79009410,CDM,278,RC,,,both,,,1074,794.76,,,794.76,Other,150% of Medicare + 9.63% HCRA Surcharge,483.3,45,,483.3,percent of total billed charges,Critical Access Hospital RCC factor,365.16,34,,365.16,percent of total billed charges,Implant Device,365.16,34,,365.16,percent of total billed charges,Implant Device,365.16,34,,365.16,percent of total billed charges,Implant Device,365.16,34,,365.16,percent of total billed charges,Implant Device,365.16,34,,365.16,percent of total billed charges,Implant Device,531.63,,,531.63,Other,110% of Medicare,375.9,35,,375.9,percent of total billed charges,Implant Device,365.16,34,"Charges > $500, x 34%",365.16,percent of total billed charges,Implant Device,375.9,35,,375.9,percent of total billed charges,Implant Device,375.9,35,,375.9,percent of total billed charges,Implant Device,375.9,35,,375.9,percent of total billed charges,Implant Device,375.9,35,,375.9,percent of total billed charges,Implant Device,375.9,35,,375.9,percent of total billed charges,Implant Device,429.6,40,,429.6,percent of total billed charges,Implant Device,375.9,70,,375.9,percent of total billed charges,All Other,365.16,34,,365.16,percent of total billed charges,Implant Device,365.16,34,,365.16,percent of total billed charges,Implant Device,375.9,35,,375.9,percent of total billed charges,Implant Device,375.9,35,,375.9,percent of total billed charges,Implant Device,375.9,35,,375.9,percent of total billed charges,Implant Device,375.9,35,,375.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,794.76,
DEPUY 02.123.026 PERIART PROX HUM PLT 8H,C1713,HCPCS,,79009411,CDM,278,RC,,,both,,,4431,3278.95,,,3278.95,Other,150% of Medicare + 9.63% HCRA Surcharge,1993.95,45,,1993.95,percent of total billed charges,Critical Access Hospital RCC factor,1506.54,34,,1506.54,percent of total billed charges,Implant Device,1506.54,34,,1506.54,percent of total billed charges,Implant Device,1506.54,34,,1506.54,percent of total billed charges,Implant Device,1506.54,34,,1506.54,percent of total billed charges,Implant Device,1506.54,34,,1506.54,percent of total billed charges,Implant Device,2193.35,,,2193.35,Other,110% of Medicare,1550.85,35,,1550.85,percent of total billed charges,Implant Device,1506.54,34,"Charges > $500, x 34%",1506.54,percent of total billed charges,Implant Device,1550.85,35,,1550.85,percent of total billed charges,Implant Device,1550.85,35,,1550.85,percent of total billed charges,Implant Device,1550.85,35,,1550.85,percent of total billed charges,Implant Device,1550.85,35,,1550.85,percent of total billed charges,Implant Device,1550.85,35,,1550.85,percent of total billed charges,Implant Device,1772.4,40,,1772.4,percent of total billed charges,Implant Device,1550.85,70,,1550.85,percent of total billed charges,All Other,1506.54,34,,1506.54,percent of total billed charges,Implant Device,1506.54,34,,1506.54,percent of total billed charges,Implant Device,1550.85,35,,1550.85,percent of total billed charges,Implant Device,1550.85,35,,1550.85,percent of total billed charges,Implant Device,1550.85,35,,1550.85,percent of total billed charges,Implant Device,1550.85,35,,1550.85,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1506.54,34,"If Charge > 2,000, then 34 percent",1506.54,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3278.95,
ARTHREX AR-2324BCCS IMPLANT SYSTEM,C1713,HCPCS,,79009415,CDM,278,RC,,,both,,,1920,1420.8,,,1420.8,Other,150% of Medicare + 9.63% HCRA Surcharge,864,45,,864,percent of total billed charges,Critical Access Hospital RCC factor,652.8,34,,652.8,percent of total billed charges,Implant Device,652.8,34,,652.8,percent of total billed charges,Implant Device,652.8,34,,652.8,percent of total billed charges,Implant Device,652.8,34,,652.8,percent of total billed charges,Implant Device,652.8,34,,652.8,percent of total billed charges,Implant Device,950.4,,,950.4,Other,110% of Medicare,672,35,,672,percent of total billed charges,Implant Device,652.8,34,"Charges > $500, x 34%",652.8,percent of total billed charges,Implant Device,672,35,,672,percent of total billed charges,Implant Device,672,35,,672,percent of total billed charges,Implant Device,672,35,,672,percent of total billed charges,Implant Device,672,35,,672,percent of total billed charges,Implant Device,672,35,,672,percent of total billed charges,Implant Device,768,40,,768,percent of total billed charges,Implant Device,672,70,,672,percent of total billed charges,All Other,652.8,34,,652.8,percent of total billed charges,Implant Device,652.8,34,,652.8,percent of total billed charges,Implant Device,672,35,,672,percent of total billed charges,Implant Device,672,35,,672,percent of total billed charges,Implant Device,672,35,,672,percent of total billed charges,Implant Device,672,35,,672,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1420.8,
ARTHREX AR-1927BCT-475 CORKSCREW 4.75,C1713,HCPCS,,79009416,CDM,278,RC,,,both,,,1065,788.1,,,788.1,Other,150% of Medicare + 9.63% HCRA Surcharge,479.25,45,,479.25,percent of total billed charges,Critical Access Hospital RCC factor,362.1,34,,362.1,percent of total billed charges,Implant Device,362.1,34,,362.1,percent of total billed charges,Implant Device,362.1,34,,362.1,percent of total billed charges,Implant Device,362.1,34,,362.1,percent of total billed charges,Implant Device,362.1,34,,362.1,percent of total billed charges,Implant Device,527.18,,,527.18,Other,110% of Medicare,372.75,35,,372.75,percent of total billed charges,Implant Device,362.1,34,"Charges > $500, x 34%",362.1,percent of total billed charges,Implant Device,372.75,35,,372.75,percent of total billed charges,Implant Device,372.75,35,,372.75,percent of total billed charges,Implant Device,372.75,35,,372.75,percent of total billed charges,Implant Device,372.75,35,,372.75,percent of total billed charges,Implant Device,372.75,35,,372.75,percent of total billed charges,Implant Device,426,40,,426,percent of total billed charges,Implant Device,372.75,70,,372.75,percent of total billed charges,All Other,362.1,34,,362.1,percent of total billed charges,Implant Device,362.1,34,,362.1,percent of total billed charges,Implant Device,372.75,35,,372.75,percent of total billed charges,Implant Device,372.75,35,,372.75,percent of total billed charges,Implant Device,372.75,35,,372.75,percent of total billed charges,Implant Device,372.75,35,,372.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,788.1,
INTEGRA 606-300-009 SURIGMEND MESH 3.0,C1781,HCPCS,,79009417,CDM,278,RC,,,both,,,21450,15873.05,,,15873.05,Other,150% of Medicare + 9.63% HCRA Surcharge,9652.5,45,,9652.5,percent of total billed charges,Critical Access Hospital RCC factor,7293,34,,7293,percent of total billed charges,Implant Device,7293,34,,7293,percent of total billed charges,Implant Device,7293,34,,7293,percent of total billed charges,Implant Device,7293,34,,7293,percent of total billed charges,Implant Device,7293,34,,7293,percent of total billed charges,Implant Device,10617.75,,,10617.75,Other,110% of Medicare,7507.5,35,,7507.5,percent of total billed charges,Implant Device,7293,34,"Charges > $500, x 34%",7293,percent of total billed charges,Implant Device,7507.5,35,,7507.5,percent of total billed charges,Implant Device,7507.5,35,,7507.5,percent of total billed charges,Implant Device,7507.5,35,,7507.5,percent of total billed charges,Implant Device,7507.5,35,,7507.5,percent of total billed charges,Implant Device,7507.5,35,,7507.5,percent of total billed charges,Implant Device,8580,40,,8580,percent of total billed charges,Implant Device,7507.5,70,,7507.5,percent of total billed charges,All Other,7293,34,,7293,percent of total billed charges,Implant Device,7293,34,,7293,percent of total billed charges,Implant Device,7507.5,35,,7507.5,percent of total billed charges,Implant Device,7507.5,35,,7507.5,percent of total billed charges,Implant Device,7507.5,35,,7507.5,percent of total billed charges,Implant Device,7507.5,35,,7507.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,7293,34,"If Charge > 2,000, then 34 percent",7293,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,15873.05,
ZIMMER 00-8851-014-36 NEUTRAL LINER 36MM,C1776,HCPCS,,79009418,CDM,278,RC,,,both,,,3456,2557.45,,,2557.45,Other,150% of Medicare + 9.63% HCRA Surcharge,1555.2,45,,1555.2,percent of total billed charges,Critical Access Hospital RCC factor,1175.04,34,,1175.04,percent of total billed charges,Implant Device,1175.04,34,,1175.04,percent of total billed charges,Implant Device,1175.04,34,,1175.04,percent of total billed charges,Implant Device,1175.04,34,,1175.04,percent of total billed charges,Implant Device,1175.04,34,,1175.04,percent of total billed charges,Implant Device,1710.72,,,1710.72,Other,110% of Medicare,1209.6,35,,1209.6,percent of total billed charges,Implant Device,1175.04,34,"Charges > $500, x 34%",1175.04,percent of total billed charges,Implant Device,1209.6,35,,1209.6,percent of total billed charges,Implant Device,1209.6,35,,1209.6,percent of total billed charges,Implant Device,1209.6,35,,1209.6,percent of total billed charges,Implant Device,1209.6,35,,1209.6,percent of total billed charges,Implant Device,1209.6,35,,1209.6,percent of total billed charges,Implant Device,1382.4,40,,1382.4,percent of total billed charges,Implant Device,1209.6,70,,1209.6,percent of total billed charges,All Other,1175.04,34,,1175.04,percent of total billed charges,Implant Device,1175.04,34,,1175.04,percent of total billed charges,Implant Device,1209.6,35,,1209.6,percent of total billed charges,Implant Device,1209.6,35,,1209.6,percent of total billed charges,Implant Device,1209.6,35,,1209.6,percent of total billed charges,Implant Device,1209.6,35,,1209.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1175.04,34,"If Charge > 2,000, then 34 percent",1175.04,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2557.45,
MENTOR SMPX-370 ROUND GEL BREAST IMPLANT,C1789,HCPCS,,79009420,CDM,278,RC,,,both,,,3684,2726.17,,,2726.17,Other,150% of Medicare + 9.63% HCRA Surcharge,1657.8,45,,1657.8,percent of total billed charges,Critical Access Hospital RCC factor,1252.56,34,,1252.56,percent of total billed charges,Implant Device,1252.56,34,,1252.56,percent of total billed charges,Implant Device,1252.56,34,,1252.56,percent of total billed charges,Implant Device,1252.56,34,,1252.56,percent of total billed charges,Implant Device,1252.56,34,,1252.56,percent of total billed charges,Implant Device,1823.58,,,1823.58,Other,110% of Medicare,1289.4,35,,1289.4,percent of total billed charges,Implant Device,1252.56,34,"Charges > $500, x 34%",1252.56,percent of total billed charges,Implant Device,1289.4,35,,1289.4,percent of total billed charges,Implant Device,1289.4,35,,1289.4,percent of total billed charges,Implant Device,1289.4,35,,1289.4,percent of total billed charges,Implant Device,1289.4,35,,1289.4,percent of total billed charges,Implant Device,1289.4,35,,1289.4,percent of total billed charges,Implant Device,1473.6,40,,1473.6,percent of total billed charges,Implant Device,1289.4,70,,1289.4,percent of total billed charges,All Other,1252.56,34,,1252.56,percent of total billed charges,Implant Device,1252.56,34,,1252.56,percent of total billed charges,Implant Device,1289.4,35,,1289.4,percent of total billed charges,Implant Device,1289.4,35,,1289.4,percent of total billed charges,Implant Device,1289.4,35,,1289.4,percent of total billed charges,Implant Device,1289.4,35,,1289.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1252.56,34,"If Charge > 2,000, then 34 percent",1252.56,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2726.17,
MENTOR SMPX-405 ROUND GEL BREAST IMPLANT,C1789,HCPCS,,79009421,CDM,278,RC,,,both,,,3684,2726.17,,,2726.17,Other,150% of Medicare + 9.63% HCRA Surcharge,1657.8,45,,1657.8,percent of total billed charges,Critical Access Hospital RCC factor,1252.56,34,,1252.56,percent of total billed charges,Implant Device,1252.56,34,,1252.56,percent of total billed charges,Implant Device,1252.56,34,,1252.56,percent of total billed charges,Implant Device,1252.56,34,,1252.56,percent of total billed charges,Implant Device,1252.56,34,,1252.56,percent of total billed charges,Implant Device,1823.58,,,1823.58,Other,110% of Medicare,1289.4,35,,1289.4,percent of total billed charges,Implant Device,1252.56,34,"Charges > $500, x 34%",1252.56,percent of total billed charges,Implant Device,1289.4,35,,1289.4,percent of total billed charges,Implant Device,1289.4,35,,1289.4,percent of total billed charges,Implant Device,1289.4,35,,1289.4,percent of total billed charges,Implant Device,1289.4,35,,1289.4,percent of total billed charges,Implant Device,1289.4,35,,1289.4,percent of total billed charges,Implant Device,1473.6,40,,1473.6,percent of total billed charges,Implant Device,1289.4,70,,1289.4,percent of total billed charges,All Other,1252.56,34,,1252.56,percent of total billed charges,Implant Device,1252.56,34,,1252.56,percent of total billed charges,Implant Device,1289.4,35,,1289.4,percent of total billed charges,Implant Device,1289.4,35,,1289.4,percent of total billed charges,Implant Device,1289.4,35,,1289.4,percent of total billed charges,Implant Device,1289.4,35,,1289.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1252.56,34,"If Charge > 2,000, then 34 percent",1252.56,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2726.17,
MENTOR SMPX-440 ROUND GEL BREAST IMPLANT,C1789,HCPCS,,79009422,CDM,278,RC,,,both,,,3684,2726.17,,,2726.17,Other,150% of Medicare + 9.63% HCRA Surcharge,1657.8,45,,1657.8,percent of total billed charges,Critical Access Hospital RCC factor,1252.56,34,,1252.56,percent of total billed charges,Implant Device,1252.56,34,,1252.56,percent of total billed charges,Implant Device,1252.56,34,,1252.56,percent of total billed charges,Implant Device,1252.56,34,,1252.56,percent of total billed charges,Implant Device,1252.56,34,,1252.56,percent of total billed charges,Implant Device,1823.58,,,1823.58,Other,110% of Medicare,1289.4,35,,1289.4,percent of total billed charges,Implant Device,1252.56,34,"Charges > $500, x 34%",1252.56,percent of total billed charges,Implant Device,1289.4,35,,1289.4,percent of total billed charges,Implant Device,1289.4,35,,1289.4,percent of total billed charges,Implant Device,1289.4,35,,1289.4,percent of total billed charges,Implant Device,1289.4,35,,1289.4,percent of total billed charges,Implant Device,1289.4,35,,1289.4,percent of total billed charges,Implant Device,1473.6,40,,1473.6,percent of total billed charges,Implant Device,1289.4,70,,1289.4,percent of total billed charges,All Other,1252.56,34,,1252.56,percent of total billed charges,Implant Device,1252.56,34,,1252.56,percent of total billed charges,Implant Device,1289.4,35,,1289.4,percent of total billed charges,Implant Device,1289.4,35,,1289.4,percent of total billed charges,Implant Device,1289.4,35,,1289.4,percent of total billed charges,Implant Device,1289.4,35,,1289.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1252.56,34,"If Charge > 2,000, then 34 percent",1252.56,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2726.17,
MENTOR SMPX-465 ROUND GEL BREAST IMPLANT,C1789,HCPCS,,79009423,CDM,278,RC,,,both,,,3684,2726.17,,,2726.17,Other,150% of Medicare + 9.63% HCRA Surcharge,1657.8,45,,1657.8,percent of total billed charges,Critical Access Hospital RCC factor,1252.56,34,,1252.56,percent of total billed charges,Implant Device,1252.56,34,,1252.56,percent of total billed charges,Implant Device,1252.56,34,,1252.56,percent of total billed charges,Implant Device,1252.56,34,,1252.56,percent of total billed charges,Implant Device,1252.56,34,,1252.56,percent of total billed charges,Implant Device,1823.58,,,1823.58,Other,110% of Medicare,1289.4,35,,1289.4,percent of total billed charges,Implant Device,1252.56,34,"Charges > $500, x 34%",1252.56,percent of total billed charges,Implant Device,1289.4,35,,1289.4,percent of total billed charges,Implant Device,1289.4,35,,1289.4,percent of total billed charges,Implant Device,1289.4,35,,1289.4,percent of total billed charges,Implant Device,1289.4,35,,1289.4,percent of total billed charges,Implant Device,1289.4,35,,1289.4,percent of total billed charges,Implant Device,1473.6,40,,1473.6,percent of total billed charges,Implant Device,1289.4,70,,1289.4,percent of total billed charges,All Other,1252.56,34,,1252.56,percent of total billed charges,Implant Device,1252.56,34,,1252.56,percent of total billed charges,Implant Device,1289.4,35,,1289.4,percent of total billed charges,Implant Device,1289.4,35,,1289.4,percent of total billed charges,Implant Device,1289.4,35,,1289.4,percent of total billed charges,Implant Device,1289.4,35,,1289.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1252.56,34,"If Charge > 2,000, then 34 percent",1252.56,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2726.17,
MENTOR SMPX-490 ROUND GEL BREAST IMPLANT,C1789,HCPCS,,79009424,CDM,278,RC,,,both,,,3684,2726.17,,,2726.17,Other,150% of Medicare + 9.63% HCRA Surcharge,1657.8,45,,1657.8,percent of total billed charges,Critical Access Hospital RCC factor,1252.56,34,,1252.56,percent of total billed charges,Implant Device,1252.56,34,,1252.56,percent of total billed charges,Implant Device,1252.56,34,,1252.56,percent of total billed charges,Implant Device,1252.56,34,,1252.56,percent of total billed charges,Implant Device,1252.56,34,,1252.56,percent of total billed charges,Implant Device,1823.58,,,1823.58,Other,110% of Medicare,1289.4,35,,1289.4,percent of total billed charges,Implant Device,1252.56,34,"Charges > $500, x 34%",1252.56,percent of total billed charges,Implant Device,1289.4,35,,1289.4,percent of total billed charges,Implant Device,1289.4,35,,1289.4,percent of total billed charges,Implant Device,1289.4,35,,1289.4,percent of total billed charges,Implant Device,1289.4,35,,1289.4,percent of total billed charges,Implant Device,1289.4,35,,1289.4,percent of total billed charges,Implant Device,1473.6,40,,1473.6,percent of total billed charges,Implant Device,1289.4,70,,1289.4,percent of total billed charges,All Other,1252.56,34,,1252.56,percent of total billed charges,Implant Device,1252.56,34,,1252.56,percent of total billed charges,Implant Device,1289.4,35,,1289.4,percent of total billed charges,Implant Device,1289.4,35,,1289.4,percent of total billed charges,Implant Device,1289.4,35,,1289.4,percent of total billed charges,Implant Device,1289.4,35,,1289.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1252.56,34,"If Charge > 2,000, then 34 percent",1252.56,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2726.17,
MENTOR 350-3251BC GEL BREAST IMPLANT,C1789,HCPCS,,79009430,CDM,278,RC,,,both,,,2865,2120.11,,,2120.11,Other,150% of Medicare + 9.63% HCRA Surcharge,1289.25,45,,1289.25,percent of total billed charges,Critical Access Hospital RCC factor,974.1,34,,974.1,percent of total billed charges,Implant Device,974.1,34,,974.1,percent of total billed charges,Implant Device,974.1,34,,974.1,percent of total billed charges,Implant Device,974.1,34,,974.1,percent of total billed charges,Implant Device,974.1,34,,974.1,percent of total billed charges,Implant Device,1418.18,,,1418.18,Other,110% of Medicare,1002.75,35,,1002.75,percent of total billed charges,Implant Device,974.1,34,"Charges > $500, x 34%",974.1,percent of total billed charges,Implant Device,1002.75,35,,1002.75,percent of total billed charges,Implant Device,1002.75,35,,1002.75,percent of total billed charges,Implant Device,1002.75,35,,1002.75,percent of total billed charges,Implant Device,1002.75,35,,1002.75,percent of total billed charges,Implant Device,1002.75,35,,1002.75,percent of total billed charges,Implant Device,1146,40,,1146,percent of total billed charges,Implant Device,1002.75,70,,1002.75,percent of total billed charges,All Other,974.1,34,,974.1,percent of total billed charges,Implant Device,974.1,34,,974.1,percent of total billed charges,Implant Device,1002.75,35,,1002.75,percent of total billed charges,Implant Device,1002.75,35,,1002.75,percent of total billed charges,Implant Device,1002.75,35,,1002.75,percent of total billed charges,Implant Device,1002.75,35,,1002.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,974.1,34,"If Charge > 2,000, then 34 percent",974.1,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2120.11,
STRYKER 5572-4532 PERIPH SCREW 4.5X32MM,C1713,HCPCS,,79009435,CDM,278,RC,,,both,,,600,444,,,444,Other,150% of Medicare + 9.63% HCRA Surcharge,270,45,,270,percent of total billed charges,Critical Access Hospital RCC factor,204,34,,204,percent of total billed charges,Implant Device,204,34,,204,percent of total billed charges,Implant Device,204,34,,204,percent of total billed charges,Implant Device,204,34,,204,percent of total billed charges,Implant Device,204,34,,204,percent of total billed charges,Implant Device,297,,,297,Other,110% of Medicare,210,35,,210,percent of total billed charges,Implant Device,204,34,"Charges > $500, x 34%",204,percent of total billed charges,Implant Device,210,35,,210,percent of total billed charges,Implant Device,210,35,,210,percent of total billed charges,Implant Device,210,35,,210,percent of total billed charges,Implant Device,210,35,,210,percent of total billed charges,Implant Device,210,35,,210,percent of total billed charges,Implant Device,240,40,,240,percent of total billed charges,Implant Device,210,70,,210,percent of total billed charges,All Other,204,34,,204,percent of total billed charges,Implant Device,204,34,,204,percent of total billed charges,Implant Device,210,35,,210,percent of total billed charges,Implant Device,210,35,,210,percent of total billed charges,Implant Device,210,35,,210,percent of total billed charges,Implant Device,210,35,,210,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,444,
STRYKER 5570-3204 HUMERAL CAP 32X4MM,C1776,HCPCS,,79009436,CDM,278,RC,,,both,,,4125,3052.51,,,3052.51,Other,150% of Medicare + 9.63% HCRA Surcharge,1856.25,45,,1856.25,percent of total billed charges,Critical Access Hospital RCC factor,1402.5,34,,1402.5,percent of total billed charges,Implant Device,1402.5,34,,1402.5,percent of total billed charges,Implant Device,1402.5,34,,1402.5,percent of total billed charges,Implant Device,1402.5,34,,1402.5,percent of total billed charges,Implant Device,1402.5,34,,1402.5,percent of total billed charges,Implant Device,2041.88,,,2041.88,Other,110% of Medicare,1443.75,35,,1443.75,percent of total billed charges,Implant Device,1402.5,34,"Charges > $500, x 34%",1402.5,percent of total billed charges,Implant Device,1443.75,35,,1443.75,percent of total billed charges,Implant Device,1443.75,35,,1443.75,percent of total billed charges,Implant Device,1443.75,35,,1443.75,percent of total billed charges,Implant Device,1443.75,35,,1443.75,percent of total billed charges,Implant Device,1443.75,35,,1443.75,percent of total billed charges,Implant Device,1650,40,,1650,percent of total billed charges,Implant Device,1443.75,70,,1443.75,percent of total billed charges,All Other,1402.5,34,,1402.5,percent of total billed charges,Implant Device,1402.5,34,,1402.5,percent of total billed charges,Implant Device,1443.75,35,,1443.75,percent of total billed charges,Implant Device,1443.75,35,,1443.75,percent of total billed charges,Implant Device,1443.75,35,,1443.75,percent of total billed charges,Implant Device,1443.75,35,,1443.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1402.5,34,"If Charge > 2,000, then 34 percent",1402.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3052.51,
STRYKER 5571-S-3204 HUMERAL INSERT 32X4,C1776,HCPCS,,79009437,CDM,278,RC,,,both,,,7353,5441.24,,,5441.24,Other,150% of Medicare + 9.63% HCRA Surcharge,3308.85,45,,3308.85,percent of total billed charges,Critical Access Hospital RCC factor,2500.02,34,,2500.02,percent of total billed charges,Implant Device,2500.02,34,,2500.02,percent of total billed charges,Implant Device,2500.02,34,,2500.02,percent of total billed charges,Implant Device,2500.02,34,,2500.02,percent of total billed charges,Implant Device,2500.02,34,,2500.02,percent of total billed charges,Implant Device,3639.74,,,3639.74,Other,110% of Medicare,2573.55,35,,2573.55,percent of total billed charges,Implant Device,2500.02,34,"Charges > $500, x 34%",2500.02,percent of total billed charges,Implant Device,2573.55,35,,2573.55,percent of total billed charges,Implant Device,2573.55,35,,2573.55,percent of total billed charges,Implant Device,2573.55,35,,2573.55,percent of total billed charges,Implant Device,2573.55,35,,2573.55,percent of total billed charges,Implant Device,2573.55,35,,2573.55,percent of total billed charges,Implant Device,2941.2,40,,2941.2,percent of total billed charges,Implant Device,2573.55,70,,2573.55,percent of total billed charges,All Other,2500.02,34,,2500.02,percent of total billed charges,Implant Device,2500.02,34,,2500.02,percent of total billed charges,Implant Device,2573.55,35,,2573.55,percent of total billed charges,Implant Device,2573.55,35,,2573.55,percent of total billed charges,Implant Device,2573.55,35,,2573.55,percent of total billed charges,Implant Device,2573.55,35,,2573.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2500.02,34,"If Charge > 2,000, then 34 percent",2500.02,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5441.24,
STRYKER 5573-C-3202 GLENOSPHERE 32X2MM,C1776,HCPCS,,79009438,CDM,278,RC,,,both,,,4125,3052.51,,,3052.51,Other,150% of Medicare + 9.63% HCRA Surcharge,1856.25,45,,1856.25,percent of total billed charges,Critical Access Hospital RCC factor,1402.5,34,,1402.5,percent of total billed charges,Implant Device,1402.5,34,,1402.5,percent of total billed charges,Implant Device,1402.5,34,,1402.5,percent of total billed charges,Implant Device,1402.5,34,,1402.5,percent of total billed charges,Implant Device,1402.5,34,,1402.5,percent of total billed charges,Implant Device,2041.88,,,2041.88,Other,110% of Medicare,1443.75,35,,1443.75,percent of total billed charges,Implant Device,1402.5,34,"Charges > $500, x 34%",1402.5,percent of total billed charges,Implant Device,1443.75,35,,1443.75,percent of total billed charges,Implant Device,1443.75,35,,1443.75,percent of total billed charges,Implant Device,1443.75,35,,1443.75,percent of total billed charges,Implant Device,1443.75,35,,1443.75,percent of total billed charges,Implant Device,1443.75,35,,1443.75,percent of total billed charges,Implant Device,1650,40,,1650,percent of total billed charges,Implant Device,1443.75,70,,1443.75,percent of total billed charges,All Other,1402.5,34,,1402.5,percent of total billed charges,Implant Device,1402.5,34,,1402.5,percent of total billed charges,Implant Device,1443.75,35,,1443.75,percent of total billed charges,Implant Device,1443.75,35,,1443.75,percent of total billed charges,Implant Device,1443.75,35,,1443.75,percent of total billed charges,Implant Device,1443.75,35,,1443.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1402.5,34,"If Charge > 2,000, then 34 percent",1402.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3052.51,
STRYKER 1822-0936S TIBIAL NAIL 9X360MM,C1713,HCPCS,,79009440,CDM,278,RC,,,both,,,7143,5285.84,,,5285.84,Other,150% of Medicare + 9.63% HCRA Surcharge,3214.35,45,,3214.35,percent of total billed charges,Critical Access Hospital RCC factor,2428.62,34,,2428.62,percent of total billed charges,Implant Device,2428.62,34,,2428.62,percent of total billed charges,Implant Device,2428.62,34,,2428.62,percent of total billed charges,Implant Device,2428.62,34,,2428.62,percent of total billed charges,Implant Device,2428.62,34,,2428.62,percent of total billed charges,Implant Device,3535.79,,,3535.79,Other,110% of Medicare,2500.05,35,,2500.05,percent of total billed charges,Implant Device,2428.62,34,"Charges > $500, x 34%",2428.62,percent of total billed charges,Implant Device,2500.05,35,,2500.05,percent of total billed charges,Implant Device,2500.05,35,,2500.05,percent of total billed charges,Implant Device,2500.05,35,,2500.05,percent of total billed charges,Implant Device,2500.05,35,,2500.05,percent of total billed charges,Implant Device,2500.05,35,,2500.05,percent of total billed charges,Implant Device,2857.2,40,,2857.2,percent of total billed charges,Implant Device,2500.05,70,,2500.05,percent of total billed charges,All Other,2428.62,34,,2428.62,percent of total billed charges,Implant Device,2428.62,34,,2428.62,percent of total billed charges,Implant Device,2500.05,35,,2500.05,percent of total billed charges,Implant Device,2500.05,35,,2500.05,percent of total billed charges,Implant Device,2500.05,35,,2500.05,percent of total billed charges,Implant Device,2500.05,35,,2500.05,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2428.62,34,"If Charge > 2,000, then 34 percent",2428.62,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5285.84,
BOST SCI 72401850 AMS 700 PENILE PROSTH,C1813,HCPCS,,79009441,CDM,278,RC,,,both,,,2910,2153.41,,,2153.41,Other,150% of Medicare + 9.63% HCRA Surcharge,1309.5,45,,1309.5,percent of total billed charges,Critical Access Hospital RCC factor,989.4,34,,989.4,percent of total billed charges,Implant Device,989.4,34,,989.4,percent of total billed charges,Implant Device,989.4,34,,989.4,percent of total billed charges,Implant Device,989.4,34,,989.4,percent of total billed charges,Implant Device,989.4,34,,989.4,percent of total billed charges,Implant Device,1440.45,,,1440.45,Other,110% of Medicare,1018.5,35,,1018.5,percent of total billed charges,Implant Device,989.4,34,"Charges > $500, x 34%",989.4,percent of total billed charges,Implant Device,1018.5,35,,1018.5,percent of total billed charges,Implant Device,1018.5,35,,1018.5,percent of total billed charges,Implant Device,1018.5,35,,1018.5,percent of total billed charges,Implant Device,1018.5,35,,1018.5,percent of total billed charges,Implant Device,1018.5,35,,1018.5,percent of total billed charges,Implant Device,1164,40,,1164,percent of total billed charges,Implant Device,1018.5,70,,1018.5,percent of total billed charges,All Other,989.4,34,,989.4,percent of total billed charges,Implant Device,989.4,34,,989.4,percent of total billed charges,Implant Device,1018.5,35,,1018.5,percent of total billed charges,Implant Device,1018.5,35,,1018.5,percent of total billed charges,Implant Device,1018.5,35,,1018.5,percent of total billed charges,Implant Device,1018.5,35,,1018.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,989.4,34,"If Charge > 2,000, then 34 percent",989.4,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2153.41,
ARTHREX AR-8925SS TIGHTROPE XP,C1713,HCPCS,,79009443,CDM,278,RC,,,both,,,6408,4741.94,,,4741.94,Other,150% of Medicare + 9.63% HCRA Surcharge,2883.6,45,,2883.6,percent of total billed charges,Critical Access Hospital RCC factor,2178.72,34,,2178.72,percent of total billed charges,Implant Device,2178.72,34,,2178.72,percent of total billed charges,Implant Device,2178.72,34,,2178.72,percent of total billed charges,Implant Device,2178.72,34,,2178.72,percent of total billed charges,Implant Device,2178.72,34,,2178.72,percent of total billed charges,Implant Device,3171.96,,,3171.96,Other,110% of Medicare,2242.8,35,,2242.8,percent of total billed charges,Implant Device,2178.72,34,"Charges > $500, x 34%",2178.72,percent of total billed charges,Implant Device,2242.8,35,,2242.8,percent of total billed charges,Implant Device,2242.8,35,,2242.8,percent of total billed charges,Implant Device,2242.8,35,,2242.8,percent of total billed charges,Implant Device,2242.8,35,,2242.8,percent of total billed charges,Implant Device,2242.8,35,,2242.8,percent of total billed charges,Implant Device,2563.2,40,,2563.2,percent of total billed charges,Implant Device,2242.8,70,,2242.8,percent of total billed charges,All Other,2178.72,34,,2178.72,percent of total billed charges,Implant Device,2178.72,34,,2178.72,percent of total billed charges,Implant Device,2242.8,35,,2242.8,percent of total billed charges,Implant Device,2242.8,35,,2242.8,percent of total billed charges,Implant Device,2242.8,35,,2242.8,percent of total billed charges,Implant Device,2242.8,35,,2242.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2178.72,34,"If Charge > 2,000, then 34 percent",2178.72,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4741.94,
STRYKER 629527 COMP PLATE 7 HOLE NARROW,C1713,HCPCS,,79009444,CDM,278,RC,,,both,,,1276,944.24,,,944.24,Other,150% of Medicare + 9.63% HCRA Surcharge,574.2,45,,574.2,percent of total billed charges,Critical Access Hospital RCC factor,433.84,34,,433.84,percent of total billed charges,Implant Device,433.84,34,,433.84,percent of total billed charges,Implant Device,433.84,34,,433.84,percent of total billed charges,Implant Device,433.84,34,,433.84,percent of total billed charges,Implant Device,433.84,34,,433.84,percent of total billed charges,Implant Device,631.62,,,631.62,Other,110% of Medicare,446.6,35,,446.6,percent of total billed charges,Implant Device,433.84,34,"Charges > $500, x 34%",433.84,percent of total billed charges,Implant Device,446.6,35,,446.6,percent of total billed charges,Implant Device,446.6,35,,446.6,percent of total billed charges,Implant Device,446.6,35,,446.6,percent of total billed charges,Implant Device,446.6,35,,446.6,percent of total billed charges,Implant Device,446.6,35,,446.6,percent of total billed charges,Implant Device,510.4,40,,510.4,percent of total billed charges,Implant Device,446.6,70,,446.6,percent of total billed charges,All Other,433.84,34,,433.84,percent of total billed charges,Implant Device,433.84,34,,433.84,percent of total billed charges,Implant Device,446.6,35,,446.6,percent of total billed charges,Implant Device,446.6,35,,446.6,percent of total billed charges,Implant Device,446.6,35,,446.6,percent of total billed charges,Implant Device,446.6,35,,446.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,944.24,
IN2BONES S80 ST195 IBS SCREW 8.0X95MM,C1713,HCPCS,,79009445,CDM,278,RC,,,both,,,3585,2652.91,,,2652.91,Other,150% of Medicare + 9.63% HCRA Surcharge,1613.25,45,,1613.25,percent of total billed charges,Critical Access Hospital RCC factor,1218.9,34,,1218.9,percent of total billed charges,Implant Device,1218.9,34,,1218.9,percent of total billed charges,Implant Device,1218.9,34,,1218.9,percent of total billed charges,Implant Device,1218.9,34,,1218.9,percent of total billed charges,Implant Device,1218.9,34,,1218.9,percent of total billed charges,Implant Device,1774.58,,,1774.58,Other,110% of Medicare,1254.75,35,,1254.75,percent of total billed charges,Implant Device,1218.9,34,"Charges > $500, x 34%",1218.9,percent of total billed charges,Implant Device,1254.75,35,,1254.75,percent of total billed charges,Implant Device,1254.75,35,,1254.75,percent of total billed charges,Implant Device,1254.75,35,,1254.75,percent of total billed charges,Implant Device,1254.75,35,,1254.75,percent of total billed charges,Implant Device,1254.75,35,,1254.75,percent of total billed charges,Implant Device,1434,40,,1434,percent of total billed charges,Implant Device,1254.75,70,,1254.75,percent of total billed charges,All Other,1218.9,34,,1218.9,percent of total billed charges,Implant Device,1218.9,34,,1218.9,percent of total billed charges,Implant Device,1254.75,35,,1254.75,percent of total billed charges,Implant Device,1254.75,35,,1254.75,percent of total billed charges,Implant Device,1254.75,35,,1254.75,percent of total billed charges,Implant Device,1254.75,35,,1254.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1218.9,34,"If Charge > 2,000, then 34 percent",1218.9,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2652.91,
IN2BONES S45 ST145 IBS SCREW 4.5X45MM,C1713,HCPCS,,79009446,CDM,278,RC,,,both,,,1545,1143.3,,,1143.3,Other,150% of Medicare + 9.63% HCRA Surcharge,695.25,45,,695.25,percent of total billed charges,Critical Access Hospital RCC factor,525.3,34,,525.3,percent of total billed charges,Implant Device,525.3,34,,525.3,percent of total billed charges,Implant Device,525.3,34,,525.3,percent of total billed charges,Implant Device,525.3,34,,525.3,percent of total billed charges,Implant Device,525.3,34,,525.3,percent of total billed charges,Implant Device,764.78,,,764.78,Other,110% of Medicare,540.75,35,,540.75,percent of total billed charges,Implant Device,525.3,34,"Charges > $500, x 34%",525.3,percent of total billed charges,Implant Device,540.75,35,,540.75,percent of total billed charges,Implant Device,540.75,35,,540.75,percent of total billed charges,Implant Device,540.75,35,,540.75,percent of total billed charges,Implant Device,540.75,35,,540.75,percent of total billed charges,Implant Device,540.75,35,,540.75,percent of total billed charges,Implant Device,618,40,,618,percent of total billed charges,Implant Device,540.75,70,,540.75,percent of total billed charges,All Other,525.3,34,,525.3,percent of total billed charges,Implant Device,525.3,34,,525.3,percent of total billed charges,Implant Device,540.75,35,,540.75,percent of total billed charges,Implant Device,540.75,35,,540.75,percent of total billed charges,Implant Device,540.75,35,,540.75,percent of total billed charges,Implant Device,540.75,35,,540.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1143.3,
IN2BONES S65 ST150 IBS SCREW 6.5X50MM,C1713,HCPCS,,79009447,CDM,278,RC,,,both,,,3105,2297.71,,,2297.71,Other,150% of Medicare + 9.63% HCRA Surcharge,1397.25,45,,1397.25,percent of total billed charges,Critical Access Hospital RCC factor,1055.7,34,,1055.7,percent of total billed charges,Implant Device,1055.7,34,,1055.7,percent of total billed charges,Implant Device,1055.7,34,,1055.7,percent of total billed charges,Implant Device,1055.7,34,,1055.7,percent of total billed charges,Implant Device,1055.7,34,,1055.7,percent of total billed charges,Implant Device,1536.98,,,1536.98,Other,110% of Medicare,1086.75,35,,1086.75,percent of total billed charges,Implant Device,1055.7,34,"Charges > $500, x 34%",1055.7,percent of total billed charges,Implant Device,1086.75,35,,1086.75,percent of total billed charges,Implant Device,1086.75,35,,1086.75,percent of total billed charges,Implant Device,1086.75,35,,1086.75,percent of total billed charges,Implant Device,1086.75,35,,1086.75,percent of total billed charges,Implant Device,1086.75,35,,1086.75,percent of total billed charges,Implant Device,1242,40,,1242,percent of total billed charges,Implant Device,1086.75,70,,1086.75,percent of total billed charges,All Other,1055.7,34,,1055.7,percent of total billed charges,Implant Device,1055.7,34,,1055.7,percent of total billed charges,Implant Device,1086.75,35,,1086.75,percent of total billed charges,Implant Device,1086.75,35,,1086.75,percent of total billed charges,Implant Device,1086.75,35,,1086.75,percent of total billed charges,Implant Device,1086.75,35,,1086.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1055.7,34,"If Charge > 2,000, then 34 percent",1055.7,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2297.71,
IN2BONES T50 SN018 COMP STAPLE 18X16X16,C1713,HCPCS,,79009448,CDM,278,RC,,,both,,,4485,3318.91,,,3318.91,Other,150% of Medicare + 9.63% HCRA Surcharge,2018.25,45,,2018.25,percent of total billed charges,Critical Access Hospital RCC factor,1524.9,34,,1524.9,percent of total billed charges,Implant Device,1524.9,34,,1524.9,percent of total billed charges,Implant Device,1524.9,34,,1524.9,percent of total billed charges,Implant Device,1524.9,34,,1524.9,percent of total billed charges,Implant Device,1524.9,34,,1524.9,percent of total billed charges,Implant Device,2220.08,,,2220.08,Other,110% of Medicare,1569.75,35,,1569.75,percent of total billed charges,Implant Device,1524.9,34,"Charges > $500, x 34%",1524.9,percent of total billed charges,Implant Device,1569.75,35,,1569.75,percent of total billed charges,Implant Device,1569.75,35,,1569.75,percent of total billed charges,Implant Device,1569.75,35,,1569.75,percent of total billed charges,Implant Device,1569.75,35,,1569.75,percent of total billed charges,Implant Device,1569.75,35,,1569.75,percent of total billed charges,Implant Device,1794,40,,1794,percent of total billed charges,Implant Device,1569.75,70,,1569.75,percent of total billed charges,All Other,1524.9,34,,1524.9,percent of total billed charges,Implant Device,1524.9,34,,1524.9,percent of total billed charges,Implant Device,1569.75,35,,1569.75,percent of total billed charges,Implant Device,1569.75,35,,1569.75,percent of total billed charges,Implant Device,1569.75,35,,1569.75,percent of total billed charges,Implant Device,1569.75,35,,1569.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1524.9,34,"If Charge > 2,000, then 34 percent",1524.9,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3318.91,
MENTOR 354-9212 TISSUE EXPANDER 350CC,C1789,HCPCS,,79009450,CDM,278,RC,,,both,,,5085,3762.91,,,3762.91,Other,150% of Medicare + 9.63% HCRA Surcharge,2288.25,45,,2288.25,percent of total billed charges,Critical Access Hospital RCC factor,1728.9,34,,1728.9,percent of total billed charges,Implant Device,1728.9,34,,1728.9,percent of total billed charges,Implant Device,1728.9,34,,1728.9,percent of total billed charges,Implant Device,1728.9,34,,1728.9,percent of total billed charges,Implant Device,1728.9,34,,1728.9,percent of total billed charges,Implant Device,2517.08,,,2517.08,Other,110% of Medicare,1779.75,35,,1779.75,percent of total billed charges,Implant Device,1728.9,34,"Charges > $500, x 34%",1728.9,percent of total billed charges,Implant Device,1779.75,35,,1779.75,percent of total billed charges,Implant Device,1779.75,35,,1779.75,percent of total billed charges,Implant Device,1779.75,35,,1779.75,percent of total billed charges,Implant Device,1779.75,35,,1779.75,percent of total billed charges,Implant Device,1779.75,35,,1779.75,percent of total billed charges,Implant Device,2034,40,,2034,percent of total billed charges,Implant Device,1779.75,70,,1779.75,percent of total billed charges,All Other,1728.9,34,,1728.9,percent of total billed charges,Implant Device,1728.9,34,,1728.9,percent of total billed charges,Implant Device,1779.75,35,,1779.75,percent of total billed charges,Implant Device,1779.75,35,,1779.75,percent of total billed charges,Implant Device,1779.75,35,,1779.75,percent of total billed charges,Implant Device,1779.75,35,,1779.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1728.9,34,"If Charge > 2,000, then 34 percent",1728.9,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3762.91,
MENTOR 354-9111 TISSUE EXPANDER 250CC,C1789,HCPCS,,79009451,CDM,278,RC,,,both,,,5085,3762.91,,,3762.91,Other,150% of Medicare + 9.63% HCRA Surcharge,2288.25,45,,2288.25,percent of total billed charges,Critical Access Hospital RCC factor,1728.9,34,,1728.9,percent of total billed charges,Implant Device,1728.9,34,,1728.9,percent of total billed charges,Implant Device,1728.9,34,,1728.9,percent of total billed charges,Implant Device,1728.9,34,,1728.9,percent of total billed charges,Implant Device,1728.9,34,,1728.9,percent of total billed charges,Implant Device,2517.08,,,2517.08,Other,110% of Medicare,1779.75,35,,1779.75,percent of total billed charges,Implant Device,1728.9,34,"Charges > $500, x 34%",1728.9,percent of total billed charges,Implant Device,1779.75,35,,1779.75,percent of total billed charges,Implant Device,1779.75,35,,1779.75,percent of total billed charges,Implant Device,1779.75,35,,1779.75,percent of total billed charges,Implant Device,1779.75,35,,1779.75,percent of total billed charges,Implant Device,1779.75,35,,1779.75,percent of total billed charges,Implant Device,2034,40,,2034,percent of total billed charges,Implant Device,1779.75,70,,1779.75,percent of total billed charges,All Other,1728.9,34,,1728.9,percent of total billed charges,Implant Device,1728.9,34,,1728.9,percent of total billed charges,Implant Device,1779.75,35,,1779.75,percent of total billed charges,Implant Device,1779.75,35,,1779.75,percent of total billed charges,Implant Device,1779.75,35,,1779.75,percent of total billed charges,Implant Device,1779.75,35,,1779.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1728.9,34,"If Charge > 2,000, then 34 percent",1728.9,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3762.91,
MENTOR 350-2751BC BREAST IMPLANT 275CC,C1789,HCPCS,,79009452,CDM,278,RC,,,both,,,2865,2120.11,,,2120.11,Other,150% of Medicare + 9.63% HCRA Surcharge,1289.25,45,,1289.25,percent of total billed charges,Critical Access Hospital RCC factor,974.1,34,,974.1,percent of total billed charges,Implant Device,974.1,34,,974.1,percent of total billed charges,Implant Device,974.1,34,,974.1,percent of total billed charges,Implant Device,974.1,34,,974.1,percent of total billed charges,Implant Device,974.1,34,,974.1,percent of total billed charges,Implant Device,1418.18,,,1418.18,Other,110% of Medicare,1002.75,35,,1002.75,percent of total billed charges,Implant Device,974.1,34,"Charges > $500, x 34%",974.1,percent of total billed charges,Implant Device,1002.75,35,,1002.75,percent of total billed charges,Implant Device,1002.75,35,,1002.75,percent of total billed charges,Implant Device,1002.75,35,,1002.75,percent of total billed charges,Implant Device,1002.75,35,,1002.75,percent of total billed charges,Implant Device,1002.75,35,,1002.75,percent of total billed charges,Implant Device,1146,40,,1146,percent of total billed charges,Implant Device,1002.75,70,,1002.75,percent of total billed charges,All Other,974.1,34,,974.1,percent of total billed charges,Implant Device,974.1,34,,974.1,percent of total billed charges,Implant Device,1002.75,35,,1002.75,percent of total billed charges,Implant Device,1002.75,35,,1002.75,percent of total billed charges,Implant Device,1002.75,35,,1002.75,percent of total billed charges,Implant Device,1002.75,35,,1002.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,974.1,34,"If Charge > 2,000, then 34 percent",974.1,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2120.11,
MENTOR 350-3500 BREAST IMPLANT 500CC,C1789,HCPCS,,79009454,CDM,278,RC,,,both,,,2010,1487.41,,,1487.41,Other,150% of Medicare + 9.63% HCRA Surcharge,904.5,45,,904.5,percent of total billed charges,Critical Access Hospital RCC factor,683.4,34,,683.4,percent of total billed charges,Implant Device,683.4,34,,683.4,percent of total billed charges,Implant Device,683.4,34,,683.4,percent of total billed charges,Implant Device,683.4,34,,683.4,percent of total billed charges,Implant Device,683.4,34,,683.4,percent of total billed charges,Implant Device,994.95,,,994.95,Other,110% of Medicare,703.5,35,,703.5,percent of total billed charges,Implant Device,683.4,34,"Charges > $500, x 34%",683.4,percent of total billed charges,Implant Device,703.5,35,,703.5,percent of total billed charges,Implant Device,703.5,35,,703.5,percent of total billed charges,Implant Device,703.5,35,,703.5,percent of total billed charges,Implant Device,703.5,35,,703.5,percent of total billed charges,Implant Device,703.5,35,,703.5,percent of total billed charges,Implant Device,804,40,,804,percent of total billed charges,Implant Device,703.5,70,,703.5,percent of total billed charges,All Other,683.4,34,,683.4,percent of total billed charges,Implant Device,683.4,34,,683.4,percent of total billed charges,Implant Device,703.5,35,,703.5,percent of total billed charges,Implant Device,703.5,35,,703.5,percent of total billed charges,Implant Device,703.5,35,,703.5,percent of total billed charges,Implant Device,703.5,35,,703.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,683.4,34,"If Charge > 2,000, then 34 percent",683.4,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1487.41,
DEPUY 1365-36-340 FEMORAL HEAD +12.36MM,C1776,HCPCS,,79009456,CDM,278,RC,,,both,,,5253,3887.23,,,3887.23,Other,150% of Medicare + 9.63% HCRA Surcharge,2363.85,45,,2363.85,percent of total billed charges,Critical Access Hospital RCC factor,1786.02,34,,1786.02,percent of total billed charges,Implant Device,1786.02,34,,1786.02,percent of total billed charges,Implant Device,1786.02,34,,1786.02,percent of total billed charges,Implant Device,1786.02,34,,1786.02,percent of total billed charges,Implant Device,1786.02,34,,1786.02,percent of total billed charges,Implant Device,2600.24,,,2600.24,Other,110% of Medicare,1838.55,35,,1838.55,percent of total billed charges,Implant Device,1786.02,34,"Charges > $500, x 34%",1786.02,percent of total billed charges,Implant Device,1838.55,35,,1838.55,percent of total billed charges,Implant Device,1838.55,35,,1838.55,percent of total billed charges,Implant Device,1838.55,35,,1838.55,percent of total billed charges,Implant Device,1838.55,35,,1838.55,percent of total billed charges,Implant Device,1838.55,35,,1838.55,percent of total billed charges,Implant Device,2101.2,40,,2101.2,percent of total billed charges,Implant Device,1838.55,70,,1838.55,percent of total billed charges,All Other,1786.02,34,,1786.02,percent of total billed charges,Implant Device,1786.02,34,,1786.02,percent of total billed charges,Implant Device,1838.55,35,,1838.55,percent of total billed charges,Implant Device,1838.55,35,,1838.55,percent of total billed charges,Implant Device,1838.55,35,,1838.55,percent of total billed charges,Implant Device,1838.55,35,,1838.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1786.02,34,"If Charge > 2,000, then 34 percent",1786.02,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3887.23,
STRYKER 141-2528 HEADLESS SCREW 2.5X28MM,C1713,HCPCS,,79009457,CDM,278,RC,,,both,,,1557,1152.18,,,1152.18,Other,150% of Medicare + 9.63% HCRA Surcharge,700.65,45,,700.65,percent of total billed charges,Critical Access Hospital RCC factor,529.38,34,,529.38,percent of total billed charges,Implant Device,529.38,34,,529.38,percent of total billed charges,Implant Device,529.38,34,,529.38,percent of total billed charges,Implant Device,529.38,34,,529.38,percent of total billed charges,Implant Device,529.38,34,,529.38,percent of total billed charges,Implant Device,770.72,,,770.72,Other,110% of Medicare,544.95,35,,544.95,percent of total billed charges,Implant Device,529.38,34,"Charges > $500, x 34%",529.38,percent of total billed charges,Implant Device,544.95,35,,544.95,percent of total billed charges,Implant Device,544.95,35,,544.95,percent of total billed charges,Implant Device,544.95,35,,544.95,percent of total billed charges,Implant Device,544.95,35,,544.95,percent of total billed charges,Implant Device,544.95,35,,544.95,percent of total billed charges,Implant Device,622.8,40,,622.8,percent of total billed charges,Implant Device,544.95,70,,544.95,percent of total billed charges,All Other,529.38,34,,529.38,percent of total billed charges,Implant Device,529.38,34,,529.38,percent of total billed charges,Implant Device,544.95,35,,544.95,percent of total billed charges,Implant Device,544.95,35,,544.95,percent of total billed charges,Implant Device,544.95,35,,544.95,percent of total billed charges,Implant Device,544.95,35,,544.95,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1152.18,
STRYKER 141-2524 HEADLESS SCREW 2.5X24MM,C1713,HCPCS,,79009458,CDM,278,RC,,,both,,,1557,1152.18,,,1152.18,Other,150% of Medicare + 9.63% HCRA Surcharge,700.65,45,,700.65,percent of total billed charges,Critical Access Hospital RCC factor,529.38,34,,529.38,percent of total billed charges,Implant Device,529.38,34,,529.38,percent of total billed charges,Implant Device,529.38,34,,529.38,percent of total billed charges,Implant Device,529.38,34,,529.38,percent of total billed charges,Implant Device,529.38,34,,529.38,percent of total billed charges,Implant Device,770.72,,,770.72,Other,110% of Medicare,544.95,35,,544.95,percent of total billed charges,Implant Device,529.38,34,"Charges > $500, x 34%",529.38,percent of total billed charges,Implant Device,544.95,35,,544.95,percent of total billed charges,Implant Device,544.95,35,,544.95,percent of total billed charges,Implant Device,544.95,35,,544.95,percent of total billed charges,Implant Device,544.95,35,,544.95,percent of total billed charges,Implant Device,544.95,35,,544.95,percent of total billed charges,Implant Device,622.8,40,,622.8,percent of total billed charges,Implant Device,544.95,70,,544.95,percent of total billed charges,All Other,529.38,34,,529.38,percent of total billed charges,Implant Device,529.38,34,,529.38,percent of total billed charges,Implant Device,544.95,35,,544.95,percent of total billed charges,Implant Device,544.95,35,,544.95,percent of total billed charges,Implant Device,544.95,35,,544.95,percent of total billed charges,Implant Device,544.95,35,,544.95,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1152.18,
STRYKER 141-2523 HEADLESS SCREW 2.5X23MM,C1713,HCPCS,,79009459,CDM,278,RC,,,both,,,1557,1152.18,,,1152.18,Other,150% of Medicare + 9.63% HCRA Surcharge,700.65,45,,700.65,percent of total billed charges,Critical Access Hospital RCC factor,529.38,34,,529.38,percent of total billed charges,Implant Device,529.38,34,,529.38,percent of total billed charges,Implant Device,529.38,34,,529.38,percent of total billed charges,Implant Device,529.38,34,,529.38,percent of total billed charges,Implant Device,529.38,34,,529.38,percent of total billed charges,Implant Device,770.72,,,770.72,Other,110% of Medicare,544.95,35,,544.95,percent of total billed charges,Implant Device,529.38,34,"Charges > $500, x 34%",529.38,percent of total billed charges,Implant Device,544.95,35,,544.95,percent of total billed charges,Implant Device,544.95,35,,544.95,percent of total billed charges,Implant Device,544.95,35,,544.95,percent of total billed charges,Implant Device,544.95,35,,544.95,percent of total billed charges,Implant Device,544.95,35,,544.95,percent of total billed charges,Implant Device,622.8,40,,622.8,percent of total billed charges,Implant Device,544.95,70,,544.95,percent of total billed charges,All Other,529.38,34,,529.38,percent of total billed charges,Implant Device,529.38,34,,529.38,percent of total billed charges,Implant Device,544.95,35,,544.95,percent of total billed charges,Implant Device,544.95,35,,544.95,percent of total billed charges,Implant Device,544.95,35,,544.95,percent of total billed charges,Implant Device,544.95,35,,544.95,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1152.18,
STRYKER 657128 CORTICAL SCREW 2.7X28MM,C1713,HCPCS,,79009460,CDM,278,RC,,,both,,,294,217.56,,,217.56,Other,150% of Medicare + 9.63% HCRA Surcharge,132.3,45,,132.3,percent of total billed charges,Critical Access Hospital RCC factor,99.96,34,,99.96,percent of total billed charges,Implant Device,99.96,34,,99.96,percent of total billed charges,Implant Device,99.96,34,,99.96,percent of total billed charges,Implant Device,99.96,34,,99.96,percent of total billed charges,Implant Device,99.96,34,,99.96,percent of total billed charges,Implant Device,145.53,,,145.53,Other,110% of Medicare,102.9,35,,102.9,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,102.9,35,,102.9,percent of total billed charges,Implant Device,102.9,35,,102.9,percent of total billed charges,Implant Device,102.9,35,,102.9,percent of total billed charges,Implant Device,102.9,35,,102.9,percent of total billed charges,Implant Device,102.9,35,,102.9,percent of total billed charges,Implant Device,117.6,40,,117.6,percent of total billed charges,Implant Device,102.9,70,,102.9,percent of total billed charges,All Other,99.96,34,,99.96,percent of total billed charges,Implant Device,99.96,34,,99.96,percent of total billed charges,Implant Device,102.9,35,,102.9,percent of total billed charges,Implant Device,102.9,35,,102.9,percent of total billed charges,Implant Device,102.9,35,,102.9,percent of total billed charges,Implant Device,102.9,35,,102.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,217.56,
STRYKER 325046 CANNULATED SCREW 4.0X46MM,C1713,HCPCS,,79009461,CDM,278,RC,,,both,,,824,609.76,,,609.76,Other,150% of Medicare + 9.63% HCRA Surcharge,370.8,45,,370.8,percent of total billed charges,Critical Access Hospital RCC factor,280.16,34,,280.16,percent of total billed charges,Implant Device,280.16,34,,280.16,percent of total billed charges,Implant Device,280.16,34,,280.16,percent of total billed charges,Implant Device,280.16,34,,280.16,percent of total billed charges,Implant Device,280.16,34,,280.16,percent of total billed charges,Implant Device,407.88,,,407.88,Other,110% of Medicare,288.4,35,,288.4,percent of total billed charges,Implant Device,280.16,34,"Charges > $500, x 34%",280.16,percent of total billed charges,Implant Device,288.4,35,,288.4,percent of total billed charges,Implant Device,288.4,35,,288.4,percent of total billed charges,Implant Device,288.4,35,,288.4,percent of total billed charges,Implant Device,288.4,35,,288.4,percent of total billed charges,Implant Device,288.4,35,,288.4,percent of total billed charges,Implant Device,329.6,40,,329.6,percent of total billed charges,Implant Device,288.4,70,,288.4,percent of total billed charges,All Other,280.16,34,,280.16,percent of total billed charges,Implant Device,280.16,34,,280.16,percent of total billed charges,Implant Device,288.4,35,,288.4,percent of total billed charges,Implant Device,288.4,35,,288.4,percent of total billed charges,Implant Device,288.4,35,,288.4,percent of total billed charges,Implant Device,288.4,35,,288.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,609.76,
DEPUY 1018-36-511 FEMORAL HEAD 036MM,C1776,HCPCS,,79009464,CDM,278,RC,,,both,,,6682,4944.7,,,4944.7,Other,150% of Medicare + 9.63% HCRA Surcharge,3006.9,45,,3006.9,percent of total billed charges,Critical Access Hospital RCC factor,2271.88,34,,2271.88,percent of total billed charges,Implant Device,2271.88,34,,2271.88,percent of total billed charges,Implant Device,2271.88,34,,2271.88,percent of total billed charges,Implant Device,2271.88,34,,2271.88,percent of total billed charges,Implant Device,2271.88,34,,2271.88,percent of total billed charges,Implant Device,3307.59,,,3307.59,Other,110% of Medicare,2338.7,35,,2338.7,percent of total billed charges,Implant Device,2271.88,34,"Charges > $500, x 34%",2271.88,percent of total billed charges,Implant Device,2338.7,35,,2338.7,percent of total billed charges,Implant Device,2338.7,35,,2338.7,percent of total billed charges,Implant Device,2338.7,35,,2338.7,percent of total billed charges,Implant Device,2338.7,35,,2338.7,percent of total billed charges,Implant Device,2338.7,35,,2338.7,percent of total billed charges,Implant Device,2672.8,40,,2672.8,percent of total billed charges,Implant Device,2338.7,70,,2338.7,percent of total billed charges,All Other,2271.88,34,,2271.88,percent of total billed charges,Implant Device,2271.88,34,,2271.88,percent of total billed charges,Implant Device,2338.7,35,,2338.7,percent of total billed charges,Implant Device,2338.7,35,,2338.7,percent of total billed charges,Implant Device,2338.7,35,,2338.7,percent of total billed charges,Implant Device,2338.7,35,,2338.7,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2271.88,34,"If Charge > 2,000, then 34 percent",2271.88,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4944.7,
ZIMMER 08A022LL CANCELLOUS CHIPS 15CC,C1713,HCPCS,,79009465,CDM,278,RC,,,both,,,630,466.2,,,466.2,Other,150% of Medicare + 9.63% HCRA Surcharge,283.5,45,,283.5,percent of total billed charges,Critical Access Hospital RCC factor,214.2,34,,214.2,percent of total billed charges,Implant Device,214.2,34,,214.2,percent of total billed charges,Implant Device,214.2,34,,214.2,percent of total billed charges,Implant Device,214.2,34,,214.2,percent of total billed charges,Implant Device,214.2,34,,214.2,percent of total billed charges,Implant Device,311.85,,,311.85,Other,110% of Medicare,220.5,35,,220.5,percent of total billed charges,Implant Device,214.2,34,"Charges > $500, x 34%",214.2,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,252,40,,252,percent of total billed charges,Implant Device,220.5,70,,220.5,percent of total billed charges,All Other,214.2,34,,214.2,percent of total billed charges,Implant Device,214.2,34,,214.2,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,220.5,35,,220.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,466.2,
ZIMMER 08A020LL CANCELLOUS CHIPS 30CC,C1713,HCPCS,,79009466,CDM,278,RC,,,both,,,993,734.82,,,734.82,Other,150% of Medicare + 9.63% HCRA Surcharge,446.85,45,,446.85,percent of total billed charges,Critical Access Hospital RCC factor,337.62,34,,337.62,percent of total billed charges,Implant Device,337.62,34,,337.62,percent of total billed charges,Implant Device,337.62,34,,337.62,percent of total billed charges,Implant Device,337.62,34,,337.62,percent of total billed charges,Implant Device,337.62,34,,337.62,percent of total billed charges,Implant Device,491.54,,,491.54,Other,110% of Medicare,347.55,35,,347.55,percent of total billed charges,Implant Device,337.62,34,"Charges > $500, x 34%",337.62,percent of total billed charges,Implant Device,347.55,35,,347.55,percent of total billed charges,Implant Device,347.55,35,,347.55,percent of total billed charges,Implant Device,347.55,35,,347.55,percent of total billed charges,Implant Device,347.55,35,,347.55,percent of total billed charges,Implant Device,347.55,35,,347.55,percent of total billed charges,Implant Device,397.2,40,,397.2,percent of total billed charges,Implant Device,347.55,70,,347.55,percent of total billed charges,All Other,337.62,34,,337.62,percent of total billed charges,Implant Device,337.62,34,,337.62,percent of total billed charges,Implant Device,347.55,35,,347.55,percent of total billed charges,Implant Device,347.55,35,,347.55,percent of total billed charges,Implant Device,347.55,35,,347.55,percent of total billed charges,Implant Device,347.55,35,,347.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,734.82,
ZIMMER 08A021LL CANCELLOUS CHIPS 60CC,C1713,HCPCS,,79009467,CDM,278,RC,,,both,,,1626,1203.24,,,1203.24,Other,150% of Medicare + 9.63% HCRA Surcharge,731.7,45,,731.7,percent of total billed charges,Critical Access Hospital RCC factor,552.84,34,,552.84,percent of total billed charges,Implant Device,552.84,34,,552.84,percent of total billed charges,Implant Device,552.84,34,,552.84,percent of total billed charges,Implant Device,552.84,34,,552.84,percent of total billed charges,Implant Device,552.84,34,,552.84,percent of total billed charges,Implant Device,804.87,,,804.87,Other,110% of Medicare,569.1,35,,569.1,percent of total billed charges,Implant Device,552.84,34,"Charges > $500, x 34%",552.84,percent of total billed charges,Implant Device,569.1,35,,569.1,percent of total billed charges,Implant Device,569.1,35,,569.1,percent of total billed charges,Implant Device,569.1,35,,569.1,percent of total billed charges,Implant Device,569.1,35,,569.1,percent of total billed charges,Implant Device,569.1,35,,569.1,percent of total billed charges,Implant Device,650.4,40,,650.4,percent of total billed charges,Implant Device,569.1,70,,569.1,percent of total billed charges,All Other,552.84,34,,552.84,percent of total billed charges,Implant Device,552.84,34,,552.84,percent of total billed charges,Implant Device,569.1,35,,569.1,percent of total billed charges,Implant Device,569.1,35,,569.1,percent of total billed charges,Implant Device,569.1,35,,569.1,percent of total billed charges,Implant Device,569.1,35,,569.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1203.24,
IN2BONES M40 SE020 RTS MTP IMPLANT SZ 2,C1713,HCPCS,,79009470,CDM,278,RC,,,both,,,4785,3540.91,,,3540.91,Other,150% of Medicare + 9.63% HCRA Surcharge,2153.25,45,,2153.25,percent of total billed charges,Critical Access Hospital RCC factor,1626.9,34,,1626.9,percent of total billed charges,Implant Device,1626.9,34,,1626.9,percent of total billed charges,Implant Device,1626.9,34,,1626.9,percent of total billed charges,Implant Device,1626.9,34,,1626.9,percent of total billed charges,Implant Device,1626.9,34,,1626.9,percent of total billed charges,Implant Device,2368.58,,,2368.58,Other,110% of Medicare,1674.75,35,,1674.75,percent of total billed charges,Implant Device,1626.9,34,"Charges > $500, x 34%",1626.9,percent of total billed charges,Implant Device,1674.75,35,,1674.75,percent of total billed charges,Implant Device,1674.75,35,,1674.75,percent of total billed charges,Implant Device,1674.75,35,,1674.75,percent of total billed charges,Implant Device,1674.75,35,,1674.75,percent of total billed charges,Implant Device,1674.75,35,,1674.75,percent of total billed charges,Implant Device,1914,40,,1914,percent of total billed charges,Implant Device,1674.75,70,,1674.75,percent of total billed charges,All Other,1626.9,34,,1626.9,percent of total billed charges,Implant Device,1626.9,34,,1626.9,percent of total billed charges,Implant Device,1674.75,35,,1674.75,percent of total billed charges,Implant Device,1674.75,35,,1674.75,percent of total billed charges,Implant Device,1674.75,35,,1674.75,percent of total billed charges,Implant Device,1674.75,35,,1674.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1626.9,34,"If Charge > 2,000, then 34 percent",1626.9,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3540.91,
STRYKER 1822-1236S TIBIAL NAIL 12X360MM,C1713,HCPCS,,79009471,CDM,278,RC,,,both,,,3529,2611.47,,,2611.47,Other,150% of Medicare + 9.63% HCRA Surcharge,1588.05,45,,1588.05,percent of total billed charges,Critical Access Hospital RCC factor,1199.86,34,,1199.86,percent of total billed charges,Implant Device,1199.86,34,,1199.86,percent of total billed charges,Implant Device,1199.86,34,,1199.86,percent of total billed charges,Implant Device,1199.86,34,,1199.86,percent of total billed charges,Implant Device,1199.86,34,,1199.86,percent of total billed charges,Implant Device,1746.86,,,1746.86,Other,110% of Medicare,1235.15,35,,1235.15,percent of total billed charges,Implant Device,1199.86,34,"Charges > $500, x 34%",1199.86,percent of total billed charges,Implant Device,1235.15,35,,1235.15,percent of total billed charges,Implant Device,1235.15,35,,1235.15,percent of total billed charges,Implant Device,1235.15,35,,1235.15,percent of total billed charges,Implant Device,1235.15,35,,1235.15,percent of total billed charges,Implant Device,1235.15,35,,1235.15,percent of total billed charges,Implant Device,1411.6,40,,1411.6,percent of total billed charges,Implant Device,1235.15,70,,1235.15,percent of total billed charges,All Other,1199.86,34,,1199.86,percent of total billed charges,Implant Device,1199.86,34,,1199.86,percent of total billed charges,Implant Device,1235.15,35,,1235.15,percent of total billed charges,Implant Device,1235.15,35,,1235.15,percent of total billed charges,Implant Device,1235.15,35,,1235.15,percent of total billed charges,Implant Device,1235.15,35,,1235.15,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1199.86,34,"If Charge > 2,000, then 34 percent",1199.86,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2611.47,
ZIMMER 00-5952-040-14 ARTICULR SURF 14MM,C1776,HCPCS,,79009472,CDM,278,RC,,,both,,,2496,1847.05,,,1847.05,Other,150% of Medicare + 9.63% HCRA Surcharge,1123.2,45,,1123.2,percent of total billed charges,Critical Access Hospital RCC factor,848.64,34,,848.64,percent of total billed charges,Implant Device,848.64,34,,848.64,percent of total billed charges,Implant Device,848.64,34,,848.64,percent of total billed charges,Implant Device,848.64,34,,848.64,percent of total billed charges,Implant Device,848.64,34,,848.64,percent of total billed charges,Implant Device,1235.52,,,1235.52,Other,110% of Medicare,873.6,35,,873.6,percent of total billed charges,Implant Device,848.64,34,"Charges > $500, x 34%",848.64,percent of total billed charges,Implant Device,873.6,35,,873.6,percent of total billed charges,Implant Device,873.6,35,,873.6,percent of total billed charges,Implant Device,873.6,35,,873.6,percent of total billed charges,Implant Device,873.6,35,,873.6,percent of total billed charges,Implant Device,873.6,35,,873.6,percent of total billed charges,Implant Device,998.4,40,,998.4,percent of total billed charges,Implant Device,873.6,70,,873.6,percent of total billed charges,All Other,848.64,34,,848.64,percent of total billed charges,Implant Device,848.64,34,,848.64,percent of total billed charges,Implant Device,873.6,35,,873.6,percent of total billed charges,Implant Device,873.6,35,,873.6,percent of total billed charges,Implant Device,873.6,35,,873.6,percent of total billed charges,Implant Device,873.6,35,,873.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,848.64,34,"If Charge > 2,000, then 34 percent",848.64,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1847.05,
ZIMMER 00-5994-051-17 ARTICULR SURF 17MM,C1776,HCPCS,,79009473,CDM,278,RC,,,both,,,6257,4630.2,,,4630.2,Other,150% of Medicare + 9.63% HCRA Surcharge,2815.65,45,,2815.65,percent of total billed charges,Critical Access Hospital RCC factor,2127.38,34,,2127.38,percent of total billed charges,Implant Device,2127.38,34,,2127.38,percent of total billed charges,Implant Device,2127.38,34,,2127.38,percent of total billed charges,Implant Device,2127.38,34,,2127.38,percent of total billed charges,Implant Device,2127.38,34,,2127.38,percent of total billed charges,Implant Device,3097.22,,,3097.22,Other,110% of Medicare,2189.95,35,,2189.95,percent of total billed charges,Implant Device,2127.38,34,"Charges > $500, x 34%",2127.38,percent of total billed charges,Implant Device,2189.95,35,,2189.95,percent of total billed charges,Implant Device,2189.95,35,,2189.95,percent of total billed charges,Implant Device,2189.95,35,,2189.95,percent of total billed charges,Implant Device,2189.95,35,,2189.95,percent of total billed charges,Implant Device,2189.95,35,,2189.95,percent of total billed charges,Implant Device,2502.8,40,,2502.8,percent of total billed charges,Implant Device,2189.95,70,,2189.95,percent of total billed charges,All Other,2127.38,34,,2127.38,percent of total billed charges,Implant Device,2127.38,34,,2127.38,percent of total billed charges,Implant Device,2189.95,35,,2189.95,percent of total billed charges,Implant Device,2189.95,35,,2189.95,percent of total billed charges,Implant Device,2189.95,35,,2189.95,percent of total billed charges,Implant Device,2189.95,35,,2189.95,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2127.38,34,"If Charge > 2,000, then 34 percent",2127.38,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4630.2,
DEPUY 04.005.436S LOCKING SCREW 4.0X46MM,C1713,HCPCS,,79009478,CDM,278,RC,,,both,,,412,304.88,,,304.88,Other,150% of Medicare + 9.63% HCRA Surcharge,185.4,45,,185.4,percent of total billed charges,Critical Access Hospital RCC factor,140.08,34,,140.08,percent of total billed charges,Implant Device,140.08,34,,140.08,percent of total billed charges,Implant Device,140.08,34,,140.08,percent of total billed charges,Implant Device,140.08,34,,140.08,percent of total billed charges,Implant Device,140.08,34,,140.08,percent of total billed charges,Implant Device,203.94,,,203.94,Other,110% of Medicare,144.2,35,,144.2,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,144.2,35,,144.2,percent of total billed charges,Implant Device,144.2,35,,144.2,percent of total billed charges,Implant Device,144.2,35,,144.2,percent of total billed charges,Implant Device,144.2,35,,144.2,percent of total billed charges,Implant Device,144.2,35,,144.2,percent of total billed charges,Implant Device,164.8,40,,164.8,percent of total billed charges,Implant Device,144.2,70,,144.2,percent of total billed charges,All Other,140.08,34,,140.08,percent of total billed charges,Implant Device,140.08,34,,140.08,percent of total billed charges,Implant Device,144.2,35,,144.2,percent of total billed charges,Implant Device,144.2,35,,144.2,percent of total billed charges,Implant Device,144.2,35,,144.2,percent of total billed charges,Implant Device,144.2,35,,144.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,304.88,
DEPUY 462.642S SPIRAL BLADE SCREW 42MM,C1713,HCPCS,,79009479,CDM,278,RC,,,both,,,2623,1941.03,,,1941.03,Other,150% of Medicare + 9.63% HCRA Surcharge,1180.35,45,,1180.35,percent of total billed charges,Critical Access Hospital RCC factor,891.82,34,,891.82,percent of total billed charges,Implant Device,891.82,34,,891.82,percent of total billed charges,Implant Device,891.82,34,,891.82,percent of total billed charges,Implant Device,891.82,34,,891.82,percent of total billed charges,Implant Device,891.82,34,,891.82,percent of total billed charges,Implant Device,1298.39,,,1298.39,Other,110% of Medicare,918.05,35,,918.05,percent of total billed charges,Implant Device,891.82,34,"Charges > $500, x 34%",891.82,percent of total billed charges,Implant Device,918.05,35,,918.05,percent of total billed charges,Implant Device,918.05,35,,918.05,percent of total billed charges,Implant Device,918.05,35,,918.05,percent of total billed charges,Implant Device,918.05,35,,918.05,percent of total billed charges,Implant Device,918.05,35,,918.05,percent of total billed charges,Implant Device,1049.2,40,,1049.2,percent of total billed charges,Implant Device,918.05,70,,918.05,percent of total billed charges,All Other,891.82,34,,891.82,percent of total billed charges,Implant Device,891.82,34,,891.82,percent of total billed charges,Implant Device,918.05,35,,918.05,percent of total billed charges,Implant Device,918.05,35,,918.05,percent of total billed charges,Implant Device,918.05,35,,918.05,percent of total billed charges,Implant Device,918.05,35,,918.05,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,891.82,34,"If Charge > 2,000, then 34 percent",891.82,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1941.03,
DEPUY 04.005.416S LOCKING SCREW 4.0X26MM,C1713,HCPCS,,79009480,CDM,278,RC,,,both,,,454,335.96,,,335.96,Other,150% of Medicare + 9.63% HCRA Surcharge,204.3,45,,204.3,percent of total billed charges,Critical Access Hospital RCC factor,154.36,34,,154.36,percent of total billed charges,Implant Device,154.36,34,,154.36,percent of total billed charges,Implant Device,154.36,34,,154.36,percent of total billed charges,Implant Device,154.36,34,,154.36,percent of total billed charges,Implant Device,154.36,34,,154.36,percent of total billed charges,Implant Device,224.73,,,224.73,Other,110% of Medicare,158.9,35,,158.9,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,158.9,35,,158.9,percent of total billed charges,Implant Device,158.9,35,,158.9,percent of total billed charges,Implant Device,158.9,35,,158.9,percent of total billed charges,Implant Device,158.9,35,,158.9,percent of total billed charges,Implant Device,158.9,35,,158.9,percent of total billed charges,Implant Device,181.6,40,,181.6,percent of total billed charges,Implant Device,158.9,70,,158.9,percent of total billed charges,All Other,154.36,34,,154.36,percent of total billed charges,Implant Device,154.36,34,,154.36,percent of total billed charges,Implant Device,158.9,35,,158.9,percent of total billed charges,Implant Device,158.9,35,,158.9,percent of total billed charges,Implant Device,158.9,35,,158.9,percent of total billed charges,Implant Device,158.9,35,,158.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,335.96,
DEPUY 04.001.230S CANN HUM NAIL 7X250MM,C1713,HCPCS,,79009481,CDM,278,RC,,,both,,,7882,5832.7,,,5832.7,Other,150% of Medicare + 9.63% HCRA Surcharge,3546.9,45,,3546.9,percent of total billed charges,Critical Access Hospital RCC factor,2679.88,34,,2679.88,percent of total billed charges,Implant Device,2679.88,34,,2679.88,percent of total billed charges,Implant Device,2679.88,34,,2679.88,percent of total billed charges,Implant Device,2679.88,34,,2679.88,percent of total billed charges,Implant Device,2679.88,34,,2679.88,percent of total billed charges,Implant Device,3901.59,,,3901.59,Other,110% of Medicare,2758.7,35,,2758.7,percent of total billed charges,Implant Device,2679.88,34,"Charges > $500, x 34%",2679.88,percent of total billed charges,Implant Device,2758.7,35,,2758.7,percent of total billed charges,Implant Device,2758.7,35,,2758.7,percent of total billed charges,Implant Device,2758.7,35,,2758.7,percent of total billed charges,Implant Device,2758.7,35,,2758.7,percent of total billed charges,Implant Device,2758.7,35,,2758.7,percent of total billed charges,Implant Device,3152.8,40,,3152.8,percent of total billed charges,Implant Device,2758.7,70,,2758.7,percent of total billed charges,All Other,2679.88,34,,2679.88,percent of total billed charges,Implant Device,2679.88,34,,2679.88,percent of total billed charges,Implant Device,2758.7,35,,2758.7,percent of total billed charges,Implant Device,2758.7,35,,2758.7,percent of total billed charges,Implant Device,2758.7,35,,2758.7,percent of total billed charges,Implant Device,2758.7,35,,2758.7,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2679.88,34,"If Charge > 2,000, then 34 percent",2679.88,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5832.7,
ZIMMER 00-5976-030-10 ART SURF SZ 10MM,C1776,HCPCS,,79009483,CDM,278,RC,,,both,,,1920,1420.8,,,1420.8,Other,150% of Medicare + 9.63% HCRA Surcharge,864,45,,864,percent of total billed charges,Critical Access Hospital RCC factor,652.8,34,,652.8,percent of total billed charges,Implant Device,652.8,34,,652.8,percent of total billed charges,Implant Device,652.8,34,,652.8,percent of total billed charges,Implant Device,652.8,34,,652.8,percent of total billed charges,Implant Device,652.8,34,,652.8,percent of total billed charges,Implant Device,950.4,,,950.4,Other,110% of Medicare,672,35,,672,percent of total billed charges,Implant Device,652.8,34,"Charges > $500, x 34%",652.8,percent of total billed charges,Implant Device,672,35,,672,percent of total billed charges,Implant Device,672,35,,672,percent of total billed charges,Implant Device,672,35,,672,percent of total billed charges,Implant Device,672,35,,672,percent of total billed charges,Implant Device,672,35,,672,percent of total billed charges,Implant Device,768,40,,768,percent of total billed charges,Implant Device,672,70,,672,percent of total billed charges,All Other,652.8,34,,652.8,percent of total billed charges,Implant Device,652.8,34,,652.8,percent of total billed charges,Implant Device,672,35,,672,percent of total billed charges,Implant Device,672,35,,672,percent of total billed charges,Implant Device,672,35,,672,percent of total billed charges,Implant Device,672,35,,672,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1420.8,
ARTHREX AR-8943C-10 LOCKING PLATE 10M,C1713,HCPCS,,79009484,CDM,278,RC,,,both,,,2550,1887.01,,,1887.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1147.5,45,,1147.5,percent of total billed charges,Critical Access Hospital RCC factor,867,34,,867,percent of total billed charges,Implant Device,867,34,,867,percent of total billed charges,Implant Device,867,34,,867,percent of total billed charges,Implant Device,867,34,,867,percent of total billed charges,Implant Device,867,34,,867,percent of total billed charges,Implant Device,1262.25,,,1262.25,Other,110% of Medicare,892.5,35,,892.5,percent of total billed charges,Implant Device,867,34,"Charges > $500, x 34%",867,percent of total billed charges,Implant Device,892.5,35,,892.5,percent of total billed charges,Implant Device,892.5,35,,892.5,percent of total billed charges,Implant Device,892.5,35,,892.5,percent of total billed charges,Implant Device,892.5,35,,892.5,percent of total billed charges,Implant Device,892.5,35,,892.5,percent of total billed charges,Implant Device,1020,40,,1020,percent of total billed charges,Implant Device,892.5,70,,892.5,percent of total billed charges,All Other,867,34,,867,percent of total billed charges,Implant Device,867,34,,867,percent of total billed charges,Implant Device,892.5,35,,892.5,percent of total billed charges,Implant Device,892.5,35,,892.5,percent of total billed charges,Implant Device,892.5,35,,892.5,percent of total billed charges,Implant Device,892.5,35,,892.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,867,34,"If Charge > 2,000, then 34 percent",867,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1887.01,
ARTHREX AR-8835L-18 3.5X18MM LOCK SCREW,C1713,HCPCS,,79009485,CDM,278,RC,,,both,,,495,366.3,,,366.3,Other,150% of Medicare + 9.63% HCRA Surcharge,222.75,45,,222.75,percent of total billed charges,Critical Access Hospital RCC factor,168.3,34,,168.3,percent of total billed charges,Implant Device,168.3,34,,168.3,percent of total billed charges,Implant Device,168.3,34,,168.3,percent of total billed charges,Implant Device,168.3,34,,168.3,percent of total billed charges,Implant Device,168.3,34,,168.3,percent of total billed charges,Implant Device,245.03,,,245.03,Other,110% of Medicare,173.25,35,,173.25,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,173.25,35,,173.25,percent of total billed charges,Implant Device,173.25,35,,173.25,percent of total billed charges,Implant Device,173.25,35,,173.25,percent of total billed charges,Implant Device,173.25,35,,173.25,percent of total billed charges,Implant Device,173.25,35,,173.25,percent of total billed charges,Implant Device,198,40,,198,percent of total billed charges,Implant Device,173.25,70,,173.25,percent of total billed charges,All Other,168.3,34,,168.3,percent of total billed charges,Implant Device,168.3,34,,168.3,percent of total billed charges,Implant Device,173.25,35,,173.25,percent of total billed charges,Implant Device,173.25,35,,173.25,percent of total billed charges,Implant Device,173.25,35,,173.25,percent of total billed charges,Implant Device,173.25,35,,173.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,366.3,
ARTHREX AR-8835L-16 3.5X16MM LOCK SCREW,C1713,HCPCS,,79009486,CDM,278,RC,,,both,,,495,366.3,,,366.3,Other,150% of Medicare + 9.63% HCRA Surcharge,222.75,45,,222.75,percent of total billed charges,Critical Access Hospital RCC factor,168.3,34,,168.3,percent of total billed charges,Implant Device,168.3,34,,168.3,percent of total billed charges,Implant Device,168.3,34,,168.3,percent of total billed charges,Implant Device,168.3,34,,168.3,percent of total billed charges,Implant Device,168.3,34,,168.3,percent of total billed charges,Implant Device,245.03,,,245.03,Other,110% of Medicare,173.25,35,,173.25,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,173.25,35,,173.25,percent of total billed charges,Implant Device,173.25,35,,173.25,percent of total billed charges,Implant Device,173.25,35,,173.25,percent of total billed charges,Implant Device,173.25,35,,173.25,percent of total billed charges,Implant Device,173.25,35,,173.25,percent of total billed charges,Implant Device,198,40,,198,percent of total billed charges,Implant Device,173.25,70,,173.25,percent of total billed charges,All Other,168.3,34,,168.3,percent of total billed charges,Implant Device,168.3,34,,168.3,percent of total billed charges,Implant Device,173.25,35,,173.25,percent of total billed charges,Implant Device,173.25,35,,173.25,percent of total billed charges,Implant Device,173.25,35,,173.25,percent of total billed charges,Implant Device,173.25,35,,173.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,366.3,
ACUMED ATF-240-S ACUTRAK FUSION SCREW 24,C1713,HCPCS,,79009487,CDM,278,RC,,,both,,,1008,745.92,,,745.92,Other,150% of Medicare + 9.63% HCRA Surcharge,453.6,45,,453.6,percent of total billed charges,Critical Access Hospital RCC factor,342.72,34,,342.72,percent of total billed charges,Implant Device,342.72,34,,342.72,percent of total billed charges,Implant Device,342.72,34,,342.72,percent of total billed charges,Implant Device,342.72,34,,342.72,percent of total billed charges,Implant Device,342.72,34,,342.72,percent of total billed charges,Implant Device,498.96,,,498.96,Other,110% of Medicare,352.8,35,,352.8,percent of total billed charges,Implant Device,342.72,34,"Charges > $500, x 34%",342.72,percent of total billed charges,Implant Device,352.8,35,,352.8,percent of total billed charges,Implant Device,352.8,35,,352.8,percent of total billed charges,Implant Device,352.8,35,,352.8,percent of total billed charges,Implant Device,352.8,35,,352.8,percent of total billed charges,Implant Device,352.8,35,,352.8,percent of total billed charges,Implant Device,403.2,40,,403.2,percent of total billed charges,Implant Device,352.8,70,,352.8,percent of total billed charges,All Other,342.72,34,,342.72,percent of total billed charges,Implant Device,342.72,34,,342.72,percent of total billed charges,Implant Device,352.8,35,,352.8,percent of total billed charges,Implant Device,352.8,35,,352.8,percent of total billed charges,Implant Device,352.8,35,,352.8,percent of total billed charges,Implant Device,352.8,35,,352.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,745.92,
MENTOR 354-9113 TISSUE EXPANDER 400CC,C1789,HCPCS,,79009490,CDM,278,RC,,,both,,,5085,3762.91,,,3762.91,Other,150% of Medicare + 9.63% HCRA Surcharge,2288.25,45,,2288.25,percent of total billed charges,Critical Access Hospital RCC factor,1728.9,34,,1728.9,percent of total billed charges,Implant Device,1728.9,34,,1728.9,percent of total billed charges,Implant Device,1728.9,34,,1728.9,percent of total billed charges,Implant Device,1728.9,34,,1728.9,percent of total billed charges,Implant Device,1728.9,34,,1728.9,percent of total billed charges,Implant Device,2517.08,,,2517.08,Other,110% of Medicare,1779.75,35,,1779.75,percent of total billed charges,Implant Device,1728.9,34,"Charges > $500, x 34%",1728.9,percent of total billed charges,Implant Device,1779.75,35,,1779.75,percent of total billed charges,Implant Device,1779.75,35,,1779.75,percent of total billed charges,Implant Device,1779.75,35,,1779.75,percent of total billed charges,Implant Device,1779.75,35,,1779.75,percent of total billed charges,Implant Device,1779.75,35,,1779.75,percent of total billed charges,Implant Device,2034,40,,2034,percent of total billed charges,Implant Device,1779.75,70,,1779.75,percent of total billed charges,All Other,1728.9,34,,1728.9,percent of total billed charges,Implant Device,1728.9,34,,1728.9,percent of total billed charges,Implant Device,1779.75,35,,1779.75,percent of total billed charges,Implant Device,1779.75,35,,1779.75,percent of total billed charges,Implant Device,1779.75,35,,1779.75,percent of total billed charges,Implant Device,1779.75,35,,1779.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1728.9,34,"If Charge > 2,000, then 34 percent",1728.9,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3762.91,
MENTOR 350-7300MC GEL IMPLANT 300CC,C1789,HCPCS,,79009491,CDM,278,RC,,,both,,,2790,2064.61,,,2064.61,Other,150% of Medicare + 9.63% HCRA Surcharge,1255.5,45,,1255.5,percent of total billed charges,Critical Access Hospital RCC factor,948.6,34,,948.6,percent of total billed charges,Implant Device,948.6,34,,948.6,percent of total billed charges,Implant Device,948.6,34,,948.6,percent of total billed charges,Implant Device,948.6,34,,948.6,percent of total billed charges,Implant Device,948.6,34,,948.6,percent of total billed charges,Implant Device,1381.05,,,1381.05,Other,110% of Medicare,976.5,35,,976.5,percent of total billed charges,Implant Device,948.6,34,"Charges > $500, x 34%",948.6,percent of total billed charges,Implant Device,976.5,35,,976.5,percent of total billed charges,Implant Device,976.5,35,,976.5,percent of total billed charges,Implant Device,976.5,35,,976.5,percent of total billed charges,Implant Device,976.5,35,,976.5,percent of total billed charges,Implant Device,976.5,35,,976.5,percent of total billed charges,Implant Device,1116,40,,1116,percent of total billed charges,Implant Device,976.5,70,,976.5,percent of total billed charges,All Other,948.6,34,,948.6,percent of total billed charges,Implant Device,948.6,34,,948.6,percent of total billed charges,Implant Device,976.5,35,,976.5,percent of total billed charges,Implant Device,976.5,35,,976.5,percent of total billed charges,Implant Device,976.5,35,,976.5,percent of total billed charges,Implant Device,976.5,35,,976.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,948.6,34,"If Charge > 2,000, then 34 percent",948.6,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2064.61,
MENTOR 350-7340MC GEL IMPLANT 340CC,C1789,HCPCS,,79009492,CDM,278,RC,,,both,,,2790,2064.61,,,2064.61,Other,150% of Medicare + 9.63% HCRA Surcharge,1255.5,45,,1255.5,percent of total billed charges,Critical Access Hospital RCC factor,948.6,34,,948.6,percent of total billed charges,Implant Device,948.6,34,,948.6,percent of total billed charges,Implant Device,948.6,34,,948.6,percent of total billed charges,Implant Device,948.6,34,,948.6,percent of total billed charges,Implant Device,948.6,34,,948.6,percent of total billed charges,Implant Device,1381.05,,,1381.05,Other,110% of Medicare,976.5,35,,976.5,percent of total billed charges,Implant Device,948.6,34,"Charges > $500, x 34%",948.6,percent of total billed charges,Implant Device,976.5,35,,976.5,percent of total billed charges,Implant Device,976.5,35,,976.5,percent of total billed charges,Implant Device,976.5,35,,976.5,percent of total billed charges,Implant Device,976.5,35,,976.5,percent of total billed charges,Implant Device,976.5,35,,976.5,percent of total billed charges,Implant Device,1116,40,,1116,percent of total billed charges,Implant Device,976.5,70,,976.5,percent of total billed charges,All Other,948.6,34,,948.6,percent of total billed charges,Implant Device,948.6,34,,948.6,percent of total billed charges,Implant Device,976.5,35,,976.5,percent of total billed charges,Implant Device,976.5,35,,976.5,percent of total billed charges,Implant Device,976.5,35,,976.5,percent of total billed charges,Implant Device,976.5,35,,976.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,948.6,34,"If Charge > 2,000, then 34 percent",948.6,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2064.61,
MENTOR 350-7320MC GEL IMPLANT 320CC,C1789,HCPCS,,79009493,CDM,278,RC,,,both,,,2790,2064.61,,,2064.61,Other,150% of Medicare + 9.63% HCRA Surcharge,1255.5,45,,1255.5,percent of total billed charges,Critical Access Hospital RCC factor,948.6,34,,948.6,percent of total billed charges,Implant Device,948.6,34,,948.6,percent of total billed charges,Implant Device,948.6,34,,948.6,percent of total billed charges,Implant Device,948.6,34,,948.6,percent of total billed charges,Implant Device,948.6,34,,948.6,percent of total billed charges,Implant Device,1381.05,,,1381.05,Other,110% of Medicare,976.5,35,,976.5,percent of total billed charges,Implant Device,948.6,34,"Charges > $500, x 34%",948.6,percent of total billed charges,Implant Device,976.5,35,,976.5,percent of total billed charges,Implant Device,976.5,35,,976.5,percent of total billed charges,Implant Device,976.5,35,,976.5,percent of total billed charges,Implant Device,976.5,35,,976.5,percent of total billed charges,Implant Device,976.5,35,,976.5,percent of total billed charges,Implant Device,1116,40,,1116,percent of total billed charges,Implant Device,976.5,70,,976.5,percent of total billed charges,All Other,948.6,34,,948.6,percent of total billed charges,Implant Device,948.6,34,,948.6,percent of total billed charges,Implant Device,976.5,35,,976.5,percent of total billed charges,Implant Device,976.5,35,,976.5,percent of total billed charges,Implant Device,976.5,35,,976.5,percent of total billed charges,Implant Device,976.5,35,,976.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,948.6,34,"If Charge > 2,000, then 34 percent",948.6,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2064.61,
ARTHREX AR-8840-26 4X26 CANCELLOUS SCREW,C1713,HCPCS,,79009498,CDM,278,RC,,,both,,,105,77.7,,,77.7,Other,150% of Medicare + 9.63% HCRA Surcharge,47.25,45,,47.25,percent of total billed charges,Critical Access Hospital RCC factor,35.7,34,,35.7,percent of total billed charges,Implant Device,35.7,34,,35.7,percent of total billed charges,Implant Device,35.7,34,,35.7,percent of total billed charges,Implant Device,35.7,34,,35.7,percent of total billed charges,Implant Device,35.7,34,,35.7,percent of total billed charges,Implant Device,51.98,,,51.98,Other,110% of Medicare,36.75,35,,36.75,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,36.75,35,,36.75,percent of total billed charges,Implant Device,36.75,35,,36.75,percent of total billed charges,Implant Device,36.75,35,,36.75,percent of total billed charges,Implant Device,36.75,35,,36.75,percent of total billed charges,Implant Device,36.75,35,,36.75,percent of total billed charges,Implant Device,42,40,,42,percent of total billed charges,Implant Device,36.75,70,,36.75,percent of total billed charges,All Other,35.7,34,,35.7,percent of total billed charges,Implant Device,35.7,34,,35.7,percent of total billed charges,Implant Device,36.75,35,,36.75,percent of total billed charges,Implant Device,36.75,35,,36.75,percent of total billed charges,Implant Device,36.75,35,,36.75,percent of total billed charges,Implant Device,36.75,35,,36.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,77.7,
ARTHREX AR-8943T-07 7H TUBULAR PLATE,C1776,HCPCS,,79009499,CDM,278,RC,,,both,,,765,566.1,,,566.1,Other,150% of Medicare + 9.63% HCRA Surcharge,344.25,45,,344.25,percent of total billed charges,Critical Access Hospital RCC factor,260.1,34,,260.1,percent of total billed charges,Implant Device,260.1,34,,260.1,percent of total billed charges,Implant Device,260.1,34,,260.1,percent of total billed charges,Implant Device,260.1,34,,260.1,percent of total billed charges,Implant Device,260.1,34,,260.1,percent of total billed charges,Implant Device,378.68,,,378.68,Other,110% of Medicare,267.75,35,,267.75,percent of total billed charges,Implant Device,260.1,34,"Charges > $500, x 34%",260.1,percent of total billed charges,Implant Device,267.75,35,,267.75,percent of total billed charges,Implant Device,267.75,35,,267.75,percent of total billed charges,Implant Device,267.75,35,,267.75,percent of total billed charges,Implant Device,267.75,35,,267.75,percent of total billed charges,Implant Device,267.75,35,,267.75,percent of total billed charges,Implant Device,306,40,,306,percent of total billed charges,Implant Device,267.75,70,,267.75,percent of total billed charges,All Other,260.1,34,,260.1,percent of total billed charges,Implant Device,260.1,34,,260.1,percent of total billed charges,Implant Device,267.75,35,,267.75,percent of total billed charges,Implant Device,267.75,35,,267.75,percent of total billed charges,Implant Device,267.75,35,,267.75,percent of total billed charges,Implant Device,267.75,35,,267.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,566.1,
ACUMED 70-0307 OLECRANON PLATE STD 7H RT,C1776,HCPCS,,79009502,CDM,278,RC,,,both,,,4128,3054.73,,,3054.73,Other,150% of Medicare + 9.63% HCRA Surcharge,1857.6,45,,1857.6,percent of total billed charges,Critical Access Hospital RCC factor,1403.52,34,,1403.52,percent of total billed charges,Implant Device,1403.52,34,,1403.52,percent of total billed charges,Implant Device,1403.52,34,,1403.52,percent of total billed charges,Implant Device,1403.52,34,,1403.52,percent of total billed charges,Implant Device,1403.52,34,,1403.52,percent of total billed charges,Implant Device,2043.36,,,2043.36,Other,110% of Medicare,1444.8,35,,1444.8,percent of total billed charges,Implant Device,1403.52,34,"Charges > $500, x 34%",1403.52,percent of total billed charges,Implant Device,1444.8,35,,1444.8,percent of total billed charges,Implant Device,1444.8,35,,1444.8,percent of total billed charges,Implant Device,1444.8,35,,1444.8,percent of total billed charges,Implant Device,1444.8,35,,1444.8,percent of total billed charges,Implant Device,1444.8,35,,1444.8,percent of total billed charges,Implant Device,1651.2,40,,1651.2,percent of total billed charges,Implant Device,1444.8,70,,1444.8,percent of total billed charges,All Other,1403.52,34,,1403.52,percent of total billed charges,Implant Device,1403.52,34,,1403.52,percent of total billed charges,Implant Device,1444.8,35,,1444.8,percent of total billed charges,Implant Device,1444.8,35,,1444.8,percent of total billed charges,Implant Device,1444.8,35,,1444.8,percent of total billed charges,Implant Device,1444.8,35,,1444.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1403.52,34,"If Charge > 2,000, then 34 percent",1403.52,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3054.73,
ACUMED 30-0322 NON LOCK SCREW 3X65MM,C1713,HCPCS,,79009503,CDM,278,RC,,,both,,,270,199.8,,,199.8,Other,150% of Medicare + 9.63% HCRA Surcharge,121.5,45,,121.5,percent of total billed charges,Critical Access Hospital RCC factor,91.8,34,,91.8,percent of total billed charges,Implant Device,91.8,34,,91.8,percent of total billed charges,Implant Device,91.8,34,,91.8,percent of total billed charges,Implant Device,91.8,34,,91.8,percent of total billed charges,Implant Device,91.8,34,,91.8,percent of total billed charges,Implant Device,133.65,,,133.65,Other,110% of Medicare,94.5,35,,94.5,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,94.5,35,,94.5,percent of total billed charges,Implant Device,94.5,35,,94.5,percent of total billed charges,Implant Device,94.5,35,,94.5,percent of total billed charges,Implant Device,94.5,35,,94.5,percent of total billed charges,Implant Device,94.5,35,,94.5,percent of total billed charges,Implant Device,108,40,,108,percent of total billed charges,Implant Device,94.5,70,,94.5,percent of total billed charges,All Other,91.8,34,,91.8,percent of total billed charges,Implant Device,91.8,34,,91.8,percent of total billed charges,Implant Device,94.5,35,,94.5,percent of total billed charges,Implant Device,94.5,35,,94.5,percent of total billed charges,Implant Device,94.5,35,,94.5,percent of total billed charges,Implant Device,94.5,35,,94.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,199.8,
ACUMED 30-0268 NON LOCK SCREW 3.5X34MM,C1713,HCPCS,,79009504,CDM,278,RC,,,both,,,315,233.1,,,233.1,Other,150% of Medicare + 9.63% HCRA Surcharge,141.75,45,,141.75,percent of total billed charges,Critical Access Hospital RCC factor,107.1,34,,107.1,percent of total billed charges,Implant Device,107.1,34,,107.1,percent of total billed charges,Implant Device,107.1,34,,107.1,percent of total billed charges,Implant Device,107.1,34,,107.1,percent of total billed charges,Implant Device,107.1,34,,107.1,percent of total billed charges,Implant Device,155.93,,,155.93,Other,110% of Medicare,110.25,35,,110.25,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,110.25,35,,110.25,percent of total billed charges,Implant Device,110.25,35,,110.25,percent of total billed charges,Implant Device,110.25,35,,110.25,percent of total billed charges,Implant Device,110.25,35,,110.25,percent of total billed charges,Implant Device,110.25,35,,110.25,percent of total billed charges,Implant Device,126,40,,126,percent of total billed charges,Implant Device,110.25,70,,110.25,percent of total billed charges,All Other,107.1,34,,107.1,percent of total billed charges,Implant Device,107.1,34,,107.1,percent of total billed charges,Implant Device,110.25,35,,110.25,percent of total billed charges,Implant Device,110.25,35,,110.25,percent of total billed charges,Implant Device,110.25,35,,110.25,percent of total billed charges,Implant Device,110.25,35,,110.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,233.1,
ACUMED 30-0269 NON LOCK SCREW 3.5X36MM,C1713,HCPCS,,79009505,CDM,278,RC,,,both,,,315,233.1,,,233.1,Other,150% of Medicare + 9.63% HCRA Surcharge,141.75,45,,141.75,percent of total billed charges,Critical Access Hospital RCC factor,107.1,34,,107.1,percent of total billed charges,Implant Device,107.1,34,,107.1,percent of total billed charges,Implant Device,107.1,34,,107.1,percent of total billed charges,Implant Device,107.1,34,,107.1,percent of total billed charges,Implant Device,107.1,34,,107.1,percent of total billed charges,Implant Device,155.93,,,155.93,Other,110% of Medicare,110.25,35,,110.25,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,110.25,35,,110.25,percent of total billed charges,Implant Device,110.25,35,,110.25,percent of total billed charges,Implant Device,110.25,35,,110.25,percent of total billed charges,Implant Device,110.25,35,,110.25,percent of total billed charges,Implant Device,110.25,35,,110.25,percent of total billed charges,Implant Device,126,40,,126,percent of total billed charges,Implant Device,110.25,70,,110.25,percent of total billed charges,All Other,107.1,34,,107.1,percent of total billed charges,Implant Device,107.1,34,,107.1,percent of total billed charges,Implant Device,110.25,35,,110.25,percent of total billed charges,Implant Device,110.25,35,,110.25,percent of total billed charges,Implant Device,110.25,35,,110.25,percent of total billed charges,Implant Device,110.25,35,,110.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,233.1,
ACUMED TS-S0904-S STEM 9.0X4.0MM,C1776,HCPCS,,79009506,CDM,278,RC,,,both,,,6069,4491.08,,,4491.08,Other,150% of Medicare + 9.63% HCRA Surcharge,2731.05,45,,2731.05,percent of total billed charges,Critical Access Hospital RCC factor,2063.46,34,,2063.46,percent of total billed charges,Implant Device,2063.46,34,,2063.46,percent of total billed charges,Implant Device,2063.46,34,,2063.46,percent of total billed charges,Implant Device,2063.46,34,,2063.46,percent of total billed charges,Implant Device,2063.46,34,,2063.46,percent of total billed charges,Implant Device,3004.16,,,3004.16,Other,110% of Medicare,2124.15,35,,2124.15,percent of total billed charges,Implant Device,2063.46,34,"Charges > $500, x 34%",2063.46,percent of total billed charges,Implant Device,2124.15,35,,2124.15,percent of total billed charges,Implant Device,2124.15,35,,2124.15,percent of total billed charges,Implant Device,2124.15,35,,2124.15,percent of total billed charges,Implant Device,2124.15,35,,2124.15,percent of total billed charges,Implant Device,2124.15,35,,2124.15,percent of total billed charges,Implant Device,2427.6,40,,2427.6,percent of total billed charges,Implant Device,2124.15,70,,2124.15,percent of total billed charges,All Other,2063.46,34,,2063.46,percent of total billed charges,Implant Device,2063.46,34,,2063.46,percent of total billed charges,Implant Device,2124.15,35,,2124.15,percent of total billed charges,Implant Device,2124.15,35,,2124.15,percent of total billed charges,Implant Device,2124.15,35,,2124.15,percent of total billed charges,Implant Device,2124.15,35,,2124.15,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2063.46,34,"If Charge > 2,000, then 34 percent",2063.46,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4491.08,
ACUMED 5001-0226R-S HEAD 26MM RIGHT,C1776,HCPCS,,79009507,CDM,278,RC,,,both,,,9279,6866.48,,,6866.48,Other,150% of Medicare + 9.63% HCRA Surcharge,4175.55,45,,4175.55,percent of total billed charges,Critical Access Hospital RCC factor,3154.86,34,,3154.86,percent of total billed charges,Implant Device,3154.86,34,,3154.86,percent of total billed charges,Implant Device,3154.86,34,,3154.86,percent of total billed charges,Implant Device,3154.86,34,,3154.86,percent of total billed charges,Implant Device,3154.86,34,,3154.86,percent of total billed charges,Implant Device,4593.11,,,4593.11,Other,110% of Medicare,3247.65,35,,3247.65,percent of total billed charges,Implant Device,3154.86,34,"Charges > $500, x 34%",3154.86,percent of total billed charges,Implant Device,3247.65,35,,3247.65,percent of total billed charges,Implant Device,3247.65,35,,3247.65,percent of total billed charges,Implant Device,3247.65,35,,3247.65,percent of total billed charges,Implant Device,3247.65,35,,3247.65,percent of total billed charges,Implant Device,3247.65,35,,3247.65,percent of total billed charges,Implant Device,3711.6,40,,3711.6,percent of total billed charges,Implant Device,3247.65,70,,3247.65,percent of total billed charges,All Other,3154.86,34,,3154.86,percent of total billed charges,Implant Device,3154.86,34,,3154.86,percent of total billed charges,Implant Device,3247.65,35,,3247.65,percent of total billed charges,Implant Device,3247.65,35,,3247.65,percent of total billed charges,Implant Device,3247.65,35,,3247.65,percent of total billed charges,Implant Device,3247.65,35,,3247.65,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3154.86,34,"If Charge > 2,000, then 34 percent",3154.86,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,6866.48,
STRYKER 658048 COMPRESSION SCREW 4X48MM,C1713,HCPCS,,79009508,CDM,278,RC,,,both,,,1854,1371.96,,,1371.96,Other,150% of Medicare + 9.63% HCRA Surcharge,834.3,45,,834.3,percent of total billed charges,Critical Access Hospital RCC factor,630.36,34,,630.36,percent of total billed charges,Implant Device,630.36,34,,630.36,percent of total billed charges,Implant Device,630.36,34,,630.36,percent of total billed charges,Implant Device,630.36,34,,630.36,percent of total billed charges,Implant Device,630.36,34,,630.36,percent of total billed charges,Implant Device,917.73,,,917.73,Other,110% of Medicare,648.9,35,,648.9,percent of total billed charges,Implant Device,630.36,34,"Charges > $500, x 34%",630.36,percent of total billed charges,Implant Device,648.9,35,,648.9,percent of total billed charges,Implant Device,648.9,35,,648.9,percent of total billed charges,Implant Device,648.9,35,,648.9,percent of total billed charges,Implant Device,648.9,35,,648.9,percent of total billed charges,Implant Device,648.9,35,,648.9,percent of total billed charges,Implant Device,741.6,40,,741.6,percent of total billed charges,Implant Device,648.9,70,,648.9,percent of total billed charges,All Other,630.36,34,,630.36,percent of total billed charges,Implant Device,630.36,34,,630.36,percent of total billed charges,Implant Device,648.9,35,,648.9,percent of total billed charges,Implant Device,648.9,35,,648.9,percent of total billed charges,Implant Device,648.9,35,,648.9,percent of total billed charges,Implant Device,648.9,35,,648.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1371.96,
DEPUY 1035-52-000 SELF CTR HIP 52X28 BLU,C1776,HCPCS,,79009509,CDM,278,RC,,,both,,,1733,1282.42,,,1282.42,Other,150% of Medicare + 9.63% HCRA Surcharge,779.85,45,,779.85,percent of total billed charges,Critical Access Hospital RCC factor,589.22,34,,589.22,percent of total billed charges,Implant Device,589.22,34,,589.22,percent of total billed charges,Implant Device,589.22,34,,589.22,percent of total billed charges,Implant Device,589.22,34,,589.22,percent of total billed charges,Implant Device,589.22,34,,589.22,percent of total billed charges,Implant Device,857.84,,,857.84,Other,110% of Medicare,606.55,35,,606.55,percent of total billed charges,Implant Device,589.22,34,"Charges > $500, x 34%",589.22,percent of total billed charges,Implant Device,606.55,35,,606.55,percent of total billed charges,Implant Device,606.55,35,,606.55,percent of total billed charges,Implant Device,606.55,35,,606.55,percent of total billed charges,Implant Device,606.55,35,,606.55,percent of total billed charges,Implant Device,606.55,35,,606.55,percent of total billed charges,Implant Device,693.2,40,,693.2,percent of total billed charges,Implant Device,606.55,70,,606.55,percent of total billed charges,All Other,589.22,34,,589.22,percent of total billed charges,Implant Device,589.22,34,,589.22,percent of total billed charges,Implant Device,606.55,35,,606.55,percent of total billed charges,Implant Device,606.55,35,,606.55,percent of total billed charges,Implant Device,606.55,35,,606.55,percent of total billed charges,Implant Device,606.55,35,,606.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1282.42,
DEPUY 209.875 CANNULATED SCREW 7.3X75MM,C1713,HCPCS,,79009510,CDM,278,RC,,,both,,,1072,793.28,,,793.28,Other,150% of Medicare + 9.63% HCRA Surcharge,482.4,45,,482.4,percent of total billed charges,Critical Access Hospital RCC factor,364.48,34,,364.48,percent of total billed charges,Implant Device,364.48,34,,364.48,percent of total billed charges,Implant Device,364.48,34,,364.48,percent of total billed charges,Implant Device,364.48,34,,364.48,percent of total billed charges,Implant Device,364.48,34,,364.48,percent of total billed charges,Implant Device,530.64,,,530.64,Other,110% of Medicare,375.2,35,,375.2,percent of total billed charges,Implant Device,364.48,34,"Charges > $500, x 34%",364.48,percent of total billed charges,Implant Device,375.2,35,,375.2,percent of total billed charges,Implant Device,375.2,35,,375.2,percent of total billed charges,Implant Device,375.2,35,,375.2,percent of total billed charges,Implant Device,375.2,35,,375.2,percent of total billed charges,Implant Device,375.2,35,,375.2,percent of total billed charges,Implant Device,428.8,40,,428.8,percent of total billed charges,Implant Device,375.2,70,,375.2,percent of total billed charges,All Other,364.48,34,,364.48,percent of total billed charges,Implant Device,364.48,34,,364.48,percent of total billed charges,Implant Device,375.2,35,,375.2,percent of total billed charges,Implant Device,375.2,35,,375.2,percent of total billed charges,Implant Device,375.2,35,,375.2,percent of total billed charges,Implant Device,375.2,35,,375.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,793.28,
DEPUY 208.895 CANNULATED SCREW 7.3X95MM,C1713,HCPCS,,79009511,CDM,278,RC,,,both,,,1072,793.28,,,793.28,Other,150% of Medicare + 9.63% HCRA Surcharge,482.4,45,,482.4,percent of total billed charges,Critical Access Hospital RCC factor,364.48,34,,364.48,percent of total billed charges,Implant Device,364.48,34,,364.48,percent of total billed charges,Implant Device,364.48,34,,364.48,percent of total billed charges,Implant Device,364.48,34,,364.48,percent of total billed charges,Implant Device,364.48,34,,364.48,percent of total billed charges,Implant Device,530.64,,,530.64,Other,110% of Medicare,375.2,35,,375.2,percent of total billed charges,Implant Device,364.48,34,"Charges > $500, x 34%",364.48,percent of total billed charges,Implant Device,375.2,35,,375.2,percent of total billed charges,Implant Device,375.2,35,,375.2,percent of total billed charges,Implant Device,375.2,35,,375.2,percent of total billed charges,Implant Device,375.2,35,,375.2,percent of total billed charges,Implant Device,375.2,35,,375.2,percent of total billed charges,Implant Device,428.8,40,,428.8,percent of total billed charges,Implant Device,375.2,70,,375.2,percent of total billed charges,All Other,364.48,34,,364.48,percent of total billed charges,Implant Device,364.48,34,,364.48,percent of total billed charges,Implant Device,375.2,35,,375.2,percent of total billed charges,Implant Device,375.2,35,,375.2,percent of total billed charges,Implant Device,375.2,35,,375.2,percent of total billed charges,Implant Device,375.2,35,,375.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,793.28,
ARROW CDC-45541-TTS 1L 4.5FR 55CM PICC,C1751,HCPCS,,79009513,CDM,278,RC,,,both,,,690,510.6,,,510.6,Other,150% of Medicare + 9.63% HCRA Surcharge,310.5,45,,310.5,percent of total billed charges,Critical Access Hospital RCC factor,234.6,34,,234.6,percent of total billed charges,Implant Device,234.6,34,,234.6,percent of total billed charges,Implant Device,234.6,34,,234.6,percent of total billed charges,Implant Device,234.6,34,,234.6,percent of total billed charges,Implant Device,234.6,34,,234.6,percent of total billed charges,Implant Device,341.55,,,341.55,Other,110% of Medicare,241.5,35,,241.5,percent of total billed charges,Implant Device,234.6,34,"Charges > $500, x 34%",234.6,percent of total billed charges,Implant Device,241.5,35,,241.5,percent of total billed charges,Implant Device,241.5,35,,241.5,percent of total billed charges,Implant Device,241.5,35,,241.5,percent of total billed charges,Implant Device,241.5,35,,241.5,percent of total billed charges,Implant Device,241.5,35,,241.5,percent of total billed charges,Implant Device,276,40,,276,percent of total billed charges,Implant Device,241.5,70,,241.5,percent of total billed charges,All Other,234.6,34,,234.6,percent of total billed charges,Implant Device,234.6,34,,234.6,percent of total billed charges,Implant Device,241.5,35,,241.5,percent of total billed charges,Implant Device,241.5,35,,241.5,percent of total billed charges,Implant Device,241.5,35,,241.5,percent of total billed charges,Implant Device,241.5,35,,241.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,510.6,
ARROW CDC-45552-TTS 2L 5.5FR 55CM PICC,C1751,HCPCS,,79009514,CDM,278,RC,,,both,,,690,510.6,,,510.6,Other,150% of Medicare + 9.63% HCRA Surcharge,310.5,45,,310.5,percent of total billed charges,Critical Access Hospital RCC factor,234.6,34,,234.6,percent of total billed charges,Implant Device,234.6,34,,234.6,percent of total billed charges,Implant Device,234.6,34,,234.6,percent of total billed charges,Implant Device,234.6,34,,234.6,percent of total billed charges,Implant Device,234.6,34,,234.6,percent of total billed charges,Implant Device,341.55,,,341.55,Other,110% of Medicare,241.5,35,,241.5,percent of total billed charges,Implant Device,234.6,34,"Charges > $500, x 34%",234.6,percent of total billed charges,Implant Device,241.5,35,,241.5,percent of total billed charges,Implant Device,241.5,35,,241.5,percent of total billed charges,Implant Device,241.5,35,,241.5,percent of total billed charges,Implant Device,241.5,35,,241.5,percent of total billed charges,Implant Device,241.5,35,,241.5,percent of total billed charges,Implant Device,276,40,,276,percent of total billed charges,Implant Device,241.5,70,,241.5,percent of total billed charges,All Other,234.6,34,,234.6,percent of total billed charges,Implant Device,234.6,34,,234.6,percent of total billed charges,Implant Device,241.5,35,,241.5,percent of total billed charges,Implant Device,241.5,35,,241.5,percent of total billed charges,Implant Device,241.5,35,,241.5,percent of total billed charges,Implant Device,241.5,35,,241.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,510.6,
ARTHREX AR-4005B-18 CHONDRAL DART 18MM,C1713,HCPCS,,79009515,CDM,278,RC,,,both,,,363,268.62,,,268.62,Other,150% of Medicare + 9.63% HCRA Surcharge,163.35,45,,163.35,percent of total billed charges,Critical Access Hospital RCC factor,123.42,34,,123.42,percent of total billed charges,Implant Device,123.42,34,,123.42,percent of total billed charges,Implant Device,123.42,34,,123.42,percent of total billed charges,Implant Device,123.42,34,,123.42,percent of total billed charges,Implant Device,123.42,34,,123.42,percent of total billed charges,Implant Device,179.69,,,179.69,Other,110% of Medicare,127.05,35,,127.05,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,127.05,35,,127.05,percent of total billed charges,Implant Device,127.05,35,,127.05,percent of total billed charges,Implant Device,127.05,35,,127.05,percent of total billed charges,Implant Device,127.05,35,,127.05,percent of total billed charges,Implant Device,127.05,35,,127.05,percent of total billed charges,Implant Device,145.2,40,,145.2,percent of total billed charges,Implant Device,127.05,70,,127.05,percent of total billed charges,All Other,123.42,34,,123.42,percent of total billed charges,Implant Device,123.42,34,,123.42,percent of total billed charges,Implant Device,127.05,35,,127.05,percent of total billed charges,Implant Device,127.05,35,,127.05,percent of total billed charges,Implant Device,127.05,35,,127.05,percent of total billed charges,Implant Device,127.05,35,,127.05,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,268.62,
EXACTECH 310-03-47 HUMERAL HEAD 47X26MM,C1776,HCPCS,,79009516,CDM,278,RC,,,both,,,2484,1838.17,,,1838.17,Other,150% of Medicare + 9.63% HCRA Surcharge,1117.8,45,,1117.8,percent of total billed charges,Critical Access Hospital RCC factor,844.56,34,,844.56,percent of total billed charges,Implant Device,844.56,34,,844.56,percent of total billed charges,Implant Device,844.56,34,,844.56,percent of total billed charges,Implant Device,844.56,34,,844.56,percent of total billed charges,Implant Device,844.56,34,,844.56,percent of total billed charges,Implant Device,1229.58,,,1229.58,Other,110% of Medicare,869.4,35,,869.4,percent of total billed charges,Implant Device,844.56,34,"Charges > $500, x 34%",844.56,percent of total billed charges,Implant Device,869.4,35,,869.4,percent of total billed charges,Implant Device,869.4,35,,869.4,percent of total billed charges,Implant Device,869.4,35,,869.4,percent of total billed charges,Implant Device,869.4,35,,869.4,percent of total billed charges,Implant Device,869.4,35,,869.4,percent of total billed charges,Implant Device,993.6,40,,993.6,percent of total billed charges,Implant Device,869.4,70,,869.4,percent of total billed charges,All Other,844.56,34,,844.56,percent of total billed charges,Implant Device,844.56,34,,844.56,percent of total billed charges,Implant Device,869.4,35,,869.4,percent of total billed charges,Implant Device,869.4,35,,869.4,percent of total billed charges,Implant Device,869.4,35,,869.4,percent of total billed charges,Implant Device,869.4,35,,869.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,844.56,34,"If Charge > 2,000, then 34 percent",844.56,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1838.17,
STRYKER 629547 COMP PLATE NARROW 7 HOLE,C1713,HCPCS,,79009517,CDM,278,RC,,,both,,,2343,1733.83,,,1733.83,Other,150% of Medicare + 9.63% HCRA Surcharge,1054.35,45,,1054.35,percent of total billed charges,Critical Access Hospital RCC factor,796.62,34,,796.62,percent of total billed charges,Implant Device,796.62,34,,796.62,percent of total billed charges,Implant Device,796.62,34,,796.62,percent of total billed charges,Implant Device,796.62,34,,796.62,percent of total billed charges,Implant Device,796.62,34,,796.62,percent of total billed charges,Implant Device,1159.79,,,1159.79,Other,110% of Medicare,820.05,35,,820.05,percent of total billed charges,Implant Device,796.62,34,"Charges > $500, x 34%",796.62,percent of total billed charges,Implant Device,820.05,35,,820.05,percent of total billed charges,Implant Device,820.05,35,,820.05,percent of total billed charges,Implant Device,820.05,35,,820.05,percent of total billed charges,Implant Device,820.05,35,,820.05,percent of total billed charges,Implant Device,820.05,35,,820.05,percent of total billed charges,Implant Device,937.2,40,,937.2,percent of total billed charges,Implant Device,820.05,70,,820.05,percent of total billed charges,All Other,796.62,34,,796.62,percent of total billed charges,Implant Device,796.62,34,,796.62,percent of total billed charges,Implant Device,820.05,35,,820.05,percent of total billed charges,Implant Device,820.05,35,,820.05,percent of total billed charges,Implant Device,820.05,35,,820.05,percent of total billed charges,Implant Device,820.05,35,,820.05,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,796.62,34,"If Charge > 2,000, then 34 percent",796.62,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1733.83,
BARD DAVOL 0600580 9 FR DUAL LUMEN CATH,C1751,HCPCS,,79009518,CDM,278,RC,,,both,,,585,432.9,,,432.9,Other,150% of Medicare + 9.63% HCRA Surcharge,263.25,45,,263.25,percent of total billed charges,Critical Access Hospital RCC factor,198.9,34,,198.9,percent of total billed charges,Implant Device,198.9,34,,198.9,percent of total billed charges,Implant Device,198.9,34,,198.9,percent of total billed charges,Implant Device,198.9,34,,198.9,percent of total billed charges,Implant Device,198.9,34,,198.9,percent of total billed charges,Implant Device,289.58,,,289.58,Other,110% of Medicare,204.75,35,,204.75,percent of total billed charges,Implant Device,198.9,34,"Charges > $500, x 34%",198.9,percent of total billed charges,Implant Device,204.75,35,,204.75,percent of total billed charges,Implant Device,204.75,35,,204.75,percent of total billed charges,Implant Device,204.75,35,,204.75,percent of total billed charges,Implant Device,204.75,35,,204.75,percent of total billed charges,Implant Device,204.75,35,,204.75,percent of total billed charges,Implant Device,234,40,,234,percent of total billed charges,Implant Device,204.75,70,,204.75,percent of total billed charges,All Other,198.9,34,,198.9,percent of total billed charges,Implant Device,198.9,34,,198.9,percent of total billed charges,Implant Device,204.75,35,,204.75,percent of total billed charges,Implant Device,204.75,35,,204.75,percent of total billed charges,Implant Device,204.75,35,,204.75,percent of total billed charges,Implant Device,204.75,35,,204.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,432.9,
BARD DAVOL 0805910 HICKMAN 9.5 DUAL CATH,C1751,HCPCS,,79009520,CDM,278,RC,,,both,,,1476,1092.24,,,1092.24,Other,150% of Medicare + 9.63% HCRA Surcharge,664.2,45,,664.2,percent of total billed charges,Critical Access Hospital RCC factor,501.84,34,,501.84,percent of total billed charges,Implant Device,501.84,34,,501.84,percent of total billed charges,Implant Device,501.84,34,,501.84,percent of total billed charges,Implant Device,501.84,34,,501.84,percent of total billed charges,Implant Device,501.84,34,,501.84,percent of total billed charges,Implant Device,730.62,,,730.62,Other,110% of Medicare,516.6,35,,516.6,percent of total billed charges,Implant Device,501.84,34,"Charges > $500, x 34%",501.84,percent of total billed charges,Implant Device,516.6,35,,516.6,percent of total billed charges,Implant Device,516.6,35,,516.6,percent of total billed charges,Implant Device,516.6,35,,516.6,percent of total billed charges,Implant Device,516.6,35,,516.6,percent of total billed charges,Implant Device,516.6,35,,516.6,percent of total billed charges,Implant Device,590.4,40,,590.4,percent of total billed charges,Implant Device,516.6,70,,516.6,percent of total billed charges,All Other,501.84,34,,501.84,percent of total billed charges,Implant Device,501.84,34,,501.84,percent of total billed charges,Implant Device,516.6,35,,516.6,percent of total billed charges,Implant Device,516.6,35,,516.6,percent of total billed charges,Implant Device,516.6,35,,516.6,percent of total billed charges,Implant Device,516.6,35,,516.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1092.24,
STRYKER 58-23010E BONE SCREW 2.3X20MM,C1713,HCPCS,,79009522,CDM,278,RC,,,both,,,426,315.24,,,315.24,Other,150% of Medicare + 9.63% HCRA Surcharge,191.7,45,,191.7,percent of total billed charges,Critical Access Hospital RCC factor,144.84,34,,144.84,percent of total billed charges,Implant Device,144.84,34,,144.84,percent of total billed charges,Implant Device,144.84,34,,144.84,percent of total billed charges,Implant Device,144.84,34,,144.84,percent of total billed charges,Implant Device,144.84,34,,144.84,percent of total billed charges,Implant Device,210.87,,,210.87,Other,110% of Medicare,149.1,35,,149.1,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,149.1,35,,149.1,percent of total billed charges,Implant Device,149.1,35,,149.1,percent of total billed charges,Implant Device,149.1,35,,149.1,percent of total billed charges,Implant Device,149.1,35,,149.1,percent of total billed charges,Implant Device,149.1,35,,149.1,percent of total billed charges,Implant Device,170.4,40,,170.4,percent of total billed charges,Implant Device,149.1,70,,149.1,percent of total billed charges,All Other,144.84,34,,144.84,percent of total billed charges,Implant Device,144.84,34,,144.84,percent of total billed charges,Implant Device,149.1,35,,149.1,percent of total billed charges,Implant Device,149.1,35,,149.1,percent of total billed charges,Implant Device,149.1,35,,149.1,percent of total billed charges,Implant Device,149.1,35,,149.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,315.24,
STRYKER 5569-P-2009 TSA HUM STEM 9X118MM,C1776,HCPCS,,79009525,CDM,278,RC,,,both,,,10500,7770.03,,,7770.03,Other,150% of Medicare + 9.63% HCRA Surcharge,4725,45,,4725,percent of total billed charges,Critical Access Hospital RCC factor,3570,34,,3570,percent of total billed charges,Implant Device,3570,34,,3570,percent of total billed charges,Implant Device,3570,34,,3570,percent of total billed charges,Implant Device,3570,34,,3570,percent of total billed charges,Implant Device,3570,34,,3570,percent of total billed charges,Implant Device,5197.5,,,5197.5,Other,110% of Medicare,3675,35,,3675,percent of total billed charges,Implant Device,3570,34,"Charges > $500, x 34%",3570,percent of total billed charges,Implant Device,3675,35,,3675,percent of total billed charges,Implant Device,3675,35,,3675,percent of total billed charges,Implant Device,3675,35,,3675,percent of total billed charges,Implant Device,3675,35,,3675,percent of total billed charges,Implant Device,3675,35,,3675,percent of total billed charges,Implant Device,4200,40,,4200,percent of total billed charges,Implant Device,3675,70,,3675,percent of total billed charges,All Other,3570,34,,3570,percent of total billed charges,Implant Device,3570,34,,3570,percent of total billed charges,Implant Device,3675,35,,3675,percent of total billed charges,Implant Device,3675,35,,3675,percent of total billed charges,Implant Device,3675,35,,3675,percent of total billed charges,Implant Device,3675,35,,3675,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3570,34,"If Charge > 2,000, then 34 percent",3570,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,7770.03,
STRYKER 5573-6536 CTR SCREW 6.5X36MM,C1713,HCPCS,,79009526,CDM,278,RC,,,both,,,837,619.38,,,619.38,Other,150% of Medicare + 9.63% HCRA Surcharge,376.65,45,,376.65,percent of total billed charges,Critical Access Hospital RCC factor,284.58,34,,284.58,percent of total billed charges,Implant Device,284.58,34,,284.58,percent of total billed charges,Implant Device,284.58,34,,284.58,percent of total billed charges,Implant Device,284.58,34,,284.58,percent of total billed charges,Implant Device,284.58,34,,284.58,percent of total billed charges,Implant Device,414.32,,,414.32,Other,110% of Medicare,292.95,35,,292.95,percent of total billed charges,Implant Device,284.58,34,"Charges > $500, x 34%",284.58,percent of total billed charges,Implant Device,292.95,35,,292.95,percent of total billed charges,Implant Device,292.95,35,,292.95,percent of total billed charges,Implant Device,292.95,35,,292.95,percent of total billed charges,Implant Device,292.95,35,,292.95,percent of total billed charges,Implant Device,292.95,35,,292.95,percent of total billed charges,Implant Device,334.8,40,,334.8,percent of total billed charges,Implant Device,292.95,70,,292.95,percent of total billed charges,All Other,284.58,34,,284.58,percent of total billed charges,Implant Device,284.58,34,,284.58,percent of total billed charges,Implant Device,292.95,35,,292.95,percent of total billed charges,Implant Device,292.95,35,,292.95,percent of total billed charges,Implant Device,292.95,35,,292.95,percent of total billed charges,Implant Device,292.95,35,,292.95,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,619.38,
STRYKER 5542-P-0044 TSA GLENOID SZ 44,C1776,HCPCS,,79009527,CDM,278,RC,,,both,,,4500,3330.01,,,3330.01,Other,150% of Medicare + 9.63% HCRA Surcharge,2025,45,,2025,percent of total billed charges,Critical Access Hospital RCC factor,1530,34,,1530,percent of total billed charges,Implant Device,1530,34,,1530,percent of total billed charges,Implant Device,1530,34,,1530,percent of total billed charges,Implant Device,1530,34,,1530,percent of total billed charges,Implant Device,1530,34,,1530,percent of total billed charges,Implant Device,2227.5,,,2227.5,Other,110% of Medicare,1575,35,,1575,percent of total billed charges,Implant Device,1530,34,"Charges > $500, x 34%",1530,percent of total billed charges,Implant Device,1575,35,,1575,percent of total billed charges,Implant Device,1575,35,,1575,percent of total billed charges,Implant Device,1575,35,,1575,percent of total billed charges,Implant Device,1575,35,,1575,percent of total billed charges,Implant Device,1575,35,,1575,percent of total billed charges,Implant Device,1800,40,,1800,percent of total billed charges,Implant Device,1575,70,,1575,percent of total billed charges,All Other,1530,34,,1530,percent of total billed charges,Implant Device,1530,34,,1530,percent of total billed charges,Implant Device,1575,35,,1575,percent of total billed charges,Implant Device,1575,35,,1575,percent of total billed charges,Implant Device,1575,35,,1575,percent of total billed charges,Implant Device,1575,35,,1575,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1530,34,"If Charge > 2,000, then 34 percent",1530,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3330.01,
STRYKER 5552-E-4818 TSA HUMERAL HD SZ18,C1776,HCPCS,,79009528,CDM,278,RC,,,both,,,10203,7550.25,,,7550.25,Other,150% of Medicare + 9.63% HCRA Surcharge,4591.35,45,,4591.35,percent of total billed charges,Critical Access Hospital RCC factor,3469.02,34,,3469.02,percent of total billed charges,Implant Device,3469.02,34,,3469.02,percent of total billed charges,Implant Device,3469.02,34,,3469.02,percent of total billed charges,Implant Device,3469.02,34,,3469.02,percent of total billed charges,Implant Device,3469.02,34,,3469.02,percent of total billed charges,Implant Device,5050.49,,,5050.49,Other,110% of Medicare,3571.05,35,,3571.05,percent of total billed charges,Implant Device,3469.02,34,"Charges > $500, x 34%",3469.02,percent of total billed charges,Implant Device,3571.05,35,,3571.05,percent of total billed charges,Implant Device,3571.05,35,,3571.05,percent of total billed charges,Implant Device,3571.05,35,,3571.05,percent of total billed charges,Implant Device,3571.05,35,,3571.05,percent of total billed charges,Implant Device,3571.05,35,,3571.05,percent of total billed charges,Implant Device,4081.2,40,,4081.2,percent of total billed charges,Implant Device,3571.05,70,,3571.05,percent of total billed charges,All Other,3469.02,34,,3469.02,percent of total billed charges,Implant Device,3469.02,34,,3469.02,percent of total billed charges,Implant Device,3571.05,35,,3571.05,percent of total billed charges,Implant Device,3571.05,35,,3571.05,percent of total billed charges,Implant Device,3571.05,35,,3571.05,percent of total billed charges,Implant Device,3571.05,35,,3571.05,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3469.02,34,"If Charge > 2,000, then 34 percent",3469.02,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,7550.25,
STRYKER 604730 CANN SCREW 4.0X30MM,C1713,HCPCS,,79009529,CDM,278,RC,,,both,,,535,395.9,,,395.9,Other,150% of Medicare + 9.63% HCRA Surcharge,240.75,45,,240.75,percent of total billed charges,Critical Access Hospital RCC factor,181.9,34,,181.9,percent of total billed charges,Implant Device,181.9,34,,181.9,percent of total billed charges,Implant Device,181.9,34,,181.9,percent of total billed charges,Implant Device,181.9,34,,181.9,percent of total billed charges,Implant Device,181.9,34,,181.9,percent of total billed charges,Implant Device,264.83,,,264.83,Other,110% of Medicare,187.25,35,,187.25,percent of total billed charges,Implant Device,181.9,34,"Charges > $500, x 34%",181.9,percent of total billed charges,Implant Device,187.25,35,,187.25,percent of total billed charges,Implant Device,187.25,35,,187.25,percent of total billed charges,Implant Device,187.25,35,,187.25,percent of total billed charges,Implant Device,187.25,35,,187.25,percent of total billed charges,Implant Device,187.25,35,,187.25,percent of total billed charges,Implant Device,214,40,,214,percent of total billed charges,Implant Device,187.25,70,,187.25,percent of total billed charges,All Other,181.9,34,,181.9,percent of total billed charges,Implant Device,181.9,34,,181.9,percent of total billed charges,Implant Device,187.25,35,,187.25,percent of total billed charges,Implant Device,187.25,35,,187.25,percent of total billed charges,Implant Device,187.25,35,,187.25,percent of total billed charges,Implant Device,187.25,35,,187.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,395.9,
DEPUY 208.412 CANN SCREW 6.5X85MM,C1713,HCPCS,,79009531,CDM,278,RC,,,both,,,683,505.42,,,505.42,Other,150% of Medicare + 9.63% HCRA Surcharge,307.35,45,,307.35,percent of total billed charges,Critical Access Hospital RCC factor,232.22,34,,232.22,percent of total billed charges,Implant Device,232.22,34,,232.22,percent of total billed charges,Implant Device,232.22,34,,232.22,percent of total billed charges,Implant Device,232.22,34,,232.22,percent of total billed charges,Implant Device,232.22,34,,232.22,percent of total billed charges,Implant Device,338.09,,,338.09,Other,110% of Medicare,239.05,35,,239.05,percent of total billed charges,Implant Device,232.22,34,"Charges > $500, x 34%",232.22,percent of total billed charges,Implant Device,239.05,35,,239.05,percent of total billed charges,Implant Device,239.05,35,,239.05,percent of total billed charges,Implant Device,239.05,35,,239.05,percent of total billed charges,Implant Device,239.05,35,,239.05,percent of total billed charges,Implant Device,239.05,35,,239.05,percent of total billed charges,Implant Device,273.2,40,,273.2,percent of total billed charges,Implant Device,239.05,70,,239.05,percent of total billed charges,All Other,232.22,34,,232.22,percent of total billed charges,Implant Device,232.22,34,,232.22,percent of total billed charges,Implant Device,239.05,35,,239.05,percent of total billed charges,Implant Device,239.05,35,,239.05,percent of total billed charges,Implant Device,239.05,35,,239.05,percent of total billed charges,Implant Device,239.05,35,,239.05,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,505.42,
DEPUY 208.413 CANN SCREW 6.5X90MM,C1713,HCPCS,,79009532,CDM,278,RC,,,both,,,683,505.42,,,505.42,Other,150% of Medicare + 9.63% HCRA Surcharge,307.35,45,,307.35,percent of total billed charges,Critical Access Hospital RCC factor,232.22,34,,232.22,percent of total billed charges,Implant Device,232.22,34,,232.22,percent of total billed charges,Implant Device,232.22,34,,232.22,percent of total billed charges,Implant Device,232.22,34,,232.22,percent of total billed charges,Implant Device,232.22,34,,232.22,percent of total billed charges,Implant Device,338.09,,,338.09,Other,110% of Medicare,239.05,35,,239.05,percent of total billed charges,Implant Device,232.22,34,"Charges > $500, x 34%",232.22,percent of total billed charges,Implant Device,239.05,35,,239.05,percent of total billed charges,Implant Device,239.05,35,,239.05,percent of total billed charges,Implant Device,239.05,35,,239.05,percent of total billed charges,Implant Device,239.05,35,,239.05,percent of total billed charges,Implant Device,239.05,35,,239.05,percent of total billed charges,Implant Device,273.2,40,,273.2,percent of total billed charges,Implant Device,239.05,70,,239.05,percent of total billed charges,All Other,232.22,34,,232.22,percent of total billed charges,Implant Device,232.22,34,,232.22,percent of total billed charges,Implant Device,239.05,35,,239.05,percent of total billed charges,Implant Device,239.05,35,,239.05,percent of total billed charges,Implant Device,239.05,35,,239.05,percent of total billed charges,Implant Device,239.05,35,,239.05,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,505.42,
DEPUY 208.414 CANN SCREW 6.5X95MM,C1713,HCPCS,,79009533,CDM,278,RC,,,both,,,1077,796.98,,,796.98,Other,150% of Medicare + 9.63% HCRA Surcharge,484.65,45,,484.65,percent of total billed charges,Critical Access Hospital RCC factor,366.18,34,,366.18,percent of total billed charges,Implant Device,366.18,34,,366.18,percent of total billed charges,Implant Device,366.18,34,,366.18,percent of total billed charges,Implant Device,366.18,34,,366.18,percent of total billed charges,Implant Device,366.18,34,,366.18,percent of total billed charges,Implant Device,533.12,,,533.12,Other,110% of Medicare,376.95,35,,376.95,percent of total billed charges,Implant Device,366.18,34,"Charges > $500, x 34%",366.18,percent of total billed charges,Implant Device,376.95,35,,376.95,percent of total billed charges,Implant Device,376.95,35,,376.95,percent of total billed charges,Implant Device,376.95,35,,376.95,percent of total billed charges,Implant Device,376.95,35,,376.95,percent of total billed charges,Implant Device,376.95,35,,376.95,percent of total billed charges,Implant Device,430.8,40,,430.8,percent of total billed charges,Implant Device,376.95,70,,376.95,percent of total billed charges,All Other,366.18,34,,366.18,percent of total billed charges,Implant Device,366.18,34,,366.18,percent of total billed charges,Implant Device,376.95,35,,376.95,percent of total billed charges,Implant Device,376.95,35,,376.95,percent of total billed charges,Implant Device,376.95,35,,376.95,percent of total billed charges,Implant Device,376.95,35,,376.95,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,796.98,
GORE PLC141000 EXCL ENDOPROS 14.5MMX10CM,C1874,HCPCS,,79009534,CDM,278,RC,,,both,,,14217,10520.62,,,10520.62,Other,150% of Medicare + 9.63% HCRA Surcharge,6397.65,45,,6397.65,percent of total billed charges,Critical Access Hospital RCC factor,4833.78,34,,4833.78,percent of total billed charges,Implant Device,4833.78,34,,4833.78,percent of total billed charges,Implant Device,4833.78,34,,4833.78,percent of total billed charges,Implant Device,4833.78,34,,4833.78,percent of total billed charges,Implant Device,4833.78,34,,4833.78,percent of total billed charges,Implant Device,7037.42,,,7037.42,Other,110% of Medicare,4975.95,35,,4975.95,percent of total billed charges,Implant Device,4833.78,34,"Charges > $500, x 34%",4833.78,percent of total billed charges,Implant Device,4975.95,35,,4975.95,percent of total billed charges,Implant Device,4975.95,35,,4975.95,percent of total billed charges,Implant Device,4975.95,35,,4975.95,percent of total billed charges,Implant Device,4975.95,35,,4975.95,percent of total billed charges,Implant Device,4975.95,35,,4975.95,percent of total billed charges,Implant Device,5686.8,40,,5686.8,percent of total billed charges,Implant Device,4975.95,70,,4975.95,percent of total billed charges,All Other,4833.78,34,,4833.78,percent of total billed charges,Implant Device,4833.78,34,,4833.78,percent of total billed charges,Implant Device,4975.95,35,,4975.95,percent of total billed charges,Implant Device,4975.95,35,,4975.95,percent of total billed charges,Implant Device,4975.95,35,,4975.95,percent of total billed charges,Implant Device,4975.95,35,,4975.95,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,4833.78,34,"If Charge > 2,000, then 34 percent",4833.78,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,10520.62,
ZIMMER 00-8851-017-36 LINER 36X66MM,C1776,HCPCS,,79009535,CDM,278,RC,,,both,,,4403,3258.23,,,3258.23,Other,150% of Medicare + 9.63% HCRA Surcharge,1981.35,45,,1981.35,percent of total billed charges,Critical Access Hospital RCC factor,1497.02,34,,1497.02,percent of total billed charges,Implant Device,1497.02,34,,1497.02,percent of total billed charges,Implant Device,1497.02,34,,1497.02,percent of total billed charges,Implant Device,1497.02,34,,1497.02,percent of total billed charges,Implant Device,1497.02,34,,1497.02,percent of total billed charges,Implant Device,2179.49,,,2179.49,Other,110% of Medicare,1541.05,35,,1541.05,percent of total billed charges,Implant Device,1497.02,34,"Charges > $500, x 34%",1497.02,percent of total billed charges,Implant Device,1541.05,35,,1541.05,percent of total billed charges,Implant Device,1541.05,35,,1541.05,percent of total billed charges,Implant Device,1541.05,35,,1541.05,percent of total billed charges,Implant Device,1541.05,35,,1541.05,percent of total billed charges,Implant Device,1541.05,35,,1541.05,percent of total billed charges,Implant Device,1761.2,40,,1761.2,percent of total billed charges,Implant Device,1541.05,70,,1541.05,percent of total billed charges,All Other,1497.02,34,,1497.02,percent of total billed charges,Implant Device,1497.02,34,,1497.02,percent of total billed charges,Implant Device,1541.05,35,,1541.05,percent of total billed charges,Implant Device,1541.05,35,,1541.05,percent of total billed charges,Implant Device,1541.05,35,,1541.05,percent of total billed charges,Implant Device,1541.05,35,,1541.05,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1497.02,34,"If Charge > 2,000, then 34 percent",1497.02,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3258.23,
ARTHREX AR-8930-10 SNAP OFF SCREW 2X10MM,C1713,HCPCS,,79009536,CDM,278,RC,,,both,,,1029,761.46,,,761.46,Other,150% of Medicare + 9.63% HCRA Surcharge,463.05,45,,463.05,percent of total billed charges,Critical Access Hospital RCC factor,349.86,34,,349.86,percent of total billed charges,Implant Device,349.86,34,,349.86,percent of total billed charges,Implant Device,349.86,34,,349.86,percent of total billed charges,Implant Device,349.86,34,,349.86,percent of total billed charges,Implant Device,349.86,34,,349.86,percent of total billed charges,Implant Device,509.36,,,509.36,Other,110% of Medicare,360.15,35,,360.15,percent of total billed charges,Implant Device,349.86,34,"Charges > $500, x 34%",349.86,percent of total billed charges,Implant Device,360.15,35,,360.15,percent of total billed charges,Implant Device,360.15,35,,360.15,percent of total billed charges,Implant Device,360.15,35,,360.15,percent of total billed charges,Implant Device,360.15,35,,360.15,percent of total billed charges,Implant Device,360.15,35,,360.15,percent of total billed charges,Implant Device,411.6,40,,411.6,percent of total billed charges,Implant Device,360.15,70,,360.15,percent of total billed charges,All Other,349.86,34,,349.86,percent of total billed charges,Implant Device,349.86,34,,349.86,percent of total billed charges,Implant Device,360.15,35,,360.15,percent of total billed charges,Implant Device,360.15,35,,360.15,percent of total billed charges,Implant Device,360.15,35,,360.15,percent of total billed charges,Implant Device,360.15,35,,360.15,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,761.46,
LIFE SPIN 132-2318-1 AILERON LAREG CORE,C1713,HCPCS,,79009537,CDM,278,RC,,,both,,,20640,15273.65,,,15273.65,Other,150% of Medicare + 9.63% HCRA Surcharge,9288,45,,9288,percent of total billed charges,Critical Access Hospital RCC factor,7017.6,34,,7017.6,percent of total billed charges,Implant Device,7017.6,34,,7017.6,percent of total billed charges,Implant Device,7017.6,34,,7017.6,percent of total billed charges,Implant Device,7017.6,34,,7017.6,percent of total billed charges,Implant Device,7017.6,34,,7017.6,percent of total billed charges,Implant Device,10216.8,,,10216.8,Other,110% of Medicare,7224,35,,7224,percent of total billed charges,Implant Device,7017.6,34,"Charges > $500, x 34%",7017.6,percent of total billed charges,Implant Device,7224,35,,7224,percent of total billed charges,Implant Device,7224,35,,7224,percent of total billed charges,Implant Device,7224,35,,7224,percent of total billed charges,Implant Device,7224,35,,7224,percent of total billed charges,Implant Device,7224,35,,7224,percent of total billed charges,Implant Device,8256,40,,8256,percent of total billed charges,Implant Device,7224,70,,7224,percent of total billed charges,All Other,7017.6,34,,7017.6,percent of total billed charges,Implant Device,7017.6,34,,7017.6,percent of total billed charges,Implant Device,7224,35,,7224,percent of total billed charges,Implant Device,7224,35,,7224,percent of total billed charges,Implant Device,7224,35,,7224,percent of total billed charges,Implant Device,7224,35,,7224,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,7017.6,34,"If Charge > 2,000, then 34 percent",7017.6,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,15273.65,
LIFE SPIN 132-2318-2 AILERON LAREG PLATE,C1713,HCPCS,,79009538,CDM,278,RC,,,both,,,13680,10123.23,,,10123.23,Other,150% of Medicare + 9.63% HCRA Surcharge,6156,45,,6156,percent of total billed charges,Critical Access Hospital RCC factor,4651.2,34,,4651.2,percent of total billed charges,Implant Device,4651.2,34,,4651.2,percent of total billed charges,Implant Device,4651.2,34,,4651.2,percent of total billed charges,Implant Device,4651.2,34,,4651.2,percent of total billed charges,Implant Device,4651.2,34,,4651.2,percent of total billed charges,Implant Device,6771.6,,,6771.6,Other,110% of Medicare,4788,35,,4788,percent of total billed charges,Implant Device,4651.2,34,"Charges > $500, x 34%",4651.2,percent of total billed charges,Implant Device,4788,35,,4788,percent of total billed charges,Implant Device,4788,35,,4788,percent of total billed charges,Implant Device,4788,35,,4788,percent of total billed charges,Implant Device,4788,35,,4788,percent of total billed charges,Implant Device,4788,35,,4788,percent of total billed charges,Implant Device,5472,40,,5472,percent of total billed charges,Implant Device,4788,70,,4788,percent of total billed charges,All Other,4651.2,34,,4651.2,percent of total billed charges,Implant Device,4651.2,34,,4651.2,percent of total billed charges,Implant Device,4788,35,,4788,percent of total billed charges,Implant Device,4788,35,,4788,percent of total billed charges,Implant Device,4788,35,,4788,percent of total billed charges,Implant Device,4788,35,,4788,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,4651.2,34,"If Charge > 2,000, then 34 percent",4651.2,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,10123.23,
IN2BONES V35 ST320 LOCK SCREW 3.5X20MM,C1713,HCPCS,,79009539,CDM,278,RC,,,both,,,870,643.8,,,643.8,Other,150% of Medicare + 9.63% HCRA Surcharge,391.5,45,,391.5,percent of total billed charges,Critical Access Hospital RCC factor,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,430.65,,,430.65,Other,110% of Medicare,304.5,35,,304.5,percent of total billed charges,Implant Device,295.8,34,"Charges > $500, x 34%",295.8,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,348,40,,348,percent of total billed charges,Implant Device,304.5,70,,304.5,percent of total billed charges,All Other,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,643.8,
DEPUY 208.880 CANNULATED SCREW 7.3X80MM,C1713,HCPCS,,79009540,CDM,278,RC,,,both,,,1072,793.28,,,793.28,Other,150% of Medicare + 9.63% HCRA Surcharge,482.4,45,,482.4,percent of total billed charges,Critical Access Hospital RCC factor,364.48,34,,364.48,percent of total billed charges,Implant Device,364.48,34,,364.48,percent of total billed charges,Implant Device,364.48,34,,364.48,percent of total billed charges,Implant Device,364.48,34,,364.48,percent of total billed charges,Implant Device,364.48,34,,364.48,percent of total billed charges,Implant Device,530.64,,,530.64,Other,110% of Medicare,375.2,35,,375.2,percent of total billed charges,Implant Device,364.48,34,"Charges > $500, x 34%",364.48,percent of total billed charges,Implant Device,375.2,35,,375.2,percent of total billed charges,Implant Device,375.2,35,,375.2,percent of total billed charges,Implant Device,375.2,35,,375.2,percent of total billed charges,Implant Device,375.2,35,,375.2,percent of total billed charges,Implant Device,375.2,35,,375.2,percent of total billed charges,Implant Device,428.8,40,,428.8,percent of total billed charges,Implant Device,375.2,70,,375.2,percent of total billed charges,All Other,364.48,34,,364.48,percent of total billed charges,Implant Device,364.48,34,,364.48,percent of total billed charges,Implant Device,375.2,35,,375.2,percent of total billed charges,Implant Device,375.2,35,,375.2,percent of total billed charges,Implant Device,375.2,35,,375.2,percent of total billed charges,Implant Device,375.2,35,,375.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,793.28,
DEPUY 208.885 CANNULATED SCREW 7.3X85MM,C1713,HCPCS,,79009541,CDM,278,RC,,,both,,,1072,793.28,,,793.28,Other,150% of Medicare + 9.63% HCRA Surcharge,482.4,45,,482.4,percent of total billed charges,Critical Access Hospital RCC factor,364.48,34,,364.48,percent of total billed charges,Implant Device,364.48,34,,364.48,percent of total billed charges,Implant Device,364.48,34,,364.48,percent of total billed charges,Implant Device,364.48,34,,364.48,percent of total billed charges,Implant Device,364.48,34,,364.48,percent of total billed charges,Implant Device,530.64,,,530.64,Other,110% of Medicare,375.2,35,,375.2,percent of total billed charges,Implant Device,364.48,34,"Charges > $500, x 34%",364.48,percent of total billed charges,Implant Device,375.2,35,,375.2,percent of total billed charges,Implant Device,375.2,35,,375.2,percent of total billed charges,Implant Device,375.2,35,,375.2,percent of total billed charges,Implant Device,375.2,35,,375.2,percent of total billed charges,Implant Device,375.2,35,,375.2,percent of total billed charges,Implant Device,428.8,40,,428.8,percent of total billed charges,Implant Device,375.2,70,,375.2,percent of total billed charges,All Other,364.48,34,,364.48,percent of total billed charges,Implant Device,364.48,34,,364.48,percent of total billed charges,Implant Device,375.2,35,,375.2,percent of total billed charges,Implant Device,375.2,35,,375.2,percent of total billed charges,Implant Device,375.2,35,,375.2,percent of total billed charges,Implant Device,375.2,35,,375.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,793.28,
DEPUY 208.890 CANNULATED SCREW 7.3X90MM,C1713,HCPCS,,79009542,CDM,278,RC,,,both,,,1072,793.28,,,793.28,Other,150% of Medicare + 9.63% HCRA Surcharge,482.4,45,,482.4,percent of total billed charges,Critical Access Hospital RCC factor,364.48,34,,364.48,percent of total billed charges,Implant Device,364.48,34,,364.48,percent of total billed charges,Implant Device,364.48,34,,364.48,percent of total billed charges,Implant Device,364.48,34,,364.48,percent of total billed charges,Implant Device,364.48,34,,364.48,percent of total billed charges,Implant Device,530.64,,,530.64,Other,110% of Medicare,375.2,35,,375.2,percent of total billed charges,Implant Device,364.48,34,"Charges > $500, x 34%",364.48,percent of total billed charges,Implant Device,375.2,35,,375.2,percent of total billed charges,Implant Device,375.2,35,,375.2,percent of total billed charges,Implant Device,375.2,35,,375.2,percent of total billed charges,Implant Device,375.2,35,,375.2,percent of total billed charges,Implant Device,375.2,35,,375.2,percent of total billed charges,Implant Device,428.8,40,,428.8,percent of total billed charges,Implant Device,375.2,70,,375.2,percent of total billed charges,All Other,364.48,34,,364.48,percent of total billed charges,Implant Device,364.48,34,,364.48,percent of total billed charges,Implant Device,375.2,35,,375.2,percent of total billed charges,Implant Device,375.2,35,,375.2,percent of total billed charges,Implant Device,375.2,35,,375.2,percent of total billed charges,Implant Device,375.2,35,,375.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,793.28,
ARTHREX SC2714-S 2.7X14MM SCREW,C1713,HCPCS,,79009544,CDM,278,RC,,,both,,,537,397.38,,,397.38,Other,150% of Medicare + 9.63% HCRA Surcharge,241.65,45,,241.65,percent of total billed charges,Critical Access Hospital RCC factor,182.58,34,,182.58,percent of total billed charges,Implant Device,182.58,34,,182.58,percent of total billed charges,Implant Device,182.58,34,,182.58,percent of total billed charges,Implant Device,182.58,34,,182.58,percent of total billed charges,Implant Device,182.58,34,,182.58,percent of total billed charges,Implant Device,265.82,,,265.82,Other,110% of Medicare,187.95,35,,187.95,percent of total billed charges,Implant Device,182.58,34,"Charges > $500, x 34%",182.58,percent of total billed charges,Implant Device,187.95,35,,187.95,percent of total billed charges,Implant Device,187.95,35,,187.95,percent of total billed charges,Implant Device,187.95,35,,187.95,percent of total billed charges,Implant Device,187.95,35,,187.95,percent of total billed charges,Implant Device,187.95,35,,187.95,percent of total billed charges,Implant Device,214.8,40,,214.8,percent of total billed charges,Implant Device,187.95,70,,187.95,percent of total billed charges,All Other,182.58,34,,182.58,percent of total billed charges,Implant Device,182.58,34,,182.58,percent of total billed charges,Implant Device,187.95,35,,187.95,percent of total billed charges,Implant Device,187.95,35,,187.95,percent of total billed charges,Implant Device,187.95,35,,187.95,percent of total billed charges,Implant Device,187.95,35,,187.95,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,397.38,
ARTHREX FIB30130L FIBULOCK NAIL LT 3X130,C1713,HCPCS,,79009545,CDM,278,RC,,,both,,,12837,9499.41,,,9499.41,Other,150% of Medicare + 9.63% HCRA Surcharge,5776.65,45,,5776.65,percent of total billed charges,Critical Access Hospital RCC factor,4364.58,34,,4364.58,percent of total billed charges,Implant Device,4364.58,34,,4364.58,percent of total billed charges,Implant Device,4364.58,34,,4364.58,percent of total billed charges,Implant Device,4364.58,34,,4364.58,percent of total billed charges,Implant Device,4364.58,34,,4364.58,percent of total billed charges,Implant Device,6354.32,,,6354.32,Other,110% of Medicare,4492.95,35,,4492.95,percent of total billed charges,Implant Device,4364.58,34,"Charges > $500, x 34%",4364.58,percent of total billed charges,Implant Device,4492.95,35,,4492.95,percent of total billed charges,Implant Device,4492.95,35,,4492.95,percent of total billed charges,Implant Device,4492.95,35,,4492.95,percent of total billed charges,Implant Device,4492.95,35,,4492.95,percent of total billed charges,Implant Device,4492.95,35,,4492.95,percent of total billed charges,Implant Device,5134.8,40,,5134.8,percent of total billed charges,Implant Device,4492.95,70,,4492.95,percent of total billed charges,All Other,4364.58,34,,4364.58,percent of total billed charges,Implant Device,4364.58,34,,4364.58,percent of total billed charges,Implant Device,4492.95,35,,4492.95,percent of total billed charges,Implant Device,4492.95,35,,4492.95,percent of total billed charges,Implant Device,4492.95,35,,4492.95,percent of total billed charges,Implant Device,4492.95,35,,4492.95,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,4364.58,34,"If Charge > 2,000, then 34 percent",4364.58,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,9499.41,
ARTHREX FIB6000 FIBULOK END CAP,C1713,HCPCS,,79009546,CDM,278,RC,,,both,,,516,381.84,,,381.84,Other,150% of Medicare + 9.63% HCRA Surcharge,232.2,45,,232.2,percent of total billed charges,Critical Access Hospital RCC factor,175.44,34,,175.44,percent of total billed charges,Implant Device,175.44,34,,175.44,percent of total billed charges,Implant Device,175.44,34,,175.44,percent of total billed charges,Implant Device,175.44,34,,175.44,percent of total billed charges,Implant Device,175.44,34,,175.44,percent of total billed charges,Implant Device,255.42,,,255.42,Other,110% of Medicare,180.6,35,,180.6,percent of total billed charges,Implant Device,175.44,34,"Charges > $500, x 34%",175.44,percent of total billed charges,Implant Device,180.6,35,,180.6,percent of total billed charges,Implant Device,180.6,35,,180.6,percent of total billed charges,Implant Device,180.6,35,,180.6,percent of total billed charges,Implant Device,180.6,35,,180.6,percent of total billed charges,Implant Device,180.6,35,,180.6,percent of total billed charges,Implant Device,206.4,40,,206.4,percent of total billed charges,Implant Device,180.6,70,,180.6,percent of total billed charges,All Other,175.44,34,,175.44,percent of total billed charges,Implant Device,175.44,34,,175.44,percent of total billed charges,Implant Device,180.6,35,,180.6,percent of total billed charges,Implant Device,180.6,35,,180.6,percent of total billed charges,Implant Device,180.6,35,,180.6,percent of total billed charges,Implant Device,180.6,35,,180.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,381.84,
STRYKER 607326 CANCELLOUS SCREW 4.0X26MM,C1713,HCPCS,,79009547,CDM,278,RC,,,both,,,133,98.42,,,98.42,Other,150% of Medicare + 9.63% HCRA Surcharge,59.85,45,,59.85,percent of total billed charges,Critical Access Hospital RCC factor,45.22,34,,45.22,percent of total billed charges,Implant Device,45.22,34,,45.22,percent of total billed charges,Implant Device,45.22,34,,45.22,percent of total billed charges,Implant Device,45.22,34,,45.22,percent of total billed charges,Implant Device,45.22,34,,45.22,percent of total billed charges,Implant Device,65.84,,,65.84,Other,110% of Medicare,46.55,35,,46.55,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,46.55,35,,46.55,percent of total billed charges,Implant Device,46.55,35,,46.55,percent of total billed charges,Implant Device,46.55,35,,46.55,percent of total billed charges,Implant Device,46.55,35,,46.55,percent of total billed charges,Implant Device,46.55,35,,46.55,percent of total billed charges,Implant Device,53.2,40,,53.2,percent of total billed charges,Implant Device,46.55,70,,46.55,percent of total billed charges,All Other,45.22,34,,45.22,percent of total billed charges,Implant Device,45.22,34,,45.22,percent of total billed charges,Implant Device,46.55,35,,46.55,percent of total billed charges,Implant Device,46.55,35,,46.55,percent of total billed charges,Implant Device,46.55,35,,46.55,percent of total billed charges,Implant Device,46.55,35,,46.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,98.42,
IN2BONES V35 ST322 LOCK SCREW 3.5X22MM,C1713,HCPCS,,79009548,CDM,278,RC,,,both,,,870,643.8,,,643.8,Other,150% of Medicare + 9.63% HCRA Surcharge,391.5,45,,391.5,percent of total billed charges,Critical Access Hospital RCC factor,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,430.65,,,430.65,Other,110% of Medicare,304.5,35,,304.5,percent of total billed charges,Implant Device,295.8,34,"Charges > $500, x 34%",295.8,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,348,40,,348,percent of total billed charges,Implant Device,304.5,70,,304.5,percent of total billed charges,All Other,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,643.8,
ZIMMER 00-5750-015-02 FEM COMP SZ E-RT,C1776,HCPCS,,79009555,CDM,278,RC,,,both,,,5175,3829.51,,,3829.51,Other,150% of Medicare + 9.63% HCRA Surcharge,2328.75,45,,2328.75,percent of total billed charges,Critical Access Hospital RCC factor,1759.5,34,,1759.5,percent of total billed charges,Implant Device,1759.5,34,,1759.5,percent of total billed charges,Implant Device,1759.5,34,,1759.5,percent of total billed charges,Implant Device,1759.5,34,,1759.5,percent of total billed charges,Implant Device,1759.5,34,,1759.5,percent of total billed charges,Implant Device,2561.63,,,2561.63,Other,110% of Medicare,1811.25,35,,1811.25,percent of total billed charges,Implant Device,1759.5,34,"Charges > $500, x 34%",1759.5,percent of total billed charges,Implant Device,1811.25,35,,1811.25,percent of total billed charges,Implant Device,1811.25,35,,1811.25,percent of total billed charges,Implant Device,1811.25,35,,1811.25,percent of total billed charges,Implant Device,1811.25,35,,1811.25,percent of total billed charges,Implant Device,1811.25,35,,1811.25,percent of total billed charges,Implant Device,2070,40,,2070,percent of total billed charges,Implant Device,1811.25,70,,1811.25,percent of total billed charges,All Other,1759.5,34,,1759.5,percent of total billed charges,Implant Device,1759.5,34,,1759.5,percent of total billed charges,Implant Device,1811.25,35,,1811.25,percent of total billed charges,Implant Device,1811.25,35,,1811.25,percent of total billed charges,Implant Device,1811.25,35,,1811.25,percent of total billed charges,Implant Device,1811.25,35,,1811.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1759.5,34,"If Charge > 2,000, then 34 percent",1759.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3829.51,
MENTOR SMXP-120RH BREAST TISSUE EXPANDER,C1789,HCPCS,,79009556,CDM,278,RC,,,both,,,6375,4717.52,,,4717.52,Other,150% of Medicare + 9.63% HCRA Surcharge,2868.75,45,,2868.75,percent of total billed charges,Critical Access Hospital RCC factor,2167.5,34,,2167.5,percent of total billed charges,Implant Device,2167.5,34,,2167.5,percent of total billed charges,Implant Device,2167.5,34,,2167.5,percent of total billed charges,Implant Device,2167.5,34,,2167.5,percent of total billed charges,Implant Device,2167.5,34,,2167.5,percent of total billed charges,Implant Device,3155.63,,,3155.63,Other,110% of Medicare,2231.25,35,,2231.25,percent of total billed charges,Implant Device,2167.5,34,"Charges > $500, x 34%",2167.5,percent of total billed charges,Implant Device,2231.25,35,,2231.25,percent of total billed charges,Implant Device,2231.25,35,,2231.25,percent of total billed charges,Implant Device,2231.25,35,,2231.25,percent of total billed charges,Implant Device,2231.25,35,,2231.25,percent of total billed charges,Implant Device,2231.25,35,,2231.25,percent of total billed charges,Implant Device,2550,40,,2550,percent of total billed charges,Implant Device,2231.25,70,,2231.25,percent of total billed charges,All Other,2167.5,34,,2167.5,percent of total billed charges,Implant Device,2167.5,34,,2167.5,percent of total billed charges,Implant Device,2231.25,35,,2231.25,percent of total billed charges,Implant Device,2231.25,35,,2231.25,percent of total billed charges,Implant Device,2231.25,35,,2231.25,percent of total billed charges,Implant Device,2231.25,35,,2231.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2167.5,34,"If Charge > 2,000, then 34 percent",2167.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4717.52,
MENTOR SMPX-350 BREAST TISSUE EXPANDER,C1789,HCPCS,,79009557,CDM,278,RC,,,both,,,3684,2726.17,,,2726.17,Other,150% of Medicare + 9.63% HCRA Surcharge,1657.8,45,,1657.8,percent of total billed charges,Critical Access Hospital RCC factor,1252.56,34,,1252.56,percent of total billed charges,Implant Device,1252.56,34,,1252.56,percent of total billed charges,Implant Device,1252.56,34,,1252.56,percent of total billed charges,Implant Device,1252.56,34,,1252.56,percent of total billed charges,Implant Device,1252.56,34,,1252.56,percent of total billed charges,Implant Device,1823.58,,,1823.58,Other,110% of Medicare,1289.4,35,,1289.4,percent of total billed charges,Implant Device,1252.56,34,"Charges > $500, x 34%",1252.56,percent of total billed charges,Implant Device,1289.4,35,,1289.4,percent of total billed charges,Implant Device,1289.4,35,,1289.4,percent of total billed charges,Implant Device,1289.4,35,,1289.4,percent of total billed charges,Implant Device,1289.4,35,,1289.4,percent of total billed charges,Implant Device,1289.4,35,,1289.4,percent of total billed charges,Implant Device,1473.6,40,,1473.6,percent of total billed charges,Implant Device,1289.4,70,,1289.4,percent of total billed charges,All Other,1252.56,34,,1252.56,percent of total billed charges,Implant Device,1252.56,34,,1252.56,percent of total billed charges,Implant Device,1289.4,35,,1289.4,percent of total billed charges,Implant Device,1289.4,35,,1289.4,percent of total billed charges,Implant Device,1289.4,35,,1289.4,percent of total billed charges,Implant Device,1289.4,35,,1289.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1252.56,34,"If Charge > 2,000, then 34 percent",1252.56,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2726.17,
MENTOR SMPX-325 BREAST TISSUE EXPANDER,C1789,HCPCS,,79009558,CDM,278,RC,,,both,,,3684,2726.17,,,2726.17,Other,150% of Medicare + 9.63% HCRA Surcharge,1657.8,45,,1657.8,percent of total billed charges,Critical Access Hospital RCC factor,1252.56,34,,1252.56,percent of total billed charges,Implant Device,1252.56,34,,1252.56,percent of total billed charges,Implant Device,1252.56,34,,1252.56,percent of total billed charges,Implant Device,1252.56,34,,1252.56,percent of total billed charges,Implant Device,1252.56,34,,1252.56,percent of total billed charges,Implant Device,1823.58,,,1823.58,Other,110% of Medicare,1289.4,35,,1289.4,percent of total billed charges,Implant Device,1252.56,34,"Charges > $500, x 34%",1252.56,percent of total billed charges,Implant Device,1289.4,35,,1289.4,percent of total billed charges,Implant Device,1289.4,35,,1289.4,percent of total billed charges,Implant Device,1289.4,35,,1289.4,percent of total billed charges,Implant Device,1289.4,35,,1289.4,percent of total billed charges,Implant Device,1289.4,35,,1289.4,percent of total billed charges,Implant Device,1473.6,40,,1473.6,percent of total billed charges,Implant Device,1289.4,70,,1289.4,percent of total billed charges,All Other,1252.56,34,,1252.56,percent of total billed charges,Implant Device,1252.56,34,,1252.56,percent of total billed charges,Implant Device,1289.4,35,,1289.4,percent of total billed charges,Implant Device,1289.4,35,,1289.4,percent of total billed charges,Implant Device,1289.4,35,,1289.4,percent of total billed charges,Implant Device,1289.4,35,,1289.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1252.56,34,"If Charge > 2,000, then 34 percent",1252.56,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2726.17,
MENTOR 350-4004BC MEMORY GEL IMPLANT,C1789,HCPCS,,79009561,CDM,278,RC,,,both,,,2940,2175.61,,,2175.61,Other,150% of Medicare + 9.63% HCRA Surcharge,1323,45,,1323,percent of total billed charges,Critical Access Hospital RCC factor,999.6,34,,999.6,percent of total billed charges,Implant Device,999.6,34,,999.6,percent of total billed charges,Implant Device,999.6,34,,999.6,percent of total billed charges,Implant Device,999.6,34,,999.6,percent of total billed charges,Implant Device,999.6,34,,999.6,percent of total billed charges,Implant Device,1455.3,,,1455.3,Other,110% of Medicare,1029,35,,1029,percent of total billed charges,Implant Device,999.6,34,"Charges > $500, x 34%",999.6,percent of total billed charges,Implant Device,1029,35,,1029,percent of total billed charges,Implant Device,1029,35,,1029,percent of total billed charges,Implant Device,1029,35,,1029,percent of total billed charges,Implant Device,1029,35,,1029,percent of total billed charges,Implant Device,1029,35,,1029,percent of total billed charges,Implant Device,1176,40,,1176,percent of total billed charges,Implant Device,1029,70,,1029,percent of total billed charges,All Other,999.6,34,,999.6,percent of total billed charges,Implant Device,999.6,34,,999.6,percent of total billed charges,Implant Device,1029,35,,1029,percent of total billed charges,Implant Device,1029,35,,1029,percent of total billed charges,Implant Device,1029,35,,1029,percent of total billed charges,Implant Device,1029,35,,1029,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,999.6,34,"If Charge > 2,000, then 34 percent",999.6,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2175.61,
MENTOR 350-3754BC MEMORY GEL IMPLANT,C1789,HCPCS,,79009562,CDM,278,RC,,,both,,,2940,2175.61,,,2175.61,Other,150% of Medicare + 9.63% HCRA Surcharge,1323,45,,1323,percent of total billed charges,Critical Access Hospital RCC factor,999.6,34,,999.6,percent of total billed charges,Implant Device,999.6,34,,999.6,percent of total billed charges,Implant Device,999.6,34,,999.6,percent of total billed charges,Implant Device,999.6,34,,999.6,percent of total billed charges,Implant Device,999.6,34,,999.6,percent of total billed charges,Implant Device,1455.3,,,1455.3,Other,110% of Medicare,1029,35,,1029,percent of total billed charges,Implant Device,999.6,34,"Charges > $500, x 34%",999.6,percent of total billed charges,Implant Device,1029,35,,1029,percent of total billed charges,Implant Device,1029,35,,1029,percent of total billed charges,Implant Device,1029,35,,1029,percent of total billed charges,Implant Device,1029,35,,1029,percent of total billed charges,Implant Device,1029,35,,1029,percent of total billed charges,Implant Device,1176,40,,1176,percent of total billed charges,Implant Device,1029,70,,1029,percent of total billed charges,All Other,999.6,34,,999.6,percent of total billed charges,Implant Device,999.6,34,,999.6,percent of total billed charges,Implant Device,1029,35,,1029,percent of total billed charges,Implant Device,1029,35,,1029,percent of total billed charges,Implant Device,1029,35,,1029,percent of total billed charges,Implant Device,1029,35,,1029,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,999.6,34,"If Charge > 2,000, then 34 percent",999.6,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2175.61,
MENTOR 350-3504BC MEMORY GEL IMPLANT,C1789,HCPCS,,79009563,CDM,278,RC,,,both,,,2940,2175.61,,,2175.61,Other,150% of Medicare + 9.63% HCRA Surcharge,1323,45,,1323,percent of total billed charges,Critical Access Hospital RCC factor,999.6,34,,999.6,percent of total billed charges,Implant Device,999.6,34,,999.6,percent of total billed charges,Implant Device,999.6,34,,999.6,percent of total billed charges,Implant Device,999.6,34,,999.6,percent of total billed charges,Implant Device,999.6,34,,999.6,percent of total billed charges,Implant Device,1455.3,,,1455.3,Other,110% of Medicare,1029,35,,1029,percent of total billed charges,Implant Device,999.6,34,"Charges > $500, x 34%",999.6,percent of total billed charges,Implant Device,1029,35,,1029,percent of total billed charges,Implant Device,1029,35,,1029,percent of total billed charges,Implant Device,1029,35,,1029,percent of total billed charges,Implant Device,1029,35,,1029,percent of total billed charges,Implant Device,1029,35,,1029,percent of total billed charges,Implant Device,1176,40,,1176,percent of total billed charges,Implant Device,1029,70,,1029,percent of total billed charges,All Other,999.6,34,,999.6,percent of total billed charges,Implant Device,999.6,34,,999.6,percent of total billed charges,Implant Device,1029,35,,1029,percent of total billed charges,Implant Device,1029,35,,1029,percent of total billed charges,Implant Device,1029,35,,1029,percent of total billed charges,Implant Device,1029,35,,1029,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,999.6,34,"If Charge > 2,000, then 34 percent",999.6,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2175.61,
MENTOR 350-3254BC MEMORY GEL IMPLANT,C1789,HCPCS,,79009564,CDM,278,RC,,,both,,,2940,2175.61,,,2175.61,Other,150% of Medicare + 9.63% HCRA Surcharge,1323,45,,1323,percent of total billed charges,Critical Access Hospital RCC factor,999.6,34,,999.6,percent of total billed charges,Implant Device,999.6,34,,999.6,percent of total billed charges,Implant Device,999.6,34,,999.6,percent of total billed charges,Implant Device,999.6,34,,999.6,percent of total billed charges,Implant Device,999.6,34,,999.6,percent of total billed charges,Implant Device,1455.3,,,1455.3,Other,110% of Medicare,1029,35,,1029,percent of total billed charges,Implant Device,999.6,34,"Charges > $500, x 34%",999.6,percent of total billed charges,Implant Device,1029,35,,1029,percent of total billed charges,Implant Device,1029,35,,1029,percent of total billed charges,Implant Device,1029,35,,1029,percent of total billed charges,Implant Device,1029,35,,1029,percent of total billed charges,Implant Device,1029,35,,1029,percent of total billed charges,Implant Device,1176,40,,1176,percent of total billed charges,Implant Device,1029,70,,1029,percent of total billed charges,All Other,999.6,34,,999.6,percent of total billed charges,Implant Device,999.6,34,,999.6,percent of total billed charges,Implant Device,1029,35,,1029,percent of total billed charges,Implant Device,1029,35,,1029,percent of total billed charges,Implant Device,1029,35,,1029,percent of total billed charges,Implant Device,1029,35,,1029,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,999.6,34,"If Charge > 2,000, then 34 percent",999.6,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2175.61,
ZIMMER 00-5950-017-02 FEM COMP SZ G-RT,C1776,HCPCS,,79009569,CDM,278,RC,,,both,,,6300,4662.02,,,4662.02,Other,150% of Medicare + 9.63% HCRA Surcharge,2835,45,,2835,percent of total billed charges,Critical Access Hospital RCC factor,2142,34,,2142,percent of total billed charges,Implant Device,2142,34,,2142,percent of total billed charges,Implant Device,2142,34,,2142,percent of total billed charges,Implant Device,2142,34,,2142,percent of total billed charges,Implant Device,2142,34,,2142,percent of total billed charges,Implant Device,3118.5,,,3118.5,Other,110% of Medicare,2205,35,,2205,percent of total billed charges,Implant Device,2142,34,"Charges > $500, x 34%",2142,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2520,40,,2520,percent of total billed charges,Implant Device,2205,70,,2205,percent of total billed charges,All Other,2142,34,,2142,percent of total billed charges,Implant Device,2142,34,,2142,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2142,34,"If Charge > 2,000, then 34 percent",2142,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4662.02,
ZIMMER 00-5972-065-38 PATELLA 38X9.5MM,C1776,HCPCS,,79009570,CDM,278,RC,,,both,,,1152,852.48,,,852.48,Other,150% of Medicare + 9.63% HCRA Surcharge,518.4,45,,518.4,percent of total billed charges,Critical Access Hospital RCC factor,391.68,34,,391.68,percent of total billed charges,Implant Device,391.68,34,,391.68,percent of total billed charges,Implant Device,391.68,34,,391.68,percent of total billed charges,Implant Device,391.68,34,,391.68,percent of total billed charges,Implant Device,391.68,34,,391.68,percent of total billed charges,Implant Device,570.24,,,570.24,Other,110% of Medicare,403.2,35,,403.2,percent of total billed charges,Implant Device,391.68,34,"Charges > $500, x 34%",391.68,percent of total billed charges,Implant Device,403.2,35,,403.2,percent of total billed charges,Implant Device,403.2,35,,403.2,percent of total billed charges,Implant Device,403.2,35,,403.2,percent of total billed charges,Implant Device,403.2,35,,403.2,percent of total billed charges,Implant Device,403.2,35,,403.2,percent of total billed charges,Implant Device,460.8,40,,460.8,percent of total billed charges,Implant Device,403.2,70,,403.2,percent of total billed charges,All Other,391.68,34,,391.68,percent of total billed charges,Implant Device,391.68,34,,391.68,percent of total billed charges,Implant Device,403.2,35,,403.2,percent of total billed charges,Implant Device,403.2,35,,403.2,percent of total billed charges,Implant Device,403.2,35,,403.2,percent of total billed charges,Implant Device,403.2,35,,403.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,852.48,
ZIMMER 00-8851-018-36 LINER 36MM SIZE QU,C1776,HCPCS,,79009571,CDM,278,RC,,,both,,,4403,3258.23,,,3258.23,Other,150% of Medicare + 9.63% HCRA Surcharge,1981.35,45,,1981.35,percent of total billed charges,Critical Access Hospital RCC factor,1497.02,34,,1497.02,percent of total billed charges,Implant Device,1497.02,34,,1497.02,percent of total billed charges,Implant Device,1497.02,34,,1497.02,percent of total billed charges,Implant Device,1497.02,34,,1497.02,percent of total billed charges,Implant Device,1497.02,34,,1497.02,percent of total billed charges,Implant Device,2179.49,,,2179.49,Other,110% of Medicare,1541.05,35,,1541.05,percent of total billed charges,Implant Device,1497.02,34,"Charges > $500, x 34%",1497.02,percent of total billed charges,Implant Device,1541.05,35,,1541.05,percent of total billed charges,Implant Device,1541.05,35,,1541.05,percent of total billed charges,Implant Device,1541.05,35,,1541.05,percent of total billed charges,Implant Device,1541.05,35,,1541.05,percent of total billed charges,Implant Device,1541.05,35,,1541.05,percent of total billed charges,Implant Device,1761.2,40,,1761.2,percent of total billed charges,Implant Device,1541.05,70,,1541.05,percent of total billed charges,All Other,1497.02,34,,1497.02,percent of total billed charges,Implant Device,1497.02,34,,1497.02,percent of total billed charges,Implant Device,1541.05,35,,1541.05,percent of total billed charges,Implant Device,1541.05,35,,1541.05,percent of total billed charges,Implant Device,1541.05,35,,1541.05,percent of total billed charges,Implant Device,1541.05,35,,1541.05,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1497.02,34,"If Charge > 2,000, then 34 percent",1497.02,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3258.23,
DEPUY 1516-50-216 TIB INSERT SIZE 2 16MM,C1776,HCPCS,,79009572,CDM,278,RC,,,both,,,5624,4161.77,,,4161.77,Other,150% of Medicare + 9.63% HCRA Surcharge,2530.8,45,,2530.8,percent of total billed charges,Critical Access Hospital RCC factor,1912.16,34,,1912.16,percent of total billed charges,Implant Device,1912.16,34,,1912.16,percent of total billed charges,Implant Device,1912.16,34,,1912.16,percent of total billed charges,Implant Device,1912.16,34,,1912.16,percent of total billed charges,Implant Device,1912.16,34,,1912.16,percent of total billed charges,Implant Device,2783.88,,,2783.88,Other,110% of Medicare,1968.4,35,,1968.4,percent of total billed charges,Implant Device,1912.16,34,"Charges > $500, x 34%",1912.16,percent of total billed charges,Implant Device,1968.4,35,,1968.4,percent of total billed charges,Implant Device,1968.4,35,,1968.4,percent of total billed charges,Implant Device,1968.4,35,,1968.4,percent of total billed charges,Implant Device,1968.4,35,,1968.4,percent of total billed charges,Implant Device,1968.4,35,,1968.4,percent of total billed charges,Implant Device,2249.6,40,,2249.6,percent of total billed charges,Implant Device,1968.4,70,,1968.4,percent of total billed charges,All Other,1912.16,34,,1912.16,percent of total billed charges,Implant Device,1912.16,34,,1912.16,percent of total billed charges,Implant Device,1968.4,35,,1968.4,percent of total billed charges,Implant Device,1968.4,35,,1968.4,percent of total billed charges,Implant Device,1968.4,35,,1968.4,percent of total billed charges,Implant Device,1968.4,35,,1968.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1912.16,34,"If Charge > 2,000, then 34 percent",1912.16,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4161.77,
ALLERGAN 1518128 ALLODERM 8X16CM RTU MED,C1781,HCPCS,,79009573,CDM,278,RC,,,both,,,15309,11328.7,,,11328.7,Other,150% of Medicare + 9.63% HCRA Surcharge,6889.05,45,,6889.05,percent of total billed charges,Critical Access Hospital RCC factor,5205.06,34,,5205.06,percent of total billed charges,Implant Device,5205.06,34,,5205.06,percent of total billed charges,Implant Device,5205.06,34,,5205.06,percent of total billed charges,Implant Device,5205.06,34,,5205.06,percent of total billed charges,Implant Device,5205.06,34,,5205.06,percent of total billed charges,Implant Device,7577.96,,,7577.96,Other,110% of Medicare,5358.15,35,,5358.15,percent of total billed charges,Implant Device,5205.06,34,"Charges > $500, x 34%",5205.06,percent of total billed charges,Implant Device,5358.15,35,,5358.15,percent of total billed charges,Implant Device,5358.15,35,,5358.15,percent of total billed charges,Implant Device,5358.15,35,,5358.15,percent of total billed charges,Implant Device,5358.15,35,,5358.15,percent of total billed charges,Implant Device,5358.15,35,,5358.15,percent of total billed charges,Implant Device,6123.6,40,,6123.6,percent of total billed charges,Implant Device,5358.15,70,,5358.15,percent of total billed charges,All Other,5205.06,34,,5205.06,percent of total billed charges,Implant Device,5205.06,34,,5205.06,percent of total billed charges,Implant Device,5358.15,35,,5358.15,percent of total billed charges,Implant Device,5358.15,35,,5358.15,percent of total billed charges,Implant Device,5358.15,35,,5358.15,percent of total billed charges,Implant Device,5358.15,35,,5358.15,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,5205.06,34,"If Charge > 2,000, then 34 percent",5205.06,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,11328.7,
DEPUY 1516-50-214 TIB INSERT SIZE 2 14MM,C1776,HCPCS,,79009574,CDM,278,RC,,,both,,,5624,4161.77,,,4161.77,Other,150% of Medicare + 9.63% HCRA Surcharge,2530.8,45,,2530.8,percent of total billed charges,Critical Access Hospital RCC factor,1912.16,34,,1912.16,percent of total billed charges,Implant Device,1912.16,34,,1912.16,percent of total billed charges,Implant Device,1912.16,34,,1912.16,percent of total billed charges,Implant Device,1912.16,34,,1912.16,percent of total billed charges,Implant Device,1912.16,34,,1912.16,percent of total billed charges,Implant Device,2783.88,,,2783.88,Other,110% of Medicare,1968.4,35,,1968.4,percent of total billed charges,Implant Device,1912.16,34,"Charges > $500, x 34%",1912.16,percent of total billed charges,Implant Device,1968.4,35,,1968.4,percent of total billed charges,Implant Device,1968.4,35,,1968.4,percent of total billed charges,Implant Device,1968.4,35,,1968.4,percent of total billed charges,Implant Device,1968.4,35,,1968.4,percent of total billed charges,Implant Device,1968.4,35,,1968.4,percent of total billed charges,Implant Device,2249.6,40,,2249.6,percent of total billed charges,Implant Device,1968.4,70,,1968.4,percent of total billed charges,All Other,1912.16,34,,1912.16,percent of total billed charges,Implant Device,1912.16,34,,1912.16,percent of total billed charges,Implant Device,1968.4,35,,1968.4,percent of total billed charges,Implant Device,1968.4,35,,1968.4,percent of total billed charges,Implant Device,1968.4,35,,1968.4,percent of total billed charges,Implant Device,1968.4,35,,1968.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1912.16,34,"If Charge > 2,000, then 34 percent",1912.16,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4161.77,
ZIMMER 00-5950-016-02 FEM COMPONENT SZ F,C1776,HCPCS,,79009575,CDM,278,RC,,,both,,,6300,4662.02,,,4662.02,Other,150% of Medicare + 9.63% HCRA Surcharge,2835,45,,2835,percent of total billed charges,Critical Access Hospital RCC factor,2142,34,,2142,percent of total billed charges,Implant Device,2142,34,,2142,percent of total billed charges,Implant Device,2142,34,,2142,percent of total billed charges,Implant Device,2142,34,,2142,percent of total billed charges,Implant Device,2142,34,,2142,percent of total billed charges,Implant Device,3118.5,,,3118.5,Other,110% of Medicare,2205,35,,2205,percent of total billed charges,Implant Device,2142,34,"Charges > $500, x 34%",2142,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2520,40,,2520,percent of total billed charges,Implant Device,2205,70,,2205,percent of total billed charges,All Other,2142,34,,2142,percent of total billed charges,Implant Device,2142,34,,2142,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2142,34,"If Charge > 2,000, then 34 percent",2142,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4662.02,
ZIMMER 00-5750-016-01 FEM COMPONENT SZ F,C1776,HCPCS,,79009576,CDM,278,RC,,,both,,,6300,4662.02,,,4662.02,Other,150% of Medicare + 9.63% HCRA Surcharge,2835,45,,2835,percent of total billed charges,Critical Access Hospital RCC factor,2142,34,,2142,percent of total billed charges,Implant Device,2142,34,,2142,percent of total billed charges,Implant Device,2142,34,,2142,percent of total billed charges,Implant Device,2142,34,,2142,percent of total billed charges,Implant Device,2142,34,,2142,percent of total billed charges,Implant Device,3118.5,,,3118.5,Other,110% of Medicare,2205,35,,2205,percent of total billed charges,Implant Device,2142,34,"Charges > $500, x 34%",2142,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2520,40,,2520,percent of total billed charges,Implant Device,2205,70,,2205,percent of total billed charges,All Other,2142,34,,2142,percent of total billed charges,Implant Device,2142,34,,2142,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2142,34,"If Charge > 2,000, then 34 percent",2142,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4662.02,
ZIMMER 00-5976-050-10 ART SURF SZ 10MM,C1776,HCPCS,,79009577,CDM,278,RC,,,both,,,2250,1665.01,,,1665.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1012.5,45,,1012.5,percent of total billed charges,Critical Access Hospital RCC factor,765,34,,765,percent of total billed charges,Implant Device,765,34,,765,percent of total billed charges,Implant Device,765,34,,765,percent of total billed charges,Implant Device,765,34,,765,percent of total billed charges,Implant Device,765,34,,765,percent of total billed charges,Implant Device,1113.75,,,1113.75,Other,110% of Medicare,787.5,35,,787.5,percent of total billed charges,Implant Device,765,34,"Charges > $500, x 34%",765,percent of total billed charges,Implant Device,787.5,35,,787.5,percent of total billed charges,Implant Device,787.5,35,,787.5,percent of total billed charges,Implant Device,787.5,35,,787.5,percent of total billed charges,Implant Device,787.5,35,,787.5,percent of total billed charges,Implant Device,787.5,35,,787.5,percent of total billed charges,Implant Device,900,40,,900,percent of total billed charges,Implant Device,787.5,70,,787.5,percent of total billed charges,All Other,765,34,,765,percent of total billed charges,Implant Device,765,34,,765,percent of total billed charges,Implant Device,787.5,35,,787.5,percent of total billed charges,Implant Device,787.5,35,,787.5,percent of total billed charges,Implant Device,787.5,35,,787.5,percent of total billed charges,Implant Device,787.5,35,,787.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,765,34,"If Charge > 2,000, then 34 percent",765,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1665.01,
ZIMMER 00-5950-017-01 FEM COMPONENT SZ G,C1776,HCPCS,,79009578,CDM,278,RC,,,both,,,6300,4662.02,,,4662.02,Other,150% of Medicare + 9.63% HCRA Surcharge,2835,45,,2835,percent of total billed charges,Critical Access Hospital RCC factor,2142,34,,2142,percent of total billed charges,Implant Device,2142,34,,2142,percent of total billed charges,Implant Device,2142,34,,2142,percent of total billed charges,Implant Device,2142,34,,2142,percent of total billed charges,Implant Device,2142,34,,2142,percent of total billed charges,Implant Device,3118.5,,,3118.5,Other,110% of Medicare,2205,35,,2205,percent of total billed charges,Implant Device,2142,34,"Charges > $500, x 34%",2142,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2520,40,,2520,percent of total billed charges,Implant Device,2205,70,,2205,percent of total billed charges,All Other,2142,34,,2142,percent of total billed charges,Implant Device,2142,34,,2142,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2142,34,"If Charge > 2,000, then 34 percent",2142,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4662.02,
DEPUY 1516-50-412 TIB INSERT SZ 4 12MM,C1776,HCPCS,,79009579,CDM,278,RC,,,both,,,5400,3996.01,,,3996.01,Other,150% of Medicare + 9.63% HCRA Surcharge,2430,45,,2430,percent of total billed charges,Critical Access Hospital RCC factor,1836,34,,1836,percent of total billed charges,Implant Device,1836,34,,1836,percent of total billed charges,Implant Device,1836,34,,1836,percent of total billed charges,Implant Device,1836,34,,1836,percent of total billed charges,Implant Device,1836,34,,1836,percent of total billed charges,Implant Device,2673,,,2673,Other,110% of Medicare,1890,35,,1890,percent of total billed charges,Implant Device,1836,34,"Charges > $500, x 34%",1836,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,2160,40,,2160,percent of total billed charges,Implant Device,1890,70,,1890,percent of total billed charges,All Other,1836,34,,1836,percent of total billed charges,Implant Device,1836,34,,1836,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1836,34,"If Charge > 2,000, then 34 percent",1836,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3996.01,
STRYKER 602720 CANN SCREW 6.5X120MM,C1713,HCPCS,,79009580,CDM,278,RC,,,both,,,1285,950.9,,,950.9,Other,150% of Medicare + 9.63% HCRA Surcharge,578.25,45,,578.25,percent of total billed charges,Critical Access Hospital RCC factor,436.9,34,,436.9,percent of total billed charges,Implant Device,436.9,34,,436.9,percent of total billed charges,Implant Device,436.9,34,,436.9,percent of total billed charges,Implant Device,436.9,34,,436.9,percent of total billed charges,Implant Device,436.9,34,,436.9,percent of total billed charges,Implant Device,636.08,,,636.08,Other,110% of Medicare,449.75,35,,449.75,percent of total billed charges,Implant Device,436.9,34,"Charges > $500, x 34%",436.9,percent of total billed charges,Implant Device,449.75,35,,449.75,percent of total billed charges,Implant Device,449.75,35,,449.75,percent of total billed charges,Implant Device,449.75,35,,449.75,percent of total billed charges,Implant Device,449.75,35,,449.75,percent of total billed charges,Implant Device,449.75,35,,449.75,percent of total billed charges,Implant Device,514,40,,514,percent of total billed charges,Implant Device,449.75,70,,449.75,percent of total billed charges,All Other,436.9,34,,436.9,percent of total billed charges,Implant Device,436.9,34,,436.9,percent of total billed charges,Implant Device,449.75,35,,449.75,percent of total billed charges,Implant Device,449.75,35,,449.75,percent of total billed charges,Implant Device,449.75,35,,449.75,percent of total billed charges,Implant Device,449.75,35,,449.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,950.9,
ACUMED TR-S0802-S RADIAL STEM 8X2MM,C1776,HCPCS,,79009581,CDM,278,RC,,,both,,,6069,4491.08,,,4491.08,Other,150% of Medicare + 9.63% HCRA Surcharge,2731.05,45,,2731.05,percent of total billed charges,Critical Access Hospital RCC factor,2063.46,34,,2063.46,percent of total billed charges,Implant Device,2063.46,34,,2063.46,percent of total billed charges,Implant Device,2063.46,34,,2063.46,percent of total billed charges,Implant Device,2063.46,34,,2063.46,percent of total billed charges,Implant Device,2063.46,34,,2063.46,percent of total billed charges,Implant Device,3004.16,,,3004.16,Other,110% of Medicare,2124.15,35,,2124.15,percent of total billed charges,Implant Device,2063.46,34,"Charges > $500, x 34%",2063.46,percent of total billed charges,Implant Device,2124.15,35,,2124.15,percent of total billed charges,Implant Device,2124.15,35,,2124.15,percent of total billed charges,Implant Device,2124.15,35,,2124.15,percent of total billed charges,Implant Device,2124.15,35,,2124.15,percent of total billed charges,Implant Device,2124.15,35,,2124.15,percent of total billed charges,Implant Device,2427.6,40,,2427.6,percent of total billed charges,Implant Device,2124.15,70,,2124.15,percent of total billed charges,All Other,2063.46,34,,2063.46,percent of total billed charges,Implant Device,2063.46,34,,2063.46,percent of total billed charges,Implant Device,2124.15,35,,2124.15,percent of total billed charges,Implant Device,2124.15,35,,2124.15,percent of total billed charges,Implant Device,2124.15,35,,2124.15,percent of total billed charges,Implant Device,2124.15,35,,2124.15,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2063.46,34,"If Charge > 2,000, then 34 percent",2063.46,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4491.08,
ACUMED 5001-0224R-S RADIAL HEAD RT 24MM,C1776,HCPCS,,79009582,CDM,278,RC,,,both,,,11871,8784.57,,,8784.57,Other,150% of Medicare + 9.63% HCRA Surcharge,5341.95,45,,5341.95,percent of total billed charges,Critical Access Hospital RCC factor,4036.14,34,,4036.14,percent of total billed charges,Implant Device,4036.14,34,,4036.14,percent of total billed charges,Implant Device,4036.14,34,,4036.14,percent of total billed charges,Implant Device,4036.14,34,,4036.14,percent of total billed charges,Implant Device,4036.14,34,,4036.14,percent of total billed charges,Implant Device,5876.15,,,5876.15,Other,110% of Medicare,4154.85,35,,4154.85,percent of total billed charges,Implant Device,4036.14,34,"Charges > $500, x 34%",4036.14,percent of total billed charges,Implant Device,4154.85,35,,4154.85,percent of total billed charges,Implant Device,4154.85,35,,4154.85,percent of total billed charges,Implant Device,4154.85,35,,4154.85,percent of total billed charges,Implant Device,4154.85,35,,4154.85,percent of total billed charges,Implant Device,4154.85,35,,4154.85,percent of total billed charges,Implant Device,4748.4,40,,4748.4,percent of total billed charges,Implant Device,4154.85,70,,4154.85,percent of total billed charges,All Other,4036.14,34,,4036.14,percent of total billed charges,Implant Device,4036.14,34,,4036.14,percent of total billed charges,Implant Device,4154.85,35,,4154.85,percent of total billed charges,Implant Device,4154.85,35,,4154.85,percent of total billed charges,Implant Device,4154.85,35,,4154.85,percent of total billed charges,Implant Device,4154.85,35,,4154.85,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,4036.14,34,"If Charge > 2,000, then 34 percent",4036.14,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,8784.57,
ARTHREX ABS-30001S DX MATRIX THICK 5X5CM,C1713,HCPCS,,79009583,CDM,278,RC,,,both,,,4950,3663.01,,,3663.01,Other,150% of Medicare + 9.63% HCRA Surcharge,2227.5,45,,2227.5,percent of total billed charges,Critical Access Hospital RCC factor,1683,34,,1683,percent of total billed charges,Implant Device,1683,34,,1683,percent of total billed charges,Implant Device,1683,34,,1683,percent of total billed charges,Implant Device,1683,34,,1683,percent of total billed charges,Implant Device,1683,34,,1683,percent of total billed charges,Implant Device,2450.25,,,2450.25,Other,110% of Medicare,1732.5,35,,1732.5,percent of total billed charges,Implant Device,1683,34,"Charges > $500, x 34%",1683,percent of total billed charges,Implant Device,1732.5,35,,1732.5,percent of total billed charges,Implant Device,1732.5,35,,1732.5,percent of total billed charges,Implant Device,1732.5,35,,1732.5,percent of total billed charges,Implant Device,1732.5,35,,1732.5,percent of total billed charges,Implant Device,1732.5,35,,1732.5,percent of total billed charges,Implant Device,1980,40,,1980,percent of total billed charges,Implant Device,1732.5,70,,1732.5,percent of total billed charges,All Other,1683,34,,1683,percent of total billed charges,Implant Device,1683,34,,1683,percent of total billed charges,Implant Device,1732.5,35,,1732.5,percent of total billed charges,Implant Device,1732.5,35,,1732.5,percent of total billed charges,Implant Device,1732.5,35,,1732.5,percent of total billed charges,Implant Device,1732.5,35,,1732.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1683,34,"If Charge > 2,000, then 34 percent",1683,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3663.01,
STRYKER 58-23020 BONE SCREW 2.3X20MM,C1713,HCPCS,,79009584,CDM,278,RC,,,both,,,426,315.24,,,315.24,Other,150% of Medicare + 9.63% HCRA Surcharge,191.7,45,,191.7,percent of total billed charges,Critical Access Hospital RCC factor,144.84,34,,144.84,percent of total billed charges,Implant Device,144.84,34,,144.84,percent of total billed charges,Implant Device,144.84,34,,144.84,percent of total billed charges,Implant Device,144.84,34,,144.84,percent of total billed charges,Implant Device,144.84,34,,144.84,percent of total billed charges,Implant Device,210.87,,,210.87,Other,110% of Medicare,149.1,35,,149.1,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,149.1,35,,149.1,percent of total billed charges,Implant Device,149.1,35,,149.1,percent of total billed charges,Implant Device,149.1,35,,149.1,percent of total billed charges,Implant Device,149.1,35,,149.1,percent of total billed charges,Implant Device,149.1,35,,149.1,percent of total billed charges,Implant Device,170.4,40,,170.4,percent of total billed charges,Implant Device,149.1,70,,149.1,percent of total billed charges,All Other,144.84,34,,144.84,percent of total billed charges,Implant Device,144.84,34,,144.84,percent of total billed charges,Implant Device,149.1,35,,149.1,percent of total billed charges,Implant Device,149.1,35,,149.1,percent of total billed charges,Implant Device,149.1,35,,149.1,percent of total billed charges,Implant Device,149.1,35,,149.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,315.24,
STRYKER 657448 NON LOCK SCREW 3.5X48MM,C1713,HCPCS,,79009587,CDM,278,RC,,,both,,,269,199.06,,,199.06,Other,150% of Medicare + 9.63% HCRA Surcharge,121.05,45,,121.05,percent of total billed charges,Critical Access Hospital RCC factor,91.46,34,,91.46,percent of total billed charges,Implant Device,91.46,34,,91.46,percent of total billed charges,Implant Device,91.46,34,,91.46,percent of total billed charges,Implant Device,91.46,34,,91.46,percent of total billed charges,Implant Device,91.46,34,,91.46,percent of total billed charges,Implant Device,133.16,,,133.16,Other,110% of Medicare,94.15,35,,94.15,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,94.15,35,,94.15,percent of total billed charges,Implant Device,94.15,35,,94.15,percent of total billed charges,Implant Device,94.15,35,,94.15,percent of total billed charges,Implant Device,94.15,35,,94.15,percent of total billed charges,Implant Device,94.15,35,,94.15,percent of total billed charges,Implant Device,107.6,40,,107.6,percent of total billed charges,Implant Device,94.15,70,,94.15,percent of total billed charges,All Other,91.46,34,,91.46,percent of total billed charges,Implant Device,91.46,34,,91.46,percent of total billed charges,Implant Device,94.15,35,,94.15,percent of total billed charges,Implant Device,94.15,35,,94.15,percent of total billed charges,Implant Device,94.15,35,,94.15,percent of total billed charges,Implant Device,94.15,35,,94.15,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,199.06,
STRYKER 657455 NON LOCK SCREW 3.5X55MM,C1713,HCPCS,,79009588,CDM,278,RC,,,both,,,269,199.06,,,199.06,Other,150% of Medicare + 9.63% HCRA Surcharge,121.05,45,,121.05,percent of total billed charges,Critical Access Hospital RCC factor,91.46,34,,91.46,percent of total billed charges,Implant Device,91.46,34,,91.46,percent of total billed charges,Implant Device,91.46,34,,91.46,percent of total billed charges,Implant Device,91.46,34,,91.46,percent of total billed charges,Implant Device,91.46,34,,91.46,percent of total billed charges,Implant Device,133.16,,,133.16,Other,110% of Medicare,94.15,35,,94.15,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,94.15,35,,94.15,percent of total billed charges,Implant Device,94.15,35,,94.15,percent of total billed charges,Implant Device,94.15,35,,94.15,percent of total billed charges,Implant Device,94.15,35,,94.15,percent of total billed charges,Implant Device,94.15,35,,94.15,percent of total billed charges,Implant Device,107.6,40,,107.6,percent of total billed charges,Implant Device,94.15,70,,94.15,percent of total billed charges,All Other,91.46,34,,91.46,percent of total billed charges,Implant Device,91.46,34,,91.46,percent of total billed charges,Implant Device,94.15,35,,94.15,percent of total billed charges,Implant Device,94.15,35,,94.15,percent of total billed charges,Implant Device,94.15,35,,94.15,percent of total billed charges,Implant Device,94.15,35,,94.15,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,199.06,
PARAGON PDMW-4X4 DERMA COLLAGEN MATRIX,C1713,HCPCS,,79009589,CDM,278,RC,,,both,,,4581,3389.95,,,3389.95,Other,150% of Medicare + 9.63% HCRA Surcharge,2061.45,45,,2061.45,percent of total billed charges,Critical Access Hospital RCC factor,1557.54,34,,1557.54,percent of total billed charges,Implant Device,1557.54,34,,1557.54,percent of total billed charges,Implant Device,1557.54,34,,1557.54,percent of total billed charges,Implant Device,1557.54,34,,1557.54,percent of total billed charges,Implant Device,1557.54,34,,1557.54,percent of total billed charges,Implant Device,2267.6,,,2267.6,Other,110% of Medicare,1603.35,35,,1603.35,percent of total billed charges,Implant Device,1557.54,34,"Charges > $500, x 34%",1557.54,percent of total billed charges,Implant Device,1603.35,35,,1603.35,percent of total billed charges,Implant Device,1603.35,35,,1603.35,percent of total billed charges,Implant Device,1603.35,35,,1603.35,percent of total billed charges,Implant Device,1603.35,35,,1603.35,percent of total billed charges,Implant Device,1603.35,35,,1603.35,percent of total billed charges,Implant Device,1832.4,40,,1832.4,percent of total billed charges,Implant Device,1603.35,70,,1603.35,percent of total billed charges,All Other,1557.54,34,,1557.54,percent of total billed charges,Implant Device,1557.54,34,,1557.54,percent of total billed charges,Implant Device,1603.35,35,,1603.35,percent of total billed charges,Implant Device,1603.35,35,,1603.35,percent of total billed charges,Implant Device,1603.35,35,,1603.35,percent of total billed charges,Implant Device,1603.35,35,,1603.35,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1557.54,34,"If Charge > 2,000, then 34 percent",1557.54,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3389.95,
ZIMMER 14355-12-100 DEG TUBULAR 1/2 PLT,C1713,HCPCS,,79009597,CDM,278,RC,,,both,,,510,377.4,,,377.4,Other,150% of Medicare + 9.63% HCRA Surcharge,229.5,45,,229.5,percent of total billed charges,Critical Access Hospital RCC factor,173.4,34,,173.4,percent of total billed charges,Implant Device,173.4,34,,173.4,percent of total billed charges,Implant Device,173.4,34,,173.4,percent of total billed charges,Implant Device,173.4,34,,173.4,percent of total billed charges,Implant Device,173.4,34,,173.4,percent of total billed charges,Implant Device,252.45,,,252.45,Other,110% of Medicare,178.5,35,,178.5,percent of total billed charges,Implant Device,173.4,34,"Charges > $500, x 34%",173.4,percent of total billed charges,Implant Device,178.5,35,,178.5,percent of total billed charges,Implant Device,178.5,35,,178.5,percent of total billed charges,Implant Device,178.5,35,,178.5,percent of total billed charges,Implant Device,178.5,35,,178.5,percent of total billed charges,Implant Device,178.5,35,,178.5,percent of total billed charges,Implant Device,204,40,,204,percent of total billed charges,Implant Device,178.5,70,,178.5,percent of total billed charges,All Other,173.4,34,,173.4,percent of total billed charges,Implant Device,173.4,34,,173.4,percent of total billed charges,Implant Device,178.5,35,,178.5,percent of total billed charges,Implant Device,178.5,35,,178.5,percent of total billed charges,Implant Device,178.5,35,,178.5,percent of total billed charges,Implant Device,178.5,35,,178.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,377.4,
ZIMMER 8153-41-044 4.0MM CANC SCREW 44MM,C1713,HCPCS,,79009598,CDM,278,RC,,,both,,,270,199.8,,,199.8,Other,150% of Medicare + 9.63% HCRA Surcharge,121.5,45,,121.5,percent of total billed charges,Critical Access Hospital RCC factor,91.8,34,,91.8,percent of total billed charges,Implant Device,91.8,34,,91.8,percent of total billed charges,Implant Device,91.8,34,,91.8,percent of total billed charges,Implant Device,91.8,34,,91.8,percent of total billed charges,Implant Device,91.8,34,,91.8,percent of total billed charges,Implant Device,133.65,,,133.65,Other,110% of Medicare,94.5,35,,94.5,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,94.5,35,,94.5,percent of total billed charges,Implant Device,94.5,35,,94.5,percent of total billed charges,Implant Device,94.5,35,,94.5,percent of total billed charges,Implant Device,94.5,35,,94.5,percent of total billed charges,Implant Device,94.5,35,,94.5,percent of total billed charges,Implant Device,108,40,,108,percent of total billed charges,Implant Device,94.5,70,,94.5,percent of total billed charges,All Other,91.8,34,,91.8,percent of total billed charges,Implant Device,91.8,34,,91.8,percent of total billed charges,Implant Device,94.5,35,,94.5,percent of total billed charges,Implant Device,94.5,35,,94.5,percent of total billed charges,Implant Device,94.5,35,,94.5,percent of total billed charges,Implant Device,94.5,35,,94.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,199.8,
ZIMMER 8146-11-380 HFN LSG SCREW 11X380,C1713,HCPCS,,79009599,CDM,278,RC,,,both,,,11790,8724.63,,,8724.63,Other,150% of Medicare + 9.63% HCRA Surcharge,5305.5,45,,5305.5,percent of total billed charges,Critical Access Hospital RCC factor,4008.6,34,,4008.6,percent of total billed charges,Implant Device,4008.6,34,,4008.6,percent of total billed charges,Implant Device,4008.6,34,,4008.6,percent of total billed charges,Implant Device,4008.6,34,,4008.6,percent of total billed charges,Implant Device,4008.6,34,,4008.6,percent of total billed charges,Implant Device,5836.05,,,5836.05,Other,110% of Medicare,4126.5,35,,4126.5,percent of total billed charges,Implant Device,4008.6,34,"Charges > $500, x 34%",4008.6,percent of total billed charges,Implant Device,4126.5,35,,4126.5,percent of total billed charges,Implant Device,4126.5,35,,4126.5,percent of total billed charges,Implant Device,4126.5,35,,4126.5,percent of total billed charges,Implant Device,4126.5,35,,4126.5,percent of total billed charges,Implant Device,4126.5,35,,4126.5,percent of total billed charges,Implant Device,4716,40,,4716,percent of total billed charges,Implant Device,4126.5,70,,4126.5,percent of total billed charges,All Other,4008.6,34,,4008.6,percent of total billed charges,Implant Device,4008.6,34,,4008.6,percent of total billed charges,Implant Device,4126.5,35,,4126.5,percent of total billed charges,Implant Device,4126.5,35,,4126.5,percent of total billed charges,Implant Device,4126.5,35,,4126.5,percent of total billed charges,Implant Device,4126.5,35,,4126.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,4008.6,34,"If Charge > 2,000, then 34 percent",4008.6,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,8724.63,
ZIMMER 8145-50-044 CORT BONE SCREW 5X44,C1713,HCPCS,,79009600,CDM,278,RC,,,both,,,1050,777,,,777,Other,150% of Medicare + 9.63% HCRA Surcharge,472.5,45,,472.5,percent of total billed charges,Critical Access Hospital RCC factor,357,34,,357,percent of total billed charges,Implant Device,357,34,,357,percent of total billed charges,Implant Device,357,34,,357,percent of total billed charges,Implant Device,357,34,,357,percent of total billed charges,Implant Device,357,34,,357,percent of total billed charges,Implant Device,519.75,,,519.75,Other,110% of Medicare,367.5,35,,367.5,percent of total billed charges,Implant Device,357,34,"Charges > $500, x 34%",357,percent of total billed charges,Implant Device,367.5,35,,367.5,percent of total billed charges,Implant Device,367.5,35,,367.5,percent of total billed charges,Implant Device,367.5,35,,367.5,percent of total billed charges,Implant Device,367.5,35,,367.5,percent of total billed charges,Implant Device,367.5,35,,367.5,percent of total billed charges,Implant Device,420,40,,420,percent of total billed charges,Implant Device,367.5,70,,367.5,percent of total billed charges,All Other,357,34,,357,percent of total billed charges,Implant Device,357,34,,357,percent of total billed charges,Implant Device,367.5,35,,367.5,percent of total billed charges,Implant Device,367.5,35,,367.5,percent of total billed charges,Implant Device,367.5,35,,367.5,percent of total billed charges,Implant Device,367.5,35,,367.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,777,
STRYKER 6704-3-081 TROCHANTERIC GRIP PLT,C1713,HCPCS,,79009601,CDM,278,RC,,,both,,,5851,4329.75,,,4329.75,Other,150% of Medicare + 9.63% HCRA Surcharge,2632.95,45,,2632.95,percent of total billed charges,Critical Access Hospital RCC factor,1989.34,34,,1989.34,percent of total billed charges,Implant Device,1989.34,34,,1989.34,percent of total billed charges,Implant Device,1989.34,34,,1989.34,percent of total billed charges,Implant Device,1989.34,34,,1989.34,percent of total billed charges,Implant Device,1989.34,34,,1989.34,percent of total billed charges,Implant Device,2896.25,,,2896.25,Other,110% of Medicare,2047.85,35,,2047.85,percent of total billed charges,Implant Device,1989.34,34,"Charges > $500, x 34%",1989.34,percent of total billed charges,Implant Device,2047.85,35,,2047.85,percent of total billed charges,Implant Device,2047.85,35,,2047.85,percent of total billed charges,Implant Device,2047.85,35,,2047.85,percent of total billed charges,Implant Device,2047.85,35,,2047.85,percent of total billed charges,Implant Device,2047.85,35,,2047.85,percent of total billed charges,Implant Device,2340.4,40,,2340.4,percent of total billed charges,Implant Device,2047.85,70,,2047.85,percent of total billed charges,All Other,1989.34,34,,1989.34,percent of total billed charges,Implant Device,1989.34,34,,1989.34,percent of total billed charges,Implant Device,2047.85,35,,2047.85,percent of total billed charges,Implant Device,2047.85,35,,2047.85,percent of total billed charges,Implant Device,2047.85,35,,2047.85,percent of total billed charges,Implant Device,2047.85,35,,2047.85,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1989.34,34,"If Charge > 2,000, then 34 percent",1989.34,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4329.75,
STRYKER 626987 PLATE-Y 7 HOLE,C1713,HCPCS,,79009605,CDM,278,RC,,,both,,,4572,3383.29,,,3383.29,Other,150% of Medicare + 9.63% HCRA Surcharge,2057.4,45,,2057.4,percent of total billed charges,Critical Access Hospital RCC factor,1554.48,34,,1554.48,percent of total billed charges,Implant Device,1554.48,34,,1554.48,percent of total billed charges,Implant Device,1554.48,34,,1554.48,percent of total billed charges,Implant Device,1554.48,34,,1554.48,percent of total billed charges,Implant Device,1554.48,34,,1554.48,percent of total billed charges,Implant Device,2263.14,,,2263.14,Other,110% of Medicare,1600.2,35,,1600.2,percent of total billed charges,Implant Device,1554.48,34,"Charges > $500, x 34%",1554.48,percent of total billed charges,Implant Device,1600.2,35,,1600.2,percent of total billed charges,Implant Device,1600.2,35,,1600.2,percent of total billed charges,Implant Device,1600.2,35,,1600.2,percent of total billed charges,Implant Device,1600.2,35,,1600.2,percent of total billed charges,Implant Device,1600.2,35,,1600.2,percent of total billed charges,Implant Device,1828.8,40,,1828.8,percent of total billed charges,Implant Device,1600.2,70,,1600.2,percent of total billed charges,All Other,1554.48,34,,1554.48,percent of total billed charges,Implant Device,1554.48,34,,1554.48,percent of total billed charges,Implant Device,1600.2,35,,1600.2,percent of total billed charges,Implant Device,1600.2,35,,1600.2,percent of total billed charges,Implant Device,1600.2,35,,1600.2,percent of total billed charges,Implant Device,1600.2,35,,1600.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1554.48,34,"If Charge > 2,000, then 34 percent",1554.48,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3383.29,
STRYKER 656010 LOCKING SCREW 2.4X10MM,C1713,HCPCS,,79009606,CDM,278,RC,,,both,,,480,355.2,,,355.2,Other,150% of Medicare + 9.63% HCRA Surcharge,216,45,,216,percent of total billed charges,Critical Access Hospital RCC factor,163.2,34,,163.2,percent of total billed charges,Implant Device,163.2,34,,163.2,percent of total billed charges,Implant Device,163.2,34,,163.2,percent of total billed charges,Implant Device,163.2,34,,163.2,percent of total billed charges,Implant Device,163.2,34,,163.2,percent of total billed charges,Implant Device,237.6,,,237.6,Other,110% of Medicare,168,35,,168,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,192,40,,192,percent of total billed charges,Implant Device,168,70,,168,percent of total billed charges,All Other,163.2,34,,163.2,percent of total billed charges,Implant Device,163.2,34,,163.2,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,355.2,
STRYKER 656012 LOCKING SCREW 2.4X12MM,C1713,HCPCS,,79009607,CDM,278,RC,,,both,,,443,327.82,,,327.82,Other,150% of Medicare + 9.63% HCRA Surcharge,199.35,45,,199.35,percent of total billed charges,Critical Access Hospital RCC factor,150.62,34,,150.62,percent of total billed charges,Implant Device,150.62,34,,150.62,percent of total billed charges,Implant Device,150.62,34,,150.62,percent of total billed charges,Implant Device,150.62,34,,150.62,percent of total billed charges,Implant Device,150.62,34,,150.62,percent of total billed charges,Implant Device,219.29,,,219.29,Other,110% of Medicare,155.05,35,,155.05,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,155.05,35,,155.05,percent of total billed charges,Implant Device,155.05,35,,155.05,percent of total billed charges,Implant Device,155.05,35,,155.05,percent of total billed charges,Implant Device,155.05,35,,155.05,percent of total billed charges,Implant Device,155.05,35,,155.05,percent of total billed charges,Implant Device,177.2,40,,177.2,percent of total billed charges,Implant Device,155.05,70,,155.05,percent of total billed charges,All Other,150.62,34,,150.62,percent of total billed charges,Implant Device,150.62,34,,150.62,percent of total billed charges,Implant Device,155.05,35,,155.05,percent of total billed charges,Implant Device,155.05,35,,155.05,percent of total billed charges,Implant Device,155.05,35,,155.05,percent of total billed charges,Implant Device,155.05,35,,155.05,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,327.82,
STRYKER 656014 LOCKING SCREW 2.4X14MM,C1713,HCPCS,,79009608,CDM,278,RC,,,both,,,443,327.82,,,327.82,Other,150% of Medicare + 9.63% HCRA Surcharge,199.35,45,,199.35,percent of total billed charges,Critical Access Hospital RCC factor,150.62,34,,150.62,percent of total billed charges,Implant Device,150.62,34,,150.62,percent of total billed charges,Implant Device,150.62,34,,150.62,percent of total billed charges,Implant Device,150.62,34,,150.62,percent of total billed charges,Implant Device,150.62,34,,150.62,percent of total billed charges,Implant Device,219.29,,,219.29,Other,110% of Medicare,155.05,35,,155.05,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,155.05,35,,155.05,percent of total billed charges,Implant Device,155.05,35,,155.05,percent of total billed charges,Implant Device,155.05,35,,155.05,percent of total billed charges,Implant Device,155.05,35,,155.05,percent of total billed charges,Implant Device,155.05,35,,155.05,percent of total billed charges,Implant Device,177.2,40,,177.2,percent of total billed charges,Implant Device,155.05,70,,155.05,percent of total billed charges,All Other,150.62,34,,150.62,percent of total billed charges,Implant Device,150.62,34,,150.62,percent of total billed charges,Implant Device,155.05,35,,155.05,percent of total billed charges,Implant Device,155.05,35,,155.05,percent of total billed charges,Implant Device,155.05,35,,155.05,percent of total billed charges,Implant Device,155.05,35,,155.05,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,327.82,
ARTHREX AR-8919DS CMC TIGHROPE IMPLANT,C1713,HCPCS,,79009609,CDM,278,RC,,,both,,,2685,1986.91,,,1986.91,Other,150% of Medicare + 9.63% HCRA Surcharge,1208.25,45,,1208.25,percent of total billed charges,Critical Access Hospital RCC factor,912.9,34,,912.9,percent of total billed charges,Implant Device,912.9,34,,912.9,percent of total billed charges,Implant Device,912.9,34,,912.9,percent of total billed charges,Implant Device,912.9,34,,912.9,percent of total billed charges,Implant Device,912.9,34,,912.9,percent of total billed charges,Implant Device,1329.08,,,1329.08,Other,110% of Medicare,939.75,35,,939.75,percent of total billed charges,Implant Device,912.9,34,"Charges > $500, x 34%",912.9,percent of total billed charges,Implant Device,939.75,35,,939.75,percent of total billed charges,Implant Device,939.75,35,,939.75,percent of total billed charges,Implant Device,939.75,35,,939.75,percent of total billed charges,Implant Device,939.75,35,,939.75,percent of total billed charges,Implant Device,939.75,35,,939.75,percent of total billed charges,Implant Device,1074,40,,1074,percent of total billed charges,Implant Device,939.75,70,,939.75,percent of total billed charges,All Other,912.9,34,,912.9,percent of total billed charges,Implant Device,912.9,34,,912.9,percent of total billed charges,Implant Device,939.75,35,,939.75,percent of total billed charges,Implant Device,939.75,35,,939.75,percent of total billed charges,Implant Device,939.75,35,,939.75,percent of total billed charges,Implant Device,939.75,35,,939.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,912.9,34,"If Charge > 2,000, then 34 percent",912.9,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1986.91,
STRYKER 629263 HUMERUS PLATE DISTAL 80MM,C1713,HCPCS,,79009610,CDM,278,RC,,,both,,,4582,3390.69,,,3390.69,Other,150% of Medicare + 9.63% HCRA Surcharge,2061.9,45,,2061.9,percent of total billed charges,Critical Access Hospital RCC factor,1557.88,34,,1557.88,percent of total billed charges,Implant Device,1557.88,34,,1557.88,percent of total billed charges,Implant Device,1557.88,34,,1557.88,percent of total billed charges,Implant Device,1557.88,34,,1557.88,percent of total billed charges,Implant Device,1557.88,34,,1557.88,percent of total billed charges,Implant Device,2268.09,,,2268.09,Other,110% of Medicare,1603.7,35,,1603.7,percent of total billed charges,Implant Device,1557.88,34,"Charges > $500, x 34%",1557.88,percent of total billed charges,Implant Device,1603.7,35,,1603.7,percent of total billed charges,Implant Device,1603.7,35,,1603.7,percent of total billed charges,Implant Device,1603.7,35,,1603.7,percent of total billed charges,Implant Device,1603.7,35,,1603.7,percent of total billed charges,Implant Device,1603.7,35,,1603.7,percent of total billed charges,Implant Device,1832.8,40,,1832.8,percent of total billed charges,Implant Device,1603.7,70,,1603.7,percent of total billed charges,All Other,1557.88,34,,1557.88,percent of total billed charges,Implant Device,1557.88,34,,1557.88,percent of total billed charges,Implant Device,1603.7,35,,1603.7,percent of total billed charges,Implant Device,1603.7,35,,1603.7,percent of total billed charges,Implant Device,1603.7,35,,1603.7,percent of total billed charges,Implant Device,1603.7,35,,1603.7,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1557.88,34,"If Charge > 2,000, then 34 percent",1557.88,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3390.69,
STRYKER 629283 HUMERUS PLATE DISTAL 69MM,C1713,HCPCS,,79009611,CDM,278,RC,,,both,,,2766,2046.85,,,2046.85,Other,150% of Medicare + 9.63% HCRA Surcharge,1244.7,45,,1244.7,percent of total billed charges,Critical Access Hospital RCC factor,940.44,34,,940.44,percent of total billed charges,Implant Device,940.44,34,,940.44,percent of total billed charges,Implant Device,940.44,34,,940.44,percent of total billed charges,Implant Device,940.44,34,,940.44,percent of total billed charges,Implant Device,940.44,34,,940.44,percent of total billed charges,Implant Device,1369.17,,,1369.17,Other,110% of Medicare,968.1,35,,968.1,percent of total billed charges,Implant Device,940.44,34,"Charges > $500, x 34%",940.44,percent of total billed charges,Implant Device,968.1,35,,968.1,percent of total billed charges,Implant Device,968.1,35,,968.1,percent of total billed charges,Implant Device,968.1,35,,968.1,percent of total billed charges,Implant Device,968.1,35,,968.1,percent of total billed charges,Implant Device,968.1,35,,968.1,percent of total billed charges,Implant Device,1106.4,40,,1106.4,percent of total billed charges,Implant Device,968.1,70,,968.1,percent of total billed charges,All Other,940.44,34,,940.44,percent of total billed charges,Implant Device,940.44,34,,940.44,percent of total billed charges,Implant Device,968.1,35,,968.1,percent of total billed charges,Implant Device,968.1,35,,968.1,percent of total billed charges,Implant Device,968.1,35,,968.1,percent of total billed charges,Implant Device,968.1,35,,968.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,940.44,34,"If Charge > 2,000, then 34 percent",940.44,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2046.85,
STRYKER 657430 BONE SCREW 3.5X30MM,C1713,HCPCS,,79009612,CDM,278,RC,,,both,,,294,217.56,,,217.56,Other,150% of Medicare + 9.63% HCRA Surcharge,132.3,45,,132.3,percent of total billed charges,Critical Access Hospital RCC factor,99.96,34,,99.96,percent of total billed charges,Implant Device,99.96,34,,99.96,percent of total billed charges,Implant Device,99.96,34,,99.96,percent of total billed charges,Implant Device,99.96,34,,99.96,percent of total billed charges,Implant Device,99.96,34,,99.96,percent of total billed charges,Implant Device,145.53,,,145.53,Other,110% of Medicare,102.9,35,,102.9,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,102.9,35,,102.9,percent of total billed charges,Implant Device,102.9,35,,102.9,percent of total billed charges,Implant Device,102.9,35,,102.9,percent of total billed charges,Implant Device,102.9,35,,102.9,percent of total billed charges,Implant Device,102.9,35,,102.9,percent of total billed charges,Implant Device,117.6,40,,117.6,percent of total billed charges,Implant Device,102.9,70,,102.9,percent of total billed charges,All Other,99.96,34,,99.96,percent of total billed charges,Implant Device,99.96,34,,99.96,percent of total billed charges,Implant Device,102.9,35,,102.9,percent of total billed charges,Implant Device,102.9,35,,102.9,percent of total billed charges,Implant Device,102.9,35,,102.9,percent of total billed charges,Implant Device,102.9,35,,102.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,217.56,
STRYKER 657438 BONE SCREW 3.5X38MM,C1713,HCPCS,,79009613,CDM,278,RC,,,both,,,294,217.56,,,217.56,Other,150% of Medicare + 9.63% HCRA Surcharge,132.3,45,,132.3,percent of total billed charges,Critical Access Hospital RCC factor,99.96,34,,99.96,percent of total billed charges,Implant Device,99.96,34,,99.96,percent of total billed charges,Implant Device,99.96,34,,99.96,percent of total billed charges,Implant Device,99.96,34,,99.96,percent of total billed charges,Implant Device,99.96,34,,99.96,percent of total billed charges,Implant Device,145.53,,,145.53,Other,110% of Medicare,102.9,35,,102.9,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,102.9,35,,102.9,percent of total billed charges,Implant Device,102.9,35,,102.9,percent of total billed charges,Implant Device,102.9,35,,102.9,percent of total billed charges,Implant Device,102.9,35,,102.9,percent of total billed charges,Implant Device,102.9,35,,102.9,percent of total billed charges,Implant Device,117.6,40,,117.6,percent of total billed charges,Implant Device,102.9,70,,102.9,percent of total billed charges,All Other,99.96,34,,99.96,percent of total billed charges,Implant Device,99.96,34,,99.96,percent of total billed charges,Implant Device,102.9,35,,102.9,percent of total billed charges,Implant Device,102.9,35,,102.9,percent of total billed charges,Implant Device,102.9,35,,102.9,percent of total billed charges,Implant Device,102.9,35,,102.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,217.56,
STRYKER 657465 BONE SCREW 3.5X65MM,C1713,HCPCS,,79009614,CDM,278,RC,,,both,,,269,199.06,,,199.06,Other,150% of Medicare + 9.63% HCRA Surcharge,121.05,45,,121.05,percent of total billed charges,Critical Access Hospital RCC factor,91.46,34,,91.46,percent of total billed charges,Implant Device,91.46,34,,91.46,percent of total billed charges,Implant Device,91.46,34,,91.46,percent of total billed charges,Implant Device,91.46,34,,91.46,percent of total billed charges,Implant Device,91.46,34,,91.46,percent of total billed charges,Implant Device,133.16,,,133.16,Other,110% of Medicare,94.15,35,,94.15,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,94.15,35,,94.15,percent of total billed charges,Implant Device,94.15,35,,94.15,percent of total billed charges,Implant Device,94.15,35,,94.15,percent of total billed charges,Implant Device,94.15,35,,94.15,percent of total billed charges,Implant Device,94.15,35,,94.15,percent of total billed charges,Implant Device,107.6,40,,107.6,percent of total billed charges,Implant Device,94.15,70,,94.15,percent of total billed charges,All Other,91.46,34,,91.46,percent of total billed charges,Implant Device,91.46,34,,91.46,percent of total billed charges,Implant Device,94.15,35,,94.15,percent of total billed charges,Implant Device,94.15,35,,94.15,percent of total billed charges,Implant Device,94.15,35,,94.15,percent of total billed charges,Implant Device,94.15,35,,94.15,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,199.06,
DEPUY 241.421 TUBLAR PLATE 12 HOLE,C1713,HCPCS,,79009615,CDM,278,RC,,,both,,,510,377.4,,,377.4,Other,150% of Medicare + 9.63% HCRA Surcharge,229.5,45,,229.5,percent of total billed charges,Critical Access Hospital RCC factor,173.4,34,,173.4,percent of total billed charges,Implant Device,173.4,34,,173.4,percent of total billed charges,Implant Device,173.4,34,,173.4,percent of total billed charges,Implant Device,173.4,34,,173.4,percent of total billed charges,Implant Device,173.4,34,,173.4,percent of total billed charges,Implant Device,252.45,,,252.45,Other,110% of Medicare,178.5,35,,178.5,percent of total billed charges,Implant Device,173.4,34,"Charges > $500, x 34%",173.4,percent of total billed charges,Implant Device,178.5,35,,178.5,percent of total billed charges,Implant Device,178.5,35,,178.5,percent of total billed charges,Implant Device,178.5,35,,178.5,percent of total billed charges,Implant Device,178.5,35,,178.5,percent of total billed charges,Implant Device,178.5,35,,178.5,percent of total billed charges,Implant Device,204,40,,204,percent of total billed charges,Implant Device,178.5,70,,178.5,percent of total billed charges,All Other,173.4,34,,173.4,percent of total billed charges,Implant Device,173.4,34,,173.4,percent of total billed charges,Implant Device,178.5,35,,178.5,percent of total billed charges,Implant Device,178.5,35,,178.5,percent of total billed charges,Implant Device,178.5,35,,178.5,percent of total billed charges,Implant Device,178.5,35,,178.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,377.4,
DEPUY 204.860 CORTEX SCREW 3.5X16MM,C1713,HCPCS,,79009616,CDM,278,RC,,,both,,,59,43.66,,,43.66,Other,150% of Medicare + 9.63% HCRA Surcharge,26.55,45,,26.55,percent of total billed charges,Critical Access Hospital RCC factor,20.06,34,,20.06,percent of total billed charges,Implant Device,20.06,34,,20.06,percent of total billed charges,Implant Device,20.06,34,,20.06,percent of total billed charges,Implant Device,20.06,34,,20.06,percent of total billed charges,Implant Device,20.06,34,,20.06,percent of total billed charges,Implant Device,29.21,,,29.21,Other,110% of Medicare,20.65,35,,20.65,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,20.65,35,,20.65,percent of total billed charges,Implant Device,20.65,35,,20.65,percent of total billed charges,Implant Device,20.65,35,,20.65,percent of total billed charges,Implant Device,20.65,35,,20.65,percent of total billed charges,Implant Device,20.65,35,,20.65,percent of total billed charges,Implant Device,23.6,40,,23.6,percent of total billed charges,Implant Device,20.65,70,,20.65,percent of total billed charges,All Other,20.06,34,,20.06,percent of total billed charges,Implant Device,20.06,34,,20.06,percent of total billed charges,Implant Device,20.65,35,,20.65,percent of total billed charges,Implant Device,20.65,35,,20.65,percent of total billed charges,Implant Device,20.65,35,,20.65,percent of total billed charges,Implant Device,20.65,35,,20.65,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,43.66,
DEPUY 206.010 CANCELLOUS SCREW 4.0X10MM,C1713,HCPCS,,79009617,CDM,278,RC,,,both,,,73,54.02,,,54.02,Other,150% of Medicare + 9.63% HCRA Surcharge,32.85,45,,32.85,percent of total billed charges,Critical Access Hospital RCC factor,24.82,34,,24.82,percent of total billed charges,Implant Device,24.82,34,,24.82,percent of total billed charges,Implant Device,24.82,34,,24.82,percent of total billed charges,Implant Device,24.82,34,,24.82,percent of total billed charges,Implant Device,24.82,34,,24.82,percent of total billed charges,Implant Device,36.14,,,36.14,Other,110% of Medicare,25.55,35,,25.55,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,25.55,35,,25.55,percent of total billed charges,Implant Device,25.55,35,,25.55,percent of total billed charges,Implant Device,25.55,35,,25.55,percent of total billed charges,Implant Device,25.55,35,,25.55,percent of total billed charges,Implant Device,25.55,35,,25.55,percent of total billed charges,Implant Device,29.2,40,,29.2,percent of total billed charges,Implant Device,25.55,70,,25.55,percent of total billed charges,All Other,24.82,34,,24.82,percent of total billed charges,Implant Device,24.82,34,,24.82,percent of total billed charges,Implant Device,25.55,35,,25.55,percent of total billed charges,Implant Device,25.55,35,,25.55,percent of total billed charges,Implant Device,25.55,35,,25.55,percent of total billed charges,Implant Device,25.55,35,,25.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,54.02,
ZIMMER 00-7711-009-20 M/L TAPER 9 EXT,C1776,HCPCS,,79009620,CDM,278,RC,,,both,,,6900,5106.02,,,5106.02,Other,150% of Medicare + 9.63% HCRA Surcharge,3105,45,,3105,percent of total billed charges,Critical Access Hospital RCC factor,2346,34,,2346,percent of total billed charges,Implant Device,2346,34,,2346,percent of total billed charges,Implant Device,2346,34,,2346,percent of total billed charges,Implant Device,2346,34,,2346,percent of total billed charges,Implant Device,2346,34,,2346,percent of total billed charges,Implant Device,3415.5,,,3415.5,Other,110% of Medicare,2415,35,,2415,percent of total billed charges,Implant Device,2346,34,"Charges > $500, x 34%",2346,percent of total billed charges,Implant Device,2415,35,,2415,percent of total billed charges,Implant Device,2415,35,,2415,percent of total billed charges,Implant Device,2415,35,,2415,percent of total billed charges,Implant Device,2415,35,,2415,percent of total billed charges,Implant Device,2415,35,,2415,percent of total billed charges,Implant Device,2760,40,,2760,percent of total billed charges,Implant Device,2415,70,,2415,percent of total billed charges,All Other,2346,34,,2346,percent of total billed charges,Implant Device,2346,34,,2346,percent of total billed charges,Implant Device,2415,35,,2415,percent of total billed charges,Implant Device,2415,35,,2415,percent of total billed charges,Implant Device,2415,35,,2415,percent of total billed charges,Implant Device,2415,35,,2415,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2346,34,"If Charge > 2,000, then 34 percent",2346,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5106.02,
ZIMMER 00-7711-006-10 M/L TAPER 6 STD,C1776,HCPCS,,79009621,CDM,278,RC,,,both,,,6900,5106.02,,,5106.02,Other,150% of Medicare + 9.63% HCRA Surcharge,3105,45,,3105,percent of total billed charges,Critical Access Hospital RCC factor,2346,34,,2346,percent of total billed charges,Implant Device,2346,34,,2346,percent of total billed charges,Implant Device,2346,34,,2346,percent of total billed charges,Implant Device,2346,34,,2346,percent of total billed charges,Implant Device,2346,34,,2346,percent of total billed charges,Implant Device,3415.5,,,3415.5,Other,110% of Medicare,2415,35,,2415,percent of total billed charges,Implant Device,2346,34,"Charges > $500, x 34%",2346,percent of total billed charges,Implant Device,2415,35,,2415,percent of total billed charges,Implant Device,2415,35,,2415,percent of total billed charges,Implant Device,2415,35,,2415,percent of total billed charges,Implant Device,2415,35,,2415,percent of total billed charges,Implant Device,2415,35,,2415,percent of total billed charges,Implant Device,2760,40,,2760,percent of total billed charges,Implant Device,2415,70,,2415,percent of total billed charges,All Other,2346,34,,2346,percent of total billed charges,Implant Device,2346,34,,2346,percent of total billed charges,Implant Device,2415,35,,2415,percent of total billed charges,Implant Device,2415,35,,2415,percent of total billed charges,Implant Device,2415,35,,2415,percent of total billed charges,Implant Device,2415,35,,2415,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2346,34,"If Charge > 2,000, then 34 percent",2346,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5106.02,
ZIMMER 00-8851-010-36 VIVACIT-E LINER,C1776,HCPCS,,79009622,CDM,278,RC,,,both,,,4403,3258.23,,,3258.23,Other,150% of Medicare + 9.63% HCRA Surcharge,1981.35,45,,1981.35,percent of total billed charges,Critical Access Hospital RCC factor,1497.02,34,,1497.02,percent of total billed charges,Implant Device,1497.02,34,,1497.02,percent of total billed charges,Implant Device,1497.02,34,,1497.02,percent of total billed charges,Implant Device,1497.02,34,,1497.02,percent of total billed charges,Implant Device,1497.02,34,,1497.02,percent of total billed charges,Implant Device,2179.49,,,2179.49,Other,110% of Medicare,1541.05,35,,1541.05,percent of total billed charges,Implant Device,1497.02,34,"Charges > $500, x 34%",1497.02,percent of total billed charges,Implant Device,1541.05,35,,1541.05,percent of total billed charges,Implant Device,1541.05,35,,1541.05,percent of total billed charges,Implant Device,1541.05,35,,1541.05,percent of total billed charges,Implant Device,1541.05,35,,1541.05,percent of total billed charges,Implant Device,1541.05,35,,1541.05,percent of total billed charges,Implant Device,1761.2,40,,1761.2,percent of total billed charges,Implant Device,1541.05,70,,1541.05,percent of total billed charges,All Other,1497.02,34,,1497.02,percent of total billed charges,Implant Device,1497.02,34,,1497.02,percent of total billed charges,Implant Device,1541.05,35,,1541.05,percent of total billed charges,Implant Device,1541.05,35,,1541.05,percent of total billed charges,Implant Device,1541.05,35,,1541.05,percent of total billed charges,Implant Device,1541.05,35,,1541.05,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1497.02,34,"If Charge > 2,000, then 34 percent",1497.02,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3258.23,
ZIMMER 11-300813 ARCOS 13X150MM SPL TPR,C1776,HCPCS,,79009623,CDM,278,RC,,,both,,,12371,9154.57,,,9154.57,Other,150% of Medicare + 9.63% HCRA Surcharge,5566.95,45,,5566.95,percent of total billed charges,Critical Access Hospital RCC factor,4206.14,34,,4206.14,percent of total billed charges,Implant Device,4206.14,34,,4206.14,percent of total billed charges,Implant Device,4206.14,34,,4206.14,percent of total billed charges,Implant Device,4206.14,34,,4206.14,percent of total billed charges,Implant Device,4206.14,34,,4206.14,percent of total billed charges,Implant Device,6123.65,,,6123.65,Other,110% of Medicare,4329.85,35,,4329.85,percent of total billed charges,Implant Device,4206.14,34,"Charges > $500, x 34%",4206.14,percent of total billed charges,Implant Device,4329.85,35,,4329.85,percent of total billed charges,Implant Device,4329.85,35,,4329.85,percent of total billed charges,Implant Device,4329.85,35,,4329.85,percent of total billed charges,Implant Device,4329.85,35,,4329.85,percent of total billed charges,Implant Device,4329.85,35,,4329.85,percent of total billed charges,Implant Device,4948.4,40,,4948.4,percent of total billed charges,Implant Device,4329.85,70,,4329.85,percent of total billed charges,All Other,4206.14,34,,4206.14,percent of total billed charges,Implant Device,4206.14,34,,4206.14,percent of total billed charges,Implant Device,4329.85,35,,4329.85,percent of total billed charges,Implant Device,4329.85,35,,4329.85,percent of total billed charges,Implant Device,4329.85,35,,4329.85,percent of total billed charges,Implant Device,4329.85,35,,4329.85,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,4206.14,34,"If Charge > 2,000, then 34 percent",4206.14,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,9154.57,
IN2BONES P65 ST432 COLAG SCREW 4.0X32MM,C1713,HCPCS,,79009624,CDM,278,RC,,,both,,,1668,1234.32,,,1234.32,Other,150% of Medicare + 9.63% HCRA Surcharge,750.6,45,,750.6,percent of total billed charges,Critical Access Hospital RCC factor,567.12,34,,567.12,percent of total billed charges,Implant Device,567.12,34,,567.12,percent of total billed charges,Implant Device,567.12,34,,567.12,percent of total billed charges,Implant Device,567.12,34,,567.12,percent of total billed charges,Implant Device,567.12,34,,567.12,percent of total billed charges,Implant Device,825.66,,,825.66,Other,110% of Medicare,583.8,35,,583.8,percent of total billed charges,Implant Device,567.12,34,"Charges > $500, x 34%",567.12,percent of total billed charges,Implant Device,583.8,35,,583.8,percent of total billed charges,Implant Device,583.8,35,,583.8,percent of total billed charges,Implant Device,583.8,35,,583.8,percent of total billed charges,Implant Device,583.8,35,,583.8,percent of total billed charges,Implant Device,583.8,35,,583.8,percent of total billed charges,Implant Device,667.2,40,,667.2,percent of total billed charges,Implant Device,583.8,70,,583.8,percent of total billed charges,All Other,567.12,34,,567.12,percent of total billed charges,Implant Device,567.12,34,,567.12,percent of total billed charges,Implant Device,583.8,35,,583.8,percent of total billed charges,Implant Device,583.8,35,,583.8,percent of total billed charges,Implant Device,583.8,35,,583.8,percent of total billed charges,Implant Device,583.8,35,,583.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1234.32,
IN2BONES P40 ST014 PLATE UNIV 4 HOLE,C1713,HCPCS,,79009625,CDM,278,RC,,,both,,,6000,4440.02,,,4440.02,Other,150% of Medicare + 9.63% HCRA Surcharge,2700,45,,2700,percent of total billed charges,Critical Access Hospital RCC factor,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2970,,,2970,Other,110% of Medicare,2100,35,,2100,percent of total billed charges,Implant Device,2040,34,"Charges > $500, x 34%",2040,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2400,40,,2400,percent of total billed charges,Implant Device,2100,70,,2100,percent of total billed charges,All Other,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2040,34,"If Charge > 2,000, then 34 percent",2040,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4440.02,
IN2BONES V35 ST214 NON LOCK SCREW 3.5X14,C1713,HCPCS,,79009626,CDM,278,RC,,,both,,,870,643.8,,,643.8,Other,150% of Medicare + 9.63% HCRA Surcharge,391.5,45,,391.5,percent of total billed charges,Critical Access Hospital RCC factor,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,430.65,,,430.65,Other,110% of Medicare,304.5,35,,304.5,percent of total billed charges,Implant Device,295.8,34,"Charges > $500, x 34%",295.8,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,348,40,,348,percent of total billed charges,Implant Device,304.5,70,,304.5,percent of total billed charges,All Other,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,643.8,
ARTHREX AR-4020C-06 BIOCOMP SCREW 6X20MM,C1713,HCPCS,,79009630,CDM,278,RC,,,both,,,885,654.9,,,654.9,Other,150% of Medicare + 9.63% HCRA Surcharge,398.25,45,,398.25,percent of total billed charges,Critical Access Hospital RCC factor,300.9,34,,300.9,percent of total billed charges,Implant Device,300.9,34,,300.9,percent of total billed charges,Implant Device,300.9,34,,300.9,percent of total billed charges,Implant Device,300.9,34,,300.9,percent of total billed charges,Implant Device,300.9,34,,300.9,percent of total billed charges,Implant Device,438.08,,,438.08,Other,110% of Medicare,309.75,35,,309.75,percent of total billed charges,Implant Device,300.9,34,"Charges > $500, x 34%",300.9,percent of total billed charges,Implant Device,309.75,35,,309.75,percent of total billed charges,Implant Device,309.75,35,,309.75,percent of total billed charges,Implant Device,309.75,35,,309.75,percent of total billed charges,Implant Device,309.75,35,,309.75,percent of total billed charges,Implant Device,309.75,35,,309.75,percent of total billed charges,Implant Device,354,40,,354,percent of total billed charges,Implant Device,309.75,70,,309.75,percent of total billed charges,All Other,300.9,34,,300.9,percent of total billed charges,Implant Device,300.9,34,,300.9,percent of total billed charges,Implant Device,309.75,35,,309.75,percent of total billed charges,Implant Device,309.75,35,,309.75,percent of total billed charges,Implant Device,309.75,35,,309.75,percent of total billed charges,Implant Device,309.75,35,,309.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,654.9,
ARTHREX AR-4020C-07 BIOCOMP SCREW 7X20MM,C1713,HCPCS,,79009631,CDM,278,RC,,,both,,,885,654.9,,,654.9,Other,150% of Medicare + 9.63% HCRA Surcharge,398.25,45,,398.25,percent of total billed charges,Critical Access Hospital RCC factor,300.9,34,,300.9,percent of total billed charges,Implant Device,300.9,34,,300.9,percent of total billed charges,Implant Device,300.9,34,,300.9,percent of total billed charges,Implant Device,300.9,34,,300.9,percent of total billed charges,Implant Device,300.9,34,,300.9,percent of total billed charges,Implant Device,438.08,,,438.08,Other,110% of Medicare,309.75,35,,309.75,percent of total billed charges,Implant Device,300.9,34,"Charges > $500, x 34%",300.9,percent of total billed charges,Implant Device,309.75,35,,309.75,percent of total billed charges,Implant Device,309.75,35,,309.75,percent of total billed charges,Implant Device,309.75,35,,309.75,percent of total billed charges,Implant Device,309.75,35,,309.75,percent of total billed charges,Implant Device,309.75,35,,309.75,percent of total billed charges,Implant Device,354,40,,354,percent of total billed charges,Implant Device,309.75,70,,309.75,percent of total billed charges,All Other,300.9,34,,300.9,percent of total billed charges,Implant Device,300.9,34,,300.9,percent of total billed charges,Implant Device,309.75,35,,309.75,percent of total billed charges,Implant Device,309.75,35,,309.75,percent of total billed charges,Implant Device,309.75,35,,309.75,percent of total billed charges,Implant Device,309.75,35,,309.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,654.9,
ARTHREX AR-4020C-08 BIOCOMP SCREW 8X20MM,C1713,HCPCS,,79009632,CDM,278,RC,,,both,,,885,654.9,,,654.9,Other,150% of Medicare + 9.63% HCRA Surcharge,398.25,45,,398.25,percent of total billed charges,Critical Access Hospital RCC factor,300.9,34,,300.9,percent of total billed charges,Implant Device,300.9,34,,300.9,percent of total billed charges,Implant Device,300.9,34,,300.9,percent of total billed charges,Implant Device,300.9,34,,300.9,percent of total billed charges,Implant Device,300.9,34,,300.9,percent of total billed charges,Implant Device,438.08,,,438.08,Other,110% of Medicare,309.75,35,,309.75,percent of total billed charges,Implant Device,300.9,34,"Charges > $500, x 34%",300.9,percent of total billed charges,Implant Device,309.75,35,,309.75,percent of total billed charges,Implant Device,309.75,35,,309.75,percent of total billed charges,Implant Device,309.75,35,,309.75,percent of total billed charges,Implant Device,309.75,35,,309.75,percent of total billed charges,Implant Device,309.75,35,,309.75,percent of total billed charges,Implant Device,354,40,,354,percent of total billed charges,Implant Device,309.75,70,,309.75,percent of total billed charges,All Other,300.9,34,,300.9,percent of total billed charges,Implant Device,300.9,34,,300.9,percent of total billed charges,Implant Device,309.75,35,,309.75,percent of total billed charges,Implant Device,309.75,35,,309.75,percent of total billed charges,Implant Device,309.75,35,,309.75,percent of total billed charges,Implant Device,309.75,35,,309.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,654.9,
ARTHREX AR-4020C-09 BIOCOMP SCREW 9X20MM,C1713,HCPCS,,79009633,CDM,278,RC,,,both,,,885,654.9,,,654.9,Other,150% of Medicare + 9.63% HCRA Surcharge,398.25,45,,398.25,percent of total billed charges,Critical Access Hospital RCC factor,300.9,34,,300.9,percent of total billed charges,Implant Device,300.9,34,,300.9,percent of total billed charges,Implant Device,300.9,34,,300.9,percent of total billed charges,Implant Device,300.9,34,,300.9,percent of total billed charges,Implant Device,300.9,34,,300.9,percent of total billed charges,Implant Device,438.08,,,438.08,Other,110% of Medicare,309.75,35,,309.75,percent of total billed charges,Implant Device,300.9,34,"Charges > $500, x 34%",300.9,percent of total billed charges,Implant Device,309.75,35,,309.75,percent of total billed charges,Implant Device,309.75,35,,309.75,percent of total billed charges,Implant Device,309.75,35,,309.75,percent of total billed charges,Implant Device,309.75,35,,309.75,percent of total billed charges,Implant Device,309.75,35,,309.75,percent of total billed charges,Implant Device,354,40,,354,percent of total billed charges,Implant Device,309.75,70,,309.75,percent of total billed charges,All Other,300.9,34,,300.9,percent of total billed charges,Implant Device,300.9,34,,300.9,percent of total billed charges,Implant Device,309.75,35,,309.75,percent of total billed charges,Implant Device,309.75,35,,309.75,percent of total billed charges,Implant Device,309.75,35,,309.75,percent of total billed charges,Implant Device,309.75,35,,309.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,654.9,
ARTHREX AR-4020C-10 BIOCOMP SCREW 10X20,C1713,HCPCS,,79009634,CDM,278,RC,,,both,,,885,654.9,,,654.9,Other,150% of Medicare + 9.63% HCRA Surcharge,398.25,45,,398.25,percent of total billed charges,Critical Access Hospital RCC factor,300.9,34,,300.9,percent of total billed charges,Implant Device,300.9,34,,300.9,percent of total billed charges,Implant Device,300.9,34,,300.9,percent of total billed charges,Implant Device,300.9,34,,300.9,percent of total billed charges,Implant Device,300.9,34,,300.9,percent of total billed charges,Implant Device,438.08,,,438.08,Other,110% of Medicare,309.75,35,,309.75,percent of total billed charges,Implant Device,300.9,34,"Charges > $500, x 34%",300.9,percent of total billed charges,Implant Device,309.75,35,,309.75,percent of total billed charges,Implant Device,309.75,35,,309.75,percent of total billed charges,Implant Device,309.75,35,,309.75,percent of total billed charges,Implant Device,309.75,35,,309.75,percent of total billed charges,Implant Device,309.75,35,,309.75,percent of total billed charges,Implant Device,354,40,,354,percent of total billed charges,Implant Device,309.75,70,,309.75,percent of total billed charges,All Other,300.9,34,,300.9,percent of total billed charges,Implant Device,300.9,34,,300.9,percent of total billed charges,Implant Device,309.75,35,,309.75,percent of total billed charges,Implant Device,309.75,35,,309.75,percent of total billed charges,Implant Device,309.75,35,,309.75,percent of total billed charges,Implant Device,309.75,35,,309.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,654.9,
ARTHREX AR-4030C-07 BIOCOMP SCREW 7X30MM,C1713,HCPCS,,79009635,CDM,278,RC,,,both,,,885,654.9,,,654.9,Other,150% of Medicare + 9.63% HCRA Surcharge,398.25,45,,398.25,percent of total billed charges,Critical Access Hospital RCC factor,300.9,34,,300.9,percent of total billed charges,Implant Device,300.9,34,,300.9,percent of total billed charges,Implant Device,300.9,34,,300.9,percent of total billed charges,Implant Device,300.9,34,,300.9,percent of total billed charges,Implant Device,300.9,34,,300.9,percent of total billed charges,Implant Device,438.08,,,438.08,Other,110% of Medicare,309.75,35,,309.75,percent of total billed charges,Implant Device,300.9,34,"Charges > $500, x 34%",300.9,percent of total billed charges,Implant Device,309.75,35,,309.75,percent of total billed charges,Implant Device,309.75,35,,309.75,percent of total billed charges,Implant Device,309.75,35,,309.75,percent of total billed charges,Implant Device,309.75,35,,309.75,percent of total billed charges,Implant Device,309.75,35,,309.75,percent of total billed charges,Implant Device,354,40,,354,percent of total billed charges,Implant Device,309.75,70,,309.75,percent of total billed charges,All Other,300.9,34,,300.9,percent of total billed charges,Implant Device,300.9,34,,300.9,percent of total billed charges,Implant Device,309.75,35,,309.75,percent of total billed charges,Implant Device,309.75,35,,309.75,percent of total billed charges,Implant Device,309.75,35,,309.75,percent of total billed charges,Implant Device,309.75,35,,309.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,654.9,
ARTHREX AR-4030C-08 BIOCOMP SCREW 8X30MM,C1713,HCPCS,,79009636,CDM,278,RC,,,both,,,885,654.9,,,654.9,Other,150% of Medicare + 9.63% HCRA Surcharge,398.25,45,,398.25,percent of total billed charges,Critical Access Hospital RCC factor,300.9,34,,300.9,percent of total billed charges,Implant Device,300.9,34,,300.9,percent of total billed charges,Implant Device,300.9,34,,300.9,percent of total billed charges,Implant Device,300.9,34,,300.9,percent of total billed charges,Implant Device,300.9,34,,300.9,percent of total billed charges,Implant Device,438.08,,,438.08,Other,110% of Medicare,309.75,35,,309.75,percent of total billed charges,Implant Device,300.9,34,"Charges > $500, x 34%",300.9,percent of total billed charges,Implant Device,309.75,35,,309.75,percent of total billed charges,Implant Device,309.75,35,,309.75,percent of total billed charges,Implant Device,309.75,35,,309.75,percent of total billed charges,Implant Device,309.75,35,,309.75,percent of total billed charges,Implant Device,309.75,35,,309.75,percent of total billed charges,Implant Device,354,40,,354,percent of total billed charges,Implant Device,309.75,70,,309.75,percent of total billed charges,All Other,300.9,34,,300.9,percent of total billed charges,Implant Device,300.9,34,,300.9,percent of total billed charges,Implant Device,309.75,35,,309.75,percent of total billed charges,Implant Device,309.75,35,,309.75,percent of total billed charges,Implant Device,309.75,35,,309.75,percent of total billed charges,Implant Device,309.75,35,,309.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,654.9,
ARTHREX AR-4030C-09 BIOCOMP SCREW 9X30MM,C1713,HCPCS,,79009637,CDM,278,RC,,,both,,,885,654.9,,,654.9,Other,150% of Medicare + 9.63% HCRA Surcharge,398.25,45,,398.25,percent of total billed charges,Critical Access Hospital RCC factor,300.9,34,,300.9,percent of total billed charges,Implant Device,300.9,34,,300.9,percent of total billed charges,Implant Device,300.9,34,,300.9,percent of total billed charges,Implant Device,300.9,34,,300.9,percent of total billed charges,Implant Device,300.9,34,,300.9,percent of total billed charges,Implant Device,438.08,,,438.08,Other,110% of Medicare,309.75,35,,309.75,percent of total billed charges,Implant Device,300.9,34,"Charges > $500, x 34%",300.9,percent of total billed charges,Implant Device,309.75,35,,309.75,percent of total billed charges,Implant Device,309.75,35,,309.75,percent of total billed charges,Implant Device,309.75,35,,309.75,percent of total billed charges,Implant Device,309.75,35,,309.75,percent of total billed charges,Implant Device,309.75,35,,309.75,percent of total billed charges,Implant Device,354,40,,354,percent of total billed charges,Implant Device,309.75,70,,309.75,percent of total billed charges,All Other,300.9,34,,300.9,percent of total billed charges,Implant Device,300.9,34,,300.9,percent of total billed charges,Implant Device,309.75,35,,309.75,percent of total billed charges,Implant Device,309.75,35,,309.75,percent of total billed charges,Implant Device,309.75,35,,309.75,percent of total billed charges,Implant Device,309.75,35,,309.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,654.9,
ARTHREX AR-4030C-10 BIOCOMP SCREW 10X30,C1713,HCPCS,,79009638,CDM,278,RC,,,both,,,885,654.9,,,654.9,Other,150% of Medicare + 9.63% HCRA Surcharge,398.25,45,,398.25,percent of total billed charges,Critical Access Hospital RCC factor,300.9,34,,300.9,percent of total billed charges,Implant Device,300.9,34,,300.9,percent of total billed charges,Implant Device,300.9,34,,300.9,percent of total billed charges,Implant Device,300.9,34,,300.9,percent of total billed charges,Implant Device,300.9,34,,300.9,percent of total billed charges,Implant Device,438.08,,,438.08,Other,110% of Medicare,309.75,35,,309.75,percent of total billed charges,Implant Device,300.9,34,"Charges > $500, x 34%",300.9,percent of total billed charges,Implant Device,309.75,35,,309.75,percent of total billed charges,Implant Device,309.75,35,,309.75,percent of total billed charges,Implant Device,309.75,35,,309.75,percent of total billed charges,Implant Device,309.75,35,,309.75,percent of total billed charges,Implant Device,309.75,35,,309.75,percent of total billed charges,Implant Device,354,40,,354,percent of total billed charges,Implant Device,309.75,70,,309.75,percent of total billed charges,All Other,300.9,34,,300.9,percent of total billed charges,Implant Device,300.9,34,,300.9,percent of total billed charges,Implant Device,309.75,35,,309.75,percent of total billed charges,Implant Device,309.75,35,,309.75,percent of total billed charges,Implant Device,309.75,35,,309.75,percent of total billed charges,Implant Device,309.75,35,,309.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,654.9,
ARTHREX AR-4030C-11 BIOCOMP SCREW 11X30,C1713,HCPCS,,79009639,CDM,278,RC,,,both,,,885,654.9,,,654.9,Other,150% of Medicare + 9.63% HCRA Surcharge,398.25,45,,398.25,percent of total billed charges,Critical Access Hospital RCC factor,300.9,34,,300.9,percent of total billed charges,Implant Device,300.9,34,,300.9,percent of total billed charges,Implant Device,300.9,34,,300.9,percent of total billed charges,Implant Device,300.9,34,,300.9,percent of total billed charges,Implant Device,300.9,34,,300.9,percent of total billed charges,Implant Device,438.08,,,438.08,Other,110% of Medicare,309.75,35,,309.75,percent of total billed charges,Implant Device,300.9,34,"Charges > $500, x 34%",300.9,percent of total billed charges,Implant Device,309.75,35,,309.75,percent of total billed charges,Implant Device,309.75,35,,309.75,percent of total billed charges,Implant Device,309.75,35,,309.75,percent of total billed charges,Implant Device,309.75,35,,309.75,percent of total billed charges,Implant Device,309.75,35,,309.75,percent of total billed charges,Implant Device,354,40,,354,percent of total billed charges,Implant Device,309.75,70,,309.75,percent of total billed charges,All Other,300.9,34,,300.9,percent of total billed charges,Implant Device,300.9,34,,300.9,percent of total billed charges,Implant Device,309.75,35,,309.75,percent of total billed charges,Implant Device,309.75,35,,309.75,percent of total billed charges,Implant Device,309.75,35,,309.75,percent of total billed charges,Implant Device,309.75,35,,309.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,654.9,
ARTHREX AR-4030C-12 BIOCOMP SCREW 12X30,C1713,HCPCS,,79009640,CDM,278,RC,,,both,,,885,654.9,,,654.9,Other,150% of Medicare + 9.63% HCRA Surcharge,398.25,45,,398.25,percent of total billed charges,Critical Access Hospital RCC factor,300.9,34,,300.9,percent of total billed charges,Implant Device,300.9,34,,300.9,percent of total billed charges,Implant Device,300.9,34,,300.9,percent of total billed charges,Implant Device,300.9,34,,300.9,percent of total billed charges,Implant Device,300.9,34,,300.9,percent of total billed charges,Implant Device,438.08,,,438.08,Other,110% of Medicare,309.75,35,,309.75,percent of total billed charges,Implant Device,300.9,34,"Charges > $500, x 34%",300.9,percent of total billed charges,Implant Device,309.75,35,,309.75,percent of total billed charges,Implant Device,309.75,35,,309.75,percent of total billed charges,Implant Device,309.75,35,,309.75,percent of total billed charges,Implant Device,309.75,35,,309.75,percent of total billed charges,Implant Device,309.75,35,,309.75,percent of total billed charges,Implant Device,354,40,,354,percent of total billed charges,Implant Device,309.75,70,,309.75,percent of total billed charges,All Other,300.9,34,,300.9,percent of total billed charges,Implant Device,300.9,34,,300.9,percent of total billed charges,Implant Device,309.75,35,,309.75,percent of total billed charges,Implant Device,309.75,35,,309.75,percent of total billed charges,Implant Device,309.75,35,,309.75,percent of total billed charges,Implant Device,309.75,35,,309.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,654.9,
STRYKER 626992 BROAD Y-PLT 2 SHAFT HOLES,C1713,HCPCS,,79009641,CDM,278,RC,,,both,,,5904,4368.97,,,4368.97,Other,150% of Medicare + 9.63% HCRA Surcharge,2656.8,45,,2656.8,percent of total billed charges,Critical Access Hospital RCC factor,2007.36,34,,2007.36,percent of total billed charges,Implant Device,2007.36,34,,2007.36,percent of total billed charges,Implant Device,2007.36,34,,2007.36,percent of total billed charges,Implant Device,2007.36,34,,2007.36,percent of total billed charges,Implant Device,2007.36,34,,2007.36,percent of total billed charges,Implant Device,2922.48,,,2922.48,Other,110% of Medicare,2066.4,35,,2066.4,percent of total billed charges,Implant Device,2007.36,34,"Charges > $500, x 34%",2007.36,percent of total billed charges,Implant Device,2066.4,35,,2066.4,percent of total billed charges,Implant Device,2066.4,35,,2066.4,percent of total billed charges,Implant Device,2066.4,35,,2066.4,percent of total billed charges,Implant Device,2066.4,35,,2066.4,percent of total billed charges,Implant Device,2066.4,35,,2066.4,percent of total billed charges,Implant Device,2361.6,40,,2361.6,percent of total billed charges,Implant Device,2066.4,70,,2066.4,percent of total billed charges,All Other,2007.36,34,,2007.36,percent of total billed charges,Implant Device,2007.36,34,,2007.36,percent of total billed charges,Implant Device,2066.4,35,,2066.4,percent of total billed charges,Implant Device,2066.4,35,,2066.4,percent of total billed charges,Implant Device,2066.4,35,,2066.4,percent of total billed charges,Implant Device,2066.4,35,,2066.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2007.36,34,"If Charge > 2,000, then 34 percent",2007.36,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4368.97,
STRYKER PLP30141 ANCHORAGE LISFRANC PLT,C1713,HCPCS,,79009642,CDM,278,RC,,,both,,,7878,5829.74,,,5829.74,Other,150% of Medicare + 9.63% HCRA Surcharge,3545.1,45,,3545.1,percent of total billed charges,Critical Access Hospital RCC factor,2678.52,34,,2678.52,percent of total billed charges,Implant Device,2678.52,34,,2678.52,percent of total billed charges,Implant Device,2678.52,34,,2678.52,percent of total billed charges,Implant Device,2678.52,34,,2678.52,percent of total billed charges,Implant Device,2678.52,34,,2678.52,percent of total billed charges,Implant Device,3899.61,,,3899.61,Other,110% of Medicare,2757.3,35,,2757.3,percent of total billed charges,Implant Device,2678.52,34,"Charges > $500, x 34%",2678.52,percent of total billed charges,Implant Device,2757.3,35,,2757.3,percent of total billed charges,Implant Device,2757.3,35,,2757.3,percent of total billed charges,Implant Device,2757.3,35,,2757.3,percent of total billed charges,Implant Device,2757.3,35,,2757.3,percent of total billed charges,Implant Device,2757.3,35,,2757.3,percent of total billed charges,Implant Device,3151.2,40,,3151.2,percent of total billed charges,Implant Device,2757.3,70,,2757.3,percent of total billed charges,All Other,2678.52,34,,2678.52,percent of total billed charges,Implant Device,2678.52,34,,2678.52,percent of total billed charges,Implant Device,2757.3,35,,2757.3,percent of total billed charges,Implant Device,2757.3,35,,2757.3,percent of total billed charges,Implant Device,2757.3,35,,2757.3,percent of total billed charges,Implant Device,2757.3,35,,2757.3,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2678.52,34,"If Charge > 2,000, then 34 percent",2678.52,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5829.74,
STRYKER PLSL3012 LOCKING SCREW 3X12MM,C1713,HCPCS,,79009643,CDM,278,RC,,,both,,,1119,828.06,,,828.06,Other,150% of Medicare + 9.63% HCRA Surcharge,503.55,45,,503.55,percent of total billed charges,Critical Access Hospital RCC factor,380.46,34,,380.46,percent of total billed charges,Implant Device,380.46,34,,380.46,percent of total billed charges,Implant Device,380.46,34,,380.46,percent of total billed charges,Implant Device,380.46,34,,380.46,percent of total billed charges,Implant Device,380.46,34,,380.46,percent of total billed charges,Implant Device,553.91,,,553.91,Other,110% of Medicare,391.65,35,,391.65,percent of total billed charges,Implant Device,380.46,34,"Charges > $500, x 34%",380.46,percent of total billed charges,Implant Device,391.65,35,,391.65,percent of total billed charges,Implant Device,391.65,35,,391.65,percent of total billed charges,Implant Device,391.65,35,,391.65,percent of total billed charges,Implant Device,391.65,35,,391.65,percent of total billed charges,Implant Device,391.65,35,,391.65,percent of total billed charges,Implant Device,447.6,40,,447.6,percent of total billed charges,Implant Device,391.65,70,,391.65,percent of total billed charges,All Other,380.46,34,,380.46,percent of total billed charges,Implant Device,380.46,34,,380.46,percent of total billed charges,Implant Device,391.65,35,,391.65,percent of total billed charges,Implant Device,391.65,35,,391.65,percent of total billed charges,Implant Device,391.65,35,,391.65,percent of total billed charges,Implant Device,391.65,35,,391.65,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,828.06,
STRYKER PLSL3020 LOCKING SCREW 3X20MM,C1713,HCPCS,,79009644,CDM,278,RC,,,both,,,1119,828.06,,,828.06,Other,150% of Medicare + 9.63% HCRA Surcharge,503.55,45,,503.55,percent of total billed charges,Critical Access Hospital RCC factor,380.46,34,,380.46,percent of total billed charges,Implant Device,380.46,34,,380.46,percent of total billed charges,Implant Device,380.46,34,,380.46,percent of total billed charges,Implant Device,380.46,34,,380.46,percent of total billed charges,Implant Device,380.46,34,,380.46,percent of total billed charges,Implant Device,553.91,,,553.91,Other,110% of Medicare,391.65,35,,391.65,percent of total billed charges,Implant Device,380.46,34,"Charges > $500, x 34%",380.46,percent of total billed charges,Implant Device,391.65,35,,391.65,percent of total billed charges,Implant Device,391.65,35,,391.65,percent of total billed charges,Implant Device,391.65,35,,391.65,percent of total billed charges,Implant Device,391.65,35,,391.65,percent of total billed charges,Implant Device,391.65,35,,391.65,percent of total billed charges,Implant Device,447.6,40,,447.6,percent of total billed charges,Implant Device,391.65,70,,391.65,percent of total billed charges,All Other,380.46,34,,380.46,percent of total billed charges,Implant Device,380.46,34,,380.46,percent of total billed charges,Implant Device,391.65,35,,391.65,percent of total billed charges,Implant Device,391.65,35,,391.65,percent of total billed charges,Implant Device,391.65,35,,391.65,percent of total billed charges,Implant Device,391.65,35,,391.65,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,828.06,
STRYKER PLSL3022 LOCKING SCREW 3X22MM,C1713,HCPCS,,79009645,CDM,278,RC,,,both,,,1098,812.52,,,812.52,Other,150% of Medicare + 9.63% HCRA Surcharge,494.1,45,,494.1,percent of total billed charges,Critical Access Hospital RCC factor,373.32,34,,373.32,percent of total billed charges,Implant Device,373.32,34,,373.32,percent of total billed charges,Implant Device,373.32,34,,373.32,percent of total billed charges,Implant Device,373.32,34,,373.32,percent of total billed charges,Implant Device,373.32,34,,373.32,percent of total billed charges,Implant Device,543.51,,,543.51,Other,110% of Medicare,384.3,35,,384.3,percent of total billed charges,Implant Device,373.32,34,"Charges > $500, x 34%",373.32,percent of total billed charges,Implant Device,384.3,35,,384.3,percent of total billed charges,Implant Device,384.3,35,,384.3,percent of total billed charges,Implant Device,384.3,35,,384.3,percent of total billed charges,Implant Device,384.3,35,,384.3,percent of total billed charges,Implant Device,384.3,35,,384.3,percent of total billed charges,Implant Device,439.2,40,,439.2,percent of total billed charges,Implant Device,384.3,70,,384.3,percent of total billed charges,All Other,373.32,34,,373.32,percent of total billed charges,Implant Device,373.32,34,,373.32,percent of total billed charges,Implant Device,384.3,35,,384.3,percent of total billed charges,Implant Device,384.3,35,,384.3,percent of total billed charges,Implant Device,384.3,35,,384.3,percent of total billed charges,Implant Device,384.3,35,,384.3,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,812.52,
BIOTRONIK 377176 SOLIA S 45 PACING LEAD,C1898,HCPCS,,79009649,CDM,278,RC,,,both,,,1950,1443,,,1443,Other,150% of Medicare + 9.63% HCRA Surcharge,877.5,45,,877.5,percent of total billed charges,Critical Access Hospital RCC factor,663,34,,663,percent of total billed charges,Implant Device,663,34,,663,percent of total billed charges,Implant Device,663,34,,663,percent of total billed charges,Implant Device,663,34,,663,percent of total billed charges,Implant Device,663,34,,663,percent of total billed charges,Implant Device,965.25,,,965.25,Other,110% of Medicare,682.5,35,,682.5,percent of total billed charges,Implant Device,663,34,"Charges > $500, x 34%",663,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,780,40,,780,percent of total billed charges,Implant Device,682.5,70,,682.5,percent of total billed charges,All Other,663,34,,663,percent of total billed charges,Implant Device,663,34,,663,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1443,
ZIMMER 00-7711-007-40 LINER 36X52MM,C1776,HCPCS,,79009650,CDM,278,RC,,,both,,,6900,5106.02,,,5106.02,Other,150% of Medicare + 9.63% HCRA Surcharge,3105,45,,3105,percent of total billed charges,Critical Access Hospital RCC factor,2346,34,,2346,percent of total billed charges,Implant Device,2346,34,,2346,percent of total billed charges,Implant Device,2346,34,,2346,percent of total billed charges,Implant Device,2346,34,,2346,percent of total billed charges,Implant Device,2346,34,,2346,percent of total billed charges,Implant Device,3415.5,,,3415.5,Other,110% of Medicare,2415,35,,2415,percent of total billed charges,Implant Device,2346,34,"Charges > $500, x 34%",2346,percent of total billed charges,Implant Device,2415,35,,2415,percent of total billed charges,Implant Device,2415,35,,2415,percent of total billed charges,Implant Device,2415,35,,2415,percent of total billed charges,Implant Device,2415,35,,2415,percent of total billed charges,Implant Device,2415,35,,2415,percent of total billed charges,Implant Device,2760,40,,2760,percent of total billed charges,Implant Device,2415,70,,2415,percent of total billed charges,All Other,2346,34,,2346,percent of total billed charges,Implant Device,2346,34,,2346,percent of total billed charges,Implant Device,2415,35,,2415,percent of total billed charges,Implant Device,2415,35,,2415,percent of total billed charges,Implant Device,2415,35,,2415,percent of total billed charges,Implant Device,2415,35,,2415,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2346,34,"If Charge > 2,000, then 34 percent",2346,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5106.02,
STRYKER PLP30172 LISFRANC PLATING MEDIUM,C1713,HCPCS,,79009651,CDM,278,RC,,,both,,,7878,5829.74,,,5829.74,Other,150% of Medicare + 9.63% HCRA Surcharge,3545.1,45,,3545.1,percent of total billed charges,Critical Access Hospital RCC factor,2678.52,34,,2678.52,percent of total billed charges,Implant Device,2678.52,34,,2678.52,percent of total billed charges,Implant Device,2678.52,34,,2678.52,percent of total billed charges,Implant Device,2678.52,34,,2678.52,percent of total billed charges,Implant Device,2678.52,34,,2678.52,percent of total billed charges,Implant Device,3899.61,,,3899.61,Other,110% of Medicare,2757.3,35,,2757.3,percent of total billed charges,Implant Device,2678.52,34,"Charges > $500, x 34%",2678.52,percent of total billed charges,Implant Device,2757.3,35,,2757.3,percent of total billed charges,Implant Device,2757.3,35,,2757.3,percent of total billed charges,Implant Device,2757.3,35,,2757.3,percent of total billed charges,Implant Device,2757.3,35,,2757.3,percent of total billed charges,Implant Device,2757.3,35,,2757.3,percent of total billed charges,Implant Device,3151.2,40,,3151.2,percent of total billed charges,Implant Device,2757.3,70,,2757.3,percent of total billed charges,All Other,2678.52,34,,2678.52,percent of total billed charges,Implant Device,2678.52,34,,2678.52,percent of total billed charges,Implant Device,2757.3,35,,2757.3,percent of total billed charges,Implant Device,2757.3,35,,2757.3,percent of total billed charges,Implant Device,2757.3,35,,2757.3,percent of total billed charges,Implant Device,2757.3,35,,2757.3,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2678.52,34,"If Charge > 2,000, then 34 percent",2678.52,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5829.74,
STRYKER PLSL3516 LOCKING SCREW 3.5X16MM,C1713,HCPCS,,79009652,CDM,278,RC,,,both,,,1119,828.06,,,828.06,Other,150% of Medicare + 9.63% HCRA Surcharge,503.55,45,,503.55,percent of total billed charges,Critical Access Hospital RCC factor,380.46,34,,380.46,percent of total billed charges,Implant Device,380.46,34,,380.46,percent of total billed charges,Implant Device,380.46,34,,380.46,percent of total billed charges,Implant Device,380.46,34,,380.46,percent of total billed charges,Implant Device,380.46,34,,380.46,percent of total billed charges,Implant Device,553.91,,,553.91,Other,110% of Medicare,391.65,35,,391.65,percent of total billed charges,Implant Device,380.46,34,"Charges > $500, x 34%",380.46,percent of total billed charges,Implant Device,391.65,35,,391.65,percent of total billed charges,Implant Device,391.65,35,,391.65,percent of total billed charges,Implant Device,391.65,35,,391.65,percent of total billed charges,Implant Device,391.65,35,,391.65,percent of total billed charges,Implant Device,391.65,35,,391.65,percent of total billed charges,Implant Device,447.6,40,,447.6,percent of total billed charges,Implant Device,391.65,70,,391.65,percent of total billed charges,All Other,380.46,34,,380.46,percent of total billed charges,Implant Device,380.46,34,,380.46,percent of total billed charges,Implant Device,391.65,35,,391.65,percent of total billed charges,Implant Device,391.65,35,,391.65,percent of total billed charges,Implant Device,391.65,35,,391.65,percent of total billed charges,Implant Device,391.65,35,,391.65,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,828.06,
STRYKER PLSL3518 LOCKING SCREW 3.5X18MM,C1713,HCPCS,,79009653,CDM,278,RC,,,both,,,1119,828.06,,,828.06,Other,150% of Medicare + 9.63% HCRA Surcharge,503.55,45,,503.55,percent of total billed charges,Critical Access Hospital RCC factor,380.46,34,,380.46,percent of total billed charges,Implant Device,380.46,34,,380.46,percent of total billed charges,Implant Device,380.46,34,,380.46,percent of total billed charges,Implant Device,380.46,34,,380.46,percent of total billed charges,Implant Device,380.46,34,,380.46,percent of total billed charges,Implant Device,553.91,,,553.91,Other,110% of Medicare,391.65,35,,391.65,percent of total billed charges,Implant Device,380.46,34,"Charges > $500, x 34%",380.46,percent of total billed charges,Implant Device,391.65,35,,391.65,percent of total billed charges,Implant Device,391.65,35,,391.65,percent of total billed charges,Implant Device,391.65,35,,391.65,percent of total billed charges,Implant Device,391.65,35,,391.65,percent of total billed charges,Implant Device,391.65,35,,391.65,percent of total billed charges,Implant Device,447.6,40,,447.6,percent of total billed charges,Implant Device,391.65,70,,391.65,percent of total billed charges,All Other,380.46,34,,380.46,percent of total billed charges,Implant Device,380.46,34,,380.46,percent of total billed charges,Implant Device,391.65,35,,391.65,percent of total billed charges,Implant Device,391.65,35,,391.65,percent of total billed charges,Implant Device,391.65,35,,391.65,percent of total billed charges,Implant Device,391.65,35,,391.65,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,828.06,
STRYKER PLSS3518 STANDARD SCREW 3.5X18MM,C1713,HCPCS,,79009654,CDM,278,RC,,,both,,,759,561.66,,,561.66,Other,150% of Medicare + 9.63% HCRA Surcharge,341.55,45,,341.55,percent of total billed charges,Critical Access Hospital RCC factor,258.06,34,,258.06,percent of total billed charges,Implant Device,258.06,34,,258.06,percent of total billed charges,Implant Device,258.06,34,,258.06,percent of total billed charges,Implant Device,258.06,34,,258.06,percent of total billed charges,Implant Device,258.06,34,,258.06,percent of total billed charges,Implant Device,375.71,,,375.71,Other,110% of Medicare,265.65,35,,265.65,percent of total billed charges,Implant Device,258.06,34,"Charges > $500, x 34%",258.06,percent of total billed charges,Implant Device,265.65,35,,265.65,percent of total billed charges,Implant Device,265.65,35,,265.65,percent of total billed charges,Implant Device,265.65,35,,265.65,percent of total billed charges,Implant Device,265.65,35,,265.65,percent of total billed charges,Implant Device,265.65,35,,265.65,percent of total billed charges,Implant Device,303.6,40,,303.6,percent of total billed charges,Implant Device,265.65,70,,265.65,percent of total billed charges,All Other,258.06,34,,258.06,percent of total billed charges,Implant Device,258.06,34,,258.06,percent of total billed charges,Implant Device,265.65,35,,265.65,percent of total billed charges,Implant Device,265.65,35,,265.65,percent of total billed charges,Implant Device,265.65,35,,265.65,percent of total billed charges,Implant Device,265.65,35,,265.65,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,561.66,
ZIMMER 00-8851-012-36 LINER SIZE KK 36MM,C1776,HCPCS,,79009655,CDM,278,RC,,,both,,,4403,3258.23,,,3258.23,Other,150% of Medicare + 9.63% HCRA Surcharge,1981.35,45,,1981.35,percent of total billed charges,Critical Access Hospital RCC factor,1497.02,34,,1497.02,percent of total billed charges,Implant Device,1497.02,34,,1497.02,percent of total billed charges,Implant Device,1497.02,34,,1497.02,percent of total billed charges,Implant Device,1497.02,34,,1497.02,percent of total billed charges,Implant Device,1497.02,34,,1497.02,percent of total billed charges,Implant Device,2179.49,,,2179.49,Other,110% of Medicare,1541.05,35,,1541.05,percent of total billed charges,Implant Device,1497.02,34,"Charges > $500, x 34%",1497.02,percent of total billed charges,Implant Device,1541.05,35,,1541.05,percent of total billed charges,Implant Device,1541.05,35,,1541.05,percent of total billed charges,Implant Device,1541.05,35,,1541.05,percent of total billed charges,Implant Device,1541.05,35,,1541.05,percent of total billed charges,Implant Device,1541.05,35,,1541.05,percent of total billed charges,Implant Device,1761.2,40,,1761.2,percent of total billed charges,Implant Device,1541.05,70,,1541.05,percent of total billed charges,All Other,1497.02,34,,1497.02,percent of total billed charges,Implant Device,1497.02,34,,1497.02,percent of total billed charges,Implant Device,1541.05,35,,1541.05,percent of total billed charges,Implant Device,1541.05,35,,1541.05,percent of total billed charges,Implant Device,1541.05,35,,1541.05,percent of total billed charges,Implant Device,1541.05,35,,1541.05,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1497.02,34,"If Charge > 2,000, then 34 percent",1497.02,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3258.23,
ZIMMER 00-5880-040-12 ART SURF SZ D 12MM,C1776,HCPCS,,79009656,CDM,278,RC,,,both,,,5823,4309.03,,,4309.03,Other,150% of Medicare + 9.63% HCRA Surcharge,2620.35,45,,2620.35,percent of total billed charges,Critical Access Hospital RCC factor,1979.82,34,,1979.82,percent of total billed charges,Implant Device,1979.82,34,,1979.82,percent of total billed charges,Implant Device,1979.82,34,,1979.82,percent of total billed charges,Implant Device,1979.82,34,,1979.82,percent of total billed charges,Implant Device,1979.82,34,,1979.82,percent of total billed charges,Implant Device,2882.39,,,2882.39,Other,110% of Medicare,2038.05,35,,2038.05,percent of total billed charges,Implant Device,1979.82,34,"Charges > $500, x 34%",1979.82,percent of total billed charges,Implant Device,2038.05,35,,2038.05,percent of total billed charges,Implant Device,2038.05,35,,2038.05,percent of total billed charges,Implant Device,2038.05,35,,2038.05,percent of total billed charges,Implant Device,2038.05,35,,2038.05,percent of total billed charges,Implant Device,2038.05,35,,2038.05,percent of total billed charges,Implant Device,2329.2,40,,2329.2,percent of total billed charges,Implant Device,2038.05,70,,2038.05,percent of total billed charges,All Other,1979.82,34,,1979.82,percent of total billed charges,Implant Device,1979.82,34,,1979.82,percent of total billed charges,Implant Device,2038.05,35,,2038.05,percent of total billed charges,Implant Device,2038.05,35,,2038.05,percent of total billed charges,Implant Device,2038.05,35,,2038.05,percent of total billed charges,Implant Device,2038.05,35,,2038.05,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1979.82,34,"If Charge > 2,000, then 34 percent",1979.82,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4309.03,
ZIMMER 00-5880-014-02 FEM COMP SZ D RT,C1776,HCPCS,,79009657,CDM,278,RC,,,both,,,26520,19624.87,,,19624.87,Other,150% of Medicare + 9.63% HCRA Surcharge,11934,45,,11934,percent of total billed charges,Critical Access Hospital RCC factor,9016.8,34,,9016.8,percent of total billed charges,Implant Device,9016.8,34,,9016.8,percent of total billed charges,Implant Device,9016.8,34,,9016.8,percent of total billed charges,Implant Device,9016.8,34,,9016.8,percent of total billed charges,Implant Device,9016.8,34,,9016.8,percent of total billed charges,Implant Device,13127.4,,,13127.4,Other,110% of Medicare,9282,35,,9282,percent of total billed charges,Implant Device,9016.8,34,"Charges > $500, x 34%",9016.8,percent of total billed charges,Implant Device,9282,35,,9282,percent of total billed charges,Implant Device,9282,35,,9282,percent of total billed charges,Implant Device,9282,35,,9282,percent of total billed charges,Implant Device,9282,35,,9282,percent of total billed charges,Implant Device,9282,35,,9282,percent of total billed charges,Implant Device,10608,40,,10608,percent of total billed charges,Implant Device,9282,70,,9282,percent of total billed charges,All Other,9016.8,34,,9016.8,percent of total billed charges,Implant Device,9016.8,34,,9016.8,percent of total billed charges,Implant Device,9282,35,,9282,percent of total billed charges,Implant Device,9282,35,,9282,percent of total billed charges,Implant Device,9282,35,,9282,percent of total billed charges,Implant Device,9282,35,,9282,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,9016.8,34,"If Charge > 2,000, then 34 percent",9016.8,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,19624.87,
IN2BONES V35 ST318 LOCK SCREW 3.5X18MM,C1713,HCPCS,,79009658,CDM,278,RC,,,both,,,870,643.8,,,643.8,Other,150% of Medicare + 9.63% HCRA Surcharge,391.5,45,,391.5,percent of total billed charges,Critical Access Hospital RCC factor,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,430.65,,,430.65,Other,110% of Medicare,304.5,35,,304.5,percent of total billed charges,Implant Device,295.8,34,"Charges > $500, x 34%",295.8,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,348,40,,348,percent of total billed charges,Implant Device,304.5,70,,304.5,percent of total billed charges,All Other,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,643.8,
ARTHREX AR-8724-32 CORTEX SCREW 2.4X32MM,C1713,HCPCS,,79009659,CDM,278,RC,,,both,,,474,350.76,,,350.76,Other,150% of Medicare + 9.63% HCRA Surcharge,213.3,45,,213.3,percent of total billed charges,Critical Access Hospital RCC factor,161.16,34,,161.16,percent of total billed charges,Implant Device,161.16,34,,161.16,percent of total billed charges,Implant Device,161.16,34,,161.16,percent of total billed charges,Implant Device,161.16,34,,161.16,percent of total billed charges,Implant Device,161.16,34,,161.16,percent of total billed charges,Implant Device,234.63,,,234.63,Other,110% of Medicare,165.9,35,,165.9,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,165.9,35,,165.9,percent of total billed charges,Implant Device,165.9,35,,165.9,percent of total billed charges,Implant Device,165.9,35,,165.9,percent of total billed charges,Implant Device,165.9,35,,165.9,percent of total billed charges,Implant Device,165.9,35,,165.9,percent of total billed charges,Implant Device,189.6,40,,189.6,percent of total billed charges,Implant Device,165.9,70,,165.9,percent of total billed charges,All Other,161.16,34,,161.16,percent of total billed charges,Implant Device,161.16,34,,161.16,percent of total billed charges,Implant Device,165.9,35,,165.9,percent of total billed charges,Implant Device,165.9,35,,165.9,percent of total billed charges,Implant Device,165.9,35,,165.9,percent of total billed charges,Implant Device,165.9,35,,165.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,350.76,
MENTOR SMPX-215 GEL BREAST IMPLANT 215CC,C1789,HCPCS,,79009661,CDM,278,RC,,,both,,,3684,2726.17,,,2726.17,Other,150% of Medicare + 9.63% HCRA Surcharge,1657.8,45,,1657.8,percent of total billed charges,Critical Access Hospital RCC factor,1252.56,34,,1252.56,percent of total billed charges,Implant Device,1252.56,34,,1252.56,percent of total billed charges,Implant Device,1252.56,34,,1252.56,percent of total billed charges,Implant Device,1252.56,34,,1252.56,percent of total billed charges,Implant Device,1252.56,34,,1252.56,percent of total billed charges,Implant Device,1823.58,,,1823.58,Other,110% of Medicare,1289.4,35,,1289.4,percent of total billed charges,Implant Device,1252.56,34,"Charges > $500, x 34%",1252.56,percent of total billed charges,Implant Device,1289.4,35,,1289.4,percent of total billed charges,Implant Device,1289.4,35,,1289.4,percent of total billed charges,Implant Device,1289.4,35,,1289.4,percent of total billed charges,Implant Device,1289.4,35,,1289.4,percent of total billed charges,Implant Device,1289.4,35,,1289.4,percent of total billed charges,Implant Device,1473.6,40,,1473.6,percent of total billed charges,Implant Device,1289.4,70,,1289.4,percent of total billed charges,All Other,1252.56,34,,1252.56,percent of total billed charges,Implant Device,1252.56,34,,1252.56,percent of total billed charges,Implant Device,1289.4,35,,1289.4,percent of total billed charges,Implant Device,1289.4,35,,1289.4,percent of total billed charges,Implant Device,1289.4,35,,1289.4,percent of total billed charges,Implant Device,1289.4,35,,1289.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1252.56,34,"If Charge > 2,000, then 34 percent",1252.56,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2726.17,
MENTOR SMPX-240 GEL BREAST IMPLANT 240CC,C1789,HCPCS,,79009662,CDM,278,RC,,,both,,,3684,2726.17,,,2726.17,Other,150% of Medicare + 9.63% HCRA Surcharge,1657.8,45,,1657.8,percent of total billed charges,Critical Access Hospital RCC factor,1252.56,34,,1252.56,percent of total billed charges,Implant Device,1252.56,34,,1252.56,percent of total billed charges,Implant Device,1252.56,34,,1252.56,percent of total billed charges,Implant Device,1252.56,34,,1252.56,percent of total billed charges,Implant Device,1252.56,34,,1252.56,percent of total billed charges,Implant Device,1823.58,,,1823.58,Other,110% of Medicare,1289.4,35,,1289.4,percent of total billed charges,Implant Device,1252.56,34,"Charges > $500, x 34%",1252.56,percent of total billed charges,Implant Device,1289.4,35,,1289.4,percent of total billed charges,Implant Device,1289.4,35,,1289.4,percent of total billed charges,Implant Device,1289.4,35,,1289.4,percent of total billed charges,Implant Device,1289.4,35,,1289.4,percent of total billed charges,Implant Device,1289.4,35,,1289.4,percent of total billed charges,Implant Device,1473.6,40,,1473.6,percent of total billed charges,Implant Device,1289.4,70,,1289.4,percent of total billed charges,All Other,1252.56,34,,1252.56,percent of total billed charges,Implant Device,1252.56,34,,1252.56,percent of total billed charges,Implant Device,1289.4,35,,1289.4,percent of total billed charges,Implant Device,1289.4,35,,1289.4,percent of total billed charges,Implant Device,1289.4,35,,1289.4,percent of total billed charges,Implant Device,1289.4,35,,1289.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1252.56,34,"If Charge > 2,000, then 34 percent",1252.56,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2726.17,
MENTOR SMPX-270 GEL BREAST IMPLANT 270CC,C1789,HCPCS,,79009663,CDM,278,RC,,,both,,,3684,2726.17,,,2726.17,Other,150% of Medicare + 9.63% HCRA Surcharge,1657.8,45,,1657.8,percent of total billed charges,Critical Access Hospital RCC factor,1252.56,34,,1252.56,percent of total billed charges,Implant Device,1252.56,34,,1252.56,percent of total billed charges,Implant Device,1252.56,34,,1252.56,percent of total billed charges,Implant Device,1252.56,34,,1252.56,percent of total billed charges,Implant Device,1252.56,34,,1252.56,percent of total billed charges,Implant Device,1823.58,,,1823.58,Other,110% of Medicare,1289.4,35,,1289.4,percent of total billed charges,Implant Device,1252.56,34,"Charges > $500, x 34%",1252.56,percent of total billed charges,Implant Device,1289.4,35,,1289.4,percent of total billed charges,Implant Device,1289.4,35,,1289.4,percent of total billed charges,Implant Device,1289.4,35,,1289.4,percent of total billed charges,Implant Device,1289.4,35,,1289.4,percent of total billed charges,Implant Device,1289.4,35,,1289.4,percent of total billed charges,Implant Device,1473.6,40,,1473.6,percent of total billed charges,Implant Device,1289.4,70,,1289.4,percent of total billed charges,All Other,1252.56,34,,1252.56,percent of total billed charges,Implant Device,1252.56,34,,1252.56,percent of total billed charges,Implant Device,1289.4,35,,1289.4,percent of total billed charges,Implant Device,1289.4,35,,1289.4,percent of total billed charges,Implant Device,1289.4,35,,1289.4,percent of total billed charges,Implant Device,1289.4,35,,1289.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1252.56,34,"If Charge > 2,000, then 34 percent",1252.56,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2726.17,
MENTOR SMPX-295 GEL BREAST IMPLANT 295CC,C1789,HCPCS,,79009664,CDM,278,RC,,,both,,,3684,2726.17,,,2726.17,Other,150% of Medicare + 9.63% HCRA Surcharge,1657.8,45,,1657.8,percent of total billed charges,Critical Access Hospital RCC factor,1252.56,34,,1252.56,percent of total billed charges,Implant Device,1252.56,34,,1252.56,percent of total billed charges,Implant Device,1252.56,34,,1252.56,percent of total billed charges,Implant Device,1252.56,34,,1252.56,percent of total billed charges,Implant Device,1252.56,34,,1252.56,percent of total billed charges,Implant Device,1823.58,,,1823.58,Other,110% of Medicare,1289.4,35,,1289.4,percent of total billed charges,Implant Device,1252.56,34,"Charges > $500, x 34%",1252.56,percent of total billed charges,Implant Device,1289.4,35,,1289.4,percent of total billed charges,Implant Device,1289.4,35,,1289.4,percent of total billed charges,Implant Device,1289.4,35,,1289.4,percent of total billed charges,Implant Device,1289.4,35,,1289.4,percent of total billed charges,Implant Device,1289.4,35,,1289.4,percent of total billed charges,Implant Device,1473.6,40,,1473.6,percent of total billed charges,Implant Device,1289.4,70,,1289.4,percent of total billed charges,All Other,1252.56,34,,1252.56,percent of total billed charges,Implant Device,1252.56,34,,1252.56,percent of total billed charges,Implant Device,1289.4,35,,1289.4,percent of total billed charges,Implant Device,1289.4,35,,1289.4,percent of total billed charges,Implant Device,1289.4,35,,1289.4,percent of total billed charges,Implant Device,1289.4,35,,1289.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1252.56,34,"If Charge > 2,000, then 34 percent",1252.56,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2726.17,
STRYKER 53-23009E LOCKING SCREW 2.3X9MM,C1713,HCPCS,,79009669,CDM,278,RC,,,both,,,515,381.1,,,381.1,Other,150% of Medicare + 9.63% HCRA Surcharge,231.75,45,,231.75,percent of total billed charges,Critical Access Hospital RCC factor,175.1,34,,175.1,percent of total billed charges,Implant Device,175.1,34,,175.1,percent of total billed charges,Implant Device,175.1,34,,175.1,percent of total billed charges,Implant Device,175.1,34,,175.1,percent of total billed charges,Implant Device,175.1,34,,175.1,percent of total billed charges,Implant Device,254.93,,,254.93,Other,110% of Medicare,180.25,35,,180.25,percent of total billed charges,Implant Device,175.1,34,"Charges > $500, x 34%",175.1,percent of total billed charges,Implant Device,180.25,35,,180.25,percent of total billed charges,Implant Device,180.25,35,,180.25,percent of total billed charges,Implant Device,180.25,35,,180.25,percent of total billed charges,Implant Device,180.25,35,,180.25,percent of total billed charges,Implant Device,180.25,35,,180.25,percent of total billed charges,Implant Device,206,40,,206,percent of total billed charges,Implant Device,180.25,70,,180.25,percent of total billed charges,All Other,175.1,34,,175.1,percent of total billed charges,Implant Device,175.1,34,,175.1,percent of total billed charges,Implant Device,180.25,35,,180.25,percent of total billed charges,Implant Device,180.25,35,,180.25,percent of total billed charges,Implant Device,180.25,35,,180.25,percent of total billed charges,Implant Device,180.25,35,,180.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,381.1,
ACUMED CO-S2322 SMOOTH PEG 2.3X22MM,C1713,HCPCS,,79009670,CDM,278,RC,,,both,,,324,239.76,,,239.76,Other,150% of Medicare + 9.63% HCRA Surcharge,145.8,45,,145.8,percent of total billed charges,Critical Access Hospital RCC factor,110.16,34,,110.16,percent of total billed charges,Implant Device,110.16,34,,110.16,percent of total billed charges,Implant Device,110.16,34,,110.16,percent of total billed charges,Implant Device,110.16,34,,110.16,percent of total billed charges,Implant Device,110.16,34,,110.16,percent of total billed charges,Implant Device,160.38,,,160.38,Other,110% of Medicare,113.4,35,,113.4,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,129.6,40,,129.6,percent of total billed charges,Implant Device,113.4,70,,113.4,percent of total billed charges,All Other,110.16,34,,110.16,percent of total billed charges,Implant Device,110.16,34,,110.16,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,239.76,
ARTHREX AR-8967-2850 CANN SCREW 6.7X50MM,C1713,HCPCS,,79009671,CDM,278,RC,,,both,,,1074,794.76,,,794.76,Other,150% of Medicare + 9.63% HCRA Surcharge,483.3,45,,483.3,percent of total billed charges,Critical Access Hospital RCC factor,365.16,34,,365.16,percent of total billed charges,Implant Device,365.16,34,,365.16,percent of total billed charges,Implant Device,365.16,34,,365.16,percent of total billed charges,Implant Device,365.16,34,,365.16,percent of total billed charges,Implant Device,365.16,34,,365.16,percent of total billed charges,Implant Device,531.63,,,531.63,Other,110% of Medicare,375.9,35,,375.9,percent of total billed charges,Implant Device,365.16,34,"Charges > $500, x 34%",365.16,percent of total billed charges,Implant Device,375.9,35,,375.9,percent of total billed charges,Implant Device,375.9,35,,375.9,percent of total billed charges,Implant Device,375.9,35,,375.9,percent of total billed charges,Implant Device,375.9,35,,375.9,percent of total billed charges,Implant Device,375.9,35,,375.9,percent of total billed charges,Implant Device,429.6,40,,429.6,percent of total billed charges,Implant Device,375.9,70,,375.9,percent of total billed charges,All Other,365.16,34,,365.16,percent of total billed charges,Implant Device,365.16,34,,365.16,percent of total billed charges,Implant Device,375.9,35,,375.9,percent of total billed charges,Implant Device,375.9,35,,375.9,percent of total billed charges,Implant Device,375.9,35,,375.9,percent of total billed charges,Implant Device,375.9,35,,375.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,794.76,
ARTHREX AR-8967-2870 CANN SCREW 6.7X70MM,C1713,HCPCS,,79009672,CDM,278,RC,,,both,,,1074,794.76,,,794.76,Other,150% of Medicare + 9.63% HCRA Surcharge,483.3,45,,483.3,percent of total billed charges,Critical Access Hospital RCC factor,365.16,34,,365.16,percent of total billed charges,Implant Device,365.16,34,,365.16,percent of total billed charges,Implant Device,365.16,34,,365.16,percent of total billed charges,Implant Device,365.16,34,,365.16,percent of total billed charges,Implant Device,365.16,34,,365.16,percent of total billed charges,Implant Device,531.63,,,531.63,Other,110% of Medicare,375.9,35,,375.9,percent of total billed charges,Implant Device,365.16,34,"Charges > $500, x 34%",365.16,percent of total billed charges,Implant Device,375.9,35,,375.9,percent of total billed charges,Implant Device,375.9,35,,375.9,percent of total billed charges,Implant Device,375.9,35,,375.9,percent of total billed charges,Implant Device,375.9,35,,375.9,percent of total billed charges,Implant Device,375.9,35,,375.9,percent of total billed charges,Implant Device,429.6,40,,429.6,percent of total billed charges,Implant Device,375.9,70,,375.9,percent of total billed charges,All Other,365.16,34,,365.16,percent of total billed charges,Implant Device,365.16,34,,365.16,percent of total billed charges,Implant Device,375.9,35,,375.9,percent of total billed charges,Implant Device,375.9,35,,375.9,percent of total billed charges,Implant Device,375.9,35,,375.9,percent of total billed charges,Implant Device,375.9,35,,375.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,794.76,
ARTHREX ABS-2008-03 CORTICAL FIBER 5CC,C1713,HCPCS,,79009674,CDM,278,RC,,,both,,,2100,1554.01,,,1554.01,Other,150% of Medicare + 9.63% HCRA Surcharge,945,45,,945,percent of total billed charges,Critical Access Hospital RCC factor,714,34,,714,percent of total billed charges,Implant Device,714,34,,714,percent of total billed charges,Implant Device,714,34,,714,percent of total billed charges,Implant Device,714,34,,714,percent of total billed charges,Implant Device,714,34,,714,percent of total billed charges,Implant Device,1039.5,,,1039.5,Other,110% of Medicare,735,35,,735,percent of total billed charges,Implant Device,714,34,"Charges > $500, x 34%",714,percent of total billed charges,Implant Device,735,35,,735,percent of total billed charges,Implant Device,735,35,,735,percent of total billed charges,Implant Device,735,35,,735,percent of total billed charges,Implant Device,735,35,,735,percent of total billed charges,Implant Device,735,35,,735,percent of total billed charges,Implant Device,840,40,,840,percent of total billed charges,Implant Device,735,70,,735,percent of total billed charges,All Other,714,34,,714,percent of total billed charges,Implant Device,714,34,,714,percent of total billed charges,Implant Device,735,35,,735,percent of total billed charges,Implant Device,735,35,,735,percent of total billed charges,Implant Device,735,35,,735,percent of total billed charges,Implant Device,735,35,,735,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,714,34,"If Charge > 2,000, then 34 percent",714,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1554.01,
DEPUY 04.005.430 LOCKING SCREW 4.0X40MM,C1713,HCPCS,,79009677,CDM,278,RC,,,both,,,364,269.36,,,269.36,Other,150% of Medicare + 9.63% HCRA Surcharge,163.8,45,,163.8,percent of total billed charges,Critical Access Hospital RCC factor,123.76,34,,123.76,percent of total billed charges,Implant Device,123.76,34,,123.76,percent of total billed charges,Implant Device,123.76,34,,123.76,percent of total billed charges,Implant Device,123.76,34,,123.76,percent of total billed charges,Implant Device,123.76,34,,123.76,percent of total billed charges,Implant Device,180.18,,,180.18,Other,110% of Medicare,127.4,35,,127.4,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,127.4,35,,127.4,percent of total billed charges,Implant Device,127.4,35,,127.4,percent of total billed charges,Implant Device,127.4,35,,127.4,percent of total billed charges,Implant Device,127.4,35,,127.4,percent of total billed charges,Implant Device,127.4,35,,127.4,percent of total billed charges,Implant Device,145.6,40,,145.6,percent of total billed charges,Implant Device,127.4,70,,127.4,percent of total billed charges,All Other,123.76,34,,123.76,percent of total billed charges,Implant Device,123.76,34,,123.76,percent of total billed charges,Implant Device,127.4,35,,127.4,percent of total billed charges,Implant Device,127.4,35,,127.4,percent of total billed charges,Implant Device,127.4,35,,127.4,percent of total billed charges,Implant Device,127.4,35,,127.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,269.36,
DEPUY 04.001.426S CANN HUM NAIL 9X230MM,C1713,HCPCS,,79009679,CDM,278,RC,,,both,,,3810,2819.41,,,2819.41,Other,150% of Medicare + 9.63% HCRA Surcharge,1714.5,45,,1714.5,percent of total billed charges,Critical Access Hospital RCC factor,1295.4,34,,1295.4,percent of total billed charges,Implant Device,1295.4,34,,1295.4,percent of total billed charges,Implant Device,1295.4,34,,1295.4,percent of total billed charges,Implant Device,1295.4,34,,1295.4,percent of total billed charges,Implant Device,1295.4,34,,1295.4,percent of total billed charges,Implant Device,1885.95,,,1885.95,Other,110% of Medicare,1333.5,35,,1333.5,percent of total billed charges,Implant Device,1295.4,34,"Charges > $500, x 34%",1295.4,percent of total billed charges,Implant Device,1333.5,35,,1333.5,percent of total billed charges,Implant Device,1333.5,35,,1333.5,percent of total billed charges,Implant Device,1333.5,35,,1333.5,percent of total billed charges,Implant Device,1333.5,35,,1333.5,percent of total billed charges,Implant Device,1333.5,35,,1333.5,percent of total billed charges,Implant Device,1524,40,,1524,percent of total billed charges,Implant Device,1333.5,70,,1333.5,percent of total billed charges,All Other,1295.4,34,,1295.4,percent of total billed charges,Implant Device,1295.4,34,,1295.4,percent of total billed charges,Implant Device,1333.5,35,,1333.5,percent of total billed charges,Implant Device,1333.5,35,,1333.5,percent of total billed charges,Implant Device,1333.5,35,,1333.5,percent of total billed charges,Implant Device,1333.5,35,,1333.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1295.4,34,"If Charge > 2,000, then 34 percent",1295.4,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2819.41,
ZIMMER 14250-30 CANN SCREW 4.5X30MM,C1713,HCPCS,,79009680,CDM,278,RC,,,both,,,468,346.32,,,346.32,Other,150% of Medicare + 9.63% HCRA Surcharge,210.6,45,,210.6,percent of total billed charges,Critical Access Hospital RCC factor,159.12,34,,159.12,percent of total billed charges,Implant Device,159.12,34,,159.12,percent of total billed charges,Implant Device,159.12,34,,159.12,percent of total billed charges,Implant Device,159.12,34,,159.12,percent of total billed charges,Implant Device,159.12,34,,159.12,percent of total billed charges,Implant Device,231.66,,,231.66,Other,110% of Medicare,163.8,35,,163.8,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,163.8,35,,163.8,percent of total billed charges,Implant Device,163.8,35,,163.8,percent of total billed charges,Implant Device,163.8,35,,163.8,percent of total billed charges,Implant Device,163.8,35,,163.8,percent of total billed charges,Implant Device,163.8,35,,163.8,percent of total billed charges,Implant Device,187.2,40,,187.2,percent of total billed charges,Implant Device,163.8,70,,163.8,percent of total billed charges,All Other,159.12,34,,159.12,percent of total billed charges,Implant Device,159.12,34,,159.12,percent of total billed charges,Implant Device,163.8,35,,163.8,percent of total billed charges,Implant Device,163.8,35,,163.8,percent of total billed charges,Implant Device,163.8,35,,163.8,percent of total billed charges,Implant Device,163.8,35,,163.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,346.32,
ZIMMER 14200-20 CANN SCREW 4.5X20MM,C1713,HCPCS,,79009681,CDM,278,RC,,,both,,,468,346.32,,,346.32,Other,150% of Medicare + 9.63% HCRA Surcharge,210.6,45,,210.6,percent of total billed charges,Critical Access Hospital RCC factor,159.12,34,,159.12,percent of total billed charges,Implant Device,159.12,34,,159.12,percent of total billed charges,Implant Device,159.12,34,,159.12,percent of total billed charges,Implant Device,159.12,34,,159.12,percent of total billed charges,Implant Device,159.12,34,,159.12,percent of total billed charges,Implant Device,231.66,,,231.66,Other,110% of Medicare,163.8,35,,163.8,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,163.8,35,,163.8,percent of total billed charges,Implant Device,163.8,35,,163.8,percent of total billed charges,Implant Device,163.8,35,,163.8,percent of total billed charges,Implant Device,163.8,35,,163.8,percent of total billed charges,Implant Device,163.8,35,,163.8,percent of total billed charges,Implant Device,187.2,40,,187.2,percent of total billed charges,Implant Device,163.8,70,,163.8,percent of total billed charges,All Other,159.12,34,,159.12,percent of total billed charges,Implant Device,159.12,34,,159.12,percent of total billed charges,Implant Device,163.8,35,,163.8,percent of total billed charges,Implant Device,163.8,35,,163.8,percent of total billed charges,Implant Device,163.8,35,,163.8,percent of total billed charges,Implant Device,163.8,35,,163.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,346.32,
DEPSYN 1221-32-050 ACET LINER 32 X50 MM,C1776,HCPCS,,79009683,CDM,278,RC,,,both,,,2565,1898.11,,,1898.11,Other,150% of Medicare + 9.63% HCRA Surcharge,1154.25,45,,1154.25,percent of total billed charges,Critical Access Hospital RCC factor,872.1,34,,872.1,percent of total billed charges,Implant Device,872.1,34,,872.1,percent of total billed charges,Implant Device,872.1,34,,872.1,percent of total billed charges,Implant Device,872.1,34,,872.1,percent of total billed charges,Implant Device,872.1,34,,872.1,percent of total billed charges,Implant Device,1269.68,,,1269.68,Other,110% of Medicare,897.75,35,,897.75,percent of total billed charges,Implant Device,872.1,34,"Charges > $500, x 34%",872.1,percent of total billed charges,Implant Device,897.75,35,,897.75,percent of total billed charges,Implant Device,897.75,35,,897.75,percent of total billed charges,Implant Device,897.75,35,,897.75,percent of total billed charges,Implant Device,897.75,35,,897.75,percent of total billed charges,Implant Device,897.75,35,,897.75,percent of total billed charges,Implant Device,1026,40,,1026,percent of total billed charges,Implant Device,897.75,70,,897.75,percent of total billed charges,All Other,872.1,34,,872.1,percent of total billed charges,Implant Device,872.1,34,,872.1,percent of total billed charges,Implant Device,897.75,35,,897.75,percent of total billed charges,Implant Device,897.75,35,,897.75,percent of total billed charges,Implant Device,897.75,35,,897.75,percent of total billed charges,Implant Device,897.75,35,,897.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,872.1,34,"If Charge > 2,000, then 34 percent",872.1,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1898.11,
PARA P50-353-3530 LOCKING SCREW 3.5X30MM,C1713,HCPCS,,79009684,CDM,278,RC,,,both,,,791,585.34,,,585.34,Other,150% of Medicare + 9.63% HCRA Surcharge,355.95,45,,355.95,percent of total billed charges,Critical Access Hospital RCC factor,268.94,34,,268.94,percent of total billed charges,Implant Device,268.94,34,,268.94,percent of total billed charges,Implant Device,268.94,34,,268.94,percent of total billed charges,Implant Device,268.94,34,,268.94,percent of total billed charges,Implant Device,268.94,34,,268.94,percent of total billed charges,Implant Device,391.55,,,391.55,Other,110% of Medicare,276.85,35,,276.85,percent of total billed charges,Implant Device,268.94,34,"Charges > $500, x 34%",268.94,percent of total billed charges,Implant Device,276.85,35,,276.85,percent of total billed charges,Implant Device,276.85,35,,276.85,percent of total billed charges,Implant Device,276.85,35,,276.85,percent of total billed charges,Implant Device,276.85,35,,276.85,percent of total billed charges,Implant Device,276.85,35,,276.85,percent of total billed charges,Implant Device,316.4,40,,316.4,percent of total billed charges,Implant Device,276.85,70,,276.85,percent of total billed charges,All Other,268.94,34,,268.94,percent of total billed charges,Implant Device,268.94,34,,268.94,percent of total billed charges,Implant Device,276.85,35,,276.85,percent of total billed charges,Implant Device,276.85,35,,276.85,percent of total billed charges,Implant Device,276.85,35,,276.85,percent of total billed charges,Implant Device,276.85,35,,276.85,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,585.34,
PARA P50-353-4234 LOCKING SCREW 4.2X34MM,C1713,HCPCS,,79009685,CDM,278,RC,,,both,,,816,603.84,,,603.84,Other,150% of Medicare + 9.63% HCRA Surcharge,367.2,45,,367.2,percent of total billed charges,Critical Access Hospital RCC factor,277.44,34,,277.44,percent of total billed charges,Implant Device,277.44,34,,277.44,percent of total billed charges,Implant Device,277.44,34,,277.44,percent of total billed charges,Implant Device,277.44,34,,277.44,percent of total billed charges,Implant Device,277.44,34,,277.44,percent of total billed charges,Implant Device,403.92,,,403.92,Other,110% of Medicare,285.6,35,,285.6,percent of total billed charges,Implant Device,277.44,34,"Charges > $500, x 34%",277.44,percent of total billed charges,Implant Device,285.6,35,,285.6,percent of total billed charges,Implant Device,285.6,35,,285.6,percent of total billed charges,Implant Device,285.6,35,,285.6,percent of total billed charges,Implant Device,285.6,35,,285.6,percent of total billed charges,Implant Device,285.6,35,,285.6,percent of total billed charges,Implant Device,326.4,40,,326.4,percent of total billed charges,Implant Device,285.6,70,,285.6,percent of total billed charges,All Other,277.44,34,,277.44,percent of total billed charges,Implant Device,277.44,34,,277.44,percent of total billed charges,Implant Device,285.6,35,,285.6,percent of total billed charges,Implant Device,285.6,35,,285.6,percent of total billed charges,Implant Device,285.6,35,,285.6,percent of total billed charges,Implant Device,285.6,35,,285.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,603.84,
PARAGON 28 P99-192-2515 K WIRE 2.5MM,C1713,HCPCS,,79009686,CDM,278,RC,,,both,,,102,75.48,,,75.48,Other,150% of Medicare + 9.63% HCRA Surcharge,45.9,45,,45.9,percent of total billed charges,Critical Access Hospital RCC factor,34.68,34,,34.68,percent of total billed charges,Implant Device,34.68,34,,34.68,percent of total billed charges,Implant Device,34.68,34,,34.68,percent of total billed charges,Implant Device,34.68,34,,34.68,percent of total billed charges,Implant Device,34.68,34,,34.68,percent of total billed charges,Implant Device,50.49,,,50.49,Other,110% of Medicare,35.7,35,,35.7,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,35.7,35,,35.7,percent of total billed charges,Implant Device,35.7,35,,35.7,percent of total billed charges,Implant Device,35.7,35,,35.7,percent of total billed charges,Implant Device,35.7,35,,35.7,percent of total billed charges,Implant Device,35.7,35,,35.7,percent of total billed charges,Implant Device,40.8,40,,40.8,percent of total billed charges,Implant Device,35.7,70,,35.7,percent of total billed charges,All Other,34.68,34,,34.68,percent of total billed charges,Implant Device,34.68,34,,34.68,percent of total billed charges,Implant Device,35.7,35,,35.7,percent of total billed charges,Implant Device,35.7,35,,35.7,percent of total billed charges,Implant Device,35.7,35,,35.7,percent of total billed charges,Implant Device,35.7,35,,35.7,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,75.48,
MW SMXP150RH BRST TISSUE EXPANDERS 750CC,C1789,HCPCS,,79009690,CDM,278,RC,,,both,,,6375,4717.52,,,4717.52,Other,150% of Medicare + 9.63% HCRA Surcharge,2868.75,45,,2868.75,percent of total billed charges,Critical Access Hospital RCC factor,2167.5,34,,2167.5,percent of total billed charges,Implant Device,2167.5,34,,2167.5,percent of total billed charges,Implant Device,2167.5,34,,2167.5,percent of total billed charges,Implant Device,2167.5,34,,2167.5,percent of total billed charges,Implant Device,2167.5,34,,2167.5,percent of total billed charges,Implant Device,3155.63,,,3155.63,Other,110% of Medicare,2231.25,35,,2231.25,percent of total billed charges,Implant Device,2167.5,34,"Charges > $500, x 34%",2167.5,percent of total billed charges,Implant Device,2231.25,35,,2231.25,percent of total billed charges,Implant Device,2231.25,35,,2231.25,percent of total billed charges,Implant Device,2231.25,35,,2231.25,percent of total billed charges,Implant Device,2231.25,35,,2231.25,percent of total billed charges,Implant Device,2231.25,35,,2231.25,percent of total billed charges,Implant Device,2550,40,,2550,percent of total billed charges,Implant Device,2231.25,70,,2231.25,percent of total billed charges,All Other,2167.5,34,,2167.5,percent of total billed charges,Implant Device,2167.5,34,,2167.5,percent of total billed charges,Implant Device,2231.25,35,,2231.25,percent of total billed charges,Implant Device,2231.25,35,,2231.25,percent of total billed charges,Implant Device,2231.25,35,,2231.25,percent of total billed charges,Implant Device,2231.25,35,,2231.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2167.5,34,"If Charge > 2,000, then 34 percent",2167.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4717.52,
MW SMXP155RH BRST TISSUE EXPANDERS 850CC,C1789,HCPCS,,79009691,CDM,278,RC,,,both,,,6375,4717.52,,,4717.52,Other,150% of Medicare + 9.63% HCRA Surcharge,2868.75,45,,2868.75,percent of total billed charges,Critical Access Hospital RCC factor,2167.5,34,,2167.5,percent of total billed charges,Implant Device,2167.5,34,,2167.5,percent of total billed charges,Implant Device,2167.5,34,,2167.5,percent of total billed charges,Implant Device,2167.5,34,,2167.5,percent of total billed charges,Implant Device,2167.5,34,,2167.5,percent of total billed charges,Implant Device,3155.63,,,3155.63,Other,110% of Medicare,2231.25,35,,2231.25,percent of total billed charges,Implant Device,2167.5,34,"Charges > $500, x 34%",2167.5,percent of total billed charges,Implant Device,2231.25,35,,2231.25,percent of total billed charges,Implant Device,2231.25,35,,2231.25,percent of total billed charges,Implant Device,2231.25,35,,2231.25,percent of total billed charges,Implant Device,2231.25,35,,2231.25,percent of total billed charges,Implant Device,2231.25,35,,2231.25,percent of total billed charges,Implant Device,2550,40,,2550,percent of total billed charges,Implant Device,2231.25,70,,2231.25,percent of total billed charges,All Other,2167.5,34,,2167.5,percent of total billed charges,Implant Device,2167.5,34,,2167.5,percent of total billed charges,Implant Device,2231.25,35,,2231.25,percent of total billed charges,Implant Device,2231.25,35,,2231.25,percent of total billed charges,Implant Device,2231.25,35,,2231.25,percent of total billed charges,Implant Device,2231.25,35,,2231.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2167.5,34,"If Charge > 2,000, then 34 percent",2167.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4717.52,
MW SMPX605 MEMORY GEL IMPLANTS 605CC,C1789,HCPCS,,79009692,CDM,278,RC,,,both,,,3684,2726.17,,,2726.17,Other,150% of Medicare + 9.63% HCRA Surcharge,1657.8,45,,1657.8,percent of total billed charges,Critical Access Hospital RCC factor,1252.56,34,,1252.56,percent of total billed charges,Implant Device,1252.56,34,,1252.56,percent of total billed charges,Implant Device,1252.56,34,,1252.56,percent of total billed charges,Implant Device,1252.56,34,,1252.56,percent of total billed charges,Implant Device,1252.56,34,,1252.56,percent of total billed charges,Implant Device,1823.58,,,1823.58,Other,110% of Medicare,1289.4,35,,1289.4,percent of total billed charges,Implant Device,1252.56,34,"Charges > $500, x 34%",1252.56,percent of total billed charges,Implant Device,1289.4,35,,1289.4,percent of total billed charges,Implant Device,1289.4,35,,1289.4,percent of total billed charges,Implant Device,1289.4,35,,1289.4,percent of total billed charges,Implant Device,1289.4,35,,1289.4,percent of total billed charges,Implant Device,1289.4,35,,1289.4,percent of total billed charges,Implant Device,1473.6,40,,1473.6,percent of total billed charges,Implant Device,1289.4,70,,1289.4,percent of total billed charges,All Other,1252.56,34,,1252.56,percent of total billed charges,Implant Device,1252.56,34,,1252.56,percent of total billed charges,Implant Device,1289.4,35,,1289.4,percent of total billed charges,Implant Device,1289.4,35,,1289.4,percent of total billed charges,Implant Device,1289.4,35,,1289.4,percent of total billed charges,Implant Device,1289.4,35,,1289.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1252.56,34,"If Charge > 2,000, then 34 percent",1252.56,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2726.17,
MW SMPX630 MEMORY GEL IMPLANTS 630CC,C1789,HCPCS,,79009693,CDM,278,RC,,,both,,,3684,2726.17,,,2726.17,Other,150% of Medicare + 9.63% HCRA Surcharge,1657.8,45,,1657.8,percent of total billed charges,Critical Access Hospital RCC factor,1252.56,34,,1252.56,percent of total billed charges,Implant Device,1252.56,34,,1252.56,percent of total billed charges,Implant Device,1252.56,34,,1252.56,percent of total billed charges,Implant Device,1252.56,34,,1252.56,percent of total billed charges,Implant Device,1252.56,34,,1252.56,percent of total billed charges,Implant Device,1823.58,,,1823.58,Other,110% of Medicare,1289.4,35,,1289.4,percent of total billed charges,Implant Device,1252.56,34,"Charges > $500, x 34%",1252.56,percent of total billed charges,Implant Device,1289.4,35,,1289.4,percent of total billed charges,Implant Device,1289.4,35,,1289.4,percent of total billed charges,Implant Device,1289.4,35,,1289.4,percent of total billed charges,Implant Device,1289.4,35,,1289.4,percent of total billed charges,Implant Device,1289.4,35,,1289.4,percent of total billed charges,Implant Device,1473.6,40,,1473.6,percent of total billed charges,Implant Device,1289.4,70,,1289.4,percent of total billed charges,All Other,1252.56,34,,1252.56,percent of total billed charges,Implant Device,1252.56,34,,1252.56,percent of total billed charges,Implant Device,1289.4,35,,1289.4,percent of total billed charges,Implant Device,1289.4,35,,1289.4,percent of total billed charges,Implant Device,1289.4,35,,1289.4,percent of total billed charges,Implant Device,1289.4,35,,1289.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1252.56,34,"If Charge > 2,000, then 34 percent",1252.56,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2726.17,
MW SMPX685 MEMORY GEL IMPLANTS 685CC,C1789,HCPCS,,79009694,CDM,278,RC,,,both,,,3684,2726.17,,,2726.17,Other,150% of Medicare + 9.63% HCRA Surcharge,1657.8,45,,1657.8,percent of total billed charges,Critical Access Hospital RCC factor,1252.56,34,,1252.56,percent of total billed charges,Implant Device,1252.56,34,,1252.56,percent of total billed charges,Implant Device,1252.56,34,,1252.56,percent of total billed charges,Implant Device,1252.56,34,,1252.56,percent of total billed charges,Implant Device,1252.56,34,,1252.56,percent of total billed charges,Implant Device,1823.58,,,1823.58,Other,110% of Medicare,1289.4,35,,1289.4,percent of total billed charges,Implant Device,1252.56,34,"Charges > $500, x 34%",1252.56,percent of total billed charges,Implant Device,1289.4,35,,1289.4,percent of total billed charges,Implant Device,1289.4,35,,1289.4,percent of total billed charges,Implant Device,1289.4,35,,1289.4,percent of total billed charges,Implant Device,1289.4,35,,1289.4,percent of total billed charges,Implant Device,1289.4,35,,1289.4,percent of total billed charges,Implant Device,1473.6,40,,1473.6,percent of total billed charges,Implant Device,1289.4,70,,1289.4,percent of total billed charges,All Other,1252.56,34,,1252.56,percent of total billed charges,Implant Device,1252.56,34,,1252.56,percent of total billed charges,Implant Device,1289.4,35,,1289.4,percent of total billed charges,Implant Device,1289.4,35,,1289.4,percent of total billed charges,Implant Device,1289.4,35,,1289.4,percent of total billed charges,Implant Device,1289.4,35,,1289.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1252.56,34,"If Charge > 2,000, then 34 percent",1252.56,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2726.17,
MW SMPX755 MEMORY GEL IMPLANTS 755CC,C1789,HCPCS,,79009695,CDM,278,RC,,,both,,,3684,2726.17,,,2726.17,Other,150% of Medicare + 9.63% HCRA Surcharge,1657.8,45,,1657.8,percent of total billed charges,Critical Access Hospital RCC factor,1252.56,34,,1252.56,percent of total billed charges,Implant Device,1252.56,34,,1252.56,percent of total billed charges,Implant Device,1252.56,34,,1252.56,percent of total billed charges,Implant Device,1252.56,34,,1252.56,percent of total billed charges,Implant Device,1252.56,34,,1252.56,percent of total billed charges,Implant Device,1823.58,,,1823.58,Other,110% of Medicare,1289.4,35,,1289.4,percent of total billed charges,Implant Device,1252.56,34,"Charges > $500, x 34%",1252.56,percent of total billed charges,Implant Device,1289.4,35,,1289.4,percent of total billed charges,Implant Device,1289.4,35,,1289.4,percent of total billed charges,Implant Device,1289.4,35,,1289.4,percent of total billed charges,Implant Device,1289.4,35,,1289.4,percent of total billed charges,Implant Device,1289.4,35,,1289.4,percent of total billed charges,Implant Device,1473.6,40,,1473.6,percent of total billed charges,Implant Device,1289.4,70,,1289.4,percent of total billed charges,All Other,1252.56,34,,1252.56,percent of total billed charges,Implant Device,1252.56,34,,1252.56,percent of total billed charges,Implant Device,1289.4,35,,1289.4,percent of total billed charges,Implant Device,1289.4,35,,1289.4,percent of total billed charges,Implant Device,1289.4,35,,1289.4,percent of total billed charges,Implant Device,1289.4,35,,1289.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1252.56,34,"If Charge > 2,000, then 34 percent",1252.56,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2726.17,
ALLERGAN 151672 ALLODERM 6X12CM RTU THIN,C1781,HCPCS,,79009697,CDM,278,RC,,,both,,,9510,7037.42,,,7037.42,Other,150% of Medicare + 9.63% HCRA Surcharge,4279.5,45,,4279.5,percent of total billed charges,Critical Access Hospital RCC factor,3233.4,34,,3233.4,percent of total billed charges,Implant Device,3233.4,34,,3233.4,percent of total billed charges,Implant Device,3233.4,34,,3233.4,percent of total billed charges,Implant Device,3233.4,34,,3233.4,percent of total billed charges,Implant Device,3233.4,34,,3233.4,percent of total billed charges,Implant Device,4707.45,,,4707.45,Other,110% of Medicare,3328.5,35,,3328.5,percent of total billed charges,Implant Device,3233.4,34,"Charges > $500, x 34%",3233.4,percent of total billed charges,Implant Device,3328.5,35,,3328.5,percent of total billed charges,Implant Device,3328.5,35,,3328.5,percent of total billed charges,Implant Device,3328.5,35,,3328.5,percent of total billed charges,Implant Device,3328.5,35,,3328.5,percent of total billed charges,Implant Device,3328.5,35,,3328.5,percent of total billed charges,Implant Device,3804,40,,3804,percent of total billed charges,Implant Device,3328.5,70,,3328.5,percent of total billed charges,All Other,3233.4,34,,3233.4,percent of total billed charges,Implant Device,3233.4,34,,3233.4,percent of total billed charges,Implant Device,3328.5,35,,3328.5,percent of total billed charges,Implant Device,3328.5,35,,3328.5,percent of total billed charges,Implant Device,3328.5,35,,3328.5,percent of total billed charges,Implant Device,3328.5,35,,3328.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3233.4,34,"If Charge > 2,000, then 34 percent",3233.4,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,7037.42,
ZIMMER 11-363660 MODULAR HEAD COMP 6MM,C1776,HCPCS,,79009698,CDM,278,RC,,,both,,,1152,852.48,,,852.48,Other,150% of Medicare + 9.63% HCRA Surcharge,518.4,45,,518.4,percent of total billed charges,Critical Access Hospital RCC factor,391.68,34,,391.68,percent of total billed charges,Implant Device,391.68,34,,391.68,percent of total billed charges,Implant Device,391.68,34,,391.68,percent of total billed charges,Implant Device,391.68,34,,391.68,percent of total billed charges,Implant Device,391.68,34,,391.68,percent of total billed charges,Implant Device,570.24,,,570.24,Other,110% of Medicare,403.2,35,,403.2,percent of total billed charges,Implant Device,391.68,34,"Charges > $500, x 34%",391.68,percent of total billed charges,Implant Device,403.2,35,,403.2,percent of total billed charges,Implant Device,403.2,35,,403.2,percent of total billed charges,Implant Device,403.2,35,,403.2,percent of total billed charges,Implant Device,403.2,35,,403.2,percent of total billed charges,Implant Device,403.2,35,,403.2,percent of total billed charges,Implant Device,460.8,40,,460.8,percent of total billed charges,Implant Device,403.2,70,,403.2,percent of total billed charges,All Other,391.68,34,,391.68,percent of total billed charges,Implant Device,391.68,34,,391.68,percent of total billed charges,Implant Device,403.2,35,,403.2,percent of total billed charges,Implant Device,403.2,35,,403.2,percent of total billed charges,Implant Device,403.2,35,,403.2,percent of total billed charges,Implant Device,403.2,35,,403.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,852.48,
ZIMMER 11-300815 STS DISTAL STEM 15X150,C1776,HCPCS,,79009699,CDM,278,RC,,,both,,,10199,7547.29,,,7547.29,Other,150% of Medicare + 9.63% HCRA Surcharge,4589.55,45,,4589.55,percent of total billed charges,Critical Access Hospital RCC factor,3467.66,34,,3467.66,percent of total billed charges,Implant Device,3467.66,34,,3467.66,percent of total billed charges,Implant Device,3467.66,34,,3467.66,percent of total billed charges,Implant Device,3467.66,34,,3467.66,percent of total billed charges,Implant Device,3467.66,34,,3467.66,percent of total billed charges,Implant Device,5048.51,,,5048.51,Other,110% of Medicare,3569.65,35,,3569.65,percent of total billed charges,Implant Device,3467.66,34,"Charges > $500, x 34%",3467.66,percent of total billed charges,Implant Device,3569.65,35,,3569.65,percent of total billed charges,Implant Device,3569.65,35,,3569.65,percent of total billed charges,Implant Device,3569.65,35,,3569.65,percent of total billed charges,Implant Device,3569.65,35,,3569.65,percent of total billed charges,Implant Device,3569.65,35,,3569.65,percent of total billed charges,Implant Device,4079.6,40,,4079.6,percent of total billed charges,Implant Device,3569.65,70,,3569.65,percent of total billed charges,All Other,3467.66,34,,3467.66,percent of total billed charges,Implant Device,3467.66,34,,3467.66,percent of total billed charges,Implant Device,3569.65,35,,3569.65,percent of total billed charges,Implant Device,3569.65,35,,3569.65,percent of total billed charges,Implant Device,3569.65,35,,3569.65,percent of total billed charges,Implant Device,3569.65,35,,3569.65,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3467.66,34,"If Charge > 2,000, then 34 percent",3467.66,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,7547.29,
ARTHREX AR-8724V-10 LOCK SCREW 2.4X10,C1713,HCPCS,,79009700,CDM,278,RC,,,both,,,420,310.8,,,310.8,Other,150% of Medicare + 9.63% HCRA Surcharge,189,45,,189,percent of total billed charges,Critical Access Hospital RCC factor,142.8,34,,142.8,percent of total billed charges,Implant Device,142.8,34,,142.8,percent of total billed charges,Implant Device,142.8,34,,142.8,percent of total billed charges,Implant Device,142.8,34,,142.8,percent of total billed charges,Implant Device,142.8,34,,142.8,percent of total billed charges,Implant Device,207.9,,,207.9,Other,110% of Medicare,147,35,,147,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,147,35,,147,percent of total billed charges,Implant Device,147,35,,147,percent of total billed charges,Implant Device,147,35,,147,percent of total billed charges,Implant Device,147,35,,147,percent of total billed charges,Implant Device,147,35,,147,percent of total billed charges,Implant Device,168,40,,168,percent of total billed charges,Implant Device,147,70,,147,percent of total billed charges,All Other,142.8,34,,142.8,percent of total billed charges,Implant Device,142.8,34,,142.8,percent of total billed charges,Implant Device,147,35,,147,percent of total billed charges,Implant Device,147,35,,147,percent of total billed charges,Implant Device,147,35,,147,percent of total billed charges,Implant Device,147,35,,147,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,310.8,
DEPUY 04.005.424 LOCKING SCREW 4X34MM,C1713,HCPCS,,79009701,CDM,278,RC,,,both,,,364,269.36,,,269.36,Other,150% of Medicare + 9.63% HCRA Surcharge,163.8,45,,163.8,percent of total billed charges,Critical Access Hospital RCC factor,123.76,34,,123.76,percent of total billed charges,Implant Device,123.76,34,,123.76,percent of total billed charges,Implant Device,123.76,34,,123.76,percent of total billed charges,Implant Device,123.76,34,,123.76,percent of total billed charges,Implant Device,123.76,34,,123.76,percent of total billed charges,Implant Device,180.18,,,180.18,Other,110% of Medicare,127.4,35,,127.4,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,127.4,35,,127.4,percent of total billed charges,Implant Device,127.4,35,,127.4,percent of total billed charges,Implant Device,127.4,35,,127.4,percent of total billed charges,Implant Device,127.4,35,,127.4,percent of total billed charges,Implant Device,127.4,35,,127.4,percent of total billed charges,Implant Device,145.6,40,,145.6,percent of total billed charges,Implant Device,127.4,70,,127.4,percent of total billed charges,All Other,123.76,34,,123.76,percent of total billed charges,Implant Device,123.76,34,,123.76,percent of total billed charges,Implant Device,127.4,35,,127.4,percent of total billed charges,Implant Device,127.4,35,,127.4,percent of total billed charges,Implant Device,127.4,35,,127.4,percent of total billed charges,Implant Device,127.4,35,,127.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,269.36,
DEPUY 04.001.232S CANN HUM NAIL 7X260MM,C1713,HCPCS,,79009702,CDM,278,RC,,,both,,,3810,2819.41,,,2819.41,Other,150% of Medicare + 9.63% HCRA Surcharge,1714.5,45,,1714.5,percent of total billed charges,Critical Access Hospital RCC factor,1295.4,34,,1295.4,percent of total billed charges,Implant Device,1295.4,34,,1295.4,percent of total billed charges,Implant Device,1295.4,34,,1295.4,percent of total billed charges,Implant Device,1295.4,34,,1295.4,percent of total billed charges,Implant Device,1295.4,34,,1295.4,percent of total billed charges,Implant Device,1885.95,,,1885.95,Other,110% of Medicare,1333.5,35,,1333.5,percent of total billed charges,Implant Device,1295.4,34,"Charges > $500, x 34%",1295.4,percent of total billed charges,Implant Device,1333.5,35,,1333.5,percent of total billed charges,Implant Device,1333.5,35,,1333.5,percent of total billed charges,Implant Device,1333.5,35,,1333.5,percent of total billed charges,Implant Device,1333.5,35,,1333.5,percent of total billed charges,Implant Device,1333.5,35,,1333.5,percent of total billed charges,Implant Device,1524,40,,1524,percent of total billed charges,Implant Device,1333.5,70,,1333.5,percent of total billed charges,All Other,1295.4,34,,1295.4,percent of total billed charges,Implant Device,1295.4,34,,1295.4,percent of total billed charges,Implant Device,1333.5,35,,1333.5,percent of total billed charges,Implant Device,1333.5,35,,1333.5,percent of total billed charges,Implant Device,1333.5,35,,1333.5,percent of total billed charges,Implant Device,1333.5,35,,1333.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1295.4,34,"If Charge > 2,000, then 34 percent",1295.4,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2819.41,
STRYKER 5017-3-150S HALF PIN SD 30X150MM,C1713,HCPCS,,79009704,CDM,278,RC,,,both,,,437,323.38,,,323.38,Other,150% of Medicare + 9.63% HCRA Surcharge,196.65,45,,196.65,percent of total billed charges,Critical Access Hospital RCC factor,148.58,34,,148.58,percent of total billed charges,Implant Device,148.58,34,,148.58,percent of total billed charges,Implant Device,148.58,34,,148.58,percent of total billed charges,Implant Device,148.58,34,,148.58,percent of total billed charges,Implant Device,148.58,34,,148.58,percent of total billed charges,Implant Device,216.32,,,216.32,Other,110% of Medicare,152.95,35,,152.95,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,152.95,35,,152.95,percent of total billed charges,Implant Device,152.95,35,,152.95,percent of total billed charges,Implant Device,152.95,35,,152.95,percent of total billed charges,Implant Device,152.95,35,,152.95,percent of total billed charges,Implant Device,152.95,35,,152.95,percent of total billed charges,Implant Device,174.8,40,,174.8,percent of total billed charges,Implant Device,152.95,70,,152.95,percent of total billed charges,All Other,148.58,34,,148.58,percent of total billed charges,Implant Device,148.58,34,,148.58,percent of total billed charges,Implant Device,152.95,35,,152.95,percent of total billed charges,Implant Device,152.95,35,,152.95,percent of total billed charges,Implant Device,152.95,35,,152.95,percent of total billed charges,Implant Device,152.95,35,,152.95,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,323.38,
STRYKER 5038-1-080 APEX 3X80MM HALF PIN,C1713,HCPCS,,79009706,CDM,278,RC,,,both,,,114,84.36,,,84.36,Other,150% of Medicare + 9.63% HCRA Surcharge,51.3,45,,51.3,percent of total billed charges,Critical Access Hospital RCC factor,38.76,34,,38.76,percent of total billed charges,Implant Device,38.76,34,,38.76,percent of total billed charges,Implant Device,38.76,34,,38.76,percent of total billed charges,Implant Device,38.76,34,,38.76,percent of total billed charges,Implant Device,38.76,34,,38.76,percent of total billed charges,Implant Device,56.43,,,56.43,Other,110% of Medicare,39.9,35,,39.9,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,39.9,35,,39.9,percent of total billed charges,Implant Device,39.9,35,,39.9,percent of total billed charges,Implant Device,39.9,35,,39.9,percent of total billed charges,Implant Device,39.9,35,,39.9,percent of total billed charges,Implant Device,39.9,35,,39.9,percent of total billed charges,Implant Device,45.6,40,,45.6,percent of total billed charges,Implant Device,39.9,70,,39.9,percent of total billed charges,All Other,38.76,34,,38.76,percent of total billed charges,Implant Device,38.76,34,,38.76,percent of total billed charges,Implant Device,39.9,35,,39.9,percent of total billed charges,Implant Device,39.9,35,,39.9,percent of total billed charges,Implant Device,39.9,35,,39.9,percent of total billed charges,Implant Device,39.9,35,,39.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,84.36,
STRYKER 5070-4-312 TRANSFIX 1.5X43,C1713,HCPCS,,79009707,CDM,278,RC,,,both,,,216,159.84,,,159.84,Other,150% of Medicare + 9.63% HCRA Surcharge,97.2,45,,97.2,percent of total billed charges,Critical Access Hospital RCC factor,73.44,34,,73.44,percent of total billed charges,Implant Device,73.44,34,,73.44,percent of total billed charges,Implant Device,73.44,34,,73.44,percent of total billed charges,Implant Device,73.44,34,,73.44,percent of total billed charges,Implant Device,73.44,34,,73.44,percent of total billed charges,Implant Device,106.92,,,106.92,Other,110% of Medicare,75.6,35,,75.6,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,75.6,35,,75.6,percent of total billed charges,Implant Device,75.6,35,,75.6,percent of total billed charges,Implant Device,75.6,35,,75.6,percent of total billed charges,Implant Device,75.6,35,,75.6,percent of total billed charges,Implant Device,75.6,35,,75.6,percent of total billed charges,Implant Device,86.4,40,,86.4,percent of total billed charges,Implant Device,75.6,70,,75.6,percent of total billed charges,All Other,73.44,34,,73.44,percent of total billed charges,Implant Device,73.44,34,,73.44,percent of total billed charges,Implant Device,75.6,35,,75.6,percent of total billed charges,Implant Device,75.6,35,,75.6,percent of total billed charges,Implant Device,75.6,35,,75.6,percent of total billed charges,Implant Device,75.6,35,,75.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,159.84,
ZIMMER 00-7711-011-10 FEMORAL STEM 12/14,C1776,HCPCS,,79009708,CDM,278,RC,,,both,,,8910,6593.42,,,6593.42,Other,150% of Medicare + 9.63% HCRA Surcharge,4009.5,45,,4009.5,percent of total billed charges,Critical Access Hospital RCC factor,3029.4,34,,3029.4,percent of total billed charges,Implant Device,3029.4,34,,3029.4,percent of total billed charges,Implant Device,3029.4,34,,3029.4,percent of total billed charges,Implant Device,3029.4,34,,3029.4,percent of total billed charges,Implant Device,3029.4,34,,3029.4,percent of total billed charges,Implant Device,4410.45,,,4410.45,Other,110% of Medicare,3118.5,35,,3118.5,percent of total billed charges,Implant Device,3029.4,34,"Charges > $500, x 34%",3029.4,percent of total billed charges,Implant Device,3118.5,35,,3118.5,percent of total billed charges,Implant Device,3118.5,35,,3118.5,percent of total billed charges,Implant Device,3118.5,35,,3118.5,percent of total billed charges,Implant Device,3118.5,35,,3118.5,percent of total billed charges,Implant Device,3118.5,35,,3118.5,percent of total billed charges,Implant Device,3564,40,,3564,percent of total billed charges,Implant Device,3118.5,70,,3118.5,percent of total billed charges,All Other,3029.4,34,,3029.4,percent of total billed charges,Implant Device,3029.4,34,,3029.4,percent of total billed charges,Implant Device,3118.5,35,,3118.5,percent of total billed charges,Implant Device,3118.5,35,,3118.5,percent of total billed charges,Implant Device,3118.5,35,,3118.5,percent of total billed charges,Implant Device,3118.5,35,,3118.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3029.4,34,"If Charge > 2,000, then 34 percent",3029.4,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,6593.42,
ZIMMER 00-5976-050-17 ART SURF SZ 17MM,C1776,HCPCS,,79009709,CDM,278,RC,,,both,,,2250,1665.01,,,1665.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1012.5,45,,1012.5,percent of total billed charges,Critical Access Hospital RCC factor,765,34,,765,percent of total billed charges,Implant Device,765,34,,765,percent of total billed charges,Implant Device,765,34,,765,percent of total billed charges,Implant Device,765,34,,765,percent of total billed charges,Implant Device,765,34,,765,percent of total billed charges,Implant Device,1113.75,,,1113.75,Other,110% of Medicare,787.5,35,,787.5,percent of total billed charges,Implant Device,765,34,"Charges > $500, x 34%",765,percent of total billed charges,Implant Device,787.5,35,,787.5,percent of total billed charges,Implant Device,787.5,35,,787.5,percent of total billed charges,Implant Device,787.5,35,,787.5,percent of total billed charges,Implant Device,787.5,35,,787.5,percent of total billed charges,Implant Device,787.5,35,,787.5,percent of total billed charges,Implant Device,900,40,,900,percent of total billed charges,Implant Device,787.5,70,,787.5,percent of total billed charges,All Other,765,34,,765,percent of total billed charges,Implant Device,765,34,,765,percent of total billed charges,Implant Device,787.5,35,,787.5,percent of total billed charges,Implant Device,787.5,35,,787.5,percent of total billed charges,Implant Device,787.5,35,,787.5,percent of total billed charges,Implant Device,787.5,35,,787.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,765,34,"If Charge > 2,000, then 34 percent",765,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1665.01,
ZIMMER 00-8852-015-36 RIM LINER SZ 36MM,C1776,HCPCS,,79009710,CDM,278,RC,,,both,,,3456,2557.45,,,2557.45,Other,150% of Medicare + 9.63% HCRA Surcharge,1555.2,45,,1555.2,percent of total billed charges,Critical Access Hospital RCC factor,1175.04,34,,1175.04,percent of total billed charges,Implant Device,1175.04,34,,1175.04,percent of total billed charges,Implant Device,1175.04,34,,1175.04,percent of total billed charges,Implant Device,1175.04,34,,1175.04,percent of total billed charges,Implant Device,1175.04,34,,1175.04,percent of total billed charges,Implant Device,1710.72,,,1710.72,Other,110% of Medicare,1209.6,35,,1209.6,percent of total billed charges,Implant Device,1175.04,34,"Charges > $500, x 34%",1175.04,percent of total billed charges,Implant Device,1209.6,35,,1209.6,percent of total billed charges,Implant Device,1209.6,35,,1209.6,percent of total billed charges,Implant Device,1209.6,35,,1209.6,percent of total billed charges,Implant Device,1209.6,35,,1209.6,percent of total billed charges,Implant Device,1209.6,35,,1209.6,percent of total billed charges,Implant Device,1382.4,40,,1382.4,percent of total billed charges,Implant Device,1209.6,70,,1209.6,percent of total billed charges,All Other,1175.04,34,,1175.04,percent of total billed charges,Implant Device,1175.04,34,,1175.04,percent of total billed charges,Implant Device,1209.6,35,,1209.6,percent of total billed charges,Implant Device,1209.6,35,,1209.6,percent of total billed charges,Implant Device,1209.6,35,,1209.6,percent of total billed charges,Implant Device,1209.6,35,,1209.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1175.04,34,"If Charge > 2,000, then 34 percent",1175.04,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2557.45,
ZIMMER 07.01595.001 TACKS,C1713,HCPCS,,79009711,CDM,278,RC,,,both,,,540,399.6,,,399.6,Other,150% of Medicare + 9.63% HCRA Surcharge,243,45,,243,percent of total billed charges,Critical Access Hospital RCC factor,183.6,34,,183.6,percent of total billed charges,Implant Device,183.6,34,,183.6,percent of total billed charges,Implant Device,183.6,34,,183.6,percent of total billed charges,Implant Device,183.6,34,,183.6,percent of total billed charges,Implant Device,183.6,34,,183.6,percent of total billed charges,Implant Device,267.3,,,267.3,Other,110% of Medicare,189,35,,189,percent of total billed charges,Implant Device,183.6,34,"Charges > $500, x 34%",183.6,percent of total billed charges,Implant Device,189,35,,189,percent of total billed charges,Implant Device,189,35,,189,percent of total billed charges,Implant Device,189,35,,189,percent of total billed charges,Implant Device,189,35,,189,percent of total billed charges,Implant Device,189,35,,189,percent of total billed charges,Implant Device,216,40,,216,percent of total billed charges,Implant Device,189,70,,189,percent of total billed charges,All Other,183.6,34,,183.6,percent of total billed charges,Implant Device,183.6,34,,183.6,percent of total billed charges,Implant Device,189,35,,189,percent of total billed charges,Implant Device,189,35,,189,percent of total billed charges,Implant Device,189,35,,189,percent of total billed charges,Implant Device,189,35,,189,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,399.6,
ZIMMER 07.01616.005 INVIZIA PLATE 42MM,C1713,HCPCS,,79009713,CDM,278,RC,,,both,,,8985,6648.92,,,6648.92,Other,150% of Medicare + 9.63% HCRA Surcharge,4043.25,45,,4043.25,percent of total billed charges,Critical Access Hospital RCC factor,3054.9,34,,3054.9,percent of total billed charges,Implant Device,3054.9,34,,3054.9,percent of total billed charges,Implant Device,3054.9,34,,3054.9,percent of total billed charges,Implant Device,3054.9,34,,3054.9,percent of total billed charges,Implant Device,3054.9,34,,3054.9,percent of total billed charges,Implant Device,4447.58,,,4447.58,Other,110% of Medicare,3144.75,35,,3144.75,percent of total billed charges,Implant Device,3054.9,34,"Charges > $500, x 34%",3054.9,percent of total billed charges,Implant Device,3144.75,35,,3144.75,percent of total billed charges,Implant Device,3144.75,35,,3144.75,percent of total billed charges,Implant Device,3144.75,35,,3144.75,percent of total billed charges,Implant Device,3144.75,35,,3144.75,percent of total billed charges,Implant Device,3144.75,35,,3144.75,percent of total billed charges,Implant Device,3594,40,,3594,percent of total billed charges,Implant Device,3144.75,70,,3144.75,percent of total billed charges,All Other,3054.9,34,,3054.9,percent of total billed charges,Implant Device,3054.9,34,,3054.9,percent of total billed charges,Implant Device,3144.75,35,,3144.75,percent of total billed charges,Implant Device,3144.75,35,,3144.75,percent of total billed charges,Implant Device,3144.75,35,,3144.75,percent of total billed charges,Implant Device,3144.75,35,,3144.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3054.9,34,"If Charge > 2,000, then 34 percent",3054.9,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,6648.92,
ZIMMER 07.00812.007 VA SCREWS 16MM,C1713,HCPCS,,79009714,CDM,278,RC,,,both,,,1785,1320.9,,,1320.9,Other,150% of Medicare + 9.63% HCRA Surcharge,803.25,45,,803.25,percent of total billed charges,Critical Access Hospital RCC factor,606.9,34,,606.9,percent of total billed charges,Implant Device,606.9,34,,606.9,percent of total billed charges,Implant Device,606.9,34,,606.9,percent of total billed charges,Implant Device,606.9,34,,606.9,percent of total billed charges,Implant Device,606.9,34,,606.9,percent of total billed charges,Implant Device,883.58,,,883.58,Other,110% of Medicare,624.75,35,,624.75,percent of total billed charges,Implant Device,606.9,34,"Charges > $500, x 34%",606.9,percent of total billed charges,Implant Device,624.75,35,,624.75,percent of total billed charges,Implant Device,624.75,35,,624.75,percent of total billed charges,Implant Device,624.75,35,,624.75,percent of total billed charges,Implant Device,624.75,35,,624.75,percent of total billed charges,Implant Device,624.75,35,,624.75,percent of total billed charges,Implant Device,714,40,,714,percent of total billed charges,Implant Device,624.75,70,,624.75,percent of total billed charges,All Other,606.9,34,,606.9,percent of total billed charges,Implant Device,606.9,34,,606.9,percent of total billed charges,Implant Device,624.75,35,,624.75,percent of total billed charges,Implant Device,624.75,35,,624.75,percent of total billed charges,Implant Device,624.75,35,,624.75,percent of total billed charges,Implant Device,624.75,35,,624.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1320.9,
ZIMMER 8824-4707 MM CAGE 7X14X18,C1713,HCPCS,,79009715,CDM,278,RC,,,both,,,6015,4451.12,,,4451.12,Other,150% of Medicare + 9.63% HCRA Surcharge,2706.75,45,,2706.75,percent of total billed charges,Critical Access Hospital RCC factor,2045.1,34,,2045.1,percent of total billed charges,Implant Device,2045.1,34,,2045.1,percent of total billed charges,Implant Device,2045.1,34,,2045.1,percent of total billed charges,Implant Device,2045.1,34,,2045.1,percent of total billed charges,Implant Device,2045.1,34,,2045.1,percent of total billed charges,Implant Device,2977.43,,,2977.43,Other,110% of Medicare,2105.25,35,,2105.25,percent of total billed charges,Implant Device,2045.1,34,"Charges > $500, x 34%",2045.1,percent of total billed charges,Implant Device,2105.25,35,,2105.25,percent of total billed charges,Implant Device,2105.25,35,,2105.25,percent of total billed charges,Implant Device,2105.25,35,,2105.25,percent of total billed charges,Implant Device,2105.25,35,,2105.25,percent of total billed charges,Implant Device,2105.25,35,,2105.25,percent of total billed charges,Implant Device,2406,40,,2406,percent of total billed charges,Implant Device,2105.25,70,,2105.25,percent of total billed charges,All Other,2045.1,34,,2045.1,percent of total billed charges,Implant Device,2045.1,34,,2045.1,percent of total billed charges,Implant Device,2105.25,35,,2105.25,percent of total billed charges,Implant Device,2105.25,35,,2105.25,percent of total billed charges,Implant Device,2105.25,35,,2105.25,percent of total billed charges,Implant Device,2105.25,35,,2105.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2045.1,34,"If Charge > 2,000, then 34 percent",2045.1,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4451.12,
ZIMMER CM68905 PLATFORM CM PUTTY 5CC,C1713,HCPCS,,79009716,CDM,278,RC,,,both,,,3309,2448.67,,,2448.67,Other,150% of Medicare + 9.63% HCRA Surcharge,1489.05,45,,1489.05,percent of total billed charges,Critical Access Hospital RCC factor,1125.06,34,,1125.06,percent of total billed charges,Implant Device,1125.06,34,,1125.06,percent of total billed charges,Implant Device,1125.06,34,,1125.06,percent of total billed charges,Implant Device,1125.06,34,,1125.06,percent of total billed charges,Implant Device,1125.06,34,,1125.06,percent of total billed charges,Implant Device,1637.96,,,1637.96,Other,110% of Medicare,1158.15,35,,1158.15,percent of total billed charges,Implant Device,1125.06,34,"Charges > $500, x 34%",1125.06,percent of total billed charges,Implant Device,1158.15,35,,1158.15,percent of total billed charges,Implant Device,1158.15,35,,1158.15,percent of total billed charges,Implant Device,1158.15,35,,1158.15,percent of total billed charges,Implant Device,1158.15,35,,1158.15,percent of total billed charges,Implant Device,1158.15,35,,1158.15,percent of total billed charges,Implant Device,1323.6,40,,1323.6,percent of total billed charges,Implant Device,1158.15,70,,1158.15,percent of total billed charges,All Other,1125.06,34,,1125.06,percent of total billed charges,Implant Device,1125.06,34,,1125.06,percent of total billed charges,Implant Device,1158.15,35,,1158.15,percent of total billed charges,Implant Device,1158.15,35,,1158.15,percent of total billed charges,Implant Device,1158.15,35,,1158.15,percent of total billed charges,Implant Device,1158.15,35,,1158.15,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1125.06,34,"If Charge > 2,000, then 34 percent",1125.06,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2448.67,
ZIMMER 8824-4706 CAGE 6X14X18,C1713,HCPCS,,79009717,CDM,278,RC,,,both,,,6015,4451.12,,,4451.12,Other,150% of Medicare + 9.63% HCRA Surcharge,2706.75,45,,2706.75,percent of total billed charges,Critical Access Hospital RCC factor,2045.1,34,,2045.1,percent of total billed charges,Implant Device,2045.1,34,,2045.1,percent of total billed charges,Implant Device,2045.1,34,,2045.1,percent of total billed charges,Implant Device,2045.1,34,,2045.1,percent of total billed charges,Implant Device,2045.1,34,,2045.1,percent of total billed charges,Implant Device,2977.43,,,2977.43,Other,110% of Medicare,2105.25,35,,2105.25,percent of total billed charges,Implant Device,2045.1,34,"Charges > $500, x 34%",2045.1,percent of total billed charges,Implant Device,2105.25,35,,2105.25,percent of total billed charges,Implant Device,2105.25,35,,2105.25,percent of total billed charges,Implant Device,2105.25,35,,2105.25,percent of total billed charges,Implant Device,2105.25,35,,2105.25,percent of total billed charges,Implant Device,2105.25,35,,2105.25,percent of total billed charges,Implant Device,2406,40,,2406,percent of total billed charges,Implant Device,2105.25,70,,2105.25,percent of total billed charges,All Other,2045.1,34,,2045.1,percent of total billed charges,Implant Device,2045.1,34,,2045.1,percent of total billed charges,Implant Device,2105.25,35,,2105.25,percent of total billed charges,Implant Device,2105.25,35,,2105.25,percent of total billed charges,Implant Device,2105.25,35,,2105.25,percent of total billed charges,Implant Device,2105.25,35,,2105.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2045.1,34,"If Charge > 2,000, then 34 percent",2045.1,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4451.12,
ZIMMER 00-5976-040-10 ART SURF SZ 10MM,C1776,HCPCS,,79009719,CDM,278,RC,,,both,,,1920,1420.8,,,1420.8,Other,150% of Medicare + 9.63% HCRA Surcharge,864,45,,864,percent of total billed charges,Critical Access Hospital RCC factor,652.8,34,,652.8,percent of total billed charges,Implant Device,652.8,34,,652.8,percent of total billed charges,Implant Device,652.8,34,,652.8,percent of total billed charges,Implant Device,652.8,34,,652.8,percent of total billed charges,Implant Device,652.8,34,,652.8,percent of total billed charges,Implant Device,950.4,,,950.4,Other,110% of Medicare,672,35,,672,percent of total billed charges,Implant Device,652.8,34,"Charges > $500, x 34%",652.8,percent of total billed charges,Implant Device,672,35,,672,percent of total billed charges,Implant Device,672,35,,672,percent of total billed charges,Implant Device,672,35,,672,percent of total billed charges,Implant Device,672,35,,672,percent of total billed charges,Implant Device,672,35,,672,percent of total billed charges,Implant Device,768,40,,768,percent of total billed charges,Implant Device,672,70,,672,percent of total billed charges,All Other,652.8,34,,652.8,percent of total billed charges,Implant Device,652.8,34,,652.8,percent of total billed charges,Implant Device,672,35,,672,percent of total billed charges,Implant Device,672,35,,672,percent of total billed charges,Implant Device,672,35,,672,percent of total billed charges,Implant Device,672,35,,672,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1420.8,
LIFENET BL-1600-002 BONE MATRIX-MED-5.4,C1713,HCPCS,,79009721,CDM,278,RC,,,both,,,7344,5434.58,,,5434.58,Other,150% of Medicare + 9.63% HCRA Surcharge,3304.8,45,,3304.8,percent of total billed charges,Critical Access Hospital RCC factor,2496.96,34,,2496.96,percent of total billed charges,Implant Device,2496.96,34,,2496.96,percent of total billed charges,Implant Device,2496.96,34,,2496.96,percent of total billed charges,Implant Device,2496.96,34,,2496.96,percent of total billed charges,Implant Device,2496.96,34,,2496.96,percent of total billed charges,Implant Device,3635.28,,,3635.28,Other,110% of Medicare,2570.4,35,,2570.4,percent of total billed charges,Implant Device,2496.96,34,"Charges > $500, x 34%",2496.96,percent of total billed charges,Implant Device,2570.4,35,,2570.4,percent of total billed charges,Implant Device,2570.4,35,,2570.4,percent of total billed charges,Implant Device,2570.4,35,,2570.4,percent of total billed charges,Implant Device,2570.4,35,,2570.4,percent of total billed charges,Implant Device,2570.4,35,,2570.4,percent of total billed charges,Implant Device,2937.6,40,,2937.6,percent of total billed charges,Implant Device,2570.4,70,,2570.4,percent of total billed charges,All Other,2496.96,34,,2496.96,percent of total billed charges,Implant Device,2496.96,34,,2496.96,percent of total billed charges,Implant Device,2570.4,35,,2570.4,percent of total billed charges,Implant Device,2570.4,35,,2570.4,percent of total billed charges,Implant Device,2570.4,35,,2570.4,percent of total billed charges,Implant Device,2570.4,35,,2570.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2496.96,34,"If Charge > 2,000, then 34 percent",2496.96,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5434.58,
STRYKER 5568-0009 HUMERAL FRACTURE STEM,C1776,HCPCS,,79009722,CDM,278,RC,,,both,,,11250,8325.03,,,8325.03,Other,150% of Medicare + 9.63% HCRA Surcharge,5062.5,45,,5062.5,percent of total billed charges,Critical Access Hospital RCC factor,3825,34,,3825,percent of total billed charges,Implant Device,3825,34,,3825,percent of total billed charges,Implant Device,3825,34,,3825,percent of total billed charges,Implant Device,3825,34,,3825,percent of total billed charges,Implant Device,3825,34,,3825,percent of total billed charges,Implant Device,5568.75,,,5568.75,Other,110% of Medicare,3937.5,35,,3937.5,percent of total billed charges,Implant Device,3825,34,"Charges > $500, x 34%",3825,percent of total billed charges,Implant Device,3937.5,35,,3937.5,percent of total billed charges,Implant Device,3937.5,35,,3937.5,percent of total billed charges,Implant Device,3937.5,35,,3937.5,percent of total billed charges,Implant Device,3937.5,35,,3937.5,percent of total billed charges,Implant Device,3937.5,35,,3937.5,percent of total billed charges,Implant Device,4500,40,,4500,percent of total billed charges,Implant Device,3937.5,70,,3937.5,percent of total billed charges,All Other,3825,34,,3825,percent of total billed charges,Implant Device,3825,34,,3825,percent of total billed charges,Implant Device,3937.5,35,,3937.5,percent of total billed charges,Implant Device,3937.5,35,,3937.5,percent of total billed charges,Implant Device,3937.5,35,,3937.5,percent of total billed charges,Implant Device,3937.5,35,,3937.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3825,34,"If Charge > 2,000, then 34 percent",3825,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,8325.03,
ARTHREX AR-1371E INTERFERENCE SCREW 7X25,C1713,HCPCS,,79009723,CDM,278,RC,,,both,,,345,255.3,,,255.3,Other,150% of Medicare + 9.63% HCRA Surcharge,155.25,45,,155.25,percent of total billed charges,Critical Access Hospital RCC factor,117.3,34,,117.3,percent of total billed charges,Implant Device,117.3,34,,117.3,percent of total billed charges,Implant Device,117.3,34,,117.3,percent of total billed charges,Implant Device,117.3,34,,117.3,percent of total billed charges,Implant Device,117.3,34,,117.3,percent of total billed charges,Implant Device,170.78,,,170.78,Other,110% of Medicare,120.75,35,,120.75,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,120.75,35,,120.75,percent of total billed charges,Implant Device,120.75,35,,120.75,percent of total billed charges,Implant Device,120.75,35,,120.75,percent of total billed charges,Implant Device,120.75,35,,120.75,percent of total billed charges,Implant Device,120.75,35,,120.75,percent of total billed charges,Implant Device,138,40,,138,percent of total billed charges,Implant Device,120.75,70,,120.75,percent of total billed charges,All Other,117.3,34,,117.3,percent of total billed charges,Implant Device,117.3,34,,117.3,percent of total billed charges,Implant Device,120.75,35,,120.75,percent of total billed charges,Implant Device,120.75,35,,120.75,percent of total billed charges,Implant Device,120.75,35,,120.75,percent of total billed charges,Implant Device,120.75,35,,120.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,255.3,
ARTHREX AR-1380E INTERFERENCE SCREW 8X20,C1713,HCPCS,,79009724,CDM,278,RC,,,both,,,345,255.3,,,255.3,Other,150% of Medicare + 9.63% HCRA Surcharge,155.25,45,,155.25,percent of total billed charges,Critical Access Hospital RCC factor,117.3,34,,117.3,percent of total billed charges,Implant Device,117.3,34,,117.3,percent of total billed charges,Implant Device,117.3,34,,117.3,percent of total billed charges,Implant Device,117.3,34,,117.3,percent of total billed charges,Implant Device,117.3,34,,117.3,percent of total billed charges,Implant Device,170.78,,,170.78,Other,110% of Medicare,120.75,35,,120.75,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,120.75,35,,120.75,percent of total billed charges,Implant Device,120.75,35,,120.75,percent of total billed charges,Implant Device,120.75,35,,120.75,percent of total billed charges,Implant Device,120.75,35,,120.75,percent of total billed charges,Implant Device,120.75,35,,120.75,percent of total billed charges,Implant Device,138,40,,138,percent of total billed charges,Implant Device,120.75,70,,120.75,percent of total billed charges,All Other,117.3,34,,117.3,percent of total billed charges,Implant Device,117.3,34,,117.3,percent of total billed charges,Implant Device,120.75,35,,120.75,percent of total billed charges,Implant Device,120.75,35,,120.75,percent of total billed charges,Implant Device,120.75,35,,120.75,percent of total billed charges,Implant Device,120.75,35,,120.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,255.3,
ARTHREX AR-1381E INTERFERENCE SCREW 8X25,C1713,HCPCS,,79009725,CDM,278,RC,,,both,,,345,255.3,,,255.3,Other,150% of Medicare + 9.63% HCRA Surcharge,155.25,45,,155.25,percent of total billed charges,Critical Access Hospital RCC factor,117.3,34,,117.3,percent of total billed charges,Implant Device,117.3,34,,117.3,percent of total billed charges,Implant Device,117.3,34,,117.3,percent of total billed charges,Implant Device,117.3,34,,117.3,percent of total billed charges,Implant Device,117.3,34,,117.3,percent of total billed charges,Implant Device,170.78,,,170.78,Other,110% of Medicare,120.75,35,,120.75,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,120.75,35,,120.75,percent of total billed charges,Implant Device,120.75,35,,120.75,percent of total billed charges,Implant Device,120.75,35,,120.75,percent of total billed charges,Implant Device,120.75,35,,120.75,percent of total billed charges,Implant Device,120.75,35,,120.75,percent of total billed charges,Implant Device,138,40,,138,percent of total billed charges,Implant Device,120.75,70,,120.75,percent of total billed charges,All Other,117.3,34,,117.3,percent of total billed charges,Implant Device,117.3,34,,117.3,percent of total billed charges,Implant Device,120.75,35,,120.75,percent of total billed charges,Implant Device,120.75,35,,120.75,percent of total billed charges,Implant Device,120.75,35,,120.75,percent of total billed charges,Implant Device,120.75,35,,120.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,255.3,
ZIMMER 00-5950-014-01 FEM COMP SZ D-LT,C1776,HCPCS,,79009726,CDM,278,RC,,,both,,,6300,4662.02,,,4662.02,Other,150% of Medicare + 9.63% HCRA Surcharge,2835,45,,2835,percent of total billed charges,Critical Access Hospital RCC factor,2142,34,,2142,percent of total billed charges,Implant Device,2142,34,,2142,percent of total billed charges,Implant Device,2142,34,,2142,percent of total billed charges,Implant Device,2142,34,,2142,percent of total billed charges,Implant Device,2142,34,,2142,percent of total billed charges,Implant Device,3118.5,,,3118.5,Other,110% of Medicare,2205,35,,2205,percent of total billed charges,Implant Device,2142,34,"Charges > $500, x 34%",2142,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2520,40,,2520,percent of total billed charges,Implant Device,2205,70,,2205,percent of total billed charges,All Other,2142,34,,2142,percent of total billed charges,Implant Device,2142,34,,2142,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2142,34,"If Charge > 2,000, then 34 percent",2142,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4662.02,
ZIMMER 00-7711-009-40 FEMORAL STEM 12/14,C1776,HCPCS,,79009727,CDM,278,RC,,,both,,,6900,5106.02,,,5106.02,Other,150% of Medicare + 9.63% HCRA Surcharge,3105,45,,3105,percent of total billed charges,Critical Access Hospital RCC factor,2346,34,,2346,percent of total billed charges,Implant Device,2346,34,,2346,percent of total billed charges,Implant Device,2346,34,,2346,percent of total billed charges,Implant Device,2346,34,,2346,percent of total billed charges,Implant Device,2346,34,,2346,percent of total billed charges,Implant Device,3415.5,,,3415.5,Other,110% of Medicare,2415,35,,2415,percent of total billed charges,Implant Device,2346,34,"Charges > $500, x 34%",2346,percent of total billed charges,Implant Device,2415,35,,2415,percent of total billed charges,Implant Device,2415,35,,2415,percent of total billed charges,Implant Device,2415,35,,2415,percent of total billed charges,Implant Device,2415,35,,2415,percent of total billed charges,Implant Device,2415,35,,2415,percent of total billed charges,Implant Device,2760,40,,2760,percent of total billed charges,Implant Device,2415,70,,2415,percent of total billed charges,All Other,2346,34,,2346,percent of total billed charges,Implant Device,2346,34,,2346,percent of total billed charges,Implant Device,2415,35,,2415,percent of total billed charges,Implant Device,2415,35,,2415,percent of total billed charges,Implant Device,2415,35,,2415,percent of total billed charges,Implant Device,2415,35,,2415,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2346,34,"If Charge > 2,000, then 34 percent",2346,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5106.02,
ZIMMER 00-5750-015-01 FEM COMP SZ 3 LT,C1776,HCPCS,,79009728,CDM,278,RC,,,both,,,6300,4662.02,,,4662.02,Other,150% of Medicare + 9.63% HCRA Surcharge,2835,45,,2835,percent of total billed charges,Critical Access Hospital RCC factor,2142,34,,2142,percent of total billed charges,Implant Device,2142,34,,2142,percent of total billed charges,Implant Device,2142,34,,2142,percent of total billed charges,Implant Device,2142,34,,2142,percent of total billed charges,Implant Device,2142,34,,2142,percent of total billed charges,Implant Device,3118.5,,,3118.5,Other,110% of Medicare,2205,35,,2205,percent of total billed charges,Implant Device,2142,34,"Charges > $500, x 34%",2142,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2520,40,,2520,percent of total billed charges,Implant Device,2205,70,,2205,percent of total billed charges,All Other,2142,34,,2142,percent of total billed charges,Implant Device,2142,34,,2142,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2142,34,"If Charge > 2,000, then 34 percent",2142,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4662.02,
ZIMMER 00-2359-048-45 LOCK SCREW 4.5X48,C1713,HCPCS,,79009729,CDM,278,RC,,,both,,,445,329.3,,,329.3,Other,150% of Medicare + 9.63% HCRA Surcharge,200.25,45,,200.25,percent of total billed charges,Critical Access Hospital RCC factor,151.3,34,,151.3,percent of total billed charges,Implant Device,151.3,34,,151.3,percent of total billed charges,Implant Device,151.3,34,,151.3,percent of total billed charges,Implant Device,151.3,34,,151.3,percent of total billed charges,Implant Device,151.3,34,,151.3,percent of total billed charges,Implant Device,220.28,,,220.28,Other,110% of Medicare,155.75,35,,155.75,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,155.75,35,,155.75,percent of total billed charges,Implant Device,155.75,35,,155.75,percent of total billed charges,Implant Device,155.75,35,,155.75,percent of total billed charges,Implant Device,155.75,35,,155.75,percent of total billed charges,Implant Device,155.75,35,,155.75,percent of total billed charges,Implant Device,178,40,,178,percent of total billed charges,Implant Device,155.75,70,,155.75,percent of total billed charges,All Other,151.3,34,,151.3,percent of total billed charges,Implant Device,151.3,34,,151.3,percent of total billed charges,Implant Device,155.75,35,,155.75,percent of total billed charges,Implant Device,155.75,35,,155.75,percent of total billed charges,Implant Device,155.75,35,,155.75,percent of total billed charges,Implant Device,155.75,35,,155.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,329.3,
DEPUY 224.571 LCP PLATE 7 HOLE 4.5X134MM,C1713,HCPCS,,79009731,CDM,278,RC,,,both,,,1156,855.44,,,855.44,Other,150% of Medicare + 9.63% HCRA Surcharge,520.2,45,,520.2,percent of total billed charges,Critical Access Hospital RCC factor,393.04,34,,393.04,percent of total billed charges,Implant Device,393.04,34,,393.04,percent of total billed charges,Implant Device,393.04,34,,393.04,percent of total billed charges,Implant Device,393.04,34,,393.04,percent of total billed charges,Implant Device,393.04,34,,393.04,percent of total billed charges,Implant Device,572.22,,,572.22,Other,110% of Medicare,404.6,35,,404.6,percent of total billed charges,Implant Device,393.04,34,"Charges > $500, x 34%",393.04,percent of total billed charges,Implant Device,404.6,35,,404.6,percent of total billed charges,Implant Device,404.6,35,,404.6,percent of total billed charges,Implant Device,404.6,35,,404.6,percent of total billed charges,Implant Device,404.6,35,,404.6,percent of total billed charges,Implant Device,404.6,35,,404.6,percent of total billed charges,Implant Device,462.4,40,,462.4,percent of total billed charges,Implant Device,404.6,70,,404.6,percent of total billed charges,All Other,393.04,34,,393.04,percent of total billed charges,Implant Device,393.04,34,,393.04,percent of total billed charges,Implant Device,404.6,35,,404.6,percent of total billed charges,Implant Device,404.6,35,,404.6,percent of total billed charges,Implant Device,404.6,35,,404.6,percent of total billed charges,Implant Device,404.6,35,,404.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,855.44,
STRYKER 607430 CANCELLOUS SCREW 4.0X4MM,C1713,HCPCS,,79009732,CDM,278,RC,,,both,,,137,101.38,,,101.38,Other,150% of Medicare + 9.63% HCRA Surcharge,61.65,45,,61.65,percent of total billed charges,Critical Access Hospital RCC factor,46.58,34,,46.58,percent of total billed charges,Implant Device,46.58,34,,46.58,percent of total billed charges,Implant Device,46.58,34,,46.58,percent of total billed charges,Implant Device,46.58,34,,46.58,percent of total billed charges,Implant Device,46.58,34,,46.58,percent of total billed charges,Implant Device,67.82,,,67.82,Other,110% of Medicare,47.95,35,,47.95,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,47.95,35,,47.95,percent of total billed charges,Implant Device,47.95,35,,47.95,percent of total billed charges,Implant Device,47.95,35,,47.95,percent of total billed charges,Implant Device,47.95,35,,47.95,percent of total billed charges,Implant Device,47.95,35,,47.95,percent of total billed charges,Implant Device,54.8,40,,54.8,percent of total billed charges,Implant Device,47.95,70,,47.95,percent of total billed charges,All Other,46.58,34,,46.58,percent of total billed charges,Implant Device,46.58,34,,46.58,percent of total billed charges,Implant Device,47.95,35,,47.95,percent of total billed charges,Implant Device,47.95,35,,47.95,percent of total billed charges,Implant Device,47.95,35,,47.95,percent of total billed charges,Implant Device,47.95,35,,47.95,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,101.38,
STRYKER 627734 TIBIA PLATE RT 4H 71MM,C1713,HCPCS,,79009733,CDM,278,RC,,,both,,,6524,4827.78,,,4827.78,Other,150% of Medicare + 9.63% HCRA Surcharge,2935.8,45,,2935.8,percent of total billed charges,Critical Access Hospital RCC factor,2218.16,34,,2218.16,percent of total billed charges,Implant Device,2218.16,34,,2218.16,percent of total billed charges,Implant Device,2218.16,34,,2218.16,percent of total billed charges,Implant Device,2218.16,34,,2218.16,percent of total billed charges,Implant Device,2218.16,34,,2218.16,percent of total billed charges,Implant Device,3229.38,,,3229.38,Other,110% of Medicare,2283.4,35,,2283.4,percent of total billed charges,Implant Device,2218.16,34,"Charges > $500, x 34%",2218.16,percent of total billed charges,Implant Device,2283.4,35,,2283.4,percent of total billed charges,Implant Device,2283.4,35,,2283.4,percent of total billed charges,Implant Device,2283.4,35,,2283.4,percent of total billed charges,Implant Device,2283.4,35,,2283.4,percent of total billed charges,Implant Device,2283.4,35,,2283.4,percent of total billed charges,Implant Device,2609.6,40,,2609.6,percent of total billed charges,Implant Device,2283.4,70,,2283.4,percent of total billed charges,All Other,2218.16,34,,2218.16,percent of total billed charges,Implant Device,2218.16,34,,2218.16,percent of total billed charges,Implant Device,2283.4,35,,2283.4,percent of total billed charges,Implant Device,2283.4,35,,2283.4,percent of total billed charges,Implant Device,2283.4,35,,2283.4,percent of total billed charges,Implant Device,2283.4,35,,2283.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2218.16,34,"If Charge > 2,000, then 34 percent",2218.16,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4827.78,
STRYKER 6721-0737 NECK ANGLE HIP STERN,C1776,HCPCS,,79009734,CDM,278,RC,,,both,,,6953,5145.24,,,5145.24,Other,150% of Medicare + 9.63% HCRA Surcharge,3128.85,45,,3128.85,percent of total billed charges,Critical Access Hospital RCC factor,2364.02,34,,2364.02,percent of total billed charges,Implant Device,2364.02,34,,2364.02,percent of total billed charges,Implant Device,2364.02,34,,2364.02,percent of total billed charges,Implant Device,2364.02,34,,2364.02,percent of total billed charges,Implant Device,2364.02,34,,2364.02,percent of total billed charges,Implant Device,3441.74,,,3441.74,Other,110% of Medicare,2433.55,35,,2433.55,percent of total billed charges,Implant Device,2364.02,34,"Charges > $500, x 34%",2364.02,percent of total billed charges,Implant Device,2433.55,35,,2433.55,percent of total billed charges,Implant Device,2433.55,35,,2433.55,percent of total billed charges,Implant Device,2433.55,35,,2433.55,percent of total billed charges,Implant Device,2433.55,35,,2433.55,percent of total billed charges,Implant Device,2433.55,35,,2433.55,percent of total billed charges,Implant Device,2781.2,40,,2781.2,percent of total billed charges,Implant Device,2433.55,70,,2433.55,percent of total billed charges,All Other,2364.02,34,,2364.02,percent of total billed charges,Implant Device,2364.02,34,,2364.02,percent of total billed charges,Implant Device,2433.55,35,,2433.55,percent of total billed charges,Implant Device,2433.55,35,,2433.55,percent of total billed charges,Implant Device,2433.55,35,,2433.55,percent of total billed charges,Implant Device,2433.55,35,,2433.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2364.02,34,"If Charge > 2,000, then 34 percent",2364.02,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5145.24,
STRYKER 626984 SLIM Y-PLATE 4 HOLES,C1713,HCPCS,,79009735,CDM,278,RC,,,both,,,3200,2368.01,,,2368.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1440,45,,1440,percent of total billed charges,Critical Access Hospital RCC factor,1088,34,,1088,percent of total billed charges,Implant Device,1088,34,,1088,percent of total billed charges,Implant Device,1088,34,,1088,percent of total billed charges,Implant Device,1088,34,,1088,percent of total billed charges,Implant Device,1088,34,,1088,percent of total billed charges,Implant Device,1584,,,1584,Other,110% of Medicare,1120,35,,1120,percent of total billed charges,Implant Device,1088,34,"Charges > $500, x 34%",1088,percent of total billed charges,Implant Device,1120,35,,1120,percent of total billed charges,Implant Device,1120,35,,1120,percent of total billed charges,Implant Device,1120,35,,1120,percent of total billed charges,Implant Device,1120,35,,1120,percent of total billed charges,Implant Device,1120,35,,1120,percent of total billed charges,Implant Device,1280,40,,1280,percent of total billed charges,Implant Device,1120,70,,1120,percent of total billed charges,All Other,1088,34,,1088,percent of total billed charges,Implant Device,1088,34,,1088,percent of total billed charges,Implant Device,1120,35,,1120,percent of total billed charges,Implant Device,1120,35,,1120,percent of total billed charges,Implant Device,1120,35,,1120,percent of total billed charges,Implant Device,1120,35,,1120,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1088,34,"If Charge > 2,000, then 34 percent",1088,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2368.01,
STRYKER 656110 BONE SCREW 2.4X10MM,C1713,HCPCS,,79009736,CDM,278,RC,,,both,,,383,283.42,,,283.42,Other,150% of Medicare + 9.63% HCRA Surcharge,172.35,45,,172.35,percent of total billed charges,Critical Access Hospital RCC factor,130.22,34,,130.22,percent of total billed charges,Implant Device,130.22,34,,130.22,percent of total billed charges,Implant Device,130.22,34,,130.22,percent of total billed charges,Implant Device,130.22,34,,130.22,percent of total billed charges,Implant Device,130.22,34,,130.22,percent of total billed charges,Implant Device,189.59,,,189.59,Other,110% of Medicare,134.05,35,,134.05,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,134.05,35,,134.05,percent of total billed charges,Implant Device,134.05,35,,134.05,percent of total billed charges,Implant Device,134.05,35,,134.05,percent of total billed charges,Implant Device,134.05,35,,134.05,percent of total billed charges,Implant Device,134.05,35,,134.05,percent of total billed charges,Implant Device,153.2,40,,153.2,percent of total billed charges,Implant Device,134.05,70,,134.05,percent of total billed charges,All Other,130.22,34,,130.22,percent of total billed charges,Implant Device,130.22,34,,130.22,percent of total billed charges,Implant Device,134.05,35,,134.05,percent of total billed charges,Implant Device,134.05,35,,134.05,percent of total billed charges,Implant Device,134.05,35,,134.05,percent of total billed charges,Implant Device,134.05,35,,134.05,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,283.42,
STRYKER 5569-P-2008 MODULAR HUMERAL STEM,C1776,HCPCS,,79009738,CDM,278,RC,,,both,,,23397,17313.84,,,17313.84,Other,150% of Medicare + 9.63% HCRA Surcharge,10528.65,45,,10528.65,percent of total billed charges,Critical Access Hospital RCC factor,7954.98,34,,7954.98,percent of total billed charges,Implant Device,7954.98,34,,7954.98,percent of total billed charges,Implant Device,7954.98,34,,7954.98,percent of total billed charges,Implant Device,7954.98,34,,7954.98,percent of total billed charges,Implant Device,7954.98,34,,7954.98,percent of total billed charges,Implant Device,11581.52,,,11581.52,Other,110% of Medicare,8188.95,35,,8188.95,percent of total billed charges,Implant Device,7954.98,34,"Charges > $500, x 34%",7954.98,percent of total billed charges,Implant Device,8188.95,35,,8188.95,percent of total billed charges,Implant Device,8188.95,35,,8188.95,percent of total billed charges,Implant Device,8188.95,35,,8188.95,percent of total billed charges,Implant Device,8188.95,35,,8188.95,percent of total billed charges,Implant Device,8188.95,35,,8188.95,percent of total billed charges,Implant Device,9358.8,40,,9358.8,percent of total billed charges,Implant Device,8188.95,70,,8188.95,percent of total billed charges,All Other,7954.98,34,,7954.98,percent of total billed charges,Implant Device,7954.98,34,,7954.98,percent of total billed charges,Implant Device,8188.95,35,,8188.95,percent of total billed charges,Implant Device,8188.95,35,,8188.95,percent of total billed charges,Implant Device,8188.95,35,,8188.95,percent of total billed charges,Implant Device,8188.95,35,,8188.95,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,7954.98,34,"If Charge > 2,000, then 34 percent",7954.98,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,17313.84,
ARTHREX AR-2600SBS-8 SPEEDBRIDGE KIT,C1713,HCPCS,,79009740,CDM,278,RC,,,both,,,5730,4240.21,,,4240.21,Other,150% of Medicare + 9.63% HCRA Surcharge,2578.5,45,,2578.5,percent of total billed charges,Critical Access Hospital RCC factor,1948.2,34,,1948.2,percent of total billed charges,Implant Device,1948.2,34,,1948.2,percent of total billed charges,Implant Device,1948.2,34,,1948.2,percent of total billed charges,Implant Device,1948.2,34,,1948.2,percent of total billed charges,Implant Device,1948.2,34,,1948.2,percent of total billed charges,Implant Device,2836.35,,,2836.35,Other,110% of Medicare,2005.5,35,,2005.5,percent of total billed charges,Implant Device,1948.2,34,"Charges > $500, x 34%",1948.2,percent of total billed charges,Implant Device,2005.5,35,,2005.5,percent of total billed charges,Implant Device,2005.5,35,,2005.5,percent of total billed charges,Implant Device,2005.5,35,,2005.5,percent of total billed charges,Implant Device,2005.5,35,,2005.5,percent of total billed charges,Implant Device,2005.5,35,,2005.5,percent of total billed charges,Implant Device,2292,40,,2292,percent of total billed charges,Implant Device,2005.5,70,,2005.5,percent of total billed charges,All Other,1948.2,34,,1948.2,percent of total billed charges,Implant Device,1948.2,34,,1948.2,percent of total billed charges,Implant Device,2005.5,35,,2005.5,percent of total billed charges,Implant Device,2005.5,35,,2005.5,percent of total billed charges,Implant Device,2005.5,35,,2005.5,percent of total billed charges,Implant Device,2005.5,35,,2005.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1948.2,34,"If Charge > 2,000, then 34 percent",1948.2,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4240.21,
STRYKER 40-35040 BONE SCREW 3.5X40MM,C1713,HCPCS,,79009741,CDM,278,RC,,,both,,,216,159.84,,,159.84,Other,150% of Medicare + 9.63% HCRA Surcharge,97.2,45,,97.2,percent of total billed charges,Critical Access Hospital RCC factor,73.44,34,,73.44,percent of total billed charges,Implant Device,73.44,34,,73.44,percent of total billed charges,Implant Device,73.44,34,,73.44,percent of total billed charges,Implant Device,73.44,34,,73.44,percent of total billed charges,Implant Device,73.44,34,,73.44,percent of total billed charges,Implant Device,106.92,,,106.92,Other,110% of Medicare,75.6,35,,75.6,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,75.6,35,,75.6,percent of total billed charges,Implant Device,75.6,35,,75.6,percent of total billed charges,Implant Device,75.6,35,,75.6,percent of total billed charges,Implant Device,75.6,35,,75.6,percent of total billed charges,Implant Device,75.6,35,,75.6,percent of total billed charges,Implant Device,86.4,40,,86.4,percent of total billed charges,Implant Device,75.6,70,,75.6,percent of total billed charges,All Other,73.44,34,,73.44,percent of total billed charges,Implant Device,73.44,34,,73.44,percent of total billed charges,Implant Device,75.6,35,,75.6,percent of total billed charges,Implant Device,75.6,35,,75.6,percent of total billed charges,Implant Device,75.6,35,,75.6,percent of total billed charges,Implant Device,75.6,35,,75.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,159.84,
ACUMED PL-LEM12 12H LOCKING MEDIAL PLT,C1713,HCPCS,,79009742,CDM,278,RC,,,both,,,4320,3196.81,,,3196.81,Other,150% of Medicare + 9.63% HCRA Surcharge,1944,45,,1944,percent of total billed charges,Critical Access Hospital RCC factor,1468.8,34,,1468.8,percent of total billed charges,Implant Device,1468.8,34,,1468.8,percent of total billed charges,Implant Device,1468.8,34,,1468.8,percent of total billed charges,Implant Device,1468.8,34,,1468.8,percent of total billed charges,Implant Device,1468.8,34,,1468.8,percent of total billed charges,Implant Device,2138.4,,,2138.4,Other,110% of Medicare,1512,35,,1512,percent of total billed charges,Implant Device,1468.8,34,"Charges > $500, x 34%",1468.8,percent of total billed charges,Implant Device,1512,35,,1512,percent of total billed charges,Implant Device,1512,35,,1512,percent of total billed charges,Implant Device,1512,35,,1512,percent of total billed charges,Implant Device,1512,35,,1512,percent of total billed charges,Implant Device,1512,35,,1512,percent of total billed charges,Implant Device,1728,40,,1728,percent of total billed charges,Implant Device,1512,70,,1512,percent of total billed charges,All Other,1468.8,34,,1468.8,percent of total billed charges,Implant Device,1468.8,34,,1468.8,percent of total billed charges,Implant Device,1512,35,,1512,percent of total billed charges,Implant Device,1512,35,,1512,percent of total billed charges,Implant Device,1512,35,,1512,percent of total billed charges,Implant Device,1512,35,,1512,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1468.8,34,"If Charge > 2,000, then 34 percent",1468.8,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3196.81,
ACUMED PL-LEL10L LT 10H LOCK LATERAL PLT,C1713,HCPCS,,79009743,CDM,278,RC,,,both,,,4320,3196.81,,,3196.81,Other,150% of Medicare + 9.63% HCRA Surcharge,1944,45,,1944,percent of total billed charges,Critical Access Hospital RCC factor,1468.8,34,,1468.8,percent of total billed charges,Implant Device,1468.8,34,,1468.8,percent of total billed charges,Implant Device,1468.8,34,,1468.8,percent of total billed charges,Implant Device,1468.8,34,,1468.8,percent of total billed charges,Implant Device,1468.8,34,,1468.8,percent of total billed charges,Implant Device,2138.4,,,2138.4,Other,110% of Medicare,1512,35,,1512,percent of total billed charges,Implant Device,1468.8,34,"Charges > $500, x 34%",1468.8,percent of total billed charges,Implant Device,1512,35,,1512,percent of total billed charges,Implant Device,1512,35,,1512,percent of total billed charges,Implant Device,1512,35,,1512,percent of total billed charges,Implant Device,1512,35,,1512,percent of total billed charges,Implant Device,1512,35,,1512,percent of total billed charges,Implant Device,1728,40,,1728,percent of total billed charges,Implant Device,1512,70,,1512,percent of total billed charges,All Other,1468.8,34,,1468.8,percent of total billed charges,Implant Device,1468.8,34,,1468.8,percent of total billed charges,Implant Device,1512,35,,1512,percent of total billed charges,Implant Device,1512,35,,1512,percent of total billed charges,Implant Device,1512,35,,1512,percent of total billed charges,Implant Device,1512,35,,1512,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1468.8,34,"If Charge > 2,000, then 34 percent",1468.8,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3196.81,
ACUMED 30-0267 3.5X32 LOCK HEXALOBE SCRW,C1713,HCPCS,,79009744,CDM,278,RC,,,both,,,315,233.1,,,233.1,Other,150% of Medicare + 9.63% HCRA Surcharge,141.75,45,,141.75,percent of total billed charges,Critical Access Hospital RCC factor,107.1,34,,107.1,percent of total billed charges,Implant Device,107.1,34,,107.1,percent of total billed charges,Implant Device,107.1,34,,107.1,percent of total billed charges,Implant Device,107.1,34,,107.1,percent of total billed charges,Implant Device,107.1,34,,107.1,percent of total billed charges,Implant Device,155.93,,,155.93,Other,110% of Medicare,110.25,35,,110.25,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,110.25,35,,110.25,percent of total billed charges,Implant Device,110.25,35,,110.25,percent of total billed charges,Implant Device,110.25,35,,110.25,percent of total billed charges,Implant Device,110.25,35,,110.25,percent of total billed charges,Implant Device,110.25,35,,110.25,percent of total billed charges,Implant Device,126,40,,126,percent of total billed charges,Implant Device,110.25,70,,110.25,percent of total billed charges,All Other,107.1,34,,107.1,percent of total billed charges,Implant Device,107.1,34,,107.1,percent of total billed charges,Implant Device,110.25,35,,110.25,percent of total billed charges,Implant Device,110.25,35,,110.25,percent of total billed charges,Implant Device,110.25,35,,110.25,percent of total billed charges,Implant Device,110.25,35,,110.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,233.1,
ACUMED 30-0270 3.5X38 LOCK HEXALOBE SCRW,C1713,HCPCS,,79009745,CDM,278,RC,,,both,,,315,233.1,,,233.1,Other,150% of Medicare + 9.63% HCRA Surcharge,141.75,45,,141.75,percent of total billed charges,Critical Access Hospital RCC factor,107.1,34,,107.1,percent of total billed charges,Implant Device,107.1,34,,107.1,percent of total billed charges,Implant Device,107.1,34,,107.1,percent of total billed charges,Implant Device,107.1,34,,107.1,percent of total billed charges,Implant Device,107.1,34,,107.1,percent of total billed charges,Implant Device,155.93,,,155.93,Other,110% of Medicare,110.25,35,,110.25,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,110.25,35,,110.25,percent of total billed charges,Implant Device,110.25,35,,110.25,percent of total billed charges,Implant Device,110.25,35,,110.25,percent of total billed charges,Implant Device,110.25,35,,110.25,percent of total billed charges,Implant Device,110.25,35,,110.25,percent of total billed charges,Implant Device,126,40,,126,percent of total billed charges,Implant Device,110.25,70,,110.25,percent of total billed charges,All Other,107.1,34,,107.1,percent of total billed charges,Implant Device,107.1,34,,107.1,percent of total billed charges,Implant Device,110.25,35,,110.25,percent of total billed charges,Implant Device,110.25,35,,110.25,percent of total billed charges,Implant Device,110.25,35,,110.25,percent of total billed charges,Implant Device,110.25,35,,110.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,233.1,
ACUMED 30-0275 3.5X60 LOCK HEXALOBE SCRW,C1713,HCPCS,,79009746,CDM,278,RC,,,both,,,405,299.7,,,299.7,Other,150% of Medicare + 9.63% HCRA Surcharge,182.25,45,,182.25,percent of total billed charges,Critical Access Hospital RCC factor,137.7,34,,137.7,percent of total billed charges,Implant Device,137.7,34,,137.7,percent of total billed charges,Implant Device,137.7,34,,137.7,percent of total billed charges,Implant Device,137.7,34,,137.7,percent of total billed charges,Implant Device,137.7,34,,137.7,percent of total billed charges,Implant Device,200.48,,,200.48,Other,110% of Medicare,141.75,35,,141.75,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,141.75,35,,141.75,percent of total billed charges,Implant Device,141.75,35,,141.75,percent of total billed charges,Implant Device,141.75,35,,141.75,percent of total billed charges,Implant Device,141.75,35,,141.75,percent of total billed charges,Implant Device,141.75,35,,141.75,percent of total billed charges,Implant Device,162,40,,162,percent of total billed charges,Implant Device,141.75,70,,141.75,percent of total billed charges,All Other,137.7,34,,137.7,percent of total billed charges,Implant Device,137.7,34,,137.7,percent of total billed charges,Implant Device,141.75,35,,141.75,percent of total billed charges,Implant Device,141.75,35,,141.75,percent of total billed charges,Implant Device,141.75,35,,141.75,percent of total billed charges,Implant Device,141.75,35,,141.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,299.7,
ZIMMER 00-5750-014-01 FEMORAL COMP SZ D,C1776,HCPCS,,79009747,CDM,278,RC,,,both,,,9450,6993.02,,,6993.02,Other,150% of Medicare + 9.63% HCRA Surcharge,4252.5,45,,4252.5,percent of total billed charges,Critical Access Hospital RCC factor,3213,34,,3213,percent of total billed charges,Implant Device,3213,34,,3213,percent of total billed charges,Implant Device,3213,34,,3213,percent of total billed charges,Implant Device,3213,34,,3213,percent of total billed charges,Implant Device,3213,34,,3213,percent of total billed charges,Implant Device,4677.75,,,4677.75,Other,110% of Medicare,3307.5,35,,3307.5,percent of total billed charges,Implant Device,3213,34,"Charges > $500, x 34%",3213,percent of total billed charges,Implant Device,3307.5,35,,3307.5,percent of total billed charges,Implant Device,3307.5,35,,3307.5,percent of total billed charges,Implant Device,3307.5,35,,3307.5,percent of total billed charges,Implant Device,3307.5,35,,3307.5,percent of total billed charges,Implant Device,3307.5,35,,3307.5,percent of total billed charges,Implant Device,3780,40,,3780,percent of total billed charges,Implant Device,3307.5,70,,3307.5,percent of total billed charges,All Other,3213,34,,3213,percent of total billed charges,Implant Device,3213,34,,3213,percent of total billed charges,Implant Device,3307.5,35,,3307.5,percent of total billed charges,Implant Device,3307.5,35,,3307.5,percent of total billed charges,Implant Device,3307.5,35,,3307.5,percent of total billed charges,Implant Device,3307.5,35,,3307.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3213,34,"If Charge > 2,000, then 34 percent",3213,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,6993.02,
ZIMMER 00-5970-018-01 FEMORAL COMP SZ H,C1776,HCPCS,,79009748,CDM,278,RC,,,both,,,5415,4007.11,,,4007.11,Other,150% of Medicare + 9.63% HCRA Surcharge,2436.75,45,,2436.75,percent of total billed charges,Critical Access Hospital RCC factor,1841.1,34,,1841.1,percent of total billed charges,Implant Device,1841.1,34,,1841.1,percent of total billed charges,Implant Device,1841.1,34,,1841.1,percent of total billed charges,Implant Device,1841.1,34,,1841.1,percent of total billed charges,Implant Device,1841.1,34,,1841.1,percent of total billed charges,Implant Device,2680.43,,,2680.43,Other,110% of Medicare,1895.25,35,,1895.25,percent of total billed charges,Implant Device,1841.1,34,"Charges > $500, x 34%",1841.1,percent of total billed charges,Implant Device,1895.25,35,,1895.25,percent of total billed charges,Implant Device,1895.25,35,,1895.25,percent of total billed charges,Implant Device,1895.25,35,,1895.25,percent of total billed charges,Implant Device,1895.25,35,,1895.25,percent of total billed charges,Implant Device,1895.25,35,,1895.25,percent of total billed charges,Implant Device,2166,40,,2166,percent of total billed charges,Implant Device,1895.25,70,,1895.25,percent of total billed charges,All Other,1841.1,34,,1841.1,percent of total billed charges,Implant Device,1841.1,34,,1841.1,percent of total billed charges,Implant Device,1895.25,35,,1895.25,percent of total billed charges,Implant Device,1895.25,35,,1895.25,percent of total billed charges,Implant Device,1895.25,35,,1895.25,percent of total billed charges,Implant Device,1895.25,35,,1895.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1841.1,34,"If Charge > 2,000, then 34 percent",1841.1,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4007.11,
EXACTECH 314-13-22 GLENOID POST AUG LT,C1713,HCPCS,,79009749,CDM,278,RC,,,both,,,9834,7277.18,,,7277.18,Other,150% of Medicare + 9.63% HCRA Surcharge,4425.3,45,,4425.3,percent of total billed charges,Critical Access Hospital RCC factor,3343.56,34,,3343.56,percent of total billed charges,Implant Device,3343.56,34,,3343.56,percent of total billed charges,Implant Device,3343.56,34,,3343.56,percent of total billed charges,Implant Device,3343.56,34,,3343.56,percent of total billed charges,Implant Device,3343.56,34,,3343.56,percent of total billed charges,Implant Device,4867.83,,,4867.83,Other,110% of Medicare,3441.9,35,,3441.9,percent of total billed charges,Implant Device,3343.56,34,"Charges > $500, x 34%",3343.56,percent of total billed charges,Implant Device,3441.9,35,,3441.9,percent of total billed charges,Implant Device,3441.9,35,,3441.9,percent of total billed charges,Implant Device,3441.9,35,,3441.9,percent of total billed charges,Implant Device,3441.9,35,,3441.9,percent of total billed charges,Implant Device,3441.9,35,,3441.9,percent of total billed charges,Implant Device,3933.6,40,,3933.6,percent of total billed charges,Implant Device,3441.9,70,,3441.9,percent of total billed charges,All Other,3343.56,34,,3343.56,percent of total billed charges,Implant Device,3343.56,34,,3343.56,percent of total billed charges,Implant Device,3441.9,35,,3441.9,percent of total billed charges,Implant Device,3441.9,35,,3441.9,percent of total billed charges,Implant Device,3441.9,35,,3441.9,percent of total billed charges,Implant Device,3441.9,35,,3441.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3343.56,34,"If Charge > 2,000, then 34 percent",3343.56,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,7277.18,
DEPUY 04.005.434S LOCKING SCREW 4.0X44MM,C1713,HCPCS,,79009750,CDM,278,RC,,,both,,,412,304.88,,,304.88,Other,150% of Medicare + 9.63% HCRA Surcharge,185.4,45,,185.4,percent of total billed charges,Critical Access Hospital RCC factor,140.08,34,,140.08,percent of total billed charges,Implant Device,140.08,34,,140.08,percent of total billed charges,Implant Device,140.08,34,,140.08,percent of total billed charges,Implant Device,140.08,34,,140.08,percent of total billed charges,Implant Device,140.08,34,,140.08,percent of total billed charges,Implant Device,203.94,,,203.94,Other,110% of Medicare,144.2,35,,144.2,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,144.2,35,,144.2,percent of total billed charges,Implant Device,144.2,35,,144.2,percent of total billed charges,Implant Device,144.2,35,,144.2,percent of total billed charges,Implant Device,144.2,35,,144.2,percent of total billed charges,Implant Device,144.2,35,,144.2,percent of total billed charges,Implant Device,164.8,40,,164.8,percent of total billed charges,Implant Device,144.2,70,,144.2,percent of total billed charges,All Other,140.08,34,,140.08,percent of total billed charges,Implant Device,140.08,34,,140.08,percent of total billed charges,Implant Device,144.2,35,,144.2,percent of total billed charges,Implant Device,144.2,35,,144.2,percent of total billed charges,Implant Device,144.2,35,,144.2,percent of total billed charges,Implant Device,144.2,35,,144.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,304.88,
DEPUY 04.001.428S CANN HUM NAIL 9X240MM,C1713,HCPCS,,79009751,CDM,278,RC,,,both,,,3810,2819.41,,,2819.41,Other,150% of Medicare + 9.63% HCRA Surcharge,1714.5,45,,1714.5,percent of total billed charges,Critical Access Hospital RCC factor,1295.4,34,,1295.4,percent of total billed charges,Implant Device,1295.4,34,,1295.4,percent of total billed charges,Implant Device,1295.4,34,,1295.4,percent of total billed charges,Implant Device,1295.4,34,,1295.4,percent of total billed charges,Implant Device,1295.4,34,,1295.4,percent of total billed charges,Implant Device,1885.95,,,1885.95,Other,110% of Medicare,1333.5,35,,1333.5,percent of total billed charges,Implant Device,1295.4,34,"Charges > $500, x 34%",1295.4,percent of total billed charges,Implant Device,1333.5,35,,1333.5,percent of total billed charges,Implant Device,1333.5,35,,1333.5,percent of total billed charges,Implant Device,1333.5,35,,1333.5,percent of total billed charges,Implant Device,1333.5,35,,1333.5,percent of total billed charges,Implant Device,1333.5,35,,1333.5,percent of total billed charges,Implant Device,1524,40,,1524,percent of total billed charges,Implant Device,1333.5,70,,1333.5,percent of total billed charges,All Other,1295.4,34,,1295.4,percent of total billed charges,Implant Device,1295.4,34,,1295.4,percent of total billed charges,Implant Device,1333.5,35,,1333.5,percent of total billed charges,Implant Device,1333.5,35,,1333.5,percent of total billed charges,Implant Device,1333.5,35,,1333.5,percent of total billed charges,Implant Device,1333.5,35,,1333.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1295.4,34,"If Charge > 2,000, then 34 percent",1295.4,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2819.41,
KINAMED 35-100-1010 CERCLAGE SYSTEM,C1713,HCPCS,,79009752,CDM,278,RC,,,both,,,1305,965.7,,,965.7,Other,150% of Medicare + 9.63% HCRA Surcharge,587.25,45,,587.25,percent of total billed charges,Critical Access Hospital RCC factor,443.7,34,,443.7,percent of total billed charges,Implant Device,443.7,34,,443.7,percent of total billed charges,Implant Device,443.7,34,,443.7,percent of total billed charges,Implant Device,443.7,34,,443.7,percent of total billed charges,Implant Device,443.7,34,,443.7,percent of total billed charges,Implant Device,645.98,,,645.98,Other,110% of Medicare,456.75,35,,456.75,percent of total billed charges,Implant Device,443.7,34,"Charges > $500, x 34%",443.7,percent of total billed charges,Implant Device,456.75,35,,456.75,percent of total billed charges,Implant Device,456.75,35,,456.75,percent of total billed charges,Implant Device,456.75,35,,456.75,percent of total billed charges,Implant Device,456.75,35,,456.75,percent of total billed charges,Implant Device,456.75,35,,456.75,percent of total billed charges,Implant Device,522,40,,522,percent of total billed charges,Implant Device,456.75,70,,456.75,percent of total billed charges,All Other,443.7,34,,443.7,percent of total billed charges,Implant Device,443.7,34,,443.7,percent of total billed charges,Implant Device,456.75,35,,456.75,percent of total billed charges,Implant Device,456.75,35,,456.75,percent of total billed charges,Implant Device,456.75,35,,456.75,percent of total billed charges,Implant Device,456.75,35,,456.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,965.7,
ZIMMER 00-5950-015-01 FEM COMP SZ E-LT,C1776,HCPCS,,79009753,CDM,278,RC,,,both,,,6300,4662.02,,,4662.02,Other,150% of Medicare + 9.63% HCRA Surcharge,2835,45,,2835,percent of total billed charges,Critical Access Hospital RCC factor,2142,34,,2142,percent of total billed charges,Implant Device,2142,34,,2142,percent of total billed charges,Implant Device,2142,34,,2142,percent of total billed charges,Implant Device,2142,34,,2142,percent of total billed charges,Implant Device,2142,34,,2142,percent of total billed charges,Implant Device,3118.5,,,3118.5,Other,110% of Medicare,2205,35,,2205,percent of total billed charges,Implant Device,2142,34,"Charges > $500, x 34%",2142,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2520,40,,2520,percent of total billed charges,Implant Device,2205,70,,2205,percent of total billed charges,All Other,2142,34,,2142,percent of total billed charges,Implant Device,2142,34,,2142,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2142,34,"If Charge > 2,000, then 34 percent",2142,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4662.02,
ACUMED AT2-C14-S MICRO SCREW 14MM,C1713,HCPCS,,79009754,CDM,278,RC,,,both,,,2448,1811.53,,,1811.53,Other,150% of Medicare + 9.63% HCRA Surcharge,1101.6,45,,1101.6,percent of total billed charges,Critical Access Hospital RCC factor,832.32,34,,832.32,percent of total billed charges,Implant Device,832.32,34,,832.32,percent of total billed charges,Implant Device,832.32,34,,832.32,percent of total billed charges,Implant Device,832.32,34,,832.32,percent of total billed charges,Implant Device,832.32,34,,832.32,percent of total billed charges,Implant Device,1211.76,,,1211.76,Other,110% of Medicare,856.8,35,,856.8,percent of total billed charges,Implant Device,832.32,34,"Charges > $500, x 34%",832.32,percent of total billed charges,Implant Device,856.8,35,,856.8,percent of total billed charges,Implant Device,856.8,35,,856.8,percent of total billed charges,Implant Device,856.8,35,,856.8,percent of total billed charges,Implant Device,856.8,35,,856.8,percent of total billed charges,Implant Device,856.8,35,,856.8,percent of total billed charges,Implant Device,979.2,40,,979.2,percent of total billed charges,Implant Device,856.8,70,,856.8,percent of total billed charges,All Other,832.32,34,,832.32,percent of total billed charges,Implant Device,832.32,34,,832.32,percent of total billed charges,Implant Device,856.8,35,,856.8,percent of total billed charges,Implant Device,856.8,35,,856.8,percent of total billed charges,Implant Device,856.8,35,,856.8,percent of total billed charges,Implant Device,856.8,35,,856.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,832.32,34,"If Charge > 2,000, then 34 percent",832.32,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1811.53,
DEPUY 1365-36-330 FEM HEAD 12.14 36MM,C1776,HCPCS,,79009756,CDM,278,RC,,,both,,,5255,3888.71,,,3888.71,Other,150% of Medicare + 9.63% HCRA Surcharge,2364.75,45,,2364.75,percent of total billed charges,Critical Access Hospital RCC factor,1786.7,34,,1786.7,percent of total billed charges,Implant Device,1786.7,34,,1786.7,percent of total billed charges,Implant Device,1786.7,34,,1786.7,percent of total billed charges,Implant Device,1786.7,34,,1786.7,percent of total billed charges,Implant Device,1786.7,34,,1786.7,percent of total billed charges,Implant Device,2601.23,,,2601.23,Other,110% of Medicare,1839.25,35,,1839.25,percent of total billed charges,Implant Device,1786.7,34,"Charges > $500, x 34%",1786.7,percent of total billed charges,Implant Device,1839.25,35,,1839.25,percent of total billed charges,Implant Device,1839.25,35,,1839.25,percent of total billed charges,Implant Device,1839.25,35,,1839.25,percent of total billed charges,Implant Device,1839.25,35,,1839.25,percent of total billed charges,Implant Device,1839.25,35,,1839.25,percent of total billed charges,Implant Device,2102,40,,2102,percent of total billed charges,Implant Device,1839.25,70,,1839.25,percent of total billed charges,All Other,1786.7,34,,1786.7,percent of total billed charges,Implant Device,1786.7,34,,1786.7,percent of total billed charges,Implant Device,1839.25,35,,1839.25,percent of total billed charges,Implant Device,1839.25,35,,1839.25,percent of total billed charges,Implant Device,1839.25,35,,1839.25,percent of total billed charges,Implant Device,1839.25,35,,1839.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1786.7,34,"If Charge > 2,000, then 34 percent",1786.7,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3888.71,
ACUMED TR-S1004-S STEM 10X4MM,C1776,HCPCS,,79009757,CDM,278,RC,,,both,,,6951,5143.76,,,5143.76,Other,150% of Medicare + 9.63% HCRA Surcharge,3127.95,45,,3127.95,percent of total billed charges,Critical Access Hospital RCC factor,2363.34,34,,2363.34,percent of total billed charges,Implant Device,2363.34,34,,2363.34,percent of total billed charges,Implant Device,2363.34,34,,2363.34,percent of total billed charges,Implant Device,2363.34,34,,2363.34,percent of total billed charges,Implant Device,2363.34,34,,2363.34,percent of total billed charges,Implant Device,3440.75,,,3440.75,Other,110% of Medicare,2432.85,35,,2432.85,percent of total billed charges,Implant Device,2363.34,34,"Charges > $500, x 34%",2363.34,percent of total billed charges,Implant Device,2432.85,35,,2432.85,percent of total billed charges,Implant Device,2432.85,35,,2432.85,percent of total billed charges,Implant Device,2432.85,35,,2432.85,percent of total billed charges,Implant Device,2432.85,35,,2432.85,percent of total billed charges,Implant Device,2432.85,35,,2432.85,percent of total billed charges,Implant Device,2780.4,40,,2780.4,percent of total billed charges,Implant Device,2432.85,70,,2432.85,percent of total billed charges,All Other,2363.34,34,,2363.34,percent of total billed charges,Implant Device,2363.34,34,,2363.34,percent of total billed charges,Implant Device,2432.85,35,,2432.85,percent of total billed charges,Implant Device,2432.85,35,,2432.85,percent of total billed charges,Implant Device,2432.85,35,,2432.85,percent of total billed charges,Implant Device,2432.85,35,,2432.85,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2363.34,34,"If Charge > 2,000, then 34 percent",2363.34,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5143.76,
STRYKER 619920 WASHER T8 & T10 SCREWS,C1713,HCPCS,,79009758,CDM,278,RC,,,both,,,84,62.16,,,62.16,Other,150% of Medicare + 9.63% HCRA Surcharge,37.8,45,,37.8,percent of total billed charges,Critical Access Hospital RCC factor,28.56,34,,28.56,percent of total billed charges,Implant Device,28.56,34,,28.56,percent of total billed charges,Implant Device,28.56,34,,28.56,percent of total billed charges,Implant Device,28.56,34,,28.56,percent of total billed charges,Implant Device,28.56,34,,28.56,percent of total billed charges,Implant Device,41.58,,,41.58,Other,110% of Medicare,29.4,35,,29.4,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,29.4,35,,29.4,percent of total billed charges,Implant Device,29.4,35,,29.4,percent of total billed charges,Implant Device,29.4,35,,29.4,percent of total billed charges,Implant Device,29.4,35,,29.4,percent of total billed charges,Implant Device,29.4,35,,29.4,percent of total billed charges,Implant Device,33.6,40,,33.6,percent of total billed charges,Implant Device,29.4,70,,29.4,percent of total billed charges,All Other,28.56,34,,28.56,percent of total billed charges,Implant Device,28.56,34,,28.56,percent of total billed charges,Implant Device,29.4,35,,29.4,percent of total billed charges,Implant Device,29.4,35,,29.4,percent of total billed charges,Implant Device,29.4,35,,29.4,percent of total billed charges,Implant Device,29.4,35,,29.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,62.16,
STRYKER 626880 LOCK PLATE TALAR NECK T8,C1713,HCPCS,,79009759,CDM,278,RC,,,both,,,5148,3809.53,,,3809.53,Other,150% of Medicare + 9.63% HCRA Surcharge,2316.6,45,,2316.6,percent of total billed charges,Critical Access Hospital RCC factor,1750.32,34,,1750.32,percent of total billed charges,Implant Device,1750.32,34,,1750.32,percent of total billed charges,Implant Device,1750.32,34,,1750.32,percent of total billed charges,Implant Device,1750.32,34,,1750.32,percent of total billed charges,Implant Device,1750.32,34,,1750.32,percent of total billed charges,Implant Device,2548.26,,,2548.26,Other,110% of Medicare,1801.8,35,,1801.8,percent of total billed charges,Implant Device,1750.32,34,"Charges > $500, x 34%",1750.32,percent of total billed charges,Implant Device,1801.8,35,,1801.8,percent of total billed charges,Implant Device,1801.8,35,,1801.8,percent of total billed charges,Implant Device,1801.8,35,,1801.8,percent of total billed charges,Implant Device,1801.8,35,,1801.8,percent of total billed charges,Implant Device,1801.8,35,,1801.8,percent of total billed charges,Implant Device,2059.2,40,,2059.2,percent of total billed charges,Implant Device,1801.8,70,,1801.8,percent of total billed charges,All Other,1750.32,34,,1750.32,percent of total billed charges,Implant Device,1750.32,34,,1750.32,percent of total billed charges,Implant Device,1801.8,35,,1801.8,percent of total billed charges,Implant Device,1801.8,35,,1801.8,percent of total billed charges,Implant Device,1801.8,35,,1801.8,percent of total billed charges,Implant Device,1801.8,35,,1801.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1750.32,34,"If Charge > 2,000, then 34 percent",1750.32,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3809.53,
DEPUY 02.112.085 CLAVICLE PLT 8H 3.5X115,C1713,HCPCS,,79009760,CDM,278,RC,,,both,,,2523,1867.03,,,1867.03,Other,150% of Medicare + 9.63% HCRA Surcharge,1135.35,45,,1135.35,percent of total billed charges,Critical Access Hospital RCC factor,857.82,34,,857.82,percent of total billed charges,Implant Device,857.82,34,,857.82,percent of total billed charges,Implant Device,857.82,34,,857.82,percent of total billed charges,Implant Device,857.82,34,,857.82,percent of total billed charges,Implant Device,857.82,34,,857.82,percent of total billed charges,Implant Device,1248.89,,,1248.89,Other,110% of Medicare,883.05,35,,883.05,percent of total billed charges,Implant Device,857.82,34,"Charges > $500, x 34%",857.82,percent of total billed charges,Implant Device,883.05,35,,883.05,percent of total billed charges,Implant Device,883.05,35,,883.05,percent of total billed charges,Implant Device,883.05,35,,883.05,percent of total billed charges,Implant Device,883.05,35,,883.05,percent of total billed charges,Implant Device,883.05,35,,883.05,percent of total billed charges,Implant Device,1009.2,40,,1009.2,percent of total billed charges,Implant Device,883.05,70,,883.05,percent of total billed charges,All Other,857.82,34,,857.82,percent of total billed charges,Implant Device,857.82,34,,857.82,percent of total billed charges,Implant Device,883.05,35,,883.05,percent of total billed charges,Implant Device,883.05,35,,883.05,percent of total billed charges,Implant Device,883.05,35,,883.05,percent of total billed charges,Implant Device,883.05,35,,883.05,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,857.82,34,"If Charge > 2,000, then 34 percent",857.82,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1867.03,
DEPUY 02.112.031 CLAVICLE PLT 8H 3.5X120,C1713,HCPCS,,79009761,CDM,278,RC,,,both,,,2549,1886.27,,,1886.27,Other,150% of Medicare + 9.63% HCRA Surcharge,1147.05,45,,1147.05,percent of total billed charges,Critical Access Hospital RCC factor,866.66,34,,866.66,percent of total billed charges,Implant Device,866.66,34,,866.66,percent of total billed charges,Implant Device,866.66,34,,866.66,percent of total billed charges,Implant Device,866.66,34,,866.66,percent of total billed charges,Implant Device,866.66,34,,866.66,percent of total billed charges,Implant Device,1261.76,,,1261.76,Other,110% of Medicare,892.15,35,,892.15,percent of total billed charges,Implant Device,866.66,34,"Charges > $500, x 34%",866.66,percent of total billed charges,Implant Device,892.15,35,,892.15,percent of total billed charges,Implant Device,892.15,35,,892.15,percent of total billed charges,Implant Device,892.15,35,,892.15,percent of total billed charges,Implant Device,892.15,35,,892.15,percent of total billed charges,Implant Device,892.15,35,,892.15,percent of total billed charges,Implant Device,1019.6,40,,1019.6,percent of total billed charges,Implant Device,892.15,70,,892.15,percent of total billed charges,All Other,866.66,34,,866.66,percent of total billed charges,Implant Device,866.66,34,,866.66,percent of total billed charges,Implant Device,892.15,35,,892.15,percent of total billed charges,Implant Device,892.15,35,,892.15,percent of total billed charges,Implant Device,892.15,35,,892.15,percent of total billed charges,Implant Device,892.15,35,,892.15,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,866.66,34,"If Charge > 2,000, then 34 percent",866.66,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1886.27,
STRYKER 656328 LOCKING SCREW T8 2.7XL28,C1713,HCPCS,,79009762,CDM,278,RC,,,both,,,492,364.08,,,364.08,Other,150% of Medicare + 9.63% HCRA Surcharge,221.4,45,,221.4,percent of total billed charges,Critical Access Hospital RCC factor,167.28,34,,167.28,percent of total billed charges,Implant Device,167.28,34,,167.28,percent of total billed charges,Implant Device,167.28,34,,167.28,percent of total billed charges,Implant Device,167.28,34,,167.28,percent of total billed charges,Implant Device,167.28,34,,167.28,percent of total billed charges,Implant Device,243.54,,,243.54,Other,110% of Medicare,172.2,35,,172.2,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,172.2,35,,172.2,percent of total billed charges,Implant Device,172.2,35,,172.2,percent of total billed charges,Implant Device,172.2,35,,172.2,percent of total billed charges,Implant Device,172.2,35,,172.2,percent of total billed charges,Implant Device,172.2,35,,172.2,percent of total billed charges,Implant Device,196.8,40,,196.8,percent of total billed charges,Implant Device,172.2,70,,172.2,percent of total billed charges,All Other,167.28,34,,167.28,percent of total billed charges,Implant Device,167.28,34,,167.28,percent of total billed charges,Implant Device,172.2,35,,172.2,percent of total billed charges,Implant Device,172.2,35,,172.2,percent of total billed charges,Implant Device,172.2,35,,172.2,percent of total billed charges,Implant Device,172.2,35,,172.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,364.08,
ZIMMER 00-7711-011-20 M/L TAPER 11MM,C1776,HCPCS,,79009763,CDM,278,RC,,,both,,,6900,5106.02,,,5106.02,Other,150% of Medicare + 9.63% HCRA Surcharge,3105,45,,3105,percent of total billed charges,Critical Access Hospital RCC factor,2346,34,,2346,percent of total billed charges,Implant Device,2346,34,,2346,percent of total billed charges,Implant Device,2346,34,,2346,percent of total billed charges,Implant Device,2346,34,,2346,percent of total billed charges,Implant Device,2346,34,,2346,percent of total billed charges,Implant Device,3415.5,,,3415.5,Other,110% of Medicare,2415,35,,2415,percent of total billed charges,Implant Device,2346,34,"Charges > $500, x 34%",2346,percent of total billed charges,Implant Device,2415,35,,2415,percent of total billed charges,Implant Device,2415,35,,2415,percent of total billed charges,Implant Device,2415,35,,2415,percent of total billed charges,Implant Device,2415,35,,2415,percent of total billed charges,Implant Device,2415,35,,2415,percent of total billed charges,Implant Device,2760,40,,2760,percent of total billed charges,Implant Device,2415,70,,2415,percent of total billed charges,All Other,2346,34,,2346,percent of total billed charges,Implant Device,2346,34,,2346,percent of total billed charges,Implant Device,2415,35,,2415,percent of total billed charges,Implant Device,2415,35,,2415,percent of total billed charges,Implant Device,2415,35,,2415,percent of total billed charges,Implant Device,2415,35,,2415,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2346,34,"If Charge > 2,000, then 34 percent",2346,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5106.02,
MENTOR 350-9113 BREAST EXPANDER 450CC,C1789,HCPCS,,79009764,CDM,278,RC,,,both,,,5475,4051.51,,,4051.51,Other,150% of Medicare + 9.63% HCRA Surcharge,2463.75,45,,2463.75,percent of total billed charges,Critical Access Hospital RCC factor,1861.5,34,,1861.5,percent of total billed charges,Implant Device,1861.5,34,,1861.5,percent of total billed charges,Implant Device,1861.5,34,,1861.5,percent of total billed charges,Implant Device,1861.5,34,,1861.5,percent of total billed charges,Implant Device,1861.5,34,,1861.5,percent of total billed charges,Implant Device,2710.13,,,2710.13,Other,110% of Medicare,1916.25,35,,1916.25,percent of total billed charges,Implant Device,1861.5,34,"Charges > $500, x 34%",1861.5,percent of total billed charges,Implant Device,1916.25,35,,1916.25,percent of total billed charges,Implant Device,1916.25,35,,1916.25,percent of total billed charges,Implant Device,1916.25,35,,1916.25,percent of total billed charges,Implant Device,1916.25,35,,1916.25,percent of total billed charges,Implant Device,1916.25,35,,1916.25,percent of total billed charges,Implant Device,2190,40,,2190,percent of total billed charges,Implant Device,1916.25,70,,1916.25,percent of total billed charges,All Other,1861.5,34,,1861.5,percent of total billed charges,Implant Device,1861.5,34,,1861.5,percent of total billed charges,Implant Device,1916.25,35,,1916.25,percent of total billed charges,Implant Device,1916.25,35,,1916.25,percent of total billed charges,Implant Device,1916.25,35,,1916.25,percent of total billed charges,Implant Device,1916.25,35,,1916.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1861.5,34,"If Charge > 2,000, then 34 percent",1861.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4051.51,
MENTOR 350-9214 BREAST EXPANDER 550CC,C1789,HCPCS,,79009765,CDM,278,RC,,,both,,,5475,4051.51,,,4051.51,Other,150% of Medicare + 9.63% HCRA Surcharge,2463.75,45,,2463.75,percent of total billed charges,Critical Access Hospital RCC factor,1861.5,34,,1861.5,percent of total billed charges,Implant Device,1861.5,34,,1861.5,percent of total billed charges,Implant Device,1861.5,34,,1861.5,percent of total billed charges,Implant Device,1861.5,34,,1861.5,percent of total billed charges,Implant Device,1861.5,34,,1861.5,percent of total billed charges,Implant Device,2710.13,,,2710.13,Other,110% of Medicare,1916.25,35,,1916.25,percent of total billed charges,Implant Device,1861.5,34,"Charges > $500, x 34%",1861.5,percent of total billed charges,Implant Device,1916.25,35,,1916.25,percent of total billed charges,Implant Device,1916.25,35,,1916.25,percent of total billed charges,Implant Device,1916.25,35,,1916.25,percent of total billed charges,Implant Device,1916.25,35,,1916.25,percent of total billed charges,Implant Device,1916.25,35,,1916.25,percent of total billed charges,Implant Device,2190,40,,2190,percent of total billed charges,Implant Device,1916.25,70,,1916.25,percent of total billed charges,All Other,1861.5,34,,1861.5,percent of total billed charges,Implant Device,1861.5,34,,1861.5,percent of total billed charges,Implant Device,1916.25,35,,1916.25,percent of total billed charges,Implant Device,1916.25,35,,1916.25,percent of total billed charges,Implant Device,1916.25,35,,1916.25,percent of total billed charges,Implant Device,1916.25,35,,1916.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1861.5,34,"If Charge > 2,000, then 34 percent",1861.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4051.51,
S&N 71333436 ACETAB LINER SZ G 32X+4MM,C1776,HCPCS,,79009766,CDM,278,RC,,,both,,,4516,3341.85,,,3341.85,Other,150% of Medicare + 9.63% HCRA Surcharge,2032.2,45,,2032.2,percent of total billed charges,Critical Access Hospital RCC factor,1535.44,34,,1535.44,percent of total billed charges,Implant Device,1535.44,34,,1535.44,percent of total billed charges,Implant Device,1535.44,34,,1535.44,percent of total billed charges,Implant Device,1535.44,34,,1535.44,percent of total billed charges,Implant Device,1535.44,34,,1535.44,percent of total billed charges,Implant Device,2235.42,,,2235.42,Other,110% of Medicare,1580.6,35,,1580.6,percent of total billed charges,Implant Device,1535.44,34,"Charges > $500, x 34%",1535.44,percent of total billed charges,Implant Device,1580.6,35,,1580.6,percent of total billed charges,Implant Device,1580.6,35,,1580.6,percent of total billed charges,Implant Device,1580.6,35,,1580.6,percent of total billed charges,Implant Device,1580.6,35,,1580.6,percent of total billed charges,Implant Device,1580.6,35,,1580.6,percent of total billed charges,Implant Device,1806.4,40,,1806.4,percent of total billed charges,Implant Device,1580.6,70,,1580.6,percent of total billed charges,All Other,1535.44,34,,1535.44,percent of total billed charges,Implant Device,1535.44,34,,1535.44,percent of total billed charges,Implant Device,1580.6,35,,1580.6,percent of total billed charges,Implant Device,1580.6,35,,1580.6,percent of total billed charges,Implant Device,1580.6,35,,1580.6,percent of total billed charges,Implant Device,1580.6,35,,1580.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1535.44,34,"If Charge > 2,000, then 34 percent",1535.44,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3341.85,
S&N 71343216 FEM HEAD 12/14 TAPER 32MM,C1776,HCPCS,,79009767,CDM,278,RC,,,both,,,5554,4109.97,,,4109.97,Other,150% of Medicare + 9.63% HCRA Surcharge,2499.3,45,,2499.3,percent of total billed charges,Critical Access Hospital RCC factor,1888.36,34,,1888.36,percent of total billed charges,Implant Device,1888.36,34,,1888.36,percent of total billed charges,Implant Device,1888.36,34,,1888.36,percent of total billed charges,Implant Device,1888.36,34,,1888.36,percent of total billed charges,Implant Device,1888.36,34,,1888.36,percent of total billed charges,Implant Device,2749.23,,,2749.23,Other,110% of Medicare,1943.9,35,,1943.9,percent of total billed charges,Implant Device,1888.36,34,"Charges > $500, x 34%",1888.36,percent of total billed charges,Implant Device,1943.9,35,,1943.9,percent of total billed charges,Implant Device,1943.9,35,,1943.9,percent of total billed charges,Implant Device,1943.9,35,,1943.9,percent of total billed charges,Implant Device,1943.9,35,,1943.9,percent of total billed charges,Implant Device,1943.9,35,,1943.9,percent of total billed charges,Implant Device,2221.6,40,,2221.6,percent of total billed charges,Implant Device,1943.9,70,,1943.9,percent of total billed charges,All Other,1888.36,34,,1888.36,percent of total billed charges,Implant Device,1888.36,34,,1888.36,percent of total billed charges,Implant Device,1943.9,35,,1943.9,percent of total billed charges,Implant Device,1943.9,35,,1943.9,percent of total billed charges,Implant Device,1943.9,35,,1943.9,percent of total billed charges,Implant Device,1943.9,35,,1943.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1888.36,34,"If Charge > 2,000, then 34 percent",1888.36,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4109.97,
ALLERGAN CM1516 ALLODERM CONTOUR THIN,C1781,HCPCS,,79009768,CDM,278,RC,,,both,,,18426,13635.29,,,13635.29,Other,150% of Medicare + 9.63% HCRA Surcharge,8291.7,45,,8291.7,percent of total billed charges,Critical Access Hospital RCC factor,6264.84,34,,6264.84,percent of total billed charges,Implant Device,6264.84,34,,6264.84,percent of total billed charges,Implant Device,6264.84,34,,6264.84,percent of total billed charges,Implant Device,6264.84,34,,6264.84,percent of total billed charges,Implant Device,6264.84,34,,6264.84,percent of total billed charges,Implant Device,9120.87,,,9120.87,Other,110% of Medicare,6449.1,35,,6449.1,percent of total billed charges,Implant Device,6264.84,34,"Charges > $500, x 34%",6264.84,percent of total billed charges,Implant Device,6449.1,35,,6449.1,percent of total billed charges,Implant Device,6449.1,35,,6449.1,percent of total billed charges,Implant Device,6449.1,35,,6449.1,percent of total billed charges,Implant Device,6449.1,35,,6449.1,percent of total billed charges,Implant Device,6449.1,35,,6449.1,percent of total billed charges,Implant Device,7370.4,40,,7370.4,percent of total billed charges,Implant Device,6449.1,70,,6449.1,percent of total billed charges,All Other,6264.84,34,,6264.84,percent of total billed charges,Implant Device,6264.84,34,,6264.84,percent of total billed charges,Implant Device,6449.1,35,,6449.1,percent of total billed charges,Implant Device,6449.1,35,,6449.1,percent of total billed charges,Implant Device,6449.1,35,,6449.1,percent of total billed charges,Implant Device,6449.1,35,,6449.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,6264.84,34,"If Charge > 2,000, then 34 percent",6264.84,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,13635.29,
ALLERGAN CS1516 ALLODERM CONTOUR THIN,C1781,HCPCS,,79009769,CDM,278,RC,,,both,,,10749,7954.29,,,7954.29,Other,150% of Medicare + 9.63% HCRA Surcharge,4837.05,45,,4837.05,percent of total billed charges,Critical Access Hospital RCC factor,3654.66,34,,3654.66,percent of total billed charges,Implant Device,3654.66,34,,3654.66,percent of total billed charges,Implant Device,3654.66,34,,3654.66,percent of total billed charges,Implant Device,3654.66,34,,3654.66,percent of total billed charges,Implant Device,3654.66,34,,3654.66,percent of total billed charges,Implant Device,5320.76,,,5320.76,Other,110% of Medicare,3762.15,35,,3762.15,percent of total billed charges,Implant Device,3654.66,34,"Charges > $500, x 34%",3654.66,percent of total billed charges,Implant Device,3762.15,35,,3762.15,percent of total billed charges,Implant Device,3762.15,35,,3762.15,percent of total billed charges,Implant Device,3762.15,35,,3762.15,percent of total billed charges,Implant Device,3762.15,35,,3762.15,percent of total billed charges,Implant Device,3762.15,35,,3762.15,percent of total billed charges,Implant Device,4299.6,40,,4299.6,percent of total billed charges,Implant Device,3762.15,70,,3762.15,percent of total billed charges,All Other,3654.66,34,,3654.66,percent of total billed charges,Implant Device,3654.66,34,,3654.66,percent of total billed charges,Implant Device,3762.15,35,,3762.15,percent of total billed charges,Implant Device,3762.15,35,,3762.15,percent of total billed charges,Implant Device,3762.15,35,,3762.15,percent of total billed charges,Implant Device,3762.15,35,,3762.15,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3654.66,34,"If Charge > 2,000, then 34 percent",3654.66,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,7954.29,
ZIMMER 00-5994-051-10 ART SURF E.F 10MM,C1776,HCPCS,,79009770,CDM,278,RC,,,both,,,6320,4676.82,,,4676.82,Other,150% of Medicare + 9.63% HCRA Surcharge,2844,45,,2844,percent of total billed charges,Critical Access Hospital RCC factor,2148.8,34,,2148.8,percent of total billed charges,Implant Device,2148.8,34,,2148.8,percent of total billed charges,Implant Device,2148.8,34,,2148.8,percent of total billed charges,Implant Device,2148.8,34,,2148.8,percent of total billed charges,Implant Device,2148.8,34,,2148.8,percent of total billed charges,Implant Device,3128.4,,,3128.4,Other,110% of Medicare,2212,35,,2212,percent of total billed charges,Implant Device,2148.8,34,"Charges > $500, x 34%",2148.8,percent of total billed charges,Implant Device,2212,35,,2212,percent of total billed charges,Implant Device,2212,35,,2212,percent of total billed charges,Implant Device,2212,35,,2212,percent of total billed charges,Implant Device,2212,35,,2212,percent of total billed charges,Implant Device,2212,35,,2212,percent of total billed charges,Implant Device,2528,40,,2528,percent of total billed charges,Implant Device,2212,70,,2212,percent of total billed charges,All Other,2148.8,34,,2148.8,percent of total billed charges,Implant Device,2148.8,34,,2148.8,percent of total billed charges,Implant Device,2212,35,,2212,percent of total billed charges,Implant Device,2212,35,,2212,percent of total billed charges,Implant Device,2212,35,,2212,percent of total billed charges,Implant Device,2212,35,,2212,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2148.8,34,"If Charge > 2,000, then 34 percent",2148.8,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4676.82,
IN2BONES P62 ST414 NON LOCK SCREW 2.4X14,C1713,HCPCS,,79009772,CDM,278,RC,,,both,,,870,643.8,,,643.8,Other,150% of Medicare + 9.63% HCRA Surcharge,391.5,45,,391.5,percent of total billed charges,Critical Access Hospital RCC factor,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,430.65,,,430.65,Other,110% of Medicare,304.5,35,,304.5,percent of total billed charges,Implant Device,295.8,34,"Charges > $500, x 34%",295.8,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,348,40,,348,percent of total billed charges,Implant Device,304.5,70,,304.5,percent of total billed charges,All Other,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,643.8,
MENTOR SMXP130RH BREAST EXPANDER 475CC,C1789,HCPCS,,79009773,CDM,278,RC,,,both,,,6375,4717.52,,,4717.52,Other,150% of Medicare + 9.63% HCRA Surcharge,2868.75,45,,2868.75,percent of total billed charges,Critical Access Hospital RCC factor,2167.5,34,,2167.5,percent of total billed charges,Implant Device,2167.5,34,,2167.5,percent of total billed charges,Implant Device,2167.5,34,,2167.5,percent of total billed charges,Implant Device,2167.5,34,,2167.5,percent of total billed charges,Implant Device,2167.5,34,,2167.5,percent of total billed charges,Implant Device,3155.63,,,3155.63,Other,110% of Medicare,2231.25,35,,2231.25,percent of total billed charges,Implant Device,2167.5,34,"Charges > $500, x 34%",2167.5,percent of total billed charges,Implant Device,2231.25,35,,2231.25,percent of total billed charges,Implant Device,2231.25,35,,2231.25,percent of total billed charges,Implant Device,2231.25,35,,2231.25,percent of total billed charges,Implant Device,2231.25,35,,2231.25,percent of total billed charges,Implant Device,2231.25,35,,2231.25,percent of total billed charges,Implant Device,2550,40,,2550,percent of total billed charges,Implant Device,2231.25,70,,2231.25,percent of total billed charges,All Other,2167.5,34,,2167.5,percent of total billed charges,Implant Device,2167.5,34,,2167.5,percent of total billed charges,Implant Device,2231.25,35,,2231.25,percent of total billed charges,Implant Device,2231.25,35,,2231.25,percent of total billed charges,Implant Device,2231.25,35,,2231.25,percent of total billed charges,Implant Device,2231.25,35,,2231.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2167.5,34,"If Charge > 2,000, then 34 percent",2167.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4717.52,
MENTOR SMXP136RH BREAST EXPANDER 500CC,C1789,HCPCS,,79009774,CDM,278,RC,,,both,,,6375,4717.52,,,4717.52,Other,150% of Medicare + 9.63% HCRA Surcharge,2868.75,45,,2868.75,percent of total billed charges,Critical Access Hospital RCC factor,2167.5,34,,2167.5,percent of total billed charges,Implant Device,2167.5,34,,2167.5,percent of total billed charges,Implant Device,2167.5,34,,2167.5,percent of total billed charges,Implant Device,2167.5,34,,2167.5,percent of total billed charges,Implant Device,2167.5,34,,2167.5,percent of total billed charges,Implant Device,3155.63,,,3155.63,Other,110% of Medicare,2231.25,35,,2231.25,percent of total billed charges,Implant Device,2167.5,34,"Charges > $500, x 34%",2167.5,percent of total billed charges,Implant Device,2231.25,35,,2231.25,percent of total billed charges,Implant Device,2231.25,35,,2231.25,percent of total billed charges,Implant Device,2231.25,35,,2231.25,percent of total billed charges,Implant Device,2231.25,35,,2231.25,percent of total billed charges,Implant Device,2231.25,35,,2231.25,percent of total billed charges,Implant Device,2550,40,,2550,percent of total billed charges,Implant Device,2231.25,70,,2231.25,percent of total billed charges,All Other,2167.5,34,,2167.5,percent of total billed charges,Implant Device,2167.5,34,,2167.5,percent of total billed charges,Implant Device,2231.25,35,,2231.25,percent of total billed charges,Implant Device,2231.25,35,,2231.25,percent of total billed charges,Implant Device,2231.25,35,,2231.25,percent of total billed charges,Implant Device,2231.25,35,,2231.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2167.5,34,"If Charge > 2,000, then 34 percent",2167.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4717.52,
DEPUY 1221-40-156 ACET LINER+4 X 40X56MM,C1776,HCPCS,,79009775,CDM,278,RC,,,both,,,2565,1898.11,,,1898.11,Other,150% of Medicare + 9.63% HCRA Surcharge,1154.25,45,,1154.25,percent of total billed charges,Critical Access Hospital RCC factor,872.1,34,,872.1,percent of total billed charges,Implant Device,872.1,34,,872.1,percent of total billed charges,Implant Device,872.1,34,,872.1,percent of total billed charges,Implant Device,872.1,34,,872.1,percent of total billed charges,Implant Device,872.1,34,,872.1,percent of total billed charges,Implant Device,1269.68,,,1269.68,Other,110% of Medicare,897.75,35,,897.75,percent of total billed charges,Implant Device,872.1,34,"Charges > $500, x 34%",872.1,percent of total billed charges,Implant Device,897.75,35,,897.75,percent of total billed charges,Implant Device,897.75,35,,897.75,percent of total billed charges,Implant Device,897.75,35,,897.75,percent of total billed charges,Implant Device,897.75,35,,897.75,percent of total billed charges,Implant Device,897.75,35,,897.75,percent of total billed charges,Implant Device,1026,40,,1026,percent of total billed charges,Implant Device,897.75,70,,897.75,percent of total billed charges,All Other,872.1,34,,872.1,percent of total billed charges,Implant Device,872.1,34,,872.1,percent of total billed charges,Implant Device,897.75,35,,897.75,percent of total billed charges,Implant Device,897.75,35,,897.75,percent of total billed charges,Implant Device,897.75,35,,897.75,percent of total billed charges,Implant Device,897.75,35,,897.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,872.1,34,"If Charge > 2,000, then 34 percent",872.1,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1898.11,
DEPUY 1365-42-500 FEM HEAD 40MM 11/13,C1776,HCPCS,,79009776,CDM,278,RC,,,both,,,4572,3383.29,,,3383.29,Other,150% of Medicare + 9.63% HCRA Surcharge,2057.4,45,,2057.4,percent of total billed charges,Critical Access Hospital RCC factor,1554.48,34,,1554.48,percent of total billed charges,Implant Device,1554.48,34,,1554.48,percent of total billed charges,Implant Device,1554.48,34,,1554.48,percent of total billed charges,Implant Device,1554.48,34,,1554.48,percent of total billed charges,Implant Device,1554.48,34,,1554.48,percent of total billed charges,Implant Device,2263.14,,,2263.14,Other,110% of Medicare,1600.2,35,,1600.2,percent of total billed charges,Implant Device,1554.48,34,"Charges > $500, x 34%",1554.48,percent of total billed charges,Implant Device,1600.2,35,,1600.2,percent of total billed charges,Implant Device,1600.2,35,,1600.2,percent of total billed charges,Implant Device,1600.2,35,,1600.2,percent of total billed charges,Implant Device,1600.2,35,,1600.2,percent of total billed charges,Implant Device,1600.2,35,,1600.2,percent of total billed charges,Implant Device,1828.8,40,,1828.8,percent of total billed charges,Implant Device,1600.2,70,,1600.2,percent of total billed charges,All Other,1554.48,34,,1554.48,percent of total billed charges,Implant Device,1554.48,34,,1554.48,percent of total billed charges,Implant Device,1600.2,35,,1600.2,percent of total billed charges,Implant Device,1600.2,35,,1600.2,percent of total billed charges,Implant Device,1600.2,35,,1600.2,percent of total billed charges,Implant Device,1600.2,35,,1600.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1554.48,34,"If Charge > 2,000, then 34 percent",1554.48,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3383.29,
ZIMMER 32-8105-027-04 HUMERAL ASSY 4',C1713,HCPCS,,79009777,CDM,278,RC,,,both,,,16200,11988.04,,,11988.04,Other,150% of Medicare + 9.63% HCRA Surcharge,7290,45,,7290,percent of total billed charges,Critical Access Hospital RCC factor,5508,34,,5508,percent of total billed charges,Implant Device,5508,34,,5508,percent of total billed charges,Implant Device,5508,34,,5508,percent of total billed charges,Implant Device,5508,34,,5508,percent of total billed charges,Implant Device,5508,34,,5508,percent of total billed charges,Implant Device,8019,,,8019,Other,110% of Medicare,5670,35,,5670,percent of total billed charges,Implant Device,5508,34,"Charges > $500, x 34%",5508,percent of total billed charges,Implant Device,5670,35,,5670,percent of total billed charges,Implant Device,5670,35,,5670,percent of total billed charges,Implant Device,5670,35,,5670,percent of total billed charges,Implant Device,5670,35,,5670,percent of total billed charges,Implant Device,5670,35,,5670,percent of total billed charges,Implant Device,6480,40,,6480,percent of total billed charges,Implant Device,5670,70,,5670,percent of total billed charges,All Other,5508,34,,5508,percent of total billed charges,Implant Device,5508,34,,5508,percent of total billed charges,Implant Device,5670,35,,5670,percent of total billed charges,Implant Device,5670,35,,5670,percent of total billed charges,Implant Device,5670,35,,5670,percent of total billed charges,Implant Device,5670,35,,5670,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,5508,34,"If Charge > 2,000, then 34 percent",5508,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,11988.04,
"ZIMMER 32-8105-043-01 ULNA ASSEMBLY 3""",C1713,HCPCS,,79009778,CDM,278,RC,,,both,,,14700,10878.04,,,10878.04,Other,150% of Medicare + 9.63% HCRA Surcharge,6615,45,,6615,percent of total billed charges,Critical Access Hospital RCC factor,4998,34,,4998,percent of total billed charges,Implant Device,4998,34,,4998,percent of total billed charges,Implant Device,4998,34,,4998,percent of total billed charges,Implant Device,4998,34,,4998,percent of total billed charges,Implant Device,4998,34,,4998,percent of total billed charges,Implant Device,7276.5,,,7276.5,Other,110% of Medicare,5145,35,,5145,percent of total billed charges,Implant Device,4998,34,"Charges > $500, x 34%",4998,percent of total billed charges,Implant Device,5145,35,,5145,percent of total billed charges,Implant Device,5145,35,,5145,percent of total billed charges,Implant Device,5145,35,,5145,percent of total billed charges,Implant Device,5145,35,,5145,percent of total billed charges,Implant Device,5145,35,,5145,percent of total billed charges,Implant Device,5880,40,,5880,percent of total billed charges,Implant Device,5145,70,,5145,percent of total billed charges,All Other,4998,34,,4998,percent of total billed charges,Implant Device,4998,34,,4998,percent of total billed charges,Implant Device,5145,35,,5145,percent of total billed charges,Implant Device,5145,35,,5145,percent of total billed charges,Implant Device,5145,35,,5145,percent of total billed charges,Implant Device,5145,35,,5145,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,4998,34,"If Charge > 2,000, then 34 percent",4998,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,10878.04,
ARTHREX AR-9943BL-04 LOCK DIS FIB PLT LT,C1713,HCPCS,,79009780,CDM,278,RC,,,both,,,2574,1904.77,,,1904.77,Other,150% of Medicare + 9.63% HCRA Surcharge,1158.3,45,,1158.3,percent of total billed charges,Critical Access Hospital RCC factor,875.16,34,,875.16,percent of total billed charges,Implant Device,875.16,34,,875.16,percent of total billed charges,Implant Device,875.16,34,,875.16,percent of total billed charges,Implant Device,875.16,34,,875.16,percent of total billed charges,Implant Device,875.16,34,,875.16,percent of total billed charges,Implant Device,1274.13,,,1274.13,Other,110% of Medicare,900.9,35,,900.9,percent of total billed charges,Implant Device,875.16,34,"Charges > $500, x 34%",875.16,percent of total billed charges,Implant Device,900.9,35,,900.9,percent of total billed charges,Implant Device,900.9,35,,900.9,percent of total billed charges,Implant Device,900.9,35,,900.9,percent of total billed charges,Implant Device,900.9,35,,900.9,percent of total billed charges,Implant Device,900.9,35,,900.9,percent of total billed charges,Implant Device,1029.6,40,,1029.6,percent of total billed charges,Implant Device,900.9,70,,900.9,percent of total billed charges,All Other,875.16,34,,875.16,percent of total billed charges,Implant Device,875.16,34,,875.16,percent of total billed charges,Implant Device,900.9,35,,900.9,percent of total billed charges,Implant Device,900.9,35,,900.9,percent of total billed charges,Implant Device,900.9,35,,900.9,percent of total billed charges,Implant Device,900.9,35,,900.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,875.16,34,"If Charge > 2,000, then 34 percent",875.16,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1904.77,
STRYKER 5018-6-200 APEX HALF PIN 5X200,C1713,HCPCS,,79009782,CDM,278,RC,,,both,,,257,190.18,,,190.18,Other,150% of Medicare + 9.63% HCRA Surcharge,115.65,45,,115.65,percent of total billed charges,Critical Access Hospital RCC factor,87.38,34,,87.38,percent of total billed charges,Implant Device,87.38,34,,87.38,percent of total billed charges,Implant Device,87.38,34,,87.38,percent of total billed charges,Implant Device,87.38,34,,87.38,percent of total billed charges,Implant Device,87.38,34,,87.38,percent of total billed charges,Implant Device,127.22,,,127.22,Other,110% of Medicare,89.95,35,,89.95,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,89.95,35,,89.95,percent of total billed charges,Implant Device,89.95,35,,89.95,percent of total billed charges,Implant Device,89.95,35,,89.95,percent of total billed charges,Implant Device,89.95,35,,89.95,percent of total billed charges,Implant Device,89.95,35,,89.95,percent of total billed charges,Implant Device,102.8,40,,102.8,percent of total billed charges,Implant Device,89.95,70,,89.95,percent of total billed charges,All Other,87.38,34,,87.38,percent of total billed charges,Implant Device,87.38,34,,87.38,percent of total billed charges,Implant Device,89.95,35,,89.95,percent of total billed charges,Implant Device,89.95,35,,89.95,percent of total billed charges,Implant Device,89.95,35,,89.95,percent of total billed charges,Implant Device,89.95,35,,89.95,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,190.18,
DEPUY 1221-32-150 ACETABULAR LINER 32X50,C1776,HCPCS,,79009783,CDM,278,RC,,,both,,,2565,1898.11,,,1898.11,Other,150% of Medicare + 9.63% HCRA Surcharge,1154.25,45,,1154.25,percent of total billed charges,Critical Access Hospital RCC factor,872.1,34,,872.1,percent of total billed charges,Implant Device,872.1,34,,872.1,percent of total billed charges,Implant Device,872.1,34,,872.1,percent of total billed charges,Implant Device,872.1,34,,872.1,percent of total billed charges,Implant Device,872.1,34,,872.1,percent of total billed charges,Implant Device,1269.68,,,1269.68,Other,110% of Medicare,897.75,35,,897.75,percent of total billed charges,Implant Device,872.1,34,"Charges > $500, x 34%",872.1,percent of total billed charges,Implant Device,897.75,35,,897.75,percent of total billed charges,Implant Device,897.75,35,,897.75,percent of total billed charges,Implant Device,897.75,35,,897.75,percent of total billed charges,Implant Device,897.75,35,,897.75,percent of total billed charges,Implant Device,897.75,35,,897.75,percent of total billed charges,Implant Device,1026,40,,1026,percent of total billed charges,Implant Device,897.75,70,,897.75,percent of total billed charges,All Other,872.1,34,,872.1,percent of total billed charges,Implant Device,872.1,34,,872.1,percent of total billed charges,Implant Device,897.75,35,,897.75,percent of total billed charges,Implant Device,897.75,35,,897.75,percent of total billed charges,Implant Device,897.75,35,,897.75,percent of total billed charges,Implant Device,897.75,35,,897.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,872.1,34,"If Charge > 2,000, then 34 percent",872.1,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1898.11,
ZIMMER 00-5850-030-14 SEG SYS SZ C 14MM,C1776,HCPCS,,79009784,CDM,278,RC,,,both,,,6200,4588.02,,,4588.02,Other,150% of Medicare + 9.63% HCRA Surcharge,2790,45,,2790,percent of total billed charges,Critical Access Hospital RCC factor,2108,34,,2108,percent of total billed charges,Implant Device,2108,34,,2108,percent of total billed charges,Implant Device,2108,34,,2108,percent of total billed charges,Implant Device,2108,34,,2108,percent of total billed charges,Implant Device,2108,34,,2108,percent of total billed charges,Implant Device,3069,,,3069,Other,110% of Medicare,2170,35,,2170,percent of total billed charges,Implant Device,2108,34,"Charges > $500, x 34%",2108,percent of total billed charges,Implant Device,2170,35,,2170,percent of total billed charges,Implant Device,2170,35,,2170,percent of total billed charges,Implant Device,2170,35,,2170,percent of total billed charges,Implant Device,2170,35,,2170,percent of total billed charges,Implant Device,2170,35,,2170,percent of total billed charges,Implant Device,2480,40,,2480,percent of total billed charges,Implant Device,2170,70,,2170,percent of total billed charges,All Other,2108,34,,2108,percent of total billed charges,Implant Device,2108,34,,2108,percent of total billed charges,Implant Device,2170,35,,2170,percent of total billed charges,Implant Device,2170,35,,2170,percent of total billed charges,Implant Device,2170,35,,2170,percent of total billed charges,Implant Device,2170,35,,2170,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2108,34,"If Charge > 2,000, then 34 percent",2108,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4588.02,
ZIMMER 00-5850-071-13 SEG SYS HINGE KIT,C1776,HCPCS,,79009785,CDM,278,RC,,,both,,,6857,5074.2,,,5074.2,Other,150% of Medicare + 9.63% HCRA Surcharge,3085.65,45,,3085.65,percent of total billed charges,Critical Access Hospital RCC factor,2331.38,34,,2331.38,percent of total billed charges,Implant Device,2331.38,34,,2331.38,percent of total billed charges,Implant Device,2331.38,34,,2331.38,percent of total billed charges,Implant Device,2331.38,34,,2331.38,percent of total billed charges,Implant Device,2331.38,34,,2331.38,percent of total billed charges,Implant Device,3394.22,,,3394.22,Other,110% of Medicare,2399.95,35,,2399.95,percent of total billed charges,Implant Device,2331.38,34,"Charges > $500, x 34%",2331.38,percent of total billed charges,Implant Device,2399.95,35,,2399.95,percent of total billed charges,Implant Device,2399.95,35,,2399.95,percent of total billed charges,Implant Device,2399.95,35,,2399.95,percent of total billed charges,Implant Device,2399.95,35,,2399.95,percent of total billed charges,Implant Device,2399.95,35,,2399.95,percent of total billed charges,Implant Device,2742.8,40,,2742.8,percent of total billed charges,Implant Device,2399.95,70,,2399.95,percent of total billed charges,All Other,2331.38,34,,2331.38,percent of total billed charges,Implant Device,2331.38,34,,2331.38,percent of total billed charges,Implant Device,2399.95,35,,2399.95,percent of total billed charges,Implant Device,2399.95,35,,2399.95,percent of total billed charges,Implant Device,2399.95,35,,2399.95,percent of total billed charges,Implant Device,2399.95,35,,2399.95,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2331.38,34,"If Charge > 2,000, then 34 percent",2331.38,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5074.2,
ZIMMER 00-5852-050-16 FLUTED STEM 16X130,C1776,HCPCS,,79009786,CDM,278,RC,,,both,,,11878,8789.75,,,8789.75,Other,150% of Medicare + 9.63% HCRA Surcharge,5345.1,45,,5345.1,percent of total billed charges,Critical Access Hospital RCC factor,4038.52,34,,4038.52,percent of total billed charges,Implant Device,4038.52,34,,4038.52,percent of total billed charges,Implant Device,4038.52,34,,4038.52,percent of total billed charges,Implant Device,4038.52,34,,4038.52,percent of total billed charges,Implant Device,4038.52,34,,4038.52,percent of total billed charges,Implant Device,5879.61,,,5879.61,Other,110% of Medicare,4157.3,35,,4157.3,percent of total billed charges,Implant Device,4038.52,34,"Charges > $500, x 34%",4038.52,percent of total billed charges,Implant Device,4157.3,35,,4157.3,percent of total billed charges,Implant Device,4157.3,35,,4157.3,percent of total billed charges,Implant Device,4157.3,35,,4157.3,percent of total billed charges,Implant Device,4157.3,35,,4157.3,percent of total billed charges,Implant Device,4157.3,35,,4157.3,percent of total billed charges,Implant Device,4751.2,40,,4751.2,percent of total billed charges,Implant Device,4157.3,70,,4157.3,percent of total billed charges,All Other,4038.52,34,,4038.52,percent of total billed charges,Implant Device,4038.52,34,,4038.52,percent of total billed charges,Implant Device,4157.3,35,,4157.3,percent of total billed charges,Implant Device,4157.3,35,,4157.3,percent of total billed charges,Implant Device,4157.3,35,,4157.3,percent of total billed charges,Implant Device,4157.3,35,,4157.3,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,4038.52,34,"If Charge > 2,000, then 34 percent",4038.52,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,8789.75,
ZIMMER 00-5850-043-01 SEG FEM/TIB 80MM,C1776,HCPCS,,79009787,CDM,278,RC,,,both,,,10705,7921.73,,,7921.73,Other,150% of Medicare + 9.63% HCRA Surcharge,4817.25,45,,4817.25,percent of total billed charges,Critical Access Hospital RCC factor,3639.7,34,,3639.7,percent of total billed charges,Implant Device,3639.7,34,,3639.7,percent of total billed charges,Implant Device,3639.7,34,,3639.7,percent of total billed charges,Implant Device,3639.7,34,,3639.7,percent of total billed charges,Implant Device,3639.7,34,,3639.7,percent of total billed charges,Implant Device,5298.98,,,5298.98,Other,110% of Medicare,3746.75,35,,3746.75,percent of total billed charges,Implant Device,3639.7,34,"Charges > $500, x 34%",3639.7,percent of total billed charges,Implant Device,3746.75,35,,3746.75,percent of total billed charges,Implant Device,3746.75,35,,3746.75,percent of total billed charges,Implant Device,3746.75,35,,3746.75,percent of total billed charges,Implant Device,3746.75,35,,3746.75,percent of total billed charges,Implant Device,3746.75,35,,3746.75,percent of total billed charges,Implant Device,4282,40,,4282,percent of total billed charges,Implant Device,3746.75,70,,3746.75,percent of total billed charges,All Other,3639.7,34,,3639.7,percent of total billed charges,Implant Device,3639.7,34,,3639.7,percent of total billed charges,Implant Device,3746.75,35,,3746.75,percent of total billed charges,Implant Device,3746.75,35,,3746.75,percent of total billed charges,Implant Device,3746.75,35,,3746.75,percent of total billed charges,Implant Device,3746.75,35,,3746.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3639.7,34,"If Charge > 2,000, then 34 percent",3639.7,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,7921.73,
IN2BONES V35 ST428 TRANSVERSE SCREW 2X28,C1713,HCPCS,,79009789,CDM,278,RC,,,both,,,870,643.8,,,643.8,Other,150% of Medicare + 9.63% HCRA Surcharge,391.5,45,,391.5,percent of total billed charges,Critical Access Hospital RCC factor,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,430.65,,,430.65,Other,110% of Medicare,304.5,35,,304.5,percent of total billed charges,Implant Device,295.8,34,"Charges > $500, x 34%",295.8,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,348,40,,348,percent of total billed charges,Implant Device,304.5,70,,304.5,percent of total billed charges,All Other,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,643.8,
IN2BONES P40 ST236 COLINK VIEW PLT 6H,C1713,HCPCS,,79009790,CDM,278,RC,,,both,,,6600,4884.02,,,4884.02,Other,150% of Medicare + 9.63% HCRA Surcharge,2970,45,,2970,percent of total billed charges,Critical Access Hospital RCC factor,2244,34,,2244,percent of total billed charges,Implant Device,2244,34,,2244,percent of total billed charges,Implant Device,2244,34,,2244,percent of total billed charges,Implant Device,2244,34,,2244,percent of total billed charges,Implant Device,2244,34,,2244,percent of total billed charges,Implant Device,3267,,,3267,Other,110% of Medicare,2310,35,,2310,percent of total billed charges,Implant Device,2244,34,"Charges > $500, x 34%",2244,percent of total billed charges,Implant Device,2310,35,,2310,percent of total billed charges,Implant Device,2310,35,,2310,percent of total billed charges,Implant Device,2310,35,,2310,percent of total billed charges,Implant Device,2310,35,,2310,percent of total billed charges,Implant Device,2310,35,,2310,percent of total billed charges,Implant Device,2640,40,,2640,percent of total billed charges,Implant Device,2310,70,,2310,percent of total billed charges,All Other,2244,34,,2244,percent of total billed charges,Implant Device,2244,34,,2244,percent of total billed charges,Implant Device,2310,35,,2310,percent of total billed charges,Implant Device,2310,35,,2310,percent of total billed charges,Implant Device,2310,35,,2310,percent of total billed charges,Implant Device,2310,35,,2310,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2244,34,"If Charge > 2,000, then 34 percent",2244,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4884.02,
STRYKER IH3030 HEADLESS SCREW 3.0X30MM,C1713,HCPCS,,79009801,CDM,278,RC,,,both,,,784,580.16,,,580.16,Other,150% of Medicare + 9.63% HCRA Surcharge,352.8,45,,352.8,percent of total billed charges,Critical Access Hospital RCC factor,266.56,34,,266.56,percent of total billed charges,Implant Device,266.56,34,,266.56,percent of total billed charges,Implant Device,266.56,34,,266.56,percent of total billed charges,Implant Device,266.56,34,,266.56,percent of total billed charges,Implant Device,266.56,34,,266.56,percent of total billed charges,Implant Device,388.08,,,388.08,Other,110% of Medicare,274.4,35,,274.4,percent of total billed charges,Implant Device,266.56,34,"Charges > $500, x 34%",266.56,percent of total billed charges,Implant Device,274.4,35,,274.4,percent of total billed charges,Implant Device,274.4,35,,274.4,percent of total billed charges,Implant Device,274.4,35,,274.4,percent of total billed charges,Implant Device,274.4,35,,274.4,percent of total billed charges,Implant Device,274.4,35,,274.4,percent of total billed charges,Implant Device,313.6,40,,313.6,percent of total billed charges,Implant Device,274.4,70,,274.4,percent of total billed charges,All Other,266.56,34,,266.56,percent of total billed charges,Implant Device,266.56,34,,266.56,percent of total billed charges,Implant Device,274.4,35,,274.4,percent of total billed charges,Implant Device,274.4,35,,274.4,percent of total billed charges,Implant Device,274.4,35,,274.4,percent of total billed charges,Implant Device,274.4,35,,274.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,580.16,
SUTURE PC09X PARIETEX MESH ROUND 9CM,C1781,HCPCS,,79009802,CDM,278,RC,,,both,,,1354,1001.96,,,1001.96,Other,150% of Medicare + 9.63% HCRA Surcharge,609.3,45,,609.3,percent of total billed charges,Critical Access Hospital RCC factor,460.36,34,,460.36,percent of total billed charges,Implant Device,460.36,34,,460.36,percent of total billed charges,Implant Device,460.36,34,,460.36,percent of total billed charges,Implant Device,460.36,34,,460.36,percent of total billed charges,Implant Device,460.36,34,,460.36,percent of total billed charges,Implant Device,670.23,,,670.23,Other,110% of Medicare,473.9,35,,473.9,percent of total billed charges,Implant Device,460.36,34,"Charges > $500, x 34%",460.36,percent of total billed charges,Implant Device,473.9,35,,473.9,percent of total billed charges,Implant Device,473.9,35,,473.9,percent of total billed charges,Implant Device,473.9,35,,473.9,percent of total billed charges,Implant Device,473.9,35,,473.9,percent of total billed charges,Implant Device,473.9,35,,473.9,percent of total billed charges,Implant Device,541.6,40,,541.6,percent of total billed charges,Implant Device,473.9,70,,473.9,percent of total billed charges,All Other,460.36,34,,460.36,percent of total billed charges,Implant Device,460.36,34,,460.36,percent of total billed charges,Implant Device,473.9,35,,473.9,percent of total billed charges,Implant Device,473.9,35,,473.9,percent of total billed charges,Implant Device,473.9,35,,473.9,percent of total billed charges,Implant Device,473.9,35,,473.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1001.96,
IN2BONES BGP001-01 BIO V PUTTY 1CC,C1713,HCPCS,,79009807,CDM,278,RC,,,both,,,2355,1742.71,,,1742.71,Other,150% of Medicare + 9.63% HCRA Surcharge,1059.75,45,,1059.75,percent of total billed charges,Critical Access Hospital RCC factor,800.7,34,,800.7,percent of total billed charges,Implant Device,800.7,34,,800.7,percent of total billed charges,Implant Device,800.7,34,,800.7,percent of total billed charges,Implant Device,800.7,34,,800.7,percent of total billed charges,Implant Device,800.7,34,,800.7,percent of total billed charges,Implant Device,1165.73,,,1165.73,Other,110% of Medicare,824.25,35,,824.25,percent of total billed charges,Implant Device,800.7,34,"Charges > $500, x 34%",800.7,percent of total billed charges,Implant Device,824.25,35,,824.25,percent of total billed charges,Implant Device,824.25,35,,824.25,percent of total billed charges,Implant Device,824.25,35,,824.25,percent of total billed charges,Implant Device,824.25,35,,824.25,percent of total billed charges,Implant Device,824.25,35,,824.25,percent of total billed charges,Implant Device,942,40,,942,percent of total billed charges,Implant Device,824.25,70,,824.25,percent of total billed charges,All Other,800.7,34,,800.7,percent of total billed charges,Implant Device,800.7,34,,800.7,percent of total billed charges,Implant Device,824.25,35,,824.25,percent of total billed charges,Implant Device,824.25,35,,824.25,percent of total billed charges,Implant Device,824.25,35,,824.25,percent of total billed charges,Implant Device,824.25,35,,824.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,800.7,34,"If Charge > 2,000, then 34 percent",800.7,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1742.71,
IN2BONES P65 ST440 COLAG SCREW 4.0X40MM,C1713,HCPCS,,79009808,CDM,278,RC,,,both,,,1668,1234.32,,,1234.32,Other,150% of Medicare + 9.63% HCRA Surcharge,750.6,45,,750.6,percent of total billed charges,Critical Access Hospital RCC factor,567.12,34,,567.12,percent of total billed charges,Implant Device,567.12,34,,567.12,percent of total billed charges,Implant Device,567.12,34,,567.12,percent of total billed charges,Implant Device,567.12,34,,567.12,percent of total billed charges,Implant Device,567.12,34,,567.12,percent of total billed charges,Implant Device,825.66,,,825.66,Other,110% of Medicare,583.8,35,,583.8,percent of total billed charges,Implant Device,567.12,34,"Charges > $500, x 34%",567.12,percent of total billed charges,Implant Device,583.8,35,,583.8,percent of total billed charges,Implant Device,583.8,35,,583.8,percent of total billed charges,Implant Device,583.8,35,,583.8,percent of total billed charges,Implant Device,583.8,35,,583.8,percent of total billed charges,Implant Device,583.8,35,,583.8,percent of total billed charges,Implant Device,667.2,40,,667.2,percent of total billed charges,Implant Device,583.8,70,,583.8,percent of total billed charges,All Other,567.12,34,,567.12,percent of total billed charges,Implant Device,567.12,34,,567.12,percent of total billed charges,Implant Device,583.8,35,,583.8,percent of total billed charges,Implant Device,583.8,35,,583.8,percent of total billed charges,Implant Device,583.8,35,,583.8,percent of total billed charges,Implant Device,583.8,35,,583.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1234.32,
STRYKER 1221-36-056 ACETAB LINER 35X55MM,C1776,HCPCS,,79009811,CDM,278,RC,,,both,,,4500,3330.01,,,3330.01,Other,150% of Medicare + 9.63% HCRA Surcharge,2025,45,,2025,percent of total billed charges,Critical Access Hospital RCC factor,1530,34,,1530,percent of total billed charges,Implant Device,1530,34,,1530,percent of total billed charges,Implant Device,1530,34,,1530,percent of total billed charges,Implant Device,1530,34,,1530,percent of total billed charges,Implant Device,1530,34,,1530,percent of total billed charges,Implant Device,2227.5,,,2227.5,Other,110% of Medicare,1575,35,,1575,percent of total billed charges,Implant Device,1530,34,"Charges > $500, x 34%",1530,percent of total billed charges,Implant Device,1575,35,,1575,percent of total billed charges,Implant Device,1575,35,,1575,percent of total billed charges,Implant Device,1575,35,,1575,percent of total billed charges,Implant Device,1575,35,,1575,percent of total billed charges,Implant Device,1575,35,,1575,percent of total billed charges,Implant Device,1800,40,,1800,percent of total billed charges,Implant Device,1575,70,,1575,percent of total billed charges,All Other,1530,34,,1530,percent of total billed charges,Implant Device,1530,34,,1530,percent of total billed charges,Implant Device,1575,35,,1575,percent of total billed charges,Implant Device,1575,35,,1575,percent of total billed charges,Implant Device,1575,35,,1575,percent of total billed charges,Implant Device,1575,35,,1575,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1530,34,"If Charge > 2,000, then 34 percent",1530,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3330.01,
IN2BONES P40 ST255 LAPIDUS PLT +1MM LT,C1713,HCPCS,,79009812,CDM,278,RC,,,both,,,6000,4440.02,,,4440.02,Other,150% of Medicare + 9.63% HCRA Surcharge,2700,45,,2700,percent of total billed charges,Critical Access Hospital RCC factor,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2970,,,2970,Other,110% of Medicare,2100,35,,2100,percent of total billed charges,Implant Device,2040,34,"Charges > $500, x 34%",2040,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2400,40,,2400,percent of total billed charges,Implant Device,2100,70,,2100,percent of total billed charges,All Other,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2040,34,"If Charge > 2,000, then 34 percent",2040,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4440.02,
IN2BONES V30 ST418 TRANS SCREW 3.0X18MM,C1713,HCPCS,,79009813,CDM,278,RC,,,both,,,870,643.8,,,643.8,Other,150% of Medicare + 9.63% HCRA Surcharge,391.5,45,,391.5,percent of total billed charges,Critical Access Hospital RCC factor,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,430.65,,,430.65,Other,110% of Medicare,304.5,35,,304.5,percent of total billed charges,Implant Device,295.8,34,"Charges > $500, x 34%",295.8,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,348,40,,348,percent of total billed charges,Implant Device,304.5,70,,304.5,percent of total billed charges,All Other,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,643.8,
IN2BONES P67 ST434 COLAG SCREW 4X34MM,C1713,HCPCS,,79009814,CDM,278,RC,,,both,,,1668,1234.32,,,1234.32,Other,150% of Medicare + 9.63% HCRA Surcharge,750.6,45,,750.6,percent of total billed charges,Critical Access Hospital RCC factor,567.12,34,,567.12,percent of total billed charges,Implant Device,567.12,34,,567.12,percent of total billed charges,Implant Device,567.12,34,,567.12,percent of total billed charges,Implant Device,567.12,34,,567.12,percent of total billed charges,Implant Device,567.12,34,,567.12,percent of total billed charges,Implant Device,825.66,,,825.66,Other,110% of Medicare,583.8,35,,583.8,percent of total billed charges,Implant Device,567.12,34,"Charges > $500, x 34%",567.12,percent of total billed charges,Implant Device,583.8,35,,583.8,percent of total billed charges,Implant Device,583.8,35,,583.8,percent of total billed charges,Implant Device,583.8,35,,583.8,percent of total billed charges,Implant Device,583.8,35,,583.8,percent of total billed charges,Implant Device,583.8,35,,583.8,percent of total billed charges,Implant Device,667.2,40,,667.2,percent of total billed charges,Implant Device,583.8,70,,583.8,percent of total billed charges,All Other,567.12,34,,567.12,percent of total billed charges,Implant Device,567.12,34,,567.12,percent of total billed charges,Implant Device,583.8,35,,583.8,percent of total billed charges,Implant Device,583.8,35,,583.8,percent of total billed charges,Implant Device,583.8,35,,583.8,percent of total billed charges,Implant Device,583.8,35,,583.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1234.32,
ARTHREX AR-1288-70 ACL TIGHTROPE 7MM,C1713,HCPCS,,79009815,CDM,278,RC,,,both,,,2085,1542.91,,,1542.91,Other,150% of Medicare + 9.63% HCRA Surcharge,938.25,45,,938.25,percent of total billed charges,Critical Access Hospital RCC factor,708.9,34,,708.9,percent of total billed charges,Implant Device,708.9,34,,708.9,percent of total billed charges,Implant Device,708.9,34,,708.9,percent of total billed charges,Implant Device,708.9,34,,708.9,percent of total billed charges,Implant Device,708.9,34,,708.9,percent of total billed charges,Implant Device,1032.08,,,1032.08,Other,110% of Medicare,729.75,35,,729.75,percent of total billed charges,Implant Device,708.9,34,"Charges > $500, x 34%",708.9,percent of total billed charges,Implant Device,729.75,35,,729.75,percent of total billed charges,Implant Device,729.75,35,,729.75,percent of total billed charges,Implant Device,729.75,35,,729.75,percent of total billed charges,Implant Device,729.75,35,,729.75,percent of total billed charges,Implant Device,729.75,35,,729.75,percent of total billed charges,Implant Device,834,40,,834,percent of total billed charges,Implant Device,729.75,70,,729.75,percent of total billed charges,All Other,708.9,34,,708.9,percent of total billed charges,Implant Device,708.9,34,,708.9,percent of total billed charges,Implant Device,729.75,35,,729.75,percent of total billed charges,Implant Device,729.75,35,,729.75,percent of total billed charges,Implant Device,729.75,35,,729.75,percent of total billed charges,Implant Device,729.75,35,,729.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,708.9,34,"If Charge > 2,000, then 34 percent",708.9,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1542.91,
ARTHREX AR-1288-75 ACL TIGHTROPE 7.5MM,C1713,HCPCS,,79009816,CDM,278,RC,,,both,,,2085,1542.91,,,1542.91,Other,150% of Medicare + 9.63% HCRA Surcharge,938.25,45,,938.25,percent of total billed charges,Critical Access Hospital RCC factor,708.9,34,,708.9,percent of total billed charges,Implant Device,708.9,34,,708.9,percent of total billed charges,Implant Device,708.9,34,,708.9,percent of total billed charges,Implant Device,708.9,34,,708.9,percent of total billed charges,Implant Device,708.9,34,,708.9,percent of total billed charges,Implant Device,1032.08,,,1032.08,Other,110% of Medicare,729.75,35,,729.75,percent of total billed charges,Implant Device,708.9,34,"Charges > $500, x 34%",708.9,percent of total billed charges,Implant Device,729.75,35,,729.75,percent of total billed charges,Implant Device,729.75,35,,729.75,percent of total billed charges,Implant Device,729.75,35,,729.75,percent of total billed charges,Implant Device,729.75,35,,729.75,percent of total billed charges,Implant Device,729.75,35,,729.75,percent of total billed charges,Implant Device,834,40,,834,percent of total billed charges,Implant Device,729.75,70,,729.75,percent of total billed charges,All Other,708.9,34,,708.9,percent of total billed charges,Implant Device,708.9,34,,708.9,percent of total billed charges,Implant Device,729.75,35,,729.75,percent of total billed charges,Implant Device,729.75,35,,729.75,percent of total billed charges,Implant Device,729.75,35,,729.75,percent of total billed charges,Implant Device,729.75,35,,729.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,708.9,34,"If Charge > 2,000, then 34 percent",708.9,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1542.91,
ARTHREX AR-1288-80 ACL TIGHTROPE 8MM,C1713,HCPCS,,79009817,CDM,278,RC,,,both,,,2085,1542.91,,,1542.91,Other,150% of Medicare + 9.63% HCRA Surcharge,938.25,45,,938.25,percent of total billed charges,Critical Access Hospital RCC factor,708.9,34,,708.9,percent of total billed charges,Implant Device,708.9,34,,708.9,percent of total billed charges,Implant Device,708.9,34,,708.9,percent of total billed charges,Implant Device,708.9,34,,708.9,percent of total billed charges,Implant Device,708.9,34,,708.9,percent of total billed charges,Implant Device,1032.08,,,1032.08,Other,110% of Medicare,729.75,35,,729.75,percent of total billed charges,Implant Device,708.9,34,"Charges > $500, x 34%",708.9,percent of total billed charges,Implant Device,729.75,35,,729.75,percent of total billed charges,Implant Device,729.75,35,,729.75,percent of total billed charges,Implant Device,729.75,35,,729.75,percent of total billed charges,Implant Device,729.75,35,,729.75,percent of total billed charges,Implant Device,729.75,35,,729.75,percent of total billed charges,Implant Device,834,40,,834,percent of total billed charges,Implant Device,729.75,70,,729.75,percent of total billed charges,All Other,708.9,34,,708.9,percent of total billed charges,Implant Device,708.9,34,,708.9,percent of total billed charges,Implant Device,729.75,35,,729.75,percent of total billed charges,Implant Device,729.75,35,,729.75,percent of total billed charges,Implant Device,729.75,35,,729.75,percent of total billed charges,Implant Device,729.75,35,,729.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,708.9,34,"If Charge > 2,000, then 34 percent",708.9,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1542.91,
ARTHREX AR-1288-85 ACL TIGHTROPE 8.5MM,C1713,HCPCS,,79009818,CDM,278,RC,,,both,,,2085,1542.91,,,1542.91,Other,150% of Medicare + 9.63% HCRA Surcharge,938.25,45,,938.25,percent of total billed charges,Critical Access Hospital RCC factor,708.9,34,,708.9,percent of total billed charges,Implant Device,708.9,34,,708.9,percent of total billed charges,Implant Device,708.9,34,,708.9,percent of total billed charges,Implant Device,708.9,34,,708.9,percent of total billed charges,Implant Device,708.9,34,,708.9,percent of total billed charges,Implant Device,1032.08,,,1032.08,Other,110% of Medicare,729.75,35,,729.75,percent of total billed charges,Implant Device,708.9,34,"Charges > $500, x 34%",708.9,percent of total billed charges,Implant Device,729.75,35,,729.75,percent of total billed charges,Implant Device,729.75,35,,729.75,percent of total billed charges,Implant Device,729.75,35,,729.75,percent of total billed charges,Implant Device,729.75,35,,729.75,percent of total billed charges,Implant Device,729.75,35,,729.75,percent of total billed charges,Implant Device,834,40,,834,percent of total billed charges,Implant Device,729.75,70,,729.75,percent of total billed charges,All Other,708.9,34,,708.9,percent of total billed charges,Implant Device,708.9,34,,708.9,percent of total billed charges,Implant Device,729.75,35,,729.75,percent of total billed charges,Implant Device,729.75,35,,729.75,percent of total billed charges,Implant Device,729.75,35,,729.75,percent of total billed charges,Implant Device,729.75,35,,729.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,708.9,34,"If Charge > 2,000, then 34 percent",708.9,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1542.91,
ARTHREX AR-1288-90 ACL TIGHTROPE 9MM,C1713,HCPCS,,79009819,CDM,278,RC,,,both,,,2085,1542.91,,,1542.91,Other,150% of Medicare + 9.63% HCRA Surcharge,938.25,45,,938.25,percent of total billed charges,Critical Access Hospital RCC factor,708.9,34,,708.9,percent of total billed charges,Implant Device,708.9,34,,708.9,percent of total billed charges,Implant Device,708.9,34,,708.9,percent of total billed charges,Implant Device,708.9,34,,708.9,percent of total billed charges,Implant Device,708.9,34,,708.9,percent of total billed charges,Implant Device,1032.08,,,1032.08,Other,110% of Medicare,729.75,35,,729.75,percent of total billed charges,Implant Device,708.9,34,"Charges > $500, x 34%",708.9,percent of total billed charges,Implant Device,729.75,35,,729.75,percent of total billed charges,Implant Device,729.75,35,,729.75,percent of total billed charges,Implant Device,729.75,35,,729.75,percent of total billed charges,Implant Device,729.75,35,,729.75,percent of total billed charges,Implant Device,729.75,35,,729.75,percent of total billed charges,Implant Device,834,40,,834,percent of total billed charges,Implant Device,729.75,70,,729.75,percent of total billed charges,All Other,708.9,34,,708.9,percent of total billed charges,Implant Device,708.9,34,,708.9,percent of total billed charges,Implant Device,729.75,35,,729.75,percent of total billed charges,Implant Device,729.75,35,,729.75,percent of total billed charges,Implant Device,729.75,35,,729.75,percent of total billed charges,Implant Device,729.75,35,,729.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,708.9,34,"If Charge > 2,000, then 34 percent",708.9,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1542.91,
ARTHREX AR-1288-95 ACL TIGHTROPE 9.5MM,C1713,HCPCS,,79009820,CDM,278,RC,,,both,,,2085,1542.91,,,1542.91,Other,150% of Medicare + 9.63% HCRA Surcharge,938.25,45,,938.25,percent of total billed charges,Critical Access Hospital RCC factor,708.9,34,,708.9,percent of total billed charges,Implant Device,708.9,34,,708.9,percent of total billed charges,Implant Device,708.9,34,,708.9,percent of total billed charges,Implant Device,708.9,34,,708.9,percent of total billed charges,Implant Device,708.9,34,,708.9,percent of total billed charges,Implant Device,1032.08,,,1032.08,Other,110% of Medicare,729.75,35,,729.75,percent of total billed charges,Implant Device,708.9,34,"Charges > $500, x 34%",708.9,percent of total billed charges,Implant Device,729.75,35,,729.75,percent of total billed charges,Implant Device,729.75,35,,729.75,percent of total billed charges,Implant Device,729.75,35,,729.75,percent of total billed charges,Implant Device,729.75,35,,729.75,percent of total billed charges,Implant Device,729.75,35,,729.75,percent of total billed charges,Implant Device,834,40,,834,percent of total billed charges,Implant Device,729.75,70,,729.75,percent of total billed charges,All Other,708.9,34,,708.9,percent of total billed charges,Implant Device,708.9,34,,708.9,percent of total billed charges,Implant Device,729.75,35,,729.75,percent of total billed charges,Implant Device,729.75,35,,729.75,percent of total billed charges,Implant Device,729.75,35,,729.75,percent of total billed charges,Implant Device,729.75,35,,729.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,708.9,34,"If Charge > 2,000, then 34 percent",708.9,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1542.91,
ARTHREX AR-1288-100 ACL TIGHTROPE 10MM,C1713,HCPCS,,79009821,CDM,278,RC,,,both,,,2085,1542.91,,,1542.91,Other,150% of Medicare + 9.63% HCRA Surcharge,938.25,45,,938.25,percent of total billed charges,Critical Access Hospital RCC factor,708.9,34,,708.9,percent of total billed charges,Implant Device,708.9,34,,708.9,percent of total billed charges,Implant Device,708.9,34,,708.9,percent of total billed charges,Implant Device,708.9,34,,708.9,percent of total billed charges,Implant Device,708.9,34,,708.9,percent of total billed charges,Implant Device,1032.08,,,1032.08,Other,110% of Medicare,729.75,35,,729.75,percent of total billed charges,Implant Device,708.9,34,"Charges > $500, x 34%",708.9,percent of total billed charges,Implant Device,729.75,35,,729.75,percent of total billed charges,Implant Device,729.75,35,,729.75,percent of total billed charges,Implant Device,729.75,35,,729.75,percent of total billed charges,Implant Device,729.75,35,,729.75,percent of total billed charges,Implant Device,729.75,35,,729.75,percent of total billed charges,Implant Device,834,40,,834,percent of total billed charges,Implant Device,729.75,70,,729.75,percent of total billed charges,All Other,708.9,34,,708.9,percent of total billed charges,Implant Device,708.9,34,,708.9,percent of total billed charges,Implant Device,729.75,35,,729.75,percent of total billed charges,Implant Device,729.75,35,,729.75,percent of total billed charges,Implant Device,729.75,35,,729.75,percent of total billed charges,Implant Device,729.75,35,,729.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,708.9,34,"If Charge > 2,000, then 34 percent",708.9,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1542.91,
STRYKER 1832-1035S PROX HUM NAIL 8X100MM,C1713,HCPCS,,79009831,CDM,278,RC,,,both,,,4307,3187.19,,,3187.19,Other,150% of Medicare + 9.63% HCRA Surcharge,1938.15,45,,1938.15,percent of total billed charges,Critical Access Hospital RCC factor,1464.38,34,,1464.38,percent of total billed charges,Implant Device,1464.38,34,,1464.38,percent of total billed charges,Implant Device,1464.38,34,,1464.38,percent of total billed charges,Implant Device,1464.38,34,,1464.38,percent of total billed charges,Implant Device,1464.38,34,,1464.38,percent of total billed charges,Implant Device,2131.97,,,2131.97,Other,110% of Medicare,1507.45,35,,1507.45,percent of total billed charges,Implant Device,1464.38,34,"Charges > $500, x 34%",1464.38,percent of total billed charges,Implant Device,1507.45,35,,1507.45,percent of total billed charges,Implant Device,1507.45,35,,1507.45,percent of total billed charges,Implant Device,1507.45,35,,1507.45,percent of total billed charges,Implant Device,1507.45,35,,1507.45,percent of total billed charges,Implant Device,1507.45,35,,1507.45,percent of total billed charges,Implant Device,1722.8,40,,1722.8,percent of total billed charges,Implant Device,1507.45,70,,1507.45,percent of total billed charges,All Other,1464.38,34,,1464.38,percent of total billed charges,Implant Device,1464.38,34,,1464.38,percent of total billed charges,Implant Device,1507.45,35,,1507.45,percent of total billed charges,Implant Device,1507.45,35,,1507.45,percent of total billed charges,Implant Device,1507.45,35,,1507.45,percent of total billed charges,Implant Device,1507.45,35,,1507.45,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1464.38,34,"If Charge > 2,000, then 34 percent",1464.38,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3187.19,
ARTHREX AFLEX500 ARTHROFLEX 30X40X.5MM,C1713,HCPCS,,79009833,CDM,278,RC,,,both,,,3345,2475.31,,,2475.31,Other,150% of Medicare + 9.63% HCRA Surcharge,1505.25,45,,1505.25,percent of total billed charges,Critical Access Hospital RCC factor,1137.3,34,,1137.3,percent of total billed charges,Implant Device,1137.3,34,,1137.3,percent of total billed charges,Implant Device,1137.3,34,,1137.3,percent of total billed charges,Implant Device,1137.3,34,,1137.3,percent of total billed charges,Implant Device,1137.3,34,,1137.3,percent of total billed charges,Implant Device,1655.78,,,1655.78,Other,110% of Medicare,1170.75,35,,1170.75,percent of total billed charges,Implant Device,1137.3,34,"Charges > $500, x 34%",1137.3,percent of total billed charges,Implant Device,1170.75,35,,1170.75,percent of total billed charges,Implant Device,1170.75,35,,1170.75,percent of total billed charges,Implant Device,1170.75,35,,1170.75,percent of total billed charges,Implant Device,1170.75,35,,1170.75,percent of total billed charges,Implant Device,1170.75,35,,1170.75,percent of total billed charges,Implant Device,1338,40,,1338,percent of total billed charges,Implant Device,1170.75,70,,1170.75,percent of total billed charges,All Other,1137.3,34,,1137.3,percent of total billed charges,Implant Device,1137.3,34,,1137.3,percent of total billed charges,Implant Device,1170.75,35,,1170.75,percent of total billed charges,Implant Device,1170.75,35,,1170.75,percent of total billed charges,Implant Device,1170.75,35,,1170.75,percent of total billed charges,Implant Device,1170.75,35,,1170.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1137.3,34,"If Charge > 2,000, then 34 percent",1137.3,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2475.31,
STRYKER 1896-4030S LOCKING SCREW 4X30MM,C1713,HCPCS,,79009834,CDM,278,RC,,,both,,,405,299.7,,,299.7,Other,150% of Medicare + 9.63% HCRA Surcharge,182.25,45,,182.25,percent of total billed charges,Critical Access Hospital RCC factor,137.7,34,,137.7,percent of total billed charges,Implant Device,137.7,34,,137.7,percent of total billed charges,Implant Device,137.7,34,,137.7,percent of total billed charges,Implant Device,137.7,34,,137.7,percent of total billed charges,Implant Device,137.7,34,,137.7,percent of total billed charges,Implant Device,200.48,,,200.48,Other,110% of Medicare,141.75,35,,141.75,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,141.75,35,,141.75,percent of total billed charges,Implant Device,141.75,35,,141.75,percent of total billed charges,Implant Device,141.75,35,,141.75,percent of total billed charges,Implant Device,141.75,35,,141.75,percent of total billed charges,Implant Device,141.75,35,,141.75,percent of total billed charges,Implant Device,162,40,,162,percent of total billed charges,Implant Device,141.75,70,,141.75,percent of total billed charges,All Other,137.7,34,,137.7,percent of total billed charges,Implant Device,137.7,34,,137.7,percent of total billed charges,Implant Device,141.75,35,,141.75,percent of total billed charges,Implant Device,141.75,35,,141.75,percent of total billed charges,Implant Device,141.75,35,,141.75,percent of total billed charges,Implant Device,141.75,35,,141.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,299.7,
STRYKER 5568-0010 HUM FRACTURE STEM 10MM,C1776,HCPCS,,79009840,CDM,278,RC,,,both,,,23622,17480.34,,,17480.34,Other,150% of Medicare + 9.63% HCRA Surcharge,10629.9,45,,10629.9,percent of total billed charges,Critical Access Hospital RCC factor,8031.48,34,,8031.48,percent of total billed charges,Implant Device,8031.48,34,,8031.48,percent of total billed charges,Implant Device,8031.48,34,,8031.48,percent of total billed charges,Implant Device,8031.48,34,,8031.48,percent of total billed charges,Implant Device,8031.48,34,,8031.48,percent of total billed charges,Implant Device,11692.89,,,11692.89,Other,110% of Medicare,8267.7,35,,8267.7,percent of total billed charges,Implant Device,8031.48,34,"Charges > $500, x 34%",8031.48,percent of total billed charges,Implant Device,8267.7,35,,8267.7,percent of total billed charges,Implant Device,8267.7,35,,8267.7,percent of total billed charges,Implant Device,8267.7,35,,8267.7,percent of total billed charges,Implant Device,8267.7,35,,8267.7,percent of total billed charges,Implant Device,8267.7,35,,8267.7,percent of total billed charges,Implant Device,9448.8,40,,9448.8,percent of total billed charges,Implant Device,8267.7,70,,8267.7,percent of total billed charges,All Other,8031.48,34,,8031.48,percent of total billed charges,Implant Device,8031.48,34,,8031.48,percent of total billed charges,Implant Device,8267.7,35,,8267.7,percent of total billed charges,Implant Device,8267.7,35,,8267.7,percent of total billed charges,Implant Device,8267.7,35,,8267.7,percent of total billed charges,Implant Device,8267.7,35,,8267.7,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,8031.48,34,"If Charge > 2,000, then 34 percent",8031.48,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,17480.34,
SI-BONE 7045M-90 IFUSE 3D 7X45MM,C1713,HCPCS,,79009842,CDM,278,RC,,,both,,,10200,7548.03,,,7548.03,Other,150% of Medicare + 9.63% HCRA Surcharge,4590,45,,4590,percent of total billed charges,Critical Access Hospital RCC factor,3468,34,,3468,percent of total billed charges,Implant Device,3468,34,,3468,percent of total billed charges,Implant Device,3468,34,,3468,percent of total billed charges,Implant Device,3468,34,,3468,percent of total billed charges,Implant Device,3468,34,,3468,percent of total billed charges,Implant Device,5049,,,5049,Other,110% of Medicare,3570,35,,3570,percent of total billed charges,Implant Device,3468,34,"Charges > $500, x 34%",3468,percent of total billed charges,Implant Device,3570,35,,3570,percent of total billed charges,Implant Device,3570,35,,3570,percent of total billed charges,Implant Device,3570,35,,3570,percent of total billed charges,Implant Device,3570,35,,3570,percent of total billed charges,Implant Device,3570,35,,3570,percent of total billed charges,Implant Device,4080,40,,4080,percent of total billed charges,Implant Device,3570,70,,3570,percent of total billed charges,All Other,3468,34,,3468,percent of total billed charges,Implant Device,3468,34,,3468,percent of total billed charges,Implant Device,3570,35,,3570,percent of total billed charges,Implant Device,3570,35,,3570,percent of total billed charges,Implant Device,3570,35,,3570,percent of total billed charges,Implant Device,3570,35,,3570,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3468,34,"If Charge > 2,000, then 34 percent",3468,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,7548.03,
SI-BONE 7035M-90 IFUSE -3D 7X35MM,C1713,HCPCS,,79009847,CDM,278,RC,,,both,,,10200,7548.03,,,7548.03,Other,150% of Medicare + 9.63% HCRA Surcharge,4590,45,,4590,percent of total billed charges,Critical Access Hospital RCC factor,3468,34,,3468,percent of total billed charges,Implant Device,3468,34,,3468,percent of total billed charges,Implant Device,3468,34,,3468,percent of total billed charges,Implant Device,3468,34,,3468,percent of total billed charges,Implant Device,3468,34,,3468,percent of total billed charges,Implant Device,5049,,,5049,Other,110% of Medicare,3570,35,,3570,percent of total billed charges,Implant Device,3468,34,"Charges > $500, x 34%",3468,percent of total billed charges,Implant Device,3570,35,,3570,percent of total billed charges,Implant Device,3570,35,,3570,percent of total billed charges,Implant Device,3570,35,,3570,percent of total billed charges,Implant Device,3570,35,,3570,percent of total billed charges,Implant Device,3570,35,,3570,percent of total billed charges,Implant Device,4080,40,,4080,percent of total billed charges,Implant Device,3570,70,,3570,percent of total billed charges,All Other,3468,34,,3468,percent of total billed charges,Implant Device,3468,34,,3468,percent of total billed charges,Implant Device,3570,35,,3570,percent of total billed charges,Implant Device,3570,35,,3570,percent of total billed charges,Implant Device,3570,35,,3570,percent of total billed charges,Implant Device,3570,35,,3570,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3468,34,"If Charge > 2,000, then 34 percent",3468,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,7548.03,
DEPUY 02.112.012 CLAVICLE PLT 3.5X94MM,C1713,HCPCS,,79009848,CDM,278,RC,,,both,,,2370,1753.81,,,1753.81,Other,150% of Medicare + 9.63% HCRA Surcharge,1066.5,45,,1066.5,percent of total billed charges,Critical Access Hospital RCC factor,805.8,34,,805.8,percent of total billed charges,Implant Device,805.8,34,,805.8,percent of total billed charges,Implant Device,805.8,34,,805.8,percent of total billed charges,Implant Device,805.8,34,,805.8,percent of total billed charges,Implant Device,805.8,34,,805.8,percent of total billed charges,Implant Device,1173.15,,,1173.15,Other,110% of Medicare,829.5,35,,829.5,percent of total billed charges,Implant Device,805.8,34,"Charges > $500, x 34%",805.8,percent of total billed charges,Implant Device,829.5,35,,829.5,percent of total billed charges,Implant Device,829.5,35,,829.5,percent of total billed charges,Implant Device,829.5,35,,829.5,percent of total billed charges,Implant Device,829.5,35,,829.5,percent of total billed charges,Implant Device,829.5,35,,829.5,percent of total billed charges,Implant Device,948,40,,948,percent of total billed charges,Implant Device,829.5,70,,829.5,percent of total billed charges,All Other,805.8,34,,805.8,percent of total billed charges,Implant Device,805.8,34,,805.8,percent of total billed charges,Implant Device,829.5,35,,829.5,percent of total billed charges,Implant Device,829.5,35,,829.5,percent of total billed charges,Implant Device,829.5,35,,829.5,percent of total billed charges,Implant Device,829.5,35,,829.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,805.8,34,"If Charge > 2,000, then 34 percent",805.8,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1753.81,
DEPUY 201.762 CORTEX SCREW 2.4X12MM,C1713,HCPCS,,79009849,CDM,278,RC,,,both,,,130,96.2,,,96.2,Other,150% of Medicare + 9.63% HCRA Surcharge,58.5,45,,58.5,percent of total billed charges,Critical Access Hospital RCC factor,44.2,34,,44.2,percent of total billed charges,Implant Device,44.2,34,,44.2,percent of total billed charges,Implant Device,44.2,34,,44.2,percent of total billed charges,Implant Device,44.2,34,,44.2,percent of total billed charges,Implant Device,44.2,34,,44.2,percent of total billed charges,Implant Device,64.35,,,64.35,Other,110% of Medicare,45.5,35,,45.5,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,45.5,35,,45.5,percent of total billed charges,Implant Device,45.5,35,,45.5,percent of total billed charges,Implant Device,45.5,35,,45.5,percent of total billed charges,Implant Device,45.5,35,,45.5,percent of total billed charges,Implant Device,45.5,35,,45.5,percent of total billed charges,Implant Device,52,40,,52,percent of total billed charges,Implant Device,45.5,70,,45.5,percent of total billed charges,All Other,44.2,34,,44.2,percent of total billed charges,Implant Device,44.2,34,,44.2,percent of total billed charges,Implant Device,45.5,35,,45.5,percent of total billed charges,Implant Device,45.5,35,,45.5,percent of total billed charges,Implant Device,45.5,35,,45.5,percent of total billed charges,Implant Device,45.5,35,,45.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,96.2,
DEPUY 293.74 5.0MM STEINMAN PIN,C1713,HCPCS,,79009850,CDM,278,RC,,,both,,,505,373.7,,,373.7,Other,150% of Medicare + 9.63% HCRA Surcharge,227.25,45,,227.25,percent of total billed charges,Critical Access Hospital RCC factor,171.7,34,,171.7,percent of total billed charges,Implant Device,171.7,34,,171.7,percent of total billed charges,Implant Device,171.7,34,,171.7,percent of total billed charges,Implant Device,171.7,34,,171.7,percent of total billed charges,Implant Device,171.7,34,,171.7,percent of total billed charges,Implant Device,249.98,,,249.98,Other,110% of Medicare,176.75,35,,176.75,percent of total billed charges,Implant Device,171.7,34,"Charges > $500, x 34%",171.7,percent of total billed charges,Implant Device,176.75,35,,176.75,percent of total billed charges,Implant Device,176.75,35,,176.75,percent of total billed charges,Implant Device,176.75,35,,176.75,percent of total billed charges,Implant Device,176.75,35,,176.75,percent of total billed charges,Implant Device,176.75,35,,176.75,percent of total billed charges,Implant Device,202,40,,202,percent of total billed charges,Implant Device,176.75,70,,176.75,percent of total billed charges,All Other,171.7,34,,171.7,percent of total billed charges,Implant Device,171.7,34,,171.7,percent of total billed charges,Implant Device,176.75,35,,176.75,percent of total billed charges,Implant Device,176.75,35,,176.75,percent of total billed charges,Implant Device,176.75,35,,176.75,percent of total billed charges,Implant Device,176.75,35,,176.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,373.7,
DEPUY 390.012 EXFIX 30DEG OUTRIGGER 11MM,C1713,HCPCS,,79009851,CDM,278,RC,,,both,,,522,386.28,,,386.28,Other,150% of Medicare + 9.63% HCRA Surcharge,234.9,45,,234.9,percent of total billed charges,Critical Access Hospital RCC factor,177.48,34,,177.48,percent of total billed charges,Implant Device,177.48,34,,177.48,percent of total billed charges,Implant Device,177.48,34,,177.48,percent of total billed charges,Implant Device,177.48,34,,177.48,percent of total billed charges,Implant Device,177.48,34,,177.48,percent of total billed charges,Implant Device,258.39,,,258.39,Other,110% of Medicare,182.7,35,,182.7,percent of total billed charges,Implant Device,177.48,34,"Charges > $500, x 34%",177.48,percent of total billed charges,Implant Device,182.7,35,,182.7,percent of total billed charges,Implant Device,182.7,35,,182.7,percent of total billed charges,Implant Device,182.7,35,,182.7,percent of total billed charges,Implant Device,182.7,35,,182.7,percent of total billed charges,Implant Device,182.7,35,,182.7,percent of total billed charges,Implant Device,208.8,40,,208.8,percent of total billed charges,Implant Device,182.7,70,,182.7,percent of total billed charges,All Other,177.48,34,,177.48,percent of total billed charges,Implant Device,177.48,34,,177.48,percent of total billed charges,Implant Device,182.7,35,,182.7,percent of total billed charges,Implant Device,182.7,35,,182.7,percent of total billed charges,Implant Device,182.7,35,,182.7,percent of total billed charges,Implant Device,182.7,35,,182.7,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,386.28,
DEPUY 390.010 LG EXFIX PIN CLAMP,C1713,HCPCS,,79009852,CDM,278,RC,,,both,,,946,700.04,,,700.04,Other,150% of Medicare + 9.63% HCRA Surcharge,425.7,45,,425.7,percent of total billed charges,Critical Access Hospital RCC factor,321.64,34,,321.64,percent of total billed charges,Implant Device,321.64,34,,321.64,percent of total billed charges,Implant Device,321.64,34,,321.64,percent of total billed charges,Implant Device,321.64,34,,321.64,percent of total billed charges,Implant Device,321.64,34,,321.64,percent of total billed charges,Implant Device,468.27,,,468.27,Other,110% of Medicare,331.1,35,,331.1,percent of total billed charges,Implant Device,321.64,34,"Charges > $500, x 34%",321.64,percent of total billed charges,Implant Device,331.1,35,,331.1,percent of total billed charges,Implant Device,331.1,35,,331.1,percent of total billed charges,Implant Device,331.1,35,,331.1,percent of total billed charges,Implant Device,331.1,35,,331.1,percent of total billed charges,Implant Device,331.1,35,,331.1,percent of total billed charges,Implant Device,378.4,40,,378.4,percent of total billed charges,Implant Device,331.1,70,,331.1,percent of total billed charges,All Other,321.64,34,,321.64,percent of total billed charges,Implant Device,321.64,34,,321.64,percent of total billed charges,Implant Device,331.1,35,,331.1,percent of total billed charges,Implant Device,331.1,35,,331.1,percent of total billed charges,Implant Device,331.1,35,,331.1,percent of total billed charges,Implant Device,331.1,35,,331.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,700.04,
DEPUY 394.86 EXFIX 11MM CRB FBR ROD 350,C1713,HCPCS,,79009853,CDM,278,RC,,,both,,,1026,759.24,,,759.24,Other,150% of Medicare + 9.63% HCRA Surcharge,461.7,45,,461.7,percent of total billed charges,Critical Access Hospital RCC factor,348.84,34,,348.84,percent of total billed charges,Implant Device,348.84,34,,348.84,percent of total billed charges,Implant Device,348.84,34,,348.84,percent of total billed charges,Implant Device,348.84,34,,348.84,percent of total billed charges,Implant Device,348.84,34,,348.84,percent of total billed charges,Implant Device,507.87,,,507.87,Other,110% of Medicare,359.1,35,,359.1,percent of total billed charges,Implant Device,348.84,34,"Charges > $500, x 34%",348.84,percent of total billed charges,Implant Device,359.1,35,,359.1,percent of total billed charges,Implant Device,359.1,35,,359.1,percent of total billed charges,Implant Device,359.1,35,,359.1,percent of total billed charges,Implant Device,359.1,35,,359.1,percent of total billed charges,Implant Device,359.1,35,,359.1,percent of total billed charges,Implant Device,410.4,40,,410.4,percent of total billed charges,Implant Device,359.1,70,,359.1,percent of total billed charges,All Other,348.84,34,,348.84,percent of total billed charges,Implant Device,348.84,34,,348.84,percent of total billed charges,Implant Device,359.1,35,,359.1,percent of total billed charges,Implant Device,359.1,35,,359.1,percent of total billed charges,Implant Device,359.1,35,,359.1,percent of total billed charges,Implant Device,359.1,35,,359.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,759.24,
DEPUY 294.785 5.0MM SCHANZ SCREW 60MM,C1713,HCPCS,,79009854,CDM,278,RC,,,both,,,305,225.7,,,225.7,Other,150% of Medicare + 9.63% HCRA Surcharge,137.25,45,,137.25,percent of total billed charges,Critical Access Hospital RCC factor,103.7,34,,103.7,percent of total billed charges,Implant Device,103.7,34,,103.7,percent of total billed charges,Implant Device,103.7,34,,103.7,percent of total billed charges,Implant Device,103.7,34,,103.7,percent of total billed charges,Implant Device,103.7,34,,103.7,percent of total billed charges,Implant Device,150.98,,,150.98,Other,110% of Medicare,106.75,35,,106.75,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,106.75,35,,106.75,percent of total billed charges,Implant Device,106.75,35,,106.75,percent of total billed charges,Implant Device,106.75,35,,106.75,percent of total billed charges,Implant Device,106.75,35,,106.75,percent of total billed charges,Implant Device,106.75,35,,106.75,percent of total billed charges,Implant Device,122,40,,122,percent of total billed charges,Implant Device,106.75,70,,106.75,percent of total billed charges,All Other,103.7,34,,103.7,percent of total billed charges,Implant Device,103.7,34,,103.7,percent of total billed charges,Implant Device,106.75,35,,106.75,percent of total billed charges,Implant Device,106.75,35,,106.75,percent of total billed charges,Implant Device,106.75,35,,106.75,percent of total billed charges,Implant Device,106.75,35,,106.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,225.7,
DEPUY 394.82 EXFIX 11MM CRBN FBR ROD 150,C1713,HCPCS,,79009855,CDM,278,RC,,,both,,,958,708.92,,,708.92,Other,150% of Medicare + 9.63% HCRA Surcharge,431.1,45,,431.1,percent of total billed charges,Critical Access Hospital RCC factor,325.72,34,,325.72,percent of total billed charges,Implant Device,325.72,34,,325.72,percent of total billed charges,Implant Device,325.72,34,,325.72,percent of total billed charges,Implant Device,325.72,34,,325.72,percent of total billed charges,Implant Device,325.72,34,,325.72,percent of total billed charges,Implant Device,474.21,,,474.21,Other,110% of Medicare,335.3,35,,335.3,percent of total billed charges,Implant Device,325.72,34,"Charges > $500, x 34%",325.72,percent of total billed charges,Implant Device,335.3,35,,335.3,percent of total billed charges,Implant Device,335.3,35,,335.3,percent of total billed charges,Implant Device,335.3,35,,335.3,percent of total billed charges,Implant Device,335.3,35,,335.3,percent of total billed charges,Implant Device,335.3,35,,335.3,percent of total billed charges,Implant Device,383.2,40,,383.2,percent of total billed charges,Implant Device,335.3,70,,335.3,percent of total billed charges,All Other,325.72,34,,325.72,percent of total billed charges,Implant Device,325.72,34,,325.72,percent of total billed charges,Implant Device,335.3,35,,335.3,percent of total billed charges,Implant Device,335.3,35,,335.3,percent of total billed charges,Implant Device,335.3,35,,335.3,percent of total billed charges,Implant Device,335.3,35,,335.3,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,708.92,
DEPUY 394.83 EXFIX 11MM CRBN FBR ROD 200,C1713,HCPCS,,79009856,CDM,278,RC,,,both,,,958,708.92,,,708.92,Other,150% of Medicare + 9.63% HCRA Surcharge,431.1,45,,431.1,percent of total billed charges,Critical Access Hospital RCC factor,325.72,34,,325.72,percent of total billed charges,Implant Device,325.72,34,,325.72,percent of total billed charges,Implant Device,325.72,34,,325.72,percent of total billed charges,Implant Device,325.72,34,,325.72,percent of total billed charges,Implant Device,325.72,34,,325.72,percent of total billed charges,Implant Device,474.21,,,474.21,Other,110% of Medicare,335.3,35,,335.3,percent of total billed charges,Implant Device,325.72,34,"Charges > $500, x 34%",325.72,percent of total billed charges,Implant Device,335.3,35,,335.3,percent of total billed charges,Implant Device,335.3,35,,335.3,percent of total billed charges,Implant Device,335.3,35,,335.3,percent of total billed charges,Implant Device,335.3,35,,335.3,percent of total billed charges,Implant Device,335.3,35,,335.3,percent of total billed charges,Implant Device,383.2,40,,383.2,percent of total billed charges,Implant Device,335.3,70,,335.3,percent of total billed charges,All Other,325.72,34,,325.72,percent of total billed charges,Implant Device,325.72,34,,325.72,percent of total billed charges,Implant Device,335.3,35,,335.3,percent of total billed charges,Implant Device,335.3,35,,335.3,percent of total billed charges,Implant Device,335.3,35,,335.3,percent of total billed charges,Implant Device,335.3,35,,335.3,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,708.92,
STRYKER 3525-1380S NAIL KIT 11X38X125,C1713,HCPCS,,79009857,CDM,278,RC,,,both,,,5438,4024.13,,,4024.13,Other,150% of Medicare + 9.63% HCRA Surcharge,2447.1,45,,2447.1,percent of total billed charges,Critical Access Hospital RCC factor,1848.92,34,,1848.92,percent of total billed charges,Implant Device,1848.92,34,,1848.92,percent of total billed charges,Implant Device,1848.92,34,,1848.92,percent of total billed charges,Implant Device,1848.92,34,,1848.92,percent of total billed charges,Implant Device,1848.92,34,,1848.92,percent of total billed charges,Implant Device,2691.81,,,2691.81,Other,110% of Medicare,1903.3,35,,1903.3,percent of total billed charges,Implant Device,1848.92,34,"Charges > $500, x 34%",1848.92,percent of total billed charges,Implant Device,1903.3,35,,1903.3,percent of total billed charges,Implant Device,1903.3,35,,1903.3,percent of total billed charges,Implant Device,1903.3,35,,1903.3,percent of total billed charges,Implant Device,1903.3,35,,1903.3,percent of total billed charges,Implant Device,1903.3,35,,1903.3,percent of total billed charges,Implant Device,2175.2,40,,2175.2,percent of total billed charges,Implant Device,1903.3,70,,1903.3,percent of total billed charges,All Other,1848.92,34,,1848.92,percent of total billed charges,Implant Device,1848.92,34,,1848.92,percent of total billed charges,Implant Device,1903.3,35,,1903.3,percent of total billed charges,Implant Device,1903.3,35,,1903.3,percent of total billed charges,Implant Device,1903.3,35,,1903.3,percent of total billed charges,Implant Device,1903.3,35,,1903.3,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1848.92,34,"If Charge > 2,000, then 34 percent",1848.92,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4024.13,
STRYKER 54-25385 VOLAR SMARTLOCK DR PLT,C1713,HCPCS,,79009858,CDM,278,RC,,,both,,,2590,1916.61,,,1916.61,Other,150% of Medicare + 9.63% HCRA Surcharge,1165.5,45,,1165.5,percent of total billed charges,Critical Access Hospital RCC factor,880.6,34,,880.6,percent of total billed charges,Implant Device,880.6,34,,880.6,percent of total billed charges,Implant Device,880.6,34,,880.6,percent of total billed charges,Implant Device,880.6,34,,880.6,percent of total billed charges,Implant Device,880.6,34,,880.6,percent of total billed charges,Implant Device,1282.05,,,1282.05,Other,110% of Medicare,906.5,35,,906.5,percent of total billed charges,Implant Device,880.6,34,"Charges > $500, x 34%",880.6,percent of total billed charges,Implant Device,906.5,35,,906.5,percent of total billed charges,Implant Device,906.5,35,,906.5,percent of total billed charges,Implant Device,906.5,35,,906.5,percent of total billed charges,Implant Device,906.5,35,,906.5,percent of total billed charges,Implant Device,906.5,35,,906.5,percent of total billed charges,Implant Device,1036,40,,1036,percent of total billed charges,Implant Device,906.5,70,,906.5,percent of total billed charges,All Other,880.6,34,,880.6,percent of total billed charges,Implant Device,880.6,34,,880.6,percent of total billed charges,Implant Device,906.5,35,,906.5,percent of total billed charges,Implant Device,906.5,35,,906.5,percent of total billed charges,Implant Device,906.5,35,,906.5,percent of total billed charges,Implant Device,906.5,35,,906.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,880.6,34,"If Charge > 2,000, then 34 percent",880.6,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1916.61,
STRYKER 3425-0420S GAMMA NAIL RT 10X420,C1713,HCPCS,,79009862,CDM,278,RC,,,both,,,4920,3640.81,,,3640.81,Other,150% of Medicare + 9.63% HCRA Surcharge,2214,45,,2214,percent of total billed charges,Critical Access Hospital RCC factor,1672.8,34,,1672.8,percent of total billed charges,Implant Device,1672.8,34,,1672.8,percent of total billed charges,Implant Device,1672.8,34,,1672.8,percent of total billed charges,Implant Device,1672.8,34,,1672.8,percent of total billed charges,Implant Device,1672.8,34,,1672.8,percent of total billed charges,Implant Device,2435.4,,,2435.4,Other,110% of Medicare,1722,35,,1722,percent of total billed charges,Implant Device,1672.8,34,"Charges > $500, x 34%",1672.8,percent of total billed charges,Implant Device,1722,35,,1722,percent of total billed charges,Implant Device,1722,35,,1722,percent of total billed charges,Implant Device,1722,35,,1722,percent of total billed charges,Implant Device,1722,35,,1722,percent of total billed charges,Implant Device,1722,35,,1722,percent of total billed charges,Implant Device,1968,40,,1968,percent of total billed charges,Implant Device,1722,70,,1722,percent of total billed charges,All Other,1672.8,34,,1672.8,percent of total billed charges,Implant Device,1672.8,34,,1672.8,percent of total billed charges,Implant Device,1722,35,,1722,percent of total billed charges,Implant Device,1722,35,,1722,percent of total billed charges,Implant Device,1722,35,,1722,percent of total billed charges,Implant Device,1722,35,,1722,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1672.8,34,"If Charge > 2,000, then 34 percent",1672.8,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3640.81,
STRYKER 3525-1360S NAIL KIT 11X360X125,C1713,HCPCS,,79009863,CDM,278,RC,,,both,,,4969,3677.07,,,3677.07,Other,150% of Medicare + 9.63% HCRA Surcharge,2236.05,45,,2236.05,percent of total billed charges,Critical Access Hospital RCC factor,1689.46,34,,1689.46,percent of total billed charges,Implant Device,1689.46,34,,1689.46,percent of total billed charges,Implant Device,1689.46,34,,1689.46,percent of total billed charges,Implant Device,1689.46,34,,1689.46,percent of total billed charges,Implant Device,1689.46,34,,1689.46,percent of total billed charges,Implant Device,2459.66,,,2459.66,Other,110% of Medicare,1739.15,35,,1739.15,percent of total billed charges,Implant Device,1689.46,34,"Charges > $500, x 34%",1689.46,percent of total billed charges,Implant Device,1739.15,35,,1739.15,percent of total billed charges,Implant Device,1739.15,35,,1739.15,percent of total billed charges,Implant Device,1739.15,35,,1739.15,percent of total billed charges,Implant Device,1739.15,35,,1739.15,percent of total billed charges,Implant Device,1739.15,35,,1739.15,percent of total billed charges,Implant Device,1987.6,40,,1987.6,percent of total billed charges,Implant Device,1739.15,70,,1739.15,percent of total billed charges,All Other,1689.46,34,,1689.46,percent of total billed charges,Implant Device,1689.46,34,,1689.46,percent of total billed charges,Implant Device,1739.15,35,,1739.15,percent of total billed charges,Implant Device,1739.15,35,,1739.15,percent of total billed charges,Implant Device,1739.15,35,,1739.15,percent of total billed charges,Implant Device,1739.15,35,,1739.15,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1689.46,34,"If Charge > 2,000, then 34 percent",1689.46,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3677.07,
STRYKER 40-35044 BONE SCREW T10 3.5X44MM,C1713,HCPCS,,79009864,CDM,278,RC,,,both,,,163,120.62,,,120.62,Other,150% of Medicare + 9.63% HCRA Surcharge,73.35,45,,73.35,percent of total billed charges,Critical Access Hospital RCC factor,55.42,34,,55.42,percent of total billed charges,Implant Device,55.42,34,,55.42,percent of total billed charges,Implant Device,55.42,34,,55.42,percent of total billed charges,Implant Device,55.42,34,,55.42,percent of total billed charges,Implant Device,55.42,34,,55.42,percent of total billed charges,Implant Device,80.69,,,80.69,Other,110% of Medicare,57.05,35,,57.05,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,57.05,35,,57.05,percent of total billed charges,Implant Device,57.05,35,,57.05,percent of total billed charges,Implant Device,57.05,35,,57.05,percent of total billed charges,Implant Device,57.05,35,,57.05,percent of total billed charges,Implant Device,57.05,35,,57.05,percent of total billed charges,Implant Device,65.2,40,,65.2,percent of total billed charges,Implant Device,57.05,70,,57.05,percent of total billed charges,All Other,55.42,34,,55.42,percent of total billed charges,Implant Device,55.42,34,,55.42,percent of total billed charges,Implant Device,57.05,35,,57.05,percent of total billed charges,Implant Device,57.05,35,,57.05,percent of total billed charges,Implant Device,57.05,35,,57.05,percent of total billed charges,Implant Device,57.05,35,,57.05,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,120.62,
STRYKER 4922-2-160 POST 90DEG ANGLE 11MM,C1713,HCPCS,,79009865,CDM,278,RC,,,both,,,435,321.9,,,321.9,Other,150% of Medicare + 9.63% HCRA Surcharge,195.75,45,,195.75,percent of total billed charges,Critical Access Hospital RCC factor,147.9,34,,147.9,percent of total billed charges,Implant Device,147.9,34,,147.9,percent of total billed charges,Implant Device,147.9,34,,147.9,percent of total billed charges,Implant Device,147.9,34,,147.9,percent of total billed charges,Implant Device,147.9,34,,147.9,percent of total billed charges,Implant Device,215.33,,,215.33,Other,110% of Medicare,152.25,35,,152.25,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,152.25,35,,152.25,percent of total billed charges,Implant Device,152.25,35,,152.25,percent of total billed charges,Implant Device,152.25,35,,152.25,percent of total billed charges,Implant Device,152.25,35,,152.25,percent of total billed charges,Implant Device,152.25,35,,152.25,percent of total billed charges,Implant Device,174,40,,174,percent of total billed charges,Implant Device,152.25,70,,152.25,percent of total billed charges,All Other,147.9,34,,147.9,percent of total billed charges,Implant Device,147.9,34,,147.9,percent of total billed charges,Implant Device,152.25,35,,152.25,percent of total billed charges,Implant Device,152.25,35,,152.25,percent of total billed charges,Implant Device,152.25,35,,152.25,percent of total billed charges,Implant Device,152.25,35,,152.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,321.9,
STRYKER 1024-54-409 TIB INSERT SZ 4X9MM,C1776,HCPCS,,79009866,CDM,278,RC,,,both,,,2495,1846.31,,,1846.31,Other,150% of Medicare + 9.63% HCRA Surcharge,1122.75,45,,1122.75,percent of total billed charges,Critical Access Hospital RCC factor,848.3,34,,848.3,percent of total billed charges,Implant Device,848.3,34,,848.3,percent of total billed charges,Implant Device,848.3,34,,848.3,percent of total billed charges,Implant Device,848.3,34,,848.3,percent of total billed charges,Implant Device,848.3,34,,848.3,percent of total billed charges,Implant Device,1235.03,,,1235.03,Other,110% of Medicare,873.25,35,,873.25,percent of total billed charges,Implant Device,848.3,34,"Charges > $500, x 34%",848.3,percent of total billed charges,Implant Device,873.25,35,,873.25,percent of total billed charges,Implant Device,873.25,35,,873.25,percent of total billed charges,Implant Device,873.25,35,,873.25,percent of total billed charges,Implant Device,873.25,35,,873.25,percent of total billed charges,Implant Device,873.25,35,,873.25,percent of total billed charges,Implant Device,998,40,,998,percent of total billed charges,Implant Device,873.25,70,,873.25,percent of total billed charges,All Other,848.3,34,,848.3,percent of total billed charges,Implant Device,848.3,34,,848.3,percent of total billed charges,Implant Device,873.25,35,,873.25,percent of total billed charges,Implant Device,873.25,35,,873.25,percent of total billed charges,Implant Device,873.25,35,,873.25,percent of total billed charges,Implant Device,873.25,35,,873.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,848.3,34,"If Charge > 2,000, then 34 percent",848.3,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1846.31,
STRYKER 658050 HDLESS COMP SCREW 4X50MM,C1713,HCPCS,,79009867,CDM,278,RC,,,both,,,1983,1467.42,,,1467.42,Other,150% of Medicare + 9.63% HCRA Surcharge,892.35,45,,892.35,percent of total billed charges,Critical Access Hospital RCC factor,674.22,34,,674.22,percent of total billed charges,Implant Device,674.22,34,,674.22,percent of total billed charges,Implant Device,674.22,34,,674.22,percent of total billed charges,Implant Device,674.22,34,,674.22,percent of total billed charges,Implant Device,674.22,34,,674.22,percent of total billed charges,Implant Device,981.59,,,981.59,Other,110% of Medicare,694.05,35,,694.05,percent of total billed charges,Implant Device,674.22,34,"Charges > $500, x 34%",674.22,percent of total billed charges,Implant Device,694.05,35,,694.05,percent of total billed charges,Implant Device,694.05,35,,694.05,percent of total billed charges,Implant Device,694.05,35,,694.05,percent of total billed charges,Implant Device,694.05,35,,694.05,percent of total billed charges,Implant Device,694.05,35,,694.05,percent of total billed charges,Implant Device,793.2,40,,793.2,percent of total billed charges,Implant Device,694.05,70,,694.05,percent of total billed charges,All Other,674.22,34,,674.22,percent of total billed charges,Implant Device,674.22,34,,674.22,percent of total billed charges,Implant Device,694.05,35,,694.05,percent of total billed charges,Implant Device,694.05,35,,694.05,percent of total billed charges,Implant Device,694.05,35,,694.05,percent of total billed charges,Implant Device,694.05,35,,694.05,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1467.42,
STRYKER 658580 HDLESS COMP SCREW 7X80MM,C1713,HCPCS,,79009868,CDM,278,RC,,,both,,,3351,2479.75,,,2479.75,Other,150% of Medicare + 9.63% HCRA Surcharge,1507.95,45,,1507.95,percent of total billed charges,Critical Access Hospital RCC factor,1139.34,34,,1139.34,percent of total billed charges,Implant Device,1139.34,34,,1139.34,percent of total billed charges,Implant Device,1139.34,34,,1139.34,percent of total billed charges,Implant Device,1139.34,34,,1139.34,percent of total billed charges,Implant Device,1139.34,34,,1139.34,percent of total billed charges,Implant Device,1658.75,,,1658.75,Other,110% of Medicare,1172.85,35,,1172.85,percent of total billed charges,Implant Device,1139.34,34,"Charges > $500, x 34%",1139.34,percent of total billed charges,Implant Device,1172.85,35,,1172.85,percent of total billed charges,Implant Device,1172.85,35,,1172.85,percent of total billed charges,Implant Device,1172.85,35,,1172.85,percent of total billed charges,Implant Device,1172.85,35,,1172.85,percent of total billed charges,Implant Device,1172.85,35,,1172.85,percent of total billed charges,Implant Device,1340.4,40,,1340.4,percent of total billed charges,Implant Device,1172.85,70,,1172.85,percent of total billed charges,All Other,1139.34,34,,1139.34,percent of total billed charges,Implant Device,1139.34,34,,1139.34,percent of total billed charges,Implant Device,1172.85,35,,1172.85,percent of total billed charges,Implant Device,1172.85,35,,1172.85,percent of total billed charges,Implant Device,1172.85,35,,1172.85,percent of total billed charges,Implant Device,1172.85,35,,1172.85,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1139.34,34,"If Charge > 2,000, then 34 percent",1139.34,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2479.75,
STRYKER 658585 HDLESS COMP SCREW 7X85MM,C1713,HCPCS,,79009869,CDM,278,RC,,,both,,,3351,2479.75,,,2479.75,Other,150% of Medicare + 9.63% HCRA Surcharge,1507.95,45,,1507.95,percent of total billed charges,Critical Access Hospital RCC factor,1139.34,34,,1139.34,percent of total billed charges,Implant Device,1139.34,34,,1139.34,percent of total billed charges,Implant Device,1139.34,34,,1139.34,percent of total billed charges,Implant Device,1139.34,34,,1139.34,percent of total billed charges,Implant Device,1139.34,34,,1139.34,percent of total billed charges,Implant Device,1658.75,,,1658.75,Other,110% of Medicare,1172.85,35,,1172.85,percent of total billed charges,Implant Device,1139.34,34,"Charges > $500, x 34%",1139.34,percent of total billed charges,Implant Device,1172.85,35,,1172.85,percent of total billed charges,Implant Device,1172.85,35,,1172.85,percent of total billed charges,Implant Device,1172.85,35,,1172.85,percent of total billed charges,Implant Device,1172.85,35,,1172.85,percent of total billed charges,Implant Device,1172.85,35,,1172.85,percent of total billed charges,Implant Device,1340.4,40,,1340.4,percent of total billed charges,Implant Device,1172.85,70,,1172.85,percent of total billed charges,All Other,1139.34,34,,1139.34,percent of total billed charges,Implant Device,1139.34,34,,1139.34,percent of total billed charges,Implant Device,1172.85,35,,1172.85,percent of total billed charges,Implant Device,1172.85,35,,1172.85,percent of total billed charges,Implant Device,1172.85,35,,1172.85,percent of total billed charges,Implant Device,1172.85,35,,1172.85,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1139.34,34,"If Charge > 2,000, then 34 percent",1139.34,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2479.75,
STRYKER 658590 HDLESS COMP SCREW 7X90MM,C1713,HCPCS,,79009870,CDM,278,RC,,,both,,,3351,2479.75,,,2479.75,Other,150% of Medicare + 9.63% HCRA Surcharge,1507.95,45,,1507.95,percent of total billed charges,Critical Access Hospital RCC factor,1139.34,34,,1139.34,percent of total billed charges,Implant Device,1139.34,34,,1139.34,percent of total billed charges,Implant Device,1139.34,34,,1139.34,percent of total billed charges,Implant Device,1139.34,34,,1139.34,percent of total billed charges,Implant Device,1139.34,34,,1139.34,percent of total billed charges,Implant Device,1658.75,,,1658.75,Other,110% of Medicare,1172.85,35,,1172.85,percent of total billed charges,Implant Device,1139.34,34,"Charges > $500, x 34%",1139.34,percent of total billed charges,Implant Device,1172.85,35,,1172.85,percent of total billed charges,Implant Device,1172.85,35,,1172.85,percent of total billed charges,Implant Device,1172.85,35,,1172.85,percent of total billed charges,Implant Device,1172.85,35,,1172.85,percent of total billed charges,Implant Device,1172.85,35,,1172.85,percent of total billed charges,Implant Device,1340.4,40,,1340.4,percent of total billed charges,Implant Device,1172.85,70,,1172.85,percent of total billed charges,All Other,1139.34,34,,1139.34,percent of total billed charges,Implant Device,1139.34,34,,1139.34,percent of total billed charges,Implant Device,1172.85,35,,1172.85,percent of total billed charges,Implant Device,1172.85,35,,1172.85,percent of total billed charges,Implant Device,1172.85,35,,1172.85,percent of total billed charges,Implant Device,1172.85,35,,1172.85,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1139.34,34,"If Charge > 2,000, then 34 percent",1139.34,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2479.75,
STRYKER EZXP20-16-16 STAPLE 20X26X16MM,C1713,HCPCS,,79009872,CDM,278,RC,,,both,,,7575,5605.52,,,5605.52,Other,150% of Medicare + 9.63% HCRA Surcharge,3408.75,45,,3408.75,percent of total billed charges,Critical Access Hospital RCC factor,2575.5,34,,2575.5,percent of total billed charges,Implant Device,2575.5,34,,2575.5,percent of total billed charges,Implant Device,2575.5,34,,2575.5,percent of total billed charges,Implant Device,2575.5,34,,2575.5,percent of total billed charges,Implant Device,2575.5,34,,2575.5,percent of total billed charges,Implant Device,3749.63,,,3749.63,Other,110% of Medicare,2651.25,35,,2651.25,percent of total billed charges,Implant Device,2575.5,34,"Charges > $500, x 34%",2575.5,percent of total billed charges,Implant Device,2651.25,35,,2651.25,percent of total billed charges,Implant Device,2651.25,35,,2651.25,percent of total billed charges,Implant Device,2651.25,35,,2651.25,percent of total billed charges,Implant Device,2651.25,35,,2651.25,percent of total billed charges,Implant Device,2651.25,35,,2651.25,percent of total billed charges,Implant Device,3030,40,,3030,percent of total billed charges,Implant Device,2651.25,70,,2651.25,percent of total billed charges,All Other,2575.5,34,,2575.5,percent of total billed charges,Implant Device,2575.5,34,,2575.5,percent of total billed charges,Implant Device,2651.25,35,,2651.25,percent of total billed charges,Implant Device,2651.25,35,,2651.25,percent of total billed charges,Implant Device,2651.25,35,,2651.25,percent of total billed charges,Implant Device,2651.25,35,,2651.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2575.5,34,"If Charge > 2,000, then 34 percent",2575.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5605.52,
STRYKER IC4044 HEADED SCREW 4.0X44MM,C1713,HCPCS,,79009873,CDM,278,RC,,,both,,,450,333,,,333,Other,150% of Medicare + 9.63% HCRA Surcharge,202.5,45,,202.5,percent of total billed charges,Critical Access Hospital RCC factor,153,34,,153,percent of total billed charges,Implant Device,153,34,,153,percent of total billed charges,Implant Device,153,34,,153,percent of total billed charges,Implant Device,153,34,,153,percent of total billed charges,Implant Device,153,34,,153,percent of total billed charges,Implant Device,222.75,,,222.75,Other,110% of Medicare,157.5,35,,157.5,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,157.5,35,,157.5,percent of total billed charges,Implant Device,157.5,35,,157.5,percent of total billed charges,Implant Device,157.5,35,,157.5,percent of total billed charges,Implant Device,157.5,35,,157.5,percent of total billed charges,Implant Device,157.5,35,,157.5,percent of total billed charges,Implant Device,180,40,,180,percent of total billed charges,Implant Device,157.5,70,,157.5,percent of total billed charges,All Other,153,34,,153,percent of total billed charges,Implant Device,153,34,,153,percent of total billed charges,Implant Device,157.5,35,,157.5,percent of total billed charges,Implant Device,157.5,35,,157.5,percent of total billed charges,Implant Device,157.5,35,,157.5,percent of total billed charges,Implant Device,157.5,35,,157.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,333,
ARTHREX AR-2323BCT-2 SWIVELOCK 4.75X22MM,C1713,HCPCS,,79009878,CDM,278,RC,,,both,,,255,188.7,,,188.7,Other,150% of Medicare + 9.63% HCRA Surcharge,114.75,45,,114.75,percent of total billed charges,Critical Access Hospital RCC factor,86.7,34,,86.7,percent of total billed charges,Implant Device,86.7,34,,86.7,percent of total billed charges,Implant Device,86.7,34,,86.7,percent of total billed charges,Implant Device,86.7,34,,86.7,percent of total billed charges,Implant Device,86.7,34,,86.7,percent of total billed charges,Implant Device,126.23,,,126.23,Other,110% of Medicare,89.25,35,,89.25,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,89.25,35,,89.25,percent of total billed charges,Implant Device,89.25,35,,89.25,percent of total billed charges,Implant Device,89.25,35,,89.25,percent of total billed charges,Implant Device,89.25,35,,89.25,percent of total billed charges,Implant Device,89.25,35,,89.25,percent of total billed charges,Implant Device,102,40,,102,percent of total billed charges,Implant Device,89.25,70,,89.25,percent of total billed charges,All Other,86.7,34,,86.7,percent of total billed charges,Implant Device,86.7,34,,86.7,percent of total billed charges,Implant Device,89.25,35,,89.25,percent of total billed charges,Implant Device,89.25,35,,89.25,percent of total billed charges,Implant Device,89.25,35,,89.25,percent of total billed charges,Implant Device,89.25,35,,89.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,188.7,
ZIMMER 11-301352 ARCOS CON SZ B 80MM,C1776,HCPCS,,79009879,CDM,278,RC,,,both,,,24006,17764.5,,,17764.5,Other,150% of Medicare + 9.63% HCRA Surcharge,10802.7,45,,10802.7,percent of total billed charges,Critical Access Hospital RCC factor,8162.04,34,,8162.04,percent of total billed charges,Implant Device,8162.04,34,,8162.04,percent of total billed charges,Implant Device,8162.04,34,,8162.04,percent of total billed charges,Implant Device,8162.04,34,,8162.04,percent of total billed charges,Implant Device,8162.04,34,,8162.04,percent of total billed charges,Implant Device,11882.97,,,11882.97,Other,110% of Medicare,8402.1,35,,8402.1,percent of total billed charges,Implant Device,8162.04,34,"Charges > $500, x 34%",8162.04,percent of total billed charges,Implant Device,8402.1,35,,8402.1,percent of total billed charges,Implant Device,8402.1,35,,8402.1,percent of total billed charges,Implant Device,8402.1,35,,8402.1,percent of total billed charges,Implant Device,8402.1,35,,8402.1,percent of total billed charges,Implant Device,8402.1,35,,8402.1,percent of total billed charges,Implant Device,9602.4,40,,9602.4,percent of total billed charges,Implant Device,8402.1,70,,8402.1,percent of total billed charges,All Other,8162.04,34,,8162.04,percent of total billed charges,Implant Device,8162.04,34,,8162.04,percent of total billed charges,Implant Device,8402.1,35,,8402.1,percent of total billed charges,Implant Device,8402.1,35,,8402.1,percent of total billed charges,Implant Device,8402.1,35,,8402.1,percent of total billed charges,Implant Device,8402.1,35,,8402.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,8162.04,34,"If Charge > 2,000, then 34 percent",8162.04,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,17764.5,
ZIMMER 12-115116 CER BIOLOXD MOD 32MM,C1776,HCPCS,,79009880,CDM,278,RC,,,both,,,3075,2275.51,,,2275.51,Other,150% of Medicare + 9.63% HCRA Surcharge,1383.75,45,,1383.75,percent of total billed charges,Critical Access Hospital RCC factor,1045.5,34,,1045.5,percent of total billed charges,Implant Device,1045.5,34,,1045.5,percent of total billed charges,Implant Device,1045.5,34,,1045.5,percent of total billed charges,Implant Device,1045.5,34,,1045.5,percent of total billed charges,Implant Device,1045.5,34,,1045.5,percent of total billed charges,Implant Device,1522.13,,,1522.13,Other,110% of Medicare,1076.25,35,,1076.25,percent of total billed charges,Implant Device,1045.5,34,"Charges > $500, x 34%",1045.5,percent of total billed charges,Implant Device,1076.25,35,,1076.25,percent of total billed charges,Implant Device,1076.25,35,,1076.25,percent of total billed charges,Implant Device,1076.25,35,,1076.25,percent of total billed charges,Implant Device,1076.25,35,,1076.25,percent of total billed charges,Implant Device,1076.25,35,,1076.25,percent of total billed charges,Implant Device,1230,40,,1230,percent of total billed charges,Implant Device,1076.25,70,,1076.25,percent of total billed charges,All Other,1045.5,34,,1045.5,percent of total billed charges,Implant Device,1045.5,34,,1045.5,percent of total billed charges,Implant Device,1076.25,35,,1076.25,percent of total billed charges,Implant Device,1076.25,35,,1076.25,percent of total billed charges,Implant Device,1076.25,35,,1076.25,percent of total billed charges,Implant Device,1076.25,35,,1076.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1045.5,34,"If Charge > 2,000, then 34 percent",1045.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2275.51,
ZIMMER 00-2232-002-28 CBL ASSY CERCLAGE,C1713,HCPCS,,79009881,CDM,278,RC,,,both,,,1357,1004.18,,,1004.18,Other,150% of Medicare + 9.63% HCRA Surcharge,610.65,45,,610.65,percent of total billed charges,Critical Access Hospital RCC factor,461.38,34,,461.38,percent of total billed charges,Implant Device,461.38,34,,461.38,percent of total billed charges,Implant Device,461.38,34,,461.38,percent of total billed charges,Implant Device,461.38,34,,461.38,percent of total billed charges,Implant Device,461.38,34,,461.38,percent of total billed charges,Implant Device,671.72,,,671.72,Other,110% of Medicare,474.95,35,,474.95,percent of total billed charges,Implant Device,461.38,34,"Charges > $500, x 34%",461.38,percent of total billed charges,Implant Device,474.95,35,,474.95,percent of total billed charges,Implant Device,474.95,35,,474.95,percent of total billed charges,Implant Device,474.95,35,,474.95,percent of total billed charges,Implant Device,474.95,35,,474.95,percent of total billed charges,Implant Device,474.95,35,,474.95,percent of total billed charges,Implant Device,542.8,40,,542.8,percent of total billed charges,Implant Device,474.95,70,,474.95,percent of total billed charges,All Other,461.38,34,,461.38,percent of total billed charges,Implant Device,461.38,34,,461.38,percent of total billed charges,Implant Device,474.95,35,,474.95,percent of total billed charges,Implant Device,474.95,35,,474.95,percent of total billed charges,Implant Device,474.95,35,,474.95,percent of total billed charges,Implant Device,474.95,35,,474.95,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1004.18,
ZIMMER 00-2232-005-18 CBL RDY GTR,C1713,HCPCS,,79009882,CDM,278,RC,,,both,,,845,625.3,,,625.3,Other,150% of Medicare + 9.63% HCRA Surcharge,380.25,45,,380.25,percent of total billed charges,Critical Access Hospital RCC factor,287.3,34,,287.3,percent of total billed charges,Implant Device,287.3,34,,287.3,percent of total billed charges,Implant Device,287.3,34,,287.3,percent of total billed charges,Implant Device,287.3,34,,287.3,percent of total billed charges,Implant Device,287.3,34,,287.3,percent of total billed charges,Implant Device,418.28,,,418.28,Other,110% of Medicare,295.75,35,,295.75,percent of total billed charges,Implant Device,287.3,34,"Charges > $500, x 34%",287.3,percent of total billed charges,Implant Device,295.75,35,,295.75,percent of total billed charges,Implant Device,295.75,35,,295.75,percent of total billed charges,Implant Device,295.75,35,,295.75,percent of total billed charges,Implant Device,295.75,35,,295.75,percent of total billed charges,Implant Device,295.75,35,,295.75,percent of total billed charges,Implant Device,338,40,,338,percent of total billed charges,Implant Device,295.75,70,,295.75,percent of total billed charges,All Other,287.3,34,,287.3,percent of total billed charges,Implant Device,287.3,34,,287.3,percent of total billed charges,Implant Device,295.75,35,,295.75,percent of total billed charges,Implant Device,295.75,35,,295.75,percent of total billed charges,Implant Device,295.75,35,,295.75,percent of total billed charges,Implant Device,295.75,35,,295.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,625.3,
AESULAP NB012Z ENDURO TIBIAL COMP SZ T2,C1776,HCPCS,,79009883,CDM,278,RC,,,both,,,10710,7925.43,,,7925.43,Other,150% of Medicare + 9.63% HCRA Surcharge,4819.5,45,,4819.5,percent of total billed charges,Critical Access Hospital RCC factor,3641.4,34,,3641.4,percent of total billed charges,Implant Device,3641.4,34,,3641.4,percent of total billed charges,Implant Device,3641.4,34,,3641.4,percent of total billed charges,Implant Device,3641.4,34,,3641.4,percent of total billed charges,Implant Device,3641.4,34,,3641.4,percent of total billed charges,Implant Device,5301.45,,,5301.45,Other,110% of Medicare,3748.5,35,,3748.5,percent of total billed charges,Implant Device,3641.4,34,"Charges > $500, x 34%",3641.4,percent of total billed charges,Implant Device,3748.5,35,,3748.5,percent of total billed charges,Implant Device,3748.5,35,,3748.5,percent of total billed charges,Implant Device,3748.5,35,,3748.5,percent of total billed charges,Implant Device,3748.5,35,,3748.5,percent of total billed charges,Implant Device,3748.5,35,,3748.5,percent of total billed charges,Implant Device,4284,40,,4284,percent of total billed charges,Implant Device,3748.5,70,,3748.5,percent of total billed charges,All Other,3641.4,34,,3641.4,percent of total billed charges,Implant Device,3641.4,34,,3641.4,percent of total billed charges,Implant Device,3748.5,35,,3748.5,percent of total billed charges,Implant Device,3748.5,35,,3748.5,percent of total billed charges,Implant Device,3748.5,35,,3748.5,percent of total billed charges,Implant Device,3748.5,35,,3748.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3641.4,34,"If Charge > 2,000, then 34 percent",3641.4,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,7925.43,
AESULAP NB018Z ENDURO FEM COMP SZ F2R,C1776,HCPCS,,79009884,CDM,278,RC,,,both,,,21900,16206.05,,,16206.05,Other,150% of Medicare + 9.63% HCRA Surcharge,9855,45,,9855,percent of total billed charges,Critical Access Hospital RCC factor,7446,34,,7446,percent of total billed charges,Implant Device,7446,34,,7446,percent of total billed charges,Implant Device,7446,34,,7446,percent of total billed charges,Implant Device,7446,34,,7446,percent of total billed charges,Implant Device,7446,34,,7446,percent of total billed charges,Implant Device,10840.5,,,10840.5,Other,110% of Medicare,7665,35,,7665,percent of total billed charges,Implant Device,7446,34,"Charges > $500, x 34%",7446,percent of total billed charges,Implant Device,7665,35,,7665,percent of total billed charges,Implant Device,7665,35,,7665,percent of total billed charges,Implant Device,7665,35,,7665,percent of total billed charges,Implant Device,7665,35,,7665,percent of total billed charges,Implant Device,7665,35,,7665,percent of total billed charges,Implant Device,8760,40,,8760,percent of total billed charges,Implant Device,7665,70,,7665,percent of total billed charges,All Other,7446,34,,7446,percent of total billed charges,Implant Device,7446,34,,7446,percent of total billed charges,Implant Device,7665,35,,7665,percent of total billed charges,Implant Device,7665,35,,7665,percent of total billed charges,Implant Device,7665,35,,7665,percent of total billed charges,Implant Device,7665,35,,7665,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,7446,34,"If Charge > 2,000, then 34 percent",7446,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,16206.05,
AESULAP NR192Z TIBIA OFFSET STEM 15X52,C1776,HCPCS,,79009885,CDM,278,RC,,,both,,,7560,5594.42,,,5594.42,Other,150% of Medicare + 9.63% HCRA Surcharge,3402,45,,3402,percent of total billed charges,Critical Access Hospital RCC factor,2570.4,34,,2570.4,percent of total billed charges,Implant Device,2570.4,34,,2570.4,percent of total billed charges,Implant Device,2570.4,34,,2570.4,percent of total billed charges,Implant Device,2570.4,34,,2570.4,percent of total billed charges,Implant Device,2570.4,34,,2570.4,percent of total billed charges,Implant Device,3742.2,,,3742.2,Other,110% of Medicare,2646,35,,2646,percent of total billed charges,Implant Device,2570.4,34,"Charges > $500, x 34%",2570.4,percent of total billed charges,Implant Device,2646,35,,2646,percent of total billed charges,Implant Device,2646,35,,2646,percent of total billed charges,Implant Device,2646,35,,2646,percent of total billed charges,Implant Device,2646,35,,2646,percent of total billed charges,Implant Device,2646,35,,2646,percent of total billed charges,Implant Device,3024,40,,3024,percent of total billed charges,Implant Device,2646,70,,2646,percent of total billed charges,All Other,2570.4,34,,2570.4,percent of total billed charges,Implant Device,2570.4,34,,2570.4,percent of total billed charges,Implant Device,2646,35,,2646,percent of total billed charges,Implant Device,2646,35,,2646,percent of total billed charges,Implant Device,2646,35,,2646,percent of total billed charges,Implant Device,2646,35,,2646,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2570.4,34,"If Charge > 2,000, then 34 percent",2570.4,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5594.42,
AESCULAP NR400Z NUT FOR FEMUR EXTENSTION,C1713,HCPCS,,79009886,CDM,278,RC,,,both,,,1890,1398.6,,,1398.6,Other,150% of Medicare + 9.63% HCRA Surcharge,850.5,45,,850.5,percent of total billed charges,Critical Access Hospital RCC factor,642.6,34,,642.6,percent of total billed charges,Implant Device,642.6,34,,642.6,percent of total billed charges,Implant Device,642.6,34,,642.6,percent of total billed charges,Implant Device,642.6,34,,642.6,percent of total billed charges,Implant Device,642.6,34,,642.6,percent of total billed charges,Implant Device,935.55,,,935.55,Other,110% of Medicare,661.5,35,,661.5,percent of total billed charges,Implant Device,642.6,34,"Charges > $500, x 34%",642.6,percent of total billed charges,Implant Device,661.5,35,,661.5,percent of total billed charges,Implant Device,661.5,35,,661.5,percent of total billed charges,Implant Device,661.5,35,,661.5,percent of total billed charges,Implant Device,661.5,35,,661.5,percent of total billed charges,Implant Device,661.5,35,,661.5,percent of total billed charges,Implant Device,756,40,,756,percent of total billed charges,Implant Device,661.5,70,,661.5,percent of total billed charges,All Other,642.6,34,,642.6,percent of total billed charges,Implant Device,642.6,34,,642.6,percent of total billed charges,Implant Device,661.5,35,,661.5,percent of total billed charges,Implant Device,661.5,35,,661.5,percent of total billed charges,Implant Device,661.5,35,,661.5,percent of total billed charges,Implant Device,661.5,35,,661.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1398.6,
AESCULAP NR409Z FEMUR EXT STEM 19X117MM,C1776,HCPCS,,79009887,CDM,278,RC,,,both,,,8580,6349.22,,,6349.22,Other,150% of Medicare + 9.63% HCRA Surcharge,3861,45,,3861,percent of total billed charges,Critical Access Hospital RCC factor,2917.2,34,,2917.2,percent of total billed charges,Implant Device,2917.2,34,,2917.2,percent of total billed charges,Implant Device,2917.2,34,,2917.2,percent of total billed charges,Implant Device,2917.2,34,,2917.2,percent of total billed charges,Implant Device,2917.2,34,,2917.2,percent of total billed charges,Implant Device,4247.1,,,4247.1,Other,110% of Medicare,3003,35,,3003,percent of total billed charges,Implant Device,2917.2,34,"Charges > $500, x 34%",2917.2,percent of total billed charges,Implant Device,3003,35,,3003,percent of total billed charges,Implant Device,3003,35,,3003,percent of total billed charges,Implant Device,3003,35,,3003,percent of total billed charges,Implant Device,3003,35,,3003,percent of total billed charges,Implant Device,3003,35,,3003,percent of total billed charges,Implant Device,3432,40,,3432,percent of total billed charges,Implant Device,3003,70,,3003,percent of total billed charges,All Other,2917.2,34,,2917.2,percent of total billed charges,Implant Device,2917.2,34,,2917.2,percent of total billed charges,Implant Device,3003,35,,3003,percent of total billed charges,Implant Device,3003,35,,3003,percent of total billed charges,Implant Device,3003,35,,3003,percent of total billed charges,Implant Device,3003,35,,3003,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2917.2,34,"If Charge > 2,000, then 34 percent",2917.2,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,6349.22,
AESCULAP NR882Z ENDURO MENISCAL COMP 14,C1776,HCPCS,,79009888,CDM,278,RC,,,both,,,4455,3296.71,,,3296.71,Other,150% of Medicare + 9.63% HCRA Surcharge,2004.75,45,,2004.75,percent of total billed charges,Critical Access Hospital RCC factor,1514.7,34,,1514.7,percent of total billed charges,Implant Device,1514.7,34,,1514.7,percent of total billed charges,Implant Device,1514.7,34,,1514.7,percent of total billed charges,Implant Device,1514.7,34,,1514.7,percent of total billed charges,Implant Device,1514.7,34,,1514.7,percent of total billed charges,Implant Device,2205.23,,,2205.23,Other,110% of Medicare,1559.25,35,,1559.25,percent of total billed charges,Implant Device,1514.7,34,"Charges > $500, x 34%",1514.7,percent of total billed charges,Implant Device,1559.25,35,,1559.25,percent of total billed charges,Implant Device,1559.25,35,,1559.25,percent of total billed charges,Implant Device,1559.25,35,,1559.25,percent of total billed charges,Implant Device,1559.25,35,,1559.25,percent of total billed charges,Implant Device,1559.25,35,,1559.25,percent of total billed charges,Implant Device,1782,40,,1782,percent of total billed charges,Implant Device,1559.25,70,,1559.25,percent of total billed charges,All Other,1514.7,34,,1514.7,percent of total billed charges,Implant Device,1514.7,34,,1514.7,percent of total billed charges,Implant Device,1559.25,35,,1559.25,percent of total billed charges,Implant Device,1559.25,35,,1559.25,percent of total billed charges,Implant Device,1559.25,35,,1559.25,percent of total billed charges,Implant Device,1559.25,35,,1559.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1514.7,34,"If Charge > 2,000, then 34 percent",1514.7,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3296.71,
AESCULAP NX043 PATELLA 3-PEGS P3,C1776,HCPCS,,79009889,CDM,278,RC,,,both,,,1200,888,,,888,Other,150% of Medicare + 9.63% HCRA Surcharge,540,45,,540,percent of total billed charges,Critical Access Hospital RCC factor,408,34,,408,percent of total billed charges,Implant Device,408,34,,408,percent of total billed charges,Implant Device,408,34,,408,percent of total billed charges,Implant Device,408,34,,408,percent of total billed charges,Implant Device,408,34,,408,percent of total billed charges,Implant Device,594,,,594,Other,110% of Medicare,420,35,,420,percent of total billed charges,Implant Device,408,34,"Charges > $500, x 34%",408,percent of total billed charges,Implant Device,420,35,,420,percent of total billed charges,Implant Device,420,35,,420,percent of total billed charges,Implant Device,420,35,,420,percent of total billed charges,Implant Device,420,35,,420,percent of total billed charges,Implant Device,420,35,,420,percent of total billed charges,Implant Device,480,40,,480,percent of total billed charges,Implant Device,420,70,,420,percent of total billed charges,All Other,408,34,,408,percent of total billed charges,Implant Device,408,34,,408,percent of total billed charges,Implant Device,420,35,,420,percent of total billed charges,Implant Device,420,35,,420,percent of total billed charges,Implant Device,420,35,,420,percent of total billed charges,Implant Device,420,35,,420,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,888,
STRYKER 3102-2006 ALLOWRAP 4X4CM,Q4150,HCPCS,,79009890,CDM,278,RC,,,both,,,7200,5328.02,,,5328.02,Other,150% of Medicare + 9.63% HCRA Surcharge,3240,45,,3240,percent of total billed charges,Critical Access Hospital RCC factor,2448,34,,2448,percent of total billed charges,Implant Device,2448,34,,2448,percent of total billed charges,Implant Device,2448,34,,2448,percent of total billed charges,Implant Device,2448,34,,2448,percent of total billed charges,Implant Device,2448,34,,2448,percent of total billed charges,Implant Device,3564,,,3564,Other,110% of Medicare,2520,35,,2520,percent of total billed charges,Implant Device,2448,34,"Charges > $500, x 34%",2448,percent of total billed charges,Implant Device,2520,35,,2520,percent of total billed charges,Implant Device,2520,35,,2520,percent of total billed charges,Implant Device,2520,35,,2520,percent of total billed charges,Implant Device,2520,35,,2520,percent of total billed charges,Implant Device,2520,35,,2520,percent of total billed charges,Implant Device,2880,40,,2880,percent of total billed charges,Implant Device,2520,70,,2520,percent of total billed charges,All Other,2448,34,,2448,percent of total billed charges,Implant Device,2448,34,,2448,percent of total billed charges,Implant Device,2520,35,,2520,percent of total billed charges,Implant Device,2520,35,,2520,percent of total billed charges,Implant Device,2520,35,,2520,percent of total billed charges,Implant Device,2520,35,,2520,percent of total billed charges,Implant Device,976.07,,,976.07,Other,100% of Medicaid,976.07,,,976.07,Other,100% of Medicaid,976.07,,,976.07,Other,100% of Medicaid,976.07,,,976.07,Other,100% of Medicaid,2196.15,,,2196.15,Other,225% of Medicaid,1493.38,,,1493.38,Other,153% of Medicaid,2196.15,,,2196.15,Other,225% of Medicaid,1366.49,,,1366.49,Other,140% of Medicaid,2448,34,"If Charge > 2,000, then 34 percent",2448,percent of total billed charges,Implants,2537.77,,,2537.77,Other,260% of Medicaid,3162.45,,,3162.45,Other,324% of Medicaid,2098.54,,,2098.54,Other,215% of Medicaid,2098.54,,,2098.54,Other,215% of Medicaid,1220.08,,,1220.08,Other,125% of Medicaid,976.07,5328.02,
MENTOR 350-2650 BREAST IMPLANT 650CC,C1789,HCPCS,,79009891,CDM,278,RC,,,both,,,2010,1487.41,,,1487.41,Other,150% of Medicare + 9.63% HCRA Surcharge,904.5,45,,904.5,percent of total billed charges,Critical Access Hospital RCC factor,683.4,34,,683.4,percent of total billed charges,Implant Device,683.4,34,,683.4,percent of total billed charges,Implant Device,683.4,34,,683.4,percent of total billed charges,Implant Device,683.4,34,,683.4,percent of total billed charges,Implant Device,683.4,34,,683.4,percent of total billed charges,Implant Device,994.95,,,994.95,Other,110% of Medicare,703.5,35,,703.5,percent of total billed charges,Implant Device,683.4,34,"Charges > $500, x 34%",683.4,percent of total billed charges,Implant Device,703.5,35,,703.5,percent of total billed charges,Implant Device,703.5,35,,703.5,percent of total billed charges,Implant Device,703.5,35,,703.5,percent of total billed charges,Implant Device,703.5,35,,703.5,percent of total billed charges,Implant Device,703.5,35,,703.5,percent of total billed charges,Implant Device,804,40,,804,percent of total billed charges,Implant Device,703.5,70,,703.5,percent of total billed charges,All Other,683.4,34,,683.4,percent of total billed charges,Implant Device,683.4,34,,683.4,percent of total billed charges,Implant Device,703.5,35,,703.5,percent of total billed charges,Implant Device,703.5,35,,703.5,percent of total billed charges,Implant Device,703.5,35,,703.5,percent of total billed charges,Implant Device,703.5,35,,703.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,683.4,34,"If Charge > 2,000, then 34 percent",683.4,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1487.41,
STRYKER 5510-F-401 FEMORAL COMP SZ 4 LT,C1776,HCPCS,,79009892,CDM,278,RC,,,both,,,4450,3293.01,,,3293.01,Other,150% of Medicare + 9.63% HCRA Surcharge,2002.5,45,,2002.5,percent of total billed charges,Critical Access Hospital RCC factor,1513,34,,1513,percent of total billed charges,Implant Device,1513,34,,1513,percent of total billed charges,Implant Device,1513,34,,1513,percent of total billed charges,Implant Device,1513,34,,1513,percent of total billed charges,Implant Device,1513,34,,1513,percent of total billed charges,Implant Device,2202.75,,,2202.75,Other,110% of Medicare,1557.5,35,,1557.5,percent of total billed charges,Implant Device,1513,34,"Charges > $500, x 34%",1513,percent of total billed charges,Implant Device,1557.5,35,,1557.5,percent of total billed charges,Implant Device,1557.5,35,,1557.5,percent of total billed charges,Implant Device,1557.5,35,,1557.5,percent of total billed charges,Implant Device,1557.5,35,,1557.5,percent of total billed charges,Implant Device,1557.5,35,,1557.5,percent of total billed charges,Implant Device,1780,40,,1780,percent of total billed charges,Implant Device,1557.5,70,,1557.5,percent of total billed charges,All Other,1513,34,,1513,percent of total billed charges,Implant Device,1513,34,,1513,percent of total billed charges,Implant Device,1557.5,35,,1557.5,percent of total billed charges,Implant Device,1557.5,35,,1557.5,percent of total billed charges,Implant Device,1557.5,35,,1557.5,percent of total billed charges,Implant Device,1557.5,35,,1557.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1513,34,"If Charge > 2,000, then 34 percent",1513,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3293.01,
STRYKER 5520-B-400 TIBIAL BASEPLATE SZ 4,C1776,HCPCS,,79009893,CDM,278,RC,,,both,,,3300,2442.01,,,2442.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1485,45,,1485,percent of total billed charges,Critical Access Hospital RCC factor,1122,34,,1122,percent of total billed charges,Implant Device,1122,34,,1122,percent of total billed charges,Implant Device,1122,34,,1122,percent of total billed charges,Implant Device,1122,34,,1122,percent of total billed charges,Implant Device,1122,34,,1122,percent of total billed charges,Implant Device,1633.5,,,1633.5,Other,110% of Medicare,1155,35,,1155,percent of total billed charges,Implant Device,1122,34,"Charges > $500, x 34%",1122,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,1320,40,,1320,percent of total billed charges,Implant Device,1155,70,,1155,percent of total billed charges,All Other,1122,34,,1122,percent of total billed charges,Implant Device,1122,34,,1122,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1122,34,"If Charge > 2,000, then 34 percent",1122,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2442.01,
STRYKER 5530-G-409 TIB INSERT SZ 4 9MM,C1776,HCPCS,,79009894,CDM,278,RC,,,both,,,3300,2442.01,,,2442.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1485,45,,1485,percent of total billed charges,Critical Access Hospital RCC factor,1122,34,,1122,percent of total billed charges,Implant Device,1122,34,,1122,percent of total billed charges,Implant Device,1122,34,,1122,percent of total billed charges,Implant Device,1122,34,,1122,percent of total billed charges,Implant Device,1122,34,,1122,percent of total billed charges,Implant Device,1633.5,,,1633.5,Other,110% of Medicare,1155,35,,1155,percent of total billed charges,Implant Device,1122,34,"Charges > $500, x 34%",1122,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,1320,40,,1320,percent of total billed charges,Implant Device,1155,70,,1155,percent of total billed charges,All Other,1122,34,,1122,percent of total billed charges,Implant Device,1122,34,,1122,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1122,34,"If Charge > 2,000, then 34 percent",1122,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2442.01,
ALLERGAN SCF-365 BREAST IMPLANT 365CC,C1789,HCPCS,,79009895,CDM,278,RC,,,both,,,4005,2963.71,,,2963.71,Other,150% of Medicare + 9.63% HCRA Surcharge,1802.25,45,,1802.25,percent of total billed charges,Critical Access Hospital RCC factor,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1982.48,,,1982.48,Other,110% of Medicare,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1361.7,34,"Charges > $500, x 34%",1361.7,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1602,40,,1602,percent of total billed charges,Implant Device,1401.75,70,,1401.75,percent of total billed charges,All Other,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1361.7,34,"If Charge > 2,000, then 34 percent",1361.7,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2963.71,
ALLERGEN SCF-385 BREAST IMPLANT 385CC,C1789,HCPCS,,79009896,CDM,278,RC,,,both,,,4005,2963.71,,,2963.71,Other,150% of Medicare + 9.63% HCRA Surcharge,1802.25,45,,1802.25,percent of total billed charges,Critical Access Hospital RCC factor,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1982.48,,,1982.48,Other,110% of Medicare,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1361.7,34,"Charges > $500, x 34%",1361.7,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1602,40,,1602,percent of total billed charges,Implant Device,1401.75,70,,1401.75,percent of total billed charges,All Other,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1361.7,34,"If Charge > 2,000, then 34 percent",1361.7,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2963.71,
ALLERGEN SCF-415 BREAST IMPLANT 415CC,C1789,HCPCS,,79009897,CDM,278,RC,,,both,,,4005,2963.71,,,2963.71,Other,150% of Medicare + 9.63% HCRA Surcharge,1802.25,45,,1802.25,percent of total billed charges,Critical Access Hospital RCC factor,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1982.48,,,1982.48,Other,110% of Medicare,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1361.7,34,"Charges > $500, x 34%",1361.7,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1602,40,,1602,percent of total billed charges,Implant Device,1401.75,70,,1401.75,percent of total billed charges,All Other,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1361.7,34,"If Charge > 2,000, then 34 percent",1361.7,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2963.71,
ALLERGEN SCF-450 BREAST IMPLANT 450CC,C1789,HCPCS,,79009898,CDM,278,RC,,,both,,,4005,2963.71,,,2963.71,Other,150% of Medicare + 9.63% HCRA Surcharge,1802.25,45,,1802.25,percent of total billed charges,Critical Access Hospital RCC factor,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1982.48,,,1982.48,Other,110% of Medicare,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1361.7,34,"Charges > $500, x 34%",1361.7,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1602,40,,1602,percent of total billed charges,Implant Device,1401.75,70,,1401.75,percent of total billed charges,All Other,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1361.7,34,"If Charge > 2,000, then 34 percent",1361.7,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2963.71,
ALLERGEN SCF-485 BREAST IMPLANT 485CC,C1789,HCPCS,,79009899,CDM,278,RC,,,both,,,4005,2963.71,,,2963.71,Other,150% of Medicare + 9.63% HCRA Surcharge,1802.25,45,,1802.25,percent of total billed charges,Critical Access Hospital RCC factor,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1982.48,,,1982.48,Other,110% of Medicare,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1361.7,34,"Charges > $500, x 34%",1361.7,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1602,40,,1602,percent of total billed charges,Implant Device,1401.75,70,,1401.75,percent of total billed charges,All Other,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1361.7,34,"If Charge > 2,000, then 34 percent",1361.7,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2963.71,
ALLERGEN SCM-345 BREAST IMPLANT 345CC,C1789,HCPCS,,79009900,CDM,278,RC,,,both,,,4005,2963.71,,,2963.71,Other,150% of Medicare + 9.63% HCRA Surcharge,1802.25,45,,1802.25,percent of total billed charges,Critical Access Hospital RCC factor,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1982.48,,,1982.48,Other,110% of Medicare,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1361.7,34,"Charges > $500, x 34%",1361.7,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1602,40,,1602,percent of total billed charges,Implant Device,1401.75,70,,1401.75,percent of total billed charges,All Other,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1361.7,34,"If Charge > 2,000, then 34 percent",1361.7,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2963.71,
ALLERGEN SCM-360 BREAST IMPLANT 360CC,C1789,HCPCS,,79009901,CDM,278,RC,,,both,,,4005,2963.71,,,2963.71,Other,150% of Medicare + 9.63% HCRA Surcharge,1802.25,45,,1802.25,percent of total billed charges,Critical Access Hospital RCC factor,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1982.48,,,1982.48,Other,110% of Medicare,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1361.7,34,"Charges > $500, x 34%",1361.7,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1602,40,,1602,percent of total billed charges,Implant Device,1401.75,70,,1401.75,percent of total billed charges,All Other,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1361.7,34,"If Charge > 2,000, then 34 percent",1361.7,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2963.71,
ALLERGEN SCM-375 BREAST IMPLANT 375CC,C1789,HCPCS,,79009902,CDM,278,RC,,,both,,,4005,2963.71,,,2963.71,Other,150% of Medicare + 9.63% HCRA Surcharge,1802.25,45,,1802.25,percent of total billed charges,Critical Access Hospital RCC factor,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1982.48,,,1982.48,Other,110% of Medicare,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1361.7,34,"Charges > $500, x 34%",1361.7,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1602,40,,1602,percent of total billed charges,Implant Device,1401.75,70,,1401.75,percent of total billed charges,All Other,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1361.7,34,"If Charge > 2,000, then 34 percent",1361.7,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2963.71,
IN2BONES P35 ST424 TRANS SCREW 3.5X24MM,C1713,HCPCS,,79009912,CDM,278,RC,,,both,,,870,643.8,,,643.8,Other,150% of Medicare + 9.63% HCRA Surcharge,391.5,45,,391.5,percent of total billed charges,Critical Access Hospital RCC factor,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,430.65,,,430.65,Other,110% of Medicare,304.5,35,,304.5,percent of total billed charges,Implant Device,295.8,34,"Charges > $500, x 34%",295.8,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,348,40,,348,percent of total billed charges,Implant Device,304.5,70,,304.5,percent of total billed charges,All Other,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,643.8,
IN2BONES P40 ST136 COLINK PLATE 6 HOLE,C1713,HCPCS,,79009913,CDM,278,RC,,,both,,,6000,4440.02,,,4440.02,Other,150% of Medicare + 9.63% HCRA Surcharge,2700,45,,2700,percent of total billed charges,Critical Access Hospital RCC factor,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2970,,,2970,Other,110% of Medicare,2100,35,,2100,percent of total billed charges,Implant Device,2040,34,"Charges > $500, x 34%",2040,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2400,40,,2400,percent of total billed charges,Implant Device,2100,70,,2100,percent of total billed charges,All Other,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2040,34,"If Charge > 2,000, then 34 percent",2040,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4440.02,
IN2BONES V35 ST312 LOCK SCREW 3.5X12MM,C1713,HCPCS,,79009914,CDM,278,RC,,,both,,,870,643.8,,,643.8,Other,150% of Medicare + 9.63% HCRA Surcharge,391.5,45,,391.5,percent of total billed charges,Critical Access Hospital RCC factor,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,430.65,,,430.65,Other,110% of Medicare,304.5,35,,304.5,percent of total billed charges,Implant Device,295.8,34,"Charges > $500, x 34%",295.8,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,348,40,,348,percent of total billed charges,Implant Device,304.5,70,,304.5,percent of total billed charges,All Other,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,643.8,
IN2BONES V35 ST420 TRANS SCREW 3.5X20MM,C1713,HCPCS,,79009915,CDM,278,RC,,,both,,,870,643.8,,,643.8,Other,150% of Medicare + 9.63% HCRA Surcharge,391.5,45,,391.5,percent of total billed charges,Critical Access Hospital RCC factor,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,430.65,,,430.65,Other,110% of Medicare,304.5,35,,304.5,percent of total billed charges,Implant Device,295.8,34,"Charges > $500, x 34%",295.8,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,348,40,,348,percent of total billed charges,Implant Device,304.5,70,,304.5,percent of total billed charges,All Other,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,643.8,
STRYKER 663142 CANN COMP SCREW 5X42MM,C1713,HCPCS,,79009916,CDM,278,RC,,,both,,,2336,1728.65,,,1728.65,Other,150% of Medicare + 9.63% HCRA Surcharge,1051.2,45,,1051.2,percent of total billed charges,Critical Access Hospital RCC factor,794.24,34,,794.24,percent of total billed charges,Implant Device,794.24,34,,794.24,percent of total billed charges,Implant Device,794.24,34,,794.24,percent of total billed charges,Implant Device,794.24,34,,794.24,percent of total billed charges,Implant Device,794.24,34,,794.24,percent of total billed charges,Implant Device,1156.32,,,1156.32,Other,110% of Medicare,817.6,35,,817.6,percent of total billed charges,Implant Device,794.24,34,"Charges > $500, x 34%",794.24,percent of total billed charges,Implant Device,817.6,35,,817.6,percent of total billed charges,Implant Device,817.6,35,,817.6,percent of total billed charges,Implant Device,817.6,35,,817.6,percent of total billed charges,Implant Device,817.6,35,,817.6,percent of total billed charges,Implant Device,817.6,35,,817.6,percent of total billed charges,Implant Device,934.4,40,,934.4,percent of total billed charges,Implant Device,817.6,70,,817.6,percent of total billed charges,All Other,794.24,34,,794.24,percent of total billed charges,Implant Device,794.24,34,,794.24,percent of total billed charges,Implant Device,817.6,35,,817.6,percent of total billed charges,Implant Device,817.6,35,,817.6,percent of total billed charges,Implant Device,817.6,35,,817.6,percent of total billed charges,Implant Device,817.6,35,,817.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,794.24,34,"If Charge > 2,000, then 34 percent",794.24,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1728.65,
DEPUY 456.307S TI HELICAL BLADE 11X110MM,C1713,HCPCS,,79009918,CDM,278,RC,,,both,,,1301,962.74,,,962.74,Other,150% of Medicare + 9.63% HCRA Surcharge,585.45,45,,585.45,percent of total billed charges,Critical Access Hospital RCC factor,442.34,34,,442.34,percent of total billed charges,Implant Device,442.34,34,,442.34,percent of total billed charges,Implant Device,442.34,34,,442.34,percent of total billed charges,Implant Device,442.34,34,,442.34,percent of total billed charges,Implant Device,442.34,34,,442.34,percent of total billed charges,Implant Device,644,,,644,Other,110% of Medicare,455.35,35,,455.35,percent of total billed charges,Implant Device,442.34,34,"Charges > $500, x 34%",442.34,percent of total billed charges,Implant Device,455.35,35,,455.35,percent of total billed charges,Implant Device,455.35,35,,455.35,percent of total billed charges,Implant Device,455.35,35,,455.35,percent of total billed charges,Implant Device,455.35,35,,455.35,percent of total billed charges,Implant Device,455.35,35,,455.35,percent of total billed charges,Implant Device,520.4,40,,520.4,percent of total billed charges,Implant Device,455.35,70,,455.35,percent of total billed charges,All Other,442.34,34,,442.34,percent of total billed charges,Implant Device,442.34,34,,442.34,percent of total billed charges,Implant Device,455.35,35,,455.35,percent of total billed charges,Implant Device,455.35,35,,455.35,percent of total billed charges,Implant Device,455.35,35,,455.35,percent of total billed charges,Implant Device,455.35,35,,455.35,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,962.74,
DEPUY 02.112.010 CLAVICLE PLT 3.5X81MM,C1713,HCPCS,,79009919,CDM,278,RC,,,both,,,2331,1724.95,,,1724.95,Other,150% of Medicare + 9.63% HCRA Surcharge,1048.95,45,,1048.95,percent of total billed charges,Critical Access Hospital RCC factor,792.54,34,,792.54,percent of total billed charges,Implant Device,792.54,34,,792.54,percent of total billed charges,Implant Device,792.54,34,,792.54,percent of total billed charges,Implant Device,792.54,34,,792.54,percent of total billed charges,Implant Device,792.54,34,,792.54,percent of total billed charges,Implant Device,1153.85,,,1153.85,Other,110% of Medicare,815.85,35,,815.85,percent of total billed charges,Implant Device,792.54,34,"Charges > $500, x 34%",792.54,percent of total billed charges,Implant Device,815.85,35,,815.85,percent of total billed charges,Implant Device,815.85,35,,815.85,percent of total billed charges,Implant Device,815.85,35,,815.85,percent of total billed charges,Implant Device,815.85,35,,815.85,percent of total billed charges,Implant Device,815.85,35,,815.85,percent of total billed charges,Implant Device,932.4,40,,932.4,percent of total billed charges,Implant Device,815.85,70,,815.85,percent of total billed charges,All Other,792.54,34,,792.54,percent of total billed charges,Implant Device,792.54,34,,792.54,percent of total billed charges,Implant Device,815.85,35,,815.85,percent of total billed charges,Implant Device,815.85,35,,815.85,percent of total billed charges,Implant Device,815.85,35,,815.85,percent of total billed charges,Implant Device,815.85,35,,815.85,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,792.54,34,"If Charge > 2,000, then 34 percent",792.54,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1724.95,
IN2BONES P60 ST021 PLANTAR PLT LRG 5H,C1713,HCPCS,,79009920,CDM,278,RC,,,both,,,5748,4253.53,,,4253.53,Other,150% of Medicare + 9.63% HCRA Surcharge,2586.6,45,,2586.6,percent of total billed charges,Critical Access Hospital RCC factor,1954.32,34,,1954.32,percent of total billed charges,Implant Device,1954.32,34,,1954.32,percent of total billed charges,Implant Device,1954.32,34,,1954.32,percent of total billed charges,Implant Device,1954.32,34,,1954.32,percent of total billed charges,Implant Device,1954.32,34,,1954.32,percent of total billed charges,Implant Device,2845.26,,,2845.26,Other,110% of Medicare,2011.8,35,,2011.8,percent of total billed charges,Implant Device,1954.32,34,"Charges > $500, x 34%",1954.32,percent of total billed charges,Implant Device,2011.8,35,,2011.8,percent of total billed charges,Implant Device,2011.8,35,,2011.8,percent of total billed charges,Implant Device,2011.8,35,,2011.8,percent of total billed charges,Implant Device,2011.8,35,,2011.8,percent of total billed charges,Implant Device,2011.8,35,,2011.8,percent of total billed charges,Implant Device,2299.2,40,,2299.2,percent of total billed charges,Implant Device,2011.8,70,,2011.8,percent of total billed charges,All Other,1954.32,34,,1954.32,percent of total billed charges,Implant Device,1954.32,34,,1954.32,percent of total billed charges,Implant Device,2011.8,35,,2011.8,percent of total billed charges,Implant Device,2011.8,35,,2011.8,percent of total billed charges,Implant Device,2011.8,35,,2011.8,percent of total billed charges,Implant Device,2011.8,35,,2011.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1954.32,34,"If Charge > 2,000, then 34 percent",1954.32,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4253.53,
STRYKER DCELL205 DERMACELL TISSUE 8X16CM,C1789,HCPCS,,79009921,CDM,278,RC,,,both,,,10500,7770.03,,,7770.03,Other,150% of Medicare + 9.63% HCRA Surcharge,4725,45,,4725,percent of total billed charges,Critical Access Hospital RCC factor,3570,34,,3570,percent of total billed charges,Implant Device,3570,34,,3570,percent of total billed charges,Implant Device,3570,34,,3570,percent of total billed charges,Implant Device,3570,34,,3570,percent of total billed charges,Implant Device,3570,34,,3570,percent of total billed charges,Implant Device,5197.5,,,5197.5,Other,110% of Medicare,3675,35,,3675,percent of total billed charges,Implant Device,3570,34,"Charges > $500, x 34%",3570,percent of total billed charges,Implant Device,3675,35,,3675,percent of total billed charges,Implant Device,3675,35,,3675,percent of total billed charges,Implant Device,3675,35,,3675,percent of total billed charges,Implant Device,3675,35,,3675,percent of total billed charges,Implant Device,3675,35,,3675,percent of total billed charges,Implant Device,4200,40,,4200,percent of total billed charges,Implant Device,3675,70,,3675,percent of total billed charges,All Other,3570,34,,3570,percent of total billed charges,Implant Device,3570,34,,3570,percent of total billed charges,Implant Device,3675,35,,3675,percent of total billed charges,Implant Device,3675,35,,3675,percent of total billed charges,Implant Device,3675,35,,3675,percent of total billed charges,Implant Device,3675,35,,3675,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3570,34,"If Charge > 2,000, then 34 percent",3570,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,7770.03,
ARTHREX AR-3602 FIBERTAK W/SUTURETAPE,C1713,HCPCS,,79009922,CDM,278,RC,,,both,,,1065,788.1,,,788.1,Other,150% of Medicare + 9.63% HCRA Surcharge,479.25,45,,479.25,percent of total billed charges,Critical Access Hospital RCC factor,362.1,34,,362.1,percent of total billed charges,Implant Device,362.1,34,,362.1,percent of total billed charges,Implant Device,362.1,34,,362.1,percent of total billed charges,Implant Device,362.1,34,,362.1,percent of total billed charges,Implant Device,362.1,34,,362.1,percent of total billed charges,Implant Device,527.18,,,527.18,Other,110% of Medicare,372.75,35,,372.75,percent of total billed charges,Implant Device,362.1,34,"Charges > $500, x 34%",362.1,percent of total billed charges,Implant Device,372.75,35,,372.75,percent of total billed charges,Implant Device,372.75,35,,372.75,percent of total billed charges,Implant Device,372.75,35,,372.75,percent of total billed charges,Implant Device,372.75,35,,372.75,percent of total billed charges,Implant Device,372.75,35,,372.75,percent of total billed charges,Implant Device,426,40,,426,percent of total billed charges,Implant Device,372.75,70,,372.75,percent of total billed charges,All Other,362.1,34,,362.1,percent of total billed charges,Implant Device,362.1,34,,362.1,percent of total billed charges,Implant Device,372.75,35,,372.75,percent of total billed charges,Implant Device,372.75,35,,372.75,percent of total billed charges,Implant Device,372.75,35,,372.75,percent of total billed charges,Implant Device,372.75,35,,372.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,788.1,
ARTHREX AR-3602-2 FIBERTAK W/SUTURETAPE,C1713,HCPCS,,79009923,CDM,278,RC,,,both,,,1110,821.4,,,821.4,Other,150% of Medicare + 9.63% HCRA Surcharge,499.5,45,,499.5,percent of total billed charges,Critical Access Hospital RCC factor,377.4,34,,377.4,percent of total billed charges,Implant Device,377.4,34,,377.4,percent of total billed charges,Implant Device,377.4,34,,377.4,percent of total billed charges,Implant Device,377.4,34,,377.4,percent of total billed charges,Implant Device,377.4,34,,377.4,percent of total billed charges,Implant Device,549.45,,,549.45,Other,110% of Medicare,388.5,35,,388.5,percent of total billed charges,Implant Device,377.4,34,"Charges > $500, x 34%",377.4,percent of total billed charges,Implant Device,388.5,35,,388.5,percent of total billed charges,Implant Device,388.5,35,,388.5,percent of total billed charges,Implant Device,388.5,35,,388.5,percent of total billed charges,Implant Device,388.5,35,,388.5,percent of total billed charges,Implant Device,388.5,35,,388.5,percent of total billed charges,Implant Device,444,40,,444,percent of total billed charges,Implant Device,388.5,70,,388.5,percent of total billed charges,All Other,377.4,34,,377.4,percent of total billed charges,Implant Device,377.4,34,,377.4,percent of total billed charges,Implant Device,388.5,35,,388.5,percent of total billed charges,Implant Device,388.5,35,,388.5,percent of total billed charges,Implant Device,388.5,35,,388.5,percent of total billed charges,Implant Device,388.5,35,,388.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,821.4,
STRYKER 5018-5-200 5X200 APEX HALF PIN,C1713,HCPCS,,79009929,CDM,278,RC,,,both,,,297,219.78,,,219.78,Other,150% of Medicare + 9.63% HCRA Surcharge,133.65,45,,133.65,percent of total billed charges,Critical Access Hospital RCC factor,100.98,34,,100.98,percent of total billed charges,Implant Device,100.98,34,,100.98,percent of total billed charges,Implant Device,100.98,34,,100.98,percent of total billed charges,Implant Device,100.98,34,,100.98,percent of total billed charges,Implant Device,100.98,34,,100.98,percent of total billed charges,Implant Device,147.02,,,147.02,Other,110% of Medicare,103.95,35,,103.95,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,103.95,35,,103.95,percent of total billed charges,Implant Device,103.95,35,,103.95,percent of total billed charges,Implant Device,103.95,35,,103.95,percent of total billed charges,Implant Device,103.95,35,,103.95,percent of total billed charges,Implant Device,103.95,35,,103.95,percent of total billed charges,Implant Device,118.8,40,,118.8,percent of total billed charges,Implant Device,103.95,70,,103.95,percent of total billed charges,All Other,100.98,34,,100.98,percent of total billed charges,Implant Device,100.98,34,,100.98,percent of total billed charges,Implant Device,103.95,35,,103.95,percent of total billed charges,Implant Device,103.95,35,,103.95,percent of total billed charges,Implant Device,103.95,35,,103.95,percent of total billed charges,Implant Device,103.95,35,,103.95,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,219.78,
STRYKER 502-11-52E ACETABULAR SHELL 52MM,C1776,HCPCS,,79009930,CDM,278,RC,,,both,,,3150,2331.01,,,2331.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1417.5,45,,1417.5,percent of total billed charges,Critical Access Hospital RCC factor,1071,34,,1071,percent of total billed charges,Implant Device,1071,34,,1071,percent of total billed charges,Implant Device,1071,34,,1071,percent of total billed charges,Implant Device,1071,34,,1071,percent of total billed charges,Implant Device,1071,34,,1071,percent of total billed charges,Implant Device,1559.25,,,1559.25,Other,110% of Medicare,1102.5,35,,1102.5,percent of total billed charges,Implant Device,1071,34,"Charges > $500, x 34%",1071,percent of total billed charges,Implant Device,1102.5,35,,1102.5,percent of total billed charges,Implant Device,1102.5,35,,1102.5,percent of total billed charges,Implant Device,1102.5,35,,1102.5,percent of total billed charges,Implant Device,1102.5,35,,1102.5,percent of total billed charges,Implant Device,1102.5,35,,1102.5,percent of total billed charges,Implant Device,1260,40,,1260,percent of total billed charges,Implant Device,1102.5,70,,1102.5,percent of total billed charges,All Other,1071,34,,1071,percent of total billed charges,Implant Device,1071,34,,1071,percent of total billed charges,Implant Device,1102.5,35,,1102.5,percent of total billed charges,Implant Device,1102.5,35,,1102.5,percent of total billed charges,Implant Device,1102.5,35,,1102.5,percent of total billed charges,Implant Device,1102.5,35,,1102.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1071,34,"If Charge > 2,000, then 34 percent",1071,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2331.01,
STRYKER 6519-1-040 FEMORAL HEAD 40MM,C1713,HCPCS,,79009931,CDM,278,RC,,,both,,,2850,2109.01,,,2109.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1282.5,45,,1282.5,percent of total billed charges,Critical Access Hospital RCC factor,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,1410.75,,,1410.75,Other,110% of Medicare,997.5,35,,997.5,percent of total billed charges,Implant Device,969,34,"Charges > $500, x 34%",969,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,1140,40,,1140,percent of total billed charges,Implant Device,997.5,70,,997.5,percent of total billed charges,All Other,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,969,34,"If Charge > 2,000, then 34 percent",969,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2109.01,
STRYKER 6519-T-100 ADAPTOR SLEEVE V40,C1776,HCPCS,,79009932,CDM,278,RC,,,both,,,150,111,,,111,Other,150% of Medicare + 9.63% HCRA Surcharge,67.5,45,,67.5,percent of total billed charges,Critical Access Hospital RCC factor,51,34,,51,percent of total billed charges,Implant Device,51,34,,51,percent of total billed charges,Implant Device,51,34,,51,percent of total billed charges,Implant Device,51,34,,51,percent of total billed charges,Implant Device,51,34,,51,percent of total billed charges,Implant Device,74.25,,,74.25,Other,110% of Medicare,52.5,35,,52.5,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,52.5,35,,52.5,percent of total billed charges,Implant Device,52.5,35,,52.5,percent of total billed charges,Implant Device,52.5,35,,52.5,percent of total billed charges,Implant Device,52.5,35,,52.5,percent of total billed charges,Implant Device,52.5,35,,52.5,percent of total billed charges,Implant Device,60,40,,60,percent of total billed charges,Implant Device,52.5,70,,52.5,percent of total billed charges,All Other,51,34,,51,percent of total billed charges,Implant Device,51,34,,51,percent of total billed charges,Implant Device,52.5,35,,52.5,percent of total billed charges,Implant Device,52.5,35,,52.5,percent of total billed charges,Implant Device,52.5,35,,52.5,percent of total billed charges,Implant Device,52.5,35,,52.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,111,
STRYKER 6721-0435 HIP STEM SZ 4 35X105MM,C1776,HCPCS,,79009933,CDM,278,RC,,,both,,,6953,5145.24,,,5145.24,Other,150% of Medicare + 9.63% HCRA Surcharge,3128.85,45,,3128.85,percent of total billed charges,Critical Access Hospital RCC factor,2364.02,34,,2364.02,percent of total billed charges,Implant Device,2364.02,34,,2364.02,percent of total billed charges,Implant Device,2364.02,34,,2364.02,percent of total billed charges,Implant Device,2364.02,34,,2364.02,percent of total billed charges,Implant Device,2364.02,34,,2364.02,percent of total billed charges,Implant Device,3441.74,,,3441.74,Other,110% of Medicare,2433.55,35,,2433.55,percent of total billed charges,Implant Device,2364.02,34,"Charges > $500, x 34%",2364.02,percent of total billed charges,Implant Device,2433.55,35,,2433.55,percent of total billed charges,Implant Device,2433.55,35,,2433.55,percent of total billed charges,Implant Device,2433.55,35,,2433.55,percent of total billed charges,Implant Device,2433.55,35,,2433.55,percent of total billed charges,Implant Device,2433.55,35,,2433.55,percent of total billed charges,Implant Device,2781.2,40,,2781.2,percent of total billed charges,Implant Device,2433.55,70,,2433.55,percent of total billed charges,All Other,2364.02,34,,2364.02,percent of total billed charges,Implant Device,2364.02,34,,2364.02,percent of total billed charges,Implant Device,2433.55,35,,2433.55,percent of total billed charges,Implant Device,2433.55,35,,2433.55,percent of total billed charges,Implant Device,2433.55,35,,2433.55,percent of total billed charges,Implant Device,2433.55,35,,2433.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2364.02,34,"If Charge > 2,000, then 34 percent",2364.02,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5145.24,
ARTHREX AR-8724V24 LOCK SCREW 2.4X24MM,C1713,HCPCS,,79009934,CDM,278,RC,,,both,,,420,310.8,,,310.8,Other,150% of Medicare + 9.63% HCRA Surcharge,189,45,,189,percent of total billed charges,Critical Access Hospital RCC factor,142.8,34,,142.8,percent of total billed charges,Implant Device,142.8,34,,142.8,percent of total billed charges,Implant Device,142.8,34,,142.8,percent of total billed charges,Implant Device,142.8,34,,142.8,percent of total billed charges,Implant Device,142.8,34,,142.8,percent of total billed charges,Implant Device,207.9,,,207.9,Other,110% of Medicare,147,35,,147,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,147,35,,147,percent of total billed charges,Implant Device,147,35,,147,percent of total billed charges,Implant Device,147,35,,147,percent of total billed charges,Implant Device,147,35,,147,percent of total billed charges,Implant Device,147,35,,147,percent of total billed charges,Implant Device,168,40,,168,percent of total billed charges,Implant Device,147,70,,147,percent of total billed charges,All Other,142.8,34,,142.8,percent of total billed charges,Implant Device,142.8,34,,142.8,percent of total billed charges,Implant Device,147,35,,147,percent of total billed charges,Implant Device,147,35,,147,percent of total billed charges,Implant Device,147,35,,147,percent of total billed charges,Implant Device,147,35,,147,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,310.8,
ARTHREX AR-8735-12 CORT SCREW 3.5X12MM,C1713,HCPCS,,79009935,CDM,278,RC,,,both,,,180,133.2,,,133.2,Other,150% of Medicare + 9.63% HCRA Surcharge,81,45,,81,percent of total billed charges,Critical Access Hospital RCC factor,61.2,34,,61.2,percent of total billed charges,Implant Device,61.2,34,,61.2,percent of total billed charges,Implant Device,61.2,34,,61.2,percent of total billed charges,Implant Device,61.2,34,,61.2,percent of total billed charges,Implant Device,61.2,34,,61.2,percent of total billed charges,Implant Device,89.1,,,89.1,Other,110% of Medicare,63,35,,63,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,63,35,,63,percent of total billed charges,Implant Device,63,35,,63,percent of total billed charges,Implant Device,63,35,,63,percent of total billed charges,Implant Device,63,35,,63,percent of total billed charges,Implant Device,63,35,,63,percent of total billed charges,Implant Device,72,40,,72,percent of total billed charges,Implant Device,63,70,,63,percent of total billed charges,All Other,61.2,34,,61.2,percent of total billed charges,Implant Device,61.2,34,,61.2,percent of total billed charges,Implant Device,63,35,,63,percent of total billed charges,Implant Device,63,35,,63,percent of total billed charges,Implant Device,63,35,,63,percent of total billed charges,Implant Device,63,35,,63,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,133.2,
ARTHREX AR-8735-13 CORT SCREW 3.5X13MM,C1713,HCPCS,,79009936,CDM,278,RC,,,both,,,180,133.2,,,133.2,Other,150% of Medicare + 9.63% HCRA Surcharge,81,45,,81,percent of total billed charges,Critical Access Hospital RCC factor,61.2,34,,61.2,percent of total billed charges,Implant Device,61.2,34,,61.2,percent of total billed charges,Implant Device,61.2,34,,61.2,percent of total billed charges,Implant Device,61.2,34,,61.2,percent of total billed charges,Implant Device,61.2,34,,61.2,percent of total billed charges,Implant Device,89.1,,,89.1,Other,110% of Medicare,63,35,,63,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,63,35,,63,percent of total billed charges,Implant Device,63,35,,63,percent of total billed charges,Implant Device,63,35,,63,percent of total billed charges,Implant Device,63,35,,63,percent of total billed charges,Implant Device,63,35,,63,percent of total billed charges,Implant Device,72,40,,72,percent of total billed charges,Implant Device,63,70,,63,percent of total billed charges,All Other,61.2,34,,61.2,percent of total billed charges,Implant Device,61.2,34,,61.2,percent of total billed charges,Implant Device,63,35,,63,percent of total billed charges,Implant Device,63,35,,63,percent of total billed charges,Implant Device,63,35,,63,percent of total billed charges,Implant Device,63,35,,63,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,133.2,
ARTHREX AR-8735-14 CORT SCREW 3.5X14MM,C1713,HCPCS,,79009937,CDM,278,RC,,,both,,,180,133.2,,,133.2,Other,150% of Medicare + 9.63% HCRA Surcharge,81,45,,81,percent of total billed charges,Critical Access Hospital RCC factor,61.2,34,,61.2,percent of total billed charges,Implant Device,61.2,34,,61.2,percent of total billed charges,Implant Device,61.2,34,,61.2,percent of total billed charges,Implant Device,61.2,34,,61.2,percent of total billed charges,Implant Device,61.2,34,,61.2,percent of total billed charges,Implant Device,89.1,,,89.1,Other,110% of Medicare,63,35,,63,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,63,35,,63,percent of total billed charges,Implant Device,63,35,,63,percent of total billed charges,Implant Device,63,35,,63,percent of total billed charges,Implant Device,63,35,,63,percent of total billed charges,Implant Device,63,35,,63,percent of total billed charges,Implant Device,72,40,,72,percent of total billed charges,Implant Device,63,70,,63,percent of total billed charges,All Other,61.2,34,,61.2,percent of total billed charges,Implant Device,61.2,34,,61.2,percent of total billed charges,Implant Device,63,35,,63,percent of total billed charges,Implant Device,63,35,,63,percent of total billed charges,Implant Device,63,35,,63,percent of total billed charges,Implant Device,63,35,,63,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,133.2,
ARTHREX AR-8735-16 CORT SCREW 3.5X16MM,C1713,HCPCS,,79009938,CDM,278,RC,,,both,,,180,133.2,,,133.2,Other,150% of Medicare + 9.63% HCRA Surcharge,81,45,,81,percent of total billed charges,Critical Access Hospital RCC factor,61.2,34,,61.2,percent of total billed charges,Implant Device,61.2,34,,61.2,percent of total billed charges,Implant Device,61.2,34,,61.2,percent of total billed charges,Implant Device,61.2,34,,61.2,percent of total billed charges,Implant Device,61.2,34,,61.2,percent of total billed charges,Implant Device,89.1,,,89.1,Other,110% of Medicare,63,35,,63,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,63,35,,63,percent of total billed charges,Implant Device,63,35,,63,percent of total billed charges,Implant Device,63,35,,63,percent of total billed charges,Implant Device,63,35,,63,percent of total billed charges,Implant Device,63,35,,63,percent of total billed charges,Implant Device,72,40,,72,percent of total billed charges,Implant Device,63,70,,63,percent of total billed charges,All Other,61.2,34,,61.2,percent of total billed charges,Implant Device,61.2,34,,61.2,percent of total billed charges,Implant Device,63,35,,63,percent of total billed charges,Implant Device,63,35,,63,percent of total billed charges,Implant Device,63,35,,63,percent of total billed charges,Implant Device,63,35,,63,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,133.2,
ARTHREX AR-8916VNL-03 DISTAL RADIUS PLT,C1713,HCPCS,,79009939,CDM,278,RC,,,both,,,2385,1764.91,,,1764.91,Other,150% of Medicare + 9.63% HCRA Surcharge,1073.25,45,,1073.25,percent of total billed charges,Critical Access Hospital RCC factor,810.9,34,,810.9,percent of total billed charges,Implant Device,810.9,34,,810.9,percent of total billed charges,Implant Device,810.9,34,,810.9,percent of total billed charges,Implant Device,810.9,34,,810.9,percent of total billed charges,Implant Device,810.9,34,,810.9,percent of total billed charges,Implant Device,1180.58,,,1180.58,Other,110% of Medicare,834.75,35,,834.75,percent of total billed charges,Implant Device,810.9,34,"Charges > $500, x 34%",810.9,percent of total billed charges,Implant Device,834.75,35,,834.75,percent of total billed charges,Implant Device,834.75,35,,834.75,percent of total billed charges,Implant Device,834.75,35,,834.75,percent of total billed charges,Implant Device,834.75,35,,834.75,percent of total billed charges,Implant Device,834.75,35,,834.75,percent of total billed charges,Implant Device,954,40,,954,percent of total billed charges,Implant Device,834.75,70,,834.75,percent of total billed charges,All Other,810.9,34,,810.9,percent of total billed charges,Implant Device,810.9,34,,810.9,percent of total billed charges,Implant Device,834.75,35,,834.75,percent of total billed charges,Implant Device,834.75,35,,834.75,percent of total billed charges,Implant Device,834.75,35,,834.75,percent of total billed charges,Implant Device,834.75,35,,834.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,810.9,34,"If Charge > 2,000, then 34 percent",810.9,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1764.91,
ZIMMER 00-7711-007-20 FEM STEM SIZE 7.5,C1776,HCPCS,,79009941,CDM,278,RC,,,both,,,6900,5106.02,,,5106.02,Other,150% of Medicare + 9.63% HCRA Surcharge,3105,45,,3105,percent of total billed charges,Critical Access Hospital RCC factor,2346,34,,2346,percent of total billed charges,Implant Device,2346,34,,2346,percent of total billed charges,Implant Device,2346,34,,2346,percent of total billed charges,Implant Device,2346,34,,2346,percent of total billed charges,Implant Device,2346,34,,2346,percent of total billed charges,Implant Device,3415.5,,,3415.5,Other,110% of Medicare,2415,35,,2415,percent of total billed charges,Implant Device,2346,34,"Charges > $500, x 34%",2346,percent of total billed charges,Implant Device,2415,35,,2415,percent of total billed charges,Implant Device,2415,35,,2415,percent of total billed charges,Implant Device,2415,35,,2415,percent of total billed charges,Implant Device,2415,35,,2415,percent of total billed charges,Implant Device,2415,35,,2415,percent of total billed charges,Implant Device,2760,40,,2760,percent of total billed charges,Implant Device,2415,70,,2415,percent of total billed charges,All Other,2346,34,,2346,percent of total billed charges,Implant Device,2346,34,,2346,percent of total billed charges,Implant Device,2415,35,,2415,percent of total billed charges,Implant Device,2415,35,,2415,percent of total billed charges,Implant Device,2415,35,,2415,percent of total billed charges,Implant Device,2415,35,,2415,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2346,34,"If Charge > 2,000, then 34 percent",2346,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5106.02,
ZIMMER 110035368 BONE CEMENT R,C1713,HCPCS,,79009942,CDM,278,RC,,,both,,,210,155.4,,,155.4,Other,150% of Medicare + 9.63% HCRA Surcharge,94.5,45,,94.5,percent of total billed charges,Critical Access Hospital RCC factor,71.4,34,,71.4,percent of total billed charges,Implant Device,71.4,34,,71.4,percent of total billed charges,Implant Device,71.4,34,,71.4,percent of total billed charges,Implant Device,71.4,34,,71.4,percent of total billed charges,Implant Device,71.4,34,,71.4,percent of total billed charges,Implant Device,103.95,,,103.95,Other,110% of Medicare,73.5,35,,73.5,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,73.5,35,,73.5,percent of total billed charges,Implant Device,73.5,35,,73.5,percent of total billed charges,Implant Device,73.5,35,,73.5,percent of total billed charges,Implant Device,73.5,35,,73.5,percent of total billed charges,Implant Device,73.5,35,,73.5,percent of total billed charges,Implant Device,84,40,,84,percent of total billed charges,Implant Device,73.5,70,,73.5,percent of total billed charges,All Other,71.4,34,,71.4,percent of total billed charges,Implant Device,71.4,34,,71.4,percent of total billed charges,Implant Device,73.5,35,,73.5,percent of total billed charges,Implant Device,73.5,35,,73.5,percent of total billed charges,Implant Device,73.5,35,,73.5,percent of total billed charges,Implant Device,73.5,35,,73.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,155.4,
ZIMMER 110034355 BONE CEMENT W/GENTAMICN,C1713,HCPCS,,79009943,CDM,278,RC,,,both,,,825,610.5,,,610.5,Other,150% of Medicare + 9.63% HCRA Surcharge,371.25,45,,371.25,percent of total billed charges,Critical Access Hospital RCC factor,280.5,34,,280.5,percent of total billed charges,Implant Device,280.5,34,,280.5,percent of total billed charges,Implant Device,280.5,34,,280.5,percent of total billed charges,Implant Device,280.5,34,,280.5,percent of total billed charges,Implant Device,280.5,34,,280.5,percent of total billed charges,Implant Device,408.38,,,408.38,Other,110% of Medicare,288.75,35,,288.75,percent of total billed charges,Implant Device,280.5,34,"Charges > $500, x 34%",280.5,percent of total billed charges,Implant Device,288.75,35,,288.75,percent of total billed charges,Implant Device,288.75,35,,288.75,percent of total billed charges,Implant Device,288.75,35,,288.75,percent of total billed charges,Implant Device,288.75,35,,288.75,percent of total billed charges,Implant Device,288.75,35,,288.75,percent of total billed charges,Implant Device,330,40,,330,percent of total billed charges,Implant Device,288.75,70,,288.75,percent of total billed charges,All Other,280.5,34,,280.5,percent of total billed charges,Implant Device,280.5,34,,280.5,percent of total billed charges,Implant Device,288.75,35,,288.75,percent of total billed charges,Implant Device,288.75,35,,288.75,percent of total billed charges,Implant Device,288.75,35,,288.75,percent of total billed charges,Implant Device,288.75,35,,288.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,610.5,
MTF HP1412 FLEX HD PLIABLE ACELL DERMIS,C1713,HCPCS,,79009944,CDM,278,RC,,,both,,,3517,2602.59,,,2602.59,Other,150% of Medicare + 9.63% HCRA Surcharge,1582.65,45,,1582.65,percent of total billed charges,Critical Access Hospital RCC factor,1195.78,34,,1195.78,percent of total billed charges,Implant Device,1195.78,34,,1195.78,percent of total billed charges,Implant Device,1195.78,34,,1195.78,percent of total billed charges,Implant Device,1195.78,34,,1195.78,percent of total billed charges,Implant Device,1195.78,34,,1195.78,percent of total billed charges,Implant Device,1740.92,,,1740.92,Other,110% of Medicare,1230.95,35,,1230.95,percent of total billed charges,Implant Device,1195.78,34,"Charges > $500, x 34%",1195.78,percent of total billed charges,Implant Device,1230.95,35,,1230.95,percent of total billed charges,Implant Device,1230.95,35,,1230.95,percent of total billed charges,Implant Device,1230.95,35,,1230.95,percent of total billed charges,Implant Device,1230.95,35,,1230.95,percent of total billed charges,Implant Device,1230.95,35,,1230.95,percent of total billed charges,Implant Device,1406.8,40,,1406.8,percent of total billed charges,Implant Device,1230.95,70,,1230.95,percent of total billed charges,All Other,1195.78,34,,1195.78,percent of total billed charges,Implant Device,1195.78,34,,1195.78,percent of total billed charges,Implant Device,1230.95,35,,1230.95,percent of total billed charges,Implant Device,1230.95,35,,1230.95,percent of total billed charges,Implant Device,1230.95,35,,1230.95,percent of total billed charges,Implant Device,1230.95,35,,1230.95,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1195.78,34,"If Charge > 2,000, then 34 percent",1195.78,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2602.59,
MTF HP 1816 FLEX PLIABLE ACELL DERMIS,C1713,HCPCS,,79009945,CDM,278,RC,,,both,,,9868,7302.34,,,7302.34,Other,150% of Medicare + 9.63% HCRA Surcharge,4440.6,45,,4440.6,percent of total billed charges,Critical Access Hospital RCC factor,3355.12,34,,3355.12,percent of total billed charges,Implant Device,3355.12,34,,3355.12,percent of total billed charges,Implant Device,3355.12,34,,3355.12,percent of total billed charges,Implant Device,3355.12,34,,3355.12,percent of total billed charges,Implant Device,3355.12,34,,3355.12,percent of total billed charges,Implant Device,4884.66,,,4884.66,Other,110% of Medicare,3453.8,35,,3453.8,percent of total billed charges,Implant Device,3355.12,34,"Charges > $500, x 34%",3355.12,percent of total billed charges,Implant Device,3453.8,35,,3453.8,percent of total billed charges,Implant Device,3453.8,35,,3453.8,percent of total billed charges,Implant Device,3453.8,35,,3453.8,percent of total billed charges,Implant Device,3453.8,35,,3453.8,percent of total billed charges,Implant Device,3453.8,35,,3453.8,percent of total billed charges,Implant Device,3947.2,40,,3947.2,percent of total billed charges,Implant Device,3453.8,70,,3453.8,percent of total billed charges,All Other,3355.12,34,,3355.12,percent of total billed charges,Implant Device,3355.12,34,,3355.12,percent of total billed charges,Implant Device,3453.8,35,,3453.8,percent of total billed charges,Implant Device,3453.8,35,,3453.8,percent of total billed charges,Implant Device,3453.8,35,,3453.8,percent of total billed charges,Implant Device,3453.8,35,,3453.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3355.12,34,"If Charge > 2,000, then 34 percent",3355.12,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,7302.34,
MENTOR 350-9111 BREAST TISSUE EXPANDER,C1789,HCPCS,,79009946,CDM,278,RC,,,both,,,5475,4051.51,,,4051.51,Other,150% of Medicare + 9.63% HCRA Surcharge,2463.75,45,,2463.75,percent of total billed charges,Critical Access Hospital RCC factor,1861.5,34,,1861.5,percent of total billed charges,Implant Device,1861.5,34,,1861.5,percent of total billed charges,Implant Device,1861.5,34,,1861.5,percent of total billed charges,Implant Device,1861.5,34,,1861.5,percent of total billed charges,Implant Device,1861.5,34,,1861.5,percent of total billed charges,Implant Device,2710.13,,,2710.13,Other,110% of Medicare,1916.25,35,,1916.25,percent of total billed charges,Implant Device,1861.5,34,"Charges > $500, x 34%",1861.5,percent of total billed charges,Implant Device,1916.25,35,,1916.25,percent of total billed charges,Implant Device,1916.25,35,,1916.25,percent of total billed charges,Implant Device,1916.25,35,,1916.25,percent of total billed charges,Implant Device,1916.25,35,,1916.25,percent of total billed charges,Implant Device,1916.25,35,,1916.25,percent of total billed charges,Implant Device,2190,40,,2190,percent of total billed charges,Implant Device,1916.25,70,,1916.25,percent of total billed charges,All Other,1861.5,34,,1861.5,percent of total billed charges,Implant Device,1861.5,34,,1861.5,percent of total billed charges,Implant Device,1916.25,35,,1916.25,percent of total billed charges,Implant Device,1916.25,35,,1916.25,percent of total billed charges,Implant Device,1916.25,35,,1916.25,percent of total billed charges,Implant Device,1916.25,35,,1916.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1861.5,34,"If Charge > 2,000, then 34 percent",1861.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4051.51,
MENTOR 350-9112 BREAST TISSUE EXPANDER,C1789,HCPCS,,79009947,CDM,278,RC,,,both,,,5475,4051.51,,,4051.51,Other,150% of Medicare + 9.63% HCRA Surcharge,2463.75,45,,2463.75,percent of total billed charges,Critical Access Hospital RCC factor,1861.5,34,,1861.5,percent of total billed charges,Implant Device,1861.5,34,,1861.5,percent of total billed charges,Implant Device,1861.5,34,,1861.5,percent of total billed charges,Implant Device,1861.5,34,,1861.5,percent of total billed charges,Implant Device,1861.5,34,,1861.5,percent of total billed charges,Implant Device,2710.13,,,2710.13,Other,110% of Medicare,1916.25,35,,1916.25,percent of total billed charges,Implant Device,1861.5,34,"Charges > $500, x 34%",1861.5,percent of total billed charges,Implant Device,1916.25,35,,1916.25,percent of total billed charges,Implant Device,1916.25,35,,1916.25,percent of total billed charges,Implant Device,1916.25,35,,1916.25,percent of total billed charges,Implant Device,1916.25,35,,1916.25,percent of total billed charges,Implant Device,1916.25,35,,1916.25,percent of total billed charges,Implant Device,2190,40,,2190,percent of total billed charges,Implant Device,1916.25,70,,1916.25,percent of total billed charges,All Other,1861.5,34,,1861.5,percent of total billed charges,Implant Device,1861.5,34,,1861.5,percent of total billed charges,Implant Device,1916.25,35,,1916.25,percent of total billed charges,Implant Device,1916.25,35,,1916.25,percent of total billed charges,Implant Device,1916.25,35,,1916.25,percent of total billed charges,Implant Device,1916.25,35,,1916.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1861.5,34,"If Charge > 2,000, then 34 percent",1861.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4051.51,
MENTOR 350-7275MC GEL IMPLANT 275CC,C1789,HCPCS,,79009948,CDM,278,RC,,,both,,,2790,2064.61,,,2064.61,Other,150% of Medicare + 9.63% HCRA Surcharge,1255.5,45,,1255.5,percent of total billed charges,Critical Access Hospital RCC factor,948.6,34,,948.6,percent of total billed charges,Implant Device,948.6,34,,948.6,percent of total billed charges,Implant Device,948.6,34,,948.6,percent of total billed charges,Implant Device,948.6,34,,948.6,percent of total billed charges,Implant Device,948.6,34,,948.6,percent of total billed charges,Implant Device,1381.05,,,1381.05,Other,110% of Medicare,976.5,35,,976.5,percent of total billed charges,Implant Device,948.6,34,"Charges > $500, x 34%",948.6,percent of total billed charges,Implant Device,976.5,35,,976.5,percent of total billed charges,Implant Device,976.5,35,,976.5,percent of total billed charges,Implant Device,976.5,35,,976.5,percent of total billed charges,Implant Device,976.5,35,,976.5,percent of total billed charges,Implant Device,976.5,35,,976.5,percent of total billed charges,Implant Device,1116,40,,1116,percent of total billed charges,Implant Device,976.5,70,,976.5,percent of total billed charges,All Other,948.6,34,,948.6,percent of total billed charges,Implant Device,948.6,34,,948.6,percent of total billed charges,Implant Device,976.5,35,,976.5,percent of total billed charges,Implant Device,976.5,35,,976.5,percent of total billed charges,Implant Device,976.5,35,,976.5,percent of total billed charges,Implant Device,976.5,35,,976.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,948.6,34,"If Charge > 2,000, then 34 percent",948.6,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2064.61,
ALLERGAN SCLP-300 BREAST IMPLANT 300CC,C1789,HCPCS,,79009950,CDM,278,RC,,,both,,,4005,2963.71,,,2963.71,Other,150% of Medicare + 9.63% HCRA Surcharge,1802.25,45,,1802.25,percent of total billed charges,Critical Access Hospital RCC factor,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1982.48,,,1982.48,Other,110% of Medicare,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1361.7,34,"Charges > $500, x 34%",1361.7,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1602,40,,1602,percent of total billed charges,Implant Device,1401.75,70,,1401.75,percent of total billed charges,All Other,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1361.7,34,"If Charge > 2,000, then 34 percent",1361.7,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2963.71,
ALLERGAN SCL-230 BREAST IMPLANT 230CC,C1789,HCPCS,,79009952,CDM,278,RC,,,both,,,4005,2963.71,,,2963.71,Other,150% of Medicare + 9.63% HCRA Surcharge,1802.25,45,,1802.25,percent of total billed charges,Critical Access Hospital RCC factor,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1982.48,,,1982.48,Other,110% of Medicare,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1361.7,34,"Charges > $500, x 34%",1361.7,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1602,40,,1602,percent of total billed charges,Implant Device,1401.75,70,,1401.75,percent of total billed charges,All Other,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1361.7,34,"If Charge > 2,000, then 34 percent",1361.7,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2963.71,
ALLERGAN SCL-260 BREAST IMPLANT 260CC,C1789,HCPCS,,79009953,CDM,278,RC,,,both,,,4005,2963.71,,,2963.71,Other,150% of Medicare + 9.63% HCRA Surcharge,1802.25,45,,1802.25,percent of total billed charges,Critical Access Hospital RCC factor,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1982.48,,,1982.48,Other,110% of Medicare,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1361.7,34,"Charges > $500, x 34%",1361.7,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1602,40,,1602,percent of total billed charges,Implant Device,1401.75,70,,1401.75,percent of total billed charges,All Other,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1361.7,34,"If Charge > 2,000, then 34 percent",1361.7,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2963.71,
ZIMMER 8145-11-180 HIP FRAC NAIL 11X180,C1713,HCPCS,,79009956,CDM,278,RC,,,both,,,4464,3303.37,,,3303.37,Other,150% of Medicare + 9.63% HCRA Surcharge,2008.8,45,,2008.8,percent of total billed charges,Critical Access Hospital RCC factor,1517.76,34,,1517.76,percent of total billed charges,Implant Device,1517.76,34,,1517.76,percent of total billed charges,Implant Device,1517.76,34,,1517.76,percent of total billed charges,Implant Device,1517.76,34,,1517.76,percent of total billed charges,Implant Device,1517.76,34,,1517.76,percent of total billed charges,Implant Device,2209.68,,,2209.68,Other,110% of Medicare,1562.4,35,,1562.4,percent of total billed charges,Implant Device,1517.76,34,"Charges > $500, x 34%",1517.76,percent of total billed charges,Implant Device,1562.4,35,,1562.4,percent of total billed charges,Implant Device,1562.4,35,,1562.4,percent of total billed charges,Implant Device,1562.4,35,,1562.4,percent of total billed charges,Implant Device,1562.4,35,,1562.4,percent of total billed charges,Implant Device,1562.4,35,,1562.4,percent of total billed charges,Implant Device,1785.6,40,,1785.6,percent of total billed charges,Implant Device,1562.4,70,,1562.4,percent of total billed charges,All Other,1517.76,34,,1517.76,percent of total billed charges,Implant Device,1517.76,34,,1517.76,percent of total billed charges,Implant Device,1562.4,35,,1562.4,percent of total billed charges,Implant Device,1562.4,35,,1562.4,percent of total billed charges,Implant Device,1562.4,35,,1562.4,percent of total billed charges,Implant Device,1562.4,35,,1562.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1517.76,34,"If Charge > 2,000, then 34 percent",1517.76,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3303.37,
IN2BONES P73 ST220 VAL SCREW 3.5X20MM,C1713,HCPCS,,79009960,CDM,278,RC,,,both,,,870,643.8,,,643.8,Other,150% of Medicare + 9.63% HCRA Surcharge,391.5,45,,391.5,percent of total billed charges,Critical Access Hospital RCC factor,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,430.65,,,430.65,Other,110% of Medicare,304.5,35,,304.5,percent of total billed charges,Implant Device,295.8,34,"Charges > $500, x 34%",295.8,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,348,40,,348,percent of total billed charges,Implant Device,304.5,70,,304.5,percent of total billed charges,All Other,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,643.8,
IN2BONES V35 ST220 NON LOCK SCREW 3.5X20,C1713,HCPCS,,79009961,CDM,278,RC,,,both,,,612,452.88,,,452.88,Other,150% of Medicare + 9.63% HCRA Surcharge,275.4,45,,275.4,percent of total billed charges,Critical Access Hospital RCC factor,208.08,34,,208.08,percent of total billed charges,Implant Device,208.08,34,,208.08,percent of total billed charges,Implant Device,208.08,34,,208.08,percent of total billed charges,Implant Device,208.08,34,,208.08,percent of total billed charges,Implant Device,208.08,34,,208.08,percent of total billed charges,Implant Device,302.94,,,302.94,Other,110% of Medicare,214.2,35,,214.2,percent of total billed charges,Implant Device,208.08,34,"Charges > $500, x 34%",208.08,percent of total billed charges,Implant Device,214.2,35,,214.2,percent of total billed charges,Implant Device,214.2,35,,214.2,percent of total billed charges,Implant Device,214.2,35,,214.2,percent of total billed charges,Implant Device,214.2,35,,214.2,percent of total billed charges,Implant Device,214.2,35,,214.2,percent of total billed charges,Implant Device,244.8,40,,244.8,percent of total billed charges,Implant Device,214.2,70,,214.2,percent of total billed charges,All Other,208.08,34,,208.08,percent of total billed charges,Implant Device,208.08,34,,208.08,percent of total billed charges,Implant Device,214.2,35,,214.2,percent of total billed charges,Implant Device,214.2,35,,214.2,percent of total billed charges,Implant Device,214.2,35,,214.2,percent of total billed charges,Implant Device,214.2,35,,214.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,452.88,
IN2BONES P72 ST018 NON LOCK SCREW 2.7X18,C1713,HCPCS,,79009962,CDM,278,RC,,,both,,,870,643.8,,,643.8,Other,150% of Medicare + 9.63% HCRA Surcharge,391.5,45,,391.5,percent of total billed charges,Critical Access Hospital RCC factor,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,430.65,,,430.65,Other,110% of Medicare,304.5,35,,304.5,percent of total billed charges,Implant Device,295.8,34,"Charges > $500, x 34%",295.8,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,348,40,,348,percent of total billed charges,Implant Device,304.5,70,,304.5,percent of total billed charges,All Other,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,643.8,
IN2BONES P72 ST112 LOCK SCREW 2.7X12MM,C1713,HCPCS,,79009963,CDM,278,RC,,,both,,,870,643.8,,,643.8,Other,150% of Medicare + 9.63% HCRA Surcharge,391.5,45,,391.5,percent of total billed charges,Critical Access Hospital RCC factor,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,430.65,,,430.65,Other,110% of Medicare,304.5,35,,304.5,percent of total billed charges,Implant Device,295.8,34,"Charges > $500, x 34%",295.8,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,348,40,,348,percent of total billed charges,Implant Device,304.5,70,,304.5,percent of total billed charges,All Other,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,643.8,
IN2BONES P70 ST105 LAT FIB PLT 5 HOLE RT,C1713,HCPCS,,79009964,CDM,278,RC,,,both,,,6000,4440.02,,,4440.02,Other,150% of Medicare + 9.63% HCRA Surcharge,2700,45,,2700,percent of total billed charges,Critical Access Hospital RCC factor,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2970,,,2970,Other,110% of Medicare,2100,35,,2100,percent of total billed charges,Implant Device,2040,34,"Charges > $500, x 34%",2040,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2400,40,,2400,percent of total billed charges,Implant Device,2100,70,,2100,percent of total billed charges,All Other,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2040,34,"If Charge > 2,000, then 34 percent",2040,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4440.02,
IN2BONES P73 ST214 VAL SCREW 3.5MM,C1713,HCPCS,,79009965,CDM,278,RC,,,both,,,870,643.8,,,643.8,Other,150% of Medicare + 9.63% HCRA Surcharge,391.5,45,,391.5,percent of total billed charges,Critical Access Hospital RCC factor,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,430.65,,,430.65,Other,110% of Medicare,304.5,35,,304.5,percent of total billed charges,Implant Device,295.8,34,"Charges > $500, x 34%",295.8,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,348,40,,348,percent of total billed charges,Implant Device,304.5,70,,304.5,percent of total billed charges,All Other,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,643.8,
IN2BONES P72 ST116 LOCK SCREW 2.7X16MM,C1713,HCPCS,,79009966,CDM,278,RC,,,both,,,870,643.8,,,643.8,Other,150% of Medicare + 9.63% HCRA Surcharge,391.5,45,,391.5,percent of total billed charges,Critical Access Hospital RCC factor,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,430.65,,,430.65,Other,110% of Medicare,304.5,35,,304.5,percent of total billed charges,Implant Device,295.8,34,"Charges > $500, x 34%",295.8,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,348,40,,348,percent of total billed charges,Implant Device,304.5,70,,304.5,percent of total billed charges,All Other,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,643.8,
IN2BONES P73 ST214 VAL SCREW 3.5X14MM,C1713,HCPCS,,79009967,CDM,278,RC,,,both,,,870,643.8,,,643.8,Other,150% of Medicare + 9.63% HCRA Surcharge,391.5,45,,391.5,percent of total billed charges,Critical Access Hospital RCC factor,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,430.65,,,430.65,Other,110% of Medicare,304.5,35,,304.5,percent of total billed charges,Implant Device,295.8,34,"Charges > $500, x 34%",295.8,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,348,40,,348,percent of total billed charges,Implant Device,304.5,70,,304.5,percent of total billed charges,All Other,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,643.8,
IN2BONES P72 ST120 LOCK SCREW 2.7X20MM,C1713,HCPCS,,79009968,CDM,278,RC,,,both,,,870,643.8,,,643.8,Other,150% of Medicare + 9.63% HCRA Surcharge,391.5,45,,391.5,percent of total billed charges,Critical Access Hospital RCC factor,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,430.65,,,430.65,Other,110% of Medicare,304.5,35,,304.5,percent of total billed charges,Implant Device,295.8,34,"Charges > $500, x 34%",295.8,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,348,40,,348,percent of total billed charges,Implant Device,304.5,70,,304.5,percent of total billed charges,All Other,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,643.8,
IN2BONES P72 ST114 LOCK SCREW 2.7X14MM,C1713,HCPCS,,79009969,CDM,278,RC,,,both,,,870,643.8,,,643.8,Other,150% of Medicare + 9.63% HCRA Surcharge,391.5,45,,391.5,percent of total billed charges,Critical Access Hospital RCC factor,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,430.65,,,430.65,Other,110% of Medicare,304.5,35,,304.5,percent of total billed charges,Implant Device,295.8,34,"Charges > $500, x 34%",295.8,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,348,40,,348,percent of total billed charges,Implant Device,304.5,70,,304.5,percent of total billed charges,All Other,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,643.8,
ARTHREX AR-8990ST FIBERTAK SUTURE ANCHOR,C1713,HCPCS,,79009970,CDM,278,RC,,,both,,,1395,1032.3,,,1032.3,Other,150% of Medicare + 9.63% HCRA Surcharge,627.75,45,,627.75,percent of total billed charges,Critical Access Hospital RCC factor,474.3,34,,474.3,percent of total billed charges,Implant Device,474.3,34,,474.3,percent of total billed charges,Implant Device,474.3,34,,474.3,percent of total billed charges,Implant Device,474.3,34,,474.3,percent of total billed charges,Implant Device,474.3,34,,474.3,percent of total billed charges,Implant Device,690.53,,,690.53,Other,110% of Medicare,488.25,35,,488.25,percent of total billed charges,Implant Device,474.3,34,"Charges > $500, x 34%",474.3,percent of total billed charges,Implant Device,488.25,35,,488.25,percent of total billed charges,Implant Device,488.25,35,,488.25,percent of total billed charges,Implant Device,488.25,35,,488.25,percent of total billed charges,Implant Device,488.25,35,,488.25,percent of total billed charges,Implant Device,488.25,35,,488.25,percent of total billed charges,Implant Device,558,40,,558,percent of total billed charges,Implant Device,488.25,70,,488.25,percent of total billed charges,All Other,474.3,34,,474.3,percent of total billed charges,Implant Device,474.3,34,,474.3,percent of total billed charges,Implant Device,488.25,35,,488.25,percent of total billed charges,Implant Device,488.25,35,,488.25,percent of total billed charges,Implant Device,488.25,35,,488.25,percent of total billed charges,Implant Device,488.25,35,,488.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1032.3,
ARTHREX AR-3632 FIBERTAK ANCHOR 2.6MM,C1713,HCPCS,,79009972,CDM,278,RC,,,both,,,1110,821.4,,,821.4,Other,150% of Medicare + 9.63% HCRA Surcharge,499.5,45,,499.5,percent of total billed charges,Critical Access Hospital RCC factor,377.4,34,,377.4,percent of total billed charges,Implant Device,377.4,34,,377.4,percent of total billed charges,Implant Device,377.4,34,,377.4,percent of total billed charges,Implant Device,377.4,34,,377.4,percent of total billed charges,Implant Device,377.4,34,,377.4,percent of total billed charges,Implant Device,549.45,,,549.45,Other,110% of Medicare,388.5,35,,388.5,percent of total billed charges,Implant Device,377.4,34,"Charges > $500, x 34%",377.4,percent of total billed charges,Implant Device,388.5,35,,388.5,percent of total billed charges,Implant Device,388.5,35,,388.5,percent of total billed charges,Implant Device,388.5,35,,388.5,percent of total billed charges,Implant Device,388.5,35,,388.5,percent of total billed charges,Implant Device,388.5,35,,388.5,percent of total billed charges,Implant Device,444,40,,444,percent of total billed charges,Implant Device,388.5,70,,388.5,percent of total billed charges,All Other,377.4,34,,377.4,percent of total billed charges,Implant Device,377.4,34,,377.4,percent of total billed charges,Implant Device,388.5,35,,388.5,percent of total billed charges,Implant Device,388.5,35,,388.5,percent of total billed charges,Implant Device,388.5,35,,388.5,percent of total billed charges,Implant Device,388.5,35,,388.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,821.4,
ARTHREX AR-8925T TIGHTROPE TITANIUM,C1713,HCPCS,,79009975,CDM,278,RC,,,both,,,4485,3318.91,,,3318.91,Other,150% of Medicare + 9.63% HCRA Surcharge,2018.25,45,,2018.25,percent of total billed charges,Critical Access Hospital RCC factor,1524.9,34,,1524.9,percent of total billed charges,Implant Device,1524.9,34,,1524.9,percent of total billed charges,Implant Device,1524.9,34,,1524.9,percent of total billed charges,Implant Device,1524.9,34,,1524.9,percent of total billed charges,Implant Device,1524.9,34,,1524.9,percent of total billed charges,Implant Device,2220.08,,,2220.08,Other,110% of Medicare,1569.75,35,,1569.75,percent of total billed charges,Implant Device,1524.9,34,"Charges > $500, x 34%",1524.9,percent of total billed charges,Implant Device,1569.75,35,,1569.75,percent of total billed charges,Implant Device,1569.75,35,,1569.75,percent of total billed charges,Implant Device,1569.75,35,,1569.75,percent of total billed charges,Implant Device,1569.75,35,,1569.75,percent of total billed charges,Implant Device,1569.75,35,,1569.75,percent of total billed charges,Implant Device,1794,40,,1794,percent of total billed charges,Implant Device,1569.75,70,,1569.75,percent of total billed charges,All Other,1524.9,34,,1524.9,percent of total billed charges,Implant Device,1524.9,34,,1524.9,percent of total billed charges,Implant Device,1569.75,35,,1569.75,percent of total billed charges,Implant Device,1569.75,35,,1569.75,percent of total billed charges,Implant Device,1569.75,35,,1569.75,percent of total billed charges,Implant Device,1569.75,35,,1569.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1524.9,34,"If Charge > 2,000, then 34 percent",1524.9,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3318.91,
DEPUY 1960-40-450 FEM POST STABLZD SZ 4N,C1776,HCPCS,,79009976,CDM,278,RC,,,both,,,8580,6349.22,,,6349.22,Other,150% of Medicare + 9.63% HCRA Surcharge,3861,45,,3861,percent of total billed charges,Critical Access Hospital RCC factor,2917.2,34,,2917.2,percent of total billed charges,Implant Device,2917.2,34,,2917.2,percent of total billed charges,Implant Device,2917.2,34,,2917.2,percent of total billed charges,Implant Device,2917.2,34,,2917.2,percent of total billed charges,Implant Device,2917.2,34,,2917.2,percent of total billed charges,Implant Device,4247.1,,,4247.1,Other,110% of Medicare,3003,35,,3003,percent of total billed charges,Implant Device,2917.2,34,"Charges > $500, x 34%",2917.2,percent of total billed charges,Implant Device,3003,35,,3003,percent of total billed charges,Implant Device,3003,35,,3003,percent of total billed charges,Implant Device,3003,35,,3003,percent of total billed charges,Implant Device,3003,35,,3003,percent of total billed charges,Implant Device,3003,35,,3003,percent of total billed charges,Implant Device,3432,40,,3432,percent of total billed charges,Implant Device,3003,70,,3003,percent of total billed charges,All Other,2917.2,34,,2917.2,percent of total billed charges,Implant Device,2917.2,34,,2917.2,percent of total billed charges,Implant Device,3003,35,,3003,percent of total billed charges,Implant Device,3003,35,,3003,percent of total billed charges,Implant Device,3003,35,,3003,percent of total billed charges,Implant Device,3003,35,,3003,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2917.2,34,"If Charge > 2,000, then 34 percent",2917.2,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,6349.22,
DEPUY 1961-92-141 TIBIAL INSERT SZ4 10MM,C1776,HCPCS,,79009977,CDM,278,RC,,,both,,,4200,3108.01,,,3108.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1890,45,,1890,percent of total billed charges,Critical Access Hospital RCC factor,1428,34,,1428,percent of total billed charges,Implant Device,1428,34,,1428,percent of total billed charges,Implant Device,1428,34,,1428,percent of total billed charges,Implant Device,1428,34,,1428,percent of total billed charges,Implant Device,1428,34,,1428,percent of total billed charges,Implant Device,2079,,,2079,Other,110% of Medicare,1470,35,,1470,percent of total billed charges,Implant Device,1428,34,"Charges > $500, x 34%",1428,percent of total billed charges,Implant Device,1470,35,,1470,percent of total billed charges,Implant Device,1470,35,,1470,percent of total billed charges,Implant Device,1470,35,,1470,percent of total billed charges,Implant Device,1470,35,,1470,percent of total billed charges,Implant Device,1470,35,,1470,percent of total billed charges,Implant Device,1680,40,,1680,percent of total billed charges,Implant Device,1470,70,,1470,percent of total billed charges,All Other,1428,34,,1428,percent of total billed charges,Implant Device,1428,34,,1428,percent of total billed charges,Implant Device,1470,35,,1470,percent of total billed charges,Implant Device,1470,35,,1470,percent of total billed charges,Implant Device,1470,35,,1470,percent of total billed charges,Implant Device,1470,35,,1470,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1428,34,"If Charge > 2,000, then 34 percent",1428,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3108.01,
ZIMMER 00-7711-016-20 M/L TAPER 16.25MM,C1776,HCPCS,,79009978,CDM,278,RC,,,both,,,6900,5106.02,,,5106.02,Other,150% of Medicare + 9.63% HCRA Surcharge,3105,45,,3105,percent of total billed charges,Critical Access Hospital RCC factor,2346,34,,2346,percent of total billed charges,Implant Device,2346,34,,2346,percent of total billed charges,Implant Device,2346,34,,2346,percent of total billed charges,Implant Device,2346,34,,2346,percent of total billed charges,Implant Device,2346,34,,2346,percent of total billed charges,Implant Device,3415.5,,,3415.5,Other,110% of Medicare,2415,35,,2415,percent of total billed charges,Implant Device,2346,34,"Charges > $500, x 34%",2346,percent of total billed charges,Implant Device,2415,35,,2415,percent of total billed charges,Implant Device,2415,35,,2415,percent of total billed charges,Implant Device,2415,35,,2415,percent of total billed charges,Implant Device,2415,35,,2415,percent of total billed charges,Implant Device,2415,35,,2415,percent of total billed charges,Implant Device,2760,40,,2760,percent of total billed charges,Implant Device,2415,70,,2415,percent of total billed charges,All Other,2346,34,,2346,percent of total billed charges,Implant Device,2346,34,,2346,percent of total billed charges,Implant Device,2415,35,,2415,percent of total billed charges,Implant Device,2415,35,,2415,percent of total billed charges,Implant Device,2415,35,,2415,percent of total billed charges,Implant Device,2415,35,,2415,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2346,34,"If Charge > 2,000, then 34 percent",2346,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5106.02,
ZIMMER 00-7711-006-40 M/L TAPER 7.5MM,C1776,HCPCS,,79009979,CDM,278,RC,,,both,,,6900,5106.02,,,5106.02,Other,150% of Medicare + 9.63% HCRA Surcharge,3105,45,,3105,percent of total billed charges,Critical Access Hospital RCC factor,2346,34,,2346,percent of total billed charges,Implant Device,2346,34,,2346,percent of total billed charges,Implant Device,2346,34,,2346,percent of total billed charges,Implant Device,2346,34,,2346,percent of total billed charges,Implant Device,2346,34,,2346,percent of total billed charges,Implant Device,3415.5,,,3415.5,Other,110% of Medicare,2415,35,,2415,percent of total billed charges,Implant Device,2346,34,"Charges > $500, x 34%",2346,percent of total billed charges,Implant Device,2415,35,,2415,percent of total billed charges,Implant Device,2415,35,,2415,percent of total billed charges,Implant Device,2415,35,,2415,percent of total billed charges,Implant Device,2415,35,,2415,percent of total billed charges,Implant Device,2415,35,,2415,percent of total billed charges,Implant Device,2760,40,,2760,percent of total billed charges,Implant Device,2415,70,,2415,percent of total billed charges,All Other,2346,34,,2346,percent of total billed charges,Implant Device,2346,34,,2346,percent of total billed charges,Implant Device,2415,35,,2415,percent of total billed charges,Implant Device,2415,35,,2415,percent of total billed charges,Implant Device,2415,35,,2415,percent of total billed charges,Implant Device,2415,35,,2415,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2346,34,"If Charge > 2,000, then 34 percent",2346,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5106.02,
MENTOR 350-2251BC SILICONE IMPLANT 225CC,C1789,HCPCS,,79009983,CDM,278,RC,,,both,,,2865,2120.11,,,2120.11,Other,150% of Medicare + 9.63% HCRA Surcharge,1289.25,45,,1289.25,percent of total billed charges,Critical Access Hospital RCC factor,974.1,34,,974.1,percent of total billed charges,Implant Device,974.1,34,,974.1,percent of total billed charges,Implant Device,974.1,34,,974.1,percent of total billed charges,Implant Device,974.1,34,,974.1,percent of total billed charges,Implant Device,974.1,34,,974.1,percent of total billed charges,Implant Device,1418.18,,,1418.18,Other,110% of Medicare,1002.75,35,,1002.75,percent of total billed charges,Implant Device,974.1,34,"Charges > $500, x 34%",974.1,percent of total billed charges,Implant Device,1002.75,35,,1002.75,percent of total billed charges,Implant Device,1002.75,35,,1002.75,percent of total billed charges,Implant Device,1002.75,35,,1002.75,percent of total billed charges,Implant Device,1002.75,35,,1002.75,percent of total billed charges,Implant Device,1002.75,35,,1002.75,percent of total billed charges,Implant Device,1146,40,,1146,percent of total billed charges,Implant Device,1002.75,70,,1002.75,percent of total billed charges,All Other,974.1,34,,974.1,percent of total billed charges,Implant Device,974.1,34,,974.1,percent of total billed charges,Implant Device,1002.75,35,,1002.75,percent of total billed charges,Implant Device,1002.75,35,,1002.75,percent of total billed charges,Implant Device,1002.75,35,,1002.75,percent of total billed charges,Implant Device,1002.75,35,,1002.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,974.1,34,"If Charge > 2,000, then 34 percent",974.1,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2120.11,
MENTOR SMPX270 SILICONE IMPLANT 270CC,C1789,HCPCS,,79009985,CDM,278,RC,,,both,,,3684,2726.17,,,2726.17,Other,150% of Medicare + 9.63% HCRA Surcharge,1657.8,45,,1657.8,percent of total billed charges,Critical Access Hospital RCC factor,1252.56,34,,1252.56,percent of total billed charges,Implant Device,1252.56,34,,1252.56,percent of total billed charges,Implant Device,1252.56,34,,1252.56,percent of total billed charges,Implant Device,1252.56,34,,1252.56,percent of total billed charges,Implant Device,1252.56,34,,1252.56,percent of total billed charges,Implant Device,1823.58,,,1823.58,Other,110% of Medicare,1289.4,35,,1289.4,percent of total billed charges,Implant Device,1252.56,34,"Charges > $500, x 34%",1252.56,percent of total billed charges,Implant Device,1289.4,35,,1289.4,percent of total billed charges,Implant Device,1289.4,35,,1289.4,percent of total billed charges,Implant Device,1289.4,35,,1289.4,percent of total billed charges,Implant Device,1289.4,35,,1289.4,percent of total billed charges,Implant Device,1289.4,35,,1289.4,percent of total billed charges,Implant Device,1473.6,40,,1473.6,percent of total billed charges,Implant Device,1289.4,70,,1289.4,percent of total billed charges,All Other,1252.56,34,,1252.56,percent of total billed charges,Implant Device,1252.56,34,,1252.56,percent of total billed charges,Implant Device,1289.4,35,,1289.4,percent of total billed charges,Implant Device,1289.4,35,,1289.4,percent of total billed charges,Implant Device,1289.4,35,,1289.4,percent of total billed charges,Implant Device,1289.4,35,,1289.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1252.56,34,"If Charge > 2,000, then 34 percent",1252.56,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2726.17,
MENTOR SMPX295 SILICONE IMPLANT 295CC,C1789,HCPCS,,79009986,CDM,278,RC,,,both,,,3684,2726.17,,,2726.17,Other,150% of Medicare + 9.63% HCRA Surcharge,1657.8,45,,1657.8,percent of total billed charges,Critical Access Hospital RCC factor,1252.56,34,,1252.56,percent of total billed charges,Implant Device,1252.56,34,,1252.56,percent of total billed charges,Implant Device,1252.56,34,,1252.56,percent of total billed charges,Implant Device,1252.56,34,,1252.56,percent of total billed charges,Implant Device,1252.56,34,,1252.56,percent of total billed charges,Implant Device,1823.58,,,1823.58,Other,110% of Medicare,1289.4,35,,1289.4,percent of total billed charges,Implant Device,1252.56,34,"Charges > $500, x 34%",1252.56,percent of total billed charges,Implant Device,1289.4,35,,1289.4,percent of total billed charges,Implant Device,1289.4,35,,1289.4,percent of total billed charges,Implant Device,1289.4,35,,1289.4,percent of total billed charges,Implant Device,1289.4,35,,1289.4,percent of total billed charges,Implant Device,1289.4,35,,1289.4,percent of total billed charges,Implant Device,1473.6,40,,1473.6,percent of total billed charges,Implant Device,1289.4,70,,1289.4,percent of total billed charges,All Other,1252.56,34,,1252.56,percent of total billed charges,Implant Device,1252.56,34,,1252.56,percent of total billed charges,Implant Device,1289.4,35,,1289.4,percent of total billed charges,Implant Device,1289.4,35,,1289.4,percent of total billed charges,Implant Device,1289.4,35,,1289.4,percent of total billed charges,Implant Device,1289.4,35,,1289.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1252.56,34,"If Charge > 2,000, then 34 percent",1252.56,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2726.17,
MENTOR SMPX325 SILICONE IMPLANT 325CC,C1789,HCPCS,,79009987,CDM,278,RC,,,both,,,3684,2726.17,,,2726.17,Other,150% of Medicare + 9.63% HCRA Surcharge,1657.8,45,,1657.8,percent of total billed charges,Critical Access Hospital RCC factor,1252.56,34,,1252.56,percent of total billed charges,Implant Device,1252.56,34,,1252.56,percent of total billed charges,Implant Device,1252.56,34,,1252.56,percent of total billed charges,Implant Device,1252.56,34,,1252.56,percent of total billed charges,Implant Device,1252.56,34,,1252.56,percent of total billed charges,Implant Device,1823.58,,,1823.58,Other,110% of Medicare,1289.4,35,,1289.4,percent of total billed charges,Implant Device,1252.56,34,"Charges > $500, x 34%",1252.56,percent of total billed charges,Implant Device,1289.4,35,,1289.4,percent of total billed charges,Implant Device,1289.4,35,,1289.4,percent of total billed charges,Implant Device,1289.4,35,,1289.4,percent of total billed charges,Implant Device,1289.4,35,,1289.4,percent of total billed charges,Implant Device,1289.4,35,,1289.4,percent of total billed charges,Implant Device,1473.6,40,,1473.6,percent of total billed charges,Implant Device,1289.4,70,,1289.4,percent of total billed charges,All Other,1252.56,34,,1252.56,percent of total billed charges,Implant Device,1252.56,34,,1252.56,percent of total billed charges,Implant Device,1289.4,35,,1289.4,percent of total billed charges,Implant Device,1289.4,35,,1289.4,percent of total billed charges,Implant Device,1289.4,35,,1289.4,percent of total billed charges,Implant Device,1289.4,35,,1289.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1252.56,34,"If Charge > 2,000, then 34 percent",1252.56,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2726.17,
ALLERGAN 1516616 ALLODERM RTU 6X16CM,C1776,HCPCS,,79009991,CDM,278,RC,,,both,,,13401,9916.77,,,9916.77,Other,150% of Medicare + 9.63% HCRA Surcharge,6030.45,45,,6030.45,percent of total billed charges,Critical Access Hospital RCC factor,4556.34,34,,4556.34,percent of total billed charges,Implant Device,4556.34,34,,4556.34,percent of total billed charges,Implant Device,4556.34,34,,4556.34,percent of total billed charges,Implant Device,4556.34,34,,4556.34,percent of total billed charges,Implant Device,4556.34,34,,4556.34,percent of total billed charges,Implant Device,6633.5,,,6633.5,Other,110% of Medicare,4690.35,35,,4690.35,percent of total billed charges,Implant Device,4556.34,34,"Charges > $500, x 34%",4556.34,percent of total billed charges,Implant Device,4690.35,35,,4690.35,percent of total billed charges,Implant Device,4690.35,35,,4690.35,percent of total billed charges,Implant Device,4690.35,35,,4690.35,percent of total billed charges,Implant Device,4690.35,35,,4690.35,percent of total billed charges,Implant Device,4690.35,35,,4690.35,percent of total billed charges,Implant Device,5360.4,40,,5360.4,percent of total billed charges,Implant Device,4690.35,70,,4690.35,percent of total billed charges,All Other,4556.34,34,,4556.34,percent of total billed charges,Implant Device,4556.34,34,,4556.34,percent of total billed charges,Implant Device,4690.35,35,,4690.35,percent of total billed charges,Implant Device,4690.35,35,,4690.35,percent of total billed charges,Implant Device,4690.35,35,,4690.35,percent of total billed charges,Implant Device,4690.35,35,,4690.35,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,4556.34,34,"If Charge > 2,000, then 34 percent",4556.34,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,9916.77,
STRYKER 6721-0535 HIP STEM SIZE 5 127',C1776,HCPCS,,79009993,CDM,278,RC,,,both,,,6953,5145.24,,,5145.24,Other,150% of Medicare + 9.63% HCRA Surcharge,3128.85,45,,3128.85,percent of total billed charges,Critical Access Hospital RCC factor,2364.02,34,,2364.02,percent of total billed charges,Implant Device,2364.02,34,,2364.02,percent of total billed charges,Implant Device,2364.02,34,,2364.02,percent of total billed charges,Implant Device,2364.02,34,,2364.02,percent of total billed charges,Implant Device,2364.02,34,,2364.02,percent of total billed charges,Implant Device,3441.74,,,3441.74,Other,110% of Medicare,2433.55,35,,2433.55,percent of total billed charges,Implant Device,2364.02,34,"Charges > $500, x 34%",2364.02,percent of total billed charges,Implant Device,2433.55,35,,2433.55,percent of total billed charges,Implant Device,2433.55,35,,2433.55,percent of total billed charges,Implant Device,2433.55,35,,2433.55,percent of total billed charges,Implant Device,2433.55,35,,2433.55,percent of total billed charges,Implant Device,2433.55,35,,2433.55,percent of total billed charges,Implant Device,2781.2,40,,2781.2,percent of total billed charges,Implant Device,2433.55,70,,2433.55,percent of total billed charges,All Other,2364.02,34,,2364.02,percent of total billed charges,Implant Device,2364.02,34,,2364.02,percent of total billed charges,Implant Device,2433.55,35,,2433.55,percent of total billed charges,Implant Device,2433.55,35,,2433.55,percent of total billed charges,Implant Device,2433.55,35,,2433.55,percent of total billed charges,Implant Device,2433.55,35,,2433.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2364.02,34,"If Charge > 2,000, then 34 percent",2364.02,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5145.24,
STRYKER UH1-53-26 UHR BIPOLAR 26X53MM,C1776,HCPCS,,79009994,CDM,278,RC,,,both,,,1391,1029.34,,,1029.34,Other,150% of Medicare + 9.63% HCRA Surcharge,625.95,45,,625.95,percent of total billed charges,Critical Access Hospital RCC factor,472.94,34,,472.94,percent of total billed charges,Implant Device,472.94,34,,472.94,percent of total billed charges,Implant Device,472.94,34,,472.94,percent of total billed charges,Implant Device,472.94,34,,472.94,percent of total billed charges,Implant Device,472.94,34,,472.94,percent of total billed charges,Implant Device,688.55,,,688.55,Other,110% of Medicare,486.85,35,,486.85,percent of total billed charges,Implant Device,472.94,34,"Charges > $500, x 34%",472.94,percent of total billed charges,Implant Device,486.85,35,,486.85,percent of total billed charges,Implant Device,486.85,35,,486.85,percent of total billed charges,Implant Device,486.85,35,,486.85,percent of total billed charges,Implant Device,486.85,35,,486.85,percent of total billed charges,Implant Device,486.85,35,,486.85,percent of total billed charges,Implant Device,556.4,40,,556.4,percent of total billed charges,Implant Device,486.85,70,,486.85,percent of total billed charges,All Other,472.94,34,,472.94,percent of total billed charges,Implant Device,472.94,34,,472.94,percent of total billed charges,Implant Device,486.85,35,,486.85,percent of total billed charges,Implant Device,486.85,35,,486.85,percent of total billed charges,Implant Device,486.85,35,,486.85,percent of total billed charges,Implant Device,486.85,35,,486.85,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1029.34,
STRYKER 627608 DIS LAT FEMUR PLT 8H L202,C1713,HCPCS,,79009995,CDM,278,RC,,,both,,,7501,5550.76,,,5550.76,Other,150% of Medicare + 9.63% HCRA Surcharge,3375.45,45,,3375.45,percent of total billed charges,Critical Access Hospital RCC factor,2550.34,34,,2550.34,percent of total billed charges,Implant Device,2550.34,34,,2550.34,percent of total billed charges,Implant Device,2550.34,34,,2550.34,percent of total billed charges,Implant Device,2550.34,34,,2550.34,percent of total billed charges,Implant Device,2550.34,34,,2550.34,percent of total billed charges,Implant Device,3713,,,3713,Other,110% of Medicare,2625.35,35,,2625.35,percent of total billed charges,Implant Device,2550.34,34,"Charges > $500, x 34%",2550.34,percent of total billed charges,Implant Device,2625.35,35,,2625.35,percent of total billed charges,Implant Device,2625.35,35,,2625.35,percent of total billed charges,Implant Device,2625.35,35,,2625.35,percent of total billed charges,Implant Device,2625.35,35,,2625.35,percent of total billed charges,Implant Device,2625.35,35,,2625.35,percent of total billed charges,Implant Device,3000.4,40,,3000.4,percent of total billed charges,Implant Device,2625.35,70,,2625.35,percent of total billed charges,All Other,2550.34,34,,2550.34,percent of total billed charges,Implant Device,2550.34,34,,2550.34,percent of total billed charges,Implant Device,2625.35,35,,2625.35,percent of total billed charges,Implant Device,2625.35,35,,2625.35,percent of total billed charges,Implant Device,2625.35,35,,2625.35,percent of total billed charges,Implant Device,2625.35,35,,2625.35,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2550.34,34,"If Charge > 2,000, then 34 percent",2550.34,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5550.76,
STRYKER 661144 LOCKING SCREW 5.0/L44MM,C1713,HCPCS,,79009996,CDM,278,RC,,,both,,,616,455.84,,,455.84,Other,150% of Medicare + 9.63% HCRA Surcharge,277.2,45,,277.2,percent of total billed charges,Critical Access Hospital RCC factor,209.44,34,,209.44,percent of total billed charges,Implant Device,209.44,34,,209.44,percent of total billed charges,Implant Device,209.44,34,,209.44,percent of total billed charges,Implant Device,209.44,34,,209.44,percent of total billed charges,Implant Device,209.44,34,,209.44,percent of total billed charges,Implant Device,304.92,,,304.92,Other,110% of Medicare,215.6,35,,215.6,percent of total billed charges,Implant Device,209.44,34,"Charges > $500, x 34%",209.44,percent of total billed charges,Implant Device,215.6,35,,215.6,percent of total billed charges,Implant Device,215.6,35,,215.6,percent of total billed charges,Implant Device,215.6,35,,215.6,percent of total billed charges,Implant Device,215.6,35,,215.6,percent of total billed charges,Implant Device,215.6,35,,215.6,percent of total billed charges,Implant Device,246.4,40,,246.4,percent of total billed charges,Implant Device,215.6,70,,215.6,percent of total billed charges,All Other,209.44,34,,209.44,percent of total billed charges,Implant Device,209.44,34,,209.44,percent of total billed charges,Implant Device,215.6,35,,215.6,percent of total billed charges,Implant Device,215.6,35,,215.6,percent of total billed charges,Implant Device,215.6,35,,215.6,percent of total billed charges,Implant Device,215.6,35,,215.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,455.84,
STRYKER 661155 LOCKING SCREW 5.0/L55MM,C1713,HCPCS,,79009997,CDM,278,RC,,,both,,,616,455.84,,,455.84,Other,150% of Medicare + 9.63% HCRA Surcharge,277.2,45,,277.2,percent of total billed charges,Critical Access Hospital RCC factor,209.44,34,,209.44,percent of total billed charges,Implant Device,209.44,34,,209.44,percent of total billed charges,Implant Device,209.44,34,,209.44,percent of total billed charges,Implant Device,209.44,34,,209.44,percent of total billed charges,Implant Device,209.44,34,,209.44,percent of total billed charges,Implant Device,304.92,,,304.92,Other,110% of Medicare,215.6,35,,215.6,percent of total billed charges,Implant Device,209.44,34,"Charges > $500, x 34%",209.44,percent of total billed charges,Implant Device,215.6,35,,215.6,percent of total billed charges,Implant Device,215.6,35,,215.6,percent of total billed charges,Implant Device,215.6,35,,215.6,percent of total billed charges,Implant Device,215.6,35,,215.6,percent of total billed charges,Implant Device,215.6,35,,215.6,percent of total billed charges,Implant Device,246.4,40,,246.4,percent of total billed charges,Implant Device,215.6,70,,215.6,percent of total billed charges,All Other,209.44,34,,209.44,percent of total billed charges,Implant Device,209.44,34,,209.44,percent of total billed charges,Implant Device,215.6,35,,215.6,percent of total billed charges,Implant Device,215.6,35,,215.6,percent of total billed charges,Implant Device,215.6,35,,215.6,percent of total billed charges,Implant Device,215.6,35,,215.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,455.84,
STRYKER 661740 LOCKING SCREW 4.5/L40MM,C1713,HCPCS,,79009998,CDM,278,RC,,,both,,,139,102.86,,,102.86,Other,150% of Medicare + 9.63% HCRA Surcharge,62.55,45,,62.55,percent of total billed charges,Critical Access Hospital RCC factor,47.26,34,,47.26,percent of total billed charges,Implant Device,47.26,34,,47.26,percent of total billed charges,Implant Device,47.26,34,,47.26,percent of total billed charges,Implant Device,47.26,34,,47.26,percent of total billed charges,Implant Device,47.26,34,,47.26,percent of total billed charges,Implant Device,68.81,,,68.81,Other,110% of Medicare,48.65,35,,48.65,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,48.65,35,,48.65,percent of total billed charges,Implant Device,48.65,35,,48.65,percent of total billed charges,Implant Device,48.65,35,,48.65,percent of total billed charges,Implant Device,48.65,35,,48.65,percent of total billed charges,Implant Device,48.65,35,,48.65,percent of total billed charges,Implant Device,55.6,40,,55.6,percent of total billed charges,Implant Device,48.65,70,,48.65,percent of total billed charges,All Other,47.26,34,,47.26,percent of total billed charges,Implant Device,47.26,34,,47.26,percent of total billed charges,Implant Device,48.65,35,,48.65,percent of total billed charges,Implant Device,48.65,35,,48.65,percent of total billed charges,Implant Device,48.65,35,,48.65,percent of total billed charges,Implant Device,48.65,35,,48.65,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,102.86,
STRYKER 661742 LOCKING SCREW 4.5/L42MM,C1713,HCPCS,,79009999,CDM,278,RC,,,both,,,139,102.86,,,102.86,Other,150% of Medicare + 9.63% HCRA Surcharge,62.55,45,,62.55,percent of total billed charges,Critical Access Hospital RCC factor,47.26,34,,47.26,percent of total billed charges,Implant Device,47.26,34,,47.26,percent of total billed charges,Implant Device,47.26,34,,47.26,percent of total billed charges,Implant Device,47.26,34,,47.26,percent of total billed charges,Implant Device,47.26,34,,47.26,percent of total billed charges,Implant Device,68.81,,,68.81,Other,110% of Medicare,48.65,35,,48.65,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,48.65,35,,48.65,percent of total billed charges,Implant Device,48.65,35,,48.65,percent of total billed charges,Implant Device,48.65,35,,48.65,percent of total billed charges,Implant Device,48.65,35,,48.65,percent of total billed charges,Implant Device,48.65,35,,48.65,percent of total billed charges,Implant Device,55.6,40,,55.6,percent of total billed charges,Implant Device,48.65,70,,48.65,percent of total billed charges,All Other,47.26,34,,47.26,percent of total billed charges,Implant Device,47.26,34,,47.26,percent of total billed charges,Implant Device,48.65,35,,48.65,percent of total billed charges,Implant Device,48.65,35,,48.65,percent of total billed charges,Implant Device,48.65,35,,48.65,percent of total billed charges,Implant Device,48.65,35,,48.65,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,102.86,
STRYKER 1850-1138S FEM NAIL LT 11X380MM,C1713,HCPCS,,79010000,CDM,278,RC,,,both,,,4545,3363.31,,,3363.31,Other,150% of Medicare + 9.63% HCRA Surcharge,2045.25,45,,2045.25,percent of total billed charges,Critical Access Hospital RCC factor,1545.3,34,,1545.3,percent of total billed charges,Implant Device,1545.3,34,,1545.3,percent of total billed charges,Implant Device,1545.3,34,,1545.3,percent of total billed charges,Implant Device,1545.3,34,,1545.3,percent of total billed charges,Implant Device,1545.3,34,,1545.3,percent of total billed charges,Implant Device,2249.78,,,2249.78,Other,110% of Medicare,1590.75,35,,1590.75,percent of total billed charges,Implant Device,1545.3,34,"Charges > $500, x 34%",1545.3,percent of total billed charges,Implant Device,1590.75,35,,1590.75,percent of total billed charges,Implant Device,1590.75,35,,1590.75,percent of total billed charges,Implant Device,1590.75,35,,1590.75,percent of total billed charges,Implant Device,1590.75,35,,1590.75,percent of total billed charges,Implant Device,1590.75,35,,1590.75,percent of total billed charges,Implant Device,1818,40,,1818,percent of total billed charges,Implant Device,1590.75,70,,1590.75,percent of total billed charges,All Other,1545.3,34,,1545.3,percent of total billed charges,Implant Device,1545.3,34,,1545.3,percent of total billed charges,Implant Device,1590.75,35,,1590.75,percent of total billed charges,Implant Device,1590.75,35,,1590.75,percent of total billed charges,Implant Device,1590.75,35,,1590.75,percent of total billed charges,Implant Device,1590.75,35,,1590.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1545.3,34,"If Charge > 2,000, then 34 percent",1545.3,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3363.31,
ZIMMER 00-7711-007-10 FEM STEM 7.5 12/14,C1776,HCPCS,,79010001,CDM,278,RC,,,both,,,6900,5106.02,,,5106.02,Other,150% of Medicare + 9.63% HCRA Surcharge,3105,45,,3105,percent of total billed charges,Critical Access Hospital RCC factor,2346,34,,2346,percent of total billed charges,Implant Device,2346,34,,2346,percent of total billed charges,Implant Device,2346,34,,2346,percent of total billed charges,Implant Device,2346,34,,2346,percent of total billed charges,Implant Device,2346,34,,2346,percent of total billed charges,Implant Device,3415.5,,,3415.5,Other,110% of Medicare,2415,35,,2415,percent of total billed charges,Implant Device,2346,34,"Charges > $500, x 34%",2346,percent of total billed charges,Implant Device,2415,35,,2415,percent of total billed charges,Implant Device,2415,35,,2415,percent of total billed charges,Implant Device,2415,35,,2415,percent of total billed charges,Implant Device,2415,35,,2415,percent of total billed charges,Implant Device,2415,35,,2415,percent of total billed charges,Implant Device,2760,40,,2760,percent of total billed charges,Implant Device,2415,70,,2415,percent of total billed charges,All Other,2346,34,,2346,percent of total billed charges,Implant Device,2346,34,,2346,percent of total billed charges,Implant Device,2415,35,,2415,percent of total billed charges,Implant Device,2415,35,,2415,percent of total billed charges,Implant Device,2415,35,,2415,percent of total billed charges,Implant Device,2415,35,,2415,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2346,34,"If Charge > 2,000, then 34 percent",2346,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5106.02,
DEPUY 1217-30-500 BONE SCREW 6.5X30MM,C1713,HCPCS,,79010002,CDM,278,RC,,,both,,,228,168.72,,,168.72,Other,150% of Medicare + 9.63% HCRA Surcharge,102.6,45,,102.6,percent of total billed charges,Critical Access Hospital RCC factor,77.52,34,,77.52,percent of total billed charges,Implant Device,77.52,34,,77.52,percent of total billed charges,Implant Device,77.52,34,,77.52,percent of total billed charges,Implant Device,77.52,34,,77.52,percent of total billed charges,Implant Device,77.52,34,,77.52,percent of total billed charges,Implant Device,112.86,,,112.86,Other,110% of Medicare,79.8,35,,79.8,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,79.8,35,,79.8,percent of total billed charges,Implant Device,79.8,35,,79.8,percent of total billed charges,Implant Device,79.8,35,,79.8,percent of total billed charges,Implant Device,79.8,35,,79.8,percent of total billed charges,Implant Device,79.8,35,,79.8,percent of total billed charges,Implant Device,91.2,40,,91.2,percent of total billed charges,Implant Device,79.8,70,,79.8,percent of total billed charges,All Other,77.52,34,,77.52,percent of total billed charges,Implant Device,77.52,34,,77.52,percent of total billed charges,Implant Device,79.8,35,,79.8,percent of total billed charges,Implant Device,79.8,35,,79.8,percent of total billed charges,Implant Device,79.8,35,,79.8,percent of total billed charges,Implant Device,79.8,35,,79.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,168.72,
IN2BONES P72 ST014 LOCK SCREW 2.7X14MM,C1713,HCPCS,,79010004,CDM,278,RC,,,both,,,870,643.8,,,643.8,Other,150% of Medicare + 9.63% HCRA Surcharge,391.5,45,,391.5,percent of total billed charges,Critical Access Hospital RCC factor,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,430.65,,,430.65,Other,110% of Medicare,304.5,35,,304.5,percent of total billed charges,Implant Device,295.8,34,"Charges > $500, x 34%",295.8,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,348,40,,348,percent of total billed charges,Implant Device,304.5,70,,304.5,percent of total billed charges,All Other,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,643.8,
IN2BONES P72 ST110 LOCK SCREW 2.7X10MM,C1713,HCPCS,,79010005,CDM,278,RC,,,both,,,870,643.8,,,643.8,Other,150% of Medicare + 9.63% HCRA Surcharge,391.5,45,,391.5,percent of total billed charges,Critical Access Hospital RCC factor,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,430.65,,,430.65,Other,110% of Medicare,304.5,35,,304.5,percent of total billed charges,Implant Device,295.8,34,"Charges > $500, x 34%",295.8,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,348,40,,348,percent of total billed charges,Implant Device,304.5,70,,304.5,percent of total billed charges,All Other,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,643.8,
IN2BONES P73 ST110 LOCK SCREW 3.5X10MM,C1713,HCPCS,,79010006,CDM,278,RC,,,both,,,870,643.8,,,643.8,Other,150% of Medicare + 9.63% HCRA Surcharge,391.5,45,,391.5,percent of total billed charges,Critical Access Hospital RCC factor,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,430.65,,,430.65,Other,110% of Medicare,304.5,35,,304.5,percent of total billed charges,Implant Device,295.8,34,"Charges > $500, x 34%",295.8,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,348,40,,348,percent of total billed charges,Implant Device,304.5,70,,304.5,percent of total billed charges,All Other,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,643.8,
IN2BONES P72 ST108 LOCK SCREW 2.7X8MM,C1713,HCPCS,,79010007,CDM,278,RC,,,both,,,870,643.8,,,643.8,Other,150% of Medicare + 9.63% HCRA Surcharge,391.5,45,,391.5,percent of total billed charges,Critical Access Hospital RCC factor,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,430.65,,,430.65,Other,110% of Medicare,304.5,35,,304.5,percent of total billed charges,Implant Device,295.8,34,"Charges > $500, x 34%",295.8,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,348,40,,348,percent of total billed charges,Implant Device,304.5,70,,304.5,percent of total billed charges,All Other,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,643.8,
IN2BONES P73 ST010 LOCK SCREW 3.5X10MM,C1713,HCPCS,,79010008,CDM,278,RC,,,both,,,870,643.8,,,643.8,Other,150% of Medicare + 9.63% HCRA Surcharge,391.5,45,,391.5,percent of total billed charges,Critical Access Hospital RCC factor,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,430.65,,,430.65,Other,110% of Medicare,304.5,35,,304.5,percent of total billed charges,Implant Device,295.8,34,"Charges > $500, x 34%",295.8,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,348,40,,348,percent of total billed charges,Implant Device,304.5,70,,304.5,percent of total billed charges,All Other,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,643.8,
IN2BONES P73 ST112 LOCK SCREW 3.5X12MM,C1713,HCPCS,,79010009,CDM,278,RC,,,both,,,870,643.8,,,643.8,Other,150% of Medicare + 9.63% HCRA Surcharge,391.5,45,,391.5,percent of total billed charges,Critical Access Hospital RCC factor,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,430.65,,,430.65,Other,110% of Medicare,304.5,35,,304.5,percent of total billed charges,Implant Device,295.8,34,"Charges > $500, x 34%",295.8,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,348,40,,348,percent of total billed charges,Implant Device,304.5,70,,304.5,percent of total billed charges,All Other,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,643.8,
STRYKER 3525-0440S 3 S NAIL 10X440X125MM,C1713,HCPCS,,79010010,CDM,278,RC,,,both,,,5438,4024.13,,,4024.13,Other,150% of Medicare + 9.63% HCRA Surcharge,2447.1,45,,2447.1,percent of total billed charges,Critical Access Hospital RCC factor,1848.92,34,,1848.92,percent of total billed charges,Implant Device,1848.92,34,,1848.92,percent of total billed charges,Implant Device,1848.92,34,,1848.92,percent of total billed charges,Implant Device,1848.92,34,,1848.92,percent of total billed charges,Implant Device,1848.92,34,,1848.92,percent of total billed charges,Implant Device,2691.81,,,2691.81,Other,110% of Medicare,1903.3,35,,1903.3,percent of total billed charges,Implant Device,1848.92,34,"Charges > $500, x 34%",1848.92,percent of total billed charges,Implant Device,1903.3,35,,1903.3,percent of total billed charges,Implant Device,1903.3,35,,1903.3,percent of total billed charges,Implant Device,1903.3,35,,1903.3,percent of total billed charges,Implant Device,1903.3,35,,1903.3,percent of total billed charges,Implant Device,1903.3,35,,1903.3,percent of total billed charges,Implant Device,2175.2,40,,2175.2,percent of total billed charges,Implant Device,1903.3,70,,1903.3,percent of total billed charges,All Other,1848.92,34,,1848.92,percent of total billed charges,Implant Device,1848.92,34,,1848.92,percent of total billed charges,Implant Device,1903.3,35,,1903.3,percent of total billed charges,Implant Device,1903.3,35,,1903.3,percent of total billed charges,Implant Device,1903.3,35,,1903.3,percent of total billed charges,Implant Device,1903.3,35,,1903.3,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1848.92,34,"If Charge > 2,000, then 34 percent",1848.92,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4024.13,
ARTHREX AR-8935-12 CORT SCREW 3.5X12MM,C1713,HCPCS,,79010011,CDM,278,RC,,,both,,,195,144.3,,,144.3,Other,150% of Medicare + 9.63% HCRA Surcharge,87.75,45,,87.75,percent of total billed charges,Critical Access Hospital RCC factor,66.3,34,,66.3,percent of total billed charges,Implant Device,66.3,34,,66.3,percent of total billed charges,Implant Device,66.3,34,,66.3,percent of total billed charges,Implant Device,66.3,34,,66.3,percent of total billed charges,Implant Device,66.3,34,,66.3,percent of total billed charges,Implant Device,96.53,,,96.53,Other,110% of Medicare,68.25,35,,68.25,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,68.25,35,,68.25,percent of total billed charges,Implant Device,68.25,35,,68.25,percent of total billed charges,Implant Device,68.25,35,,68.25,percent of total billed charges,Implant Device,68.25,35,,68.25,percent of total billed charges,Implant Device,68.25,35,,68.25,percent of total billed charges,Implant Device,78,40,,78,percent of total billed charges,Implant Device,68.25,70,,68.25,percent of total billed charges,All Other,66.3,34,,66.3,percent of total billed charges,Implant Device,66.3,34,,66.3,percent of total billed charges,Implant Device,68.25,35,,68.25,percent of total billed charges,Implant Device,68.25,35,,68.25,percent of total billed charges,Implant Device,68.25,35,,68.25,percent of total billed charges,Implant Device,68.25,35,,68.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,144.3,
STRYKER 5510-F-602 FEM COMP SZ 6 RT,C1776,HCPCS,,79010012,CDM,278,RC,,,both,,,5100,3774.01,,,3774.01,Other,150% of Medicare + 9.63% HCRA Surcharge,2295,45,,2295,percent of total billed charges,Critical Access Hospital RCC factor,1734,34,,1734,percent of total billed charges,Implant Device,1734,34,,1734,percent of total billed charges,Implant Device,1734,34,,1734,percent of total billed charges,Implant Device,1734,34,,1734,percent of total billed charges,Implant Device,1734,34,,1734,percent of total billed charges,Implant Device,2524.5,,,2524.5,Other,110% of Medicare,1785,35,,1785,percent of total billed charges,Implant Device,1734,34,"Charges > $500, x 34%",1734,percent of total billed charges,Implant Device,1785,35,,1785,percent of total billed charges,Implant Device,1785,35,,1785,percent of total billed charges,Implant Device,1785,35,,1785,percent of total billed charges,Implant Device,1785,35,,1785,percent of total billed charges,Implant Device,1785,35,,1785,percent of total billed charges,Implant Device,2040,40,,2040,percent of total billed charges,Implant Device,1785,70,,1785,percent of total billed charges,All Other,1734,34,,1734,percent of total billed charges,Implant Device,1734,34,,1734,percent of total billed charges,Implant Device,1785,35,,1785,percent of total billed charges,Implant Device,1785,35,,1785,percent of total billed charges,Implant Device,1785,35,,1785,percent of total billed charges,Implant Device,1785,35,,1785,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1734,34,"If Charge > 2,000, then 34 percent",1734,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3774.01,
STRYKER 5520-B-600 TIBIAL BASEPLATE SZ 6,C1776,HCPCS,,79010013,CDM,278,RC,,,both,,,3300,2442.01,,,2442.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1485,45,,1485,percent of total billed charges,Critical Access Hospital RCC factor,1122,34,,1122,percent of total billed charges,Implant Device,1122,34,,1122,percent of total billed charges,Implant Device,1122,34,,1122,percent of total billed charges,Implant Device,1122,34,,1122,percent of total billed charges,Implant Device,1122,34,,1122,percent of total billed charges,Implant Device,1633.5,,,1633.5,Other,110% of Medicare,1155,35,,1155,percent of total billed charges,Implant Device,1122,34,"Charges > $500, x 34%",1122,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,1320,40,,1320,percent of total billed charges,Implant Device,1155,70,,1155,percent of total billed charges,All Other,1122,34,,1122,percent of total billed charges,Implant Device,1122,34,,1122,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1122,34,"If Charge > 2,000, then 34 percent",1122,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2442.01,
STRYKER 5530-G-613 TIB BEARING SZ 6 13MM,C1776,HCPCS,,79010014,CDM,278,RC,,,both,,,3300,2442.01,,,2442.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1485,45,,1485,percent of total billed charges,Critical Access Hospital RCC factor,1122,34,,1122,percent of total billed charges,Implant Device,1122,34,,1122,percent of total billed charges,Implant Device,1122,34,,1122,percent of total billed charges,Implant Device,1122,34,,1122,percent of total billed charges,Implant Device,1122,34,,1122,percent of total billed charges,Implant Device,1633.5,,,1633.5,Other,110% of Medicare,1155,35,,1155,percent of total billed charges,Implant Device,1122,34,"Charges > $500, x 34%",1122,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,1320,40,,1320,percent of total billed charges,Implant Device,1155,70,,1155,percent of total billed charges,All Other,1122,34,,1122,percent of total billed charges,Implant Device,1122,34,,1122,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1122,34,"If Charge > 2,000, then 34 percent",1122,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2442.01,
STRYKER 5551-G-350 PATELLA SIZE A35 10MM,C1776,HCPCS,,79010015,CDM,278,RC,,,both,,,1500,1110,,,1110,Other,150% of Medicare + 9.63% HCRA Surcharge,675,45,,675,percent of total billed charges,Critical Access Hospital RCC factor,510,34,,510,percent of total billed charges,Implant Device,510,34,,510,percent of total billed charges,Implant Device,510,34,,510,percent of total billed charges,Implant Device,510,34,,510,percent of total billed charges,Implant Device,510,34,,510,percent of total billed charges,Implant Device,742.5,,,742.5,Other,110% of Medicare,525,35,,525,percent of total billed charges,Implant Device,510,34,"Charges > $500, x 34%",510,percent of total billed charges,Implant Device,525,35,,525,percent of total billed charges,Implant Device,525,35,,525,percent of total billed charges,Implant Device,525,35,,525,percent of total billed charges,Implant Device,525,35,,525,percent of total billed charges,Implant Device,525,35,,525,percent of total billed charges,Implant Device,600,40,,600,percent of total billed charges,Implant Device,525,70,,525,percent of total billed charges,All Other,510,34,,510,percent of total billed charges,Implant Device,510,34,,510,percent of total billed charges,Implant Device,525,35,,525,percent of total billed charges,Implant Device,525,35,,525,percent of total billed charges,Implant Device,525,35,,525,percent of total billed charges,Implant Device,525,35,,525,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1110,
ZIMMER 00-5950-016-06 FEM COMP SZ F -RT,C1776,HCPCS,,79010016,CDM,278,RC,,,both,,,5175,3829.51,,,3829.51,Other,150% of Medicare + 9.63% HCRA Surcharge,2328.75,45,,2328.75,percent of total billed charges,Critical Access Hospital RCC factor,1759.5,34,,1759.5,percent of total billed charges,Implant Device,1759.5,34,,1759.5,percent of total billed charges,Implant Device,1759.5,34,,1759.5,percent of total billed charges,Implant Device,1759.5,34,,1759.5,percent of total billed charges,Implant Device,1759.5,34,,1759.5,percent of total billed charges,Implant Device,2561.63,,,2561.63,Other,110% of Medicare,1811.25,35,,1811.25,percent of total billed charges,Implant Device,1759.5,34,"Charges > $500, x 34%",1759.5,percent of total billed charges,Implant Device,1811.25,35,,1811.25,percent of total billed charges,Implant Device,1811.25,35,,1811.25,percent of total billed charges,Implant Device,1811.25,35,,1811.25,percent of total billed charges,Implant Device,1811.25,35,,1811.25,percent of total billed charges,Implant Device,1811.25,35,,1811.25,percent of total billed charges,Implant Device,2070,40,,2070,percent of total billed charges,Implant Device,1811.25,70,,1811.25,percent of total billed charges,All Other,1759.5,34,,1759.5,percent of total billed charges,Implant Device,1759.5,34,,1759.5,percent of total billed charges,Implant Device,1811.25,35,,1811.25,percent of total billed charges,Implant Device,1811.25,35,,1811.25,percent of total billed charges,Implant Device,1811.25,35,,1811.25,percent of total billed charges,Implant Device,1811.25,35,,1811.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1759.5,34,"If Charge > 2,000, then 34 percent",1759.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3829.51,
ZIMMER 00-5994-042-14 ART SURF 14MM,C1776,HCPCS,,79010017,CDM,278,RC,,,both,,,6465,4784.12,,,4784.12,Other,150% of Medicare + 9.63% HCRA Surcharge,2909.25,45,,2909.25,percent of total billed charges,Critical Access Hospital RCC factor,2198.1,34,,2198.1,percent of total billed charges,Implant Device,2198.1,34,,2198.1,percent of total billed charges,Implant Device,2198.1,34,,2198.1,percent of total billed charges,Implant Device,2198.1,34,,2198.1,percent of total billed charges,Implant Device,2198.1,34,,2198.1,percent of total billed charges,Implant Device,3200.18,,,3200.18,Other,110% of Medicare,2262.75,35,,2262.75,percent of total billed charges,Implant Device,2198.1,34,"Charges > $500, x 34%",2198.1,percent of total billed charges,Implant Device,2262.75,35,,2262.75,percent of total billed charges,Implant Device,2262.75,35,,2262.75,percent of total billed charges,Implant Device,2262.75,35,,2262.75,percent of total billed charges,Implant Device,2262.75,35,,2262.75,percent of total billed charges,Implant Device,2262.75,35,,2262.75,percent of total billed charges,Implant Device,2586,40,,2586,percent of total billed charges,Implant Device,2262.75,70,,2262.75,percent of total billed charges,All Other,2198.1,34,,2198.1,percent of total billed charges,Implant Device,2198.1,34,,2198.1,percent of total billed charges,Implant Device,2262.75,35,,2262.75,percent of total billed charges,Implant Device,2262.75,35,,2262.75,percent of total billed charges,Implant Device,2262.75,35,,2262.75,percent of total billed charges,Implant Device,2262.75,35,,2262.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2198.1,34,"If Charge > 2,000, then 34 percent",2198.1,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4784.12,
DEPUY 212.107 LOCKING SCREW 3.5X22MM,C1713,HCPCS,,79010018,CDM,278,RC,,,both,,,327,241.98,,,241.98,Other,150% of Medicare + 9.63% HCRA Surcharge,147.15,45,,147.15,percent of total billed charges,Critical Access Hospital RCC factor,111.18,34,,111.18,percent of total billed charges,Implant Device,111.18,34,,111.18,percent of total billed charges,Implant Device,111.18,34,,111.18,percent of total billed charges,Implant Device,111.18,34,,111.18,percent of total billed charges,Implant Device,111.18,34,,111.18,percent of total billed charges,Implant Device,161.87,,,161.87,Other,110% of Medicare,114.45,35,,114.45,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,114.45,35,,114.45,percent of total billed charges,Implant Device,114.45,35,,114.45,percent of total billed charges,Implant Device,114.45,35,,114.45,percent of total billed charges,Implant Device,114.45,35,,114.45,percent of total billed charges,Implant Device,114.45,35,,114.45,percent of total billed charges,Implant Device,130.8,40,,130.8,percent of total billed charges,Implant Device,114.45,70,,114.45,percent of total billed charges,All Other,111.18,34,,111.18,percent of total billed charges,Implant Device,111.18,34,,111.18,percent of total billed charges,Implant Device,114.45,35,,114.45,percent of total billed charges,Implant Device,114.45,35,,114.45,percent of total billed charges,Implant Device,114.45,35,,114.45,percent of total billed charges,Implant Device,114.45,35,,114.45,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,241.98,
ZIMMER 00-5988-006-38 TIB AUG SZ 6 15MM,C1776,HCPCS,,79010019,CDM,278,RC,,,both,,,3617,2676.59,,,2676.59,Other,150% of Medicare + 9.63% HCRA Surcharge,1627.65,45,,1627.65,percent of total billed charges,Critical Access Hospital RCC factor,1229.78,34,,1229.78,percent of total billed charges,Implant Device,1229.78,34,,1229.78,percent of total billed charges,Implant Device,1229.78,34,,1229.78,percent of total billed charges,Implant Device,1229.78,34,,1229.78,percent of total billed charges,Implant Device,1229.78,34,,1229.78,percent of total billed charges,Implant Device,1790.42,,,1790.42,Other,110% of Medicare,1265.95,35,,1265.95,percent of total billed charges,Implant Device,1229.78,34,"Charges > $500, x 34%",1229.78,percent of total billed charges,Implant Device,1265.95,35,,1265.95,percent of total billed charges,Implant Device,1265.95,35,,1265.95,percent of total billed charges,Implant Device,1265.95,35,,1265.95,percent of total billed charges,Implant Device,1265.95,35,,1265.95,percent of total billed charges,Implant Device,1265.95,35,,1265.95,percent of total billed charges,Implant Device,1446.8,40,,1446.8,percent of total billed charges,Implant Device,1265.95,70,,1265.95,percent of total billed charges,All Other,1229.78,34,,1229.78,percent of total billed charges,Implant Device,1229.78,34,,1229.78,percent of total billed charges,Implant Device,1265.95,35,,1265.95,percent of total billed charges,Implant Device,1265.95,35,,1265.95,percent of total billed charges,Implant Device,1265.95,35,,1265.95,percent of total billed charges,Implant Device,1265.95,35,,1265.95,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1229.78,34,"If Charge > 2,000, then 34 percent",1229.78,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2676.59,
ZIMMER 00-5988-011-17 STEM EXT 17X155MM,C1776,HCPCS,,79010020,CDM,278,RC,,,both,,,2970,2197.81,,,2197.81,Other,150% of Medicare + 9.63% HCRA Surcharge,1336.5,45,,1336.5,percent of total billed charges,Critical Access Hospital RCC factor,1009.8,34,,1009.8,percent of total billed charges,Implant Device,1009.8,34,,1009.8,percent of total billed charges,Implant Device,1009.8,34,,1009.8,percent of total billed charges,Implant Device,1009.8,34,,1009.8,percent of total billed charges,Implant Device,1009.8,34,,1009.8,percent of total billed charges,Implant Device,1470.15,,,1470.15,Other,110% of Medicare,1039.5,35,,1039.5,percent of total billed charges,Implant Device,1009.8,34,"Charges > $500, x 34%",1009.8,percent of total billed charges,Implant Device,1039.5,35,,1039.5,percent of total billed charges,Implant Device,1039.5,35,,1039.5,percent of total billed charges,Implant Device,1039.5,35,,1039.5,percent of total billed charges,Implant Device,1039.5,35,,1039.5,percent of total billed charges,Implant Device,1039.5,35,,1039.5,percent of total billed charges,Implant Device,1188,40,,1188,percent of total billed charges,Implant Device,1039.5,70,,1039.5,percent of total billed charges,All Other,1009.8,34,,1009.8,percent of total billed charges,Implant Device,1009.8,34,,1009.8,percent of total billed charges,Implant Device,1039.5,35,,1039.5,percent of total billed charges,Implant Device,1039.5,35,,1039.5,percent of total billed charges,Implant Device,1039.5,35,,1039.5,percent of total billed charges,Implant Device,1039.5,35,,1039.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1009.8,34,"If Charge > 2,000, then 34 percent",1009.8,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2197.81,
DEPUY 02.127-220 3.5X117MM PROX TIB PLT,C1713,HCPCS,,79010021,CDM,278,RC,,,both,,,4394,3251.57,,,3251.57,Other,150% of Medicare + 9.63% HCRA Surcharge,1977.3,45,,1977.3,percent of total billed charges,Critical Access Hospital RCC factor,1493.96,34,,1493.96,percent of total billed charges,Implant Device,1493.96,34,,1493.96,percent of total billed charges,Implant Device,1493.96,34,,1493.96,percent of total billed charges,Implant Device,1493.96,34,,1493.96,percent of total billed charges,Implant Device,1493.96,34,,1493.96,percent of total billed charges,Implant Device,2175.03,,,2175.03,Other,110% of Medicare,1537.9,35,,1537.9,percent of total billed charges,Implant Device,1493.96,34,"Charges > $500, x 34%",1493.96,percent of total billed charges,Implant Device,1537.9,35,,1537.9,percent of total billed charges,Implant Device,1537.9,35,,1537.9,percent of total billed charges,Implant Device,1537.9,35,,1537.9,percent of total billed charges,Implant Device,1537.9,35,,1537.9,percent of total billed charges,Implant Device,1537.9,35,,1537.9,percent of total billed charges,Implant Device,1757.6,40,,1757.6,percent of total billed charges,Implant Device,1537.9,70,,1537.9,percent of total billed charges,All Other,1493.96,34,,1493.96,percent of total billed charges,Implant Device,1493.96,34,,1493.96,percent of total billed charges,Implant Device,1537.9,35,,1537.9,percent of total billed charges,Implant Device,1537.9,35,,1537.9,percent of total billed charges,Implant Device,1537.9,35,,1537.9,percent of total billed charges,Implant Device,1537.9,35,,1537.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1493.96,34,"If Charge > 2,000, then 34 percent",1493.96,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3251.57,
DEPUY 02.127.158 3.5X58MM ANG LOCK SCREW,C1713,HCPCS,,79010022,CDM,278,RC,,,both,,,427,315.98,,,315.98,Other,150% of Medicare + 9.63% HCRA Surcharge,192.15,45,,192.15,percent of total billed charges,Critical Access Hospital RCC factor,145.18,34,,145.18,percent of total billed charges,Implant Device,145.18,34,,145.18,percent of total billed charges,Implant Device,145.18,34,,145.18,percent of total billed charges,Implant Device,145.18,34,,145.18,percent of total billed charges,Implant Device,145.18,34,,145.18,percent of total billed charges,Implant Device,211.37,,,211.37,Other,110% of Medicare,149.45,35,,149.45,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,149.45,35,,149.45,percent of total billed charges,Implant Device,149.45,35,,149.45,percent of total billed charges,Implant Device,149.45,35,,149.45,percent of total billed charges,Implant Device,149.45,35,,149.45,percent of total billed charges,Implant Device,149.45,35,,149.45,percent of total billed charges,Implant Device,170.8,40,,170.8,percent of total billed charges,Implant Device,149.45,70,,149.45,percent of total billed charges,All Other,145.18,34,,145.18,percent of total billed charges,Implant Device,145.18,34,,145.18,percent of total billed charges,Implant Device,149.45,35,,149.45,percent of total billed charges,Implant Device,149.45,35,,149.45,percent of total billed charges,Implant Device,149.45,35,,149.45,percent of total billed charges,Implant Device,149.45,35,,149.45,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,315.98,
DEPUY 02.127.134 3.5X34MM ANG LOCK SCREW,C1713,HCPCS,,79010023,CDM,278,RC,,,both,,,414,306.36,,,306.36,Other,150% of Medicare + 9.63% HCRA Surcharge,186.3,45,,186.3,percent of total billed charges,Critical Access Hospital RCC factor,140.76,34,,140.76,percent of total billed charges,Implant Device,140.76,34,,140.76,percent of total billed charges,Implant Device,140.76,34,,140.76,percent of total billed charges,Implant Device,140.76,34,,140.76,percent of total billed charges,Implant Device,140.76,34,,140.76,percent of total billed charges,Implant Device,204.93,,,204.93,Other,110% of Medicare,144.9,35,,144.9,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,144.9,35,,144.9,percent of total billed charges,Implant Device,144.9,35,,144.9,percent of total billed charges,Implant Device,144.9,35,,144.9,percent of total billed charges,Implant Device,144.9,35,,144.9,percent of total billed charges,Implant Device,144.9,35,,144.9,percent of total billed charges,Implant Device,165.6,40,,165.6,percent of total billed charges,Implant Device,144.9,70,,144.9,percent of total billed charges,All Other,140.76,34,,140.76,percent of total billed charges,Implant Device,140.76,34,,140.76,percent of total billed charges,Implant Device,144.9,35,,144.9,percent of total billed charges,Implant Device,144.9,35,,144.9,percent of total billed charges,Implant Device,144.9,35,,144.9,percent of total billed charges,Implant Device,144.9,35,,144.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,306.36,
ARTHREX AR-8827-12 CORT SCREW 2.7X12MM,C1713,HCPCS,,79010026,CDM,278,RC,,,both,,,135,99.9,,,99.9,Other,150% of Medicare + 9.63% HCRA Surcharge,60.75,45,,60.75,percent of total billed charges,Critical Access Hospital RCC factor,45.9,34,,45.9,percent of total billed charges,Implant Device,45.9,34,,45.9,percent of total billed charges,Implant Device,45.9,34,,45.9,percent of total billed charges,Implant Device,45.9,34,,45.9,percent of total billed charges,Implant Device,45.9,34,,45.9,percent of total billed charges,Implant Device,66.83,,,66.83,Other,110% of Medicare,47.25,35,,47.25,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,47.25,35,,47.25,percent of total billed charges,Implant Device,47.25,35,,47.25,percent of total billed charges,Implant Device,47.25,35,,47.25,percent of total billed charges,Implant Device,47.25,35,,47.25,percent of total billed charges,Implant Device,47.25,35,,47.25,percent of total billed charges,Implant Device,54,40,,54,percent of total billed charges,Implant Device,47.25,70,,47.25,percent of total billed charges,All Other,45.9,34,,45.9,percent of total billed charges,Implant Device,45.9,34,,45.9,percent of total billed charges,Implant Device,47.25,35,,47.25,percent of total billed charges,Implant Device,47.25,35,,47.25,percent of total billed charges,Implant Device,47.25,35,,47.25,percent of total billed charges,Implant Device,47.25,35,,47.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,99.9,
ARTHREX AR-8840C-40 SCREW 4.0X40MM,C1713,HCPCS,,79010027,CDM,278,RC,,,both,,,708,523.92,,,523.92,Other,150% of Medicare + 9.63% HCRA Surcharge,318.6,45,,318.6,percent of total billed charges,Critical Access Hospital RCC factor,240.72,34,,240.72,percent of total billed charges,Implant Device,240.72,34,,240.72,percent of total billed charges,Implant Device,240.72,34,,240.72,percent of total billed charges,Implant Device,240.72,34,,240.72,percent of total billed charges,Implant Device,240.72,34,,240.72,percent of total billed charges,Implant Device,350.46,,,350.46,Other,110% of Medicare,247.8,35,,247.8,percent of total billed charges,Implant Device,240.72,34,"Charges > $500, x 34%",240.72,percent of total billed charges,Implant Device,247.8,35,,247.8,percent of total billed charges,Implant Device,247.8,35,,247.8,percent of total billed charges,Implant Device,247.8,35,,247.8,percent of total billed charges,Implant Device,247.8,35,,247.8,percent of total billed charges,Implant Device,247.8,35,,247.8,percent of total billed charges,Implant Device,283.2,40,,283.2,percent of total billed charges,Implant Device,247.8,70,,247.8,percent of total billed charges,All Other,240.72,34,,240.72,percent of total billed charges,Implant Device,240.72,34,,240.72,percent of total billed charges,Implant Device,247.8,35,,247.8,percent of total billed charges,Implant Device,247.8,35,,247.8,percent of total billed charges,Implant Device,247.8,35,,247.8,percent of total billed charges,Implant Device,247.8,35,,247.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,523.92,
ARTHREX AR-8973DS FIBULOCK SYSTEM,C1713,HCPCS,,79010029,CDM,278,RC,,,both,,,2100,1554.01,,,1554.01,Other,150% of Medicare + 9.63% HCRA Surcharge,945,45,,945,percent of total billed charges,Critical Access Hospital RCC factor,714,34,,714,percent of total billed charges,Implant Device,714,34,,714,percent of total billed charges,Implant Device,714,34,,714,percent of total billed charges,Implant Device,714,34,,714,percent of total billed charges,Implant Device,714,34,,714,percent of total billed charges,Implant Device,1039.5,,,1039.5,Other,110% of Medicare,735,35,,735,percent of total billed charges,Implant Device,714,34,"Charges > $500, x 34%",714,percent of total billed charges,Implant Device,735,35,,735,percent of total billed charges,Implant Device,735,35,,735,percent of total billed charges,Implant Device,735,35,,735,percent of total billed charges,Implant Device,735,35,,735,percent of total billed charges,Implant Device,735,35,,735,percent of total billed charges,Implant Device,840,40,,840,percent of total billed charges,Implant Device,735,70,,735,percent of total billed charges,All Other,714,34,,714,percent of total billed charges,Implant Device,714,34,,714,percent of total billed charges,Implant Device,735,35,,735,percent of total billed charges,Implant Device,735,35,,735,percent of total billed charges,Implant Device,735,35,,735,percent of total billed charges,Implant Device,735,35,,735,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,714,34,"If Charge > 2,000, then 34 percent",714,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1554.01,
ARTHREX FIB30130R 3.0X130MM FIB NAIL RT,C1713,HCPCS,,79010030,CDM,278,RC,,,both,,,8985,6648.92,,,6648.92,Other,150% of Medicare + 9.63% HCRA Surcharge,4043.25,45,,4043.25,percent of total billed charges,Critical Access Hospital RCC factor,3054.9,34,,3054.9,percent of total billed charges,Implant Device,3054.9,34,,3054.9,percent of total billed charges,Implant Device,3054.9,34,,3054.9,percent of total billed charges,Implant Device,3054.9,34,,3054.9,percent of total billed charges,Implant Device,3054.9,34,,3054.9,percent of total billed charges,Implant Device,4447.58,,,4447.58,Other,110% of Medicare,3144.75,35,,3144.75,percent of total billed charges,Implant Device,3054.9,34,"Charges > $500, x 34%",3054.9,percent of total billed charges,Implant Device,3144.75,35,,3144.75,percent of total billed charges,Implant Device,3144.75,35,,3144.75,percent of total billed charges,Implant Device,3144.75,35,,3144.75,percent of total billed charges,Implant Device,3144.75,35,,3144.75,percent of total billed charges,Implant Device,3144.75,35,,3144.75,percent of total billed charges,Implant Device,3594,40,,3594,percent of total billed charges,Implant Device,3144.75,70,,3144.75,percent of total billed charges,All Other,3054.9,34,,3054.9,percent of total billed charges,Implant Device,3054.9,34,,3054.9,percent of total billed charges,Implant Device,3144.75,35,,3144.75,percent of total billed charges,Implant Device,3144.75,35,,3144.75,percent of total billed charges,Implant Device,3144.75,35,,3144.75,percent of total billed charges,Implant Device,3144.75,35,,3144.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3054.9,34,"If Charge > 2,000, then 34 percent",3054.9,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,6648.92,
IN2BONES P70 ST104 COLINK LAT FIB PLT 4H,C1713,HCPCS,,79010032,CDM,278,RC,,,both,,,6000,4440.02,,,4440.02,Other,150% of Medicare + 9.63% HCRA Surcharge,2700,45,,2700,percent of total billed charges,Critical Access Hospital RCC factor,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2970,,,2970,Other,110% of Medicare,2100,35,,2100,percent of total billed charges,Implant Device,2040,34,"Charges > $500, x 34%",2040,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2400,40,,2400,percent of total billed charges,Implant Device,2100,70,,2100,percent of total billed charges,All Other,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2040,34,"If Charge > 2,000, then 34 percent",2040,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4440.02,
IN2BONES P73 ST016 CORT SCREW 3.5X16MM,C1713,HCPCS,,79010033,CDM,278,RC,,,both,,,612,452.88,,,452.88,Other,150% of Medicare + 9.63% HCRA Surcharge,275.4,45,,275.4,percent of total billed charges,Critical Access Hospital RCC factor,208.08,34,,208.08,percent of total billed charges,Implant Device,208.08,34,,208.08,percent of total billed charges,Implant Device,208.08,34,,208.08,percent of total billed charges,Implant Device,208.08,34,,208.08,percent of total billed charges,Implant Device,208.08,34,,208.08,percent of total billed charges,Implant Device,302.94,,,302.94,Other,110% of Medicare,214.2,35,,214.2,percent of total billed charges,Implant Device,208.08,34,"Charges > $500, x 34%",208.08,percent of total billed charges,Implant Device,214.2,35,,214.2,percent of total billed charges,Implant Device,214.2,35,,214.2,percent of total billed charges,Implant Device,214.2,35,,214.2,percent of total billed charges,Implant Device,214.2,35,,214.2,percent of total billed charges,Implant Device,214.2,35,,214.2,percent of total billed charges,Implant Device,244.8,40,,244.8,percent of total billed charges,Implant Device,214.2,70,,214.2,percent of total billed charges,All Other,208.08,34,,208.08,percent of total billed charges,Implant Device,208.08,34,,208.08,percent of total billed charges,Implant Device,214.2,35,,214.2,percent of total billed charges,Implant Device,214.2,35,,214.2,percent of total billed charges,Implant Device,214.2,35,,214.2,percent of total billed charges,Implant Device,214.2,35,,214.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,452.88,
IN2BONES P73 ST018 CORT SCREW 3.5X18MM,C1713,HCPCS,,79010034,CDM,278,RC,,,both,,,612,452.88,,,452.88,Other,150% of Medicare + 9.63% HCRA Surcharge,275.4,45,,275.4,percent of total billed charges,Critical Access Hospital RCC factor,208.08,34,,208.08,percent of total billed charges,Implant Device,208.08,34,,208.08,percent of total billed charges,Implant Device,208.08,34,,208.08,percent of total billed charges,Implant Device,208.08,34,,208.08,percent of total billed charges,Implant Device,208.08,34,,208.08,percent of total billed charges,Implant Device,302.94,,,302.94,Other,110% of Medicare,214.2,35,,214.2,percent of total billed charges,Implant Device,208.08,34,"Charges > $500, x 34%",208.08,percent of total billed charges,Implant Device,214.2,35,,214.2,percent of total billed charges,Implant Device,214.2,35,,214.2,percent of total billed charges,Implant Device,214.2,35,,214.2,percent of total billed charges,Implant Device,214.2,35,,214.2,percent of total billed charges,Implant Device,214.2,35,,214.2,percent of total billed charges,Implant Device,244.8,40,,244.8,percent of total billed charges,Implant Device,214.2,70,,214.2,percent of total billed charges,All Other,208.08,34,,208.08,percent of total billed charges,Implant Device,208.08,34,,208.08,percent of total billed charges,Implant Device,214.2,35,,214.2,percent of total billed charges,Implant Device,214.2,35,,214.2,percent of total billed charges,Implant Device,214.2,35,,214.2,percent of total billed charges,Implant Device,214.2,35,,214.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,452.88,
IN2BONES P72 ST020 CORT SCREW 2.7X20MM,C1713,HCPCS,,79010035,CDM,278,RC,,,both,,,870,643.8,,,643.8,Other,150% of Medicare + 9.63% HCRA Surcharge,391.5,45,,391.5,percent of total billed charges,Critical Access Hospital RCC factor,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,430.65,,,430.65,Other,110% of Medicare,304.5,35,,304.5,percent of total billed charges,Implant Device,295.8,34,"Charges > $500, x 34%",295.8,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,348,40,,348,percent of total billed charges,Implant Device,304.5,70,,304.5,percent of total billed charges,All Other,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,643.8,
ZIMMER 11-301311 ARCOS CON SZ A HI 60MM,C1776,HCPCS,,79010036,CDM,278,RC,,,both,,,19784,14640.21,,,14640.21,Other,150% of Medicare + 9.63% HCRA Surcharge,8902.8,45,,8902.8,percent of total billed charges,Critical Access Hospital RCC factor,6726.56,34,,6726.56,percent of total billed charges,Implant Device,6726.56,34,,6726.56,percent of total billed charges,Implant Device,6726.56,34,,6726.56,percent of total billed charges,Implant Device,6726.56,34,,6726.56,percent of total billed charges,Implant Device,6726.56,34,,6726.56,percent of total billed charges,Implant Device,9793.08,,,9793.08,Other,110% of Medicare,6924.4,35,,6924.4,percent of total billed charges,Implant Device,6726.56,34,"Charges > $500, x 34%",6726.56,percent of total billed charges,Implant Device,6924.4,35,,6924.4,percent of total billed charges,Implant Device,6924.4,35,,6924.4,percent of total billed charges,Implant Device,6924.4,35,,6924.4,percent of total billed charges,Implant Device,6924.4,35,,6924.4,percent of total billed charges,Implant Device,6924.4,35,,6924.4,percent of total billed charges,Implant Device,7913.6,40,,7913.6,percent of total billed charges,Implant Device,6924.4,70,,6924.4,percent of total billed charges,All Other,6726.56,34,,6726.56,percent of total billed charges,Implant Device,6726.56,34,,6726.56,percent of total billed charges,Implant Device,6924.4,35,,6924.4,percent of total billed charges,Implant Device,6924.4,35,,6924.4,percent of total billed charges,Implant Device,6924.4,35,,6924.4,percent of total billed charges,Implant Device,6924.4,35,,6924.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,6726.56,34,"If Charge > 2,000, then 34 percent",6726.56,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,14640.21,
STRYKER 502-11-58F ACETABULAR SHELL 58MM,C1776,HCPCS,,79010037,CDM,278,RC,,,both,,,3150,2331.01,,,2331.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1417.5,45,,1417.5,percent of total billed charges,Critical Access Hospital RCC factor,1071,34,,1071,percent of total billed charges,Implant Device,1071,34,,1071,percent of total billed charges,Implant Device,1071,34,,1071,percent of total billed charges,Implant Device,1071,34,,1071,percent of total billed charges,Implant Device,1071,34,,1071,percent of total billed charges,Implant Device,1559.25,,,1559.25,Other,110% of Medicare,1102.5,35,,1102.5,percent of total billed charges,Implant Device,1071,34,"Charges > $500, x 34%",1071,percent of total billed charges,Implant Device,1102.5,35,,1102.5,percent of total billed charges,Implant Device,1102.5,35,,1102.5,percent of total billed charges,Implant Device,1102.5,35,,1102.5,percent of total billed charges,Implant Device,1102.5,35,,1102.5,percent of total billed charges,Implant Device,1102.5,35,,1102.5,percent of total billed charges,Implant Device,1260,40,,1260,percent of total billed charges,Implant Device,1102.5,70,,1102.5,percent of total billed charges,All Other,1071,34,,1071,percent of total billed charges,Implant Device,1071,34,,1071,percent of total billed charges,Implant Device,1102.5,35,,1102.5,percent of total billed charges,Implant Device,1102.5,35,,1102.5,percent of total billed charges,Implant Device,1102.5,35,,1102.5,percent of total billed charges,Implant Device,1102.5,35,,1102.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1071,34,"If Charge > 2,000, then 34 percent",1071,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2331.01,
STRYKER 623-00-44F INSERT 44MM,C1776,HCPCS,,79010038,CDM,278,RC,,,both,,,3300,2442.01,,,2442.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1485,45,,1485,percent of total billed charges,Critical Access Hospital RCC factor,1122,34,,1122,percent of total billed charges,Implant Device,1122,34,,1122,percent of total billed charges,Implant Device,1122,34,,1122,percent of total billed charges,Implant Device,1122,34,,1122,percent of total billed charges,Implant Device,1122,34,,1122,percent of total billed charges,Implant Device,1633.5,,,1633.5,Other,110% of Medicare,1155,35,,1155,percent of total billed charges,Implant Device,1122,34,"Charges > $500, x 34%",1122,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,1320,40,,1320,percent of total billed charges,Implant Device,1155,70,,1155,percent of total billed charges,All Other,1122,34,,1122,percent of total billed charges,Implant Device,1122,34,,1122,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1122,34,"If Charge > 2,000, then 34 percent",1122,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2442.01,
STRYKER 6721-0837 HIP STEM 37X117MM SZ 8,C1776,HCPCS,,79010039,CDM,278,RC,,,both,,,6750,4995.02,,,4995.02,Other,150% of Medicare + 9.63% HCRA Surcharge,3037.5,45,,3037.5,percent of total billed charges,Critical Access Hospital RCC factor,2295,34,,2295,percent of total billed charges,Implant Device,2295,34,,2295,percent of total billed charges,Implant Device,2295,34,,2295,percent of total billed charges,Implant Device,2295,34,,2295,percent of total billed charges,Implant Device,2295,34,,2295,percent of total billed charges,Implant Device,3341.25,,,3341.25,Other,110% of Medicare,2362.5,35,,2362.5,percent of total billed charges,Implant Device,2295,34,"Charges > $500, x 34%",2295,percent of total billed charges,Implant Device,2362.5,35,,2362.5,percent of total billed charges,Implant Device,2362.5,35,,2362.5,percent of total billed charges,Implant Device,2362.5,35,,2362.5,percent of total billed charges,Implant Device,2362.5,35,,2362.5,percent of total billed charges,Implant Device,2362.5,35,,2362.5,percent of total billed charges,Implant Device,2700,40,,2700,percent of total billed charges,Implant Device,2362.5,70,,2362.5,percent of total billed charges,All Other,2295,34,,2295,percent of total billed charges,Implant Device,2295,34,,2295,percent of total billed charges,Implant Device,2362.5,35,,2362.5,percent of total billed charges,Implant Device,2362.5,35,,2362.5,percent of total billed charges,Implant Device,2362.5,35,,2362.5,percent of total billed charges,Implant Device,2362.5,35,,2362.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2295,34,"If Charge > 2,000, then 34 percent",2295,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4995.02,
STRYKER 6519-1-044 FEMORAL HEAD 44MM,C1776,HCPCS,,79010040,CDM,278,RC,,,both,,,2850,2109.01,,,2109.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1282.5,45,,1282.5,percent of total billed charges,Critical Access Hospital RCC factor,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,1410.75,,,1410.75,Other,110% of Medicare,997.5,35,,997.5,percent of total billed charges,Implant Device,969,34,"Charges > $500, x 34%",969,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,1140,40,,1140,percent of total billed charges,Implant Device,997.5,70,,997.5,percent of total billed charges,All Other,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,969,34,"If Charge > 2,000, then 34 percent",969,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2109.01,
STRYKER 657460 BONE SCREW 3.5X44MM,C1713,HCPCS,,79010043,CDM,278,RC,,,both,,,294,217.56,,,217.56,Other,150% of Medicare + 9.63% HCRA Surcharge,132.3,45,,132.3,percent of total billed charges,Critical Access Hospital RCC factor,99.96,34,,99.96,percent of total billed charges,Implant Device,99.96,34,,99.96,percent of total billed charges,Implant Device,99.96,34,,99.96,percent of total billed charges,Implant Device,99.96,34,,99.96,percent of total billed charges,Implant Device,99.96,34,,99.96,percent of total billed charges,Implant Device,145.53,,,145.53,Other,110% of Medicare,102.9,35,,102.9,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,102.9,35,,102.9,percent of total billed charges,Implant Device,102.9,35,,102.9,percent of total billed charges,Implant Device,102.9,35,,102.9,percent of total billed charges,Implant Device,102.9,35,,102.9,percent of total billed charges,Implant Device,102.9,35,,102.9,percent of total billed charges,Implant Device,117.6,40,,117.6,percent of total billed charges,Implant Device,102.9,70,,102.9,percent of total billed charges,All Other,99.96,34,,99.96,percent of total billed charges,Implant Device,99.96,34,,99.96,percent of total billed charges,Implant Device,102.9,35,,102.9,percent of total billed charges,Implant Device,102.9,35,,102.9,percent of total billed charges,Implant Device,102.9,35,,102.9,percent of total billed charges,Implant Device,102.9,35,,102.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,217.56,
STRYKER 5510-F-502 FEMORAL COMP SZ 5 RT,C1776,HCPCS,,79010046,CDM,278,RC,,,both,,,5100,3774.01,,,3774.01,Other,150% of Medicare + 9.63% HCRA Surcharge,2295,45,,2295,percent of total billed charges,Critical Access Hospital RCC factor,1734,34,,1734,percent of total billed charges,Implant Device,1734,34,,1734,percent of total billed charges,Implant Device,1734,34,,1734,percent of total billed charges,Implant Device,1734,34,,1734,percent of total billed charges,Implant Device,1734,34,,1734,percent of total billed charges,Implant Device,2524.5,,,2524.5,Other,110% of Medicare,1785,35,,1785,percent of total billed charges,Implant Device,1734,34,"Charges > $500, x 34%",1734,percent of total billed charges,Implant Device,1785,35,,1785,percent of total billed charges,Implant Device,1785,35,,1785,percent of total billed charges,Implant Device,1785,35,,1785,percent of total billed charges,Implant Device,1785,35,,1785,percent of total billed charges,Implant Device,1785,35,,1785,percent of total billed charges,Implant Device,2040,40,,2040,percent of total billed charges,Implant Device,1785,70,,1785,percent of total billed charges,All Other,1734,34,,1734,percent of total billed charges,Implant Device,1734,34,,1734,percent of total billed charges,Implant Device,1785,35,,1785,percent of total billed charges,Implant Device,1785,35,,1785,percent of total billed charges,Implant Device,1785,35,,1785,percent of total billed charges,Implant Device,1785,35,,1785,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1734,34,"If Charge > 2,000, then 34 percent",1734,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3774.01,
STRYKER 5520-B-500 TIBIAL BASEPLATE SZ 5,C1776,HCPCS,,79010047,CDM,278,RC,,,both,,,3300,2442.01,,,2442.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1485,45,,1485,percent of total billed charges,Critical Access Hospital RCC factor,1122,34,,1122,percent of total billed charges,Implant Device,1122,34,,1122,percent of total billed charges,Implant Device,1122,34,,1122,percent of total billed charges,Implant Device,1122,34,,1122,percent of total billed charges,Implant Device,1122,34,,1122,percent of total billed charges,Implant Device,1633.5,,,1633.5,Other,110% of Medicare,1155,35,,1155,percent of total billed charges,Implant Device,1122,34,"Charges > $500, x 34%",1122,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,1320,40,,1320,percent of total billed charges,Implant Device,1155,70,,1155,percent of total billed charges,All Other,1122,34,,1122,percent of total billed charges,Implant Device,1122,34,,1122,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1122,34,"If Charge > 2,000, then 34 percent",1122,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2442.01,
STRYKER 5530-G-509 TIBIAL BEARING INSERT,C1776,HCPCS,,79010048,CDM,278,RC,,,both,,,3300,2442.01,,,2442.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1485,45,,1485,percent of total billed charges,Critical Access Hospital RCC factor,1122,34,,1122,percent of total billed charges,Implant Device,1122,34,,1122,percent of total billed charges,Implant Device,1122,34,,1122,percent of total billed charges,Implant Device,1122,34,,1122,percent of total billed charges,Implant Device,1122,34,,1122,percent of total billed charges,Implant Device,1633.5,,,1633.5,Other,110% of Medicare,1155,35,,1155,percent of total billed charges,Implant Device,1122,34,"Charges > $500, x 34%",1122,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,1320,40,,1320,percent of total billed charges,Implant Device,1155,70,,1155,percent of total billed charges,All Other,1122,34,,1122,percent of total billed charges,Implant Device,1122,34,,1122,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1122,34,"If Charge > 2,000, then 34 percent",1122,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2442.01,
STRYKER 5510-F-202 FEMORAL COMP SZ 2 RT,C1776,HCPCS,,79010049,CDM,278,RC,,,both,,,5100,3774.01,,,3774.01,Other,150% of Medicare + 9.63% HCRA Surcharge,2295,45,,2295,percent of total billed charges,Critical Access Hospital RCC factor,1734,34,,1734,percent of total billed charges,Implant Device,1734,34,,1734,percent of total billed charges,Implant Device,1734,34,,1734,percent of total billed charges,Implant Device,1734,34,,1734,percent of total billed charges,Implant Device,1734,34,,1734,percent of total billed charges,Implant Device,2524.5,,,2524.5,Other,110% of Medicare,1785,35,,1785,percent of total billed charges,Implant Device,1734,34,"Charges > $500, x 34%",1734,percent of total billed charges,Implant Device,1785,35,,1785,percent of total billed charges,Implant Device,1785,35,,1785,percent of total billed charges,Implant Device,1785,35,,1785,percent of total billed charges,Implant Device,1785,35,,1785,percent of total billed charges,Implant Device,1785,35,,1785,percent of total billed charges,Implant Device,2040,40,,2040,percent of total billed charges,Implant Device,1785,70,,1785,percent of total billed charges,All Other,1734,34,,1734,percent of total billed charges,Implant Device,1734,34,,1734,percent of total billed charges,Implant Device,1785,35,,1785,percent of total billed charges,Implant Device,1785,35,,1785,percent of total billed charges,Implant Device,1785,35,,1785,percent of total billed charges,Implant Device,1785,35,,1785,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1734,34,"If Charge > 2,000, then 34 percent",1734,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3774.01,
STRYKER 5520-B-200 TIBIAL BASEPLATE SZ 2,C1776,HCPCS,,79010050,CDM,278,RC,,,both,,,3300,2442.01,,,2442.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1485,45,,1485,percent of total billed charges,Critical Access Hospital RCC factor,1122,34,,1122,percent of total billed charges,Implant Device,1122,34,,1122,percent of total billed charges,Implant Device,1122,34,,1122,percent of total billed charges,Implant Device,1122,34,,1122,percent of total billed charges,Implant Device,1122,34,,1122,percent of total billed charges,Implant Device,1633.5,,,1633.5,Other,110% of Medicare,1155,35,,1155,percent of total billed charges,Implant Device,1122,34,"Charges > $500, x 34%",1122,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,1320,40,,1320,percent of total billed charges,Implant Device,1155,70,,1155,percent of total billed charges,All Other,1122,34,,1122,percent of total billed charges,Implant Device,1122,34,,1122,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1122,34,"If Charge > 2,000, then 34 percent",1122,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2442.01,
STRYKER 5530-G-209 TIBIAL BEARING INSERT,C1776,HCPCS,,79010051,CDM,278,RC,,,both,,,3300,2442.01,,,2442.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1485,45,,1485,percent of total billed charges,Critical Access Hospital RCC factor,1122,34,,1122,percent of total billed charges,Implant Device,1122,34,,1122,percent of total billed charges,Implant Device,1122,34,,1122,percent of total billed charges,Implant Device,1122,34,,1122,percent of total billed charges,Implant Device,1122,34,,1122,percent of total billed charges,Implant Device,1633.5,,,1633.5,Other,110% of Medicare,1155,35,,1155,percent of total billed charges,Implant Device,1122,34,"Charges > $500, x 34%",1122,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,1320,40,,1320,percent of total billed charges,Implant Device,1155,70,,1155,percent of total billed charges,All Other,1122,34,,1122,percent of total billed charges,Implant Device,1122,34,,1122,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1122,34,"If Charge > 2,000, then 34 percent",1122,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2442.01,
STRYKER 5551-G-299 PATELLA SIZE A29X9MM,C1776,HCPCS,,79010052,CDM,278,RC,,,both,,,1669,1235.06,,,1235.06,Other,150% of Medicare + 9.63% HCRA Surcharge,751.05,45,,751.05,percent of total billed charges,Critical Access Hospital RCC factor,567.46,34,,567.46,percent of total billed charges,Implant Device,567.46,34,,567.46,percent of total billed charges,Implant Device,567.46,34,,567.46,percent of total billed charges,Implant Device,567.46,34,,567.46,percent of total billed charges,Implant Device,567.46,34,,567.46,percent of total billed charges,Implant Device,826.16,,,826.16,Other,110% of Medicare,584.15,35,,584.15,percent of total billed charges,Implant Device,567.46,34,"Charges > $500, x 34%",567.46,percent of total billed charges,Implant Device,584.15,35,,584.15,percent of total billed charges,Implant Device,584.15,35,,584.15,percent of total billed charges,Implant Device,584.15,35,,584.15,percent of total billed charges,Implant Device,584.15,35,,584.15,percent of total billed charges,Implant Device,584.15,35,,584.15,percent of total billed charges,Implant Device,667.6,40,,667.6,percent of total billed charges,Implant Device,584.15,70,,584.15,percent of total billed charges,All Other,567.46,34,,567.46,percent of total billed charges,Implant Device,567.46,34,,567.46,percent of total billed charges,Implant Device,584.15,35,,584.15,percent of total billed charges,Implant Device,584.15,35,,584.15,percent of total billed charges,Implant Device,584.15,35,,584.15,percent of total billed charges,Implant Device,584.15,35,,584.15,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1235.06,
ZIMMER 00-5988-007-26 TIB BLOCK SZ 7 5MM,C1776,HCPCS,,79010057,CDM,278,RC,,,both,,,3061,2265.15,,,2265.15,Other,150% of Medicare + 9.63% HCRA Surcharge,1377.45,45,,1377.45,percent of total billed charges,Critical Access Hospital RCC factor,1040.74,34,,1040.74,percent of total billed charges,Implant Device,1040.74,34,,1040.74,percent of total billed charges,Implant Device,1040.74,34,,1040.74,percent of total billed charges,Implant Device,1040.74,34,,1040.74,percent of total billed charges,Implant Device,1040.74,34,,1040.74,percent of total billed charges,Implant Device,1515.2,,,1515.2,Other,110% of Medicare,1071.35,35,,1071.35,percent of total billed charges,Implant Device,1040.74,34,"Charges > $500, x 34%",1040.74,percent of total billed charges,Implant Device,1071.35,35,,1071.35,percent of total billed charges,Implant Device,1071.35,35,,1071.35,percent of total billed charges,Implant Device,1071.35,35,,1071.35,percent of total billed charges,Implant Device,1071.35,35,,1071.35,percent of total billed charges,Implant Device,1071.35,35,,1071.35,percent of total billed charges,Implant Device,1224.4,40,,1224.4,percent of total billed charges,Implant Device,1071.35,70,,1071.35,percent of total billed charges,All Other,1040.74,34,,1040.74,percent of total billed charges,Implant Device,1040.74,34,,1040.74,percent of total billed charges,Implant Device,1071.35,35,,1071.35,percent of total billed charges,Implant Device,1071.35,35,,1071.35,percent of total billed charges,Implant Device,1071.35,35,,1071.35,percent of total billed charges,Implant Device,1071.35,35,,1071.35,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1040.74,34,"If Charge > 2,000, then 34 percent",1040.74,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2265.15,
STRYKER 6704-3-091 DALL MILES GRIP PLATE,C1713,HCPCS,,79010058,CDM,278,RC,,,both,,,3607,2669.19,,,2669.19,Other,150% of Medicare + 9.63% HCRA Surcharge,1623.15,45,,1623.15,percent of total billed charges,Critical Access Hospital RCC factor,1226.38,34,,1226.38,percent of total billed charges,Implant Device,1226.38,34,,1226.38,percent of total billed charges,Implant Device,1226.38,34,,1226.38,percent of total billed charges,Implant Device,1226.38,34,,1226.38,percent of total billed charges,Implant Device,1226.38,34,,1226.38,percent of total billed charges,Implant Device,1785.47,,,1785.47,Other,110% of Medicare,1262.45,35,,1262.45,percent of total billed charges,Implant Device,1226.38,34,"Charges > $500, x 34%",1226.38,percent of total billed charges,Implant Device,1262.45,35,,1262.45,percent of total billed charges,Implant Device,1262.45,35,,1262.45,percent of total billed charges,Implant Device,1262.45,35,,1262.45,percent of total billed charges,Implant Device,1262.45,35,,1262.45,percent of total billed charges,Implant Device,1262.45,35,,1262.45,percent of total billed charges,Implant Device,1442.8,40,,1442.8,percent of total billed charges,Implant Device,1262.45,70,,1262.45,percent of total billed charges,All Other,1226.38,34,,1226.38,percent of total billed charges,Implant Device,1226.38,34,,1226.38,percent of total billed charges,Implant Device,1262.45,35,,1262.45,percent of total billed charges,Implant Device,1262.45,35,,1262.45,percent of total billed charges,Implant Device,1262.45,35,,1262.45,percent of total billed charges,Implant Device,1262.45,35,,1262.45,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1226.38,34,"If Charge > 2,000, then 34 percent",1226.38,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2669.19,
ACUMED TR-50904-5 RADIAL 9X4MM,C1776,HCPCS,,79010059,CDM,278,RC,,,both,,,6951,5143.76,,,5143.76,Other,150% of Medicare + 9.63% HCRA Surcharge,3127.95,45,,3127.95,percent of total billed charges,Critical Access Hospital RCC factor,2363.34,34,,2363.34,percent of total billed charges,Implant Device,2363.34,34,,2363.34,percent of total billed charges,Implant Device,2363.34,34,,2363.34,percent of total billed charges,Implant Device,2363.34,34,,2363.34,percent of total billed charges,Implant Device,2363.34,34,,2363.34,percent of total billed charges,Implant Device,3440.75,,,3440.75,Other,110% of Medicare,2432.85,35,,2432.85,percent of total billed charges,Implant Device,2363.34,34,"Charges > $500, x 34%",2363.34,percent of total billed charges,Implant Device,2432.85,35,,2432.85,percent of total billed charges,Implant Device,2432.85,35,,2432.85,percent of total billed charges,Implant Device,2432.85,35,,2432.85,percent of total billed charges,Implant Device,2432.85,35,,2432.85,percent of total billed charges,Implant Device,2432.85,35,,2432.85,percent of total billed charges,Implant Device,2780.4,40,,2780.4,percent of total billed charges,Implant Device,2432.85,70,,2432.85,percent of total billed charges,All Other,2363.34,34,,2363.34,percent of total billed charges,Implant Device,2363.34,34,,2363.34,percent of total billed charges,Implant Device,2432.85,35,,2432.85,percent of total billed charges,Implant Device,2432.85,35,,2432.85,percent of total billed charges,Implant Device,2432.85,35,,2432.85,percent of total billed charges,Implant Device,2432.85,35,,2432.85,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2363.34,34,"If Charge > 2,000, then 34 percent",2363.34,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5143.76,
ACUMED 5001-0222L-S RADIAL HEAD LT 22MM,C1776,HCPCS,,79010060,CDM,278,RC,,,both,,,11196,8285.07,,,8285.07,Other,150% of Medicare + 9.63% HCRA Surcharge,5038.2,45,,5038.2,percent of total billed charges,Critical Access Hospital RCC factor,3806.64,34,,3806.64,percent of total billed charges,Implant Device,3806.64,34,,3806.64,percent of total billed charges,Implant Device,3806.64,34,,3806.64,percent of total billed charges,Implant Device,3806.64,34,,3806.64,percent of total billed charges,Implant Device,3806.64,34,,3806.64,percent of total billed charges,Implant Device,5542.02,,,5542.02,Other,110% of Medicare,3918.6,35,,3918.6,percent of total billed charges,Implant Device,3806.64,34,"Charges > $500, x 34%",3806.64,percent of total billed charges,Implant Device,3918.6,35,,3918.6,percent of total billed charges,Implant Device,3918.6,35,,3918.6,percent of total billed charges,Implant Device,3918.6,35,,3918.6,percent of total billed charges,Implant Device,3918.6,35,,3918.6,percent of total billed charges,Implant Device,3918.6,35,,3918.6,percent of total billed charges,Implant Device,4478.4,40,,4478.4,percent of total billed charges,Implant Device,3918.6,70,,3918.6,percent of total billed charges,All Other,3806.64,34,,3806.64,percent of total billed charges,Implant Device,3806.64,34,,3806.64,percent of total billed charges,Implant Device,3918.6,35,,3918.6,percent of total billed charges,Implant Device,3918.6,35,,3918.6,percent of total billed charges,Implant Device,3918.6,35,,3918.6,percent of total billed charges,Implant Device,3918.6,35,,3918.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3806.64,34,"If Charge > 2,000, then 34 percent",3806.64,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,8285.07,
MIMEDX TN-5220 AMNIOFIX WRAP 2X2CM,C1713,HCPCS,,79010061,CDM,278,RC,,,both,,,2175,1609.51,,,1609.51,Other,150% of Medicare + 9.63% HCRA Surcharge,978.75,45,,978.75,percent of total billed charges,Critical Access Hospital RCC factor,739.5,34,,739.5,percent of total billed charges,Implant Device,739.5,34,,739.5,percent of total billed charges,Implant Device,739.5,34,,739.5,percent of total billed charges,Implant Device,739.5,34,,739.5,percent of total billed charges,Implant Device,739.5,34,,739.5,percent of total billed charges,Implant Device,1076.63,,,1076.63,Other,110% of Medicare,761.25,35,,761.25,percent of total billed charges,Implant Device,739.5,34,"Charges > $500, x 34%",739.5,percent of total billed charges,Implant Device,761.25,35,,761.25,percent of total billed charges,Implant Device,761.25,35,,761.25,percent of total billed charges,Implant Device,761.25,35,,761.25,percent of total billed charges,Implant Device,761.25,35,,761.25,percent of total billed charges,Implant Device,761.25,35,,761.25,percent of total billed charges,Implant Device,870,40,,870,percent of total billed charges,Implant Device,761.25,70,,761.25,percent of total billed charges,All Other,739.5,34,,739.5,percent of total billed charges,Implant Device,739.5,34,,739.5,percent of total billed charges,Implant Device,761.25,35,,761.25,percent of total billed charges,Implant Device,761.25,35,,761.25,percent of total billed charges,Implant Device,761.25,35,,761.25,percent of total billed charges,Implant Device,761.25,35,,761.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,739.5,34,"If Charge > 2,000, then 34 percent",739.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1609.51,
MIMEDX TN-5460 AMNIOFIX WRAP 4X6CM,C1713,HCPCS,,79010062,CDM,278,RC,,,both,,,8328,6162.74,,,6162.74,Other,150% of Medicare + 9.63% HCRA Surcharge,3747.6,45,,3747.6,percent of total billed charges,Critical Access Hospital RCC factor,2831.52,34,,2831.52,percent of total billed charges,Implant Device,2831.52,34,,2831.52,percent of total billed charges,Implant Device,2831.52,34,,2831.52,percent of total billed charges,Implant Device,2831.52,34,,2831.52,percent of total billed charges,Implant Device,2831.52,34,,2831.52,percent of total billed charges,Implant Device,4122.36,,,4122.36,Other,110% of Medicare,2914.8,35,,2914.8,percent of total billed charges,Implant Device,2831.52,34,"Charges > $500, x 34%",2831.52,percent of total billed charges,Implant Device,2914.8,35,,2914.8,percent of total billed charges,Implant Device,2914.8,35,,2914.8,percent of total billed charges,Implant Device,2914.8,35,,2914.8,percent of total billed charges,Implant Device,2914.8,35,,2914.8,percent of total billed charges,Implant Device,2914.8,35,,2914.8,percent of total billed charges,Implant Device,3331.2,40,,3331.2,percent of total billed charges,Implant Device,2914.8,70,,2914.8,percent of total billed charges,All Other,2831.52,34,,2831.52,percent of total billed charges,Implant Device,2831.52,34,,2831.52,percent of total billed charges,Implant Device,2914.8,35,,2914.8,percent of total billed charges,Implant Device,2914.8,35,,2914.8,percent of total billed charges,Implant Device,2914.8,35,,2914.8,percent of total billed charges,Implant Device,2914.8,35,,2914.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2831.52,34,"If Charge > 2,000, then 34 percent",2831.52,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,6162.74,
MIMEDX AU-5760 AMNIOFIX SURGICAL 7X6CM,C1713,HCPCS,,79010063,CDM,278,RC,,,both,,,7785,5760.92,,,5760.92,Other,150% of Medicare + 9.63% HCRA Surcharge,3503.25,45,,3503.25,percent of total billed charges,Critical Access Hospital RCC factor,2646.9,34,,2646.9,percent of total billed charges,Implant Device,2646.9,34,,2646.9,percent of total billed charges,Implant Device,2646.9,34,,2646.9,percent of total billed charges,Implant Device,2646.9,34,,2646.9,percent of total billed charges,Implant Device,2646.9,34,,2646.9,percent of total billed charges,Implant Device,3853.58,,,3853.58,Other,110% of Medicare,2724.75,35,,2724.75,percent of total billed charges,Implant Device,2646.9,34,"Charges > $500, x 34%",2646.9,percent of total billed charges,Implant Device,2724.75,35,,2724.75,percent of total billed charges,Implant Device,2724.75,35,,2724.75,percent of total billed charges,Implant Device,2724.75,35,,2724.75,percent of total billed charges,Implant Device,2724.75,35,,2724.75,percent of total billed charges,Implant Device,2724.75,35,,2724.75,percent of total billed charges,Implant Device,3114,40,,3114,percent of total billed charges,Implant Device,2724.75,70,,2724.75,percent of total billed charges,All Other,2646.9,34,,2646.9,percent of total billed charges,Implant Device,2646.9,34,,2646.9,percent of total billed charges,Implant Device,2724.75,35,,2724.75,percent of total billed charges,Implant Device,2724.75,35,,2724.75,percent of total billed charges,Implant Device,2724.75,35,,2724.75,percent of total billed charges,Implant Device,2724.75,35,,2724.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2646.9,34,"If Charge > 2,000, then 34 percent",2646.9,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5760.92,
MIMEDX APS-5260 AMNIOFIX SURGICAL 2X6CM,C1713,HCPCS,,79010064,CDM,278,RC,,,both,,,2010,1487.41,,,1487.41,Other,150% of Medicare + 9.63% HCRA Surcharge,904.5,45,,904.5,percent of total billed charges,Critical Access Hospital RCC factor,683.4,34,,683.4,percent of total billed charges,Implant Device,683.4,34,,683.4,percent of total billed charges,Implant Device,683.4,34,,683.4,percent of total billed charges,Implant Device,683.4,34,,683.4,percent of total billed charges,Implant Device,683.4,34,,683.4,percent of total billed charges,Implant Device,994.95,,,994.95,Other,110% of Medicare,703.5,35,,703.5,percent of total billed charges,Implant Device,683.4,34,"Charges > $500, x 34%",683.4,percent of total billed charges,Implant Device,703.5,35,,703.5,percent of total billed charges,Implant Device,703.5,35,,703.5,percent of total billed charges,Implant Device,703.5,35,,703.5,percent of total billed charges,Implant Device,703.5,35,,703.5,percent of total billed charges,Implant Device,703.5,35,,703.5,percent of total billed charges,Implant Device,804,40,,804,percent of total billed charges,Implant Device,703.5,70,,703.5,percent of total billed charges,All Other,683.4,34,,683.4,percent of total billed charges,Implant Device,683.4,34,,683.4,percent of total billed charges,Implant Device,703.5,35,,703.5,percent of total billed charges,Implant Device,703.5,35,,703.5,percent of total billed charges,Implant Device,703.5,35,,703.5,percent of total billed charges,Implant Device,703.5,35,,703.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,683.4,34,"If Charge > 2,000, then 34 percent",683.4,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1487.41,
MIMEDX APS-5212 AMNIOFIX SURGICAL 2X12CM,C1713,HCPCS,,79010065,CDM,278,RC,,,both,,,6165,4562.12,,,4562.12,Other,150% of Medicare + 9.63% HCRA Surcharge,2774.25,45,,2774.25,percent of total billed charges,Critical Access Hospital RCC factor,2096.1,34,,2096.1,percent of total billed charges,Implant Device,2096.1,34,,2096.1,percent of total billed charges,Implant Device,2096.1,34,,2096.1,percent of total billed charges,Implant Device,2096.1,34,,2096.1,percent of total billed charges,Implant Device,2096.1,34,,2096.1,percent of total billed charges,Implant Device,3051.68,,,3051.68,Other,110% of Medicare,2157.75,35,,2157.75,percent of total billed charges,Implant Device,2096.1,34,"Charges > $500, x 34%",2096.1,percent of total billed charges,Implant Device,2157.75,35,,2157.75,percent of total billed charges,Implant Device,2157.75,35,,2157.75,percent of total billed charges,Implant Device,2157.75,35,,2157.75,percent of total billed charges,Implant Device,2157.75,35,,2157.75,percent of total billed charges,Implant Device,2157.75,35,,2157.75,percent of total billed charges,Implant Device,2466,40,,2466,percent of total billed charges,Implant Device,2157.75,70,,2157.75,percent of total billed charges,All Other,2096.1,34,,2096.1,percent of total billed charges,Implant Device,2096.1,34,,2096.1,percent of total billed charges,Implant Device,2157.75,35,,2157.75,percent of total billed charges,Implant Device,2157.75,35,,2157.75,percent of total billed charges,Implant Device,2157.75,35,,2157.75,percent of total billed charges,Implant Device,2157.75,35,,2157.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2096.1,34,"If Charge > 2,000, then 34 percent",2096.1,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4562.12,
STRYKER 5510-F-301 FEMORAL COMP SZ 3 LT,C1776,HCPCS,,79010066,CDM,278,RC,,,both,,,4450,3293.01,,,3293.01,Other,150% of Medicare + 9.63% HCRA Surcharge,2002.5,45,,2002.5,percent of total billed charges,Critical Access Hospital RCC factor,1513,34,,1513,percent of total billed charges,Implant Device,1513,34,,1513,percent of total billed charges,Implant Device,1513,34,,1513,percent of total billed charges,Implant Device,1513,34,,1513,percent of total billed charges,Implant Device,1513,34,,1513,percent of total billed charges,Implant Device,2202.75,,,2202.75,Other,110% of Medicare,1557.5,35,,1557.5,percent of total billed charges,Implant Device,1513,34,"Charges > $500, x 34%",1513,percent of total billed charges,Implant Device,1557.5,35,,1557.5,percent of total billed charges,Implant Device,1557.5,35,,1557.5,percent of total billed charges,Implant Device,1557.5,35,,1557.5,percent of total billed charges,Implant Device,1557.5,35,,1557.5,percent of total billed charges,Implant Device,1557.5,35,,1557.5,percent of total billed charges,Implant Device,1780,40,,1780,percent of total billed charges,Implant Device,1557.5,70,,1557.5,percent of total billed charges,All Other,1513,34,,1513,percent of total billed charges,Implant Device,1513,34,,1513,percent of total billed charges,Implant Device,1557.5,35,,1557.5,percent of total billed charges,Implant Device,1557.5,35,,1557.5,percent of total billed charges,Implant Device,1557.5,35,,1557.5,percent of total billed charges,Implant Device,1557.5,35,,1557.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1513,34,"If Charge > 2,000, then 34 percent",1513,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3293.01,
STRYKER 5520-B-300 TIB BASEPLATE SZ 3,C1776,HCPCS,,79010067,CDM,278,RC,,,both,,,3300,2442.01,,,2442.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1485,45,,1485,percent of total billed charges,Critical Access Hospital RCC factor,1122,34,,1122,percent of total billed charges,Implant Device,1122,34,,1122,percent of total billed charges,Implant Device,1122,34,,1122,percent of total billed charges,Implant Device,1122,34,,1122,percent of total billed charges,Implant Device,1122,34,,1122,percent of total billed charges,Implant Device,1633.5,,,1633.5,Other,110% of Medicare,1155,35,,1155,percent of total billed charges,Implant Device,1122,34,"Charges > $500, x 34%",1122,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,1320,40,,1320,percent of total billed charges,Implant Device,1155,70,,1155,percent of total billed charges,All Other,1122,34,,1122,percent of total billed charges,Implant Device,1122,34,,1122,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1122,34,"If Charge > 2,000, then 34 percent",1122,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2442.01,
STRYKER 5530-G-311 TIB INSERT SZ 3 11MM,C1776,HCPCS,,79010068,CDM,278,RC,,,both,,,3300,2442.01,,,2442.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1485,45,,1485,percent of total billed charges,Critical Access Hospital RCC factor,1122,34,,1122,percent of total billed charges,Implant Device,1122,34,,1122,percent of total billed charges,Implant Device,1122,34,,1122,percent of total billed charges,Implant Device,1122,34,,1122,percent of total billed charges,Implant Device,1122,34,,1122,percent of total billed charges,Implant Device,1633.5,,,1633.5,Other,110% of Medicare,1155,35,,1155,percent of total billed charges,Implant Device,1122,34,"Charges > $500, x 34%",1122,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,1320,40,,1320,percent of total billed charges,Implant Device,1155,70,,1155,percent of total billed charges,All Other,1122,34,,1122,percent of total billed charges,Implant Device,1122,34,,1122,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1122,34,"If Charge > 2,000, then 34 percent",1122,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2442.01,
WRIGHT 4700010 SWANSON FINGER JOINT #0,C1776,HCPCS,,79010069,CDM,278,RC,,,both,,,4989,3691.87,,,3691.87,Other,150% of Medicare + 9.63% HCRA Surcharge,2245.05,45,,2245.05,percent of total billed charges,Critical Access Hospital RCC factor,1696.26,34,,1696.26,percent of total billed charges,Implant Device,1696.26,34,,1696.26,percent of total billed charges,Implant Device,1696.26,34,,1696.26,percent of total billed charges,Implant Device,1696.26,34,,1696.26,percent of total billed charges,Implant Device,1696.26,34,,1696.26,percent of total billed charges,Implant Device,2469.56,,,2469.56,Other,110% of Medicare,1746.15,35,,1746.15,percent of total billed charges,Implant Device,1696.26,34,"Charges > $500, x 34%",1696.26,percent of total billed charges,Implant Device,1746.15,35,,1746.15,percent of total billed charges,Implant Device,1746.15,35,,1746.15,percent of total billed charges,Implant Device,1746.15,35,,1746.15,percent of total billed charges,Implant Device,1746.15,35,,1746.15,percent of total billed charges,Implant Device,1746.15,35,,1746.15,percent of total billed charges,Implant Device,1995.6,40,,1995.6,percent of total billed charges,Implant Device,1746.15,70,,1746.15,percent of total billed charges,All Other,1696.26,34,,1696.26,percent of total billed charges,Implant Device,1696.26,34,,1696.26,percent of total billed charges,Implant Device,1746.15,35,,1746.15,percent of total billed charges,Implant Device,1746.15,35,,1746.15,percent of total billed charges,Implant Device,1746.15,35,,1746.15,percent of total billed charges,Implant Device,1746.15,35,,1746.15,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1696.26,34,"If Charge > 2,000, then 34 percent",1696.26,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3691.87,
ZIMMER 00-7711-005-10 FEM STEM SZ 5,C1776,HCPCS,,79010070,CDM,278,RC,,,both,,,6900,5106.02,,,5106.02,Other,150% of Medicare + 9.63% HCRA Surcharge,3105,45,,3105,percent of total billed charges,Critical Access Hospital RCC factor,2346,34,,2346,percent of total billed charges,Implant Device,2346,34,,2346,percent of total billed charges,Implant Device,2346,34,,2346,percent of total billed charges,Implant Device,2346,34,,2346,percent of total billed charges,Implant Device,2346,34,,2346,percent of total billed charges,Implant Device,3415.5,,,3415.5,Other,110% of Medicare,2415,35,,2415,percent of total billed charges,Implant Device,2346,34,"Charges > $500, x 34%",2346,percent of total billed charges,Implant Device,2415,35,,2415,percent of total billed charges,Implant Device,2415,35,,2415,percent of total billed charges,Implant Device,2415,35,,2415,percent of total billed charges,Implant Device,2415,35,,2415,percent of total billed charges,Implant Device,2415,35,,2415,percent of total billed charges,Implant Device,2760,40,,2760,percent of total billed charges,Implant Device,2415,70,,2415,percent of total billed charges,All Other,2346,34,,2346,percent of total billed charges,Implant Device,2346,34,,2346,percent of total billed charges,Implant Device,2415,35,,2415,percent of total billed charges,Implant Device,2415,35,,2415,percent of total billed charges,Implant Device,2415,35,,2415,percent of total billed charges,Implant Device,2415,35,,2415,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2346,34,"If Charge > 2,000, then 34 percent",2346,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5106.02,
ZIMMER 00-5976-050-14 ART SURF BLUE 14MM,C1776,HCPCS,,79010072,CDM,278,RC,,,both,,,2250,1665.01,,,1665.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1012.5,45,,1012.5,percent of total billed charges,Critical Access Hospital RCC factor,765,34,,765,percent of total billed charges,Implant Device,765,34,,765,percent of total billed charges,Implant Device,765,34,,765,percent of total billed charges,Implant Device,765,34,,765,percent of total billed charges,Implant Device,765,34,,765,percent of total billed charges,Implant Device,1113.75,,,1113.75,Other,110% of Medicare,787.5,35,,787.5,percent of total billed charges,Implant Device,765,34,"Charges > $500, x 34%",765,percent of total billed charges,Implant Device,787.5,35,,787.5,percent of total billed charges,Implant Device,787.5,35,,787.5,percent of total billed charges,Implant Device,787.5,35,,787.5,percent of total billed charges,Implant Device,787.5,35,,787.5,percent of total billed charges,Implant Device,787.5,35,,787.5,percent of total billed charges,Implant Device,900,40,,900,percent of total billed charges,Implant Device,787.5,70,,787.5,percent of total billed charges,All Other,765,34,,765,percent of total billed charges,Implant Device,765,34,,765,percent of total billed charges,Implant Device,787.5,35,,787.5,percent of total billed charges,Implant Device,787.5,35,,787.5,percent of total billed charges,Implant Device,787.5,35,,787.5,percent of total billed charges,Implant Device,787.5,35,,787.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,765,34,"If Charge > 2,000, then 34 percent",765,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1665.01,
ZIMMER 00-5950-014-02 FEM COMP SZ D RT,C1776,HCPCS,,79010073,CDM,278,RC,,,both,,,6300,4662.02,,,4662.02,Other,150% of Medicare + 9.63% HCRA Surcharge,2835,45,,2835,percent of total billed charges,Critical Access Hospital RCC factor,2142,34,,2142,percent of total billed charges,Implant Device,2142,34,,2142,percent of total billed charges,Implant Device,2142,34,,2142,percent of total billed charges,Implant Device,2142,34,,2142,percent of total billed charges,Implant Device,2142,34,,2142,percent of total billed charges,Implant Device,3118.5,,,3118.5,Other,110% of Medicare,2205,35,,2205,percent of total billed charges,Implant Device,2142,34,"Charges > $500, x 34%",2142,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2520,40,,2520,percent of total billed charges,Implant Device,2205,70,,2205,percent of total billed charges,All Other,2142,34,,2142,percent of total billed charges,Implant Device,2142,34,,2142,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2142,34,"If Charge > 2,000, then 34 percent",2142,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4662.02,
ZIMMER 11-301313 CONE PRX BODY SZ C 60MM,C1776,HCPCS,,79010074,CDM,278,RC,,,both,,,21456,15877.49,,,15877.49,Other,150% of Medicare + 9.63% HCRA Surcharge,9655.2,45,,9655.2,percent of total billed charges,Critical Access Hospital RCC factor,7295.04,34,,7295.04,percent of total billed charges,Implant Device,7295.04,34,,7295.04,percent of total billed charges,Implant Device,7295.04,34,,7295.04,percent of total billed charges,Implant Device,7295.04,34,,7295.04,percent of total billed charges,Implant Device,7295.04,34,,7295.04,percent of total billed charges,Implant Device,10620.72,,,10620.72,Other,110% of Medicare,7509.6,35,,7509.6,percent of total billed charges,Implant Device,7295.04,34,"Charges > $500, x 34%",7295.04,percent of total billed charges,Implant Device,7509.6,35,,7509.6,percent of total billed charges,Implant Device,7509.6,35,,7509.6,percent of total billed charges,Implant Device,7509.6,35,,7509.6,percent of total billed charges,Implant Device,7509.6,35,,7509.6,percent of total billed charges,Implant Device,7509.6,35,,7509.6,percent of total billed charges,Implant Device,8582.4,40,,8582.4,percent of total billed charges,Implant Device,7509.6,70,,7509.6,percent of total billed charges,All Other,7295.04,34,,7295.04,percent of total billed charges,Implant Device,7295.04,34,,7295.04,percent of total billed charges,Implant Device,7509.6,35,,7509.6,percent of total billed charges,Implant Device,7509.6,35,,7509.6,percent of total billed charges,Implant Device,7509.6,35,,7509.6,percent of total billed charges,Implant Device,7509.6,35,,7509.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,7295.04,34,"If Charge > 2,000, then 34 percent",7295.04,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,15877.49,
MTF HP1616 FLEX HD PLIABLE ACELL DERMIS,C1713,HCPCS,,79010075,CDM,278,RC,,,both,,,7010,5187.42,,,5187.42,Other,150% of Medicare + 9.63% HCRA Surcharge,3154.5,45,,3154.5,percent of total billed charges,Critical Access Hospital RCC factor,2383.4,34,,2383.4,percent of total billed charges,Implant Device,2383.4,34,,2383.4,percent of total billed charges,Implant Device,2383.4,34,,2383.4,percent of total billed charges,Implant Device,2383.4,34,,2383.4,percent of total billed charges,Implant Device,2383.4,34,,2383.4,percent of total billed charges,Implant Device,3469.95,,,3469.95,Other,110% of Medicare,2453.5,35,,2453.5,percent of total billed charges,Implant Device,2383.4,34,"Charges > $500, x 34%",2383.4,percent of total billed charges,Implant Device,2453.5,35,,2453.5,percent of total billed charges,Implant Device,2453.5,35,,2453.5,percent of total billed charges,Implant Device,2453.5,35,,2453.5,percent of total billed charges,Implant Device,2453.5,35,,2453.5,percent of total billed charges,Implant Device,2453.5,35,,2453.5,percent of total billed charges,Implant Device,2804,40,,2804,percent of total billed charges,Implant Device,2453.5,70,,2453.5,percent of total billed charges,All Other,2383.4,34,,2383.4,percent of total billed charges,Implant Device,2383.4,34,,2383.4,percent of total billed charges,Implant Device,2453.5,35,,2453.5,percent of total billed charges,Implant Device,2453.5,35,,2453.5,percent of total billed charges,Implant Device,2453.5,35,,2453.5,percent of total billed charges,Implant Device,2453.5,35,,2453.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2383.4,34,"If Charge > 2,000, then 34 percent",2383.4,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5187.42,
MENTOR 350-4751BC GEL IMPLANT 475CC,C1789,HCPCS,,79010076,CDM,278,RC,,,both,,,2865,2120.11,,,2120.11,Other,150% of Medicare + 9.63% HCRA Surcharge,1289.25,45,,1289.25,percent of total billed charges,Critical Access Hospital RCC factor,974.1,34,,974.1,percent of total billed charges,Implant Device,974.1,34,,974.1,percent of total billed charges,Implant Device,974.1,34,,974.1,percent of total billed charges,Implant Device,974.1,34,,974.1,percent of total billed charges,Implant Device,974.1,34,,974.1,percent of total billed charges,Implant Device,1418.18,,,1418.18,Other,110% of Medicare,1002.75,35,,1002.75,percent of total billed charges,Implant Device,974.1,34,"Charges > $500, x 34%",974.1,percent of total billed charges,Implant Device,1002.75,35,,1002.75,percent of total billed charges,Implant Device,1002.75,35,,1002.75,percent of total billed charges,Implant Device,1002.75,35,,1002.75,percent of total billed charges,Implant Device,1002.75,35,,1002.75,percent of total billed charges,Implant Device,1002.75,35,,1002.75,percent of total billed charges,Implant Device,1146,40,,1146,percent of total billed charges,Implant Device,1002.75,70,,1002.75,percent of total billed charges,All Other,974.1,34,,974.1,percent of total billed charges,Implant Device,974.1,34,,974.1,percent of total billed charges,Implant Device,1002.75,35,,1002.75,percent of total billed charges,Implant Device,1002.75,35,,1002.75,percent of total billed charges,Implant Device,1002.75,35,,1002.75,percent of total billed charges,Implant Device,1002.75,35,,1002.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,974.1,34,"If Charge > 2,000, then 34 percent",974.1,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2120.11,
MENTOR 350-5251BC GEL IMPLANT 525CC,C1789,HCPCS,,79010077,CDM,278,RC,,,both,,,2865,2120.11,,,2120.11,Other,150% of Medicare + 9.63% HCRA Surcharge,1289.25,45,,1289.25,percent of total billed charges,Critical Access Hospital RCC factor,974.1,34,,974.1,percent of total billed charges,Implant Device,974.1,34,,974.1,percent of total billed charges,Implant Device,974.1,34,,974.1,percent of total billed charges,Implant Device,974.1,34,,974.1,percent of total billed charges,Implant Device,974.1,34,,974.1,percent of total billed charges,Implant Device,1418.18,,,1418.18,Other,110% of Medicare,1002.75,35,,1002.75,percent of total billed charges,Implant Device,974.1,34,"Charges > $500, x 34%",974.1,percent of total billed charges,Implant Device,1002.75,35,,1002.75,percent of total billed charges,Implant Device,1002.75,35,,1002.75,percent of total billed charges,Implant Device,1002.75,35,,1002.75,percent of total billed charges,Implant Device,1002.75,35,,1002.75,percent of total billed charges,Implant Device,1002.75,35,,1002.75,percent of total billed charges,Implant Device,1146,40,,1146,percent of total billed charges,Implant Device,1002.75,70,,1002.75,percent of total billed charges,All Other,974.1,34,,974.1,percent of total billed charges,Implant Device,974.1,34,,974.1,percent of total billed charges,Implant Device,1002.75,35,,1002.75,percent of total billed charges,Implant Device,1002.75,35,,1002.75,percent of total billed charges,Implant Device,1002.75,35,,1002.75,percent of total billed charges,Implant Device,1002.75,35,,1002.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,974.1,34,"If Charge > 2,000, then 34 percent",974.1,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2120.11,
MENTOR 350-9114 BREAST TISSUE EXPANDER,C1789,HCPCS,,79010078,CDM,278,RC,,,both,,,5475,4051.51,,,4051.51,Other,150% of Medicare + 9.63% HCRA Surcharge,2463.75,45,,2463.75,percent of total billed charges,Critical Access Hospital RCC factor,1861.5,34,,1861.5,percent of total billed charges,Implant Device,1861.5,34,,1861.5,percent of total billed charges,Implant Device,1861.5,34,,1861.5,percent of total billed charges,Implant Device,1861.5,34,,1861.5,percent of total billed charges,Implant Device,1861.5,34,,1861.5,percent of total billed charges,Implant Device,2710.13,,,2710.13,Other,110% of Medicare,1916.25,35,,1916.25,percent of total billed charges,Implant Device,1861.5,34,"Charges > $500, x 34%",1861.5,percent of total billed charges,Implant Device,1916.25,35,,1916.25,percent of total billed charges,Implant Device,1916.25,35,,1916.25,percent of total billed charges,Implant Device,1916.25,35,,1916.25,percent of total billed charges,Implant Device,1916.25,35,,1916.25,percent of total billed charges,Implant Device,1916.25,35,,1916.25,percent of total billed charges,Implant Device,2190,40,,2190,percent of total billed charges,Implant Device,1916.25,70,,1916.25,percent of total billed charges,All Other,1861.5,34,,1861.5,percent of total billed charges,Implant Device,1861.5,34,,1861.5,percent of total billed charges,Implant Device,1916.25,35,,1916.25,percent of total billed charges,Implant Device,1916.25,35,,1916.25,percent of total billed charges,Implant Device,1916.25,35,,1916.25,percent of total billed charges,Implant Device,1916.25,35,,1916.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1861.5,34,"If Charge > 2,000, then 34 percent",1861.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4051.51,
MENTOR 350-9215 BREAST TISSUE EXPANDER,C1789,HCPCS,,79010079,CDM,278,RC,,,both,,,5475,4051.51,,,4051.51,Other,150% of Medicare + 9.63% HCRA Surcharge,2463.75,45,,2463.75,percent of total billed charges,Critical Access Hospital RCC factor,1861.5,34,,1861.5,percent of total billed charges,Implant Device,1861.5,34,,1861.5,percent of total billed charges,Implant Device,1861.5,34,,1861.5,percent of total billed charges,Implant Device,1861.5,34,,1861.5,percent of total billed charges,Implant Device,1861.5,34,,1861.5,percent of total billed charges,Implant Device,2710.13,,,2710.13,Other,110% of Medicare,1916.25,35,,1916.25,percent of total billed charges,Implant Device,1861.5,34,"Charges > $500, x 34%",1861.5,percent of total billed charges,Implant Device,1916.25,35,,1916.25,percent of total billed charges,Implant Device,1916.25,35,,1916.25,percent of total billed charges,Implant Device,1916.25,35,,1916.25,percent of total billed charges,Implant Device,1916.25,35,,1916.25,percent of total billed charges,Implant Device,1916.25,35,,1916.25,percent of total billed charges,Implant Device,2190,40,,2190,percent of total billed charges,Implant Device,1916.25,70,,1916.25,percent of total billed charges,All Other,1861.5,34,,1861.5,percent of total billed charges,Implant Device,1861.5,34,,1861.5,percent of total billed charges,Implant Device,1916.25,35,,1916.25,percent of total billed charges,Implant Device,1916.25,35,,1916.25,percent of total billed charges,Implant Device,1916.25,35,,1916.25,percent of total billed charges,Implant Device,1916.25,35,,1916.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1861.5,34,"If Charge > 2,000, then 34 percent",1861.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4051.51,
STRYKER 657308 LOCKING SCREW 3.5X8MM,C1713,HCPCS,,79010084,CDM,278,RC,,,both,,,494,365.56,,,365.56,Other,150% of Medicare + 9.63% HCRA Surcharge,222.3,45,,222.3,percent of total billed charges,Critical Access Hospital RCC factor,167.96,34,,167.96,percent of total billed charges,Implant Device,167.96,34,,167.96,percent of total billed charges,Implant Device,167.96,34,,167.96,percent of total billed charges,Implant Device,167.96,34,,167.96,percent of total billed charges,Implant Device,167.96,34,,167.96,percent of total billed charges,Implant Device,244.53,,,244.53,Other,110% of Medicare,172.9,35,,172.9,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,172.9,35,,172.9,percent of total billed charges,Implant Device,172.9,35,,172.9,percent of total billed charges,Implant Device,172.9,35,,172.9,percent of total billed charges,Implant Device,172.9,35,,172.9,percent of total billed charges,Implant Device,172.9,35,,172.9,percent of total billed charges,Implant Device,197.6,40,,197.6,percent of total billed charges,Implant Device,172.9,70,,172.9,percent of total billed charges,All Other,167.96,34,,167.96,percent of total billed charges,Implant Device,167.96,34,,167.96,percent of total billed charges,Implant Device,172.9,35,,172.9,percent of total billed charges,Implant Device,172.9,35,,172.9,percent of total billed charges,Implant Device,172.9,35,,172.9,percent of total billed charges,Implant Device,172.9,35,,172.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,365.56,
NEOTRACT UL400-4 UROLIFT SYSTEM,L8699,HCPCS,,79010088,CDM,278,RC,,,both,,,2925,2164.51,,,2164.51,Other,150% of Medicare + 9.63% HCRA Surcharge,1316.25,45,,1316.25,percent of total billed charges,Critical Access Hospital RCC factor,994.5,34,,994.5,percent of total billed charges,Implant Device,994.5,34,,994.5,percent of total billed charges,Implant Device,994.5,34,,994.5,percent of total billed charges,Implant Device,994.5,34,,994.5,percent of total billed charges,Implant Device,994.5,34,,994.5,percent of total billed charges,Implant Device,1447.88,,,1447.88,Other,110% of Medicare,1023.75,35,,1023.75,percent of total billed charges,Implant Device,994.5,34,"Charges > $500, x 34%",994.5,percent of total billed charges,Implant Device,1023.75,35,,1023.75,percent of total billed charges,Implant Device,1023.75,35,,1023.75,percent of total billed charges,Implant Device,1023.75,35,,1023.75,percent of total billed charges,Implant Device,1023.75,35,,1023.75,percent of total billed charges,Implant Device,1023.75,35,,1023.75,percent of total billed charges,Implant Device,1170,40,,1170,percent of total billed charges,Implant Device,1023.75,70,,1023.75,percent of total billed charges,All Other,994.5,34,,994.5,percent of total billed charges,Implant Device,994.5,34,,994.5,percent of total billed charges,Implant Device,1023.75,35,,1023.75,percent of total billed charges,Implant Device,1023.75,35,,1023.75,percent of total billed charges,Implant Device,1023.75,35,,1023.75,percent of total billed charges,Implant Device,1023.75,35,,1023.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,994.5,34,"If Charge > 2,000, then 34 percent",994.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2164.51,
MTF 471816 FLEX HD ACELL DERMIS 8X16,C1713,HCPCS,,79010089,CDM,278,RC,,,both,,,9868,7302.34,,,7302.34,Other,150% of Medicare + 9.63% HCRA Surcharge,4440.6,45,,4440.6,percent of total billed charges,Critical Access Hospital RCC factor,3355.12,34,,3355.12,percent of total billed charges,Implant Device,3355.12,34,,3355.12,percent of total billed charges,Implant Device,3355.12,34,,3355.12,percent of total billed charges,Implant Device,3355.12,34,,3355.12,percent of total billed charges,Implant Device,3355.12,34,,3355.12,percent of total billed charges,Implant Device,4884.66,,,4884.66,Other,110% of Medicare,3453.8,35,,3453.8,percent of total billed charges,Implant Device,3355.12,34,"Charges > $500, x 34%",3355.12,percent of total billed charges,Implant Device,3453.8,35,,3453.8,percent of total billed charges,Implant Device,3453.8,35,,3453.8,percent of total billed charges,Implant Device,3453.8,35,,3453.8,percent of total billed charges,Implant Device,3453.8,35,,3453.8,percent of total billed charges,Implant Device,3453.8,35,,3453.8,percent of total billed charges,Implant Device,3947.2,40,,3947.2,percent of total billed charges,Implant Device,3453.8,70,,3453.8,percent of total billed charges,All Other,3355.12,34,,3355.12,percent of total billed charges,Implant Device,3355.12,34,,3355.12,percent of total billed charges,Implant Device,3453.8,35,,3453.8,percent of total billed charges,Implant Device,3453.8,35,,3453.8,percent of total billed charges,Implant Device,3453.8,35,,3453.8,percent of total billed charges,Implant Device,3453.8,35,,3453.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3355.12,34,"If Charge > 2,000, then 34 percent",3355.12,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,7302.34,
STRYKER 6720-0435 HIP STEM SZ 4 35X105MM,C1776,HCPCS,,79010090,CDM,278,RC,,,both,,,6953,5145.24,,,5145.24,Other,150% of Medicare + 9.63% HCRA Surcharge,3128.85,45,,3128.85,percent of total billed charges,Critical Access Hospital RCC factor,2364.02,34,,2364.02,percent of total billed charges,Implant Device,2364.02,34,,2364.02,percent of total billed charges,Implant Device,2364.02,34,,2364.02,percent of total billed charges,Implant Device,2364.02,34,,2364.02,percent of total billed charges,Implant Device,2364.02,34,,2364.02,percent of total billed charges,Implant Device,3441.74,,,3441.74,Other,110% of Medicare,2433.55,35,,2433.55,percent of total billed charges,Implant Device,2364.02,34,"Charges > $500, x 34%",2364.02,percent of total billed charges,Implant Device,2433.55,35,,2433.55,percent of total billed charges,Implant Device,2433.55,35,,2433.55,percent of total billed charges,Implant Device,2433.55,35,,2433.55,percent of total billed charges,Implant Device,2433.55,35,,2433.55,percent of total billed charges,Implant Device,2433.55,35,,2433.55,percent of total billed charges,Implant Device,2781.2,40,,2781.2,percent of total billed charges,Implant Device,2433.55,70,,2433.55,percent of total billed charges,All Other,2364.02,34,,2364.02,percent of total billed charges,Implant Device,2364.02,34,,2364.02,percent of total billed charges,Implant Device,2433.55,35,,2433.55,percent of total billed charges,Implant Device,2433.55,35,,2433.55,percent of total billed charges,Implant Device,2433.55,35,,2433.55,percent of total billed charges,Implant Device,2433.55,35,,2433.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2364.02,34,"If Charge > 2,000, then 34 percent",2364.02,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5145.24,
STRYKER 702-04-56F ACETABULAR SHELL 56MM,C1776,HCPCS,,79010091,CDM,278,RC,,,both,,,3337,2469.39,,,2469.39,Other,150% of Medicare + 9.63% HCRA Surcharge,1501.65,45,,1501.65,percent of total billed charges,Critical Access Hospital RCC factor,1134.58,34,,1134.58,percent of total billed charges,Implant Device,1134.58,34,,1134.58,percent of total billed charges,Implant Device,1134.58,34,,1134.58,percent of total billed charges,Implant Device,1134.58,34,,1134.58,percent of total billed charges,Implant Device,1134.58,34,,1134.58,percent of total billed charges,Implant Device,1651.82,,,1651.82,Other,110% of Medicare,1167.95,35,,1167.95,percent of total billed charges,Implant Device,1134.58,34,"Charges > $500, x 34%",1134.58,percent of total billed charges,Implant Device,1167.95,35,,1167.95,percent of total billed charges,Implant Device,1167.95,35,,1167.95,percent of total billed charges,Implant Device,1167.95,35,,1167.95,percent of total billed charges,Implant Device,1167.95,35,,1167.95,percent of total billed charges,Implant Device,1167.95,35,,1167.95,percent of total billed charges,Implant Device,1334.8,40,,1334.8,percent of total billed charges,Implant Device,1167.95,70,,1167.95,percent of total billed charges,All Other,1134.58,34,,1134.58,percent of total billed charges,Implant Device,1134.58,34,,1134.58,percent of total billed charges,Implant Device,1167.95,35,,1167.95,percent of total billed charges,Implant Device,1167.95,35,,1167.95,percent of total billed charges,Implant Device,1167.95,35,,1167.95,percent of total billed charges,Implant Device,1167.95,35,,1167.95,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1134.58,34,"If Charge > 2,000, then 34 percent",1134.58,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2469.39,
STRYKER 7030-6535 HEX SCREW 6.5X35MM,C1713,HCPCS,,79010092,CDM,278,RC,,,both,,,159,117.66,,,117.66,Other,150% of Medicare + 9.63% HCRA Surcharge,71.55,45,,71.55,percent of total billed charges,Critical Access Hospital RCC factor,54.06,34,,54.06,percent of total billed charges,Implant Device,54.06,34,,54.06,percent of total billed charges,Implant Device,54.06,34,,54.06,percent of total billed charges,Implant Device,54.06,34,,54.06,percent of total billed charges,Implant Device,54.06,34,,54.06,percent of total billed charges,Implant Device,78.71,,,78.71,Other,110% of Medicare,55.65,35,,55.65,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,55.65,35,,55.65,percent of total billed charges,Implant Device,55.65,35,,55.65,percent of total billed charges,Implant Device,55.65,35,,55.65,percent of total billed charges,Implant Device,55.65,35,,55.65,percent of total billed charges,Implant Device,55.65,35,,55.65,percent of total billed charges,Implant Device,63.6,40,,63.6,percent of total billed charges,Implant Device,55.65,70,,55.65,percent of total billed charges,All Other,54.06,34,,54.06,percent of total billed charges,Implant Device,54.06,34,,54.06,percent of total billed charges,Implant Device,55.65,35,,55.65,percent of total billed charges,Implant Device,55.65,35,,55.65,percent of total billed charges,Implant Device,55.65,35,,55.65,percent of total billed charges,Implant Device,55.65,35,,55.65,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,117.66,
EXACTECH 308-10-00 PROX BODY MED +0MM,C1776,HCPCS,,79010093,CDM,278,RC,,,both,,,17730,13120.24,,,13120.24,Other,150% of Medicare + 9.63% HCRA Surcharge,7978.5,45,,7978.5,percent of total billed charges,Critical Access Hospital RCC factor,6028.2,34,,6028.2,percent of total billed charges,Implant Device,6028.2,34,,6028.2,percent of total billed charges,Implant Device,6028.2,34,,6028.2,percent of total billed charges,Implant Device,6028.2,34,,6028.2,percent of total billed charges,Implant Device,6028.2,34,,6028.2,percent of total billed charges,Implant Device,8776.35,,,8776.35,Other,110% of Medicare,6205.5,35,,6205.5,percent of total billed charges,Implant Device,6028.2,34,"Charges > $500, x 34%",6028.2,percent of total billed charges,Implant Device,6205.5,35,,6205.5,percent of total billed charges,Implant Device,6205.5,35,,6205.5,percent of total billed charges,Implant Device,6205.5,35,,6205.5,percent of total billed charges,Implant Device,6205.5,35,,6205.5,percent of total billed charges,Implant Device,6205.5,35,,6205.5,percent of total billed charges,Implant Device,7092,40,,7092,percent of total billed charges,Implant Device,6205.5,70,,6205.5,percent of total billed charges,All Other,6028.2,34,,6028.2,percent of total billed charges,Implant Device,6028.2,34,,6028.2,percent of total billed charges,Implant Device,6205.5,35,,6205.5,percent of total billed charges,Implant Device,6205.5,35,,6205.5,percent of total billed charges,Implant Device,6205.5,35,,6205.5,percent of total billed charges,Implant Device,6205.5,35,,6205.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,6028.2,34,"If Charge > 2,000, then 34 percent",6028.2,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,13120.24,
EXACTECH 308-01-11 DISTAL STEM 11X80MM,C1776,HCPCS,,79010094,CDM,278,RC,,,both,,,16980,12565.24,,,12565.24,Other,150% of Medicare + 9.63% HCRA Surcharge,7641,45,,7641,percent of total billed charges,Critical Access Hospital RCC factor,5773.2,34,,5773.2,percent of total billed charges,Implant Device,5773.2,34,,5773.2,percent of total billed charges,Implant Device,5773.2,34,,5773.2,percent of total billed charges,Implant Device,5773.2,34,,5773.2,percent of total billed charges,Implant Device,5773.2,34,,5773.2,percent of total billed charges,Implant Device,8405.1,,,8405.1,Other,110% of Medicare,5943,35,,5943,percent of total billed charges,Implant Device,5773.2,34,"Charges > $500, x 34%",5773.2,percent of total billed charges,Implant Device,5943,35,,5943,percent of total billed charges,Implant Device,5943,35,,5943,percent of total billed charges,Implant Device,5943,35,,5943,percent of total billed charges,Implant Device,5943,35,,5943,percent of total billed charges,Implant Device,5943,35,,5943,percent of total billed charges,Implant Device,6792,40,,6792,percent of total billed charges,Implant Device,5943,70,,5943,percent of total billed charges,All Other,5773.2,34,,5773.2,percent of total billed charges,Implant Device,5773.2,34,,5773.2,percent of total billed charges,Implant Device,5943,35,,5943,percent of total billed charges,Implant Device,5943,35,,5943,percent of total billed charges,Implant Device,5943,35,,5943,percent of total billed charges,Implant Device,5943,35,,5943,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,5773.2,34,"If Charge > 2,000, then 34 percent",5773.2,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,12565.24,
EXACTECH 308-05-31 DIS FIXTN RING 31.5MM,C1776,HCPCS,,79010095,CDM,278,RC,,,both,,,5454,4035.97,,,4035.97,Other,150% of Medicare + 9.63% HCRA Surcharge,2454.3,45,,2454.3,percent of total billed charges,Critical Access Hospital RCC factor,1854.36,34,,1854.36,percent of total billed charges,Implant Device,1854.36,34,,1854.36,percent of total billed charges,Implant Device,1854.36,34,,1854.36,percent of total billed charges,Implant Device,1854.36,34,,1854.36,percent of total billed charges,Implant Device,1854.36,34,,1854.36,percent of total billed charges,Implant Device,2699.73,,,2699.73,Other,110% of Medicare,1908.9,35,,1908.9,percent of total billed charges,Implant Device,1854.36,34,"Charges > $500, x 34%",1854.36,percent of total billed charges,Implant Device,1908.9,35,,1908.9,percent of total billed charges,Implant Device,1908.9,35,,1908.9,percent of total billed charges,Implant Device,1908.9,35,,1908.9,percent of total billed charges,Implant Device,1908.9,35,,1908.9,percent of total billed charges,Implant Device,1908.9,35,,1908.9,percent of total billed charges,Implant Device,2181.6,40,,2181.6,percent of total billed charges,Implant Device,1908.9,70,,1908.9,percent of total billed charges,All Other,1854.36,34,,1854.36,percent of total billed charges,Implant Device,1854.36,34,,1854.36,percent of total billed charges,Implant Device,1908.9,35,,1908.9,percent of total billed charges,Implant Device,1908.9,35,,1908.9,percent of total billed charges,Implant Device,1908.9,35,,1908.9,percent of total billed charges,Implant Device,1908.9,35,,1908.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1854.36,34,"If Charge > 2,000, then 34 percent",1854.36,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4035.97,
ARTHREX AR-1675BC-CP LA ANKLE IMP SYS,C1713,HCPCS,,79010096,CDM,278,RC,,,both,,,5250,3885.01,,,3885.01,Other,150% of Medicare + 9.63% HCRA Surcharge,2362.5,45,,2362.5,percent of total billed charges,Critical Access Hospital RCC factor,1785,34,,1785,percent of total billed charges,Implant Device,1785,34,,1785,percent of total billed charges,Implant Device,1785,34,,1785,percent of total billed charges,Implant Device,1785,34,,1785,percent of total billed charges,Implant Device,1785,34,,1785,percent of total billed charges,Implant Device,2598.75,,,2598.75,Other,110% of Medicare,1837.5,35,,1837.5,percent of total billed charges,Implant Device,1785,34,"Charges > $500, x 34%",1785,percent of total billed charges,Implant Device,1837.5,35,,1837.5,percent of total billed charges,Implant Device,1837.5,35,,1837.5,percent of total billed charges,Implant Device,1837.5,35,,1837.5,percent of total billed charges,Implant Device,1837.5,35,,1837.5,percent of total billed charges,Implant Device,1837.5,35,,1837.5,percent of total billed charges,Implant Device,2100,40,,2100,percent of total billed charges,Implant Device,1837.5,70,,1837.5,percent of total billed charges,All Other,1785,34,,1785,percent of total billed charges,Implant Device,1785,34,,1785,percent of total billed charges,Implant Device,1837.5,35,,1837.5,percent of total billed charges,Implant Device,1837.5,35,,1837.5,percent of total billed charges,Implant Device,1837.5,35,,1837.5,percent of total billed charges,Implant Device,1837.5,35,,1837.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1785,34,"If Charge > 2,000, then 34 percent",1785,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3885.01,
ALLERGAN 15181216 ALLODERM RTU 12X16CM,C1781,HCPCS,,79010097,CDM,278,RC,,,both,,,15303,11324.26,,,11324.26,Other,150% of Medicare + 9.63% HCRA Surcharge,6886.35,45,,6886.35,percent of total billed charges,Critical Access Hospital RCC factor,5203.02,34,,5203.02,percent of total billed charges,Implant Device,5203.02,34,,5203.02,percent of total billed charges,Implant Device,5203.02,34,,5203.02,percent of total billed charges,Implant Device,5203.02,34,,5203.02,percent of total billed charges,Implant Device,5203.02,34,,5203.02,percent of total billed charges,Implant Device,7574.99,,,7574.99,Other,110% of Medicare,5356.05,35,,5356.05,percent of total billed charges,Implant Device,5203.02,34,"Charges > $500, x 34%",5203.02,percent of total billed charges,Implant Device,5356.05,35,,5356.05,percent of total billed charges,Implant Device,5356.05,35,,5356.05,percent of total billed charges,Implant Device,5356.05,35,,5356.05,percent of total billed charges,Implant Device,5356.05,35,,5356.05,percent of total billed charges,Implant Device,5356.05,35,,5356.05,percent of total billed charges,Implant Device,6121.2,40,,6121.2,percent of total billed charges,Implant Device,5356.05,70,,5356.05,percent of total billed charges,All Other,5203.02,34,,5203.02,percent of total billed charges,Implant Device,5203.02,34,,5203.02,percent of total billed charges,Implant Device,5356.05,35,,5356.05,percent of total billed charges,Implant Device,5356.05,35,,5356.05,percent of total billed charges,Implant Device,5356.05,35,,5356.05,percent of total billed charges,Implant Device,5356.05,35,,5356.05,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,5203.02,34,"If Charge > 2,000, then 34 percent",5203.02,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,11324.26,
DEPUY 02.123.029 PERIART HUM PLT 10H,C1713,HCPCS,,79010098,CDM,278,RC,,,both,,,4715,3489.11,,,3489.11,Other,150% of Medicare + 9.63% HCRA Surcharge,2121.75,45,,2121.75,percent of total billed charges,Critical Access Hospital RCC factor,1603.1,34,,1603.1,percent of total billed charges,Implant Device,1603.1,34,,1603.1,percent of total billed charges,Implant Device,1603.1,34,,1603.1,percent of total billed charges,Implant Device,1603.1,34,,1603.1,percent of total billed charges,Implant Device,1603.1,34,,1603.1,percent of total billed charges,Implant Device,2333.93,,,2333.93,Other,110% of Medicare,1650.25,35,,1650.25,percent of total billed charges,Implant Device,1603.1,34,"Charges > $500, x 34%",1603.1,percent of total billed charges,Implant Device,1650.25,35,,1650.25,percent of total billed charges,Implant Device,1650.25,35,,1650.25,percent of total billed charges,Implant Device,1650.25,35,,1650.25,percent of total billed charges,Implant Device,1650.25,35,,1650.25,percent of total billed charges,Implant Device,1650.25,35,,1650.25,percent of total billed charges,Implant Device,1886,40,,1886,percent of total billed charges,Implant Device,1650.25,70,,1650.25,percent of total billed charges,All Other,1603.1,34,,1603.1,percent of total billed charges,Implant Device,1603.1,34,,1603.1,percent of total billed charges,Implant Device,1650.25,35,,1650.25,percent of total billed charges,Implant Device,1650.25,35,,1650.25,percent of total billed charges,Implant Device,1650.25,35,,1650.25,percent of total billed charges,Implant Device,1650.25,35,,1650.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1603.1,34,"If Charge > 2,000, then 34 percent",1603.1,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3489.11,
ARTHREX-AR-8945-32PT CANN SCREW 4.5X32MM,C1713,HCPCS,,79010099,CDM,278,RC,,,both,,,750,555,,,555,Other,150% of Medicare + 9.63% HCRA Surcharge,337.5,45,,337.5,percent of total billed charges,Critical Access Hospital RCC factor,255,34,,255,percent of total billed charges,Implant Device,255,34,,255,percent of total billed charges,Implant Device,255,34,,255,percent of total billed charges,Implant Device,255,34,,255,percent of total billed charges,Implant Device,255,34,,255,percent of total billed charges,Implant Device,371.25,,,371.25,Other,110% of Medicare,262.5,35,,262.5,percent of total billed charges,Implant Device,255,34,"Charges > $500, x 34%",255,percent of total billed charges,Implant Device,262.5,35,,262.5,percent of total billed charges,Implant Device,262.5,35,,262.5,percent of total billed charges,Implant Device,262.5,35,,262.5,percent of total billed charges,Implant Device,262.5,35,,262.5,percent of total billed charges,Implant Device,262.5,35,,262.5,percent of total billed charges,Implant Device,300,40,,300,percent of total billed charges,Implant Device,262.5,70,,262.5,percent of total billed charges,All Other,255,34,,255,percent of total billed charges,Implant Device,255,34,,255,percent of total billed charges,Implant Device,262.5,35,,262.5,percent of total billed charges,Implant Device,262.5,35,,262.5,percent of total billed charges,Implant Device,262.5,35,,262.5,percent of total billed charges,Implant Device,262.5,35,,262.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,555,
ARTHREX ABS-2013-05 ALLOSYNC BONE PUTTY,C1713,HCPCS,,79010100,CDM,278,RC,,,both,,,2400,1776.01,,,1776.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1080,45,,1080,percent of total billed charges,Critical Access Hospital RCC factor,816,34,,816,percent of total billed charges,Implant Device,816,34,,816,percent of total billed charges,Implant Device,816,34,,816,percent of total billed charges,Implant Device,816,34,,816,percent of total billed charges,Implant Device,816,34,,816,percent of total billed charges,Implant Device,1188,,,1188,Other,110% of Medicare,840,35,,840,percent of total billed charges,Implant Device,816,34,"Charges > $500, x 34%",816,percent of total billed charges,Implant Device,840,35,,840,percent of total billed charges,Implant Device,840,35,,840,percent of total billed charges,Implant Device,840,35,,840,percent of total billed charges,Implant Device,840,35,,840,percent of total billed charges,Implant Device,840,35,,840,percent of total billed charges,Implant Device,960,40,,960,percent of total billed charges,Implant Device,840,70,,840,percent of total billed charges,All Other,816,34,,816,percent of total billed charges,Implant Device,816,34,,816,percent of total billed charges,Implant Device,840,35,,840,percent of total billed charges,Implant Device,840,35,,840,percent of total billed charges,Implant Device,840,35,,840,percent of total billed charges,Implant Device,840,35,,840,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,816,34,"If Charge > 2,000, then 34 percent",816,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1776.01,
STRYKER 626830 LAG SCREW 4.1X30MM,C1713,HCPCS,,79010102,CDM,278,RC,,,both,,,927,685.98,,,685.98,Other,150% of Medicare + 9.63% HCRA Surcharge,417.15,45,,417.15,percent of total billed charges,Critical Access Hospital RCC factor,315.18,34,,315.18,percent of total billed charges,Implant Device,315.18,34,,315.18,percent of total billed charges,Implant Device,315.18,34,,315.18,percent of total billed charges,Implant Device,315.18,34,,315.18,percent of total billed charges,Implant Device,315.18,34,,315.18,percent of total billed charges,Implant Device,458.87,,,458.87,Other,110% of Medicare,324.45,35,,324.45,percent of total billed charges,Implant Device,315.18,34,"Charges > $500, x 34%",315.18,percent of total billed charges,Implant Device,324.45,35,,324.45,percent of total billed charges,Implant Device,324.45,35,,324.45,percent of total billed charges,Implant Device,324.45,35,,324.45,percent of total billed charges,Implant Device,324.45,35,,324.45,percent of total billed charges,Implant Device,324.45,35,,324.45,percent of total billed charges,Implant Device,370.8,40,,370.8,percent of total billed charges,Implant Device,324.45,70,,324.45,percent of total billed charges,All Other,315.18,34,,315.18,percent of total billed charges,Implant Device,315.18,34,,315.18,percent of total billed charges,Implant Device,324.45,35,,324.45,percent of total billed charges,Implant Device,324.45,35,,324.45,percent of total billed charges,Implant Device,324.45,35,,324.45,percent of total billed charges,Implant Device,324.45,35,,324.45,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,685.98,
STRYKER 626846 LAG SCREW 4.1X46MM,C1713,HCPCS,,79010103,CDM,278,RC,,,both,,,927,685.98,,,685.98,Other,150% of Medicare + 9.63% HCRA Surcharge,417.15,45,,417.15,percent of total billed charges,Critical Access Hospital RCC factor,315.18,34,,315.18,percent of total billed charges,Implant Device,315.18,34,,315.18,percent of total billed charges,Implant Device,315.18,34,,315.18,percent of total billed charges,Implant Device,315.18,34,,315.18,percent of total billed charges,Implant Device,315.18,34,,315.18,percent of total billed charges,Implant Device,458.87,,,458.87,Other,110% of Medicare,324.45,35,,324.45,percent of total billed charges,Implant Device,315.18,34,"Charges > $500, x 34%",315.18,percent of total billed charges,Implant Device,324.45,35,,324.45,percent of total billed charges,Implant Device,324.45,35,,324.45,percent of total billed charges,Implant Device,324.45,35,,324.45,percent of total billed charges,Implant Device,324.45,35,,324.45,percent of total billed charges,Implant Device,324.45,35,,324.45,percent of total billed charges,Implant Device,370.8,40,,370.8,percent of total billed charges,Implant Device,324.45,70,,324.45,percent of total billed charges,All Other,315.18,34,,315.18,percent of total billed charges,Implant Device,315.18,34,,315.18,percent of total billed charges,Implant Device,324.45,35,,324.45,percent of total billed charges,Implant Device,324.45,35,,324.45,percent of total billed charges,Implant Device,324.45,35,,324.45,percent of total billed charges,Implant Device,324.45,35,,324.45,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,685.98,
STRYKER 626898 POLYAXIAL LOCK PLATE LONG,C1713,HCPCS,,79010104,CDM,278,RC,,,both,,,7729,5719.48,,,5719.48,Other,150% of Medicare + 9.63% HCRA Surcharge,3478.05,45,,3478.05,percent of total billed charges,Critical Access Hospital RCC factor,2627.86,34,,2627.86,percent of total billed charges,Implant Device,2627.86,34,,2627.86,percent of total billed charges,Implant Device,2627.86,34,,2627.86,percent of total billed charges,Implant Device,2627.86,34,,2627.86,percent of total billed charges,Implant Device,2627.86,34,,2627.86,percent of total billed charges,Implant Device,3825.86,,,3825.86,Other,110% of Medicare,2705.15,35,,2705.15,percent of total billed charges,Implant Device,2627.86,34,"Charges > $500, x 34%",2627.86,percent of total billed charges,Implant Device,2705.15,35,,2705.15,percent of total billed charges,Implant Device,2705.15,35,,2705.15,percent of total billed charges,Implant Device,2705.15,35,,2705.15,percent of total billed charges,Implant Device,2705.15,35,,2705.15,percent of total billed charges,Implant Device,2705.15,35,,2705.15,percent of total billed charges,Implant Device,3091.6,40,,3091.6,percent of total billed charges,Implant Device,2705.15,70,,2705.15,percent of total billed charges,All Other,2627.86,34,,2627.86,percent of total billed charges,Implant Device,2627.86,34,,2627.86,percent of total billed charges,Implant Device,2705.15,35,,2705.15,percent of total billed charges,Implant Device,2705.15,35,,2705.15,percent of total billed charges,Implant Device,2705.15,35,,2705.15,percent of total billed charges,Implant Device,2705.15,35,,2705.15,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2627.86,34,"If Charge > 2,000, then 34 percent",2627.86,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5719.48,
DEPUY 208.409 6.5X70MM CANNULATED SCREW,C1713,HCPCS,,79010105,CDM,278,RC,,,both,,,683,505.42,,,505.42,Other,150% of Medicare + 9.63% HCRA Surcharge,307.35,45,,307.35,percent of total billed charges,Critical Access Hospital RCC factor,232.22,34,,232.22,percent of total billed charges,Implant Device,232.22,34,,232.22,percent of total billed charges,Implant Device,232.22,34,,232.22,percent of total billed charges,Implant Device,232.22,34,,232.22,percent of total billed charges,Implant Device,232.22,34,,232.22,percent of total billed charges,Implant Device,338.09,,,338.09,Other,110% of Medicare,239.05,35,,239.05,percent of total billed charges,Implant Device,232.22,34,"Charges > $500, x 34%",232.22,percent of total billed charges,Implant Device,239.05,35,,239.05,percent of total billed charges,Implant Device,239.05,35,,239.05,percent of total billed charges,Implant Device,239.05,35,,239.05,percent of total billed charges,Implant Device,239.05,35,,239.05,percent of total billed charges,Implant Device,239.05,35,,239.05,percent of total billed charges,Implant Device,273.2,40,,273.2,percent of total billed charges,Implant Device,239.05,70,,239.05,percent of total billed charges,All Other,232.22,34,,232.22,percent of total billed charges,Implant Device,232.22,34,,232.22,percent of total billed charges,Implant Device,239.05,35,,239.05,percent of total billed charges,Implant Device,239.05,35,,239.05,percent of total billed charges,Implant Device,239.05,35,,239.05,percent of total billed charges,Implant Device,239.05,35,,239.05,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,505.42,
DEPUY 208.410 6.5X75MM CANNULATED SCREW,C1713,HCPCS,,79010106,CDM,278,RC,,,both,,,683,505.42,,,505.42,Other,150% of Medicare + 9.63% HCRA Surcharge,307.35,45,,307.35,percent of total billed charges,Critical Access Hospital RCC factor,232.22,34,,232.22,percent of total billed charges,Implant Device,232.22,34,,232.22,percent of total billed charges,Implant Device,232.22,34,,232.22,percent of total billed charges,Implant Device,232.22,34,,232.22,percent of total billed charges,Implant Device,232.22,34,,232.22,percent of total billed charges,Implant Device,338.09,,,338.09,Other,110% of Medicare,239.05,35,,239.05,percent of total billed charges,Implant Device,232.22,34,"Charges > $500, x 34%",232.22,percent of total billed charges,Implant Device,239.05,35,,239.05,percent of total billed charges,Implant Device,239.05,35,,239.05,percent of total billed charges,Implant Device,239.05,35,,239.05,percent of total billed charges,Implant Device,239.05,35,,239.05,percent of total billed charges,Implant Device,239.05,35,,239.05,percent of total billed charges,Implant Device,273.2,40,,273.2,percent of total billed charges,Implant Device,239.05,70,,239.05,percent of total billed charges,All Other,232.22,34,,232.22,percent of total billed charges,Implant Device,232.22,34,,232.22,percent of total billed charges,Implant Device,239.05,35,,239.05,percent of total billed charges,Implant Device,239.05,35,,239.05,percent of total billed charges,Implant Device,239.05,35,,239.05,percent of total billed charges,Implant Device,239.05,35,,239.05,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,505.42,
DEPUY 208.473 6.5X85MM CANNULATED SCREW,C1713,HCPCS,,79010107,CDM,278,RC,,,both,,,683,505.42,,,505.42,Other,150% of Medicare + 9.63% HCRA Surcharge,307.35,45,,307.35,percent of total billed charges,Critical Access Hospital RCC factor,232.22,34,,232.22,percent of total billed charges,Implant Device,232.22,34,,232.22,percent of total billed charges,Implant Device,232.22,34,,232.22,percent of total billed charges,Implant Device,232.22,34,,232.22,percent of total billed charges,Implant Device,232.22,34,,232.22,percent of total billed charges,Implant Device,338.09,,,338.09,Other,110% of Medicare,239.05,35,,239.05,percent of total billed charges,Implant Device,232.22,34,"Charges > $500, x 34%",232.22,percent of total billed charges,Implant Device,239.05,35,,239.05,percent of total billed charges,Implant Device,239.05,35,,239.05,percent of total billed charges,Implant Device,239.05,35,,239.05,percent of total billed charges,Implant Device,239.05,35,,239.05,percent of total billed charges,Implant Device,239.05,35,,239.05,percent of total billed charges,Implant Device,273.2,40,,273.2,percent of total billed charges,Implant Device,239.05,70,,239.05,percent of total billed charges,All Other,232.22,34,,232.22,percent of total billed charges,Implant Device,232.22,34,,232.22,percent of total billed charges,Implant Device,239.05,35,,239.05,percent of total billed charges,Implant Device,239.05,35,,239.05,percent of total billed charges,Implant Device,239.05,35,,239.05,percent of total billed charges,Implant Device,239.05,35,,239.05,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,505.42,
STRYKER 6260-9-028 V40 LIFT HEAD 28MM/-4,C1776,HCPCS,,79010108,CDM,278,RC,,,both,,,1391,1029.34,,,1029.34,Other,150% of Medicare + 9.63% HCRA Surcharge,625.95,45,,625.95,percent of total billed charges,Critical Access Hospital RCC factor,472.94,34,,472.94,percent of total billed charges,Implant Device,472.94,34,,472.94,percent of total billed charges,Implant Device,472.94,34,,472.94,percent of total billed charges,Implant Device,472.94,34,,472.94,percent of total billed charges,Implant Device,472.94,34,,472.94,percent of total billed charges,Implant Device,688.55,,,688.55,Other,110% of Medicare,486.85,35,,486.85,percent of total billed charges,Implant Device,472.94,34,"Charges > $500, x 34%",472.94,percent of total billed charges,Implant Device,486.85,35,,486.85,percent of total billed charges,Implant Device,486.85,35,,486.85,percent of total billed charges,Implant Device,486.85,35,,486.85,percent of total billed charges,Implant Device,486.85,35,,486.85,percent of total billed charges,Implant Device,486.85,35,,486.85,percent of total billed charges,Implant Device,556.4,40,,556.4,percent of total billed charges,Implant Device,486.85,70,,486.85,percent of total billed charges,All Other,472.94,34,,472.94,percent of total billed charges,Implant Device,472.94,34,,472.94,percent of total billed charges,Implant Device,486.85,35,,486.85,percent of total billed charges,Implant Device,486.85,35,,486.85,percent of total billed charges,Implant Device,486.85,35,,486.85,percent of total billed charges,Implant Device,486.85,35,,486.85,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1029.34,
STRYKER UH1-48-28 UHR BIPOLAR 28X48MM,C1776,HCPCS,,79010109,CDM,278,RC,,,both,,,1391,1029.34,,,1029.34,Other,150% of Medicare + 9.63% HCRA Surcharge,625.95,45,,625.95,percent of total billed charges,Critical Access Hospital RCC factor,472.94,34,,472.94,percent of total billed charges,Implant Device,472.94,34,,472.94,percent of total billed charges,Implant Device,472.94,34,,472.94,percent of total billed charges,Implant Device,472.94,34,,472.94,percent of total billed charges,Implant Device,472.94,34,,472.94,percent of total billed charges,Implant Device,688.55,,,688.55,Other,110% of Medicare,486.85,35,,486.85,percent of total billed charges,Implant Device,472.94,34,"Charges > $500, x 34%",472.94,percent of total billed charges,Implant Device,486.85,35,,486.85,percent of total billed charges,Implant Device,486.85,35,,486.85,percent of total billed charges,Implant Device,486.85,35,,486.85,percent of total billed charges,Implant Device,486.85,35,,486.85,percent of total billed charges,Implant Device,486.85,35,,486.85,percent of total billed charges,Implant Device,556.4,40,,556.4,percent of total billed charges,Implant Device,486.85,70,,486.85,percent of total billed charges,All Other,472.94,34,,472.94,percent of total billed charges,Implant Device,472.94,34,,472.94,percent of total billed charges,Implant Device,486.85,35,,486.85,percent of total billed charges,Implant Device,486.85,35,,486.85,percent of total billed charges,Implant Device,486.85,35,,486.85,percent of total billed charges,Implant Device,486.85,35,,486.85,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1029.34,
STRYKER 6265-2-003 RELIANCE PF HIP #3/13,C1776,HCPCS,,79010110,CDM,278,RC,,,both,,,3750,2775.01,,,2775.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1687.5,45,,1687.5,percent of total billed charges,Critical Access Hospital RCC factor,1275,34,,1275,percent of total billed charges,Implant Device,1275,34,,1275,percent of total billed charges,Implant Device,1275,34,,1275,percent of total billed charges,Implant Device,1275,34,,1275,percent of total billed charges,Implant Device,1275,34,,1275,percent of total billed charges,Implant Device,1856.25,,,1856.25,Other,110% of Medicare,1312.5,35,,1312.5,percent of total billed charges,Implant Device,1275,34,"Charges > $500, x 34%",1275,percent of total billed charges,Implant Device,1312.5,35,,1312.5,percent of total billed charges,Implant Device,1312.5,35,,1312.5,percent of total billed charges,Implant Device,1312.5,35,,1312.5,percent of total billed charges,Implant Device,1312.5,35,,1312.5,percent of total billed charges,Implant Device,1312.5,35,,1312.5,percent of total billed charges,Implant Device,1500,40,,1500,percent of total billed charges,Implant Device,1312.5,70,,1312.5,percent of total billed charges,All Other,1275,34,,1275,percent of total billed charges,Implant Device,1275,34,,1275,percent of total billed charges,Implant Device,1312.5,35,,1312.5,percent of total billed charges,Implant Device,1312.5,35,,1312.5,percent of total billed charges,Implant Device,1312.5,35,,1312.5,percent of total billed charges,Implant Device,1312.5,35,,1312.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1275,34,"If Charge > 2,000, then 34 percent",1275,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2775.01,
STRYKER UH1-54-28 UHR BIPOLAR 28X54MM,C1776,HCPCS,,79010111,CDM,278,RC,,,both,,,1500,1110,,,1110,Other,150% of Medicare + 9.63% HCRA Surcharge,675,45,,675,percent of total billed charges,Critical Access Hospital RCC factor,510,34,,510,percent of total billed charges,Implant Device,510,34,,510,percent of total billed charges,Implant Device,510,34,,510,percent of total billed charges,Implant Device,510,34,,510,percent of total billed charges,Implant Device,510,34,,510,percent of total billed charges,Implant Device,742.5,,,742.5,Other,110% of Medicare,525,35,,525,percent of total billed charges,Implant Device,510,34,"Charges > $500, x 34%",510,percent of total billed charges,Implant Device,525,35,,525,percent of total billed charges,Implant Device,525,35,,525,percent of total billed charges,Implant Device,525,35,,525,percent of total billed charges,Implant Device,525,35,,525,percent of total billed charges,Implant Device,525,35,,525,percent of total billed charges,Implant Device,600,40,,600,percent of total billed charges,Implant Device,525,70,,525,percent of total billed charges,All Other,510,34,,510,percent of total billed charges,Implant Device,510,34,,510,percent of total billed charges,Implant Device,525,35,,525,percent of total billed charges,Implant Device,525,35,,525,percent of total billed charges,Implant Device,525,35,,525,percent of total billed charges,Implant Device,525,35,,525,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1110,
STRYKER 702-04-52E ACETABULAR SHELL 52MM,C1776,HCPCS,,79010113,CDM,278,RC,,,both,,,3337,2469.39,,,2469.39,Other,150% of Medicare + 9.63% HCRA Surcharge,1501.65,45,,1501.65,percent of total billed charges,Critical Access Hospital RCC factor,1134.58,34,,1134.58,percent of total billed charges,Implant Device,1134.58,34,,1134.58,percent of total billed charges,Implant Device,1134.58,34,,1134.58,percent of total billed charges,Implant Device,1134.58,34,,1134.58,percent of total billed charges,Implant Device,1134.58,34,,1134.58,percent of total billed charges,Implant Device,1651.82,,,1651.82,Other,110% of Medicare,1167.95,35,,1167.95,percent of total billed charges,Implant Device,1134.58,34,"Charges > $500, x 34%",1134.58,percent of total billed charges,Implant Device,1167.95,35,,1167.95,percent of total billed charges,Implant Device,1167.95,35,,1167.95,percent of total billed charges,Implant Device,1167.95,35,,1167.95,percent of total billed charges,Implant Device,1167.95,35,,1167.95,percent of total billed charges,Implant Device,1167.95,35,,1167.95,percent of total billed charges,Implant Device,1334.8,40,,1334.8,percent of total billed charges,Implant Device,1167.95,70,,1167.95,percent of total billed charges,All Other,1134.58,34,,1134.58,percent of total billed charges,Implant Device,1134.58,34,,1134.58,percent of total billed charges,Implant Device,1167.95,35,,1167.95,percent of total billed charges,Implant Device,1167.95,35,,1167.95,percent of total billed charges,Implant Device,1167.95,35,,1167.95,percent of total billed charges,Implant Device,1167.95,35,,1167.95,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1134.58,34,"If Charge > 2,000, then 34 percent",1134.58,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2469.39,
STRYKER 6519-T-204 ADAPTOR SLEEVE +4MM,C1776,HCPCS,,79010114,CDM,278,RC,,,both,,,150,111,,,111,Other,150% of Medicare + 9.63% HCRA Surcharge,67.5,45,,67.5,percent of total billed charges,Critical Access Hospital RCC factor,51,34,,51,percent of total billed charges,Implant Device,51,34,,51,percent of total billed charges,Implant Device,51,34,,51,percent of total billed charges,Implant Device,51,34,,51,percent of total billed charges,Implant Device,51,34,,51,percent of total billed charges,Implant Device,74.25,,,74.25,Other,110% of Medicare,52.5,35,,52.5,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,52.5,35,,52.5,percent of total billed charges,Implant Device,52.5,35,,52.5,percent of total billed charges,Implant Device,52.5,35,,52.5,percent of total billed charges,Implant Device,52.5,35,,52.5,percent of total billed charges,Implant Device,52.5,35,,52.5,percent of total billed charges,Implant Device,60,40,,60,percent of total billed charges,Implant Device,52.5,70,,52.5,percent of total billed charges,All Other,51,34,,51,percent of total billed charges,Implant Device,51,34,,51,percent of total billed charges,Implant Device,52.5,35,,52.5,percent of total billed charges,Implant Device,52.5,35,,52.5,percent of total billed charges,Implant Device,52.5,35,,52.5,percent of total billed charges,Implant Device,52.5,35,,52.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,111,
STRYKER 7030-6530 HEX SCREW 6.5X30MM,C1713,HCPCS,,79010115,CDM,278,RC,,,both,,,159,117.66,,,117.66,Other,150% of Medicare + 9.63% HCRA Surcharge,71.55,45,,71.55,percent of total billed charges,Critical Access Hospital RCC factor,54.06,34,,54.06,percent of total billed charges,Implant Device,54.06,34,,54.06,percent of total billed charges,Implant Device,54.06,34,,54.06,percent of total billed charges,Implant Device,54.06,34,,54.06,percent of total billed charges,Implant Device,54.06,34,,54.06,percent of total billed charges,Implant Device,78.71,,,78.71,Other,110% of Medicare,55.65,35,,55.65,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,55.65,35,,55.65,percent of total billed charges,Implant Device,55.65,35,,55.65,percent of total billed charges,Implant Device,55.65,35,,55.65,percent of total billed charges,Implant Device,55.65,35,,55.65,percent of total billed charges,Implant Device,55.65,35,,55.65,percent of total billed charges,Implant Device,63.6,40,,63.6,percent of total billed charges,Implant Device,55.65,70,,55.65,percent of total billed charges,All Other,54.06,34,,54.06,percent of total billed charges,Implant Device,54.06,34,,54.06,percent of total billed charges,Implant Device,55.65,35,,55.65,percent of total billed charges,Implant Device,55.65,35,,55.65,percent of total billed charges,Implant Device,55.65,35,,55.65,percent of total billed charges,Implant Device,55.65,35,,55.65,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,117.66,
STRYKER EZMXP08-08-08 XPRESS STAPLE,C1713,HCPCS,,79010116,CDM,278,RC,,,both,,,3686,2727.65,,,2727.65,Other,150% of Medicare + 9.63% HCRA Surcharge,1658.7,45,,1658.7,percent of total billed charges,Critical Access Hospital RCC factor,1253.24,34,,1253.24,percent of total billed charges,Implant Device,1253.24,34,,1253.24,percent of total billed charges,Implant Device,1253.24,34,,1253.24,percent of total billed charges,Implant Device,1253.24,34,,1253.24,percent of total billed charges,Implant Device,1253.24,34,,1253.24,percent of total billed charges,Implant Device,1824.57,,,1824.57,Other,110% of Medicare,1290.1,35,,1290.1,percent of total billed charges,Implant Device,1253.24,34,"Charges > $500, x 34%",1253.24,percent of total billed charges,Implant Device,1290.1,35,,1290.1,percent of total billed charges,Implant Device,1290.1,35,,1290.1,percent of total billed charges,Implant Device,1290.1,35,,1290.1,percent of total billed charges,Implant Device,1290.1,35,,1290.1,percent of total billed charges,Implant Device,1290.1,35,,1290.1,percent of total billed charges,Implant Device,1474.4,40,,1474.4,percent of total billed charges,Implant Device,1290.1,70,,1290.1,percent of total billed charges,All Other,1253.24,34,,1253.24,percent of total billed charges,Implant Device,1253.24,34,,1253.24,percent of total billed charges,Implant Device,1290.1,35,,1290.1,percent of total billed charges,Implant Device,1290.1,35,,1290.1,percent of total billed charges,Implant Device,1290.1,35,,1290.1,percent of total billed charges,Implant Device,1290.1,35,,1290.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1253.24,34,"If Charge > 2,000, then 34 percent",1253.24,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2727.65,
STRYKER EZMXP10-10-10 XPRESS STAPLE,C1713,HCPCS,,79010117,CDM,278,RC,,,both,,,3812,2820.89,,,2820.89,Other,150% of Medicare + 9.63% HCRA Surcharge,1715.4,45,,1715.4,percent of total billed charges,Critical Access Hospital RCC factor,1296.08,34,,1296.08,percent of total billed charges,Implant Device,1296.08,34,,1296.08,percent of total billed charges,Implant Device,1296.08,34,,1296.08,percent of total billed charges,Implant Device,1296.08,34,,1296.08,percent of total billed charges,Implant Device,1296.08,34,,1296.08,percent of total billed charges,Implant Device,1886.94,,,1886.94,Other,110% of Medicare,1334.2,35,,1334.2,percent of total billed charges,Implant Device,1296.08,34,"Charges > $500, x 34%",1296.08,percent of total billed charges,Implant Device,1334.2,35,,1334.2,percent of total billed charges,Implant Device,1334.2,35,,1334.2,percent of total billed charges,Implant Device,1334.2,35,,1334.2,percent of total billed charges,Implant Device,1334.2,35,,1334.2,percent of total billed charges,Implant Device,1334.2,35,,1334.2,percent of total billed charges,Implant Device,1524.8,40,,1524.8,percent of total billed charges,Implant Device,1334.2,70,,1334.2,percent of total billed charges,All Other,1296.08,34,,1296.08,percent of total billed charges,Implant Device,1296.08,34,,1296.08,percent of total billed charges,Implant Device,1334.2,35,,1334.2,percent of total billed charges,Implant Device,1334.2,35,,1334.2,percent of total billed charges,Implant Device,1334.2,35,,1334.2,percent of total billed charges,Implant Device,1334.2,35,,1334.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1296.08,34,"If Charge > 2,000, then 34 percent",1296.08,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2820.89,
IN2BONES T50 SN012 COMP STAPLE 12X12X12,C1713,HCPCS,,79010119,CDM,278,RC,,,both,,,4860,3596.41,,,3596.41,Other,150% of Medicare + 9.63% HCRA Surcharge,2187,45,,2187,percent of total billed charges,Critical Access Hospital RCC factor,1652.4,34,,1652.4,percent of total billed charges,Implant Device,1652.4,34,,1652.4,percent of total billed charges,Implant Device,1652.4,34,,1652.4,percent of total billed charges,Implant Device,1652.4,34,,1652.4,percent of total billed charges,Implant Device,1652.4,34,,1652.4,percent of total billed charges,Implant Device,2405.7,,,2405.7,Other,110% of Medicare,1701,35,,1701,percent of total billed charges,Implant Device,1652.4,34,"Charges > $500, x 34%",1652.4,percent of total billed charges,Implant Device,1701,35,,1701,percent of total billed charges,Implant Device,1701,35,,1701,percent of total billed charges,Implant Device,1701,35,,1701,percent of total billed charges,Implant Device,1701,35,,1701,percent of total billed charges,Implant Device,1701,35,,1701,percent of total billed charges,Implant Device,1944,40,,1944,percent of total billed charges,Implant Device,1701,70,,1701,percent of total billed charges,All Other,1652.4,34,,1652.4,percent of total billed charges,Implant Device,1652.4,34,,1652.4,percent of total billed charges,Implant Device,1701,35,,1701,percent of total billed charges,Implant Device,1701,35,,1701,percent of total billed charges,Implant Device,1701,35,,1701,percent of total billed charges,Implant Device,1701,35,,1701,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1652.4,34,"If Charge > 2,000, then 34 percent",1652.4,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3596.41,
ZIMMER 1442565 STEINMAN PIN 1.6MMX6',C1713,HCPCS,,79010120,CDM,278,RC,,,both,,,135,99.9,,,99.9,Other,150% of Medicare + 9.63% HCRA Surcharge,60.75,45,,60.75,percent of total billed charges,Critical Access Hospital RCC factor,45.9,34,,45.9,percent of total billed charges,Implant Device,45.9,34,,45.9,percent of total billed charges,Implant Device,45.9,34,,45.9,percent of total billed charges,Implant Device,45.9,34,,45.9,percent of total billed charges,Implant Device,45.9,34,,45.9,percent of total billed charges,Implant Device,66.83,,,66.83,Other,110% of Medicare,47.25,35,,47.25,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,47.25,35,,47.25,percent of total billed charges,Implant Device,47.25,35,,47.25,percent of total billed charges,Implant Device,47.25,35,,47.25,percent of total billed charges,Implant Device,47.25,35,,47.25,percent of total billed charges,Implant Device,47.25,35,,47.25,percent of total billed charges,Implant Device,54,40,,54,percent of total billed charges,Implant Device,47.25,70,,47.25,percent of total billed charges,All Other,45.9,34,,45.9,percent of total billed charges,Implant Device,45.9,34,,45.9,percent of total billed charges,Implant Device,47.25,35,,47.25,percent of total billed charges,Implant Device,47.25,35,,47.25,percent of total billed charges,Implant Device,47.25,35,,47.25,percent of total billed charges,Implant Device,47.25,35,,47.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,99.9,
ZIMMER 110007549 CANN SCREW 4.0X34MM,C1713,HCPCS,,79010121,CDM,278,RC,,,both,,,540,399.6,,,399.6,Other,150% of Medicare + 9.63% HCRA Surcharge,243,45,,243,percent of total billed charges,Critical Access Hospital RCC factor,183.6,34,,183.6,percent of total billed charges,Implant Device,183.6,34,,183.6,percent of total billed charges,Implant Device,183.6,34,,183.6,percent of total billed charges,Implant Device,183.6,34,,183.6,percent of total billed charges,Implant Device,183.6,34,,183.6,percent of total billed charges,Implant Device,267.3,,,267.3,Other,110% of Medicare,189,35,,189,percent of total billed charges,Implant Device,183.6,34,"Charges > $500, x 34%",183.6,percent of total billed charges,Implant Device,189,35,,189,percent of total billed charges,Implant Device,189,35,,189,percent of total billed charges,Implant Device,189,35,,189,percent of total billed charges,Implant Device,189,35,,189,percent of total billed charges,Implant Device,189,35,,189,percent of total billed charges,Implant Device,216,40,,216,percent of total billed charges,Implant Device,189,70,,189,percent of total billed charges,All Other,183.6,34,,183.6,percent of total billed charges,Implant Device,183.6,34,,183.6,percent of total billed charges,Implant Device,189,35,,189,percent of total billed charges,Implant Device,189,35,,189,percent of total billed charges,Implant Device,189,35,,189,percent of total billed charges,Implant Device,189,35,,189,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,399.6,
IN2BONES T50 SN015 COMP STAPLE 15X12X12,C1713,HCPCS,,79010122,CDM,278,RC,,,both,,,4485,3318.91,,,3318.91,Other,150% of Medicare + 9.63% HCRA Surcharge,2018.25,45,,2018.25,percent of total billed charges,Critical Access Hospital RCC factor,1524.9,34,,1524.9,percent of total billed charges,Implant Device,1524.9,34,,1524.9,percent of total billed charges,Implant Device,1524.9,34,,1524.9,percent of total billed charges,Implant Device,1524.9,34,,1524.9,percent of total billed charges,Implant Device,1524.9,34,,1524.9,percent of total billed charges,Implant Device,2220.08,,,2220.08,Other,110% of Medicare,1569.75,35,,1569.75,percent of total billed charges,Implant Device,1524.9,34,"Charges > $500, x 34%",1524.9,percent of total billed charges,Implant Device,1569.75,35,,1569.75,percent of total billed charges,Implant Device,1569.75,35,,1569.75,percent of total billed charges,Implant Device,1569.75,35,,1569.75,percent of total billed charges,Implant Device,1569.75,35,,1569.75,percent of total billed charges,Implant Device,1569.75,35,,1569.75,percent of total billed charges,Implant Device,1794,40,,1794,percent of total billed charges,Implant Device,1569.75,70,,1569.75,percent of total billed charges,All Other,1524.9,34,,1524.9,percent of total billed charges,Implant Device,1524.9,34,,1524.9,percent of total billed charges,Implant Device,1569.75,35,,1569.75,percent of total billed charges,Implant Device,1569.75,35,,1569.75,percent of total billed charges,Implant Device,1569.75,35,,1569.75,percent of total billed charges,Implant Device,1569.75,35,,1569.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1524.9,34,"If Charge > 2,000, then 34 percent",1524.9,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3318.91,
ACUMED CA-4140 4X14MM CANCELLOUS SCREW,C1713,HCPCS,,79010123,CDM,278,RC,,,both,,,411,304.14,,,304.14,Other,150% of Medicare + 9.63% HCRA Surcharge,184.95,45,,184.95,percent of total billed charges,Critical Access Hospital RCC factor,139.74,34,,139.74,percent of total billed charges,Implant Device,139.74,34,,139.74,percent of total billed charges,Implant Device,139.74,34,,139.74,percent of total billed charges,Implant Device,139.74,34,,139.74,percent of total billed charges,Implant Device,139.74,34,,139.74,percent of total billed charges,Implant Device,203.45,,,203.45,Other,110% of Medicare,143.85,35,,143.85,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,143.85,35,,143.85,percent of total billed charges,Implant Device,143.85,35,,143.85,percent of total billed charges,Implant Device,143.85,35,,143.85,percent of total billed charges,Implant Device,143.85,35,,143.85,percent of total billed charges,Implant Device,143.85,35,,143.85,percent of total billed charges,Implant Device,164.4,40,,164.4,percent of total billed charges,Implant Device,143.85,70,,143.85,percent of total billed charges,All Other,139.74,34,,139.74,percent of total billed charges,Implant Device,139.74,34,,139.74,percent of total billed charges,Implant Device,143.85,35,,143.85,percent of total billed charges,Implant Device,143.85,35,,143.85,percent of total billed charges,Implant Device,143.85,35,,143.85,percent of total billed charges,Implant Device,143.85,35,,143.85,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,304.14,
ACUMED CA-4160 4X16MM CANCELLOUS SCREW,C1713,HCPCS,,79010124,CDM,278,RC,,,both,,,411,304.14,,,304.14,Other,150% of Medicare + 9.63% HCRA Surcharge,184.95,45,,184.95,percent of total billed charges,Critical Access Hospital RCC factor,139.74,34,,139.74,percent of total billed charges,Implant Device,139.74,34,,139.74,percent of total billed charges,Implant Device,139.74,34,,139.74,percent of total billed charges,Implant Device,139.74,34,,139.74,percent of total billed charges,Implant Device,139.74,34,,139.74,percent of total billed charges,Implant Device,203.45,,,203.45,Other,110% of Medicare,143.85,35,,143.85,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,143.85,35,,143.85,percent of total billed charges,Implant Device,143.85,35,,143.85,percent of total billed charges,Implant Device,143.85,35,,143.85,percent of total billed charges,Implant Device,143.85,35,,143.85,percent of total billed charges,Implant Device,143.85,35,,143.85,percent of total billed charges,Implant Device,164.4,40,,164.4,percent of total billed charges,Implant Device,143.85,70,,143.85,percent of total billed charges,All Other,139.74,34,,139.74,percent of total billed charges,Implant Device,139.74,34,,139.74,percent of total billed charges,Implant Device,143.85,35,,143.85,percent of total billed charges,Implant Device,143.85,35,,143.85,percent of total billed charges,Implant Device,143.85,35,,143.85,percent of total billed charges,Implant Device,143.85,35,,143.85,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,304.14,
EXACTECH 320-15-08 HUMERAL LINER 42MM,C1776,HCPCS,,79010126,CDM,278,RC,,,both,,,5925,4384.51,,,4384.51,Other,150% of Medicare + 9.63% HCRA Surcharge,2666.25,45,,2666.25,percent of total billed charges,Critical Access Hospital RCC factor,2014.5,34,,2014.5,percent of total billed charges,Implant Device,2014.5,34,,2014.5,percent of total billed charges,Implant Device,2014.5,34,,2014.5,percent of total billed charges,Implant Device,2014.5,34,,2014.5,percent of total billed charges,Implant Device,2014.5,34,,2014.5,percent of total billed charges,Implant Device,2932.88,,,2932.88,Other,110% of Medicare,2073.75,35,,2073.75,percent of total billed charges,Implant Device,2014.5,34,"Charges > $500, x 34%",2014.5,percent of total billed charges,Implant Device,2073.75,35,,2073.75,percent of total billed charges,Implant Device,2073.75,35,,2073.75,percent of total billed charges,Implant Device,2073.75,35,,2073.75,percent of total billed charges,Implant Device,2073.75,35,,2073.75,percent of total billed charges,Implant Device,2073.75,35,,2073.75,percent of total billed charges,Implant Device,2370,40,,2370,percent of total billed charges,Implant Device,2073.75,70,,2073.75,percent of total billed charges,All Other,2014.5,34,,2014.5,percent of total billed charges,Implant Device,2014.5,34,,2014.5,percent of total billed charges,Implant Device,2073.75,35,,2073.75,percent of total billed charges,Implant Device,2073.75,35,,2073.75,percent of total billed charges,Implant Device,2073.75,35,,2073.75,percent of total billed charges,Implant Device,2073.75,35,,2073.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2014.5,34,"If Charge > 2,000, then 34 percent",2014.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4384.51,
STRYKER 5569-P-2013 HUMERAL STEM 13MM,C1776,HCPCS,,79010127,CDM,278,RC,,,both,,,10500,7770.03,,,7770.03,Other,150% of Medicare + 9.63% HCRA Surcharge,4725,45,,4725,percent of total billed charges,Critical Access Hospital RCC factor,3570,34,,3570,percent of total billed charges,Implant Device,3570,34,,3570,percent of total billed charges,Implant Device,3570,34,,3570,percent of total billed charges,Implant Device,3570,34,,3570,percent of total billed charges,Implant Device,3570,34,,3570,percent of total billed charges,Implant Device,5197.5,,,5197.5,Other,110% of Medicare,3675,35,,3675,percent of total billed charges,Implant Device,3570,34,"Charges > $500, x 34%",3570,percent of total billed charges,Implant Device,3675,35,,3675,percent of total billed charges,Implant Device,3675,35,,3675,percent of total billed charges,Implant Device,3675,35,,3675,percent of total billed charges,Implant Device,3675,35,,3675,percent of total billed charges,Implant Device,3675,35,,3675,percent of total billed charges,Implant Device,4200,40,,4200,percent of total billed charges,Implant Device,3675,70,,3675,percent of total billed charges,All Other,3570,34,,3570,percent of total billed charges,Implant Device,3570,34,,3570,percent of total billed charges,Implant Device,3675,35,,3675,percent of total billed charges,Implant Device,3675,35,,3675,percent of total billed charges,Implant Device,3675,35,,3675,percent of total billed charges,Implant Device,3675,35,,3675,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3570,34,"If Charge > 2,000, then 34 percent",3570,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,7770.03,
STRYKER 5530-G-309 TIB INSERT SZ 3 9MM,C1776,HCPCS,,79010128,CDM,278,RC,,,both,,,3300,2442.01,,,2442.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1485,45,,1485,percent of total billed charges,Critical Access Hospital RCC factor,1122,34,,1122,percent of total billed charges,Implant Device,1122,34,,1122,percent of total billed charges,Implant Device,1122,34,,1122,percent of total billed charges,Implant Device,1122,34,,1122,percent of total billed charges,Implant Device,1122,34,,1122,percent of total billed charges,Implant Device,1633.5,,,1633.5,Other,110% of Medicare,1155,35,,1155,percent of total billed charges,Implant Device,1122,34,"Charges > $500, x 34%",1122,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,1320,40,,1320,percent of total billed charges,Implant Device,1155,70,,1155,percent of total billed charges,All Other,1122,34,,1122,percent of total billed charges,Implant Device,1122,34,,1122,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1122,34,"If Charge > 2,000, then 34 percent",1122,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2442.01,
STRYKER 326100S ASNIS CANN 6.5MM DRILL,C1713,HCPCS,,79010129,CDM,278,RC,,,both,,,765,566.1,,,566.1,Other,150% of Medicare + 9.63% HCRA Surcharge,344.25,45,,344.25,percent of total billed charges,Critical Access Hospital RCC factor,260.1,34,,260.1,percent of total billed charges,Implant Device,260.1,34,,260.1,percent of total billed charges,Implant Device,260.1,34,,260.1,percent of total billed charges,Implant Device,260.1,34,,260.1,percent of total billed charges,Implant Device,260.1,34,,260.1,percent of total billed charges,Implant Device,378.68,,,378.68,Other,110% of Medicare,267.75,35,,267.75,percent of total billed charges,Implant Device,260.1,34,"Charges > $500, x 34%",260.1,percent of total billed charges,Implant Device,267.75,35,,267.75,percent of total billed charges,Implant Device,267.75,35,,267.75,percent of total billed charges,Implant Device,267.75,35,,267.75,percent of total billed charges,Implant Device,267.75,35,,267.75,percent of total billed charges,Implant Device,267.75,35,,267.75,percent of total billed charges,Implant Device,306,40,,306,percent of total billed charges,Implant Device,267.75,70,,267.75,percent of total billed charges,All Other,260.1,34,,260.1,percent of total billed charges,Implant Device,260.1,34,,260.1,percent of total billed charges,Implant Device,267.75,35,,267.75,percent of total billed charges,Implant Device,267.75,35,,267.75,percent of total billed charges,Implant Device,267.75,35,,267.75,percent of total billed charges,Implant Device,267.75,35,,267.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,566.1,
STRYKER IC4034 HEADED SCREW 4.0X34MM,C1713,HCPCS,,79010130,CDM,278,RC,,,both,,,961,711.14,,,711.14,Other,150% of Medicare + 9.63% HCRA Surcharge,432.45,45,,432.45,percent of total billed charges,Critical Access Hospital RCC factor,326.74,34,,326.74,percent of total billed charges,Implant Device,326.74,34,,326.74,percent of total billed charges,Implant Device,326.74,34,,326.74,percent of total billed charges,Implant Device,326.74,34,,326.74,percent of total billed charges,Implant Device,326.74,34,,326.74,percent of total billed charges,Implant Device,475.7,,,475.7,Other,110% of Medicare,336.35,35,,336.35,percent of total billed charges,Implant Device,326.74,34,"Charges > $500, x 34%",326.74,percent of total billed charges,Implant Device,336.35,35,,336.35,percent of total billed charges,Implant Device,336.35,35,,336.35,percent of total billed charges,Implant Device,336.35,35,,336.35,percent of total billed charges,Implant Device,336.35,35,,336.35,percent of total billed charges,Implant Device,336.35,35,,336.35,percent of total billed charges,Implant Device,384.4,40,,384.4,percent of total billed charges,Implant Device,336.35,70,,336.35,percent of total billed charges,All Other,326.74,34,,326.74,percent of total billed charges,Implant Device,326.74,34,,326.74,percent of total billed charges,Implant Device,336.35,35,,336.35,percent of total billed charges,Implant Device,336.35,35,,336.35,percent of total billed charges,Implant Device,336.35,35,,336.35,percent of total billed charges,Implant Device,336.35,35,,336.35,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,711.14,
DEPUY 3L92508 CORAIL COLLAR SIZE 18,C1776,HCPCS,,79010133,CDM,278,RC,,,both,,,13446,9950.07,,,9950.07,Other,150% of Medicare + 9.63% HCRA Surcharge,6050.7,45,,6050.7,percent of total billed charges,Critical Access Hospital RCC factor,4571.64,34,,4571.64,percent of total billed charges,Implant Device,4571.64,34,,4571.64,percent of total billed charges,Implant Device,4571.64,34,,4571.64,percent of total billed charges,Implant Device,4571.64,34,,4571.64,percent of total billed charges,Implant Device,4571.64,34,,4571.64,percent of total billed charges,Implant Device,6655.77,,,6655.77,Other,110% of Medicare,4706.1,35,,4706.1,percent of total billed charges,Implant Device,4571.64,34,"Charges > $500, x 34%",4571.64,percent of total billed charges,Implant Device,4706.1,35,,4706.1,percent of total billed charges,Implant Device,4706.1,35,,4706.1,percent of total billed charges,Implant Device,4706.1,35,,4706.1,percent of total billed charges,Implant Device,4706.1,35,,4706.1,percent of total billed charges,Implant Device,4706.1,35,,4706.1,percent of total billed charges,Implant Device,5378.4,40,,5378.4,percent of total billed charges,Implant Device,4706.1,70,,4706.1,percent of total billed charges,All Other,4571.64,34,,4571.64,percent of total billed charges,Implant Device,4571.64,34,,4571.64,percent of total billed charges,Implant Device,4706.1,35,,4706.1,percent of total billed charges,Implant Device,4706.1,35,,4706.1,percent of total billed charges,Implant Device,4706.1,35,,4706.1,percent of total billed charges,Implant Device,4706.1,35,,4706.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,4571.64,34,"If Charge > 2,000, then 34 percent",4571.64,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,9950.07,
STRYKER 657426 BONE SCREW T10 FT,C1713,HCPCS,,79010134,CDM,278,RC,,,both,,,294,217.56,,,217.56,Other,150% of Medicare + 9.63% HCRA Surcharge,132.3,45,,132.3,percent of total billed charges,Critical Access Hospital RCC factor,99.96,34,,99.96,percent of total billed charges,Implant Device,99.96,34,,99.96,percent of total billed charges,Implant Device,99.96,34,,99.96,percent of total billed charges,Implant Device,99.96,34,,99.96,percent of total billed charges,Implant Device,99.96,34,,99.96,percent of total billed charges,Implant Device,145.53,,,145.53,Other,110% of Medicare,102.9,35,,102.9,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,102.9,35,,102.9,percent of total billed charges,Implant Device,102.9,35,,102.9,percent of total billed charges,Implant Device,102.9,35,,102.9,percent of total billed charges,Implant Device,102.9,35,,102.9,percent of total billed charges,Implant Device,102.9,35,,102.9,percent of total billed charges,Implant Device,117.6,40,,117.6,percent of total billed charges,Implant Device,102.9,70,,102.9,percent of total billed charges,All Other,99.96,34,,99.96,percent of total billed charges,Implant Device,99.96,34,,99.96,percent of total billed charges,Implant Device,102.9,35,,102.9,percent of total billed charges,Implant Device,102.9,35,,102.9,percent of total billed charges,Implant Device,102.9,35,,102.9,percent of total billed charges,Implant Device,102.9,35,,102.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,217.56,
LIFENET BL-1600-001 BONE MATRIX - 1CC,C1713,HCPCS,,79010135,CDM,278,RC,,,both,,,1650,1221,,,1221,Other,150% of Medicare + 9.63% HCRA Surcharge,742.5,45,,742.5,percent of total billed charges,Critical Access Hospital RCC factor,561,34,,561,percent of total billed charges,Implant Device,561,34,,561,percent of total billed charges,Implant Device,561,34,,561,percent of total billed charges,Implant Device,561,34,,561,percent of total billed charges,Implant Device,561,34,,561,percent of total billed charges,Implant Device,816.75,,,816.75,Other,110% of Medicare,577.5,35,,577.5,percent of total billed charges,Implant Device,561,34,"Charges > $500, x 34%",561,percent of total billed charges,Implant Device,577.5,35,,577.5,percent of total billed charges,Implant Device,577.5,35,,577.5,percent of total billed charges,Implant Device,577.5,35,,577.5,percent of total billed charges,Implant Device,577.5,35,,577.5,percent of total billed charges,Implant Device,577.5,35,,577.5,percent of total billed charges,Implant Device,660,40,,660,percent of total billed charges,Implant Device,577.5,70,,577.5,percent of total billed charges,All Other,561,34,,561,percent of total billed charges,Implant Device,561,34,,561,percent of total billed charges,Implant Device,577.5,35,,577.5,percent of total billed charges,Implant Device,577.5,35,,577.5,percent of total billed charges,Implant Device,577.5,35,,577.5,percent of total billed charges,Implant Device,577.5,35,,577.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1221,
LIFENET BL-1600-003 BONE MATRIX 10CC,C1713,HCPCS,,79010136,CDM,278,RC,,,both,,,13104,9696.99,,,9696.99,Other,150% of Medicare + 9.63% HCRA Surcharge,5896.8,45,,5896.8,percent of total billed charges,Critical Access Hospital RCC factor,4455.36,34,,4455.36,percent of total billed charges,Implant Device,4455.36,34,,4455.36,percent of total billed charges,Implant Device,4455.36,34,,4455.36,percent of total billed charges,Implant Device,4455.36,34,,4455.36,percent of total billed charges,Implant Device,4455.36,34,,4455.36,percent of total billed charges,Implant Device,6486.48,,,6486.48,Other,110% of Medicare,4586.4,35,,4586.4,percent of total billed charges,Implant Device,4455.36,34,"Charges > $500, x 34%",4455.36,percent of total billed charges,Implant Device,4586.4,35,,4586.4,percent of total billed charges,Implant Device,4586.4,35,,4586.4,percent of total billed charges,Implant Device,4586.4,35,,4586.4,percent of total billed charges,Implant Device,4586.4,35,,4586.4,percent of total billed charges,Implant Device,4586.4,35,,4586.4,percent of total billed charges,Implant Device,5241.6,40,,5241.6,percent of total billed charges,Implant Device,4586.4,70,,4586.4,percent of total billed charges,All Other,4455.36,34,,4455.36,percent of total billed charges,Implant Device,4455.36,34,,4455.36,percent of total billed charges,Implant Device,4586.4,35,,4586.4,percent of total billed charges,Implant Device,4586.4,35,,4586.4,percent of total billed charges,Implant Device,4586.4,35,,4586.4,percent of total billed charges,Implant Device,4586.4,35,,4586.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,4455.36,34,"If Charge > 2,000, then 34 percent",4455.36,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,9696.99,
STRYKER 657470 BONE SCREW T10 3.5XL70MM,C1713,HCPCS,,79010137,CDM,278,RC,,,both,,,269,199.06,,,199.06,Other,150% of Medicare + 9.63% HCRA Surcharge,121.05,45,,121.05,percent of total billed charges,Critical Access Hospital RCC factor,91.46,34,,91.46,percent of total billed charges,Implant Device,91.46,34,,91.46,percent of total billed charges,Implant Device,91.46,34,,91.46,percent of total billed charges,Implant Device,91.46,34,,91.46,percent of total billed charges,Implant Device,91.46,34,,91.46,percent of total billed charges,Implant Device,133.16,,,133.16,Other,110% of Medicare,94.15,35,,94.15,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,94.15,35,,94.15,percent of total billed charges,Implant Device,94.15,35,,94.15,percent of total billed charges,Implant Device,94.15,35,,94.15,percent of total billed charges,Implant Device,94.15,35,,94.15,percent of total billed charges,Implant Device,94.15,35,,94.15,percent of total billed charges,Implant Device,107.6,40,,107.6,percent of total billed charges,Implant Device,94.15,70,,94.15,percent of total billed charges,All Other,91.46,34,,91.46,percent of total billed charges,Implant Device,91.46,34,,91.46,percent of total billed charges,Implant Device,94.15,35,,94.15,percent of total billed charges,Implant Device,94.15,35,,94.15,percent of total billed charges,Implant Device,94.15,35,,94.15,percent of total billed charges,Implant Device,94.15,35,,94.15,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,199.06,
LSI 021030 RDQLU 2-0 MONOGLIDE,C1776,HCPCS,,79010142,CDM,278,RC,,,both,,,96,71.04,,,71.04,Other,150% of Medicare + 9.63% HCRA Surcharge,43.2,45,,43.2,percent of total billed charges,Critical Access Hospital RCC factor,32.64,34,,32.64,percent of total billed charges,Implant Device,32.64,34,,32.64,percent of total billed charges,Implant Device,32.64,34,,32.64,percent of total billed charges,Implant Device,32.64,34,,32.64,percent of total billed charges,Implant Device,32.64,34,,32.64,percent of total billed charges,Implant Device,47.52,,,47.52,Other,110% of Medicare,33.6,35,,33.6,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,33.6,35,,33.6,percent of total billed charges,Implant Device,33.6,35,,33.6,percent of total billed charges,Implant Device,33.6,35,,33.6,percent of total billed charges,Implant Device,33.6,35,,33.6,percent of total billed charges,Implant Device,33.6,35,,33.6,percent of total billed charges,Implant Device,38.4,40,,38.4,percent of total billed charges,Implant Device,33.6,70,,33.6,percent of total billed charges,All Other,32.64,34,,32.64,percent of total billed charges,Implant Device,32.64,34,,32.64,percent of total billed charges,Implant Device,33.6,35,,33.6,percent of total billed charges,Implant Device,33.6,35,,33.6,percent of total billed charges,Implant Device,33.6,35,,33.6,percent of total billed charges,Implant Device,33.6,35,,33.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,71.04,
EXACTECH 320-36-00 HUMERAL LINER 36MM,C1776,HCPCS,,79010143,CDM,278,RC,,,both,,,2325,1720.51,,,1720.51,Other,150% of Medicare + 9.63% HCRA Surcharge,1046.25,45,,1046.25,percent of total billed charges,Critical Access Hospital RCC factor,790.5,34,,790.5,percent of total billed charges,Implant Device,790.5,34,,790.5,percent of total billed charges,Implant Device,790.5,34,,790.5,percent of total billed charges,Implant Device,790.5,34,,790.5,percent of total billed charges,Implant Device,790.5,34,,790.5,percent of total billed charges,Implant Device,1150.88,,,1150.88,Other,110% of Medicare,813.75,35,,813.75,percent of total billed charges,Implant Device,790.5,34,"Charges > $500, x 34%",790.5,percent of total billed charges,Implant Device,813.75,35,,813.75,percent of total billed charges,Implant Device,813.75,35,,813.75,percent of total billed charges,Implant Device,813.75,35,,813.75,percent of total billed charges,Implant Device,813.75,35,,813.75,percent of total billed charges,Implant Device,813.75,35,,813.75,percent of total billed charges,Implant Device,930,40,,930,percent of total billed charges,Implant Device,813.75,70,,813.75,percent of total billed charges,All Other,790.5,34,,790.5,percent of total billed charges,Implant Device,790.5,34,,790.5,percent of total billed charges,Implant Device,813.75,35,,813.75,percent of total billed charges,Implant Device,813.75,35,,813.75,percent of total billed charges,Implant Device,813.75,35,,813.75,percent of total billed charges,Implant Device,813.75,35,,813.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,790.5,34,"If Charge > 2,000, then 34 percent",790.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1720.51,
STRYKER 2360-5037S IMN 5X37.5 LOCK SCREW,C1713,HCPCS,,79010144,CDM,278,RC,,,both,,,682,504.68,,,504.68,Other,150% of Medicare + 9.63% HCRA Surcharge,306.9,45,,306.9,percent of total billed charges,Critical Access Hospital RCC factor,231.88,34,,231.88,percent of total billed charges,Implant Device,231.88,34,,231.88,percent of total billed charges,Implant Device,231.88,34,,231.88,percent of total billed charges,Implant Device,231.88,34,,231.88,percent of total billed charges,Implant Device,231.88,34,,231.88,percent of total billed charges,Implant Device,337.59,,,337.59,Other,110% of Medicare,238.7,35,,238.7,percent of total billed charges,Implant Device,231.88,34,"Charges > $500, x 34%",231.88,percent of total billed charges,Implant Device,238.7,35,,238.7,percent of total billed charges,Implant Device,238.7,35,,238.7,percent of total billed charges,Implant Device,238.7,35,,238.7,percent of total billed charges,Implant Device,238.7,35,,238.7,percent of total billed charges,Implant Device,238.7,35,,238.7,percent of total billed charges,Implant Device,272.8,40,,272.8,percent of total billed charges,Implant Device,238.7,70,,238.7,percent of total billed charges,All Other,231.88,34,,231.88,percent of total billed charges,Implant Device,231.88,34,,231.88,percent of total billed charges,Implant Device,238.7,35,,238.7,percent of total billed charges,Implant Device,238.7,35,,238.7,percent of total billed charges,Implant Device,238.7,35,,238.7,percent of total billed charges,Implant Device,238.7,35,,238.7,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,504.68,
STRYKER 2360-5040S IMN 5X40 LOCK SCREW,C1713,HCPCS,,79010145,CDM,278,RC,,,both,,,682,504.68,,,504.68,Other,150% of Medicare + 9.63% HCRA Surcharge,306.9,45,,306.9,percent of total billed charges,Critical Access Hospital RCC factor,231.88,34,,231.88,percent of total billed charges,Implant Device,231.88,34,,231.88,percent of total billed charges,Implant Device,231.88,34,,231.88,percent of total billed charges,Implant Device,231.88,34,,231.88,percent of total billed charges,Implant Device,231.88,34,,231.88,percent of total billed charges,Implant Device,337.59,,,337.59,Other,110% of Medicare,238.7,35,,238.7,percent of total billed charges,Implant Device,231.88,34,"Charges > $500, x 34%",231.88,percent of total billed charges,Implant Device,238.7,35,,238.7,percent of total billed charges,Implant Device,238.7,35,,238.7,percent of total billed charges,Implant Device,238.7,35,,238.7,percent of total billed charges,Implant Device,238.7,35,,238.7,percent of total billed charges,Implant Device,238.7,35,,238.7,percent of total billed charges,Implant Device,272.8,40,,272.8,percent of total billed charges,Implant Device,238.7,70,,238.7,percent of total billed charges,All Other,231.88,34,,231.88,percent of total billed charges,Implant Device,231.88,34,,231.88,percent of total billed charges,Implant Device,238.7,35,,238.7,percent of total billed charges,Implant Device,238.7,35,,238.7,percent of total billed charges,Implant Device,238.7,35,,238.7,percent of total billed charges,Implant Device,238.7,35,,238.7,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,504.68,
STRYKER 2360-5042S IMN 5X42.5 LOCK SCREW,C1713,HCPCS,,79010146,CDM,278,RC,,,both,,,682,504.68,,,504.68,Other,150% of Medicare + 9.63% HCRA Surcharge,306.9,45,,306.9,percent of total billed charges,Critical Access Hospital RCC factor,231.88,34,,231.88,percent of total billed charges,Implant Device,231.88,34,,231.88,percent of total billed charges,Implant Device,231.88,34,,231.88,percent of total billed charges,Implant Device,231.88,34,,231.88,percent of total billed charges,Implant Device,231.88,34,,231.88,percent of total billed charges,Implant Device,337.59,,,337.59,Other,110% of Medicare,238.7,35,,238.7,percent of total billed charges,Implant Device,231.88,34,"Charges > $500, x 34%",231.88,percent of total billed charges,Implant Device,238.7,35,,238.7,percent of total billed charges,Implant Device,238.7,35,,238.7,percent of total billed charges,Implant Device,238.7,35,,238.7,percent of total billed charges,Implant Device,238.7,35,,238.7,percent of total billed charges,Implant Device,238.7,35,,238.7,percent of total billed charges,Implant Device,272.8,40,,272.8,percent of total billed charges,Implant Device,238.7,70,,238.7,percent of total billed charges,All Other,231.88,34,,231.88,percent of total billed charges,Implant Device,231.88,34,,231.88,percent of total billed charges,Implant Device,238.7,35,,238.7,percent of total billed charges,Implant Device,238.7,35,,238.7,percent of total billed charges,Implant Device,238.7,35,,238.7,percent of total billed charges,Implant Device,238.7,35,,238.7,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,504.68,
STRYKER 2360-5047S IMN 5X47.5 LOCK SCREW,C1713,HCPCS,,79010147,CDM,278,RC,,,both,,,682,504.68,,,504.68,Other,150% of Medicare + 9.63% HCRA Surcharge,306.9,45,,306.9,percent of total billed charges,Critical Access Hospital RCC factor,231.88,34,,231.88,percent of total billed charges,Implant Device,231.88,34,,231.88,percent of total billed charges,Implant Device,231.88,34,,231.88,percent of total billed charges,Implant Device,231.88,34,,231.88,percent of total billed charges,Implant Device,231.88,34,,231.88,percent of total billed charges,Implant Device,337.59,,,337.59,Other,110% of Medicare,238.7,35,,238.7,percent of total billed charges,Implant Device,231.88,34,"Charges > $500, x 34%",231.88,percent of total billed charges,Implant Device,238.7,35,,238.7,percent of total billed charges,Implant Device,238.7,35,,238.7,percent of total billed charges,Implant Device,238.7,35,,238.7,percent of total billed charges,Implant Device,238.7,35,,238.7,percent of total billed charges,Implant Device,238.7,35,,238.7,percent of total billed charges,Implant Device,272.8,40,,272.8,percent of total billed charges,Implant Device,238.7,70,,238.7,percent of total billed charges,All Other,231.88,34,,231.88,percent of total billed charges,Implant Device,231.88,34,,231.88,percent of total billed charges,Implant Device,238.7,35,,238.7,percent of total billed charges,Implant Device,238.7,35,,238.7,percent of total billed charges,Implant Device,238.7,35,,238.7,percent of total billed charges,Implant Device,238.7,35,,238.7,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,504.68,
STRYKER 2341-1033S TIBIAL NAIL 10X330MM,C1713,HCPCS,,79010148,CDM,278,RC,,,both,,,9801,7252.76,,,7252.76,Other,150% of Medicare + 9.63% HCRA Surcharge,4410.45,45,,4410.45,percent of total billed charges,Critical Access Hospital RCC factor,3332.34,34,,3332.34,percent of total billed charges,Implant Device,3332.34,34,,3332.34,percent of total billed charges,Implant Device,3332.34,34,,3332.34,percent of total billed charges,Implant Device,3332.34,34,,3332.34,percent of total billed charges,Implant Device,3332.34,34,,3332.34,percent of total billed charges,Implant Device,4851.5,,,4851.5,Other,110% of Medicare,3430.35,35,,3430.35,percent of total billed charges,Implant Device,3332.34,34,"Charges > $500, x 34%",3332.34,percent of total billed charges,Implant Device,3430.35,35,,3430.35,percent of total billed charges,Implant Device,3430.35,35,,3430.35,percent of total billed charges,Implant Device,3430.35,35,,3430.35,percent of total billed charges,Implant Device,3430.35,35,,3430.35,percent of total billed charges,Implant Device,3430.35,35,,3430.35,percent of total billed charges,Implant Device,3920.4,40,,3920.4,percent of total billed charges,Implant Device,3430.35,70,,3430.35,percent of total billed charges,All Other,3332.34,34,,3332.34,percent of total billed charges,Implant Device,3332.34,34,,3332.34,percent of total billed charges,Implant Device,3430.35,35,,3430.35,percent of total billed charges,Implant Device,3430.35,35,,3430.35,percent of total billed charges,Implant Device,3430.35,35,,3430.35,percent of total billed charges,Implant Device,3430.35,35,,3430.35,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3332.34,34,"If Charge > 2,000, then 34 percent",3332.34,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,7252.76,
EXACTECH 320-01-36 GLENOSPHERE 36MM,C1776,HCPCS,,79010151,CDM,278,RC,,,both,,,4050,2997.01,,,2997.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1822.5,45,,1822.5,percent of total billed charges,Critical Access Hospital RCC factor,1377,34,,1377,percent of total billed charges,Implant Device,1377,34,,1377,percent of total billed charges,Implant Device,1377,34,,1377,percent of total billed charges,Implant Device,1377,34,,1377,percent of total billed charges,Implant Device,1377,34,,1377,percent of total billed charges,Implant Device,2004.75,,,2004.75,Other,110% of Medicare,1417.5,35,,1417.5,percent of total billed charges,Implant Device,1377,34,"Charges > $500, x 34%",1377,percent of total billed charges,Implant Device,1417.5,35,,1417.5,percent of total billed charges,Implant Device,1417.5,35,,1417.5,percent of total billed charges,Implant Device,1417.5,35,,1417.5,percent of total billed charges,Implant Device,1417.5,35,,1417.5,percent of total billed charges,Implant Device,1417.5,35,,1417.5,percent of total billed charges,Implant Device,1620,40,,1620,percent of total billed charges,Implant Device,1417.5,70,,1417.5,percent of total billed charges,All Other,1377,34,,1377,percent of total billed charges,Implant Device,1377,34,,1377,percent of total billed charges,Implant Device,1417.5,35,,1417.5,percent of total billed charges,Implant Device,1417.5,35,,1417.5,percent of total billed charges,Implant Device,1417.5,35,,1417.5,percent of total billed charges,Implant Device,1417.5,35,,1417.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1377,34,"If Charge > 2,000, then 34 percent",1377,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2997.01,
STRYKER 658385 COMPRESSION SCREW 7X85MM,C1713,HCPCS,,79010152,CDM,278,RC,,,both,,,2471,1828.55,,,1828.55,Other,150% of Medicare + 9.63% HCRA Surcharge,1111.95,45,,1111.95,percent of total billed charges,Critical Access Hospital RCC factor,840.14,34,,840.14,percent of total billed charges,Implant Device,840.14,34,,840.14,percent of total billed charges,Implant Device,840.14,34,,840.14,percent of total billed charges,Implant Device,840.14,34,,840.14,percent of total billed charges,Implant Device,840.14,34,,840.14,percent of total billed charges,Implant Device,1223.15,,,1223.15,Other,110% of Medicare,864.85,35,,864.85,percent of total billed charges,Implant Device,840.14,34,"Charges > $500, x 34%",840.14,percent of total billed charges,Implant Device,864.85,35,,864.85,percent of total billed charges,Implant Device,864.85,35,,864.85,percent of total billed charges,Implant Device,864.85,35,,864.85,percent of total billed charges,Implant Device,864.85,35,,864.85,percent of total billed charges,Implant Device,864.85,35,,864.85,percent of total billed charges,Implant Device,988.4,40,,988.4,percent of total billed charges,Implant Device,864.85,70,,864.85,percent of total billed charges,All Other,840.14,34,,840.14,percent of total billed charges,Implant Device,840.14,34,,840.14,percent of total billed charges,Implant Device,864.85,35,,864.85,percent of total billed charges,Implant Device,864.85,35,,864.85,percent of total billed charges,Implant Device,864.85,35,,864.85,percent of total billed charges,Implant Device,864.85,35,,864.85,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,840.14,34,"If Charge > 2,000, then 34 percent",840.14,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1828.55,
STRYKER 658380 COMPRESSION SCREW 7X80MM,C1713,HCPCS,,79010153,CDM,278,RC,,,both,,,2471,1828.55,,,1828.55,Other,150% of Medicare + 9.63% HCRA Surcharge,1111.95,45,,1111.95,percent of total billed charges,Critical Access Hospital RCC factor,840.14,34,,840.14,percent of total billed charges,Implant Device,840.14,34,,840.14,percent of total billed charges,Implant Device,840.14,34,,840.14,percent of total billed charges,Implant Device,840.14,34,,840.14,percent of total billed charges,Implant Device,840.14,34,,840.14,percent of total billed charges,Implant Device,1223.15,,,1223.15,Other,110% of Medicare,864.85,35,,864.85,percent of total billed charges,Implant Device,840.14,34,"Charges > $500, x 34%",840.14,percent of total billed charges,Implant Device,864.85,35,,864.85,percent of total billed charges,Implant Device,864.85,35,,864.85,percent of total billed charges,Implant Device,864.85,35,,864.85,percent of total billed charges,Implant Device,864.85,35,,864.85,percent of total billed charges,Implant Device,864.85,35,,864.85,percent of total billed charges,Implant Device,988.4,40,,988.4,percent of total billed charges,Implant Device,864.85,70,,864.85,percent of total billed charges,All Other,840.14,34,,840.14,percent of total billed charges,Implant Device,840.14,34,,840.14,percent of total billed charges,Implant Device,864.85,35,,864.85,percent of total billed charges,Implant Device,864.85,35,,864.85,percent of total billed charges,Implant Device,864.85,35,,864.85,percent of total billed charges,Implant Device,864.85,35,,864.85,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,840.14,34,"If Charge > 2,000, then 34 percent",840.14,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1828.55,
STRYKER 626844 LAG SCREW 4.1X44MM,C1713,HCPCS,,79010154,CDM,278,RC,,,both,,,897,663.78,,,663.78,Other,150% of Medicare + 9.63% HCRA Surcharge,403.65,45,,403.65,percent of total billed charges,Critical Access Hospital RCC factor,304.98,34,,304.98,percent of total billed charges,Implant Device,304.98,34,,304.98,percent of total billed charges,Implant Device,304.98,34,,304.98,percent of total billed charges,Implant Device,304.98,34,,304.98,percent of total billed charges,Implant Device,304.98,34,,304.98,percent of total billed charges,Implant Device,444.02,,,444.02,Other,110% of Medicare,313.95,35,,313.95,percent of total billed charges,Implant Device,304.98,34,"Charges > $500, x 34%",304.98,percent of total billed charges,Implant Device,313.95,35,,313.95,percent of total billed charges,Implant Device,313.95,35,,313.95,percent of total billed charges,Implant Device,313.95,35,,313.95,percent of total billed charges,Implant Device,313.95,35,,313.95,percent of total billed charges,Implant Device,313.95,35,,313.95,percent of total billed charges,Implant Device,358.8,40,,358.8,percent of total billed charges,Implant Device,313.95,70,,313.95,percent of total billed charges,All Other,304.98,34,,304.98,percent of total billed charges,Implant Device,304.98,34,,304.98,percent of total billed charges,Implant Device,313.95,35,,313.95,percent of total billed charges,Implant Device,313.95,35,,313.95,percent of total billed charges,Implant Device,313.95,35,,313.95,percent of total billed charges,Implant Device,313.95,35,,313.95,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,663.78,
STRYKER 626822 LAG SCREW 4.1X22MM,C1713,HCPCS,,79010155,CDM,278,RC,,,both,,,897,663.78,,,663.78,Other,150% of Medicare + 9.63% HCRA Surcharge,403.65,45,,403.65,percent of total billed charges,Critical Access Hospital RCC factor,304.98,34,,304.98,percent of total billed charges,Implant Device,304.98,34,,304.98,percent of total billed charges,Implant Device,304.98,34,,304.98,percent of total billed charges,Implant Device,304.98,34,,304.98,percent of total billed charges,Implant Device,304.98,34,,304.98,percent of total billed charges,Implant Device,444.02,,,444.02,Other,110% of Medicare,313.95,35,,313.95,percent of total billed charges,Implant Device,304.98,34,"Charges > $500, x 34%",304.98,percent of total billed charges,Implant Device,313.95,35,,313.95,percent of total billed charges,Implant Device,313.95,35,,313.95,percent of total billed charges,Implant Device,313.95,35,,313.95,percent of total billed charges,Implant Device,313.95,35,,313.95,percent of total billed charges,Implant Device,313.95,35,,313.95,percent of total billed charges,Implant Device,358.8,40,,358.8,percent of total billed charges,Implant Device,313.95,70,,313.95,percent of total billed charges,All Other,304.98,34,,304.98,percent of total billed charges,Implant Device,304.98,34,,304.98,percent of total billed charges,Implant Device,313.95,35,,313.95,percent of total billed charges,Implant Device,313.95,35,,313.95,percent of total billed charges,Implant Device,313.95,35,,313.95,percent of total billed charges,Implant Device,313.95,35,,313.95,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,663.78,
STRYKER 626993 BROAD Y-PLT 3 SHAFT HOLES,C1713,HCPCS,,79010156,CDM,278,RC,,,both,,,3757,2780.19,,,2780.19,Other,150% of Medicare + 9.63% HCRA Surcharge,1690.65,45,,1690.65,percent of total billed charges,Critical Access Hospital RCC factor,1277.38,34,,1277.38,percent of total billed charges,Implant Device,1277.38,34,,1277.38,percent of total billed charges,Implant Device,1277.38,34,,1277.38,percent of total billed charges,Implant Device,1277.38,34,,1277.38,percent of total billed charges,Implant Device,1277.38,34,,1277.38,percent of total billed charges,Implant Device,1859.72,,,1859.72,Other,110% of Medicare,1314.95,35,,1314.95,percent of total billed charges,Implant Device,1277.38,34,"Charges > $500, x 34%",1277.38,percent of total billed charges,Implant Device,1314.95,35,,1314.95,percent of total billed charges,Implant Device,1314.95,35,,1314.95,percent of total billed charges,Implant Device,1314.95,35,,1314.95,percent of total billed charges,Implant Device,1314.95,35,,1314.95,percent of total billed charges,Implant Device,1314.95,35,,1314.95,percent of total billed charges,Implant Device,1502.8,40,,1502.8,percent of total billed charges,Implant Device,1314.95,70,,1314.95,percent of total billed charges,All Other,1277.38,34,,1277.38,percent of total billed charges,Implant Device,1277.38,34,,1277.38,percent of total billed charges,Implant Device,1314.95,35,,1314.95,percent of total billed charges,Implant Device,1314.95,35,,1314.95,percent of total billed charges,Implant Device,1314.95,35,,1314.95,percent of total billed charges,Implant Device,1314.95,35,,1314.95,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1277.38,34,"If Charge > 2,000, then 34 percent",1277.38,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2780.19,
SI-BONE 7050M-90 IFUSE 3D 7.0X50MM,C1713,HCPCS,,79010157,CDM,278,RC,,,both,,,10200,7548.03,,,7548.03,Other,150% of Medicare + 9.63% HCRA Surcharge,4590,45,,4590,percent of total billed charges,Critical Access Hospital RCC factor,3468,34,,3468,percent of total billed charges,Implant Device,3468,34,,3468,percent of total billed charges,Implant Device,3468,34,,3468,percent of total billed charges,Implant Device,3468,34,,3468,percent of total billed charges,Implant Device,3468,34,,3468,percent of total billed charges,Implant Device,5049,,,5049,Other,110% of Medicare,3570,35,,3570,percent of total billed charges,Implant Device,3468,34,"Charges > $500, x 34%",3468,percent of total billed charges,Implant Device,3570,35,,3570,percent of total billed charges,Implant Device,3570,35,,3570,percent of total billed charges,Implant Device,3570,35,,3570,percent of total billed charges,Implant Device,3570,35,,3570,percent of total billed charges,Implant Device,3570,35,,3570,percent of total billed charges,Implant Device,4080,40,,4080,percent of total billed charges,Implant Device,3570,70,,3570,percent of total billed charges,All Other,3468,34,,3468,percent of total billed charges,Implant Device,3468,34,,3468,percent of total billed charges,Implant Device,3570,35,,3570,percent of total billed charges,Implant Device,3570,35,,3570,percent of total billed charges,Implant Device,3570,35,,3570,percent of total billed charges,Implant Device,3570,35,,3570,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3468,34,"If Charge > 2,000, then 34 percent",3468,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,7548.03,
SI-BONE 7040M-90 IFUSE 3D 7.0X40MM,C1713,HCPCS,,79010158,CDM,278,RC,,,both,,,10200,7548.03,,,7548.03,Other,150% of Medicare + 9.63% HCRA Surcharge,4590,45,,4590,percent of total billed charges,Critical Access Hospital RCC factor,3468,34,,3468,percent of total billed charges,Implant Device,3468,34,,3468,percent of total billed charges,Implant Device,3468,34,,3468,percent of total billed charges,Implant Device,3468,34,,3468,percent of total billed charges,Implant Device,3468,34,,3468,percent of total billed charges,Implant Device,5049,,,5049,Other,110% of Medicare,3570,35,,3570,percent of total billed charges,Implant Device,3468,34,"Charges > $500, x 34%",3468,percent of total billed charges,Implant Device,3570,35,,3570,percent of total billed charges,Implant Device,3570,35,,3570,percent of total billed charges,Implant Device,3570,35,,3570,percent of total billed charges,Implant Device,3570,35,,3570,percent of total billed charges,Implant Device,3570,35,,3570,percent of total billed charges,Implant Device,4080,40,,4080,percent of total billed charges,Implant Device,3570,70,,3570,percent of total billed charges,All Other,3468,34,,3468,percent of total billed charges,Implant Device,3468,34,,3468,percent of total billed charges,Implant Device,3570,35,,3570,percent of total billed charges,Implant Device,3570,35,,3570,percent of total billed charges,Implant Device,3570,35,,3570,percent of total billed charges,Implant Device,3570,35,,3570,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3468,34,"If Charge > 2,000, then 34 percent",3468,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,7548.03,
SI-BONE 7055M-90 IFUSE 3D 7.0X55MM,C1713,HCPCS,,79010159,CDM,278,RC,,,both,,,10200,7548.03,,,7548.03,Other,150% of Medicare + 9.63% HCRA Surcharge,4590,45,,4590,percent of total billed charges,Critical Access Hospital RCC factor,3468,34,,3468,percent of total billed charges,Implant Device,3468,34,,3468,percent of total billed charges,Implant Device,3468,34,,3468,percent of total billed charges,Implant Device,3468,34,,3468,percent of total billed charges,Implant Device,3468,34,,3468,percent of total billed charges,Implant Device,5049,,,5049,Other,110% of Medicare,3570,35,,3570,percent of total billed charges,Implant Device,3468,34,"Charges > $500, x 34%",3468,percent of total billed charges,Implant Device,3570,35,,3570,percent of total billed charges,Implant Device,3570,35,,3570,percent of total billed charges,Implant Device,3570,35,,3570,percent of total billed charges,Implant Device,3570,35,,3570,percent of total billed charges,Implant Device,3570,35,,3570,percent of total billed charges,Implant Device,4080,40,,4080,percent of total billed charges,Implant Device,3570,70,,3570,percent of total billed charges,All Other,3468,34,,3468,percent of total billed charges,Implant Device,3468,34,,3468,percent of total billed charges,Implant Device,3570,35,,3570,percent of total billed charges,Implant Device,3570,35,,3570,percent of total billed charges,Implant Device,3570,35,,3570,percent of total billed charges,Implant Device,3570,35,,3570,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3468,34,"If Charge > 2,000, then 34 percent",3468,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,7548.03,
STRYKER 6721-0635 HIP STEM SZ 0 35X111MM,C1776,HCPCS,,79010160,CDM,278,RC,,,both,,,6953,5145.24,,,5145.24,Other,150% of Medicare + 9.63% HCRA Surcharge,3128.85,45,,3128.85,percent of total billed charges,Critical Access Hospital RCC factor,2364.02,34,,2364.02,percent of total billed charges,Implant Device,2364.02,34,,2364.02,percent of total billed charges,Implant Device,2364.02,34,,2364.02,percent of total billed charges,Implant Device,2364.02,34,,2364.02,percent of total billed charges,Implant Device,2364.02,34,,2364.02,percent of total billed charges,Implant Device,3441.74,,,3441.74,Other,110% of Medicare,2433.55,35,,2433.55,percent of total billed charges,Implant Device,2364.02,34,"Charges > $500, x 34%",2364.02,percent of total billed charges,Implant Device,2433.55,35,,2433.55,percent of total billed charges,Implant Device,2433.55,35,,2433.55,percent of total billed charges,Implant Device,2433.55,35,,2433.55,percent of total billed charges,Implant Device,2433.55,35,,2433.55,percent of total billed charges,Implant Device,2433.55,35,,2433.55,percent of total billed charges,Implant Device,2781.2,40,,2781.2,percent of total billed charges,Implant Device,2433.55,70,,2433.55,percent of total billed charges,All Other,2364.02,34,,2364.02,percent of total billed charges,Implant Device,2364.02,34,,2364.02,percent of total billed charges,Implant Device,2433.55,35,,2433.55,percent of total billed charges,Implant Device,2433.55,35,,2433.55,percent of total billed charges,Implant Device,2433.55,35,,2433.55,percent of total billed charges,Implant Device,2433.55,35,,2433.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2364.02,34,"If Charge > 2,000, then 34 percent",2364.02,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5145.24,
STRYKER 5510-F-402 RETAINING FEM SZ 4 RT,C1776,HCPCS,,79010161,CDM,278,RC,,,both,,,5100,3774.01,,,3774.01,Other,150% of Medicare + 9.63% HCRA Surcharge,2295,45,,2295,percent of total billed charges,Critical Access Hospital RCC factor,1734,34,,1734,percent of total billed charges,Implant Device,1734,34,,1734,percent of total billed charges,Implant Device,1734,34,,1734,percent of total billed charges,Implant Device,1734,34,,1734,percent of total billed charges,Implant Device,1734,34,,1734,percent of total billed charges,Implant Device,2524.5,,,2524.5,Other,110% of Medicare,1785,35,,1785,percent of total billed charges,Implant Device,1734,34,"Charges > $500, x 34%",1734,percent of total billed charges,Implant Device,1785,35,,1785,percent of total billed charges,Implant Device,1785,35,,1785,percent of total billed charges,Implant Device,1785,35,,1785,percent of total billed charges,Implant Device,1785,35,,1785,percent of total billed charges,Implant Device,1785,35,,1785,percent of total billed charges,Implant Device,2040,40,,2040,percent of total billed charges,Implant Device,1785,70,,1785,percent of total billed charges,All Other,1734,34,,1734,percent of total billed charges,Implant Device,1734,34,,1734,percent of total billed charges,Implant Device,1785,35,,1785,percent of total billed charges,Implant Device,1785,35,,1785,percent of total billed charges,Implant Device,1785,35,,1785,percent of total billed charges,Implant Device,1785,35,,1785,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1734,34,"If Charge > 2,000, then 34 percent",1734,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3774.01,
STRYKER 5530-G-311-E TIB INSERT SZ3 11MM,C1776,HCPCS,,79010162,CDM,278,RC,,,both,,,3300,2442.01,,,2442.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1485,45,,1485,percent of total billed charges,Critical Access Hospital RCC factor,1122,34,,1122,percent of total billed charges,Implant Device,1122,34,,1122,percent of total billed charges,Implant Device,1122,34,,1122,percent of total billed charges,Implant Device,1122,34,,1122,percent of total billed charges,Implant Device,1122,34,,1122,percent of total billed charges,Implant Device,1633.5,,,1633.5,Other,110% of Medicare,1155,35,,1155,percent of total billed charges,Implant Device,1122,34,"Charges > $500, x 34%",1122,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,1320,40,,1320,percent of total billed charges,Implant Device,1155,70,,1155,percent of total billed charges,All Other,1122,34,,1122,percent of total billed charges,Implant Device,1122,34,,1122,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1122,34,"If Charge > 2,000, then 34 percent",1122,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2442.01,
GORE PLC141200 EXCL ENDOPROS 14.5MMX12CM,C1874,HCPCS,,79010163,CDM,278,RC,,,both,,,14571,10782.58,,,10782.58,Other,150% of Medicare + 9.63% HCRA Surcharge,6556.95,45,,6556.95,percent of total billed charges,Critical Access Hospital RCC factor,4954.14,34,,4954.14,percent of total billed charges,Implant Device,4954.14,34,,4954.14,percent of total billed charges,Implant Device,4954.14,34,,4954.14,percent of total billed charges,Implant Device,4954.14,34,,4954.14,percent of total billed charges,Implant Device,4954.14,34,,4954.14,percent of total billed charges,Implant Device,7212.65,,,7212.65,Other,110% of Medicare,5099.85,35,,5099.85,percent of total billed charges,Implant Device,4954.14,34,"Charges > $500, x 34%",4954.14,percent of total billed charges,Implant Device,5099.85,35,,5099.85,percent of total billed charges,Implant Device,5099.85,35,,5099.85,percent of total billed charges,Implant Device,5099.85,35,,5099.85,percent of total billed charges,Implant Device,5099.85,35,,5099.85,percent of total billed charges,Implant Device,5099.85,35,,5099.85,percent of total billed charges,Implant Device,5828.4,40,,5828.4,percent of total billed charges,Implant Device,5099.85,70,,5099.85,percent of total billed charges,All Other,4954.14,34,,4954.14,percent of total billed charges,Implant Device,4954.14,34,,4954.14,percent of total billed charges,Implant Device,5099.85,35,,5099.85,percent of total billed charges,Implant Device,5099.85,35,,5099.85,percent of total billed charges,Implant Device,5099.85,35,,5099.85,percent of total billed charges,Implant Device,5099.85,35,,5099.85,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,4954.14,34,"If Charge > 2,000, then 34 percent",4954.14,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,10782.58,
ARTHREX ABS-2810-1808 EVAN WEDGE 18X18X8,C1713,HCPCS,,79010166,CDM,278,RC,,,both,,,4650,3441.01,,,3441.01,Other,150% of Medicare + 9.63% HCRA Surcharge,2092.5,45,,2092.5,percent of total billed charges,Critical Access Hospital RCC factor,1581,34,,1581,percent of total billed charges,Implant Device,1581,34,,1581,percent of total billed charges,Implant Device,1581,34,,1581,percent of total billed charges,Implant Device,1581,34,,1581,percent of total billed charges,Implant Device,1581,34,,1581,percent of total billed charges,Implant Device,2301.75,,,2301.75,Other,110% of Medicare,1627.5,35,,1627.5,percent of total billed charges,Implant Device,1581,34,"Charges > $500, x 34%",1581,percent of total billed charges,Implant Device,1627.5,35,,1627.5,percent of total billed charges,Implant Device,1627.5,35,,1627.5,percent of total billed charges,Implant Device,1627.5,35,,1627.5,percent of total billed charges,Implant Device,1627.5,35,,1627.5,percent of total billed charges,Implant Device,1627.5,35,,1627.5,percent of total billed charges,Implant Device,1860,40,,1860,percent of total billed charges,Implant Device,1627.5,70,,1627.5,percent of total billed charges,All Other,1581,34,,1581,percent of total billed charges,Implant Device,1581,34,,1581,percent of total billed charges,Implant Device,1627.5,35,,1627.5,percent of total billed charges,Implant Device,1627.5,35,,1627.5,percent of total billed charges,Implant Device,1627.5,35,,1627.5,percent of total billed charges,Implant Device,1627.5,35,,1627.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1581,34,"If Charge > 2,000, then 34 percent",1581,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3441.01,
STRYKER 3525-1340S NAIL KIT 11X340X125MM,C1713,HCPCS,,79010168,CDM,278,RC,,,both,,,4969,3677.07,,,3677.07,Other,150% of Medicare + 9.63% HCRA Surcharge,2236.05,45,,2236.05,percent of total billed charges,Critical Access Hospital RCC factor,1689.46,34,,1689.46,percent of total billed charges,Implant Device,1689.46,34,,1689.46,percent of total billed charges,Implant Device,1689.46,34,,1689.46,percent of total billed charges,Implant Device,1689.46,34,,1689.46,percent of total billed charges,Implant Device,1689.46,34,,1689.46,percent of total billed charges,Implant Device,2459.66,,,2459.66,Other,110% of Medicare,1739.15,35,,1739.15,percent of total billed charges,Implant Device,1689.46,34,"Charges > $500, x 34%",1689.46,percent of total billed charges,Implant Device,1739.15,35,,1739.15,percent of total billed charges,Implant Device,1739.15,35,,1739.15,percent of total billed charges,Implant Device,1739.15,35,,1739.15,percent of total billed charges,Implant Device,1739.15,35,,1739.15,percent of total billed charges,Implant Device,1739.15,35,,1739.15,percent of total billed charges,Implant Device,1987.6,40,,1987.6,percent of total billed charges,Implant Device,1739.15,70,,1739.15,percent of total billed charges,All Other,1689.46,34,,1689.46,percent of total billed charges,Implant Device,1689.46,34,,1689.46,percent of total billed charges,Implant Device,1739.15,35,,1739.15,percent of total billed charges,Implant Device,1739.15,35,,1739.15,percent of total billed charges,Implant Device,1739.15,35,,1739.15,percent of total billed charges,Implant Device,1739.15,35,,1739.15,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1689.46,34,"If Charge > 2,000, then 34 percent",1689.46,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3677.07,
STRYKER 2341-1137S TIBIAL NAIL 11X375MM,C1713,HCPCS,,79010169,CDM,278,RC,,,both,,,6378,4719.74,,,4719.74,Other,150% of Medicare + 9.63% HCRA Surcharge,2870.1,45,,2870.1,percent of total billed charges,Critical Access Hospital RCC factor,2168.52,34,,2168.52,percent of total billed charges,Implant Device,2168.52,34,,2168.52,percent of total billed charges,Implant Device,2168.52,34,,2168.52,percent of total billed charges,Implant Device,2168.52,34,,2168.52,percent of total billed charges,Implant Device,2168.52,34,,2168.52,percent of total billed charges,Implant Device,3157.11,,,3157.11,Other,110% of Medicare,2232.3,35,,2232.3,percent of total billed charges,Implant Device,2168.52,34,"Charges > $500, x 34%",2168.52,percent of total billed charges,Implant Device,2232.3,35,,2232.3,percent of total billed charges,Implant Device,2232.3,35,,2232.3,percent of total billed charges,Implant Device,2232.3,35,,2232.3,percent of total billed charges,Implant Device,2232.3,35,,2232.3,percent of total billed charges,Implant Device,2232.3,35,,2232.3,percent of total billed charges,Implant Device,2551.2,40,,2551.2,percent of total billed charges,Implant Device,2232.3,70,,2232.3,percent of total billed charges,All Other,2168.52,34,,2168.52,percent of total billed charges,Implant Device,2168.52,34,,2168.52,percent of total billed charges,Implant Device,2232.3,35,,2232.3,percent of total billed charges,Implant Device,2232.3,35,,2232.3,percent of total billed charges,Implant Device,2232.3,35,,2232.3,percent of total billed charges,Implant Device,2232.3,35,,2232.3,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2168.52,34,"If Charge > 2,000, then 34 percent",2168.52,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4719.74,
STRYKER 2360-5045S LOCK SCREW 5X45MM,C1713,HCPCS,,79010171,CDM,278,RC,,,both,,,682,504.68,,,504.68,Other,150% of Medicare + 9.63% HCRA Surcharge,306.9,45,,306.9,percent of total billed charges,Critical Access Hospital RCC factor,231.88,34,,231.88,percent of total billed charges,Implant Device,231.88,34,,231.88,percent of total billed charges,Implant Device,231.88,34,,231.88,percent of total billed charges,Implant Device,231.88,34,,231.88,percent of total billed charges,Implant Device,231.88,34,,231.88,percent of total billed charges,Implant Device,337.59,,,337.59,Other,110% of Medicare,238.7,35,,238.7,percent of total billed charges,Implant Device,231.88,34,"Charges > $500, x 34%",231.88,percent of total billed charges,Implant Device,238.7,35,,238.7,percent of total billed charges,Implant Device,238.7,35,,238.7,percent of total billed charges,Implant Device,238.7,35,,238.7,percent of total billed charges,Implant Device,238.7,35,,238.7,percent of total billed charges,Implant Device,238.7,35,,238.7,percent of total billed charges,Implant Device,272.8,40,,272.8,percent of total billed charges,Implant Device,238.7,70,,238.7,percent of total billed charges,All Other,231.88,34,,231.88,percent of total billed charges,Implant Device,231.88,34,,231.88,percent of total billed charges,Implant Device,238.7,35,,238.7,percent of total billed charges,Implant Device,238.7,35,,238.7,percent of total billed charges,Implant Device,238.7,35,,238.7,percent of total billed charges,Implant Device,238.7,35,,238.7,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,504.68,
STRYKER 2360-5055S LOCK SCREW 5X55MM,C1713,HCPCS,,79010172,CDM,278,RC,,,both,,,682,504.68,,,504.68,Other,150% of Medicare + 9.63% HCRA Surcharge,306.9,45,,306.9,percent of total billed charges,Critical Access Hospital RCC factor,231.88,34,,231.88,percent of total billed charges,Implant Device,231.88,34,,231.88,percent of total billed charges,Implant Device,231.88,34,,231.88,percent of total billed charges,Implant Device,231.88,34,,231.88,percent of total billed charges,Implant Device,231.88,34,,231.88,percent of total billed charges,Implant Device,337.59,,,337.59,Other,110% of Medicare,238.7,35,,238.7,percent of total billed charges,Implant Device,231.88,34,"Charges > $500, x 34%",231.88,percent of total billed charges,Implant Device,238.7,35,,238.7,percent of total billed charges,Implant Device,238.7,35,,238.7,percent of total billed charges,Implant Device,238.7,35,,238.7,percent of total billed charges,Implant Device,238.7,35,,238.7,percent of total billed charges,Implant Device,238.7,35,,238.7,percent of total billed charges,Implant Device,272.8,40,,272.8,percent of total billed charges,Implant Device,238.7,70,,238.7,percent of total billed charges,All Other,231.88,34,,231.88,percent of total billed charges,Implant Device,231.88,34,,231.88,percent of total billed charges,Implant Device,238.7,35,,238.7,percent of total billed charges,Implant Device,238.7,35,,238.7,percent of total billed charges,Implant Device,238.7,35,,238.7,percent of total billed charges,Implant Device,238.7,35,,238.7,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,504.68,
STRYKER 2361-5045S ADV LOCK SCREW 5X45MM,C1713,HCPCS,,79010173,CDM,278,RC,,,both,,,887,656.38,,,656.38,Other,150% of Medicare + 9.63% HCRA Surcharge,399.15,45,,399.15,percent of total billed charges,Critical Access Hospital RCC factor,301.58,34,,301.58,percent of total billed charges,Implant Device,301.58,34,,301.58,percent of total billed charges,Implant Device,301.58,34,,301.58,percent of total billed charges,Implant Device,301.58,34,,301.58,percent of total billed charges,Implant Device,301.58,34,,301.58,percent of total billed charges,Implant Device,439.07,,,439.07,Other,110% of Medicare,310.45,35,,310.45,percent of total billed charges,Implant Device,301.58,34,"Charges > $500, x 34%",301.58,percent of total billed charges,Implant Device,310.45,35,,310.45,percent of total billed charges,Implant Device,310.45,35,,310.45,percent of total billed charges,Implant Device,310.45,35,,310.45,percent of total billed charges,Implant Device,310.45,35,,310.45,percent of total billed charges,Implant Device,310.45,35,,310.45,percent of total billed charges,Implant Device,354.8,40,,354.8,percent of total billed charges,Implant Device,310.45,70,,310.45,percent of total billed charges,All Other,301.58,34,,301.58,percent of total billed charges,Implant Device,301.58,34,,301.58,percent of total billed charges,Implant Device,310.45,35,,310.45,percent of total billed charges,Implant Device,310.45,35,,310.45,percent of total billed charges,Implant Device,310.45,35,,310.45,percent of total billed charges,Implant Device,310.45,35,,310.45,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,656.38,
STRYKER 2361-5052S ADV LOCK SCREW 5X52MM,C1713,HCPCS,,79010174,CDM,278,RC,,,both,,,956,707.44,,,707.44,Other,150% of Medicare + 9.63% HCRA Surcharge,430.2,45,,430.2,percent of total billed charges,Critical Access Hospital RCC factor,325.04,34,,325.04,percent of total billed charges,Implant Device,325.04,34,,325.04,percent of total billed charges,Implant Device,325.04,34,,325.04,percent of total billed charges,Implant Device,325.04,34,,325.04,percent of total billed charges,Implant Device,325.04,34,,325.04,percent of total billed charges,Implant Device,473.22,,,473.22,Other,110% of Medicare,334.6,35,,334.6,percent of total billed charges,Implant Device,325.04,34,"Charges > $500, x 34%",325.04,percent of total billed charges,Implant Device,334.6,35,,334.6,percent of total billed charges,Implant Device,334.6,35,,334.6,percent of total billed charges,Implant Device,334.6,35,,334.6,percent of total billed charges,Implant Device,334.6,35,,334.6,percent of total billed charges,Implant Device,334.6,35,,334.6,percent of total billed charges,Implant Device,382.4,40,,382.4,percent of total billed charges,Implant Device,334.6,70,,334.6,percent of total billed charges,All Other,325.04,34,,325.04,percent of total billed charges,Implant Device,325.04,34,,325.04,percent of total billed charges,Implant Device,334.6,35,,334.6,percent of total billed charges,Implant Device,334.6,35,,334.6,percent of total billed charges,Implant Device,334.6,35,,334.6,percent of total billed charges,Implant Device,334.6,35,,334.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,707.44,
ARTHREX AR8717DS-0907 STAPLE 9X7MM W/INS,C1713,HCPCS,,79010175,CDM,278,RC,,,both,,,4485,3318.91,,,3318.91,Other,150% of Medicare + 9.63% HCRA Surcharge,2018.25,45,,2018.25,percent of total billed charges,Critical Access Hospital RCC factor,1524.9,34,,1524.9,percent of total billed charges,Implant Device,1524.9,34,,1524.9,percent of total billed charges,Implant Device,1524.9,34,,1524.9,percent of total billed charges,Implant Device,1524.9,34,,1524.9,percent of total billed charges,Implant Device,1524.9,34,,1524.9,percent of total billed charges,Implant Device,2220.08,,,2220.08,Other,110% of Medicare,1569.75,35,,1569.75,percent of total billed charges,Implant Device,1524.9,34,"Charges > $500, x 34%",1524.9,percent of total billed charges,Implant Device,1569.75,35,,1569.75,percent of total billed charges,Implant Device,1569.75,35,,1569.75,percent of total billed charges,Implant Device,1569.75,35,,1569.75,percent of total billed charges,Implant Device,1569.75,35,,1569.75,percent of total billed charges,Implant Device,1569.75,35,,1569.75,percent of total billed charges,Implant Device,1794,40,,1794,percent of total billed charges,Implant Device,1569.75,70,,1569.75,percent of total billed charges,All Other,1524.9,34,,1524.9,percent of total billed charges,Implant Device,1524.9,34,,1524.9,percent of total billed charges,Implant Device,1569.75,35,,1569.75,percent of total billed charges,Implant Device,1569.75,35,,1569.75,percent of total billed charges,Implant Device,1569.75,35,,1569.75,percent of total billed charges,Implant Device,1569.75,35,,1569.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1524.9,34,"If Charge > 2,000, then 34 percent",1524.9,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3318.91,
EXACTECH 521-78-31 THREADED PIN 3.2MM,C1713,HCPCS,,79010176,CDM,278,RC,,,both,,,1050,777,,,777,Other,150% of Medicare + 9.63% HCRA Surcharge,472.5,45,,472.5,percent of total billed charges,Critical Access Hospital RCC factor,357,34,,357,percent of total billed charges,Implant Device,357,34,,357,percent of total billed charges,Implant Device,357,34,,357,percent of total billed charges,Implant Device,357,34,,357,percent of total billed charges,Implant Device,357,34,,357,percent of total billed charges,Implant Device,519.75,,,519.75,Other,110% of Medicare,367.5,35,,367.5,percent of total billed charges,Implant Device,357,34,"Charges > $500, x 34%",357,percent of total billed charges,Implant Device,367.5,35,,367.5,percent of total billed charges,Implant Device,367.5,35,,367.5,percent of total billed charges,Implant Device,367.5,35,,367.5,percent of total billed charges,Implant Device,367.5,35,,367.5,percent of total billed charges,Implant Device,367.5,35,,367.5,percent of total billed charges,Implant Device,420,40,,420,percent of total billed charges,Implant Device,367.5,70,,367.5,percent of total billed charges,All Other,357,34,,357,percent of total billed charges,Implant Device,357,34,,357,percent of total billed charges,Implant Device,367.5,35,,367.5,percent of total billed charges,Implant Device,367.5,35,,367.5,percent of total billed charges,Implant Device,367.5,35,,367.5,percent of total billed charges,Implant Device,367.5,35,,367.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,777,
EXACTECH 300-01-12 HUMERAL STEM 12MM,C1776,HCPCS,,79010177,CDM,278,RC,,,both,,,4425,3274.51,,,3274.51,Other,150% of Medicare + 9.63% HCRA Surcharge,1991.25,45,,1991.25,percent of total billed charges,Critical Access Hospital RCC factor,1504.5,34,,1504.5,percent of total billed charges,Implant Device,1504.5,34,,1504.5,percent of total billed charges,Implant Device,1504.5,34,,1504.5,percent of total billed charges,Implant Device,1504.5,34,,1504.5,percent of total billed charges,Implant Device,1504.5,34,,1504.5,percent of total billed charges,Implant Device,2190.38,,,2190.38,Other,110% of Medicare,1548.75,35,,1548.75,percent of total billed charges,Implant Device,1504.5,34,"Charges > $500, x 34%",1504.5,percent of total billed charges,Implant Device,1548.75,35,,1548.75,percent of total billed charges,Implant Device,1548.75,35,,1548.75,percent of total billed charges,Implant Device,1548.75,35,,1548.75,percent of total billed charges,Implant Device,1548.75,35,,1548.75,percent of total billed charges,Implant Device,1548.75,35,,1548.75,percent of total billed charges,Implant Device,1770,40,,1770,percent of total billed charges,Implant Device,1548.75,70,,1548.75,percent of total billed charges,All Other,1504.5,34,,1504.5,percent of total billed charges,Implant Device,1504.5,34,,1504.5,percent of total billed charges,Implant Device,1548.75,35,,1548.75,percent of total billed charges,Implant Device,1548.75,35,,1548.75,percent of total billed charges,Implant Device,1548.75,35,,1548.75,percent of total billed charges,Implant Device,1548.75,35,,1548.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1504.5,34,"If Charge > 2,000, then 34 percent",1504.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3274.51,
IN2BONES P70 ST205 FIB PLATE LEFT 5 HOLE,C1713,HCPCS,,79010178,CDM,278,RC,,,both,,,6000,4440.02,,,4440.02,Other,150% of Medicare + 9.63% HCRA Surcharge,2700,45,,2700,percent of total billed charges,Critical Access Hospital RCC factor,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2970,,,2970,Other,110% of Medicare,2100,35,,2100,percent of total billed charges,Implant Device,2040,34,"Charges > $500, x 34%",2040,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2400,40,,2400,percent of total billed charges,Implant Device,2100,70,,2100,percent of total billed charges,All Other,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2040,34,"If Charge > 2,000, then 34 percent",2040,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4440.02,
IN2BONES P72 ST210 LOCK SCREW 2.7X10MM,C1713,HCPCS,,79010179,CDM,278,RC,,,both,,,870,643.8,,,643.8,Other,150% of Medicare + 9.63% HCRA Surcharge,391.5,45,,391.5,percent of total billed charges,Critical Access Hospital RCC factor,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,430.65,,,430.65,Other,110% of Medicare,304.5,35,,304.5,percent of total billed charges,Implant Device,295.8,34,"Charges > $500, x 34%",295.8,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,348,40,,348,percent of total billed charges,Implant Device,304.5,70,,304.5,percent of total billed charges,All Other,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,643.8,
IN2BONES P72 ST214 LOCK SCREW 2.7X14MM,C1713,HCPCS,,79010180,CDM,278,RC,,,both,,,870,643.8,,,643.8,Other,150% of Medicare + 9.63% HCRA Surcharge,391.5,45,,391.5,percent of total billed charges,Critical Access Hospital RCC factor,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,430.65,,,430.65,Other,110% of Medicare,304.5,35,,304.5,percent of total billed charges,Implant Device,295.8,34,"Charges > $500, x 34%",295.8,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,348,40,,348,percent of total billed charges,Implant Device,304.5,70,,304.5,percent of total billed charges,All Other,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,643.8,
IN2BONES P72 ST216 LOCK SCREW 2.7X16MM,C1713,HCPCS,,79010181,CDM,278,RC,,,both,,,870,643.8,,,643.8,Other,150% of Medicare + 9.63% HCRA Surcharge,391.5,45,,391.5,percent of total billed charges,Critical Access Hospital RCC factor,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,430.65,,,430.65,Other,110% of Medicare,304.5,35,,304.5,percent of total billed charges,Implant Device,295.8,34,"Charges > $500, x 34%",295.8,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,348,40,,348,percent of total billed charges,Implant Device,304.5,70,,304.5,percent of total billed charges,All Other,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,643.8,
IN2BONES P73 ST012 CORT SCREW 3.5X12MM,C1713,HCPCS,,79010182,CDM,278,RC,,,both,,,870,643.8,,,643.8,Other,150% of Medicare + 9.63% HCRA Surcharge,391.5,45,,391.5,percent of total billed charges,Critical Access Hospital RCC factor,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,430.65,,,430.65,Other,110% of Medicare,304.5,35,,304.5,percent of total billed charges,Implant Device,295.8,34,"Charges > $500, x 34%",295.8,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,348,40,,348,percent of total billed charges,Implant Device,304.5,70,,304.5,percent of total billed charges,All Other,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,643.8,
IN2BONES P73 ST014 CORT SCREW 3.5X14MM,C1713,HCPCS,,79010183,CDM,278,RC,,,both,,,612,452.88,,,452.88,Other,150% of Medicare + 9.63% HCRA Surcharge,275.4,45,,275.4,percent of total billed charges,Critical Access Hospital RCC factor,208.08,34,,208.08,percent of total billed charges,Implant Device,208.08,34,,208.08,percent of total billed charges,Implant Device,208.08,34,,208.08,percent of total billed charges,Implant Device,208.08,34,,208.08,percent of total billed charges,Implant Device,208.08,34,,208.08,percent of total billed charges,Implant Device,302.94,,,302.94,Other,110% of Medicare,214.2,35,,214.2,percent of total billed charges,Implant Device,208.08,34,"Charges > $500, x 34%",208.08,percent of total billed charges,Implant Device,214.2,35,,214.2,percent of total billed charges,Implant Device,214.2,35,,214.2,percent of total billed charges,Implant Device,214.2,35,,214.2,percent of total billed charges,Implant Device,214.2,35,,214.2,percent of total billed charges,Implant Device,214.2,35,,214.2,percent of total billed charges,Implant Device,244.8,40,,244.8,percent of total billed charges,Implant Device,214.2,70,,214.2,percent of total billed charges,All Other,208.08,34,,208.08,percent of total billed charges,Implant Device,208.08,34,,208.08,percent of total billed charges,Implant Device,214.2,35,,214.2,percent of total billed charges,Implant Device,214.2,35,,214.2,percent of total billed charges,Implant Device,214.2,35,,214.2,percent of total billed charges,Implant Device,214.2,35,,214.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,452.88,
IN2BONES P67 ST415 COLAG SCREW 4.0X45MM,C1713,HCPCS,,79010184,CDM,278,RC,,,both,,,1485,1098.9,,,1098.9,Other,150% of Medicare + 9.63% HCRA Surcharge,668.25,45,,668.25,percent of total billed charges,Critical Access Hospital RCC factor,504.9,34,,504.9,percent of total billed charges,Implant Device,504.9,34,,504.9,percent of total billed charges,Implant Device,504.9,34,,504.9,percent of total billed charges,Implant Device,504.9,34,,504.9,percent of total billed charges,Implant Device,504.9,34,,504.9,percent of total billed charges,Implant Device,735.08,,,735.08,Other,110% of Medicare,519.75,35,,519.75,percent of total billed charges,Implant Device,504.9,34,"Charges > $500, x 34%",504.9,percent of total billed charges,Implant Device,519.75,35,,519.75,percent of total billed charges,Implant Device,519.75,35,,519.75,percent of total billed charges,Implant Device,519.75,35,,519.75,percent of total billed charges,Implant Device,519.75,35,,519.75,percent of total billed charges,Implant Device,519.75,35,,519.75,percent of total billed charges,Implant Device,594,40,,594,percent of total billed charges,Implant Device,519.75,70,,519.75,percent of total billed charges,All Other,504.9,34,,504.9,percent of total billed charges,Implant Device,504.9,34,,504.9,percent of total billed charges,Implant Device,519.75,35,,519.75,percent of total billed charges,Implant Device,519.75,35,,519.75,percent of total billed charges,Implant Device,519.75,35,,519.75,percent of total billed charges,Implant Device,519.75,35,,519.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1098.9,
ALLERGAN SCM-240 GEL BREAST IMPLANT 240,C1789,HCPCS,,79010185,CDM,278,RC,,,both,,,4005,2963.71,,,2963.71,Other,150% of Medicare + 9.63% HCRA Surcharge,1802.25,45,,1802.25,percent of total billed charges,Critical Access Hospital RCC factor,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1982.48,,,1982.48,Other,110% of Medicare,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1361.7,34,"Charges > $500, x 34%",1361.7,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1602,40,,1602,percent of total billed charges,Implant Device,1401.75,70,,1401.75,percent of total billed charges,All Other,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1361.7,34,"If Charge > 2,000, then 34 percent",1361.7,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2963.71,
ALLERGAN SCM-275 GEL BREAST IMPLANT 275,C1789,HCPCS,,79010186,CDM,278,RC,,,both,,,4005,2963.71,,,2963.71,Other,150% of Medicare + 9.63% HCRA Surcharge,1802.25,45,,1802.25,percent of total billed charges,Critical Access Hospital RCC factor,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1982.48,,,1982.48,Other,110% of Medicare,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1361.7,34,"Charges > $500, x 34%",1361.7,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1602,40,,1602,percent of total billed charges,Implant Device,1401.75,70,,1401.75,percent of total billed charges,All Other,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1361.7,34,"If Charge > 2,000, then 34 percent",1361.7,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2963.71,
ALLERGAN SCLP-14 GEL BREAST IMPLANT 145,C1789,HCPCS,,79010189,CDM,278,RC,,,both,,,4005,2963.71,,,2963.71,Other,150% of Medicare + 9.63% HCRA Surcharge,1802.25,45,,1802.25,percent of total billed charges,Critical Access Hospital RCC factor,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1982.48,,,1982.48,Other,110% of Medicare,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1361.7,34,"Charges > $500, x 34%",1361.7,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1602,40,,1602,percent of total billed charges,Implant Device,1401.75,70,,1401.75,percent of total billed charges,All Other,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1361.7,34,"If Charge > 2,000, then 34 percent",1361.7,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2963.71,
ALLERGAN SCLP-190 GEL BREAST IMPLANT 190,C1789,HCPCS,,79010190,CDM,278,RC,,,both,,,4005,2963.71,,,2963.71,Other,150% of Medicare + 9.63% HCRA Surcharge,1802.25,45,,1802.25,percent of total billed charges,Critical Access Hospital RCC factor,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1982.48,,,1982.48,Other,110% of Medicare,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1361.7,34,"Charges > $500, x 34%",1361.7,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1602,40,,1602,percent of total billed charges,Implant Device,1401.75,70,,1401.75,percent of total billed charges,All Other,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1361.7,34,"If Charge > 2,000, then 34 percent",1361.7,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2963.71,
ALLERGAN SCLP-220 GEL BREAST IMPLANT 220,C1789,HCPCS,,79010191,CDM,278,RC,,,both,,,4005,2963.71,,,2963.71,Other,150% of Medicare + 9.63% HCRA Surcharge,1802.25,45,,1802.25,percent of total billed charges,Critical Access Hospital RCC factor,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1982.48,,,1982.48,Other,110% of Medicare,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1361.7,34,"Charges > $500, x 34%",1361.7,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1602,40,,1602,percent of total billed charges,Implant Device,1401.75,70,,1401.75,percent of total billed charges,All Other,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1361.7,34,"If Charge > 2,000, then 34 percent",1361.7,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2963.71,
ALLERGAN SCLP-250 GEL BREAST IMPLANT 250,C1789,HCPCS,,79010192,CDM,278,RC,,,both,,,4005,2963.71,,,2963.71,Other,150% of Medicare + 9.63% HCRA Surcharge,1802.25,45,,1802.25,percent of total billed charges,Critical Access Hospital RCC factor,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1982.48,,,1982.48,Other,110% of Medicare,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1361.7,34,"Charges > $500, x 34%",1361.7,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1602,40,,1602,percent of total billed charges,Implant Device,1401.75,70,,1401.75,percent of total billed charges,All Other,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1361.7,34,"If Charge > 2,000, then 34 percent",1361.7,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2963.71,
MENTOR SMXP100RH TISSUE EXPANDER 225CC,C1789,HCPCS,,79010197,CDM,278,RC,,,both,,,6375,4717.52,,,4717.52,Other,150% of Medicare + 9.63% HCRA Surcharge,2868.75,45,,2868.75,percent of total billed charges,Critical Access Hospital RCC factor,2167.5,34,,2167.5,percent of total billed charges,Implant Device,2167.5,34,,2167.5,percent of total billed charges,Implant Device,2167.5,34,,2167.5,percent of total billed charges,Implant Device,2167.5,34,,2167.5,percent of total billed charges,Implant Device,2167.5,34,,2167.5,percent of total billed charges,Implant Device,3155.63,,,3155.63,Other,110% of Medicare,2231.25,35,,2231.25,percent of total billed charges,Implant Device,2167.5,34,"Charges > $500, x 34%",2167.5,percent of total billed charges,Implant Device,2231.25,35,,2231.25,percent of total billed charges,Implant Device,2231.25,35,,2231.25,percent of total billed charges,Implant Device,2231.25,35,,2231.25,percent of total billed charges,Implant Device,2231.25,35,,2231.25,percent of total billed charges,Implant Device,2231.25,35,,2231.25,percent of total billed charges,Implant Device,2550,40,,2550,percent of total billed charges,Implant Device,2231.25,70,,2231.25,percent of total billed charges,All Other,2167.5,34,,2167.5,percent of total billed charges,Implant Device,2167.5,34,,2167.5,percent of total billed charges,Implant Device,2231.25,35,,2231.25,percent of total billed charges,Implant Device,2231.25,35,,2231.25,percent of total billed charges,Implant Device,2231.25,35,,2231.25,percent of total billed charges,Implant Device,2231.25,35,,2231.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2167.5,34,"If Charge > 2,000, then 34 percent",2167.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4717.52,
MENTOR SMXP110RH TISSUE EXPANDER 110CC,C1789,HCPCS,,79010198,CDM,278,RC,,,both,,,6375,4717.52,,,4717.52,Other,150% of Medicare + 9.63% HCRA Surcharge,2868.75,45,,2868.75,percent of total billed charges,Critical Access Hospital RCC factor,2167.5,34,,2167.5,percent of total billed charges,Implant Device,2167.5,34,,2167.5,percent of total billed charges,Implant Device,2167.5,34,,2167.5,percent of total billed charges,Implant Device,2167.5,34,,2167.5,percent of total billed charges,Implant Device,2167.5,34,,2167.5,percent of total billed charges,Implant Device,3155.63,,,3155.63,Other,110% of Medicare,2231.25,35,,2231.25,percent of total billed charges,Implant Device,2167.5,34,"Charges > $500, x 34%",2167.5,percent of total billed charges,Implant Device,2231.25,35,,2231.25,percent of total billed charges,Implant Device,2231.25,35,,2231.25,percent of total billed charges,Implant Device,2231.25,35,,2231.25,percent of total billed charges,Implant Device,2231.25,35,,2231.25,percent of total billed charges,Implant Device,2231.25,35,,2231.25,percent of total billed charges,Implant Device,2550,40,,2550,percent of total billed charges,Implant Device,2231.25,70,,2231.25,percent of total billed charges,All Other,2167.5,34,,2167.5,percent of total billed charges,Implant Device,2167.5,34,,2167.5,percent of total billed charges,Implant Device,2231.25,35,,2231.25,percent of total billed charges,Implant Device,2231.25,35,,2231.25,percent of total billed charges,Implant Device,2231.25,35,,2231.25,percent of total billed charges,Implant Device,2231.25,35,,2231.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2167.5,34,"If Charge > 2,000, then 34 percent",2167.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4717.52,
IN2BONES P72 ST212 LOCK SCREW 2.7X12MM,C1713,HCPCS,,79010199,CDM,278,RC,,,both,,,870,643.8,,,643.8,Other,150% of Medicare + 9.63% HCRA Surcharge,391.5,45,,391.5,percent of total billed charges,Critical Access Hospital RCC factor,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,430.65,,,430.65,Other,110% of Medicare,304.5,35,,304.5,percent of total billed charges,Implant Device,295.8,34,"Charges > $500, x 34%",295.8,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,348,40,,348,percent of total billed charges,Implant Device,304.5,70,,304.5,percent of total billed charges,All Other,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,643.8,
WRIGHT 4151150030 VALOR SCREW 5X30MM,C1713,HCPCS,,79010202,CDM,278,RC,,,both,,,885,654.9,,,654.9,Other,150% of Medicare + 9.63% HCRA Surcharge,398.25,45,,398.25,percent of total billed charges,Critical Access Hospital RCC factor,300.9,34,,300.9,percent of total billed charges,Implant Device,300.9,34,,300.9,percent of total billed charges,Implant Device,300.9,34,,300.9,percent of total billed charges,Implant Device,300.9,34,,300.9,percent of total billed charges,Implant Device,300.9,34,,300.9,percent of total billed charges,Implant Device,438.08,,,438.08,Other,110% of Medicare,309.75,35,,309.75,percent of total billed charges,Implant Device,300.9,34,"Charges > $500, x 34%",300.9,percent of total billed charges,Implant Device,309.75,35,,309.75,percent of total billed charges,Implant Device,309.75,35,,309.75,percent of total billed charges,Implant Device,309.75,35,,309.75,percent of total billed charges,Implant Device,309.75,35,,309.75,percent of total billed charges,Implant Device,309.75,35,,309.75,percent of total billed charges,Implant Device,354,40,,354,percent of total billed charges,Implant Device,309.75,70,,309.75,percent of total billed charges,All Other,300.9,34,,300.9,percent of total billed charges,Implant Device,300.9,34,,300.9,percent of total billed charges,Implant Device,309.75,35,,309.75,percent of total billed charges,Implant Device,309.75,35,,309.75,percent of total billed charges,Implant Device,309.75,35,,309.75,percent of total billed charges,Implant Device,309.75,35,,309.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,654.9,
WRIGHT 4151150040 VALOR SCREW 5X40MM,C1713,HCPCS,,79010203,CDM,278,RC,,,both,,,885,654.9,,,654.9,Other,150% of Medicare + 9.63% HCRA Surcharge,398.25,45,,398.25,percent of total billed charges,Critical Access Hospital RCC factor,300.9,34,,300.9,percent of total billed charges,Implant Device,300.9,34,,300.9,percent of total billed charges,Implant Device,300.9,34,,300.9,percent of total billed charges,Implant Device,300.9,34,,300.9,percent of total billed charges,Implant Device,300.9,34,,300.9,percent of total billed charges,Implant Device,438.08,,,438.08,Other,110% of Medicare,309.75,35,,309.75,percent of total billed charges,Implant Device,300.9,34,"Charges > $500, x 34%",300.9,percent of total billed charges,Implant Device,309.75,35,,309.75,percent of total billed charges,Implant Device,309.75,35,,309.75,percent of total billed charges,Implant Device,309.75,35,,309.75,percent of total billed charges,Implant Device,309.75,35,,309.75,percent of total billed charges,Implant Device,309.75,35,,309.75,percent of total billed charges,Implant Device,354,40,,354,percent of total billed charges,Implant Device,309.75,70,,309.75,percent of total billed charges,All Other,300.9,34,,300.9,percent of total billed charges,Implant Device,300.9,34,,300.9,percent of total billed charges,Implant Device,309.75,35,,309.75,percent of total billed charges,Implant Device,309.75,35,,309.75,percent of total billed charges,Implant Device,309.75,35,,309.75,percent of total billed charges,Implant Device,309.75,35,,309.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,654.9,
WRIGHT 4151150075 VALOR SCREW 5X75MM,C1713,HCPCS,,79010204,CDM,278,RC,,,both,,,885,654.9,,,654.9,Other,150% of Medicare + 9.63% HCRA Surcharge,398.25,45,,398.25,percent of total billed charges,Critical Access Hospital RCC factor,300.9,34,,300.9,percent of total billed charges,Implant Device,300.9,34,,300.9,percent of total billed charges,Implant Device,300.9,34,,300.9,percent of total billed charges,Implant Device,300.9,34,,300.9,percent of total billed charges,Implant Device,300.9,34,,300.9,percent of total billed charges,Implant Device,438.08,,,438.08,Other,110% of Medicare,309.75,35,,309.75,percent of total billed charges,Implant Device,300.9,34,"Charges > $500, x 34%",300.9,percent of total billed charges,Implant Device,309.75,35,,309.75,percent of total billed charges,Implant Device,309.75,35,,309.75,percent of total billed charges,Implant Device,309.75,35,,309.75,percent of total billed charges,Implant Device,309.75,35,,309.75,percent of total billed charges,Implant Device,309.75,35,,309.75,percent of total billed charges,Implant Device,354,40,,354,percent of total billed charges,Implant Device,309.75,70,,309.75,percent of total billed charges,All Other,300.9,34,,300.9,percent of total billed charges,Implant Device,300.9,34,,300.9,percent of total billed charges,Implant Device,309.75,35,,309.75,percent of total billed charges,Implant Device,309.75,35,,309.75,percent of total billed charges,Implant Device,309.75,35,,309.75,percent of total billed charges,Implant Device,309.75,35,,309.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,654.9,
WRIGHT 4151200003 VALOR NAIL END CAP,C1713,HCPCS,,79010205,CDM,278,RC,,,both,,,885,654.9,,,654.9,Other,150% of Medicare + 9.63% HCRA Surcharge,398.25,45,,398.25,percent of total billed charges,Critical Access Hospital RCC factor,300.9,34,,300.9,percent of total billed charges,Implant Device,300.9,34,,300.9,percent of total billed charges,Implant Device,300.9,34,,300.9,percent of total billed charges,Implant Device,300.9,34,,300.9,percent of total billed charges,Implant Device,300.9,34,,300.9,percent of total billed charges,Implant Device,438.08,,,438.08,Other,110% of Medicare,309.75,35,,309.75,percent of total billed charges,Implant Device,300.9,34,"Charges > $500, x 34%",300.9,percent of total billed charges,Implant Device,309.75,35,,309.75,percent of total billed charges,Implant Device,309.75,35,,309.75,percent of total billed charges,Implant Device,309.75,35,,309.75,percent of total billed charges,Implant Device,309.75,35,,309.75,percent of total billed charges,Implant Device,309.75,35,,309.75,percent of total billed charges,Implant Device,354,40,,354,percent of total billed charges,Implant Device,309.75,70,,309.75,percent of total billed charges,All Other,300.9,34,,300.9,percent of total billed charges,Implant Device,300.9,34,,300.9,percent of total billed charges,Implant Device,309.75,35,,309.75,percent of total billed charges,Implant Device,309.75,35,,309.75,percent of total billed charges,Implant Device,309.75,35,,309.75,percent of total billed charges,Implant Device,309.75,35,,309.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,654.9,
WRIGHT 415101025L VALOR NAIL 10X250MM,C1713,HCPCS,,79010208,CDM,278,RC,,,both,,,10485,7758.93,,,7758.93,Other,150% of Medicare + 9.63% HCRA Surcharge,4718.25,45,,4718.25,percent of total billed charges,Critical Access Hospital RCC factor,3564.9,34,,3564.9,percent of total billed charges,Implant Device,3564.9,34,,3564.9,percent of total billed charges,Implant Device,3564.9,34,,3564.9,percent of total billed charges,Implant Device,3564.9,34,,3564.9,percent of total billed charges,Implant Device,3564.9,34,,3564.9,percent of total billed charges,Implant Device,5190.08,,,5190.08,Other,110% of Medicare,3669.75,35,,3669.75,percent of total billed charges,Implant Device,3564.9,34,"Charges > $500, x 34%",3564.9,percent of total billed charges,Implant Device,3669.75,35,,3669.75,percent of total billed charges,Implant Device,3669.75,35,,3669.75,percent of total billed charges,Implant Device,3669.75,35,,3669.75,percent of total billed charges,Implant Device,3669.75,35,,3669.75,percent of total billed charges,Implant Device,3669.75,35,,3669.75,percent of total billed charges,Implant Device,4194,40,,4194,percent of total billed charges,Implant Device,3669.75,70,,3669.75,percent of total billed charges,All Other,3564.9,34,,3564.9,percent of total billed charges,Implant Device,3564.9,34,,3564.9,percent of total billed charges,Implant Device,3669.75,35,,3669.75,percent of total billed charges,Implant Device,3669.75,35,,3669.75,percent of total billed charges,Implant Device,3669.75,35,,3669.75,percent of total billed charges,Implant Device,3669.75,35,,3669.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3564.9,34,"If Charge > 2,000, then 34 percent",3564.9,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,7758.93,
ZIMMER 00-8146-11-360 LONG NAIL 11X360MM,C1713,HCPCS,,79010209,CDM,278,RC,,,both,,,12150,8991.03,,,8991.03,Other,150% of Medicare + 9.63% HCRA Surcharge,5467.5,45,,5467.5,percent of total billed charges,Critical Access Hospital RCC factor,4131,34,,4131,percent of total billed charges,Implant Device,4131,34,,4131,percent of total billed charges,Implant Device,4131,34,,4131,percent of total billed charges,Implant Device,4131,34,,4131,percent of total billed charges,Implant Device,4131,34,,4131,percent of total billed charges,Implant Device,6014.25,,,6014.25,Other,110% of Medicare,4252.5,35,,4252.5,percent of total billed charges,Implant Device,4131,34,"Charges > $500, x 34%",4131,percent of total billed charges,Implant Device,4252.5,35,,4252.5,percent of total billed charges,Implant Device,4252.5,35,,4252.5,percent of total billed charges,Implant Device,4252.5,35,,4252.5,percent of total billed charges,Implant Device,4252.5,35,,4252.5,percent of total billed charges,Implant Device,4252.5,35,,4252.5,percent of total billed charges,Implant Device,4860,40,,4860,percent of total billed charges,Implant Device,4252.5,70,,4252.5,percent of total billed charges,All Other,4131,34,,4131,percent of total billed charges,Implant Device,4131,34,,4131,percent of total billed charges,Implant Device,4252.5,35,,4252.5,percent of total billed charges,Implant Device,4252.5,35,,4252.5,percent of total billed charges,Implant Device,4252.5,35,,4252.5,percent of total billed charges,Implant Device,4252.5,35,,4252.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,4131,34,"If Charge > 2,000, then 34 percent",4131,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,8991.03,
ZIMMER 00-2359-014-45 LOCK SCREW 4.5X16,C1713,HCPCS,,79010210,CDM,278,RC,,,both,,,445,329.3,,,329.3,Other,150% of Medicare + 9.63% HCRA Surcharge,200.25,45,,200.25,percent of total billed charges,Critical Access Hospital RCC factor,151.3,34,,151.3,percent of total billed charges,Implant Device,151.3,34,,151.3,percent of total billed charges,Implant Device,151.3,34,,151.3,percent of total billed charges,Implant Device,151.3,34,,151.3,percent of total billed charges,Implant Device,151.3,34,,151.3,percent of total billed charges,Implant Device,220.28,,,220.28,Other,110% of Medicare,155.75,35,,155.75,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,155.75,35,,155.75,percent of total billed charges,Implant Device,155.75,35,,155.75,percent of total billed charges,Implant Device,155.75,35,,155.75,percent of total billed charges,Implant Device,155.75,35,,155.75,percent of total billed charges,Implant Device,155.75,35,,155.75,percent of total billed charges,Implant Device,178,40,,178,percent of total billed charges,Implant Device,155.75,70,,155.75,percent of total billed charges,All Other,151.3,34,,151.3,percent of total billed charges,Implant Device,151.3,34,,151.3,percent of total billed charges,Implant Device,155.75,35,,155.75,percent of total billed charges,Implant Device,155.75,35,,155.75,percent of total billed charges,Implant Device,155.75,35,,155.75,percent of total billed charges,Implant Device,155.75,35,,155.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,329.3,
STRYKER 5510-F-302 FEM COMPONENT SZ 3,C1776,HCPCS,,79010211,CDM,278,RC,,,both,,,4450,3293.01,,,3293.01,Other,150% of Medicare + 9.63% HCRA Surcharge,2002.5,45,,2002.5,percent of total billed charges,Critical Access Hospital RCC factor,1513,34,,1513,percent of total billed charges,Implant Device,1513,34,,1513,percent of total billed charges,Implant Device,1513,34,,1513,percent of total billed charges,Implant Device,1513,34,,1513,percent of total billed charges,Implant Device,1513,34,,1513,percent of total billed charges,Implant Device,2202.75,,,2202.75,Other,110% of Medicare,1557.5,35,,1557.5,percent of total billed charges,Implant Device,1513,34,"Charges > $500, x 34%",1513,percent of total billed charges,Implant Device,1557.5,35,,1557.5,percent of total billed charges,Implant Device,1557.5,35,,1557.5,percent of total billed charges,Implant Device,1557.5,35,,1557.5,percent of total billed charges,Implant Device,1557.5,35,,1557.5,percent of total billed charges,Implant Device,1557.5,35,,1557.5,percent of total billed charges,Implant Device,1780,40,,1780,percent of total billed charges,Implant Device,1557.5,70,,1557.5,percent of total billed charges,All Other,1513,34,,1513,percent of total billed charges,Implant Device,1513,34,,1513,percent of total billed charges,Implant Device,1557.5,35,,1557.5,percent of total billed charges,Implant Device,1557.5,35,,1557.5,percent of total billed charges,Implant Device,1557.5,35,,1557.5,percent of total billed charges,Implant Device,1557.5,35,,1557.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1513,34,"If Charge > 2,000, then 34 percent",1513,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3293.01,
ARTHREX AR-1938PS SUTURE ANCHOR 3X12.7MM,C1713,HCPCS,,79010212,CDM,278,RC,,,both,,,1155,854.7,,,854.7,Other,150% of Medicare + 9.63% HCRA Surcharge,519.75,45,,519.75,percent of total billed charges,Critical Access Hospital RCC factor,392.7,34,,392.7,percent of total billed charges,Implant Device,392.7,34,,392.7,percent of total billed charges,Implant Device,392.7,34,,392.7,percent of total billed charges,Implant Device,392.7,34,,392.7,percent of total billed charges,Implant Device,392.7,34,,392.7,percent of total billed charges,Implant Device,571.73,,,571.73,Other,110% of Medicare,404.25,35,,404.25,percent of total billed charges,Implant Device,392.7,34,"Charges > $500, x 34%",392.7,percent of total billed charges,Implant Device,404.25,35,,404.25,percent of total billed charges,Implant Device,404.25,35,,404.25,percent of total billed charges,Implant Device,404.25,35,,404.25,percent of total billed charges,Implant Device,404.25,35,,404.25,percent of total billed charges,Implant Device,404.25,35,,404.25,percent of total billed charges,Implant Device,462,40,,462,percent of total billed charges,Implant Device,404.25,70,,404.25,percent of total billed charges,All Other,392.7,34,,392.7,percent of total billed charges,Implant Device,392.7,34,,392.7,percent of total billed charges,Implant Device,404.25,35,,404.25,percent of total billed charges,Implant Device,404.25,35,,404.25,percent of total billed charges,Implant Device,404.25,35,,404.25,percent of total billed charges,Implant Device,404.25,35,,404.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,854.7,
STRYKER 3425-0440S GAMMA NAIL 10X440X125,C1713,HCPCS,,79010214,CDM,278,RC,,,both,,,5438,4024.13,,,4024.13,Other,150% of Medicare + 9.63% HCRA Surcharge,2447.1,45,,2447.1,percent of total billed charges,Critical Access Hospital RCC factor,1848.92,34,,1848.92,percent of total billed charges,Implant Device,1848.92,34,,1848.92,percent of total billed charges,Implant Device,1848.92,34,,1848.92,percent of total billed charges,Implant Device,1848.92,34,,1848.92,percent of total billed charges,Implant Device,1848.92,34,,1848.92,percent of total billed charges,Implant Device,2691.81,,,2691.81,Other,110% of Medicare,1903.3,35,,1903.3,percent of total billed charges,Implant Device,1848.92,34,"Charges > $500, x 34%",1848.92,percent of total billed charges,Implant Device,1903.3,35,,1903.3,percent of total billed charges,Implant Device,1903.3,35,,1903.3,percent of total billed charges,Implant Device,1903.3,35,,1903.3,percent of total billed charges,Implant Device,1903.3,35,,1903.3,percent of total billed charges,Implant Device,1903.3,35,,1903.3,percent of total billed charges,Implant Device,2175.2,40,,2175.2,percent of total billed charges,Implant Device,1903.3,70,,1903.3,percent of total billed charges,All Other,1848.92,34,,1848.92,percent of total billed charges,Implant Device,1848.92,34,,1848.92,percent of total billed charges,Implant Device,1903.3,35,,1903.3,percent of total billed charges,Implant Device,1903.3,35,,1903.3,percent of total billed charges,Implant Device,1903.3,35,,1903.3,percent of total billed charges,Implant Device,1903.3,35,,1903.3,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1848.92,34,"If Charge > 2,000, then 34 percent",1848.92,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4024.13,
DEPUY 3L93711 CONRAIL2 LAT COX SIZE 11,C1776,HCPCS,,79010215,CDM,278,RC,,,both,,,13446,9950.07,,,9950.07,Other,150% of Medicare + 9.63% HCRA Surcharge,6050.7,45,,6050.7,percent of total billed charges,Critical Access Hospital RCC factor,4571.64,34,,4571.64,percent of total billed charges,Implant Device,4571.64,34,,4571.64,percent of total billed charges,Implant Device,4571.64,34,,4571.64,percent of total billed charges,Implant Device,4571.64,34,,4571.64,percent of total billed charges,Implant Device,4571.64,34,,4571.64,percent of total billed charges,Implant Device,6655.77,,,6655.77,Other,110% of Medicare,4706.1,35,,4706.1,percent of total billed charges,Implant Device,4571.64,34,"Charges > $500, x 34%",4571.64,percent of total billed charges,Implant Device,4706.1,35,,4706.1,percent of total billed charges,Implant Device,4706.1,35,,4706.1,percent of total billed charges,Implant Device,4706.1,35,,4706.1,percent of total billed charges,Implant Device,4706.1,35,,4706.1,percent of total billed charges,Implant Device,4706.1,35,,4706.1,percent of total billed charges,Implant Device,5378.4,40,,5378.4,percent of total billed charges,Implant Device,4706.1,70,,4706.1,percent of total billed charges,All Other,4571.64,34,,4571.64,percent of total billed charges,Implant Device,4571.64,34,,4571.64,percent of total billed charges,Implant Device,4706.1,35,,4706.1,percent of total billed charges,Implant Device,4706.1,35,,4706.1,percent of total billed charges,Implant Device,4706.1,35,,4706.1,percent of total billed charges,Implant Device,4706.1,35,,4706.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,4571.64,34,"If Charge > 2,000, then 34 percent",4571.64,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,9950.07,
ARTHREX AR-7297 TENDON DRESSING KIT,C1713,HCPCS,,79010216,CDM,278,RC,,,both,,,1800,1332,,,1332,Other,150% of Medicare + 9.63% HCRA Surcharge,810,45,,810,percent of total billed charges,Critical Access Hospital RCC factor,612,34,,612,percent of total billed charges,Implant Device,612,34,,612,percent of total billed charges,Implant Device,612,34,,612,percent of total billed charges,Implant Device,612,34,,612,percent of total billed charges,Implant Device,612,34,,612,percent of total billed charges,Implant Device,891,,,891,Other,110% of Medicare,630,35,,630,percent of total billed charges,Implant Device,612,34,"Charges > $500, x 34%",612,percent of total billed charges,Implant Device,630,35,,630,percent of total billed charges,Implant Device,630,35,,630,percent of total billed charges,Implant Device,630,35,,630,percent of total billed charges,Implant Device,630,35,,630,percent of total billed charges,Implant Device,630,35,,630,percent of total billed charges,Implant Device,720,40,,720,percent of total billed charges,Implant Device,630,70,,630,percent of total billed charges,All Other,612,34,,612,percent of total billed charges,Implant Device,612,34,,612,percent of total billed charges,Implant Device,630,35,,630,percent of total billed charges,Implant Device,630,35,,630,percent of total billed charges,Implant Device,630,35,,630,percent of total billed charges,Implant Device,630,35,,630,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1332,
STRYKER 661485 CORTEX SCREW 3.5X85MM,C1713,HCPCS,,79010217,CDM,278,RC,,,both,,,122,90.28,,,90.28,Other,150% of Medicare + 9.63% HCRA Surcharge,54.9,45,,54.9,percent of total billed charges,Critical Access Hospital RCC factor,41.48,34,,41.48,percent of total billed charges,Implant Device,41.48,34,,41.48,percent of total billed charges,Implant Device,41.48,34,,41.48,percent of total billed charges,Implant Device,41.48,34,,41.48,percent of total billed charges,Implant Device,41.48,34,,41.48,percent of total billed charges,Implant Device,60.39,,,60.39,Other,110% of Medicare,42.7,35,,42.7,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,42.7,35,,42.7,percent of total billed charges,Implant Device,42.7,35,,42.7,percent of total billed charges,Implant Device,42.7,35,,42.7,percent of total billed charges,Implant Device,42.7,35,,42.7,percent of total billed charges,Implant Device,42.7,35,,42.7,percent of total billed charges,Implant Device,48.8,40,,48.8,percent of total billed charges,Implant Device,42.7,70,,42.7,percent of total billed charges,All Other,41.48,34,,41.48,percent of total billed charges,Implant Device,41.48,34,,41.48,percent of total billed charges,Implant Device,42.7,35,,42.7,percent of total billed charges,Implant Device,42.7,35,,42.7,percent of total billed charges,Implant Device,42.7,35,,42.7,percent of total billed charges,Implant Device,42.7,35,,42.7,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,90.28,
ARTHREX ABS-2012-05 ALLOSYNC DBM PUTTY,C1713,HCPCS,,79010220,CDM,278,RC,,,both,,,2400,1776.01,,,1776.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1080,45,,1080,percent of total billed charges,Critical Access Hospital RCC factor,816,34,,816,percent of total billed charges,Implant Device,816,34,,816,percent of total billed charges,Implant Device,816,34,,816,percent of total billed charges,Implant Device,816,34,,816,percent of total billed charges,Implant Device,816,34,,816,percent of total billed charges,Implant Device,1188,,,1188,Other,110% of Medicare,840,35,,840,percent of total billed charges,Implant Device,816,34,"Charges > $500, x 34%",816,percent of total billed charges,Implant Device,840,35,,840,percent of total billed charges,Implant Device,840,35,,840,percent of total billed charges,Implant Device,840,35,,840,percent of total billed charges,Implant Device,840,35,,840,percent of total billed charges,Implant Device,840,35,,840,percent of total billed charges,Implant Device,960,40,,960,percent of total billed charges,Implant Device,840,70,,840,percent of total billed charges,All Other,816,34,,816,percent of total billed charges,Implant Device,816,34,,816,percent of total billed charges,Implant Device,840,35,,840,percent of total billed charges,Implant Device,840,35,,840,percent of total billed charges,Implant Device,840,35,,840,percent of total billed charges,Implant Device,840,35,,840,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,816,34,"If Charge > 2,000, then 34 percent",816,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1776.01,
ARTHREX AR-8967-1845 CANN SCREW 6.7X45MM,C1713,HCPCS,,79010221,CDM,278,RC,,,both,,,750,555,,,555,Other,150% of Medicare + 9.63% HCRA Surcharge,337.5,45,,337.5,percent of total billed charges,Critical Access Hospital RCC factor,255,34,,255,percent of total billed charges,Implant Device,255,34,,255,percent of total billed charges,Implant Device,255,34,,255,percent of total billed charges,Implant Device,255,34,,255,percent of total billed charges,Implant Device,255,34,,255,percent of total billed charges,Implant Device,371.25,,,371.25,Other,110% of Medicare,262.5,35,,262.5,percent of total billed charges,Implant Device,255,34,"Charges > $500, x 34%",255,percent of total billed charges,Implant Device,262.5,35,,262.5,percent of total billed charges,Implant Device,262.5,35,,262.5,percent of total billed charges,Implant Device,262.5,35,,262.5,percent of total billed charges,Implant Device,262.5,35,,262.5,percent of total billed charges,Implant Device,262.5,35,,262.5,percent of total billed charges,Implant Device,300,40,,300,percent of total billed charges,Implant Device,262.5,70,,262.5,percent of total billed charges,All Other,255,34,,255,percent of total billed charges,Implant Device,255,34,,255,percent of total billed charges,Implant Device,262.5,35,,262.5,percent of total billed charges,Implant Device,262.5,35,,262.5,percent of total billed charges,Implant Device,262.5,35,,262.5,percent of total billed charges,Implant Device,262.5,35,,262.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,555,
STRYKER UH1-50-26 UHR BIPOLAR 26X50MM,C1776,HCPCS,,79010222,CDM,278,RC,,,both,,,1391,1029.34,,,1029.34,Other,150% of Medicare + 9.63% HCRA Surcharge,625.95,45,,625.95,percent of total billed charges,Critical Access Hospital RCC factor,472.94,34,,472.94,percent of total billed charges,Implant Device,472.94,34,,472.94,percent of total billed charges,Implant Device,472.94,34,,472.94,percent of total billed charges,Implant Device,472.94,34,,472.94,percent of total billed charges,Implant Device,472.94,34,,472.94,percent of total billed charges,Implant Device,688.55,,,688.55,Other,110% of Medicare,486.85,35,,486.85,percent of total billed charges,Implant Device,472.94,34,"Charges > $500, x 34%",472.94,percent of total billed charges,Implant Device,486.85,35,,486.85,percent of total billed charges,Implant Device,486.85,35,,486.85,percent of total billed charges,Implant Device,486.85,35,,486.85,percent of total billed charges,Implant Device,486.85,35,,486.85,percent of total billed charges,Implant Device,486.85,35,,486.85,percent of total billed charges,Implant Device,556.4,40,,556.4,percent of total billed charges,Implant Device,486.85,70,,486.85,percent of total billed charges,All Other,472.94,34,,472.94,percent of total billed charges,Implant Device,472.94,34,,472.94,percent of total billed charges,Implant Device,486.85,35,,486.85,percent of total billed charges,Implant Device,486.85,35,,486.85,percent of total billed charges,Implant Device,486.85,35,,486.85,percent of total billed charges,Implant Device,486.85,35,,486.85,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1029.34,
STRYKER 6721-0330 ACCOLADE II 127 SZ3,C1776,HCPCS,,79010223,CDM,278,RC,,,both,,,6953,5145.24,,,5145.24,Other,150% of Medicare + 9.63% HCRA Surcharge,3128.85,45,,3128.85,percent of total billed charges,Critical Access Hospital RCC factor,2364.02,34,,2364.02,percent of total billed charges,Implant Device,2364.02,34,,2364.02,percent of total billed charges,Implant Device,2364.02,34,,2364.02,percent of total billed charges,Implant Device,2364.02,34,,2364.02,percent of total billed charges,Implant Device,2364.02,34,,2364.02,percent of total billed charges,Implant Device,3441.74,,,3441.74,Other,110% of Medicare,2433.55,35,,2433.55,percent of total billed charges,Implant Device,2364.02,34,"Charges > $500, x 34%",2364.02,percent of total billed charges,Implant Device,2433.55,35,,2433.55,percent of total billed charges,Implant Device,2433.55,35,,2433.55,percent of total billed charges,Implant Device,2433.55,35,,2433.55,percent of total billed charges,Implant Device,2433.55,35,,2433.55,percent of total billed charges,Implant Device,2433.55,35,,2433.55,percent of total billed charges,Implant Device,2781.2,40,,2781.2,percent of total billed charges,Implant Device,2433.55,70,,2433.55,percent of total billed charges,All Other,2364.02,34,,2364.02,percent of total billed charges,Implant Device,2364.02,34,,2364.02,percent of total billed charges,Implant Device,2433.55,35,,2433.55,percent of total billed charges,Implant Device,2433.55,35,,2433.55,percent of total billed charges,Implant Device,2433.55,35,,2433.55,percent of total billed charges,Implant Device,2433.55,35,,2433.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2364.02,34,"If Charge > 2,000, then 34 percent",2364.02,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5145.24,
STRYKER UH1-44026 UHR BIPOLAR 26X44MM,C1776,HCPCS,,79010224,CDM,278,RC,,,both,,,1391,1029.34,,,1029.34,Other,150% of Medicare + 9.63% HCRA Surcharge,625.95,45,,625.95,percent of total billed charges,Critical Access Hospital RCC factor,472.94,34,,472.94,percent of total billed charges,Implant Device,472.94,34,,472.94,percent of total billed charges,Implant Device,472.94,34,,472.94,percent of total billed charges,Implant Device,472.94,34,,472.94,percent of total billed charges,Implant Device,472.94,34,,472.94,percent of total billed charges,Implant Device,688.55,,,688.55,Other,110% of Medicare,486.85,35,,486.85,percent of total billed charges,Implant Device,472.94,34,"Charges > $500, x 34%",472.94,percent of total billed charges,Implant Device,486.85,35,,486.85,percent of total billed charges,Implant Device,486.85,35,,486.85,percent of total billed charges,Implant Device,486.85,35,,486.85,percent of total billed charges,Implant Device,486.85,35,,486.85,percent of total billed charges,Implant Device,486.85,35,,486.85,percent of total billed charges,Implant Device,556.4,40,,556.4,percent of total billed charges,Implant Device,486.85,70,,486.85,percent of total billed charges,All Other,472.94,34,,472.94,percent of total billed charges,Implant Device,472.94,34,,472.94,percent of total billed charges,Implant Device,486.85,35,,486.85,percent of total billed charges,Implant Device,486.85,35,,486.85,percent of total billed charges,Implant Device,486.85,35,,486.85,percent of total billed charges,Implant Device,486.85,35,,486.85,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1029.34,
DJO 130-03-032 PATELLA DOME 3D 32MM,C1776,HCPCS,,79010225,CDM,278,RC,,,both,,,1500,1110,,,1110,Other,150% of Medicare + 9.63% HCRA Surcharge,675,45,,675,percent of total billed charges,Critical Access Hospital RCC factor,510,34,,510,percent of total billed charges,Implant Device,510,34,,510,percent of total billed charges,Implant Device,510,34,,510,percent of total billed charges,Implant Device,510,34,,510,percent of total billed charges,Implant Device,510,34,,510,percent of total billed charges,Implant Device,742.5,,,742.5,Other,110% of Medicare,525,35,,525,percent of total billed charges,Implant Device,510,34,"Charges > $500, x 34%",510,percent of total billed charges,Implant Device,525,35,,525,percent of total billed charges,Implant Device,525,35,,525,percent of total billed charges,Implant Device,525,35,,525,percent of total billed charges,Implant Device,525,35,,525,percent of total billed charges,Implant Device,525,35,,525,percent of total billed charges,Implant Device,600,40,,600,percent of total billed charges,Implant Device,525,70,,525,percent of total billed charges,All Other,510,34,,510,percent of total billed charges,Implant Device,510,34,,510,percent of total billed charges,Implant Device,525,35,,525,percent of total billed charges,Implant Device,525,35,,525,percent of total billed charges,Implant Device,525,35,,525,percent of total billed charges,Implant Device,525,35,,525,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1110,
DJO 242-01-106 FEMUR SIZE 6 LEFT,C1776,HCPCS,,79010226,CDM,278,RC,,,both,,,7500,5550.02,,,5550.02,Other,150% of Medicare + 9.63% HCRA Surcharge,3375,45,,3375,percent of total billed charges,Critical Access Hospital RCC factor,2550,34,,2550,percent of total billed charges,Implant Device,2550,34,,2550,percent of total billed charges,Implant Device,2550,34,,2550,percent of total billed charges,Implant Device,2550,34,,2550,percent of total billed charges,Implant Device,2550,34,,2550,percent of total billed charges,Implant Device,3712.5,,,3712.5,Other,110% of Medicare,2625,35,,2625,percent of total billed charges,Implant Device,2550,34,"Charges > $500, x 34%",2550,percent of total billed charges,Implant Device,2625,35,,2625,percent of total billed charges,Implant Device,2625,35,,2625,percent of total billed charges,Implant Device,2625,35,,2625,percent of total billed charges,Implant Device,2625,35,,2625,percent of total billed charges,Implant Device,2625,35,,2625,percent of total billed charges,Implant Device,3000,40,,3000,percent of total billed charges,Implant Device,2625,70,,2625,percent of total billed charges,All Other,2550,34,,2550,percent of total billed charges,Implant Device,2550,34,,2550,percent of total billed charges,Implant Device,2625,35,,2625,percent of total billed charges,Implant Device,2625,35,,2625,percent of total billed charges,Implant Device,2625,35,,2625,percent of total billed charges,Implant Device,2625,35,,2625,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2550,34,"If Charge > 2,000, then 34 percent",2550,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5550.02,
DJO 343-10-755 TIBIAL INSERT SIZE 5 10MM,C1776,HCPCS,,79010227,CDM,278,RC,,,both,,,3000,2220.01,,,2220.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1350,45,,1350,percent of total billed charges,Critical Access Hospital RCC factor,1020,34,,1020,percent of total billed charges,Implant Device,1020,34,,1020,percent of total billed charges,Implant Device,1020,34,,1020,percent of total billed charges,Implant Device,1020,34,,1020,percent of total billed charges,Implant Device,1020,34,,1020,percent of total billed charges,Implant Device,1485,,,1485,Other,110% of Medicare,1050,35,,1050,percent of total billed charges,Implant Device,1020,34,"Charges > $500, x 34%",1020,percent of total billed charges,Implant Device,1050,35,,1050,percent of total billed charges,Implant Device,1050,35,,1050,percent of total billed charges,Implant Device,1050,35,,1050,percent of total billed charges,Implant Device,1050,35,,1050,percent of total billed charges,Implant Device,1050,35,,1050,percent of total billed charges,Implant Device,1200,40,,1200,percent of total billed charges,Implant Device,1050,70,,1050,percent of total billed charges,All Other,1020,34,,1020,percent of total billed charges,Implant Device,1020,34,,1020,percent of total billed charges,Implant Device,1050,35,,1050,percent of total billed charges,Implant Device,1050,35,,1050,percent of total billed charges,Implant Device,1050,35,,1050,percent of total billed charges,Implant Device,1050,35,,1050,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1020,34,"If Charge > 2,000, then 34 percent",1020,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2220.01,
DJO 351-01-105 FINNED BASEPLATE SZ 5 LT,C1776,HCPCS,,79010228,CDM,278,RC,,,both,,,4500,3330.01,,,3330.01,Other,150% of Medicare + 9.63% HCRA Surcharge,2025,45,,2025,percent of total billed charges,Critical Access Hospital RCC factor,1530,34,,1530,percent of total billed charges,Implant Device,1530,34,,1530,percent of total billed charges,Implant Device,1530,34,,1530,percent of total billed charges,Implant Device,1530,34,,1530,percent of total billed charges,Implant Device,1530,34,,1530,percent of total billed charges,Implant Device,2227.5,,,2227.5,Other,110% of Medicare,1575,35,,1575,percent of total billed charges,Implant Device,1530,34,"Charges > $500, x 34%",1530,percent of total billed charges,Implant Device,1575,35,,1575,percent of total billed charges,Implant Device,1575,35,,1575,percent of total billed charges,Implant Device,1575,35,,1575,percent of total billed charges,Implant Device,1575,35,,1575,percent of total billed charges,Implant Device,1575,35,,1575,percent of total billed charges,Implant Device,1800,40,,1800,percent of total billed charges,Implant Device,1575,70,,1575,percent of total billed charges,All Other,1530,34,,1530,percent of total billed charges,Implant Device,1530,34,,1530,percent of total billed charges,Implant Device,1575,35,,1575,percent of total billed charges,Implant Device,1575,35,,1575,percent of total billed charges,Implant Device,1575,35,,1575,percent of total billed charges,Implant Device,1575,35,,1575,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1530,34,"If Charge > 2,000, then 34 percent",1530,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3330.01,
DJO 130-03-035 PATELLA DOME 3D 35MM,C1776,HCPCS,,79010229,CDM,278,RC,,,both,,,1500,1110,,,1110,Other,150% of Medicare + 9.63% HCRA Surcharge,675,45,,675,percent of total billed charges,Critical Access Hospital RCC factor,510,34,,510,percent of total billed charges,Implant Device,510,34,,510,percent of total billed charges,Implant Device,510,34,,510,percent of total billed charges,Implant Device,510,34,,510,percent of total billed charges,Implant Device,510,34,,510,percent of total billed charges,Implant Device,742.5,,,742.5,Other,110% of Medicare,525,35,,525,percent of total billed charges,Implant Device,510,34,"Charges > $500, x 34%",510,percent of total billed charges,Implant Device,525,35,,525,percent of total billed charges,Implant Device,525,35,,525,percent of total billed charges,Implant Device,525,35,,525,percent of total billed charges,Implant Device,525,35,,525,percent of total billed charges,Implant Device,525,35,,525,percent of total billed charges,Implant Device,600,40,,600,percent of total billed charges,Implant Device,525,70,,525,percent of total billed charges,All Other,510,34,,510,percent of total billed charges,Implant Device,510,34,,510,percent of total billed charges,Implant Device,525,35,,525,percent of total billed charges,Implant Device,525,35,,525,percent of total billed charges,Implant Device,525,35,,525,percent of total billed charges,Implant Device,525,35,,525,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1110,
DJO 242-01-108 FEMUR SIZE 8 LEFT,C1776,HCPCS,,79010230,CDM,278,RC,,,both,,,7500,5550.02,,,5550.02,Other,150% of Medicare + 9.63% HCRA Surcharge,3375,45,,3375,percent of total billed charges,Critical Access Hospital RCC factor,2550,34,,2550,percent of total billed charges,Implant Device,2550,34,,2550,percent of total billed charges,Implant Device,2550,34,,2550,percent of total billed charges,Implant Device,2550,34,,2550,percent of total billed charges,Implant Device,2550,34,,2550,percent of total billed charges,Implant Device,3712.5,,,3712.5,Other,110% of Medicare,2625,35,,2625,percent of total billed charges,Implant Device,2550,34,"Charges > $500, x 34%",2550,percent of total billed charges,Implant Device,2625,35,,2625,percent of total billed charges,Implant Device,2625,35,,2625,percent of total billed charges,Implant Device,2625,35,,2625,percent of total billed charges,Implant Device,2625,35,,2625,percent of total billed charges,Implant Device,2625,35,,2625,percent of total billed charges,Implant Device,3000,40,,3000,percent of total billed charges,Implant Device,2625,70,,2625,percent of total billed charges,All Other,2550,34,,2550,percent of total billed charges,Implant Device,2550,34,,2550,percent of total billed charges,Implant Device,2625,35,,2625,percent of total billed charges,Implant Device,2625,35,,2625,percent of total billed charges,Implant Device,2625,35,,2625,percent of total billed charges,Implant Device,2625,35,,2625,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2550,34,"If Charge > 2,000, then 34 percent",2550,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5550.02,
DJO 343-10-708 TIBIAL INSERT SIZE 8 10MM,C1776,HCPCS,,79010231,CDM,278,RC,,,both,,,3000,2220.01,,,2220.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1350,45,,1350,percent of total billed charges,Critical Access Hospital RCC factor,1020,34,,1020,percent of total billed charges,Implant Device,1020,34,,1020,percent of total billed charges,Implant Device,1020,34,,1020,percent of total billed charges,Implant Device,1020,34,,1020,percent of total billed charges,Implant Device,1020,34,,1020,percent of total billed charges,Implant Device,1485,,,1485,Other,110% of Medicare,1050,35,,1050,percent of total billed charges,Implant Device,1020,34,"Charges > $500, x 34%",1020,percent of total billed charges,Implant Device,1050,35,,1050,percent of total billed charges,Implant Device,1050,35,,1050,percent of total billed charges,Implant Device,1050,35,,1050,percent of total billed charges,Implant Device,1050,35,,1050,percent of total billed charges,Implant Device,1050,35,,1050,percent of total billed charges,Implant Device,1200,40,,1200,percent of total billed charges,Implant Device,1050,70,,1050,percent of total billed charges,All Other,1020,34,,1020,percent of total billed charges,Implant Device,1020,34,,1020,percent of total billed charges,Implant Device,1050,35,,1050,percent of total billed charges,Implant Device,1050,35,,1050,percent of total billed charges,Implant Device,1050,35,,1050,percent of total billed charges,Implant Device,1050,35,,1050,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1020,34,"If Charge > 2,000, then 34 percent",1020,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2220.01,
DJO 351-01-108 FINNED BASEPLATE SZ 8 LT,C1776,HCPCS,,79010232,CDM,278,RC,,,both,,,4500,3330.01,,,3330.01,Other,150% of Medicare + 9.63% HCRA Surcharge,2025,45,,2025,percent of total billed charges,Critical Access Hospital RCC factor,1530,34,,1530,percent of total billed charges,Implant Device,1530,34,,1530,percent of total billed charges,Implant Device,1530,34,,1530,percent of total billed charges,Implant Device,1530,34,,1530,percent of total billed charges,Implant Device,1530,34,,1530,percent of total billed charges,Implant Device,2227.5,,,2227.5,Other,110% of Medicare,1575,35,,1575,percent of total billed charges,Implant Device,1530,34,"Charges > $500, x 34%",1530,percent of total billed charges,Implant Device,1575,35,,1575,percent of total billed charges,Implant Device,1575,35,,1575,percent of total billed charges,Implant Device,1575,35,,1575,percent of total billed charges,Implant Device,1575,35,,1575,percent of total billed charges,Implant Device,1575,35,,1575,percent of total billed charges,Implant Device,1800,40,,1800,percent of total billed charges,Implant Device,1575,70,,1575,percent of total billed charges,All Other,1530,34,,1530,percent of total billed charges,Implant Device,1530,34,,1530,percent of total billed charges,Implant Device,1575,35,,1575,percent of total billed charges,Implant Device,1575,35,,1575,percent of total billed charges,Implant Device,1575,35,,1575,percent of total billed charges,Implant Device,1575,35,,1575,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1530,34,"If Charge > 2,000, then 34 percent",1530,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3330.01,
DJO 343-10-706 TIBIAL INSERT SIZE 6 10MM,C1776,HCPCS,,79010233,CDM,278,RC,,,both,,,3000,2220.01,,,2220.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1350,45,,1350,percent of total billed charges,Critical Access Hospital RCC factor,1020,34,,1020,percent of total billed charges,Implant Device,1020,34,,1020,percent of total billed charges,Implant Device,1020,34,,1020,percent of total billed charges,Implant Device,1020,34,,1020,percent of total billed charges,Implant Device,1020,34,,1020,percent of total billed charges,Implant Device,1485,,,1485,Other,110% of Medicare,1050,35,,1050,percent of total billed charges,Implant Device,1020,34,"Charges > $500, x 34%",1020,percent of total billed charges,Implant Device,1050,35,,1050,percent of total billed charges,Implant Device,1050,35,,1050,percent of total billed charges,Implant Device,1050,35,,1050,percent of total billed charges,Implant Device,1050,35,,1050,percent of total billed charges,Implant Device,1050,35,,1050,percent of total billed charges,Implant Device,1200,40,,1200,percent of total billed charges,Implant Device,1050,70,,1050,percent of total billed charges,All Other,1020,34,,1020,percent of total billed charges,Implant Device,1020,34,,1020,percent of total billed charges,Implant Device,1050,35,,1050,percent of total billed charges,Implant Device,1050,35,,1050,percent of total billed charges,Implant Device,1050,35,,1050,percent of total billed charges,Implant Device,1050,35,,1050,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1020,34,"If Charge > 2,000, then 34 percent",1020,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2220.01,
DJO 351-01-106 FINNED BASEPLATE SZ 6 LT,C1776,HCPCS,,79010234,CDM,278,RC,,,both,,,4500,3330.01,,,3330.01,Other,150% of Medicare + 9.63% HCRA Surcharge,2025,45,,2025,percent of total billed charges,Critical Access Hospital RCC factor,1530,34,,1530,percent of total billed charges,Implant Device,1530,34,,1530,percent of total billed charges,Implant Device,1530,34,,1530,percent of total billed charges,Implant Device,1530,34,,1530,percent of total billed charges,Implant Device,1530,34,,1530,percent of total billed charges,Implant Device,2227.5,,,2227.5,Other,110% of Medicare,1575,35,,1575,percent of total billed charges,Implant Device,1530,34,"Charges > $500, x 34%",1530,percent of total billed charges,Implant Device,1575,35,,1575,percent of total billed charges,Implant Device,1575,35,,1575,percent of total billed charges,Implant Device,1575,35,,1575,percent of total billed charges,Implant Device,1575,35,,1575,percent of total billed charges,Implant Device,1575,35,,1575,percent of total billed charges,Implant Device,1800,40,,1800,percent of total billed charges,Implant Device,1575,70,,1575,percent of total billed charges,All Other,1530,34,,1530,percent of total billed charges,Implant Device,1530,34,,1530,percent of total billed charges,Implant Device,1575,35,,1575,percent of total billed charges,Implant Device,1575,35,,1575,percent of total billed charges,Implant Device,1575,35,,1575,percent of total billed charges,Implant Device,1575,35,,1575,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1530,34,"If Charge > 2,000, then 34 percent",1530,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3330.01,
DJO 430-99-054 HEMISPHERICAL SHELL 54MM,C1776,HCPCS,,79010237,CDM,278,RC,,,both,,,4200,3108.01,,,3108.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1890,45,,1890,percent of total billed charges,Critical Access Hospital RCC factor,1428,34,,1428,percent of total billed charges,Implant Device,1428,34,,1428,percent of total billed charges,Implant Device,1428,34,,1428,percent of total billed charges,Implant Device,1428,34,,1428,percent of total billed charges,Implant Device,1428,34,,1428,percent of total billed charges,Implant Device,2079,,,2079,Other,110% of Medicare,1470,35,,1470,percent of total billed charges,Implant Device,1428,34,"Charges > $500, x 34%",1428,percent of total billed charges,Implant Device,1470,35,,1470,percent of total billed charges,Implant Device,1470,35,,1470,percent of total billed charges,Implant Device,1470,35,,1470,percent of total billed charges,Implant Device,1470,35,,1470,percent of total billed charges,Implant Device,1470,35,,1470,percent of total billed charges,Implant Device,1680,40,,1680,percent of total billed charges,Implant Device,1470,70,,1470,percent of total billed charges,All Other,1428,34,,1428,percent of total billed charges,Implant Device,1428,34,,1428,percent of total billed charges,Implant Device,1470,35,,1470,percent of total billed charges,Implant Device,1470,35,,1470,percent of total billed charges,Implant Device,1470,35,,1470,percent of total billed charges,Implant Device,1470,35,,1470,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1428,34,"If Charge > 2,000, then 34 percent",1428,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3108.01,
DJO 932-36-754 ACETABULAR LINER 36MM,C1776,HCPCS,,79010238,CDM,278,RC,,,both,,,4500,3330.01,,,3330.01,Other,150% of Medicare + 9.63% HCRA Surcharge,2025,45,,2025,percent of total billed charges,Critical Access Hospital RCC factor,1530,34,,1530,percent of total billed charges,Implant Device,1530,34,,1530,percent of total billed charges,Implant Device,1530,34,,1530,percent of total billed charges,Implant Device,1530,34,,1530,percent of total billed charges,Implant Device,1530,34,,1530,percent of total billed charges,Implant Device,2227.5,,,2227.5,Other,110% of Medicare,1575,35,,1575,percent of total billed charges,Implant Device,1530,34,"Charges > $500, x 34%",1530,percent of total billed charges,Implant Device,1575,35,,1575,percent of total billed charges,Implant Device,1575,35,,1575,percent of total billed charges,Implant Device,1575,35,,1575,percent of total billed charges,Implant Device,1575,35,,1575,percent of total billed charges,Implant Device,1575,35,,1575,percent of total billed charges,Implant Device,1800,40,,1800,percent of total billed charges,Implant Device,1575,70,,1575,percent of total billed charges,All Other,1530,34,,1530,percent of total billed charges,Implant Device,1530,34,,1530,percent of total billed charges,Implant Device,1575,35,,1575,percent of total billed charges,Implant Device,1575,35,,1575,percent of total billed charges,Implant Device,1575,35,,1575,percent of total billed charges,Implant Device,1575,35,,1575,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1530,34,"If Charge > 2,000, then 34 percent",1530,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3330.01,
DJO D111-18-1102 HIP STEM SIZE 11,C1776,HCPCS,,79010239,CDM,278,RC,,,both,,,7320,5416.82,,,5416.82,Other,150% of Medicare + 9.63% HCRA Surcharge,3294,45,,3294,percent of total billed charges,Critical Access Hospital RCC factor,2488.8,34,,2488.8,percent of total billed charges,Implant Device,2488.8,34,,2488.8,percent of total billed charges,Implant Device,2488.8,34,,2488.8,percent of total billed charges,Implant Device,2488.8,34,,2488.8,percent of total billed charges,Implant Device,2488.8,34,,2488.8,percent of total billed charges,Implant Device,3623.4,,,3623.4,Other,110% of Medicare,2562,35,,2562,percent of total billed charges,Implant Device,2488.8,34,"Charges > $500, x 34%",2488.8,percent of total billed charges,Implant Device,2562,35,,2562,percent of total billed charges,Implant Device,2562,35,,2562,percent of total billed charges,Implant Device,2562,35,,2562,percent of total billed charges,Implant Device,2562,35,,2562,percent of total billed charges,Implant Device,2562,35,,2562,percent of total billed charges,Implant Device,2928,40,,2928,percent of total billed charges,Implant Device,2562,70,,2562,percent of total billed charges,All Other,2488.8,34,,2488.8,percent of total billed charges,Implant Device,2488.8,34,,2488.8,percent of total billed charges,Implant Device,2562,35,,2562,percent of total billed charges,Implant Device,2562,35,,2562,percent of total billed charges,Implant Device,2562,35,,2562,percent of total billed charges,Implant Device,2562,35,,2562,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2488.8,34,"If Charge > 2,000, then 34 percent",2488.8,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5416.82,
DJO D111-152-632 FEMORAL HEAD SIZE 36MM,C1776,HCPCS,,79010240,CDM,278,RC,,,both,,,3000,2220.01,,,2220.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1350,45,,1350,percent of total billed charges,Critical Access Hospital RCC factor,1020,34,,1020,percent of total billed charges,Implant Device,1020,34,,1020,percent of total billed charges,Implant Device,1020,34,,1020,percent of total billed charges,Implant Device,1020,34,,1020,percent of total billed charges,Implant Device,1020,34,,1020,percent of total billed charges,Implant Device,1485,,,1485,Other,110% of Medicare,1050,35,,1050,percent of total billed charges,Implant Device,1020,34,"Charges > $500, x 34%",1020,percent of total billed charges,Implant Device,1050,35,,1050,percent of total billed charges,Implant Device,1050,35,,1050,percent of total billed charges,Implant Device,1050,35,,1050,percent of total billed charges,Implant Device,1050,35,,1050,percent of total billed charges,Implant Device,1050,35,,1050,percent of total billed charges,Implant Device,1200,40,,1200,percent of total billed charges,Implant Device,1050,70,,1050,percent of total billed charges,All Other,1020,34,,1020,percent of total billed charges,Implant Device,1020,34,,1020,percent of total billed charges,Implant Device,1050,35,,1050,percent of total billed charges,Implant Device,1050,35,,1050,percent of total billed charges,Implant Device,1050,35,,1050,percent of total billed charges,Implant Device,1050,35,,1050,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1020,34,"If Charge > 2,000, then 34 percent",1020,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2220.01,
DJO 242-02-10-8 FEMUR SIZE 8 RIGHT,C1776,HCPCS,,79010241,CDM,278,RC,,,both,,,7500,5550.02,,,5550.02,Other,150% of Medicare + 9.63% HCRA Surcharge,3375,45,,3375,percent of total billed charges,Critical Access Hospital RCC factor,2550,34,,2550,percent of total billed charges,Implant Device,2550,34,,2550,percent of total billed charges,Implant Device,2550,34,,2550,percent of total billed charges,Implant Device,2550,34,,2550,percent of total billed charges,Implant Device,2550,34,,2550,percent of total billed charges,Implant Device,3712.5,,,3712.5,Other,110% of Medicare,2625,35,,2625,percent of total billed charges,Implant Device,2550,34,"Charges > $500, x 34%",2550,percent of total billed charges,Implant Device,2625,35,,2625,percent of total billed charges,Implant Device,2625,35,,2625,percent of total billed charges,Implant Device,2625,35,,2625,percent of total billed charges,Implant Device,2625,35,,2625,percent of total billed charges,Implant Device,2625,35,,2625,percent of total billed charges,Implant Device,3000,40,,3000,percent of total billed charges,Implant Device,2625,70,,2625,percent of total billed charges,All Other,2550,34,,2550,percent of total billed charges,Implant Device,2550,34,,2550,percent of total billed charges,Implant Device,2625,35,,2625,percent of total billed charges,Implant Device,2625,35,,2625,percent of total billed charges,Implant Device,2625,35,,2625,percent of total billed charges,Implant Device,2625,35,,2625,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2550,34,"If Charge > 2,000, then 34 percent",2550,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5550.02,
DJO 343-11-708 TIBIAL INSERT SIZE 8 11MM,C1776,HCPCS,,79010242,CDM,278,RC,,,both,,,3000,2220.01,,,2220.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1350,45,,1350,percent of total billed charges,Critical Access Hospital RCC factor,1020,34,,1020,percent of total billed charges,Implant Device,1020,34,,1020,percent of total billed charges,Implant Device,1020,34,,1020,percent of total billed charges,Implant Device,1020,34,,1020,percent of total billed charges,Implant Device,1020,34,,1020,percent of total billed charges,Implant Device,1485,,,1485,Other,110% of Medicare,1050,35,,1050,percent of total billed charges,Implant Device,1020,34,"Charges > $500, x 34%",1020,percent of total billed charges,Implant Device,1050,35,,1050,percent of total billed charges,Implant Device,1050,35,,1050,percent of total billed charges,Implant Device,1050,35,,1050,percent of total billed charges,Implant Device,1050,35,,1050,percent of total billed charges,Implant Device,1050,35,,1050,percent of total billed charges,Implant Device,1200,40,,1200,percent of total billed charges,Implant Device,1050,70,,1050,percent of total billed charges,All Other,1020,34,,1020,percent of total billed charges,Implant Device,1020,34,,1020,percent of total billed charges,Implant Device,1050,35,,1050,percent of total billed charges,Implant Device,1050,35,,1050,percent of total billed charges,Implant Device,1050,35,,1050,percent of total billed charges,Implant Device,1050,35,,1050,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1020,34,"If Charge > 2,000, then 34 percent",1020,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2220.01,
DJO 351-02-108 FINNED BASEPLATE SZ 8 RT,C1776,HCPCS,,79010243,CDM,278,RC,,,both,,,4500,3330.01,,,3330.01,Other,150% of Medicare + 9.63% HCRA Surcharge,2025,45,,2025,percent of total billed charges,Critical Access Hospital RCC factor,1530,34,,1530,percent of total billed charges,Implant Device,1530,34,,1530,percent of total billed charges,Implant Device,1530,34,,1530,percent of total billed charges,Implant Device,1530,34,,1530,percent of total billed charges,Implant Device,1530,34,,1530,percent of total billed charges,Implant Device,2227.5,,,2227.5,Other,110% of Medicare,1575,35,,1575,percent of total billed charges,Implant Device,1530,34,"Charges > $500, x 34%",1530,percent of total billed charges,Implant Device,1575,35,,1575,percent of total billed charges,Implant Device,1575,35,,1575,percent of total billed charges,Implant Device,1575,35,,1575,percent of total billed charges,Implant Device,1575,35,,1575,percent of total billed charges,Implant Device,1575,35,,1575,percent of total billed charges,Implant Device,1800,40,,1800,percent of total billed charges,Implant Device,1575,70,,1575,percent of total billed charges,All Other,1530,34,,1530,percent of total billed charges,Implant Device,1530,34,,1530,percent of total billed charges,Implant Device,1575,35,,1575,percent of total billed charges,Implant Device,1575,35,,1575,percent of total billed charges,Implant Device,1575,35,,1575,percent of total billed charges,Implant Device,1575,35,,1575,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1530,34,"If Charge > 2,000, then 34 percent",1530,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3330.01,
STRYKER 601770S CANN SCREW 5X70MM,C1713,HCPCS,,79010244,CDM,278,RC,,,both,,,490,362.6,,,362.6,Other,150% of Medicare + 9.63% HCRA Surcharge,220.5,45,,220.5,percent of total billed charges,Critical Access Hospital RCC factor,166.6,34,,166.6,percent of total billed charges,Implant Device,166.6,34,,166.6,percent of total billed charges,Implant Device,166.6,34,,166.6,percent of total billed charges,Implant Device,166.6,34,,166.6,percent of total billed charges,Implant Device,166.6,34,,166.6,percent of total billed charges,Implant Device,242.55,,,242.55,Other,110% of Medicare,171.5,35,,171.5,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,171.5,35,,171.5,percent of total billed charges,Implant Device,171.5,35,,171.5,percent of total billed charges,Implant Device,171.5,35,,171.5,percent of total billed charges,Implant Device,171.5,35,,171.5,percent of total billed charges,Implant Device,171.5,35,,171.5,percent of total billed charges,Implant Device,196,40,,196,percent of total billed charges,Implant Device,171.5,70,,171.5,percent of total billed charges,All Other,166.6,34,,166.6,percent of total billed charges,Implant Device,166.6,34,,166.6,percent of total billed charges,Implant Device,171.5,35,,171.5,percent of total billed charges,Implant Device,171.5,35,,171.5,percent of total billed charges,Implant Device,171.5,35,,171.5,percent of total billed charges,Implant Device,171.5,35,,171.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,362.6,
STRYKER 604624 CANN SCREW 4.0X24MM,C1713,HCPCS,,79010245,CDM,278,RC,,,both,,,446,330.04,,,330.04,Other,150% of Medicare + 9.63% HCRA Surcharge,200.7,45,,200.7,percent of total billed charges,Critical Access Hospital RCC factor,151.64,34,,151.64,percent of total billed charges,Implant Device,151.64,34,,151.64,percent of total billed charges,Implant Device,151.64,34,,151.64,percent of total billed charges,Implant Device,151.64,34,,151.64,percent of total billed charges,Implant Device,151.64,34,,151.64,percent of total billed charges,Implant Device,220.77,,,220.77,Other,110% of Medicare,156.1,35,,156.1,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,156.1,35,,156.1,percent of total billed charges,Implant Device,156.1,35,,156.1,percent of total billed charges,Implant Device,156.1,35,,156.1,percent of total billed charges,Implant Device,156.1,35,,156.1,percent of total billed charges,Implant Device,156.1,35,,156.1,percent of total billed charges,Implant Device,178.4,40,,178.4,percent of total billed charges,Implant Device,156.1,70,,156.1,percent of total billed charges,All Other,151.64,34,,151.64,percent of total billed charges,Implant Device,151.64,34,,151.64,percent of total billed charges,Implant Device,156.1,35,,156.1,percent of total billed charges,Implant Device,156.1,35,,156.1,percent of total billed charges,Implant Device,156.1,35,,156.1,percent of total billed charges,Implant Device,156.1,35,,156.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,330.04,
STRYKER 626994 BROAD Y PLT 4 SHAFT HOLES,C1713,HCPCS,,79010246,CDM,278,RC,,,both,,,3757,2780.19,,,2780.19,Other,150% of Medicare + 9.63% HCRA Surcharge,1690.65,45,,1690.65,percent of total billed charges,Critical Access Hospital RCC factor,1277.38,34,,1277.38,percent of total billed charges,Implant Device,1277.38,34,,1277.38,percent of total billed charges,Implant Device,1277.38,34,,1277.38,percent of total billed charges,Implant Device,1277.38,34,,1277.38,percent of total billed charges,Implant Device,1277.38,34,,1277.38,percent of total billed charges,Implant Device,1859.72,,,1859.72,Other,110% of Medicare,1314.95,35,,1314.95,percent of total billed charges,Implant Device,1277.38,34,"Charges > $500, x 34%",1277.38,percent of total billed charges,Implant Device,1314.95,35,,1314.95,percent of total billed charges,Implant Device,1314.95,35,,1314.95,percent of total billed charges,Implant Device,1314.95,35,,1314.95,percent of total billed charges,Implant Device,1314.95,35,,1314.95,percent of total billed charges,Implant Device,1314.95,35,,1314.95,percent of total billed charges,Implant Device,1502.8,40,,1502.8,percent of total billed charges,Implant Device,1314.95,70,,1314.95,percent of total billed charges,All Other,1277.38,34,,1277.38,percent of total billed charges,Implant Device,1277.38,34,,1277.38,percent of total billed charges,Implant Device,1314.95,35,,1314.95,percent of total billed charges,Implant Device,1314.95,35,,1314.95,percent of total billed charges,Implant Device,1314.95,35,,1314.95,percent of total billed charges,Implant Device,1314.95,35,,1314.95,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1277.38,34,"If Charge > 2,000, then 34 percent",1277.38,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2780.19,
STRYKER 2341-1237S TIBIAL NAIL 12X375MM,C1713,HCPCS,,79010248,CDM,278,RC,,,both,,,6378,4719.74,,,4719.74,Other,150% of Medicare + 9.63% HCRA Surcharge,2870.1,45,,2870.1,percent of total billed charges,Critical Access Hospital RCC factor,2168.52,34,,2168.52,percent of total billed charges,Implant Device,2168.52,34,,2168.52,percent of total billed charges,Implant Device,2168.52,34,,2168.52,percent of total billed charges,Implant Device,2168.52,34,,2168.52,percent of total billed charges,Implant Device,2168.52,34,,2168.52,percent of total billed charges,Implant Device,3157.11,,,3157.11,Other,110% of Medicare,2232.3,35,,2232.3,percent of total billed charges,Implant Device,2168.52,34,"Charges > $500, x 34%",2168.52,percent of total billed charges,Implant Device,2232.3,35,,2232.3,percent of total billed charges,Implant Device,2232.3,35,,2232.3,percent of total billed charges,Implant Device,2232.3,35,,2232.3,percent of total billed charges,Implant Device,2232.3,35,,2232.3,percent of total billed charges,Implant Device,2232.3,35,,2232.3,percent of total billed charges,Implant Device,2551.2,40,,2551.2,percent of total billed charges,Implant Device,2232.3,70,,2232.3,percent of total billed charges,All Other,2168.52,34,,2168.52,percent of total billed charges,Implant Device,2168.52,34,,2168.52,percent of total billed charges,Implant Device,2232.3,35,,2232.3,percent of total billed charges,Implant Device,2232.3,35,,2232.3,percent of total billed charges,Implant Device,2232.3,35,,2232.3,percent of total billed charges,Implant Device,2232.3,35,,2232.3,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2168.52,34,"If Charge > 2,000, then 34 percent",2168.52,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4719.74,
STRYKER 2361-5037S LOCK SCREW 5X37.5MM,C1713,HCPCS,,79010249,CDM,278,RC,,,both,,,956,707.44,,,707.44,Other,150% of Medicare + 9.63% HCRA Surcharge,430.2,45,,430.2,percent of total billed charges,Critical Access Hospital RCC factor,325.04,34,,325.04,percent of total billed charges,Implant Device,325.04,34,,325.04,percent of total billed charges,Implant Device,325.04,34,,325.04,percent of total billed charges,Implant Device,325.04,34,,325.04,percent of total billed charges,Implant Device,325.04,34,,325.04,percent of total billed charges,Implant Device,473.22,,,473.22,Other,110% of Medicare,334.6,35,,334.6,percent of total billed charges,Implant Device,325.04,34,"Charges > $500, x 34%",325.04,percent of total billed charges,Implant Device,334.6,35,,334.6,percent of total billed charges,Implant Device,334.6,35,,334.6,percent of total billed charges,Implant Device,334.6,35,,334.6,percent of total billed charges,Implant Device,334.6,35,,334.6,percent of total billed charges,Implant Device,334.6,35,,334.6,percent of total billed charges,Implant Device,382.4,40,,382.4,percent of total billed charges,Implant Device,334.6,70,,334.6,percent of total billed charges,All Other,325.04,34,,325.04,percent of total billed charges,Implant Device,325.04,34,,325.04,percent of total billed charges,Implant Device,334.6,35,,334.6,percent of total billed charges,Implant Device,334.6,35,,334.6,percent of total billed charges,Implant Device,334.6,35,,334.6,percent of total billed charges,Implant Device,334.6,35,,334.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,707.44,
STRYKER 2361-5050S LOCK SCREW 4X50MM,C1713,HCPCS,,79010250,CDM,278,RC,,,both,,,887,656.38,,,656.38,Other,150% of Medicare + 9.63% HCRA Surcharge,399.15,45,,399.15,percent of total billed charges,Critical Access Hospital RCC factor,301.58,34,,301.58,percent of total billed charges,Implant Device,301.58,34,,301.58,percent of total billed charges,Implant Device,301.58,34,,301.58,percent of total billed charges,Implant Device,301.58,34,,301.58,percent of total billed charges,Implant Device,301.58,34,,301.58,percent of total billed charges,Implant Device,439.07,,,439.07,Other,110% of Medicare,310.45,35,,310.45,percent of total billed charges,Implant Device,301.58,34,"Charges > $500, x 34%",301.58,percent of total billed charges,Implant Device,310.45,35,,310.45,percent of total billed charges,Implant Device,310.45,35,,310.45,percent of total billed charges,Implant Device,310.45,35,,310.45,percent of total billed charges,Implant Device,310.45,35,,310.45,percent of total billed charges,Implant Device,310.45,35,,310.45,percent of total billed charges,Implant Device,354.8,40,,354.8,percent of total billed charges,Implant Device,310.45,70,,310.45,percent of total billed charges,All Other,301.58,34,,301.58,percent of total billed charges,Implant Device,301.58,34,,301.58,percent of total billed charges,Implant Device,310.45,35,,310.45,percent of total billed charges,Implant Device,310.45,35,,310.45,percent of total billed charges,Implant Device,310.45,35,,310.45,percent of total billed charges,Implant Device,310.45,35,,310.45,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,656.38,
IN2BONES P67 ST432 CANN SCREW 4.0X32MM,C1713,HCPCS,,79010252,CDM,278,RC,,,both,,,870,643.8,,,643.8,Other,150% of Medicare + 9.63% HCRA Surcharge,391.5,45,,391.5,percent of total billed charges,Critical Access Hospital RCC factor,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,430.65,,,430.65,Other,110% of Medicare,304.5,35,,304.5,percent of total billed charges,Implant Device,295.8,34,"Charges > $500, x 34%",295.8,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,348,40,,348,percent of total billed charges,Implant Device,304.5,70,,304.5,percent of total billed charges,All Other,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,643.8,
EXACTECH 320-15-07 GLENOID BASEPLATE LT,C1776,HCPCS,,79010253,CDM,278,RC,,,both,,,5925,4384.51,,,4384.51,Other,150% of Medicare + 9.63% HCRA Surcharge,2666.25,45,,2666.25,percent of total billed charges,Critical Access Hospital RCC factor,2014.5,34,,2014.5,percent of total billed charges,Implant Device,2014.5,34,,2014.5,percent of total billed charges,Implant Device,2014.5,34,,2014.5,percent of total billed charges,Implant Device,2014.5,34,,2014.5,percent of total billed charges,Implant Device,2014.5,34,,2014.5,percent of total billed charges,Implant Device,2932.88,,,2932.88,Other,110% of Medicare,2073.75,35,,2073.75,percent of total billed charges,Implant Device,2014.5,34,"Charges > $500, x 34%",2014.5,percent of total billed charges,Implant Device,2073.75,35,,2073.75,percent of total billed charges,Implant Device,2073.75,35,,2073.75,percent of total billed charges,Implant Device,2073.75,35,,2073.75,percent of total billed charges,Implant Device,2073.75,35,,2073.75,percent of total billed charges,Implant Device,2073.75,35,,2073.75,percent of total billed charges,Implant Device,2370,40,,2370,percent of total billed charges,Implant Device,2073.75,70,,2073.75,percent of total billed charges,All Other,2014.5,34,,2014.5,percent of total billed charges,Implant Device,2014.5,34,,2014.5,percent of total billed charges,Implant Device,2073.75,35,,2073.75,percent of total billed charges,Implant Device,2073.75,35,,2073.75,percent of total billed charges,Implant Device,2073.75,35,,2073.75,percent of total billed charges,Implant Device,2073.75,35,,2073.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2014.5,34,"If Charge > 2,000, then 34 percent",2014.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4384.51,
IN2BONES P72 ST016 NON LOCK SCREW 2.7X16,C1713,HCPCS,,79010255,CDM,278,RC,,,both,,,870,643.8,,,643.8,Other,150% of Medicare + 9.63% HCRA Surcharge,391.5,45,,391.5,percent of total billed charges,Critical Access Hospital RCC factor,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,430.65,,,430.65,Other,110% of Medicare,304.5,35,,304.5,percent of total billed charges,Implant Device,295.8,34,"Charges > $500, x 34%",295.8,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,348,40,,348,percent of total billed charges,Implant Device,304.5,70,,304.5,percent of total billed charges,All Other,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,643.8,
EXACTECH 315-PEG DRILL GUIDE HOLDING PIN,C1713,HCPCS,,79010256,CDM,278,RC,,,both,,,240,177.6,,,177.6,Other,150% of Medicare + 9.63% HCRA Surcharge,108,45,,108,percent of total billed charges,Critical Access Hospital RCC factor,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,118.8,,,118.8,Other,110% of Medicare,84,35,,84,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,96,40,,96,percent of total billed charges,Implant Device,84,70,,84,percent of total billed charges,All Other,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,177.6,
EXACTECH 311-01-41 SHORT HEAD TRIAL 41MM,C1713,HCPCS,,79010257,CDM,278,RC,,,both,,,456,337.44,,,337.44,Other,150% of Medicare + 9.63% HCRA Surcharge,205.2,45,,205.2,percent of total billed charges,Critical Access Hospital RCC factor,155.04,34,,155.04,percent of total billed charges,Implant Device,155.04,34,,155.04,percent of total billed charges,Implant Device,155.04,34,,155.04,percent of total billed charges,Implant Device,155.04,34,,155.04,percent of total billed charges,Implant Device,155.04,34,,155.04,percent of total billed charges,Implant Device,225.72,,,225.72,Other,110% of Medicare,159.6,35,,159.6,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,159.6,35,,159.6,percent of total billed charges,Implant Device,159.6,35,,159.6,percent of total billed charges,Implant Device,159.6,35,,159.6,percent of total billed charges,Implant Device,159.6,35,,159.6,percent of total billed charges,Implant Device,159.6,35,,159.6,percent of total billed charges,Implant Device,182.4,40,,182.4,percent of total billed charges,Implant Device,159.6,70,,159.6,percent of total billed charges,All Other,155.04,34,,155.04,percent of total billed charges,Implant Device,155.04,34,,155.04,percent of total billed charges,Implant Device,159.6,35,,159.6,percent of total billed charges,Implant Device,159.6,35,,159.6,percent of total billed charges,Implant Device,159.6,35,,159.6,percent of total billed charges,Implant Device,159.6,35,,159.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,337.44,
EXACTECH 311-01-38 SHORT HEAD TRIAL 38MM,C1713,HCPCS,,79010258,CDM,278,RC,,,both,,,402,297.48,,,297.48,Other,150% of Medicare + 9.63% HCRA Surcharge,180.9,45,,180.9,percent of total billed charges,Critical Access Hospital RCC factor,136.68,34,,136.68,percent of total billed charges,Implant Device,136.68,34,,136.68,percent of total billed charges,Implant Device,136.68,34,,136.68,percent of total billed charges,Implant Device,136.68,34,,136.68,percent of total billed charges,Implant Device,136.68,34,,136.68,percent of total billed charges,Implant Device,198.99,,,198.99,Other,110% of Medicare,140.7,35,,140.7,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,140.7,35,,140.7,percent of total billed charges,Implant Device,140.7,35,,140.7,percent of total billed charges,Implant Device,140.7,35,,140.7,percent of total billed charges,Implant Device,140.7,35,,140.7,percent of total billed charges,Implant Device,140.7,35,,140.7,percent of total billed charges,Implant Device,160.8,40,,160.8,percent of total billed charges,Implant Device,140.7,70,,140.7,percent of total billed charges,All Other,136.68,34,,136.68,percent of total billed charges,Implant Device,136.68,34,,136.68,percent of total billed charges,Implant Device,140.7,35,,140.7,percent of total billed charges,Implant Device,140.7,35,,140.7,percent of total billed charges,Implant Device,140.7,35,,140.7,percent of total billed charges,Implant Device,140.7,35,,140.7,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,297.48,
STRYKER 602890 CANN SCREW 6.5X90MM,C1713,HCPCS,,79010259,CDM,278,RC,,,both,,,696,515.04,,,515.04,Other,150% of Medicare + 9.63% HCRA Surcharge,313.2,45,,313.2,percent of total billed charges,Critical Access Hospital RCC factor,236.64,34,,236.64,percent of total billed charges,Implant Device,236.64,34,,236.64,percent of total billed charges,Implant Device,236.64,34,,236.64,percent of total billed charges,Implant Device,236.64,34,,236.64,percent of total billed charges,Implant Device,236.64,34,,236.64,percent of total billed charges,Implant Device,344.52,,,344.52,Other,110% of Medicare,243.6,35,,243.6,percent of total billed charges,Implant Device,236.64,34,"Charges > $500, x 34%",236.64,percent of total billed charges,Implant Device,243.6,35,,243.6,percent of total billed charges,Implant Device,243.6,35,,243.6,percent of total billed charges,Implant Device,243.6,35,,243.6,percent of total billed charges,Implant Device,243.6,35,,243.6,percent of total billed charges,Implant Device,243.6,35,,243.6,percent of total billed charges,Implant Device,278.4,40,,278.4,percent of total billed charges,Implant Device,243.6,70,,243.6,percent of total billed charges,All Other,236.64,34,,236.64,percent of total billed charges,Implant Device,236.64,34,,236.64,percent of total billed charges,Implant Device,243.6,35,,243.6,percent of total billed charges,Implant Device,243.6,35,,243.6,percent of total billed charges,Implant Device,243.6,35,,243.6,percent of total billed charges,Implant Device,243.6,35,,243.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,515.04,
ZIMMER 11-301331 CONE PROX BODY SZ A 70,C1776,HCPCS,,79010260,CDM,278,RC,,,both,,,19784,14640.21,,,14640.21,Other,150% of Medicare + 9.63% HCRA Surcharge,8902.8,45,,8902.8,percent of total billed charges,Critical Access Hospital RCC factor,6726.56,34,,6726.56,percent of total billed charges,Implant Device,6726.56,34,,6726.56,percent of total billed charges,Implant Device,6726.56,34,,6726.56,percent of total billed charges,Implant Device,6726.56,34,,6726.56,percent of total billed charges,Implant Device,6726.56,34,,6726.56,percent of total billed charges,Implant Device,9793.08,,,9793.08,Other,110% of Medicare,6924.4,35,,6924.4,percent of total billed charges,Implant Device,6726.56,34,"Charges > $500, x 34%",6726.56,percent of total billed charges,Implant Device,6924.4,35,,6924.4,percent of total billed charges,Implant Device,6924.4,35,,6924.4,percent of total billed charges,Implant Device,6924.4,35,,6924.4,percent of total billed charges,Implant Device,6924.4,35,,6924.4,percent of total billed charges,Implant Device,6924.4,35,,6924.4,percent of total billed charges,Implant Device,7913.6,40,,7913.6,percent of total billed charges,Implant Device,6924.4,70,,6924.4,percent of total billed charges,All Other,6726.56,34,,6726.56,percent of total billed charges,Implant Device,6726.56,34,,6726.56,percent of total billed charges,Implant Device,6924.4,35,,6924.4,percent of total billed charges,Implant Device,6924.4,35,,6924.4,percent of total billed charges,Implant Device,6924.4,35,,6924.4,percent of total billed charges,Implant Device,6924.4,35,,6924.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,6726.56,34,"If Charge > 2,000, then 34 percent",6726.56,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,14640.21,
ZIMMER 11-301312 CONE PROX BODY SZ B 60,C1776,HCPCS,,79010261,CDM,278,RC,,,both,,,19784,14640.21,,,14640.21,Other,150% of Medicare + 9.63% HCRA Surcharge,8902.8,45,,8902.8,percent of total billed charges,Critical Access Hospital RCC factor,6726.56,34,,6726.56,percent of total billed charges,Implant Device,6726.56,34,,6726.56,percent of total billed charges,Implant Device,6726.56,34,,6726.56,percent of total billed charges,Implant Device,6726.56,34,,6726.56,percent of total billed charges,Implant Device,6726.56,34,,6726.56,percent of total billed charges,Implant Device,9793.08,,,9793.08,Other,110% of Medicare,6924.4,35,,6924.4,percent of total billed charges,Implant Device,6726.56,34,"Charges > $500, x 34%",6726.56,percent of total billed charges,Implant Device,6924.4,35,,6924.4,percent of total billed charges,Implant Device,6924.4,35,,6924.4,percent of total billed charges,Implant Device,6924.4,35,,6924.4,percent of total billed charges,Implant Device,6924.4,35,,6924.4,percent of total billed charges,Implant Device,6924.4,35,,6924.4,percent of total billed charges,Implant Device,7913.6,40,,7913.6,percent of total billed charges,Implant Device,6924.4,70,,6924.4,percent of total billed charges,All Other,6726.56,34,,6726.56,percent of total billed charges,Implant Device,6726.56,34,,6726.56,percent of total billed charges,Implant Device,6924.4,35,,6924.4,percent of total billed charges,Implant Device,6924.4,35,,6924.4,percent of total billed charges,Implant Device,6924.4,35,,6924.4,percent of total billed charges,Implant Device,6924.4,35,,6924.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,6726.56,34,"If Charge > 2,000, then 34 percent",6726.56,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,14640.21,
ZIMMER 00-7711-010-10 FEM STEM SIZE 10,C1776,HCPCS,,79010262,CDM,278,RC,,,both,,,6900,5106.02,,,5106.02,Other,150% of Medicare + 9.63% HCRA Surcharge,3105,45,,3105,percent of total billed charges,Critical Access Hospital RCC factor,2346,34,,2346,percent of total billed charges,Implant Device,2346,34,,2346,percent of total billed charges,Implant Device,2346,34,,2346,percent of total billed charges,Implant Device,2346,34,,2346,percent of total billed charges,Implant Device,2346,34,,2346,percent of total billed charges,Implant Device,3415.5,,,3415.5,Other,110% of Medicare,2415,35,,2415,percent of total billed charges,Implant Device,2346,34,"Charges > $500, x 34%",2346,percent of total billed charges,Implant Device,2415,35,,2415,percent of total billed charges,Implant Device,2415,35,,2415,percent of total billed charges,Implant Device,2415,35,,2415,percent of total billed charges,Implant Device,2415,35,,2415,percent of total billed charges,Implant Device,2415,35,,2415,percent of total billed charges,Implant Device,2760,40,,2760,percent of total billed charges,Implant Device,2415,70,,2415,percent of total billed charges,All Other,2346,34,,2346,percent of total billed charges,Implant Device,2346,34,,2346,percent of total billed charges,Implant Device,2415,35,,2415,percent of total billed charges,Implant Device,2415,35,,2415,percent of total billed charges,Implant Device,2415,35,,2415,percent of total billed charges,Implant Device,2415,35,,2415,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2346,34,"If Charge > 2,000, then 34 percent",2346,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5106.02,
ZIMMER 11-300814 DISTAL STEM 14X150MM,C1776,HCPCS,,79010263,CDM,278,RC,,,both,,,11059,8183.69,,,8183.69,Other,150% of Medicare + 9.63% HCRA Surcharge,4976.55,45,,4976.55,percent of total billed charges,Critical Access Hospital RCC factor,3760.06,34,,3760.06,percent of total billed charges,Implant Device,3760.06,34,,3760.06,percent of total billed charges,Implant Device,3760.06,34,,3760.06,percent of total billed charges,Implant Device,3760.06,34,,3760.06,percent of total billed charges,Implant Device,3760.06,34,,3760.06,percent of total billed charges,Implant Device,5474.21,,,5474.21,Other,110% of Medicare,3870.65,35,,3870.65,percent of total billed charges,Implant Device,3760.06,34,"Charges > $500, x 34%",3760.06,percent of total billed charges,Implant Device,3870.65,35,,3870.65,percent of total billed charges,Implant Device,3870.65,35,,3870.65,percent of total billed charges,Implant Device,3870.65,35,,3870.65,percent of total billed charges,Implant Device,3870.65,35,,3870.65,percent of total billed charges,Implant Device,3870.65,35,,3870.65,percent of total billed charges,Implant Device,4423.6,40,,4423.6,percent of total billed charges,Implant Device,3870.65,70,,3870.65,percent of total billed charges,All Other,3760.06,34,,3760.06,percent of total billed charges,Implant Device,3760.06,34,,3760.06,percent of total billed charges,Implant Device,3870.65,35,,3870.65,percent of total billed charges,Implant Device,3870.65,35,,3870.65,percent of total billed charges,Implant Device,3870.65,35,,3870.65,percent of total billed charges,Implant Device,3870.65,35,,3870.65,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3760.06,34,"If Charge > 2,000, then 34 percent",3760.06,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,8183.69,
MENTOR SMXP140RH TISSUE EXPANDER 600CC,C1789,HCPCS,,79010264,CDM,278,RC,,,both,,,6375,4717.52,,,4717.52,Other,150% of Medicare + 9.63% HCRA Surcharge,2868.75,45,,2868.75,percent of total billed charges,Critical Access Hospital RCC factor,2167.5,34,,2167.5,percent of total billed charges,Implant Device,2167.5,34,,2167.5,percent of total billed charges,Implant Device,2167.5,34,,2167.5,percent of total billed charges,Implant Device,2167.5,34,,2167.5,percent of total billed charges,Implant Device,2167.5,34,,2167.5,percent of total billed charges,Implant Device,3155.63,,,3155.63,Other,110% of Medicare,2231.25,35,,2231.25,percent of total billed charges,Implant Device,2167.5,34,"Charges > $500, x 34%",2167.5,percent of total billed charges,Implant Device,2231.25,35,,2231.25,percent of total billed charges,Implant Device,2231.25,35,,2231.25,percent of total billed charges,Implant Device,2231.25,35,,2231.25,percent of total billed charges,Implant Device,2231.25,35,,2231.25,percent of total billed charges,Implant Device,2231.25,35,,2231.25,percent of total billed charges,Implant Device,2550,40,,2550,percent of total billed charges,Implant Device,2231.25,70,,2231.25,percent of total billed charges,All Other,2167.5,34,,2167.5,percent of total billed charges,Implant Device,2167.5,34,,2167.5,percent of total billed charges,Implant Device,2231.25,35,,2231.25,percent of total billed charges,Implant Device,2231.25,35,,2231.25,percent of total billed charges,Implant Device,2231.25,35,,2231.25,percent of total billed charges,Implant Device,2231.25,35,,2231.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2167.5,34,"If Charge > 2,000, then 34 percent",2167.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4717.52,
ALLERGAN SCM-445 GEL BREAST IMPLANTS 445,C1789,HCPCS,,79010265,CDM,278,RC,,,both,,,4005,2963.71,,,2963.71,Other,150% of Medicare + 9.63% HCRA Surcharge,1802.25,45,,1802.25,percent of total billed charges,Critical Access Hospital RCC factor,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1982.48,,,1982.48,Other,110% of Medicare,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1361.7,34,"Charges > $500, x 34%",1361.7,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1602,40,,1602,percent of total billed charges,Implant Device,1401.75,70,,1401.75,percent of total billed charges,All Other,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1361.7,34,"If Charge > 2,000, then 34 percent",1361.7,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2963.71,
ALLERGAN SCM-485 GEL BREAST IMPLANTS 485,C1789,HCPCS,,79010266,CDM,278,RC,,,both,,,4005,2963.71,,,2963.71,Other,150% of Medicare + 9.63% HCRA Surcharge,1802.25,45,,1802.25,percent of total billed charges,Critical Access Hospital RCC factor,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1982.48,,,1982.48,Other,110% of Medicare,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1361.7,34,"Charges > $500, x 34%",1361.7,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1602,40,,1602,percent of total billed charges,Implant Device,1401.75,70,,1401.75,percent of total billed charges,All Other,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1361.7,34,"If Charge > 2,000, then 34 percent",1361.7,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2963.71,
ALLERGAN SCLP-320 GEL BREAST IMPLANT 320,C1789,HCPCS,,79010269,CDM,278,RC,,,both,,,4005,2963.71,,,2963.71,Other,150% of Medicare + 9.63% HCRA Surcharge,1802.25,45,,1802.25,percent of total billed charges,Critical Access Hospital RCC factor,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1982.48,,,1982.48,Other,110% of Medicare,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1361.7,34,"Charges > $500, x 34%",1361.7,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1602,40,,1602,percent of total billed charges,Implant Device,1401.75,70,,1401.75,percent of total billed charges,All Other,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1361.7,34,"If Charge > 2,000, then 34 percent",1361.7,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2963.71,
ALLERGAN SCLP-360 GEL BREAST IMPLANT 360,C1789,HCPCS,,79010270,CDM,278,RC,,,both,,,4005,2963.71,,,2963.71,Other,150% of Medicare + 9.63% HCRA Surcharge,1802.25,45,,1802.25,percent of total billed charges,Critical Access Hospital RCC factor,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1982.48,,,1982.48,Other,110% of Medicare,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1361.7,34,"Charges > $500, x 34%",1361.7,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1602,40,,1602,percent of total billed charges,Implant Device,1401.75,70,,1401.75,percent of total billed charges,All Other,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1361.7,34,"If Charge > 2,000, then 34 percent",1361.7,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2963.71,
ALLERGAN SCLP-400 GEL BREAST IMPLANT 400,C1789,HCPCS,,79010271,CDM,278,RC,,,both,,,4005,2963.71,,,2963.71,Other,150% of Medicare + 9.63% HCRA Surcharge,1802.25,45,,1802.25,percent of total billed charges,Critical Access Hospital RCC factor,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1982.48,,,1982.48,Other,110% of Medicare,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1361.7,34,"Charges > $500, x 34%",1361.7,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1602,40,,1602,percent of total billed charges,Implant Device,1401.75,70,,1401.75,percent of total billed charges,All Other,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1361.7,34,"If Charge > 2,000, then 34 percent",1361.7,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2963.71,
ARTHREX AR-8952MT-03 T-PLATE 3 HOLE,C1713,HCPCS,,79010275,CDM,278,RC,,,both,,,2085,1542.91,,,1542.91,Other,150% of Medicare + 9.63% HCRA Surcharge,938.25,45,,938.25,percent of total billed charges,Critical Access Hospital RCC factor,708.9,34,,708.9,percent of total billed charges,Implant Device,708.9,34,,708.9,percent of total billed charges,Implant Device,708.9,34,,708.9,percent of total billed charges,Implant Device,708.9,34,,708.9,percent of total billed charges,Implant Device,708.9,34,,708.9,percent of total billed charges,Implant Device,1032.08,,,1032.08,Other,110% of Medicare,729.75,35,,729.75,percent of total billed charges,Implant Device,708.9,34,"Charges > $500, x 34%",708.9,percent of total billed charges,Implant Device,729.75,35,,729.75,percent of total billed charges,Implant Device,729.75,35,,729.75,percent of total billed charges,Implant Device,729.75,35,,729.75,percent of total billed charges,Implant Device,729.75,35,,729.75,percent of total billed charges,Implant Device,729.75,35,,729.75,percent of total billed charges,Implant Device,834,40,,834,percent of total billed charges,Implant Device,729.75,70,,729.75,percent of total billed charges,All Other,708.9,34,,708.9,percent of total billed charges,Implant Device,708.9,34,,708.9,percent of total billed charges,Implant Device,729.75,35,,729.75,percent of total billed charges,Implant Device,729.75,35,,729.75,percent of total billed charges,Implant Device,729.75,35,,729.75,percent of total billed charges,Implant Device,729.75,35,,729.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,708.9,34,"If Charge > 2,000, then 34 percent",708.9,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1542.91,
ARTHREX AR-8719DS-1515 STAPLE 15X15MM,C1713,HCPCS,,79010276,CDM,278,RC,,,both,,,6885,5094.92,,,5094.92,Other,150% of Medicare + 9.63% HCRA Surcharge,3098.25,45,,3098.25,percent of total billed charges,Critical Access Hospital RCC factor,2340.9,34,,2340.9,percent of total billed charges,Implant Device,2340.9,34,,2340.9,percent of total billed charges,Implant Device,2340.9,34,,2340.9,percent of total billed charges,Implant Device,2340.9,34,,2340.9,percent of total billed charges,Implant Device,2340.9,34,,2340.9,percent of total billed charges,Implant Device,3408.08,,,3408.08,Other,110% of Medicare,2409.75,35,,2409.75,percent of total billed charges,Implant Device,2340.9,34,"Charges > $500, x 34%",2340.9,percent of total billed charges,Implant Device,2409.75,35,,2409.75,percent of total billed charges,Implant Device,2409.75,35,,2409.75,percent of total billed charges,Implant Device,2409.75,35,,2409.75,percent of total billed charges,Implant Device,2409.75,35,,2409.75,percent of total billed charges,Implant Device,2409.75,35,,2409.75,percent of total billed charges,Implant Device,2754,40,,2754,percent of total billed charges,Implant Device,2409.75,70,,2409.75,percent of total billed charges,All Other,2340.9,34,,2340.9,percent of total billed charges,Implant Device,2340.9,34,,2340.9,percent of total billed charges,Implant Device,2409.75,35,,2409.75,percent of total billed charges,Implant Device,2409.75,35,,2409.75,percent of total billed charges,Implant Device,2409.75,35,,2409.75,percent of total billed charges,Implant Device,2409.75,35,,2409.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2340.9,34,"If Charge > 2,000, then 34 percent",2340.9,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5094.92,
ARTHREX ABS-2810-1810 EVANS WEDGE 10MM,C1713,HCPCS,,79010277,CDM,278,RC,,,both,,,6645,4917.32,,,4917.32,Other,150% of Medicare + 9.63% HCRA Surcharge,2990.25,45,,2990.25,percent of total billed charges,Critical Access Hospital RCC factor,2259.3,34,,2259.3,percent of total billed charges,Implant Device,2259.3,34,,2259.3,percent of total billed charges,Implant Device,2259.3,34,,2259.3,percent of total billed charges,Implant Device,2259.3,34,,2259.3,percent of total billed charges,Implant Device,2259.3,34,,2259.3,percent of total billed charges,Implant Device,3289.28,,,3289.28,Other,110% of Medicare,2325.75,35,,2325.75,percent of total billed charges,Implant Device,2259.3,34,"Charges > $500, x 34%",2259.3,percent of total billed charges,Implant Device,2325.75,35,,2325.75,percent of total billed charges,Implant Device,2325.75,35,,2325.75,percent of total billed charges,Implant Device,2325.75,35,,2325.75,percent of total billed charges,Implant Device,2325.75,35,,2325.75,percent of total billed charges,Implant Device,2325.75,35,,2325.75,percent of total billed charges,Implant Device,2658,40,,2658,percent of total billed charges,Implant Device,2325.75,70,,2325.75,percent of total billed charges,All Other,2259.3,34,,2259.3,percent of total billed charges,Implant Device,2259.3,34,,2259.3,percent of total billed charges,Implant Device,2325.75,35,,2325.75,percent of total billed charges,Implant Device,2325.75,35,,2325.75,percent of total billed charges,Implant Device,2325.75,35,,2325.75,percent of total billed charges,Implant Device,2325.75,35,,2325.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2259.3,34,"If Charge > 2,000, then 34 percent",2259.3,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4917.32,
ARTHREX ABS-2800-1665 COTTON WEDGE 6.5MM,C1713,HCPCS,,79010278,CDM,278,RC,,,both,,,4800,3552.01,,,3552.01,Other,150% of Medicare + 9.63% HCRA Surcharge,2160,45,,2160,percent of total billed charges,Critical Access Hospital RCC factor,1632,34,,1632,percent of total billed charges,Implant Device,1632,34,,1632,percent of total billed charges,Implant Device,1632,34,,1632,percent of total billed charges,Implant Device,1632,34,,1632,percent of total billed charges,Implant Device,1632,34,,1632,percent of total billed charges,Implant Device,2376,,,2376,Other,110% of Medicare,1680,35,,1680,percent of total billed charges,Implant Device,1632,34,"Charges > $500, x 34%",1632,percent of total billed charges,Implant Device,1680,35,,1680,percent of total billed charges,Implant Device,1680,35,,1680,percent of total billed charges,Implant Device,1680,35,,1680,percent of total billed charges,Implant Device,1680,35,,1680,percent of total billed charges,Implant Device,1680,35,,1680,percent of total billed charges,Implant Device,1920,40,,1920,percent of total billed charges,Implant Device,1680,70,,1680,percent of total billed charges,All Other,1632,34,,1632,percent of total billed charges,Implant Device,1632,34,,1632,percent of total billed charges,Implant Device,1680,35,,1680,percent of total billed charges,Implant Device,1680,35,,1680,percent of total billed charges,Implant Device,1680,35,,1680,percent of total billed charges,Implant Device,1680,35,,1680,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1632,34,"If Charge > 2,000, then 34 percent",1632,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3552.01,
STRYKER DCELL214 DERMACELL TISSUE 6X16CM,C1789,HCPCS,,79010279,CDM,278,RC,,,both,,,7875,5827.52,,,5827.52,Other,150% of Medicare + 9.63% HCRA Surcharge,3543.75,45,,3543.75,percent of total billed charges,Critical Access Hospital RCC factor,2677.5,34,,2677.5,percent of total billed charges,Implant Device,2677.5,34,,2677.5,percent of total billed charges,Implant Device,2677.5,34,,2677.5,percent of total billed charges,Implant Device,2677.5,34,,2677.5,percent of total billed charges,Implant Device,2677.5,34,,2677.5,percent of total billed charges,Implant Device,3898.13,,,3898.13,Other,110% of Medicare,2756.25,35,,2756.25,percent of total billed charges,Implant Device,2677.5,34,"Charges > $500, x 34%",2677.5,percent of total billed charges,Implant Device,2756.25,35,,2756.25,percent of total billed charges,Implant Device,2756.25,35,,2756.25,percent of total billed charges,Implant Device,2756.25,35,,2756.25,percent of total billed charges,Implant Device,2756.25,35,,2756.25,percent of total billed charges,Implant Device,2756.25,35,,2756.25,percent of total billed charges,Implant Device,3150,40,,3150,percent of total billed charges,Implant Device,2756.25,70,,2756.25,percent of total billed charges,All Other,2677.5,34,,2677.5,percent of total billed charges,Implant Device,2677.5,34,,2677.5,percent of total billed charges,Implant Device,2756.25,35,,2756.25,percent of total billed charges,Implant Device,2756.25,35,,2756.25,percent of total billed charges,Implant Device,2756.25,35,,2756.25,percent of total billed charges,Implant Device,2756.25,35,,2756.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2677.5,34,"If Charge > 2,000, then 34 percent",2677.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5827.52,
STRYKER 656120 BONE SCREW T8 2.4XL20MM,C1713,HCPCS,,79010281,CDM,278,RC,,,both,,,258,190.92,,,190.92,Other,150% of Medicare + 9.63% HCRA Surcharge,116.1,45,,116.1,percent of total billed charges,Critical Access Hospital RCC factor,87.72,34,,87.72,percent of total billed charges,Implant Device,87.72,34,,87.72,percent of total billed charges,Implant Device,87.72,34,,87.72,percent of total billed charges,Implant Device,87.72,34,,87.72,percent of total billed charges,Implant Device,87.72,34,,87.72,percent of total billed charges,Implant Device,127.71,,,127.71,Other,110% of Medicare,90.3,35,,90.3,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,90.3,35,,90.3,percent of total billed charges,Implant Device,90.3,35,,90.3,percent of total billed charges,Implant Device,90.3,35,,90.3,percent of total billed charges,Implant Device,90.3,35,,90.3,percent of total billed charges,Implant Device,90.3,35,,90.3,percent of total billed charges,Implant Device,103.2,40,,103.2,percent of total billed charges,Implant Device,90.3,70,,90.3,percent of total billed charges,All Other,87.72,34,,87.72,percent of total billed charges,Implant Device,87.72,34,,87.72,percent of total billed charges,Implant Device,90.3,35,,90.3,percent of total billed charges,Implant Device,90.3,35,,90.3,percent of total billed charges,Implant Device,90.3,35,,90.3,percent of total billed charges,Implant Device,90.3,35,,90.3,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,190.92,
STRYKER 663038 COMP SCREW 4.0XL40MM,C1713,HCPCS,,79010282,CDM,278,RC,,,both,,,2559,1893.67,,,1893.67,Other,150% of Medicare + 9.63% HCRA Surcharge,1151.55,45,,1151.55,percent of total billed charges,Critical Access Hospital RCC factor,870.06,34,,870.06,percent of total billed charges,Implant Device,870.06,34,,870.06,percent of total billed charges,Implant Device,870.06,34,,870.06,percent of total billed charges,Implant Device,870.06,34,,870.06,percent of total billed charges,Implant Device,870.06,34,,870.06,percent of total billed charges,Implant Device,1266.71,,,1266.71,Other,110% of Medicare,895.65,35,,895.65,percent of total billed charges,Implant Device,870.06,34,"Charges > $500, x 34%",870.06,percent of total billed charges,Implant Device,895.65,35,,895.65,percent of total billed charges,Implant Device,895.65,35,,895.65,percent of total billed charges,Implant Device,895.65,35,,895.65,percent of total billed charges,Implant Device,895.65,35,,895.65,percent of total billed charges,Implant Device,895.65,35,,895.65,percent of total billed charges,Implant Device,1023.6,40,,1023.6,percent of total billed charges,Implant Device,895.65,70,,895.65,percent of total billed charges,All Other,870.06,34,,870.06,percent of total billed charges,Implant Device,870.06,34,,870.06,percent of total billed charges,Implant Device,895.65,35,,895.65,percent of total billed charges,Implant Device,895.65,35,,895.65,percent of total billed charges,Implant Device,895.65,35,,895.65,percent of total billed charges,Implant Device,895.65,35,,895.65,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,870.06,34,"If Charge > 2,000, then 34 percent",870.06,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1893.67,
STRYKER 663040 COMP SCREW 4.0XL38MM,C1713,HCPCS,,79010283,CDM,278,RC,,,both,,,2559,1893.67,,,1893.67,Other,150% of Medicare + 9.63% HCRA Surcharge,1151.55,45,,1151.55,percent of total billed charges,Critical Access Hospital RCC factor,870.06,34,,870.06,percent of total billed charges,Implant Device,870.06,34,,870.06,percent of total billed charges,Implant Device,870.06,34,,870.06,percent of total billed charges,Implant Device,870.06,34,,870.06,percent of total billed charges,Implant Device,870.06,34,,870.06,percent of total billed charges,Implant Device,1266.71,,,1266.71,Other,110% of Medicare,895.65,35,,895.65,percent of total billed charges,Implant Device,870.06,34,"Charges > $500, x 34%",870.06,percent of total billed charges,Implant Device,895.65,35,,895.65,percent of total billed charges,Implant Device,895.65,35,,895.65,percent of total billed charges,Implant Device,895.65,35,,895.65,percent of total billed charges,Implant Device,895.65,35,,895.65,percent of total billed charges,Implant Device,895.65,35,,895.65,percent of total billed charges,Implant Device,1023.6,40,,1023.6,percent of total billed charges,Implant Device,895.65,70,,895.65,percent of total billed charges,All Other,870.06,34,,870.06,percent of total billed charges,Implant Device,870.06,34,,870.06,percent of total billed charges,Implant Device,895.65,35,,895.65,percent of total billed charges,Implant Device,895.65,35,,895.65,percent of total billed charges,Implant Device,895.65,35,,895.65,percent of total billed charges,Implant Device,895.65,35,,895.65,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,870.06,34,"If Charge > 2,000, then 34 percent",870.06,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1893.67,
STRYKER 663044 COMP SCREW 4.0XL44MM,C1713,HCPCS,,79010284,CDM,278,RC,,,both,,,2559,1893.67,,,1893.67,Other,150% of Medicare + 9.63% HCRA Surcharge,1151.55,45,,1151.55,percent of total billed charges,Critical Access Hospital RCC factor,870.06,34,,870.06,percent of total billed charges,Implant Device,870.06,34,,870.06,percent of total billed charges,Implant Device,870.06,34,,870.06,percent of total billed charges,Implant Device,870.06,34,,870.06,percent of total billed charges,Implant Device,870.06,34,,870.06,percent of total billed charges,Implant Device,1266.71,,,1266.71,Other,110% of Medicare,895.65,35,,895.65,percent of total billed charges,Implant Device,870.06,34,"Charges > $500, x 34%",870.06,percent of total billed charges,Implant Device,895.65,35,,895.65,percent of total billed charges,Implant Device,895.65,35,,895.65,percent of total billed charges,Implant Device,895.65,35,,895.65,percent of total billed charges,Implant Device,895.65,35,,895.65,percent of total billed charges,Implant Device,895.65,35,,895.65,percent of total billed charges,Implant Device,1023.6,40,,1023.6,percent of total billed charges,Implant Device,895.65,70,,895.65,percent of total billed charges,All Other,870.06,34,,870.06,percent of total billed charges,Implant Device,870.06,34,,870.06,percent of total billed charges,Implant Device,895.65,35,,895.65,percent of total billed charges,Implant Device,895.65,35,,895.65,percent of total billed charges,Implant Device,895.65,35,,895.65,percent of total billed charges,Implant Device,895.65,35,,895.65,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,870.06,34,"If Charge > 2,000, then 34 percent",870.06,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1893.67,
DJO 242-01-107 FEMUR SIZE 7L,C1776,HCPCS,,79010285,CDM,278,RC,,,both,,,7500,5550.02,,,5550.02,Other,150% of Medicare + 9.63% HCRA Surcharge,3375,45,,3375,percent of total billed charges,Critical Access Hospital RCC factor,2550,34,,2550,percent of total billed charges,Implant Device,2550,34,,2550,percent of total billed charges,Implant Device,2550,34,,2550,percent of total billed charges,Implant Device,2550,34,,2550,percent of total billed charges,Implant Device,2550,34,,2550,percent of total billed charges,Implant Device,3712.5,,,3712.5,Other,110% of Medicare,2625,35,,2625,percent of total billed charges,Implant Device,2550,34,"Charges > $500, x 34%",2550,percent of total billed charges,Implant Device,2625,35,,2625,percent of total billed charges,Implant Device,2625,35,,2625,percent of total billed charges,Implant Device,2625,35,,2625,percent of total billed charges,Implant Device,2625,35,,2625,percent of total billed charges,Implant Device,2625,35,,2625,percent of total billed charges,Implant Device,3000,40,,3000,percent of total billed charges,Implant Device,2625,70,,2625,percent of total billed charges,All Other,2550,34,,2550,percent of total billed charges,Implant Device,2550,34,,2550,percent of total billed charges,Implant Device,2625,35,,2625,percent of total billed charges,Implant Device,2625,35,,2625,percent of total billed charges,Implant Device,2625,35,,2625,percent of total billed charges,Implant Device,2625,35,,2625,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2550,34,"If Charge > 2,000, then 34 percent",2550,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5550.02,
DJO 430-99-058 HEMI SHELL 58MM,C1776,HCPCS,,79010286,CDM,278,RC,,,both,,,4200,3108.01,,,3108.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1890,45,,1890,percent of total billed charges,Critical Access Hospital RCC factor,1428,34,,1428,percent of total billed charges,Implant Device,1428,34,,1428,percent of total billed charges,Implant Device,1428,34,,1428,percent of total billed charges,Implant Device,1428,34,,1428,percent of total billed charges,Implant Device,1428,34,,1428,percent of total billed charges,Implant Device,2079,,,2079,Other,110% of Medicare,1470,35,,1470,percent of total billed charges,Implant Device,1428,34,"Charges > $500, x 34%",1428,percent of total billed charges,Implant Device,1470,35,,1470,percent of total billed charges,Implant Device,1470,35,,1470,percent of total billed charges,Implant Device,1470,35,,1470,percent of total billed charges,Implant Device,1470,35,,1470,percent of total billed charges,Implant Device,1470,35,,1470,percent of total billed charges,Implant Device,1680,40,,1680,percent of total billed charges,Implant Device,1470,70,,1470,percent of total billed charges,All Other,1428,34,,1428,percent of total billed charges,Implant Device,1428,34,,1428,percent of total billed charges,Implant Device,1470,35,,1470,percent of total billed charges,Implant Device,1470,35,,1470,percent of total billed charges,Implant Device,1470,35,,1470,percent of total billed charges,Implant Device,1470,35,,1470,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1428,34,"If Charge > 2,000, then 34 percent",1428,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3108.01,
DJO 935-36-256 ACETABULAR LINER 36MM,C1776,HCPCS,,79010287,CDM,278,RC,,,both,,,4500,3330.01,,,3330.01,Other,150% of Medicare + 9.63% HCRA Surcharge,2025,45,,2025,percent of total billed charges,Critical Access Hospital RCC factor,1530,34,,1530,percent of total billed charges,Implant Device,1530,34,,1530,percent of total billed charges,Implant Device,1530,34,,1530,percent of total billed charges,Implant Device,1530,34,,1530,percent of total billed charges,Implant Device,1530,34,,1530,percent of total billed charges,Implant Device,2227.5,,,2227.5,Other,110% of Medicare,1575,35,,1575,percent of total billed charges,Implant Device,1530,34,"Charges > $500, x 34%",1530,percent of total billed charges,Implant Device,1575,35,,1575,percent of total billed charges,Implant Device,1575,35,,1575,percent of total billed charges,Implant Device,1575,35,,1575,percent of total billed charges,Implant Device,1575,35,,1575,percent of total billed charges,Implant Device,1575,35,,1575,percent of total billed charges,Implant Device,1800,40,,1800,percent of total billed charges,Implant Device,1575,70,,1575,percent of total billed charges,All Other,1530,34,,1530,percent of total billed charges,Implant Device,1530,34,,1530,percent of total billed charges,Implant Device,1575,35,,1575,percent of total billed charges,Implant Device,1575,35,,1575,percent of total billed charges,Implant Device,1575,35,,1575,percent of total billed charges,Implant Device,1575,35,,1575,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1530,34,"If Charge > 2,000, then 34 percent",1530,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3330.01,
DJO D111-18-1402 HIP STEM SIZE 14,C1776,HCPCS,,79010288,CDM,278,RC,,,both,,,7320,5416.82,,,5416.82,Other,150% of Medicare + 9.63% HCRA Surcharge,3294,45,,3294,percent of total billed charges,Critical Access Hospital RCC factor,2488.8,34,,2488.8,percent of total billed charges,Implant Device,2488.8,34,,2488.8,percent of total billed charges,Implant Device,2488.8,34,,2488.8,percent of total billed charges,Implant Device,2488.8,34,,2488.8,percent of total billed charges,Implant Device,2488.8,34,,2488.8,percent of total billed charges,Implant Device,3623.4,,,3623.4,Other,110% of Medicare,2562,35,,2562,percent of total billed charges,Implant Device,2488.8,34,"Charges > $500, x 34%",2488.8,percent of total billed charges,Implant Device,2562,35,,2562,percent of total billed charges,Implant Device,2562,35,,2562,percent of total billed charges,Implant Device,2562,35,,2562,percent of total billed charges,Implant Device,2562,35,,2562,percent of total billed charges,Implant Device,2562,35,,2562,percent of total billed charges,Implant Device,2928,40,,2928,percent of total billed charges,Implant Device,2562,70,,2562,percent of total billed charges,All Other,2488.8,34,,2488.8,percent of total billed charges,Implant Device,2488.8,34,,2488.8,percent of total billed charges,Implant Device,2562,35,,2562,percent of total billed charges,Implant Device,2562,35,,2562,percent of total billed charges,Implant Device,2562,35,,2562,percent of total billed charges,Implant Device,2562,35,,2562,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2488.8,34,"If Charge > 2,000, then 34 percent",2488.8,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5416.82,
ARTHREX ABS-2800-1675 COTTON WEDGE 7.5MM,C1713,HCPCS,,79010289,CDM,278,RC,,,both,,,4800,3552.01,,,3552.01,Other,150% of Medicare + 9.63% HCRA Surcharge,2160,45,,2160,percent of total billed charges,Critical Access Hospital RCC factor,1632,34,,1632,percent of total billed charges,Implant Device,1632,34,,1632,percent of total billed charges,Implant Device,1632,34,,1632,percent of total billed charges,Implant Device,1632,34,,1632,percent of total billed charges,Implant Device,1632,34,,1632,percent of total billed charges,Implant Device,2376,,,2376,Other,110% of Medicare,1680,35,,1680,percent of total billed charges,Implant Device,1632,34,"Charges > $500, x 34%",1632,percent of total billed charges,Implant Device,1680,35,,1680,percent of total billed charges,Implant Device,1680,35,,1680,percent of total billed charges,Implant Device,1680,35,,1680,percent of total billed charges,Implant Device,1680,35,,1680,percent of total billed charges,Implant Device,1680,35,,1680,percent of total billed charges,Implant Device,1920,40,,1920,percent of total billed charges,Implant Device,1680,70,,1680,percent of total billed charges,All Other,1632,34,,1632,percent of total billed charges,Implant Device,1632,34,,1632,percent of total billed charges,Implant Device,1680,35,,1680,percent of total billed charges,Implant Device,1680,35,,1680,percent of total billed charges,Implant Device,1680,35,,1680,percent of total billed charges,Implant Device,1680,35,,1680,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1632,34,"If Charge > 2,000, then 34 percent",1632,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3552.01,
BARD AVSM06060 6X60X80CM VASCULAR STENT,C1876,HCPCS,,79010290,CDM,278,RC,,,both,,,9585,7092.92,,,7092.92,Other,150% of Medicare + 9.63% HCRA Surcharge,4313.25,45,,4313.25,percent of total billed charges,Critical Access Hospital RCC factor,3258.9,34,,3258.9,percent of total billed charges,Implant Device,3258.9,34,,3258.9,percent of total billed charges,Implant Device,3258.9,34,,3258.9,percent of total billed charges,Implant Device,3258.9,34,,3258.9,percent of total billed charges,Implant Device,3258.9,34,,3258.9,percent of total billed charges,Implant Device,4744.58,,,4744.58,Other,110% of Medicare,3354.75,35,,3354.75,percent of total billed charges,Implant Device,3258.9,34,"Charges > $500, x 34%",3258.9,percent of total billed charges,Implant Device,3354.75,35,,3354.75,percent of total billed charges,Implant Device,3354.75,35,,3354.75,percent of total billed charges,Implant Device,3354.75,35,,3354.75,percent of total billed charges,Implant Device,3354.75,35,,3354.75,percent of total billed charges,Implant Device,3354.75,35,,3354.75,percent of total billed charges,Implant Device,3834,40,,3834,percent of total billed charges,Implant Device,3354.75,70,,3354.75,percent of total billed charges,All Other,3258.9,34,,3258.9,percent of total billed charges,Implant Device,3258.9,34,,3258.9,percent of total billed charges,Implant Device,3354.75,35,,3354.75,percent of total billed charges,Implant Device,3354.75,35,,3354.75,percent of total billed charges,Implant Device,3354.75,35,,3354.75,percent of total billed charges,Implant Device,3354.75,35,,3354.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3258.9,34,"If Charge > 2,000, then 34 percent",3258.9,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,7092.92,
BARD AVSM06080 6X80X80CM VASCULAR STENT,C1876,HCPCS,,79010291,CDM,278,RC,,,both,,,14250,10545.04,,,10545.04,Other,150% of Medicare + 9.63% HCRA Surcharge,6412.5,45,,6412.5,percent of total billed charges,Critical Access Hospital RCC factor,4845,34,,4845,percent of total billed charges,Implant Device,4845,34,,4845,percent of total billed charges,Implant Device,4845,34,,4845,percent of total billed charges,Implant Device,4845,34,,4845,percent of total billed charges,Implant Device,4845,34,,4845,percent of total billed charges,Implant Device,7053.75,,,7053.75,Other,110% of Medicare,4987.5,35,,4987.5,percent of total billed charges,Implant Device,4845,34,"Charges > $500, x 34%",4845,percent of total billed charges,Implant Device,4987.5,35,,4987.5,percent of total billed charges,Implant Device,4987.5,35,,4987.5,percent of total billed charges,Implant Device,4987.5,35,,4987.5,percent of total billed charges,Implant Device,4987.5,35,,4987.5,percent of total billed charges,Implant Device,4987.5,35,,4987.5,percent of total billed charges,Implant Device,5700,40,,5700,percent of total billed charges,Implant Device,4987.5,70,,4987.5,percent of total billed charges,All Other,4845,34,,4845,percent of total billed charges,Implant Device,4845,34,,4845,percent of total billed charges,Implant Device,4987.5,35,,4987.5,percent of total billed charges,Implant Device,4987.5,35,,4987.5,percent of total billed charges,Implant Device,4987.5,35,,4987.5,percent of total billed charges,Implant Device,4987.5,35,,4987.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,4845,34,"If Charge > 2,000, then 34 percent",4845,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,10545.04,
BARD AVSM08080 8X80X80CM VASCULAR STENT,C1876,HCPCS,,79010292,CDM,278,RC,,,both,,,14250,10545.04,,,10545.04,Other,150% of Medicare + 9.63% HCRA Surcharge,6412.5,45,,6412.5,percent of total billed charges,Critical Access Hospital RCC factor,4845,34,,4845,percent of total billed charges,Implant Device,4845,34,,4845,percent of total billed charges,Implant Device,4845,34,,4845,percent of total billed charges,Implant Device,4845,34,,4845,percent of total billed charges,Implant Device,4845,34,,4845,percent of total billed charges,Implant Device,7053.75,,,7053.75,Other,110% of Medicare,4987.5,35,,4987.5,percent of total billed charges,Implant Device,4845,34,"Charges > $500, x 34%",4845,percent of total billed charges,Implant Device,4987.5,35,,4987.5,percent of total billed charges,Implant Device,4987.5,35,,4987.5,percent of total billed charges,Implant Device,4987.5,35,,4987.5,percent of total billed charges,Implant Device,4987.5,35,,4987.5,percent of total billed charges,Implant Device,4987.5,35,,4987.5,percent of total billed charges,Implant Device,5700,40,,5700,percent of total billed charges,Implant Device,4987.5,70,,4987.5,percent of total billed charges,All Other,4845,34,,4845,percent of total billed charges,Implant Device,4845,34,,4845,percent of total billed charges,Implant Device,4987.5,35,,4987.5,percent of total billed charges,Implant Device,4987.5,35,,4987.5,percent of total billed charges,Implant Device,4987.5,35,,4987.5,percent of total billed charges,Implant Device,4987.5,35,,4987.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,4845,34,"If Charge > 2,000, then 34 percent",4845,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,10545.04,
BARD AVSM10040 10X40X80CM VASCULAR STENT,C1876,HCPCS,,79010293,CDM,278,RC,,,both,,,9585,7092.92,,,7092.92,Other,150% of Medicare + 9.63% HCRA Surcharge,4313.25,45,,4313.25,percent of total billed charges,Critical Access Hospital RCC factor,3258.9,34,,3258.9,percent of total billed charges,Implant Device,3258.9,34,,3258.9,percent of total billed charges,Implant Device,3258.9,34,,3258.9,percent of total billed charges,Implant Device,3258.9,34,,3258.9,percent of total billed charges,Implant Device,3258.9,34,,3258.9,percent of total billed charges,Implant Device,4744.58,,,4744.58,Other,110% of Medicare,3354.75,35,,3354.75,percent of total billed charges,Implant Device,3258.9,34,"Charges > $500, x 34%",3258.9,percent of total billed charges,Implant Device,3354.75,35,,3354.75,percent of total billed charges,Implant Device,3354.75,35,,3354.75,percent of total billed charges,Implant Device,3354.75,35,,3354.75,percent of total billed charges,Implant Device,3354.75,35,,3354.75,percent of total billed charges,Implant Device,3354.75,35,,3354.75,percent of total billed charges,Implant Device,3834,40,,3834,percent of total billed charges,Implant Device,3354.75,70,,3354.75,percent of total billed charges,All Other,3258.9,34,,3258.9,percent of total billed charges,Implant Device,3258.9,34,,3258.9,percent of total billed charges,Implant Device,3354.75,35,,3354.75,percent of total billed charges,Implant Device,3354.75,35,,3354.75,percent of total billed charges,Implant Device,3354.75,35,,3354.75,percent of total billed charges,Implant Device,3354.75,35,,3354.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3258.9,34,"If Charge > 2,000, then 34 percent",3258.9,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,7092.92,
BARD AVSM10060 10X60X80CM VASCULAR STENT,C1876,HCPCS,,79010294,CDM,278,RC,,,both,,,9585,7092.92,,,7092.92,Other,150% of Medicare + 9.63% HCRA Surcharge,4313.25,45,,4313.25,percent of total billed charges,Critical Access Hospital RCC factor,3258.9,34,,3258.9,percent of total billed charges,Implant Device,3258.9,34,,3258.9,percent of total billed charges,Implant Device,3258.9,34,,3258.9,percent of total billed charges,Implant Device,3258.9,34,,3258.9,percent of total billed charges,Implant Device,3258.9,34,,3258.9,percent of total billed charges,Implant Device,4744.58,,,4744.58,Other,110% of Medicare,3354.75,35,,3354.75,percent of total billed charges,Implant Device,3258.9,34,"Charges > $500, x 34%",3258.9,percent of total billed charges,Implant Device,3354.75,35,,3354.75,percent of total billed charges,Implant Device,3354.75,35,,3354.75,percent of total billed charges,Implant Device,3354.75,35,,3354.75,percent of total billed charges,Implant Device,3354.75,35,,3354.75,percent of total billed charges,Implant Device,3354.75,35,,3354.75,percent of total billed charges,Implant Device,3834,40,,3834,percent of total billed charges,Implant Device,3354.75,70,,3354.75,percent of total billed charges,All Other,3258.9,34,,3258.9,percent of total billed charges,Implant Device,3258.9,34,,3258.9,percent of total billed charges,Implant Device,3354.75,35,,3354.75,percent of total billed charges,Implant Device,3354.75,35,,3354.75,percent of total billed charges,Implant Device,3354.75,35,,3354.75,percent of total billed charges,Implant Device,3354.75,35,,3354.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3258.9,34,"If Charge > 2,000, then 34 percent",3258.9,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,7092.92,
IN2BONES V30 ST214 NON LOCK SCREW 3X14MM,C1713,HCPCS,,79010295,CDM,278,RC,,,both,,,735,543.9,,,543.9,Other,150% of Medicare + 9.63% HCRA Surcharge,330.75,45,,330.75,percent of total billed charges,Critical Access Hospital RCC factor,249.9,34,,249.9,percent of total billed charges,Implant Device,249.9,34,,249.9,percent of total billed charges,Implant Device,249.9,34,,249.9,percent of total billed charges,Implant Device,249.9,34,,249.9,percent of total billed charges,Implant Device,249.9,34,,249.9,percent of total billed charges,Implant Device,363.83,,,363.83,Other,110% of Medicare,257.25,35,,257.25,percent of total billed charges,Implant Device,249.9,34,"Charges > $500, x 34%",249.9,percent of total billed charges,Implant Device,257.25,35,,257.25,percent of total billed charges,Implant Device,257.25,35,,257.25,percent of total billed charges,Implant Device,257.25,35,,257.25,percent of total billed charges,Implant Device,257.25,35,,257.25,percent of total billed charges,Implant Device,257.25,35,,257.25,percent of total billed charges,Implant Device,294,40,,294,percent of total billed charges,Implant Device,257.25,70,,257.25,percent of total billed charges,All Other,249.9,34,,249.9,percent of total billed charges,Implant Device,249.9,34,,249.9,percent of total billed charges,Implant Device,257.25,35,,257.25,percent of total billed charges,Implant Device,257.25,35,,257.25,percent of total billed charges,Implant Device,257.25,35,,257.25,percent of total billed charges,Implant Device,257.25,35,,257.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,543.9,
ARTHREX ABS-2810-2010 EVAN WEDG 20X20X10,C1713,HCPCS,,79010296,CDM,278,RC,,,both,,,6858,5074.94,,,5074.94,Other,150% of Medicare + 9.63% HCRA Surcharge,3086.1,45,,3086.1,percent of total billed charges,Critical Access Hospital RCC factor,2331.72,34,,2331.72,percent of total billed charges,Implant Device,2331.72,34,,2331.72,percent of total billed charges,Implant Device,2331.72,34,,2331.72,percent of total billed charges,Implant Device,2331.72,34,,2331.72,percent of total billed charges,Implant Device,2331.72,34,,2331.72,percent of total billed charges,Implant Device,3394.71,,,3394.71,Other,110% of Medicare,2400.3,35,,2400.3,percent of total billed charges,Implant Device,2331.72,34,"Charges > $500, x 34%",2331.72,percent of total billed charges,Implant Device,2400.3,35,,2400.3,percent of total billed charges,Implant Device,2400.3,35,,2400.3,percent of total billed charges,Implant Device,2400.3,35,,2400.3,percent of total billed charges,Implant Device,2400.3,35,,2400.3,percent of total billed charges,Implant Device,2400.3,35,,2400.3,percent of total billed charges,Implant Device,2743.2,40,,2743.2,percent of total billed charges,Implant Device,2400.3,70,,2400.3,percent of total billed charges,All Other,2331.72,34,,2331.72,percent of total billed charges,Implant Device,2331.72,34,,2331.72,percent of total billed charges,Implant Device,2400.3,35,,2400.3,percent of total billed charges,Implant Device,2400.3,35,,2400.3,percent of total billed charges,Implant Device,2400.3,35,,2400.3,percent of total billed charges,Implant Device,2400.3,35,,2400.3,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2331.72,34,"If Charge > 2,000, then 34 percent",2331.72,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5074.94,
DEPUY 1961-92-145 TIBIAL INSERT SZ4 20MM,C1776,HCPCS,,79010297,CDM,278,RC,,,both,,,5735,4243.91,,,4243.91,Other,150% of Medicare + 9.63% HCRA Surcharge,2580.75,45,,2580.75,percent of total billed charges,Critical Access Hospital RCC factor,1949.9,34,,1949.9,percent of total billed charges,Implant Device,1949.9,34,,1949.9,percent of total billed charges,Implant Device,1949.9,34,,1949.9,percent of total billed charges,Implant Device,1949.9,34,,1949.9,percent of total billed charges,Implant Device,1949.9,34,,1949.9,percent of total billed charges,Implant Device,2838.83,,,2838.83,Other,110% of Medicare,2007.25,35,,2007.25,percent of total billed charges,Implant Device,1949.9,34,"Charges > $500, x 34%",1949.9,percent of total billed charges,Implant Device,2007.25,35,,2007.25,percent of total billed charges,Implant Device,2007.25,35,,2007.25,percent of total billed charges,Implant Device,2007.25,35,,2007.25,percent of total billed charges,Implant Device,2007.25,35,,2007.25,percent of total billed charges,Implant Device,2007.25,35,,2007.25,percent of total billed charges,Implant Device,2294,40,,2294,percent of total billed charges,Implant Device,2007.25,70,,2007.25,percent of total billed charges,All Other,1949.9,34,,1949.9,percent of total billed charges,Implant Device,1949.9,34,,1949.9,percent of total billed charges,Implant Device,2007.25,35,,2007.25,percent of total billed charges,Implant Device,2007.25,35,,2007.25,percent of total billed charges,Implant Device,2007.25,35,,2007.25,percent of total billed charges,Implant Device,2007.25,35,,2007.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1949.9,34,"If Charge > 2,000, then 34 percent",1949.9,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4243.91,
EXACTECH 314-13-32 GLENOID POST AUGMENT,C1713,HCPCS,,79010298,CDM,278,RC,,,both,,,4725,3496.51,,,3496.51,Other,150% of Medicare + 9.63% HCRA Surcharge,2126.25,45,,2126.25,percent of total billed charges,Critical Access Hospital RCC factor,1606.5,34,,1606.5,percent of total billed charges,Implant Device,1606.5,34,,1606.5,percent of total billed charges,Implant Device,1606.5,34,,1606.5,percent of total billed charges,Implant Device,1606.5,34,,1606.5,percent of total billed charges,Implant Device,1606.5,34,,1606.5,percent of total billed charges,Implant Device,2338.88,,,2338.88,Other,110% of Medicare,1653.75,35,,1653.75,percent of total billed charges,Implant Device,1606.5,34,"Charges > $500, x 34%",1606.5,percent of total billed charges,Implant Device,1653.75,35,,1653.75,percent of total billed charges,Implant Device,1653.75,35,,1653.75,percent of total billed charges,Implant Device,1653.75,35,,1653.75,percent of total billed charges,Implant Device,1653.75,35,,1653.75,percent of total billed charges,Implant Device,1653.75,35,,1653.75,percent of total billed charges,Implant Device,1890,40,,1890,percent of total billed charges,Implant Device,1653.75,70,,1653.75,percent of total billed charges,All Other,1606.5,34,,1606.5,percent of total billed charges,Implant Device,1606.5,34,,1606.5,percent of total billed charges,Implant Device,1653.75,35,,1653.75,percent of total billed charges,Implant Device,1653.75,35,,1653.75,percent of total billed charges,Implant Device,1653.75,35,,1653.75,percent of total billed charges,Implant Device,1653.75,35,,1653.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1606.5,34,"If Charge > 2,000, then 34 percent",1606.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3496.51,
ACUMED 5001-02244L-S RADIAL HEAD 24MM L,C1776,HCPCS,,79010299,CDM,278,RC,,,both,,,11196,8285.07,,,8285.07,Other,150% of Medicare + 9.63% HCRA Surcharge,5038.2,45,,5038.2,percent of total billed charges,Critical Access Hospital RCC factor,3806.64,34,,3806.64,percent of total billed charges,Implant Device,3806.64,34,,3806.64,percent of total billed charges,Implant Device,3806.64,34,,3806.64,percent of total billed charges,Implant Device,3806.64,34,,3806.64,percent of total billed charges,Implant Device,3806.64,34,,3806.64,percent of total billed charges,Implant Device,5542.02,,,5542.02,Other,110% of Medicare,3918.6,35,,3918.6,percent of total billed charges,Implant Device,3806.64,34,"Charges > $500, x 34%",3806.64,percent of total billed charges,Implant Device,3918.6,35,,3918.6,percent of total billed charges,Implant Device,3918.6,35,,3918.6,percent of total billed charges,Implant Device,3918.6,35,,3918.6,percent of total billed charges,Implant Device,3918.6,35,,3918.6,percent of total billed charges,Implant Device,3918.6,35,,3918.6,percent of total billed charges,Implant Device,4478.4,40,,4478.4,percent of total billed charges,Implant Device,3918.6,70,,3918.6,percent of total billed charges,All Other,3806.64,34,,3806.64,percent of total billed charges,Implant Device,3806.64,34,,3806.64,percent of total billed charges,Implant Device,3918.6,35,,3918.6,percent of total billed charges,Implant Device,3918.6,35,,3918.6,percent of total billed charges,Implant Device,3918.6,35,,3918.6,percent of total billed charges,Implant Device,3918.6,35,,3918.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3806.64,34,"If Charge > 2,000, then 34 percent",3806.64,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,8285.07,
ALLERGAN SCL-170 BREAST IMPLANT 170CC,C1789,HCPCS,,79010300,CDM,278,RC,,,both,,,4005,2963.71,,,2963.71,Other,150% of Medicare + 9.63% HCRA Surcharge,1802.25,45,,1802.25,percent of total billed charges,Critical Access Hospital RCC factor,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1982.48,,,1982.48,Other,110% of Medicare,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1361.7,34,"Charges > $500, x 34%",1361.7,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1602,40,,1602,percent of total billed charges,Implant Device,1401.75,70,,1401.75,percent of total billed charges,All Other,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1361.7,34,"If Charge > 2,000, then 34 percent",1361.7,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2963.71,
ALLERGAN SCL-200 BREAST IMPLANT 200CC,C1789,HCPCS,,79010301,CDM,278,RC,,,both,,,4005,2963.71,,,2963.71,Other,150% of Medicare + 9.63% HCRA Surcharge,1802.25,45,,1802.25,percent of total billed charges,Critical Access Hospital RCC factor,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1982.48,,,1982.48,Other,110% of Medicare,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1361.7,34,"Charges > $500, x 34%",1361.7,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1602,40,,1602,percent of total billed charges,Implant Device,1401.75,70,,1401.75,percent of total billed charges,All Other,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1361.7,34,"If Charge > 2,000, then 34 percent",1361.7,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2963.71,
EXACTECH SPC0423 TAPERED WEDGE 54MM LONG,C1713,HCPCS,,79010304,CDM,278,RC,,,both,,,10625,7862.53,,,7862.53,Other,150% of Medicare + 9.63% HCRA Surcharge,4781.25,45,,4781.25,percent of total billed charges,Critical Access Hospital RCC factor,3612.5,34,,3612.5,percent of total billed charges,Implant Device,3612.5,34,,3612.5,percent of total billed charges,Implant Device,3612.5,34,,3612.5,percent of total billed charges,Implant Device,3612.5,34,,3612.5,percent of total billed charges,Implant Device,3612.5,34,,3612.5,percent of total billed charges,Implant Device,5259.38,,,5259.38,Other,110% of Medicare,3718.75,35,,3718.75,percent of total billed charges,Implant Device,3612.5,34,"Charges > $500, x 34%",3612.5,percent of total billed charges,Implant Device,3718.75,35,,3718.75,percent of total billed charges,Implant Device,3718.75,35,,3718.75,percent of total billed charges,Implant Device,3718.75,35,,3718.75,percent of total billed charges,Implant Device,3718.75,35,,3718.75,percent of total billed charges,Implant Device,3718.75,35,,3718.75,percent of total billed charges,Implant Device,4250,40,,4250,percent of total billed charges,Implant Device,3718.75,70,,3718.75,percent of total billed charges,All Other,3612.5,34,,3612.5,percent of total billed charges,Implant Device,3612.5,34,,3612.5,percent of total billed charges,Implant Device,3718.75,35,,3718.75,percent of total billed charges,Implant Device,3718.75,35,,3718.75,percent of total billed charges,Implant Device,3718.75,35,,3718.75,percent of total billed charges,Implant Device,3718.75,35,,3718.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3612.5,34,"If Charge > 2,000, then 34 percent",3612.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,7862.53,
ACUMED TR-S0902-S STEM 9.0X2.0MM,C1776,HCPCS,,79010305,CDM,278,RC,,,both,,,6951,5143.76,,,5143.76,Other,150% of Medicare + 9.63% HCRA Surcharge,3127.95,45,,3127.95,percent of total billed charges,Critical Access Hospital RCC factor,2363.34,34,,2363.34,percent of total billed charges,Implant Device,2363.34,34,,2363.34,percent of total billed charges,Implant Device,2363.34,34,,2363.34,percent of total billed charges,Implant Device,2363.34,34,,2363.34,percent of total billed charges,Implant Device,2363.34,34,,2363.34,percent of total billed charges,Implant Device,3440.75,,,3440.75,Other,110% of Medicare,2432.85,35,,2432.85,percent of total billed charges,Implant Device,2363.34,34,"Charges > $500, x 34%",2363.34,percent of total billed charges,Implant Device,2432.85,35,,2432.85,percent of total billed charges,Implant Device,2432.85,35,,2432.85,percent of total billed charges,Implant Device,2432.85,35,,2432.85,percent of total billed charges,Implant Device,2432.85,35,,2432.85,percent of total billed charges,Implant Device,2432.85,35,,2432.85,percent of total billed charges,Implant Device,2780.4,40,,2780.4,percent of total billed charges,Implant Device,2432.85,70,,2432.85,percent of total billed charges,All Other,2363.34,34,,2363.34,percent of total billed charges,Implant Device,2363.34,34,,2363.34,percent of total billed charges,Implant Device,2432.85,35,,2432.85,percent of total billed charges,Implant Device,2432.85,35,,2432.85,percent of total billed charges,Implant Device,2432.85,35,,2432.85,percent of total billed charges,Implant Device,2432.85,35,,2432.85,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2363.34,34,"If Charge > 2,000, then 34 percent",2363.34,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5143.76,
ZIMMER 00-7711-009-10 FEM STEM SIZE 9,C1776,HCPCS,,79010306,CDM,278,RC,,,both,,,6912,5114.9,,,5114.9,Other,150% of Medicare + 9.63% HCRA Surcharge,3110.4,45,,3110.4,percent of total billed charges,Critical Access Hospital RCC factor,2350.08,34,,2350.08,percent of total billed charges,Implant Device,2350.08,34,,2350.08,percent of total billed charges,Implant Device,2350.08,34,,2350.08,percent of total billed charges,Implant Device,2350.08,34,,2350.08,percent of total billed charges,Implant Device,2350.08,34,,2350.08,percent of total billed charges,Implant Device,3421.44,,,3421.44,Other,110% of Medicare,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2350.08,34,"Charges > $500, x 34%",2350.08,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2764.8,40,,2764.8,percent of total billed charges,Implant Device,2419.2,70,,2419.2,percent of total billed charges,All Other,2350.08,34,,2350.08,percent of total billed charges,Implant Device,2350.08,34,,2350.08,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2350.08,34,"If Charge > 2,000, then 34 percent",2350.08,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5114.9,
ZIMMER 00-5988-004-39 TIB AUG BLOCK 20MM,C1776,HCPCS,,79010308,CDM,278,RC,,,both,,,3456,2557.45,,,2557.45,Other,150% of Medicare + 9.63% HCRA Surcharge,1555.2,45,,1555.2,percent of total billed charges,Critical Access Hospital RCC factor,1175.04,34,,1175.04,percent of total billed charges,Implant Device,1175.04,34,,1175.04,percent of total billed charges,Implant Device,1175.04,34,,1175.04,percent of total billed charges,Implant Device,1175.04,34,,1175.04,percent of total billed charges,Implant Device,1175.04,34,,1175.04,percent of total billed charges,Implant Device,1710.72,,,1710.72,Other,110% of Medicare,1209.6,35,,1209.6,percent of total billed charges,Implant Device,1175.04,34,"Charges > $500, x 34%",1175.04,percent of total billed charges,Implant Device,1209.6,35,,1209.6,percent of total billed charges,Implant Device,1209.6,35,,1209.6,percent of total billed charges,Implant Device,1209.6,35,,1209.6,percent of total billed charges,Implant Device,1209.6,35,,1209.6,percent of total billed charges,Implant Device,1209.6,35,,1209.6,percent of total billed charges,Implant Device,1382.4,40,,1382.4,percent of total billed charges,Implant Device,1209.6,70,,1209.6,percent of total billed charges,All Other,1175.04,34,,1175.04,percent of total billed charges,Implant Device,1175.04,34,,1175.04,percent of total billed charges,Implant Device,1209.6,35,,1209.6,percent of total billed charges,Implant Device,1209.6,35,,1209.6,percent of total billed charges,Implant Device,1209.6,35,,1209.6,percent of total billed charges,Implant Device,1209.6,35,,1209.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1175.04,34,"If Charge > 2,000, then 34 percent",1175.04,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2557.45,
DEPUY 02.112.018 CLAVICLE PLT 3.5X123MM,C1713,HCPCS,,79010309,CDM,278,RC,,,both,,,2459,1819.67,,,1819.67,Other,150% of Medicare + 9.63% HCRA Surcharge,1106.55,45,,1106.55,percent of total billed charges,Critical Access Hospital RCC factor,836.06,34,,836.06,percent of total billed charges,Implant Device,836.06,34,,836.06,percent of total billed charges,Implant Device,836.06,34,,836.06,percent of total billed charges,Implant Device,836.06,34,,836.06,percent of total billed charges,Implant Device,836.06,34,,836.06,percent of total billed charges,Implant Device,1217.21,,,1217.21,Other,110% of Medicare,860.65,35,,860.65,percent of total billed charges,Implant Device,836.06,34,"Charges > $500, x 34%",836.06,percent of total billed charges,Implant Device,860.65,35,,860.65,percent of total billed charges,Implant Device,860.65,35,,860.65,percent of total billed charges,Implant Device,860.65,35,,860.65,percent of total billed charges,Implant Device,860.65,35,,860.65,percent of total billed charges,Implant Device,860.65,35,,860.65,percent of total billed charges,Implant Device,983.6,40,,983.6,percent of total billed charges,Implant Device,860.65,70,,860.65,percent of total billed charges,All Other,836.06,34,,836.06,percent of total billed charges,Implant Device,836.06,34,,836.06,percent of total billed charges,Implant Device,860.65,35,,860.65,percent of total billed charges,Implant Device,860.65,35,,860.65,percent of total billed charges,Implant Device,860.65,35,,860.65,percent of total billed charges,Implant Device,860.65,35,,860.65,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,836.06,34,"If Charge > 2,000, then 34 percent",836.06,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1819.67,
IN2BONES P67 ST428 COLAG SCREW 4X28MM,C1713,HCPCS,,79010310,CDM,278,RC,,,both,,,1485,1098.9,,,1098.9,Other,150% of Medicare + 9.63% HCRA Surcharge,668.25,45,,668.25,percent of total billed charges,Critical Access Hospital RCC factor,504.9,34,,504.9,percent of total billed charges,Implant Device,504.9,34,,504.9,percent of total billed charges,Implant Device,504.9,34,,504.9,percent of total billed charges,Implant Device,504.9,34,,504.9,percent of total billed charges,Implant Device,504.9,34,,504.9,percent of total billed charges,Implant Device,735.08,,,735.08,Other,110% of Medicare,519.75,35,,519.75,percent of total billed charges,Implant Device,504.9,34,"Charges > $500, x 34%",504.9,percent of total billed charges,Implant Device,519.75,35,,519.75,percent of total billed charges,Implant Device,519.75,35,,519.75,percent of total billed charges,Implant Device,519.75,35,,519.75,percent of total billed charges,Implant Device,519.75,35,,519.75,percent of total billed charges,Implant Device,519.75,35,,519.75,percent of total billed charges,Implant Device,594,40,,594,percent of total billed charges,Implant Device,519.75,70,,519.75,percent of total billed charges,All Other,504.9,34,,504.9,percent of total billed charges,Implant Device,504.9,34,,504.9,percent of total billed charges,Implant Device,519.75,35,,519.75,percent of total billed charges,Implant Device,519.75,35,,519.75,percent of total billed charges,Implant Device,519.75,35,,519.75,percent of total billed charges,Implant Device,519.75,35,,519.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1098.9,
MIMEDX GS-5440 EPIFIX 4X4CM,Q4186,HCPCS,,79010311,CDM,278,RC,,,both,,,8685,6426.92,,,6426.92,Other,150% of Medicare + 9.63% HCRA Surcharge,3908.25,45,,3908.25,percent of total billed charges,Critical Access Hospital RCC factor,2952.9,34,,2952.9,percent of total billed charges,Implant Device,2952.9,34,,2952.9,percent of total billed charges,Implant Device,2952.9,34,,2952.9,percent of total billed charges,Implant Device,2952.9,34,,2952.9,percent of total billed charges,Implant Device,2952.9,34,,2952.9,percent of total billed charges,Implant Device,4299.08,,,4299.08,Other,110% of Medicare,3039.75,35,,3039.75,percent of total billed charges,Implant Device,2952.9,34,"Charges > $500, x 34%",2952.9,percent of total billed charges,Implant Device,3039.75,35,,3039.75,percent of total billed charges,Implant Device,3039.75,35,,3039.75,percent of total billed charges,Implant Device,3039.75,35,,3039.75,percent of total billed charges,Implant Device,3039.75,35,,3039.75,percent of total billed charges,Implant Device,3039.75,35,,3039.75,percent of total billed charges,Implant Device,3474,40,,3474,percent of total billed charges,Implant Device,3039.75,70,,3039.75,percent of total billed charges,All Other,2952.9,34,,2952.9,percent of total billed charges,Implant Device,2952.9,34,,2952.9,percent of total billed charges,Implant Device,3039.75,35,,3039.75,percent of total billed charges,Implant Device,3039.75,35,,3039.75,percent of total billed charges,Implant Device,3039.75,35,,3039.75,percent of total billed charges,Implant Device,3039.75,35,,3039.75,percent of total billed charges,Implant Device,976.07,,,976.07,Other,100% of Medicaid,976.07,,,976.07,Other,100% of Medicaid,976.07,,,976.07,Other,100% of Medicaid,976.07,,,976.07,Other,100% of Medicaid,2196.16,,,2196.16,Other,225% of Medicaid,1493.39,,,1493.39,Other,153% of Medicaid,2196.16,,,2196.16,Other,225% of Medicaid,1366.5,,,1366.5,Other,140% of Medicaid,2952.9,34,"If Charge > 2,000, then 34 percent",2952.9,percent of total billed charges,Implants,2537.78,,,2537.78,Other,260% of Medicaid,3162.47,,,3162.47,Other,324% of Medicaid,2098.55,,,2098.55,Other,215% of Medicaid,2098.55,,,2098.55,Other,215% of Medicaid,1220.09,,,1220.09,Other,125% of Medicaid,976.07,6426.92,
ZIMMER 00-5976-040-17 ART SURF SZ 17MM,C1776,HCPCS,,79010312,CDM,278,RC,,,both,,,2250,1665.01,,,1665.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1012.5,45,,1012.5,percent of total billed charges,Critical Access Hospital RCC factor,765,34,,765,percent of total billed charges,Implant Device,765,34,,765,percent of total billed charges,Implant Device,765,34,,765,percent of total billed charges,Implant Device,765,34,,765,percent of total billed charges,Implant Device,765,34,,765,percent of total billed charges,Implant Device,1113.75,,,1113.75,Other,110% of Medicare,787.5,35,,787.5,percent of total billed charges,Implant Device,765,34,"Charges > $500, x 34%",765,percent of total billed charges,Implant Device,787.5,35,,787.5,percent of total billed charges,Implant Device,787.5,35,,787.5,percent of total billed charges,Implant Device,787.5,35,,787.5,percent of total billed charges,Implant Device,787.5,35,,787.5,percent of total billed charges,Implant Device,787.5,35,,787.5,percent of total billed charges,Implant Device,900,40,,900,percent of total billed charges,Implant Device,787.5,70,,787.5,percent of total billed charges,All Other,765,34,,765,percent of total billed charges,Implant Device,765,34,,765,percent of total billed charges,Implant Device,787.5,35,,787.5,percent of total billed charges,Implant Device,787.5,35,,787.5,percent of total billed charges,Implant Device,787.5,35,,787.5,percent of total billed charges,Implant Device,787.5,35,,787.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,765,34,"If Charge > 2,000, then 34 percent",765,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1665.01,
STRYKER 3425-1380S NAIL KIT 11X380MMX125,C1713,HCPCS,,79010313,CDM,278,RC,,,both,,,5438,4024.13,,,4024.13,Other,150% of Medicare + 9.63% HCRA Surcharge,2447.1,45,,2447.1,percent of total billed charges,Critical Access Hospital RCC factor,1848.92,34,,1848.92,percent of total billed charges,Implant Device,1848.92,34,,1848.92,percent of total billed charges,Implant Device,1848.92,34,,1848.92,percent of total billed charges,Implant Device,1848.92,34,,1848.92,percent of total billed charges,Implant Device,1848.92,34,,1848.92,percent of total billed charges,Implant Device,2691.81,,,2691.81,Other,110% of Medicare,1903.3,35,,1903.3,percent of total billed charges,Implant Device,1848.92,34,"Charges > $500, x 34%",1848.92,percent of total billed charges,Implant Device,1903.3,35,,1903.3,percent of total billed charges,Implant Device,1903.3,35,,1903.3,percent of total billed charges,Implant Device,1903.3,35,,1903.3,percent of total billed charges,Implant Device,1903.3,35,,1903.3,percent of total billed charges,Implant Device,1903.3,35,,1903.3,percent of total billed charges,Implant Device,2175.2,40,,2175.2,percent of total billed charges,Implant Device,1903.3,70,,1903.3,percent of total billed charges,All Other,1848.92,34,,1848.92,percent of total billed charges,Implant Device,1848.92,34,,1848.92,percent of total billed charges,Implant Device,1903.3,35,,1903.3,percent of total billed charges,Implant Device,1903.3,35,,1903.3,percent of total billed charges,Implant Device,1903.3,35,,1903.3,percent of total billed charges,Implant Device,1903.3,35,,1903.3,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1848.92,34,"If Charge > 2,000, then 34 percent",1848.92,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4024.13,
STRYKER 5530-G-409-E TIB INSERT SZ 4 9MM,C1776,HCPCS,,79010314,CDM,278,RC,,,both,,,3300,2442.01,,,2442.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1485,45,,1485,percent of total billed charges,Critical Access Hospital RCC factor,1122,34,,1122,percent of total billed charges,Implant Device,1122,34,,1122,percent of total billed charges,Implant Device,1122,34,,1122,percent of total billed charges,Implant Device,1122,34,,1122,percent of total billed charges,Implant Device,1122,34,,1122,percent of total billed charges,Implant Device,1633.5,,,1633.5,Other,110% of Medicare,1155,35,,1155,percent of total billed charges,Implant Device,1122,34,"Charges > $500, x 34%",1122,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,1320,40,,1320,percent of total billed charges,Implant Device,1155,70,,1155,percent of total billed charges,All Other,1122,34,,1122,percent of total billed charges,Implant Device,1122,34,,1122,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1122,34,"If Charge > 2,000, then 34 percent",1122,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2442.01,
DJO 241-01-105 FEMUR SIZE 5 LEFT,C1776,HCPCS,,79010315,CDM,278,RC,,,both,,,7500,5550.02,,,5550.02,Other,150% of Medicare + 9.63% HCRA Surcharge,3375,45,,3375,percent of total billed charges,Critical Access Hospital RCC factor,2550,34,,2550,percent of total billed charges,Implant Device,2550,34,,2550,percent of total billed charges,Implant Device,2550,34,,2550,percent of total billed charges,Implant Device,2550,34,,2550,percent of total billed charges,Implant Device,2550,34,,2550,percent of total billed charges,Implant Device,3712.5,,,3712.5,Other,110% of Medicare,2625,35,,2625,percent of total billed charges,Implant Device,2550,34,"Charges > $500, x 34%",2550,percent of total billed charges,Implant Device,2625,35,,2625,percent of total billed charges,Implant Device,2625,35,,2625,percent of total billed charges,Implant Device,2625,35,,2625,percent of total billed charges,Implant Device,2625,35,,2625,percent of total billed charges,Implant Device,2625,35,,2625,percent of total billed charges,Implant Device,3000,40,,3000,percent of total billed charges,Implant Device,2625,70,,2625,percent of total billed charges,All Other,2550,34,,2550,percent of total billed charges,Implant Device,2550,34,,2550,percent of total billed charges,Implant Device,2625,35,,2625,percent of total billed charges,Implant Device,2625,35,,2625,percent of total billed charges,Implant Device,2625,35,,2625,percent of total billed charges,Implant Device,2625,35,,2625,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2550,34,"If Charge > 2,000, then 34 percent",2550,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5550.02,
DJO 341-10-705 TIBIAL INSERT SIZE 5 10MM,C1776,HCPCS,,79010316,CDM,278,RC,,,both,,,3000,2220.01,,,2220.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1350,45,,1350,percent of total billed charges,Critical Access Hospital RCC factor,1020,34,,1020,percent of total billed charges,Implant Device,1020,34,,1020,percent of total billed charges,Implant Device,1020,34,,1020,percent of total billed charges,Implant Device,1020,34,,1020,percent of total billed charges,Implant Device,1020,34,,1020,percent of total billed charges,Implant Device,1485,,,1485,Other,110% of Medicare,1050,35,,1050,percent of total billed charges,Implant Device,1020,34,"Charges > $500, x 34%",1020,percent of total billed charges,Implant Device,1050,35,,1050,percent of total billed charges,Implant Device,1050,35,,1050,percent of total billed charges,Implant Device,1050,35,,1050,percent of total billed charges,Implant Device,1050,35,,1050,percent of total billed charges,Implant Device,1050,35,,1050,percent of total billed charges,Implant Device,1200,40,,1200,percent of total billed charges,Implant Device,1050,70,,1050,percent of total billed charges,All Other,1020,34,,1020,percent of total billed charges,Implant Device,1020,34,,1020,percent of total billed charges,Implant Device,1050,35,,1050,percent of total billed charges,Implant Device,1050,35,,1050,percent of total billed charges,Implant Device,1050,35,,1050,percent of total billed charges,Implant Device,1050,35,,1050,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1020,34,"If Charge > 2,000, then 34 percent",1020,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2220.01,
DJO 241-01-106 FEMUR SIZE 6 LEFT,C1776,HCPCS,,79010317,CDM,278,RC,,,both,,,7500,5550.02,,,5550.02,Other,150% of Medicare + 9.63% HCRA Surcharge,3375,45,,3375,percent of total billed charges,Critical Access Hospital RCC factor,2550,34,,2550,percent of total billed charges,Implant Device,2550,34,,2550,percent of total billed charges,Implant Device,2550,34,,2550,percent of total billed charges,Implant Device,2550,34,,2550,percent of total billed charges,Implant Device,2550,34,,2550,percent of total billed charges,Implant Device,3712.5,,,3712.5,Other,110% of Medicare,2625,35,,2625,percent of total billed charges,Implant Device,2550,34,"Charges > $500, x 34%",2550,percent of total billed charges,Implant Device,2625,35,,2625,percent of total billed charges,Implant Device,2625,35,,2625,percent of total billed charges,Implant Device,2625,35,,2625,percent of total billed charges,Implant Device,2625,35,,2625,percent of total billed charges,Implant Device,2625,35,,2625,percent of total billed charges,Implant Device,3000,40,,3000,percent of total billed charges,Implant Device,2625,70,,2625,percent of total billed charges,All Other,2550,34,,2550,percent of total billed charges,Implant Device,2550,34,,2550,percent of total billed charges,Implant Device,2625,35,,2625,percent of total billed charges,Implant Device,2625,35,,2625,percent of total billed charges,Implant Device,2625,35,,2625,percent of total billed charges,Implant Device,2625,35,,2625,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2550,34,"If Charge > 2,000, then 34 percent",2550,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5550.02,
DJO 341-10-706 TIBIAL INSERT SIZE 6 10MM,C1776,HCPCS,,79010318,CDM,278,RC,,,both,,,3000,2220.01,,,2220.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1350,45,,1350,percent of total billed charges,Critical Access Hospital RCC factor,1020,34,,1020,percent of total billed charges,Implant Device,1020,34,,1020,percent of total billed charges,Implant Device,1020,34,,1020,percent of total billed charges,Implant Device,1020,34,,1020,percent of total billed charges,Implant Device,1020,34,,1020,percent of total billed charges,Implant Device,1485,,,1485,Other,110% of Medicare,1050,35,,1050,percent of total billed charges,Implant Device,1020,34,"Charges > $500, x 34%",1020,percent of total billed charges,Implant Device,1050,35,,1050,percent of total billed charges,Implant Device,1050,35,,1050,percent of total billed charges,Implant Device,1050,35,,1050,percent of total billed charges,Implant Device,1050,35,,1050,percent of total billed charges,Implant Device,1050,35,,1050,percent of total billed charges,Implant Device,1200,40,,1200,percent of total billed charges,Implant Device,1050,70,,1050,percent of total billed charges,All Other,1020,34,,1020,percent of total billed charges,Implant Device,1020,34,,1020,percent of total billed charges,Implant Device,1050,35,,1050,percent of total billed charges,Implant Device,1050,35,,1050,percent of total billed charges,Implant Device,1050,35,,1050,percent of total billed charges,Implant Device,1050,35,,1050,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1020,34,"If Charge > 2,000, then 34 percent",1020,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2220.01,
DJO 351-03-106 BASEPLATE SIZE 6 LEFT,C1776,HCPCS,,79010319,CDM,278,RC,,,both,,,4500,3330.01,,,3330.01,Other,150% of Medicare + 9.63% HCRA Surcharge,2025,45,,2025,percent of total billed charges,Critical Access Hospital RCC factor,1530,34,,1530,percent of total billed charges,Implant Device,1530,34,,1530,percent of total billed charges,Implant Device,1530,34,,1530,percent of total billed charges,Implant Device,1530,34,,1530,percent of total billed charges,Implant Device,1530,34,,1530,percent of total billed charges,Implant Device,2227.5,,,2227.5,Other,110% of Medicare,1575,35,,1575,percent of total billed charges,Implant Device,1530,34,"Charges > $500, x 34%",1530,percent of total billed charges,Implant Device,1575,35,,1575,percent of total billed charges,Implant Device,1575,35,,1575,percent of total billed charges,Implant Device,1575,35,,1575,percent of total billed charges,Implant Device,1575,35,,1575,percent of total billed charges,Implant Device,1575,35,,1575,percent of total billed charges,Implant Device,1800,40,,1800,percent of total billed charges,Implant Device,1575,70,,1575,percent of total billed charges,All Other,1530,34,,1530,percent of total billed charges,Implant Device,1530,34,,1530,percent of total billed charges,Implant Device,1575,35,,1575,percent of total billed charges,Implant Device,1575,35,,1575,percent of total billed charges,Implant Device,1575,35,,1575,percent of total billed charges,Implant Device,1575,35,,1575,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1530,34,"If Charge > 2,000, then 34 percent",1530,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3330.01,
ARTHREX AR-8643-34 HEADLESS SCRW 4.3X34,C1713,HCPCS,,79010322,CDM,278,RC,,,both,,,1608,1189.92,,,1189.92,Other,150% of Medicare + 9.63% HCRA Surcharge,723.6,45,,723.6,percent of total billed charges,Critical Access Hospital RCC factor,546.72,34,,546.72,percent of total billed charges,Implant Device,546.72,34,,546.72,percent of total billed charges,Implant Device,546.72,34,,546.72,percent of total billed charges,Implant Device,546.72,34,,546.72,percent of total billed charges,Implant Device,546.72,34,,546.72,percent of total billed charges,Implant Device,795.96,,,795.96,Other,110% of Medicare,562.8,35,,562.8,percent of total billed charges,Implant Device,546.72,34,"Charges > $500, x 34%",546.72,percent of total billed charges,Implant Device,562.8,35,,562.8,percent of total billed charges,Implant Device,562.8,35,,562.8,percent of total billed charges,Implant Device,562.8,35,,562.8,percent of total billed charges,Implant Device,562.8,35,,562.8,percent of total billed charges,Implant Device,562.8,35,,562.8,percent of total billed charges,Implant Device,643.2,40,,643.2,percent of total billed charges,Implant Device,562.8,70,,562.8,percent of total billed charges,All Other,546.72,34,,546.72,percent of total billed charges,Implant Device,546.72,34,,546.72,percent of total billed charges,Implant Device,562.8,35,,562.8,percent of total billed charges,Implant Device,562.8,35,,562.8,percent of total billed charges,Implant Device,562.8,35,,562.8,percent of total billed charges,Implant Device,562.8,35,,562.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1189.92,
ARTHREX AR-8643-36 HEADLESS SCRW 4.3X36,C1713,HCPCS,,79010323,CDM,278,RC,,,both,,,1608,1189.92,,,1189.92,Other,150% of Medicare + 9.63% HCRA Surcharge,723.6,45,,723.6,percent of total billed charges,Critical Access Hospital RCC factor,546.72,34,,546.72,percent of total billed charges,Implant Device,546.72,34,,546.72,percent of total billed charges,Implant Device,546.72,34,,546.72,percent of total billed charges,Implant Device,546.72,34,,546.72,percent of total billed charges,Implant Device,546.72,34,,546.72,percent of total billed charges,Implant Device,795.96,,,795.96,Other,110% of Medicare,562.8,35,,562.8,percent of total billed charges,Implant Device,546.72,34,"Charges > $500, x 34%",546.72,percent of total billed charges,Implant Device,562.8,35,,562.8,percent of total billed charges,Implant Device,562.8,35,,562.8,percent of total billed charges,Implant Device,562.8,35,,562.8,percent of total billed charges,Implant Device,562.8,35,,562.8,percent of total billed charges,Implant Device,562.8,35,,562.8,percent of total billed charges,Implant Device,643.2,40,,643.2,percent of total billed charges,Implant Device,562.8,70,,562.8,percent of total billed charges,All Other,546.72,34,,546.72,percent of total billed charges,Implant Device,546.72,34,,546.72,percent of total billed charges,Implant Device,562.8,35,,562.8,percent of total billed charges,Implant Device,562.8,35,,562.8,percent of total billed charges,Implant Device,562.8,35,,562.8,percent of total billed charges,Implant Device,562.8,35,,562.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1189.92,
ZIMMER 00-8851-016-36 LINER 36MM SZ 00,C1776,HCPCS,,79010324,CDM,278,RC,,,both,,,3456,2557.45,,,2557.45,Other,150% of Medicare + 9.63% HCRA Surcharge,1555.2,45,,1555.2,percent of total billed charges,Critical Access Hospital RCC factor,1175.04,34,,1175.04,percent of total billed charges,Implant Device,1175.04,34,,1175.04,percent of total billed charges,Implant Device,1175.04,34,,1175.04,percent of total billed charges,Implant Device,1175.04,34,,1175.04,percent of total billed charges,Implant Device,1175.04,34,,1175.04,percent of total billed charges,Implant Device,1710.72,,,1710.72,Other,110% of Medicare,1209.6,35,,1209.6,percent of total billed charges,Implant Device,1175.04,34,"Charges > $500, x 34%",1175.04,percent of total billed charges,Implant Device,1209.6,35,,1209.6,percent of total billed charges,Implant Device,1209.6,35,,1209.6,percent of total billed charges,Implant Device,1209.6,35,,1209.6,percent of total billed charges,Implant Device,1209.6,35,,1209.6,percent of total billed charges,Implant Device,1209.6,35,,1209.6,percent of total billed charges,Implant Device,1382.4,40,,1382.4,percent of total billed charges,Implant Device,1209.6,70,,1209.6,percent of total billed charges,All Other,1175.04,34,,1175.04,percent of total billed charges,Implant Device,1175.04,34,,1175.04,percent of total billed charges,Implant Device,1209.6,35,,1209.6,percent of total billed charges,Implant Device,1209.6,35,,1209.6,percent of total billed charges,Implant Device,1209.6,35,,1209.6,percent of total billed charges,Implant Device,1209.6,35,,1209.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1175.04,34,"If Charge > 2,000, then 34 percent",1175.04,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2557.45,
ARTHREX AR-8941PS KNOTLESS CORKSCREW 3.9,C1713,HCPCS,,79010325,CDM,278,RC,,,both,,,1650,1221,,,1221,Other,150% of Medicare + 9.63% HCRA Surcharge,742.5,45,,742.5,percent of total billed charges,Critical Access Hospital RCC factor,561,34,,561,percent of total billed charges,Implant Device,561,34,,561,percent of total billed charges,Implant Device,561,34,,561,percent of total billed charges,Implant Device,561,34,,561,percent of total billed charges,Implant Device,561,34,,561,percent of total billed charges,Implant Device,816.75,,,816.75,Other,110% of Medicare,577.5,35,,577.5,percent of total billed charges,Implant Device,561,34,"Charges > $500, x 34%",561,percent of total billed charges,Implant Device,577.5,35,,577.5,percent of total billed charges,Implant Device,577.5,35,,577.5,percent of total billed charges,Implant Device,577.5,35,,577.5,percent of total billed charges,Implant Device,577.5,35,,577.5,percent of total billed charges,Implant Device,577.5,35,,577.5,percent of total billed charges,Implant Device,660,40,,660,percent of total billed charges,Implant Device,577.5,70,,577.5,percent of total billed charges,All Other,561,34,,561,percent of total billed charges,Implant Device,561,34,,561,percent of total billed charges,Implant Device,577.5,35,,577.5,percent of total billed charges,Implant Device,577.5,35,,577.5,percent of total billed charges,Implant Device,577.5,35,,577.5,percent of total billed charges,Implant Device,577.5,35,,577.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1221,
ARTHREX AR-1941PS CORKSCREW 3.9X11.2MM,C1713,HCPCS,,79010344,CDM,278,RC,,,both,,,1155,854.7,,,854.7,Other,150% of Medicare + 9.63% HCRA Surcharge,519.75,45,,519.75,percent of total billed charges,Critical Access Hospital RCC factor,392.7,34,,392.7,percent of total billed charges,Implant Device,392.7,34,,392.7,percent of total billed charges,Implant Device,392.7,34,,392.7,percent of total billed charges,Implant Device,392.7,34,,392.7,percent of total billed charges,Implant Device,392.7,34,,392.7,percent of total billed charges,Implant Device,571.73,,,571.73,Other,110% of Medicare,404.25,35,,404.25,percent of total billed charges,Implant Device,392.7,34,"Charges > $500, x 34%",392.7,percent of total billed charges,Implant Device,404.25,35,,404.25,percent of total billed charges,Implant Device,404.25,35,,404.25,percent of total billed charges,Implant Device,404.25,35,,404.25,percent of total billed charges,Implant Device,404.25,35,,404.25,percent of total billed charges,Implant Device,404.25,35,,404.25,percent of total billed charges,Implant Device,462,40,,462,percent of total billed charges,Implant Device,404.25,70,,404.25,percent of total billed charges,All Other,392.7,34,,392.7,percent of total billed charges,Implant Device,392.7,34,,392.7,percent of total billed charges,Implant Device,404.25,35,,404.25,percent of total billed charges,Implant Device,404.25,35,,404.25,percent of total billed charges,Implant Device,404.25,35,,404.25,percent of total billed charges,Implant Device,404.25,35,,404.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,854.7,
ALLERGAN SCL-140 BREAST IMPLANT 140CC,C1789,HCPCS,,79010349,CDM,278,RC,,,both,,,4005,2963.71,,,2963.71,Other,150% of Medicare + 9.63% HCRA Surcharge,1802.25,45,,1802.25,percent of total billed charges,Critical Access Hospital RCC factor,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1982.48,,,1982.48,Other,110% of Medicare,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1361.7,34,"Charges > $500, x 34%",1361.7,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1602,40,,1602,percent of total billed charges,Implant Device,1401.75,70,,1401.75,percent of total billed charges,All Other,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1361.7,34,"If Charge > 2,000, then 34 percent",1361.7,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2963.71,
DEPUY 458.948S 5.0X48MM TI LOCK SCREW,C1713,HCPCS,,79010351,CDM,278,RC,,,both,,,456,337.44,,,337.44,Other,150% of Medicare + 9.63% HCRA Surcharge,205.2,45,,205.2,percent of total billed charges,Critical Access Hospital RCC factor,155.04,34,,155.04,percent of total billed charges,Implant Device,155.04,34,,155.04,percent of total billed charges,Implant Device,155.04,34,,155.04,percent of total billed charges,Implant Device,155.04,34,,155.04,percent of total billed charges,Implant Device,155.04,34,,155.04,percent of total billed charges,Implant Device,225.72,,,225.72,Other,110% of Medicare,159.6,35,,159.6,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,159.6,35,,159.6,percent of total billed charges,Implant Device,159.6,35,,159.6,percent of total billed charges,Implant Device,159.6,35,,159.6,percent of total billed charges,Implant Device,159.6,35,,159.6,percent of total billed charges,Implant Device,159.6,35,,159.6,percent of total billed charges,Implant Device,182.4,40,,182.4,percent of total billed charges,Implant Device,159.6,70,,159.6,percent of total billed charges,All Other,155.04,34,,155.04,percent of total billed charges,Implant Device,155.04,34,,155.04,percent of total billed charges,Implant Device,159.6,35,,159.6,percent of total billed charges,Implant Device,159.6,35,,159.6,percent of total billed charges,Implant Device,159.6,35,,159.6,percent of total billed charges,Implant Device,159.6,35,,159.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,337.44,
DEPUY 456.418S 11X380MM TI FIX NAIL,C1713,HCPCS,,79010352,CDM,278,RC,,,both,,,364,269.36,,,269.36,Other,150% of Medicare + 9.63% HCRA Surcharge,163.8,45,,163.8,percent of total billed charges,Critical Access Hospital RCC factor,123.76,34,,123.76,percent of total billed charges,Implant Device,123.76,34,,123.76,percent of total billed charges,Implant Device,123.76,34,,123.76,percent of total billed charges,Implant Device,123.76,34,,123.76,percent of total billed charges,Implant Device,123.76,34,,123.76,percent of total billed charges,Implant Device,180.18,,,180.18,Other,110% of Medicare,127.4,35,,127.4,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,127.4,35,,127.4,percent of total billed charges,Implant Device,127.4,35,,127.4,percent of total billed charges,Implant Device,127.4,35,,127.4,percent of total billed charges,Implant Device,127.4,35,,127.4,percent of total billed charges,Implant Device,127.4,35,,127.4,percent of total billed charges,Implant Device,145.6,40,,145.6,percent of total billed charges,Implant Device,127.4,70,,127.4,percent of total billed charges,All Other,123.76,34,,123.76,percent of total billed charges,Implant Device,123.76,34,,123.76,percent of total billed charges,Implant Device,127.4,35,,127.4,percent of total billed charges,Implant Device,127.4,35,,127.4,percent of total billed charges,Implant Device,127.4,35,,127.4,percent of total billed charges,Implant Device,127.4,35,,127.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,269.36,
DEPUY 1365-36-730 FEM HEAD 12/14 36MM,C1776,HCPCS,,79010354,CDM,278,RC,,,both,,,8077,5977,,,5977,Other,150% of Medicare + 9.63% HCRA Surcharge,3634.65,45,,3634.65,percent of total billed charges,Critical Access Hospital RCC factor,2746.18,34,,2746.18,percent of total billed charges,Implant Device,2746.18,34,,2746.18,percent of total billed charges,Implant Device,2746.18,34,,2746.18,percent of total billed charges,Implant Device,2746.18,34,,2746.18,percent of total billed charges,Implant Device,2746.18,34,,2746.18,percent of total billed charges,Implant Device,3998.12,,,3998.12,Other,110% of Medicare,2826.95,35,,2826.95,percent of total billed charges,Implant Device,2746.18,34,"Charges > $500, x 34%",2746.18,percent of total billed charges,Implant Device,2826.95,35,,2826.95,percent of total billed charges,Implant Device,2826.95,35,,2826.95,percent of total billed charges,Implant Device,2826.95,35,,2826.95,percent of total billed charges,Implant Device,2826.95,35,,2826.95,percent of total billed charges,Implant Device,2826.95,35,,2826.95,percent of total billed charges,Implant Device,3230.8,40,,3230.8,percent of total billed charges,Implant Device,2826.95,70,,2826.95,percent of total billed charges,All Other,2746.18,34,,2746.18,percent of total billed charges,Implant Device,2746.18,34,,2746.18,percent of total billed charges,Implant Device,2826.95,35,,2826.95,percent of total billed charges,Implant Device,2826.95,35,,2826.95,percent of total billed charges,Implant Device,2826.95,35,,2826.95,percent of total billed charges,Implant Device,2826.95,35,,2826.95,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2746.18,34,"If Charge > 2,000, then 34 percent",2746.18,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5977,
BOST SCI M0061456170 7X20 URETERAL STENT,C1874,HCPCS,,79010355,CDM,278,RC,,,both,,,410,303.4,,,303.4,Other,150% of Medicare + 9.63% HCRA Surcharge,184.5,45,,184.5,percent of total billed charges,Critical Access Hospital RCC factor,139.4,34,,139.4,percent of total billed charges,Implant Device,139.4,34,,139.4,percent of total billed charges,Implant Device,139.4,34,,139.4,percent of total billed charges,Implant Device,139.4,34,,139.4,percent of total billed charges,Implant Device,139.4,34,,139.4,percent of total billed charges,Implant Device,202.95,,,202.95,Other,110% of Medicare,143.5,35,,143.5,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,143.5,35,,143.5,percent of total billed charges,Implant Device,143.5,35,,143.5,percent of total billed charges,Implant Device,143.5,35,,143.5,percent of total billed charges,Implant Device,143.5,35,,143.5,percent of total billed charges,Implant Device,143.5,35,,143.5,percent of total billed charges,Implant Device,164,40,,164,percent of total billed charges,Implant Device,143.5,70,,143.5,percent of total billed charges,All Other,139.4,34,,139.4,percent of total billed charges,Implant Device,139.4,34,,139.4,percent of total billed charges,Implant Device,143.5,35,,143.5,percent of total billed charges,Implant Device,143.5,35,,143.5,percent of total billed charges,Implant Device,143.5,35,,143.5,percent of total billed charges,Implant Device,143.5,35,,143.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,303.4,
BOST SCI M0061456500 7X22 URETERAL STENT,C1874,HCPCS,,79010356,CDM,278,RC,,,both,,,410,303.4,,,303.4,Other,150% of Medicare + 9.63% HCRA Surcharge,184.5,45,,184.5,percent of total billed charges,Critical Access Hospital RCC factor,139.4,34,,139.4,percent of total billed charges,Implant Device,139.4,34,,139.4,percent of total billed charges,Implant Device,139.4,34,,139.4,percent of total billed charges,Implant Device,139.4,34,,139.4,percent of total billed charges,Implant Device,139.4,34,,139.4,percent of total billed charges,Implant Device,202.95,,,202.95,Other,110% of Medicare,143.5,35,,143.5,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,143.5,35,,143.5,percent of total billed charges,Implant Device,143.5,35,,143.5,percent of total billed charges,Implant Device,143.5,35,,143.5,percent of total billed charges,Implant Device,143.5,35,,143.5,percent of total billed charges,Implant Device,143.5,35,,143.5,percent of total billed charges,Implant Device,164,40,,164,percent of total billed charges,Implant Device,143.5,70,,143.5,percent of total billed charges,All Other,139.4,34,,139.4,percent of total billed charges,Implant Device,139.4,34,,139.4,percent of total billed charges,Implant Device,143.5,35,,143.5,percent of total billed charges,Implant Device,143.5,35,,143.5,percent of total billed charges,Implant Device,143.5,35,,143.5,percent of total billed charges,Implant Device,143.5,35,,143.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,303.4,
BOST SCI M0061456510 7X24 URETERAL STENT,C1874,HCPCS,,79010357,CDM,278,RC,,,both,,,410,303.4,,,303.4,Other,150% of Medicare + 9.63% HCRA Surcharge,184.5,45,,184.5,percent of total billed charges,Critical Access Hospital RCC factor,139.4,34,,139.4,percent of total billed charges,Implant Device,139.4,34,,139.4,percent of total billed charges,Implant Device,139.4,34,,139.4,percent of total billed charges,Implant Device,139.4,34,,139.4,percent of total billed charges,Implant Device,139.4,34,,139.4,percent of total billed charges,Implant Device,202.95,,,202.95,Other,110% of Medicare,143.5,35,,143.5,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,143.5,35,,143.5,percent of total billed charges,Implant Device,143.5,35,,143.5,percent of total billed charges,Implant Device,143.5,35,,143.5,percent of total billed charges,Implant Device,143.5,35,,143.5,percent of total billed charges,Implant Device,143.5,35,,143.5,percent of total billed charges,Implant Device,164,40,,164,percent of total billed charges,Implant Device,143.5,70,,143.5,percent of total billed charges,All Other,139.4,34,,139.4,percent of total billed charges,Implant Device,139.4,34,,139.4,percent of total billed charges,Implant Device,143.5,35,,143.5,percent of total billed charges,Implant Device,143.5,35,,143.5,percent of total billed charges,Implant Device,143.5,35,,143.5,percent of total billed charges,Implant Device,143.5,35,,143.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,303.4,
BOST SCI M0061456520 7X26 URETERAL STENT,C1874,HCPCS,,79010358,CDM,278,RC,,,both,,,410,303.4,,,303.4,Other,150% of Medicare + 9.63% HCRA Surcharge,184.5,45,,184.5,percent of total billed charges,Critical Access Hospital RCC factor,139.4,34,,139.4,percent of total billed charges,Implant Device,139.4,34,,139.4,percent of total billed charges,Implant Device,139.4,34,,139.4,percent of total billed charges,Implant Device,139.4,34,,139.4,percent of total billed charges,Implant Device,139.4,34,,139.4,percent of total billed charges,Implant Device,202.95,,,202.95,Other,110% of Medicare,143.5,35,,143.5,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,143.5,35,,143.5,percent of total billed charges,Implant Device,143.5,35,,143.5,percent of total billed charges,Implant Device,143.5,35,,143.5,percent of total billed charges,Implant Device,143.5,35,,143.5,percent of total billed charges,Implant Device,143.5,35,,143.5,percent of total billed charges,Implant Device,164,40,,164,percent of total billed charges,Implant Device,143.5,70,,143.5,percent of total billed charges,All Other,139.4,34,,139.4,percent of total billed charges,Implant Device,139.4,34,,139.4,percent of total billed charges,Implant Device,143.5,35,,143.5,percent of total billed charges,Implant Device,143.5,35,,143.5,percent of total billed charges,Implant Device,143.5,35,,143.5,percent of total billed charges,Implant Device,143.5,35,,143.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,303.4,
BOST SCI M0061752820 8X24 URETERAL STENT,C1874,HCPCS,,79010359,CDM,278,RC,,,both,,,425,314.5,,,314.5,Other,150% of Medicare + 9.63% HCRA Surcharge,191.25,45,,191.25,percent of total billed charges,Critical Access Hospital RCC factor,144.5,34,,144.5,percent of total billed charges,Implant Device,144.5,34,,144.5,percent of total billed charges,Implant Device,144.5,34,,144.5,percent of total billed charges,Implant Device,144.5,34,,144.5,percent of total billed charges,Implant Device,144.5,34,,144.5,percent of total billed charges,Implant Device,210.38,,,210.38,Other,110% of Medicare,148.75,35,,148.75,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,148.75,35,,148.75,percent of total billed charges,Implant Device,148.75,35,,148.75,percent of total billed charges,Implant Device,148.75,35,,148.75,percent of total billed charges,Implant Device,148.75,35,,148.75,percent of total billed charges,Implant Device,148.75,35,,148.75,percent of total billed charges,Implant Device,170,40,,170,percent of total billed charges,Implant Device,148.75,70,,148.75,percent of total billed charges,All Other,144.5,34,,144.5,percent of total billed charges,Implant Device,144.5,34,,144.5,percent of total billed charges,Implant Device,148.75,35,,148.75,percent of total billed charges,Implant Device,148.75,35,,148.75,percent of total billed charges,Implant Device,148.75,35,,148.75,percent of total billed charges,Implant Device,148.75,35,,148.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,314.5,
BOST SCI M0061752830 8X26 URETERAL STENT,C1874,HCPCS,,79010360,CDM,278,RC,,,both,,,425,314.5,,,314.5,Other,150% of Medicare + 9.63% HCRA Surcharge,191.25,45,,191.25,percent of total billed charges,Critical Access Hospital RCC factor,144.5,34,,144.5,percent of total billed charges,Implant Device,144.5,34,,144.5,percent of total billed charges,Implant Device,144.5,34,,144.5,percent of total billed charges,Implant Device,144.5,34,,144.5,percent of total billed charges,Implant Device,144.5,34,,144.5,percent of total billed charges,Implant Device,210.38,,,210.38,Other,110% of Medicare,148.75,35,,148.75,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,148.75,35,,148.75,percent of total billed charges,Implant Device,148.75,35,,148.75,percent of total billed charges,Implant Device,148.75,35,,148.75,percent of total billed charges,Implant Device,148.75,35,,148.75,percent of total billed charges,Implant Device,148.75,35,,148.75,percent of total billed charges,Implant Device,170,40,,170,percent of total billed charges,Implant Device,148.75,70,,148.75,percent of total billed charges,All Other,144.5,34,,144.5,percent of total billed charges,Implant Device,144.5,34,,144.5,percent of total billed charges,Implant Device,148.75,35,,148.75,percent of total billed charges,Implant Device,148.75,35,,148.75,percent of total billed charges,Implant Device,148.75,35,,148.75,percent of total billed charges,Implant Device,148.75,35,,148.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,314.5,
ZIMMER 42-5570-001-14 STEM EXT 14X-30MM,C1776,HCPCS,,79010361,CDM,278,RC,,,both,,,5850,4329.01,,,4329.01,Other,150% of Medicare + 9.63% HCRA Surcharge,2632.5,45,,2632.5,percent of total billed charges,Critical Access Hospital RCC factor,1989,34,,1989,percent of total billed charges,Implant Device,1989,34,,1989,percent of total billed charges,Implant Device,1989,34,,1989,percent of total billed charges,Implant Device,1989,34,,1989,percent of total billed charges,Implant Device,1989,34,,1989,percent of total billed charges,Implant Device,2895.75,,,2895.75,Other,110% of Medicare,2047.5,35,,2047.5,percent of total billed charges,Implant Device,1989,34,"Charges > $500, x 34%",1989,percent of total billed charges,Implant Device,2047.5,35,,2047.5,percent of total billed charges,Implant Device,2047.5,35,,2047.5,percent of total billed charges,Implant Device,2047.5,35,,2047.5,percent of total billed charges,Implant Device,2047.5,35,,2047.5,percent of total billed charges,Implant Device,2047.5,35,,2047.5,percent of total billed charges,Implant Device,2340,40,,2340,percent of total billed charges,Implant Device,2047.5,70,,2047.5,percent of total billed charges,All Other,1989,34,,1989,percent of total billed charges,Implant Device,1989,34,,1989,percent of total billed charges,Implant Device,2047.5,35,,2047.5,percent of total billed charges,Implant Device,2047.5,35,,2047.5,percent of total billed charges,Implant Device,2047.5,35,,2047.5,percent of total billed charges,Implant Device,2047.5,35,,2047.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1989,34,"If Charge > 2,000, then 34 percent",1989,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4329.01,
ZIMMER 42-5400-000-32 PATELLA 32X8.5MM,C1776,HCPCS,,79010362,CDM,278,RC,,,both,,,1539,1138.86,,,1138.86,Other,150% of Medicare + 9.63% HCRA Surcharge,692.55,45,,692.55,percent of total billed charges,Critical Access Hospital RCC factor,523.26,34,,523.26,percent of total billed charges,Implant Device,523.26,34,,523.26,percent of total billed charges,Implant Device,523.26,34,,523.26,percent of total billed charges,Implant Device,523.26,34,,523.26,percent of total billed charges,Implant Device,523.26,34,,523.26,percent of total billed charges,Implant Device,761.81,,,761.81,Other,110% of Medicare,538.65,35,,538.65,percent of total billed charges,Implant Device,523.26,34,"Charges > $500, x 34%",523.26,percent of total billed charges,Implant Device,538.65,35,,538.65,percent of total billed charges,Implant Device,538.65,35,,538.65,percent of total billed charges,Implant Device,538.65,35,,538.65,percent of total billed charges,Implant Device,538.65,35,,538.65,percent of total billed charges,Implant Device,538.65,35,,538.65,percent of total billed charges,Implant Device,615.6,40,,615.6,percent of total billed charges,Implant Device,538.65,70,,538.65,percent of total billed charges,All Other,523.26,34,,523.26,percent of total billed charges,Implant Device,523.26,34,,523.26,percent of total billed charges,Implant Device,538.65,35,,538.65,percent of total billed charges,Implant Device,538.65,35,,538.65,percent of total billed charges,Implant Device,538.65,35,,538.65,percent of total billed charges,Implant Device,538.65,35,,538.65,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1138.86,
ZIMMER 42-5320-075-01 TIBIA LEFT SIZE F,C1776,HCPCS,,79010363,CDM,278,RC,,,both,,,2304,1704.97,,,1704.97,Other,150% of Medicare + 9.63% HCRA Surcharge,1036.8,45,,1036.8,percent of total billed charges,Critical Access Hospital RCC factor,783.36,34,,783.36,percent of total billed charges,Implant Device,783.36,34,,783.36,percent of total billed charges,Implant Device,783.36,34,,783.36,percent of total billed charges,Implant Device,783.36,34,,783.36,percent of total billed charges,Implant Device,783.36,34,,783.36,percent of total billed charges,Implant Device,1140.48,,,1140.48,Other,110% of Medicare,806.4,35,,806.4,percent of total billed charges,Implant Device,783.36,34,"Charges > $500, x 34%",783.36,percent of total billed charges,Implant Device,806.4,35,,806.4,percent of total billed charges,Implant Device,806.4,35,,806.4,percent of total billed charges,Implant Device,806.4,35,,806.4,percent of total billed charges,Implant Device,806.4,35,,806.4,percent of total billed charges,Implant Device,806.4,35,,806.4,percent of total billed charges,Implant Device,921.6,40,,921.6,percent of total billed charges,Implant Device,806.4,70,,806.4,percent of total billed charges,All Other,783.36,34,,783.36,percent of total billed charges,Implant Device,783.36,34,,783.36,percent of total billed charges,Implant Device,806.4,35,,806.4,percent of total billed charges,Implant Device,806.4,35,,806.4,percent of total billed charges,Implant Device,806.4,35,,806.4,percent of total billed charges,Implant Device,806.4,35,,806.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,783.36,34,"If Charge > 2,000, then 34 percent",783.36,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1704.97,
ZIMMER 42-5026-064-01 FEMUR LEFT SIZE 8,C1776,HCPCS,,79010364,CDM,278,RC,,,both,,,6300,4662.02,,,4662.02,Other,150% of Medicare + 9.63% HCRA Surcharge,2835,45,,2835,percent of total billed charges,Critical Access Hospital RCC factor,2142,34,,2142,percent of total billed charges,Implant Device,2142,34,,2142,percent of total billed charges,Implant Device,2142,34,,2142,percent of total billed charges,Implant Device,2142,34,,2142,percent of total billed charges,Implant Device,2142,34,,2142,percent of total billed charges,Implant Device,3118.5,,,3118.5,Other,110% of Medicare,2205,35,,2205,percent of total billed charges,Implant Device,2142,34,"Charges > $500, x 34%",2142,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2520,40,,2520,percent of total billed charges,Implant Device,2205,70,,2205,percent of total billed charges,All Other,2142,34,,2142,percent of total billed charges,Implant Device,2142,34,,2142,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2142,34,"If Charge > 2,000, then 34 percent",2142,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4662.02,
ZIMMER 42-5121-008-10 ACT SURF LT 10MM,C1776,HCPCS,,79010365,CDM,278,RC,,,both,,,3648,2699.53,,,2699.53,Other,150% of Medicare + 9.63% HCRA Surcharge,1641.6,45,,1641.6,percent of total billed charges,Critical Access Hospital RCC factor,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1805.76,,,1805.76,Other,110% of Medicare,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1240.32,34,"Charges > $500, x 34%",1240.32,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1459.2,40,,1459.2,percent of total billed charges,Implant Device,1276.8,70,,1276.8,percent of total billed charges,All Other,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1240.32,34,"If Charge > 2,000, then 34 percent",1240.32,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2699.53,
ZIMMER 42-5320-075-02 TIBIA RT SIZE F,C1776,HCPCS,,79010366,CDM,278,RC,,,both,,,2304,1704.97,,,1704.97,Other,150% of Medicare + 9.63% HCRA Surcharge,1036.8,45,,1036.8,percent of total billed charges,Critical Access Hospital RCC factor,783.36,34,,783.36,percent of total billed charges,Implant Device,783.36,34,,783.36,percent of total billed charges,Implant Device,783.36,34,,783.36,percent of total billed charges,Implant Device,783.36,34,,783.36,percent of total billed charges,Implant Device,783.36,34,,783.36,percent of total billed charges,Implant Device,1140.48,,,1140.48,Other,110% of Medicare,806.4,35,,806.4,percent of total billed charges,Implant Device,783.36,34,"Charges > $500, x 34%",783.36,percent of total billed charges,Implant Device,806.4,35,,806.4,percent of total billed charges,Implant Device,806.4,35,,806.4,percent of total billed charges,Implant Device,806.4,35,,806.4,percent of total billed charges,Implant Device,806.4,35,,806.4,percent of total billed charges,Implant Device,806.4,35,,806.4,percent of total billed charges,Implant Device,921.6,40,,921.6,percent of total billed charges,Implant Device,806.4,70,,806.4,percent of total billed charges,All Other,783.36,34,,783.36,percent of total billed charges,Implant Device,783.36,34,,783.36,percent of total billed charges,Implant Device,806.4,35,,806.4,percent of total billed charges,Implant Device,806.4,35,,806.4,percent of total billed charges,Implant Device,806.4,35,,806.4,percent of total billed charges,Implant Device,806.4,35,,806.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,783.36,34,"If Charge > 2,000, then 34 percent",783.36,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1704.97,
ZIMMER 42-5221-008-12 ART SURF RT 12MM,C1776,HCPCS,,79010367,CDM,278,RC,,,both,,,4116,3045.85,,,3045.85,Other,150% of Medicare + 9.63% HCRA Surcharge,1852.2,45,,1852.2,percent of total billed charges,Critical Access Hospital RCC factor,1399.44,34,,1399.44,percent of total billed charges,Implant Device,1399.44,34,,1399.44,percent of total billed charges,Implant Device,1399.44,34,,1399.44,percent of total billed charges,Implant Device,1399.44,34,,1399.44,percent of total billed charges,Implant Device,1399.44,34,,1399.44,percent of total billed charges,Implant Device,2037.42,,,2037.42,Other,110% of Medicare,1440.6,35,,1440.6,percent of total billed charges,Implant Device,1399.44,34,"Charges > $500, x 34%",1399.44,percent of total billed charges,Implant Device,1440.6,35,,1440.6,percent of total billed charges,Implant Device,1440.6,35,,1440.6,percent of total billed charges,Implant Device,1440.6,35,,1440.6,percent of total billed charges,Implant Device,1440.6,35,,1440.6,percent of total billed charges,Implant Device,1440.6,35,,1440.6,percent of total billed charges,Implant Device,1646.4,40,,1646.4,percent of total billed charges,Implant Device,1440.6,70,,1440.6,percent of total billed charges,All Other,1399.44,34,,1399.44,percent of total billed charges,Implant Device,1399.44,34,,1399.44,percent of total billed charges,Implant Device,1440.6,35,,1440.6,percent of total billed charges,Implant Device,1440.6,35,,1440.6,percent of total billed charges,Implant Device,1440.6,35,,1440.6,percent of total billed charges,Implant Device,1440.6,35,,1440.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1399.44,34,"If Charge > 2,000, then 34 percent",1399.44,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3045.85,
ZIMMER 42-5026-068-02 FEMUR RT SIZE 10,C1776,HCPCS,,79010368,CDM,278,RC,,,both,,,10200,7548.03,,,7548.03,Other,150% of Medicare + 9.63% HCRA Surcharge,4590,45,,4590,percent of total billed charges,Critical Access Hospital RCC factor,3468,34,,3468,percent of total billed charges,Implant Device,3468,34,,3468,percent of total billed charges,Implant Device,3468,34,,3468,percent of total billed charges,Implant Device,3468,34,,3468,percent of total billed charges,Implant Device,3468,34,,3468,percent of total billed charges,Implant Device,5049,,,5049,Other,110% of Medicare,3570,35,,3570,percent of total billed charges,Implant Device,3468,34,"Charges > $500, x 34%",3468,percent of total billed charges,Implant Device,3570,35,,3570,percent of total billed charges,Implant Device,3570,35,,3570,percent of total billed charges,Implant Device,3570,35,,3570,percent of total billed charges,Implant Device,3570,35,,3570,percent of total billed charges,Implant Device,3570,35,,3570,percent of total billed charges,Implant Device,4080,40,,4080,percent of total billed charges,Implant Device,3570,70,,3570,percent of total billed charges,All Other,3468,34,,3468,percent of total billed charges,Implant Device,3468,34,,3468,percent of total billed charges,Implant Device,3570,35,,3570,percent of total billed charges,Implant Device,3570,35,,3570,percent of total billed charges,Implant Device,3570,35,,3570,percent of total billed charges,Implant Device,3570,35,,3570,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3468,34,"If Charge > 2,000, then 34 percent",3468,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,7548.03,
STRYKER 1059-2310 ACCOLADE DISTAL SPACER,C1776,HCPCS,,79010369,CDM,278,RC,,,both,,,150,111,,,111,Other,150% of Medicare + 9.63% HCRA Surcharge,67.5,45,,67.5,percent of total billed charges,Critical Access Hospital RCC factor,51,34,,51,percent of total billed charges,Implant Device,51,34,,51,percent of total billed charges,Implant Device,51,34,,51,percent of total billed charges,Implant Device,51,34,,51,percent of total billed charges,Implant Device,51,34,,51,percent of total billed charges,Implant Device,74.25,,,74.25,Other,110% of Medicare,52.5,35,,52.5,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,52.5,35,,52.5,percent of total billed charges,Implant Device,52.5,35,,52.5,percent of total billed charges,Implant Device,52.5,35,,52.5,percent of total billed charges,Implant Device,52.5,35,,52.5,percent of total billed charges,Implant Device,52.5,35,,52.5,percent of total billed charges,Implant Device,60,40,,60,percent of total billed charges,Implant Device,52.5,70,,52.5,percent of total billed charges,All Other,51,34,,51,percent of total billed charges,Implant Device,51,34,,51,percent of total billed charges,Implant Device,52.5,35,,52.5,percent of total billed charges,Implant Device,52.5,35,,52.5,percent of total billed charges,Implant Device,52.5,35,,52.5,percent of total billed charges,Implant Device,52.5,35,,52.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,111,
STRYKER 6057-0335D ACCOLADE C CS 127NK,C1776,HCPCS,,79010370,CDM,278,RC,,,both,,,5006,3704.45,,,3704.45,Other,150% of Medicare + 9.63% HCRA Surcharge,2252.7,45,,2252.7,percent of total billed charges,Critical Access Hospital RCC factor,1702.04,34,,1702.04,percent of total billed charges,Implant Device,1702.04,34,,1702.04,percent of total billed charges,Implant Device,1702.04,34,,1702.04,percent of total billed charges,Implant Device,1702.04,34,,1702.04,percent of total billed charges,Implant Device,1702.04,34,,1702.04,percent of total billed charges,Implant Device,2477.97,,,2477.97,Other,110% of Medicare,1752.1,35,,1752.1,percent of total billed charges,Implant Device,1702.04,34,"Charges > $500, x 34%",1702.04,percent of total billed charges,Implant Device,1752.1,35,,1752.1,percent of total billed charges,Implant Device,1752.1,35,,1752.1,percent of total billed charges,Implant Device,1752.1,35,,1752.1,percent of total billed charges,Implant Device,1752.1,35,,1752.1,percent of total billed charges,Implant Device,1752.1,35,,1752.1,percent of total billed charges,Implant Device,2002.4,40,,2002.4,percent of total billed charges,Implant Device,1752.1,70,,1752.1,percent of total billed charges,All Other,1702.04,34,,1702.04,percent of total billed charges,Implant Device,1702.04,34,,1702.04,percent of total billed charges,Implant Device,1752.1,35,,1752.1,percent of total billed charges,Implant Device,1752.1,35,,1752.1,percent of total billed charges,Implant Device,1752.1,35,,1752.1,percent of total billed charges,Implant Device,1752.1,35,,1752.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1702.04,34,"If Charge > 2,000, then 34 percent",1702.04,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3704.45,
STRYKER 6260-9-026 V440 COCR LFIT HEAD,C1776,HCPCS,,79010371,CDM,278,RC,,,both,,,1391,1029.34,,,1029.34,Other,150% of Medicare + 9.63% HCRA Surcharge,625.95,45,,625.95,percent of total billed charges,Critical Access Hospital RCC factor,472.94,34,,472.94,percent of total billed charges,Implant Device,472.94,34,,472.94,percent of total billed charges,Implant Device,472.94,34,,472.94,percent of total billed charges,Implant Device,472.94,34,,472.94,percent of total billed charges,Implant Device,472.94,34,,472.94,percent of total billed charges,Implant Device,688.55,,,688.55,Other,110% of Medicare,486.85,35,,486.85,percent of total billed charges,Implant Device,472.94,34,"Charges > $500, x 34%",472.94,percent of total billed charges,Implant Device,486.85,35,,486.85,percent of total billed charges,Implant Device,486.85,35,,486.85,percent of total billed charges,Implant Device,486.85,35,,486.85,percent of total billed charges,Implant Device,486.85,35,,486.85,percent of total billed charges,Implant Device,486.85,35,,486.85,percent of total billed charges,Implant Device,556.4,40,,556.4,percent of total billed charges,Implant Device,486.85,70,,486.85,percent of total billed charges,All Other,472.94,34,,472.94,percent of total billed charges,Implant Device,472.94,34,,472.94,percent of total billed charges,Implant Device,486.85,35,,486.85,percent of total billed charges,Implant Device,486.85,35,,486.85,percent of total billed charges,Implant Device,486.85,35,,486.85,percent of total billed charges,Implant Device,486.85,35,,486.85,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1029.34,
BOS SCI M0061802300 CONTOUR STENT 7FRX20,C1874,HCPCS,,79010372,CDM,278,RC,,,both,,,425,314.5,,,314.5,Other,150% of Medicare + 9.63% HCRA Surcharge,191.25,45,,191.25,percent of total billed charges,Critical Access Hospital RCC factor,144.5,34,,144.5,percent of total billed charges,Implant Device,144.5,34,,144.5,percent of total billed charges,Implant Device,144.5,34,,144.5,percent of total billed charges,Implant Device,144.5,34,,144.5,percent of total billed charges,Implant Device,144.5,34,,144.5,percent of total billed charges,Implant Device,210.38,,,210.38,Other,110% of Medicare,148.75,35,,148.75,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,148.75,35,,148.75,percent of total billed charges,Implant Device,148.75,35,,148.75,percent of total billed charges,Implant Device,148.75,35,,148.75,percent of total billed charges,Implant Device,148.75,35,,148.75,percent of total billed charges,Implant Device,148.75,35,,148.75,percent of total billed charges,Implant Device,170,40,,170,percent of total billed charges,Implant Device,148.75,70,,148.75,percent of total billed charges,All Other,144.5,34,,144.5,percent of total billed charges,Implant Device,144.5,34,,144.5,percent of total billed charges,Implant Device,148.75,35,,148.75,percent of total billed charges,Implant Device,148.75,35,,148.75,percent of total billed charges,Implant Device,148.75,35,,148.75,percent of total billed charges,Implant Device,148.75,35,,148.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,314.5,
BOS SCI M0061802310 CONTOUR STENT 7FRX22,C1874,HCPCS,,79010373,CDM,278,RC,,,both,,,425,314.5,,,314.5,Other,150% of Medicare + 9.63% HCRA Surcharge,191.25,45,,191.25,percent of total billed charges,Critical Access Hospital RCC factor,144.5,34,,144.5,percent of total billed charges,Implant Device,144.5,34,,144.5,percent of total billed charges,Implant Device,144.5,34,,144.5,percent of total billed charges,Implant Device,144.5,34,,144.5,percent of total billed charges,Implant Device,144.5,34,,144.5,percent of total billed charges,Implant Device,210.38,,,210.38,Other,110% of Medicare,148.75,35,,148.75,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,148.75,35,,148.75,percent of total billed charges,Implant Device,148.75,35,,148.75,percent of total billed charges,Implant Device,148.75,35,,148.75,percent of total billed charges,Implant Device,148.75,35,,148.75,percent of total billed charges,Implant Device,148.75,35,,148.75,percent of total billed charges,Implant Device,170,40,,170,percent of total billed charges,Implant Device,148.75,70,,148.75,percent of total billed charges,All Other,144.5,34,,144.5,percent of total billed charges,Implant Device,144.5,34,,144.5,percent of total billed charges,Implant Device,148.75,35,,148.75,percent of total billed charges,Implant Device,148.75,35,,148.75,percent of total billed charges,Implant Device,148.75,35,,148.75,percent of total billed charges,Implant Device,148.75,35,,148.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,314.5,
BOS SCI M0061802320 CONTOUR STENT 7FRX24,C1874,HCPCS,,79010374,CDM,278,RC,,,both,,,425,314.5,,,314.5,Other,150% of Medicare + 9.63% HCRA Surcharge,191.25,45,,191.25,percent of total billed charges,Critical Access Hospital RCC factor,144.5,34,,144.5,percent of total billed charges,Implant Device,144.5,34,,144.5,percent of total billed charges,Implant Device,144.5,34,,144.5,percent of total billed charges,Implant Device,144.5,34,,144.5,percent of total billed charges,Implant Device,144.5,34,,144.5,percent of total billed charges,Implant Device,210.38,,,210.38,Other,110% of Medicare,148.75,35,,148.75,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,148.75,35,,148.75,percent of total billed charges,Implant Device,148.75,35,,148.75,percent of total billed charges,Implant Device,148.75,35,,148.75,percent of total billed charges,Implant Device,148.75,35,,148.75,percent of total billed charges,Implant Device,148.75,35,,148.75,percent of total billed charges,Implant Device,170,40,,170,percent of total billed charges,Implant Device,148.75,70,,148.75,percent of total billed charges,All Other,144.5,34,,144.5,percent of total billed charges,Implant Device,144.5,34,,144.5,percent of total billed charges,Implant Device,148.75,35,,148.75,percent of total billed charges,Implant Device,148.75,35,,148.75,percent of total billed charges,Implant Device,148.75,35,,148.75,percent of total billed charges,Implant Device,148.75,35,,148.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,314.5,
BOS SCI M0061802320 CONTOUR STENT 7FRX26,C1874,HCPCS,,79010375,CDM,278,RC,,,both,,,425,314.5,,,314.5,Other,150% of Medicare + 9.63% HCRA Surcharge,191.25,45,,191.25,percent of total billed charges,Critical Access Hospital RCC factor,144.5,34,,144.5,percent of total billed charges,Implant Device,144.5,34,,144.5,percent of total billed charges,Implant Device,144.5,34,,144.5,percent of total billed charges,Implant Device,144.5,34,,144.5,percent of total billed charges,Implant Device,144.5,34,,144.5,percent of total billed charges,Implant Device,210.38,,,210.38,Other,110% of Medicare,148.75,35,,148.75,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,148.75,35,,148.75,percent of total billed charges,Implant Device,148.75,35,,148.75,percent of total billed charges,Implant Device,148.75,35,,148.75,percent of total billed charges,Implant Device,148.75,35,,148.75,percent of total billed charges,Implant Device,148.75,35,,148.75,percent of total billed charges,Implant Device,170,40,,170,percent of total billed charges,Implant Device,148.75,70,,148.75,percent of total billed charges,All Other,144.5,34,,144.5,percent of total billed charges,Implant Device,144.5,34,,144.5,percent of total billed charges,Implant Device,148.75,35,,148.75,percent of total billed charges,Implant Device,148.75,35,,148.75,percent of total billed charges,Implant Device,148.75,35,,148.75,percent of total billed charges,Implant Device,148.75,35,,148.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,314.5,
DEPUY 1221-36-052 ACETAB LINER 36/52MM,C1776,HCPCS,,79010378,CDM,278,RC,,,both,,,2565,1898.11,,,1898.11,Other,150% of Medicare + 9.63% HCRA Surcharge,1154.25,45,,1154.25,percent of total billed charges,Critical Access Hospital RCC factor,872.1,34,,872.1,percent of total billed charges,Implant Device,872.1,34,,872.1,percent of total billed charges,Implant Device,872.1,34,,872.1,percent of total billed charges,Implant Device,872.1,34,,872.1,percent of total billed charges,Implant Device,872.1,34,,872.1,percent of total billed charges,Implant Device,1269.68,,,1269.68,Other,110% of Medicare,897.75,35,,897.75,percent of total billed charges,Implant Device,872.1,34,"Charges > $500, x 34%",872.1,percent of total billed charges,Implant Device,897.75,35,,897.75,percent of total billed charges,Implant Device,897.75,35,,897.75,percent of total billed charges,Implant Device,897.75,35,,897.75,percent of total billed charges,Implant Device,897.75,35,,897.75,percent of total billed charges,Implant Device,897.75,35,,897.75,percent of total billed charges,Implant Device,1026,40,,1026,percent of total billed charges,Implant Device,897.75,70,,897.75,percent of total billed charges,All Other,872.1,34,,872.1,percent of total billed charges,Implant Device,872.1,34,,872.1,percent of total billed charges,Implant Device,897.75,35,,897.75,percent of total billed charges,Implant Device,897.75,35,,897.75,percent of total billed charges,Implant Device,897.75,35,,897.75,percent of total billed charges,Implant Device,897.75,35,,897.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,872.1,34,"If Charge > 2,000, then 34 percent",872.1,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1898.11,
ZIMMER 48-6001 BONUS TRIAD ALLOGRAFT 1CC,C1713,HCPCS,,79010379,CDM,278,RC,,,both,,,1950,1443,,,1443,Other,150% of Medicare + 9.63% HCRA Surcharge,877.5,45,,877.5,percent of total billed charges,Critical Access Hospital RCC factor,663,34,,663,percent of total billed charges,Implant Device,663,34,,663,percent of total billed charges,Implant Device,663,34,,663,percent of total billed charges,Implant Device,663,34,,663,percent of total billed charges,Implant Device,663,34,,663,percent of total billed charges,Implant Device,965.25,,,965.25,Other,110% of Medicare,682.5,35,,682.5,percent of total billed charges,Implant Device,663,34,"Charges > $500, x 34%",663,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,780,40,,780,percent of total billed charges,Implant Device,682.5,70,,682.5,percent of total billed charges,All Other,663,34,,663,percent of total billed charges,Implant Device,663,34,,663,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1443,
ZIMMER 48-6005 BONUS TRIAD ALLOGRAFT 5CC,C1713,HCPCS,,79010380,CDM,278,RC,,,both,,,8550,6327.02,,,6327.02,Other,150% of Medicare + 9.63% HCRA Surcharge,3847.5,45,,3847.5,percent of total billed charges,Critical Access Hospital RCC factor,2907,34,,2907,percent of total billed charges,Implant Device,2907,34,,2907,percent of total billed charges,Implant Device,2907,34,,2907,percent of total billed charges,Implant Device,2907,34,,2907,percent of total billed charges,Implant Device,2907,34,,2907,percent of total billed charges,Implant Device,4232.25,,,4232.25,Other,110% of Medicare,2992.5,35,,2992.5,percent of total billed charges,Implant Device,2907,34,"Charges > $500, x 34%",2907,percent of total billed charges,Implant Device,2992.5,35,,2992.5,percent of total billed charges,Implant Device,2992.5,35,,2992.5,percent of total billed charges,Implant Device,2992.5,35,,2992.5,percent of total billed charges,Implant Device,2992.5,35,,2992.5,percent of total billed charges,Implant Device,2992.5,35,,2992.5,percent of total billed charges,Implant Device,3420,40,,3420,percent of total billed charges,Implant Device,2992.5,70,,2992.5,percent of total billed charges,All Other,2907,34,,2907,percent of total billed charges,Implant Device,2907,34,,2907,percent of total billed charges,Implant Device,2992.5,35,,2992.5,percent of total billed charges,Implant Device,2992.5,35,,2992.5,percent of total billed charges,Implant Device,2992.5,35,,2992.5,percent of total billed charges,Implant Device,2992.5,35,,2992.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2907,34,"If Charge > 2,000, then 34 percent",2907,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,6327.02,
DEPUY 3L92506 CONRAIL AMT COLLAR SZ 16,C1776,HCPCS,,79010381,CDM,278,RC,,,both,,,13446,9950.07,,,9950.07,Other,150% of Medicare + 9.63% HCRA Surcharge,6050.7,45,,6050.7,percent of total billed charges,Critical Access Hospital RCC factor,4571.64,34,,4571.64,percent of total billed charges,Implant Device,4571.64,34,,4571.64,percent of total billed charges,Implant Device,4571.64,34,,4571.64,percent of total billed charges,Implant Device,4571.64,34,,4571.64,percent of total billed charges,Implant Device,4571.64,34,,4571.64,percent of total billed charges,Implant Device,6655.77,,,6655.77,Other,110% of Medicare,4706.1,35,,4706.1,percent of total billed charges,Implant Device,4571.64,34,"Charges > $500, x 34%",4571.64,percent of total billed charges,Implant Device,4706.1,35,,4706.1,percent of total billed charges,Implant Device,4706.1,35,,4706.1,percent of total billed charges,Implant Device,4706.1,35,,4706.1,percent of total billed charges,Implant Device,4706.1,35,,4706.1,percent of total billed charges,Implant Device,4706.1,35,,4706.1,percent of total billed charges,Implant Device,5378.4,40,,5378.4,percent of total billed charges,Implant Device,4706.1,70,,4706.1,percent of total billed charges,All Other,4571.64,34,,4571.64,percent of total billed charges,Implant Device,4571.64,34,,4571.64,percent of total billed charges,Implant Device,4706.1,35,,4706.1,percent of total billed charges,Implant Device,4706.1,35,,4706.1,percent of total billed charges,Implant Device,4706.1,35,,4706.1,percent of total billed charges,Implant Device,4706.1,35,,4706.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,4571.64,34,"If Charge > 2,000, then 34 percent",4571.64,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,9950.07,
DEPUY 1221-36-054 ACETAB LINER 36IDX54OD,C1776,HCPCS,,79010382,CDM,278,RC,,,both,,,2565,1898.11,,,1898.11,Other,150% of Medicare + 9.63% HCRA Surcharge,1154.25,45,,1154.25,percent of total billed charges,Critical Access Hospital RCC factor,872.1,34,,872.1,percent of total billed charges,Implant Device,872.1,34,,872.1,percent of total billed charges,Implant Device,872.1,34,,872.1,percent of total billed charges,Implant Device,872.1,34,,872.1,percent of total billed charges,Implant Device,872.1,34,,872.1,percent of total billed charges,Implant Device,1269.68,,,1269.68,Other,110% of Medicare,897.75,35,,897.75,percent of total billed charges,Implant Device,872.1,34,"Charges > $500, x 34%",872.1,percent of total billed charges,Implant Device,897.75,35,,897.75,percent of total billed charges,Implant Device,897.75,35,,897.75,percent of total billed charges,Implant Device,897.75,35,,897.75,percent of total billed charges,Implant Device,897.75,35,,897.75,percent of total billed charges,Implant Device,897.75,35,,897.75,percent of total billed charges,Implant Device,1026,40,,1026,percent of total billed charges,Implant Device,897.75,70,,897.75,percent of total billed charges,All Other,872.1,34,,872.1,percent of total billed charges,Implant Device,872.1,34,,872.1,percent of total billed charges,Implant Device,897.75,35,,897.75,percent of total billed charges,Implant Device,897.75,35,,897.75,percent of total billed charges,Implant Device,897.75,35,,897.75,percent of total billed charges,Implant Device,897.75,35,,897.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,872.1,34,"If Charge > 2,000, then 34 percent",872.1,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1898.11,
IN2BONES V35 ST218 NON LOCK SCREW 3.5X18,C1713,HCPCS,,79010383,CDM,278,RC,,,both,,,870,643.8,,,643.8,Other,150% of Medicare + 9.63% HCRA Surcharge,391.5,45,,391.5,percent of total billed charges,Critical Access Hospital RCC factor,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,430.65,,,430.65,Other,110% of Medicare,304.5,35,,304.5,percent of total billed charges,Implant Device,295.8,34,"Charges > $500, x 34%",295.8,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,348,40,,348,percent of total billed charges,Implant Device,304.5,70,,304.5,percent of total billed charges,All Other,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,643.8,
EXACTECH 310-00-44 HUMERAL HEAD 44X14MM,C1776,HCPCS,,79010384,CDM,278,RC,,,both,,,4968,3676.33,,,3676.33,Other,150% of Medicare + 9.63% HCRA Surcharge,2235.6,45,,2235.6,percent of total billed charges,Critical Access Hospital RCC factor,1689.12,34,,1689.12,percent of total billed charges,Implant Device,1689.12,34,,1689.12,percent of total billed charges,Implant Device,1689.12,34,,1689.12,percent of total billed charges,Implant Device,1689.12,34,,1689.12,percent of total billed charges,Implant Device,1689.12,34,,1689.12,percent of total billed charges,Implant Device,2459.16,,,2459.16,Other,110% of Medicare,1738.8,35,,1738.8,percent of total billed charges,Implant Device,1689.12,34,"Charges > $500, x 34%",1689.12,percent of total billed charges,Implant Device,1738.8,35,,1738.8,percent of total billed charges,Implant Device,1738.8,35,,1738.8,percent of total billed charges,Implant Device,1738.8,35,,1738.8,percent of total billed charges,Implant Device,1738.8,35,,1738.8,percent of total billed charges,Implant Device,1738.8,35,,1738.8,percent of total billed charges,Implant Device,1987.2,40,,1987.2,percent of total billed charges,Implant Device,1738.8,70,,1738.8,percent of total billed charges,All Other,1689.12,34,,1689.12,percent of total billed charges,Implant Device,1689.12,34,,1689.12,percent of total billed charges,Implant Device,1738.8,35,,1738.8,percent of total billed charges,Implant Device,1738.8,35,,1738.8,percent of total billed charges,Implant Device,1738.8,35,,1738.8,percent of total billed charges,Implant Device,1738.8,35,,1738.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1689.12,34,"If Charge > 2,000, then 34 percent",1689.12,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3676.33,
EXACTECH 300-50-46 REPLICATOR PLT 4.5MM,C1713,HCPCS,,79010385,CDM,278,RC,,,both,,,2430,1798.21,,,1798.21,Other,150% of Medicare + 9.63% HCRA Surcharge,1093.5,45,,1093.5,percent of total billed charges,Critical Access Hospital RCC factor,826.2,34,,826.2,percent of total billed charges,Implant Device,826.2,34,,826.2,percent of total billed charges,Implant Device,826.2,34,,826.2,percent of total billed charges,Implant Device,826.2,34,,826.2,percent of total billed charges,Implant Device,826.2,34,,826.2,percent of total billed charges,Implant Device,1202.85,,,1202.85,Other,110% of Medicare,850.5,35,,850.5,percent of total billed charges,Implant Device,826.2,34,"Charges > $500, x 34%",826.2,percent of total billed charges,Implant Device,850.5,35,,850.5,percent of total billed charges,Implant Device,850.5,35,,850.5,percent of total billed charges,Implant Device,850.5,35,,850.5,percent of total billed charges,Implant Device,850.5,35,,850.5,percent of total billed charges,Implant Device,850.5,35,,850.5,percent of total billed charges,Implant Device,972,40,,972,percent of total billed charges,Implant Device,850.5,70,,850.5,percent of total billed charges,All Other,826.2,34,,826.2,percent of total billed charges,Implant Device,826.2,34,,826.2,percent of total billed charges,Implant Device,850.5,35,,850.5,percent of total billed charges,Implant Device,850.5,35,,850.5,percent of total billed charges,Implant Device,850.5,35,,850.5,percent of total billed charges,Implant Device,850.5,35,,850.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,826.2,34,"If Charge > 2,000, then 34 percent",826.2,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1798.21,
EXACTECH 300-30-06 PRESERVE STEM 6MM,C1776,HCPCS,,79010386,CDM,278,RC,,,both,,,6000,4440.02,,,4440.02,Other,150% of Medicare + 9.63% HCRA Surcharge,2700,45,,2700,percent of total billed charges,Critical Access Hospital RCC factor,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2970,,,2970,Other,110% of Medicare,2100,35,,2100,percent of total billed charges,Implant Device,2040,34,"Charges > $500, x 34%",2040,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2400,40,,2400,percent of total billed charges,Implant Device,2100,70,,2100,percent of total billed charges,All Other,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2040,34,"If Charge > 2,000, then 34 percent",2040,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4440.02,
STRYKER 1851-0938S FEMORAL NAIL 9X380,C1713,HCPCS,,79010387,CDM,278,RC,,,both,,,4545,3363.31,,,3363.31,Other,150% of Medicare + 9.63% HCRA Surcharge,2045.25,45,,2045.25,percent of total billed charges,Critical Access Hospital RCC factor,1545.3,34,,1545.3,percent of total billed charges,Implant Device,1545.3,34,,1545.3,percent of total billed charges,Implant Device,1545.3,34,,1545.3,percent of total billed charges,Implant Device,1545.3,34,,1545.3,percent of total billed charges,Implant Device,1545.3,34,,1545.3,percent of total billed charges,Implant Device,2249.78,,,2249.78,Other,110% of Medicare,1590.75,35,,1590.75,percent of total billed charges,Implant Device,1545.3,34,"Charges > $500, x 34%",1545.3,percent of total billed charges,Implant Device,1590.75,35,,1590.75,percent of total billed charges,Implant Device,1590.75,35,,1590.75,percent of total billed charges,Implant Device,1590.75,35,,1590.75,percent of total billed charges,Implant Device,1590.75,35,,1590.75,percent of total billed charges,Implant Device,1590.75,35,,1590.75,percent of total billed charges,Implant Device,1818,40,,1818,percent of total billed charges,Implant Device,1590.75,70,,1590.75,percent of total billed charges,All Other,1545.3,34,,1545.3,percent of total billed charges,Implant Device,1545.3,34,,1545.3,percent of total billed charges,Implant Device,1590.75,35,,1590.75,percent of total billed charges,Implant Device,1590.75,35,,1590.75,percent of total billed charges,Implant Device,1590.75,35,,1590.75,percent of total billed charges,Implant Device,1590.75,35,,1590.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1545.3,34,"If Charge > 2,000, then 34 percent",1545.3,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3363.31,
MENTOR 350-9213 BREAST TISSUE EXPANDER,C1789,HCPCS,,79010389,CDM,278,RC,,,both,,,5475,4051.51,,,4051.51,Other,150% of Medicare + 9.63% HCRA Surcharge,2463.75,45,,2463.75,percent of total billed charges,Critical Access Hospital RCC factor,1861.5,34,,1861.5,percent of total billed charges,Implant Device,1861.5,34,,1861.5,percent of total billed charges,Implant Device,1861.5,34,,1861.5,percent of total billed charges,Implant Device,1861.5,34,,1861.5,percent of total billed charges,Implant Device,1861.5,34,,1861.5,percent of total billed charges,Implant Device,2710.13,,,2710.13,Other,110% of Medicare,1916.25,35,,1916.25,percent of total billed charges,Implant Device,1861.5,34,"Charges > $500, x 34%",1861.5,percent of total billed charges,Implant Device,1916.25,35,,1916.25,percent of total billed charges,Implant Device,1916.25,35,,1916.25,percent of total billed charges,Implant Device,1916.25,35,,1916.25,percent of total billed charges,Implant Device,1916.25,35,,1916.25,percent of total billed charges,Implant Device,1916.25,35,,1916.25,percent of total billed charges,Implant Device,2190,40,,2190,percent of total billed charges,Implant Device,1916.25,70,,1916.25,percent of total billed charges,All Other,1861.5,34,,1861.5,percent of total billed charges,Implant Device,1861.5,34,,1861.5,percent of total billed charges,Implant Device,1916.25,35,,1916.25,percent of total billed charges,Implant Device,1916.25,35,,1916.25,percent of total billed charges,Implant Device,1916.25,35,,1916.25,percent of total billed charges,Implant Device,1916.25,35,,1916.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1861.5,34,"If Charge > 2,000, then 34 percent",1861.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4051.51,
ALLERGAN SCM-330 BREAST IMPLANT 330CC,C1789,HCPCS,,79010390,CDM,278,RC,,,both,,,4005,2963.71,,,2963.71,Other,150% of Medicare + 9.63% HCRA Surcharge,1802.25,45,,1802.25,percent of total billed charges,Critical Access Hospital RCC factor,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1982.48,,,1982.48,Other,110% of Medicare,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1361.7,34,"Charges > $500, x 34%",1361.7,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1602,40,,1602,percent of total billed charges,Implant Device,1401.75,70,,1401.75,percent of total billed charges,All Other,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1361.7,34,"If Charge > 2,000, then 34 percent",1361.7,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2963.71,
ALLERGAN SCLP-265 BREAST IMPLANT 265CC,C1789,HCPCS,,79010392,CDM,278,RC,,,both,,,4005,2963.71,,,2963.71,Other,150% of Medicare + 9.63% HCRA Surcharge,1802.25,45,,1802.25,percent of total billed charges,Critical Access Hospital RCC factor,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1982.48,,,1982.48,Other,110% of Medicare,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1361.7,34,"Charges > $500, x 34%",1361.7,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1602,40,,1602,percent of total billed charges,Implant Device,1401.75,70,,1401.75,percent of total billed charges,All Other,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1361.7,34,"If Charge > 2,000, then 34 percent",1361.7,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2963.71,
ALLERGAN SCLP-280 BREAST IMPLANT 280CC,C1789,HCPCS,,79010393,CDM,278,RC,,,both,,,4005,2963.71,,,2963.71,Other,150% of Medicare + 9.63% HCRA Surcharge,1802.25,45,,1802.25,percent of total billed charges,Critical Access Hospital RCC factor,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1982.48,,,1982.48,Other,110% of Medicare,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1361.7,34,"Charges > $500, x 34%",1361.7,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1602,40,,1602,percent of total billed charges,Implant Device,1401.75,70,,1401.75,percent of total billed charges,All Other,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1361.7,34,"If Charge > 2,000, then 34 percent",1361.7,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2963.71,
ZIMMER 8145-11-340 HIP FRAC NAIL 11X340,C1713,HCPCS,,79010397,CDM,278,RC,,,both,,,7290,5394.62,,,5394.62,Other,150% of Medicare + 9.63% HCRA Surcharge,3280.5,45,,3280.5,percent of total billed charges,Critical Access Hospital RCC factor,2478.6,34,,2478.6,percent of total billed charges,Implant Device,2478.6,34,,2478.6,percent of total billed charges,Implant Device,2478.6,34,,2478.6,percent of total billed charges,Implant Device,2478.6,34,,2478.6,percent of total billed charges,Implant Device,2478.6,34,,2478.6,percent of total billed charges,Implant Device,3608.55,,,3608.55,Other,110% of Medicare,2551.5,35,,2551.5,percent of total billed charges,Implant Device,2478.6,34,"Charges > $500, x 34%",2478.6,percent of total billed charges,Implant Device,2551.5,35,,2551.5,percent of total billed charges,Implant Device,2551.5,35,,2551.5,percent of total billed charges,Implant Device,2551.5,35,,2551.5,percent of total billed charges,Implant Device,2551.5,35,,2551.5,percent of total billed charges,Implant Device,2551.5,35,,2551.5,percent of total billed charges,Implant Device,2916,40,,2916,percent of total billed charges,Implant Device,2551.5,70,,2551.5,percent of total billed charges,All Other,2478.6,34,,2478.6,percent of total billed charges,Implant Device,2478.6,34,,2478.6,percent of total billed charges,Implant Device,2551.5,35,,2551.5,percent of total billed charges,Implant Device,2551.5,35,,2551.5,percent of total billed charges,Implant Device,2551.5,35,,2551.5,percent of total billed charges,Implant Device,2551.5,35,,2551.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2478.6,34,"If Charge > 2,000, then 34 percent",2478.6,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5394.62,
ARTHREX AR-8862DS SUTURETAPE IMPLANT SYS,C1713,HCPCS,,79010398,CDM,278,RC,,,both,,,4485,3318.91,,,3318.91,Other,150% of Medicare + 9.63% HCRA Surcharge,2018.25,45,,2018.25,percent of total billed charges,Critical Access Hospital RCC factor,1524.9,34,,1524.9,percent of total billed charges,Implant Device,1524.9,34,,1524.9,percent of total billed charges,Implant Device,1524.9,34,,1524.9,percent of total billed charges,Implant Device,1524.9,34,,1524.9,percent of total billed charges,Implant Device,1524.9,34,,1524.9,percent of total billed charges,Implant Device,2220.08,,,2220.08,Other,110% of Medicare,1569.75,35,,1569.75,percent of total billed charges,Implant Device,1524.9,34,"Charges > $500, x 34%",1524.9,percent of total billed charges,Implant Device,1569.75,35,,1569.75,percent of total billed charges,Implant Device,1569.75,35,,1569.75,percent of total billed charges,Implant Device,1569.75,35,,1569.75,percent of total billed charges,Implant Device,1569.75,35,,1569.75,percent of total billed charges,Implant Device,1569.75,35,,1569.75,percent of total billed charges,Implant Device,1794,40,,1794,percent of total billed charges,Implant Device,1569.75,70,,1569.75,percent of total billed charges,All Other,1524.9,34,,1524.9,percent of total billed charges,Implant Device,1524.9,34,,1524.9,percent of total billed charges,Implant Device,1569.75,35,,1569.75,percent of total billed charges,Implant Device,1569.75,35,,1569.75,percent of total billed charges,Implant Device,1569.75,35,,1569.75,percent of total billed charges,Implant Device,1569.75,35,,1569.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1524.9,34,"If Charge > 2,000, then 34 percent",1524.9,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3318.91,
DEPUY 1365-36-720 FEM HEAD 12.14 TAPER,C1776,HCPCS,,79010399,CDM,278,RC,,,both,,,8077,5977,,,5977,Other,150% of Medicare + 9.63% HCRA Surcharge,3634.65,45,,3634.65,percent of total billed charges,Critical Access Hospital RCC factor,2746.18,34,,2746.18,percent of total billed charges,Implant Device,2746.18,34,,2746.18,percent of total billed charges,Implant Device,2746.18,34,,2746.18,percent of total billed charges,Implant Device,2746.18,34,,2746.18,percent of total billed charges,Implant Device,2746.18,34,,2746.18,percent of total billed charges,Implant Device,3998.12,,,3998.12,Other,110% of Medicare,2826.95,35,,2826.95,percent of total billed charges,Implant Device,2746.18,34,"Charges > $500, x 34%",2746.18,percent of total billed charges,Implant Device,2826.95,35,,2826.95,percent of total billed charges,Implant Device,2826.95,35,,2826.95,percent of total billed charges,Implant Device,2826.95,35,,2826.95,percent of total billed charges,Implant Device,2826.95,35,,2826.95,percent of total billed charges,Implant Device,2826.95,35,,2826.95,percent of total billed charges,Implant Device,3230.8,40,,3230.8,percent of total billed charges,Implant Device,2826.95,70,,2826.95,percent of total billed charges,All Other,2746.18,34,,2746.18,percent of total billed charges,Implant Device,2746.18,34,,2746.18,percent of total billed charges,Implant Device,2826.95,35,,2826.95,percent of total billed charges,Implant Device,2826.95,35,,2826.95,percent of total billed charges,Implant Device,2826.95,35,,2826.95,percent of total billed charges,Implant Device,2826.95,35,,2826.95,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2746.18,34,"If Charge > 2,000, then 34 percent",2746.18,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5977,
ARTHROSURFACE 9M52-2545-W ART COMPONENT,L8641,HCPCS,,79010400,CDM,278,RC,,,both,,,5205,3851.71,,,3851.71,Other,150% of Medicare + 9.63% HCRA Surcharge,2342.25,45,,2342.25,percent of total billed charges,Critical Access Hospital RCC factor,1769.7,34,,1769.7,percent of total billed charges,Implant Device,1769.7,34,,1769.7,percent of total billed charges,Implant Device,1769.7,34,,1769.7,percent of total billed charges,Implant Device,1769.7,34,,1769.7,percent of total billed charges,Implant Device,1769.7,34,,1769.7,percent of total billed charges,Implant Device,2576.48,,,2576.48,Other,110% of Medicare,1821.75,35,,1821.75,percent of total billed charges,Implant Device,1769.7,34,"Charges > $500, x 34%",1769.7,percent of total billed charges,Implant Device,1821.75,35,,1821.75,percent of total billed charges,Implant Device,1821.75,35,,1821.75,percent of total billed charges,Implant Device,1821.75,35,,1821.75,percent of total billed charges,Implant Device,1821.75,35,,1821.75,percent of total billed charges,Implant Device,1821.75,35,,1821.75,percent of total billed charges,Implant Device,2082,40,,2082,percent of total billed charges,Implant Device,1821.75,70,,1821.75,percent of total billed charges,All Other,1769.7,34,,1769.7,percent of total billed charges,Implant Device,1769.7,34,,1769.7,percent of total billed charges,Implant Device,1821.75,35,,1821.75,percent of total billed charges,Implant Device,1821.75,35,,1821.75,percent of total billed charges,Implant Device,1821.75,35,,1821.75,percent of total billed charges,Implant Device,1821.75,35,,1821.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1769.7,34,"If Charge > 2,000, then 34 percent",1769.7,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3851.71,
STRYKER 5571-S-3606 X3 HUMRAL INSRT 36X6,C1776,HCPCS,,79010402,CDM,278,RC,,,both,,,4500,3330.01,,,3330.01,Other,150% of Medicare + 9.63% HCRA Surcharge,2025,45,,2025,percent of total billed charges,Critical Access Hospital RCC factor,1530,34,,1530,percent of total billed charges,Implant Device,1530,34,,1530,percent of total billed charges,Implant Device,1530,34,,1530,percent of total billed charges,Implant Device,1530,34,,1530,percent of total billed charges,Implant Device,1530,34,,1530,percent of total billed charges,Implant Device,2227.5,,,2227.5,Other,110% of Medicare,1575,35,,1575,percent of total billed charges,Implant Device,1530,34,"Charges > $500, x 34%",1530,percent of total billed charges,Implant Device,1575,35,,1575,percent of total billed charges,Implant Device,1575,35,,1575,percent of total billed charges,Implant Device,1575,35,,1575,percent of total billed charges,Implant Device,1575,35,,1575,percent of total billed charges,Implant Device,1575,35,,1575,percent of total billed charges,Implant Device,1800,40,,1800,percent of total billed charges,Implant Device,1575,70,,1575,percent of total billed charges,All Other,1530,34,,1530,percent of total billed charges,Implant Device,1530,34,,1530,percent of total billed charges,Implant Device,1575,35,,1575,percent of total billed charges,Implant Device,1575,35,,1575,percent of total billed charges,Implant Device,1575,35,,1575,percent of total billed charges,Implant Device,1575,35,,1575,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1530,34,"If Charge > 2,000, then 34 percent",1530,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3330.01,
STRYKER 5510-F-501 FEMORAL COMP SZ 5 LT,C1776,HCPCS,,79010403,CDM,278,RC,,,both,,,4450,3293.01,,,3293.01,Other,150% of Medicare + 9.63% HCRA Surcharge,2002.5,45,,2002.5,percent of total billed charges,Critical Access Hospital RCC factor,1513,34,,1513,percent of total billed charges,Implant Device,1513,34,,1513,percent of total billed charges,Implant Device,1513,34,,1513,percent of total billed charges,Implant Device,1513,34,,1513,percent of total billed charges,Implant Device,1513,34,,1513,percent of total billed charges,Implant Device,2202.75,,,2202.75,Other,110% of Medicare,1557.5,35,,1557.5,percent of total billed charges,Implant Device,1513,34,"Charges > $500, x 34%",1513,percent of total billed charges,Implant Device,1557.5,35,,1557.5,percent of total billed charges,Implant Device,1557.5,35,,1557.5,percent of total billed charges,Implant Device,1557.5,35,,1557.5,percent of total billed charges,Implant Device,1557.5,35,,1557.5,percent of total billed charges,Implant Device,1557.5,35,,1557.5,percent of total billed charges,Implant Device,1780,40,,1780,percent of total billed charges,Implant Device,1557.5,70,,1557.5,percent of total billed charges,All Other,1513,34,,1513,percent of total billed charges,Implant Device,1513,34,,1513,percent of total billed charges,Implant Device,1557.5,35,,1557.5,percent of total billed charges,Implant Device,1557.5,35,,1557.5,percent of total billed charges,Implant Device,1557.5,35,,1557.5,percent of total billed charges,Implant Device,1557.5,35,,1557.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1513,34,"If Charge > 2,000, then 34 percent",1513,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3293.01,
ACUMED AT2-C30 ACUTRAK BONE SCREW 30MM,C1713,HCPCS,,79010404,CDM,278,RC,,,both,,,2448,1811.53,,,1811.53,Other,150% of Medicare + 9.63% HCRA Surcharge,1101.6,45,,1101.6,percent of total billed charges,Critical Access Hospital RCC factor,832.32,34,,832.32,percent of total billed charges,Implant Device,832.32,34,,832.32,percent of total billed charges,Implant Device,832.32,34,,832.32,percent of total billed charges,Implant Device,832.32,34,,832.32,percent of total billed charges,Implant Device,832.32,34,,832.32,percent of total billed charges,Implant Device,1211.76,,,1211.76,Other,110% of Medicare,856.8,35,,856.8,percent of total billed charges,Implant Device,832.32,34,"Charges > $500, x 34%",832.32,percent of total billed charges,Implant Device,856.8,35,,856.8,percent of total billed charges,Implant Device,856.8,35,,856.8,percent of total billed charges,Implant Device,856.8,35,,856.8,percent of total billed charges,Implant Device,856.8,35,,856.8,percent of total billed charges,Implant Device,856.8,35,,856.8,percent of total billed charges,Implant Device,979.2,40,,979.2,percent of total billed charges,Implant Device,856.8,70,,856.8,percent of total billed charges,All Other,832.32,34,,832.32,percent of total billed charges,Implant Device,832.32,34,,832.32,percent of total billed charges,Implant Device,856.8,35,,856.8,percent of total billed charges,Implant Device,856.8,35,,856.8,percent of total billed charges,Implant Device,856.8,35,,856.8,percent of total billed charges,Implant Device,856.8,35,,856.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,832.32,34,"If Charge > 2,000, then 34 percent",832.32,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1811.53,
STRYKER 626828 LAG SCREW 4.1X28MM,C1713,HCPCS,,79010406,CDM,278,RC,,,both,,,927,685.98,,,685.98,Other,150% of Medicare + 9.63% HCRA Surcharge,417.15,45,,417.15,percent of total billed charges,Critical Access Hospital RCC factor,315.18,34,,315.18,percent of total billed charges,Implant Device,315.18,34,,315.18,percent of total billed charges,Implant Device,315.18,34,,315.18,percent of total billed charges,Implant Device,315.18,34,,315.18,percent of total billed charges,Implant Device,315.18,34,,315.18,percent of total billed charges,Implant Device,458.87,,,458.87,Other,110% of Medicare,324.45,35,,324.45,percent of total billed charges,Implant Device,315.18,34,"Charges > $500, x 34%",315.18,percent of total billed charges,Implant Device,324.45,35,,324.45,percent of total billed charges,Implant Device,324.45,35,,324.45,percent of total billed charges,Implant Device,324.45,35,,324.45,percent of total billed charges,Implant Device,324.45,35,,324.45,percent of total billed charges,Implant Device,324.45,35,,324.45,percent of total billed charges,Implant Device,370.8,40,,370.8,percent of total billed charges,Implant Device,324.45,70,,324.45,percent of total billed charges,All Other,315.18,34,,315.18,percent of total billed charges,Implant Device,315.18,34,,315.18,percent of total billed charges,Implant Device,324.45,35,,324.45,percent of total billed charges,Implant Device,324.45,35,,324.45,percent of total billed charges,Implant Device,324.45,35,,324.45,percent of total billed charges,Implant Device,324.45,35,,324.45,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,685.98,
ALLERGAN 133-MV-14-T TISSUE EXPANDER 500,C1789,HCPCS,,79010410,CDM,278,RC,,,both,,,4725,3496.51,,,3496.51,Other,150% of Medicare + 9.63% HCRA Surcharge,2126.25,45,,2126.25,percent of total billed charges,Critical Access Hospital RCC factor,1606.5,34,,1606.5,percent of total billed charges,Implant Device,1606.5,34,,1606.5,percent of total billed charges,Implant Device,1606.5,34,,1606.5,percent of total billed charges,Implant Device,1606.5,34,,1606.5,percent of total billed charges,Implant Device,1606.5,34,,1606.5,percent of total billed charges,Implant Device,2338.88,,,2338.88,Other,110% of Medicare,1653.75,35,,1653.75,percent of total billed charges,Implant Device,1606.5,34,"Charges > $500, x 34%",1606.5,percent of total billed charges,Implant Device,1653.75,35,,1653.75,percent of total billed charges,Implant Device,1653.75,35,,1653.75,percent of total billed charges,Implant Device,1653.75,35,,1653.75,percent of total billed charges,Implant Device,1653.75,35,,1653.75,percent of total billed charges,Implant Device,1653.75,35,,1653.75,percent of total billed charges,Implant Device,1890,40,,1890,percent of total billed charges,Implant Device,1653.75,70,,1653.75,percent of total billed charges,All Other,1606.5,34,,1606.5,percent of total billed charges,Implant Device,1606.5,34,,1606.5,percent of total billed charges,Implant Device,1653.75,35,,1653.75,percent of total billed charges,Implant Device,1653.75,35,,1653.75,percent of total billed charges,Implant Device,1653.75,35,,1653.75,percent of total billed charges,Implant Device,1653.75,35,,1653.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1606.5,34,"If Charge > 2,000, then 34 percent",1606.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3496.51,
ALLERGAN 133-MV-15-T TISSUE EXPANDER 600,C1789,HCPCS,,79010411,CDM,278,RC,,,both,,,4725,3496.51,,,3496.51,Other,150% of Medicare + 9.63% HCRA Surcharge,2126.25,45,,2126.25,percent of total billed charges,Critical Access Hospital RCC factor,1606.5,34,,1606.5,percent of total billed charges,Implant Device,1606.5,34,,1606.5,percent of total billed charges,Implant Device,1606.5,34,,1606.5,percent of total billed charges,Implant Device,1606.5,34,,1606.5,percent of total billed charges,Implant Device,1606.5,34,,1606.5,percent of total billed charges,Implant Device,2338.88,,,2338.88,Other,110% of Medicare,1653.75,35,,1653.75,percent of total billed charges,Implant Device,1606.5,34,"Charges > $500, x 34%",1606.5,percent of total billed charges,Implant Device,1653.75,35,,1653.75,percent of total billed charges,Implant Device,1653.75,35,,1653.75,percent of total billed charges,Implant Device,1653.75,35,,1653.75,percent of total billed charges,Implant Device,1653.75,35,,1653.75,percent of total billed charges,Implant Device,1653.75,35,,1653.75,percent of total billed charges,Implant Device,1890,40,,1890,percent of total billed charges,Implant Device,1653.75,70,,1653.75,percent of total billed charges,All Other,1606.5,34,,1606.5,percent of total billed charges,Implant Device,1606.5,34,,1606.5,percent of total billed charges,Implant Device,1653.75,35,,1653.75,percent of total billed charges,Implant Device,1653.75,35,,1653.75,percent of total billed charges,Implant Device,1653.75,35,,1653.75,percent of total billed charges,Implant Device,1653.75,35,,1653.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1606.5,34,"If Charge > 2,000, then 34 percent",1606.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3496.51,
ALLERGAN 133-MV-16-T TISSUE EXPANDER 700,C1789,HCPCS,,79010412,CDM,278,RC,,,both,,,4725,3496.51,,,3496.51,Other,150% of Medicare + 9.63% HCRA Surcharge,2126.25,45,,2126.25,percent of total billed charges,Critical Access Hospital RCC factor,1606.5,34,,1606.5,percent of total billed charges,Implant Device,1606.5,34,,1606.5,percent of total billed charges,Implant Device,1606.5,34,,1606.5,percent of total billed charges,Implant Device,1606.5,34,,1606.5,percent of total billed charges,Implant Device,1606.5,34,,1606.5,percent of total billed charges,Implant Device,2338.88,,,2338.88,Other,110% of Medicare,1653.75,35,,1653.75,percent of total billed charges,Implant Device,1606.5,34,"Charges > $500, x 34%",1606.5,percent of total billed charges,Implant Device,1653.75,35,,1653.75,percent of total billed charges,Implant Device,1653.75,35,,1653.75,percent of total billed charges,Implant Device,1653.75,35,,1653.75,percent of total billed charges,Implant Device,1653.75,35,,1653.75,percent of total billed charges,Implant Device,1653.75,35,,1653.75,percent of total billed charges,Implant Device,1890,40,,1890,percent of total billed charges,Implant Device,1653.75,70,,1653.75,percent of total billed charges,All Other,1606.5,34,,1606.5,percent of total billed charges,Implant Device,1606.5,34,,1606.5,percent of total billed charges,Implant Device,1653.75,35,,1653.75,percent of total billed charges,Implant Device,1653.75,35,,1653.75,percent of total billed charges,Implant Device,1653.75,35,,1653.75,percent of total billed charges,Implant Device,1653.75,35,,1653.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1606.5,34,"If Charge > 2,000, then 34 percent",1606.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3496.51,
ALLERGAN SSM-485 BREAST IMPLANT 485CC,C1789,HCPCS,,79010413,CDM,278,RC,,,both,,,4005,2963.71,,,2963.71,Other,150% of Medicare + 9.63% HCRA Surcharge,1802.25,45,,1802.25,percent of total billed charges,Critical Access Hospital RCC factor,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1982.48,,,1982.48,Other,110% of Medicare,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1361.7,34,"Charges > $500, x 34%",1361.7,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1602,40,,1602,percent of total billed charges,Implant Device,1401.75,70,,1401.75,percent of total billed charges,All Other,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1361.7,34,"If Charge > 2,000, then 34 percent",1361.7,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2963.71,
ALLERGAN SSM-520 BREAST IMPLANT 520CC,C1789,HCPCS,,79010414,CDM,278,RC,,,both,,,4005,2963.71,,,2963.71,Other,150% of Medicare + 9.63% HCRA Surcharge,1802.25,45,,1802.25,percent of total billed charges,Critical Access Hospital RCC factor,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1982.48,,,1982.48,Other,110% of Medicare,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1361.7,34,"Charges > $500, x 34%",1361.7,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1602,40,,1602,percent of total billed charges,Implant Device,1401.75,70,,1401.75,percent of total billed charges,All Other,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1361.7,34,"If Charge > 2,000, then 34 percent",1361.7,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2963.71,
ALLERGAN SSM-560 BREAST IMPLANT 560CC,C1789,HCPCS,,79010415,CDM,278,RC,,,both,,,4005,2963.71,,,2963.71,Other,150% of Medicare + 9.63% HCRA Surcharge,1802.25,45,,1802.25,percent of total billed charges,Critical Access Hospital RCC factor,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1982.48,,,1982.48,Other,110% of Medicare,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1361.7,34,"Charges > $500, x 34%",1361.7,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1602,40,,1602,percent of total billed charges,Implant Device,1401.75,70,,1401.75,percent of total billed charges,All Other,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1361.7,34,"If Charge > 2,000, then 34 percent",1361.7,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2963.71,
ALLERGAN SSM-600 BREAST IMPLANT 600CC,C1789,HCPCS,,79010416,CDM,278,RC,,,both,,,4005,2963.71,,,2963.71,Other,150% of Medicare + 9.63% HCRA Surcharge,1802.25,45,,1802.25,percent of total billed charges,Critical Access Hospital RCC factor,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1982.48,,,1982.48,Other,110% of Medicare,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1361.7,34,"Charges > $500, x 34%",1361.7,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1602,40,,1602,percent of total billed charges,Implant Device,1401.75,70,,1401.75,percent of total billed charges,All Other,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1361.7,34,"If Charge > 2,000, then 34 percent",1361.7,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2963.71,
ZIMMER 42-5026-062-01 FEMUR STANDARD LT,C1776,HCPCS,,79010422,CDM,278,RC,,,both,,,10200,7548.03,,,7548.03,Other,150% of Medicare + 9.63% HCRA Surcharge,4590,45,,4590,percent of total billed charges,Critical Access Hospital RCC factor,3468,34,,3468,percent of total billed charges,Implant Device,3468,34,,3468,percent of total billed charges,Implant Device,3468,34,,3468,percent of total billed charges,Implant Device,3468,34,,3468,percent of total billed charges,Implant Device,3468,34,,3468,percent of total billed charges,Implant Device,5049,,,5049,Other,110% of Medicare,3570,35,,3570,percent of total billed charges,Implant Device,3468,34,"Charges > $500, x 34%",3468,percent of total billed charges,Implant Device,3570,35,,3570,percent of total billed charges,Implant Device,3570,35,,3570,percent of total billed charges,Implant Device,3570,35,,3570,percent of total billed charges,Implant Device,3570,35,,3570,percent of total billed charges,Implant Device,3570,35,,3570,percent of total billed charges,Implant Device,4080,40,,4080,percent of total billed charges,Implant Device,3570,70,,3570,percent of total billed charges,All Other,3468,34,,3468,percent of total billed charges,Implant Device,3468,34,,3468,percent of total billed charges,Implant Device,3570,35,,3570,percent of total billed charges,Implant Device,3570,35,,3570,percent of total billed charges,Implant Device,3570,35,,3570,percent of total billed charges,Implant Device,3570,35,,3570,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3468,34,"If Charge > 2,000, then 34 percent",3468,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,7548.03,
ZIMMER 42-5320-071-01 TIBIA 5 DEG LT,C1776,HCPCS,,79010423,CDM,278,RC,,,both,,,4433,3280.43,,,3280.43,Other,150% of Medicare + 9.63% HCRA Surcharge,1994.85,45,,1994.85,percent of total billed charges,Critical Access Hospital RCC factor,1507.22,34,,1507.22,percent of total billed charges,Implant Device,1507.22,34,,1507.22,percent of total billed charges,Implant Device,1507.22,34,,1507.22,percent of total billed charges,Implant Device,1507.22,34,,1507.22,percent of total billed charges,Implant Device,1507.22,34,,1507.22,percent of total billed charges,Implant Device,2194.34,,,2194.34,Other,110% of Medicare,1551.55,35,,1551.55,percent of total billed charges,Implant Device,1507.22,34,"Charges > $500, x 34%",1507.22,percent of total billed charges,Implant Device,1551.55,35,,1551.55,percent of total billed charges,Implant Device,1551.55,35,,1551.55,percent of total billed charges,Implant Device,1551.55,35,,1551.55,percent of total billed charges,Implant Device,1551.55,35,,1551.55,percent of total billed charges,Implant Device,1551.55,35,,1551.55,percent of total billed charges,Implant Device,1773.2,40,,1773.2,percent of total billed charges,Implant Device,1551.55,70,,1551.55,percent of total billed charges,All Other,1507.22,34,,1507.22,percent of total billed charges,Implant Device,1507.22,34,,1507.22,percent of total billed charges,Implant Device,1551.55,35,,1551.55,percent of total billed charges,Implant Device,1551.55,35,,1551.55,percent of total billed charges,Implant Device,1551.55,35,,1551.55,percent of total billed charges,Implant Device,1551.55,35,,1551.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1507.22,34,"If Charge > 2,000, then 34 percent",1507.22,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3280.43,
ZIMMER 42-5121-007-10 ART SURF LT 10MM,C1776,HCPCS,,79010424,CDM,278,RC,,,both,,,3450,2553.01,,,2553.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1552.5,45,,1552.5,percent of total billed charges,Critical Access Hospital RCC factor,1173,34,,1173,percent of total billed charges,Implant Device,1173,34,,1173,percent of total billed charges,Implant Device,1173,34,,1173,percent of total billed charges,Implant Device,1173,34,,1173,percent of total billed charges,Implant Device,1173,34,,1173,percent of total billed charges,Implant Device,1707.75,,,1707.75,Other,110% of Medicare,1207.5,35,,1207.5,percent of total billed charges,Implant Device,1173,34,"Charges > $500, x 34%",1173,percent of total billed charges,Implant Device,1207.5,35,,1207.5,percent of total billed charges,Implant Device,1207.5,35,,1207.5,percent of total billed charges,Implant Device,1207.5,35,,1207.5,percent of total billed charges,Implant Device,1207.5,35,,1207.5,percent of total billed charges,Implant Device,1207.5,35,,1207.5,percent of total billed charges,Implant Device,1380,40,,1380,percent of total billed charges,Implant Device,1207.5,70,,1207.5,percent of total billed charges,All Other,1173,34,,1173,percent of total billed charges,Implant Device,1173,34,,1173,percent of total billed charges,Implant Device,1207.5,35,,1207.5,percent of total billed charges,Implant Device,1207.5,35,,1207.5,percent of total billed charges,Implant Device,1207.5,35,,1207.5,percent of total billed charges,Implant Device,1207.5,35,,1207.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1173,34,"If Charge > 2,000, then 34 percent",1173,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2553.01,
ZIMMER SP26000 PEG SCREW 2.5X26MM,C1713,HCPCS,,79010425,CDM,278,RC,,,both,,,288,213.12,,,213.12,Other,150% of Medicare + 9.63% HCRA Surcharge,129.6,45,,129.6,percent of total billed charges,Critical Access Hospital RCC factor,97.92,34,,97.92,percent of total billed charges,Implant Device,97.92,34,,97.92,percent of total billed charges,Implant Device,97.92,34,,97.92,percent of total billed charges,Implant Device,97.92,34,,97.92,percent of total billed charges,Implant Device,97.92,34,,97.92,percent of total billed charges,Implant Device,142.56,,,142.56,Other,110% of Medicare,100.8,35,,100.8,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,100.8,35,,100.8,percent of total billed charges,Implant Device,100.8,35,,100.8,percent of total billed charges,Implant Device,100.8,35,,100.8,percent of total billed charges,Implant Device,100.8,35,,100.8,percent of total billed charges,Implant Device,100.8,35,,100.8,percent of total billed charges,Implant Device,115.2,40,,115.2,percent of total billed charges,Implant Device,100.8,70,,100.8,percent of total billed charges,All Other,97.92,34,,97.92,percent of total billed charges,Implant Device,97.92,34,,97.92,percent of total billed charges,Implant Device,100.8,35,,100.8,percent of total billed charges,Implant Device,100.8,35,,100.8,percent of total billed charges,Implant Device,100.8,35,,100.8,percent of total billed charges,Implant Device,100.8,35,,100.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,213.12,
ZIMMER TP18000 PARTIAL THREAD 2.5X18MM,C1713,HCPCS,,79010426,CDM,278,RC,,,both,,,288,213.12,,,213.12,Other,150% of Medicare + 9.63% HCRA Surcharge,129.6,45,,129.6,percent of total billed charges,Critical Access Hospital RCC factor,97.92,34,,97.92,percent of total billed charges,Implant Device,97.92,34,,97.92,percent of total billed charges,Implant Device,97.92,34,,97.92,percent of total billed charges,Implant Device,97.92,34,,97.92,percent of total billed charges,Implant Device,97.92,34,,97.92,percent of total billed charges,Implant Device,142.56,,,142.56,Other,110% of Medicare,100.8,35,,100.8,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,100.8,35,,100.8,percent of total billed charges,Implant Device,100.8,35,,100.8,percent of total billed charges,Implant Device,100.8,35,,100.8,percent of total billed charges,Implant Device,100.8,35,,100.8,percent of total billed charges,Implant Device,100.8,35,,100.8,percent of total billed charges,Implant Device,115.2,40,,115.2,percent of total billed charges,Implant Device,100.8,70,,100.8,percent of total billed charges,All Other,97.92,34,,97.92,percent of total billed charges,Implant Device,97.92,34,,97.92,percent of total billed charges,Implant Device,100.8,35,,100.8,percent of total billed charges,Implant Device,100.8,35,,100.8,percent of total billed charges,Implant Device,100.8,35,,100.8,percent of total billed charges,Implant Device,100.8,35,,100.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,213.12,
ZIMMER TP24000 PARTIAL THREAD 2.5X24MM,C1713,HCPCS,,79010427,CDM,278,RC,,,both,,,288,213.12,,,213.12,Other,150% of Medicare + 9.63% HCRA Surcharge,129.6,45,,129.6,percent of total billed charges,Critical Access Hospital RCC factor,97.92,34,,97.92,percent of total billed charges,Implant Device,97.92,34,,97.92,percent of total billed charges,Implant Device,97.92,34,,97.92,percent of total billed charges,Implant Device,97.92,34,,97.92,percent of total billed charges,Implant Device,97.92,34,,97.92,percent of total billed charges,Implant Device,142.56,,,142.56,Other,110% of Medicare,100.8,35,,100.8,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,100.8,35,,100.8,percent of total billed charges,Implant Device,100.8,35,,100.8,percent of total billed charges,Implant Device,100.8,35,,100.8,percent of total billed charges,Implant Device,100.8,35,,100.8,percent of total billed charges,Implant Device,100.8,35,,100.8,percent of total billed charges,Implant Device,115.2,40,,115.2,percent of total billed charges,Implant Device,100.8,70,,100.8,percent of total billed charges,All Other,97.92,34,,97.92,percent of total billed charges,Implant Device,97.92,34,,97.92,percent of total billed charges,Implant Device,100.8,35,,100.8,percent of total billed charges,Implant Device,100.8,35,,100.8,percent of total billed charges,Implant Device,100.8,35,,100.8,percent of total billed charges,Implant Device,100.8,35,,100.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,213.12,
ALLERGAN 133S-MV-14-T TISSUE EXPANDR 500,C1789,HCPCS,,79010428,CDM,278,RC,,,both,,,4725,3496.51,,,3496.51,Other,150% of Medicare + 9.63% HCRA Surcharge,2126.25,45,,2126.25,percent of total billed charges,Critical Access Hospital RCC factor,1606.5,34,,1606.5,percent of total billed charges,Implant Device,1606.5,34,,1606.5,percent of total billed charges,Implant Device,1606.5,34,,1606.5,percent of total billed charges,Implant Device,1606.5,34,,1606.5,percent of total billed charges,Implant Device,1606.5,34,,1606.5,percent of total billed charges,Implant Device,2338.88,,,2338.88,Other,110% of Medicare,1653.75,35,,1653.75,percent of total billed charges,Implant Device,1606.5,34,"Charges > $500, x 34%",1606.5,percent of total billed charges,Implant Device,1653.75,35,,1653.75,percent of total billed charges,Implant Device,1653.75,35,,1653.75,percent of total billed charges,Implant Device,1653.75,35,,1653.75,percent of total billed charges,Implant Device,1653.75,35,,1653.75,percent of total billed charges,Implant Device,1653.75,35,,1653.75,percent of total billed charges,Implant Device,1890,40,,1890,percent of total billed charges,Implant Device,1653.75,70,,1653.75,percent of total billed charges,All Other,1606.5,34,,1606.5,percent of total billed charges,Implant Device,1606.5,34,,1606.5,percent of total billed charges,Implant Device,1653.75,35,,1653.75,percent of total billed charges,Implant Device,1653.75,35,,1653.75,percent of total billed charges,Implant Device,1653.75,35,,1653.75,percent of total billed charges,Implant Device,1653.75,35,,1653.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1606.5,34,"If Charge > 2,000, then 34 percent",1606.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3496.51,
ALLERGAN 133S-MV-15-T TISSUE EXPANDR 600,C1789,HCPCS,,79010429,CDM,278,RC,,,both,,,4725,3496.51,,,3496.51,Other,150% of Medicare + 9.63% HCRA Surcharge,2126.25,45,,2126.25,percent of total billed charges,Critical Access Hospital RCC factor,1606.5,34,,1606.5,percent of total billed charges,Implant Device,1606.5,34,,1606.5,percent of total billed charges,Implant Device,1606.5,34,,1606.5,percent of total billed charges,Implant Device,1606.5,34,,1606.5,percent of total billed charges,Implant Device,1606.5,34,,1606.5,percent of total billed charges,Implant Device,2338.88,,,2338.88,Other,110% of Medicare,1653.75,35,,1653.75,percent of total billed charges,Implant Device,1606.5,34,"Charges > $500, x 34%",1606.5,percent of total billed charges,Implant Device,1653.75,35,,1653.75,percent of total billed charges,Implant Device,1653.75,35,,1653.75,percent of total billed charges,Implant Device,1653.75,35,,1653.75,percent of total billed charges,Implant Device,1653.75,35,,1653.75,percent of total billed charges,Implant Device,1653.75,35,,1653.75,percent of total billed charges,Implant Device,1890,40,,1890,percent of total billed charges,Implant Device,1653.75,70,,1653.75,percent of total billed charges,All Other,1606.5,34,,1606.5,percent of total billed charges,Implant Device,1606.5,34,,1606.5,percent of total billed charges,Implant Device,1653.75,35,,1653.75,percent of total billed charges,Implant Device,1653.75,35,,1653.75,percent of total billed charges,Implant Device,1653.75,35,,1653.75,percent of total billed charges,Implant Device,1653.75,35,,1653.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1606.5,34,"If Charge > 2,000, then 34 percent",1606.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3496.51,
ALLERGAN 133S-MV-16-T TISSUE EXPANDR 700,C1789,HCPCS,,79010430,CDM,278,RC,,,both,,,4725,3496.51,,,3496.51,Other,150% of Medicare + 9.63% HCRA Surcharge,2126.25,45,,2126.25,percent of total billed charges,Critical Access Hospital RCC factor,1606.5,34,,1606.5,percent of total billed charges,Implant Device,1606.5,34,,1606.5,percent of total billed charges,Implant Device,1606.5,34,,1606.5,percent of total billed charges,Implant Device,1606.5,34,,1606.5,percent of total billed charges,Implant Device,1606.5,34,,1606.5,percent of total billed charges,Implant Device,2338.88,,,2338.88,Other,110% of Medicare,1653.75,35,,1653.75,percent of total billed charges,Implant Device,1606.5,34,"Charges > $500, x 34%",1606.5,percent of total billed charges,Implant Device,1653.75,35,,1653.75,percent of total billed charges,Implant Device,1653.75,35,,1653.75,percent of total billed charges,Implant Device,1653.75,35,,1653.75,percent of total billed charges,Implant Device,1653.75,35,,1653.75,percent of total billed charges,Implant Device,1653.75,35,,1653.75,percent of total billed charges,Implant Device,1890,40,,1890,percent of total billed charges,Implant Device,1653.75,70,,1653.75,percent of total billed charges,All Other,1606.5,34,,1606.5,percent of total billed charges,Implant Device,1606.5,34,,1606.5,percent of total billed charges,Implant Device,1653.75,35,,1653.75,percent of total billed charges,Implant Device,1653.75,35,,1653.75,percent of total billed charges,Implant Device,1653.75,35,,1653.75,percent of total billed charges,Implant Device,1653.75,35,,1653.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1606.5,34,"If Charge > 2,000, then 34 percent",1606.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3496.51,
BOS SCI M0061802340 CONTOR STENT 7FRX28,C1874,HCPCS,,79010431,CDM,278,RC,,,both,,,425,314.5,,,314.5,Other,150% of Medicare + 9.63% HCRA Surcharge,191.25,45,,191.25,percent of total billed charges,Critical Access Hospital RCC factor,144.5,34,,144.5,percent of total billed charges,Implant Device,144.5,34,,144.5,percent of total billed charges,Implant Device,144.5,34,,144.5,percent of total billed charges,Implant Device,144.5,34,,144.5,percent of total billed charges,Implant Device,144.5,34,,144.5,percent of total billed charges,Implant Device,210.38,,,210.38,Other,110% of Medicare,148.75,35,,148.75,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,148.75,35,,148.75,percent of total billed charges,Implant Device,148.75,35,,148.75,percent of total billed charges,Implant Device,148.75,35,,148.75,percent of total billed charges,Implant Device,148.75,35,,148.75,percent of total billed charges,Implant Device,148.75,35,,148.75,percent of total billed charges,Implant Device,170,40,,170,percent of total billed charges,Implant Device,148.75,70,,148.75,percent of total billed charges,All Other,144.5,34,,144.5,percent of total billed charges,Implant Device,144.5,34,,144.5,percent of total billed charges,Implant Device,148.75,35,,148.75,percent of total billed charges,Implant Device,148.75,35,,148.75,percent of total billed charges,Implant Device,148.75,35,,148.75,percent of total billed charges,Implant Device,148.75,35,,148.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,314.5,
DEPUY 214.054 CORTEX SCREW 4.5X54MM,C1713,HCPCS,,79010432,CDM,278,RC,,,both,,,59,43.66,,,43.66,Other,150% of Medicare + 9.63% HCRA Surcharge,26.55,45,,26.55,percent of total billed charges,Critical Access Hospital RCC factor,20.06,34,,20.06,percent of total billed charges,Implant Device,20.06,34,,20.06,percent of total billed charges,Implant Device,20.06,34,,20.06,percent of total billed charges,Implant Device,20.06,34,,20.06,percent of total billed charges,Implant Device,20.06,34,,20.06,percent of total billed charges,Implant Device,29.21,,,29.21,Other,110% of Medicare,20.65,35,,20.65,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,20.65,35,,20.65,percent of total billed charges,Implant Device,20.65,35,,20.65,percent of total billed charges,Implant Device,20.65,35,,20.65,percent of total billed charges,Implant Device,20.65,35,,20.65,percent of total billed charges,Implant Device,20.65,35,,20.65,percent of total billed charges,Implant Device,23.6,40,,23.6,percent of total billed charges,Implant Device,20.65,70,,20.65,percent of total billed charges,All Other,20.06,34,,20.06,percent of total billed charges,Implant Device,20.06,34,,20.06,percent of total billed charges,Implant Device,20.65,35,,20.65,percent of total billed charges,Implant Device,20.65,35,,20.65,percent of total billed charges,Implant Device,20.65,35,,20.65,percent of total billed charges,Implant Device,20.65,35,,20.65,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,43.66,
STRYKER 628308 ANTERIOR MIDSHAFT PLT 8H,C1713,HCPCS,,79010433,CDM,278,RC,,,both,,,3069,2271.07,,,2271.07,Other,150% of Medicare + 9.63% HCRA Surcharge,1381.05,45,,1381.05,percent of total billed charges,Critical Access Hospital RCC factor,1043.46,34,,1043.46,percent of total billed charges,Implant Device,1043.46,34,,1043.46,percent of total billed charges,Implant Device,1043.46,34,,1043.46,percent of total billed charges,Implant Device,1043.46,34,,1043.46,percent of total billed charges,Implant Device,1043.46,34,,1043.46,percent of total billed charges,Implant Device,1519.16,,,1519.16,Other,110% of Medicare,1074.15,35,,1074.15,percent of total billed charges,Implant Device,1043.46,34,"Charges > $500, x 34%",1043.46,percent of total billed charges,Implant Device,1074.15,35,,1074.15,percent of total billed charges,Implant Device,1074.15,35,,1074.15,percent of total billed charges,Implant Device,1074.15,35,,1074.15,percent of total billed charges,Implant Device,1074.15,35,,1074.15,percent of total billed charges,Implant Device,1074.15,35,,1074.15,percent of total billed charges,Implant Device,1227.6,40,,1227.6,percent of total billed charges,Implant Device,1074.15,70,,1074.15,percent of total billed charges,All Other,1043.46,34,,1043.46,percent of total billed charges,Implant Device,1043.46,34,,1043.46,percent of total billed charges,Implant Device,1074.15,35,,1074.15,percent of total billed charges,Implant Device,1074.15,35,,1074.15,percent of total billed charges,Implant Device,1074.15,35,,1074.15,percent of total billed charges,Implant Device,1074.15,35,,1074.15,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1043.46,34,"If Charge > 2,000, then 34 percent",1043.46,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2271.07,
STRYKER 657028 LOCKING SCREW 2.7X28MM,C1713,HCPCS,,79010434,CDM,278,RC,,,both,,,494,365.56,,,365.56,Other,150% of Medicare + 9.63% HCRA Surcharge,222.3,45,,222.3,percent of total billed charges,Critical Access Hospital RCC factor,167.96,34,,167.96,percent of total billed charges,Implant Device,167.96,34,,167.96,percent of total billed charges,Implant Device,167.96,34,,167.96,percent of total billed charges,Implant Device,167.96,34,,167.96,percent of total billed charges,Implant Device,167.96,34,,167.96,percent of total billed charges,Implant Device,244.53,,,244.53,Other,110% of Medicare,172.9,35,,172.9,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,172.9,35,,172.9,percent of total billed charges,Implant Device,172.9,35,,172.9,percent of total billed charges,Implant Device,172.9,35,,172.9,percent of total billed charges,Implant Device,172.9,35,,172.9,percent of total billed charges,Implant Device,172.9,35,,172.9,percent of total billed charges,Implant Device,197.6,40,,197.6,percent of total billed charges,Implant Device,172.9,70,,172.9,percent of total billed charges,All Other,167.96,34,,167.96,percent of total billed charges,Implant Device,167.96,34,,167.96,percent of total billed charges,Implant Device,172.9,35,,172.9,percent of total billed charges,Implant Device,172.9,35,,172.9,percent of total billed charges,Implant Device,172.9,35,,172.9,percent of total billed charges,Implant Device,172.9,35,,172.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,365.56,
STRYKER 657120 BONE SCREW 2.7X20MM,C1713,HCPCS,,79010435,CDM,278,RC,,,both,,,294,217.56,,,217.56,Other,150% of Medicare + 9.63% HCRA Surcharge,132.3,45,,132.3,percent of total billed charges,Critical Access Hospital RCC factor,99.96,34,,99.96,percent of total billed charges,Implant Device,99.96,34,,99.96,percent of total billed charges,Implant Device,99.96,34,,99.96,percent of total billed charges,Implant Device,99.96,34,,99.96,percent of total billed charges,Implant Device,99.96,34,,99.96,percent of total billed charges,Implant Device,145.53,,,145.53,Other,110% of Medicare,102.9,35,,102.9,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,102.9,35,,102.9,percent of total billed charges,Implant Device,102.9,35,,102.9,percent of total billed charges,Implant Device,102.9,35,,102.9,percent of total billed charges,Implant Device,102.9,35,,102.9,percent of total billed charges,Implant Device,102.9,35,,102.9,percent of total billed charges,Implant Device,117.6,40,,117.6,percent of total billed charges,Implant Device,102.9,70,,102.9,percent of total billed charges,All Other,99.96,34,,99.96,percent of total billed charges,Implant Device,99.96,34,,99.96,percent of total billed charges,Implant Device,102.9,35,,102.9,percent of total billed charges,Implant Device,102.9,35,,102.9,percent of total billed charges,Implant Device,102.9,35,,102.9,percent of total billed charges,Implant Device,102.9,35,,102.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,217.56,
ARTHREX AR-8724-10PT 2.4X10MM PT SCREW,C1713,HCPCS,,79010436,CDM,278,RC,,,both,,,624,461.76,,,461.76,Other,150% of Medicare + 9.63% HCRA Surcharge,280.8,45,,280.8,percent of total billed charges,Critical Access Hospital RCC factor,212.16,34,,212.16,percent of total billed charges,Implant Device,212.16,34,,212.16,percent of total billed charges,Implant Device,212.16,34,,212.16,percent of total billed charges,Implant Device,212.16,34,,212.16,percent of total billed charges,Implant Device,212.16,34,,212.16,percent of total billed charges,Implant Device,308.88,,,308.88,Other,110% of Medicare,218.4,35,,218.4,percent of total billed charges,Implant Device,212.16,34,"Charges > $500, x 34%",212.16,percent of total billed charges,Implant Device,218.4,35,,218.4,percent of total billed charges,Implant Device,218.4,35,,218.4,percent of total billed charges,Implant Device,218.4,35,,218.4,percent of total billed charges,Implant Device,218.4,35,,218.4,percent of total billed charges,Implant Device,218.4,35,,218.4,percent of total billed charges,Implant Device,249.6,40,,249.6,percent of total billed charges,Implant Device,218.4,70,,218.4,percent of total billed charges,All Other,212.16,34,,212.16,percent of total billed charges,Implant Device,212.16,34,,212.16,percent of total billed charges,Implant Device,218.4,35,,218.4,percent of total billed charges,Implant Device,218.4,35,,218.4,percent of total billed charges,Implant Device,218.4,35,,218.4,percent of total billed charges,Implant Device,218.4,35,,218.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,461.76,
ARTHREX AR-8724-12PT 2.4X12MM PT SCREW,C1713,HCPCS,,79010437,CDM,278,RC,,,both,,,624,461.76,,,461.76,Other,150% of Medicare + 9.63% HCRA Surcharge,280.8,45,,280.8,percent of total billed charges,Critical Access Hospital RCC factor,212.16,34,,212.16,percent of total billed charges,Implant Device,212.16,34,,212.16,percent of total billed charges,Implant Device,212.16,34,,212.16,percent of total billed charges,Implant Device,212.16,34,,212.16,percent of total billed charges,Implant Device,212.16,34,,212.16,percent of total billed charges,Implant Device,308.88,,,308.88,Other,110% of Medicare,218.4,35,,218.4,percent of total billed charges,Implant Device,212.16,34,"Charges > $500, x 34%",212.16,percent of total billed charges,Implant Device,218.4,35,,218.4,percent of total billed charges,Implant Device,218.4,35,,218.4,percent of total billed charges,Implant Device,218.4,35,,218.4,percent of total billed charges,Implant Device,218.4,35,,218.4,percent of total billed charges,Implant Device,218.4,35,,218.4,percent of total billed charges,Implant Device,249.6,40,,249.6,percent of total billed charges,Implant Device,218.4,70,,218.4,percent of total billed charges,All Other,212.16,34,,212.16,percent of total billed charges,Implant Device,212.16,34,,212.16,percent of total billed charges,Implant Device,218.4,35,,218.4,percent of total billed charges,Implant Device,218.4,35,,218.4,percent of total billed charges,Implant Device,218.4,35,,218.4,percent of total billed charges,Implant Device,218.4,35,,218.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,461.76,
ARTHREX AR-8724-14PT 2.4X14MM PT SCREW,C1713,HCPCS,,79010438,CDM,278,RC,,,both,,,624,461.76,,,461.76,Other,150% of Medicare + 9.63% HCRA Surcharge,280.8,45,,280.8,percent of total billed charges,Critical Access Hospital RCC factor,212.16,34,,212.16,percent of total billed charges,Implant Device,212.16,34,,212.16,percent of total billed charges,Implant Device,212.16,34,,212.16,percent of total billed charges,Implant Device,212.16,34,,212.16,percent of total billed charges,Implant Device,212.16,34,,212.16,percent of total billed charges,Implant Device,308.88,,,308.88,Other,110% of Medicare,218.4,35,,218.4,percent of total billed charges,Implant Device,212.16,34,"Charges > $500, x 34%",212.16,percent of total billed charges,Implant Device,218.4,35,,218.4,percent of total billed charges,Implant Device,218.4,35,,218.4,percent of total billed charges,Implant Device,218.4,35,,218.4,percent of total billed charges,Implant Device,218.4,35,,218.4,percent of total billed charges,Implant Device,218.4,35,,218.4,percent of total billed charges,Implant Device,249.6,40,,249.6,percent of total billed charges,Implant Device,218.4,70,,218.4,percent of total billed charges,All Other,212.16,34,,212.16,percent of total billed charges,Implant Device,212.16,34,,212.16,percent of total billed charges,Implant Device,218.4,35,,218.4,percent of total billed charges,Implant Device,218.4,35,,218.4,percent of total billed charges,Implant Device,218.4,35,,218.4,percent of total billed charges,Implant Device,218.4,35,,218.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,461.76,
STRYKER 5510-F-701 FEMORAL COMP #7 LT,C1776,HCPCS,,79010440,CDM,278,RC,,,both,,,5100,3774.01,,,3774.01,Other,150% of Medicare + 9.63% HCRA Surcharge,2295,45,,2295,percent of total billed charges,Critical Access Hospital RCC factor,1734,34,,1734,percent of total billed charges,Implant Device,1734,34,,1734,percent of total billed charges,Implant Device,1734,34,,1734,percent of total billed charges,Implant Device,1734,34,,1734,percent of total billed charges,Implant Device,1734,34,,1734,percent of total billed charges,Implant Device,2524.5,,,2524.5,Other,110% of Medicare,1785,35,,1785,percent of total billed charges,Implant Device,1734,34,"Charges > $500, x 34%",1734,percent of total billed charges,Implant Device,1785,35,,1785,percent of total billed charges,Implant Device,1785,35,,1785,percent of total billed charges,Implant Device,1785,35,,1785,percent of total billed charges,Implant Device,1785,35,,1785,percent of total billed charges,Implant Device,1785,35,,1785,percent of total billed charges,Implant Device,2040,40,,2040,percent of total billed charges,Implant Device,1785,70,,1785,percent of total billed charges,All Other,1734,34,,1734,percent of total billed charges,Implant Device,1734,34,,1734,percent of total billed charges,Implant Device,1785,35,,1785,percent of total billed charges,Implant Device,1785,35,,1785,percent of total billed charges,Implant Device,1785,35,,1785,percent of total billed charges,Implant Device,1785,35,,1785,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1734,34,"If Charge > 2,000, then 34 percent",1734,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3774.01,
STRYKER 5530-G-611 TIB INSERT SZ 6 11MM,C1776,HCPCS,,79010441,CDM,278,RC,,,both,,,3300,2442.01,,,2442.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1485,45,,1485,percent of total billed charges,Critical Access Hospital RCC factor,1122,34,,1122,percent of total billed charges,Implant Device,1122,34,,1122,percent of total billed charges,Implant Device,1122,34,,1122,percent of total billed charges,Implant Device,1122,34,,1122,percent of total billed charges,Implant Device,1122,34,,1122,percent of total billed charges,Implant Device,1633.5,,,1633.5,Other,110% of Medicare,1155,35,,1155,percent of total billed charges,Implant Device,1122,34,"Charges > $500, x 34%",1122,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,1320,40,,1320,percent of total billed charges,Implant Device,1155,70,,1155,percent of total billed charges,All Other,1122,34,,1122,percent of total billed charges,Implant Device,1122,34,,1122,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1122,34,"If Charge > 2,000, then 34 percent",1122,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2442.01,
ZIMMER 00-5750-014-02 FEMORAL COMP SZ D,C1776,HCPCS,,79010442,CDM,278,RC,,,both,,,6300,4662.02,,,4662.02,Other,150% of Medicare + 9.63% HCRA Surcharge,2835,45,,2835,percent of total billed charges,Critical Access Hospital RCC factor,2142,34,,2142,percent of total billed charges,Implant Device,2142,34,,2142,percent of total billed charges,Implant Device,2142,34,,2142,percent of total billed charges,Implant Device,2142,34,,2142,percent of total billed charges,Implant Device,2142,34,,2142,percent of total billed charges,Implant Device,3118.5,,,3118.5,Other,110% of Medicare,2205,35,,2205,percent of total billed charges,Implant Device,2142,34,"Charges > $500, x 34%",2142,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2520,40,,2520,percent of total billed charges,Implant Device,2205,70,,2205,percent of total billed charges,All Other,2142,34,,2142,percent of total billed charges,Implant Device,2142,34,,2142,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2142,34,"If Charge > 2,000, then 34 percent",2142,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4662.02,
BOST SCI M00516710 ESOPHAGEAL 18X123MM,C1874,HCPCS,,79010444,CDM,278,RC,,,both,,,6649,4920.28,,,4920.28,Other,150% of Medicare + 9.63% HCRA Surcharge,2992.05,45,,2992.05,percent of total billed charges,Critical Access Hospital RCC factor,2260.66,34,,2260.66,percent of total billed charges,Implant Device,2260.66,34,,2260.66,percent of total billed charges,Implant Device,2260.66,34,,2260.66,percent of total billed charges,Implant Device,2260.66,34,,2260.66,percent of total billed charges,Implant Device,2260.66,34,,2260.66,percent of total billed charges,Implant Device,3291.26,,,3291.26,Other,110% of Medicare,2327.15,35,,2327.15,percent of total billed charges,Implant Device,2260.66,34,"Charges > $500, x 34%",2260.66,percent of total billed charges,Implant Device,2327.15,35,,2327.15,percent of total billed charges,Implant Device,2327.15,35,,2327.15,percent of total billed charges,Implant Device,2327.15,35,,2327.15,percent of total billed charges,Implant Device,2327.15,35,,2327.15,percent of total billed charges,Implant Device,2327.15,35,,2327.15,percent of total billed charges,Implant Device,2659.6,40,,2659.6,percent of total billed charges,Implant Device,2327.15,70,,2327.15,percent of total billed charges,All Other,2260.66,34,,2260.66,percent of total billed charges,Implant Device,2260.66,34,,2260.66,percent of total billed charges,Implant Device,2327.15,35,,2327.15,percent of total billed charges,Implant Device,2327.15,35,,2327.15,percent of total billed charges,Implant Device,2327.15,35,,2327.15,percent of total billed charges,Implant Device,2327.15,35,,2327.15,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2260.66,34,"If Charge > 2,000, then 34 percent",2260.66,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4920.28,
DEPUY 02.231.008S LOCKING SCREW 5X8MM,C1713,HCPCS,,79010445,CDM,278,RC,,,both,,,788,583.12,,,583.12,Other,150% of Medicare + 9.63% HCRA Surcharge,354.6,45,,354.6,percent of total billed charges,Critical Access Hospital RCC factor,267.92,34,,267.92,percent of total billed charges,Implant Device,267.92,34,,267.92,percent of total billed charges,Implant Device,267.92,34,,267.92,percent of total billed charges,Implant Device,267.92,34,,267.92,percent of total billed charges,Implant Device,267.92,34,,267.92,percent of total billed charges,Implant Device,390.06,,,390.06,Other,110% of Medicare,275.8,35,,275.8,percent of total billed charges,Implant Device,267.92,34,"Charges > $500, x 34%",267.92,percent of total billed charges,Implant Device,275.8,35,,275.8,percent of total billed charges,Implant Device,275.8,35,,275.8,percent of total billed charges,Implant Device,275.8,35,,275.8,percent of total billed charges,Implant Device,275.8,35,,275.8,percent of total billed charges,Implant Device,275.8,35,,275.8,percent of total billed charges,Implant Device,315.2,40,,315.2,percent of total billed charges,Implant Device,275.8,70,,275.8,percent of total billed charges,All Other,267.92,34,,267.92,percent of total billed charges,Implant Device,267.92,34,,267.92,percent of total billed charges,Implant Device,275.8,35,,275.8,percent of total billed charges,Implant Device,275.8,35,,275.8,percent of total billed charges,Implant Device,275.8,35,,275.8,percent of total billed charges,Implant Device,275.8,35,,275.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,583.12,
IN2BONES V35 ST216 NON-LOCK SCREW 3.5X16,C1713,HCPCS,,79010446,CDM,278,RC,,,both,,,870,643.8,,,643.8,Other,150% of Medicare + 9.63% HCRA Surcharge,391.5,45,,391.5,percent of total billed charges,Critical Access Hospital RCC factor,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,430.65,,,430.65,Other,110% of Medicare,304.5,35,,304.5,percent of total billed charges,Implant Device,295.8,34,"Charges > $500, x 34%",295.8,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,348,40,,348,percent of total billed charges,Implant Device,304.5,70,,304.5,percent of total billed charges,All Other,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,643.8,
ARTHREX AR-2326PSLC SWIVELOCK 3.9MM,C1713,HCPCS,,79010448,CDM,278,RC,,,both,,,1125,832.5,,,832.5,Other,150% of Medicare + 9.63% HCRA Surcharge,506.25,45,,506.25,percent of total billed charges,Critical Access Hospital RCC factor,382.5,34,,382.5,percent of total billed charges,Implant Device,382.5,34,,382.5,percent of total billed charges,Implant Device,382.5,34,,382.5,percent of total billed charges,Implant Device,382.5,34,,382.5,percent of total billed charges,Implant Device,382.5,34,,382.5,percent of total billed charges,Implant Device,556.88,,,556.88,Other,110% of Medicare,393.75,35,,393.75,percent of total billed charges,Implant Device,382.5,34,"Charges > $500, x 34%",382.5,percent of total billed charges,Implant Device,393.75,35,,393.75,percent of total billed charges,Implant Device,393.75,35,,393.75,percent of total billed charges,Implant Device,393.75,35,,393.75,percent of total billed charges,Implant Device,393.75,35,,393.75,percent of total billed charges,Implant Device,393.75,35,,393.75,percent of total billed charges,Implant Device,450,40,,450,percent of total billed charges,Implant Device,393.75,70,,393.75,percent of total billed charges,All Other,382.5,34,,382.5,percent of total billed charges,Implant Device,382.5,34,,382.5,percent of total billed charges,Implant Device,393.75,35,,393.75,percent of total billed charges,Implant Device,393.75,35,,393.75,percent of total billed charges,Implant Device,393.75,35,,393.75,percent of total billed charges,Implant Device,393.75,35,,393.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,832.5,
STRYKER 1832-3824S HUMERAL NAIL RT 240MM,C1713,HCPCS,,79010451,CDM,278,RC,,,both,,,4152,3072.49,,,3072.49,Other,150% of Medicare + 9.63% HCRA Surcharge,1868.4,45,,1868.4,percent of total billed charges,Critical Access Hospital RCC factor,1411.68,34,,1411.68,percent of total billed charges,Implant Device,1411.68,34,,1411.68,percent of total billed charges,Implant Device,1411.68,34,,1411.68,percent of total billed charges,Implant Device,1411.68,34,,1411.68,percent of total billed charges,Implant Device,1411.68,34,,1411.68,percent of total billed charges,Implant Device,2055.24,,,2055.24,Other,110% of Medicare,1453.2,35,,1453.2,percent of total billed charges,Implant Device,1411.68,34,"Charges > $500, x 34%",1411.68,percent of total billed charges,Implant Device,1453.2,35,,1453.2,percent of total billed charges,Implant Device,1453.2,35,,1453.2,percent of total billed charges,Implant Device,1453.2,35,,1453.2,percent of total billed charges,Implant Device,1453.2,35,,1453.2,percent of total billed charges,Implant Device,1453.2,35,,1453.2,percent of total billed charges,Implant Device,1660.8,40,,1660.8,percent of total billed charges,Implant Device,1453.2,70,,1453.2,percent of total billed charges,All Other,1411.68,34,,1411.68,percent of total billed charges,Implant Device,1411.68,34,,1411.68,percent of total billed charges,Implant Device,1453.2,35,,1453.2,percent of total billed charges,Implant Device,1453.2,35,,1453.2,percent of total billed charges,Implant Device,1453.2,35,,1453.2,percent of total billed charges,Implant Device,1453.2,35,,1453.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1411.68,34,"If Charge > 2,000, then 34 percent",1411.68,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3072.49,
EXACTECH 320-31-36 GLENOSPHERE 36MM,C1776,HCPCS,,79010452,CDM,278,RC,,,both,,,4050,2997.01,,,2997.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1822.5,45,,1822.5,percent of total billed charges,Critical Access Hospital RCC factor,1377,34,,1377,percent of total billed charges,Implant Device,1377,34,,1377,percent of total billed charges,Implant Device,1377,34,,1377,percent of total billed charges,Implant Device,1377,34,,1377,percent of total billed charges,Implant Device,1377,34,,1377,percent of total billed charges,Implant Device,2004.75,,,2004.75,Other,110% of Medicare,1417.5,35,,1417.5,percent of total billed charges,Implant Device,1377,34,"Charges > $500, x 34%",1377,percent of total billed charges,Implant Device,1417.5,35,,1417.5,percent of total billed charges,Implant Device,1417.5,35,,1417.5,percent of total billed charges,Implant Device,1417.5,35,,1417.5,percent of total billed charges,Implant Device,1417.5,35,,1417.5,percent of total billed charges,Implant Device,1417.5,35,,1417.5,percent of total billed charges,Implant Device,1620,40,,1620,percent of total billed charges,Implant Device,1417.5,70,,1417.5,percent of total billed charges,All Other,1377,34,,1377,percent of total billed charges,Implant Device,1377,34,,1377,percent of total billed charges,Implant Device,1417.5,35,,1417.5,percent of total billed charges,Implant Device,1417.5,35,,1417.5,percent of total billed charges,Implant Device,1417.5,35,,1417.5,percent of total billed charges,Implant Device,1417.5,35,,1417.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1377,34,"If Charge > 2,000, then 34 percent",1377,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2997.01,
EXACTECH 320-35-02 GLENOID BASEPLT 10DEG,C1776,HCPCS,,79010453,CDM,278,RC,,,both,,,5925,4384.51,,,4384.51,Other,150% of Medicare + 9.63% HCRA Surcharge,2666.25,45,,2666.25,percent of total billed charges,Critical Access Hospital RCC factor,2014.5,34,,2014.5,percent of total billed charges,Implant Device,2014.5,34,,2014.5,percent of total billed charges,Implant Device,2014.5,34,,2014.5,percent of total billed charges,Implant Device,2014.5,34,,2014.5,percent of total billed charges,Implant Device,2014.5,34,,2014.5,percent of total billed charges,Implant Device,2932.88,,,2932.88,Other,110% of Medicare,2073.75,35,,2073.75,percent of total billed charges,Implant Device,2014.5,34,"Charges > $500, x 34%",2014.5,percent of total billed charges,Implant Device,2073.75,35,,2073.75,percent of total billed charges,Implant Device,2073.75,35,,2073.75,percent of total billed charges,Implant Device,2073.75,35,,2073.75,percent of total billed charges,Implant Device,2073.75,35,,2073.75,percent of total billed charges,Implant Device,2073.75,35,,2073.75,percent of total billed charges,Implant Device,2370,40,,2370,percent of total billed charges,Implant Device,2073.75,70,,2073.75,percent of total billed charges,All Other,2014.5,34,,2014.5,percent of total billed charges,Implant Device,2014.5,34,,2014.5,percent of total billed charges,Implant Device,2073.75,35,,2073.75,percent of total billed charges,Implant Device,2073.75,35,,2073.75,percent of total billed charges,Implant Device,2073.75,35,,2073.75,percent of total billed charges,Implant Device,2073.75,35,,2073.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2014.5,34,"If Charge > 2,000, then 34 percent",2014.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4384.51,
EXACTECH 320-35-08 GLENOID BASEPLATE RT,C1776,HCPCS,,79010454,CDM,278,RC,,,both,,,5925,4384.51,,,4384.51,Other,150% of Medicare + 9.63% HCRA Surcharge,2666.25,45,,2666.25,percent of total billed charges,Critical Access Hospital RCC factor,2014.5,34,,2014.5,percent of total billed charges,Implant Device,2014.5,34,,2014.5,percent of total billed charges,Implant Device,2014.5,34,,2014.5,percent of total billed charges,Implant Device,2014.5,34,,2014.5,percent of total billed charges,Implant Device,2014.5,34,,2014.5,percent of total billed charges,Implant Device,2932.88,,,2932.88,Other,110% of Medicare,2073.75,35,,2073.75,percent of total billed charges,Implant Device,2014.5,34,"Charges > $500, x 34%",2014.5,percent of total billed charges,Implant Device,2073.75,35,,2073.75,percent of total billed charges,Implant Device,2073.75,35,,2073.75,percent of total billed charges,Implant Device,2073.75,35,,2073.75,percent of total billed charges,Implant Device,2073.75,35,,2073.75,percent of total billed charges,Implant Device,2073.75,35,,2073.75,percent of total billed charges,Implant Device,2370,40,,2370,percent of total billed charges,Implant Device,2073.75,70,,2073.75,percent of total billed charges,All Other,2014.5,34,,2014.5,percent of total billed charges,Implant Device,2014.5,34,,2014.5,percent of total billed charges,Implant Device,2073.75,35,,2073.75,percent of total billed charges,Implant Device,2073.75,35,,2073.75,percent of total billed charges,Implant Device,2073.75,35,,2073.75,percent of total billed charges,Implant Device,2073.75,35,,2073.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2014.5,34,"If Charge > 2,000, then 34 percent",2014.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4384.51,
STRYKER 5510-F-601 RETAINING FEM SZ 8 LT,C1776,HCPCS,,79010455,CDM,278,RC,,,both,,,5100,3774.01,,,3774.01,Other,150% of Medicare + 9.63% HCRA Surcharge,2295,45,,2295,percent of total billed charges,Critical Access Hospital RCC factor,1734,34,,1734,percent of total billed charges,Implant Device,1734,34,,1734,percent of total billed charges,Implant Device,1734,34,,1734,percent of total billed charges,Implant Device,1734,34,,1734,percent of total billed charges,Implant Device,1734,34,,1734,percent of total billed charges,Implant Device,2524.5,,,2524.5,Other,110% of Medicare,1785,35,,1785,percent of total billed charges,Implant Device,1734,34,"Charges > $500, x 34%",1734,percent of total billed charges,Implant Device,1785,35,,1785,percent of total billed charges,Implant Device,1785,35,,1785,percent of total billed charges,Implant Device,1785,35,,1785,percent of total billed charges,Implant Device,1785,35,,1785,percent of total billed charges,Implant Device,1785,35,,1785,percent of total billed charges,Implant Device,2040,40,,2040,percent of total billed charges,Implant Device,1785,70,,1785,percent of total billed charges,All Other,1734,34,,1734,percent of total billed charges,Implant Device,1734,34,,1734,percent of total billed charges,Implant Device,1785,35,,1785,percent of total billed charges,Implant Device,1785,35,,1785,percent of total billed charges,Implant Device,1785,35,,1785,percent of total billed charges,Implant Device,1785,35,,1785,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1734,34,"If Charge > 2,000, then 34 percent",1734,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3774.01,
STRYKER 5530-G-509-E TIB BEARING INSERT,C1776,HCPCS,,79010456,CDM,278,RC,,,both,,,3300,2442.01,,,2442.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1485,45,,1485,percent of total billed charges,Critical Access Hospital RCC factor,1122,34,,1122,percent of total billed charges,Implant Device,1122,34,,1122,percent of total billed charges,Implant Device,1122,34,,1122,percent of total billed charges,Implant Device,1122,34,,1122,percent of total billed charges,Implant Device,1122,34,,1122,percent of total billed charges,Implant Device,1633.5,,,1633.5,Other,110% of Medicare,1155,35,,1155,percent of total billed charges,Implant Device,1122,34,"Charges > $500, x 34%",1122,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,1320,40,,1320,percent of total billed charges,Implant Device,1155,70,,1155,percent of total billed charges,All Other,1122,34,,1122,percent of total billed charges,Implant Device,1122,34,,1122,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1122,34,"If Charge > 2,000, then 34 percent",1122,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2442.01,
EXACTECH 320-40-00 HUMERAL LINER 40MM,C1776,HCPCS,,79010457,CDM,278,RC,,,both,,,2325,1720.51,,,1720.51,Other,150% of Medicare + 9.63% HCRA Surcharge,1046.25,45,,1046.25,percent of total billed charges,Critical Access Hospital RCC factor,790.5,34,,790.5,percent of total billed charges,Implant Device,790.5,34,,790.5,percent of total billed charges,Implant Device,790.5,34,,790.5,percent of total billed charges,Implant Device,790.5,34,,790.5,percent of total billed charges,Implant Device,790.5,34,,790.5,percent of total billed charges,Implant Device,1150.88,,,1150.88,Other,110% of Medicare,813.75,35,,813.75,percent of total billed charges,Implant Device,790.5,34,"Charges > $500, x 34%",790.5,percent of total billed charges,Implant Device,813.75,35,,813.75,percent of total billed charges,Implant Device,813.75,35,,813.75,percent of total billed charges,Implant Device,813.75,35,,813.75,percent of total billed charges,Implant Device,813.75,35,,813.75,percent of total billed charges,Implant Device,813.75,35,,813.75,percent of total billed charges,Implant Device,930,40,,930,percent of total billed charges,Implant Device,813.75,70,,813.75,percent of total billed charges,All Other,790.5,34,,790.5,percent of total billed charges,Implant Device,790.5,34,,790.5,percent of total billed charges,Implant Device,813.75,35,,813.75,percent of total billed charges,Implant Device,813.75,35,,813.75,percent of total billed charges,Implant Device,813.75,35,,813.75,percent of total billed charges,Implant Device,813.75,35,,813.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,790.5,34,"If Charge > 2,000, then 34 percent",790.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1720.51,
EXACTECH 320-31-40 GLENOSPHERE 40MM,C1776,HCPCS,,79010458,CDM,278,RC,,,both,,,4050,2997.01,,,2997.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1822.5,45,,1822.5,percent of total billed charges,Critical Access Hospital RCC factor,1377,34,,1377,percent of total billed charges,Implant Device,1377,34,,1377,percent of total billed charges,Implant Device,1377,34,,1377,percent of total billed charges,Implant Device,1377,34,,1377,percent of total billed charges,Implant Device,1377,34,,1377,percent of total billed charges,Implant Device,2004.75,,,2004.75,Other,110% of Medicare,1417.5,35,,1417.5,percent of total billed charges,Implant Device,1377,34,"Charges > $500, x 34%",1377,percent of total billed charges,Implant Device,1417.5,35,,1417.5,percent of total billed charges,Implant Device,1417.5,35,,1417.5,percent of total billed charges,Implant Device,1417.5,35,,1417.5,percent of total billed charges,Implant Device,1417.5,35,,1417.5,percent of total billed charges,Implant Device,1417.5,35,,1417.5,percent of total billed charges,Implant Device,1620,40,,1620,percent of total billed charges,Implant Device,1417.5,70,,1417.5,percent of total billed charges,All Other,1377,34,,1377,percent of total billed charges,Implant Device,1377,34,,1377,percent of total billed charges,Implant Device,1417.5,35,,1417.5,percent of total billed charges,Implant Device,1417.5,35,,1417.5,percent of total billed charges,Implant Device,1417.5,35,,1417.5,percent of total billed charges,Implant Device,1417.5,35,,1417.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1377,34,"If Charge > 2,000, then 34 percent",1377,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2997.01,
EXACTECH 320-35-01 SM GLENOID PLATE,C1776,HCPCS,,79010459,CDM,278,RC,,,both,,,4590,3396.61,,,3396.61,Other,150% of Medicare + 9.63% HCRA Surcharge,2065.5,45,,2065.5,percent of total billed charges,Critical Access Hospital RCC factor,1560.6,34,,1560.6,percent of total billed charges,Implant Device,1560.6,34,,1560.6,percent of total billed charges,Implant Device,1560.6,34,,1560.6,percent of total billed charges,Implant Device,1560.6,34,,1560.6,percent of total billed charges,Implant Device,1560.6,34,,1560.6,percent of total billed charges,Implant Device,2272.05,,,2272.05,Other,110% of Medicare,1606.5,35,,1606.5,percent of total billed charges,Implant Device,1560.6,34,"Charges > $500, x 34%",1560.6,percent of total billed charges,Implant Device,1606.5,35,,1606.5,percent of total billed charges,Implant Device,1606.5,35,,1606.5,percent of total billed charges,Implant Device,1606.5,35,,1606.5,percent of total billed charges,Implant Device,1606.5,35,,1606.5,percent of total billed charges,Implant Device,1606.5,35,,1606.5,percent of total billed charges,Implant Device,1836,40,,1836,percent of total billed charges,Implant Device,1606.5,70,,1606.5,percent of total billed charges,All Other,1560.6,34,,1560.6,percent of total billed charges,Implant Device,1560.6,34,,1560.6,percent of total billed charges,Implant Device,1606.5,35,,1606.5,percent of total billed charges,Implant Device,1606.5,35,,1606.5,percent of total billed charges,Implant Device,1606.5,35,,1606.5,percent of total billed charges,Implant Device,1606.5,35,,1606.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1560.6,34,"If Charge > 2,000, then 34 percent",1560.6,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3396.61,
ALLERGAN SCLP-165 BREAST IMPLANT 165CC,C1789,HCPCS,,79010463,CDM,278,RC,,,both,,,4005,2963.71,,,2963.71,Other,150% of Medicare + 9.63% HCRA Surcharge,1802.25,45,,1802.25,percent of total billed charges,Critical Access Hospital RCC factor,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1982.48,,,1982.48,Other,110% of Medicare,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1361.7,34,"Charges > $500, x 34%",1361.7,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1602,40,,1602,percent of total billed charges,Implant Device,1401.75,70,,1401.75,percent of total billed charges,All Other,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1361.7,34,"If Charge > 2,000, then 34 percent",1361.7,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2963.71,
STRYKER AA01-43F54V 54MM OZARK PLATE,C1713,HCPCS,,79010467,CDM,278,RC,,,both,,,2250,1665.01,,,1665.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1012.5,45,,1012.5,percent of total billed charges,Critical Access Hospital RCC factor,765,34,,765,percent of total billed charges,Implant Device,765,34,,765,percent of total billed charges,Implant Device,765,34,,765,percent of total billed charges,Implant Device,765,34,,765,percent of total billed charges,Implant Device,765,34,,765,percent of total billed charges,Implant Device,1113.75,,,1113.75,Other,110% of Medicare,787.5,35,,787.5,percent of total billed charges,Implant Device,765,34,"Charges > $500, x 34%",765,percent of total billed charges,Implant Device,787.5,35,,787.5,percent of total billed charges,Implant Device,787.5,35,,787.5,percent of total billed charges,Implant Device,787.5,35,,787.5,percent of total billed charges,Implant Device,787.5,35,,787.5,percent of total billed charges,Implant Device,787.5,35,,787.5,percent of total billed charges,Implant Device,900,40,,900,percent of total billed charges,Implant Device,787.5,70,,787.5,percent of total billed charges,All Other,765,34,,765,percent of total billed charges,Implant Device,765,34,,765,percent of total billed charges,Implant Device,787.5,35,,787.5,percent of total billed charges,Implant Device,787.5,35,,787.5,percent of total billed charges,Implant Device,787.5,35,,787.5,percent of total billed charges,Implant Device,787.5,35,,787.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,765,34,"If Charge > 2,000, then 34 percent",765,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1665.01,
STRYKER 8801-04014CA 4.0X14 VST SCREW,C1713,HCPCS,,79010468,CDM,278,RC,,,both,,,450,333,,,333,Other,150% of Medicare + 9.63% HCRA Surcharge,202.5,45,,202.5,percent of total billed charges,Critical Access Hospital RCC factor,153,34,,153,percent of total billed charges,Implant Device,153,34,,153,percent of total billed charges,Implant Device,153,34,,153,percent of total billed charges,Implant Device,153,34,,153,percent of total billed charges,Implant Device,153,34,,153,percent of total billed charges,Implant Device,222.75,,,222.75,Other,110% of Medicare,157.5,35,,157.5,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,157.5,35,,157.5,percent of total billed charges,Implant Device,157.5,35,,157.5,percent of total billed charges,Implant Device,157.5,35,,157.5,percent of total billed charges,Implant Device,157.5,35,,157.5,percent of total billed charges,Implant Device,157.5,35,,157.5,percent of total billed charges,Implant Device,180,40,,180,percent of total billed charges,Implant Device,157.5,70,,157.5,percent of total billed charges,All Other,153,34,,153,percent of total billed charges,Implant Device,153,34,,153,percent of total billed charges,Implant Device,157.5,35,,157.5,percent of total billed charges,Implant Device,157.5,35,,157.5,percent of total billed charges,Implant Device,157.5,35,,157.5,percent of total billed charges,Implant Device,157.5,35,,157.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,333,
ULRICH CS 2250-12-24-6 SM VBR 12X24040MM,C1713,HCPCS,,79010471,CDM,278,RC,,,both,,,21735,16083.95,,,16083.95,Other,150% of Medicare + 9.63% HCRA Surcharge,9780.75,45,,9780.75,percent of total billed charges,Critical Access Hospital RCC factor,7389.9,34,,7389.9,percent of total billed charges,Implant Device,7389.9,34,,7389.9,percent of total billed charges,Implant Device,7389.9,34,,7389.9,percent of total billed charges,Implant Device,7389.9,34,,7389.9,percent of total billed charges,Implant Device,7389.9,34,,7389.9,percent of total billed charges,Implant Device,10758.83,,,10758.83,Other,110% of Medicare,7607.25,35,,7607.25,percent of total billed charges,Implant Device,7389.9,34,"Charges > $500, x 34%",7389.9,percent of total billed charges,Implant Device,7607.25,35,,7607.25,percent of total billed charges,Implant Device,7607.25,35,,7607.25,percent of total billed charges,Implant Device,7607.25,35,,7607.25,percent of total billed charges,Implant Device,7607.25,35,,7607.25,percent of total billed charges,Implant Device,7607.25,35,,7607.25,percent of total billed charges,Implant Device,8694,40,,8694,percent of total billed charges,Implant Device,7607.25,70,,7607.25,percent of total billed charges,All Other,7389.9,34,,7389.9,percent of total billed charges,Implant Device,7389.9,34,,7389.9,percent of total billed charges,Implant Device,7607.25,35,,7607.25,percent of total billed charges,Implant Device,7607.25,35,,7607.25,percent of total billed charges,Implant Device,7607.25,35,,7607.25,percent of total billed charges,Implant Device,7607.25,35,,7607.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,7389.9,34,"If Charge > 2,000, then 34 percent",7389.9,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,16083.95,
ULRICH CS2259 SM VBR SCREW SET TI,C1713,HCPCS,,79010472,CDM,278,RC,,,both,,,2394,1771.57,,,1771.57,Other,150% of Medicare + 9.63% HCRA Surcharge,1077.3,45,,1077.3,percent of total billed charges,Critical Access Hospital RCC factor,813.96,34,,813.96,percent of total billed charges,Implant Device,813.96,34,,813.96,percent of total billed charges,Implant Device,813.96,34,,813.96,percent of total billed charges,Implant Device,813.96,34,,813.96,percent of total billed charges,Implant Device,813.96,34,,813.96,percent of total billed charges,Implant Device,1185.03,,,1185.03,Other,110% of Medicare,837.9,35,,837.9,percent of total billed charges,Implant Device,813.96,34,"Charges > $500, x 34%",813.96,percent of total billed charges,Implant Device,837.9,35,,837.9,percent of total billed charges,Implant Device,837.9,35,,837.9,percent of total billed charges,Implant Device,837.9,35,,837.9,percent of total billed charges,Implant Device,837.9,35,,837.9,percent of total billed charges,Implant Device,837.9,35,,837.9,percent of total billed charges,Implant Device,957.6,40,,957.6,percent of total billed charges,Implant Device,837.9,70,,837.9,percent of total billed charges,All Other,813.96,34,,813.96,percent of total billed charges,Implant Device,813.96,34,,813.96,percent of total billed charges,Implant Device,837.9,35,,837.9,percent of total billed charges,Implant Device,837.9,35,,837.9,percent of total billed charges,Implant Device,837.9,35,,837.9,percent of total billed charges,Implant Device,837.9,35,,837.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,813.96,34,"If Charge > 2,000, then 34 percent",813.96,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1771.57,
WOUND WCI-05-SACRXP SURG COLLAGEN(PUTTY),C1713,HCPCS,,79010474,CDM,278,RC,,,both,,,4485,3318.91,,,3318.91,Other,150% of Medicare + 9.63% HCRA Surcharge,2018.25,45,,2018.25,percent of total billed charges,Critical Access Hospital RCC factor,1524.9,34,,1524.9,percent of total billed charges,Implant Device,1524.9,34,,1524.9,percent of total billed charges,Implant Device,1524.9,34,,1524.9,percent of total billed charges,Implant Device,1524.9,34,,1524.9,percent of total billed charges,Implant Device,1524.9,34,,1524.9,percent of total billed charges,Implant Device,2220.08,,,2220.08,Other,110% of Medicare,1569.75,35,,1569.75,percent of total billed charges,Implant Device,1524.9,34,"Charges > $500, x 34%",1524.9,percent of total billed charges,Implant Device,1569.75,35,,1569.75,percent of total billed charges,Implant Device,1569.75,35,,1569.75,percent of total billed charges,Implant Device,1569.75,35,,1569.75,percent of total billed charges,Implant Device,1569.75,35,,1569.75,percent of total billed charges,Implant Device,1569.75,35,,1569.75,percent of total billed charges,Implant Device,1794,40,,1794,percent of total billed charges,Implant Device,1569.75,70,,1569.75,percent of total billed charges,All Other,1524.9,34,,1524.9,percent of total billed charges,Implant Device,1524.9,34,,1524.9,percent of total billed charges,Implant Device,1569.75,35,,1569.75,percent of total billed charges,Implant Device,1569.75,35,,1569.75,percent of total billed charges,Implant Device,1569.75,35,,1569.75,percent of total billed charges,Implant Device,1569.75,35,,1569.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1524.9,34,"If Charge > 2,000, then 34 percent",1524.9,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3318.91,
DEPUY 1365-36-740 FEMORAL HEAD 36MM,C1776,HCPCS,,79010481,CDM,278,RC,,,both,,,9349,6918.28,,,6918.28,Other,150% of Medicare + 9.63% HCRA Surcharge,4207.05,45,,4207.05,percent of total billed charges,Critical Access Hospital RCC factor,3178.66,34,,3178.66,percent of total billed charges,Implant Device,3178.66,34,,3178.66,percent of total billed charges,Implant Device,3178.66,34,,3178.66,percent of total billed charges,Implant Device,3178.66,34,,3178.66,percent of total billed charges,Implant Device,3178.66,34,,3178.66,percent of total billed charges,Implant Device,4627.76,,,4627.76,Other,110% of Medicare,3272.15,35,,3272.15,percent of total billed charges,Implant Device,3178.66,34,"Charges > $500, x 34%",3178.66,percent of total billed charges,Implant Device,3272.15,35,,3272.15,percent of total billed charges,Implant Device,3272.15,35,,3272.15,percent of total billed charges,Implant Device,3272.15,35,,3272.15,percent of total billed charges,Implant Device,3272.15,35,,3272.15,percent of total billed charges,Implant Device,3272.15,35,,3272.15,percent of total billed charges,Implant Device,3739.6,40,,3739.6,percent of total billed charges,Implant Device,3272.15,70,,3272.15,percent of total billed charges,All Other,3178.66,34,,3178.66,percent of total billed charges,Implant Device,3178.66,34,,3178.66,percent of total billed charges,Implant Device,3272.15,35,,3272.15,percent of total billed charges,Implant Device,3272.15,35,,3272.15,percent of total billed charges,Implant Device,3272.15,35,,3272.15,percent of total billed charges,Implant Device,3272.15,35,,3272.15,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3178.66,34,"If Charge > 2,000, then 34 percent",3178.66,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,6918.28,
ARTHREX AR-5025B-18 BIOCOMP SCREW 18MM,C1713,HCPCS,,79010482,CDM,278,RC,,,both,,,1695,1254.3,,,1254.3,Other,150% of Medicare + 9.63% HCRA Surcharge,762.75,45,,762.75,percent of total billed charges,Critical Access Hospital RCC factor,576.3,34,,576.3,percent of total billed charges,Implant Device,576.3,34,,576.3,percent of total billed charges,Implant Device,576.3,34,,576.3,percent of total billed charges,Implant Device,576.3,34,,576.3,percent of total billed charges,Implant Device,576.3,34,,576.3,percent of total billed charges,Implant Device,839.03,,,839.03,Other,110% of Medicare,593.25,35,,593.25,percent of total billed charges,Implant Device,576.3,34,"Charges > $500, x 34%",576.3,percent of total billed charges,Implant Device,593.25,35,,593.25,percent of total billed charges,Implant Device,593.25,35,,593.25,percent of total billed charges,Implant Device,593.25,35,,593.25,percent of total billed charges,Implant Device,593.25,35,,593.25,percent of total billed charges,Implant Device,593.25,35,,593.25,percent of total billed charges,Implant Device,678,40,,678,percent of total billed charges,Implant Device,593.25,70,,593.25,percent of total billed charges,All Other,576.3,34,,576.3,percent of total billed charges,Implant Device,576.3,34,,576.3,percent of total billed charges,Implant Device,593.25,35,,593.25,percent of total billed charges,Implant Device,593.25,35,,593.25,percent of total billed charges,Implant Device,593.25,35,,593.25,percent of total billed charges,Implant Device,593.25,35,,593.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1254.3,
ARTHREX AR-5025B-20 BIOCOMP SCREW 20MM,C1713,HCPCS,,79010483,CDM,278,RC,,,both,,,1695,1254.3,,,1254.3,Other,150% of Medicare + 9.63% HCRA Surcharge,762.75,45,,762.75,percent of total billed charges,Critical Access Hospital RCC factor,576.3,34,,576.3,percent of total billed charges,Implant Device,576.3,34,,576.3,percent of total billed charges,Implant Device,576.3,34,,576.3,percent of total billed charges,Implant Device,576.3,34,,576.3,percent of total billed charges,Implant Device,576.3,34,,576.3,percent of total billed charges,Implant Device,839.03,,,839.03,Other,110% of Medicare,593.25,35,,593.25,percent of total billed charges,Implant Device,576.3,34,"Charges > $500, x 34%",576.3,percent of total billed charges,Implant Device,593.25,35,,593.25,percent of total billed charges,Implant Device,593.25,35,,593.25,percent of total billed charges,Implant Device,593.25,35,,593.25,percent of total billed charges,Implant Device,593.25,35,,593.25,percent of total billed charges,Implant Device,593.25,35,,593.25,percent of total billed charges,Implant Device,678,40,,678,percent of total billed charges,Implant Device,593.25,70,,593.25,percent of total billed charges,All Other,576.3,34,,576.3,percent of total billed charges,Implant Device,576.3,34,,576.3,percent of total billed charges,Implant Device,593.25,35,,593.25,percent of total billed charges,Implant Device,593.25,35,,593.25,percent of total billed charges,Implant Device,593.25,35,,593.25,percent of total billed charges,Implant Device,593.25,35,,593.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1254.3,
ZIMMER 00-8755-013-36 LINER 36MM SIZE LL,C1776,HCPCS,,79010487,CDM,278,RC,,,both,,,2304,1704.97,,,1704.97,Other,150% of Medicare + 9.63% HCRA Surcharge,1036.8,45,,1036.8,percent of total billed charges,Critical Access Hospital RCC factor,783.36,34,,783.36,percent of total billed charges,Implant Device,783.36,34,,783.36,percent of total billed charges,Implant Device,783.36,34,,783.36,percent of total billed charges,Implant Device,783.36,34,,783.36,percent of total billed charges,Implant Device,783.36,34,,783.36,percent of total billed charges,Implant Device,1140.48,,,1140.48,Other,110% of Medicare,806.4,35,,806.4,percent of total billed charges,Implant Device,783.36,34,"Charges > $500, x 34%",783.36,percent of total billed charges,Implant Device,806.4,35,,806.4,percent of total billed charges,Implant Device,806.4,35,,806.4,percent of total billed charges,Implant Device,806.4,35,,806.4,percent of total billed charges,Implant Device,806.4,35,,806.4,percent of total billed charges,Implant Device,806.4,35,,806.4,percent of total billed charges,Implant Device,921.6,40,,921.6,percent of total billed charges,Implant Device,806.4,70,,806.4,percent of total billed charges,All Other,783.36,34,,783.36,percent of total billed charges,Implant Device,783.36,34,,783.36,percent of total billed charges,Implant Device,806.4,35,,806.4,percent of total billed charges,Implant Device,806.4,35,,806.4,percent of total billed charges,Implant Device,806.4,35,,806.4,percent of total billed charges,Implant Device,806.4,35,,806.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,783.36,34,"If Charge > 2,000, then 34 percent",783.36,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1704.97,
ARTHREX AR-8978-CP INTERNAL BRACE,C1713,HCPCS,,79010488,CDM,278,RC,,,both,,,4485,3318.91,,,3318.91,Other,150% of Medicare + 9.63% HCRA Surcharge,2018.25,45,,2018.25,percent of total billed charges,Critical Access Hospital RCC factor,1524.9,34,,1524.9,percent of total billed charges,Implant Device,1524.9,34,,1524.9,percent of total billed charges,Implant Device,1524.9,34,,1524.9,percent of total billed charges,Implant Device,1524.9,34,,1524.9,percent of total billed charges,Implant Device,1524.9,34,,1524.9,percent of total billed charges,Implant Device,2220.08,,,2220.08,Other,110% of Medicare,1569.75,35,,1569.75,percent of total billed charges,Implant Device,1524.9,34,"Charges > $500, x 34%",1524.9,percent of total billed charges,Implant Device,1569.75,35,,1569.75,percent of total billed charges,Implant Device,1569.75,35,,1569.75,percent of total billed charges,Implant Device,1569.75,35,,1569.75,percent of total billed charges,Implant Device,1569.75,35,,1569.75,percent of total billed charges,Implant Device,1569.75,35,,1569.75,percent of total billed charges,Implant Device,1794,40,,1794,percent of total billed charges,Implant Device,1569.75,70,,1569.75,percent of total billed charges,All Other,1524.9,34,,1524.9,percent of total billed charges,Implant Device,1524.9,34,,1524.9,percent of total billed charges,Implant Device,1569.75,35,,1569.75,percent of total billed charges,Implant Device,1569.75,35,,1569.75,percent of total billed charges,Implant Device,1569.75,35,,1569.75,percent of total billed charges,Implant Device,1569.75,35,,1569.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1524.9,34,"If Charge > 2,000, then 34 percent",1524.9,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3318.91,
ZIMMER SP16000 PEG SCREW 2.5X16MM,C1713,HCPCS,,79010489,CDM,278,RC,,,both,,,288,213.12,,,213.12,Other,150% of Medicare + 9.63% HCRA Surcharge,129.6,45,,129.6,percent of total billed charges,Critical Access Hospital RCC factor,97.92,34,,97.92,percent of total billed charges,Implant Device,97.92,34,,97.92,percent of total billed charges,Implant Device,97.92,34,,97.92,percent of total billed charges,Implant Device,97.92,34,,97.92,percent of total billed charges,Implant Device,97.92,34,,97.92,percent of total billed charges,Implant Device,142.56,,,142.56,Other,110% of Medicare,100.8,35,,100.8,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,100.8,35,,100.8,percent of total billed charges,Implant Device,100.8,35,,100.8,percent of total billed charges,Implant Device,100.8,35,,100.8,percent of total billed charges,Implant Device,100.8,35,,100.8,percent of total billed charges,Implant Device,100.8,35,,100.8,percent of total billed charges,Implant Device,115.2,40,,115.2,percent of total billed charges,Implant Device,100.8,70,,100.8,percent of total billed charges,All Other,97.92,34,,97.92,percent of total billed charges,Implant Device,97.92,34,,97.92,percent of total billed charges,Implant Device,100.8,35,,100.8,percent of total billed charges,Implant Device,100.8,35,,100.8,percent of total billed charges,Implant Device,100.8,35,,100.8,percent of total billed charges,Implant Device,100.8,35,,100.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,213.12,
ZIMMER SP18000 PEG SCREW 2.5X18MM,C1713,HCPCS,,79010490,CDM,278,RC,,,both,,,288,213.12,,,213.12,Other,150% of Medicare + 9.63% HCRA Surcharge,129.6,45,,129.6,percent of total billed charges,Critical Access Hospital RCC factor,97.92,34,,97.92,percent of total billed charges,Implant Device,97.92,34,,97.92,percent of total billed charges,Implant Device,97.92,34,,97.92,percent of total billed charges,Implant Device,97.92,34,,97.92,percent of total billed charges,Implant Device,97.92,34,,97.92,percent of total billed charges,Implant Device,142.56,,,142.56,Other,110% of Medicare,100.8,35,,100.8,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,100.8,35,,100.8,percent of total billed charges,Implant Device,100.8,35,,100.8,percent of total billed charges,Implant Device,100.8,35,,100.8,percent of total billed charges,Implant Device,100.8,35,,100.8,percent of total billed charges,Implant Device,100.8,35,,100.8,percent of total billed charges,Implant Device,115.2,40,,115.2,percent of total billed charges,Implant Device,100.8,70,,100.8,percent of total billed charges,All Other,97.92,34,,97.92,percent of total billed charges,Implant Device,97.92,34,,97.92,percent of total billed charges,Implant Device,100.8,35,,100.8,percent of total billed charges,Implant Device,100.8,35,,100.8,percent of total billed charges,Implant Device,100.8,35,,100.8,percent of total billed charges,Implant Device,100.8,35,,100.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,213.12,
WRIGHT 4310001 SWANSON HAMMERTOE SZ 1,C1776,HCPCS,,79010492,CDM,278,RC,,,both,,,3390,2508.61,,,2508.61,Other,150% of Medicare + 9.63% HCRA Surcharge,1525.5,45,,1525.5,percent of total billed charges,Critical Access Hospital RCC factor,1152.6,34,,1152.6,percent of total billed charges,Implant Device,1152.6,34,,1152.6,percent of total billed charges,Implant Device,1152.6,34,,1152.6,percent of total billed charges,Implant Device,1152.6,34,,1152.6,percent of total billed charges,Implant Device,1152.6,34,,1152.6,percent of total billed charges,Implant Device,1678.05,,,1678.05,Other,110% of Medicare,1186.5,35,,1186.5,percent of total billed charges,Implant Device,1152.6,34,"Charges > $500, x 34%",1152.6,percent of total billed charges,Implant Device,1186.5,35,,1186.5,percent of total billed charges,Implant Device,1186.5,35,,1186.5,percent of total billed charges,Implant Device,1186.5,35,,1186.5,percent of total billed charges,Implant Device,1186.5,35,,1186.5,percent of total billed charges,Implant Device,1186.5,35,,1186.5,percent of total billed charges,Implant Device,1356,40,,1356,percent of total billed charges,Implant Device,1186.5,70,,1186.5,percent of total billed charges,All Other,1152.6,34,,1152.6,percent of total billed charges,Implant Device,1152.6,34,,1152.6,percent of total billed charges,Implant Device,1186.5,35,,1186.5,percent of total billed charges,Implant Device,1186.5,35,,1186.5,percent of total billed charges,Implant Device,1186.5,35,,1186.5,percent of total billed charges,Implant Device,1186.5,35,,1186.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1152.6,34,"If Charge > 2,000, then 34 percent",1152.6,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2508.61,
STRYKER 1236-2-852 ADM X3 INSERT 28MM,C1713,HCPCS,,79010493,CDM,278,RC,,,both,,,2503,1852.23,,,1852.23,Other,150% of Medicare + 9.63% HCRA Surcharge,1126.35,45,,1126.35,percent of total billed charges,Critical Access Hospital RCC factor,851.02,34,,851.02,percent of total billed charges,Implant Device,851.02,34,,851.02,percent of total billed charges,Implant Device,851.02,34,,851.02,percent of total billed charges,Implant Device,851.02,34,,851.02,percent of total billed charges,Implant Device,851.02,34,,851.02,percent of total billed charges,Implant Device,1238.99,,,1238.99,Other,110% of Medicare,876.05,35,,876.05,percent of total billed charges,Implant Device,851.02,34,"Charges > $500, x 34%",851.02,percent of total billed charges,Implant Device,876.05,35,,876.05,percent of total billed charges,Implant Device,876.05,35,,876.05,percent of total billed charges,Implant Device,876.05,35,,876.05,percent of total billed charges,Implant Device,876.05,35,,876.05,percent of total billed charges,Implant Device,876.05,35,,876.05,percent of total billed charges,Implant Device,1001.2,40,,1001.2,percent of total billed charges,Implant Device,876.05,70,,876.05,percent of total billed charges,All Other,851.02,34,,851.02,percent of total billed charges,Implant Device,851.02,34,,851.02,percent of total billed charges,Implant Device,876.05,35,,876.05,percent of total billed charges,Implant Device,876.05,35,,876.05,percent of total billed charges,Implant Device,876.05,35,,876.05,percent of total billed charges,Implant Device,876.05,35,,876.05,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,851.02,34,"If Charge > 2,000, then 34 percent",851.02,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1852.23,
STRYKER 626-00-46F MDM COCR LINER 46MM F,C1776,HCPCS,,79010494,CDM,278,RC,,,both,,,3300,2442.01,,,2442.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1485,45,,1485,percent of total billed charges,Critical Access Hospital RCC factor,1122,34,,1122,percent of total billed charges,Implant Device,1122,34,,1122,percent of total billed charges,Implant Device,1122,34,,1122,percent of total billed charges,Implant Device,1122,34,,1122,percent of total billed charges,Implant Device,1122,34,,1122,percent of total billed charges,Implant Device,1633.5,,,1633.5,Other,110% of Medicare,1155,35,,1155,percent of total billed charges,Implant Device,1122,34,"Charges > $500, x 34%",1122,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,1320,40,,1320,percent of total billed charges,Implant Device,1155,70,,1155,percent of total billed charges,All Other,1122,34,,1122,percent of total billed charges,Implant Device,1122,34,,1122,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1122,34,"If Charge > 2,000, then 34 percent",1122,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2442.01,
STRYKER 6485-3-815 15X127 CUR FEM STEM,C1776,HCPCS,,79010495,CDM,278,RC,,,both,,,7722,5714.3,,,5714.3,Other,150% of Medicare + 9.63% HCRA Surcharge,3474.9,45,,3474.9,percent of total billed charges,Critical Access Hospital RCC factor,2625.48,34,,2625.48,percent of total billed charges,Implant Device,2625.48,34,,2625.48,percent of total billed charges,Implant Device,2625.48,34,,2625.48,percent of total billed charges,Implant Device,2625.48,34,,2625.48,percent of total billed charges,Implant Device,2625.48,34,,2625.48,percent of total billed charges,Implant Device,3822.39,,,3822.39,Other,110% of Medicare,2702.7,35,,2702.7,percent of total billed charges,Implant Device,2625.48,34,"Charges > $500, x 34%",2625.48,percent of total billed charges,Implant Device,2702.7,35,,2702.7,percent of total billed charges,Implant Device,2702.7,35,,2702.7,percent of total billed charges,Implant Device,2702.7,35,,2702.7,percent of total billed charges,Implant Device,2702.7,35,,2702.7,percent of total billed charges,Implant Device,2702.7,35,,2702.7,percent of total billed charges,Implant Device,3088.8,40,,3088.8,percent of total billed charges,Implant Device,2702.7,70,,2702.7,percent of total billed charges,All Other,2625.48,34,,2625.48,percent of total billed charges,Implant Device,2625.48,34,,2625.48,percent of total billed charges,Implant Device,2702.7,35,,2702.7,percent of total billed charges,Implant Device,2702.7,35,,2702.7,percent of total billed charges,Implant Device,2702.7,35,,2702.7,percent of total billed charges,Implant Device,2702.7,35,,2702.7,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2625.48,34,"If Charge > 2,000, then 34 percent",2625.48,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5714.3,
STRYKER 6491-1-001 PROXIMAL FEMUR NEU,C1776,HCPCS,,79010496,CDM,278,RC,,,both,,,13833,10236.45,,,10236.45,Other,150% of Medicare + 9.63% HCRA Surcharge,6224.85,45,,6224.85,percent of total billed charges,Critical Access Hospital RCC factor,4703.22,34,,4703.22,percent of total billed charges,Implant Device,4703.22,34,,4703.22,percent of total billed charges,Implant Device,4703.22,34,,4703.22,percent of total billed charges,Implant Device,4703.22,34,,4703.22,percent of total billed charges,Implant Device,4703.22,34,,4703.22,percent of total billed charges,Implant Device,6847.34,,,6847.34,Other,110% of Medicare,4841.55,35,,4841.55,percent of total billed charges,Implant Device,4703.22,34,"Charges > $500, x 34%",4703.22,percent of total billed charges,Implant Device,4841.55,35,,4841.55,percent of total billed charges,Implant Device,4841.55,35,,4841.55,percent of total billed charges,Implant Device,4841.55,35,,4841.55,percent of total billed charges,Implant Device,4841.55,35,,4841.55,percent of total billed charges,Implant Device,4841.55,35,,4841.55,percent of total billed charges,Implant Device,5533.2,40,,5533.2,percent of total billed charges,Implant Device,4841.55,70,,4841.55,percent of total billed charges,All Other,4703.22,34,,4703.22,percent of total billed charges,Implant Device,4703.22,34,,4703.22,percent of total billed charges,Implant Device,4841.55,35,,4841.55,percent of total billed charges,Implant Device,4841.55,35,,4841.55,percent of total billed charges,Implant Device,4841.55,35,,4841.55,percent of total billed charges,Implant Device,4841.55,35,,4841.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,4703.22,34,"If Charge > 2,000, then 34 percent",4703.22,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,10236.45,
ZIMMER 00-5988-007-10 TIB AUG SZ 7 10MM,C1776,HCPCS,,79010497,CDM,278,RC,,,both,,,3968,2936.33,,,2936.33,Other,150% of Medicare + 9.63% HCRA Surcharge,1785.6,45,,1785.6,percent of total billed charges,Critical Access Hospital RCC factor,1349.12,34,,1349.12,percent of total billed charges,Implant Device,1349.12,34,,1349.12,percent of total billed charges,Implant Device,1349.12,34,,1349.12,percent of total billed charges,Implant Device,1349.12,34,,1349.12,percent of total billed charges,Implant Device,1349.12,34,,1349.12,percent of total billed charges,Implant Device,1964.16,,,1964.16,Other,110% of Medicare,1388.8,35,,1388.8,percent of total billed charges,Implant Device,1349.12,34,"Charges > $500, x 34%",1349.12,percent of total billed charges,Implant Device,1388.8,35,,1388.8,percent of total billed charges,Implant Device,1388.8,35,,1388.8,percent of total billed charges,Implant Device,1388.8,35,,1388.8,percent of total billed charges,Implant Device,1388.8,35,,1388.8,percent of total billed charges,Implant Device,1388.8,35,,1388.8,percent of total billed charges,Implant Device,1587.2,40,,1587.2,percent of total billed charges,Implant Device,1388.8,70,,1388.8,percent of total billed charges,All Other,1349.12,34,,1349.12,percent of total billed charges,Implant Device,1349.12,34,,1349.12,percent of total billed charges,Implant Device,1388.8,35,,1388.8,percent of total billed charges,Implant Device,1388.8,35,,1388.8,percent of total billed charges,Implant Device,1388.8,35,,1388.8,percent of total billed charges,Implant Device,1388.8,35,,1388.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1349.12,34,"If Charge > 2,000, then 34 percent",1349.12,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2936.33,
STRYKER UH1-52-26 UHR BIPOLAR 26X52MM,C1776,HCPCS,,79010498,CDM,278,RC,,,both,,,1500,1110,,,1110,Other,150% of Medicare + 9.63% HCRA Surcharge,675,45,,675,percent of total billed charges,Critical Access Hospital RCC factor,510,34,,510,percent of total billed charges,Implant Device,510,34,,510,percent of total billed charges,Implant Device,510,34,,510,percent of total billed charges,Implant Device,510,34,,510,percent of total billed charges,Implant Device,510,34,,510,percent of total billed charges,Implant Device,742.5,,,742.5,Other,110% of Medicare,525,35,,525,percent of total billed charges,Implant Device,510,34,"Charges > $500, x 34%",510,percent of total billed charges,Implant Device,525,35,,525,percent of total billed charges,Implant Device,525,35,,525,percent of total billed charges,Implant Device,525,35,,525,percent of total billed charges,Implant Device,525,35,,525,percent of total billed charges,Implant Device,525,35,,525,percent of total billed charges,Implant Device,600,40,,600,percent of total billed charges,Implant Device,525,70,,525,percent of total billed charges,All Other,510,34,,510,percent of total billed charges,Implant Device,510,34,,510,percent of total billed charges,Implant Device,525,35,,525,percent of total billed charges,Implant Device,525,35,,525,percent of total billed charges,Implant Device,525,35,,525,percent of total billed charges,Implant Device,525,35,,525,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1110,
STRYKER 2341-1140S TIBIAL NAIL 11X405MM,C1713,HCPCS,,79010499,CDM,278,RC,,,both,,,6378,4719.74,,,4719.74,Other,150% of Medicare + 9.63% HCRA Surcharge,2870.1,45,,2870.1,percent of total billed charges,Critical Access Hospital RCC factor,2168.52,34,,2168.52,percent of total billed charges,Implant Device,2168.52,34,,2168.52,percent of total billed charges,Implant Device,2168.52,34,,2168.52,percent of total billed charges,Implant Device,2168.52,34,,2168.52,percent of total billed charges,Implant Device,2168.52,34,,2168.52,percent of total billed charges,Implant Device,3157.11,,,3157.11,Other,110% of Medicare,2232.3,35,,2232.3,percent of total billed charges,Implant Device,2168.52,34,"Charges > $500, x 34%",2168.52,percent of total billed charges,Implant Device,2232.3,35,,2232.3,percent of total billed charges,Implant Device,2232.3,35,,2232.3,percent of total billed charges,Implant Device,2232.3,35,,2232.3,percent of total billed charges,Implant Device,2232.3,35,,2232.3,percent of total billed charges,Implant Device,2232.3,35,,2232.3,percent of total billed charges,Implant Device,2551.2,40,,2551.2,percent of total billed charges,Implant Device,2232.3,70,,2232.3,percent of total billed charges,All Other,2168.52,34,,2168.52,percent of total billed charges,Implant Device,2168.52,34,,2168.52,percent of total billed charges,Implant Device,2232.3,35,,2232.3,percent of total billed charges,Implant Device,2232.3,35,,2232.3,percent of total billed charges,Implant Device,2232.3,35,,2232.3,percent of total billed charges,Implant Device,2232.3,35,,2232.3,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2168.52,34,"If Charge > 2,000, then 34 percent",2168.52,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4719.74,
STRYKER 2361-5065S LOCKING SCREW 5X65MM,C1713,HCPCS,,79010501,CDM,278,RC,,,both,,,887,656.38,,,656.38,Other,150% of Medicare + 9.63% HCRA Surcharge,399.15,45,,399.15,percent of total billed charges,Critical Access Hospital RCC factor,301.58,34,,301.58,percent of total billed charges,Implant Device,301.58,34,,301.58,percent of total billed charges,Implant Device,301.58,34,,301.58,percent of total billed charges,Implant Device,301.58,34,,301.58,percent of total billed charges,Implant Device,301.58,34,,301.58,percent of total billed charges,Implant Device,439.07,,,439.07,Other,110% of Medicare,310.45,35,,310.45,percent of total billed charges,Implant Device,301.58,34,"Charges > $500, x 34%",301.58,percent of total billed charges,Implant Device,310.45,35,,310.45,percent of total billed charges,Implant Device,310.45,35,,310.45,percent of total billed charges,Implant Device,310.45,35,,310.45,percent of total billed charges,Implant Device,310.45,35,,310.45,percent of total billed charges,Implant Device,310.45,35,,310.45,percent of total billed charges,Implant Device,354.8,40,,354.8,percent of total billed charges,Implant Device,310.45,70,,310.45,percent of total billed charges,All Other,301.58,34,,301.58,percent of total billed charges,Implant Device,301.58,34,,301.58,percent of total billed charges,Implant Device,310.45,35,,310.45,percent of total billed charges,Implant Device,310.45,35,,310.45,percent of total billed charges,Implant Device,310.45,35,,310.45,percent of total billed charges,Implant Device,310.45,35,,310.45,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,656.38,
ACUMED PL-UL06 ULNA SHORTENING PLATE 6H,C1713,HCPCS,,79010503,CDM,278,RC,,,both,,,3975,2941.51,,,2941.51,Other,150% of Medicare + 9.63% HCRA Surcharge,1788.75,45,,1788.75,percent of total billed charges,Critical Access Hospital RCC factor,1351.5,34,,1351.5,percent of total billed charges,Implant Device,1351.5,34,,1351.5,percent of total billed charges,Implant Device,1351.5,34,,1351.5,percent of total billed charges,Implant Device,1351.5,34,,1351.5,percent of total billed charges,Implant Device,1351.5,34,,1351.5,percent of total billed charges,Implant Device,1967.63,,,1967.63,Other,110% of Medicare,1391.25,35,,1391.25,percent of total billed charges,Implant Device,1351.5,34,"Charges > $500, x 34%",1351.5,percent of total billed charges,Implant Device,1391.25,35,,1391.25,percent of total billed charges,Implant Device,1391.25,35,,1391.25,percent of total billed charges,Implant Device,1391.25,35,,1391.25,percent of total billed charges,Implant Device,1391.25,35,,1391.25,percent of total billed charges,Implant Device,1391.25,35,,1391.25,percent of total billed charges,Implant Device,1590,40,,1590,percent of total billed charges,Implant Device,1391.25,70,,1391.25,percent of total billed charges,All Other,1351.5,34,,1351.5,percent of total billed charges,Implant Device,1351.5,34,,1351.5,percent of total billed charges,Implant Device,1391.25,35,,1391.25,percent of total billed charges,Implant Device,1391.25,35,,1391.25,percent of total billed charges,Implant Device,1391.25,35,,1391.25,percent of total billed charges,Implant Device,1391.25,35,,1391.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1351.5,34,"If Charge > 2,000, then 34 percent",1351.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2941.51,
ACUMED 80-0422 SHORTENING REDUCTION PEG,C1713,HCPCS,,79010505,CDM,278,RC,,,both,,,513,379.62,,,379.62,Other,150% of Medicare + 9.63% HCRA Surcharge,230.85,45,,230.85,percent of total billed charges,Critical Access Hospital RCC factor,174.42,34,,174.42,percent of total billed charges,Implant Device,174.42,34,,174.42,percent of total billed charges,Implant Device,174.42,34,,174.42,percent of total billed charges,Implant Device,174.42,34,,174.42,percent of total billed charges,Implant Device,174.42,34,,174.42,percent of total billed charges,Implant Device,253.94,,,253.94,Other,110% of Medicare,179.55,35,,179.55,percent of total billed charges,Implant Device,174.42,34,"Charges > $500, x 34%",174.42,percent of total billed charges,Implant Device,179.55,35,,179.55,percent of total billed charges,Implant Device,179.55,35,,179.55,percent of total billed charges,Implant Device,179.55,35,,179.55,percent of total billed charges,Implant Device,179.55,35,,179.55,percent of total billed charges,Implant Device,179.55,35,,179.55,percent of total billed charges,Implant Device,205.2,40,,205.2,percent of total billed charges,Implant Device,179.55,70,,179.55,percent of total billed charges,All Other,174.42,34,,174.42,percent of total billed charges,Implant Device,174.42,34,,174.42,percent of total billed charges,Implant Device,179.55,35,,179.55,percent of total billed charges,Implant Device,179.55,35,,179.55,percent of total billed charges,Implant Device,179.55,35,,179.55,percent of total billed charges,Implant Device,179.55,35,,179.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,379.62,
ACUMED 30-0233 LOCKING SCREW 3.5X10MM,C1713,HCPCS,,79010506,CDM,278,RC,,,both,,,450,333,,,333,Other,150% of Medicare + 9.63% HCRA Surcharge,202.5,45,,202.5,percent of total billed charges,Critical Access Hospital RCC factor,153,34,,153,percent of total billed charges,Implant Device,153,34,,153,percent of total billed charges,Implant Device,153,34,,153,percent of total billed charges,Implant Device,153,34,,153,percent of total billed charges,Implant Device,153,34,,153,percent of total billed charges,Implant Device,222.75,,,222.75,Other,110% of Medicare,157.5,35,,157.5,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,157.5,35,,157.5,percent of total billed charges,Implant Device,157.5,35,,157.5,percent of total billed charges,Implant Device,157.5,35,,157.5,percent of total billed charges,Implant Device,157.5,35,,157.5,percent of total billed charges,Implant Device,157.5,35,,157.5,percent of total billed charges,Implant Device,180,40,,180,percent of total billed charges,Implant Device,157.5,70,,157.5,percent of total billed charges,All Other,153,34,,153,percent of total billed charges,Implant Device,153,34,,153,percent of total billed charges,Implant Device,157.5,35,,157.5,percent of total billed charges,Implant Device,157.5,35,,157.5,percent of total billed charges,Implant Device,157.5,35,,157.5,percent of total billed charges,Implant Device,157.5,35,,157.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,333,
STRYKER KS14 FIXOS SNAP OFF 2.7X14MM,C1713,HCPCS,,79010507,CDM,278,RC,,,both,,,1250,925,,,925,Other,150% of Medicare + 9.63% HCRA Surcharge,562.5,45,,562.5,percent of total billed charges,Critical Access Hospital RCC factor,425,34,,425,percent of total billed charges,Implant Device,425,34,,425,percent of total billed charges,Implant Device,425,34,,425,percent of total billed charges,Implant Device,425,34,,425,percent of total billed charges,Implant Device,425,34,,425,percent of total billed charges,Implant Device,618.75,,,618.75,Other,110% of Medicare,437.5,35,,437.5,percent of total billed charges,Implant Device,425,34,"Charges > $500, x 34%",425,percent of total billed charges,Implant Device,437.5,35,,437.5,percent of total billed charges,Implant Device,437.5,35,,437.5,percent of total billed charges,Implant Device,437.5,35,,437.5,percent of total billed charges,Implant Device,437.5,35,,437.5,percent of total billed charges,Implant Device,437.5,35,,437.5,percent of total billed charges,Implant Device,500,40,,500,percent of total billed charges,Implant Device,437.5,70,,437.5,percent of total billed charges,All Other,425,34,,425,percent of total billed charges,Implant Device,425,34,,425,percent of total billed charges,Implant Device,437.5,35,,437.5,percent of total billed charges,Implant Device,437.5,35,,437.5,percent of total billed charges,Implant Device,437.5,35,,437.5,percent of total billed charges,Implant Device,437.5,35,,437.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,925,
STRYKER 40-20115S ASNIS MICRO 2.0X15/6MM,C1713,HCPCS,,79010508,CDM,278,RC,,,both,,,493,364.82,,,364.82,Other,150% of Medicare + 9.63% HCRA Surcharge,221.85,45,,221.85,percent of total billed charges,Critical Access Hospital RCC factor,167.62,34,,167.62,percent of total billed charges,Implant Device,167.62,34,,167.62,percent of total billed charges,Implant Device,167.62,34,,167.62,percent of total billed charges,Implant Device,167.62,34,,167.62,percent of total billed charges,Implant Device,167.62,34,,167.62,percent of total billed charges,Implant Device,244.04,,,244.04,Other,110% of Medicare,172.55,35,,172.55,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,172.55,35,,172.55,percent of total billed charges,Implant Device,172.55,35,,172.55,percent of total billed charges,Implant Device,172.55,35,,172.55,percent of total billed charges,Implant Device,172.55,35,,172.55,percent of total billed charges,Implant Device,172.55,35,,172.55,percent of total billed charges,Implant Device,197.2,40,,197.2,percent of total billed charges,Implant Device,172.55,70,,172.55,percent of total billed charges,All Other,167.62,34,,167.62,percent of total billed charges,Implant Device,167.62,34,,167.62,percent of total billed charges,Implant Device,172.55,35,,172.55,percent of total billed charges,Implant Device,172.55,35,,172.55,percent of total billed charges,Implant Device,172.55,35,,172.55,percent of total billed charges,Implant Device,172.55,35,,172.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,364.82,
STRYKER 40-20113S ASNIS MICRO 2.0X13/6MM,C1713,HCPCS,,79010509,CDM,278,RC,,,both,,,493,364.82,,,364.82,Other,150% of Medicare + 9.63% HCRA Surcharge,221.85,45,,221.85,percent of total billed charges,Critical Access Hospital RCC factor,167.62,34,,167.62,percent of total billed charges,Implant Device,167.62,34,,167.62,percent of total billed charges,Implant Device,167.62,34,,167.62,percent of total billed charges,Implant Device,167.62,34,,167.62,percent of total billed charges,Implant Device,167.62,34,,167.62,percent of total billed charges,Implant Device,244.04,,,244.04,Other,110% of Medicare,172.55,35,,172.55,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,172.55,35,,172.55,percent of total billed charges,Implant Device,172.55,35,,172.55,percent of total billed charges,Implant Device,172.55,35,,172.55,percent of total billed charges,Implant Device,172.55,35,,172.55,percent of total billed charges,Implant Device,172.55,35,,172.55,percent of total billed charges,Implant Device,197.2,40,,197.2,percent of total billed charges,Implant Device,172.55,70,,172.55,percent of total billed charges,All Other,167.62,34,,167.62,percent of total billed charges,Implant Device,167.62,34,,167.62,percent of total billed charges,Implant Device,172.55,35,,172.55,percent of total billed charges,Implant Device,172.55,35,,172.55,percent of total billed charges,Implant Device,172.55,35,,172.55,percent of total billed charges,Implant Device,172.55,35,,172.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,364.82,
STRYKER 6260-9-226 V40 COCR LFIT HEAD 26,C1776,HCPCS,,79010510,CDM,278,RC,,,both,,,1391,1029.34,,,1029.34,Other,150% of Medicare + 9.63% HCRA Surcharge,625.95,45,,625.95,percent of total billed charges,Critical Access Hospital RCC factor,472.94,34,,472.94,percent of total billed charges,Implant Device,472.94,34,,472.94,percent of total billed charges,Implant Device,472.94,34,,472.94,percent of total billed charges,Implant Device,472.94,34,,472.94,percent of total billed charges,Implant Device,472.94,34,,472.94,percent of total billed charges,Implant Device,688.55,,,688.55,Other,110% of Medicare,486.85,35,,486.85,percent of total billed charges,Implant Device,472.94,34,"Charges > $500, x 34%",472.94,percent of total billed charges,Implant Device,486.85,35,,486.85,percent of total billed charges,Implant Device,486.85,35,,486.85,percent of total billed charges,Implant Device,486.85,35,,486.85,percent of total billed charges,Implant Device,486.85,35,,486.85,percent of total billed charges,Implant Device,486.85,35,,486.85,percent of total billed charges,Implant Device,556.4,40,,556.4,percent of total billed charges,Implant Device,486.85,70,,486.85,percent of total billed charges,All Other,472.94,34,,472.94,percent of total billed charges,Implant Device,472.94,34,,472.94,percent of total billed charges,Implant Device,486.85,35,,486.85,percent of total billed charges,Implant Device,486.85,35,,486.85,percent of total billed charges,Implant Device,486.85,35,,486.85,percent of total billed charges,Implant Device,486.85,35,,486.85,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1029.34,
STRYKER 3525-3400S LONG NAIL KIT R1/5 LT,C1713,HCPCS,,79010511,CDM,278,RC,,,both,,,5438,4024.13,,,4024.13,Other,150% of Medicare + 9.63% HCRA Surcharge,2447.1,45,,2447.1,percent of total billed charges,Critical Access Hospital RCC factor,1848.92,34,,1848.92,percent of total billed charges,Implant Device,1848.92,34,,1848.92,percent of total billed charges,Implant Device,1848.92,34,,1848.92,percent of total billed charges,Implant Device,1848.92,34,,1848.92,percent of total billed charges,Implant Device,1848.92,34,,1848.92,percent of total billed charges,Implant Device,2691.81,,,2691.81,Other,110% of Medicare,1903.3,35,,1903.3,percent of total billed charges,Implant Device,1848.92,34,"Charges > $500, x 34%",1848.92,percent of total billed charges,Implant Device,1903.3,35,,1903.3,percent of total billed charges,Implant Device,1903.3,35,,1903.3,percent of total billed charges,Implant Device,1903.3,35,,1903.3,percent of total billed charges,Implant Device,1903.3,35,,1903.3,percent of total billed charges,Implant Device,1903.3,35,,1903.3,percent of total billed charges,Implant Device,2175.2,40,,2175.2,percent of total billed charges,Implant Device,1903.3,70,,1903.3,percent of total billed charges,All Other,1848.92,34,,1848.92,percent of total billed charges,Implant Device,1848.92,34,,1848.92,percent of total billed charges,Implant Device,1903.3,35,,1903.3,percent of total billed charges,Implant Device,1903.3,35,,1903.3,percent of total billed charges,Implant Device,1903.3,35,,1903.3,percent of total billed charges,Implant Device,1903.3,35,,1903.3,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1848.92,34,"If Charge > 2,000, then 34 percent",1848.92,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4024.13,
STRYKER 5530-G-609 TIBIAL INSERT SZ6 9MM,C1776,HCPCS,,79010512,CDM,278,RC,,,both,,,3300,2442.01,,,2442.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1485,45,,1485,percent of total billed charges,Critical Access Hospital RCC factor,1122,34,,1122,percent of total billed charges,Implant Device,1122,34,,1122,percent of total billed charges,Implant Device,1122,34,,1122,percent of total billed charges,Implant Device,1122,34,,1122,percent of total billed charges,Implant Device,1122,34,,1122,percent of total billed charges,Implant Device,1633.5,,,1633.5,Other,110% of Medicare,1155,35,,1155,percent of total billed charges,Implant Device,1122,34,"Charges > $500, x 34%",1122,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,1320,40,,1320,percent of total billed charges,Implant Device,1155,70,,1155,percent of total billed charges,All Other,1122,34,,1122,percent of total billed charges,Implant Device,1122,34,,1122,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1122,34,"If Charge > 2,000, then 34 percent",1122,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2442.01,
ARTHREX AR-1288BTB-100 BTB TIGHTROPE,C1713,HCPCS,,79010513,CDM,278,RC,,,both,,,3300,2442.01,,,2442.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1485,45,,1485,percent of total billed charges,Critical Access Hospital RCC factor,1122,34,,1122,percent of total billed charges,Implant Device,1122,34,,1122,percent of total billed charges,Implant Device,1122,34,,1122,percent of total billed charges,Implant Device,1122,34,,1122,percent of total billed charges,Implant Device,1122,34,,1122,percent of total billed charges,Implant Device,1633.5,,,1633.5,Other,110% of Medicare,1155,35,,1155,percent of total billed charges,Implant Device,1122,34,"Charges > $500, x 34%",1122,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,1320,40,,1320,percent of total billed charges,Implant Device,1155,70,,1155,percent of total billed charges,All Other,1122,34,,1122,percent of total billed charges,Implant Device,1122,34,,1122,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1122,34,"If Charge > 2,000, then 34 percent",1122,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2442.01,
STRYKER 656422 BONE SCREW 2.7X22MM,C1713,HCPCS,,79010515,CDM,278,RC,,,both,,,258,190.92,,,190.92,Other,150% of Medicare + 9.63% HCRA Surcharge,116.1,45,,116.1,percent of total billed charges,Critical Access Hospital RCC factor,87.72,34,,87.72,percent of total billed charges,Implant Device,87.72,34,,87.72,percent of total billed charges,Implant Device,87.72,34,,87.72,percent of total billed charges,Implant Device,87.72,34,,87.72,percent of total billed charges,Implant Device,87.72,34,,87.72,percent of total billed charges,Implant Device,127.71,,,127.71,Other,110% of Medicare,90.3,35,,90.3,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,90.3,35,,90.3,percent of total billed charges,Implant Device,90.3,35,,90.3,percent of total billed charges,Implant Device,90.3,35,,90.3,percent of total billed charges,Implant Device,90.3,35,,90.3,percent of total billed charges,Implant Device,90.3,35,,90.3,percent of total billed charges,Implant Device,103.2,40,,103.2,percent of total billed charges,Implant Device,90.3,70,,90.3,percent of total billed charges,All Other,87.72,34,,87.72,percent of total billed charges,Implant Device,87.72,34,,87.72,percent of total billed charges,Implant Device,90.3,35,,90.3,percent of total billed charges,Implant Device,90.3,35,,90.3,percent of total billed charges,Implant Device,90.3,35,,90.3,percent of total billed charges,Implant Device,90.3,35,,90.3,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,190.92,
STRYKER 627304 TIBIA PLATE LEFT 4H 121MM,C1713,HCPCS,,79010516,CDM,278,RC,,,both,,,6049,4476.28,,,4476.28,Other,150% of Medicare + 9.63% HCRA Surcharge,2722.05,45,,2722.05,percent of total billed charges,Critical Access Hospital RCC factor,2056.66,34,,2056.66,percent of total billed charges,Implant Device,2056.66,34,,2056.66,percent of total billed charges,Implant Device,2056.66,34,,2056.66,percent of total billed charges,Implant Device,2056.66,34,,2056.66,percent of total billed charges,Implant Device,2056.66,34,,2056.66,percent of total billed charges,Implant Device,2994.26,,,2994.26,Other,110% of Medicare,2117.15,35,,2117.15,percent of total billed charges,Implant Device,2056.66,34,"Charges > $500, x 34%",2056.66,percent of total billed charges,Implant Device,2117.15,35,,2117.15,percent of total billed charges,Implant Device,2117.15,35,,2117.15,percent of total billed charges,Implant Device,2117.15,35,,2117.15,percent of total billed charges,Implant Device,2117.15,35,,2117.15,percent of total billed charges,Implant Device,2117.15,35,,2117.15,percent of total billed charges,Implant Device,2419.6,40,,2419.6,percent of total billed charges,Implant Device,2117.15,70,,2117.15,percent of total billed charges,All Other,2056.66,34,,2056.66,percent of total billed charges,Implant Device,2056.66,34,,2056.66,percent of total billed charges,Implant Device,2117.15,35,,2117.15,percent of total billed charges,Implant Device,2117.15,35,,2117.15,percent of total billed charges,Implant Device,2117.15,35,,2117.15,percent of total billed charges,Implant Device,2117.15,35,,2117.15,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2056.66,34,"If Charge > 2,000, then 34 percent",2056.66,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4476.28,
ZOOM 2232 NANOVA LARGE VAS-Q-CLIP,C1713,HCPCS,,79010517,CDM,278,RC,,,both,,,68,50.32,,,50.32,Other,150% of Medicare + 9.63% HCRA Surcharge,30.6,45,,30.6,percent of total billed charges,Critical Access Hospital RCC factor,23.12,34,,23.12,percent of total billed charges,Implant Device,23.12,34,,23.12,percent of total billed charges,Implant Device,23.12,34,,23.12,percent of total billed charges,Implant Device,23.12,34,,23.12,percent of total billed charges,Implant Device,23.12,34,,23.12,percent of total billed charges,Implant Device,33.66,,,33.66,Other,110% of Medicare,23.8,35,,23.8,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,23.8,35,,23.8,percent of total billed charges,Implant Device,23.8,35,,23.8,percent of total billed charges,Implant Device,23.8,35,,23.8,percent of total billed charges,Implant Device,23.8,35,,23.8,percent of total billed charges,Implant Device,23.8,35,,23.8,percent of total billed charges,Implant Device,27.2,40,,27.2,percent of total billed charges,Implant Device,23.8,70,,23.8,percent of total billed charges,All Other,23.12,34,,23.12,percent of total billed charges,Implant Device,23.12,34,,23.12,percent of total billed charges,Implant Device,23.8,35,,23.8,percent of total billed charges,Implant Device,23.8,35,,23.8,percent of total billed charges,Implant Device,23.8,35,,23.8,percent of total billed charges,Implant Device,23.8,35,,23.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,50.32,
STRYKER 3425-1360S LONG NAIL KIT R1/5 RT,C1713,HCPCS,,79010518,CDM,278,RC,,,both,,,4969,3677.07,,,3677.07,Other,150% of Medicare + 9.63% HCRA Surcharge,2236.05,45,,2236.05,percent of total billed charges,Critical Access Hospital RCC factor,1689.46,34,,1689.46,percent of total billed charges,Implant Device,1689.46,34,,1689.46,percent of total billed charges,Implant Device,1689.46,34,,1689.46,percent of total billed charges,Implant Device,1689.46,34,,1689.46,percent of total billed charges,Implant Device,1689.46,34,,1689.46,percent of total billed charges,Implant Device,2459.66,,,2459.66,Other,110% of Medicare,1739.15,35,,1739.15,percent of total billed charges,Implant Device,1689.46,34,"Charges > $500, x 34%",1689.46,percent of total billed charges,Implant Device,1739.15,35,,1739.15,percent of total billed charges,Implant Device,1739.15,35,,1739.15,percent of total billed charges,Implant Device,1739.15,35,,1739.15,percent of total billed charges,Implant Device,1739.15,35,,1739.15,percent of total billed charges,Implant Device,1739.15,35,,1739.15,percent of total billed charges,Implant Device,1987.6,40,,1987.6,percent of total billed charges,Implant Device,1739.15,70,,1739.15,percent of total billed charges,All Other,1689.46,34,,1689.46,percent of total billed charges,Implant Device,1689.46,34,,1689.46,percent of total billed charges,Implant Device,1739.15,35,,1739.15,percent of total billed charges,Implant Device,1739.15,35,,1739.15,percent of total billed charges,Implant Device,1739.15,35,,1739.15,percent of total billed charges,Implant Device,1739.15,35,,1739.15,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1689.46,34,"If Charge > 2,000, then 34 percent",1689.46,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3677.07,
ARTHREX AR-8940-28 CANCELLS SCREW,C1713,HCPCS,,79010519,CDM,278,RC,,,both,,,258,190.92,,,190.92,Other,150% of Medicare + 9.63% HCRA Surcharge,116.1,45,,116.1,percent of total billed charges,Critical Access Hospital RCC factor,87.72,34,,87.72,percent of total billed charges,Implant Device,87.72,34,,87.72,percent of total billed charges,Implant Device,87.72,34,,87.72,percent of total billed charges,Implant Device,87.72,34,,87.72,percent of total billed charges,Implant Device,87.72,34,,87.72,percent of total billed charges,Implant Device,127.71,,,127.71,Other,110% of Medicare,90.3,35,,90.3,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,90.3,35,,90.3,percent of total billed charges,Implant Device,90.3,35,,90.3,percent of total billed charges,Implant Device,90.3,35,,90.3,percent of total billed charges,Implant Device,90.3,35,,90.3,percent of total billed charges,Implant Device,90.3,35,,90.3,percent of total billed charges,Implant Device,103.2,40,,103.2,percent of total billed charges,Implant Device,90.3,70,,90.3,percent of total billed charges,All Other,87.72,34,,87.72,percent of total billed charges,Implant Device,87.72,34,,87.72,percent of total billed charges,Implant Device,90.3,35,,90.3,percent of total billed charges,Implant Device,90.3,35,,90.3,percent of total billed charges,Implant Device,90.3,35,,90.3,percent of total billed charges,Implant Device,90.3,35,,90.3,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,190.92,
BOST SCI 180-221 CONTOUR STENT W/O WIRE,C1874,HCPCS,,79010520,CDM,278,RC,,,both,,,425,314.5,,,314.5,Other,150% of Medicare + 9.63% HCRA Surcharge,191.25,45,,191.25,percent of total billed charges,Critical Access Hospital RCC factor,144.5,34,,144.5,percent of total billed charges,Implant Device,144.5,34,,144.5,percent of total billed charges,Implant Device,144.5,34,,144.5,percent of total billed charges,Implant Device,144.5,34,,144.5,percent of total billed charges,Implant Device,144.5,34,,144.5,percent of total billed charges,Implant Device,210.38,,,210.38,Other,110% of Medicare,148.75,35,,148.75,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,148.75,35,,148.75,percent of total billed charges,Implant Device,148.75,35,,148.75,percent of total billed charges,Implant Device,148.75,35,,148.75,percent of total billed charges,Implant Device,148.75,35,,148.75,percent of total billed charges,Implant Device,148.75,35,,148.75,percent of total billed charges,Implant Device,170,40,,170,percent of total billed charges,Implant Device,148.75,70,,148.75,percent of total billed charges,All Other,144.5,34,,144.5,percent of total billed charges,Implant Device,144.5,34,,144.5,percent of total billed charges,Implant Device,148.75,35,,148.75,percent of total billed charges,Implant Device,148.75,35,,148.75,percent of total billed charges,Implant Device,148.75,35,,148.75,percent of total billed charges,Implant Device,148.75,35,,148.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,314.5,
BOST SCI 180-222 CONTOUR STENT W/O WIRE,C1874,HCPCS,,79010521,CDM,278,RC,,,both,,,425,314.5,,,314.5,Other,150% of Medicare + 9.63% HCRA Surcharge,191.25,45,,191.25,percent of total billed charges,Critical Access Hospital RCC factor,144.5,34,,144.5,percent of total billed charges,Implant Device,144.5,34,,144.5,percent of total billed charges,Implant Device,144.5,34,,144.5,percent of total billed charges,Implant Device,144.5,34,,144.5,percent of total billed charges,Implant Device,144.5,34,,144.5,percent of total billed charges,Implant Device,210.38,,,210.38,Other,110% of Medicare,148.75,35,,148.75,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,148.75,35,,148.75,percent of total billed charges,Implant Device,148.75,35,,148.75,percent of total billed charges,Implant Device,148.75,35,,148.75,percent of total billed charges,Implant Device,148.75,35,,148.75,percent of total billed charges,Implant Device,148.75,35,,148.75,percent of total billed charges,Implant Device,170,40,,170,percent of total billed charges,Implant Device,148.75,70,,148.75,percent of total billed charges,All Other,144.5,34,,144.5,percent of total billed charges,Implant Device,144.5,34,,144.5,percent of total billed charges,Implant Device,148.75,35,,148.75,percent of total billed charges,Implant Device,148.75,35,,148.75,percent of total billed charges,Implant Device,148.75,35,,148.75,percent of total billed charges,Implant Device,148.75,35,,148.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,314.5,
BOST SCI 180-223 CONTOUR STENT W/O WIRE,C1874,HCPCS,,79010522,CDM,278,RC,,,both,,,425,314.5,,,314.5,Other,150% of Medicare + 9.63% HCRA Surcharge,191.25,45,,191.25,percent of total billed charges,Critical Access Hospital RCC factor,144.5,34,,144.5,percent of total billed charges,Implant Device,144.5,34,,144.5,percent of total billed charges,Implant Device,144.5,34,,144.5,percent of total billed charges,Implant Device,144.5,34,,144.5,percent of total billed charges,Implant Device,144.5,34,,144.5,percent of total billed charges,Implant Device,210.38,,,210.38,Other,110% of Medicare,148.75,35,,148.75,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,148.75,35,,148.75,percent of total billed charges,Implant Device,148.75,35,,148.75,percent of total billed charges,Implant Device,148.75,35,,148.75,percent of total billed charges,Implant Device,148.75,35,,148.75,percent of total billed charges,Implant Device,148.75,35,,148.75,percent of total billed charges,Implant Device,170,40,,170,percent of total billed charges,Implant Device,148.75,70,,148.75,percent of total billed charges,All Other,144.5,34,,144.5,percent of total billed charges,Implant Device,144.5,34,,144.5,percent of total billed charges,Implant Device,148.75,35,,148.75,percent of total billed charges,Implant Device,148.75,35,,148.75,percent of total billed charges,Implant Device,148.75,35,,148.75,percent of total billed charges,Implant Device,148.75,35,,148.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,314.5,
BOST SCI 180-224 CONTOUR STENT W/O WIRE,C1874,HCPCS,,79010523,CDM,278,RC,,,both,,,425,314.5,,,314.5,Other,150% of Medicare + 9.63% HCRA Surcharge,191.25,45,,191.25,percent of total billed charges,Critical Access Hospital RCC factor,144.5,34,,144.5,percent of total billed charges,Implant Device,144.5,34,,144.5,percent of total billed charges,Implant Device,144.5,34,,144.5,percent of total billed charges,Implant Device,144.5,34,,144.5,percent of total billed charges,Implant Device,144.5,34,,144.5,percent of total billed charges,Implant Device,210.38,,,210.38,Other,110% of Medicare,148.75,35,,148.75,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,148.75,35,,148.75,percent of total billed charges,Implant Device,148.75,35,,148.75,percent of total billed charges,Implant Device,148.75,35,,148.75,percent of total billed charges,Implant Device,148.75,35,,148.75,percent of total billed charges,Implant Device,148.75,35,,148.75,percent of total billed charges,Implant Device,170,40,,170,percent of total billed charges,Implant Device,148.75,70,,148.75,percent of total billed charges,All Other,144.5,34,,144.5,percent of total billed charges,Implant Device,144.5,34,,144.5,percent of total billed charges,Implant Device,148.75,35,,148.75,percent of total billed charges,Implant Device,148.75,35,,148.75,percent of total billed charges,Implant Device,148.75,35,,148.75,percent of total billed charges,Implant Device,148.75,35,,148.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,314.5,
ALLERGAN SCF-560 BREAST IMPLANT 560CC,C1789,HCPCS,,79010525,CDM,278,RC,,,both,,,4005,2963.71,,,2963.71,Other,150% of Medicare + 9.63% HCRA Surcharge,1802.25,45,,1802.25,percent of total billed charges,Critical Access Hospital RCC factor,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1982.48,,,1982.48,Other,110% of Medicare,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1361.7,34,"Charges > $500, x 34%",1361.7,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1602,40,,1602,percent of total billed charges,Implant Device,1401.75,70,,1401.75,percent of total billed charges,All Other,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1361.7,34,"If Charge > 2,000, then 34 percent",1361.7,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2963.71,
ALLERGAN SCF-520 BREAST IMPLANT 520CC,C1789,HCPCS,,79010526,CDM,278,RC,,,both,,,4005,2963.71,,,2963.71,Other,150% of Medicare + 9.63% HCRA Surcharge,1802.25,45,,1802.25,percent of total billed charges,Critical Access Hospital RCC factor,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1982.48,,,1982.48,Other,110% of Medicare,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1361.7,34,"Charges > $500, x 34%",1361.7,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1602,40,,1602,percent of total billed charges,Implant Device,1401.75,70,,1401.75,percent of total billed charges,All Other,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1361.7,34,"If Charge > 2,000, then 34 percent",1361.7,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2963.71,
ALLERGAN SCM-405 BREAST IMPLANT 405CC,C1789,HCPCS,,79010527,CDM,278,RC,,,both,,,4005,2963.71,,,2963.71,Other,150% of Medicare + 9.63% HCRA Surcharge,1802.25,45,,1802.25,percent of total billed charges,Critical Access Hospital RCC factor,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1982.48,,,1982.48,Other,110% of Medicare,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1361.7,34,"Charges > $500, x 34%",1361.7,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1602,40,,1602,percent of total billed charges,Implant Device,1401.75,70,,1401.75,percent of total billed charges,All Other,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1361.7,34,"If Charge > 2,000, then 34 percent",1361.7,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2963.71,
ALLERGAN SCLP-340 BREAST IMPLANT 340CC,C1789,HCPCS,,79010528,CDM,278,RC,,,both,,,4005,2963.71,,,2963.71,Other,150% of Medicare + 9.63% HCRA Surcharge,1802.25,45,,1802.25,percent of total billed charges,Critical Access Hospital RCC factor,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1982.48,,,1982.48,Other,110% of Medicare,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1361.7,34,"Charges > $500, x 34%",1361.7,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1602,40,,1602,percent of total billed charges,Implant Device,1401.75,70,,1401.75,percent of total billed charges,All Other,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1361.7,34,"If Charge > 2,000, then 34 percent",1361.7,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2963.71,
STRYKER 5571-S-3206 X3 HUMRAL INSRT 32X6,C1776,HCPCS,,79010533,CDM,278,RC,,,both,,,3525,2608.51,,,2608.51,Other,150% of Medicare + 9.63% HCRA Surcharge,1586.25,45,,1586.25,percent of total billed charges,Critical Access Hospital RCC factor,1198.5,34,,1198.5,percent of total billed charges,Implant Device,1198.5,34,,1198.5,percent of total billed charges,Implant Device,1198.5,34,,1198.5,percent of total billed charges,Implant Device,1198.5,34,,1198.5,percent of total billed charges,Implant Device,1198.5,34,,1198.5,percent of total billed charges,Implant Device,1744.88,,,1744.88,Other,110% of Medicare,1233.75,35,,1233.75,percent of total billed charges,Implant Device,1198.5,34,"Charges > $500, x 34%",1198.5,percent of total billed charges,Implant Device,1233.75,35,,1233.75,percent of total billed charges,Implant Device,1233.75,35,,1233.75,percent of total billed charges,Implant Device,1233.75,35,,1233.75,percent of total billed charges,Implant Device,1233.75,35,,1233.75,percent of total billed charges,Implant Device,1233.75,35,,1233.75,percent of total billed charges,Implant Device,1410,40,,1410,percent of total billed charges,Implant Device,1233.75,70,,1233.75,percent of total billed charges,All Other,1198.5,34,,1198.5,percent of total billed charges,Implant Device,1198.5,34,,1198.5,percent of total billed charges,Implant Device,1233.75,35,,1233.75,percent of total billed charges,Implant Device,1233.75,35,,1233.75,percent of total billed charges,Implant Device,1233.75,35,,1233.75,percent of total billed charges,Implant Device,1233.75,35,,1233.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1198.5,34,"If Charge > 2,000, then 34 percent",1198.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2608.51,
BDC 50-7700 PLEURX PLEURAL CATH & KIT,C1729,HCPCS,,79010534,CDM,278,RC,,,both,,,2544,1882.57,,,1882.57,Other,150% of Medicare + 9.63% HCRA Surcharge,1144.8,45,,1144.8,percent of total billed charges,Critical Access Hospital RCC factor,864.96,34,,864.96,percent of total billed charges,Implant Device,864.96,34,,864.96,percent of total billed charges,Implant Device,864.96,34,,864.96,percent of total billed charges,Implant Device,864.96,34,,864.96,percent of total billed charges,Implant Device,864.96,34,,864.96,percent of total billed charges,Implant Device,1259.28,,,1259.28,Other,110% of Medicare,890.4,35,,890.4,percent of total billed charges,Implant Device,864.96,34,"Charges > $500, x 34%",864.96,percent of total billed charges,Implant Device,890.4,35,,890.4,percent of total billed charges,Implant Device,890.4,35,,890.4,percent of total billed charges,Implant Device,890.4,35,,890.4,percent of total billed charges,Implant Device,890.4,35,,890.4,percent of total billed charges,Implant Device,890.4,35,,890.4,percent of total billed charges,Implant Device,1017.6,40,,1017.6,percent of total billed charges,Implant Device,890.4,70,,890.4,percent of total billed charges,All Other,864.96,34,,864.96,percent of total billed charges,Implant Device,864.96,34,,864.96,percent of total billed charges,Implant Device,890.4,35,,890.4,percent of total billed charges,Implant Device,890.4,35,,890.4,percent of total billed charges,Implant Device,890.4,35,,890.4,percent of total billed charges,Implant Device,890.4,35,,890.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,864.96,34,"If Charge > 2,000, then 34 percent",864.96,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1882.57,
STRYKER UH1-47-28 UHR BIPOLAR 28X47MM,C1776,HCPCS,,79010535,CDM,278,RC,,,both,,,1500,1110,,,1110,Other,150% of Medicare + 9.63% HCRA Surcharge,675,45,,675,percent of total billed charges,Critical Access Hospital RCC factor,510,34,,510,percent of total billed charges,Implant Device,510,34,,510,percent of total billed charges,Implant Device,510,34,,510,percent of total billed charges,Implant Device,510,34,,510,percent of total billed charges,Implant Device,510,34,,510,percent of total billed charges,Implant Device,742.5,,,742.5,Other,110% of Medicare,525,35,,525,percent of total billed charges,Implant Device,510,34,"Charges > $500, x 34%",510,percent of total billed charges,Implant Device,525,35,,525,percent of total billed charges,Implant Device,525,35,,525,percent of total billed charges,Implant Device,525,35,,525,percent of total billed charges,Implant Device,525,35,,525,percent of total billed charges,Implant Device,525,35,,525,percent of total billed charges,Implant Device,600,40,,600,percent of total billed charges,Implant Device,525,70,,525,percent of total billed charges,All Other,510,34,,510,percent of total billed charges,Implant Device,510,34,,510,percent of total billed charges,Implant Device,525,35,,525,percent of total billed charges,Implant Device,525,35,,525,percent of total billed charges,Implant Device,525,35,,525,percent of total billed charges,Implant Device,525,35,,525,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1110,
ZIMMER 00-5964-017-51 FLEX FEM SZ G-LT,C1776,HCPCS,,79010536,CDM,278,RC,,,both,,,5175,3829.51,,,3829.51,Other,150% of Medicare + 9.63% HCRA Surcharge,2328.75,45,,2328.75,percent of total billed charges,Critical Access Hospital RCC factor,1759.5,34,,1759.5,percent of total billed charges,Implant Device,1759.5,34,,1759.5,percent of total billed charges,Implant Device,1759.5,34,,1759.5,percent of total billed charges,Implant Device,1759.5,34,,1759.5,percent of total billed charges,Implant Device,1759.5,34,,1759.5,percent of total billed charges,Implant Device,2561.63,,,2561.63,Other,110% of Medicare,1811.25,35,,1811.25,percent of total billed charges,Implant Device,1759.5,34,"Charges > $500, x 34%",1759.5,percent of total billed charges,Implant Device,1811.25,35,,1811.25,percent of total billed charges,Implant Device,1811.25,35,,1811.25,percent of total billed charges,Implant Device,1811.25,35,,1811.25,percent of total billed charges,Implant Device,1811.25,35,,1811.25,percent of total billed charges,Implant Device,1811.25,35,,1811.25,percent of total billed charges,Implant Device,2070,40,,2070,percent of total billed charges,Implant Device,1811.25,70,,1811.25,percent of total billed charges,All Other,1759.5,34,,1759.5,percent of total billed charges,Implant Device,1759.5,34,,1759.5,percent of total billed charges,Implant Device,1811.25,35,,1811.25,percent of total billed charges,Implant Device,1811.25,35,,1811.25,percent of total billed charges,Implant Device,1811.25,35,,1811.25,percent of total billed charges,Implant Device,1811.25,35,,1811.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1759.5,34,"If Charge > 2,000, then 34 percent",1759.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3829.51,
ZIMMER 00-5996-025-17 ALL POLY TIB SZ 5,C1776,HCPCS,,79010537,CDM,278,RC,,,both,,,3900,2886.01,,,2886.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1755,45,,1755,percent of total billed charges,Critical Access Hospital RCC factor,1326,34,,1326,percent of total billed charges,Implant Device,1326,34,,1326,percent of total billed charges,Implant Device,1326,34,,1326,percent of total billed charges,Implant Device,1326,34,,1326,percent of total billed charges,Implant Device,1326,34,,1326,percent of total billed charges,Implant Device,1930.5,,,1930.5,Other,110% of Medicare,1365,35,,1365,percent of total billed charges,Implant Device,1326,34,"Charges > $500, x 34%",1326,percent of total billed charges,Implant Device,1365,35,,1365,percent of total billed charges,Implant Device,1365,35,,1365,percent of total billed charges,Implant Device,1365,35,,1365,percent of total billed charges,Implant Device,1365,35,,1365,percent of total billed charges,Implant Device,1365,35,,1365,percent of total billed charges,Implant Device,1560,40,,1560,percent of total billed charges,Implant Device,1365,70,,1365,percent of total billed charges,All Other,1326,34,,1326,percent of total billed charges,Implant Device,1326,34,,1326,percent of total billed charges,Implant Device,1365,35,,1365,percent of total billed charges,Implant Device,1365,35,,1365,percent of total billed charges,Implant Device,1365,35,,1365,percent of total billed charges,Implant Device,1365,35,,1365,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1326,34,"If Charge > 2,000, then 34 percent",1326,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2886.01,
STRYKER DCELL204 SOFT TISSUE 6X16CM,C1789,HCPCS,,79010538,CDM,278,RC,,,both,,,7875,5827.52,,,5827.52,Other,150% of Medicare + 9.63% HCRA Surcharge,3543.75,45,,3543.75,percent of total billed charges,Critical Access Hospital RCC factor,2677.5,34,,2677.5,percent of total billed charges,Implant Device,2677.5,34,,2677.5,percent of total billed charges,Implant Device,2677.5,34,,2677.5,percent of total billed charges,Implant Device,2677.5,34,,2677.5,percent of total billed charges,Implant Device,2677.5,34,,2677.5,percent of total billed charges,Implant Device,3898.13,,,3898.13,Other,110% of Medicare,2756.25,35,,2756.25,percent of total billed charges,Implant Device,2677.5,34,"Charges > $500, x 34%",2677.5,percent of total billed charges,Implant Device,2756.25,35,,2756.25,percent of total billed charges,Implant Device,2756.25,35,,2756.25,percent of total billed charges,Implant Device,2756.25,35,,2756.25,percent of total billed charges,Implant Device,2756.25,35,,2756.25,percent of total billed charges,Implant Device,2756.25,35,,2756.25,percent of total billed charges,Implant Device,3150,40,,3150,percent of total billed charges,Implant Device,2756.25,70,,2756.25,percent of total billed charges,All Other,2677.5,34,,2677.5,percent of total billed charges,Implant Device,2677.5,34,,2677.5,percent of total billed charges,Implant Device,2756.25,35,,2756.25,percent of total billed charges,Implant Device,2756.25,35,,2756.25,percent of total billed charges,Implant Device,2756.25,35,,2756.25,percent of total billed charges,Implant Device,2756.25,35,,2756.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2677.5,34,"If Charge > 2,000, then 34 percent",2677.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5827.52,
EXACTECH SPC0523 TAPERED WEDGE 60MM,C1713,HCPCS,,79010539,CDM,278,RC,,,both,,,10625,7862.53,,,7862.53,Other,150% of Medicare + 9.63% HCRA Surcharge,4781.25,45,,4781.25,percent of total billed charges,Critical Access Hospital RCC factor,3612.5,34,,3612.5,percent of total billed charges,Implant Device,3612.5,34,,3612.5,percent of total billed charges,Implant Device,3612.5,34,,3612.5,percent of total billed charges,Implant Device,3612.5,34,,3612.5,percent of total billed charges,Implant Device,3612.5,34,,3612.5,percent of total billed charges,Implant Device,5259.38,,,5259.38,Other,110% of Medicare,3718.75,35,,3718.75,percent of total billed charges,Implant Device,3612.5,34,"Charges > $500, x 34%",3612.5,percent of total billed charges,Implant Device,3718.75,35,,3718.75,percent of total billed charges,Implant Device,3718.75,35,,3718.75,percent of total billed charges,Implant Device,3718.75,35,,3718.75,percent of total billed charges,Implant Device,3718.75,35,,3718.75,percent of total billed charges,Implant Device,3718.75,35,,3718.75,percent of total billed charges,Implant Device,4250,40,,4250,percent of total billed charges,Implant Device,3718.75,70,,3718.75,percent of total billed charges,All Other,3612.5,34,,3612.5,percent of total billed charges,Implant Device,3612.5,34,,3612.5,percent of total billed charges,Implant Device,3718.75,35,,3718.75,percent of total billed charges,Implant Device,3718.75,35,,3718.75,percent of total billed charges,Implant Device,3718.75,35,,3718.75,percent of total billed charges,Implant Device,3718.75,35,,3718.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3612.5,34,"If Charge > 2,000, then 34 percent",3612.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,7862.53,
ZIMMER CS15000 CORTICAL SCREW 3.5X15MM,C1713,HCPCS,,79010540,CDM,278,RC,,,both,,,288,213.12,,,213.12,Other,150% of Medicare + 9.63% HCRA Surcharge,129.6,45,,129.6,percent of total billed charges,Critical Access Hospital RCC factor,97.92,34,,97.92,percent of total billed charges,Implant Device,97.92,34,,97.92,percent of total billed charges,Implant Device,97.92,34,,97.92,percent of total billed charges,Implant Device,97.92,34,,97.92,percent of total billed charges,Implant Device,97.92,34,,97.92,percent of total billed charges,Implant Device,142.56,,,142.56,Other,110% of Medicare,100.8,35,,100.8,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,100.8,35,,100.8,percent of total billed charges,Implant Device,100.8,35,,100.8,percent of total billed charges,Implant Device,100.8,35,,100.8,percent of total billed charges,Implant Device,100.8,35,,100.8,percent of total billed charges,Implant Device,100.8,35,,100.8,percent of total billed charges,Implant Device,115.2,40,,115.2,percent of total billed charges,Implant Device,100.8,70,,100.8,percent of total billed charges,All Other,97.92,34,,97.92,percent of total billed charges,Implant Device,97.92,34,,97.92,percent of total billed charges,Implant Device,100.8,35,,100.8,percent of total billed charges,Implant Device,100.8,35,,100.8,percent of total billed charges,Implant Device,100.8,35,,100.8,percent of total billed charges,Implant Device,100.8,35,,100.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,213.12,
STRYKER 628227 LATERAL PLATE 7 HOLE RT,C1713,HCPCS,,79010541,CDM,278,RC,,,both,,,3785,2800.91,,,2800.91,Other,150% of Medicare + 9.63% HCRA Surcharge,1703.25,45,,1703.25,percent of total billed charges,Critical Access Hospital RCC factor,1286.9,34,,1286.9,percent of total billed charges,Implant Device,1286.9,34,,1286.9,percent of total billed charges,Implant Device,1286.9,34,,1286.9,percent of total billed charges,Implant Device,1286.9,34,,1286.9,percent of total billed charges,Implant Device,1286.9,34,,1286.9,percent of total billed charges,Implant Device,1873.58,,,1873.58,Other,110% of Medicare,1324.75,35,,1324.75,percent of total billed charges,Implant Device,1286.9,34,"Charges > $500, x 34%",1286.9,percent of total billed charges,Implant Device,1324.75,35,,1324.75,percent of total billed charges,Implant Device,1324.75,35,,1324.75,percent of total billed charges,Implant Device,1324.75,35,,1324.75,percent of total billed charges,Implant Device,1324.75,35,,1324.75,percent of total billed charges,Implant Device,1324.75,35,,1324.75,percent of total billed charges,Implant Device,1514,40,,1514,percent of total billed charges,Implant Device,1324.75,70,,1324.75,percent of total billed charges,All Other,1286.9,34,,1286.9,percent of total billed charges,Implant Device,1286.9,34,,1286.9,percent of total billed charges,Implant Device,1324.75,35,,1324.75,percent of total billed charges,Implant Device,1324.75,35,,1324.75,percent of total billed charges,Implant Device,1324.75,35,,1324.75,percent of total billed charges,Implant Device,1324.75,35,,1324.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1286.9,34,"If Charge > 2,000, then 34 percent",1286.9,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2800.91,
STRYKER 657122 BONE SCREW 2.7X22MM,C1713,HCPCS,,79010542,CDM,278,RC,,,both,,,294,217.56,,,217.56,Other,150% of Medicare + 9.63% HCRA Surcharge,132.3,45,,132.3,percent of total billed charges,Critical Access Hospital RCC factor,99.96,34,,99.96,percent of total billed charges,Implant Device,99.96,34,,99.96,percent of total billed charges,Implant Device,99.96,34,,99.96,percent of total billed charges,Implant Device,99.96,34,,99.96,percent of total billed charges,Implant Device,99.96,34,,99.96,percent of total billed charges,Implant Device,145.53,,,145.53,Other,110% of Medicare,102.9,35,,102.9,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,102.9,35,,102.9,percent of total billed charges,Implant Device,102.9,35,,102.9,percent of total billed charges,Implant Device,102.9,35,,102.9,percent of total billed charges,Implant Device,102.9,35,,102.9,percent of total billed charges,Implant Device,102.9,35,,102.9,percent of total billed charges,Implant Device,117.6,40,,117.6,percent of total billed charges,Implant Device,102.9,70,,102.9,percent of total billed charges,All Other,99.96,34,,99.96,percent of total billed charges,Implant Device,99.96,34,,99.96,percent of total billed charges,Implant Device,102.9,35,,102.9,percent of total billed charges,Implant Device,102.9,35,,102.9,percent of total billed charges,Implant Device,102.9,35,,102.9,percent of total billed charges,Implant Device,102.9,35,,102.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,217.56,
STRYKER 657124 BONE SCREW 2.7X24MM,C1713,HCPCS,,79010543,CDM,278,RC,,,both,,,269,199.06,,,199.06,Other,150% of Medicare + 9.63% HCRA Surcharge,121.05,45,,121.05,percent of total billed charges,Critical Access Hospital RCC factor,91.46,34,,91.46,percent of total billed charges,Implant Device,91.46,34,,91.46,percent of total billed charges,Implant Device,91.46,34,,91.46,percent of total billed charges,Implant Device,91.46,34,,91.46,percent of total billed charges,Implant Device,91.46,34,,91.46,percent of total billed charges,Implant Device,133.16,,,133.16,Other,110% of Medicare,94.15,35,,94.15,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,94.15,35,,94.15,percent of total billed charges,Implant Device,94.15,35,,94.15,percent of total billed charges,Implant Device,94.15,35,,94.15,percent of total billed charges,Implant Device,94.15,35,,94.15,percent of total billed charges,Implant Device,94.15,35,,94.15,percent of total billed charges,Implant Device,107.6,40,,107.6,percent of total billed charges,Implant Device,94.15,70,,94.15,percent of total billed charges,All Other,91.46,34,,91.46,percent of total billed charges,Implant Device,91.46,34,,91.46,percent of total billed charges,Implant Device,94.15,35,,94.15,percent of total billed charges,Implant Device,94.15,35,,94.15,percent of total billed charges,Implant Device,94.15,35,,94.15,percent of total billed charges,Implant Device,94.15,35,,94.15,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,199.06,
STRYKER 657132 BONE SCREW 2.7X32MM,C1713,HCPCS,,79010544,CDM,278,RC,,,both,,,269,199.06,,,199.06,Other,150% of Medicare + 9.63% HCRA Surcharge,121.05,45,,121.05,percent of total billed charges,Critical Access Hospital RCC factor,91.46,34,,91.46,percent of total billed charges,Implant Device,91.46,34,,91.46,percent of total billed charges,Implant Device,91.46,34,,91.46,percent of total billed charges,Implant Device,91.46,34,,91.46,percent of total billed charges,Implant Device,91.46,34,,91.46,percent of total billed charges,Implant Device,133.16,,,133.16,Other,110% of Medicare,94.15,35,,94.15,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,94.15,35,,94.15,percent of total billed charges,Implant Device,94.15,35,,94.15,percent of total billed charges,Implant Device,94.15,35,,94.15,percent of total billed charges,Implant Device,94.15,35,,94.15,percent of total billed charges,Implant Device,94.15,35,,94.15,percent of total billed charges,Implant Device,107.6,40,,107.6,percent of total billed charges,Implant Device,94.15,70,,94.15,percent of total billed charges,All Other,91.46,34,,91.46,percent of total billed charges,Implant Device,91.46,34,,91.46,percent of total billed charges,Implant Device,94.15,35,,94.15,percent of total billed charges,Implant Device,94.15,35,,94.15,percent of total billed charges,Implant Device,94.15,35,,94.15,percent of total billed charges,Implant Device,94.15,35,,94.15,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,199.06,
ARTHREX AR-1662BCS =723S SWIVELOCK 7X23,C1713,HCPCS,,79010547,CDM,278,RC,,,both,,,2157,1596.19,,,1596.19,Other,150% of Medicare + 9.63% HCRA Surcharge,970.65,45,,970.65,percent of total billed charges,Critical Access Hospital RCC factor,733.38,34,,733.38,percent of total billed charges,Implant Device,733.38,34,,733.38,percent of total billed charges,Implant Device,733.38,34,,733.38,percent of total billed charges,Implant Device,733.38,34,,733.38,percent of total billed charges,Implant Device,733.38,34,,733.38,percent of total billed charges,Implant Device,1067.72,,,1067.72,Other,110% of Medicare,754.95,35,,754.95,percent of total billed charges,Implant Device,733.38,34,"Charges > $500, x 34%",733.38,percent of total billed charges,Implant Device,754.95,35,,754.95,percent of total billed charges,Implant Device,754.95,35,,754.95,percent of total billed charges,Implant Device,754.95,35,,754.95,percent of total billed charges,Implant Device,754.95,35,,754.95,percent of total billed charges,Implant Device,754.95,35,,754.95,percent of total billed charges,Implant Device,862.8,40,,862.8,percent of total billed charges,Implant Device,754.95,70,,754.95,percent of total billed charges,All Other,733.38,34,,733.38,percent of total billed charges,Implant Device,733.38,34,,733.38,percent of total billed charges,Implant Device,754.95,35,,754.95,percent of total billed charges,Implant Device,754.95,35,,754.95,percent of total billed charges,Implant Device,754.95,35,,754.95,percent of total billed charges,Implant Device,754.95,35,,754.95,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,733.38,34,"If Charge > 2,000, then 34 percent",733.38,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1596.19,
DEPUY 02.112.013 CLAVICLE PLATE 3.5X94MM,C1713,HCPCS,,79010553,CDM,278,RC,,,both,,,2370,1753.81,,,1753.81,Other,150% of Medicare + 9.63% HCRA Surcharge,1066.5,45,,1066.5,percent of total billed charges,Critical Access Hospital RCC factor,805.8,34,,805.8,percent of total billed charges,Implant Device,805.8,34,,805.8,percent of total billed charges,Implant Device,805.8,34,,805.8,percent of total billed charges,Implant Device,805.8,34,,805.8,percent of total billed charges,Implant Device,805.8,34,,805.8,percent of total billed charges,Implant Device,1173.15,,,1173.15,Other,110% of Medicare,829.5,35,,829.5,percent of total billed charges,Implant Device,805.8,34,"Charges > $500, x 34%",805.8,percent of total billed charges,Implant Device,829.5,35,,829.5,percent of total billed charges,Implant Device,829.5,35,,829.5,percent of total billed charges,Implant Device,829.5,35,,829.5,percent of total billed charges,Implant Device,829.5,35,,829.5,percent of total billed charges,Implant Device,829.5,35,,829.5,percent of total billed charges,Implant Device,948,40,,948,percent of total billed charges,Implant Device,829.5,70,,829.5,percent of total billed charges,All Other,805.8,34,,805.8,percent of total billed charges,Implant Device,805.8,34,,805.8,percent of total billed charges,Implant Device,829.5,35,,829.5,percent of total billed charges,Implant Device,829.5,35,,829.5,percent of total billed charges,Implant Device,829.5,35,,829.5,percent of total billed charges,Implant Device,829.5,35,,829.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,805.8,34,"If Charge > 2,000, then 34 percent",805.8,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1753.81,
STRYKER 658350 HEADLESS COMP SCREW 7X50,C1713,HCPCS,,79010555,CDM,278,RC,,,both,,,2079,1538.47,,,1538.47,Other,150% of Medicare + 9.63% HCRA Surcharge,935.55,45,,935.55,percent of total billed charges,Critical Access Hospital RCC factor,706.86,34,,706.86,percent of total billed charges,Implant Device,706.86,34,,706.86,percent of total billed charges,Implant Device,706.86,34,,706.86,percent of total billed charges,Implant Device,706.86,34,,706.86,percent of total billed charges,Implant Device,706.86,34,,706.86,percent of total billed charges,Implant Device,1029.11,,,1029.11,Other,110% of Medicare,727.65,35,,727.65,percent of total billed charges,Implant Device,706.86,34,"Charges > $500, x 34%",706.86,percent of total billed charges,Implant Device,727.65,35,,727.65,percent of total billed charges,Implant Device,727.65,35,,727.65,percent of total billed charges,Implant Device,727.65,35,,727.65,percent of total billed charges,Implant Device,727.65,35,,727.65,percent of total billed charges,Implant Device,727.65,35,,727.65,percent of total billed charges,Implant Device,831.6,40,,831.6,percent of total billed charges,Implant Device,727.65,70,,727.65,percent of total billed charges,All Other,706.86,34,,706.86,percent of total billed charges,Implant Device,706.86,34,,706.86,percent of total billed charges,Implant Device,727.65,35,,727.65,percent of total billed charges,Implant Device,727.65,35,,727.65,percent of total billed charges,Implant Device,727.65,35,,727.65,percent of total billed charges,Implant Device,727.65,35,,727.65,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,706.86,34,"If Charge > 2,000, then 34 percent",706.86,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1538.47,
ARTHREX AR-2264 AC TIGHTROPE - TWIN TALE,C1713,HCPCS,,79010559,CDM,278,RC,,,both,,,1725,1276.5,,,1276.5,Other,150% of Medicare + 9.63% HCRA Surcharge,776.25,45,,776.25,percent of total billed charges,Critical Access Hospital RCC factor,586.5,34,,586.5,percent of total billed charges,Implant Device,586.5,34,,586.5,percent of total billed charges,Implant Device,586.5,34,,586.5,percent of total billed charges,Implant Device,586.5,34,,586.5,percent of total billed charges,Implant Device,586.5,34,,586.5,percent of total billed charges,Implant Device,853.88,,,853.88,Other,110% of Medicare,603.75,35,,603.75,percent of total billed charges,Implant Device,586.5,34,"Charges > $500, x 34%",586.5,percent of total billed charges,Implant Device,603.75,35,,603.75,percent of total billed charges,Implant Device,603.75,35,,603.75,percent of total billed charges,Implant Device,603.75,35,,603.75,percent of total billed charges,Implant Device,603.75,35,,603.75,percent of total billed charges,Implant Device,603.75,35,,603.75,percent of total billed charges,Implant Device,690,40,,690,percent of total billed charges,Implant Device,603.75,70,,603.75,percent of total billed charges,All Other,586.5,34,,586.5,percent of total billed charges,Implant Device,586.5,34,,586.5,percent of total billed charges,Implant Device,603.75,35,,603.75,percent of total billed charges,Implant Device,603.75,35,,603.75,percent of total billed charges,Implant Device,603.75,35,,603.75,percent of total billed charges,Implant Device,603.75,35,,603.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1276.5,
ZIMMER 110010265 ACETABULAR SHELL 54MM,C1776,HCPCS,,79010560,CDM,278,RC,,,both,,,11515,8521.13,,,8521.13,Other,150% of Medicare + 9.63% HCRA Surcharge,5181.75,45,,5181.75,percent of total billed charges,Critical Access Hospital RCC factor,3915.1,34,,3915.1,percent of total billed charges,Implant Device,3915.1,34,,3915.1,percent of total billed charges,Implant Device,3915.1,34,,3915.1,percent of total billed charges,Implant Device,3915.1,34,,3915.1,percent of total billed charges,Implant Device,3915.1,34,,3915.1,percent of total billed charges,Implant Device,5699.93,,,5699.93,Other,110% of Medicare,4030.25,35,,4030.25,percent of total billed charges,Implant Device,3915.1,34,"Charges > $500, x 34%",3915.1,percent of total billed charges,Implant Device,4030.25,35,,4030.25,percent of total billed charges,Implant Device,4030.25,35,,4030.25,percent of total billed charges,Implant Device,4030.25,35,,4030.25,percent of total billed charges,Implant Device,4030.25,35,,4030.25,percent of total billed charges,Implant Device,4030.25,35,,4030.25,percent of total billed charges,Implant Device,4606,40,,4606,percent of total billed charges,Implant Device,4030.25,70,,4030.25,percent of total billed charges,All Other,3915.1,34,,3915.1,percent of total billed charges,Implant Device,3915.1,34,,3915.1,percent of total billed charges,Implant Device,4030.25,35,,4030.25,percent of total billed charges,Implant Device,4030.25,35,,4030.25,percent of total billed charges,Implant Device,4030.25,35,,4030.25,percent of total billed charges,Implant Device,4030.25,35,,4030.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3915.1,34,"If Charge > 2,000, then 34 percent",3915.1,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,8521.13,
ZIMMER 110024464 ACETABULAR LINER 44MM,C1776,HCPCS,,79010561,CDM,278,RC,,,both,,,3840,2841.61,,,2841.61,Other,150% of Medicare + 9.63% HCRA Surcharge,1728,45,,1728,percent of total billed charges,Critical Access Hospital RCC factor,1305.6,34,,1305.6,percent of total billed charges,Implant Device,1305.6,34,,1305.6,percent of total billed charges,Implant Device,1305.6,34,,1305.6,percent of total billed charges,Implant Device,1305.6,34,,1305.6,percent of total billed charges,Implant Device,1305.6,34,,1305.6,percent of total billed charges,Implant Device,1900.8,,,1900.8,Other,110% of Medicare,1344,35,,1344,percent of total billed charges,Implant Device,1305.6,34,"Charges > $500, x 34%",1305.6,percent of total billed charges,Implant Device,1344,35,,1344,percent of total billed charges,Implant Device,1344,35,,1344,percent of total billed charges,Implant Device,1344,35,,1344,percent of total billed charges,Implant Device,1344,35,,1344,percent of total billed charges,Implant Device,1344,35,,1344,percent of total billed charges,Implant Device,1536,40,,1536,percent of total billed charges,Implant Device,1344,70,,1344,percent of total billed charges,All Other,1305.6,34,,1305.6,percent of total billed charges,Implant Device,1305.6,34,,1305.6,percent of total billed charges,Implant Device,1344,35,,1344,percent of total billed charges,Implant Device,1344,35,,1344,percent of total billed charges,Implant Device,1344,35,,1344,percent of total billed charges,Implant Device,1344,35,,1344,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1305.6,34,"If Charge > 2,000, then 34 percent",1305.6,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2841.61,
ZIMMER EP-200150 BEARING 28MMX44MM SZ F,C1776,HCPCS,,79010562,CDM,278,RC,,,both,,,3675,2719.51,,,2719.51,Other,150% of Medicare + 9.63% HCRA Surcharge,1653.75,45,,1653.75,percent of total billed charges,Critical Access Hospital RCC factor,1249.5,34,,1249.5,percent of total billed charges,Implant Device,1249.5,34,,1249.5,percent of total billed charges,Implant Device,1249.5,34,,1249.5,percent of total billed charges,Implant Device,1249.5,34,,1249.5,percent of total billed charges,Implant Device,1249.5,34,,1249.5,percent of total billed charges,Implant Device,1819.13,,,1819.13,Other,110% of Medicare,1286.25,35,,1286.25,percent of total billed charges,Implant Device,1249.5,34,"Charges > $500, x 34%",1249.5,percent of total billed charges,Implant Device,1286.25,35,,1286.25,percent of total billed charges,Implant Device,1286.25,35,,1286.25,percent of total billed charges,Implant Device,1286.25,35,,1286.25,percent of total billed charges,Implant Device,1286.25,35,,1286.25,percent of total billed charges,Implant Device,1286.25,35,,1286.25,percent of total billed charges,Implant Device,1470,40,,1470,percent of total billed charges,Implant Device,1286.25,70,,1286.25,percent of total billed charges,All Other,1249.5,34,,1249.5,percent of total billed charges,Implant Device,1249.5,34,,1249.5,percent of total billed charges,Implant Device,1286.25,35,,1286.25,percent of total billed charges,Implant Device,1286.25,35,,1286.25,percent of total billed charges,Implant Device,1286.25,35,,1286.25,percent of total billed charges,Implant Device,1286.25,35,,1286.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1249.5,34,"If Charge > 2,000, then 34 percent",1249.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2719.51,
ZIMMER 650-1055 CERAMIC HEAD 28MM,C1776,HCPCS,,79010563,CDM,278,RC,,,both,,,3075,2275.51,,,2275.51,Other,150% of Medicare + 9.63% HCRA Surcharge,1383.75,45,,1383.75,percent of total billed charges,Critical Access Hospital RCC factor,1045.5,34,,1045.5,percent of total billed charges,Implant Device,1045.5,34,,1045.5,percent of total billed charges,Implant Device,1045.5,34,,1045.5,percent of total billed charges,Implant Device,1045.5,34,,1045.5,percent of total billed charges,Implant Device,1045.5,34,,1045.5,percent of total billed charges,Implant Device,1522.13,,,1522.13,Other,110% of Medicare,1076.25,35,,1076.25,percent of total billed charges,Implant Device,1045.5,34,"Charges > $500, x 34%",1045.5,percent of total billed charges,Implant Device,1076.25,35,,1076.25,percent of total billed charges,Implant Device,1076.25,35,,1076.25,percent of total billed charges,Implant Device,1076.25,35,,1076.25,percent of total billed charges,Implant Device,1076.25,35,,1076.25,percent of total billed charges,Implant Device,1076.25,35,,1076.25,percent of total billed charges,Implant Device,1230,40,,1230,percent of total billed charges,Implant Device,1076.25,70,,1076.25,percent of total billed charges,All Other,1045.5,34,,1045.5,percent of total billed charges,Implant Device,1045.5,34,,1045.5,percent of total billed charges,Implant Device,1076.25,35,,1076.25,percent of total billed charges,Implant Device,1076.25,35,,1076.25,percent of total billed charges,Implant Device,1076.25,35,,1076.25,percent of total billed charges,Implant Device,1076.25,35,,1076.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1045.5,34,"If Charge > 2,000, then 34 percent",1045.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2275.51,
ZIMMER 650-1065 ADAPTER TYPE 1 TAPER,C1776,HCPCS,,79010564,CDM,278,RC,,,both,,,480,355.2,,,355.2,Other,150% of Medicare + 9.63% HCRA Surcharge,216,45,,216,percent of total billed charges,Critical Access Hospital RCC factor,163.2,34,,163.2,percent of total billed charges,Implant Device,163.2,34,,163.2,percent of total billed charges,Implant Device,163.2,34,,163.2,percent of total billed charges,Implant Device,163.2,34,,163.2,percent of total billed charges,Implant Device,163.2,34,,163.2,percent of total billed charges,Implant Device,237.6,,,237.6,Other,110% of Medicare,168,35,,168,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,192,40,,192,percent of total billed charges,Implant Device,168,70,,168,percent of total billed charges,All Other,163.2,34,,163.2,percent of total billed charges,Implant Device,163.2,34,,163.2,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,355.2,
STRYKER 5030-5-250 TRANSFIXING PIN,C1713,HCPCS,,79010565,CDM,278,RC,,,both,,,275,203.5,,,203.5,Other,150% of Medicare + 9.63% HCRA Surcharge,123.75,45,,123.75,percent of total billed charges,Critical Access Hospital RCC factor,93.5,34,,93.5,percent of total billed charges,Implant Device,93.5,34,,93.5,percent of total billed charges,Implant Device,93.5,34,,93.5,percent of total billed charges,Implant Device,93.5,34,,93.5,percent of total billed charges,Implant Device,93.5,34,,93.5,percent of total billed charges,Implant Device,136.13,,,136.13,Other,110% of Medicare,96.25,35,,96.25,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,96.25,35,,96.25,percent of total billed charges,Implant Device,96.25,35,,96.25,percent of total billed charges,Implant Device,96.25,35,,96.25,percent of total billed charges,Implant Device,96.25,35,,96.25,percent of total billed charges,Implant Device,96.25,35,,96.25,percent of total billed charges,Implant Device,110,40,,110,percent of total billed charges,Implant Device,96.25,70,,96.25,percent of total billed charges,All Other,93.5,34,,93.5,percent of total billed charges,Implant Device,93.5,34,,93.5,percent of total billed charges,Implant Device,96.25,35,,96.25,percent of total billed charges,Implant Device,96.25,35,,96.25,percent of total billed charges,Implant Device,96.25,35,,96.25,percent of total billed charges,Implant Device,96.25,35,,96.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,203.5,
STRYKER 661146 5.6X46MM LOCKING SCREW,C1713,HCPCS,,79010566,CDM,278,RC,,,both,,,616,455.84,,,455.84,Other,150% of Medicare + 9.63% HCRA Surcharge,277.2,45,,277.2,percent of total billed charges,Critical Access Hospital RCC factor,209.44,34,,209.44,percent of total billed charges,Implant Device,209.44,34,,209.44,percent of total billed charges,Implant Device,209.44,34,,209.44,percent of total billed charges,Implant Device,209.44,34,,209.44,percent of total billed charges,Implant Device,209.44,34,,209.44,percent of total billed charges,Implant Device,304.92,,,304.92,Other,110% of Medicare,215.6,35,,215.6,percent of total billed charges,Implant Device,209.44,34,"Charges > $500, x 34%",209.44,percent of total billed charges,Implant Device,215.6,35,,215.6,percent of total billed charges,Implant Device,215.6,35,,215.6,percent of total billed charges,Implant Device,215.6,35,,215.6,percent of total billed charges,Implant Device,215.6,35,,215.6,percent of total billed charges,Implant Device,215.6,35,,215.6,percent of total billed charges,Implant Device,246.4,40,,246.4,percent of total billed charges,Implant Device,215.6,70,,215.6,percent of total billed charges,All Other,209.44,34,,209.44,percent of total billed charges,Implant Device,209.44,34,,209.44,percent of total billed charges,Implant Device,215.6,35,,215.6,percent of total billed charges,Implant Device,215.6,35,,215.6,percent of total billed charges,Implant Device,215.6,35,,215.6,percent of total billed charges,Implant Device,215.6,35,,215.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,455.84,
STRYKER 661126 5X26MM LOCKING SCREW,C1713,HCPCS,,79010567,CDM,278,RC,,,both,,,616,455.84,,,455.84,Other,150% of Medicare + 9.63% HCRA Surcharge,277.2,45,,277.2,percent of total billed charges,Critical Access Hospital RCC factor,209.44,34,,209.44,percent of total billed charges,Implant Device,209.44,34,,209.44,percent of total billed charges,Implant Device,209.44,34,,209.44,percent of total billed charges,Implant Device,209.44,34,,209.44,percent of total billed charges,Implant Device,209.44,34,,209.44,percent of total billed charges,Implant Device,304.92,,,304.92,Other,110% of Medicare,215.6,35,,215.6,percent of total billed charges,Implant Device,209.44,34,"Charges > $500, x 34%",209.44,percent of total billed charges,Implant Device,215.6,35,,215.6,percent of total billed charges,Implant Device,215.6,35,,215.6,percent of total billed charges,Implant Device,215.6,35,,215.6,percent of total billed charges,Implant Device,215.6,35,,215.6,percent of total billed charges,Implant Device,215.6,35,,215.6,percent of total billed charges,Implant Device,246.4,40,,246.4,percent of total billed charges,Implant Device,215.6,70,,215.6,percent of total billed charges,All Other,209.44,34,,209.44,percent of total billed charges,Implant Device,209.44,34,,209.44,percent of total billed charges,Implant Device,215.6,35,,215.6,percent of total billed charges,Implant Device,215.6,35,,215.6,percent of total billed charges,Implant Device,215.6,35,,215.6,percent of total billed charges,Implant Device,215.6,35,,215.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,455.84,
STRYKER 661180 5X80MM LOCKING SCREW,C1713,HCPCS,,79010568,CDM,278,RC,,,both,,,616,455.84,,,455.84,Other,150% of Medicare + 9.63% HCRA Surcharge,277.2,45,,277.2,percent of total billed charges,Critical Access Hospital RCC factor,209.44,34,,209.44,percent of total billed charges,Implant Device,209.44,34,,209.44,percent of total billed charges,Implant Device,209.44,34,,209.44,percent of total billed charges,Implant Device,209.44,34,,209.44,percent of total billed charges,Implant Device,209.44,34,,209.44,percent of total billed charges,Implant Device,304.92,,,304.92,Other,110% of Medicare,215.6,35,,215.6,percent of total billed charges,Implant Device,209.44,34,"Charges > $500, x 34%",209.44,percent of total billed charges,Implant Device,215.6,35,,215.6,percent of total billed charges,Implant Device,215.6,35,,215.6,percent of total billed charges,Implant Device,215.6,35,,215.6,percent of total billed charges,Implant Device,215.6,35,,215.6,percent of total billed charges,Implant Device,215.6,35,,215.6,percent of total billed charges,Implant Device,246.4,40,,246.4,percent of total billed charges,Implant Device,215.6,70,,215.6,percent of total billed charges,All Other,209.44,34,,209.44,percent of total billed charges,Implant Device,209.44,34,,209.44,percent of total billed charges,Implant Device,215.6,35,,215.6,percent of total billed charges,Implant Device,215.6,35,,215.6,percent of total billed charges,Implant Device,215.6,35,,215.6,percent of total billed charges,Implant Device,215.6,35,,215.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,455.84,
STRYKER 608080 6X80MM CANCELLOUS SCREW,C1713,HCPCS,,79010569,CDM,278,RC,,,both,,,155,114.7,,,114.7,Other,150% of Medicare + 9.63% HCRA Surcharge,69.75,45,,69.75,percent of total billed charges,Critical Access Hospital RCC factor,52.7,34,,52.7,percent of total billed charges,Implant Device,52.7,34,,52.7,percent of total billed charges,Implant Device,52.7,34,,52.7,percent of total billed charges,Implant Device,52.7,34,,52.7,percent of total billed charges,Implant Device,52.7,34,,52.7,percent of total billed charges,Implant Device,76.73,,,76.73,Other,110% of Medicare,54.25,35,,54.25,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,54.25,35,,54.25,percent of total billed charges,Implant Device,54.25,35,,54.25,percent of total billed charges,Implant Device,54.25,35,,54.25,percent of total billed charges,Implant Device,54.25,35,,54.25,percent of total billed charges,Implant Device,54.25,35,,54.25,percent of total billed charges,Implant Device,62,40,,62,percent of total billed charges,Implant Device,54.25,70,,54.25,percent of total billed charges,All Other,52.7,34,,52.7,percent of total billed charges,Implant Device,52.7,34,,52.7,percent of total billed charges,Implant Device,54.25,35,,54.25,percent of total billed charges,Implant Device,54.25,35,,54.25,percent of total billed charges,Implant Device,54.25,35,,54.25,percent of total billed charges,Implant Device,54.25,35,,54.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,114.7,
STRYKER 661736 4.5X36MM NON LOCK SCREW,C1713,HCPCS,,79010570,CDM,278,RC,,,both,,,139,102.86,,,102.86,Other,150% of Medicare + 9.63% HCRA Surcharge,62.55,45,,62.55,percent of total billed charges,Critical Access Hospital RCC factor,47.26,34,,47.26,percent of total billed charges,Implant Device,47.26,34,,47.26,percent of total billed charges,Implant Device,47.26,34,,47.26,percent of total billed charges,Implant Device,47.26,34,,47.26,percent of total billed charges,Implant Device,47.26,34,,47.26,percent of total billed charges,Implant Device,68.81,,,68.81,Other,110% of Medicare,48.65,35,,48.65,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,48.65,35,,48.65,percent of total billed charges,Implant Device,48.65,35,,48.65,percent of total billed charges,Implant Device,48.65,35,,48.65,percent of total billed charges,Implant Device,48.65,35,,48.65,percent of total billed charges,Implant Device,48.65,35,,48.65,percent of total billed charges,Implant Device,55.6,40,,55.6,percent of total billed charges,Implant Device,48.65,70,,48.65,percent of total billed charges,All Other,47.26,34,,47.26,percent of total billed charges,Implant Device,47.26,34,,47.26,percent of total billed charges,Implant Device,48.65,35,,48.65,percent of total billed charges,Implant Device,48.65,35,,48.65,percent of total billed charges,Implant Device,48.65,35,,48.65,percent of total billed charges,Implant Device,48.65,35,,48.65,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,102.86,
STRYKER 628008 PLATE 8 HOLE LEFT,C1713,HCPCS,,79010571,CDM,278,RC,,,both,,,3069,2271.07,,,2271.07,Other,150% of Medicare + 9.63% HCRA Surcharge,1381.05,45,,1381.05,percent of total billed charges,Critical Access Hospital RCC factor,1043.46,34,,1043.46,percent of total billed charges,Implant Device,1043.46,34,,1043.46,percent of total billed charges,Implant Device,1043.46,34,,1043.46,percent of total billed charges,Implant Device,1043.46,34,,1043.46,percent of total billed charges,Implant Device,1043.46,34,,1043.46,percent of total billed charges,Implant Device,1519.16,,,1519.16,Other,110% of Medicare,1074.15,35,,1074.15,percent of total billed charges,Implant Device,1043.46,34,"Charges > $500, x 34%",1043.46,percent of total billed charges,Implant Device,1074.15,35,,1074.15,percent of total billed charges,Implant Device,1074.15,35,,1074.15,percent of total billed charges,Implant Device,1074.15,35,,1074.15,percent of total billed charges,Implant Device,1074.15,35,,1074.15,percent of total billed charges,Implant Device,1074.15,35,,1074.15,percent of total billed charges,Implant Device,1227.6,40,,1227.6,percent of total billed charges,Implant Device,1074.15,70,,1074.15,percent of total billed charges,All Other,1043.46,34,,1043.46,percent of total billed charges,Implant Device,1043.46,34,,1043.46,percent of total billed charges,Implant Device,1074.15,35,,1074.15,percent of total billed charges,Implant Device,1074.15,35,,1074.15,percent of total billed charges,Implant Device,1074.15,35,,1074.15,percent of total billed charges,Implant Device,1074.15,35,,1074.15,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1043.46,34,"If Charge > 2,000, then 34 percent",1043.46,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2271.07,
STRYKER 607346 4X4MM L46MM CAN TI SCREW,C1713,HCPCS,,79010576,CDM,278,RC,,,both,,,133,98.42,,,98.42,Other,150% of Medicare + 9.63% HCRA Surcharge,59.85,45,,59.85,percent of total billed charges,Critical Access Hospital RCC factor,45.22,34,,45.22,percent of total billed charges,Implant Device,45.22,34,,45.22,percent of total billed charges,Implant Device,45.22,34,,45.22,percent of total billed charges,Implant Device,45.22,34,,45.22,percent of total billed charges,Implant Device,45.22,34,,45.22,percent of total billed charges,Implant Device,65.84,,,65.84,Other,110% of Medicare,46.55,35,,46.55,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,46.55,35,,46.55,percent of total billed charges,Implant Device,46.55,35,,46.55,percent of total billed charges,Implant Device,46.55,35,,46.55,percent of total billed charges,Implant Device,46.55,35,,46.55,percent of total billed charges,Implant Device,46.55,35,,46.55,percent of total billed charges,Implant Device,53.2,40,,53.2,percent of total billed charges,Implant Device,46.55,70,,46.55,percent of total billed charges,All Other,45.22,34,,45.22,percent of total billed charges,Implant Device,45.22,34,,45.22,percent of total billed charges,Implant Device,46.55,35,,46.55,percent of total billed charges,Implant Device,46.55,35,,46.55,percent of total billed charges,Implant Device,46.55,35,,46.55,percent of total billed charges,Implant Device,46.55,35,,46.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,98.42,
STRYKER 5026-8-120 HALF PIN 3/5X20X120MM,C1713,HCPCS,,79010577,CDM,278,RC,,,both,,,312,230.88,,,230.88,Other,150% of Medicare + 9.63% HCRA Surcharge,140.4,45,,140.4,percent of total billed charges,Critical Access Hospital RCC factor,106.08,34,,106.08,percent of total billed charges,Implant Device,106.08,34,,106.08,percent of total billed charges,Implant Device,106.08,34,,106.08,percent of total billed charges,Implant Device,106.08,34,,106.08,percent of total billed charges,Implant Device,106.08,34,,106.08,percent of total billed charges,Implant Device,154.44,,,154.44,Other,110% of Medicare,109.2,35,,109.2,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,109.2,35,,109.2,percent of total billed charges,Implant Device,109.2,35,,109.2,percent of total billed charges,Implant Device,109.2,35,,109.2,percent of total billed charges,Implant Device,109.2,35,,109.2,percent of total billed charges,Implant Device,109.2,35,,109.2,percent of total billed charges,Implant Device,124.8,40,,124.8,percent of total billed charges,Implant Device,109.2,70,,109.2,percent of total billed charges,All Other,106.08,34,,106.08,percent of total billed charges,Implant Device,106.08,34,,106.08,percent of total billed charges,Implant Device,109.2,35,,109.2,percent of total billed charges,Implant Device,109.2,35,,109.2,percent of total billed charges,Implant Device,109.2,35,,109.2,percent of total billed charges,Implant Device,109.2,35,,109.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,230.88,
STRYKER 629363 OLECRANON PLT RT 3H 65MM,C1713,HCPCS,,79010578,CDM,278,RC,,,both,,,2543,1881.83,,,1881.83,Other,150% of Medicare + 9.63% HCRA Surcharge,1144.35,45,,1144.35,percent of total billed charges,Critical Access Hospital RCC factor,864.62,34,,864.62,percent of total billed charges,Implant Device,864.62,34,,864.62,percent of total billed charges,Implant Device,864.62,34,,864.62,percent of total billed charges,Implant Device,864.62,34,,864.62,percent of total billed charges,Implant Device,864.62,34,,864.62,percent of total billed charges,Implant Device,1258.79,,,1258.79,Other,110% of Medicare,890.05,35,,890.05,percent of total billed charges,Implant Device,864.62,34,"Charges > $500, x 34%",864.62,percent of total billed charges,Implant Device,890.05,35,,890.05,percent of total billed charges,Implant Device,890.05,35,,890.05,percent of total billed charges,Implant Device,890.05,35,,890.05,percent of total billed charges,Implant Device,890.05,35,,890.05,percent of total billed charges,Implant Device,890.05,35,,890.05,percent of total billed charges,Implant Device,1017.2,40,,1017.2,percent of total billed charges,Implant Device,890.05,70,,890.05,percent of total billed charges,All Other,864.62,34,,864.62,percent of total billed charges,Implant Device,864.62,34,,864.62,percent of total billed charges,Implant Device,890.05,35,,890.05,percent of total billed charges,Implant Device,890.05,35,,890.05,percent of total billed charges,Implant Device,890.05,35,,890.05,percent of total billed charges,Implant Device,890.05,35,,890.05,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,864.62,34,"If Charge > 2,000, then 34 percent",864.62,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1881.83,
DEPUY 04.005.420S LOCK SCREW 4X30MM,C1713,HCPCS,,79010580,CDM,278,RC,,,both,,,412,304.88,,,304.88,Other,150% of Medicare + 9.63% HCRA Surcharge,185.4,45,,185.4,percent of total billed charges,Critical Access Hospital RCC factor,140.08,34,,140.08,percent of total billed charges,Implant Device,140.08,34,,140.08,percent of total billed charges,Implant Device,140.08,34,,140.08,percent of total billed charges,Implant Device,140.08,34,,140.08,percent of total billed charges,Implant Device,140.08,34,,140.08,percent of total billed charges,Implant Device,203.94,,,203.94,Other,110% of Medicare,144.2,35,,144.2,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,144.2,35,,144.2,percent of total billed charges,Implant Device,144.2,35,,144.2,percent of total billed charges,Implant Device,144.2,35,,144.2,percent of total billed charges,Implant Device,144.2,35,,144.2,percent of total billed charges,Implant Device,144.2,35,,144.2,percent of total billed charges,Implant Device,164.8,40,,164.8,percent of total billed charges,Implant Device,144.2,70,,144.2,percent of total billed charges,All Other,140.08,34,,140.08,percent of total billed charges,Implant Device,140.08,34,,140.08,percent of total billed charges,Implant Device,144.2,35,,144.2,percent of total billed charges,Implant Device,144.2,35,,144.2,percent of total billed charges,Implant Device,144.2,35,,144.2,percent of total billed charges,Implant Device,144.2,35,,144.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,304.88,
STRYKER 542-11-50E TRIDENT PSL HA CLUSTE,C1776,HCPCS,,79010581,CDM,278,RC,,,both,,,3150,2331.01,,,2331.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1417.5,45,,1417.5,percent of total billed charges,Critical Access Hospital RCC factor,1071,34,,1071,percent of total billed charges,Implant Device,1071,34,,1071,percent of total billed charges,Implant Device,1071,34,,1071,percent of total billed charges,Implant Device,1071,34,,1071,percent of total billed charges,Implant Device,1071,34,,1071,percent of total billed charges,Implant Device,1559.25,,,1559.25,Other,110% of Medicare,1102.5,35,,1102.5,percent of total billed charges,Implant Device,1071,34,"Charges > $500, x 34%",1071,percent of total billed charges,Implant Device,1102.5,35,,1102.5,percent of total billed charges,Implant Device,1102.5,35,,1102.5,percent of total billed charges,Implant Device,1102.5,35,,1102.5,percent of total billed charges,Implant Device,1102.5,35,,1102.5,percent of total billed charges,Implant Device,1102.5,35,,1102.5,percent of total billed charges,Implant Device,1260,40,,1260,percent of total billed charges,Implant Device,1102.5,70,,1102.5,percent of total billed charges,All Other,1071,34,,1071,percent of total billed charges,Implant Device,1071,34,,1071,percent of total billed charges,Implant Device,1102.5,35,,1102.5,percent of total billed charges,Implant Device,1102.5,35,,1102.5,percent of total billed charges,Implant Device,1102.5,35,,1102.5,percent of total billed charges,Implant Device,1102.5,35,,1102.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1071,34,"If Charge > 2,000, then 34 percent",1071,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2331.01,
DEPUY 1365-36-240 FEM HEAD +9 36MM,C1776,HCPCS,,79010582,CDM,278,RC,,,both,,,5549,4106.27,,,4106.27,Other,150% of Medicare + 9.63% HCRA Surcharge,2497.05,45,,2497.05,percent of total billed charges,Critical Access Hospital RCC factor,1886.66,34,,1886.66,percent of total billed charges,Implant Device,1886.66,34,,1886.66,percent of total billed charges,Implant Device,1886.66,34,,1886.66,percent of total billed charges,Implant Device,1886.66,34,,1886.66,percent of total billed charges,Implant Device,1886.66,34,,1886.66,percent of total billed charges,Implant Device,2746.76,,,2746.76,Other,110% of Medicare,1942.15,35,,1942.15,percent of total billed charges,Implant Device,1886.66,34,"Charges > $500, x 34%",1886.66,percent of total billed charges,Implant Device,1942.15,35,,1942.15,percent of total billed charges,Implant Device,1942.15,35,,1942.15,percent of total billed charges,Implant Device,1942.15,35,,1942.15,percent of total billed charges,Implant Device,1942.15,35,,1942.15,percent of total billed charges,Implant Device,1942.15,35,,1942.15,percent of total billed charges,Implant Device,2219.6,40,,2219.6,percent of total billed charges,Implant Device,1942.15,70,,1942.15,percent of total billed charges,All Other,1886.66,34,,1886.66,percent of total billed charges,Implant Device,1886.66,34,,1886.66,percent of total billed charges,Implant Device,1942.15,35,,1942.15,percent of total billed charges,Implant Device,1942.15,35,,1942.15,percent of total billed charges,Implant Device,1942.15,35,,1942.15,percent of total billed charges,Implant Device,1942.15,35,,1942.15,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1886.66,34,"If Charge > 2,000, then 34 percent",1886.66,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4106.27,
DEPUY 1365-36-250 FEM HEAD +12 36MM,C1776,HCPCS,,79010583,CDM,278,RC,,,both,,,5549,4106.27,,,4106.27,Other,150% of Medicare + 9.63% HCRA Surcharge,2497.05,45,,2497.05,percent of total billed charges,Critical Access Hospital RCC factor,1886.66,34,,1886.66,percent of total billed charges,Implant Device,1886.66,34,,1886.66,percent of total billed charges,Implant Device,1886.66,34,,1886.66,percent of total billed charges,Implant Device,1886.66,34,,1886.66,percent of total billed charges,Implant Device,1886.66,34,,1886.66,percent of total billed charges,Implant Device,2746.76,,,2746.76,Other,110% of Medicare,1942.15,35,,1942.15,percent of total billed charges,Implant Device,1886.66,34,"Charges > $500, x 34%",1886.66,percent of total billed charges,Implant Device,1942.15,35,,1942.15,percent of total billed charges,Implant Device,1942.15,35,,1942.15,percent of total billed charges,Implant Device,1942.15,35,,1942.15,percent of total billed charges,Implant Device,1942.15,35,,1942.15,percent of total billed charges,Implant Device,1942.15,35,,1942.15,percent of total billed charges,Implant Device,2219.6,40,,2219.6,percent of total billed charges,Implant Device,1942.15,70,,1942.15,percent of total billed charges,All Other,1886.66,34,,1886.66,percent of total billed charges,Implant Device,1886.66,34,,1886.66,percent of total billed charges,Implant Device,1942.15,35,,1942.15,percent of total billed charges,Implant Device,1942.15,35,,1942.15,percent of total billed charges,Implant Device,1942.15,35,,1942.15,percent of total billed charges,Implant Device,1942.15,35,,1942.15,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1886.66,34,"If Charge > 2,000, then 34 percent",1886.66,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4106.27,
DEPUY 02.211.139S 2.7X3.5MM DISTAL PLATE,C1713,HCPCS,,79010585,CDM,278,RC,,,both,,,1757,1300.18,,,1300.18,Other,150% of Medicare + 9.63% HCRA Surcharge,790.65,45,,790.65,percent of total billed charges,Critical Access Hospital RCC factor,597.38,34,,597.38,percent of total billed charges,Implant Device,597.38,34,,597.38,percent of total billed charges,Implant Device,597.38,34,,597.38,percent of total billed charges,Implant Device,597.38,34,,597.38,percent of total billed charges,Implant Device,597.38,34,,597.38,percent of total billed charges,Implant Device,869.72,,,869.72,Other,110% of Medicare,614.95,35,,614.95,percent of total billed charges,Implant Device,597.38,34,"Charges > $500, x 34%",597.38,percent of total billed charges,Implant Device,614.95,35,,614.95,percent of total billed charges,Implant Device,614.95,35,,614.95,percent of total billed charges,Implant Device,614.95,35,,614.95,percent of total billed charges,Implant Device,614.95,35,,614.95,percent of total billed charges,Implant Device,614.95,35,,614.95,percent of total billed charges,Implant Device,702.8,40,,702.8,percent of total billed charges,Implant Device,614.95,70,,614.95,percent of total billed charges,All Other,597.38,34,,597.38,percent of total billed charges,Implant Device,597.38,34,,597.38,percent of total billed charges,Implant Device,614.95,35,,614.95,percent of total billed charges,Implant Device,614.95,35,,614.95,percent of total billed charges,Implant Device,614.95,35,,614.95,percent of total billed charges,Implant Device,614.95,35,,614.95,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1300.18,
STRYKER 1896-5025S TS2 LOCK SCREW 5X25MM,C1713,HCPCS,,79010586,CDM,278,RC,,,both,,,441,326.34,,,326.34,Other,150% of Medicare + 9.63% HCRA Surcharge,198.45,45,,198.45,percent of total billed charges,Critical Access Hospital RCC factor,149.94,34,,149.94,percent of total billed charges,Implant Device,149.94,34,,149.94,percent of total billed charges,Implant Device,149.94,34,,149.94,percent of total billed charges,Implant Device,149.94,34,,149.94,percent of total billed charges,Implant Device,149.94,34,,149.94,percent of total billed charges,Implant Device,218.3,,,218.3,Other,110% of Medicare,154.35,35,,154.35,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,154.35,35,,154.35,percent of total billed charges,Implant Device,154.35,35,,154.35,percent of total billed charges,Implant Device,154.35,35,,154.35,percent of total billed charges,Implant Device,154.35,35,,154.35,percent of total billed charges,Implant Device,154.35,35,,154.35,percent of total billed charges,Implant Device,176.4,40,,176.4,percent of total billed charges,Implant Device,154.35,70,,154.35,percent of total billed charges,All Other,149.94,34,,149.94,percent of total billed charges,Implant Device,149.94,34,,149.94,percent of total billed charges,Implant Device,154.35,35,,154.35,percent of total billed charges,Implant Device,154.35,35,,154.35,percent of total billed charges,Implant Device,154.35,35,,154.35,percent of total billed charges,Implant Device,154.35,35,,154.35,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,326.34,
ZIMMER 42-5299-003-01 ART SURF INSERTER,C1776,HCPCS,,79010587,CDM,278,RC,,,both,,,420,310.8,,,310.8,Other,150% of Medicare + 9.63% HCRA Surcharge,189,45,,189,percent of total billed charges,Critical Access Hospital RCC factor,142.8,34,,142.8,percent of total billed charges,Implant Device,142.8,34,,142.8,percent of total billed charges,Implant Device,142.8,34,,142.8,percent of total billed charges,Implant Device,142.8,34,,142.8,percent of total billed charges,Implant Device,142.8,34,,142.8,percent of total billed charges,Implant Device,207.9,,,207.9,Other,110% of Medicare,147,35,,147,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,147,35,,147,percent of total billed charges,Implant Device,147,35,,147,percent of total billed charges,Implant Device,147,35,,147,percent of total billed charges,Implant Device,147,35,,147,percent of total billed charges,Implant Device,147,35,,147,percent of total billed charges,Implant Device,168,40,,168,percent of total billed charges,Implant Device,147,70,,147,percent of total billed charges,All Other,142.8,34,,142.8,percent of total billed charges,Implant Device,142.8,34,,142.8,percent of total billed charges,Implant Device,147,35,,147,percent of total billed charges,Implant Device,147,35,,147,percent of total billed charges,Implant Device,147,35,,147,percent of total billed charges,Implant Device,147,35,,147,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,310.8,
ZIMMER 00-5983-040-33 HEADED SCREW 33MM,C1713,HCPCS,,79010588,CDM,278,RC,,,both,,,237,175.38,,,175.38,Other,150% of Medicare + 9.63% HCRA Surcharge,106.65,45,,106.65,percent of total billed charges,Critical Access Hospital RCC factor,80.58,34,,80.58,percent of total billed charges,Implant Device,80.58,34,,80.58,percent of total billed charges,Implant Device,80.58,34,,80.58,percent of total billed charges,Implant Device,80.58,34,,80.58,percent of total billed charges,Implant Device,80.58,34,,80.58,percent of total billed charges,Implant Device,117.32,,,117.32,Other,110% of Medicare,82.95,35,,82.95,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,82.95,35,,82.95,percent of total billed charges,Implant Device,82.95,35,,82.95,percent of total billed charges,Implant Device,82.95,35,,82.95,percent of total billed charges,Implant Device,82.95,35,,82.95,percent of total billed charges,Implant Device,82.95,35,,82.95,percent of total billed charges,Implant Device,94.8,40,,94.8,percent of total billed charges,Implant Device,82.95,70,,82.95,percent of total billed charges,All Other,80.58,34,,80.58,percent of total billed charges,Implant Device,80.58,34,,80.58,percent of total billed charges,Implant Device,82.95,35,,82.95,percent of total billed charges,Implant Device,82.95,35,,82.95,percent of total billed charges,Implant Device,82.95,35,,82.95,percent of total billed charges,Implant Device,82.95,35,,82.95,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,175.38,
ZIMMER 42-5580-004-02 PARTIAL FEMUR SZ 4,C1776,HCPCS,,79010589,CDM,278,RC,,,both,,,5550,4107.01,,,4107.01,Other,150% of Medicare + 9.63% HCRA Surcharge,2497.5,45,,2497.5,percent of total billed charges,Critical Access Hospital RCC factor,1887,34,,1887,percent of total billed charges,Implant Device,1887,34,,1887,percent of total billed charges,Implant Device,1887,34,,1887,percent of total billed charges,Implant Device,1887,34,,1887,percent of total billed charges,Implant Device,1887,34,,1887,percent of total billed charges,Implant Device,2747.25,,,2747.25,Other,110% of Medicare,1942.5,35,,1942.5,percent of total billed charges,Implant Device,1887,34,"Charges > $500, x 34%",1887,percent of total billed charges,Implant Device,1942.5,35,,1942.5,percent of total billed charges,Implant Device,1942.5,35,,1942.5,percent of total billed charges,Implant Device,1942.5,35,,1942.5,percent of total billed charges,Implant Device,1942.5,35,,1942.5,percent of total billed charges,Implant Device,1942.5,35,,1942.5,percent of total billed charges,Implant Device,2220,40,,2220,percent of total billed charges,Implant Device,1942.5,70,,1942.5,percent of total billed charges,All Other,1887,34,,1887,percent of total billed charges,Implant Device,1887,34,,1887,percent of total billed charges,Implant Device,1942.5,35,,1942.5,percent of total billed charges,Implant Device,1942.5,35,,1942.5,percent of total billed charges,Implant Device,1942.5,35,,1942.5,percent of total billed charges,Implant Device,1942.5,35,,1942.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1887,34,"If Charge > 2,000, then 34 percent",1887,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4107.01,
ZIMMER 42-5380-007-02 PARTIAL TIB SZ G,C1776,HCPCS,,79010590,CDM,278,RC,,,both,,,2325,1720.51,,,1720.51,Other,150% of Medicare + 9.63% HCRA Surcharge,1046.25,45,,1046.25,percent of total billed charges,Critical Access Hospital RCC factor,790.5,34,,790.5,percent of total billed charges,Implant Device,790.5,34,,790.5,percent of total billed charges,Implant Device,790.5,34,,790.5,percent of total billed charges,Implant Device,790.5,34,,790.5,percent of total billed charges,Implant Device,790.5,34,,790.5,percent of total billed charges,Implant Device,1150.88,,,1150.88,Other,110% of Medicare,813.75,35,,813.75,percent of total billed charges,Implant Device,790.5,34,"Charges > $500, x 34%",790.5,percent of total billed charges,Implant Device,813.75,35,,813.75,percent of total billed charges,Implant Device,813.75,35,,813.75,percent of total billed charges,Implant Device,813.75,35,,813.75,percent of total billed charges,Implant Device,813.75,35,,813.75,percent of total billed charges,Implant Device,813.75,35,,813.75,percent of total billed charges,Implant Device,930,40,,930,percent of total billed charges,Implant Device,813.75,70,,813.75,percent of total billed charges,All Other,790.5,34,,790.5,percent of total billed charges,Implant Device,790.5,34,,790.5,percent of total billed charges,Implant Device,813.75,35,,813.75,percent of total billed charges,Implant Device,813.75,35,,813.75,percent of total billed charges,Implant Device,813.75,35,,813.75,percent of total billed charges,Implant Device,813.75,35,,813.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,790.5,34,"If Charge > 2,000, then 34 percent",790.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1720.51,
ZIMMER 42-5282-007-08 ART SURF SZ G 8MM,C1776,HCPCS,,79010591,CDM,278,RC,,,both,,,3450,2553.01,,,2553.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1552.5,45,,1552.5,percent of total billed charges,Critical Access Hospital RCC factor,1173,34,,1173,percent of total billed charges,Implant Device,1173,34,,1173,percent of total billed charges,Implant Device,1173,34,,1173,percent of total billed charges,Implant Device,1173,34,,1173,percent of total billed charges,Implant Device,1173,34,,1173,percent of total billed charges,Implant Device,1707.75,,,1707.75,Other,110% of Medicare,1207.5,35,,1207.5,percent of total billed charges,Implant Device,1173,34,"Charges > $500, x 34%",1173,percent of total billed charges,Implant Device,1207.5,35,,1207.5,percent of total billed charges,Implant Device,1207.5,35,,1207.5,percent of total billed charges,Implant Device,1207.5,35,,1207.5,percent of total billed charges,Implant Device,1207.5,35,,1207.5,percent of total billed charges,Implant Device,1207.5,35,,1207.5,percent of total billed charges,Implant Device,1380,40,,1380,percent of total billed charges,Implant Device,1207.5,70,,1207.5,percent of total billed charges,All Other,1173,34,,1173,percent of total billed charges,Implant Device,1173,34,,1173,percent of total billed charges,Implant Device,1207.5,35,,1207.5,percent of total billed charges,Implant Device,1207.5,35,,1207.5,percent of total billed charges,Implant Device,1207.5,35,,1207.5,percent of total billed charges,Implant Device,1207.5,35,,1207.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1173,34,"If Charge > 2,000, then 34 percent",1173,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2553.01,
BARD 5957750 VENTRALIGHT ST 4.5' CIRCLE,C1781,HCPCS,,79010592,CDM,278,RC,,,both,,,1458,1078.92,,,1078.92,Other,150% of Medicare + 9.63% HCRA Surcharge,656.1,45,,656.1,percent of total billed charges,Critical Access Hospital RCC factor,495.72,34,,495.72,percent of total billed charges,Implant Device,495.72,34,,495.72,percent of total billed charges,Implant Device,495.72,34,,495.72,percent of total billed charges,Implant Device,495.72,34,,495.72,percent of total billed charges,Implant Device,495.72,34,,495.72,percent of total billed charges,Implant Device,721.71,,,721.71,Other,110% of Medicare,510.3,35,,510.3,percent of total billed charges,Implant Device,495.72,34,"Charges > $500, x 34%",495.72,percent of total billed charges,Implant Device,510.3,35,,510.3,percent of total billed charges,Implant Device,510.3,35,,510.3,percent of total billed charges,Implant Device,510.3,35,,510.3,percent of total billed charges,Implant Device,510.3,35,,510.3,percent of total billed charges,Implant Device,510.3,35,,510.3,percent of total billed charges,Implant Device,583.2,40,,583.2,percent of total billed charges,Implant Device,510.3,70,,510.3,percent of total billed charges,All Other,495.72,34,,495.72,percent of total billed charges,Implant Device,495.72,34,,495.72,percent of total billed charges,Implant Device,510.3,35,,510.3,percent of total billed charges,Implant Device,510.3,35,,510.3,percent of total billed charges,Implant Device,510.3,35,,510.3,percent of total billed charges,Implant Device,510.3,35,,510.3,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1078.92,
BARD 5954460 VENTRALIGHT ST 4X6,C1781,HCPCS,,79010593,CDM,278,RC,,,both,,,2175,1609.51,,,1609.51,Other,150% of Medicare + 9.63% HCRA Surcharge,978.75,45,,978.75,percent of total billed charges,Critical Access Hospital RCC factor,739.5,34,,739.5,percent of total billed charges,Implant Device,739.5,34,,739.5,percent of total billed charges,Implant Device,739.5,34,,739.5,percent of total billed charges,Implant Device,739.5,34,,739.5,percent of total billed charges,Implant Device,739.5,34,,739.5,percent of total billed charges,Implant Device,1076.63,,,1076.63,Other,110% of Medicare,761.25,35,,761.25,percent of total billed charges,Implant Device,739.5,34,"Charges > $500, x 34%",739.5,percent of total billed charges,Implant Device,761.25,35,,761.25,percent of total billed charges,Implant Device,761.25,35,,761.25,percent of total billed charges,Implant Device,761.25,35,,761.25,percent of total billed charges,Implant Device,761.25,35,,761.25,percent of total billed charges,Implant Device,761.25,35,,761.25,percent of total billed charges,Implant Device,870,40,,870,percent of total billed charges,Implant Device,761.25,70,,761.25,percent of total billed charges,All Other,739.5,34,,739.5,percent of total billed charges,Implant Device,739.5,34,,739.5,percent of total billed charges,Implant Device,761.25,35,,761.25,percent of total billed charges,Implant Device,761.25,35,,761.25,percent of total billed charges,Implant Device,761.25,35,,761.25,percent of total billed charges,Implant Device,761.25,35,,761.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,739.5,34,"If Charge > 2,000, then 34 percent",739.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1609.51,
BARD 5954680 VENTRALIGHT ST 6X8',C1781,HCPCS,,79010594,CDM,278,RC,,,both,,,3590,2656.61,,,2656.61,Other,150% of Medicare + 9.63% HCRA Surcharge,1615.5,45,,1615.5,percent of total billed charges,Critical Access Hospital RCC factor,1220.6,34,,1220.6,percent of total billed charges,Implant Device,1220.6,34,,1220.6,percent of total billed charges,Implant Device,1220.6,34,,1220.6,percent of total billed charges,Implant Device,1220.6,34,,1220.6,percent of total billed charges,Implant Device,1220.6,34,,1220.6,percent of total billed charges,Implant Device,1777.05,,,1777.05,Other,110% of Medicare,1256.5,35,,1256.5,percent of total billed charges,Implant Device,1220.6,34,"Charges > $500, x 34%",1220.6,percent of total billed charges,Implant Device,1256.5,35,,1256.5,percent of total billed charges,Implant Device,1256.5,35,,1256.5,percent of total billed charges,Implant Device,1256.5,35,,1256.5,percent of total billed charges,Implant Device,1256.5,35,,1256.5,percent of total billed charges,Implant Device,1256.5,35,,1256.5,percent of total billed charges,Implant Device,1436,40,,1436,percent of total billed charges,Implant Device,1256.5,70,,1256.5,percent of total billed charges,All Other,1220.6,34,,1220.6,percent of total billed charges,Implant Device,1220.6,34,,1220.6,percent of total billed charges,Implant Device,1256.5,35,,1256.5,percent of total billed charges,Implant Device,1256.5,35,,1256.5,percent of total billed charges,Implant Device,1256.5,35,,1256.5,percent of total billed charges,Implant Device,1256.5,35,,1256.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1220.6,34,"If Charge > 2,000, then 34 percent",1220.6,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2656.61,
BARD 0112950 PERFIX PLUG SMALL,C1781,HCPCS,,79010595,CDM,278,RC,,,both,,,803,594.22,,,594.22,Other,150% of Medicare + 9.63% HCRA Surcharge,361.35,45,,361.35,percent of total billed charges,Critical Access Hospital RCC factor,273.02,34,,273.02,percent of total billed charges,Implant Device,273.02,34,,273.02,percent of total billed charges,Implant Device,273.02,34,,273.02,percent of total billed charges,Implant Device,273.02,34,,273.02,percent of total billed charges,Implant Device,273.02,34,,273.02,percent of total billed charges,Implant Device,397.49,,,397.49,Other,110% of Medicare,281.05,35,,281.05,percent of total billed charges,Implant Device,273.02,34,"Charges > $500, x 34%",273.02,percent of total billed charges,Implant Device,281.05,35,,281.05,percent of total billed charges,Implant Device,281.05,35,,281.05,percent of total billed charges,Implant Device,281.05,35,,281.05,percent of total billed charges,Implant Device,281.05,35,,281.05,percent of total billed charges,Implant Device,281.05,35,,281.05,percent of total billed charges,Implant Device,321.2,40,,321.2,percent of total billed charges,Implant Device,281.05,70,,281.05,percent of total billed charges,All Other,273.02,34,,273.02,percent of total billed charges,Implant Device,273.02,34,,273.02,percent of total billed charges,Implant Device,281.05,35,,281.05,percent of total billed charges,Implant Device,281.05,35,,281.05,percent of total billed charges,Implant Device,281.05,35,,281.05,percent of total billed charges,Implant Device,281.05,35,,281.05,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,594.22,
BARD 0112960 PERFIX PLUG MED,C1781,HCPCS,,79010596,CDM,278,RC,,,both,,,810,599.4,,,599.4,Other,150% of Medicare + 9.63% HCRA Surcharge,364.5,45,,364.5,percent of total billed charges,Critical Access Hospital RCC factor,275.4,34,,275.4,percent of total billed charges,Implant Device,275.4,34,,275.4,percent of total billed charges,Implant Device,275.4,34,,275.4,percent of total billed charges,Implant Device,275.4,34,,275.4,percent of total billed charges,Implant Device,275.4,34,,275.4,percent of total billed charges,Implant Device,400.95,,,400.95,Other,110% of Medicare,283.5,35,,283.5,percent of total billed charges,Implant Device,275.4,34,"Charges > $500, x 34%",275.4,percent of total billed charges,Implant Device,283.5,35,,283.5,percent of total billed charges,Implant Device,283.5,35,,283.5,percent of total billed charges,Implant Device,283.5,35,,283.5,percent of total billed charges,Implant Device,283.5,35,,283.5,percent of total billed charges,Implant Device,283.5,35,,283.5,percent of total billed charges,Implant Device,324,40,,324,percent of total billed charges,Implant Device,283.5,70,,283.5,percent of total billed charges,All Other,275.4,34,,275.4,percent of total billed charges,Implant Device,275.4,34,,275.4,percent of total billed charges,Implant Device,283.5,35,,283.5,percent of total billed charges,Implant Device,283.5,35,,283.5,percent of total billed charges,Implant Device,283.5,35,,283.5,percent of total billed charges,Implant Device,283.5,35,,283.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,599.4,
BARD 0112970 PERFIX PLUG LG,C1781,HCPCS,,79010597,CDM,278,RC,,,both,,,818,605.32,,,605.32,Other,150% of Medicare + 9.63% HCRA Surcharge,368.1,45,,368.1,percent of total billed charges,Critical Access Hospital RCC factor,278.12,34,,278.12,percent of total billed charges,Implant Device,278.12,34,,278.12,percent of total billed charges,Implant Device,278.12,34,,278.12,percent of total billed charges,Implant Device,278.12,34,,278.12,percent of total billed charges,Implant Device,278.12,34,,278.12,percent of total billed charges,Implant Device,404.91,,,404.91,Other,110% of Medicare,286.3,35,,286.3,percent of total billed charges,Implant Device,278.12,34,"Charges > $500, x 34%",278.12,percent of total billed charges,Implant Device,286.3,35,,286.3,percent of total billed charges,Implant Device,286.3,35,,286.3,percent of total billed charges,Implant Device,286.3,35,,286.3,percent of total billed charges,Implant Device,286.3,35,,286.3,percent of total billed charges,Implant Device,286.3,35,,286.3,percent of total billed charges,Implant Device,327.2,40,,327.2,percent of total billed charges,Implant Device,286.3,70,,286.3,percent of total billed charges,All Other,278.12,34,,278.12,percent of total billed charges,Implant Device,278.12,34,,278.12,percent of total billed charges,Implant Device,286.3,35,,286.3,percent of total billed charges,Implant Device,286.3,35,,286.3,percent of total billed charges,Implant Device,286.3,35,,286.3,percent of total billed charges,Implant Device,286.3,35,,286.3,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,605.32,
BARD 0112980 PERFIX PLUG XL,C1781,HCPCS,,79010598,CDM,278,RC,,,both,,,948,701.52,,,701.52,Other,150% of Medicare + 9.63% HCRA Surcharge,426.6,45,,426.6,percent of total billed charges,Critical Access Hospital RCC factor,322.32,34,,322.32,percent of total billed charges,Implant Device,322.32,34,,322.32,percent of total billed charges,Implant Device,322.32,34,,322.32,percent of total billed charges,Implant Device,322.32,34,,322.32,percent of total billed charges,Implant Device,322.32,34,,322.32,percent of total billed charges,Implant Device,469.26,,,469.26,Other,110% of Medicare,331.8,35,,331.8,percent of total billed charges,Implant Device,322.32,34,"Charges > $500, x 34%",322.32,percent of total billed charges,Implant Device,331.8,35,,331.8,percent of total billed charges,Implant Device,331.8,35,,331.8,percent of total billed charges,Implant Device,331.8,35,,331.8,percent of total billed charges,Implant Device,331.8,35,,331.8,percent of total billed charges,Implant Device,331.8,35,,331.8,percent of total billed charges,Implant Device,379.2,40,,379.2,percent of total billed charges,Implant Device,331.8,70,,331.8,percent of total billed charges,All Other,322.32,34,,322.32,percent of total billed charges,Implant Device,322.32,34,,322.32,percent of total billed charges,Implant Device,331.8,35,,331.8,percent of total billed charges,Implant Device,331.8,35,,331.8,percent of total billed charges,Implant Device,331.8,35,,331.8,percent of total billed charges,Implant Device,331.8,35,,331.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,701.52,
BARD 5954460 VENTRALEX SR SMALKL,C1781,HCPCS,,79010599,CDM,278,RC,,,both,,,1770,1309.8,,,1309.8,Other,150% of Medicare + 9.63% HCRA Surcharge,796.5,45,,796.5,percent of total billed charges,Critical Access Hospital RCC factor,601.8,34,,601.8,percent of total billed charges,Implant Device,601.8,34,,601.8,percent of total billed charges,Implant Device,601.8,34,,601.8,percent of total billed charges,Implant Device,601.8,34,,601.8,percent of total billed charges,Implant Device,601.8,34,,601.8,percent of total billed charges,Implant Device,876.15,,,876.15,Other,110% of Medicare,619.5,35,,619.5,percent of total billed charges,Implant Device,601.8,34,"Charges > $500, x 34%",601.8,percent of total billed charges,Implant Device,619.5,35,,619.5,percent of total billed charges,Implant Device,619.5,35,,619.5,percent of total billed charges,Implant Device,619.5,35,,619.5,percent of total billed charges,Implant Device,619.5,35,,619.5,percent of total billed charges,Implant Device,619.5,35,,619.5,percent of total billed charges,Implant Device,708,40,,708,percent of total billed charges,Implant Device,619.5,70,,619.5,percent of total billed charges,All Other,601.8,34,,601.8,percent of total billed charges,Implant Device,601.8,34,,601.8,percent of total billed charges,Implant Device,619.5,35,,619.5,percent of total billed charges,Implant Device,619.5,35,,619.5,percent of total billed charges,Implant Device,619.5,35,,619.5,percent of total billed charges,Implant Device,619.5,35,,619.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1309.8,
BARD 5950009 VENTRALEX SR XL,C1781,HCPCS,,79010600,CDM,278,RC,,,both,,,2580,1909.21,,,1909.21,Other,150% of Medicare + 9.63% HCRA Surcharge,1161,45,,1161,percent of total billed charges,Critical Access Hospital RCC factor,877.2,34,,877.2,percent of total billed charges,Implant Device,877.2,34,,877.2,percent of total billed charges,Implant Device,877.2,34,,877.2,percent of total billed charges,Implant Device,877.2,34,,877.2,percent of total billed charges,Implant Device,877.2,34,,877.2,percent of total billed charges,Implant Device,1277.1,,,1277.1,Other,110% of Medicare,903,35,,903,percent of total billed charges,Implant Device,877.2,34,"Charges > $500, x 34%",877.2,percent of total billed charges,Implant Device,903,35,,903,percent of total billed charges,Implant Device,903,35,,903,percent of total billed charges,Implant Device,903,35,,903,percent of total billed charges,Implant Device,903,35,,903,percent of total billed charges,Implant Device,903,35,,903,percent of total billed charges,Implant Device,1032,40,,1032,percent of total billed charges,Implant Device,903,70,,903,percent of total billed charges,All Other,877.2,34,,877.2,percent of total billed charges,Implant Device,877.2,34,,877.2,percent of total billed charges,Implant Device,903,35,,903,percent of total billed charges,Implant Device,903,35,,903,percent of total billed charges,Implant Device,903,35,,903,percent of total billed charges,Implant Device,903,35,,903,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,877.2,34,"If Charge > 2,000, then 34 percent",877.2,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1909.21,
BARD 0117016 BARD SOFT MESH 12X12',C1781,HCPCS,,79010601,CDM,278,RC,,,both,,,639,472.86,,,472.86,Other,150% of Medicare + 9.63% HCRA Surcharge,287.55,45,,287.55,percent of total billed charges,Critical Access Hospital RCC factor,217.26,34,,217.26,percent of total billed charges,Implant Device,217.26,34,,217.26,percent of total billed charges,Implant Device,217.26,34,,217.26,percent of total billed charges,Implant Device,217.26,34,,217.26,percent of total billed charges,Implant Device,217.26,34,,217.26,percent of total billed charges,Implant Device,316.31,,,316.31,Other,110% of Medicare,223.65,35,,223.65,percent of total billed charges,Implant Device,217.26,34,"Charges > $500, x 34%",217.26,percent of total billed charges,Implant Device,223.65,35,,223.65,percent of total billed charges,Implant Device,223.65,35,,223.65,percent of total billed charges,Implant Device,223.65,35,,223.65,percent of total billed charges,Implant Device,223.65,35,,223.65,percent of total billed charges,Implant Device,223.65,35,,223.65,percent of total billed charges,Implant Device,255.6,40,,255.6,percent of total billed charges,Implant Device,223.65,70,,223.65,percent of total billed charges,All Other,217.26,34,,217.26,percent of total billed charges,Implant Device,217.26,34,,217.26,percent of total billed charges,Implant Device,223.65,35,,223.65,percent of total billed charges,Implant Device,223.65,35,,223.65,percent of total billed charges,Implant Device,223.65,35,,223.65,percent of total billed charges,Implant Device,223.65,35,,223.65,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,472.86,
BARD 0117011 BARD SOFT MESH 6X6',C1781,HCPCS,,79010602,CDM,278,RC,,,both,,,1386,1025.64,,,1025.64,Other,150% of Medicare + 9.63% HCRA Surcharge,623.7,45,,623.7,percent of total billed charges,Critical Access Hospital RCC factor,471.24,34,,471.24,percent of total billed charges,Implant Device,471.24,34,,471.24,percent of total billed charges,Implant Device,471.24,34,,471.24,percent of total billed charges,Implant Device,471.24,34,,471.24,percent of total billed charges,Implant Device,471.24,34,,471.24,percent of total billed charges,Implant Device,686.07,,,686.07,Other,110% of Medicare,485.1,35,,485.1,percent of total billed charges,Implant Device,471.24,34,"Charges > $500, x 34%",471.24,percent of total billed charges,Implant Device,485.1,35,,485.1,percent of total billed charges,Implant Device,485.1,35,,485.1,percent of total billed charges,Implant Device,485.1,35,,485.1,percent of total billed charges,Implant Device,485.1,35,,485.1,percent of total billed charges,Implant Device,485.1,35,,485.1,percent of total billed charges,Implant Device,554.4,40,,554.4,percent of total billed charges,Implant Device,485.1,70,,485.1,percent of total billed charges,All Other,471.24,34,,471.24,percent of total billed charges,Implant Device,471.24,34,,471.24,percent of total billed charges,Implant Device,485.1,35,,485.1,percent of total billed charges,Implant Device,485.1,35,,485.1,percent of total billed charges,Implant Device,485.1,35,,485.1,percent of total billed charges,Implant Device,485.1,35,,485.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1025.64,
DEPUY 02.112.091 CLAV PLT 6H 3.5X105MM,C1713,HCPCS,,79010603,CDM,278,RC,,,both,,,2397,1773.79,,,1773.79,Other,150% of Medicare + 9.63% HCRA Surcharge,1078.65,45,,1078.65,percent of total billed charges,Critical Access Hospital RCC factor,814.98,34,,814.98,percent of total billed charges,Implant Device,814.98,34,,814.98,percent of total billed charges,Implant Device,814.98,34,,814.98,percent of total billed charges,Implant Device,814.98,34,,814.98,percent of total billed charges,Implant Device,814.98,34,,814.98,percent of total billed charges,Implant Device,1186.52,,,1186.52,Other,110% of Medicare,838.95,35,,838.95,percent of total billed charges,Implant Device,814.98,34,"Charges > $500, x 34%",814.98,percent of total billed charges,Implant Device,838.95,35,,838.95,percent of total billed charges,Implant Device,838.95,35,,838.95,percent of total billed charges,Implant Device,838.95,35,,838.95,percent of total billed charges,Implant Device,838.95,35,,838.95,percent of total billed charges,Implant Device,838.95,35,,838.95,percent of total billed charges,Implant Device,958.8,40,,958.8,percent of total billed charges,Implant Device,838.95,70,,838.95,percent of total billed charges,All Other,814.98,34,,814.98,percent of total billed charges,Implant Device,814.98,34,,814.98,percent of total billed charges,Implant Device,838.95,35,,838.95,percent of total billed charges,Implant Device,838.95,35,,838.95,percent of total billed charges,Implant Device,838.95,35,,838.95,percent of total billed charges,Implant Device,838.95,35,,838.95,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,814.98,34,"If Charge > 2,000, then 34 percent",814.98,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1773.79,
DEPUY 201.368.97 CORTEX SCREW 2X18MM,C1713,HCPCS,,79010604,CDM,278,RC,,,both,,,93,68.82,,,68.82,Other,150% of Medicare + 9.63% HCRA Surcharge,41.85,45,,41.85,percent of total billed charges,Critical Access Hospital RCC factor,31.62,34,,31.62,percent of total billed charges,Implant Device,31.62,34,,31.62,percent of total billed charges,Implant Device,31.62,34,,31.62,percent of total billed charges,Implant Device,31.62,34,,31.62,percent of total billed charges,Implant Device,31.62,34,,31.62,percent of total billed charges,Implant Device,46.04,,,46.04,Other,110% of Medicare,32.55,35,,32.55,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,32.55,35,,32.55,percent of total billed charges,Implant Device,32.55,35,,32.55,percent of total billed charges,Implant Device,32.55,35,,32.55,percent of total billed charges,Implant Device,32.55,35,,32.55,percent of total billed charges,Implant Device,32.55,35,,32.55,percent of total billed charges,Implant Device,37.2,40,,37.2,percent of total billed charges,Implant Device,32.55,70,,32.55,percent of total billed charges,All Other,31.62,34,,31.62,percent of total billed charges,Implant Device,31.62,34,,31.62,percent of total billed charges,Implant Device,32.55,35,,32.55,percent of total billed charges,Implant Device,32.55,35,,32.55,percent of total billed charges,Implant Device,32.55,35,,32.55,percent of total billed charges,Implant Device,32.55,35,,32.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,68.82,
EXACTECH 320-32-36 GLENOSPHERE 36MM,C1776,HCPCS,,79010606,CDM,278,RC,,,both,,,9018,6673.34,,,6673.34,Other,150% of Medicare + 9.63% HCRA Surcharge,4058.1,45,,4058.1,percent of total billed charges,Critical Access Hospital RCC factor,3066.12,34,,3066.12,percent of total billed charges,Implant Device,3066.12,34,,3066.12,percent of total billed charges,Implant Device,3066.12,34,,3066.12,percent of total billed charges,Implant Device,3066.12,34,,3066.12,percent of total billed charges,Implant Device,3066.12,34,,3066.12,percent of total billed charges,Implant Device,4463.91,,,4463.91,Other,110% of Medicare,3156.3,35,,3156.3,percent of total billed charges,Implant Device,3066.12,34,"Charges > $500, x 34%",3066.12,percent of total billed charges,Implant Device,3156.3,35,,3156.3,percent of total billed charges,Implant Device,3156.3,35,,3156.3,percent of total billed charges,Implant Device,3156.3,35,,3156.3,percent of total billed charges,Implant Device,3156.3,35,,3156.3,percent of total billed charges,Implant Device,3156.3,35,,3156.3,percent of total billed charges,Implant Device,3607.2,40,,3607.2,percent of total billed charges,Implant Device,3156.3,70,,3156.3,percent of total billed charges,All Other,3066.12,34,,3066.12,percent of total billed charges,Implant Device,3066.12,34,,3066.12,percent of total billed charges,Implant Device,3156.3,35,,3156.3,percent of total billed charges,Implant Device,3156.3,35,,3156.3,percent of total billed charges,Implant Device,3156.3,35,,3156.3,percent of total billed charges,Implant Device,3156.3,35,,3156.3,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3066.12,34,"If Charge > 2,000, then 34 percent",3066.12,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,6673.34,
STRYKER 5510-F-702 FEM COMP SZ 7 RT,C1776,HCPCS,,79010607,CDM,278,RC,,,both,,,5100,3774.01,,,3774.01,Other,150% of Medicare + 9.63% HCRA Surcharge,2295,45,,2295,percent of total billed charges,Critical Access Hospital RCC factor,1734,34,,1734,percent of total billed charges,Implant Device,1734,34,,1734,percent of total billed charges,Implant Device,1734,34,,1734,percent of total billed charges,Implant Device,1734,34,,1734,percent of total billed charges,Implant Device,1734,34,,1734,percent of total billed charges,Implant Device,2524.5,,,2524.5,Other,110% of Medicare,1785,35,,1785,percent of total billed charges,Implant Device,1734,34,"Charges > $500, x 34%",1734,percent of total billed charges,Implant Device,1785,35,,1785,percent of total billed charges,Implant Device,1785,35,,1785,percent of total billed charges,Implant Device,1785,35,,1785,percent of total billed charges,Implant Device,1785,35,,1785,percent of total billed charges,Implant Device,1785,35,,1785,percent of total billed charges,Implant Device,2040,40,,2040,percent of total billed charges,Implant Device,1785,70,,1785,percent of total billed charges,All Other,1734,34,,1734,percent of total billed charges,Implant Device,1734,34,,1734,percent of total billed charges,Implant Device,1785,35,,1785,percent of total billed charges,Implant Device,1785,35,,1785,percent of total billed charges,Implant Device,1785,35,,1785,percent of total billed charges,Implant Device,1785,35,,1785,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1734,34,"If Charge > 2,000, then 34 percent",1734,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3774.01,
STRYKER 5521-B-600 TIB BASEPLATE SZ 6 LT,C1776,HCPCS,,79010608,CDM,278,RC,,,both,,,3337,2469.39,,,2469.39,Other,150% of Medicare + 9.63% HCRA Surcharge,1501.65,45,,1501.65,percent of total billed charges,Critical Access Hospital RCC factor,1134.58,34,,1134.58,percent of total billed charges,Implant Device,1134.58,34,,1134.58,percent of total billed charges,Implant Device,1134.58,34,,1134.58,percent of total billed charges,Implant Device,1134.58,34,,1134.58,percent of total billed charges,Implant Device,1134.58,34,,1134.58,percent of total billed charges,Implant Device,1651.82,,,1651.82,Other,110% of Medicare,1167.95,35,,1167.95,percent of total billed charges,Implant Device,1134.58,34,"Charges > $500, x 34%",1134.58,percent of total billed charges,Implant Device,1167.95,35,,1167.95,percent of total billed charges,Implant Device,1167.95,35,,1167.95,percent of total billed charges,Implant Device,1167.95,35,,1167.95,percent of total billed charges,Implant Device,1167.95,35,,1167.95,percent of total billed charges,Implant Device,1167.95,35,,1167.95,percent of total billed charges,Implant Device,1334.8,40,,1334.8,percent of total billed charges,Implant Device,1167.95,70,,1167.95,percent of total billed charges,All Other,1134.58,34,,1134.58,percent of total billed charges,Implant Device,1134.58,34,,1134.58,percent of total billed charges,Implant Device,1167.95,35,,1167.95,percent of total billed charges,Implant Device,1167.95,35,,1167.95,percent of total billed charges,Implant Device,1167.95,35,,1167.95,percent of total billed charges,Implant Device,1167.95,35,,1167.95,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1134.58,34,"If Charge > 2,000, then 34 percent",1134.58,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2469.39,
STRYKER 5531-G-613 TIB INSERT SZ 6 13MM,C1776,HCPCS,,79010609,CDM,278,RC,,,both,,,3300,2442.01,,,2442.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1485,45,,1485,percent of total billed charges,Critical Access Hospital RCC factor,1122,34,,1122,percent of total billed charges,Implant Device,1122,34,,1122,percent of total billed charges,Implant Device,1122,34,,1122,percent of total billed charges,Implant Device,1122,34,,1122,percent of total billed charges,Implant Device,1122,34,,1122,percent of total billed charges,Implant Device,1633.5,,,1633.5,Other,110% of Medicare,1155,35,,1155,percent of total billed charges,Implant Device,1122,34,"Charges > $500, x 34%",1122,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,1320,40,,1320,percent of total billed charges,Implant Device,1155,70,,1155,percent of total billed charges,All Other,1122,34,,1122,percent of total billed charges,Implant Device,1122,34,,1122,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1122,34,"If Charge > 2,000, then 34 percent",1122,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2442.01,
GORE PLC121200 EXCL CONTRAL LEG 16X12X12,C1874,HCPCS,,79010610,CDM,278,RC,,,both,,,14934,11051.2,,,11051.2,Other,150% of Medicare + 9.63% HCRA Surcharge,6720.3,45,,6720.3,percent of total billed charges,Critical Access Hospital RCC factor,5077.56,34,,5077.56,percent of total billed charges,Implant Device,5077.56,34,,5077.56,percent of total billed charges,Implant Device,5077.56,34,,5077.56,percent of total billed charges,Implant Device,5077.56,34,,5077.56,percent of total billed charges,Implant Device,5077.56,34,,5077.56,percent of total billed charges,Implant Device,7392.33,,,7392.33,Other,110% of Medicare,5226.9,35,,5226.9,percent of total billed charges,Implant Device,5077.56,34,"Charges > $500, x 34%",5077.56,percent of total billed charges,Implant Device,5226.9,35,,5226.9,percent of total billed charges,Implant Device,5226.9,35,,5226.9,percent of total billed charges,Implant Device,5226.9,35,,5226.9,percent of total billed charges,Implant Device,5226.9,35,,5226.9,percent of total billed charges,Implant Device,5226.9,35,,5226.9,percent of total billed charges,Implant Device,5973.6,40,,5973.6,percent of total billed charges,Implant Device,5226.9,70,,5226.9,percent of total billed charges,All Other,5077.56,34,,5077.56,percent of total billed charges,Implant Device,5077.56,34,,5077.56,percent of total billed charges,Implant Device,5226.9,35,,5226.9,percent of total billed charges,Implant Device,5226.9,35,,5226.9,percent of total billed charges,Implant Device,5226.9,35,,5226.9,percent of total billed charges,Implant Device,5226.9,35,,5226.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,5077.56,34,"If Charge > 2,000, then 34 percent",5077.56,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,11051.2,
GORE PLL161007 EXCLUDER ILIAC EX 16X10X7,C1874,HCPCS,,79010611,CDM,278,RC,,,both,,,10509,7776.69,,,7776.69,Other,150% of Medicare + 9.63% HCRA Surcharge,4729.05,45,,4729.05,percent of total billed charges,Critical Access Hospital RCC factor,3573.06,34,,3573.06,percent of total billed charges,Implant Device,3573.06,34,,3573.06,percent of total billed charges,Implant Device,3573.06,34,,3573.06,percent of total billed charges,Implant Device,3573.06,34,,3573.06,percent of total billed charges,Implant Device,3573.06,34,,3573.06,percent of total billed charges,Implant Device,5201.96,,,5201.96,Other,110% of Medicare,3678.15,35,,3678.15,percent of total billed charges,Implant Device,3573.06,34,"Charges > $500, x 34%",3573.06,percent of total billed charges,Implant Device,3678.15,35,,3678.15,percent of total billed charges,Implant Device,3678.15,35,,3678.15,percent of total billed charges,Implant Device,3678.15,35,,3678.15,percent of total billed charges,Implant Device,3678.15,35,,3678.15,percent of total billed charges,Implant Device,3678.15,35,,3678.15,percent of total billed charges,Implant Device,4203.6,40,,4203.6,percent of total billed charges,Implant Device,3678.15,70,,3678.15,percent of total billed charges,All Other,3573.06,34,,3573.06,percent of total billed charges,Implant Device,3573.06,34,,3573.06,percent of total billed charges,Implant Device,3678.15,35,,3678.15,percent of total billed charges,Implant Device,3678.15,35,,3678.15,percent of total billed charges,Implant Device,3678.15,35,,3678.15,percent of total billed charges,Implant Device,3678.15,35,,3678.15,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3573.06,34,"If Charge > 2,000, then 34 percent",3573.06,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,7776.69,
GORE RLT231216 EXCLUDER TRUNK 23X12X16,C1874,HCPCS,,79010612,CDM,278,RC,,,both,,,36426,26955.33,,,26955.33,Other,150% of Medicare + 9.63% HCRA Surcharge,16391.7,45,,16391.7,percent of total billed charges,Critical Access Hospital RCC factor,12384.84,34,,12384.84,percent of total billed charges,Implant Device,12384.84,34,,12384.84,percent of total billed charges,Implant Device,12384.84,34,,12384.84,percent of total billed charges,Implant Device,12384.84,34,,12384.84,percent of total billed charges,Implant Device,12384.84,34,,12384.84,percent of total billed charges,Implant Device,18030.87,,,18030.87,Other,110% of Medicare,12749.1,35,,12749.1,percent of total billed charges,Implant Device,12384.84,34,"Charges > $500, x 34%",12384.84,percent of total billed charges,Implant Device,12749.1,35,,12749.1,percent of total billed charges,Implant Device,12749.1,35,,12749.1,percent of total billed charges,Implant Device,12749.1,35,,12749.1,percent of total billed charges,Implant Device,12749.1,35,,12749.1,percent of total billed charges,Implant Device,12749.1,35,,12749.1,percent of total billed charges,Implant Device,14570.4,40,,14570.4,percent of total billed charges,Implant Device,12749.1,70,,12749.1,percent of total billed charges,All Other,12384.84,34,,12384.84,percent of total billed charges,Implant Device,12384.84,34,,12384.84,percent of total billed charges,Implant Device,12749.1,35,,12749.1,percent of total billed charges,Implant Device,12749.1,35,,12749.1,percent of total billed charges,Implant Device,12749.1,35,,12749.1,percent of total billed charges,Implant Device,12749.1,35,,12749.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,12384.84,34,"If Charge > 2,000, then 34 percent",12384.84,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,26955.33,
STRYKER 1236-2-854 ADM X3 INSERT ID 28MM,C1713,HCPCS,,79010613,CDM,278,RC,,,both,,,2503,1852.23,,,1852.23,Other,150% of Medicare + 9.63% HCRA Surcharge,1126.35,45,,1126.35,percent of total billed charges,Critical Access Hospital RCC factor,851.02,34,,851.02,percent of total billed charges,Implant Device,851.02,34,,851.02,percent of total billed charges,Implant Device,851.02,34,,851.02,percent of total billed charges,Implant Device,851.02,34,,851.02,percent of total billed charges,Implant Device,851.02,34,,851.02,percent of total billed charges,Implant Device,1238.99,,,1238.99,Other,110% of Medicare,876.05,35,,876.05,percent of total billed charges,Implant Device,851.02,34,"Charges > $500, x 34%",851.02,percent of total billed charges,Implant Device,876.05,35,,876.05,percent of total billed charges,Implant Device,876.05,35,,876.05,percent of total billed charges,Implant Device,876.05,35,,876.05,percent of total billed charges,Implant Device,876.05,35,,876.05,percent of total billed charges,Implant Device,876.05,35,,876.05,percent of total billed charges,Implant Device,1001.2,40,,1001.2,percent of total billed charges,Implant Device,876.05,70,,876.05,percent of total billed charges,All Other,851.02,34,,851.02,percent of total billed charges,Implant Device,851.02,34,,851.02,percent of total billed charges,Implant Device,876.05,35,,876.05,percent of total billed charges,Implant Device,876.05,35,,876.05,percent of total billed charges,Implant Device,876.05,35,,876.05,percent of total billed charges,Implant Device,876.05,35,,876.05,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,851.02,34,"If Charge > 2,000, then 34 percent",851.02,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1852.23,
STRYKER 6210-0-710 FLEX OSTEO 12X120MM,C1713,HCPCS,,79010614,CDM,278,RC,,,both,,,1809,1338.66,,,1338.66,Other,150% of Medicare + 9.63% HCRA Surcharge,814.05,45,,814.05,percent of total billed charges,Critical Access Hospital RCC factor,615.06,34,,615.06,percent of total billed charges,Implant Device,615.06,34,,615.06,percent of total billed charges,Implant Device,615.06,34,,615.06,percent of total billed charges,Implant Device,615.06,34,,615.06,percent of total billed charges,Implant Device,615.06,34,,615.06,percent of total billed charges,Implant Device,895.46,,,895.46,Other,110% of Medicare,633.15,35,,633.15,percent of total billed charges,Implant Device,615.06,34,"Charges > $500, x 34%",615.06,percent of total billed charges,Implant Device,633.15,35,,633.15,percent of total billed charges,Implant Device,633.15,35,,633.15,percent of total billed charges,Implant Device,633.15,35,,633.15,percent of total billed charges,Implant Device,633.15,35,,633.15,percent of total billed charges,Implant Device,633.15,35,,633.15,percent of total billed charges,Implant Device,723.6,40,,723.6,percent of total billed charges,Implant Device,633.15,70,,633.15,percent of total billed charges,All Other,615.06,34,,615.06,percent of total billed charges,Implant Device,615.06,34,,615.06,percent of total billed charges,Implant Device,633.15,35,,633.15,percent of total billed charges,Implant Device,633.15,35,,633.15,percent of total billed charges,Implant Device,633.15,35,,633.15,percent of total billed charges,Implant Device,633.15,35,,633.15,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1338.66,
STRYKER 6276-1-325 MOD PROX CONE BODY 25,C1776,HCPCS,,79010615,CDM,278,RC,,,both,,,12717,9410.61,,,9410.61,Other,150% of Medicare + 9.63% HCRA Surcharge,5722.65,45,,5722.65,percent of total billed charges,Critical Access Hospital RCC factor,4323.78,34,,4323.78,percent of total billed charges,Implant Device,4323.78,34,,4323.78,percent of total billed charges,Implant Device,4323.78,34,,4323.78,percent of total billed charges,Implant Device,4323.78,34,,4323.78,percent of total billed charges,Implant Device,4323.78,34,,4323.78,percent of total billed charges,Implant Device,6294.92,,,6294.92,Other,110% of Medicare,4450.95,35,,4450.95,percent of total billed charges,Implant Device,4323.78,34,"Charges > $500, x 34%",4323.78,percent of total billed charges,Implant Device,4450.95,35,,4450.95,percent of total billed charges,Implant Device,4450.95,35,,4450.95,percent of total billed charges,Implant Device,4450.95,35,,4450.95,percent of total billed charges,Implant Device,4450.95,35,,4450.95,percent of total billed charges,Implant Device,4450.95,35,,4450.95,percent of total billed charges,Implant Device,5086.8,40,,5086.8,percent of total billed charges,Implant Device,4450.95,70,,4450.95,percent of total billed charges,All Other,4323.78,34,,4323.78,percent of total billed charges,Implant Device,4323.78,34,,4323.78,percent of total billed charges,Implant Device,4450.95,35,,4450.95,percent of total billed charges,Implant Device,4450.95,35,,4450.95,percent of total billed charges,Implant Device,4450.95,35,,4450.95,percent of total billed charges,Implant Device,4450.95,35,,4450.95,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,4323.78,34,"If Charge > 2,000, then 34 percent",4323.78,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,9410.61,
STRYKER 6570-0-228 DELTA V-40 CERAMIC HD,C1776,HCPCS,,79010616,CDM,278,RC,,,both,,,2503,1852.23,,,1852.23,Other,150% of Medicare + 9.63% HCRA Surcharge,1126.35,45,,1126.35,percent of total billed charges,Critical Access Hospital RCC factor,851.02,34,,851.02,percent of total billed charges,Implant Device,851.02,34,,851.02,percent of total billed charges,Implant Device,851.02,34,,851.02,percent of total billed charges,Implant Device,851.02,34,,851.02,percent of total billed charges,Implant Device,851.02,34,,851.02,percent of total billed charges,Implant Device,1238.99,,,1238.99,Other,110% of Medicare,876.05,35,,876.05,percent of total billed charges,Implant Device,851.02,34,"Charges > $500, x 34%",851.02,percent of total billed charges,Implant Device,876.05,35,,876.05,percent of total billed charges,Implant Device,876.05,35,,876.05,percent of total billed charges,Implant Device,876.05,35,,876.05,percent of total billed charges,Implant Device,876.05,35,,876.05,percent of total billed charges,Implant Device,876.05,35,,876.05,percent of total billed charges,Implant Device,1001.2,40,,1001.2,percent of total billed charges,Implant Device,876.05,70,,876.05,percent of total billed charges,All Other,851.02,34,,851.02,percent of total billed charges,Implant Device,851.02,34,,851.02,percent of total billed charges,Implant Device,876.05,35,,876.05,percent of total billed charges,Implant Device,876.05,35,,876.05,percent of total billed charges,Implant Device,876.05,35,,876.05,percent of total billed charges,Implant Device,876.05,35,,876.05,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,851.02,34,"If Charge > 2,000, then 34 percent",851.02,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1852.23,
STRYKER 2341-0931S TIBIAL NAIL 09X315MM,C1713,HCPCS,,79010617,CDM,278,RC,,,both,,,4792,3546.09,,,3546.09,Other,150% of Medicare + 9.63% HCRA Surcharge,2156.4,45,,2156.4,percent of total billed charges,Critical Access Hospital RCC factor,1629.28,34,,1629.28,percent of total billed charges,Implant Device,1629.28,34,,1629.28,percent of total billed charges,Implant Device,1629.28,34,,1629.28,percent of total billed charges,Implant Device,1629.28,34,,1629.28,percent of total billed charges,Implant Device,1629.28,34,,1629.28,percent of total billed charges,Implant Device,2372.04,,,2372.04,Other,110% of Medicare,1677.2,35,,1677.2,percent of total billed charges,Implant Device,1629.28,34,"Charges > $500, x 34%",1629.28,percent of total billed charges,Implant Device,1677.2,35,,1677.2,percent of total billed charges,Implant Device,1677.2,35,,1677.2,percent of total billed charges,Implant Device,1677.2,35,,1677.2,percent of total billed charges,Implant Device,1677.2,35,,1677.2,percent of total billed charges,Implant Device,1677.2,35,,1677.2,percent of total billed charges,Implant Device,1916.8,40,,1916.8,percent of total billed charges,Implant Device,1677.2,70,,1677.2,percent of total billed charges,All Other,1629.28,34,,1629.28,percent of total billed charges,Implant Device,1629.28,34,,1629.28,percent of total billed charges,Implant Device,1677.2,35,,1677.2,percent of total billed charges,Implant Device,1677.2,35,,1677.2,percent of total billed charges,Implant Device,1677.2,35,,1677.2,percent of total billed charges,Implant Device,1677.2,35,,1677.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1629.28,34,"If Charge > 2,000, then 34 percent",1629.28,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3546.09,
STRYKER 2360-5035S LOCK SCREW 5X35MM,C1713,HCPCS,,79010618,CDM,278,RC,,,both,,,682,504.68,,,504.68,Other,150% of Medicare + 9.63% HCRA Surcharge,306.9,45,,306.9,percent of total billed charges,Critical Access Hospital RCC factor,231.88,34,,231.88,percent of total billed charges,Implant Device,231.88,34,,231.88,percent of total billed charges,Implant Device,231.88,34,,231.88,percent of total billed charges,Implant Device,231.88,34,,231.88,percent of total billed charges,Implant Device,231.88,34,,231.88,percent of total billed charges,Implant Device,337.59,,,337.59,Other,110% of Medicare,238.7,35,,238.7,percent of total billed charges,Implant Device,231.88,34,"Charges > $500, x 34%",231.88,percent of total billed charges,Implant Device,238.7,35,,238.7,percent of total billed charges,Implant Device,238.7,35,,238.7,percent of total billed charges,Implant Device,238.7,35,,238.7,percent of total billed charges,Implant Device,238.7,35,,238.7,percent of total billed charges,Implant Device,238.7,35,,238.7,percent of total billed charges,Implant Device,272.8,40,,272.8,percent of total billed charges,Implant Device,238.7,70,,238.7,percent of total billed charges,All Other,231.88,34,,231.88,percent of total billed charges,Implant Device,231.88,34,,231.88,percent of total billed charges,Implant Device,238.7,35,,238.7,percent of total billed charges,Implant Device,238.7,35,,238.7,percent of total billed charges,Implant Device,238.7,35,,238.7,percent of total billed charges,Implant Device,238.7,35,,238.7,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,504.68,
STRYKER 2360-5050S LOCK SCREW 5X50MM,C1713,HCPCS,,79010619,CDM,278,RC,,,both,,,682,504.68,,,504.68,Other,150% of Medicare + 9.63% HCRA Surcharge,306.9,45,,306.9,percent of total billed charges,Critical Access Hospital RCC factor,231.88,34,,231.88,percent of total billed charges,Implant Device,231.88,34,,231.88,percent of total billed charges,Implant Device,231.88,34,,231.88,percent of total billed charges,Implant Device,231.88,34,,231.88,percent of total billed charges,Implant Device,231.88,34,,231.88,percent of total billed charges,Implant Device,337.59,,,337.59,Other,110% of Medicare,238.7,35,,238.7,percent of total billed charges,Implant Device,231.88,34,"Charges > $500, x 34%",231.88,percent of total billed charges,Implant Device,238.7,35,,238.7,percent of total billed charges,Implant Device,238.7,35,,238.7,percent of total billed charges,Implant Device,238.7,35,,238.7,percent of total billed charges,Implant Device,238.7,35,,238.7,percent of total billed charges,Implant Device,238.7,35,,238.7,percent of total billed charges,Implant Device,272.8,40,,272.8,percent of total billed charges,Implant Device,238.7,70,,238.7,percent of total billed charges,All Other,231.88,34,,231.88,percent of total billed charges,Implant Device,231.88,34,,231.88,percent of total billed charges,Implant Device,238.7,35,,238.7,percent of total billed charges,Implant Device,238.7,35,,238.7,percent of total billed charges,Implant Device,238.7,35,,238.7,percent of total billed charges,Implant Device,238.7,35,,238.7,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,504.68,
DEPUY 456.396S FIXATION NAIL 11MM/126,C1713,HCPCS,,79010620,CDM,278,RC,,,both,,,3604,2666.97,,,2666.97,Other,150% of Medicare + 9.63% HCRA Surcharge,1621.8,45,,1621.8,percent of total billed charges,Critical Access Hospital RCC factor,1225.36,34,,1225.36,percent of total billed charges,Implant Device,1225.36,34,,1225.36,percent of total billed charges,Implant Device,1225.36,34,,1225.36,percent of total billed charges,Implant Device,1225.36,34,,1225.36,percent of total billed charges,Implant Device,1225.36,34,,1225.36,percent of total billed charges,Implant Device,1783.98,,,1783.98,Other,110% of Medicare,1261.4,35,,1261.4,percent of total billed charges,Implant Device,1225.36,34,"Charges > $500, x 34%",1225.36,percent of total billed charges,Implant Device,1261.4,35,,1261.4,percent of total billed charges,Implant Device,1261.4,35,,1261.4,percent of total billed charges,Implant Device,1261.4,35,,1261.4,percent of total billed charges,Implant Device,1261.4,35,,1261.4,percent of total billed charges,Implant Device,1261.4,35,,1261.4,percent of total billed charges,Implant Device,1441.6,40,,1441.6,percent of total billed charges,Implant Device,1261.4,70,,1261.4,percent of total billed charges,All Other,1225.36,34,,1225.36,percent of total billed charges,Implant Device,1225.36,34,,1225.36,percent of total billed charges,Implant Device,1261.4,35,,1261.4,percent of total billed charges,Implant Device,1261.4,35,,1261.4,percent of total billed charges,Implant Device,1261.4,35,,1261.4,percent of total billed charges,Implant Device,1261.4,35,,1261.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1225.36,34,"If Charge > 2,000, then 34 percent",1225.36,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2666.97,
STRYKER 608070 6MM CANCELLOUS TI SCREW,C1713,HCPCS,,79010621,CDM,278,RC,,,both,,,155,114.7,,,114.7,Other,150% of Medicare + 9.63% HCRA Surcharge,69.75,45,,69.75,percent of total billed charges,Critical Access Hospital RCC factor,52.7,34,,52.7,percent of total billed charges,Implant Device,52.7,34,,52.7,percent of total billed charges,Implant Device,52.7,34,,52.7,percent of total billed charges,Implant Device,52.7,34,,52.7,percent of total billed charges,Implant Device,52.7,34,,52.7,percent of total billed charges,Implant Device,76.73,,,76.73,Other,110% of Medicare,54.25,35,,54.25,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,54.25,35,,54.25,percent of total billed charges,Implant Device,54.25,35,,54.25,percent of total billed charges,Implant Device,54.25,35,,54.25,percent of total billed charges,Implant Device,54.25,35,,54.25,percent of total billed charges,Implant Device,54.25,35,,54.25,percent of total billed charges,Implant Device,62,40,,62,percent of total billed charges,Implant Device,54.25,70,,54.25,percent of total billed charges,All Other,52.7,34,,52.7,percent of total billed charges,Implant Device,52.7,34,,52.7,percent of total billed charges,Implant Device,54.25,35,,54.25,percent of total billed charges,Implant Device,54.25,35,,54.25,percent of total billed charges,Implant Device,54.25,35,,54.25,percent of total billed charges,Implant Device,54.25,35,,54.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,114.7,
STRYKER 627642 DISTAL LATERAL PLATE 12H,C1713,HCPCS,,79010622,CDM,278,RC,,,both,,,7836,5798.66,,,5798.66,Other,150% of Medicare + 9.63% HCRA Surcharge,3526.2,45,,3526.2,percent of total billed charges,Critical Access Hospital RCC factor,2664.24,34,,2664.24,percent of total billed charges,Implant Device,2664.24,34,,2664.24,percent of total billed charges,Implant Device,2664.24,34,,2664.24,percent of total billed charges,Implant Device,2664.24,34,,2664.24,percent of total billed charges,Implant Device,2664.24,34,,2664.24,percent of total billed charges,Implant Device,3878.82,,,3878.82,Other,110% of Medicare,2742.6,35,,2742.6,percent of total billed charges,Implant Device,2664.24,34,"Charges > $500, x 34%",2664.24,percent of total billed charges,Implant Device,2742.6,35,,2742.6,percent of total billed charges,Implant Device,2742.6,35,,2742.6,percent of total billed charges,Implant Device,2742.6,35,,2742.6,percent of total billed charges,Implant Device,2742.6,35,,2742.6,percent of total billed charges,Implant Device,2742.6,35,,2742.6,percent of total billed charges,Implant Device,3134.4,40,,3134.4,percent of total billed charges,Implant Device,2742.6,70,,2742.6,percent of total billed charges,All Other,2664.24,34,,2664.24,percent of total billed charges,Implant Device,2664.24,34,,2664.24,percent of total billed charges,Implant Device,2742.6,35,,2742.6,percent of total billed charges,Implant Device,2742.6,35,,2742.6,percent of total billed charges,Implant Device,2742.6,35,,2742.6,percent of total billed charges,Implant Device,2742.6,35,,2742.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2664.24,34,"If Charge > 2,000, then 34 percent",2664.24,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5798.66,
ZIMMER CS110000 CORTICAL SCREW 3.5X11MM,C1713,HCPCS,,79010623,CDM,278,RC,,,both,,,510,377.4,,,377.4,Other,150% of Medicare + 9.63% HCRA Surcharge,229.5,45,,229.5,percent of total billed charges,Critical Access Hospital RCC factor,173.4,34,,173.4,percent of total billed charges,Implant Device,173.4,34,,173.4,percent of total billed charges,Implant Device,173.4,34,,173.4,percent of total billed charges,Implant Device,173.4,34,,173.4,percent of total billed charges,Implant Device,173.4,34,,173.4,percent of total billed charges,Implant Device,252.45,,,252.45,Other,110% of Medicare,178.5,35,,178.5,percent of total billed charges,Implant Device,173.4,34,"Charges > $500, x 34%",173.4,percent of total billed charges,Implant Device,178.5,35,,178.5,percent of total billed charges,Implant Device,178.5,35,,178.5,percent of total billed charges,Implant Device,178.5,35,,178.5,percent of total billed charges,Implant Device,178.5,35,,178.5,percent of total billed charges,Implant Device,178.5,35,,178.5,percent of total billed charges,Implant Device,204,40,,204,percent of total billed charges,Implant Device,178.5,70,,178.5,percent of total billed charges,All Other,173.4,34,,173.4,percent of total billed charges,Implant Device,173.4,34,,173.4,percent of total billed charges,Implant Device,178.5,35,,178.5,percent of total billed charges,Implant Device,178.5,35,,178.5,percent of total billed charges,Implant Device,178.5,35,,178.5,percent of total billed charges,Implant Device,178.5,35,,178.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,377.4,
OSSIO OF10129190 HAMMERTOE IMPL 2.9X19MM,C1776,HCPCS,,79010625,CDM,278,RC,,,both,,,3300,2442.01,,,2442.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1485,45,,1485,percent of total billed charges,Critical Access Hospital RCC factor,1122,34,,1122,percent of total billed charges,Implant Device,1122,34,,1122,percent of total billed charges,Implant Device,1122,34,,1122,percent of total billed charges,Implant Device,1122,34,,1122,percent of total billed charges,Implant Device,1122,34,,1122,percent of total billed charges,Implant Device,1633.5,,,1633.5,Other,110% of Medicare,1155,35,,1155,percent of total billed charges,Implant Device,1122,34,"Charges > $500, x 34%",1122,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,1320,40,,1320,percent of total billed charges,Implant Device,1155,70,,1155,percent of total billed charges,All Other,1122,34,,1122,percent of total billed charges,Implant Device,1122,34,,1122,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1122,34,"If Charge > 2,000, then 34 percent",1122,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2442.01,
ZIMMER 00-5850-043-20 DISTAL FEM XT SZ C,C1776,HCPCS,,79010626,CDM,278,RC,,,both,,,27047,20014.85,,,20014.85,Other,150% of Medicare + 9.63% HCRA Surcharge,12171.15,45,,12171.15,percent of total billed charges,Critical Access Hospital RCC factor,9195.98,34,,9195.98,percent of total billed charges,Implant Device,9195.98,34,,9195.98,percent of total billed charges,Implant Device,9195.98,34,,9195.98,percent of total billed charges,Implant Device,9195.98,34,,9195.98,percent of total billed charges,Implant Device,9195.98,34,,9195.98,percent of total billed charges,Implant Device,13388.27,,,13388.27,Other,110% of Medicare,9466.45,35,,9466.45,percent of total billed charges,Implant Device,9195.98,34,"Charges > $500, x 34%",9195.98,percent of total billed charges,Implant Device,9466.45,35,,9466.45,percent of total billed charges,Implant Device,9466.45,35,,9466.45,percent of total billed charges,Implant Device,9466.45,35,,9466.45,percent of total billed charges,Implant Device,9466.45,35,,9466.45,percent of total billed charges,Implant Device,9466.45,35,,9466.45,percent of total billed charges,Implant Device,10818.8,40,,10818.8,percent of total billed charges,Implant Device,9466.45,70,,9466.45,percent of total billed charges,All Other,9195.98,34,,9195.98,percent of total billed charges,Implant Device,9195.98,34,,9195.98,percent of total billed charges,Implant Device,9466.45,35,,9466.45,percent of total billed charges,Implant Device,9466.45,35,,9466.45,percent of total billed charges,Implant Device,9466.45,35,,9466.45,percent of total billed charges,Implant Device,9466.45,35,,9466.45,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,9195.98,34,"If Charge > 2,000, then 34 percent",9195.98,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,20014.85,
IN2BONES P65 ST555 COLAG SCREW 5.0X55MM,C1713,HCPCS,,79010627,CDM,278,RC,,,both,,,2508,1855.93,,,1855.93,Other,150% of Medicare + 9.63% HCRA Surcharge,1128.6,45,,1128.6,percent of total billed charges,Critical Access Hospital RCC factor,852.72,34,,852.72,percent of total billed charges,Implant Device,852.72,34,,852.72,percent of total billed charges,Implant Device,852.72,34,,852.72,percent of total billed charges,Implant Device,852.72,34,,852.72,percent of total billed charges,Implant Device,852.72,34,,852.72,percent of total billed charges,Implant Device,1241.46,,,1241.46,Other,110% of Medicare,877.8,35,,877.8,percent of total billed charges,Implant Device,852.72,34,"Charges > $500, x 34%",852.72,percent of total billed charges,Implant Device,877.8,35,,877.8,percent of total billed charges,Implant Device,877.8,35,,877.8,percent of total billed charges,Implant Device,877.8,35,,877.8,percent of total billed charges,Implant Device,877.8,35,,877.8,percent of total billed charges,Implant Device,877.8,35,,877.8,percent of total billed charges,Implant Device,1003.2,40,,1003.2,percent of total billed charges,Implant Device,877.8,70,,877.8,percent of total billed charges,All Other,852.72,34,,852.72,percent of total billed charges,Implant Device,852.72,34,,852.72,percent of total billed charges,Implant Device,877.8,35,,877.8,percent of total billed charges,Implant Device,877.8,35,,877.8,percent of total billed charges,Implant Device,877.8,35,,877.8,percent of total billed charges,Implant Device,877.8,35,,877.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,852.72,34,"If Charge > 2,000, then 34 percent",852.72,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1855.93,
IN2BONES P65 ST050 WASHER 5.0MM,C1713,HCPCS,,79010628,CDM,278,RC,,,both,,,1185,876.9,,,876.9,Other,150% of Medicare + 9.63% HCRA Surcharge,533.25,45,,533.25,percent of total billed charges,Critical Access Hospital RCC factor,402.9,34,,402.9,percent of total billed charges,Implant Device,402.9,34,,402.9,percent of total billed charges,Implant Device,402.9,34,,402.9,percent of total billed charges,Implant Device,402.9,34,,402.9,percent of total billed charges,Implant Device,402.9,34,,402.9,percent of total billed charges,Implant Device,586.58,,,586.58,Other,110% of Medicare,414.75,35,,414.75,percent of total billed charges,Implant Device,402.9,34,"Charges > $500, x 34%",402.9,percent of total billed charges,Implant Device,414.75,35,,414.75,percent of total billed charges,Implant Device,414.75,35,,414.75,percent of total billed charges,Implant Device,414.75,35,,414.75,percent of total billed charges,Implant Device,414.75,35,,414.75,percent of total billed charges,Implant Device,414.75,35,,414.75,percent of total billed charges,Implant Device,474,40,,474,percent of total billed charges,Implant Device,414.75,70,,414.75,percent of total billed charges,All Other,402.9,34,,402.9,percent of total billed charges,Implant Device,402.9,34,,402.9,percent of total billed charges,Implant Device,414.75,35,,414.75,percent of total billed charges,Implant Device,414.75,35,,414.75,percent of total billed charges,Implant Device,414.75,35,,414.75,percent of total billed charges,Implant Device,414.75,35,,414.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,876.9,
DEPUY L20316 CONRAIL 2 SZ 16,C1776,HCPCS,,79010637,CDM,278,RC,,,both,,,14060,10404.44,,,10404.44,Other,150% of Medicare + 9.63% HCRA Surcharge,6327,45,,6327,percent of total billed charges,Critical Access Hospital RCC factor,4780.4,34,,4780.4,percent of total billed charges,Implant Device,4780.4,34,,4780.4,percent of total billed charges,Implant Device,4780.4,34,,4780.4,percent of total billed charges,Implant Device,4780.4,34,,4780.4,percent of total billed charges,Implant Device,4780.4,34,,4780.4,percent of total billed charges,Implant Device,6959.7,,,6959.7,Other,110% of Medicare,4921,35,,4921,percent of total billed charges,Implant Device,4780.4,34,"Charges > $500, x 34%",4780.4,percent of total billed charges,Implant Device,4921,35,,4921,percent of total billed charges,Implant Device,4921,35,,4921,percent of total billed charges,Implant Device,4921,35,,4921,percent of total billed charges,Implant Device,4921,35,,4921,percent of total billed charges,Implant Device,4921,35,,4921,percent of total billed charges,Implant Device,5624,40,,5624,percent of total billed charges,Implant Device,4921,70,,4921,percent of total billed charges,All Other,4780.4,34,,4780.4,percent of total billed charges,Implant Device,4780.4,34,,4780.4,percent of total billed charges,Implant Device,4921,35,,4921,percent of total billed charges,Implant Device,4921,35,,4921,percent of total billed charges,Implant Device,4921,35,,4921,percent of total billed charges,Implant Device,4921,35,,4921,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,4780.4,34,"If Charge > 2,000, then 34 percent",4780.4,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,10404.44,
STRYKER 657336 3.5/L36MM LOCKING SCREW,C1713,HCPCS,,79010639,CDM,278,RC,,,both,,,494,365.56,,,365.56,Other,150% of Medicare + 9.63% HCRA Surcharge,222.3,45,,222.3,percent of total billed charges,Critical Access Hospital RCC factor,167.96,34,,167.96,percent of total billed charges,Implant Device,167.96,34,,167.96,percent of total billed charges,Implant Device,167.96,34,,167.96,percent of total billed charges,Implant Device,167.96,34,,167.96,percent of total billed charges,Implant Device,167.96,34,,167.96,percent of total billed charges,Implant Device,244.53,,,244.53,Other,110% of Medicare,172.9,35,,172.9,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,172.9,35,,172.9,percent of total billed charges,Implant Device,172.9,35,,172.9,percent of total billed charges,Implant Device,172.9,35,,172.9,percent of total billed charges,Implant Device,172.9,35,,172.9,percent of total billed charges,Implant Device,172.9,35,,172.9,percent of total billed charges,Implant Device,197.6,40,,197.6,percent of total billed charges,Implant Device,172.9,70,,172.9,percent of total billed charges,All Other,167.96,34,,167.96,percent of total billed charges,Implant Device,167.96,34,,167.96,percent of total billed charges,Implant Device,172.9,35,,172.9,percent of total billed charges,Implant Device,172.9,35,,172.9,percent of total billed charges,Implant Device,172.9,35,,172.9,percent of total billed charges,Implant Device,172.9,35,,172.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,365.56,
STRYKER 657440 3.5/L40MM BONE SCREW,C1713,HCPCS,,79010640,CDM,278,RC,,,both,,,269,199.06,,,199.06,Other,150% of Medicare + 9.63% HCRA Surcharge,121.05,45,,121.05,percent of total billed charges,Critical Access Hospital RCC factor,91.46,34,,91.46,percent of total billed charges,Implant Device,91.46,34,,91.46,percent of total billed charges,Implant Device,91.46,34,,91.46,percent of total billed charges,Implant Device,91.46,34,,91.46,percent of total billed charges,Implant Device,91.46,34,,91.46,percent of total billed charges,Implant Device,133.16,,,133.16,Other,110% of Medicare,94.15,35,,94.15,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,94.15,35,,94.15,percent of total billed charges,Implant Device,94.15,35,,94.15,percent of total billed charges,Implant Device,94.15,35,,94.15,percent of total billed charges,Implant Device,94.15,35,,94.15,percent of total billed charges,Implant Device,94.15,35,,94.15,percent of total billed charges,Implant Device,107.6,40,,107.6,percent of total billed charges,Implant Device,94.15,70,,94.15,percent of total billed charges,All Other,91.46,34,,91.46,percent of total billed charges,Implant Device,91.46,34,,91.46,percent of total billed charges,Implant Device,94.15,35,,94.15,percent of total billed charges,Implant Device,94.15,35,,94.15,percent of total billed charges,Implant Device,94.15,35,,94.15,percent of total billed charges,Implant Device,94.15,35,,94.15,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,199.06,
IN2BONES P73 ST114 3.5X14MM LOCK SCREW,C1713,HCPCS,,79010641,CDM,278,RC,,,both,,,870,643.8,,,643.8,Other,150% of Medicare + 9.63% HCRA Surcharge,391.5,45,,391.5,percent of total billed charges,Critical Access Hospital RCC factor,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,430.65,,,430.65,Other,110% of Medicare,304.5,35,,304.5,percent of total billed charges,Implant Device,295.8,34,"Charges > $500, x 34%",295.8,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,348,40,,348,percent of total billed charges,Implant Device,304.5,70,,304.5,percent of total billed charges,All Other,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,643.8,
EXACTECH 320-40-13 HUMERAL LINER +2.5 40,C1776,HCPCS,,79010642,CDM,278,RC,,,both,,,2835,2097.91,,,2097.91,Other,150% of Medicare + 9.63% HCRA Surcharge,1275.75,45,,1275.75,percent of total billed charges,Critical Access Hospital RCC factor,963.9,34,,963.9,percent of total billed charges,Implant Device,963.9,34,,963.9,percent of total billed charges,Implant Device,963.9,34,,963.9,percent of total billed charges,Implant Device,963.9,34,,963.9,percent of total billed charges,Implant Device,963.9,34,,963.9,percent of total billed charges,Implant Device,1403.33,,,1403.33,Other,110% of Medicare,992.25,35,,992.25,percent of total billed charges,Implant Device,963.9,34,"Charges > $500, x 34%",963.9,percent of total billed charges,Implant Device,992.25,35,,992.25,percent of total billed charges,Implant Device,992.25,35,,992.25,percent of total billed charges,Implant Device,992.25,35,,992.25,percent of total billed charges,Implant Device,992.25,35,,992.25,percent of total billed charges,Implant Device,992.25,35,,992.25,percent of total billed charges,Implant Device,1134,40,,1134,percent of total billed charges,Implant Device,992.25,70,,992.25,percent of total billed charges,All Other,963.9,34,,963.9,percent of total billed charges,Implant Device,963.9,34,,963.9,percent of total billed charges,Implant Device,992.25,35,,992.25,percent of total billed charges,Implant Device,992.25,35,,992.25,percent of total billed charges,Implant Device,992.25,35,,992.25,percent of total billed charges,Implant Device,992.25,35,,992.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,963.9,34,"If Charge > 2,000, then 34 percent",963.9,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2097.91,
EXACTECH 308-08-12 PROXIMAL BODY +12.5MM,C1776,HCPCS,,79010643,CDM,278,RC,,,both,,,21732,16081.73,,,16081.73,Other,150% of Medicare + 9.63% HCRA Surcharge,9779.4,45,,9779.4,percent of total billed charges,Critical Access Hospital RCC factor,7388.88,34,,7388.88,percent of total billed charges,Implant Device,7388.88,34,,7388.88,percent of total billed charges,Implant Device,7388.88,34,,7388.88,percent of total billed charges,Implant Device,7388.88,34,,7388.88,percent of total billed charges,Implant Device,7388.88,34,,7388.88,percent of total billed charges,Implant Device,10757.34,,,10757.34,Other,110% of Medicare,7606.2,35,,7606.2,percent of total billed charges,Implant Device,7388.88,34,"Charges > $500, x 34%",7388.88,percent of total billed charges,Implant Device,7606.2,35,,7606.2,percent of total billed charges,Implant Device,7606.2,35,,7606.2,percent of total billed charges,Implant Device,7606.2,35,,7606.2,percent of total billed charges,Implant Device,7606.2,35,,7606.2,percent of total billed charges,Implant Device,7606.2,35,,7606.2,percent of total billed charges,Implant Device,8692.8,40,,8692.8,percent of total billed charges,Implant Device,7606.2,70,,7606.2,percent of total billed charges,All Other,7388.88,34,,7388.88,percent of total billed charges,Implant Device,7388.88,34,,7388.88,percent of total billed charges,Implant Device,7606.2,35,,7606.2,percent of total billed charges,Implant Device,7606.2,35,,7606.2,percent of total billed charges,Implant Device,7606.2,35,,7606.2,percent of total billed charges,Implant Device,7606.2,35,,7606.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,7388.88,34,"If Charge > 2,000, then 34 percent",7388.88,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,16081.73,
EXACTECH 308-15-12 LOCK SCREW SIZE 12.5,C1713,HCPCS,,79010644,CDM,278,RC,,,both,,,1752,1296.48,,,1296.48,Other,150% of Medicare + 9.63% HCRA Surcharge,788.4,45,,788.4,percent of total billed charges,Critical Access Hospital RCC factor,595.68,34,,595.68,percent of total billed charges,Implant Device,595.68,34,,595.68,percent of total billed charges,Implant Device,595.68,34,,595.68,percent of total billed charges,Implant Device,595.68,34,,595.68,percent of total billed charges,Implant Device,595.68,34,,595.68,percent of total billed charges,Implant Device,867.24,,,867.24,Other,110% of Medicare,613.2,35,,613.2,percent of total billed charges,Implant Device,595.68,34,"Charges > $500, x 34%",595.68,percent of total billed charges,Implant Device,613.2,35,,613.2,percent of total billed charges,Implant Device,613.2,35,,613.2,percent of total billed charges,Implant Device,613.2,35,,613.2,percent of total billed charges,Implant Device,613.2,35,,613.2,percent of total billed charges,Implant Device,613.2,35,,613.2,percent of total billed charges,Implant Device,700.8,40,,700.8,percent of total billed charges,Implant Device,613.2,70,,613.2,percent of total billed charges,All Other,595.68,34,,595.68,percent of total billed charges,Implant Device,595.68,34,,595.68,percent of total billed charges,Implant Device,613.2,35,,613.2,percent of total billed charges,Implant Device,613.2,35,,613.2,percent of total billed charges,Implant Device,613.2,35,,613.2,percent of total billed charges,Implant Device,613.2,35,,613.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1296.48,
EXACTECH 308-01-09 DISTAL STEM 9X80MM,C1776,HCPCS,,79010645,CDM,278,RC,,,both,,,17490,12942.64,,,12942.64,Other,150% of Medicare + 9.63% HCRA Surcharge,7870.5,45,,7870.5,percent of total billed charges,Critical Access Hospital RCC factor,5946.6,34,,5946.6,percent of total billed charges,Implant Device,5946.6,34,,5946.6,percent of total billed charges,Implant Device,5946.6,34,,5946.6,percent of total billed charges,Implant Device,5946.6,34,,5946.6,percent of total billed charges,Implant Device,5946.6,34,,5946.6,percent of total billed charges,Implant Device,8657.55,,,8657.55,Other,110% of Medicare,6121.5,35,,6121.5,percent of total billed charges,Implant Device,5946.6,34,"Charges > $500, x 34%",5946.6,percent of total billed charges,Implant Device,6121.5,35,,6121.5,percent of total billed charges,Implant Device,6121.5,35,,6121.5,percent of total billed charges,Implant Device,6121.5,35,,6121.5,percent of total billed charges,Implant Device,6121.5,35,,6121.5,percent of total billed charges,Implant Device,6121.5,35,,6121.5,percent of total billed charges,Implant Device,6996,40,,6996,percent of total billed charges,Implant Device,6121.5,70,,6121.5,percent of total billed charges,All Other,5946.6,34,,5946.6,percent of total billed charges,Implant Device,5946.6,34,,5946.6,percent of total billed charges,Implant Device,6121.5,35,,6121.5,percent of total billed charges,Implant Device,6121.5,35,,6121.5,percent of total billed charges,Implant Device,6121.5,35,,6121.5,percent of total billed charges,Implant Device,6121.5,35,,6121.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,5946.6,34,"If Charge > 2,000, then 34 percent",5946.6,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,12942.64,
EXACTECH 308-05-20 DISTAL FIX RING 20.5,C1776,HCPCS,,79010646,CDM,278,RC,,,both,,,5619,4158.07,,,4158.07,Other,150% of Medicare + 9.63% HCRA Surcharge,2528.55,45,,2528.55,percent of total billed charges,Critical Access Hospital RCC factor,1910.46,34,,1910.46,percent of total billed charges,Implant Device,1910.46,34,,1910.46,percent of total billed charges,Implant Device,1910.46,34,,1910.46,percent of total billed charges,Implant Device,1910.46,34,,1910.46,percent of total billed charges,Implant Device,1910.46,34,,1910.46,percent of total billed charges,Implant Device,2781.41,,,2781.41,Other,110% of Medicare,1966.65,35,,1966.65,percent of total billed charges,Implant Device,1910.46,34,"Charges > $500, x 34%",1910.46,percent of total billed charges,Implant Device,1966.65,35,,1966.65,percent of total billed charges,Implant Device,1966.65,35,,1966.65,percent of total billed charges,Implant Device,1966.65,35,,1966.65,percent of total billed charges,Implant Device,1966.65,35,,1966.65,percent of total billed charges,Implant Device,1966.65,35,,1966.65,percent of total billed charges,Implant Device,2247.6,40,,2247.6,percent of total billed charges,Implant Device,1966.65,70,,1966.65,percent of total billed charges,All Other,1910.46,34,,1910.46,percent of total billed charges,Implant Device,1910.46,34,,1910.46,percent of total billed charges,Implant Device,1966.65,35,,1966.65,percent of total billed charges,Implant Device,1966.65,35,,1966.65,percent of total billed charges,Implant Device,1966.65,35,,1966.65,percent of total billed charges,Implant Device,1966.65,35,,1966.65,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1910.46,34,"If Charge > 2,000, then 34 percent",1910.46,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4158.07,
ZIMMER 8163-35-020 MDS SCREW 3.5X20MM,C1713,HCPCS,,79010647,CDM,278,RC,,,both,,,1080,799.2,,,799.2,Other,150% of Medicare + 9.63% HCRA Surcharge,486,45,,486,percent of total billed charges,Critical Access Hospital RCC factor,367.2,34,,367.2,percent of total billed charges,Implant Device,367.2,34,,367.2,percent of total billed charges,Implant Device,367.2,34,,367.2,percent of total billed charges,Implant Device,367.2,34,,367.2,percent of total billed charges,Implant Device,367.2,34,,367.2,percent of total billed charges,Implant Device,534.6,,,534.6,Other,110% of Medicare,378,35,,378,percent of total billed charges,Implant Device,367.2,34,"Charges > $500, x 34%",367.2,percent of total billed charges,Implant Device,378,35,,378,percent of total billed charges,Implant Device,378,35,,378,percent of total billed charges,Implant Device,378,35,,378,percent of total billed charges,Implant Device,378,35,,378,percent of total billed charges,Implant Device,378,35,,378,percent of total billed charges,Implant Device,432,40,,432,percent of total billed charges,Implant Device,378,70,,378,percent of total billed charges,All Other,367.2,34,,367.2,percent of total billed charges,Implant Device,367.2,34,,367.2,percent of total billed charges,Implant Device,378,35,,378,percent of total billed charges,Implant Device,378,35,,378,percent of total billed charges,Implant Device,378,35,,378,percent of total billed charges,Implant Device,378,35,,378,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,799.2,
ZIMMER 8161-35-024 CORT SCRW 3.5X24MM,C1713,HCPCS,,79010648,CDM,278,RC,,,both,,,780,577.2,,,577.2,Other,150% of Medicare + 9.63% HCRA Surcharge,351,45,,351,percent of total billed charges,Critical Access Hospital RCC factor,265.2,34,,265.2,percent of total billed charges,Implant Device,265.2,34,,265.2,percent of total billed charges,Implant Device,265.2,34,,265.2,percent of total billed charges,Implant Device,265.2,34,,265.2,percent of total billed charges,Implant Device,265.2,34,,265.2,percent of total billed charges,Implant Device,386.1,,,386.1,Other,110% of Medicare,273,35,,273,percent of total billed charges,Implant Device,265.2,34,"Charges > $500, x 34%",265.2,percent of total billed charges,Implant Device,273,35,,273,percent of total billed charges,Implant Device,273,35,,273,percent of total billed charges,Implant Device,273,35,,273,percent of total billed charges,Implant Device,273,35,,273,percent of total billed charges,Implant Device,273,35,,273,percent of total billed charges,Implant Device,312,40,,312,percent of total billed charges,Implant Device,273,70,,273,percent of total billed charges,All Other,265.2,34,,265.2,percent of total billed charges,Implant Device,265.2,34,,265.2,percent of total billed charges,Implant Device,273,35,,273,percent of total billed charges,Implant Device,273,35,,273,percent of total billed charges,Implant Device,273,35,,273,percent of total billed charges,Implant Device,273,35,,273,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,577.2,
IN2BONES P92 ST015 CORT SCREW 2.4X15MM,C1713,HCPCS,,79010650,CDM,278,RC,,,both,,,612,452.88,,,452.88,Other,150% of Medicare + 9.63% HCRA Surcharge,275.4,45,,275.4,percent of total billed charges,Critical Access Hospital RCC factor,208.08,34,,208.08,percent of total billed charges,Implant Device,208.08,34,,208.08,percent of total billed charges,Implant Device,208.08,34,,208.08,percent of total billed charges,Implant Device,208.08,34,,208.08,percent of total billed charges,Implant Device,208.08,34,,208.08,percent of total billed charges,Implant Device,302.94,,,302.94,Other,110% of Medicare,214.2,35,,214.2,percent of total billed charges,Implant Device,208.08,34,"Charges > $500, x 34%",208.08,percent of total billed charges,Implant Device,214.2,35,,214.2,percent of total billed charges,Implant Device,214.2,35,,214.2,percent of total billed charges,Implant Device,214.2,35,,214.2,percent of total billed charges,Implant Device,214.2,35,,214.2,percent of total billed charges,Implant Device,214.2,35,,214.2,percent of total billed charges,Implant Device,244.8,40,,244.8,percent of total billed charges,Implant Device,214.2,70,,214.2,percent of total billed charges,All Other,208.08,34,,208.08,percent of total billed charges,Implant Device,208.08,34,,208.08,percent of total billed charges,Implant Device,214.2,35,,214.2,percent of total billed charges,Implant Device,214.2,35,,214.2,percent of total billed charges,Implant Device,214.2,35,,214.2,percent of total billed charges,Implant Device,214.2,35,,214.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,452.88,
IN2BONES P92 ST016 CORT SCREW 2.4X16MM,C1713,HCPCS,,79010651,CDM,278,RC,,,both,,,612,452.88,,,452.88,Other,150% of Medicare + 9.63% HCRA Surcharge,275.4,45,,275.4,percent of total billed charges,Critical Access Hospital RCC factor,208.08,34,,208.08,percent of total billed charges,Implant Device,208.08,34,,208.08,percent of total billed charges,Implant Device,208.08,34,,208.08,percent of total billed charges,Implant Device,208.08,34,,208.08,percent of total billed charges,Implant Device,208.08,34,,208.08,percent of total billed charges,Implant Device,302.94,,,302.94,Other,110% of Medicare,214.2,35,,214.2,percent of total billed charges,Implant Device,208.08,34,"Charges > $500, x 34%",208.08,percent of total billed charges,Implant Device,214.2,35,,214.2,percent of total billed charges,Implant Device,214.2,35,,214.2,percent of total billed charges,Implant Device,214.2,35,,214.2,percent of total billed charges,Implant Device,214.2,35,,214.2,percent of total billed charges,Implant Device,214.2,35,,214.2,percent of total billed charges,Implant Device,244.8,40,,244.8,percent of total billed charges,Implant Device,214.2,70,,214.2,percent of total billed charges,All Other,208.08,34,,208.08,percent of total billed charges,Implant Device,208.08,34,,208.08,percent of total billed charges,Implant Device,214.2,35,,214.2,percent of total billed charges,Implant Device,214.2,35,,214.2,percent of total billed charges,Implant Device,214.2,35,,214.2,percent of total billed charges,Implant Device,214.2,35,,214.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,452.88,
BARD 0112770 MESH PERFIX PLUG 0112770,C1781,HCPCS,,79010654,CDM,278,RC,,,both,,,435,321.9,,,321.9,Other,150% of Medicare + 9.63% HCRA Surcharge,195.75,45,,195.75,percent of total billed charges,Critical Access Hospital RCC factor,147.9,34,,147.9,percent of total billed charges,Implant Device,147.9,34,,147.9,percent of total billed charges,Implant Device,147.9,34,,147.9,percent of total billed charges,Implant Device,147.9,34,,147.9,percent of total billed charges,Implant Device,147.9,34,,147.9,percent of total billed charges,Implant Device,215.33,,,215.33,Other,110% of Medicare,152.25,35,,152.25,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,152.25,35,,152.25,percent of total billed charges,Implant Device,152.25,35,,152.25,percent of total billed charges,Implant Device,152.25,35,,152.25,percent of total billed charges,Implant Device,152.25,35,,152.25,percent of total billed charges,Implant Device,152.25,35,,152.25,percent of total billed charges,Implant Device,174,40,,174,percent of total billed charges,Implant Device,152.25,70,,152.25,percent of total billed charges,All Other,147.9,34,,147.9,percent of total billed charges,Implant Device,147.9,34,,147.9,percent of total billed charges,Implant Device,152.25,35,,152.25,percent of total billed charges,Implant Device,152.25,35,,152.25,percent of total billed charges,Implant Device,152.25,35,,152.25,percent of total billed charges,Implant Device,152.25,35,,152.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,321.9,
STRYKER CALCANEUS MESH PLATE,C1713,HCPCS,,79010655,CDM,278,RC,,,both,,,2174,1608.77,,,1608.77,Other,150% of Medicare + 9.63% HCRA Surcharge,978.3,45,,978.3,percent of total billed charges,Critical Access Hospital RCC factor,739.16,34,,739.16,percent of total billed charges,Implant Device,739.16,34,,739.16,percent of total billed charges,Implant Device,739.16,34,,739.16,percent of total billed charges,Implant Device,739.16,34,,739.16,percent of total billed charges,Implant Device,739.16,34,,739.16,percent of total billed charges,Implant Device,1076.13,,,1076.13,Other,110% of Medicare,760.9,35,,760.9,percent of total billed charges,Implant Device,739.16,34,"Charges > $500, x 34%",739.16,percent of total billed charges,Implant Device,760.9,35,,760.9,percent of total billed charges,Implant Device,760.9,35,,760.9,percent of total billed charges,Implant Device,760.9,35,,760.9,percent of total billed charges,Implant Device,760.9,35,,760.9,percent of total billed charges,Implant Device,760.9,35,,760.9,percent of total billed charges,Implant Device,869.6,40,,869.6,percent of total billed charges,Implant Device,760.9,70,,760.9,percent of total billed charges,All Other,739.16,34,,739.16,percent of total billed charges,Implant Device,739.16,34,,739.16,percent of total billed charges,Implant Device,760.9,35,,760.9,percent of total billed charges,Implant Device,760.9,35,,760.9,percent of total billed charges,Implant Device,760.9,35,,760.9,percent of total billed charges,Implant Device,760.9,35,,760.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,739.16,34,"If Charge > 2,000, then 34 percent",739.16,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1608.77,
STRYKER 5027-4-180 APEX HALF PIN 4X180MM,C1713,HCPCS,,79010656,CDM,278,RC,,,both,,,148,109.52,,,109.52,Other,150% of Medicare + 9.63% HCRA Surcharge,66.6,45,,66.6,percent of total billed charges,Critical Access Hospital RCC factor,50.32,34,,50.32,percent of total billed charges,Implant Device,50.32,34,,50.32,percent of total billed charges,Implant Device,50.32,34,,50.32,percent of total billed charges,Implant Device,50.32,34,,50.32,percent of total billed charges,Implant Device,50.32,34,,50.32,percent of total billed charges,Implant Device,73.26,,,73.26,Other,110% of Medicare,51.8,35,,51.8,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,51.8,35,,51.8,percent of total billed charges,Implant Device,51.8,35,,51.8,percent of total billed charges,Implant Device,51.8,35,,51.8,percent of total billed charges,Implant Device,51.8,35,,51.8,percent of total billed charges,Implant Device,51.8,35,,51.8,percent of total billed charges,Implant Device,59.2,40,,59.2,percent of total billed charges,Implant Device,51.8,70,,51.8,percent of total billed charges,All Other,50.32,34,,50.32,percent of total billed charges,Implant Device,50.32,34,,50.32,percent of total billed charges,Implant Device,51.8,35,,51.8,percent of total billed charges,Implant Device,51.8,35,,51.8,percent of total billed charges,Implant Device,51.8,35,,51.8,percent of total billed charges,Implant Device,51.8,35,,51.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,109.52,
EXACTECH 314-13-24 CAGE GLENOID LEFT,C1713,HCPCS,,79010661,CDM,278,RC,,,both,,,9834,7277.18,,,7277.18,Other,150% of Medicare + 9.63% HCRA Surcharge,4425.3,45,,4425.3,percent of total billed charges,Critical Access Hospital RCC factor,3343.56,34,,3343.56,percent of total billed charges,Implant Device,3343.56,34,,3343.56,percent of total billed charges,Implant Device,3343.56,34,,3343.56,percent of total billed charges,Implant Device,3343.56,34,,3343.56,percent of total billed charges,Implant Device,3343.56,34,,3343.56,percent of total billed charges,Implant Device,4867.83,,,4867.83,Other,110% of Medicare,3441.9,35,,3441.9,percent of total billed charges,Implant Device,3343.56,34,"Charges > $500, x 34%",3343.56,percent of total billed charges,Implant Device,3441.9,35,,3441.9,percent of total billed charges,Implant Device,3441.9,35,,3441.9,percent of total billed charges,Implant Device,3441.9,35,,3441.9,percent of total billed charges,Implant Device,3441.9,35,,3441.9,percent of total billed charges,Implant Device,3441.9,35,,3441.9,percent of total billed charges,Implant Device,3933.6,40,,3933.6,percent of total billed charges,Implant Device,3441.9,70,,3441.9,percent of total billed charges,All Other,3343.56,34,,3343.56,percent of total billed charges,Implant Device,3343.56,34,,3343.56,percent of total billed charges,Implant Device,3441.9,35,,3441.9,percent of total billed charges,Implant Device,3441.9,35,,3441.9,percent of total billed charges,Implant Device,3441.9,35,,3441.9,percent of total billed charges,Implant Device,3441.9,35,,3441.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3343.56,34,"If Charge > 2,000, then 34 percent",3343.56,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,7277.18,
BARD 5950030 VENTRIO ST 3.1X4.7,C1781,HCPCS,,79010662,CDM,278,RC,,,both,,,1776,1314.24,,,1314.24,Other,150% of Medicare + 9.63% HCRA Surcharge,799.2,45,,799.2,percent of total billed charges,Critical Access Hospital RCC factor,603.84,34,,603.84,percent of total billed charges,Implant Device,603.84,34,,603.84,percent of total billed charges,Implant Device,603.84,34,,603.84,percent of total billed charges,Implant Device,603.84,34,,603.84,percent of total billed charges,Implant Device,603.84,34,,603.84,percent of total billed charges,Implant Device,879.12,,,879.12,Other,110% of Medicare,621.6,35,,621.6,percent of total billed charges,Implant Device,603.84,34,"Charges > $500, x 34%",603.84,percent of total billed charges,Implant Device,621.6,35,,621.6,percent of total billed charges,Implant Device,621.6,35,,621.6,percent of total billed charges,Implant Device,621.6,35,,621.6,percent of total billed charges,Implant Device,621.6,35,,621.6,percent of total billed charges,Implant Device,621.6,35,,621.6,percent of total billed charges,Implant Device,710.4,40,,710.4,percent of total billed charges,Implant Device,621.6,70,,621.6,percent of total billed charges,All Other,603.84,34,,603.84,percent of total billed charges,Implant Device,603.84,34,,603.84,percent of total billed charges,Implant Device,621.6,35,,621.6,percent of total billed charges,Implant Device,621.6,35,,621.6,percent of total billed charges,Implant Device,621.6,35,,621.6,percent of total billed charges,Implant Device,621.6,35,,621.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1314.24,
BARD 5950008 VENTRALEX ST M,C1781,HCPCS,,79010663,CDM,278,RC,,,both,,,1359,1005.66,,,1005.66,Other,150% of Medicare + 9.63% HCRA Surcharge,611.55,45,,611.55,percent of total billed charges,Critical Access Hospital RCC factor,462.06,34,,462.06,percent of total billed charges,Implant Device,462.06,34,,462.06,percent of total billed charges,Implant Device,462.06,34,,462.06,percent of total billed charges,Implant Device,462.06,34,,462.06,percent of total billed charges,Implant Device,462.06,34,,462.06,percent of total billed charges,Implant Device,672.71,,,672.71,Other,110% of Medicare,475.65,35,,475.65,percent of total billed charges,Implant Device,462.06,34,"Charges > $500, x 34%",462.06,percent of total billed charges,Implant Device,475.65,35,,475.65,percent of total billed charges,Implant Device,475.65,35,,475.65,percent of total billed charges,Implant Device,475.65,35,,475.65,percent of total billed charges,Implant Device,475.65,35,,475.65,percent of total billed charges,Implant Device,475.65,35,,475.65,percent of total billed charges,Implant Device,543.6,40,,543.6,percent of total billed charges,Implant Device,475.65,70,,475.65,percent of total billed charges,All Other,462.06,34,,462.06,percent of total billed charges,Implant Device,462.06,34,,462.06,percent of total billed charges,Implant Device,475.65,35,,475.65,percent of total billed charges,Implant Device,475.65,35,,475.65,percent of total billed charges,Implant Device,475.65,35,,475.65,percent of total billed charges,Implant Device,475.65,35,,475.65,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1005.66,
BARD 5950070 VENTRIO ST XL 7.7X9.7,C1781,HCPCS,,79010664,CDM,278,RC,,,both,,,4512,3338.89,,,3338.89,Other,150% of Medicare + 9.63% HCRA Surcharge,2030.4,45,,2030.4,percent of total billed charges,Critical Access Hospital RCC factor,1534.08,34,,1534.08,percent of total billed charges,Implant Device,1534.08,34,,1534.08,percent of total billed charges,Implant Device,1534.08,34,,1534.08,percent of total billed charges,Implant Device,1534.08,34,,1534.08,percent of total billed charges,Implant Device,1534.08,34,,1534.08,percent of total billed charges,Implant Device,2233.44,,,2233.44,Other,110% of Medicare,1579.2,35,,1579.2,percent of total billed charges,Implant Device,1534.08,34,"Charges > $500, x 34%",1534.08,percent of total billed charges,Implant Device,1579.2,35,,1579.2,percent of total billed charges,Implant Device,1579.2,35,,1579.2,percent of total billed charges,Implant Device,1579.2,35,,1579.2,percent of total billed charges,Implant Device,1579.2,35,,1579.2,percent of total billed charges,Implant Device,1579.2,35,,1579.2,percent of total billed charges,Implant Device,1804.8,40,,1804.8,percent of total billed charges,Implant Device,1579.2,70,,1579.2,percent of total billed charges,All Other,1534.08,34,,1534.08,percent of total billed charges,Implant Device,1534.08,34,,1534.08,percent of total billed charges,Implant Device,1579.2,35,,1579.2,percent of total billed charges,Implant Device,1579.2,35,,1579.2,percent of total billed charges,Implant Device,1579.2,35,,1579.2,percent of total billed charges,Implant Device,1579.2,35,,1579.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1534.08,34,"If Charge > 2,000, then 34 percent",1534.08,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3338.89,
IN2BONES P67 ST426 CANN SCREW 4.0X26MM,C1713,HCPCS,,79010665,CDM,278,RC,,,both,,,1485,1098.9,,,1098.9,Other,150% of Medicare + 9.63% HCRA Surcharge,668.25,45,,668.25,percent of total billed charges,Critical Access Hospital RCC factor,504.9,34,,504.9,percent of total billed charges,Implant Device,504.9,34,,504.9,percent of total billed charges,Implant Device,504.9,34,,504.9,percent of total billed charges,Implant Device,504.9,34,,504.9,percent of total billed charges,Implant Device,504.9,34,,504.9,percent of total billed charges,Implant Device,735.08,,,735.08,Other,110% of Medicare,519.75,35,,519.75,percent of total billed charges,Implant Device,504.9,34,"Charges > $500, x 34%",504.9,percent of total billed charges,Implant Device,519.75,35,,519.75,percent of total billed charges,Implant Device,519.75,35,,519.75,percent of total billed charges,Implant Device,519.75,35,,519.75,percent of total billed charges,Implant Device,519.75,35,,519.75,percent of total billed charges,Implant Device,519.75,35,,519.75,percent of total billed charges,Implant Device,594,40,,594,percent of total billed charges,Implant Device,519.75,70,,519.75,percent of total billed charges,All Other,504.9,34,,504.9,percent of total billed charges,Implant Device,504.9,34,,504.9,percent of total billed charges,Implant Device,519.75,35,,519.75,percent of total billed charges,Implant Device,519.75,35,,519.75,percent of total billed charges,Implant Device,519.75,35,,519.75,percent of total billed charges,Implant Device,519.75,35,,519.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1098.9,
IN2BONES P67 ST430 CANN SCREW 4.0X30MM,C1713,HCPCS,,79010666,CDM,278,RC,,,both,,,1485,1098.9,,,1098.9,Other,150% of Medicare + 9.63% HCRA Surcharge,668.25,45,,668.25,percent of total billed charges,Critical Access Hospital RCC factor,504.9,34,,504.9,percent of total billed charges,Implant Device,504.9,34,,504.9,percent of total billed charges,Implant Device,504.9,34,,504.9,percent of total billed charges,Implant Device,504.9,34,,504.9,percent of total billed charges,Implant Device,504.9,34,,504.9,percent of total billed charges,Implant Device,735.08,,,735.08,Other,110% of Medicare,519.75,35,,519.75,percent of total billed charges,Implant Device,504.9,34,"Charges > $500, x 34%",504.9,percent of total billed charges,Implant Device,519.75,35,,519.75,percent of total billed charges,Implant Device,519.75,35,,519.75,percent of total billed charges,Implant Device,519.75,35,,519.75,percent of total billed charges,Implant Device,519.75,35,,519.75,percent of total billed charges,Implant Device,519.75,35,,519.75,percent of total billed charges,Implant Device,594,40,,594,percent of total billed charges,Implant Device,519.75,70,,519.75,percent of total billed charges,All Other,504.9,34,,504.9,percent of total billed charges,Implant Device,504.9,34,,504.9,percent of total billed charges,Implant Device,519.75,35,,519.75,percent of total billed charges,Implant Device,519.75,35,,519.75,percent of total billed charges,Implant Device,519.75,35,,519.75,percent of total billed charges,Implant Device,519.75,35,,519.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1098.9,
IN2BONES P40 ST237 MTP PLATE LEFT,C1713,HCPCS,,79010667,CDM,278,RC,,,both,,,6000,4440.02,,,4440.02,Other,150% of Medicare + 9.63% HCRA Surcharge,2700,45,,2700,percent of total billed charges,Critical Access Hospital RCC factor,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2970,,,2970,Other,110% of Medicare,2100,35,,2100,percent of total billed charges,Implant Device,2040,34,"Charges > $500, x 34%",2040,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2400,40,,2400,percent of total billed charges,Implant Device,2100,70,,2100,percent of total billed charges,All Other,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2040,34,"If Charge > 2,000, then 34 percent",2040,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4440.02,
STRYKER 57-10310 T PLATE 1.7MM 10 HOLE,C1713,HCPCS,,79010668,CDM,278,RC,,,both,,,1322,978.28,,,978.28,Other,150% of Medicare + 9.63% HCRA Surcharge,594.9,45,,594.9,percent of total billed charges,Critical Access Hospital RCC factor,449.48,34,,449.48,percent of total billed charges,Implant Device,449.48,34,,449.48,percent of total billed charges,Implant Device,449.48,34,,449.48,percent of total billed charges,Implant Device,449.48,34,,449.48,percent of total billed charges,Implant Device,449.48,34,,449.48,percent of total billed charges,Implant Device,654.39,,,654.39,Other,110% of Medicare,462.7,35,,462.7,percent of total billed charges,Implant Device,449.48,34,"Charges > $500, x 34%",449.48,percent of total billed charges,Implant Device,462.7,35,,462.7,percent of total billed charges,Implant Device,462.7,35,,462.7,percent of total billed charges,Implant Device,462.7,35,,462.7,percent of total billed charges,Implant Device,462.7,35,,462.7,percent of total billed charges,Implant Device,462.7,35,,462.7,percent of total billed charges,Implant Device,528.8,40,,528.8,percent of total billed charges,Implant Device,462.7,70,,462.7,percent of total billed charges,All Other,449.48,34,,449.48,percent of total billed charges,Implant Device,449.48,34,,449.48,percent of total billed charges,Implant Device,462.7,35,,462.7,percent of total billed charges,Implant Device,462.7,35,,462.7,percent of total billed charges,Implant Device,462.7,35,,462.7,percent of total billed charges,Implant Device,462.7,35,,462.7,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,978.28,
STRYKER 623-10-36F INSERT 10 DEGREE 36MM,C1713,HCPCS,,79010669,CDM,278,RC,,,both,,,2503,1852.23,,,1852.23,Other,150% of Medicare + 9.63% HCRA Surcharge,1126.35,45,,1126.35,percent of total billed charges,Critical Access Hospital RCC factor,851.02,34,,851.02,percent of total billed charges,Implant Device,851.02,34,,851.02,percent of total billed charges,Implant Device,851.02,34,,851.02,percent of total billed charges,Implant Device,851.02,34,,851.02,percent of total billed charges,Implant Device,851.02,34,,851.02,percent of total billed charges,Implant Device,1238.99,,,1238.99,Other,110% of Medicare,876.05,35,,876.05,percent of total billed charges,Implant Device,851.02,34,"Charges > $500, x 34%",851.02,percent of total billed charges,Implant Device,876.05,35,,876.05,percent of total billed charges,Implant Device,876.05,35,,876.05,percent of total billed charges,Implant Device,876.05,35,,876.05,percent of total billed charges,Implant Device,876.05,35,,876.05,percent of total billed charges,Implant Device,876.05,35,,876.05,percent of total billed charges,Implant Device,1001.2,40,,1001.2,percent of total billed charges,Implant Device,876.05,70,,876.05,percent of total billed charges,All Other,851.02,34,,851.02,percent of total billed charges,Implant Device,851.02,34,,851.02,percent of total billed charges,Implant Device,876.05,35,,876.05,percent of total billed charges,Implant Device,876.05,35,,876.05,percent of total billed charges,Implant Device,876.05,35,,876.05,percent of total billed charges,Implant Device,876.05,35,,876.05,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,851.02,34,"If Charge > 2,000, then 34 percent",851.02,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1852.23,
STRYKER 57-10310 HAND LOCK T PLATE,C1713,HCPCS,,79010670,CDM,278,RC,,,both,,,1322,978.28,,,978.28,Other,150% of Medicare + 9.63% HCRA Surcharge,594.9,45,,594.9,percent of total billed charges,Critical Access Hospital RCC factor,449.48,34,,449.48,percent of total billed charges,Implant Device,449.48,34,,449.48,percent of total billed charges,Implant Device,449.48,34,,449.48,percent of total billed charges,Implant Device,449.48,34,,449.48,percent of total billed charges,Implant Device,449.48,34,,449.48,percent of total billed charges,Implant Device,654.39,,,654.39,Other,110% of Medicare,462.7,35,,462.7,percent of total billed charges,Implant Device,449.48,34,"Charges > $500, x 34%",449.48,percent of total billed charges,Implant Device,462.7,35,,462.7,percent of total billed charges,Implant Device,462.7,35,,462.7,percent of total billed charges,Implant Device,462.7,35,,462.7,percent of total billed charges,Implant Device,462.7,35,,462.7,percent of total billed charges,Implant Device,462.7,35,,462.7,percent of total billed charges,Implant Device,528.8,40,,528.8,percent of total billed charges,Implant Device,462.7,70,,462.7,percent of total billed charges,All Other,449.48,34,,449.48,percent of total billed charges,Implant Device,449.48,34,,449.48,percent of total billed charges,Implant Device,462.7,35,,462.7,percent of total billed charges,Implant Device,462.7,35,,462.7,percent of total billed charges,Implant Device,462.7,35,,462.7,percent of total billed charges,Implant Device,462.7,35,,462.7,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,978.28,
STRYKER 663711 LOCKING SCREW 2.3X11MM,C1713,HCPCS,,79010671,CDM,278,RC,,,both,,,468,346.32,,,346.32,Other,150% of Medicare + 9.63% HCRA Surcharge,210.6,45,,210.6,percent of total billed charges,Critical Access Hospital RCC factor,159.12,34,,159.12,percent of total billed charges,Implant Device,159.12,34,,159.12,percent of total billed charges,Implant Device,159.12,34,,159.12,percent of total billed charges,Implant Device,159.12,34,,159.12,percent of total billed charges,Implant Device,159.12,34,,159.12,percent of total billed charges,Implant Device,231.66,,,231.66,Other,110% of Medicare,163.8,35,,163.8,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,163.8,35,,163.8,percent of total billed charges,Implant Device,163.8,35,,163.8,percent of total billed charges,Implant Device,163.8,35,,163.8,percent of total billed charges,Implant Device,163.8,35,,163.8,percent of total billed charges,Implant Device,163.8,35,,163.8,percent of total billed charges,Implant Device,187.2,40,,187.2,percent of total billed charges,Implant Device,163.8,70,,163.8,percent of total billed charges,All Other,159.12,34,,159.12,percent of total billed charges,Implant Device,159.12,34,,159.12,percent of total billed charges,Implant Device,163.8,35,,163.8,percent of total billed charges,Implant Device,163.8,35,,163.8,percent of total billed charges,Implant Device,163.8,35,,163.8,percent of total billed charges,Implant Device,163.8,35,,163.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,346.32,
STRYKER 663712 LOCKING SCREW 2.3X12MM,C1713,HCPCS,,79010672,CDM,278,RC,,,both,,,468,346.32,,,346.32,Other,150% of Medicare + 9.63% HCRA Surcharge,210.6,45,,210.6,percent of total billed charges,Critical Access Hospital RCC factor,159.12,34,,159.12,percent of total billed charges,Implant Device,159.12,34,,159.12,percent of total billed charges,Implant Device,159.12,34,,159.12,percent of total billed charges,Implant Device,159.12,34,,159.12,percent of total billed charges,Implant Device,159.12,34,,159.12,percent of total billed charges,Implant Device,231.66,,,231.66,Other,110% of Medicare,163.8,35,,163.8,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,163.8,35,,163.8,percent of total billed charges,Implant Device,163.8,35,,163.8,percent of total billed charges,Implant Device,163.8,35,,163.8,percent of total billed charges,Implant Device,163.8,35,,163.8,percent of total billed charges,Implant Device,163.8,35,,163.8,percent of total billed charges,Implant Device,187.2,40,,187.2,percent of total billed charges,Implant Device,163.8,70,,163.8,percent of total billed charges,All Other,159.12,34,,159.12,percent of total billed charges,Implant Device,159.12,34,,159.12,percent of total billed charges,Implant Device,163.8,35,,163.8,percent of total billed charges,Implant Device,163.8,35,,163.8,percent of total billed charges,Implant Device,163.8,35,,163.8,percent of total billed charges,Implant Device,163.8,35,,163.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,346.32,
STRYKER 663808 BONE SCREW 2.3X8MM,C1713,HCPCS,,79010673,CDM,278,RC,,,both,,,368,272.32,,,272.32,Other,150% of Medicare + 9.63% HCRA Surcharge,165.6,45,,165.6,percent of total billed charges,Critical Access Hospital RCC factor,125.12,34,,125.12,percent of total billed charges,Implant Device,125.12,34,,125.12,percent of total billed charges,Implant Device,125.12,34,,125.12,percent of total billed charges,Implant Device,125.12,34,,125.12,percent of total billed charges,Implant Device,125.12,34,,125.12,percent of total billed charges,Implant Device,182.16,,,182.16,Other,110% of Medicare,128.8,35,,128.8,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,128.8,35,,128.8,percent of total billed charges,Implant Device,128.8,35,,128.8,percent of total billed charges,Implant Device,128.8,35,,128.8,percent of total billed charges,Implant Device,128.8,35,,128.8,percent of total billed charges,Implant Device,128.8,35,,128.8,percent of total billed charges,Implant Device,147.2,40,,147.2,percent of total billed charges,Implant Device,128.8,70,,128.8,percent of total billed charges,All Other,125.12,34,,125.12,percent of total billed charges,Implant Device,125.12,34,,125.12,percent of total billed charges,Implant Device,128.8,35,,128.8,percent of total billed charges,Implant Device,128.8,35,,128.8,percent of total billed charges,Implant Device,128.8,35,,128.8,percent of total billed charges,Implant Device,128.8,35,,128.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,272.32,
STRYKER 663812 BONE SCREW 2.3X12MM,C1713,HCPCS,,79010674,CDM,278,RC,,,both,,,324,239.76,,,239.76,Other,150% of Medicare + 9.63% HCRA Surcharge,145.8,45,,145.8,percent of total billed charges,Critical Access Hospital RCC factor,110.16,34,,110.16,percent of total billed charges,Implant Device,110.16,34,,110.16,percent of total billed charges,Implant Device,110.16,34,,110.16,percent of total billed charges,Implant Device,110.16,34,,110.16,percent of total billed charges,Implant Device,110.16,34,,110.16,percent of total billed charges,Implant Device,160.38,,,160.38,Other,110% of Medicare,113.4,35,,113.4,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,129.6,40,,129.6,percent of total billed charges,Implant Device,113.4,70,,113.4,percent of total billed charges,All Other,110.16,34,,110.16,percent of total billed charges,Implant Device,110.16,34,,110.16,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,239.76,
STRYKER 663813 BONE SCREW 2.3X13MM,C1713,HCPCS,,79010675,CDM,278,RC,,,both,,,324,239.76,,,239.76,Other,150% of Medicare + 9.63% HCRA Surcharge,145.8,45,,145.8,percent of total billed charges,Critical Access Hospital RCC factor,110.16,34,,110.16,percent of total billed charges,Implant Device,110.16,34,,110.16,percent of total billed charges,Implant Device,110.16,34,,110.16,percent of total billed charges,Implant Device,110.16,34,,110.16,percent of total billed charges,Implant Device,110.16,34,,110.16,percent of total billed charges,Implant Device,160.38,,,160.38,Other,110% of Medicare,113.4,35,,113.4,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,129.6,40,,129.6,percent of total billed charges,Implant Device,113.4,70,,113.4,percent of total billed charges,All Other,110.16,34,,110.16,percent of total billed charges,Implant Device,110.16,34,,110.16,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,239.76,
STRYKER 663815 BONE SCREW 2.3X15MM,C1713,HCPCS,,79010676,CDM,278,RC,,,both,,,324,239.76,,,239.76,Other,150% of Medicare + 9.63% HCRA Surcharge,145.8,45,,145.8,percent of total billed charges,Critical Access Hospital RCC factor,110.16,34,,110.16,percent of total billed charges,Implant Device,110.16,34,,110.16,percent of total billed charges,Implant Device,110.16,34,,110.16,percent of total billed charges,Implant Device,110.16,34,,110.16,percent of total billed charges,Implant Device,110.16,34,,110.16,percent of total billed charges,Implant Device,160.38,,,160.38,Other,110% of Medicare,113.4,35,,113.4,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,129.6,40,,129.6,percent of total billed charges,Implant Device,113.4,70,,113.4,percent of total billed charges,All Other,110.16,34,,110.16,percent of total billed charges,Implant Device,110.16,34,,110.16,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,239.76,
STRYKER 702-04-58F SHELL SIZE 58MM,C1776,HCPCS,,79010677,CDM,278,RC,,,both,,,3750,2775.01,,,2775.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1687.5,45,,1687.5,percent of total billed charges,Critical Access Hospital RCC factor,1275,34,,1275,percent of total billed charges,Implant Device,1275,34,,1275,percent of total billed charges,Implant Device,1275,34,,1275,percent of total billed charges,Implant Device,1275,34,,1275,percent of total billed charges,Implant Device,1275,34,,1275,percent of total billed charges,Implant Device,1856.25,,,1856.25,Other,110% of Medicare,1312.5,35,,1312.5,percent of total billed charges,Implant Device,1275,34,"Charges > $500, x 34%",1275,percent of total billed charges,Implant Device,1312.5,35,,1312.5,percent of total billed charges,Implant Device,1312.5,35,,1312.5,percent of total billed charges,Implant Device,1312.5,35,,1312.5,percent of total billed charges,Implant Device,1312.5,35,,1312.5,percent of total billed charges,Implant Device,1312.5,35,,1312.5,percent of total billed charges,Implant Device,1500,40,,1500,percent of total billed charges,Implant Device,1312.5,70,,1312.5,percent of total billed charges,All Other,1275,34,,1275,percent of total billed charges,Implant Device,1275,34,,1275,percent of total billed charges,Implant Device,1312.5,35,,1312.5,percent of total billed charges,Implant Device,1312.5,35,,1312.5,percent of total billed charges,Implant Device,1312.5,35,,1312.5,percent of total billed charges,Implant Device,1312.5,35,,1312.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1275,34,"If Charge > 2,000, then 34 percent",1275,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2775.01,
STRYKER 2333-0934S FEMORAL NAIL 9X340MM,C1713,HCPCS,,79010678,CDM,278,RC,,,both,,,7570,5601.82,,,5601.82,Other,150% of Medicare + 9.63% HCRA Surcharge,3406.5,45,,3406.5,percent of total billed charges,Critical Access Hospital RCC factor,2573.8,34,,2573.8,percent of total billed charges,Implant Device,2573.8,34,,2573.8,percent of total billed charges,Implant Device,2573.8,34,,2573.8,percent of total billed charges,Implant Device,2573.8,34,,2573.8,percent of total billed charges,Implant Device,2573.8,34,,2573.8,percent of total billed charges,Implant Device,3747.15,,,3747.15,Other,110% of Medicare,2649.5,35,,2649.5,percent of total billed charges,Implant Device,2573.8,34,"Charges > $500, x 34%",2573.8,percent of total billed charges,Implant Device,2649.5,35,,2649.5,percent of total billed charges,Implant Device,2649.5,35,,2649.5,percent of total billed charges,Implant Device,2649.5,35,,2649.5,percent of total billed charges,Implant Device,2649.5,35,,2649.5,percent of total billed charges,Implant Device,2649.5,35,,2649.5,percent of total billed charges,Implant Device,3028,40,,3028,percent of total billed charges,Implant Device,2649.5,70,,2649.5,percent of total billed charges,All Other,2573.8,34,,2573.8,percent of total billed charges,Implant Device,2573.8,34,,2573.8,percent of total billed charges,Implant Device,2649.5,35,,2649.5,percent of total billed charges,Implant Device,2649.5,35,,2649.5,percent of total billed charges,Implant Device,2649.5,35,,2649.5,percent of total billed charges,Implant Device,2649.5,35,,2649.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2573.8,34,"If Charge > 2,000, then 34 percent",2573.8,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5601.82,
STRYKER 2360-5032S LOCKING SCREW 5X32MM,C1713,HCPCS,,79010679,CDM,278,RC,,,both,,,682,504.68,,,504.68,Other,150% of Medicare + 9.63% HCRA Surcharge,306.9,45,,306.9,percent of total billed charges,Critical Access Hospital RCC factor,231.88,34,,231.88,percent of total billed charges,Implant Device,231.88,34,,231.88,percent of total billed charges,Implant Device,231.88,34,,231.88,percent of total billed charges,Implant Device,231.88,34,,231.88,percent of total billed charges,Implant Device,231.88,34,,231.88,percent of total billed charges,Implant Device,337.59,,,337.59,Other,110% of Medicare,238.7,35,,238.7,percent of total billed charges,Implant Device,231.88,34,"Charges > $500, x 34%",231.88,percent of total billed charges,Implant Device,238.7,35,,238.7,percent of total billed charges,Implant Device,238.7,35,,238.7,percent of total billed charges,Implant Device,238.7,35,,238.7,percent of total billed charges,Implant Device,238.7,35,,238.7,percent of total billed charges,Implant Device,238.7,35,,238.7,percent of total billed charges,Implant Device,272.8,40,,272.8,percent of total billed charges,Implant Device,238.7,70,,238.7,percent of total billed charges,All Other,231.88,34,,231.88,percent of total billed charges,Implant Device,231.88,34,,231.88,percent of total billed charges,Implant Device,238.7,35,,238.7,percent of total billed charges,Implant Device,238.7,35,,238.7,percent of total billed charges,Implant Device,238.7,35,,238.7,percent of total billed charges,Implant Device,238.7,35,,238.7,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,504.68,
STRYKER 2360-5052S LOCKING SCREW 5X52MM,C1713,HCPCS,,79010680,CDM,278,RC,,,both,,,762,563.88,,,563.88,Other,150% of Medicare + 9.63% HCRA Surcharge,342.9,45,,342.9,percent of total billed charges,Critical Access Hospital RCC factor,259.08,34,,259.08,percent of total billed charges,Implant Device,259.08,34,,259.08,percent of total billed charges,Implant Device,259.08,34,,259.08,percent of total billed charges,Implant Device,259.08,34,,259.08,percent of total billed charges,Implant Device,259.08,34,,259.08,percent of total billed charges,Implant Device,377.19,,,377.19,Other,110% of Medicare,266.7,35,,266.7,percent of total billed charges,Implant Device,259.08,34,"Charges > $500, x 34%",259.08,percent of total billed charges,Implant Device,266.7,35,,266.7,percent of total billed charges,Implant Device,266.7,35,,266.7,percent of total billed charges,Implant Device,266.7,35,,266.7,percent of total billed charges,Implant Device,266.7,35,,266.7,percent of total billed charges,Implant Device,266.7,35,,266.7,percent of total billed charges,Implant Device,304.8,40,,304.8,percent of total billed charges,Implant Device,266.7,70,,266.7,percent of total billed charges,All Other,259.08,34,,259.08,percent of total billed charges,Implant Device,259.08,34,,259.08,percent of total billed charges,Implant Device,266.7,35,,266.7,percent of total billed charges,Implant Device,266.7,35,,266.7,percent of total billed charges,Implant Device,266.7,35,,266.7,percent of total billed charges,Implant Device,266.7,35,,266.7,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,563.88,
STRYKER 1059-4514 ACCOLADE SPACER,C1776,HCPCS,,79010681,CDM,278,RC,,,both,,,150,111,,,111,Other,150% of Medicare + 9.63% HCRA Surcharge,67.5,45,,67.5,percent of total billed charges,Critical Access Hospital RCC factor,51,34,,51,percent of total billed charges,Implant Device,51,34,,51,percent of total billed charges,Implant Device,51,34,,51,percent of total billed charges,Implant Device,51,34,,51,percent of total billed charges,Implant Device,51,34,,51,percent of total billed charges,Implant Device,74.25,,,74.25,Other,110% of Medicare,52.5,35,,52.5,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,52.5,35,,52.5,percent of total billed charges,Implant Device,52.5,35,,52.5,percent of total billed charges,Implant Device,52.5,35,,52.5,percent of total billed charges,Implant Device,52.5,35,,52.5,percent of total billed charges,Implant Device,52.5,35,,52.5,percent of total billed charges,Implant Device,60,40,,60,percent of total billed charges,Implant Device,52.5,70,,52.5,percent of total billed charges,All Other,51,34,,51,percent of total billed charges,Implant Device,51,34,,51,percent of total billed charges,Implant Device,52.5,35,,52.5,percent of total billed charges,Implant Device,52.5,35,,52.5,percent of total billed charges,Implant Device,52.5,35,,52.5,percent of total billed charges,Implant Device,52.5,35,,52.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,111,
STRYKER 6057-0537D ACCOLADE FEM STEM,C1776,HCPCS,,79010682,CDM,278,RC,,,both,,,3750,2775.01,,,2775.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1687.5,45,,1687.5,percent of total billed charges,Critical Access Hospital RCC factor,1275,34,,1275,percent of total billed charges,Implant Device,1275,34,,1275,percent of total billed charges,Implant Device,1275,34,,1275,percent of total billed charges,Implant Device,1275,34,,1275,percent of total billed charges,Implant Device,1275,34,,1275,percent of total billed charges,Implant Device,1856.25,,,1856.25,Other,110% of Medicare,1312.5,35,,1312.5,percent of total billed charges,Implant Device,1275,34,"Charges > $500, x 34%",1275,percent of total billed charges,Implant Device,1312.5,35,,1312.5,percent of total billed charges,Implant Device,1312.5,35,,1312.5,percent of total billed charges,Implant Device,1312.5,35,,1312.5,percent of total billed charges,Implant Device,1312.5,35,,1312.5,percent of total billed charges,Implant Device,1312.5,35,,1312.5,percent of total billed charges,Implant Device,1500,40,,1500,percent of total billed charges,Implant Device,1312.5,70,,1312.5,percent of total billed charges,All Other,1275,34,,1275,percent of total billed charges,Implant Device,1275,34,,1275,percent of total billed charges,Implant Device,1312.5,35,,1312.5,percent of total billed charges,Implant Device,1312.5,35,,1312.5,percent of total billed charges,Implant Device,1312.5,35,,1312.5,percent of total billed charges,Implant Device,1312.5,35,,1312.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1275,34,"If Charge > 2,000, then 34 percent",1275,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2775.01,
STRYKER 626983 Y PLATE 3 SHAFT HOLES,C1713,HCPCS,,79010683,CDM,278,RC,,,both,,,3198,2366.53,,,2366.53,Other,150% of Medicare + 9.63% HCRA Surcharge,1439.1,45,,1439.1,percent of total billed charges,Critical Access Hospital RCC factor,1087.32,34,,1087.32,percent of total billed charges,Implant Device,1087.32,34,,1087.32,percent of total billed charges,Implant Device,1087.32,34,,1087.32,percent of total billed charges,Implant Device,1087.32,34,,1087.32,percent of total billed charges,Implant Device,1087.32,34,,1087.32,percent of total billed charges,Implant Device,1583.01,,,1583.01,Other,110% of Medicare,1119.3,35,,1119.3,percent of total billed charges,Implant Device,1087.32,34,"Charges > $500, x 34%",1087.32,percent of total billed charges,Implant Device,1119.3,35,,1119.3,percent of total billed charges,Implant Device,1119.3,35,,1119.3,percent of total billed charges,Implant Device,1119.3,35,,1119.3,percent of total billed charges,Implant Device,1119.3,35,,1119.3,percent of total billed charges,Implant Device,1119.3,35,,1119.3,percent of total billed charges,Implant Device,1279.2,40,,1279.2,percent of total billed charges,Implant Device,1119.3,70,,1119.3,percent of total billed charges,All Other,1087.32,34,,1087.32,percent of total billed charges,Implant Device,1087.32,34,,1087.32,percent of total billed charges,Implant Device,1119.3,35,,1119.3,percent of total billed charges,Implant Device,1119.3,35,,1119.3,percent of total billed charges,Implant Device,1119.3,35,,1119.3,percent of total billed charges,Implant Device,1119.3,35,,1119.3,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1087.32,34,"If Charge > 2,000, then 34 percent",1087.32,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2366.53,
STRYKER DCELL203 TISSUE5X16CM 0.75-150MM,C1789,HCPCS,,79010684,CDM,278,RC,,,both,,,9750,7215.02,,,7215.02,Other,150% of Medicare + 9.63% HCRA Surcharge,4387.5,45,,4387.5,percent of total billed charges,Critical Access Hospital RCC factor,3315,34,,3315,percent of total billed charges,Implant Device,3315,34,,3315,percent of total billed charges,Implant Device,3315,34,,3315,percent of total billed charges,Implant Device,3315,34,,3315,percent of total billed charges,Implant Device,3315,34,,3315,percent of total billed charges,Implant Device,4826.25,,,4826.25,Other,110% of Medicare,3412.5,35,,3412.5,percent of total billed charges,Implant Device,3315,34,"Charges > $500, x 34%",3315,percent of total billed charges,Implant Device,3412.5,35,,3412.5,percent of total billed charges,Implant Device,3412.5,35,,3412.5,percent of total billed charges,Implant Device,3412.5,35,,3412.5,percent of total billed charges,Implant Device,3412.5,35,,3412.5,percent of total billed charges,Implant Device,3412.5,35,,3412.5,percent of total billed charges,Implant Device,3900,40,,3900,percent of total billed charges,Implant Device,3412.5,70,,3412.5,percent of total billed charges,All Other,3315,34,,3315,percent of total billed charges,Implant Device,3315,34,,3315,percent of total billed charges,Implant Device,3412.5,35,,3412.5,percent of total billed charges,Implant Device,3412.5,35,,3412.5,percent of total billed charges,Implant Device,3412.5,35,,3412.5,percent of total billed charges,Implant Device,3412.5,35,,3412.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3315,34,"If Charge > 2,000, then 34 percent",3315,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,7215.02,
ARTHREX AR-7234PSL SWIVERLOCK FORK 4.75,C1713,HCPCS,,79010685,CDM,278,RC,,,both,,,1305,965.7,,,965.7,Other,150% of Medicare + 9.63% HCRA Surcharge,587.25,45,,587.25,percent of total billed charges,Critical Access Hospital RCC factor,443.7,34,,443.7,percent of total billed charges,Implant Device,443.7,34,,443.7,percent of total billed charges,Implant Device,443.7,34,,443.7,percent of total billed charges,Implant Device,443.7,34,,443.7,percent of total billed charges,Implant Device,443.7,34,,443.7,percent of total billed charges,Implant Device,645.98,,,645.98,Other,110% of Medicare,456.75,35,,456.75,percent of total billed charges,Implant Device,443.7,34,"Charges > $500, x 34%",443.7,percent of total billed charges,Implant Device,456.75,35,,456.75,percent of total billed charges,Implant Device,456.75,35,,456.75,percent of total billed charges,Implant Device,456.75,35,,456.75,percent of total billed charges,Implant Device,456.75,35,,456.75,percent of total billed charges,Implant Device,456.75,35,,456.75,percent of total billed charges,Implant Device,522,40,,522,percent of total billed charges,Implant Device,456.75,70,,456.75,percent of total billed charges,All Other,443.7,34,,443.7,percent of total billed charges,Implant Device,443.7,34,,443.7,percent of total billed charges,Implant Device,456.75,35,,456.75,percent of total billed charges,Implant Device,456.75,35,,456.75,percent of total billed charges,Implant Device,456.75,35,,456.75,percent of total billed charges,Implant Device,456.75,35,,456.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,965.7,
LIFENET HEALTH FCON FLEXIGRAFT TENDON,C1713,HCPCS,,79010686,CDM,278,RC,,,both,,,4314,3192.37,,,3192.37,Other,150% of Medicare + 9.63% HCRA Surcharge,1941.3,45,,1941.3,percent of total billed charges,Critical Access Hospital RCC factor,1466.76,34,,1466.76,percent of total billed charges,Implant Device,1466.76,34,,1466.76,percent of total billed charges,Implant Device,1466.76,34,,1466.76,percent of total billed charges,Implant Device,1466.76,34,,1466.76,percent of total billed charges,Implant Device,1466.76,34,,1466.76,percent of total billed charges,Implant Device,2135.43,,,2135.43,Other,110% of Medicare,1509.9,35,,1509.9,percent of total billed charges,Implant Device,1466.76,34,"Charges > $500, x 34%",1466.76,percent of total billed charges,Implant Device,1509.9,35,,1509.9,percent of total billed charges,Implant Device,1509.9,35,,1509.9,percent of total billed charges,Implant Device,1509.9,35,,1509.9,percent of total billed charges,Implant Device,1509.9,35,,1509.9,percent of total billed charges,Implant Device,1509.9,35,,1509.9,percent of total billed charges,Implant Device,1725.6,40,,1725.6,percent of total billed charges,Implant Device,1509.9,70,,1509.9,percent of total billed charges,All Other,1466.76,34,,1466.76,percent of total billed charges,Implant Device,1466.76,34,,1466.76,percent of total billed charges,Implant Device,1509.9,35,,1509.9,percent of total billed charges,Implant Device,1509.9,35,,1509.9,percent of total billed charges,Implant Device,1509.9,35,,1509.9,percent of total billed charges,Implant Device,1509.9,35,,1509.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1466.76,34,"If Charge > 2,000, then 34 percent",1466.76,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3192.37,
DEPUY 202.222 2.7 x 22MM LOCKING SCREW,C1713,HCPCS,,79010687,CDM,278,RC,,,both,,,300,222,,,222,Other,150% of Medicare + 9.63% HCRA Surcharge,135,45,,135,percent of total billed charges,Critical Access Hospital RCC factor,102,34,,102,percent of total billed charges,Implant Device,102,34,,102,percent of total billed charges,Implant Device,102,34,,102,percent of total billed charges,Implant Device,102,34,,102,percent of total billed charges,Implant Device,102,34,,102,percent of total billed charges,Implant Device,148.5,,,148.5,Other,110% of Medicare,105,35,,105,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,105,35,,105,percent of total billed charges,Implant Device,105,35,,105,percent of total billed charges,Implant Device,105,35,,105,percent of total billed charges,Implant Device,105,35,,105,percent of total billed charges,Implant Device,105,35,,105,percent of total billed charges,Implant Device,120,40,,120,percent of total billed charges,Implant Device,105,70,,105,percent of total billed charges,All Other,102,34,,102,percent of total billed charges,Implant Device,102,34,,102,percent of total billed charges,Implant Device,105,35,,105,percent of total billed charges,Implant Device,105,35,,105,percent of total billed charges,Implant Device,105,35,,105,percent of total billed charges,Implant Device,105,35,,105,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,222,
DEPUY 02.112.011 CLAVCL PLATE 3.5 X 81MM,C1713,HCPCS,,79010688,CDM,278,RC,,,both,,,2331,1724.95,,,1724.95,Other,150% of Medicare + 9.63% HCRA Surcharge,1048.95,45,,1048.95,percent of total billed charges,Critical Access Hospital RCC factor,792.54,34,,792.54,percent of total billed charges,Implant Device,792.54,34,,792.54,percent of total billed charges,Implant Device,792.54,34,,792.54,percent of total billed charges,Implant Device,792.54,34,,792.54,percent of total billed charges,Implant Device,792.54,34,,792.54,percent of total billed charges,Implant Device,1153.85,,,1153.85,Other,110% of Medicare,815.85,35,,815.85,percent of total billed charges,Implant Device,792.54,34,"Charges > $500, x 34%",792.54,percent of total billed charges,Implant Device,815.85,35,,815.85,percent of total billed charges,Implant Device,815.85,35,,815.85,percent of total billed charges,Implant Device,815.85,35,,815.85,percent of total billed charges,Implant Device,815.85,35,,815.85,percent of total billed charges,Implant Device,815.85,35,,815.85,percent of total billed charges,Implant Device,932.4,40,,932.4,percent of total billed charges,Implant Device,815.85,70,,815.85,percent of total billed charges,All Other,792.54,34,,792.54,percent of total billed charges,Implant Device,792.54,34,,792.54,percent of total billed charges,Implant Device,815.85,35,,815.85,percent of total billed charges,Implant Device,815.85,35,,815.85,percent of total billed charges,Implant Device,815.85,35,,815.85,percent of total billed charges,Implant Device,815.85,35,,815.85,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,792.54,34,"If Charge > 2,000, then 34 percent",792.54,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1724.95,
STRYKER 5552-S-4416 REUNION HUMERAL HD,C1776,HCPCS,,79010689,CDM,278,RC,,,both,,,4500,3330.01,,,3330.01,Other,150% of Medicare + 9.63% HCRA Surcharge,2025,45,,2025,percent of total billed charges,Critical Access Hospital RCC factor,1530,34,,1530,percent of total billed charges,Implant Device,1530,34,,1530,percent of total billed charges,Implant Device,1530,34,,1530,percent of total billed charges,Implant Device,1530,34,,1530,percent of total billed charges,Implant Device,1530,34,,1530,percent of total billed charges,Implant Device,2227.5,,,2227.5,Other,110% of Medicare,1575,35,,1575,percent of total billed charges,Implant Device,1530,34,"Charges > $500, x 34%",1530,percent of total billed charges,Implant Device,1575,35,,1575,percent of total billed charges,Implant Device,1575,35,,1575,percent of total billed charges,Implant Device,1575,35,,1575,percent of total billed charges,Implant Device,1575,35,,1575,percent of total billed charges,Implant Device,1575,35,,1575,percent of total billed charges,Implant Device,1800,40,,1800,percent of total billed charges,Implant Device,1575,70,,1575,percent of total billed charges,All Other,1530,34,,1530,percent of total billed charges,Implant Device,1530,34,,1530,percent of total billed charges,Implant Device,1575,35,,1575,percent of total billed charges,Implant Device,1575,35,,1575,percent of total billed charges,Implant Device,1575,35,,1575,percent of total billed charges,Implant Device,1575,35,,1575,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1530,34,"If Charge > 2,000, then 34 percent",1530,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3330.01,
CER BIOLOXD MOD HD 28MM STD,C1776,HCPCS,,79010691,CDM,278,RC,,,both,,,3075,2275.51,,,2275.51,Other,150% of Medicare + 9.63% HCRA Surcharge,1383.75,45,,1383.75,percent of total billed charges,Critical Access Hospital RCC factor,1045.5,34,,1045.5,percent of total billed charges,Implant Device,1045.5,34,,1045.5,percent of total billed charges,Implant Device,1045.5,34,,1045.5,percent of total billed charges,Implant Device,1045.5,34,,1045.5,percent of total billed charges,Implant Device,1045.5,34,,1045.5,percent of total billed charges,Implant Device,1522.13,,,1522.13,Other,110% of Medicare,1076.25,35,,1076.25,percent of total billed charges,Implant Device,1045.5,34,"Charges > $500, x 34%",1045.5,percent of total billed charges,Implant Device,1076.25,35,,1076.25,percent of total billed charges,Implant Device,1076.25,35,,1076.25,percent of total billed charges,Implant Device,1076.25,35,,1076.25,percent of total billed charges,Implant Device,1076.25,35,,1076.25,percent of total billed charges,Implant Device,1076.25,35,,1076.25,percent of total billed charges,Implant Device,1230,40,,1230,percent of total billed charges,Implant Device,1076.25,70,,1076.25,percent of total billed charges,All Other,1045.5,34,,1045.5,percent of total billed charges,Implant Device,1045.5,34,,1045.5,percent of total billed charges,Implant Device,1076.25,35,,1076.25,percent of total billed charges,Implant Device,1076.25,35,,1076.25,percent of total billed charges,Implant Device,1076.25,35,,1076.25,percent of total billed charges,Implant Device,1076.25,35,,1076.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1045.5,34,"If Charge > 2,000, then 34 percent",1045.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2275.51,
ZIMMER 00-5001-053-00 BIPOLAR SHELL 53MM,C1776,HCPCS,,79010692,CDM,278,RC,,,both,,,960,710.4,,,710.4,Other,150% of Medicare + 9.63% HCRA Surcharge,432,45,,432,percent of total billed charges,Critical Access Hospital RCC factor,326.4,34,,326.4,percent of total billed charges,Implant Device,326.4,34,,326.4,percent of total billed charges,Implant Device,326.4,34,,326.4,percent of total billed charges,Implant Device,326.4,34,,326.4,percent of total billed charges,Implant Device,326.4,34,,326.4,percent of total billed charges,Implant Device,475.2,,,475.2,Other,110% of Medicare,336,35,,336,percent of total billed charges,Implant Device,326.4,34,"Charges > $500, x 34%",326.4,percent of total billed charges,Implant Device,336,35,,336,percent of total billed charges,Implant Device,336,35,,336,percent of total billed charges,Implant Device,336,35,,336,percent of total billed charges,Implant Device,336,35,,336,percent of total billed charges,Implant Device,336,35,,336,percent of total billed charges,Implant Device,384,40,,384,percent of total billed charges,Implant Device,336,70,,336,percent of total billed charges,All Other,326.4,34,,326.4,percent of total billed charges,Implant Device,326.4,34,,326.4,percent of total billed charges,Implant Device,336,35,,336,percent of total billed charges,Implant Device,336,35,,336,percent of total billed charges,Implant Device,336,35,,336,percent of total billed charges,Implant Device,336,35,,336,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,710.4,
ZIMMER 00-7711-012-10 FEMORAL STEM 12/14,C1713,HCPCS,,79010693,CDM,278,RC,,,both,,,6900,5106.02,,,5106.02,Other,150% of Medicare + 9.63% HCRA Surcharge,3105,45,,3105,percent of total billed charges,Critical Access Hospital RCC factor,2346,34,,2346,percent of total billed charges,Implant Device,2346,34,,2346,percent of total billed charges,Implant Device,2346,34,,2346,percent of total billed charges,Implant Device,2346,34,,2346,percent of total billed charges,Implant Device,2346,34,,2346,percent of total billed charges,Implant Device,3415.5,,,3415.5,Other,110% of Medicare,2415,35,,2415,percent of total billed charges,Implant Device,2346,34,"Charges > $500, x 34%",2346,percent of total billed charges,Implant Device,2415,35,,2415,percent of total billed charges,Implant Device,2415,35,,2415,percent of total billed charges,Implant Device,2415,35,,2415,percent of total billed charges,Implant Device,2415,35,,2415,percent of total billed charges,Implant Device,2415,35,,2415,percent of total billed charges,Implant Device,2760,40,,2760,percent of total billed charges,Implant Device,2415,70,,2415,percent of total billed charges,All Other,2346,34,,2346,percent of total billed charges,Implant Device,2346,34,,2346,percent of total billed charges,Implant Device,2415,35,,2415,percent of total billed charges,Implant Device,2415,35,,2415,percent of total billed charges,Implant Device,2415,35,,2415,percent of total billed charges,Implant Device,2415,35,,2415,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2346,34,"If Charge > 2,000, then 34 percent",2346,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5106.02,
STRYKER DCELL202 SOFT TISSUE 4X16CM,C1789,HCPCS,,79010694,CDM,278,RC,,,both,,,7799,5771.28,,,5771.28,Other,150% of Medicare + 9.63% HCRA Surcharge,3509.55,45,,3509.55,percent of total billed charges,Critical Access Hospital RCC factor,2651.66,34,,2651.66,percent of total billed charges,Implant Device,2651.66,34,,2651.66,percent of total billed charges,Implant Device,2651.66,34,,2651.66,percent of total billed charges,Implant Device,2651.66,34,,2651.66,percent of total billed charges,Implant Device,2651.66,34,,2651.66,percent of total billed charges,Implant Device,3860.51,,,3860.51,Other,110% of Medicare,2729.65,35,,2729.65,percent of total billed charges,Implant Device,2651.66,34,"Charges > $500, x 34%",2651.66,percent of total billed charges,Implant Device,2729.65,35,,2729.65,percent of total billed charges,Implant Device,2729.65,35,,2729.65,percent of total billed charges,Implant Device,2729.65,35,,2729.65,percent of total billed charges,Implant Device,2729.65,35,,2729.65,percent of total billed charges,Implant Device,2729.65,35,,2729.65,percent of total billed charges,Implant Device,3119.6,40,,3119.6,percent of total billed charges,Implant Device,2729.65,70,,2729.65,percent of total billed charges,All Other,2651.66,34,,2651.66,percent of total billed charges,Implant Device,2651.66,34,,2651.66,percent of total billed charges,Implant Device,2729.65,35,,2729.65,percent of total billed charges,Implant Device,2729.65,35,,2729.65,percent of total billed charges,Implant Device,2729.65,35,,2729.65,percent of total billed charges,Implant Device,2729.65,35,,2729.65,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2651.66,34,"If Charge > 2,000, then 34 percent",2651.66,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5771.28,
ZIMMER 00-5988-020-10 STEM EXT 16X145MM,C1776,HCPCS,,79010695,CDM,278,RC,,,both,,,4481,3315.95,,,3315.95,Other,150% of Medicare + 9.63% HCRA Surcharge,2016.45,45,,2016.45,percent of total billed charges,Critical Access Hospital RCC factor,1523.54,34,,1523.54,percent of total billed charges,Implant Device,1523.54,34,,1523.54,percent of total billed charges,Implant Device,1523.54,34,,1523.54,percent of total billed charges,Implant Device,1523.54,34,,1523.54,percent of total billed charges,Implant Device,1523.54,34,,1523.54,percent of total billed charges,Implant Device,2218.1,,,2218.1,Other,110% of Medicare,1568.35,35,,1568.35,percent of total billed charges,Implant Device,1523.54,34,"Charges > $500, x 34%",1523.54,percent of total billed charges,Implant Device,1568.35,35,,1568.35,percent of total billed charges,Implant Device,1568.35,35,,1568.35,percent of total billed charges,Implant Device,1568.35,35,,1568.35,percent of total billed charges,Implant Device,1568.35,35,,1568.35,percent of total billed charges,Implant Device,1568.35,35,,1568.35,percent of total billed charges,Implant Device,1792.4,40,,1792.4,percent of total billed charges,Implant Device,1568.35,70,,1568.35,percent of total billed charges,All Other,1523.54,34,,1523.54,percent of total billed charges,Implant Device,1523.54,34,,1523.54,percent of total billed charges,Implant Device,1568.35,35,,1568.35,percent of total billed charges,Implant Device,1568.35,35,,1568.35,percent of total billed charges,Implant Device,1568.35,35,,1568.35,percent of total billed charges,Implant Device,1568.35,35,,1568.35,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1523.54,34,"If Charge > 2,000, then 34 percent",1523.54,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3315.95,
STRYKER 627344 LATERAL TIBIA PLATE HOLE,C1713,HCPCS,,79010696,CDM,278,RC,,,both,,,6669,4935.08,,,4935.08,Other,150% of Medicare + 9.63% HCRA Surcharge,3001.05,45,,3001.05,percent of total billed charges,Critical Access Hospital RCC factor,2267.46,34,,2267.46,percent of total billed charges,Implant Device,2267.46,34,,2267.46,percent of total billed charges,Implant Device,2267.46,34,,2267.46,percent of total billed charges,Implant Device,2267.46,34,,2267.46,percent of total billed charges,Implant Device,2267.46,34,,2267.46,percent of total billed charges,Implant Device,3301.16,,,3301.16,Other,110% of Medicare,2334.15,35,,2334.15,percent of total billed charges,Implant Device,2267.46,34,"Charges > $500, x 34%",2267.46,percent of total billed charges,Implant Device,2334.15,35,,2334.15,percent of total billed charges,Implant Device,2334.15,35,,2334.15,percent of total billed charges,Implant Device,2334.15,35,,2334.15,percent of total billed charges,Implant Device,2334.15,35,,2334.15,percent of total billed charges,Implant Device,2334.15,35,,2334.15,percent of total billed charges,Implant Device,2667.6,40,,2667.6,percent of total billed charges,Implant Device,2334.15,70,,2334.15,percent of total billed charges,All Other,2267.46,34,,2267.46,percent of total billed charges,Implant Device,2267.46,34,,2267.46,percent of total billed charges,Implant Device,2334.15,35,,2334.15,percent of total billed charges,Implant Device,2334.15,35,,2334.15,percent of total billed charges,Implant Device,2334.15,35,,2334.15,percent of total billed charges,Implant Device,2334.15,35,,2334.15,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2267.46,34,"If Charge > 2,000, then 34 percent",2267.46,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4935.08,
JOINT RESTOR FOUND SPD-001 PRESUT TENDON,C1762,HCPCS,,79010701,CDM,278,RC,,,both,,,6975,5161.52,,,5161.52,Other,150% of Medicare + 9.63% HCRA Surcharge,3138.75,45,,3138.75,percent of total billed charges,Critical Access Hospital RCC factor,2371.5,34,,2371.5,percent of total billed charges,Implant Device,2371.5,34,,2371.5,percent of total billed charges,Implant Device,2371.5,34,,2371.5,percent of total billed charges,Implant Device,2371.5,34,,2371.5,percent of total billed charges,Implant Device,2371.5,34,,2371.5,percent of total billed charges,Implant Device,3452.63,,,3452.63,Other,110% of Medicare,2441.25,35,,2441.25,percent of total billed charges,Implant Device,2371.5,34,"Charges > $500, x 34%",2371.5,percent of total billed charges,Implant Device,2441.25,35,,2441.25,percent of total billed charges,Implant Device,2441.25,35,,2441.25,percent of total billed charges,Implant Device,2441.25,35,,2441.25,percent of total billed charges,Implant Device,2441.25,35,,2441.25,percent of total billed charges,Implant Device,2441.25,35,,2441.25,percent of total billed charges,Implant Device,2790,40,,2790,percent of total billed charges,Implant Device,2441.25,70,,2441.25,percent of total billed charges,All Other,2371.5,34,,2371.5,percent of total billed charges,Implant Device,2371.5,34,,2371.5,percent of total billed charges,Implant Device,2441.25,35,,2441.25,percent of total billed charges,Implant Device,2441.25,35,,2441.25,percent of total billed charges,Implant Device,2441.25,35,,2441.25,percent of total billed charges,Implant Device,2441.25,35,,2441.25,percent of total billed charges,Implant Device,976.07,,,976.07,Other,100% of Medicaid,976.07,,,976.07,Other,100% of Medicaid,976.07,,,976.07,Other,100% of Medicaid,976.07,,,976.07,Other,100% of Medicaid,2196.16,,,2196.16,Other,225% of Medicaid,1493.39,,,1493.39,Other,153% of Medicaid,2196.16,,,2196.16,Other,225% of Medicaid,1366.5,,,1366.5,Other,140% of Medicaid,2371.5,34,"If Charge > 2,000, then 34 percent",2371.5,percent of total billed charges,Implants,2537.78,,,2537.78,Other,260% of Medicaid,3162.47,,,3162.47,Other,324% of Medicaid,2098.55,,,2098.55,Other,215% of Medicaid,2098.55,,,2098.55,Other,215% of Medicaid,1220.09,,,1220.09,Other,125% of Medicaid,976.07,5161.52,
EXACTECH 320-35-04 GLENOID PLATE SMALL,C1776,HCPCS,,79010702,CDM,278,RC,,,both,,,5925,4384.51,,,4384.51,Other,150% of Medicare + 9.63% HCRA Surcharge,2666.25,45,,2666.25,percent of total billed charges,Critical Access Hospital RCC factor,2014.5,34,,2014.5,percent of total billed charges,Implant Device,2014.5,34,,2014.5,percent of total billed charges,Implant Device,2014.5,34,,2014.5,percent of total billed charges,Implant Device,2014.5,34,,2014.5,percent of total billed charges,Implant Device,2014.5,34,,2014.5,percent of total billed charges,Implant Device,2932.88,,,2932.88,Other,110% of Medicare,2073.75,35,,2073.75,percent of total billed charges,Implant Device,2014.5,34,"Charges > $500, x 34%",2014.5,percent of total billed charges,Implant Device,2073.75,35,,2073.75,percent of total billed charges,Implant Device,2073.75,35,,2073.75,percent of total billed charges,Implant Device,2073.75,35,,2073.75,percent of total billed charges,Implant Device,2073.75,35,,2073.75,percent of total billed charges,Implant Device,2073.75,35,,2073.75,percent of total billed charges,Implant Device,2370,40,,2370,percent of total billed charges,Implant Device,2073.75,70,,2073.75,percent of total billed charges,All Other,2014.5,34,,2014.5,percent of total billed charges,Implant Device,2014.5,34,,2014.5,percent of total billed charges,Implant Device,2073.75,35,,2073.75,percent of total billed charges,Implant Device,2073.75,35,,2073.75,percent of total billed charges,Implant Device,2073.75,35,,2073.75,percent of total billed charges,Implant Device,2073.75,35,,2073.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2014.5,34,"If Charge > 2,000, then 34 percent",2014.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4384.51,
STRYKER 6280-0-336 FEMORAL HEAD 36X10MM,C1776,HCPCS,,79010703,CDM,278,RC,,,both,,,7362,5447.9,,,5447.9,Other,150% of Medicare + 9.63% HCRA Surcharge,3312.9,45,,3312.9,percent of total billed charges,Critical Access Hospital RCC factor,2503.08,34,,2503.08,percent of total billed charges,Implant Device,2503.08,34,,2503.08,percent of total billed charges,Implant Device,2503.08,34,,2503.08,percent of total billed charges,Implant Device,2503.08,34,,2503.08,percent of total billed charges,Implant Device,2503.08,34,,2503.08,percent of total billed charges,Implant Device,3644.19,,,3644.19,Other,110% of Medicare,2576.7,35,,2576.7,percent of total billed charges,Implant Device,2503.08,34,"Charges > $500, x 34%",2503.08,percent of total billed charges,Implant Device,2576.7,35,,2576.7,percent of total billed charges,Implant Device,2576.7,35,,2576.7,percent of total billed charges,Implant Device,2576.7,35,,2576.7,percent of total billed charges,Implant Device,2576.7,35,,2576.7,percent of total billed charges,Implant Device,2576.7,35,,2576.7,percent of total billed charges,Implant Device,2944.8,40,,2944.8,percent of total billed charges,Implant Device,2576.7,70,,2576.7,percent of total billed charges,All Other,2503.08,34,,2503.08,percent of total billed charges,Implant Device,2503.08,34,,2503.08,percent of total billed charges,Implant Device,2576.7,35,,2576.7,percent of total billed charges,Implant Device,2576.7,35,,2576.7,percent of total billed charges,Implant Device,2576.7,35,,2576.7,percent of total billed charges,Implant Device,2576.7,35,,2576.7,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2503.08,34,"If Charge > 2,000, then 34 percent",2503.08,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5447.9,
STRYKER 663-10-36H INSERT TRIDENT 36MM,C1776,HCPCS,,79010704,CDM,278,RC,,,both,,,5222,3864.29,,,3864.29,Other,150% of Medicare + 9.63% HCRA Surcharge,2349.9,45,,2349.9,percent of total billed charges,Critical Access Hospital RCC factor,1775.48,34,,1775.48,percent of total billed charges,Implant Device,1775.48,34,,1775.48,percent of total billed charges,Implant Device,1775.48,34,,1775.48,percent of total billed charges,Implant Device,1775.48,34,,1775.48,percent of total billed charges,Implant Device,1775.48,34,,1775.48,percent of total billed charges,Implant Device,2584.89,,,2584.89,Other,110% of Medicare,1827.7,35,,1827.7,percent of total billed charges,Implant Device,1775.48,34,"Charges > $500, x 34%",1775.48,percent of total billed charges,Implant Device,1827.7,35,,1827.7,percent of total billed charges,Implant Device,1827.7,35,,1827.7,percent of total billed charges,Implant Device,1827.7,35,,1827.7,percent of total billed charges,Implant Device,1827.7,35,,1827.7,percent of total billed charges,Implant Device,1827.7,35,,1827.7,percent of total billed charges,Implant Device,2088.8,40,,2088.8,percent of total billed charges,Implant Device,1827.7,70,,1827.7,percent of total billed charges,All Other,1775.48,34,,1775.48,percent of total billed charges,Implant Device,1775.48,34,,1775.48,percent of total billed charges,Implant Device,1827.7,35,,1827.7,percent of total billed charges,Implant Device,1827.7,35,,1827.7,percent of total billed charges,Implant Device,1827.7,35,,1827.7,percent of total billed charges,Implant Device,1827.7,35,,1827.7,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1775.48,34,"If Charge > 2,000, then 34 percent",1775.48,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3864.29,
STRYKER 7030-6515 SCREW 6.5X15MM,C1713,HCPCS,,79010705,CDM,278,RC,,,both,,,159,117.66,,,117.66,Other,150% of Medicare + 9.63% HCRA Surcharge,71.55,45,,71.55,percent of total billed charges,Critical Access Hospital RCC factor,54.06,34,,54.06,percent of total billed charges,Implant Device,54.06,34,,54.06,percent of total billed charges,Implant Device,54.06,34,,54.06,percent of total billed charges,Implant Device,54.06,34,,54.06,percent of total billed charges,Implant Device,54.06,34,,54.06,percent of total billed charges,Implant Device,78.71,,,78.71,Other,110% of Medicare,55.65,35,,55.65,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,55.65,35,,55.65,percent of total billed charges,Implant Device,55.65,35,,55.65,percent of total billed charges,Implant Device,55.65,35,,55.65,percent of total billed charges,Implant Device,55.65,35,,55.65,percent of total billed charges,Implant Device,55.65,35,,55.65,percent of total billed charges,Implant Device,63.6,40,,63.6,percent of total billed charges,Implant Device,55.65,70,,55.65,percent of total billed charges,All Other,54.06,34,,54.06,percent of total billed charges,Implant Device,54.06,34,,54.06,percent of total billed charges,Implant Device,55.65,35,,55.65,percent of total billed charges,Implant Device,55.65,35,,55.65,percent of total billed charges,Implant Device,55.65,35,,55.65,percent of total billed charges,Implant Device,55.65,35,,55.65,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,117.66,
STRYKER 709-04-66H ACETABULAR SHELL 66MM,C1776,HCPCS,,79010706,CDM,278,RC,,,both,,,9155,6774.72,,,6774.72,Other,150% of Medicare + 9.63% HCRA Surcharge,4119.75,45,,4119.75,percent of total billed charges,Critical Access Hospital RCC factor,3112.7,34,,3112.7,percent of total billed charges,Implant Device,3112.7,34,,3112.7,percent of total billed charges,Implant Device,3112.7,34,,3112.7,percent of total billed charges,Implant Device,3112.7,34,,3112.7,percent of total billed charges,Implant Device,3112.7,34,,3112.7,percent of total billed charges,Implant Device,4531.73,,,4531.73,Other,110% of Medicare,3204.25,35,,3204.25,percent of total billed charges,Implant Device,3112.7,34,"Charges > $500, x 34%",3112.7,percent of total billed charges,Implant Device,3204.25,35,,3204.25,percent of total billed charges,Implant Device,3204.25,35,,3204.25,percent of total billed charges,Implant Device,3204.25,35,,3204.25,percent of total billed charges,Implant Device,3204.25,35,,3204.25,percent of total billed charges,Implant Device,3204.25,35,,3204.25,percent of total billed charges,Implant Device,3662,40,,3662,percent of total billed charges,Implant Device,3204.25,70,,3204.25,percent of total billed charges,All Other,3112.7,34,,3112.7,percent of total billed charges,Implant Device,3112.7,34,,3112.7,percent of total billed charges,Implant Device,3204.25,35,,3204.25,percent of total billed charges,Implant Device,3204.25,35,,3204.25,percent of total billed charges,Implant Device,3204.25,35,,3204.25,percent of total billed charges,Implant Device,3204.25,35,,3204.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3112.7,34,"If Charge > 2,000, then 34 percent",3112.7,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,6774.72,
STRYKER 6519-1-028 FEMORAL HEAD 28MM,C1776,HCPCS,,79010707,CDM,278,RC,,,both,,,2850,2109.01,,,2109.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1282.5,45,,1282.5,percent of total billed charges,Critical Access Hospital RCC factor,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,1410.75,,,1410.75,Other,110% of Medicare,997.5,35,,997.5,percent of total billed charges,Implant Device,969,34,"Charges > $500, x 34%",969,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,1140,40,,1140,percent of total billed charges,Implant Device,997.5,70,,997.5,percent of total billed charges,All Other,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,969,34,"If Charge > 2,000, then 34 percent",969,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2109.01,
STRYKER 702-04-54E ACETABULAR SHELL 54MM,C1776,HCPCS,,79010708,CDM,278,RC,,,both,,,3337,2469.39,,,2469.39,Other,150% of Medicare + 9.63% HCRA Surcharge,1501.65,45,,1501.65,percent of total billed charges,Critical Access Hospital RCC factor,1134.58,34,,1134.58,percent of total billed charges,Implant Device,1134.58,34,,1134.58,percent of total billed charges,Implant Device,1134.58,34,,1134.58,percent of total billed charges,Implant Device,1134.58,34,,1134.58,percent of total billed charges,Implant Device,1134.58,34,,1134.58,percent of total billed charges,Implant Device,1651.82,,,1651.82,Other,110% of Medicare,1167.95,35,,1167.95,percent of total billed charges,Implant Device,1134.58,34,"Charges > $500, x 34%",1134.58,percent of total billed charges,Implant Device,1167.95,35,,1167.95,percent of total billed charges,Implant Device,1167.95,35,,1167.95,percent of total billed charges,Implant Device,1167.95,35,,1167.95,percent of total billed charges,Implant Device,1167.95,35,,1167.95,percent of total billed charges,Implant Device,1167.95,35,,1167.95,percent of total billed charges,Implant Device,1334.8,40,,1334.8,percent of total billed charges,Implant Device,1167.95,70,,1167.95,percent of total billed charges,All Other,1134.58,34,,1134.58,percent of total billed charges,Implant Device,1134.58,34,,1134.58,percent of total billed charges,Implant Device,1167.95,35,,1167.95,percent of total billed charges,Implant Device,1167.95,35,,1167.95,percent of total billed charges,Implant Device,1167.95,35,,1167.95,percent of total billed charges,Implant Device,1167.95,35,,1167.95,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1134.58,34,"If Charge > 2,000, then 34 percent",1134.58,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2469.39,
STRYKER 7030-6525 HEX SCREW 6.5X25MM,C1713,HCPCS,,79010709,CDM,278,RC,,,both,,,159,117.66,,,117.66,Other,150% of Medicare + 9.63% HCRA Surcharge,71.55,45,,71.55,percent of total billed charges,Critical Access Hospital RCC factor,54.06,34,,54.06,percent of total billed charges,Implant Device,54.06,34,,54.06,percent of total billed charges,Implant Device,54.06,34,,54.06,percent of total billed charges,Implant Device,54.06,34,,54.06,percent of total billed charges,Implant Device,54.06,34,,54.06,percent of total billed charges,Implant Device,78.71,,,78.71,Other,110% of Medicare,55.65,35,,55.65,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,55.65,35,,55.65,percent of total billed charges,Implant Device,55.65,35,,55.65,percent of total billed charges,Implant Device,55.65,35,,55.65,percent of total billed charges,Implant Device,55.65,35,,55.65,percent of total billed charges,Implant Device,55.65,35,,55.65,percent of total billed charges,Implant Device,63.6,40,,63.6,percent of total billed charges,Implant Device,55.65,70,,55.65,percent of total billed charges,All Other,54.06,34,,54.06,percent of total billed charges,Implant Device,54.06,34,,54.06,percent of total billed charges,Implant Device,55.65,35,,55.65,percent of total billed charges,Implant Device,55.65,35,,55.65,percent of total billed charges,Implant Device,55.65,35,,55.65,percent of total billed charges,Implant Device,55.65,35,,55.65,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,117.66,
STRYKER 7030-6525 HEX SCREW 6.5X25MM,C1776,HCPCS,,79010710,CDM,278,RC,,,both,,,8474,6270.78,,,6270.78,Other,150% of Medicare + 9.63% HCRA Surcharge,3813.3,45,,3813.3,percent of total billed charges,Critical Access Hospital RCC factor,2881.16,34,,2881.16,percent of total billed charges,Implant Device,2881.16,34,,2881.16,percent of total billed charges,Implant Device,2881.16,34,,2881.16,percent of total billed charges,Implant Device,2881.16,34,,2881.16,percent of total billed charges,Implant Device,2881.16,34,,2881.16,percent of total billed charges,Implant Device,4194.63,,,4194.63,Other,110% of Medicare,2965.9,35,,2965.9,percent of total billed charges,Implant Device,2881.16,34,"Charges > $500, x 34%",2881.16,percent of total billed charges,Implant Device,2965.9,35,,2965.9,percent of total billed charges,Implant Device,2965.9,35,,2965.9,percent of total billed charges,Implant Device,2965.9,35,,2965.9,percent of total billed charges,Implant Device,2965.9,35,,2965.9,percent of total billed charges,Implant Device,2965.9,35,,2965.9,percent of total billed charges,Implant Device,3389.6,40,,3389.6,percent of total billed charges,Implant Device,2965.9,70,,2965.9,percent of total billed charges,All Other,2881.16,34,,2881.16,percent of total billed charges,Implant Device,2881.16,34,,2881.16,percent of total billed charges,Implant Device,2965.9,35,,2965.9,percent of total billed charges,Implant Device,2965.9,35,,2965.9,percent of total billed charges,Implant Device,2965.9,35,,2965.9,percent of total billed charges,Implant Device,2965.9,35,,2965.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2881.16,34,"If Charge > 2,000, then 34 percent",2881.16,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,6270.78,
EXACTECH 300-30-10 PRESERVE STEM 10MM,C1776,HCPCS,,79010711,CDM,278,RC,,,both,,,6000,4440.02,,,4440.02,Other,150% of Medicare + 9.63% HCRA Surcharge,2700,45,,2700,percent of total billed charges,Critical Access Hospital RCC factor,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2970,,,2970,Other,110% of Medicare,2100,35,,2100,percent of total billed charges,Implant Device,2040,34,"Charges > $500, x 34%",2040,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2400,40,,2400,percent of total billed charges,Implant Device,2100,70,,2100,percent of total billed charges,All Other,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2040,34,"If Charge > 2,000, then 34 percent",2040,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4440.02,
DEPUY SYNTHES 02.112.006 CLAVICLE PLATE,C1776,HCPCS,,79010712,CDM,278,RC,,,both,,,2292,1696.09,,,1696.09,Other,150% of Medicare + 9.63% HCRA Surcharge,1031.4,45,,1031.4,percent of total billed charges,Critical Access Hospital RCC factor,779.28,34,,779.28,percent of total billed charges,Implant Device,779.28,34,,779.28,percent of total billed charges,Implant Device,779.28,34,,779.28,percent of total billed charges,Implant Device,779.28,34,,779.28,percent of total billed charges,Implant Device,779.28,34,,779.28,percent of total billed charges,Implant Device,1134.54,,,1134.54,Other,110% of Medicare,802.2,35,,802.2,percent of total billed charges,Implant Device,779.28,34,"Charges > $500, x 34%",779.28,percent of total billed charges,Implant Device,802.2,35,,802.2,percent of total billed charges,Implant Device,802.2,35,,802.2,percent of total billed charges,Implant Device,802.2,35,,802.2,percent of total billed charges,Implant Device,802.2,35,,802.2,percent of total billed charges,Implant Device,802.2,35,,802.2,percent of total billed charges,Implant Device,916.8,40,,916.8,percent of total billed charges,Implant Device,802.2,70,,802.2,percent of total billed charges,All Other,779.28,34,,779.28,percent of total billed charges,Implant Device,779.28,34,,779.28,percent of total billed charges,Implant Device,802.2,35,,802.2,percent of total billed charges,Implant Device,802.2,35,,802.2,percent of total billed charges,Implant Device,802.2,35,,802.2,percent of total billed charges,Implant Device,802.2,35,,802.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,779.28,34,"If Charge > 2,000, then 34 percent",779.28,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1696.09,
MEDTRONIC NEURO TH90G01 PROGRAMMER,C1787,HCPCS,,79010715,CDM,278,RC,,,both,,,5850,4329.01,,,4329.01,Other,150% of Medicare + 9.63% HCRA Surcharge,2632.5,45,,2632.5,percent of total billed charges,Critical Access Hospital RCC factor,1989,34,,1989,percent of total billed charges,Implant Device,1989,34,,1989,percent of total billed charges,Implant Device,1989,34,,1989,percent of total billed charges,Implant Device,1989,34,,1989,percent of total billed charges,Implant Device,1989,34,,1989,percent of total billed charges,Implant Device,2895.75,,,2895.75,Other,110% of Medicare,2047.5,35,,2047.5,percent of total billed charges,Implant Device,1989,34,"Charges > $500, x 34%",1989,percent of total billed charges,Implant Device,2047.5,35,,2047.5,percent of total billed charges,Implant Device,2047.5,35,,2047.5,percent of total billed charges,Implant Device,2047.5,35,,2047.5,percent of total billed charges,Implant Device,2047.5,35,,2047.5,percent of total billed charges,Implant Device,2047.5,35,,2047.5,percent of total billed charges,Implant Device,2340,40,,2340,percent of total billed charges,Implant Device,2047.5,70,,2047.5,percent of total billed charges,All Other,1989,34,,1989,percent of total billed charges,Implant Device,1989,34,,1989,percent of total billed charges,Implant Device,2047.5,35,,2047.5,percent of total billed charges,Implant Device,2047.5,35,,2047.5,percent of total billed charges,Implant Device,2047.5,35,,2047.5,percent of total billed charges,Implant Device,2047.5,35,,2047.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1989,34,"If Charge > 2,000, then 34 percent",1989,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4329.01,
STRYKER 5567-P-3011 PRESS-FIT HUMRL STEM,C1776,HCPCS,,79010718,CDM,278,RC,,,both,,,8925,6604.52,,,6604.52,Other,150% of Medicare + 9.63% HCRA Surcharge,4016.25,45,,4016.25,percent of total billed charges,Critical Access Hospital RCC factor,3034.5,34,,3034.5,percent of total billed charges,Implant Device,3034.5,34,,3034.5,percent of total billed charges,Implant Device,3034.5,34,,3034.5,percent of total billed charges,Implant Device,3034.5,34,,3034.5,percent of total billed charges,Implant Device,3034.5,34,,3034.5,percent of total billed charges,Implant Device,4417.88,,,4417.88,Other,110% of Medicare,3123.75,35,,3123.75,percent of total billed charges,Implant Device,3034.5,34,"Charges > $500, x 34%",3034.5,percent of total billed charges,Implant Device,3123.75,35,,3123.75,percent of total billed charges,Implant Device,3123.75,35,,3123.75,percent of total billed charges,Implant Device,3123.75,35,,3123.75,percent of total billed charges,Implant Device,3123.75,35,,3123.75,percent of total billed charges,Implant Device,3123.75,35,,3123.75,percent of total billed charges,Implant Device,3570,40,,3570,percent of total billed charges,Implant Device,3123.75,70,,3123.75,percent of total billed charges,All Other,3034.5,34,,3034.5,percent of total billed charges,Implant Device,3034.5,34,,3034.5,percent of total billed charges,Implant Device,3123.75,35,,3123.75,percent of total billed charges,Implant Device,3123.75,35,,3123.75,percent of total billed charges,Implant Device,3123.75,35,,3123.75,percent of total billed charges,Implant Device,3123.75,35,,3123.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3034.5,34,"If Charge > 2,000, then 34 percent",3034.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,6604.52,
ALLERGAN SCLP-440 GEL BREAST IMPLANT 440,C1789,HCPCS,,79010719,CDM,278,RC,,,both,,,4005,2963.71,,,2963.71,Other,150% of Medicare + 9.63% HCRA Surcharge,1802.25,45,,1802.25,percent of total billed charges,Critical Access Hospital RCC factor,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1982.48,,,1982.48,Other,110% of Medicare,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1361.7,34,"Charges > $500, x 34%",1361.7,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1602,40,,1602,percent of total billed charges,Implant Device,1401.75,70,,1401.75,percent of total billed charges,All Other,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1361.7,34,"If Charge > 2,000, then 34 percent",1361.7,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2963.71,
ALLERGAN SCLP-490 GEL BREAST IMPLANT 490,C1789,HCPCS,,79010720,CDM,278,RC,,,both,,,4005,2963.71,,,2963.71,Other,150% of Medicare + 9.63% HCRA Surcharge,1802.25,45,,1802.25,percent of total billed charges,Critical Access Hospital RCC factor,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1982.48,,,1982.48,Other,110% of Medicare,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1361.7,34,"Charges > $500, x 34%",1361.7,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1602,40,,1602,percent of total billed charges,Implant Device,1401.75,70,,1401.75,percent of total billed charges,All Other,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1361.7,34,"If Charge > 2,000, then 34 percent",1361.7,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2963.71,
ALLERGAN SCLP-540 GEL BREAST IMPLANT,C1789,HCPCS,,79010721,CDM,278,RC,,,both,,,4005,2963.71,,,2963.71,Other,150% of Medicare + 9.63% HCRA Surcharge,1802.25,45,,1802.25,percent of total billed charges,Critical Access Hospital RCC factor,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1982.48,,,1982.48,Other,110% of Medicare,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1361.7,34,"Charges > $500, x 34%",1361.7,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1602,40,,1602,percent of total billed charges,Implant Device,1401.75,70,,1401.75,percent of total billed charges,All Other,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1361.7,34,"If Charge > 2,000, then 34 percent",1361.7,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2963.71,
ALLERGAN SCL-350 GEL BREAST IMPLANT,C1789,HCPCS,,79010722,CDM,278,RC,,,both,,,4005,2963.71,,,2963.71,Other,150% of Medicare + 9.63% HCRA Surcharge,1802.25,45,,1802.25,percent of total billed charges,Critical Access Hospital RCC factor,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1982.48,,,1982.48,Other,110% of Medicare,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1361.7,34,"Charges > $500, x 34%",1361.7,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1602,40,,1602,percent of total billed charges,Implant Device,1401.75,70,,1401.75,percent of total billed charges,All Other,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1361.7,34,"If Charge > 2,000, then 34 percent",1361.7,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2963.71,
ALLERGAN SCL-380 BREAST IMPLANT 380CC,C1789,HCPCS,,79010723,CDM,278,RC,,,both,,,4005,2963.71,,,2963.71,Other,150% of Medicare + 9.63% HCRA Surcharge,1802.25,45,,1802.25,percent of total billed charges,Critical Access Hospital RCC factor,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1982.48,,,1982.48,Other,110% of Medicare,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1361.7,34,"Charges > $500, x 34%",1361.7,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1602,40,,1602,percent of total billed charges,Implant Device,1401.75,70,,1401.75,percent of total billed charges,All Other,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1361.7,34,"If Charge > 2,000, then 34 percent",1361.7,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2963.71,
ALLERGAN SCL-410 BREAST IMPLANT 410CC,C1789,HCPCS,,79010724,CDM,278,RC,,,both,,,4005,2963.71,,,2963.71,Other,150% of Medicare + 9.63% HCRA Surcharge,1802.25,45,,1802.25,percent of total billed charges,Critical Access Hospital RCC factor,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1982.48,,,1982.48,Other,110% of Medicare,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1361.7,34,"Charges > $500, x 34%",1361.7,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1602,40,,1602,percent of total billed charges,Implant Device,1401.75,70,,1401.75,percent of total billed charges,All Other,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1361.7,34,"If Charge > 2,000, then 34 percent",1361.7,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2963.71,
ALLERGAN SCL-460 BREAST IMPLANT 460CC,C1789,HCPCS,,79010725,CDM,278,RC,,,both,,,4005,2963.71,,,2963.71,Other,150% of Medicare + 9.63% HCRA Surcharge,1802.25,45,,1802.25,percent of total billed charges,Critical Access Hospital RCC factor,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1982.48,,,1982.48,Other,110% of Medicare,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1361.7,34,"Charges > $500, x 34%",1361.7,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1602,40,,1602,percent of total billed charges,Implant Device,1401.75,70,,1401.75,percent of total billed charges,All Other,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1361.7,34,"If Charge > 2,000, then 34 percent",1361.7,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2963.71,
ALLERGAN 151664 ALLODERM THIN 4 X 16CM,C1781,HCPCS,,79010733,CDM,278,RC,,,both,,,8451,6253.76,,,6253.76,Other,150% of Medicare + 9.63% HCRA Surcharge,3802.95,45,,3802.95,percent of total billed charges,Critical Access Hospital RCC factor,2873.34,34,,2873.34,percent of total billed charges,Implant Device,2873.34,34,,2873.34,percent of total billed charges,Implant Device,2873.34,34,,2873.34,percent of total billed charges,Implant Device,2873.34,34,,2873.34,percent of total billed charges,Implant Device,2873.34,34,,2873.34,percent of total billed charges,Implant Device,4183.25,,,4183.25,Other,110% of Medicare,2957.85,35,,2957.85,percent of total billed charges,Implant Device,2873.34,34,"Charges > $500, x 34%",2873.34,percent of total billed charges,Implant Device,2957.85,35,,2957.85,percent of total billed charges,Implant Device,2957.85,35,,2957.85,percent of total billed charges,Implant Device,2957.85,35,,2957.85,percent of total billed charges,Implant Device,2957.85,35,,2957.85,percent of total billed charges,Implant Device,2957.85,35,,2957.85,percent of total billed charges,Implant Device,3380.4,40,,3380.4,percent of total billed charges,Implant Device,2957.85,70,,2957.85,percent of total billed charges,All Other,2873.34,34,,2873.34,percent of total billed charges,Implant Device,2873.34,34,,2873.34,percent of total billed charges,Implant Device,2957.85,35,,2957.85,percent of total billed charges,Implant Device,2957.85,35,,2957.85,percent of total billed charges,Implant Device,2957.85,35,,2957.85,percent of total billed charges,Implant Device,2957.85,35,,2957.85,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2873.34,34,"If Charge > 2,000, then 34 percent",2873.34,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,6253.76,
STRYKER 6057-0435D CEMENTED HIP STEM,C1776,HCPCS,,79010734,CDM,278,RC,,,both,,,5006,3704.45,,,3704.45,Other,150% of Medicare + 9.63% HCRA Surcharge,2252.7,45,,2252.7,percent of total billed charges,Critical Access Hospital RCC factor,1702.04,34,,1702.04,percent of total billed charges,Implant Device,1702.04,34,,1702.04,percent of total billed charges,Implant Device,1702.04,34,,1702.04,percent of total billed charges,Implant Device,1702.04,34,,1702.04,percent of total billed charges,Implant Device,1702.04,34,,1702.04,percent of total billed charges,Implant Device,2477.97,,,2477.97,Other,110% of Medicare,1752.1,35,,1752.1,percent of total billed charges,Implant Device,1702.04,34,"Charges > $500, x 34%",1702.04,percent of total billed charges,Implant Device,1752.1,35,,1752.1,percent of total billed charges,Implant Device,1752.1,35,,1752.1,percent of total billed charges,Implant Device,1752.1,35,,1752.1,percent of total billed charges,Implant Device,1752.1,35,,1752.1,percent of total billed charges,Implant Device,1752.1,35,,1752.1,percent of total billed charges,Implant Device,2002.4,40,,2002.4,percent of total billed charges,Implant Device,1752.1,70,,1752.1,percent of total billed charges,All Other,1702.04,34,,1702.04,percent of total billed charges,Implant Device,1702.04,34,,1702.04,percent of total billed charges,Implant Device,1752.1,35,,1752.1,percent of total billed charges,Implant Device,1752.1,35,,1752.1,percent of total billed charges,Implant Device,1752.1,35,,1752.1,percent of total billed charges,Implant Device,1752.1,35,,1752.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1702.04,34,"If Charge > 2,000, then 34 percent",1702.04,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3704.45,
ALLERGAN 151648 ALLODERM THIN 4 X 12CM,C1781,HCPCS,,79010735,CDM,278,RC,,,both,,,6339,4690.88,,,4690.88,Other,150% of Medicare + 9.63% HCRA Surcharge,2852.55,45,,2852.55,percent of total billed charges,Critical Access Hospital RCC factor,2155.26,34,,2155.26,percent of total billed charges,Implant Device,2155.26,34,,2155.26,percent of total billed charges,Implant Device,2155.26,34,,2155.26,percent of total billed charges,Implant Device,2155.26,34,,2155.26,percent of total billed charges,Implant Device,2155.26,34,,2155.26,percent of total billed charges,Implant Device,3137.81,,,3137.81,Other,110% of Medicare,2218.65,35,,2218.65,percent of total billed charges,Implant Device,2155.26,34,"Charges > $500, x 34%",2155.26,percent of total billed charges,Implant Device,2218.65,35,,2218.65,percent of total billed charges,Implant Device,2218.65,35,,2218.65,percent of total billed charges,Implant Device,2218.65,35,,2218.65,percent of total billed charges,Implant Device,2218.65,35,,2218.65,percent of total billed charges,Implant Device,2218.65,35,,2218.65,percent of total billed charges,Implant Device,2535.6,40,,2535.6,percent of total billed charges,Implant Device,2218.65,70,,2218.65,percent of total billed charges,All Other,2155.26,34,,2155.26,percent of total billed charges,Implant Device,2155.26,34,,2155.26,percent of total billed charges,Implant Device,2218.65,35,,2218.65,percent of total billed charges,Implant Device,2218.65,35,,2218.65,percent of total billed charges,Implant Device,2218.65,35,,2218.65,percent of total billed charges,Implant Device,2218.65,35,,2218.65,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2155.26,34,"If Charge > 2,000, then 34 percent",2155.26,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4690.88,
ARTHREX AR-8933V-14 3X14MM VAL SCREW,C1713,HCPCS,,79010736,CDM,278,RC,,,both,,,569,421.06,,,421.06,Other,150% of Medicare + 9.63% HCRA Surcharge,256.05,45,,256.05,percent of total billed charges,Critical Access Hospital RCC factor,193.46,34,,193.46,percent of total billed charges,Implant Device,193.46,34,,193.46,percent of total billed charges,Implant Device,193.46,34,,193.46,percent of total billed charges,Implant Device,193.46,34,,193.46,percent of total billed charges,Implant Device,193.46,34,,193.46,percent of total billed charges,Implant Device,281.66,,,281.66,Other,110% of Medicare,199.15,35,,199.15,percent of total billed charges,Implant Device,193.46,34,"Charges > $500, x 34%",193.46,percent of total billed charges,Implant Device,199.15,35,,199.15,percent of total billed charges,Implant Device,199.15,35,,199.15,percent of total billed charges,Implant Device,199.15,35,,199.15,percent of total billed charges,Implant Device,199.15,35,,199.15,percent of total billed charges,Implant Device,199.15,35,,199.15,percent of total billed charges,Implant Device,227.6,40,,227.6,percent of total billed charges,Implant Device,199.15,70,,199.15,percent of total billed charges,All Other,193.46,34,,193.46,percent of total billed charges,Implant Device,193.46,34,,193.46,percent of total billed charges,Implant Device,199.15,35,,199.15,percent of total billed charges,Implant Device,199.15,35,,199.15,percent of total billed charges,Implant Device,199.15,35,,199.15,percent of total billed charges,Implant Device,199.15,35,,199.15,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,421.06,
ARTHREX AR-8935-10 3.5X10 LO PRO SCREW,C1713,HCPCS,,79010737,CDM,278,RC,,,both,,,258,190.92,,,190.92,Other,150% of Medicare + 9.63% HCRA Surcharge,116.1,45,,116.1,percent of total billed charges,Critical Access Hospital RCC factor,87.72,34,,87.72,percent of total billed charges,Implant Device,87.72,34,,87.72,percent of total billed charges,Implant Device,87.72,34,,87.72,percent of total billed charges,Implant Device,87.72,34,,87.72,percent of total billed charges,Implant Device,87.72,34,,87.72,percent of total billed charges,Implant Device,127.71,,,127.71,Other,110% of Medicare,90.3,35,,90.3,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,90.3,35,,90.3,percent of total billed charges,Implant Device,90.3,35,,90.3,percent of total billed charges,Implant Device,90.3,35,,90.3,percent of total billed charges,Implant Device,90.3,35,,90.3,percent of total billed charges,Implant Device,90.3,35,,90.3,percent of total billed charges,Implant Device,103.2,40,,103.2,percent of total billed charges,Implant Device,90.3,70,,90.3,percent of total billed charges,All Other,87.72,34,,87.72,percent of total billed charges,Implant Device,87.72,34,,87.72,percent of total billed charges,Implant Device,90.3,35,,90.3,percent of total billed charges,Implant Device,90.3,35,,90.3,percent of total billed charges,Implant Device,90.3,35,,90.3,percent of total billed charges,Implant Device,90.3,35,,90.3,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,190.92,
ARTHREX AR-9943BL-05 LOCK DIS PLT LT,C1713,HCPCS,,79010739,CDM,278,RC,,,both,,,3000,2220.01,,,2220.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1350,45,,1350,percent of total billed charges,Critical Access Hospital RCC factor,1020,34,,1020,percent of total billed charges,Implant Device,1020,34,,1020,percent of total billed charges,Implant Device,1020,34,,1020,percent of total billed charges,Implant Device,1020,34,,1020,percent of total billed charges,Implant Device,1020,34,,1020,percent of total billed charges,Implant Device,1485,,,1485,Other,110% of Medicare,1050,35,,1050,percent of total billed charges,Implant Device,1020,34,"Charges > $500, x 34%",1020,percent of total billed charges,Implant Device,1050,35,,1050,percent of total billed charges,Implant Device,1050,35,,1050,percent of total billed charges,Implant Device,1050,35,,1050,percent of total billed charges,Implant Device,1050,35,,1050,percent of total billed charges,Implant Device,1050,35,,1050,percent of total billed charges,Implant Device,1200,40,,1200,percent of total billed charges,Implant Device,1050,70,,1050,percent of total billed charges,All Other,1020,34,,1020,percent of total billed charges,Implant Device,1020,34,,1020,percent of total billed charges,Implant Device,1050,35,,1050,percent of total billed charges,Implant Device,1050,35,,1050,percent of total billed charges,Implant Device,1050,35,,1050,percent of total billed charges,Implant Device,1050,35,,1050,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1020,34,"If Charge > 2,000, then 34 percent",1020,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2220.01,
STRYKER 709-04-60G TRITANIUM MULTIHOLE,C1776,HCPCS,,79010740,CDM,278,RC,,,both,,,9155,6774.72,,,6774.72,Other,150% of Medicare + 9.63% HCRA Surcharge,4119.75,45,,4119.75,percent of total billed charges,Critical Access Hospital RCC factor,3112.7,34,,3112.7,percent of total billed charges,Implant Device,3112.7,34,,3112.7,percent of total billed charges,Implant Device,3112.7,34,,3112.7,percent of total billed charges,Implant Device,3112.7,34,,3112.7,percent of total billed charges,Implant Device,3112.7,34,,3112.7,percent of total billed charges,Implant Device,4531.73,,,4531.73,Other,110% of Medicare,3204.25,35,,3204.25,percent of total billed charges,Implant Device,3112.7,34,"Charges > $500, x 34%",3112.7,percent of total billed charges,Implant Device,3204.25,35,,3204.25,percent of total billed charges,Implant Device,3204.25,35,,3204.25,percent of total billed charges,Implant Device,3204.25,35,,3204.25,percent of total billed charges,Implant Device,3204.25,35,,3204.25,percent of total billed charges,Implant Device,3204.25,35,,3204.25,percent of total billed charges,Implant Device,3662,40,,3662,percent of total billed charges,Implant Device,3204.25,70,,3204.25,percent of total billed charges,All Other,3112.7,34,,3112.7,percent of total billed charges,Implant Device,3112.7,34,,3112.7,percent of total billed charges,Implant Device,3204.25,35,,3204.25,percent of total billed charges,Implant Device,3204.25,35,,3204.25,percent of total billed charges,Implant Device,3204.25,35,,3204.25,percent of total billed charges,Implant Device,3204.25,35,,3204.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3112.7,34,"If Charge > 2,000, then 34 percent",3112.7,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,6774.72,
STRYKER 626-00-48G MDM COCR LINER 48MM G,C1776,HCPCS,,79010741,CDM,278,RC,,,both,,,3893,2880.83,,,2880.83,Other,150% of Medicare + 9.63% HCRA Surcharge,1751.85,45,,1751.85,percent of total billed charges,Critical Access Hospital RCC factor,1323.62,34,,1323.62,percent of total billed charges,Implant Device,1323.62,34,,1323.62,percent of total billed charges,Implant Device,1323.62,34,,1323.62,percent of total billed charges,Implant Device,1323.62,34,,1323.62,percent of total billed charges,Implant Device,1323.62,34,,1323.62,percent of total billed charges,Implant Device,1927.04,,,1927.04,Other,110% of Medicare,1362.55,35,,1362.55,percent of total billed charges,Implant Device,1323.62,34,"Charges > $500, x 34%",1323.62,percent of total billed charges,Implant Device,1362.55,35,,1362.55,percent of total billed charges,Implant Device,1362.55,35,,1362.55,percent of total billed charges,Implant Device,1362.55,35,,1362.55,percent of total billed charges,Implant Device,1362.55,35,,1362.55,percent of total billed charges,Implant Device,1362.55,35,,1362.55,percent of total billed charges,Implant Device,1557.2,40,,1557.2,percent of total billed charges,Implant Device,1362.55,70,,1362.55,percent of total billed charges,All Other,1323.62,34,,1323.62,percent of total billed charges,Implant Device,1323.62,34,,1323.62,percent of total billed charges,Implant Device,1362.55,35,,1362.55,percent of total billed charges,Implant Device,1362.55,35,,1362.55,percent of total billed charges,Implant Device,1362.55,35,,1362.55,percent of total billed charges,Implant Device,1362.55,35,,1362.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1323.62,34,"If Charge > 2,000, then 34 percent",1323.62,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2880.83,
STRYKER 6276-7-019 DISTAL STEM 19X155MM,C1776,HCPCS,,79010742,CDM,278,RC,,,both,,,9112,6742.9,,,6742.9,Other,150% of Medicare + 9.63% HCRA Surcharge,4100.4,45,,4100.4,percent of total billed charges,Critical Access Hospital RCC factor,3098.08,34,,3098.08,percent of total billed charges,Implant Device,3098.08,34,,3098.08,percent of total billed charges,Implant Device,3098.08,34,,3098.08,percent of total billed charges,Implant Device,3098.08,34,,3098.08,percent of total billed charges,Implant Device,3098.08,34,,3098.08,percent of total billed charges,Implant Device,4510.44,,,4510.44,Other,110% of Medicare,3189.2,35,,3189.2,percent of total billed charges,Implant Device,3098.08,34,"Charges > $500, x 34%",3098.08,percent of total billed charges,Implant Device,3189.2,35,,3189.2,percent of total billed charges,Implant Device,3189.2,35,,3189.2,percent of total billed charges,Implant Device,3189.2,35,,3189.2,percent of total billed charges,Implant Device,3189.2,35,,3189.2,percent of total billed charges,Implant Device,3189.2,35,,3189.2,percent of total billed charges,Implant Device,3644.8,40,,3644.8,percent of total billed charges,Implant Device,3189.2,70,,3189.2,percent of total billed charges,All Other,3098.08,34,,3098.08,percent of total billed charges,Implant Device,3098.08,34,,3098.08,percent of total billed charges,Implant Device,3189.2,35,,3189.2,percent of total billed charges,Implant Device,3189.2,35,,3189.2,percent of total billed charges,Implant Device,3189.2,35,,3189.2,percent of total billed charges,Implant Device,3189.2,35,,3189.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3098.08,34,"If Charge > 2,000, then 34 percent",3098.08,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,6742.9,
STRYKER 6570-0-028 CERAMIC HEAD 28/-4,C1776,HCPCS,,79010743,CDM,278,RC,,,both,,,2503,1852.23,,,1852.23,Other,150% of Medicare + 9.63% HCRA Surcharge,1126.35,45,,1126.35,percent of total billed charges,Critical Access Hospital RCC factor,851.02,34,,851.02,percent of total billed charges,Implant Device,851.02,34,,851.02,percent of total billed charges,Implant Device,851.02,34,,851.02,percent of total billed charges,Implant Device,851.02,34,,851.02,percent of total billed charges,Implant Device,851.02,34,,851.02,percent of total billed charges,Implant Device,1238.99,,,1238.99,Other,110% of Medicare,876.05,35,,876.05,percent of total billed charges,Implant Device,851.02,34,"Charges > $500, x 34%",851.02,percent of total billed charges,Implant Device,876.05,35,,876.05,percent of total billed charges,Implant Device,876.05,35,,876.05,percent of total billed charges,Implant Device,876.05,35,,876.05,percent of total billed charges,Implant Device,876.05,35,,876.05,percent of total billed charges,Implant Device,876.05,35,,876.05,percent of total billed charges,Implant Device,1001.2,40,,1001.2,percent of total billed charges,Implant Device,876.05,70,,876.05,percent of total billed charges,All Other,851.02,34,,851.02,percent of total billed charges,Implant Device,851.02,34,,851.02,percent of total billed charges,Implant Device,876.05,35,,876.05,percent of total billed charges,Implant Device,876.05,35,,876.05,percent of total billed charges,Implant Device,876.05,35,,876.05,percent of total billed charges,Implant Device,876.05,35,,876.05,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,851.02,34,"If Charge > 2,000, then 34 percent",851.02,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1852.23,
STRYKER 1059-6715 ACCOLADE DISTAL SPACER,C1776,HCPCS,,79010744,CDM,278,RC,,,both,,,150,111,,,111,Other,150% of Medicare + 9.63% HCRA Surcharge,67.5,45,,67.5,percent of total billed charges,Critical Access Hospital RCC factor,51,34,,51,percent of total billed charges,Implant Device,51,34,,51,percent of total billed charges,Implant Device,51,34,,51,percent of total billed charges,Implant Device,51,34,,51,percent of total billed charges,Implant Device,51,34,,51,percent of total billed charges,Implant Device,74.25,,,74.25,Other,110% of Medicare,52.5,35,,52.5,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,52.5,35,,52.5,percent of total billed charges,Implant Device,52.5,35,,52.5,percent of total billed charges,Implant Device,52.5,35,,52.5,percent of total billed charges,Implant Device,52.5,35,,52.5,percent of total billed charges,Implant Device,52.5,35,,52.5,percent of total billed charges,Implant Device,60,40,,60,percent of total billed charges,Implant Device,52.5,70,,52.5,percent of total billed charges,All Other,51,34,,51,percent of total billed charges,Implant Device,51,34,,51,percent of total billed charges,Implant Device,52.5,35,,52.5,percent of total billed charges,Implant Device,52.5,35,,52.5,percent of total billed charges,Implant Device,52.5,35,,52.5,percent of total billed charges,Implant Device,52.5,35,,52.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,111,
STRYKER 6057-0637D FEMORAL STEM SZ 6,C1776,HCPCS,,79010745,CDM,278,RC,,,both,,,3750,2775.01,,,2775.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1687.5,45,,1687.5,percent of total billed charges,Critical Access Hospital RCC factor,1275,34,,1275,percent of total billed charges,Implant Device,1275,34,,1275,percent of total billed charges,Implant Device,1275,34,,1275,percent of total billed charges,Implant Device,1275,34,,1275,percent of total billed charges,Implant Device,1275,34,,1275,percent of total billed charges,Implant Device,1856.25,,,1856.25,Other,110% of Medicare,1312.5,35,,1312.5,percent of total billed charges,Implant Device,1275,34,"Charges > $500, x 34%",1275,percent of total billed charges,Implant Device,1312.5,35,,1312.5,percent of total billed charges,Implant Device,1312.5,35,,1312.5,percent of total billed charges,Implant Device,1312.5,35,,1312.5,percent of total billed charges,Implant Device,1312.5,35,,1312.5,percent of total billed charges,Implant Device,1312.5,35,,1312.5,percent of total billed charges,Implant Device,1500,40,,1500,percent of total billed charges,Implant Device,1312.5,70,,1312.5,percent of total billed charges,All Other,1275,34,,1275,percent of total billed charges,Implant Device,1275,34,,1275,percent of total billed charges,Implant Device,1312.5,35,,1312.5,percent of total billed charges,Implant Device,1312.5,35,,1312.5,percent of total billed charges,Implant Device,1312.5,35,,1312.5,percent of total billed charges,Implant Device,1312.5,35,,1312.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1275,34,"If Charge > 2,000, then 34 percent",1275,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2775.01,
BOS SCI M0061801560 CONTOUR 6FRX22-30,C1874,HCPCS,,79010750,CDM,278,RC,,,both,,,428,316.72,,,316.72,Other,150% of Medicare + 9.63% HCRA Surcharge,192.6,45,,192.6,percent of total billed charges,Critical Access Hospital RCC factor,145.52,34,,145.52,percent of total billed charges,Implant Device,145.52,34,,145.52,percent of total billed charges,Implant Device,145.52,34,,145.52,percent of total billed charges,Implant Device,145.52,34,,145.52,percent of total billed charges,Implant Device,145.52,34,,145.52,percent of total billed charges,Implant Device,211.86,,,211.86,Other,110% of Medicare,149.8,35,,149.8,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,149.8,35,,149.8,percent of total billed charges,Implant Device,149.8,35,,149.8,percent of total billed charges,Implant Device,149.8,35,,149.8,percent of total billed charges,Implant Device,149.8,35,,149.8,percent of total billed charges,Implant Device,149.8,35,,149.8,percent of total billed charges,Implant Device,171.2,40,,171.2,percent of total billed charges,Implant Device,149.8,70,,149.8,percent of total billed charges,All Other,145.52,34,,145.52,percent of total billed charges,Implant Device,145.52,34,,145.52,percent of total billed charges,Implant Device,149.8,35,,149.8,percent of total billed charges,Implant Device,149.8,35,,149.8,percent of total billed charges,Implant Device,149.8,35,,149.8,percent of total billed charges,Implant Device,149.8,35,,149.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,316.72,
STRYKER 623-00-36F TRIDENT INSERT 36MM,C1776,HCPCS,,79010751,CDM,278,RC,,,both,,,2503,1852.23,,,1852.23,Other,150% of Medicare + 9.63% HCRA Surcharge,1126.35,45,,1126.35,percent of total billed charges,Critical Access Hospital RCC factor,851.02,34,,851.02,percent of total billed charges,Implant Device,851.02,34,,851.02,percent of total billed charges,Implant Device,851.02,34,,851.02,percent of total billed charges,Implant Device,851.02,34,,851.02,percent of total billed charges,Implant Device,851.02,34,,851.02,percent of total billed charges,Implant Device,1238.99,,,1238.99,Other,110% of Medicare,876.05,35,,876.05,percent of total billed charges,Implant Device,851.02,34,"Charges > $500, x 34%",851.02,percent of total billed charges,Implant Device,876.05,35,,876.05,percent of total billed charges,Implant Device,876.05,35,,876.05,percent of total billed charges,Implant Device,876.05,35,,876.05,percent of total billed charges,Implant Device,876.05,35,,876.05,percent of total billed charges,Implant Device,876.05,35,,876.05,percent of total billed charges,Implant Device,1001.2,40,,1001.2,percent of total billed charges,Implant Device,876.05,70,,876.05,percent of total billed charges,All Other,851.02,34,,851.02,percent of total billed charges,Implant Device,851.02,34,,851.02,percent of total billed charges,Implant Device,876.05,35,,876.05,percent of total billed charges,Implant Device,876.05,35,,876.05,percent of total billed charges,Implant Device,876.05,35,,876.05,percent of total billed charges,Implant Device,876.05,35,,876.05,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,851.02,34,"If Charge > 2,000, then 34 percent",851.02,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1852.23,
STRYKER 629537 COMPRESSION PLT 7H 91MM,C1713,HCPCS,,79010752,CDM,278,RC,,,both,,,1172,867.28,,,867.28,Other,150% of Medicare + 9.63% HCRA Surcharge,527.4,45,,527.4,percent of total billed charges,Critical Access Hospital RCC factor,398.48,34,,398.48,percent of total billed charges,Implant Device,398.48,34,,398.48,percent of total billed charges,Implant Device,398.48,34,,398.48,percent of total billed charges,Implant Device,398.48,34,,398.48,percent of total billed charges,Implant Device,398.48,34,,398.48,percent of total billed charges,Implant Device,580.14,,,580.14,Other,110% of Medicare,410.2,35,,410.2,percent of total billed charges,Implant Device,398.48,34,"Charges > $500, x 34%",398.48,percent of total billed charges,Implant Device,410.2,35,,410.2,percent of total billed charges,Implant Device,410.2,35,,410.2,percent of total billed charges,Implant Device,410.2,35,,410.2,percent of total billed charges,Implant Device,410.2,35,,410.2,percent of total billed charges,Implant Device,410.2,35,,410.2,percent of total billed charges,Implant Device,468.8,40,,468.8,percent of total billed charges,Implant Device,410.2,70,,410.2,percent of total billed charges,All Other,398.48,34,,398.48,percent of total billed charges,Implant Device,398.48,34,,398.48,percent of total billed charges,Implant Device,410.2,35,,410.2,percent of total billed charges,Implant Device,410.2,35,,410.2,percent of total billed charges,Implant Device,410.2,35,,410.2,percent of total billed charges,Implant Device,410.2,35,,410.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,867.28,
STRYKER 629746 BROAD LOCK PLATE 2.7X56MM,C1713,HCPCS,,79010753,CDM,278,RC,,,both,,,3318,2455.33,,,2455.33,Other,150% of Medicare + 9.63% HCRA Surcharge,1493.1,45,,1493.1,percent of total billed charges,Critical Access Hospital RCC factor,1128.12,34,,1128.12,percent of total billed charges,Implant Device,1128.12,34,,1128.12,percent of total billed charges,Implant Device,1128.12,34,,1128.12,percent of total billed charges,Implant Device,1128.12,34,,1128.12,percent of total billed charges,Implant Device,1128.12,34,,1128.12,percent of total billed charges,Implant Device,1642.41,,,1642.41,Other,110% of Medicare,1161.3,35,,1161.3,percent of total billed charges,Implant Device,1128.12,34,"Charges > $500, x 34%",1128.12,percent of total billed charges,Implant Device,1161.3,35,,1161.3,percent of total billed charges,Implant Device,1161.3,35,,1161.3,percent of total billed charges,Implant Device,1161.3,35,,1161.3,percent of total billed charges,Implant Device,1161.3,35,,1161.3,percent of total billed charges,Implant Device,1161.3,35,,1161.3,percent of total billed charges,Implant Device,1327.2,40,,1327.2,percent of total billed charges,Implant Device,1161.3,70,,1161.3,percent of total billed charges,All Other,1128.12,34,,1128.12,percent of total billed charges,Implant Device,1128.12,34,,1128.12,percent of total billed charges,Implant Device,1161.3,35,,1161.3,percent of total billed charges,Implant Device,1161.3,35,,1161.3,percent of total billed charges,Implant Device,1161.3,35,,1161.3,percent of total billed charges,Implant Device,1161.3,35,,1161.3,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1128.12,34,"If Charge > 2,000, then 34 percent",1128.12,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2455.33,
STRYKER 656415 BONE SCREW 2.7X15MM,C1713,HCPCS,,79010754,CDM,278,RC,,,both,,,395,292.3,,,292.3,Other,150% of Medicare + 9.63% HCRA Surcharge,177.75,45,,177.75,percent of total billed charges,Critical Access Hospital RCC factor,134.3,34,,134.3,percent of total billed charges,Implant Device,134.3,34,,134.3,percent of total billed charges,Implant Device,134.3,34,,134.3,percent of total billed charges,Implant Device,134.3,34,,134.3,percent of total billed charges,Implant Device,134.3,34,,134.3,percent of total billed charges,Implant Device,195.53,,,195.53,Other,110% of Medicare,138.25,35,,138.25,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,138.25,35,,138.25,percent of total billed charges,Implant Device,138.25,35,,138.25,percent of total billed charges,Implant Device,138.25,35,,138.25,percent of total billed charges,Implant Device,138.25,35,,138.25,percent of total billed charges,Implant Device,138.25,35,,138.25,percent of total billed charges,Implant Device,158,40,,158,percent of total billed charges,Implant Device,138.25,70,,138.25,percent of total billed charges,All Other,134.3,34,,134.3,percent of total billed charges,Implant Device,134.3,34,,134.3,percent of total billed charges,Implant Device,138.25,35,,138.25,percent of total billed charges,Implant Device,138.25,35,,138.25,percent of total billed charges,Implant Device,138.25,35,,138.25,percent of total billed charges,Implant Device,138.25,35,,138.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,292.3,
STRYKER 5517-F-601 FEM COMP SZ 6 LT,C1776,HCPCS,,79010755,CDM,278,RC,,,both,,,5840,4321.61,,,4321.61,Other,150% of Medicare + 9.63% HCRA Surcharge,2628,45,,2628,percent of total billed charges,Critical Access Hospital RCC factor,1985.6,34,,1985.6,percent of total billed charges,Implant Device,1985.6,34,,1985.6,percent of total billed charges,Implant Device,1985.6,34,,1985.6,percent of total billed charges,Implant Device,1985.6,34,,1985.6,percent of total billed charges,Implant Device,1985.6,34,,1985.6,percent of total billed charges,Implant Device,2890.8,,,2890.8,Other,110% of Medicare,2044,35,,2044,percent of total billed charges,Implant Device,1985.6,34,"Charges > $500, x 34%",1985.6,percent of total billed charges,Implant Device,2044,35,,2044,percent of total billed charges,Implant Device,2044,35,,2044,percent of total billed charges,Implant Device,2044,35,,2044,percent of total billed charges,Implant Device,2044,35,,2044,percent of total billed charges,Implant Device,2044,35,,2044,percent of total billed charges,Implant Device,2336,40,,2336,percent of total billed charges,Implant Device,2044,70,,2044,percent of total billed charges,All Other,1985.6,34,,1985.6,percent of total billed charges,Implant Device,1985.6,34,,1985.6,percent of total billed charges,Implant Device,2044,35,,2044,percent of total billed charges,Implant Device,2044,35,,2044,percent of total billed charges,Implant Device,2044,35,,2044,percent of total billed charges,Implant Device,2044,35,,2044,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1985.6,34,"If Charge > 2,000, then 34 percent",1985.6,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4321.61,
STRYKER 5531-G-609-E TIB INSERT SZ 6 9MM,C1776,HCPCS,,79010756,CDM,278,RC,,,both,,,2781,2057.95,,,2057.95,Other,150% of Medicare + 9.63% HCRA Surcharge,1251.45,45,,1251.45,percent of total billed charges,Critical Access Hospital RCC factor,945.54,34,,945.54,percent of total billed charges,Implant Device,945.54,34,,945.54,percent of total billed charges,Implant Device,945.54,34,,945.54,percent of total billed charges,Implant Device,945.54,34,,945.54,percent of total billed charges,Implant Device,945.54,34,,945.54,percent of total billed charges,Implant Device,1376.6,,,1376.6,Other,110% of Medicare,973.35,35,,973.35,percent of total billed charges,Implant Device,945.54,34,"Charges > $500, x 34%",945.54,percent of total billed charges,Implant Device,973.35,35,,973.35,percent of total billed charges,Implant Device,973.35,35,,973.35,percent of total billed charges,Implant Device,973.35,35,,973.35,percent of total billed charges,Implant Device,973.35,35,,973.35,percent of total billed charges,Implant Device,973.35,35,,973.35,percent of total billed charges,Implant Device,1112.4,40,,1112.4,percent of total billed charges,Implant Device,973.35,70,,973.35,percent of total billed charges,All Other,945.54,34,,945.54,percent of total billed charges,Implant Device,945.54,34,,945.54,percent of total billed charges,Implant Device,973.35,35,,973.35,percent of total billed charges,Implant Device,973.35,35,,973.35,percent of total billed charges,Implant Device,973.35,35,,973.35,percent of total billed charges,Implant Device,973.35,35,,973.35,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,945.54,34,"If Charge > 2,000, then 34 percent",945.54,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2057.95,
STRYKER 5536-B-600 BASEPLATE SIZE 6,C1776,HCPCS,,79010757,CDM,278,RC,,,both,,,4172,3087.29,,,3087.29,Other,150% of Medicare + 9.63% HCRA Surcharge,1877.4,45,,1877.4,percent of total billed charges,Critical Access Hospital RCC factor,1418.48,34,,1418.48,percent of total billed charges,Implant Device,1418.48,34,,1418.48,percent of total billed charges,Implant Device,1418.48,34,,1418.48,percent of total billed charges,Implant Device,1418.48,34,,1418.48,percent of total billed charges,Implant Device,1418.48,34,,1418.48,percent of total billed charges,Implant Device,2065.14,,,2065.14,Other,110% of Medicare,1460.2,35,,1460.2,percent of total billed charges,Implant Device,1418.48,34,"Charges > $500, x 34%",1418.48,percent of total billed charges,Implant Device,1460.2,35,,1460.2,percent of total billed charges,Implant Device,1460.2,35,,1460.2,percent of total billed charges,Implant Device,1460.2,35,,1460.2,percent of total billed charges,Implant Device,1460.2,35,,1460.2,percent of total billed charges,Implant Device,1460.2,35,,1460.2,percent of total billed charges,Implant Device,1668.8,40,,1668.8,percent of total billed charges,Implant Device,1460.2,70,,1460.2,percent of total billed charges,All Other,1418.48,34,,1418.48,percent of total billed charges,Implant Device,1418.48,34,,1418.48,percent of total billed charges,Implant Device,1460.2,35,,1460.2,percent of total billed charges,Implant Device,1460.2,35,,1460.2,percent of total billed charges,Implant Device,1460.2,35,,1460.2,percent of total billed charges,Implant Device,1460.2,35,,1460.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1418.48,34,"If Charge > 2,000, then 34 percent",1418.48,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3087.29,
STRYKER 5552-L-381 PATELLA 38X11MM,C1776,HCPCS,,79010759,CDM,278,RC,,,both,,,2225,1646.51,,,1646.51,Other,150% of Medicare + 9.63% HCRA Surcharge,1001.25,45,,1001.25,percent of total billed charges,Critical Access Hospital RCC factor,756.5,34,,756.5,percent of total billed charges,Implant Device,756.5,34,,756.5,percent of total billed charges,Implant Device,756.5,34,,756.5,percent of total billed charges,Implant Device,756.5,34,,756.5,percent of total billed charges,Implant Device,756.5,34,,756.5,percent of total billed charges,Implant Device,1101.38,,,1101.38,Other,110% of Medicare,778.75,35,,778.75,percent of total billed charges,Implant Device,756.5,34,"Charges > $500, x 34%",756.5,percent of total billed charges,Implant Device,778.75,35,,778.75,percent of total billed charges,Implant Device,778.75,35,,778.75,percent of total billed charges,Implant Device,778.75,35,,778.75,percent of total billed charges,Implant Device,778.75,35,,778.75,percent of total billed charges,Implant Device,778.75,35,,778.75,percent of total billed charges,Implant Device,890,40,,890,percent of total billed charges,Implant Device,778.75,70,,778.75,percent of total billed charges,All Other,756.5,34,,756.5,percent of total billed charges,Implant Device,756.5,34,,756.5,percent of total billed charges,Implant Device,778.75,35,,778.75,percent of total billed charges,Implant Device,778.75,35,,778.75,percent of total billed charges,Implant Device,778.75,35,,778.75,percent of total billed charges,Implant Device,778.75,35,,778.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,756.5,34,"If Charge > 2,000, then 34 percent",756.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1646.51,
STRYKER 628225 SUPERIOR LATERL PLATE 5,C1713,HCPCS,,79010761,CDM,278,RC,,,both,,,3069,2271.07,,,2271.07,Other,150% of Medicare + 9.63% HCRA Surcharge,1381.05,45,,1381.05,percent of total billed charges,Critical Access Hospital RCC factor,1043.46,34,,1043.46,percent of total billed charges,Implant Device,1043.46,34,,1043.46,percent of total billed charges,Implant Device,1043.46,34,,1043.46,percent of total billed charges,Implant Device,1043.46,34,,1043.46,percent of total billed charges,Implant Device,1043.46,34,,1043.46,percent of total billed charges,Implant Device,1519.16,,,1519.16,Other,110% of Medicare,1074.15,35,,1074.15,percent of total billed charges,Implant Device,1043.46,34,"Charges > $500, x 34%",1043.46,percent of total billed charges,Implant Device,1074.15,35,,1074.15,percent of total billed charges,Implant Device,1074.15,35,,1074.15,percent of total billed charges,Implant Device,1074.15,35,,1074.15,percent of total billed charges,Implant Device,1074.15,35,,1074.15,percent of total billed charges,Implant Device,1074.15,35,,1074.15,percent of total billed charges,Implant Device,1227.6,40,,1227.6,percent of total billed charges,Implant Device,1074.15,70,,1074.15,percent of total billed charges,All Other,1043.46,34,,1043.46,percent of total billed charges,Implant Device,1043.46,34,,1043.46,percent of total billed charges,Implant Device,1074.15,35,,1074.15,percent of total billed charges,Implant Device,1074.15,35,,1074.15,percent of total billed charges,Implant Device,1074.15,35,,1074.15,percent of total billed charges,Implant Device,1074.15,35,,1074.15,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1043.46,34,"If Charge > 2,000, then 34 percent",1043.46,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2271.07,
STRYKER 657008 LOCKING SCREW 2.7X8MM,C1713,HCPCS,,79010762,CDM,278,RC,,,both,,,494,365.56,,,365.56,Other,150% of Medicare + 9.63% HCRA Surcharge,222.3,45,,222.3,percent of total billed charges,Critical Access Hospital RCC factor,167.96,34,,167.96,percent of total billed charges,Implant Device,167.96,34,,167.96,percent of total billed charges,Implant Device,167.96,34,,167.96,percent of total billed charges,Implant Device,167.96,34,,167.96,percent of total billed charges,Implant Device,167.96,34,,167.96,percent of total billed charges,Implant Device,244.53,,,244.53,Other,110% of Medicare,172.9,35,,172.9,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,172.9,35,,172.9,percent of total billed charges,Implant Device,172.9,35,,172.9,percent of total billed charges,Implant Device,172.9,35,,172.9,percent of total billed charges,Implant Device,172.9,35,,172.9,percent of total billed charges,Implant Device,172.9,35,,172.9,percent of total billed charges,Implant Device,197.6,40,,197.6,percent of total billed charges,Implant Device,172.9,70,,172.9,percent of total billed charges,All Other,167.96,34,,167.96,percent of total billed charges,Implant Device,167.96,34,,167.96,percent of total billed charges,Implant Device,172.9,35,,172.9,percent of total billed charges,Implant Device,172.9,35,,172.9,percent of total billed charges,Implant Device,172.9,35,,172.9,percent of total billed charges,Implant Device,172.9,35,,172.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,365.56,
STRYKER ORTHO 657110 BONE SCREW 2.7X10MM,C1713,HCPCS,,79010763,CDM,278,RC,,,both,,,269,199.06,,,199.06,Other,150% of Medicare + 9.63% HCRA Surcharge,121.05,45,,121.05,percent of total billed charges,Critical Access Hospital RCC factor,91.46,34,,91.46,percent of total billed charges,Implant Device,91.46,34,,91.46,percent of total billed charges,Implant Device,91.46,34,,91.46,percent of total billed charges,Implant Device,91.46,34,,91.46,percent of total billed charges,Implant Device,91.46,34,,91.46,percent of total billed charges,Implant Device,133.16,,,133.16,Other,110% of Medicare,94.15,35,,94.15,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,94.15,35,,94.15,percent of total billed charges,Implant Device,94.15,35,,94.15,percent of total billed charges,Implant Device,94.15,35,,94.15,percent of total billed charges,Implant Device,94.15,35,,94.15,percent of total billed charges,Implant Device,94.15,35,,94.15,percent of total billed charges,Implant Device,107.6,40,,107.6,percent of total billed charges,Implant Device,94.15,70,,94.15,percent of total billed charges,All Other,91.46,34,,91.46,percent of total billed charges,Implant Device,91.46,34,,91.46,percent of total billed charges,Implant Device,94.15,35,,94.15,percent of total billed charges,Implant Device,94.15,35,,94.15,percent of total billed charges,Implant Device,94.15,35,,94.15,percent of total billed charges,Implant Device,94.15,35,,94.15,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,199.06,
STRYKER ORTHO 626982 PLATE 2 SHAFT HOLES,C1713,HCPCS,,79010764,CDM,278,RC,,,both,,,3200,2368.01,,,2368.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1440,45,,1440,percent of total billed charges,Critical Access Hospital RCC factor,1088,34,,1088,percent of total billed charges,Implant Device,1088,34,,1088,percent of total billed charges,Implant Device,1088,34,,1088,percent of total billed charges,Implant Device,1088,34,,1088,percent of total billed charges,Implant Device,1088,34,,1088,percent of total billed charges,Implant Device,1584,,,1584,Other,110% of Medicare,1120,35,,1120,percent of total billed charges,Implant Device,1088,34,"Charges > $500, x 34%",1088,percent of total billed charges,Implant Device,1120,35,,1120,percent of total billed charges,Implant Device,1120,35,,1120,percent of total billed charges,Implant Device,1120,35,,1120,percent of total billed charges,Implant Device,1120,35,,1120,percent of total billed charges,Implant Device,1120,35,,1120,percent of total billed charges,Implant Device,1280,40,,1280,percent of total billed charges,Implant Device,1120,70,,1120,percent of total billed charges,All Other,1088,34,,1088,percent of total billed charges,Implant Device,1088,34,,1088,percent of total billed charges,Implant Device,1120,35,,1120,percent of total billed charges,Implant Device,1120,35,,1120,percent of total billed charges,Implant Device,1120,35,,1120,percent of total billed charges,Implant Device,1120,35,,1120,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1088,34,"If Charge > 2,000, then 34 percent",1088,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2368.01,
ARTHREX AR-8978P SWIVELOCK SL 3.5X8.5MM,C1713,HCPCS,,79010766,CDM,278,RC,,,both,,,1824,1349.76,,,1349.76,Other,150% of Medicare + 9.63% HCRA Surcharge,820.8,45,,820.8,percent of total billed charges,Critical Access Hospital RCC factor,620.16,34,,620.16,percent of total billed charges,Implant Device,620.16,34,,620.16,percent of total billed charges,Implant Device,620.16,34,,620.16,percent of total billed charges,Implant Device,620.16,34,,620.16,percent of total billed charges,Implant Device,620.16,34,,620.16,percent of total billed charges,Implant Device,902.88,,,902.88,Other,110% of Medicare,638.4,35,,638.4,percent of total billed charges,Implant Device,620.16,34,"Charges > $500, x 34%",620.16,percent of total billed charges,Implant Device,638.4,35,,638.4,percent of total billed charges,Implant Device,638.4,35,,638.4,percent of total billed charges,Implant Device,638.4,35,,638.4,percent of total billed charges,Implant Device,638.4,35,,638.4,percent of total billed charges,Implant Device,638.4,35,,638.4,percent of total billed charges,Implant Device,729.6,40,,729.6,percent of total billed charges,Implant Device,638.4,70,,638.4,percent of total billed charges,All Other,620.16,34,,620.16,percent of total billed charges,Implant Device,620.16,34,,620.16,percent of total billed charges,Implant Device,638.4,35,,638.4,percent of total billed charges,Implant Device,638.4,35,,638.4,percent of total billed charges,Implant Device,638.4,35,,638.4,percent of total billed charges,Implant Device,638.4,35,,638.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1349.76,
ZIMMER 00-7818-099-00 FEM HEAD 12/14,C1776,HCPCS,,79010767,CDM,278,RC,,,both,,,480,355.2,,,355.2,Other,150% of Medicare + 9.63% HCRA Surcharge,216,45,,216,percent of total billed charges,Critical Access Hospital RCC factor,163.2,34,,163.2,percent of total billed charges,Implant Device,163.2,34,,163.2,percent of total billed charges,Implant Device,163.2,34,,163.2,percent of total billed charges,Implant Device,163.2,34,,163.2,percent of total billed charges,Implant Device,163.2,34,,163.2,percent of total billed charges,Implant Device,237.6,,,237.6,Other,110% of Medicare,168,35,,168,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,192,40,,192,percent of total billed charges,Implant Device,168,70,,168,percent of total billed charges,All Other,163.2,34,,163.2,percent of total billed charges,Implant Device,163.2,34,,163.2,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,355.2,
ZIMMER 00-7818-045-00 FEM HEAD 12/14,C1776,HCPCS,,79010768,CDM,278,RC,,,both,,,1245,921.3,,,921.3,Other,150% of Medicare + 9.63% HCRA Surcharge,560.25,45,,560.25,percent of total billed charges,Critical Access Hospital RCC factor,423.3,34,,423.3,percent of total billed charges,Implant Device,423.3,34,,423.3,percent of total billed charges,Implant Device,423.3,34,,423.3,percent of total billed charges,Implant Device,423.3,34,,423.3,percent of total billed charges,Implant Device,423.3,34,,423.3,percent of total billed charges,Implant Device,616.28,,,616.28,Other,110% of Medicare,435.75,35,,435.75,percent of total billed charges,Implant Device,423.3,34,"Charges > $500, x 34%",423.3,percent of total billed charges,Implant Device,435.75,35,,435.75,percent of total billed charges,Implant Device,435.75,35,,435.75,percent of total billed charges,Implant Device,435.75,35,,435.75,percent of total billed charges,Implant Device,435.75,35,,435.75,percent of total billed charges,Implant Device,435.75,35,,435.75,percent of total billed charges,Implant Device,498,40,,498,percent of total billed charges,Implant Device,435.75,70,,435.75,percent of total billed charges,All Other,423.3,34,,423.3,percent of total billed charges,Implant Device,423.3,34,,423.3,percent of total billed charges,Implant Device,435.75,35,,435.75,percent of total billed charges,Implant Device,435.75,35,,435.75,percent of total billed charges,Implant Device,435.75,35,,435.75,percent of total billed charges,Implant Device,435.75,35,,435.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,921.3,
ZIMMER 8145-10-115 LAG SCREW 115X10.5MM,C1713,HCPCS,,79010769,CDM,278,RC,,,both,,,1152,852.48,,,852.48,Other,150% of Medicare + 9.63% HCRA Surcharge,518.4,45,,518.4,percent of total billed charges,Critical Access Hospital RCC factor,391.68,34,,391.68,percent of total billed charges,Implant Device,391.68,34,,391.68,percent of total billed charges,Implant Device,391.68,34,,391.68,percent of total billed charges,Implant Device,391.68,34,,391.68,percent of total billed charges,Implant Device,391.68,34,,391.68,percent of total billed charges,Implant Device,570.24,,,570.24,Other,110% of Medicare,403.2,35,,403.2,percent of total billed charges,Implant Device,391.68,34,"Charges > $500, x 34%",391.68,percent of total billed charges,Implant Device,403.2,35,,403.2,percent of total billed charges,Implant Device,403.2,35,,403.2,percent of total billed charges,Implant Device,403.2,35,,403.2,percent of total billed charges,Implant Device,403.2,35,,403.2,percent of total billed charges,Implant Device,403.2,35,,403.2,percent of total billed charges,Implant Device,460.8,40,,460.8,percent of total billed charges,Implant Device,403.2,70,,403.2,percent of total billed charges,All Other,391.68,34,,391.68,percent of total billed charges,Implant Device,391.68,34,,391.68,percent of total billed charges,Implant Device,403.2,35,,403.2,percent of total billed charges,Implant Device,403.2,35,,403.2,percent of total billed charges,Implant Device,403.2,35,,403.2,percent of total billed charges,Implant Device,403.2,35,,403.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,852.48,
ZIMMER 8146-11-420 SCREW 130 DEG 11X420,C1713,HCPCS,,79010770,CDM,278,RC,,,both,,,12660,9368.43,,,9368.43,Other,150% of Medicare + 9.63% HCRA Surcharge,5697,45,,5697,percent of total billed charges,Critical Access Hospital RCC factor,4304.4,34,,4304.4,percent of total billed charges,Implant Device,4304.4,34,,4304.4,percent of total billed charges,Implant Device,4304.4,34,,4304.4,percent of total billed charges,Implant Device,4304.4,34,,4304.4,percent of total billed charges,Implant Device,4304.4,34,,4304.4,percent of total billed charges,Implant Device,6266.7,,,6266.7,Other,110% of Medicare,4431,35,,4431,percent of total billed charges,Implant Device,4304.4,34,"Charges > $500, x 34%",4304.4,percent of total billed charges,Implant Device,4431,35,,4431,percent of total billed charges,Implant Device,4431,35,,4431,percent of total billed charges,Implant Device,4431,35,,4431,percent of total billed charges,Implant Device,4431,35,,4431,percent of total billed charges,Implant Device,4431,35,,4431,percent of total billed charges,Implant Device,5064,40,,5064,percent of total billed charges,Implant Device,4431,70,,4431,percent of total billed charges,All Other,4304.4,34,,4304.4,percent of total billed charges,Implant Device,4304.4,34,,4304.4,percent of total billed charges,Implant Device,4431,35,,4431,percent of total billed charges,Implant Device,4431,35,,4431,percent of total billed charges,Implant Device,4431,35,,4431,percent of total billed charges,Implant Device,4431,35,,4431,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,4304.4,34,"If Charge > 2,000, then 34 percent",4304.4,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,9368.43,
STRYKER 702-04-48D TRITANIUM CLUSTERHOLE,C1776,HCPCS,,79010771,CDM,278,RC,,,both,,,3337,2469.39,,,2469.39,Other,150% of Medicare + 9.63% HCRA Surcharge,1501.65,45,,1501.65,percent of total billed charges,Critical Access Hospital RCC factor,1134.58,34,,1134.58,percent of total billed charges,Implant Device,1134.58,34,,1134.58,percent of total billed charges,Implant Device,1134.58,34,,1134.58,percent of total billed charges,Implant Device,1134.58,34,,1134.58,percent of total billed charges,Implant Device,1134.58,34,,1134.58,percent of total billed charges,Implant Device,1651.82,,,1651.82,Other,110% of Medicare,1167.95,35,,1167.95,percent of total billed charges,Implant Device,1134.58,34,"Charges > $500, x 34%",1134.58,percent of total billed charges,Implant Device,1167.95,35,,1167.95,percent of total billed charges,Implant Device,1167.95,35,,1167.95,percent of total billed charges,Implant Device,1167.95,35,,1167.95,percent of total billed charges,Implant Device,1167.95,35,,1167.95,percent of total billed charges,Implant Device,1167.95,35,,1167.95,percent of total billed charges,Implant Device,1334.8,40,,1334.8,percent of total billed charges,Implant Device,1167.95,70,,1167.95,percent of total billed charges,All Other,1134.58,34,,1134.58,percent of total billed charges,Implant Device,1134.58,34,,1134.58,percent of total billed charges,Implant Device,1167.95,35,,1167.95,percent of total billed charges,Implant Device,1167.95,35,,1167.95,percent of total billed charges,Implant Device,1167.95,35,,1167.95,percent of total billed charges,Implant Device,1167.95,35,,1167.95,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1134.58,34,"If Charge > 2,000, then 34 percent",1134.58,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2469.39,
STRYKER 5517-F-502 FEMORAL COMP SZ 5 RT,C1776,HCPCS,,79010772,CDM,278,RC,,,both,,,6600,4884.02,,,4884.02,Other,150% of Medicare + 9.63% HCRA Surcharge,2970,45,,2970,percent of total billed charges,Critical Access Hospital RCC factor,2244,34,,2244,percent of total billed charges,Implant Device,2244,34,,2244,percent of total billed charges,Implant Device,2244,34,,2244,percent of total billed charges,Implant Device,2244,34,,2244,percent of total billed charges,Implant Device,2244,34,,2244,percent of total billed charges,Implant Device,3267,,,3267,Other,110% of Medicare,2310,35,,2310,percent of total billed charges,Implant Device,2244,34,"Charges > $500, x 34%",2244,percent of total billed charges,Implant Device,2310,35,,2310,percent of total billed charges,Implant Device,2310,35,,2310,percent of total billed charges,Implant Device,2310,35,,2310,percent of total billed charges,Implant Device,2310,35,,2310,percent of total billed charges,Implant Device,2310,35,,2310,percent of total billed charges,Implant Device,2640,40,,2640,percent of total billed charges,Implant Device,2310,70,,2310,percent of total billed charges,All Other,2244,34,,2244,percent of total billed charges,Implant Device,2244,34,,2244,percent of total billed charges,Implant Device,2310,35,,2310,percent of total billed charges,Implant Device,2310,35,,2310,percent of total billed charges,Implant Device,2310,35,,2310,percent of total billed charges,Implant Device,2310,35,,2310,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2244,34,"If Charge > 2,000, then 34 percent",2244,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4884.02,
STRYKER 5531-G-409-E TIB BEARING INS SZ4,C1776,HCPCS,,79010773,CDM,278,RC,,,both,,,2781,2057.95,,,2057.95,Other,150% of Medicare + 9.63% HCRA Surcharge,1251.45,45,,1251.45,percent of total billed charges,Critical Access Hospital RCC factor,945.54,34,,945.54,percent of total billed charges,Implant Device,945.54,34,,945.54,percent of total billed charges,Implant Device,945.54,34,,945.54,percent of total billed charges,Implant Device,945.54,34,,945.54,percent of total billed charges,Implant Device,945.54,34,,945.54,percent of total billed charges,Implant Device,1376.6,,,1376.6,Other,110% of Medicare,973.35,35,,973.35,percent of total billed charges,Implant Device,945.54,34,"Charges > $500, x 34%",945.54,percent of total billed charges,Implant Device,973.35,35,,973.35,percent of total billed charges,Implant Device,973.35,35,,973.35,percent of total billed charges,Implant Device,973.35,35,,973.35,percent of total billed charges,Implant Device,973.35,35,,973.35,percent of total billed charges,Implant Device,973.35,35,,973.35,percent of total billed charges,Implant Device,1112.4,40,,1112.4,percent of total billed charges,Implant Device,973.35,70,,973.35,percent of total billed charges,All Other,945.54,34,,945.54,percent of total billed charges,Implant Device,945.54,34,,945.54,percent of total billed charges,Implant Device,973.35,35,,973.35,percent of total billed charges,Implant Device,973.35,35,,973.35,percent of total billed charges,Implant Device,973.35,35,,973.35,percent of total billed charges,Implant Device,973.35,35,,973.35,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,945.54,34,"If Charge > 2,000, then 34 percent",945.54,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2057.95,
STRYKER 5536-B-400 TIBIAL BASEPLATE SZ 4,C1776,HCPCS,,79010774,CDM,278,RC,,,both,,,4172,3087.29,,,3087.29,Other,150% of Medicare + 9.63% HCRA Surcharge,1877.4,45,,1877.4,percent of total billed charges,Critical Access Hospital RCC factor,1418.48,34,,1418.48,percent of total billed charges,Implant Device,1418.48,34,,1418.48,percent of total billed charges,Implant Device,1418.48,34,,1418.48,percent of total billed charges,Implant Device,1418.48,34,,1418.48,percent of total billed charges,Implant Device,1418.48,34,,1418.48,percent of total billed charges,Implant Device,2065.14,,,2065.14,Other,110% of Medicare,1460.2,35,,1460.2,percent of total billed charges,Implant Device,1418.48,34,"Charges > $500, x 34%",1418.48,percent of total billed charges,Implant Device,1460.2,35,,1460.2,percent of total billed charges,Implant Device,1460.2,35,,1460.2,percent of total billed charges,Implant Device,1460.2,35,,1460.2,percent of total billed charges,Implant Device,1460.2,35,,1460.2,percent of total billed charges,Implant Device,1460.2,35,,1460.2,percent of total billed charges,Implant Device,1668.8,40,,1668.8,percent of total billed charges,Implant Device,1460.2,70,,1460.2,percent of total billed charges,All Other,1418.48,34,,1418.48,percent of total billed charges,Implant Device,1418.48,34,,1418.48,percent of total billed charges,Implant Device,1460.2,35,,1460.2,percent of total billed charges,Implant Device,1460.2,35,,1460.2,percent of total billed charges,Implant Device,1460.2,35,,1460.2,percent of total billed charges,Implant Device,1460.2,35,,1460.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1418.48,34,"If Charge > 2,000, then 34 percent",1418.48,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3087.29,
STRYKER 5552-L-299 PATELLA 29X9MM,C1776,HCPCS,,79010775,CDM,278,RC,,,both,,,1800,1332,,,1332,Other,150% of Medicare + 9.63% HCRA Surcharge,810,45,,810,percent of total billed charges,Critical Access Hospital RCC factor,612,34,,612,percent of total billed charges,Implant Device,612,34,,612,percent of total billed charges,Implant Device,612,34,,612,percent of total billed charges,Implant Device,612,34,,612,percent of total billed charges,Implant Device,612,34,,612,percent of total billed charges,Implant Device,891,,,891,Other,110% of Medicare,630,35,,630,percent of total billed charges,Implant Device,612,34,"Charges > $500, x 34%",612,percent of total billed charges,Implant Device,630,35,,630,percent of total billed charges,Implant Device,630,35,,630,percent of total billed charges,Implant Device,630,35,,630,percent of total billed charges,Implant Device,630,35,,630,percent of total billed charges,Implant Device,630,35,,630,percent of total billed charges,Implant Device,720,40,,720,percent of total billed charges,Implant Device,630,70,,630,percent of total billed charges,All Other,612,34,,612,percent of total billed charges,Implant Device,612,34,,612,percent of total billed charges,Implant Device,630,35,,630,percent of total billed charges,Implant Device,630,35,,630,percent of total billed charges,Implant Device,630,35,,630,percent of total billed charges,Implant Device,630,35,,630,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1332,
STRYKER 702-04-50D TRITANIUM CLUSTERHOLE,C1776,HCPCS,,79010776,CDM,278,RC,,,both,,,3337,2469.39,,,2469.39,Other,150% of Medicare + 9.63% HCRA Surcharge,1501.65,45,,1501.65,percent of total billed charges,Critical Access Hospital RCC factor,1134.58,34,,1134.58,percent of total billed charges,Implant Device,1134.58,34,,1134.58,percent of total billed charges,Implant Device,1134.58,34,,1134.58,percent of total billed charges,Implant Device,1134.58,34,,1134.58,percent of total billed charges,Implant Device,1134.58,34,,1134.58,percent of total billed charges,Implant Device,1651.82,,,1651.82,Other,110% of Medicare,1167.95,35,,1167.95,percent of total billed charges,Implant Device,1134.58,34,"Charges > $500, x 34%",1134.58,percent of total billed charges,Implant Device,1167.95,35,,1167.95,percent of total billed charges,Implant Device,1167.95,35,,1167.95,percent of total billed charges,Implant Device,1167.95,35,,1167.95,percent of total billed charges,Implant Device,1167.95,35,,1167.95,percent of total billed charges,Implant Device,1167.95,35,,1167.95,percent of total billed charges,Implant Device,1334.8,40,,1334.8,percent of total billed charges,Implant Device,1167.95,70,,1167.95,percent of total billed charges,All Other,1134.58,34,,1134.58,percent of total billed charges,Implant Device,1134.58,34,,1134.58,percent of total billed charges,Implant Device,1167.95,35,,1167.95,percent of total billed charges,Implant Device,1167.95,35,,1167.95,percent of total billed charges,Implant Device,1167.95,35,,1167.95,percent of total billed charges,Implant Device,1167.95,35,,1167.95,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1134.58,34,"If Charge > 2,000, then 34 percent",1134.58,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2469.39,
IN2BONES P92 ST013 SCREW 2.4X13MM,C1713,HCPCS,,79010777,CDM,278,RC,,,both,,,612,452.88,,,452.88,Other,150% of Medicare + 9.63% HCRA Surcharge,275.4,45,,275.4,percent of total billed charges,Critical Access Hospital RCC factor,208.08,34,,208.08,percent of total billed charges,Implant Device,208.08,34,,208.08,percent of total billed charges,Implant Device,208.08,34,,208.08,percent of total billed charges,Implant Device,208.08,34,,208.08,percent of total billed charges,Implant Device,208.08,34,,208.08,percent of total billed charges,Implant Device,302.94,,,302.94,Other,110% of Medicare,214.2,35,,214.2,percent of total billed charges,Implant Device,208.08,34,"Charges > $500, x 34%",208.08,percent of total billed charges,Implant Device,214.2,35,,214.2,percent of total billed charges,Implant Device,214.2,35,,214.2,percent of total billed charges,Implant Device,214.2,35,,214.2,percent of total billed charges,Implant Device,214.2,35,,214.2,percent of total billed charges,Implant Device,214.2,35,,214.2,percent of total billed charges,Implant Device,244.8,40,,244.8,percent of total billed charges,Implant Device,214.2,70,,214.2,percent of total billed charges,All Other,208.08,34,,208.08,percent of total billed charges,Implant Device,208.08,34,,208.08,percent of total billed charges,Implant Device,214.2,35,,214.2,percent of total billed charges,Implant Device,214.2,35,,214.2,percent of total billed charges,Implant Device,214.2,35,,214.2,percent of total billed charges,Implant Device,214.2,35,,214.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,452.88,
ARTHREX AR-1788J-CP INTERNAL BRACE KIT,C1713,HCPCS,,79010778,CDM,278,RC,,,both,,,4485,3318.91,,,3318.91,Other,150% of Medicare + 9.63% HCRA Surcharge,2018.25,45,,2018.25,percent of total billed charges,Critical Access Hospital RCC factor,1524.9,34,,1524.9,percent of total billed charges,Implant Device,1524.9,34,,1524.9,percent of total billed charges,Implant Device,1524.9,34,,1524.9,percent of total billed charges,Implant Device,1524.9,34,,1524.9,percent of total billed charges,Implant Device,1524.9,34,,1524.9,percent of total billed charges,Implant Device,2220.08,,,2220.08,Other,110% of Medicare,1569.75,35,,1569.75,percent of total billed charges,Implant Device,1524.9,34,"Charges > $500, x 34%",1524.9,percent of total billed charges,Implant Device,1569.75,35,,1569.75,percent of total billed charges,Implant Device,1569.75,35,,1569.75,percent of total billed charges,Implant Device,1569.75,35,,1569.75,percent of total billed charges,Implant Device,1569.75,35,,1569.75,percent of total billed charges,Implant Device,1569.75,35,,1569.75,percent of total billed charges,Implant Device,1794,40,,1794,percent of total billed charges,Implant Device,1569.75,70,,1569.75,percent of total billed charges,All Other,1524.9,34,,1524.9,percent of total billed charges,Implant Device,1524.9,34,,1524.9,percent of total billed charges,Implant Device,1569.75,35,,1569.75,percent of total billed charges,Implant Device,1569.75,35,,1569.75,percent of total billed charges,Implant Device,1569.75,35,,1569.75,percent of total billed charges,Implant Device,1569.75,35,,1569.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1524.9,34,"If Charge > 2,000, then 34 percent",1524.9,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3318.91,
STRYKER 6485-2-211 FEM BUSHING 11MM,C1776,HCPCS,,79010779,CDM,278,RC,,,both,,,4199,3107.27,,,3107.27,Other,150% of Medicare + 9.63% HCRA Surcharge,1889.55,45,,1889.55,percent of total billed charges,Critical Access Hospital RCC factor,1427.66,34,,1427.66,percent of total billed charges,Implant Device,1427.66,34,,1427.66,percent of total billed charges,Implant Device,1427.66,34,,1427.66,percent of total billed charges,Implant Device,1427.66,34,,1427.66,percent of total billed charges,Implant Device,1427.66,34,,1427.66,percent of total billed charges,Implant Device,2078.51,,,2078.51,Other,110% of Medicare,1469.65,35,,1469.65,percent of total billed charges,Implant Device,1427.66,34,"Charges > $500, x 34%",1427.66,percent of total billed charges,Implant Device,1469.65,35,,1469.65,percent of total billed charges,Implant Device,1469.65,35,,1469.65,percent of total billed charges,Implant Device,1469.65,35,,1469.65,percent of total billed charges,Implant Device,1469.65,35,,1469.65,percent of total billed charges,Implant Device,1469.65,35,,1469.65,percent of total billed charges,Implant Device,1679.6,40,,1679.6,percent of total billed charges,Implant Device,1469.65,70,,1469.65,percent of total billed charges,All Other,1427.66,34,,1427.66,percent of total billed charges,Implant Device,1427.66,34,,1427.66,percent of total billed charges,Implant Device,1469.65,35,,1469.65,percent of total billed charges,Implant Device,1469.65,35,,1469.65,percent of total billed charges,Implant Device,1469.65,35,,1469.65,percent of total billed charges,Implant Device,1469.65,35,,1469.65,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1427.66,34,"If Charge > 2,000, then 34 percent",1427.66,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3107.27,
STRYKER 6485-3-115 CEMENTED STEM 15X127,C1776,HCPCS,,79010780,CDM,278,RC,,,both,,,7722,5714.3,,,5714.3,Other,150% of Medicare + 9.63% HCRA Surcharge,3474.9,45,,3474.9,percent of total billed charges,Critical Access Hospital RCC factor,2625.48,34,,2625.48,percent of total billed charges,Implant Device,2625.48,34,,2625.48,percent of total billed charges,Implant Device,2625.48,34,,2625.48,percent of total billed charges,Implant Device,2625.48,34,,2625.48,percent of total billed charges,Implant Device,2625.48,34,,2625.48,percent of total billed charges,Implant Device,3822.39,,,3822.39,Other,110% of Medicare,2702.7,35,,2702.7,percent of total billed charges,Implant Device,2625.48,34,"Charges > $500, x 34%",2625.48,percent of total billed charges,Implant Device,2702.7,35,,2702.7,percent of total billed charges,Implant Device,2702.7,35,,2702.7,percent of total billed charges,Implant Device,2702.7,35,,2702.7,percent of total billed charges,Implant Device,2702.7,35,,2702.7,percent of total billed charges,Implant Device,2702.7,35,,2702.7,percent of total billed charges,Implant Device,3088.8,40,,3088.8,percent of total billed charges,Implant Device,2702.7,70,,2702.7,percent of total billed charges,All Other,2625.48,34,,2625.48,percent of total billed charges,Implant Device,2625.48,34,,2625.48,percent of total billed charges,Implant Device,2702.7,35,,2702.7,percent of total billed charges,Implant Device,2702.7,35,,2702.7,percent of total billed charges,Implant Device,2702.7,35,,2702.7,percent of total billed charges,Implant Device,2702.7,35,,2702.7,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2625.48,34,"If Charge > 2,000, then 34 percent",2625.48,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5714.3,
DEPUY 02.118.556 SELF TAPPING SCREW,C1713,HCPCS,,79010782,CDM,278,RC,,,both,,,125,92.5,,,92.5,Other,150% of Medicare + 9.63% HCRA Surcharge,56.25,45,,56.25,percent of total billed charges,Critical Access Hospital RCC factor,42.5,34,,42.5,percent of total billed charges,Implant Device,42.5,34,,42.5,percent of total billed charges,Implant Device,42.5,34,,42.5,percent of total billed charges,Implant Device,42.5,34,,42.5,percent of total billed charges,Implant Device,42.5,34,,42.5,percent of total billed charges,Implant Device,61.88,,,61.88,Other,110% of Medicare,43.75,35,,43.75,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,43.75,35,,43.75,percent of total billed charges,Implant Device,43.75,35,,43.75,percent of total billed charges,Implant Device,43.75,35,,43.75,percent of total billed charges,Implant Device,43.75,35,,43.75,percent of total billed charges,Implant Device,43.75,35,,43.75,percent of total billed charges,Implant Device,50,40,,50,percent of total billed charges,Implant Device,43.75,70,,43.75,percent of total billed charges,All Other,42.5,34,,42.5,percent of total billed charges,Implant Device,42.5,34,,42.5,percent of total billed charges,Implant Device,43.75,35,,43.75,percent of total billed charges,Implant Device,43.75,35,,43.75,percent of total billed charges,Implant Device,43.75,35,,43.75,percent of total billed charges,Implant Device,43.75,35,,43.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,92.5,
DEPUY 04.037.053S TFN LONG NAIL 10X320MM,C1713,HCPCS,,79010785,CDM,278,RC,,,both,,,6153,4553.24,,,4553.24,Other,150% of Medicare + 9.63% HCRA Surcharge,2768.85,45,,2768.85,percent of total billed charges,Critical Access Hospital RCC factor,2092.02,34,,2092.02,percent of total billed charges,Implant Device,2092.02,34,,2092.02,percent of total billed charges,Implant Device,2092.02,34,,2092.02,percent of total billed charges,Implant Device,2092.02,34,,2092.02,percent of total billed charges,Implant Device,2092.02,34,,2092.02,percent of total billed charges,Implant Device,3045.74,,,3045.74,Other,110% of Medicare,2153.55,35,,2153.55,percent of total billed charges,Implant Device,2092.02,34,"Charges > $500, x 34%",2092.02,percent of total billed charges,Implant Device,2153.55,35,,2153.55,percent of total billed charges,Implant Device,2153.55,35,,2153.55,percent of total billed charges,Implant Device,2153.55,35,,2153.55,percent of total billed charges,Implant Device,2153.55,35,,2153.55,percent of total billed charges,Implant Device,2153.55,35,,2153.55,percent of total billed charges,Implant Device,2461.2,40,,2461.2,percent of total billed charges,Implant Device,2153.55,70,,2153.55,percent of total billed charges,All Other,2092.02,34,,2092.02,percent of total billed charges,Implant Device,2092.02,34,,2092.02,percent of total billed charges,Implant Device,2153.55,35,,2153.55,percent of total billed charges,Implant Device,2153.55,35,,2153.55,percent of total billed charges,Implant Device,2153.55,35,,2153.55,percent of total billed charges,Implant Device,2153.55,35,,2153.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2092.02,34,"If Charge > 2,000, then 34 percent",2092.02,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4553.24,
IN2BONES P92 ST014 SCREW 2.4X14MM,C1713,HCPCS,,79010788,CDM,278,RC,,,both,,,612,452.88,,,452.88,Other,150% of Medicare + 9.63% HCRA Surcharge,275.4,45,,275.4,percent of total billed charges,Critical Access Hospital RCC factor,208.08,34,,208.08,percent of total billed charges,Implant Device,208.08,34,,208.08,percent of total billed charges,Implant Device,208.08,34,,208.08,percent of total billed charges,Implant Device,208.08,34,,208.08,percent of total billed charges,Implant Device,208.08,34,,208.08,percent of total billed charges,Implant Device,302.94,,,302.94,Other,110% of Medicare,214.2,35,,214.2,percent of total billed charges,Implant Device,208.08,34,"Charges > $500, x 34%",208.08,percent of total billed charges,Implant Device,214.2,35,,214.2,percent of total billed charges,Implant Device,214.2,35,,214.2,percent of total billed charges,Implant Device,214.2,35,,214.2,percent of total billed charges,Implant Device,214.2,35,,214.2,percent of total billed charges,Implant Device,214.2,35,,214.2,percent of total billed charges,Implant Device,244.8,40,,244.8,percent of total billed charges,Implant Device,214.2,70,,214.2,percent of total billed charges,All Other,208.08,34,,208.08,percent of total billed charges,Implant Device,208.08,34,,208.08,percent of total billed charges,Implant Device,214.2,35,,214.2,percent of total billed charges,Implant Device,214.2,35,,214.2,percent of total billed charges,Implant Device,214.2,35,,214.2,percent of total billed charges,Implant Device,214.2,35,,214.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,452.88,
DEPUY 04.037.112S TFN NAIL 170X11 125DEG,C1713,HCPCS,,79010789,CDM,278,RC,,,both,,,3718,2751.33,,,2751.33,Other,150% of Medicare + 9.63% HCRA Surcharge,1673.1,45,,1673.1,percent of total billed charges,Critical Access Hospital RCC factor,1264.12,34,,1264.12,percent of total billed charges,Implant Device,1264.12,34,,1264.12,percent of total billed charges,Implant Device,1264.12,34,,1264.12,percent of total billed charges,Implant Device,1264.12,34,,1264.12,percent of total billed charges,Implant Device,1264.12,34,,1264.12,percent of total billed charges,Implant Device,1840.41,,,1840.41,Other,110% of Medicare,1301.3,35,,1301.3,percent of total billed charges,Implant Device,1264.12,34,"Charges > $500, x 34%",1264.12,percent of total billed charges,Implant Device,1301.3,35,,1301.3,percent of total billed charges,Implant Device,1301.3,35,,1301.3,percent of total billed charges,Implant Device,1301.3,35,,1301.3,percent of total billed charges,Implant Device,1301.3,35,,1301.3,percent of total billed charges,Implant Device,1301.3,35,,1301.3,percent of total billed charges,Implant Device,1487.2,40,,1487.2,percent of total billed charges,Implant Device,1301.3,70,,1301.3,percent of total billed charges,All Other,1264.12,34,,1264.12,percent of total billed charges,Implant Device,1264.12,34,,1264.12,percent of total billed charges,Implant Device,1301.3,35,,1301.3,percent of total billed charges,Implant Device,1301.3,35,,1301.3,percent of total billed charges,Implant Device,1301.3,35,,1301.3,percent of total billed charges,Implant Device,1301.3,35,,1301.3,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1264.12,34,"If Charge > 2,000, then 34 percent",1264.12,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2751.33,
ALLERGAN SCL-290 BREAST IMPLANT 290CC,C1789,HCPCS,,79010790,CDM,278,RC,,,both,,,4005,2963.71,,,2963.71,Other,150% of Medicare + 9.63% HCRA Surcharge,1802.25,45,,1802.25,percent of total billed charges,Critical Access Hospital RCC factor,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1982.48,,,1982.48,Other,110% of Medicare,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1361.7,34,"Charges > $500, x 34%",1361.7,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1602,40,,1602,percent of total billed charges,Implant Device,1401.75,70,,1401.75,percent of total billed charges,All Other,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1361.7,34,"If Charge > 2,000, then 34 percent",1361.7,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2963.71,
GORE HA70045A PROPATEN VASCULAR GRAFT,C1768,HCPCS,,79010792,CDM,278,RC,,,both,,,3684,2726.17,,,2726.17,Other,150% of Medicare + 9.63% HCRA Surcharge,1657.8,45,,1657.8,percent of total billed charges,Critical Access Hospital RCC factor,1252.56,34,,1252.56,percent of total billed charges,Implant Device,1252.56,34,,1252.56,percent of total billed charges,Implant Device,1252.56,34,,1252.56,percent of total billed charges,Implant Device,1252.56,34,,1252.56,percent of total billed charges,Implant Device,1252.56,34,,1252.56,percent of total billed charges,Implant Device,1823.58,,,1823.58,Other,110% of Medicare,1289.4,35,,1289.4,percent of total billed charges,Implant Device,1252.56,34,"Charges > $500, x 34%",1252.56,percent of total billed charges,Implant Device,1289.4,35,,1289.4,percent of total billed charges,Implant Device,1289.4,35,,1289.4,percent of total billed charges,Implant Device,1289.4,35,,1289.4,percent of total billed charges,Implant Device,1289.4,35,,1289.4,percent of total billed charges,Implant Device,1289.4,35,,1289.4,percent of total billed charges,Implant Device,1473.6,40,,1473.6,percent of total billed charges,Implant Device,1289.4,70,,1289.4,percent of total billed charges,All Other,1252.56,34,,1252.56,percent of total billed charges,Implant Device,1252.56,34,,1252.56,percent of total billed charges,Implant Device,1289.4,35,,1289.4,percent of total billed charges,Implant Device,1289.4,35,,1289.4,percent of total billed charges,Implant Device,1289.4,35,,1289.4,percent of total billed charges,Implant Device,1289.4,35,,1289.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1252.56,34,"If Charge > 2,000, then 34 percent",1252.56,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2726.17,
STRYKER 623-00-36G POLY INSERT 36MM,C1776,HCPCS,,79010793,CDM,278,RC,,,both,,,2503,1852.23,,,1852.23,Other,150% of Medicare + 9.63% HCRA Surcharge,1126.35,45,,1126.35,percent of total billed charges,Critical Access Hospital RCC factor,851.02,34,,851.02,percent of total billed charges,Implant Device,851.02,34,,851.02,percent of total billed charges,Implant Device,851.02,34,,851.02,percent of total billed charges,Implant Device,851.02,34,,851.02,percent of total billed charges,Implant Device,851.02,34,,851.02,percent of total billed charges,Implant Device,1238.99,,,1238.99,Other,110% of Medicare,876.05,35,,876.05,percent of total billed charges,Implant Device,851.02,34,"Charges > $500, x 34%",851.02,percent of total billed charges,Implant Device,876.05,35,,876.05,percent of total billed charges,Implant Device,876.05,35,,876.05,percent of total billed charges,Implant Device,876.05,35,,876.05,percent of total billed charges,Implant Device,876.05,35,,876.05,percent of total billed charges,Implant Device,876.05,35,,876.05,percent of total billed charges,Implant Device,1001.2,40,,1001.2,percent of total billed charges,Implant Device,876.05,70,,876.05,percent of total billed charges,All Other,851.02,34,,851.02,percent of total billed charges,Implant Device,851.02,34,,851.02,percent of total billed charges,Implant Device,876.05,35,,876.05,percent of total billed charges,Implant Device,876.05,35,,876.05,percent of total billed charges,Implant Device,876.05,35,,876.05,percent of total billed charges,Implant Device,876.05,35,,876.05,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,851.02,34,"If Charge > 2,000, then 34 percent",851.02,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1852.23,
STRYKER 702-04-60G ACETABULAR SHELL 60MM,C1776,HCPCS,,79010794,CDM,278,RC,,,both,,,3337,2469.39,,,2469.39,Other,150% of Medicare + 9.63% HCRA Surcharge,1501.65,45,,1501.65,percent of total billed charges,Critical Access Hospital RCC factor,1134.58,34,,1134.58,percent of total billed charges,Implant Device,1134.58,34,,1134.58,percent of total billed charges,Implant Device,1134.58,34,,1134.58,percent of total billed charges,Implant Device,1134.58,34,,1134.58,percent of total billed charges,Implant Device,1134.58,34,,1134.58,percent of total billed charges,Implant Device,1651.82,,,1651.82,Other,110% of Medicare,1167.95,35,,1167.95,percent of total billed charges,Implant Device,1134.58,34,"Charges > $500, x 34%",1134.58,percent of total billed charges,Implant Device,1167.95,35,,1167.95,percent of total billed charges,Implant Device,1167.95,35,,1167.95,percent of total billed charges,Implant Device,1167.95,35,,1167.95,percent of total billed charges,Implant Device,1167.95,35,,1167.95,percent of total billed charges,Implant Device,1167.95,35,,1167.95,percent of total billed charges,Implant Device,1334.8,40,,1334.8,percent of total billed charges,Implant Device,1167.95,70,,1167.95,percent of total billed charges,All Other,1134.58,34,,1134.58,percent of total billed charges,Implant Device,1134.58,34,,1134.58,percent of total billed charges,Implant Device,1167.95,35,,1167.95,percent of total billed charges,Implant Device,1167.95,35,,1167.95,percent of total billed charges,Implant Device,1167.95,35,,1167.95,percent of total billed charges,Implant Device,1167.95,35,,1167.95,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1134.58,34,"If Charge > 2,000, then 34 percent",1134.58,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2469.39,
STRYKER 6276-1-227 MODULAR HIP SYS 27MM,C1776,HCPCS,,79010795,CDM,278,RC,,,both,,,11948,8841.55,,,8841.55,Other,150% of Medicare + 9.63% HCRA Surcharge,5376.6,45,,5376.6,percent of total billed charges,Critical Access Hospital RCC factor,4062.32,34,,4062.32,percent of total billed charges,Implant Device,4062.32,34,,4062.32,percent of total billed charges,Implant Device,4062.32,34,,4062.32,percent of total billed charges,Implant Device,4062.32,34,,4062.32,percent of total billed charges,Implant Device,4062.32,34,,4062.32,percent of total billed charges,Implant Device,5914.26,,,5914.26,Other,110% of Medicare,4181.8,35,,4181.8,percent of total billed charges,Implant Device,4062.32,34,"Charges > $500, x 34%",4062.32,percent of total billed charges,Implant Device,4181.8,35,,4181.8,percent of total billed charges,Implant Device,4181.8,35,,4181.8,percent of total billed charges,Implant Device,4181.8,35,,4181.8,percent of total billed charges,Implant Device,4181.8,35,,4181.8,percent of total billed charges,Implant Device,4181.8,35,,4181.8,percent of total billed charges,Implant Device,4779.2,40,,4779.2,percent of total billed charges,Implant Device,4181.8,70,,4181.8,percent of total billed charges,All Other,4062.32,34,,4062.32,percent of total billed charges,Implant Device,4062.32,34,,4062.32,percent of total billed charges,Implant Device,4181.8,35,,4181.8,percent of total billed charges,Implant Device,4181.8,35,,4181.8,percent of total billed charges,Implant Device,4181.8,35,,4181.8,percent of total billed charges,Implant Device,4181.8,35,,4181.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,4062.32,34,"If Charge > 2,000, then 34 percent",4062.32,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,8841.55,
STRYKER 663-00-36G ECCENTRIC INSERT SZ36,C1776,HCPCS,,79010796,CDM,278,RC,,,both,,,2503,1852.23,,,1852.23,Other,150% of Medicare + 9.63% HCRA Surcharge,1126.35,45,,1126.35,percent of total billed charges,Critical Access Hospital RCC factor,851.02,34,,851.02,percent of total billed charges,Implant Device,851.02,34,,851.02,percent of total billed charges,Implant Device,851.02,34,,851.02,percent of total billed charges,Implant Device,851.02,34,,851.02,percent of total billed charges,Implant Device,851.02,34,,851.02,percent of total billed charges,Implant Device,1238.99,,,1238.99,Other,110% of Medicare,876.05,35,,876.05,percent of total billed charges,Implant Device,851.02,34,"Charges > $500, x 34%",851.02,percent of total billed charges,Implant Device,876.05,35,,876.05,percent of total billed charges,Implant Device,876.05,35,,876.05,percent of total billed charges,Implant Device,876.05,35,,876.05,percent of total billed charges,Implant Device,876.05,35,,876.05,percent of total billed charges,Implant Device,876.05,35,,876.05,percent of total billed charges,Implant Device,1001.2,40,,1001.2,percent of total billed charges,Implant Device,876.05,70,,876.05,percent of total billed charges,All Other,851.02,34,,851.02,percent of total billed charges,Implant Device,851.02,34,,851.02,percent of total billed charges,Implant Device,876.05,35,,876.05,percent of total billed charges,Implant Device,876.05,35,,876.05,percent of total billed charges,Implant Device,876.05,35,,876.05,percent of total billed charges,Implant Device,876.05,35,,876.05,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,851.02,34,"If Charge > 2,000, then 34 percent",851.02,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1852.23,
STRYKER 7030-6520 HEX SCREW 6.5X20MM,C1713,HCPCS,,79010797,CDM,278,RC,,,both,,,159,117.66,,,117.66,Other,150% of Medicare + 9.63% HCRA Surcharge,71.55,45,,71.55,percent of total billed charges,Critical Access Hospital RCC factor,54.06,34,,54.06,percent of total billed charges,Implant Device,54.06,34,,54.06,percent of total billed charges,Implant Device,54.06,34,,54.06,percent of total billed charges,Implant Device,54.06,34,,54.06,percent of total billed charges,Implant Device,54.06,34,,54.06,percent of total billed charges,Implant Device,78.71,,,78.71,Other,110% of Medicare,55.65,35,,55.65,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,55.65,35,,55.65,percent of total billed charges,Implant Device,55.65,35,,55.65,percent of total billed charges,Implant Device,55.65,35,,55.65,percent of total billed charges,Implant Device,55.65,35,,55.65,percent of total billed charges,Implant Device,55.65,35,,55.65,percent of total billed charges,Implant Device,63.6,40,,63.6,percent of total billed charges,Implant Device,55.65,70,,55.65,percent of total billed charges,All Other,54.06,34,,54.06,percent of total billed charges,Implant Device,54.06,34,,54.06,percent of total billed charges,Implant Device,55.65,35,,55.65,percent of total billed charges,Implant Device,55.65,35,,55.65,percent of total billed charges,Implant Device,55.65,35,,55.65,percent of total billed charges,Implant Device,55.65,35,,55.65,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,117.66,
STRYKER 7030-6540 HEX SCREW 6.5X40MM,C1713,HCPCS,,79010798,CDM,278,RC,,,both,,,159,117.66,,,117.66,Other,150% of Medicare + 9.63% HCRA Surcharge,71.55,45,,71.55,percent of total billed charges,Critical Access Hospital RCC factor,54.06,34,,54.06,percent of total billed charges,Implant Device,54.06,34,,54.06,percent of total billed charges,Implant Device,54.06,34,,54.06,percent of total billed charges,Implant Device,54.06,34,,54.06,percent of total billed charges,Implant Device,54.06,34,,54.06,percent of total billed charges,Implant Device,78.71,,,78.71,Other,110% of Medicare,55.65,35,,55.65,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,55.65,35,,55.65,percent of total billed charges,Implant Device,55.65,35,,55.65,percent of total billed charges,Implant Device,55.65,35,,55.65,percent of total billed charges,Implant Device,55.65,35,,55.65,percent of total billed charges,Implant Device,55.65,35,,55.65,percent of total billed charges,Implant Device,63.6,40,,63.6,percent of total billed charges,Implant Device,55.65,70,,55.65,percent of total billed charges,All Other,54.06,34,,54.06,percent of total billed charges,Implant Device,54.06,34,,54.06,percent of total billed charges,Implant Device,55.65,35,,55.65,percent of total billed charges,Implant Device,55.65,35,,55.65,percent of total billed charges,Implant Device,55.65,35,,55.65,percent of total billed charges,Implant Device,55.65,35,,55.65,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,117.66,
STRYKER 709-04-62G ACETABULAR SHELL 62MM,C1776,HCPCS,,79010799,CDM,278,RC,,,both,,,9269,6859.08,,,6859.08,Other,150% of Medicare + 9.63% HCRA Surcharge,4171.05,45,,4171.05,percent of total billed charges,Critical Access Hospital RCC factor,3151.46,34,,3151.46,percent of total billed charges,Implant Device,3151.46,34,,3151.46,percent of total billed charges,Implant Device,3151.46,34,,3151.46,percent of total billed charges,Implant Device,3151.46,34,,3151.46,percent of total billed charges,Implant Device,3151.46,34,,3151.46,percent of total billed charges,Implant Device,4588.16,,,4588.16,Other,110% of Medicare,3244.15,35,,3244.15,percent of total billed charges,Implant Device,3151.46,34,"Charges > $500, x 34%",3151.46,percent of total billed charges,Implant Device,3244.15,35,,3244.15,percent of total billed charges,Implant Device,3244.15,35,,3244.15,percent of total billed charges,Implant Device,3244.15,35,,3244.15,percent of total billed charges,Implant Device,3244.15,35,,3244.15,percent of total billed charges,Implant Device,3244.15,35,,3244.15,percent of total billed charges,Implant Device,3707.6,40,,3707.6,percent of total billed charges,Implant Device,3244.15,70,,3244.15,percent of total billed charges,All Other,3151.46,34,,3151.46,percent of total billed charges,Implant Device,3151.46,34,,3151.46,percent of total billed charges,Implant Device,3244.15,35,,3244.15,percent of total billed charges,Implant Device,3244.15,35,,3244.15,percent of total billed charges,Implant Device,3244.15,35,,3244.15,percent of total billed charges,Implant Device,3244.15,35,,3244.15,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3151.46,34,"If Charge > 2,000, then 34 percent",3151.46,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,6859.08,
ALLERGAN 133S-MV-12-T TISSUE EXPANDER,C1789,HCPCS,,79010800,CDM,278,RC,,,both,,,4785,3540.91,,,3540.91,Other,150% of Medicare + 9.63% HCRA Surcharge,2153.25,45,,2153.25,percent of total billed charges,Critical Access Hospital RCC factor,1626.9,34,,1626.9,percent of total billed charges,Implant Device,1626.9,34,,1626.9,percent of total billed charges,Implant Device,1626.9,34,,1626.9,percent of total billed charges,Implant Device,1626.9,34,,1626.9,percent of total billed charges,Implant Device,1626.9,34,,1626.9,percent of total billed charges,Implant Device,2368.58,,,2368.58,Other,110% of Medicare,1674.75,35,,1674.75,percent of total billed charges,Implant Device,1626.9,34,"Charges > $500, x 34%",1626.9,percent of total billed charges,Implant Device,1674.75,35,,1674.75,percent of total billed charges,Implant Device,1674.75,35,,1674.75,percent of total billed charges,Implant Device,1674.75,35,,1674.75,percent of total billed charges,Implant Device,1674.75,35,,1674.75,percent of total billed charges,Implant Device,1674.75,35,,1674.75,percent of total billed charges,Implant Device,1914,40,,1914,percent of total billed charges,Implant Device,1674.75,70,,1674.75,percent of total billed charges,All Other,1626.9,34,,1626.9,percent of total billed charges,Implant Device,1626.9,34,,1626.9,percent of total billed charges,Implant Device,1674.75,35,,1674.75,percent of total billed charges,Implant Device,1674.75,35,,1674.75,percent of total billed charges,Implant Device,1674.75,35,,1674.75,percent of total billed charges,Implant Device,1674.75,35,,1674.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1626.9,34,"If Charge > 2,000, then 34 percent",1626.9,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3540.91,
ALLERGAN 133S-MV-13-T TISSUE EXPANDER,C1789,HCPCS,,79010801,CDM,278,RC,,,both,,,4785,3540.91,,,3540.91,Other,150% of Medicare + 9.63% HCRA Surcharge,2153.25,45,,2153.25,percent of total billed charges,Critical Access Hospital RCC factor,1626.9,34,,1626.9,percent of total billed charges,Implant Device,1626.9,34,,1626.9,percent of total billed charges,Implant Device,1626.9,34,,1626.9,percent of total billed charges,Implant Device,1626.9,34,,1626.9,percent of total billed charges,Implant Device,1626.9,34,,1626.9,percent of total billed charges,Implant Device,2368.58,,,2368.58,Other,110% of Medicare,1674.75,35,,1674.75,percent of total billed charges,Implant Device,1626.9,34,"Charges > $500, x 34%",1626.9,percent of total billed charges,Implant Device,1674.75,35,,1674.75,percent of total billed charges,Implant Device,1674.75,35,,1674.75,percent of total billed charges,Implant Device,1674.75,35,,1674.75,percent of total billed charges,Implant Device,1674.75,35,,1674.75,percent of total billed charges,Implant Device,1674.75,35,,1674.75,percent of total billed charges,Implant Device,1914,40,,1914,percent of total billed charges,Implant Device,1674.75,70,,1674.75,percent of total billed charges,All Other,1626.9,34,,1626.9,percent of total billed charges,Implant Device,1626.9,34,,1626.9,percent of total billed charges,Implant Device,1674.75,35,,1674.75,percent of total billed charges,Implant Device,1674.75,35,,1674.75,percent of total billed charges,Implant Device,1674.75,35,,1674.75,percent of total billed charges,Implant Device,1674.75,35,,1674.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1626.9,34,"If Charge > 2,000, then 34 percent",1626.9,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3540.91,
BAXTER HEMOSTATIC ADS201844 MATRIX,C1713,HCPCS,,79010803,CDM,278,RC,,,both,,,540,399.6,,,399.6,Other,150% of Medicare + 9.63% HCRA Surcharge,243,45,,243,percent of total billed charges,Critical Access Hospital RCC factor,183.6,34,,183.6,percent of total billed charges,Implant Device,183.6,34,,183.6,percent of total billed charges,Implant Device,183.6,34,,183.6,percent of total billed charges,Implant Device,183.6,34,,183.6,percent of total billed charges,Implant Device,183.6,34,,183.6,percent of total billed charges,Implant Device,267.3,,,267.3,Other,110% of Medicare,189,35,,189,percent of total billed charges,Implant Device,183.6,34,"Charges > $500, x 34%",183.6,percent of total billed charges,Implant Device,189,35,,189,percent of total billed charges,Implant Device,189,35,,189,percent of total billed charges,Implant Device,189,35,,189,percent of total billed charges,Implant Device,189,35,,189,percent of total billed charges,Implant Device,189,35,,189,percent of total billed charges,Implant Device,216,40,,216,percent of total billed charges,Implant Device,189,70,,189,percent of total billed charges,All Other,183.6,34,,183.6,percent of total billed charges,Implant Device,183.6,34,,183.6,percent of total billed charges,Implant Device,189,35,,189,percent of total billed charges,Implant Device,189,35,,189,percent of total billed charges,Implant Device,189,35,,189,percent of total billed charges,Implant Device,189,35,,189,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,399.6,
STRYKER 663814 BONE SCREW 2.3X14MM,C1713,HCPCS,,79010804,CDM,278,RC,,,both,,,324,239.76,,,239.76,Other,150% of Medicare + 9.63% HCRA Surcharge,145.8,45,,145.8,percent of total billed charges,Critical Access Hospital RCC factor,110.16,34,,110.16,percent of total billed charges,Implant Device,110.16,34,,110.16,percent of total billed charges,Implant Device,110.16,34,,110.16,percent of total billed charges,Implant Device,110.16,34,,110.16,percent of total billed charges,Implant Device,110.16,34,,110.16,percent of total billed charges,Implant Device,160.38,,,160.38,Other,110% of Medicare,113.4,35,,113.4,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,129.6,40,,129.6,percent of total billed charges,Implant Device,113.4,70,,113.4,percent of total billed charges,All Other,110.16,34,,110.16,percent of total billed charges,Implant Device,110.16,34,,110.16,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,239.76,
SMITH & NEPHEW 4565 BIOINDUCTIVE IMPLANT,C1713,HCPCS,,79010805,CDM,278,RC,,,both,,,6000,4440.02,,,4440.02,Other,150% of Medicare + 9.63% HCRA Surcharge,2700,45,,2700,percent of total billed charges,Critical Access Hospital RCC factor,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2970,,,2970,Other,110% of Medicare,2100,35,,2100,percent of total billed charges,Implant Device,2040,34,"Charges > $500, x 34%",2040,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2400,40,,2400,percent of total billed charges,Implant Device,2100,70,,2100,percent of total billed charges,All Other,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2040,34,"If Charge > 2,000, then 34 percent",2040,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4440.02,
SMITH & NEPHEW 4403 BONE ANCHORS,C1713,HCPCS,,79010806,CDM,278,RC,,,both,,,3000,2220.01,,,2220.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1350,45,,1350,percent of total billed charges,Critical Access Hospital RCC factor,1020,34,,1020,percent of total billed charges,Implant Device,1020,34,,1020,percent of total billed charges,Implant Device,1020,34,,1020,percent of total billed charges,Implant Device,1020,34,,1020,percent of total billed charges,Implant Device,1020,34,,1020,percent of total billed charges,Implant Device,1485,,,1485,Other,110% of Medicare,1050,35,,1050,percent of total billed charges,Implant Device,1020,34,"Charges > $500, x 34%",1020,percent of total billed charges,Implant Device,1050,35,,1050,percent of total billed charges,Implant Device,1050,35,,1050,percent of total billed charges,Implant Device,1050,35,,1050,percent of total billed charges,Implant Device,1050,35,,1050,percent of total billed charges,Implant Device,1050,35,,1050,percent of total billed charges,Implant Device,1200,40,,1200,percent of total billed charges,Implant Device,1050,70,,1050,percent of total billed charges,All Other,1020,34,,1020,percent of total billed charges,Implant Device,1020,34,,1020,percent of total billed charges,Implant Device,1050,35,,1050,percent of total billed charges,Implant Device,1050,35,,1050,percent of total billed charges,Implant Device,1050,35,,1050,percent of total billed charges,Implant Device,1050,35,,1050,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1020,34,"If Charge > 2,000, then 34 percent",1020,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2220.01,
SMITH & NEPHEW 2504-1 TENDON ANCHORS,C1713,HCPCS,,79010807,CDM,278,RC,,,both,,,3000,2220.01,,,2220.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1350,45,,1350,percent of total billed charges,Critical Access Hospital RCC factor,1020,34,,1020,percent of total billed charges,Implant Device,1020,34,,1020,percent of total billed charges,Implant Device,1020,34,,1020,percent of total billed charges,Implant Device,1020,34,,1020,percent of total billed charges,Implant Device,1020,34,,1020,percent of total billed charges,Implant Device,1485,,,1485,Other,110% of Medicare,1050,35,,1050,percent of total billed charges,Implant Device,1020,34,"Charges > $500, x 34%",1020,percent of total billed charges,Implant Device,1050,35,,1050,percent of total billed charges,Implant Device,1050,35,,1050,percent of total billed charges,Implant Device,1050,35,,1050,percent of total billed charges,Implant Device,1050,35,,1050,percent of total billed charges,Implant Device,1050,35,,1050,percent of total billed charges,Implant Device,1200,40,,1200,percent of total billed charges,Implant Device,1050,70,,1050,percent of total billed charges,All Other,1020,34,,1020,percent of total billed charges,Implant Device,1020,34,,1020,percent of total billed charges,Implant Device,1050,35,,1050,percent of total billed charges,Implant Device,1050,35,,1050,percent of total billed charges,Implant Device,1050,35,,1050,percent of total billed charges,Implant Device,1050,35,,1050,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1020,34,"If Charge > 2,000, then 34 percent",1020,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2220.01,
EXACTECH 320-35-07 GLENOID BASEPLATE,C1776,HCPCS,,79010808,CDM,278,RC,,,both,,,5925,4384.51,,,4384.51,Other,150% of Medicare + 9.63% HCRA Surcharge,2666.25,45,,2666.25,percent of total billed charges,Critical Access Hospital RCC factor,2014.5,34,,2014.5,percent of total billed charges,Implant Device,2014.5,34,,2014.5,percent of total billed charges,Implant Device,2014.5,34,,2014.5,percent of total billed charges,Implant Device,2014.5,34,,2014.5,percent of total billed charges,Implant Device,2014.5,34,,2014.5,percent of total billed charges,Implant Device,2932.88,,,2932.88,Other,110% of Medicare,2073.75,35,,2073.75,percent of total billed charges,Implant Device,2014.5,34,"Charges > $500, x 34%",2014.5,percent of total billed charges,Implant Device,2073.75,35,,2073.75,percent of total billed charges,Implant Device,2073.75,35,,2073.75,percent of total billed charges,Implant Device,2073.75,35,,2073.75,percent of total billed charges,Implant Device,2073.75,35,,2073.75,percent of total billed charges,Implant Device,2073.75,35,,2073.75,percent of total billed charges,Implant Device,2370,40,,2370,percent of total billed charges,Implant Device,2073.75,70,,2073.75,percent of total billed charges,All Other,2014.5,34,,2014.5,percent of total billed charges,Implant Device,2014.5,34,,2014.5,percent of total billed charges,Implant Device,2073.75,35,,2073.75,percent of total billed charges,Implant Device,2073.75,35,,2073.75,percent of total billed charges,Implant Device,2073.75,35,,2073.75,percent of total billed charges,Implant Device,2073.75,35,,2073.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2014.5,34,"If Charge > 2,000, then 34 percent",2014.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4384.51,
STRYKER 656413 BONE SCREW 2.7X13MM,C1713,HCPCS,,79010809,CDM,278,RC,,,both,,,389,287.86,,,287.86,Other,150% of Medicare + 9.63% HCRA Surcharge,175.05,45,,175.05,percent of total billed charges,Critical Access Hospital RCC factor,132.26,34,,132.26,percent of total billed charges,Implant Device,132.26,34,,132.26,percent of total billed charges,Implant Device,132.26,34,,132.26,percent of total billed charges,Implant Device,132.26,34,,132.26,percent of total billed charges,Implant Device,132.26,34,,132.26,percent of total billed charges,Implant Device,192.56,,,192.56,Other,110% of Medicare,136.15,35,,136.15,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,136.15,35,,136.15,percent of total billed charges,Implant Device,136.15,35,,136.15,percent of total billed charges,Implant Device,136.15,35,,136.15,percent of total billed charges,Implant Device,136.15,35,,136.15,percent of total billed charges,Implant Device,136.15,35,,136.15,percent of total billed charges,Implant Device,155.6,40,,155.6,percent of total billed charges,Implant Device,136.15,70,,136.15,percent of total billed charges,All Other,132.26,34,,132.26,percent of total billed charges,Implant Device,132.26,34,,132.26,percent of total billed charges,Implant Device,136.15,35,,136.15,percent of total billed charges,Implant Device,136.15,35,,136.15,percent of total billed charges,Implant Device,136.15,35,,136.15,percent of total billed charges,Implant Device,136.15,35,,136.15,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,287.86,
BARD 1201015 PHASIX ST 10X15CM MESH,C1781,HCPCS,,79010812,CDM,278,RC,,,both,,,8001,5920.76,,,5920.76,Other,150% of Medicare + 9.63% HCRA Surcharge,3600.45,45,,3600.45,percent of total billed charges,Critical Access Hospital RCC factor,2720.34,34,,2720.34,percent of total billed charges,Implant Device,2720.34,34,,2720.34,percent of total billed charges,Implant Device,2720.34,34,,2720.34,percent of total billed charges,Implant Device,2720.34,34,,2720.34,percent of total billed charges,Implant Device,2720.34,34,,2720.34,percent of total billed charges,Implant Device,3960.5,,,3960.5,Other,110% of Medicare,2800.35,35,,2800.35,percent of total billed charges,Implant Device,2720.34,34,"Charges > $500, x 34%",2720.34,percent of total billed charges,Implant Device,2800.35,35,,2800.35,percent of total billed charges,Implant Device,2800.35,35,,2800.35,percent of total billed charges,Implant Device,2800.35,35,,2800.35,percent of total billed charges,Implant Device,2800.35,35,,2800.35,percent of total billed charges,Implant Device,2800.35,35,,2800.35,percent of total billed charges,Implant Device,3200.4,40,,3200.4,percent of total billed charges,Implant Device,2800.35,70,,2800.35,percent of total billed charges,All Other,2720.34,34,,2720.34,percent of total billed charges,Implant Device,2720.34,34,,2720.34,percent of total billed charges,Implant Device,2800.35,35,,2800.35,percent of total billed charges,Implant Device,2800.35,35,,2800.35,percent of total billed charges,Implant Device,2800.35,35,,2800.35,percent of total billed charges,Implant Device,2800.35,35,,2800.35,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2720.34,34,"If Charge > 2,000, then 34 percent",2720.34,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5920.76,
BARD 1201520 PHASIX ST 15X20CM MESH,C1781,HCPCS,,79010813,CDM,278,RC,,,both,,,14889,11017.9,,,11017.9,Other,150% of Medicare + 9.63% HCRA Surcharge,6700.05,45,,6700.05,percent of total billed charges,Critical Access Hospital RCC factor,5062.26,34,,5062.26,percent of total billed charges,Implant Device,5062.26,34,,5062.26,percent of total billed charges,Implant Device,5062.26,34,,5062.26,percent of total billed charges,Implant Device,5062.26,34,,5062.26,percent of total billed charges,Implant Device,5062.26,34,,5062.26,percent of total billed charges,Implant Device,7370.06,,,7370.06,Other,110% of Medicare,5211.15,35,,5211.15,percent of total billed charges,Implant Device,5062.26,34,"Charges > $500, x 34%",5062.26,percent of total billed charges,Implant Device,5211.15,35,,5211.15,percent of total billed charges,Implant Device,5211.15,35,,5211.15,percent of total billed charges,Implant Device,5211.15,35,,5211.15,percent of total billed charges,Implant Device,5211.15,35,,5211.15,percent of total billed charges,Implant Device,5211.15,35,,5211.15,percent of total billed charges,Implant Device,5955.6,40,,5955.6,percent of total billed charges,Implant Device,5211.15,70,,5211.15,percent of total billed charges,All Other,5062.26,34,,5062.26,percent of total billed charges,Implant Device,5062.26,34,,5062.26,percent of total billed charges,Implant Device,5211.15,35,,5211.15,percent of total billed charges,Implant Device,5211.15,35,,5211.15,percent of total billed charges,Implant Device,5211.15,35,,5211.15,percent of total billed charges,Implant Device,5211.15,35,,5211.15,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,5062.26,34,"If Charge > 2,000, then 34 percent",5062.26,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,11017.9,
BARD 1201325 PHASIX ST 13X25CM MESH,C1781,HCPCS,,79010814,CDM,278,RC,,,both,,,15678,11601.76,,,11601.76,Other,150% of Medicare + 9.63% HCRA Surcharge,7055.1,45,,7055.1,percent of total billed charges,Critical Access Hospital RCC factor,5330.52,34,,5330.52,percent of total billed charges,Implant Device,5330.52,34,,5330.52,percent of total billed charges,Implant Device,5330.52,34,,5330.52,percent of total billed charges,Implant Device,5330.52,34,,5330.52,percent of total billed charges,Implant Device,5330.52,34,,5330.52,percent of total billed charges,Implant Device,7760.61,,,7760.61,Other,110% of Medicare,5487.3,35,,5487.3,percent of total billed charges,Implant Device,5330.52,34,"Charges > $500, x 34%",5330.52,percent of total billed charges,Implant Device,5487.3,35,,5487.3,percent of total billed charges,Implant Device,5487.3,35,,5487.3,percent of total billed charges,Implant Device,5487.3,35,,5487.3,percent of total billed charges,Implant Device,5487.3,35,,5487.3,percent of total billed charges,Implant Device,5487.3,35,,5487.3,percent of total billed charges,Implant Device,6271.2,40,,6271.2,percent of total billed charges,Implant Device,5487.3,70,,5487.3,percent of total billed charges,All Other,5330.52,34,,5330.52,percent of total billed charges,Implant Device,5330.52,34,,5330.52,percent of total billed charges,Implant Device,5487.3,35,,5487.3,percent of total billed charges,Implant Device,5487.3,35,,5487.3,percent of total billed charges,Implant Device,5487.3,35,,5487.3,percent of total billed charges,Implant Device,5487.3,35,,5487.3,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,5330.52,34,"If Charge > 2,000, then 34 percent",5330.52,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,11601.76,
BARD 1202025 PHASIX ST 20X25CM MESH,C1781,HCPCS,,79010815,CDM,278,RC,,,both,,,24309,17988.72,,,17988.72,Other,150% of Medicare + 9.63% HCRA Surcharge,10939.05,45,,10939.05,percent of total billed charges,Critical Access Hospital RCC factor,8265.06,34,,8265.06,percent of total billed charges,Implant Device,8265.06,34,,8265.06,percent of total billed charges,Implant Device,8265.06,34,,8265.06,percent of total billed charges,Implant Device,8265.06,34,,8265.06,percent of total billed charges,Implant Device,8265.06,34,,8265.06,percent of total billed charges,Implant Device,12032.96,,,12032.96,Other,110% of Medicare,8508.15,35,,8508.15,percent of total billed charges,Implant Device,8265.06,34,"Charges > $500, x 34%",8265.06,percent of total billed charges,Implant Device,8508.15,35,,8508.15,percent of total billed charges,Implant Device,8508.15,35,,8508.15,percent of total billed charges,Implant Device,8508.15,35,,8508.15,percent of total billed charges,Implant Device,8508.15,35,,8508.15,percent of total billed charges,Implant Device,8508.15,35,,8508.15,percent of total billed charges,Implant Device,9723.6,40,,9723.6,percent of total billed charges,Implant Device,8508.15,70,,8508.15,percent of total billed charges,All Other,8265.06,34,,8265.06,percent of total billed charges,Implant Device,8265.06,34,,8265.06,percent of total billed charges,Implant Device,8508.15,35,,8508.15,percent of total billed charges,Implant Device,8508.15,35,,8508.15,percent of total billed charges,Implant Device,8508.15,35,,8508.15,percent of total billed charges,Implant Device,8508.15,35,,8508.15,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,8265.06,34,"If Charge > 2,000, then 34 percent",8265.06,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,17988.72,
IN2BONES P67 ST436 CANN SCREW 4X36MM,C1713,HCPCS,,79010817,CDM,278,RC,,,both,,,1485,1098.9,,,1098.9,Other,150% of Medicare + 9.63% HCRA Surcharge,668.25,45,,668.25,percent of total billed charges,Critical Access Hospital RCC factor,504.9,34,,504.9,percent of total billed charges,Implant Device,504.9,34,,504.9,percent of total billed charges,Implant Device,504.9,34,,504.9,percent of total billed charges,Implant Device,504.9,34,,504.9,percent of total billed charges,Implant Device,504.9,34,,504.9,percent of total billed charges,Implant Device,735.08,,,735.08,Other,110% of Medicare,519.75,35,,519.75,percent of total billed charges,Implant Device,504.9,34,"Charges > $500, x 34%",504.9,percent of total billed charges,Implant Device,519.75,35,,519.75,percent of total billed charges,Implant Device,519.75,35,,519.75,percent of total billed charges,Implant Device,519.75,35,,519.75,percent of total billed charges,Implant Device,519.75,35,,519.75,percent of total billed charges,Implant Device,519.75,35,,519.75,percent of total billed charges,Implant Device,594,40,,594,percent of total billed charges,Implant Device,519.75,70,,519.75,percent of total billed charges,All Other,504.9,34,,504.9,percent of total billed charges,Implant Device,504.9,34,,504.9,percent of total billed charges,Implant Device,519.75,35,,519.75,percent of total billed charges,Implant Device,519.75,35,,519.75,percent of total billed charges,Implant Device,519.75,35,,519.75,percent of total billed charges,Implant Device,519.75,35,,519.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1098.9,
ACUMED 40-0027-S FIBULA ROD 3.0X145MM,C1713,HCPCS,,79010818,CDM,278,RC,,,both,,,5994,4435.57,,,4435.57,Other,150% of Medicare + 9.63% HCRA Surcharge,2697.3,45,,2697.3,percent of total billed charges,Critical Access Hospital RCC factor,2037.96,34,,2037.96,percent of total billed charges,Implant Device,2037.96,34,,2037.96,percent of total billed charges,Implant Device,2037.96,34,,2037.96,percent of total billed charges,Implant Device,2037.96,34,,2037.96,percent of total billed charges,Implant Device,2037.96,34,,2037.96,percent of total billed charges,Implant Device,2967.03,,,2967.03,Other,110% of Medicare,2097.9,35,,2097.9,percent of total billed charges,Implant Device,2037.96,34,"Charges > $500, x 34%",2037.96,percent of total billed charges,Implant Device,2097.9,35,,2097.9,percent of total billed charges,Implant Device,2097.9,35,,2097.9,percent of total billed charges,Implant Device,2097.9,35,,2097.9,percent of total billed charges,Implant Device,2097.9,35,,2097.9,percent of total billed charges,Implant Device,2097.9,35,,2097.9,percent of total billed charges,Implant Device,2397.6,40,,2397.6,percent of total billed charges,Implant Device,2097.9,70,,2097.9,percent of total billed charges,All Other,2037.96,34,,2037.96,percent of total billed charges,Implant Device,2037.96,34,,2037.96,percent of total billed charges,Implant Device,2097.9,35,,2097.9,percent of total billed charges,Implant Device,2097.9,35,,2097.9,percent of total billed charges,Implant Device,2097.9,35,,2097.9,percent of total billed charges,Implant Device,2097.9,35,,2097.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2037.96,34,"If Charge > 2,000, then 34 percent",2037.96,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4435.57,
ACUMED CO-3200-S CORTICAL SCREW 3.5X20MM,C1713,HCPCS,,79010819,CDM,278,RC,,,both,,,324,239.76,,,239.76,Other,150% of Medicare + 9.63% HCRA Surcharge,145.8,45,,145.8,percent of total billed charges,Critical Access Hospital RCC factor,110.16,34,,110.16,percent of total billed charges,Implant Device,110.16,34,,110.16,percent of total billed charges,Implant Device,110.16,34,,110.16,percent of total billed charges,Implant Device,110.16,34,,110.16,percent of total billed charges,Implant Device,110.16,34,,110.16,percent of total billed charges,Implant Device,160.38,,,160.38,Other,110% of Medicare,113.4,35,,113.4,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,129.6,40,,129.6,percent of total billed charges,Implant Device,113.4,70,,113.4,percent of total billed charges,All Other,110.16,34,,110.16,percent of total billed charges,Implant Device,110.16,34,,110.16,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,239.76,
ACUMED 3005-40040 CANN SCREW 4.0X40MM,C1713,HCPCS,,79010820,CDM,278,RC,,,both,,,849,628.26,,,628.26,Other,150% of Medicare + 9.63% HCRA Surcharge,382.05,45,,382.05,percent of total billed charges,Critical Access Hospital RCC factor,288.66,34,,288.66,percent of total billed charges,Implant Device,288.66,34,,288.66,percent of total billed charges,Implant Device,288.66,34,,288.66,percent of total billed charges,Implant Device,288.66,34,,288.66,percent of total billed charges,Implant Device,288.66,34,,288.66,percent of total billed charges,Implant Device,420.26,,,420.26,Other,110% of Medicare,297.15,35,,297.15,percent of total billed charges,Implant Device,288.66,34,"Charges > $500, x 34%",288.66,percent of total billed charges,Implant Device,297.15,35,,297.15,percent of total billed charges,Implant Device,297.15,35,,297.15,percent of total billed charges,Implant Device,297.15,35,,297.15,percent of total billed charges,Implant Device,297.15,35,,297.15,percent of total billed charges,Implant Device,297.15,35,,297.15,percent of total billed charges,Implant Device,339.6,40,,339.6,percent of total billed charges,Implant Device,297.15,70,,297.15,percent of total billed charges,All Other,288.66,34,,288.66,percent of total billed charges,Implant Device,288.66,34,,288.66,percent of total billed charges,Implant Device,297.15,35,,297.15,percent of total billed charges,Implant Device,297.15,35,,297.15,percent of total billed charges,Implant Device,297.15,35,,297.15,percent of total billed charges,Implant Device,297.15,35,,297.15,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,628.26,
EXACTECH 320-35-03 GLENOID PLATE LEFT,C1776,HCPCS,,79010825,CDM,278,RC,,,both,,,5925,4384.51,,,4384.51,Other,150% of Medicare + 9.63% HCRA Surcharge,2666.25,45,,2666.25,percent of total billed charges,Critical Access Hospital RCC factor,2014.5,34,,2014.5,percent of total billed charges,Implant Device,2014.5,34,,2014.5,percent of total billed charges,Implant Device,2014.5,34,,2014.5,percent of total billed charges,Implant Device,2014.5,34,,2014.5,percent of total billed charges,Implant Device,2014.5,34,,2014.5,percent of total billed charges,Implant Device,2932.88,,,2932.88,Other,110% of Medicare,2073.75,35,,2073.75,percent of total billed charges,Implant Device,2014.5,34,"Charges > $500, x 34%",2014.5,percent of total billed charges,Implant Device,2073.75,35,,2073.75,percent of total billed charges,Implant Device,2073.75,35,,2073.75,percent of total billed charges,Implant Device,2073.75,35,,2073.75,percent of total billed charges,Implant Device,2073.75,35,,2073.75,percent of total billed charges,Implant Device,2073.75,35,,2073.75,percent of total billed charges,Implant Device,2370,40,,2370,percent of total billed charges,Implant Device,2073.75,70,,2073.75,percent of total billed charges,All Other,2014.5,34,,2014.5,percent of total billed charges,Implant Device,2014.5,34,,2014.5,percent of total billed charges,Implant Device,2073.75,35,,2073.75,percent of total billed charges,Implant Device,2073.75,35,,2073.75,percent of total billed charges,Implant Device,2073.75,35,,2073.75,percent of total billed charges,Implant Device,2073.75,35,,2073.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2014.5,34,"If Charge > 2,000, then 34 percent",2014.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4384.51,
ZIMMER 574201040 FEM STEM 12/14 SZ 4,C1776,HCPCS,,79010826,CDM,278,RC,,,both,,,7398,5474.54,,,5474.54,Other,150% of Medicare + 9.63% HCRA Surcharge,3329.1,45,,3329.1,percent of total billed charges,Critical Access Hospital RCC factor,2515.32,34,,2515.32,percent of total billed charges,Implant Device,2515.32,34,,2515.32,percent of total billed charges,Implant Device,2515.32,34,,2515.32,percent of total billed charges,Implant Device,2515.32,34,,2515.32,percent of total billed charges,Implant Device,2515.32,34,,2515.32,percent of total billed charges,Implant Device,3662.01,,,3662.01,Other,110% of Medicare,2589.3,35,,2589.3,percent of total billed charges,Implant Device,2515.32,34,"Charges > $500, x 34%",2515.32,percent of total billed charges,Implant Device,2589.3,35,,2589.3,percent of total billed charges,Implant Device,2589.3,35,,2589.3,percent of total billed charges,Implant Device,2589.3,35,,2589.3,percent of total billed charges,Implant Device,2589.3,35,,2589.3,percent of total billed charges,Implant Device,2589.3,35,,2589.3,percent of total billed charges,Implant Device,2959.2,40,,2959.2,percent of total billed charges,Implant Device,2589.3,70,,2589.3,percent of total billed charges,All Other,2515.32,34,,2515.32,percent of total billed charges,Implant Device,2515.32,34,,2515.32,percent of total billed charges,Implant Device,2589.3,35,,2589.3,percent of total billed charges,Implant Device,2589.3,35,,2589.3,percent of total billed charges,Implant Device,2589.3,35,,2589.3,percent of total billed charges,Implant Device,2589.3,35,,2589.3,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2515.32,34,"If Charge > 2,000, then 34 percent",2515.32,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5474.54,
ZIMMER 00-5980-057-03 TIBIAL COMP SZ 9,C1713,HCPCS,,79010827,CDM,278,RC,,,both,,,2466,1824.85,,,1824.85,Other,150% of Medicare + 9.63% HCRA Surcharge,1109.7,45,,1109.7,percent of total billed charges,Critical Access Hospital RCC factor,838.44,34,,838.44,percent of total billed charges,Implant Device,838.44,34,,838.44,percent of total billed charges,Implant Device,838.44,34,,838.44,percent of total billed charges,Implant Device,838.44,34,,838.44,percent of total billed charges,Implant Device,838.44,34,,838.44,percent of total billed charges,Implant Device,1220.67,,,1220.67,Other,110% of Medicare,863.1,35,,863.1,percent of total billed charges,Implant Device,838.44,34,"Charges > $500, x 34%",838.44,percent of total billed charges,Implant Device,863.1,35,,863.1,percent of total billed charges,Implant Device,863.1,35,,863.1,percent of total billed charges,Implant Device,863.1,35,,863.1,percent of total billed charges,Implant Device,863.1,35,,863.1,percent of total billed charges,Implant Device,863.1,35,,863.1,percent of total billed charges,Implant Device,986.4,40,,986.4,percent of total billed charges,Implant Device,863.1,70,,863.1,percent of total billed charges,All Other,838.44,34,,838.44,percent of total billed charges,Implant Device,838.44,34,,838.44,percent of total billed charges,Implant Device,863.1,35,,863.1,percent of total billed charges,Implant Device,863.1,35,,863.1,percent of total billed charges,Implant Device,863.1,35,,863.1,percent of total billed charges,Implant Device,863.1,35,,863.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,838.44,34,"If Charge > 2,000, then 34 percent",838.44,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1824.85,
"ZIMMER 32-8105-043-02 ULNA ASSEMBLY 3""",C1713,HCPCS,,79010828,CDM,278,RC,,,both,,,14700,10878.04,,,10878.04,Other,150% of Medicare + 9.63% HCRA Surcharge,6615,45,,6615,percent of total billed charges,Critical Access Hospital RCC factor,4998,34,,4998,percent of total billed charges,Implant Device,4998,34,,4998,percent of total billed charges,Implant Device,4998,34,,4998,percent of total billed charges,Implant Device,4998,34,,4998,percent of total billed charges,Implant Device,4998,34,,4998,percent of total billed charges,Implant Device,7276.5,,,7276.5,Other,110% of Medicare,5145,35,,5145,percent of total billed charges,Implant Device,4998,34,"Charges > $500, x 34%",4998,percent of total billed charges,Implant Device,5145,35,,5145,percent of total billed charges,Implant Device,5145,35,,5145,percent of total billed charges,Implant Device,5145,35,,5145,percent of total billed charges,Implant Device,5145,35,,5145,percent of total billed charges,Implant Device,5145,35,,5145,percent of total billed charges,Implant Device,5880,40,,5880,percent of total billed charges,Implant Device,5145,70,,5145,percent of total billed charges,All Other,4998,34,,4998,percent of total billed charges,Implant Device,4998,34,,4998,percent of total billed charges,Implant Device,5145,35,,5145,percent of total billed charges,Implant Device,5145,35,,5145,percent of total billed charges,Implant Device,5145,35,,5145,percent of total billed charges,Implant Device,5145,35,,5145,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,4998,34,"If Charge > 2,000, then 34 percent",4998,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,10878.04,
MEDTRONIC NMRM6122 TYRX NEURO ENVELOPE,C1781,HCPCS,,79010836,CDM,278,RC,,,both,,,3885,2874.91,,,2874.91,Other,150% of Medicare + 9.63% HCRA Surcharge,1748.25,45,,1748.25,percent of total billed charges,Critical Access Hospital RCC factor,1320.9,34,,1320.9,percent of total billed charges,Implant Device,1320.9,34,,1320.9,percent of total billed charges,Implant Device,1320.9,34,,1320.9,percent of total billed charges,Implant Device,1320.9,34,,1320.9,percent of total billed charges,Implant Device,1320.9,34,,1320.9,percent of total billed charges,Implant Device,1923.08,,,1923.08,Other,110% of Medicare,1359.75,35,,1359.75,percent of total billed charges,Implant Device,1320.9,34,"Charges > $500, x 34%",1320.9,percent of total billed charges,Implant Device,1359.75,35,,1359.75,percent of total billed charges,Implant Device,1359.75,35,,1359.75,percent of total billed charges,Implant Device,1359.75,35,,1359.75,percent of total billed charges,Implant Device,1359.75,35,,1359.75,percent of total billed charges,Implant Device,1359.75,35,,1359.75,percent of total billed charges,Implant Device,1554,40,,1554,percent of total billed charges,Implant Device,1359.75,70,,1359.75,percent of total billed charges,All Other,1320.9,34,,1320.9,percent of total billed charges,Implant Device,1320.9,34,,1320.9,percent of total billed charges,Implant Device,1359.75,35,,1359.75,percent of total billed charges,Implant Device,1359.75,35,,1359.75,percent of total billed charges,Implant Device,1359.75,35,,1359.75,percent of total billed charges,Implant Device,1359.75,35,,1359.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1320.9,34,"If Charge > 2,000, then 34 percent",1320.9,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2874.91,
IN2BONES P92 ST011 CORT SCREW 2.4X11MM,C1713,HCPCS,,79010837,CDM,278,RC,,,both,,,612,452.88,,,452.88,Other,150% of Medicare + 9.63% HCRA Surcharge,275.4,45,,275.4,percent of total billed charges,Critical Access Hospital RCC factor,208.08,34,,208.08,percent of total billed charges,Implant Device,208.08,34,,208.08,percent of total billed charges,Implant Device,208.08,34,,208.08,percent of total billed charges,Implant Device,208.08,34,,208.08,percent of total billed charges,Implant Device,208.08,34,,208.08,percent of total billed charges,Implant Device,302.94,,,302.94,Other,110% of Medicare,214.2,35,,214.2,percent of total billed charges,Implant Device,208.08,34,"Charges > $500, x 34%",208.08,percent of total billed charges,Implant Device,214.2,35,,214.2,percent of total billed charges,Implant Device,214.2,35,,214.2,percent of total billed charges,Implant Device,214.2,35,,214.2,percent of total billed charges,Implant Device,214.2,35,,214.2,percent of total billed charges,Implant Device,214.2,35,,214.2,percent of total billed charges,Implant Device,244.8,40,,244.8,percent of total billed charges,Implant Device,214.2,70,,214.2,percent of total billed charges,All Other,208.08,34,,208.08,percent of total billed charges,Implant Device,208.08,34,,208.08,percent of total billed charges,Implant Device,214.2,35,,214.2,percent of total billed charges,Implant Device,214.2,35,,214.2,percent of total billed charges,Implant Device,214.2,35,,214.2,percent of total billed charges,Implant Device,214.2,35,,214.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,452.88,
IN2BONES P92 ST012 CORT SCREW 2.4X12MM,C1713,HCPCS,,79010838,CDM,278,RC,,,both,,,612,452.88,,,452.88,Other,150% of Medicare + 9.63% HCRA Surcharge,275.4,45,,275.4,percent of total billed charges,Critical Access Hospital RCC factor,208.08,34,,208.08,percent of total billed charges,Implant Device,208.08,34,,208.08,percent of total billed charges,Implant Device,208.08,34,,208.08,percent of total billed charges,Implant Device,208.08,34,,208.08,percent of total billed charges,Implant Device,208.08,34,,208.08,percent of total billed charges,Implant Device,302.94,,,302.94,Other,110% of Medicare,214.2,35,,214.2,percent of total billed charges,Implant Device,208.08,34,"Charges > $500, x 34%",208.08,percent of total billed charges,Implant Device,214.2,35,,214.2,percent of total billed charges,Implant Device,214.2,35,,214.2,percent of total billed charges,Implant Device,214.2,35,,214.2,percent of total billed charges,Implant Device,214.2,35,,214.2,percent of total billed charges,Implant Device,214.2,35,,214.2,percent of total billed charges,Implant Device,244.8,40,,244.8,percent of total billed charges,Implant Device,214.2,70,,214.2,percent of total billed charges,All Other,208.08,34,,208.08,percent of total billed charges,Implant Device,208.08,34,,208.08,percent of total billed charges,Implant Device,214.2,35,,214.2,percent of total billed charges,Implant Device,214.2,35,,214.2,percent of total billed charges,Implant Device,214.2,35,,214.2,percent of total billed charges,Implant Device,214.2,35,,214.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,452.88,
LIFENET RFP10 FRESH PLUG ALLOGRAFT 10MM,C1713,HCPCS,,79010840,CDM,278,RC,,,both,,,7125,5272.52,,,5272.52,Other,150% of Medicare + 9.63% HCRA Surcharge,3206.25,45,,3206.25,percent of total billed charges,Critical Access Hospital RCC factor,2422.5,34,,2422.5,percent of total billed charges,Implant Device,2422.5,34,,2422.5,percent of total billed charges,Implant Device,2422.5,34,,2422.5,percent of total billed charges,Implant Device,2422.5,34,,2422.5,percent of total billed charges,Implant Device,2422.5,34,,2422.5,percent of total billed charges,Implant Device,3526.88,,,3526.88,Other,110% of Medicare,2493.75,35,,2493.75,percent of total billed charges,Implant Device,2422.5,34,"Charges > $500, x 34%",2422.5,percent of total billed charges,Implant Device,2493.75,35,,2493.75,percent of total billed charges,Implant Device,2493.75,35,,2493.75,percent of total billed charges,Implant Device,2493.75,35,,2493.75,percent of total billed charges,Implant Device,2493.75,35,,2493.75,percent of total billed charges,Implant Device,2493.75,35,,2493.75,percent of total billed charges,Implant Device,2850,40,,2850,percent of total billed charges,Implant Device,2493.75,70,,2493.75,percent of total billed charges,All Other,2422.5,34,,2422.5,percent of total billed charges,Implant Device,2422.5,34,,2422.5,percent of total billed charges,Implant Device,2493.75,35,,2493.75,percent of total billed charges,Implant Device,2493.75,35,,2493.75,percent of total billed charges,Implant Device,2493.75,35,,2493.75,percent of total billed charges,Implant Device,2493.75,35,,2493.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2422.5,34,"If Charge > 2,000, then 34 percent",2422.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5272.52,
STRYKER UH1-50-28 BIPOLAR COMP 50X28MM,C1776,HCPCS,,79010841,CDM,278,RC,,,both,,,1391,1029.34,,,1029.34,Other,150% of Medicare + 9.63% HCRA Surcharge,625.95,45,,625.95,percent of total billed charges,Critical Access Hospital RCC factor,472.94,34,,472.94,percent of total billed charges,Implant Device,472.94,34,,472.94,percent of total billed charges,Implant Device,472.94,34,,472.94,percent of total billed charges,Implant Device,472.94,34,,472.94,percent of total billed charges,Implant Device,472.94,34,,472.94,percent of total billed charges,Implant Device,688.55,,,688.55,Other,110% of Medicare,486.85,35,,486.85,percent of total billed charges,Implant Device,472.94,34,"Charges > $500, x 34%",472.94,percent of total billed charges,Implant Device,486.85,35,,486.85,percent of total billed charges,Implant Device,486.85,35,,486.85,percent of total billed charges,Implant Device,486.85,35,,486.85,percent of total billed charges,Implant Device,486.85,35,,486.85,percent of total billed charges,Implant Device,486.85,35,,486.85,percent of total billed charges,Implant Device,556.4,40,,556.4,percent of total billed charges,Implant Device,486.85,70,,486.85,percent of total billed charges,All Other,472.94,34,,472.94,percent of total billed charges,Implant Device,472.94,34,,472.94,percent of total billed charges,Implant Device,486.85,35,,486.85,percent of total billed charges,Implant Device,486.85,35,,486.85,percent of total billed charges,Implant Device,486.85,35,,486.85,percent of total billed charges,Implant Device,486.85,35,,486.85,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1029.34,
ZIMMER 574201060 FEM STEM 12/14 SIZE 6,C1776,HCPCS,,79010842,CDM,278,RC,,,both,,,8573,6344.04,,,6344.04,Other,150% of Medicare + 9.63% HCRA Surcharge,3857.85,45,,3857.85,percent of total billed charges,Critical Access Hospital RCC factor,2914.82,34,,2914.82,percent of total billed charges,Implant Device,2914.82,34,,2914.82,percent of total billed charges,Implant Device,2914.82,34,,2914.82,percent of total billed charges,Implant Device,2914.82,34,,2914.82,percent of total billed charges,Implant Device,2914.82,34,,2914.82,percent of total billed charges,Implant Device,4243.64,,,4243.64,Other,110% of Medicare,3000.55,35,,3000.55,percent of total billed charges,Implant Device,2914.82,34,"Charges > $500, x 34%",2914.82,percent of total billed charges,Implant Device,3000.55,35,,3000.55,percent of total billed charges,Implant Device,3000.55,35,,3000.55,percent of total billed charges,Implant Device,3000.55,35,,3000.55,percent of total billed charges,Implant Device,3000.55,35,,3000.55,percent of total billed charges,Implant Device,3000.55,35,,3000.55,percent of total billed charges,Implant Device,3429.2,40,,3429.2,percent of total billed charges,Implant Device,3000.55,70,,3000.55,percent of total billed charges,All Other,2914.82,34,,2914.82,percent of total billed charges,Implant Device,2914.82,34,,2914.82,percent of total billed charges,Implant Device,3000.55,35,,3000.55,percent of total billed charges,Implant Device,3000.55,35,,3000.55,percent of total billed charges,Implant Device,3000.55,35,,3000.55,percent of total billed charges,Implant Device,3000.55,35,,3000.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2914.82,34,"If Charge > 2,000, then 34 percent",2914.82,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,6344.04,
ZIMMER 00-5950-013-02 FEM COMP SZ C RT,C1776,HCPCS,,79010843,CDM,278,RC,,,both,,,7200,5328.02,,,5328.02,Other,150% of Medicare + 9.63% HCRA Surcharge,3240,45,,3240,percent of total billed charges,Critical Access Hospital RCC factor,2448,34,,2448,percent of total billed charges,Implant Device,2448,34,,2448,percent of total billed charges,Implant Device,2448,34,,2448,percent of total billed charges,Implant Device,2448,34,,2448,percent of total billed charges,Implant Device,2448,34,,2448,percent of total billed charges,Implant Device,3564,,,3564,Other,110% of Medicare,2520,35,,2520,percent of total billed charges,Implant Device,2448,34,"Charges > $500, x 34%",2448,percent of total billed charges,Implant Device,2520,35,,2520,percent of total billed charges,Implant Device,2520,35,,2520,percent of total billed charges,Implant Device,2520,35,,2520,percent of total billed charges,Implant Device,2520,35,,2520,percent of total billed charges,Implant Device,2520,35,,2520,percent of total billed charges,Implant Device,2880,40,,2880,percent of total billed charges,Implant Device,2520,70,,2520,percent of total billed charges,All Other,2448,34,,2448,percent of total billed charges,Implant Device,2448,34,,2448,percent of total billed charges,Implant Device,2520,35,,2520,percent of total billed charges,Implant Device,2520,35,,2520,percent of total billed charges,Implant Device,2520,35,,2520,percent of total billed charges,Implant Device,2520,35,,2520,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2448,34,"If Charge > 2,000, then 34 percent",2448,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5328.02,
EXACTECH SPC0323 TAPERED WEDGE STEM 46MM,C1713,HCPCS,,79010844,CDM,278,RC,,,both,,,10625,7862.53,,,7862.53,Other,150% of Medicare + 9.63% HCRA Surcharge,4781.25,45,,4781.25,percent of total billed charges,Critical Access Hospital RCC factor,3612.5,34,,3612.5,percent of total billed charges,Implant Device,3612.5,34,,3612.5,percent of total billed charges,Implant Device,3612.5,34,,3612.5,percent of total billed charges,Implant Device,3612.5,34,,3612.5,percent of total billed charges,Implant Device,3612.5,34,,3612.5,percent of total billed charges,Implant Device,5259.38,,,5259.38,Other,110% of Medicare,3718.75,35,,3718.75,percent of total billed charges,Implant Device,3612.5,34,"Charges > $500, x 34%",3612.5,percent of total billed charges,Implant Device,3718.75,35,,3718.75,percent of total billed charges,Implant Device,3718.75,35,,3718.75,percent of total billed charges,Implant Device,3718.75,35,,3718.75,percent of total billed charges,Implant Device,3718.75,35,,3718.75,percent of total billed charges,Implant Device,3718.75,35,,3718.75,percent of total billed charges,Implant Device,4250,40,,4250,percent of total billed charges,Implant Device,3718.75,70,,3718.75,percent of total billed charges,All Other,3612.5,34,,3612.5,percent of total billed charges,Implant Device,3612.5,34,,3612.5,percent of total billed charges,Implant Device,3718.75,35,,3718.75,percent of total billed charges,Implant Device,3718.75,35,,3718.75,percent of total billed charges,Implant Device,3718.75,35,,3718.75,percent of total billed charges,Implant Device,3718.75,35,,3718.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3612.5,34,"If Charge > 2,000, then 34 percent",3612.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,7862.53,
EXACTECH 300-30-08 HUMERAL STEM 8MM,C1776,HCPCS,,79010845,CDM,278,RC,,,both,,,6000,4440.02,,,4440.02,Other,150% of Medicare + 9.63% HCRA Surcharge,2700,45,,2700,percent of total billed charges,Critical Access Hospital RCC factor,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2970,,,2970,Other,110% of Medicare,2100,35,,2100,percent of total billed charges,Implant Device,2040,34,"Charges > $500, x 34%",2040,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2400,40,,2400,percent of total billed charges,Implant Device,2100,70,,2100,percent of total billed charges,All Other,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2040,34,"If Charge > 2,000, then 34 percent",2040,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4440.02,
STRYKER 657018 LOCKING SCREW 2.7X18MM,C1713,HCPCS,,79010846,CDM,278,RC,,,both,,,494,365.56,,,365.56,Other,150% of Medicare + 9.63% HCRA Surcharge,222.3,45,,222.3,percent of total billed charges,Critical Access Hospital RCC factor,167.96,34,,167.96,percent of total billed charges,Implant Device,167.96,34,,167.96,percent of total billed charges,Implant Device,167.96,34,,167.96,percent of total billed charges,Implant Device,167.96,34,,167.96,percent of total billed charges,Implant Device,167.96,34,,167.96,percent of total billed charges,Implant Device,244.53,,,244.53,Other,110% of Medicare,172.9,35,,172.9,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,172.9,35,,172.9,percent of total billed charges,Implant Device,172.9,35,,172.9,percent of total billed charges,Implant Device,172.9,35,,172.9,percent of total billed charges,Implant Device,172.9,35,,172.9,percent of total billed charges,Implant Device,172.9,35,,172.9,percent of total billed charges,Implant Device,197.6,40,,197.6,percent of total billed charges,Implant Device,172.9,70,,172.9,percent of total billed charges,All Other,167.96,34,,167.96,percent of total billed charges,Implant Device,167.96,34,,167.96,percent of total billed charges,Implant Device,172.9,35,,172.9,percent of total billed charges,Implant Device,172.9,35,,172.9,percent of total billed charges,Implant Device,172.9,35,,172.9,percent of total billed charges,Implant Device,172.9,35,,172.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,365.56,
ARTHREX AR-8949-050 CALCAC STEP PLT 5MM,C1713,HCPCS,,79010847,CDM,278,RC,,,both,,,4695,3474.31,,,3474.31,Other,150% of Medicare + 9.63% HCRA Surcharge,2112.75,45,,2112.75,percent of total billed charges,Critical Access Hospital RCC factor,1596.3,34,,1596.3,percent of total billed charges,Implant Device,1596.3,34,,1596.3,percent of total billed charges,Implant Device,1596.3,34,,1596.3,percent of total billed charges,Implant Device,1596.3,34,,1596.3,percent of total billed charges,Implant Device,1596.3,34,,1596.3,percent of total billed charges,Implant Device,2324.03,,,2324.03,Other,110% of Medicare,1643.25,35,,1643.25,percent of total billed charges,Implant Device,1596.3,34,"Charges > $500, x 34%",1596.3,percent of total billed charges,Implant Device,1643.25,35,,1643.25,percent of total billed charges,Implant Device,1643.25,35,,1643.25,percent of total billed charges,Implant Device,1643.25,35,,1643.25,percent of total billed charges,Implant Device,1643.25,35,,1643.25,percent of total billed charges,Implant Device,1643.25,35,,1643.25,percent of total billed charges,Implant Device,1878,40,,1878,percent of total billed charges,Implant Device,1643.25,70,,1643.25,percent of total billed charges,All Other,1596.3,34,,1596.3,percent of total billed charges,Implant Device,1596.3,34,,1596.3,percent of total billed charges,Implant Device,1643.25,35,,1643.25,percent of total billed charges,Implant Device,1643.25,35,,1643.25,percent of total billed charges,Implant Device,1643.25,35,,1643.25,percent of total billed charges,Implant Device,1643.25,35,,1643.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1596.3,34,"If Charge > 2,000, then 34 percent",1596.3,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3474.31,
STRYKER 325236S CANN SCREW 4X36MM,C1713,HCPCS,,79010848,CDM,278,RC,,,both,,,446,330.04,,,330.04,Other,150% of Medicare + 9.63% HCRA Surcharge,200.7,45,,200.7,percent of total billed charges,Critical Access Hospital RCC factor,151.64,34,,151.64,percent of total billed charges,Implant Device,151.64,34,,151.64,percent of total billed charges,Implant Device,151.64,34,,151.64,percent of total billed charges,Implant Device,151.64,34,,151.64,percent of total billed charges,Implant Device,151.64,34,,151.64,percent of total billed charges,Implant Device,220.77,,,220.77,Other,110% of Medicare,156.1,35,,156.1,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,156.1,35,,156.1,percent of total billed charges,Implant Device,156.1,35,,156.1,percent of total billed charges,Implant Device,156.1,35,,156.1,percent of total billed charges,Implant Device,156.1,35,,156.1,percent of total billed charges,Implant Device,156.1,35,,156.1,percent of total billed charges,Implant Device,178.4,40,,178.4,percent of total billed charges,Implant Device,156.1,70,,156.1,percent of total billed charges,All Other,151.64,34,,151.64,percent of total billed charges,Implant Device,151.64,34,,151.64,percent of total billed charges,Implant Device,156.1,35,,156.1,percent of total billed charges,Implant Device,156.1,35,,156.1,percent of total billed charges,Implant Device,156.1,35,,156.1,percent of total billed charges,Implant Device,156.1,35,,156.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,330.04,
STRYKER 325242S ASNIS CANN SCREW 4X42MM,C1713,HCPCS,,79010849,CDM,278,RC,,,both,,,446,330.04,,,330.04,Other,150% of Medicare + 9.63% HCRA Surcharge,200.7,45,,200.7,percent of total billed charges,Critical Access Hospital RCC factor,151.64,34,,151.64,percent of total billed charges,Implant Device,151.64,34,,151.64,percent of total billed charges,Implant Device,151.64,34,,151.64,percent of total billed charges,Implant Device,151.64,34,,151.64,percent of total billed charges,Implant Device,151.64,34,,151.64,percent of total billed charges,Implant Device,220.77,,,220.77,Other,110% of Medicare,156.1,35,,156.1,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,156.1,35,,156.1,percent of total billed charges,Implant Device,156.1,35,,156.1,percent of total billed charges,Implant Device,156.1,35,,156.1,percent of total billed charges,Implant Device,156.1,35,,156.1,percent of total billed charges,Implant Device,156.1,35,,156.1,percent of total billed charges,Implant Device,178.4,40,,178.4,percent of total billed charges,Implant Device,156.1,70,,156.1,percent of total billed charges,All Other,151.64,34,,151.64,percent of total billed charges,Implant Device,151.64,34,,151.64,percent of total billed charges,Implant Device,156.1,35,,156.1,percent of total billed charges,Implant Device,156.1,35,,156.1,percent of total billed charges,Implant Device,156.1,35,,156.1,percent of total billed charges,Implant Device,156.1,35,,156.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,330.04,
STRYKER 325246S ASNIS CANN SCREW 4X46MM,C1713,HCPCS,,79010850,CDM,278,RC,,,both,,,446,330.04,,,330.04,Other,150% of Medicare + 9.63% HCRA Surcharge,200.7,45,,200.7,percent of total billed charges,Critical Access Hospital RCC factor,151.64,34,,151.64,percent of total billed charges,Implant Device,151.64,34,,151.64,percent of total billed charges,Implant Device,151.64,34,,151.64,percent of total billed charges,Implant Device,151.64,34,,151.64,percent of total billed charges,Implant Device,151.64,34,,151.64,percent of total billed charges,Implant Device,220.77,,,220.77,Other,110% of Medicare,156.1,35,,156.1,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,156.1,35,,156.1,percent of total billed charges,Implant Device,156.1,35,,156.1,percent of total billed charges,Implant Device,156.1,35,,156.1,percent of total billed charges,Implant Device,156.1,35,,156.1,percent of total billed charges,Implant Device,156.1,35,,156.1,percent of total billed charges,Implant Device,178.4,40,,178.4,percent of total billed charges,Implant Device,156.1,70,,156.1,percent of total billed charges,All Other,151.64,34,,151.64,percent of total billed charges,Implant Device,151.64,34,,151.64,percent of total billed charges,Implant Device,156.1,35,,156.1,percent of total billed charges,Implant Device,156.1,35,,156.1,percent of total billed charges,Implant Device,156.1,35,,156.1,percent of total billed charges,Implant Device,156.1,35,,156.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,330.04,
STRYKER 325238 CANN SCREW 4X38MM,C1713,HCPCS,,79010852,CDM,278,RC,,,both,,,535,395.9,,,395.9,Other,150% of Medicare + 9.63% HCRA Surcharge,240.75,45,,240.75,percent of total billed charges,Critical Access Hospital RCC factor,181.9,34,,181.9,percent of total billed charges,Implant Device,181.9,34,,181.9,percent of total billed charges,Implant Device,181.9,34,,181.9,percent of total billed charges,Implant Device,181.9,34,,181.9,percent of total billed charges,Implant Device,181.9,34,,181.9,percent of total billed charges,Implant Device,264.83,,,264.83,Other,110% of Medicare,187.25,35,,187.25,percent of total billed charges,Implant Device,181.9,34,"Charges > $500, x 34%",181.9,percent of total billed charges,Implant Device,187.25,35,,187.25,percent of total billed charges,Implant Device,187.25,35,,187.25,percent of total billed charges,Implant Device,187.25,35,,187.25,percent of total billed charges,Implant Device,187.25,35,,187.25,percent of total billed charges,Implant Device,187.25,35,,187.25,percent of total billed charges,Implant Device,214,40,,214,percent of total billed charges,Implant Device,187.25,70,,187.25,percent of total billed charges,All Other,181.9,34,,181.9,percent of total billed charges,Implant Device,181.9,34,,181.9,percent of total billed charges,Implant Device,187.25,35,,187.25,percent of total billed charges,Implant Device,187.25,35,,187.25,percent of total billed charges,Implant Device,187.25,35,,187.25,percent of total billed charges,Implant Device,187.25,35,,187.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,395.9,
STRYKER 5534-A-309 TIBIA COMP SZ 3 9MM,C1776,HCPCS,,79010853,CDM,278,RC,,,both,,,3337,2469.39,,,2469.39,Other,150% of Medicare + 9.63% HCRA Surcharge,1501.65,45,,1501.65,percent of total billed charges,Critical Access Hospital RCC factor,1134.58,34,,1134.58,percent of total billed charges,Implant Device,1134.58,34,,1134.58,percent of total billed charges,Implant Device,1134.58,34,,1134.58,percent of total billed charges,Implant Device,1134.58,34,,1134.58,percent of total billed charges,Implant Device,1134.58,34,,1134.58,percent of total billed charges,Implant Device,1651.82,,,1651.82,Other,110% of Medicare,1167.95,35,,1167.95,percent of total billed charges,Implant Device,1134.58,34,"Charges > $500, x 34%",1134.58,percent of total billed charges,Implant Device,1167.95,35,,1167.95,percent of total billed charges,Implant Device,1167.95,35,,1167.95,percent of total billed charges,Implant Device,1167.95,35,,1167.95,percent of total billed charges,Implant Device,1167.95,35,,1167.95,percent of total billed charges,Implant Device,1167.95,35,,1167.95,percent of total billed charges,Implant Device,1334.8,40,,1334.8,percent of total billed charges,Implant Device,1167.95,70,,1167.95,percent of total billed charges,All Other,1134.58,34,,1134.58,percent of total billed charges,Implant Device,1134.58,34,,1134.58,percent of total billed charges,Implant Device,1167.95,35,,1167.95,percent of total billed charges,Implant Device,1167.95,35,,1167.95,percent of total billed charges,Implant Device,1167.95,35,,1167.95,percent of total billed charges,Implant Device,1167.95,35,,1167.95,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1134.58,34,"If Charge > 2,000, then 34 percent",1134.58,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2469.39,
ARTHREX AR-8958-02S PLATE 2 HOLE,C1713,HCPCS,,79010855,CDM,278,RC,,,both,,,3645,2697.31,,,2697.31,Other,150% of Medicare + 9.63% HCRA Surcharge,1640.25,45,,1640.25,percent of total billed charges,Critical Access Hospital RCC factor,1239.3,34,,1239.3,percent of total billed charges,Implant Device,1239.3,34,,1239.3,percent of total billed charges,Implant Device,1239.3,34,,1239.3,percent of total billed charges,Implant Device,1239.3,34,,1239.3,percent of total billed charges,Implant Device,1239.3,34,,1239.3,percent of total billed charges,Implant Device,1804.28,,,1804.28,Other,110% of Medicare,1275.75,35,,1275.75,percent of total billed charges,Implant Device,1239.3,34,"Charges > $500, x 34%",1239.3,percent of total billed charges,Implant Device,1275.75,35,,1275.75,percent of total billed charges,Implant Device,1275.75,35,,1275.75,percent of total billed charges,Implant Device,1275.75,35,,1275.75,percent of total billed charges,Implant Device,1275.75,35,,1275.75,percent of total billed charges,Implant Device,1275.75,35,,1275.75,percent of total billed charges,Implant Device,1458,40,,1458,percent of total billed charges,Implant Device,1275.75,70,,1275.75,percent of total billed charges,All Other,1239.3,34,,1239.3,percent of total billed charges,Implant Device,1239.3,34,,1239.3,percent of total billed charges,Implant Device,1275.75,35,,1275.75,percent of total billed charges,Implant Device,1275.75,35,,1275.75,percent of total billed charges,Implant Device,1275.75,35,,1275.75,percent of total billed charges,Implant Device,1275.75,35,,1275.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1239.3,34,"If Charge > 2,000, then 34 percent",1239.3,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2697.31,
STRYKER 5517-F-602 FEMORAL COMP SIZE 6,C1776,HCPCS,,79010856,CDM,278,RC,,,both,,,5840,4321.61,,,4321.61,Other,150% of Medicare + 9.63% HCRA Surcharge,2628,45,,2628,percent of total billed charges,Critical Access Hospital RCC factor,1985.6,34,,1985.6,percent of total billed charges,Implant Device,1985.6,34,,1985.6,percent of total billed charges,Implant Device,1985.6,34,,1985.6,percent of total billed charges,Implant Device,1985.6,34,,1985.6,percent of total billed charges,Implant Device,1985.6,34,,1985.6,percent of total billed charges,Implant Device,2890.8,,,2890.8,Other,110% of Medicare,2044,35,,2044,percent of total billed charges,Implant Device,1985.6,34,"Charges > $500, x 34%",1985.6,percent of total billed charges,Implant Device,2044,35,,2044,percent of total billed charges,Implant Device,2044,35,,2044,percent of total billed charges,Implant Device,2044,35,,2044,percent of total billed charges,Implant Device,2044,35,,2044,percent of total billed charges,Implant Device,2044,35,,2044,percent of total billed charges,Implant Device,2336,40,,2336,percent of total billed charges,Implant Device,2044,70,,2044,percent of total billed charges,All Other,1985.6,34,,1985.6,percent of total billed charges,Implant Device,1985.6,34,,1985.6,percent of total billed charges,Implant Device,2044,35,,2044,percent of total billed charges,Implant Device,2044,35,,2044,percent of total billed charges,Implant Device,2044,35,,2044,percent of total billed charges,Implant Device,2044,35,,2044,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1985.6,34,"If Charge > 2,000, then 34 percent",1985.6,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4321.61,
STRYKER 5531-G-511-E TIB BEARING INSERT,C1776,HCPCS,,79010857,CDM,278,RC,,,both,,,2781,2057.95,,,2057.95,Other,150% of Medicare + 9.63% HCRA Surcharge,1251.45,45,,1251.45,percent of total billed charges,Critical Access Hospital RCC factor,945.54,34,,945.54,percent of total billed charges,Implant Device,945.54,34,,945.54,percent of total billed charges,Implant Device,945.54,34,,945.54,percent of total billed charges,Implant Device,945.54,34,,945.54,percent of total billed charges,Implant Device,945.54,34,,945.54,percent of total billed charges,Implant Device,1376.6,,,1376.6,Other,110% of Medicare,973.35,35,,973.35,percent of total billed charges,Implant Device,945.54,34,"Charges > $500, x 34%",945.54,percent of total billed charges,Implant Device,973.35,35,,973.35,percent of total billed charges,Implant Device,973.35,35,,973.35,percent of total billed charges,Implant Device,973.35,35,,973.35,percent of total billed charges,Implant Device,973.35,35,,973.35,percent of total billed charges,Implant Device,973.35,35,,973.35,percent of total billed charges,Implant Device,1112.4,40,,1112.4,percent of total billed charges,Implant Device,973.35,70,,973.35,percent of total billed charges,All Other,945.54,34,,945.54,percent of total billed charges,Implant Device,945.54,34,,945.54,percent of total billed charges,Implant Device,973.35,35,,973.35,percent of total billed charges,Implant Device,973.35,35,,973.35,percent of total billed charges,Implant Device,973.35,35,,973.35,percent of total billed charges,Implant Device,973.35,35,,973.35,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,945.54,34,"If Charge > 2,000, then 34 percent",945.54,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2057.95,
STRYKER 5536-B-500 TIB BASEPLATE SIZE 5,C1776,HCPCS,,79010858,CDM,278,RC,,,both,,,4172,3087.29,,,3087.29,Other,150% of Medicare + 9.63% HCRA Surcharge,1877.4,45,,1877.4,percent of total billed charges,Critical Access Hospital RCC factor,1418.48,34,,1418.48,percent of total billed charges,Implant Device,1418.48,34,,1418.48,percent of total billed charges,Implant Device,1418.48,34,,1418.48,percent of total billed charges,Implant Device,1418.48,34,,1418.48,percent of total billed charges,Implant Device,1418.48,34,,1418.48,percent of total billed charges,Implant Device,2065.14,,,2065.14,Other,110% of Medicare,1460.2,35,,1460.2,percent of total billed charges,Implant Device,1418.48,34,"Charges > $500, x 34%",1418.48,percent of total billed charges,Implant Device,1460.2,35,,1460.2,percent of total billed charges,Implant Device,1460.2,35,,1460.2,percent of total billed charges,Implant Device,1460.2,35,,1460.2,percent of total billed charges,Implant Device,1460.2,35,,1460.2,percent of total billed charges,Implant Device,1460.2,35,,1460.2,percent of total billed charges,Implant Device,1668.8,40,,1668.8,percent of total billed charges,Implant Device,1460.2,70,,1460.2,percent of total billed charges,All Other,1418.48,34,,1418.48,percent of total billed charges,Implant Device,1418.48,34,,1418.48,percent of total billed charges,Implant Device,1460.2,35,,1460.2,percent of total billed charges,Implant Device,1460.2,35,,1460.2,percent of total billed charges,Implant Device,1460.2,35,,1460.2,percent of total billed charges,Implant Device,1460.2,35,,1460.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1418.48,34,"If Charge > 2,000, then 34 percent",1418.48,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3087.29,
STRYKER 5552-L-350 PATELLA 35X10MM,C1776,HCPCS,,79010859,CDM,278,RC,,,both,,,2225,1646.51,,,1646.51,Other,150% of Medicare + 9.63% HCRA Surcharge,1001.25,45,,1001.25,percent of total billed charges,Critical Access Hospital RCC factor,756.5,34,,756.5,percent of total billed charges,Implant Device,756.5,34,,756.5,percent of total billed charges,Implant Device,756.5,34,,756.5,percent of total billed charges,Implant Device,756.5,34,,756.5,percent of total billed charges,Implant Device,756.5,34,,756.5,percent of total billed charges,Implant Device,1101.38,,,1101.38,Other,110% of Medicare,778.75,35,,778.75,percent of total billed charges,Implant Device,756.5,34,"Charges > $500, x 34%",756.5,percent of total billed charges,Implant Device,778.75,35,,778.75,percent of total billed charges,Implant Device,778.75,35,,778.75,percent of total billed charges,Implant Device,778.75,35,,778.75,percent of total billed charges,Implant Device,778.75,35,,778.75,percent of total billed charges,Implant Device,778.75,35,,778.75,percent of total billed charges,Implant Device,890,40,,890,percent of total billed charges,Implant Device,778.75,70,,778.75,percent of total billed charges,All Other,756.5,34,,756.5,percent of total billed charges,Implant Device,756.5,34,,756.5,percent of total billed charges,Implant Device,778.75,35,,778.75,percent of total billed charges,Implant Device,778.75,35,,778.75,percent of total billed charges,Implant Device,778.75,35,,778.75,percent of total billed charges,Implant Device,778.75,35,,778.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,756.5,34,"If Charge > 2,000, then 34 percent",756.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1646.51,
STRYKER 6478-6-605 STEM 11X80MM,C1776,HCPCS,,79010860,CDM,278,RC,,,both,,,2940,2175.61,,,2175.61,Other,150% of Medicare + 9.63% HCRA Surcharge,1323,45,,1323,percent of total billed charges,Critical Access Hospital RCC factor,999.6,34,,999.6,percent of total billed charges,Implant Device,999.6,34,,999.6,percent of total billed charges,Implant Device,999.6,34,,999.6,percent of total billed charges,Implant Device,999.6,34,,999.6,percent of total billed charges,Implant Device,999.6,34,,999.6,percent of total billed charges,Implant Device,1455.3,,,1455.3,Other,110% of Medicare,1029,35,,1029,percent of total billed charges,Implant Device,999.6,34,"Charges > $500, x 34%",999.6,percent of total billed charges,Implant Device,1029,35,,1029,percent of total billed charges,Implant Device,1029,35,,1029,percent of total billed charges,Implant Device,1029,35,,1029,percent of total billed charges,Implant Device,1029,35,,1029,percent of total billed charges,Implant Device,1029,35,,1029,percent of total billed charges,Implant Device,1176,40,,1176,percent of total billed charges,Implant Device,1029,70,,1029,percent of total billed charges,All Other,999.6,34,,999.6,percent of total billed charges,Implant Device,999.6,34,,999.6,percent of total billed charges,Implant Device,1029,35,,1029,percent of total billed charges,Implant Device,1029,35,,1029,percent of total billed charges,Implant Device,1029,35,,1029,percent of total billed charges,Implant Device,1029,35,,1029,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,999.6,34,"If Charge > 2,000, then 34 percent",999.6,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2175.61,
STRYKER 6481-2-140 TIBIAL SLEEVE,C1776,HCPCS,,79010861,CDM,278,RC,,,both,,,1337,989.38,,,989.38,Other,150% of Medicare + 9.63% HCRA Surcharge,601.65,45,,601.65,percent of total billed charges,Critical Access Hospital RCC factor,454.58,34,,454.58,percent of total billed charges,Implant Device,454.58,34,,454.58,percent of total billed charges,Implant Device,454.58,34,,454.58,percent of total billed charges,Implant Device,454.58,34,,454.58,percent of total billed charges,Implant Device,454.58,34,,454.58,percent of total billed charges,Implant Device,661.82,,,661.82,Other,110% of Medicare,467.95,35,,467.95,percent of total billed charges,Implant Device,454.58,34,"Charges > $500, x 34%",454.58,percent of total billed charges,Implant Device,467.95,35,,467.95,percent of total billed charges,Implant Device,467.95,35,,467.95,percent of total billed charges,Implant Device,467.95,35,,467.95,percent of total billed charges,Implant Device,467.95,35,,467.95,percent of total billed charges,Implant Device,467.95,35,,467.95,percent of total billed charges,Implant Device,534.8,40,,534.8,percent of total billed charges,Implant Device,467.95,70,,467.95,percent of total billed charges,All Other,454.58,34,,454.58,percent of total billed charges,Implant Device,454.58,34,,454.58,percent of total billed charges,Implant Device,467.95,35,,467.95,percent of total billed charges,Implant Device,467.95,35,,467.95,percent of total billed charges,Implant Device,467.95,35,,467.95,percent of total billed charges,Implant Device,467.95,35,,467.95,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,989.38,
STRYKER 6481-3-111 TIBIAL BASEPLATE SZ 2,C1776,HCPCS,,79010862,CDM,278,RC,,,both,,,8597,6361.8,,,6361.8,Other,150% of Medicare + 9.63% HCRA Surcharge,3868.65,45,,3868.65,percent of total billed charges,Critical Access Hospital RCC factor,2922.98,34,,2922.98,percent of total billed charges,Implant Device,2922.98,34,,2922.98,percent of total billed charges,Implant Device,2922.98,34,,2922.98,percent of total billed charges,Implant Device,2922.98,34,,2922.98,percent of total billed charges,Implant Device,2922.98,34,,2922.98,percent of total billed charges,Implant Device,4255.52,,,4255.52,Other,110% of Medicare,3008.95,35,,3008.95,percent of total billed charges,Implant Device,2922.98,34,"Charges > $500, x 34%",2922.98,percent of total billed charges,Implant Device,3008.95,35,,3008.95,percent of total billed charges,Implant Device,3008.95,35,,3008.95,percent of total billed charges,Implant Device,3008.95,35,,3008.95,percent of total billed charges,Implant Device,3008.95,35,,3008.95,percent of total billed charges,Implant Device,3008.95,35,,3008.95,percent of total billed charges,Implant Device,3438.8,40,,3438.8,percent of total billed charges,Implant Device,3008.95,70,,3008.95,percent of total billed charges,All Other,2922.98,34,,2922.98,percent of total billed charges,Implant Device,2922.98,34,,2922.98,percent of total billed charges,Implant Device,3008.95,35,,3008.95,percent of total billed charges,Implant Device,3008.95,35,,3008.95,percent of total billed charges,Implant Device,3008.95,35,,3008.95,percent of total billed charges,Implant Device,3008.95,35,,3008.95,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2922.98,34,"If Charge > 2,000, then 34 percent",2922.98,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,6361.8,
STRYKER 6481-3-210 TIBIAL INSERT 10MM,C1776,HCPCS,,79010863,CDM,278,RC,,,both,,,2973,2200.03,,,2200.03,Other,150% of Medicare + 9.63% HCRA Surcharge,1337.85,45,,1337.85,percent of total billed charges,Critical Access Hospital RCC factor,1010.82,34,,1010.82,percent of total billed charges,Implant Device,1010.82,34,,1010.82,percent of total billed charges,Implant Device,1010.82,34,,1010.82,percent of total billed charges,Implant Device,1010.82,34,,1010.82,percent of total billed charges,Implant Device,1010.82,34,,1010.82,percent of total billed charges,Implant Device,1471.64,,,1471.64,Other,110% of Medicare,1040.55,35,,1040.55,percent of total billed charges,Implant Device,1010.82,34,"Charges > $500, x 34%",1010.82,percent of total billed charges,Implant Device,1040.55,35,,1040.55,percent of total billed charges,Implant Device,1040.55,35,,1040.55,percent of total billed charges,Implant Device,1040.55,35,,1040.55,percent of total billed charges,Implant Device,1040.55,35,,1040.55,percent of total billed charges,Implant Device,1040.55,35,,1040.55,percent of total billed charges,Implant Device,1189.2,40,,1189.2,percent of total billed charges,Implant Device,1040.55,70,,1040.55,percent of total billed charges,All Other,1010.82,34,,1010.82,percent of total billed charges,Implant Device,1010.82,34,,1010.82,percent of total billed charges,Implant Device,1040.55,35,,1040.55,percent of total billed charges,Implant Device,1040.55,35,,1040.55,percent of total billed charges,Implant Device,1040.55,35,,1040.55,percent of total billed charges,Implant Device,1040.55,35,,1040.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1010.82,34,"If Charge > 2,000, then 34 percent",1010.82,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2200.03,
STRYKER 6485-3-113 FEMORAL STEM 13X127MM,C1776,HCPCS,,79010864,CDM,278,RC,,,both,,,7254,5367.98,,,5367.98,Other,150% of Medicare + 9.63% HCRA Surcharge,3264.3,45,,3264.3,percent of total billed charges,Critical Access Hospital RCC factor,2466.36,34,,2466.36,percent of total billed charges,Implant Device,2466.36,34,,2466.36,percent of total billed charges,Implant Device,2466.36,34,,2466.36,percent of total billed charges,Implant Device,2466.36,34,,2466.36,percent of total billed charges,Implant Device,2466.36,34,,2466.36,percent of total billed charges,Implant Device,3590.73,,,3590.73,Other,110% of Medicare,2538.9,35,,2538.9,percent of total billed charges,Implant Device,2466.36,34,"Charges > $500, x 34%",2466.36,percent of total billed charges,Implant Device,2538.9,35,,2538.9,percent of total billed charges,Implant Device,2538.9,35,,2538.9,percent of total billed charges,Implant Device,2538.9,35,,2538.9,percent of total billed charges,Implant Device,2538.9,35,,2538.9,percent of total billed charges,Implant Device,2538.9,35,,2538.9,percent of total billed charges,Implant Device,2901.6,40,,2901.6,percent of total billed charges,Implant Device,2538.9,70,,2538.9,percent of total billed charges,All Other,2466.36,34,,2466.36,percent of total billed charges,Implant Device,2466.36,34,,2466.36,percent of total billed charges,Implant Device,2538.9,35,,2538.9,percent of total billed charges,Implant Device,2538.9,35,,2538.9,percent of total billed charges,Implant Device,2538.9,35,,2538.9,percent of total billed charges,Implant Device,2538.9,35,,2538.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2466.36,34,"If Charge > 2,000, then 34 percent",2466.36,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5367.98,
ALLERGAN 68HP-320 SALINE IMPLANT 320CC,C1789,HCPCS,,79010865,CDM,278,RC,,,both,,,1776,1314.24,,,1314.24,Other,150% of Medicare + 9.63% HCRA Surcharge,799.2,45,,799.2,percent of total billed charges,Critical Access Hospital RCC factor,603.84,34,,603.84,percent of total billed charges,Implant Device,603.84,34,,603.84,percent of total billed charges,Implant Device,603.84,34,,603.84,percent of total billed charges,Implant Device,603.84,34,,603.84,percent of total billed charges,Implant Device,603.84,34,,603.84,percent of total billed charges,Implant Device,879.12,,,879.12,Other,110% of Medicare,621.6,35,,621.6,percent of total billed charges,Implant Device,603.84,34,"Charges > $500, x 34%",603.84,percent of total billed charges,Implant Device,621.6,35,,621.6,percent of total billed charges,Implant Device,621.6,35,,621.6,percent of total billed charges,Implant Device,621.6,35,,621.6,percent of total billed charges,Implant Device,621.6,35,,621.6,percent of total billed charges,Implant Device,621.6,35,,621.6,percent of total billed charges,Implant Device,710.4,40,,710.4,percent of total billed charges,Implant Device,621.6,70,,621.6,percent of total billed charges,All Other,603.84,34,,603.84,percent of total billed charges,Implant Device,603.84,34,,603.84,percent of total billed charges,Implant Device,621.6,35,,621.6,percent of total billed charges,Implant Device,621.6,35,,621.6,percent of total billed charges,Implant Device,621.6,35,,621.6,percent of total billed charges,Implant Device,621.6,35,,621.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1314.24,
ALLERGAN 68HP-350 SALINE IMPLANT 350CC,C1789,HCPCS,,79010866,CDM,278,RC,,,both,,,1776,1314.24,,,1314.24,Other,150% of Medicare + 9.63% HCRA Surcharge,799.2,45,,799.2,percent of total billed charges,Critical Access Hospital RCC factor,603.84,34,,603.84,percent of total billed charges,Implant Device,603.84,34,,603.84,percent of total billed charges,Implant Device,603.84,34,,603.84,percent of total billed charges,Implant Device,603.84,34,,603.84,percent of total billed charges,Implant Device,603.84,34,,603.84,percent of total billed charges,Implant Device,879.12,,,879.12,Other,110% of Medicare,621.6,35,,621.6,percent of total billed charges,Implant Device,603.84,34,"Charges > $500, x 34%",603.84,percent of total billed charges,Implant Device,621.6,35,,621.6,percent of total billed charges,Implant Device,621.6,35,,621.6,percent of total billed charges,Implant Device,621.6,35,,621.6,percent of total billed charges,Implant Device,621.6,35,,621.6,percent of total billed charges,Implant Device,621.6,35,,621.6,percent of total billed charges,Implant Device,710.4,40,,710.4,percent of total billed charges,Implant Device,621.6,70,,621.6,percent of total billed charges,All Other,603.84,34,,603.84,percent of total billed charges,Implant Device,603.84,34,,603.84,percent of total billed charges,Implant Device,621.6,35,,621.6,percent of total billed charges,Implant Device,621.6,35,,621.6,percent of total billed charges,Implant Device,621.6,35,,621.6,percent of total billed charges,Implant Device,621.6,35,,621.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1314.24,
ALLERGAN 68HP-400 SALINE IMPLANT 400CC,C1789,HCPCS,,79010867,CDM,278,RC,,,both,,,1776,1314.24,,,1314.24,Other,150% of Medicare + 9.63% HCRA Surcharge,799.2,45,,799.2,percent of total billed charges,Critical Access Hospital RCC factor,603.84,34,,603.84,percent of total billed charges,Implant Device,603.84,34,,603.84,percent of total billed charges,Implant Device,603.84,34,,603.84,percent of total billed charges,Implant Device,603.84,34,,603.84,percent of total billed charges,Implant Device,603.84,34,,603.84,percent of total billed charges,Implant Device,879.12,,,879.12,Other,110% of Medicare,621.6,35,,621.6,percent of total billed charges,Implant Device,603.84,34,"Charges > $500, x 34%",603.84,percent of total billed charges,Implant Device,621.6,35,,621.6,percent of total billed charges,Implant Device,621.6,35,,621.6,percent of total billed charges,Implant Device,621.6,35,,621.6,percent of total billed charges,Implant Device,621.6,35,,621.6,percent of total billed charges,Implant Device,621.6,35,,621.6,percent of total billed charges,Implant Device,710.4,40,,710.4,percent of total billed charges,Implant Device,621.6,70,,621.6,percent of total billed charges,All Other,603.84,34,,603.84,percent of total billed charges,Implant Device,603.84,34,,603.84,percent of total billed charges,Implant Device,621.6,35,,621.6,percent of total billed charges,Implant Device,621.6,35,,621.6,percent of total billed charges,Implant Device,621.6,35,,621.6,percent of total billed charges,Implant Device,621.6,35,,621.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1314.24,
ALLERGAN 68HP-425 SALINE IMPLANT 425CC,C1789,HCPCS,,79010868,CDM,278,RC,,,both,,,1776,1314.24,,,1314.24,Other,150% of Medicare + 9.63% HCRA Surcharge,799.2,45,,799.2,percent of total billed charges,Critical Access Hospital RCC factor,603.84,34,,603.84,percent of total billed charges,Implant Device,603.84,34,,603.84,percent of total billed charges,Implant Device,603.84,34,,603.84,percent of total billed charges,Implant Device,603.84,34,,603.84,percent of total billed charges,Implant Device,603.84,34,,603.84,percent of total billed charges,Implant Device,879.12,,,879.12,Other,110% of Medicare,621.6,35,,621.6,percent of total billed charges,Implant Device,603.84,34,"Charges > $500, x 34%",603.84,percent of total billed charges,Implant Device,621.6,35,,621.6,percent of total billed charges,Implant Device,621.6,35,,621.6,percent of total billed charges,Implant Device,621.6,35,,621.6,percent of total billed charges,Implant Device,621.6,35,,621.6,percent of total billed charges,Implant Device,621.6,35,,621.6,percent of total billed charges,Implant Device,710.4,40,,710.4,percent of total billed charges,Implant Device,621.6,70,,621.6,percent of total billed charges,All Other,603.84,34,,603.84,percent of total billed charges,Implant Device,603.84,34,,603.84,percent of total billed charges,Implant Device,621.6,35,,621.6,percent of total billed charges,Implant Device,621.6,35,,621.6,percent of total billed charges,Implant Device,621.6,35,,621.6,percent of total billed charges,Implant Device,621.6,35,,621.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1314.24,
ALLERGAN 68HP-465 SALINE IMPLANT 465CC,C1789,HCPCS,,79010869,CDM,278,RC,,,both,,,1776,1314.24,,,1314.24,Other,150% of Medicare + 9.63% HCRA Surcharge,799.2,45,,799.2,percent of total billed charges,Critical Access Hospital RCC factor,603.84,34,,603.84,percent of total billed charges,Implant Device,603.84,34,,603.84,percent of total billed charges,Implant Device,603.84,34,,603.84,percent of total billed charges,Implant Device,603.84,34,,603.84,percent of total billed charges,Implant Device,603.84,34,,603.84,percent of total billed charges,Implant Device,879.12,,,879.12,Other,110% of Medicare,621.6,35,,621.6,percent of total billed charges,Implant Device,603.84,34,"Charges > $500, x 34%",603.84,percent of total billed charges,Implant Device,621.6,35,,621.6,percent of total billed charges,Implant Device,621.6,35,,621.6,percent of total billed charges,Implant Device,621.6,35,,621.6,percent of total billed charges,Implant Device,621.6,35,,621.6,percent of total billed charges,Implant Device,621.6,35,,621.6,percent of total billed charges,Implant Device,710.4,40,,710.4,percent of total billed charges,Implant Device,621.6,70,,621.6,percent of total billed charges,All Other,603.84,34,,603.84,percent of total billed charges,Implant Device,603.84,34,,603.84,percent of total billed charges,Implant Device,621.6,35,,621.6,percent of total billed charges,Implant Device,621.6,35,,621.6,percent of total billed charges,Implant Device,621.6,35,,621.6,percent of total billed charges,Implant Device,621.6,35,,621.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1314.24,
ALLERGAN 68-270 SALINE IMPLANT 270CC,C1789,HCPCS,,79010870,CDM,278,RC,,,both,,,1776,1314.24,,,1314.24,Other,150% of Medicare + 9.63% HCRA Surcharge,799.2,45,,799.2,percent of total billed charges,Critical Access Hospital RCC factor,603.84,34,,603.84,percent of total billed charges,Implant Device,603.84,34,,603.84,percent of total billed charges,Implant Device,603.84,34,,603.84,percent of total billed charges,Implant Device,603.84,34,,603.84,percent of total billed charges,Implant Device,603.84,34,,603.84,percent of total billed charges,Implant Device,879.12,,,879.12,Other,110% of Medicare,621.6,35,,621.6,percent of total billed charges,Implant Device,603.84,34,"Charges > $500, x 34%",603.84,percent of total billed charges,Implant Device,621.6,35,,621.6,percent of total billed charges,Implant Device,621.6,35,,621.6,percent of total billed charges,Implant Device,621.6,35,,621.6,percent of total billed charges,Implant Device,621.6,35,,621.6,percent of total billed charges,Implant Device,621.6,35,,621.6,percent of total billed charges,Implant Device,710.4,40,,710.4,percent of total billed charges,Implant Device,621.6,70,,621.6,percent of total billed charges,All Other,603.84,34,,603.84,percent of total billed charges,Implant Device,603.84,34,,603.84,percent of total billed charges,Implant Device,621.6,35,,621.6,percent of total billed charges,Implant Device,621.6,35,,621.6,percent of total billed charges,Implant Device,621.6,35,,621.6,percent of total billed charges,Implant Device,621.6,35,,621.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1314.24,
ALLERGAN 68-300 SALINE IMPLANT 300CC,C1789,HCPCS,,79010871,CDM,278,RC,,,both,,,1776,1314.24,,,1314.24,Other,150% of Medicare + 9.63% HCRA Surcharge,799.2,45,,799.2,percent of total billed charges,Critical Access Hospital RCC factor,603.84,34,,603.84,percent of total billed charges,Implant Device,603.84,34,,603.84,percent of total billed charges,Implant Device,603.84,34,,603.84,percent of total billed charges,Implant Device,603.84,34,,603.84,percent of total billed charges,Implant Device,603.84,34,,603.84,percent of total billed charges,Implant Device,879.12,,,879.12,Other,110% of Medicare,621.6,35,,621.6,percent of total billed charges,Implant Device,603.84,34,"Charges > $500, x 34%",603.84,percent of total billed charges,Implant Device,621.6,35,,621.6,percent of total billed charges,Implant Device,621.6,35,,621.6,percent of total billed charges,Implant Device,621.6,35,,621.6,percent of total billed charges,Implant Device,621.6,35,,621.6,percent of total billed charges,Implant Device,621.6,35,,621.6,percent of total billed charges,Implant Device,710.4,40,,710.4,percent of total billed charges,Implant Device,621.6,70,,621.6,percent of total billed charges,All Other,603.84,34,,603.84,percent of total billed charges,Implant Device,603.84,34,,603.84,percent of total billed charges,Implant Device,621.6,35,,621.6,percent of total billed charges,Implant Device,621.6,35,,621.6,percent of total billed charges,Implant Device,621.6,35,,621.6,percent of total billed charges,Implant Device,621.6,35,,621.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1314.24,
ALLERGAN 68-330 SALINE IMPLANT 330CC,C1789,HCPCS,,79010872,CDM,278,RC,,,both,,,1776,1314.24,,,1314.24,Other,150% of Medicare + 9.63% HCRA Surcharge,799.2,45,,799.2,percent of total billed charges,Critical Access Hospital RCC factor,603.84,34,,603.84,percent of total billed charges,Implant Device,603.84,34,,603.84,percent of total billed charges,Implant Device,603.84,34,,603.84,percent of total billed charges,Implant Device,603.84,34,,603.84,percent of total billed charges,Implant Device,603.84,34,,603.84,percent of total billed charges,Implant Device,879.12,,,879.12,Other,110% of Medicare,621.6,35,,621.6,percent of total billed charges,Implant Device,603.84,34,"Charges > $500, x 34%",603.84,percent of total billed charges,Implant Device,621.6,35,,621.6,percent of total billed charges,Implant Device,621.6,35,,621.6,percent of total billed charges,Implant Device,621.6,35,,621.6,percent of total billed charges,Implant Device,621.6,35,,621.6,percent of total billed charges,Implant Device,621.6,35,,621.6,percent of total billed charges,Implant Device,710.4,40,,710.4,percent of total billed charges,Implant Device,621.6,70,,621.6,percent of total billed charges,All Other,603.84,34,,603.84,percent of total billed charges,Implant Device,603.84,34,,603.84,percent of total billed charges,Implant Device,621.6,35,,621.6,percent of total billed charges,Implant Device,621.6,35,,621.6,percent of total billed charges,Implant Device,621.6,35,,621.6,percent of total billed charges,Implant Device,621.6,35,,621.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1314.24,
ALLERGAN 133S-MX12T TISSUE EXPANDER,C1789,HCPCS,,79010881,CDM,278,RC,,,both,,,4785,3540.91,,,3540.91,Other,150% of Medicare + 9.63% HCRA Surcharge,2153.25,45,,2153.25,percent of total billed charges,Critical Access Hospital RCC factor,1626.9,34,,1626.9,percent of total billed charges,Implant Device,1626.9,34,,1626.9,percent of total billed charges,Implant Device,1626.9,34,,1626.9,percent of total billed charges,Implant Device,1626.9,34,,1626.9,percent of total billed charges,Implant Device,1626.9,34,,1626.9,percent of total billed charges,Implant Device,2368.58,,,2368.58,Other,110% of Medicare,1674.75,35,,1674.75,percent of total billed charges,Implant Device,1626.9,34,"Charges > $500, x 34%",1626.9,percent of total billed charges,Implant Device,1674.75,35,,1674.75,percent of total billed charges,Implant Device,1674.75,35,,1674.75,percent of total billed charges,Implant Device,1674.75,35,,1674.75,percent of total billed charges,Implant Device,1674.75,35,,1674.75,percent of total billed charges,Implant Device,1674.75,35,,1674.75,percent of total billed charges,Implant Device,1914,40,,1914,percent of total billed charges,Implant Device,1674.75,70,,1674.75,percent of total billed charges,All Other,1626.9,34,,1626.9,percent of total billed charges,Implant Device,1626.9,34,,1626.9,percent of total billed charges,Implant Device,1674.75,35,,1674.75,percent of total billed charges,Implant Device,1674.75,35,,1674.75,percent of total billed charges,Implant Device,1674.75,35,,1674.75,percent of total billed charges,Implant Device,1674.75,35,,1674.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1626.9,34,"If Charge > 2,000, then 34 percent",1626.9,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3540.91,
ALLERGAN 133X-MX13T TISSUE EXPANDER,C1789,HCPCS,,79010882,CDM,278,RC,,,both,,,4785,3540.91,,,3540.91,Other,150% of Medicare + 9.63% HCRA Surcharge,2153.25,45,,2153.25,percent of total billed charges,Critical Access Hospital RCC factor,1626.9,34,,1626.9,percent of total billed charges,Implant Device,1626.9,34,,1626.9,percent of total billed charges,Implant Device,1626.9,34,,1626.9,percent of total billed charges,Implant Device,1626.9,34,,1626.9,percent of total billed charges,Implant Device,1626.9,34,,1626.9,percent of total billed charges,Implant Device,2368.58,,,2368.58,Other,110% of Medicare,1674.75,35,,1674.75,percent of total billed charges,Implant Device,1626.9,34,"Charges > $500, x 34%",1626.9,percent of total billed charges,Implant Device,1674.75,35,,1674.75,percent of total billed charges,Implant Device,1674.75,35,,1674.75,percent of total billed charges,Implant Device,1674.75,35,,1674.75,percent of total billed charges,Implant Device,1674.75,35,,1674.75,percent of total billed charges,Implant Device,1674.75,35,,1674.75,percent of total billed charges,Implant Device,1914,40,,1914,percent of total billed charges,Implant Device,1674.75,70,,1674.75,percent of total billed charges,All Other,1626.9,34,,1626.9,percent of total billed charges,Implant Device,1626.9,34,,1626.9,percent of total billed charges,Implant Device,1674.75,35,,1674.75,percent of total billed charges,Implant Device,1674.75,35,,1674.75,percent of total billed charges,Implant Device,1674.75,35,,1674.75,percent of total billed charges,Implant Device,1674.75,35,,1674.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1626.9,34,"If Charge > 2,000, then 34 percent",1626.9,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3540.91,
ALLERGAN 133S-SV-11-T TISSUE EXPANDER,C1789,HCPCS,,79010883,CDM,278,RC,,,both,,,4785,3540.91,,,3540.91,Other,150% of Medicare + 9.63% HCRA Surcharge,2153.25,45,,2153.25,percent of total billed charges,Critical Access Hospital RCC factor,1626.9,34,,1626.9,percent of total billed charges,Implant Device,1626.9,34,,1626.9,percent of total billed charges,Implant Device,1626.9,34,,1626.9,percent of total billed charges,Implant Device,1626.9,34,,1626.9,percent of total billed charges,Implant Device,1626.9,34,,1626.9,percent of total billed charges,Implant Device,2368.58,,,2368.58,Other,110% of Medicare,1674.75,35,,1674.75,percent of total billed charges,Implant Device,1626.9,34,"Charges > $500, x 34%",1626.9,percent of total billed charges,Implant Device,1674.75,35,,1674.75,percent of total billed charges,Implant Device,1674.75,35,,1674.75,percent of total billed charges,Implant Device,1674.75,35,,1674.75,percent of total billed charges,Implant Device,1674.75,35,,1674.75,percent of total billed charges,Implant Device,1674.75,35,,1674.75,percent of total billed charges,Implant Device,1914,40,,1914,percent of total billed charges,Implant Device,1674.75,70,,1674.75,percent of total billed charges,All Other,1626.9,34,,1626.9,percent of total billed charges,Implant Device,1626.9,34,,1626.9,percent of total billed charges,Implant Device,1674.75,35,,1674.75,percent of total billed charges,Implant Device,1674.75,35,,1674.75,percent of total billed charges,Implant Device,1674.75,35,,1674.75,percent of total billed charges,Implant Device,1674.75,35,,1674.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1626.9,34,"If Charge > 2,000, then 34 percent",1626.9,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3540.91,
ALLERGAN 133S-SV-T TISSUE EXPANDER,C1789,HCPCS,,79010884,CDM,278,RC,,,both,,,4785,3540.91,,,3540.91,Other,150% of Medicare + 9.63% HCRA Surcharge,2153.25,45,,2153.25,percent of total billed charges,Critical Access Hospital RCC factor,1626.9,34,,1626.9,percent of total billed charges,Implant Device,1626.9,34,,1626.9,percent of total billed charges,Implant Device,1626.9,34,,1626.9,percent of total billed charges,Implant Device,1626.9,34,,1626.9,percent of total billed charges,Implant Device,1626.9,34,,1626.9,percent of total billed charges,Implant Device,2368.58,,,2368.58,Other,110% of Medicare,1674.75,35,,1674.75,percent of total billed charges,Implant Device,1626.9,34,"Charges > $500, x 34%",1626.9,percent of total billed charges,Implant Device,1674.75,35,,1674.75,percent of total billed charges,Implant Device,1674.75,35,,1674.75,percent of total billed charges,Implant Device,1674.75,35,,1674.75,percent of total billed charges,Implant Device,1674.75,35,,1674.75,percent of total billed charges,Implant Device,1674.75,35,,1674.75,percent of total billed charges,Implant Device,1914,40,,1914,percent of total billed charges,Implant Device,1674.75,70,,1674.75,percent of total billed charges,All Other,1626.9,34,,1626.9,percent of total billed charges,Implant Device,1626.9,34,,1626.9,percent of total billed charges,Implant Device,1674.75,35,,1674.75,percent of total billed charges,Implant Device,1674.75,35,,1674.75,percent of total billed charges,Implant Device,1674.75,35,,1674.75,percent of total billed charges,Implant Device,1674.75,35,,1674.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1626.9,34,"If Charge > 2,000, then 34 percent",1626.9,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3540.91,
ALLERGAN 68LP-175 SALINE IMPLANT 175CC,C1789,HCPCS,,79010885,CDM,278,RC,,,both,,,1776,1314.24,,,1314.24,Other,150% of Medicare + 9.63% HCRA Surcharge,799.2,45,,799.2,percent of total billed charges,Critical Access Hospital RCC factor,603.84,34,,603.84,percent of total billed charges,Implant Device,603.84,34,,603.84,percent of total billed charges,Implant Device,603.84,34,,603.84,percent of total billed charges,Implant Device,603.84,34,,603.84,percent of total billed charges,Implant Device,603.84,34,,603.84,percent of total billed charges,Implant Device,879.12,,,879.12,Other,110% of Medicare,621.6,35,,621.6,percent of total billed charges,Implant Device,603.84,34,"Charges > $500, x 34%",603.84,percent of total billed charges,Implant Device,621.6,35,,621.6,percent of total billed charges,Implant Device,621.6,35,,621.6,percent of total billed charges,Implant Device,621.6,35,,621.6,percent of total billed charges,Implant Device,621.6,35,,621.6,percent of total billed charges,Implant Device,621.6,35,,621.6,percent of total billed charges,Implant Device,710.4,40,,710.4,percent of total billed charges,Implant Device,621.6,70,,621.6,percent of total billed charges,All Other,603.84,34,,603.84,percent of total billed charges,Implant Device,603.84,34,,603.84,percent of total billed charges,Implant Device,621.6,35,,621.6,percent of total billed charges,Implant Device,621.6,35,,621.6,percent of total billed charges,Implant Device,621.6,35,,621.6,percent of total billed charges,Implant Device,621.6,35,,621.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1314.24,
ALLERGAN 68LP-200 SALINE IMPLANT 200CC,C1789,HCPCS,,79010886,CDM,278,RC,,,both,,,1776,1314.24,,,1314.24,Other,150% of Medicare + 9.63% HCRA Surcharge,799.2,45,,799.2,percent of total billed charges,Critical Access Hospital RCC factor,603.84,34,,603.84,percent of total billed charges,Implant Device,603.84,34,,603.84,percent of total billed charges,Implant Device,603.84,34,,603.84,percent of total billed charges,Implant Device,603.84,34,,603.84,percent of total billed charges,Implant Device,603.84,34,,603.84,percent of total billed charges,Implant Device,879.12,,,879.12,Other,110% of Medicare,621.6,35,,621.6,percent of total billed charges,Implant Device,603.84,34,"Charges > $500, x 34%",603.84,percent of total billed charges,Implant Device,621.6,35,,621.6,percent of total billed charges,Implant Device,621.6,35,,621.6,percent of total billed charges,Implant Device,621.6,35,,621.6,percent of total billed charges,Implant Device,621.6,35,,621.6,percent of total billed charges,Implant Device,621.6,35,,621.6,percent of total billed charges,Implant Device,710.4,40,,710.4,percent of total billed charges,Implant Device,621.6,70,,621.6,percent of total billed charges,All Other,603.84,34,,603.84,percent of total billed charges,Implant Device,603.84,34,,603.84,percent of total billed charges,Implant Device,621.6,35,,621.6,percent of total billed charges,Implant Device,621.6,35,,621.6,percent of total billed charges,Implant Device,621.6,35,,621.6,percent of total billed charges,Implant Device,621.6,35,,621.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1314.24,
ALLERGAN 68LP-225 SALINE IMPLANT 225CC,C1789,HCPCS,,79010887,CDM,278,RC,,,both,,,1776,1314.24,,,1314.24,Other,150% of Medicare + 9.63% HCRA Surcharge,799.2,45,,799.2,percent of total billed charges,Critical Access Hospital RCC factor,603.84,34,,603.84,percent of total billed charges,Implant Device,603.84,34,,603.84,percent of total billed charges,Implant Device,603.84,34,,603.84,percent of total billed charges,Implant Device,603.84,34,,603.84,percent of total billed charges,Implant Device,603.84,34,,603.84,percent of total billed charges,Implant Device,879.12,,,879.12,Other,110% of Medicare,621.6,35,,621.6,percent of total billed charges,Implant Device,603.84,34,"Charges > $500, x 34%",603.84,percent of total billed charges,Implant Device,621.6,35,,621.6,percent of total billed charges,Implant Device,621.6,35,,621.6,percent of total billed charges,Implant Device,621.6,35,,621.6,percent of total billed charges,Implant Device,621.6,35,,621.6,percent of total billed charges,Implant Device,621.6,35,,621.6,percent of total billed charges,Implant Device,710.4,40,,710.4,percent of total billed charges,Implant Device,621.6,70,,621.6,percent of total billed charges,All Other,603.84,34,,603.84,percent of total billed charges,Implant Device,603.84,34,,603.84,percent of total billed charges,Implant Device,621.6,35,,621.6,percent of total billed charges,Implant Device,621.6,35,,621.6,percent of total billed charges,Implant Device,621.6,35,,621.6,percent of total billed charges,Implant Device,621.6,35,,621.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1314.24,
ALLERGAN 68LP-250 SALINE IMPLANT 250CC,C1789,HCPCS,,79010888,CDM,278,RC,,,both,,,1776,1314.24,,,1314.24,Other,150% of Medicare + 9.63% HCRA Surcharge,799.2,45,,799.2,percent of total billed charges,Critical Access Hospital RCC factor,603.84,34,,603.84,percent of total billed charges,Implant Device,603.84,34,,603.84,percent of total billed charges,Implant Device,603.84,34,,603.84,percent of total billed charges,Implant Device,603.84,34,,603.84,percent of total billed charges,Implant Device,603.84,34,,603.84,percent of total billed charges,Implant Device,879.12,,,879.12,Other,110% of Medicare,621.6,35,,621.6,percent of total billed charges,Implant Device,603.84,34,"Charges > $500, x 34%",603.84,percent of total billed charges,Implant Device,621.6,35,,621.6,percent of total billed charges,Implant Device,621.6,35,,621.6,percent of total billed charges,Implant Device,621.6,35,,621.6,percent of total billed charges,Implant Device,621.6,35,,621.6,percent of total billed charges,Implant Device,621.6,35,,621.6,percent of total billed charges,Implant Device,710.4,40,,710.4,percent of total billed charges,Implant Device,621.6,70,,621.6,percent of total billed charges,All Other,603.84,34,,603.84,percent of total billed charges,Implant Device,603.84,34,,603.84,percent of total billed charges,Implant Device,621.6,35,,621.6,percent of total billed charges,Implant Device,621.6,35,,621.6,percent of total billed charges,Implant Device,621.6,35,,621.6,percent of total billed charges,Implant Device,621.6,35,,621.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1314.24,
ALLERGAN CM1516P ALLODERM CONTOUR MEDIUM,C1781,HCPCS,,79010892,CDM,278,RC,,,both,,,11292,8356.11,,,8356.11,Other,150% of Medicare + 9.63% HCRA Surcharge,5081.4,45,,5081.4,percent of total billed charges,Critical Access Hospital RCC factor,3839.28,34,,3839.28,percent of total billed charges,Implant Device,3839.28,34,,3839.28,percent of total billed charges,Implant Device,3839.28,34,,3839.28,percent of total billed charges,Implant Device,3839.28,34,,3839.28,percent of total billed charges,Implant Device,3839.28,34,,3839.28,percent of total billed charges,Implant Device,5589.54,,,5589.54,Other,110% of Medicare,3952.2,35,,3952.2,percent of total billed charges,Implant Device,3839.28,34,"Charges > $500, x 34%",3839.28,percent of total billed charges,Implant Device,3952.2,35,,3952.2,percent of total billed charges,Implant Device,3952.2,35,,3952.2,percent of total billed charges,Implant Device,3952.2,35,,3952.2,percent of total billed charges,Implant Device,3952.2,35,,3952.2,percent of total billed charges,Implant Device,3952.2,35,,3952.2,percent of total billed charges,Implant Device,4516.8,40,,4516.8,percent of total billed charges,Implant Device,3952.2,70,,3952.2,percent of total billed charges,All Other,3839.28,34,,3839.28,percent of total billed charges,Implant Device,3839.28,34,,3839.28,percent of total billed charges,Implant Device,3952.2,35,,3952.2,percent of total billed charges,Implant Device,3952.2,35,,3952.2,percent of total billed charges,Implant Device,3952.2,35,,3952.2,percent of total billed charges,Implant Device,3952.2,35,,3952.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3839.28,34,"If Charge > 2,000, then 34 percent",3839.28,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,8356.11,
ALLERGAN CS1516P ALLODERM CONTOUR SMALL,C1781,HCPCS,,79010893,CDM,278,RC,,,both,,,6588,4875.14,,,4875.14,Other,150% of Medicare + 9.63% HCRA Surcharge,2964.6,45,,2964.6,percent of total billed charges,Critical Access Hospital RCC factor,2239.92,34,,2239.92,percent of total billed charges,Implant Device,2239.92,34,,2239.92,percent of total billed charges,Implant Device,2239.92,34,,2239.92,percent of total billed charges,Implant Device,2239.92,34,,2239.92,percent of total billed charges,Implant Device,2239.92,34,,2239.92,percent of total billed charges,Implant Device,3261.06,,,3261.06,Other,110% of Medicare,2305.8,35,,2305.8,percent of total billed charges,Implant Device,2239.92,34,"Charges > $500, x 34%",2239.92,percent of total billed charges,Implant Device,2305.8,35,,2305.8,percent of total billed charges,Implant Device,2305.8,35,,2305.8,percent of total billed charges,Implant Device,2305.8,35,,2305.8,percent of total billed charges,Implant Device,2305.8,35,,2305.8,percent of total billed charges,Implant Device,2305.8,35,,2305.8,percent of total billed charges,Implant Device,2635.2,40,,2635.2,percent of total billed charges,Implant Device,2305.8,70,,2305.8,percent of total billed charges,All Other,2239.92,34,,2239.92,percent of total billed charges,Implant Device,2239.92,34,,2239.92,percent of total billed charges,Implant Device,2305.8,35,,2305.8,percent of total billed charges,Implant Device,2305.8,35,,2305.8,percent of total billed charges,Implant Device,2305.8,35,,2305.8,percent of total billed charges,Implant Device,2305.8,35,,2305.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2239.92,34,"If Charge > 2,000, then 34 percent",2239.92,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4875.14,
EXACTECH 300-30-09 PRESERVE STEM 9MM,C1776,HCPCS,,79010894,CDM,278,RC,,,both,,,6000,4440.02,,,4440.02,Other,150% of Medicare + 9.63% HCRA Surcharge,2700,45,,2700,percent of total billed charges,Critical Access Hospital RCC factor,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2970,,,2970,Other,110% of Medicare,2100,35,,2100,percent of total billed charges,Implant Device,2040,34,"Charges > $500, x 34%",2040,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2400,40,,2400,percent of total billed charges,Implant Device,2100,70,,2100,percent of total billed charges,All Other,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2040,34,"If Charge > 2,000, then 34 percent",2040,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4440.02,
STRYKER 57-13108 COMPRESSION PLT 6 HOLE,C1713,HCPCS,,79010895,CDM,278,RC,,,both,,,951,703.74,,,703.74,Other,150% of Medicare + 9.63% HCRA Surcharge,427.95,45,,427.95,percent of total billed charges,Critical Access Hospital RCC factor,323.34,34,,323.34,percent of total billed charges,Implant Device,323.34,34,,323.34,percent of total billed charges,Implant Device,323.34,34,,323.34,percent of total billed charges,Implant Device,323.34,34,,323.34,percent of total billed charges,Implant Device,323.34,34,,323.34,percent of total billed charges,Implant Device,470.75,,,470.75,Other,110% of Medicare,332.85,35,,332.85,percent of total billed charges,Implant Device,323.34,34,"Charges > $500, x 34%",323.34,percent of total billed charges,Implant Device,332.85,35,,332.85,percent of total billed charges,Implant Device,332.85,35,,332.85,percent of total billed charges,Implant Device,332.85,35,,332.85,percent of total billed charges,Implant Device,332.85,35,,332.85,percent of total billed charges,Implant Device,332.85,35,,332.85,percent of total billed charges,Implant Device,380.4,40,,380.4,percent of total billed charges,Implant Device,332.85,70,,332.85,percent of total billed charges,All Other,323.34,34,,323.34,percent of total billed charges,Implant Device,323.34,34,,323.34,percent of total billed charges,Implant Device,332.85,35,,332.85,percent of total billed charges,Implant Device,332.85,35,,332.85,percent of total billed charges,Implant Device,332.85,35,,332.85,percent of total billed charges,Implant Device,332.85,35,,332.85,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,703.74,
STRYKER 663809 BONE SCREW 2.3X9MM,C1713,HCPCS,,79010896,CDM,278,RC,,,both,,,368,272.32,,,272.32,Other,150% of Medicare + 9.63% HCRA Surcharge,165.6,45,,165.6,percent of total billed charges,Critical Access Hospital RCC factor,125.12,34,,125.12,percent of total billed charges,Implant Device,125.12,34,,125.12,percent of total billed charges,Implant Device,125.12,34,,125.12,percent of total billed charges,Implant Device,125.12,34,,125.12,percent of total billed charges,Implant Device,125.12,34,,125.12,percent of total billed charges,Implant Device,182.16,,,182.16,Other,110% of Medicare,128.8,35,,128.8,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,128.8,35,,128.8,percent of total billed charges,Implant Device,128.8,35,,128.8,percent of total billed charges,Implant Device,128.8,35,,128.8,percent of total billed charges,Implant Device,128.8,35,,128.8,percent of total billed charges,Implant Device,128.8,35,,128.8,percent of total billed charges,Implant Device,147.2,40,,147.2,percent of total billed charges,Implant Device,128.8,70,,128.8,percent of total billed charges,All Other,125.12,34,,125.12,percent of total billed charges,Implant Device,125.12,34,,125.12,percent of total billed charges,Implant Device,128.8,35,,128.8,percent of total billed charges,Implant Device,128.8,35,,128.8,percent of total billed charges,Implant Device,128.8,35,,128.8,percent of total billed charges,Implant Device,128.8,35,,128.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,272.32,
STRYKER 663810 BONE SCREW 2.3X10MM,C1713,HCPCS,,79010897,CDM,278,RC,,,both,,,324,239.76,,,239.76,Other,150% of Medicare + 9.63% HCRA Surcharge,145.8,45,,145.8,percent of total billed charges,Critical Access Hospital RCC factor,110.16,34,,110.16,percent of total billed charges,Implant Device,110.16,34,,110.16,percent of total billed charges,Implant Device,110.16,34,,110.16,percent of total billed charges,Implant Device,110.16,34,,110.16,percent of total billed charges,Implant Device,110.16,34,,110.16,percent of total billed charges,Implant Device,160.38,,,160.38,Other,110% of Medicare,113.4,35,,113.4,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,129.6,40,,129.6,percent of total billed charges,Implant Device,113.4,70,,113.4,percent of total billed charges,All Other,110.16,34,,110.16,percent of total billed charges,Implant Device,110.16,34,,110.16,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,239.76,
STRYKER 663811 BONE SCREW 2.3X11MM,C1713,HCPCS,,79010898,CDM,278,RC,,,both,,,324,239.76,,,239.76,Other,150% of Medicare + 9.63% HCRA Surcharge,145.8,45,,145.8,percent of total billed charges,Critical Access Hospital RCC factor,110.16,34,,110.16,percent of total billed charges,Implant Device,110.16,34,,110.16,percent of total billed charges,Implant Device,110.16,34,,110.16,percent of total billed charges,Implant Device,110.16,34,,110.16,percent of total billed charges,Implant Device,110.16,34,,110.16,percent of total billed charges,Implant Device,160.38,,,160.38,Other,110% of Medicare,113.4,35,,113.4,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,129.6,40,,129.6,percent of total billed charges,Implant Device,113.4,70,,113.4,percent of total billed charges,All Other,110.16,34,,110.16,percent of total billed charges,Implant Device,110.16,34,,110.16,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,239.76,
DEPUY 04.037.142S SHORT NAIL 11X130MM,C1713,HCPCS,,79010901,CDM,278,RC,,,both,,,3718,2751.33,,,2751.33,Other,150% of Medicare + 9.63% HCRA Surcharge,1673.1,45,,1673.1,percent of total billed charges,Critical Access Hospital RCC factor,1264.12,34,,1264.12,percent of total billed charges,Implant Device,1264.12,34,,1264.12,percent of total billed charges,Implant Device,1264.12,34,,1264.12,percent of total billed charges,Implant Device,1264.12,34,,1264.12,percent of total billed charges,Implant Device,1264.12,34,,1264.12,percent of total billed charges,Implant Device,1840.41,,,1840.41,Other,110% of Medicare,1301.3,35,,1301.3,percent of total billed charges,Implant Device,1264.12,34,"Charges > $500, x 34%",1264.12,percent of total billed charges,Implant Device,1301.3,35,,1301.3,percent of total billed charges,Implant Device,1301.3,35,,1301.3,percent of total billed charges,Implant Device,1301.3,35,,1301.3,percent of total billed charges,Implant Device,1301.3,35,,1301.3,percent of total billed charges,Implant Device,1301.3,35,,1301.3,percent of total billed charges,Implant Device,1487.2,40,,1487.2,percent of total billed charges,Implant Device,1301.3,70,,1301.3,percent of total billed charges,All Other,1264.12,34,,1264.12,percent of total billed charges,Implant Device,1264.12,34,,1264.12,percent of total billed charges,Implant Device,1301.3,35,,1301.3,percent of total billed charges,Implant Device,1301.3,35,,1301.3,percent of total billed charges,Implant Device,1301.3,35,,1301.3,percent of total billed charges,Implant Device,1301.3,35,,1301.3,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1264.12,34,"If Charge > 2,000, then 34 percent",1264.12,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2751.33,
DEPUY 04.038.400S HELICAL BLADE 100MM,C1713,HCPCS,,79010902,CDM,278,RC,,,both,,,1766,1306.84,,,1306.84,Other,150% of Medicare + 9.63% HCRA Surcharge,794.7,45,,794.7,percent of total billed charges,Critical Access Hospital RCC factor,600.44,34,,600.44,percent of total billed charges,Implant Device,600.44,34,,600.44,percent of total billed charges,Implant Device,600.44,34,,600.44,percent of total billed charges,Implant Device,600.44,34,,600.44,percent of total billed charges,Implant Device,600.44,34,,600.44,percent of total billed charges,Implant Device,874.17,,,874.17,Other,110% of Medicare,618.1,35,,618.1,percent of total billed charges,Implant Device,600.44,34,"Charges > $500, x 34%",600.44,percent of total billed charges,Implant Device,618.1,35,,618.1,percent of total billed charges,Implant Device,618.1,35,,618.1,percent of total billed charges,Implant Device,618.1,35,,618.1,percent of total billed charges,Implant Device,618.1,35,,618.1,percent of total billed charges,Implant Device,618.1,35,,618.1,percent of total billed charges,Implant Device,706.4,40,,706.4,percent of total billed charges,Implant Device,618.1,70,,618.1,percent of total billed charges,All Other,600.44,34,,600.44,percent of total billed charges,Implant Device,600.44,34,,600.44,percent of total billed charges,Implant Device,618.1,35,,618.1,percent of total billed charges,Implant Device,618.1,35,,618.1,percent of total billed charges,Implant Device,618.1,35,,618.1,percent of total billed charges,Implant Device,618.1,35,,618.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1306.84,
ZIMMER US 574202020 ACETABULAR SYST 36MM,C1776,HCPCS,,79010904,CDM,278,RC,,,both,,,6912,5114.9,,,5114.9,Other,150% of Medicare + 9.63% HCRA Surcharge,3110.4,45,,3110.4,percent of total billed charges,Critical Access Hospital RCC factor,2350.08,34,,2350.08,percent of total billed charges,Implant Device,2350.08,34,,2350.08,percent of total billed charges,Implant Device,2350.08,34,,2350.08,percent of total billed charges,Implant Device,2350.08,34,,2350.08,percent of total billed charges,Implant Device,2350.08,34,,2350.08,percent of total billed charges,Implant Device,3421.44,,,3421.44,Other,110% of Medicare,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2350.08,34,"Charges > $500, x 34%",2350.08,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2764.8,40,,2764.8,percent of total billed charges,Implant Device,2419.2,70,,2419.2,percent of total billed charges,All Other,2350.08,34,,2350.08,percent of total billed charges,Implant Device,2350.08,34,,2350.08,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2350.08,34,"If Charge > 2,000, then 34 percent",2350.08,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5114.9,
ZIMMER US 574203030 FEMORAL HEAD 12/14,C1776,HCPCS,,79010905,CDM,278,RC,,,both,,,6912,5114.9,,,5114.9,Other,150% of Medicare + 9.63% HCRA Surcharge,3110.4,45,,3110.4,percent of total billed charges,Critical Access Hospital RCC factor,2350.08,34,,2350.08,percent of total billed charges,Implant Device,2350.08,34,,2350.08,percent of total billed charges,Implant Device,2350.08,34,,2350.08,percent of total billed charges,Implant Device,2350.08,34,,2350.08,percent of total billed charges,Implant Device,2350.08,34,,2350.08,percent of total billed charges,Implant Device,3421.44,,,3421.44,Other,110% of Medicare,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2350.08,34,"Charges > $500, x 34%",2350.08,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2764.8,40,,2764.8,percent of total billed charges,Implant Device,2419.2,70,,2419.2,percent of total billed charges,All Other,2350.08,34,,2350.08,percent of total billed charges,Implant Device,2350.08,34,,2350.08,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2350.08,34,"If Charge > 2,000, then 34 percent",2350.08,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5114.9,
ZIMMER US 8145-09-180 HIP NAIL 9X180MM,C1713,HCPCS,,79010906,CDM,278,RC,,,both,,,4464,3303.37,,,3303.37,Other,150% of Medicare + 9.63% HCRA Surcharge,2008.8,45,,2008.8,percent of total billed charges,Critical Access Hospital RCC factor,1517.76,34,,1517.76,percent of total billed charges,Implant Device,1517.76,34,,1517.76,percent of total billed charges,Implant Device,1517.76,34,,1517.76,percent of total billed charges,Implant Device,1517.76,34,,1517.76,percent of total billed charges,Implant Device,1517.76,34,,1517.76,percent of total billed charges,Implant Device,2209.68,,,2209.68,Other,110% of Medicare,1562.4,35,,1562.4,percent of total billed charges,Implant Device,1517.76,34,"Charges > $500, x 34%",1517.76,percent of total billed charges,Implant Device,1562.4,35,,1562.4,percent of total billed charges,Implant Device,1562.4,35,,1562.4,percent of total billed charges,Implant Device,1562.4,35,,1562.4,percent of total billed charges,Implant Device,1562.4,35,,1562.4,percent of total billed charges,Implant Device,1562.4,35,,1562.4,percent of total billed charges,Implant Device,1785.6,40,,1785.6,percent of total billed charges,Implant Device,1562.4,70,,1562.4,percent of total billed charges,All Other,1517.76,34,,1517.76,percent of total billed charges,Implant Device,1517.76,34,,1517.76,percent of total billed charges,Implant Device,1562.4,35,,1562.4,percent of total billed charges,Implant Device,1562.4,35,,1562.4,percent of total billed charges,Implant Device,1562.4,35,,1562.4,percent of total billed charges,Implant Device,1562.4,35,,1562.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1517.76,34,"If Charge > 2,000, then 34 percent",1517.76,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3303.37,
ZIMMER US 574201050 FEMORAL STEM SIZE 5,C1776,HCPCS,,79010907,CDM,278,RC,,,both,,,8573,6344.04,,,6344.04,Other,150% of Medicare + 9.63% HCRA Surcharge,3857.85,45,,3857.85,percent of total billed charges,Critical Access Hospital RCC factor,2914.82,34,,2914.82,percent of total billed charges,Implant Device,2914.82,34,,2914.82,percent of total billed charges,Implant Device,2914.82,34,,2914.82,percent of total billed charges,Implant Device,2914.82,34,,2914.82,percent of total billed charges,Implant Device,2914.82,34,,2914.82,percent of total billed charges,Implant Device,4243.64,,,4243.64,Other,110% of Medicare,3000.55,35,,3000.55,percent of total billed charges,Implant Device,2914.82,34,"Charges > $500, x 34%",2914.82,percent of total billed charges,Implant Device,3000.55,35,,3000.55,percent of total billed charges,Implant Device,3000.55,35,,3000.55,percent of total billed charges,Implant Device,3000.55,35,,3000.55,percent of total billed charges,Implant Device,3000.55,35,,3000.55,percent of total billed charges,Implant Device,3000.55,35,,3000.55,percent of total billed charges,Implant Device,3429.2,40,,3429.2,percent of total billed charges,Implant Device,3000.55,70,,3000.55,percent of total billed charges,All Other,2914.82,34,,2914.82,percent of total billed charges,Implant Device,2914.82,34,,2914.82,percent of total billed charges,Implant Device,3000.55,35,,3000.55,percent of total billed charges,Implant Device,3000.55,35,,3000.55,percent of total billed charges,Implant Device,3000.55,35,,3000.55,percent of total billed charges,Implant Device,3000.55,35,,3000.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2914.82,34,"If Charge > 2,000, then 34 percent",2914.82,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,6344.04,
ONIC NEURO CX01A BONE CEMENT,C1776,HCPCS,,79010910,CDM,278,RC,,,both,,,1063,786.62,,,786.62,Other,150% of Medicare + 9.63% HCRA Surcharge,478.35,45,,478.35,percent of total billed charges,Critical Access Hospital RCC factor,361.42,34,,361.42,percent of total billed charges,Implant Device,361.42,34,,361.42,percent of total billed charges,Implant Device,361.42,34,,361.42,percent of total billed charges,Implant Device,361.42,34,,361.42,percent of total billed charges,Implant Device,361.42,34,,361.42,percent of total billed charges,Implant Device,526.19,,,526.19,Other,110% of Medicare,372.05,35,,372.05,percent of total billed charges,Implant Device,361.42,34,"Charges > $500, x 34%",361.42,percent of total billed charges,Implant Device,372.05,35,,372.05,percent of total billed charges,Implant Device,372.05,35,,372.05,percent of total billed charges,Implant Device,372.05,35,,372.05,percent of total billed charges,Implant Device,372.05,35,,372.05,percent of total billed charges,Implant Device,372.05,35,,372.05,percent of total billed charges,Implant Device,425.2,40,,425.2,percent of total billed charges,Implant Device,372.05,70,,372.05,percent of total billed charges,All Other,361.42,34,,361.42,percent of total billed charges,Implant Device,361.42,34,,361.42,percent of total billed charges,Implant Device,372.05,35,,372.05,percent of total billed charges,Implant Device,372.05,35,,372.05,percent of total billed charges,Implant Device,372.05,35,,372.05,percent of total billed charges,Implant Device,372.05,35,,372.05,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,786.62,
STRYKER ORTHO 40-30128 SCREW 3.0X28MM,C1713,HCPCS,,79010913,CDM,278,RC,,,both,,,493,364.82,,,364.82,Other,150% of Medicare + 9.63% HCRA Surcharge,221.85,45,,221.85,percent of total billed charges,Critical Access Hospital RCC factor,167.62,34,,167.62,percent of total billed charges,Implant Device,167.62,34,,167.62,percent of total billed charges,Implant Device,167.62,34,,167.62,percent of total billed charges,Implant Device,167.62,34,,167.62,percent of total billed charges,Implant Device,167.62,34,,167.62,percent of total billed charges,Implant Device,244.04,,,244.04,Other,110% of Medicare,172.55,35,,172.55,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,172.55,35,,172.55,percent of total billed charges,Implant Device,172.55,35,,172.55,percent of total billed charges,Implant Device,172.55,35,,172.55,percent of total billed charges,Implant Device,172.55,35,,172.55,percent of total billed charges,Implant Device,172.55,35,,172.55,percent of total billed charges,Implant Device,197.2,40,,197.2,percent of total billed charges,Implant Device,172.55,70,,172.55,percent of total billed charges,All Other,167.62,34,,167.62,percent of total billed charges,Implant Device,167.62,34,,167.62,percent of total billed charges,Implant Device,172.55,35,,172.55,percent of total billed charges,Implant Device,172.55,35,,172.55,percent of total billed charges,Implant Device,172.55,35,,172.55,percent of total billed charges,Implant Device,172.55,35,,172.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,364.82,
STRYKER ORTHO 40-30132 SCREW 3.0X32MM,C1713,HCPCS,,79010914,CDM,278,RC,,,both,,,493,364.82,,,364.82,Other,150% of Medicare + 9.63% HCRA Surcharge,221.85,45,,221.85,percent of total billed charges,Critical Access Hospital RCC factor,167.62,34,,167.62,percent of total billed charges,Implant Device,167.62,34,,167.62,percent of total billed charges,Implant Device,167.62,34,,167.62,percent of total billed charges,Implant Device,167.62,34,,167.62,percent of total billed charges,Implant Device,167.62,34,,167.62,percent of total billed charges,Implant Device,244.04,,,244.04,Other,110% of Medicare,172.55,35,,172.55,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,172.55,35,,172.55,percent of total billed charges,Implant Device,172.55,35,,172.55,percent of total billed charges,Implant Device,172.55,35,,172.55,percent of total billed charges,Implant Device,172.55,35,,172.55,percent of total billed charges,Implant Device,172.55,35,,172.55,percent of total billed charges,Implant Device,197.2,40,,197.2,percent of total billed charges,Implant Device,172.55,70,,172.55,percent of total billed charges,All Other,167.62,34,,167.62,percent of total billed charges,Implant Device,167.62,34,,167.62,percent of total billed charges,Implant Device,172.55,35,,172.55,percent of total billed charges,Implant Device,172.55,35,,172.55,percent of total billed charges,Implant Device,172.55,35,,172.55,percent of total billed charges,Implant Device,172.55,35,,172.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,364.82,
STRYKER ORTHO 663036  SCREW 4.0X36MM,C1713,HCPCS,,79010915,CDM,278,RC,,,both,,,2559,1893.67,,,1893.67,Other,150% of Medicare + 9.63% HCRA Surcharge,1151.55,45,,1151.55,percent of total billed charges,Critical Access Hospital RCC factor,870.06,34,,870.06,percent of total billed charges,Implant Device,870.06,34,,870.06,percent of total billed charges,Implant Device,870.06,34,,870.06,percent of total billed charges,Implant Device,870.06,34,,870.06,percent of total billed charges,Implant Device,870.06,34,,870.06,percent of total billed charges,Implant Device,1266.71,,,1266.71,Other,110% of Medicare,895.65,35,,895.65,percent of total billed charges,Implant Device,870.06,34,"Charges > $500, x 34%",870.06,percent of total billed charges,Implant Device,895.65,35,,895.65,percent of total billed charges,Implant Device,895.65,35,,895.65,percent of total billed charges,Implant Device,895.65,35,,895.65,percent of total billed charges,Implant Device,895.65,35,,895.65,percent of total billed charges,Implant Device,895.65,35,,895.65,percent of total billed charges,Implant Device,1023.6,40,,1023.6,percent of total billed charges,Implant Device,895.65,70,,895.65,percent of total billed charges,All Other,870.06,34,,870.06,percent of total billed charges,Implant Device,870.06,34,,870.06,percent of total billed charges,Implant Device,895.65,35,,895.65,percent of total billed charges,Implant Device,895.65,35,,895.65,percent of total billed charges,Implant Device,895.65,35,,895.65,percent of total billed charges,Implant Device,895.65,35,,895.65,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,870.06,34,"If Charge > 2,000, then 34 percent",870.06,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1893.67,
DEPUY SYNTHES 04.038.405S BLADE 105MM,C1713,HCPCS,,79010917,CDM,278,RC,,,both,,,1766,1306.84,,,1306.84,Other,150% of Medicare + 9.63% HCRA Surcharge,794.7,45,,794.7,percent of total billed charges,Critical Access Hospital RCC factor,600.44,34,,600.44,percent of total billed charges,Implant Device,600.44,34,,600.44,percent of total billed charges,Implant Device,600.44,34,,600.44,percent of total billed charges,Implant Device,600.44,34,,600.44,percent of total billed charges,Implant Device,600.44,34,,600.44,percent of total billed charges,Implant Device,874.17,,,874.17,Other,110% of Medicare,618.1,35,,618.1,percent of total billed charges,Implant Device,600.44,34,"Charges > $500, x 34%",600.44,percent of total billed charges,Implant Device,618.1,35,,618.1,percent of total billed charges,Implant Device,618.1,35,,618.1,percent of total billed charges,Implant Device,618.1,35,,618.1,percent of total billed charges,Implant Device,618.1,35,,618.1,percent of total billed charges,Implant Device,618.1,35,,618.1,percent of total billed charges,Implant Device,706.4,40,,706.4,percent of total billed charges,Implant Device,618.1,70,,618.1,percent of total billed charges,All Other,600.44,34,,600.44,percent of total billed charges,Implant Device,600.44,34,,600.44,percent of total billed charges,Implant Device,618.1,35,,618.1,percent of total billed charges,Implant Device,618.1,35,,618.1,percent of total billed charges,Implant Device,618.1,35,,618.1,percent of total billed charges,Implant Device,618.1,35,,618.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1306.84,
DEPUY 204.014 CORTEX SCREW 3.5X14MM,C1713,HCPCS,,79010920,CDM,278,RC,,,both,,,43,31.82,,,31.82,Other,150% of Medicare + 9.63% HCRA Surcharge,19.35,45,,19.35,percent of total billed charges,Critical Access Hospital RCC factor,14.62,34,,14.62,percent of total billed charges,Implant Device,14.62,34,,14.62,percent of total billed charges,Implant Device,14.62,34,,14.62,percent of total billed charges,Implant Device,14.62,34,,14.62,percent of total billed charges,Implant Device,14.62,34,,14.62,percent of total billed charges,Implant Device,21.29,,,21.29,Other,110% of Medicare,15.05,35,,15.05,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,15.05,35,,15.05,percent of total billed charges,Implant Device,15.05,35,,15.05,percent of total billed charges,Implant Device,15.05,35,,15.05,percent of total billed charges,Implant Device,15.05,35,,15.05,percent of total billed charges,Implant Device,15.05,35,,15.05,percent of total billed charges,Implant Device,17.2,40,,17.2,percent of total billed charges,Implant Device,15.05,70,,15.05,percent of total billed charges,All Other,14.62,34,,14.62,percent of total billed charges,Implant Device,14.62,34,,14.62,percent of total billed charges,Implant Device,15.05,35,,15.05,percent of total billed charges,Implant Device,15.05,35,,15.05,percent of total billed charges,Implant Device,15.05,35,,15.05,percent of total billed charges,Implant Device,15.05,35,,15.05,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,31.82,
DEPUY 212.120 LOCKING SCREW 3.5X20MM,C1713,HCPCS,,79010921,CDM,278,RC,,,both,,,327,241.98,,,241.98,Other,150% of Medicare + 9.63% HCRA Surcharge,147.15,45,,147.15,percent of total billed charges,Critical Access Hospital RCC factor,111.18,34,,111.18,percent of total billed charges,Implant Device,111.18,34,,111.18,percent of total billed charges,Implant Device,111.18,34,,111.18,percent of total billed charges,Implant Device,111.18,34,,111.18,percent of total billed charges,Implant Device,111.18,34,,111.18,percent of total billed charges,Implant Device,161.87,,,161.87,Other,110% of Medicare,114.45,35,,114.45,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,114.45,35,,114.45,percent of total billed charges,Implant Device,114.45,35,,114.45,percent of total billed charges,Implant Device,114.45,35,,114.45,percent of total billed charges,Implant Device,114.45,35,,114.45,percent of total billed charges,Implant Device,114.45,35,,114.45,percent of total billed charges,Implant Device,130.8,40,,130.8,percent of total billed charges,Implant Device,114.45,70,,114.45,percent of total billed charges,All Other,111.18,34,,111.18,percent of total billed charges,Implant Device,111.18,34,,111.18,percent of total billed charges,Implant Device,114.45,35,,114.45,percent of total billed charges,Implant Device,114.45,35,,114.45,percent of total billed charges,Implant Device,114.45,35,,114.45,percent of total billed charges,Implant Device,114.45,35,,114.45,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,241.98,
DEPUY 04.037.242S NAIL 170X12MM 130 DEG,C1713,HCPCS,,79010922,CDM,278,RC,,,both,,,4247,3142.79,,,3142.79,Other,150% of Medicare + 9.63% HCRA Surcharge,1911.15,45,,1911.15,percent of total billed charges,Critical Access Hospital RCC factor,1443.98,34,,1443.98,percent of total billed charges,Implant Device,1443.98,34,,1443.98,percent of total billed charges,Implant Device,1443.98,34,,1443.98,percent of total billed charges,Implant Device,1443.98,34,,1443.98,percent of total billed charges,Implant Device,1443.98,34,,1443.98,percent of total billed charges,Implant Device,2102.27,,,2102.27,Other,110% of Medicare,1486.45,35,,1486.45,percent of total billed charges,Implant Device,1443.98,34,"Charges > $500, x 34%",1443.98,percent of total billed charges,Implant Device,1486.45,35,,1486.45,percent of total billed charges,Implant Device,1486.45,35,,1486.45,percent of total billed charges,Implant Device,1486.45,35,,1486.45,percent of total billed charges,Implant Device,1486.45,35,,1486.45,percent of total billed charges,Implant Device,1486.45,35,,1486.45,percent of total billed charges,Implant Device,1698.8,40,,1698.8,percent of total billed charges,Implant Device,1486.45,70,,1486.45,percent of total billed charges,All Other,1443.98,34,,1443.98,percent of total billed charges,Implant Device,1443.98,34,,1443.98,percent of total billed charges,Implant Device,1486.45,35,,1486.45,percent of total billed charges,Implant Device,1486.45,35,,1486.45,percent of total billed charges,Implant Device,1486.45,35,,1486.45,percent of total billed charges,Implant Device,1486.45,35,,1486.45,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1443.98,34,"If Charge > 2,000, then 34 percent",1443.98,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3142.79,
MEDTRONIC TH90P01 PATIENT PROGRAMMER,C1787,HCPCS,,79010929,CDM,278,RC,,,both,,,4722,3494.29,,,3494.29,Other,150% of Medicare + 9.63% HCRA Surcharge,2124.9,45,,2124.9,percent of total billed charges,Critical Access Hospital RCC factor,1605.48,34,,1605.48,percent of total billed charges,Implant Device,1605.48,34,,1605.48,percent of total billed charges,Implant Device,1605.48,34,,1605.48,percent of total billed charges,Implant Device,1605.48,34,,1605.48,percent of total billed charges,Implant Device,1605.48,34,,1605.48,percent of total billed charges,Implant Device,2337.39,,,2337.39,Other,110% of Medicare,1652.7,35,,1652.7,percent of total billed charges,Implant Device,1605.48,34,"Charges > $500, x 34%",1605.48,percent of total billed charges,Implant Device,1652.7,35,,1652.7,percent of total billed charges,Implant Device,1652.7,35,,1652.7,percent of total billed charges,Implant Device,1652.7,35,,1652.7,percent of total billed charges,Implant Device,1652.7,35,,1652.7,percent of total billed charges,Implant Device,1652.7,35,,1652.7,percent of total billed charges,Implant Device,1888.8,40,,1888.8,percent of total billed charges,Implant Device,1652.7,70,,1652.7,percent of total billed charges,All Other,1605.48,34,,1605.48,percent of total billed charges,Implant Device,1605.48,34,,1605.48,percent of total billed charges,Implant Device,1652.7,35,,1652.7,percent of total billed charges,Implant Device,1652.7,35,,1652.7,percent of total billed charges,Implant Device,1652.7,35,,1652.7,percent of total billed charges,Implant Device,1652.7,35,,1652.7,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1605.48,34,"If Charge > 2,000, then 34 percent",1605.48,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3494.29,
ZIMMER 574202050 FEMORAL STEM 12/14 SZ 5,C1776,HCPCS,,79010930,CDM,278,RC,,,both,,,6912,5114.9,,,5114.9,Other,150% of Medicare + 9.63% HCRA Surcharge,3110.4,45,,3110.4,percent of total billed charges,Critical Access Hospital RCC factor,2350.08,34,,2350.08,percent of total billed charges,Implant Device,2350.08,34,,2350.08,percent of total billed charges,Implant Device,2350.08,34,,2350.08,percent of total billed charges,Implant Device,2350.08,34,,2350.08,percent of total billed charges,Implant Device,2350.08,34,,2350.08,percent of total billed charges,Implant Device,3421.44,,,3421.44,Other,110% of Medicare,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2350.08,34,"Charges > $500, x 34%",2350.08,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2764.8,40,,2764.8,percent of total billed charges,Implant Device,2419.2,70,,2419.2,percent of total billed charges,All Other,2350.08,34,,2350.08,percent of total billed charges,Implant Device,2350.08,34,,2350.08,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2350.08,34,"If Charge > 2,000, then 34 percent",2350.08,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5114.9,
ZIMMER 574203020 FEM STEM 12/14 SZ 2,C1776,HCPCS,,79010931,CDM,278,RC,,,both,,,8573,6344.04,,,6344.04,Other,150% of Medicare + 9.63% HCRA Surcharge,3857.85,45,,3857.85,percent of total billed charges,Critical Access Hospital RCC factor,2914.82,34,,2914.82,percent of total billed charges,Implant Device,2914.82,34,,2914.82,percent of total billed charges,Implant Device,2914.82,34,,2914.82,percent of total billed charges,Implant Device,2914.82,34,,2914.82,percent of total billed charges,Implant Device,2914.82,34,,2914.82,percent of total billed charges,Implant Device,4243.64,,,4243.64,Other,110% of Medicare,3000.55,35,,3000.55,percent of total billed charges,Implant Device,2914.82,34,"Charges > $500, x 34%",2914.82,percent of total billed charges,Implant Device,3000.55,35,,3000.55,percent of total billed charges,Implant Device,3000.55,35,,3000.55,percent of total billed charges,Implant Device,3000.55,35,,3000.55,percent of total billed charges,Implant Device,3000.55,35,,3000.55,percent of total billed charges,Implant Device,3000.55,35,,3000.55,percent of total billed charges,Implant Device,3429.2,40,,3429.2,percent of total billed charges,Implant Device,3000.55,70,,3000.55,percent of total billed charges,All Other,2914.82,34,,2914.82,percent of total billed charges,Implant Device,2914.82,34,,2914.82,percent of total billed charges,Implant Device,3000.55,35,,3000.55,percent of total billed charges,Implant Device,3000.55,35,,3000.55,percent of total billed charges,Implant Device,3000.55,35,,3000.55,percent of total billed charges,Implant Device,3000.55,35,,3000.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2914.82,34,"If Charge > 2,000, then 34 percent",2914.82,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,6344.04,
ZIMMER 574201010 FEM STEM 12/14 SZ 1,C1776,HCPCS,,79010932,CDM,278,RC,,,both,,,6912,5114.9,,,5114.9,Other,150% of Medicare + 9.63% HCRA Surcharge,3110.4,45,,3110.4,percent of total billed charges,Critical Access Hospital RCC factor,2350.08,34,,2350.08,percent of total billed charges,Implant Device,2350.08,34,,2350.08,percent of total billed charges,Implant Device,2350.08,34,,2350.08,percent of total billed charges,Implant Device,2350.08,34,,2350.08,percent of total billed charges,Implant Device,2350.08,34,,2350.08,percent of total billed charges,Implant Device,3421.44,,,3421.44,Other,110% of Medicare,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2350.08,34,"Charges > $500, x 34%",2350.08,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2764.8,40,,2764.8,percent of total billed charges,Implant Device,2419.2,70,,2419.2,percent of total billed charges,All Other,2350.08,34,,2350.08,percent of total billed charges,Implant Device,2350.08,34,,2350.08,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2350.08,34,"If Charge > 2,000, then 34 percent",2350.08,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5114.9,
ARTHREX AR-9943BR-06 LOCK DIS FIB PLT RT,C1713,HCPCS,,79010933,CDM,278,RC,,,both,,,2325,1720.51,,,1720.51,Other,150% of Medicare + 9.63% HCRA Surcharge,1046.25,45,,1046.25,percent of total billed charges,Critical Access Hospital RCC factor,790.5,34,,790.5,percent of total billed charges,Implant Device,790.5,34,,790.5,percent of total billed charges,Implant Device,790.5,34,,790.5,percent of total billed charges,Implant Device,790.5,34,,790.5,percent of total billed charges,Implant Device,790.5,34,,790.5,percent of total billed charges,Implant Device,1150.88,,,1150.88,Other,110% of Medicare,813.75,35,,813.75,percent of total billed charges,Implant Device,790.5,34,"Charges > $500, x 34%",790.5,percent of total billed charges,Implant Device,813.75,35,,813.75,percent of total billed charges,Implant Device,813.75,35,,813.75,percent of total billed charges,Implant Device,813.75,35,,813.75,percent of total billed charges,Implant Device,813.75,35,,813.75,percent of total billed charges,Implant Device,813.75,35,,813.75,percent of total billed charges,Implant Device,930,40,,930,percent of total billed charges,Implant Device,813.75,70,,813.75,percent of total billed charges,All Other,790.5,34,,790.5,percent of total billed charges,Implant Device,790.5,34,,790.5,percent of total billed charges,Implant Device,813.75,35,,813.75,percent of total billed charges,Implant Device,813.75,35,,813.75,percent of total billed charges,Implant Device,813.75,35,,813.75,percent of total billed charges,Implant Device,813.75,35,,813.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,790.5,34,"If Charge > 2,000, then 34 percent",790.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1720.51,
ZIMMER 1318-11-050 DVR LOCK NARROW PLATE,C1713,HCPCS,,79010934,CDM,278,RC,,,both,,,2682,1984.69,,,1984.69,Other,150% of Medicare + 9.63% HCRA Surcharge,1206.9,45,,1206.9,percent of total billed charges,Critical Access Hospital RCC factor,911.88,34,,911.88,percent of total billed charges,Implant Device,911.88,34,,911.88,percent of total billed charges,Implant Device,911.88,34,,911.88,percent of total billed charges,Implant Device,911.88,34,,911.88,percent of total billed charges,Implant Device,911.88,34,,911.88,percent of total billed charges,Implant Device,1327.59,,,1327.59,Other,110% of Medicare,938.7,35,,938.7,percent of total billed charges,Implant Device,911.88,34,"Charges > $500, x 34%",911.88,percent of total billed charges,Implant Device,938.7,35,,938.7,percent of total billed charges,Implant Device,938.7,35,,938.7,percent of total billed charges,Implant Device,938.7,35,,938.7,percent of total billed charges,Implant Device,938.7,35,,938.7,percent of total billed charges,Implant Device,938.7,35,,938.7,percent of total billed charges,Implant Device,1072.8,40,,1072.8,percent of total billed charges,Implant Device,938.7,70,,938.7,percent of total billed charges,All Other,911.88,34,,911.88,percent of total billed charges,Implant Device,911.88,34,,911.88,percent of total billed charges,Implant Device,938.7,35,,938.7,percent of total billed charges,Implant Device,938.7,35,,938.7,percent of total billed charges,Implant Device,938.7,35,,938.7,percent of total billed charges,Implant Device,938.7,35,,938.7,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,911.88,34,"If Charge > 2,000, then 34 percent",911.88,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1984.69,
ZIMMER 1312-27-213 NON LOCK SCREW 2.7X13,C1713,HCPCS,,79010936,CDM,278,RC,,,both,,,216,159.84,,,159.84,Other,150% of Medicare + 9.63% HCRA Surcharge,97.2,45,,97.2,percent of total billed charges,Critical Access Hospital RCC factor,73.44,34,,73.44,percent of total billed charges,Implant Device,73.44,34,,73.44,percent of total billed charges,Implant Device,73.44,34,,73.44,percent of total billed charges,Implant Device,73.44,34,,73.44,percent of total billed charges,Implant Device,73.44,34,,73.44,percent of total billed charges,Implant Device,106.92,,,106.92,Other,110% of Medicare,75.6,35,,75.6,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,75.6,35,,75.6,percent of total billed charges,Implant Device,75.6,35,,75.6,percent of total billed charges,Implant Device,75.6,35,,75.6,percent of total billed charges,Implant Device,75.6,35,,75.6,percent of total billed charges,Implant Device,75.6,35,,75.6,percent of total billed charges,Implant Device,86.4,40,,86.4,percent of total billed charges,Implant Device,75.6,70,,75.6,percent of total billed charges,All Other,73.44,34,,73.44,percent of total billed charges,Implant Device,73.44,34,,73.44,percent of total billed charges,Implant Device,75.6,35,,75.6,percent of total billed charges,Implant Device,75.6,35,,75.6,percent of total billed charges,Implant Device,75.6,35,,75.6,percent of total billed charges,Implant Device,75.6,35,,75.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,159.84,
ZIMMER 1312-27-214 NON LOCK SCREW 2.7X14,C1713,HCPCS,,79010937,CDM,278,RC,,,both,,,216,159.84,,,159.84,Other,150% of Medicare + 9.63% HCRA Surcharge,97.2,45,,97.2,percent of total billed charges,Critical Access Hospital RCC factor,73.44,34,,73.44,percent of total billed charges,Implant Device,73.44,34,,73.44,percent of total billed charges,Implant Device,73.44,34,,73.44,percent of total billed charges,Implant Device,73.44,34,,73.44,percent of total billed charges,Implant Device,73.44,34,,73.44,percent of total billed charges,Implant Device,106.92,,,106.92,Other,110% of Medicare,75.6,35,,75.6,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,75.6,35,,75.6,percent of total billed charges,Implant Device,75.6,35,,75.6,percent of total billed charges,Implant Device,75.6,35,,75.6,percent of total billed charges,Implant Device,75.6,35,,75.6,percent of total billed charges,Implant Device,75.6,35,,75.6,percent of total billed charges,Implant Device,86.4,40,,86.4,percent of total billed charges,Implant Device,75.6,70,,75.6,percent of total billed charges,All Other,73.44,34,,73.44,percent of total billed charges,Implant Device,73.44,34,,73.44,percent of total billed charges,Implant Device,75.6,35,,75.6,percent of total billed charges,Implant Device,75.6,35,,75.6,percent of total billed charges,Implant Device,75.6,35,,75.6,percent of total billed charges,Implant Device,75.6,35,,75.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,159.84,
ZIMMER 1312-27-215 NON LOCK SCREW 2.7X15,C1713,HCPCS,,79010938,CDM,278,RC,,,both,,,216,159.84,,,159.84,Other,150% of Medicare + 9.63% HCRA Surcharge,97.2,45,,97.2,percent of total billed charges,Critical Access Hospital RCC factor,73.44,34,,73.44,percent of total billed charges,Implant Device,73.44,34,,73.44,percent of total billed charges,Implant Device,73.44,34,,73.44,percent of total billed charges,Implant Device,73.44,34,,73.44,percent of total billed charges,Implant Device,73.44,34,,73.44,percent of total billed charges,Implant Device,106.92,,,106.92,Other,110% of Medicare,75.6,35,,75.6,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,75.6,35,,75.6,percent of total billed charges,Implant Device,75.6,35,,75.6,percent of total billed charges,Implant Device,75.6,35,,75.6,percent of total billed charges,Implant Device,75.6,35,,75.6,percent of total billed charges,Implant Device,75.6,35,,75.6,percent of total billed charges,Implant Device,86.4,40,,86.4,percent of total billed charges,Implant Device,75.6,70,,75.6,percent of total billed charges,All Other,73.44,34,,73.44,percent of total billed charges,Implant Device,73.44,34,,73.44,percent of total billed charges,Implant Device,75.6,35,,75.6,percent of total billed charges,Implant Device,75.6,35,,75.6,percent of total billed charges,Implant Device,75.6,35,,75.6,percent of total billed charges,Implant Device,75.6,35,,75.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,159.84,
ZIMMER 1312-27-112 LOCK SCREW 2.7X12MM,C1713,HCPCS,,79010939,CDM,278,RC,,,both,,,360,266.4,,,266.4,Other,150% of Medicare + 9.63% HCRA Surcharge,162,45,,162,percent of total billed charges,Critical Access Hospital RCC factor,122.4,34,,122.4,percent of total billed charges,Implant Device,122.4,34,,122.4,percent of total billed charges,Implant Device,122.4,34,,122.4,percent of total billed charges,Implant Device,122.4,34,,122.4,percent of total billed charges,Implant Device,122.4,34,,122.4,percent of total billed charges,Implant Device,178.2,,,178.2,Other,110% of Medicare,126,35,,126,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,126,35,,126,percent of total billed charges,Implant Device,126,35,,126,percent of total billed charges,Implant Device,126,35,,126,percent of total billed charges,Implant Device,126,35,,126,percent of total billed charges,Implant Device,126,35,,126,percent of total billed charges,Implant Device,144,40,,144,percent of total billed charges,Implant Device,126,70,,126,percent of total billed charges,All Other,122.4,34,,122.4,percent of total billed charges,Implant Device,122.4,34,,122.4,percent of total billed charges,Implant Device,126,35,,126,percent of total billed charges,Implant Device,126,35,,126,percent of total billed charges,Implant Device,126,35,,126,percent of total billed charges,Implant Device,126,35,,126,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,266.4,
ZIMMER 1312-27-114 LOCK SCREW 2.7X14MM,C1713,HCPCS,,79010940,CDM,278,RC,,,both,,,360,266.4,,,266.4,Other,150% of Medicare + 9.63% HCRA Surcharge,162,45,,162,percent of total billed charges,Critical Access Hospital RCC factor,122.4,34,,122.4,percent of total billed charges,Implant Device,122.4,34,,122.4,percent of total billed charges,Implant Device,122.4,34,,122.4,percent of total billed charges,Implant Device,122.4,34,,122.4,percent of total billed charges,Implant Device,122.4,34,,122.4,percent of total billed charges,Implant Device,178.2,,,178.2,Other,110% of Medicare,126,35,,126,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,126,35,,126,percent of total billed charges,Implant Device,126,35,,126,percent of total billed charges,Implant Device,126,35,,126,percent of total billed charges,Implant Device,126,35,,126,percent of total billed charges,Implant Device,126,35,,126,percent of total billed charges,Implant Device,144,40,,144,percent of total billed charges,Implant Device,126,70,,126,percent of total billed charges,All Other,122.4,34,,122.4,percent of total billed charges,Implant Device,122.4,34,,122.4,percent of total billed charges,Implant Device,126,35,,126,percent of total billed charges,Implant Device,126,35,,126,percent of total billed charges,Implant Device,126,35,,126,percent of total billed charges,Implant Device,126,35,,126,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,266.4,
ZIMMER 1312-27-116 LOCK SCREW 2.7X16MM,C1713,HCPCS,,79010941,CDM,278,RC,,,both,,,360,266.4,,,266.4,Other,150% of Medicare + 9.63% HCRA Surcharge,162,45,,162,percent of total billed charges,Critical Access Hospital RCC factor,122.4,34,,122.4,percent of total billed charges,Implant Device,122.4,34,,122.4,percent of total billed charges,Implant Device,122.4,34,,122.4,percent of total billed charges,Implant Device,122.4,34,,122.4,percent of total billed charges,Implant Device,122.4,34,,122.4,percent of total billed charges,Implant Device,178.2,,,178.2,Other,110% of Medicare,126,35,,126,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,126,35,,126,percent of total billed charges,Implant Device,126,35,,126,percent of total billed charges,Implant Device,126,35,,126,percent of total billed charges,Implant Device,126,35,,126,percent of total billed charges,Implant Device,126,35,,126,percent of total billed charges,Implant Device,144,40,,144,percent of total billed charges,Implant Device,126,70,,126,percent of total billed charges,All Other,122.4,34,,122.4,percent of total billed charges,Implant Device,122.4,34,,122.4,percent of total billed charges,Implant Device,126,35,,126,percent of total billed charges,Implant Device,126,35,,126,percent of total billed charges,Implant Device,126,35,,126,percent of total billed charges,Implant Device,126,35,,126,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,266.4,
ZIMMER 1312-27-118 LOCK SCREW 2.7X18MM,C1713,HCPCS,,79010942,CDM,278,RC,,,both,,,360,266.4,,,266.4,Other,150% of Medicare + 9.63% HCRA Surcharge,162,45,,162,percent of total billed charges,Critical Access Hospital RCC factor,122.4,34,,122.4,percent of total billed charges,Implant Device,122.4,34,,122.4,percent of total billed charges,Implant Device,122.4,34,,122.4,percent of total billed charges,Implant Device,122.4,34,,122.4,percent of total billed charges,Implant Device,122.4,34,,122.4,percent of total billed charges,Implant Device,178.2,,,178.2,Other,110% of Medicare,126,35,,126,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,126,35,,126,percent of total billed charges,Implant Device,126,35,,126,percent of total billed charges,Implant Device,126,35,,126,percent of total billed charges,Implant Device,126,35,,126,percent of total billed charges,Implant Device,126,35,,126,percent of total billed charges,Implant Device,144,40,,144,percent of total billed charges,Implant Device,126,70,,126,percent of total billed charges,All Other,122.4,34,,122.4,percent of total billed charges,Implant Device,122.4,34,,122.4,percent of total billed charges,Implant Device,126,35,,126,percent of total billed charges,Implant Device,126,35,,126,percent of total billed charges,Implant Device,126,35,,126,percent of total billed charges,Implant Device,126,35,,126,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,266.4,
STRYKER STO-16P SMART TOE 16MM,C1776,HCPCS,,79010943,CDM,278,RC,,,both,,,1999,1479.26,,,1479.26,Other,150% of Medicare + 9.63% HCRA Surcharge,899.55,45,,899.55,percent of total billed charges,Critical Access Hospital RCC factor,679.66,34,,679.66,percent of total billed charges,Implant Device,679.66,34,,679.66,percent of total billed charges,Implant Device,679.66,34,,679.66,percent of total billed charges,Implant Device,679.66,34,,679.66,percent of total billed charges,Implant Device,679.66,34,,679.66,percent of total billed charges,Implant Device,989.51,,,989.51,Other,110% of Medicare,699.65,35,,699.65,percent of total billed charges,Implant Device,679.66,34,"Charges > $500, x 34%",679.66,percent of total billed charges,Implant Device,699.65,35,,699.65,percent of total billed charges,Implant Device,699.65,35,,699.65,percent of total billed charges,Implant Device,699.65,35,,699.65,percent of total billed charges,Implant Device,699.65,35,,699.65,percent of total billed charges,Implant Device,699.65,35,,699.65,percent of total billed charges,Implant Device,799.6,40,,799.6,percent of total billed charges,Implant Device,699.65,70,,699.65,percent of total billed charges,All Other,679.66,34,,679.66,percent of total billed charges,Implant Device,679.66,34,,679.66,percent of total billed charges,Implant Device,699.65,35,,699.65,percent of total billed charges,Implant Device,699.65,35,,699.65,percent of total billed charges,Implant Device,699.65,35,,699.65,percent of total billed charges,Implant Device,699.65,35,,699.65,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1479.26,
STRYKER STOXS-13 SMART TOE 13MM,C1776,HCPCS,,79010944,CDM,278,RC,,,both,,,1999,1479.26,,,1479.26,Other,150% of Medicare + 9.63% HCRA Surcharge,899.55,45,,899.55,percent of total billed charges,Critical Access Hospital RCC factor,679.66,34,,679.66,percent of total billed charges,Implant Device,679.66,34,,679.66,percent of total billed charges,Implant Device,679.66,34,,679.66,percent of total billed charges,Implant Device,679.66,34,,679.66,percent of total billed charges,Implant Device,679.66,34,,679.66,percent of total billed charges,Implant Device,989.51,,,989.51,Other,110% of Medicare,699.65,35,,699.65,percent of total billed charges,Implant Device,679.66,34,"Charges > $500, x 34%",679.66,percent of total billed charges,Implant Device,699.65,35,,699.65,percent of total billed charges,Implant Device,699.65,35,,699.65,percent of total billed charges,Implant Device,699.65,35,,699.65,percent of total billed charges,Implant Device,699.65,35,,699.65,percent of total billed charges,Implant Device,699.65,35,,699.65,percent of total billed charges,Implant Device,799.6,40,,799.6,percent of total billed charges,Implant Device,699.65,70,,699.65,percent of total billed charges,All Other,679.66,34,,679.66,percent of total billed charges,Implant Device,679.66,34,,679.66,percent of total billed charges,Implant Device,699.65,35,,699.65,percent of total billed charges,Implant Device,699.65,35,,699.65,percent of total billed charges,Implant Device,699.65,35,,699.65,percent of total billed charges,Implant Device,699.65,35,,699.65,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1479.26,
STRYKER UH1-49-26 BIPOLAR COMP 49X26MM,C1776,HCPCS,,79010948,CDM,278,RC,,,both,,,1391,1029.34,,,1029.34,Other,150% of Medicare + 9.63% HCRA Surcharge,625.95,45,,625.95,percent of total billed charges,Critical Access Hospital RCC factor,472.94,34,,472.94,percent of total billed charges,Implant Device,472.94,34,,472.94,percent of total billed charges,Implant Device,472.94,34,,472.94,percent of total billed charges,Implant Device,472.94,34,,472.94,percent of total billed charges,Implant Device,472.94,34,,472.94,percent of total billed charges,Implant Device,688.55,,,688.55,Other,110% of Medicare,486.85,35,,486.85,percent of total billed charges,Implant Device,472.94,34,"Charges > $500, x 34%",472.94,percent of total billed charges,Implant Device,486.85,35,,486.85,percent of total billed charges,Implant Device,486.85,35,,486.85,percent of total billed charges,Implant Device,486.85,35,,486.85,percent of total billed charges,Implant Device,486.85,35,,486.85,percent of total billed charges,Implant Device,486.85,35,,486.85,percent of total billed charges,Implant Device,556.4,40,,556.4,percent of total billed charges,Implant Device,486.85,70,,486.85,percent of total billed charges,All Other,472.94,34,,472.94,percent of total billed charges,Implant Device,472.94,34,,472.94,percent of total billed charges,Implant Device,486.85,35,,486.85,percent of total billed charges,Implant Device,486.85,35,,486.85,percent of total billed charges,Implant Device,486.85,35,,486.85,percent of total billed charges,Implant Device,486.85,35,,486.85,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1029.34,
ARTHREX AR-8923BC SUTURE ANCHOR 2.9MM,C1713,HCPCS,,79010949,CDM,278,RC,,,both,,,240,177.6,,,177.6,Other,150% of Medicare + 9.63% HCRA Surcharge,108,45,,108,percent of total billed charges,Critical Access Hospital RCC factor,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,118.8,,,118.8,Other,110% of Medicare,84,35,,84,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,96,40,,96,percent of total billed charges,Implant Device,84,70,,84,percent of total billed charges,All Other,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,177.6,
STRYKER 5517-F-402 FEMORAL COMP SZ 4 RT,C1776,HCPCS,,79010951,CDM,278,RC,,,both,,,5840,4321.61,,,4321.61,Other,150% of Medicare + 9.63% HCRA Surcharge,2628,45,,2628,percent of total billed charges,Critical Access Hospital RCC factor,1985.6,34,,1985.6,percent of total billed charges,Implant Device,1985.6,34,,1985.6,percent of total billed charges,Implant Device,1985.6,34,,1985.6,percent of total billed charges,Implant Device,1985.6,34,,1985.6,percent of total billed charges,Implant Device,1985.6,34,,1985.6,percent of total billed charges,Implant Device,2890.8,,,2890.8,Other,110% of Medicare,2044,35,,2044,percent of total billed charges,Implant Device,1985.6,34,"Charges > $500, x 34%",1985.6,percent of total billed charges,Implant Device,2044,35,,2044,percent of total billed charges,Implant Device,2044,35,,2044,percent of total billed charges,Implant Device,2044,35,,2044,percent of total billed charges,Implant Device,2044,35,,2044,percent of total billed charges,Implant Device,2044,35,,2044,percent of total billed charges,Implant Device,2336,40,,2336,percent of total billed charges,Implant Device,2044,70,,2044,percent of total billed charges,All Other,1985.6,34,,1985.6,percent of total billed charges,Implant Device,1985.6,34,,1985.6,percent of total billed charges,Implant Device,2044,35,,2044,percent of total billed charges,Implant Device,2044,35,,2044,percent of total billed charges,Implant Device,2044,35,,2044,percent of total billed charges,Implant Device,2044,35,,2044,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1985.6,34,"If Charge > 2,000, then 34 percent",1985.6,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4321.61,
STRYKER 5552-L-320 PATELLA 32X10MM,C1776,HCPCS,,79010952,CDM,278,RC,,,both,,,2225,1646.51,,,1646.51,Other,150% of Medicare + 9.63% HCRA Surcharge,1001.25,45,,1001.25,percent of total billed charges,Critical Access Hospital RCC factor,756.5,34,,756.5,percent of total billed charges,Implant Device,756.5,34,,756.5,percent of total billed charges,Implant Device,756.5,34,,756.5,percent of total billed charges,Implant Device,756.5,34,,756.5,percent of total billed charges,Implant Device,756.5,34,,756.5,percent of total billed charges,Implant Device,1101.38,,,1101.38,Other,110% of Medicare,778.75,35,,778.75,percent of total billed charges,Implant Device,756.5,34,"Charges > $500, x 34%",756.5,percent of total billed charges,Implant Device,778.75,35,,778.75,percent of total billed charges,Implant Device,778.75,35,,778.75,percent of total billed charges,Implant Device,778.75,35,,778.75,percent of total billed charges,Implant Device,778.75,35,,778.75,percent of total billed charges,Implant Device,778.75,35,,778.75,percent of total billed charges,Implant Device,890,40,,890,percent of total billed charges,Implant Device,778.75,70,,778.75,percent of total billed charges,All Other,756.5,34,,756.5,percent of total billed charges,Implant Device,756.5,34,,756.5,percent of total billed charges,Implant Device,778.75,35,,778.75,percent of total billed charges,Implant Device,778.75,35,,778.75,percent of total billed charges,Implant Device,778.75,35,,778.75,percent of total billed charges,Implant Device,778.75,35,,778.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,756.5,34,"If Charge > 2,000, then 34 percent",756.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1646.51,
STRYKER 5531-G-411-E TIB BEARING INS 11,C1776,HCPCS,,79010953,CDM,278,RC,,,both,,,2781,2057.95,,,2057.95,Other,150% of Medicare + 9.63% HCRA Surcharge,1251.45,45,,1251.45,percent of total billed charges,Critical Access Hospital RCC factor,945.54,34,,945.54,percent of total billed charges,Implant Device,945.54,34,,945.54,percent of total billed charges,Implant Device,945.54,34,,945.54,percent of total billed charges,Implant Device,945.54,34,,945.54,percent of total billed charges,Implant Device,945.54,34,,945.54,percent of total billed charges,Implant Device,1376.6,,,1376.6,Other,110% of Medicare,973.35,35,,973.35,percent of total billed charges,Implant Device,945.54,34,"Charges > $500, x 34%",945.54,percent of total billed charges,Implant Device,973.35,35,,973.35,percent of total billed charges,Implant Device,973.35,35,,973.35,percent of total billed charges,Implant Device,973.35,35,,973.35,percent of total billed charges,Implant Device,973.35,35,,973.35,percent of total billed charges,Implant Device,973.35,35,,973.35,percent of total billed charges,Implant Device,1112.4,40,,1112.4,percent of total billed charges,Implant Device,973.35,70,,973.35,percent of total billed charges,All Other,945.54,34,,945.54,percent of total billed charges,Implant Device,945.54,34,,945.54,percent of total billed charges,Implant Device,973.35,35,,973.35,percent of total billed charges,Implant Device,973.35,35,,973.35,percent of total billed charges,Implant Device,973.35,35,,973.35,percent of total billed charges,Implant Device,973.35,35,,973.35,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,945.54,34,"If Charge > 2,000, then 34 percent",945.54,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2057.95,
STRYKER 5531-G-509-E TIB BEARING INS 9MM,C1776,HCPCS,,79010954,CDM,278,RC,,,both,,,2781,2057.95,,,2057.95,Other,150% of Medicare + 9.63% HCRA Surcharge,1251.45,45,,1251.45,percent of total billed charges,Critical Access Hospital RCC factor,945.54,34,,945.54,percent of total billed charges,Implant Device,945.54,34,,945.54,percent of total billed charges,Implant Device,945.54,34,,945.54,percent of total billed charges,Implant Device,945.54,34,,945.54,percent of total billed charges,Implant Device,945.54,34,,945.54,percent of total billed charges,Implant Device,1376.6,,,1376.6,Other,110% of Medicare,973.35,35,,973.35,percent of total billed charges,Implant Device,945.54,34,"Charges > $500, x 34%",945.54,percent of total billed charges,Implant Device,973.35,35,,973.35,percent of total billed charges,Implant Device,973.35,35,,973.35,percent of total billed charges,Implant Device,973.35,35,,973.35,percent of total billed charges,Implant Device,973.35,35,,973.35,percent of total billed charges,Implant Device,973.35,35,,973.35,percent of total billed charges,Implant Device,1112.4,40,,1112.4,percent of total billed charges,Implant Device,973.35,70,,973.35,percent of total billed charges,All Other,945.54,34,,945.54,percent of total billed charges,Implant Device,945.54,34,,945.54,percent of total billed charges,Implant Device,973.35,35,,973.35,percent of total billed charges,Implant Device,973.35,35,,973.35,percent of total billed charges,Implant Device,973.35,35,,973.35,percent of total billed charges,Implant Device,973.35,35,,973.35,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,945.54,34,"If Charge > 2,000, then 34 percent",945.54,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2057.95,
STRYKER 5517-F-501 FEMORAL COMP SZ 5 LT,C1776,HCPCS,,79010955,CDM,278,RC,,,both,,,5840,4321.61,,,4321.61,Other,150% of Medicare + 9.63% HCRA Surcharge,2628,45,,2628,percent of total billed charges,Critical Access Hospital RCC factor,1985.6,34,,1985.6,percent of total billed charges,Implant Device,1985.6,34,,1985.6,percent of total billed charges,Implant Device,1985.6,34,,1985.6,percent of total billed charges,Implant Device,1985.6,34,,1985.6,percent of total billed charges,Implant Device,1985.6,34,,1985.6,percent of total billed charges,Implant Device,2890.8,,,2890.8,Other,110% of Medicare,2044,35,,2044,percent of total billed charges,Implant Device,1985.6,34,"Charges > $500, x 34%",1985.6,percent of total billed charges,Implant Device,2044,35,,2044,percent of total billed charges,Implant Device,2044,35,,2044,percent of total billed charges,Implant Device,2044,35,,2044,percent of total billed charges,Implant Device,2044,35,,2044,percent of total billed charges,Implant Device,2044,35,,2044,percent of total billed charges,Implant Device,2336,40,,2336,percent of total billed charges,Implant Device,2044,70,,2044,percent of total billed charges,All Other,1985.6,34,,1985.6,percent of total billed charges,Implant Device,1985.6,34,,1985.6,percent of total billed charges,Implant Device,2044,35,,2044,percent of total billed charges,Implant Device,2044,35,,2044,percent of total billed charges,Implant Device,2044,35,,2044,percent of total billed charges,Implant Device,2044,35,,2044,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1985.6,34,"If Charge > 2,000, then 34 percent",1985.6,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4321.61,
STRYKER 5517-F-701 FEMORAL COMP SZ 7 LT,C1776,HCPCS,,79010956,CDM,278,RC,,,both,,,5840,4321.61,,,4321.61,Other,150% of Medicare + 9.63% HCRA Surcharge,2628,45,,2628,percent of total billed charges,Critical Access Hospital RCC factor,1985.6,34,,1985.6,percent of total billed charges,Implant Device,1985.6,34,,1985.6,percent of total billed charges,Implant Device,1985.6,34,,1985.6,percent of total billed charges,Implant Device,1985.6,34,,1985.6,percent of total billed charges,Implant Device,1985.6,34,,1985.6,percent of total billed charges,Implant Device,2890.8,,,2890.8,Other,110% of Medicare,2044,35,,2044,percent of total billed charges,Implant Device,1985.6,34,"Charges > $500, x 34%",1985.6,percent of total billed charges,Implant Device,2044,35,,2044,percent of total billed charges,Implant Device,2044,35,,2044,percent of total billed charges,Implant Device,2044,35,,2044,percent of total billed charges,Implant Device,2044,35,,2044,percent of total billed charges,Implant Device,2044,35,,2044,percent of total billed charges,Implant Device,2336,40,,2336,percent of total billed charges,Implant Device,2044,70,,2044,percent of total billed charges,All Other,1985.6,34,,1985.6,percent of total billed charges,Implant Device,1985.6,34,,1985.6,percent of total billed charges,Implant Device,2044,35,,2044,percent of total billed charges,Implant Device,2044,35,,2044,percent of total billed charges,Implant Device,2044,35,,2044,percent of total billed charges,Implant Device,2044,35,,2044,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1985.6,34,"If Charge > 2,000, then 34 percent",1985.6,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4321.61,
STRYKER 5531-G-709-E TIB BEARING INS 9MM,C1776,HCPCS,,79010957,CDM,278,RC,,,both,,,2781,2057.95,,,2057.95,Other,150% of Medicare + 9.63% HCRA Surcharge,1251.45,45,,1251.45,percent of total billed charges,Critical Access Hospital RCC factor,945.54,34,,945.54,percent of total billed charges,Implant Device,945.54,34,,945.54,percent of total billed charges,Implant Device,945.54,34,,945.54,percent of total billed charges,Implant Device,945.54,34,,945.54,percent of total billed charges,Implant Device,945.54,34,,945.54,percent of total billed charges,Implant Device,1376.6,,,1376.6,Other,110% of Medicare,973.35,35,,973.35,percent of total billed charges,Implant Device,945.54,34,"Charges > $500, x 34%",945.54,percent of total billed charges,Implant Device,973.35,35,,973.35,percent of total billed charges,Implant Device,973.35,35,,973.35,percent of total billed charges,Implant Device,973.35,35,,973.35,percent of total billed charges,Implant Device,973.35,35,,973.35,percent of total billed charges,Implant Device,973.35,35,,973.35,percent of total billed charges,Implant Device,1112.4,40,,1112.4,percent of total billed charges,Implant Device,973.35,70,,973.35,percent of total billed charges,All Other,945.54,34,,945.54,percent of total billed charges,Implant Device,945.54,34,,945.54,percent of total billed charges,Implant Device,973.35,35,,973.35,percent of total billed charges,Implant Device,973.35,35,,973.35,percent of total billed charges,Implant Device,973.35,35,,973.35,percent of total billed charges,Implant Device,973.35,35,,973.35,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,945.54,34,"If Charge > 2,000, then 34 percent",945.54,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2057.95,
STRYKER 5536-B-700 TIB BASEPLT COMP SZ 7,C1776,HCPCS,,79010958,CDM,278,RC,,,both,,,4172,3087.29,,,3087.29,Other,150% of Medicare + 9.63% HCRA Surcharge,1877.4,45,,1877.4,percent of total billed charges,Critical Access Hospital RCC factor,1418.48,34,,1418.48,percent of total billed charges,Implant Device,1418.48,34,,1418.48,percent of total billed charges,Implant Device,1418.48,34,,1418.48,percent of total billed charges,Implant Device,1418.48,34,,1418.48,percent of total billed charges,Implant Device,1418.48,34,,1418.48,percent of total billed charges,Implant Device,2065.14,,,2065.14,Other,110% of Medicare,1460.2,35,,1460.2,percent of total billed charges,Implant Device,1418.48,34,"Charges > $500, x 34%",1418.48,percent of total billed charges,Implant Device,1460.2,35,,1460.2,percent of total billed charges,Implant Device,1460.2,35,,1460.2,percent of total billed charges,Implant Device,1460.2,35,,1460.2,percent of total billed charges,Implant Device,1460.2,35,,1460.2,percent of total billed charges,Implant Device,1460.2,35,,1460.2,percent of total billed charges,Implant Device,1668.8,40,,1668.8,percent of total billed charges,Implant Device,1460.2,70,,1460.2,percent of total billed charges,All Other,1418.48,34,,1418.48,percent of total billed charges,Implant Device,1418.48,34,,1418.48,percent of total billed charges,Implant Device,1460.2,35,,1460.2,percent of total billed charges,Implant Device,1460.2,35,,1460.2,percent of total billed charges,Implant Device,1460.2,35,,1460.2,percent of total billed charges,Implant Device,1460.2,35,,1460.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1418.48,34,"If Charge > 2,000, then 34 percent",1418.48,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3087.29,
STRYKER 629346 OLECRANON PLATE 6 HOLE LT,C1713,HCPCS,,79010959,CDM,278,RC,,,both,,,2804,2074.97,,,2074.97,Other,150% of Medicare + 9.63% HCRA Surcharge,1261.8,45,,1261.8,percent of total billed charges,Critical Access Hospital RCC factor,953.36,34,,953.36,percent of total billed charges,Implant Device,953.36,34,,953.36,percent of total billed charges,Implant Device,953.36,34,,953.36,percent of total billed charges,Implant Device,953.36,34,,953.36,percent of total billed charges,Implant Device,953.36,34,,953.36,percent of total billed charges,Implant Device,1387.98,,,1387.98,Other,110% of Medicare,981.4,35,,981.4,percent of total billed charges,Implant Device,953.36,34,"Charges > $500, x 34%",953.36,percent of total billed charges,Implant Device,981.4,35,,981.4,percent of total billed charges,Implant Device,981.4,35,,981.4,percent of total billed charges,Implant Device,981.4,35,,981.4,percent of total billed charges,Implant Device,981.4,35,,981.4,percent of total billed charges,Implant Device,981.4,35,,981.4,percent of total billed charges,Implant Device,1121.6,40,,1121.6,percent of total billed charges,Implant Device,981.4,70,,981.4,percent of total billed charges,All Other,953.36,34,,953.36,percent of total billed charges,Implant Device,953.36,34,,953.36,percent of total billed charges,Implant Device,981.4,35,,981.4,percent of total billed charges,Implant Device,981.4,35,,981.4,percent of total billed charges,Implant Device,981.4,35,,981.4,percent of total billed charges,Implant Device,981.4,35,,981.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,953.36,34,"If Charge > 2,000, then 34 percent",953.36,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2074.97,
ARTHREX AR-1530P-CP FOREFOOT IMPLANY SYS,C1713,HCPCS,,79010962,CDM,278,RC,,,both,,,4185,3096.91,,,3096.91,Other,150% of Medicare + 9.63% HCRA Surcharge,1883.25,45,,1883.25,percent of total billed charges,Critical Access Hospital RCC factor,1422.9,34,,1422.9,percent of total billed charges,Implant Device,1422.9,34,,1422.9,percent of total billed charges,Implant Device,1422.9,34,,1422.9,percent of total billed charges,Implant Device,1422.9,34,,1422.9,percent of total billed charges,Implant Device,1422.9,34,,1422.9,percent of total billed charges,Implant Device,2071.58,,,2071.58,Other,110% of Medicare,1464.75,35,,1464.75,percent of total billed charges,Implant Device,1422.9,34,"Charges > $500, x 34%",1422.9,percent of total billed charges,Implant Device,1464.75,35,,1464.75,percent of total billed charges,Implant Device,1464.75,35,,1464.75,percent of total billed charges,Implant Device,1464.75,35,,1464.75,percent of total billed charges,Implant Device,1464.75,35,,1464.75,percent of total billed charges,Implant Device,1464.75,35,,1464.75,percent of total billed charges,Implant Device,1674,40,,1674,percent of total billed charges,Implant Device,1464.75,70,,1464.75,percent of total billed charges,All Other,1422.9,34,,1422.9,percent of total billed charges,Implant Device,1422.9,34,,1422.9,percent of total billed charges,Implant Device,1464.75,35,,1464.75,percent of total billed charges,Implant Device,1464.75,35,,1464.75,percent of total billed charges,Implant Device,1464.75,35,,1464.75,percent of total billed charges,Implant Device,1464.75,35,,1464.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1422.9,34,"If Charge > 2,000, then 34 percent",1422.9,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3096.91,
STRYKER 5571-S-3608 HUM INSERT 36X8MM,C1776,HCPCS,,79010963,CDM,278,RC,,,both,,,3525,2608.51,,,2608.51,Other,150% of Medicare + 9.63% HCRA Surcharge,1586.25,45,,1586.25,percent of total billed charges,Critical Access Hospital RCC factor,1198.5,34,,1198.5,percent of total billed charges,Implant Device,1198.5,34,,1198.5,percent of total billed charges,Implant Device,1198.5,34,,1198.5,percent of total billed charges,Implant Device,1198.5,34,,1198.5,percent of total billed charges,Implant Device,1198.5,34,,1198.5,percent of total billed charges,Implant Device,1744.88,,,1744.88,Other,110% of Medicare,1233.75,35,,1233.75,percent of total billed charges,Implant Device,1198.5,34,"Charges > $500, x 34%",1198.5,percent of total billed charges,Implant Device,1233.75,35,,1233.75,percent of total billed charges,Implant Device,1233.75,35,,1233.75,percent of total billed charges,Implant Device,1233.75,35,,1233.75,percent of total billed charges,Implant Device,1233.75,35,,1233.75,percent of total billed charges,Implant Device,1233.75,35,,1233.75,percent of total billed charges,Implant Device,1410,40,,1410,percent of total billed charges,Implant Device,1233.75,70,,1233.75,percent of total billed charges,All Other,1198.5,34,,1198.5,percent of total billed charges,Implant Device,1198.5,34,,1198.5,percent of total billed charges,Implant Device,1233.75,35,,1233.75,percent of total billed charges,Implant Device,1233.75,35,,1233.75,percent of total billed charges,Implant Device,1233.75,35,,1233.75,percent of total billed charges,Implant Device,1233.75,35,,1233.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1198.5,34,"If Charge > 2,000, then 34 percent",1198.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2608.51,
STRYKER 2341-1034S TIBIAL NAIL 10X345MM,C1713,HCPCS,,79010964,CDM,278,RC,,,both,,,6378,4719.74,,,4719.74,Other,150% of Medicare + 9.63% HCRA Surcharge,2870.1,45,,2870.1,percent of total billed charges,Critical Access Hospital RCC factor,2168.52,34,,2168.52,percent of total billed charges,Implant Device,2168.52,34,,2168.52,percent of total billed charges,Implant Device,2168.52,34,,2168.52,percent of total billed charges,Implant Device,2168.52,34,,2168.52,percent of total billed charges,Implant Device,2168.52,34,,2168.52,percent of total billed charges,Implant Device,3157.11,,,3157.11,Other,110% of Medicare,2232.3,35,,2232.3,percent of total billed charges,Implant Device,2168.52,34,"Charges > $500, x 34%",2168.52,percent of total billed charges,Implant Device,2232.3,35,,2232.3,percent of total billed charges,Implant Device,2232.3,35,,2232.3,percent of total billed charges,Implant Device,2232.3,35,,2232.3,percent of total billed charges,Implant Device,2232.3,35,,2232.3,percent of total billed charges,Implant Device,2232.3,35,,2232.3,percent of total billed charges,Implant Device,2551.2,40,,2551.2,percent of total billed charges,Implant Device,2232.3,70,,2232.3,percent of total billed charges,All Other,2168.52,34,,2168.52,percent of total billed charges,Implant Device,2168.52,34,,2168.52,percent of total billed charges,Implant Device,2232.3,35,,2232.3,percent of total billed charges,Implant Device,2232.3,35,,2232.3,percent of total billed charges,Implant Device,2232.3,35,,2232.3,percent of total billed charges,Implant Device,2232.3,35,,2232.3,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2168.52,34,"If Charge > 2,000, then 34 percent",2168.52,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4719.74,
STRYKER 2360-5065S LOCKING SCREW 5X65MM,C1713,HCPCS,,79010965,CDM,278,RC,,,both,,,682,504.68,,,504.68,Other,150% of Medicare + 9.63% HCRA Surcharge,306.9,45,,306.9,percent of total billed charges,Critical Access Hospital RCC factor,231.88,34,,231.88,percent of total billed charges,Implant Device,231.88,34,,231.88,percent of total billed charges,Implant Device,231.88,34,,231.88,percent of total billed charges,Implant Device,231.88,34,,231.88,percent of total billed charges,Implant Device,231.88,34,,231.88,percent of total billed charges,Implant Device,337.59,,,337.59,Other,110% of Medicare,238.7,35,,238.7,percent of total billed charges,Implant Device,231.88,34,"Charges > $500, x 34%",231.88,percent of total billed charges,Implant Device,238.7,35,,238.7,percent of total billed charges,Implant Device,238.7,35,,238.7,percent of total billed charges,Implant Device,238.7,35,,238.7,percent of total billed charges,Implant Device,238.7,35,,238.7,percent of total billed charges,Implant Device,238.7,35,,238.7,percent of total billed charges,Implant Device,272.8,40,,272.8,percent of total billed charges,Implant Device,238.7,70,,238.7,percent of total billed charges,All Other,231.88,34,,231.88,percent of total billed charges,Implant Device,231.88,34,,231.88,percent of total billed charges,Implant Device,238.7,35,,238.7,percent of total billed charges,Implant Device,238.7,35,,238.7,percent of total billed charges,Implant Device,238.7,35,,238.7,percent of total billed charges,Implant Device,238.7,35,,238.7,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,504.68,
STRYKER UH1-54-26 BIPOLAR COMP 26X54MM,C1776,HCPCS,,79010966,CDM,278,RC,,,both,,,1391,1029.34,,,1029.34,Other,150% of Medicare + 9.63% HCRA Surcharge,625.95,45,,625.95,percent of total billed charges,Critical Access Hospital RCC factor,472.94,34,,472.94,percent of total billed charges,Implant Device,472.94,34,,472.94,percent of total billed charges,Implant Device,472.94,34,,472.94,percent of total billed charges,Implant Device,472.94,34,,472.94,percent of total billed charges,Implant Device,472.94,34,,472.94,percent of total billed charges,Implant Device,688.55,,,688.55,Other,110% of Medicare,486.85,35,,486.85,percent of total billed charges,Implant Device,472.94,34,"Charges > $500, x 34%",472.94,percent of total billed charges,Implant Device,486.85,35,,486.85,percent of total billed charges,Implant Device,486.85,35,,486.85,percent of total billed charges,Implant Device,486.85,35,,486.85,percent of total billed charges,Implant Device,486.85,35,,486.85,percent of total billed charges,Implant Device,486.85,35,,486.85,percent of total billed charges,Implant Device,556.4,40,,556.4,percent of total billed charges,Implant Device,486.85,70,,486.85,percent of total billed charges,All Other,472.94,34,,472.94,percent of total billed charges,Implant Device,472.94,34,,472.94,percent of total billed charges,Implant Device,486.85,35,,486.85,percent of total billed charges,Implant Device,486.85,35,,486.85,percent of total billed charges,Implant Device,486.85,35,,486.85,percent of total billed charges,Implant Device,486.85,35,,486.85,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1029.34,
IN2BONES P40 ST015 PLATE 5 HOLE,C1713,HCPCS,,79010968,CDM,278,RC,,,both,,,4611,3412.15,,,3412.15,Other,150% of Medicare + 9.63% HCRA Surcharge,2074.95,45,,2074.95,percent of total billed charges,Critical Access Hospital RCC factor,1567.74,34,,1567.74,percent of total billed charges,Implant Device,1567.74,34,,1567.74,percent of total billed charges,Implant Device,1567.74,34,,1567.74,percent of total billed charges,Implant Device,1567.74,34,,1567.74,percent of total billed charges,Implant Device,1567.74,34,,1567.74,percent of total billed charges,Implant Device,2282.45,,,2282.45,Other,110% of Medicare,1613.85,35,,1613.85,percent of total billed charges,Implant Device,1567.74,34,"Charges > $500, x 34%",1567.74,percent of total billed charges,Implant Device,1613.85,35,,1613.85,percent of total billed charges,Implant Device,1613.85,35,,1613.85,percent of total billed charges,Implant Device,1613.85,35,,1613.85,percent of total billed charges,Implant Device,1613.85,35,,1613.85,percent of total billed charges,Implant Device,1613.85,35,,1613.85,percent of total billed charges,Implant Device,1844.4,40,,1844.4,percent of total billed charges,Implant Device,1613.85,70,,1613.85,percent of total billed charges,All Other,1567.74,34,,1567.74,percent of total billed charges,Implant Device,1567.74,34,,1567.74,percent of total billed charges,Implant Device,1613.85,35,,1613.85,percent of total billed charges,Implant Device,1613.85,35,,1613.85,percent of total billed charges,Implant Device,1613.85,35,,1613.85,percent of total billed charges,Implant Device,1613.85,35,,1613.85,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1567.74,34,"If Charge > 2,000, then 34 percent",1567.74,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3412.15,
IN2BONES V30 ST210 NON LOCK SCREW 3X10MM,C1713,HCPCS,,79010969,CDM,278,RC,,,both,,,735,543.9,,,543.9,Other,150% of Medicare + 9.63% HCRA Surcharge,330.75,45,,330.75,percent of total billed charges,Critical Access Hospital RCC factor,249.9,34,,249.9,percent of total billed charges,Implant Device,249.9,34,,249.9,percent of total billed charges,Implant Device,249.9,34,,249.9,percent of total billed charges,Implant Device,249.9,34,,249.9,percent of total billed charges,Implant Device,249.9,34,,249.9,percent of total billed charges,Implant Device,363.83,,,363.83,Other,110% of Medicare,257.25,35,,257.25,percent of total billed charges,Implant Device,249.9,34,"Charges > $500, x 34%",249.9,percent of total billed charges,Implant Device,257.25,35,,257.25,percent of total billed charges,Implant Device,257.25,35,,257.25,percent of total billed charges,Implant Device,257.25,35,,257.25,percent of total billed charges,Implant Device,257.25,35,,257.25,percent of total billed charges,Implant Device,257.25,35,,257.25,percent of total billed charges,Implant Device,294,40,,294,percent of total billed charges,Implant Device,257.25,70,,257.25,percent of total billed charges,All Other,249.9,34,,249.9,percent of total billed charges,Implant Device,249.9,34,,249.9,percent of total billed charges,Implant Device,257.25,35,,257.25,percent of total billed charges,Implant Device,257.25,35,,257.25,percent of total billed charges,Implant Device,257.25,35,,257.25,percent of total billed charges,Implant Device,257.25,35,,257.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,543.9,
ZIMMER US 574201030 FEM STEM 12/14 TAPER,C1776,HCPCS,,79010971,CDM,278,RC,,,both,,,6912,5114.9,,,5114.9,Other,150% of Medicare + 9.63% HCRA Surcharge,3110.4,45,,3110.4,percent of total billed charges,Critical Access Hospital RCC factor,2350.08,34,,2350.08,percent of total billed charges,Implant Device,2350.08,34,,2350.08,percent of total billed charges,Implant Device,2350.08,34,,2350.08,percent of total billed charges,Implant Device,2350.08,34,,2350.08,percent of total billed charges,Implant Device,2350.08,34,,2350.08,percent of total billed charges,Implant Device,3421.44,,,3421.44,Other,110% of Medicare,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2350.08,34,"Charges > $500, x 34%",2350.08,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2764.8,40,,2764.8,percent of total billed charges,Implant Device,2419.2,70,,2419.2,percent of total billed charges,All Other,2350.08,34,,2350.08,percent of total billed charges,Implant Device,2350.08,34,,2350.08,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2350.08,34,"If Charge > 2,000, then 34 percent",2350.08,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5114.9,
STRYKER ORTHO 663812 BONE SCREW 2.3X12MM,C1713,HCPCS,,79010972,CDM,278,RC,,,both,,,368,272.32,,,272.32,Other,150% of Medicare + 9.63% HCRA Surcharge,165.6,45,,165.6,percent of total billed charges,Critical Access Hospital RCC factor,125.12,34,,125.12,percent of total billed charges,Implant Device,125.12,34,,125.12,percent of total billed charges,Implant Device,125.12,34,,125.12,percent of total billed charges,Implant Device,125.12,34,,125.12,percent of total billed charges,Implant Device,125.12,34,,125.12,percent of total billed charges,Implant Device,182.16,,,182.16,Other,110% of Medicare,128.8,35,,128.8,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,128.8,35,,128.8,percent of total billed charges,Implant Device,128.8,35,,128.8,percent of total billed charges,Implant Device,128.8,35,,128.8,percent of total billed charges,Implant Device,128.8,35,,128.8,percent of total billed charges,Implant Device,128.8,35,,128.8,percent of total billed charges,Implant Device,147.2,40,,147.2,percent of total billed charges,Implant Device,128.8,70,,128.8,percent of total billed charges,All Other,125.12,34,,125.12,percent of total billed charges,Implant Device,125.12,34,,125.12,percent of total billed charges,Implant Device,128.8,35,,128.8,percent of total billed charges,Implant Device,128.8,35,,128.8,percent of total billed charges,Implant Device,128.8,35,,128.8,percent of total billed charges,Implant Device,128.8,35,,128.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,272.32,
ZIMMER 8145-10-120 LAG SCREW 10.5X120MM,C1713,HCPCS,,79010974,CDM,278,RC,,,both,,,2052,1518.49,,,1518.49,Other,150% of Medicare + 9.63% HCRA Surcharge,923.4,45,,923.4,percent of total billed charges,Critical Access Hospital RCC factor,697.68,34,,697.68,percent of total billed charges,Implant Device,697.68,34,,697.68,percent of total billed charges,Implant Device,697.68,34,,697.68,percent of total billed charges,Implant Device,697.68,34,,697.68,percent of total billed charges,Implant Device,697.68,34,,697.68,percent of total billed charges,Implant Device,1015.74,,,1015.74,Other,110% of Medicare,718.2,35,,718.2,percent of total billed charges,Implant Device,697.68,34,"Charges > $500, x 34%",697.68,percent of total billed charges,Implant Device,718.2,35,,718.2,percent of total billed charges,Implant Device,718.2,35,,718.2,percent of total billed charges,Implant Device,718.2,35,,718.2,percent of total billed charges,Implant Device,718.2,35,,718.2,percent of total billed charges,Implant Device,718.2,35,,718.2,percent of total billed charges,Implant Device,820.8,40,,820.8,percent of total billed charges,Implant Device,718.2,70,,718.2,percent of total billed charges,All Other,697.68,34,,697.68,percent of total billed charges,Implant Device,697.68,34,,697.68,percent of total billed charges,Implant Device,718.2,35,,718.2,percent of total billed charges,Implant Device,718.2,35,,718.2,percent of total billed charges,Implant Device,718.2,35,,718.2,percent of total billed charges,Implant Device,718.2,35,,718.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,697.68,34,"If Charge > 2,000, then 34 percent",697.68,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1518.49,
GORE BXA051901A VBX VIABAHN 5X19X80,C1874,HCPCS,,79010975,CDM,278,RC,,,both,,,9765,7226.12,,,7226.12,Other,150% of Medicare + 9.63% HCRA Surcharge,4394.25,45,,4394.25,percent of total billed charges,Critical Access Hospital RCC factor,3320.1,34,,3320.1,percent of total billed charges,Implant Device,3320.1,34,,3320.1,percent of total billed charges,Implant Device,3320.1,34,,3320.1,percent of total billed charges,Implant Device,3320.1,34,,3320.1,percent of total billed charges,Implant Device,3320.1,34,,3320.1,percent of total billed charges,Implant Device,4833.68,,,4833.68,Other,110% of Medicare,3417.75,35,,3417.75,percent of total billed charges,Implant Device,3320.1,34,"Charges > $500, x 34%",3320.1,percent of total billed charges,Implant Device,3417.75,35,,3417.75,percent of total billed charges,Implant Device,3417.75,35,,3417.75,percent of total billed charges,Implant Device,3417.75,35,,3417.75,percent of total billed charges,Implant Device,3417.75,35,,3417.75,percent of total billed charges,Implant Device,3417.75,35,,3417.75,percent of total billed charges,Implant Device,3906,40,,3906,percent of total billed charges,Implant Device,3417.75,70,,3417.75,percent of total billed charges,All Other,3320.1,34,,3320.1,percent of total billed charges,Implant Device,3320.1,34,,3320.1,percent of total billed charges,Implant Device,3417.75,35,,3417.75,percent of total billed charges,Implant Device,3417.75,35,,3417.75,percent of total billed charges,Implant Device,3417.75,35,,3417.75,percent of total billed charges,Implant Device,3417.75,35,,3417.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3320.1,34,"If Charge > 2,000, then 34 percent",3320.1,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,7226.12,
GORE BXA052901A VBX VIABAHN 5X29X80,C1874,HCPCS,,79010976,CDM,278,RC,,,both,,,9765,7226.12,,,7226.12,Other,150% of Medicare + 9.63% HCRA Surcharge,4394.25,45,,4394.25,percent of total billed charges,Critical Access Hospital RCC factor,3320.1,34,,3320.1,percent of total billed charges,Implant Device,3320.1,34,,3320.1,percent of total billed charges,Implant Device,3320.1,34,,3320.1,percent of total billed charges,Implant Device,3320.1,34,,3320.1,percent of total billed charges,Implant Device,3320.1,34,,3320.1,percent of total billed charges,Implant Device,4833.68,,,4833.68,Other,110% of Medicare,3417.75,35,,3417.75,percent of total billed charges,Implant Device,3320.1,34,"Charges > $500, x 34%",3320.1,percent of total billed charges,Implant Device,3417.75,35,,3417.75,percent of total billed charges,Implant Device,3417.75,35,,3417.75,percent of total billed charges,Implant Device,3417.75,35,,3417.75,percent of total billed charges,Implant Device,3417.75,35,,3417.75,percent of total billed charges,Implant Device,3417.75,35,,3417.75,percent of total billed charges,Implant Device,3906,40,,3906,percent of total billed charges,Implant Device,3417.75,70,,3417.75,percent of total billed charges,All Other,3320.1,34,,3320.1,percent of total billed charges,Implant Device,3320.1,34,,3320.1,percent of total billed charges,Implant Device,3417.75,35,,3417.75,percent of total billed charges,Implant Device,3417.75,35,,3417.75,percent of total billed charges,Implant Device,3417.75,35,,3417.75,percent of total billed charges,Implant Device,3417.75,35,,3417.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3320.1,34,"If Charge > 2,000, then 34 percent",3320.1,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,7226.12,
STRYKER 6570-0-328 FEMORAL HEAD 28X-2.7,C1776,HCPCS,,79010977,CDM,278,RC,,,both,,,2503,1852.23,,,1852.23,Other,150% of Medicare + 9.63% HCRA Surcharge,1126.35,45,,1126.35,percent of total billed charges,Critical Access Hospital RCC factor,851.02,34,,851.02,percent of total billed charges,Implant Device,851.02,34,,851.02,percent of total billed charges,Implant Device,851.02,34,,851.02,percent of total billed charges,Implant Device,851.02,34,,851.02,percent of total billed charges,Implant Device,851.02,34,,851.02,percent of total billed charges,Implant Device,1238.99,,,1238.99,Other,110% of Medicare,876.05,35,,876.05,percent of total billed charges,Implant Device,851.02,34,"Charges > $500, x 34%",851.02,percent of total billed charges,Implant Device,876.05,35,,876.05,percent of total billed charges,Implant Device,876.05,35,,876.05,percent of total billed charges,Implant Device,876.05,35,,876.05,percent of total billed charges,Implant Device,876.05,35,,876.05,percent of total billed charges,Implant Device,876.05,35,,876.05,percent of total billed charges,Implant Device,1001.2,40,,1001.2,percent of total billed charges,Implant Device,876.05,70,,876.05,percent of total billed charges,All Other,851.02,34,,851.02,percent of total billed charges,Implant Device,851.02,34,,851.02,percent of total billed charges,Implant Device,876.05,35,,876.05,percent of total billed charges,Implant Device,876.05,35,,876.05,percent of total billed charges,Implant Device,876.05,35,,876.05,percent of total billed charges,Implant Device,876.05,35,,876.05,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,851.02,34,"If Charge > 2,000, then 34 percent",851.02,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1852.23,
ARTHREX ABS-2810-1806 WEDGE 18X18X6.5MM,C1713,HCPCS,,79010979,CDM,278,RC,,,both,,,6645,4917.32,,,4917.32,Other,150% of Medicare + 9.63% HCRA Surcharge,2990.25,45,,2990.25,percent of total billed charges,Critical Access Hospital RCC factor,2259.3,34,,2259.3,percent of total billed charges,Implant Device,2259.3,34,,2259.3,percent of total billed charges,Implant Device,2259.3,34,,2259.3,percent of total billed charges,Implant Device,2259.3,34,,2259.3,percent of total billed charges,Implant Device,2259.3,34,,2259.3,percent of total billed charges,Implant Device,3289.28,,,3289.28,Other,110% of Medicare,2325.75,35,,2325.75,percent of total billed charges,Implant Device,2259.3,34,"Charges > $500, x 34%",2259.3,percent of total billed charges,Implant Device,2325.75,35,,2325.75,percent of total billed charges,Implant Device,2325.75,35,,2325.75,percent of total billed charges,Implant Device,2325.75,35,,2325.75,percent of total billed charges,Implant Device,2325.75,35,,2325.75,percent of total billed charges,Implant Device,2325.75,35,,2325.75,percent of total billed charges,Implant Device,2658,40,,2658,percent of total billed charges,Implant Device,2325.75,70,,2325.75,percent of total billed charges,All Other,2259.3,34,,2259.3,percent of total billed charges,Implant Device,2259.3,34,,2259.3,percent of total billed charges,Implant Device,2325.75,35,,2325.75,percent of total billed charges,Implant Device,2325.75,35,,2325.75,percent of total billed charges,Implant Device,2325.75,35,,2325.75,percent of total billed charges,Implant Device,2325.75,35,,2325.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2259.3,34,"If Charge > 2,000, then 34 percent",2259.3,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4917.32,
ARTHREX AR-8951ML LISFRANC PLATE MED LT,C1713,HCPCS,,79010980,CDM,278,RC,,,both,,,3429,2537.47,,,2537.47,Other,150% of Medicare + 9.63% HCRA Surcharge,1543.05,45,,1543.05,percent of total billed charges,Critical Access Hospital RCC factor,1165.86,34,,1165.86,percent of total billed charges,Implant Device,1165.86,34,,1165.86,percent of total billed charges,Implant Device,1165.86,34,,1165.86,percent of total billed charges,Implant Device,1165.86,34,,1165.86,percent of total billed charges,Implant Device,1165.86,34,,1165.86,percent of total billed charges,Implant Device,1697.36,,,1697.36,Other,110% of Medicare,1200.15,35,,1200.15,percent of total billed charges,Implant Device,1165.86,34,"Charges > $500, x 34%",1165.86,percent of total billed charges,Implant Device,1200.15,35,,1200.15,percent of total billed charges,Implant Device,1200.15,35,,1200.15,percent of total billed charges,Implant Device,1200.15,35,,1200.15,percent of total billed charges,Implant Device,1200.15,35,,1200.15,percent of total billed charges,Implant Device,1200.15,35,,1200.15,percent of total billed charges,Implant Device,1371.6,40,,1371.6,percent of total billed charges,Implant Device,1200.15,70,,1200.15,percent of total billed charges,All Other,1165.86,34,,1165.86,percent of total billed charges,Implant Device,1165.86,34,,1165.86,percent of total billed charges,Implant Device,1200.15,35,,1200.15,percent of total billed charges,Implant Device,1200.15,35,,1200.15,percent of total billed charges,Implant Device,1200.15,35,,1200.15,percent of total billed charges,Implant Device,1200.15,35,,1200.15,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1165.86,34,"If Charge > 2,000, then 34 percent",1165.86,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2537.47,
ARTHREX AR-2324BCCT SWIVELOCK 4.75,C1713,HCPCS,,79010981,CDM,278,RC,,,both,,,1590,1176.6,,,1176.6,Other,150% of Medicare + 9.63% HCRA Surcharge,715.5,45,,715.5,percent of total billed charges,Critical Access Hospital RCC factor,540.6,34,,540.6,percent of total billed charges,Implant Device,540.6,34,,540.6,percent of total billed charges,Implant Device,540.6,34,,540.6,percent of total billed charges,Implant Device,540.6,34,,540.6,percent of total billed charges,Implant Device,540.6,34,,540.6,percent of total billed charges,Implant Device,787.05,,,787.05,Other,110% of Medicare,556.5,35,,556.5,percent of total billed charges,Implant Device,540.6,34,"Charges > $500, x 34%",540.6,percent of total billed charges,Implant Device,556.5,35,,556.5,percent of total billed charges,Implant Device,556.5,35,,556.5,percent of total billed charges,Implant Device,556.5,35,,556.5,percent of total billed charges,Implant Device,556.5,35,,556.5,percent of total billed charges,Implant Device,556.5,35,,556.5,percent of total billed charges,Implant Device,636,40,,636,percent of total billed charges,Implant Device,556.5,70,,556.5,percent of total billed charges,All Other,540.6,34,,540.6,percent of total billed charges,Implant Device,540.6,34,,540.6,percent of total billed charges,Implant Device,556.5,35,,556.5,percent of total billed charges,Implant Device,556.5,35,,556.5,percent of total billed charges,Implant Device,556.5,35,,556.5,percent of total billed charges,Implant Device,556.5,35,,556.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1176.6,
ARTHREX AR-2324BCCTT SWIVELOCK 4.75,C1713,HCPCS,,79010982,CDM,278,RC,,,both,,,1590,1176.6,,,1176.6,Other,150% of Medicare + 9.63% HCRA Surcharge,715.5,45,,715.5,percent of total billed charges,Critical Access Hospital RCC factor,540.6,34,,540.6,percent of total billed charges,Implant Device,540.6,34,,540.6,percent of total billed charges,Implant Device,540.6,34,,540.6,percent of total billed charges,Implant Device,540.6,34,,540.6,percent of total billed charges,Implant Device,540.6,34,,540.6,percent of total billed charges,Implant Device,787.05,,,787.05,Other,110% of Medicare,556.5,35,,556.5,percent of total billed charges,Implant Device,540.6,34,"Charges > $500, x 34%",540.6,percent of total billed charges,Implant Device,556.5,35,,556.5,percent of total billed charges,Implant Device,556.5,35,,556.5,percent of total billed charges,Implant Device,556.5,35,,556.5,percent of total billed charges,Implant Device,556.5,35,,556.5,percent of total billed charges,Implant Device,556.5,35,,556.5,percent of total billed charges,Implant Device,636,40,,636,percent of total billed charges,Implant Device,556.5,70,,556.5,percent of total billed charges,All Other,540.6,34,,540.6,percent of total billed charges,Implant Device,540.6,34,,540.6,percent of total billed charges,Implant Device,556.5,35,,556.5,percent of total billed charges,Implant Device,556.5,35,,556.5,percent of total billed charges,Implant Device,556.5,35,,556.5,percent of total billed charges,Implant Device,556.5,35,,556.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1176.6,
IN2BONES USA P70 ST107 FIBULA PLATE,C1713,HCPCS,,79010983,CDM,278,RC,,,both,,,6000,4440.02,,,4440.02,Other,150% of Medicare + 9.63% HCRA Surcharge,2700,45,,2700,percent of total billed charges,Critical Access Hospital RCC factor,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2970,,,2970,Other,110% of Medicare,2100,35,,2100,percent of total billed charges,Implant Device,2040,34,"Charges > $500, x 34%",2040,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2400,40,,2400,percent of total billed charges,Implant Device,2100,70,,2100,percent of total billed charges,All Other,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2040,34,"If Charge > 2,000, then 34 percent",2040,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4440.02,
IN2BONES USA P67 ST445 SCREW 4.0X45MM,C1713,HCPCS,,79010984,CDM,278,RC,,,both,,,870,643.8,,,643.8,Other,150% of Medicare + 9.63% HCRA Surcharge,391.5,45,,391.5,percent of total billed charges,Critical Access Hospital RCC factor,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,430.65,,,430.65,Other,110% of Medicare,304.5,35,,304.5,percent of total billed charges,Implant Device,295.8,34,"Charges > $500, x 34%",295.8,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,348,40,,348,percent of total billed charges,Implant Device,304.5,70,,304.5,percent of total billed charges,All Other,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,643.8,
IN2BONES USA P73 ST212 SCREW 3.5X12MM,C1713,HCPCS,,79010985,CDM,278,RC,,,both,,,870,643.8,,,643.8,Other,150% of Medicare + 9.63% HCRA Surcharge,391.5,45,,391.5,percent of total billed charges,Critical Access Hospital RCC factor,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,430.65,,,430.65,Other,110% of Medicare,304.5,35,,304.5,percent of total billed charges,Implant Device,295.8,34,"Charges > $500, x 34%",295.8,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,348,40,,348,percent of total billed charges,Implant Device,304.5,70,,304.5,percent of total billed charges,All Other,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,643.8,
ARTHREX AR-1593BC ACL FIXATION SYSTEM,C1713,HCPCS,,79010986,CDM,278,RC,,,both,,,2175,1609.51,,,1609.51,Other,150% of Medicare + 9.63% HCRA Surcharge,978.75,45,,978.75,percent of total billed charges,Critical Access Hospital RCC factor,739.5,34,,739.5,percent of total billed charges,Implant Device,739.5,34,,739.5,percent of total billed charges,Implant Device,739.5,34,,739.5,percent of total billed charges,Implant Device,739.5,34,,739.5,percent of total billed charges,Implant Device,739.5,34,,739.5,percent of total billed charges,Implant Device,1076.63,,,1076.63,Other,110% of Medicare,761.25,35,,761.25,percent of total billed charges,Implant Device,739.5,34,"Charges > $500, x 34%",739.5,percent of total billed charges,Implant Device,761.25,35,,761.25,percent of total billed charges,Implant Device,761.25,35,,761.25,percent of total billed charges,Implant Device,761.25,35,,761.25,percent of total billed charges,Implant Device,761.25,35,,761.25,percent of total billed charges,Implant Device,761.25,35,,761.25,percent of total billed charges,Implant Device,870,40,,870,percent of total billed charges,Implant Device,761.25,70,,761.25,percent of total billed charges,All Other,739.5,34,,739.5,percent of total billed charges,Implant Device,739.5,34,,739.5,percent of total billed charges,Implant Device,761.25,35,,761.25,percent of total billed charges,Implant Device,761.25,35,,761.25,percent of total billed charges,Implant Device,761.25,35,,761.25,percent of total billed charges,Implant Device,761.25,35,,761.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,739.5,34,"If Charge > 2,000, then 34 percent",739.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1609.51,
EXACTECH 320-36-03 HUMERAL LINER 36MM,C1776,HCPCS,,79010987,CDM,278,RC,,,both,,,2325,1720.51,,,1720.51,Other,150% of Medicare + 9.63% HCRA Surcharge,1046.25,45,,1046.25,percent of total billed charges,Critical Access Hospital RCC factor,790.5,34,,790.5,percent of total billed charges,Implant Device,790.5,34,,790.5,percent of total billed charges,Implant Device,790.5,34,,790.5,percent of total billed charges,Implant Device,790.5,34,,790.5,percent of total billed charges,Implant Device,790.5,34,,790.5,percent of total billed charges,Implant Device,1150.88,,,1150.88,Other,110% of Medicare,813.75,35,,813.75,percent of total billed charges,Implant Device,790.5,34,"Charges > $500, x 34%",790.5,percent of total billed charges,Implant Device,813.75,35,,813.75,percent of total billed charges,Implant Device,813.75,35,,813.75,percent of total billed charges,Implant Device,813.75,35,,813.75,percent of total billed charges,Implant Device,813.75,35,,813.75,percent of total billed charges,Implant Device,813.75,35,,813.75,percent of total billed charges,Implant Device,930,40,,930,percent of total billed charges,Implant Device,813.75,70,,813.75,percent of total billed charges,All Other,790.5,34,,790.5,percent of total billed charges,Implant Device,790.5,34,,790.5,percent of total billed charges,Implant Device,813.75,35,,813.75,percent of total billed charges,Implant Device,813.75,35,,813.75,percent of total billed charges,Implant Device,813.75,35,,813.75,percent of total billed charges,Implant Device,813.75,35,,813.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,790.5,34,"If Charge > 2,000, then 34 percent",790.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1720.51,
ARTHREX AR-1586RC-07 RETROSCREW 7X20MM,C1713,HCPCS,,79010988,CDM,278,RC,,,both,,,705,521.7,,,521.7,Other,150% of Medicare + 9.63% HCRA Surcharge,317.25,45,,317.25,percent of total billed charges,Critical Access Hospital RCC factor,239.7,34,,239.7,percent of total billed charges,Implant Device,239.7,34,,239.7,percent of total billed charges,Implant Device,239.7,34,,239.7,percent of total billed charges,Implant Device,239.7,34,,239.7,percent of total billed charges,Implant Device,239.7,34,,239.7,percent of total billed charges,Implant Device,348.98,,,348.98,Other,110% of Medicare,246.75,35,,246.75,percent of total billed charges,Implant Device,239.7,34,"Charges > $500, x 34%",239.7,percent of total billed charges,Implant Device,246.75,35,,246.75,percent of total billed charges,Implant Device,246.75,35,,246.75,percent of total billed charges,Implant Device,246.75,35,,246.75,percent of total billed charges,Implant Device,246.75,35,,246.75,percent of total billed charges,Implant Device,246.75,35,,246.75,percent of total billed charges,Implant Device,282,40,,282,percent of total billed charges,Implant Device,246.75,70,,246.75,percent of total billed charges,All Other,239.7,34,,239.7,percent of total billed charges,Implant Device,239.7,34,,239.7,percent of total billed charges,Implant Device,246.75,35,,246.75,percent of total billed charges,Implant Device,246.75,35,,246.75,percent of total billed charges,Implant Device,246.75,35,,246.75,percent of total billed charges,Implant Device,246.75,35,,246.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,521.7,
ARTHREX AR-1586RC-08 RETROSCREW 8X20MM,C1713,HCPCS,,79010989,CDM,278,RC,,,both,,,705,521.7,,,521.7,Other,150% of Medicare + 9.63% HCRA Surcharge,317.25,45,,317.25,percent of total billed charges,Critical Access Hospital RCC factor,239.7,34,,239.7,percent of total billed charges,Implant Device,239.7,34,,239.7,percent of total billed charges,Implant Device,239.7,34,,239.7,percent of total billed charges,Implant Device,239.7,34,,239.7,percent of total billed charges,Implant Device,239.7,34,,239.7,percent of total billed charges,Implant Device,348.98,,,348.98,Other,110% of Medicare,246.75,35,,246.75,percent of total billed charges,Implant Device,239.7,34,"Charges > $500, x 34%",239.7,percent of total billed charges,Implant Device,246.75,35,,246.75,percent of total billed charges,Implant Device,246.75,35,,246.75,percent of total billed charges,Implant Device,246.75,35,,246.75,percent of total billed charges,Implant Device,246.75,35,,246.75,percent of total billed charges,Implant Device,246.75,35,,246.75,percent of total billed charges,Implant Device,282,40,,282,percent of total billed charges,Implant Device,246.75,70,,246.75,percent of total billed charges,All Other,239.7,34,,239.7,percent of total billed charges,Implant Device,239.7,34,,239.7,percent of total billed charges,Implant Device,246.75,35,,246.75,percent of total billed charges,Implant Device,246.75,35,,246.75,percent of total billed charges,Implant Device,246.75,35,,246.75,percent of total billed charges,Implant Device,246.75,35,,246.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,521.7,
ARTHREX AR-1586RC-09 RETROSCREW 9X20MM,C1713,HCPCS,,79010990,CDM,278,RC,,,both,,,705,521.7,,,521.7,Other,150% of Medicare + 9.63% HCRA Surcharge,317.25,45,,317.25,percent of total billed charges,Critical Access Hospital RCC factor,239.7,34,,239.7,percent of total billed charges,Implant Device,239.7,34,,239.7,percent of total billed charges,Implant Device,239.7,34,,239.7,percent of total billed charges,Implant Device,239.7,34,,239.7,percent of total billed charges,Implant Device,239.7,34,,239.7,percent of total billed charges,Implant Device,348.98,,,348.98,Other,110% of Medicare,246.75,35,,246.75,percent of total billed charges,Implant Device,239.7,34,"Charges > $500, x 34%",239.7,percent of total billed charges,Implant Device,246.75,35,,246.75,percent of total billed charges,Implant Device,246.75,35,,246.75,percent of total billed charges,Implant Device,246.75,35,,246.75,percent of total billed charges,Implant Device,246.75,35,,246.75,percent of total billed charges,Implant Device,246.75,35,,246.75,percent of total billed charges,Implant Device,282,40,,282,percent of total billed charges,Implant Device,246.75,70,,246.75,percent of total billed charges,All Other,239.7,34,,239.7,percent of total billed charges,Implant Device,239.7,34,,239.7,percent of total billed charges,Implant Device,246.75,35,,246.75,percent of total billed charges,Implant Device,246.75,35,,246.75,percent of total billed charges,Implant Device,246.75,35,,246.75,percent of total billed charges,Implant Device,246.75,35,,246.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,521.7,
ARTHREX AR-1586RC-10 RETROSCREW 10X20MM,C1713,HCPCS,,79010991,CDM,278,RC,,,both,,,705,521.7,,,521.7,Other,150% of Medicare + 9.63% HCRA Surcharge,317.25,45,,317.25,percent of total billed charges,Critical Access Hospital RCC factor,239.7,34,,239.7,percent of total billed charges,Implant Device,239.7,34,,239.7,percent of total billed charges,Implant Device,239.7,34,,239.7,percent of total billed charges,Implant Device,239.7,34,,239.7,percent of total billed charges,Implant Device,239.7,34,,239.7,percent of total billed charges,Implant Device,348.98,,,348.98,Other,110% of Medicare,246.75,35,,246.75,percent of total billed charges,Implant Device,239.7,34,"Charges > $500, x 34%",239.7,percent of total billed charges,Implant Device,246.75,35,,246.75,percent of total billed charges,Implant Device,246.75,35,,246.75,percent of total billed charges,Implant Device,246.75,35,,246.75,percent of total billed charges,Implant Device,246.75,35,,246.75,percent of total billed charges,Implant Device,246.75,35,,246.75,percent of total billed charges,Implant Device,282,40,,282,percent of total billed charges,Implant Device,246.75,70,,246.75,percent of total billed charges,All Other,239.7,34,,239.7,percent of total billed charges,Implant Device,239.7,34,,239.7,percent of total billed charges,Implant Device,246.75,35,,246.75,percent of total billed charges,Implant Device,246.75,35,,246.75,percent of total billed charges,Implant Device,246.75,35,,246.75,percent of total billed charges,Implant Device,246.75,35,,246.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,521.7,
ARTHREX AR-1586RB-07 RETROSCREW 7X20MM,C1713,HCPCS,,79011003,CDM,278,RC,,,both,,,582,430.68,,,430.68,Other,150% of Medicare + 9.63% HCRA Surcharge,261.9,45,,261.9,percent of total billed charges,Critical Access Hospital RCC factor,197.88,34,,197.88,percent of total billed charges,Implant Device,197.88,34,,197.88,percent of total billed charges,Implant Device,197.88,34,,197.88,percent of total billed charges,Implant Device,197.88,34,,197.88,percent of total billed charges,Implant Device,197.88,34,,197.88,percent of total billed charges,Implant Device,288.09,,,288.09,Other,110% of Medicare,203.7,35,,203.7,percent of total billed charges,Implant Device,197.88,34,"Charges > $500, x 34%",197.88,percent of total billed charges,Implant Device,203.7,35,,203.7,percent of total billed charges,Implant Device,203.7,35,,203.7,percent of total billed charges,Implant Device,203.7,35,,203.7,percent of total billed charges,Implant Device,203.7,35,,203.7,percent of total billed charges,Implant Device,203.7,35,,203.7,percent of total billed charges,Implant Device,232.8,40,,232.8,percent of total billed charges,Implant Device,203.7,70,,203.7,percent of total billed charges,All Other,197.88,34,,197.88,percent of total billed charges,Implant Device,197.88,34,,197.88,percent of total billed charges,Implant Device,203.7,35,,203.7,percent of total billed charges,Implant Device,203.7,35,,203.7,percent of total billed charges,Implant Device,203.7,35,,203.7,percent of total billed charges,Implant Device,203.7,35,,203.7,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,430.68,
ARTHREX AR-1586RB-09 RETROSCREW 9X20MM,C1713,HCPCS,,79011004,CDM,278,RC,,,both,,,582,430.68,,,430.68,Other,150% of Medicare + 9.63% HCRA Surcharge,261.9,45,,261.9,percent of total billed charges,Critical Access Hospital RCC factor,197.88,34,,197.88,percent of total billed charges,Implant Device,197.88,34,,197.88,percent of total billed charges,Implant Device,197.88,34,,197.88,percent of total billed charges,Implant Device,197.88,34,,197.88,percent of total billed charges,Implant Device,197.88,34,,197.88,percent of total billed charges,Implant Device,288.09,,,288.09,Other,110% of Medicare,203.7,35,,203.7,percent of total billed charges,Implant Device,197.88,34,"Charges > $500, x 34%",197.88,percent of total billed charges,Implant Device,203.7,35,,203.7,percent of total billed charges,Implant Device,203.7,35,,203.7,percent of total billed charges,Implant Device,203.7,35,,203.7,percent of total billed charges,Implant Device,203.7,35,,203.7,percent of total billed charges,Implant Device,203.7,35,,203.7,percent of total billed charges,Implant Device,232.8,40,,232.8,percent of total billed charges,Implant Device,203.7,70,,203.7,percent of total billed charges,All Other,197.88,34,,197.88,percent of total billed charges,Implant Device,197.88,34,,197.88,percent of total billed charges,Implant Device,203.7,35,,203.7,percent of total billed charges,Implant Device,203.7,35,,203.7,percent of total billed charges,Implant Device,203.7,35,,203.7,percent of total billed charges,Implant Device,203.7,35,,203.7,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,430.68,
ARTHREX AR-1586RB-10 RETROCSREW 10/20MM,C1713,HCPCS,,79011005,CDM,278,RC,,,both,,,582,430.68,,,430.68,Other,150% of Medicare + 9.63% HCRA Surcharge,261.9,45,,261.9,percent of total billed charges,Critical Access Hospital RCC factor,197.88,34,,197.88,percent of total billed charges,Implant Device,197.88,34,,197.88,percent of total billed charges,Implant Device,197.88,34,,197.88,percent of total billed charges,Implant Device,197.88,34,,197.88,percent of total billed charges,Implant Device,197.88,34,,197.88,percent of total billed charges,Implant Device,288.09,,,288.09,Other,110% of Medicare,203.7,35,,203.7,percent of total billed charges,Implant Device,197.88,34,"Charges > $500, x 34%",197.88,percent of total billed charges,Implant Device,203.7,35,,203.7,percent of total billed charges,Implant Device,203.7,35,,203.7,percent of total billed charges,Implant Device,203.7,35,,203.7,percent of total billed charges,Implant Device,203.7,35,,203.7,percent of total billed charges,Implant Device,203.7,35,,203.7,percent of total billed charges,Implant Device,232.8,40,,232.8,percent of total billed charges,Implant Device,203.7,70,,203.7,percent of total billed charges,All Other,197.88,34,,197.88,percent of total billed charges,Implant Device,197.88,34,,197.88,percent of total billed charges,Implant Device,203.7,35,,203.7,percent of total billed charges,Implant Device,203.7,35,,203.7,percent of total billed charges,Implant Device,203.7,35,,203.7,percent of total billed charges,Implant Device,203.7,35,,203.7,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,430.68,
ZIMMER 574201020 FEMORAL STEM 12/14 SZ 2,C1776,HCPCS,,79011026,CDM,278,RC,,,both,,,6912,5114.9,,,5114.9,Other,150% of Medicare + 9.63% HCRA Surcharge,3110.4,45,,3110.4,percent of total billed charges,Critical Access Hospital RCC factor,2350.08,34,,2350.08,percent of total billed charges,Implant Device,2350.08,34,,2350.08,percent of total billed charges,Implant Device,2350.08,34,,2350.08,percent of total billed charges,Implant Device,2350.08,34,,2350.08,percent of total billed charges,Implant Device,2350.08,34,,2350.08,percent of total billed charges,Implant Device,3421.44,,,3421.44,Other,110% of Medicare,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2350.08,34,"Charges > $500, x 34%",2350.08,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2764.8,40,,2764.8,percent of total billed charges,Implant Device,2419.2,70,,2419.2,percent of total billed charges,All Other,2350.08,34,,2350.08,percent of total billed charges,Implant Device,2350.08,34,,2350.08,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2350.08,34,"If Charge > 2,000, then 34 percent",2350.08,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5114.9,
ZIMMER 574201065 FEM STEM 12/14 SZ 6.5,C1776,HCPCS,,79011027,CDM,278,RC,,,both,,,8573,6344.04,,,6344.04,Other,150% of Medicare + 9.63% HCRA Surcharge,3857.85,45,,3857.85,percent of total billed charges,Critical Access Hospital RCC factor,2914.82,34,,2914.82,percent of total billed charges,Implant Device,2914.82,34,,2914.82,percent of total billed charges,Implant Device,2914.82,34,,2914.82,percent of total billed charges,Implant Device,2914.82,34,,2914.82,percent of total billed charges,Implant Device,2914.82,34,,2914.82,percent of total billed charges,Implant Device,4243.64,,,4243.64,Other,110% of Medicare,3000.55,35,,3000.55,percent of total billed charges,Implant Device,2914.82,34,"Charges > $500, x 34%",2914.82,percent of total billed charges,Implant Device,3000.55,35,,3000.55,percent of total billed charges,Implant Device,3000.55,35,,3000.55,percent of total billed charges,Implant Device,3000.55,35,,3000.55,percent of total billed charges,Implant Device,3000.55,35,,3000.55,percent of total billed charges,Implant Device,3000.55,35,,3000.55,percent of total billed charges,Implant Device,3429.2,40,,3429.2,percent of total billed charges,Implant Device,3000.55,70,,3000.55,percent of total billed charges,All Other,2914.82,34,,2914.82,percent of total billed charges,Implant Device,2914.82,34,,2914.82,percent of total billed charges,Implant Device,3000.55,35,,3000.55,percent of total billed charges,Implant Device,3000.55,35,,3000.55,percent of total billed charges,Implant Device,3000.55,35,,3000.55,percent of total billed charges,Implant Device,3000.55,35,,3000.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2914.82,34,"If Charge > 2,000, then 34 percent",2914.82,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,6344.04,
ARTHREX AR-3638 FIBERTAK KNOTLESS,C1713,HCPCS,,79011028,CDM,278,RC,,,both,,,1800,1332,,,1332,Other,150% of Medicare + 9.63% HCRA Surcharge,810,45,,810,percent of total billed charges,Critical Access Hospital RCC factor,612,34,,612,percent of total billed charges,Implant Device,612,34,,612,percent of total billed charges,Implant Device,612,34,,612,percent of total billed charges,Implant Device,612,34,,612,percent of total billed charges,Implant Device,612,34,,612,percent of total billed charges,Implant Device,891,,,891,Other,110% of Medicare,630,35,,630,percent of total billed charges,Implant Device,612,34,"Charges > $500, x 34%",612,percent of total billed charges,Implant Device,630,35,,630,percent of total billed charges,Implant Device,630,35,,630,percent of total billed charges,Implant Device,630,35,,630,percent of total billed charges,Implant Device,630,35,,630,percent of total billed charges,Implant Device,630,35,,630,percent of total billed charges,Implant Device,720,40,,720,percent of total billed charges,Implant Device,630,70,,630,percent of total billed charges,All Other,612,34,,612,percent of total billed charges,Implant Device,612,34,,612,percent of total billed charges,Implant Device,630,35,,630,percent of total billed charges,Implant Device,630,35,,630,percent of total billed charges,Implant Device,630,35,,630,percent of total billed charges,Implant Device,630,35,,630,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1332,
ARTHREX AR-8740-40PTS CANN SCREWS 4.0X40,C1713,HCPCS,,79011030,CDM,278,RC,,,both,,,536,396.64,,,396.64,Other,150% of Medicare + 9.63% HCRA Surcharge,241.2,45,,241.2,percent of total billed charges,Critical Access Hospital RCC factor,182.24,34,,182.24,percent of total billed charges,Implant Device,182.24,34,,182.24,percent of total billed charges,Implant Device,182.24,34,,182.24,percent of total billed charges,Implant Device,182.24,34,,182.24,percent of total billed charges,Implant Device,182.24,34,,182.24,percent of total billed charges,Implant Device,265.32,,,265.32,Other,110% of Medicare,187.6,35,,187.6,percent of total billed charges,Implant Device,182.24,34,"Charges > $500, x 34%",182.24,percent of total billed charges,Implant Device,187.6,35,,187.6,percent of total billed charges,Implant Device,187.6,35,,187.6,percent of total billed charges,Implant Device,187.6,35,,187.6,percent of total billed charges,Implant Device,187.6,35,,187.6,percent of total billed charges,Implant Device,187.6,35,,187.6,percent of total billed charges,Implant Device,214.4,40,,214.4,percent of total billed charges,Implant Device,187.6,70,,187.6,percent of total billed charges,All Other,182.24,34,,182.24,percent of total billed charges,Implant Device,182.24,34,,182.24,percent of total billed charges,Implant Device,187.6,35,,187.6,percent of total billed charges,Implant Device,187.6,35,,187.6,percent of total billed charges,Implant Device,187.6,35,,187.6,percent of total billed charges,Implant Device,187.6,35,,187.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,396.64,
ARTHREX AR-8933V-10 VAL SCREW 3X10MM,C1713,HCPCS,,79011031,CDM,278,RC,,,both,,,569,421.06,,,421.06,Other,150% of Medicare + 9.63% HCRA Surcharge,256.05,45,,256.05,percent of total billed charges,Critical Access Hospital RCC factor,193.46,34,,193.46,percent of total billed charges,Implant Device,193.46,34,,193.46,percent of total billed charges,Implant Device,193.46,34,,193.46,percent of total billed charges,Implant Device,193.46,34,,193.46,percent of total billed charges,Implant Device,193.46,34,,193.46,percent of total billed charges,Implant Device,281.66,,,281.66,Other,110% of Medicare,199.15,35,,199.15,percent of total billed charges,Implant Device,193.46,34,"Charges > $500, x 34%",193.46,percent of total billed charges,Implant Device,199.15,35,,199.15,percent of total billed charges,Implant Device,199.15,35,,199.15,percent of total billed charges,Implant Device,199.15,35,,199.15,percent of total billed charges,Implant Device,199.15,35,,199.15,percent of total billed charges,Implant Device,199.15,35,,199.15,percent of total billed charges,Implant Device,227.6,40,,227.6,percent of total billed charges,Implant Device,199.15,70,,199.15,percent of total billed charges,All Other,193.46,34,,193.46,percent of total billed charges,Implant Device,193.46,34,,193.46,percent of total billed charges,Implant Device,199.15,35,,199.15,percent of total billed charges,Implant Device,199.15,35,,199.15,percent of total billed charges,Implant Device,199.15,35,,199.15,percent of total billed charges,Implant Device,199.15,35,,199.15,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,421.06,
ARTHREX AR-8933V-16 VAL SCREW 3X16MM,C1713,HCPCS,,79011032,CDM,278,RC,,,both,,,569,421.06,,,421.06,Other,150% of Medicare + 9.63% HCRA Surcharge,256.05,45,,256.05,percent of total billed charges,Critical Access Hospital RCC factor,193.46,34,,193.46,percent of total billed charges,Implant Device,193.46,34,,193.46,percent of total billed charges,Implant Device,193.46,34,,193.46,percent of total billed charges,Implant Device,193.46,34,,193.46,percent of total billed charges,Implant Device,193.46,34,,193.46,percent of total billed charges,Implant Device,281.66,,,281.66,Other,110% of Medicare,199.15,35,,199.15,percent of total billed charges,Implant Device,193.46,34,"Charges > $500, x 34%",193.46,percent of total billed charges,Implant Device,199.15,35,,199.15,percent of total billed charges,Implant Device,199.15,35,,199.15,percent of total billed charges,Implant Device,199.15,35,,199.15,percent of total billed charges,Implant Device,199.15,35,,199.15,percent of total billed charges,Implant Device,199.15,35,,199.15,percent of total billed charges,Implant Device,227.6,40,,227.6,percent of total billed charges,Implant Device,199.15,70,,199.15,percent of total billed charges,All Other,193.46,34,,193.46,percent of total billed charges,Implant Device,193.46,34,,193.46,percent of total billed charges,Implant Device,199.15,35,,199.15,percent of total billed charges,Implant Device,199.15,35,,199.15,percent of total billed charges,Implant Device,199.15,35,,199.15,percent of total billed charges,Implant Device,199.15,35,,199.15,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,421.06,
ARTHREX AR-9943BR-04 DIS FIB PLT RT 4H,C1713,HCPCS,,79011033,CDM,278,RC,,,both,,,1950,1443,,,1443,Other,150% of Medicare + 9.63% HCRA Surcharge,877.5,45,,877.5,percent of total billed charges,Critical Access Hospital RCC factor,663,34,,663,percent of total billed charges,Implant Device,663,34,,663,percent of total billed charges,Implant Device,663,34,,663,percent of total billed charges,Implant Device,663,34,,663,percent of total billed charges,Implant Device,663,34,,663,percent of total billed charges,Implant Device,965.25,,,965.25,Other,110% of Medicare,682.5,35,,682.5,percent of total billed charges,Implant Device,663,34,"Charges > $500, x 34%",663,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,780,40,,780,percent of total billed charges,Implant Device,682.5,70,,682.5,percent of total billed charges,All Other,663,34,,663,percent of total billed charges,Implant Device,663,34,,663,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,682.5,35,,682.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1443,
STRYKER 2331-1036S FEM NAIL LT 10X360MM,C1713,HCPCS,,79011034,CDM,278,RC,,,both,,,7570,5601.82,,,5601.82,Other,150% of Medicare + 9.63% HCRA Surcharge,3406.5,45,,3406.5,percent of total billed charges,Critical Access Hospital RCC factor,2573.8,34,,2573.8,percent of total billed charges,Implant Device,2573.8,34,,2573.8,percent of total billed charges,Implant Device,2573.8,34,,2573.8,percent of total billed charges,Implant Device,2573.8,34,,2573.8,percent of total billed charges,Implant Device,2573.8,34,,2573.8,percent of total billed charges,Implant Device,3747.15,,,3747.15,Other,110% of Medicare,2649.5,35,,2649.5,percent of total billed charges,Implant Device,2573.8,34,"Charges > $500, x 34%",2573.8,percent of total billed charges,Implant Device,2649.5,35,,2649.5,percent of total billed charges,Implant Device,2649.5,35,,2649.5,percent of total billed charges,Implant Device,2649.5,35,,2649.5,percent of total billed charges,Implant Device,2649.5,35,,2649.5,percent of total billed charges,Implant Device,2649.5,35,,2649.5,percent of total billed charges,Implant Device,3028,40,,3028,percent of total billed charges,Implant Device,2649.5,70,,2649.5,percent of total billed charges,All Other,2573.8,34,,2573.8,percent of total billed charges,Implant Device,2573.8,34,,2573.8,percent of total billed charges,Implant Device,2649.5,35,,2649.5,percent of total billed charges,Implant Device,2649.5,35,,2649.5,percent of total billed charges,Implant Device,2649.5,35,,2649.5,percent of total billed charges,Implant Device,2649.5,35,,2649.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2573.8,34,"If Charge > 2,000, then 34 percent",2573.8,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5601.82,
STRYKER IC3014 HEADED SCREW 3X14MM,C1713,HCPCS,,79011035,CDM,278,RC,,,both,,,493,364.82,,,364.82,Other,150% of Medicare + 9.63% HCRA Surcharge,221.85,45,,221.85,percent of total billed charges,Critical Access Hospital RCC factor,167.62,34,,167.62,percent of total billed charges,Implant Device,167.62,34,,167.62,percent of total billed charges,Implant Device,167.62,34,,167.62,percent of total billed charges,Implant Device,167.62,34,,167.62,percent of total billed charges,Implant Device,167.62,34,,167.62,percent of total billed charges,Implant Device,244.04,,,244.04,Other,110% of Medicare,172.55,35,,172.55,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,172.55,35,,172.55,percent of total billed charges,Implant Device,172.55,35,,172.55,percent of total billed charges,Implant Device,172.55,35,,172.55,percent of total billed charges,Implant Device,172.55,35,,172.55,percent of total billed charges,Implant Device,172.55,35,,172.55,percent of total billed charges,Implant Device,197.2,40,,197.2,percent of total billed charges,Implant Device,172.55,70,,172.55,percent of total billed charges,All Other,167.62,34,,167.62,percent of total billed charges,Implant Device,167.62,34,,167.62,percent of total billed charges,Implant Device,172.55,35,,172.55,percent of total billed charges,Implant Device,172.55,35,,172.55,percent of total billed charges,Implant Device,172.55,35,,172.55,percent of total billed charges,Implant Device,172.55,35,,172.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,364.82,
STRYKER IH3018 HEADLESS SCREW 3X18MM,C1713,HCPCS,,79011036,CDM,278,RC,,,both,,,858,634.92,,,634.92,Other,150% of Medicare + 9.63% HCRA Surcharge,386.1,45,,386.1,percent of total billed charges,Critical Access Hospital RCC factor,291.72,34,,291.72,percent of total billed charges,Implant Device,291.72,34,,291.72,percent of total billed charges,Implant Device,291.72,34,,291.72,percent of total billed charges,Implant Device,291.72,34,,291.72,percent of total billed charges,Implant Device,291.72,34,,291.72,percent of total billed charges,Implant Device,424.71,,,424.71,Other,110% of Medicare,300.3,35,,300.3,percent of total billed charges,Implant Device,291.72,34,"Charges > $500, x 34%",291.72,percent of total billed charges,Implant Device,300.3,35,,300.3,percent of total billed charges,Implant Device,300.3,35,,300.3,percent of total billed charges,Implant Device,300.3,35,,300.3,percent of total billed charges,Implant Device,300.3,35,,300.3,percent of total billed charges,Implant Device,300.3,35,,300.3,percent of total billed charges,Implant Device,343.2,40,,343.2,percent of total billed charges,Implant Device,300.3,70,,300.3,percent of total billed charges,All Other,291.72,34,,291.72,percent of total billed charges,Implant Device,291.72,34,,291.72,percent of total billed charges,Implant Device,300.3,35,,300.3,percent of total billed charges,Implant Device,300.3,35,,300.3,percent of total billed charges,Implant Device,300.3,35,,300.3,percent of total billed charges,Implant Device,300.3,35,,300.3,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,634.92,
STRYKER 623-10-36E INSERT 10 DEGREE 36MM,C1713,HCPCS,,79011037,CDM,278,RC,,,both,,,2503,1852.23,,,1852.23,Other,150% of Medicare + 9.63% HCRA Surcharge,1126.35,45,,1126.35,percent of total billed charges,Critical Access Hospital RCC factor,851.02,34,,851.02,percent of total billed charges,Implant Device,851.02,34,,851.02,percent of total billed charges,Implant Device,851.02,34,,851.02,percent of total billed charges,Implant Device,851.02,34,,851.02,percent of total billed charges,Implant Device,851.02,34,,851.02,percent of total billed charges,Implant Device,1238.99,,,1238.99,Other,110% of Medicare,876.05,35,,876.05,percent of total billed charges,Implant Device,851.02,34,"Charges > $500, x 34%",851.02,percent of total billed charges,Implant Device,876.05,35,,876.05,percent of total billed charges,Implant Device,876.05,35,,876.05,percent of total billed charges,Implant Device,876.05,35,,876.05,percent of total billed charges,Implant Device,876.05,35,,876.05,percent of total billed charges,Implant Device,876.05,35,,876.05,percent of total billed charges,Implant Device,1001.2,40,,1001.2,percent of total billed charges,Implant Device,876.05,70,,876.05,percent of total billed charges,All Other,851.02,34,,851.02,percent of total billed charges,Implant Device,851.02,34,,851.02,percent of total billed charges,Implant Device,876.05,35,,876.05,percent of total billed charges,Implant Device,876.05,35,,876.05,percent of total billed charges,Implant Device,876.05,35,,876.05,percent of total billed charges,Implant Device,876.05,35,,876.05,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,851.02,34,"If Charge > 2,000, then 34 percent",851.02,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1852.23,
STRYKER 656326 LOCKING SCREW 2.7X26MM,C1713,HCPCS,,79011039,CDM,278,RC,,,both,,,443,327.82,,,327.82,Other,150% of Medicare + 9.63% HCRA Surcharge,199.35,45,,199.35,percent of total billed charges,Critical Access Hospital RCC factor,150.62,34,,150.62,percent of total billed charges,Implant Device,150.62,34,,150.62,percent of total billed charges,Implant Device,150.62,34,,150.62,percent of total billed charges,Implant Device,150.62,34,,150.62,percent of total billed charges,Implant Device,150.62,34,,150.62,percent of total billed charges,Implant Device,219.29,,,219.29,Other,110% of Medicare,155.05,35,,155.05,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,155.05,35,,155.05,percent of total billed charges,Implant Device,155.05,35,,155.05,percent of total billed charges,Implant Device,155.05,35,,155.05,percent of total billed charges,Implant Device,155.05,35,,155.05,percent of total billed charges,Implant Device,155.05,35,,155.05,percent of total billed charges,Implant Device,177.2,40,,177.2,percent of total billed charges,Implant Device,155.05,70,,155.05,percent of total billed charges,All Other,150.62,34,,150.62,percent of total billed charges,Implant Device,150.62,34,,150.62,percent of total billed charges,Implant Device,155.05,35,,155.05,percent of total billed charges,Implant Device,155.05,35,,155.05,percent of total billed charges,Implant Device,155.05,35,,155.05,percent of total billed charges,Implant Device,155.05,35,,155.05,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,327.82,
ARTHREX AR-8914DS MINI TIGHROPE 1.1MM,C1713,HCPCS,,79011040,CDM,278,RC,,,both,,,2085,1542.91,,,1542.91,Other,150% of Medicare + 9.63% HCRA Surcharge,938.25,45,,938.25,percent of total billed charges,Critical Access Hospital RCC factor,708.9,34,,708.9,percent of total billed charges,Implant Device,708.9,34,,708.9,percent of total billed charges,Implant Device,708.9,34,,708.9,percent of total billed charges,Implant Device,708.9,34,,708.9,percent of total billed charges,Implant Device,708.9,34,,708.9,percent of total billed charges,Implant Device,1032.08,,,1032.08,Other,110% of Medicare,729.75,35,,729.75,percent of total billed charges,Implant Device,708.9,34,"Charges > $500, x 34%",708.9,percent of total billed charges,Implant Device,729.75,35,,729.75,percent of total billed charges,Implant Device,729.75,35,,729.75,percent of total billed charges,Implant Device,729.75,35,,729.75,percent of total billed charges,Implant Device,729.75,35,,729.75,percent of total billed charges,Implant Device,729.75,35,,729.75,percent of total billed charges,Implant Device,834,40,,834,percent of total billed charges,Implant Device,729.75,70,,729.75,percent of total billed charges,All Other,708.9,34,,708.9,percent of total billed charges,Implant Device,708.9,34,,708.9,percent of total billed charges,Implant Device,729.75,35,,729.75,percent of total billed charges,Implant Device,729.75,35,,729.75,percent of total billed charges,Implant Device,729.75,35,,729.75,percent of total billed charges,Implant Device,729.75,35,,729.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,708.9,34,"If Charge > 2,000, then 34 percent",708.9,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1542.91,
STRYKER 6276-7-025 MOD HIP SYS 155X25MM,C1776,HCPCS,,79011041,CDM,278,RC,,,both,,,8561,6335.16,,,6335.16,Other,150% of Medicare + 9.63% HCRA Surcharge,3852.45,45,,3852.45,percent of total billed charges,Critical Access Hospital RCC factor,2910.74,34,,2910.74,percent of total billed charges,Implant Device,2910.74,34,,2910.74,percent of total billed charges,Implant Device,2910.74,34,,2910.74,percent of total billed charges,Implant Device,2910.74,34,,2910.74,percent of total billed charges,Implant Device,2910.74,34,,2910.74,percent of total billed charges,Implant Device,4237.7,,,4237.7,Other,110% of Medicare,2996.35,35,,2996.35,percent of total billed charges,Implant Device,2910.74,34,"Charges > $500, x 34%",2910.74,percent of total billed charges,Implant Device,2996.35,35,,2996.35,percent of total billed charges,Implant Device,2996.35,35,,2996.35,percent of total billed charges,Implant Device,2996.35,35,,2996.35,percent of total billed charges,Implant Device,2996.35,35,,2996.35,percent of total billed charges,Implant Device,2996.35,35,,2996.35,percent of total billed charges,Implant Device,3424.4,40,,3424.4,percent of total billed charges,Implant Device,2996.35,70,,2996.35,percent of total billed charges,All Other,2910.74,34,,2910.74,percent of total billed charges,Implant Device,2910.74,34,,2910.74,percent of total billed charges,Implant Device,2996.35,35,,2996.35,percent of total billed charges,Implant Device,2996.35,35,,2996.35,percent of total billed charges,Implant Device,2996.35,35,,2996.35,percent of total billed charges,Implant Device,2996.35,35,,2996.35,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2910.74,34,"If Charge > 2,000, then 34 percent",2910.74,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,6335.16,
STRYKER 5531-G-611-E TIB BEARING INS SZ6,C1776,HCPCS,,79011042,CDM,278,RC,,,both,,,2781,2057.95,,,2057.95,Other,150% of Medicare + 9.63% HCRA Surcharge,1251.45,45,,1251.45,percent of total billed charges,Critical Access Hospital RCC factor,945.54,34,,945.54,percent of total billed charges,Implant Device,945.54,34,,945.54,percent of total billed charges,Implant Device,945.54,34,,945.54,percent of total billed charges,Implant Device,945.54,34,,945.54,percent of total billed charges,Implant Device,945.54,34,,945.54,percent of total billed charges,Implant Device,1376.6,,,1376.6,Other,110% of Medicare,973.35,35,,973.35,percent of total billed charges,Implant Device,945.54,34,"Charges > $500, x 34%",945.54,percent of total billed charges,Implant Device,973.35,35,,973.35,percent of total billed charges,Implant Device,973.35,35,,973.35,percent of total billed charges,Implant Device,973.35,35,,973.35,percent of total billed charges,Implant Device,973.35,35,,973.35,percent of total billed charges,Implant Device,973.35,35,,973.35,percent of total billed charges,Implant Device,1112.4,40,,1112.4,percent of total billed charges,Implant Device,973.35,70,,973.35,percent of total billed charges,All Other,945.54,34,,945.54,percent of total billed charges,Implant Device,945.54,34,,945.54,percent of total billed charges,Implant Device,973.35,35,,973.35,percent of total billed charges,Implant Device,973.35,35,,973.35,percent of total billed charges,Implant Device,973.35,35,,973.35,percent of total billed charges,Implant Device,973.35,35,,973.35,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,945.54,34,"If Charge > 2,000, then 34 percent",945.54,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2057.95,
STRYKER 5551-G-381-E PATELLA SZ A38 11MM,C1776,HCPCS,,79011043,CDM,278,RC,,,both,,,1669,1235.06,,,1235.06,Other,150% of Medicare + 9.63% HCRA Surcharge,751.05,45,,751.05,percent of total billed charges,Critical Access Hospital RCC factor,567.46,34,,567.46,percent of total billed charges,Implant Device,567.46,34,,567.46,percent of total billed charges,Implant Device,567.46,34,,567.46,percent of total billed charges,Implant Device,567.46,34,,567.46,percent of total billed charges,Implant Device,567.46,34,,567.46,percent of total billed charges,Implant Device,826.16,,,826.16,Other,110% of Medicare,584.15,35,,584.15,percent of total billed charges,Implant Device,567.46,34,"Charges > $500, x 34%",567.46,percent of total billed charges,Implant Device,584.15,35,,584.15,percent of total billed charges,Implant Device,584.15,35,,584.15,percent of total billed charges,Implant Device,584.15,35,,584.15,percent of total billed charges,Implant Device,584.15,35,,584.15,percent of total billed charges,Implant Device,584.15,35,,584.15,percent of total billed charges,Implant Device,667.6,40,,667.6,percent of total billed charges,Implant Device,584.15,70,,584.15,percent of total billed charges,All Other,567.46,34,,567.46,percent of total billed charges,Implant Device,567.46,34,,567.46,percent of total billed charges,Implant Device,584.15,35,,584.15,percent of total billed charges,Implant Device,584.15,35,,584.15,percent of total billed charges,Implant Device,584.15,35,,584.15,percent of total billed charges,Implant Device,584.15,35,,584.15,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1235.06,
STRYKER 5560-S-115 CEMENTED STEM 15X50,C1776,HCPCS,,79011046,CDM,278,RC,,,both,,,3324,2459.77,,,2459.77,Other,150% of Medicare + 9.63% HCRA Surcharge,1495.8,45,,1495.8,percent of total billed charges,Critical Access Hospital RCC factor,1130.16,34,,1130.16,percent of total billed charges,Implant Device,1130.16,34,,1130.16,percent of total billed charges,Implant Device,1130.16,34,,1130.16,percent of total billed charges,Implant Device,1130.16,34,,1130.16,percent of total billed charges,Implant Device,1130.16,34,,1130.16,percent of total billed charges,Implant Device,1645.38,,,1645.38,Other,110% of Medicare,1163.4,35,,1163.4,percent of total billed charges,Implant Device,1130.16,34,"Charges > $500, x 34%",1130.16,percent of total billed charges,Implant Device,1163.4,35,,1163.4,percent of total billed charges,Implant Device,1163.4,35,,1163.4,percent of total billed charges,Implant Device,1163.4,35,,1163.4,percent of total billed charges,Implant Device,1163.4,35,,1163.4,percent of total billed charges,Implant Device,1163.4,35,,1163.4,percent of total billed charges,Implant Device,1329.6,40,,1329.6,percent of total billed charges,Implant Device,1163.4,70,,1163.4,percent of total billed charges,All Other,1130.16,34,,1130.16,percent of total billed charges,Implant Device,1130.16,34,,1130.16,percent of total billed charges,Implant Device,1163.4,35,,1163.4,percent of total billed charges,Implant Device,1163.4,35,,1163.4,percent of total billed charges,Implant Device,1163.4,35,,1163.4,percent of total billed charges,Implant Device,1163.4,35,,1163.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1130.16,34,"If Charge > 2,000, then 34 percent",1130.16,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2459.77,
STRYKER 5551-G-299-E PATELLA SZ A29 9MM,C1776,HCPCS,,79011047,CDM,278,RC,,,both,,,1669,1235.06,,,1235.06,Other,150% of Medicare + 9.63% HCRA Surcharge,751.05,45,,751.05,percent of total billed charges,Critical Access Hospital RCC factor,567.46,34,,567.46,percent of total billed charges,Implant Device,567.46,34,,567.46,percent of total billed charges,Implant Device,567.46,34,,567.46,percent of total billed charges,Implant Device,567.46,34,,567.46,percent of total billed charges,Implant Device,567.46,34,,567.46,percent of total billed charges,Implant Device,826.16,,,826.16,Other,110% of Medicare,584.15,35,,584.15,percent of total billed charges,Implant Device,567.46,34,"Charges > $500, x 34%",567.46,percent of total billed charges,Implant Device,584.15,35,,584.15,percent of total billed charges,Implant Device,584.15,35,,584.15,percent of total billed charges,Implant Device,584.15,35,,584.15,percent of total billed charges,Implant Device,584.15,35,,584.15,percent of total billed charges,Implant Device,584.15,35,,584.15,percent of total billed charges,Implant Device,667.6,40,,667.6,percent of total billed charges,Implant Device,584.15,70,,584.15,percent of total billed charges,All Other,567.46,34,,567.46,percent of total billed charges,Implant Device,567.46,34,,567.46,percent of total billed charges,Implant Device,584.15,35,,584.15,percent of total billed charges,Implant Device,584.15,35,,584.15,percent of total billed charges,Implant Device,584.15,35,,584.15,percent of total billed charges,Implant Device,584.15,35,,584.15,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1235.06,
STRYKER 5521-B-500 TIBIAL BASEPLATE SZ 5,C1776,HCPCS,,79011050,CDM,278,RC,,,both,,,3337,2469.39,,,2469.39,Other,150% of Medicare + 9.63% HCRA Surcharge,1501.65,45,,1501.65,percent of total billed charges,Critical Access Hospital RCC factor,1134.58,34,,1134.58,percent of total billed charges,Implant Device,1134.58,34,,1134.58,percent of total billed charges,Implant Device,1134.58,34,,1134.58,percent of total billed charges,Implant Device,1134.58,34,,1134.58,percent of total billed charges,Implant Device,1134.58,34,,1134.58,percent of total billed charges,Implant Device,1651.82,,,1651.82,Other,110% of Medicare,1167.95,35,,1167.95,percent of total billed charges,Implant Device,1134.58,34,"Charges > $500, x 34%",1134.58,percent of total billed charges,Implant Device,1167.95,35,,1167.95,percent of total billed charges,Implant Device,1167.95,35,,1167.95,percent of total billed charges,Implant Device,1167.95,35,,1167.95,percent of total billed charges,Implant Device,1167.95,35,,1167.95,percent of total billed charges,Implant Device,1167.95,35,,1167.95,percent of total billed charges,Implant Device,1334.8,40,,1334.8,percent of total billed charges,Implant Device,1167.95,70,,1167.95,percent of total billed charges,All Other,1134.58,34,,1134.58,percent of total billed charges,Implant Device,1134.58,34,,1134.58,percent of total billed charges,Implant Device,1167.95,35,,1167.95,percent of total billed charges,Implant Device,1167.95,35,,1167.95,percent of total billed charges,Implant Device,1167.95,35,,1167.95,percent of total billed charges,Implant Device,1167.95,35,,1167.95,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1134.58,34,"If Charge > 2,000, then 34 percent",1134.58,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2469.39,
STRYKER 5551-G-320-E PATELLA SZ A32 10MM,C1776,HCPCS,,79011051,CDM,278,RC,,,both,,,1669,1235.06,,,1235.06,Other,150% of Medicare + 9.63% HCRA Surcharge,751.05,45,,751.05,percent of total billed charges,Critical Access Hospital RCC factor,567.46,34,,567.46,percent of total billed charges,Implant Device,567.46,34,,567.46,percent of total billed charges,Implant Device,567.46,34,,567.46,percent of total billed charges,Implant Device,567.46,34,,567.46,percent of total billed charges,Implant Device,567.46,34,,567.46,percent of total billed charges,Implant Device,826.16,,,826.16,Other,110% of Medicare,584.15,35,,584.15,percent of total billed charges,Implant Device,567.46,34,"Charges > $500, x 34%",567.46,percent of total billed charges,Implant Device,584.15,35,,584.15,percent of total billed charges,Implant Device,584.15,35,,584.15,percent of total billed charges,Implant Device,584.15,35,,584.15,percent of total billed charges,Implant Device,584.15,35,,584.15,percent of total billed charges,Implant Device,584.15,35,,584.15,percent of total billed charges,Implant Device,667.6,40,,667.6,percent of total billed charges,Implant Device,584.15,70,,584.15,percent of total billed charges,All Other,567.46,34,,567.46,percent of total billed charges,Implant Device,567.46,34,,567.46,percent of total billed charges,Implant Device,584.15,35,,584.15,percent of total billed charges,Implant Device,584.15,35,,584.15,percent of total billed charges,Implant Device,584.15,35,,584.15,percent of total billed charges,Implant Device,584.15,35,,584.15,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1235.06,
ARTHREX AR-1662BCC-7 SWIVELOCK 7X19,C1713,HCPCS,,79011053,CDM,278,RC,,,both,,,1305,965.7,,,965.7,Other,150% of Medicare + 9.63% HCRA Surcharge,587.25,45,,587.25,percent of total billed charges,Critical Access Hospital RCC factor,443.7,34,,443.7,percent of total billed charges,Implant Device,443.7,34,,443.7,percent of total billed charges,Implant Device,443.7,34,,443.7,percent of total billed charges,Implant Device,443.7,34,,443.7,percent of total billed charges,Implant Device,443.7,34,,443.7,percent of total billed charges,Implant Device,645.98,,,645.98,Other,110% of Medicare,456.75,35,,456.75,percent of total billed charges,Implant Device,443.7,34,"Charges > $500, x 34%",443.7,percent of total billed charges,Implant Device,456.75,35,,456.75,percent of total billed charges,Implant Device,456.75,35,,456.75,percent of total billed charges,Implant Device,456.75,35,,456.75,percent of total billed charges,Implant Device,456.75,35,,456.75,percent of total billed charges,Implant Device,456.75,35,,456.75,percent of total billed charges,Implant Device,522,40,,522,percent of total billed charges,Implant Device,456.75,70,,456.75,percent of total billed charges,All Other,443.7,34,,443.7,percent of total billed charges,Implant Device,443.7,34,,443.7,percent of total billed charges,Implant Device,456.75,35,,456.75,percent of total billed charges,Implant Device,456.75,35,,456.75,percent of total billed charges,Implant Device,456.75,35,,456.75,percent of total billed charges,Implant Device,456.75,35,,456.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,965.7,
STRYKER ORTHO 6276-1-223 HIP SYS 23MM,C1776,HCPCS,,79011054,CDM,278,RC,,,both,,,11948,8841.55,,,8841.55,Other,150% of Medicare + 9.63% HCRA Surcharge,5376.6,45,,5376.6,percent of total billed charges,Critical Access Hospital RCC factor,4062.32,34,,4062.32,percent of total billed charges,Implant Device,4062.32,34,,4062.32,percent of total billed charges,Implant Device,4062.32,34,,4062.32,percent of total billed charges,Implant Device,4062.32,34,,4062.32,percent of total billed charges,Implant Device,4062.32,34,,4062.32,percent of total billed charges,Implant Device,5914.26,,,5914.26,Other,110% of Medicare,4181.8,35,,4181.8,percent of total billed charges,Implant Device,4062.32,34,"Charges > $500, x 34%",4062.32,percent of total billed charges,Implant Device,4181.8,35,,4181.8,percent of total billed charges,Implant Device,4181.8,35,,4181.8,percent of total billed charges,Implant Device,4181.8,35,,4181.8,percent of total billed charges,Implant Device,4181.8,35,,4181.8,percent of total billed charges,Implant Device,4181.8,35,,4181.8,percent of total billed charges,Implant Device,4779.2,40,,4779.2,percent of total billed charges,Implant Device,4181.8,70,,4181.8,percent of total billed charges,All Other,4062.32,34,,4062.32,percent of total billed charges,Implant Device,4062.32,34,,4062.32,percent of total billed charges,Implant Device,4181.8,35,,4181.8,percent of total billed charges,Implant Device,4181.8,35,,4181.8,percent of total billed charges,Implant Device,4181.8,35,,4181.8,percent of total billed charges,Implant Device,4181.8,35,,4181.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,4062.32,34,"If Charge > 2,000, then 34 percent",4062.32,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,8841.55,
STRYKER ORTHO 6276-7-018 STEM 155X18MM,C1776,HCPCS,,79011055,CDM,278,RC,,,both,,,8561,6335.16,,,6335.16,Other,150% of Medicare + 9.63% HCRA Surcharge,3852.45,45,,3852.45,percent of total billed charges,Critical Access Hospital RCC factor,2910.74,34,,2910.74,percent of total billed charges,Implant Device,2910.74,34,,2910.74,percent of total billed charges,Implant Device,2910.74,34,,2910.74,percent of total billed charges,Implant Device,2910.74,34,,2910.74,percent of total billed charges,Implant Device,2910.74,34,,2910.74,percent of total billed charges,Implant Device,4237.7,,,4237.7,Other,110% of Medicare,2996.35,35,,2996.35,percent of total billed charges,Implant Device,2910.74,34,"Charges > $500, x 34%",2910.74,percent of total billed charges,Implant Device,2996.35,35,,2996.35,percent of total billed charges,Implant Device,2996.35,35,,2996.35,percent of total billed charges,Implant Device,2996.35,35,,2996.35,percent of total billed charges,Implant Device,2996.35,35,,2996.35,percent of total billed charges,Implant Device,2996.35,35,,2996.35,percent of total billed charges,Implant Device,3424.4,40,,3424.4,percent of total billed charges,Implant Device,2996.35,70,,2996.35,percent of total billed charges,All Other,2910.74,34,,2910.74,percent of total billed charges,Implant Device,2910.74,34,,2910.74,percent of total billed charges,Implant Device,2996.35,35,,2996.35,percent of total billed charges,Implant Device,2996.35,35,,2996.35,percent of total billed charges,Implant Device,2996.35,35,,2996.35,percent of total billed charges,Implant Device,2996.35,35,,2996.35,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2910.74,34,"If Charge > 2,000, then 34 percent",2910.74,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,6335.16,
ORGANOGENSIS 515-008 PURAPLY GRAFT 5X5CM,C1768,HCPCS,,79011056,CDM,278,RC,,,both,,,8250,6105.02,,,6105.02,Other,150% of Medicare + 9.63% HCRA Surcharge,3712.5,45,,3712.5,percent of total billed charges,Critical Access Hospital RCC factor,2805,34,,2805,percent of total billed charges,Implant Device,2805,34,,2805,percent of total billed charges,Implant Device,2805,34,,2805,percent of total billed charges,Implant Device,2805,34,,2805,percent of total billed charges,Implant Device,2805,34,,2805,percent of total billed charges,Implant Device,4083.75,,,4083.75,Other,110% of Medicare,2887.5,35,,2887.5,percent of total billed charges,Implant Device,2805,34,"Charges > $500, x 34%",2805,percent of total billed charges,Implant Device,2887.5,35,,2887.5,percent of total billed charges,Implant Device,2887.5,35,,2887.5,percent of total billed charges,Implant Device,2887.5,35,,2887.5,percent of total billed charges,Implant Device,2887.5,35,,2887.5,percent of total billed charges,Implant Device,2887.5,35,,2887.5,percent of total billed charges,Implant Device,3300,40,,3300,percent of total billed charges,Implant Device,2887.5,70,,2887.5,percent of total billed charges,All Other,2805,34,,2805,percent of total billed charges,Implant Device,2805,34,,2805,percent of total billed charges,Implant Device,2887.5,35,,2887.5,percent of total billed charges,Implant Device,2887.5,35,,2887.5,percent of total billed charges,Implant Device,2887.5,35,,2887.5,percent of total billed charges,Implant Device,2887.5,35,,2887.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2805,34,"If Charge > 2,000, then 34 percent",2805,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,6105.02,
STRYKER 3525-1400S LONG NAIL KIT 11X400,C1713,HCPCS,,79011058,CDM,278,RC,,,both,,,5438,4024.13,,,4024.13,Other,150% of Medicare + 9.63% HCRA Surcharge,2447.1,45,,2447.1,percent of total billed charges,Critical Access Hospital RCC factor,1848.92,34,,1848.92,percent of total billed charges,Implant Device,1848.92,34,,1848.92,percent of total billed charges,Implant Device,1848.92,34,,1848.92,percent of total billed charges,Implant Device,1848.92,34,,1848.92,percent of total billed charges,Implant Device,1848.92,34,,1848.92,percent of total billed charges,Implant Device,2691.81,,,2691.81,Other,110% of Medicare,1903.3,35,,1903.3,percent of total billed charges,Implant Device,1848.92,34,"Charges > $500, x 34%",1848.92,percent of total billed charges,Implant Device,1903.3,35,,1903.3,percent of total billed charges,Implant Device,1903.3,35,,1903.3,percent of total billed charges,Implant Device,1903.3,35,,1903.3,percent of total billed charges,Implant Device,1903.3,35,,1903.3,percent of total billed charges,Implant Device,1903.3,35,,1903.3,percent of total billed charges,Implant Device,2175.2,40,,2175.2,percent of total billed charges,Implant Device,1903.3,70,,1903.3,percent of total billed charges,All Other,1848.92,34,,1848.92,percent of total billed charges,Implant Device,1848.92,34,,1848.92,percent of total billed charges,Implant Device,1903.3,35,,1903.3,percent of total billed charges,Implant Device,1903.3,35,,1903.3,percent of total billed charges,Implant Device,1903.3,35,,1903.3,percent of total billed charges,Implant Device,1903.3,35,,1903.3,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1848.92,34,"If Charge > 2,000, then 34 percent",1848.92,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4024.13,
STRYKER 6057-0230D HIP STEM SZ 2 30X124,C1776,HCPCS,,79011059,CDM,278,RC,,,both,,,5006,3704.45,,,3704.45,Other,150% of Medicare + 9.63% HCRA Surcharge,2252.7,45,,2252.7,percent of total billed charges,Critical Access Hospital RCC factor,1702.04,34,,1702.04,percent of total billed charges,Implant Device,1702.04,34,,1702.04,percent of total billed charges,Implant Device,1702.04,34,,1702.04,percent of total billed charges,Implant Device,1702.04,34,,1702.04,percent of total billed charges,Implant Device,1702.04,34,,1702.04,percent of total billed charges,Implant Device,2477.97,,,2477.97,Other,110% of Medicare,1752.1,35,,1752.1,percent of total billed charges,Implant Device,1702.04,34,"Charges > $500, x 34%",1702.04,percent of total billed charges,Implant Device,1752.1,35,,1752.1,percent of total billed charges,Implant Device,1752.1,35,,1752.1,percent of total billed charges,Implant Device,1752.1,35,,1752.1,percent of total billed charges,Implant Device,1752.1,35,,1752.1,percent of total billed charges,Implant Device,1752.1,35,,1752.1,percent of total billed charges,Implant Device,2002.4,40,,2002.4,percent of total billed charges,Implant Device,1752.1,70,,1752.1,percent of total billed charges,All Other,1702.04,34,,1702.04,percent of total billed charges,Implant Device,1702.04,34,,1702.04,percent of total billed charges,Implant Device,1752.1,35,,1752.1,percent of total billed charges,Implant Device,1752.1,35,,1752.1,percent of total billed charges,Implant Device,1752.1,35,,1752.1,percent of total billed charges,Implant Device,1752.1,35,,1752.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1702.04,34,"If Charge > 2,000, then 34 percent",1702.04,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3704.45,
DEPUY 1294-35-120 TIB TRAY ROTATING SZ 2,C1776,HCPCS,,79011060,CDM,278,RC,,,both,,,14804,10955,,,10955,Other,150% of Medicare + 9.63% HCRA Surcharge,6661.8,45,,6661.8,percent of total billed charges,Critical Access Hospital RCC factor,5033.36,34,,5033.36,percent of total billed charges,Implant Device,5033.36,34,,5033.36,percent of total billed charges,Implant Device,5033.36,34,,5033.36,percent of total billed charges,Implant Device,5033.36,34,,5033.36,percent of total billed charges,Implant Device,5033.36,34,,5033.36,percent of total billed charges,Implant Device,7327.98,,,7327.98,Other,110% of Medicare,5181.4,35,,5181.4,percent of total billed charges,Implant Device,5033.36,34,"Charges > $500, x 34%",5033.36,percent of total billed charges,Implant Device,5181.4,35,,5181.4,percent of total billed charges,Implant Device,5181.4,35,,5181.4,percent of total billed charges,Implant Device,5181.4,35,,5181.4,percent of total billed charges,Implant Device,5181.4,35,,5181.4,percent of total billed charges,Implant Device,5181.4,35,,5181.4,percent of total billed charges,Implant Device,5921.6,40,,5921.6,percent of total billed charges,Implant Device,5181.4,70,,5181.4,percent of total billed charges,All Other,5033.36,34,,5033.36,percent of total billed charges,Implant Device,5033.36,34,,5033.36,percent of total billed charges,Implant Device,5181.4,35,,5181.4,percent of total billed charges,Implant Device,5181.4,35,,5181.4,percent of total billed charges,Implant Device,5181.4,35,,5181.4,percent of total billed charges,Implant Device,5181.4,35,,5181.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,5033.36,34,"If Charge > 2,000, then 34 percent",5033.36,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,10955,
ZIMMER 574201040 FEMORAL STEM 12/14 SZ 4,C1776,HCPCS,,79011061,CDM,278,RC,,,both,,,8573,6344.04,,,6344.04,Other,150% of Medicare + 9.63% HCRA Surcharge,3857.85,45,,3857.85,percent of total billed charges,Critical Access Hospital RCC factor,2914.82,34,,2914.82,percent of total billed charges,Implant Device,2914.82,34,,2914.82,percent of total billed charges,Implant Device,2914.82,34,,2914.82,percent of total billed charges,Implant Device,2914.82,34,,2914.82,percent of total billed charges,Implant Device,2914.82,34,,2914.82,percent of total billed charges,Implant Device,4243.64,,,4243.64,Other,110% of Medicare,3000.55,35,,3000.55,percent of total billed charges,Implant Device,2914.82,34,"Charges > $500, x 34%",2914.82,percent of total billed charges,Implant Device,3000.55,35,,3000.55,percent of total billed charges,Implant Device,3000.55,35,,3000.55,percent of total billed charges,Implant Device,3000.55,35,,3000.55,percent of total billed charges,Implant Device,3000.55,35,,3000.55,percent of total billed charges,Implant Device,3000.55,35,,3000.55,percent of total billed charges,Implant Device,3429.2,40,,3429.2,percent of total billed charges,Implant Device,3000.55,70,,3000.55,percent of total billed charges,All Other,2914.82,34,,2914.82,percent of total billed charges,Implant Device,2914.82,34,,2914.82,percent of total billed charges,Implant Device,3000.55,35,,3000.55,percent of total billed charges,Implant Device,3000.55,35,,3000.55,percent of total billed charges,Implant Device,3000.55,35,,3000.55,percent of total billed charges,Implant Device,3000.55,35,,3000.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2914.82,34,"If Charge > 2,000, then 34 percent",2914.82,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,6344.04,
STRYKER 629626 NARROW LOCK PLT 2X34MM 6H,C1713,HCPCS,,79011066,CDM,278,RC,,,both,,,2268,1678.33,,,1678.33,Other,150% of Medicare + 9.63% HCRA Surcharge,1020.6,45,,1020.6,percent of total billed charges,Critical Access Hospital RCC factor,771.12,34,,771.12,percent of total billed charges,Implant Device,771.12,34,,771.12,percent of total billed charges,Implant Device,771.12,34,,771.12,percent of total billed charges,Implant Device,771.12,34,,771.12,percent of total billed charges,Implant Device,771.12,34,,771.12,percent of total billed charges,Implant Device,1122.66,,,1122.66,Other,110% of Medicare,793.8,35,,793.8,percent of total billed charges,Implant Device,771.12,34,"Charges > $500, x 34%",771.12,percent of total billed charges,Implant Device,793.8,35,,793.8,percent of total billed charges,Implant Device,793.8,35,,793.8,percent of total billed charges,Implant Device,793.8,35,,793.8,percent of total billed charges,Implant Device,793.8,35,,793.8,percent of total billed charges,Implant Device,793.8,35,,793.8,percent of total billed charges,Implant Device,907.2,40,,907.2,percent of total billed charges,Implant Device,793.8,70,,793.8,percent of total billed charges,All Other,771.12,34,,771.12,percent of total billed charges,Implant Device,771.12,34,,771.12,percent of total billed charges,Implant Device,793.8,35,,793.8,percent of total billed charges,Implant Device,793.8,35,,793.8,percent of total billed charges,Implant Device,793.8,35,,793.8,percent of total billed charges,Implant Device,793.8,35,,793.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,771.12,34,"If Charge > 2,000, then 34 percent",771.12,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1678.33,
STRYKER 629628 NARROW LOCK PLT 2X46MM 8H,C1713,HCPCS,,79011067,CDM,278,RC,,,both,,,2268,1678.33,,,1678.33,Other,150% of Medicare + 9.63% HCRA Surcharge,1020.6,45,,1020.6,percent of total billed charges,Critical Access Hospital RCC factor,771.12,34,,771.12,percent of total billed charges,Implant Device,771.12,34,,771.12,percent of total billed charges,Implant Device,771.12,34,,771.12,percent of total billed charges,Implant Device,771.12,34,,771.12,percent of total billed charges,Implant Device,771.12,34,,771.12,percent of total billed charges,Implant Device,1122.66,,,1122.66,Other,110% of Medicare,793.8,35,,793.8,percent of total billed charges,Implant Device,771.12,34,"Charges > $500, x 34%",771.12,percent of total billed charges,Implant Device,793.8,35,,793.8,percent of total billed charges,Implant Device,793.8,35,,793.8,percent of total billed charges,Implant Device,793.8,35,,793.8,percent of total billed charges,Implant Device,793.8,35,,793.8,percent of total billed charges,Implant Device,793.8,35,,793.8,percent of total billed charges,Implant Device,907.2,40,,907.2,percent of total billed charges,Implant Device,793.8,70,,793.8,percent of total billed charges,All Other,771.12,34,,771.12,percent of total billed charges,Implant Device,771.12,34,,771.12,percent of total billed charges,Implant Device,793.8,35,,793.8,percent of total billed charges,Implant Device,793.8,35,,793.8,percent of total billed charges,Implant Device,793.8,35,,793.8,percent of total billed charges,Implant Device,793.8,35,,793.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,771.12,34,"If Charge > 2,000, then 34 percent",771.12,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1678.33,
STRYKER 657610 LOCKING SCREW 2X10MM,C1713,HCPCS,,79011068,CDM,278,RC,,,both,,,443,327.82,,,327.82,Other,150% of Medicare + 9.63% HCRA Surcharge,199.35,45,,199.35,percent of total billed charges,Critical Access Hospital RCC factor,150.62,34,,150.62,percent of total billed charges,Implant Device,150.62,34,,150.62,percent of total billed charges,Implant Device,150.62,34,,150.62,percent of total billed charges,Implant Device,150.62,34,,150.62,percent of total billed charges,Implant Device,150.62,34,,150.62,percent of total billed charges,Implant Device,219.29,,,219.29,Other,110% of Medicare,155.05,35,,155.05,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,155.05,35,,155.05,percent of total billed charges,Implant Device,155.05,35,,155.05,percent of total billed charges,Implant Device,155.05,35,,155.05,percent of total billed charges,Implant Device,155.05,35,,155.05,percent of total billed charges,Implant Device,155.05,35,,155.05,percent of total billed charges,Implant Device,177.2,40,,177.2,percent of total billed charges,Implant Device,155.05,70,,155.05,percent of total billed charges,All Other,150.62,34,,150.62,percent of total billed charges,Implant Device,150.62,34,,150.62,percent of total billed charges,Implant Device,155.05,35,,155.05,percent of total billed charges,Implant Device,155.05,35,,155.05,percent of total billed charges,Implant Device,155.05,35,,155.05,percent of total billed charges,Implant Device,155.05,35,,155.05,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,327.82,
STRYKER 657612 LOCKING SCREW 2X12MM,C1713,HCPCS,,79011069,CDM,278,RC,,,both,,,676,500.24,,,500.24,Other,150% of Medicare + 9.63% HCRA Surcharge,304.2,45,,304.2,percent of total billed charges,Critical Access Hospital RCC factor,229.84,34,,229.84,percent of total billed charges,Implant Device,229.84,34,,229.84,percent of total billed charges,Implant Device,229.84,34,,229.84,percent of total billed charges,Implant Device,229.84,34,,229.84,percent of total billed charges,Implant Device,229.84,34,,229.84,percent of total billed charges,Implant Device,334.62,,,334.62,Other,110% of Medicare,236.6,35,,236.6,percent of total billed charges,Implant Device,229.84,34,"Charges > $500, x 34%",229.84,percent of total billed charges,Implant Device,236.6,35,,236.6,percent of total billed charges,Implant Device,236.6,35,,236.6,percent of total billed charges,Implant Device,236.6,35,,236.6,percent of total billed charges,Implant Device,236.6,35,,236.6,percent of total billed charges,Implant Device,236.6,35,,236.6,percent of total billed charges,Implant Device,270.4,40,,270.4,percent of total billed charges,Implant Device,236.6,70,,236.6,percent of total billed charges,All Other,229.84,34,,229.84,percent of total billed charges,Implant Device,229.84,34,,229.84,percent of total billed charges,Implant Device,236.6,35,,236.6,percent of total billed charges,Implant Device,236.6,35,,236.6,percent of total billed charges,Implant Device,236.6,35,,236.6,percent of total billed charges,Implant Device,236.6,35,,236.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,500.24,
STRYKER 657614 LOCKING SCREW 2X14MM,C1713,HCPCS,,79011070,CDM,278,RC,,,both,,,443,327.82,,,327.82,Other,150% of Medicare + 9.63% HCRA Surcharge,199.35,45,,199.35,percent of total billed charges,Critical Access Hospital RCC factor,150.62,34,,150.62,percent of total billed charges,Implant Device,150.62,34,,150.62,percent of total billed charges,Implant Device,150.62,34,,150.62,percent of total billed charges,Implant Device,150.62,34,,150.62,percent of total billed charges,Implant Device,150.62,34,,150.62,percent of total billed charges,Implant Device,219.29,,,219.29,Other,110% of Medicare,155.05,35,,155.05,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,155.05,35,,155.05,percent of total billed charges,Implant Device,155.05,35,,155.05,percent of total billed charges,Implant Device,155.05,35,,155.05,percent of total billed charges,Implant Device,155.05,35,,155.05,percent of total billed charges,Implant Device,155.05,35,,155.05,percent of total billed charges,Implant Device,177.2,40,,177.2,percent of total billed charges,Implant Device,155.05,70,,155.05,percent of total billed charges,All Other,150.62,34,,150.62,percent of total billed charges,Implant Device,150.62,34,,150.62,percent of total billed charges,Implant Device,155.05,35,,155.05,percent of total billed charges,Implant Device,155.05,35,,155.05,percent of total billed charges,Implant Device,155.05,35,,155.05,percent of total billed charges,Implant Device,155.05,35,,155.05,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,327.82,
ZIMMER 00-8775-032-04 FEM HEAD 32X+7MM,C1776,HCPCS,,79011073,CDM,278,RC,,,both,,,2880,2131.21,,,2131.21,Other,150% of Medicare + 9.63% HCRA Surcharge,1296,45,,1296,percent of total billed charges,Critical Access Hospital RCC factor,979.2,34,,979.2,percent of total billed charges,Implant Device,979.2,34,,979.2,percent of total billed charges,Implant Device,979.2,34,,979.2,percent of total billed charges,Implant Device,979.2,34,,979.2,percent of total billed charges,Implant Device,979.2,34,,979.2,percent of total billed charges,Implant Device,1425.6,,,1425.6,Other,110% of Medicare,1008,35,,1008,percent of total billed charges,Implant Device,979.2,34,"Charges > $500, x 34%",979.2,percent of total billed charges,Implant Device,1008,35,,1008,percent of total billed charges,Implant Device,1008,35,,1008,percent of total billed charges,Implant Device,1008,35,,1008,percent of total billed charges,Implant Device,1008,35,,1008,percent of total billed charges,Implant Device,1008,35,,1008,percent of total billed charges,Implant Device,1152,40,,1152,percent of total billed charges,Implant Device,1008,70,,1008,percent of total billed charges,All Other,979.2,34,,979.2,percent of total billed charges,Implant Device,979.2,34,,979.2,percent of total billed charges,Implant Device,1008,35,,1008,percent of total billed charges,Implant Device,1008,35,,1008,percent of total billed charges,Implant Device,1008,35,,1008,percent of total billed charges,Implant Device,1008,35,,1008,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,979.2,34,"If Charge > 2,000, then 34 percent",979.2,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2131.21,
ZIMMER 105424 ACETABULAR LOCK RING SZ 24,C1776,HCPCS,,79011074,CDM,278,RC,,,both,,,338,250.12,,,250.12,Other,150% of Medicare + 9.63% HCRA Surcharge,152.1,45,,152.1,percent of total billed charges,Critical Access Hospital RCC factor,114.92,34,,114.92,percent of total billed charges,Implant Device,114.92,34,,114.92,percent of total billed charges,Implant Device,114.92,34,,114.92,percent of total billed charges,Implant Device,114.92,34,,114.92,percent of total billed charges,Implant Device,114.92,34,,114.92,percent of total billed charges,Implant Device,167.31,,,167.31,Other,110% of Medicare,118.3,35,,118.3,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,118.3,35,,118.3,percent of total billed charges,Implant Device,118.3,35,,118.3,percent of total billed charges,Implant Device,118.3,35,,118.3,percent of total billed charges,Implant Device,118.3,35,,118.3,percent of total billed charges,Implant Device,118.3,35,,118.3,percent of total billed charges,Implant Device,135.2,40,,135.2,percent of total billed charges,Implant Device,118.3,70,,118.3,percent of total billed charges,All Other,114.92,34,,114.92,percent of total billed charges,Implant Device,114.92,34,,114.92,percent of total billed charges,Implant Device,118.3,35,,118.3,percent of total billed charges,Implant Device,118.3,35,,118.3,percent of total billed charges,Implant Device,118.3,35,,118.3,percent of total billed charges,Implant Device,118.3,35,,118.3,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,250.12,
ZIMMER 105423 ACETABULAR LOCK RING SZ 23,C1776,HCPCS,,79011075,CDM,278,RC,,,both,,,338,250.12,,,250.12,Other,150% of Medicare + 9.63% HCRA Surcharge,152.1,45,,152.1,percent of total billed charges,Critical Access Hospital RCC factor,114.92,34,,114.92,percent of total billed charges,Implant Device,114.92,34,,114.92,percent of total billed charges,Implant Device,114.92,34,,114.92,percent of total billed charges,Implant Device,114.92,34,,114.92,percent of total billed charges,Implant Device,114.92,34,,114.92,percent of total billed charges,Implant Device,167.31,,,167.31,Other,110% of Medicare,118.3,35,,118.3,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,118.3,35,,118.3,percent of total billed charges,Implant Device,118.3,35,,118.3,percent of total billed charges,Implant Device,118.3,35,,118.3,percent of total billed charges,Implant Device,118.3,35,,118.3,percent of total billed charges,Implant Device,118.3,35,,118.3,percent of total billed charges,Implant Device,135.2,40,,135.2,percent of total billed charges,Implant Device,118.3,70,,118.3,percent of total billed charges,All Other,114.92,34,,114.92,percent of total billed charges,Implant Device,114.92,34,,114.92,percent of total billed charges,Implant Device,118.3,35,,118.3,percent of total billed charges,Implant Device,118.3,35,,118.3,percent of total billed charges,Implant Device,118.3,35,,118.3,percent of total billed charges,Implant Device,118.3,35,,118.3,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,250.12,
ZIMMER 11-363666 MODULAR HEAD COMP 36MM,C1776,HCPCS,,79011076,CDM,278,RC,,,both,,,1152,852.48,,,852.48,Other,150% of Medicare + 9.63% HCRA Surcharge,518.4,45,,518.4,percent of total billed charges,Critical Access Hospital RCC factor,391.68,34,,391.68,percent of total billed charges,Implant Device,391.68,34,,391.68,percent of total billed charges,Implant Device,391.68,34,,391.68,percent of total billed charges,Implant Device,391.68,34,,391.68,percent of total billed charges,Implant Device,391.68,34,,391.68,percent of total billed charges,Implant Device,570.24,,,570.24,Other,110% of Medicare,403.2,35,,403.2,percent of total billed charges,Implant Device,391.68,34,"Charges > $500, x 34%",391.68,percent of total billed charges,Implant Device,403.2,35,,403.2,percent of total billed charges,Implant Device,403.2,35,,403.2,percent of total billed charges,Implant Device,403.2,35,,403.2,percent of total billed charges,Implant Device,403.2,35,,403.2,percent of total billed charges,Implant Device,403.2,35,,403.2,percent of total billed charges,Implant Device,460.8,40,,460.8,percent of total billed charges,Implant Device,403.2,70,,403.2,percent of total billed charges,All Other,391.68,34,,391.68,percent of total billed charges,Implant Device,391.68,34,,391.68,percent of total billed charges,Implant Device,403.2,35,,403.2,percent of total billed charges,Implant Device,403.2,35,,403.2,percent of total billed charges,Implant Device,403.2,35,,403.2,percent of total billed charges,Implant Device,403.2,35,,403.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,852.48,
ZIMMER EP-108524 ACETABULAR LINER 40MM,C1776,HCPCS,,79011077,CDM,278,RC,,,both,,,3456,2557.45,,,2557.45,Other,150% of Medicare + 9.63% HCRA Surcharge,1555.2,45,,1555.2,percent of total billed charges,Critical Access Hospital RCC factor,1175.04,34,,1175.04,percent of total billed charges,Implant Device,1175.04,34,,1175.04,percent of total billed charges,Implant Device,1175.04,34,,1175.04,percent of total billed charges,Implant Device,1175.04,34,,1175.04,percent of total billed charges,Implant Device,1175.04,34,,1175.04,percent of total billed charges,Implant Device,1710.72,,,1710.72,Other,110% of Medicare,1209.6,35,,1209.6,percent of total billed charges,Implant Device,1175.04,34,"Charges > $500, x 34%",1175.04,percent of total billed charges,Implant Device,1209.6,35,,1209.6,percent of total billed charges,Implant Device,1209.6,35,,1209.6,percent of total billed charges,Implant Device,1209.6,35,,1209.6,percent of total billed charges,Implant Device,1209.6,35,,1209.6,percent of total billed charges,Implant Device,1209.6,35,,1209.6,percent of total billed charges,Implant Device,1382.4,40,,1382.4,percent of total billed charges,Implant Device,1209.6,70,,1209.6,percent of total billed charges,All Other,1175.04,34,,1175.04,percent of total billed charges,Implant Device,1175.04,34,,1175.04,percent of total billed charges,Implant Device,1209.6,35,,1209.6,percent of total billed charges,Implant Device,1209.6,35,,1209.6,percent of total billed charges,Implant Device,1209.6,35,,1209.6,percent of total billed charges,Implant Device,1209.6,35,,1209.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1175.04,34,"If Charge > 2,000, then 34 percent",1175.04,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2557.45,
ARTHREX AR-7267 FIBERTAPE CERCLAGESUTURE,C1713,HCPCS,,79011078,CDM,278,RC,,,both,,,1350,999,,,999,Other,150% of Medicare + 9.63% HCRA Surcharge,607.5,45,,607.5,percent of total billed charges,Critical Access Hospital RCC factor,459,34,,459,percent of total billed charges,Implant Device,459,34,,459,percent of total billed charges,Implant Device,459,34,,459,percent of total billed charges,Implant Device,459,34,,459,percent of total billed charges,Implant Device,459,34,,459,percent of total billed charges,Implant Device,668.25,,,668.25,Other,110% of Medicare,472.5,35,,472.5,percent of total billed charges,Implant Device,459,34,"Charges > $500, x 34%",459,percent of total billed charges,Implant Device,472.5,35,,472.5,percent of total billed charges,Implant Device,472.5,35,,472.5,percent of total billed charges,Implant Device,472.5,35,,472.5,percent of total billed charges,Implant Device,472.5,35,,472.5,percent of total billed charges,Implant Device,472.5,35,,472.5,percent of total billed charges,Implant Device,540,40,,540,percent of total billed charges,Implant Device,472.5,70,,472.5,percent of total billed charges,All Other,459,34,,459,percent of total billed charges,Implant Device,459,34,,459,percent of total billed charges,Implant Device,472.5,35,,472.5,percent of total billed charges,Implant Device,472.5,35,,472.5,percent of total billed charges,Implant Device,472.5,35,,472.5,percent of total billed charges,Implant Device,472.5,35,,472.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,999,
ARTHREX AR-7267T TIGERTAPE CERCLAGESUTUR,C1713,HCPCS,,79011079,CDM,278,RC,,,both,,,1350,999,,,999,Other,150% of Medicare + 9.63% HCRA Surcharge,607.5,45,,607.5,percent of total billed charges,Critical Access Hospital RCC factor,459,34,,459,percent of total billed charges,Implant Device,459,34,,459,percent of total billed charges,Implant Device,459,34,,459,percent of total billed charges,Implant Device,459,34,,459,percent of total billed charges,Implant Device,459,34,,459,percent of total billed charges,Implant Device,668.25,,,668.25,Other,110% of Medicare,472.5,35,,472.5,percent of total billed charges,Implant Device,459,34,"Charges > $500, x 34%",459,percent of total billed charges,Implant Device,472.5,35,,472.5,percent of total billed charges,Implant Device,472.5,35,,472.5,percent of total billed charges,Implant Device,472.5,35,,472.5,percent of total billed charges,Implant Device,472.5,35,,472.5,percent of total billed charges,Implant Device,472.5,35,,472.5,percent of total billed charges,Implant Device,540,40,,540,percent of total billed charges,Implant Device,472.5,70,,472.5,percent of total billed charges,All Other,459,34,,459,percent of total billed charges,Implant Device,459,34,,459,percent of total billed charges,Implant Device,472.5,35,,472.5,percent of total billed charges,Implant Device,472.5,35,,472.5,percent of total billed charges,Implant Device,472.5,35,,472.5,percent of total billed charges,Implant Device,472.5,35,,472.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,999,
DEPUY SYNTHES 04.037.042S NAIL 10X170MM,C1713,HCPCS,,79011082,CDM,278,RC,,,both,,,3718,2751.33,,,2751.33,Other,150% of Medicare + 9.63% HCRA Surcharge,1673.1,45,,1673.1,percent of total billed charges,Critical Access Hospital RCC factor,1264.12,34,,1264.12,percent of total billed charges,Implant Device,1264.12,34,,1264.12,percent of total billed charges,Implant Device,1264.12,34,,1264.12,percent of total billed charges,Implant Device,1264.12,34,,1264.12,percent of total billed charges,Implant Device,1264.12,34,,1264.12,percent of total billed charges,Implant Device,1840.41,,,1840.41,Other,110% of Medicare,1301.3,35,,1301.3,percent of total billed charges,Implant Device,1264.12,34,"Charges > $500, x 34%",1264.12,percent of total billed charges,Implant Device,1301.3,35,,1301.3,percent of total billed charges,Implant Device,1301.3,35,,1301.3,percent of total billed charges,Implant Device,1301.3,35,,1301.3,percent of total billed charges,Implant Device,1301.3,35,,1301.3,percent of total billed charges,Implant Device,1301.3,35,,1301.3,percent of total billed charges,Implant Device,1487.2,40,,1487.2,percent of total billed charges,Implant Device,1301.3,70,,1301.3,percent of total billed charges,All Other,1264.12,34,,1264.12,percent of total billed charges,Implant Device,1264.12,34,,1264.12,percent of total billed charges,Implant Device,1301.3,35,,1301.3,percent of total billed charges,Implant Device,1301.3,35,,1301.3,percent of total billed charges,Implant Device,1301.3,35,,1301.3,percent of total billed charges,Implant Device,1301.3,35,,1301.3,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1264.12,34,"If Charge > 2,000, then 34 percent",1264.12,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2751.33,
ARTHREX AR-8935L-10 LOCK SCREW 3.5X10MM,C1713,HCPCS,,79011083,CDM,278,RC,,,both,,,645,477.3,,,477.3,Other,150% of Medicare + 9.63% HCRA Surcharge,290.25,45,,290.25,percent of total billed charges,Critical Access Hospital RCC factor,219.3,34,,219.3,percent of total billed charges,Implant Device,219.3,34,,219.3,percent of total billed charges,Implant Device,219.3,34,,219.3,percent of total billed charges,Implant Device,219.3,34,,219.3,percent of total billed charges,Implant Device,219.3,34,,219.3,percent of total billed charges,Implant Device,319.28,,,319.28,Other,110% of Medicare,225.75,35,,225.75,percent of total billed charges,Implant Device,219.3,34,"Charges > $500, x 34%",219.3,percent of total billed charges,Implant Device,225.75,35,,225.75,percent of total billed charges,Implant Device,225.75,35,,225.75,percent of total billed charges,Implant Device,225.75,35,,225.75,percent of total billed charges,Implant Device,225.75,35,,225.75,percent of total billed charges,Implant Device,225.75,35,,225.75,percent of total billed charges,Implant Device,258,40,,258,percent of total billed charges,Implant Device,225.75,70,,225.75,percent of total billed charges,All Other,219.3,34,,219.3,percent of total billed charges,Implant Device,219.3,34,,219.3,percent of total billed charges,Implant Device,225.75,35,,225.75,percent of total billed charges,Implant Device,225.75,35,,225.75,percent of total billed charges,Implant Device,225.75,35,,225.75,percent of total billed charges,Implant Device,225.75,35,,225.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,477.3,
ARTHREX AR-8935L-12 LOCK SCREW 3.5X12MM,C1713,HCPCS,,79011084,CDM,278,RC,,,both,,,450,333,,,333,Other,150% of Medicare + 9.63% HCRA Surcharge,202.5,45,,202.5,percent of total billed charges,Critical Access Hospital RCC factor,153,34,,153,percent of total billed charges,Implant Device,153,34,,153,percent of total billed charges,Implant Device,153,34,,153,percent of total billed charges,Implant Device,153,34,,153,percent of total billed charges,Implant Device,153,34,,153,percent of total billed charges,Implant Device,222.75,,,222.75,Other,110% of Medicare,157.5,35,,157.5,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,157.5,35,,157.5,percent of total billed charges,Implant Device,157.5,35,,157.5,percent of total billed charges,Implant Device,157.5,35,,157.5,percent of total billed charges,Implant Device,157.5,35,,157.5,percent of total billed charges,Implant Device,157.5,35,,157.5,percent of total billed charges,Implant Device,180,40,,180,percent of total billed charges,Implant Device,157.5,70,,157.5,percent of total billed charges,All Other,153,34,,153,percent of total billed charges,Implant Device,153,34,,153,percent of total billed charges,Implant Device,157.5,35,,157.5,percent of total billed charges,Implant Device,157.5,35,,157.5,percent of total billed charges,Implant Device,157.5,35,,157.5,percent of total billed charges,Implant Device,157.5,35,,157.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,333,
ARTHREX AR-8940-14 4.0X14MM,C1713,HCPCS,,79011085,CDM,278,RC,,,both,,,258,190.92,,,190.92,Other,150% of Medicare + 9.63% HCRA Surcharge,116.1,45,,116.1,percent of total billed charges,Critical Access Hospital RCC factor,87.72,34,,87.72,percent of total billed charges,Implant Device,87.72,34,,87.72,percent of total billed charges,Implant Device,87.72,34,,87.72,percent of total billed charges,Implant Device,87.72,34,,87.72,percent of total billed charges,Implant Device,87.72,34,,87.72,percent of total billed charges,Implant Device,127.71,,,127.71,Other,110% of Medicare,90.3,35,,90.3,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,90.3,35,,90.3,percent of total billed charges,Implant Device,90.3,35,,90.3,percent of total billed charges,Implant Device,90.3,35,,90.3,percent of total billed charges,Implant Device,90.3,35,,90.3,percent of total billed charges,Implant Device,90.3,35,,90.3,percent of total billed charges,Implant Device,103.2,40,,103.2,percent of total billed charges,Implant Device,90.3,70,,90.3,percent of total billed charges,All Other,87.72,34,,87.72,percent of total billed charges,Implant Device,87.72,34,,87.72,percent of total billed charges,Implant Device,90.3,35,,90.3,percent of total billed charges,Implant Device,90.3,35,,90.3,percent of total billed charges,Implant Device,90.3,35,,90.3,percent of total billed charges,Implant Device,90.3,35,,90.3,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,190.92,
ARTHREX AR-9943T-08 TUBULAR PLATE 8H,C1713,HCPCS,,79011086,CDM,278,RC,,,both,,,1137,841.38,,,841.38,Other,150% of Medicare + 9.63% HCRA Surcharge,511.65,45,,511.65,percent of total billed charges,Critical Access Hospital RCC factor,386.58,34,,386.58,percent of total billed charges,Implant Device,386.58,34,,386.58,percent of total billed charges,Implant Device,386.58,34,,386.58,percent of total billed charges,Implant Device,386.58,34,,386.58,percent of total billed charges,Implant Device,386.58,34,,386.58,percent of total billed charges,Implant Device,562.82,,,562.82,Other,110% of Medicare,397.95,35,,397.95,percent of total billed charges,Implant Device,386.58,34,"Charges > $500, x 34%",386.58,percent of total billed charges,Implant Device,397.95,35,,397.95,percent of total billed charges,Implant Device,397.95,35,,397.95,percent of total billed charges,Implant Device,397.95,35,,397.95,percent of total billed charges,Implant Device,397.95,35,,397.95,percent of total billed charges,Implant Device,397.95,35,,397.95,percent of total billed charges,Implant Device,454.8,40,,454.8,percent of total billed charges,Implant Device,397.95,70,,397.95,percent of total billed charges,All Other,386.58,34,,386.58,percent of total billed charges,Implant Device,386.58,34,,386.58,percent of total billed charges,Implant Device,397.95,35,,397.95,percent of total billed charges,Implant Device,397.95,35,,397.95,percent of total billed charges,Implant Device,397.95,35,,397.95,percent of total billed charges,Implant Device,397.95,35,,397.95,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,841.38,
STRYKER 7512-21646LO-G3 CORPECTMY W/SCRE,C1713,HCPCS,,79011089,CDM,278,RC,,,both,,,22050,16317.06,,,16317.06,Other,150% of Medicare + 9.63% HCRA Surcharge,9922.5,45,,9922.5,percent of total billed charges,Critical Access Hospital RCC factor,7497,34,,7497,percent of total billed charges,Implant Device,7497,34,,7497,percent of total billed charges,Implant Device,7497,34,,7497,percent of total billed charges,Implant Device,7497,34,,7497,percent of total billed charges,Implant Device,7497,34,,7497,percent of total billed charges,Implant Device,10914.75,,,10914.75,Other,110% of Medicare,7717.5,35,,7717.5,percent of total billed charges,Implant Device,7497,34,"Charges > $500, x 34%",7497,percent of total billed charges,Implant Device,7717.5,35,,7717.5,percent of total billed charges,Implant Device,7717.5,35,,7717.5,percent of total billed charges,Implant Device,7717.5,35,,7717.5,percent of total billed charges,Implant Device,7717.5,35,,7717.5,percent of total billed charges,Implant Device,7717.5,35,,7717.5,percent of total billed charges,Implant Device,8820,40,,8820,percent of total billed charges,Implant Device,7717.5,70,,7717.5,percent of total billed charges,All Other,7497,34,,7497,percent of total billed charges,Implant Device,7497,34,,7497,percent of total billed charges,Implant Device,7717.5,35,,7717.5,percent of total billed charges,Implant Device,7717.5,35,,7717.5,percent of total billed charges,Implant Device,7717.5,35,,7717.5,percent of total billed charges,Implant Device,7717.5,35,,7717.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,7497,34,"If Charge > 2,000, then 34 percent",7497,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,16317.06,
STRYKER 2102-1905 VITOSS FOAM PACK 5CC,C1713,HCPCS,,79011090,CDM,278,RC,,,both,,,4505,3333.71,,,3333.71,Other,150% of Medicare + 9.63% HCRA Surcharge,2027.25,45,,2027.25,percent of total billed charges,Critical Access Hospital RCC factor,1531.7,34,,1531.7,percent of total billed charges,Implant Device,1531.7,34,,1531.7,percent of total billed charges,Implant Device,1531.7,34,,1531.7,percent of total billed charges,Implant Device,1531.7,34,,1531.7,percent of total billed charges,Implant Device,1531.7,34,,1531.7,percent of total billed charges,Implant Device,2229.98,,,2229.98,Other,110% of Medicare,1576.75,35,,1576.75,percent of total billed charges,Implant Device,1531.7,34,"Charges > $500, x 34%",1531.7,percent of total billed charges,Implant Device,1576.75,35,,1576.75,percent of total billed charges,Implant Device,1576.75,35,,1576.75,percent of total billed charges,Implant Device,1576.75,35,,1576.75,percent of total billed charges,Implant Device,1576.75,35,,1576.75,percent of total billed charges,Implant Device,1576.75,35,,1576.75,percent of total billed charges,Implant Device,1802,40,,1802,percent of total billed charges,Implant Device,1576.75,70,,1576.75,percent of total billed charges,All Other,1531.7,34,,1531.7,percent of total billed charges,Implant Device,1531.7,34,,1531.7,percent of total billed charges,Implant Device,1576.75,35,,1576.75,percent of total billed charges,Implant Device,1576.75,35,,1576.75,percent of total billed charges,Implant Device,1576.75,35,,1576.75,percent of total billed charges,Implant Device,1576.75,35,,1576.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1531.7,34,"If Charge > 2,000, then 34 percent",1531.7,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3333.71,
STRYKER AA01-45F52V 2 LEVEL PLATE 52MM,C1713,HCPCS,,79011091,CDM,278,RC,,,both,,,3825,2830.51,,,2830.51,Other,150% of Medicare + 9.63% HCRA Surcharge,1721.25,45,,1721.25,percent of total billed charges,Critical Access Hospital RCC factor,1300.5,34,,1300.5,percent of total billed charges,Implant Device,1300.5,34,,1300.5,percent of total billed charges,Implant Device,1300.5,34,,1300.5,percent of total billed charges,Implant Device,1300.5,34,,1300.5,percent of total billed charges,Implant Device,1300.5,34,,1300.5,percent of total billed charges,Implant Device,1893.38,,,1893.38,Other,110% of Medicare,1338.75,35,,1338.75,percent of total billed charges,Implant Device,1300.5,34,"Charges > $500, x 34%",1300.5,percent of total billed charges,Implant Device,1338.75,35,,1338.75,percent of total billed charges,Implant Device,1338.75,35,,1338.75,percent of total billed charges,Implant Device,1338.75,35,,1338.75,percent of total billed charges,Implant Device,1338.75,35,,1338.75,percent of total billed charges,Implant Device,1338.75,35,,1338.75,percent of total billed charges,Implant Device,1530,40,,1530,percent of total billed charges,Implant Device,1338.75,70,,1338.75,percent of total billed charges,All Other,1300.5,34,,1300.5,percent of total billed charges,Implant Device,1300.5,34,,1300.5,percent of total billed charges,Implant Device,1338.75,35,,1338.75,percent of total billed charges,Implant Device,1338.75,35,,1338.75,percent of total billed charges,Implant Device,1338.75,35,,1338.75,percent of total billed charges,Implant Device,1338.75,35,,1338.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1300.5,34,"If Charge > 2,000, then 34 percent",1300.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2830.51,
DEPUY 04.038.395S HELICAL BLADE 95MM,C1713,HCPCS,,79011093,CDM,278,RC,,,both,,,1766,1306.84,,,1306.84,Other,150% of Medicare + 9.63% HCRA Surcharge,794.7,45,,794.7,percent of total billed charges,Critical Access Hospital RCC factor,600.44,34,,600.44,percent of total billed charges,Implant Device,600.44,34,,600.44,percent of total billed charges,Implant Device,600.44,34,,600.44,percent of total billed charges,Implant Device,600.44,34,,600.44,percent of total billed charges,Implant Device,600.44,34,,600.44,percent of total billed charges,Implant Device,874.17,,,874.17,Other,110% of Medicare,618.1,35,,618.1,percent of total billed charges,Implant Device,600.44,34,"Charges > $500, x 34%",600.44,percent of total billed charges,Implant Device,618.1,35,,618.1,percent of total billed charges,Implant Device,618.1,35,,618.1,percent of total billed charges,Implant Device,618.1,35,,618.1,percent of total billed charges,Implant Device,618.1,35,,618.1,percent of total billed charges,Implant Device,618.1,35,,618.1,percent of total billed charges,Implant Device,706.4,40,,706.4,percent of total billed charges,Implant Device,618.1,70,,618.1,percent of total billed charges,All Other,600.44,34,,600.44,percent of total billed charges,Implant Device,600.44,34,,600.44,percent of total billed charges,Implant Device,618.1,35,,618.1,percent of total billed charges,Implant Device,618.1,35,,618.1,percent of total billed charges,Implant Device,618.1,35,,618.1,percent of total billed charges,Implant Device,618.1,35,,618.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1306.84,
ZIMMER 42-5121-009-11 ARTICULR SURF LT 8,C1776,HCPCS,,79011094,CDM,278,RC,,,both,,,3648,2699.53,,,2699.53,Other,150% of Medicare + 9.63% HCRA Surcharge,1641.6,45,,1641.6,percent of total billed charges,Critical Access Hospital RCC factor,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1805.76,,,1805.76,Other,110% of Medicare,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1240.32,34,"Charges > $500, x 34%",1240.32,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1459.2,40,,1459.2,percent of total billed charges,Implant Device,1276.8,70,,1276.8,percent of total billed charges,All Other,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1240.32,34,"If Charge > 2,000, then 34 percent",1240.32,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2699.53,
ZIMMER 42-5400-000-35 PATELLA 35X9MM,C1776,HCPCS,,79011095,CDM,278,RC,,,both,,,1539,1138.86,,,1138.86,Other,150% of Medicare + 9.63% HCRA Surcharge,692.55,45,,692.55,percent of total billed charges,Critical Access Hospital RCC factor,523.26,34,,523.26,percent of total billed charges,Implant Device,523.26,34,,523.26,percent of total billed charges,Implant Device,523.26,34,,523.26,percent of total billed charges,Implant Device,523.26,34,,523.26,percent of total billed charges,Implant Device,523.26,34,,523.26,percent of total billed charges,Implant Device,761.81,,,761.81,Other,110% of Medicare,538.65,35,,538.65,percent of total billed charges,Implant Device,523.26,34,"Charges > $500, x 34%",523.26,percent of total billed charges,Implant Device,538.65,35,,538.65,percent of total billed charges,Implant Device,538.65,35,,538.65,percent of total billed charges,Implant Device,538.65,35,,538.65,percent of total billed charges,Implant Device,538.65,35,,538.65,percent of total billed charges,Implant Device,538.65,35,,538.65,percent of total billed charges,Implant Device,615.6,40,,615.6,percent of total billed charges,Implant Device,538.65,70,,538.65,percent of total billed charges,All Other,523.26,34,,523.26,percent of total billed charges,Implant Device,523.26,34,,523.26,percent of total billed charges,Implant Device,538.65,35,,538.65,percent of total billed charges,Implant Device,538.65,35,,538.65,percent of total billed charges,Implant Device,538.65,35,,538.65,percent of total billed charges,Implant Device,538.65,35,,538.65,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1138.86,
ZIMMER 42-5320-079-01 TIBIA 5 DEG SZ G,C1776,HCPCS,,79011096,CDM,278,RC,,,both,,,4433,3280.43,,,3280.43,Other,150% of Medicare + 9.63% HCRA Surcharge,1994.85,45,,1994.85,percent of total billed charges,Critical Access Hospital RCC factor,1507.22,34,,1507.22,percent of total billed charges,Implant Device,1507.22,34,,1507.22,percent of total billed charges,Implant Device,1507.22,34,,1507.22,percent of total billed charges,Implant Device,1507.22,34,,1507.22,percent of total billed charges,Implant Device,1507.22,34,,1507.22,percent of total billed charges,Implant Device,2194.34,,,2194.34,Other,110% of Medicare,1551.55,35,,1551.55,percent of total billed charges,Implant Device,1507.22,34,"Charges > $500, x 34%",1507.22,percent of total billed charges,Implant Device,1551.55,35,,1551.55,percent of total billed charges,Implant Device,1551.55,35,,1551.55,percent of total billed charges,Implant Device,1551.55,35,,1551.55,percent of total billed charges,Implant Device,1551.55,35,,1551.55,percent of total billed charges,Implant Device,1551.55,35,,1551.55,percent of total billed charges,Implant Device,1773.2,40,,1773.2,percent of total billed charges,Implant Device,1551.55,70,,1551.55,percent of total billed charges,All Other,1507.22,34,,1507.22,percent of total billed charges,Implant Device,1507.22,34,,1507.22,percent of total billed charges,Implant Device,1551.55,35,,1551.55,percent of total billed charges,Implant Device,1551.55,35,,1551.55,percent of total billed charges,Implant Device,1551.55,35,,1551.55,percent of total billed charges,Implant Device,1551.55,35,,1551.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1507.22,34,"If Charge > 2,000, then 34 percent",1507.22,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3280.43,
ZIMMER 42-5026-070-01 FEMUR LEFT SZ 11,C1776,HCPCS,,79011097,CDM,278,RC,,,both,,,10200,7548.03,,,7548.03,Other,150% of Medicare + 9.63% HCRA Surcharge,4590,45,,4590,percent of total billed charges,Critical Access Hospital RCC factor,3468,34,,3468,percent of total billed charges,Implant Device,3468,34,,3468,percent of total billed charges,Implant Device,3468,34,,3468,percent of total billed charges,Implant Device,3468,34,,3468,percent of total billed charges,Implant Device,3468,34,,3468,percent of total billed charges,Implant Device,5049,,,5049,Other,110% of Medicare,3570,35,,3570,percent of total billed charges,Implant Device,3468,34,"Charges > $500, x 34%",3468,percent of total billed charges,Implant Device,3570,35,,3570,percent of total billed charges,Implant Device,3570,35,,3570,percent of total billed charges,Implant Device,3570,35,,3570,percent of total billed charges,Implant Device,3570,35,,3570,percent of total billed charges,Implant Device,3570,35,,3570,percent of total billed charges,Implant Device,4080,40,,4080,percent of total billed charges,Implant Device,3570,70,,3570,percent of total billed charges,All Other,3468,34,,3468,percent of total billed charges,Implant Device,3468,34,,3468,percent of total billed charges,Implant Device,3570,35,,3570,percent of total billed charges,Implant Device,3570,35,,3570,percent of total billed charges,Implant Device,3570,35,,3570,percent of total billed charges,Implant Device,3570,35,,3570,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3468,34,"If Charge > 2,000, then 34 percent",3468,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,7548.03,
ZIMMER 574202030 FEMORAL STEM 12/14 SZ 3,C1776,HCPCS,,79011098,CDM,278,RC,,,both,,,6912,5114.9,,,5114.9,Other,150% of Medicare + 9.63% HCRA Surcharge,3110.4,45,,3110.4,percent of total billed charges,Critical Access Hospital RCC factor,2350.08,34,,2350.08,percent of total billed charges,Implant Device,2350.08,34,,2350.08,percent of total billed charges,Implant Device,2350.08,34,,2350.08,percent of total billed charges,Implant Device,2350.08,34,,2350.08,percent of total billed charges,Implant Device,2350.08,34,,2350.08,percent of total billed charges,Implant Device,3421.44,,,3421.44,Other,110% of Medicare,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2350.08,34,"Charges > $500, x 34%",2350.08,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2764.8,40,,2764.8,percent of total billed charges,Implant Device,2419.2,70,,2419.2,percent of total billed charges,All Other,2350.08,34,,2350.08,percent of total billed charges,Implant Device,2350.08,34,,2350.08,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2350.08,34,"If Charge > 2,000, then 34 percent",2350.08,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5114.9,
STRYKER 657126 BONE SCREW 2.7X26MM,C1713,HCPCS,,79011099,CDM,278,RC,,,both,,,294,217.56,,,217.56,Other,150% of Medicare + 9.63% HCRA Surcharge,132.3,45,,132.3,percent of total billed charges,Critical Access Hospital RCC factor,99.96,34,,99.96,percent of total billed charges,Implant Device,99.96,34,,99.96,percent of total billed charges,Implant Device,99.96,34,,99.96,percent of total billed charges,Implant Device,99.96,34,,99.96,percent of total billed charges,Implant Device,99.96,34,,99.96,percent of total billed charges,Implant Device,145.53,,,145.53,Other,110% of Medicare,102.9,35,,102.9,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,102.9,35,,102.9,percent of total billed charges,Implant Device,102.9,35,,102.9,percent of total billed charges,Implant Device,102.9,35,,102.9,percent of total billed charges,Implant Device,102.9,35,,102.9,percent of total billed charges,Implant Device,102.9,35,,102.9,percent of total billed charges,Implant Device,117.6,40,,117.6,percent of total billed charges,Implant Device,102.9,70,,102.9,percent of total billed charges,All Other,99.96,34,,99.96,percent of total billed charges,Implant Device,99.96,34,,99.96,percent of total billed charges,Implant Device,102.9,35,,102.9,percent of total billed charges,Implant Device,102.9,35,,102.9,percent of total billed charges,Implant Device,102.9,35,,102.9,percent of total billed charges,Implant Device,102.9,35,,102.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,217.56,
EXACTECH 314-13-34 POSTERIOR AUGMENT,C1713,HCPCS,,79011101,CDM,278,RC,,,both,,,4725,3496.51,,,3496.51,Other,150% of Medicare + 9.63% HCRA Surcharge,2126.25,45,,2126.25,percent of total billed charges,Critical Access Hospital RCC factor,1606.5,34,,1606.5,percent of total billed charges,Implant Device,1606.5,34,,1606.5,percent of total billed charges,Implant Device,1606.5,34,,1606.5,percent of total billed charges,Implant Device,1606.5,34,,1606.5,percent of total billed charges,Implant Device,1606.5,34,,1606.5,percent of total billed charges,Implant Device,2338.88,,,2338.88,Other,110% of Medicare,1653.75,35,,1653.75,percent of total billed charges,Implant Device,1606.5,34,"Charges > $500, x 34%",1606.5,percent of total billed charges,Implant Device,1653.75,35,,1653.75,percent of total billed charges,Implant Device,1653.75,35,,1653.75,percent of total billed charges,Implant Device,1653.75,35,,1653.75,percent of total billed charges,Implant Device,1653.75,35,,1653.75,percent of total billed charges,Implant Device,1653.75,35,,1653.75,percent of total billed charges,Implant Device,1890,40,,1890,percent of total billed charges,Implant Device,1653.75,70,,1653.75,percent of total billed charges,All Other,1606.5,34,,1606.5,percent of total billed charges,Implant Device,1606.5,34,,1606.5,percent of total billed charges,Implant Device,1653.75,35,,1653.75,percent of total billed charges,Implant Device,1653.75,35,,1653.75,percent of total billed charges,Implant Device,1653.75,35,,1653.75,percent of total billed charges,Implant Device,1653.75,35,,1653.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1606.5,34,"If Charge > 2,000, then 34 percent",1606.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3496.51,
EXACTECH 300-30-07 HUMERAL STEM 7MM,C1776,HCPCS,,79011102,CDM,278,RC,,,both,,,6000,4440.02,,,4440.02,Other,150% of Medicare + 9.63% HCRA Surcharge,2700,45,,2700,percent of total billed charges,Critical Access Hospital RCC factor,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2970,,,2970,Other,110% of Medicare,2100,35,,2100,percent of total billed charges,Implant Device,2040,34,"Charges > $500, x 34%",2040,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2400,40,,2400,percent of total billed charges,Implant Device,2100,70,,2100,percent of total billed charges,All Other,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2040,34,"If Charge > 2,000, then 34 percent",2040,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4440.02,
STRYKER 6720-0635 HIP STEM 132 DEGREE,C1776,HCPCS,,79011103,CDM,278,RC,,,both,,,6953,5145.24,,,5145.24,Other,150% of Medicare + 9.63% HCRA Surcharge,3128.85,45,,3128.85,percent of total billed charges,Critical Access Hospital RCC factor,2364.02,34,,2364.02,percent of total billed charges,Implant Device,2364.02,34,,2364.02,percent of total billed charges,Implant Device,2364.02,34,,2364.02,percent of total billed charges,Implant Device,2364.02,34,,2364.02,percent of total billed charges,Implant Device,2364.02,34,,2364.02,percent of total billed charges,Implant Device,3441.74,,,3441.74,Other,110% of Medicare,2433.55,35,,2433.55,percent of total billed charges,Implant Device,2364.02,34,"Charges > $500, x 34%",2364.02,percent of total billed charges,Implant Device,2433.55,35,,2433.55,percent of total billed charges,Implant Device,2433.55,35,,2433.55,percent of total billed charges,Implant Device,2433.55,35,,2433.55,percent of total billed charges,Implant Device,2433.55,35,,2433.55,percent of total billed charges,Implant Device,2433.55,35,,2433.55,percent of total billed charges,Implant Device,2781.2,40,,2781.2,percent of total billed charges,Implant Device,2433.55,70,,2433.55,percent of total billed charges,All Other,2364.02,34,,2364.02,percent of total billed charges,Implant Device,2364.02,34,,2364.02,percent of total billed charges,Implant Device,2433.55,35,,2433.55,percent of total billed charges,Implant Device,2433.55,35,,2433.55,percent of total billed charges,Implant Device,2433.55,35,,2433.55,percent of total billed charges,Implant Device,2433.55,35,,2433.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2364.02,34,"If Charge > 2,000, then 34 percent",2364.02,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5145.24,
STRYKER UH1-43-26 UNIVERSAL HEAD 43X26MM,C1776,HCPCS,,79011104,CDM,278,RC,,,both,,,1391,1029.34,,,1029.34,Other,150% of Medicare + 9.63% HCRA Surcharge,625.95,45,,625.95,percent of total billed charges,Critical Access Hospital RCC factor,472.94,34,,472.94,percent of total billed charges,Implant Device,472.94,34,,472.94,percent of total billed charges,Implant Device,472.94,34,,472.94,percent of total billed charges,Implant Device,472.94,34,,472.94,percent of total billed charges,Implant Device,472.94,34,,472.94,percent of total billed charges,Implant Device,688.55,,,688.55,Other,110% of Medicare,486.85,35,,486.85,percent of total billed charges,Implant Device,472.94,34,"Charges > $500, x 34%",472.94,percent of total billed charges,Implant Device,486.85,35,,486.85,percent of total billed charges,Implant Device,486.85,35,,486.85,percent of total billed charges,Implant Device,486.85,35,,486.85,percent of total billed charges,Implant Device,486.85,35,,486.85,percent of total billed charges,Implant Device,486.85,35,,486.85,percent of total billed charges,Implant Device,556.4,40,,556.4,percent of total billed charges,Implant Device,486.85,70,,486.85,percent of total billed charges,All Other,472.94,34,,472.94,percent of total billed charges,Implant Device,472.94,34,,472.94,percent of total billed charges,Implant Device,486.85,35,,486.85,percent of total billed charges,Implant Device,486.85,35,,486.85,percent of total billed charges,Implant Device,486.85,35,,486.85,percent of total billed charges,Implant Device,486.85,35,,486.85,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1029.34,
STRYKER 5552-S-4020 HUM HEAD SZ 40X20MM,C1776,HCPCS,,79011105,CDM,278,RC,,,both,,,3675,2719.51,,,2719.51,Other,150% of Medicare + 9.63% HCRA Surcharge,1653.75,45,,1653.75,percent of total billed charges,Critical Access Hospital RCC factor,1249.5,34,,1249.5,percent of total billed charges,Implant Device,1249.5,34,,1249.5,percent of total billed charges,Implant Device,1249.5,34,,1249.5,percent of total billed charges,Implant Device,1249.5,34,,1249.5,percent of total billed charges,Implant Device,1249.5,34,,1249.5,percent of total billed charges,Implant Device,1819.13,,,1819.13,Other,110% of Medicare,1286.25,35,,1286.25,percent of total billed charges,Implant Device,1249.5,34,"Charges > $500, x 34%",1249.5,percent of total billed charges,Implant Device,1286.25,35,,1286.25,percent of total billed charges,Implant Device,1286.25,35,,1286.25,percent of total billed charges,Implant Device,1286.25,35,,1286.25,percent of total billed charges,Implant Device,1286.25,35,,1286.25,percent of total billed charges,Implant Device,1286.25,35,,1286.25,percent of total billed charges,Implant Device,1470,40,,1470,percent of total billed charges,Implant Device,1286.25,70,,1286.25,percent of total billed charges,All Other,1249.5,34,,1249.5,percent of total billed charges,Implant Device,1249.5,34,,1249.5,percent of total billed charges,Implant Device,1286.25,35,,1286.25,percent of total billed charges,Implant Device,1286.25,35,,1286.25,percent of total billed charges,Implant Device,1286.25,35,,1286.25,percent of total billed charges,Implant Device,1286.25,35,,1286.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1249.5,34,"If Charge > 2,000, then 34 percent",1249.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2719.51,
ACUMED CO-N2320 NON TOGGLING SCRW 2.3X20,C1713,HCPCS,,79011106,CDM,278,RC,,,both,,,324,239.76,,,239.76,Other,150% of Medicare + 9.63% HCRA Surcharge,145.8,45,,145.8,percent of total billed charges,Critical Access Hospital RCC factor,110.16,34,,110.16,percent of total billed charges,Implant Device,110.16,34,,110.16,percent of total billed charges,Implant Device,110.16,34,,110.16,percent of total billed charges,Implant Device,110.16,34,,110.16,percent of total billed charges,Implant Device,110.16,34,,110.16,percent of total billed charges,Implant Device,160.38,,,160.38,Other,110% of Medicare,113.4,35,,113.4,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,129.6,40,,129.6,percent of total billed charges,Implant Device,113.4,70,,113.4,percent of total billed charges,All Other,110.16,34,,110.16,percent of total billed charges,Implant Device,110.16,34,,110.16,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,239.76,
ARTHREX AR-8730-24PT PT SCREW 3.0X24MM,C1713,HCPCS,,79011107,CDM,278,RC,,,both,,,488,361.12,,,361.12,Other,150% of Medicare + 9.63% HCRA Surcharge,219.6,45,,219.6,percent of total billed charges,Critical Access Hospital RCC factor,165.92,34,,165.92,percent of total billed charges,Implant Device,165.92,34,,165.92,percent of total billed charges,Implant Device,165.92,34,,165.92,percent of total billed charges,Implant Device,165.92,34,,165.92,percent of total billed charges,Implant Device,165.92,34,,165.92,percent of total billed charges,Implant Device,241.56,,,241.56,Other,110% of Medicare,170.8,35,,170.8,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,170.8,35,,170.8,percent of total billed charges,Implant Device,170.8,35,,170.8,percent of total billed charges,Implant Device,170.8,35,,170.8,percent of total billed charges,Implant Device,170.8,35,,170.8,percent of total billed charges,Implant Device,170.8,35,,170.8,percent of total billed charges,Implant Device,195.2,40,,195.2,percent of total billed charges,Implant Device,170.8,70,,170.8,percent of total billed charges,All Other,165.92,34,,165.92,percent of total billed charges,Implant Device,165.92,34,,165.92,percent of total billed charges,Implant Device,170.8,35,,170.8,percent of total billed charges,Implant Device,170.8,35,,170.8,percent of total billed charges,Implant Device,170.8,35,,170.8,percent of total billed charges,Implant Device,170.8,35,,170.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,361.12,
ARTHREX AR-8730-20PT PT SCREW 3.0X20MM,C1713,HCPCS,,79011108,CDM,278,RC,,,both,,,450,333,,,333,Other,150% of Medicare + 9.63% HCRA Surcharge,202.5,45,,202.5,percent of total billed charges,Critical Access Hospital RCC factor,153,34,,153,percent of total billed charges,Implant Device,153,34,,153,percent of total billed charges,Implant Device,153,34,,153,percent of total billed charges,Implant Device,153,34,,153,percent of total billed charges,Implant Device,153,34,,153,percent of total billed charges,Implant Device,222.75,,,222.75,Other,110% of Medicare,157.5,35,,157.5,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,157.5,35,,157.5,percent of total billed charges,Implant Device,157.5,35,,157.5,percent of total billed charges,Implant Device,157.5,35,,157.5,percent of total billed charges,Implant Device,157.5,35,,157.5,percent of total billed charges,Implant Device,157.5,35,,157.5,percent of total billed charges,Implant Device,180,40,,180,percent of total billed charges,Implant Device,157.5,70,,157.5,percent of total billed charges,All Other,153,34,,153,percent of total billed charges,Implant Device,153,34,,153,percent of total billed charges,Implant Device,157.5,35,,157.5,percent of total billed charges,Implant Device,157.5,35,,157.5,percent of total billed charges,Implant Device,157.5,35,,157.5,percent of total billed charges,Implant Device,157.5,35,,157.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,333,
ARTHREX AR-8944-P MTP SHORT PLATE,C1713,HCPCS,,79011109,CDM,278,RC,,,both,,,2685,1986.91,,,1986.91,Other,150% of Medicare + 9.63% HCRA Surcharge,1208.25,45,,1208.25,percent of total billed charges,Critical Access Hospital RCC factor,912.9,34,,912.9,percent of total billed charges,Implant Device,912.9,34,,912.9,percent of total billed charges,Implant Device,912.9,34,,912.9,percent of total billed charges,Implant Device,912.9,34,,912.9,percent of total billed charges,Implant Device,912.9,34,,912.9,percent of total billed charges,Implant Device,1329.08,,,1329.08,Other,110% of Medicare,939.75,35,,939.75,percent of total billed charges,Implant Device,912.9,34,"Charges > $500, x 34%",912.9,percent of total billed charges,Implant Device,939.75,35,,939.75,percent of total billed charges,Implant Device,939.75,35,,939.75,percent of total billed charges,Implant Device,939.75,35,,939.75,percent of total billed charges,Implant Device,939.75,35,,939.75,percent of total billed charges,Implant Device,939.75,35,,939.75,percent of total billed charges,Implant Device,1074,40,,1074,percent of total billed charges,Implant Device,939.75,70,,939.75,percent of total billed charges,All Other,912.9,34,,912.9,percent of total billed charges,Implant Device,912.9,34,,912.9,percent of total billed charges,Implant Device,939.75,35,,939.75,percent of total billed charges,Implant Device,939.75,35,,939.75,percent of total billed charges,Implant Device,939.75,35,,939.75,percent of total billed charges,Implant Device,939.75,35,,939.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,912.9,34,"If Charge > 2,000, then 34 percent",912.9,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1986.91,
PHILIPS 88901 PV .035 DIGITAL IVUS CATH,C1753,HCPCS,,79011110,CDM,278,RC,,,both,,,2850,2109.01,,,2109.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1282.5,45,,1282.5,percent of total billed charges,Critical Access Hospital RCC factor,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,1410.75,,,1410.75,Other,110% of Medicare,997.5,35,,997.5,percent of total billed charges,Implant Device,969,34,"Charges > $500, x 34%",969,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,1140,40,,1140,percent of total billed charges,Implant Device,997.5,70,,997.5,percent of total billed charges,All Other,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,969,34,"If Charge > 2,000, then 34 percent",969,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2109.01,
PHILIPS 014R PV .014P DIGITAL IVUS CATH,C1753,HCPCS,,79011111,CDM,278,RC,,,both,,,2625,1942.51,,,1942.51,Other,150% of Medicare + 9.63% HCRA Surcharge,1181.25,45,,1181.25,percent of total billed charges,Critical Access Hospital RCC factor,892.5,34,,892.5,percent of total billed charges,Implant Device,892.5,34,,892.5,percent of total billed charges,Implant Device,892.5,34,,892.5,percent of total billed charges,Implant Device,892.5,34,,892.5,percent of total billed charges,Implant Device,892.5,34,,892.5,percent of total billed charges,Implant Device,1299.38,,,1299.38,Other,110% of Medicare,918.75,35,,918.75,percent of total billed charges,Implant Device,892.5,34,"Charges > $500, x 34%",892.5,percent of total billed charges,Implant Device,918.75,35,,918.75,percent of total billed charges,Implant Device,918.75,35,,918.75,percent of total billed charges,Implant Device,918.75,35,,918.75,percent of total billed charges,Implant Device,918.75,35,,918.75,percent of total billed charges,Implant Device,918.75,35,,918.75,percent of total billed charges,Implant Device,1050,40,,1050,percent of total billed charges,Implant Device,918.75,70,,918.75,percent of total billed charges,All Other,892.5,34,,892.5,percent of total billed charges,Implant Device,892.5,34,,892.5,percent of total billed charges,Implant Device,918.75,35,,918.75,percent of total billed charges,Implant Device,918.75,35,,918.75,percent of total billed charges,Implant Device,918.75,35,,918.75,percent of total billed charges,Implant Device,918.75,35,,918.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,892.5,34,"If Charge > 2,000, then 34 percent",892.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1942.51,
ARTHREX AR-7298 UNIVERSAL SUTURE KIT,C1713,HCPCS,,79011113,CDM,278,RC,,,both,,,1200,888,,,888,Other,150% of Medicare + 9.63% HCRA Surcharge,540,45,,540,percent of total billed charges,Critical Access Hospital RCC factor,408,34,,408,percent of total billed charges,Implant Device,408,34,,408,percent of total billed charges,Implant Device,408,34,,408,percent of total billed charges,Implant Device,408,34,,408,percent of total billed charges,Implant Device,408,34,,408,percent of total billed charges,Implant Device,594,,,594,Other,110% of Medicare,420,35,,420,percent of total billed charges,Implant Device,408,34,"Charges > $500, x 34%",408,percent of total billed charges,Implant Device,420,35,,420,percent of total billed charges,Implant Device,420,35,,420,percent of total billed charges,Implant Device,420,35,,420,percent of total billed charges,Implant Device,420,35,,420,percent of total billed charges,Implant Device,420,35,,420,percent of total billed charges,Implant Device,480,40,,480,percent of total billed charges,Implant Device,420,70,,420,percent of total billed charges,All Other,408,34,,408,percent of total billed charges,Implant Device,408,34,,408,percent of total billed charges,Implant Device,420,35,,420,percent of total billed charges,Implant Device,420,35,,420,percent of total billed charges,Implant Device,420,35,,420,percent of total billed charges,Implant Device,420,35,,420,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,888,
ARTHREX AR-2324KBCCT SWIVELOCK 4.75X19.1,C1713,HCPCS,,79011118,CDM,278,RC,,,both,,,1590,1176.6,,,1176.6,Other,150% of Medicare + 9.63% HCRA Surcharge,715.5,45,,715.5,percent of total billed charges,Critical Access Hospital RCC factor,540.6,34,,540.6,percent of total billed charges,Implant Device,540.6,34,,540.6,percent of total billed charges,Implant Device,540.6,34,,540.6,percent of total billed charges,Implant Device,540.6,34,,540.6,percent of total billed charges,Implant Device,540.6,34,,540.6,percent of total billed charges,Implant Device,787.05,,,787.05,Other,110% of Medicare,556.5,35,,556.5,percent of total billed charges,Implant Device,540.6,34,"Charges > $500, x 34%",540.6,percent of total billed charges,Implant Device,556.5,35,,556.5,percent of total billed charges,Implant Device,556.5,35,,556.5,percent of total billed charges,Implant Device,556.5,35,,556.5,percent of total billed charges,Implant Device,556.5,35,,556.5,percent of total billed charges,Implant Device,556.5,35,,556.5,percent of total billed charges,Implant Device,636,40,,636,percent of total billed charges,Implant Device,556.5,70,,556.5,percent of total billed charges,All Other,540.6,34,,540.6,percent of total billed charges,Implant Device,540.6,34,,540.6,percent of total billed charges,Implant Device,556.5,35,,556.5,percent of total billed charges,Implant Device,556.5,35,,556.5,percent of total billed charges,Implant Device,556.5,35,,556.5,percent of total billed charges,Implant Device,556.5,35,,556.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1176.6,
ARTHREX AR-2324KBCCTT SWIVELCK 4.75X19.1,C1713,HCPCS,,79011119,CDM,278,RC,,,both,,,1590,1176.6,,,1176.6,Other,150% of Medicare + 9.63% HCRA Surcharge,715.5,45,,715.5,percent of total billed charges,Critical Access Hospital RCC factor,540.6,34,,540.6,percent of total billed charges,Implant Device,540.6,34,,540.6,percent of total billed charges,Implant Device,540.6,34,,540.6,percent of total billed charges,Implant Device,540.6,34,,540.6,percent of total billed charges,Implant Device,540.6,34,,540.6,percent of total billed charges,Implant Device,787.05,,,787.05,Other,110% of Medicare,556.5,35,,556.5,percent of total billed charges,Implant Device,540.6,34,"Charges > $500, x 34%",540.6,percent of total billed charges,Implant Device,556.5,35,,556.5,percent of total billed charges,Implant Device,556.5,35,,556.5,percent of total billed charges,Implant Device,556.5,35,,556.5,percent of total billed charges,Implant Device,556.5,35,,556.5,percent of total billed charges,Implant Device,556.5,35,,556.5,percent of total billed charges,Implant Device,636,40,,636,percent of total billed charges,Implant Device,556.5,70,,556.5,percent of total billed charges,All Other,540.6,34,,540.6,percent of total billed charges,Implant Device,540.6,34,,540.6,percent of total billed charges,Implant Device,556.5,35,,556.5,percent of total billed charges,Implant Device,556.5,35,,556.5,percent of total billed charges,Implant Device,556.5,35,,556.5,percent of total billed charges,Implant Device,556.5,35,,556.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1176.6,
STRYKER 5567-P-3010 HUMERAL STEM 10X94MM,C1776,HCPCS,,79011120,CDM,278,RC,,,both,,,8925,6604.52,,,6604.52,Other,150% of Medicare + 9.63% HCRA Surcharge,4016.25,45,,4016.25,percent of total billed charges,Critical Access Hospital RCC factor,3034.5,34,,3034.5,percent of total billed charges,Implant Device,3034.5,34,,3034.5,percent of total billed charges,Implant Device,3034.5,34,,3034.5,percent of total billed charges,Implant Device,3034.5,34,,3034.5,percent of total billed charges,Implant Device,3034.5,34,,3034.5,percent of total billed charges,Implant Device,4417.88,,,4417.88,Other,110% of Medicare,3123.75,35,,3123.75,percent of total billed charges,Implant Device,3034.5,34,"Charges > $500, x 34%",3034.5,percent of total billed charges,Implant Device,3123.75,35,,3123.75,percent of total billed charges,Implant Device,3123.75,35,,3123.75,percent of total billed charges,Implant Device,3123.75,35,,3123.75,percent of total billed charges,Implant Device,3123.75,35,,3123.75,percent of total billed charges,Implant Device,3123.75,35,,3123.75,percent of total billed charges,Implant Device,3570,40,,3570,percent of total billed charges,Implant Device,3123.75,70,,3123.75,percent of total billed charges,All Other,3034.5,34,,3034.5,percent of total billed charges,Implant Device,3034.5,34,,3034.5,percent of total billed charges,Implant Device,3123.75,35,,3123.75,percent of total billed charges,Implant Device,3123.75,35,,3123.75,percent of total billed charges,Implant Device,3123.75,35,,3123.75,percent of total billed charges,Implant Device,3123.75,35,,3123.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3034.5,34,"If Charge > 2,000, then 34 percent",3034.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,6604.52,
STRYKER 5571-C-3604 HUMERAL INS 36X4MM,C1776,HCPCS,,79011121,CDM,278,RC,,,both,,,3525,2608.51,,,2608.51,Other,150% of Medicare + 9.63% HCRA Surcharge,1586.25,45,,1586.25,percent of total billed charges,Critical Access Hospital RCC factor,1198.5,34,,1198.5,percent of total billed charges,Implant Device,1198.5,34,,1198.5,percent of total billed charges,Implant Device,1198.5,34,,1198.5,percent of total billed charges,Implant Device,1198.5,34,,1198.5,percent of total billed charges,Implant Device,1198.5,34,,1198.5,percent of total billed charges,Implant Device,1744.88,,,1744.88,Other,110% of Medicare,1233.75,35,,1233.75,percent of total billed charges,Implant Device,1198.5,34,"Charges > $500, x 34%",1198.5,percent of total billed charges,Implant Device,1233.75,35,,1233.75,percent of total billed charges,Implant Device,1233.75,35,,1233.75,percent of total billed charges,Implant Device,1233.75,35,,1233.75,percent of total billed charges,Implant Device,1233.75,35,,1233.75,percent of total billed charges,Implant Device,1233.75,35,,1233.75,percent of total billed charges,Implant Device,1410,40,,1410,percent of total billed charges,Implant Device,1233.75,70,,1233.75,percent of total billed charges,All Other,1198.5,34,,1198.5,percent of total billed charges,Implant Device,1198.5,34,,1198.5,percent of total billed charges,Implant Device,1233.75,35,,1233.75,percent of total billed charges,Implant Device,1233.75,35,,1233.75,percent of total billed charges,Implant Device,1233.75,35,,1233.75,percent of total billed charges,Implant Device,1233.75,35,,1233.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1198.5,34,"If Charge > 2,000, then 34 percent",1198.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2608.51,
S&N 71343212 FEM HEAD 12/14 32MM +12,C1776,HCPCS,,79011122,CDM,278,RC,,,both,,,15660,11588.44,,,11588.44,Other,150% of Medicare + 9.63% HCRA Surcharge,7047,45,,7047,percent of total billed charges,Critical Access Hospital RCC factor,5324.4,34,,5324.4,percent of total billed charges,Implant Device,5324.4,34,,5324.4,percent of total billed charges,Implant Device,5324.4,34,,5324.4,percent of total billed charges,Implant Device,5324.4,34,,5324.4,percent of total billed charges,Implant Device,5324.4,34,,5324.4,percent of total billed charges,Implant Device,7751.7,,,7751.7,Other,110% of Medicare,5481,35,,5481,percent of total billed charges,Implant Device,5324.4,34,"Charges > $500, x 34%",5324.4,percent of total billed charges,Implant Device,5481,35,,5481,percent of total billed charges,Implant Device,5481,35,,5481,percent of total billed charges,Implant Device,5481,35,,5481,percent of total billed charges,Implant Device,5481,35,,5481,percent of total billed charges,Implant Device,5481,35,,5481,percent of total billed charges,Implant Device,6264,40,,6264,percent of total billed charges,Implant Device,5481,70,,5481,percent of total billed charges,All Other,5324.4,34,,5324.4,percent of total billed charges,Implant Device,5324.4,34,,5324.4,percent of total billed charges,Implant Device,5481,35,,5481,percent of total billed charges,Implant Device,5481,35,,5481,percent of total billed charges,Implant Device,5481,35,,5481,percent of total billed charges,Implant Device,5481,35,,5481,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,5324.4,34,"If Charge > 2,000, then 34 percent",5324.4,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,11588.44,
MEDTRONIC AB9U14100090 14X100 ABRE STENT,C1876,HCPCS,,79011123,CDM,278,RC,,,both,,,5685,4206.91,,,4206.91,Other,150% of Medicare + 9.63% HCRA Surcharge,2558.25,45,,2558.25,percent of total billed charges,Critical Access Hospital RCC factor,1932.9,34,,1932.9,percent of total billed charges,Implant Device,1932.9,34,,1932.9,percent of total billed charges,Implant Device,1932.9,34,,1932.9,percent of total billed charges,Implant Device,1932.9,34,,1932.9,percent of total billed charges,Implant Device,1932.9,34,,1932.9,percent of total billed charges,Implant Device,2814.08,,,2814.08,Other,110% of Medicare,1989.75,35,,1989.75,percent of total billed charges,Implant Device,1932.9,34,"Charges > $500, x 34%",1932.9,percent of total billed charges,Implant Device,1989.75,35,,1989.75,percent of total billed charges,Implant Device,1989.75,35,,1989.75,percent of total billed charges,Implant Device,1989.75,35,,1989.75,percent of total billed charges,Implant Device,1989.75,35,,1989.75,percent of total billed charges,Implant Device,1989.75,35,,1989.75,percent of total billed charges,Implant Device,2274,40,,2274,percent of total billed charges,Implant Device,1989.75,70,,1989.75,percent of total billed charges,All Other,1932.9,34,,1932.9,percent of total billed charges,Implant Device,1932.9,34,,1932.9,percent of total billed charges,Implant Device,1989.75,35,,1989.75,percent of total billed charges,Implant Device,1989.75,35,,1989.75,percent of total billed charges,Implant Device,1989.75,35,,1989.75,percent of total billed charges,Implant Device,1989.75,35,,1989.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1932.9,34,"If Charge > 2,000, then 34 percent",1932.9,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4206.91,
MEDTRONIC AB9U16100090 16X100 ABRE STENT,C1876,HCPCS,,79011124,CDM,278,RC,,,both,,,5685,4206.91,,,4206.91,Other,150% of Medicare + 9.63% HCRA Surcharge,2558.25,45,,2558.25,percent of total billed charges,Critical Access Hospital RCC factor,1932.9,34,,1932.9,percent of total billed charges,Implant Device,1932.9,34,,1932.9,percent of total billed charges,Implant Device,1932.9,34,,1932.9,percent of total billed charges,Implant Device,1932.9,34,,1932.9,percent of total billed charges,Implant Device,1932.9,34,,1932.9,percent of total billed charges,Implant Device,2814.08,,,2814.08,Other,110% of Medicare,1989.75,35,,1989.75,percent of total billed charges,Implant Device,1932.9,34,"Charges > $500, x 34%",1932.9,percent of total billed charges,Implant Device,1989.75,35,,1989.75,percent of total billed charges,Implant Device,1989.75,35,,1989.75,percent of total billed charges,Implant Device,1989.75,35,,1989.75,percent of total billed charges,Implant Device,1989.75,35,,1989.75,percent of total billed charges,Implant Device,1989.75,35,,1989.75,percent of total billed charges,Implant Device,2274,40,,2274,percent of total billed charges,Implant Device,1989.75,70,,1989.75,percent of total billed charges,All Other,1932.9,34,,1932.9,percent of total billed charges,Implant Device,1932.9,34,,1932.9,percent of total billed charges,Implant Device,1989.75,35,,1989.75,percent of total billed charges,Implant Device,1989.75,35,,1989.75,percent of total billed charges,Implant Device,1989.75,35,,1989.75,percent of total billed charges,Implant Device,1989.75,35,,1989.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1932.9,34,"If Charge > 2,000, then 34 percent",1932.9,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4206.91,
MEDTRONIC AB9U18100090 18X100 ABRE STENT,C1876,HCPCS,,79011125,CDM,278,RC,,,both,,,5685,4206.91,,,4206.91,Other,150% of Medicare + 9.63% HCRA Surcharge,2558.25,45,,2558.25,percent of total billed charges,Critical Access Hospital RCC factor,1932.9,34,,1932.9,percent of total billed charges,Implant Device,1932.9,34,,1932.9,percent of total billed charges,Implant Device,1932.9,34,,1932.9,percent of total billed charges,Implant Device,1932.9,34,,1932.9,percent of total billed charges,Implant Device,1932.9,34,,1932.9,percent of total billed charges,Implant Device,2814.08,,,2814.08,Other,110% of Medicare,1989.75,35,,1989.75,percent of total billed charges,Implant Device,1932.9,34,"Charges > $500, x 34%",1932.9,percent of total billed charges,Implant Device,1989.75,35,,1989.75,percent of total billed charges,Implant Device,1989.75,35,,1989.75,percent of total billed charges,Implant Device,1989.75,35,,1989.75,percent of total billed charges,Implant Device,1989.75,35,,1989.75,percent of total billed charges,Implant Device,1989.75,35,,1989.75,percent of total billed charges,Implant Device,2274,40,,2274,percent of total billed charges,Implant Device,1989.75,70,,1989.75,percent of total billed charges,All Other,1932.9,34,,1932.9,percent of total billed charges,Implant Device,1932.9,34,,1932.9,percent of total billed charges,Implant Device,1989.75,35,,1989.75,percent of total billed charges,Implant Device,1989.75,35,,1989.75,percent of total billed charges,Implant Device,1989.75,35,,1989.75,percent of total billed charges,Implant Device,1989.75,35,,1989.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1932.9,34,"If Charge > 2,000, then 34 percent",1932.9,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4206.91,
MEDTRONIC AB9U14120090 14X120 ABRE STENT,C1876,HCPCS,,79011126,CDM,278,RC,,,both,,,5685,4206.91,,,4206.91,Other,150% of Medicare + 9.63% HCRA Surcharge,2558.25,45,,2558.25,percent of total billed charges,Critical Access Hospital RCC factor,1932.9,34,,1932.9,percent of total billed charges,Implant Device,1932.9,34,,1932.9,percent of total billed charges,Implant Device,1932.9,34,,1932.9,percent of total billed charges,Implant Device,1932.9,34,,1932.9,percent of total billed charges,Implant Device,1932.9,34,,1932.9,percent of total billed charges,Implant Device,2814.08,,,2814.08,Other,110% of Medicare,1989.75,35,,1989.75,percent of total billed charges,Implant Device,1932.9,34,"Charges > $500, x 34%",1932.9,percent of total billed charges,Implant Device,1989.75,35,,1989.75,percent of total billed charges,Implant Device,1989.75,35,,1989.75,percent of total billed charges,Implant Device,1989.75,35,,1989.75,percent of total billed charges,Implant Device,1989.75,35,,1989.75,percent of total billed charges,Implant Device,1989.75,35,,1989.75,percent of total billed charges,Implant Device,2274,40,,2274,percent of total billed charges,Implant Device,1989.75,70,,1989.75,percent of total billed charges,All Other,1932.9,34,,1932.9,percent of total billed charges,Implant Device,1932.9,34,,1932.9,percent of total billed charges,Implant Device,1989.75,35,,1989.75,percent of total billed charges,Implant Device,1989.75,35,,1989.75,percent of total billed charges,Implant Device,1989.75,35,,1989.75,percent of total billed charges,Implant Device,1989.75,35,,1989.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1932.9,34,"If Charge > 2,000, then 34 percent",1932.9,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4206.91,
MEDTRONIC AB9U16120090 16X120 ABRE STENT,C1876,HCPCS,,79011127,CDM,278,RC,,,both,,,5685,4206.91,,,4206.91,Other,150% of Medicare + 9.63% HCRA Surcharge,2558.25,45,,2558.25,percent of total billed charges,Critical Access Hospital RCC factor,1932.9,34,,1932.9,percent of total billed charges,Implant Device,1932.9,34,,1932.9,percent of total billed charges,Implant Device,1932.9,34,,1932.9,percent of total billed charges,Implant Device,1932.9,34,,1932.9,percent of total billed charges,Implant Device,1932.9,34,,1932.9,percent of total billed charges,Implant Device,2814.08,,,2814.08,Other,110% of Medicare,1989.75,35,,1989.75,percent of total billed charges,Implant Device,1932.9,34,"Charges > $500, x 34%",1932.9,percent of total billed charges,Implant Device,1989.75,35,,1989.75,percent of total billed charges,Implant Device,1989.75,35,,1989.75,percent of total billed charges,Implant Device,1989.75,35,,1989.75,percent of total billed charges,Implant Device,1989.75,35,,1989.75,percent of total billed charges,Implant Device,1989.75,35,,1989.75,percent of total billed charges,Implant Device,2274,40,,2274,percent of total billed charges,Implant Device,1989.75,70,,1989.75,percent of total billed charges,All Other,1932.9,34,,1932.9,percent of total billed charges,Implant Device,1932.9,34,,1932.9,percent of total billed charges,Implant Device,1989.75,35,,1989.75,percent of total billed charges,Implant Device,1989.75,35,,1989.75,percent of total billed charges,Implant Device,1989.75,35,,1989.75,percent of total billed charges,Implant Device,1989.75,35,,1989.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1932.9,34,"If Charge > 2,000, then 34 percent",1932.9,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4206.91,
MEDTRONIC AB9U18120090 18X120 ABRE STENT,C1876,HCPCS,,79011128,CDM,278,RC,,,both,,,5685,4206.91,,,4206.91,Other,150% of Medicare + 9.63% HCRA Surcharge,2558.25,45,,2558.25,percent of total billed charges,Critical Access Hospital RCC factor,1932.9,34,,1932.9,percent of total billed charges,Implant Device,1932.9,34,,1932.9,percent of total billed charges,Implant Device,1932.9,34,,1932.9,percent of total billed charges,Implant Device,1932.9,34,,1932.9,percent of total billed charges,Implant Device,1932.9,34,,1932.9,percent of total billed charges,Implant Device,2814.08,,,2814.08,Other,110% of Medicare,1989.75,35,,1989.75,percent of total billed charges,Implant Device,1932.9,34,"Charges > $500, x 34%",1932.9,percent of total billed charges,Implant Device,1989.75,35,,1989.75,percent of total billed charges,Implant Device,1989.75,35,,1989.75,percent of total billed charges,Implant Device,1989.75,35,,1989.75,percent of total billed charges,Implant Device,1989.75,35,,1989.75,percent of total billed charges,Implant Device,1989.75,35,,1989.75,percent of total billed charges,Implant Device,2274,40,,2274,percent of total billed charges,Implant Device,1989.75,70,,1989.75,percent of total billed charges,All Other,1932.9,34,,1932.9,percent of total billed charges,Implant Device,1932.9,34,,1932.9,percent of total billed charges,Implant Device,1989.75,35,,1989.75,percent of total billed charges,Implant Device,1989.75,35,,1989.75,percent of total billed charges,Implant Device,1989.75,35,,1989.75,percent of total billed charges,Implant Device,1989.75,35,,1989.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1932.9,34,"If Charge > 2,000, then 34 percent",1932.9,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4206.91,
MEDTRONIC AB9U14150090 14X150 ABRE STENT,C1876,HCPCS,,79011129,CDM,278,RC,,,both,,,6375,4717.52,,,4717.52,Other,150% of Medicare + 9.63% HCRA Surcharge,2868.75,45,,2868.75,percent of total billed charges,Critical Access Hospital RCC factor,2167.5,34,,2167.5,percent of total billed charges,Implant Device,2167.5,34,,2167.5,percent of total billed charges,Implant Device,2167.5,34,,2167.5,percent of total billed charges,Implant Device,2167.5,34,,2167.5,percent of total billed charges,Implant Device,2167.5,34,,2167.5,percent of total billed charges,Implant Device,3155.63,,,3155.63,Other,110% of Medicare,2231.25,35,,2231.25,percent of total billed charges,Implant Device,2167.5,34,"Charges > $500, x 34%",2167.5,percent of total billed charges,Implant Device,2231.25,35,,2231.25,percent of total billed charges,Implant Device,2231.25,35,,2231.25,percent of total billed charges,Implant Device,2231.25,35,,2231.25,percent of total billed charges,Implant Device,2231.25,35,,2231.25,percent of total billed charges,Implant Device,2231.25,35,,2231.25,percent of total billed charges,Implant Device,2550,40,,2550,percent of total billed charges,Implant Device,2231.25,70,,2231.25,percent of total billed charges,All Other,2167.5,34,,2167.5,percent of total billed charges,Implant Device,2167.5,34,,2167.5,percent of total billed charges,Implant Device,2231.25,35,,2231.25,percent of total billed charges,Implant Device,2231.25,35,,2231.25,percent of total billed charges,Implant Device,2231.25,35,,2231.25,percent of total billed charges,Implant Device,2231.25,35,,2231.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2167.5,34,"If Charge > 2,000, then 34 percent",2167.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4717.52,
MEDTRONIC AB9U16150090 16X150 ABRE STENT,C1876,HCPCS,,79011130,CDM,278,RC,,,both,,,6375,4717.52,,,4717.52,Other,150% of Medicare + 9.63% HCRA Surcharge,2868.75,45,,2868.75,percent of total billed charges,Critical Access Hospital RCC factor,2167.5,34,,2167.5,percent of total billed charges,Implant Device,2167.5,34,,2167.5,percent of total billed charges,Implant Device,2167.5,34,,2167.5,percent of total billed charges,Implant Device,2167.5,34,,2167.5,percent of total billed charges,Implant Device,2167.5,34,,2167.5,percent of total billed charges,Implant Device,3155.63,,,3155.63,Other,110% of Medicare,2231.25,35,,2231.25,percent of total billed charges,Implant Device,2167.5,34,"Charges > $500, x 34%",2167.5,percent of total billed charges,Implant Device,2231.25,35,,2231.25,percent of total billed charges,Implant Device,2231.25,35,,2231.25,percent of total billed charges,Implant Device,2231.25,35,,2231.25,percent of total billed charges,Implant Device,2231.25,35,,2231.25,percent of total billed charges,Implant Device,2231.25,35,,2231.25,percent of total billed charges,Implant Device,2550,40,,2550,percent of total billed charges,Implant Device,2231.25,70,,2231.25,percent of total billed charges,All Other,2167.5,34,,2167.5,percent of total billed charges,Implant Device,2167.5,34,,2167.5,percent of total billed charges,Implant Device,2231.25,35,,2231.25,percent of total billed charges,Implant Device,2231.25,35,,2231.25,percent of total billed charges,Implant Device,2231.25,35,,2231.25,percent of total billed charges,Implant Device,2231.25,35,,2231.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2167.5,34,"If Charge > 2,000, then 34 percent",2167.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4717.52,
MEDTRONIC AB9U18150090 18X150 ABRE STENT,C1876,HCPCS,,79011131,CDM,278,RC,,,both,,,6375,4717.52,,,4717.52,Other,150% of Medicare + 9.63% HCRA Surcharge,2868.75,45,,2868.75,percent of total billed charges,Critical Access Hospital RCC factor,2167.5,34,,2167.5,percent of total billed charges,Implant Device,2167.5,34,,2167.5,percent of total billed charges,Implant Device,2167.5,34,,2167.5,percent of total billed charges,Implant Device,2167.5,34,,2167.5,percent of total billed charges,Implant Device,2167.5,34,,2167.5,percent of total billed charges,Implant Device,3155.63,,,3155.63,Other,110% of Medicare,2231.25,35,,2231.25,percent of total billed charges,Implant Device,2167.5,34,"Charges > $500, x 34%",2167.5,percent of total billed charges,Implant Device,2231.25,35,,2231.25,percent of total billed charges,Implant Device,2231.25,35,,2231.25,percent of total billed charges,Implant Device,2231.25,35,,2231.25,percent of total billed charges,Implant Device,2231.25,35,,2231.25,percent of total billed charges,Implant Device,2231.25,35,,2231.25,percent of total billed charges,Implant Device,2550,40,,2550,percent of total billed charges,Implant Device,2231.25,70,,2231.25,percent of total billed charges,All Other,2167.5,34,,2167.5,percent of total billed charges,Implant Device,2167.5,34,,2167.5,percent of total billed charges,Implant Device,2231.25,35,,2231.25,percent of total billed charges,Implant Device,2231.25,35,,2231.25,percent of total billed charges,Implant Device,2231.25,35,,2231.25,percent of total billed charges,Implant Device,2231.25,35,,2231.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2167.5,34,"If Charge > 2,000, then 34 percent",2167.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4717.52,
STRYKER 2341-0933S TIBIAL NAIL 79X330MM,C1713,HCPCS,,79011133,CDM,278,RC,,,both,,,4792,3546.09,,,3546.09,Other,150% of Medicare + 9.63% HCRA Surcharge,2156.4,45,,2156.4,percent of total billed charges,Critical Access Hospital RCC factor,1629.28,34,,1629.28,percent of total billed charges,Implant Device,1629.28,34,,1629.28,percent of total billed charges,Implant Device,1629.28,34,,1629.28,percent of total billed charges,Implant Device,1629.28,34,,1629.28,percent of total billed charges,Implant Device,1629.28,34,,1629.28,percent of total billed charges,Implant Device,2372.04,,,2372.04,Other,110% of Medicare,1677.2,35,,1677.2,percent of total billed charges,Implant Device,1629.28,34,"Charges > $500, x 34%",1629.28,percent of total billed charges,Implant Device,1677.2,35,,1677.2,percent of total billed charges,Implant Device,1677.2,35,,1677.2,percent of total billed charges,Implant Device,1677.2,35,,1677.2,percent of total billed charges,Implant Device,1677.2,35,,1677.2,percent of total billed charges,Implant Device,1677.2,35,,1677.2,percent of total billed charges,Implant Device,1916.8,40,,1916.8,percent of total billed charges,Implant Device,1677.2,70,,1677.2,percent of total billed charges,All Other,1629.28,34,,1629.28,percent of total billed charges,Implant Device,1629.28,34,,1629.28,percent of total billed charges,Implant Device,1677.2,35,,1677.2,percent of total billed charges,Implant Device,1677.2,35,,1677.2,percent of total billed charges,Implant Device,1677.2,35,,1677.2,percent of total billed charges,Implant Device,1677.2,35,,1677.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1629.28,34,"If Charge > 2,000, then 34 percent",1629.28,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3546.09,
STRYKER 657714 BONE SCREW 2.0X14MM,C1713,HCPCS,,79011134,CDM,278,RC,,,both,,,395,292.3,,,292.3,Other,150% of Medicare + 9.63% HCRA Surcharge,177.75,45,,177.75,percent of total billed charges,Critical Access Hospital RCC factor,134.3,34,,134.3,percent of total billed charges,Implant Device,134.3,34,,134.3,percent of total billed charges,Implant Device,134.3,34,,134.3,percent of total billed charges,Implant Device,134.3,34,,134.3,percent of total billed charges,Implant Device,134.3,34,,134.3,percent of total billed charges,Implant Device,195.53,,,195.53,Other,110% of Medicare,138.25,35,,138.25,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,138.25,35,,138.25,percent of total billed charges,Implant Device,138.25,35,,138.25,percent of total billed charges,Implant Device,138.25,35,,138.25,percent of total billed charges,Implant Device,138.25,35,,138.25,percent of total billed charges,Implant Device,138.25,35,,138.25,percent of total billed charges,Implant Device,158,40,,158,percent of total billed charges,Implant Device,138.25,70,,138.25,percent of total billed charges,All Other,134.3,34,,134.3,percent of total billed charges,Implant Device,134.3,34,,134.3,percent of total billed charges,Implant Device,138.25,35,,138.25,percent of total billed charges,Implant Device,138.25,35,,138.25,percent of total billed charges,Implant Device,138.25,35,,138.25,percent of total billed charges,Implant Device,138.25,35,,138.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,292.3,
STRYKER 657716 BONE SCREW 2.0X16MM,C1713,HCPCS,,79011135,CDM,278,RC,,,both,,,258,190.92,,,190.92,Other,150% of Medicare + 9.63% HCRA Surcharge,116.1,45,,116.1,percent of total billed charges,Critical Access Hospital RCC factor,87.72,34,,87.72,percent of total billed charges,Implant Device,87.72,34,,87.72,percent of total billed charges,Implant Device,87.72,34,,87.72,percent of total billed charges,Implant Device,87.72,34,,87.72,percent of total billed charges,Implant Device,87.72,34,,87.72,percent of total billed charges,Implant Device,127.71,,,127.71,Other,110% of Medicare,90.3,35,,90.3,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,90.3,35,,90.3,percent of total billed charges,Implant Device,90.3,35,,90.3,percent of total billed charges,Implant Device,90.3,35,,90.3,percent of total billed charges,Implant Device,90.3,35,,90.3,percent of total billed charges,Implant Device,90.3,35,,90.3,percent of total billed charges,Implant Device,103.2,40,,103.2,percent of total billed charges,Implant Device,90.3,70,,90.3,percent of total billed charges,All Other,87.72,34,,87.72,percent of total billed charges,Implant Device,87.72,34,,87.72,percent of total billed charges,Implant Device,90.3,35,,90.3,percent of total billed charges,Implant Device,90.3,35,,90.3,percent of total billed charges,Implant Device,90.3,35,,90.3,percent of total billed charges,Implant Device,90.3,35,,90.3,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,190.92,
STRYKER 657718 BONE SCREW 2.0X18MM,C1713,HCPCS,,79011136,CDM,278,RC,,,both,,,389,287.86,,,287.86,Other,150% of Medicare + 9.63% HCRA Surcharge,175.05,45,,175.05,percent of total billed charges,Critical Access Hospital RCC factor,132.26,34,,132.26,percent of total billed charges,Implant Device,132.26,34,,132.26,percent of total billed charges,Implant Device,132.26,34,,132.26,percent of total billed charges,Implant Device,132.26,34,,132.26,percent of total billed charges,Implant Device,132.26,34,,132.26,percent of total billed charges,Implant Device,192.56,,,192.56,Other,110% of Medicare,136.15,35,,136.15,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,136.15,35,,136.15,percent of total billed charges,Implant Device,136.15,35,,136.15,percent of total billed charges,Implant Device,136.15,35,,136.15,percent of total billed charges,Implant Device,136.15,35,,136.15,percent of total billed charges,Implant Device,136.15,35,,136.15,percent of total billed charges,Implant Device,155.6,40,,155.6,percent of total billed charges,Implant Device,136.15,70,,136.15,percent of total billed charges,All Other,132.26,34,,132.26,percent of total billed charges,Implant Device,132.26,34,,132.26,percent of total billed charges,Implant Device,136.15,35,,136.15,percent of total billed charges,Implant Device,136.15,35,,136.15,percent of total billed charges,Implant Device,136.15,35,,136.15,percent of total billed charges,Implant Device,136.15,35,,136.15,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,287.86,
EXACTECH 300-30-11 PRESERVE STEM 11MM,C1776,HCPCS,,79011138,CDM,278,RC,,,both,,,6000,4440.02,,,4440.02,Other,150% of Medicare + 9.63% HCRA Surcharge,2700,45,,2700,percent of total billed charges,Critical Access Hospital RCC factor,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2970,,,2970,Other,110% of Medicare,2100,35,,2100,percent of total billed charges,Implant Device,2040,34,"Charges > $500, x 34%",2040,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2400,40,,2400,percent of total billed charges,Implant Device,2100,70,,2100,percent of total billed charges,All Other,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2040,34,"If Charge > 2,000, then 34 percent",2040,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4440.02,
STRYKER 656111 BONE SCREW 2.4X11MM,C1713,HCPCS,,79011139,CDM,278,RC,,,both,,,389,287.86,,,287.86,Other,150% of Medicare + 9.63% HCRA Surcharge,175.05,45,,175.05,percent of total billed charges,Critical Access Hospital RCC factor,132.26,34,,132.26,percent of total billed charges,Implant Device,132.26,34,,132.26,percent of total billed charges,Implant Device,132.26,34,,132.26,percent of total billed charges,Implant Device,132.26,34,,132.26,percent of total billed charges,Implant Device,132.26,34,,132.26,percent of total billed charges,Implant Device,192.56,,,192.56,Other,110% of Medicare,136.15,35,,136.15,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,136.15,35,,136.15,percent of total billed charges,Implant Device,136.15,35,,136.15,percent of total billed charges,Implant Device,136.15,35,,136.15,percent of total billed charges,Implant Device,136.15,35,,136.15,percent of total billed charges,Implant Device,136.15,35,,136.15,percent of total billed charges,Implant Device,155.6,40,,155.6,percent of total billed charges,Implant Device,136.15,70,,136.15,percent of total billed charges,All Other,132.26,34,,132.26,percent of total billed charges,Implant Device,132.26,34,,132.26,percent of total billed charges,Implant Device,136.15,35,,136.15,percent of total billed charges,Implant Device,136.15,35,,136.15,percent of total billed charges,Implant Device,136.15,35,,136.15,percent of total billed charges,Implant Device,136.15,35,,136.15,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,287.86,
STRYKER 656113 BONE SCREW 2.4X13MM,C1713,HCPCS,,79011140,CDM,278,RC,,,both,,,395,292.3,,,292.3,Other,150% of Medicare + 9.63% HCRA Surcharge,177.75,45,,177.75,percent of total billed charges,Critical Access Hospital RCC factor,134.3,34,,134.3,percent of total billed charges,Implant Device,134.3,34,,134.3,percent of total billed charges,Implant Device,134.3,34,,134.3,percent of total billed charges,Implant Device,134.3,34,,134.3,percent of total billed charges,Implant Device,134.3,34,,134.3,percent of total billed charges,Implant Device,195.53,,,195.53,Other,110% of Medicare,138.25,35,,138.25,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,138.25,35,,138.25,percent of total billed charges,Implant Device,138.25,35,,138.25,percent of total billed charges,Implant Device,138.25,35,,138.25,percent of total billed charges,Implant Device,138.25,35,,138.25,percent of total billed charges,Implant Device,138.25,35,,138.25,percent of total billed charges,Implant Device,158,40,,158,percent of total billed charges,Implant Device,138.25,70,,138.25,percent of total billed charges,All Other,134.3,34,,134.3,percent of total billed charges,Implant Device,134.3,34,,134.3,percent of total billed charges,Implant Device,138.25,35,,138.25,percent of total billed charges,Implant Device,138.25,35,,138.25,percent of total billed charges,Implant Device,138.25,35,,138.25,percent of total billed charges,Implant Device,138.25,35,,138.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,292.3,
STRYKER 657713 BONE SCREW 2.0X13MM,C1713,HCPCS,,79011141,CDM,278,RC,,,both,,,258,190.92,,,190.92,Other,150% of Medicare + 9.63% HCRA Surcharge,116.1,45,,116.1,percent of total billed charges,Critical Access Hospital RCC factor,87.72,34,,87.72,percent of total billed charges,Implant Device,87.72,34,,87.72,percent of total billed charges,Implant Device,87.72,34,,87.72,percent of total billed charges,Implant Device,87.72,34,,87.72,percent of total billed charges,Implant Device,87.72,34,,87.72,percent of total billed charges,Implant Device,127.71,,,127.71,Other,110% of Medicare,90.3,35,,90.3,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,90.3,35,,90.3,percent of total billed charges,Implant Device,90.3,35,,90.3,percent of total billed charges,Implant Device,90.3,35,,90.3,percent of total billed charges,Implant Device,90.3,35,,90.3,percent of total billed charges,Implant Device,90.3,35,,90.3,percent of total billed charges,Implant Device,103.2,40,,103.2,percent of total billed charges,Implant Device,90.3,70,,90.3,percent of total billed charges,All Other,87.72,34,,87.72,percent of total billed charges,Implant Device,87.72,34,,87.72,percent of total billed charges,Implant Device,90.3,35,,90.3,percent of total billed charges,Implant Device,90.3,35,,90.3,percent of total billed charges,Implant Device,90.3,35,,90.3,percent of total billed charges,Implant Device,90.3,35,,90.3,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,190.92,
ZIMMER 00-5880-040-14 ROTATIN HINGE 14MM,C1776,HCPCS,,79011146,CDM,278,RC,,,both,,,5765,4266.11,,,4266.11,Other,150% of Medicare + 9.63% HCRA Surcharge,2594.25,45,,2594.25,percent of total billed charges,Critical Access Hospital RCC factor,1960.1,34,,1960.1,percent of total billed charges,Implant Device,1960.1,34,,1960.1,percent of total billed charges,Implant Device,1960.1,34,,1960.1,percent of total billed charges,Implant Device,1960.1,34,,1960.1,percent of total billed charges,Implant Device,1960.1,34,,1960.1,percent of total billed charges,Implant Device,2853.68,,,2853.68,Other,110% of Medicare,2017.75,35,,2017.75,percent of total billed charges,Implant Device,1960.1,34,"Charges > $500, x 34%",1960.1,percent of total billed charges,Implant Device,2017.75,35,,2017.75,percent of total billed charges,Implant Device,2017.75,35,,2017.75,percent of total billed charges,Implant Device,2017.75,35,,2017.75,percent of total billed charges,Implant Device,2017.75,35,,2017.75,percent of total billed charges,Implant Device,2017.75,35,,2017.75,percent of total billed charges,Implant Device,2306,40,,2306,percent of total billed charges,Implant Device,2017.75,70,,2017.75,percent of total billed charges,All Other,1960.1,34,,1960.1,percent of total billed charges,Implant Device,1960.1,34,,1960.1,percent of total billed charges,Implant Device,2017.75,35,,2017.75,percent of total billed charges,Implant Device,2017.75,35,,2017.75,percent of total billed charges,Implant Device,2017.75,35,,2017.75,percent of total billed charges,Implant Device,2017.75,35,,2017.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1960.1,34,"If Charge > 2,000, then 34 percent",1960.1,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4266.11,
ZIMMER 00-5880-014-01 ROTATING HINGE FEM,C1776,HCPCS,,79011147,CDM,278,RC,,,both,,,26254,19428.03,,,19428.03,Other,150% of Medicare + 9.63% HCRA Surcharge,11814.3,45,,11814.3,percent of total billed charges,Critical Access Hospital RCC factor,8926.36,34,,8926.36,percent of total billed charges,Implant Device,8926.36,34,,8926.36,percent of total billed charges,Implant Device,8926.36,34,,8926.36,percent of total billed charges,Implant Device,8926.36,34,,8926.36,percent of total billed charges,Implant Device,8926.36,34,,8926.36,percent of total billed charges,Implant Device,12995.73,,,12995.73,Other,110% of Medicare,9188.9,35,,9188.9,percent of total billed charges,Implant Device,8926.36,34,"Charges > $500, x 34%",8926.36,percent of total billed charges,Implant Device,9188.9,35,,9188.9,percent of total billed charges,Implant Device,9188.9,35,,9188.9,percent of total billed charges,Implant Device,9188.9,35,,9188.9,percent of total billed charges,Implant Device,9188.9,35,,9188.9,percent of total billed charges,Implant Device,9188.9,35,,9188.9,percent of total billed charges,Implant Device,10501.6,40,,10501.6,percent of total billed charges,Implant Device,9188.9,70,,9188.9,percent of total billed charges,All Other,8926.36,34,,8926.36,percent of total billed charges,Implant Device,8926.36,34,,8926.36,percent of total billed charges,Implant Device,9188.9,35,,9188.9,percent of total billed charges,Implant Device,9188.9,35,,9188.9,percent of total billed charges,Implant Device,9188.9,35,,9188.9,percent of total billed charges,Implant Device,9188.9,35,,9188.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,8926.36,34,"If Charge > 2,000, then 34 percent",8926.36,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,19428.03,
ZIMMER 00-5880-040-17 ART SURF 17MM,C1776,HCPCS,,79011148,CDM,278,RC,,,both,,,5765,4266.11,,,4266.11,Other,150% of Medicare + 9.63% HCRA Surcharge,2594.25,45,,2594.25,percent of total billed charges,Critical Access Hospital RCC factor,1960.1,34,,1960.1,percent of total billed charges,Implant Device,1960.1,34,,1960.1,percent of total billed charges,Implant Device,1960.1,34,,1960.1,percent of total billed charges,Implant Device,1960.1,34,,1960.1,percent of total billed charges,Implant Device,1960.1,34,,1960.1,percent of total billed charges,Implant Device,2853.68,,,2853.68,Other,110% of Medicare,2017.75,35,,2017.75,percent of total billed charges,Implant Device,1960.1,34,"Charges > $500, x 34%",1960.1,percent of total billed charges,Implant Device,2017.75,35,,2017.75,percent of total billed charges,Implant Device,2017.75,35,,2017.75,percent of total billed charges,Implant Device,2017.75,35,,2017.75,percent of total billed charges,Implant Device,2017.75,35,,2017.75,percent of total billed charges,Implant Device,2017.75,35,,2017.75,percent of total billed charges,Implant Device,2306,40,,2306,percent of total billed charges,Implant Device,2017.75,70,,2017.75,percent of total billed charges,All Other,1960.1,34,,1960.1,percent of total billed charges,Implant Device,1960.1,34,,1960.1,percent of total billed charges,Implant Device,2017.75,35,,2017.75,percent of total billed charges,Implant Device,2017.75,35,,2017.75,percent of total billed charges,Implant Device,2017.75,35,,2017.75,percent of total billed charges,Implant Device,2017.75,35,,2017.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1960.1,34,"If Charge > 2,000, then 34 percent",1960.1,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4266.11,
J&J 151650805 TIBIAL INSERT SIZE 8 5MM,C1776,HCPCS,,79011149,CDM,278,RC,,,both,,,4200,3108.01,,,3108.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1890,45,,1890,percent of total billed charges,Critical Access Hospital RCC factor,1428,34,,1428,percent of total billed charges,Implant Device,1428,34,,1428,percent of total billed charges,Implant Device,1428,34,,1428,percent of total billed charges,Implant Device,1428,34,,1428,percent of total billed charges,Implant Device,1428,34,,1428,percent of total billed charges,Implant Device,2079,,,2079,Other,110% of Medicare,1470,35,,1470,percent of total billed charges,Implant Device,1428,34,"Charges > $500, x 34%",1428,percent of total billed charges,Implant Device,1470,35,,1470,percent of total billed charges,Implant Device,1470,35,,1470,percent of total billed charges,Implant Device,1470,35,,1470,percent of total billed charges,Implant Device,1470,35,,1470,percent of total billed charges,Implant Device,1470,35,,1470,percent of total billed charges,Implant Device,1680,40,,1680,percent of total billed charges,Implant Device,1470,70,,1470,percent of total billed charges,All Other,1428,34,,1428,percent of total billed charges,Implant Device,1428,34,,1428,percent of total billed charges,Implant Device,1470,35,,1470,percent of total billed charges,Implant Device,1470,35,,1470,percent of total billed charges,Implant Device,1470,35,,1470,percent of total billed charges,Implant Device,1470,35,,1470,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1428,34,"If Charge > 2,000, then 34 percent",1428,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3108.01,
STRYKER 629512 COMP PLT NARROW 12H 150MM,C1713,HCPCS,,79011150,CDM,278,RC,,,both,,,2564,1897.37,,,1897.37,Other,150% of Medicare + 9.63% HCRA Surcharge,1153.8,45,,1153.8,percent of total billed charges,Critical Access Hospital RCC factor,871.76,34,,871.76,percent of total billed charges,Implant Device,871.76,34,,871.76,percent of total billed charges,Implant Device,871.76,34,,871.76,percent of total billed charges,Implant Device,871.76,34,,871.76,percent of total billed charges,Implant Device,871.76,34,,871.76,percent of total billed charges,Implant Device,1269.18,,,1269.18,Other,110% of Medicare,897.4,35,,897.4,percent of total billed charges,Implant Device,871.76,34,"Charges > $500, x 34%",871.76,percent of total billed charges,Implant Device,897.4,35,,897.4,percent of total billed charges,Implant Device,897.4,35,,897.4,percent of total billed charges,Implant Device,897.4,35,,897.4,percent of total billed charges,Implant Device,897.4,35,,897.4,percent of total billed charges,Implant Device,897.4,35,,897.4,percent of total billed charges,Implant Device,1025.6,40,,1025.6,percent of total billed charges,Implant Device,897.4,70,,897.4,percent of total billed charges,All Other,871.76,34,,871.76,percent of total billed charges,Implant Device,871.76,34,,871.76,percent of total billed charges,Implant Device,897.4,35,,897.4,percent of total billed charges,Implant Device,897.4,35,,897.4,percent of total billed charges,Implant Device,897.4,35,,897.4,percent of total billed charges,Implant Device,897.4,35,,897.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,871.76,34,"If Charge > 2,000, then 34 percent",871.76,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1897.37,
IN2BONES P40 ST012 UNIVERSAL PLATE 2H,C1713,HCPCS,,79011151,CDM,278,RC,,,both,,,6000,4440.02,,,4440.02,Other,150% of Medicare + 9.63% HCRA Surcharge,2700,45,,2700,percent of total billed charges,Critical Access Hospital RCC factor,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2970,,,2970,Other,110% of Medicare,2100,35,,2100,percent of total billed charges,Implant Device,2040,34,"Charges > $500, x 34%",2040,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2400,40,,2400,percent of total billed charges,Implant Device,2100,70,,2100,percent of total billed charges,All Other,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2040,34,"If Charge > 2,000, then 34 percent",2040,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4440.02,
IN2BONES V35 ST222 LOCK SCREW 3.5X22MM,C1713,HCPCS,,79011152,CDM,278,RC,,,both,,,870,643.8,,,643.8,Other,150% of Medicare + 9.63% HCRA Surcharge,391.5,45,,391.5,percent of total billed charges,Critical Access Hospital RCC factor,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,430.65,,,430.65,Other,110% of Medicare,304.5,35,,304.5,percent of total billed charges,Implant Device,295.8,34,"Charges > $500, x 34%",295.8,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,348,40,,348,percent of total billed charges,Implant Device,304.5,70,,304.5,percent of total billed charges,All Other,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,643.8,
IN2BONES P67 ST440 CANN SCREW 4.0X40MM,C1713,HCPCS,,79011153,CDM,278,RC,,,both,,,870,643.8,,,643.8,Other,150% of Medicare + 9.63% HCRA Surcharge,391.5,45,,391.5,percent of total billed charges,Critical Access Hospital RCC factor,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,430.65,,,430.65,Other,110% of Medicare,304.5,35,,304.5,percent of total billed charges,Implant Device,295.8,34,"Charges > $500, x 34%",295.8,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,348,40,,348,percent of total billed charges,Implant Device,304.5,70,,304.5,percent of total billed charges,All Other,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,643.8,
EXACTECH 306-02-10 HUMERAL STEM 10X200MM,C1776,HCPCS,,79011154,CDM,278,RC,,,both,,,12672,9377.31,,,9377.31,Other,150% of Medicare + 9.63% HCRA Surcharge,5702.4,45,,5702.4,percent of total billed charges,Critical Access Hospital RCC factor,4308.48,34,,4308.48,percent of total billed charges,Implant Device,4308.48,34,,4308.48,percent of total billed charges,Implant Device,4308.48,34,,4308.48,percent of total billed charges,Implant Device,4308.48,34,,4308.48,percent of total billed charges,Implant Device,4308.48,34,,4308.48,percent of total billed charges,Implant Device,6272.64,,,6272.64,Other,110% of Medicare,4435.2,35,,4435.2,percent of total billed charges,Implant Device,4308.48,34,"Charges > $500, x 34%",4308.48,percent of total billed charges,Implant Device,4435.2,35,,4435.2,percent of total billed charges,Implant Device,4435.2,35,,4435.2,percent of total billed charges,Implant Device,4435.2,35,,4435.2,percent of total billed charges,Implant Device,4435.2,35,,4435.2,percent of total billed charges,Implant Device,4435.2,35,,4435.2,percent of total billed charges,Implant Device,5068.8,40,,5068.8,percent of total billed charges,Implant Device,4435.2,70,,4435.2,percent of total billed charges,All Other,4308.48,34,,4308.48,percent of total billed charges,Implant Device,4308.48,34,,4308.48,percent of total billed charges,Implant Device,4435.2,35,,4435.2,percent of total billed charges,Implant Device,4435.2,35,,4435.2,percent of total billed charges,Implant Device,4435.2,35,,4435.2,percent of total billed charges,Implant Device,4435.2,35,,4435.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,4308.48,34,"If Charge > 2,000, then 34 percent",4308.48,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,9377.31,
ARTHREX AR-2658 DISTAL CLAVICAL BUTTON,C1713,HCPCS,,79011155,CDM,278,RC,,,both,,,1500,1110,,,1110,Other,150% of Medicare + 9.63% HCRA Surcharge,675,45,,675,percent of total billed charges,Critical Access Hospital RCC factor,510,34,,510,percent of total billed charges,Implant Device,510,34,,510,percent of total billed charges,Implant Device,510,34,,510,percent of total billed charges,Implant Device,510,34,,510,percent of total billed charges,Implant Device,510,34,,510,percent of total billed charges,Implant Device,742.5,,,742.5,Other,110% of Medicare,525,35,,525,percent of total billed charges,Implant Device,510,34,"Charges > $500, x 34%",510,percent of total billed charges,Implant Device,525,35,,525,percent of total billed charges,Implant Device,525,35,,525,percent of total billed charges,Implant Device,525,35,,525,percent of total billed charges,Implant Device,525,35,,525,percent of total billed charges,Implant Device,525,35,,525,percent of total billed charges,Implant Device,600,40,,600,percent of total billed charges,Implant Device,525,70,,525,percent of total billed charges,All Other,510,34,,510,percent of total billed charges,Implant Device,510,34,,510,percent of total billed charges,Implant Device,525,35,,525,percent of total billed charges,Implant Device,525,35,,525,percent of total billed charges,Implant Device,525,35,,525,percent of total billed charges,Implant Device,525,35,,525,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1110,
STRYKER 629730 LOCK PLT NARROW 2.7X79MM,C1713,HCPCS,,79011162,CDM,278,RC,,,both,,,3108,2299.93,,,2299.93,Other,150% of Medicare + 9.63% HCRA Surcharge,1398.6,45,,1398.6,percent of total billed charges,Critical Access Hospital RCC factor,1056.72,34,,1056.72,percent of total billed charges,Implant Device,1056.72,34,,1056.72,percent of total billed charges,Implant Device,1056.72,34,,1056.72,percent of total billed charges,Implant Device,1056.72,34,,1056.72,percent of total billed charges,Implant Device,1056.72,34,,1056.72,percent of total billed charges,Implant Device,1538.46,,,1538.46,Other,110% of Medicare,1087.8,35,,1087.8,percent of total billed charges,Implant Device,1056.72,34,"Charges > $500, x 34%",1056.72,percent of total billed charges,Implant Device,1087.8,35,,1087.8,percent of total billed charges,Implant Device,1087.8,35,,1087.8,percent of total billed charges,Implant Device,1087.8,35,,1087.8,percent of total billed charges,Implant Device,1087.8,35,,1087.8,percent of total billed charges,Implant Device,1087.8,35,,1087.8,percent of total billed charges,Implant Device,1243.2,40,,1243.2,percent of total billed charges,Implant Device,1087.8,70,,1087.8,percent of total billed charges,All Other,1056.72,34,,1056.72,percent of total billed charges,Implant Device,1056.72,34,,1056.72,percent of total billed charges,Implant Device,1087.8,35,,1087.8,percent of total billed charges,Implant Device,1087.8,35,,1087.8,percent of total billed charges,Implant Device,1087.8,35,,1087.8,percent of total billed charges,Implant Device,1087.8,35,,1087.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1056.72,34,"If Charge > 2,000, then 34 percent",1056.72,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2299.93,
ARTHREX AR-3680 FIBERTAK BUTTON IMPL SYS,C1713,HCPCS,,79011164,CDM,278,RC,,,both,,,3384,2504.17,,,2504.17,Other,150% of Medicare + 9.63% HCRA Surcharge,1522.8,45,,1522.8,percent of total billed charges,Critical Access Hospital RCC factor,1150.56,34,,1150.56,percent of total billed charges,Implant Device,1150.56,34,,1150.56,percent of total billed charges,Implant Device,1150.56,34,,1150.56,percent of total billed charges,Implant Device,1150.56,34,,1150.56,percent of total billed charges,Implant Device,1150.56,34,,1150.56,percent of total billed charges,Implant Device,1675.08,,,1675.08,Other,110% of Medicare,1184.4,35,,1184.4,percent of total billed charges,Implant Device,1150.56,34,"Charges > $500, x 34%",1150.56,percent of total billed charges,Implant Device,1184.4,35,,1184.4,percent of total billed charges,Implant Device,1184.4,35,,1184.4,percent of total billed charges,Implant Device,1184.4,35,,1184.4,percent of total billed charges,Implant Device,1184.4,35,,1184.4,percent of total billed charges,Implant Device,1184.4,35,,1184.4,percent of total billed charges,Implant Device,1353.6,40,,1353.6,percent of total billed charges,Implant Device,1184.4,70,,1184.4,percent of total billed charges,All Other,1150.56,34,,1150.56,percent of total billed charges,Implant Device,1150.56,34,,1150.56,percent of total billed charges,Implant Device,1184.4,35,,1184.4,percent of total billed charges,Implant Device,1184.4,35,,1184.4,percent of total billed charges,Implant Device,1184.4,35,,1184.4,percent of total billed charges,Implant Device,1184.4,35,,1184.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1150.56,34,"If Charge > 2,000, then 34 percent",1150.56,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2504.17,
ACUMED TR-S1002-S STEM 10X2.0MM,C1776,HCPCS,,79011166,CDM,278,RC,,,both,,,6951,5143.76,,,5143.76,Other,150% of Medicare + 9.63% HCRA Surcharge,3127.95,45,,3127.95,percent of total billed charges,Critical Access Hospital RCC factor,2363.34,34,,2363.34,percent of total billed charges,Implant Device,2363.34,34,,2363.34,percent of total billed charges,Implant Device,2363.34,34,,2363.34,percent of total billed charges,Implant Device,2363.34,34,,2363.34,percent of total billed charges,Implant Device,2363.34,34,,2363.34,percent of total billed charges,Implant Device,3440.75,,,3440.75,Other,110% of Medicare,2432.85,35,,2432.85,percent of total billed charges,Implant Device,2363.34,34,"Charges > $500, x 34%",2363.34,percent of total billed charges,Implant Device,2432.85,35,,2432.85,percent of total billed charges,Implant Device,2432.85,35,,2432.85,percent of total billed charges,Implant Device,2432.85,35,,2432.85,percent of total billed charges,Implant Device,2432.85,35,,2432.85,percent of total billed charges,Implant Device,2432.85,35,,2432.85,percent of total billed charges,Implant Device,2780.4,40,,2780.4,percent of total billed charges,Implant Device,2432.85,70,,2432.85,percent of total billed charges,All Other,2363.34,34,,2363.34,percent of total billed charges,Implant Device,2363.34,34,,2363.34,percent of total billed charges,Implant Device,2432.85,35,,2432.85,percent of total billed charges,Implant Device,2432.85,35,,2432.85,percent of total billed charges,Implant Device,2432.85,35,,2432.85,percent of total billed charges,Implant Device,2432.85,35,,2432.85,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2363.34,34,"If Charge > 2,000, then 34 percent",2363.34,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5143.76,
ACUMED 5001-0524L-S HEAD 24MM LEFT,C1776,HCPCS,,79011167,CDM,278,RC,,,both,,,11871,8784.57,,,8784.57,Other,150% of Medicare + 9.63% HCRA Surcharge,5341.95,45,,5341.95,percent of total billed charges,Critical Access Hospital RCC factor,4036.14,34,,4036.14,percent of total billed charges,Implant Device,4036.14,34,,4036.14,percent of total billed charges,Implant Device,4036.14,34,,4036.14,percent of total billed charges,Implant Device,4036.14,34,,4036.14,percent of total billed charges,Implant Device,4036.14,34,,4036.14,percent of total billed charges,Implant Device,5876.15,,,5876.15,Other,110% of Medicare,4154.85,35,,4154.85,percent of total billed charges,Implant Device,4036.14,34,"Charges > $500, x 34%",4036.14,percent of total billed charges,Implant Device,4154.85,35,,4154.85,percent of total billed charges,Implant Device,4154.85,35,,4154.85,percent of total billed charges,Implant Device,4154.85,35,,4154.85,percent of total billed charges,Implant Device,4154.85,35,,4154.85,percent of total billed charges,Implant Device,4154.85,35,,4154.85,percent of total billed charges,Implant Device,4748.4,40,,4748.4,percent of total billed charges,Implant Device,4154.85,70,,4154.85,percent of total billed charges,All Other,4036.14,34,,4036.14,percent of total billed charges,Implant Device,4036.14,34,,4036.14,percent of total billed charges,Implant Device,4154.85,35,,4154.85,percent of total billed charges,Implant Device,4154.85,35,,4154.85,percent of total billed charges,Implant Device,4154.85,35,,4154.85,percent of total billed charges,Implant Device,4154.85,35,,4154.85,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,4036.14,34,"If Charge > 2,000, then 34 percent",4036.14,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,8784.57,
ACUMED AT2-M20 BONE SCREW 20MM,C1713,HCPCS,,79011168,CDM,278,RC,,,both,,,1617,1196.58,,,1196.58,Other,150% of Medicare + 9.63% HCRA Surcharge,727.65,45,,727.65,percent of total billed charges,Critical Access Hospital RCC factor,549.78,34,,549.78,percent of total billed charges,Implant Device,549.78,34,,549.78,percent of total billed charges,Implant Device,549.78,34,,549.78,percent of total billed charges,Implant Device,549.78,34,,549.78,percent of total billed charges,Implant Device,549.78,34,,549.78,percent of total billed charges,Implant Device,800.42,,,800.42,Other,110% of Medicare,565.95,35,,565.95,percent of total billed charges,Implant Device,549.78,34,"Charges > $500, x 34%",549.78,percent of total billed charges,Implant Device,565.95,35,,565.95,percent of total billed charges,Implant Device,565.95,35,,565.95,percent of total billed charges,Implant Device,565.95,35,,565.95,percent of total billed charges,Implant Device,565.95,35,,565.95,percent of total billed charges,Implant Device,565.95,35,,565.95,percent of total billed charges,Implant Device,646.8,40,,646.8,percent of total billed charges,Implant Device,565.95,70,,565.95,percent of total billed charges,All Other,549.78,34,,549.78,percent of total billed charges,Implant Device,549.78,34,,549.78,percent of total billed charges,Implant Device,565.95,35,,565.95,percent of total billed charges,Implant Device,565.95,35,,565.95,percent of total billed charges,Implant Device,565.95,35,,565.95,percent of total billed charges,Implant Device,565.95,35,,565.95,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1196.58,
ALLERGAN SCM-520 BREAST IMPLANT 520CC,C1789,HCPCS,,79011169,CDM,278,RC,,,both,,,4005,2963.71,,,2963.71,Other,150% of Medicare + 9.63% HCRA Surcharge,1802.25,45,,1802.25,percent of total billed charges,Critical Access Hospital RCC factor,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1982.48,,,1982.48,Other,110% of Medicare,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1361.7,34,"Charges > $500, x 34%",1361.7,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1602,40,,1602,percent of total billed charges,Implant Device,1401.75,70,,1401.75,percent of total billed charges,All Other,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1361.7,34,"If Charge > 2,000, then 34 percent",1361.7,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2963.71,
ALLERGAN SCM-560 BREAST IMPLANT 560CC,C1789,HCPCS,,79011170,CDM,278,RC,,,both,,,4005,2963.71,,,2963.71,Other,150% of Medicare + 9.63% HCRA Surcharge,1802.25,45,,1802.25,percent of total billed charges,Critical Access Hospital RCC factor,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1982.48,,,1982.48,Other,110% of Medicare,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1361.7,34,"Charges > $500, x 34%",1361.7,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1602,40,,1602,percent of total billed charges,Implant Device,1401.75,70,,1401.75,percent of total billed charges,All Other,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1361.7,34,"If Charge > 2,000, then 34 percent",1361.7,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2963.71,
ALLERGAN SCM-600 BREAST IMPLANT 600CC,C1789,HCPCS,,79011171,CDM,278,RC,,,both,,,4005,2963.71,,,2963.71,Other,150% of Medicare + 9.63% HCRA Surcharge,1802.25,45,,1802.25,percent of total billed charges,Critical Access Hospital RCC factor,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1982.48,,,1982.48,Other,110% of Medicare,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1361.7,34,"Charges > $500, x 34%",1361.7,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1602,40,,1602,percent of total billed charges,Implant Device,1401.75,70,,1401.75,percent of total billed charges,All Other,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1361.7,34,"If Charge > 2,000, then 34 percent",1361.7,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2963.71,
ALLERGAN SCM-640 BREAST IMPLANT 640CC,C1789,HCPCS,,79011172,CDM,278,RC,,,both,,,4005,2963.71,,,2963.71,Other,150% of Medicare + 9.63% HCRA Surcharge,1802.25,45,,1802.25,percent of total billed charges,Critical Access Hospital RCC factor,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1982.48,,,1982.48,Other,110% of Medicare,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1361.7,34,"Charges > $500, x 34%",1361.7,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1602,40,,1602,percent of total billed charges,Implant Device,1401.75,70,,1401.75,percent of total billed charges,All Other,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1361.7,34,"If Charge > 2,000, then 34 percent",1361.7,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2963.71,
ALLERGAN 133S-FV-14-T EXPANDER 600CC,C1789,HCPCS,,79011174,CDM,278,RC,,,both,,,4785,3540.91,,,3540.91,Other,150% of Medicare + 9.63% HCRA Surcharge,2153.25,45,,2153.25,percent of total billed charges,Critical Access Hospital RCC factor,1626.9,34,,1626.9,percent of total billed charges,Implant Device,1626.9,34,,1626.9,percent of total billed charges,Implant Device,1626.9,34,,1626.9,percent of total billed charges,Implant Device,1626.9,34,,1626.9,percent of total billed charges,Implant Device,1626.9,34,,1626.9,percent of total billed charges,Implant Device,2368.58,,,2368.58,Other,110% of Medicare,1674.75,35,,1674.75,percent of total billed charges,Implant Device,1626.9,34,"Charges > $500, x 34%",1626.9,percent of total billed charges,Implant Device,1674.75,35,,1674.75,percent of total billed charges,Implant Device,1674.75,35,,1674.75,percent of total billed charges,Implant Device,1674.75,35,,1674.75,percent of total billed charges,Implant Device,1674.75,35,,1674.75,percent of total billed charges,Implant Device,1674.75,35,,1674.75,percent of total billed charges,Implant Device,1914,40,,1914,percent of total billed charges,Implant Device,1674.75,70,,1674.75,percent of total billed charges,All Other,1626.9,34,,1626.9,percent of total billed charges,Implant Device,1626.9,34,,1626.9,percent of total billed charges,Implant Device,1674.75,35,,1674.75,percent of total billed charges,Implant Device,1674.75,35,,1674.75,percent of total billed charges,Implant Device,1674.75,35,,1674.75,percent of total billed charges,Implant Device,1674.75,35,,1674.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1626.9,34,"If Charge > 2,000, then 34 percent",1626.9,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3540.91,
ALLERGAN 133S-FV-15-T EXPANDER 750CC,C1789,HCPCS,,79011175,CDM,278,RC,,,both,,,4785,3540.91,,,3540.91,Other,150% of Medicare + 9.63% HCRA Surcharge,2153.25,45,,2153.25,percent of total billed charges,Critical Access Hospital RCC factor,1626.9,34,,1626.9,percent of total billed charges,Implant Device,1626.9,34,,1626.9,percent of total billed charges,Implant Device,1626.9,34,,1626.9,percent of total billed charges,Implant Device,1626.9,34,,1626.9,percent of total billed charges,Implant Device,1626.9,34,,1626.9,percent of total billed charges,Implant Device,2368.58,,,2368.58,Other,110% of Medicare,1674.75,35,,1674.75,percent of total billed charges,Implant Device,1626.9,34,"Charges > $500, x 34%",1626.9,percent of total billed charges,Implant Device,1674.75,35,,1674.75,percent of total billed charges,Implant Device,1674.75,35,,1674.75,percent of total billed charges,Implant Device,1674.75,35,,1674.75,percent of total billed charges,Implant Device,1674.75,35,,1674.75,percent of total billed charges,Implant Device,1674.75,35,,1674.75,percent of total billed charges,Implant Device,1914,40,,1914,percent of total billed charges,Implant Device,1674.75,70,,1674.75,percent of total billed charges,All Other,1626.9,34,,1626.9,percent of total billed charges,Implant Device,1626.9,34,,1626.9,percent of total billed charges,Implant Device,1674.75,35,,1674.75,percent of total billed charges,Implant Device,1674.75,35,,1674.75,percent of total billed charges,Implant Device,1674.75,35,,1674.75,percent of total billed charges,Implant Device,1674.75,35,,1674.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1626.9,34,"If Charge > 2,000, then 34 percent",1626.9,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3540.91,
ALLERGAN 133S-FV-16-T EXPANDER 850CC,C1789,HCPCS,,79011176,CDM,278,RC,,,both,,,4785,3540.91,,,3540.91,Other,150% of Medicare + 9.63% HCRA Surcharge,2153.25,45,,2153.25,percent of total billed charges,Critical Access Hospital RCC factor,1626.9,34,,1626.9,percent of total billed charges,Implant Device,1626.9,34,,1626.9,percent of total billed charges,Implant Device,1626.9,34,,1626.9,percent of total billed charges,Implant Device,1626.9,34,,1626.9,percent of total billed charges,Implant Device,1626.9,34,,1626.9,percent of total billed charges,Implant Device,2368.58,,,2368.58,Other,110% of Medicare,1674.75,35,,1674.75,percent of total billed charges,Implant Device,1626.9,34,"Charges > $500, x 34%",1626.9,percent of total billed charges,Implant Device,1674.75,35,,1674.75,percent of total billed charges,Implant Device,1674.75,35,,1674.75,percent of total billed charges,Implant Device,1674.75,35,,1674.75,percent of total billed charges,Implant Device,1674.75,35,,1674.75,percent of total billed charges,Implant Device,1674.75,35,,1674.75,percent of total billed charges,Implant Device,1914,40,,1914,percent of total billed charges,Implant Device,1674.75,70,,1674.75,percent of total billed charges,All Other,1626.9,34,,1626.9,percent of total billed charges,Implant Device,1626.9,34,,1626.9,percent of total billed charges,Implant Device,1674.75,35,,1674.75,percent of total billed charges,Implant Device,1674.75,35,,1674.75,percent of total billed charges,Implant Device,1674.75,35,,1674.75,percent of total billed charges,Implant Device,1674.75,35,,1674.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1626.9,34,"If Charge > 2,000, then 34 percent",1626.9,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3540.91,
ALLERGAN SCM-685 BREAST IMPLANT 685CC,C1789,HCPCS,,79011177,CDM,278,RC,,,both,,,4005,2963.71,,,2963.71,Other,150% of Medicare + 9.63% HCRA Surcharge,1802.25,45,,1802.25,percent of total billed charges,Critical Access Hospital RCC factor,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1982.48,,,1982.48,Other,110% of Medicare,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1361.7,34,"Charges > $500, x 34%",1361.7,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1602,40,,1602,percent of total billed charges,Implant Device,1401.75,70,,1401.75,percent of total billed charges,All Other,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1361.7,34,"If Charge > 2,000, then 34 percent",1361.7,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2963.71,
ALLERGAN SCM-755 BREAST IMPLANT 755CC,C1789,HCPCS,,79011178,CDM,278,RC,,,both,,,4005,2963.71,,,2963.71,Other,150% of Medicare + 9.63% HCRA Surcharge,1802.25,45,,1802.25,percent of total billed charges,Critical Access Hospital RCC factor,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1982.48,,,1982.48,Other,110% of Medicare,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1361.7,34,"Charges > $500, x 34%",1361.7,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1602,40,,1602,percent of total billed charges,Implant Device,1401.75,70,,1401.75,percent of total billed charges,All Other,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1361.7,34,"If Charge > 2,000, then 34 percent",1361.7,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2963.71,
ALLERGAN SCLP-590 BREAST IMPLANT 5900CC,C1789,HCPCS,,79011179,CDM,278,RC,,,both,,,4005,2963.71,,,2963.71,Other,150% of Medicare + 9.63% HCRA Surcharge,1802.25,45,,1802.25,percent of total billed charges,Critical Access Hospital RCC factor,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1982.48,,,1982.48,Other,110% of Medicare,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1361.7,34,"Charges > $500, x 34%",1361.7,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1602,40,,1602,percent of total billed charges,Implant Device,1401.75,70,,1401.75,percent of total billed charges,All Other,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1361.7,34,"If Charge > 2,000, then 34 percent",1361.7,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2963.71,
ALLERGAN SCLP-640 BREAST IMPLANT 640CC,C1789,HCPCS,,79011180,CDM,278,RC,,,both,,,4005,2963.71,,,2963.71,Other,150% of Medicare + 9.63% HCRA Surcharge,1802.25,45,,1802.25,percent of total billed charges,Critical Access Hospital RCC factor,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1982.48,,,1982.48,Other,110% of Medicare,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1361.7,34,"Charges > $500, x 34%",1361.7,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1602,40,,1602,percent of total billed charges,Implant Device,1401.75,70,,1401.75,percent of total billed charges,All Other,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1361.7,34,,1361.7,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,1401.75,35,,1401.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1361.7,34,"If Charge > 2,000, then 34 percent",1361.7,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2963.71,
STRYKER 629750 LOCK PLATE 2.7X9MM 10H,C1713,HCPCS,,79011186,CDM,278,RC,,,both,,,3318,2455.33,,,2455.33,Other,150% of Medicare + 9.63% HCRA Surcharge,1493.1,45,,1493.1,percent of total billed charges,Critical Access Hospital RCC factor,1128.12,34,,1128.12,percent of total billed charges,Implant Device,1128.12,34,,1128.12,percent of total billed charges,Implant Device,1128.12,34,,1128.12,percent of total billed charges,Implant Device,1128.12,34,,1128.12,percent of total billed charges,Implant Device,1128.12,34,,1128.12,percent of total billed charges,Implant Device,1642.41,,,1642.41,Other,110% of Medicare,1161.3,35,,1161.3,percent of total billed charges,Implant Device,1128.12,34,"Charges > $500, x 34%",1128.12,percent of total billed charges,Implant Device,1161.3,35,,1161.3,percent of total billed charges,Implant Device,1161.3,35,,1161.3,percent of total billed charges,Implant Device,1161.3,35,,1161.3,percent of total billed charges,Implant Device,1161.3,35,,1161.3,percent of total billed charges,Implant Device,1161.3,35,,1161.3,percent of total billed charges,Implant Device,1327.2,40,,1327.2,percent of total billed charges,Implant Device,1161.3,70,,1161.3,percent of total billed charges,All Other,1128.12,34,,1128.12,percent of total billed charges,Implant Device,1128.12,34,,1128.12,percent of total billed charges,Implant Device,1161.3,35,,1161.3,percent of total billed charges,Implant Device,1161.3,35,,1161.3,percent of total billed charges,Implant Device,1161.3,35,,1161.3,percent of total billed charges,Implant Device,1161.3,35,,1161.3,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1128.12,34,"If Charge > 2,000, then 34 percent",1128.12,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2455.33,
STRYKER 626682 TUBULAR PLATE 12H 143MM,C1713,HCPCS,,79011189,CDM,278,RC,,,both,,,1097,811.78,,,811.78,Other,150% of Medicare + 9.63% HCRA Surcharge,493.65,45,,493.65,percent of total billed charges,Critical Access Hospital RCC factor,372.98,34,,372.98,percent of total billed charges,Implant Device,372.98,34,,372.98,percent of total billed charges,Implant Device,372.98,34,,372.98,percent of total billed charges,Implant Device,372.98,34,,372.98,percent of total billed charges,Implant Device,372.98,34,,372.98,percent of total billed charges,Implant Device,543.02,,,543.02,Other,110% of Medicare,383.95,35,,383.95,percent of total billed charges,Implant Device,372.98,34,"Charges > $500, x 34%",372.98,percent of total billed charges,Implant Device,383.95,35,,383.95,percent of total billed charges,Implant Device,383.95,35,,383.95,percent of total billed charges,Implant Device,383.95,35,,383.95,percent of total billed charges,Implant Device,383.95,35,,383.95,percent of total billed charges,Implant Device,383.95,35,,383.95,percent of total billed charges,Implant Device,438.8,40,,438.8,percent of total billed charges,Implant Device,383.95,70,,383.95,percent of total billed charges,All Other,372.98,34,,372.98,percent of total billed charges,Implant Device,372.98,34,,372.98,percent of total billed charges,Implant Device,383.95,35,,383.95,percent of total billed charges,Implant Device,383.95,35,,383.95,percent of total billed charges,Implant Device,383.95,35,,383.95,percent of total billed charges,Implant Device,383.95,35,,383.95,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,811.78,
IN2BONES T50 SN010 COMP STAPLE 10X10X10,C1713,HCPCS,,79011190,CDM,278,RC,,,both,,,4485,3318.91,,,3318.91,Other,150% of Medicare + 9.63% HCRA Surcharge,2018.25,45,,2018.25,percent of total billed charges,Critical Access Hospital RCC factor,1524.9,34,,1524.9,percent of total billed charges,Implant Device,1524.9,34,,1524.9,percent of total billed charges,Implant Device,1524.9,34,,1524.9,percent of total billed charges,Implant Device,1524.9,34,,1524.9,percent of total billed charges,Implant Device,1524.9,34,,1524.9,percent of total billed charges,Implant Device,2220.08,,,2220.08,Other,110% of Medicare,1569.75,35,,1569.75,percent of total billed charges,Implant Device,1524.9,34,"Charges > $500, x 34%",1524.9,percent of total billed charges,Implant Device,1569.75,35,,1569.75,percent of total billed charges,Implant Device,1569.75,35,,1569.75,percent of total billed charges,Implant Device,1569.75,35,,1569.75,percent of total billed charges,Implant Device,1569.75,35,,1569.75,percent of total billed charges,Implant Device,1569.75,35,,1569.75,percent of total billed charges,Implant Device,1794,40,,1794,percent of total billed charges,Implant Device,1569.75,70,,1569.75,percent of total billed charges,All Other,1524.9,34,,1524.9,percent of total billed charges,Implant Device,1524.9,34,,1524.9,percent of total billed charges,Implant Device,1569.75,35,,1569.75,percent of total billed charges,Implant Device,1569.75,35,,1569.75,percent of total billed charges,Implant Device,1569.75,35,,1569.75,percent of total billed charges,Implant Device,1569.75,35,,1569.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1524.9,34,"If Charge > 2,000, then 34 percent",1524.9,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3318.91,
ZIMMER 110010244 ACETABULAR SHELL 52MM,C1776,HCPCS,,79011191,CDM,278,RC,,,both,,,8602,6365.5,,,6365.5,Other,150% of Medicare + 9.63% HCRA Surcharge,3870.9,45,,3870.9,percent of total billed charges,Critical Access Hospital RCC factor,2924.68,34,,2924.68,percent of total billed charges,Implant Device,2924.68,34,,2924.68,percent of total billed charges,Implant Device,2924.68,34,,2924.68,percent of total billed charges,Implant Device,2924.68,34,,2924.68,percent of total billed charges,Implant Device,2924.68,34,,2924.68,percent of total billed charges,Implant Device,4257.99,,,4257.99,Other,110% of Medicare,3010.7,35,,3010.7,percent of total billed charges,Implant Device,2924.68,34,"Charges > $500, x 34%",2924.68,percent of total billed charges,Implant Device,3010.7,35,,3010.7,percent of total billed charges,Implant Device,3010.7,35,,3010.7,percent of total billed charges,Implant Device,3010.7,35,,3010.7,percent of total billed charges,Implant Device,3010.7,35,,3010.7,percent of total billed charges,Implant Device,3010.7,35,,3010.7,percent of total billed charges,Implant Device,3440.8,40,,3440.8,percent of total billed charges,Implant Device,3010.7,70,,3010.7,percent of total billed charges,All Other,2924.68,34,,2924.68,percent of total billed charges,Implant Device,2924.68,34,,2924.68,percent of total billed charges,Implant Device,3010.7,35,,3010.7,percent of total billed charges,Implant Device,3010.7,35,,3010.7,percent of total billed charges,Implant Device,3010.7,35,,3010.7,percent of total billed charges,Implant Device,3010.7,35,,3010.7,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2924.68,34,"If Charge > 2,000, then 34 percent",2924.68,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,6365.5,
ZIMMER 30123605 LINER 36MM SIZE E,C1776,HCPCS,,79011192,CDM,278,RC,,,both,,,3456,2557.45,,,2557.45,Other,150% of Medicare + 9.63% HCRA Surcharge,1555.2,45,,1555.2,percent of total billed charges,Critical Access Hospital RCC factor,1175.04,34,,1175.04,percent of total billed charges,Implant Device,1175.04,34,,1175.04,percent of total billed charges,Implant Device,1175.04,34,,1175.04,percent of total billed charges,Implant Device,1175.04,34,,1175.04,percent of total billed charges,Implant Device,1175.04,34,,1175.04,percent of total billed charges,Implant Device,1710.72,,,1710.72,Other,110% of Medicare,1209.6,35,,1209.6,percent of total billed charges,Implant Device,1175.04,34,"Charges > $500, x 34%",1175.04,percent of total billed charges,Implant Device,1209.6,35,,1209.6,percent of total billed charges,Implant Device,1209.6,35,,1209.6,percent of total billed charges,Implant Device,1209.6,35,,1209.6,percent of total billed charges,Implant Device,1209.6,35,,1209.6,percent of total billed charges,Implant Device,1209.6,35,,1209.6,percent of total billed charges,Implant Device,1382.4,40,,1382.4,percent of total billed charges,Implant Device,1209.6,70,,1209.6,percent of total billed charges,All Other,1175.04,34,,1175.04,percent of total billed charges,Implant Device,1175.04,34,,1175.04,percent of total billed charges,Implant Device,1209.6,35,,1209.6,percent of total billed charges,Implant Device,1209.6,35,,1209.6,percent of total billed charges,Implant Device,1209.6,35,,1209.6,percent of total billed charges,Implant Device,1209.6,35,,1209.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1175.04,34,"If Charge > 2,000, then 34 percent",1175.04,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2557.45,
ZIMMER 574202000 FEM STEM 12/14 TAPER,C1776,HCPCS,,79011193,CDM,278,RC,,,both,,,6912,5114.9,,,5114.9,Other,150% of Medicare + 9.63% HCRA Surcharge,3110.4,45,,3110.4,percent of total billed charges,Critical Access Hospital RCC factor,2350.08,34,,2350.08,percent of total billed charges,Implant Device,2350.08,34,,2350.08,percent of total billed charges,Implant Device,2350.08,34,,2350.08,percent of total billed charges,Implant Device,2350.08,34,,2350.08,percent of total billed charges,Implant Device,2350.08,34,,2350.08,percent of total billed charges,Implant Device,3421.44,,,3421.44,Other,110% of Medicare,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2350.08,34,"Charges > $500, x 34%",2350.08,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2764.8,40,,2764.8,percent of total billed charges,Implant Device,2419.2,70,,2419.2,percent of total billed charges,All Other,2350.08,34,,2350.08,percent of total billed charges,Implant Device,2350.08,34,,2350.08,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2350.08,34,"If Charge > 2,000, then 34 percent",2350.08,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5114.9,
ZIMMER 110010245 ACETABULAR SHELL 54MM,C1776,HCPCS,,79011194,CDM,278,RC,,,both,,,8602,6365.5,,,6365.5,Other,150% of Medicare + 9.63% HCRA Surcharge,3870.9,45,,3870.9,percent of total billed charges,Critical Access Hospital RCC factor,2924.68,34,,2924.68,percent of total billed charges,Implant Device,2924.68,34,,2924.68,percent of total billed charges,Implant Device,2924.68,34,,2924.68,percent of total billed charges,Implant Device,2924.68,34,,2924.68,percent of total billed charges,Implant Device,2924.68,34,,2924.68,percent of total billed charges,Implant Device,4257.99,,,4257.99,Other,110% of Medicare,3010.7,35,,3010.7,percent of total billed charges,Implant Device,2924.68,34,"Charges > $500, x 34%",2924.68,percent of total billed charges,Implant Device,3010.7,35,,3010.7,percent of total billed charges,Implant Device,3010.7,35,,3010.7,percent of total billed charges,Implant Device,3010.7,35,,3010.7,percent of total billed charges,Implant Device,3010.7,35,,3010.7,percent of total billed charges,Implant Device,3010.7,35,,3010.7,percent of total billed charges,Implant Device,3440.8,40,,3440.8,percent of total billed charges,Implant Device,3010.7,70,,3010.7,percent of total billed charges,All Other,2924.68,34,,2924.68,percent of total billed charges,Implant Device,2924.68,34,,2924.68,percent of total billed charges,Implant Device,3010.7,35,,3010.7,percent of total billed charges,Implant Device,3010.7,35,,3010.7,percent of total billed charges,Implant Device,3010.7,35,,3010.7,percent of total billed charges,Implant Device,3010.7,35,,3010.7,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2924.68,34,"If Charge > 2,000, then 34 percent",2924.68,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,6365.5,
ZIMMER 30103606 LINER 36MM SIZE F,C1776,HCPCS,,79011195,CDM,278,RC,,,both,,,3456,2557.45,,,2557.45,Other,150% of Medicare + 9.63% HCRA Surcharge,1555.2,45,,1555.2,percent of total billed charges,Critical Access Hospital RCC factor,1175.04,34,,1175.04,percent of total billed charges,Implant Device,1175.04,34,,1175.04,percent of total billed charges,Implant Device,1175.04,34,,1175.04,percent of total billed charges,Implant Device,1175.04,34,,1175.04,percent of total billed charges,Implant Device,1175.04,34,,1175.04,percent of total billed charges,Implant Device,1710.72,,,1710.72,Other,110% of Medicare,1209.6,35,,1209.6,percent of total billed charges,Implant Device,1175.04,34,"Charges > $500, x 34%",1175.04,percent of total billed charges,Implant Device,1209.6,35,,1209.6,percent of total billed charges,Implant Device,1209.6,35,,1209.6,percent of total billed charges,Implant Device,1209.6,35,,1209.6,percent of total billed charges,Implant Device,1209.6,35,,1209.6,percent of total billed charges,Implant Device,1209.6,35,,1209.6,percent of total billed charges,Implant Device,1382.4,40,,1382.4,percent of total billed charges,Implant Device,1209.6,70,,1209.6,percent of total billed charges,All Other,1175.04,34,,1175.04,percent of total billed charges,Implant Device,1175.04,34,,1175.04,percent of total billed charges,Implant Device,1209.6,35,,1209.6,percent of total billed charges,Implant Device,1209.6,35,,1209.6,percent of total billed charges,Implant Device,1209.6,35,,1209.6,percent of total billed charges,Implant Device,1209.6,35,,1209.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1175.04,34,"If Charge > 2,000, then 34 percent",1175.04,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2557.45,
ZIMMER 650-0661 CERAMIC HEAD 36MM TYPE 1,C1776,HCPCS,,79011196,CDM,278,RC,,,both,,,3825,2830.51,,,2830.51,Other,150% of Medicare + 9.63% HCRA Surcharge,1721.25,45,,1721.25,percent of total billed charges,Critical Access Hospital RCC factor,1300.5,34,,1300.5,percent of total billed charges,Implant Device,1300.5,34,,1300.5,percent of total billed charges,Implant Device,1300.5,34,,1300.5,percent of total billed charges,Implant Device,1300.5,34,,1300.5,percent of total billed charges,Implant Device,1300.5,34,,1300.5,percent of total billed charges,Implant Device,1893.38,,,1893.38,Other,110% of Medicare,1338.75,35,,1338.75,percent of total billed charges,Implant Device,1300.5,34,"Charges > $500, x 34%",1300.5,percent of total billed charges,Implant Device,1338.75,35,,1338.75,percent of total billed charges,Implant Device,1338.75,35,,1338.75,percent of total billed charges,Implant Device,1338.75,35,,1338.75,percent of total billed charges,Implant Device,1338.75,35,,1338.75,percent of total billed charges,Implant Device,1338.75,35,,1338.75,percent of total billed charges,Implant Device,1530,40,,1530,percent of total billed charges,Implant Device,1338.75,70,,1338.75,percent of total billed charges,All Other,1300.5,34,,1300.5,percent of total billed charges,Implant Device,1300.5,34,,1300.5,percent of total billed charges,Implant Device,1338.75,35,,1338.75,percent of total billed charges,Implant Device,1338.75,35,,1338.75,percent of total billed charges,Implant Device,1338.75,35,,1338.75,percent of total billed charges,Implant Device,1338.75,35,,1338.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1300.5,34,"If Charge > 2,000, then 34 percent",1300.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2830.51,
ZIMMER 30123607 LINER 36MM SIZE G,C1776,HCPCS,,79011197,CDM,278,RC,,,both,,,3456,2557.45,,,2557.45,Other,150% of Medicare + 9.63% HCRA Surcharge,1555.2,45,,1555.2,percent of total billed charges,Critical Access Hospital RCC factor,1175.04,34,,1175.04,percent of total billed charges,Implant Device,1175.04,34,,1175.04,percent of total billed charges,Implant Device,1175.04,34,,1175.04,percent of total billed charges,Implant Device,1175.04,34,,1175.04,percent of total billed charges,Implant Device,1175.04,34,,1175.04,percent of total billed charges,Implant Device,1710.72,,,1710.72,Other,110% of Medicare,1209.6,35,,1209.6,percent of total billed charges,Implant Device,1175.04,34,"Charges > $500, x 34%",1175.04,percent of total billed charges,Implant Device,1209.6,35,,1209.6,percent of total billed charges,Implant Device,1209.6,35,,1209.6,percent of total billed charges,Implant Device,1209.6,35,,1209.6,percent of total billed charges,Implant Device,1209.6,35,,1209.6,percent of total billed charges,Implant Device,1209.6,35,,1209.6,percent of total billed charges,Implant Device,1382.4,40,,1382.4,percent of total billed charges,Implant Device,1209.6,70,,1209.6,percent of total billed charges,All Other,1175.04,34,,1175.04,percent of total billed charges,Implant Device,1175.04,34,,1175.04,percent of total billed charges,Implant Device,1209.6,35,,1209.6,percent of total billed charges,Implant Device,1209.6,35,,1209.6,percent of total billed charges,Implant Device,1209.6,35,,1209.6,percent of total billed charges,Implant Device,1209.6,35,,1209.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1175.04,34,"If Charge > 2,000, then 34 percent",1175.04,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2557.45,
ZIMMER 110010248 ACETABULAR SHELL 60MM,C1776,HCPCS,,79011198,CDM,278,RC,,,both,,,8602,6365.5,,,6365.5,Other,150% of Medicare + 9.63% HCRA Surcharge,3870.9,45,,3870.9,percent of total billed charges,Critical Access Hospital RCC factor,2924.68,34,,2924.68,percent of total billed charges,Implant Device,2924.68,34,,2924.68,percent of total billed charges,Implant Device,2924.68,34,,2924.68,percent of total billed charges,Implant Device,2924.68,34,,2924.68,percent of total billed charges,Implant Device,2924.68,34,,2924.68,percent of total billed charges,Implant Device,4257.99,,,4257.99,Other,110% of Medicare,3010.7,35,,3010.7,percent of total billed charges,Implant Device,2924.68,34,"Charges > $500, x 34%",2924.68,percent of total billed charges,Implant Device,3010.7,35,,3010.7,percent of total billed charges,Implant Device,3010.7,35,,3010.7,percent of total billed charges,Implant Device,3010.7,35,,3010.7,percent of total billed charges,Implant Device,3010.7,35,,3010.7,percent of total billed charges,Implant Device,3010.7,35,,3010.7,percent of total billed charges,Implant Device,3440.8,40,,3440.8,percent of total billed charges,Implant Device,3010.7,70,,3010.7,percent of total billed charges,All Other,2924.68,34,,2924.68,percent of total billed charges,Implant Device,2924.68,34,,2924.68,percent of total billed charges,Implant Device,3010.7,35,,3010.7,percent of total billed charges,Implant Device,3010.7,35,,3010.7,percent of total billed charges,Implant Device,3010.7,35,,3010.7,percent of total billed charges,Implant Device,3010.7,35,,3010.7,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2924.68,34,"If Charge > 2,000, then 34 percent",2924.68,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,6365.5,
STRYKER 709-04-52E ACETABULAR SHELL 52MM,C1776,HCPCS,,79011199,CDM,278,RC,,,both,,,9296,6879.06,,,6879.06,Other,150% of Medicare + 9.63% HCRA Surcharge,4183.2,45,,4183.2,percent of total billed charges,Critical Access Hospital RCC factor,3160.64,34,,3160.64,percent of total billed charges,Implant Device,3160.64,34,,3160.64,percent of total billed charges,Implant Device,3160.64,34,,3160.64,percent of total billed charges,Implant Device,3160.64,34,,3160.64,percent of total billed charges,Implant Device,3160.64,34,,3160.64,percent of total billed charges,Implant Device,4601.52,,,4601.52,Other,110% of Medicare,3253.6,35,,3253.6,percent of total billed charges,Implant Device,3160.64,34,"Charges > $500, x 34%",3160.64,percent of total billed charges,Implant Device,3253.6,35,,3253.6,percent of total billed charges,Implant Device,3253.6,35,,3253.6,percent of total billed charges,Implant Device,3253.6,35,,3253.6,percent of total billed charges,Implant Device,3253.6,35,,3253.6,percent of total billed charges,Implant Device,3253.6,35,,3253.6,percent of total billed charges,Implant Device,3718.4,40,,3718.4,percent of total billed charges,Implant Device,3253.6,70,,3253.6,percent of total billed charges,All Other,3160.64,34,,3160.64,percent of total billed charges,Implant Device,3160.64,34,,3160.64,percent of total billed charges,Implant Device,3253.6,35,,3253.6,percent of total billed charges,Implant Device,3253.6,35,,3253.6,percent of total billed charges,Implant Device,3253.6,35,,3253.6,percent of total billed charges,Implant Device,3253.6,35,,3253.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3160.64,34,"If Charge > 2,000, then 34 percent",3160.64,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,6879.06,
STRYKER 661416 CORTEX SCREW 73.5X16MM,C1713,HCPCS,,79011201,CDM,278,RC,,,both,,,122,90.28,,,90.28,Other,150% of Medicare + 9.63% HCRA Surcharge,54.9,45,,54.9,percent of total billed charges,Critical Access Hospital RCC factor,41.48,34,,41.48,percent of total billed charges,Implant Device,41.48,34,,41.48,percent of total billed charges,Implant Device,41.48,34,,41.48,percent of total billed charges,Implant Device,41.48,34,,41.48,percent of total billed charges,Implant Device,41.48,34,,41.48,percent of total billed charges,Implant Device,60.39,,,60.39,Other,110% of Medicare,42.7,35,,42.7,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,42.7,35,,42.7,percent of total billed charges,Implant Device,42.7,35,,42.7,percent of total billed charges,Implant Device,42.7,35,,42.7,percent of total billed charges,Implant Device,42.7,35,,42.7,percent of total billed charges,Implant Device,42.7,35,,42.7,percent of total billed charges,Implant Device,48.8,40,,48.8,percent of total billed charges,Implant Device,42.7,70,,42.7,percent of total billed charges,All Other,41.48,34,,41.48,percent of total billed charges,Implant Device,41.48,34,,41.48,percent of total billed charges,Implant Device,42.7,35,,42.7,percent of total billed charges,Implant Device,42.7,35,,42.7,percent of total billed charges,Implant Device,42.7,35,,42.7,percent of total billed charges,Implant Device,42.7,35,,42.7,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,90.28,
STRYKER 5537-G-422 TIB INSERT SZ 4 22MM,C1776,HCPCS,,79011202,CDM,278,RC,,,both,,,6650,4921.02,,,4921.02,Other,150% of Medicare + 9.63% HCRA Surcharge,2992.5,45,,2992.5,percent of total billed charges,Critical Access Hospital RCC factor,2261,34,,2261,percent of total billed charges,Implant Device,2261,34,,2261,percent of total billed charges,Implant Device,2261,34,,2261,percent of total billed charges,Implant Device,2261,34,,2261,percent of total billed charges,Implant Device,2261,34,,2261,percent of total billed charges,Implant Device,3291.75,,,3291.75,Other,110% of Medicare,2327.5,35,,2327.5,percent of total billed charges,Implant Device,2261,34,"Charges > $500, x 34%",2261,percent of total billed charges,Implant Device,2327.5,35,,2327.5,percent of total billed charges,Implant Device,2327.5,35,,2327.5,percent of total billed charges,Implant Device,2327.5,35,,2327.5,percent of total billed charges,Implant Device,2327.5,35,,2327.5,percent of total billed charges,Implant Device,2327.5,35,,2327.5,percent of total billed charges,Implant Device,2660,40,,2660,percent of total billed charges,Implant Device,2327.5,70,,2327.5,percent of total billed charges,All Other,2261,34,,2261,percent of total billed charges,Implant Device,2261,34,,2261,percent of total billed charges,Implant Device,2327.5,35,,2327.5,percent of total billed charges,Implant Device,2327.5,35,,2327.5,percent of total billed charges,Implant Device,2327.5,35,,2327.5,percent of total billed charges,Implant Device,2327.5,35,,2327.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2261,34,"If Charge > 2,000, then 34 percent",2261,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4921.02,
STRYKER 5560-S-112 STEM 12X50MM,C1776,HCPCS,,79011203,CDM,278,RC,,,both,,,3324,2459.77,,,2459.77,Other,150% of Medicare + 9.63% HCRA Surcharge,1495.8,45,,1495.8,percent of total billed charges,Critical Access Hospital RCC factor,1130.16,34,,1130.16,percent of total billed charges,Implant Device,1130.16,34,,1130.16,percent of total billed charges,Implant Device,1130.16,34,,1130.16,percent of total billed charges,Implant Device,1130.16,34,,1130.16,percent of total billed charges,Implant Device,1130.16,34,,1130.16,percent of total billed charges,Implant Device,1645.38,,,1645.38,Other,110% of Medicare,1163.4,35,,1163.4,percent of total billed charges,Implant Device,1130.16,34,"Charges > $500, x 34%",1130.16,percent of total billed charges,Implant Device,1163.4,35,,1163.4,percent of total billed charges,Implant Device,1163.4,35,,1163.4,percent of total billed charges,Implant Device,1163.4,35,,1163.4,percent of total billed charges,Implant Device,1163.4,35,,1163.4,percent of total billed charges,Implant Device,1163.4,35,,1163.4,percent of total billed charges,Implant Device,1329.6,40,,1329.6,percent of total billed charges,Implant Device,1163.4,70,,1163.4,percent of total billed charges,All Other,1130.16,34,,1130.16,percent of total billed charges,Implant Device,1130.16,34,,1130.16,percent of total billed charges,Implant Device,1163.4,35,,1163.4,percent of total billed charges,Implant Device,1163.4,35,,1163.4,percent of total billed charges,Implant Device,1163.4,35,,1163.4,percent of total billed charges,Implant Device,1163.4,35,,1163.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1130.16,34,"If Charge > 2,000, then 34 percent",1130.16,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2459.77,
ZIMMER 00-1147-036-40 CANN SCREW 4X36MM,C1713,HCPCS,,79011204,CDM,278,RC,,,both,,,605,447.7,,,447.7,Other,150% of Medicare + 9.63% HCRA Surcharge,272.25,45,,272.25,percent of total billed charges,Critical Access Hospital RCC factor,205.7,34,,205.7,percent of total billed charges,Implant Device,205.7,34,,205.7,percent of total billed charges,Implant Device,205.7,34,,205.7,percent of total billed charges,Implant Device,205.7,34,,205.7,percent of total billed charges,Implant Device,205.7,34,,205.7,percent of total billed charges,Implant Device,299.48,,,299.48,Other,110% of Medicare,211.75,35,,211.75,percent of total billed charges,Implant Device,205.7,34,"Charges > $500, x 34%",205.7,percent of total billed charges,Implant Device,211.75,35,,211.75,percent of total billed charges,Implant Device,211.75,35,,211.75,percent of total billed charges,Implant Device,211.75,35,,211.75,percent of total billed charges,Implant Device,211.75,35,,211.75,percent of total billed charges,Implant Device,211.75,35,,211.75,percent of total billed charges,Implant Device,242,40,,242,percent of total billed charges,Implant Device,211.75,70,,211.75,percent of total billed charges,All Other,205.7,34,,205.7,percent of total billed charges,Implant Device,205.7,34,,205.7,percent of total billed charges,Implant Device,211.75,35,,211.75,percent of total billed charges,Implant Device,211.75,35,,211.75,percent of total billed charges,Implant Device,211.75,35,,211.75,percent of total billed charges,Implant Device,211.75,35,,211.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,447.7,
IN2BONES P40 ST137 MTP REVISION PLATE RT,C1713,HCPCS,,79011205,CDM,278,RC,,,both,,,6000,4440.02,,,4440.02,Other,150% of Medicare + 9.63% HCRA Surcharge,2700,45,,2700,percent of total billed charges,Critical Access Hospital RCC factor,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2970,,,2970,Other,110% of Medicare,2100,35,,2100,percent of total billed charges,Implant Device,2040,34,"Charges > $500, x 34%",2040,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2400,40,,2400,percent of total billed charges,Implant Device,2100,70,,2100,percent of total billed charges,All Other,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2040,34,"If Charge > 2,000, then 34 percent",2040,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4440.02,
STRYKER IH2518 HEADLESS SCREW 2.5X18MM,C1713,HCPCS,,79011206,CDM,278,RC,,,both,,,858,634.92,,,634.92,Other,150% of Medicare + 9.63% HCRA Surcharge,386.1,45,,386.1,percent of total billed charges,Critical Access Hospital RCC factor,291.72,34,,291.72,percent of total billed charges,Implant Device,291.72,34,,291.72,percent of total billed charges,Implant Device,291.72,34,,291.72,percent of total billed charges,Implant Device,291.72,34,,291.72,percent of total billed charges,Implant Device,291.72,34,,291.72,percent of total billed charges,Implant Device,424.71,,,424.71,Other,110% of Medicare,300.3,35,,300.3,percent of total billed charges,Implant Device,291.72,34,"Charges > $500, x 34%",291.72,percent of total billed charges,Implant Device,300.3,35,,300.3,percent of total billed charges,Implant Device,300.3,35,,300.3,percent of total billed charges,Implant Device,300.3,35,,300.3,percent of total billed charges,Implant Device,300.3,35,,300.3,percent of total billed charges,Implant Device,300.3,35,,300.3,percent of total billed charges,Implant Device,343.2,40,,343.2,percent of total billed charges,Implant Device,300.3,70,,300.3,percent of total billed charges,All Other,291.72,34,,291.72,percent of total billed charges,Implant Device,291.72,34,,291.72,percent of total billed charges,Implant Device,300.3,35,,300.3,percent of total billed charges,Implant Device,300.3,35,,300.3,percent of total billed charges,Implant Device,300.3,35,,300.3,percent of total billed charges,Implant Device,300.3,35,,300.3,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,634.92,
STRYKER IH2520 HEADLESS SCREW 2.5X20MM,C1713,HCPCS,,79011207,CDM,278,RC,,,both,,,858,634.92,,,634.92,Other,150% of Medicare + 9.63% HCRA Surcharge,386.1,45,,386.1,percent of total billed charges,Critical Access Hospital RCC factor,291.72,34,,291.72,percent of total billed charges,Implant Device,291.72,34,,291.72,percent of total billed charges,Implant Device,291.72,34,,291.72,percent of total billed charges,Implant Device,291.72,34,,291.72,percent of total billed charges,Implant Device,291.72,34,,291.72,percent of total billed charges,Implant Device,424.71,,,424.71,Other,110% of Medicare,300.3,35,,300.3,percent of total billed charges,Implant Device,291.72,34,"Charges > $500, x 34%",291.72,percent of total billed charges,Implant Device,300.3,35,,300.3,percent of total billed charges,Implant Device,300.3,35,,300.3,percent of total billed charges,Implant Device,300.3,35,,300.3,percent of total billed charges,Implant Device,300.3,35,,300.3,percent of total billed charges,Implant Device,300.3,35,,300.3,percent of total billed charges,Implant Device,343.2,40,,343.2,percent of total billed charges,Implant Device,300.3,70,,300.3,percent of total billed charges,All Other,291.72,34,,291.72,percent of total billed charges,Implant Device,291.72,34,,291.72,percent of total billed charges,Implant Device,300.3,35,,300.3,percent of total billed charges,Implant Device,300.3,35,,300.3,percent of total billed charges,Implant Device,300.3,35,,300.3,percent of total billed charges,Implant Device,300.3,35,,300.3,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,634.92,
ZIMMER 00-2359-032-45 LOCK SCREW 4.5X32,C1713,HCPCS,,79011212,CDM,278,RC,,,both,,,445,329.3,,,329.3,Other,150% of Medicare + 9.63% HCRA Surcharge,200.25,45,,200.25,percent of total billed charges,Critical Access Hospital RCC factor,151.3,34,,151.3,percent of total billed charges,Implant Device,151.3,34,,151.3,percent of total billed charges,Implant Device,151.3,34,,151.3,percent of total billed charges,Implant Device,151.3,34,,151.3,percent of total billed charges,Implant Device,151.3,34,,151.3,percent of total billed charges,Implant Device,220.28,,,220.28,Other,110% of Medicare,155.75,35,,155.75,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,155.75,35,,155.75,percent of total billed charges,Implant Device,155.75,35,,155.75,percent of total billed charges,Implant Device,155.75,35,,155.75,percent of total billed charges,Implant Device,155.75,35,,155.75,percent of total billed charges,Implant Device,155.75,35,,155.75,percent of total billed charges,Implant Device,178,40,,178,percent of total billed charges,Implant Device,155.75,70,,155.75,percent of total billed charges,All Other,151.3,34,,151.3,percent of total billed charges,Implant Device,151.3,34,,151.3,percent of total billed charges,Implant Device,155.75,35,,155.75,percent of total billed charges,Implant Device,155.75,35,,155.75,percent of total billed charges,Implant Device,155.75,35,,155.75,percent of total billed charges,Implant Device,155.75,35,,155.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,329.3,
MEDTRONIC RONYX20008UX ONYX DES 2X8MM,C1874,HCPCS,,79011213,CDM,278,RC,,,both,,,2475,1831.51,,,1831.51,Other,150% of Medicare + 9.63% HCRA Surcharge,1113.75,45,,1113.75,percent of total billed charges,Critical Access Hospital RCC factor,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,1225.13,,,1225.13,Other,110% of Medicare,866.25,35,,866.25,percent of total billed charges,Implant Device,841.5,34,"Charges > $500, x 34%",841.5,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,990,40,,990,percent of total billed charges,Implant Device,866.25,70,,866.25,percent of total billed charges,All Other,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,841.5,34,"If Charge > 2,000, then 34 percent",841.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1831.51,
MEDTRONIC RONYX20012UX ONYX DES 2X12MM,C1874,HCPCS,,79011214,CDM,278,RC,,,both,,,2475,1831.51,,,1831.51,Other,150% of Medicare + 9.63% HCRA Surcharge,1113.75,45,,1113.75,percent of total billed charges,Critical Access Hospital RCC factor,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,1225.13,,,1225.13,Other,110% of Medicare,866.25,35,,866.25,percent of total billed charges,Implant Device,841.5,34,"Charges > $500, x 34%",841.5,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,990,40,,990,percent of total billed charges,Implant Device,866.25,70,,866.25,percent of total billed charges,All Other,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,841.5,34,"If Charge > 2,000, then 34 percent",841.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1831.51,
MEDTRONIC RONYX20015UX ONYX DES 2X15MM,C1874,HCPCS,,79011215,CDM,278,RC,,,both,,,2475,1831.51,,,1831.51,Other,150% of Medicare + 9.63% HCRA Surcharge,1113.75,45,,1113.75,percent of total billed charges,Critical Access Hospital RCC factor,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,1225.13,,,1225.13,Other,110% of Medicare,866.25,35,,866.25,percent of total billed charges,Implant Device,841.5,34,"Charges > $500, x 34%",841.5,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,990,40,,990,percent of total billed charges,Implant Device,866.25,70,,866.25,percent of total billed charges,All Other,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,841.5,34,"If Charge > 2,000, then 34 percent",841.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1831.51,
MEDTRONIC RONYX20018UX DES 2X18MM,C1874,HCPCS,,79011216,CDM,278,RC,,,both,,,2475,1831.51,,,1831.51,Other,150% of Medicare + 9.63% HCRA Surcharge,1113.75,45,,1113.75,percent of total billed charges,Critical Access Hospital RCC factor,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,1225.13,,,1225.13,Other,110% of Medicare,866.25,35,,866.25,percent of total billed charges,Implant Device,841.5,34,"Charges > $500, x 34%",841.5,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,990,40,,990,percent of total billed charges,Implant Device,866.25,70,,866.25,percent of total billed charges,All Other,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,841.5,34,"If Charge > 2,000, then 34 percent",841.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1831.51,
MEDTRONIC RONYX20022UX ONYX DES 2X22MM,C1874,HCPCS,,79011217,CDM,278,RC,,,both,,,2475,1831.51,,,1831.51,Other,150% of Medicare + 9.63% HCRA Surcharge,1113.75,45,,1113.75,percent of total billed charges,Critical Access Hospital RCC factor,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,1225.13,,,1225.13,Other,110% of Medicare,866.25,35,,866.25,percent of total billed charges,Implant Device,841.5,34,"Charges > $500, x 34%",841.5,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,990,40,,990,percent of total billed charges,Implant Device,866.25,70,,866.25,percent of total billed charges,All Other,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,841.5,34,"If Charge > 2,000, then 34 percent",841.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1831.51,
MEDTRONIC RONYX22508UX ONYX DES 2.25X8MM,C1874,HCPCS,,79011218,CDM,278,RC,,,both,,,2475,1831.51,,,1831.51,Other,150% of Medicare + 9.63% HCRA Surcharge,1113.75,45,,1113.75,percent of total billed charges,Critical Access Hospital RCC factor,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,1225.13,,,1225.13,Other,110% of Medicare,866.25,35,,866.25,percent of total billed charges,Implant Device,841.5,34,"Charges > $500, x 34%",841.5,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,990,40,,990,percent of total billed charges,Implant Device,866.25,70,,866.25,percent of total billed charges,All Other,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,841.5,34,"If Charge > 2,000, then 34 percent",841.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1831.51,
MEDTRONIC RONYX22512UX ONYX DES 2.25X12,C1874,HCPCS,,79011219,CDM,278,RC,,,both,,,2475,1831.51,,,1831.51,Other,150% of Medicare + 9.63% HCRA Surcharge,1113.75,45,,1113.75,percent of total billed charges,Critical Access Hospital RCC factor,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,1225.13,,,1225.13,Other,110% of Medicare,866.25,35,,866.25,percent of total billed charges,Implant Device,841.5,34,"Charges > $500, x 34%",841.5,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,990,40,,990,percent of total billed charges,Implant Device,866.25,70,,866.25,percent of total billed charges,All Other,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,841.5,34,"If Charge > 2,000, then 34 percent",841.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1831.51,
MEDTRONIC RONYX22515UX ONYX DES 2.25X15,C1874,HCPCS,,79011220,CDM,278,RC,,,both,,,2475,1831.51,,,1831.51,Other,150% of Medicare + 9.63% HCRA Surcharge,1113.75,45,,1113.75,percent of total billed charges,Critical Access Hospital RCC factor,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,1225.13,,,1225.13,Other,110% of Medicare,866.25,35,,866.25,percent of total billed charges,Implant Device,841.5,34,"Charges > $500, x 34%",841.5,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,990,40,,990,percent of total billed charges,Implant Device,866.25,70,,866.25,percent of total billed charges,All Other,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,841.5,34,"If Charge > 2,000, then 34 percent",841.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1831.51,
MEDTRONIC RONYX22518UX ONYX DES 2.25X18,C1874,HCPCS,,79011221,CDM,278,RC,,,both,,,2475,1831.51,,,1831.51,Other,150% of Medicare + 9.63% HCRA Surcharge,1113.75,45,,1113.75,percent of total billed charges,Critical Access Hospital RCC factor,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,1225.13,,,1225.13,Other,110% of Medicare,866.25,35,,866.25,percent of total billed charges,Implant Device,841.5,34,"Charges > $500, x 34%",841.5,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,990,40,,990,percent of total billed charges,Implant Device,866.25,70,,866.25,percent of total billed charges,All Other,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,841.5,34,"If Charge > 2,000, then 34 percent",841.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1831.51,
MEDTRONIC RONYX22522UX ONYX DES 2.25X22,C1874,HCPCS,,79011222,CDM,278,RC,,,both,,,2475,1831.51,,,1831.51,Other,150% of Medicare + 9.63% HCRA Surcharge,1113.75,45,,1113.75,percent of total billed charges,Critical Access Hospital RCC factor,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,1225.13,,,1225.13,Other,110% of Medicare,866.25,35,,866.25,percent of total billed charges,Implant Device,841.5,34,"Charges > $500, x 34%",841.5,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,990,40,,990,percent of total billed charges,Implant Device,866.25,70,,866.25,percent of total billed charges,All Other,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,841.5,34,"If Charge > 2,000, then 34 percent",841.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1831.51,
MEDTRONIC RONYX22526UX ONYX DES 2.25X26,C1874,HCPCS,,79011223,CDM,278,RC,,,both,,,2475,1831.51,,,1831.51,Other,150% of Medicare + 9.63% HCRA Surcharge,1113.75,45,,1113.75,percent of total billed charges,Critical Access Hospital RCC factor,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,1225.13,,,1225.13,Other,110% of Medicare,866.25,35,,866.25,percent of total billed charges,Implant Device,841.5,34,"Charges > $500, x 34%",841.5,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,990,40,,990,percent of total billed charges,Implant Device,866.25,70,,866.25,percent of total billed charges,All Other,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,841.5,34,"If Charge > 2,000, then 34 percent",841.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1831.51,
MEDTRONIC RONYX22530UX ONYX DES 2.25X30,C1874,HCPCS,,79011224,CDM,278,RC,,,both,,,2475,1831.51,,,1831.51,Other,150% of Medicare + 9.63% HCRA Surcharge,1113.75,45,,1113.75,percent of total billed charges,Critical Access Hospital RCC factor,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,1225.13,,,1225.13,Other,110% of Medicare,866.25,35,,866.25,percent of total billed charges,Implant Device,841.5,34,"Charges > $500, x 34%",841.5,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,990,40,,990,percent of total billed charges,Implant Device,866.25,70,,866.25,percent of total billed charges,All Other,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,841.5,34,"If Charge > 2,000, then 34 percent",841.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1831.51,
MEDTRONIC RONYX22534UX ONYX DES 2.25X34,C1874,HCPCS,,79011225,CDM,278,RC,,,both,,,2475,1831.51,,,1831.51,Other,150% of Medicare + 9.63% HCRA Surcharge,1113.75,45,,1113.75,percent of total billed charges,Critical Access Hospital RCC factor,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,1225.13,,,1225.13,Other,110% of Medicare,866.25,35,,866.25,percent of total billed charges,Implant Device,841.5,34,"Charges > $500, x 34%",841.5,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,990,40,,990,percent of total billed charges,Implant Device,866.25,70,,866.25,percent of total billed charges,All Other,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,841.5,34,"If Charge > 2,000, then 34 percent",841.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1831.51,
MEDTRONIC RONYX22538UX ONYX DES 2.25X38,C1874,HCPCS,,79011226,CDM,278,RC,,,both,,,2475,1831.51,,,1831.51,Other,150% of Medicare + 9.63% HCRA Surcharge,1113.75,45,,1113.75,percent of total billed charges,Critical Access Hospital RCC factor,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,1225.13,,,1225.13,Other,110% of Medicare,866.25,35,,866.25,percent of total billed charges,Implant Device,841.5,34,"Charges > $500, x 34%",841.5,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,990,40,,990,percent of total billed charges,Implant Device,866.25,70,,866.25,percent of total billed charges,All Other,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,841.5,34,"If Charge > 2,000, then 34 percent",841.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1831.51,
MEDTRONIC RONYX25008UX ONYX DES 2.5X8MM,C1874,HCPCS,,79011227,CDM,278,RC,,,both,,,2475,1831.51,,,1831.51,Other,150% of Medicare + 9.63% HCRA Surcharge,1113.75,45,,1113.75,percent of total billed charges,Critical Access Hospital RCC factor,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,1225.13,,,1225.13,Other,110% of Medicare,866.25,35,,866.25,percent of total billed charges,Implant Device,841.5,34,"Charges > $500, x 34%",841.5,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,990,40,,990,percent of total billed charges,Implant Device,866.25,70,,866.25,percent of total billed charges,All Other,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,841.5,34,"If Charge > 2,000, then 34 percent",841.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1831.51,
MEDTRONIC RONYX25012UX ONYX DES 2.5X12MM,C1874,HCPCS,,79011228,CDM,278,RC,,,both,,,2475,1831.51,,,1831.51,Other,150% of Medicare + 9.63% HCRA Surcharge,1113.75,45,,1113.75,percent of total billed charges,Critical Access Hospital RCC factor,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,1225.13,,,1225.13,Other,110% of Medicare,866.25,35,,866.25,percent of total billed charges,Implant Device,841.5,34,"Charges > $500, x 34%",841.5,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,990,40,,990,percent of total billed charges,Implant Device,866.25,70,,866.25,percent of total billed charges,All Other,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,841.5,34,"If Charge > 2,000, then 34 percent",841.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1831.51,
MEDTRONIC RONYX25015UX ONYX DES 2.5X15MM,C1874,HCPCS,,79011229,CDM,278,RC,,,both,,,2475,1831.51,,,1831.51,Other,150% of Medicare + 9.63% HCRA Surcharge,1113.75,45,,1113.75,percent of total billed charges,Critical Access Hospital RCC factor,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,1225.13,,,1225.13,Other,110% of Medicare,866.25,35,,866.25,percent of total billed charges,Implant Device,841.5,34,"Charges > $500, x 34%",841.5,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,990,40,,990,percent of total billed charges,Implant Device,866.25,70,,866.25,percent of total billed charges,All Other,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,841.5,34,"If Charge > 2,000, then 34 percent",841.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1831.51,
MEDTRONIC RONYX25018UX ONYX DES 2.5X18MM,C1874,HCPCS,,79011230,CDM,278,RC,,,both,,,2475,1831.51,,,1831.51,Other,150% of Medicare + 9.63% HCRA Surcharge,1113.75,45,,1113.75,percent of total billed charges,Critical Access Hospital RCC factor,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,1225.13,,,1225.13,Other,110% of Medicare,866.25,35,,866.25,percent of total billed charges,Implant Device,841.5,34,"Charges > $500, x 34%",841.5,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,990,40,,990,percent of total billed charges,Implant Device,866.25,70,,866.25,percent of total billed charges,All Other,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,841.5,34,"If Charge > 2,000, then 34 percent",841.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1831.51,
MEDTRONIC RONYX25022UX ONYX DES 2.5X22MM,C1874,HCPCS,,79011231,CDM,278,RC,,,both,,,2475,1831.51,,,1831.51,Other,150% of Medicare + 9.63% HCRA Surcharge,1113.75,45,,1113.75,percent of total billed charges,Critical Access Hospital RCC factor,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,1225.13,,,1225.13,Other,110% of Medicare,866.25,35,,866.25,percent of total billed charges,Implant Device,841.5,34,"Charges > $500, x 34%",841.5,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,990,40,,990,percent of total billed charges,Implant Device,866.25,70,,866.25,percent of total billed charges,All Other,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,841.5,34,"If Charge > 2,000, then 34 percent",841.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1831.51,
MDTRONIC RONYX25026UX ONYX DES 2.5X26MM,C1874,HCPCS,,79011232,CDM,278,RC,,,both,,,2475,1831.51,,,1831.51,Other,150% of Medicare + 9.63% HCRA Surcharge,1113.75,45,,1113.75,percent of total billed charges,Critical Access Hospital RCC factor,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,1225.13,,,1225.13,Other,110% of Medicare,866.25,35,,866.25,percent of total billed charges,Implant Device,841.5,34,"Charges > $500, x 34%",841.5,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,990,40,,990,percent of total billed charges,Implant Device,866.25,70,,866.25,percent of total billed charges,All Other,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,841.5,34,"If Charge > 2,000, then 34 percent",841.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1831.51,
MEDTRONIC RONYX25030UX ONYX DES 2.5X30MM,C1874,HCPCS,,79011233,CDM,278,RC,,,both,,,2475,1831.51,,,1831.51,Other,150% of Medicare + 9.63% HCRA Surcharge,1113.75,45,,1113.75,percent of total billed charges,Critical Access Hospital RCC factor,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,1225.13,,,1225.13,Other,110% of Medicare,866.25,35,,866.25,percent of total billed charges,Implant Device,841.5,34,"Charges > $500, x 34%",841.5,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,990,40,,990,percent of total billed charges,Implant Device,866.25,70,,866.25,percent of total billed charges,All Other,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,841.5,34,"If Charge > 2,000, then 34 percent",841.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1831.51,
MEDTRONIC RONYX25034UX ONYX DES 2.5X34MM,C1874,HCPCS,,79011234,CDM,278,RC,,,both,,,2475,1831.51,,,1831.51,Other,150% of Medicare + 9.63% HCRA Surcharge,1113.75,45,,1113.75,percent of total billed charges,Critical Access Hospital RCC factor,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,1225.13,,,1225.13,Other,110% of Medicare,866.25,35,,866.25,percent of total billed charges,Implant Device,841.5,34,"Charges > $500, x 34%",841.5,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,990,40,,990,percent of total billed charges,Implant Device,866.25,70,,866.25,percent of total billed charges,All Other,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,841.5,34,"If Charge > 2,000, then 34 percent",841.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1831.51,
MEDTRONIC RONYX25038UX ONYX DES 2.5X38MM,C1874,HCPCS,,79011235,CDM,278,RC,,,both,,,2475,1831.51,,,1831.51,Other,150% of Medicare + 9.63% HCRA Surcharge,1113.75,45,,1113.75,percent of total billed charges,Critical Access Hospital RCC factor,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,1225.13,,,1225.13,Other,110% of Medicare,866.25,35,,866.25,percent of total billed charges,Implant Device,841.5,34,"Charges > $500, x 34%",841.5,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,990,40,,990,percent of total billed charges,Implant Device,866.25,70,,866.25,percent of total billed charges,All Other,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,841.5,34,"If Charge > 2,000, then 34 percent",841.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1831.51,
MEDTRONIC RONYX27508UX ONYX DES 2.75X8MM,C1874,HCPCS,,79011236,CDM,278,RC,,,both,,,2475,1831.51,,,1831.51,Other,150% of Medicare + 9.63% HCRA Surcharge,1113.75,45,,1113.75,percent of total billed charges,Critical Access Hospital RCC factor,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,1225.13,,,1225.13,Other,110% of Medicare,866.25,35,,866.25,percent of total billed charges,Implant Device,841.5,34,"Charges > $500, x 34%",841.5,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,990,40,,990,percent of total billed charges,Implant Device,866.25,70,,866.25,percent of total billed charges,All Other,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,841.5,34,"If Charge > 2,000, then 34 percent",841.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1831.51,
MEDTRONIC RONYX27512UX ONYX DES 2.75X12,C1874,HCPCS,,79011237,CDM,278,RC,,,both,,,2475,1831.51,,,1831.51,Other,150% of Medicare + 9.63% HCRA Surcharge,1113.75,45,,1113.75,percent of total billed charges,Critical Access Hospital RCC factor,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,1225.13,,,1225.13,Other,110% of Medicare,866.25,35,,866.25,percent of total billed charges,Implant Device,841.5,34,"Charges > $500, x 34%",841.5,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,990,40,,990,percent of total billed charges,Implant Device,866.25,70,,866.25,percent of total billed charges,All Other,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,841.5,34,"If Charge > 2,000, then 34 percent",841.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1831.51,
MEDTRONIC RONYX27515UX ONYX DES 2.75X15,C1874,HCPCS,,79011238,CDM,278,RC,,,both,,,2475,1831.51,,,1831.51,Other,150% of Medicare + 9.63% HCRA Surcharge,1113.75,45,,1113.75,percent of total billed charges,Critical Access Hospital RCC factor,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,1225.13,,,1225.13,Other,110% of Medicare,866.25,35,,866.25,percent of total billed charges,Implant Device,841.5,34,"Charges > $500, x 34%",841.5,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,990,40,,990,percent of total billed charges,Implant Device,866.25,70,,866.25,percent of total billed charges,All Other,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,841.5,34,"If Charge > 2,000, then 34 percent",841.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1831.51,
MEDTRONIC RONYX27518UX ONYX DES 2.75X18,C1874,HCPCS,,79011239,CDM,278,RC,,,both,,,2475,1831.51,,,1831.51,Other,150% of Medicare + 9.63% HCRA Surcharge,1113.75,45,,1113.75,percent of total billed charges,Critical Access Hospital RCC factor,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,1225.13,,,1225.13,Other,110% of Medicare,866.25,35,,866.25,percent of total billed charges,Implant Device,841.5,34,"Charges > $500, x 34%",841.5,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,990,40,,990,percent of total billed charges,Implant Device,866.25,70,,866.25,percent of total billed charges,All Other,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,841.5,34,"If Charge > 2,000, then 34 percent",841.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1831.51,
MEDTRONIC RONYX27522UX ONYX DES 2.75X22,C1874,HCPCS,,79011240,CDM,278,RC,,,both,,,2475,1831.51,,,1831.51,Other,150% of Medicare + 9.63% HCRA Surcharge,1113.75,45,,1113.75,percent of total billed charges,Critical Access Hospital RCC factor,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,1225.13,,,1225.13,Other,110% of Medicare,866.25,35,,866.25,percent of total billed charges,Implant Device,841.5,34,"Charges > $500, x 34%",841.5,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,990,40,,990,percent of total billed charges,Implant Device,866.25,70,,866.25,percent of total billed charges,All Other,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,841.5,34,"If Charge > 2,000, then 34 percent",841.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1831.51,
MEDTRONIC RONYX27526UX ONYX DES 2.75X26,C1874,HCPCS,,79011241,CDM,278,RC,,,both,,,2475,1831.51,,,1831.51,Other,150% of Medicare + 9.63% HCRA Surcharge,1113.75,45,,1113.75,percent of total billed charges,Critical Access Hospital RCC factor,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,1225.13,,,1225.13,Other,110% of Medicare,866.25,35,,866.25,percent of total billed charges,Implant Device,841.5,34,"Charges > $500, x 34%",841.5,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,990,40,,990,percent of total billed charges,Implant Device,866.25,70,,866.25,percent of total billed charges,All Other,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,841.5,34,"If Charge > 2,000, then 34 percent",841.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1831.51,
MEDTRONIC RONYX27530UX ONYX DES 2.75X30,C1874,HCPCS,,79011242,CDM,278,RC,,,both,,,2475,1831.51,,,1831.51,Other,150% of Medicare + 9.63% HCRA Surcharge,1113.75,45,,1113.75,percent of total billed charges,Critical Access Hospital RCC factor,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,1225.13,,,1225.13,Other,110% of Medicare,866.25,35,,866.25,percent of total billed charges,Implant Device,841.5,34,"Charges > $500, x 34%",841.5,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,990,40,,990,percent of total billed charges,Implant Device,866.25,70,,866.25,percent of total billed charges,All Other,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,841.5,34,"If Charge > 2,000, then 34 percent",841.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1831.51,
MEDTRONIC RONYX27534UX ONYX DES 2.75X34,C1874,HCPCS,,79011243,CDM,278,RC,,,both,,,2475,1831.51,,,1831.51,Other,150% of Medicare + 9.63% HCRA Surcharge,1113.75,45,,1113.75,percent of total billed charges,Critical Access Hospital RCC factor,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,1225.13,,,1225.13,Other,110% of Medicare,866.25,35,,866.25,percent of total billed charges,Implant Device,841.5,34,"Charges > $500, x 34%",841.5,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,990,40,,990,percent of total billed charges,Implant Device,866.25,70,,866.25,percent of total billed charges,All Other,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,841.5,34,"If Charge > 2,000, then 34 percent",841.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1831.51,
MEDTRONIC RONYX27538UX ONYX DES 2.75X38,C1874,HCPCS,,79011244,CDM,278,RC,,,both,,,2475,1831.51,,,1831.51,Other,150% of Medicare + 9.63% HCRA Surcharge,1113.75,45,,1113.75,percent of total billed charges,Critical Access Hospital RCC factor,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,1225.13,,,1225.13,Other,110% of Medicare,866.25,35,,866.25,percent of total billed charges,Implant Device,841.5,34,"Charges > $500, x 34%",841.5,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,990,40,,990,percent of total billed charges,Implant Device,866.25,70,,866.25,percent of total billed charges,All Other,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,841.5,34,"If Charge > 2,000, then 34 percent",841.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1831.51,
MEDTRONIC RONYX30008UX ONYX DES 3X8MM,C1874,HCPCS,,79011245,CDM,278,RC,,,both,,,2475,1831.51,,,1831.51,Other,150% of Medicare + 9.63% HCRA Surcharge,1113.75,45,,1113.75,percent of total billed charges,Critical Access Hospital RCC factor,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,1225.13,,,1225.13,Other,110% of Medicare,866.25,35,,866.25,percent of total billed charges,Implant Device,841.5,34,"Charges > $500, x 34%",841.5,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,990,40,,990,percent of total billed charges,Implant Device,866.25,70,,866.25,percent of total billed charges,All Other,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,841.5,34,"If Charge > 2,000, then 34 percent",841.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1831.51,
MEDTRONIC RONYX30012UX ONYX DES 3X12MM,C1874,HCPCS,,79011246,CDM,278,RC,,,both,,,2475,1831.51,,,1831.51,Other,150% of Medicare + 9.63% HCRA Surcharge,1113.75,45,,1113.75,percent of total billed charges,Critical Access Hospital RCC factor,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,1225.13,,,1225.13,Other,110% of Medicare,866.25,35,,866.25,percent of total billed charges,Implant Device,841.5,34,"Charges > $500, x 34%",841.5,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,990,40,,990,percent of total billed charges,Implant Device,866.25,70,,866.25,percent of total billed charges,All Other,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,841.5,34,"If Charge > 2,000, then 34 percent",841.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1831.51,
MEDTRONIC RONYX30015UX ONYX DES 3X15MM,C1874,HCPCS,,79011247,CDM,278,RC,,,both,,,2475,1831.51,,,1831.51,Other,150% of Medicare + 9.63% HCRA Surcharge,1113.75,45,,1113.75,percent of total billed charges,Critical Access Hospital RCC factor,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,1225.13,,,1225.13,Other,110% of Medicare,866.25,35,,866.25,percent of total billed charges,Implant Device,841.5,34,"Charges > $500, x 34%",841.5,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,990,40,,990,percent of total billed charges,Implant Device,866.25,70,,866.25,percent of total billed charges,All Other,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,841.5,34,"If Charge > 2,000, then 34 percent",841.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1831.51,
MEDTRONIC RONYX30018UX ONYX DES 3X18MM,C1874,HCPCS,,79011248,CDM,278,RC,,,both,,,2475,1831.51,,,1831.51,Other,150% of Medicare + 9.63% HCRA Surcharge,1113.75,45,,1113.75,percent of total billed charges,Critical Access Hospital RCC factor,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,1225.13,,,1225.13,Other,110% of Medicare,866.25,35,,866.25,percent of total billed charges,Implant Device,841.5,34,"Charges > $500, x 34%",841.5,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,990,40,,990,percent of total billed charges,Implant Device,866.25,70,,866.25,percent of total billed charges,All Other,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,841.5,34,"If Charge > 2,000, then 34 percent",841.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1831.51,
MEDTRONIC RONYX30022UX ONYX DES 3X22MM,C1874,HCPCS,,79011249,CDM,278,RC,,,both,,,2475,1831.51,,,1831.51,Other,150% of Medicare + 9.63% HCRA Surcharge,1113.75,45,,1113.75,percent of total billed charges,Critical Access Hospital RCC factor,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,1225.13,,,1225.13,Other,110% of Medicare,866.25,35,,866.25,percent of total billed charges,Implant Device,841.5,34,"Charges > $500, x 34%",841.5,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,990,40,,990,percent of total billed charges,Implant Device,866.25,70,,866.25,percent of total billed charges,All Other,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,841.5,34,"If Charge > 2,000, then 34 percent",841.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1831.51,
MEDTRONIC RONYX30026UX ONYX DES 3X26MM,C1874,HCPCS,,79011250,CDM,278,RC,,,both,,,2475,1831.51,,,1831.51,Other,150% of Medicare + 9.63% HCRA Surcharge,1113.75,45,,1113.75,percent of total billed charges,Critical Access Hospital RCC factor,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,1225.13,,,1225.13,Other,110% of Medicare,866.25,35,,866.25,percent of total billed charges,Implant Device,841.5,34,"Charges > $500, x 34%",841.5,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,990,40,,990,percent of total billed charges,Implant Device,866.25,70,,866.25,percent of total billed charges,All Other,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,841.5,34,"If Charge > 2,000, then 34 percent",841.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1831.51,
MEDTRONIC RONYX30030UX ONYX DES 3X30MM,C1874,HCPCS,,79011251,CDM,278,RC,,,both,,,2475,1831.51,,,1831.51,Other,150% of Medicare + 9.63% HCRA Surcharge,1113.75,45,,1113.75,percent of total billed charges,Critical Access Hospital RCC factor,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,1225.13,,,1225.13,Other,110% of Medicare,866.25,35,,866.25,percent of total billed charges,Implant Device,841.5,34,"Charges > $500, x 34%",841.5,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,990,40,,990,percent of total billed charges,Implant Device,866.25,70,,866.25,percent of total billed charges,All Other,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,841.5,34,"If Charge > 2,000, then 34 percent",841.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1831.51,
MEDTRONIC RONYX30034UX ONYX DES 3X34MM,C1874,HCPCS,,79011252,CDM,278,RC,,,both,,,2475,1831.51,,,1831.51,Other,150% of Medicare + 9.63% HCRA Surcharge,1113.75,45,,1113.75,percent of total billed charges,Critical Access Hospital RCC factor,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,1225.13,,,1225.13,Other,110% of Medicare,866.25,35,,866.25,percent of total billed charges,Implant Device,841.5,34,"Charges > $500, x 34%",841.5,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,990,40,,990,percent of total billed charges,Implant Device,866.25,70,,866.25,percent of total billed charges,All Other,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,841.5,34,"If Charge > 2,000, then 34 percent",841.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1831.51,
MEDTRONIC RONYX30038UX ONYX DES 3X38MM,C1874,HCPCS,,79011253,CDM,278,RC,,,both,,,2475,1831.51,,,1831.51,Other,150% of Medicare + 9.63% HCRA Surcharge,1113.75,45,,1113.75,percent of total billed charges,Critical Access Hospital RCC factor,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,1225.13,,,1225.13,Other,110% of Medicare,866.25,35,,866.25,percent of total billed charges,Implant Device,841.5,34,"Charges > $500, x 34%",841.5,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,990,40,,990,percent of total billed charges,Implant Device,866.25,70,,866.25,percent of total billed charges,All Other,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,841.5,34,"If Charge > 2,000, then 34 percent",841.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1831.51,
MEDTRONIC RONYX35008UX ONYX DES 3.5X8MM,C1874,HCPCS,,79011254,CDM,278,RC,,,both,,,2475,1831.51,,,1831.51,Other,150% of Medicare + 9.63% HCRA Surcharge,1113.75,45,,1113.75,percent of total billed charges,Critical Access Hospital RCC factor,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,1225.13,,,1225.13,Other,110% of Medicare,866.25,35,,866.25,percent of total billed charges,Implant Device,841.5,34,"Charges > $500, x 34%",841.5,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,990,40,,990,percent of total billed charges,Implant Device,866.25,70,,866.25,percent of total billed charges,All Other,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,841.5,34,"If Charge > 2,000, then 34 percent",841.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1831.51,
MEDTRONIC RONYX35012UX ONYX DES 3.5X12MM,C1874,HCPCS,,79011255,CDM,278,RC,,,both,,,2475,1831.51,,,1831.51,Other,150% of Medicare + 9.63% HCRA Surcharge,1113.75,45,,1113.75,percent of total billed charges,Critical Access Hospital RCC factor,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,1225.13,,,1225.13,Other,110% of Medicare,866.25,35,,866.25,percent of total billed charges,Implant Device,841.5,34,"Charges > $500, x 34%",841.5,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,990,40,,990,percent of total billed charges,Implant Device,866.25,70,,866.25,percent of total billed charges,All Other,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,841.5,34,"If Charge > 2,000, then 34 percent",841.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1831.51,
MEDTRONIC RONYX35015UX ONYX DES 3.5X15MM,C1874,HCPCS,,79011256,CDM,278,RC,,,both,,,2475,1831.51,,,1831.51,Other,150% of Medicare + 9.63% HCRA Surcharge,1113.75,45,,1113.75,percent of total billed charges,Critical Access Hospital RCC factor,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,1225.13,,,1225.13,Other,110% of Medicare,866.25,35,,866.25,percent of total billed charges,Implant Device,841.5,34,"Charges > $500, x 34%",841.5,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,990,40,,990,percent of total billed charges,Implant Device,866.25,70,,866.25,percent of total billed charges,All Other,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,841.5,34,"If Charge > 2,000, then 34 percent",841.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1831.51,
MEDTRONIC RONYX35018UX ONYX DES 3.5X18MM,C1874,HCPCS,,79011257,CDM,278,RC,,,both,,,2475,1831.51,,,1831.51,Other,150% of Medicare + 9.63% HCRA Surcharge,1113.75,45,,1113.75,percent of total billed charges,Critical Access Hospital RCC factor,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,1225.13,,,1225.13,Other,110% of Medicare,866.25,35,,866.25,percent of total billed charges,Implant Device,841.5,34,"Charges > $500, x 34%",841.5,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,990,40,,990,percent of total billed charges,Implant Device,866.25,70,,866.25,percent of total billed charges,All Other,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,841.5,34,"If Charge > 2,000, then 34 percent",841.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1831.51,
MEDTRONIC RONYX35022UX ONYX DES 3.5X22MM,C1874,HCPCS,,79011258,CDM,278,RC,,,both,,,2475,1831.51,,,1831.51,Other,150% of Medicare + 9.63% HCRA Surcharge,1113.75,45,,1113.75,percent of total billed charges,Critical Access Hospital RCC factor,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,1225.13,,,1225.13,Other,110% of Medicare,866.25,35,,866.25,percent of total billed charges,Implant Device,841.5,34,"Charges > $500, x 34%",841.5,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,990,40,,990,percent of total billed charges,Implant Device,866.25,70,,866.25,percent of total billed charges,All Other,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,841.5,34,"If Charge > 2,000, then 34 percent",841.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1831.51,
MEDTRONIC RONYX35026UX ONYX DES 3.5X26MM,C1874,HCPCS,,79011259,CDM,278,RC,,,both,,,2475,1831.51,,,1831.51,Other,150% of Medicare + 9.63% HCRA Surcharge,1113.75,45,,1113.75,percent of total billed charges,Critical Access Hospital RCC factor,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,1225.13,,,1225.13,Other,110% of Medicare,866.25,35,,866.25,percent of total billed charges,Implant Device,841.5,34,"Charges > $500, x 34%",841.5,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,990,40,,990,percent of total billed charges,Implant Device,866.25,70,,866.25,percent of total billed charges,All Other,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,841.5,34,"If Charge > 2,000, then 34 percent",841.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1831.51,
MEDTRONIC RONYX35030UX ONYX DES 3.5X30MM,C1874,HCPCS,,79011260,CDM,278,RC,,,both,,,2475,1831.51,,,1831.51,Other,150% of Medicare + 9.63% HCRA Surcharge,1113.75,45,,1113.75,percent of total billed charges,Critical Access Hospital RCC factor,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,1225.13,,,1225.13,Other,110% of Medicare,866.25,35,,866.25,percent of total billed charges,Implant Device,841.5,34,"Charges > $500, x 34%",841.5,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,990,40,,990,percent of total billed charges,Implant Device,866.25,70,,866.25,percent of total billed charges,All Other,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,841.5,34,"If Charge > 2,000, then 34 percent",841.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1831.51,
MEDTRONIC RONYX35034UX ONYX DES 3.5X34MM,C1874,HCPCS,,79011261,CDM,278,RC,,,both,,,2475,1831.51,,,1831.51,Other,150% of Medicare + 9.63% HCRA Surcharge,1113.75,45,,1113.75,percent of total billed charges,Critical Access Hospital RCC factor,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,1225.13,,,1225.13,Other,110% of Medicare,866.25,35,,866.25,percent of total billed charges,Implant Device,841.5,34,"Charges > $500, x 34%",841.5,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,990,40,,990,percent of total billed charges,Implant Device,866.25,70,,866.25,percent of total billed charges,All Other,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,841.5,34,"If Charge > 2,000, then 34 percent",841.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1831.51,
MEDTRONIC RONYX35038UX ONYX DES 3.5X38MM,C1874,HCPCS,,79011262,CDM,278,RC,,,both,,,2475,1831.51,,,1831.51,Other,150% of Medicare + 9.63% HCRA Surcharge,1113.75,45,,1113.75,percent of total billed charges,Critical Access Hospital RCC factor,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,1225.13,,,1225.13,Other,110% of Medicare,866.25,35,,866.25,percent of total billed charges,Implant Device,841.5,34,"Charges > $500, x 34%",841.5,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,990,40,,990,percent of total billed charges,Implant Device,866.25,70,,866.25,percent of total billed charges,All Other,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,841.5,34,"If Charge > 2,000, then 34 percent",841.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1831.51,
MEDTRONIC RONYX40008UX ONYX DES 4X8MM,C1874,HCPCS,,79011263,CDM,278,RC,,,both,,,2475,1831.51,,,1831.51,Other,150% of Medicare + 9.63% HCRA Surcharge,1113.75,45,,1113.75,percent of total billed charges,Critical Access Hospital RCC factor,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,1225.13,,,1225.13,Other,110% of Medicare,866.25,35,,866.25,percent of total billed charges,Implant Device,841.5,34,"Charges > $500, x 34%",841.5,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,990,40,,990,percent of total billed charges,Implant Device,866.25,70,,866.25,percent of total billed charges,All Other,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,841.5,34,"If Charge > 2,000, then 34 percent",841.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1831.51,
MEDTRONIC RONYX40012UX ONYX DES 4X12MM,C1874,HCPCS,,79011264,CDM,278,RC,,,both,,,2475,1831.51,,,1831.51,Other,150% of Medicare + 9.63% HCRA Surcharge,1113.75,45,,1113.75,percent of total billed charges,Critical Access Hospital RCC factor,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,1225.13,,,1225.13,Other,110% of Medicare,866.25,35,,866.25,percent of total billed charges,Implant Device,841.5,34,"Charges > $500, x 34%",841.5,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,990,40,,990,percent of total billed charges,Implant Device,866.25,70,,866.25,percent of total billed charges,All Other,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,841.5,34,"If Charge > 2,000, then 34 percent",841.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1831.51,
MEDTRONIC RONYX40015UX ONYX DES 4X15MM,C1874,HCPCS,,79011265,CDM,278,RC,,,both,,,2475,1831.51,,,1831.51,Other,150% of Medicare + 9.63% HCRA Surcharge,1113.75,45,,1113.75,percent of total billed charges,Critical Access Hospital RCC factor,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,1225.13,,,1225.13,Other,110% of Medicare,866.25,35,,866.25,percent of total billed charges,Implant Device,841.5,34,"Charges > $500, x 34%",841.5,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,990,40,,990,percent of total billed charges,Implant Device,866.25,70,,866.25,percent of total billed charges,All Other,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,841.5,34,"If Charge > 2,000, then 34 percent",841.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1831.51,
MEDTRONIC RONYX40018UX ONYX DES 4X18MM,C1874,HCPCS,,79011266,CDM,278,RC,,,both,,,2475,1831.51,,,1831.51,Other,150% of Medicare + 9.63% HCRA Surcharge,1113.75,45,,1113.75,percent of total billed charges,Critical Access Hospital RCC factor,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,1225.13,,,1225.13,Other,110% of Medicare,866.25,35,,866.25,percent of total billed charges,Implant Device,841.5,34,"Charges > $500, x 34%",841.5,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,990,40,,990,percent of total billed charges,Implant Device,866.25,70,,866.25,percent of total billed charges,All Other,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,841.5,34,"If Charge > 2,000, then 34 percent",841.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1831.51,
MEDTRONIC RONYX40022UX ONYX DES 4X22MM,C1874,HCPCS,,79011267,CDM,278,RC,,,both,,,2475,1831.51,,,1831.51,Other,150% of Medicare + 9.63% HCRA Surcharge,1113.75,45,,1113.75,percent of total billed charges,Critical Access Hospital RCC factor,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,1225.13,,,1225.13,Other,110% of Medicare,866.25,35,,866.25,percent of total billed charges,Implant Device,841.5,34,"Charges > $500, x 34%",841.5,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,990,40,,990,percent of total billed charges,Implant Device,866.25,70,,866.25,percent of total billed charges,All Other,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,841.5,34,"If Charge > 2,000, then 34 percent",841.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1831.51,
MEDTRONIC RONYX40026UX ONYX DES 4X26MM,C1874,HCPCS,,79011268,CDM,278,RC,,,both,,,2475,1831.51,,,1831.51,Other,150% of Medicare + 9.63% HCRA Surcharge,1113.75,45,,1113.75,percent of total billed charges,Critical Access Hospital RCC factor,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,1225.13,,,1225.13,Other,110% of Medicare,866.25,35,,866.25,percent of total billed charges,Implant Device,841.5,34,"Charges > $500, x 34%",841.5,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,990,40,,990,percent of total billed charges,Implant Device,866.25,70,,866.25,percent of total billed charges,All Other,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,841.5,34,"If Charge > 2,000, then 34 percent",841.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1831.51,
MEDTRONIC RONYX40030UX ONYX DES 4X30MM,C1874,HCPCS,,79011269,CDM,278,RC,,,both,,,2475,1831.51,,,1831.51,Other,150% of Medicare + 9.63% HCRA Surcharge,1113.75,45,,1113.75,percent of total billed charges,Critical Access Hospital RCC factor,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,1225.13,,,1225.13,Other,110% of Medicare,866.25,35,,866.25,percent of total billed charges,Implant Device,841.5,34,"Charges > $500, x 34%",841.5,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,990,40,,990,percent of total billed charges,Implant Device,866.25,70,,866.25,percent of total billed charges,All Other,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,841.5,34,"If Charge > 2,000, then 34 percent",841.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1831.51,
MEDTRONIC RONYX40034UX ONYX DES 4X34MM,C1874,HCPCS,,79011270,CDM,278,RC,,,both,,,2475,1831.51,,,1831.51,Other,150% of Medicare + 9.63% HCRA Surcharge,1113.75,45,,1113.75,percent of total billed charges,Critical Access Hospital RCC factor,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,1225.13,,,1225.13,Other,110% of Medicare,866.25,35,,866.25,percent of total billed charges,Implant Device,841.5,34,"Charges > $500, x 34%",841.5,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,990,40,,990,percent of total billed charges,Implant Device,866.25,70,,866.25,percent of total billed charges,All Other,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,841.5,34,"If Charge > 2,000, then 34 percent",841.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1831.51,
MEDTRONIC RONYX40038UX ONYX DES 4X38MM,C1874,HCPCS,,79011271,CDM,278,RC,,,both,,,2475,1831.51,,,1831.51,Other,150% of Medicare + 9.63% HCRA Surcharge,1113.75,45,,1113.75,percent of total billed charges,Critical Access Hospital RCC factor,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,1225.13,,,1225.13,Other,110% of Medicare,866.25,35,,866.25,percent of total billed charges,Implant Device,841.5,34,"Charges > $500, x 34%",841.5,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,990,40,,990,percent of total billed charges,Implant Device,866.25,70,,866.25,percent of total billed charges,All Other,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,841.5,34,"If Charge > 2,000, then 34 percent",841.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1831.51,
MEDTRONIC RONYX45015UX ONYX DES 4.5X15MM,C1874,HCPCS,,79011272,CDM,278,RC,,,both,,,2475,1831.51,,,1831.51,Other,150% of Medicare + 9.63% HCRA Surcharge,1113.75,45,,1113.75,percent of total billed charges,Critical Access Hospital RCC factor,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,1225.13,,,1225.13,Other,110% of Medicare,866.25,35,,866.25,percent of total billed charges,Implant Device,841.5,34,"Charges > $500, x 34%",841.5,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,990,40,,990,percent of total billed charges,Implant Device,866.25,70,,866.25,percent of total billed charges,All Other,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,841.5,34,"If Charge > 2,000, then 34 percent",841.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1831.51,
MEDTRONIC RONYX45018UX ONYX DES 4.5X18MM,C1874,HCPCS,,79011273,CDM,278,RC,,,both,,,2475,1831.51,,,1831.51,Other,150% of Medicare + 9.63% HCRA Surcharge,1113.75,45,,1113.75,percent of total billed charges,Critical Access Hospital RCC factor,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,1225.13,,,1225.13,Other,110% of Medicare,866.25,35,,866.25,percent of total billed charges,Implant Device,841.5,34,"Charges > $500, x 34%",841.5,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,990,40,,990,percent of total billed charges,Implant Device,866.25,70,,866.25,percent of total billed charges,All Other,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,841.5,34,"If Charge > 2,000, then 34 percent",841.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1831.51,
MEDTRONIC RONYX45022UX ONYX DES 4.5X22MM,C1874,HCPCS,,79011274,CDM,278,RC,,,both,,,2475,1831.51,,,1831.51,Other,150% of Medicare + 9.63% HCRA Surcharge,1113.75,45,,1113.75,percent of total billed charges,Critical Access Hospital RCC factor,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,1225.13,,,1225.13,Other,110% of Medicare,866.25,35,,866.25,percent of total billed charges,Implant Device,841.5,34,"Charges > $500, x 34%",841.5,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,990,40,,990,percent of total billed charges,Implant Device,866.25,70,,866.25,percent of total billed charges,All Other,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,841.5,34,"If Charge > 2,000, then 34 percent",841.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1831.51,
MEDTRONIC RONYX50015UX ONYX DES 5X15MM,C1874,HCPCS,,79011275,CDM,278,RC,,,both,,,2475,1831.51,,,1831.51,Other,150% of Medicare + 9.63% HCRA Surcharge,1113.75,45,,1113.75,percent of total billed charges,Critical Access Hospital RCC factor,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,1225.13,,,1225.13,Other,110% of Medicare,866.25,35,,866.25,percent of total billed charges,Implant Device,841.5,34,"Charges > $500, x 34%",841.5,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,990,40,,990,percent of total billed charges,Implant Device,866.25,70,,866.25,percent of total billed charges,All Other,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,841.5,34,"If Charge > 2,000, then 34 percent",841.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1831.51,
MEDTRONIC RONYX50018UX ONYX DES 5X18MM,C1874,HCPCS,,79011276,CDM,278,RC,,,both,,,2475,1831.51,,,1831.51,Other,150% of Medicare + 9.63% HCRA Surcharge,1113.75,45,,1113.75,percent of total billed charges,Critical Access Hospital RCC factor,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,1225.13,,,1225.13,Other,110% of Medicare,866.25,35,,866.25,percent of total billed charges,Implant Device,841.5,34,"Charges > $500, x 34%",841.5,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,990,40,,990,percent of total billed charges,Implant Device,866.25,70,,866.25,percent of total billed charges,All Other,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,841.5,34,"If Charge > 2,000, then 34 percent",841.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1831.51,
MEDTRONIC RONYX50022UX ONYX DES 5X22MM,C1874,HCPCS,,79011277,CDM,278,RC,,,both,,,2475,1831.51,,,1831.51,Other,150% of Medicare + 9.63% HCRA Surcharge,1113.75,45,,1113.75,percent of total billed charges,Critical Access Hospital RCC factor,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,1225.13,,,1225.13,Other,110% of Medicare,866.25,35,,866.25,percent of total billed charges,Implant Device,841.5,34,"Charges > $500, x 34%",841.5,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,990,40,,990,percent of total billed charges,Implant Device,866.25,70,,866.25,percent of total billed charges,All Other,841.5,34,,841.5,percent of total billed charges,Implant Device,841.5,34,,841.5,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,866.25,35,,866.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,841.5,34,"If Charge > 2,000, then 34 percent",841.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1831.51,
ABBOTT 1550225-08 SIERRA DES 2.25X8MM,C1874,HCPCS,,79011278,CDM,278,RC,,,both,,,2850,2109.01,,,2109.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1282.5,45,,1282.5,percent of total billed charges,Critical Access Hospital RCC factor,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,1410.75,,,1410.75,Other,110% of Medicare,997.5,35,,997.5,percent of total billed charges,Implant Device,969,34,"Charges > $500, x 34%",969,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,1140,40,,1140,percent of total billed charges,Implant Device,997.5,70,,997.5,percent of total billed charges,All Other,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,969,34,"If Charge > 2,000, then 34 percent",969,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2109.01,
ABBOTT 1550225-12 SIERRA DES 2.25X12MM,C1874,HCPCS,,79011279,CDM,278,RC,,,both,,,2850,2109.01,,,2109.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1282.5,45,,1282.5,percent of total billed charges,Critical Access Hospital RCC factor,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,1410.75,,,1410.75,Other,110% of Medicare,997.5,35,,997.5,percent of total billed charges,Implant Device,969,34,"Charges > $500, x 34%",969,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,1140,40,,1140,percent of total billed charges,Implant Device,997.5,70,,997.5,percent of total billed charges,All Other,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,969,34,"If Charge > 2,000, then 34 percent",969,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2109.01,
ABBOTT 1550225-15 SIERRA DES 2.25X15MM,C1874,HCPCS,,79011280,CDM,278,RC,,,both,,,2850,2109.01,,,2109.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1282.5,45,,1282.5,percent of total billed charges,Critical Access Hospital RCC factor,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,1410.75,,,1410.75,Other,110% of Medicare,997.5,35,,997.5,percent of total billed charges,Implant Device,969,34,"Charges > $500, x 34%",969,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,1140,40,,1140,percent of total billed charges,Implant Device,997.5,70,,997.5,percent of total billed charges,All Other,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,969,34,"If Charge > 2,000, then 34 percent",969,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2109.01,
ABBOTT 1550225-18 SIERRA DES 2.25X18MM,C1874,HCPCS,,79011281,CDM,278,RC,,,both,,,2850,2109.01,,,2109.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1282.5,45,,1282.5,percent of total billed charges,Critical Access Hospital RCC factor,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,1410.75,,,1410.75,Other,110% of Medicare,997.5,35,,997.5,percent of total billed charges,Implant Device,969,34,"Charges > $500, x 34%",969,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,1140,40,,1140,percent of total billed charges,Implant Device,997.5,70,,997.5,percent of total billed charges,All Other,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,969,34,"If Charge > 2,000, then 34 percent",969,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2109.01,
ABBOTT 1550225-23 SIERRA DES 2.25X23MM,C1874,HCPCS,,79011282,CDM,278,RC,,,both,,,2850,2109.01,,,2109.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1282.5,45,,1282.5,percent of total billed charges,Critical Access Hospital RCC factor,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,1410.75,,,1410.75,Other,110% of Medicare,997.5,35,,997.5,percent of total billed charges,Implant Device,969,34,"Charges > $500, x 34%",969,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,1140,40,,1140,percent of total billed charges,Implant Device,997.5,70,,997.5,percent of total billed charges,All Other,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,969,34,"If Charge > 2,000, then 34 percent",969,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2109.01,
ABBOTT 1550225-28 SIERRA DES 2.25X28MM,C1874,HCPCS,,79011283,CDM,278,RC,,,both,,,2850,2109.01,,,2109.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1282.5,45,,1282.5,percent of total billed charges,Critical Access Hospital RCC factor,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,1410.75,,,1410.75,Other,110% of Medicare,997.5,35,,997.5,percent of total billed charges,Implant Device,969,34,"Charges > $500, x 34%",969,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,1140,40,,1140,percent of total billed charges,Implant Device,997.5,70,,997.5,percent of total billed charges,All Other,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,969,34,"If Charge > 2,000, then 34 percent",969,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2109.01,
ABBOTT 1550225-33 SIERRA DES 2.25X33MM,C1874,HCPCS,,79011284,CDM,278,RC,,,both,,,2850,2109.01,,,2109.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1282.5,45,,1282.5,percent of total billed charges,Critical Access Hospital RCC factor,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,1410.75,,,1410.75,Other,110% of Medicare,997.5,35,,997.5,percent of total billed charges,Implant Device,969,34,"Charges > $500, x 34%",969,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,1140,40,,1140,percent of total billed charges,Implant Device,997.5,70,,997.5,percent of total billed charges,All Other,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,969,34,"If Charge > 2,000, then 34 percent",969,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2109.01,
ABBOTT 1550225-38 SIERRA DES 2.25X38MM,C1874,HCPCS,,79011285,CDM,278,RC,,,both,,,2850,2109.01,,,2109.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1282.5,45,,1282.5,percent of total billed charges,Critical Access Hospital RCC factor,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,1410.75,,,1410.75,Other,110% of Medicare,997.5,35,,997.5,percent of total billed charges,Implant Device,969,34,"Charges > $500, x 34%",969,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,1140,40,,1140,percent of total billed charges,Implant Device,997.5,70,,997.5,percent of total billed charges,All Other,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,969,34,"If Charge > 2,000, then 34 percent",969,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2109.01,
ABBOTT 1550250-08 SIERRA DES 2.5X8MM,C1874,HCPCS,,79011286,CDM,278,RC,,,both,,,2850,2109.01,,,2109.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1282.5,45,,1282.5,percent of total billed charges,Critical Access Hospital RCC factor,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,1410.75,,,1410.75,Other,110% of Medicare,997.5,35,,997.5,percent of total billed charges,Implant Device,969,34,"Charges > $500, x 34%",969,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,1140,40,,1140,percent of total billed charges,Implant Device,997.5,70,,997.5,percent of total billed charges,All Other,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,969,34,"If Charge > 2,000, then 34 percent",969,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2109.01,
ABBOTT 1550250-12 SIERRA DES 2.5X12MM,C1874,HCPCS,,79011287,CDM,278,RC,,,both,,,2850,2109.01,,,2109.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1282.5,45,,1282.5,percent of total billed charges,Critical Access Hospital RCC factor,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,1410.75,,,1410.75,Other,110% of Medicare,997.5,35,,997.5,percent of total billed charges,Implant Device,969,34,"Charges > $500, x 34%",969,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,1140,40,,1140,percent of total billed charges,Implant Device,997.5,70,,997.5,percent of total billed charges,All Other,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,969,34,"If Charge > 2,000, then 34 percent",969,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2109.01,
ABBOTT 1550250-15 SIERRA DES 2.5X15MM,C1874,HCPCS,,79011288,CDM,278,RC,,,both,,,2850,2109.01,,,2109.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1282.5,45,,1282.5,percent of total billed charges,Critical Access Hospital RCC factor,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,1410.75,,,1410.75,Other,110% of Medicare,997.5,35,,997.5,percent of total billed charges,Implant Device,969,34,"Charges > $500, x 34%",969,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,1140,40,,1140,percent of total billed charges,Implant Device,997.5,70,,997.5,percent of total billed charges,All Other,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,969,34,"If Charge > 2,000, then 34 percent",969,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2109.01,
ABBOTT 1550250-18 SIERRA DES 2.5X18MM,C1874,HCPCS,,79011289,CDM,278,RC,,,both,,,2850,2109.01,,,2109.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1282.5,45,,1282.5,percent of total billed charges,Critical Access Hospital RCC factor,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,1410.75,,,1410.75,Other,110% of Medicare,997.5,35,,997.5,percent of total billed charges,Implant Device,969,34,"Charges > $500, x 34%",969,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,1140,40,,1140,percent of total billed charges,Implant Device,997.5,70,,997.5,percent of total billed charges,All Other,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,969,34,"If Charge > 2,000, then 34 percent",969,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2109.01,
ABBOTT 1550250-23 SIERRA DES 2.5X23MM,C1874,HCPCS,,79011290,CDM,278,RC,,,both,,,2850,2109.01,,,2109.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1282.5,45,,1282.5,percent of total billed charges,Critical Access Hospital RCC factor,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,1410.75,,,1410.75,Other,110% of Medicare,997.5,35,,997.5,percent of total billed charges,Implant Device,969,34,"Charges > $500, x 34%",969,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,1140,40,,1140,percent of total billed charges,Implant Device,997.5,70,,997.5,percent of total billed charges,All Other,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,969,34,"If Charge > 2,000, then 34 percent",969,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2109.01,
ABBOTT 1550250-28 SIERRA DES 2.5X28MM,C1874,HCPCS,,79011291,CDM,278,RC,,,both,,,2850,2109.01,,,2109.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1282.5,45,,1282.5,percent of total billed charges,Critical Access Hospital RCC factor,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,1410.75,,,1410.75,Other,110% of Medicare,997.5,35,,997.5,percent of total billed charges,Implant Device,969,34,"Charges > $500, x 34%",969,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,1140,40,,1140,percent of total billed charges,Implant Device,997.5,70,,997.5,percent of total billed charges,All Other,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,969,34,"If Charge > 2,000, then 34 percent",969,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2109.01,
ABBOTT 1550250-35 SIERRA DES 2.5X33MM,C1874,HCPCS,,79011292,CDM,278,RC,,,both,,,2850,2109.01,,,2109.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1282.5,45,,1282.5,percent of total billed charges,Critical Access Hospital RCC factor,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,1410.75,,,1410.75,Other,110% of Medicare,997.5,35,,997.5,percent of total billed charges,Implant Device,969,34,"Charges > $500, x 34%",969,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,1140,40,,1140,percent of total billed charges,Implant Device,997.5,70,,997.5,percent of total billed charges,All Other,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,969,34,"If Charge > 2,000, then 34 percent",969,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2109.01,
ABBOTT 1550250-38 SIERRA DES 2.5X38MM,C1874,HCPCS,,79011293,CDM,278,RC,,,both,,,2850,2109.01,,,2109.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1282.5,45,,1282.5,percent of total billed charges,Critical Access Hospital RCC factor,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,1410.75,,,1410.75,Other,110% of Medicare,997.5,35,,997.5,percent of total billed charges,Implant Device,969,34,"Charges > $500, x 34%",969,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,1140,40,,1140,percent of total billed charges,Implant Device,997.5,70,,997.5,percent of total billed charges,All Other,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,969,34,"If Charge > 2,000, then 34 percent",969,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2109.01,
ABBOTT 1550275-08 SIERRA DES 2.75X8MM,C1874,HCPCS,,79011294,CDM,278,RC,,,both,,,2850,2109.01,,,2109.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1282.5,45,,1282.5,percent of total billed charges,Critical Access Hospital RCC factor,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,1410.75,,,1410.75,Other,110% of Medicare,997.5,35,,997.5,percent of total billed charges,Implant Device,969,34,"Charges > $500, x 34%",969,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,1140,40,,1140,percent of total billed charges,Implant Device,997.5,70,,997.5,percent of total billed charges,All Other,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,969,34,"If Charge > 2,000, then 34 percent",969,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2109.01,
ABBOTT 1550275-12 SIERRA DES 2.75X12MM,C1874,HCPCS,,79011295,CDM,278,RC,,,both,,,2850,2109.01,,,2109.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1282.5,45,,1282.5,percent of total billed charges,Critical Access Hospital RCC factor,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,1410.75,,,1410.75,Other,110% of Medicare,997.5,35,,997.5,percent of total billed charges,Implant Device,969,34,"Charges > $500, x 34%",969,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,1140,40,,1140,percent of total billed charges,Implant Device,997.5,70,,997.5,percent of total billed charges,All Other,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,969,34,"If Charge > 2,000, then 34 percent",969,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2109.01,
ABBOTT 1550275-15 SIERRA DES 2.75X15MM,C1874,HCPCS,,79011296,CDM,278,RC,,,both,,,2850,2109.01,,,2109.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1282.5,45,,1282.5,percent of total billed charges,Critical Access Hospital RCC factor,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,1410.75,,,1410.75,Other,110% of Medicare,997.5,35,,997.5,percent of total billed charges,Implant Device,969,34,"Charges > $500, x 34%",969,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,1140,40,,1140,percent of total billed charges,Implant Device,997.5,70,,997.5,percent of total billed charges,All Other,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,969,34,"If Charge > 2,000, then 34 percent",969,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2109.01,
ABBOTT 1550275-18 SIERRA DES 2.75X18MM,C1874,HCPCS,,79011297,CDM,278,RC,,,both,,,2850,2109.01,,,2109.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1282.5,45,,1282.5,percent of total billed charges,Critical Access Hospital RCC factor,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,1410.75,,,1410.75,Other,110% of Medicare,997.5,35,,997.5,percent of total billed charges,Implant Device,969,34,"Charges > $500, x 34%",969,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,1140,40,,1140,percent of total billed charges,Implant Device,997.5,70,,997.5,percent of total billed charges,All Other,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,969,34,"If Charge > 2,000, then 34 percent",969,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2109.01,
ABBOTT 1550275-23 SIERRA DES 2.75X23MM,C1874,HCPCS,,79011298,CDM,278,RC,,,both,,,2850,2109.01,,,2109.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1282.5,45,,1282.5,percent of total billed charges,Critical Access Hospital RCC factor,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,1410.75,,,1410.75,Other,110% of Medicare,997.5,35,,997.5,percent of total billed charges,Implant Device,969,34,"Charges > $500, x 34%",969,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,1140,40,,1140,percent of total billed charges,Implant Device,997.5,70,,997.5,percent of total billed charges,All Other,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,969,34,"If Charge > 2,000, then 34 percent",969,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2109.01,
ABBOTT 1550275-28 SIERRA DES 2.75X28MM,C1874,HCPCS,,79011299,CDM,278,RC,,,both,,,2850,2109.01,,,2109.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1282.5,45,,1282.5,percent of total billed charges,Critical Access Hospital RCC factor,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,1410.75,,,1410.75,Other,110% of Medicare,997.5,35,,997.5,percent of total billed charges,Implant Device,969,34,"Charges > $500, x 34%",969,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,1140,40,,1140,percent of total billed charges,Implant Device,997.5,70,,997.5,percent of total billed charges,All Other,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,969,34,"If Charge > 2,000, then 34 percent",969,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2109.01,
ABBOTT 1550275-33 SIERRA DES 2.75X33MM,C1874,HCPCS,,79011300,CDM,278,RC,,,both,,,2850,2109.01,,,2109.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1282.5,45,,1282.5,percent of total billed charges,Critical Access Hospital RCC factor,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,1410.75,,,1410.75,Other,110% of Medicare,997.5,35,,997.5,percent of total billed charges,Implant Device,969,34,"Charges > $500, x 34%",969,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,1140,40,,1140,percent of total billed charges,Implant Device,997.5,70,,997.5,percent of total billed charges,All Other,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,969,34,"If Charge > 2,000, then 34 percent",969,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2109.01,
ABBOTT 1550275-38 SIERRA DES 2.75X38MM,C1874,HCPCS,,79011301,CDM,278,RC,,,both,,,2850,2109.01,,,2109.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1282.5,45,,1282.5,percent of total billed charges,Critical Access Hospital RCC factor,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,1410.75,,,1410.75,Other,110% of Medicare,997.5,35,,997.5,percent of total billed charges,Implant Device,969,34,"Charges > $500, x 34%",969,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,1140,40,,1140,percent of total billed charges,Implant Device,997.5,70,,997.5,percent of total billed charges,All Other,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,969,34,"If Charge > 2,000, then 34 percent",969,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2109.01,
ABBOTT 1550300-08 SIERRA DES 3X8MM,C1874,HCPCS,,79011302,CDM,278,RC,,,both,,,2850,2109.01,,,2109.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1282.5,45,,1282.5,percent of total billed charges,Critical Access Hospital RCC factor,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,1410.75,,,1410.75,Other,110% of Medicare,997.5,35,,997.5,percent of total billed charges,Implant Device,969,34,"Charges > $500, x 34%",969,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,1140,40,,1140,percent of total billed charges,Implant Device,997.5,70,,997.5,percent of total billed charges,All Other,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,969,34,"If Charge > 2,000, then 34 percent",969,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2109.01,
ABBOTT 1550300-12 SIERRA DES 3X12MM,C1874,HCPCS,,79011303,CDM,278,RC,,,both,,,2850,2109.01,,,2109.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1282.5,45,,1282.5,percent of total billed charges,Critical Access Hospital RCC factor,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,1410.75,,,1410.75,Other,110% of Medicare,997.5,35,,997.5,percent of total billed charges,Implant Device,969,34,"Charges > $500, x 34%",969,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,1140,40,,1140,percent of total billed charges,Implant Device,997.5,70,,997.5,percent of total billed charges,All Other,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,969,34,"If Charge > 2,000, then 34 percent",969,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2109.01,
ABBOTT 1550300-15 SIERRA DES 3X15MM,C1874,HCPCS,,79011304,CDM,278,RC,,,both,,,2850,2109.01,,,2109.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1282.5,45,,1282.5,percent of total billed charges,Critical Access Hospital RCC factor,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,1410.75,,,1410.75,Other,110% of Medicare,997.5,35,,997.5,percent of total billed charges,Implant Device,969,34,"Charges > $500, x 34%",969,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,1140,40,,1140,percent of total billed charges,Implant Device,997.5,70,,997.5,percent of total billed charges,All Other,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,969,34,"If Charge > 2,000, then 34 percent",969,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2109.01,
ABBOTT 1550300-18 SIERRA DES 3X18MM,C1874,HCPCS,,79011305,CDM,278,RC,,,both,,,2850,2109.01,,,2109.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1282.5,45,,1282.5,percent of total billed charges,Critical Access Hospital RCC factor,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,1410.75,,,1410.75,Other,110% of Medicare,997.5,35,,997.5,percent of total billed charges,Implant Device,969,34,"Charges > $500, x 34%",969,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,1140,40,,1140,percent of total billed charges,Implant Device,997.5,70,,997.5,percent of total billed charges,All Other,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,969,34,"If Charge > 2,000, then 34 percent",969,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2109.01,
ABBOTT 1550300-23 SIERRA DES 3X23MM,C1874,HCPCS,,79011306,CDM,278,RC,,,both,,,2850,2109.01,,,2109.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1282.5,45,,1282.5,percent of total billed charges,Critical Access Hospital RCC factor,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,1410.75,,,1410.75,Other,110% of Medicare,997.5,35,,997.5,percent of total billed charges,Implant Device,969,34,"Charges > $500, x 34%",969,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,1140,40,,1140,percent of total billed charges,Implant Device,997.5,70,,997.5,percent of total billed charges,All Other,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,969,34,"If Charge > 2,000, then 34 percent",969,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2109.01,
ABBOTT 1550300-28 SIERRA DES 3X28MM,C1874,HCPCS,,79011307,CDM,278,RC,,,both,,,2850,2109.01,,,2109.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1282.5,45,,1282.5,percent of total billed charges,Critical Access Hospital RCC factor,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,1410.75,,,1410.75,Other,110% of Medicare,997.5,35,,997.5,percent of total billed charges,Implant Device,969,34,"Charges > $500, x 34%",969,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,1140,40,,1140,percent of total billed charges,Implant Device,997.5,70,,997.5,percent of total billed charges,All Other,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,969,34,"If Charge > 2,000, then 34 percent",969,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2109.01,
ABBOTT 1550300-33 SIERRA DES 3X33MM,C1874,HCPCS,,79011308,CDM,278,RC,,,both,,,2850,2109.01,,,2109.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1282.5,45,,1282.5,percent of total billed charges,Critical Access Hospital RCC factor,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,1410.75,,,1410.75,Other,110% of Medicare,997.5,35,,997.5,percent of total billed charges,Implant Device,969,34,"Charges > $500, x 34%",969,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,1140,40,,1140,percent of total billed charges,Implant Device,997.5,70,,997.5,percent of total billed charges,All Other,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,969,34,"If Charge > 2,000, then 34 percent",969,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2109.01,
ABBOTT 1550300-38 SIERRA DES 3X38MM,C1874,HCPCS,,79011309,CDM,278,RC,,,both,,,2850,2109.01,,,2109.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1282.5,45,,1282.5,percent of total billed charges,Critical Access Hospital RCC factor,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,1410.75,,,1410.75,Other,110% of Medicare,997.5,35,,997.5,percent of total billed charges,Implant Device,969,34,"Charges > $500, x 34%",969,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,1140,40,,1140,percent of total billed charges,Implant Device,997.5,70,,997.5,percent of total billed charges,All Other,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,969,34,"If Charge > 2,000, then 34 percent",969,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2109.01,
ABBOTT 1550325-08 SIERRA DES 3.25X8MM,C1874,HCPCS,,79011310,CDM,278,RC,,,both,,,2850,2109.01,,,2109.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1282.5,45,,1282.5,percent of total billed charges,Critical Access Hospital RCC factor,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,1410.75,,,1410.75,Other,110% of Medicare,997.5,35,,997.5,percent of total billed charges,Implant Device,969,34,"Charges > $500, x 34%",969,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,1140,40,,1140,percent of total billed charges,Implant Device,997.5,70,,997.5,percent of total billed charges,All Other,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,969,34,"If Charge > 2,000, then 34 percent",969,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2109.01,
ABBOTT 1550325-12 SIERRA DES 3.25X12MM,C1874,HCPCS,,79011311,CDM,278,RC,,,both,,,2850,2109.01,,,2109.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1282.5,45,,1282.5,percent of total billed charges,Critical Access Hospital RCC factor,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,1410.75,,,1410.75,Other,110% of Medicare,997.5,35,,997.5,percent of total billed charges,Implant Device,969,34,"Charges > $500, x 34%",969,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,1140,40,,1140,percent of total billed charges,Implant Device,997.5,70,,997.5,percent of total billed charges,All Other,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,969,34,"If Charge > 2,000, then 34 percent",969,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2109.01,
ABBOTT 1550325-15 SIERRA DES 3.25X15MM,C1874,HCPCS,,79011312,CDM,278,RC,,,both,,,2850,2109.01,,,2109.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1282.5,45,,1282.5,percent of total billed charges,Critical Access Hospital RCC factor,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,1410.75,,,1410.75,Other,110% of Medicare,997.5,35,,997.5,percent of total billed charges,Implant Device,969,34,"Charges > $500, x 34%",969,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,1140,40,,1140,percent of total billed charges,Implant Device,997.5,70,,997.5,percent of total billed charges,All Other,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,969,34,"If Charge > 2,000, then 34 percent",969,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2109.01,
ABBOTT 1550325-18 SIERRA DES 3.25X18MM,C1874,HCPCS,,79011313,CDM,278,RC,,,both,,,2850,2109.01,,,2109.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1282.5,45,,1282.5,percent of total billed charges,Critical Access Hospital RCC factor,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,1410.75,,,1410.75,Other,110% of Medicare,997.5,35,,997.5,percent of total billed charges,Implant Device,969,34,"Charges > $500, x 34%",969,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,1140,40,,1140,percent of total billed charges,Implant Device,997.5,70,,997.5,percent of total billed charges,All Other,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,969,34,"If Charge > 2,000, then 34 percent",969,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2109.01,
ABBOTT 1550325-23 SIERRA DES 3.25X23MM,C1874,HCPCS,,79011314,CDM,278,RC,,,both,,,2850,2109.01,,,2109.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1282.5,45,,1282.5,percent of total billed charges,Critical Access Hospital RCC factor,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,1410.75,,,1410.75,Other,110% of Medicare,997.5,35,,997.5,percent of total billed charges,Implant Device,969,34,"Charges > $500, x 34%",969,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,1140,40,,1140,percent of total billed charges,Implant Device,997.5,70,,997.5,percent of total billed charges,All Other,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,969,34,"If Charge > 2,000, then 34 percent",969,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2109.01,
ABBOTT 1550325-28 SIERRA DES 3.25X28MM,C1874,HCPCS,,79011315,CDM,278,RC,,,both,,,2850,2109.01,,,2109.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1282.5,45,,1282.5,percent of total billed charges,Critical Access Hospital RCC factor,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,1410.75,,,1410.75,Other,110% of Medicare,997.5,35,,997.5,percent of total billed charges,Implant Device,969,34,"Charges > $500, x 34%",969,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,1140,40,,1140,percent of total billed charges,Implant Device,997.5,70,,997.5,percent of total billed charges,All Other,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,969,34,"If Charge > 2,000, then 34 percent",969,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2109.01,
ABBOTT 1550325-33 SIERRA DES 3.25X33MM,C1874,HCPCS,,79011316,CDM,278,RC,,,both,,,2850,2109.01,,,2109.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1282.5,45,,1282.5,percent of total billed charges,Critical Access Hospital RCC factor,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,1410.75,,,1410.75,Other,110% of Medicare,997.5,35,,997.5,percent of total billed charges,Implant Device,969,34,"Charges > $500, x 34%",969,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,1140,40,,1140,percent of total billed charges,Implant Device,997.5,70,,997.5,percent of total billed charges,All Other,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,969,34,"If Charge > 2,000, then 34 percent",969,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2109.01,
ABBOTT 1550325-38 SIERRA DES 3.25X38MM,C1874,HCPCS,,79011317,CDM,278,RC,,,both,,,2850,2109.01,,,2109.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1282.5,45,,1282.5,percent of total billed charges,Critical Access Hospital RCC factor,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,1410.75,,,1410.75,Other,110% of Medicare,997.5,35,,997.5,percent of total billed charges,Implant Device,969,34,"Charges > $500, x 34%",969,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,1140,40,,1140,percent of total billed charges,Implant Device,997.5,70,,997.5,percent of total billed charges,All Other,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,969,34,"If Charge > 2,000, then 34 percent",969,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2109.01,
ABBOTT 1550350-08 SIERRA DES 3.5X8MM,C1874,HCPCS,,79011318,CDM,278,RC,,,both,,,2850,2109.01,,,2109.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1282.5,45,,1282.5,percent of total billed charges,Critical Access Hospital RCC factor,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,1410.75,,,1410.75,Other,110% of Medicare,997.5,35,,997.5,percent of total billed charges,Implant Device,969,34,"Charges > $500, x 34%",969,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,1140,40,,1140,percent of total billed charges,Implant Device,997.5,70,,997.5,percent of total billed charges,All Other,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,969,34,"If Charge > 2,000, then 34 percent",969,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2109.01,
ABBOTT 1550350-12 SIERRA DES 3.5X12MM,C1874,HCPCS,,79011319,CDM,278,RC,,,both,,,2850,2109.01,,,2109.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1282.5,45,,1282.5,percent of total billed charges,Critical Access Hospital RCC factor,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,1410.75,,,1410.75,Other,110% of Medicare,997.5,35,,997.5,percent of total billed charges,Implant Device,969,34,"Charges > $500, x 34%",969,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,1140,40,,1140,percent of total billed charges,Implant Device,997.5,70,,997.5,percent of total billed charges,All Other,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,969,34,"If Charge > 2,000, then 34 percent",969,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2109.01,
ABBOTT 1550350-15 SIERRA DES 3.5X15MM,C1874,HCPCS,,79011320,CDM,278,RC,,,both,,,2850,2109.01,,,2109.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1282.5,45,,1282.5,percent of total billed charges,Critical Access Hospital RCC factor,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,1410.75,,,1410.75,Other,110% of Medicare,997.5,35,,997.5,percent of total billed charges,Implant Device,969,34,"Charges > $500, x 34%",969,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,1140,40,,1140,percent of total billed charges,Implant Device,997.5,70,,997.5,percent of total billed charges,All Other,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,969,34,"If Charge > 2,000, then 34 percent",969,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2109.01,
ABBOTT 1550350-18 SIERRA DES 3.5X18MM,C1874,HCPCS,,79011321,CDM,278,RC,,,both,,,2850,2109.01,,,2109.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1282.5,45,,1282.5,percent of total billed charges,Critical Access Hospital RCC factor,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,1410.75,,,1410.75,Other,110% of Medicare,997.5,35,,997.5,percent of total billed charges,Implant Device,969,34,"Charges > $500, x 34%",969,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,1140,40,,1140,percent of total billed charges,Implant Device,997.5,70,,997.5,percent of total billed charges,All Other,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,969,34,"If Charge > 2,000, then 34 percent",969,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2109.01,
ABBOTT 1550350-23 SIERRA DES 3.5X23MM,C1874,HCPCS,,79011322,CDM,278,RC,,,both,,,2850,2109.01,,,2109.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1282.5,45,,1282.5,percent of total billed charges,Critical Access Hospital RCC factor,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,1410.75,,,1410.75,Other,110% of Medicare,997.5,35,,997.5,percent of total billed charges,Implant Device,969,34,"Charges > $500, x 34%",969,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,1140,40,,1140,percent of total billed charges,Implant Device,997.5,70,,997.5,percent of total billed charges,All Other,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,969,34,"If Charge > 2,000, then 34 percent",969,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2109.01,
ABBOTT 1550350-28 SIERRA DES 3.5X28MM,C1874,HCPCS,,79011323,CDM,278,RC,,,both,,,2850,2109.01,,,2109.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1282.5,45,,1282.5,percent of total billed charges,Critical Access Hospital RCC factor,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,1410.75,,,1410.75,Other,110% of Medicare,997.5,35,,997.5,percent of total billed charges,Implant Device,969,34,"Charges > $500, x 34%",969,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,1140,40,,1140,percent of total billed charges,Implant Device,997.5,70,,997.5,percent of total billed charges,All Other,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,969,34,"If Charge > 2,000, then 34 percent",969,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2109.01,
ABBOTT 1550350-33 SIERRA DES 3.5X33MM,C1874,HCPCS,,79011324,CDM,278,RC,,,both,,,2850,2109.01,,,2109.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1282.5,45,,1282.5,percent of total billed charges,Critical Access Hospital RCC factor,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,1410.75,,,1410.75,Other,110% of Medicare,997.5,35,,997.5,percent of total billed charges,Implant Device,969,34,"Charges > $500, x 34%",969,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,1140,40,,1140,percent of total billed charges,Implant Device,997.5,70,,997.5,percent of total billed charges,All Other,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,969,34,"If Charge > 2,000, then 34 percent",969,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2109.01,
ABBOTT 1550350-38 SIERRA DES 3.5X38MM,C1874,HCPCS,,79011325,CDM,278,RC,,,both,,,2850,2109.01,,,2109.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1282.5,45,,1282.5,percent of total billed charges,Critical Access Hospital RCC factor,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,1410.75,,,1410.75,Other,110% of Medicare,997.5,35,,997.5,percent of total billed charges,Implant Device,969,34,"Charges > $500, x 34%",969,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,1140,40,,1140,percent of total billed charges,Implant Device,997.5,70,,997.5,percent of total billed charges,All Other,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,969,34,"If Charge > 2,000, then 34 percent",969,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2109.01,
ABBOTT 1550400-08 SIERRA DES 4X8MM,C1874,HCPCS,,79011326,CDM,278,RC,,,both,,,2850,2109.01,,,2109.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1282.5,45,,1282.5,percent of total billed charges,Critical Access Hospital RCC factor,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,1410.75,,,1410.75,Other,110% of Medicare,997.5,35,,997.5,percent of total billed charges,Implant Device,969,34,"Charges > $500, x 34%",969,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,1140,40,,1140,percent of total billed charges,Implant Device,997.5,70,,997.5,percent of total billed charges,All Other,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,969,34,"If Charge > 2,000, then 34 percent",969,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2109.01,
ABBOTT 1550400-12 SIERRA DES 4X12MM,C1874,HCPCS,,79011327,CDM,278,RC,,,both,,,2850,2109.01,,,2109.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1282.5,45,,1282.5,percent of total billed charges,Critical Access Hospital RCC factor,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,1410.75,,,1410.75,Other,110% of Medicare,997.5,35,,997.5,percent of total billed charges,Implant Device,969,34,"Charges > $500, x 34%",969,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,1140,40,,1140,percent of total billed charges,Implant Device,997.5,70,,997.5,percent of total billed charges,All Other,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,969,34,"If Charge > 2,000, then 34 percent",969,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2109.01,
BARD 0115310 MEDIUM LEFT 3DMAX 3X5,C1781,HCPCS,,79011328,CDM,278,RC,,,both,,,474,350.76,,,350.76,Other,150% of Medicare + 9.63% HCRA Surcharge,213.3,45,,213.3,percent of total billed charges,Critical Access Hospital RCC factor,161.16,34,,161.16,percent of total billed charges,Implant Device,161.16,34,,161.16,percent of total billed charges,Implant Device,161.16,34,,161.16,percent of total billed charges,Implant Device,161.16,34,,161.16,percent of total billed charges,Implant Device,161.16,34,,161.16,percent of total billed charges,Implant Device,234.63,,,234.63,Other,110% of Medicare,165.9,35,,165.9,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,165.9,35,,165.9,percent of total billed charges,Implant Device,165.9,35,,165.9,percent of total billed charges,Implant Device,165.9,35,,165.9,percent of total billed charges,Implant Device,165.9,35,,165.9,percent of total billed charges,Implant Device,165.9,35,,165.9,percent of total billed charges,Implant Device,189.6,40,,189.6,percent of total billed charges,Implant Device,165.9,70,,165.9,percent of total billed charges,All Other,161.16,34,,161.16,percent of total billed charges,Implant Device,161.16,34,,161.16,percent of total billed charges,Implant Device,165.9,35,,165.9,percent of total billed charges,Implant Device,165.9,35,,165.9,percent of total billed charges,Implant Device,165.9,35,,165.9,percent of total billed charges,Implant Device,165.9,35,,165.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,350.76,
BARD 0115320 MEDIUM RIGHT 3DMAX 3X5,C1781,HCPCS,,79011329,CDM,278,RC,,,both,,,474,350.76,,,350.76,Other,150% of Medicare + 9.63% HCRA Surcharge,213.3,45,,213.3,percent of total billed charges,Critical Access Hospital RCC factor,161.16,34,,161.16,percent of total billed charges,Implant Device,161.16,34,,161.16,percent of total billed charges,Implant Device,161.16,34,,161.16,percent of total billed charges,Implant Device,161.16,34,,161.16,percent of total billed charges,Implant Device,161.16,34,,161.16,percent of total billed charges,Implant Device,234.63,,,234.63,Other,110% of Medicare,165.9,35,,165.9,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,165.9,35,,165.9,percent of total billed charges,Implant Device,165.9,35,,165.9,percent of total billed charges,Implant Device,165.9,35,,165.9,percent of total billed charges,Implant Device,165.9,35,,165.9,percent of total billed charges,Implant Device,165.9,35,,165.9,percent of total billed charges,Implant Device,189.6,40,,189.6,percent of total billed charges,Implant Device,165.9,70,,165.9,percent of total billed charges,All Other,161.16,34,,161.16,percent of total billed charges,Implant Device,161.16,34,,161.16,percent of total billed charges,Implant Device,165.9,35,,165.9,percent of total billed charges,Implant Device,165.9,35,,165.9,percent of total billed charges,Implant Device,165.9,35,,165.9,percent of total billed charges,Implant Device,165.9,35,,165.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,350.76,
ABBOTT 1550400-15 SIERRA DES 4X15MM,C1874,HCPCS,,79011330,CDM,278,RC,,,both,,,2850,2109.01,,,2109.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1282.5,45,,1282.5,percent of total billed charges,Critical Access Hospital RCC factor,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,1410.75,,,1410.75,Other,110% of Medicare,997.5,35,,997.5,percent of total billed charges,Implant Device,969,34,"Charges > $500, x 34%",969,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,1140,40,,1140,percent of total billed charges,Implant Device,997.5,70,,997.5,percent of total billed charges,All Other,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,969,34,"If Charge > 2,000, then 34 percent",969,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2109.01,
ABBOTT 1550400-18 SIERRA DES 4X18MM,C1874,HCPCS,,79011331,CDM,278,RC,,,both,,,2850,2109.01,,,2109.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1282.5,45,,1282.5,percent of total billed charges,Critical Access Hospital RCC factor,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,1410.75,,,1410.75,Other,110% of Medicare,997.5,35,,997.5,percent of total billed charges,Implant Device,969,34,"Charges > $500, x 34%",969,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,1140,40,,1140,percent of total billed charges,Implant Device,997.5,70,,997.5,percent of total billed charges,All Other,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,969,34,"If Charge > 2,000, then 34 percent",969,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2109.01,
ABBOTT 1550400-23 SIERRA DES 4X23MM,C1874,HCPCS,,79011332,CDM,278,RC,,,both,,,2850,2109.01,,,2109.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1282.5,45,,1282.5,percent of total billed charges,Critical Access Hospital RCC factor,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,1410.75,,,1410.75,Other,110% of Medicare,997.5,35,,997.5,percent of total billed charges,Implant Device,969,34,"Charges > $500, x 34%",969,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,1140,40,,1140,percent of total billed charges,Implant Device,997.5,70,,997.5,percent of total billed charges,All Other,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,969,34,"If Charge > 2,000, then 34 percent",969,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2109.01,
ABBOTT 1550400-28 SIERRA DES 4X28MM,C1874,HCPCS,,79011333,CDM,278,RC,,,both,,,2850,2109.01,,,2109.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1282.5,45,,1282.5,percent of total billed charges,Critical Access Hospital RCC factor,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,1410.75,,,1410.75,Other,110% of Medicare,997.5,35,,997.5,percent of total billed charges,Implant Device,969,34,"Charges > $500, x 34%",969,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,1140,40,,1140,percent of total billed charges,Implant Device,997.5,70,,997.5,percent of total billed charges,All Other,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,969,34,"If Charge > 2,000, then 34 percent",969,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2109.01,
ABBOTT 1550400-33 SIERRA DES 4X33MM,C1874,HCPCS,,79011334,CDM,278,RC,,,both,,,2850,2109.01,,,2109.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1282.5,45,,1282.5,percent of total billed charges,Critical Access Hospital RCC factor,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,1410.75,,,1410.75,Other,110% of Medicare,997.5,35,,997.5,percent of total billed charges,Implant Device,969,34,"Charges > $500, x 34%",969,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,1140,40,,1140,percent of total billed charges,Implant Device,997.5,70,,997.5,percent of total billed charges,All Other,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,969,34,"If Charge > 2,000, then 34 percent",969,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2109.01,
ABBOTT 1550400-38 SIERRA DES 4X38MM,C1874,HCPCS,,79011335,CDM,278,RC,,,both,,,2850,2109.01,,,2109.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1282.5,45,,1282.5,percent of total billed charges,Critical Access Hospital RCC factor,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,1410.75,,,1410.75,Other,110% of Medicare,997.5,35,,997.5,percent of total billed charges,Implant Device,969,34,"Charges > $500, x 34%",969,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,1140,40,,1140,percent of total billed charges,Implant Device,997.5,70,,997.5,percent of total billed charges,All Other,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,969,34,"If Charge > 2,000, then 34 percent",969,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2109.01,
DEPUY 02.112.009 LCP CLAVICLE PLATE 6H,C1713,HCPCS,,79011350,CDM,278,RC,,,both,,,2397,1773.79,,,1773.79,Other,150% of Medicare + 9.63% HCRA Surcharge,1078.65,45,,1078.65,percent of total billed charges,Critical Access Hospital RCC factor,814.98,34,,814.98,percent of total billed charges,Implant Device,814.98,34,,814.98,percent of total billed charges,Implant Device,814.98,34,,814.98,percent of total billed charges,Implant Device,814.98,34,,814.98,percent of total billed charges,Implant Device,814.98,34,,814.98,percent of total billed charges,Implant Device,1186.52,,,1186.52,Other,110% of Medicare,838.95,35,,838.95,percent of total billed charges,Implant Device,814.98,34,"Charges > $500, x 34%",814.98,percent of total billed charges,Implant Device,838.95,35,,838.95,percent of total billed charges,Implant Device,838.95,35,,838.95,percent of total billed charges,Implant Device,838.95,35,,838.95,percent of total billed charges,Implant Device,838.95,35,,838.95,percent of total billed charges,Implant Device,838.95,35,,838.95,percent of total billed charges,Implant Device,958.8,40,,958.8,percent of total billed charges,Implant Device,838.95,70,,838.95,percent of total billed charges,All Other,814.98,34,,814.98,percent of total billed charges,Implant Device,814.98,34,,814.98,percent of total billed charges,Implant Device,838.95,35,,838.95,percent of total billed charges,Implant Device,838.95,35,,838.95,percent of total billed charges,Implant Device,838.95,35,,838.95,percent of total billed charges,Implant Device,838.95,35,,838.95,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,814.98,34,"If Charge > 2,000, then 34 percent",814.98,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1773.79,
STRYKER 5542-P-0056 PEGGED GLENOID SZ 56,C1776,HCPCS,,79011461,CDM,278,RC,,,both,,,3675,2719.51,,,2719.51,Other,150% of Medicare + 9.63% HCRA Surcharge,1653.75,45,,1653.75,percent of total billed charges,Critical Access Hospital RCC factor,1249.5,34,,1249.5,percent of total billed charges,Implant Device,1249.5,34,,1249.5,percent of total billed charges,Implant Device,1249.5,34,,1249.5,percent of total billed charges,Implant Device,1249.5,34,,1249.5,percent of total billed charges,Implant Device,1249.5,34,,1249.5,percent of total billed charges,Implant Device,1819.13,,,1819.13,Other,110% of Medicare,1286.25,35,,1286.25,percent of total billed charges,Implant Device,1249.5,34,"Charges > $500, x 34%",1249.5,percent of total billed charges,Implant Device,1286.25,35,,1286.25,percent of total billed charges,Implant Device,1286.25,35,,1286.25,percent of total billed charges,Implant Device,1286.25,35,,1286.25,percent of total billed charges,Implant Device,1286.25,35,,1286.25,percent of total billed charges,Implant Device,1286.25,35,,1286.25,percent of total billed charges,Implant Device,1470,40,,1470,percent of total billed charges,Implant Device,1286.25,70,,1286.25,percent of total billed charges,All Other,1249.5,34,,1249.5,percent of total billed charges,Implant Device,1249.5,34,,1249.5,percent of total billed charges,Implant Device,1286.25,35,,1286.25,percent of total billed charges,Implant Device,1286.25,35,,1286.25,percent of total billed charges,Implant Device,1286.25,35,,1286.25,percent of total billed charges,Implant Device,1286.25,35,,1286.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1249.5,34,"If Charge > 2,000, then 34 percent",1249.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2719.51,
STRYKER 5552-E-5217 HUM HEAD SZ 52X17MM,C1776,HCPCS,,79011462,CDM,278,RC,,,both,,,3675,2719.51,,,2719.51,Other,150% of Medicare + 9.63% HCRA Surcharge,1653.75,45,,1653.75,percent of total billed charges,Critical Access Hospital RCC factor,1249.5,34,,1249.5,percent of total billed charges,Implant Device,1249.5,34,,1249.5,percent of total billed charges,Implant Device,1249.5,34,,1249.5,percent of total billed charges,Implant Device,1249.5,34,,1249.5,percent of total billed charges,Implant Device,1249.5,34,,1249.5,percent of total billed charges,Implant Device,1819.13,,,1819.13,Other,110% of Medicare,1286.25,35,,1286.25,percent of total billed charges,Implant Device,1249.5,34,"Charges > $500, x 34%",1249.5,percent of total billed charges,Implant Device,1286.25,35,,1286.25,percent of total billed charges,Implant Device,1286.25,35,,1286.25,percent of total billed charges,Implant Device,1286.25,35,,1286.25,percent of total billed charges,Implant Device,1286.25,35,,1286.25,percent of total billed charges,Implant Device,1286.25,35,,1286.25,percent of total billed charges,Implant Device,1470,40,,1470,percent of total billed charges,Implant Device,1286.25,70,,1286.25,percent of total billed charges,All Other,1249.5,34,,1249.5,percent of total billed charges,Implant Device,1249.5,34,,1249.5,percent of total billed charges,Implant Device,1286.25,35,,1286.25,percent of total billed charges,Implant Device,1286.25,35,,1286.25,percent of total billed charges,Implant Device,1286.25,35,,1286.25,percent of total billed charges,Implant Device,1286.25,35,,1286.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1249.5,34,"If Charge > 2,000, then 34 percent",1249.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2719.51,
STRYKER 5567-P-3017 HUM STEM 17X102MM,C1776,HCPCS,,79011463,CDM,278,RC,,,both,,,16950,12543.04,,,12543.04,Other,150% of Medicare + 9.63% HCRA Surcharge,7627.5,45,,7627.5,percent of total billed charges,Critical Access Hospital RCC factor,5763,34,,5763,percent of total billed charges,Implant Device,5763,34,,5763,percent of total billed charges,Implant Device,5763,34,,5763,percent of total billed charges,Implant Device,5763,34,,5763,percent of total billed charges,Implant Device,5763,34,,5763,percent of total billed charges,Implant Device,8390.25,,,8390.25,Other,110% of Medicare,5932.5,35,,5932.5,percent of total billed charges,Implant Device,5763,34,"Charges > $500, x 34%",5763,percent of total billed charges,Implant Device,5932.5,35,,5932.5,percent of total billed charges,Implant Device,5932.5,35,,5932.5,percent of total billed charges,Implant Device,5932.5,35,,5932.5,percent of total billed charges,Implant Device,5932.5,35,,5932.5,percent of total billed charges,Implant Device,5932.5,35,,5932.5,percent of total billed charges,Implant Device,6780,40,,6780,percent of total billed charges,Implant Device,5932.5,70,,5932.5,percent of total billed charges,All Other,5763,34,,5763,percent of total billed charges,Implant Device,5763,34,,5763,percent of total billed charges,Implant Device,5932.5,35,,5932.5,percent of total billed charges,Implant Device,5932.5,35,,5932.5,percent of total billed charges,Implant Device,5932.5,35,,5932.5,percent of total billed charges,Implant Device,5932.5,35,,5932.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,5763,34,"If Charge > 2,000, then 34 percent",5763,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,12543.04,
BIOTRONIK 434887 PK PAPYRUS 2.5X15MM,C1874,HCPCS,,79011480,CDM,278,RC,,,both,,,9000,6660.02,,,6660.02,Other,150% of Medicare + 9.63% HCRA Surcharge,4050,45,,4050,percent of total billed charges,Critical Access Hospital RCC factor,3060,34,,3060,percent of total billed charges,Implant Device,3060,34,,3060,percent of total billed charges,Implant Device,3060,34,,3060,percent of total billed charges,Implant Device,3060,34,,3060,percent of total billed charges,Implant Device,3060,34,,3060,percent of total billed charges,Implant Device,4455,,,4455,Other,110% of Medicare,3150,35,,3150,percent of total billed charges,Implant Device,3060,34,"Charges > $500, x 34%",3060,percent of total billed charges,Implant Device,3150,35,,3150,percent of total billed charges,Implant Device,3150,35,,3150,percent of total billed charges,Implant Device,3150,35,,3150,percent of total billed charges,Implant Device,3150,35,,3150,percent of total billed charges,Implant Device,3150,35,,3150,percent of total billed charges,Implant Device,3600,40,,3600,percent of total billed charges,Implant Device,3150,70,,3150,percent of total billed charges,All Other,3060,34,,3060,percent of total billed charges,Implant Device,3060,34,,3060,percent of total billed charges,Implant Device,3150,35,,3150,percent of total billed charges,Implant Device,3150,35,,3150,percent of total billed charges,Implant Device,3150,35,,3150,percent of total billed charges,Implant Device,3150,35,,3150,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3060,34,"If Charge > 2,000, then 34 percent",3060,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,6660.02,
BIOTRONIK 434888 PK PAPYRUS 3.0X15MM,C1874,HCPCS,,79011481,CDM,278,RC,,,both,,,9000,6660.02,,,6660.02,Other,150% of Medicare + 9.63% HCRA Surcharge,4050,45,,4050,percent of total billed charges,Critical Access Hospital RCC factor,3060,34,,3060,percent of total billed charges,Implant Device,3060,34,,3060,percent of total billed charges,Implant Device,3060,34,,3060,percent of total billed charges,Implant Device,3060,34,,3060,percent of total billed charges,Implant Device,3060,34,,3060,percent of total billed charges,Implant Device,4455,,,4455,Other,110% of Medicare,3150,35,,3150,percent of total billed charges,Implant Device,3060,34,"Charges > $500, x 34%",3060,percent of total billed charges,Implant Device,3150,35,,3150,percent of total billed charges,Implant Device,3150,35,,3150,percent of total billed charges,Implant Device,3150,35,,3150,percent of total billed charges,Implant Device,3150,35,,3150,percent of total billed charges,Implant Device,3150,35,,3150,percent of total billed charges,Implant Device,3600,40,,3600,percent of total billed charges,Implant Device,3150,70,,3150,percent of total billed charges,All Other,3060,34,,3060,percent of total billed charges,Implant Device,3060,34,,3060,percent of total billed charges,Implant Device,3150,35,,3150,percent of total billed charges,Implant Device,3150,35,,3150,percent of total billed charges,Implant Device,3150,35,,3150,percent of total billed charges,Implant Device,3150,35,,3150,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3060,34,"If Charge > 2,000, then 34 percent",3060,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,6660.02,
BIOTRONIK 434889 PK PAPYRUS 3.5X15MM,C1874,HCPCS,,79011482,CDM,278,RC,,,both,,,9000,6660.02,,,6660.02,Other,150% of Medicare + 9.63% HCRA Surcharge,4050,45,,4050,percent of total billed charges,Critical Access Hospital RCC factor,3060,34,,3060,percent of total billed charges,Implant Device,3060,34,,3060,percent of total billed charges,Implant Device,3060,34,,3060,percent of total billed charges,Implant Device,3060,34,,3060,percent of total billed charges,Implant Device,3060,34,,3060,percent of total billed charges,Implant Device,4455,,,4455,Other,110% of Medicare,3150,35,,3150,percent of total billed charges,Implant Device,3060,34,"Charges > $500, x 34%",3060,percent of total billed charges,Implant Device,3150,35,,3150,percent of total billed charges,Implant Device,3150,35,,3150,percent of total billed charges,Implant Device,3150,35,,3150,percent of total billed charges,Implant Device,3150,35,,3150,percent of total billed charges,Implant Device,3150,35,,3150,percent of total billed charges,Implant Device,3600,40,,3600,percent of total billed charges,Implant Device,3150,70,,3150,percent of total billed charges,All Other,3060,34,,3060,percent of total billed charges,Implant Device,3060,34,,3060,percent of total billed charges,Implant Device,3150,35,,3150,percent of total billed charges,Implant Device,3150,35,,3150,percent of total billed charges,Implant Device,3150,35,,3150,percent of total billed charges,Implant Device,3150,35,,3150,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3060,34,"If Charge > 2,000, then 34 percent",3060,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,6660.02,
BIOTRONIK 434895 PK PAPYRUS 3.5X20MM,C1874,HCPCS,,79011483,CDM,278,RC,,,both,,,9000,6660.02,,,6660.02,Other,150% of Medicare + 9.63% HCRA Surcharge,4050,45,,4050,percent of total billed charges,Critical Access Hospital RCC factor,3060,34,,3060,percent of total billed charges,Implant Device,3060,34,,3060,percent of total billed charges,Implant Device,3060,34,,3060,percent of total billed charges,Implant Device,3060,34,,3060,percent of total billed charges,Implant Device,3060,34,,3060,percent of total billed charges,Implant Device,4455,,,4455,Other,110% of Medicare,3150,35,,3150,percent of total billed charges,Implant Device,3060,34,"Charges > $500, x 34%",3060,percent of total billed charges,Implant Device,3150,35,,3150,percent of total billed charges,Implant Device,3150,35,,3150,percent of total billed charges,Implant Device,3150,35,,3150,percent of total billed charges,Implant Device,3150,35,,3150,percent of total billed charges,Implant Device,3150,35,,3150,percent of total billed charges,Implant Device,3600,40,,3600,percent of total billed charges,Implant Device,3150,70,,3150,percent of total billed charges,All Other,3060,34,,3060,percent of total billed charges,Implant Device,3060,34,,3060,percent of total billed charges,Implant Device,3150,35,,3150,percent of total billed charges,Implant Device,3150,35,,3150,percent of total billed charges,Implant Device,3150,35,,3150,percent of total billed charges,Implant Device,3150,35,,3150,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3060,34,"If Charge > 2,000, then 34 percent",3060,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,6660.02,
EXACTECH 320-40-03 HUM LINER 40MM +2.5,C1776,HCPCS,,79011567,CDM,278,RC,,,both,,,2325,1720.51,,,1720.51,Other,150% of Medicare + 9.63% HCRA Surcharge,1046.25,45,,1046.25,percent of total billed charges,Critical Access Hospital RCC factor,790.5,34,,790.5,percent of total billed charges,Implant Device,790.5,34,,790.5,percent of total billed charges,Implant Device,790.5,34,,790.5,percent of total billed charges,Implant Device,790.5,34,,790.5,percent of total billed charges,Implant Device,790.5,34,,790.5,percent of total billed charges,Implant Device,1150.88,,,1150.88,Other,110% of Medicare,813.75,35,,813.75,percent of total billed charges,Implant Device,790.5,34,"Charges > $500, x 34%",790.5,percent of total billed charges,Implant Device,813.75,35,,813.75,percent of total billed charges,Implant Device,813.75,35,,813.75,percent of total billed charges,Implant Device,813.75,35,,813.75,percent of total billed charges,Implant Device,813.75,35,,813.75,percent of total billed charges,Implant Device,813.75,35,,813.75,percent of total billed charges,Implant Device,930,40,,930,percent of total billed charges,Implant Device,813.75,70,,813.75,percent of total billed charges,All Other,790.5,34,,790.5,percent of total billed charges,Implant Device,790.5,34,,790.5,percent of total billed charges,Implant Device,813.75,35,,813.75,percent of total billed charges,Implant Device,813.75,35,,813.75,percent of total billed charges,Implant Device,813.75,35,,813.75,percent of total billed charges,Implant Device,813.75,35,,813.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,790.5,34,"If Charge > 2,000, then 34 percent",790.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1720.51,
BIOTRONIK 434893 PK PAPYRUS 2.5X20MM,C1874,HCPCS,,79011589,CDM,278,RC,,,both,,,9000,6660.02,,,6660.02,Other,150% of Medicare + 9.63% HCRA Surcharge,4050,45,,4050,percent of total billed charges,Critical Access Hospital RCC factor,3060,34,,3060,percent of total billed charges,Implant Device,3060,34,,3060,percent of total billed charges,Implant Device,3060,34,,3060,percent of total billed charges,Implant Device,3060,34,,3060,percent of total billed charges,Implant Device,3060,34,,3060,percent of total billed charges,Implant Device,4455,,,4455,Other,110% of Medicare,3150,35,,3150,percent of total billed charges,Implant Device,3060,34,"Charges > $500, x 34%",3060,percent of total billed charges,Implant Device,3150,35,,3150,percent of total billed charges,Implant Device,3150,35,,3150,percent of total billed charges,Implant Device,3150,35,,3150,percent of total billed charges,Implant Device,3150,35,,3150,percent of total billed charges,Implant Device,3150,35,,3150,percent of total billed charges,Implant Device,3600,40,,3600,percent of total billed charges,Implant Device,3150,70,,3150,percent of total billed charges,All Other,3060,34,,3060,percent of total billed charges,Implant Device,3060,34,,3060,percent of total billed charges,Implant Device,3150,35,,3150,percent of total billed charges,Implant Device,3150,35,,3150,percent of total billed charges,Implant Device,3150,35,,3150,percent of total billed charges,Implant Device,3150,35,,3150,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3060,34,"If Charge > 2,000, then 34 percent",3060,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,6660.02,
BIOTRONIK 434894 PK PAPYRUS 3X20MM,C1874,HCPCS,,79011590,CDM,278,RC,,,both,,,9000,6660.02,,,6660.02,Other,150% of Medicare + 9.63% HCRA Surcharge,4050,45,,4050,percent of total billed charges,Critical Access Hospital RCC factor,3060,34,,3060,percent of total billed charges,Implant Device,3060,34,,3060,percent of total billed charges,Implant Device,3060,34,,3060,percent of total billed charges,Implant Device,3060,34,,3060,percent of total billed charges,Implant Device,3060,34,,3060,percent of total billed charges,Implant Device,4455,,,4455,Other,110% of Medicare,3150,35,,3150,percent of total billed charges,Implant Device,3060,34,"Charges > $500, x 34%",3060,percent of total billed charges,Implant Device,3150,35,,3150,percent of total billed charges,Implant Device,3150,35,,3150,percent of total billed charges,Implant Device,3150,35,,3150,percent of total billed charges,Implant Device,3150,35,,3150,percent of total billed charges,Implant Device,3150,35,,3150,percent of total billed charges,Implant Device,3600,40,,3600,percent of total billed charges,Implant Device,3150,70,,3150,percent of total billed charges,All Other,3060,34,,3060,percent of total billed charges,Implant Device,3060,34,,3060,percent of total billed charges,Implant Device,3150,35,,3150,percent of total billed charges,Implant Device,3150,35,,3150,percent of total billed charges,Implant Device,3150,35,,3150,percent of total billed charges,Implant Device,3150,35,,3150,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3060,34,"If Charge > 2,000, then 34 percent",3060,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,6660.02,
BIOTRONIK 434890 PK PAPYRUS 4X15MM,C1874,HCPCS,,79011591,CDM,278,RC,,,both,,,9000,6660.02,,,6660.02,Other,150% of Medicare + 9.63% HCRA Surcharge,4050,45,,4050,percent of total billed charges,Critical Access Hospital RCC factor,3060,34,,3060,percent of total billed charges,Implant Device,3060,34,,3060,percent of total billed charges,Implant Device,3060,34,,3060,percent of total billed charges,Implant Device,3060,34,,3060,percent of total billed charges,Implant Device,3060,34,,3060,percent of total billed charges,Implant Device,4455,,,4455,Other,110% of Medicare,3150,35,,3150,percent of total billed charges,Implant Device,3060,34,"Charges > $500, x 34%",3060,percent of total billed charges,Implant Device,3150,35,,3150,percent of total billed charges,Implant Device,3150,35,,3150,percent of total billed charges,Implant Device,3150,35,,3150,percent of total billed charges,Implant Device,3150,35,,3150,percent of total billed charges,Implant Device,3150,35,,3150,percent of total billed charges,Implant Device,3600,40,,3600,percent of total billed charges,Implant Device,3150,70,,3150,percent of total billed charges,All Other,3060,34,,3060,percent of total billed charges,Implant Device,3060,34,,3060,percent of total billed charges,Implant Device,3150,35,,3150,percent of total billed charges,Implant Device,3150,35,,3150,percent of total billed charges,Implant Device,3150,35,,3150,percent of total billed charges,Implant Device,3150,35,,3150,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3060,34,"If Charge > 2,000, then 34 percent",3060,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,6660.02,
BIOTRONIK 434896 PK PAPYRUS 4X20MM,C1874,HCPCS,,79011592,CDM,278,RC,,,both,,,9000,6660.02,,,6660.02,Other,150% of Medicare + 9.63% HCRA Surcharge,4050,45,,4050,percent of total billed charges,Critical Access Hospital RCC factor,3060,34,,3060,percent of total billed charges,Implant Device,3060,34,,3060,percent of total billed charges,Implant Device,3060,34,,3060,percent of total billed charges,Implant Device,3060,34,,3060,percent of total billed charges,Implant Device,3060,34,,3060,percent of total billed charges,Implant Device,4455,,,4455,Other,110% of Medicare,3150,35,,3150,percent of total billed charges,Implant Device,3060,34,"Charges > $500, x 34%",3060,percent of total billed charges,Implant Device,3150,35,,3150,percent of total billed charges,Implant Device,3150,35,,3150,percent of total billed charges,Implant Device,3150,35,,3150,percent of total billed charges,Implant Device,3150,35,,3150,percent of total billed charges,Implant Device,3150,35,,3150,percent of total billed charges,Implant Device,3600,40,,3600,percent of total billed charges,Implant Device,3150,70,,3150,percent of total billed charges,All Other,3060,34,,3060,percent of total billed charges,Implant Device,3060,34,,3060,percent of total billed charges,Implant Device,3150,35,,3150,percent of total billed charges,Implant Device,3150,35,,3150,percent of total billed charges,Implant Device,3150,35,,3150,percent of total billed charges,Implant Device,3150,35,,3150,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3060,34,"If Charge > 2,000, then 34 percent",3060,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,6660.02,
BIOTRONIK 434891 PK PAPYRUS 4.5X15MM,C1874,HCPCS,,79011593,CDM,278,RC,,,both,,,9000,6660.02,,,6660.02,Other,150% of Medicare + 9.63% HCRA Surcharge,4050,45,,4050,percent of total billed charges,Critical Access Hospital RCC factor,3060,34,,3060,percent of total billed charges,Implant Device,3060,34,,3060,percent of total billed charges,Implant Device,3060,34,,3060,percent of total billed charges,Implant Device,3060,34,,3060,percent of total billed charges,Implant Device,3060,34,,3060,percent of total billed charges,Implant Device,4455,,,4455,Other,110% of Medicare,3150,35,,3150,percent of total billed charges,Implant Device,3060,34,"Charges > $500, x 34%",3060,percent of total billed charges,Implant Device,3150,35,,3150,percent of total billed charges,Implant Device,3150,35,,3150,percent of total billed charges,Implant Device,3150,35,,3150,percent of total billed charges,Implant Device,3150,35,,3150,percent of total billed charges,Implant Device,3150,35,,3150,percent of total billed charges,Implant Device,3600,40,,3600,percent of total billed charges,Implant Device,3150,70,,3150,percent of total billed charges,All Other,3060,34,,3060,percent of total billed charges,Implant Device,3060,34,,3060,percent of total billed charges,Implant Device,3150,35,,3150,percent of total billed charges,Implant Device,3150,35,,3150,percent of total billed charges,Implant Device,3150,35,,3150,percent of total billed charges,Implant Device,3150,35,,3150,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3060,34,"If Charge > 2,000, then 34 percent",3060,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,6660.02,
BIOTRONIK 434892 PK PAPYRUS 5X15MM,C1874,HCPCS,,79011594,CDM,278,RC,,,both,,,9000,6660.02,,,6660.02,Other,150% of Medicare + 9.63% HCRA Surcharge,4050,45,,4050,percent of total billed charges,Critical Access Hospital RCC factor,3060,34,,3060,percent of total billed charges,Implant Device,3060,34,,3060,percent of total billed charges,Implant Device,3060,34,,3060,percent of total billed charges,Implant Device,3060,34,,3060,percent of total billed charges,Implant Device,3060,34,,3060,percent of total billed charges,Implant Device,4455,,,4455,Other,110% of Medicare,3150,35,,3150,percent of total billed charges,Implant Device,3060,34,"Charges > $500, x 34%",3060,percent of total billed charges,Implant Device,3150,35,,3150,percent of total billed charges,Implant Device,3150,35,,3150,percent of total billed charges,Implant Device,3150,35,,3150,percent of total billed charges,Implant Device,3150,35,,3150,percent of total billed charges,Implant Device,3150,35,,3150,percent of total billed charges,Implant Device,3600,40,,3600,percent of total billed charges,Implant Device,3150,70,,3150,percent of total billed charges,All Other,3060,34,,3060,percent of total billed charges,Implant Device,3060,34,,3060,percent of total billed charges,Implant Device,3150,35,,3150,percent of total billed charges,Implant Device,3150,35,,3150,percent of total billed charges,Implant Device,3150,35,,3150,percent of total billed charges,Implant Device,3150,35,,3150,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3060,34,"If Charge > 2,000, then 34 percent",3060,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,6660.02,
ARTHREX AR-8830-14 CAN SCREW 3X14MM,C1713,HCPCS,,79011612,CDM,278,RC,,,both,,,105,77.7,,,77.7,Other,150% of Medicare + 9.63% HCRA Surcharge,47.25,45,,47.25,percent of total billed charges,Critical Access Hospital RCC factor,35.7,34,,35.7,percent of total billed charges,Implant Device,35.7,34,,35.7,percent of total billed charges,Implant Device,35.7,34,,35.7,percent of total billed charges,Implant Device,35.7,34,,35.7,percent of total billed charges,Implant Device,35.7,34,,35.7,percent of total billed charges,Implant Device,51.98,,,51.98,Other,110% of Medicare,36.75,35,,36.75,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,36.75,35,,36.75,percent of total billed charges,Implant Device,36.75,35,,36.75,percent of total billed charges,Implant Device,36.75,35,,36.75,percent of total billed charges,Implant Device,36.75,35,,36.75,percent of total billed charges,Implant Device,36.75,35,,36.75,percent of total billed charges,Implant Device,42,40,,42,percent of total billed charges,Implant Device,36.75,70,,36.75,percent of total billed charges,All Other,35.7,34,,35.7,percent of total billed charges,Implant Device,35.7,34,,35.7,percent of total billed charges,Implant Device,36.75,35,,36.75,percent of total billed charges,Implant Device,36.75,35,,36.75,percent of total billed charges,Implant Device,36.75,35,,36.75,percent of total billed charges,Implant Device,36.75,35,,36.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,77.7,
ARTHREX AR-8870W CANN SCREW 4.0X44MM,C1713,HCPCS,,79011613,CDM,278,RC,,,both,,,138,102.12,,,102.12,Other,150% of Medicare + 9.63% HCRA Surcharge,62.1,45,,62.1,percent of total billed charges,Critical Access Hospital RCC factor,46.92,34,,46.92,percent of total billed charges,Implant Device,46.92,34,,46.92,percent of total billed charges,Implant Device,46.92,34,,46.92,percent of total billed charges,Implant Device,46.92,34,,46.92,percent of total billed charges,Implant Device,46.92,34,,46.92,percent of total billed charges,Implant Device,68.31,,,68.31,Other,110% of Medicare,48.3,35,,48.3,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,48.3,35,,48.3,percent of total billed charges,Implant Device,48.3,35,,48.3,percent of total billed charges,Implant Device,48.3,35,,48.3,percent of total billed charges,Implant Device,48.3,35,,48.3,percent of total billed charges,Implant Device,48.3,35,,48.3,percent of total billed charges,Implant Device,55.2,40,,55.2,percent of total billed charges,Implant Device,48.3,70,,48.3,percent of total billed charges,All Other,46.92,34,,46.92,percent of total billed charges,Implant Device,46.92,34,,46.92,percent of total billed charges,Implant Device,48.3,35,,48.3,percent of total billed charges,Implant Device,48.3,35,,48.3,percent of total billed charges,Implant Device,48.3,35,,48.3,percent of total billed charges,Implant Device,48.3,35,,48.3,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,102.12,
DEPUY 04.038.385S HELICAL BLADE 85MM,C1713,HCPCS,,79011614,CDM,278,RC,,,both,,,1766,1306.84,,,1306.84,Other,150% of Medicare + 9.63% HCRA Surcharge,794.7,45,,794.7,percent of total billed charges,Critical Access Hospital RCC factor,600.44,34,,600.44,percent of total billed charges,Implant Device,600.44,34,,600.44,percent of total billed charges,Implant Device,600.44,34,,600.44,percent of total billed charges,Implant Device,600.44,34,,600.44,percent of total billed charges,Implant Device,600.44,34,,600.44,percent of total billed charges,Implant Device,874.17,,,874.17,Other,110% of Medicare,618.1,35,,618.1,percent of total billed charges,Implant Device,600.44,34,"Charges > $500, x 34%",600.44,percent of total billed charges,Implant Device,618.1,35,,618.1,percent of total billed charges,Implant Device,618.1,35,,618.1,percent of total billed charges,Implant Device,618.1,35,,618.1,percent of total billed charges,Implant Device,618.1,35,,618.1,percent of total billed charges,Implant Device,618.1,35,,618.1,percent of total billed charges,Implant Device,706.4,40,,706.4,percent of total billed charges,Implant Device,618.1,70,,618.1,percent of total billed charges,All Other,600.44,34,,600.44,percent of total billed charges,Implant Device,600.44,34,,600.44,percent of total billed charges,Implant Device,618.1,35,,618.1,percent of total billed charges,Implant Device,618.1,35,,618.1,percent of total billed charges,Implant Device,618.1,35,,618.1,percent of total billed charges,Implant Device,618.1,35,,618.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1306.84,
DEPUY 04.005.522S LOCK SCREW 5.0X32MM,C1713,HCPCS,,79011615,CDM,278,RC,,,both,,,412,304.88,,,304.88,Other,150% of Medicare + 9.63% HCRA Surcharge,185.4,45,,185.4,percent of total billed charges,Critical Access Hospital RCC factor,140.08,34,,140.08,percent of total billed charges,Implant Device,140.08,34,,140.08,percent of total billed charges,Implant Device,140.08,34,,140.08,percent of total billed charges,Implant Device,140.08,34,,140.08,percent of total billed charges,Implant Device,140.08,34,,140.08,percent of total billed charges,Implant Device,203.94,,,203.94,Other,110% of Medicare,144.2,35,,144.2,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,144.2,35,,144.2,percent of total billed charges,Implant Device,144.2,35,,144.2,percent of total billed charges,Implant Device,144.2,35,,144.2,percent of total billed charges,Implant Device,144.2,35,,144.2,percent of total billed charges,Implant Device,144.2,35,,144.2,percent of total billed charges,Implant Device,164.8,40,,164.8,percent of total billed charges,Implant Device,144.2,70,,144.2,percent of total billed charges,All Other,140.08,34,,140.08,percent of total billed charges,Implant Device,140.08,34,,140.08,percent of total billed charges,Implant Device,144.2,35,,144.2,percent of total billed charges,Implant Device,144.2,35,,144.2,percent of total billed charges,Implant Device,144.2,35,,144.2,percent of total billed charges,Implant Device,144.2,35,,144.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,304.88,
STRYKER 2341-1239S TIBIAL NAIL 12X390MM,C1713,HCPCS,,79011616,CDM,278,RC,,,both,,,6378,4719.74,,,4719.74,Other,150% of Medicare + 9.63% HCRA Surcharge,2870.1,45,,2870.1,percent of total billed charges,Critical Access Hospital RCC factor,2168.52,34,,2168.52,percent of total billed charges,Implant Device,2168.52,34,,2168.52,percent of total billed charges,Implant Device,2168.52,34,,2168.52,percent of total billed charges,Implant Device,2168.52,34,,2168.52,percent of total billed charges,Implant Device,2168.52,34,,2168.52,percent of total billed charges,Implant Device,3157.11,,,3157.11,Other,110% of Medicare,2232.3,35,,2232.3,percent of total billed charges,Implant Device,2168.52,34,"Charges > $500, x 34%",2168.52,percent of total billed charges,Implant Device,2232.3,35,,2232.3,percent of total billed charges,Implant Device,2232.3,35,,2232.3,percent of total billed charges,Implant Device,2232.3,35,,2232.3,percent of total billed charges,Implant Device,2232.3,35,,2232.3,percent of total billed charges,Implant Device,2232.3,35,,2232.3,percent of total billed charges,Implant Device,2551.2,40,,2551.2,percent of total billed charges,Implant Device,2232.3,70,,2232.3,percent of total billed charges,All Other,2168.52,34,,2168.52,percent of total billed charges,Implant Device,2168.52,34,,2168.52,percent of total billed charges,Implant Device,2232.3,35,,2232.3,percent of total billed charges,Implant Device,2232.3,35,,2232.3,percent of total billed charges,Implant Device,2232.3,35,,2232.3,percent of total billed charges,Implant Device,2232.3,35,,2232.3,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2168.52,34,"If Charge > 2,000, then 34 percent",2168.52,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4719.74,
STRYKER 627510 LOCK COMP PLT 10H 136X4MM,C1713,HCPCS,,79011633,CDM,278,RC,,,both,,,4476,3312.25,,,3312.25,Other,150% of Medicare + 9.63% HCRA Surcharge,2014.2,45,,2014.2,percent of total billed charges,Critical Access Hospital RCC factor,1521.84,34,,1521.84,percent of total billed charges,Implant Device,1521.84,34,,1521.84,percent of total billed charges,Implant Device,1521.84,34,,1521.84,percent of total billed charges,Implant Device,1521.84,34,,1521.84,percent of total billed charges,Implant Device,1521.84,34,,1521.84,percent of total billed charges,Implant Device,2215.62,,,2215.62,Other,110% of Medicare,1566.6,35,,1566.6,percent of total billed charges,Implant Device,1521.84,34,"Charges > $500, x 34%",1521.84,percent of total billed charges,Implant Device,1566.6,35,,1566.6,percent of total billed charges,Implant Device,1566.6,35,,1566.6,percent of total billed charges,Implant Device,1566.6,35,,1566.6,percent of total billed charges,Implant Device,1566.6,35,,1566.6,percent of total billed charges,Implant Device,1566.6,35,,1566.6,percent of total billed charges,Implant Device,1790.4,40,,1790.4,percent of total billed charges,Implant Device,1566.6,70,,1566.6,percent of total billed charges,All Other,1521.84,34,,1521.84,percent of total billed charges,Implant Device,1521.84,34,,1521.84,percent of total billed charges,Implant Device,1566.6,35,,1566.6,percent of total billed charges,Implant Device,1566.6,35,,1566.6,percent of total billed charges,Implant Device,1566.6,35,,1566.6,percent of total billed charges,Implant Device,1566.6,35,,1566.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1521.84,34,"If Charge > 2,000, then 34 percent",1521.84,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3312.25,
STRYKER 627589 LOCK COMP PLT 9H 173X5MM,C1713,HCPCS,,79011634,CDM,278,RC,,,both,,,5824,4309.77,,,4309.77,Other,150% of Medicare + 9.63% HCRA Surcharge,2620.8,45,,2620.8,percent of total billed charges,Critical Access Hospital RCC factor,1980.16,34,,1980.16,percent of total billed charges,Implant Device,1980.16,34,,1980.16,percent of total billed charges,Implant Device,1980.16,34,,1980.16,percent of total billed charges,Implant Device,1980.16,34,,1980.16,percent of total billed charges,Implant Device,1980.16,34,,1980.16,percent of total billed charges,Implant Device,2882.88,,,2882.88,Other,110% of Medicare,2038.4,35,,2038.4,percent of total billed charges,Implant Device,1980.16,34,"Charges > $500, x 34%",1980.16,percent of total billed charges,Implant Device,2038.4,35,,2038.4,percent of total billed charges,Implant Device,2038.4,35,,2038.4,percent of total billed charges,Implant Device,2038.4,35,,2038.4,percent of total billed charges,Implant Device,2038.4,35,,2038.4,percent of total billed charges,Implant Device,2038.4,35,,2038.4,percent of total billed charges,Implant Device,2329.6,40,,2329.6,percent of total billed charges,Implant Device,2038.4,70,,2038.4,percent of total billed charges,All Other,1980.16,34,,1980.16,percent of total billed charges,Implant Device,1980.16,34,,1980.16,percent of total billed charges,Implant Device,2038.4,35,,2038.4,percent of total billed charges,Implant Device,2038.4,35,,2038.4,percent of total billed charges,Implant Device,2038.4,35,,2038.4,percent of total billed charges,Implant Device,2038.4,35,,2038.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1980.16,34,"If Charge > 2,000, then 34 percent",1980.16,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4309.77,
STRYKER 661718 CORTEX SCREW 4.5X18MM,C1713,HCPCS,,79011635,CDM,278,RC,,,both,,,139,102.86,,,102.86,Other,150% of Medicare + 9.63% HCRA Surcharge,62.55,45,,62.55,percent of total billed charges,Critical Access Hospital RCC factor,47.26,34,,47.26,percent of total billed charges,Implant Device,47.26,34,,47.26,percent of total billed charges,Implant Device,47.26,34,,47.26,percent of total billed charges,Implant Device,47.26,34,,47.26,percent of total billed charges,Implant Device,47.26,34,,47.26,percent of total billed charges,Implant Device,68.81,,,68.81,Other,110% of Medicare,48.65,35,,48.65,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,48.65,35,,48.65,percent of total billed charges,Implant Device,48.65,35,,48.65,percent of total billed charges,Implant Device,48.65,35,,48.65,percent of total billed charges,Implant Device,48.65,35,,48.65,percent of total billed charges,Implant Device,48.65,35,,48.65,percent of total billed charges,Implant Device,55.6,40,,55.6,percent of total billed charges,Implant Device,48.65,70,,48.65,percent of total billed charges,All Other,47.26,34,,47.26,percent of total billed charges,Implant Device,47.26,34,,47.26,percent of total billed charges,Implant Device,48.65,35,,48.65,percent of total billed charges,Implant Device,48.65,35,,48.65,percent of total billed charges,Implant Device,48.65,35,,48.65,percent of total billed charges,Implant Device,48.65,35,,48.65,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,102.86,
STRYKER 661726 CORTEX SCREW 4.5X26MM,C1713,HCPCS,,79011636,CDM,278,RC,,,both,,,139,102.86,,,102.86,Other,150% of Medicare + 9.63% HCRA Surcharge,62.55,45,,62.55,percent of total billed charges,Critical Access Hospital RCC factor,47.26,34,,47.26,percent of total billed charges,Implant Device,47.26,34,,47.26,percent of total billed charges,Implant Device,47.26,34,,47.26,percent of total billed charges,Implant Device,47.26,34,,47.26,percent of total billed charges,Implant Device,47.26,34,,47.26,percent of total billed charges,Implant Device,68.81,,,68.81,Other,110% of Medicare,48.65,35,,48.65,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,48.65,35,,48.65,percent of total billed charges,Implant Device,48.65,35,,48.65,percent of total billed charges,Implant Device,48.65,35,,48.65,percent of total billed charges,Implant Device,48.65,35,,48.65,percent of total billed charges,Implant Device,48.65,35,,48.65,percent of total billed charges,Implant Device,55.6,40,,55.6,percent of total billed charges,Implant Device,48.65,70,,48.65,percent of total billed charges,All Other,47.26,34,,47.26,percent of total billed charges,Implant Device,47.26,34,,47.26,percent of total billed charges,Implant Device,48.65,35,,48.65,percent of total billed charges,Implant Device,48.65,35,,48.65,percent of total billed charges,Implant Device,48.65,35,,48.65,percent of total billed charges,Implant Device,48.65,35,,48.65,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,102.86,
J&J 631-400 TRU-FILL N-BCA TWO VIALS,C1713,HCPCS,,79011637,CDM,278,RC,,,both,,,23250,17205.06,,,17205.06,Other,150% of Medicare + 9.63% HCRA Surcharge,10462.5,45,,10462.5,percent of total billed charges,Critical Access Hospital RCC factor,7905,34,,7905,percent of total billed charges,Implant Device,7905,34,,7905,percent of total billed charges,Implant Device,7905,34,,7905,percent of total billed charges,Implant Device,7905,34,,7905,percent of total billed charges,Implant Device,7905,34,,7905,percent of total billed charges,Implant Device,11508.75,,,11508.75,Other,110% of Medicare,8137.5,35,,8137.5,percent of total billed charges,Implant Device,7905,34,"Charges > $500, x 34%",7905,percent of total billed charges,Implant Device,8137.5,35,,8137.5,percent of total billed charges,Implant Device,8137.5,35,,8137.5,percent of total billed charges,Implant Device,8137.5,35,,8137.5,percent of total billed charges,Implant Device,8137.5,35,,8137.5,percent of total billed charges,Implant Device,8137.5,35,,8137.5,percent of total billed charges,Implant Device,9300,40,,9300,percent of total billed charges,Implant Device,8137.5,70,,8137.5,percent of total billed charges,All Other,7905,34,,7905,percent of total billed charges,Implant Device,7905,34,,7905,percent of total billed charges,Implant Device,8137.5,35,,8137.5,percent of total billed charges,Implant Device,8137.5,35,,8137.5,percent of total billed charges,Implant Device,8137.5,35,,8137.5,percent of total billed charges,Implant Device,8137.5,35,,8137.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,7905,34,"If Charge > 2,000, then 34 percent",7905,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,17205.06,
J&J 631-500 TRU-FILL N-BCA SINGLE VIALS,C1713,HCPCS,,79011638,CDM,278,RC,,,both,,,13323,9859.05,,,9859.05,Other,150% of Medicare + 9.63% HCRA Surcharge,5995.35,45,,5995.35,percent of total billed charges,Critical Access Hospital RCC factor,4529.82,34,,4529.82,percent of total billed charges,Implant Device,4529.82,34,,4529.82,percent of total billed charges,Implant Device,4529.82,34,,4529.82,percent of total billed charges,Implant Device,4529.82,34,,4529.82,percent of total billed charges,Implant Device,4529.82,34,,4529.82,percent of total billed charges,Implant Device,6594.89,,,6594.89,Other,110% of Medicare,4663.05,35,,4663.05,percent of total billed charges,Implant Device,4529.82,34,"Charges > $500, x 34%",4529.82,percent of total billed charges,Implant Device,4663.05,35,,4663.05,percent of total billed charges,Implant Device,4663.05,35,,4663.05,percent of total billed charges,Implant Device,4663.05,35,,4663.05,percent of total billed charges,Implant Device,4663.05,35,,4663.05,percent of total billed charges,Implant Device,4663.05,35,,4663.05,percent of total billed charges,Implant Device,5329.2,40,,5329.2,percent of total billed charges,Implant Device,4663.05,70,,4663.05,percent of total billed charges,All Other,4529.82,34,,4529.82,percent of total billed charges,Implant Device,4529.82,34,,4529.82,percent of total billed charges,Implant Device,4663.05,35,,4663.05,percent of total billed charges,Implant Device,4663.05,35,,4663.05,percent of total billed charges,Implant Device,4663.05,35,,4663.05,percent of total billed charges,Implant Device,4663.05,35,,4663.05,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,4529.82,34,"If Charge > 2,000, then 34 percent",4529.82,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,9859.05,
STRYKER 661414 CORTEX SCREW 3.5X14MM,C1713,HCPCS,,79011639,CDM,278,RC,,,both,,,122,90.28,,,90.28,Other,150% of Medicare + 9.63% HCRA Surcharge,54.9,45,,54.9,percent of total billed charges,Critical Access Hospital RCC factor,41.48,34,,41.48,percent of total billed charges,Implant Device,41.48,34,,41.48,percent of total billed charges,Implant Device,41.48,34,,41.48,percent of total billed charges,Implant Device,41.48,34,,41.48,percent of total billed charges,Implant Device,41.48,34,,41.48,percent of total billed charges,Implant Device,60.39,,,60.39,Other,110% of Medicare,42.7,35,,42.7,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,42.7,35,,42.7,percent of total billed charges,Implant Device,42.7,35,,42.7,percent of total billed charges,Implant Device,42.7,35,,42.7,percent of total billed charges,Implant Device,42.7,35,,42.7,percent of total billed charges,Implant Device,42.7,35,,42.7,percent of total billed charges,Implant Device,48.8,40,,48.8,percent of total billed charges,Implant Device,42.7,70,,42.7,percent of total billed charges,All Other,41.48,34,,41.48,percent of total billed charges,Implant Device,41.48,34,,41.48,percent of total billed charges,Implant Device,42.7,35,,42.7,percent of total billed charges,Implant Device,42.7,35,,42.7,percent of total billed charges,Implant Device,42.7,35,,42.7,percent of total billed charges,Implant Device,42.7,35,,42.7,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,90.28,
STRYKER 657712 BONE SCREW 2.0X12MM,C1713,HCPCS,,79011640,CDM,278,RC,,,both,,,395,292.3,,,292.3,Other,150% of Medicare + 9.63% HCRA Surcharge,177.75,45,,177.75,percent of total billed charges,Critical Access Hospital RCC factor,134.3,34,,134.3,percent of total billed charges,Implant Device,134.3,34,,134.3,percent of total billed charges,Implant Device,134.3,34,,134.3,percent of total billed charges,Implant Device,134.3,34,,134.3,percent of total billed charges,Implant Device,134.3,34,,134.3,percent of total billed charges,Implant Device,195.53,,,195.53,Other,110% of Medicare,138.25,35,,138.25,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,138.25,35,,138.25,percent of total billed charges,Implant Device,138.25,35,,138.25,percent of total billed charges,Implant Device,138.25,35,,138.25,percent of total billed charges,Implant Device,138.25,35,,138.25,percent of total billed charges,Implant Device,138.25,35,,138.25,percent of total billed charges,Implant Device,158,40,,158,percent of total billed charges,Implant Device,138.25,70,,138.25,percent of total billed charges,All Other,134.3,34,,134.3,percent of total billed charges,Implant Device,134.3,34,,134.3,percent of total billed charges,Implant Device,138.25,35,,138.25,percent of total billed charges,Implant Device,138.25,35,,138.25,percent of total billed charges,Implant Device,138.25,35,,138.25,percent of total billed charges,Implant Device,138.25,35,,138.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,292.3,
ARTHREX AR-8929 PARS QUAD REPAIR KIT,C1882,HCPCS,,79011646,CDM,278,RC,,,both,,,7500,5550.02,,,5550.02,Other,150% of Medicare + 9.63% HCRA Surcharge,3375,45,,3375,percent of total billed charges,Critical Access Hospital RCC factor,2550,34,,2550,percent of total billed charges,Implant Device,2550,34,,2550,percent of total billed charges,Implant Device,2550,34,,2550,percent of total billed charges,Implant Device,2550,34,,2550,percent of total billed charges,Implant Device,2550,34,,2550,percent of total billed charges,Implant Device,3712.5,,,3712.5,Other,110% of Medicare,2625,35,,2625,percent of total billed charges,Implant Device,2550,34,"Charges > $500, x 34%",2550,percent of total billed charges,Implant Device,2625,35,,2625,percent of total billed charges,Implant Device,2625,35,,2625,percent of total billed charges,Implant Device,2625,35,,2625,percent of total billed charges,Implant Device,2625,35,,2625,percent of total billed charges,Implant Device,2625,35,,2625,percent of total billed charges,Implant Device,3000,40,,3000,percent of total billed charges,Implant Device,2625,70,,2625,percent of total billed charges,All Other,2550,34,,2550,percent of total billed charges,Implant Device,2550,34,,2550,percent of total billed charges,Implant Device,2625,35,,2625,percent of total billed charges,Implant Device,2625,35,,2625,percent of total billed charges,Implant Device,2625,35,,2625,percent of total billed charges,Implant Device,2625,35,,2625,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2550,34,"If Charge > 2,000, then 34 percent",2550,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5550.02,
STRYKER 2341-1031S TIBIAL NAIL 10X315MM,C1713,HCPCS,,79011647,CDM,278,RC,,,both,,,4792,3546.09,,,3546.09,Other,150% of Medicare + 9.63% HCRA Surcharge,2156.4,45,,2156.4,percent of total billed charges,Critical Access Hospital RCC factor,1629.28,34,,1629.28,percent of total billed charges,Implant Device,1629.28,34,,1629.28,percent of total billed charges,Implant Device,1629.28,34,,1629.28,percent of total billed charges,Implant Device,1629.28,34,,1629.28,percent of total billed charges,Implant Device,1629.28,34,,1629.28,percent of total billed charges,Implant Device,2372.04,,,2372.04,Other,110% of Medicare,1677.2,35,,1677.2,percent of total billed charges,Implant Device,1629.28,34,"Charges > $500, x 34%",1629.28,percent of total billed charges,Implant Device,1677.2,35,,1677.2,percent of total billed charges,Implant Device,1677.2,35,,1677.2,percent of total billed charges,Implant Device,1677.2,35,,1677.2,percent of total billed charges,Implant Device,1677.2,35,,1677.2,percent of total billed charges,Implant Device,1677.2,35,,1677.2,percent of total billed charges,Implant Device,1916.8,40,,1916.8,percent of total billed charges,Implant Device,1677.2,70,,1677.2,percent of total billed charges,All Other,1629.28,34,,1629.28,percent of total billed charges,Implant Device,1629.28,34,,1629.28,percent of total billed charges,Implant Device,1677.2,35,,1677.2,percent of total billed charges,Implant Device,1677.2,35,,1677.2,percent of total billed charges,Implant Device,1677.2,35,,1677.2,percent of total billed charges,Implant Device,1677.2,35,,1677.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1629.28,34,"If Charge > 2,000, then 34 percent",1629.28,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3546.09,
STRYKER 2361-5075S LOCKING SCREW 5X75MM,C1713,HCPCS,,79011648,CDM,278,RC,,,both,,,887,656.38,,,656.38,Other,150% of Medicare + 9.63% HCRA Surcharge,399.15,45,,399.15,percent of total billed charges,Critical Access Hospital RCC factor,301.58,34,,301.58,percent of total billed charges,Implant Device,301.58,34,,301.58,percent of total billed charges,Implant Device,301.58,34,,301.58,percent of total billed charges,Implant Device,301.58,34,,301.58,percent of total billed charges,Implant Device,301.58,34,,301.58,percent of total billed charges,Implant Device,439.07,,,439.07,Other,110% of Medicare,310.45,35,,310.45,percent of total billed charges,Implant Device,301.58,34,"Charges > $500, x 34%",301.58,percent of total billed charges,Implant Device,310.45,35,,310.45,percent of total billed charges,Implant Device,310.45,35,,310.45,percent of total billed charges,Implant Device,310.45,35,,310.45,percent of total billed charges,Implant Device,310.45,35,,310.45,percent of total billed charges,Implant Device,310.45,35,,310.45,percent of total billed charges,Implant Device,354.8,40,,354.8,percent of total billed charges,Implant Device,310.45,70,,310.45,percent of total billed charges,All Other,301.58,34,,301.58,percent of total billed charges,Implant Device,301.58,34,,301.58,percent of total billed charges,Implant Device,310.45,35,,310.45,percent of total billed charges,Implant Device,310.45,35,,310.45,percent of total billed charges,Implant Device,310.45,35,,310.45,percent of total billed charges,Implant Device,310.45,35,,310.45,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,656.38,
STRYKER 607330 CANCELLOUS SCREW 4.0X30MM,C1713,HCPCS,,79011649,CDM,278,RC,,,both,,,133,98.42,,,98.42,Other,150% of Medicare + 9.63% HCRA Surcharge,59.85,45,,59.85,percent of total billed charges,Critical Access Hospital RCC factor,45.22,34,,45.22,percent of total billed charges,Implant Device,45.22,34,,45.22,percent of total billed charges,Implant Device,45.22,34,,45.22,percent of total billed charges,Implant Device,45.22,34,,45.22,percent of total billed charges,Implant Device,45.22,34,,45.22,percent of total billed charges,Implant Device,65.84,,,65.84,Other,110% of Medicare,46.55,35,,46.55,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,46.55,35,,46.55,percent of total billed charges,Implant Device,46.55,35,,46.55,percent of total billed charges,Implant Device,46.55,35,,46.55,percent of total billed charges,Implant Device,46.55,35,,46.55,percent of total billed charges,Implant Device,46.55,35,,46.55,percent of total billed charges,Implant Device,53.2,40,,53.2,percent of total billed charges,Implant Device,46.55,70,,46.55,percent of total billed charges,All Other,45.22,34,,45.22,percent of total billed charges,Implant Device,45.22,34,,45.22,percent of total billed charges,Implant Device,46.55,35,,46.55,percent of total billed charges,Implant Device,46.55,35,,46.55,percent of total billed charges,Implant Device,46.55,35,,46.55,percent of total billed charges,Implant Device,46.55,35,,46.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,98.42,
STRYKER 607350 CANCELLOUS SCREW 4.0X50MM,C1713,HCPCS,,79011650,CDM,278,RC,,,both,,,133,98.42,,,98.42,Other,150% of Medicare + 9.63% HCRA Surcharge,59.85,45,,59.85,percent of total billed charges,Critical Access Hospital RCC factor,45.22,34,,45.22,percent of total billed charges,Implant Device,45.22,34,,45.22,percent of total billed charges,Implant Device,45.22,34,,45.22,percent of total billed charges,Implant Device,45.22,34,,45.22,percent of total billed charges,Implant Device,45.22,34,,45.22,percent of total billed charges,Implant Device,65.84,,,65.84,Other,110% of Medicare,46.55,35,,46.55,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,46.55,35,,46.55,percent of total billed charges,Implant Device,46.55,35,,46.55,percent of total billed charges,Implant Device,46.55,35,,46.55,percent of total billed charges,Implant Device,46.55,35,,46.55,percent of total billed charges,Implant Device,46.55,35,,46.55,percent of total billed charges,Implant Device,53.2,40,,53.2,percent of total billed charges,Implant Device,46.55,70,,46.55,percent of total billed charges,All Other,45.22,34,,45.22,percent of total billed charges,Implant Device,45.22,34,,45.22,percent of total billed charges,Implant Device,46.55,35,,46.55,percent of total billed charges,Implant Device,46.55,35,,46.55,percent of total billed charges,Implant Device,46.55,35,,46.55,percent of total billed charges,Implant Device,46.55,35,,46.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,98.42,
IN2BONES P72 ST024 NON LOCK SCREW 2.7X24,C1713,HCPCS,,79011651,CDM,278,RC,,,both,,,870,643.8,,,643.8,Other,150% of Medicare + 9.63% HCRA Surcharge,391.5,45,,391.5,percent of total billed charges,Critical Access Hospital RCC factor,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,430.65,,,430.65,Other,110% of Medicare,304.5,35,,304.5,percent of total billed charges,Implant Device,295.8,34,"Charges > $500, x 34%",295.8,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,348,40,,348,percent of total billed charges,Implant Device,304.5,70,,304.5,percent of total billed charges,All Other,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,643.8,
IN2BONES S65 ST170 CANN SCREW 6.5X70MM,C1713,HCPCS,,79011652,CDM,278,RC,,,both,,,3105,2297.71,,,2297.71,Other,150% of Medicare + 9.63% HCRA Surcharge,1397.25,45,,1397.25,percent of total billed charges,Critical Access Hospital RCC factor,1055.7,34,,1055.7,percent of total billed charges,Implant Device,1055.7,34,,1055.7,percent of total billed charges,Implant Device,1055.7,34,,1055.7,percent of total billed charges,Implant Device,1055.7,34,,1055.7,percent of total billed charges,Implant Device,1055.7,34,,1055.7,percent of total billed charges,Implant Device,1536.98,,,1536.98,Other,110% of Medicare,1086.75,35,,1086.75,percent of total billed charges,Implant Device,1055.7,34,"Charges > $500, x 34%",1055.7,percent of total billed charges,Implant Device,1086.75,35,,1086.75,percent of total billed charges,Implant Device,1086.75,35,,1086.75,percent of total billed charges,Implant Device,1086.75,35,,1086.75,percent of total billed charges,Implant Device,1086.75,35,,1086.75,percent of total billed charges,Implant Device,1086.75,35,,1086.75,percent of total billed charges,Implant Device,1242,40,,1242,percent of total billed charges,Implant Device,1086.75,70,,1086.75,percent of total billed charges,All Other,1055.7,34,,1055.7,percent of total billed charges,Implant Device,1055.7,34,,1055.7,percent of total billed charges,Implant Device,1086.75,35,,1086.75,percent of total billed charges,Implant Device,1086.75,35,,1086.75,percent of total billed charges,Implant Device,1086.75,35,,1086.75,percent of total billed charges,Implant Device,1086.75,35,,1086.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1055.7,34,"If Charge > 2,000, then 34 percent",1055.7,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2297.71,
IN2BONES S65 ST175 CANN SCREW 6.5X75MM,C1713,HCPCS,,79011653,CDM,278,RC,,,both,,,3105,2297.71,,,2297.71,Other,150% of Medicare + 9.63% HCRA Surcharge,1397.25,45,,1397.25,percent of total billed charges,Critical Access Hospital RCC factor,1055.7,34,,1055.7,percent of total billed charges,Implant Device,1055.7,34,,1055.7,percent of total billed charges,Implant Device,1055.7,34,,1055.7,percent of total billed charges,Implant Device,1055.7,34,,1055.7,percent of total billed charges,Implant Device,1055.7,34,,1055.7,percent of total billed charges,Implant Device,1536.98,,,1536.98,Other,110% of Medicare,1086.75,35,,1086.75,percent of total billed charges,Implant Device,1055.7,34,"Charges > $500, x 34%",1055.7,percent of total billed charges,Implant Device,1086.75,35,,1086.75,percent of total billed charges,Implant Device,1086.75,35,,1086.75,percent of total billed charges,Implant Device,1086.75,35,,1086.75,percent of total billed charges,Implant Device,1086.75,35,,1086.75,percent of total billed charges,Implant Device,1086.75,35,,1086.75,percent of total billed charges,Implant Device,1242,40,,1242,percent of total billed charges,Implant Device,1086.75,70,,1086.75,percent of total billed charges,All Other,1055.7,34,,1055.7,percent of total billed charges,Implant Device,1055.7,34,,1055.7,percent of total billed charges,Implant Device,1086.75,35,,1086.75,percent of total billed charges,Implant Device,1086.75,35,,1086.75,percent of total billed charges,Implant Device,1086.75,35,,1086.75,percent of total billed charges,Implant Device,1086.75,35,,1086.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1055.7,34,"If Charge > 2,000, then 34 percent",1055.7,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2297.71,
ARTHREX AR-1588RTT TIGHTROPE W/FIBERTAG,C1713,HCPCS,,79011654,CDM,278,RC,,,both,,,1575,1165.5,,,1165.5,Other,150% of Medicare + 9.63% HCRA Surcharge,708.75,45,,708.75,percent of total billed charges,Critical Access Hospital RCC factor,535.5,34,,535.5,percent of total billed charges,Implant Device,535.5,34,,535.5,percent of total billed charges,Implant Device,535.5,34,,535.5,percent of total billed charges,Implant Device,535.5,34,,535.5,percent of total billed charges,Implant Device,535.5,34,,535.5,percent of total billed charges,Implant Device,779.63,,,779.63,Other,110% of Medicare,551.25,35,,551.25,percent of total billed charges,Implant Device,535.5,34,"Charges > $500, x 34%",535.5,percent of total billed charges,Implant Device,551.25,35,,551.25,percent of total billed charges,Implant Device,551.25,35,,551.25,percent of total billed charges,Implant Device,551.25,35,,551.25,percent of total billed charges,Implant Device,551.25,35,,551.25,percent of total billed charges,Implant Device,551.25,35,,551.25,percent of total billed charges,Implant Device,630,40,,630,percent of total billed charges,Implant Device,551.25,70,,551.25,percent of total billed charges,All Other,535.5,34,,535.5,percent of total billed charges,Implant Device,535.5,34,,535.5,percent of total billed charges,Implant Device,551.25,35,,551.25,percent of total billed charges,Implant Device,551.25,35,,551.25,percent of total billed charges,Implant Device,551.25,35,,551.25,percent of total billed charges,Implant Device,551.25,35,,551.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1165.5,
"ARTHREX AR-1588TNT TIGHTROPE W/FIB, ABS",C1713,HCPCS,,79011655,CDM,278,RC,,,both,,,1005,743.7,,,743.7,Other,150% of Medicare + 9.63% HCRA Surcharge,452.25,45,,452.25,percent of total billed charges,Critical Access Hospital RCC factor,341.7,34,,341.7,percent of total billed charges,Implant Device,341.7,34,,341.7,percent of total billed charges,Implant Device,341.7,34,,341.7,percent of total billed charges,Implant Device,341.7,34,,341.7,percent of total billed charges,Implant Device,341.7,34,,341.7,percent of total billed charges,Implant Device,497.48,,,497.48,Other,110% of Medicare,351.75,35,,351.75,percent of total billed charges,Implant Device,341.7,34,"Charges > $500, x 34%",341.7,percent of total billed charges,Implant Device,351.75,35,,351.75,percent of total billed charges,Implant Device,351.75,35,,351.75,percent of total billed charges,Implant Device,351.75,35,,351.75,percent of total billed charges,Implant Device,351.75,35,,351.75,percent of total billed charges,Implant Device,351.75,35,,351.75,percent of total billed charges,Implant Device,402,40,,402,percent of total billed charges,Implant Device,351.75,70,,351.75,percent of total billed charges,All Other,341.7,34,,341.7,percent of total billed charges,Implant Device,341.7,34,,341.7,percent of total billed charges,Implant Device,351.75,35,,351.75,percent of total billed charges,Implant Device,351.75,35,,351.75,percent of total billed charges,Implant Device,351.75,35,,351.75,percent of total billed charges,Implant Device,351.75,35,,351.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,743.7,
DEPUY 02.112.090 CLAVICLE PLT 6H 3.5X105,C1713,HCPCS,,79011656,CDM,278,RC,,,both,,,2397,1773.79,,,1773.79,Other,150% of Medicare + 9.63% HCRA Surcharge,1078.65,45,,1078.65,percent of total billed charges,Critical Access Hospital RCC factor,814.98,34,,814.98,percent of total billed charges,Implant Device,814.98,34,,814.98,percent of total billed charges,Implant Device,814.98,34,,814.98,percent of total billed charges,Implant Device,814.98,34,,814.98,percent of total billed charges,Implant Device,814.98,34,,814.98,percent of total billed charges,Implant Device,1186.52,,,1186.52,Other,110% of Medicare,838.95,35,,838.95,percent of total billed charges,Implant Device,814.98,34,"Charges > $500, x 34%",814.98,percent of total billed charges,Implant Device,838.95,35,,838.95,percent of total billed charges,Implant Device,838.95,35,,838.95,percent of total billed charges,Implant Device,838.95,35,,838.95,percent of total billed charges,Implant Device,838.95,35,,838.95,percent of total billed charges,Implant Device,838.95,35,,838.95,percent of total billed charges,Implant Device,958.8,40,,958.8,percent of total billed charges,Implant Device,838.95,70,,838.95,percent of total billed charges,All Other,814.98,34,,814.98,percent of total billed charges,Implant Device,814.98,34,,814.98,percent of total billed charges,Implant Device,838.95,35,,838.95,percent of total billed charges,Implant Device,838.95,35,,838.95,percent of total billed charges,Implant Device,838.95,35,,838.95,percent of total billed charges,Implant Device,838.95,35,,838.95,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,814.98,34,"If Charge > 2,000, then 34 percent",814.98,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1773.79,
STRYKER 5567-P-3012 HUMERAL STEM 12X96MM,C1776,HCPCS,,79011659,CDM,278,RC,,,both,,,8925,6604.52,,,6604.52,Other,150% of Medicare + 9.63% HCRA Surcharge,4016.25,45,,4016.25,percent of total billed charges,Critical Access Hospital RCC factor,3034.5,34,,3034.5,percent of total billed charges,Implant Device,3034.5,34,,3034.5,percent of total billed charges,Implant Device,3034.5,34,,3034.5,percent of total billed charges,Implant Device,3034.5,34,,3034.5,percent of total billed charges,Implant Device,3034.5,34,,3034.5,percent of total billed charges,Implant Device,4417.88,,,4417.88,Other,110% of Medicare,3123.75,35,,3123.75,percent of total billed charges,Implant Device,3034.5,34,"Charges > $500, x 34%",3034.5,percent of total billed charges,Implant Device,3123.75,35,,3123.75,percent of total billed charges,Implant Device,3123.75,35,,3123.75,percent of total billed charges,Implant Device,3123.75,35,,3123.75,percent of total billed charges,Implant Device,3123.75,35,,3123.75,percent of total billed charges,Implant Device,3123.75,35,,3123.75,percent of total billed charges,Implant Device,3570,40,,3570,percent of total billed charges,Implant Device,3123.75,70,,3123.75,percent of total billed charges,All Other,3034.5,34,,3034.5,percent of total billed charges,Implant Device,3034.5,34,,3034.5,percent of total billed charges,Implant Device,3123.75,35,,3123.75,percent of total billed charges,Implant Device,3123.75,35,,3123.75,percent of total billed charges,Implant Device,3123.75,35,,3123.75,percent of total billed charges,Implant Device,3123.75,35,,3123.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3034.5,34,"If Charge > 2,000, then 34 percent",3034.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,6604.52,
ZIMMER 574202060 FEM STEM 12/14 TAPER,C1776,HCPCS,,79011660,CDM,278,RC,,,both,,,6912,5114.9,,,5114.9,Other,150% of Medicare + 9.63% HCRA Surcharge,3110.4,45,,3110.4,percent of total billed charges,Critical Access Hospital RCC factor,2350.08,34,,2350.08,percent of total billed charges,Implant Device,2350.08,34,,2350.08,percent of total billed charges,Implant Device,2350.08,34,,2350.08,percent of total billed charges,Implant Device,2350.08,34,,2350.08,percent of total billed charges,Implant Device,2350.08,34,,2350.08,percent of total billed charges,Implant Device,3421.44,,,3421.44,Other,110% of Medicare,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2350.08,34,"Charges > $500, x 34%",2350.08,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2764.8,40,,2764.8,percent of total billed charges,Implant Device,2419.2,70,,2419.2,percent of total billed charges,All Other,2350.08,34,,2350.08,percent of total billed charges,Implant Device,2350.08,34,,2350.08,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2350.08,34,"If Charge > 2,000, then 34 percent",2350.08,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5114.9,
BARD AVSM08100 8X100X80CM VASCULAR STENT,C1876,HCPCS,,79011661,CDM,278,RC,,,both,,,8100,5994.02,,,5994.02,Other,150% of Medicare + 9.63% HCRA Surcharge,3645,45,,3645,percent of total billed charges,Critical Access Hospital RCC factor,2754,34,,2754,percent of total billed charges,Implant Device,2754,34,,2754,percent of total billed charges,Implant Device,2754,34,,2754,percent of total billed charges,Implant Device,2754,34,,2754,percent of total billed charges,Implant Device,2754,34,,2754,percent of total billed charges,Implant Device,4009.5,,,4009.5,Other,110% of Medicare,2835,35,,2835,percent of total billed charges,Implant Device,2754,34,"Charges > $500, x 34%",2754,percent of total billed charges,Implant Device,2835,35,,2835,percent of total billed charges,Implant Device,2835,35,,2835,percent of total billed charges,Implant Device,2835,35,,2835,percent of total billed charges,Implant Device,2835,35,,2835,percent of total billed charges,Implant Device,2835,35,,2835,percent of total billed charges,Implant Device,3240,40,,3240,percent of total billed charges,Implant Device,2835,70,,2835,percent of total billed charges,All Other,2754,34,,2754,percent of total billed charges,Implant Device,2754,34,,2754,percent of total billed charges,Implant Device,2835,35,,2835,percent of total billed charges,Implant Device,2835,35,,2835,percent of total billed charges,Implant Device,2835,35,,2835,percent of total billed charges,Implant Device,2835,35,,2835,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2754,34,"If Charge > 2,000, then 34 percent",2754,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5994.02,
ZIMMER 110007541 CANN SCREW 4.0X26MM,C1713,HCPCS,,79011666,CDM,278,RC,,,both,,,540,399.6,,,399.6,Other,150% of Medicare + 9.63% HCRA Surcharge,243,45,,243,percent of total billed charges,Critical Access Hospital RCC factor,183.6,34,,183.6,percent of total billed charges,Implant Device,183.6,34,,183.6,percent of total billed charges,Implant Device,183.6,34,,183.6,percent of total billed charges,Implant Device,183.6,34,,183.6,percent of total billed charges,Implant Device,183.6,34,,183.6,percent of total billed charges,Implant Device,267.3,,,267.3,Other,110% of Medicare,189,35,,189,percent of total billed charges,Implant Device,183.6,34,"Charges > $500, x 34%",183.6,percent of total billed charges,Implant Device,189,35,,189,percent of total billed charges,Implant Device,189,35,,189,percent of total billed charges,Implant Device,189,35,,189,percent of total billed charges,Implant Device,189,35,,189,percent of total billed charges,Implant Device,189,35,,189,percent of total billed charges,Implant Device,216,40,,216,percent of total billed charges,Implant Device,189,70,,189,percent of total billed charges,All Other,183.6,34,,183.6,percent of total billed charges,Implant Device,183.6,34,,183.6,percent of total billed charges,Implant Device,189,35,,189,percent of total billed charges,Implant Device,189,35,,189,percent of total billed charges,Implant Device,189,35,,189,percent of total billed charges,Implant Device,189,35,,189,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,399.6,
EXSOMED EXINN923640 INNATE IMPL 3.6X40MM,C1713,HCPCS,,79011667,CDM,278,RC,,,both,,,3885,2874.91,,,2874.91,Other,150% of Medicare + 9.63% HCRA Surcharge,1748.25,45,,1748.25,percent of total billed charges,Critical Access Hospital RCC factor,1320.9,34,,1320.9,percent of total billed charges,Implant Device,1320.9,34,,1320.9,percent of total billed charges,Implant Device,1320.9,34,,1320.9,percent of total billed charges,Implant Device,1320.9,34,,1320.9,percent of total billed charges,Implant Device,1320.9,34,,1320.9,percent of total billed charges,Implant Device,1923.08,,,1923.08,Other,110% of Medicare,1359.75,35,,1359.75,percent of total billed charges,Implant Device,1320.9,34,"Charges > $500, x 34%",1320.9,percent of total billed charges,Implant Device,1359.75,35,,1359.75,percent of total billed charges,Implant Device,1359.75,35,,1359.75,percent of total billed charges,Implant Device,1359.75,35,,1359.75,percent of total billed charges,Implant Device,1359.75,35,,1359.75,percent of total billed charges,Implant Device,1359.75,35,,1359.75,percent of total billed charges,Implant Device,1554,40,,1554,percent of total billed charges,Implant Device,1359.75,70,,1359.75,percent of total billed charges,All Other,1320.9,34,,1320.9,percent of total billed charges,Implant Device,1320.9,34,,1320.9,percent of total billed charges,Implant Device,1359.75,35,,1359.75,percent of total billed charges,Implant Device,1359.75,35,,1359.75,percent of total billed charges,Implant Device,1359.75,35,,1359.75,percent of total billed charges,Implant Device,1359.75,35,,1359.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1320.9,34,"If Charge > 2,000, then 34 percent",1320.9,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2874.91,
EXSOMED EXINN913600 INNATE INSTR KIT 3.6,C1713,HCPCS,,79011668,CDM,278,RC,,,both,,,1095,810.3,,,810.3,Other,150% of Medicare + 9.63% HCRA Surcharge,492.75,45,,492.75,percent of total billed charges,Critical Access Hospital RCC factor,372.3,34,,372.3,percent of total billed charges,Implant Device,372.3,34,,372.3,percent of total billed charges,Implant Device,372.3,34,,372.3,percent of total billed charges,Implant Device,372.3,34,,372.3,percent of total billed charges,Implant Device,372.3,34,,372.3,percent of total billed charges,Implant Device,542.03,,,542.03,Other,110% of Medicare,383.25,35,,383.25,percent of total billed charges,Implant Device,372.3,34,"Charges > $500, x 34%",372.3,percent of total billed charges,Implant Device,383.25,35,,383.25,percent of total billed charges,Implant Device,383.25,35,,383.25,percent of total billed charges,Implant Device,383.25,35,,383.25,percent of total billed charges,Implant Device,383.25,35,,383.25,percent of total billed charges,Implant Device,383.25,35,,383.25,percent of total billed charges,Implant Device,438,40,,438,percent of total billed charges,Implant Device,383.25,70,,383.25,percent of total billed charges,All Other,372.3,34,,372.3,percent of total billed charges,Implant Device,372.3,34,,372.3,percent of total billed charges,Implant Device,383.25,35,,383.25,percent of total billed charges,Implant Device,383.25,35,,383.25,percent of total billed charges,Implant Device,383.25,35,,383.25,percent of total billed charges,Implant Device,383.25,35,,383.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,810.3,
STRYKER 656115 BONE SCREW 2.4X15MM,C1713,HCPCS,,79011669,CDM,278,RC,,,both,,,395,292.3,,,292.3,Other,150% of Medicare + 9.63% HCRA Surcharge,177.75,45,,177.75,percent of total billed charges,Critical Access Hospital RCC factor,134.3,34,,134.3,percent of total billed charges,Implant Device,134.3,34,,134.3,percent of total billed charges,Implant Device,134.3,34,,134.3,percent of total billed charges,Implant Device,134.3,34,,134.3,percent of total billed charges,Implant Device,134.3,34,,134.3,percent of total billed charges,Implant Device,195.53,,,195.53,Other,110% of Medicare,138.25,35,,138.25,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,138.25,35,,138.25,percent of total billed charges,Implant Device,138.25,35,,138.25,percent of total billed charges,Implant Device,138.25,35,,138.25,percent of total billed charges,Implant Device,138.25,35,,138.25,percent of total billed charges,Implant Device,138.25,35,,138.25,percent of total billed charges,Implant Device,158,40,,158,percent of total billed charges,Implant Device,138.25,70,,138.25,percent of total billed charges,All Other,134.3,34,,134.3,percent of total billed charges,Implant Device,134.3,34,,134.3,percent of total billed charges,Implant Device,138.25,35,,138.25,percent of total billed charges,Implant Device,138.25,35,,138.25,percent of total billed charges,Implant Device,138.25,35,,138.25,percent of total billed charges,Implant Device,138.25,35,,138.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,292.3,
STRYKER 657715 BONE SCREW 2.0X15MM,C1713,HCPCS,,79011670,CDM,278,RC,,,both,,,258,190.92,,,190.92,Other,150% of Medicare + 9.63% HCRA Surcharge,116.1,45,,116.1,percent of total billed charges,Critical Access Hospital RCC factor,87.72,34,,87.72,percent of total billed charges,Implant Device,87.72,34,,87.72,percent of total billed charges,Implant Device,87.72,34,,87.72,percent of total billed charges,Implant Device,87.72,34,,87.72,percent of total billed charges,Implant Device,87.72,34,,87.72,percent of total billed charges,Implant Device,127.71,,,127.71,Other,110% of Medicare,90.3,35,,90.3,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,90.3,35,,90.3,percent of total billed charges,Implant Device,90.3,35,,90.3,percent of total billed charges,Implant Device,90.3,35,,90.3,percent of total billed charges,Implant Device,90.3,35,,90.3,percent of total billed charges,Implant Device,90.3,35,,90.3,percent of total billed charges,Implant Device,103.2,40,,103.2,percent of total billed charges,Implant Device,90.3,70,,90.3,percent of total billed charges,All Other,87.72,34,,87.72,percent of total billed charges,Implant Device,87.72,34,,87.72,percent of total billed charges,Implant Device,90.3,35,,90.3,percent of total billed charges,Implant Device,90.3,35,,90.3,percent of total billed charges,Implant Device,90.3,35,,90.3,percent of total billed charges,Implant Device,90.3,35,,90.3,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,190.92,
STRYKER IC3024 HEADED SCREW 3.0X24MM,C1713,HCPCS,,79011671,CDM,278,RC,,,both,,,493,364.82,,,364.82,Other,150% of Medicare + 9.63% HCRA Surcharge,221.85,45,,221.85,percent of total billed charges,Critical Access Hospital RCC factor,167.62,34,,167.62,percent of total billed charges,Implant Device,167.62,34,,167.62,percent of total billed charges,Implant Device,167.62,34,,167.62,percent of total billed charges,Implant Device,167.62,34,,167.62,percent of total billed charges,Implant Device,167.62,34,,167.62,percent of total billed charges,Implant Device,244.04,,,244.04,Other,110% of Medicare,172.55,35,,172.55,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,172.55,35,,172.55,percent of total billed charges,Implant Device,172.55,35,,172.55,percent of total billed charges,Implant Device,172.55,35,,172.55,percent of total billed charges,Implant Device,172.55,35,,172.55,percent of total billed charges,Implant Device,172.55,35,,172.55,percent of total billed charges,Implant Device,197.2,40,,197.2,percent of total billed charges,Implant Device,172.55,70,,172.55,percent of total billed charges,All Other,167.62,34,,167.62,percent of total billed charges,Implant Device,167.62,34,,167.62,percent of total billed charges,Implant Device,172.55,35,,172.55,percent of total billed charges,Implant Device,172.55,35,,172.55,percent of total billed charges,Implant Device,172.55,35,,172.55,percent of total billed charges,Implant Device,172.55,35,,172.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,364.82,
STRYKER IC3026 HEADED SCREW 3.0X26MM,C1713,HCPCS,,79011672,CDM,278,RC,,,both,,,493,364.82,,,364.82,Other,150% of Medicare + 9.63% HCRA Surcharge,221.85,45,,221.85,percent of total billed charges,Critical Access Hospital RCC factor,167.62,34,,167.62,percent of total billed charges,Implant Device,167.62,34,,167.62,percent of total billed charges,Implant Device,167.62,34,,167.62,percent of total billed charges,Implant Device,167.62,34,,167.62,percent of total billed charges,Implant Device,167.62,34,,167.62,percent of total billed charges,Implant Device,244.04,,,244.04,Other,110% of Medicare,172.55,35,,172.55,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,172.55,35,,172.55,percent of total billed charges,Implant Device,172.55,35,,172.55,percent of total billed charges,Implant Device,172.55,35,,172.55,percent of total billed charges,Implant Device,172.55,35,,172.55,percent of total billed charges,Implant Device,172.55,35,,172.55,percent of total billed charges,Implant Device,197.2,40,,197.2,percent of total billed charges,Implant Device,172.55,70,,172.55,percent of total billed charges,All Other,167.62,34,,167.62,percent of total billed charges,Implant Device,167.62,34,,167.62,percent of total billed charges,Implant Device,172.55,35,,172.55,percent of total billed charges,Implant Device,172.55,35,,172.55,percent of total billed charges,Implant Device,172.55,35,,172.55,percent of total billed charges,Implant Device,172.55,35,,172.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,364.82,
STRYKER IC3028 HEADED SCREW 3.0X28MM,C1713,HCPCS,,79011673,CDM,278,RC,,,both,,,493,364.82,,,364.82,Other,150% of Medicare + 9.63% HCRA Surcharge,221.85,45,,221.85,percent of total billed charges,Critical Access Hospital RCC factor,167.62,34,,167.62,percent of total billed charges,Implant Device,167.62,34,,167.62,percent of total billed charges,Implant Device,167.62,34,,167.62,percent of total billed charges,Implant Device,167.62,34,,167.62,percent of total billed charges,Implant Device,167.62,34,,167.62,percent of total billed charges,Implant Device,244.04,,,244.04,Other,110% of Medicare,172.55,35,,172.55,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,172.55,35,,172.55,percent of total billed charges,Implant Device,172.55,35,,172.55,percent of total billed charges,Implant Device,172.55,35,,172.55,percent of total billed charges,Implant Device,172.55,35,,172.55,percent of total billed charges,Implant Device,172.55,35,,172.55,percent of total billed charges,Implant Device,197.2,40,,197.2,percent of total billed charges,Implant Device,172.55,70,,172.55,percent of total billed charges,All Other,167.62,34,,167.62,percent of total billed charges,Implant Device,167.62,34,,167.62,percent of total billed charges,Implant Device,172.55,35,,172.55,percent of total billed charges,Implant Device,172.55,35,,172.55,percent of total billed charges,Implant Device,172.55,35,,172.55,percent of total billed charges,Implant Device,172.55,35,,172.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,364.82,
STRYKER IH2530 HEADLESS SCREW 2.5X30MM,C1713,HCPCS,,79011674,CDM,278,RC,,,both,,,858,634.92,,,634.92,Other,150% of Medicare + 9.63% HCRA Surcharge,386.1,45,,386.1,percent of total billed charges,Critical Access Hospital RCC factor,291.72,34,,291.72,percent of total billed charges,Implant Device,291.72,34,,291.72,percent of total billed charges,Implant Device,291.72,34,,291.72,percent of total billed charges,Implant Device,291.72,34,,291.72,percent of total billed charges,Implant Device,291.72,34,,291.72,percent of total billed charges,Implant Device,424.71,,,424.71,Other,110% of Medicare,300.3,35,,300.3,percent of total billed charges,Implant Device,291.72,34,"Charges > $500, x 34%",291.72,percent of total billed charges,Implant Device,300.3,35,,300.3,percent of total billed charges,Implant Device,300.3,35,,300.3,percent of total billed charges,Implant Device,300.3,35,,300.3,percent of total billed charges,Implant Device,300.3,35,,300.3,percent of total billed charges,Implant Device,300.3,35,,300.3,percent of total billed charges,Implant Device,343.2,40,,343.2,percent of total billed charges,Implant Device,300.3,70,,300.3,percent of total billed charges,All Other,291.72,34,,291.72,percent of total billed charges,Implant Device,291.72,34,,291.72,percent of total billed charges,Implant Device,300.3,35,,300.3,percent of total billed charges,Implant Device,300.3,35,,300.3,percent of total billed charges,Implant Device,300.3,35,,300.3,percent of total billed charges,Implant Device,300.3,35,,300.3,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,634.92,
STRYKER IH2536 HEADLESS SCREW 2.5X36MM,C1713,HCPCS,,79011675,CDM,278,RC,,,both,,,858,634.92,,,634.92,Other,150% of Medicare + 9.63% HCRA Surcharge,386.1,45,,386.1,percent of total billed charges,Critical Access Hospital RCC factor,291.72,34,,291.72,percent of total billed charges,Implant Device,291.72,34,,291.72,percent of total billed charges,Implant Device,291.72,34,,291.72,percent of total billed charges,Implant Device,291.72,34,,291.72,percent of total billed charges,Implant Device,291.72,34,,291.72,percent of total billed charges,Implant Device,424.71,,,424.71,Other,110% of Medicare,300.3,35,,300.3,percent of total billed charges,Implant Device,291.72,34,"Charges > $500, x 34%",291.72,percent of total billed charges,Implant Device,300.3,35,,300.3,percent of total billed charges,Implant Device,300.3,35,,300.3,percent of total billed charges,Implant Device,300.3,35,,300.3,percent of total billed charges,Implant Device,300.3,35,,300.3,percent of total billed charges,Implant Device,300.3,35,,300.3,percent of total billed charges,Implant Device,343.2,40,,343.2,percent of total billed charges,Implant Device,300.3,70,,300.3,percent of total billed charges,All Other,291.72,34,,291.72,percent of total billed charges,Implant Device,291.72,34,,291.72,percent of total billed charges,Implant Device,300.3,35,,300.3,percent of total billed charges,Implant Device,300.3,35,,300.3,percent of total billed charges,Implant Device,300.3,35,,300.3,percent of total billed charges,Implant Device,300.3,35,,300.3,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,634.92,
STRYKER IH3026 HEADLESS SCREW 3.0X26MM,C1713,HCPCS,,79011676,CDM,278,RC,,,both,,,858,634.92,,,634.92,Other,150% of Medicare + 9.63% HCRA Surcharge,386.1,45,,386.1,percent of total billed charges,Critical Access Hospital RCC factor,291.72,34,,291.72,percent of total billed charges,Implant Device,291.72,34,,291.72,percent of total billed charges,Implant Device,291.72,34,,291.72,percent of total billed charges,Implant Device,291.72,34,,291.72,percent of total billed charges,Implant Device,291.72,34,,291.72,percent of total billed charges,Implant Device,424.71,,,424.71,Other,110% of Medicare,300.3,35,,300.3,percent of total billed charges,Implant Device,291.72,34,"Charges > $500, x 34%",291.72,percent of total billed charges,Implant Device,300.3,35,,300.3,percent of total billed charges,Implant Device,300.3,35,,300.3,percent of total billed charges,Implant Device,300.3,35,,300.3,percent of total billed charges,Implant Device,300.3,35,,300.3,percent of total billed charges,Implant Device,300.3,35,,300.3,percent of total billed charges,Implant Device,343.2,40,,343.2,percent of total billed charges,Implant Device,300.3,70,,300.3,percent of total billed charges,All Other,291.72,34,,291.72,percent of total billed charges,Implant Device,291.72,34,,291.72,percent of total billed charges,Implant Device,300.3,35,,300.3,percent of total billed charges,Implant Device,300.3,35,,300.3,percent of total billed charges,Implant Device,300.3,35,,300.3,percent of total billed charges,Implant Device,300.3,35,,300.3,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,634.92,
STRYKER IH3036 HEADLESS SCREW 3.0X36MM,C1713,HCPCS,,79011677,CDM,278,RC,,,both,,,888,657.12,,,657.12,Other,150% of Medicare + 9.63% HCRA Surcharge,399.6,45,,399.6,percent of total billed charges,Critical Access Hospital RCC factor,301.92,34,,301.92,percent of total billed charges,Implant Device,301.92,34,,301.92,percent of total billed charges,Implant Device,301.92,34,,301.92,percent of total billed charges,Implant Device,301.92,34,,301.92,percent of total billed charges,Implant Device,301.92,34,,301.92,percent of total billed charges,Implant Device,439.56,,,439.56,Other,110% of Medicare,310.8,35,,310.8,percent of total billed charges,Implant Device,301.92,34,"Charges > $500, x 34%",301.92,percent of total billed charges,Implant Device,310.8,35,,310.8,percent of total billed charges,Implant Device,310.8,35,,310.8,percent of total billed charges,Implant Device,310.8,35,,310.8,percent of total billed charges,Implant Device,310.8,35,,310.8,percent of total billed charges,Implant Device,310.8,35,,310.8,percent of total billed charges,Implant Device,355.2,40,,355.2,percent of total billed charges,Implant Device,310.8,70,,310.8,percent of total billed charges,All Other,301.92,34,,301.92,percent of total billed charges,Implant Device,301.92,34,,301.92,percent of total billed charges,Implant Device,310.8,35,,310.8,percent of total billed charges,Implant Device,310.8,35,,310.8,percent of total billed charges,Implant Device,310.8,35,,310.8,percent of total billed charges,Implant Device,310.8,35,,310.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,657.12,
STRYKER 5567-P-3015 HUMERAL STEM 15X99MM,C1776,HCPCS,,79011679,CDM,278,RC,,,both,,,8925,6604.52,,,6604.52,Other,150% of Medicare + 9.63% HCRA Surcharge,4016.25,45,,4016.25,percent of total billed charges,Critical Access Hospital RCC factor,3034.5,34,,3034.5,percent of total billed charges,Implant Device,3034.5,34,,3034.5,percent of total billed charges,Implant Device,3034.5,34,,3034.5,percent of total billed charges,Implant Device,3034.5,34,,3034.5,percent of total billed charges,Implant Device,3034.5,34,,3034.5,percent of total billed charges,Implant Device,4417.88,,,4417.88,Other,110% of Medicare,3123.75,35,,3123.75,percent of total billed charges,Implant Device,3034.5,34,"Charges > $500, x 34%",3034.5,percent of total billed charges,Implant Device,3123.75,35,,3123.75,percent of total billed charges,Implant Device,3123.75,35,,3123.75,percent of total billed charges,Implant Device,3123.75,35,,3123.75,percent of total billed charges,Implant Device,3123.75,35,,3123.75,percent of total billed charges,Implant Device,3123.75,35,,3123.75,percent of total billed charges,Implant Device,3570,40,,3570,percent of total billed charges,Implant Device,3123.75,70,,3123.75,percent of total billed charges,All Other,3034.5,34,,3034.5,percent of total billed charges,Implant Device,3034.5,34,,3034.5,percent of total billed charges,Implant Device,3123.75,35,,3123.75,percent of total billed charges,Implant Device,3123.75,35,,3123.75,percent of total billed charges,Implant Device,3123.75,35,,3123.75,percent of total billed charges,Implant Device,3123.75,35,,3123.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3034.5,34,"If Charge > 2,000, then 34 percent",3034.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,6604.52,
ARTHREX AR-1698-CP BRACE LISFRANC KIT,C1713,HCPCS,,79011681,CDM,278,RC,,,both,,,4485,3318.91,,,3318.91,Other,150% of Medicare + 9.63% HCRA Surcharge,2018.25,45,,2018.25,percent of total billed charges,Critical Access Hospital RCC factor,1524.9,34,,1524.9,percent of total billed charges,Implant Device,1524.9,34,,1524.9,percent of total billed charges,Implant Device,1524.9,34,,1524.9,percent of total billed charges,Implant Device,1524.9,34,,1524.9,percent of total billed charges,Implant Device,1524.9,34,,1524.9,percent of total billed charges,Implant Device,2220.08,,,2220.08,Other,110% of Medicare,1569.75,35,,1569.75,percent of total billed charges,Implant Device,1524.9,34,"Charges > $500, x 34%",1524.9,percent of total billed charges,Implant Device,1569.75,35,,1569.75,percent of total billed charges,Implant Device,1569.75,35,,1569.75,percent of total billed charges,Implant Device,1569.75,35,,1569.75,percent of total billed charges,Implant Device,1569.75,35,,1569.75,percent of total billed charges,Implant Device,1569.75,35,,1569.75,percent of total billed charges,Implant Device,1794,40,,1794,percent of total billed charges,Implant Device,1569.75,70,,1569.75,percent of total billed charges,All Other,1524.9,34,,1524.9,percent of total billed charges,Implant Device,1524.9,34,,1524.9,percent of total billed charges,Implant Device,1569.75,35,,1569.75,percent of total billed charges,Implant Device,1569.75,35,,1569.75,percent of total billed charges,Implant Device,1569.75,35,,1569.75,percent of total billed charges,Implant Device,1569.75,35,,1569.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1524.9,34,"If Charge > 2,000, then 34 percent",1524.9,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3318.91,
ARTHREX AR-13227 BB-TAK MTP,C1713,HCPCS,,79011682,CDM,278,RC,,,both,,,163,120.62,,,120.62,Other,150% of Medicare + 9.63% HCRA Surcharge,73.35,45,,73.35,percent of total billed charges,Critical Access Hospital RCC factor,55.42,34,,55.42,percent of total billed charges,Implant Device,55.42,34,,55.42,percent of total billed charges,Implant Device,55.42,34,,55.42,percent of total billed charges,Implant Device,55.42,34,,55.42,percent of total billed charges,Implant Device,55.42,34,,55.42,percent of total billed charges,Implant Device,80.69,,,80.69,Other,110% of Medicare,57.05,35,,57.05,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,57.05,35,,57.05,percent of total billed charges,Implant Device,57.05,35,,57.05,percent of total billed charges,Implant Device,57.05,35,,57.05,percent of total billed charges,Implant Device,57.05,35,,57.05,percent of total billed charges,Implant Device,57.05,35,,57.05,percent of total billed charges,Implant Device,65.2,40,,65.2,percent of total billed charges,Implant Device,57.05,70,,57.05,percent of total billed charges,All Other,55.42,34,,55.42,percent of total billed charges,Implant Device,55.42,34,,55.42,percent of total billed charges,Implant Device,57.05,35,,57.05,percent of total billed charges,Implant Device,57.05,35,,57.05,percent of total billed charges,Implant Device,57.05,35,,57.05,percent of total billed charges,Implant Device,57.05,35,,57.05,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,120.62,
ARTHREX AR-9933-12 CORT SCREW 3.0X12MM,C1713,HCPCS,,79011683,CDM,278,RC,,,both,,,375,277.5,,,277.5,Other,150% of Medicare + 9.63% HCRA Surcharge,168.75,45,,168.75,percent of total billed charges,Critical Access Hospital RCC factor,127.5,34,,127.5,percent of total billed charges,Implant Device,127.5,34,,127.5,percent of total billed charges,Implant Device,127.5,34,,127.5,percent of total billed charges,Implant Device,127.5,34,,127.5,percent of total billed charges,Implant Device,127.5,34,,127.5,percent of total billed charges,Implant Device,185.63,,,185.63,Other,110% of Medicare,131.25,35,,131.25,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,131.25,35,,131.25,percent of total billed charges,Implant Device,131.25,35,,131.25,percent of total billed charges,Implant Device,131.25,35,,131.25,percent of total billed charges,Implant Device,131.25,35,,131.25,percent of total billed charges,Implant Device,131.25,35,,131.25,percent of total billed charges,Implant Device,150,40,,150,percent of total billed charges,Implant Device,131.25,70,,131.25,percent of total billed charges,All Other,127.5,34,,127.5,percent of total billed charges,Implant Device,127.5,34,,127.5,percent of total billed charges,Implant Device,131.25,35,,131.25,percent of total billed charges,Implant Device,131.25,35,,131.25,percent of total billed charges,Implant Device,131.25,35,,131.25,percent of total billed charges,Implant Device,131.25,35,,131.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,277.5,
ARTHREX AR-9933-14 CORT SCREW 3.0X14MM,C1713,HCPCS,,79011684,CDM,278,RC,,,both,,,537,397.38,,,397.38,Other,150% of Medicare + 9.63% HCRA Surcharge,241.65,45,,241.65,percent of total billed charges,Critical Access Hospital RCC factor,182.58,34,,182.58,percent of total billed charges,Implant Device,182.58,34,,182.58,percent of total billed charges,Implant Device,182.58,34,,182.58,percent of total billed charges,Implant Device,182.58,34,,182.58,percent of total billed charges,Implant Device,182.58,34,,182.58,percent of total billed charges,Implant Device,265.82,,,265.82,Other,110% of Medicare,187.95,35,,187.95,percent of total billed charges,Implant Device,182.58,34,"Charges > $500, x 34%",182.58,percent of total billed charges,Implant Device,187.95,35,,187.95,percent of total billed charges,Implant Device,187.95,35,,187.95,percent of total billed charges,Implant Device,187.95,35,,187.95,percent of total billed charges,Implant Device,187.95,35,,187.95,percent of total billed charges,Implant Device,187.95,35,,187.95,percent of total billed charges,Implant Device,214.8,40,,214.8,percent of total billed charges,Implant Device,187.95,70,,187.95,percent of total billed charges,All Other,182.58,34,,182.58,percent of total billed charges,Implant Device,182.58,34,,182.58,percent of total billed charges,Implant Device,187.95,35,,187.95,percent of total billed charges,Implant Device,187.95,35,,187.95,percent of total billed charges,Implant Device,187.95,35,,187.95,percent of total billed charges,Implant Device,187.95,35,,187.95,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,397.38,
ARTHREX AR-9944P-0L MAXFORCE MTP PLT LT,C1713,HCPCS,,79011685,CDM,278,RC,,,both,,,5985,4428.91,,,4428.91,Other,150% of Medicare + 9.63% HCRA Surcharge,2693.25,45,,2693.25,percent of total billed charges,Critical Access Hospital RCC factor,2034.9,34,,2034.9,percent of total billed charges,Implant Device,2034.9,34,,2034.9,percent of total billed charges,Implant Device,2034.9,34,,2034.9,percent of total billed charges,Implant Device,2034.9,34,,2034.9,percent of total billed charges,Implant Device,2034.9,34,,2034.9,percent of total billed charges,Implant Device,2962.58,,,2962.58,Other,110% of Medicare,2094.75,35,,2094.75,percent of total billed charges,Implant Device,2034.9,34,"Charges > $500, x 34%",2034.9,percent of total billed charges,Implant Device,2094.75,35,,2094.75,percent of total billed charges,Implant Device,2094.75,35,,2094.75,percent of total billed charges,Implant Device,2094.75,35,,2094.75,percent of total billed charges,Implant Device,2094.75,35,,2094.75,percent of total billed charges,Implant Device,2094.75,35,,2094.75,percent of total billed charges,Implant Device,2394,40,,2394,percent of total billed charges,Implant Device,2094.75,70,,2094.75,percent of total billed charges,All Other,2034.9,34,,2034.9,percent of total billed charges,Implant Device,2034.9,34,,2034.9,percent of total billed charges,Implant Device,2094.75,35,,2094.75,percent of total billed charges,Implant Device,2094.75,35,,2094.75,percent of total billed charges,Implant Device,2094.75,35,,2094.75,percent of total billed charges,Implant Device,2094.75,35,,2094.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2034.9,34,"If Charge > 2,000, then 34 percent",2034.9,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4428.91,
STRYKER 1826-1034S SUPRCNDLR NAIL 10X340,C1713,HCPCS,,79011688,CDM,278,RC,,,both,,,4633,3428.43,,,3428.43,Other,150% of Medicare + 9.63% HCRA Surcharge,2084.85,45,,2084.85,percent of total billed charges,Critical Access Hospital RCC factor,1575.22,34,,1575.22,percent of total billed charges,Implant Device,1575.22,34,,1575.22,percent of total billed charges,Implant Device,1575.22,34,,1575.22,percent of total billed charges,Implant Device,1575.22,34,,1575.22,percent of total billed charges,Implant Device,1575.22,34,,1575.22,percent of total billed charges,Implant Device,2293.34,,,2293.34,Other,110% of Medicare,1621.55,35,,1621.55,percent of total billed charges,Implant Device,1575.22,34,"Charges > $500, x 34%",1575.22,percent of total billed charges,Implant Device,1621.55,35,,1621.55,percent of total billed charges,Implant Device,1621.55,35,,1621.55,percent of total billed charges,Implant Device,1621.55,35,,1621.55,percent of total billed charges,Implant Device,1621.55,35,,1621.55,percent of total billed charges,Implant Device,1621.55,35,,1621.55,percent of total billed charges,Implant Device,1853.2,40,,1853.2,percent of total billed charges,Implant Device,1621.55,70,,1621.55,percent of total billed charges,All Other,1575.22,34,,1575.22,percent of total billed charges,Implant Device,1575.22,34,,1575.22,percent of total billed charges,Implant Device,1621.55,35,,1621.55,percent of total billed charges,Implant Device,1621.55,35,,1621.55,percent of total billed charges,Implant Device,1621.55,35,,1621.55,percent of total billed charges,Implant Device,1621.55,35,,1621.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1575.22,34,"If Charge > 2,000, then 34 percent",1575.22,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3428.43,
STRYKER 2360-5060S LOCK SCREW 5X60MM,C1713,HCPCS,,79011690,CDM,278,RC,,,both,,,762,563.88,,,563.88,Other,150% of Medicare + 9.63% HCRA Surcharge,342.9,45,,342.9,percent of total billed charges,Critical Access Hospital RCC factor,259.08,34,,259.08,percent of total billed charges,Implant Device,259.08,34,,259.08,percent of total billed charges,Implant Device,259.08,34,,259.08,percent of total billed charges,Implant Device,259.08,34,,259.08,percent of total billed charges,Implant Device,259.08,34,,259.08,percent of total billed charges,Implant Device,377.19,,,377.19,Other,110% of Medicare,266.7,35,,266.7,percent of total billed charges,Implant Device,259.08,34,"Charges > $500, x 34%",259.08,percent of total billed charges,Implant Device,266.7,35,,266.7,percent of total billed charges,Implant Device,266.7,35,,266.7,percent of total billed charges,Implant Device,266.7,35,,266.7,percent of total billed charges,Implant Device,266.7,35,,266.7,percent of total billed charges,Implant Device,266.7,35,,266.7,percent of total billed charges,Implant Device,304.8,40,,304.8,percent of total billed charges,Implant Device,266.7,70,,266.7,percent of total billed charges,All Other,259.08,34,,259.08,percent of total billed charges,Implant Device,259.08,34,,259.08,percent of total billed charges,Implant Device,266.7,35,,266.7,percent of total billed charges,Implant Device,266.7,35,,266.7,percent of total billed charges,Implant Device,266.7,35,,266.7,percent of total billed charges,Implant Device,266.7,35,,266.7,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,563.88,
STRYKER 2360-5075S LOCK SCREW 5X75MM,C1713,HCPCS,,79011691,CDM,278,RC,,,both,,,956,707.44,,,707.44,Other,150% of Medicare + 9.63% HCRA Surcharge,430.2,45,,430.2,percent of total billed charges,Critical Access Hospital RCC factor,325.04,34,,325.04,percent of total billed charges,Implant Device,325.04,34,,325.04,percent of total billed charges,Implant Device,325.04,34,,325.04,percent of total billed charges,Implant Device,325.04,34,,325.04,percent of total billed charges,Implant Device,325.04,34,,325.04,percent of total billed charges,Implant Device,473.22,,,473.22,Other,110% of Medicare,334.6,35,,334.6,percent of total billed charges,Implant Device,325.04,34,"Charges > $500, x 34%",325.04,percent of total billed charges,Implant Device,334.6,35,,334.6,percent of total billed charges,Implant Device,334.6,35,,334.6,percent of total billed charges,Implant Device,334.6,35,,334.6,percent of total billed charges,Implant Device,334.6,35,,334.6,percent of total billed charges,Implant Device,334.6,35,,334.6,percent of total billed charges,Implant Device,382.4,40,,382.4,percent of total billed charges,Implant Device,334.6,70,,334.6,percent of total billed charges,All Other,325.04,34,,325.04,percent of total billed charges,Implant Device,325.04,34,,325.04,percent of total billed charges,Implant Device,334.6,35,,334.6,percent of total billed charges,Implant Device,334.6,35,,334.6,percent of total billed charges,Implant Device,334.6,35,,334.6,percent of total billed charges,Implant Device,334.6,35,,334.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,707.44,
STRYKER 2360-5080S LOCK SCREW 5X80MM,C1713,HCPCS,,79011692,CDM,278,RC,,,both,,,762,563.88,,,563.88,Other,150% of Medicare + 9.63% HCRA Surcharge,342.9,45,,342.9,percent of total billed charges,Critical Access Hospital RCC factor,259.08,34,,259.08,percent of total billed charges,Implant Device,259.08,34,,259.08,percent of total billed charges,Implant Device,259.08,34,,259.08,percent of total billed charges,Implant Device,259.08,34,,259.08,percent of total billed charges,Implant Device,259.08,34,,259.08,percent of total billed charges,Implant Device,377.19,,,377.19,Other,110% of Medicare,266.7,35,,266.7,percent of total billed charges,Implant Device,259.08,34,"Charges > $500, x 34%",259.08,percent of total billed charges,Implant Device,266.7,35,,266.7,percent of total billed charges,Implant Device,266.7,35,,266.7,percent of total billed charges,Implant Device,266.7,35,,266.7,percent of total billed charges,Implant Device,266.7,35,,266.7,percent of total billed charges,Implant Device,266.7,35,,266.7,percent of total billed charges,Implant Device,304.8,40,,304.8,percent of total billed charges,Implant Device,266.7,70,,266.7,percent of total billed charges,All Other,259.08,34,,259.08,percent of total billed charges,Implant Device,259.08,34,,259.08,percent of total billed charges,Implant Device,266.7,35,,266.7,percent of total billed charges,Implant Device,266.7,35,,266.7,percent of total billed charges,Implant Device,266.7,35,,266.7,percent of total billed charges,Implant Device,266.7,35,,266.7,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,563.88,
STRYKER 626673 TUBULAR PLATE 3 HOLE 35MM,C1713,HCPCS,,79011693,CDM,278,RC,,,both,,,759,561.66,,,561.66,Other,150% of Medicare + 9.63% HCRA Surcharge,341.55,45,,341.55,percent of total billed charges,Critical Access Hospital RCC factor,258.06,34,,258.06,percent of total billed charges,Implant Device,258.06,34,,258.06,percent of total billed charges,Implant Device,258.06,34,,258.06,percent of total billed charges,Implant Device,258.06,34,,258.06,percent of total billed charges,Implant Device,258.06,34,,258.06,percent of total billed charges,Implant Device,375.71,,,375.71,Other,110% of Medicare,265.65,35,,265.65,percent of total billed charges,Implant Device,258.06,34,"Charges > $500, x 34%",258.06,percent of total billed charges,Implant Device,265.65,35,,265.65,percent of total billed charges,Implant Device,265.65,35,,265.65,percent of total billed charges,Implant Device,265.65,35,,265.65,percent of total billed charges,Implant Device,265.65,35,,265.65,percent of total billed charges,Implant Device,265.65,35,,265.65,percent of total billed charges,Implant Device,303.6,40,,303.6,percent of total billed charges,Implant Device,265.65,70,,265.65,percent of total billed charges,All Other,258.06,34,,258.06,percent of total billed charges,Implant Device,258.06,34,,258.06,percent of total billed charges,Implant Device,265.65,35,,265.65,percent of total billed charges,Implant Device,265.65,35,,265.65,percent of total billed charges,Implant Device,265.65,35,,265.65,percent of total billed charges,Implant Device,265.65,35,,265.65,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,561.66,
WRIGHT FFNS1010 STAPLE NITINOL 10X10MM,C1713,HCPCS,,79011695,CDM,278,RC,,,both,,,5410,4003.41,,,4003.41,Other,150% of Medicare + 9.63% HCRA Surcharge,2434.5,45,,2434.5,percent of total billed charges,Critical Access Hospital RCC factor,1839.4,34,,1839.4,percent of total billed charges,Implant Device,1839.4,34,,1839.4,percent of total billed charges,Implant Device,1839.4,34,,1839.4,percent of total billed charges,Implant Device,1839.4,34,,1839.4,percent of total billed charges,Implant Device,1839.4,34,,1839.4,percent of total billed charges,Implant Device,2677.95,,,2677.95,Other,110% of Medicare,1893.5,35,,1893.5,percent of total billed charges,Implant Device,1839.4,34,"Charges > $500, x 34%",1839.4,percent of total billed charges,Implant Device,1893.5,35,,1893.5,percent of total billed charges,Implant Device,1893.5,35,,1893.5,percent of total billed charges,Implant Device,1893.5,35,,1893.5,percent of total billed charges,Implant Device,1893.5,35,,1893.5,percent of total billed charges,Implant Device,1893.5,35,,1893.5,percent of total billed charges,Implant Device,2164,40,,2164,percent of total billed charges,Implant Device,1893.5,70,,1893.5,percent of total billed charges,All Other,1839.4,34,,1839.4,percent of total billed charges,Implant Device,1839.4,34,,1839.4,percent of total billed charges,Implant Device,1893.5,35,,1893.5,percent of total billed charges,Implant Device,1893.5,35,,1893.5,percent of total billed charges,Implant Device,1893.5,35,,1893.5,percent of total billed charges,Implant Device,1893.5,35,,1893.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1839.4,34,"If Charge > 2,000, then 34 percent",1839.4,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4003.41,
STRYKER 40-20114S CANN SCREW 2.0X14/6MM,C1713,HCPCS,,79011696,CDM,278,RC,,,both,,,493,364.82,,,364.82,Other,150% of Medicare + 9.63% HCRA Surcharge,221.85,45,,221.85,percent of total billed charges,Critical Access Hospital RCC factor,167.62,34,,167.62,percent of total billed charges,Implant Device,167.62,34,,167.62,percent of total billed charges,Implant Device,167.62,34,,167.62,percent of total billed charges,Implant Device,167.62,34,,167.62,percent of total billed charges,Implant Device,167.62,34,,167.62,percent of total billed charges,Implant Device,244.04,,,244.04,Other,110% of Medicare,172.55,35,,172.55,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,172.55,35,,172.55,percent of total billed charges,Implant Device,172.55,35,,172.55,percent of total billed charges,Implant Device,172.55,35,,172.55,percent of total billed charges,Implant Device,172.55,35,,172.55,percent of total billed charges,Implant Device,172.55,35,,172.55,percent of total billed charges,Implant Device,197.2,40,,197.2,percent of total billed charges,Implant Device,172.55,70,,172.55,percent of total billed charges,All Other,167.62,34,,167.62,percent of total billed charges,Implant Device,167.62,34,,167.62,percent of total billed charges,Implant Device,172.55,35,,172.55,percent of total billed charges,Implant Device,172.55,35,,172.55,percent of total billed charges,Implant Device,172.55,35,,172.55,percent of total billed charges,Implant Device,172.55,35,,172.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,364.82,
STRYKER 40-30122S CANN SCREW 3.0X22/5MM,C1713,HCPCS,,79011697,CDM,278,RC,,,both,,,964,713.36,,,713.36,Other,150% of Medicare + 9.63% HCRA Surcharge,433.8,45,,433.8,percent of total billed charges,Critical Access Hospital RCC factor,327.76,34,,327.76,percent of total billed charges,Implant Device,327.76,34,,327.76,percent of total billed charges,Implant Device,327.76,34,,327.76,percent of total billed charges,Implant Device,327.76,34,,327.76,percent of total billed charges,Implant Device,327.76,34,,327.76,percent of total billed charges,Implant Device,477.18,,,477.18,Other,110% of Medicare,337.4,35,,337.4,percent of total billed charges,Implant Device,327.76,34,"Charges > $500, x 34%",327.76,percent of total billed charges,Implant Device,337.4,35,,337.4,percent of total billed charges,Implant Device,337.4,35,,337.4,percent of total billed charges,Implant Device,337.4,35,,337.4,percent of total billed charges,Implant Device,337.4,35,,337.4,percent of total billed charges,Implant Device,337.4,35,,337.4,percent of total billed charges,Implant Device,385.6,40,,385.6,percent of total billed charges,Implant Device,337.4,70,,337.4,percent of total billed charges,All Other,327.76,34,,327.76,percent of total billed charges,Implant Device,327.76,34,,327.76,percent of total billed charges,Implant Device,337.4,35,,337.4,percent of total billed charges,Implant Device,337.4,35,,337.4,percent of total billed charges,Implant Device,337.4,35,,337.4,percent of total billed charges,Implant Device,337.4,35,,337.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,713.36,
STRYKER 40-301128S CANN SCREW 3.0X28/6MM,C1713,HCPCS,,79011698,CDM,278,RC,,,both,,,493,364.82,,,364.82,Other,150% of Medicare + 9.63% HCRA Surcharge,221.85,45,,221.85,percent of total billed charges,Critical Access Hospital RCC factor,167.62,34,,167.62,percent of total billed charges,Implant Device,167.62,34,,167.62,percent of total billed charges,Implant Device,167.62,34,,167.62,percent of total billed charges,Implant Device,167.62,34,,167.62,percent of total billed charges,Implant Device,167.62,34,,167.62,percent of total billed charges,Implant Device,244.04,,,244.04,Other,110% of Medicare,172.55,35,,172.55,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,172.55,35,,172.55,percent of total billed charges,Implant Device,172.55,35,,172.55,percent of total billed charges,Implant Device,172.55,35,,172.55,percent of total billed charges,Implant Device,172.55,35,,172.55,percent of total billed charges,Implant Device,172.55,35,,172.55,percent of total billed charges,Implant Device,197.2,40,,197.2,percent of total billed charges,Implant Device,172.55,70,,172.55,percent of total billed charges,All Other,167.62,34,,167.62,percent of total billed charges,Implant Device,167.62,34,,167.62,percent of total billed charges,Implant Device,172.55,35,,172.55,percent of total billed charges,Implant Device,172.55,35,,172.55,percent of total billed charges,Implant Device,172.55,35,,172.55,percent of total billed charges,Implant Device,172.55,35,,172.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,364.82,
DEPUY 02.112.008 CLAV PLT 3.5X108MM 6H,C1713,HCPCS,,79011699,CDM,278,RC,,,both,,,2397,1773.79,,,1773.79,Other,150% of Medicare + 9.63% HCRA Surcharge,1078.65,45,,1078.65,percent of total billed charges,Critical Access Hospital RCC factor,814.98,34,,814.98,percent of total billed charges,Implant Device,814.98,34,,814.98,percent of total billed charges,Implant Device,814.98,34,,814.98,percent of total billed charges,Implant Device,814.98,34,,814.98,percent of total billed charges,Implant Device,814.98,34,,814.98,percent of total billed charges,Implant Device,1186.52,,,1186.52,Other,110% of Medicare,838.95,35,,838.95,percent of total billed charges,Implant Device,814.98,34,"Charges > $500, x 34%",814.98,percent of total billed charges,Implant Device,838.95,35,,838.95,percent of total billed charges,Implant Device,838.95,35,,838.95,percent of total billed charges,Implant Device,838.95,35,,838.95,percent of total billed charges,Implant Device,838.95,35,,838.95,percent of total billed charges,Implant Device,838.95,35,,838.95,percent of total billed charges,Implant Device,958.8,40,,958.8,percent of total billed charges,Implant Device,838.95,70,,838.95,percent of total billed charges,All Other,814.98,34,,814.98,percent of total billed charges,Implant Device,814.98,34,,814.98,percent of total billed charges,Implant Device,838.95,35,,838.95,percent of total billed charges,Implant Device,838.95,35,,838.95,percent of total billed charges,Implant Device,838.95,35,,838.95,percent of total billed charges,Implant Device,838.95,35,,838.95,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,814.98,34,"If Charge > 2,000, then 34 percent",814.98,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1773.79,
STRYKER 3425-1400S LONG NAIL 11X400X125,C1713,HCPCS,,79011700,CDM,278,RC,,,both,,,4969,3677.07,,,3677.07,Other,150% of Medicare + 9.63% HCRA Surcharge,2236.05,45,,2236.05,percent of total billed charges,Critical Access Hospital RCC factor,1689.46,34,,1689.46,percent of total billed charges,Implant Device,1689.46,34,,1689.46,percent of total billed charges,Implant Device,1689.46,34,,1689.46,percent of total billed charges,Implant Device,1689.46,34,,1689.46,percent of total billed charges,Implant Device,1689.46,34,,1689.46,percent of total billed charges,Implant Device,2459.66,,,2459.66,Other,110% of Medicare,1739.15,35,,1739.15,percent of total billed charges,Implant Device,1689.46,34,"Charges > $500, x 34%",1689.46,percent of total billed charges,Implant Device,1739.15,35,,1739.15,percent of total billed charges,Implant Device,1739.15,35,,1739.15,percent of total billed charges,Implant Device,1739.15,35,,1739.15,percent of total billed charges,Implant Device,1739.15,35,,1739.15,percent of total billed charges,Implant Device,1739.15,35,,1739.15,percent of total billed charges,Implant Device,1987.6,40,,1987.6,percent of total billed charges,Implant Device,1739.15,70,,1739.15,percent of total billed charges,All Other,1689.46,34,,1689.46,percent of total billed charges,Implant Device,1689.46,34,,1689.46,percent of total billed charges,Implant Device,1739.15,35,,1739.15,percent of total billed charges,Implant Device,1739.15,35,,1739.15,percent of total billed charges,Implant Device,1739.15,35,,1739.15,percent of total billed charges,Implant Device,1739.15,35,,1739.15,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1689.46,34,"If Charge > 2,000, then 34 percent",1689.46,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3677.07,
STRYKER 40-35034 LOCK BONE SCREW 3.5X34,C1713,HCPCS,,79011701,CDM,278,RC,,,both,,,192,142.08,,,142.08,Other,150% of Medicare + 9.63% HCRA Surcharge,86.4,45,,86.4,percent of total billed charges,Critical Access Hospital RCC factor,65.28,34,,65.28,percent of total billed charges,Implant Device,65.28,34,,65.28,percent of total billed charges,Implant Device,65.28,34,,65.28,percent of total billed charges,Implant Device,65.28,34,,65.28,percent of total billed charges,Implant Device,65.28,34,,65.28,percent of total billed charges,Implant Device,95.04,,,95.04,Other,110% of Medicare,67.2,35,,67.2,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,67.2,35,,67.2,percent of total billed charges,Implant Device,67.2,35,,67.2,percent of total billed charges,Implant Device,67.2,35,,67.2,percent of total billed charges,Implant Device,67.2,35,,67.2,percent of total billed charges,Implant Device,67.2,35,,67.2,percent of total billed charges,Implant Device,76.8,40,,76.8,percent of total billed charges,Implant Device,67.2,70,,67.2,percent of total billed charges,All Other,65.28,34,,65.28,percent of total billed charges,Implant Device,65.28,34,,65.28,percent of total billed charges,Implant Device,67.2,35,,67.2,percent of total billed charges,Implant Device,67.2,35,,67.2,percent of total billed charges,Implant Device,67.2,35,,67.2,percent of total billed charges,Implant Device,67.2,35,,67.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,142.08,
ZIMMER 574202080 FEMORAL STEM 12/14 SZ 8,C1776,HCPCS,,79011703,CDM,278,RC,,,both,,,6912,5114.9,,,5114.9,Other,150% of Medicare + 9.63% HCRA Surcharge,3110.4,45,,3110.4,percent of total billed charges,Critical Access Hospital RCC factor,2350.08,34,,2350.08,percent of total billed charges,Implant Device,2350.08,34,,2350.08,percent of total billed charges,Implant Device,2350.08,34,,2350.08,percent of total billed charges,Implant Device,2350.08,34,,2350.08,percent of total billed charges,Implant Device,2350.08,34,,2350.08,percent of total billed charges,Implant Device,3421.44,,,3421.44,Other,110% of Medicare,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2350.08,34,"Charges > $500, x 34%",2350.08,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2764.8,40,,2764.8,percent of total billed charges,Implant Device,2419.2,70,,2419.2,percent of total billed charges,All Other,2350.08,34,,2350.08,percent of total billed charges,Implant Device,2350.08,34,,2350.08,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2350.08,34,"If Charge > 2,000, then 34 percent",2350.08,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5114.9,
ARTHREX AR-8720-16PT CANN SCREW 2.0X16MM,C1713,HCPCS,,79011704,CDM,278,RC,,,both,,,420,310.8,,,310.8,Other,150% of Medicare + 9.63% HCRA Surcharge,189,45,,189,percent of total billed charges,Critical Access Hospital RCC factor,142.8,34,,142.8,percent of total billed charges,Implant Device,142.8,34,,142.8,percent of total billed charges,Implant Device,142.8,34,,142.8,percent of total billed charges,Implant Device,142.8,34,,142.8,percent of total billed charges,Implant Device,142.8,34,,142.8,percent of total billed charges,Implant Device,207.9,,,207.9,Other,110% of Medicare,147,35,,147,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,147,35,,147,percent of total billed charges,Implant Device,147,35,,147,percent of total billed charges,Implant Device,147,35,,147,percent of total billed charges,Implant Device,147,35,,147,percent of total billed charges,Implant Device,147,35,,147,percent of total billed charges,Implant Device,168,40,,168,percent of total billed charges,Implant Device,147,70,,147,percent of total billed charges,All Other,142.8,34,,142.8,percent of total billed charges,Implant Device,142.8,34,,142.8,percent of total billed charges,Implant Device,147,35,,147,percent of total billed charges,Implant Device,147,35,,147,percent of total billed charges,Implant Device,147,35,,147,percent of total billed charges,Implant Device,147,35,,147,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,310.8,
ARTHREX AR-8720-18PT CANN SCREW 2.0X18MM,C1713,HCPCS,,79011705,CDM,278,RC,,,both,,,600,444,,,444,Other,150% of Medicare + 9.63% HCRA Surcharge,270,45,,270,percent of total billed charges,Critical Access Hospital RCC factor,204,34,,204,percent of total billed charges,Implant Device,204,34,,204,percent of total billed charges,Implant Device,204,34,,204,percent of total billed charges,Implant Device,204,34,,204,percent of total billed charges,Implant Device,204,34,,204,percent of total billed charges,Implant Device,297,,,297,Other,110% of Medicare,210,35,,210,percent of total billed charges,Implant Device,204,34,"Charges > $500, x 34%",204,percent of total billed charges,Implant Device,210,35,,210,percent of total billed charges,Implant Device,210,35,,210,percent of total billed charges,Implant Device,210,35,,210,percent of total billed charges,Implant Device,210,35,,210,percent of total billed charges,Implant Device,210,35,,210,percent of total billed charges,Implant Device,240,40,,240,percent of total billed charges,Implant Device,210,70,,210,percent of total billed charges,All Other,204,34,,204,percent of total billed charges,Implant Device,204,34,,204,percent of total billed charges,Implant Device,210,35,,210,percent of total billed charges,Implant Device,210,35,,210,percent of total billed charges,Implant Device,210,35,,210,percent of total billed charges,Implant Device,210,35,,210,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,444,
ARTHREX AR-8724-16PT CANN SCREW 2.4X16MM,C1713,HCPCS,,79011706,CDM,278,RC,,,both,,,624,461.76,,,461.76,Other,150% of Medicare + 9.63% HCRA Surcharge,280.8,45,,280.8,percent of total billed charges,Critical Access Hospital RCC factor,212.16,34,,212.16,percent of total billed charges,Implant Device,212.16,34,,212.16,percent of total billed charges,Implant Device,212.16,34,,212.16,percent of total billed charges,Implant Device,212.16,34,,212.16,percent of total billed charges,Implant Device,212.16,34,,212.16,percent of total billed charges,Implant Device,308.88,,,308.88,Other,110% of Medicare,218.4,35,,218.4,percent of total billed charges,Implant Device,212.16,34,"Charges > $500, x 34%",212.16,percent of total billed charges,Implant Device,218.4,35,,218.4,percent of total billed charges,Implant Device,218.4,35,,218.4,percent of total billed charges,Implant Device,218.4,35,,218.4,percent of total billed charges,Implant Device,218.4,35,,218.4,percent of total billed charges,Implant Device,218.4,35,,218.4,percent of total billed charges,Implant Device,249.6,40,,249.6,percent of total billed charges,Implant Device,218.4,70,,218.4,percent of total billed charges,All Other,212.16,34,,212.16,percent of total billed charges,Implant Device,212.16,34,,212.16,percent of total billed charges,Implant Device,218.4,35,,218.4,percent of total billed charges,Implant Device,218.4,35,,218.4,percent of total billed charges,Implant Device,218.4,35,,218.4,percent of total billed charges,Implant Device,218.4,35,,218.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,461.76,
ZIMMER 00-5750-016-02 FEM COMP SZ F RT,C1776,HCPCS,,79011709,CDM,278,RC,,,both,,,6300,4662.02,,,4662.02,Other,150% of Medicare + 9.63% HCRA Surcharge,2835,45,,2835,percent of total billed charges,Critical Access Hospital RCC factor,2142,34,,2142,percent of total billed charges,Implant Device,2142,34,,2142,percent of total billed charges,Implant Device,2142,34,,2142,percent of total billed charges,Implant Device,2142,34,,2142,percent of total billed charges,Implant Device,2142,34,,2142,percent of total billed charges,Implant Device,3118.5,,,3118.5,Other,110% of Medicare,2205,35,,2205,percent of total billed charges,Implant Device,2142,34,"Charges > $500, x 34%",2142,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2520,40,,2520,percent of total billed charges,Implant Device,2205,70,,2205,percent of total billed charges,All Other,2142,34,,2142,percent of total billed charges,Implant Device,2142,34,,2142,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2142,34,"If Charge > 2,000, then 34 percent",2142,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4662.02,
ZIMMER 00-5972-065-41 PATELLA SZ 41 10MM,C1776,HCPCS,,79011710,CDM,278,RC,,,both,,,1152,852.48,,,852.48,Other,150% of Medicare + 9.63% HCRA Surcharge,518.4,45,,518.4,percent of total billed charges,Critical Access Hospital RCC factor,391.68,34,,391.68,percent of total billed charges,Implant Device,391.68,34,,391.68,percent of total billed charges,Implant Device,391.68,34,,391.68,percent of total billed charges,Implant Device,391.68,34,,391.68,percent of total billed charges,Implant Device,391.68,34,,391.68,percent of total billed charges,Implant Device,570.24,,,570.24,Other,110% of Medicare,403.2,35,,403.2,percent of total billed charges,Implant Device,391.68,34,"Charges > $500, x 34%",391.68,percent of total billed charges,Implant Device,403.2,35,,403.2,percent of total billed charges,Implant Device,403.2,35,,403.2,percent of total billed charges,Implant Device,403.2,35,,403.2,percent of total billed charges,Implant Device,403.2,35,,403.2,percent of total billed charges,Implant Device,403.2,35,,403.2,percent of total billed charges,Implant Device,460.8,40,,460.8,percent of total billed charges,Implant Device,403.2,70,,403.2,percent of total billed charges,All Other,391.68,34,,391.68,percent of total billed charges,Implant Device,391.68,34,,391.68,percent of total billed charges,Implant Device,403.2,35,,403.2,percent of total billed charges,Implant Device,403.2,35,,403.2,percent of total billed charges,Implant Device,403.2,35,,403.2,percent of total billed charges,Implant Device,403.2,35,,403.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,852.48,
ZIMMER 110007545 CANNULATED SCREW 4X30MM,C1713,HCPCS,,79011712,CDM,278,RC,,,both,,,510,377.4,,,377.4,Other,150% of Medicare + 9.63% HCRA Surcharge,229.5,45,,229.5,percent of total billed charges,Critical Access Hospital RCC factor,173.4,34,,173.4,percent of total billed charges,Implant Device,173.4,34,,173.4,percent of total billed charges,Implant Device,173.4,34,,173.4,percent of total billed charges,Implant Device,173.4,34,,173.4,percent of total billed charges,Implant Device,173.4,34,,173.4,percent of total billed charges,Implant Device,252.45,,,252.45,Other,110% of Medicare,178.5,35,,178.5,percent of total billed charges,Implant Device,173.4,34,"Charges > $500, x 34%",173.4,percent of total billed charges,Implant Device,178.5,35,,178.5,percent of total billed charges,Implant Device,178.5,35,,178.5,percent of total billed charges,Implant Device,178.5,35,,178.5,percent of total billed charges,Implant Device,178.5,35,,178.5,percent of total billed charges,Implant Device,178.5,35,,178.5,percent of total billed charges,Implant Device,204,40,,204,percent of total billed charges,Implant Device,178.5,70,,178.5,percent of total billed charges,All Other,173.4,34,,173.4,percent of total billed charges,Implant Device,173.4,34,,173.4,percent of total billed charges,Implant Device,178.5,35,,178.5,percent of total billed charges,Implant Device,178.5,35,,178.5,percent of total billed charges,Implant Device,178.5,35,,178.5,percent of total billed charges,Implant Device,178.5,35,,178.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,377.4,
ARTHREX AR-8643-28 HEADLESS SCRW 4.3X28,C1713,HCPCS,,79011714,CDM,278,RC,,,both,,,1608,1189.92,,,1189.92,Other,150% of Medicare + 9.63% HCRA Surcharge,723.6,45,,723.6,percent of total billed charges,Critical Access Hospital RCC factor,546.72,34,,546.72,percent of total billed charges,Implant Device,546.72,34,,546.72,percent of total billed charges,Implant Device,546.72,34,,546.72,percent of total billed charges,Implant Device,546.72,34,,546.72,percent of total billed charges,Implant Device,546.72,34,,546.72,percent of total billed charges,Implant Device,795.96,,,795.96,Other,110% of Medicare,562.8,35,,562.8,percent of total billed charges,Implant Device,546.72,34,"Charges > $500, x 34%",546.72,percent of total billed charges,Implant Device,562.8,35,,562.8,percent of total billed charges,Implant Device,562.8,35,,562.8,percent of total billed charges,Implant Device,562.8,35,,562.8,percent of total billed charges,Implant Device,562.8,35,,562.8,percent of total billed charges,Implant Device,562.8,35,,562.8,percent of total billed charges,Implant Device,643.2,40,,643.2,percent of total billed charges,Implant Device,562.8,70,,562.8,percent of total billed charges,All Other,546.72,34,,546.72,percent of total billed charges,Implant Device,546.72,34,,546.72,percent of total billed charges,Implant Device,562.8,35,,562.8,percent of total billed charges,Implant Device,562.8,35,,562.8,percent of total billed charges,Implant Device,562.8,35,,562.8,percent of total billed charges,Implant Device,562.8,35,,562.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1189.92,
"WRIGHT 52020212 PLT, STRAIGHT PINCH 6H",C1713,HCPCS,,79011715,CDM,278,RC,,,both,,,6888,5097.14,,,5097.14,Other,150% of Medicare + 9.63% HCRA Surcharge,3099.6,45,,3099.6,percent of total billed charges,Critical Access Hospital RCC factor,2341.92,34,,2341.92,percent of total billed charges,Implant Device,2341.92,34,,2341.92,percent of total billed charges,Implant Device,2341.92,34,,2341.92,percent of total billed charges,Implant Device,2341.92,34,,2341.92,percent of total billed charges,Implant Device,2341.92,34,,2341.92,percent of total billed charges,Implant Device,3409.56,,,3409.56,Other,110% of Medicare,2410.8,35,,2410.8,percent of total billed charges,Implant Device,2341.92,34,"Charges > $500, x 34%",2341.92,percent of total billed charges,Implant Device,2410.8,35,,2410.8,percent of total billed charges,Implant Device,2410.8,35,,2410.8,percent of total billed charges,Implant Device,2410.8,35,,2410.8,percent of total billed charges,Implant Device,2410.8,35,,2410.8,percent of total billed charges,Implant Device,2410.8,35,,2410.8,percent of total billed charges,Implant Device,2755.2,40,,2755.2,percent of total billed charges,Implant Device,2410.8,70,,2410.8,percent of total billed charges,All Other,2341.92,34,,2341.92,percent of total billed charges,Implant Device,2341.92,34,,2341.92,percent of total billed charges,Implant Device,2410.8,35,,2410.8,percent of total billed charges,Implant Device,2410.8,35,,2410.8,percent of total billed charges,Implant Device,2410.8,35,,2410.8,percent of total billed charges,Implant Device,2410.8,35,,2410.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2341.92,34,"If Charge > 2,000, then 34 percent",2341.92,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5097.14,
WRIGHT 5201020008 LOCKING SCREW 2.0X8MM,C1713,HCPCS,,79011716,CDM,278,RC,,,both,,,1617,1196.58,,,1196.58,Other,150% of Medicare + 9.63% HCRA Surcharge,727.65,45,,727.65,percent of total billed charges,Critical Access Hospital RCC factor,549.78,34,,549.78,percent of total billed charges,Implant Device,549.78,34,,549.78,percent of total billed charges,Implant Device,549.78,34,,549.78,percent of total billed charges,Implant Device,549.78,34,,549.78,percent of total billed charges,Implant Device,549.78,34,,549.78,percent of total billed charges,Implant Device,800.42,,,800.42,Other,110% of Medicare,565.95,35,,565.95,percent of total billed charges,Implant Device,549.78,34,"Charges > $500, x 34%",549.78,percent of total billed charges,Implant Device,565.95,35,,565.95,percent of total billed charges,Implant Device,565.95,35,,565.95,percent of total billed charges,Implant Device,565.95,35,,565.95,percent of total billed charges,Implant Device,565.95,35,,565.95,percent of total billed charges,Implant Device,565.95,35,,565.95,percent of total billed charges,Implant Device,646.8,40,,646.8,percent of total billed charges,Implant Device,565.95,70,,565.95,percent of total billed charges,All Other,549.78,34,,549.78,percent of total billed charges,Implant Device,549.78,34,,549.78,percent of total billed charges,Implant Device,565.95,35,,565.95,percent of total billed charges,Implant Device,565.95,35,,565.95,percent of total billed charges,Implant Device,565.95,35,,565.95,percent of total billed charges,Implant Device,565.95,35,,565.95,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1196.58,
WRIGHT 5201020010 LOCKING SCREW 2.0X10MM,C1713,HCPCS,,79011717,CDM,278,RC,,,both,,,1617,1196.58,,,1196.58,Other,150% of Medicare + 9.63% HCRA Surcharge,727.65,45,,727.65,percent of total billed charges,Critical Access Hospital RCC factor,549.78,34,,549.78,percent of total billed charges,Implant Device,549.78,34,,549.78,percent of total billed charges,Implant Device,549.78,34,,549.78,percent of total billed charges,Implant Device,549.78,34,,549.78,percent of total billed charges,Implant Device,549.78,34,,549.78,percent of total billed charges,Implant Device,800.42,,,800.42,Other,110% of Medicare,565.95,35,,565.95,percent of total billed charges,Implant Device,549.78,34,"Charges > $500, x 34%",549.78,percent of total billed charges,Implant Device,565.95,35,,565.95,percent of total billed charges,Implant Device,565.95,35,,565.95,percent of total billed charges,Implant Device,565.95,35,,565.95,percent of total billed charges,Implant Device,565.95,35,,565.95,percent of total billed charges,Implant Device,565.95,35,,565.95,percent of total billed charges,Implant Device,646.8,40,,646.8,percent of total billed charges,Implant Device,565.95,70,,565.95,percent of total billed charges,All Other,549.78,34,,549.78,percent of total billed charges,Implant Device,549.78,34,,549.78,percent of total billed charges,Implant Device,565.95,35,,565.95,percent of total billed charges,Implant Device,565.95,35,,565.95,percent of total billed charges,Implant Device,565.95,35,,565.95,percent of total billed charges,Implant Device,565.95,35,,565.95,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1196.58,
WRIGHT 5201120012 NON LOCK SCREW 2X12MM,C1713,HCPCS,,79011718,CDM,278,RC,,,both,,,684,506.16,,,506.16,Other,150% of Medicare + 9.63% HCRA Surcharge,307.8,45,,307.8,percent of total billed charges,Critical Access Hospital RCC factor,232.56,34,,232.56,percent of total billed charges,Implant Device,232.56,34,,232.56,percent of total billed charges,Implant Device,232.56,34,,232.56,percent of total billed charges,Implant Device,232.56,34,,232.56,percent of total billed charges,Implant Device,232.56,34,,232.56,percent of total billed charges,Implant Device,338.58,,,338.58,Other,110% of Medicare,239.4,35,,239.4,percent of total billed charges,Implant Device,232.56,34,"Charges > $500, x 34%",232.56,percent of total billed charges,Implant Device,239.4,35,,239.4,percent of total billed charges,Implant Device,239.4,35,,239.4,percent of total billed charges,Implant Device,239.4,35,,239.4,percent of total billed charges,Implant Device,239.4,35,,239.4,percent of total billed charges,Implant Device,239.4,35,,239.4,percent of total billed charges,Implant Device,273.6,40,,273.6,percent of total billed charges,Implant Device,239.4,70,,239.4,percent of total billed charges,All Other,232.56,34,,232.56,percent of total billed charges,Implant Device,232.56,34,,232.56,percent of total billed charges,Implant Device,239.4,35,,239.4,percent of total billed charges,Implant Device,239.4,35,,239.4,percent of total billed charges,Implant Device,239.4,35,,239.4,percent of total billed charges,Implant Device,239.4,35,,239.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,506.16,
ZIMMER 00-8852-009-32 LINER 32X50 SZ HH,C1776,HCPCS,,79011722,CDM,278,RC,,,both,,,3456,2557.45,,,2557.45,Other,150% of Medicare + 9.63% HCRA Surcharge,1555.2,45,,1555.2,percent of total billed charges,Critical Access Hospital RCC factor,1175.04,34,,1175.04,percent of total billed charges,Implant Device,1175.04,34,,1175.04,percent of total billed charges,Implant Device,1175.04,34,,1175.04,percent of total billed charges,Implant Device,1175.04,34,,1175.04,percent of total billed charges,Implant Device,1175.04,34,,1175.04,percent of total billed charges,Implant Device,1710.72,,,1710.72,Other,110% of Medicare,1209.6,35,,1209.6,percent of total billed charges,Implant Device,1175.04,34,"Charges > $500, x 34%",1175.04,percent of total billed charges,Implant Device,1209.6,35,,1209.6,percent of total billed charges,Implant Device,1209.6,35,,1209.6,percent of total billed charges,Implant Device,1209.6,35,,1209.6,percent of total billed charges,Implant Device,1209.6,35,,1209.6,percent of total billed charges,Implant Device,1209.6,35,,1209.6,percent of total billed charges,Implant Device,1382.4,40,,1382.4,percent of total billed charges,Implant Device,1209.6,70,,1209.6,percent of total billed charges,All Other,1175.04,34,,1175.04,percent of total billed charges,Implant Device,1175.04,34,,1175.04,percent of total billed charges,Implant Device,1209.6,35,,1209.6,percent of total billed charges,Implant Device,1209.6,35,,1209.6,percent of total billed charges,Implant Device,1209.6,35,,1209.6,percent of total billed charges,Implant Device,1209.6,35,,1209.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1175.04,34,"If Charge > 2,000, then 34 percent",1175.04,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2557.45,
ZIMMER 574203010 FEM STEM 12/14 SZ 1,C1776,HCPCS,,79011723,CDM,278,RC,,,both,,,8573,6344.04,,,6344.04,Other,150% of Medicare + 9.63% HCRA Surcharge,3857.85,45,,3857.85,percent of total billed charges,Critical Access Hospital RCC factor,2914.82,34,,2914.82,percent of total billed charges,Implant Device,2914.82,34,,2914.82,percent of total billed charges,Implant Device,2914.82,34,,2914.82,percent of total billed charges,Implant Device,2914.82,34,,2914.82,percent of total billed charges,Implant Device,2914.82,34,,2914.82,percent of total billed charges,Implant Device,4243.64,,,4243.64,Other,110% of Medicare,3000.55,35,,3000.55,percent of total billed charges,Implant Device,2914.82,34,"Charges > $500, x 34%",2914.82,percent of total billed charges,Implant Device,3000.55,35,,3000.55,percent of total billed charges,Implant Device,3000.55,35,,3000.55,percent of total billed charges,Implant Device,3000.55,35,,3000.55,percent of total billed charges,Implant Device,3000.55,35,,3000.55,percent of total billed charges,Implant Device,3000.55,35,,3000.55,percent of total billed charges,Implant Device,3429.2,40,,3429.2,percent of total billed charges,Implant Device,3000.55,70,,3000.55,percent of total billed charges,All Other,2914.82,34,,2914.82,percent of total billed charges,Implant Device,2914.82,34,,2914.82,percent of total billed charges,Implant Device,3000.55,35,,3000.55,percent of total billed charges,Implant Device,3000.55,35,,3000.55,percent of total billed charges,Implant Device,3000.55,35,,3000.55,percent of total billed charges,Implant Device,3000.55,35,,3000.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2914.82,34,"If Charge > 2,000, then 34 percent",2914.82,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,6344.04,
J&J 1506-11-009 TIBIAL BASE SIZE 9,C1776,HCPCS,,79011724,CDM,278,RC,,,both,,,6300,4662.02,,,4662.02,Other,150% of Medicare + 9.63% HCRA Surcharge,2835,45,,2835,percent of total billed charges,Critical Access Hospital RCC factor,2142,34,,2142,percent of total billed charges,Implant Device,2142,34,,2142,percent of total billed charges,Implant Device,2142,34,,2142,percent of total billed charges,Implant Device,2142,34,,2142,percent of total billed charges,Implant Device,2142,34,,2142,percent of total billed charges,Implant Device,3118.5,,,3118.5,Other,110% of Medicare,2205,35,,2205,percent of total billed charges,Implant Device,2142,34,"Charges > $500, x 34%",2142,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2520,40,,2520,percent of total billed charges,Implant Device,2205,70,,2205,percent of total billed charges,All Other,2142,34,,2142,percent of total billed charges,Implant Device,2142,34,,2142,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2142,34,"If Charge > 2,000, then 34 percent",2142,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4662.02,
J&J 1504-11-208 FEMORAL COMPONENT SIZE 8,C1776,HCPCS,,79011725,CDM,278,RC,,,both,,,6000,4440.02,,,4440.02,Other,150% of Medicare + 9.63% HCRA Surcharge,2700,45,,2700,percent of total billed charges,Critical Access Hospital RCC factor,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2970,,,2970,Other,110% of Medicare,2100,35,,2100,percent of total billed charges,Implant Device,2040,34,"Charges > $500, x 34%",2040,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2400,40,,2400,percent of total billed charges,Implant Device,2100,70,,2100,percent of total billed charges,All Other,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2040,34,"If Charge > 2,000, then 34 percent",2040,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4440.02,
J&J 1518-20-038 PATELLA MEDIAL 38MM,C1776,HCPCS,,79011726,CDM,278,RC,,,both,,,2100,1554.01,,,1554.01,Other,150% of Medicare + 9.63% HCRA Surcharge,945,45,,945,percent of total billed charges,Critical Access Hospital RCC factor,714,34,,714,percent of total billed charges,Implant Device,714,34,,714,percent of total billed charges,Implant Device,714,34,,714,percent of total billed charges,Implant Device,714,34,,714,percent of total billed charges,Implant Device,714,34,,714,percent of total billed charges,Implant Device,1039.5,,,1039.5,Other,110% of Medicare,735,35,,735,percent of total billed charges,Implant Device,714,34,"Charges > $500, x 34%",714,percent of total billed charges,Implant Device,735,35,,735,percent of total billed charges,Implant Device,735,35,,735,percent of total billed charges,Implant Device,735,35,,735,percent of total billed charges,Implant Device,735,35,,735,percent of total billed charges,Implant Device,735,35,,735,percent of total billed charges,Implant Device,840,40,,840,percent of total billed charges,Implant Device,735,70,,735,percent of total billed charges,All Other,714,34,,714,percent of total billed charges,Implant Device,714,34,,714,percent of total billed charges,Implant Device,735,35,,735,percent of total billed charges,Implant Device,735,35,,735,percent of total billed charges,Implant Device,735,35,,735,percent of total billed charges,Implant Device,735,35,,735,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,714,34,"If Charge > 2,000, then 34 percent",714,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1554.01,
J&J 1516-50-807 TIBIAL INSERT 7MM SIZE 8,C1776,HCPCS,,79011727,CDM,278,RC,,,both,,,4200,3108.01,,,3108.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1890,45,,1890,percent of total billed charges,Critical Access Hospital RCC factor,1428,34,,1428,percent of total billed charges,Implant Device,1428,34,,1428,percent of total billed charges,Implant Device,1428,34,,1428,percent of total billed charges,Implant Device,1428,34,,1428,percent of total billed charges,Implant Device,1428,34,,1428,percent of total billed charges,Implant Device,2079,,,2079,Other,110% of Medicare,1470,35,,1470,percent of total billed charges,Implant Device,1428,34,"Charges > $500, x 34%",1428,percent of total billed charges,Implant Device,1470,35,,1470,percent of total billed charges,Implant Device,1470,35,,1470,percent of total billed charges,Implant Device,1470,35,,1470,percent of total billed charges,Implant Device,1470,35,,1470,percent of total billed charges,Implant Device,1470,35,,1470,percent of total billed charges,Implant Device,1680,40,,1680,percent of total billed charges,Implant Device,1470,70,,1470,percent of total billed charges,All Other,1428,34,,1428,percent of total billed charges,Implant Device,1428,34,,1428,percent of total billed charges,Implant Device,1470,35,,1470,percent of total billed charges,Implant Device,1470,35,,1470,percent of total billed charges,Implant Device,1470,35,,1470,percent of total billed charges,Implant Device,1470,35,,1470,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1428,34,"If Charge > 2,000, then 34 percent",1428,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3108.01,
J&J 1024-53-408 TIBIAL INSERT 8MM SIZE 4,C1776,HCPCS,,79011728,CDM,278,RC,,,both,,,2850,2109.01,,,2109.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1282.5,45,,1282.5,percent of total billed charges,Critical Access Hospital RCC factor,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,1410.75,,,1410.75,Other,110% of Medicare,997.5,35,,997.5,percent of total billed charges,Implant Device,969,34,"Charges > $500, x 34%",969,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,1140,40,,1140,percent of total billed charges,Implant Device,997.5,70,,997.5,percent of total billed charges,All Other,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,969,34,"If Charge > 2,000, then 34 percent",969,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2109.01,
J&J 1024-51-400 TIBIAL TRAY SIZE 4,C1776,HCPCS,,79011729,CDM,278,RC,,,both,,,3600,2664.01,,,2664.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1620,45,,1620,percent of total billed charges,Critical Access Hospital RCC factor,1224,34,,1224,percent of total billed charges,Implant Device,1224,34,,1224,percent of total billed charges,Implant Device,1224,34,,1224,percent of total billed charges,Implant Device,1224,34,,1224,percent of total billed charges,Implant Device,1224,34,,1224,percent of total billed charges,Implant Device,1782,,,1782,Other,110% of Medicare,1260,35,,1260,percent of total billed charges,Implant Device,1224,34,"Charges > $500, x 34%",1224,percent of total billed charges,Implant Device,1260,35,,1260,percent of total billed charges,Implant Device,1260,35,,1260,percent of total billed charges,Implant Device,1260,35,,1260,percent of total billed charges,Implant Device,1260,35,,1260,percent of total billed charges,Implant Device,1260,35,,1260,percent of total billed charges,Implant Device,1440,40,,1440,percent of total billed charges,Implant Device,1260,70,,1260,percent of total billed charges,All Other,1224,34,,1224,percent of total billed charges,Implant Device,1224,34,,1224,percent of total billed charges,Implant Device,1260,35,,1260,percent of total billed charges,Implant Device,1260,35,,1260,percent of total billed charges,Implant Device,1260,35,,1260,percent of total billed charges,Implant Device,1260,35,,1260,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1224,34,"If Charge > 2,000, then 34 percent",1224,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2664.01,
J&J 1024-07-500 FEMORAL COMPONENTS SZ 5,C1776,HCPCS,,79011730,CDM,278,RC,,,both,,,4200,3108.01,,,3108.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1890,45,,1890,percent of total billed charges,Critical Access Hospital RCC factor,1428,34,,1428,percent of total billed charges,Implant Device,1428,34,,1428,percent of total billed charges,Implant Device,1428,34,,1428,percent of total billed charges,Implant Device,1428,34,,1428,percent of total billed charges,Implant Device,1428,34,,1428,percent of total billed charges,Implant Device,2079,,,2079,Other,110% of Medicare,1470,35,,1470,percent of total billed charges,Implant Device,1428,34,"Charges > $500, x 34%",1428,percent of total billed charges,Implant Device,1470,35,,1470,percent of total billed charges,Implant Device,1470,35,,1470,percent of total billed charges,Implant Device,1470,35,,1470,percent of total billed charges,Implant Device,1470,35,,1470,percent of total billed charges,Implant Device,1470,35,,1470,percent of total billed charges,Implant Device,1680,40,,1680,percent of total billed charges,Implant Device,1470,70,,1470,percent of total billed charges,All Other,1428,34,,1428,percent of total billed charges,Implant Device,1428,34,,1428,percent of total billed charges,Implant Device,1470,35,,1470,percent of total billed charges,Implant Device,1470,35,,1470,percent of total billed charges,Implant Device,1470,35,,1470,percent of total billed charges,Implant Device,1470,35,,1470,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1428,34,"If Charge > 2,000, then 34 percent",1428,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3108.01,
STRYKER 657711 BONE SCREW 2.0X11MM,C1713,HCPCS,,79011731,CDM,278,RC,,,both,,,395,292.3,,,292.3,Other,150% of Medicare + 9.63% HCRA Surcharge,177.75,45,,177.75,percent of total billed charges,Critical Access Hospital RCC factor,134.3,34,,134.3,percent of total billed charges,Implant Device,134.3,34,,134.3,percent of total billed charges,Implant Device,134.3,34,,134.3,percent of total billed charges,Implant Device,134.3,34,,134.3,percent of total billed charges,Implant Device,134.3,34,,134.3,percent of total billed charges,Implant Device,195.53,,,195.53,Other,110% of Medicare,138.25,35,,138.25,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,138.25,35,,138.25,percent of total billed charges,Implant Device,138.25,35,,138.25,percent of total billed charges,Implant Device,138.25,35,,138.25,percent of total billed charges,Implant Device,138.25,35,,138.25,percent of total billed charges,Implant Device,138.25,35,,138.25,percent of total billed charges,Implant Device,158,40,,158,percent of total billed charges,Implant Device,138.25,70,,138.25,percent of total billed charges,All Other,134.3,34,,134.3,percent of total billed charges,Implant Device,134.3,34,,134.3,percent of total billed charges,Implant Device,138.25,35,,138.25,percent of total billed charges,Implant Device,138.25,35,,138.25,percent of total billed charges,Implant Device,138.25,35,,138.25,percent of total billed charges,Implant Device,138.25,35,,138.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,292.3,
STRYKER 627638 DIS LAT FEMUR PLT 8 HOLE,C1713,HCPCS,,79011733,CDM,278,RC,,,both,,,7501,5550.76,,,5550.76,Other,150% of Medicare + 9.63% HCRA Surcharge,3375.45,45,,3375.45,percent of total billed charges,Critical Access Hospital RCC factor,2550.34,34,,2550.34,percent of total billed charges,Implant Device,2550.34,34,,2550.34,percent of total billed charges,Implant Device,2550.34,34,,2550.34,percent of total billed charges,Implant Device,2550.34,34,,2550.34,percent of total billed charges,Implant Device,2550.34,34,,2550.34,percent of total billed charges,Implant Device,3713,,,3713,Other,110% of Medicare,2625.35,35,,2625.35,percent of total billed charges,Implant Device,2550.34,34,"Charges > $500, x 34%",2550.34,percent of total billed charges,Implant Device,2625.35,35,,2625.35,percent of total billed charges,Implant Device,2625.35,35,,2625.35,percent of total billed charges,Implant Device,2625.35,35,,2625.35,percent of total billed charges,Implant Device,2625.35,35,,2625.35,percent of total billed charges,Implant Device,2625.35,35,,2625.35,percent of total billed charges,Implant Device,3000.4,40,,3000.4,percent of total billed charges,Implant Device,2625.35,70,,2625.35,percent of total billed charges,All Other,2550.34,34,,2550.34,percent of total billed charges,Implant Device,2550.34,34,,2550.34,percent of total billed charges,Implant Device,2625.35,35,,2625.35,percent of total billed charges,Implant Device,2625.35,35,,2625.35,percent of total billed charges,Implant Device,2625.35,35,,2625.35,percent of total billed charges,Implant Device,2625.35,35,,2625.35,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2550.34,34,"If Charge > 2,000, then 34 percent",2550.34,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5550.76,
STRYKER 661150 LOCKING SCREW 5.0X50MM,C1713,HCPCS,,79011734,CDM,278,RC,,,both,,,616,455.84,,,455.84,Other,150% of Medicare + 9.63% HCRA Surcharge,277.2,45,,277.2,percent of total billed charges,Critical Access Hospital RCC factor,209.44,34,,209.44,percent of total billed charges,Implant Device,209.44,34,,209.44,percent of total billed charges,Implant Device,209.44,34,,209.44,percent of total billed charges,Implant Device,209.44,34,,209.44,percent of total billed charges,Implant Device,209.44,34,,209.44,percent of total billed charges,Implant Device,304.92,,,304.92,Other,110% of Medicare,215.6,35,,215.6,percent of total billed charges,Implant Device,209.44,34,"Charges > $500, x 34%",209.44,percent of total billed charges,Implant Device,215.6,35,,215.6,percent of total billed charges,Implant Device,215.6,35,,215.6,percent of total billed charges,Implant Device,215.6,35,,215.6,percent of total billed charges,Implant Device,215.6,35,,215.6,percent of total billed charges,Implant Device,215.6,35,,215.6,percent of total billed charges,Implant Device,246.4,40,,246.4,percent of total billed charges,Implant Device,215.6,70,,215.6,percent of total billed charges,All Other,209.44,34,,209.44,percent of total billed charges,Implant Device,209.44,34,,209.44,percent of total billed charges,Implant Device,215.6,35,,215.6,percent of total billed charges,Implant Device,215.6,35,,215.6,percent of total billed charges,Implant Device,215.6,35,,215.6,percent of total billed charges,Implant Device,215.6,35,,215.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,455.84,
STRYKER 661750 CORTEX SCREW 4.5X50MM,C1713,HCPCS,,79011735,CDM,278,RC,,,both,,,139,102.86,,,102.86,Other,150% of Medicare + 9.63% HCRA Surcharge,62.55,45,,62.55,percent of total billed charges,Critical Access Hospital RCC factor,47.26,34,,47.26,percent of total billed charges,Implant Device,47.26,34,,47.26,percent of total billed charges,Implant Device,47.26,34,,47.26,percent of total billed charges,Implant Device,47.26,34,,47.26,percent of total billed charges,Implant Device,47.26,34,,47.26,percent of total billed charges,Implant Device,68.81,,,68.81,Other,110% of Medicare,48.65,35,,48.65,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,48.65,35,,48.65,percent of total billed charges,Implant Device,48.65,35,,48.65,percent of total billed charges,Implant Device,48.65,35,,48.65,percent of total billed charges,Implant Device,48.65,35,,48.65,percent of total billed charges,Implant Device,48.65,35,,48.65,percent of total billed charges,Implant Device,55.6,40,,55.6,percent of total billed charges,Implant Device,48.65,70,,48.65,percent of total billed charges,All Other,47.26,34,,47.26,percent of total billed charges,Implant Device,47.26,34,,47.26,percent of total billed charges,Implant Device,48.65,35,,48.65,percent of total billed charges,Implant Device,48.65,35,,48.65,percent of total billed charges,Implant Device,48.65,35,,48.65,percent of total billed charges,Implant Device,48.65,35,,48.65,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,102.86,
ARTHREX AR-1360TR-BC MPFL IMPLANT SYSTEM,C1713,HCPCS,,79011738,CDM,278,RC,,,both,,,5985,4428.91,,,4428.91,Other,150% of Medicare + 9.63% HCRA Surcharge,2693.25,45,,2693.25,percent of total billed charges,Critical Access Hospital RCC factor,2034.9,34,,2034.9,percent of total billed charges,Implant Device,2034.9,34,,2034.9,percent of total billed charges,Implant Device,2034.9,34,,2034.9,percent of total billed charges,Implant Device,2034.9,34,,2034.9,percent of total billed charges,Implant Device,2034.9,34,,2034.9,percent of total billed charges,Implant Device,2962.58,,,2962.58,Other,110% of Medicare,2094.75,35,,2094.75,percent of total billed charges,Implant Device,2034.9,34,"Charges > $500, x 34%",2034.9,percent of total billed charges,Implant Device,2094.75,35,,2094.75,percent of total billed charges,Implant Device,2094.75,35,,2094.75,percent of total billed charges,Implant Device,2094.75,35,,2094.75,percent of total billed charges,Implant Device,2094.75,35,,2094.75,percent of total billed charges,Implant Device,2094.75,35,,2094.75,percent of total billed charges,Implant Device,2394,40,,2394,percent of total billed charges,Implant Device,2094.75,70,,2094.75,percent of total billed charges,All Other,2034.9,34,,2034.9,percent of total billed charges,Implant Device,2034.9,34,,2034.9,percent of total billed charges,Implant Device,2094.75,35,,2094.75,percent of total billed charges,Implant Device,2094.75,35,,2094.75,percent of total billed charges,Implant Device,2094.75,35,,2094.75,percent of total billed charges,Implant Device,2094.75,35,,2094.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2034.9,34,"If Charge > 2,000, then 34 percent",2034.9,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4428.91,
STRYKER 626832 LAG SCREW 4.1X132MM,C1713,HCPCS,,79011739,CDM,278,RC,,,both,,,927,685.98,,,685.98,Other,150% of Medicare + 9.63% HCRA Surcharge,417.15,45,,417.15,percent of total billed charges,Critical Access Hospital RCC factor,315.18,34,,315.18,percent of total billed charges,Implant Device,315.18,34,,315.18,percent of total billed charges,Implant Device,315.18,34,,315.18,percent of total billed charges,Implant Device,315.18,34,,315.18,percent of total billed charges,Implant Device,315.18,34,,315.18,percent of total billed charges,Implant Device,458.87,,,458.87,Other,110% of Medicare,324.45,35,,324.45,percent of total billed charges,Implant Device,315.18,34,"Charges > $500, x 34%",315.18,percent of total billed charges,Implant Device,324.45,35,,324.45,percent of total billed charges,Implant Device,324.45,35,,324.45,percent of total billed charges,Implant Device,324.45,35,,324.45,percent of total billed charges,Implant Device,324.45,35,,324.45,percent of total billed charges,Implant Device,324.45,35,,324.45,percent of total billed charges,Implant Device,370.8,40,,370.8,percent of total billed charges,Implant Device,324.45,70,,324.45,percent of total billed charges,All Other,315.18,34,,315.18,percent of total billed charges,Implant Device,315.18,34,,315.18,percent of total billed charges,Implant Device,324.45,35,,324.45,percent of total billed charges,Implant Device,324.45,35,,324.45,percent of total billed charges,Implant Device,324.45,35,,324.45,percent of total billed charges,Implant Device,324.45,35,,324.45,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,685.98,
STRYKER 626965 PLATE STRAIGHT 5 HOLES,C1713,HCPCS,,79011740,CDM,278,RC,,,both,,,2921,2161.55,,,2161.55,Other,150% of Medicare + 9.63% HCRA Surcharge,1314.45,45,,1314.45,percent of total billed charges,Critical Access Hospital RCC factor,993.14,34,,993.14,percent of total billed charges,Implant Device,993.14,34,,993.14,percent of total billed charges,Implant Device,993.14,34,,993.14,percent of total billed charges,Implant Device,993.14,34,,993.14,percent of total billed charges,Implant Device,993.14,34,,993.14,percent of total billed charges,Implant Device,1445.9,,,1445.9,Other,110% of Medicare,1022.35,35,,1022.35,percent of total billed charges,Implant Device,993.14,34,"Charges > $500, x 34%",993.14,percent of total billed charges,Implant Device,1022.35,35,,1022.35,percent of total billed charges,Implant Device,1022.35,35,,1022.35,percent of total billed charges,Implant Device,1022.35,35,,1022.35,percent of total billed charges,Implant Device,1022.35,35,,1022.35,percent of total billed charges,Implant Device,1022.35,35,,1022.35,percent of total billed charges,Implant Device,1168.4,40,,1168.4,percent of total billed charges,Implant Device,1022.35,70,,1022.35,percent of total billed charges,All Other,993.14,34,,993.14,percent of total billed charges,Implant Device,993.14,34,,993.14,percent of total billed charges,Implant Device,1022.35,35,,1022.35,percent of total billed charges,Implant Device,1022.35,35,,1022.35,percent of total billed charges,Implant Device,1022.35,35,,1022.35,percent of total billed charges,Implant Device,1022.35,35,,1022.35,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,993.14,34,"If Charge > 2,000, then 34 percent",993.14,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2161.55,
STRYKER 658038 COMP SCRW HEADLESS 4X38MM,C1713,HCPCS,,79011741,CDM,278,RC,,,both,,,1242,919.08,,,919.08,Other,150% of Medicare + 9.63% HCRA Surcharge,558.9,45,,558.9,percent of total billed charges,Critical Access Hospital RCC factor,422.28,34,,422.28,percent of total billed charges,Implant Device,422.28,34,,422.28,percent of total billed charges,Implant Device,422.28,34,,422.28,percent of total billed charges,Implant Device,422.28,34,,422.28,percent of total billed charges,Implant Device,422.28,34,,422.28,percent of total billed charges,Implant Device,614.79,,,614.79,Other,110% of Medicare,434.7,35,,434.7,percent of total billed charges,Implant Device,422.28,34,"Charges > $500, x 34%",422.28,percent of total billed charges,Implant Device,434.7,35,,434.7,percent of total billed charges,Implant Device,434.7,35,,434.7,percent of total billed charges,Implant Device,434.7,35,,434.7,percent of total billed charges,Implant Device,434.7,35,,434.7,percent of total billed charges,Implant Device,434.7,35,,434.7,percent of total billed charges,Implant Device,496.8,40,,496.8,percent of total billed charges,Implant Device,434.7,70,,434.7,percent of total billed charges,All Other,422.28,34,,422.28,percent of total billed charges,Implant Device,422.28,34,,422.28,percent of total billed charges,Implant Device,434.7,35,,434.7,percent of total billed charges,Implant Device,434.7,35,,434.7,percent of total billed charges,Implant Device,434.7,35,,434.7,percent of total billed charges,Implant Device,434.7,35,,434.7,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,919.08,
STRYKER 658575 COMP SCRW HEADLESS 7X75MM,C1713,HCPCS,,79011742,CDM,278,RC,,,both,,,2079,1538.47,,,1538.47,Other,150% of Medicare + 9.63% HCRA Surcharge,935.55,45,,935.55,percent of total billed charges,Critical Access Hospital RCC factor,706.86,34,,706.86,percent of total billed charges,Implant Device,706.86,34,,706.86,percent of total billed charges,Implant Device,706.86,34,,706.86,percent of total billed charges,Implant Device,706.86,34,,706.86,percent of total billed charges,Implant Device,706.86,34,,706.86,percent of total billed charges,Implant Device,1029.11,,,1029.11,Other,110% of Medicare,727.65,35,,727.65,percent of total billed charges,Implant Device,706.86,34,"Charges > $500, x 34%",706.86,percent of total billed charges,Implant Device,727.65,35,,727.65,percent of total billed charges,Implant Device,727.65,35,,727.65,percent of total billed charges,Implant Device,727.65,35,,727.65,percent of total billed charges,Implant Device,727.65,35,,727.65,percent of total billed charges,Implant Device,727.65,35,,727.65,percent of total billed charges,Implant Device,831.6,40,,831.6,percent of total billed charges,Implant Device,727.65,70,,727.65,percent of total billed charges,All Other,706.86,34,,706.86,percent of total billed charges,Implant Device,706.86,34,,706.86,percent of total billed charges,Implant Device,727.65,35,,727.65,percent of total billed charges,Implant Device,727.65,35,,727.65,percent of total billed charges,Implant Device,727.65,35,,727.65,percent of total billed charges,Implant Device,727.65,35,,727.65,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,706.86,34,"If Charge > 2,000, then 34 percent",706.86,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1538.47,
STRYKER 658595 COMP SCRW HEADLESS 7X95MM,C1713,HCPCS,,79011743,CDM,278,RC,,,both,,,2079,1538.47,,,1538.47,Other,150% of Medicare + 9.63% HCRA Surcharge,935.55,45,,935.55,percent of total billed charges,Critical Access Hospital RCC factor,706.86,34,,706.86,percent of total billed charges,Implant Device,706.86,34,,706.86,percent of total billed charges,Implant Device,706.86,34,,706.86,percent of total billed charges,Implant Device,706.86,34,,706.86,percent of total billed charges,Implant Device,706.86,34,,706.86,percent of total billed charges,Implant Device,1029.11,,,1029.11,Other,110% of Medicare,727.65,35,,727.65,percent of total billed charges,Implant Device,706.86,34,"Charges > $500, x 34%",706.86,percent of total billed charges,Implant Device,727.65,35,,727.65,percent of total billed charges,Implant Device,727.65,35,,727.65,percent of total billed charges,Implant Device,727.65,35,,727.65,percent of total billed charges,Implant Device,727.65,35,,727.65,percent of total billed charges,Implant Device,727.65,35,,727.65,percent of total billed charges,Implant Device,831.6,40,,831.6,percent of total billed charges,Implant Device,727.65,70,,727.65,percent of total billed charges,All Other,706.86,34,,706.86,percent of total billed charges,Implant Device,706.86,34,,706.86,percent of total billed charges,Implant Device,727.65,35,,727.65,percent of total billed charges,Implant Device,727.65,35,,727.65,percent of total billed charges,Implant Device,727.65,35,,727.65,percent of total billed charges,Implant Device,727.65,35,,727.65,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,706.86,34,"If Charge > 2,000, then 34 percent",706.86,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1538.47,
IN2BONES P70 ST204 PLATE 4 HOLE LEFT,C1713,HCPCS,,79011746,CDM,278,RC,,,both,,,6000,4440.02,,,4440.02,Other,150% of Medicare + 9.63% HCRA Surcharge,2700,45,,2700,percent of total billed charges,Critical Access Hospital RCC factor,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2970,,,2970,Other,110% of Medicare,2100,35,,2100,percent of total billed charges,Implant Device,2040,34,"Charges > $500, x 34%",2040,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2400,40,,2400,percent of total billed charges,Implant Device,2100,70,,2100,percent of total billed charges,All Other,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2040,34,"If Charge > 2,000, then 34 percent",2040,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4440.02,
ZIMMER 110007555 CANNULATED SCREW 4X40MM,C1713,HCPCS,,79011747,CDM,278,RC,,,both,,,540,399.6,,,399.6,Other,150% of Medicare + 9.63% HCRA Surcharge,243,45,,243,percent of total billed charges,Critical Access Hospital RCC factor,183.6,34,,183.6,percent of total billed charges,Implant Device,183.6,34,,183.6,percent of total billed charges,Implant Device,183.6,34,,183.6,percent of total billed charges,Implant Device,183.6,34,,183.6,percent of total billed charges,Implant Device,183.6,34,,183.6,percent of total billed charges,Implant Device,267.3,,,267.3,Other,110% of Medicare,189,35,,189,percent of total billed charges,Implant Device,183.6,34,"Charges > $500, x 34%",183.6,percent of total billed charges,Implant Device,189,35,,189,percent of total billed charges,Implant Device,189,35,,189,percent of total billed charges,Implant Device,189,35,,189,percent of total billed charges,Implant Device,189,35,,189,percent of total billed charges,Implant Device,189,35,,189,percent of total billed charges,Implant Device,216,40,,216,percent of total billed charges,Implant Device,189,70,,189,percent of total billed charges,All Other,183.6,34,,183.6,percent of total billed charges,Implant Device,183.6,34,,183.6,percent of total billed charges,Implant Device,189,35,,189,percent of total billed charges,Implant Device,189,35,,189,percent of total billed charges,Implant Device,189,35,,189,percent of total billed charges,Implant Device,189,35,,189,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,399.6,
ARTHREX AR-2600SBS-10 SPEEDBRIDGE KIT,C1713,HCPCS,,79011748,CDM,278,RC,,,both,,,6450,4773.02,,,4773.02,Other,150% of Medicare + 9.63% HCRA Surcharge,2902.5,45,,2902.5,percent of total billed charges,Critical Access Hospital RCC factor,2193,34,,2193,percent of total billed charges,Implant Device,2193,34,,2193,percent of total billed charges,Implant Device,2193,34,,2193,percent of total billed charges,Implant Device,2193,34,,2193,percent of total billed charges,Implant Device,2193,34,,2193,percent of total billed charges,Implant Device,3192.75,,,3192.75,Other,110% of Medicare,2257.5,35,,2257.5,percent of total billed charges,Implant Device,2193,34,"Charges > $500, x 34%",2193,percent of total billed charges,Implant Device,2257.5,35,,2257.5,percent of total billed charges,Implant Device,2257.5,35,,2257.5,percent of total billed charges,Implant Device,2257.5,35,,2257.5,percent of total billed charges,Implant Device,2257.5,35,,2257.5,percent of total billed charges,Implant Device,2257.5,35,,2257.5,percent of total billed charges,Implant Device,2580,40,,2580,percent of total billed charges,Implant Device,2257.5,70,,2257.5,percent of total billed charges,All Other,2193,34,,2193,percent of total billed charges,Implant Device,2193,34,,2193,percent of total billed charges,Implant Device,2257.5,35,,2257.5,percent of total billed charges,Implant Device,2257.5,35,,2257.5,percent of total billed charges,Implant Device,2257.5,35,,2257.5,percent of total billed charges,Implant Device,2257.5,35,,2257.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2193,34,"If Charge > 2,000, then 34 percent",2193,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4773.02,
J&J 1504-10-226 FEMORAL COMPONENT SIZE 6,C1776,HCPCS,,79011749,CDM,278,RC,,,both,,,4800,3552.01,,,3552.01,Other,150% of Medicare + 9.63% HCRA Surcharge,2160,45,,2160,percent of total billed charges,Critical Access Hospital RCC factor,1632,34,,1632,percent of total billed charges,Implant Device,1632,34,,1632,percent of total billed charges,Implant Device,1632,34,,1632,percent of total billed charges,Implant Device,1632,34,,1632,percent of total billed charges,Implant Device,1632,34,,1632,percent of total billed charges,Implant Device,2376,,,2376,Other,110% of Medicare,1680,35,,1680,percent of total billed charges,Implant Device,1632,34,"Charges > $500, x 34%",1632,percent of total billed charges,Implant Device,1680,35,,1680,percent of total billed charges,Implant Device,1680,35,,1680,percent of total billed charges,Implant Device,1680,35,,1680,percent of total billed charges,Implant Device,1680,35,,1680,percent of total billed charges,Implant Device,1680,35,,1680,percent of total billed charges,Implant Device,1920,40,,1920,percent of total billed charges,Implant Device,1680,70,,1680,percent of total billed charges,All Other,1632,34,,1632,percent of total billed charges,Implant Device,1632,34,,1632,percent of total billed charges,Implant Device,1680,35,,1680,percent of total billed charges,Implant Device,1680,35,,1680,percent of total billed charges,Implant Device,1680,35,,1680,percent of total billed charges,Implant Device,1680,35,,1680,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1632,34,"If Charge > 2,000, then 34 percent",1632,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3552.01,
J&J 1506-80-005 TIBIAL BASE SIZE 5,C1776,HCPCS,,79011750,CDM,278,RC,,,both,,,3900,2886.01,,,2886.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1755,45,,1755,percent of total billed charges,Critical Access Hospital RCC factor,1326,34,,1326,percent of total billed charges,Implant Device,1326,34,,1326,percent of total billed charges,Implant Device,1326,34,,1326,percent of total billed charges,Implant Device,1326,34,,1326,percent of total billed charges,Implant Device,1326,34,,1326,percent of total billed charges,Implant Device,1930.5,,,1930.5,Other,110% of Medicare,1365,35,,1365,percent of total billed charges,Implant Device,1326,34,"Charges > $500, x 34%",1326,percent of total billed charges,Implant Device,1365,35,,1365,percent of total billed charges,Implant Device,1365,35,,1365,percent of total billed charges,Implant Device,1365,35,,1365,percent of total billed charges,Implant Device,1365,35,,1365,percent of total billed charges,Implant Device,1365,35,,1365,percent of total billed charges,Implant Device,1560,40,,1560,percent of total billed charges,Implant Device,1365,70,,1365,percent of total billed charges,All Other,1326,34,,1326,percent of total billed charges,Implant Device,1326,34,,1326,percent of total billed charges,Implant Device,1365,35,,1365,percent of total billed charges,Implant Device,1365,35,,1365,percent of total billed charges,Implant Device,1365,35,,1365,percent of total billed charges,Implant Device,1365,35,,1365,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1326,34,"If Charge > 2,000, then 34 percent",1326,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2886.01,
J&J 1518-20-035 PATELLA 35MM,C1776,HCPCS,,79011751,CDM,278,RC,,,both,,,2100,1554.01,,,1554.01,Other,150% of Medicare + 9.63% HCRA Surcharge,945,45,,945,percent of total billed charges,Critical Access Hospital RCC factor,714,34,,714,percent of total billed charges,Implant Device,714,34,,714,percent of total billed charges,Implant Device,714,34,,714,percent of total billed charges,Implant Device,714,34,,714,percent of total billed charges,Implant Device,714,34,,714,percent of total billed charges,Implant Device,1039.5,,,1039.5,Other,110% of Medicare,735,35,,735,percent of total billed charges,Implant Device,714,34,"Charges > $500, x 34%",714,percent of total billed charges,Implant Device,735,35,,735,percent of total billed charges,Implant Device,735,35,,735,percent of total billed charges,Implant Device,735,35,,735,percent of total billed charges,Implant Device,735,35,,735,percent of total billed charges,Implant Device,735,35,,735,percent of total billed charges,Implant Device,840,40,,840,percent of total billed charges,Implant Device,735,70,,735,percent of total billed charges,All Other,714,34,,714,percent of total billed charges,Implant Device,714,34,,714,percent of total billed charges,Implant Device,735,35,,735,percent of total billed charges,Implant Device,735,35,,735,percent of total billed charges,Implant Device,735,35,,735,percent of total billed charges,Implant Device,735,35,,735,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,714,34,"If Charge > 2,000, then 34 percent",714,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1554.01,
J&J 1516-50-608 TIBIAL INSERT SIZE 6 8MM,C1776,HCPCS,,79011752,CDM,278,RC,,,both,,,5400,3996.01,,,3996.01,Other,150% of Medicare + 9.63% HCRA Surcharge,2430,45,,2430,percent of total billed charges,Critical Access Hospital RCC factor,1836,34,,1836,percent of total billed charges,Implant Device,1836,34,,1836,percent of total billed charges,Implant Device,1836,34,,1836,percent of total billed charges,Implant Device,1836,34,,1836,percent of total billed charges,Implant Device,1836,34,,1836,percent of total billed charges,Implant Device,2673,,,2673,Other,110% of Medicare,1890,35,,1890,percent of total billed charges,Implant Device,1836,34,"Charges > $500, x 34%",1836,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,2160,40,,2160,percent of total billed charges,Implant Device,1890,70,,1890,percent of total billed charges,All Other,1836,34,,1836,percent of total billed charges,Implant Device,1836,34,,1836,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1836,34,"If Charge > 2,000, then 34 percent",1836,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3996.01,
ZIMMER 574202075 FEM STEM 12/14 TAPER,C1776,HCPCS,,79011753,CDM,278,RC,,,both,,,8573,6344.04,,,6344.04,Other,150% of Medicare + 9.63% HCRA Surcharge,3857.85,45,,3857.85,percent of total billed charges,Critical Access Hospital RCC factor,2914.82,34,,2914.82,percent of total billed charges,Implant Device,2914.82,34,,2914.82,percent of total billed charges,Implant Device,2914.82,34,,2914.82,percent of total billed charges,Implant Device,2914.82,34,,2914.82,percent of total billed charges,Implant Device,2914.82,34,,2914.82,percent of total billed charges,Implant Device,4243.64,,,4243.64,Other,110% of Medicare,3000.55,35,,3000.55,percent of total billed charges,Implant Device,2914.82,34,"Charges > $500, x 34%",2914.82,percent of total billed charges,Implant Device,3000.55,35,,3000.55,percent of total billed charges,Implant Device,3000.55,35,,3000.55,percent of total billed charges,Implant Device,3000.55,35,,3000.55,percent of total billed charges,Implant Device,3000.55,35,,3000.55,percent of total billed charges,Implant Device,3000.55,35,,3000.55,percent of total billed charges,Implant Device,3429.2,40,,3429.2,percent of total billed charges,Implant Device,3000.55,70,,3000.55,percent of total billed charges,All Other,2914.82,34,,2914.82,percent of total billed charges,Implant Device,2914.82,34,,2914.82,percent of total billed charges,Implant Device,3000.55,35,,3000.55,percent of total billed charges,Implant Device,3000.55,35,,3000.55,percent of total billed charges,Implant Device,3000.55,35,,3000.55,percent of total billed charges,Implant Device,3000.55,35,,3000.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2914.82,34,"If Charge > 2,000, then 34 percent",2914.82,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,6344.04,
ZIMMER 574202040 FEM STEM 12/14 TAPER,C1776,HCPCS,,79011754,CDM,278,RC,,,both,,,6912,5114.9,,,5114.9,Other,150% of Medicare + 9.63% HCRA Surcharge,3110.4,45,,3110.4,percent of total billed charges,Critical Access Hospital RCC factor,2350.08,34,,2350.08,percent of total billed charges,Implant Device,2350.08,34,,2350.08,percent of total billed charges,Implant Device,2350.08,34,,2350.08,percent of total billed charges,Implant Device,2350.08,34,,2350.08,percent of total billed charges,Implant Device,2350.08,34,,2350.08,percent of total billed charges,Implant Device,3421.44,,,3421.44,Other,110% of Medicare,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2350.08,34,"Charges > $500, x 34%",2350.08,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2764.8,40,,2764.8,percent of total billed charges,Implant Device,2419.2,70,,2419.2,percent of total billed charges,All Other,2350.08,34,,2350.08,percent of total billed charges,Implant Device,2350.08,34,,2350.08,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2350.08,34,"If Charge > 2,000, then 34 percent",2350.08,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5114.9,
J&J 202.622 CORTICAL SCREW 3.0X22MM,C1713,HCPCS,,79011755,CDM,278,RC,,,both,,,523,387.02,,,387.02,Other,150% of Medicare + 9.63% HCRA Surcharge,235.35,45,,235.35,percent of total billed charges,Critical Access Hospital RCC factor,177.82,34,,177.82,percent of total billed charges,Implant Device,177.82,34,,177.82,percent of total billed charges,Implant Device,177.82,34,,177.82,percent of total billed charges,Implant Device,177.82,34,,177.82,percent of total billed charges,Implant Device,177.82,34,,177.82,percent of total billed charges,Implant Device,258.89,,,258.89,Other,110% of Medicare,183.05,35,,183.05,percent of total billed charges,Implant Device,177.82,34,"Charges > $500, x 34%",177.82,percent of total billed charges,Implant Device,183.05,35,,183.05,percent of total billed charges,Implant Device,183.05,35,,183.05,percent of total billed charges,Implant Device,183.05,35,,183.05,percent of total billed charges,Implant Device,183.05,35,,183.05,percent of total billed charges,Implant Device,183.05,35,,183.05,percent of total billed charges,Implant Device,209.2,40,,209.2,percent of total billed charges,Implant Device,183.05,70,,183.05,percent of total billed charges,All Other,177.82,34,,177.82,percent of total billed charges,Implant Device,177.82,34,,177.82,percent of total billed charges,Implant Device,183.05,35,,183.05,percent of total billed charges,Implant Device,183.05,35,,183.05,percent of total billed charges,Implant Device,183.05,35,,183.05,percent of total billed charges,Implant Device,183.05,35,,183.05,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,387.02,
ZIMMER 650-0660 CERAMIC HEAD 36/-3MM,C1776,HCPCS,,79011756,CDM,278,RC,,,both,,,2880,2131.21,,,2131.21,Other,150% of Medicare + 9.63% HCRA Surcharge,1296,45,,1296,percent of total billed charges,Critical Access Hospital RCC factor,979.2,34,,979.2,percent of total billed charges,Implant Device,979.2,34,,979.2,percent of total billed charges,Implant Device,979.2,34,,979.2,percent of total billed charges,Implant Device,979.2,34,,979.2,percent of total billed charges,Implant Device,979.2,34,,979.2,percent of total billed charges,Implant Device,1425.6,,,1425.6,Other,110% of Medicare,1008,35,,1008,percent of total billed charges,Implant Device,979.2,34,"Charges > $500, x 34%",979.2,percent of total billed charges,Implant Device,1008,35,,1008,percent of total billed charges,Implant Device,1008,35,,1008,percent of total billed charges,Implant Device,1008,35,,1008,percent of total billed charges,Implant Device,1008,35,,1008,percent of total billed charges,Implant Device,1008,35,,1008,percent of total billed charges,Implant Device,1152,40,,1152,percent of total billed charges,Implant Device,1008,70,,1008,percent of total billed charges,All Other,979.2,34,,979.2,percent of total billed charges,Implant Device,979.2,34,,979.2,percent of total billed charges,Implant Device,1008,35,,1008,percent of total billed charges,Implant Device,1008,35,,1008,percent of total billed charges,Implant Device,1008,35,,1008,percent of total billed charges,Implant Device,1008,35,,1008,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,979.2,34,"If Charge > 2,000, then 34 percent",979.2,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2131.21,
ZIMMER 11-300914 DISTAL STEM 14X190MM,C1776,HCPCS,,79011757,CDM,278,RC,,,both,,,10199,7547.29,,,7547.29,Other,150% of Medicare + 9.63% HCRA Surcharge,4589.55,45,,4589.55,percent of total billed charges,Critical Access Hospital RCC factor,3467.66,34,,3467.66,percent of total billed charges,Implant Device,3467.66,34,,3467.66,percent of total billed charges,Implant Device,3467.66,34,,3467.66,percent of total billed charges,Implant Device,3467.66,34,,3467.66,percent of total billed charges,Implant Device,3467.66,34,,3467.66,percent of total billed charges,Implant Device,5048.51,,,5048.51,Other,110% of Medicare,3569.65,35,,3569.65,percent of total billed charges,Implant Device,3467.66,34,"Charges > $500, x 34%",3467.66,percent of total billed charges,Implant Device,3569.65,35,,3569.65,percent of total billed charges,Implant Device,3569.65,35,,3569.65,percent of total billed charges,Implant Device,3569.65,35,,3569.65,percent of total billed charges,Implant Device,3569.65,35,,3569.65,percent of total billed charges,Implant Device,3569.65,35,,3569.65,percent of total billed charges,Implant Device,4079.6,40,,4079.6,percent of total billed charges,Implant Device,3569.65,70,,3569.65,percent of total billed charges,All Other,3467.66,34,,3467.66,percent of total billed charges,Implant Device,3467.66,34,,3467.66,percent of total billed charges,Implant Device,3569.65,35,,3569.65,percent of total billed charges,Implant Device,3569.65,35,,3569.65,percent of total billed charges,Implant Device,3569.65,35,,3569.65,percent of total billed charges,Implant Device,3569.65,35,,3569.65,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3467.66,34,"If Charge > 2,000, then 34 percent",3467.66,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,7547.29,
ZIMMER 163667 MOD HEAD COMP 32X-6MM NECK,C1776,HCPCS,,79011758,CDM,278,RC,,,both,,,1152,852.48,,,852.48,Other,150% of Medicare + 9.63% HCRA Surcharge,518.4,45,,518.4,percent of total billed charges,Critical Access Hospital RCC factor,391.68,34,,391.68,percent of total billed charges,Implant Device,391.68,34,,391.68,percent of total billed charges,Implant Device,391.68,34,,391.68,percent of total billed charges,Implant Device,391.68,34,,391.68,percent of total billed charges,Implant Device,391.68,34,,391.68,percent of total billed charges,Implant Device,570.24,,,570.24,Other,110% of Medicare,403.2,35,,403.2,percent of total billed charges,Implant Device,391.68,34,"Charges > $500, x 34%",391.68,percent of total billed charges,Implant Device,403.2,35,,403.2,percent of total billed charges,Implant Device,403.2,35,,403.2,percent of total billed charges,Implant Device,403.2,35,,403.2,percent of total billed charges,Implant Device,403.2,35,,403.2,percent of total billed charges,Implant Device,403.2,35,,403.2,percent of total billed charges,Implant Device,460.8,40,,460.8,percent of total billed charges,Implant Device,403.2,70,,403.2,percent of total billed charges,All Other,391.68,34,,391.68,percent of total billed charges,Implant Device,391.68,34,,391.68,percent of total billed charges,Implant Device,403.2,35,,403.2,percent of total billed charges,Implant Device,403.2,35,,403.2,percent of total billed charges,Implant Device,403.2,35,,403.2,percent of total billed charges,Implant Device,403.2,35,,403.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,852.48,
ZIMMER 00-8851-009-32 LINER 32MM SIZE HH,C1776,HCPCS,,79011759,CDM,278,RC,,,both,,,3456,2557.45,,,2557.45,Other,150% of Medicare + 9.63% HCRA Surcharge,1555.2,45,,1555.2,percent of total billed charges,Critical Access Hospital RCC factor,1175.04,34,,1175.04,percent of total billed charges,Implant Device,1175.04,34,,1175.04,percent of total billed charges,Implant Device,1175.04,34,,1175.04,percent of total billed charges,Implant Device,1175.04,34,,1175.04,percent of total billed charges,Implant Device,1175.04,34,,1175.04,percent of total billed charges,Implant Device,1710.72,,,1710.72,Other,110% of Medicare,1209.6,35,,1209.6,percent of total billed charges,Implant Device,1175.04,34,"Charges > $500, x 34%",1175.04,percent of total billed charges,Implant Device,1209.6,35,,1209.6,percent of total billed charges,Implant Device,1209.6,35,,1209.6,percent of total billed charges,Implant Device,1209.6,35,,1209.6,percent of total billed charges,Implant Device,1209.6,35,,1209.6,percent of total billed charges,Implant Device,1209.6,35,,1209.6,percent of total billed charges,Implant Device,1382.4,40,,1382.4,percent of total billed charges,Implant Device,1209.6,70,,1209.6,percent of total billed charges,All Other,1175.04,34,,1175.04,percent of total billed charges,Implant Device,1175.04,34,,1175.04,percent of total billed charges,Implant Device,1209.6,35,,1209.6,percent of total billed charges,Implant Device,1209.6,35,,1209.6,percent of total billed charges,Implant Device,1209.6,35,,1209.6,percent of total billed charges,Implant Device,1209.6,35,,1209.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1175.04,34,"If Charge > 2,000, then 34 percent",1175.04,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2557.45,
ARTHREX AR-4570S FIBERSTITCH IMPLANT,C1713,HCPCS,,79011760,CDM,278,RC,,,both,,,1485,1098.9,,,1098.9,Other,150% of Medicare + 9.63% HCRA Surcharge,668.25,45,,668.25,percent of total billed charges,Critical Access Hospital RCC factor,504.9,34,,504.9,percent of total billed charges,Implant Device,504.9,34,,504.9,percent of total billed charges,Implant Device,504.9,34,,504.9,percent of total billed charges,Implant Device,504.9,34,,504.9,percent of total billed charges,Implant Device,504.9,34,,504.9,percent of total billed charges,Implant Device,735.08,,,735.08,Other,110% of Medicare,519.75,35,,519.75,percent of total billed charges,Implant Device,504.9,34,"Charges > $500, x 34%",504.9,percent of total billed charges,Implant Device,519.75,35,,519.75,percent of total billed charges,Implant Device,519.75,35,,519.75,percent of total billed charges,Implant Device,519.75,35,,519.75,percent of total billed charges,Implant Device,519.75,35,,519.75,percent of total billed charges,Implant Device,519.75,35,,519.75,percent of total billed charges,Implant Device,594,40,,594,percent of total billed charges,Implant Device,519.75,70,,519.75,percent of total billed charges,All Other,504.9,34,,504.9,percent of total billed charges,Implant Device,504.9,34,,504.9,percent of total billed charges,Implant Device,519.75,35,,519.75,percent of total billed charges,Implant Device,519.75,35,,519.75,percent of total billed charges,Implant Device,519.75,35,,519.75,percent of total billed charges,Implant Device,519.75,35,,519.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1098.9,
J&J 1516-50-706 TIBIAL INSERT SIZE 7 6MM,C1776,HCPCS,,79011762,CDM,278,RC,,,both,,,4200,3108.01,,,3108.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1890,45,,1890,percent of total billed charges,Critical Access Hospital RCC factor,1428,34,,1428,percent of total billed charges,Implant Device,1428,34,,1428,percent of total billed charges,Implant Device,1428,34,,1428,percent of total billed charges,Implant Device,1428,34,,1428,percent of total billed charges,Implant Device,1428,34,,1428,percent of total billed charges,Implant Device,2079,,,2079,Other,110% of Medicare,1470,35,,1470,percent of total billed charges,Implant Device,1428,34,"Charges > $500, x 34%",1428,percent of total billed charges,Implant Device,1470,35,,1470,percent of total billed charges,Implant Device,1470,35,,1470,percent of total billed charges,Implant Device,1470,35,,1470,percent of total billed charges,Implant Device,1470,35,,1470,percent of total billed charges,Implant Device,1470,35,,1470,percent of total billed charges,Implant Device,1680,40,,1680,percent of total billed charges,Implant Device,1470,70,,1470,percent of total billed charges,All Other,1428,34,,1428,percent of total billed charges,Implant Device,1428,34,,1428,percent of total billed charges,Implant Device,1470,35,,1470,percent of total billed charges,Implant Device,1470,35,,1470,percent of total billed charges,Implant Device,1470,35,,1470,percent of total billed charges,Implant Device,1470,35,,1470,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1428,34,"If Charge > 2,000, then 34 percent",1428,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3108.01,
J&J 1504-11-207 FEMORAL COMP SZ 7 RT,C1776,HCPCS,,79011763,CDM,278,RC,,,both,,,6000,4440.02,,,4440.02,Other,150% of Medicare + 9.63% HCRA Surcharge,2700,45,,2700,percent of total billed charges,Critical Access Hospital RCC factor,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2970,,,2970,Other,110% of Medicare,2100,35,,2100,percent of total billed charges,Implant Device,2040,34,"Charges > $500, x 34%",2040,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2400,40,,2400,percent of total billed charges,Implant Device,2100,70,,2100,percent of total billed charges,All Other,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2040,34,"If Charge > 2,000, then 34 percent",2040,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4440.02,
J&J 1506-11-008 TIBIAL BASE SIZE 8,C1776,HCPCS,,79011764,CDM,278,RC,,,both,,,6300,4662.02,,,4662.02,Other,150% of Medicare + 9.63% HCRA Surcharge,2835,45,,2835,percent of total billed charges,Critical Access Hospital RCC factor,2142,34,,2142,percent of total billed charges,Implant Device,2142,34,,2142,percent of total billed charges,Implant Device,2142,34,,2142,percent of total billed charges,Implant Device,2142,34,,2142,percent of total billed charges,Implant Device,2142,34,,2142,percent of total billed charges,Implant Device,3118.5,,,3118.5,Other,110% of Medicare,2205,35,,2205,percent of total billed charges,Implant Device,2142,34,"Charges > $500, x 34%",2142,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2520,40,,2520,percent of total billed charges,Implant Device,2205,70,,2205,percent of total billed charges,All Other,2142,34,,2142,percent of total billed charges,Implant Device,2142,34,,2142,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2142,34,"If Charge > 2,000, then 34 percent",2142,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4662.02,
J&J 1518-20-041 PATELLA DOME 41MM,C1776,HCPCS,,79011765,CDM,278,RC,,,both,,,2100,1554.01,,,1554.01,Other,150% of Medicare + 9.63% HCRA Surcharge,945,45,,945,percent of total billed charges,Critical Access Hospital RCC factor,714,34,,714,percent of total billed charges,Implant Device,714,34,,714,percent of total billed charges,Implant Device,714,34,,714,percent of total billed charges,Implant Device,714,34,,714,percent of total billed charges,Implant Device,714,34,,714,percent of total billed charges,Implant Device,1039.5,,,1039.5,Other,110% of Medicare,735,35,,735,percent of total billed charges,Implant Device,714,34,"Charges > $500, x 34%",714,percent of total billed charges,Implant Device,735,35,,735,percent of total billed charges,Implant Device,735,35,,735,percent of total billed charges,Implant Device,735,35,,735,percent of total billed charges,Implant Device,735,35,,735,percent of total billed charges,Implant Device,735,35,,735,percent of total billed charges,Implant Device,840,40,,840,percent of total billed charges,Implant Device,735,70,,735,percent of total billed charges,All Other,714,34,,714,percent of total billed charges,Implant Device,714,34,,714,percent of total billed charges,Implant Device,735,35,,735,percent of total billed charges,Implant Device,735,35,,735,percent of total billed charges,Implant Device,735,35,,735,percent of total billed charges,Implant Device,735,35,,735,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,714,34,"If Charge > 2,000, then 34 percent",714,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1554.01,
ARTHREX AR-13227T-BB-TAK MTP THREADED,C1713,HCPCS,,79011766,CDM,278,RC,,,both,,,255,188.7,,,188.7,Other,150% of Medicare + 9.63% HCRA Surcharge,114.75,45,,114.75,percent of total billed charges,Critical Access Hospital RCC factor,86.7,34,,86.7,percent of total billed charges,Implant Device,86.7,34,,86.7,percent of total billed charges,Implant Device,86.7,34,,86.7,percent of total billed charges,Implant Device,86.7,34,,86.7,percent of total billed charges,Implant Device,86.7,34,,86.7,percent of total billed charges,Implant Device,126.23,,,126.23,Other,110% of Medicare,89.25,35,,89.25,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,89.25,35,,89.25,percent of total billed charges,Implant Device,89.25,35,,89.25,percent of total billed charges,Implant Device,89.25,35,,89.25,percent of total billed charges,Implant Device,89.25,35,,89.25,percent of total billed charges,Implant Device,89.25,35,,89.25,percent of total billed charges,Implant Device,102,40,,102,percent of total billed charges,Implant Device,89.25,70,,89.25,percent of total billed charges,All Other,86.7,34,,86.7,percent of total billed charges,Implant Device,86.7,34,,86.7,percent of total billed charges,Implant Device,89.25,35,,89.25,percent of total billed charges,Implant Device,89.25,35,,89.25,percent of total billed charges,Implant Device,89.25,35,,89.25,percent of total billed charges,Implant Device,89.25,35,,89.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,188.7,
ARTHREX AR-9933-16 CORTICAL SCREW 3X16MM,C1713,HCPCS,,79011767,CDM,278,RC,,,both,,,375,277.5,,,277.5,Other,150% of Medicare + 9.63% HCRA Surcharge,168.75,45,,168.75,percent of total billed charges,Critical Access Hospital RCC factor,127.5,34,,127.5,percent of total billed charges,Implant Device,127.5,34,,127.5,percent of total billed charges,Implant Device,127.5,34,,127.5,percent of total billed charges,Implant Device,127.5,34,,127.5,percent of total billed charges,Implant Device,127.5,34,,127.5,percent of total billed charges,Implant Device,185.63,,,185.63,Other,110% of Medicare,131.25,35,,131.25,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,131.25,35,,131.25,percent of total billed charges,Implant Device,131.25,35,,131.25,percent of total billed charges,Implant Device,131.25,35,,131.25,percent of total billed charges,Implant Device,131.25,35,,131.25,percent of total billed charges,Implant Device,131.25,35,,131.25,percent of total billed charges,Implant Device,150,40,,150,percent of total billed charges,Implant Device,131.25,70,,131.25,percent of total billed charges,All Other,127.5,34,,127.5,percent of total billed charges,Implant Device,127.5,34,,127.5,percent of total billed charges,Implant Device,131.25,35,,131.25,percent of total billed charges,Implant Device,131.25,35,,131.25,percent of total billed charges,Implant Device,131.25,35,,131.25,percent of total billed charges,Implant Device,131.25,35,,131.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,277.5,
ARTHREX AR-7324PSLC SWIVERLCK FORKED TIP,C1713,HCPCS,,79011768,CDM,278,RC,,,both,,,1305,965.7,,,965.7,Other,150% of Medicare + 9.63% HCRA Surcharge,587.25,45,,587.25,percent of total billed charges,Critical Access Hospital RCC factor,443.7,34,,443.7,percent of total billed charges,Implant Device,443.7,34,,443.7,percent of total billed charges,Implant Device,443.7,34,,443.7,percent of total billed charges,Implant Device,443.7,34,,443.7,percent of total billed charges,Implant Device,443.7,34,,443.7,percent of total billed charges,Implant Device,645.98,,,645.98,Other,110% of Medicare,456.75,35,,456.75,percent of total billed charges,Implant Device,443.7,34,"Charges > $500, x 34%",443.7,percent of total billed charges,Implant Device,456.75,35,,456.75,percent of total billed charges,Implant Device,456.75,35,,456.75,percent of total billed charges,Implant Device,456.75,35,,456.75,percent of total billed charges,Implant Device,456.75,35,,456.75,percent of total billed charges,Implant Device,456.75,35,,456.75,percent of total billed charges,Implant Device,522,40,,522,percent of total billed charges,Implant Device,456.75,70,,456.75,percent of total billed charges,All Other,443.7,34,,443.7,percent of total billed charges,Implant Device,443.7,34,,443.7,percent of total billed charges,Implant Device,456.75,35,,456.75,percent of total billed charges,Implant Device,456.75,35,,456.75,percent of total billed charges,Implant Device,456.75,35,,456.75,percent of total billed charges,Implant Device,456.75,35,,456.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,965.7,
ARTHREX AR-4570 FIBERSTITCH 12 DEG CURVE,C1713,HCPCS,,79011769,CDM,278,RC,,,both,,,1485,1098.9,,,1098.9,Other,150% of Medicare + 9.63% HCRA Surcharge,668.25,45,,668.25,percent of total billed charges,Critical Access Hospital RCC factor,504.9,34,,504.9,percent of total billed charges,Implant Device,504.9,34,,504.9,percent of total billed charges,Implant Device,504.9,34,,504.9,percent of total billed charges,Implant Device,504.9,34,,504.9,percent of total billed charges,Implant Device,504.9,34,,504.9,percent of total billed charges,Implant Device,735.08,,,735.08,Other,110% of Medicare,519.75,35,,519.75,percent of total billed charges,Implant Device,504.9,34,"Charges > $500, x 34%",504.9,percent of total billed charges,Implant Device,519.75,35,,519.75,percent of total billed charges,Implant Device,519.75,35,,519.75,percent of total billed charges,Implant Device,519.75,35,,519.75,percent of total billed charges,Implant Device,519.75,35,,519.75,percent of total billed charges,Implant Device,519.75,35,,519.75,percent of total billed charges,Implant Device,594,40,,594,percent of total billed charges,Implant Device,519.75,70,,519.75,percent of total billed charges,All Other,504.9,34,,504.9,percent of total billed charges,Implant Device,504.9,34,,504.9,percent of total billed charges,Implant Device,519.75,35,,519.75,percent of total billed charges,Implant Device,519.75,35,,519.75,percent of total billed charges,Implant Device,519.75,35,,519.75,percent of total billed charges,Implant Device,519.75,35,,519.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1098.9,
ARTHREX AR-4570R FIBERSTITCH REV ANGLE,C1713,HCPCS,,79011771,CDM,278,RC,,,both,,,1485,1098.9,,,1098.9,Other,150% of Medicare + 9.63% HCRA Surcharge,668.25,45,,668.25,percent of total billed charges,Critical Access Hospital RCC factor,504.9,34,,504.9,percent of total billed charges,Implant Device,504.9,34,,504.9,percent of total billed charges,Implant Device,504.9,34,,504.9,percent of total billed charges,Implant Device,504.9,34,,504.9,percent of total billed charges,Implant Device,504.9,34,,504.9,percent of total billed charges,Implant Device,735.08,,,735.08,Other,110% of Medicare,519.75,35,,519.75,percent of total billed charges,Implant Device,504.9,34,"Charges > $500, x 34%",504.9,percent of total billed charges,Implant Device,519.75,35,,519.75,percent of total billed charges,Implant Device,519.75,35,,519.75,percent of total billed charges,Implant Device,519.75,35,,519.75,percent of total billed charges,Implant Device,519.75,35,,519.75,percent of total billed charges,Implant Device,519.75,35,,519.75,percent of total billed charges,Implant Device,594,40,,594,percent of total billed charges,Implant Device,519.75,70,,519.75,percent of total billed charges,All Other,504.9,34,,504.9,percent of total billed charges,Implant Device,504.9,34,,504.9,percent of total billed charges,Implant Device,519.75,35,,519.75,percent of total billed charges,Implant Device,519.75,35,,519.75,percent of total billed charges,Implant Device,519.75,35,,519.75,percent of total billed charges,Implant Device,519.75,35,,519.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1098.9,
ARTHREX AR-4570-24 FIBERSTITCH 24 DEG,C1713,HCPCS,,79011772,CDM,278,RC,,,both,,,1485,1098.9,,,1098.9,Other,150% of Medicare + 9.63% HCRA Surcharge,668.25,45,,668.25,percent of total billed charges,Critical Access Hospital RCC factor,504.9,34,,504.9,percent of total billed charges,Implant Device,504.9,34,,504.9,percent of total billed charges,Implant Device,504.9,34,,504.9,percent of total billed charges,Implant Device,504.9,34,,504.9,percent of total billed charges,Implant Device,504.9,34,,504.9,percent of total billed charges,Implant Device,735.08,,,735.08,Other,110% of Medicare,519.75,35,,519.75,percent of total billed charges,Implant Device,504.9,34,"Charges > $500, x 34%",504.9,percent of total billed charges,Implant Device,519.75,35,,519.75,percent of total billed charges,Implant Device,519.75,35,,519.75,percent of total billed charges,Implant Device,519.75,35,,519.75,percent of total billed charges,Implant Device,519.75,35,,519.75,percent of total billed charges,Implant Device,519.75,35,,519.75,percent of total billed charges,Implant Device,594,40,,594,percent of total billed charges,Implant Device,519.75,70,,519.75,percent of total billed charges,All Other,504.9,34,,504.9,percent of total billed charges,Implant Device,504.9,34,,504.9,percent of total billed charges,Implant Device,519.75,35,,519.75,percent of total billed charges,Implant Device,519.75,35,,519.75,percent of total billed charges,Implant Device,519.75,35,,519.75,percent of total billed charges,Implant Device,519.75,35,,519.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1098.9,
JOINT VRG-351 VERSAGRAFT PRESUTURD TENDN,C1713,HCPCS,,79011773,CDM,278,RC,,,both,,,3870,2863.81,,,2863.81,Other,150% of Medicare + 9.63% HCRA Surcharge,1741.5,45,,1741.5,percent of total billed charges,Critical Access Hospital RCC factor,1315.8,34,,1315.8,percent of total billed charges,Implant Device,1315.8,34,,1315.8,percent of total billed charges,Implant Device,1315.8,34,,1315.8,percent of total billed charges,Implant Device,1315.8,34,,1315.8,percent of total billed charges,Implant Device,1315.8,34,,1315.8,percent of total billed charges,Implant Device,1915.65,,,1915.65,Other,110% of Medicare,1354.5,35,,1354.5,percent of total billed charges,Implant Device,1315.8,34,"Charges > $500, x 34%",1315.8,percent of total billed charges,Implant Device,1354.5,35,,1354.5,percent of total billed charges,Implant Device,1354.5,35,,1354.5,percent of total billed charges,Implant Device,1354.5,35,,1354.5,percent of total billed charges,Implant Device,1354.5,35,,1354.5,percent of total billed charges,Implant Device,1354.5,35,,1354.5,percent of total billed charges,Implant Device,1548,40,,1548,percent of total billed charges,Implant Device,1354.5,70,,1354.5,percent of total billed charges,All Other,1315.8,34,,1315.8,percent of total billed charges,Implant Device,1315.8,34,,1315.8,percent of total billed charges,Implant Device,1354.5,35,,1354.5,percent of total billed charges,Implant Device,1354.5,35,,1354.5,percent of total billed charges,Implant Device,1354.5,35,,1354.5,percent of total billed charges,Implant Device,1354.5,35,,1354.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1315.8,34,"If Charge > 2,000, then 34 percent",1315.8,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2863.81,
ZIMMER 110007553 CANNULATED SCREW 4X38MM,C1713,HCPCS,,79011774,CDM,278,RC,,,both,,,529,391.46,,,391.46,Other,150% of Medicare + 9.63% HCRA Surcharge,238.05,45,,238.05,percent of total billed charges,Critical Access Hospital RCC factor,179.86,34,,179.86,percent of total billed charges,Implant Device,179.86,34,,179.86,percent of total billed charges,Implant Device,179.86,34,,179.86,percent of total billed charges,Implant Device,179.86,34,,179.86,percent of total billed charges,Implant Device,179.86,34,,179.86,percent of total billed charges,Implant Device,261.86,,,261.86,Other,110% of Medicare,185.15,35,,185.15,percent of total billed charges,Implant Device,179.86,34,"Charges > $500, x 34%",179.86,percent of total billed charges,Implant Device,185.15,35,,185.15,percent of total billed charges,Implant Device,185.15,35,,185.15,percent of total billed charges,Implant Device,185.15,35,,185.15,percent of total billed charges,Implant Device,185.15,35,,185.15,percent of total billed charges,Implant Device,185.15,35,,185.15,percent of total billed charges,Implant Device,211.6,40,,211.6,percent of total billed charges,Implant Device,185.15,70,,185.15,percent of total billed charges,All Other,179.86,34,,179.86,percent of total billed charges,Implant Device,179.86,34,,179.86,percent of total billed charges,Implant Device,185.15,35,,185.15,percent of total billed charges,Implant Device,185.15,35,,185.15,percent of total billed charges,Implant Device,185.15,35,,185.15,percent of total billed charges,Implant Device,185.15,35,,185.15,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,391.46,
STRYKER 2341-0936S TIBIAL NAIL 9X360MM,C1713,HCPCS,,79011775,CDM,278,RC,,,both,,,6378,4719.74,,,4719.74,Other,150% of Medicare + 9.63% HCRA Surcharge,2870.1,45,,2870.1,percent of total billed charges,Critical Access Hospital RCC factor,2168.52,34,,2168.52,percent of total billed charges,Implant Device,2168.52,34,,2168.52,percent of total billed charges,Implant Device,2168.52,34,,2168.52,percent of total billed charges,Implant Device,2168.52,34,,2168.52,percent of total billed charges,Implant Device,2168.52,34,,2168.52,percent of total billed charges,Implant Device,3157.11,,,3157.11,Other,110% of Medicare,2232.3,35,,2232.3,percent of total billed charges,Implant Device,2168.52,34,"Charges > $500, x 34%",2168.52,percent of total billed charges,Implant Device,2232.3,35,,2232.3,percent of total billed charges,Implant Device,2232.3,35,,2232.3,percent of total billed charges,Implant Device,2232.3,35,,2232.3,percent of total billed charges,Implant Device,2232.3,35,,2232.3,percent of total billed charges,Implant Device,2232.3,35,,2232.3,percent of total billed charges,Implant Device,2551.2,40,,2551.2,percent of total billed charges,Implant Device,2232.3,70,,2232.3,percent of total billed charges,All Other,2168.52,34,,2168.52,percent of total billed charges,Implant Device,2168.52,34,,2168.52,percent of total billed charges,Implant Device,2232.3,35,,2232.3,percent of total billed charges,Implant Device,2232.3,35,,2232.3,percent of total billed charges,Implant Device,2232.3,35,,2232.3,percent of total billed charges,Implant Device,2232.3,35,,2232.3,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2168.52,34,"If Charge > 2,000, then 34 percent",2168.52,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4719.74,
STRYKER 2361-5040S LOCKING SCREW 5X40MM,C1713,HCPCS,,79011776,CDM,278,RC,,,both,,,887,656.38,,,656.38,Other,150% of Medicare + 9.63% HCRA Surcharge,399.15,45,,399.15,percent of total billed charges,Critical Access Hospital RCC factor,301.58,34,,301.58,percent of total billed charges,Implant Device,301.58,34,,301.58,percent of total billed charges,Implant Device,301.58,34,,301.58,percent of total billed charges,Implant Device,301.58,34,,301.58,percent of total billed charges,Implant Device,301.58,34,,301.58,percent of total billed charges,Implant Device,439.07,,,439.07,Other,110% of Medicare,310.45,35,,310.45,percent of total billed charges,Implant Device,301.58,34,"Charges > $500, x 34%",301.58,percent of total billed charges,Implant Device,310.45,35,,310.45,percent of total billed charges,Implant Device,310.45,35,,310.45,percent of total billed charges,Implant Device,310.45,35,,310.45,percent of total billed charges,Implant Device,310.45,35,,310.45,percent of total billed charges,Implant Device,310.45,35,,310.45,percent of total billed charges,Implant Device,354.8,40,,354.8,percent of total billed charges,Implant Device,310.45,70,,310.45,percent of total billed charges,All Other,301.58,34,,301.58,percent of total billed charges,Implant Device,301.58,34,,301.58,percent of total billed charges,Implant Device,310.45,35,,310.45,percent of total billed charges,Implant Device,310.45,35,,310.45,percent of total billed charges,Implant Device,310.45,35,,310.45,percent of total billed charges,Implant Device,310.45,35,,310.45,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,656.38,
ABBOTT MN10450-50A SLIMTIP DRG LEAD,C1898,HCPCS,,79011777,CDM,278,RC,,,both,,,7800,5772.02,,,5772.02,Other,150% of Medicare + 9.63% HCRA Surcharge,3510,45,,3510,percent of total billed charges,Critical Access Hospital RCC factor,2652,34,,2652,percent of total billed charges,Implant Device,2652,34,,2652,percent of total billed charges,Implant Device,2652,34,,2652,percent of total billed charges,Implant Device,2652,34,,2652,percent of total billed charges,Implant Device,2652,34,,2652,percent of total billed charges,Implant Device,3861,,,3861,Other,110% of Medicare,2730,35,,2730,percent of total billed charges,Implant Device,2652,34,"Charges > $500, x 34%",2652,percent of total billed charges,Implant Device,2730,35,,2730,percent of total billed charges,Implant Device,2730,35,,2730,percent of total billed charges,Implant Device,2730,35,,2730,percent of total billed charges,Implant Device,2730,35,,2730,percent of total billed charges,Implant Device,2730,35,,2730,percent of total billed charges,Implant Device,3120,40,,3120,percent of total billed charges,Implant Device,2730,70,,2730,percent of total billed charges,All Other,2652,34,,2652,percent of total billed charges,Implant Device,2652,34,,2652,percent of total billed charges,Implant Device,2730,35,,2730,percent of total billed charges,Implant Device,2730,35,,2730,percent of total billed charges,Implant Device,2730,35,,2730,percent of total billed charges,Implant Device,2730,35,,2730,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2652,34,"If Charge > 2,000, then 34 percent",2652,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5772.02,
DJO 412-02-052 BIPOLAR MODULAR 52X29MM,C1776,HCPCS,,79011780,CDM,278,RC,,,both,,,1380,1021.2,,,1021.2,Other,150% of Medicare + 9.63% HCRA Surcharge,621,45,,621,percent of total billed charges,Critical Access Hospital RCC factor,469.2,34,,469.2,percent of total billed charges,Implant Device,469.2,34,,469.2,percent of total billed charges,Implant Device,469.2,34,,469.2,percent of total billed charges,Implant Device,469.2,34,,469.2,percent of total billed charges,Implant Device,469.2,34,,469.2,percent of total billed charges,Implant Device,683.1,,,683.1,Other,110% of Medicare,483,35,,483,percent of total billed charges,Implant Device,469.2,34,"Charges > $500, x 34%",469.2,percent of total billed charges,Implant Device,483,35,,483,percent of total billed charges,Implant Device,483,35,,483,percent of total billed charges,Implant Device,483,35,,483,percent of total billed charges,Implant Device,483,35,,483,percent of total billed charges,Implant Device,483,35,,483,percent of total billed charges,Implant Device,552,40,,552,percent of total billed charges,Implant Device,483,70,,483,percent of total billed charges,All Other,469.2,34,,469.2,percent of total billed charges,Implant Device,469.2,34,,469.2,percent of total billed charges,Implant Device,483,35,,483,percent of total billed charges,Implant Device,483,35,,483,percent of total billed charges,Implant Device,483,35,,483,percent of total billed charges,Implant Device,483,35,,483,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1021.2,
DJO PR111-152-611 FEMORAL HEAD 28MM,C1713,HCPCS,,79011781,CDM,278,RC,,,both,,,4350,3219.01,,,3219.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1957.5,45,,1957.5,percent of total billed charges,Critical Access Hospital RCC factor,1479,34,,1479,percent of total billed charges,Implant Device,1479,34,,1479,percent of total billed charges,Implant Device,1479,34,,1479,percent of total billed charges,Implant Device,1479,34,,1479,percent of total billed charges,Implant Device,1479,34,,1479,percent of total billed charges,Implant Device,2153.25,,,2153.25,Other,110% of Medicare,1522.5,35,,1522.5,percent of total billed charges,Implant Device,1479,34,"Charges > $500, x 34%",1479,percent of total billed charges,Implant Device,1522.5,35,,1522.5,percent of total billed charges,Implant Device,1522.5,35,,1522.5,percent of total billed charges,Implant Device,1522.5,35,,1522.5,percent of total billed charges,Implant Device,1522.5,35,,1522.5,percent of total billed charges,Implant Device,1522.5,35,,1522.5,percent of total billed charges,Implant Device,1740,40,,1740,percent of total billed charges,Implant Device,1522.5,70,,1522.5,percent of total billed charges,All Other,1479,34,,1479,percent of total billed charges,Implant Device,1479,34,,1479,percent of total billed charges,Implant Device,1522.5,35,,1522.5,percent of total billed charges,Implant Device,1522.5,35,,1522.5,percent of total billed charges,Implant Device,1522.5,35,,1522.5,percent of total billed charges,Implant Device,1522.5,35,,1522.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1479,34,"If Charge > 2,000, then 34 percent",1479,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3219.01,
DJO D111-18-1304 HIP STEM SIZE 13,C1776,HCPCS,,79011782,CDM,278,RC,,,both,,,7320,5416.82,,,5416.82,Other,150% of Medicare + 9.63% HCRA Surcharge,3294,45,,3294,percent of total billed charges,Critical Access Hospital RCC factor,2488.8,34,,2488.8,percent of total billed charges,Implant Device,2488.8,34,,2488.8,percent of total billed charges,Implant Device,2488.8,34,,2488.8,percent of total billed charges,Implant Device,2488.8,34,,2488.8,percent of total billed charges,Implant Device,2488.8,34,,2488.8,percent of total billed charges,Implant Device,3623.4,,,3623.4,Other,110% of Medicare,2562,35,,2562,percent of total billed charges,Implant Device,2488.8,34,"Charges > $500, x 34%",2488.8,percent of total billed charges,Implant Device,2562,35,,2562,percent of total billed charges,Implant Device,2562,35,,2562,percent of total billed charges,Implant Device,2562,35,,2562,percent of total billed charges,Implant Device,2562,35,,2562,percent of total billed charges,Implant Device,2562,35,,2562,percent of total billed charges,Implant Device,2928,40,,2928,percent of total billed charges,Implant Device,2562,70,,2562,percent of total billed charges,All Other,2488.8,34,,2488.8,percent of total billed charges,Implant Device,2488.8,34,,2488.8,percent of total billed charges,Implant Device,2562,35,,2562,percent of total billed charges,Implant Device,2562,35,,2562,percent of total billed charges,Implant Device,2562,35,,2562,percent of total billed charges,Implant Device,2562,35,,2562,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2488.8,34,"If Charge > 2,000, then 34 percent",2488.8,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5416.82,
EXACTECH 320-06-38 GLENOSPHERE 38MM,C1776,HCPCS,,79011783,CDM,278,RC,,,both,,,4050,2997.01,,,2997.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1822.5,45,,1822.5,percent of total billed charges,Critical Access Hospital RCC factor,1377,34,,1377,percent of total billed charges,Implant Device,1377,34,,1377,percent of total billed charges,Implant Device,1377,34,,1377,percent of total billed charges,Implant Device,1377,34,,1377,percent of total billed charges,Implant Device,1377,34,,1377,percent of total billed charges,Implant Device,2004.75,,,2004.75,Other,110% of Medicare,1417.5,35,,1417.5,percent of total billed charges,Implant Device,1377,34,"Charges > $500, x 34%",1377,percent of total billed charges,Implant Device,1417.5,35,,1417.5,percent of total billed charges,Implant Device,1417.5,35,,1417.5,percent of total billed charges,Implant Device,1417.5,35,,1417.5,percent of total billed charges,Implant Device,1417.5,35,,1417.5,percent of total billed charges,Implant Device,1417.5,35,,1417.5,percent of total billed charges,Implant Device,1620,40,,1620,percent of total billed charges,Implant Device,1417.5,70,,1417.5,percent of total billed charges,All Other,1377,34,,1377,percent of total billed charges,Implant Device,1377,34,,1377,percent of total billed charges,Implant Device,1417.5,35,,1417.5,percent of total billed charges,Implant Device,1417.5,35,,1417.5,percent of total billed charges,Implant Device,1417.5,35,,1417.5,percent of total billed charges,Implant Device,1417.5,35,,1417.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1377,34,"If Charge > 2,000, then 34 percent",1377,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2997.01,
STRYKER 629546 COMPRESSION PLATE 6 HOLE,C1713,HCPCS,,79011784,CDM,278,RC,,,both,,,1172,867.28,,,867.28,Other,150% of Medicare + 9.63% HCRA Surcharge,527.4,45,,527.4,percent of total billed charges,Critical Access Hospital RCC factor,398.48,34,,398.48,percent of total billed charges,Implant Device,398.48,34,,398.48,percent of total billed charges,Implant Device,398.48,34,,398.48,percent of total billed charges,Implant Device,398.48,34,,398.48,percent of total billed charges,Implant Device,398.48,34,,398.48,percent of total billed charges,Implant Device,580.14,,,580.14,Other,110% of Medicare,410.2,35,,410.2,percent of total billed charges,Implant Device,398.48,34,"Charges > $500, x 34%",398.48,percent of total billed charges,Implant Device,410.2,35,,410.2,percent of total billed charges,Implant Device,410.2,35,,410.2,percent of total billed charges,Implant Device,410.2,35,,410.2,percent of total billed charges,Implant Device,410.2,35,,410.2,percent of total billed charges,Implant Device,410.2,35,,410.2,percent of total billed charges,Implant Device,468.8,40,,468.8,percent of total billed charges,Implant Device,410.2,70,,410.2,percent of total billed charges,All Other,398.48,34,,398.48,percent of total billed charges,Implant Device,398.48,34,,398.48,percent of total billed charges,Implant Device,410.2,35,,410.2,percent of total billed charges,Implant Device,410.2,35,,410.2,percent of total billed charges,Implant Device,410.2,35,,410.2,percent of total billed charges,Implant Device,410.2,35,,410.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,867.28,
ALLERGAN SCL-320 BREAST IMPLANT 320CC,C1789,HCPCS,,79011786,CDM,278,RC,,,both,,,3975,2941.51,,,2941.51,Other,150% of Medicare + 9.63% HCRA Surcharge,1788.75,45,,1788.75,percent of total billed charges,Critical Access Hospital RCC factor,1351.5,34,,1351.5,percent of total billed charges,Implant Device,1351.5,34,,1351.5,percent of total billed charges,Implant Device,1351.5,34,,1351.5,percent of total billed charges,Implant Device,1351.5,34,,1351.5,percent of total billed charges,Implant Device,1351.5,34,,1351.5,percent of total billed charges,Implant Device,1967.63,,,1967.63,Other,110% of Medicare,1391.25,35,,1391.25,percent of total billed charges,Implant Device,1351.5,34,"Charges > $500, x 34%",1351.5,percent of total billed charges,Implant Device,1391.25,35,,1391.25,percent of total billed charges,Implant Device,1391.25,35,,1391.25,percent of total billed charges,Implant Device,1391.25,35,,1391.25,percent of total billed charges,Implant Device,1391.25,35,,1391.25,percent of total billed charges,Implant Device,1391.25,35,,1391.25,percent of total billed charges,Implant Device,1590,40,,1590,percent of total billed charges,Implant Device,1391.25,70,,1391.25,percent of total billed charges,All Other,1351.5,34,,1351.5,percent of total billed charges,Implant Device,1351.5,34,,1351.5,percent of total billed charges,Implant Device,1391.25,35,,1391.25,percent of total billed charges,Implant Device,1391.25,35,,1391.25,percent of total billed charges,Implant Device,1391.25,35,,1391.25,percent of total billed charges,Implant Device,1391.25,35,,1391.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1351.5,34,"If Charge > 2,000, then 34 percent",1351.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2941.51,
IN2BONES P40 ST013 PLATE 3 HOLE,C1713,HCPCS,,79011789,CDM,278,RC,,,both,,,4611,3412.15,,,3412.15,Other,150% of Medicare + 9.63% HCRA Surcharge,2074.95,45,,2074.95,percent of total billed charges,Critical Access Hospital RCC factor,1567.74,34,,1567.74,percent of total billed charges,Implant Device,1567.74,34,,1567.74,percent of total billed charges,Implant Device,1567.74,34,,1567.74,percent of total billed charges,Implant Device,1567.74,34,,1567.74,percent of total billed charges,Implant Device,1567.74,34,,1567.74,percent of total billed charges,Implant Device,2282.45,,,2282.45,Other,110% of Medicare,1613.85,35,,1613.85,percent of total billed charges,Implant Device,1567.74,34,"Charges > $500, x 34%",1567.74,percent of total billed charges,Implant Device,1613.85,35,,1613.85,percent of total billed charges,Implant Device,1613.85,35,,1613.85,percent of total billed charges,Implant Device,1613.85,35,,1613.85,percent of total billed charges,Implant Device,1613.85,35,,1613.85,percent of total billed charges,Implant Device,1613.85,35,,1613.85,percent of total billed charges,Implant Device,1844.4,40,,1844.4,percent of total billed charges,Implant Device,1613.85,70,,1613.85,percent of total billed charges,All Other,1567.74,34,,1567.74,percent of total billed charges,Implant Device,1567.74,34,,1567.74,percent of total billed charges,Implant Device,1613.85,35,,1613.85,percent of total billed charges,Implant Device,1613.85,35,,1613.85,percent of total billed charges,Implant Device,1613.85,35,,1613.85,percent of total billed charges,Implant Device,1613.85,35,,1613.85,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1567.74,34,"If Charge > 2,000, then 34 percent",1567.74,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3412.15,
IN2BONES V35 ST310 LOCK SCREW 3.5X10MM,C1713,HCPCS,,79011790,CDM,278,RC,,,both,,,870,643.8,,,643.8,Other,150% of Medicare + 9.63% HCRA Surcharge,391.5,45,,391.5,percent of total billed charges,Critical Access Hospital RCC factor,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,430.65,,,430.65,Other,110% of Medicare,304.5,35,,304.5,percent of total billed charges,Implant Device,295.8,34,"Charges > $500, x 34%",295.8,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,348,40,,348,percent of total billed charges,Implant Device,304.5,70,,304.5,percent of total billed charges,All Other,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,643.8,
IN2BONES P65 ST675 COLOG SCREW 6.7X75MM,C1713,HCPCS,,79011791,CDM,278,RC,,,both,,,3225,2386.51,,,2386.51,Other,150% of Medicare + 9.63% HCRA Surcharge,1451.25,45,,1451.25,percent of total billed charges,Critical Access Hospital RCC factor,1096.5,34,,1096.5,percent of total billed charges,Implant Device,1096.5,34,,1096.5,percent of total billed charges,Implant Device,1096.5,34,,1096.5,percent of total billed charges,Implant Device,1096.5,34,,1096.5,percent of total billed charges,Implant Device,1096.5,34,,1096.5,percent of total billed charges,Implant Device,1596.38,,,1596.38,Other,110% of Medicare,1128.75,35,,1128.75,percent of total billed charges,Implant Device,1096.5,34,"Charges > $500, x 34%",1096.5,percent of total billed charges,Implant Device,1128.75,35,,1128.75,percent of total billed charges,Implant Device,1128.75,35,,1128.75,percent of total billed charges,Implant Device,1128.75,35,,1128.75,percent of total billed charges,Implant Device,1128.75,35,,1128.75,percent of total billed charges,Implant Device,1128.75,35,,1128.75,percent of total billed charges,Implant Device,1290,40,,1290,percent of total billed charges,Implant Device,1128.75,70,,1128.75,percent of total billed charges,All Other,1096.5,34,,1096.5,percent of total billed charges,Implant Device,1096.5,34,,1096.5,percent of total billed charges,Implant Device,1128.75,35,,1128.75,percent of total billed charges,Implant Device,1128.75,35,,1128.75,percent of total billed charges,Implant Device,1128.75,35,,1128.75,percent of total billed charges,Implant Device,1128.75,35,,1128.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1096.5,34,"If Charge > 2,000, then 34 percent",1096.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2386.51,
ZIMMER 110007551 CANNULATED SCREW 4X36MM,C1713,HCPCS,,79011793,CDM,278,RC,,,both,,,540,399.6,,,399.6,Other,150% of Medicare + 9.63% HCRA Surcharge,243,45,,243,percent of total billed charges,Critical Access Hospital RCC factor,183.6,34,,183.6,percent of total billed charges,Implant Device,183.6,34,,183.6,percent of total billed charges,Implant Device,183.6,34,,183.6,percent of total billed charges,Implant Device,183.6,34,,183.6,percent of total billed charges,Implant Device,183.6,34,,183.6,percent of total billed charges,Implant Device,267.3,,,267.3,Other,110% of Medicare,189,35,,189,percent of total billed charges,Implant Device,183.6,34,"Charges > $500, x 34%",183.6,percent of total billed charges,Implant Device,189,35,,189,percent of total billed charges,Implant Device,189,35,,189,percent of total billed charges,Implant Device,189,35,,189,percent of total billed charges,Implant Device,189,35,,189,percent of total billed charges,Implant Device,189,35,,189,percent of total billed charges,Implant Device,216,40,,216,percent of total billed charges,Implant Device,189,70,,189,percent of total billed charges,All Other,183.6,34,,183.6,percent of total billed charges,Implant Device,183.6,34,,183.6,percent of total billed charges,Implant Device,189,35,,189,percent of total billed charges,Implant Device,189,35,,189,percent of total billed charges,Implant Device,189,35,,189,percent of total billed charges,Implant Device,189,35,,189,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,399.6,
ZIMMER 110008349 FLAT WASHER 5.0MM,C1713,HCPCS,,79011794,CDM,278,RC,,,both,,,390,288.6,,,288.6,Other,150% of Medicare + 9.63% HCRA Surcharge,175.5,45,,175.5,percent of total billed charges,Critical Access Hospital RCC factor,132.6,34,,132.6,percent of total billed charges,Implant Device,132.6,34,,132.6,percent of total billed charges,Implant Device,132.6,34,,132.6,percent of total billed charges,Implant Device,132.6,34,,132.6,percent of total billed charges,Implant Device,132.6,34,,132.6,percent of total billed charges,Implant Device,193.05,,,193.05,Other,110% of Medicare,136.5,35,,136.5,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,136.5,35,,136.5,percent of total billed charges,Implant Device,136.5,35,,136.5,percent of total billed charges,Implant Device,136.5,35,,136.5,percent of total billed charges,Implant Device,136.5,35,,136.5,percent of total billed charges,Implant Device,136.5,35,,136.5,percent of total billed charges,Implant Device,156,40,,156,percent of total billed charges,Implant Device,136.5,70,,136.5,percent of total billed charges,All Other,132.6,34,,132.6,percent of total billed charges,Implant Device,132.6,34,,132.6,percent of total billed charges,Implant Device,136.5,35,,136.5,percent of total billed charges,Implant Device,136.5,35,,136.5,percent of total billed charges,Implant Device,136.5,35,,136.5,percent of total billed charges,Implant Device,136.5,35,,136.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,288.6,
EXACTECH 320-08-38 GLENOSPHERE 38MM +4MM,C1776,HCPCS,,79011795,CDM,278,RC,,,both,,,5610,4151.41,,,4151.41,Other,150% of Medicare + 9.63% HCRA Surcharge,2524.5,45,,2524.5,percent of total billed charges,Critical Access Hospital RCC factor,1907.4,34,,1907.4,percent of total billed charges,Implant Device,1907.4,34,,1907.4,percent of total billed charges,Implant Device,1907.4,34,,1907.4,percent of total billed charges,Implant Device,1907.4,34,,1907.4,percent of total billed charges,Implant Device,1907.4,34,,1907.4,percent of total billed charges,Implant Device,2776.95,,,2776.95,Other,110% of Medicare,1963.5,35,,1963.5,percent of total billed charges,Implant Device,1907.4,34,"Charges > $500, x 34%",1907.4,percent of total billed charges,Implant Device,1963.5,35,,1963.5,percent of total billed charges,Implant Device,1963.5,35,,1963.5,percent of total billed charges,Implant Device,1963.5,35,,1963.5,percent of total billed charges,Implant Device,1963.5,35,,1963.5,percent of total billed charges,Implant Device,1963.5,35,,1963.5,percent of total billed charges,Implant Device,2244,40,,2244,percent of total billed charges,Implant Device,1963.5,70,,1963.5,percent of total billed charges,All Other,1907.4,34,,1907.4,percent of total billed charges,Implant Device,1907.4,34,,1907.4,percent of total billed charges,Implant Device,1963.5,35,,1963.5,percent of total billed charges,Implant Device,1963.5,35,,1963.5,percent of total billed charges,Implant Device,1963.5,35,,1963.5,percent of total billed charges,Implant Device,1963.5,35,,1963.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1907.4,34,"If Charge > 2,000, then 34 percent",1907.4,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4151.41,
ZIMMER 00-5001-042-22 LINER 22MM,C1776,HCPCS,,79011796,CDM,278,RC,,,both,,,789,583.86,,,583.86,Other,150% of Medicare + 9.63% HCRA Surcharge,355.05,45,,355.05,percent of total billed charges,Critical Access Hospital RCC factor,268.26,34,,268.26,percent of total billed charges,Implant Device,268.26,34,,268.26,percent of total billed charges,Implant Device,268.26,34,,268.26,percent of total billed charges,Implant Device,268.26,34,,268.26,percent of total billed charges,Implant Device,268.26,34,,268.26,percent of total billed charges,Implant Device,390.56,,,390.56,Other,110% of Medicare,276.15,35,,276.15,percent of total billed charges,Implant Device,268.26,34,"Charges > $500, x 34%",268.26,percent of total billed charges,Implant Device,276.15,35,,276.15,percent of total billed charges,Implant Device,276.15,35,,276.15,percent of total billed charges,Implant Device,276.15,35,,276.15,percent of total billed charges,Implant Device,276.15,35,,276.15,percent of total billed charges,Implant Device,276.15,35,,276.15,percent of total billed charges,Implant Device,315.6,40,,315.6,percent of total billed charges,Implant Device,276.15,70,,276.15,percent of total billed charges,All Other,268.26,34,,268.26,percent of total billed charges,Implant Device,268.26,34,,268.26,percent of total billed charges,Implant Device,276.15,35,,276.15,percent of total billed charges,Implant Device,276.15,35,,276.15,percent of total billed charges,Implant Device,276.15,35,,276.15,percent of total billed charges,Implant Device,276.15,35,,276.15,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,583.86,
ZIMMER 00-8018-022-02 FEM HEAD 12/14,C1776,HCPCS,,79011797,CDM,278,RC,,,both,,,1152,852.48,,,852.48,Other,150% of Medicare + 9.63% HCRA Surcharge,518.4,45,,518.4,percent of total billed charges,Critical Access Hospital RCC factor,391.68,34,,391.68,percent of total billed charges,Implant Device,391.68,34,,391.68,percent of total billed charges,Implant Device,391.68,34,,391.68,percent of total billed charges,Implant Device,391.68,34,,391.68,percent of total billed charges,Implant Device,391.68,34,,391.68,percent of total billed charges,Implant Device,570.24,,,570.24,Other,110% of Medicare,403.2,35,,403.2,percent of total billed charges,Implant Device,391.68,34,"Charges > $500, x 34%",391.68,percent of total billed charges,Implant Device,403.2,35,,403.2,percent of total billed charges,Implant Device,403.2,35,,403.2,percent of total billed charges,Implant Device,403.2,35,,403.2,percent of total billed charges,Implant Device,403.2,35,,403.2,percent of total billed charges,Implant Device,403.2,35,,403.2,percent of total billed charges,Implant Device,460.8,40,,460.8,percent of total billed charges,Implant Device,403.2,70,,403.2,percent of total billed charges,All Other,391.68,34,,391.68,percent of total billed charges,Implant Device,391.68,34,,391.68,percent of total billed charges,Implant Device,403.2,35,,403.2,percent of total billed charges,Implant Device,403.2,35,,403.2,percent of total billed charges,Implant Device,403.2,35,,403.2,percent of total billed charges,Implant Device,403.2,35,,403.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,852.48,
J&J 1504-10-105 FEM POSTERIOR SZ 5 LT,C1776,HCPCS,,79011798,CDM,278,RC,,,both,,,4800,3552.01,,,3552.01,Other,150% of Medicare + 9.63% HCRA Surcharge,2160,45,,2160,percent of total billed charges,Critical Access Hospital RCC factor,1632,34,,1632,percent of total billed charges,Implant Device,1632,34,,1632,percent of total billed charges,Implant Device,1632,34,,1632,percent of total billed charges,Implant Device,1632,34,,1632,percent of total billed charges,Implant Device,1632,34,,1632,percent of total billed charges,Implant Device,2376,,,2376,Other,110% of Medicare,1680,35,,1680,percent of total billed charges,Implant Device,1632,34,"Charges > $500, x 34%",1632,percent of total billed charges,Implant Device,1680,35,,1680,percent of total billed charges,Implant Device,1680,35,,1680,percent of total billed charges,Implant Device,1680,35,,1680,percent of total billed charges,Implant Device,1680,35,,1680,percent of total billed charges,Implant Device,1680,35,,1680,percent of total billed charges,Implant Device,1920,40,,1920,percent of total billed charges,Implant Device,1680,70,,1680,percent of total billed charges,All Other,1632,34,,1632,percent of total billed charges,Implant Device,1632,34,,1632,percent of total billed charges,Implant Device,1680,35,,1680,percent of total billed charges,Implant Device,1680,35,,1680,percent of total billed charges,Implant Device,1680,35,,1680,percent of total billed charges,Implant Device,1680,35,,1680,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1632,34,"If Charge > 2,000, then 34 percent",1632,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3552.01,
J&J 1516-50-505 TIBIAL INSERT SIZE 5X5MM,C1776,HCPCS,,79011799,CDM,278,RC,,,both,,,5400,3996.01,,,3996.01,Other,150% of Medicare + 9.63% HCRA Surcharge,2430,45,,2430,percent of total billed charges,Critical Access Hospital RCC factor,1836,34,,1836,percent of total billed charges,Implant Device,1836,34,,1836,percent of total billed charges,Implant Device,1836,34,,1836,percent of total billed charges,Implant Device,1836,34,,1836,percent of total billed charges,Implant Device,1836,34,,1836,percent of total billed charges,Implant Device,2673,,,2673,Other,110% of Medicare,1890,35,,1890,percent of total billed charges,Implant Device,1836,34,"Charges > $500, x 34%",1836,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,2160,40,,2160,percent of total billed charges,Implant Device,1890,70,,1890,percent of total billed charges,All Other,1836,34,,1836,percent of total billed charges,Implant Device,1836,34,,1836,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1836,34,"If Charge > 2,000, then 34 percent",1836,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3996.01,
J&J 1024-53-309 TIBIAL INSERT SIZE 3X9MM,C1776,HCPCS,,79011800,CDM,278,RC,,,both,,,2850,2109.01,,,2109.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1282.5,45,,1282.5,percent of total billed charges,Critical Access Hospital RCC factor,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,1410.75,,,1410.75,Other,110% of Medicare,997.5,35,,997.5,percent of total billed charges,Implant Device,969,34,"Charges > $500, x 34%",969,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,1140,40,,1140,percent of total billed charges,Implant Device,997.5,70,,997.5,percent of total billed charges,All Other,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,969,34,"If Charge > 2,000, then 34 percent",969,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2109.01,
J&J 1024-53-409 TIBIAL INSERT SIZE 4X9MM,C1776,HCPCS,,79011801,CDM,278,RC,,,both,,,2850,2109.01,,,2109.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1282.5,45,,1282.5,percent of total billed charges,Critical Access Hospital RCC factor,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,1410.75,,,1410.75,Other,110% of Medicare,997.5,35,,997.5,percent of total billed charges,Implant Device,969,34,"Charges > $500, x 34%",969,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,1140,40,,1140,percent of total billed charges,Implant Device,997.5,70,,997.5,percent of total billed charges,All Other,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,969,34,"If Charge > 2,000, then 34 percent",969,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2109.01,
J&J 02.240.056 CANNULATED SCREW 3.7X56MM,C1713,HCPCS,,79011802,CDM,278,RC,,,both,,,503,372.22,,,372.22,Other,150% of Medicare + 9.63% HCRA Surcharge,226.35,45,,226.35,percent of total billed charges,Critical Access Hospital RCC factor,171.02,34,,171.02,percent of total billed charges,Implant Device,171.02,34,,171.02,percent of total billed charges,Implant Device,171.02,34,,171.02,percent of total billed charges,Implant Device,171.02,34,,171.02,percent of total billed charges,Implant Device,171.02,34,,171.02,percent of total billed charges,Implant Device,248.99,,,248.99,Other,110% of Medicare,176.05,35,,176.05,percent of total billed charges,Implant Device,171.02,34,"Charges > $500, x 34%",171.02,percent of total billed charges,Implant Device,176.05,35,,176.05,percent of total billed charges,Implant Device,176.05,35,,176.05,percent of total billed charges,Implant Device,176.05,35,,176.05,percent of total billed charges,Implant Device,176.05,35,,176.05,percent of total billed charges,Implant Device,176.05,35,,176.05,percent of total billed charges,Implant Device,201.2,40,,201.2,percent of total billed charges,Implant Device,176.05,70,,176.05,percent of total billed charges,All Other,171.02,34,,171.02,percent of total billed charges,Implant Device,171.02,34,,171.02,percent of total billed charges,Implant Device,176.05,35,,176.05,percent of total billed charges,Implant Device,176.05,35,,176.05,percent of total billed charges,Implant Device,176.05,35,,176.05,percent of total billed charges,Implant Device,176.05,35,,176.05,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,372.22,
J&J 02.240.024 CANNULATED SCREW 3.7X24MM,C1713,HCPCS,,79011803,CDM,278,RC,,,both,,,503,372.22,,,372.22,Other,150% of Medicare + 9.63% HCRA Surcharge,226.35,45,,226.35,percent of total billed charges,Critical Access Hospital RCC factor,171.02,34,,171.02,percent of total billed charges,Implant Device,171.02,34,,171.02,percent of total billed charges,Implant Device,171.02,34,,171.02,percent of total billed charges,Implant Device,171.02,34,,171.02,percent of total billed charges,Implant Device,171.02,34,,171.02,percent of total billed charges,Implant Device,248.99,,,248.99,Other,110% of Medicare,176.05,35,,176.05,percent of total billed charges,Implant Device,171.02,34,"Charges > $500, x 34%",171.02,percent of total billed charges,Implant Device,176.05,35,,176.05,percent of total billed charges,Implant Device,176.05,35,,176.05,percent of total billed charges,Implant Device,176.05,35,,176.05,percent of total billed charges,Implant Device,176.05,35,,176.05,percent of total billed charges,Implant Device,176.05,35,,176.05,percent of total billed charges,Implant Device,201.2,40,,201.2,percent of total billed charges,Implant Device,176.05,70,,176.05,percent of total billed charges,All Other,171.02,34,,171.02,percent of total billed charges,Implant Device,171.02,34,,171.02,percent of total billed charges,Implant Device,176.05,35,,176.05,percent of total billed charges,Implant Device,176.05,35,,176.05,percent of total billed charges,Implant Device,176.05,35,,176.05,percent of total billed charges,Implant Device,176.05,35,,176.05,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,372.22,
TRI-STATE OF2012430S FIXATION NAIL SYS,C1713,HCPCS,,79011804,CDM,278,RC,,,both,,,7485,5538.92,,,5538.92,Other,150% of Medicare + 9.63% HCRA Surcharge,3368.25,45,,3368.25,percent of total billed charges,Critical Access Hospital RCC factor,2544.9,34,,2544.9,percent of total billed charges,Implant Device,2544.9,34,,2544.9,percent of total billed charges,Implant Device,2544.9,34,,2544.9,percent of total billed charges,Implant Device,2544.9,34,,2544.9,percent of total billed charges,Implant Device,2544.9,34,,2544.9,percent of total billed charges,Implant Device,3705.08,,,3705.08,Other,110% of Medicare,2619.75,35,,2619.75,percent of total billed charges,Implant Device,2544.9,34,"Charges > $500, x 34%",2544.9,percent of total billed charges,Implant Device,2619.75,35,,2619.75,percent of total billed charges,Implant Device,2619.75,35,,2619.75,percent of total billed charges,Implant Device,2619.75,35,,2619.75,percent of total billed charges,Implant Device,2619.75,35,,2619.75,percent of total billed charges,Implant Device,2619.75,35,,2619.75,percent of total billed charges,Implant Device,2994,40,,2994,percent of total billed charges,Implant Device,2619.75,70,,2619.75,percent of total billed charges,All Other,2544.9,34,,2544.9,percent of total billed charges,Implant Device,2544.9,34,,2544.9,percent of total billed charges,Implant Device,2619.75,35,,2619.75,percent of total billed charges,Implant Device,2619.75,35,,2619.75,percent of total billed charges,Implant Device,2619.75,35,,2619.75,percent of total billed charges,Implant Device,2619.75,35,,2619.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2544.9,34,"If Charge > 2,000, then 34 percent",2544.9,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5538.92,
STRYKER 2341-1131S TIBIAL NAIL 11X315MM,C1713,HCPCS,,79011805,CDM,278,RC,,,both,,,6378,4719.74,,,4719.74,Other,150% of Medicare + 9.63% HCRA Surcharge,2870.1,45,,2870.1,percent of total billed charges,Critical Access Hospital RCC factor,2168.52,34,,2168.52,percent of total billed charges,Implant Device,2168.52,34,,2168.52,percent of total billed charges,Implant Device,2168.52,34,,2168.52,percent of total billed charges,Implant Device,2168.52,34,,2168.52,percent of total billed charges,Implant Device,2168.52,34,,2168.52,percent of total billed charges,Implant Device,3157.11,,,3157.11,Other,110% of Medicare,2232.3,35,,2232.3,percent of total billed charges,Implant Device,2168.52,34,"Charges > $500, x 34%",2168.52,percent of total billed charges,Implant Device,2232.3,35,,2232.3,percent of total billed charges,Implant Device,2232.3,35,,2232.3,percent of total billed charges,Implant Device,2232.3,35,,2232.3,percent of total billed charges,Implant Device,2232.3,35,,2232.3,percent of total billed charges,Implant Device,2232.3,35,,2232.3,percent of total billed charges,Implant Device,2551.2,40,,2551.2,percent of total billed charges,Implant Device,2232.3,70,,2232.3,percent of total billed charges,All Other,2168.52,34,,2168.52,percent of total billed charges,Implant Device,2168.52,34,,2168.52,percent of total billed charges,Implant Device,2232.3,35,,2232.3,percent of total billed charges,Implant Device,2232.3,35,,2232.3,percent of total billed charges,Implant Device,2232.3,35,,2232.3,percent of total billed charges,Implant Device,2232.3,35,,2232.3,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2168.52,34,"If Charge > 2,000, then 34 percent",2168.52,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4719.74,
STRYKER 2360-5057S LOCK SCREW 5X57.5MM,C1713,HCPCS,,79011806,CDM,278,RC,,,both,,,682,504.68,,,504.68,Other,150% of Medicare + 9.63% HCRA Surcharge,306.9,45,,306.9,percent of total billed charges,Critical Access Hospital RCC factor,231.88,34,,231.88,percent of total billed charges,Implant Device,231.88,34,,231.88,percent of total billed charges,Implant Device,231.88,34,,231.88,percent of total billed charges,Implant Device,231.88,34,,231.88,percent of total billed charges,Implant Device,231.88,34,,231.88,percent of total billed charges,Implant Device,337.59,,,337.59,Other,110% of Medicare,238.7,35,,238.7,percent of total billed charges,Implant Device,231.88,34,"Charges > $500, x 34%",231.88,percent of total billed charges,Implant Device,238.7,35,,238.7,percent of total billed charges,Implant Device,238.7,35,,238.7,percent of total billed charges,Implant Device,238.7,35,,238.7,percent of total billed charges,Implant Device,238.7,35,,238.7,percent of total billed charges,Implant Device,238.7,35,,238.7,percent of total billed charges,Implant Device,272.8,40,,272.8,percent of total billed charges,Implant Device,238.7,70,,238.7,percent of total billed charges,All Other,231.88,34,,231.88,percent of total billed charges,Implant Device,231.88,34,,231.88,percent of total billed charges,Implant Device,238.7,35,,238.7,percent of total billed charges,Implant Device,238.7,35,,238.7,percent of total billed charges,Implant Device,238.7,35,,238.7,percent of total billed charges,Implant Device,238.7,35,,238.7,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,504.68,
STRYKER 2360-5070S LOCKING SCREW 5X70MM,C1713,HCPCS,,79011807,CDM,278,RC,,,both,,,762,563.88,,,563.88,Other,150% of Medicare + 9.63% HCRA Surcharge,342.9,45,,342.9,percent of total billed charges,Critical Access Hospital RCC factor,259.08,34,,259.08,percent of total billed charges,Implant Device,259.08,34,,259.08,percent of total billed charges,Implant Device,259.08,34,,259.08,percent of total billed charges,Implant Device,259.08,34,,259.08,percent of total billed charges,Implant Device,259.08,34,,259.08,percent of total billed charges,Implant Device,377.19,,,377.19,Other,110% of Medicare,266.7,35,,266.7,percent of total billed charges,Implant Device,259.08,34,"Charges > $500, x 34%",259.08,percent of total billed charges,Implant Device,266.7,35,,266.7,percent of total billed charges,Implant Device,266.7,35,,266.7,percent of total billed charges,Implant Device,266.7,35,,266.7,percent of total billed charges,Implant Device,266.7,35,,266.7,percent of total billed charges,Implant Device,266.7,35,,266.7,percent of total billed charges,Implant Device,304.8,40,,304.8,percent of total billed charges,Implant Device,266.7,70,,266.7,percent of total billed charges,All Other,259.08,34,,259.08,percent of total billed charges,Implant Device,259.08,34,,259.08,percent of total billed charges,Implant Device,266.7,35,,266.7,percent of total billed charges,Implant Device,266.7,35,,266.7,percent of total billed charges,Implant Device,266.7,35,,266.7,percent of total billed charges,Implant Device,266.7,35,,266.7,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,563.88,
BOST SCI 720185-01 AMS CONCEAL RESERVOIR,C1813,HCPCS,,79011810,CDM,278,RC,,,both,,,8895,6582.32,,,6582.32,Other,150% of Medicare + 9.63% HCRA Surcharge,4002.75,45,,4002.75,percent of total billed charges,Critical Access Hospital RCC factor,3024.3,34,,3024.3,percent of total billed charges,Implant Device,3024.3,34,,3024.3,percent of total billed charges,Implant Device,3024.3,34,,3024.3,percent of total billed charges,Implant Device,3024.3,34,,3024.3,percent of total billed charges,Implant Device,3024.3,34,,3024.3,percent of total billed charges,Implant Device,4403.03,,,4403.03,Other,110% of Medicare,3113.25,35,,3113.25,percent of total billed charges,Implant Device,3024.3,34,"Charges > $500, x 34%",3024.3,percent of total billed charges,Implant Device,3113.25,35,,3113.25,percent of total billed charges,Implant Device,3113.25,35,,3113.25,percent of total billed charges,Implant Device,3113.25,35,,3113.25,percent of total billed charges,Implant Device,3113.25,35,,3113.25,percent of total billed charges,Implant Device,3113.25,35,,3113.25,percent of total billed charges,Implant Device,3558,40,,3558,percent of total billed charges,Implant Device,3113.25,70,,3113.25,percent of total billed charges,All Other,3024.3,34,,3024.3,percent of total billed charges,Implant Device,3024.3,34,,3024.3,percent of total billed charges,Implant Device,3113.25,35,,3113.25,percent of total billed charges,Implant Device,3113.25,35,,3113.25,percent of total billed charges,Implant Device,3113.25,35,,3113.25,percent of total billed charges,Implant Device,3113.25,35,,3113.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3024.3,34,"If Charge > 2,000, then 34 percent",3024.3,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,6582.32,
BOST SCI 72404237 AMS 700 CX MS PUMP,C1813,HCPCS,,79011811,CDM,278,RC,,,both,,,33765,24986.18,,,24986.18,Other,150% of Medicare + 9.63% HCRA Surcharge,15194.25,45,,15194.25,percent of total billed charges,Critical Access Hospital RCC factor,11480.1,34,,11480.1,percent of total billed charges,Implant Device,11480.1,34,,11480.1,percent of total billed charges,Implant Device,11480.1,34,,11480.1,percent of total billed charges,Implant Device,11480.1,34,,11480.1,percent of total billed charges,Implant Device,11480.1,34,,11480.1,percent of total billed charges,Implant Device,16713.68,,,16713.68,Other,110% of Medicare,11817.75,35,,11817.75,percent of total billed charges,Implant Device,11480.1,34,"Charges > $500, x 34%",11480.1,percent of total billed charges,Implant Device,11817.75,35,,11817.75,percent of total billed charges,Implant Device,11817.75,35,,11817.75,percent of total billed charges,Implant Device,11817.75,35,,11817.75,percent of total billed charges,Implant Device,11817.75,35,,11817.75,percent of total billed charges,Implant Device,11817.75,35,,11817.75,percent of total billed charges,Implant Device,13506,40,,13506,percent of total billed charges,Implant Device,11817.75,70,,11817.75,percent of total billed charges,All Other,11480.1,34,,11480.1,percent of total billed charges,Implant Device,11480.1,34,,11480.1,percent of total billed charges,Implant Device,11817.75,35,,11817.75,percent of total billed charges,Implant Device,11817.75,35,,11817.75,percent of total billed charges,Implant Device,11817.75,35,,11817.75,percent of total billed charges,Implant Device,11817.75,35,,11817.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,11480.1,34,"If Charge > 2,000, then 34 percent",11480.1,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,24986.18,
JOINT VRG-001 VERSAGRAFT PRESUTURED TNDN,C1713,HCPCS,,79011818,CDM,278,RC,,,both,,,3870,2863.81,,,2863.81,Other,150% of Medicare + 9.63% HCRA Surcharge,1741.5,45,,1741.5,percent of total billed charges,Critical Access Hospital RCC factor,1315.8,34,,1315.8,percent of total billed charges,Implant Device,1315.8,34,,1315.8,percent of total billed charges,Implant Device,1315.8,34,,1315.8,percent of total billed charges,Implant Device,1315.8,34,,1315.8,percent of total billed charges,Implant Device,1315.8,34,,1315.8,percent of total billed charges,Implant Device,1915.65,,,1915.65,Other,110% of Medicare,1354.5,35,,1354.5,percent of total billed charges,Implant Device,1315.8,34,"Charges > $500, x 34%",1315.8,percent of total billed charges,Implant Device,1354.5,35,,1354.5,percent of total billed charges,Implant Device,1354.5,35,,1354.5,percent of total billed charges,Implant Device,1354.5,35,,1354.5,percent of total billed charges,Implant Device,1354.5,35,,1354.5,percent of total billed charges,Implant Device,1354.5,35,,1354.5,percent of total billed charges,Implant Device,1548,40,,1548,percent of total billed charges,Implant Device,1354.5,70,,1354.5,percent of total billed charges,All Other,1315.8,34,,1315.8,percent of total billed charges,Implant Device,1315.8,34,,1315.8,percent of total billed charges,Implant Device,1354.5,35,,1354.5,percent of total billed charges,Implant Device,1354.5,35,,1354.5,percent of total billed charges,Implant Device,1354.5,35,,1354.5,percent of total billed charges,Implant Device,1354.5,35,,1354.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1315.8,34,"If Charge > 2,000, then 34 percent",1315.8,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2863.81,
STRYKER 6720-0535 HIP STEM SZ 5 132 DEG,C1776,HCPCS,,79011820,CDM,278,RC,,,both,,,6953,5145.24,,,5145.24,Other,150% of Medicare + 9.63% HCRA Surcharge,3128.85,45,,3128.85,percent of total billed charges,Critical Access Hospital RCC factor,2364.02,34,,2364.02,percent of total billed charges,Implant Device,2364.02,34,,2364.02,percent of total billed charges,Implant Device,2364.02,34,,2364.02,percent of total billed charges,Implant Device,2364.02,34,,2364.02,percent of total billed charges,Implant Device,2364.02,34,,2364.02,percent of total billed charges,Implant Device,3441.74,,,3441.74,Other,110% of Medicare,2433.55,35,,2433.55,percent of total billed charges,Implant Device,2364.02,34,"Charges > $500, x 34%",2364.02,percent of total billed charges,Implant Device,2433.55,35,,2433.55,percent of total billed charges,Implant Device,2433.55,35,,2433.55,percent of total billed charges,Implant Device,2433.55,35,,2433.55,percent of total billed charges,Implant Device,2433.55,35,,2433.55,percent of total billed charges,Implant Device,2433.55,35,,2433.55,percent of total billed charges,Implant Device,2781.2,40,,2781.2,percent of total billed charges,Implant Device,2433.55,70,,2433.55,percent of total billed charges,All Other,2364.02,34,,2364.02,percent of total billed charges,Implant Device,2364.02,34,,2364.02,percent of total billed charges,Implant Device,2433.55,35,,2433.55,percent of total billed charges,Implant Device,2433.55,35,,2433.55,percent of total billed charges,Implant Device,2433.55,35,,2433.55,percent of total billed charges,Implant Device,2433.55,35,,2433.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2364.02,34,"If Charge > 2,000, then 34 percent",2364.02,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5145.24,
J&J 1504-11-125 FEMORAL COMPONENT SIZE 5,C1776,HCPCS,,79011821,CDM,278,RC,,,both,,,6000,4440.02,,,4440.02,Other,150% of Medicare + 9.63% HCRA Surcharge,2700,45,,2700,percent of total billed charges,Critical Access Hospital RCC factor,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2970,,,2970,Other,110% of Medicare,2100,35,,2100,percent of total billed charges,Implant Device,2040,34,"Charges > $500, x 34%",2040,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2400,40,,2400,percent of total billed charges,Implant Device,2100,70,,2100,percent of total billed charges,All Other,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2040,34,"If Charge > 2,000, then 34 percent",2040,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4440.02,
J&J 1516-50-510 TIBIAL INSERT 10MM SZ 5,C1776,HCPCS,,79011822,CDM,278,RC,,,both,,,4200,3108.01,,,3108.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1890,45,,1890,percent of total billed charges,Critical Access Hospital RCC factor,1428,34,,1428,percent of total billed charges,Implant Device,1428,34,,1428,percent of total billed charges,Implant Device,1428,34,,1428,percent of total billed charges,Implant Device,1428,34,,1428,percent of total billed charges,Implant Device,1428,34,,1428,percent of total billed charges,Implant Device,2079,,,2079,Other,110% of Medicare,1470,35,,1470,percent of total billed charges,Implant Device,1428,34,"Charges > $500, x 34%",1428,percent of total billed charges,Implant Device,1470,35,,1470,percent of total billed charges,Implant Device,1470,35,,1470,percent of total billed charges,Implant Device,1470,35,,1470,percent of total billed charges,Implant Device,1470,35,,1470,percent of total billed charges,Implant Device,1470,35,,1470,percent of total billed charges,Implant Device,1680,40,,1680,percent of total billed charges,Implant Device,1470,70,,1470,percent of total billed charges,All Other,1428,34,,1428,percent of total billed charges,Implant Device,1428,34,,1428,percent of total billed charges,Implant Device,1470,35,,1470,percent of total billed charges,Implant Device,1470,35,,1470,percent of total billed charges,Implant Device,1470,35,,1470,percent of total billed charges,Implant Device,1470,35,,1470,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1428,34,"If Charge > 2,000, then 34 percent",1428,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3108.01,
J&J 1506-11-005 TIBIAL BASE SIZE 5,C1776,HCPCS,,79011823,CDM,278,RC,,,both,,,6300,4662.02,,,4662.02,Other,150% of Medicare + 9.63% HCRA Surcharge,2835,45,,2835,percent of total billed charges,Critical Access Hospital RCC factor,2142,34,,2142,percent of total billed charges,Implant Device,2142,34,,2142,percent of total billed charges,Implant Device,2142,34,,2142,percent of total billed charges,Implant Device,2142,34,,2142,percent of total billed charges,Implant Device,2142,34,,2142,percent of total billed charges,Implant Device,3118.5,,,3118.5,Other,110% of Medicare,2205,35,,2205,percent of total billed charges,Implant Device,2142,34,"Charges > $500, x 34%",2142,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2520,40,,2520,percent of total billed charges,Implant Device,2205,70,,2205,percent of total billed charges,All Other,2142,34,,2142,percent of total billed charges,Implant Device,2142,34,,2142,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2142,34,"If Charge > 2,000, then 34 percent",2142,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4662.02,
ZIMMER 110007547 CANN SCREW 4.0X34MM,C1713,HCPCS,,79011824,CDM,278,RC,,,both,,,529,391.46,,,391.46,Other,150% of Medicare + 9.63% HCRA Surcharge,238.05,45,,238.05,percent of total billed charges,Critical Access Hospital RCC factor,179.86,34,,179.86,percent of total billed charges,Implant Device,179.86,34,,179.86,percent of total billed charges,Implant Device,179.86,34,,179.86,percent of total billed charges,Implant Device,179.86,34,,179.86,percent of total billed charges,Implant Device,179.86,34,,179.86,percent of total billed charges,Implant Device,261.86,,,261.86,Other,110% of Medicare,185.15,35,,185.15,percent of total billed charges,Implant Device,179.86,34,"Charges > $500, x 34%",179.86,percent of total billed charges,Implant Device,185.15,35,,185.15,percent of total billed charges,Implant Device,185.15,35,,185.15,percent of total billed charges,Implant Device,185.15,35,,185.15,percent of total billed charges,Implant Device,185.15,35,,185.15,percent of total billed charges,Implant Device,185.15,35,,185.15,percent of total billed charges,Implant Device,211.6,40,,211.6,percent of total billed charges,Implant Device,185.15,70,,185.15,percent of total billed charges,All Other,179.86,34,,179.86,percent of total billed charges,Implant Device,179.86,34,,179.86,percent of total billed charges,Implant Device,185.15,35,,185.15,percent of total billed charges,Implant Device,185.15,35,,185.15,percent of total billed charges,Implant Device,185.15,35,,185.15,percent of total billed charges,Implant Device,185.15,35,,185.15,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,391.46,
IN2BONES V30 ST420 TRANSVERSE SCREW 3X20,C1713,HCPCS,,79011831,CDM,278,RC,,,both,,,870,643.8,,,643.8,Other,150% of Medicare + 9.63% HCRA Surcharge,391.5,45,,391.5,percent of total billed charges,Critical Access Hospital RCC factor,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,430.65,,,430.65,Other,110% of Medicare,304.5,35,,304.5,percent of total billed charges,Implant Device,295.8,34,"Charges > $500, x 34%",295.8,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,348,40,,348,percent of total billed charges,Implant Device,304.5,70,,304.5,percent of total billed charges,All Other,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,643.8,
ARTHREX AR-2271 ACUTE AC REPAIR KIT,C1713,HCPCS,,79011832,CDM,278,RC,,,both,,,3375,2497.51,,,2497.51,Other,150% of Medicare + 9.63% HCRA Surcharge,1518.75,45,,1518.75,percent of total billed charges,Critical Access Hospital RCC factor,1147.5,34,,1147.5,percent of total billed charges,Implant Device,1147.5,34,,1147.5,percent of total billed charges,Implant Device,1147.5,34,,1147.5,percent of total billed charges,Implant Device,1147.5,34,,1147.5,percent of total billed charges,Implant Device,1147.5,34,,1147.5,percent of total billed charges,Implant Device,1670.63,,,1670.63,Other,110% of Medicare,1181.25,35,,1181.25,percent of total billed charges,Implant Device,1147.5,34,"Charges > $500, x 34%",1147.5,percent of total billed charges,Implant Device,1181.25,35,,1181.25,percent of total billed charges,Implant Device,1181.25,35,,1181.25,percent of total billed charges,Implant Device,1181.25,35,,1181.25,percent of total billed charges,Implant Device,1181.25,35,,1181.25,percent of total billed charges,Implant Device,1181.25,35,,1181.25,percent of total billed charges,Implant Device,1350,40,,1350,percent of total billed charges,Implant Device,1181.25,70,,1181.25,percent of total billed charges,All Other,1147.5,34,,1147.5,percent of total billed charges,Implant Device,1147.5,34,,1147.5,percent of total billed charges,Implant Device,1181.25,35,,1181.25,percent of total billed charges,Implant Device,1181.25,35,,1181.25,percent of total billed charges,Implant Device,1181.25,35,,1181.25,percent of total billed charges,Implant Device,1181.25,35,,1181.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1147.5,34,"If Charge > 2,000, then 34 percent",1147.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2497.51,
EXACTECH 320-06-42 GLENOSPHERE 42MM,C1776,HCPCS,,79011833,CDM,278,RC,,,both,,,4050,2997.01,,,2997.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1822.5,45,,1822.5,percent of total billed charges,Critical Access Hospital RCC factor,1377,34,,1377,percent of total billed charges,Implant Device,1377,34,,1377,percent of total billed charges,Implant Device,1377,34,,1377,percent of total billed charges,Implant Device,1377,34,,1377,percent of total billed charges,Implant Device,1377,34,,1377,percent of total billed charges,Implant Device,2004.75,,,2004.75,Other,110% of Medicare,1417.5,35,,1417.5,percent of total billed charges,Implant Device,1377,34,"Charges > $500, x 34%",1377,percent of total billed charges,Implant Device,1417.5,35,,1417.5,percent of total billed charges,Implant Device,1417.5,35,,1417.5,percent of total billed charges,Implant Device,1417.5,35,,1417.5,percent of total billed charges,Implant Device,1417.5,35,,1417.5,percent of total billed charges,Implant Device,1417.5,35,,1417.5,percent of total billed charges,Implant Device,1620,40,,1620,percent of total billed charges,Implant Device,1417.5,70,,1417.5,percent of total billed charges,All Other,1377,34,,1377,percent of total billed charges,Implant Device,1377,34,,1377,percent of total billed charges,Implant Device,1417.5,35,,1417.5,percent of total billed charges,Implant Device,1417.5,35,,1417.5,percent of total billed charges,Implant Device,1417.5,35,,1417.5,percent of total billed charges,Implant Device,1417.5,35,,1417.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1377,34,"If Charge > 2,000, then 34 percent",1377,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2997.01,
GORE BXA083901A VIABAHN 8X39MM STENT,C1874,HCPCS,,79011839,CDM,278,RC,,,both,,,10722,7934.31,,,7934.31,Other,150% of Medicare + 9.63% HCRA Surcharge,4824.9,45,,4824.9,percent of total billed charges,Critical Access Hospital RCC factor,3645.48,34,,3645.48,percent of total billed charges,Implant Device,3645.48,34,,3645.48,percent of total billed charges,Implant Device,3645.48,34,,3645.48,percent of total billed charges,Implant Device,3645.48,34,,3645.48,percent of total billed charges,Implant Device,3645.48,34,,3645.48,percent of total billed charges,Implant Device,5307.39,,,5307.39,Other,110% of Medicare,3752.7,35,,3752.7,percent of total billed charges,Implant Device,3645.48,34,"Charges > $500, x 34%",3645.48,percent of total billed charges,Implant Device,3752.7,35,,3752.7,percent of total billed charges,Implant Device,3752.7,35,,3752.7,percent of total billed charges,Implant Device,3752.7,35,,3752.7,percent of total billed charges,Implant Device,3752.7,35,,3752.7,percent of total billed charges,Implant Device,3752.7,35,,3752.7,percent of total billed charges,Implant Device,4288.8,40,,4288.8,percent of total billed charges,Implant Device,3752.7,70,,3752.7,percent of total billed charges,All Other,3645.48,34,,3645.48,percent of total billed charges,Implant Device,3645.48,34,,3645.48,percent of total billed charges,Implant Device,3752.7,35,,3752.7,percent of total billed charges,Implant Device,3752.7,35,,3752.7,percent of total billed charges,Implant Device,3752.7,35,,3752.7,percent of total billed charges,Implant Device,3752.7,35,,3752.7,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3645.48,34,"If Charge > 2,000, then 34 percent",3645.48,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,7934.31,
STRYKER 2361-5060S LOCKING SCREW 5X60MM,C1713,HCPCS,,79011842,CDM,278,RC,,,both,,,956,707.44,,,707.44,Other,150% of Medicare + 9.63% HCRA Surcharge,430.2,45,,430.2,percent of total billed charges,Critical Access Hospital RCC factor,325.04,34,,325.04,percent of total billed charges,Implant Device,325.04,34,,325.04,percent of total billed charges,Implant Device,325.04,34,,325.04,percent of total billed charges,Implant Device,325.04,34,,325.04,percent of total billed charges,Implant Device,325.04,34,,325.04,percent of total billed charges,Implant Device,473.22,,,473.22,Other,110% of Medicare,334.6,35,,334.6,percent of total billed charges,Implant Device,325.04,34,"Charges > $500, x 34%",325.04,percent of total billed charges,Implant Device,334.6,35,,334.6,percent of total billed charges,Implant Device,334.6,35,,334.6,percent of total billed charges,Implant Device,334.6,35,,334.6,percent of total billed charges,Implant Device,334.6,35,,334.6,percent of total billed charges,Implant Device,334.6,35,,334.6,percent of total billed charges,Implant Device,382.4,40,,382.4,percent of total billed charges,Implant Device,334.6,70,,334.6,percent of total billed charges,All Other,325.04,34,,325.04,percent of total billed charges,Implant Device,325.04,34,,325.04,percent of total billed charges,Implant Device,334.6,35,,334.6,percent of total billed charges,Implant Device,334.6,35,,334.6,percent of total billed charges,Implant Device,334.6,35,,334.6,percent of total billed charges,Implant Device,334.6,35,,334.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,707.44,
J&J 1504-10-126 FEMORAL COMPONENET SZ 6,C1776,HCPCS,,79011844,CDM,278,RC,,,both,,,4800,3552.01,,,3552.01,Other,150% of Medicare + 9.63% HCRA Surcharge,2160,45,,2160,percent of total billed charges,Critical Access Hospital RCC factor,1632,34,,1632,percent of total billed charges,Implant Device,1632,34,,1632,percent of total billed charges,Implant Device,1632,34,,1632,percent of total billed charges,Implant Device,1632,34,,1632,percent of total billed charges,Implant Device,1632,34,,1632,percent of total billed charges,Implant Device,2376,,,2376,Other,110% of Medicare,1680,35,,1680,percent of total billed charges,Implant Device,1632,34,"Charges > $500, x 34%",1632,percent of total billed charges,Implant Device,1680,35,,1680,percent of total billed charges,Implant Device,1680,35,,1680,percent of total billed charges,Implant Device,1680,35,,1680,percent of total billed charges,Implant Device,1680,35,,1680,percent of total billed charges,Implant Device,1680,35,,1680,percent of total billed charges,Implant Device,1920,40,,1920,percent of total billed charges,Implant Device,1680,70,,1680,percent of total billed charges,All Other,1632,34,,1632,percent of total billed charges,Implant Device,1632,34,,1632,percent of total billed charges,Implant Device,1680,35,,1680,percent of total billed charges,Implant Device,1680,35,,1680,percent of total billed charges,Implant Device,1680,35,,1680,percent of total billed charges,Implant Device,1680,35,,1680,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1632,34,"If Charge > 2,000, then 34 percent",1632,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3552.01,
STRYKER 628205 SUPERIOR LATERAL PLT 5H,C1713,HCPCS,,79011845,CDM,278,RC,,,both,,,3069,2271.07,,,2271.07,Other,150% of Medicare + 9.63% HCRA Surcharge,1381.05,45,,1381.05,percent of total billed charges,Critical Access Hospital RCC factor,1043.46,34,,1043.46,percent of total billed charges,Implant Device,1043.46,34,,1043.46,percent of total billed charges,Implant Device,1043.46,34,,1043.46,percent of total billed charges,Implant Device,1043.46,34,,1043.46,percent of total billed charges,Implant Device,1043.46,34,,1043.46,percent of total billed charges,Implant Device,1519.16,,,1519.16,Other,110% of Medicare,1074.15,35,,1074.15,percent of total billed charges,Implant Device,1043.46,34,"Charges > $500, x 34%",1043.46,percent of total billed charges,Implant Device,1074.15,35,,1074.15,percent of total billed charges,Implant Device,1074.15,35,,1074.15,percent of total billed charges,Implant Device,1074.15,35,,1074.15,percent of total billed charges,Implant Device,1074.15,35,,1074.15,percent of total billed charges,Implant Device,1074.15,35,,1074.15,percent of total billed charges,Implant Device,1227.6,40,,1227.6,percent of total billed charges,Implant Device,1074.15,70,,1074.15,percent of total billed charges,All Other,1043.46,34,,1043.46,percent of total billed charges,Implant Device,1043.46,34,,1043.46,percent of total billed charges,Implant Device,1074.15,35,,1074.15,percent of total billed charges,Implant Device,1074.15,35,,1074.15,percent of total billed charges,Implant Device,1074.15,35,,1074.15,percent of total billed charges,Implant Device,1074.15,35,,1074.15,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1043.46,34,"If Charge > 2,000, then 34 percent",1043.46,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2271.07,
STRYKER 5567-P-3013 HUMERAL STEM 13X97MM,C1776,HCPCS,,79011848,CDM,278,RC,,,both,,,8925,6604.52,,,6604.52,Other,150% of Medicare + 9.63% HCRA Surcharge,4016.25,45,,4016.25,percent of total billed charges,Critical Access Hospital RCC factor,3034.5,34,,3034.5,percent of total billed charges,Implant Device,3034.5,34,,3034.5,percent of total billed charges,Implant Device,3034.5,34,,3034.5,percent of total billed charges,Implant Device,3034.5,34,,3034.5,percent of total billed charges,Implant Device,3034.5,34,,3034.5,percent of total billed charges,Implant Device,4417.88,,,4417.88,Other,110% of Medicare,3123.75,35,,3123.75,percent of total billed charges,Implant Device,3034.5,34,"Charges > $500, x 34%",3034.5,percent of total billed charges,Implant Device,3123.75,35,,3123.75,percent of total billed charges,Implant Device,3123.75,35,,3123.75,percent of total billed charges,Implant Device,3123.75,35,,3123.75,percent of total billed charges,Implant Device,3123.75,35,,3123.75,percent of total billed charges,Implant Device,3123.75,35,,3123.75,percent of total billed charges,Implant Device,3570,40,,3570,percent of total billed charges,Implant Device,3123.75,70,,3123.75,percent of total billed charges,All Other,3034.5,34,,3034.5,percent of total billed charges,Implant Device,3034.5,34,,3034.5,percent of total billed charges,Implant Device,3123.75,35,,3123.75,percent of total billed charges,Implant Device,3123.75,35,,3123.75,percent of total billed charges,Implant Device,3123.75,35,,3123.75,percent of total billed charges,Implant Device,3123.75,35,,3123.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3034.5,34,"If Charge > 2,000, then 34 percent",3034.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,6604.52,
ARTHREX AR-8735L-12 LOCK SCREW 3.5X14MM,C1713,HCPCS,,79011849,CDM,278,RC,,,both,,,255,188.7,,,188.7,Other,150% of Medicare + 9.63% HCRA Surcharge,114.75,45,,114.75,percent of total billed charges,Critical Access Hospital RCC factor,86.7,34,,86.7,percent of total billed charges,Implant Device,86.7,34,,86.7,percent of total billed charges,Implant Device,86.7,34,,86.7,percent of total billed charges,Implant Device,86.7,34,,86.7,percent of total billed charges,Implant Device,86.7,34,,86.7,percent of total billed charges,Implant Device,126.23,,,126.23,Other,110% of Medicare,89.25,35,,89.25,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,89.25,35,,89.25,percent of total billed charges,Implant Device,89.25,35,,89.25,percent of total billed charges,Implant Device,89.25,35,,89.25,percent of total billed charges,Implant Device,89.25,35,,89.25,percent of total billed charges,Implant Device,89.25,35,,89.25,percent of total billed charges,Implant Device,102,40,,102,percent of total billed charges,Implant Device,89.25,70,,89.25,percent of total billed charges,All Other,86.7,34,,86.7,percent of total billed charges,Implant Device,86.7,34,,86.7,percent of total billed charges,Implant Device,89.25,35,,89.25,percent of total billed charges,Implant Device,89.25,35,,89.25,percent of total billed charges,Implant Device,89.25,35,,89.25,percent of total billed charges,Implant Device,89.25,35,,89.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,188.7,
ABBOTT MN10350-50A SLIMTIP DRG LEAD,C1898,HCPCS,,79011853,CDM,278,RC,,,both,,,2100,1554.01,,,1554.01,Other,150% of Medicare + 9.63% HCRA Surcharge,945,45,,945,percent of total billed charges,Critical Access Hospital RCC factor,714,34,,714,percent of total billed charges,Implant Device,714,34,,714,percent of total billed charges,Implant Device,714,34,,714,percent of total billed charges,Implant Device,714,34,,714,percent of total billed charges,Implant Device,714,34,,714,percent of total billed charges,Implant Device,1039.5,,,1039.5,Other,110% of Medicare,735,35,,735,percent of total billed charges,Implant Device,714,34,"Charges > $500, x 34%",714,percent of total billed charges,Implant Device,735,35,,735,percent of total billed charges,Implant Device,735,35,,735,percent of total billed charges,Implant Device,735,35,,735,percent of total billed charges,Implant Device,735,35,,735,percent of total billed charges,Implant Device,735,35,,735,percent of total billed charges,Implant Device,840,40,,840,percent of total billed charges,Implant Device,735,70,,735,percent of total billed charges,All Other,714,34,,714,percent of total billed charges,Implant Device,714,34,,714,percent of total billed charges,Implant Device,735,35,,735,percent of total billed charges,Implant Device,735,35,,735,percent of total billed charges,Implant Device,735,35,,735,percent of total billed charges,Implant Device,735,35,,735,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,714,34,"If Charge > 2,000, then 34 percent",714,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1554.01,
WRIGHT K30003010 AUGMENT BONE GRAFT 3CC,C1713,HCPCS,,79011855,CDM,278,RC,,,both,,,13425,9934.53,,,9934.53,Other,150% of Medicare + 9.63% HCRA Surcharge,6041.25,45,,6041.25,percent of total billed charges,Critical Access Hospital RCC factor,4564.5,34,,4564.5,percent of total billed charges,Implant Device,4564.5,34,,4564.5,percent of total billed charges,Implant Device,4564.5,34,,4564.5,percent of total billed charges,Implant Device,4564.5,34,,4564.5,percent of total billed charges,Implant Device,4564.5,34,,4564.5,percent of total billed charges,Implant Device,6645.38,,,6645.38,Other,110% of Medicare,4698.75,35,,4698.75,percent of total billed charges,Implant Device,4564.5,34,"Charges > $500, x 34%",4564.5,percent of total billed charges,Implant Device,4698.75,35,,4698.75,percent of total billed charges,Implant Device,4698.75,35,,4698.75,percent of total billed charges,Implant Device,4698.75,35,,4698.75,percent of total billed charges,Implant Device,4698.75,35,,4698.75,percent of total billed charges,Implant Device,4698.75,35,,4698.75,percent of total billed charges,Implant Device,5370,40,,5370,percent of total billed charges,Implant Device,4698.75,70,,4698.75,percent of total billed charges,All Other,4564.5,34,,4564.5,percent of total billed charges,Implant Device,4564.5,34,,4564.5,percent of total billed charges,Implant Device,4698.75,35,,4698.75,percent of total billed charges,Implant Device,4698.75,35,,4698.75,percent of total billed charges,Implant Device,4698.75,35,,4698.75,percent of total billed charges,Implant Device,4698.75,35,,4698.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,4564.5,34,"If Charge > 2,000, then 34 percent",4564.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,9934.53,
WRIGHT FFNS2020 STAPLE NITINOL 20X20MM,C1713,HCPCS,,79011856,CDM,278,RC,,,both,,,9396,6953.06,,,6953.06,Other,150% of Medicare + 9.63% HCRA Surcharge,4228.2,45,,4228.2,percent of total billed charges,Critical Access Hospital RCC factor,3194.64,34,,3194.64,percent of total billed charges,Implant Device,3194.64,34,,3194.64,percent of total billed charges,Implant Device,3194.64,34,,3194.64,percent of total billed charges,Implant Device,3194.64,34,,3194.64,percent of total billed charges,Implant Device,3194.64,34,,3194.64,percent of total billed charges,Implant Device,4651.02,,,4651.02,Other,110% of Medicare,3288.6,35,,3288.6,percent of total billed charges,Implant Device,3194.64,34,"Charges > $500, x 34%",3194.64,percent of total billed charges,Implant Device,3288.6,35,,3288.6,percent of total billed charges,Implant Device,3288.6,35,,3288.6,percent of total billed charges,Implant Device,3288.6,35,,3288.6,percent of total billed charges,Implant Device,3288.6,35,,3288.6,percent of total billed charges,Implant Device,3288.6,35,,3288.6,percent of total billed charges,Implant Device,3758.4,40,,3758.4,percent of total billed charges,Implant Device,3288.6,70,,3288.6,percent of total billed charges,All Other,3194.64,34,,3194.64,percent of total billed charges,Implant Device,3194.64,34,,3194.64,percent of total billed charges,Implant Device,3288.6,35,,3288.6,percent of total billed charges,Implant Device,3288.6,35,,3288.6,percent of total billed charges,Implant Device,3288.6,35,,3288.6,percent of total billed charges,Implant Device,3288.6,35,,3288.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3194.64,34,"If Charge > 2,000, then 34 percent",3194.64,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,6953.06,
STRYKER 602645S CANNULATED SCREW 6.5X45,C1713,HCPCS,,79011857,CDM,278,RC,,,both,,,696,515.04,,,515.04,Other,150% of Medicare + 9.63% HCRA Surcharge,313.2,45,,313.2,percent of total billed charges,Critical Access Hospital RCC factor,236.64,34,,236.64,percent of total billed charges,Implant Device,236.64,34,,236.64,percent of total billed charges,Implant Device,236.64,34,,236.64,percent of total billed charges,Implant Device,236.64,34,,236.64,percent of total billed charges,Implant Device,236.64,34,,236.64,percent of total billed charges,Implant Device,344.52,,,344.52,Other,110% of Medicare,243.6,35,,243.6,percent of total billed charges,Implant Device,236.64,34,"Charges > $500, x 34%",236.64,percent of total billed charges,Implant Device,243.6,35,,243.6,percent of total billed charges,Implant Device,243.6,35,,243.6,percent of total billed charges,Implant Device,243.6,35,,243.6,percent of total billed charges,Implant Device,243.6,35,,243.6,percent of total billed charges,Implant Device,243.6,35,,243.6,percent of total billed charges,Implant Device,278.4,40,,278.4,percent of total billed charges,Implant Device,243.6,70,,243.6,percent of total billed charges,All Other,236.64,34,,236.64,percent of total billed charges,Implant Device,236.64,34,,236.64,percent of total billed charges,Implant Device,243.6,35,,243.6,percent of total billed charges,Implant Device,243.6,35,,243.6,percent of total billed charges,Implant Device,243.6,35,,243.6,percent of total billed charges,Implant Device,243.6,35,,243.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,515.04,
STRYKER 658375 COMPRESSION SCREW 7X75MM,C1713,HCPCS,,79011858,CDM,278,RC,,,both,,,2471,1828.55,,,1828.55,Other,150% of Medicare + 9.63% HCRA Surcharge,1111.95,45,,1111.95,percent of total billed charges,Critical Access Hospital RCC factor,840.14,34,,840.14,percent of total billed charges,Implant Device,840.14,34,,840.14,percent of total billed charges,Implant Device,840.14,34,,840.14,percent of total billed charges,Implant Device,840.14,34,,840.14,percent of total billed charges,Implant Device,840.14,34,,840.14,percent of total billed charges,Implant Device,1223.15,,,1223.15,Other,110% of Medicare,864.85,35,,864.85,percent of total billed charges,Implant Device,840.14,34,"Charges > $500, x 34%",840.14,percent of total billed charges,Implant Device,864.85,35,,864.85,percent of total billed charges,Implant Device,864.85,35,,864.85,percent of total billed charges,Implant Device,864.85,35,,864.85,percent of total billed charges,Implant Device,864.85,35,,864.85,percent of total billed charges,Implant Device,864.85,35,,864.85,percent of total billed charges,Implant Device,988.4,40,,988.4,percent of total billed charges,Implant Device,864.85,70,,864.85,percent of total billed charges,All Other,840.14,34,,840.14,percent of total billed charges,Implant Device,840.14,34,,840.14,percent of total billed charges,Implant Device,864.85,35,,864.85,percent of total billed charges,Implant Device,864.85,35,,864.85,percent of total billed charges,Implant Device,864.85,35,,864.85,percent of total billed charges,Implant Device,864.85,35,,864.85,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,840.14,34,"If Charge > 2,000, then 34 percent",840.14,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1828.55,
J&J 04.001.430S HUMERAL NAIL 9X250MM,C1713,HCPCS,,79011859,CDM,278,RC,,,both,,,3772,2791.29,,,2791.29,Other,150% of Medicare + 9.63% HCRA Surcharge,1697.4,45,,1697.4,percent of total billed charges,Critical Access Hospital RCC factor,1282.48,34,,1282.48,percent of total billed charges,Implant Device,1282.48,34,,1282.48,percent of total billed charges,Implant Device,1282.48,34,,1282.48,percent of total billed charges,Implant Device,1282.48,34,,1282.48,percent of total billed charges,Implant Device,1282.48,34,,1282.48,percent of total billed charges,Implant Device,1867.14,,,1867.14,Other,110% of Medicare,1320.2,35,,1320.2,percent of total billed charges,Implant Device,1282.48,34,"Charges > $500, x 34%",1282.48,percent of total billed charges,Implant Device,1320.2,35,,1320.2,percent of total billed charges,Implant Device,1320.2,35,,1320.2,percent of total billed charges,Implant Device,1320.2,35,,1320.2,percent of total billed charges,Implant Device,1320.2,35,,1320.2,percent of total billed charges,Implant Device,1320.2,35,,1320.2,percent of total billed charges,Implant Device,1508.8,40,,1508.8,percent of total billed charges,Implant Device,1320.2,70,,1320.2,percent of total billed charges,All Other,1282.48,34,,1282.48,percent of total billed charges,Implant Device,1282.48,34,,1282.48,percent of total billed charges,Implant Device,1320.2,35,,1320.2,percent of total billed charges,Implant Device,1320.2,35,,1320.2,percent of total billed charges,Implant Device,1320.2,35,,1320.2,percent of total billed charges,Implant Device,1320.2,35,,1320.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1282.48,34,"If Charge > 2,000, then 34 percent",1282.48,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2791.29,
ZIMMER 00-5001-042-00 BIPOLAR CUP SHELL,C1776,HCPCS,,79011860,CDM,278,RC,,,both,,,1152,852.48,,,852.48,Other,150% of Medicare + 9.63% HCRA Surcharge,518.4,45,,518.4,percent of total billed charges,Critical Access Hospital RCC factor,391.68,34,,391.68,percent of total billed charges,Implant Device,391.68,34,,391.68,percent of total billed charges,Implant Device,391.68,34,,391.68,percent of total billed charges,Implant Device,391.68,34,,391.68,percent of total billed charges,Implant Device,391.68,34,,391.68,percent of total billed charges,Implant Device,570.24,,,570.24,Other,110% of Medicare,403.2,35,,403.2,percent of total billed charges,Implant Device,391.68,34,"Charges > $500, x 34%",391.68,percent of total billed charges,Implant Device,403.2,35,,403.2,percent of total billed charges,Implant Device,403.2,35,,403.2,percent of total billed charges,Implant Device,403.2,35,,403.2,percent of total billed charges,Implant Device,403.2,35,,403.2,percent of total billed charges,Implant Device,403.2,35,,403.2,percent of total billed charges,Implant Device,460.8,40,,460.8,percent of total billed charges,Implant Device,403.2,70,,403.2,percent of total billed charges,All Other,391.68,34,,391.68,percent of total billed charges,Implant Device,391.68,34,,391.68,percent of total billed charges,Implant Device,403.2,35,,403.2,percent of total billed charges,Implant Device,403.2,35,,403.2,percent of total billed charges,Implant Device,403.2,35,,403.2,percent of total billed charges,Implant Device,403.2,35,,403.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,852.48,
ZIMMER 802202202 FEMORAL HEAD 22MM,C1776,HCPCS,,79011861,CDM,278,RC,,,both,,,1152,852.48,,,852.48,Other,150% of Medicare + 9.63% HCRA Surcharge,518.4,45,,518.4,percent of total billed charges,Critical Access Hospital RCC factor,391.68,34,,391.68,percent of total billed charges,Implant Device,391.68,34,,391.68,percent of total billed charges,Implant Device,391.68,34,,391.68,percent of total billed charges,Implant Device,391.68,34,,391.68,percent of total billed charges,Implant Device,391.68,34,,391.68,percent of total billed charges,Implant Device,570.24,,,570.24,Other,110% of Medicare,403.2,35,,403.2,percent of total billed charges,Implant Device,391.68,34,"Charges > $500, x 34%",391.68,percent of total billed charges,Implant Device,403.2,35,,403.2,percent of total billed charges,Implant Device,403.2,35,,403.2,percent of total billed charges,Implant Device,403.2,35,,403.2,percent of total billed charges,Implant Device,403.2,35,,403.2,percent of total billed charges,Implant Device,403.2,35,,403.2,percent of total billed charges,Implant Device,460.8,40,,460.8,percent of total billed charges,Implant Device,403.2,70,,403.2,percent of total billed charges,All Other,391.68,34,,391.68,percent of total billed charges,Implant Device,391.68,34,,391.68,percent of total billed charges,Implant Device,403.2,35,,403.2,percent of total billed charges,Implant Device,403.2,35,,403.2,percent of total billed charges,Implant Device,403.2,35,,403.2,percent of total billed charges,Implant Device,403.2,35,,403.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,852.48,
BOST H74938046660750 6X60X75CM LD STENT,C1876,HCPCS,,79011872,CDM,278,RC,,,both,,,1976,1462.24,,,1462.24,Other,150% of Medicare + 9.63% HCRA Surcharge,889.2,45,,889.2,percent of total billed charges,Critical Access Hospital RCC factor,671.84,34,,671.84,percent of total billed charges,Implant Device,671.84,34,,671.84,percent of total billed charges,Implant Device,671.84,34,,671.84,percent of total billed charges,Implant Device,671.84,34,,671.84,percent of total billed charges,Implant Device,671.84,34,,671.84,percent of total billed charges,Implant Device,978.12,,,978.12,Other,110% of Medicare,691.6,35,,691.6,percent of total billed charges,Implant Device,671.84,34,"Charges > $500, x 34%",671.84,percent of total billed charges,Implant Device,691.6,35,,691.6,percent of total billed charges,Implant Device,691.6,35,,691.6,percent of total billed charges,Implant Device,691.6,35,,691.6,percent of total billed charges,Implant Device,691.6,35,,691.6,percent of total billed charges,Implant Device,691.6,35,,691.6,percent of total billed charges,Implant Device,790.4,40,,790.4,percent of total billed charges,Implant Device,691.6,70,,691.6,percent of total billed charges,All Other,671.84,34,,671.84,percent of total billed charges,Implant Device,671.84,34,,671.84,percent of total billed charges,Implant Device,691.6,35,,691.6,percent of total billed charges,Implant Device,691.6,35,,691.6,percent of total billed charges,Implant Device,691.6,35,,691.6,percent of total billed charges,Implant Device,691.6,35,,691.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1462.24,
BOST H74938046920750 9X30X75CM LD STENT,C1876,HCPCS,,79011873,CDM,278,RC,,,both,,,1976,1462.24,,,1462.24,Other,150% of Medicare + 9.63% HCRA Surcharge,889.2,45,,889.2,percent of total billed charges,Critical Access Hospital RCC factor,671.84,34,,671.84,percent of total billed charges,Implant Device,671.84,34,,671.84,percent of total billed charges,Implant Device,671.84,34,,671.84,percent of total billed charges,Implant Device,671.84,34,,671.84,percent of total billed charges,Implant Device,671.84,34,,671.84,percent of total billed charges,Implant Device,978.12,,,978.12,Other,110% of Medicare,691.6,35,,691.6,percent of total billed charges,Implant Device,671.84,34,"Charges > $500, x 34%",671.84,percent of total billed charges,Implant Device,691.6,35,,691.6,percent of total billed charges,Implant Device,691.6,35,,691.6,percent of total billed charges,Implant Device,691.6,35,,691.6,percent of total billed charges,Implant Device,691.6,35,,691.6,percent of total billed charges,Implant Device,691.6,35,,691.6,percent of total billed charges,Implant Device,790.4,40,,790.4,percent of total billed charges,Implant Device,691.6,70,,691.6,percent of total billed charges,All Other,671.84,34,,671.84,percent of total billed charges,Implant Device,671.84,34,,671.84,percent of total billed charges,Implant Device,691.6,35,,691.6,percent of total billed charges,Implant Device,691.6,35,,691.6,percent of total billed charges,Implant Device,691.6,35,,691.6,percent of total billed charges,Implant Device,691.6,35,,691.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1462.24,
BOST H74938047630130 6X30X135CM LD STENT,C1876,HCPCS,,79011874,CDM,278,RC,,,both,,,1976,1462.24,,,1462.24,Other,150% of Medicare + 9.63% HCRA Surcharge,889.2,45,,889.2,percent of total billed charges,Critical Access Hospital RCC factor,671.84,34,,671.84,percent of total billed charges,Implant Device,671.84,34,,671.84,percent of total billed charges,Implant Device,671.84,34,,671.84,percent of total billed charges,Implant Device,671.84,34,,671.84,percent of total billed charges,Implant Device,671.84,34,,671.84,percent of total billed charges,Implant Device,978.12,,,978.12,Other,110% of Medicare,691.6,35,,691.6,percent of total billed charges,Implant Device,671.84,34,"Charges > $500, x 34%",671.84,percent of total billed charges,Implant Device,691.6,35,,691.6,percent of total billed charges,Implant Device,691.6,35,,691.6,percent of total billed charges,Implant Device,691.6,35,,691.6,percent of total billed charges,Implant Device,691.6,35,,691.6,percent of total billed charges,Implant Device,691.6,35,,691.6,percent of total billed charges,Implant Device,790.4,40,,790.4,percent of total billed charges,Implant Device,691.6,70,,691.6,percent of total billed charges,All Other,671.84,34,,671.84,percent of total billed charges,Implant Device,671.84,34,,671.84,percent of total billed charges,Implant Device,691.6,35,,691.6,percent of total billed charges,Implant Device,691.6,35,,691.6,percent of total billed charges,Implant Device,691.6,35,,691.6,percent of total billed charges,Implant Device,691.6,35,,691.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1462.24,
BOST H74938047730130 7X30X135CM LD STENT,C1876,HCPCS,,79011875,CDM,278,RC,,,both,,,1976,1462.24,,,1462.24,Other,150% of Medicare + 9.63% HCRA Surcharge,889.2,45,,889.2,percent of total billed charges,Critical Access Hospital RCC factor,671.84,34,,671.84,percent of total billed charges,Implant Device,671.84,34,,671.84,percent of total billed charges,Implant Device,671.84,34,,671.84,percent of total billed charges,Implant Device,671.84,34,,671.84,percent of total billed charges,Implant Device,671.84,34,,671.84,percent of total billed charges,Implant Device,978.12,,,978.12,Other,110% of Medicare,691.6,35,,691.6,percent of total billed charges,Implant Device,671.84,34,"Charges > $500, x 34%",671.84,percent of total billed charges,Implant Device,691.6,35,,691.6,percent of total billed charges,Implant Device,691.6,35,,691.6,percent of total billed charges,Implant Device,691.6,35,,691.6,percent of total billed charges,Implant Device,691.6,35,,691.6,percent of total billed charges,Implant Device,691.6,35,,691.6,percent of total billed charges,Implant Device,790.4,40,,790.4,percent of total billed charges,Implant Device,691.6,70,,691.6,percent of total billed charges,All Other,671.84,34,,671.84,percent of total billed charges,Implant Device,671.84,34,,671.84,percent of total billed charges,Implant Device,691.6,35,,691.6,percent of total billed charges,Implant Device,691.6,35,,691.6,percent of total billed charges,Implant Device,691.6,35,,691.6,percent of total billed charges,Implant Device,691.6,35,,691.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1462.24,
BOST H74937912719150 7X19X150CM SD STENT,C1876,HCPCS,,79011876,CDM,278,RC,,,both,,,1976,1462.24,,,1462.24,Other,150% of Medicare + 9.63% HCRA Surcharge,889.2,45,,889.2,percent of total billed charges,Critical Access Hospital RCC factor,671.84,34,,671.84,percent of total billed charges,Implant Device,671.84,34,,671.84,percent of total billed charges,Implant Device,671.84,34,,671.84,percent of total billed charges,Implant Device,671.84,34,,671.84,percent of total billed charges,Implant Device,671.84,34,,671.84,percent of total billed charges,Implant Device,978.12,,,978.12,Other,110% of Medicare,691.6,35,,691.6,percent of total billed charges,Implant Device,671.84,34,"Charges > $500, x 34%",671.84,percent of total billed charges,Implant Device,691.6,35,,691.6,percent of total billed charges,Implant Device,691.6,35,,691.6,percent of total billed charges,Implant Device,691.6,35,,691.6,percent of total billed charges,Implant Device,691.6,35,,691.6,percent of total billed charges,Implant Device,691.6,35,,691.6,percent of total billed charges,Implant Device,790.4,40,,790.4,percent of total billed charges,Implant Device,691.6,70,,691.6,percent of total billed charges,All Other,671.84,34,,671.84,percent of total billed charges,Implant Device,671.84,34,,671.84,percent of total billed charges,Implant Device,691.6,35,,691.6,percent of total billed charges,Implant Device,691.6,35,,691.6,percent of total billed charges,Implant Device,691.6,35,,691.6,percent of total billed charges,Implant Device,691.6,35,,691.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1462.24,
BOST H74939293064030 6X40X130CM STENT,C1876,HCPCS,,79011877,CDM,278,RC,,,both,,,1623,1201.02,,,1201.02,Other,150% of Medicare + 9.63% HCRA Surcharge,730.35,45,,730.35,percent of total billed charges,Critical Access Hospital RCC factor,551.82,34,,551.82,percent of total billed charges,Implant Device,551.82,34,,551.82,percent of total billed charges,Implant Device,551.82,34,,551.82,percent of total billed charges,Implant Device,551.82,34,,551.82,percent of total billed charges,Implant Device,551.82,34,,551.82,percent of total billed charges,Implant Device,803.39,,,803.39,Other,110% of Medicare,568.05,35,,568.05,percent of total billed charges,Implant Device,551.82,34,"Charges > $500, x 34%",551.82,percent of total billed charges,Implant Device,568.05,35,,568.05,percent of total billed charges,Implant Device,568.05,35,,568.05,percent of total billed charges,Implant Device,568.05,35,,568.05,percent of total billed charges,Implant Device,568.05,35,,568.05,percent of total billed charges,Implant Device,568.05,35,,568.05,percent of total billed charges,Implant Device,649.2,40,,649.2,percent of total billed charges,Implant Device,568.05,70,,568.05,percent of total billed charges,All Other,551.82,34,,551.82,percent of total billed charges,Implant Device,551.82,34,,551.82,percent of total billed charges,Implant Device,568.05,35,,568.05,percent of total billed charges,Implant Device,568.05,35,,568.05,percent of total billed charges,Implant Device,568.05,35,,568.05,percent of total billed charges,Implant Device,568.05,35,,568.05,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1201.02,
BOST H74939293068030 6X80X130CM STENT,C1876,HCPCS,,79011878,CDM,278,RC,,,both,,,1623,1201.02,,,1201.02,Other,150% of Medicare + 9.63% HCRA Surcharge,730.35,45,,730.35,percent of total billed charges,Critical Access Hospital RCC factor,551.82,34,,551.82,percent of total billed charges,Implant Device,551.82,34,,551.82,percent of total billed charges,Implant Device,551.82,34,,551.82,percent of total billed charges,Implant Device,551.82,34,,551.82,percent of total billed charges,Implant Device,551.82,34,,551.82,percent of total billed charges,Implant Device,803.39,,,803.39,Other,110% of Medicare,568.05,35,,568.05,percent of total billed charges,Implant Device,551.82,34,"Charges > $500, x 34%",551.82,percent of total billed charges,Implant Device,568.05,35,,568.05,percent of total billed charges,Implant Device,568.05,35,,568.05,percent of total billed charges,Implant Device,568.05,35,,568.05,percent of total billed charges,Implant Device,568.05,35,,568.05,percent of total billed charges,Implant Device,568.05,35,,568.05,percent of total billed charges,Implant Device,649.2,40,,649.2,percent of total billed charges,Implant Device,568.05,70,,568.05,percent of total billed charges,All Other,551.82,34,,551.82,percent of total billed charges,Implant Device,551.82,34,,551.82,percent of total billed charges,Implant Device,568.05,35,,568.05,percent of total billed charges,Implant Device,568.05,35,,568.05,percent of total billed charges,Implant Device,568.05,35,,568.05,percent of total billed charges,Implant Device,568.05,35,,568.05,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1201.02,
BOST H74939293061030 6X100X130CM STENT,C1876,HCPCS,,79011879,CDM,278,RC,,,both,,,1623,1201.02,,,1201.02,Other,150% of Medicare + 9.63% HCRA Surcharge,730.35,45,,730.35,percent of total billed charges,Critical Access Hospital RCC factor,551.82,34,,551.82,percent of total billed charges,Implant Device,551.82,34,,551.82,percent of total billed charges,Implant Device,551.82,34,,551.82,percent of total billed charges,Implant Device,551.82,34,,551.82,percent of total billed charges,Implant Device,551.82,34,,551.82,percent of total billed charges,Implant Device,803.39,,,803.39,Other,110% of Medicare,568.05,35,,568.05,percent of total billed charges,Implant Device,551.82,34,"Charges > $500, x 34%",551.82,percent of total billed charges,Implant Device,568.05,35,,568.05,percent of total billed charges,Implant Device,568.05,35,,568.05,percent of total billed charges,Implant Device,568.05,35,,568.05,percent of total billed charges,Implant Device,568.05,35,,568.05,percent of total billed charges,Implant Device,568.05,35,,568.05,percent of total billed charges,Implant Device,649.2,40,,649.2,percent of total billed charges,Implant Device,568.05,70,,568.05,percent of total billed charges,All Other,551.82,34,,551.82,percent of total billed charges,Implant Device,551.82,34,,551.82,percent of total billed charges,Implant Device,568.05,35,,568.05,percent of total billed charges,Implant Device,568.05,35,,568.05,percent of total billed charges,Implant Device,568.05,35,,568.05,percent of total billed charges,Implant Device,568.05,35,,568.05,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1201.02,
BOST H74939293061530 6X150X130CM STENT,C1876,HCPCS,,79011880,CDM,278,RC,,,both,,,2117,1566.59,,,1566.59,Other,150% of Medicare + 9.63% HCRA Surcharge,952.65,45,,952.65,percent of total billed charges,Critical Access Hospital RCC factor,719.78,34,,719.78,percent of total billed charges,Implant Device,719.78,34,,719.78,percent of total billed charges,Implant Device,719.78,34,,719.78,percent of total billed charges,Implant Device,719.78,34,,719.78,percent of total billed charges,Implant Device,719.78,34,,719.78,percent of total billed charges,Implant Device,1047.92,,,1047.92,Other,110% of Medicare,740.95,35,,740.95,percent of total billed charges,Implant Device,719.78,34,"Charges > $500, x 34%",719.78,percent of total billed charges,Implant Device,740.95,35,,740.95,percent of total billed charges,Implant Device,740.95,35,,740.95,percent of total billed charges,Implant Device,740.95,35,,740.95,percent of total billed charges,Implant Device,740.95,35,,740.95,percent of total billed charges,Implant Device,740.95,35,,740.95,percent of total billed charges,Implant Device,846.8,40,,846.8,percent of total billed charges,Implant Device,740.95,70,,740.95,percent of total billed charges,All Other,719.78,34,,719.78,percent of total billed charges,Implant Device,719.78,34,,719.78,percent of total billed charges,Implant Device,740.95,35,,740.95,percent of total billed charges,Implant Device,740.95,35,,740.95,percent of total billed charges,Implant Device,740.95,35,,740.95,percent of total billed charges,Implant Device,740.95,35,,740.95,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,719.78,34,"If Charge > 2,000, then 34 percent",719.78,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1566.59,
BOST H74939293074030 7X40X130CM STENT,C1876,HCPCS,,79011881,CDM,278,RC,,,both,,,1623,1201.02,,,1201.02,Other,150% of Medicare + 9.63% HCRA Surcharge,730.35,45,,730.35,percent of total billed charges,Critical Access Hospital RCC factor,551.82,34,,551.82,percent of total billed charges,Implant Device,551.82,34,,551.82,percent of total billed charges,Implant Device,551.82,34,,551.82,percent of total billed charges,Implant Device,551.82,34,,551.82,percent of total billed charges,Implant Device,551.82,34,,551.82,percent of total billed charges,Implant Device,803.39,,,803.39,Other,110% of Medicare,568.05,35,,568.05,percent of total billed charges,Implant Device,551.82,34,"Charges > $500, x 34%",551.82,percent of total billed charges,Implant Device,568.05,35,,568.05,percent of total billed charges,Implant Device,568.05,35,,568.05,percent of total billed charges,Implant Device,568.05,35,,568.05,percent of total billed charges,Implant Device,568.05,35,,568.05,percent of total billed charges,Implant Device,568.05,35,,568.05,percent of total billed charges,Implant Device,649.2,40,,649.2,percent of total billed charges,Implant Device,568.05,70,,568.05,percent of total billed charges,All Other,551.82,34,,551.82,percent of total billed charges,Implant Device,551.82,34,,551.82,percent of total billed charges,Implant Device,568.05,35,,568.05,percent of total billed charges,Implant Device,568.05,35,,568.05,percent of total billed charges,Implant Device,568.05,35,,568.05,percent of total billed charges,Implant Device,568.05,35,,568.05,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1201.02,
BOST H74939293078030 7X80X130CM STENT,C1876,HCPCS,,79011882,CDM,278,RC,,,both,,,1623,1201.02,,,1201.02,Other,150% of Medicare + 9.63% HCRA Surcharge,730.35,45,,730.35,percent of total billed charges,Critical Access Hospital RCC factor,551.82,34,,551.82,percent of total billed charges,Implant Device,551.82,34,,551.82,percent of total billed charges,Implant Device,551.82,34,,551.82,percent of total billed charges,Implant Device,551.82,34,,551.82,percent of total billed charges,Implant Device,551.82,34,,551.82,percent of total billed charges,Implant Device,803.39,,,803.39,Other,110% of Medicare,568.05,35,,568.05,percent of total billed charges,Implant Device,551.82,34,"Charges > $500, x 34%",551.82,percent of total billed charges,Implant Device,568.05,35,,568.05,percent of total billed charges,Implant Device,568.05,35,,568.05,percent of total billed charges,Implant Device,568.05,35,,568.05,percent of total billed charges,Implant Device,568.05,35,,568.05,percent of total billed charges,Implant Device,568.05,35,,568.05,percent of total billed charges,Implant Device,649.2,40,,649.2,percent of total billed charges,Implant Device,568.05,70,,568.05,percent of total billed charges,All Other,551.82,34,,551.82,percent of total billed charges,Implant Device,551.82,34,,551.82,percent of total billed charges,Implant Device,568.05,35,,568.05,percent of total billed charges,Implant Device,568.05,35,,568.05,percent of total billed charges,Implant Device,568.05,35,,568.05,percent of total billed charges,Implant Device,568.05,35,,568.05,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1201.02,
BOST H74939293071030 7X100X130CM STENT,C1876,HCPCS,,79011883,CDM,278,RC,,,both,,,1623,1201.02,,,1201.02,Other,150% of Medicare + 9.63% HCRA Surcharge,730.35,45,,730.35,percent of total billed charges,Critical Access Hospital RCC factor,551.82,34,,551.82,percent of total billed charges,Implant Device,551.82,34,,551.82,percent of total billed charges,Implant Device,551.82,34,,551.82,percent of total billed charges,Implant Device,551.82,34,,551.82,percent of total billed charges,Implant Device,551.82,34,,551.82,percent of total billed charges,Implant Device,803.39,,,803.39,Other,110% of Medicare,568.05,35,,568.05,percent of total billed charges,Implant Device,551.82,34,"Charges > $500, x 34%",551.82,percent of total billed charges,Implant Device,568.05,35,,568.05,percent of total billed charges,Implant Device,568.05,35,,568.05,percent of total billed charges,Implant Device,568.05,35,,568.05,percent of total billed charges,Implant Device,568.05,35,,568.05,percent of total billed charges,Implant Device,568.05,35,,568.05,percent of total billed charges,Implant Device,649.2,40,,649.2,percent of total billed charges,Implant Device,568.05,70,,568.05,percent of total billed charges,All Other,551.82,34,,551.82,percent of total billed charges,Implant Device,551.82,34,,551.82,percent of total billed charges,Implant Device,568.05,35,,568.05,percent of total billed charges,Implant Device,568.05,35,,568.05,percent of total billed charges,Implant Device,568.05,35,,568.05,percent of total billed charges,Implant Device,568.05,35,,568.05,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1201.02,
BOST H74939293071530 7X150X130CM STENT,C1876,HCPCS,,79011884,CDM,278,RC,,,both,,,2117,1566.59,,,1566.59,Other,150% of Medicare + 9.63% HCRA Surcharge,952.65,45,,952.65,percent of total billed charges,Critical Access Hospital RCC factor,719.78,34,,719.78,percent of total billed charges,Implant Device,719.78,34,,719.78,percent of total billed charges,Implant Device,719.78,34,,719.78,percent of total billed charges,Implant Device,719.78,34,,719.78,percent of total billed charges,Implant Device,719.78,34,,719.78,percent of total billed charges,Implant Device,1047.92,,,1047.92,Other,110% of Medicare,740.95,35,,740.95,percent of total billed charges,Implant Device,719.78,34,"Charges > $500, x 34%",719.78,percent of total billed charges,Implant Device,740.95,35,,740.95,percent of total billed charges,Implant Device,740.95,35,,740.95,percent of total billed charges,Implant Device,740.95,35,,740.95,percent of total billed charges,Implant Device,740.95,35,,740.95,percent of total billed charges,Implant Device,740.95,35,,740.95,percent of total billed charges,Implant Device,846.8,40,,846.8,percent of total billed charges,Implant Device,740.95,70,,740.95,percent of total billed charges,All Other,719.78,34,,719.78,percent of total billed charges,Implant Device,719.78,34,,719.78,percent of total billed charges,Implant Device,740.95,35,,740.95,percent of total billed charges,Implant Device,740.95,35,,740.95,percent of total billed charges,Implant Device,740.95,35,,740.95,percent of total billed charges,Implant Device,740.95,35,,740.95,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,719.78,34,"If Charge > 2,000, then 34 percent",719.78,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1566.59,
BOST H74939200084070 8X40X75 EPIC STENT,C1876,HCPCS,,79011885,CDM,278,RC,,,both,,,1553,1149.22,,,1149.22,Other,150% of Medicare + 9.63% HCRA Surcharge,698.85,45,,698.85,percent of total billed charges,Critical Access Hospital RCC factor,528.02,34,,528.02,percent of total billed charges,Implant Device,528.02,34,,528.02,percent of total billed charges,Implant Device,528.02,34,,528.02,percent of total billed charges,Implant Device,528.02,34,,528.02,percent of total billed charges,Implant Device,528.02,34,,528.02,percent of total billed charges,Implant Device,768.74,,,768.74,Other,110% of Medicare,543.55,35,,543.55,percent of total billed charges,Implant Device,528.02,34,"Charges > $500, x 34%",528.02,percent of total billed charges,Implant Device,543.55,35,,543.55,percent of total billed charges,Implant Device,543.55,35,,543.55,percent of total billed charges,Implant Device,543.55,35,,543.55,percent of total billed charges,Implant Device,543.55,35,,543.55,percent of total billed charges,Implant Device,543.55,35,,543.55,percent of total billed charges,Implant Device,621.2,40,,621.2,percent of total billed charges,Implant Device,543.55,70,,543.55,percent of total billed charges,All Other,528.02,34,,528.02,percent of total billed charges,Implant Device,528.02,34,,528.02,percent of total billed charges,Implant Device,543.55,35,,543.55,percent of total billed charges,Implant Device,543.55,35,,543.55,percent of total billed charges,Implant Device,543.55,35,,543.55,percent of total billed charges,Implant Device,543.55,35,,543.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1149.22,
BOST H74939200088070 8X80X75 EPIC STENT,C1876,HCPCS,,79011886,CDM,278,RC,,,both,,,1553,1149.22,,,1149.22,Other,150% of Medicare + 9.63% HCRA Surcharge,698.85,45,,698.85,percent of total billed charges,Critical Access Hospital RCC factor,528.02,34,,528.02,percent of total billed charges,Implant Device,528.02,34,,528.02,percent of total billed charges,Implant Device,528.02,34,,528.02,percent of total billed charges,Implant Device,528.02,34,,528.02,percent of total billed charges,Implant Device,528.02,34,,528.02,percent of total billed charges,Implant Device,768.74,,,768.74,Other,110% of Medicare,543.55,35,,543.55,percent of total billed charges,Implant Device,528.02,34,"Charges > $500, x 34%",528.02,percent of total billed charges,Implant Device,543.55,35,,543.55,percent of total billed charges,Implant Device,543.55,35,,543.55,percent of total billed charges,Implant Device,543.55,35,,543.55,percent of total billed charges,Implant Device,543.55,35,,543.55,percent of total billed charges,Implant Device,543.55,35,,543.55,percent of total billed charges,Implant Device,621.2,40,,621.2,percent of total billed charges,Implant Device,543.55,70,,543.55,percent of total billed charges,All Other,528.02,34,,528.02,percent of total billed charges,Implant Device,528.02,34,,528.02,percent of total billed charges,Implant Device,543.55,35,,543.55,percent of total billed charges,Implant Device,543.55,35,,543.55,percent of total billed charges,Implant Device,543.55,35,,543.55,percent of total billed charges,Implant Device,543.55,35,,543.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1149.22,
BOST H74939200094070 9X40X75 EPIC STENT,C1876,HCPCS,,79011887,CDM,278,RC,,,both,,,1553,1149.22,,,1149.22,Other,150% of Medicare + 9.63% HCRA Surcharge,698.85,45,,698.85,percent of total billed charges,Critical Access Hospital RCC factor,528.02,34,,528.02,percent of total billed charges,Implant Device,528.02,34,,528.02,percent of total billed charges,Implant Device,528.02,34,,528.02,percent of total billed charges,Implant Device,528.02,34,,528.02,percent of total billed charges,Implant Device,528.02,34,,528.02,percent of total billed charges,Implant Device,768.74,,,768.74,Other,110% of Medicare,543.55,35,,543.55,percent of total billed charges,Implant Device,528.02,34,"Charges > $500, x 34%",528.02,percent of total billed charges,Implant Device,543.55,35,,543.55,percent of total billed charges,Implant Device,543.55,35,,543.55,percent of total billed charges,Implant Device,543.55,35,,543.55,percent of total billed charges,Implant Device,543.55,35,,543.55,percent of total billed charges,Implant Device,543.55,35,,543.55,percent of total billed charges,Implant Device,621.2,40,,621.2,percent of total billed charges,Implant Device,543.55,70,,543.55,percent of total billed charges,All Other,528.02,34,,528.02,percent of total billed charges,Implant Device,528.02,34,,528.02,percent of total billed charges,Implant Device,543.55,35,,543.55,percent of total billed charges,Implant Device,543.55,35,,543.55,percent of total billed charges,Implant Device,543.55,35,,543.55,percent of total billed charges,Implant Device,543.55,35,,543.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1149.22,
BOST H74939200096070 9X60X75 EPIC STENT,C1876,HCPCS,,79011888,CDM,278,RC,,,both,,,1553,1149.22,,,1149.22,Other,150% of Medicare + 9.63% HCRA Surcharge,698.85,45,,698.85,percent of total billed charges,Critical Access Hospital RCC factor,528.02,34,,528.02,percent of total billed charges,Implant Device,528.02,34,,528.02,percent of total billed charges,Implant Device,528.02,34,,528.02,percent of total billed charges,Implant Device,528.02,34,,528.02,percent of total billed charges,Implant Device,528.02,34,,528.02,percent of total billed charges,Implant Device,768.74,,,768.74,Other,110% of Medicare,543.55,35,,543.55,percent of total billed charges,Implant Device,528.02,34,"Charges > $500, x 34%",528.02,percent of total billed charges,Implant Device,543.55,35,,543.55,percent of total billed charges,Implant Device,543.55,35,,543.55,percent of total billed charges,Implant Device,543.55,35,,543.55,percent of total billed charges,Implant Device,543.55,35,,543.55,percent of total billed charges,Implant Device,543.55,35,,543.55,percent of total billed charges,Implant Device,621.2,40,,621.2,percent of total billed charges,Implant Device,543.55,70,,543.55,percent of total billed charges,All Other,528.02,34,,528.02,percent of total billed charges,Implant Device,528.02,34,,528.02,percent of total billed charges,Implant Device,543.55,35,,543.55,percent of total billed charges,Implant Device,543.55,35,,543.55,percent of total billed charges,Implant Device,543.55,35,,543.55,percent of total billed charges,Implant Device,543.55,35,,543.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1149.22,
BOST H74939200104070 10X40X75 EPIC STENT,C1876,HCPCS,,79011889,CDM,278,RC,,,both,,,1553,1149.22,,,1149.22,Other,150% of Medicare + 9.63% HCRA Surcharge,698.85,45,,698.85,percent of total billed charges,Critical Access Hospital RCC factor,528.02,34,,528.02,percent of total billed charges,Implant Device,528.02,34,,528.02,percent of total billed charges,Implant Device,528.02,34,,528.02,percent of total billed charges,Implant Device,528.02,34,,528.02,percent of total billed charges,Implant Device,528.02,34,,528.02,percent of total billed charges,Implant Device,768.74,,,768.74,Other,110% of Medicare,543.55,35,,543.55,percent of total billed charges,Implant Device,528.02,34,"Charges > $500, x 34%",528.02,percent of total billed charges,Implant Device,543.55,35,,543.55,percent of total billed charges,Implant Device,543.55,35,,543.55,percent of total billed charges,Implant Device,543.55,35,,543.55,percent of total billed charges,Implant Device,543.55,35,,543.55,percent of total billed charges,Implant Device,543.55,35,,543.55,percent of total billed charges,Implant Device,621.2,40,,621.2,percent of total billed charges,Implant Device,543.55,70,,543.55,percent of total billed charges,All Other,528.02,34,,528.02,percent of total billed charges,Implant Device,528.02,34,,528.02,percent of total billed charges,Implant Device,543.55,35,,543.55,percent of total billed charges,Implant Device,543.55,35,,543.55,percent of total billed charges,Implant Device,543.55,35,,543.55,percent of total billed charges,Implant Device,543.55,35,,543.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1149.22,
BOST H74939200106070 EPIC STENT,C1876,HCPCS,,79011890,CDM,278,RC,,,both,,,1553,1149.22,,,1149.22,Other,150% of Medicare + 9.63% HCRA Surcharge,698.85,45,,698.85,percent of total billed charges,Critical Access Hospital RCC factor,528.02,34,,528.02,percent of total billed charges,Implant Device,528.02,34,,528.02,percent of total billed charges,Implant Device,528.02,34,,528.02,percent of total billed charges,Implant Device,528.02,34,,528.02,percent of total billed charges,Implant Device,528.02,34,,528.02,percent of total billed charges,Implant Device,768.74,,,768.74,Other,110% of Medicare,543.55,35,,543.55,percent of total billed charges,Implant Device,528.02,34,"Charges > $500, x 34%",528.02,percent of total billed charges,Implant Device,543.55,35,,543.55,percent of total billed charges,Implant Device,543.55,35,,543.55,percent of total billed charges,Implant Device,543.55,35,,543.55,percent of total billed charges,Implant Device,543.55,35,,543.55,percent of total billed charges,Implant Device,543.55,35,,543.55,percent of total billed charges,Implant Device,621.2,40,,621.2,percent of total billed charges,Implant Device,543.55,70,,543.55,percent of total billed charges,All Other,528.02,34,,528.02,percent of total billed charges,Implant Device,528.02,34,,528.02,percent of total billed charges,Implant Device,543.55,35,,543.55,percent of total billed charges,Implant Device,543.55,35,,543.55,percent of total billed charges,Implant Device,543.55,35,,543.55,percent of total billed charges,Implant Device,543.55,35,,543.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1149.22,
BOST H74939200124070 12X40X75 EPIC STENT,C1876,HCPCS,,79011891,CDM,278,RC,,,both,,,1553,1149.22,,,1149.22,Other,150% of Medicare + 9.63% HCRA Surcharge,698.85,45,,698.85,percent of total billed charges,Critical Access Hospital RCC factor,528.02,34,,528.02,percent of total billed charges,Implant Device,528.02,34,,528.02,percent of total billed charges,Implant Device,528.02,34,,528.02,percent of total billed charges,Implant Device,528.02,34,,528.02,percent of total billed charges,Implant Device,528.02,34,,528.02,percent of total billed charges,Implant Device,768.74,,,768.74,Other,110% of Medicare,543.55,35,,543.55,percent of total billed charges,Implant Device,528.02,34,"Charges > $500, x 34%",528.02,percent of total billed charges,Implant Device,543.55,35,,543.55,percent of total billed charges,Implant Device,543.55,35,,543.55,percent of total billed charges,Implant Device,543.55,35,,543.55,percent of total billed charges,Implant Device,543.55,35,,543.55,percent of total billed charges,Implant Device,543.55,35,,543.55,percent of total billed charges,Implant Device,621.2,40,,621.2,percent of total billed charges,Implant Device,543.55,70,,543.55,percent of total billed charges,All Other,528.02,34,,528.02,percent of total billed charges,Implant Device,528.02,34,,528.02,percent of total billed charges,Implant Device,543.55,35,,543.55,percent of total billed charges,Implant Device,543.55,35,,543.55,percent of total billed charges,Implant Device,543.55,35,,543.55,percent of total billed charges,Implant Device,543.55,35,,543.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1149.22,
BOST H74939200126070 12X60X75 EPIC STENT,C1876,HCPCS,,79011892,CDM,278,RC,,,both,,,1553,1149.22,,,1149.22,Other,150% of Medicare + 9.63% HCRA Surcharge,698.85,45,,698.85,percent of total billed charges,Critical Access Hospital RCC factor,528.02,34,,528.02,percent of total billed charges,Implant Device,528.02,34,,528.02,percent of total billed charges,Implant Device,528.02,34,,528.02,percent of total billed charges,Implant Device,528.02,34,,528.02,percent of total billed charges,Implant Device,528.02,34,,528.02,percent of total billed charges,Implant Device,768.74,,,768.74,Other,110% of Medicare,543.55,35,,543.55,percent of total billed charges,Implant Device,528.02,34,"Charges > $500, x 34%",528.02,percent of total billed charges,Implant Device,543.55,35,,543.55,percent of total billed charges,Implant Device,543.55,35,,543.55,percent of total billed charges,Implant Device,543.55,35,,543.55,percent of total billed charges,Implant Device,543.55,35,,543.55,percent of total billed charges,Implant Device,543.55,35,,543.55,percent of total billed charges,Implant Device,621.2,40,,621.2,percent of total billed charges,Implant Device,543.55,70,,543.55,percent of total billed charges,All Other,528.02,34,,528.02,percent of total billed charges,Implant Device,528.02,34,,528.02,percent of total billed charges,Implant Device,543.55,35,,543.55,percent of total billed charges,Implant Device,543.55,35,,543.55,percent of total billed charges,Implant Device,543.55,35,,543.55,percent of total billed charges,Implant Device,543.55,35,,543.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1149.22,
BOST H74939294600410 6X40X130 ELU STENT,C1874,HCPCS,,79011893,CDM,278,RC,,,both,,,5925,4384.51,,,4384.51,Other,150% of Medicare + 9.63% HCRA Surcharge,2666.25,45,,2666.25,percent of total billed charges,Critical Access Hospital RCC factor,2014.5,34,,2014.5,percent of total billed charges,Implant Device,2014.5,34,,2014.5,percent of total billed charges,Implant Device,2014.5,34,,2014.5,percent of total billed charges,Implant Device,2014.5,34,,2014.5,percent of total billed charges,Implant Device,2014.5,34,,2014.5,percent of total billed charges,Implant Device,2932.88,,,2932.88,Other,110% of Medicare,2073.75,35,,2073.75,percent of total billed charges,Implant Device,2014.5,34,"Charges > $500, x 34%",2014.5,percent of total billed charges,Implant Device,2073.75,35,,2073.75,percent of total billed charges,Implant Device,2073.75,35,,2073.75,percent of total billed charges,Implant Device,2073.75,35,,2073.75,percent of total billed charges,Implant Device,2073.75,35,,2073.75,percent of total billed charges,Implant Device,2073.75,35,,2073.75,percent of total billed charges,Implant Device,2370,40,,2370,percent of total billed charges,Implant Device,2073.75,70,,2073.75,percent of total billed charges,All Other,2014.5,34,,2014.5,percent of total billed charges,Implant Device,2014.5,34,,2014.5,percent of total billed charges,Implant Device,2073.75,35,,2073.75,percent of total billed charges,Implant Device,2073.75,35,,2073.75,percent of total billed charges,Implant Device,2073.75,35,,2073.75,percent of total billed charges,Implant Device,2073.75,35,,2073.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2014.5,34,"If Charge > 2,000, then 34 percent",2014.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4384.51,
BOST H74939294600810 6X80X130 ELU STENT,C1874,HCPCS,,79011894,CDM,278,RC,,,both,,,7725,5716.52,,,5716.52,Other,150% of Medicare + 9.63% HCRA Surcharge,3476.25,45,,3476.25,percent of total billed charges,Critical Access Hospital RCC factor,2626.5,34,,2626.5,percent of total billed charges,Implant Device,2626.5,34,,2626.5,percent of total billed charges,Implant Device,2626.5,34,,2626.5,percent of total billed charges,Implant Device,2626.5,34,,2626.5,percent of total billed charges,Implant Device,2626.5,34,,2626.5,percent of total billed charges,Implant Device,3823.88,,,3823.88,Other,110% of Medicare,2703.75,35,,2703.75,percent of total billed charges,Implant Device,2626.5,34,"Charges > $500, x 34%",2626.5,percent of total billed charges,Implant Device,2703.75,35,,2703.75,percent of total billed charges,Implant Device,2703.75,35,,2703.75,percent of total billed charges,Implant Device,2703.75,35,,2703.75,percent of total billed charges,Implant Device,2703.75,35,,2703.75,percent of total billed charges,Implant Device,2703.75,35,,2703.75,percent of total billed charges,Implant Device,3090,40,,3090,percent of total billed charges,Implant Device,2703.75,70,,2703.75,percent of total billed charges,All Other,2626.5,34,,2626.5,percent of total billed charges,Implant Device,2626.5,34,,2626.5,percent of total billed charges,Implant Device,2703.75,35,,2703.75,percent of total billed charges,Implant Device,2703.75,35,,2703.75,percent of total billed charges,Implant Device,2703.75,35,,2703.75,percent of total billed charges,Implant Device,2703.75,35,,2703.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2626.5,34,"If Charge > 2,000, then 34 percent",2626.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5716.52,
BOST H74939294601210 6X120X130 ELU STENT,C1874,HCPCS,,79011895,CDM,278,RC,,,both,,,8625,6382.52,,,6382.52,Other,150% of Medicare + 9.63% HCRA Surcharge,3881.25,45,,3881.25,percent of total billed charges,Critical Access Hospital RCC factor,2932.5,34,,2932.5,percent of total billed charges,Implant Device,2932.5,34,,2932.5,percent of total billed charges,Implant Device,2932.5,34,,2932.5,percent of total billed charges,Implant Device,2932.5,34,,2932.5,percent of total billed charges,Implant Device,2932.5,34,,2932.5,percent of total billed charges,Implant Device,4269.38,,,4269.38,Other,110% of Medicare,3018.75,35,,3018.75,percent of total billed charges,Implant Device,2932.5,34,"Charges > $500, x 34%",2932.5,percent of total billed charges,Implant Device,3018.75,35,,3018.75,percent of total billed charges,Implant Device,3018.75,35,,3018.75,percent of total billed charges,Implant Device,3018.75,35,,3018.75,percent of total billed charges,Implant Device,3018.75,35,,3018.75,percent of total billed charges,Implant Device,3018.75,35,,3018.75,percent of total billed charges,Implant Device,3450,40,,3450,percent of total billed charges,Implant Device,3018.75,70,,3018.75,percent of total billed charges,All Other,2932.5,34,,2932.5,percent of total billed charges,Implant Device,2932.5,34,,2932.5,percent of total billed charges,Implant Device,3018.75,35,,3018.75,percent of total billed charges,Implant Device,3018.75,35,,3018.75,percent of total billed charges,Implant Device,3018.75,35,,3018.75,percent of total billed charges,Implant Device,3018.75,35,,3018.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2932.5,34,"If Charge > 2,000, then 34 percent",2932.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,6382.52,
BOST H74939294700410 7X40X130 ELU STENT,C1874,HCPCS,,79011896,CDM,278,RC,,,both,,,5925,4384.51,,,4384.51,Other,150% of Medicare + 9.63% HCRA Surcharge,2666.25,45,,2666.25,percent of total billed charges,Critical Access Hospital RCC factor,2014.5,34,,2014.5,percent of total billed charges,Implant Device,2014.5,34,,2014.5,percent of total billed charges,Implant Device,2014.5,34,,2014.5,percent of total billed charges,Implant Device,2014.5,34,,2014.5,percent of total billed charges,Implant Device,2014.5,34,,2014.5,percent of total billed charges,Implant Device,2932.88,,,2932.88,Other,110% of Medicare,2073.75,35,,2073.75,percent of total billed charges,Implant Device,2014.5,34,"Charges > $500, x 34%",2014.5,percent of total billed charges,Implant Device,2073.75,35,,2073.75,percent of total billed charges,Implant Device,2073.75,35,,2073.75,percent of total billed charges,Implant Device,2073.75,35,,2073.75,percent of total billed charges,Implant Device,2073.75,35,,2073.75,percent of total billed charges,Implant Device,2073.75,35,,2073.75,percent of total billed charges,Implant Device,2370,40,,2370,percent of total billed charges,Implant Device,2073.75,70,,2073.75,percent of total billed charges,All Other,2014.5,34,,2014.5,percent of total billed charges,Implant Device,2014.5,34,,2014.5,percent of total billed charges,Implant Device,2073.75,35,,2073.75,percent of total billed charges,Implant Device,2073.75,35,,2073.75,percent of total billed charges,Implant Device,2073.75,35,,2073.75,percent of total billed charges,Implant Device,2073.75,35,,2073.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2014.5,34,"If Charge > 2,000, then 34 percent",2014.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4384.51,
BOST H74939294700810 7X80X130 ELU STENT,C1874,HCPCS,,79011897,CDM,278,RC,,,both,,,7725,5716.52,,,5716.52,Other,150% of Medicare + 9.63% HCRA Surcharge,3476.25,45,,3476.25,percent of total billed charges,Critical Access Hospital RCC factor,2626.5,34,,2626.5,percent of total billed charges,Implant Device,2626.5,34,,2626.5,percent of total billed charges,Implant Device,2626.5,34,,2626.5,percent of total billed charges,Implant Device,2626.5,34,,2626.5,percent of total billed charges,Implant Device,2626.5,34,,2626.5,percent of total billed charges,Implant Device,3823.88,,,3823.88,Other,110% of Medicare,2703.75,35,,2703.75,percent of total billed charges,Implant Device,2626.5,34,"Charges > $500, x 34%",2626.5,percent of total billed charges,Implant Device,2703.75,35,,2703.75,percent of total billed charges,Implant Device,2703.75,35,,2703.75,percent of total billed charges,Implant Device,2703.75,35,,2703.75,percent of total billed charges,Implant Device,2703.75,35,,2703.75,percent of total billed charges,Implant Device,2703.75,35,,2703.75,percent of total billed charges,Implant Device,3090,40,,3090,percent of total billed charges,Implant Device,2703.75,70,,2703.75,percent of total billed charges,All Other,2626.5,34,,2626.5,percent of total billed charges,Implant Device,2626.5,34,,2626.5,percent of total billed charges,Implant Device,2703.75,35,,2703.75,percent of total billed charges,Implant Device,2703.75,35,,2703.75,percent of total billed charges,Implant Device,2703.75,35,,2703.75,percent of total billed charges,Implant Device,2703.75,35,,2703.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2626.5,34,"If Charge > 2,000, then 34 percent",2626.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5716.52,
BOST H74939294701210 7X120X130 ELU STENT,C1874,HCPCS,,79011898,CDM,278,RC,,,both,,,8625,6382.52,,,6382.52,Other,150% of Medicare + 9.63% HCRA Surcharge,3881.25,45,,3881.25,percent of total billed charges,Critical Access Hospital RCC factor,2932.5,34,,2932.5,percent of total billed charges,Implant Device,2932.5,34,,2932.5,percent of total billed charges,Implant Device,2932.5,34,,2932.5,percent of total billed charges,Implant Device,2932.5,34,,2932.5,percent of total billed charges,Implant Device,2932.5,34,,2932.5,percent of total billed charges,Implant Device,4269.38,,,4269.38,Other,110% of Medicare,3018.75,35,,3018.75,percent of total billed charges,Implant Device,2932.5,34,"Charges > $500, x 34%",2932.5,percent of total billed charges,Implant Device,3018.75,35,,3018.75,percent of total billed charges,Implant Device,3018.75,35,,3018.75,percent of total billed charges,Implant Device,3018.75,35,,3018.75,percent of total billed charges,Implant Device,3018.75,35,,3018.75,percent of total billed charges,Implant Device,3018.75,35,,3018.75,percent of total billed charges,Implant Device,3450,40,,3450,percent of total billed charges,Implant Device,3018.75,70,,3018.75,percent of total billed charges,All Other,2932.5,34,,2932.5,percent of total billed charges,Implant Device,2932.5,34,,2932.5,percent of total billed charges,Implant Device,3018.75,35,,3018.75,percent of total billed charges,Implant Device,3018.75,35,,3018.75,percent of total billed charges,Implant Device,3018.75,35,,3018.75,percent of total billed charges,Implant Device,3018.75,35,,3018.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2932.5,34,"If Charge > 2,000, then 34 percent",2932.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,6382.52,
STRYKER 628207 SUPERIOR LAT PLT 7H LT,C1713,HCPCS,,79011899,CDM,278,RC,,,both,,,3785,2800.91,,,2800.91,Other,150% of Medicare + 9.63% HCRA Surcharge,1703.25,45,,1703.25,percent of total billed charges,Critical Access Hospital RCC factor,1286.9,34,,1286.9,percent of total billed charges,Implant Device,1286.9,34,,1286.9,percent of total billed charges,Implant Device,1286.9,34,,1286.9,percent of total billed charges,Implant Device,1286.9,34,,1286.9,percent of total billed charges,Implant Device,1286.9,34,,1286.9,percent of total billed charges,Implant Device,1873.58,,,1873.58,Other,110% of Medicare,1324.75,35,,1324.75,percent of total billed charges,Implant Device,1286.9,34,"Charges > $500, x 34%",1286.9,percent of total billed charges,Implant Device,1324.75,35,,1324.75,percent of total billed charges,Implant Device,1324.75,35,,1324.75,percent of total billed charges,Implant Device,1324.75,35,,1324.75,percent of total billed charges,Implant Device,1324.75,35,,1324.75,percent of total billed charges,Implant Device,1324.75,35,,1324.75,percent of total billed charges,Implant Device,1514,40,,1514,percent of total billed charges,Implant Device,1324.75,70,,1324.75,percent of total billed charges,All Other,1286.9,34,,1286.9,percent of total billed charges,Implant Device,1286.9,34,,1286.9,percent of total billed charges,Implant Device,1324.75,35,,1324.75,percent of total billed charges,Implant Device,1324.75,35,,1324.75,percent of total billed charges,Implant Device,1324.75,35,,1324.75,percent of total billed charges,Implant Device,1324.75,35,,1324.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1286.9,34,"If Charge > 2,000, then 34 percent",1286.9,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2800.91,
ARTHREX AR-8840CL-50 CANN SCREW 4X50MM,C1713,HCPCS,,79011900,CDM,278,RC,,,both,,,708,523.92,,,523.92,Other,150% of Medicare + 9.63% HCRA Surcharge,318.6,45,,318.6,percent of total billed charges,Critical Access Hospital RCC factor,240.72,34,,240.72,percent of total billed charges,Implant Device,240.72,34,,240.72,percent of total billed charges,Implant Device,240.72,34,,240.72,percent of total billed charges,Implant Device,240.72,34,,240.72,percent of total billed charges,Implant Device,240.72,34,,240.72,percent of total billed charges,Implant Device,350.46,,,350.46,Other,110% of Medicare,247.8,35,,247.8,percent of total billed charges,Implant Device,240.72,34,"Charges > $500, x 34%",240.72,percent of total billed charges,Implant Device,247.8,35,,247.8,percent of total billed charges,Implant Device,247.8,35,,247.8,percent of total billed charges,Implant Device,247.8,35,,247.8,percent of total billed charges,Implant Device,247.8,35,,247.8,percent of total billed charges,Implant Device,247.8,35,,247.8,percent of total billed charges,Implant Device,283.2,40,,283.2,percent of total billed charges,Implant Device,247.8,70,,247.8,percent of total billed charges,All Other,240.72,34,,240.72,percent of total billed charges,Implant Device,240.72,34,,240.72,percent of total billed charges,Implant Device,247.8,35,,247.8,percent of total billed charges,Implant Device,247.8,35,,247.8,percent of total billed charges,Implant Device,247.8,35,,247.8,percent of total billed charges,Implant Device,247.8,35,,247.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,523.92,
BOST H74939294601010 6X100X130 ELU STENT,C1874,HCPCS,,79011901,CDM,278,RC,,,both,,,7725,5716.52,,,5716.52,Other,150% of Medicare + 9.63% HCRA Surcharge,3476.25,45,,3476.25,percent of total billed charges,Critical Access Hospital RCC factor,2626.5,34,,2626.5,percent of total billed charges,Implant Device,2626.5,34,,2626.5,percent of total billed charges,Implant Device,2626.5,34,,2626.5,percent of total billed charges,Implant Device,2626.5,34,,2626.5,percent of total billed charges,Implant Device,2626.5,34,,2626.5,percent of total billed charges,Implant Device,3823.88,,,3823.88,Other,110% of Medicare,2703.75,35,,2703.75,percent of total billed charges,Implant Device,2626.5,34,"Charges > $500, x 34%",2626.5,percent of total billed charges,Implant Device,2703.75,35,,2703.75,percent of total billed charges,Implant Device,2703.75,35,,2703.75,percent of total billed charges,Implant Device,2703.75,35,,2703.75,percent of total billed charges,Implant Device,2703.75,35,,2703.75,percent of total billed charges,Implant Device,2703.75,35,,2703.75,percent of total billed charges,Implant Device,3090,40,,3090,percent of total billed charges,Implant Device,2703.75,70,,2703.75,percent of total billed charges,All Other,2626.5,34,,2626.5,percent of total billed charges,Implant Device,2626.5,34,,2626.5,percent of total billed charges,Implant Device,2703.75,35,,2703.75,percent of total billed charges,Implant Device,2703.75,35,,2703.75,percent of total billed charges,Implant Device,2703.75,35,,2703.75,percent of total billed charges,Implant Device,2703.75,35,,2703.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2626.5,34,"If Charge > 2,000, then 34 percent",2626.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5716.52,
STRYKER 5567-P-3016 HUM STEM 16X101MM,C1776,HCPCS,,79011903,CDM,278,RC,,,both,,,8925,6604.52,,,6604.52,Other,150% of Medicare + 9.63% HCRA Surcharge,4016.25,45,,4016.25,percent of total billed charges,Critical Access Hospital RCC factor,3034.5,34,,3034.5,percent of total billed charges,Implant Device,3034.5,34,,3034.5,percent of total billed charges,Implant Device,3034.5,34,,3034.5,percent of total billed charges,Implant Device,3034.5,34,,3034.5,percent of total billed charges,Implant Device,3034.5,34,,3034.5,percent of total billed charges,Implant Device,4417.88,,,4417.88,Other,110% of Medicare,3123.75,35,,3123.75,percent of total billed charges,Implant Device,3034.5,34,"Charges > $500, x 34%",3034.5,percent of total billed charges,Implant Device,3123.75,35,,3123.75,percent of total billed charges,Implant Device,3123.75,35,,3123.75,percent of total billed charges,Implant Device,3123.75,35,,3123.75,percent of total billed charges,Implant Device,3123.75,35,,3123.75,percent of total billed charges,Implant Device,3123.75,35,,3123.75,percent of total billed charges,Implant Device,3570,40,,3570,percent of total billed charges,Implant Device,3123.75,70,,3123.75,percent of total billed charges,All Other,3034.5,34,,3034.5,percent of total billed charges,Implant Device,3034.5,34,,3034.5,percent of total billed charges,Implant Device,3123.75,35,,3123.75,percent of total billed charges,Implant Device,3123.75,35,,3123.75,percent of total billed charges,Implant Device,3123.75,35,,3123.75,percent of total billed charges,Implant Device,3123.75,35,,3123.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3034.5,34,"If Charge > 2,000, then 34 percent",3034.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,6604.52,
ZIMMER 1318-14-050 DVR VOLAR PLATE RIGHT,C1713,HCPCS,,79011904,CDM,278,RC,,,both,,,2970,2197.81,,,2197.81,Other,150% of Medicare + 9.63% HCRA Surcharge,1336.5,45,,1336.5,percent of total billed charges,Critical Access Hospital RCC factor,1009.8,34,,1009.8,percent of total billed charges,Implant Device,1009.8,34,,1009.8,percent of total billed charges,Implant Device,1009.8,34,,1009.8,percent of total billed charges,Implant Device,1009.8,34,,1009.8,percent of total billed charges,Implant Device,1009.8,34,,1009.8,percent of total billed charges,Implant Device,1470.15,,,1470.15,Other,110% of Medicare,1039.5,35,,1039.5,percent of total billed charges,Implant Device,1009.8,34,"Charges > $500, x 34%",1009.8,percent of total billed charges,Implant Device,1039.5,35,,1039.5,percent of total billed charges,Implant Device,1039.5,35,,1039.5,percent of total billed charges,Implant Device,1039.5,35,,1039.5,percent of total billed charges,Implant Device,1039.5,35,,1039.5,percent of total billed charges,Implant Device,1039.5,35,,1039.5,percent of total billed charges,Implant Device,1188,40,,1188,percent of total billed charges,Implant Device,1039.5,70,,1039.5,percent of total billed charges,All Other,1009.8,34,,1009.8,percent of total billed charges,Implant Device,1009.8,34,,1009.8,percent of total billed charges,Implant Device,1039.5,35,,1039.5,percent of total billed charges,Implant Device,1039.5,35,,1039.5,percent of total billed charges,Implant Device,1039.5,35,,1039.5,percent of total billed charges,Implant Device,1039.5,35,,1039.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1009.8,34,"If Charge > 2,000, then 34 percent",1009.8,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2197.81,
ZIMMER 1312-27-110 LOCK SCREW 2.7X10MM,C1713,HCPCS,,79011905,CDM,278,RC,,,both,,,360,266.4,,,266.4,Other,150% of Medicare + 9.63% HCRA Surcharge,162,45,,162,percent of total billed charges,Critical Access Hospital RCC factor,122.4,34,,122.4,percent of total billed charges,Implant Device,122.4,34,,122.4,percent of total billed charges,Implant Device,122.4,34,,122.4,percent of total billed charges,Implant Device,122.4,34,,122.4,percent of total billed charges,Implant Device,122.4,34,,122.4,percent of total billed charges,Implant Device,178.2,,,178.2,Other,110% of Medicare,126,35,,126,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,126,35,,126,percent of total billed charges,Implant Device,126,35,,126,percent of total billed charges,Implant Device,126,35,,126,percent of total billed charges,Implant Device,126,35,,126,percent of total billed charges,Implant Device,126,35,,126,percent of total billed charges,Implant Device,144,40,,144,percent of total billed charges,Implant Device,126,70,,126,percent of total billed charges,All Other,122.4,34,,122.4,percent of total billed charges,Implant Device,122.4,34,,122.4,percent of total billed charges,Implant Device,126,35,,126,percent of total billed charges,Implant Device,126,35,,126,percent of total billed charges,Implant Device,126,35,,126,percent of total billed charges,Implant Device,126,35,,126,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,266.4,
ZIMMER 1312-27-210 NON LOCK SCREW 2.7X10,C1713,HCPCS,,79011906,CDM,278,RC,,,both,,,216,159.84,,,159.84,Other,150% of Medicare + 9.63% HCRA Surcharge,97.2,45,,97.2,percent of total billed charges,Critical Access Hospital RCC factor,73.44,34,,73.44,percent of total billed charges,Implant Device,73.44,34,,73.44,percent of total billed charges,Implant Device,73.44,34,,73.44,percent of total billed charges,Implant Device,73.44,34,,73.44,percent of total billed charges,Implant Device,73.44,34,,73.44,percent of total billed charges,Implant Device,106.92,,,106.92,Other,110% of Medicare,75.6,35,,75.6,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,75.6,35,,75.6,percent of total billed charges,Implant Device,75.6,35,,75.6,percent of total billed charges,Implant Device,75.6,35,,75.6,percent of total billed charges,Implant Device,75.6,35,,75.6,percent of total billed charges,Implant Device,75.6,35,,75.6,percent of total billed charges,Implant Device,86.4,40,,86.4,percent of total billed charges,Implant Device,75.6,70,,75.6,percent of total billed charges,All Other,73.44,34,,73.44,percent of total billed charges,Implant Device,73.44,34,,73.44,percent of total billed charges,Implant Device,75.6,35,,75.6,percent of total billed charges,Implant Device,75.6,35,,75.6,percent of total billed charges,Implant Device,75.6,35,,75.6,percent of total billed charges,Implant Device,75.6,35,,75.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,159.84,
ZIMMER 1312-27-218 NON LOCK SCREW 2.7X18,C1713,HCPCS,,79011907,CDM,278,RC,,,both,,,216,159.84,,,159.84,Other,150% of Medicare + 9.63% HCRA Surcharge,97.2,45,,97.2,percent of total billed charges,Critical Access Hospital RCC factor,73.44,34,,73.44,percent of total billed charges,Implant Device,73.44,34,,73.44,percent of total billed charges,Implant Device,73.44,34,,73.44,percent of total billed charges,Implant Device,73.44,34,,73.44,percent of total billed charges,Implant Device,73.44,34,,73.44,percent of total billed charges,Implant Device,106.92,,,106.92,Other,110% of Medicare,75.6,35,,75.6,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,75.6,35,,75.6,percent of total billed charges,Implant Device,75.6,35,,75.6,percent of total billed charges,Implant Device,75.6,35,,75.6,percent of total billed charges,Implant Device,75.6,35,,75.6,percent of total billed charges,Implant Device,75.6,35,,75.6,percent of total billed charges,Implant Device,86.4,40,,86.4,percent of total billed charges,Implant Device,75.6,70,,75.6,percent of total billed charges,All Other,73.44,34,,73.44,percent of total billed charges,Implant Device,73.44,34,,73.44,percent of total billed charges,Implant Device,75.6,35,,75.6,percent of total billed charges,Implant Device,75.6,35,,75.6,percent of total billed charges,Implant Device,75.6,35,,75.6,percent of total billed charges,Implant Device,75.6,35,,75.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,159.84,
ZIMMER 02.03150.028 CORTICAL SCREW 5X28,C1713,HCPCS,,79011911,CDM,278,RC,,,both,,,523,387.02,,,387.02,Other,150% of Medicare + 9.63% HCRA Surcharge,235.35,45,,235.35,percent of total billed charges,Critical Access Hospital RCC factor,177.82,34,,177.82,percent of total billed charges,Implant Device,177.82,34,,177.82,percent of total billed charges,Implant Device,177.82,34,,177.82,percent of total billed charges,Implant Device,177.82,34,,177.82,percent of total billed charges,Implant Device,177.82,34,,177.82,percent of total billed charges,Implant Device,258.89,,,258.89,Other,110% of Medicare,183.05,35,,183.05,percent of total billed charges,Implant Device,177.82,34,"Charges > $500, x 34%",177.82,percent of total billed charges,Implant Device,183.05,35,,183.05,percent of total billed charges,Implant Device,183.05,35,,183.05,percent of total billed charges,Implant Device,183.05,35,,183.05,percent of total billed charges,Implant Device,183.05,35,,183.05,percent of total billed charges,Implant Device,183.05,35,,183.05,percent of total billed charges,Implant Device,209.2,40,,209.2,percent of total billed charges,Implant Device,183.05,70,,183.05,percent of total billed charges,All Other,177.82,34,,177.82,percent of total billed charges,Implant Device,177.82,34,,177.82,percent of total billed charges,Implant Device,183.05,35,,183.05,percent of total billed charges,Implant Device,183.05,35,,183.05,percent of total billed charges,Implant Device,183.05,35,,183.05,percent of total billed charges,Implant Device,183.05,35,,183.05,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,387.02,
ZIMMER 02.3150.030 CORTICAL SCREW 5X30,C1713,HCPCS,,79011912,CDM,278,RC,,,both,,,523,387.02,,,387.02,Other,150% of Medicare + 9.63% HCRA Surcharge,235.35,45,,235.35,percent of total billed charges,Critical Access Hospital RCC factor,177.82,34,,177.82,percent of total billed charges,Implant Device,177.82,34,,177.82,percent of total billed charges,Implant Device,177.82,34,,177.82,percent of total billed charges,Implant Device,177.82,34,,177.82,percent of total billed charges,Implant Device,177.82,34,,177.82,percent of total billed charges,Implant Device,258.89,,,258.89,Other,110% of Medicare,183.05,35,,183.05,percent of total billed charges,Implant Device,177.82,34,"Charges > $500, x 34%",177.82,percent of total billed charges,Implant Device,183.05,35,,183.05,percent of total billed charges,Implant Device,183.05,35,,183.05,percent of total billed charges,Implant Device,183.05,35,,183.05,percent of total billed charges,Implant Device,183.05,35,,183.05,percent of total billed charges,Implant Device,183.05,35,,183.05,percent of total billed charges,Implant Device,209.2,40,,209.2,percent of total billed charges,Implant Device,183.05,70,,183.05,percent of total billed charges,All Other,177.82,34,,177.82,percent of total billed charges,Implant Device,177.82,34,,177.82,percent of total billed charges,Implant Device,183.05,35,,183.05,percent of total billed charges,Implant Device,183.05,35,,183.05,percent of total billed charges,Implant Device,183.05,35,,183.05,percent of total billed charges,Implant Device,183.05,35,,183.05,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,387.02,
ZIMMER 02.03151.016 UNICORT SCREW 5X16,C1713,HCPCS,,79011913,CDM,278,RC,,,both,,,478,353.72,,,353.72,Other,150% of Medicare + 9.63% HCRA Surcharge,215.1,45,,215.1,percent of total billed charges,Critical Access Hospital RCC factor,162.52,34,,162.52,percent of total billed charges,Implant Device,162.52,34,,162.52,percent of total billed charges,Implant Device,162.52,34,,162.52,percent of total billed charges,Implant Device,162.52,34,,162.52,percent of total billed charges,Implant Device,162.52,34,,162.52,percent of total billed charges,Implant Device,236.61,,,236.61,Other,110% of Medicare,167.3,35,,167.3,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,167.3,35,,167.3,percent of total billed charges,Implant Device,167.3,35,,167.3,percent of total billed charges,Implant Device,167.3,35,,167.3,percent of total billed charges,Implant Device,167.3,35,,167.3,percent of total billed charges,Implant Device,167.3,35,,167.3,percent of total billed charges,Implant Device,191.2,40,,191.2,percent of total billed charges,Implant Device,167.3,70,,167.3,percent of total billed charges,All Other,162.52,34,,162.52,percent of total billed charges,Implant Device,162.52,34,,162.52,percent of total billed charges,Implant Device,167.3,35,,167.3,percent of total billed charges,Implant Device,167.3,35,,167.3,percent of total billed charges,Implant Device,167.3,35,,167.3,percent of total billed charges,Implant Device,167.3,35,,167.3,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,353.72,
ZIMMER 02.03150.026 CORTICAL SCREW 5X26,C1713,HCPCS,,79011914,CDM,278,RC,,,both,,,523,387.02,,,387.02,Other,150% of Medicare + 9.63% HCRA Surcharge,235.35,45,,235.35,percent of total billed charges,Critical Access Hospital RCC factor,177.82,34,,177.82,percent of total billed charges,Implant Device,177.82,34,,177.82,percent of total billed charges,Implant Device,177.82,34,,177.82,percent of total billed charges,Implant Device,177.82,34,,177.82,percent of total billed charges,Implant Device,177.82,34,,177.82,percent of total billed charges,Implant Device,258.89,,,258.89,Other,110% of Medicare,183.05,35,,183.05,percent of total billed charges,Implant Device,177.82,34,"Charges > $500, x 34%",177.82,percent of total billed charges,Implant Device,183.05,35,,183.05,percent of total billed charges,Implant Device,183.05,35,,183.05,percent of total billed charges,Implant Device,183.05,35,,183.05,percent of total billed charges,Implant Device,183.05,35,,183.05,percent of total billed charges,Implant Device,183.05,35,,183.05,percent of total billed charges,Implant Device,209.2,40,,209.2,percent of total billed charges,Implant Device,183.05,70,,183.05,percent of total billed charges,All Other,177.82,34,,177.82,percent of total billed charges,Implant Device,177.82,34,,177.82,percent of total billed charges,Implant Device,183.05,35,,183.05,percent of total billed charges,Implant Device,183.05,35,,183.05,percent of total billed charges,Implant Device,183.05,35,,183.05,percent of total billed charges,Implant Device,183.05,35,,183.05,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,387.02,
STRYKER 326095 ASNIS CANN SCREW 6.5X95MM,C1713,HCPCS,,79011935,CDM,278,RC,,,both,,,765,566.1,,,566.1,Other,150% of Medicare + 9.63% HCRA Surcharge,344.25,45,,344.25,percent of total billed charges,Critical Access Hospital RCC factor,260.1,34,,260.1,percent of total billed charges,Implant Device,260.1,34,,260.1,percent of total billed charges,Implant Device,260.1,34,,260.1,percent of total billed charges,Implant Device,260.1,34,,260.1,percent of total billed charges,Implant Device,260.1,34,,260.1,percent of total billed charges,Implant Device,378.68,,,378.68,Other,110% of Medicare,267.75,35,,267.75,percent of total billed charges,Implant Device,260.1,34,"Charges > $500, x 34%",260.1,percent of total billed charges,Implant Device,267.75,35,,267.75,percent of total billed charges,Implant Device,267.75,35,,267.75,percent of total billed charges,Implant Device,267.75,35,,267.75,percent of total billed charges,Implant Device,267.75,35,,267.75,percent of total billed charges,Implant Device,267.75,35,,267.75,percent of total billed charges,Implant Device,306,40,,306,percent of total billed charges,Implant Device,267.75,70,,267.75,percent of total billed charges,All Other,260.1,34,,260.1,percent of total billed charges,Implant Device,260.1,34,,260.1,percent of total billed charges,Implant Device,267.75,35,,267.75,percent of total billed charges,Implant Device,267.75,35,,267.75,percent of total billed charges,Implant Device,267.75,35,,267.75,percent of total billed charges,Implant Device,267.75,35,,267.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,566.1,
STRYKER 629688 NAR LOCK PLT 2.4X56MM 8HL,C1713,HCPCS,,79011937,CDM,278,RC,,,both,,,2688,1989.13,,,1989.13,Other,150% of Medicare + 9.63% HCRA Surcharge,1209.6,45,,1209.6,percent of total billed charges,Critical Access Hospital RCC factor,913.92,34,,913.92,percent of total billed charges,Implant Device,913.92,34,,913.92,percent of total billed charges,Implant Device,913.92,34,,913.92,percent of total billed charges,Implant Device,913.92,34,,913.92,percent of total billed charges,Implant Device,913.92,34,,913.92,percent of total billed charges,Implant Device,1330.56,,,1330.56,Other,110% of Medicare,940.8,35,,940.8,percent of total billed charges,Implant Device,913.92,34,"Charges > $500, x 34%",913.92,percent of total billed charges,Implant Device,940.8,35,,940.8,percent of total billed charges,Implant Device,940.8,35,,940.8,percent of total billed charges,Implant Device,940.8,35,,940.8,percent of total billed charges,Implant Device,940.8,35,,940.8,percent of total billed charges,Implant Device,940.8,35,,940.8,percent of total billed charges,Implant Device,1075.2,40,,1075.2,percent of total billed charges,Implant Device,940.8,70,,940.8,percent of total billed charges,All Other,913.92,34,,913.92,percent of total billed charges,Implant Device,913.92,34,,913.92,percent of total billed charges,Implant Device,940.8,35,,940.8,percent of total billed charges,Implant Device,940.8,35,,940.8,percent of total billed charges,Implant Device,940.8,35,,940.8,percent of total billed charges,Implant Device,940.8,35,,940.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,913.92,34,"If Charge > 2,000, then 34 percent",913.92,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1989.13,
ARTHREX AR-8933V-20 LOCKING SCREW 3X20MM,C1713,HCPCS,,79011939,CDM,278,RC,,,both,,,525,388.5,,,388.5,Other,150% of Medicare + 9.63% HCRA Surcharge,236.25,45,,236.25,percent of total billed charges,Critical Access Hospital RCC factor,178.5,34,,178.5,percent of total billed charges,Implant Device,178.5,34,,178.5,percent of total billed charges,Implant Device,178.5,34,,178.5,percent of total billed charges,Implant Device,178.5,34,,178.5,percent of total billed charges,Implant Device,178.5,34,,178.5,percent of total billed charges,Implant Device,259.88,,,259.88,Other,110% of Medicare,183.75,35,,183.75,percent of total billed charges,Implant Device,178.5,34,"Charges > $500, x 34%",178.5,percent of total billed charges,Implant Device,183.75,35,,183.75,percent of total billed charges,Implant Device,183.75,35,,183.75,percent of total billed charges,Implant Device,183.75,35,,183.75,percent of total billed charges,Implant Device,183.75,35,,183.75,percent of total billed charges,Implant Device,183.75,35,,183.75,percent of total billed charges,Implant Device,210,40,,210,percent of total billed charges,Implant Device,183.75,70,,183.75,percent of total billed charges,All Other,178.5,34,,178.5,percent of total billed charges,Implant Device,178.5,34,,178.5,percent of total billed charges,Implant Device,183.75,35,,183.75,percent of total billed charges,Implant Device,183.75,35,,183.75,percent of total billed charges,Implant Device,183.75,35,,183.75,percent of total billed charges,Implant Device,183.75,35,,183.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,388.5,
ZIMMER 574203040 FEM STEM 12/14 SZ 4,C1776,HCPCS,,79011940,CDM,278,RC,,,both,,,6912,5114.9,,,5114.9,Other,150% of Medicare + 9.63% HCRA Surcharge,3110.4,45,,3110.4,percent of total billed charges,Critical Access Hospital RCC factor,2350.08,34,,2350.08,percent of total billed charges,Implant Device,2350.08,34,,2350.08,percent of total billed charges,Implant Device,2350.08,34,,2350.08,percent of total billed charges,Implant Device,2350.08,34,,2350.08,percent of total billed charges,Implant Device,2350.08,34,,2350.08,percent of total billed charges,Implant Device,3421.44,,,3421.44,Other,110% of Medicare,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2350.08,34,"Charges > $500, x 34%",2350.08,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2764.8,40,,2764.8,percent of total billed charges,Implant Device,2419.2,70,,2419.2,percent of total billed charges,All Other,2350.08,34,,2350.08,percent of total billed charges,Implant Device,2350.08,34,,2350.08,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2350.08,34,"If Charge > 2,000, then 34 percent",2350.08,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5114.9,
J&J 1516-50-506 TIBIAL INSERT 4MM SIZE 5,C1776,HCPCS,,79011942,CDM,278,RC,,,both,,,5400,3996.01,,,3996.01,Other,150% of Medicare + 9.63% HCRA Surcharge,2430,45,,2430,percent of total billed charges,Critical Access Hospital RCC factor,1836,34,,1836,percent of total billed charges,Implant Device,1836,34,,1836,percent of total billed charges,Implant Device,1836,34,,1836,percent of total billed charges,Implant Device,1836,34,,1836,percent of total billed charges,Implant Device,1836,34,,1836,percent of total billed charges,Implant Device,2673,,,2673,Other,110% of Medicare,1890,35,,1890,percent of total billed charges,Implant Device,1836,34,"Charges > $500, x 34%",1836,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,2160,40,,2160,percent of total billed charges,Implant Device,1890,70,,1890,percent of total billed charges,All Other,1836,34,,1836,percent of total billed charges,Implant Device,1836,34,,1836,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1836,34,"If Charge > 2,000, then 34 percent",1836,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3996.01,
J&J 1504-11-105 FEMORAL COMP SIZE 5 LT,C1776,HCPCS,,79011943,CDM,278,RC,,,both,,,6000,4440.02,,,4440.02,Other,150% of Medicare + 9.63% HCRA Surcharge,2700,45,,2700,percent of total billed charges,Critical Access Hospital RCC factor,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2970,,,2970,Other,110% of Medicare,2100,35,,2100,percent of total billed charges,Implant Device,2040,34,"Charges > $500, x 34%",2040,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2400,40,,2400,percent of total billed charges,Implant Device,2100,70,,2100,percent of total billed charges,All Other,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2040,34,"If Charge > 2,000, then 34 percent",2040,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4440.02,
STRYKER 6721-0230 HIP STEM 127 DEGREE,C1776,HCPCS,,79011945,CDM,278,RC,,,both,,,6953,5145.24,,,5145.24,Other,150% of Medicare + 9.63% HCRA Surcharge,3128.85,45,,3128.85,percent of total billed charges,Critical Access Hospital RCC factor,2364.02,34,,2364.02,percent of total billed charges,Implant Device,2364.02,34,,2364.02,percent of total billed charges,Implant Device,2364.02,34,,2364.02,percent of total billed charges,Implant Device,2364.02,34,,2364.02,percent of total billed charges,Implant Device,2364.02,34,,2364.02,percent of total billed charges,Implant Device,3441.74,,,3441.74,Other,110% of Medicare,2433.55,35,,2433.55,percent of total billed charges,Implant Device,2364.02,34,"Charges > $500, x 34%",2364.02,percent of total billed charges,Implant Device,2433.55,35,,2433.55,percent of total billed charges,Implant Device,2433.55,35,,2433.55,percent of total billed charges,Implant Device,2433.55,35,,2433.55,percent of total billed charges,Implant Device,2433.55,35,,2433.55,percent of total billed charges,Implant Device,2433.55,35,,2433.55,percent of total billed charges,Implant Device,2781.2,40,,2781.2,percent of total billed charges,Implant Device,2433.55,70,,2433.55,percent of total billed charges,All Other,2364.02,34,,2364.02,percent of total billed charges,Implant Device,2364.02,34,,2364.02,percent of total billed charges,Implant Device,2433.55,35,,2433.55,percent of total billed charges,Implant Device,2433.55,35,,2433.55,percent of total billed charges,Implant Device,2433.55,35,,2433.55,percent of total billed charges,Implant Device,2433.55,35,,2433.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2364.02,34,"If Charge > 2,000, then 34 percent",2364.02,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5145.24,
ALLERGAN 133S-MV-11-T EXPANDER 250CC,L8600,HCPCS,,79011946,CDM,278,RC,,,both,,,4650,3441.01,,,3441.01,Other,150% of Medicare + 9.63% HCRA Surcharge,2092.5,45,,2092.5,percent of total billed charges,Critical Access Hospital RCC factor,1581,34,,1581,percent of total billed charges,Implant Device,1581,34,,1581,percent of total billed charges,Implant Device,1581,34,,1581,percent of total billed charges,Implant Device,1581,34,,1581,percent of total billed charges,Implant Device,1581,34,,1581,percent of total billed charges,Implant Device,2301.75,,,2301.75,Other,110% of Medicare,1627.5,35,,1627.5,percent of total billed charges,Implant Device,1581,34,"Charges > $500, x 34%",1581,percent of total billed charges,Implant Device,1627.5,35,,1627.5,percent of total billed charges,Implant Device,1627.5,35,,1627.5,percent of total billed charges,Implant Device,1627.5,35,,1627.5,percent of total billed charges,Implant Device,1627.5,35,,1627.5,percent of total billed charges,Implant Device,1627.5,35,,1627.5,percent of total billed charges,Implant Device,1860,40,,1860,percent of total billed charges,Implant Device,1627.5,70,,1627.5,percent of total billed charges,All Other,1581,34,,1581,percent of total billed charges,Implant Device,1581,34,,1581,percent of total billed charges,Implant Device,1627.5,35,,1627.5,percent of total billed charges,Implant Device,1627.5,35,,1627.5,percent of total billed charges,Implant Device,1627.5,35,,1627.5,percent of total billed charges,Implant Device,1627.5,35,,1627.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1581,34,"If Charge > 2,000, then 34 percent",1581,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3441.01,
ALLERGAN SCL-110 GEL BREAST IMPL 110CC,L8600,HCPCS,,79011947,CDM,278,RC,,,both,,,3975,2941.51,,,2941.51,Other,150% of Medicare + 9.63% HCRA Surcharge,1788.75,45,,1788.75,percent of total billed charges,Critical Access Hospital RCC factor,1351.5,34,,1351.5,percent of total billed charges,Implant Device,1351.5,34,,1351.5,percent of total billed charges,Implant Device,1351.5,34,,1351.5,percent of total billed charges,Implant Device,1351.5,34,,1351.5,percent of total billed charges,Implant Device,1351.5,34,,1351.5,percent of total billed charges,Implant Device,1967.63,,,1967.63,Other,110% of Medicare,1391.25,35,,1391.25,percent of total billed charges,Implant Device,1351.5,34,"Charges > $500, x 34%",1351.5,percent of total billed charges,Implant Device,1391.25,35,,1391.25,percent of total billed charges,Implant Device,1391.25,35,,1391.25,percent of total billed charges,Implant Device,1391.25,35,,1391.25,percent of total billed charges,Implant Device,1391.25,35,,1391.25,percent of total billed charges,Implant Device,1391.25,35,,1391.25,percent of total billed charges,Implant Device,1590,40,,1590,percent of total billed charges,Implant Device,1391.25,70,,1391.25,percent of total billed charges,All Other,1351.5,34,,1351.5,percent of total billed charges,Implant Device,1351.5,34,,1351.5,percent of total billed charges,Implant Device,1391.25,35,,1391.25,percent of total billed charges,Implant Device,1391.25,35,,1391.25,percent of total billed charges,Implant Device,1391.25,35,,1391.25,percent of total billed charges,Implant Device,1391.25,35,,1391.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1351.5,34,"If Charge > 2,000, then 34 percent",1351.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2941.51,
ABBOTT MN10450-90A SLIM TIP DRG LEAD,C1778,HCPCS,,79011949,CDM,278,RC,,,both,,,7800,5772.02,,,5772.02,Other,150% of Medicare + 9.63% HCRA Surcharge,3510,45,,3510,percent of total billed charges,Critical Access Hospital RCC factor,2652,34,,2652,percent of total billed charges,Implant Device,2652,34,,2652,percent of total billed charges,Implant Device,2652,34,,2652,percent of total billed charges,Implant Device,2652,34,,2652,percent of total billed charges,Implant Device,2652,34,,2652,percent of total billed charges,Implant Device,3861,,,3861,Other,110% of Medicare,2730,35,,2730,percent of total billed charges,Implant Device,2652,34,"Charges > $500, x 34%",2652,percent of total billed charges,Implant Device,2730,35,,2730,percent of total billed charges,Implant Device,2730,35,,2730,percent of total billed charges,Implant Device,2730,35,,2730,percent of total billed charges,Implant Device,2730,35,,2730,percent of total billed charges,Implant Device,2730,35,,2730,percent of total billed charges,Implant Device,3120,40,,3120,percent of total billed charges,Implant Device,2730,70,,2730,percent of total billed charges,All Other,2652,34,,2652,percent of total billed charges,Implant Device,2652,34,,2652,percent of total billed charges,Implant Device,2730,35,,2730,percent of total billed charges,Implant Device,2730,35,,2730,percent of total billed charges,Implant Device,2730,35,,2730,percent of total billed charges,Implant Device,2730,35,,2730,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2652,34,"If Charge > 2,000, then 34 percent",2652,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5772.02,
ABBOTT 3660 PROCLAIM XR 5 IPG,C1767,HCPCS,,79011951,CDM,278,RC,,,both,,,76410,56543.59,,,56543.59,Other,150% of Medicare + 9.63% HCRA Surcharge,34384.5,45,,34384.5,percent of total billed charges,Critical Access Hospital RCC factor,25979.4,34,,25979.4,percent of total billed charges,Implant Device,25979.4,34,,25979.4,percent of total billed charges,Implant Device,25979.4,34,,25979.4,percent of total billed charges,Implant Device,25979.4,34,,25979.4,percent of total billed charges,Implant Device,25979.4,34,,25979.4,percent of total billed charges,Implant Device,37822.95,,,37822.95,Other,110% of Medicare,26743.5,35,,26743.5,percent of total billed charges,Implant Device,25979.4,34,"Charges > $500, x 34%",25979.4,percent of total billed charges,Implant Device,26743.5,35,,26743.5,percent of total billed charges,Implant Device,26743.5,35,,26743.5,percent of total billed charges,Implant Device,26743.5,35,,26743.5,percent of total billed charges,Implant Device,26743.5,35,,26743.5,percent of total billed charges,Implant Device,26743.5,35,,26743.5,percent of total billed charges,Implant Device,30564,40,,30564,percent of total billed charges,Implant Device,26743.5,70,,26743.5,percent of total billed charges,All Other,25979.4,34,,25979.4,percent of total billed charges,Implant Device,25979.4,34,,25979.4,percent of total billed charges,Implant Device,26743.5,35,,26743.5,percent of total billed charges,Implant Device,26743.5,35,,26743.5,percent of total billed charges,Implant Device,26743.5,35,,26743.5,percent of total billed charges,Implant Device,26743.5,35,,26743.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,25979.4,34,"If Charge > 2,000, then 34 percent",25979.4,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,56543.59,
J&J 1504-11-225 FEMORAL COMP SZ 5 RT,C1776,HCPCS,,79011952,CDM,278,RC,,,both,,,6000,4440.02,,,4440.02,Other,150% of Medicare + 9.63% HCRA Surcharge,2700,45,,2700,percent of total billed charges,Critical Access Hospital RCC factor,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2970,,,2970,Other,110% of Medicare,2100,35,,2100,percent of total billed charges,Implant Device,2040,34,"Charges > $500, x 34%",2040,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2400,40,,2400,percent of total billed charges,Implant Device,2100,70,,2100,percent of total billed charges,All Other,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2040,34,"If Charge > 2,000, then 34 percent",2040,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4440.02,
J&J 1504-10-207 FEMORAL COMP SZ 7 RT,C1776,HCPCS,,79011953,CDM,278,RC,,,both,,,4800,3552.01,,,3552.01,Other,150% of Medicare + 9.63% HCRA Surcharge,2160,45,,2160,percent of total billed charges,Critical Access Hospital RCC factor,1632,34,,1632,percent of total billed charges,Implant Device,1632,34,,1632,percent of total billed charges,Implant Device,1632,34,,1632,percent of total billed charges,Implant Device,1632,34,,1632,percent of total billed charges,Implant Device,1632,34,,1632,percent of total billed charges,Implant Device,2376,,,2376,Other,110% of Medicare,1680,35,,1680,percent of total billed charges,Implant Device,1632,34,"Charges > $500, x 34%",1632,percent of total billed charges,Implant Device,1680,35,,1680,percent of total billed charges,Implant Device,1680,35,,1680,percent of total billed charges,Implant Device,1680,35,,1680,percent of total billed charges,Implant Device,1680,35,,1680,percent of total billed charges,Implant Device,1680,35,,1680,percent of total billed charges,Implant Device,1920,40,,1920,percent of total billed charges,Implant Device,1680,70,,1680,percent of total billed charges,All Other,1632,34,,1632,percent of total billed charges,Implant Device,1632,34,,1632,percent of total billed charges,Implant Device,1680,35,,1680,percent of total billed charges,Implant Device,1680,35,,1680,percent of total billed charges,Implant Device,1680,35,,1680,percent of total billed charges,Implant Device,1680,35,,1680,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1632,34,"If Charge > 2,000, then 34 percent",1632,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3552.01,
J&J 1516-50-705 TIBIAL INSERT SIZE 7 5MM,C1776,HCPCS,,79011954,CDM,278,RC,,,both,,,5400,3996.01,,,3996.01,Other,150% of Medicare + 9.63% HCRA Surcharge,2430,45,,2430,percent of total billed charges,Critical Access Hospital RCC factor,1836,34,,1836,percent of total billed charges,Implant Device,1836,34,,1836,percent of total billed charges,Implant Device,1836,34,,1836,percent of total billed charges,Implant Device,1836,34,,1836,percent of total billed charges,Implant Device,1836,34,,1836,percent of total billed charges,Implant Device,2673,,,2673,Other,110% of Medicare,1890,35,,1890,percent of total billed charges,Implant Device,1836,34,"Charges > $500, x 34%",1836,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,2160,40,,2160,percent of total billed charges,Implant Device,1890,70,,1890,percent of total billed charges,All Other,1836,34,,1836,percent of total billed charges,Implant Device,1836,34,,1836,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1836,34,"If Charge > 2,000, then 34 percent",1836,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3996.01,
J&J 1506-80-006 TIBIAL BASE SIZE 6,C1776,HCPCS,,79011955,CDM,278,RC,,,both,,,3900,2886.01,,,2886.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1755,45,,1755,percent of total billed charges,Critical Access Hospital RCC factor,1326,34,,1326,percent of total billed charges,Implant Device,1326,34,,1326,percent of total billed charges,Implant Device,1326,34,,1326,percent of total billed charges,Implant Device,1326,34,,1326,percent of total billed charges,Implant Device,1326,34,,1326,percent of total billed charges,Implant Device,1930.5,,,1930.5,Other,110% of Medicare,1365,35,,1365,percent of total billed charges,Implant Device,1326,34,"Charges > $500, x 34%",1326,percent of total billed charges,Implant Device,1365,35,,1365,percent of total billed charges,Implant Device,1365,35,,1365,percent of total billed charges,Implant Device,1365,35,,1365,percent of total billed charges,Implant Device,1365,35,,1365,percent of total billed charges,Implant Device,1365,35,,1365,percent of total billed charges,Implant Device,1560,40,,1560,percent of total billed charges,Implant Device,1365,70,,1365,percent of total billed charges,All Other,1326,34,,1326,percent of total billed charges,Implant Device,1326,34,,1326,percent of total billed charges,Implant Device,1365,35,,1365,percent of total billed charges,Implant Device,1365,35,,1365,percent of total billed charges,Implant Device,1365,35,,1365,percent of total billed charges,Implant Device,1365,35,,1365,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1326,34,"If Charge > 2,000, then 34 percent",1326,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2886.01,
J&J 202.880 CORTEX SCREW 2.7 X 20MM,C1713,HCPCS,,79011956,CDM,278,RC,,,both,,,88,65.12,,,65.12,Other,150% of Medicare + 9.63% HCRA Surcharge,39.6,45,,39.6,percent of total billed charges,Critical Access Hospital RCC factor,29.92,34,,29.92,percent of total billed charges,Implant Device,29.92,34,,29.92,percent of total billed charges,Implant Device,29.92,34,,29.92,percent of total billed charges,Implant Device,29.92,34,,29.92,percent of total billed charges,Implant Device,29.92,34,,29.92,percent of total billed charges,Implant Device,43.56,,,43.56,Other,110% of Medicare,30.8,35,,30.8,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,30.8,35,,30.8,percent of total billed charges,Implant Device,30.8,35,,30.8,percent of total billed charges,Implant Device,30.8,35,,30.8,percent of total billed charges,Implant Device,30.8,35,,30.8,percent of total billed charges,Implant Device,30.8,35,,30.8,percent of total billed charges,Implant Device,35.2,40,,35.2,percent of total billed charges,Implant Device,30.8,70,,30.8,percent of total billed charges,All Other,29.92,34,,29.92,percent of total billed charges,Implant Device,29.92,34,,29.92,percent of total billed charges,Implant Device,30.8,35,,30.8,percent of total billed charges,Implant Device,30.8,35,,30.8,percent of total billed charges,Implant Device,30.8,35,,30.8,percent of total billed charges,Implant Device,30.8,35,,30.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,65.12,
J&J 202.882 CORTEX SCREW 2.7 X 22MM,C1713,HCPCS,,79011957,CDM,278,RC,,,both,,,88,65.12,,,65.12,Other,150% of Medicare + 9.63% HCRA Surcharge,39.6,45,,39.6,percent of total billed charges,Critical Access Hospital RCC factor,29.92,34,,29.92,percent of total billed charges,Implant Device,29.92,34,,29.92,percent of total billed charges,Implant Device,29.92,34,,29.92,percent of total billed charges,Implant Device,29.92,34,,29.92,percent of total billed charges,Implant Device,29.92,34,,29.92,percent of total billed charges,Implant Device,43.56,,,43.56,Other,110% of Medicare,30.8,35,,30.8,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,30.8,35,,30.8,percent of total billed charges,Implant Device,30.8,35,,30.8,percent of total billed charges,Implant Device,30.8,35,,30.8,percent of total billed charges,Implant Device,30.8,35,,30.8,percent of total billed charges,Implant Device,30.8,35,,30.8,percent of total billed charges,Implant Device,35.2,40,,35.2,percent of total billed charges,Implant Device,30.8,70,,30.8,percent of total billed charges,All Other,29.92,34,,29.92,percent of total billed charges,Implant Device,29.92,34,,29.92,percent of total billed charges,Implant Device,30.8,35,,30.8,percent of total billed charges,Implant Device,30.8,35,,30.8,percent of total billed charges,Implant Device,30.8,35,,30.8,percent of total billed charges,Implant Device,30.8,35,,30.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,65.12,
J&J 02.112.625S LCP CLAVICLE PLATE 2.7MM,C1713,HCPCS,,79011958,CDM,278,RC,,,both,,,4130,3056.21,,,3056.21,Other,150% of Medicare + 9.63% HCRA Surcharge,1858.5,45,,1858.5,percent of total billed charges,Critical Access Hospital RCC factor,1404.2,34,,1404.2,percent of total billed charges,Implant Device,1404.2,34,,1404.2,percent of total billed charges,Implant Device,1404.2,34,,1404.2,percent of total billed charges,Implant Device,1404.2,34,,1404.2,percent of total billed charges,Implant Device,1404.2,34,,1404.2,percent of total billed charges,Implant Device,2044.35,,,2044.35,Other,110% of Medicare,1445.5,35,,1445.5,percent of total billed charges,Implant Device,1404.2,34,"Charges > $500, x 34%",1404.2,percent of total billed charges,Implant Device,1445.5,35,,1445.5,percent of total billed charges,Implant Device,1445.5,35,,1445.5,percent of total billed charges,Implant Device,1445.5,35,,1445.5,percent of total billed charges,Implant Device,1445.5,35,,1445.5,percent of total billed charges,Implant Device,1445.5,35,,1445.5,percent of total billed charges,Implant Device,1652,40,,1652,percent of total billed charges,Implant Device,1445.5,70,,1445.5,percent of total billed charges,All Other,1404.2,34,,1404.2,percent of total billed charges,Implant Device,1404.2,34,,1404.2,percent of total billed charges,Implant Device,1445.5,35,,1445.5,percent of total billed charges,Implant Device,1445.5,35,,1445.5,percent of total billed charges,Implant Device,1445.5,35,,1445.5,percent of total billed charges,Implant Device,1445.5,35,,1445.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1404.2,34,"If Charge > 2,000, then 34 percent",1404.2,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3056.21,
ARTHREX AR-7000-26FT CANN SCRW 3.75X26MM,C1713,HCPCS,,79011959,CDM,278,RC,,,both,,,858,634.92,,,634.92,Other,150% of Medicare + 9.63% HCRA Surcharge,386.1,45,,386.1,percent of total billed charges,Critical Access Hospital RCC factor,291.72,34,,291.72,percent of total billed charges,Implant Device,291.72,34,,291.72,percent of total billed charges,Implant Device,291.72,34,,291.72,percent of total billed charges,Implant Device,291.72,34,,291.72,percent of total billed charges,Implant Device,291.72,34,,291.72,percent of total billed charges,Implant Device,424.71,,,424.71,Other,110% of Medicare,300.3,35,,300.3,percent of total billed charges,Implant Device,291.72,34,"Charges > $500, x 34%",291.72,percent of total billed charges,Implant Device,300.3,35,,300.3,percent of total billed charges,Implant Device,300.3,35,,300.3,percent of total billed charges,Implant Device,300.3,35,,300.3,percent of total billed charges,Implant Device,300.3,35,,300.3,percent of total billed charges,Implant Device,300.3,35,,300.3,percent of total billed charges,Implant Device,343.2,40,,343.2,percent of total billed charges,Implant Device,300.3,70,,300.3,percent of total billed charges,All Other,291.72,34,,291.72,percent of total billed charges,Implant Device,291.72,34,,291.72,percent of total billed charges,Implant Device,300.3,35,,300.3,percent of total billed charges,Implant Device,300.3,35,,300.3,percent of total billed charges,Implant Device,300.3,35,,300.3,percent of total billed charges,Implant Device,300.3,35,,300.3,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,634.92,
DJO 940-01-52F ACETABULAR CUP 52MM,C1776,HCPCS,,79011960,CDM,278,RC,,,both,,,4200,3108.01,,,3108.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1890,45,,1890,percent of total billed charges,Critical Access Hospital RCC factor,1428,34,,1428,percent of total billed charges,Implant Device,1428,34,,1428,percent of total billed charges,Implant Device,1428,34,,1428,percent of total billed charges,Implant Device,1428,34,,1428,percent of total billed charges,Implant Device,1428,34,,1428,percent of total billed charges,Implant Device,2079,,,2079,Other,110% of Medicare,1470,35,,1470,percent of total billed charges,Implant Device,1428,34,"Charges > $500, x 34%",1428,percent of total billed charges,Implant Device,1470,35,,1470,percent of total billed charges,Implant Device,1470,35,,1470,percent of total billed charges,Implant Device,1470,35,,1470,percent of total billed charges,Implant Device,1470,35,,1470,percent of total billed charges,Implant Device,1470,35,,1470,percent of total billed charges,Implant Device,1680,40,,1680,percent of total billed charges,Implant Device,1470,70,,1470,percent of total billed charges,All Other,1428,34,,1428,percent of total billed charges,Implant Device,1428,34,,1428,percent of total billed charges,Implant Device,1470,35,,1470,percent of total billed charges,Implant Device,1470,35,,1470,percent of total billed charges,Implant Device,1470,35,,1470,percent of total billed charges,Implant Device,1470,35,,1470,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1428,34,"If Charge > 2,000, then 34 percent",1428,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3108.01,
DJ0 942-01-36F LINER 36MM,C1776,HCPCS,,79011961,CDM,278,RC,,,both,,,4500,3330.01,,,3330.01,Other,150% of Medicare + 9.63% HCRA Surcharge,2025,45,,2025,percent of total billed charges,Critical Access Hospital RCC factor,1530,34,,1530,percent of total billed charges,Implant Device,1530,34,,1530,percent of total billed charges,Implant Device,1530,34,,1530,percent of total billed charges,Implant Device,1530,34,,1530,percent of total billed charges,Implant Device,1530,34,,1530,percent of total billed charges,Implant Device,2227.5,,,2227.5,Other,110% of Medicare,1575,35,,1575,percent of total billed charges,Implant Device,1530,34,"Charges > $500, x 34%",1530,percent of total billed charges,Implant Device,1575,35,,1575,percent of total billed charges,Implant Device,1575,35,,1575,percent of total billed charges,Implant Device,1575,35,,1575,percent of total billed charges,Implant Device,1575,35,,1575,percent of total billed charges,Implant Device,1575,35,,1575,percent of total billed charges,Implant Device,1800,40,,1800,percent of total billed charges,Implant Device,1575,70,,1575,percent of total billed charges,All Other,1530,34,,1530,percent of total billed charges,Implant Device,1530,34,,1530,percent of total billed charges,Implant Device,1575,35,,1575,percent of total billed charges,Implant Device,1575,35,,1575,percent of total billed charges,Implant Device,1575,35,,1575,percent of total billed charges,Implant Device,1575,35,,1575,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1530,34,"If Charge > 2,000, then 34 percent",1530,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3330.01,
STRYKER 1822-0828S TIBIAL NAIL 8 X 285MM,C1889,HCPCS,,79011962,CDM,278,RC,,,both,,,3529,2611.47,,,2611.47,Other,150% of Medicare + 9.63% HCRA Surcharge,1588.05,45,,1588.05,percent of total billed charges,Critical Access Hospital RCC factor,1199.86,34,,1199.86,percent of total billed charges,Implant Device,1199.86,34,,1199.86,percent of total billed charges,Implant Device,1199.86,34,,1199.86,percent of total billed charges,Implant Device,1199.86,34,,1199.86,percent of total billed charges,Implant Device,1199.86,34,,1199.86,percent of total billed charges,Implant Device,1746.86,,,1746.86,Other,110% of Medicare,1235.15,35,,1235.15,percent of total billed charges,Implant Device,1199.86,34,"Charges > $500, x 34%",1199.86,percent of total billed charges,Implant Device,1235.15,35,,1235.15,percent of total billed charges,Implant Device,1235.15,35,,1235.15,percent of total billed charges,Implant Device,1235.15,35,,1235.15,percent of total billed charges,Implant Device,1235.15,35,,1235.15,percent of total billed charges,Implant Device,1235.15,35,,1235.15,percent of total billed charges,Implant Device,1411.6,40,,1411.6,percent of total billed charges,Implant Device,1235.15,70,,1235.15,percent of total billed charges,All Other,1199.86,34,,1199.86,percent of total billed charges,Implant Device,1199.86,34,,1199.86,percent of total billed charges,Implant Device,1235.15,35,,1235.15,percent of total billed charges,Implant Device,1235.15,35,,1235.15,percent of total billed charges,Implant Device,1235.15,35,,1235.15,percent of total billed charges,Implant Device,1235.15,35,,1235.15,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1199.86,34,"If Charge > 2,000, then 34 percent",1199.86,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2611.47,
DJO 111-18-1403 HIP STEM SIZE 14,C1776,HCPCS,,79011963,CDM,278,RC,,,both,,,8400,6216.02,,,6216.02,Other,150% of Medicare + 9.63% HCRA Surcharge,3780,45,,3780,percent of total billed charges,Critical Access Hospital RCC factor,2856,34,,2856,percent of total billed charges,Implant Device,2856,34,,2856,percent of total billed charges,Implant Device,2856,34,,2856,percent of total billed charges,Implant Device,2856,34,,2856,percent of total billed charges,Implant Device,2856,34,,2856,percent of total billed charges,Implant Device,4158,,,4158,Other,110% of Medicare,2940,35,,2940,percent of total billed charges,Implant Device,2856,34,"Charges > $500, x 34%",2856,percent of total billed charges,Implant Device,2940,35,,2940,percent of total billed charges,Implant Device,2940,35,,2940,percent of total billed charges,Implant Device,2940,35,,2940,percent of total billed charges,Implant Device,2940,35,,2940,percent of total billed charges,Implant Device,2940,35,,2940,percent of total billed charges,Implant Device,3360,40,,3360,percent of total billed charges,Implant Device,2940,70,,2940,percent of total billed charges,All Other,2856,34,,2856,percent of total billed charges,Implant Device,2856,34,,2856,percent of total billed charges,Implant Device,2940,35,,2940,percent of total billed charges,Implant Device,2940,35,,2940,percent of total billed charges,Implant Device,2940,35,,2940,percent of total billed charges,Implant Device,2940,35,,2940,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2856,34,"If Charge > 2,000, then 34 percent",2856,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,6216.02,
IN2BONES P70 ST008 TUBULAR PLATE 8 HOLE,C1713,HCPCS,,79011971,CDM,278,RC,,,both,,,6000,4440.02,,,4440.02,Other,150% of Medicare + 9.63% HCRA Surcharge,2700,45,,2700,percent of total billed charges,Critical Access Hospital RCC factor,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2970,,,2970,Other,110% of Medicare,2100,35,,2100,percent of total billed charges,Implant Device,2040,34,"Charges > $500, x 34%",2040,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2400,40,,2400,percent of total billed charges,Implant Device,2100,70,,2100,percent of total billed charges,All Other,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2040,34,"If Charge > 2,000, then 34 percent",2040,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4440.02,
ZIMMER 42-5121-008-12 ART SURFACE LT12MM,C1776,HCPCS,,79011972,CDM,278,RC,,,both,,,3648,2699.53,,,2699.53,Other,150% of Medicare + 9.63% HCRA Surcharge,1641.6,45,,1641.6,percent of total billed charges,Critical Access Hospital RCC factor,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1805.76,,,1805.76,Other,110% of Medicare,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1240.32,34,"Charges > $500, x 34%",1240.32,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1459.2,40,,1459.2,percent of total billed charges,Implant Device,1276.8,70,,1276.8,percent of total billed charges,All Other,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1240.32,34,"If Charge > 2,000, then 34 percent",1240.32,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2699.53,
ZIMMER 42-5221-009-11 ART SURFACE RT11MM,C1776,HCPCS,,79011973,CDM,278,RC,,,both,,,3648,2699.53,,,2699.53,Other,150% of Medicare + 9.63% HCRA Surcharge,1641.6,45,,1641.6,percent of total billed charges,Critical Access Hospital RCC factor,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1805.76,,,1805.76,Other,110% of Medicare,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1240.32,34,"Charges > $500, x 34%",1240.32,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1459.2,40,,1459.2,percent of total billed charges,Implant Device,1276.8,70,,1276.8,percent of total billed charges,All Other,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1240.32,34,"If Charge > 2,000, then 34 percent",1240.32,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2699.53,
ZIMMER 42-5026-070-02 FEMUR RT SIZE 11,C1776,HCPCS,,79011974,CDM,278,RC,,,both,,,6300,4662.02,,,4662.02,Other,150% of Medicare + 9.63% HCRA Surcharge,2835,45,,2835,percent of total billed charges,Critical Access Hospital RCC factor,2142,34,,2142,percent of total billed charges,Implant Device,2142,34,,2142,percent of total billed charges,Implant Device,2142,34,,2142,percent of total billed charges,Implant Device,2142,34,,2142,percent of total billed charges,Implant Device,2142,34,,2142,percent of total billed charges,Implant Device,3118.5,,,3118.5,Other,110% of Medicare,2205,35,,2205,percent of total billed charges,Implant Device,2142,34,"Charges > $500, x 34%",2142,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2520,40,,2520,percent of total billed charges,Implant Device,2205,70,,2205,percent of total billed charges,All Other,2142,34,,2142,percent of total billed charges,Implant Device,2142,34,,2142,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2142,34,"If Charge > 2,000, then 34 percent",2142,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4662.02,
ZIMMER 42-5320-079-02 TIBIA 5° RT SZ G,C1776,HCPCS,,79011975,CDM,278,RC,,,both,,,4433,3280.43,,,3280.43,Other,150% of Medicare + 9.63% HCRA Surcharge,1994.85,45,,1994.85,percent of total billed charges,Critical Access Hospital RCC factor,1507.22,34,,1507.22,percent of total billed charges,Implant Device,1507.22,34,,1507.22,percent of total billed charges,Implant Device,1507.22,34,,1507.22,percent of total billed charges,Implant Device,1507.22,34,,1507.22,percent of total billed charges,Implant Device,1507.22,34,,1507.22,percent of total billed charges,Implant Device,2194.34,,,2194.34,Other,110% of Medicare,1551.55,35,,1551.55,percent of total billed charges,Implant Device,1507.22,34,"Charges > $500, x 34%",1507.22,percent of total billed charges,Implant Device,1551.55,35,,1551.55,percent of total billed charges,Implant Device,1551.55,35,,1551.55,percent of total billed charges,Implant Device,1551.55,35,,1551.55,percent of total billed charges,Implant Device,1551.55,35,,1551.55,percent of total billed charges,Implant Device,1551.55,35,,1551.55,percent of total billed charges,Implant Device,1773.2,40,,1773.2,percent of total billed charges,Implant Device,1551.55,70,,1551.55,percent of total billed charges,All Other,1507.22,34,,1507.22,percent of total billed charges,Implant Device,1507.22,34,,1507.22,percent of total billed charges,Implant Device,1551.55,35,,1551.55,percent of total billed charges,Implant Device,1551.55,35,,1551.55,percent of total billed charges,Implant Device,1551.55,35,,1551.55,percent of total billed charges,Implant Device,1551.55,35,,1551.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1507.22,34,"If Charge > 2,000, then 34 percent",1507.22,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3280.43,
ZIMMER 42-5121-008-13 ART SURFACE LT13MM,C1776,HCPCS,,79011976,CDM,278,RC,,,both,,,3648,2699.53,,,2699.53,Other,150% of Medicare + 9.63% HCRA Surcharge,1641.6,45,,1641.6,percent of total billed charges,Critical Access Hospital RCC factor,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1805.76,,,1805.76,Other,110% of Medicare,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1240.32,34,"Charges > $500, x 34%",1240.32,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1459.2,40,,1459.2,percent of total billed charges,Implant Device,1276.8,70,,1276.8,percent of total billed charges,All Other,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1240.32,34,"If Charge > 2,000, then 34 percent",1240.32,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2699.53,
ZIMMER 42-5221-009-14 ART SURFACE RT14mm,C1776,HCPCS,,79011982,CDM,278,RC,,,both,,,4116,3045.85,,,3045.85,Other,150% of Medicare + 9.63% HCRA Surcharge,1852.2,45,,1852.2,percent of total billed charges,Critical Access Hospital RCC factor,1399.44,34,,1399.44,percent of total billed charges,Implant Device,1399.44,34,,1399.44,percent of total billed charges,Implant Device,1399.44,34,,1399.44,percent of total billed charges,Implant Device,1399.44,34,,1399.44,percent of total billed charges,Implant Device,1399.44,34,,1399.44,percent of total billed charges,Implant Device,2037.42,,,2037.42,Other,110% of Medicare,1440.6,35,,1440.6,percent of total billed charges,Implant Device,1399.44,34,"Charges > $500, x 34%",1399.44,percent of total billed charges,Implant Device,1440.6,35,,1440.6,percent of total billed charges,Implant Device,1440.6,35,,1440.6,percent of total billed charges,Implant Device,1440.6,35,,1440.6,percent of total billed charges,Implant Device,1440.6,35,,1440.6,percent of total billed charges,Implant Device,1440.6,35,,1440.6,percent of total billed charges,Implant Device,1646.4,40,,1646.4,percent of total billed charges,Implant Device,1440.6,70,,1440.6,percent of total billed charges,All Other,1399.44,34,,1399.44,percent of total billed charges,Implant Device,1399.44,34,,1399.44,percent of total billed charges,Implant Device,1440.6,35,,1440.6,percent of total billed charges,Implant Device,1440.6,35,,1440.6,percent of total billed charges,Implant Device,1440.6,35,,1440.6,percent of total billed charges,Implant Device,1440.6,35,,1440.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1399.44,34,"If Charge > 2,000, then 34 percent",1399.44,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3045.85,
stryker  629630 10 hole locking plate,C1713,HCPCS,,79011983,CDM,278,RC,,,both,,,2268,1678.33,,,1678.33,Other,150% of Medicare + 9.63% HCRA Surcharge,1020.6,45,,1020.6,percent of total billed charges,Critical Access Hospital RCC factor,771.12,34,,771.12,percent of total billed charges,Implant Device,771.12,34,,771.12,percent of total billed charges,Implant Device,771.12,34,,771.12,percent of total billed charges,Implant Device,771.12,34,,771.12,percent of total billed charges,Implant Device,771.12,34,,771.12,percent of total billed charges,Implant Device,1122.66,,,1122.66,Other,110% of Medicare,793.8,35,,793.8,percent of total billed charges,Implant Device,771.12,34,"Charges > $500, x 34%",771.12,percent of total billed charges,Implant Device,793.8,35,,793.8,percent of total billed charges,Implant Device,793.8,35,,793.8,percent of total billed charges,Implant Device,793.8,35,,793.8,percent of total billed charges,Implant Device,793.8,35,,793.8,percent of total billed charges,Implant Device,793.8,35,,793.8,percent of total billed charges,Implant Device,907.2,40,,907.2,percent of total billed charges,Implant Device,793.8,70,,793.8,percent of total billed charges,All Other,771.12,34,,771.12,percent of total billed charges,Implant Device,771.12,34,,771.12,percent of total billed charges,Implant Device,793.8,35,,793.8,percent of total billed charges,Implant Device,793.8,35,,793.8,percent of total billed charges,Implant Device,793.8,35,,793.8,percent of total billed charges,Implant Device,793.8,35,,793.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,771.12,34,"If Charge > 2,000, then 34 percent",771.12,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1678.33,
Stryker 657720 bone screw 2mm l20mm,C1713,HCPCS,,79011984,CDM,278,RC,,,both,,,258,190.92,,,190.92,Other,150% of Medicare + 9.63% HCRA Surcharge,116.1,45,,116.1,percent of total billed charges,Critical Access Hospital RCC factor,87.72,34,,87.72,percent of total billed charges,Implant Device,87.72,34,,87.72,percent of total billed charges,Implant Device,87.72,34,,87.72,percent of total billed charges,Implant Device,87.72,34,,87.72,percent of total billed charges,Implant Device,87.72,34,,87.72,percent of total billed charges,Implant Device,127.71,,,127.71,Other,110% of Medicare,90.3,35,,90.3,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,90.3,35,,90.3,percent of total billed charges,Implant Device,90.3,35,,90.3,percent of total billed charges,Implant Device,90.3,35,,90.3,percent of total billed charges,Implant Device,90.3,35,,90.3,percent of total billed charges,Implant Device,90.3,35,,90.3,percent of total billed charges,Implant Device,103.2,40,,103.2,percent of total billed charges,Implant Device,90.3,70,,90.3,percent of total billed charges,All Other,87.72,34,,87.72,percent of total billed charges,Implant Device,87.72,34,,87.72,percent of total billed charges,Implant Device,90.3,35,,90.3,percent of total billed charges,Implant Device,90.3,35,,90.3,percent of total billed charges,Implant Device,90.3,35,,90.3,percent of total billed charges,Implant Device,90.3,35,,90.3,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,190.92,
stryker 3102-1001 allograft dbm putty1cc,C1762,HCPCS,,79011985,CDM,278,RC,,,both,,,309,228.66,,,228.66,Other,150% of Medicare + 9.63% HCRA Surcharge,139.05,45,,139.05,percent of total billed charges,Critical Access Hospital RCC factor,105.06,34,,105.06,percent of total billed charges,Implant Device,105.06,34,,105.06,percent of total billed charges,Implant Device,105.06,34,,105.06,percent of total billed charges,Implant Device,105.06,34,,105.06,percent of total billed charges,Implant Device,105.06,34,,105.06,percent of total billed charges,Implant Device,152.96,,,152.96,Other,110% of Medicare,108.15,35,,108.15,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,108.15,35,,108.15,percent of total billed charges,Implant Device,108.15,35,,108.15,percent of total billed charges,Implant Device,108.15,35,,108.15,percent of total billed charges,Implant Device,108.15,35,,108.15,percent of total billed charges,Implant Device,108.15,35,,108.15,percent of total billed charges,Implant Device,123.6,40,,123.6,percent of total billed charges,Implant Device,108.15,70,,108.15,percent of total billed charges,All Other,105.06,34,,105.06,percent of total billed charges,Implant Device,105.06,34,,105.06,percent of total billed charges,Implant Device,108.15,35,,108.15,percent of total billed charges,Implant Device,108.15,35,,108.15,percent of total billed charges,Implant Device,108.15,35,,108.15,percent of total billed charges,Implant Device,108.15,35,,108.15,percent of total billed charges,Implant Device,976.07,,,976.07,Other,100% of Medicaid,976.07,,,976.07,Other,100% of Medicaid,976.07,,,976.07,Other,100% of Medicaid,976.07,,,976.07,Other,100% of Medicaid,2196.16,,,2196.16,Other,225% of Medicaid,1493.39,,,1493.39,Other,153% of Medicaid,2196.16,,,2196.16,Other,225% of Medicaid,1366.5,,,1366.5,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,2537.78,,,2537.78,Other,260% of Medicaid,3162.47,,,3162.47,Other,324% of Medicaid,2098.55,,,2098.55,Other,215% of Medicaid,2098.55,,,2098.55,Other,215% of Medicaid,1220.09,,,1220.09,Other,125% of Medicaid,0.01,3162.47,
J&J  1506-11-006 tibial base size 6,C1776,HCPCS,,79011986,CDM,278,RC,,,both,,,6300,4662.02,,,4662.02,Other,150% of Medicare + 9.63% HCRA Surcharge,2835,45,,2835,percent of total billed charges,Critical Access Hospital RCC factor,2142,34,,2142,percent of total billed charges,Implant Device,2142,34,,2142,percent of total billed charges,Implant Device,2142,34,,2142,percent of total billed charges,Implant Device,2142,34,,2142,percent of total billed charges,Implant Device,2142,34,,2142,percent of total billed charges,Implant Device,3118.5,,,3118.5,Other,110% of Medicare,2205,35,,2205,percent of total billed charges,Implant Device,2142,34,"Charges > $500, x 34%",2142,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2520,40,,2520,percent of total billed charges,Implant Device,2205,70,,2205,percent of total billed charges,All Other,2142,34,,2142,percent of total billed charges,Implant Device,2142,34,,2142,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2142,34,"If Charge > 2,000, then 34 percent",2142,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4662.02,
ARTHREX AR-9943C-10 10 hole lock plate,C1713,HCPCS,,79011987,CDM,278,RC,,,both,,,2268,1678.33,,,1678.33,Other,150% of Medicare + 9.63% HCRA Surcharge,1020.6,45,,1020.6,percent of total billed charges,Critical Access Hospital RCC factor,771.12,34,,771.12,percent of total billed charges,Implant Device,771.12,34,,771.12,percent of total billed charges,Implant Device,771.12,34,,771.12,percent of total billed charges,Implant Device,771.12,34,,771.12,percent of total billed charges,Implant Device,771.12,34,,771.12,percent of total billed charges,Implant Device,1122.66,,,1122.66,Other,110% of Medicare,793.8,35,,793.8,percent of total billed charges,Implant Device,771.12,34,"Charges > $500, x 34%",771.12,percent of total billed charges,Implant Device,793.8,35,,793.8,percent of total billed charges,Implant Device,793.8,35,,793.8,percent of total billed charges,Implant Device,793.8,35,,793.8,percent of total billed charges,Implant Device,793.8,35,,793.8,percent of total billed charges,Implant Device,793.8,35,,793.8,percent of total billed charges,Implant Device,907.2,40,,907.2,percent of total billed charges,Implant Device,793.8,70,,793.8,percent of total billed charges,All Other,771.12,34,,771.12,percent of total billed charges,Implant Device,771.12,34,,771.12,percent of total billed charges,Implant Device,793.8,35,,793.8,percent of total billed charges,Implant Device,793.8,35,,793.8,percent of total billed charges,Implant Device,793.8,35,,793.8,percent of total billed charges,Implant Device,793.8,35,,793.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,771.12,34,"If Charge > 2,000, then 34 percent",771.12,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1678.33,
WRIGHT MED FFNS0808 NITINOL KIT 8MMX8MM,C1713,HCPCS,,79011988,CDM,278,RC,,,both,,,6951,5143.76,,,5143.76,Other,150% of Medicare + 9.63% HCRA Surcharge,3127.95,45,,3127.95,percent of total billed charges,Critical Access Hospital RCC factor,2363.34,34,,2363.34,percent of total billed charges,Implant Device,2363.34,34,,2363.34,percent of total billed charges,Implant Device,2363.34,34,,2363.34,percent of total billed charges,Implant Device,2363.34,34,,2363.34,percent of total billed charges,Implant Device,2363.34,34,,2363.34,percent of total billed charges,Implant Device,3440.75,,,3440.75,Other,110% of Medicare,2432.85,35,,2432.85,percent of total billed charges,Implant Device,2363.34,34,"Charges > $500, x 34%",2363.34,percent of total billed charges,Implant Device,2432.85,35,,2432.85,percent of total billed charges,Implant Device,2432.85,35,,2432.85,percent of total billed charges,Implant Device,2432.85,35,,2432.85,percent of total billed charges,Implant Device,2432.85,35,,2432.85,percent of total billed charges,Implant Device,2432.85,35,,2432.85,percent of total billed charges,Implant Device,2780.4,40,,2780.4,percent of total billed charges,Implant Device,2432.85,70,,2432.85,percent of total billed charges,All Other,2363.34,34,,2363.34,percent of total billed charges,Implant Device,2363.34,34,,2363.34,percent of total billed charges,Implant Device,2432.85,35,,2432.85,percent of total billed charges,Implant Device,2432.85,35,,2432.85,percent of total billed charges,Implant Device,2432.85,35,,2432.85,percent of total billed charges,Implant Device,2432.85,35,,2432.85,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2363.34,34,"If Charge > 2,000, then 34 percent",2363.34,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5143.76,
STRYKER 40-30124 3.0 CANN SCREW 24MM,C1713,HCPCS,,79011989,CDM,278,RC,,,both,,,493,364.82,,,364.82,Other,150% of Medicare + 9.63% HCRA Surcharge,221.85,45,,221.85,percent of total billed charges,Critical Access Hospital RCC factor,167.62,34,,167.62,percent of total billed charges,Implant Device,167.62,34,,167.62,percent of total billed charges,Implant Device,167.62,34,,167.62,percent of total billed charges,Implant Device,167.62,34,,167.62,percent of total billed charges,Implant Device,167.62,34,,167.62,percent of total billed charges,Implant Device,244.04,,,244.04,Other,110% of Medicare,172.55,35,,172.55,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,172.55,35,,172.55,percent of total billed charges,Implant Device,172.55,35,,172.55,percent of total billed charges,Implant Device,172.55,35,,172.55,percent of total billed charges,Implant Device,172.55,35,,172.55,percent of total billed charges,Implant Device,172.55,35,,172.55,percent of total billed charges,Implant Device,197.2,40,,197.2,percent of total billed charges,Implant Device,172.55,70,,172.55,percent of total billed charges,All Other,167.62,34,,167.62,percent of total billed charges,Implant Device,167.62,34,,167.62,percent of total billed charges,Implant Device,172.55,35,,172.55,percent of total billed charges,Implant Device,172.55,35,,172.55,percent of total billed charges,Implant Device,172.55,35,,172.55,percent of total billed charges,Implant Device,172.55,35,,172.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,364.82,
STRYKER 40-30126 3.0 CANN SCREW 26MM,C1713,HCPCS,,79011990,CDM,278,RC,,,both,,,964,713.36,,,713.36,Other,150% of Medicare + 9.63% HCRA Surcharge,433.8,45,,433.8,percent of total billed charges,Critical Access Hospital RCC factor,327.76,34,,327.76,percent of total billed charges,Implant Device,327.76,34,,327.76,percent of total billed charges,Implant Device,327.76,34,,327.76,percent of total billed charges,Implant Device,327.76,34,,327.76,percent of total billed charges,Implant Device,327.76,34,,327.76,percent of total billed charges,Implant Device,477.18,,,477.18,Other,110% of Medicare,337.4,35,,337.4,percent of total billed charges,Implant Device,327.76,34,"Charges > $500, x 34%",327.76,percent of total billed charges,Implant Device,337.4,35,,337.4,percent of total billed charges,Implant Device,337.4,35,,337.4,percent of total billed charges,Implant Device,337.4,35,,337.4,percent of total billed charges,Implant Device,337.4,35,,337.4,percent of total billed charges,Implant Device,337.4,35,,337.4,percent of total billed charges,Implant Device,385.6,40,,385.6,percent of total billed charges,Implant Device,337.4,70,,337.4,percent of total billed charges,All Other,327.76,34,,327.76,percent of total billed charges,Implant Device,327.76,34,,327.76,percent of total billed charges,Implant Device,337.4,35,,337.4,percent of total billed charges,Implant Device,337.4,35,,337.4,percent of total billed charges,Implant Device,337.4,35,,337.4,percent of total billed charges,Implant Device,337.4,35,,337.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,713.36,
Zimmer00-5001-047-00 BIPOLAR SHELL 47mm,C1776,HCPCS,,79011991,CDM,278,RC,,,both,,,960,710.4,,,710.4,Other,150% of Medicare + 9.63% HCRA Surcharge,432,45,,432,percent of total billed charges,Critical Access Hospital RCC factor,326.4,34,,326.4,percent of total billed charges,Implant Device,326.4,34,,326.4,percent of total billed charges,Implant Device,326.4,34,,326.4,percent of total billed charges,Implant Device,326.4,34,,326.4,percent of total billed charges,Implant Device,326.4,34,,326.4,percent of total billed charges,Implant Device,475.2,,,475.2,Other,110% of Medicare,336,35,,336,percent of total billed charges,Implant Device,326.4,34,"Charges > $500, x 34%",326.4,percent of total billed charges,Implant Device,336,35,,336,percent of total billed charges,Implant Device,336,35,,336,percent of total billed charges,Implant Device,336,35,,336,percent of total billed charges,Implant Device,336,35,,336,percent of total billed charges,Implant Device,336,35,,336,percent of total billed charges,Implant Device,384,40,,384,percent of total billed charges,Implant Device,336,70,,336,percent of total billed charges,All Other,326.4,34,,326.4,percent of total billed charges,Implant Device,326.4,34,,326.4,percent of total billed charges,Implant Device,336,35,,336,percent of total billed charges,Implant Device,336,35,,336,percent of total billed charges,Implant Device,336,35,,336,percent of total billed charges,Implant Device,336,35,,336,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,710.4,
KINAMED 35-100-1040 SUPRCABLCERCLGE SYST,C1713,HCPCS,,79011992,CDM,278,RC,,,both,,,1383,1023.42,,,1023.42,Other,150% of Medicare + 9.63% HCRA Surcharge,622.35,45,,622.35,percent of total billed charges,Critical Access Hospital RCC factor,470.22,34,,470.22,percent of total billed charges,Implant Device,470.22,34,,470.22,percent of total billed charges,Implant Device,470.22,34,,470.22,percent of total billed charges,Implant Device,470.22,34,,470.22,percent of total billed charges,Implant Device,470.22,34,,470.22,percent of total billed charges,Implant Device,684.59,,,684.59,Other,110% of Medicare,484.05,35,,484.05,percent of total billed charges,Implant Device,470.22,34,"Charges > $500, x 34%",470.22,percent of total billed charges,Implant Device,484.05,35,,484.05,percent of total billed charges,Implant Device,484.05,35,,484.05,percent of total billed charges,Implant Device,484.05,35,,484.05,percent of total billed charges,Implant Device,484.05,35,,484.05,percent of total billed charges,Implant Device,484.05,35,,484.05,percent of total billed charges,Implant Device,553.2,40,,553.2,percent of total billed charges,Implant Device,484.05,70,,484.05,percent of total billed charges,All Other,470.22,34,,470.22,percent of total billed charges,Implant Device,470.22,34,,470.22,percent of total billed charges,Implant Device,484.05,35,,484.05,percent of total billed charges,Implant Device,484.05,35,,484.05,percent of total billed charges,Implant Device,484.05,35,,484.05,percent of total billed charges,Implant Device,484.05,35,,484.05,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1023.42,
OSTEOSET MINI BEAD FAST CURE 5CC,C1763,HCPCS,,79011993,CDM,278,RC,,,both,,,3561,2635.15,,,2635.15,Other,150% of Medicare + 9.63% HCRA Surcharge,1602.45,45,,1602.45,percent of total billed charges,Critical Access Hospital RCC factor,1210.74,34,,1210.74,percent of total billed charges,Implant Device,1210.74,34,,1210.74,percent of total billed charges,Implant Device,1210.74,34,,1210.74,percent of total billed charges,Implant Device,1210.74,34,,1210.74,percent of total billed charges,Implant Device,1210.74,34,,1210.74,percent of total billed charges,Implant Device,1762.7,,,1762.7,Other,110% of Medicare,1246.35,35,,1246.35,percent of total billed charges,Implant Device,1210.74,34,"Charges > $500, x 34%",1210.74,percent of total billed charges,Implant Device,1246.35,35,,1246.35,percent of total billed charges,Implant Device,1246.35,35,,1246.35,percent of total billed charges,Implant Device,1246.35,35,,1246.35,percent of total billed charges,Implant Device,1246.35,35,,1246.35,percent of total billed charges,Implant Device,1246.35,35,,1246.35,percent of total billed charges,Implant Device,1424.4,40,,1424.4,percent of total billed charges,Implant Device,1246.35,70,,1246.35,percent of total billed charges,All Other,1210.74,34,,1210.74,percent of total billed charges,Implant Device,1210.74,34,,1210.74,percent of total billed charges,Implant Device,1246.35,35,,1246.35,percent of total billed charges,Implant Device,1246.35,35,,1246.35,percent of total billed charges,Implant Device,1246.35,35,,1246.35,percent of total billed charges,Implant Device,1246.35,35,,1246.35,percent of total billed charges,Implant Device,976.07,,,976.07,Other,100% of Medicaid,976.07,,,976.07,Other,100% of Medicaid,976.07,,,976.07,Other,100% of Medicaid,976.07,,,976.07,Other,100% of Medicaid,2196.16,,,2196.16,Other,225% of Medicaid,1493.39,,,1493.39,Other,153% of Medicaid,2196.16,,,2196.16,Other,225% of Medicaid,1366.5,,,1366.5,Other,140% of Medicaid,1210.74,34,"If Charge > 2,000, then 34 percent",1210.74,percent of total billed charges,Implants,2537.78,,,2537.78,Other,260% of Medicaid,3162.47,,,3162.47,Other,324% of Medicaid,2098.55,,,2098.55,Other,215% of Medicaid,2098.55,,,2098.55,Other,215% of Medicaid,1220.09,,,1220.09,Other,125% of Medicaid,976.07,3162.47,
MEDTRONIC NEURO 3560031 REVISION KIT,C2623,HCPCS,,79011994,CDM,278,RC,,,both,,,1065,788.1,,,788.1,Other,150% of Medicare + 9.63% HCRA Surcharge,479.25,45,,479.25,percent of total billed charges,Critical Access Hospital RCC factor,362.1,34,,362.1,percent of total billed charges,Implant Device,362.1,34,,362.1,percent of total billed charges,Implant Device,362.1,34,,362.1,percent of total billed charges,Implant Device,362.1,34,,362.1,percent of total billed charges,Implant Device,362.1,34,,362.1,percent of total billed charges,Implant Device,527.18,,,527.18,Other,110% of Medicare,372.75,35,,372.75,percent of total billed charges,Implant Device,362.1,34,"Charges > $500, x 34%",362.1,percent of total billed charges,Implant Device,372.75,35,,372.75,percent of total billed charges,Implant Device,372.75,35,,372.75,percent of total billed charges,Implant Device,372.75,35,,372.75,percent of total billed charges,Implant Device,372.75,35,,372.75,percent of total billed charges,Implant Device,372.75,35,,372.75,percent of total billed charges,Implant Device,426,40,,426,percent of total billed charges,Implant Device,372.75,70,,372.75,percent of total billed charges,All Other,362.1,34,,362.1,percent of total billed charges,Implant Device,362.1,34,,362.1,percent of total billed charges,Implant Device,372.75,35,,372.75,percent of total billed charges,Implant Device,372.75,35,,372.75,percent of total billed charges,Implant Device,372.75,35,,372.75,percent of total billed charges,Implant Device,372.75,35,,372.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,788.1,
IN2BONES P72 ST022 CORT SCREW 2.7X22MM,C1713,HCPCS,,79011995,CDM,278,RC,,,both,,,870,643.8,,,643.8,Other,150% of Medicare + 9.63% HCRA Surcharge,391.5,45,,391.5,percent of total billed charges,Critical Access Hospital RCC factor,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,430.65,,,430.65,Other,110% of Medicare,304.5,35,,304.5,percent of total billed charges,Implant Device,295.8,34,"Charges > $500, x 34%",295.8,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,348,40,,348,percent of total billed charges,Implant Device,304.5,70,,304.5,percent of total billed charges,All Other,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,643.8,
EXACTECH 320-08-42 GLENOSPHERE&LOCK CAP,C1776,HCPCS,,79011996,CDM,278,RC,,,both,,,5610,4151.41,,,4151.41,Other,150% of Medicare + 9.63% HCRA Surcharge,2524.5,45,,2524.5,percent of total billed charges,Critical Access Hospital RCC factor,1907.4,34,,1907.4,percent of total billed charges,Implant Device,1907.4,34,,1907.4,percent of total billed charges,Implant Device,1907.4,34,,1907.4,percent of total billed charges,Implant Device,1907.4,34,,1907.4,percent of total billed charges,Implant Device,1907.4,34,,1907.4,percent of total billed charges,Implant Device,2776.95,,,2776.95,Other,110% of Medicare,1963.5,35,,1963.5,percent of total billed charges,Implant Device,1907.4,34,"Charges > $500, x 34%",1907.4,percent of total billed charges,Implant Device,1963.5,35,,1963.5,percent of total billed charges,Implant Device,1963.5,35,,1963.5,percent of total billed charges,Implant Device,1963.5,35,,1963.5,percent of total billed charges,Implant Device,1963.5,35,,1963.5,percent of total billed charges,Implant Device,1963.5,35,,1963.5,percent of total billed charges,Implant Device,2244,40,,2244,percent of total billed charges,Implant Device,1963.5,70,,1963.5,percent of total billed charges,All Other,1907.4,34,,1907.4,percent of total billed charges,Implant Device,1907.4,34,,1907.4,percent of total billed charges,Implant Device,1963.5,35,,1963.5,percent of total billed charges,Implant Device,1963.5,35,,1963.5,percent of total billed charges,Implant Device,1963.5,35,,1963.5,percent of total billed charges,Implant Device,1963.5,35,,1963.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1907.4,34,"If Charge > 2,000, then 34 percent",1907.4,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4151.41,
ZIMMER 110007561 CANNULATED SCREW 4X46MM,C1713,HCPCS,,79011997,CDM,278,RC,,,both,,,702,519.48,,,519.48,Other,150% of Medicare + 9.63% HCRA Surcharge,315.9,45,,315.9,percent of total billed charges,Critical Access Hospital RCC factor,238.68,34,,238.68,percent of total billed charges,Implant Device,238.68,34,,238.68,percent of total billed charges,Implant Device,238.68,34,,238.68,percent of total billed charges,Implant Device,238.68,34,,238.68,percent of total billed charges,Implant Device,238.68,34,,238.68,percent of total billed charges,Implant Device,347.49,,,347.49,Other,110% of Medicare,245.7,35,,245.7,percent of total billed charges,Implant Device,238.68,34,"Charges > $500, x 34%",238.68,percent of total billed charges,Implant Device,245.7,35,,245.7,percent of total billed charges,Implant Device,245.7,35,,245.7,percent of total billed charges,Implant Device,245.7,35,,245.7,percent of total billed charges,Implant Device,245.7,35,,245.7,percent of total billed charges,Implant Device,245.7,35,,245.7,percent of total billed charges,Implant Device,280.8,40,,280.8,percent of total billed charges,Implant Device,245.7,70,,245.7,percent of total billed charges,All Other,238.68,34,,238.68,percent of total billed charges,Implant Device,238.68,34,,238.68,percent of total billed charges,Implant Device,245.7,35,,245.7,percent of total billed charges,Implant Device,245.7,35,,245.7,percent of total billed charges,Implant Device,245.7,35,,245.7,percent of total billed charges,Implant Device,245.7,35,,245.7,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,519.48,
STRYKER 607438 CANCELLOUS SCREW 4X38X14,C1713,HCPCS,,79011998,CDM,278,RC,,,both,,,133,98.42,,,98.42,Other,150% of Medicare + 9.63% HCRA Surcharge,59.85,45,,59.85,percent of total billed charges,Critical Access Hospital RCC factor,45.22,34,,45.22,percent of total billed charges,Implant Device,45.22,34,,45.22,percent of total billed charges,Implant Device,45.22,34,,45.22,percent of total billed charges,Implant Device,45.22,34,,45.22,percent of total billed charges,Implant Device,45.22,34,,45.22,percent of total billed charges,Implant Device,65.84,,,65.84,Other,110% of Medicare,46.55,35,,46.55,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,46.55,35,,46.55,percent of total billed charges,Implant Device,46.55,35,,46.55,percent of total billed charges,Implant Device,46.55,35,,46.55,percent of total billed charges,Implant Device,46.55,35,,46.55,percent of total billed charges,Implant Device,46.55,35,,46.55,percent of total billed charges,Implant Device,53.2,40,,53.2,percent of total billed charges,Implant Device,46.55,70,,46.55,percent of total billed charges,All Other,45.22,34,,45.22,percent of total billed charges,Implant Device,45.22,34,,45.22,percent of total billed charges,Implant Device,46.55,35,,46.55,percent of total billed charges,Implant Device,46.55,35,,46.55,percent of total billed charges,Implant Device,46.55,35,,46.55,percent of total billed charges,Implant Device,46.55,35,,46.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,98.42,
STRYKER 607442 CANCELLOUS SCREW 4X42X14,C1713,HCPCS,,79011999,CDM,278,RC,,,both,,,133,98.42,,,98.42,Other,150% of Medicare + 9.63% HCRA Surcharge,59.85,45,,59.85,percent of total billed charges,Critical Access Hospital RCC factor,45.22,34,,45.22,percent of total billed charges,Implant Device,45.22,34,,45.22,percent of total billed charges,Implant Device,45.22,34,,45.22,percent of total billed charges,Implant Device,45.22,34,,45.22,percent of total billed charges,Implant Device,45.22,34,,45.22,percent of total billed charges,Implant Device,65.84,,,65.84,Other,110% of Medicare,46.55,35,,46.55,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,46.55,35,,46.55,percent of total billed charges,Implant Device,46.55,35,,46.55,percent of total billed charges,Implant Device,46.55,35,,46.55,percent of total billed charges,Implant Device,46.55,35,,46.55,percent of total billed charges,Implant Device,46.55,35,,46.55,percent of total billed charges,Implant Device,53.2,40,,53.2,percent of total billed charges,Implant Device,46.55,70,,46.55,percent of total billed charges,All Other,45.22,34,,45.22,percent of total billed charges,Implant Device,45.22,34,,45.22,percent of total billed charges,Implant Device,46.55,35,,46.55,percent of total billed charges,Implant Device,46.55,35,,46.55,percent of total billed charges,Implant Device,46.55,35,,46.55,percent of total billed charges,Implant Device,46.55,35,,46.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,98.42,
J&J 1504-10-107 FEM POSTERIOR SZ 7 LT,C1776,HCPCS,,79012000,CDM,278,RC,,,both,,,4800,3552.01,,,3552.01,Other,150% of Medicare + 9.63% HCRA Surcharge,2160,45,,2160,percent of total billed charges,Critical Access Hospital RCC factor,1632,34,,1632,percent of total billed charges,Implant Device,1632,34,,1632,percent of total billed charges,Implant Device,1632,34,,1632,percent of total billed charges,Implant Device,1632,34,,1632,percent of total billed charges,Implant Device,1632,34,,1632,percent of total billed charges,Implant Device,2376,,,2376,Other,110% of Medicare,1680,35,,1680,percent of total billed charges,Implant Device,1632,34,"Charges > $500, x 34%",1632,percent of total billed charges,Implant Device,1680,35,,1680,percent of total billed charges,Implant Device,1680,35,,1680,percent of total billed charges,Implant Device,1680,35,,1680,percent of total billed charges,Implant Device,1680,35,,1680,percent of total billed charges,Implant Device,1680,35,,1680,percent of total billed charges,Implant Device,1920,40,,1920,percent of total billed charges,Implant Device,1680,70,,1680,percent of total billed charges,All Other,1632,34,,1632,percent of total billed charges,Implant Device,1632,34,,1632,percent of total billed charges,Implant Device,1680,35,,1680,percent of total billed charges,Implant Device,1680,35,,1680,percent of total billed charges,Implant Device,1680,35,,1680,percent of total billed charges,Implant Device,1680,35,,1680,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1632,34,"If Charge > 2,000, then 34 percent",1632,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3552.01,
J&J 1506-80-007 TIBIAL BASE SZ 7,C1776,HCPCS,,79012001,CDM,278,RC,,,both,,,3900,2886.01,,,2886.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1755,45,,1755,percent of total billed charges,Critical Access Hospital RCC factor,1326,34,,1326,percent of total billed charges,Implant Device,1326,34,,1326,percent of total billed charges,Implant Device,1326,34,,1326,percent of total billed charges,Implant Device,1326,34,,1326,percent of total billed charges,Implant Device,1326,34,,1326,percent of total billed charges,Implant Device,1930.5,,,1930.5,Other,110% of Medicare,1365,35,,1365,percent of total billed charges,Implant Device,1326,34,"Charges > $500, x 34%",1326,percent of total billed charges,Implant Device,1365,35,,1365,percent of total billed charges,Implant Device,1365,35,,1365,percent of total billed charges,Implant Device,1365,35,,1365,percent of total billed charges,Implant Device,1365,35,,1365,percent of total billed charges,Implant Device,1365,35,,1365,percent of total billed charges,Implant Device,1560,40,,1560,percent of total billed charges,Implant Device,1365,70,,1365,percent of total billed charges,All Other,1326,34,,1326,percent of total billed charges,Implant Device,1326,34,,1326,percent of total billed charges,Implant Device,1365,35,,1365,percent of total billed charges,Implant Device,1365,35,,1365,percent of total billed charges,Implant Device,1365,35,,1365,percent of total billed charges,Implant Device,1365,35,,1365,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1326,34,"If Charge > 2,000, then 34 percent",1326,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2886.01,
J&J 1516-50-708 TIBIAL INSERT 8MM SZ 7,C1776,HCPCS,,79012002,CDM,278,RC,,,both,,,5400,3996.01,,,3996.01,Other,150% of Medicare + 9.63% HCRA Surcharge,2430,45,,2430,percent of total billed charges,Critical Access Hospital RCC factor,1836,34,,1836,percent of total billed charges,Implant Device,1836,34,,1836,percent of total billed charges,Implant Device,1836,34,,1836,percent of total billed charges,Implant Device,1836,34,,1836,percent of total billed charges,Implant Device,1836,34,,1836,percent of total billed charges,Implant Device,2673,,,2673,Other,110% of Medicare,1890,35,,1890,percent of total billed charges,Implant Device,1836,34,"Charges > $500, x 34%",1836,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,2160,40,,2160,percent of total billed charges,Implant Device,1890,70,,1890,percent of total billed charges,All Other,1836,34,,1836,percent of total billed charges,Implant Device,1836,34,,1836,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1836,34,"If Charge > 2,000, then 34 percent",1836,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3996.01,
J&J 1504-11-206 FEM POSTERIOR SZ 6 RT,C1776,HCPCS,,79012003,CDM,278,RC,,,both,,,6000,4440.02,,,4440.02,Other,150% of Medicare + 9.63% HCRA Surcharge,2700,45,,2700,percent of total billed charges,Critical Access Hospital RCC factor,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2970,,,2970,Other,110% of Medicare,2100,35,,2100,percent of total billed charges,Implant Device,2040,34,"Charges > $500, x 34%",2040,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2400,40,,2400,percent of total billed charges,Implant Device,2100,70,,2100,percent of total billed charges,All Other,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2040,34,"If Charge > 2,000, then 34 percent",2040,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4440.02,
J&J 1516-50-605 TIBIAL INSERT 5MM SZ 6,C1776,HCPCS,,79012004,CDM,278,RC,,,both,,,5400,3996.01,,,3996.01,Other,150% of Medicare + 9.63% HCRA Surcharge,2430,45,,2430,percent of total billed charges,Critical Access Hospital RCC factor,1836,34,,1836,percent of total billed charges,Implant Device,1836,34,,1836,percent of total billed charges,Implant Device,1836,34,,1836,percent of total billed charges,Implant Device,1836,34,,1836,percent of total billed charges,Implant Device,1836,34,,1836,percent of total billed charges,Implant Device,2673,,,2673,Other,110% of Medicare,1890,35,,1890,percent of total billed charges,Implant Device,1836,34,"Charges > $500, x 34%",1836,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,2160,40,,2160,percent of total billed charges,Implant Device,1890,70,,1890,percent of total billed charges,All Other,1836,34,,1836,percent of total billed charges,Implant Device,1836,34,,1836,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1836,34,"If Charge > 2,000, then 34 percent",1836,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3996.01,
J&J 207.616 CANNULATED SCREW 4.0X16MM,C1713,HCPCS,,79012007,CDM,278,RC,,,both,,,519,384.06,,,384.06,Other,150% of Medicare + 9.63% HCRA Surcharge,233.55,45,,233.55,percent of total billed charges,Critical Access Hospital RCC factor,176.46,34,,176.46,percent of total billed charges,Implant Device,176.46,34,,176.46,percent of total billed charges,Implant Device,176.46,34,,176.46,percent of total billed charges,Implant Device,176.46,34,,176.46,percent of total billed charges,Implant Device,176.46,34,,176.46,percent of total billed charges,Implant Device,256.91,,,256.91,Other,110% of Medicare,181.65,35,,181.65,percent of total billed charges,Implant Device,176.46,34,"Charges > $500, x 34%",176.46,percent of total billed charges,Implant Device,181.65,35,,181.65,percent of total billed charges,Implant Device,181.65,35,,181.65,percent of total billed charges,Implant Device,181.65,35,,181.65,percent of total billed charges,Implant Device,181.65,35,,181.65,percent of total billed charges,Implant Device,181.65,35,,181.65,percent of total billed charges,Implant Device,207.6,40,,207.6,percent of total billed charges,Implant Device,181.65,70,,181.65,percent of total billed charges,All Other,176.46,34,,176.46,percent of total billed charges,Implant Device,176.46,34,,176.46,percent of total billed charges,Implant Device,181.65,35,,181.65,percent of total billed charges,Implant Device,181.65,35,,181.65,percent of total billed charges,Implant Device,181.65,35,,181.65,percent of total billed charges,Implant Device,181.65,35,,181.65,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,384.06,
STRYKER 658355 COMPRESSION SCREW 7X55MM,C1713,HCPCS,,79012009,CDM,278,RC,,,both,,,2079,1538.47,,,1538.47,Other,150% of Medicare + 9.63% HCRA Surcharge,935.55,45,,935.55,percent of total billed charges,Critical Access Hospital RCC factor,706.86,34,,706.86,percent of total billed charges,Implant Device,706.86,34,,706.86,percent of total billed charges,Implant Device,706.86,34,,706.86,percent of total billed charges,Implant Device,706.86,34,,706.86,percent of total billed charges,Implant Device,706.86,34,,706.86,percent of total billed charges,Implant Device,1029.11,,,1029.11,Other,110% of Medicare,727.65,35,,727.65,percent of total billed charges,Implant Device,706.86,34,"Charges > $500, x 34%",706.86,percent of total billed charges,Implant Device,727.65,35,,727.65,percent of total billed charges,Implant Device,727.65,35,,727.65,percent of total billed charges,Implant Device,727.65,35,,727.65,percent of total billed charges,Implant Device,727.65,35,,727.65,percent of total billed charges,Implant Device,727.65,35,,727.65,percent of total billed charges,Implant Device,831.6,40,,831.6,percent of total billed charges,Implant Device,727.65,70,,727.65,percent of total billed charges,All Other,706.86,34,,706.86,percent of total billed charges,Implant Device,706.86,34,,706.86,percent of total billed charges,Implant Device,727.65,35,,727.65,percent of total billed charges,Implant Device,727.65,35,,727.65,percent of total billed charges,Implant Device,727.65,35,,727.65,percent of total billed charges,Implant Device,727.65,35,,727.65,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,706.86,34,"If Charge > 2,000, then 34 percent",706.86,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1538.47,
J&J 1024-56-207 TIBIAL INSERT 7MM SIZE 2,C1776,HCPCS,,79012011,CDM,278,RC,,,both,,,6000,4440.02,,,4440.02,Other,150% of Medicare + 9.63% HCRA Surcharge,2700,45,,2700,percent of total billed charges,Critical Access Hospital RCC factor,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2970,,,2970,Other,110% of Medicare,2100,35,,2100,percent of total billed charges,Implant Device,2040,34,"Charges > $500, x 34%",2040,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2400,40,,2400,percent of total billed charges,Implant Device,2100,70,,2100,percent of total billed charges,All Other,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2040,34,"If Charge > 2,000, then 34 percent",2040,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4440.02,
WRIGHT 59202010 LATERAL FUSION PLT SMALL,C1713,HCPCS,,79012012,CDM,278,RC,,,both,,,10353,7661.25,,,7661.25,Other,150% of Medicare + 9.63% HCRA Surcharge,4658.85,45,,4658.85,percent of total billed charges,Critical Access Hospital RCC factor,3520.02,34,,3520.02,percent of total billed charges,Implant Device,3520.02,34,,3520.02,percent of total billed charges,Implant Device,3520.02,34,,3520.02,percent of total billed charges,Implant Device,3520.02,34,,3520.02,percent of total billed charges,Implant Device,3520.02,34,,3520.02,percent of total billed charges,Implant Device,5124.74,,,5124.74,Other,110% of Medicare,3623.55,35,,3623.55,percent of total billed charges,Implant Device,3520.02,34,"Charges > $500, x 34%",3520.02,percent of total billed charges,Implant Device,3623.55,35,,3623.55,percent of total billed charges,Implant Device,3623.55,35,,3623.55,percent of total billed charges,Implant Device,3623.55,35,,3623.55,percent of total billed charges,Implant Device,3623.55,35,,3623.55,percent of total billed charges,Implant Device,3623.55,35,,3623.55,percent of total billed charges,Implant Device,4141.2,40,,4141.2,percent of total billed charges,Implant Device,3623.55,70,,3623.55,percent of total billed charges,All Other,3520.02,34,,3520.02,percent of total billed charges,Implant Device,3520.02,34,,3520.02,percent of total billed charges,Implant Device,3623.55,35,,3623.55,percent of total billed charges,Implant Device,3623.55,35,,3623.55,percent of total billed charges,Implant Device,3623.55,35,,3623.55,percent of total billed charges,Implant Device,3623.55,35,,3623.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3520.02,34,"If Charge > 2,000, then 34 percent",3520.02,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,7661.25,
WRIGHT 59215526 LOCKING SCREW 5.5X26MM,C1713,HCPCS,,79012013,CDM,278,RC,,,both,,,1341,992.34,,,992.34,Other,150% of Medicare + 9.63% HCRA Surcharge,603.45,45,,603.45,percent of total billed charges,Critical Access Hospital RCC factor,455.94,34,,455.94,percent of total billed charges,Implant Device,455.94,34,,455.94,percent of total billed charges,Implant Device,455.94,34,,455.94,percent of total billed charges,Implant Device,455.94,34,,455.94,percent of total billed charges,Implant Device,455.94,34,,455.94,percent of total billed charges,Implant Device,663.8,,,663.8,Other,110% of Medicare,469.35,35,,469.35,percent of total billed charges,Implant Device,455.94,34,"Charges > $500, x 34%",455.94,percent of total billed charges,Implant Device,469.35,35,,469.35,percent of total billed charges,Implant Device,469.35,35,,469.35,percent of total billed charges,Implant Device,469.35,35,,469.35,percent of total billed charges,Implant Device,469.35,35,,469.35,percent of total billed charges,Implant Device,469.35,35,,469.35,percent of total billed charges,Implant Device,536.4,40,,536.4,percent of total billed charges,Implant Device,469.35,70,,469.35,percent of total billed charges,All Other,455.94,34,,455.94,percent of total billed charges,Implant Device,455.94,34,,455.94,percent of total billed charges,Implant Device,469.35,35,,469.35,percent of total billed charges,Implant Device,469.35,35,,469.35,percent of total billed charges,Implant Device,469.35,35,,469.35,percent of total billed charges,Implant Device,469.35,35,,469.35,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,992.34,
WRIGHT 59215528 LOCKING SCREW 5.5X28MM,C1713,HCPCS,,79012014,CDM,278,RC,,,both,,,1341,992.34,,,992.34,Other,150% of Medicare + 9.63% HCRA Surcharge,603.45,45,,603.45,percent of total billed charges,Critical Access Hospital RCC factor,455.94,34,,455.94,percent of total billed charges,Implant Device,455.94,34,,455.94,percent of total billed charges,Implant Device,455.94,34,,455.94,percent of total billed charges,Implant Device,455.94,34,,455.94,percent of total billed charges,Implant Device,455.94,34,,455.94,percent of total billed charges,Implant Device,663.8,,,663.8,Other,110% of Medicare,469.35,35,,469.35,percent of total billed charges,Implant Device,455.94,34,"Charges > $500, x 34%",455.94,percent of total billed charges,Implant Device,469.35,35,,469.35,percent of total billed charges,Implant Device,469.35,35,,469.35,percent of total billed charges,Implant Device,469.35,35,,469.35,percent of total billed charges,Implant Device,469.35,35,,469.35,percent of total billed charges,Implant Device,469.35,35,,469.35,percent of total billed charges,Implant Device,536.4,40,,536.4,percent of total billed charges,Implant Device,469.35,70,,469.35,percent of total billed charges,All Other,455.94,34,,455.94,percent of total billed charges,Implant Device,455.94,34,,455.94,percent of total billed charges,Implant Device,469.35,35,,469.35,percent of total billed charges,Implant Device,469.35,35,,469.35,percent of total billed charges,Implant Device,469.35,35,,469.35,percent of total billed charges,Implant Device,469.35,35,,469.35,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,992.34,
WRIGHT 59215530 LOCKING SCREW 5.5X30MM,C1713,HCPCS,,79012015,CDM,278,RC,,,both,,,1341,992.34,,,992.34,Other,150% of Medicare + 9.63% HCRA Surcharge,603.45,45,,603.45,percent of total billed charges,Critical Access Hospital RCC factor,455.94,34,,455.94,percent of total billed charges,Implant Device,455.94,34,,455.94,percent of total billed charges,Implant Device,455.94,34,,455.94,percent of total billed charges,Implant Device,455.94,34,,455.94,percent of total billed charges,Implant Device,455.94,34,,455.94,percent of total billed charges,Implant Device,663.8,,,663.8,Other,110% of Medicare,469.35,35,,469.35,percent of total billed charges,Implant Device,455.94,34,"Charges > $500, x 34%",455.94,percent of total billed charges,Implant Device,469.35,35,,469.35,percent of total billed charges,Implant Device,469.35,35,,469.35,percent of total billed charges,Implant Device,469.35,35,,469.35,percent of total billed charges,Implant Device,469.35,35,,469.35,percent of total billed charges,Implant Device,469.35,35,,469.35,percent of total billed charges,Implant Device,536.4,40,,536.4,percent of total billed charges,Implant Device,469.35,70,,469.35,percent of total billed charges,All Other,455.94,34,,455.94,percent of total billed charges,Implant Device,455.94,34,,455.94,percent of total billed charges,Implant Device,469.35,35,,469.35,percent of total billed charges,Implant Device,469.35,35,,469.35,percent of total billed charges,Implant Device,469.35,35,,469.35,percent of total billed charges,Implant Device,469.35,35,,469.35,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,992.34,
WRIGHT 777654562 HEADED SCREW 6.5X16MM,C1713,HCPCS,,79012019,CDM,278,RC,,,both,,,2706,2002.45,,,2002.45,Other,150% of Medicare + 9.63% HCRA Surcharge,1217.7,45,,1217.7,percent of total billed charges,Critical Access Hospital RCC factor,920.04,34,,920.04,percent of total billed charges,Implant Device,920.04,34,,920.04,percent of total billed charges,Implant Device,920.04,34,,920.04,percent of total billed charges,Implant Device,920.04,34,,920.04,percent of total billed charges,Implant Device,920.04,34,,920.04,percent of total billed charges,Implant Device,1339.47,,,1339.47,Other,110% of Medicare,947.1,35,,947.1,percent of total billed charges,Implant Device,920.04,34,"Charges > $500, x 34%",920.04,percent of total billed charges,Implant Device,947.1,35,,947.1,percent of total billed charges,Implant Device,947.1,35,,947.1,percent of total billed charges,Implant Device,947.1,35,,947.1,percent of total billed charges,Implant Device,947.1,35,,947.1,percent of total billed charges,Implant Device,947.1,35,,947.1,percent of total billed charges,Implant Device,1082.4,40,,1082.4,percent of total billed charges,Implant Device,947.1,70,,947.1,percent of total billed charges,All Other,920.04,34,,920.04,percent of total billed charges,Implant Device,920.04,34,,920.04,percent of total billed charges,Implant Device,947.1,35,,947.1,percent of total billed charges,Implant Device,947.1,35,,947.1,percent of total billed charges,Implant Device,947.1,35,,947.1,percent of total billed charges,Implant Device,947.1,35,,947.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,920.04,34,"If Charge > 2,000, then 34 percent",920.04,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2002.45,
WRIGHT 59225532 CORTICAL SCREW 5.5X32MM,C1713,HCPCS,,79012020,CDM,278,RC,,,both,,,567,419.58,,,419.58,Other,150% of Medicare + 9.63% HCRA Surcharge,255.15,45,,255.15,percent of total billed charges,Critical Access Hospital RCC factor,192.78,34,,192.78,percent of total billed charges,Implant Device,192.78,34,,192.78,percent of total billed charges,Implant Device,192.78,34,,192.78,percent of total billed charges,Implant Device,192.78,34,,192.78,percent of total billed charges,Implant Device,192.78,34,,192.78,percent of total billed charges,Implant Device,280.67,,,280.67,Other,110% of Medicare,198.45,35,,198.45,percent of total billed charges,Implant Device,192.78,34,"Charges > $500, x 34%",192.78,percent of total billed charges,Implant Device,198.45,35,,198.45,percent of total billed charges,Implant Device,198.45,35,,198.45,percent of total billed charges,Implant Device,198.45,35,,198.45,percent of total billed charges,Implant Device,198.45,35,,198.45,percent of total billed charges,Implant Device,198.45,35,,198.45,percent of total billed charges,Implant Device,226.8,40,,226.8,percent of total billed charges,Implant Device,198.45,70,,198.45,percent of total billed charges,All Other,192.78,34,,192.78,percent of total billed charges,Implant Device,192.78,34,,192.78,percent of total billed charges,Implant Device,198.45,35,,198.45,percent of total billed charges,Implant Device,198.45,35,,198.45,percent of total billed charges,Implant Device,198.45,35,,198.45,percent of total billed charges,Implant Device,198.45,35,,198.45,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,419.58,
WRIGHT 59225538 CORTICAL SCREW 5.5X38MM,C1713,HCPCS,,79012021,CDM,278,RC,,,both,,,567,419.58,,,419.58,Other,150% of Medicare + 9.63% HCRA Surcharge,255.15,45,,255.15,percent of total billed charges,Critical Access Hospital RCC factor,192.78,34,,192.78,percent of total billed charges,Implant Device,192.78,34,,192.78,percent of total billed charges,Implant Device,192.78,34,,192.78,percent of total billed charges,Implant Device,192.78,34,,192.78,percent of total billed charges,Implant Device,192.78,34,,192.78,percent of total billed charges,Implant Device,280.67,,,280.67,Other,110% of Medicare,198.45,35,,198.45,percent of total billed charges,Implant Device,192.78,34,"Charges > $500, x 34%",192.78,percent of total billed charges,Implant Device,198.45,35,,198.45,percent of total billed charges,Implant Device,198.45,35,,198.45,percent of total billed charges,Implant Device,198.45,35,,198.45,percent of total billed charges,Implant Device,198.45,35,,198.45,percent of total billed charges,Implant Device,198.45,35,,198.45,percent of total billed charges,Implant Device,226.8,40,,226.8,percent of total billed charges,Implant Device,198.45,70,,198.45,percent of total billed charges,All Other,192.78,34,,192.78,percent of total billed charges,Implant Device,192.78,34,,192.78,percent of total billed charges,Implant Device,198.45,35,,198.45,percent of total billed charges,Implant Device,198.45,35,,198.45,percent of total billed charges,Implant Device,198.45,35,,198.45,percent of total billed charges,Implant Device,198.45,35,,198.45,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,419.58,
STRYKER 627235 HUMERUS PLATE 125MM 5 H,C1713,HCPCS,,79012023,CDM,278,RC,,,both,,,6151,4551.76,,,4551.76,Other,150% of Medicare + 9.63% HCRA Surcharge,2767.95,45,,2767.95,percent of total billed charges,Critical Access Hospital RCC factor,2091.34,34,,2091.34,percent of total billed charges,Implant Device,2091.34,34,,2091.34,percent of total billed charges,Implant Device,2091.34,34,,2091.34,percent of total billed charges,Implant Device,2091.34,34,,2091.34,percent of total billed charges,Implant Device,2091.34,34,,2091.34,percent of total billed charges,Implant Device,3044.75,,,3044.75,Other,110% of Medicare,2152.85,35,,2152.85,percent of total billed charges,Implant Device,2091.34,34,"Charges > $500, x 34%",2091.34,percent of total billed charges,Implant Device,2152.85,35,,2152.85,percent of total billed charges,Implant Device,2152.85,35,,2152.85,percent of total billed charges,Implant Device,2152.85,35,,2152.85,percent of total billed charges,Implant Device,2152.85,35,,2152.85,percent of total billed charges,Implant Device,2152.85,35,,2152.85,percent of total billed charges,Implant Device,2460.4,40,,2460.4,percent of total billed charges,Implant Device,2152.85,70,,2152.85,percent of total billed charges,All Other,2091.34,34,,2091.34,percent of total billed charges,Implant Device,2091.34,34,,2091.34,percent of total billed charges,Implant Device,2152.85,35,,2152.85,percent of total billed charges,Implant Device,2152.85,35,,2152.85,percent of total billed charges,Implant Device,2152.85,35,,2152.85,percent of total billed charges,Implant Device,2152.85,35,,2152.85,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2091.34,34,"If Charge > 2,000, then 34 percent",2091.34,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4551.76,
BOST SCI 72404132 AMS 800 CUFF WITH IZ,C1815,HCPCS,,79012024,CDM,278,RC,,,both,,,19815,14663.15,,,14663.15,Other,150% of Medicare + 9.63% HCRA Surcharge,8916.75,45,,8916.75,percent of total billed charges,Critical Access Hospital RCC factor,6737.1,34,,6737.1,percent of total billed charges,Implant Device,6737.1,34,,6737.1,percent of total billed charges,Implant Device,6737.1,34,,6737.1,percent of total billed charges,Implant Device,6737.1,34,,6737.1,percent of total billed charges,Implant Device,6737.1,34,,6737.1,percent of total billed charges,Implant Device,9808.43,,,9808.43,Other,110% of Medicare,6935.25,35,,6935.25,percent of total billed charges,Implant Device,6737.1,34,"Charges > $500, x 34%",6737.1,percent of total billed charges,Implant Device,6935.25,35,,6935.25,percent of total billed charges,Implant Device,6935.25,35,,6935.25,percent of total billed charges,Implant Device,6935.25,35,,6935.25,percent of total billed charges,Implant Device,6935.25,35,,6935.25,percent of total billed charges,Implant Device,6935.25,35,,6935.25,percent of total billed charges,Implant Device,7926,40,,7926,percent of total billed charges,Implant Device,6935.25,70,,6935.25,percent of total billed charges,All Other,6737.1,34,,6737.1,percent of total billed charges,Implant Device,6737.1,34,,6737.1,percent of total billed charges,Implant Device,6935.25,35,,6935.25,percent of total billed charges,Implant Device,6935.25,35,,6935.25,percent of total billed charges,Implant Device,6935.25,35,,6935.25,percent of total billed charges,Implant Device,6935.25,35,,6935.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,6737.1,34,"If Charge > 2,000, then 34 percent",6737.1,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,14663.15,
BOST 72400024 AMS 800 PRESS REG BALLOON,C1815,HCPCS,,79012025,CDM,278,RC,,,both,,,9540,7059.62,,,7059.62,Other,150% of Medicare + 9.63% HCRA Surcharge,4293,45,,4293,percent of total billed charges,Critical Access Hospital RCC factor,3243.6,34,,3243.6,percent of total billed charges,Implant Device,3243.6,34,,3243.6,percent of total billed charges,Implant Device,3243.6,34,,3243.6,percent of total billed charges,Implant Device,3243.6,34,,3243.6,percent of total billed charges,Implant Device,3243.6,34,,3243.6,percent of total billed charges,Implant Device,4722.3,,,4722.3,Other,110% of Medicare,3339,35,,3339,percent of total billed charges,Implant Device,3243.6,34,"Charges > $500, x 34%",3243.6,percent of total billed charges,Implant Device,3339,35,,3339,percent of total billed charges,Implant Device,3339,35,,3339,percent of total billed charges,Implant Device,3339,35,,3339,percent of total billed charges,Implant Device,3339,35,,3339,percent of total billed charges,Implant Device,3339,35,,3339,percent of total billed charges,Implant Device,3816,40,,3816,percent of total billed charges,Implant Device,3339,70,,3339,percent of total billed charges,All Other,3243.6,34,,3243.6,percent of total billed charges,Implant Device,3243.6,34,,3243.6,percent of total billed charges,Implant Device,3339,35,,3339,percent of total billed charges,Implant Device,3339,35,,3339,percent of total billed charges,Implant Device,3339,35,,3339,percent of total billed charges,Implant Device,3339,35,,3339,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3243.6,34,"If Charge > 2,000, then 34 percent",3243.6,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,7059.62,
BOST SCI 72404127 AMS 800 PUMP WITH IZ,C1815,HCPCS,,79012026,CDM,278,RC,,,both,,,20085,14862.95,,,14862.95,Other,150% of Medicare + 9.63% HCRA Surcharge,9038.25,45,,9038.25,percent of total billed charges,Critical Access Hospital RCC factor,6828.9,34,,6828.9,percent of total billed charges,Implant Device,6828.9,34,,6828.9,percent of total billed charges,Implant Device,6828.9,34,,6828.9,percent of total billed charges,Implant Device,6828.9,34,,6828.9,percent of total billed charges,Implant Device,6828.9,34,,6828.9,percent of total billed charges,Implant Device,9942.08,,,9942.08,Other,110% of Medicare,7029.75,35,,7029.75,percent of total billed charges,Implant Device,6828.9,34,"Charges > $500, x 34%",6828.9,percent of total billed charges,Implant Device,7029.75,35,,7029.75,percent of total billed charges,Implant Device,7029.75,35,,7029.75,percent of total billed charges,Implant Device,7029.75,35,,7029.75,percent of total billed charges,Implant Device,7029.75,35,,7029.75,percent of total billed charges,Implant Device,7029.75,35,,7029.75,percent of total billed charges,Implant Device,8034,40,,8034,percent of total billed charges,Implant Device,7029.75,70,,7029.75,percent of total billed charges,All Other,6828.9,34,,6828.9,percent of total billed charges,Implant Device,6828.9,34,,6828.9,percent of total billed charges,Implant Device,7029.75,35,,7029.75,percent of total billed charges,Implant Device,7029.75,35,,7029.75,percent of total billed charges,Implant Device,7029.75,35,,7029.75,percent of total billed charges,Implant Device,7029.75,35,,7029.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,6828.9,34,"If Charge > 2,000, then 34 percent",6828.9,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,14862.95,
ZIMMER 45-5221-008-11 ART SURF RT SZ 11M,C1776,HCPCS,,79012028,CDM,278,RC,,,both,,,3648,2699.53,,,2699.53,Other,150% of Medicare + 9.63% HCRA Surcharge,1641.6,45,,1641.6,percent of total billed charges,Critical Access Hospital RCC factor,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1805.76,,,1805.76,Other,110% of Medicare,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1240.32,34,"Charges > $500, x 34%",1240.32,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1459.2,40,,1459.2,percent of total billed charges,Implant Device,1276.8,70,,1276.8,percent of total billed charges,All Other,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1240.32,34,"If Charge > 2,000, then 34 percent",1240.32,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2699.53,
BOST SCI 72404130 ART URINARY SPHINCTER,C1815,HCPCS,,79012029,CDM,278,RC,,,both,,,20850,15429.05,,,15429.05,Other,150% of Medicare + 9.63% HCRA Surcharge,9382.5,45,,9382.5,percent of total billed charges,Critical Access Hospital RCC factor,7089,34,,7089,percent of total billed charges,Implant Device,7089,34,,7089,percent of total billed charges,Implant Device,7089,34,,7089,percent of total billed charges,Implant Device,7089,34,,7089,percent of total billed charges,Implant Device,7089,34,,7089,percent of total billed charges,Implant Device,10320.75,,,10320.75,Other,110% of Medicare,7297.5,35,,7297.5,percent of total billed charges,Implant Device,7089,34,"Charges > $500, x 34%",7089,percent of total billed charges,Implant Device,7297.5,35,,7297.5,percent of total billed charges,Implant Device,7297.5,35,,7297.5,percent of total billed charges,Implant Device,7297.5,35,,7297.5,percent of total billed charges,Implant Device,7297.5,35,,7297.5,percent of total billed charges,Implant Device,7297.5,35,,7297.5,percent of total billed charges,Implant Device,8340,40,,8340,percent of total billed charges,Implant Device,7297.5,70,,7297.5,percent of total billed charges,All Other,7089,34,,7089,percent of total billed charges,Implant Device,7089,34,,7089,percent of total billed charges,Implant Device,7297.5,35,,7297.5,percent of total billed charges,Implant Device,7297.5,35,,7297.5,percent of total billed charges,Implant Device,7297.5,35,,7297.5,percent of total billed charges,Implant Device,7297.5,35,,7297.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,7089,34,"If Charge > 2,000, then 34 percent",7089,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,15429.05,
ZIMMER 42-5320-083-02 TIBIA STEM 5 DEG H,C1776,HCPCS,,79012030,CDM,278,RC,,,both,,,2304,1704.97,,,1704.97,Other,150% of Medicare + 9.63% HCRA Surcharge,1036.8,45,,1036.8,percent of total billed charges,Critical Access Hospital RCC factor,783.36,34,,783.36,percent of total billed charges,Implant Device,783.36,34,,783.36,percent of total billed charges,Implant Device,783.36,34,,783.36,percent of total billed charges,Implant Device,783.36,34,,783.36,percent of total billed charges,Implant Device,783.36,34,,783.36,percent of total billed charges,Implant Device,1140.48,,,1140.48,Other,110% of Medicare,806.4,35,,806.4,percent of total billed charges,Implant Device,783.36,34,"Charges > $500, x 34%",783.36,percent of total billed charges,Implant Device,806.4,35,,806.4,percent of total billed charges,Implant Device,806.4,35,,806.4,percent of total billed charges,Implant Device,806.4,35,,806.4,percent of total billed charges,Implant Device,806.4,35,,806.4,percent of total billed charges,Implant Device,806.4,35,,806.4,percent of total billed charges,Implant Device,921.6,40,,921.6,percent of total billed charges,Implant Device,806.4,70,,806.4,percent of total billed charges,All Other,783.36,34,,783.36,percent of total billed charges,Implant Device,783.36,34,,783.36,percent of total billed charges,Implant Device,806.4,35,,806.4,percent of total billed charges,Implant Device,806.4,35,,806.4,percent of total billed charges,Implant Device,806.4,35,,806.4,percent of total billed charges,Implant Device,806.4,35,,806.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,783.36,34,"If Charge > 2,000, then 34 percent",783.36,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1704.97,
ZIMMER 42-5221-009-12 ART SURF RT 12MM,C1776,HCPCS,,79012031,CDM,278,RC,,,both,,,3648,2699.53,,,2699.53,Other,150% of Medicare + 9.63% HCRA Surcharge,1641.6,45,,1641.6,percent of total billed charges,Critical Access Hospital RCC factor,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1805.76,,,1805.76,Other,110% of Medicare,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1240.32,34,"Charges > $500, x 34%",1240.32,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1459.2,40,,1459.2,percent of total billed charges,Implant Device,1276.8,70,,1276.8,percent of total billed charges,All Other,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1240.32,34,"If Charge > 2,000, then 34 percent",1240.32,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2699.53,
KINAMED 35-200-1020 GRIP PLATE 2 HOLE,C1713,HCPCS,,79012032,CDM,278,RC,,,both,,,7965,5894.12,,,5894.12,Other,150% of Medicare + 9.63% HCRA Surcharge,3584.25,45,,3584.25,percent of total billed charges,Critical Access Hospital RCC factor,2708.1,34,,2708.1,percent of total billed charges,Implant Device,2708.1,34,,2708.1,percent of total billed charges,Implant Device,2708.1,34,,2708.1,percent of total billed charges,Implant Device,2708.1,34,,2708.1,percent of total billed charges,Implant Device,2708.1,34,,2708.1,percent of total billed charges,Implant Device,3942.68,,,3942.68,Other,110% of Medicare,2787.75,35,,2787.75,percent of total billed charges,Implant Device,2708.1,34,"Charges > $500, x 34%",2708.1,percent of total billed charges,Implant Device,2787.75,35,,2787.75,percent of total billed charges,Implant Device,2787.75,35,,2787.75,percent of total billed charges,Implant Device,2787.75,35,,2787.75,percent of total billed charges,Implant Device,2787.75,35,,2787.75,percent of total billed charges,Implant Device,2787.75,35,,2787.75,percent of total billed charges,Implant Device,3186,40,,3186,percent of total billed charges,Implant Device,2787.75,70,,2787.75,percent of total billed charges,All Other,2708.1,34,,2708.1,percent of total billed charges,Implant Device,2708.1,34,,2708.1,percent of total billed charges,Implant Device,2787.75,35,,2787.75,percent of total billed charges,Implant Device,2787.75,35,,2787.75,percent of total billed charges,Implant Device,2787.75,35,,2787.75,percent of total billed charges,Implant Device,2787.75,35,,2787.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2708.1,34,"If Charge > 2,000, then 34 percent",2708.1,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5894.12,
ZIMMER 45-5026-064-02 FEMUR RIGHT SIZE 8,C1776,HCPCS,,79012033,CDM,278,RC,,,both,,,10200,7548.03,,,7548.03,Other,150% of Medicare + 9.63% HCRA Surcharge,4590,45,,4590,percent of total billed charges,Critical Access Hospital RCC factor,3468,34,,3468,percent of total billed charges,Implant Device,3468,34,,3468,percent of total billed charges,Implant Device,3468,34,,3468,percent of total billed charges,Implant Device,3468,34,,3468,percent of total billed charges,Implant Device,3468,34,,3468,percent of total billed charges,Implant Device,5049,,,5049,Other,110% of Medicare,3570,35,,3570,percent of total billed charges,Implant Device,3468,34,"Charges > $500, x 34%",3468,percent of total billed charges,Implant Device,3570,35,,3570,percent of total billed charges,Implant Device,3570,35,,3570,percent of total billed charges,Implant Device,3570,35,,3570,percent of total billed charges,Implant Device,3570,35,,3570,percent of total billed charges,Implant Device,3570,35,,3570,percent of total billed charges,Implant Device,4080,40,,4080,percent of total billed charges,Implant Device,3570,70,,3570,percent of total billed charges,All Other,3468,34,,3468,percent of total billed charges,Implant Device,3468,34,,3468,percent of total billed charges,Implant Device,3570,35,,3570,percent of total billed charges,Implant Device,3570,35,,3570,percent of total billed charges,Implant Device,3570,35,,3570,percent of total billed charges,Implant Device,3570,35,,3570,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3468,34,"If Charge > 2,000, then 34 percent",3468,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,7548.03,
J&J 212.136 LOCKING SCREW 3.5X46MM,C1713,HCPCS,,79012034,CDM,278,RC,,,both,,,327,241.98,,,241.98,Other,150% of Medicare + 9.63% HCRA Surcharge,147.15,45,,147.15,percent of total billed charges,Critical Access Hospital RCC factor,111.18,34,,111.18,percent of total billed charges,Implant Device,111.18,34,,111.18,percent of total billed charges,Implant Device,111.18,34,,111.18,percent of total billed charges,Implant Device,111.18,34,,111.18,percent of total billed charges,Implant Device,111.18,34,,111.18,percent of total billed charges,Implant Device,161.87,,,161.87,Other,110% of Medicare,114.45,35,,114.45,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,114.45,35,,114.45,percent of total billed charges,Implant Device,114.45,35,,114.45,percent of total billed charges,Implant Device,114.45,35,,114.45,percent of total billed charges,Implant Device,114.45,35,,114.45,percent of total billed charges,Implant Device,114.45,35,,114.45,percent of total billed charges,Implant Device,130.8,40,,130.8,percent of total billed charges,Implant Device,114.45,70,,114.45,percent of total billed charges,All Other,111.18,34,,111.18,percent of total billed charges,Implant Device,111.18,34,,111.18,percent of total billed charges,Implant Device,114.45,35,,114.45,percent of total billed charges,Implant Device,114.45,35,,114.45,percent of total billed charges,Implant Device,114.45,35,,114.45,percent of total billed charges,Implant Device,114.45,35,,114.45,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,241.98,
J&J 212.116 LOCKING SCREW 3.5X38MM,C1713,HCPCS,,79012035,CDM,278,RC,,,both,,,327,241.98,,,241.98,Other,150% of Medicare + 9.63% HCRA Surcharge,147.15,45,,147.15,percent of total billed charges,Critical Access Hospital RCC factor,111.18,34,,111.18,percent of total billed charges,Implant Device,111.18,34,,111.18,percent of total billed charges,Implant Device,111.18,34,,111.18,percent of total billed charges,Implant Device,111.18,34,,111.18,percent of total billed charges,Implant Device,111.18,34,,111.18,percent of total billed charges,Implant Device,161.87,,,161.87,Other,110% of Medicare,114.45,35,,114.45,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,114.45,35,,114.45,percent of total billed charges,Implant Device,114.45,35,,114.45,percent of total billed charges,Implant Device,114.45,35,,114.45,percent of total billed charges,Implant Device,114.45,35,,114.45,percent of total billed charges,Implant Device,114.45,35,,114.45,percent of total billed charges,Implant Device,130.8,40,,130.8,percent of total billed charges,Implant Device,114.45,70,,114.45,percent of total billed charges,All Other,111.18,34,,111.18,percent of total billed charges,Implant Device,111.18,34,,111.18,percent of total billed charges,Implant Device,114.45,35,,114.45,percent of total billed charges,Implant Device,114.45,35,,114.45,percent of total billed charges,Implant Device,114.45,35,,114.45,percent of total billed charges,Implant Device,114.45,35,,114.45,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,241.98,
EXACTECH 300-01-14 HUMERAL STEM 14MM,C1776,HCPCS,,79012036,CDM,278,RC,,,both,,,4425,3274.51,,,3274.51,Other,150% of Medicare + 9.63% HCRA Surcharge,1991.25,45,,1991.25,percent of total billed charges,Critical Access Hospital RCC factor,1504.5,34,,1504.5,percent of total billed charges,Implant Device,1504.5,34,,1504.5,percent of total billed charges,Implant Device,1504.5,34,,1504.5,percent of total billed charges,Implant Device,1504.5,34,,1504.5,percent of total billed charges,Implant Device,1504.5,34,,1504.5,percent of total billed charges,Implant Device,2190.38,,,2190.38,Other,110% of Medicare,1548.75,35,,1548.75,percent of total billed charges,Implant Device,1504.5,34,"Charges > $500, x 34%",1504.5,percent of total billed charges,Implant Device,1548.75,35,,1548.75,percent of total billed charges,Implant Device,1548.75,35,,1548.75,percent of total billed charges,Implant Device,1548.75,35,,1548.75,percent of total billed charges,Implant Device,1548.75,35,,1548.75,percent of total billed charges,Implant Device,1548.75,35,,1548.75,percent of total billed charges,Implant Device,1770,40,,1770,percent of total billed charges,Implant Device,1548.75,70,,1548.75,percent of total billed charges,All Other,1504.5,34,,1504.5,percent of total billed charges,Implant Device,1504.5,34,,1504.5,percent of total billed charges,Implant Device,1548.75,35,,1548.75,percent of total billed charges,Implant Device,1548.75,35,,1548.75,percent of total billed charges,Implant Device,1548.75,35,,1548.75,percent of total billed charges,Implant Device,1548.75,35,,1548.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1504.5,34,"If Charge > 2,000, then 34 percent",1504.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3274.51,
IN2BONES C20 ST171 COLINK NC PLATE RIGHT,C1713,HCPCS,,79012037,CDM,278,RC,,,both,,,6000,4440.02,,,4440.02,Other,150% of Medicare + 9.63% HCRA Surcharge,2700,45,,2700,percent of total billed charges,Critical Access Hospital RCC factor,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2970,,,2970,Other,110% of Medicare,2100,35,,2100,percent of total billed charges,Implant Device,2040,34,"Charges > $500, x 34%",2040,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2400,40,,2400,percent of total billed charges,Implant Device,2100,70,,2100,percent of total billed charges,All Other,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2040,34,"If Charge > 2,000, then 34 percent",2040,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4440.02,
IN2BONES P73 ST122 LOCK SCREW 3.5X22MM,C1713,HCPCS,,79012039,CDM,278,RC,,,both,,,870,643.8,,,643.8,Other,150% of Medicare + 9.63% HCRA Surcharge,391.5,45,,391.5,percent of total billed charges,Critical Access Hospital RCC factor,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,430.65,,,430.65,Other,110% of Medicare,304.5,35,,304.5,percent of total billed charges,Implant Device,295.8,34,"Charges > $500, x 34%",295.8,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,348,40,,348,percent of total billed charges,Implant Device,304.5,70,,304.5,percent of total billed charges,All Other,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,643.8,
IN2BONES P73 ST120 LOCK SCREW 3.5X20MM,C1713,HCPCS,,79012040,CDM,278,RC,,,both,,,870,643.8,,,643.8,Other,150% of Medicare + 9.63% HCRA Surcharge,391.5,45,,391.5,percent of total billed charges,Critical Access Hospital RCC factor,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,430.65,,,430.65,Other,110% of Medicare,304.5,35,,304.5,percent of total billed charges,Implant Device,295.8,34,"Charges > $500, x 34%",295.8,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,348,40,,348,percent of total billed charges,Implant Device,304.5,70,,304.5,percent of total billed charges,All Other,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,643.8,
IN2BONES P73 ST116 LOCK SCREW 3.5X16MM,C1713,HCPCS,,79012041,CDM,278,RC,,,both,,,870,643.8,,,643.8,Other,150% of Medicare + 9.63% HCRA Surcharge,391.5,45,,391.5,percent of total billed charges,Critical Access Hospital RCC factor,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,430.65,,,430.65,Other,110% of Medicare,304.5,35,,304.5,percent of total billed charges,Implant Device,295.8,34,"Charges > $500, x 34%",295.8,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,348,40,,348,percent of total billed charges,Implant Device,304.5,70,,304.5,percent of total billed charges,All Other,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,643.8,
IN2BONES P73 ST216 VAL LOCK SCREW,C1713,HCPCS,,79012042,CDM,278,RC,,,both,,,870,643.8,,,643.8,Other,150% of Medicare + 9.63% HCRA Surcharge,391.5,45,,391.5,percent of total billed charges,Critical Access Hospital RCC factor,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,430.65,,,430.65,Other,110% of Medicare,304.5,35,,304.5,percent of total billed charges,Implant Device,295.8,34,"Charges > $500, x 34%",295.8,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,348,40,,348,percent of total billed charges,Implant Device,304.5,70,,304.5,percent of total billed charges,All Other,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,643.8,
WRIGHT OP101024 TRICORTICAL WEDGE LARGE,C1762,HCPCS,,79012043,CDM,278,RC,,,both,,,10839,8020.89,,,8020.89,Other,150% of Medicare + 9.63% HCRA Surcharge,4877.55,45,,4877.55,percent of total billed charges,Critical Access Hospital RCC factor,3685.26,34,,3685.26,percent of total billed charges,Implant Device,3685.26,34,,3685.26,percent of total billed charges,Implant Device,3685.26,34,,3685.26,percent of total billed charges,Implant Device,3685.26,34,,3685.26,percent of total billed charges,Implant Device,3685.26,34,,3685.26,percent of total billed charges,Implant Device,5365.31,,,5365.31,Other,110% of Medicare,3793.65,35,,3793.65,percent of total billed charges,Implant Device,3685.26,34,"Charges > $500, x 34%",3685.26,percent of total billed charges,Implant Device,3793.65,35,,3793.65,percent of total billed charges,Implant Device,3793.65,35,,3793.65,percent of total billed charges,Implant Device,3793.65,35,,3793.65,percent of total billed charges,Implant Device,3793.65,35,,3793.65,percent of total billed charges,Implant Device,3793.65,35,,3793.65,percent of total billed charges,Implant Device,4335.6,40,,4335.6,percent of total billed charges,Implant Device,3793.65,70,,3793.65,percent of total billed charges,All Other,3685.26,34,,3685.26,percent of total billed charges,Implant Device,3685.26,34,,3685.26,percent of total billed charges,Implant Device,3793.65,35,,3793.65,percent of total billed charges,Implant Device,3793.65,35,,3793.65,percent of total billed charges,Implant Device,3793.65,35,,3793.65,percent of total billed charges,Implant Device,3793.65,35,,3793.65,percent of total billed charges,Implant Device,976.07,,,976.07,Other,100% of Medicaid,976.07,,,976.07,Other,100% of Medicaid,976.07,,,976.07,Other,100% of Medicaid,976.07,,,976.07,Other,100% of Medicaid,2196.16,,,2196.16,Other,225% of Medicaid,1493.39,,,1493.39,Other,153% of Medicaid,2196.16,,,2196.16,Other,225% of Medicaid,1366.5,,,1366.5,Other,140% of Medicaid,3685.26,34,"If Charge > 2,000, then 34 percent",3685.26,percent of total billed charges,Implants,2537.78,,,2537.78,Other,260% of Medicaid,3162.47,,,3162.47,Other,324% of Medicaid,2098.55,,,2098.55,Other,215% of Medicaid,2098.55,,,2098.55,Other,215% of Medicaid,1220.09,,,1220.09,Other,125% of Medicaid,976.07,8020.89,
WRIGHT 58802710 LOCKING SCREW 2.7X10MM,C1713,HCPCS,,79012045,CDM,278,RC,,,both,,,1317,974.58,,,974.58,Other,150% of Medicare + 9.63% HCRA Surcharge,592.65,45,,592.65,percent of total billed charges,Critical Access Hospital RCC factor,447.78,34,,447.78,percent of total billed charges,Implant Device,447.78,34,,447.78,percent of total billed charges,Implant Device,447.78,34,,447.78,percent of total billed charges,Implant Device,447.78,34,,447.78,percent of total billed charges,Implant Device,447.78,34,,447.78,percent of total billed charges,Implant Device,651.92,,,651.92,Other,110% of Medicare,460.95,35,,460.95,percent of total billed charges,Implant Device,447.78,34,"Charges > $500, x 34%",447.78,percent of total billed charges,Implant Device,460.95,35,,460.95,percent of total billed charges,Implant Device,460.95,35,,460.95,percent of total billed charges,Implant Device,460.95,35,,460.95,percent of total billed charges,Implant Device,460.95,35,,460.95,percent of total billed charges,Implant Device,460.95,35,,460.95,percent of total billed charges,Implant Device,526.8,40,,526.8,percent of total billed charges,Implant Device,460.95,70,,460.95,percent of total billed charges,All Other,447.78,34,,447.78,percent of total billed charges,Implant Device,447.78,34,,447.78,percent of total billed charges,Implant Device,460.95,35,,460.95,percent of total billed charges,Implant Device,460.95,35,,460.95,percent of total billed charges,Implant Device,460.95,35,,460.95,percent of total billed charges,Implant Device,460.95,35,,460.95,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,974.58,
WRIGHT 58813516 CORTICAL SCREW 3.5X16MM,C1713,HCPCS,,79012046,CDM,278,RC,,,both,,,672,497.28,,,497.28,Other,150% of Medicare + 9.63% HCRA Surcharge,302.4,45,,302.4,percent of total billed charges,Critical Access Hospital RCC factor,228.48,34,,228.48,percent of total billed charges,Implant Device,228.48,34,,228.48,percent of total billed charges,Implant Device,228.48,34,,228.48,percent of total billed charges,Implant Device,228.48,34,,228.48,percent of total billed charges,Implant Device,228.48,34,,228.48,percent of total billed charges,Implant Device,332.64,,,332.64,Other,110% of Medicare,235.2,35,,235.2,percent of total billed charges,Implant Device,228.48,34,"Charges > $500, x 34%",228.48,percent of total billed charges,Implant Device,235.2,35,,235.2,percent of total billed charges,Implant Device,235.2,35,,235.2,percent of total billed charges,Implant Device,235.2,35,,235.2,percent of total billed charges,Implant Device,235.2,35,,235.2,percent of total billed charges,Implant Device,235.2,35,,235.2,percent of total billed charges,Implant Device,268.8,40,,268.8,percent of total billed charges,Implant Device,235.2,70,,235.2,percent of total billed charges,All Other,228.48,34,,228.48,percent of total billed charges,Implant Device,228.48,34,,228.48,percent of total billed charges,Implant Device,235.2,35,,235.2,percent of total billed charges,Implant Device,235.2,35,,235.2,percent of total billed charges,Implant Device,235.2,35,,235.2,percent of total billed charges,Implant Device,235.2,35,,235.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,497.28,
WRIGHT 58803512 LOCKING SCREW 3.5X12MM,C1713,HCPCS,,79012048,CDM,278,RC,,,both,,,1317,974.58,,,974.58,Other,150% of Medicare + 9.63% HCRA Surcharge,592.65,45,,592.65,percent of total billed charges,Critical Access Hospital RCC factor,447.78,34,,447.78,percent of total billed charges,Implant Device,447.78,34,,447.78,percent of total billed charges,Implant Device,447.78,34,,447.78,percent of total billed charges,Implant Device,447.78,34,,447.78,percent of total billed charges,Implant Device,447.78,34,,447.78,percent of total billed charges,Implant Device,651.92,,,651.92,Other,110% of Medicare,460.95,35,,460.95,percent of total billed charges,Implant Device,447.78,34,"Charges > $500, x 34%",447.78,percent of total billed charges,Implant Device,460.95,35,,460.95,percent of total billed charges,Implant Device,460.95,35,,460.95,percent of total billed charges,Implant Device,460.95,35,,460.95,percent of total billed charges,Implant Device,460.95,35,,460.95,percent of total billed charges,Implant Device,460.95,35,,460.95,percent of total billed charges,Implant Device,526.8,40,,526.8,percent of total billed charges,Implant Device,460.95,70,,460.95,percent of total billed charges,All Other,447.78,34,,447.78,percent of total billed charges,Implant Device,447.78,34,,447.78,percent of total billed charges,Implant Device,460.95,35,,460.95,percent of total billed charges,Implant Device,460.95,35,,460.95,percent of total billed charges,Implant Device,460.95,35,,460.95,percent of total billed charges,Implant Device,460.95,35,,460.95,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,974.58,
WRIGHT 58813518 CORTICAL SCREW 3.5X18MM,C1713,HCPCS,,79012051,CDM,278,RC,,,both,,,672,497.28,,,497.28,Other,150% of Medicare + 9.63% HCRA Surcharge,302.4,45,,302.4,percent of total billed charges,Critical Access Hospital RCC factor,228.48,34,,228.48,percent of total billed charges,Implant Device,228.48,34,,228.48,percent of total billed charges,Implant Device,228.48,34,,228.48,percent of total billed charges,Implant Device,228.48,34,,228.48,percent of total billed charges,Implant Device,228.48,34,,228.48,percent of total billed charges,Implant Device,332.64,,,332.64,Other,110% of Medicare,235.2,35,,235.2,percent of total billed charges,Implant Device,228.48,34,"Charges > $500, x 34%",228.48,percent of total billed charges,Implant Device,235.2,35,,235.2,percent of total billed charges,Implant Device,235.2,35,,235.2,percent of total billed charges,Implant Device,235.2,35,,235.2,percent of total billed charges,Implant Device,235.2,35,,235.2,percent of total billed charges,Implant Device,235.2,35,,235.2,percent of total billed charges,Implant Device,268.8,40,,268.8,percent of total billed charges,Implant Device,235.2,70,,235.2,percent of total billed charges,All Other,228.48,34,,228.48,percent of total billed charges,Implant Device,228.48,34,,228.48,percent of total billed charges,Implant Device,235.2,35,,235.2,percent of total billed charges,Implant Device,235.2,35,,235.2,percent of total billed charges,Implant Device,235.2,35,,235.2,percent of total billed charges,Implant Device,235.2,35,,235.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,497.28,
WRIGHT 587115RT MTP FUSION SM 3 DEG RT,C1713,HCPCS,,79012052,CDM,278,RC,,,both,,,8943,6617.84,,,6617.84,Other,150% of Medicare + 9.63% HCRA Surcharge,4024.35,45,,4024.35,percent of total billed charges,Critical Access Hospital RCC factor,3040.62,34,,3040.62,percent of total billed charges,Implant Device,3040.62,34,,3040.62,percent of total billed charges,Implant Device,3040.62,34,,3040.62,percent of total billed charges,Implant Device,3040.62,34,,3040.62,percent of total billed charges,Implant Device,3040.62,34,,3040.62,percent of total billed charges,Implant Device,4426.79,,,4426.79,Other,110% of Medicare,3130.05,35,,3130.05,percent of total billed charges,Implant Device,3040.62,34,"Charges > $500, x 34%",3040.62,percent of total billed charges,Implant Device,3130.05,35,,3130.05,percent of total billed charges,Implant Device,3130.05,35,,3130.05,percent of total billed charges,Implant Device,3130.05,35,,3130.05,percent of total billed charges,Implant Device,3130.05,35,,3130.05,percent of total billed charges,Implant Device,3130.05,35,,3130.05,percent of total billed charges,Implant Device,3577.2,40,,3577.2,percent of total billed charges,Implant Device,3130.05,70,,3130.05,percent of total billed charges,All Other,3040.62,34,,3040.62,percent of total billed charges,Implant Device,3040.62,34,,3040.62,percent of total billed charges,Implant Device,3130.05,35,,3130.05,percent of total billed charges,Implant Device,3130.05,35,,3130.05,percent of total billed charges,Implant Device,3130.05,35,,3130.05,percent of total billed charges,Implant Device,3130.05,35,,3130.05,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3040.62,34,"If Charge > 2,000, then 34 percent",3040.62,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,6617.84,
STRYKER 601634S CANN SCREW 5X34MM,C1713,HCPCS,,79012053,CDM,278,RC,,,both,,,490,362.6,,,362.6,Other,150% of Medicare + 9.63% HCRA Surcharge,220.5,45,,220.5,percent of total billed charges,Critical Access Hospital RCC factor,166.6,34,,166.6,percent of total billed charges,Implant Device,166.6,34,,166.6,percent of total billed charges,Implant Device,166.6,34,,166.6,percent of total billed charges,Implant Device,166.6,34,,166.6,percent of total billed charges,Implant Device,166.6,34,,166.6,percent of total billed charges,Implant Device,242.55,,,242.55,Other,110% of Medicare,171.5,35,,171.5,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,171.5,35,,171.5,percent of total billed charges,Implant Device,171.5,35,,171.5,percent of total billed charges,Implant Device,171.5,35,,171.5,percent of total billed charges,Implant Device,171.5,35,,171.5,percent of total billed charges,Implant Device,171.5,35,,171.5,percent of total billed charges,Implant Device,196,40,,196,percent of total billed charges,Implant Device,171.5,70,,171.5,percent of total billed charges,All Other,166.6,34,,166.6,percent of total billed charges,Implant Device,166.6,34,,166.6,percent of total billed charges,Implant Device,171.5,35,,171.5,percent of total billed charges,Implant Device,171.5,35,,171.5,percent of total billed charges,Implant Device,171.5,35,,171.5,percent of total billed charges,Implant Device,171.5,35,,171.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,362.6,
STRYKER 601650S CANN SCREW 5X50MM,C1713,HCPCS,,79012054,CDM,278,RC,,,both,,,490,362.6,,,362.6,Other,150% of Medicare + 9.63% HCRA Surcharge,220.5,45,,220.5,percent of total billed charges,Critical Access Hospital RCC factor,166.6,34,,166.6,percent of total billed charges,Implant Device,166.6,34,,166.6,percent of total billed charges,Implant Device,166.6,34,,166.6,percent of total billed charges,Implant Device,166.6,34,,166.6,percent of total billed charges,Implant Device,166.6,34,,166.6,percent of total billed charges,Implant Device,242.55,,,242.55,Other,110% of Medicare,171.5,35,,171.5,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,171.5,35,,171.5,percent of total billed charges,Implant Device,171.5,35,,171.5,percent of total billed charges,Implant Device,171.5,35,,171.5,percent of total billed charges,Implant Device,171.5,35,,171.5,percent of total billed charges,Implant Device,171.5,35,,171.5,percent of total billed charges,Implant Device,196,40,,196,percent of total billed charges,Implant Device,171.5,70,,171.5,percent of total billed charges,All Other,166.6,34,,166.6,percent of total billed charges,Implant Device,166.6,34,,166.6,percent of total billed charges,Implant Device,171.5,35,,171.5,percent of total billed charges,Implant Device,171.5,35,,171.5,percent of total billed charges,Implant Device,171.5,35,,171.5,percent of total billed charges,Implant Device,171.5,35,,171.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,362.6,
STRYKER 601655S CANN SCREW 4X55MM,C1713,HCPCS,,79012055,CDM,278,RC,,,both,,,490,362.6,,,362.6,Other,150% of Medicare + 9.63% HCRA Surcharge,220.5,45,,220.5,percent of total billed charges,Critical Access Hospital RCC factor,166.6,34,,166.6,percent of total billed charges,Implant Device,166.6,34,,166.6,percent of total billed charges,Implant Device,166.6,34,,166.6,percent of total billed charges,Implant Device,166.6,34,,166.6,percent of total billed charges,Implant Device,166.6,34,,166.6,percent of total billed charges,Implant Device,242.55,,,242.55,Other,110% of Medicare,171.5,35,,171.5,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,171.5,35,,171.5,percent of total billed charges,Implant Device,171.5,35,,171.5,percent of total billed charges,Implant Device,171.5,35,,171.5,percent of total billed charges,Implant Device,171.5,35,,171.5,percent of total billed charges,Implant Device,171.5,35,,171.5,percent of total billed charges,Implant Device,196,40,,196,percent of total billed charges,Implant Device,171.5,70,,171.5,percent of total billed charges,All Other,166.6,34,,166.6,percent of total billed charges,Implant Device,166.6,34,,166.6,percent of total billed charges,Implant Device,171.5,35,,171.5,percent of total billed charges,Implant Device,171.5,35,,171.5,percent of total billed charges,Implant Device,171.5,35,,171.5,percent of total billed charges,Implant Device,171.5,35,,171.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,362.6,
STRYKER 658034 HEADLESS COMP SCRW 4X34MM,C1713,HCPCS,,79012056,CDM,278,RC,,,both,,,1242,919.08,,,919.08,Other,150% of Medicare + 9.63% HCRA Surcharge,558.9,45,,558.9,percent of total billed charges,Critical Access Hospital RCC factor,422.28,34,,422.28,percent of total billed charges,Implant Device,422.28,34,,422.28,percent of total billed charges,Implant Device,422.28,34,,422.28,percent of total billed charges,Implant Device,422.28,34,,422.28,percent of total billed charges,Implant Device,422.28,34,,422.28,percent of total billed charges,Implant Device,614.79,,,614.79,Other,110% of Medicare,434.7,35,,434.7,percent of total billed charges,Implant Device,422.28,34,"Charges > $500, x 34%",422.28,percent of total billed charges,Implant Device,434.7,35,,434.7,percent of total billed charges,Implant Device,434.7,35,,434.7,percent of total billed charges,Implant Device,434.7,35,,434.7,percent of total billed charges,Implant Device,434.7,35,,434.7,percent of total billed charges,Implant Device,434.7,35,,434.7,percent of total billed charges,Implant Device,496.8,40,,496.8,percent of total billed charges,Implant Device,434.7,70,,434.7,percent of total billed charges,All Other,422.28,34,,422.28,percent of total billed charges,Implant Device,422.28,34,,422.28,percent of total billed charges,Implant Device,434.7,35,,434.7,percent of total billed charges,Implant Device,434.7,35,,434.7,percent of total billed charges,Implant Device,434.7,35,,434.7,percent of total billed charges,Implant Device,434.7,35,,434.7,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,919.08,
STRYKER 658040 HEADLESS COMP SCRW 4X40MM,C1713,HCPCS,,79012057,CDM,278,RC,,,both,,,1266,936.84,,,936.84,Other,150% of Medicare + 9.63% HCRA Surcharge,569.7,45,,569.7,percent of total billed charges,Critical Access Hospital RCC factor,430.44,34,,430.44,percent of total billed charges,Implant Device,430.44,34,,430.44,percent of total billed charges,Implant Device,430.44,34,,430.44,percent of total billed charges,Implant Device,430.44,34,,430.44,percent of total billed charges,Implant Device,430.44,34,,430.44,percent of total billed charges,Implant Device,626.67,,,626.67,Other,110% of Medicare,443.1,35,,443.1,percent of total billed charges,Implant Device,430.44,34,"Charges > $500, x 34%",430.44,percent of total billed charges,Implant Device,443.1,35,,443.1,percent of total billed charges,Implant Device,443.1,35,,443.1,percent of total billed charges,Implant Device,443.1,35,,443.1,percent of total billed charges,Implant Device,443.1,35,,443.1,percent of total billed charges,Implant Device,443.1,35,,443.1,percent of total billed charges,Implant Device,506.4,40,,506.4,percent of total billed charges,Implant Device,443.1,70,,443.1,percent of total billed charges,All Other,430.44,34,,430.44,percent of total billed charges,Implant Device,430.44,34,,430.44,percent of total billed charges,Implant Device,443.1,35,,443.1,percent of total billed charges,Implant Device,443.1,35,,443.1,percent of total billed charges,Implant Device,443.1,35,,443.1,percent of total billed charges,Implant Device,443.1,35,,443.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,936.84,
ARTHOSURFACE 9M52-1545-W 15MM ART COMP,L8641,HCPCS,,79012059,CDM,278,RC,,,both,,,5205,3851.71,,,3851.71,Other,150% of Medicare + 9.63% HCRA Surcharge,2342.25,45,,2342.25,percent of total billed charges,Critical Access Hospital RCC factor,1769.7,34,,1769.7,percent of total billed charges,Implant Device,1769.7,34,,1769.7,percent of total billed charges,Implant Device,1769.7,34,,1769.7,percent of total billed charges,Implant Device,1769.7,34,,1769.7,percent of total billed charges,Implant Device,1769.7,34,,1769.7,percent of total billed charges,Implant Device,2576.48,,,2576.48,Other,110% of Medicare,1821.75,35,,1821.75,percent of total billed charges,Implant Device,1769.7,34,"Charges > $500, x 34%",1769.7,percent of total billed charges,Implant Device,1821.75,35,,1821.75,percent of total billed charges,Implant Device,1821.75,35,,1821.75,percent of total billed charges,Implant Device,1821.75,35,,1821.75,percent of total billed charges,Implant Device,1821.75,35,,1821.75,percent of total billed charges,Implant Device,1821.75,35,,1821.75,percent of total billed charges,Implant Device,2082,40,,2082,percent of total billed charges,Implant Device,1821.75,70,,1821.75,percent of total billed charges,All Other,1769.7,34,,1769.7,percent of total billed charges,Implant Device,1769.7,34,,1769.7,percent of total billed charges,Implant Device,1821.75,35,,1821.75,percent of total billed charges,Implant Device,1821.75,35,,1821.75,percent of total billed charges,Implant Device,1821.75,35,,1821.75,percent of total billed charges,Implant Device,1821.75,35,,1821.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1769.7,34,"If Charge > 2,000, then 34 percent",1769.7,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3851.71,
ZIMMER 110007559 CANNULATED SCREW 4X44MM,C1713,HCPCS,,79012060,CDM,278,RC,,,both,,,529,391.46,,,391.46,Other,150% of Medicare + 9.63% HCRA Surcharge,238.05,45,,238.05,percent of total billed charges,Critical Access Hospital RCC factor,179.86,34,,179.86,percent of total billed charges,Implant Device,179.86,34,,179.86,percent of total billed charges,Implant Device,179.86,34,,179.86,percent of total billed charges,Implant Device,179.86,34,,179.86,percent of total billed charges,Implant Device,179.86,34,,179.86,percent of total billed charges,Implant Device,261.86,,,261.86,Other,110% of Medicare,185.15,35,,185.15,percent of total billed charges,Implant Device,179.86,34,"Charges > $500, x 34%",179.86,percent of total billed charges,Implant Device,185.15,35,,185.15,percent of total billed charges,Implant Device,185.15,35,,185.15,percent of total billed charges,Implant Device,185.15,35,,185.15,percent of total billed charges,Implant Device,185.15,35,,185.15,percent of total billed charges,Implant Device,185.15,35,,185.15,percent of total billed charges,Implant Device,211.6,40,,211.6,percent of total billed charges,Implant Device,185.15,70,,185.15,percent of total billed charges,All Other,179.86,34,,179.86,percent of total billed charges,Implant Device,179.86,34,,179.86,percent of total billed charges,Implant Device,185.15,35,,185.15,percent of total billed charges,Implant Device,185.15,35,,185.15,percent of total billed charges,Implant Device,185.15,35,,185.15,percent of total billed charges,Implant Device,185.15,35,,185.15,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,391.46,
J&J 02.124.416 CONDYLAR PLT 4.5MM 16H,C1713,HCPCS,,79012061,CDM,278,RC,,,both,,,5096,3771.05,,,3771.05,Other,150% of Medicare + 9.63% HCRA Surcharge,2293.2,45,,2293.2,percent of total billed charges,Critical Access Hospital RCC factor,1732.64,34,,1732.64,percent of total billed charges,Implant Device,1732.64,34,,1732.64,percent of total billed charges,Implant Device,1732.64,34,,1732.64,percent of total billed charges,Implant Device,1732.64,34,,1732.64,percent of total billed charges,Implant Device,1732.64,34,,1732.64,percent of total billed charges,Implant Device,2522.52,,,2522.52,Other,110% of Medicare,1783.6,35,,1783.6,percent of total billed charges,Implant Device,1732.64,34,"Charges > $500, x 34%",1732.64,percent of total billed charges,Implant Device,1783.6,35,,1783.6,percent of total billed charges,Implant Device,1783.6,35,,1783.6,percent of total billed charges,Implant Device,1783.6,35,,1783.6,percent of total billed charges,Implant Device,1783.6,35,,1783.6,percent of total billed charges,Implant Device,1783.6,35,,1783.6,percent of total billed charges,Implant Device,2038.4,40,,2038.4,percent of total billed charges,Implant Device,1783.6,70,,1783.6,percent of total billed charges,All Other,1732.64,34,,1732.64,percent of total billed charges,Implant Device,1732.64,34,,1732.64,percent of total billed charges,Implant Device,1783.6,35,,1783.6,percent of total billed charges,Implant Device,1783.6,35,,1783.6,percent of total billed charges,Implant Device,1783.6,35,,1783.6,percent of total billed charges,Implant Device,1783.6,35,,1783.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1732.64,34,"If Charge > 2,000, then 34 percent",1732.64,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3771.05,
J&J 214.844 CORTEX SCREW 4.5X44MM,C1713,HCPCS,,79012064,CDM,278,RC,,,both,,,57,42.18,,,42.18,Other,150% of Medicare + 9.63% HCRA Surcharge,25.65,45,,25.65,percent of total billed charges,Critical Access Hospital RCC factor,19.38,34,,19.38,percent of total billed charges,Implant Device,19.38,34,,19.38,percent of total billed charges,Implant Device,19.38,34,,19.38,percent of total billed charges,Implant Device,19.38,34,,19.38,percent of total billed charges,Implant Device,19.38,34,,19.38,percent of total billed charges,Implant Device,28.22,,,28.22,Other,110% of Medicare,19.95,35,,19.95,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,19.95,35,,19.95,percent of total billed charges,Implant Device,19.95,35,,19.95,percent of total billed charges,Implant Device,19.95,35,,19.95,percent of total billed charges,Implant Device,19.95,35,,19.95,percent of total billed charges,Implant Device,19.95,35,,19.95,percent of total billed charges,Implant Device,22.8,40,,22.8,percent of total billed charges,Implant Device,19.95,70,,19.95,percent of total billed charges,All Other,19.38,34,,19.38,percent of total billed charges,Implant Device,19.38,34,,19.38,percent of total billed charges,Implant Device,19.95,35,,19.95,percent of total billed charges,Implant Device,19.95,35,,19.95,percent of total billed charges,Implant Device,19.95,35,,19.95,percent of total billed charges,Implant Device,19.95,35,,19.95,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,42.18,
J&J 42.231.240 LOCKING SCREW 5X40MM,C1713,HCPCS,,79012066,CDM,278,RC,,,both,,,513,379.62,,,379.62,Other,150% of Medicare + 9.63% HCRA Surcharge,230.85,45,,230.85,percent of total billed charges,Critical Access Hospital RCC factor,174.42,34,,174.42,percent of total billed charges,Implant Device,174.42,34,,174.42,percent of total billed charges,Implant Device,174.42,34,,174.42,percent of total billed charges,Implant Device,174.42,34,,174.42,percent of total billed charges,Implant Device,174.42,34,,174.42,percent of total billed charges,Implant Device,253.94,,,253.94,Other,110% of Medicare,179.55,35,,179.55,percent of total billed charges,Implant Device,174.42,34,"Charges > $500, x 34%",174.42,percent of total billed charges,Implant Device,179.55,35,,179.55,percent of total billed charges,Implant Device,179.55,35,,179.55,percent of total billed charges,Implant Device,179.55,35,,179.55,percent of total billed charges,Implant Device,179.55,35,,179.55,percent of total billed charges,Implant Device,179.55,35,,179.55,percent of total billed charges,Implant Device,205.2,40,,205.2,percent of total billed charges,Implant Device,179.55,70,,179.55,percent of total billed charges,All Other,174.42,34,,174.42,percent of total billed charges,Implant Device,174.42,34,,174.42,percent of total billed charges,Implant Device,179.55,35,,179.55,percent of total billed charges,Implant Device,179.55,35,,179.55,percent of total billed charges,Implant Device,179.55,35,,179.55,percent of total billed charges,Implant Device,179.55,35,,179.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,379.62,
J&J 42.231.275 LOCKING SCREW 5X75MM,C1713,HCPCS,,79012067,CDM,278,RC,,,both,,,513,379.62,,,379.62,Other,150% of Medicare + 9.63% HCRA Surcharge,230.85,45,,230.85,percent of total billed charges,Critical Access Hospital RCC factor,174.42,34,,174.42,percent of total billed charges,Implant Device,174.42,34,,174.42,percent of total billed charges,Implant Device,174.42,34,,174.42,percent of total billed charges,Implant Device,174.42,34,,174.42,percent of total billed charges,Implant Device,174.42,34,,174.42,percent of total billed charges,Implant Device,253.94,,,253.94,Other,110% of Medicare,179.55,35,,179.55,percent of total billed charges,Implant Device,174.42,34,"Charges > $500, x 34%",174.42,percent of total billed charges,Implant Device,179.55,35,,179.55,percent of total billed charges,Implant Device,179.55,35,,179.55,percent of total billed charges,Implant Device,179.55,35,,179.55,percent of total billed charges,Implant Device,179.55,35,,179.55,percent of total billed charges,Implant Device,179.55,35,,179.55,percent of total billed charges,Implant Device,205.2,40,,205.2,percent of total billed charges,Implant Device,179.55,70,,179.55,percent of total billed charges,All Other,174.42,34,,174.42,percent of total billed charges,Implant Device,174.42,34,,174.42,percent of total billed charges,Implant Device,179.55,35,,179.55,percent of total billed charges,Implant Device,179.55,35,,179.55,percent of total billed charges,Implant Device,179.55,35,,179.55,percent of total billed charges,Implant Device,179.55,35,,179.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,379.62,
J&J 42.231.270 LOCKING SCREW 5X70MM,C1713,HCPCS,,79012068,CDM,278,RC,,,both,,,513,379.62,,,379.62,Other,150% of Medicare + 9.63% HCRA Surcharge,230.85,45,,230.85,percent of total billed charges,Critical Access Hospital RCC factor,174.42,34,,174.42,percent of total billed charges,Implant Device,174.42,34,,174.42,percent of total billed charges,Implant Device,174.42,34,,174.42,percent of total billed charges,Implant Device,174.42,34,,174.42,percent of total billed charges,Implant Device,174.42,34,,174.42,percent of total billed charges,Implant Device,253.94,,,253.94,Other,110% of Medicare,179.55,35,,179.55,percent of total billed charges,Implant Device,174.42,34,"Charges > $500, x 34%",174.42,percent of total billed charges,Implant Device,179.55,35,,179.55,percent of total billed charges,Implant Device,179.55,35,,179.55,percent of total billed charges,Implant Device,179.55,35,,179.55,percent of total billed charges,Implant Device,179.55,35,,179.55,percent of total billed charges,Implant Device,179.55,35,,179.55,percent of total billed charges,Implant Device,205.2,40,,205.2,percent of total billed charges,Implant Device,179.55,70,,179.55,percent of total billed charges,All Other,174.42,34,,174.42,percent of total billed charges,Implant Device,174.42,34,,174.42,percent of total billed charges,Implant Device,179.55,35,,179.55,percent of total billed charges,Implant Device,179.55,35,,179.55,percent of total billed charges,Implant Device,179.55,35,,179.55,percent of total billed charges,Implant Device,179.55,35,,179.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,379.62,
J&J 42.231.265 LOCKING SCREW 5X65MM,C1713,HCPCS,,79012069,CDM,278,RC,,,both,,,513,379.62,,,379.62,Other,150% of Medicare + 9.63% HCRA Surcharge,230.85,45,,230.85,percent of total billed charges,Critical Access Hospital RCC factor,174.42,34,,174.42,percent of total billed charges,Implant Device,174.42,34,,174.42,percent of total billed charges,Implant Device,174.42,34,,174.42,percent of total billed charges,Implant Device,174.42,34,,174.42,percent of total billed charges,Implant Device,174.42,34,,174.42,percent of total billed charges,Implant Device,253.94,,,253.94,Other,110% of Medicare,179.55,35,,179.55,percent of total billed charges,Implant Device,174.42,34,"Charges > $500, x 34%",174.42,percent of total billed charges,Implant Device,179.55,35,,179.55,percent of total billed charges,Implant Device,179.55,35,,179.55,percent of total billed charges,Implant Device,179.55,35,,179.55,percent of total billed charges,Implant Device,179.55,35,,179.55,percent of total billed charges,Implant Device,179.55,35,,179.55,percent of total billed charges,Implant Device,205.2,40,,205.2,percent of total billed charges,Implant Device,179.55,70,,179.55,percent of total billed charges,All Other,174.42,34,,174.42,percent of total billed charges,Implant Device,174.42,34,,174.42,percent of total billed charges,Implant Device,179.55,35,,179.55,percent of total billed charges,Implant Device,179.55,35,,179.55,percent of total billed charges,Implant Device,179.55,35,,179.55,percent of total billed charges,Implant Device,179.55,35,,179.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,379.62,
J&J 42.231.228 LOCKING SCREW 5X28MM,C1713,HCPCS,,79012070,CDM,278,RC,,,both,,,513,379.62,,,379.62,Other,150% of Medicare + 9.63% HCRA Surcharge,230.85,45,,230.85,percent of total billed charges,Critical Access Hospital RCC factor,174.42,34,,174.42,percent of total billed charges,Implant Device,174.42,34,,174.42,percent of total billed charges,Implant Device,174.42,34,,174.42,percent of total billed charges,Implant Device,174.42,34,,174.42,percent of total billed charges,Implant Device,174.42,34,,174.42,percent of total billed charges,Implant Device,253.94,,,253.94,Other,110% of Medicare,179.55,35,,179.55,percent of total billed charges,Implant Device,174.42,34,"Charges > $500, x 34%",174.42,percent of total billed charges,Implant Device,179.55,35,,179.55,percent of total billed charges,Implant Device,179.55,35,,179.55,percent of total billed charges,Implant Device,179.55,35,,179.55,percent of total billed charges,Implant Device,179.55,35,,179.55,percent of total billed charges,Implant Device,179.55,35,,179.55,percent of total billed charges,Implant Device,205.2,40,,205.2,percent of total billed charges,Implant Device,179.55,70,,179.55,percent of total billed charges,All Other,174.42,34,,174.42,percent of total billed charges,Implant Device,174.42,34,,174.42,percent of total billed charges,Implant Device,179.55,35,,179.55,percent of total billed charges,Implant Device,179.55,35,,179.55,percent of total billed charges,Implant Device,179.55,35,,179.55,percent of total billed charges,Implant Device,179.55,35,,179.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,379.62,
J&J 42.231.232 LOCKING SCREW 5X32MM,C1713,HCPCS,,79012071,CDM,278,RC,,,both,,,529,391.46,,,391.46,Other,150% of Medicare + 9.63% HCRA Surcharge,238.05,45,,238.05,percent of total billed charges,Critical Access Hospital RCC factor,179.86,34,,179.86,percent of total billed charges,Implant Device,179.86,34,,179.86,percent of total billed charges,Implant Device,179.86,34,,179.86,percent of total billed charges,Implant Device,179.86,34,,179.86,percent of total billed charges,Implant Device,179.86,34,,179.86,percent of total billed charges,Implant Device,261.86,,,261.86,Other,110% of Medicare,185.15,35,,185.15,percent of total billed charges,Implant Device,179.86,34,"Charges > $500, x 34%",179.86,percent of total billed charges,Implant Device,185.15,35,,185.15,percent of total billed charges,Implant Device,185.15,35,,185.15,percent of total billed charges,Implant Device,185.15,35,,185.15,percent of total billed charges,Implant Device,185.15,35,,185.15,percent of total billed charges,Implant Device,185.15,35,,185.15,percent of total billed charges,Implant Device,211.6,40,,211.6,percent of total billed charges,Implant Device,185.15,70,,185.15,percent of total billed charges,All Other,179.86,34,,179.86,percent of total billed charges,Implant Device,179.86,34,,179.86,percent of total billed charges,Implant Device,185.15,35,,185.15,percent of total billed charges,Implant Device,185.15,35,,185.15,percent of total billed charges,Implant Device,185.15,35,,185.15,percent of total billed charges,Implant Device,185.15,35,,185.15,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,391.46,
J&J 42.231.230 LOCKING SCREW 5X30MM,C1713,HCPCS,,79012072,CDM,278,RC,,,both,,,513,379.62,,,379.62,Other,150% of Medicare + 9.63% HCRA Surcharge,230.85,45,,230.85,percent of total billed charges,Critical Access Hospital RCC factor,174.42,34,,174.42,percent of total billed charges,Implant Device,174.42,34,,174.42,percent of total billed charges,Implant Device,174.42,34,,174.42,percent of total billed charges,Implant Device,174.42,34,,174.42,percent of total billed charges,Implant Device,174.42,34,,174.42,percent of total billed charges,Implant Device,253.94,,,253.94,Other,110% of Medicare,179.55,35,,179.55,percent of total billed charges,Implant Device,174.42,34,"Charges > $500, x 34%",174.42,percent of total billed charges,Implant Device,179.55,35,,179.55,percent of total billed charges,Implant Device,179.55,35,,179.55,percent of total billed charges,Implant Device,179.55,35,,179.55,percent of total billed charges,Implant Device,179.55,35,,179.55,percent of total billed charges,Implant Device,179.55,35,,179.55,percent of total billed charges,Implant Device,205.2,40,,205.2,percent of total billed charges,Implant Device,179.55,70,,179.55,percent of total billed charges,All Other,174.42,34,,174.42,percent of total billed charges,Implant Device,174.42,34,,174.42,percent of total billed charges,Implant Device,179.55,35,,179.55,percent of total billed charges,Implant Device,179.55,35,,179.55,percent of total billed charges,Implant Device,179.55,35,,179.55,percent of total billed charges,Implant Device,179.55,35,,179.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,379.62,
J&J 42.231.226 LOCKING SCREW 5X26MM,C1713,HCPCS,,79012073,CDM,278,RC,,,both,,,529,391.46,,,391.46,Other,150% of Medicare + 9.63% HCRA Surcharge,238.05,45,,238.05,percent of total billed charges,Critical Access Hospital RCC factor,179.86,34,,179.86,percent of total billed charges,Implant Device,179.86,34,,179.86,percent of total billed charges,Implant Device,179.86,34,,179.86,percent of total billed charges,Implant Device,179.86,34,,179.86,percent of total billed charges,Implant Device,179.86,34,,179.86,percent of total billed charges,Implant Device,261.86,,,261.86,Other,110% of Medicare,185.15,35,,185.15,percent of total billed charges,Implant Device,179.86,34,"Charges > $500, x 34%",179.86,percent of total billed charges,Implant Device,185.15,35,,185.15,percent of total billed charges,Implant Device,185.15,35,,185.15,percent of total billed charges,Implant Device,185.15,35,,185.15,percent of total billed charges,Implant Device,185.15,35,,185.15,percent of total billed charges,Implant Device,185.15,35,,185.15,percent of total billed charges,Implant Device,211.6,40,,211.6,percent of total billed charges,Implant Device,185.15,70,,185.15,percent of total billed charges,All Other,179.86,34,,179.86,percent of total billed charges,Implant Device,179.86,34,,179.86,percent of total billed charges,Implant Device,185.15,35,,185.15,percent of total billed charges,Implant Device,185.15,35,,185.15,percent of total billed charges,Implant Device,185.15,35,,185.15,percent of total billed charges,Implant Device,185.15,35,,185.15,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,391.46,
IN2BONES P43 ST016 CORTICAL SCREW 3X16MM,C1713,HCPCS,,79012074,CDM,278,RC,,,both,,,870,643.8,,,643.8,Other,150% of Medicare + 9.63% HCRA Surcharge,391.5,45,,391.5,percent of total billed charges,Critical Access Hospital RCC factor,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,430.65,,,430.65,Other,110% of Medicare,304.5,35,,304.5,percent of total billed charges,Implant Device,295.8,34,"Charges > $500, x 34%",295.8,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,348,40,,348,percent of total billed charges,Implant Device,304.5,70,,304.5,percent of total billed charges,All Other,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,643.8,
IN2BONES P43 ST116 LOCKING SCREW 3X16MM,C1713,HCPCS,,79012075,CDM,278,RC,,,both,,,870,643.8,,,643.8,Other,150% of Medicare + 9.63% HCRA Surcharge,391.5,45,,391.5,percent of total billed charges,Critical Access Hospital RCC factor,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,430.65,,,430.65,Other,110% of Medicare,304.5,35,,304.5,percent of total billed charges,Implant Device,295.8,34,"Charges > $500, x 34%",295.8,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,348,40,,348,percent of total billed charges,Implant Device,304.5,70,,304.5,percent of total billed charges,All Other,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,643.8,
IN2BONES P73 ST118 LOCKING SCREW 3.5X18,C1713,HCPCS,,79012076,CDM,278,RC,,,both,,,870,643.8,,,643.8,Other,150% of Medicare + 9.63% HCRA Surcharge,391.5,45,,391.5,percent of total billed charges,Critical Access Hospital RCC factor,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,430.65,,,430.65,Other,110% of Medicare,304.5,35,,304.5,percent of total billed charges,Implant Device,295.8,34,"Charges > $500, x 34%",295.8,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,348,40,,348,percent of total billed charges,Implant Device,304.5,70,,304.5,percent of total billed charges,All Other,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,643.8,
ARTHREX AR-18720-14 CORTICAL SCREW 2X14,C1713,HCPCS,,79012079,CDM,278,RC,,,both,,,474,350.76,,,350.76,Other,150% of Medicare + 9.63% HCRA Surcharge,213.3,45,,213.3,percent of total billed charges,Critical Access Hospital RCC factor,161.16,34,,161.16,percent of total billed charges,Implant Device,161.16,34,,161.16,percent of total billed charges,Implant Device,161.16,34,,161.16,percent of total billed charges,Implant Device,161.16,34,,161.16,percent of total billed charges,Implant Device,161.16,34,,161.16,percent of total billed charges,Implant Device,234.63,,,234.63,Other,110% of Medicare,165.9,35,,165.9,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,165.9,35,,165.9,percent of total billed charges,Implant Device,165.9,35,,165.9,percent of total billed charges,Implant Device,165.9,35,,165.9,percent of total billed charges,Implant Device,165.9,35,,165.9,percent of total billed charges,Implant Device,165.9,35,,165.9,percent of total billed charges,Implant Device,189.6,40,,189.6,percent of total billed charges,Implant Device,165.9,70,,165.9,percent of total billed charges,All Other,161.16,34,,161.16,percent of total billed charges,Implant Device,161.16,34,,161.16,percent of total billed charges,Implant Device,165.9,35,,165.9,percent of total billed charges,Implant Device,165.9,35,,165.9,percent of total billed charges,Implant Device,165.9,35,,165.9,percent of total billed charges,Implant Device,165.9,35,,165.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,350.76,
STRYKER 658345 COMPRESSION SCREW 7X45MM,C1713,HCPCS,,79012080,CDM,278,RC,,,both,,,2079,1538.47,,,1538.47,Other,150% of Medicare + 9.63% HCRA Surcharge,935.55,45,,935.55,percent of total billed charges,Critical Access Hospital RCC factor,706.86,34,,706.86,percent of total billed charges,Implant Device,706.86,34,,706.86,percent of total billed charges,Implant Device,706.86,34,,706.86,percent of total billed charges,Implant Device,706.86,34,,706.86,percent of total billed charges,Implant Device,706.86,34,,706.86,percent of total billed charges,Implant Device,1029.11,,,1029.11,Other,110% of Medicare,727.65,35,,727.65,percent of total billed charges,Implant Device,706.86,34,"Charges > $500, x 34%",706.86,percent of total billed charges,Implant Device,727.65,35,,727.65,percent of total billed charges,Implant Device,727.65,35,,727.65,percent of total billed charges,Implant Device,727.65,35,,727.65,percent of total billed charges,Implant Device,727.65,35,,727.65,percent of total billed charges,Implant Device,727.65,35,,727.65,percent of total billed charges,Implant Device,831.6,40,,831.6,percent of total billed charges,Implant Device,727.65,70,,727.65,percent of total billed charges,All Other,706.86,34,,706.86,percent of total billed charges,Implant Device,706.86,34,,706.86,percent of total billed charges,Implant Device,727.65,35,,727.65,percent of total billed charges,Implant Device,727.65,35,,727.65,percent of total billed charges,Implant Device,727.65,35,,727.65,percent of total billed charges,Implant Device,727.65,35,,727.65,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,706.86,34,"If Charge > 2,000, then 34 percent",706.86,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1538.47,
IN2BONES C20 ST031 LISFRANC PLATE SMALL,C1713,HCPCS,,79012081,CDM,278,RC,,,both,,,6000,4440.02,,,4440.02,Other,150% of Medicare + 9.63% HCRA Surcharge,2700,45,,2700,percent of total billed charges,Critical Access Hospital RCC factor,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2970,,,2970,Other,110% of Medicare,2100,35,,2100,percent of total billed charges,Implant Device,2040,34,"Charges > $500, x 34%",2040,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2400,40,,2400,percent of total billed charges,Implant Device,2100,70,,2100,percent of total billed charges,All Other,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2040,34,"If Charge > 2,000, then 34 percent",2040,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4440.02,
J&J 1504-11-210 FEMORAL COMPONENT SZ 10,C1776,HCPCS,,79012082,CDM,278,RC,,,both,,,6000,4440.02,,,4440.02,Other,150% of Medicare + 9.63% HCRA Surcharge,2700,45,,2700,percent of total billed charges,Critical Access Hospital RCC factor,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2970,,,2970,Other,110% of Medicare,2100,35,,2100,percent of total billed charges,Implant Device,2040,34,"Charges > $500, x 34%",2040,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2400,40,,2400,percent of total billed charges,Implant Device,2100,70,,2100,percent of total billed charges,All Other,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2040,34,"If Charge > 2,000, then 34 percent",2040,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4440.02,
J&J 1516-51-006 TIBIAL INSERT 6MM SZ 10,C1776,HCPCS,,79012083,CDM,278,RC,,,both,,,4200,3108.01,,,3108.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1890,45,,1890,percent of total billed charges,Critical Access Hospital RCC factor,1428,34,,1428,percent of total billed charges,Implant Device,1428,34,,1428,percent of total billed charges,Implant Device,1428,34,,1428,percent of total billed charges,Implant Device,1428,34,,1428,percent of total billed charges,Implant Device,1428,34,,1428,percent of total billed charges,Implant Device,2079,,,2079,Other,110% of Medicare,1470,35,,1470,percent of total billed charges,Implant Device,1428,34,"Charges > $500, x 34%",1428,percent of total billed charges,Implant Device,1470,35,,1470,percent of total billed charges,Implant Device,1470,35,,1470,percent of total billed charges,Implant Device,1470,35,,1470,percent of total billed charges,Implant Device,1470,35,,1470,percent of total billed charges,Implant Device,1470,35,,1470,percent of total billed charges,Implant Device,1680,40,,1680,percent of total billed charges,Implant Device,1470,70,,1470,percent of total billed charges,All Other,1428,34,,1428,percent of total billed charges,Implant Device,1428,34,,1428,percent of total billed charges,Implant Device,1470,35,,1470,percent of total billed charges,Implant Device,1470,35,,1470,percent of total billed charges,Implant Device,1470,35,,1470,percent of total billed charges,Implant Device,1470,35,,1470,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1428,34,"If Charge > 2,000, then 34 percent",1428,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3108.01,
J&J 1506-11-010 TIBIAL BASE SZ 10,C1776,HCPCS,,79012084,CDM,278,RC,,,both,,,6300,4662.02,,,4662.02,Other,150% of Medicare + 9.63% HCRA Surcharge,2835,45,,2835,percent of total billed charges,Critical Access Hospital RCC factor,2142,34,,2142,percent of total billed charges,Implant Device,2142,34,,2142,percent of total billed charges,Implant Device,2142,34,,2142,percent of total billed charges,Implant Device,2142,34,,2142,percent of total billed charges,Implant Device,2142,34,,2142,percent of total billed charges,Implant Device,3118.5,,,3118.5,Other,110% of Medicare,2205,35,,2205,percent of total billed charges,Implant Device,2142,34,"Charges > $500, x 34%",2142,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2520,40,,2520,percent of total billed charges,Implant Device,2205,70,,2205,percent of total billed charges,All Other,2142,34,,2142,percent of total billed charges,Implant Device,2142,34,,2142,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2142,34,"If Charge > 2,000, then 34 percent",2142,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4662.02,
J&J 3322020 BONE CEMENT 20G,C1713,HCPCS,,79012085,CDM,278,RC,,,both,,,627,463.98,,,463.98,Other,150% of Medicare + 9.63% HCRA Surcharge,282.15,45,,282.15,percent of total billed charges,Critical Access Hospital RCC factor,213.18,34,,213.18,percent of total billed charges,Implant Device,213.18,34,,213.18,percent of total billed charges,Implant Device,213.18,34,,213.18,percent of total billed charges,Implant Device,213.18,34,,213.18,percent of total billed charges,Implant Device,213.18,34,,213.18,percent of total billed charges,Implant Device,310.37,,,310.37,Other,110% of Medicare,219.45,35,,219.45,percent of total billed charges,Implant Device,213.18,34,"Charges > $500, x 34%",213.18,percent of total billed charges,Implant Device,219.45,35,,219.45,percent of total billed charges,Implant Device,219.45,35,,219.45,percent of total billed charges,Implant Device,219.45,35,,219.45,percent of total billed charges,Implant Device,219.45,35,,219.45,percent of total billed charges,Implant Device,219.45,35,,219.45,percent of total billed charges,Implant Device,250.8,40,,250.8,percent of total billed charges,Implant Device,219.45,70,,219.45,percent of total billed charges,All Other,213.18,34,,213.18,percent of total billed charges,Implant Device,213.18,34,,213.18,percent of total billed charges,Implant Device,219.45,35,,219.45,percent of total billed charges,Implant Device,219.45,35,,219.45,percent of total billed charges,Implant Device,219.45,35,,219.45,percent of total billed charges,Implant Device,219.45,35,,219.45,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,463.98,
IN2BONES S27 S120 SNAP OFF SCREW 2.7X20,C1713,HCPCS,,79012086,CDM,278,RC,,,both,,,1275,943.5,,,943.5,Other,150% of Medicare + 9.63% HCRA Surcharge,573.75,45,,573.75,percent of total billed charges,Critical Access Hospital RCC factor,433.5,34,,433.5,percent of total billed charges,Implant Device,433.5,34,,433.5,percent of total billed charges,Implant Device,433.5,34,,433.5,percent of total billed charges,Implant Device,433.5,34,,433.5,percent of total billed charges,Implant Device,433.5,34,,433.5,percent of total billed charges,Implant Device,631.13,,,631.13,Other,110% of Medicare,446.25,35,,446.25,percent of total billed charges,Implant Device,433.5,34,"Charges > $500, x 34%",433.5,percent of total billed charges,Implant Device,446.25,35,,446.25,percent of total billed charges,Implant Device,446.25,35,,446.25,percent of total billed charges,Implant Device,446.25,35,,446.25,percent of total billed charges,Implant Device,446.25,35,,446.25,percent of total billed charges,Implant Device,446.25,35,,446.25,percent of total billed charges,Implant Device,510,40,,510,percent of total billed charges,Implant Device,446.25,70,,446.25,percent of total billed charges,All Other,433.5,34,,433.5,percent of total billed charges,Implant Device,433.5,34,,433.5,percent of total billed charges,Implant Device,446.25,35,,446.25,percent of total billed charges,Implant Device,446.25,35,,446.25,percent of total billed charges,Implant Device,446.25,35,,446.25,percent of total billed charges,Implant Device,446.25,35,,446.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,943.5,
IN2BONES P70 ST207 FIBULA PLATE LEFT,C1713,HCPCS,,79012087,CDM,278,RC,,,both,,,6000,4440.02,,,4440.02,Other,150% of Medicare + 9.63% HCRA Surcharge,2700,45,,2700,percent of total billed charges,Critical Access Hospital RCC factor,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2970,,,2970,Other,110% of Medicare,2100,35,,2100,percent of total billed charges,Implant Device,2040,34,"Charges > $500, x 34%",2040,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2400,40,,2400,percent of total billed charges,Implant Device,2100,70,,2100,percent of total billed charges,All Other,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2040,34,"If Charge > 2,000, then 34 percent",2040,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4440.02,
ZIMMER 110007603 CANNULATED SCREW 4X38MM,C1713,HCPCS,,79012088,CDM,278,RC,,,both,,,1020,754.8,,,754.8,Other,150% of Medicare + 9.63% HCRA Surcharge,459,45,,459,percent of total billed charges,Critical Access Hospital RCC factor,346.8,34,,346.8,percent of total billed charges,Implant Device,346.8,34,,346.8,percent of total billed charges,Implant Device,346.8,34,,346.8,percent of total billed charges,Implant Device,346.8,34,,346.8,percent of total billed charges,Implant Device,346.8,34,,346.8,percent of total billed charges,Implant Device,504.9,,,504.9,Other,110% of Medicare,357,35,,357,percent of total billed charges,Implant Device,346.8,34,"Charges > $500, x 34%",346.8,percent of total billed charges,Implant Device,357,35,,357,percent of total billed charges,Implant Device,357,35,,357,percent of total billed charges,Implant Device,357,35,,357,percent of total billed charges,Implant Device,357,35,,357,percent of total billed charges,Implant Device,357,35,,357,percent of total billed charges,Implant Device,408,40,,408,percent of total billed charges,Implant Device,357,70,,357,percent of total billed charges,All Other,346.8,34,,346.8,percent of total billed charges,Implant Device,346.8,34,,346.8,percent of total billed charges,Implant Device,357,35,,357,percent of total billed charges,Implant Device,357,35,,357,percent of total billed charges,Implant Device,357,35,,357,percent of total billed charges,Implant Device,357,35,,357,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,754.8,
ZIMMER 110007605 CANULATED SCREW 4X40MM,C1713,HCPCS,,79012089,CDM,278,RC,,,both,,,1020,754.8,,,754.8,Other,150% of Medicare + 9.63% HCRA Surcharge,459,45,,459,percent of total billed charges,Critical Access Hospital RCC factor,346.8,34,,346.8,percent of total billed charges,Implant Device,346.8,34,,346.8,percent of total billed charges,Implant Device,346.8,34,,346.8,percent of total billed charges,Implant Device,346.8,34,,346.8,percent of total billed charges,Implant Device,346.8,34,,346.8,percent of total billed charges,Implant Device,504.9,,,504.9,Other,110% of Medicare,357,35,,357,percent of total billed charges,Implant Device,346.8,34,"Charges > $500, x 34%",346.8,percent of total billed charges,Implant Device,357,35,,357,percent of total billed charges,Implant Device,357,35,,357,percent of total billed charges,Implant Device,357,35,,357,percent of total billed charges,Implant Device,357,35,,357,percent of total billed charges,Implant Device,357,35,,357,percent of total billed charges,Implant Device,408,40,,408,percent of total billed charges,Implant Device,357,70,,357,percent of total billed charges,All Other,346.8,34,,346.8,percent of total billed charges,Implant Device,346.8,34,,346.8,percent of total billed charges,Implant Device,357,35,,357,percent of total billed charges,Implant Device,357,35,,357,percent of total billed charges,Implant Device,357,35,,357,percent of total billed charges,Implant Device,357,35,,357,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,754.8,
ZIMMER 183008 FEMORAL CEMENTED RT 65MM,C1776,HCPCS,,79012090,CDM,278,RC,,,both,,,6300,4662.02,,,4662.02,Other,150% of Medicare + 9.63% HCRA Surcharge,2835,45,,2835,percent of total billed charges,Critical Access Hospital RCC factor,2142,34,,2142,percent of total billed charges,Implant Device,2142,34,,2142,percent of total billed charges,Implant Device,2142,34,,2142,percent of total billed charges,Implant Device,2142,34,,2142,percent of total billed charges,Implant Device,2142,34,,2142,percent of total billed charges,Implant Device,3118.5,,,3118.5,Other,110% of Medicare,2205,35,,2205,percent of total billed charges,Implant Device,2142,34,"Charges > $500, x 34%",2142,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2520,40,,2520,percent of total billed charges,Implant Device,2205,70,,2205,percent of total billed charges,All Other,2142,34,,2142,percent of total billed charges,Implant Device,2142,34,,2142,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2142,34,"If Charge > 2,000, then 34 percent",2142,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4662.02,
ZIMMER 141233 TIBIAL PLATE 71MM,C1776,HCPCS,,79012091,CDM,278,RC,,,both,,,2304,1704.97,,,1704.97,Other,150% of Medicare + 9.63% HCRA Surcharge,1036.8,45,,1036.8,percent of total billed charges,Critical Access Hospital RCC factor,783.36,34,,783.36,percent of total billed charges,Implant Device,783.36,34,,783.36,percent of total billed charges,Implant Device,783.36,34,,783.36,percent of total billed charges,Implant Device,783.36,34,,783.36,percent of total billed charges,Implant Device,783.36,34,,783.36,percent of total billed charges,Implant Device,1140.48,,,1140.48,Other,110% of Medicare,806.4,35,,806.4,percent of total billed charges,Implant Device,783.36,34,"Charges > $500, x 34%",783.36,percent of total billed charges,Implant Device,806.4,35,,806.4,percent of total billed charges,Implant Device,806.4,35,,806.4,percent of total billed charges,Implant Device,806.4,35,,806.4,percent of total billed charges,Implant Device,806.4,35,,806.4,percent of total billed charges,Implant Device,806.4,35,,806.4,percent of total billed charges,Implant Device,921.6,40,,921.6,percent of total billed charges,Implant Device,806.4,70,,806.4,percent of total billed charges,All Other,783.36,34,,783.36,percent of total billed charges,Implant Device,783.36,34,,783.36,percent of total billed charges,Implant Device,806.4,35,,806.4,percent of total billed charges,Implant Device,806.4,35,,806.4,percent of total billed charges,Implant Device,806.4,35,,806.4,percent of total billed charges,Implant Device,806.4,35,,806.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,783.36,34,"If Charge > 2,000, then 34 percent",783.36,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1704.97,
ZIMMER EP-189062 TIBIAL BEARING 12X71MM,C1776,HCPCS,,79012092,CDM,278,RC,,,both,,,3648,2699.53,,,2699.53,Other,150% of Medicare + 9.63% HCRA Surcharge,1641.6,45,,1641.6,percent of total billed charges,Critical Access Hospital RCC factor,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1805.76,,,1805.76,Other,110% of Medicare,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1240.32,34,"Charges > $500, x 34%",1240.32,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1459.2,40,,1459.2,percent of total billed charges,Implant Device,1276.8,70,,1276.8,percent of total billed charges,All Other,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1240.32,34,"If Charge > 2,000, then 34 percent",1240.32,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2699.53,
ZIMMER 184764 PATELLA 3 PEG STD 31X8MM,C1776,HCPCS,,79012093,CDM,278,RC,,,both,,,1152,852.48,,,852.48,Other,150% of Medicare + 9.63% HCRA Surcharge,518.4,45,,518.4,percent of total billed charges,Critical Access Hospital RCC factor,391.68,34,,391.68,percent of total billed charges,Implant Device,391.68,34,,391.68,percent of total billed charges,Implant Device,391.68,34,,391.68,percent of total billed charges,Implant Device,391.68,34,,391.68,percent of total billed charges,Implant Device,391.68,34,,391.68,percent of total billed charges,Implant Device,570.24,,,570.24,Other,110% of Medicare,403.2,35,,403.2,percent of total billed charges,Implant Device,391.68,34,"Charges > $500, x 34%",391.68,percent of total billed charges,Implant Device,403.2,35,,403.2,percent of total billed charges,Implant Device,403.2,35,,403.2,percent of total billed charges,Implant Device,403.2,35,,403.2,percent of total billed charges,Implant Device,403.2,35,,403.2,percent of total billed charges,Implant Device,403.2,35,,403.2,percent of total billed charges,Implant Device,460.8,40,,460.8,percent of total billed charges,Implant Device,403.2,70,,403.2,percent of total billed charges,All Other,391.68,34,,391.68,percent of total billed charges,Implant Device,391.68,34,,391.68,percent of total billed charges,Implant Device,403.2,35,,403.2,percent of total billed charges,Implant Device,403.2,35,,403.2,percent of total billed charges,Implant Device,403.2,35,,403.2,percent of total billed charges,Implant Device,403.2,35,,403.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,852.48,
STRYKER 3102-1002 DBM PUTTY 2.5CC,C1762,HCPCS,,79012094,CDM,278,RC,,,both,,,735,543.9,,,543.9,Other,150% of Medicare + 9.63% HCRA Surcharge,330.75,45,,330.75,percent of total billed charges,Critical Access Hospital RCC factor,249.9,34,,249.9,percent of total billed charges,Implant Device,249.9,34,,249.9,percent of total billed charges,Implant Device,249.9,34,,249.9,percent of total billed charges,Implant Device,249.9,34,,249.9,percent of total billed charges,Implant Device,249.9,34,,249.9,percent of total billed charges,Implant Device,363.83,,,363.83,Other,110% of Medicare,257.25,35,,257.25,percent of total billed charges,Implant Device,249.9,34,"Charges > $500, x 34%",249.9,percent of total billed charges,Implant Device,257.25,35,,257.25,percent of total billed charges,Implant Device,257.25,35,,257.25,percent of total billed charges,Implant Device,257.25,35,,257.25,percent of total billed charges,Implant Device,257.25,35,,257.25,percent of total billed charges,Implant Device,257.25,35,,257.25,percent of total billed charges,Implant Device,294,40,,294,percent of total billed charges,Implant Device,257.25,70,,257.25,percent of total billed charges,All Other,249.9,34,,249.9,percent of total billed charges,Implant Device,249.9,34,,249.9,percent of total billed charges,Implant Device,257.25,35,,257.25,percent of total billed charges,Implant Device,257.25,35,,257.25,percent of total billed charges,Implant Device,257.25,35,,257.25,percent of total billed charges,Implant Device,257.25,35,,257.25,percent of total billed charges,Implant Device,976.07,,,976.07,Other,100% of Medicaid,976.07,,,976.07,Other,100% of Medicaid,976.07,,,976.07,Other,100% of Medicaid,976.07,,,976.07,Other,100% of Medicaid,2196.16,,,2196.16,Other,225% of Medicaid,1493.39,,,1493.39,Other,153% of Medicaid,2196.16,,,2196.16,Other,225% of Medicaid,1366.5,,,1366.5,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,2537.78,,,2537.78,Other,260% of Medicaid,3162.47,,,3162.47,Other,324% of Medicaid,2098.55,,,2098.55,Other,215% of Medicaid,2098.55,,,2098.55,Other,215% of Medicaid,1220.09,,,1220.09,Other,125% of Medicaid,0.01,3162.47,
STRYKER 3102-1005 DBM PUTTY 5CC,C1762,HCPCS,,79012095,CDM,278,RC,,,both,,,1577,1166.98,,,1166.98,Other,150% of Medicare + 9.63% HCRA Surcharge,709.65,45,,709.65,percent of total billed charges,Critical Access Hospital RCC factor,536.18,34,,536.18,percent of total billed charges,Implant Device,536.18,34,,536.18,percent of total billed charges,Implant Device,536.18,34,,536.18,percent of total billed charges,Implant Device,536.18,34,,536.18,percent of total billed charges,Implant Device,536.18,34,,536.18,percent of total billed charges,Implant Device,780.62,,,780.62,Other,110% of Medicare,551.95,35,,551.95,percent of total billed charges,Implant Device,536.18,34,"Charges > $500, x 34%",536.18,percent of total billed charges,Implant Device,551.95,35,,551.95,percent of total billed charges,Implant Device,551.95,35,,551.95,percent of total billed charges,Implant Device,551.95,35,,551.95,percent of total billed charges,Implant Device,551.95,35,,551.95,percent of total billed charges,Implant Device,551.95,35,,551.95,percent of total billed charges,Implant Device,630.8,40,,630.8,percent of total billed charges,Implant Device,551.95,70,,551.95,percent of total billed charges,All Other,536.18,34,,536.18,percent of total billed charges,Implant Device,536.18,34,,536.18,percent of total billed charges,Implant Device,551.95,35,,551.95,percent of total billed charges,Implant Device,551.95,35,,551.95,percent of total billed charges,Implant Device,551.95,35,,551.95,percent of total billed charges,Implant Device,551.95,35,,551.95,percent of total billed charges,Implant Device,976.07,,,976.07,Other,100% of Medicaid,976.07,,,976.07,Other,100% of Medicaid,976.07,,,976.07,Other,100% of Medicaid,976.07,,,976.07,Other,100% of Medicaid,2196.16,,,2196.16,Other,225% of Medicaid,1493.39,,,1493.39,Other,153% of Medicaid,2196.16,,,2196.16,Other,225% of Medicaid,1366.5,,,1366.5,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,2537.78,,,2537.78,Other,260% of Medicaid,3162.47,,,3162.47,Other,324% of Medicaid,2098.55,,,2098.55,Other,215% of Medicaid,2098.55,,,2098.55,Other,215% of Medicaid,1220.09,,,1220.09,Other,125% of Medicaid,0.01,3162.47,
STRYKER 3102-1010 DBM PUTTY 10CC,C1762,HCPCS,,79012096,CDM,278,RC,,,both,,,2460,1820.41,,,1820.41,Other,150% of Medicare + 9.63% HCRA Surcharge,1107,45,,1107,percent of total billed charges,Critical Access Hospital RCC factor,836.4,34,,836.4,percent of total billed charges,Implant Device,836.4,34,,836.4,percent of total billed charges,Implant Device,836.4,34,,836.4,percent of total billed charges,Implant Device,836.4,34,,836.4,percent of total billed charges,Implant Device,836.4,34,,836.4,percent of total billed charges,Implant Device,1217.7,,,1217.7,Other,110% of Medicare,861,35,,861,percent of total billed charges,Implant Device,836.4,34,"Charges > $500, x 34%",836.4,percent of total billed charges,Implant Device,861,35,,861,percent of total billed charges,Implant Device,861,35,,861,percent of total billed charges,Implant Device,861,35,,861,percent of total billed charges,Implant Device,861,35,,861,percent of total billed charges,Implant Device,861,35,,861,percent of total billed charges,Implant Device,984,40,,984,percent of total billed charges,Implant Device,861,70,,861,percent of total billed charges,All Other,836.4,34,,836.4,percent of total billed charges,Implant Device,836.4,34,,836.4,percent of total billed charges,Implant Device,861,35,,861,percent of total billed charges,Implant Device,861,35,,861,percent of total billed charges,Implant Device,861,35,,861,percent of total billed charges,Implant Device,861,35,,861,percent of total billed charges,Implant Device,976.07,,,976.07,Other,100% of Medicaid,976.07,,,976.07,Other,100% of Medicaid,976.07,,,976.07,Other,100% of Medicaid,976.07,,,976.07,Other,100% of Medicaid,2196.16,,,2196.16,Other,225% of Medicaid,1493.39,,,1493.39,Other,153% of Medicaid,2196.16,,,2196.16,Other,225% of Medicaid,1366.5,,,1366.5,Other,140% of Medicaid,836.4,34,"If Charge > 2,000, then 34 percent",836.4,percent of total billed charges,Implants,2537.78,,,2537.78,Other,260% of Medicaid,3162.47,,,3162.47,Other,324% of Medicaid,2098.55,,,2098.55,Other,215% of Medicaid,2098.55,,,2098.55,Other,215% of Medicaid,1220.09,,,1220.09,Other,125% of Medicaid,836.4,3162.47,
J&J 02.112.622 CLAVICLE PLATE LEFT 2.7MM,C1713,HCPCS,,79012097,CDM,278,RC,,,both,,,3122,2310.29,,,2310.29,Other,150% of Medicare + 9.63% HCRA Surcharge,1404.9,45,,1404.9,percent of total billed charges,Critical Access Hospital RCC factor,1061.48,34,,1061.48,percent of total billed charges,Implant Device,1061.48,34,,1061.48,percent of total billed charges,Implant Device,1061.48,34,,1061.48,percent of total billed charges,Implant Device,1061.48,34,,1061.48,percent of total billed charges,Implant Device,1061.48,34,,1061.48,percent of total billed charges,Implant Device,1545.39,,,1545.39,Other,110% of Medicare,1092.7,35,,1092.7,percent of total billed charges,Implant Device,1061.48,34,"Charges > $500, x 34%",1061.48,percent of total billed charges,Implant Device,1092.7,35,,1092.7,percent of total billed charges,Implant Device,1092.7,35,,1092.7,percent of total billed charges,Implant Device,1092.7,35,,1092.7,percent of total billed charges,Implant Device,1092.7,35,,1092.7,percent of total billed charges,Implant Device,1092.7,35,,1092.7,percent of total billed charges,Implant Device,1248.8,40,,1248.8,percent of total billed charges,Implant Device,1092.7,70,,1092.7,percent of total billed charges,All Other,1061.48,34,,1061.48,percent of total billed charges,Implant Device,1061.48,34,,1061.48,percent of total billed charges,Implant Device,1092.7,35,,1092.7,percent of total billed charges,Implant Device,1092.7,35,,1092.7,percent of total billed charges,Implant Device,1092.7,35,,1092.7,percent of total billed charges,Implant Device,1092.7,35,,1092.7,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1061.48,34,"If Charge > 2,000, then 34 percent",1061.48,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2310.29,
J&J 247.370 LCP PLATE 12 HOLE 2.7X97MM,C1713,HCPCS,,79012099,CDM,278,RC,,,both,,,1165,862.1,,,862.1,Other,150% of Medicare + 9.63% HCRA Surcharge,524.25,45,,524.25,percent of total billed charges,Critical Access Hospital RCC factor,396.1,34,,396.1,percent of total billed charges,Implant Device,396.1,34,,396.1,percent of total billed charges,Implant Device,396.1,34,,396.1,percent of total billed charges,Implant Device,396.1,34,,396.1,percent of total billed charges,Implant Device,396.1,34,,396.1,percent of total billed charges,Implant Device,576.68,,,576.68,Other,110% of Medicare,407.75,35,,407.75,percent of total billed charges,Implant Device,396.1,34,"Charges > $500, x 34%",396.1,percent of total billed charges,Implant Device,407.75,35,,407.75,percent of total billed charges,Implant Device,407.75,35,,407.75,percent of total billed charges,Implant Device,407.75,35,,407.75,percent of total billed charges,Implant Device,407.75,35,,407.75,percent of total billed charges,Implant Device,407.75,35,,407.75,percent of total billed charges,Implant Device,466,40,,466,percent of total billed charges,Implant Device,407.75,70,,407.75,percent of total billed charges,All Other,396.1,34,,396.1,percent of total billed charges,Implant Device,396.1,34,,396.1,percent of total billed charges,Implant Device,407.75,35,,407.75,percent of total billed charges,Implant Device,407.75,35,,407.75,percent of total billed charges,Implant Device,407.75,35,,407.75,percent of total billed charges,Implant Device,407.75,35,,407.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,862.1,
J&J 02.124.415 LCP CURVED PLT 4.5X301MM,C1713,HCPCS,,79012101,CDM,278,RC,,,both,,,5157,3816.19,,,3816.19,Other,150% of Medicare + 9.63% HCRA Surcharge,2320.65,45,,2320.65,percent of total billed charges,Critical Access Hospital RCC factor,1753.38,34,,1753.38,percent of total billed charges,Implant Device,1753.38,34,,1753.38,percent of total billed charges,Implant Device,1753.38,34,,1753.38,percent of total billed charges,Implant Device,1753.38,34,,1753.38,percent of total billed charges,Implant Device,1753.38,34,,1753.38,percent of total billed charges,Implant Device,2552.72,,,2552.72,Other,110% of Medicare,1804.95,35,,1804.95,percent of total billed charges,Implant Device,1753.38,34,"Charges > $500, x 34%",1753.38,percent of total billed charges,Implant Device,1804.95,35,,1804.95,percent of total billed charges,Implant Device,1804.95,35,,1804.95,percent of total billed charges,Implant Device,1804.95,35,,1804.95,percent of total billed charges,Implant Device,1804.95,35,,1804.95,percent of total billed charges,Implant Device,1804.95,35,,1804.95,percent of total billed charges,Implant Device,2062.8,40,,2062.8,percent of total billed charges,Implant Device,1804.95,70,,1804.95,percent of total billed charges,All Other,1753.38,34,,1753.38,percent of total billed charges,Implant Device,1753.38,34,,1753.38,percent of total billed charges,Implant Device,1804.95,35,,1804.95,percent of total billed charges,Implant Device,1804.95,35,,1804.95,percent of total billed charges,Implant Device,1804.95,35,,1804.95,percent of total billed charges,Implant Device,1804.95,35,,1804.95,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1753.38,34,"If Charge > 2,000, then 34 percent",1753.38,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3816.19,
J&J 42.231.280 SCREW SELF TAPPING 5X80MM,C1713,HCPCS,,79012102,CDM,278,RC,,,both,,,513,379.62,,,379.62,Other,150% of Medicare + 9.63% HCRA Surcharge,230.85,45,,230.85,percent of total billed charges,Critical Access Hospital RCC factor,174.42,34,,174.42,percent of total billed charges,Implant Device,174.42,34,,174.42,percent of total billed charges,Implant Device,174.42,34,,174.42,percent of total billed charges,Implant Device,174.42,34,,174.42,percent of total billed charges,Implant Device,174.42,34,,174.42,percent of total billed charges,Implant Device,253.94,,,253.94,Other,110% of Medicare,179.55,35,,179.55,percent of total billed charges,Implant Device,174.42,34,"Charges > $500, x 34%",174.42,percent of total billed charges,Implant Device,179.55,35,,179.55,percent of total billed charges,Implant Device,179.55,35,,179.55,percent of total billed charges,Implant Device,179.55,35,,179.55,percent of total billed charges,Implant Device,179.55,35,,179.55,percent of total billed charges,Implant Device,179.55,35,,179.55,percent of total billed charges,Implant Device,205.2,40,,205.2,percent of total billed charges,Implant Device,179.55,70,,179.55,percent of total billed charges,All Other,174.42,34,,174.42,percent of total billed charges,Implant Device,174.42,34,,174.42,percent of total billed charges,Implant Device,179.55,35,,179.55,percent of total billed charges,Implant Device,179.55,35,,179.55,percent of total billed charges,Implant Device,179.55,35,,179.55,percent of total billed charges,Implant Device,179.55,35,,179.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,379.62,
J&J 04.013.616S FEMORAL NAIL 12X180MM,C1713,HCPCS,,79012103,CDM,278,RC,,,both,,,3094,2289.57,,,2289.57,Other,150% of Medicare + 9.63% HCRA Surcharge,1392.3,45,,1392.3,percent of total billed charges,Critical Access Hospital RCC factor,1051.96,34,,1051.96,percent of total billed charges,Implant Device,1051.96,34,,1051.96,percent of total billed charges,Implant Device,1051.96,34,,1051.96,percent of total billed charges,Implant Device,1051.96,34,,1051.96,percent of total billed charges,Implant Device,1051.96,34,,1051.96,percent of total billed charges,Implant Device,1531.53,,,1531.53,Other,110% of Medicare,1082.9,35,,1082.9,percent of total billed charges,Implant Device,1051.96,34,"Charges > $500, x 34%",1051.96,percent of total billed charges,Implant Device,1082.9,35,,1082.9,percent of total billed charges,Implant Device,1082.9,35,,1082.9,percent of total billed charges,Implant Device,1082.9,35,,1082.9,percent of total billed charges,Implant Device,1082.9,35,,1082.9,percent of total billed charges,Implant Device,1082.9,35,,1082.9,percent of total billed charges,Implant Device,1237.6,40,,1237.6,percent of total billed charges,Implant Device,1082.9,70,,1082.9,percent of total billed charges,All Other,1051.96,34,,1051.96,percent of total billed charges,Implant Device,1051.96,34,,1051.96,percent of total billed charges,Implant Device,1082.9,35,,1082.9,percent of total billed charges,Implant Device,1082.9,35,,1082.9,percent of total billed charges,Implant Device,1082.9,35,,1082.9,percent of total billed charges,Implant Device,1082.9,35,,1082.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1051.96,34,"If Charge > 2,000, then 34 percent",1051.96,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2289.57,
AXONICS 50050 URETHERAL BULKING SYSTEM,L8606,HCPCS,,79012106,CDM,278,RC,,,both,,,3450,2553.01,,,2553.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1552.5,45,,1552.5,percent of total billed charges,Critical Access Hospital RCC factor,1173,34,,1173,percent of total billed charges,Implant Device,1173,34,,1173,percent of total billed charges,Implant Device,1173,34,,1173,percent of total billed charges,Implant Device,1173,34,,1173,percent of total billed charges,Implant Device,1173,34,,1173,percent of total billed charges,Implant Device,1707.75,,,1707.75,Other,110% of Medicare,1207.5,35,,1207.5,percent of total billed charges,Implant Device,1173,34,"Charges > $500, x 34%",1173,percent of total billed charges,Implant Device,1207.5,35,,1207.5,percent of total billed charges,Implant Device,1207.5,35,,1207.5,percent of total billed charges,Implant Device,1207.5,35,,1207.5,percent of total billed charges,Implant Device,1207.5,35,,1207.5,percent of total billed charges,Implant Device,1207.5,35,,1207.5,percent of total billed charges,Implant Device,1380,40,,1380,percent of total billed charges,Implant Device,1207.5,70,,1207.5,percent of total billed charges,All Other,1173,34,,1173,percent of total billed charges,Implant Device,1173,34,,1173,percent of total billed charges,Implant Device,1207.5,35,,1207.5,percent of total billed charges,Implant Device,1207.5,35,,1207.5,percent of total billed charges,Implant Device,1207.5,35,,1207.5,percent of total billed charges,Implant Device,1207.5,35,,1207.5,percent of total billed charges,Implant Device,976.07,,,976.07,Other,100% of Medicaid,976.07,,,976.07,Other,100% of Medicaid,976.07,,,976.07,Other,100% of Medicaid,976.07,,,976.07,Other,100% of Medicaid,2196.15,,,2196.15,Other,225% of Medicaid,1493.38,,,1493.38,Other,153% of Medicaid,2196.15,,,2196.15,Other,225% of Medicaid,1366.49,,,1366.49,Other,140% of Medicaid,1173,34,"If Charge > 2,000, then 34 percent",1173,percent of total billed charges,Implants,2537.77,,,2537.77,Other,260% of Medicaid,3162.45,,,3162.45,Other,324% of Medicaid,2098.54,,,2098.54,Other,215% of Medicaid,2098.54,,,2098.54,Other,215% of Medicaid,1220.08,,,1220.08,Other,125% of Medicaid,976.07,3162.45,
STRYKER 3102-1910 EVANS WEDGE 10X22X20MM,C1762,HCPCS,,79012107,CDM,278,RC,,,both,,,8151,6031.76,,,6031.76,Other,150% of Medicare + 9.63% HCRA Surcharge,3667.95,45,,3667.95,percent of total billed charges,Critical Access Hospital RCC factor,2771.34,34,,2771.34,percent of total billed charges,Implant Device,2771.34,34,,2771.34,percent of total billed charges,Implant Device,2771.34,34,,2771.34,percent of total billed charges,Implant Device,2771.34,34,,2771.34,percent of total billed charges,Implant Device,2771.34,34,,2771.34,percent of total billed charges,Implant Device,4034.75,,,4034.75,Other,110% of Medicare,2852.85,35,,2852.85,percent of total billed charges,Implant Device,2771.34,34,"Charges > $500, x 34%",2771.34,percent of total billed charges,Implant Device,2852.85,35,,2852.85,percent of total billed charges,Implant Device,2852.85,35,,2852.85,percent of total billed charges,Implant Device,2852.85,35,,2852.85,percent of total billed charges,Implant Device,2852.85,35,,2852.85,percent of total billed charges,Implant Device,2852.85,35,,2852.85,percent of total billed charges,Implant Device,3260.4,40,,3260.4,percent of total billed charges,Implant Device,2852.85,70,,2852.85,percent of total billed charges,All Other,2771.34,34,,2771.34,percent of total billed charges,Implant Device,2771.34,34,,2771.34,percent of total billed charges,Implant Device,2852.85,35,,2852.85,percent of total billed charges,Implant Device,2852.85,35,,2852.85,percent of total billed charges,Implant Device,2852.85,35,,2852.85,percent of total billed charges,Implant Device,2852.85,35,,2852.85,percent of total billed charges,Implant Device,976.07,,,976.07,Other,100% of Medicaid,976.07,,,976.07,Other,100% of Medicaid,976.07,,,976.07,Other,100% of Medicaid,976.07,,,976.07,Other,100% of Medicaid,2196.16,,,2196.16,Other,225% of Medicaid,1493.39,,,1493.39,Other,153% of Medicaid,2196.16,,,2196.16,Other,225% of Medicaid,1366.5,,,1366.5,Other,140% of Medicaid,2771.34,34,"If Charge > 2,000, then 34 percent",2771.34,percent of total billed charges,Implants,2537.78,,,2537.78,Other,260% of Medicaid,3162.47,,,3162.47,Other,324% of Medicaid,2098.55,,,2098.55,Other,215% of Medicaid,2098.55,,,2098.55,Other,215% of Medicaid,1220.09,,,1220.09,Other,125% of Medicaid,976.07,6031.76,
STRYKER EZXP15-15-15 STAPLE 15X15X15MM,C1713,HCPCS,,79012108,CDM,278,RC,,,both,,,4274,3162.77,,,3162.77,Other,150% of Medicare + 9.63% HCRA Surcharge,1923.3,45,,1923.3,percent of total billed charges,Critical Access Hospital RCC factor,1453.16,34,,1453.16,percent of total billed charges,Implant Device,1453.16,34,,1453.16,percent of total billed charges,Implant Device,1453.16,34,,1453.16,percent of total billed charges,Implant Device,1453.16,34,,1453.16,percent of total billed charges,Implant Device,1453.16,34,,1453.16,percent of total billed charges,Implant Device,2115.63,,,2115.63,Other,110% of Medicare,1495.9,35,,1495.9,percent of total billed charges,Implant Device,1453.16,34,"Charges > $500, x 34%",1453.16,percent of total billed charges,Implant Device,1495.9,35,,1495.9,percent of total billed charges,Implant Device,1495.9,35,,1495.9,percent of total billed charges,Implant Device,1495.9,35,,1495.9,percent of total billed charges,Implant Device,1495.9,35,,1495.9,percent of total billed charges,Implant Device,1495.9,35,,1495.9,percent of total billed charges,Implant Device,1709.6,40,,1709.6,percent of total billed charges,Implant Device,1495.9,70,,1495.9,percent of total billed charges,All Other,1453.16,34,,1453.16,percent of total billed charges,Implant Device,1453.16,34,,1453.16,percent of total billed charges,Implant Device,1495.9,35,,1495.9,percent of total billed charges,Implant Device,1495.9,35,,1495.9,percent of total billed charges,Implant Device,1495.9,35,,1495.9,percent of total billed charges,Implant Device,1495.9,35,,1495.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1453.16,34,"If Charge > 2,000, then 34 percent",1453.16,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3162.77,
WRIGHT FFNS1515 STAPLE 15X15MM,C1713,HCPCS,,79012109,CDM,278,RC,,,both,,,7517,5562.6,,,5562.6,Other,150% of Medicare + 9.63% HCRA Surcharge,3382.65,45,,3382.65,percent of total billed charges,Critical Access Hospital RCC factor,2555.78,34,,2555.78,percent of total billed charges,Implant Device,2555.78,34,,2555.78,percent of total billed charges,Implant Device,2555.78,34,,2555.78,percent of total billed charges,Implant Device,2555.78,34,,2555.78,percent of total billed charges,Implant Device,2555.78,34,,2555.78,percent of total billed charges,Implant Device,3720.92,,,3720.92,Other,110% of Medicare,2630.95,35,,2630.95,percent of total billed charges,Implant Device,2555.78,34,"Charges > $500, x 34%",2555.78,percent of total billed charges,Implant Device,2630.95,35,,2630.95,percent of total billed charges,Implant Device,2630.95,35,,2630.95,percent of total billed charges,Implant Device,2630.95,35,,2630.95,percent of total billed charges,Implant Device,2630.95,35,,2630.95,percent of total billed charges,Implant Device,2630.95,35,,2630.95,percent of total billed charges,Implant Device,3006.8,40,,3006.8,percent of total billed charges,Implant Device,2630.95,70,,2630.95,percent of total billed charges,All Other,2555.78,34,,2555.78,percent of total billed charges,Implant Device,2555.78,34,,2555.78,percent of total billed charges,Implant Device,2630.95,35,,2630.95,percent of total billed charges,Implant Device,2630.95,35,,2630.95,percent of total billed charges,Implant Device,2630.95,35,,2630.95,percent of total billed charges,Implant Device,2630.95,35,,2630.95,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2555.78,34,"If Charge > 2,000, then 34 percent",2555.78,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5562.6,
WRIGHT 58820024 FIXATION PIN 1.4MM,C1713,HCPCS,,79012110,CDM,278,RC,,,both,,,341,252.34,,,252.34,Other,150% of Medicare + 9.63% HCRA Surcharge,153.45,45,,153.45,percent of total billed charges,Critical Access Hospital RCC factor,115.94,34,,115.94,percent of total billed charges,Implant Device,115.94,34,,115.94,percent of total billed charges,Implant Device,115.94,34,,115.94,percent of total billed charges,Implant Device,115.94,34,,115.94,percent of total billed charges,Implant Device,115.94,34,,115.94,percent of total billed charges,Implant Device,168.8,,,168.8,Other,110% of Medicare,119.35,35,,119.35,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,119.35,35,,119.35,percent of total billed charges,Implant Device,119.35,35,,119.35,percent of total billed charges,Implant Device,119.35,35,,119.35,percent of total billed charges,Implant Device,119.35,35,,119.35,percent of total billed charges,Implant Device,119.35,35,,119.35,percent of total billed charges,Implant Device,136.4,40,,136.4,percent of total billed charges,Implant Device,119.35,70,,119.35,percent of total billed charges,All Other,115.94,34,,115.94,percent of total billed charges,Implant Device,115.94,34,,115.94,percent of total billed charges,Implant Device,119.35,35,,119.35,percent of total billed charges,Implant Device,119.35,35,,119.35,percent of total billed charges,Implant Device,119.35,35,,119.35,percent of total billed charges,Implant Device,119.35,35,,119.35,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,252.34,
J&J 04.013.544S FEMORAL NAIL 11MM,C1889,HCPCS,,79012111,CDM,278,RC,,,both,,,3375,2497.51,,,2497.51,Other,150% of Medicare + 9.63% HCRA Surcharge,1518.75,45,,1518.75,percent of total billed charges,Critical Access Hospital RCC factor,1147.5,34,,1147.5,percent of total billed charges,Implant Device,1147.5,34,,1147.5,percent of total billed charges,Implant Device,1147.5,34,,1147.5,percent of total billed charges,Implant Device,1147.5,34,,1147.5,percent of total billed charges,Implant Device,1147.5,34,,1147.5,percent of total billed charges,Implant Device,1670.63,,,1670.63,Other,110% of Medicare,1181.25,35,,1181.25,percent of total billed charges,Implant Device,1147.5,34,"Charges > $500, x 34%",1147.5,percent of total billed charges,Implant Device,1181.25,35,,1181.25,percent of total billed charges,Implant Device,1181.25,35,,1181.25,percent of total billed charges,Implant Device,1181.25,35,,1181.25,percent of total billed charges,Implant Device,1181.25,35,,1181.25,percent of total billed charges,Implant Device,1181.25,35,,1181.25,percent of total billed charges,Implant Device,1350,40,,1350,percent of total billed charges,Implant Device,1181.25,70,,1181.25,percent of total billed charges,All Other,1147.5,34,,1147.5,percent of total billed charges,Implant Device,1147.5,34,,1147.5,percent of total billed charges,Implant Device,1181.25,35,,1181.25,percent of total billed charges,Implant Device,1181.25,35,,1181.25,percent of total billed charges,Implant Device,1181.25,35,,1181.25,percent of total billed charges,Implant Device,1181.25,35,,1181.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1147.5,34,"If Charge > 2,000, then 34 percent",1147.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2497.51,
J&J 42.231.255 LOCKING SCREW 5X55MM,C1713,HCPCS,,79012112,CDM,278,RC,,,both,,,513,379.62,,,379.62,Other,150% of Medicare + 9.63% HCRA Surcharge,230.85,45,,230.85,percent of total billed charges,Critical Access Hospital RCC factor,174.42,34,,174.42,percent of total billed charges,Implant Device,174.42,34,,174.42,percent of total billed charges,Implant Device,174.42,34,,174.42,percent of total billed charges,Implant Device,174.42,34,,174.42,percent of total billed charges,Implant Device,174.42,34,,174.42,percent of total billed charges,Implant Device,253.94,,,253.94,Other,110% of Medicare,179.55,35,,179.55,percent of total billed charges,Implant Device,174.42,34,"Charges > $500, x 34%",174.42,percent of total billed charges,Implant Device,179.55,35,,179.55,percent of total billed charges,Implant Device,179.55,35,,179.55,percent of total billed charges,Implant Device,179.55,35,,179.55,percent of total billed charges,Implant Device,179.55,35,,179.55,percent of total billed charges,Implant Device,179.55,35,,179.55,percent of total billed charges,Implant Device,205.2,40,,205.2,percent of total billed charges,Implant Device,179.55,70,,179.55,percent of total billed charges,All Other,174.42,34,,174.42,percent of total billed charges,Implant Device,174.42,34,,174.42,percent of total billed charges,Implant Device,179.55,35,,179.55,percent of total billed charges,Implant Device,179.55,35,,179.55,percent of total billed charges,Implant Device,179.55,35,,179.55,percent of total billed charges,Implant Device,179.55,35,,179.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,379.62,
J&J 42.231.260 SELF TAPPING SCREW 5X60MM,C1713,HCPCS,,79012113,CDM,278,RC,,,both,,,513,379.62,,,379.62,Other,150% of Medicare + 9.63% HCRA Surcharge,230.85,45,,230.85,percent of total billed charges,Critical Access Hospital RCC factor,174.42,34,,174.42,percent of total billed charges,Implant Device,174.42,34,,174.42,percent of total billed charges,Implant Device,174.42,34,,174.42,percent of total billed charges,Implant Device,174.42,34,,174.42,percent of total billed charges,Implant Device,174.42,34,,174.42,percent of total billed charges,Implant Device,253.94,,,253.94,Other,110% of Medicare,179.55,35,,179.55,percent of total billed charges,Implant Device,174.42,34,"Charges > $500, x 34%",174.42,percent of total billed charges,Implant Device,179.55,35,,179.55,percent of total billed charges,Implant Device,179.55,35,,179.55,percent of total billed charges,Implant Device,179.55,35,,179.55,percent of total billed charges,Implant Device,179.55,35,,179.55,percent of total billed charges,Implant Device,179.55,35,,179.55,percent of total billed charges,Implant Device,205.2,40,,205.2,percent of total billed charges,Implant Device,179.55,70,,179.55,percent of total billed charges,All Other,174.42,34,,174.42,percent of total billed charges,Implant Device,174.42,34,,174.42,percent of total billed charges,Implant Device,179.55,35,,179.55,percent of total billed charges,Implant Device,179.55,35,,179.55,percent of total billed charges,Implant Device,179.55,35,,179.55,percent of total billed charges,Implant Device,179.55,35,,179.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,379.62,
J&J 02.124.413 CURVED PLT 12H 266MM LT,C1713,HCPCS,,79012114,CDM,278,RC,,,both,,,4685,3466.91,,,3466.91,Other,150% of Medicare + 9.63% HCRA Surcharge,2108.25,45,,2108.25,percent of total billed charges,Critical Access Hospital RCC factor,1592.9,34,,1592.9,percent of total billed charges,Implant Device,1592.9,34,,1592.9,percent of total billed charges,Implant Device,1592.9,34,,1592.9,percent of total billed charges,Implant Device,1592.9,34,,1592.9,percent of total billed charges,Implant Device,1592.9,34,,1592.9,percent of total billed charges,Implant Device,2319.08,,,2319.08,Other,110% of Medicare,1639.75,35,,1639.75,percent of total billed charges,Implant Device,1592.9,34,"Charges > $500, x 34%",1592.9,percent of total billed charges,Implant Device,1639.75,35,,1639.75,percent of total billed charges,Implant Device,1639.75,35,,1639.75,percent of total billed charges,Implant Device,1639.75,35,,1639.75,percent of total billed charges,Implant Device,1639.75,35,,1639.75,percent of total billed charges,Implant Device,1639.75,35,,1639.75,percent of total billed charges,Implant Device,1874,40,,1874,percent of total billed charges,Implant Device,1639.75,70,,1639.75,percent of total billed charges,All Other,1592.9,34,,1592.9,percent of total billed charges,Implant Device,1592.9,34,,1592.9,percent of total billed charges,Implant Device,1639.75,35,,1639.75,percent of total billed charges,Implant Device,1639.75,35,,1639.75,percent of total billed charges,Implant Device,1639.75,35,,1639.75,percent of total billed charges,Implant Device,1639.75,35,,1639.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1592.9,34,"If Charge > 2,000, then 34 percent",1592.9,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3466.91,
J&J 208.437 CANNULATED SCREW 6.5X75MM,C1713,HCPCS,,79012115,CDM,278,RC,,,both,,,683,505.42,,,505.42,Other,150% of Medicare + 9.63% HCRA Surcharge,307.35,45,,307.35,percent of total billed charges,Critical Access Hospital RCC factor,232.22,34,,232.22,percent of total billed charges,Implant Device,232.22,34,,232.22,percent of total billed charges,Implant Device,232.22,34,,232.22,percent of total billed charges,Implant Device,232.22,34,,232.22,percent of total billed charges,Implant Device,232.22,34,,232.22,percent of total billed charges,Implant Device,338.09,,,338.09,Other,110% of Medicare,239.05,35,,239.05,percent of total billed charges,Implant Device,232.22,34,"Charges > $500, x 34%",232.22,percent of total billed charges,Implant Device,239.05,35,,239.05,percent of total billed charges,Implant Device,239.05,35,,239.05,percent of total billed charges,Implant Device,239.05,35,,239.05,percent of total billed charges,Implant Device,239.05,35,,239.05,percent of total billed charges,Implant Device,239.05,35,,239.05,percent of total billed charges,Implant Device,273.2,40,,273.2,percent of total billed charges,Implant Device,239.05,70,,239.05,percent of total billed charges,All Other,232.22,34,,232.22,percent of total billed charges,Implant Device,232.22,34,,232.22,percent of total billed charges,Implant Device,239.05,35,,239.05,percent of total billed charges,Implant Device,239.05,35,,239.05,percent of total billed charges,Implant Device,239.05,35,,239.05,percent of total billed charges,Implant Device,239.05,35,,239.05,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,505.42,
STRYKER 2341-0934S TIBIAL NAIL 9X345MM,C1889,HCPCS,,79012116,CDM,278,RC,,,both,,,6378,4719.74,,,4719.74,Other,150% of Medicare + 9.63% HCRA Surcharge,2870.1,45,,2870.1,percent of total billed charges,Critical Access Hospital RCC factor,2168.52,34,,2168.52,percent of total billed charges,Implant Device,2168.52,34,,2168.52,percent of total billed charges,Implant Device,2168.52,34,,2168.52,percent of total billed charges,Implant Device,2168.52,34,,2168.52,percent of total billed charges,Implant Device,2168.52,34,,2168.52,percent of total billed charges,Implant Device,3157.11,,,3157.11,Other,110% of Medicare,2232.3,35,,2232.3,percent of total billed charges,Implant Device,2168.52,34,"Charges > $500, x 34%",2168.52,percent of total billed charges,Implant Device,2232.3,35,,2232.3,percent of total billed charges,Implant Device,2232.3,35,,2232.3,percent of total billed charges,Implant Device,2232.3,35,,2232.3,percent of total billed charges,Implant Device,2232.3,35,,2232.3,percent of total billed charges,Implant Device,2232.3,35,,2232.3,percent of total billed charges,Implant Device,2551.2,40,,2551.2,percent of total billed charges,Implant Device,2232.3,70,,2232.3,percent of total billed charges,All Other,2168.52,34,,2168.52,percent of total billed charges,Implant Device,2168.52,34,,2168.52,percent of total billed charges,Implant Device,2232.3,35,,2232.3,percent of total billed charges,Implant Device,2232.3,35,,2232.3,percent of total billed charges,Implant Device,2232.3,35,,2232.3,percent of total billed charges,Implant Device,2232.3,35,,2232.3,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2168.52,34,"If Charge > 2,000, then 34 percent",2168.52,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4719.74,
ZIMMER 42-5121-009-13 ARTIC SURF LT 13MM,C1776,HCPCS,,79012117,CDM,278,RC,,,both,,,4116,3045.85,,,3045.85,Other,150% of Medicare + 9.63% HCRA Surcharge,1852.2,45,,1852.2,percent of total billed charges,Critical Access Hospital RCC factor,1399.44,34,,1399.44,percent of total billed charges,Implant Device,1399.44,34,,1399.44,percent of total billed charges,Implant Device,1399.44,34,,1399.44,percent of total billed charges,Implant Device,1399.44,34,,1399.44,percent of total billed charges,Implant Device,1399.44,34,,1399.44,percent of total billed charges,Implant Device,2037.42,,,2037.42,Other,110% of Medicare,1440.6,35,,1440.6,percent of total billed charges,Implant Device,1399.44,34,"Charges > $500, x 34%",1399.44,percent of total billed charges,Implant Device,1440.6,35,,1440.6,percent of total billed charges,Implant Device,1440.6,35,,1440.6,percent of total billed charges,Implant Device,1440.6,35,,1440.6,percent of total billed charges,Implant Device,1440.6,35,,1440.6,percent of total billed charges,Implant Device,1440.6,35,,1440.6,percent of total billed charges,Implant Device,1646.4,40,,1646.4,percent of total billed charges,Implant Device,1440.6,70,,1440.6,percent of total billed charges,All Other,1399.44,34,,1399.44,percent of total billed charges,Implant Device,1399.44,34,,1399.44,percent of total billed charges,Implant Device,1440.6,35,,1440.6,percent of total billed charges,Implant Device,1440.6,35,,1440.6,percent of total billed charges,Implant Device,1440.6,35,,1440.6,percent of total billed charges,Implant Device,1440.6,35,,1440.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1399.44,34,"If Charge > 2,000, then 34 percent",1399.44,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3045.85,
ZIMMER 42-5026-066-01 FEMUR LEFT SIZE 9,C1776,HCPCS,,79012118,CDM,278,RC,,,both,,,10200,7548.03,,,7548.03,Other,150% of Medicare + 9.63% HCRA Surcharge,4590,45,,4590,percent of total billed charges,Critical Access Hospital RCC factor,3468,34,,3468,percent of total billed charges,Implant Device,3468,34,,3468,percent of total billed charges,Implant Device,3468,34,,3468,percent of total billed charges,Implant Device,3468,34,,3468,percent of total billed charges,Implant Device,3468,34,,3468,percent of total billed charges,Implant Device,5049,,,5049,Other,110% of Medicare,3570,35,,3570,percent of total billed charges,Implant Device,3468,34,"Charges > $500, x 34%",3468,percent of total billed charges,Implant Device,3570,35,,3570,percent of total billed charges,Implant Device,3570,35,,3570,percent of total billed charges,Implant Device,3570,35,,3570,percent of total billed charges,Implant Device,3570,35,,3570,percent of total billed charges,Implant Device,3570,35,,3570,percent of total billed charges,Implant Device,4080,40,,4080,percent of total billed charges,Implant Device,3570,70,,3570,percent of total billed charges,All Other,3468,34,,3468,percent of total billed charges,Implant Device,3468,34,,3468,percent of total billed charges,Implant Device,3570,35,,3570,percent of total billed charges,Implant Device,3570,35,,3570,percent of total billed charges,Implant Device,3570,35,,3570,percent of total billed charges,Implant Device,3570,35,,3570,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3468,34,"If Charge > 2,000, then 34 percent",3468,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,7548.03,
ZIMMER 42-5121-009-12 ARTIC SURF LT 12MM,C1776,HCPCS,,79012119,CDM,278,RC,,,both,,,3648,2699.53,,,2699.53,Other,150% of Medicare + 9.63% HCRA Surcharge,1641.6,45,,1641.6,percent of total billed charges,Critical Access Hospital RCC factor,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1805.76,,,1805.76,Other,110% of Medicare,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1240.32,34,"Charges > $500, x 34%",1240.32,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1459.2,40,,1459.2,percent of total billed charges,Implant Device,1276.8,70,,1276.8,percent of total billed charges,All Other,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1240.32,34,"If Charge > 2,000, then 34 percent",1240.32,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2699.53,
J&J 1504-10-109 FEMORAL COMPONENT SIZE 9,C1776,HCPCS,,79012120,CDM,278,RC,,,both,,,4800,3552.01,,,3552.01,Other,150% of Medicare + 9.63% HCRA Surcharge,2160,45,,2160,percent of total billed charges,Critical Access Hospital RCC factor,1632,34,,1632,percent of total billed charges,Implant Device,1632,34,,1632,percent of total billed charges,Implant Device,1632,34,,1632,percent of total billed charges,Implant Device,1632,34,,1632,percent of total billed charges,Implant Device,1632,34,,1632,percent of total billed charges,Implant Device,2376,,,2376,Other,110% of Medicare,1680,35,,1680,percent of total billed charges,Implant Device,1632,34,"Charges > $500, x 34%",1632,percent of total billed charges,Implant Device,1680,35,,1680,percent of total billed charges,Implant Device,1680,35,,1680,percent of total billed charges,Implant Device,1680,35,,1680,percent of total billed charges,Implant Device,1680,35,,1680,percent of total billed charges,Implant Device,1680,35,,1680,percent of total billed charges,Implant Device,1920,40,,1920,percent of total billed charges,Implant Device,1680,70,,1680,percent of total billed charges,All Other,1632,34,,1632,percent of total billed charges,Implant Device,1632,34,,1632,percent of total billed charges,Implant Device,1680,35,,1680,percent of total billed charges,Implant Device,1680,35,,1680,percent of total billed charges,Implant Device,1680,35,,1680,percent of total billed charges,Implant Device,1680,35,,1680,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1632,34,"If Charge > 2,000, then 34 percent",1632,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3552.01,
J&J 1516-50-905 TIBIAL INSERT SIZE 9 5MM,C1776,HCPCS,,79012121,CDM,278,RC,,,both,,,4200,3108.01,,,3108.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1890,45,,1890,percent of total billed charges,Critical Access Hospital RCC factor,1428,34,,1428,percent of total billed charges,Implant Device,1428,34,,1428,percent of total billed charges,Implant Device,1428,34,,1428,percent of total billed charges,Implant Device,1428,34,,1428,percent of total billed charges,Implant Device,1428,34,,1428,percent of total billed charges,Implant Device,2079,,,2079,Other,110% of Medicare,1470,35,,1470,percent of total billed charges,Implant Device,1428,34,"Charges > $500, x 34%",1428,percent of total billed charges,Implant Device,1470,35,,1470,percent of total billed charges,Implant Device,1470,35,,1470,percent of total billed charges,Implant Device,1470,35,,1470,percent of total billed charges,Implant Device,1470,35,,1470,percent of total billed charges,Implant Device,1470,35,,1470,percent of total billed charges,Implant Device,1680,40,,1680,percent of total billed charges,Implant Device,1470,70,,1470,percent of total billed charges,All Other,1428,34,,1428,percent of total billed charges,Implant Device,1428,34,,1428,percent of total billed charges,Implant Device,1470,35,,1470,percent of total billed charges,Implant Device,1470,35,,1470,percent of total billed charges,Implant Device,1470,35,,1470,percent of total billed charges,Implant Device,1470,35,,1470,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1428,34,"If Charge > 2,000, then 34 percent",1428,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3108.01,
J&J 1506-80-008 TIBIAL BASE SIZE 8,C1776,HCPCS,,79012122,CDM,278,RC,,,both,,,3900,2886.01,,,2886.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1755,45,,1755,percent of total billed charges,Critical Access Hospital RCC factor,1326,34,,1326,percent of total billed charges,Implant Device,1326,34,,1326,percent of total billed charges,Implant Device,1326,34,,1326,percent of total billed charges,Implant Device,1326,34,,1326,percent of total billed charges,Implant Device,1326,34,,1326,percent of total billed charges,Implant Device,1930.5,,,1930.5,Other,110% of Medicare,1365,35,,1365,percent of total billed charges,Implant Device,1326,34,"Charges > $500, x 34%",1326,percent of total billed charges,Implant Device,1365,35,,1365,percent of total billed charges,Implant Device,1365,35,,1365,percent of total billed charges,Implant Device,1365,35,,1365,percent of total billed charges,Implant Device,1365,35,,1365,percent of total billed charges,Implant Device,1365,35,,1365,percent of total billed charges,Implant Device,1560,40,,1560,percent of total billed charges,Implant Device,1365,70,,1365,percent of total billed charges,All Other,1326,34,,1326,percent of total billed charges,Implant Device,1326,34,,1326,percent of total billed charges,Implant Device,1365,35,,1365,percent of total billed charges,Implant Device,1365,35,,1365,percent of total billed charges,Implant Device,1365,35,,1365,percent of total billed charges,Implant Device,1365,35,,1365,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1326,34,"If Charge > 2,000, then 34 percent",1326,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2886.01,
STRYKER 657615 LOCKING SCREW 2.0X15MM,C1713,HCPCS,,79012123,CDM,278,RC,,,both,,,443,327.82,,,327.82,Other,150% of Medicare + 9.63% HCRA Surcharge,199.35,45,,199.35,percent of total billed charges,Critical Access Hospital RCC factor,150.62,34,,150.62,percent of total billed charges,Implant Device,150.62,34,,150.62,percent of total billed charges,Implant Device,150.62,34,,150.62,percent of total billed charges,Implant Device,150.62,34,,150.62,percent of total billed charges,Implant Device,150.62,34,,150.62,percent of total billed charges,Implant Device,219.29,,,219.29,Other,110% of Medicare,155.05,35,,155.05,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,155.05,35,,155.05,percent of total billed charges,Implant Device,155.05,35,,155.05,percent of total billed charges,Implant Device,155.05,35,,155.05,percent of total billed charges,Implant Device,155.05,35,,155.05,percent of total billed charges,Implant Device,155.05,35,,155.05,percent of total billed charges,Implant Device,177.2,40,,177.2,percent of total billed charges,Implant Device,155.05,70,,155.05,percent of total billed charges,All Other,150.62,34,,150.62,percent of total billed charges,Implant Device,150.62,34,,150.62,percent of total billed charges,Implant Device,155.05,35,,155.05,percent of total billed charges,Implant Device,155.05,35,,155.05,percent of total billed charges,Implant Device,155.05,35,,155.05,percent of total billed charges,Implant Device,155.05,35,,155.05,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,327.82,
J&J 1506-60-008 TIBIAL BASE SIZE 8,C1776,HCPCS,,79012124,CDM,278,RC,,,both,,,15558,11512.96,,,11512.96,Other,150% of Medicare + 9.63% HCRA Surcharge,7001.1,45,,7001.1,percent of total billed charges,Critical Access Hospital RCC factor,5289.72,34,,5289.72,percent of total billed charges,Implant Device,5289.72,34,,5289.72,percent of total billed charges,Implant Device,5289.72,34,,5289.72,percent of total billed charges,Implant Device,5289.72,34,,5289.72,percent of total billed charges,Implant Device,5289.72,34,,5289.72,percent of total billed charges,Implant Device,7701.21,,,7701.21,Other,110% of Medicare,5445.3,35,,5445.3,percent of total billed charges,Implant Device,5289.72,34,"Charges > $500, x 34%",5289.72,percent of total billed charges,Implant Device,5445.3,35,,5445.3,percent of total billed charges,Implant Device,5445.3,35,,5445.3,percent of total billed charges,Implant Device,5445.3,35,,5445.3,percent of total billed charges,Implant Device,5445.3,35,,5445.3,percent of total billed charges,Implant Device,5445.3,35,,5445.3,percent of total billed charges,Implant Device,6223.2,40,,6223.2,percent of total billed charges,Implant Device,5445.3,70,,5445.3,percent of total billed charges,All Other,5289.72,34,,5289.72,percent of total billed charges,Implant Device,5289.72,34,,5289.72,percent of total billed charges,Implant Device,5445.3,35,,5445.3,percent of total billed charges,Implant Device,5445.3,35,,5445.3,percent of total billed charges,Implant Device,5445.3,35,,5445.3,percent of total billed charges,Implant Device,5445.3,35,,5445.3,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,5289.72,34,"If Charge > 2,000, then 34 percent",5289.72,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,11512.96,
J&J 1512-14-030 STEM 14X30MM,C1776,HCPCS,,79012125,CDM,278,RC,,,both,,,3315,2453.11,,,2453.11,Other,150% of Medicare + 9.63% HCRA Surcharge,1491.75,45,,1491.75,percent of total billed charges,Critical Access Hospital RCC factor,1127.1,34,,1127.1,percent of total billed charges,Implant Device,1127.1,34,,1127.1,percent of total billed charges,Implant Device,1127.1,34,,1127.1,percent of total billed charges,Implant Device,1127.1,34,,1127.1,percent of total billed charges,Implant Device,1127.1,34,,1127.1,percent of total billed charges,Implant Device,1640.93,,,1640.93,Other,110% of Medicare,1160.25,35,,1160.25,percent of total billed charges,Implant Device,1127.1,34,"Charges > $500, x 34%",1127.1,percent of total billed charges,Implant Device,1160.25,35,,1160.25,percent of total billed charges,Implant Device,1160.25,35,,1160.25,percent of total billed charges,Implant Device,1160.25,35,,1160.25,percent of total billed charges,Implant Device,1160.25,35,,1160.25,percent of total billed charges,Implant Device,1160.25,35,,1160.25,percent of total billed charges,Implant Device,1326,40,,1326,percent of total billed charges,Implant Device,1160.25,70,,1160.25,percent of total billed charges,All Other,1127.1,34,,1127.1,percent of total billed charges,Implant Device,1127.1,34,,1127.1,percent of total billed charges,Implant Device,1160.25,35,,1160.25,percent of total billed charges,Implant Device,1160.25,35,,1160.25,percent of total billed charges,Implant Device,1160.25,35,,1160.25,percent of total billed charges,Implant Device,1160.25,35,,1160.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1127.1,34,"If Charge > 2,000, then 34 percent",1127.1,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2453.11,
IN2BONES P40 ST614 COMPRESSION INSERT,C1776,HCPCS,,79012127,CDM,278,RC,,,both,,,825,610.5,,,610.5,Other,150% of Medicare + 9.63% HCRA Surcharge,371.25,45,,371.25,percent of total billed charges,Critical Access Hospital RCC factor,280.5,34,,280.5,percent of total billed charges,Implant Device,280.5,34,,280.5,percent of total billed charges,Implant Device,280.5,34,,280.5,percent of total billed charges,Implant Device,280.5,34,,280.5,percent of total billed charges,Implant Device,280.5,34,,280.5,percent of total billed charges,Implant Device,408.38,,,408.38,Other,110% of Medicare,288.75,35,,288.75,percent of total billed charges,Implant Device,280.5,34,"Charges > $500, x 34%",280.5,percent of total billed charges,Implant Device,288.75,35,,288.75,percent of total billed charges,Implant Device,288.75,35,,288.75,percent of total billed charges,Implant Device,288.75,35,,288.75,percent of total billed charges,Implant Device,288.75,35,,288.75,percent of total billed charges,Implant Device,288.75,35,,288.75,percent of total billed charges,Implant Device,330,40,,330,percent of total billed charges,Implant Device,288.75,70,,288.75,percent of total billed charges,All Other,280.5,34,,280.5,percent of total billed charges,Implant Device,280.5,34,,280.5,percent of total billed charges,Implant Device,288.75,35,,288.75,percent of total billed charges,Implant Device,288.75,35,,288.75,percent of total billed charges,Implant Device,288.75,35,,288.75,percent of total billed charges,Implant Device,288.75,35,,288.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,610.5,
IN2BONES V35 ST424 COLINK SCREW 3.5X24MM,C1713,HCPCS,,79012128,CDM,278,RC,,,both,,,870,643.8,,,643.8,Other,150% of Medicare + 9.63% HCRA Surcharge,391.5,45,,391.5,percent of total billed charges,Critical Access Hospital RCC factor,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,430.65,,,430.65,Other,110% of Medicare,304.5,35,,304.5,percent of total billed charges,Implant Device,295.8,34,"Charges > $500, x 34%",295.8,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,348,40,,348,percent of total billed charges,Implant Device,304.5,70,,304.5,percent of total billed charges,All Other,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,643.8,
WRIGHT 876P0040 MINI IGNITE 2 POWER MIX,C1734,HCPCS,,79012129,CDM,278,RC,,,both,,,8001,5920.76,,,5920.76,Other,150% of Medicare + 9.63% HCRA Surcharge,3600.45,45,,3600.45,percent of total billed charges,Critical Access Hospital RCC factor,2720.34,34,,2720.34,percent of total billed charges,Implant Device,2720.34,34,,2720.34,percent of total billed charges,Implant Device,2720.34,34,,2720.34,percent of total billed charges,Implant Device,2720.34,34,,2720.34,percent of total billed charges,Implant Device,2720.34,34,,2720.34,percent of total billed charges,Implant Device,3960.5,,,3960.5,Other,110% of Medicare,2800.35,35,,2800.35,percent of total billed charges,Implant Device,2720.34,34,"Charges > $500, x 34%",2720.34,percent of total billed charges,Implant Device,2800.35,35,,2800.35,percent of total billed charges,Implant Device,2800.35,35,,2800.35,percent of total billed charges,Implant Device,2800.35,35,,2800.35,percent of total billed charges,Implant Device,2800.35,35,,2800.35,percent of total billed charges,Implant Device,2800.35,35,,2800.35,percent of total billed charges,Implant Device,3200.4,40,,3200.4,percent of total billed charges,Implant Device,2800.35,70,,2800.35,percent of total billed charges,All Other,2720.34,34,,2720.34,percent of total billed charges,Implant Device,2720.34,34,,2720.34,percent of total billed charges,Implant Device,2800.35,35,,2800.35,percent of total billed charges,Implant Device,2800.35,35,,2800.35,percent of total billed charges,Implant Device,2800.35,35,,2800.35,percent of total billed charges,Implant Device,2800.35,35,,2800.35,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2720.34,34,"If Charge > 2,000, then 34 percent",2720.34,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5920.76,
STRYKER 41517000 ANTERIOR TIBIALIS GRAFT,C1762,HCPCS,,79012130,CDM,278,RC,,,both,,,3600,2664.01,,,2664.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1620,45,,1620,percent of total billed charges,Critical Access Hospital RCC factor,1224,34,,1224,percent of total billed charges,Implant Device,1224,34,,1224,percent of total billed charges,Implant Device,1224,34,,1224,percent of total billed charges,Implant Device,1224,34,,1224,percent of total billed charges,Implant Device,1224,34,,1224,percent of total billed charges,Implant Device,1782,,,1782,Other,110% of Medicare,1260,35,,1260,percent of total billed charges,Implant Device,1224,34,"Charges > $500, x 34%",1224,percent of total billed charges,Implant Device,1260,35,,1260,percent of total billed charges,Implant Device,1260,35,,1260,percent of total billed charges,Implant Device,1260,35,,1260,percent of total billed charges,Implant Device,1260,35,,1260,percent of total billed charges,Implant Device,1260,35,,1260,percent of total billed charges,Implant Device,1440,40,,1440,percent of total billed charges,Implant Device,1260,70,,1260,percent of total billed charges,All Other,1224,34,,1224,percent of total billed charges,Implant Device,1224,34,,1224,percent of total billed charges,Implant Device,1260,35,,1260,percent of total billed charges,Implant Device,1260,35,,1260,percent of total billed charges,Implant Device,1260,35,,1260,percent of total billed charges,Implant Device,1260,35,,1260,percent of total billed charges,Implant Device,976.07,,,976.07,Other,100% of Medicaid,976.07,,,976.07,Other,100% of Medicaid,976.07,,,976.07,Other,100% of Medicaid,976.07,,,976.07,Other,100% of Medicaid,2196.16,,,2196.16,Other,225% of Medicaid,1493.39,,,1493.39,Other,153% of Medicaid,2196.16,,,2196.16,Other,225% of Medicaid,1366.5,,,1366.5,Other,140% of Medicaid,1224,34,"If Charge > 2,000, then 34 percent",1224,percent of total billed charges,Implants,2537.78,,,2537.78,Other,260% of Medicaid,3162.47,,,3162.47,Other,324% of Medicaid,2098.55,,,2098.55,Other,215% of Medicaid,2098.55,,,2098.55,Other,215% of Medicaid,1220.09,,,1220.09,Other,125% of Medicaid,976.07,3162.47,
ZIMMER 42-5026-066-02 FEMUR RIGHT SIZE 9,C1776,HCPCS,,79012131,CDM,278,RC,,,both,,,10200,7548.03,,,7548.03,Other,150% of Medicare + 9.63% HCRA Surcharge,4590,45,,4590,percent of total billed charges,Critical Access Hospital RCC factor,3468,34,,3468,percent of total billed charges,Implant Device,3468,34,,3468,percent of total billed charges,Implant Device,3468,34,,3468,percent of total billed charges,Implant Device,3468,34,,3468,percent of total billed charges,Implant Device,3468,34,,3468,percent of total billed charges,Implant Device,5049,,,5049,Other,110% of Medicare,3570,35,,3570,percent of total billed charges,Implant Device,3468,34,"Charges > $500, x 34%",3468,percent of total billed charges,Implant Device,3570,35,,3570,percent of total billed charges,Implant Device,3570,35,,3570,percent of total billed charges,Implant Device,3570,35,,3570,percent of total billed charges,Implant Device,3570,35,,3570,percent of total billed charges,Implant Device,3570,35,,3570,percent of total billed charges,Implant Device,4080,40,,4080,percent of total billed charges,Implant Device,3570,70,,3570,percent of total billed charges,All Other,3468,34,,3468,percent of total billed charges,Implant Device,3468,34,,3468,percent of total billed charges,Implant Device,3570,35,,3570,percent of total billed charges,Implant Device,3570,35,,3570,percent of total billed charges,Implant Device,3570,35,,3570,percent of total billed charges,Implant Device,3570,35,,3570,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3468,34,"If Charge > 2,000, then 34 percent",3468,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,7548.03,
ZIMMER 42-5221-008-14 ARTIC SURF RT 14MM,C1776,HCPCS,,79012132,CDM,278,RC,,,both,,,3648,2699.53,,,2699.53,Other,150% of Medicare + 9.63% HCRA Surcharge,1641.6,45,,1641.6,percent of total billed charges,Critical Access Hospital RCC factor,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1805.76,,,1805.76,Other,110% of Medicare,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1240.32,34,"Charges > $500, x 34%",1240.32,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1459.2,40,,1459.2,percent of total billed charges,Implant Device,1276.8,70,,1276.8,percent of total billed charges,All Other,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1240.32,34,"If Charge > 2,000, then 34 percent",1240.32,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2699.53,
ZIMMER 42-5320-071-02 TIBIA STEM 5 DEG,C1776,HCPCS,,79012133,CDM,278,RC,,,both,,,4433,3280.43,,,3280.43,Other,150% of Medicare + 9.63% HCRA Surcharge,1994.85,45,,1994.85,percent of total billed charges,Critical Access Hospital RCC factor,1507.22,34,,1507.22,percent of total billed charges,Implant Device,1507.22,34,,1507.22,percent of total billed charges,Implant Device,1507.22,34,,1507.22,percent of total billed charges,Implant Device,1507.22,34,,1507.22,percent of total billed charges,Implant Device,1507.22,34,,1507.22,percent of total billed charges,Implant Device,2194.34,,,2194.34,Other,110% of Medicare,1551.55,35,,1551.55,percent of total billed charges,Implant Device,1507.22,34,"Charges > $500, x 34%",1507.22,percent of total billed charges,Implant Device,1551.55,35,,1551.55,percent of total billed charges,Implant Device,1551.55,35,,1551.55,percent of total billed charges,Implant Device,1551.55,35,,1551.55,percent of total billed charges,Implant Device,1551.55,35,,1551.55,percent of total billed charges,Implant Device,1551.55,35,,1551.55,percent of total billed charges,Implant Device,1773.2,40,,1773.2,percent of total billed charges,Implant Device,1551.55,70,,1551.55,percent of total billed charges,All Other,1507.22,34,,1507.22,percent of total billed charges,Implant Device,1507.22,34,,1507.22,percent of total billed charges,Implant Device,1551.55,35,,1551.55,percent of total billed charges,Implant Device,1551.55,35,,1551.55,percent of total billed charges,Implant Device,1551.55,35,,1551.55,percent of total billed charges,Implant Device,1551.55,35,,1551.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1507.22,34,"If Charge > 2,000, then 34 percent",1507.22,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3280.43,
ZIMMER 42-5221-003-12 ARTIC SURF RT 12MM,C1776,HCPCS,,79012134,CDM,278,RC,,,both,,,3648,2699.53,,,2699.53,Other,150% of Medicare + 9.63% HCRA Surcharge,1641.6,45,,1641.6,percent of total billed charges,Critical Access Hospital RCC factor,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1805.76,,,1805.76,Other,110% of Medicare,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1240.32,34,"Charges > $500, x 34%",1240.32,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1459.2,40,,1459.2,percent of total billed charges,Implant Device,1276.8,70,,1276.8,percent of total billed charges,All Other,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1240.32,34,"If Charge > 2,000, then 34 percent",1240.32,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2699.53,
ZIMMER 42-5026-058-02 FEMUR RIGHT SIZE 5,C1776,HCPCS,,79012135,CDM,278,RC,,,both,,,6300,4662.02,,,4662.02,Other,150% of Medicare + 9.63% HCRA Surcharge,2835,45,,2835,percent of total billed charges,Critical Access Hospital RCC factor,2142,34,,2142,percent of total billed charges,Implant Device,2142,34,,2142,percent of total billed charges,Implant Device,2142,34,,2142,percent of total billed charges,Implant Device,2142,34,,2142,percent of total billed charges,Implant Device,2142,34,,2142,percent of total billed charges,Implant Device,3118.5,,,3118.5,Other,110% of Medicare,2205,35,,2205,percent of total billed charges,Implant Device,2142,34,"Charges > $500, x 34%",2142,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2520,40,,2520,percent of total billed charges,Implant Device,2205,70,,2205,percent of total billed charges,All Other,2142,34,,2142,percent of total billed charges,Implant Device,2142,34,,2142,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2142,34,"If Charge > 2,000, then 34 percent",2142,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4662.02,
ZIMMER 42-5320-067-02 TIBIA STEM 5 DEG,C1776,HCPCS,,79012136,CDM,278,RC,,,both,,,2304,1704.97,,,1704.97,Other,150% of Medicare + 9.63% HCRA Surcharge,1036.8,45,,1036.8,percent of total billed charges,Critical Access Hospital RCC factor,783.36,34,,783.36,percent of total billed charges,Implant Device,783.36,34,,783.36,percent of total billed charges,Implant Device,783.36,34,,783.36,percent of total billed charges,Implant Device,783.36,34,,783.36,percent of total billed charges,Implant Device,783.36,34,,783.36,percent of total billed charges,Implant Device,1140.48,,,1140.48,Other,110% of Medicare,806.4,35,,806.4,percent of total billed charges,Implant Device,783.36,34,"Charges > $500, x 34%",783.36,percent of total billed charges,Implant Device,806.4,35,,806.4,percent of total billed charges,Implant Device,806.4,35,,806.4,percent of total billed charges,Implant Device,806.4,35,,806.4,percent of total billed charges,Implant Device,806.4,35,,806.4,percent of total billed charges,Implant Device,806.4,35,,806.4,percent of total billed charges,Implant Device,921.6,40,,921.6,percent of total billed charges,Implant Device,806.4,70,,806.4,percent of total billed charges,All Other,783.36,34,,783.36,percent of total billed charges,Implant Device,783.36,34,,783.36,percent of total billed charges,Implant Device,806.4,35,,806.4,percent of total billed charges,Implant Device,806.4,35,,806.4,percent of total billed charges,Implant Device,806.4,35,,806.4,percent of total billed charges,Implant Device,806.4,35,,806.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,783.36,34,"If Charge > 2,000, then 34 percent",783.36,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1704.97,
ZIMMER 00-8757-058-02 TRAB METL SHELL 58,C1776,HCPCS,,79012141,CDM,278,RC,,,both,,,3450,2553.01,,,2553.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1552.5,45,,1552.5,percent of total billed charges,Critical Access Hospital RCC factor,1173,34,,1173,percent of total billed charges,Implant Device,1173,34,,1173,percent of total billed charges,Implant Device,1173,34,,1173,percent of total billed charges,Implant Device,1173,34,,1173,percent of total billed charges,Implant Device,1173,34,,1173,percent of total billed charges,Implant Device,1707.75,,,1707.75,Other,110% of Medicare,1207.5,35,,1207.5,percent of total billed charges,Implant Device,1173,34,"Charges > $500, x 34%",1173,percent of total billed charges,Implant Device,1207.5,35,,1207.5,percent of total billed charges,Implant Device,1207.5,35,,1207.5,percent of total billed charges,Implant Device,1207.5,35,,1207.5,percent of total billed charges,Implant Device,1207.5,35,,1207.5,percent of total billed charges,Implant Device,1207.5,35,,1207.5,percent of total billed charges,Implant Device,1380,40,,1380,percent of total billed charges,Implant Device,1207.5,70,,1207.5,percent of total billed charges,All Other,1173,34,,1173,percent of total billed charges,Implant Device,1173,34,,1173,percent of total billed charges,Implant Device,1207.5,35,,1207.5,percent of total billed charges,Implant Device,1207.5,35,,1207.5,percent of total billed charges,Implant Device,1207.5,35,,1207.5,percent of total billed charges,Implant Device,1207.5,35,,1207.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1173,34,"If Charge > 2,000, then 34 percent",1173,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2553.01,
J&J 206.040 CANCELLOUS SCREW 4.0X40MM,C1713,HCPCS,,79012142,CDM,278,RC,,,both,,,47,34.78,,,34.78,Other,150% of Medicare + 9.63% HCRA Surcharge,21.15,45,,21.15,percent of total billed charges,Critical Access Hospital RCC factor,15.98,34,,15.98,percent of total billed charges,Implant Device,15.98,34,,15.98,percent of total billed charges,Implant Device,15.98,34,,15.98,percent of total billed charges,Implant Device,15.98,34,,15.98,percent of total billed charges,Implant Device,15.98,34,,15.98,percent of total billed charges,Implant Device,23.27,,,23.27,Other,110% of Medicare,16.45,35,,16.45,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,16.45,35,,16.45,percent of total billed charges,Implant Device,16.45,35,,16.45,percent of total billed charges,Implant Device,16.45,35,,16.45,percent of total billed charges,Implant Device,16.45,35,,16.45,percent of total billed charges,Implant Device,16.45,35,,16.45,percent of total billed charges,Implant Device,18.8,40,,18.8,percent of total billed charges,Implant Device,16.45,70,,16.45,percent of total billed charges,All Other,15.98,34,,15.98,percent of total billed charges,Implant Device,15.98,34,,15.98,percent of total billed charges,Implant Device,16.45,35,,16.45,percent of total billed charges,Implant Device,16.45,35,,16.45,percent of total billed charges,Implant Device,16.45,35,,16.45,percent of total billed charges,Implant Device,16.45,35,,16.45,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,34.78,
J&J 212.118 LOCKING SCREW 3.5X42MM,C1713,HCPCS,,79012143,CDM,278,RC,,,both,,,327,241.98,,,241.98,Other,150% of Medicare + 9.63% HCRA Surcharge,147.15,45,,147.15,percent of total billed charges,Critical Access Hospital RCC factor,111.18,34,,111.18,percent of total billed charges,Implant Device,111.18,34,,111.18,percent of total billed charges,Implant Device,111.18,34,,111.18,percent of total billed charges,Implant Device,111.18,34,,111.18,percent of total billed charges,Implant Device,111.18,34,,111.18,percent of total billed charges,Implant Device,161.87,,,161.87,Other,110% of Medicare,114.45,35,,114.45,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,114.45,35,,114.45,percent of total billed charges,Implant Device,114.45,35,,114.45,percent of total billed charges,Implant Device,114.45,35,,114.45,percent of total billed charges,Implant Device,114.45,35,,114.45,percent of total billed charges,Implant Device,114.45,35,,114.45,percent of total billed charges,Implant Device,130.8,40,,130.8,percent of total billed charges,Implant Device,114.45,70,,114.45,percent of total billed charges,All Other,111.18,34,,111.18,percent of total billed charges,Implant Device,111.18,34,,111.18,percent of total billed charges,Implant Device,114.45,35,,114.45,percent of total billed charges,Implant Device,114.45,35,,114.45,percent of total billed charges,Implant Device,114.45,35,,114.45,percent of total billed charges,Implant Device,114.45,35,,114.45,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,241.98,
J&J 212.112 LOCKING SCREW 3.5X32MM,C1713,HCPCS,,79012144,CDM,278,RC,,,both,,,327,241.98,,,241.98,Other,150% of Medicare + 9.63% HCRA Surcharge,147.15,45,,147.15,percent of total billed charges,Critical Access Hospital RCC factor,111.18,34,,111.18,percent of total billed charges,Implant Device,111.18,34,,111.18,percent of total billed charges,Implant Device,111.18,34,,111.18,percent of total billed charges,Implant Device,111.18,34,,111.18,percent of total billed charges,Implant Device,111.18,34,,111.18,percent of total billed charges,Implant Device,161.87,,,161.87,Other,110% of Medicare,114.45,35,,114.45,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,114.45,35,,114.45,percent of total billed charges,Implant Device,114.45,35,,114.45,percent of total billed charges,Implant Device,114.45,35,,114.45,percent of total billed charges,Implant Device,114.45,35,,114.45,percent of total billed charges,Implant Device,114.45,35,,114.45,percent of total billed charges,Implant Device,130.8,40,,130.8,percent of total billed charges,Implant Device,114.45,70,,114.45,percent of total billed charges,All Other,111.18,34,,111.18,percent of total billed charges,Implant Device,111.18,34,,111.18,percent of total billed charges,Implant Device,114.45,35,,114.45,percent of total billed charges,Implant Device,114.45,35,,114.45,percent of total billed charges,Implant Device,114.45,35,,114.45,percent of total billed charges,Implant Device,114.45,35,,114.45,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,241.98,
STRYKER 2341-0930S TIBIAL NAIL 9X300MM,C1713,HCPCS,,79012145,CDM,278,RC,,,both,,,6378,4719.74,,,4719.74,Other,150% of Medicare + 9.63% HCRA Surcharge,2870.1,45,,2870.1,percent of total billed charges,Critical Access Hospital RCC factor,2168.52,34,,2168.52,percent of total billed charges,Implant Device,2168.52,34,,2168.52,percent of total billed charges,Implant Device,2168.52,34,,2168.52,percent of total billed charges,Implant Device,2168.52,34,,2168.52,percent of total billed charges,Implant Device,2168.52,34,,2168.52,percent of total billed charges,Implant Device,3157.11,,,3157.11,Other,110% of Medicare,2232.3,35,,2232.3,percent of total billed charges,Implant Device,2168.52,34,"Charges > $500, x 34%",2168.52,percent of total billed charges,Implant Device,2232.3,35,,2232.3,percent of total billed charges,Implant Device,2232.3,35,,2232.3,percent of total billed charges,Implant Device,2232.3,35,,2232.3,percent of total billed charges,Implant Device,2232.3,35,,2232.3,percent of total billed charges,Implant Device,2232.3,35,,2232.3,percent of total billed charges,Implant Device,2551.2,40,,2551.2,percent of total billed charges,Implant Device,2232.3,70,,2232.3,percent of total billed charges,All Other,2168.52,34,,2168.52,percent of total billed charges,Implant Device,2168.52,34,,2168.52,percent of total billed charges,Implant Device,2232.3,35,,2232.3,percent of total billed charges,Implant Device,2232.3,35,,2232.3,percent of total billed charges,Implant Device,2232.3,35,,2232.3,percent of total billed charges,Implant Device,2232.3,35,,2232.3,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2168.52,34,"If Charge > 2,000, then 34 percent",2168.52,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4719.74,
ZIMMER 00-8018-028-14 FEMORAL HEAD +7 28,C1776,HCPCS,,79012146,CDM,278,RC,,,both,,,1152,852.48,,,852.48,Other,150% of Medicare + 9.63% HCRA Surcharge,518.4,45,,518.4,percent of total billed charges,Critical Access Hospital RCC factor,391.68,34,,391.68,percent of total billed charges,Implant Device,391.68,34,,391.68,percent of total billed charges,Implant Device,391.68,34,,391.68,percent of total billed charges,Implant Device,391.68,34,,391.68,percent of total billed charges,Implant Device,391.68,34,,391.68,percent of total billed charges,Implant Device,570.24,,,570.24,Other,110% of Medicare,403.2,35,,403.2,percent of total billed charges,Implant Device,391.68,34,"Charges > $500, x 34%",391.68,percent of total billed charges,Implant Device,403.2,35,,403.2,percent of total billed charges,Implant Device,403.2,35,,403.2,percent of total billed charges,Implant Device,403.2,35,,403.2,percent of total billed charges,Implant Device,403.2,35,,403.2,percent of total billed charges,Implant Device,403.2,35,,403.2,percent of total billed charges,Implant Device,460.8,40,,460.8,percent of total billed charges,Implant Device,403.2,70,,403.2,percent of total billed charges,All Other,391.68,34,,391.68,percent of total billed charges,Implant Device,391.68,34,,391.68,percent of total billed charges,Implant Device,403.2,35,,403.2,percent of total billed charges,Implant Device,403.2,35,,403.2,percent of total billed charges,Implant Device,403.2,35,,403.2,percent of total billed charges,Implant Device,403.2,35,,403.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,852.48,
STRYKER 3525-1420S NAIL KIT 11X420C450MM,C1889,HCPCS,,79012147,CDM,278,RC,,,both,,,5438,4024.13,,,4024.13,Other,150% of Medicare + 9.63% HCRA Surcharge,2447.1,45,,2447.1,percent of total billed charges,Critical Access Hospital RCC factor,1848.92,34,,1848.92,percent of total billed charges,Implant Device,1848.92,34,,1848.92,percent of total billed charges,Implant Device,1848.92,34,,1848.92,percent of total billed charges,Implant Device,1848.92,34,,1848.92,percent of total billed charges,Implant Device,1848.92,34,,1848.92,percent of total billed charges,Implant Device,2691.81,,,2691.81,Other,110% of Medicare,1903.3,35,,1903.3,percent of total billed charges,Implant Device,1848.92,34,"Charges > $500, x 34%",1848.92,percent of total billed charges,Implant Device,1903.3,35,,1903.3,percent of total billed charges,Implant Device,1903.3,35,,1903.3,percent of total billed charges,Implant Device,1903.3,35,,1903.3,percent of total billed charges,Implant Device,1903.3,35,,1903.3,percent of total billed charges,Implant Device,1903.3,35,,1903.3,percent of total billed charges,Implant Device,2175.2,40,,2175.2,percent of total billed charges,Implant Device,1903.3,70,,1903.3,percent of total billed charges,All Other,1848.92,34,,1848.92,percent of total billed charges,Implant Device,1848.92,34,,1848.92,percent of total billed charges,Implant Device,1903.3,35,,1903.3,percent of total billed charges,Implant Device,1903.3,35,,1903.3,percent of total billed charges,Implant Device,1903.3,35,,1903.3,percent of total billed charges,Implant Device,1903.3,35,,1903.3,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1848.92,34,"If Charge > 2,000, then 34 percent",1848.92,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4024.13,
STRYKER IC4032 HEADED SCREW 4.0X32MM,C1713,HCPCS,,79012148,CDM,278,RC,,,both,,,961,711.14,,,711.14,Other,150% of Medicare + 9.63% HCRA Surcharge,432.45,45,,432.45,percent of total billed charges,Critical Access Hospital RCC factor,326.74,34,,326.74,percent of total billed charges,Implant Device,326.74,34,,326.74,percent of total billed charges,Implant Device,326.74,34,,326.74,percent of total billed charges,Implant Device,326.74,34,,326.74,percent of total billed charges,Implant Device,326.74,34,,326.74,percent of total billed charges,Implant Device,475.7,,,475.7,Other,110% of Medicare,336.35,35,,336.35,percent of total billed charges,Implant Device,326.74,34,"Charges > $500, x 34%",326.74,percent of total billed charges,Implant Device,336.35,35,,336.35,percent of total billed charges,Implant Device,336.35,35,,336.35,percent of total billed charges,Implant Device,336.35,35,,336.35,percent of total billed charges,Implant Device,336.35,35,,336.35,percent of total billed charges,Implant Device,336.35,35,,336.35,percent of total billed charges,Implant Device,384.4,40,,384.4,percent of total billed charges,Implant Device,336.35,70,,336.35,percent of total billed charges,All Other,326.74,34,,326.74,percent of total billed charges,Implant Device,326.74,34,,326.74,percent of total billed charges,Implant Device,336.35,35,,336.35,percent of total billed charges,Implant Device,336.35,35,,336.35,percent of total billed charges,Implant Device,336.35,35,,336.35,percent of total billed charges,Implant Device,336.35,35,,336.35,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,711.14,
STRYKER IC4036 HEADED SCREW 4.0X36MM,C1713,HCPCS,,79012149,CDM,278,RC,,,both,,,493,364.82,,,364.82,Other,150% of Medicare + 9.63% HCRA Surcharge,221.85,45,,221.85,percent of total billed charges,Critical Access Hospital RCC factor,167.62,34,,167.62,percent of total billed charges,Implant Device,167.62,34,,167.62,percent of total billed charges,Implant Device,167.62,34,,167.62,percent of total billed charges,Implant Device,167.62,34,,167.62,percent of total billed charges,Implant Device,167.62,34,,167.62,percent of total billed charges,Implant Device,244.04,,,244.04,Other,110% of Medicare,172.55,35,,172.55,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,172.55,35,,172.55,percent of total billed charges,Implant Device,172.55,35,,172.55,percent of total billed charges,Implant Device,172.55,35,,172.55,percent of total billed charges,Implant Device,172.55,35,,172.55,percent of total billed charges,Implant Device,172.55,35,,172.55,percent of total billed charges,Implant Device,197.2,40,,197.2,percent of total billed charges,Implant Device,172.55,70,,172.55,percent of total billed charges,All Other,167.62,34,,167.62,percent of total billed charges,Implant Device,167.62,34,,167.62,percent of total billed charges,Implant Device,172.55,35,,172.55,percent of total billed charges,Implant Device,172.55,35,,172.55,percent of total billed charges,Implant Device,172.55,35,,172.55,percent of total billed charges,Implant Device,172.55,35,,172.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,364.82,
J&J 04.005.418S LOCKING SCREW 4.0X28MM,C1713,HCPCS,,79012150,CDM,278,RC,,,both,,,449,332.26,,,332.26,Other,150% of Medicare + 9.63% HCRA Surcharge,202.05,45,,202.05,percent of total billed charges,Critical Access Hospital RCC factor,152.66,34,,152.66,percent of total billed charges,Implant Device,152.66,34,,152.66,percent of total billed charges,Implant Device,152.66,34,,152.66,percent of total billed charges,Implant Device,152.66,34,,152.66,percent of total billed charges,Implant Device,152.66,34,,152.66,percent of total billed charges,Implant Device,222.26,,,222.26,Other,110% of Medicare,157.15,35,,157.15,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,157.15,35,,157.15,percent of total billed charges,Implant Device,157.15,35,,157.15,percent of total billed charges,Implant Device,157.15,35,,157.15,percent of total billed charges,Implant Device,157.15,35,,157.15,percent of total billed charges,Implant Device,157.15,35,,157.15,percent of total billed charges,Implant Device,179.6,40,,179.6,percent of total billed charges,Implant Device,157.15,70,,157.15,percent of total billed charges,All Other,152.66,34,,152.66,percent of total billed charges,Implant Device,152.66,34,,152.66,percent of total billed charges,Implant Device,157.15,35,,157.15,percent of total billed charges,Implant Device,157.15,35,,157.15,percent of total billed charges,Implant Device,157.15,35,,157.15,percent of total billed charges,Implant Device,157.15,35,,157.15,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,332.26,
J&J 202.870 CORTEX SCREW 2.7X10MM,C1713,HCPCS,,79012152,CDM,278,RC,,,both,,,88,65.12,,,65.12,Other,150% of Medicare + 9.63% HCRA Surcharge,39.6,45,,39.6,percent of total billed charges,Critical Access Hospital RCC factor,29.92,34,,29.92,percent of total billed charges,Implant Device,29.92,34,,29.92,percent of total billed charges,Implant Device,29.92,34,,29.92,percent of total billed charges,Implant Device,29.92,34,,29.92,percent of total billed charges,Implant Device,29.92,34,,29.92,percent of total billed charges,Implant Device,43.56,,,43.56,Other,110% of Medicare,30.8,35,,30.8,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,30.8,35,,30.8,percent of total billed charges,Implant Device,30.8,35,,30.8,percent of total billed charges,Implant Device,30.8,35,,30.8,percent of total billed charges,Implant Device,30.8,35,,30.8,percent of total billed charges,Implant Device,30.8,35,,30.8,percent of total billed charges,Implant Device,35.2,40,,35.2,percent of total billed charges,Implant Device,30.8,70,,30.8,percent of total billed charges,All Other,29.92,34,,29.92,percent of total billed charges,Implant Device,29.92,34,,29.92,percent of total billed charges,Implant Device,30.8,35,,30.8,percent of total billed charges,Implant Device,30.8,35,,30.8,percent of total billed charges,Implant Device,30.8,35,,30.8,percent of total billed charges,Implant Device,30.8,35,,30.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,65.12,
ZIMMER 574101040 FEMORAL STEM SIZE 4,C1776,HCPCS,,79012153,CDM,278,RC,,,both,,,6912,5114.9,,,5114.9,Other,150% of Medicare + 9.63% HCRA Surcharge,3110.4,45,,3110.4,percent of total billed charges,Critical Access Hospital RCC factor,2350.08,34,,2350.08,percent of total billed charges,Implant Device,2350.08,34,,2350.08,percent of total billed charges,Implant Device,2350.08,34,,2350.08,percent of total billed charges,Implant Device,2350.08,34,,2350.08,percent of total billed charges,Implant Device,2350.08,34,,2350.08,percent of total billed charges,Implant Device,3421.44,,,3421.44,Other,110% of Medicare,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2350.08,34,"Charges > $500, x 34%",2350.08,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2764.8,40,,2764.8,percent of total billed charges,Implant Device,2419.2,70,,2419.2,percent of total billed charges,All Other,2350.08,34,,2350.08,percent of total billed charges,Implant Device,2350.08,34,,2350.08,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2350.08,34,"If Charge > 2,000, then 34 percent",2350.08,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5114.9,
J&J 204.645 CORTEX SCREW 3.5X45MM,C1713,HCPCS,,79012155,CDM,278,RC,,,both,,,75,55.5,,,55.5,Other,150% of Medicare + 9.63% HCRA Surcharge,33.75,45,,33.75,percent of total billed charges,Critical Access Hospital RCC factor,25.5,34,,25.5,percent of total billed charges,Implant Device,25.5,34,,25.5,percent of total billed charges,Implant Device,25.5,34,,25.5,percent of total billed charges,Implant Device,25.5,34,,25.5,percent of total billed charges,Implant Device,25.5,34,,25.5,percent of total billed charges,Implant Device,37.13,,,37.13,Other,110% of Medicare,26.25,35,,26.25,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,26.25,35,,26.25,percent of total billed charges,Implant Device,26.25,35,,26.25,percent of total billed charges,Implant Device,26.25,35,,26.25,percent of total billed charges,Implant Device,26.25,35,,26.25,percent of total billed charges,Implant Device,26.25,35,,26.25,percent of total billed charges,Implant Device,30,40,,30,percent of total billed charges,Implant Device,26.25,70,,26.25,percent of total billed charges,All Other,25.5,34,,25.5,percent of total billed charges,Implant Device,25.5,34,,25.5,percent of total billed charges,Implant Device,26.25,35,,26.25,percent of total billed charges,Implant Device,26.25,35,,26.25,percent of total billed charges,Implant Device,26.25,35,,26.25,percent of total billed charges,Implant Device,26.25,35,,26.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,55.5,
J&J 245.908 PLATE 8 HOLES 3.5MM,C1713,HCPCS,,79012156,CDM,278,RC,,,both,,,1202,889.48,,,889.48,Other,150% of Medicare + 9.63% HCRA Surcharge,540.9,45,,540.9,percent of total billed charges,Critical Access Hospital RCC factor,408.68,34,,408.68,percent of total billed charges,Implant Device,408.68,34,,408.68,percent of total billed charges,Implant Device,408.68,34,,408.68,percent of total billed charges,Implant Device,408.68,34,,408.68,percent of total billed charges,Implant Device,408.68,34,,408.68,percent of total billed charges,Implant Device,594.99,,,594.99,Other,110% of Medicare,420.7,35,,420.7,percent of total billed charges,Implant Device,408.68,34,"Charges > $500, x 34%",408.68,percent of total billed charges,Implant Device,420.7,35,,420.7,percent of total billed charges,Implant Device,420.7,35,,420.7,percent of total billed charges,Implant Device,420.7,35,,420.7,percent of total billed charges,Implant Device,420.7,35,,420.7,percent of total billed charges,Implant Device,420.7,35,,420.7,percent of total billed charges,Implant Device,480.8,40,,480.8,percent of total billed charges,Implant Device,420.7,70,,420.7,percent of total billed charges,All Other,408.68,34,,408.68,percent of total billed charges,Implant Device,408.68,34,,408.68,percent of total billed charges,Implant Device,420.7,35,,420.7,percent of total billed charges,Implant Device,420.7,35,,420.7,percent of total billed charges,Implant Device,420.7,35,,420.7,percent of total billed charges,Implant Device,420.7,35,,420.7,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,889.48,
J&J 204.665 CORTEX SCREW 3.5X65MM,C1713,HCPCS,,79012157,CDM,278,RC,,,both,,,75,55.5,,,55.5,Other,150% of Medicare + 9.63% HCRA Surcharge,33.75,45,,33.75,percent of total billed charges,Critical Access Hospital RCC factor,25.5,34,,25.5,percent of total billed charges,Implant Device,25.5,34,,25.5,percent of total billed charges,Implant Device,25.5,34,,25.5,percent of total billed charges,Implant Device,25.5,34,,25.5,percent of total billed charges,Implant Device,25.5,34,,25.5,percent of total billed charges,Implant Device,37.13,,,37.13,Other,110% of Medicare,26.25,35,,26.25,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,26.25,35,,26.25,percent of total billed charges,Implant Device,26.25,35,,26.25,percent of total billed charges,Implant Device,26.25,35,,26.25,percent of total billed charges,Implant Device,26.25,35,,26.25,percent of total billed charges,Implant Device,26.25,35,,26.25,percent of total billed charges,Implant Device,30,40,,30,percent of total billed charges,Implant Device,26.25,70,,26.25,percent of total billed charges,All Other,25.5,34,,25.5,percent of total billed charges,Implant Device,25.5,34,,25.5,percent of total billed charges,Implant Device,26.25,35,,26.25,percent of total billed charges,Implant Device,26.25,35,,26.25,percent of total billed charges,Implant Device,26.25,35,,26.25,percent of total billed charges,Implant Device,26.25,35,,26.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,55.5,
J&J 204.650 CORTEX SCREW 3.5X50MM,C1713,HCPCS,,79012158,CDM,278,RC,,,both,,,75,55.5,,,55.5,Other,150% of Medicare + 9.63% HCRA Surcharge,33.75,45,,33.75,percent of total billed charges,Critical Access Hospital RCC factor,25.5,34,,25.5,percent of total billed charges,Implant Device,25.5,34,,25.5,percent of total billed charges,Implant Device,25.5,34,,25.5,percent of total billed charges,Implant Device,25.5,34,,25.5,percent of total billed charges,Implant Device,25.5,34,,25.5,percent of total billed charges,Implant Device,37.13,,,37.13,Other,110% of Medicare,26.25,35,,26.25,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,26.25,35,,26.25,percent of total billed charges,Implant Device,26.25,35,,26.25,percent of total billed charges,Implant Device,26.25,35,,26.25,percent of total billed charges,Implant Device,26.25,35,,26.25,percent of total billed charges,Implant Device,26.25,35,,26.25,percent of total billed charges,Implant Device,30,40,,30,percent of total billed charges,Implant Device,26.25,70,,26.25,percent of total billed charges,All Other,25.5,34,,25.5,percent of total billed charges,Implant Device,25.5,34,,25.5,percent of total billed charges,Implant Device,26.25,35,,26.25,percent of total billed charges,Implant Device,26.25,35,,26.25,percent of total billed charges,Implant Device,26.25,35,,26.25,percent of total billed charges,Implant Device,26.25,35,,26.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,55.5,
J&J 204.640 CORTEX SCREW 3.5X40MM,C1713,HCPCS,,79012159,CDM,278,RC,,,both,,,75,55.5,,,55.5,Other,150% of Medicare + 9.63% HCRA Surcharge,33.75,45,,33.75,percent of total billed charges,Critical Access Hospital RCC factor,25.5,34,,25.5,percent of total billed charges,Implant Device,25.5,34,,25.5,percent of total billed charges,Implant Device,25.5,34,,25.5,percent of total billed charges,Implant Device,25.5,34,,25.5,percent of total billed charges,Implant Device,25.5,34,,25.5,percent of total billed charges,Implant Device,37.13,,,37.13,Other,110% of Medicare,26.25,35,,26.25,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,26.25,35,,26.25,percent of total billed charges,Implant Device,26.25,35,,26.25,percent of total billed charges,Implant Device,26.25,35,,26.25,percent of total billed charges,Implant Device,26.25,35,,26.25,percent of total billed charges,Implant Device,26.25,35,,26.25,percent of total billed charges,Implant Device,30,40,,30,percent of total billed charges,Implant Device,26.25,70,,26.25,percent of total billed charges,All Other,25.5,34,,25.5,percent of total billed charges,Implant Device,25.5,34,,25.5,percent of total billed charges,Implant Device,26.25,35,,26.25,percent of total billed charges,Implant Device,26.25,35,,26.25,percent of total billed charges,Implant Device,26.25,35,,26.25,percent of total billed charges,Implant Device,26.25,35,,26.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,55.5,
STRYKER 627570 COMPRESSION PLT 10H 5MM,C1713,HCPCS,,79012164,CDM,278,RC,,,both,,,5824,4309.77,,,4309.77,Other,150% of Medicare + 9.63% HCRA Surcharge,2620.8,45,,2620.8,percent of total billed charges,Critical Access Hospital RCC factor,1980.16,34,,1980.16,percent of total billed charges,Implant Device,1980.16,34,,1980.16,percent of total billed charges,Implant Device,1980.16,34,,1980.16,percent of total billed charges,Implant Device,1980.16,34,,1980.16,percent of total billed charges,Implant Device,1980.16,34,,1980.16,percent of total billed charges,Implant Device,2882.88,,,2882.88,Other,110% of Medicare,2038.4,35,,2038.4,percent of total billed charges,Implant Device,1980.16,34,"Charges > $500, x 34%",1980.16,percent of total billed charges,Implant Device,2038.4,35,,2038.4,percent of total billed charges,Implant Device,2038.4,35,,2038.4,percent of total billed charges,Implant Device,2038.4,35,,2038.4,percent of total billed charges,Implant Device,2038.4,35,,2038.4,percent of total billed charges,Implant Device,2038.4,35,,2038.4,percent of total billed charges,Implant Device,2329.6,40,,2329.6,percent of total billed charges,Implant Device,2038.4,70,,2038.4,percent of total billed charges,All Other,1980.16,34,,1980.16,percent of total billed charges,Implant Device,1980.16,34,,1980.16,percent of total billed charges,Implant Device,2038.4,35,,2038.4,percent of total billed charges,Implant Device,2038.4,35,,2038.4,percent of total billed charges,Implant Device,2038.4,35,,2038.4,percent of total billed charges,Implant Device,2038.4,35,,2038.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1980.16,34,"If Charge > 2,000, then 34 percent",1980.16,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4309.77,
J&J 04.038.200S TFNA SCREW 100MM,C1713,HCPCS,,79012165,CDM,278,RC,,,both,,,1693,1252.82,,,1252.82,Other,150% of Medicare + 9.63% HCRA Surcharge,761.85,45,,761.85,percent of total billed charges,Critical Access Hospital RCC factor,575.62,34,,575.62,percent of total billed charges,Implant Device,575.62,34,,575.62,percent of total billed charges,Implant Device,575.62,34,,575.62,percent of total billed charges,Implant Device,575.62,34,,575.62,percent of total billed charges,Implant Device,575.62,34,,575.62,percent of total billed charges,Implant Device,838.04,,,838.04,Other,110% of Medicare,592.55,35,,592.55,percent of total billed charges,Implant Device,575.62,34,"Charges > $500, x 34%",575.62,percent of total billed charges,Implant Device,592.55,35,,592.55,percent of total billed charges,Implant Device,592.55,35,,592.55,percent of total billed charges,Implant Device,592.55,35,,592.55,percent of total billed charges,Implant Device,592.55,35,,592.55,percent of total billed charges,Implant Device,592.55,35,,592.55,percent of total billed charges,Implant Device,677.2,40,,677.2,percent of total billed charges,Implant Device,592.55,70,,592.55,percent of total billed charges,All Other,575.62,34,,575.62,percent of total billed charges,Implant Device,575.62,34,,575.62,percent of total billed charges,Implant Device,592.55,35,,592.55,percent of total billed charges,Implant Device,592.55,35,,592.55,percent of total billed charges,Implant Device,592.55,35,,592.55,percent of total billed charges,Implant Device,592.55,35,,592.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1252.82,
J&J 02.118.570 SELF TAP SCREW 2.7X70MM,C1713,HCPCS,,79012167,CDM,278,RC,,,both,,,125,92.5,,,92.5,Other,150% of Medicare + 9.63% HCRA Surcharge,56.25,45,,56.25,percent of total billed charges,Critical Access Hospital RCC factor,42.5,34,,42.5,percent of total billed charges,Implant Device,42.5,34,,42.5,percent of total billed charges,Implant Device,42.5,34,,42.5,percent of total billed charges,Implant Device,42.5,34,,42.5,percent of total billed charges,Implant Device,42.5,34,,42.5,percent of total billed charges,Implant Device,61.88,,,61.88,Other,110% of Medicare,43.75,35,,43.75,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,43.75,35,,43.75,percent of total billed charges,Implant Device,43.75,35,,43.75,percent of total billed charges,Implant Device,43.75,35,,43.75,percent of total billed charges,Implant Device,43.75,35,,43.75,percent of total billed charges,Implant Device,43.75,35,,43.75,percent of total billed charges,Implant Device,50,40,,50,percent of total billed charges,Implant Device,43.75,70,,43.75,percent of total billed charges,All Other,42.5,34,,42.5,percent of total billed charges,Implant Device,42.5,34,,42.5,percent of total billed charges,Implant Device,43.75,35,,43.75,percent of total billed charges,Implant Device,43.75,35,,43.75,percent of total billed charges,Implant Device,43.75,35,,43.75,percent of total billed charges,Implant Device,43.75,35,,43.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,92.5,
IN2BONES V35 ST426 COLINK SCREW 3.5X26MM,C1713,HCPCS,,79012169,CDM,278,RC,,,both,,,870,643.8,,,643.8,Other,150% of Medicare + 9.63% HCRA Surcharge,391.5,45,,391.5,percent of total billed charges,Critical Access Hospital RCC factor,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,430.65,,,430.65,Other,110% of Medicare,304.5,35,,304.5,percent of total billed charges,Implant Device,295.8,34,"Charges > $500, x 34%",295.8,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,348,40,,348,percent of total billed charges,Implant Device,304.5,70,,304.5,percent of total billed charges,All Other,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,643.8,
TORNIER SPS00GT TUBEROSITY PLATE 53MM,C1713,HCPCS,,79012172,CDM,278,RC,,,both,,,11085,8202.93,,,8202.93,Other,150% of Medicare + 9.63% HCRA Surcharge,4988.25,45,,4988.25,percent of total billed charges,Critical Access Hospital RCC factor,3768.9,34,,3768.9,percent of total billed charges,Implant Device,3768.9,34,,3768.9,percent of total billed charges,Implant Device,3768.9,34,,3768.9,percent of total billed charges,Implant Device,3768.9,34,,3768.9,percent of total billed charges,Implant Device,3768.9,34,,3768.9,percent of total billed charges,Implant Device,5487.08,,,5487.08,Other,110% of Medicare,3879.75,35,,3879.75,percent of total billed charges,Implant Device,3768.9,34,"Charges > $500, x 34%",3768.9,percent of total billed charges,Implant Device,3879.75,35,,3879.75,percent of total billed charges,Implant Device,3879.75,35,,3879.75,percent of total billed charges,Implant Device,3879.75,35,,3879.75,percent of total billed charges,Implant Device,3879.75,35,,3879.75,percent of total billed charges,Implant Device,3879.75,35,,3879.75,percent of total billed charges,Implant Device,4434,40,,4434,percent of total billed charges,Implant Device,3879.75,70,,3879.75,percent of total billed charges,All Other,3768.9,34,,3768.9,percent of total billed charges,Implant Device,3768.9,34,,3768.9,percent of total billed charges,Implant Device,3879.75,35,,3879.75,percent of total billed charges,Implant Device,3879.75,35,,3879.75,percent of total billed charges,Implant Device,3879.75,35,,3879.75,percent of total billed charges,Implant Device,3879.75,35,,3879.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3768.9,34,"If Charge > 2,000, then 34 percent",3768.9,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,8202.93,
TORNIER SPS224 NON LOCK SCREW 3.5X24MM,C1713,HCPCS,,79012173,CDM,278,RC,,,both,,,783,579.42,,,579.42,Other,150% of Medicare + 9.63% HCRA Surcharge,352.35,45,,352.35,percent of total billed charges,Critical Access Hospital RCC factor,266.22,34,,266.22,percent of total billed charges,Implant Device,266.22,34,,266.22,percent of total billed charges,Implant Device,266.22,34,,266.22,percent of total billed charges,Implant Device,266.22,34,,266.22,percent of total billed charges,Implant Device,266.22,34,,266.22,percent of total billed charges,Implant Device,387.59,,,387.59,Other,110% of Medicare,274.05,35,,274.05,percent of total billed charges,Implant Device,266.22,34,"Charges > $500, x 34%",266.22,percent of total billed charges,Implant Device,274.05,35,,274.05,percent of total billed charges,Implant Device,274.05,35,,274.05,percent of total billed charges,Implant Device,274.05,35,,274.05,percent of total billed charges,Implant Device,274.05,35,,274.05,percent of total billed charges,Implant Device,274.05,35,,274.05,percent of total billed charges,Implant Device,313.2,40,,313.2,percent of total billed charges,Implant Device,274.05,70,,274.05,percent of total billed charges,All Other,266.22,34,,266.22,percent of total billed charges,Implant Device,266.22,34,,266.22,percent of total billed charges,Implant Device,274.05,35,,274.05,percent of total billed charges,Implant Device,274.05,35,,274.05,percent of total billed charges,Implant Device,274.05,35,,274.05,percent of total billed charges,Implant Device,274.05,35,,274.05,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,579.42,
TORNIER SPS226 NON LOCK SCREW 3.5X26MM,C1713,HCPCS,,79012174,CDM,278,RC,,,both,,,783,579.42,,,579.42,Other,150% of Medicare + 9.63% HCRA Surcharge,352.35,45,,352.35,percent of total billed charges,Critical Access Hospital RCC factor,266.22,34,,266.22,percent of total billed charges,Implant Device,266.22,34,,266.22,percent of total billed charges,Implant Device,266.22,34,,266.22,percent of total billed charges,Implant Device,266.22,34,,266.22,percent of total billed charges,Implant Device,266.22,34,,266.22,percent of total billed charges,Implant Device,387.59,,,387.59,Other,110% of Medicare,274.05,35,,274.05,percent of total billed charges,Implant Device,266.22,34,"Charges > $500, x 34%",266.22,percent of total billed charges,Implant Device,274.05,35,,274.05,percent of total billed charges,Implant Device,274.05,35,,274.05,percent of total billed charges,Implant Device,274.05,35,,274.05,percent of total billed charges,Implant Device,274.05,35,,274.05,percent of total billed charges,Implant Device,274.05,35,,274.05,percent of total billed charges,Implant Device,313.2,40,,313.2,percent of total billed charges,Implant Device,274.05,70,,274.05,percent of total billed charges,All Other,266.22,34,,266.22,percent of total billed charges,Implant Device,266.22,34,,266.22,percent of total billed charges,Implant Device,274.05,35,,274.05,percent of total billed charges,Implant Device,274.05,35,,274.05,percent of total billed charges,Implant Device,274.05,35,,274.05,percent of total billed charges,Implant Device,274.05,35,,274.05,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,579.42,
TORNIER SPS428 LOCKING SCREW 3.5X28MM,C1713,HCPCS,,79012175,CDM,278,RC,,,both,,,783,579.42,,,579.42,Other,150% of Medicare + 9.63% HCRA Surcharge,352.35,45,,352.35,percent of total billed charges,Critical Access Hospital RCC factor,266.22,34,,266.22,percent of total billed charges,Implant Device,266.22,34,,266.22,percent of total billed charges,Implant Device,266.22,34,,266.22,percent of total billed charges,Implant Device,266.22,34,,266.22,percent of total billed charges,Implant Device,266.22,34,,266.22,percent of total billed charges,Implant Device,387.59,,,387.59,Other,110% of Medicare,274.05,35,,274.05,percent of total billed charges,Implant Device,266.22,34,"Charges > $500, x 34%",266.22,percent of total billed charges,Implant Device,274.05,35,,274.05,percent of total billed charges,Implant Device,274.05,35,,274.05,percent of total billed charges,Implant Device,274.05,35,,274.05,percent of total billed charges,Implant Device,274.05,35,,274.05,percent of total billed charges,Implant Device,274.05,35,,274.05,percent of total billed charges,Implant Device,313.2,40,,313.2,percent of total billed charges,Implant Device,274.05,70,,274.05,percent of total billed charges,All Other,266.22,34,,266.22,percent of total billed charges,Implant Device,266.22,34,,266.22,percent of total billed charges,Implant Device,274.05,35,,274.05,percent of total billed charges,Implant Device,274.05,35,,274.05,percent of total billed charges,Implant Device,274.05,35,,274.05,percent of total billed charges,Implant Device,274.05,35,,274.05,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,579.42,
TORNIER SPS430 LOCKING SCREW 3.5X30MM,C1713,HCPCS,,79012176,CDM,278,RC,,,both,,,783,579.42,,,579.42,Other,150% of Medicare + 9.63% HCRA Surcharge,352.35,45,,352.35,percent of total billed charges,Critical Access Hospital RCC factor,266.22,34,,266.22,percent of total billed charges,Implant Device,266.22,34,,266.22,percent of total billed charges,Implant Device,266.22,34,,266.22,percent of total billed charges,Implant Device,266.22,34,,266.22,percent of total billed charges,Implant Device,266.22,34,,266.22,percent of total billed charges,Implant Device,387.59,,,387.59,Other,110% of Medicare,274.05,35,,274.05,percent of total billed charges,Implant Device,266.22,34,"Charges > $500, x 34%",266.22,percent of total billed charges,Implant Device,274.05,35,,274.05,percent of total billed charges,Implant Device,274.05,35,,274.05,percent of total billed charges,Implant Device,274.05,35,,274.05,percent of total billed charges,Implant Device,274.05,35,,274.05,percent of total billed charges,Implant Device,274.05,35,,274.05,percent of total billed charges,Implant Device,313.2,40,,313.2,percent of total billed charges,Implant Device,274.05,70,,274.05,percent of total billed charges,All Other,266.22,34,,266.22,percent of total billed charges,Implant Device,266.22,34,,266.22,percent of total billed charges,Implant Device,274.05,35,,274.05,percent of total billed charges,Implant Device,274.05,35,,274.05,percent of total billed charges,Implant Device,274.05,35,,274.05,percent of total billed charges,Implant Device,274.05,35,,274.05,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,579.42,
TORNIER SPS434 LOCKING SCREW 3.5X34MM,C1713,HCPCS,,79012177,CDM,278,RC,,,both,,,783,579.42,,,579.42,Other,150% of Medicare + 9.63% HCRA Surcharge,352.35,45,,352.35,percent of total billed charges,Critical Access Hospital RCC factor,266.22,34,,266.22,percent of total billed charges,Implant Device,266.22,34,,266.22,percent of total billed charges,Implant Device,266.22,34,,266.22,percent of total billed charges,Implant Device,266.22,34,,266.22,percent of total billed charges,Implant Device,266.22,34,,266.22,percent of total billed charges,Implant Device,387.59,,,387.59,Other,110% of Medicare,274.05,35,,274.05,percent of total billed charges,Implant Device,266.22,34,"Charges > $500, x 34%",266.22,percent of total billed charges,Implant Device,274.05,35,,274.05,percent of total billed charges,Implant Device,274.05,35,,274.05,percent of total billed charges,Implant Device,274.05,35,,274.05,percent of total billed charges,Implant Device,274.05,35,,274.05,percent of total billed charges,Implant Device,274.05,35,,274.05,percent of total billed charges,Implant Device,313.2,40,,313.2,percent of total billed charges,Implant Device,274.05,70,,274.05,percent of total billed charges,All Other,266.22,34,,266.22,percent of total billed charges,Implant Device,266.22,34,,266.22,percent of total billed charges,Implant Device,274.05,35,,274.05,percent of total billed charges,Implant Device,274.05,35,,274.05,percent of total billed charges,Implant Device,274.05,35,,274.05,percent of total billed charges,Implant Device,274.05,35,,274.05,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,579.42,
STRYKER 2341-1134S TIBIAL NAIL 11X345MM,C1713,HCPCS,,79012178,CDM,278,RC,,,both,,,6378,4719.74,,,4719.74,Other,150% of Medicare + 9.63% HCRA Surcharge,2870.1,45,,2870.1,percent of total billed charges,Critical Access Hospital RCC factor,2168.52,34,,2168.52,percent of total billed charges,Implant Device,2168.52,34,,2168.52,percent of total billed charges,Implant Device,2168.52,34,,2168.52,percent of total billed charges,Implant Device,2168.52,34,,2168.52,percent of total billed charges,Implant Device,2168.52,34,,2168.52,percent of total billed charges,Implant Device,3157.11,,,3157.11,Other,110% of Medicare,2232.3,35,,2232.3,percent of total billed charges,Implant Device,2168.52,34,"Charges > $500, x 34%",2168.52,percent of total billed charges,Implant Device,2232.3,35,,2232.3,percent of total billed charges,Implant Device,2232.3,35,,2232.3,percent of total billed charges,Implant Device,2232.3,35,,2232.3,percent of total billed charges,Implant Device,2232.3,35,,2232.3,percent of total billed charges,Implant Device,2232.3,35,,2232.3,percent of total billed charges,Implant Device,2551.2,40,,2551.2,percent of total billed charges,Implant Device,2232.3,70,,2232.3,percent of total billed charges,All Other,2168.52,34,,2168.52,percent of total billed charges,Implant Device,2168.52,34,,2168.52,percent of total billed charges,Implant Device,2232.3,35,,2232.3,percent of total billed charges,Implant Device,2232.3,35,,2232.3,percent of total billed charges,Implant Device,2232.3,35,,2232.3,percent of total billed charges,Implant Device,2232.3,35,,2232.3,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2168.52,34,"If Charge > 2,000, then 34 percent",2168.52,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4719.74,
J&J 1504-11-108 FEMORAL COMP SZ 8 LT,C1776,HCPCS,,79012179,CDM,278,RC,,,both,,,6000,4440.02,,,4440.02,Other,150% of Medicare + 9.63% HCRA Surcharge,2700,45,,2700,percent of total billed charges,Critical Access Hospital RCC factor,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2970,,,2970,Other,110% of Medicare,2100,35,,2100,percent of total billed charges,Implant Device,2040,34,"Charges > $500, x 34%",2040,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2400,40,,2400,percent of total billed charges,Implant Device,2100,70,,2100,percent of total billed charges,All Other,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2040,34,"If Charge > 2,000, then 34 percent",2040,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4440.02,
J&J 1506-11-007 TIBIAL BASE SIZE 7,C1776,HCPCS,,79012180,CDM,278,RC,,,both,,,6300,4662.02,,,4662.02,Other,150% of Medicare + 9.63% HCRA Surcharge,2835,45,,2835,percent of total billed charges,Critical Access Hospital RCC factor,2142,34,,2142,percent of total billed charges,Implant Device,2142,34,,2142,percent of total billed charges,Implant Device,2142,34,,2142,percent of total billed charges,Implant Device,2142,34,,2142,percent of total billed charges,Implant Device,2142,34,,2142,percent of total billed charges,Implant Device,3118.5,,,3118.5,Other,110% of Medicare,2205,35,,2205,percent of total billed charges,Implant Device,2142,34,"Charges > $500, x 34%",2142,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2520,40,,2520,percent of total billed charges,Implant Device,2205,70,,2205,percent of total billed charges,All Other,2142,34,,2142,percent of total billed charges,Implant Device,2142,34,,2142,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2142,34,"If Charge > 2,000, then 34 percent",2142,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4662.02,
J&J 1504-11-106 FEMORAL COMPONENT SZ 6,C1776,HCPCS,,79012181,CDM,278,RC,,,both,,,6000,4440.02,,,4440.02,Other,150% of Medicare + 9.63% HCRA Surcharge,2700,45,,2700,percent of total billed charges,Critical Access Hospital RCC factor,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2970,,,2970,Other,110% of Medicare,2100,35,,2100,percent of total billed charges,Implant Device,2040,34,"Charges > $500, x 34%",2040,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2400,40,,2400,percent of total billed charges,Implant Device,2100,70,,2100,percent of total billed charges,All Other,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2040,34,"If Charge > 2,000, then 34 percent",2040,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4440.02,
IN2BONES S65 ST185 COMP SCREW 6.5X85MM,C1713,HCPCS,,79012182,CDM,278,RC,,,both,,,3105,2297.71,,,2297.71,Other,150% of Medicare + 9.63% HCRA Surcharge,1397.25,45,,1397.25,percent of total billed charges,Critical Access Hospital RCC factor,1055.7,34,,1055.7,percent of total billed charges,Implant Device,1055.7,34,,1055.7,percent of total billed charges,Implant Device,1055.7,34,,1055.7,percent of total billed charges,Implant Device,1055.7,34,,1055.7,percent of total billed charges,Implant Device,1055.7,34,,1055.7,percent of total billed charges,Implant Device,1536.98,,,1536.98,Other,110% of Medicare,1086.75,35,,1086.75,percent of total billed charges,Implant Device,1055.7,34,"Charges > $500, x 34%",1055.7,percent of total billed charges,Implant Device,1086.75,35,,1086.75,percent of total billed charges,Implant Device,1086.75,35,,1086.75,percent of total billed charges,Implant Device,1086.75,35,,1086.75,percent of total billed charges,Implant Device,1086.75,35,,1086.75,percent of total billed charges,Implant Device,1086.75,35,,1086.75,percent of total billed charges,Implant Device,1242,40,,1242,percent of total billed charges,Implant Device,1086.75,70,,1086.75,percent of total billed charges,All Other,1055.7,34,,1055.7,percent of total billed charges,Implant Device,1055.7,34,,1055.7,percent of total billed charges,Implant Device,1086.75,35,,1086.75,percent of total billed charges,Implant Device,1086.75,35,,1086.75,percent of total billed charges,Implant Device,1086.75,35,,1086.75,percent of total billed charges,Implant Device,1086.75,35,,1086.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1055.7,34,"If Charge > 2,000, then 34 percent",1055.7,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2297.71,
IN2BONES S65 ST190 COMP SCREW 6.5X90MM,C1713,HCPCS,,79012183,CDM,278,RC,,,both,,,3105,2297.71,,,2297.71,Other,150% of Medicare + 9.63% HCRA Surcharge,1397.25,45,,1397.25,percent of total billed charges,Critical Access Hospital RCC factor,1055.7,34,,1055.7,percent of total billed charges,Implant Device,1055.7,34,,1055.7,percent of total billed charges,Implant Device,1055.7,34,,1055.7,percent of total billed charges,Implant Device,1055.7,34,,1055.7,percent of total billed charges,Implant Device,1055.7,34,,1055.7,percent of total billed charges,Implant Device,1536.98,,,1536.98,Other,110% of Medicare,1086.75,35,,1086.75,percent of total billed charges,Implant Device,1055.7,34,"Charges > $500, x 34%",1055.7,percent of total billed charges,Implant Device,1086.75,35,,1086.75,percent of total billed charges,Implant Device,1086.75,35,,1086.75,percent of total billed charges,Implant Device,1086.75,35,,1086.75,percent of total billed charges,Implant Device,1086.75,35,,1086.75,percent of total billed charges,Implant Device,1086.75,35,,1086.75,percent of total billed charges,Implant Device,1242,40,,1242,percent of total billed charges,Implant Device,1086.75,70,,1086.75,percent of total billed charges,All Other,1055.7,34,,1055.7,percent of total billed charges,Implant Device,1055.7,34,,1055.7,percent of total billed charges,Implant Device,1086.75,35,,1086.75,percent of total billed charges,Implant Device,1086.75,35,,1086.75,percent of total billed charges,Implant Device,1086.75,35,,1086.75,percent of total billed charges,Implant Device,1086.75,35,,1086.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1055.7,34,"If Charge > 2,000, then 34 percent",1055.7,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2297.71,
BOST SCI M0068502120 ADVANTAGE FIT SYS,C1771,HCPCS,,79012184,CDM,278,RC,,,both,,,3668,2714.33,,,2714.33,Other,150% of Medicare + 9.63% HCRA Surcharge,1650.6,45,,1650.6,percent of total billed charges,Critical Access Hospital RCC factor,1247.12,34,,1247.12,percent of total billed charges,Implant Device,1247.12,34,,1247.12,percent of total billed charges,Implant Device,1247.12,34,,1247.12,percent of total billed charges,Implant Device,1247.12,34,,1247.12,percent of total billed charges,Implant Device,1247.12,34,,1247.12,percent of total billed charges,Implant Device,1815.66,,,1815.66,Other,110% of Medicare,1283.8,35,,1283.8,percent of total billed charges,Implant Device,1247.12,34,"Charges > $500, x 34%",1247.12,percent of total billed charges,Implant Device,1283.8,35,,1283.8,percent of total billed charges,Implant Device,1283.8,35,,1283.8,percent of total billed charges,Implant Device,1283.8,35,,1283.8,percent of total billed charges,Implant Device,1283.8,35,,1283.8,percent of total billed charges,Implant Device,1283.8,35,,1283.8,percent of total billed charges,Implant Device,1467.2,40,,1467.2,percent of total billed charges,Implant Device,1283.8,70,,1283.8,percent of total billed charges,All Other,1247.12,34,,1247.12,percent of total billed charges,Implant Device,1247.12,34,,1247.12,percent of total billed charges,Implant Device,1283.8,35,,1283.8,percent of total billed charges,Implant Device,1283.8,35,,1283.8,percent of total billed charges,Implant Device,1283.8,35,,1283.8,percent of total billed charges,Implant Device,1283.8,35,,1283.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1247.12,34,"If Charge > 2,000, then 34 percent",1247.12,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2714.33,
ZIMMER 574102020 FEMORAL STEM SIZE 2,C1776,HCPCS,,79012185,CDM,278,RC,,,both,,,6912,5114.9,,,5114.9,Other,150% of Medicare + 9.63% HCRA Surcharge,3110.4,45,,3110.4,percent of total billed charges,Critical Access Hospital RCC factor,2350.08,34,,2350.08,percent of total billed charges,Implant Device,2350.08,34,,2350.08,percent of total billed charges,Implant Device,2350.08,34,,2350.08,percent of total billed charges,Implant Device,2350.08,34,,2350.08,percent of total billed charges,Implant Device,2350.08,34,,2350.08,percent of total billed charges,Implant Device,3421.44,,,3421.44,Other,110% of Medicare,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2350.08,34,"Charges > $500, x 34%",2350.08,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2764.8,40,,2764.8,percent of total billed charges,Implant Device,2419.2,70,,2419.2,percent of total billed charges,All Other,2350.08,34,,2350.08,percent of total billed charges,Implant Device,2350.08,34,,2350.08,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2350.08,34,"If Charge > 2,000, then 34 percent",2350.08,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5114.9,
ZIMMER 30123606 LINER 36MM SIZE F,C1776,HCPCS,,79012186,CDM,278,RC,,,both,,,3456,2557.45,,,2557.45,Other,150% of Medicare + 9.63% HCRA Surcharge,1555.2,45,,1555.2,percent of total billed charges,Critical Access Hospital RCC factor,1175.04,34,,1175.04,percent of total billed charges,Implant Device,1175.04,34,,1175.04,percent of total billed charges,Implant Device,1175.04,34,,1175.04,percent of total billed charges,Implant Device,1175.04,34,,1175.04,percent of total billed charges,Implant Device,1175.04,34,,1175.04,percent of total billed charges,Implant Device,1710.72,,,1710.72,Other,110% of Medicare,1209.6,35,,1209.6,percent of total billed charges,Implant Device,1175.04,34,"Charges > $500, x 34%",1175.04,percent of total billed charges,Implant Device,1209.6,35,,1209.6,percent of total billed charges,Implant Device,1209.6,35,,1209.6,percent of total billed charges,Implant Device,1209.6,35,,1209.6,percent of total billed charges,Implant Device,1209.6,35,,1209.6,percent of total billed charges,Implant Device,1209.6,35,,1209.6,percent of total billed charges,Implant Device,1382.4,40,,1382.4,percent of total billed charges,Implant Device,1209.6,70,,1209.6,percent of total billed charges,All Other,1175.04,34,,1175.04,percent of total billed charges,Implant Device,1175.04,34,,1175.04,percent of total billed charges,Implant Device,1209.6,35,,1209.6,percent of total billed charges,Implant Device,1209.6,35,,1209.6,percent of total billed charges,Implant Device,1209.6,35,,1209.6,percent of total billed charges,Implant Device,1209.6,35,,1209.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1175.04,34,"If Charge > 2,000, then 34 percent",1175.04,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2557.45,
ZIMMER 8144-11-420 HIP FRACTURE NAIL,C1889,HCPCS,,79012187,CDM,278,RC,,,both,,,7290,5394.62,,,5394.62,Other,150% of Medicare + 9.63% HCRA Surcharge,3280.5,45,,3280.5,percent of total billed charges,Critical Access Hospital RCC factor,2478.6,34,,2478.6,percent of total billed charges,Implant Device,2478.6,34,,2478.6,percent of total billed charges,Implant Device,2478.6,34,,2478.6,percent of total billed charges,Implant Device,2478.6,34,,2478.6,percent of total billed charges,Implant Device,2478.6,34,,2478.6,percent of total billed charges,Implant Device,3608.55,,,3608.55,Other,110% of Medicare,2551.5,35,,2551.5,percent of total billed charges,Implant Device,2478.6,34,"Charges > $500, x 34%",2478.6,percent of total billed charges,Implant Device,2551.5,35,,2551.5,percent of total billed charges,Implant Device,2551.5,35,,2551.5,percent of total billed charges,Implant Device,2551.5,35,,2551.5,percent of total billed charges,Implant Device,2551.5,35,,2551.5,percent of total billed charges,Implant Device,2551.5,35,,2551.5,percent of total billed charges,Implant Device,2916,40,,2916,percent of total billed charges,Implant Device,2551.5,70,,2551.5,percent of total billed charges,All Other,2478.6,34,,2478.6,percent of total billed charges,Implant Device,2478.6,34,,2478.6,percent of total billed charges,Implant Device,2551.5,35,,2551.5,percent of total billed charges,Implant Device,2551.5,35,,2551.5,percent of total billed charges,Implant Device,2551.5,35,,2551.5,percent of total billed charges,Implant Device,2551.5,35,,2551.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2478.6,34,"If Charge > 2,000, then 34 percent",2478.6,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5394.62,
ZIMMER 8145-01-090 HIP SCREW 90MM,C1713,HCPCS,,79012188,CDM,278,RC,,,both,,,734,543.16,,,543.16,Other,150% of Medicare + 9.63% HCRA Surcharge,330.3,45,,330.3,percent of total billed charges,Critical Access Hospital RCC factor,249.56,34,,249.56,percent of total billed charges,Implant Device,249.56,34,,249.56,percent of total billed charges,Implant Device,249.56,34,,249.56,percent of total billed charges,Implant Device,249.56,34,,249.56,percent of total billed charges,Implant Device,249.56,34,,249.56,percent of total billed charges,Implant Device,363.33,,,363.33,Other,110% of Medicare,256.9,35,,256.9,percent of total billed charges,Implant Device,249.56,34,"Charges > $500, x 34%",249.56,percent of total billed charges,Implant Device,256.9,35,,256.9,percent of total billed charges,Implant Device,256.9,35,,256.9,percent of total billed charges,Implant Device,256.9,35,,256.9,percent of total billed charges,Implant Device,256.9,35,,256.9,percent of total billed charges,Implant Device,256.9,35,,256.9,percent of total billed charges,Implant Device,293.6,40,,293.6,percent of total billed charges,Implant Device,256.9,70,,256.9,percent of total billed charges,All Other,249.56,34,,249.56,percent of total billed charges,Implant Device,249.56,34,,249.56,percent of total billed charges,Implant Device,256.9,35,,256.9,percent of total billed charges,Implant Device,256.9,35,,256.9,percent of total billed charges,Implant Device,256.9,35,,256.9,percent of total billed charges,Implant Device,256.9,35,,256.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,543.16,
ZIMMER 8145-50-046 CORT BONE SCRW 5X46MM,C1713,HCPCS,,79012189,CDM,278,RC,,,both,,,594,439.56,,,439.56,Other,150% of Medicare + 9.63% HCRA Surcharge,267.3,45,,267.3,percent of total billed charges,Critical Access Hospital RCC factor,201.96,34,,201.96,percent of total billed charges,Implant Device,201.96,34,,201.96,percent of total billed charges,Implant Device,201.96,34,,201.96,percent of total billed charges,Implant Device,201.96,34,,201.96,percent of total billed charges,Implant Device,201.96,34,,201.96,percent of total billed charges,Implant Device,294.03,,,294.03,Other,110% of Medicare,207.9,35,,207.9,percent of total billed charges,Implant Device,201.96,34,"Charges > $500, x 34%",201.96,percent of total billed charges,Implant Device,207.9,35,,207.9,percent of total billed charges,Implant Device,207.9,35,,207.9,percent of total billed charges,Implant Device,207.9,35,,207.9,percent of total billed charges,Implant Device,207.9,35,,207.9,percent of total billed charges,Implant Device,207.9,35,,207.9,percent of total billed charges,Implant Device,237.6,40,,237.6,percent of total billed charges,Implant Device,207.9,70,,207.9,percent of total billed charges,All Other,201.96,34,,201.96,percent of total billed charges,Implant Device,201.96,34,,201.96,percent of total billed charges,Implant Device,207.9,35,,207.9,percent of total billed charges,Implant Device,207.9,35,,207.9,percent of total billed charges,Implant Device,207.9,35,,207.9,percent of total billed charges,Implant Device,207.9,35,,207.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,439.56,
ARTHREX A1360FT-BC MPFL RECONTRUC KIT,C1713,HCPCS,,79012191,CDM,278,RC,,,both,,,5985,4428.91,,,4428.91,Other,150% of Medicare + 9.63% HCRA Surcharge,2693.25,45,,2693.25,percent of total billed charges,Critical Access Hospital RCC factor,2034.9,34,,2034.9,percent of total billed charges,Implant Device,2034.9,34,,2034.9,percent of total billed charges,Implant Device,2034.9,34,,2034.9,percent of total billed charges,Implant Device,2034.9,34,,2034.9,percent of total billed charges,Implant Device,2034.9,34,,2034.9,percent of total billed charges,Implant Device,2962.58,,,2962.58,Other,110% of Medicare,2094.75,35,,2094.75,percent of total billed charges,Implant Device,2034.9,34,"Charges > $500, x 34%",2034.9,percent of total billed charges,Implant Device,2094.75,35,,2094.75,percent of total billed charges,Implant Device,2094.75,35,,2094.75,percent of total billed charges,Implant Device,2094.75,35,,2094.75,percent of total billed charges,Implant Device,2094.75,35,,2094.75,percent of total billed charges,Implant Device,2094.75,35,,2094.75,percent of total billed charges,Implant Device,2394,40,,2394,percent of total billed charges,Implant Device,2094.75,70,,2094.75,percent of total billed charges,All Other,2034.9,34,,2034.9,percent of total billed charges,Implant Device,2034.9,34,,2034.9,percent of total billed charges,Implant Device,2094.75,35,,2094.75,percent of total billed charges,Implant Device,2094.75,35,,2094.75,percent of total billed charges,Implant Device,2094.75,35,,2094.75,percent of total billed charges,Implant Device,2094.75,35,,2094.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2034.9,34,"If Charge > 2,000, then 34 percent",2034.9,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4428.91,
STRYKER 44317002 GRACILIS STRAND,C1762,HCPCS,,79012192,CDM,278,RC,,,both,,,2625,1942.51,,,1942.51,Other,150% of Medicare + 9.63% HCRA Surcharge,1181.25,45,,1181.25,percent of total billed charges,Critical Access Hospital RCC factor,892.5,34,,892.5,percent of total billed charges,Implant Device,892.5,34,,892.5,percent of total billed charges,Implant Device,892.5,34,,892.5,percent of total billed charges,Implant Device,892.5,34,,892.5,percent of total billed charges,Implant Device,892.5,34,,892.5,percent of total billed charges,Implant Device,1299.38,,,1299.38,Other,110% of Medicare,918.75,35,,918.75,percent of total billed charges,Implant Device,892.5,34,"Charges > $500, x 34%",892.5,percent of total billed charges,Implant Device,918.75,35,,918.75,percent of total billed charges,Implant Device,918.75,35,,918.75,percent of total billed charges,Implant Device,918.75,35,,918.75,percent of total billed charges,Implant Device,918.75,35,,918.75,percent of total billed charges,Implant Device,918.75,35,,918.75,percent of total billed charges,Implant Device,1050,40,,1050,percent of total billed charges,Implant Device,918.75,70,,918.75,percent of total billed charges,All Other,892.5,34,,892.5,percent of total billed charges,Implant Device,892.5,34,,892.5,percent of total billed charges,Implant Device,918.75,35,,918.75,percent of total billed charges,Implant Device,918.75,35,,918.75,percent of total billed charges,Implant Device,918.75,35,,918.75,percent of total billed charges,Implant Device,918.75,35,,918.75,percent of total billed charges,Implant Device,976.07,,,976.07,Other,100% of Medicaid,976.07,,,976.07,Other,100% of Medicaid,976.07,,,976.07,Other,100% of Medicaid,976.07,,,976.07,Other,100% of Medicaid,2196.16,,,2196.16,Other,225% of Medicaid,1493.39,,,1493.39,Other,153% of Medicaid,2196.16,,,2196.16,Other,225% of Medicaid,1366.5,,,1366.5,Other,140% of Medicaid,892.5,34,"If Charge > 2,000, then 34 percent",892.5,percent of total billed charges,Implants,2537.78,,,2537.78,Other,260% of Medicaid,3162.47,,,3162.47,Other,324% of Medicaid,2098.55,,,2098.55,Other,215% of Medicaid,2098.55,,,2098.55,Other,215% of Medicaid,1220.09,,,1220.09,Other,125% of Medicaid,892.5,3162.47,
ZIMMER 42-5221-007-12 ART SURFACE RT 12,C1776,HCPCS,,79012193,CDM,278,RC,,,both,,,3648,2699.53,,,2699.53,Other,150% of Medicare + 9.63% HCRA Surcharge,1641.6,45,,1641.6,percent of total billed charges,Critical Access Hospital RCC factor,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1805.76,,,1805.76,Other,110% of Medicare,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1240.32,34,"Charges > $500, x 34%",1240.32,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1459.2,40,,1459.2,percent of total billed charges,Implant Device,1276.8,70,,1276.8,percent of total billed charges,All Other,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1240.32,34,"If Charge > 2,000, then 34 percent",1240.32,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2699.53,
ZIMMER 42-5026-062-02 FEMUR RIGHT SIZE 7,C1776,HCPCS,,79012194,CDM,278,RC,,,both,,,10200,7548.03,,,7548.03,Other,150% of Medicare + 9.63% HCRA Surcharge,4590,45,,4590,percent of total billed charges,Critical Access Hospital RCC factor,3468,34,,3468,percent of total billed charges,Implant Device,3468,34,,3468,percent of total billed charges,Implant Device,3468,34,,3468,percent of total billed charges,Implant Device,3468,34,,3468,percent of total billed charges,Implant Device,3468,34,,3468,percent of total billed charges,Implant Device,5049,,,5049,Other,110% of Medicare,3570,35,,3570,percent of total billed charges,Implant Device,3468,34,"Charges > $500, x 34%",3468,percent of total billed charges,Implant Device,3570,35,,3570,percent of total billed charges,Implant Device,3570,35,,3570,percent of total billed charges,Implant Device,3570,35,,3570,percent of total billed charges,Implant Device,3570,35,,3570,percent of total billed charges,Implant Device,3570,35,,3570,percent of total billed charges,Implant Device,4080,40,,4080,percent of total billed charges,Implant Device,3570,70,,3570,percent of total billed charges,All Other,3468,34,,3468,percent of total billed charges,Implant Device,3468,34,,3468,percent of total billed charges,Implant Device,3570,35,,3570,percent of total billed charges,Implant Device,3570,35,,3570,percent of total billed charges,Implant Device,3570,35,,3570,percent of total billed charges,Implant Device,3570,35,,3570,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3468,34,"If Charge > 2,000, then 34 percent",3468,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,7548.03,
ZIMMER 00-5988-005-26 TIBIAL BLOCK SZ 5,C1776,HCPCS,,79012195,CDM,278,RC,,,both,,,2963,2192.63,,,2192.63,Other,150% of Medicare + 9.63% HCRA Surcharge,1333.35,45,,1333.35,percent of total billed charges,Critical Access Hospital RCC factor,1007.42,34,,1007.42,percent of total billed charges,Implant Device,1007.42,34,,1007.42,percent of total billed charges,Implant Device,1007.42,34,,1007.42,percent of total billed charges,Implant Device,1007.42,34,,1007.42,percent of total billed charges,Implant Device,1007.42,34,,1007.42,percent of total billed charges,Implant Device,1466.69,,,1466.69,Other,110% of Medicare,1037.05,35,,1037.05,percent of total billed charges,Implant Device,1007.42,34,"Charges > $500, x 34%",1007.42,percent of total billed charges,Implant Device,1037.05,35,,1037.05,percent of total billed charges,Implant Device,1037.05,35,,1037.05,percent of total billed charges,Implant Device,1037.05,35,,1037.05,percent of total billed charges,Implant Device,1037.05,35,,1037.05,percent of total billed charges,Implant Device,1037.05,35,,1037.05,percent of total billed charges,Implant Device,1185.2,40,,1185.2,percent of total billed charges,Implant Device,1037.05,70,,1037.05,percent of total billed charges,All Other,1007.42,34,,1007.42,percent of total billed charges,Implant Device,1007.42,34,,1007.42,percent of total billed charges,Implant Device,1037.05,35,,1037.05,percent of total billed charges,Implant Device,1037.05,35,,1037.05,percent of total billed charges,Implant Device,1037.05,35,,1037.05,percent of total billed charges,Implant Device,1037.05,35,,1037.05,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1007.42,34,"If Charge > 2,000, then 34 percent",1007.42,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2192.63,
ZIMMER 00-5988-021-14 STEM EXT 14X155MM,C1776,HCPCS,,79012196,CDM,278,RC,,,both,,,4337,3209.39,,,3209.39,Other,150% of Medicare + 9.63% HCRA Surcharge,1951.65,45,,1951.65,percent of total billed charges,Critical Access Hospital RCC factor,1474.58,34,,1474.58,percent of total billed charges,Implant Device,1474.58,34,,1474.58,percent of total billed charges,Implant Device,1474.58,34,,1474.58,percent of total billed charges,Implant Device,1474.58,34,,1474.58,percent of total billed charges,Implant Device,1474.58,34,,1474.58,percent of total billed charges,Implant Device,2146.82,,,2146.82,Other,110% of Medicare,1517.95,35,,1517.95,percent of total billed charges,Implant Device,1474.58,34,"Charges > $500, x 34%",1474.58,percent of total billed charges,Implant Device,1517.95,35,,1517.95,percent of total billed charges,Implant Device,1517.95,35,,1517.95,percent of total billed charges,Implant Device,1517.95,35,,1517.95,percent of total billed charges,Implant Device,1517.95,35,,1517.95,percent of total billed charges,Implant Device,1517.95,35,,1517.95,percent of total billed charges,Implant Device,1734.8,40,,1734.8,percent of total billed charges,Implant Device,1517.95,70,,1517.95,percent of total billed charges,All Other,1474.58,34,,1474.58,percent of total billed charges,Implant Device,1474.58,34,,1474.58,percent of total billed charges,Implant Device,1517.95,35,,1517.95,percent of total billed charges,Implant Device,1517.95,35,,1517.95,percent of total billed charges,Implant Device,1517.95,35,,1517.95,percent of total billed charges,Implant Device,1517.95,35,,1517.95,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1474.58,34,"If Charge > 2,000, then 34 percent",1474.58,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3209.39,
STRYKER 6720-0937 HIP STEM SZ 9 37X120MM,C1776,HCPCS,,79012197,CDM,278,RC,,,both,,,6953,5145.24,,,5145.24,Other,150% of Medicare + 9.63% HCRA Surcharge,3128.85,45,,3128.85,percent of total billed charges,Critical Access Hospital RCC factor,2364.02,34,,2364.02,percent of total billed charges,Implant Device,2364.02,34,,2364.02,percent of total billed charges,Implant Device,2364.02,34,,2364.02,percent of total billed charges,Implant Device,2364.02,34,,2364.02,percent of total billed charges,Implant Device,2364.02,34,,2364.02,percent of total billed charges,Implant Device,3441.74,,,3441.74,Other,110% of Medicare,2433.55,35,,2433.55,percent of total billed charges,Implant Device,2364.02,34,"Charges > $500, x 34%",2364.02,percent of total billed charges,Implant Device,2433.55,35,,2433.55,percent of total billed charges,Implant Device,2433.55,35,,2433.55,percent of total billed charges,Implant Device,2433.55,35,,2433.55,percent of total billed charges,Implant Device,2433.55,35,,2433.55,percent of total billed charges,Implant Device,2433.55,35,,2433.55,percent of total billed charges,Implant Device,2781.2,40,,2781.2,percent of total billed charges,Implant Device,2433.55,70,,2433.55,percent of total billed charges,All Other,2364.02,34,,2364.02,percent of total billed charges,Implant Device,2364.02,34,,2364.02,percent of total billed charges,Implant Device,2433.55,35,,2433.55,percent of total billed charges,Implant Device,2433.55,35,,2433.55,percent of total billed charges,Implant Device,2433.55,35,,2433.55,percent of total billed charges,Implant Device,2433.55,35,,2433.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2364.02,34,"If Charge > 2,000, then 34 percent",2364.02,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5145.24,
ZIMMER 574202065 FEMORAL STEM SIZE 6.5,C1776,HCPCS,,79012198,CDM,278,RC,,,both,,,6912,5114.9,,,5114.9,Other,150% of Medicare + 9.63% HCRA Surcharge,3110.4,45,,3110.4,percent of total billed charges,Critical Access Hospital RCC factor,2350.08,34,,2350.08,percent of total billed charges,Implant Device,2350.08,34,,2350.08,percent of total billed charges,Implant Device,2350.08,34,,2350.08,percent of total billed charges,Implant Device,2350.08,34,,2350.08,percent of total billed charges,Implant Device,2350.08,34,,2350.08,percent of total billed charges,Implant Device,3421.44,,,3421.44,Other,110% of Medicare,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2350.08,34,"Charges > $500, x 34%",2350.08,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2764.8,40,,2764.8,percent of total billed charges,Implant Device,2419.2,70,,2419.2,percent of total billed charges,All Other,2350.08,34,,2350.08,percent of total billed charges,Implant Device,2350.08,34,,2350.08,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2350.08,34,"If Charge > 2,000, then 34 percent",2350.08,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5114.9,
ZIMMER 183006 FEMORAL RIGHT 62.5MM,C1776,HCPCS,,79012199,CDM,278,RC,,,both,,,6300,4662.02,,,4662.02,Other,150% of Medicare + 9.63% HCRA Surcharge,2835,45,,2835,percent of total billed charges,Critical Access Hospital RCC factor,2142,34,,2142,percent of total billed charges,Implant Device,2142,34,,2142,percent of total billed charges,Implant Device,2142,34,,2142,percent of total billed charges,Implant Device,2142,34,,2142,percent of total billed charges,Implant Device,2142,34,,2142,percent of total billed charges,Implant Device,3118.5,,,3118.5,Other,110% of Medicare,2205,35,,2205,percent of total billed charges,Implant Device,2142,34,"Charges > $500, x 34%",2142,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2520,40,,2520,percent of total billed charges,Implant Device,2205,70,,2205,percent of total billed charges,All Other,2142,34,,2142,percent of total billed charges,Implant Device,2142,34,,2142,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2142,34,"If Charge > 2,000, then 34 percent",2142,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4662.02,
J&J 02.112.621 CLAVICLE PLATE RT 2.7MM,C1713,HCPCS,,79012200,CDM,278,RC,,,both,,,3218,2381.33,,,2381.33,Other,150% of Medicare + 9.63% HCRA Surcharge,1448.1,45,,1448.1,percent of total billed charges,Critical Access Hospital RCC factor,1094.12,34,,1094.12,percent of total billed charges,Implant Device,1094.12,34,,1094.12,percent of total billed charges,Implant Device,1094.12,34,,1094.12,percent of total billed charges,Implant Device,1094.12,34,,1094.12,percent of total billed charges,Implant Device,1094.12,34,,1094.12,percent of total billed charges,Implant Device,1592.91,,,1592.91,Other,110% of Medicare,1126.3,35,,1126.3,percent of total billed charges,Implant Device,1094.12,34,"Charges > $500, x 34%",1094.12,percent of total billed charges,Implant Device,1126.3,35,,1126.3,percent of total billed charges,Implant Device,1126.3,35,,1126.3,percent of total billed charges,Implant Device,1126.3,35,,1126.3,percent of total billed charges,Implant Device,1126.3,35,,1126.3,percent of total billed charges,Implant Device,1126.3,35,,1126.3,percent of total billed charges,Implant Device,1287.2,40,,1287.2,percent of total billed charges,Implant Device,1126.3,70,,1126.3,percent of total billed charges,All Other,1094.12,34,,1094.12,percent of total billed charges,Implant Device,1094.12,34,,1094.12,percent of total billed charges,Implant Device,1126.3,35,,1126.3,percent of total billed charges,Implant Device,1126.3,35,,1126.3,percent of total billed charges,Implant Device,1126.3,35,,1126.3,percent of total billed charges,Implant Device,1126.3,35,,1126.3,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1094.12,34,"If Charge > 2,000, then 34 percent",1094.12,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2381.33,
J&J 03.211.415 OLIVE WIRE 1.6MM,C1713,HCPCS,,79012201,CDM,278,RC,,,both,,,109,80.66,,,80.66,Other,150% of Medicare + 9.63% HCRA Surcharge,49.05,45,,49.05,percent of total billed charges,Critical Access Hospital RCC factor,37.06,34,,37.06,percent of total billed charges,Implant Device,37.06,34,,37.06,percent of total billed charges,Implant Device,37.06,34,,37.06,percent of total billed charges,Implant Device,37.06,34,,37.06,percent of total billed charges,Implant Device,37.06,34,,37.06,percent of total billed charges,Implant Device,53.96,,,53.96,Other,110% of Medicare,38.15,35,,38.15,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,38.15,35,,38.15,percent of total billed charges,Implant Device,38.15,35,,38.15,percent of total billed charges,Implant Device,38.15,35,,38.15,percent of total billed charges,Implant Device,38.15,35,,38.15,percent of total billed charges,Implant Device,38.15,35,,38.15,percent of total billed charges,Implant Device,43.6,40,,43.6,percent of total billed charges,Implant Device,38.15,70,,38.15,percent of total billed charges,All Other,37.06,34,,37.06,percent of total billed charges,Implant Device,37.06,34,,37.06,percent of total billed charges,Implant Device,38.15,35,,38.15,percent of total billed charges,Implant Device,38.15,35,,38.15,percent of total billed charges,Implant Device,38.15,35,,38.15,percent of total billed charges,Implant Device,38.15,35,,38.15,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,80.66,
J&J 02.111.903.01 K WIRE 2.0MM,C1713,HCPCS,,79012202,CDM,278,RC,,,both,,,112,82.88,,,82.88,Other,150% of Medicare + 9.63% HCRA Surcharge,50.4,45,,50.4,percent of total billed charges,Critical Access Hospital RCC factor,38.08,34,,38.08,percent of total billed charges,Implant Device,38.08,34,,38.08,percent of total billed charges,Implant Device,38.08,34,,38.08,percent of total billed charges,Implant Device,38.08,34,,38.08,percent of total billed charges,Implant Device,38.08,34,,38.08,percent of total billed charges,Implant Device,55.44,,,55.44,Other,110% of Medicare,39.2,35,,39.2,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,39.2,35,,39.2,percent of total billed charges,Implant Device,39.2,35,,39.2,percent of total billed charges,Implant Device,39.2,35,,39.2,percent of total billed charges,Implant Device,39.2,35,,39.2,percent of total billed charges,Implant Device,39.2,35,,39.2,percent of total billed charges,Implant Device,44.8,40,,44.8,percent of total billed charges,Implant Device,39.2,70,,39.2,percent of total billed charges,All Other,38.08,34,,38.08,percent of total billed charges,Implant Device,38.08,34,,38.08,percent of total billed charges,Implant Device,39.2,35,,39.2,percent of total billed charges,Implant Device,39.2,35,,39.2,percent of total billed charges,Implant Device,39.2,35,,39.2,percent of total billed charges,Implant Device,39.2,35,,39.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,82.88,
J&J 212.115 LOCKING SCREW 3.5X36MM,C1713,HCPCS,,79012203,CDM,278,RC,,,both,,,327,241.98,,,241.98,Other,150% of Medicare + 9.63% HCRA Surcharge,147.15,45,,147.15,percent of total billed charges,Critical Access Hospital RCC factor,111.18,34,,111.18,percent of total billed charges,Implant Device,111.18,34,,111.18,percent of total billed charges,Implant Device,111.18,34,,111.18,percent of total billed charges,Implant Device,111.18,34,,111.18,percent of total billed charges,Implant Device,111.18,34,,111.18,percent of total billed charges,Implant Device,161.87,,,161.87,Other,110% of Medicare,114.45,35,,114.45,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,114.45,35,,114.45,percent of total billed charges,Implant Device,114.45,35,,114.45,percent of total billed charges,Implant Device,114.45,35,,114.45,percent of total billed charges,Implant Device,114.45,35,,114.45,percent of total billed charges,Implant Device,114.45,35,,114.45,percent of total billed charges,Implant Device,130.8,40,,130.8,percent of total billed charges,Implant Device,114.45,70,,114.45,percent of total billed charges,All Other,111.18,34,,111.18,percent of total billed charges,Implant Device,111.18,34,,111.18,percent of total billed charges,Implant Device,114.45,35,,114.45,percent of total billed charges,Implant Device,114.45,35,,114.45,percent of total billed charges,Implant Device,114.45,35,,114.45,percent of total billed charges,Implant Device,114.45,35,,114.45,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,241.98,
J&J 242.07 TUBULAR PLATE QUARTER 7 H,C1713,HCPCS,,79012204,CDM,278,RC,,,both,,,274,202.76,,,202.76,Other,150% of Medicare + 9.63% HCRA Surcharge,123.3,45,,123.3,percent of total billed charges,Critical Access Hospital RCC factor,93.16,34,,93.16,percent of total billed charges,Implant Device,93.16,34,,93.16,percent of total billed charges,Implant Device,93.16,34,,93.16,percent of total billed charges,Implant Device,93.16,34,,93.16,percent of total billed charges,Implant Device,93.16,34,,93.16,percent of total billed charges,Implant Device,135.63,,,135.63,Other,110% of Medicare,95.9,35,,95.9,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,95.9,35,,95.9,percent of total billed charges,Implant Device,95.9,35,,95.9,percent of total billed charges,Implant Device,95.9,35,,95.9,percent of total billed charges,Implant Device,95.9,35,,95.9,percent of total billed charges,Implant Device,95.9,35,,95.9,percent of total billed charges,Implant Device,109.6,40,,109.6,percent of total billed charges,Implant Device,95.9,70,,95.9,percent of total billed charges,All Other,93.16,34,,93.16,percent of total billed charges,Implant Device,93.16,34,,93.16,percent of total billed charges,Implant Device,95.9,35,,95.9,percent of total billed charges,Implant Device,95.9,35,,95.9,percent of total billed charges,Implant Device,95.9,35,,95.9,percent of total billed charges,Implant Device,95.9,35,,95.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,202.76,
J&J 02.117.601 DIS HUMERUS PLT 2.7/3.5MM,C1713,HCPCS,,79012205,CDM,278,RC,,,both,,,3335,2467.91,,,2467.91,Other,150% of Medicare + 9.63% HCRA Surcharge,1500.75,45,,1500.75,percent of total billed charges,Critical Access Hospital RCC factor,1133.9,34,,1133.9,percent of total billed charges,Implant Device,1133.9,34,,1133.9,percent of total billed charges,Implant Device,1133.9,34,,1133.9,percent of total billed charges,Implant Device,1133.9,34,,1133.9,percent of total billed charges,Implant Device,1133.9,34,,1133.9,percent of total billed charges,Implant Device,1650.83,,,1650.83,Other,110% of Medicare,1167.25,35,,1167.25,percent of total billed charges,Implant Device,1133.9,34,"Charges > $500, x 34%",1133.9,percent of total billed charges,Implant Device,1167.25,35,,1167.25,percent of total billed charges,Implant Device,1167.25,35,,1167.25,percent of total billed charges,Implant Device,1167.25,35,,1167.25,percent of total billed charges,Implant Device,1167.25,35,,1167.25,percent of total billed charges,Implant Device,1167.25,35,,1167.25,percent of total billed charges,Implant Device,1334,40,,1334,percent of total billed charges,Implant Device,1167.25,70,,1167.25,percent of total billed charges,All Other,1133.9,34,,1133.9,percent of total billed charges,Implant Device,1133.9,34,,1133.9,percent of total billed charges,Implant Device,1167.25,35,,1167.25,percent of total billed charges,Implant Device,1167.25,35,,1167.25,percent of total billed charges,Implant Device,1167.25,35,,1167.25,percent of total billed charges,Implant Device,1167.25,35,,1167.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1133.9,34,"If Charge > 2,000, then 34 percent",1133.9,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2467.91,
J&J 02.118.536 SCREW 2.7X36MM,C1713,HCPCS,,79012206,CDM,278,RC,,,both,,,125,92.5,,,92.5,Other,150% of Medicare + 9.63% HCRA Surcharge,56.25,45,,56.25,percent of total billed charges,Critical Access Hospital RCC factor,42.5,34,,42.5,percent of total billed charges,Implant Device,42.5,34,,42.5,percent of total billed charges,Implant Device,42.5,34,,42.5,percent of total billed charges,Implant Device,42.5,34,,42.5,percent of total billed charges,Implant Device,42.5,34,,42.5,percent of total billed charges,Implant Device,61.88,,,61.88,Other,110% of Medicare,43.75,35,,43.75,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,43.75,35,,43.75,percent of total billed charges,Implant Device,43.75,35,,43.75,percent of total billed charges,Implant Device,43.75,35,,43.75,percent of total billed charges,Implant Device,43.75,35,,43.75,percent of total billed charges,Implant Device,43.75,35,,43.75,percent of total billed charges,Implant Device,50,40,,50,percent of total billed charges,Implant Device,43.75,70,,43.75,percent of total billed charges,All Other,42.5,34,,42.5,percent of total billed charges,Implant Device,42.5,34,,42.5,percent of total billed charges,Implant Device,43.75,35,,43.75,percent of total billed charges,Implant Device,43.75,35,,43.75,percent of total billed charges,Implant Device,43.75,35,,43.75,percent of total billed charges,Implant Device,43.75,35,,43.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,92.5,
J&J 02.211.054 LOCKING SCREW 2.7X54MM,C1713,HCPCS,,79012207,CDM,278,RC,,,both,,,343,253.82,,,253.82,Other,150% of Medicare + 9.63% HCRA Surcharge,154.35,45,,154.35,percent of total billed charges,Critical Access Hospital RCC factor,116.62,34,,116.62,percent of total billed charges,Implant Device,116.62,34,,116.62,percent of total billed charges,Implant Device,116.62,34,,116.62,percent of total billed charges,Implant Device,116.62,34,,116.62,percent of total billed charges,Implant Device,116.62,34,,116.62,percent of total billed charges,Implant Device,169.79,,,169.79,Other,110% of Medicare,120.05,35,,120.05,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,120.05,35,,120.05,percent of total billed charges,Implant Device,120.05,35,,120.05,percent of total billed charges,Implant Device,120.05,35,,120.05,percent of total billed charges,Implant Device,120.05,35,,120.05,percent of total billed charges,Implant Device,120.05,35,,120.05,percent of total billed charges,Implant Device,137.2,40,,137.2,percent of total billed charges,Implant Device,120.05,70,,120.05,percent of total billed charges,All Other,116.62,34,,116.62,percent of total billed charges,Implant Device,116.62,34,,116.62,percent of total billed charges,Implant Device,120.05,35,,120.05,percent of total billed charges,Implant Device,120.05,35,,120.05,percent of total billed charges,Implant Device,120.05,35,,120.05,percent of total billed charges,Implant Device,120.05,35,,120.05,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,253.82,
J&J 202.896 CORTEX SCREW 2.7X36MM,C1713,HCPCS,,79012208,CDM,278,RC,,,both,,,96,71.04,,,71.04,Other,150% of Medicare + 9.63% HCRA Surcharge,43.2,45,,43.2,percent of total billed charges,Critical Access Hospital RCC factor,32.64,34,,32.64,percent of total billed charges,Implant Device,32.64,34,,32.64,percent of total billed charges,Implant Device,32.64,34,,32.64,percent of total billed charges,Implant Device,32.64,34,,32.64,percent of total billed charges,Implant Device,32.64,34,,32.64,percent of total billed charges,Implant Device,47.52,,,47.52,Other,110% of Medicare,33.6,35,,33.6,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,33.6,35,,33.6,percent of total billed charges,Implant Device,33.6,35,,33.6,percent of total billed charges,Implant Device,33.6,35,,33.6,percent of total billed charges,Implant Device,33.6,35,,33.6,percent of total billed charges,Implant Device,33.6,35,,33.6,percent of total billed charges,Implant Device,38.4,40,,38.4,percent of total billed charges,Implant Device,33.6,70,,33.6,percent of total billed charges,All Other,32.64,34,,32.64,percent of total billed charges,Implant Device,32.64,34,,32.64,percent of total billed charges,Implant Device,33.6,35,,33.6,percent of total billed charges,Implant Device,33.6,35,,33.6,percent of total billed charges,Implant Device,33.6,35,,33.6,percent of total billed charges,Implant Device,33.6,35,,33.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,71.04,
J&J 02.117.203 DIS HUMERUS PLT 2.7/3.5MM,C1713,HCPCS,,79012209,CDM,278,RC,,,both,,,3234,2393.17,,,2393.17,Other,150% of Medicare + 9.63% HCRA Surcharge,1455.3,45,,1455.3,percent of total billed charges,Critical Access Hospital RCC factor,1099.56,34,,1099.56,percent of total billed charges,Implant Device,1099.56,34,,1099.56,percent of total billed charges,Implant Device,1099.56,34,,1099.56,percent of total billed charges,Implant Device,1099.56,34,,1099.56,percent of total billed charges,Implant Device,1099.56,34,,1099.56,percent of total billed charges,Implant Device,1600.83,,,1600.83,Other,110% of Medicare,1131.9,35,,1131.9,percent of total billed charges,Implant Device,1099.56,34,"Charges > $500, x 34%",1099.56,percent of total billed charges,Implant Device,1131.9,35,,1131.9,percent of total billed charges,Implant Device,1131.9,35,,1131.9,percent of total billed charges,Implant Device,1131.9,35,,1131.9,percent of total billed charges,Implant Device,1131.9,35,,1131.9,percent of total billed charges,Implant Device,1131.9,35,,1131.9,percent of total billed charges,Implant Device,1293.6,40,,1293.6,percent of total billed charges,Implant Device,1131.9,70,,1131.9,percent of total billed charges,All Other,1099.56,34,,1099.56,percent of total billed charges,Implant Device,1099.56,34,,1099.56,percent of total billed charges,Implant Device,1131.9,35,,1131.9,percent of total billed charges,Implant Device,1131.9,35,,1131.9,percent of total billed charges,Implant Device,1131.9,35,,1131.9,percent of total billed charges,Implant Device,1131.9,35,,1131.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1099.56,34,"If Charge > 2,000, then 34 percent",1099.56,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2393.17,
J&J 02.107.202 OLECRANON PLT 2.7/3.5MM,C1713,HCPCS,,79012210,CDM,278,RC,,,both,,,2826,2091.25,,,2091.25,Other,150% of Medicare + 9.63% HCRA Surcharge,1271.7,45,,1271.7,percent of total billed charges,Critical Access Hospital RCC factor,960.84,34,,960.84,percent of total billed charges,Implant Device,960.84,34,,960.84,percent of total billed charges,Implant Device,960.84,34,,960.84,percent of total billed charges,Implant Device,960.84,34,,960.84,percent of total billed charges,Implant Device,960.84,34,,960.84,percent of total billed charges,Implant Device,1398.87,,,1398.87,Other,110% of Medicare,989.1,35,,989.1,percent of total billed charges,Implant Device,960.84,34,"Charges > $500, x 34%",960.84,percent of total billed charges,Implant Device,989.1,35,,989.1,percent of total billed charges,Implant Device,989.1,35,,989.1,percent of total billed charges,Implant Device,989.1,35,,989.1,percent of total billed charges,Implant Device,989.1,35,,989.1,percent of total billed charges,Implant Device,989.1,35,,989.1,percent of total billed charges,Implant Device,1130.4,40,,1130.4,percent of total billed charges,Implant Device,989.1,70,,989.1,percent of total billed charges,All Other,960.84,34,,960.84,percent of total billed charges,Implant Device,960.84,34,,960.84,percent of total billed charges,Implant Device,989.1,35,,989.1,percent of total billed charges,Implant Device,989.1,35,,989.1,percent of total billed charges,Implant Device,989.1,35,,989.1,percent of total billed charges,Implant Device,989.1,35,,989.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,960.84,34,"If Charge > 2,000, then 34 percent",960.84,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2091.25,
J&J 02.118.550 SCREW 2.7X50MM,C1713,HCPCS,,79012211,CDM,278,RC,,,both,,,125,92.5,,,92.5,Other,150% of Medicare + 9.63% HCRA Surcharge,56.25,45,,56.25,percent of total billed charges,Critical Access Hospital RCC factor,42.5,34,,42.5,percent of total billed charges,Implant Device,42.5,34,,42.5,percent of total billed charges,Implant Device,42.5,34,,42.5,percent of total billed charges,Implant Device,42.5,34,,42.5,percent of total billed charges,Implant Device,42.5,34,,42.5,percent of total billed charges,Implant Device,61.88,,,61.88,Other,110% of Medicare,43.75,35,,43.75,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,43.75,35,,43.75,percent of total billed charges,Implant Device,43.75,35,,43.75,percent of total billed charges,Implant Device,43.75,35,,43.75,percent of total billed charges,Implant Device,43.75,35,,43.75,percent of total billed charges,Implant Device,43.75,35,,43.75,percent of total billed charges,Implant Device,50,40,,50,percent of total billed charges,Implant Device,43.75,70,,43.75,percent of total billed charges,All Other,42.5,34,,42.5,percent of total billed charges,Implant Device,42.5,34,,42.5,percent of total billed charges,Implant Device,43.75,35,,43.75,percent of total billed charges,Implant Device,43.75,35,,43.75,percent of total billed charges,Implant Device,43.75,35,,43.75,percent of total billed charges,Implant Device,43.75,35,,43.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,92.5,
J&J 02.118.560 SCREW 2.7X60MM,C1713,HCPCS,,79012212,CDM,278,RC,,,both,,,130,96.2,,,96.2,Other,150% of Medicare + 9.63% HCRA Surcharge,58.5,45,,58.5,percent of total billed charges,Critical Access Hospital RCC factor,44.2,34,,44.2,percent of total billed charges,Implant Device,44.2,34,,44.2,percent of total billed charges,Implant Device,44.2,34,,44.2,percent of total billed charges,Implant Device,44.2,34,,44.2,percent of total billed charges,Implant Device,44.2,34,,44.2,percent of total billed charges,Implant Device,64.35,,,64.35,Other,110% of Medicare,45.5,35,,45.5,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,45.5,35,,45.5,percent of total billed charges,Implant Device,45.5,35,,45.5,percent of total billed charges,Implant Device,45.5,35,,45.5,percent of total billed charges,Implant Device,45.5,35,,45.5,percent of total billed charges,Implant Device,45.5,35,,45.5,percent of total billed charges,Implant Device,52,40,,52,percent of total billed charges,Implant Device,45.5,70,,45.5,percent of total billed charges,All Other,44.2,34,,44.2,percent of total billed charges,Implant Device,44.2,34,,44.2,percent of total billed charges,Implant Device,45.5,35,,45.5,percent of total billed charges,Implant Device,45.5,35,,45.5,percent of total billed charges,Implant Device,45.5,35,,45.5,percent of total billed charges,Implant Device,45.5,35,,45.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,96.2,
J&J 02.211.028 LOCKING SCREW 2.7X10MM,C1713,HCPCS,,79012213,CDM,278,RC,,,both,,,357,264.18,,,264.18,Other,150% of Medicare + 9.63% HCRA Surcharge,160.65,45,,160.65,percent of total billed charges,Critical Access Hospital RCC factor,121.38,34,,121.38,percent of total billed charges,Implant Device,121.38,34,,121.38,percent of total billed charges,Implant Device,121.38,34,,121.38,percent of total billed charges,Implant Device,121.38,34,,121.38,percent of total billed charges,Implant Device,121.38,34,,121.38,percent of total billed charges,Implant Device,176.72,,,176.72,Other,110% of Medicare,124.95,35,,124.95,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,124.95,35,,124.95,percent of total billed charges,Implant Device,124.95,35,,124.95,percent of total billed charges,Implant Device,124.95,35,,124.95,percent of total billed charges,Implant Device,124.95,35,,124.95,percent of total billed charges,Implant Device,124.95,35,,124.95,percent of total billed charges,Implant Device,142.8,40,,142.8,percent of total billed charges,Implant Device,124.95,70,,124.95,percent of total billed charges,All Other,121.38,34,,121.38,percent of total billed charges,Implant Device,121.38,34,,121.38,percent of total billed charges,Implant Device,124.95,35,,124.95,percent of total billed charges,Implant Device,124.95,35,,124.95,percent of total billed charges,Implant Device,124.95,35,,124.95,percent of total billed charges,Implant Device,124.95,35,,124.95,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,264.18,
DJO 508-32-204 GLENOID BASE PLATE 30MM,C1776,HCPCS,,79012214,CDM,278,RC,,,both,,,4800,3552.01,,,3552.01,Other,150% of Medicare + 9.63% HCRA Surcharge,2160,45,,2160,percent of total billed charges,Critical Access Hospital RCC factor,1632,34,,1632,percent of total billed charges,Implant Device,1632,34,,1632,percent of total billed charges,Implant Device,1632,34,,1632,percent of total billed charges,Implant Device,1632,34,,1632,percent of total billed charges,Implant Device,1632,34,,1632,percent of total billed charges,Implant Device,2376,,,2376,Other,110% of Medicare,1680,35,,1680,percent of total billed charges,Implant Device,1632,34,"Charges > $500, x 34%",1632,percent of total billed charges,Implant Device,1680,35,,1680,percent of total billed charges,Implant Device,1680,35,,1680,percent of total billed charges,Implant Device,1680,35,,1680,percent of total billed charges,Implant Device,1680,35,,1680,percent of total billed charges,Implant Device,1680,35,,1680,percent of total billed charges,Implant Device,1920,40,,1920,percent of total billed charges,Implant Device,1680,70,,1680,percent of total billed charges,All Other,1632,34,,1632,percent of total billed charges,Implant Device,1632,34,,1632,percent of total billed charges,Implant Device,1680,35,,1680,percent of total billed charges,Implant Device,1680,35,,1680,percent of total billed charges,Implant Device,1680,35,,1680,percent of total billed charges,Implant Device,1680,35,,1680,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1632,34,"If Charge > 2,000, then 34 percent",1632,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3552.01,
DJO 506-03-130 BONE SCREW 5.0X30MM,C1776,HCPCS,,79012215,CDM,278,RC,,,both,,,360,266.4,,,266.4,Other,150% of Medicare + 9.63% HCRA Surcharge,162,45,,162,percent of total billed charges,Critical Access Hospital RCC factor,122.4,34,,122.4,percent of total billed charges,Implant Device,122.4,34,,122.4,percent of total billed charges,Implant Device,122.4,34,,122.4,percent of total billed charges,Implant Device,122.4,34,,122.4,percent of total billed charges,Implant Device,122.4,34,,122.4,percent of total billed charges,Implant Device,178.2,,,178.2,Other,110% of Medicare,126,35,,126,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,126,35,,126,percent of total billed charges,Implant Device,126,35,,126,percent of total billed charges,Implant Device,126,35,,126,percent of total billed charges,Implant Device,126,35,,126,percent of total billed charges,Implant Device,126,35,,126,percent of total billed charges,Implant Device,144,40,,144,percent of total billed charges,Implant Device,126,70,,126,percent of total billed charges,All Other,122.4,34,,122.4,percent of total billed charges,Implant Device,122.4,34,,122.4,percent of total billed charges,Implant Device,126,35,,126,percent of total billed charges,Implant Device,126,35,,126,percent of total billed charges,Implant Device,126,35,,126,percent of total billed charges,Implant Device,126,35,,126,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,266.4,
DJO 506-03-122 BONE SCREW 5.0X22MM,C1776,HCPCS,,79012216,CDM,278,RC,,,both,,,360,266.4,,,266.4,Other,150% of Medicare + 9.63% HCRA Surcharge,162,45,,162,percent of total billed charges,Critical Access Hospital RCC factor,122.4,34,,122.4,percent of total billed charges,Implant Device,122.4,34,,122.4,percent of total billed charges,Implant Device,122.4,34,,122.4,percent of total billed charges,Implant Device,122.4,34,,122.4,percent of total billed charges,Implant Device,122.4,34,,122.4,percent of total billed charges,Implant Device,178.2,,,178.2,Other,110% of Medicare,126,35,,126,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,126,35,,126,percent of total billed charges,Implant Device,126,35,,126,percent of total billed charges,Implant Device,126,35,,126,percent of total billed charges,Implant Device,126,35,,126,percent of total billed charges,Implant Device,126,35,,126,percent of total billed charges,Implant Device,144,40,,144,percent of total billed charges,Implant Device,126,70,,126,percent of total billed charges,All Other,122.4,34,,122.4,percent of total billed charges,Implant Device,122.4,34,,122.4,percent of total billed charges,Implant Device,126,35,,126,percent of total billed charges,Implant Device,126,35,,126,percent of total billed charges,Implant Device,126,35,,126,percent of total billed charges,Implant Device,126,35,,126,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,266.4,
DJO 506-03-114 BONE SCREW 5.0X14MM,C1713,HCPCS,,79012217,CDM,278,RC,,,both,,,360,266.4,,,266.4,Other,150% of Medicare + 9.63% HCRA Surcharge,162,45,,162,percent of total billed charges,Critical Access Hospital RCC factor,122.4,34,,122.4,percent of total billed charges,Implant Device,122.4,34,,122.4,percent of total billed charges,Implant Device,122.4,34,,122.4,percent of total billed charges,Implant Device,122.4,34,,122.4,percent of total billed charges,Implant Device,122.4,34,,122.4,percent of total billed charges,Implant Device,178.2,,,178.2,Other,110% of Medicare,126,35,,126,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,126,35,,126,percent of total billed charges,Implant Device,126,35,,126,percent of total billed charges,Implant Device,126,35,,126,percent of total billed charges,Implant Device,126,35,,126,percent of total billed charges,Implant Device,126,35,,126,percent of total billed charges,Implant Device,144,40,,144,percent of total billed charges,Implant Device,126,70,,126,percent of total billed charges,All Other,122.4,34,,122.4,percent of total billed charges,Implant Device,122.4,34,,122.4,percent of total billed charges,Implant Device,126,35,,126,percent of total billed charges,Implant Device,126,35,,126,percent of total billed charges,Implant Device,126,35,,126,percent of total billed charges,Implant Device,126,35,,126,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,266.4,
DJO 508-36-101 GLENOID HEAD 36MM,C1776,HCPCS,,79012218,CDM,278,RC,,,both,,,4440,3285.61,,,3285.61,Other,150% of Medicare + 9.63% HCRA Surcharge,1998,45,,1998,percent of total billed charges,Critical Access Hospital RCC factor,1509.6,34,,1509.6,percent of total billed charges,Implant Device,1509.6,34,,1509.6,percent of total billed charges,Implant Device,1509.6,34,,1509.6,percent of total billed charges,Implant Device,1509.6,34,,1509.6,percent of total billed charges,Implant Device,1509.6,34,,1509.6,percent of total billed charges,Implant Device,2197.8,,,2197.8,Other,110% of Medicare,1554,35,,1554,percent of total billed charges,Implant Device,1509.6,34,"Charges > $500, x 34%",1509.6,percent of total billed charges,Implant Device,1554,35,,1554,percent of total billed charges,Implant Device,1554,35,,1554,percent of total billed charges,Implant Device,1554,35,,1554,percent of total billed charges,Implant Device,1554,35,,1554,percent of total billed charges,Implant Device,1554,35,,1554,percent of total billed charges,Implant Device,1776,40,,1776,percent of total billed charges,Implant Device,1554,70,,1554,percent of total billed charges,All Other,1509.6,34,,1509.6,percent of total billed charges,Implant Device,1509.6,34,,1509.6,percent of total billed charges,Implant Device,1554,35,,1554,percent of total billed charges,Implant Device,1554,35,,1554,percent of total billed charges,Implant Device,1554,35,,1554,percent of total billed charges,Implant Device,1554,35,,1554,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1509.6,34,"If Charge > 2,000, then 34 percent",1509.6,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3285.61,
DJO 509-00-036 HUMRAL SOCKET INS 36MM,C1776,HCPCS,,79012219,CDM,278,RC,,,both,,,3600,2664.01,,,2664.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1620,45,,1620,percent of total billed charges,Critical Access Hospital RCC factor,1224,34,,1224,percent of total billed charges,Implant Device,1224,34,,1224,percent of total billed charges,Implant Device,1224,34,,1224,percent of total billed charges,Implant Device,1224,34,,1224,percent of total billed charges,Implant Device,1224,34,,1224,percent of total billed charges,Implant Device,1782,,,1782,Other,110% of Medicare,1260,35,,1260,percent of total billed charges,Implant Device,1224,34,"Charges > $500, x 34%",1224,percent of total billed charges,Implant Device,1260,35,,1260,percent of total billed charges,Implant Device,1260,35,,1260,percent of total billed charges,Implant Device,1260,35,,1260,percent of total billed charges,Implant Device,1260,35,,1260,percent of total billed charges,Implant Device,1260,35,,1260,percent of total billed charges,Implant Device,1440,40,,1440,percent of total billed charges,Implant Device,1260,70,,1260,percent of total billed charges,All Other,1224,34,,1224,percent of total billed charges,Implant Device,1224,34,,1224,percent of total billed charges,Implant Device,1260,35,,1260,percent of total billed charges,Implant Device,1260,35,,1260,percent of total billed charges,Implant Device,1260,35,,1260,percent of total billed charges,Implant Device,1260,35,,1260,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1224,34,"If Charge > 2,000, then 34 percent",1224,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2664.01,
DJO 530-10-108 HUMERAL STEM SZ 10X108MM,C1776,HCPCS,,79012220,CDM,278,RC,,,both,,,14400,10656.04,,,10656.04,Other,150% of Medicare + 9.63% HCRA Surcharge,6480,45,,6480,percent of total billed charges,Critical Access Hospital RCC factor,4896,34,,4896,percent of total billed charges,Implant Device,4896,34,,4896,percent of total billed charges,Implant Device,4896,34,,4896,percent of total billed charges,Implant Device,4896,34,,4896,percent of total billed charges,Implant Device,4896,34,,4896,percent of total billed charges,Implant Device,7128,,,7128,Other,110% of Medicare,5040,35,,5040,percent of total billed charges,Implant Device,4896,34,"Charges > $500, x 34%",4896,percent of total billed charges,Implant Device,5040,35,,5040,percent of total billed charges,Implant Device,5040,35,,5040,percent of total billed charges,Implant Device,5040,35,,5040,percent of total billed charges,Implant Device,5040,35,,5040,percent of total billed charges,Implant Device,5040,35,,5040,percent of total billed charges,Implant Device,5760,40,,5760,percent of total billed charges,Implant Device,5040,70,,5040,percent of total billed charges,All Other,4896,34,,4896,percent of total billed charges,Implant Device,4896,34,,4896,percent of total billed charges,Implant Device,5040,35,,5040,percent of total billed charges,Implant Device,5040,35,,5040,percent of total billed charges,Implant Device,5040,35,,5040,percent of total billed charges,Implant Device,5040,35,,5040,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,4896,34,"If Charge > 2,000, then 34 percent",4896,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,10656.04,
DJO 415-00-140 CEMENT RESTRICTOR SZ 14MM,C1889,HCPCS,,79012221,CDM,278,RC,,,both,,,240,177.6,,,177.6,Other,150% of Medicare + 9.63% HCRA Surcharge,108,45,,108,percent of total billed charges,Critical Access Hospital RCC factor,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,118.8,,,118.8,Other,110% of Medicare,84,35,,84,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,96,40,,96,percent of total billed charges,Implant Device,84,70,,84,percent of total billed charges,All Other,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,177.6,
DJO 510-08-000 MONOBLOCK SPACER W/ SCREW,C1776,HCPCS,,79012222,CDM,278,RC,,,both,,,5582,4130.69,,,4130.69,Other,150% of Medicare + 9.63% HCRA Surcharge,2511.9,45,,2511.9,percent of total billed charges,Critical Access Hospital RCC factor,1897.88,34,,1897.88,percent of total billed charges,Implant Device,1897.88,34,,1897.88,percent of total billed charges,Implant Device,1897.88,34,,1897.88,percent of total billed charges,Implant Device,1897.88,34,,1897.88,percent of total billed charges,Implant Device,1897.88,34,,1897.88,percent of total billed charges,Implant Device,2763.09,,,2763.09,Other,110% of Medicare,1953.7,35,,1953.7,percent of total billed charges,Implant Device,1897.88,34,"Charges > $500, x 34%",1897.88,percent of total billed charges,Implant Device,1953.7,35,,1953.7,percent of total billed charges,Implant Device,1953.7,35,,1953.7,percent of total billed charges,Implant Device,1953.7,35,,1953.7,percent of total billed charges,Implant Device,1953.7,35,,1953.7,percent of total billed charges,Implant Device,1953.7,35,,1953.7,percent of total billed charges,Implant Device,2232.8,40,,2232.8,percent of total billed charges,Implant Device,1953.7,70,,1953.7,percent of total billed charges,All Other,1897.88,34,,1897.88,percent of total billed charges,Implant Device,1897.88,34,,1897.88,percent of total billed charges,Implant Device,1953.7,35,,1953.7,percent of total billed charges,Implant Device,1953.7,35,,1953.7,percent of total billed charges,Implant Device,1953.7,35,,1953.7,percent of total billed charges,Implant Device,1953.7,35,,1953.7,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1897.88,34,"If Charge > 2,000, then 34 percent",1897.88,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4130.69,
J&J 07.704.105S PUTTY 5CC-FAST SET,C1734,HCPCS,,79012223,CDM,278,RC,,,both,,,3769,2789.07,,,2789.07,Other,150% of Medicare + 9.63% HCRA Surcharge,1696.05,45,,1696.05,percent of total billed charges,Critical Access Hospital RCC factor,1281.46,34,,1281.46,percent of total billed charges,Implant Device,1281.46,34,,1281.46,percent of total billed charges,Implant Device,1281.46,34,,1281.46,percent of total billed charges,Implant Device,1281.46,34,,1281.46,percent of total billed charges,Implant Device,1281.46,34,,1281.46,percent of total billed charges,Implant Device,1865.66,,,1865.66,Other,110% of Medicare,1319.15,35,,1319.15,percent of total billed charges,Implant Device,1281.46,34,"Charges > $500, x 34%",1281.46,percent of total billed charges,Implant Device,1319.15,35,,1319.15,percent of total billed charges,Implant Device,1319.15,35,,1319.15,percent of total billed charges,Implant Device,1319.15,35,,1319.15,percent of total billed charges,Implant Device,1319.15,35,,1319.15,percent of total billed charges,Implant Device,1319.15,35,,1319.15,percent of total billed charges,Implant Device,1507.6,40,,1507.6,percent of total billed charges,Implant Device,1319.15,70,,1319.15,percent of total billed charges,All Other,1281.46,34,,1281.46,percent of total billed charges,Implant Device,1281.46,34,,1281.46,percent of total billed charges,Implant Device,1319.15,35,,1319.15,percent of total billed charges,Implant Device,1319.15,35,,1319.15,percent of total billed charges,Implant Device,1319.15,35,,1319.15,percent of total billed charges,Implant Device,1319.15,35,,1319.15,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1281.46,34,"If Charge > 2,000, then 34 percent",1281.46,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2789.07,
J&J 02.112.614 CLAVICLE PLATE 2.7MM LT,C1713,HCPCS,,79012225,CDM,278,RC,,,both,,,3939,2914.87,,,2914.87,Other,150% of Medicare + 9.63% HCRA Surcharge,1772.55,45,,1772.55,percent of total billed charges,Critical Access Hospital RCC factor,1339.26,34,,1339.26,percent of total billed charges,Implant Device,1339.26,34,,1339.26,percent of total billed charges,Implant Device,1339.26,34,,1339.26,percent of total billed charges,Implant Device,1339.26,34,,1339.26,percent of total billed charges,Implant Device,1339.26,34,,1339.26,percent of total billed charges,Implant Device,1949.81,,,1949.81,Other,110% of Medicare,1378.65,35,,1378.65,percent of total billed charges,Implant Device,1339.26,34,"Charges > $500, x 34%",1339.26,percent of total billed charges,Implant Device,1378.65,35,,1378.65,percent of total billed charges,Implant Device,1378.65,35,,1378.65,percent of total billed charges,Implant Device,1378.65,35,,1378.65,percent of total billed charges,Implant Device,1378.65,35,,1378.65,percent of total billed charges,Implant Device,1378.65,35,,1378.65,percent of total billed charges,Implant Device,1575.6,40,,1575.6,percent of total billed charges,Implant Device,1378.65,70,,1378.65,percent of total billed charges,All Other,1339.26,34,,1339.26,percent of total billed charges,Implant Device,1339.26,34,,1339.26,percent of total billed charges,Implant Device,1378.65,35,,1378.65,percent of total billed charges,Implant Device,1378.65,35,,1378.65,percent of total billed charges,Implant Device,1378.65,35,,1378.65,percent of total billed charges,Implant Device,1378.65,35,,1378.65,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1339.26,34,"If Charge > 2,000, then 34 percent",1339.26,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2914.87,
J&J 202.886 CORTEX SCREW 2.7X26MM,C1713,HCPCS,,79012226,CDM,278,RC,,,both,,,88,65.12,,,65.12,Other,150% of Medicare + 9.63% HCRA Surcharge,39.6,45,,39.6,percent of total billed charges,Critical Access Hospital RCC factor,29.92,34,,29.92,percent of total billed charges,Implant Device,29.92,34,,29.92,percent of total billed charges,Implant Device,29.92,34,,29.92,percent of total billed charges,Implant Device,29.92,34,,29.92,percent of total billed charges,Implant Device,29.92,34,,29.92,percent of total billed charges,Implant Device,43.56,,,43.56,Other,110% of Medicare,30.8,35,,30.8,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,30.8,35,,30.8,percent of total billed charges,Implant Device,30.8,35,,30.8,percent of total billed charges,Implant Device,30.8,35,,30.8,percent of total billed charges,Implant Device,30.8,35,,30.8,percent of total billed charges,Implant Device,30.8,35,,30.8,percent of total billed charges,Implant Device,35.2,40,,35.2,percent of total billed charges,Implant Device,30.8,70,,30.8,percent of total billed charges,All Other,29.92,34,,29.92,percent of total billed charges,Implant Device,29.92,34,,29.92,percent of total billed charges,Implant Device,30.8,35,,30.8,percent of total billed charges,Implant Device,30.8,35,,30.8,percent of total billed charges,Implant Device,30.8,35,,30.8,percent of total billed charges,Implant Device,30.8,35,,30.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,65.12,
J&J 202.888 CORTEX SCREW 2.7X28MM,C1713,HCPCS,,79012227,CDM,278,RC,,,both,,,88,65.12,,,65.12,Other,150% of Medicare + 9.63% HCRA Surcharge,39.6,45,,39.6,percent of total billed charges,Critical Access Hospital RCC factor,29.92,34,,29.92,percent of total billed charges,Implant Device,29.92,34,,29.92,percent of total billed charges,Implant Device,29.92,34,,29.92,percent of total billed charges,Implant Device,29.92,34,,29.92,percent of total billed charges,Implant Device,29.92,34,,29.92,percent of total billed charges,Implant Device,43.56,,,43.56,Other,110% of Medicare,30.8,35,,30.8,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,30.8,35,,30.8,percent of total billed charges,Implant Device,30.8,35,,30.8,percent of total billed charges,Implant Device,30.8,35,,30.8,percent of total billed charges,Implant Device,30.8,35,,30.8,percent of total billed charges,Implant Device,30.8,35,,30.8,percent of total billed charges,Implant Device,35.2,40,,35.2,percent of total billed charges,Implant Device,30.8,70,,30.8,percent of total billed charges,All Other,29.92,34,,29.92,percent of total billed charges,Implant Device,29.92,34,,29.92,percent of total billed charges,Implant Device,30.8,35,,30.8,percent of total billed charges,Implant Device,30.8,35,,30.8,percent of total billed charges,Implant Device,30.8,35,,30.8,percent of total billed charges,Implant Device,30.8,35,,30.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,65.12,
J&J 07.704.110S PUTTY 10CC-FAST SET,C1734,HCPCS,,79012228,CDM,278,RC,,,both,,,6941,5136.36,,,5136.36,Other,150% of Medicare + 9.63% HCRA Surcharge,3123.45,45,,3123.45,percent of total billed charges,Critical Access Hospital RCC factor,2359.94,34,,2359.94,percent of total billed charges,Implant Device,2359.94,34,,2359.94,percent of total billed charges,Implant Device,2359.94,34,,2359.94,percent of total billed charges,Implant Device,2359.94,34,,2359.94,percent of total billed charges,Implant Device,2359.94,34,,2359.94,percent of total billed charges,Implant Device,3435.8,,,3435.8,Other,110% of Medicare,2429.35,35,,2429.35,percent of total billed charges,Implant Device,2359.94,34,"Charges > $500, x 34%",2359.94,percent of total billed charges,Implant Device,2429.35,35,,2429.35,percent of total billed charges,Implant Device,2429.35,35,,2429.35,percent of total billed charges,Implant Device,2429.35,35,,2429.35,percent of total billed charges,Implant Device,2429.35,35,,2429.35,percent of total billed charges,Implant Device,2429.35,35,,2429.35,percent of total billed charges,Implant Device,2776.4,40,,2776.4,percent of total billed charges,Implant Device,2429.35,70,,2429.35,percent of total billed charges,All Other,2359.94,34,,2359.94,percent of total billed charges,Implant Device,2359.94,34,,2359.94,percent of total billed charges,Implant Device,2429.35,35,,2429.35,percent of total billed charges,Implant Device,2429.35,35,,2429.35,percent of total billed charges,Implant Device,2429.35,35,,2429.35,percent of total billed charges,Implant Device,2429.35,35,,2429.35,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2359.94,34,"If Charge > 2,000, then 34 percent",2359.94,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5136.36,
ZIMMER 574101085 FEMORAL STEM SIZE 8.5,C1776,HCPCS,,79012229,CDM,278,RC,,,both,,,6912,5114.9,,,5114.9,Other,150% of Medicare + 9.63% HCRA Surcharge,3110.4,45,,3110.4,percent of total billed charges,Critical Access Hospital RCC factor,2350.08,34,,2350.08,percent of total billed charges,Implant Device,2350.08,34,,2350.08,percent of total billed charges,Implant Device,2350.08,34,,2350.08,percent of total billed charges,Implant Device,2350.08,34,,2350.08,percent of total billed charges,Implant Device,2350.08,34,,2350.08,percent of total billed charges,Implant Device,3421.44,,,3421.44,Other,110% of Medicare,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2350.08,34,"Charges > $500, x 34%",2350.08,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2764.8,40,,2764.8,percent of total billed charges,Implant Device,2419.2,70,,2419.2,percent of total billed charges,All Other,2350.08,34,,2350.08,percent of total billed charges,Implant Device,2350.08,34,,2350.08,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2350.08,34,"If Charge > 2,000, then 34 percent",2350.08,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5114.9,
ZIMMER 574201090 FEMORAL STEM SIZE 9,C1776,HCPCS,,79012230,CDM,278,RC,,,both,,,6912,5114.9,,,5114.9,Other,150% of Medicare + 9.63% HCRA Surcharge,3110.4,45,,3110.4,percent of total billed charges,Critical Access Hospital RCC factor,2350.08,34,,2350.08,percent of total billed charges,Implant Device,2350.08,34,,2350.08,percent of total billed charges,Implant Device,2350.08,34,,2350.08,percent of total billed charges,Implant Device,2350.08,34,,2350.08,percent of total billed charges,Implant Device,2350.08,34,,2350.08,percent of total billed charges,Implant Device,3421.44,,,3421.44,Other,110% of Medicare,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2350.08,34,"Charges > $500, x 34%",2350.08,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2764.8,40,,2764.8,percent of total billed charges,Implant Device,2419.2,70,,2419.2,percent of total billed charges,All Other,2350.08,34,,2350.08,percent of total billed charges,Implant Device,2350.08,34,,2350.08,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2350.08,34,"If Charge > 2,000, then 34 percent",2350.08,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5114.9,
ZIMMER 00-5001-057-28 BIPOLAR CUP LINER,C1776,HCPCS,,79012231,CDM,278,RC,,,both,,,789,583.86,,,583.86,Other,150% of Medicare + 9.63% HCRA Surcharge,355.05,45,,355.05,percent of total billed charges,Critical Access Hospital RCC factor,268.26,34,,268.26,percent of total billed charges,Implant Device,268.26,34,,268.26,percent of total billed charges,Implant Device,268.26,34,,268.26,percent of total billed charges,Implant Device,268.26,34,,268.26,percent of total billed charges,Implant Device,268.26,34,,268.26,percent of total billed charges,Implant Device,390.56,,,390.56,Other,110% of Medicare,276.15,35,,276.15,percent of total billed charges,Implant Device,268.26,34,"Charges > $500, x 34%",268.26,percent of total billed charges,Implant Device,276.15,35,,276.15,percent of total billed charges,Implant Device,276.15,35,,276.15,percent of total billed charges,Implant Device,276.15,35,,276.15,percent of total billed charges,Implant Device,276.15,35,,276.15,percent of total billed charges,Implant Device,276.15,35,,276.15,percent of total billed charges,Implant Device,315.6,40,,315.6,percent of total billed charges,Implant Device,276.15,70,,276.15,percent of total billed charges,All Other,268.26,34,,268.26,percent of total billed charges,Implant Device,268.26,34,,268.26,percent of total billed charges,Implant Device,276.15,35,,276.15,percent of total billed charges,Implant Device,276.15,35,,276.15,percent of total billed charges,Implant Device,276.15,35,,276.15,percent of total billed charges,Implant Device,276.15,35,,276.15,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,583.86,
ZIMMER 00-5001-057-00 BIPOLAR CUP SHELL,C1776,HCPCS,,79012232,CDM,278,RC,,,both,,,960,710.4,,,710.4,Other,150% of Medicare + 9.63% HCRA Surcharge,432,45,,432,percent of total billed charges,Critical Access Hospital RCC factor,326.4,34,,326.4,percent of total billed charges,Implant Device,326.4,34,,326.4,percent of total billed charges,Implant Device,326.4,34,,326.4,percent of total billed charges,Implant Device,326.4,34,,326.4,percent of total billed charges,Implant Device,326.4,34,,326.4,percent of total billed charges,Implant Device,475.2,,,475.2,Other,110% of Medicare,336,35,,336,percent of total billed charges,Implant Device,326.4,34,"Charges > $500, x 34%",326.4,percent of total billed charges,Implant Device,336,35,,336,percent of total billed charges,Implant Device,336,35,,336,percent of total billed charges,Implant Device,336,35,,336,percent of total billed charges,Implant Device,336,35,,336,percent of total billed charges,Implant Device,336,35,,336,percent of total billed charges,Implant Device,384,40,,384,percent of total billed charges,Implant Device,336,70,,336,percent of total billed charges,All Other,326.4,34,,326.4,percent of total billed charges,Implant Device,326.4,34,,326.4,percent of total billed charges,Implant Device,336,35,,336,percent of total billed charges,Implant Device,336,35,,336,percent of total billed charges,Implant Device,336,35,,336,percent of total billed charges,Implant Device,336,35,,336,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,710.4,
DJO 412-02-049 BIPOLAR MODULAR 49X28MM,C1776,HCPCS,,79012233,CDM,278,RC,,,both,,,1380,1021.2,,,1021.2,Other,150% of Medicare + 9.63% HCRA Surcharge,621,45,,621,percent of total billed charges,Critical Access Hospital RCC factor,469.2,34,,469.2,percent of total billed charges,Implant Device,469.2,34,,469.2,percent of total billed charges,Implant Device,469.2,34,,469.2,percent of total billed charges,Implant Device,469.2,34,,469.2,percent of total billed charges,Implant Device,469.2,34,,469.2,percent of total billed charges,Implant Device,683.1,,,683.1,Other,110% of Medicare,483,35,,483,percent of total billed charges,Implant Device,469.2,34,"Charges > $500, x 34%",469.2,percent of total billed charges,Implant Device,483,35,,483,percent of total billed charges,Implant Device,483,35,,483,percent of total billed charges,Implant Device,483,35,,483,percent of total billed charges,Implant Device,483,35,,483,percent of total billed charges,Implant Device,483,35,,483,percent of total billed charges,Implant Device,552,40,,552,percent of total billed charges,Implant Device,483,70,,483,percent of total billed charges,All Other,469.2,34,,469.2,percent of total billed charges,Implant Device,469.2,34,,469.2,percent of total billed charges,Implant Device,483,35,,483,percent of total billed charges,Implant Device,483,35,,483,percent of total billed charges,Implant Device,483,35,,483,percent of total billed charges,Implant Device,483,35,,483,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1021.2,
DJO 400-03-281 FEMORAL HEAD 28MM,C1776,HCPCS,,79012234,CDM,278,RC,,,both,,,4350,3219.01,,,3219.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1957.5,45,,1957.5,percent of total billed charges,Critical Access Hospital RCC factor,1479,34,,1479,percent of total billed charges,Implant Device,1479,34,,1479,percent of total billed charges,Implant Device,1479,34,,1479,percent of total billed charges,Implant Device,1479,34,,1479,percent of total billed charges,Implant Device,1479,34,,1479,percent of total billed charges,Implant Device,2153.25,,,2153.25,Other,110% of Medicare,1522.5,35,,1522.5,percent of total billed charges,Implant Device,1479,34,"Charges > $500, x 34%",1479,percent of total billed charges,Implant Device,1522.5,35,,1522.5,percent of total billed charges,Implant Device,1522.5,35,,1522.5,percent of total billed charges,Implant Device,1522.5,35,,1522.5,percent of total billed charges,Implant Device,1522.5,35,,1522.5,percent of total billed charges,Implant Device,1522.5,35,,1522.5,percent of total billed charges,Implant Device,1740,40,,1740,percent of total billed charges,Implant Device,1522.5,70,,1522.5,percent of total billed charges,All Other,1479,34,,1479,percent of total billed charges,Implant Device,1479,34,,1479,percent of total billed charges,Implant Device,1522.5,35,,1522.5,percent of total billed charges,Implant Device,1522.5,35,,1522.5,percent of total billed charges,Implant Device,1522.5,35,,1522.5,percent of total billed charges,Implant Device,1522.5,35,,1522.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1479,34,"If Charge > 2,000, then 34 percent",1479,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3219.01,
ZIMMER 42-5221-009-10 ART SURF RT 10MM,C1776,HCPCS,,79012237,CDM,278,RC,,,both,,,3648,2699.53,,,2699.53,Other,150% of Medicare + 9.63% HCRA Surcharge,1641.6,45,,1641.6,percent of total billed charges,Critical Access Hospital RCC factor,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1805.76,,,1805.76,Other,110% of Medicare,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1240.32,34,"Charges > $500, x 34%",1240.32,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1459.2,40,,1459.2,percent of total billed charges,Implant Device,1276.8,70,,1276.8,percent of total billed charges,All Other,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1240.32,34,"If Charge > 2,000, then 34 percent",1240.32,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2699.53,
ZIMMER 42-5221-009-13 ART SURF RT 13MM,C1776,HCPCS,,79012238,CDM,278,RC,,,both,,,3648,2699.53,,,2699.53,Other,150% of Medicare + 9.63% HCRA Surcharge,1641.6,45,,1641.6,percent of total billed charges,Critical Access Hospital RCC factor,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1805.76,,,1805.76,Other,110% of Medicare,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1240.32,34,"Charges > $500, x 34%",1240.32,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1459.2,40,,1459.2,percent of total billed charges,Implant Device,1276.8,70,,1276.8,percent of total billed charges,All Other,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1240.32,34,"If Charge > 2,000, then 34 percent",1240.32,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2699.53,
IN2BONES P80 ST221 CFX PLATE SMALL LEFT,C1713,HCPCS,,79012240,CDM,278,RC,,,both,,,7185,5316.92,,,5316.92,Other,150% of Medicare + 9.63% HCRA Surcharge,3233.25,45,,3233.25,percent of total billed charges,Critical Access Hospital RCC factor,2442.9,34,,2442.9,percent of total billed charges,Implant Device,2442.9,34,,2442.9,percent of total billed charges,Implant Device,2442.9,34,,2442.9,percent of total billed charges,Implant Device,2442.9,34,,2442.9,percent of total billed charges,Implant Device,2442.9,34,,2442.9,percent of total billed charges,Implant Device,3556.58,,,3556.58,Other,110% of Medicare,2514.75,35,,2514.75,percent of total billed charges,Implant Device,2442.9,34,"Charges > $500, x 34%",2442.9,percent of total billed charges,Implant Device,2514.75,35,,2514.75,percent of total billed charges,Implant Device,2514.75,35,,2514.75,percent of total billed charges,Implant Device,2514.75,35,,2514.75,percent of total billed charges,Implant Device,2514.75,35,,2514.75,percent of total billed charges,Implant Device,2514.75,35,,2514.75,percent of total billed charges,Implant Device,2874,40,,2874,percent of total billed charges,Implant Device,2514.75,70,,2514.75,percent of total billed charges,All Other,2442.9,34,,2442.9,percent of total billed charges,Implant Device,2442.9,34,,2442.9,percent of total billed charges,Implant Device,2514.75,35,,2514.75,percent of total billed charges,Implant Device,2514.75,35,,2514.75,percent of total billed charges,Implant Device,2514.75,35,,2514.75,percent of total billed charges,Implant Device,2514.75,35,,2514.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2442.9,34,"If Charge > 2,000, then 34 percent",2442.9,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5316.92,
IN2BONES P73 ST020 CORTICAL SCREW 3.5X20,C1713,HCPCS,,79012241,CDM,278,RC,,,both,,,870,643.8,,,643.8,Other,150% of Medicare + 9.63% HCRA Surcharge,391.5,45,,391.5,percent of total billed charges,Critical Access Hospital RCC factor,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,430.65,,,430.65,Other,110% of Medicare,304.5,35,,304.5,percent of total billed charges,Implant Device,295.8,34,"Charges > $500, x 34%",295.8,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,348,40,,348,percent of total billed charges,Implant Device,304.5,70,,304.5,percent of total billed charges,All Other,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,643.8,
IN2BONES P73 ST130 LOCK SCREW 3.5X30MM,C1713,HCPCS,,79012242,CDM,278,RC,,,both,,,870,643.8,,,643.8,Other,150% of Medicare + 9.63% HCRA Surcharge,391.5,45,,391.5,percent of total billed charges,Critical Access Hospital RCC factor,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,430.65,,,430.65,Other,110% of Medicare,304.5,35,,304.5,percent of total billed charges,Implant Device,295.8,34,"Charges > $500, x 34%",295.8,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,348,40,,348,percent of total billed charges,Implant Device,304.5,70,,304.5,percent of total billed charges,All Other,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,643.8,
IN2BONES P73 ST124 LOCK SCREW 3.5X24MM,C1713,HCPCS,,79012243,CDM,278,RC,,,both,,,870,643.8,,,643.8,Other,150% of Medicare + 9.63% HCRA Surcharge,391.5,45,,391.5,percent of total billed charges,Critical Access Hospital RCC factor,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,430.65,,,430.65,Other,110% of Medicare,304.5,35,,304.5,percent of total billed charges,Implant Device,295.8,34,"Charges > $500, x 34%",295.8,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,348,40,,348,percent of total billed charges,Implant Device,304.5,70,,304.5,percent of total billed charges,All Other,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,643.8,
IN2BONES P73 ST134 LOCK SCREW 3.5X34MM,C1713,HCPCS,,79012244,CDM,278,RC,,,both,,,870,643.8,,,643.8,Other,150% of Medicare + 9.63% HCRA Surcharge,391.5,45,,391.5,percent of total billed charges,Critical Access Hospital RCC factor,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,430.65,,,430.65,Other,110% of Medicare,304.5,35,,304.5,percent of total billed charges,Implant Device,295.8,34,"Charges > $500, x 34%",295.8,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,348,40,,348,percent of total billed charges,Implant Device,304.5,70,,304.5,percent of total billed charges,All Other,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,643.8,
IN2BONES P73 ST140 LOCK SCREW 3.5X40MM,C1713,HCPCS,,79012245,CDM,278,RC,,,both,,,870,643.8,,,643.8,Other,150% of Medicare + 9.63% HCRA Surcharge,391.5,45,,391.5,percent of total billed charges,Critical Access Hospital RCC factor,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,430.65,,,430.65,Other,110% of Medicare,304.5,35,,304.5,percent of total billed charges,Implant Device,295.8,34,"Charges > $500, x 34%",295.8,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,348,40,,348,percent of total billed charges,Implant Device,304.5,70,,304.5,percent of total billed charges,All Other,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,643.8,
STRYKER 1822-1028S TIBIAL NAIL 5X35MM,C1889,HCPCS,,79012248,CDM,278,RC,,,both,,,3017,2232.59,,,2232.59,Other,150% of Medicare + 9.63% HCRA Surcharge,1357.65,45,,1357.65,percent of total billed charges,Critical Access Hospital RCC factor,1025.78,34,,1025.78,percent of total billed charges,Implant Device,1025.78,34,,1025.78,percent of total billed charges,Implant Device,1025.78,34,,1025.78,percent of total billed charges,Implant Device,1025.78,34,,1025.78,percent of total billed charges,Implant Device,1025.78,34,,1025.78,percent of total billed charges,Implant Device,1493.42,,,1493.42,Other,110% of Medicare,1055.95,35,,1055.95,percent of total billed charges,Implant Device,1025.78,34,"Charges > $500, x 34%",1025.78,percent of total billed charges,Implant Device,1055.95,35,,1055.95,percent of total billed charges,Implant Device,1055.95,35,,1055.95,percent of total billed charges,Implant Device,1055.95,35,,1055.95,percent of total billed charges,Implant Device,1055.95,35,,1055.95,percent of total billed charges,Implant Device,1055.95,35,,1055.95,percent of total billed charges,Implant Device,1206.8,40,,1206.8,percent of total billed charges,Implant Device,1055.95,70,,1055.95,percent of total billed charges,All Other,1025.78,34,,1025.78,percent of total billed charges,Implant Device,1025.78,34,,1025.78,percent of total billed charges,Implant Device,1055.95,35,,1055.95,percent of total billed charges,Implant Device,1055.95,35,,1055.95,percent of total billed charges,Implant Device,1055.95,35,,1055.95,percent of total billed charges,Implant Device,1055.95,35,,1055.95,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1025.78,34,"If Charge > 2,000, then 34 percent",1025.78,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2232.59,
ZIMMER 110031000 BEARING SIZE F 28X44MM,C1776,HCPCS,,79012249,CDM,278,RC,,,both,,,2304,1704.97,,,1704.97,Other,150% of Medicare + 9.63% HCRA Surcharge,1036.8,45,,1036.8,percent of total billed charges,Critical Access Hospital RCC factor,783.36,34,,783.36,percent of total billed charges,Implant Device,783.36,34,,783.36,percent of total billed charges,Implant Device,783.36,34,,783.36,percent of total billed charges,Implant Device,783.36,34,,783.36,percent of total billed charges,Implant Device,783.36,34,,783.36,percent of total billed charges,Implant Device,1140.48,,,1140.48,Other,110% of Medicare,806.4,35,,806.4,percent of total billed charges,Implant Device,783.36,34,"Charges > $500, x 34%",783.36,percent of total billed charges,Implant Device,806.4,35,,806.4,percent of total billed charges,Implant Device,806.4,35,,806.4,percent of total billed charges,Implant Device,806.4,35,,806.4,percent of total billed charges,Implant Device,806.4,35,,806.4,percent of total billed charges,Implant Device,806.4,35,,806.4,percent of total billed charges,Implant Device,921.6,40,,921.6,percent of total billed charges,Implant Device,806.4,70,,806.4,percent of total billed charges,All Other,783.36,34,,783.36,percent of total billed charges,Implant Device,783.36,34,,783.36,percent of total billed charges,Implant Device,806.4,35,,806.4,percent of total billed charges,Implant Device,806.4,35,,806.4,percent of total billed charges,Implant Device,806.4,35,,806.4,percent of total billed charges,Implant Device,806.4,35,,806.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,783.36,34,"If Charge > 2,000, then 34 percent",783.36,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1704.97,
ZIMMER 650-1158 CERAMIC HEAD TYPE 1 28MM,C1776,HCPCS,,79012250,CDM,278,RC,,,both,,,2880,2131.21,,,2131.21,Other,150% of Medicare + 9.63% HCRA Surcharge,1296,45,,1296,percent of total billed charges,Critical Access Hospital RCC factor,979.2,34,,979.2,percent of total billed charges,Implant Device,979.2,34,,979.2,percent of total billed charges,Implant Device,979.2,34,,979.2,percent of total billed charges,Implant Device,979.2,34,,979.2,percent of total billed charges,Implant Device,979.2,34,,979.2,percent of total billed charges,Implant Device,1425.6,,,1425.6,Other,110% of Medicare,1008,35,,1008,percent of total billed charges,Implant Device,979.2,34,"Charges > $500, x 34%",979.2,percent of total billed charges,Implant Device,1008,35,,1008,percent of total billed charges,Implant Device,1008,35,,1008,percent of total billed charges,Implant Device,1008,35,,1008,percent of total billed charges,Implant Device,1008,35,,1008,percent of total billed charges,Implant Device,1008,35,,1008,percent of total billed charges,Implant Device,1152,40,,1152,percent of total billed charges,Implant Device,1008,70,,1008,percent of total billed charges,All Other,979.2,34,,979.2,percent of total billed charges,Implant Device,979.2,34,,979.2,percent of total billed charges,Implant Device,1008,35,,1008,percent of total billed charges,Implant Device,1008,35,,1008,percent of total billed charges,Implant Device,1008,35,,1008,percent of total billed charges,Implant Device,1008,35,,1008,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,979.2,34,"If Charge > 2,000, then 34 percent",979.2,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2131.21,
ZIMMER 8145-01-085 HIP SCREW 85MM,C1713,HCPCS,,79012251,CDM,278,RC,,,both,,,734,543.16,,,543.16,Other,150% of Medicare + 9.63% HCRA Surcharge,330.3,45,,330.3,percent of total billed charges,Critical Access Hospital RCC factor,249.56,34,,249.56,percent of total billed charges,Implant Device,249.56,34,,249.56,percent of total billed charges,Implant Device,249.56,34,,249.56,percent of total billed charges,Implant Device,249.56,34,,249.56,percent of total billed charges,Implant Device,249.56,34,,249.56,percent of total billed charges,Implant Device,363.33,,,363.33,Other,110% of Medicare,256.9,35,,256.9,percent of total billed charges,Implant Device,249.56,34,"Charges > $500, x 34%",249.56,percent of total billed charges,Implant Device,256.9,35,,256.9,percent of total billed charges,Implant Device,256.9,35,,256.9,percent of total billed charges,Implant Device,256.9,35,,256.9,percent of total billed charges,Implant Device,256.9,35,,256.9,percent of total billed charges,Implant Device,256.9,35,,256.9,percent of total billed charges,Implant Device,293.6,40,,293.6,percent of total billed charges,Implant Device,256.9,70,,256.9,percent of total billed charges,All Other,249.56,34,,249.56,percent of total billed charges,Implant Device,249.56,34,,249.56,percent of total billed charges,Implant Device,256.9,35,,256.9,percent of total billed charges,Implant Device,256.9,35,,256.9,percent of total billed charges,Implant Device,256.9,35,,256.9,percent of total billed charges,Implant Device,256.9,35,,256.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,543.16,
J&J 04.037.212S TFNA NAIL 12X170MM,C1889,HCPCS,,79012252,CDM,278,RC,,,both,,,3718,2751.33,,,2751.33,Other,150% of Medicare + 9.63% HCRA Surcharge,1673.1,45,,1673.1,percent of total billed charges,Critical Access Hospital RCC factor,1264.12,34,,1264.12,percent of total billed charges,Implant Device,1264.12,34,,1264.12,percent of total billed charges,Implant Device,1264.12,34,,1264.12,percent of total billed charges,Implant Device,1264.12,34,,1264.12,percent of total billed charges,Implant Device,1264.12,34,,1264.12,percent of total billed charges,Implant Device,1840.41,,,1840.41,Other,110% of Medicare,1301.3,35,,1301.3,percent of total billed charges,Implant Device,1264.12,34,"Charges > $500, x 34%",1264.12,percent of total billed charges,Implant Device,1301.3,35,,1301.3,percent of total billed charges,Implant Device,1301.3,35,,1301.3,percent of total billed charges,Implant Device,1301.3,35,,1301.3,percent of total billed charges,Implant Device,1301.3,35,,1301.3,percent of total billed charges,Implant Device,1301.3,35,,1301.3,percent of total billed charges,Implant Device,1487.2,40,,1487.2,percent of total billed charges,Implant Device,1301.3,70,,1301.3,percent of total billed charges,All Other,1264.12,34,,1264.12,percent of total billed charges,Implant Device,1264.12,34,,1264.12,percent of total billed charges,Implant Device,1301.3,35,,1301.3,percent of total billed charges,Implant Device,1301.3,35,,1301.3,percent of total billed charges,Implant Device,1301.3,35,,1301.3,percent of total billed charges,Implant Device,1301.3,35,,1301.3,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1264.12,34,"If Charge > 2,000, then 34 percent",1264.12,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2751.33,
J&J 42.231.224 OPTILINK SCREW 5.0X24MM,C1713,HCPCS,,79012254,CDM,278,RC,,,both,,,513,379.62,,,379.62,Other,150% of Medicare + 9.63% HCRA Surcharge,230.85,45,,230.85,percent of total billed charges,Critical Access Hospital RCC factor,174.42,34,,174.42,percent of total billed charges,Implant Device,174.42,34,,174.42,percent of total billed charges,Implant Device,174.42,34,,174.42,percent of total billed charges,Implant Device,174.42,34,,174.42,percent of total billed charges,Implant Device,174.42,34,,174.42,percent of total billed charges,Implant Device,253.94,,,253.94,Other,110% of Medicare,179.55,35,,179.55,percent of total billed charges,Implant Device,174.42,34,"Charges > $500, x 34%",174.42,percent of total billed charges,Implant Device,179.55,35,,179.55,percent of total billed charges,Implant Device,179.55,35,,179.55,percent of total billed charges,Implant Device,179.55,35,,179.55,percent of total billed charges,Implant Device,179.55,35,,179.55,percent of total billed charges,Implant Device,179.55,35,,179.55,percent of total billed charges,Implant Device,205.2,40,,205.2,percent of total billed charges,Implant Device,179.55,70,,179.55,percent of total billed charges,All Other,174.42,34,,174.42,percent of total billed charges,Implant Device,174.42,34,,174.42,percent of total billed charges,Implant Device,179.55,35,,179.55,percent of total billed charges,Implant Device,179.55,35,,179.55,percent of total billed charges,Implant Device,179.55,35,,179.55,percent of total billed charges,Implant Device,179.55,35,,179.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,379.62,
J&J 42.231.285 OPTILINK SCREW 5.0X85MM,C1713,HCPCS,,79012255,CDM,278,RC,,,both,,,513,379.62,,,379.62,Other,150% of Medicare + 9.63% HCRA Surcharge,230.85,45,,230.85,percent of total billed charges,Critical Access Hospital RCC factor,174.42,34,,174.42,percent of total billed charges,Implant Device,174.42,34,,174.42,percent of total billed charges,Implant Device,174.42,34,,174.42,percent of total billed charges,Implant Device,174.42,34,,174.42,percent of total billed charges,Implant Device,174.42,34,,174.42,percent of total billed charges,Implant Device,253.94,,,253.94,Other,110% of Medicare,179.55,35,,179.55,percent of total billed charges,Implant Device,174.42,34,"Charges > $500, x 34%",174.42,percent of total billed charges,Implant Device,179.55,35,,179.55,percent of total billed charges,Implant Device,179.55,35,,179.55,percent of total billed charges,Implant Device,179.55,35,,179.55,percent of total billed charges,Implant Device,179.55,35,,179.55,percent of total billed charges,Implant Device,179.55,35,,179.55,percent of total billed charges,Implant Device,205.2,40,,205.2,percent of total billed charges,Implant Device,179.55,70,,179.55,percent of total billed charges,All Other,174.42,34,,174.42,percent of total billed charges,Implant Device,174.42,34,,174.42,percent of total billed charges,Implant Device,179.55,35,,179.55,percent of total billed charges,Implant Device,179.55,35,,179.55,percent of total billed charges,Implant Device,179.55,35,,179.55,percent of total billed charges,Implant Device,179.55,35,,179.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,379.62,
J&J 02.124.417 CONDYLAR PLT 16H 4.5X336,C1713,HCPCS,,79012256,CDM,278,RC,,,both,,,5096,3771.05,,,3771.05,Other,150% of Medicare + 9.63% HCRA Surcharge,2293.2,45,,2293.2,percent of total billed charges,Critical Access Hospital RCC factor,1732.64,34,,1732.64,percent of total billed charges,Implant Device,1732.64,34,,1732.64,percent of total billed charges,Implant Device,1732.64,34,,1732.64,percent of total billed charges,Implant Device,1732.64,34,,1732.64,percent of total billed charges,Implant Device,1732.64,34,,1732.64,percent of total billed charges,Implant Device,2522.52,,,2522.52,Other,110% of Medicare,1783.6,35,,1783.6,percent of total billed charges,Implant Device,1732.64,34,"Charges > $500, x 34%",1732.64,percent of total billed charges,Implant Device,1783.6,35,,1783.6,percent of total billed charges,Implant Device,1783.6,35,,1783.6,percent of total billed charges,Implant Device,1783.6,35,,1783.6,percent of total billed charges,Implant Device,1783.6,35,,1783.6,percent of total billed charges,Implant Device,1783.6,35,,1783.6,percent of total billed charges,Implant Device,2038.4,40,,2038.4,percent of total billed charges,Implant Device,1783.6,70,,1783.6,percent of total billed charges,All Other,1732.64,34,,1732.64,percent of total billed charges,Implant Device,1732.64,34,,1732.64,percent of total billed charges,Implant Device,1783.6,35,,1783.6,percent of total billed charges,Implant Device,1783.6,35,,1783.6,percent of total billed charges,Implant Device,1783.6,35,,1783.6,percent of total billed charges,Implant Device,1783.6,35,,1783.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1732.64,34,"If Charge > 2,000, then 34 percent",1732.64,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3771.05,
ZIMMER 574102065 FEMORAL STEM SIZE 6.5,C1776,HCPCS,,79012257,CDM,278,RC,,,both,,,6912,5114.9,,,5114.9,Other,150% of Medicare + 9.63% HCRA Surcharge,3110.4,45,,3110.4,percent of total billed charges,Critical Access Hospital RCC factor,2350.08,34,,2350.08,percent of total billed charges,Implant Device,2350.08,34,,2350.08,percent of total billed charges,Implant Device,2350.08,34,,2350.08,percent of total billed charges,Implant Device,2350.08,34,,2350.08,percent of total billed charges,Implant Device,2350.08,34,,2350.08,percent of total billed charges,Implant Device,3421.44,,,3421.44,Other,110% of Medicare,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2350.08,34,"Charges > $500, x 34%",2350.08,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2764.8,40,,2764.8,percent of total billed charges,Implant Device,2419.2,70,,2419.2,percent of total billed charges,All Other,2350.08,34,,2350.08,percent of total billed charges,Implant Device,2350.08,34,,2350.08,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2350.08,34,"If Charge > 2,000, then 34 percent",2350.08,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5114.9,
ZIMMER 11-301019 DISTAL STEM 19X250MM,C1776,HCPCS,,79012258,CDM,278,RC,,,both,,,11996,8877.07,,,8877.07,Other,150% of Medicare + 9.63% HCRA Surcharge,5398.2,45,,5398.2,percent of total billed charges,Critical Access Hospital RCC factor,4078.64,34,,4078.64,percent of total billed charges,Implant Device,4078.64,34,,4078.64,percent of total billed charges,Implant Device,4078.64,34,,4078.64,percent of total billed charges,Implant Device,4078.64,34,,4078.64,percent of total billed charges,Implant Device,4078.64,34,,4078.64,percent of total billed charges,Implant Device,5938.02,,,5938.02,Other,110% of Medicare,4198.6,35,,4198.6,percent of total billed charges,Implant Device,4078.64,34,"Charges > $500, x 34%",4078.64,percent of total billed charges,Implant Device,4198.6,35,,4198.6,percent of total billed charges,Implant Device,4198.6,35,,4198.6,percent of total billed charges,Implant Device,4198.6,35,,4198.6,percent of total billed charges,Implant Device,4198.6,35,,4198.6,percent of total billed charges,Implant Device,4198.6,35,,4198.6,percent of total billed charges,Implant Device,4798.4,40,,4798.4,percent of total billed charges,Implant Device,4198.6,70,,4198.6,percent of total billed charges,All Other,4078.64,34,,4078.64,percent of total billed charges,Implant Device,4078.64,34,,4078.64,percent of total billed charges,Implant Device,4198.6,35,,4198.6,percent of total billed charges,Implant Device,4198.6,35,,4198.6,percent of total billed charges,Implant Device,4198.6,35,,4198.6,percent of total billed charges,Implant Device,4198.6,35,,4198.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,4078.64,34,"If Charge > 2,000, then 34 percent",4078.64,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,8877.07,
ZIMMER 650-1163 CERAMIC HEAD 32MM TYPE 1,C1776,HCPCS,,79012259,CDM,278,RC,,,both,,,2880,2131.21,,,2131.21,Other,150% of Medicare + 9.63% HCRA Surcharge,1296,45,,1296,percent of total billed charges,Critical Access Hospital RCC factor,979.2,34,,979.2,percent of total billed charges,Implant Device,979.2,34,,979.2,percent of total billed charges,Implant Device,979.2,34,,979.2,percent of total billed charges,Implant Device,979.2,34,,979.2,percent of total billed charges,Implant Device,979.2,34,,979.2,percent of total billed charges,Implant Device,1425.6,,,1425.6,Other,110% of Medicare,1008,35,,1008,percent of total billed charges,Implant Device,979.2,34,"Charges > $500, x 34%",979.2,percent of total billed charges,Implant Device,1008,35,,1008,percent of total billed charges,Implant Device,1008,35,,1008,percent of total billed charges,Implant Device,1008,35,,1008,percent of total billed charges,Implant Device,1008,35,,1008,percent of total billed charges,Implant Device,1008,35,,1008,percent of total billed charges,Implant Device,1152,40,,1152,percent of total billed charges,Implant Device,1008,70,,1008,percent of total billed charges,All Other,979.2,34,,979.2,percent of total billed charges,Implant Device,979.2,34,,979.2,percent of total billed charges,Implant Device,1008,35,,1008,percent of total billed charges,Implant Device,1008,35,,1008,percent of total billed charges,Implant Device,1008,35,,1008,percent of total billed charges,Implant Device,1008,35,,1008,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,979.2,34,"If Charge > 2,000, then 34 percent",979.2,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2131.21,
ZIMMER 11-302102 TROCHANTERIC CLAW 100MM,C1776,HCPCS,,79012260,CDM,278,RC,,,both,,,2903,2148.23,,,2148.23,Other,150% of Medicare + 9.63% HCRA Surcharge,1306.35,45,,1306.35,percent of total billed charges,Critical Access Hospital RCC factor,987.02,34,,987.02,percent of total billed charges,Implant Device,987.02,34,,987.02,percent of total billed charges,Implant Device,987.02,34,,987.02,percent of total billed charges,Implant Device,987.02,34,,987.02,percent of total billed charges,Implant Device,987.02,34,,987.02,percent of total billed charges,Implant Device,1436.99,,,1436.99,Other,110% of Medicare,1016.05,35,,1016.05,percent of total billed charges,Implant Device,987.02,34,"Charges > $500, x 34%",987.02,percent of total billed charges,Implant Device,1016.05,35,,1016.05,percent of total billed charges,Implant Device,1016.05,35,,1016.05,percent of total billed charges,Implant Device,1016.05,35,,1016.05,percent of total billed charges,Implant Device,1016.05,35,,1016.05,percent of total billed charges,Implant Device,1016.05,35,,1016.05,percent of total billed charges,Implant Device,1161.2,40,,1161.2,percent of total billed charges,Implant Device,1016.05,70,,1016.05,percent of total billed charges,All Other,987.02,34,,987.02,percent of total billed charges,Implant Device,987.02,34,,987.02,percent of total billed charges,Implant Device,1016.05,35,,1016.05,percent of total billed charges,Implant Device,1016.05,35,,1016.05,percent of total billed charges,Implant Device,1016.05,35,,1016.05,percent of total billed charges,Implant Device,1016.05,35,,1016.05,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,987.02,34,"If Charge > 2,000, then 34 percent",987.02,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2148.23,
ZIMMER 11-302140 TROCHANTERIC BOLT 40MM,C1713,HCPCS,,79012261,CDM,278,RC,,,both,,,1812,1340.88,,,1340.88,Other,150% of Medicare + 9.63% HCRA Surcharge,815.4,45,,815.4,percent of total billed charges,Critical Access Hospital RCC factor,616.08,34,,616.08,percent of total billed charges,Implant Device,616.08,34,,616.08,percent of total billed charges,Implant Device,616.08,34,,616.08,percent of total billed charges,Implant Device,616.08,34,,616.08,percent of total billed charges,Implant Device,616.08,34,,616.08,percent of total billed charges,Implant Device,896.94,,,896.94,Other,110% of Medicare,634.2,35,,634.2,percent of total billed charges,Implant Device,616.08,34,"Charges > $500, x 34%",616.08,percent of total billed charges,Implant Device,634.2,35,,634.2,percent of total billed charges,Implant Device,634.2,35,,634.2,percent of total billed charges,Implant Device,634.2,35,,634.2,percent of total billed charges,Implant Device,634.2,35,,634.2,percent of total billed charges,Implant Device,634.2,35,,634.2,percent of total billed charges,Implant Device,724.8,40,,724.8,percent of total billed charges,Implant Device,634.2,70,,634.2,percent of total billed charges,All Other,616.08,34,,616.08,percent of total billed charges,Implant Device,616.08,34,,616.08,percent of total billed charges,Implant Device,634.2,35,,634.2,percent of total billed charges,Implant Device,634.2,35,,634.2,percent of total billed charges,Implant Device,634.2,35,,634.2,percent of total billed charges,Implant Device,634.2,35,,634.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1340.88,
ZIMMER 00-5001-054-00 BIPOLAR SHELL 54MM,C1776,HCPCS,,79012262,CDM,278,RC,,,both,,,960,710.4,,,710.4,Other,150% of Medicare + 9.63% HCRA Surcharge,432,45,,432,percent of total billed charges,Critical Access Hospital RCC factor,326.4,34,,326.4,percent of total billed charges,Implant Device,326.4,34,,326.4,percent of total billed charges,Implant Device,326.4,34,,326.4,percent of total billed charges,Implant Device,326.4,34,,326.4,percent of total billed charges,Implant Device,326.4,34,,326.4,percent of total billed charges,Implant Device,475.2,,,475.2,Other,110% of Medicare,336,35,,336,percent of total billed charges,Implant Device,326.4,34,"Charges > $500, x 34%",326.4,percent of total billed charges,Implant Device,336,35,,336,percent of total billed charges,Implant Device,336,35,,336,percent of total billed charges,Implant Device,336,35,,336,percent of total billed charges,Implant Device,336,35,,336,percent of total billed charges,Implant Device,336,35,,336,percent of total billed charges,Implant Device,384,40,,384,percent of total billed charges,Implant Device,336,70,,336,percent of total billed charges,All Other,326.4,34,,326.4,percent of total billed charges,Implant Device,326.4,34,,326.4,percent of total billed charges,Implant Device,336,35,,336,percent of total billed charges,Implant Device,336,35,,336,percent of total billed charges,Implant Device,336,35,,336,percent of total billed charges,Implant Device,336,35,,336,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,710.4,
STRYKER 2361-5055S LOCKING SCREW 5X55MM,C1713,HCPCS,,79012266,CDM,278,RC,,,both,,,887,656.38,,,656.38,Other,150% of Medicare + 9.63% HCRA Surcharge,399.15,45,,399.15,percent of total billed charges,Critical Access Hospital RCC factor,301.58,34,,301.58,percent of total billed charges,Implant Device,301.58,34,,301.58,percent of total billed charges,Implant Device,301.58,34,,301.58,percent of total billed charges,Implant Device,301.58,34,,301.58,percent of total billed charges,Implant Device,301.58,34,,301.58,percent of total billed charges,Implant Device,439.07,,,439.07,Other,110% of Medicare,310.45,35,,310.45,percent of total billed charges,Implant Device,301.58,34,"Charges > $500, x 34%",301.58,percent of total billed charges,Implant Device,310.45,35,,310.45,percent of total billed charges,Implant Device,310.45,35,,310.45,percent of total billed charges,Implant Device,310.45,35,,310.45,percent of total billed charges,Implant Device,310.45,35,,310.45,percent of total billed charges,Implant Device,310.45,35,,310.45,percent of total billed charges,Implant Device,354.8,40,,354.8,percent of total billed charges,Implant Device,310.45,70,,310.45,percent of total billed charges,All Other,301.58,34,,301.58,percent of total billed charges,Implant Device,301.58,34,,301.58,percent of total billed charges,Implant Device,310.45,35,,310.45,percent of total billed charges,Implant Device,310.45,35,,310.45,percent of total billed charges,Implant Device,310.45,35,,310.45,percent of total billed charges,Implant Device,310.45,35,,310.45,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,656.38,
J&J 42.231.250 LOCKING SCREW 5.0X50MM,C1713,HCPCS,,79012267,CDM,278,RC,,,both,,,513,379.62,,,379.62,Other,150% of Medicare + 9.63% HCRA Surcharge,230.85,45,,230.85,percent of total billed charges,Critical Access Hospital RCC factor,174.42,34,,174.42,percent of total billed charges,Implant Device,174.42,34,,174.42,percent of total billed charges,Implant Device,174.42,34,,174.42,percent of total billed charges,Implant Device,174.42,34,,174.42,percent of total billed charges,Implant Device,174.42,34,,174.42,percent of total billed charges,Implant Device,253.94,,,253.94,Other,110% of Medicare,179.55,35,,179.55,percent of total billed charges,Implant Device,174.42,34,"Charges > $500, x 34%",174.42,percent of total billed charges,Implant Device,179.55,35,,179.55,percent of total billed charges,Implant Device,179.55,35,,179.55,percent of total billed charges,Implant Device,179.55,35,,179.55,percent of total billed charges,Implant Device,179.55,35,,179.55,percent of total billed charges,Implant Device,179.55,35,,179.55,percent of total billed charges,Implant Device,205.2,40,,205.2,percent of total billed charges,Implant Device,179.55,70,,179.55,percent of total billed charges,All Other,174.42,34,,174.42,percent of total billed charges,Implant Device,174.42,34,,174.42,percent of total billed charges,Implant Device,179.55,35,,179.55,percent of total billed charges,Implant Device,179.55,35,,179.55,percent of total billed charges,Implant Device,179.55,35,,179.55,percent of total billed charges,Implant Device,179.55,35,,179.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,379.62,
J&J 02.112.620 LCP CLAVICLE PLT 2.7MM,C1713,HCPCS,,79012269,CDM,278,RC,,,both,,,3218,2381.33,,,2381.33,Other,150% of Medicare + 9.63% HCRA Surcharge,1448.1,45,,1448.1,percent of total billed charges,Critical Access Hospital RCC factor,1094.12,34,,1094.12,percent of total billed charges,Implant Device,1094.12,34,,1094.12,percent of total billed charges,Implant Device,1094.12,34,,1094.12,percent of total billed charges,Implant Device,1094.12,34,,1094.12,percent of total billed charges,Implant Device,1094.12,34,,1094.12,percent of total billed charges,Implant Device,1592.91,,,1592.91,Other,110% of Medicare,1126.3,35,,1126.3,percent of total billed charges,Implant Device,1094.12,34,"Charges > $500, x 34%",1094.12,percent of total billed charges,Implant Device,1126.3,35,,1126.3,percent of total billed charges,Implant Device,1126.3,35,,1126.3,percent of total billed charges,Implant Device,1126.3,35,,1126.3,percent of total billed charges,Implant Device,1126.3,35,,1126.3,percent of total billed charges,Implant Device,1126.3,35,,1126.3,percent of total billed charges,Implant Device,1287.2,40,,1287.2,percent of total billed charges,Implant Device,1126.3,70,,1126.3,percent of total billed charges,All Other,1094.12,34,,1094.12,percent of total billed charges,Implant Device,1094.12,34,,1094.12,percent of total billed charges,Implant Device,1126.3,35,,1126.3,percent of total billed charges,Implant Device,1126.3,35,,1126.3,percent of total billed charges,Implant Device,1126.3,35,,1126.3,percent of total billed charges,Implant Device,1126.3,35,,1126.3,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1094.12,34,"If Charge > 2,000, then 34 percent",1094.12,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2381.33,
IN2BONES P73 ST022 CORT SCREW 3.5X22MM,C1713,HCPCS,,79012270,CDM,278,RC,,,both,,,870,643.8,,,643.8,Other,150% of Medicare + 9.63% HCRA Surcharge,391.5,45,,391.5,percent of total billed charges,Critical Access Hospital RCC factor,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,430.65,,,430.65,Other,110% of Medicare,304.5,35,,304.5,percent of total billed charges,Implant Device,295.8,34,"Charges > $500, x 34%",295.8,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,348,40,,348,percent of total billed charges,Implant Device,304.5,70,,304.5,percent of total billed charges,All Other,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,643.8,
STRYKER 3130-0170S TROCH NAIL KIT 10X170,C1889,HCPCS,,79012271,CDM,278,RC,,,both,,,2928,2166.73,,,2166.73,Other,150% of Medicare + 9.63% HCRA Surcharge,1317.6,45,,1317.6,percent of total billed charges,Critical Access Hospital RCC factor,995.52,34,,995.52,percent of total billed charges,Implant Device,995.52,34,,995.52,percent of total billed charges,Implant Device,995.52,34,,995.52,percent of total billed charges,Implant Device,995.52,34,,995.52,percent of total billed charges,Implant Device,995.52,34,,995.52,percent of total billed charges,Implant Device,1449.36,,,1449.36,Other,110% of Medicare,1024.8,35,,1024.8,percent of total billed charges,Implant Device,995.52,34,"Charges > $500, x 34%",995.52,percent of total billed charges,Implant Device,1024.8,35,,1024.8,percent of total billed charges,Implant Device,1024.8,35,,1024.8,percent of total billed charges,Implant Device,1024.8,35,,1024.8,percent of total billed charges,Implant Device,1024.8,35,,1024.8,percent of total billed charges,Implant Device,1024.8,35,,1024.8,percent of total billed charges,Implant Device,1171.2,40,,1171.2,percent of total billed charges,Implant Device,1024.8,70,,1024.8,percent of total billed charges,All Other,995.52,34,,995.52,percent of total billed charges,Implant Device,995.52,34,,995.52,percent of total billed charges,Implant Device,1024.8,35,,1024.8,percent of total billed charges,Implant Device,1024.8,35,,1024.8,percent of total billed charges,Implant Device,1024.8,35,,1024.8,percent of total billed charges,Implant Device,1024.8,35,,1024.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,995.52,34,"If Charge > 2,000, then 34 percent",995.52,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2166.73,
ZIMMER 110010246 ACETABULAR SHELL 4H 56,C1776,HCPCS,,79012280,CDM,278,RC,,,both,,,8602,6365.5,,,6365.5,Other,150% of Medicare + 9.63% HCRA Surcharge,3870.9,45,,3870.9,percent of total billed charges,Critical Access Hospital RCC factor,2924.68,34,,2924.68,percent of total billed charges,Implant Device,2924.68,34,,2924.68,percent of total billed charges,Implant Device,2924.68,34,,2924.68,percent of total billed charges,Implant Device,2924.68,34,,2924.68,percent of total billed charges,Implant Device,2924.68,34,,2924.68,percent of total billed charges,Implant Device,4257.99,,,4257.99,Other,110% of Medicare,3010.7,35,,3010.7,percent of total billed charges,Implant Device,2924.68,34,"Charges > $500, x 34%",2924.68,percent of total billed charges,Implant Device,3010.7,35,,3010.7,percent of total billed charges,Implant Device,3010.7,35,,3010.7,percent of total billed charges,Implant Device,3010.7,35,,3010.7,percent of total billed charges,Implant Device,3010.7,35,,3010.7,percent of total billed charges,Implant Device,3010.7,35,,3010.7,percent of total billed charges,Implant Device,3440.8,40,,3440.8,percent of total billed charges,Implant Device,3010.7,70,,3010.7,percent of total billed charges,All Other,2924.68,34,,2924.68,percent of total billed charges,Implant Device,2924.68,34,,2924.68,percent of total billed charges,Implant Device,3010.7,35,,3010.7,percent of total billed charges,Implant Device,3010.7,35,,3010.7,percent of total billed charges,Implant Device,3010.7,35,,3010.7,percent of total billed charges,Implant Device,3010.7,35,,3010.7,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2924.68,34,"If Charge > 2,000, then 34 percent",2924.68,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,6365.5,
ZIMMER 574101050 FEMORAL STEM SIZE 5,C1776,HCPCS,,79012281,CDM,278,RC,,,both,,,6912,5114.9,,,5114.9,Other,150% of Medicare + 9.63% HCRA Surcharge,3110.4,45,,3110.4,percent of total billed charges,Critical Access Hospital RCC factor,2350.08,34,,2350.08,percent of total billed charges,Implant Device,2350.08,34,,2350.08,percent of total billed charges,Implant Device,2350.08,34,,2350.08,percent of total billed charges,Implant Device,2350.08,34,,2350.08,percent of total billed charges,Implant Device,2350.08,34,,2350.08,percent of total billed charges,Implant Device,3421.44,,,3421.44,Other,110% of Medicare,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2350.08,34,"Charges > $500, x 34%",2350.08,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2764.8,40,,2764.8,percent of total billed charges,Implant Device,2419.2,70,,2419.2,percent of total billed charges,All Other,2350.08,34,,2350.08,percent of total billed charges,Implant Device,2350.08,34,,2350.08,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2350.08,34,"If Charge > 2,000, then 34 percent",2350.08,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5114.9,
STRYKER 658360 COMPRESSION SCREW 7X60MM,C1713,HCPCS,,79012284,CDM,278,RC,,,both,,,2471,1828.55,,,1828.55,Other,150% of Medicare + 9.63% HCRA Surcharge,1111.95,45,,1111.95,percent of total billed charges,Critical Access Hospital RCC factor,840.14,34,,840.14,percent of total billed charges,Implant Device,840.14,34,,840.14,percent of total billed charges,Implant Device,840.14,34,,840.14,percent of total billed charges,Implant Device,840.14,34,,840.14,percent of total billed charges,Implant Device,840.14,34,,840.14,percent of total billed charges,Implant Device,1223.15,,,1223.15,Other,110% of Medicare,864.85,35,,864.85,percent of total billed charges,Implant Device,840.14,34,"Charges > $500, x 34%",840.14,percent of total billed charges,Implant Device,864.85,35,,864.85,percent of total billed charges,Implant Device,864.85,35,,864.85,percent of total billed charges,Implant Device,864.85,35,,864.85,percent of total billed charges,Implant Device,864.85,35,,864.85,percent of total billed charges,Implant Device,864.85,35,,864.85,percent of total billed charges,Implant Device,988.4,40,,988.4,percent of total billed charges,Implant Device,864.85,70,,864.85,percent of total billed charges,All Other,840.14,34,,840.14,percent of total billed charges,Implant Device,840.14,34,,840.14,percent of total billed charges,Implant Device,864.85,35,,864.85,percent of total billed charges,Implant Device,864.85,35,,864.85,percent of total billed charges,Implant Device,864.85,35,,864.85,percent of total billed charges,Implant Device,864.85,35,,864.85,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,840.14,34,"If Charge > 2,000, then 34 percent",840.14,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1828.55,
BARD AVSM06100 6X100X80CM VASCULAR STENT,C1876,HCPCS,,79012285,CDM,278,RC,,,both,,,8100,5994.02,,,5994.02,Other,150% of Medicare + 9.63% HCRA Surcharge,3645,45,,3645,percent of total billed charges,Critical Access Hospital RCC factor,2754,34,,2754,percent of total billed charges,Implant Device,2754,34,,2754,percent of total billed charges,Implant Device,2754,34,,2754,percent of total billed charges,Implant Device,2754,34,,2754,percent of total billed charges,Implant Device,2754,34,,2754,percent of total billed charges,Implant Device,4009.5,,,4009.5,Other,110% of Medicare,2835,35,,2835,percent of total billed charges,Implant Device,2754,34,"Charges > $500, x 34%",2754,percent of total billed charges,Implant Device,2835,35,,2835,percent of total billed charges,Implant Device,2835,35,,2835,percent of total billed charges,Implant Device,2835,35,,2835,percent of total billed charges,Implant Device,2835,35,,2835,percent of total billed charges,Implant Device,2835,35,,2835,percent of total billed charges,Implant Device,3240,40,,3240,percent of total billed charges,Implant Device,2835,70,,2835,percent of total billed charges,All Other,2754,34,,2754,percent of total billed charges,Implant Device,2754,34,,2754,percent of total billed charges,Implant Device,2835,35,,2835,percent of total billed charges,Implant Device,2835,35,,2835,percent of total billed charges,Implant Device,2835,35,,2835,percent of total billed charges,Implant Device,2835,35,,2835,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2754,34,"If Charge > 2,000, then 34 percent",2754,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5994.02,
STRYKER 1822-1134S TIBIAL NAIL 11X345MM,C1889,HCPCS,,79012286,CDM,278,RC,,,both,,,3017,2232.59,,,2232.59,Other,150% of Medicare + 9.63% HCRA Surcharge,1357.65,45,,1357.65,percent of total billed charges,Critical Access Hospital RCC factor,1025.78,34,,1025.78,percent of total billed charges,Implant Device,1025.78,34,,1025.78,percent of total billed charges,Implant Device,1025.78,34,,1025.78,percent of total billed charges,Implant Device,1025.78,34,,1025.78,percent of total billed charges,Implant Device,1025.78,34,,1025.78,percent of total billed charges,Implant Device,1493.42,,,1493.42,Other,110% of Medicare,1055.95,35,,1055.95,percent of total billed charges,Implant Device,1025.78,34,"Charges > $500, x 34%",1025.78,percent of total billed charges,Implant Device,1055.95,35,,1055.95,percent of total billed charges,Implant Device,1055.95,35,,1055.95,percent of total billed charges,Implant Device,1055.95,35,,1055.95,percent of total billed charges,Implant Device,1055.95,35,,1055.95,percent of total billed charges,Implant Device,1055.95,35,,1055.95,percent of total billed charges,Implant Device,1206.8,40,,1206.8,percent of total billed charges,Implant Device,1055.95,70,,1055.95,percent of total billed charges,All Other,1025.78,34,,1025.78,percent of total billed charges,Implant Device,1025.78,34,,1025.78,percent of total billed charges,Implant Device,1055.95,35,,1055.95,percent of total billed charges,Implant Device,1055.95,35,,1055.95,percent of total billed charges,Implant Device,1055.95,35,,1055.95,percent of total billed charges,Implant Device,1055.95,35,,1055.95,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1025.78,34,"If Charge > 2,000, then 34 percent",1025.78,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2232.59,
ZIMMER 574101030 FEMORAL STEM SIZE 3,C1776,HCPCS,,79012289,CDM,278,RC,,,both,,,8573,6344.04,,,6344.04,Other,150% of Medicare + 9.63% HCRA Surcharge,3857.85,45,,3857.85,percent of total billed charges,Critical Access Hospital RCC factor,2914.82,34,,2914.82,percent of total billed charges,Implant Device,2914.82,34,,2914.82,percent of total billed charges,Implant Device,2914.82,34,,2914.82,percent of total billed charges,Implant Device,2914.82,34,,2914.82,percent of total billed charges,Implant Device,2914.82,34,,2914.82,percent of total billed charges,Implant Device,4243.64,,,4243.64,Other,110% of Medicare,3000.55,35,,3000.55,percent of total billed charges,Implant Device,2914.82,34,"Charges > $500, x 34%",2914.82,percent of total billed charges,Implant Device,3000.55,35,,3000.55,percent of total billed charges,Implant Device,3000.55,35,,3000.55,percent of total billed charges,Implant Device,3000.55,35,,3000.55,percent of total billed charges,Implant Device,3000.55,35,,3000.55,percent of total billed charges,Implant Device,3000.55,35,,3000.55,percent of total billed charges,Implant Device,3429.2,40,,3429.2,percent of total billed charges,Implant Device,3000.55,70,,3000.55,percent of total billed charges,All Other,2914.82,34,,2914.82,percent of total billed charges,Implant Device,2914.82,34,,2914.82,percent of total billed charges,Implant Device,3000.55,35,,3000.55,percent of total billed charges,Implant Device,3000.55,35,,3000.55,percent of total billed charges,Implant Device,3000.55,35,,3000.55,percent of total billed charges,Implant Device,3000.55,35,,3000.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2914.82,34,"If Charge > 2,000, then 34 percent",2914.82,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,6344.04,
ZIMMER 30103605 LINER 36MM SIZE E,C1776,HCPCS,,79012290,CDM,278,RC,,,both,,,3456,2557.45,,,2557.45,Other,150% of Medicare + 9.63% HCRA Surcharge,1555.2,45,,1555.2,percent of total billed charges,Critical Access Hospital RCC factor,1175.04,34,,1175.04,percent of total billed charges,Implant Device,1175.04,34,,1175.04,percent of total billed charges,Implant Device,1175.04,34,,1175.04,percent of total billed charges,Implant Device,1175.04,34,,1175.04,percent of total billed charges,Implant Device,1175.04,34,,1175.04,percent of total billed charges,Implant Device,1710.72,,,1710.72,Other,110% of Medicare,1209.6,35,,1209.6,percent of total billed charges,Implant Device,1175.04,34,"Charges > $500, x 34%",1175.04,percent of total billed charges,Implant Device,1209.6,35,,1209.6,percent of total billed charges,Implant Device,1209.6,35,,1209.6,percent of total billed charges,Implant Device,1209.6,35,,1209.6,percent of total billed charges,Implant Device,1209.6,35,,1209.6,percent of total billed charges,Implant Device,1209.6,35,,1209.6,percent of total billed charges,Implant Device,1382.4,40,,1382.4,percent of total billed charges,Implant Device,1209.6,70,,1209.6,percent of total billed charges,All Other,1175.04,34,,1175.04,percent of total billed charges,Implant Device,1175.04,34,,1175.04,percent of total billed charges,Implant Device,1209.6,35,,1209.6,percent of total billed charges,Implant Device,1209.6,35,,1209.6,percent of total billed charges,Implant Device,1209.6,35,,1209.6,percent of total billed charges,Implant Device,1209.6,35,,1209.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1175.04,34,"If Charge > 2,000, then 34 percent",1175.04,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2557.45,
ZIMMER 8145-01-080 HIP SCREW 80MM,C1713,HCPCS,,79012291,CDM,278,RC,,,both,,,846,626.04,,,626.04,Other,150% of Medicare + 9.63% HCRA Surcharge,380.7,45,,380.7,percent of total billed charges,Critical Access Hospital RCC factor,287.64,34,,287.64,percent of total billed charges,Implant Device,287.64,34,,287.64,percent of total billed charges,Implant Device,287.64,34,,287.64,percent of total billed charges,Implant Device,287.64,34,,287.64,percent of total billed charges,Implant Device,287.64,34,,287.64,percent of total billed charges,Implant Device,418.77,,,418.77,Other,110% of Medicare,296.1,35,,296.1,percent of total billed charges,Implant Device,287.64,34,"Charges > $500, x 34%",287.64,percent of total billed charges,Implant Device,296.1,35,,296.1,percent of total billed charges,Implant Device,296.1,35,,296.1,percent of total billed charges,Implant Device,296.1,35,,296.1,percent of total billed charges,Implant Device,296.1,35,,296.1,percent of total billed charges,Implant Device,296.1,35,,296.1,percent of total billed charges,Implant Device,338.4,40,,338.4,percent of total billed charges,Implant Device,296.1,70,,296.1,percent of total billed charges,All Other,287.64,34,,287.64,percent of total billed charges,Implant Device,287.64,34,,287.64,percent of total billed charges,Implant Device,296.1,35,,296.1,percent of total billed charges,Implant Device,296.1,35,,296.1,percent of total billed charges,Implant Device,296.1,35,,296.1,percent of total billed charges,Implant Device,296.1,35,,296.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,626.04,
ZIMMER 183012 FEMORAL RIGHT 70MM,C1776,HCPCS,,79012292,CDM,278,RC,,,both,,,6300,4662.02,,,4662.02,Other,150% of Medicare + 9.63% HCRA Surcharge,2835,45,,2835,percent of total billed charges,Critical Access Hospital RCC factor,2142,34,,2142,percent of total billed charges,Implant Device,2142,34,,2142,percent of total billed charges,Implant Device,2142,34,,2142,percent of total billed charges,Implant Device,2142,34,,2142,percent of total billed charges,Implant Device,2142,34,,2142,percent of total billed charges,Implant Device,3118.5,,,3118.5,Other,110% of Medicare,2205,35,,2205,percent of total billed charges,Implant Device,2142,34,"Charges > $500, x 34%",2142,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2520,40,,2520,percent of total billed charges,Implant Device,2205,70,,2205,percent of total billed charges,All Other,2142,34,,2142,percent of total billed charges,Implant Device,2142,34,,2142,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2142,34,"If Charge > 2,000, then 34 percent",2142,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4662.02,
ZIMMER 141234 TIBIAL PLATE 75MM,C1776,HCPCS,,79012293,CDM,278,RC,,,both,,,2304,1704.97,,,1704.97,Other,150% of Medicare + 9.63% HCRA Surcharge,1036.8,45,,1036.8,percent of total billed charges,Critical Access Hospital RCC factor,783.36,34,,783.36,percent of total billed charges,Implant Device,783.36,34,,783.36,percent of total billed charges,Implant Device,783.36,34,,783.36,percent of total billed charges,Implant Device,783.36,34,,783.36,percent of total billed charges,Implant Device,783.36,34,,783.36,percent of total billed charges,Implant Device,1140.48,,,1140.48,Other,110% of Medicare,806.4,35,,806.4,percent of total billed charges,Implant Device,783.36,34,"Charges > $500, x 34%",783.36,percent of total billed charges,Implant Device,806.4,35,,806.4,percent of total billed charges,Implant Device,806.4,35,,806.4,percent of total billed charges,Implant Device,806.4,35,,806.4,percent of total billed charges,Implant Device,806.4,35,,806.4,percent of total billed charges,Implant Device,806.4,35,,806.4,percent of total billed charges,Implant Device,921.6,40,,921.6,percent of total billed charges,Implant Device,806.4,70,,806.4,percent of total billed charges,All Other,783.36,34,,783.36,percent of total billed charges,Implant Device,783.36,34,,783.36,percent of total billed charges,Implant Device,806.4,35,,806.4,percent of total billed charges,Implant Device,806.4,35,,806.4,percent of total billed charges,Implant Device,806.4,35,,806.4,percent of total billed charges,Implant Device,806.4,35,,806.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,783.36,34,"If Charge > 2,000, then 34 percent",783.36,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1704.97,
ZIMMER 184766 PATELLA 34X8.5MM,C1776,HCPCS,,79012294,CDM,278,RC,,,both,,,1152,852.48,,,852.48,Other,150% of Medicare + 9.63% HCRA Surcharge,518.4,45,,518.4,percent of total billed charges,Critical Access Hospital RCC factor,391.68,34,,391.68,percent of total billed charges,Implant Device,391.68,34,,391.68,percent of total billed charges,Implant Device,391.68,34,,391.68,percent of total billed charges,Implant Device,391.68,34,,391.68,percent of total billed charges,Implant Device,391.68,34,,391.68,percent of total billed charges,Implant Device,570.24,,,570.24,Other,110% of Medicare,403.2,35,,403.2,percent of total billed charges,Implant Device,391.68,34,"Charges > $500, x 34%",391.68,percent of total billed charges,Implant Device,403.2,35,,403.2,percent of total billed charges,Implant Device,403.2,35,,403.2,percent of total billed charges,Implant Device,403.2,35,,403.2,percent of total billed charges,Implant Device,403.2,35,,403.2,percent of total billed charges,Implant Device,403.2,35,,403.2,percent of total billed charges,Implant Device,460.8,40,,460.8,percent of total billed charges,Implant Device,403.2,70,,403.2,percent of total billed charges,All Other,391.68,34,,391.68,percent of total billed charges,Implant Device,391.68,34,,391.68,percent of total billed charges,Implant Device,403.2,35,,403.2,percent of total billed charges,Implant Device,403.2,35,,403.2,percent of total billed charges,Implant Device,403.2,35,,403.2,percent of total billed charges,Implant Device,403.2,35,,403.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,852.48,
ZIMMER VE189080 TIBIAL BEARING 75X10MM,C1776,HCPCS,,79012295,CDM,278,RC,,,both,,,3648,2699.53,,,2699.53,Other,150% of Medicare + 9.63% HCRA Surcharge,1641.6,45,,1641.6,percent of total billed charges,Critical Access Hospital RCC factor,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1805.76,,,1805.76,Other,110% of Medicare,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1240.32,34,"Charges > $500, x 34%",1240.32,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1459.2,40,,1459.2,percent of total billed charges,Implant Device,1276.8,70,,1276.8,percent of total billed charges,All Other,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1240.32,34,"If Charge > 2,000, then 34 percent",1240.32,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2699.53,
J&J 02.210.124 LOCKING SCREW 2.4X24MM,C1713,HCPCS,,79012296,CDM,278,RC,,,both,,,330,244.2,,,244.2,Other,150% of Medicare + 9.63% HCRA Surcharge,148.5,45,,148.5,percent of total billed charges,Critical Access Hospital RCC factor,112.2,34,,112.2,percent of total billed charges,Implant Device,112.2,34,,112.2,percent of total billed charges,Implant Device,112.2,34,,112.2,percent of total billed charges,Implant Device,112.2,34,,112.2,percent of total billed charges,Implant Device,112.2,34,,112.2,percent of total billed charges,Implant Device,163.35,,,163.35,Other,110% of Medicare,115.5,35,,115.5,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,132,40,,132,percent of total billed charges,Implant Device,115.5,70,,115.5,percent of total billed charges,All Other,112.2,34,,112.2,percent of total billed charges,Implant Device,112.2,34,,112.2,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,244.2,
J&J 1516-50-707 TIBIAL INSERT SZ 7 7MM,C1776,HCPCS,,79012297,CDM,278,RC,,,both,,,5400,3996.01,,,3996.01,Other,150% of Medicare + 9.63% HCRA Surcharge,2430,45,,2430,percent of total billed charges,Critical Access Hospital RCC factor,1836,34,,1836,percent of total billed charges,Implant Device,1836,34,,1836,percent of total billed charges,Implant Device,1836,34,,1836,percent of total billed charges,Implant Device,1836,34,,1836,percent of total billed charges,Implant Device,1836,34,,1836,percent of total billed charges,Implant Device,2673,,,2673,Other,110% of Medicare,1890,35,,1890,percent of total billed charges,Implant Device,1836,34,"Charges > $500, x 34%",1836,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,2160,40,,2160,percent of total billed charges,Implant Device,1890,70,,1890,percent of total billed charges,All Other,1836,34,,1836,percent of total billed charges,Implant Device,1836,34,,1836,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1836,34,"If Charge > 2,000, then 34 percent",1836,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3996.01,
IN2BONES S27 ST014 SNAP OFF SCREW 2.7X14,C1713,HCPCS,,79012299,CDM,278,RC,,,both,,,1275,943.5,,,943.5,Other,150% of Medicare + 9.63% HCRA Surcharge,573.75,45,,573.75,percent of total billed charges,Critical Access Hospital RCC factor,433.5,34,,433.5,percent of total billed charges,Implant Device,433.5,34,,433.5,percent of total billed charges,Implant Device,433.5,34,,433.5,percent of total billed charges,Implant Device,433.5,34,,433.5,percent of total billed charges,Implant Device,433.5,34,,433.5,percent of total billed charges,Implant Device,631.13,,,631.13,Other,110% of Medicare,446.25,35,,446.25,percent of total billed charges,Implant Device,433.5,34,"Charges > $500, x 34%",433.5,percent of total billed charges,Implant Device,446.25,35,,446.25,percent of total billed charges,Implant Device,446.25,35,,446.25,percent of total billed charges,Implant Device,446.25,35,,446.25,percent of total billed charges,Implant Device,446.25,35,,446.25,percent of total billed charges,Implant Device,446.25,35,,446.25,percent of total billed charges,Implant Device,510,40,,510,percent of total billed charges,Implant Device,446.25,70,,446.25,percent of total billed charges,All Other,433.5,34,,433.5,percent of total billed charges,Implant Device,433.5,34,,433.5,percent of total billed charges,Implant Device,446.25,35,,446.25,percent of total billed charges,Implant Device,446.25,35,,446.25,percent of total billed charges,Implant Device,446.25,35,,446.25,percent of total billed charges,Implant Device,446.25,35,,446.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,943.5,
ZIMMER 42-5221-008-10 ART SURF RT 10MM,C1776,HCPCS,,79012314,CDM,278,RC,,,both,,,3648,2699.53,,,2699.53,Other,150% of Medicare + 9.63% HCRA Surcharge,1641.6,45,,1641.6,percent of total billed charges,Critical Access Hospital RCC factor,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1805.76,,,1805.76,Other,110% of Medicare,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1240.32,34,"Charges > $500, x 34%",1240.32,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1459.2,40,,1459.2,percent of total billed charges,Implant Device,1276.8,70,,1276.8,percent of total billed charges,All Other,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1240.32,34,"If Charge > 2,000, then 34 percent",1240.32,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2699.53,
BOST 39294-60061 6X60X130CM ELUVIA STENT,C1874,HCPCS,,79012315,CDM,278,RC,,,both,,,6825,5050.52,,,5050.52,Other,150% of Medicare + 9.63% HCRA Surcharge,3071.25,45,,3071.25,percent of total billed charges,Critical Access Hospital RCC factor,2320.5,34,,2320.5,percent of total billed charges,Implant Device,2320.5,34,,2320.5,percent of total billed charges,Implant Device,2320.5,34,,2320.5,percent of total billed charges,Implant Device,2320.5,34,,2320.5,percent of total billed charges,Implant Device,2320.5,34,,2320.5,percent of total billed charges,Implant Device,3378.38,,,3378.38,Other,110% of Medicare,2388.75,35,,2388.75,percent of total billed charges,Implant Device,2320.5,34,"Charges > $500, x 34%",2320.5,percent of total billed charges,Implant Device,2388.75,35,,2388.75,percent of total billed charges,Implant Device,2388.75,35,,2388.75,percent of total billed charges,Implant Device,2388.75,35,,2388.75,percent of total billed charges,Implant Device,2388.75,35,,2388.75,percent of total billed charges,Implant Device,2388.75,35,,2388.75,percent of total billed charges,Implant Device,2730,40,,2730,percent of total billed charges,Implant Device,2388.75,70,,2388.75,percent of total billed charges,All Other,2320.5,34,,2320.5,percent of total billed charges,Implant Device,2320.5,34,,2320.5,percent of total billed charges,Implant Device,2388.75,35,,2388.75,percent of total billed charges,Implant Device,2388.75,35,,2388.75,percent of total billed charges,Implant Device,2388.75,35,,2388.75,percent of total billed charges,Implant Device,2388.75,35,,2388.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2320.5,34,"If Charge > 2,000, then 34 percent",2320.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5050.52,
BOST 39294-70061 7X60X130CM ELUVIA STENT,C1874,HCPCS,,79012316,CDM,278,RC,,,both,,,6825,5050.52,,,5050.52,Other,150% of Medicare + 9.63% HCRA Surcharge,3071.25,45,,3071.25,percent of total billed charges,Critical Access Hospital RCC factor,2320.5,34,,2320.5,percent of total billed charges,Implant Device,2320.5,34,,2320.5,percent of total billed charges,Implant Device,2320.5,34,,2320.5,percent of total billed charges,Implant Device,2320.5,34,,2320.5,percent of total billed charges,Implant Device,2320.5,34,,2320.5,percent of total billed charges,Implant Device,3378.38,,,3378.38,Other,110% of Medicare,2388.75,35,,2388.75,percent of total billed charges,Implant Device,2320.5,34,"Charges > $500, x 34%",2320.5,percent of total billed charges,Implant Device,2388.75,35,,2388.75,percent of total billed charges,Implant Device,2388.75,35,,2388.75,percent of total billed charges,Implant Device,2388.75,35,,2388.75,percent of total billed charges,Implant Device,2388.75,35,,2388.75,percent of total billed charges,Implant Device,2388.75,35,,2388.75,percent of total billed charges,Implant Device,2730,40,,2730,percent of total billed charges,Implant Device,2388.75,70,,2388.75,percent of total billed charges,All Other,2320.5,34,,2320.5,percent of total billed charges,Implant Device,2320.5,34,,2320.5,percent of total billed charges,Implant Device,2388.75,35,,2388.75,percent of total billed charges,Implant Device,2388.75,35,,2388.75,percent of total billed charges,Implant Device,2388.75,35,,2388.75,percent of total billed charges,Implant Device,2388.75,35,,2388.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2320.5,34,"If Charge > 2,000, then 34 percent",2320.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5050.52,
BOST 39294-70101 7X100X130 ELUVIA STENT,C1874,HCPCS,,79012317,CDM,278,RC,,,both,,,7725,5716.52,,,5716.52,Other,150% of Medicare + 9.63% HCRA Surcharge,3476.25,45,,3476.25,percent of total billed charges,Critical Access Hospital RCC factor,2626.5,34,,2626.5,percent of total billed charges,Implant Device,2626.5,34,,2626.5,percent of total billed charges,Implant Device,2626.5,34,,2626.5,percent of total billed charges,Implant Device,2626.5,34,,2626.5,percent of total billed charges,Implant Device,2626.5,34,,2626.5,percent of total billed charges,Implant Device,3823.88,,,3823.88,Other,110% of Medicare,2703.75,35,,2703.75,percent of total billed charges,Implant Device,2626.5,34,"Charges > $500, x 34%",2626.5,percent of total billed charges,Implant Device,2703.75,35,,2703.75,percent of total billed charges,Implant Device,2703.75,35,,2703.75,percent of total billed charges,Implant Device,2703.75,35,,2703.75,percent of total billed charges,Implant Device,2703.75,35,,2703.75,percent of total billed charges,Implant Device,2703.75,35,,2703.75,percent of total billed charges,Implant Device,3090,40,,3090,percent of total billed charges,Implant Device,2703.75,70,,2703.75,percent of total billed charges,All Other,2626.5,34,,2626.5,percent of total billed charges,Implant Device,2626.5,34,,2626.5,percent of total billed charges,Implant Device,2703.75,35,,2703.75,percent of total billed charges,Implant Device,2703.75,35,,2703.75,percent of total billed charges,Implant Device,2703.75,35,,2703.75,percent of total billed charges,Implant Device,2703.75,35,,2703.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2626.5,34,"If Charge > 2,000, then 34 percent",2626.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5716.52,
J&J SD900-500S TRUMATCH GRAFT CAGE,C1713,HCPCS,,79012344,CDM,278,RC,,,both,,,42750,31635.11,,,31635.11,Other,150% of Medicare + 9.63% HCRA Surcharge,19237.5,45,,19237.5,percent of total billed charges,Critical Access Hospital RCC factor,14535,34,,14535,percent of total billed charges,Implant Device,14535,34,,14535,percent of total billed charges,Implant Device,14535,34,,14535,percent of total billed charges,Implant Device,14535,34,,14535,percent of total billed charges,Implant Device,14535,34,,14535,percent of total billed charges,Implant Device,21161.25,,,21161.25,Other,110% of Medicare,14962.5,35,,14962.5,percent of total billed charges,Implant Device,14535,34,"Charges > $500, x 34%",14535,percent of total billed charges,Implant Device,14962.5,35,,14962.5,percent of total billed charges,Implant Device,14962.5,35,,14962.5,percent of total billed charges,Implant Device,14962.5,35,,14962.5,percent of total billed charges,Implant Device,14962.5,35,,14962.5,percent of total billed charges,Implant Device,14962.5,35,,14962.5,percent of total billed charges,Implant Device,17100,40,,17100,percent of total billed charges,Implant Device,14962.5,70,,14962.5,percent of total billed charges,All Other,14535,34,,14535,percent of total billed charges,Implant Device,14535,34,,14535,percent of total billed charges,Implant Device,14962.5,35,,14962.5,percent of total billed charges,Implant Device,14962.5,35,,14962.5,percent of total billed charges,Implant Device,14962.5,35,,14962.5,percent of total billed charges,Implant Device,14962.5,35,,14962.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,14535,34,"If Charge > 2,000, then 34 percent",14535,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,31635.11,
ALLERGAN 133S-MX-13-T TISSUE EXPANDER,C1789,HCPCS,,79012345,CDM,278,RC,,,both,,,4650,3441.01,,,3441.01,Other,150% of Medicare + 9.63% HCRA Surcharge,2092.5,45,,2092.5,percent of total billed charges,Critical Access Hospital RCC factor,1581,34,,1581,percent of total billed charges,Implant Device,1581,34,,1581,percent of total billed charges,Implant Device,1581,34,,1581,percent of total billed charges,Implant Device,1581,34,,1581,percent of total billed charges,Implant Device,1581,34,,1581,percent of total billed charges,Implant Device,2301.75,,,2301.75,Other,110% of Medicare,1627.5,35,,1627.5,percent of total billed charges,Implant Device,1581,34,"Charges > $500, x 34%",1581,percent of total billed charges,Implant Device,1627.5,35,,1627.5,percent of total billed charges,Implant Device,1627.5,35,,1627.5,percent of total billed charges,Implant Device,1627.5,35,,1627.5,percent of total billed charges,Implant Device,1627.5,35,,1627.5,percent of total billed charges,Implant Device,1627.5,35,,1627.5,percent of total billed charges,Implant Device,1860,40,,1860,percent of total billed charges,Implant Device,1627.5,70,,1627.5,percent of total billed charges,All Other,1581,34,,1581,percent of total billed charges,Implant Device,1581,34,,1581,percent of total billed charges,Implant Device,1627.5,35,,1627.5,percent of total billed charges,Implant Device,1627.5,35,,1627.5,percent of total billed charges,Implant Device,1627.5,35,,1627.5,percent of total billed charges,Implant Device,1627.5,35,,1627.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1581,34,"If Charge > 2,000, then 34 percent",1581,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3441.01,
ALLERGAN 133S-MX-14-T TISSUE EXPANDER,C1789,HCPCS,,79012346,CDM,278,RC,,,both,,,4650,3441.01,,,3441.01,Other,150% of Medicare + 9.63% HCRA Surcharge,2092.5,45,,2092.5,percent of total billed charges,Critical Access Hospital RCC factor,1581,34,,1581,percent of total billed charges,Implant Device,1581,34,,1581,percent of total billed charges,Implant Device,1581,34,,1581,percent of total billed charges,Implant Device,1581,34,,1581,percent of total billed charges,Implant Device,1581,34,,1581,percent of total billed charges,Implant Device,2301.75,,,2301.75,Other,110% of Medicare,1627.5,35,,1627.5,percent of total billed charges,Implant Device,1581,34,"Charges > $500, x 34%",1581,percent of total billed charges,Implant Device,1627.5,35,,1627.5,percent of total billed charges,Implant Device,1627.5,35,,1627.5,percent of total billed charges,Implant Device,1627.5,35,,1627.5,percent of total billed charges,Implant Device,1627.5,35,,1627.5,percent of total billed charges,Implant Device,1627.5,35,,1627.5,percent of total billed charges,Implant Device,1860,40,,1860,percent of total billed charges,Implant Device,1627.5,70,,1627.5,percent of total billed charges,All Other,1581,34,,1581,percent of total billed charges,Implant Device,1581,34,,1581,percent of total billed charges,Implant Device,1627.5,35,,1627.5,percent of total billed charges,Implant Device,1627.5,35,,1627.5,percent of total billed charges,Implant Device,1627.5,35,,1627.5,percent of total billed charges,Implant Device,1627.5,35,,1627.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1581,34,"If Charge > 2,000, then 34 percent",1581,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3441.01,
ALLERGAN 133S-MX-15-T TISSUE EXPANDER,C1789,HCPCS,,79012347,CDM,278,RC,,,both,,,4650,3441.01,,,3441.01,Other,150% of Medicare + 9.63% HCRA Surcharge,2092.5,45,,2092.5,percent of total billed charges,Critical Access Hospital RCC factor,1581,34,,1581,percent of total billed charges,Implant Device,1581,34,,1581,percent of total billed charges,Implant Device,1581,34,,1581,percent of total billed charges,Implant Device,1581,34,,1581,percent of total billed charges,Implant Device,1581,34,,1581,percent of total billed charges,Implant Device,2301.75,,,2301.75,Other,110% of Medicare,1627.5,35,,1627.5,percent of total billed charges,Implant Device,1581,34,"Charges > $500, x 34%",1581,percent of total billed charges,Implant Device,1627.5,35,,1627.5,percent of total billed charges,Implant Device,1627.5,35,,1627.5,percent of total billed charges,Implant Device,1627.5,35,,1627.5,percent of total billed charges,Implant Device,1627.5,35,,1627.5,percent of total billed charges,Implant Device,1627.5,35,,1627.5,percent of total billed charges,Implant Device,1860,40,,1860,percent of total billed charges,Implant Device,1627.5,70,,1627.5,percent of total billed charges,All Other,1581,34,,1581,percent of total billed charges,Implant Device,1581,34,,1581,percent of total billed charges,Implant Device,1627.5,35,,1627.5,percent of total billed charges,Implant Device,1627.5,35,,1627.5,percent of total billed charges,Implant Device,1627.5,35,,1627.5,percent of total billed charges,Implant Device,1627.5,35,,1627.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1581,34,"If Charge > 2,000, then 34 percent",1581,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3441.01,
ZIMMER 8143-09-380 HIP FRAC NAIL 9X380MM,C1889,HCPCS,,79012348,CDM,278,RC,,,both,,,7290,5394.62,,,5394.62,Other,150% of Medicare + 9.63% HCRA Surcharge,3280.5,45,,3280.5,percent of total billed charges,Critical Access Hospital RCC factor,2478.6,34,,2478.6,percent of total billed charges,Implant Device,2478.6,34,,2478.6,percent of total billed charges,Implant Device,2478.6,34,,2478.6,percent of total billed charges,Implant Device,2478.6,34,,2478.6,percent of total billed charges,Implant Device,2478.6,34,,2478.6,percent of total billed charges,Implant Device,3608.55,,,3608.55,Other,110% of Medicare,2551.5,35,,2551.5,percent of total billed charges,Implant Device,2478.6,34,"Charges > $500, x 34%",2478.6,percent of total billed charges,Implant Device,2551.5,35,,2551.5,percent of total billed charges,Implant Device,2551.5,35,,2551.5,percent of total billed charges,Implant Device,2551.5,35,,2551.5,percent of total billed charges,Implant Device,2551.5,35,,2551.5,percent of total billed charges,Implant Device,2551.5,35,,2551.5,percent of total billed charges,Implant Device,2916,40,,2916,percent of total billed charges,Implant Device,2551.5,70,,2551.5,percent of total billed charges,All Other,2478.6,34,,2478.6,percent of total billed charges,Implant Device,2478.6,34,,2478.6,percent of total billed charges,Implant Device,2551.5,35,,2551.5,percent of total billed charges,Implant Device,2551.5,35,,2551.5,percent of total billed charges,Implant Device,2551.5,35,,2551.5,percent of total billed charges,Implant Device,2551.5,35,,2551.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2478.6,34,"If Charge > 2,000, then 34 percent",2478.6,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5394.62,
ZIMMER 8145-50-054 CORT BONE SCREW 5X54,C1713,HCPCS,,79012349,CDM,278,RC,,,both,,,594,439.56,,,439.56,Other,150% of Medicare + 9.63% HCRA Surcharge,267.3,45,,267.3,percent of total billed charges,Critical Access Hospital RCC factor,201.96,34,,201.96,percent of total billed charges,Implant Device,201.96,34,,201.96,percent of total billed charges,Implant Device,201.96,34,,201.96,percent of total billed charges,Implant Device,201.96,34,,201.96,percent of total billed charges,Implant Device,201.96,34,,201.96,percent of total billed charges,Implant Device,294.03,,,294.03,Other,110% of Medicare,207.9,35,,207.9,percent of total billed charges,Implant Device,201.96,34,"Charges > $500, x 34%",201.96,percent of total billed charges,Implant Device,207.9,35,,207.9,percent of total billed charges,Implant Device,207.9,35,,207.9,percent of total billed charges,Implant Device,207.9,35,,207.9,percent of total billed charges,Implant Device,207.9,35,,207.9,percent of total billed charges,Implant Device,207.9,35,,207.9,percent of total billed charges,Implant Device,237.6,40,,237.6,percent of total billed charges,Implant Device,207.9,70,,207.9,percent of total billed charges,All Other,201.96,34,,201.96,percent of total billed charges,Implant Device,201.96,34,,201.96,percent of total billed charges,Implant Device,207.9,35,,207.9,percent of total billed charges,Implant Device,207.9,35,,207.9,percent of total billed charges,Implant Device,207.9,35,,207.9,percent of total billed charges,Implant Device,207.9,35,,207.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,439.56,
J&J 412.215S LOCKING SCREW 5X42MM,C1713,HCPCS,,79012352,CDM,278,RC,,,both,,,505,373.7,,,373.7,Other,150% of Medicare + 9.63% HCRA Surcharge,227.25,45,,227.25,percent of total billed charges,Critical Access Hospital RCC factor,171.7,34,,171.7,percent of total billed charges,Implant Device,171.7,34,,171.7,percent of total billed charges,Implant Device,171.7,34,,171.7,percent of total billed charges,Implant Device,171.7,34,,171.7,percent of total billed charges,Implant Device,171.7,34,,171.7,percent of total billed charges,Implant Device,249.98,,,249.98,Other,110% of Medicare,176.75,35,,176.75,percent of total billed charges,Implant Device,171.7,34,"Charges > $500, x 34%",171.7,percent of total billed charges,Implant Device,176.75,35,,176.75,percent of total billed charges,Implant Device,176.75,35,,176.75,percent of total billed charges,Implant Device,176.75,35,,176.75,percent of total billed charges,Implant Device,176.75,35,,176.75,percent of total billed charges,Implant Device,176.75,35,,176.75,percent of total billed charges,Implant Device,202,40,,202,percent of total billed charges,Implant Device,176.75,70,,176.75,percent of total billed charges,All Other,171.7,34,,171.7,percent of total billed charges,Implant Device,171.7,34,,171.7,percent of total billed charges,Implant Device,176.75,35,,176.75,percent of total billed charges,Implant Device,176.75,35,,176.75,percent of total billed charges,Implant Device,176.75,35,,176.75,percent of total billed charges,Implant Device,176.75,35,,176.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,373.7,
J&J 04.268.000S FEMORAL NECK SYS PLT,C1713,HCPCS,,79012353,CDM,278,RC,,,both,,,1105,817.7,,,817.7,Other,150% of Medicare + 9.63% HCRA Surcharge,497.25,45,,497.25,percent of total billed charges,Critical Access Hospital RCC factor,375.7,34,,375.7,percent of total billed charges,Implant Device,375.7,34,,375.7,percent of total billed charges,Implant Device,375.7,34,,375.7,percent of total billed charges,Implant Device,375.7,34,,375.7,percent of total billed charges,Implant Device,375.7,34,,375.7,percent of total billed charges,Implant Device,546.98,,,546.98,Other,110% of Medicare,386.75,35,,386.75,percent of total billed charges,Implant Device,375.7,34,"Charges > $500, x 34%",375.7,percent of total billed charges,Implant Device,386.75,35,,386.75,percent of total billed charges,Implant Device,386.75,35,,386.75,percent of total billed charges,Implant Device,386.75,35,,386.75,percent of total billed charges,Implant Device,386.75,35,,386.75,percent of total billed charges,Implant Device,386.75,35,,386.75,percent of total billed charges,Implant Device,442,40,,442,percent of total billed charges,Implant Device,386.75,70,,386.75,percent of total billed charges,All Other,375.7,34,,375.7,percent of total billed charges,Implant Device,375.7,34,,375.7,percent of total billed charges,Implant Device,386.75,35,,386.75,percent of total billed charges,Implant Device,386.75,35,,386.75,percent of total billed charges,Implant Device,386.75,35,,386.75,percent of total billed charges,Implant Device,386.75,35,,386.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,817.7,
J&J 04.168.290S BOLT FOR FEM NECK 90MM,C1713,HCPCS,,79012354,CDM,278,RC,,,both,,,633,468.42,,,468.42,Other,150% of Medicare + 9.63% HCRA Surcharge,284.85,45,,284.85,percent of total billed charges,Critical Access Hospital RCC factor,215.22,34,,215.22,percent of total billed charges,Implant Device,215.22,34,,215.22,percent of total billed charges,Implant Device,215.22,34,,215.22,percent of total billed charges,Implant Device,215.22,34,,215.22,percent of total billed charges,Implant Device,215.22,34,,215.22,percent of total billed charges,Implant Device,313.34,,,313.34,Other,110% of Medicare,221.55,35,,221.55,percent of total billed charges,Implant Device,215.22,34,"Charges > $500, x 34%",215.22,percent of total billed charges,Implant Device,221.55,35,,221.55,percent of total billed charges,Implant Device,221.55,35,,221.55,percent of total billed charges,Implant Device,221.55,35,,221.55,percent of total billed charges,Implant Device,221.55,35,,221.55,percent of total billed charges,Implant Device,221.55,35,,221.55,percent of total billed charges,Implant Device,253.2,40,,253.2,percent of total billed charges,Implant Device,221.55,70,,221.55,percent of total billed charges,All Other,215.22,34,,215.22,percent of total billed charges,Implant Device,215.22,34,,215.22,percent of total billed charges,Implant Device,221.55,35,,221.55,percent of total billed charges,Implant Device,221.55,35,,221.55,percent of total billed charges,Implant Device,221.55,35,,221.55,percent of total billed charges,Implant Device,221.55,35,,221.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,468.42,
J&J 04.168.490S ANTIROTATION SCREW 90,C1713,HCPCS,,79012355,CDM,278,RC,,,both,,,182,134.68,,,134.68,Other,150% of Medicare + 9.63% HCRA Surcharge,81.9,45,,81.9,percent of total billed charges,Critical Access Hospital RCC factor,61.88,34,,61.88,percent of total billed charges,Implant Device,61.88,34,,61.88,percent of total billed charges,Implant Device,61.88,34,,61.88,percent of total billed charges,Implant Device,61.88,34,,61.88,percent of total billed charges,Implant Device,61.88,34,,61.88,percent of total billed charges,Implant Device,90.09,,,90.09,Other,110% of Medicare,63.7,35,,63.7,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,63.7,35,,63.7,percent of total billed charges,Implant Device,63.7,35,,63.7,percent of total billed charges,Implant Device,63.7,35,,63.7,percent of total billed charges,Implant Device,63.7,35,,63.7,percent of total billed charges,Implant Device,63.7,35,,63.7,percent of total billed charges,Implant Device,72.8,40,,72.8,percent of total billed charges,Implant Device,63.7,70,,63.7,percent of total billed charges,All Other,61.88,34,,61.88,percent of total billed charges,Implant Device,61.88,34,,61.88,percent of total billed charges,Implant Device,63.7,35,,63.7,percent of total billed charges,Implant Device,63.7,35,,63.7,percent of total billed charges,Implant Device,63.7,35,,63.7,percent of total billed charges,Implant Device,63.7,35,,63.7,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,134.68,
ZIMMER 8145-50-050 CORT BONE SCREW 5X50,C1713,HCPCS,,79012356,CDM,278,RC,,,both,,,594,439.56,,,439.56,Other,150% of Medicare + 9.63% HCRA Surcharge,267.3,45,,267.3,percent of total billed charges,Critical Access Hospital RCC factor,201.96,34,,201.96,percent of total billed charges,Implant Device,201.96,34,,201.96,percent of total billed charges,Implant Device,201.96,34,,201.96,percent of total billed charges,Implant Device,201.96,34,,201.96,percent of total billed charges,Implant Device,201.96,34,,201.96,percent of total billed charges,Implant Device,294.03,,,294.03,Other,110% of Medicare,207.9,35,,207.9,percent of total billed charges,Implant Device,201.96,34,"Charges > $500, x 34%",201.96,percent of total billed charges,Implant Device,207.9,35,,207.9,percent of total billed charges,Implant Device,207.9,35,,207.9,percent of total billed charges,Implant Device,207.9,35,,207.9,percent of total billed charges,Implant Device,207.9,35,,207.9,percent of total billed charges,Implant Device,207.9,35,,207.9,percent of total billed charges,Implant Device,237.6,40,,237.6,percent of total billed charges,Implant Device,207.9,70,,207.9,percent of total billed charges,All Other,201.96,34,,201.96,percent of total billed charges,Implant Device,201.96,34,,201.96,percent of total billed charges,Implant Device,207.9,35,,207.9,percent of total billed charges,Implant Device,207.9,35,,207.9,percent of total billed charges,Implant Device,207.9,35,,207.9,percent of total billed charges,Implant Device,207.9,35,,207.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,439.56,
STRYKER 57-10340 T-PLATE 6 HOLE 1.7MM,C1713,HCPCS,,79012357,CDM,278,RC,,,both,,,927,685.98,,,685.98,Other,150% of Medicare + 9.63% HCRA Surcharge,417.15,45,,417.15,percent of total billed charges,Critical Access Hospital RCC factor,315.18,34,,315.18,percent of total billed charges,Implant Device,315.18,34,,315.18,percent of total billed charges,Implant Device,315.18,34,,315.18,percent of total billed charges,Implant Device,315.18,34,,315.18,percent of total billed charges,Implant Device,315.18,34,,315.18,percent of total billed charges,Implant Device,458.87,,,458.87,Other,110% of Medicare,324.45,35,,324.45,percent of total billed charges,Implant Device,315.18,34,"Charges > $500, x 34%",315.18,percent of total billed charges,Implant Device,324.45,35,,324.45,percent of total billed charges,Implant Device,324.45,35,,324.45,percent of total billed charges,Implant Device,324.45,35,,324.45,percent of total billed charges,Implant Device,324.45,35,,324.45,percent of total billed charges,Implant Device,324.45,35,,324.45,percent of total billed charges,Implant Device,370.8,40,,370.8,percent of total billed charges,Implant Device,324.45,70,,324.45,percent of total billed charges,All Other,315.18,34,,315.18,percent of total billed charges,Implant Device,315.18,34,,315.18,percent of total billed charges,Implant Device,324.45,35,,324.45,percent of total billed charges,Implant Device,324.45,35,,324.45,percent of total billed charges,Implant Device,324.45,35,,324.45,percent of total billed charges,Implant Device,324.45,35,,324.45,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,685.98,
STRYKER 662509 LOCKING SCREW 1.7X9MM,C1713,HCPCS,,79012358,CDM,278,RC,,,both,,,413,305.62,,,305.62,Other,150% of Medicare + 9.63% HCRA Surcharge,185.85,45,,185.85,percent of total billed charges,Critical Access Hospital RCC factor,140.42,34,,140.42,percent of total billed charges,Implant Device,140.42,34,,140.42,percent of total billed charges,Implant Device,140.42,34,,140.42,percent of total billed charges,Implant Device,140.42,34,,140.42,percent of total billed charges,Implant Device,140.42,34,,140.42,percent of total billed charges,Implant Device,204.44,,,204.44,Other,110% of Medicare,144.55,35,,144.55,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,144.55,35,,144.55,percent of total billed charges,Implant Device,144.55,35,,144.55,percent of total billed charges,Implant Device,144.55,35,,144.55,percent of total billed charges,Implant Device,144.55,35,,144.55,percent of total billed charges,Implant Device,144.55,35,,144.55,percent of total billed charges,Implant Device,165.2,40,,165.2,percent of total billed charges,Implant Device,144.55,70,,144.55,percent of total billed charges,All Other,140.42,34,,140.42,percent of total billed charges,Implant Device,140.42,34,,140.42,percent of total billed charges,Implant Device,144.55,35,,144.55,percent of total billed charges,Implant Device,144.55,35,,144.55,percent of total billed charges,Implant Device,144.55,35,,144.55,percent of total billed charges,Implant Device,144.55,35,,144.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,305.62,
STRYKER 662510 LOCKING SCREW 1.7X10MM,C1713,HCPCS,,79012359,CDM,278,RC,,,both,,,413,305.62,,,305.62,Other,150% of Medicare + 9.63% HCRA Surcharge,185.85,45,,185.85,percent of total billed charges,Critical Access Hospital RCC factor,140.42,34,,140.42,percent of total billed charges,Implant Device,140.42,34,,140.42,percent of total billed charges,Implant Device,140.42,34,,140.42,percent of total billed charges,Implant Device,140.42,34,,140.42,percent of total billed charges,Implant Device,140.42,34,,140.42,percent of total billed charges,Implant Device,204.44,,,204.44,Other,110% of Medicare,144.55,35,,144.55,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,144.55,35,,144.55,percent of total billed charges,Implant Device,144.55,35,,144.55,percent of total billed charges,Implant Device,144.55,35,,144.55,percent of total billed charges,Implant Device,144.55,35,,144.55,percent of total billed charges,Implant Device,144.55,35,,144.55,percent of total billed charges,Implant Device,165.2,40,,165.2,percent of total billed charges,Implant Device,144.55,70,,144.55,percent of total billed charges,All Other,140.42,34,,140.42,percent of total billed charges,Implant Device,140.42,34,,140.42,percent of total billed charges,Implant Device,144.55,35,,144.55,percent of total billed charges,Implant Device,144.55,35,,144.55,percent of total billed charges,Implant Device,144.55,35,,144.55,percent of total billed charges,Implant Device,144.55,35,,144.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,305.62,
STRYKER 662607 BONE SCREW 1.7X7MM,C1713,HCPCS,,79012360,CDM,278,RC,,,both,,,324,239.76,,,239.76,Other,150% of Medicare + 9.63% HCRA Surcharge,145.8,45,,145.8,percent of total billed charges,Critical Access Hospital RCC factor,110.16,34,,110.16,percent of total billed charges,Implant Device,110.16,34,,110.16,percent of total billed charges,Implant Device,110.16,34,,110.16,percent of total billed charges,Implant Device,110.16,34,,110.16,percent of total billed charges,Implant Device,110.16,34,,110.16,percent of total billed charges,Implant Device,160.38,,,160.38,Other,110% of Medicare,113.4,35,,113.4,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,129.6,40,,129.6,percent of total billed charges,Implant Device,113.4,70,,113.4,percent of total billed charges,All Other,110.16,34,,110.16,percent of total billed charges,Implant Device,110.16,34,,110.16,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,239.76,
STRYKER 662609 BONE SCREW 1.7X9MM,C1713,HCPCS,,79012361,CDM,278,RC,,,both,,,324,239.76,,,239.76,Other,150% of Medicare + 9.63% HCRA Surcharge,145.8,45,,145.8,percent of total billed charges,Critical Access Hospital RCC factor,110.16,34,,110.16,percent of total billed charges,Implant Device,110.16,34,,110.16,percent of total billed charges,Implant Device,110.16,34,,110.16,percent of total billed charges,Implant Device,110.16,34,,110.16,percent of total billed charges,Implant Device,110.16,34,,110.16,percent of total billed charges,Implant Device,160.38,,,160.38,Other,110% of Medicare,113.4,35,,113.4,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,129.6,40,,129.6,percent of total billed charges,Implant Device,113.4,70,,113.4,percent of total billed charges,All Other,110.16,34,,110.16,percent of total billed charges,Implant Device,110.16,34,,110.16,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,239.76,
STRYKER 662610 BONE SCREW 1.7X10MM,C1713,HCPCS,,79012362,CDM,278,RC,,,both,,,324,239.76,,,239.76,Other,150% of Medicare + 9.63% HCRA Surcharge,145.8,45,,145.8,percent of total billed charges,Critical Access Hospital RCC factor,110.16,34,,110.16,percent of total billed charges,Implant Device,110.16,34,,110.16,percent of total billed charges,Implant Device,110.16,34,,110.16,percent of total billed charges,Implant Device,110.16,34,,110.16,percent of total billed charges,Implant Device,110.16,34,,110.16,percent of total billed charges,Implant Device,160.38,,,160.38,Other,110% of Medicare,113.4,35,,113.4,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,129.6,40,,129.6,percent of total billed charges,Implant Device,113.4,70,,113.4,percent of total billed charges,All Other,110.16,34,,110.16,percent of total billed charges,Implant Device,110.16,34,,110.16,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,239.76,
J&J 412.214S LOCKING SCREW 5.0X40MM,C1713,HCPCS,,79012363,CDM,278,RC,,,both,,,505,373.7,,,373.7,Other,150% of Medicare + 9.63% HCRA Surcharge,227.25,45,,227.25,percent of total billed charges,Critical Access Hospital RCC factor,171.7,34,,171.7,percent of total billed charges,Implant Device,171.7,34,,171.7,percent of total billed charges,Implant Device,171.7,34,,171.7,percent of total billed charges,Implant Device,171.7,34,,171.7,percent of total billed charges,Implant Device,171.7,34,,171.7,percent of total billed charges,Implant Device,249.98,,,249.98,Other,110% of Medicare,176.75,35,,176.75,percent of total billed charges,Implant Device,171.7,34,"Charges > $500, x 34%",171.7,percent of total billed charges,Implant Device,176.75,35,,176.75,percent of total billed charges,Implant Device,176.75,35,,176.75,percent of total billed charges,Implant Device,176.75,35,,176.75,percent of total billed charges,Implant Device,176.75,35,,176.75,percent of total billed charges,Implant Device,176.75,35,,176.75,percent of total billed charges,Implant Device,202,40,,202,percent of total billed charges,Implant Device,176.75,70,,176.75,percent of total billed charges,All Other,171.7,34,,171.7,percent of total billed charges,Implant Device,171.7,34,,171.7,percent of total billed charges,Implant Device,176.75,35,,176.75,percent of total billed charges,Implant Device,176.75,35,,176.75,percent of total billed charges,Implant Device,176.75,35,,176.75,percent of total billed charges,Implant Device,176.75,35,,176.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,373.7,
ALLERGAN 133S-MX-12-T TISSUE EXPANDER,C1789,HCPCS,,79012364,CDM,278,RC,,,both,,,4650,3441.01,,,3441.01,Other,150% of Medicare + 9.63% HCRA Surcharge,2092.5,45,,2092.5,percent of total billed charges,Critical Access Hospital RCC factor,1581,34,,1581,percent of total billed charges,Implant Device,1581,34,,1581,percent of total billed charges,Implant Device,1581,34,,1581,percent of total billed charges,Implant Device,1581,34,,1581,percent of total billed charges,Implant Device,1581,34,,1581,percent of total billed charges,Implant Device,2301.75,,,2301.75,Other,110% of Medicare,1627.5,35,,1627.5,percent of total billed charges,Implant Device,1581,34,"Charges > $500, x 34%",1581,percent of total billed charges,Implant Device,1627.5,35,,1627.5,percent of total billed charges,Implant Device,1627.5,35,,1627.5,percent of total billed charges,Implant Device,1627.5,35,,1627.5,percent of total billed charges,Implant Device,1627.5,35,,1627.5,percent of total billed charges,Implant Device,1627.5,35,,1627.5,percent of total billed charges,Implant Device,1860,40,,1860,percent of total billed charges,Implant Device,1627.5,70,,1627.5,percent of total billed charges,All Other,1581,34,,1581,percent of total billed charges,Implant Device,1581,34,,1581,percent of total billed charges,Implant Device,1627.5,35,,1627.5,percent of total billed charges,Implant Device,1627.5,35,,1627.5,percent of total billed charges,Implant Device,1627.5,35,,1627.5,percent of total billed charges,Implant Device,1627.5,35,,1627.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1581,34,"If Charge > 2,000, then 34 percent",1581,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3441.01,
STRYKER 629272S DIS POSTERIOR LAT PLT 12,C1713,HCPCS,,79012370,CDM,278,RC,,,both,,,3892,2880.09,,,2880.09,Other,150% of Medicare + 9.63% HCRA Surcharge,1751.4,45,,1751.4,percent of total billed charges,Critical Access Hospital RCC factor,1323.28,34,,1323.28,percent of total billed charges,Implant Device,1323.28,34,,1323.28,percent of total billed charges,Implant Device,1323.28,34,,1323.28,percent of total billed charges,Implant Device,1323.28,34,,1323.28,percent of total billed charges,Implant Device,1323.28,34,,1323.28,percent of total billed charges,Implant Device,1926.54,,,1926.54,Other,110% of Medicare,1362.2,35,,1362.2,percent of total billed charges,Implant Device,1323.28,34,"Charges > $500, x 34%",1323.28,percent of total billed charges,Implant Device,1362.2,35,,1362.2,percent of total billed charges,Implant Device,1362.2,35,,1362.2,percent of total billed charges,Implant Device,1362.2,35,,1362.2,percent of total billed charges,Implant Device,1362.2,35,,1362.2,percent of total billed charges,Implant Device,1362.2,35,,1362.2,percent of total billed charges,Implant Device,1556.8,40,,1556.8,percent of total billed charges,Implant Device,1362.2,70,,1362.2,percent of total billed charges,All Other,1323.28,34,,1323.28,percent of total billed charges,Implant Device,1323.28,34,,1323.28,percent of total billed charges,Implant Device,1362.2,35,,1362.2,percent of total billed charges,Implant Device,1362.2,35,,1362.2,percent of total billed charges,Implant Device,1362.2,35,,1362.2,percent of total billed charges,Implant Device,1362.2,35,,1362.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1323.28,34,"If Charge > 2,000, then 34 percent",1323.28,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2880.09,
IN2BONES P67 ST442 COLAG SCREW 4X42.5MM,C1713,HCPCS,,79012372,CDM,278,RC,,,both,,,870,643.8,,,643.8,Other,150% of Medicare + 9.63% HCRA Surcharge,391.5,45,,391.5,percent of total billed charges,Critical Access Hospital RCC factor,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,430.65,,,430.65,Other,110% of Medicare,304.5,35,,304.5,percent of total billed charges,Implant Device,295.8,34,"Charges > $500, x 34%",295.8,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,348,40,,348,percent of total billed charges,Implant Device,304.5,70,,304.5,percent of total billed charges,All Other,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,643.8,
STRYKER 3102-1205 DBM PUTTY W/CHIPS 5CC,C1734,HCPCS,,79012374,CDM,278,RC,,,both,,,1864,1379.36,,,1379.36,Other,150% of Medicare + 9.63% HCRA Surcharge,838.8,45,,838.8,percent of total billed charges,Critical Access Hospital RCC factor,633.76,34,,633.76,percent of total billed charges,Implant Device,633.76,34,,633.76,percent of total billed charges,Implant Device,633.76,34,,633.76,percent of total billed charges,Implant Device,633.76,34,,633.76,percent of total billed charges,Implant Device,633.76,34,,633.76,percent of total billed charges,Implant Device,922.68,,,922.68,Other,110% of Medicare,652.4,35,,652.4,percent of total billed charges,Implant Device,633.76,34,"Charges > $500, x 34%",633.76,percent of total billed charges,Implant Device,652.4,35,,652.4,percent of total billed charges,Implant Device,652.4,35,,652.4,percent of total billed charges,Implant Device,652.4,35,,652.4,percent of total billed charges,Implant Device,652.4,35,,652.4,percent of total billed charges,Implant Device,652.4,35,,652.4,percent of total billed charges,Implant Device,745.6,40,,745.6,percent of total billed charges,Implant Device,652.4,70,,652.4,percent of total billed charges,All Other,633.76,34,,633.76,percent of total billed charges,Implant Device,633.76,34,,633.76,percent of total billed charges,Implant Device,652.4,35,,652.4,percent of total billed charges,Implant Device,652.4,35,,652.4,percent of total billed charges,Implant Device,652.4,35,,652.4,percent of total billed charges,Implant Device,652.4,35,,652.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1379.36,
ZIMMER 110010247 ACETAB SHELL 4H SZ G 58,C1776,HCPCS,,79012383,CDM,278,RC,,,both,,,8602,6365.5,,,6365.5,Other,150% of Medicare + 9.63% HCRA Surcharge,3870.9,45,,3870.9,percent of total billed charges,Critical Access Hospital RCC factor,2924.68,34,,2924.68,percent of total billed charges,Implant Device,2924.68,34,,2924.68,percent of total billed charges,Implant Device,2924.68,34,,2924.68,percent of total billed charges,Implant Device,2924.68,34,,2924.68,percent of total billed charges,Implant Device,2924.68,34,,2924.68,percent of total billed charges,Implant Device,4257.99,,,4257.99,Other,110% of Medicare,3010.7,35,,3010.7,percent of total billed charges,Implant Device,2924.68,34,"Charges > $500, x 34%",2924.68,percent of total billed charges,Implant Device,3010.7,35,,3010.7,percent of total billed charges,Implant Device,3010.7,35,,3010.7,percent of total billed charges,Implant Device,3010.7,35,,3010.7,percent of total billed charges,Implant Device,3010.7,35,,3010.7,percent of total billed charges,Implant Device,3010.7,35,,3010.7,percent of total billed charges,Implant Device,3440.8,40,,3440.8,percent of total billed charges,Implant Device,3010.7,70,,3010.7,percent of total billed charges,All Other,2924.68,34,,2924.68,percent of total billed charges,Implant Device,2924.68,34,,2924.68,percent of total billed charges,Implant Device,3010.7,35,,3010.7,percent of total billed charges,Implant Device,3010.7,35,,3010.7,percent of total billed charges,Implant Device,3010.7,35,,3010.7,percent of total billed charges,Implant Device,3010.7,35,,3010.7,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2924.68,34,"If Charge > 2,000, then 34 percent",2924.68,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,6365.5,
ZIMMER 30103607 LINER SIZE 6 36MM,C1776,HCPCS,,79012384,CDM,278,RC,,,both,,,3456,2557.45,,,2557.45,Other,150% of Medicare + 9.63% HCRA Surcharge,1555.2,45,,1555.2,percent of total billed charges,Critical Access Hospital RCC factor,1175.04,34,,1175.04,percent of total billed charges,Implant Device,1175.04,34,,1175.04,percent of total billed charges,Implant Device,1175.04,34,,1175.04,percent of total billed charges,Implant Device,1175.04,34,,1175.04,percent of total billed charges,Implant Device,1175.04,34,,1175.04,percent of total billed charges,Implant Device,1710.72,,,1710.72,Other,110% of Medicare,1209.6,35,,1209.6,percent of total billed charges,Implant Device,1175.04,34,"Charges > $500, x 34%",1175.04,percent of total billed charges,Implant Device,1209.6,35,,1209.6,percent of total billed charges,Implant Device,1209.6,35,,1209.6,percent of total billed charges,Implant Device,1209.6,35,,1209.6,percent of total billed charges,Implant Device,1209.6,35,,1209.6,percent of total billed charges,Implant Device,1209.6,35,,1209.6,percent of total billed charges,Implant Device,1382.4,40,,1382.4,percent of total billed charges,Implant Device,1209.6,70,,1209.6,percent of total billed charges,All Other,1175.04,34,,1175.04,percent of total billed charges,Implant Device,1175.04,34,,1175.04,percent of total billed charges,Implant Device,1209.6,35,,1209.6,percent of total billed charges,Implant Device,1209.6,35,,1209.6,percent of total billed charges,Implant Device,1209.6,35,,1209.6,percent of total billed charges,Implant Device,1209.6,35,,1209.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1175.04,34,"If Charge > 2,000, then 34 percent",1175.04,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2557.45,
ZIMMER 574101065 FEMORAL STEM SIZE 6.5,C1776,HCPCS,,79012385,CDM,278,RC,,,both,,,6912,5114.9,,,5114.9,Other,150% of Medicare + 9.63% HCRA Surcharge,3110.4,45,,3110.4,percent of total billed charges,Critical Access Hospital RCC factor,2350.08,34,,2350.08,percent of total billed charges,Implant Device,2350.08,34,,2350.08,percent of total billed charges,Implant Device,2350.08,34,,2350.08,percent of total billed charges,Implant Device,2350.08,34,,2350.08,percent of total billed charges,Implant Device,2350.08,34,,2350.08,percent of total billed charges,Implant Device,3421.44,,,3421.44,Other,110% of Medicare,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2350.08,34,"Charges > $500, x 34%",2350.08,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2764.8,40,,2764.8,percent of total billed charges,Implant Device,2419.2,70,,2419.2,percent of total billed charges,All Other,2350.08,34,,2350.08,percent of total billed charges,Implant Device,2350.08,34,,2350.08,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2350.08,34,"If Charge > 2,000, then 34 percent",2350.08,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5114.9,
ZIMMER 57401070 FEMORAL STEM SIZE 7,C1776,HCPCS,,79012386,CDM,278,RC,,,both,,,6912,5114.9,,,5114.9,Other,150% of Medicare + 9.63% HCRA Surcharge,3110.4,45,,3110.4,percent of total billed charges,Critical Access Hospital RCC factor,2350.08,34,,2350.08,percent of total billed charges,Implant Device,2350.08,34,,2350.08,percent of total billed charges,Implant Device,2350.08,34,,2350.08,percent of total billed charges,Implant Device,2350.08,34,,2350.08,percent of total billed charges,Implant Device,2350.08,34,,2350.08,percent of total billed charges,Implant Device,3421.44,,,3421.44,Other,110% of Medicare,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2350.08,34,"Charges > $500, x 34%",2350.08,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2764.8,40,,2764.8,percent of total billed charges,Implant Device,2419.2,70,,2419.2,percent of total billed charges,All Other,2350.08,34,,2350.08,percent of total billed charges,Implant Device,2350.08,34,,2350.08,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2350.08,34,"If Charge > 2,000, then 34 percent",2350.08,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5114.9,
ZIMMER 574102040 FEMORAL STEM SIZE 4,C1776,HCPCS,,79012387,CDM,278,RC,,,both,,,6912,5114.9,,,5114.9,Other,150% of Medicare + 9.63% HCRA Surcharge,3110.4,45,,3110.4,percent of total billed charges,Critical Access Hospital RCC factor,2350.08,34,,2350.08,percent of total billed charges,Implant Device,2350.08,34,,2350.08,percent of total billed charges,Implant Device,2350.08,34,,2350.08,percent of total billed charges,Implant Device,2350.08,34,,2350.08,percent of total billed charges,Implant Device,2350.08,34,,2350.08,percent of total billed charges,Implant Device,3421.44,,,3421.44,Other,110% of Medicare,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2350.08,34,"Charges > $500, x 34%",2350.08,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2764.8,40,,2764.8,percent of total billed charges,Implant Device,2419.2,70,,2419.2,percent of total billed charges,All Other,2350.08,34,,2350.08,percent of total billed charges,Implant Device,2350.08,34,,2350.08,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2350.08,34,"If Charge > 2,000, then 34 percent",2350.08,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5114.9,
J&J 04.015.535S LOCKING SCREW 5X45MM,C1713,HCPCS,,79012388,CDM,278,RC,,,both,,,454,335.96,,,335.96,Other,150% of Medicare + 9.63% HCRA Surcharge,204.3,45,,204.3,percent of total billed charges,Critical Access Hospital RCC factor,154.36,34,,154.36,percent of total billed charges,Implant Device,154.36,34,,154.36,percent of total billed charges,Implant Device,154.36,34,,154.36,percent of total billed charges,Implant Device,154.36,34,,154.36,percent of total billed charges,Implant Device,154.36,34,,154.36,percent of total billed charges,Implant Device,224.73,,,224.73,Other,110% of Medicare,158.9,35,,158.9,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,158.9,35,,158.9,percent of total billed charges,Implant Device,158.9,35,,158.9,percent of total billed charges,Implant Device,158.9,35,,158.9,percent of total billed charges,Implant Device,158.9,35,,158.9,percent of total billed charges,Implant Device,158.9,35,,158.9,percent of total billed charges,Implant Device,181.6,40,,181.6,percent of total billed charges,Implant Device,158.9,70,,158.9,percent of total billed charges,All Other,154.36,34,,154.36,percent of total billed charges,Implant Device,154.36,34,,154.36,percent of total billed charges,Implant Device,158.9,35,,158.9,percent of total billed charges,Implant Device,158.9,35,,158.9,percent of total billed charges,Implant Device,158.9,35,,158.9,percent of total billed charges,Implant Device,158.9,35,,158.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,335.96,
J&J 04.005.422S LOCKING SCREW 4X32MM,C1713,HCPCS,,79012389,CDM,278,RC,,,both,,,412,304.88,,,304.88,Other,150% of Medicare + 9.63% HCRA Surcharge,185.4,45,,185.4,percent of total billed charges,Critical Access Hospital RCC factor,140.08,34,,140.08,percent of total billed charges,Implant Device,140.08,34,,140.08,percent of total billed charges,Implant Device,140.08,34,,140.08,percent of total billed charges,Implant Device,140.08,34,,140.08,percent of total billed charges,Implant Device,140.08,34,,140.08,percent of total billed charges,Implant Device,203.94,,,203.94,Other,110% of Medicare,144.2,35,,144.2,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,144.2,35,,144.2,percent of total billed charges,Implant Device,144.2,35,,144.2,percent of total billed charges,Implant Device,144.2,35,,144.2,percent of total billed charges,Implant Device,144.2,35,,144.2,percent of total billed charges,Implant Device,144.2,35,,144.2,percent of total billed charges,Implant Device,164.8,40,,164.8,percent of total billed charges,Implant Device,144.2,70,,144.2,percent of total billed charges,All Other,140.08,34,,140.08,percent of total billed charges,Implant Device,140.08,34,,140.08,percent of total billed charges,Implant Device,144.2,35,,144.2,percent of total billed charges,Implant Device,144.2,35,,144.2,percent of total billed charges,Implant Device,144.2,35,,144.2,percent of total billed charges,Implant Device,144.2,35,,144.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,304.88,
J&J 04.034.340S TIBIAL NAIL 9X300MM,C1889,HCPCS,,79012390,CDM,278,RC,,,both,,,2765,2046.11,,,2046.11,Other,150% of Medicare + 9.63% HCRA Surcharge,1244.25,45,,1244.25,percent of total billed charges,Critical Access Hospital RCC factor,940.1,34,,940.1,percent of total billed charges,Implant Device,940.1,34,,940.1,percent of total billed charges,Implant Device,940.1,34,,940.1,percent of total billed charges,Implant Device,940.1,34,,940.1,percent of total billed charges,Implant Device,940.1,34,,940.1,percent of total billed charges,Implant Device,1368.68,,,1368.68,Other,110% of Medicare,967.75,35,,967.75,percent of total billed charges,Implant Device,940.1,34,"Charges > $500, x 34%",940.1,percent of total billed charges,Implant Device,967.75,35,,967.75,percent of total billed charges,Implant Device,967.75,35,,967.75,percent of total billed charges,Implant Device,967.75,35,,967.75,percent of total billed charges,Implant Device,967.75,35,,967.75,percent of total billed charges,Implant Device,967.75,35,,967.75,percent of total billed charges,Implant Device,1106,40,,1106,percent of total billed charges,Implant Device,967.75,70,,967.75,percent of total billed charges,All Other,940.1,34,,940.1,percent of total billed charges,Implant Device,940.1,34,,940.1,percent of total billed charges,Implant Device,967.75,35,,967.75,percent of total billed charges,Implant Device,967.75,35,,967.75,percent of total billed charges,Implant Device,967.75,35,,967.75,percent of total billed charges,Implant Device,967.75,35,,967.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,940.1,34,"If Charge > 2,000, then 34 percent",940.1,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2046.11,
J&J 04.034.449S TIBAIL NAIL 10X345MM,C1889,HCPCS,,79012393,CDM,278,RC,,,both,,,2765,2046.11,,,2046.11,Other,150% of Medicare + 9.63% HCRA Surcharge,1244.25,45,,1244.25,percent of total billed charges,Critical Access Hospital RCC factor,940.1,34,,940.1,percent of total billed charges,Implant Device,940.1,34,,940.1,percent of total billed charges,Implant Device,940.1,34,,940.1,percent of total billed charges,Implant Device,940.1,34,,940.1,percent of total billed charges,Implant Device,940.1,34,,940.1,percent of total billed charges,Implant Device,1368.68,,,1368.68,Other,110% of Medicare,967.75,35,,967.75,percent of total billed charges,Implant Device,940.1,34,"Charges > $500, x 34%",940.1,percent of total billed charges,Implant Device,967.75,35,,967.75,percent of total billed charges,Implant Device,967.75,35,,967.75,percent of total billed charges,Implant Device,967.75,35,,967.75,percent of total billed charges,Implant Device,967.75,35,,967.75,percent of total billed charges,Implant Device,967.75,35,,967.75,percent of total billed charges,Implant Device,1106,40,,1106,percent of total billed charges,Implant Device,967.75,70,,967.75,percent of total billed charges,All Other,940.1,34,,940.1,percent of total billed charges,Implant Device,940.1,34,,940.1,percent of total billed charges,Implant Device,967.75,35,,967.75,percent of total billed charges,Implant Device,967.75,35,,967.75,percent of total billed charges,Implant Device,967.75,35,,967.75,percent of total billed charges,Implant Device,967.75,35,,967.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,940.1,34,"If Charge > 2,000, then 34 percent",940.1,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2046.11,
WRIGHT FFNS1212 STAPLE NITINOL 12X12MM,C1713,HCPCS,,79012394,CDM,278,RC,,,both,,,8109,6000.68,,,6000.68,Other,150% of Medicare + 9.63% HCRA Surcharge,3649.05,45,,3649.05,percent of total billed charges,Critical Access Hospital RCC factor,2757.06,34,,2757.06,percent of total billed charges,Implant Device,2757.06,34,,2757.06,percent of total billed charges,Implant Device,2757.06,34,,2757.06,percent of total billed charges,Implant Device,2757.06,34,,2757.06,percent of total billed charges,Implant Device,2757.06,34,,2757.06,percent of total billed charges,Implant Device,4013.96,,,4013.96,Other,110% of Medicare,2838.15,35,,2838.15,percent of total billed charges,Implant Device,2757.06,34,"Charges > $500, x 34%",2757.06,percent of total billed charges,Implant Device,2838.15,35,,2838.15,percent of total billed charges,Implant Device,2838.15,35,,2838.15,percent of total billed charges,Implant Device,2838.15,35,,2838.15,percent of total billed charges,Implant Device,2838.15,35,,2838.15,percent of total billed charges,Implant Device,2838.15,35,,2838.15,percent of total billed charges,Implant Device,3243.6,40,,3243.6,percent of total billed charges,Implant Device,2838.15,70,,2838.15,percent of total billed charges,All Other,2757.06,34,,2757.06,percent of total billed charges,Implant Device,2757.06,34,,2757.06,percent of total billed charges,Implant Device,2838.15,35,,2838.15,percent of total billed charges,Implant Device,2838.15,35,,2838.15,percent of total billed charges,Implant Device,2838.15,35,,2838.15,percent of total billed charges,Implant Device,2838.15,35,,2838.15,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2757.06,34,"If Charge > 2,000, then 34 percent",2757.06,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,6000.68,
J&J 04.037.165S TFNA NAIL 11X440 130 DEG,C1889,HCPCS,,79012395,CDM,278,RC,,,both,,,5212,3856.89,,,3856.89,Other,150% of Medicare + 9.63% HCRA Surcharge,2345.4,45,,2345.4,percent of total billed charges,Critical Access Hospital RCC factor,1772.08,34,,1772.08,percent of total billed charges,Implant Device,1772.08,34,,1772.08,percent of total billed charges,Implant Device,1772.08,34,,1772.08,percent of total billed charges,Implant Device,1772.08,34,,1772.08,percent of total billed charges,Implant Device,1772.08,34,,1772.08,percent of total billed charges,Implant Device,2579.94,,,2579.94,Other,110% of Medicare,1824.2,35,,1824.2,percent of total billed charges,Implant Device,1772.08,34,"Charges > $500, x 34%",1772.08,percent of total billed charges,Implant Device,1824.2,35,,1824.2,percent of total billed charges,Implant Device,1824.2,35,,1824.2,percent of total billed charges,Implant Device,1824.2,35,,1824.2,percent of total billed charges,Implant Device,1824.2,35,,1824.2,percent of total billed charges,Implant Device,1824.2,35,,1824.2,percent of total billed charges,Implant Device,2084.8,40,,2084.8,percent of total billed charges,Implant Device,1824.2,70,,1824.2,percent of total billed charges,All Other,1772.08,34,,1772.08,percent of total billed charges,Implant Device,1772.08,34,,1772.08,percent of total billed charges,Implant Device,1824.2,35,,1824.2,percent of total billed charges,Implant Device,1824.2,35,,1824.2,percent of total billed charges,Implant Device,1824.2,35,,1824.2,percent of total billed charges,Implant Device,1824.2,35,,1824.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1772.08,34,"If Charge > 2,000, then 34 percent",1772.08,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3856.89,
J&J 04.038.420S HELICAL BLADE 120MM,C1889,HCPCS,,79012396,CDM,278,RC,,,both,,,1864,1379.36,,,1379.36,Other,150% of Medicare + 9.63% HCRA Surcharge,838.8,45,,838.8,percent of total billed charges,Critical Access Hospital RCC factor,633.76,34,,633.76,percent of total billed charges,Implant Device,633.76,34,,633.76,percent of total billed charges,Implant Device,633.76,34,,633.76,percent of total billed charges,Implant Device,633.76,34,,633.76,percent of total billed charges,Implant Device,633.76,34,,633.76,percent of total billed charges,Implant Device,922.68,,,922.68,Other,110% of Medicare,652.4,35,,652.4,percent of total billed charges,Implant Device,633.76,34,"Charges > $500, x 34%",633.76,percent of total billed charges,Implant Device,652.4,35,,652.4,percent of total billed charges,Implant Device,652.4,35,,652.4,percent of total billed charges,Implant Device,652.4,35,,652.4,percent of total billed charges,Implant Device,652.4,35,,652.4,percent of total billed charges,Implant Device,652.4,35,,652.4,percent of total billed charges,Implant Device,745.6,40,,745.6,percent of total billed charges,Implant Device,652.4,70,,652.4,percent of total billed charges,All Other,633.76,34,,633.76,percent of total billed charges,Implant Device,633.76,34,,633.76,percent of total billed charges,Implant Device,652.4,35,,652.4,percent of total billed charges,Implant Device,652.4,35,,652.4,percent of total billed charges,Implant Device,652.4,35,,652.4,percent of total billed charges,Implant Device,652.4,35,,652.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1379.36,
STRYKER 2341-1133S TIBIAL NAIL 11X330MM,C1889,HCPCS,,79012397,CDM,278,RC,,,both,,,4792,3546.09,,,3546.09,Other,150% of Medicare + 9.63% HCRA Surcharge,2156.4,45,,2156.4,percent of total billed charges,Critical Access Hospital RCC factor,1629.28,34,,1629.28,percent of total billed charges,Implant Device,1629.28,34,,1629.28,percent of total billed charges,Implant Device,1629.28,34,,1629.28,percent of total billed charges,Implant Device,1629.28,34,,1629.28,percent of total billed charges,Implant Device,1629.28,34,,1629.28,percent of total billed charges,Implant Device,2372.04,,,2372.04,Other,110% of Medicare,1677.2,35,,1677.2,percent of total billed charges,Implant Device,1629.28,34,"Charges > $500, x 34%",1629.28,percent of total billed charges,Implant Device,1677.2,35,,1677.2,percent of total billed charges,Implant Device,1677.2,35,,1677.2,percent of total billed charges,Implant Device,1677.2,35,,1677.2,percent of total billed charges,Implant Device,1677.2,35,,1677.2,percent of total billed charges,Implant Device,1677.2,35,,1677.2,percent of total billed charges,Implant Device,1916.8,40,,1916.8,percent of total billed charges,Implant Device,1677.2,70,,1677.2,percent of total billed charges,All Other,1629.28,34,,1629.28,percent of total billed charges,Implant Device,1629.28,34,,1629.28,percent of total billed charges,Implant Device,1677.2,35,,1677.2,percent of total billed charges,Implant Device,1677.2,35,,1677.2,percent of total billed charges,Implant Device,1677.2,35,,1677.2,percent of total billed charges,Implant Device,1677.2,35,,1677.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1629.28,34,"If Charge > 2,000, then 34 percent",1629.28,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3546.09,
ZIMMER 183032 FEMORAL LEFT 70MM,C1776,HCPCS,,79012399,CDM,278,RC,,,both,,,6300,4662.02,,,4662.02,Other,150% of Medicare + 9.63% HCRA Surcharge,2835,45,,2835,percent of total billed charges,Critical Access Hospital RCC factor,2142,34,,2142,percent of total billed charges,Implant Device,2142,34,,2142,percent of total billed charges,Implant Device,2142,34,,2142,percent of total billed charges,Implant Device,2142,34,,2142,percent of total billed charges,Implant Device,2142,34,,2142,percent of total billed charges,Implant Device,3118.5,,,3118.5,Other,110% of Medicare,2205,35,,2205,percent of total billed charges,Implant Device,2142,34,"Charges > $500, x 34%",2142,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2520,40,,2520,percent of total billed charges,Implant Device,2205,70,,2205,percent of total billed charges,All Other,2142,34,,2142,percent of total billed charges,Implant Device,2142,34,,2142,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2142,34,"If Charge > 2,000, then 34 percent",2142,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4662.02,
ZIMMER EP-189040 TIBIAL BEARING 10X67MM,C1776,HCPCS,,79012400,CDM,278,RC,,,both,,,3648,2699.53,,,2699.53,Other,150% of Medicare + 9.63% HCRA Surcharge,1641.6,45,,1641.6,percent of total billed charges,Critical Access Hospital RCC factor,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1805.76,,,1805.76,Other,110% of Medicare,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1240.32,34,"Charges > $500, x 34%",1240.32,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1459.2,40,,1459.2,percent of total billed charges,Implant Device,1276.8,70,,1276.8,percent of total billed charges,All Other,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1240.32,34,"If Charge > 2,000, then 34 percent",1240.32,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2699.53,
ZIMMER 141232 TIBIAL PLATE 67MM,C1776,HCPCS,,79012401,CDM,278,RC,,,both,,,2304,1704.97,,,1704.97,Other,150% of Medicare + 9.63% HCRA Surcharge,1036.8,45,,1036.8,percent of total billed charges,Critical Access Hospital RCC factor,783.36,34,,783.36,percent of total billed charges,Implant Device,783.36,34,,783.36,percent of total billed charges,Implant Device,783.36,34,,783.36,percent of total billed charges,Implant Device,783.36,34,,783.36,percent of total billed charges,Implant Device,783.36,34,,783.36,percent of total billed charges,Implant Device,1140.48,,,1140.48,Other,110% of Medicare,806.4,35,,806.4,percent of total billed charges,Implant Device,783.36,34,"Charges > $500, x 34%",783.36,percent of total billed charges,Implant Device,806.4,35,,806.4,percent of total billed charges,Implant Device,806.4,35,,806.4,percent of total billed charges,Implant Device,806.4,35,,806.4,percent of total billed charges,Implant Device,806.4,35,,806.4,percent of total billed charges,Implant Device,806.4,35,,806.4,percent of total billed charges,Implant Device,921.6,40,,921.6,percent of total billed charges,Implant Device,806.4,70,,806.4,percent of total billed charges,All Other,783.36,34,,783.36,percent of total billed charges,Implant Device,783.36,34,,783.36,percent of total billed charges,Implant Device,806.4,35,,806.4,percent of total billed charges,Implant Device,806.4,35,,806.4,percent of total billed charges,Implant Device,806.4,35,,806.4,percent of total billed charges,Implant Device,806.4,35,,806.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,783.36,34,"If Charge > 2,000, then 34 percent",783.36,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1704.97,
ZIMMER 110010264 ACETABULAR SHELL 52MM,C1776,HCPCS,,79012402,CDM,278,RC,,,both,,,10383,7683.45,,,7683.45,Other,150% of Medicare + 9.63% HCRA Surcharge,4672.35,45,,4672.35,percent of total billed charges,Critical Access Hospital RCC factor,3530.22,34,,3530.22,percent of total billed charges,Implant Device,3530.22,34,,3530.22,percent of total billed charges,Implant Device,3530.22,34,,3530.22,percent of total billed charges,Implant Device,3530.22,34,,3530.22,percent of total billed charges,Implant Device,3530.22,34,,3530.22,percent of total billed charges,Implant Device,5139.59,,,5139.59,Other,110% of Medicare,3634.05,35,,3634.05,percent of total billed charges,Implant Device,3530.22,34,"Charges > $500, x 34%",3530.22,percent of total billed charges,Implant Device,3634.05,35,,3634.05,percent of total billed charges,Implant Device,3634.05,35,,3634.05,percent of total billed charges,Implant Device,3634.05,35,,3634.05,percent of total billed charges,Implant Device,3634.05,35,,3634.05,percent of total billed charges,Implant Device,3634.05,35,,3634.05,percent of total billed charges,Implant Device,4153.2,40,,4153.2,percent of total billed charges,Implant Device,3634.05,70,,3634.05,percent of total billed charges,All Other,3530.22,34,,3530.22,percent of total billed charges,Implant Device,3530.22,34,,3530.22,percent of total billed charges,Implant Device,3634.05,35,,3634.05,percent of total billed charges,Implant Device,3634.05,35,,3634.05,percent of total billed charges,Implant Device,3634.05,35,,3634.05,percent of total billed charges,Implant Device,3634.05,35,,3634.05,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3530.22,34,"If Charge > 2,000, then 34 percent",3530.22,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,7683.45,
J&J 249.919 T-PLATE 2.4X66MM 13 HOLE,C1713,HCPCS,,79012403,CDM,278,RC,,,both,,,642,475.08,,,475.08,Other,150% of Medicare + 9.63% HCRA Surcharge,288.9,45,,288.9,percent of total billed charges,Critical Access Hospital RCC factor,218.28,34,,218.28,percent of total billed charges,Implant Device,218.28,34,,218.28,percent of total billed charges,Implant Device,218.28,34,,218.28,percent of total billed charges,Implant Device,218.28,34,,218.28,percent of total billed charges,Implant Device,218.28,34,,218.28,percent of total billed charges,Implant Device,317.79,,,317.79,Other,110% of Medicare,224.7,35,,224.7,percent of total billed charges,Implant Device,218.28,34,"Charges > $500, x 34%",218.28,percent of total billed charges,Implant Device,224.7,35,,224.7,percent of total billed charges,Implant Device,224.7,35,,224.7,percent of total billed charges,Implant Device,224.7,35,,224.7,percent of total billed charges,Implant Device,224.7,35,,224.7,percent of total billed charges,Implant Device,224.7,35,,224.7,percent of total billed charges,Implant Device,256.8,40,,256.8,percent of total billed charges,Implant Device,224.7,70,,224.7,percent of total billed charges,All Other,218.28,34,,218.28,percent of total billed charges,Implant Device,218.28,34,,218.28,percent of total billed charges,Implant Device,224.7,35,,224.7,percent of total billed charges,Implant Device,224.7,35,,224.7,percent of total billed charges,Implant Device,224.7,35,,224.7,percent of total billed charges,Implant Device,224.7,35,,224.7,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,475.08,
J&J 201.776 CORTEX SCREW 2.4X26MM,C1713,HCPCS,,79012404,CDM,278,RC,,,both,,,130,96.2,,,96.2,Other,150% of Medicare + 9.63% HCRA Surcharge,58.5,45,,58.5,percent of total billed charges,Critical Access Hospital RCC factor,44.2,34,,44.2,percent of total billed charges,Implant Device,44.2,34,,44.2,percent of total billed charges,Implant Device,44.2,34,,44.2,percent of total billed charges,Implant Device,44.2,34,,44.2,percent of total billed charges,Implant Device,44.2,34,,44.2,percent of total billed charges,Implant Device,64.35,,,64.35,Other,110% of Medicare,45.5,35,,45.5,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,45.5,35,,45.5,percent of total billed charges,Implant Device,45.5,35,,45.5,percent of total billed charges,Implant Device,45.5,35,,45.5,percent of total billed charges,Implant Device,45.5,35,,45.5,percent of total billed charges,Implant Device,45.5,35,,45.5,percent of total billed charges,Implant Device,52,40,,52,percent of total billed charges,Implant Device,45.5,70,,45.5,percent of total billed charges,All Other,44.2,34,,44.2,percent of total billed charges,Implant Device,44.2,34,,44.2,percent of total billed charges,Implant Device,45.5,35,,45.5,percent of total billed charges,Implant Device,45.5,35,,45.5,percent of total billed charges,Implant Device,45.5,35,,45.5,percent of total billed charges,Implant Device,45.5,35,,45.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,96.2,
J&J 201.788 CORTEX SCREW 2.4X38MM,C1713,HCPCS,,79012405,CDM,278,RC,,,both,,,130,96.2,,,96.2,Other,150% of Medicare + 9.63% HCRA Surcharge,58.5,45,,58.5,percent of total billed charges,Critical Access Hospital RCC factor,44.2,34,,44.2,percent of total billed charges,Implant Device,44.2,34,,44.2,percent of total billed charges,Implant Device,44.2,34,,44.2,percent of total billed charges,Implant Device,44.2,34,,44.2,percent of total billed charges,Implant Device,44.2,34,,44.2,percent of total billed charges,Implant Device,64.35,,,64.35,Other,110% of Medicare,45.5,35,,45.5,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,45.5,35,,45.5,percent of total billed charges,Implant Device,45.5,35,,45.5,percent of total billed charges,Implant Device,45.5,35,,45.5,percent of total billed charges,Implant Device,45.5,35,,45.5,percent of total billed charges,Implant Device,45.5,35,,45.5,percent of total billed charges,Implant Device,52,40,,52,percent of total billed charges,Implant Device,45.5,70,,45.5,percent of total billed charges,All Other,44.2,34,,44.2,percent of total billed charges,Implant Device,44.2,34,,44.2,percent of total billed charges,Implant Device,45.5,35,,45.5,percent of total billed charges,Implant Device,45.5,35,,45.5,percent of total billed charges,Implant Device,45.5,35,,45.5,percent of total billed charges,Implant Device,45.5,35,,45.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,96.2,
J&J 201.784 CORTEX SCREW 2.4X34MM,C1713,HCPCS,,79012406,CDM,278,RC,,,both,,,130,96.2,,,96.2,Other,150% of Medicare + 9.63% HCRA Surcharge,58.5,45,,58.5,percent of total billed charges,Critical Access Hospital RCC factor,44.2,34,,44.2,percent of total billed charges,Implant Device,44.2,34,,44.2,percent of total billed charges,Implant Device,44.2,34,,44.2,percent of total billed charges,Implant Device,44.2,34,,44.2,percent of total billed charges,Implant Device,44.2,34,,44.2,percent of total billed charges,Implant Device,64.35,,,64.35,Other,110% of Medicare,45.5,35,,45.5,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,45.5,35,,45.5,percent of total billed charges,Implant Device,45.5,35,,45.5,percent of total billed charges,Implant Device,45.5,35,,45.5,percent of total billed charges,Implant Device,45.5,35,,45.5,percent of total billed charges,Implant Device,45.5,35,,45.5,percent of total billed charges,Implant Device,52,40,,52,percent of total billed charges,Implant Device,45.5,70,,45.5,percent of total billed charges,All Other,44.2,34,,44.2,percent of total billed charges,Implant Device,44.2,34,,44.2,percent of total billed charges,Implant Device,45.5,35,,45.5,percent of total billed charges,Implant Device,45.5,35,,45.5,percent of total billed charges,Implant Device,45.5,35,,45.5,percent of total billed charges,Implant Device,45.5,35,,45.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,96.2,
J&J 247.372 PLATE 2.7X76MM 8 HOLE,C1713,HCPCS,,79012407,CDM,278,RC,,,both,,,1057,782.18,,,782.18,Other,150% of Medicare + 9.63% HCRA Surcharge,475.65,45,,475.65,percent of total billed charges,Critical Access Hospital RCC factor,359.38,34,,359.38,percent of total billed charges,Implant Device,359.38,34,,359.38,percent of total billed charges,Implant Device,359.38,34,,359.38,percent of total billed charges,Implant Device,359.38,34,,359.38,percent of total billed charges,Implant Device,359.38,34,,359.38,percent of total billed charges,Implant Device,523.22,,,523.22,Other,110% of Medicare,369.95,35,,369.95,percent of total billed charges,Implant Device,359.38,34,"Charges > $500, x 34%",359.38,percent of total billed charges,Implant Device,369.95,35,,369.95,percent of total billed charges,Implant Device,369.95,35,,369.95,percent of total billed charges,Implant Device,369.95,35,,369.95,percent of total billed charges,Implant Device,369.95,35,,369.95,percent of total billed charges,Implant Device,369.95,35,,369.95,percent of total billed charges,Implant Device,422.8,40,,422.8,percent of total billed charges,Implant Device,369.95,70,,369.95,percent of total billed charges,All Other,359.38,34,,359.38,percent of total billed charges,Implant Device,359.38,34,,359.38,percent of total billed charges,Implant Device,369.95,35,,369.95,percent of total billed charges,Implant Device,369.95,35,,369.95,percent of total billed charges,Implant Device,369.95,35,,369.95,percent of total billed charges,Implant Device,369.95,35,,369.95,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,782.18,
J&J 249.615 LCP PLATE 2.4MM 7 HOLE,C1713,HCPCS,,79012409,CDM,278,RC,,,both,,,1840,1361.6,,,1361.6,Other,150% of Medicare + 9.63% HCRA Surcharge,828,45,,828,percent of total billed charges,Critical Access Hospital RCC factor,625.6,34,,625.6,percent of total billed charges,Implant Device,625.6,34,,625.6,percent of total billed charges,Implant Device,625.6,34,,625.6,percent of total billed charges,Implant Device,625.6,34,,625.6,percent of total billed charges,Implant Device,625.6,34,,625.6,percent of total billed charges,Implant Device,910.8,,,910.8,Other,110% of Medicare,644,35,,644,percent of total billed charges,Implant Device,625.6,34,"Charges > $500, x 34%",625.6,percent of total billed charges,Implant Device,644,35,,644,percent of total billed charges,Implant Device,644,35,,644,percent of total billed charges,Implant Device,644,35,,644,percent of total billed charges,Implant Device,644,35,,644,percent of total billed charges,Implant Device,644,35,,644,percent of total billed charges,Implant Device,736,40,,736,percent of total billed charges,Implant Device,644,70,,644,percent of total billed charges,All Other,625.6,34,,625.6,percent of total billed charges,Implant Device,625.6,34,,625.6,percent of total billed charges,Implant Device,644,35,,644,percent of total billed charges,Implant Device,644,35,,644,percent of total billed charges,Implant Device,644,35,,644,percent of total billed charges,Implant Device,644,35,,644,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1361.6,
J&J 201.790 CORTEX SCREW 2.4X40MM,C1713,HCPCS,,79012410,CDM,278,RC,,,both,,,130,96.2,,,96.2,Other,150% of Medicare + 9.63% HCRA Surcharge,58.5,45,,58.5,percent of total billed charges,Critical Access Hospital RCC factor,44.2,34,,44.2,percent of total billed charges,Implant Device,44.2,34,,44.2,percent of total billed charges,Implant Device,44.2,34,,44.2,percent of total billed charges,Implant Device,44.2,34,,44.2,percent of total billed charges,Implant Device,44.2,34,,44.2,percent of total billed charges,Implant Device,64.35,,,64.35,Other,110% of Medicare,45.5,35,,45.5,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,45.5,35,,45.5,percent of total billed charges,Implant Device,45.5,35,,45.5,percent of total billed charges,Implant Device,45.5,35,,45.5,percent of total billed charges,Implant Device,45.5,35,,45.5,percent of total billed charges,Implant Device,45.5,35,,45.5,percent of total billed charges,Implant Device,52,40,,52,percent of total billed charges,Implant Device,45.5,70,,45.5,percent of total billed charges,All Other,44.2,34,,44.2,percent of total billed charges,Implant Device,44.2,34,,44.2,percent of total billed charges,Implant Device,45.5,35,,45.5,percent of total billed charges,Implant Device,45.5,35,,45.5,percent of total billed charges,Implant Device,45.5,35,,45.5,percent of total billed charges,Implant Device,45.5,35,,45.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,96.2,
J&J 201.778 CORTEX SCREW 2.4X28MM,C1713,HCPCS,,79012411,CDM,278,RC,,,both,,,130,96.2,,,96.2,Other,150% of Medicare + 9.63% HCRA Surcharge,58.5,45,,58.5,percent of total billed charges,Critical Access Hospital RCC factor,44.2,34,,44.2,percent of total billed charges,Implant Device,44.2,34,,44.2,percent of total billed charges,Implant Device,44.2,34,,44.2,percent of total billed charges,Implant Device,44.2,34,,44.2,percent of total billed charges,Implant Device,44.2,34,,44.2,percent of total billed charges,Implant Device,64.35,,,64.35,Other,110% of Medicare,45.5,35,,45.5,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,45.5,35,,45.5,percent of total billed charges,Implant Device,45.5,35,,45.5,percent of total billed charges,Implant Device,45.5,35,,45.5,percent of total billed charges,Implant Device,45.5,35,,45.5,percent of total billed charges,Implant Device,45.5,35,,45.5,percent of total billed charges,Implant Device,52,40,,52,percent of total billed charges,Implant Device,45.5,70,,45.5,percent of total billed charges,All Other,44.2,34,,44.2,percent of total billed charges,Implant Device,44.2,34,,44.2,percent of total billed charges,Implant Device,45.5,35,,45.5,percent of total billed charges,Implant Device,45.5,35,,45.5,percent of total billed charges,Implant Device,45.5,35,,45.5,percent of total billed charges,Implant Device,45.5,35,,45.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,96.2,
J&J 224.591 LCP PLATE 4.5X170MM 9 HOLE,C1713,HCPCS,,79012412,CDM,278,RC,,,both,,,1282,948.68,,,948.68,Other,150% of Medicare + 9.63% HCRA Surcharge,576.9,45,,576.9,percent of total billed charges,Critical Access Hospital RCC factor,435.88,34,,435.88,percent of total billed charges,Implant Device,435.88,34,,435.88,percent of total billed charges,Implant Device,435.88,34,,435.88,percent of total billed charges,Implant Device,435.88,34,,435.88,percent of total billed charges,Implant Device,435.88,34,,435.88,percent of total billed charges,Implant Device,634.59,,,634.59,Other,110% of Medicare,448.7,35,,448.7,percent of total billed charges,Implant Device,435.88,34,"Charges > $500, x 34%",435.88,percent of total billed charges,Implant Device,448.7,35,,448.7,percent of total billed charges,Implant Device,448.7,35,,448.7,percent of total billed charges,Implant Device,448.7,35,,448.7,percent of total billed charges,Implant Device,448.7,35,,448.7,percent of total billed charges,Implant Device,448.7,35,,448.7,percent of total billed charges,Implant Device,512.8,40,,512.8,percent of total billed charges,Implant Device,448.7,70,,448.7,percent of total billed charges,All Other,435.88,34,,435.88,percent of total billed charges,Implant Device,435.88,34,,435.88,percent of total billed charges,Implant Device,448.7,35,,448.7,percent of total billed charges,Implant Device,448.7,35,,448.7,percent of total billed charges,Implant Device,448.7,35,,448.7,percent of total billed charges,Implant Device,448.7,35,,448.7,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,948.68,
J&J 214.822 CORTEX SCREW 4.5X22MM,C1713,HCPCS,,79012413,CDM,278,RC,,,both,,,57,42.18,,,42.18,Other,150% of Medicare + 9.63% HCRA Surcharge,25.65,45,,25.65,percent of total billed charges,Critical Access Hospital RCC factor,19.38,34,,19.38,percent of total billed charges,Implant Device,19.38,34,,19.38,percent of total billed charges,Implant Device,19.38,34,,19.38,percent of total billed charges,Implant Device,19.38,34,,19.38,percent of total billed charges,Implant Device,19.38,34,,19.38,percent of total billed charges,Implant Device,28.22,,,28.22,Other,110% of Medicare,19.95,35,,19.95,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,19.95,35,,19.95,percent of total billed charges,Implant Device,19.95,35,,19.95,percent of total billed charges,Implant Device,19.95,35,,19.95,percent of total billed charges,Implant Device,19.95,35,,19.95,percent of total billed charges,Implant Device,19.95,35,,19.95,percent of total billed charges,Implant Device,22.8,40,,22.8,percent of total billed charges,Implant Device,19.95,70,,19.95,percent of total billed charges,All Other,19.38,34,,19.38,percent of total billed charges,Implant Device,19.38,34,,19.38,percent of total billed charges,Implant Device,19.95,35,,19.95,percent of total billed charges,Implant Device,19.95,35,,19.95,percent of total billed charges,Implant Device,19.95,35,,19.95,percent of total billed charges,Implant Device,19.95,35,,19.95,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,42.18,
STRYKER 656411 BONE SCREW 2.7X11MM,C1713,HCPCS,,79012415,CDM,278,RC,,,both,,,395,292.3,,,292.3,Other,150% of Medicare + 9.63% HCRA Surcharge,177.75,45,,177.75,percent of total billed charges,Critical Access Hospital RCC factor,134.3,34,,134.3,percent of total billed charges,Implant Device,134.3,34,,134.3,percent of total billed charges,Implant Device,134.3,34,,134.3,percent of total billed charges,Implant Device,134.3,34,,134.3,percent of total billed charges,Implant Device,134.3,34,,134.3,percent of total billed charges,Implant Device,195.53,,,195.53,Other,110% of Medicare,138.25,35,,138.25,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,138.25,35,,138.25,percent of total billed charges,Implant Device,138.25,35,,138.25,percent of total billed charges,Implant Device,138.25,35,,138.25,percent of total billed charges,Implant Device,138.25,35,,138.25,percent of total billed charges,Implant Device,138.25,35,,138.25,percent of total billed charges,Implant Device,158,40,,158,percent of total billed charges,Implant Device,138.25,70,,138.25,percent of total billed charges,All Other,134.3,34,,134.3,percent of total billed charges,Implant Device,134.3,34,,134.3,percent of total billed charges,Implant Device,138.25,35,,138.25,percent of total billed charges,Implant Device,138.25,35,,138.25,percent of total billed charges,Implant Device,138.25,35,,138.25,percent of total billed charges,Implant Device,138.25,35,,138.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,292.3,
WRIGHT 496H020 EVOLVE HEAD 20MM,C1776,HCPCS,,79012417,CDM,278,RC,,,both,,,10086,7463.67,,,7463.67,Other,150% of Medicare + 9.63% HCRA Surcharge,4538.7,45,,4538.7,percent of total billed charges,Critical Access Hospital RCC factor,3429.24,34,,3429.24,percent of total billed charges,Implant Device,3429.24,34,,3429.24,percent of total billed charges,Implant Device,3429.24,34,,3429.24,percent of total billed charges,Implant Device,3429.24,34,,3429.24,percent of total billed charges,Implant Device,3429.24,34,,3429.24,percent of total billed charges,Implant Device,4992.57,,,4992.57,Other,110% of Medicare,3530.1,35,,3530.1,percent of total billed charges,Implant Device,3429.24,34,"Charges > $500, x 34%",3429.24,percent of total billed charges,Implant Device,3530.1,35,,3530.1,percent of total billed charges,Implant Device,3530.1,35,,3530.1,percent of total billed charges,Implant Device,3530.1,35,,3530.1,percent of total billed charges,Implant Device,3530.1,35,,3530.1,percent of total billed charges,Implant Device,3530.1,35,,3530.1,percent of total billed charges,Implant Device,4034.4,40,,4034.4,percent of total billed charges,Implant Device,3530.1,70,,3530.1,percent of total billed charges,All Other,3429.24,34,,3429.24,percent of total billed charges,Implant Device,3429.24,34,,3429.24,percent of total billed charges,Implant Device,3530.1,35,,3530.1,percent of total billed charges,Implant Device,3530.1,35,,3530.1,percent of total billed charges,Implant Device,3530.1,35,,3530.1,percent of total billed charges,Implant Device,3530.1,35,,3530.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3429.24,34,"If Charge > 2,000, then 34 percent",3429.24,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,7463.67,
WRIGHT 496S085 EVOLVE STEM 8.5MM,C1776,HCPCS,,79012418,CDM,278,RC,,,both,,,11985,8868.93,,,8868.93,Other,150% of Medicare + 9.63% HCRA Surcharge,5393.25,45,,5393.25,percent of total billed charges,Critical Access Hospital RCC factor,4074.9,34,,4074.9,percent of total billed charges,Implant Device,4074.9,34,,4074.9,percent of total billed charges,Implant Device,4074.9,34,,4074.9,percent of total billed charges,Implant Device,4074.9,34,,4074.9,percent of total billed charges,Implant Device,4074.9,34,,4074.9,percent of total billed charges,Implant Device,5932.58,,,5932.58,Other,110% of Medicare,4194.75,35,,4194.75,percent of total billed charges,Implant Device,4074.9,34,"Charges > $500, x 34%",4074.9,percent of total billed charges,Implant Device,4194.75,35,,4194.75,percent of total billed charges,Implant Device,4194.75,35,,4194.75,percent of total billed charges,Implant Device,4194.75,35,,4194.75,percent of total billed charges,Implant Device,4194.75,35,,4194.75,percent of total billed charges,Implant Device,4194.75,35,,4194.75,percent of total billed charges,Implant Device,4794,40,,4794,percent of total billed charges,Implant Device,4194.75,70,,4194.75,percent of total billed charges,All Other,4074.9,34,,4074.9,percent of total billed charges,Implant Device,4074.9,34,,4074.9,percent of total billed charges,Implant Device,4194.75,35,,4194.75,percent of total billed charges,Implant Device,4194.75,35,,4194.75,percent of total billed charges,Implant Device,4194.75,35,,4194.75,percent of total billed charges,Implant Device,4194.75,35,,4194.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,4074.9,34,"If Charge > 2,000, then 34 percent",4074.9,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,8868.93,
J&J 02.124.418 CONDYLAR PLT 4.5X370 18H,C1713,HCPCS,,79012420,CDM,278,RC,,,both,,,5428,4016.73,,,4016.73,Other,150% of Medicare + 9.63% HCRA Surcharge,2442.6,45,,2442.6,percent of total billed charges,Critical Access Hospital RCC factor,1845.52,34,,1845.52,percent of total billed charges,Implant Device,1845.52,34,,1845.52,percent of total billed charges,Implant Device,1845.52,34,,1845.52,percent of total billed charges,Implant Device,1845.52,34,,1845.52,percent of total billed charges,Implant Device,1845.52,34,,1845.52,percent of total billed charges,Implant Device,2686.86,,,2686.86,Other,110% of Medicare,1899.8,35,,1899.8,percent of total billed charges,Implant Device,1845.52,34,"Charges > $500, x 34%",1845.52,percent of total billed charges,Implant Device,1899.8,35,,1899.8,percent of total billed charges,Implant Device,1899.8,35,,1899.8,percent of total billed charges,Implant Device,1899.8,35,,1899.8,percent of total billed charges,Implant Device,1899.8,35,,1899.8,percent of total billed charges,Implant Device,1899.8,35,,1899.8,percent of total billed charges,Implant Device,2171.2,40,,2171.2,percent of total billed charges,Implant Device,1899.8,70,,1899.8,percent of total billed charges,All Other,1845.52,34,,1845.52,percent of total billed charges,Implant Device,1845.52,34,,1845.52,percent of total billed charges,Implant Device,1899.8,35,,1899.8,percent of total billed charges,Implant Device,1899.8,35,,1899.8,percent of total billed charges,Implant Device,1899.8,35,,1899.8,percent of total billed charges,Implant Device,1899.8,35,,1899.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1845.52,34,"If Charge > 2,000, then 34 percent",1845.52,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4016.73,
J&J 214.848 CORTEX SCREW 4.5X48MM,C1713,HCPCS,,79012421,CDM,278,RC,,,both,,,57,42.18,,,42.18,Other,150% of Medicare + 9.63% HCRA Surcharge,25.65,45,,25.65,percent of total billed charges,Critical Access Hospital RCC factor,19.38,34,,19.38,percent of total billed charges,Implant Device,19.38,34,,19.38,percent of total billed charges,Implant Device,19.38,34,,19.38,percent of total billed charges,Implant Device,19.38,34,,19.38,percent of total billed charges,Implant Device,19.38,34,,19.38,percent of total billed charges,Implant Device,28.22,,,28.22,Other,110% of Medicare,19.95,35,,19.95,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,19.95,35,,19.95,percent of total billed charges,Implant Device,19.95,35,,19.95,percent of total billed charges,Implant Device,19.95,35,,19.95,percent of total billed charges,Implant Device,19.95,35,,19.95,percent of total billed charges,Implant Device,19.95,35,,19.95,percent of total billed charges,Implant Device,22.8,40,,22.8,percent of total billed charges,Implant Device,19.95,70,,19.95,percent of total billed charges,All Other,19.38,34,,19.38,percent of total billed charges,Implant Device,19.38,34,,19.38,percent of total billed charges,Implant Device,19.95,35,,19.95,percent of total billed charges,Implant Device,19.95,35,,19.95,percent of total billed charges,Implant Device,19.95,35,,19.95,percent of total billed charges,Implant Device,19.95,35,,19.95,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,42.18,
J&J 42.231.290 LOCKING SCREW 5.0X90MM,C1713,HCPCS,,79012422,CDM,278,RC,,,both,,,513,379.62,,,379.62,Other,150% of Medicare + 9.63% HCRA Surcharge,230.85,45,,230.85,percent of total billed charges,Critical Access Hospital RCC factor,174.42,34,,174.42,percent of total billed charges,Implant Device,174.42,34,,174.42,percent of total billed charges,Implant Device,174.42,34,,174.42,percent of total billed charges,Implant Device,174.42,34,,174.42,percent of total billed charges,Implant Device,174.42,34,,174.42,percent of total billed charges,Implant Device,253.94,,,253.94,Other,110% of Medicare,179.55,35,,179.55,percent of total billed charges,Implant Device,174.42,34,"Charges > $500, x 34%",174.42,percent of total billed charges,Implant Device,179.55,35,,179.55,percent of total billed charges,Implant Device,179.55,35,,179.55,percent of total billed charges,Implant Device,179.55,35,,179.55,percent of total billed charges,Implant Device,179.55,35,,179.55,percent of total billed charges,Implant Device,179.55,35,,179.55,percent of total billed charges,Implant Device,205.2,40,,205.2,percent of total billed charges,Implant Device,179.55,70,,179.55,percent of total billed charges,All Other,174.42,34,,174.42,percent of total billed charges,Implant Device,174.42,34,,174.42,percent of total billed charges,Implant Device,179.55,35,,179.55,percent of total billed charges,Implant Device,179.55,35,,179.55,percent of total billed charges,Implant Device,179.55,35,,179.55,percent of total billed charges,Implant Device,179.55,35,,179.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,379.62,
J&J 04.005.432S LOCKING SCREW 4.0X42MM,C1713,HCPCS,,79012426,CDM,278,RC,,,both,,,412,304.88,,,304.88,Other,150% of Medicare + 9.63% HCRA Surcharge,185.4,45,,185.4,percent of total billed charges,Critical Access Hospital RCC factor,140.08,34,,140.08,percent of total billed charges,Implant Device,140.08,34,,140.08,percent of total billed charges,Implant Device,140.08,34,,140.08,percent of total billed charges,Implant Device,140.08,34,,140.08,percent of total billed charges,Implant Device,140.08,34,,140.08,percent of total billed charges,Implant Device,203.94,,,203.94,Other,110% of Medicare,144.2,35,,144.2,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,144.2,35,,144.2,percent of total billed charges,Implant Device,144.2,35,,144.2,percent of total billed charges,Implant Device,144.2,35,,144.2,percent of total billed charges,Implant Device,144.2,35,,144.2,percent of total billed charges,Implant Device,144.2,35,,144.2,percent of total billed charges,Implant Device,164.8,40,,164.8,percent of total billed charges,Implant Device,144.2,70,,144.2,percent of total billed charges,All Other,140.08,34,,140.08,percent of total billed charges,Implant Device,140.08,34,,140.08,percent of total billed charges,Implant Device,144.2,35,,144.2,percent of total billed charges,Implant Device,144.2,35,,144.2,percent of total billed charges,Implant Device,144.2,35,,144.2,percent of total billed charges,Implant Device,144.2,35,,144.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,304.88,
J&J 04.005.438S LOCKING SCREW 4.0X48MM,C1713,HCPCS,,79012427,CDM,278,RC,,,both,,,412,304.88,,,304.88,Other,150% of Medicare + 9.63% HCRA Surcharge,185.4,45,,185.4,percent of total billed charges,Critical Access Hospital RCC factor,140.08,34,,140.08,percent of total billed charges,Implant Device,140.08,34,,140.08,percent of total billed charges,Implant Device,140.08,34,,140.08,percent of total billed charges,Implant Device,140.08,34,,140.08,percent of total billed charges,Implant Device,140.08,34,,140.08,percent of total billed charges,Implant Device,203.94,,,203.94,Other,110% of Medicare,144.2,35,,144.2,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,144.2,35,,144.2,percent of total billed charges,Implant Device,144.2,35,,144.2,percent of total billed charges,Implant Device,144.2,35,,144.2,percent of total billed charges,Implant Device,144.2,35,,144.2,percent of total billed charges,Implant Device,144.2,35,,144.2,percent of total billed charges,Implant Device,164.8,40,,164.8,percent of total billed charges,Implant Device,144.2,70,,144.2,percent of total billed charges,All Other,140.08,34,,140.08,percent of total billed charges,Implant Device,140.08,34,,140.08,percent of total billed charges,Implant Device,144.2,35,,144.2,percent of total billed charges,Implant Device,144.2,35,,144.2,percent of total billed charges,Implant Device,144.2,35,,144.2,percent of total billed charges,Implant Device,144.2,35,,144.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,304.88,
J&J 04.005.426S LOCKING SCREW 4.0X36MM,C1713,HCPCS,,79012428,CDM,278,RC,,,both,,,412,304.88,,,304.88,Other,150% of Medicare + 9.63% HCRA Surcharge,185.4,45,,185.4,percent of total billed charges,Critical Access Hospital RCC factor,140.08,34,,140.08,percent of total billed charges,Implant Device,140.08,34,,140.08,percent of total billed charges,Implant Device,140.08,34,,140.08,percent of total billed charges,Implant Device,140.08,34,,140.08,percent of total billed charges,Implant Device,140.08,34,,140.08,percent of total billed charges,Implant Device,203.94,,,203.94,Other,110% of Medicare,144.2,35,,144.2,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,144.2,35,,144.2,percent of total billed charges,Implant Device,144.2,35,,144.2,percent of total billed charges,Implant Device,144.2,35,,144.2,percent of total billed charges,Implant Device,144.2,35,,144.2,percent of total billed charges,Implant Device,144.2,35,,144.2,percent of total billed charges,Implant Device,164.8,40,,164.8,percent of total billed charges,Implant Device,144.2,70,,144.2,percent of total billed charges,All Other,140.08,34,,140.08,percent of total billed charges,Implant Device,140.08,34,,140.08,percent of total billed charges,Implant Device,144.2,35,,144.2,percent of total billed charges,Implant Device,144.2,35,,144.2,percent of total billed charges,Implant Device,144.2,35,,144.2,percent of total billed charges,Implant Device,144.2,35,,144.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,304.88,
J&J 04.034.355S TIBIAL NAIL 9X375MM,C1889,HCPCS,,79012429,CDM,278,RC,,,both,,,2765,2046.11,,,2046.11,Other,150% of Medicare + 9.63% HCRA Surcharge,1244.25,45,,1244.25,percent of total billed charges,Critical Access Hospital RCC factor,940.1,34,,940.1,percent of total billed charges,Implant Device,940.1,34,,940.1,percent of total billed charges,Implant Device,940.1,34,,940.1,percent of total billed charges,Implant Device,940.1,34,,940.1,percent of total billed charges,Implant Device,940.1,34,,940.1,percent of total billed charges,Implant Device,1368.68,,,1368.68,Other,110% of Medicare,967.75,35,,967.75,percent of total billed charges,Implant Device,940.1,34,"Charges > $500, x 34%",940.1,percent of total billed charges,Implant Device,967.75,35,,967.75,percent of total billed charges,Implant Device,967.75,35,,967.75,percent of total billed charges,Implant Device,967.75,35,,967.75,percent of total billed charges,Implant Device,967.75,35,,967.75,percent of total billed charges,Implant Device,967.75,35,,967.75,percent of total billed charges,Implant Device,1106,40,,1106,percent of total billed charges,Implant Device,967.75,70,,967.75,percent of total billed charges,All Other,940.1,34,,940.1,percent of total billed charges,Implant Device,940.1,34,,940.1,percent of total billed charges,Implant Device,967.75,35,,967.75,percent of total billed charges,Implant Device,967.75,35,,967.75,percent of total billed charges,Implant Device,967.75,35,,967.75,percent of total billed charges,Implant Device,967.75,35,,967.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,940.1,34,"If Charge > 2,000, then 34 percent",940.1,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2046.11,
WRIGHT 58882010 HOOK PLATE SMALL,C1713,HCPCS,,79012430,CDM,278,RC,,,both,,,5835,4317.91,,,4317.91,Other,150% of Medicare + 9.63% HCRA Surcharge,2625.75,45,,2625.75,percent of total billed charges,Critical Access Hospital RCC factor,1983.9,34,,1983.9,percent of total billed charges,Implant Device,1983.9,34,,1983.9,percent of total billed charges,Implant Device,1983.9,34,,1983.9,percent of total billed charges,Implant Device,1983.9,34,,1983.9,percent of total billed charges,Implant Device,1983.9,34,,1983.9,percent of total billed charges,Implant Device,2888.33,,,2888.33,Other,110% of Medicare,2042.25,35,,2042.25,percent of total billed charges,Implant Device,1983.9,34,"Charges > $500, x 34%",1983.9,percent of total billed charges,Implant Device,2042.25,35,,2042.25,percent of total billed charges,Implant Device,2042.25,35,,2042.25,percent of total billed charges,Implant Device,2042.25,35,,2042.25,percent of total billed charges,Implant Device,2042.25,35,,2042.25,percent of total billed charges,Implant Device,2042.25,35,,2042.25,percent of total billed charges,Implant Device,2334,40,,2334,percent of total billed charges,Implant Device,2042.25,70,,2042.25,percent of total billed charges,All Other,1983.9,34,,1983.9,percent of total billed charges,Implant Device,1983.9,34,,1983.9,percent of total billed charges,Implant Device,2042.25,35,,2042.25,percent of total billed charges,Implant Device,2042.25,35,,2042.25,percent of total billed charges,Implant Device,2042.25,35,,2042.25,percent of total billed charges,Implant Device,2042.25,35,,2042.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1983.9,34,"If Charge > 2,000, then 34 percent",1983.9,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4317.91,
WRIGHT 58882030 HOOK PLATE LARGE,C1713,HCPCS,,79012431,CDM,278,RC,,,both,,,5835,4317.91,,,4317.91,Other,150% of Medicare + 9.63% HCRA Surcharge,2625.75,45,,2625.75,percent of total billed charges,Critical Access Hospital RCC factor,1983.9,34,,1983.9,percent of total billed charges,Implant Device,1983.9,34,,1983.9,percent of total billed charges,Implant Device,1983.9,34,,1983.9,percent of total billed charges,Implant Device,1983.9,34,,1983.9,percent of total billed charges,Implant Device,1983.9,34,,1983.9,percent of total billed charges,Implant Device,2888.33,,,2888.33,Other,110% of Medicare,2042.25,35,,2042.25,percent of total billed charges,Implant Device,1983.9,34,"Charges > $500, x 34%",1983.9,percent of total billed charges,Implant Device,2042.25,35,,2042.25,percent of total billed charges,Implant Device,2042.25,35,,2042.25,percent of total billed charges,Implant Device,2042.25,35,,2042.25,percent of total billed charges,Implant Device,2042.25,35,,2042.25,percent of total billed charges,Implant Device,2042.25,35,,2042.25,percent of total billed charges,Implant Device,2334,40,,2334,percent of total billed charges,Implant Device,2042.25,70,,2042.25,percent of total billed charges,All Other,1983.9,34,,1983.9,percent of total billed charges,Implant Device,1983.9,34,,1983.9,percent of total billed charges,Implant Device,2042.25,35,,2042.25,percent of total billed charges,Implant Device,2042.25,35,,2042.25,percent of total billed charges,Implant Device,2042.25,35,,2042.25,percent of total billed charges,Implant Device,2042.25,35,,2042.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1983.9,34,"If Charge > 2,000, then 34 percent",1983.9,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4317.91,
WRIGHT 58803516 LOCKING SCREW 3.5X16MM,C1713,HCPCS,,79012432,CDM,278,RC,,,both,,,1145,847.3,,,847.3,Other,150% of Medicare + 9.63% HCRA Surcharge,515.25,45,,515.25,percent of total billed charges,Critical Access Hospital RCC factor,389.3,34,,389.3,percent of total billed charges,Implant Device,389.3,34,,389.3,percent of total billed charges,Implant Device,389.3,34,,389.3,percent of total billed charges,Implant Device,389.3,34,,389.3,percent of total billed charges,Implant Device,389.3,34,,389.3,percent of total billed charges,Implant Device,566.78,,,566.78,Other,110% of Medicare,400.75,35,,400.75,percent of total billed charges,Implant Device,389.3,34,"Charges > $500, x 34%",389.3,percent of total billed charges,Implant Device,400.75,35,,400.75,percent of total billed charges,Implant Device,400.75,35,,400.75,percent of total billed charges,Implant Device,400.75,35,,400.75,percent of total billed charges,Implant Device,400.75,35,,400.75,percent of total billed charges,Implant Device,400.75,35,,400.75,percent of total billed charges,Implant Device,458,40,,458,percent of total billed charges,Implant Device,400.75,70,,400.75,percent of total billed charges,All Other,389.3,34,,389.3,percent of total billed charges,Implant Device,389.3,34,,389.3,percent of total billed charges,Implant Device,400.75,35,,400.75,percent of total billed charges,Implant Device,400.75,35,,400.75,percent of total billed charges,Implant Device,400.75,35,,400.75,percent of total billed charges,Implant Device,400.75,35,,400.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,847.3,
WRIGHT 5881003540 WASHER FOR 3.5/4 SCREW,C1713,HCPCS,,79012433,CDM,278,RC,,,both,,,122,90.28,,,90.28,Other,150% of Medicare + 9.63% HCRA Surcharge,54.9,45,,54.9,percent of total billed charges,Critical Access Hospital RCC factor,41.48,34,,41.48,percent of total billed charges,Implant Device,41.48,34,,41.48,percent of total billed charges,Implant Device,41.48,34,,41.48,percent of total billed charges,Implant Device,41.48,34,,41.48,percent of total billed charges,Implant Device,41.48,34,,41.48,percent of total billed charges,Implant Device,60.39,,,60.39,Other,110% of Medicare,42.7,35,,42.7,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,42.7,35,,42.7,percent of total billed charges,Implant Device,42.7,35,,42.7,percent of total billed charges,Implant Device,42.7,35,,42.7,percent of total billed charges,Implant Device,42.7,35,,42.7,percent of total billed charges,Implant Device,42.7,35,,42.7,percent of total billed charges,Implant Device,48.8,40,,48.8,percent of total billed charges,Implant Device,42.7,70,,42.7,percent of total billed charges,All Other,41.48,34,,41.48,percent of total billed charges,Implant Device,41.48,34,,41.48,percent of total billed charges,Implant Device,42.7,35,,42.7,percent of total billed charges,Implant Device,42.7,35,,42.7,percent of total billed charges,Implant Device,42.7,35,,42.7,percent of total billed charges,Implant Device,42.7,35,,42.7,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,90.28,
WRIGHT 58813520 CORTICAL SCREW 3.5X20MM,C1713,HCPCS,,79012434,CDM,278,RC,,,both,,,583,431.42,,,431.42,Other,150% of Medicare + 9.63% HCRA Surcharge,262.35,45,,262.35,percent of total billed charges,Critical Access Hospital RCC factor,198.22,34,,198.22,percent of total billed charges,Implant Device,198.22,34,,198.22,percent of total billed charges,Implant Device,198.22,34,,198.22,percent of total billed charges,Implant Device,198.22,34,,198.22,percent of total billed charges,Implant Device,198.22,34,,198.22,percent of total billed charges,Implant Device,288.59,,,288.59,Other,110% of Medicare,204.05,35,,204.05,percent of total billed charges,Implant Device,198.22,34,"Charges > $500, x 34%",198.22,percent of total billed charges,Implant Device,204.05,35,,204.05,percent of total billed charges,Implant Device,204.05,35,,204.05,percent of total billed charges,Implant Device,204.05,35,,204.05,percent of total billed charges,Implant Device,204.05,35,,204.05,percent of total billed charges,Implant Device,204.05,35,,204.05,percent of total billed charges,Implant Device,233.2,40,,233.2,percent of total billed charges,Implant Device,204.05,70,,204.05,percent of total billed charges,All Other,198.22,34,,198.22,percent of total billed charges,Implant Device,198.22,34,,198.22,percent of total billed charges,Implant Device,204.05,35,,204.05,percent of total billed charges,Implant Device,204.05,35,,204.05,percent of total billed charges,Implant Device,204.05,35,,204.05,percent of total billed charges,Implant Device,204.05,35,,204.05,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,431.42,
STRYKER 604634 CANNULATED SCREW 4.0X34MM,C1713,HCPCS,,79012435,CDM,278,RC,,,both,,,480,355.2,,,355.2,Other,150% of Medicare + 9.63% HCRA Surcharge,216,45,,216,percent of total billed charges,Critical Access Hospital RCC factor,163.2,34,,163.2,percent of total billed charges,Implant Device,163.2,34,,163.2,percent of total billed charges,Implant Device,163.2,34,,163.2,percent of total billed charges,Implant Device,163.2,34,,163.2,percent of total billed charges,Implant Device,163.2,34,,163.2,percent of total billed charges,Implant Device,237.6,,,237.6,Other,110% of Medicare,168,35,,168,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,192,40,,192,percent of total billed charges,Implant Device,168,70,,168,percent of total billed charges,All Other,163.2,34,,163.2,percent of total billed charges,Implant Device,163.2,34,,163.2,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,355.2,
ZIMMER 183024 FEMORAL LEFT 60MM,C1776,HCPCS,,79012437,CDM,278,RC,,,both,,,6300,4662.02,,,4662.02,Other,150% of Medicare + 9.63% HCRA Surcharge,2835,45,,2835,percent of total billed charges,Critical Access Hospital RCC factor,2142,34,,2142,percent of total billed charges,Implant Device,2142,34,,2142,percent of total billed charges,Implant Device,2142,34,,2142,percent of total billed charges,Implant Device,2142,34,,2142,percent of total billed charges,Implant Device,2142,34,,2142,percent of total billed charges,Implant Device,3118.5,,,3118.5,Other,110% of Medicare,2205,35,,2205,percent of total billed charges,Implant Device,2142,34,"Charges > $500, x 34%",2142,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2520,40,,2520,percent of total billed charges,Implant Device,2205,70,,2205,percent of total billed charges,All Other,2142,34,,2142,percent of total billed charges,Implant Device,2142,34,,2142,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2142,34,"If Charge > 2,000, then 34 percent",2142,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4662.02,
ZIMMER VE189044 TIBIAL BEARING 67X14MM,C1776,HCPCS,,79012438,CDM,278,RC,,,both,,,3648,2699.53,,,2699.53,Other,150% of Medicare + 9.63% HCRA Surcharge,1641.6,45,,1641.6,percent of total billed charges,Critical Access Hospital RCC factor,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1805.76,,,1805.76,Other,110% of Medicare,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1240.32,34,"Charges > $500, x 34%",1240.32,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1459.2,40,,1459.2,percent of total billed charges,Implant Device,1276.8,70,,1276.8,percent of total billed charges,All Other,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1240.32,34,"If Charge > 2,000, then 34 percent",1240.32,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2699.53,
STRYKER 0030721 HUMERAL STEM LRG LT 83MM,C1776,HCPCS,,79012439,CDM,278,RC,,,both,,,28299,20941.33,,,20941.33,Other,150% of Medicare + 9.63% HCRA Surcharge,12734.55,45,,12734.55,percent of total billed charges,Critical Access Hospital RCC factor,9621.66,34,,9621.66,percent of total billed charges,Implant Device,9621.66,34,,9621.66,percent of total billed charges,Implant Device,9621.66,34,,9621.66,percent of total billed charges,Implant Device,9621.66,34,,9621.66,percent of total billed charges,Implant Device,9621.66,34,,9621.66,percent of total billed charges,Implant Device,14008.01,,,14008.01,Other,110% of Medicare,9904.65,35,,9904.65,percent of total billed charges,Implant Device,9621.66,34,"Charges > $500, x 34%",9621.66,percent of total billed charges,Implant Device,9904.65,35,,9904.65,percent of total billed charges,Implant Device,9904.65,35,,9904.65,percent of total billed charges,Implant Device,9904.65,35,,9904.65,percent of total billed charges,Implant Device,9904.65,35,,9904.65,percent of total billed charges,Implant Device,9904.65,35,,9904.65,percent of total billed charges,Implant Device,11319.6,40,,11319.6,percent of total billed charges,Implant Device,9904.65,70,,9904.65,percent of total billed charges,All Other,9621.66,34,,9621.66,percent of total billed charges,Implant Device,9621.66,34,,9621.66,percent of total billed charges,Implant Device,9904.65,35,,9904.65,percent of total billed charges,Implant Device,9904.65,35,,9904.65,percent of total billed charges,Implant Device,9904.65,35,,9904.65,percent of total billed charges,Implant Device,9904.65,35,,9904.65,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,9621.66,34,"If Charge > 2,000, then 34 percent",9621.66,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,20941.33,
STRYKER DKY216 HUMERAL SPOOL LARGE LEFT,C1776,HCPCS,,79012441,CDM,278,RC,,,both,,,14151,10471.78,,,10471.78,Other,150% of Medicare + 9.63% HCRA Surcharge,6367.95,45,,6367.95,percent of total billed charges,Critical Access Hospital RCC factor,4811.34,34,,4811.34,percent of total billed charges,Implant Device,4811.34,34,,4811.34,percent of total billed charges,Implant Device,4811.34,34,,4811.34,percent of total billed charges,Implant Device,4811.34,34,,4811.34,percent of total billed charges,Implant Device,4811.34,34,,4811.34,percent of total billed charges,Implant Device,7004.75,,,7004.75,Other,110% of Medicare,4952.85,35,,4952.85,percent of total billed charges,Implant Device,4811.34,34,"Charges > $500, x 34%",4811.34,percent of total billed charges,Implant Device,4952.85,35,,4952.85,percent of total billed charges,Implant Device,4952.85,35,,4952.85,percent of total billed charges,Implant Device,4952.85,35,,4952.85,percent of total billed charges,Implant Device,4952.85,35,,4952.85,percent of total billed charges,Implant Device,4952.85,35,,4952.85,percent of total billed charges,Implant Device,5660.4,40,,5660.4,percent of total billed charges,Implant Device,4952.85,70,,4952.85,percent of total billed charges,All Other,4811.34,34,,4811.34,percent of total billed charges,Implant Device,4811.34,34,,4811.34,percent of total billed charges,Implant Device,4952.85,35,,4952.85,percent of total billed charges,Implant Device,4952.85,35,,4952.85,percent of total billed charges,Implant Device,4952.85,35,,4952.85,percent of total billed charges,Implant Device,4952.85,35,,4952.85,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,4811.34,34,"If Charge > 2,000, then 34 percent",4811.34,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,10471.78,
STRYKER EBO101 CEMENT RESTRICTOR 24MM,C1776,HCPCS,,79012443,CDM,278,RC,,,both,,,1221,903.54,,,903.54,Other,150% of Medicare + 9.63% HCRA Surcharge,549.45,45,,549.45,percent of total billed charges,Critical Access Hospital RCC factor,415.14,34,,415.14,percent of total billed charges,Implant Device,415.14,34,,415.14,percent of total billed charges,Implant Device,415.14,34,,415.14,percent of total billed charges,Implant Device,415.14,34,,415.14,percent of total billed charges,Implant Device,415.14,34,,415.14,percent of total billed charges,Implant Device,604.4,,,604.4,Other,110% of Medicare,427.35,35,,427.35,percent of total billed charges,Implant Device,415.14,34,"Charges > $500, x 34%",415.14,percent of total billed charges,Implant Device,427.35,35,,427.35,percent of total billed charges,Implant Device,427.35,35,,427.35,percent of total billed charges,Implant Device,427.35,35,,427.35,percent of total billed charges,Implant Device,427.35,35,,427.35,percent of total billed charges,Implant Device,427.35,35,,427.35,percent of total billed charges,Implant Device,488.4,40,,488.4,percent of total billed charges,Implant Device,427.35,70,,427.35,percent of total billed charges,All Other,415.14,34,,415.14,percent of total billed charges,Implant Device,415.14,34,,415.14,percent of total billed charges,Implant Device,427.35,35,,427.35,percent of total billed charges,Implant Device,427.35,35,,427.35,percent of total billed charges,Implant Device,427.35,35,,427.35,percent of total billed charges,Implant Device,427.35,35,,427.35,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,903.54,
ZIMMER 42-5020-064-02 FEMUR RIGHT SIZE 8,C1776,HCPCS,,79012444,CDM,278,RC,,,both,,,6300,4662.02,,,4662.02,Other,150% of Medicare + 9.63% HCRA Surcharge,2835,45,,2835,percent of total billed charges,Critical Access Hospital RCC factor,2142,34,,2142,percent of total billed charges,Implant Device,2142,34,,2142,percent of total billed charges,Implant Device,2142,34,,2142,percent of total billed charges,Implant Device,2142,34,,2142,percent of total billed charges,Implant Device,2142,34,,2142,percent of total billed charges,Implant Device,3118.5,,,3118.5,Other,110% of Medicare,2205,35,,2205,percent of total billed charges,Implant Device,2142,34,"Charges > $500, x 34%",2142,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2520,40,,2520,percent of total billed charges,Implant Device,2205,70,,2205,percent of total billed charges,All Other,2142,34,,2142,percent of total billed charges,Implant Device,2142,34,,2142,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2142,34,"If Charge > 2,000, then 34 percent",2142,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4662.02,
ZIMMER 42-5121-007-11 ARTI SURF LT 11MM,C1776,HCPCS,,79012445,CDM,278,RC,,,both,,,3648,2699.53,,,2699.53,Other,150% of Medicare + 9.63% HCRA Surcharge,1641.6,45,,1641.6,percent of total billed charges,Critical Access Hospital RCC factor,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1805.76,,,1805.76,Other,110% of Medicare,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1240.32,34,"Charges > $500, x 34%",1240.32,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1459.2,40,,1459.2,percent of total billed charges,Implant Device,1276.8,70,,1276.8,percent of total billed charges,All Other,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1240.32,34,"If Charge > 2,000, then 34 percent",1240.32,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2699.53,
ZIMMER 42-5020-062-01 FEMUR LEFT SIZE 7,C1776,HCPCS,,79012446,CDM,278,RC,,,both,,,6300,4662.02,,,4662.02,Other,150% of Medicare + 9.63% HCRA Surcharge,2835,45,,2835,percent of total billed charges,Critical Access Hospital RCC factor,2142,34,,2142,percent of total billed charges,Implant Device,2142,34,,2142,percent of total billed charges,Implant Device,2142,34,,2142,percent of total billed charges,Implant Device,2142,34,,2142,percent of total billed charges,Implant Device,2142,34,,2142,percent of total billed charges,Implant Device,3118.5,,,3118.5,Other,110% of Medicare,2205,35,,2205,percent of total billed charges,Implant Device,2142,34,"Charges > $500, x 34%",2142,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2520,40,,2520,percent of total billed charges,Implant Device,2205,70,,2205,percent of total billed charges,All Other,2142,34,,2142,percent of total billed charges,Implant Device,2142,34,,2142,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2142,34,"If Charge > 2,000, then 34 percent",2142,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4662.02,
STRYKER 629308 DISTAL MEDIAL PLT LT 8H,C1713,HCPCS,,79012447,CDM,278,RC,,,both,,,3892,2880.09,,,2880.09,Other,150% of Medicare + 9.63% HCRA Surcharge,1751.4,45,,1751.4,percent of total billed charges,Critical Access Hospital RCC factor,1323.28,34,,1323.28,percent of total billed charges,Implant Device,1323.28,34,,1323.28,percent of total billed charges,Implant Device,1323.28,34,,1323.28,percent of total billed charges,Implant Device,1323.28,34,,1323.28,percent of total billed charges,Implant Device,1323.28,34,,1323.28,percent of total billed charges,Implant Device,1926.54,,,1926.54,Other,110% of Medicare,1362.2,35,,1362.2,percent of total billed charges,Implant Device,1323.28,34,"Charges > $500, x 34%",1323.28,percent of total billed charges,Implant Device,1362.2,35,,1362.2,percent of total billed charges,Implant Device,1362.2,35,,1362.2,percent of total billed charges,Implant Device,1362.2,35,,1362.2,percent of total billed charges,Implant Device,1362.2,35,,1362.2,percent of total billed charges,Implant Device,1362.2,35,,1362.2,percent of total billed charges,Implant Device,1556.8,40,,1556.8,percent of total billed charges,Implant Device,1362.2,70,,1362.2,percent of total billed charges,All Other,1323.28,34,,1323.28,percent of total billed charges,Implant Device,1323.28,34,,1323.28,percent of total billed charges,Implant Device,1362.2,35,,1362.2,percent of total billed charges,Implant Device,1362.2,35,,1362.2,percent of total billed charges,Implant Device,1362.2,35,,1362.2,percent of total billed charges,Implant Device,1362.2,35,,1362.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1323.28,34,"If Charge > 2,000, then 34 percent",1323.28,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2880.09,
STRYKER 10017000 ACHILLES W/ ALLOGRAFT,C1762,HCPCS,,79012448,CDM,278,RC,,,both,,,4438,3284.13,,,3284.13,Other,150% of Medicare + 9.63% HCRA Surcharge,1997.1,45,,1997.1,percent of total billed charges,Critical Access Hospital RCC factor,1508.92,34,,1508.92,percent of total billed charges,Implant Device,1508.92,34,,1508.92,percent of total billed charges,Implant Device,1508.92,34,,1508.92,percent of total billed charges,Implant Device,1508.92,34,,1508.92,percent of total billed charges,Implant Device,1508.92,34,,1508.92,percent of total billed charges,Implant Device,2196.81,,,2196.81,Other,110% of Medicare,1553.3,35,,1553.3,percent of total billed charges,Implant Device,1508.92,34,"Charges > $500, x 34%",1508.92,percent of total billed charges,Implant Device,1553.3,35,,1553.3,percent of total billed charges,Implant Device,1553.3,35,,1553.3,percent of total billed charges,Implant Device,1553.3,35,,1553.3,percent of total billed charges,Implant Device,1553.3,35,,1553.3,percent of total billed charges,Implant Device,1553.3,35,,1553.3,percent of total billed charges,Implant Device,1775.2,40,,1775.2,percent of total billed charges,Implant Device,1553.3,70,,1553.3,percent of total billed charges,All Other,1508.92,34,,1508.92,percent of total billed charges,Implant Device,1508.92,34,,1508.92,percent of total billed charges,Implant Device,1553.3,35,,1553.3,percent of total billed charges,Implant Device,1553.3,35,,1553.3,percent of total billed charges,Implant Device,1553.3,35,,1553.3,percent of total billed charges,Implant Device,1553.3,35,,1553.3,percent of total billed charges,Implant Device,976.07,,,976.07,Other,100% of Medicaid,976.07,,,976.07,Other,100% of Medicaid,976.07,,,976.07,Other,100% of Medicaid,976.07,,,976.07,Other,100% of Medicaid,2196.16,,,2196.16,Other,225% of Medicaid,1493.39,,,1493.39,Other,153% of Medicaid,2196.16,,,2196.16,Other,225% of Medicaid,1366.5,,,1366.5,Other,140% of Medicaid,1508.92,34,"If Charge > 2,000, then 34 percent",1508.92,percent of total billed charges,Implants,2537.78,,,2537.78,Other,260% of Medicaid,3162.47,,,3162.47,Other,324% of Medicaid,2098.55,,,2098.55,Other,215% of Medicaid,2098.55,,,2098.55,Other,215% of Medicaid,1220.09,,,1220.09,Other,125% of Medicaid,976.07,3284.13,
STRYKER 18722000 TENODESIS ALLOGRAFT,C1762,HCPCS,,79012449,CDM,278,RC,,,both,,,4688,3469.13,,,3469.13,Other,150% of Medicare + 9.63% HCRA Surcharge,2109.6,45,,2109.6,percent of total billed charges,Critical Access Hospital RCC factor,1593.92,34,,1593.92,percent of total billed charges,Implant Device,1593.92,34,,1593.92,percent of total billed charges,Implant Device,1593.92,34,,1593.92,percent of total billed charges,Implant Device,1593.92,34,,1593.92,percent of total billed charges,Implant Device,1593.92,34,,1593.92,percent of total billed charges,Implant Device,2320.56,,,2320.56,Other,110% of Medicare,1640.8,35,,1640.8,percent of total billed charges,Implant Device,1593.92,34,"Charges > $500, x 34%",1593.92,percent of total billed charges,Implant Device,1640.8,35,,1640.8,percent of total billed charges,Implant Device,1640.8,35,,1640.8,percent of total billed charges,Implant Device,1640.8,35,,1640.8,percent of total billed charges,Implant Device,1640.8,35,,1640.8,percent of total billed charges,Implant Device,1640.8,35,,1640.8,percent of total billed charges,Implant Device,1875.2,40,,1875.2,percent of total billed charges,Implant Device,1640.8,70,,1640.8,percent of total billed charges,All Other,1593.92,34,,1593.92,percent of total billed charges,Implant Device,1593.92,34,,1593.92,percent of total billed charges,Implant Device,1640.8,35,,1640.8,percent of total billed charges,Implant Device,1640.8,35,,1640.8,percent of total billed charges,Implant Device,1640.8,35,,1640.8,percent of total billed charges,Implant Device,1640.8,35,,1640.8,percent of total billed charges,Implant Device,976.07,,,976.07,Other,100% of Medicaid,976.07,,,976.07,Other,100% of Medicaid,976.07,,,976.07,Other,100% of Medicaid,976.07,,,976.07,Other,100% of Medicaid,2196.16,,,2196.16,Other,225% of Medicaid,1493.39,,,1493.39,Other,153% of Medicaid,2196.16,,,2196.16,Other,225% of Medicaid,1366.5,,,1366.5,Other,140% of Medicaid,1593.92,34,"If Charge > 2,000, then 34 percent",1593.92,percent of total billed charges,Implants,2537.78,,,2537.78,Other,260% of Medicaid,3162.47,,,3162.47,Other,324% of Medicaid,2098.55,,,2098.55,Other,215% of Medicaid,2098.55,,,2098.55,Other,215% of Medicaid,1220.09,,,1220.09,Other,125% of Medicaid,976.07,3469.13,
J&J 294.56 SCHANZ SCREW 5.0MM,C1713,HCPCS,,79012450,CDM,278,RC,,,both,,,183,135.42,,,135.42,Other,150% of Medicare + 9.63% HCRA Surcharge,82.35,45,,82.35,percent of total billed charges,Critical Access Hospital RCC factor,62.22,34,,62.22,percent of total billed charges,Implant Device,62.22,34,,62.22,percent of total billed charges,Implant Device,62.22,34,,62.22,percent of total billed charges,Implant Device,62.22,34,,62.22,percent of total billed charges,Implant Device,62.22,34,,62.22,percent of total billed charges,Implant Device,90.59,,,90.59,Other,110% of Medicare,64.05,35,,64.05,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,64.05,35,,64.05,percent of total billed charges,Implant Device,64.05,35,,64.05,percent of total billed charges,Implant Device,64.05,35,,64.05,percent of total billed charges,Implant Device,64.05,35,,64.05,percent of total billed charges,Implant Device,64.05,35,,64.05,percent of total billed charges,Implant Device,73.2,40,,73.2,percent of total billed charges,Implant Device,64.05,70,,64.05,percent of total billed charges,All Other,62.22,34,,62.22,percent of total billed charges,Implant Device,62.22,34,,62.22,percent of total billed charges,Implant Device,64.05,35,,64.05,percent of total billed charges,Implant Device,64.05,35,,64.05,percent of total billed charges,Implant Device,64.05,35,,64.05,percent of total billed charges,Implant Device,64.05,35,,64.05,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,135.42,
J&J 294.950 TRANSFIXATION PIN 6X225MM,C1713,HCPCS,,79012451,CDM,278,RC,,,both,,,241,178.34,,,178.34,Other,150% of Medicare + 9.63% HCRA Surcharge,108.45,45,,108.45,percent of total billed charges,Critical Access Hospital RCC factor,81.94,34,,81.94,percent of total billed charges,Implant Device,81.94,34,,81.94,percent of total billed charges,Implant Device,81.94,34,,81.94,percent of total billed charges,Implant Device,81.94,34,,81.94,percent of total billed charges,Implant Device,81.94,34,,81.94,percent of total billed charges,Implant Device,119.3,,,119.3,Other,110% of Medicare,84.35,35,,84.35,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,84.35,35,,84.35,percent of total billed charges,Implant Device,84.35,35,,84.35,percent of total billed charges,Implant Device,84.35,35,,84.35,percent of total billed charges,Implant Device,84.35,35,,84.35,percent of total billed charges,Implant Device,84.35,35,,84.35,percent of total billed charges,Implant Device,96.4,40,,96.4,percent of total billed charges,Implant Device,84.35,70,,84.35,percent of total billed charges,All Other,81.94,34,,81.94,percent of total billed charges,Implant Device,81.94,34,,81.94,percent of total billed charges,Implant Device,84.35,35,,84.35,percent of total billed charges,Implant Device,84.35,35,,84.35,percent of total billed charges,Implant Device,84.35,35,,84.35,percent of total billed charges,Implant Device,84.35,35,,84.35,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,178.34,
J&J 09.405.960S RADIAL HEAD 19X6.5X9MM,C1776,HCPCS,,79012454,CDM,278,RC,,,both,,,10092,7468.11,,,7468.11,Other,150% of Medicare + 9.63% HCRA Surcharge,4541.4,45,,4541.4,percent of total billed charges,Critical Access Hospital RCC factor,3431.28,34,,3431.28,percent of total billed charges,Implant Device,3431.28,34,,3431.28,percent of total billed charges,Implant Device,3431.28,34,,3431.28,percent of total billed charges,Implant Device,3431.28,34,,3431.28,percent of total billed charges,Implant Device,3431.28,34,,3431.28,percent of total billed charges,Implant Device,4995.54,,,4995.54,Other,110% of Medicare,3532.2,35,,3532.2,percent of total billed charges,Implant Device,3431.28,34,"Charges > $500, x 34%",3431.28,percent of total billed charges,Implant Device,3532.2,35,,3532.2,percent of total billed charges,Implant Device,3532.2,35,,3532.2,percent of total billed charges,Implant Device,3532.2,35,,3532.2,percent of total billed charges,Implant Device,3532.2,35,,3532.2,percent of total billed charges,Implant Device,3532.2,35,,3532.2,percent of total billed charges,Implant Device,4036.8,40,,4036.8,percent of total billed charges,Implant Device,3532.2,70,,3532.2,percent of total billed charges,All Other,3431.28,34,,3431.28,percent of total billed charges,Implant Device,3431.28,34,,3431.28,percent of total billed charges,Implant Device,3532.2,35,,3532.2,percent of total billed charges,Implant Device,3532.2,35,,3532.2,percent of total billed charges,Implant Device,3532.2,35,,3532.2,percent of total billed charges,Implant Device,3532.2,35,,3532.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3431.28,34,"If Charge > 2,000, then 34 percent",3431.28,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,7468.11,
J&J 03.405.000S RADIAL HEAD INSTRU KIT,C1776,HCPCS,,79012455,CDM,278,RC,,,both,,,1062,785.88,,,785.88,Other,150% of Medicare + 9.63% HCRA Surcharge,477.9,45,,477.9,percent of total billed charges,Critical Access Hospital RCC factor,361.08,34,,361.08,percent of total billed charges,Implant Device,361.08,34,,361.08,percent of total billed charges,Implant Device,361.08,34,,361.08,percent of total billed charges,Implant Device,361.08,34,,361.08,percent of total billed charges,Implant Device,361.08,34,,361.08,percent of total billed charges,Implant Device,525.69,,,525.69,Other,110% of Medicare,371.7,35,,371.7,percent of total billed charges,Implant Device,361.08,34,"Charges > $500, x 34%",361.08,percent of total billed charges,Implant Device,371.7,35,,371.7,percent of total billed charges,Implant Device,371.7,35,,371.7,percent of total billed charges,Implant Device,371.7,35,,371.7,percent of total billed charges,Implant Device,371.7,35,,371.7,percent of total billed charges,Implant Device,371.7,35,,371.7,percent of total billed charges,Implant Device,424.8,40,,424.8,percent of total billed charges,Implant Device,371.7,70,,371.7,percent of total billed charges,All Other,361.08,34,,361.08,percent of total billed charges,Implant Device,361.08,34,,361.08,percent of total billed charges,Implant Device,371.7,35,,371.7,percent of total billed charges,Implant Device,371.7,35,,371.7,percent of total billed charges,Implant Device,371.7,35,,371.7,percent of total billed charges,Implant Device,371.7,35,,371.7,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,785.88,
J&J 02.123.024 LCP PERI HUMERUS PLT 3.5,C1713,HCPCS,,79012456,CDM,278,RC,,,both,,,4266,3156.85,,,3156.85,Other,150% of Medicare + 9.63% HCRA Surcharge,1919.7,45,,1919.7,percent of total billed charges,Critical Access Hospital RCC factor,1450.44,34,,1450.44,percent of total billed charges,Implant Device,1450.44,34,,1450.44,percent of total billed charges,Implant Device,1450.44,34,,1450.44,percent of total billed charges,Implant Device,1450.44,34,,1450.44,percent of total billed charges,Implant Device,1450.44,34,,1450.44,percent of total billed charges,Implant Device,2111.67,,,2111.67,Other,110% of Medicare,1493.1,35,,1493.1,percent of total billed charges,Implant Device,1450.44,34,"Charges > $500, x 34%",1450.44,percent of total billed charges,Implant Device,1493.1,35,,1493.1,percent of total billed charges,Implant Device,1493.1,35,,1493.1,percent of total billed charges,Implant Device,1493.1,35,,1493.1,percent of total billed charges,Implant Device,1493.1,35,,1493.1,percent of total billed charges,Implant Device,1493.1,35,,1493.1,percent of total billed charges,Implant Device,1706.4,40,,1706.4,percent of total billed charges,Implant Device,1493.1,70,,1493.1,percent of total billed charges,All Other,1450.44,34,,1450.44,percent of total billed charges,Implant Device,1450.44,34,,1450.44,percent of total billed charges,Implant Device,1493.1,35,,1493.1,percent of total billed charges,Implant Device,1493.1,35,,1493.1,percent of total billed charges,Implant Device,1493.1,35,,1493.1,percent of total billed charges,Implant Device,1493.1,35,,1493.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1450.44,34,"If Charge > 2,000, then 34 percent",1450.44,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3156.85,
J&J 02.127.144 LOCKING SCREW 3.5X44MM,C1713,HCPCS,,79012457,CDM,278,RC,,,both,,,414,306.36,,,306.36,Other,150% of Medicare + 9.63% HCRA Surcharge,186.3,45,,186.3,percent of total billed charges,Critical Access Hospital RCC factor,140.76,34,,140.76,percent of total billed charges,Implant Device,140.76,34,,140.76,percent of total billed charges,Implant Device,140.76,34,,140.76,percent of total billed charges,Implant Device,140.76,34,,140.76,percent of total billed charges,Implant Device,140.76,34,,140.76,percent of total billed charges,Implant Device,204.93,,,204.93,Other,110% of Medicare,144.9,35,,144.9,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,144.9,35,,144.9,percent of total billed charges,Implant Device,144.9,35,,144.9,percent of total billed charges,Implant Device,144.9,35,,144.9,percent of total billed charges,Implant Device,144.9,35,,144.9,percent of total billed charges,Implant Device,144.9,35,,144.9,percent of total billed charges,Implant Device,165.6,40,,165.6,percent of total billed charges,Implant Device,144.9,70,,144.9,percent of total billed charges,All Other,140.76,34,,140.76,percent of total billed charges,Implant Device,140.76,34,,140.76,percent of total billed charges,Implant Device,144.9,35,,144.9,percent of total billed charges,Implant Device,144.9,35,,144.9,percent of total billed charges,Implant Device,144.9,35,,144.9,percent of total billed charges,Implant Device,144.9,35,,144.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,306.36,
J&J 02.127.142 LOCKING SCREW 3.5X42MM,C1713,HCPCS,,79012458,CDM,278,RC,,,both,,,414,306.36,,,306.36,Other,150% of Medicare + 9.63% HCRA Surcharge,186.3,45,,186.3,percent of total billed charges,Critical Access Hospital RCC factor,140.76,34,,140.76,percent of total billed charges,Implant Device,140.76,34,,140.76,percent of total billed charges,Implant Device,140.76,34,,140.76,percent of total billed charges,Implant Device,140.76,34,,140.76,percent of total billed charges,Implant Device,140.76,34,,140.76,percent of total billed charges,Implant Device,204.93,,,204.93,Other,110% of Medicare,144.9,35,,144.9,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,144.9,35,,144.9,percent of total billed charges,Implant Device,144.9,35,,144.9,percent of total billed charges,Implant Device,144.9,35,,144.9,percent of total billed charges,Implant Device,144.9,35,,144.9,percent of total billed charges,Implant Device,144.9,35,,144.9,percent of total billed charges,Implant Device,165.6,40,,165.6,percent of total billed charges,Implant Device,144.9,70,,144.9,percent of total billed charges,All Other,140.76,34,,140.76,percent of total billed charges,Implant Device,140.76,34,,140.76,percent of total billed charges,Implant Device,144.9,35,,144.9,percent of total billed charges,Implant Device,144.9,35,,144.9,percent of total billed charges,Implant Device,144.9,35,,144.9,percent of total billed charges,Implant Device,144.9,35,,144.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,306.36,
J&J 02.127.146 LOCKING SCREW 3.5X46MM,C1713,HCPCS,,79012459,CDM,278,RC,,,both,,,414,306.36,,,306.36,Other,150% of Medicare + 9.63% HCRA Surcharge,186.3,45,,186.3,percent of total billed charges,Critical Access Hospital RCC factor,140.76,34,,140.76,percent of total billed charges,Implant Device,140.76,34,,140.76,percent of total billed charges,Implant Device,140.76,34,,140.76,percent of total billed charges,Implant Device,140.76,34,,140.76,percent of total billed charges,Implant Device,140.76,34,,140.76,percent of total billed charges,Implant Device,204.93,,,204.93,Other,110% of Medicare,144.9,35,,144.9,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,144.9,35,,144.9,percent of total billed charges,Implant Device,144.9,35,,144.9,percent of total billed charges,Implant Device,144.9,35,,144.9,percent of total billed charges,Implant Device,144.9,35,,144.9,percent of total billed charges,Implant Device,144.9,35,,144.9,percent of total billed charges,Implant Device,165.6,40,,165.6,percent of total billed charges,Implant Device,144.9,70,,144.9,percent of total billed charges,All Other,140.76,34,,140.76,percent of total billed charges,Implant Device,140.76,34,,140.76,percent of total billed charges,Implant Device,144.9,35,,144.9,percent of total billed charges,Implant Device,144.9,35,,144.9,percent of total billed charges,Implant Device,144.9,35,,144.9,percent of total billed charges,Implant Device,144.9,35,,144.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,306.36,
J&J 02.127.148 LOCKING SCREW 3.5X48MM,C1713,HCPCS,,79012460,CDM,278,RC,,,both,,,414,306.36,,,306.36,Other,150% of Medicare + 9.63% HCRA Surcharge,186.3,45,,186.3,percent of total billed charges,Critical Access Hospital RCC factor,140.76,34,,140.76,percent of total billed charges,Implant Device,140.76,34,,140.76,percent of total billed charges,Implant Device,140.76,34,,140.76,percent of total billed charges,Implant Device,140.76,34,,140.76,percent of total billed charges,Implant Device,140.76,34,,140.76,percent of total billed charges,Implant Device,204.93,,,204.93,Other,110% of Medicare,144.9,35,,144.9,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,144.9,35,,144.9,percent of total billed charges,Implant Device,144.9,35,,144.9,percent of total billed charges,Implant Device,144.9,35,,144.9,percent of total billed charges,Implant Device,144.9,35,,144.9,percent of total billed charges,Implant Device,144.9,35,,144.9,percent of total billed charges,Implant Device,165.6,40,,165.6,percent of total billed charges,Implant Device,144.9,70,,144.9,percent of total billed charges,All Other,140.76,34,,140.76,percent of total billed charges,Implant Device,140.76,34,,140.76,percent of total billed charges,Implant Device,144.9,35,,144.9,percent of total billed charges,Implant Device,144.9,35,,144.9,percent of total billed charges,Implant Device,144.9,35,,144.9,percent of total billed charges,Implant Device,144.9,35,,144.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,306.36,
J&J 02.127.261 PROXIMAL TIBIA PLT 3.5MM,C1713,HCPCS,,79012462,CDM,278,RC,,,both,,,5708,4223.93,,,4223.93,Other,150% of Medicare + 9.63% HCRA Surcharge,2568.6,45,,2568.6,percent of total billed charges,Critical Access Hospital RCC factor,1940.72,34,,1940.72,percent of total billed charges,Implant Device,1940.72,34,,1940.72,percent of total billed charges,Implant Device,1940.72,34,,1940.72,percent of total billed charges,Implant Device,1940.72,34,,1940.72,percent of total billed charges,Implant Device,1940.72,34,,1940.72,percent of total billed charges,Implant Device,2825.46,,,2825.46,Other,110% of Medicare,1997.8,35,,1997.8,percent of total billed charges,Implant Device,1940.72,34,"Charges > $500, x 34%",1940.72,percent of total billed charges,Implant Device,1997.8,35,,1997.8,percent of total billed charges,Implant Device,1997.8,35,,1997.8,percent of total billed charges,Implant Device,1997.8,35,,1997.8,percent of total billed charges,Implant Device,1997.8,35,,1997.8,percent of total billed charges,Implant Device,1997.8,35,,1997.8,percent of total billed charges,Implant Device,2283.2,40,,2283.2,percent of total billed charges,Implant Device,1997.8,70,,1997.8,percent of total billed charges,All Other,1940.72,34,,1940.72,percent of total billed charges,Implant Device,1940.72,34,,1940.72,percent of total billed charges,Implant Device,1997.8,35,,1997.8,percent of total billed charges,Implant Device,1997.8,35,,1997.8,percent of total billed charges,Implant Device,1997.8,35,,1997.8,percent of total billed charges,Implant Device,1997.8,35,,1997.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1940.72,34,"If Charge > 2,000, then 34 percent",1940.72,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4223.93,
ZIMMER 183034 FEMORAL LEFT 75MM,C1776,HCPCS,,79012464,CDM,278,RC,,,both,,,6300,4662.02,,,4662.02,Other,150% of Medicare + 9.63% HCRA Surcharge,2835,45,,2835,percent of total billed charges,Critical Access Hospital RCC factor,2142,34,,2142,percent of total billed charges,Implant Device,2142,34,,2142,percent of total billed charges,Implant Device,2142,34,,2142,percent of total billed charges,Implant Device,2142,34,,2142,percent of total billed charges,Implant Device,2142,34,,2142,percent of total billed charges,Implant Device,3118.5,,,3118.5,Other,110% of Medicare,2205,35,,2205,percent of total billed charges,Implant Device,2142,34,"Charges > $500, x 34%",2142,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2520,40,,2520,percent of total billed charges,Implant Device,2205,70,,2205,percent of total billed charges,All Other,2142,34,,2142,percent of total billed charges,Implant Device,2142,34,,2142,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2142,34,"If Charge > 2,000, then 34 percent",2142,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4662.02,
ZIMMER 141236 TIBIAL PLATE 83MM,C1713,HCPCS,,79012465,CDM,278,RC,,,both,,,2304,1704.97,,,1704.97,Other,150% of Medicare + 9.63% HCRA Surcharge,1036.8,45,,1036.8,percent of total billed charges,Critical Access Hospital RCC factor,783.36,34,,783.36,percent of total billed charges,Implant Device,783.36,34,,783.36,percent of total billed charges,Implant Device,783.36,34,,783.36,percent of total billed charges,Implant Device,783.36,34,,783.36,percent of total billed charges,Implant Device,783.36,34,,783.36,percent of total billed charges,Implant Device,1140.48,,,1140.48,Other,110% of Medicare,806.4,35,,806.4,percent of total billed charges,Implant Device,783.36,34,"Charges > $500, x 34%",783.36,percent of total billed charges,Implant Device,806.4,35,,806.4,percent of total billed charges,Implant Device,806.4,35,,806.4,percent of total billed charges,Implant Device,806.4,35,,806.4,percent of total billed charges,Implant Device,806.4,35,,806.4,percent of total billed charges,Implant Device,806.4,35,,806.4,percent of total billed charges,Implant Device,921.6,40,,921.6,percent of total billed charges,Implant Device,806.4,70,,806.4,percent of total billed charges,All Other,783.36,34,,783.36,percent of total billed charges,Implant Device,783.36,34,,783.36,percent of total billed charges,Implant Device,806.4,35,,806.4,percent of total billed charges,Implant Device,806.4,35,,806.4,percent of total billed charges,Implant Device,806.4,35,,806.4,percent of total billed charges,Implant Device,806.4,35,,806.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,783.36,34,"If Charge > 2,000, then 34 percent",783.36,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1704.97,
ZIMMER VE189120 TIBIAL BEARING 83X10MM,C1776,HCPCS,,79012466,CDM,278,RC,,,both,,,3648,2699.53,,,2699.53,Other,150% of Medicare + 9.63% HCRA Surcharge,1641.6,45,,1641.6,percent of total billed charges,Critical Access Hospital RCC factor,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1805.76,,,1805.76,Other,110% of Medicare,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1240.32,34,"Charges > $500, x 34%",1240.32,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1459.2,40,,1459.2,percent of total billed charges,Implant Device,1276.8,70,,1276.8,percent of total billed charges,All Other,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1240.32,34,"If Charge > 2,000, then 34 percent",1240.32,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2699.53,
DJO 506-03-118 BONE SCREW 5.0X18MM,C1713,HCPCS,,79012467,CDM,278,RC,,,both,,,360,266.4,,,266.4,Other,150% of Medicare + 9.63% HCRA Surcharge,162,45,,162,percent of total billed charges,Critical Access Hospital RCC factor,122.4,34,,122.4,percent of total billed charges,Implant Device,122.4,34,,122.4,percent of total billed charges,Implant Device,122.4,34,,122.4,percent of total billed charges,Implant Device,122.4,34,,122.4,percent of total billed charges,Implant Device,122.4,34,,122.4,percent of total billed charges,Implant Device,178.2,,,178.2,Other,110% of Medicare,126,35,,126,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,126,35,,126,percent of total billed charges,Implant Device,126,35,,126,percent of total billed charges,Implant Device,126,35,,126,percent of total billed charges,Implant Device,126,35,,126,percent of total billed charges,Implant Device,126,35,,126,percent of total billed charges,Implant Device,144,40,,144,percent of total billed charges,Implant Device,126,70,,126,percent of total billed charges,All Other,122.4,34,,122.4,percent of total billed charges,Implant Device,122.4,34,,122.4,percent of total billed charges,Implant Device,126,35,,126,percent of total billed charges,Implant Device,126,35,,126,percent of total billed charges,Implant Device,126,35,,126,percent of total billed charges,Implant Device,126,35,,126,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,266.4,
DJO 508-32-103 GLENOID HEAD W/ RETAIN SR,C1776,HCPCS,,79012468,CDM,278,RC,,,both,,,4440,3285.61,,,3285.61,Other,150% of Medicare + 9.63% HCRA Surcharge,1998,45,,1998,percent of total billed charges,Critical Access Hospital RCC factor,1509.6,34,,1509.6,percent of total billed charges,Implant Device,1509.6,34,,1509.6,percent of total billed charges,Implant Device,1509.6,34,,1509.6,percent of total billed charges,Implant Device,1509.6,34,,1509.6,percent of total billed charges,Implant Device,1509.6,34,,1509.6,percent of total billed charges,Implant Device,2197.8,,,2197.8,Other,110% of Medicare,1554,35,,1554,percent of total billed charges,Implant Device,1509.6,34,"Charges > $500, x 34%",1509.6,percent of total billed charges,Implant Device,1554,35,,1554,percent of total billed charges,Implant Device,1554,35,,1554,percent of total billed charges,Implant Device,1554,35,,1554,percent of total billed charges,Implant Device,1554,35,,1554,percent of total billed charges,Implant Device,1554,35,,1554,percent of total billed charges,Implant Device,1776,40,,1776,percent of total billed charges,Implant Device,1554,70,,1554,percent of total billed charges,All Other,1509.6,34,,1509.6,percent of total billed charges,Implant Device,1509.6,34,,1509.6,percent of total billed charges,Implant Device,1554,35,,1554,percent of total billed charges,Implant Device,1554,35,,1554,percent of total billed charges,Implant Device,1554,35,,1554,percent of total billed charges,Implant Device,1554,35,,1554,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1509.6,34,"If Charge > 2,000, then 34 percent",1509.6,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3285.61,
DJO 509-02-032 SMALL SOCKET INSERT 32MM,C1776,HCPCS,,79012469,CDM,278,RC,,,both,,,3600,2664.01,,,2664.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1620,45,,1620,percent of total billed charges,Critical Access Hospital RCC factor,1224,34,,1224,percent of total billed charges,Implant Device,1224,34,,1224,percent of total billed charges,Implant Device,1224,34,,1224,percent of total billed charges,Implant Device,1224,34,,1224,percent of total billed charges,Implant Device,1224,34,,1224,percent of total billed charges,Implant Device,1782,,,1782,Other,110% of Medicare,1260,35,,1260,percent of total billed charges,Implant Device,1224,34,"Charges > $500, x 34%",1224,percent of total billed charges,Implant Device,1260,35,,1260,percent of total billed charges,Implant Device,1260,35,,1260,percent of total billed charges,Implant Device,1260,35,,1260,percent of total billed charges,Implant Device,1260,35,,1260,percent of total billed charges,Implant Device,1260,35,,1260,percent of total billed charges,Implant Device,1440,40,,1440,percent of total billed charges,Implant Device,1260,70,,1260,percent of total billed charges,All Other,1224,34,,1224,percent of total billed charges,Implant Device,1224,34,,1224,percent of total billed charges,Implant Device,1260,35,,1260,percent of total billed charges,Implant Device,1260,35,,1260,percent of total billed charges,Implant Device,1260,35,,1260,percent of total billed charges,Implant Device,1260,35,,1260,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1224,34,"If Charge > 2,000, then 34 percent",1224,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2664.01,
DJO 533-08-108 HUMERAL STEM 8X108MM,C1776,HCPCS,,79012470,CDM,278,RC,,,both,,,14400,10656.04,,,10656.04,Other,150% of Medicare + 9.63% HCRA Surcharge,6480,45,,6480,percent of total billed charges,Critical Access Hospital RCC factor,4896,34,,4896,percent of total billed charges,Implant Device,4896,34,,4896,percent of total billed charges,Implant Device,4896,34,,4896,percent of total billed charges,Implant Device,4896,34,,4896,percent of total billed charges,Implant Device,4896,34,,4896,percent of total billed charges,Implant Device,7128,,,7128,Other,110% of Medicare,5040,35,,5040,percent of total billed charges,Implant Device,4896,34,"Charges > $500, x 34%",4896,percent of total billed charges,Implant Device,5040,35,,5040,percent of total billed charges,Implant Device,5040,35,,5040,percent of total billed charges,Implant Device,5040,35,,5040,percent of total billed charges,Implant Device,5040,35,,5040,percent of total billed charges,Implant Device,5040,35,,5040,percent of total billed charges,Implant Device,5760,40,,5760,percent of total billed charges,Implant Device,5040,70,,5040,percent of total billed charges,All Other,4896,34,,4896,percent of total billed charges,Implant Device,4896,34,,4896,percent of total billed charges,Implant Device,5040,35,,5040,percent of total billed charges,Implant Device,5040,35,,5040,percent of total billed charges,Implant Device,5040,35,,5040,percent of total billed charges,Implant Device,5040,35,,5040,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,4896,34,"If Charge > 2,000, then 34 percent",4896,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,10656.04,
DJO 415-00-100 CEMENT RESTRICTOR 10MM,C1713,HCPCS,,79012471,CDM,278,RC,,,both,,,240,177.6,,,177.6,Other,150% of Medicare + 9.63% HCRA Surcharge,108,45,,108,percent of total billed charges,Critical Access Hospital RCC factor,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,118.8,,,118.8,Other,110% of Medicare,84,35,,84,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,96,40,,96,percent of total billed charges,Implant Device,84,70,,84,percent of total billed charges,All Other,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,177.6,
J&J 412.213S LOCKING SCREW 5.0X38MM,C1713,HCPCS,,79012472,CDM,278,RC,,,both,,,505,373.7,,,373.7,Other,150% of Medicare + 9.63% HCRA Surcharge,227.25,45,,227.25,percent of total billed charges,Critical Access Hospital RCC factor,171.7,34,,171.7,percent of total billed charges,Implant Device,171.7,34,,171.7,percent of total billed charges,Implant Device,171.7,34,,171.7,percent of total billed charges,Implant Device,171.7,34,,171.7,percent of total billed charges,Implant Device,171.7,34,,171.7,percent of total billed charges,Implant Device,249.98,,,249.98,Other,110% of Medicare,176.75,35,,176.75,percent of total billed charges,Implant Device,171.7,34,"Charges > $500, x 34%",171.7,percent of total billed charges,Implant Device,176.75,35,,176.75,percent of total billed charges,Implant Device,176.75,35,,176.75,percent of total billed charges,Implant Device,176.75,35,,176.75,percent of total billed charges,Implant Device,176.75,35,,176.75,percent of total billed charges,Implant Device,176.75,35,,176.75,percent of total billed charges,Implant Device,202,40,,202,percent of total billed charges,Implant Device,176.75,70,,176.75,percent of total billed charges,All Other,171.7,34,,171.7,percent of total billed charges,Implant Device,171.7,34,,171.7,percent of total billed charges,Implant Device,176.75,35,,176.75,percent of total billed charges,Implant Device,176.75,35,,176.75,percent of total billed charges,Implant Device,176.75,35,,176.75,percent of total billed charges,Implant Device,176.75,35,,176.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,373.7,
J&J 04.168.295S BOLT FOR FEM NECK 95MM,C1713,HCPCS,,79012473,CDM,278,RC,,,both,,,633,468.42,,,468.42,Other,150% of Medicare + 9.63% HCRA Surcharge,284.85,45,,284.85,percent of total billed charges,Critical Access Hospital RCC factor,215.22,34,,215.22,percent of total billed charges,Implant Device,215.22,34,,215.22,percent of total billed charges,Implant Device,215.22,34,,215.22,percent of total billed charges,Implant Device,215.22,34,,215.22,percent of total billed charges,Implant Device,215.22,34,,215.22,percent of total billed charges,Implant Device,313.34,,,313.34,Other,110% of Medicare,221.55,35,,221.55,percent of total billed charges,Implant Device,215.22,34,"Charges > $500, x 34%",215.22,percent of total billed charges,Implant Device,221.55,35,,221.55,percent of total billed charges,Implant Device,221.55,35,,221.55,percent of total billed charges,Implant Device,221.55,35,,221.55,percent of total billed charges,Implant Device,221.55,35,,221.55,percent of total billed charges,Implant Device,221.55,35,,221.55,percent of total billed charges,Implant Device,253.2,40,,253.2,percent of total billed charges,Implant Device,221.55,70,,221.55,percent of total billed charges,All Other,215.22,34,,215.22,percent of total billed charges,Implant Device,215.22,34,,215.22,percent of total billed charges,Implant Device,221.55,35,,221.55,percent of total billed charges,Implant Device,221.55,35,,221.55,percent of total billed charges,Implant Device,221.55,35,,221.55,percent of total billed charges,Implant Device,221.55,35,,221.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,468.42,
J&J 04.168.495S SCREW FOR FEM NECK 95MM,C1713,HCPCS,,79012474,CDM,278,RC,,,both,,,633,468.42,,,468.42,Other,150% of Medicare + 9.63% HCRA Surcharge,284.85,45,,284.85,percent of total billed charges,Critical Access Hospital RCC factor,215.22,34,,215.22,percent of total billed charges,Implant Device,215.22,34,,215.22,percent of total billed charges,Implant Device,215.22,34,,215.22,percent of total billed charges,Implant Device,215.22,34,,215.22,percent of total billed charges,Implant Device,215.22,34,,215.22,percent of total billed charges,Implant Device,313.34,,,313.34,Other,110% of Medicare,221.55,35,,221.55,percent of total billed charges,Implant Device,215.22,34,"Charges > $500, x 34%",215.22,percent of total billed charges,Implant Device,221.55,35,,221.55,percent of total billed charges,Implant Device,221.55,35,,221.55,percent of total billed charges,Implant Device,221.55,35,,221.55,percent of total billed charges,Implant Device,221.55,35,,221.55,percent of total billed charges,Implant Device,221.55,35,,221.55,percent of total billed charges,Implant Device,253.2,40,,253.2,percent of total billed charges,Implant Device,221.55,70,,221.55,percent of total billed charges,All Other,215.22,34,,215.22,percent of total billed charges,Implant Device,215.22,34,,215.22,percent of total billed charges,Implant Device,221.55,35,,221.55,percent of total billed charges,Implant Device,221.55,35,,221.55,percent of total billed charges,Implant Device,221.55,35,,221.55,percent of total billed charges,Implant Device,221.55,35,,221.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,468.42,
ZIMMER 42-5400-000-29 PATELLA 29X8MM,C1713,HCPCS,,79012475,CDM,278,RC,,,both,,,1539,1138.86,,,1138.86,Other,150% of Medicare + 9.63% HCRA Surcharge,692.55,45,,692.55,percent of total billed charges,Critical Access Hospital RCC factor,523.26,34,,523.26,percent of total billed charges,Implant Device,523.26,34,,523.26,percent of total billed charges,Implant Device,523.26,34,,523.26,percent of total billed charges,Implant Device,523.26,34,,523.26,percent of total billed charges,Implant Device,523.26,34,,523.26,percent of total billed charges,Implant Device,761.81,,,761.81,Other,110% of Medicare,538.65,35,,538.65,percent of total billed charges,Implant Device,523.26,34,"Charges > $500, x 34%",523.26,percent of total billed charges,Implant Device,538.65,35,,538.65,percent of total billed charges,Implant Device,538.65,35,,538.65,percent of total billed charges,Implant Device,538.65,35,,538.65,percent of total billed charges,Implant Device,538.65,35,,538.65,percent of total billed charges,Implant Device,538.65,35,,538.65,percent of total billed charges,Implant Device,615.6,40,,615.6,percent of total billed charges,Implant Device,538.65,70,,538.65,percent of total billed charges,All Other,523.26,34,,523.26,percent of total billed charges,Implant Device,523.26,34,,523.26,percent of total billed charges,Implant Device,538.65,35,,538.65,percent of total billed charges,Implant Device,538.65,35,,538.65,percent of total billed charges,Implant Device,538.65,35,,538.65,percent of total billed charges,Implant Device,538.65,35,,538.65,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1138.86,
ZIMMER 42-5221-004-14 ART SURF RT 14MM,C1776,HCPCS,,79012476,CDM,278,RC,,,both,,,3648,2699.53,,,2699.53,Other,150% of Medicare + 9.63% HCRA Surcharge,1641.6,45,,1641.6,percent of total billed charges,Critical Access Hospital RCC factor,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1805.76,,,1805.76,Other,110% of Medicare,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1240.32,34,"Charges > $500, x 34%",1240.32,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1459.2,40,,1459.2,percent of total billed charges,Implant Device,1276.8,70,,1276.8,percent of total billed charges,All Other,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1240.32,34,"If Charge > 2,000, then 34 percent",1240.32,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2699.53,
J&J 04.037.012S TFNA NAIL 10X170MM 125,C1889,HCPCS,,79012481,CDM,278,RC,,,both,,,3718,2751.33,,,2751.33,Other,150% of Medicare + 9.63% HCRA Surcharge,1673.1,45,,1673.1,percent of total billed charges,Critical Access Hospital RCC factor,1264.12,34,,1264.12,percent of total billed charges,Implant Device,1264.12,34,,1264.12,percent of total billed charges,Implant Device,1264.12,34,,1264.12,percent of total billed charges,Implant Device,1264.12,34,,1264.12,percent of total billed charges,Implant Device,1264.12,34,,1264.12,percent of total billed charges,Implant Device,1840.41,,,1840.41,Other,110% of Medicare,1301.3,35,,1301.3,percent of total billed charges,Implant Device,1264.12,34,"Charges > $500, x 34%",1264.12,percent of total billed charges,Implant Device,1301.3,35,,1301.3,percent of total billed charges,Implant Device,1301.3,35,,1301.3,percent of total billed charges,Implant Device,1301.3,35,,1301.3,percent of total billed charges,Implant Device,1301.3,35,,1301.3,percent of total billed charges,Implant Device,1301.3,35,,1301.3,percent of total billed charges,Implant Device,1487.2,40,,1487.2,percent of total billed charges,Implant Device,1301.3,70,,1301.3,percent of total billed charges,All Other,1264.12,34,,1264.12,percent of total billed charges,Implant Device,1264.12,34,,1264.12,percent of total billed charges,Implant Device,1301.3,35,,1301.3,percent of total billed charges,Implant Device,1301.3,35,,1301.3,percent of total billed charges,Implant Device,1301.3,35,,1301.3,percent of total billed charges,Implant Device,1301.3,35,,1301.3,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1264.12,34,"If Charge > 2,000, then 34 percent",1264.12,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2751.33,
BOST SCI M00562321 OVAL STIFF SNARE 13MM,C1889,HCPCS,,79012483,CDM,278,RC,,,both,,,32,23.68,,,23.68,Other,150% of Medicare + 9.63% HCRA Surcharge,14.4,45,,14.4,percent of total billed charges,Critical Access Hospital RCC factor,10.88,34,,10.88,percent of total billed charges,Implant Device,10.88,34,,10.88,percent of total billed charges,Implant Device,10.88,34,,10.88,percent of total billed charges,Implant Device,10.88,34,,10.88,percent of total billed charges,Implant Device,10.88,34,,10.88,percent of total billed charges,Implant Device,15.84,,,15.84,Other,110% of Medicare,11.2,35,,11.2,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,11.2,35,,11.2,percent of total billed charges,Implant Device,11.2,35,,11.2,percent of total billed charges,Implant Device,11.2,35,,11.2,percent of total billed charges,Implant Device,11.2,35,,11.2,percent of total billed charges,Implant Device,11.2,35,,11.2,percent of total billed charges,Implant Device,12.8,40,,12.8,percent of total billed charges,Implant Device,11.2,70,,11.2,percent of total billed charges,All Other,10.88,34,,10.88,percent of total billed charges,Implant Device,10.88,34,,10.88,percent of total billed charges,Implant Device,11.2,35,,11.2,percent of total billed charges,Implant Device,11.2,35,,11.2,percent of total billed charges,Implant Device,11.2,35,,11.2,percent of total billed charges,Implant Device,11.2,35,,11.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,23.68,
ZIMMER 184768 PATELLA 37X10MM,C1776,HCPCS,,79012486,CDM,278,RC,,,both,,,1152,852.48,,,852.48,Other,150% of Medicare + 9.63% HCRA Surcharge,518.4,45,,518.4,percent of total billed charges,Critical Access Hospital RCC factor,391.68,34,,391.68,percent of total billed charges,Implant Device,391.68,34,,391.68,percent of total billed charges,Implant Device,391.68,34,,391.68,percent of total billed charges,Implant Device,391.68,34,,391.68,percent of total billed charges,Implant Device,391.68,34,,391.68,percent of total billed charges,Implant Device,570.24,,,570.24,Other,110% of Medicare,403.2,35,,403.2,percent of total billed charges,Implant Device,391.68,34,"Charges > $500, x 34%",391.68,percent of total billed charges,Implant Device,403.2,35,,403.2,percent of total billed charges,Implant Device,403.2,35,,403.2,percent of total billed charges,Implant Device,403.2,35,,403.2,percent of total billed charges,Implant Device,403.2,35,,403.2,percent of total billed charges,Implant Device,403.2,35,,403.2,percent of total billed charges,Implant Device,460.8,40,,460.8,percent of total billed charges,Implant Device,403.2,70,,403.2,percent of total billed charges,All Other,391.68,34,,391.68,percent of total billed charges,Implant Device,391.68,34,,391.68,percent of total billed charges,Implant Device,403.2,35,,403.2,percent of total billed charges,Implant Device,403.2,35,,403.2,percent of total billed charges,Implant Device,403.2,35,,403.2,percent of total billed charges,Implant Device,403.2,35,,403.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,852.48,
ZIMMER VE189060 TIBIAL BEARING 71X10MM,C1776,HCPCS,,79012487,CDM,278,RC,,,both,,,3648,2699.53,,,2699.53,Other,150% of Medicare + 9.63% HCRA Surcharge,1641.6,45,,1641.6,percent of total billed charges,Critical Access Hospital RCC factor,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1805.76,,,1805.76,Other,110% of Medicare,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1240.32,34,"Charges > $500, x 34%",1240.32,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1459.2,40,,1459.2,percent of total billed charges,Implant Device,1276.8,70,,1276.8,percent of total billed charges,All Other,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1240.32,34,"If Charge > 2,000, then 34 percent",1240.32,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2699.53,
ZIMMER 183033 FEMORAL LEFT 72.5MM,C1776,HCPCS,,79012488,CDM,278,RC,,,both,,,6300,4662.02,,,4662.02,Other,150% of Medicare + 9.63% HCRA Surcharge,2835,45,,2835,percent of total billed charges,Critical Access Hospital RCC factor,2142,34,,2142,percent of total billed charges,Implant Device,2142,34,,2142,percent of total billed charges,Implant Device,2142,34,,2142,percent of total billed charges,Implant Device,2142,34,,2142,percent of total billed charges,Implant Device,2142,34,,2142,percent of total billed charges,Implant Device,3118.5,,,3118.5,Other,110% of Medicare,2205,35,,2205,percent of total billed charges,Implant Device,2142,34,"Charges > $500, x 34%",2142,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2520,40,,2520,percent of total billed charges,Implant Device,2205,70,,2205,percent of total billed charges,All Other,2142,34,,2142,percent of total billed charges,Implant Device,2142,34,,2142,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2142,34,"If Charge > 2,000, then 34 percent",2142,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4662.02,
ZIMMER 00-5966-015-01 FEM COMP LT SZ E,C1776,HCPCS,,79012489,CDM,278,RC,,,both,,,4608,3409.93,,,3409.93,Other,150% of Medicare + 9.63% HCRA Surcharge,2073.6,45,,2073.6,percent of total billed charges,Critical Access Hospital RCC factor,1566.72,34,,1566.72,percent of total billed charges,Implant Device,1566.72,34,,1566.72,percent of total billed charges,Implant Device,1566.72,34,,1566.72,percent of total billed charges,Implant Device,1566.72,34,,1566.72,percent of total billed charges,Implant Device,1566.72,34,,1566.72,percent of total billed charges,Implant Device,2280.96,,,2280.96,Other,110% of Medicare,1612.8,35,,1612.8,percent of total billed charges,Implant Device,1566.72,34,"Charges > $500, x 34%",1566.72,percent of total billed charges,Implant Device,1612.8,35,,1612.8,percent of total billed charges,Implant Device,1612.8,35,,1612.8,percent of total billed charges,Implant Device,1612.8,35,,1612.8,percent of total billed charges,Implant Device,1612.8,35,,1612.8,percent of total billed charges,Implant Device,1612.8,35,,1612.8,percent of total billed charges,Implant Device,1843.2,40,,1843.2,percent of total billed charges,Implant Device,1612.8,70,,1612.8,percent of total billed charges,All Other,1566.72,34,,1566.72,percent of total billed charges,Implant Device,1566.72,34,,1566.72,percent of total billed charges,Implant Device,1612.8,35,,1612.8,percent of total billed charges,Implant Device,1612.8,35,,1612.8,percent of total billed charges,Implant Device,1612.8,35,,1612.8,percent of total billed charges,Implant Device,1612.8,35,,1612.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1566.72,34,"If Charge > 2,000, then 34 percent",1566.72,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3409.93,
ZIMMER 00-5966-005-14 TIBIAL COMP 14MM,C1776,HCPCS,,79012490,CDM,278,RC,,,both,,,2673,1978.03,,,1978.03,Other,150% of Medicare + 9.63% HCRA Surcharge,1202.85,45,,1202.85,percent of total billed charges,Critical Access Hospital RCC factor,908.82,34,,908.82,percent of total billed charges,Implant Device,908.82,34,,908.82,percent of total billed charges,Implant Device,908.82,34,,908.82,percent of total billed charges,Implant Device,908.82,34,,908.82,percent of total billed charges,Implant Device,908.82,34,,908.82,percent of total billed charges,Implant Device,1323.14,,,1323.14,Other,110% of Medicare,935.55,35,,935.55,percent of total billed charges,Implant Device,908.82,34,"Charges > $500, x 34%",908.82,percent of total billed charges,Implant Device,935.55,35,,935.55,percent of total billed charges,Implant Device,935.55,35,,935.55,percent of total billed charges,Implant Device,935.55,35,,935.55,percent of total billed charges,Implant Device,935.55,35,,935.55,percent of total billed charges,Implant Device,935.55,35,,935.55,percent of total billed charges,Implant Device,1069.2,40,,1069.2,percent of total billed charges,Implant Device,935.55,70,,935.55,percent of total billed charges,All Other,908.82,34,,908.82,percent of total billed charges,Implant Device,908.82,34,,908.82,percent of total billed charges,Implant Device,935.55,35,,935.55,percent of total billed charges,Implant Device,935.55,35,,935.55,percent of total billed charges,Implant Device,935.55,35,,935.55,percent of total billed charges,Implant Device,935.55,35,,935.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,908.82,34,"If Charge > 2,000, then 34 percent",908.82,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1978.03,
STRYKER EZ15-15-15 FIXATION DEV 15X15X15,C1713,HCPCS,,79012493,CDM,278,RC,,,both,,,2888,2137.13,,,2137.13,Other,150% of Medicare + 9.63% HCRA Surcharge,1299.6,45,,1299.6,percent of total billed charges,Critical Access Hospital RCC factor,981.92,34,,981.92,percent of total billed charges,Implant Device,981.92,34,,981.92,percent of total billed charges,Implant Device,981.92,34,,981.92,percent of total billed charges,Implant Device,981.92,34,,981.92,percent of total billed charges,Implant Device,981.92,34,,981.92,percent of total billed charges,Implant Device,1429.56,,,1429.56,Other,110% of Medicare,1010.8,35,,1010.8,percent of total billed charges,Implant Device,981.92,34,"Charges > $500, x 34%",981.92,percent of total billed charges,Implant Device,1010.8,35,,1010.8,percent of total billed charges,Implant Device,1010.8,35,,1010.8,percent of total billed charges,Implant Device,1010.8,35,,1010.8,percent of total billed charges,Implant Device,1010.8,35,,1010.8,percent of total billed charges,Implant Device,1010.8,35,,1010.8,percent of total billed charges,Implant Device,1155.2,40,,1155.2,percent of total billed charges,Implant Device,1010.8,70,,1010.8,percent of total billed charges,All Other,981.92,34,,981.92,percent of total billed charges,Implant Device,981.92,34,,981.92,percent of total billed charges,Implant Device,1010.8,35,,1010.8,percent of total billed charges,Implant Device,1010.8,35,,1010.8,percent of total billed charges,Implant Device,1010.8,35,,1010.8,percent of total billed charges,Implant Device,1010.8,35,,1010.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,981.92,34,"If Charge > 2,000, then 34 percent",981.92,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2137.13,
ZIMMER 183002 FEMORAL RIGHT 57.5MM,C1776,HCPCS,,79012494,CDM,278,RC,,,both,,,6300,4662.02,,,4662.02,Other,150% of Medicare + 9.63% HCRA Surcharge,2835,45,,2835,percent of total billed charges,Critical Access Hospital RCC factor,2142,34,,2142,percent of total billed charges,Implant Device,2142,34,,2142,percent of total billed charges,Implant Device,2142,34,,2142,percent of total billed charges,Implant Device,2142,34,,2142,percent of total billed charges,Implant Device,2142,34,,2142,percent of total billed charges,Implant Device,3118.5,,,3118.5,Other,110% of Medicare,2205,35,,2205,percent of total billed charges,Implant Device,2142,34,"Charges > $500, x 34%",2142,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2520,40,,2520,percent of total billed charges,Implant Device,2205,70,,2205,percent of total billed charges,All Other,2142,34,,2142,percent of total billed charges,Implant Device,2142,34,,2142,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2142,34,"If Charge > 2,000, then 34 percent",2142,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4662.02,
ZIMMER 141231 TIBIAL PLATE 63MM,C1776,HCPCS,,79012495,CDM,278,RC,,,both,,,2304,1704.97,,,1704.97,Other,150% of Medicare + 9.63% HCRA Surcharge,1036.8,45,,1036.8,percent of total billed charges,Critical Access Hospital RCC factor,783.36,34,,783.36,percent of total billed charges,Implant Device,783.36,34,,783.36,percent of total billed charges,Implant Device,783.36,34,,783.36,percent of total billed charges,Implant Device,783.36,34,,783.36,percent of total billed charges,Implant Device,783.36,34,,783.36,percent of total billed charges,Implant Device,1140.48,,,1140.48,Other,110% of Medicare,806.4,35,,806.4,percent of total billed charges,Implant Device,783.36,34,"Charges > $500, x 34%",783.36,percent of total billed charges,Implant Device,806.4,35,,806.4,percent of total billed charges,Implant Device,806.4,35,,806.4,percent of total billed charges,Implant Device,806.4,35,,806.4,percent of total billed charges,Implant Device,806.4,35,,806.4,percent of total billed charges,Implant Device,806.4,35,,806.4,percent of total billed charges,Implant Device,921.6,40,,921.6,percent of total billed charges,Implant Device,806.4,70,,806.4,percent of total billed charges,All Other,783.36,34,,783.36,percent of total billed charges,Implant Device,783.36,34,,783.36,percent of total billed charges,Implant Device,806.4,35,,806.4,percent of total billed charges,Implant Device,806.4,35,,806.4,percent of total billed charges,Implant Device,806.4,35,,806.4,percent of total billed charges,Implant Device,806.4,35,,806.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,783.36,34,"If Charge > 2,000, then 34 percent",783.36,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1704.97,
ZIMMER VE189020 TIBIAL BEARING 63X10MM,C1776,HCPCS,,79012496,CDM,278,RC,,,both,,,3648,2699.53,,,2699.53,Other,150% of Medicare + 9.63% HCRA Surcharge,1641.6,45,,1641.6,percent of total billed charges,Critical Access Hospital RCC factor,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1805.76,,,1805.76,Other,110% of Medicare,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1240.32,34,"Charges > $500, x 34%",1240.32,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1459.2,40,,1459.2,percent of total billed charges,Implant Device,1276.8,70,,1276.8,percent of total billed charges,All Other,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1240.32,34,"If Charge > 2,000, then 34 percent",1240.32,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2699.53,
ZIMMER 184762 PATELLA 28X8MM,C1776,HCPCS,,79012497,CDM,278,RC,,,both,,,1152,852.48,,,852.48,Other,150% of Medicare + 9.63% HCRA Surcharge,518.4,45,,518.4,percent of total billed charges,Critical Access Hospital RCC factor,391.68,34,,391.68,percent of total billed charges,Implant Device,391.68,34,,391.68,percent of total billed charges,Implant Device,391.68,34,,391.68,percent of total billed charges,Implant Device,391.68,34,,391.68,percent of total billed charges,Implant Device,391.68,34,,391.68,percent of total billed charges,Implant Device,570.24,,,570.24,Other,110% of Medicare,403.2,35,,403.2,percent of total billed charges,Implant Device,391.68,34,"Charges > $500, x 34%",391.68,percent of total billed charges,Implant Device,403.2,35,,403.2,percent of total billed charges,Implant Device,403.2,35,,403.2,percent of total billed charges,Implant Device,403.2,35,,403.2,percent of total billed charges,Implant Device,403.2,35,,403.2,percent of total billed charges,Implant Device,403.2,35,,403.2,percent of total billed charges,Implant Device,460.8,40,,460.8,percent of total billed charges,Implant Device,403.2,70,,403.2,percent of total billed charges,All Other,391.68,34,,391.68,percent of total billed charges,Implant Device,391.68,34,,391.68,percent of total billed charges,Implant Device,403.2,35,,403.2,percent of total billed charges,Implant Device,403.2,35,,403.2,percent of total billed charges,Implant Device,403.2,35,,403.2,percent of total billed charges,Implant Device,403.2,35,,403.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,852.48,
J&J 1504-11-226 FEMORAL COMP RT SZ 6,C1776,HCPCS,,79012499,CDM,278,RC,,,both,,,6000,4440.02,,,4440.02,Other,150% of Medicare + 9.63% HCRA Surcharge,2700,45,,2700,percent of total billed charges,Critical Access Hospital RCC factor,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2970,,,2970,Other,110% of Medicare,2100,35,,2100,percent of total billed charges,Implant Device,2040,34,"Charges > $500, x 34%",2040,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2400,40,,2400,percent of total billed charges,Implant Device,2100,70,,2100,percent of total billed charges,All Other,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2040,34,"If Charge > 2,000, then 34 percent",2040,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4440.02,
J&J 1516-50-606 TIBIAL INSERT 6MM SZ 6,C1776,HCPCS,,79012500,CDM,278,RC,,,both,,,4200,3108.01,,,3108.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1890,45,,1890,percent of total billed charges,Critical Access Hospital RCC factor,1428,34,,1428,percent of total billed charges,Implant Device,1428,34,,1428,percent of total billed charges,Implant Device,1428,34,,1428,percent of total billed charges,Implant Device,1428,34,,1428,percent of total billed charges,Implant Device,1428,34,,1428,percent of total billed charges,Implant Device,2079,,,2079,Other,110% of Medicare,1470,35,,1470,percent of total billed charges,Implant Device,1428,34,"Charges > $500, x 34%",1428,percent of total billed charges,Implant Device,1470,35,,1470,percent of total billed charges,Implant Device,1470,35,,1470,percent of total billed charges,Implant Device,1470,35,,1470,percent of total billed charges,Implant Device,1470,35,,1470,percent of total billed charges,Implant Device,1470,35,,1470,percent of total billed charges,Implant Device,1680,40,,1680,percent of total billed charges,Implant Device,1470,70,,1470,percent of total billed charges,All Other,1428,34,,1428,percent of total billed charges,Implant Device,1428,34,,1428,percent of total billed charges,Implant Device,1470,35,,1470,percent of total billed charges,Implant Device,1470,35,,1470,percent of total billed charges,Implant Device,1470,35,,1470,percent of total billed charges,Implant Device,1470,35,,1470,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1428,34,"If Charge > 2,000, then 34 percent",1428,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3108.01,
WRIGHT 45110002 SNAP OFF SCREW 2.0X12MM,C1713,HCPCS,,79012501,CDM,278,RC,,,both,,,1069,791.06,,,791.06,Other,150% of Medicare + 9.63% HCRA Surcharge,481.05,45,,481.05,percent of total billed charges,Critical Access Hospital RCC factor,363.46,34,,363.46,percent of total billed charges,Implant Device,363.46,34,,363.46,percent of total billed charges,Implant Device,363.46,34,,363.46,percent of total billed charges,Implant Device,363.46,34,,363.46,percent of total billed charges,Implant Device,363.46,34,,363.46,percent of total billed charges,Implant Device,529.16,,,529.16,Other,110% of Medicare,374.15,35,,374.15,percent of total billed charges,Implant Device,363.46,34,"Charges > $500, x 34%",363.46,percent of total billed charges,Implant Device,374.15,35,,374.15,percent of total billed charges,Implant Device,374.15,35,,374.15,percent of total billed charges,Implant Device,374.15,35,,374.15,percent of total billed charges,Implant Device,374.15,35,,374.15,percent of total billed charges,Implant Device,374.15,35,,374.15,percent of total billed charges,Implant Device,427.6,40,,427.6,percent of total billed charges,Implant Device,374.15,70,,374.15,percent of total billed charges,All Other,363.46,34,,363.46,percent of total billed charges,Implant Device,363.46,34,,363.46,percent of total billed charges,Implant Device,374.15,35,,374.15,percent of total billed charges,Implant Device,374.15,35,,374.15,percent of total billed charges,Implant Device,374.15,35,,374.15,percent of total billed charges,Implant Device,374.15,35,,374.15,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,791.06,
WRIGHT 45112013 SNAP OFF SCREW 2.0X13MM,C1713,HCPCS,,79012502,CDM,278,RC,,,both,,,1069,791.06,,,791.06,Other,150% of Medicare + 9.63% HCRA Surcharge,481.05,45,,481.05,percent of total billed charges,Critical Access Hospital RCC factor,363.46,34,,363.46,percent of total billed charges,Implant Device,363.46,34,,363.46,percent of total billed charges,Implant Device,363.46,34,,363.46,percent of total billed charges,Implant Device,363.46,34,,363.46,percent of total billed charges,Implant Device,363.46,34,,363.46,percent of total billed charges,Implant Device,529.16,,,529.16,Other,110% of Medicare,374.15,35,,374.15,percent of total billed charges,Implant Device,363.46,34,"Charges > $500, x 34%",363.46,percent of total billed charges,Implant Device,374.15,35,,374.15,percent of total billed charges,Implant Device,374.15,35,,374.15,percent of total billed charges,Implant Device,374.15,35,,374.15,percent of total billed charges,Implant Device,374.15,35,,374.15,percent of total billed charges,Implant Device,374.15,35,,374.15,percent of total billed charges,Implant Device,427.6,40,,427.6,percent of total billed charges,Implant Device,374.15,70,,374.15,percent of total billed charges,All Other,363.46,34,,363.46,percent of total billed charges,Implant Device,363.46,34,,363.46,percent of total billed charges,Implant Device,374.15,35,,374.15,percent of total billed charges,Implant Device,374.15,35,,374.15,percent of total billed charges,Implant Device,374.15,35,,374.15,percent of total billed charges,Implant Device,374.15,35,,374.15,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,791.06,
STRYKER EZ15-12-12 FIXATION DEV 15X12X12,C1713,HCPCS,,79012503,CDM,278,RC,,,both,,,2888,2137.13,,,2137.13,Other,150% of Medicare + 9.63% HCRA Surcharge,1299.6,45,,1299.6,percent of total billed charges,Critical Access Hospital RCC factor,981.92,34,,981.92,percent of total billed charges,Implant Device,981.92,34,,981.92,percent of total billed charges,Implant Device,981.92,34,,981.92,percent of total billed charges,Implant Device,981.92,34,,981.92,percent of total billed charges,Implant Device,981.92,34,,981.92,percent of total billed charges,Implant Device,1429.56,,,1429.56,Other,110% of Medicare,1010.8,35,,1010.8,percent of total billed charges,Implant Device,981.92,34,"Charges > $500, x 34%",981.92,percent of total billed charges,Implant Device,1010.8,35,,1010.8,percent of total billed charges,Implant Device,1010.8,35,,1010.8,percent of total billed charges,Implant Device,1010.8,35,,1010.8,percent of total billed charges,Implant Device,1010.8,35,,1010.8,percent of total billed charges,Implant Device,1010.8,35,,1010.8,percent of total billed charges,Implant Device,1155.2,40,,1155.2,percent of total billed charges,Implant Device,1010.8,70,,1010.8,percent of total billed charges,All Other,981.92,34,,981.92,percent of total billed charges,Implant Device,981.92,34,,981.92,percent of total billed charges,Implant Device,1010.8,35,,1010.8,percent of total billed charges,Implant Device,1010.8,35,,1010.8,percent of total billed charges,Implant Device,1010.8,35,,1010.8,percent of total billed charges,Implant Device,1010.8,35,,1010.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,981.92,34,"If Charge > 2,000, then 34 percent",981.92,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2137.13,
STRYKER IC4030 HEADED SCREW 4.0X30MM,C1713,HCPCS,,79012504,CDM,278,RC,,,both,,,961,711.14,,,711.14,Other,150% of Medicare + 9.63% HCRA Surcharge,432.45,45,,432.45,percent of total billed charges,Critical Access Hospital RCC factor,326.74,34,,326.74,percent of total billed charges,Implant Device,326.74,34,,326.74,percent of total billed charges,Implant Device,326.74,34,,326.74,percent of total billed charges,Implant Device,326.74,34,,326.74,percent of total billed charges,Implant Device,326.74,34,,326.74,percent of total billed charges,Implant Device,475.7,,,475.7,Other,110% of Medicare,336.35,35,,336.35,percent of total billed charges,Implant Device,326.74,34,"Charges > $500, x 34%",326.74,percent of total billed charges,Implant Device,336.35,35,,336.35,percent of total billed charges,Implant Device,336.35,35,,336.35,percent of total billed charges,Implant Device,336.35,35,,336.35,percent of total billed charges,Implant Device,336.35,35,,336.35,percent of total billed charges,Implant Device,336.35,35,,336.35,percent of total billed charges,Implant Device,384.4,40,,384.4,percent of total billed charges,Implant Device,336.35,70,,336.35,percent of total billed charges,All Other,326.74,34,,326.74,percent of total billed charges,Implant Device,326.74,34,,326.74,percent of total billed charges,Implant Device,336.35,35,,336.35,percent of total billed charges,Implant Device,336.35,35,,336.35,percent of total billed charges,Implant Device,336.35,35,,336.35,percent of total billed charges,Implant Device,336.35,35,,336.35,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,711.14,
STRYKER 18717000 SEMI TENODESIS GRAFT,C1762,HCPCS,,79012505,CDM,278,RC,,,both,,,4120,3048.81,,,3048.81,Other,150% of Medicare + 9.63% HCRA Surcharge,1854,45,,1854,percent of total billed charges,Critical Access Hospital RCC factor,1400.8,34,,1400.8,percent of total billed charges,Implant Device,1400.8,34,,1400.8,percent of total billed charges,Implant Device,1400.8,34,,1400.8,percent of total billed charges,Implant Device,1400.8,34,,1400.8,percent of total billed charges,Implant Device,1400.8,34,,1400.8,percent of total billed charges,Implant Device,2039.4,,,2039.4,Other,110% of Medicare,1442,35,,1442,percent of total billed charges,Implant Device,1400.8,34,"Charges > $500, x 34%",1400.8,percent of total billed charges,Implant Device,1442,35,,1442,percent of total billed charges,Implant Device,1442,35,,1442,percent of total billed charges,Implant Device,1442,35,,1442,percent of total billed charges,Implant Device,1442,35,,1442,percent of total billed charges,Implant Device,1442,35,,1442,percent of total billed charges,Implant Device,1648,40,,1648,percent of total billed charges,Implant Device,1442,70,,1442,percent of total billed charges,All Other,1400.8,34,,1400.8,percent of total billed charges,Implant Device,1400.8,34,,1400.8,percent of total billed charges,Implant Device,1442,35,,1442,percent of total billed charges,Implant Device,1442,35,,1442,percent of total billed charges,Implant Device,1442,35,,1442,percent of total billed charges,Implant Device,1442,35,,1442,percent of total billed charges,Implant Device,976.07,,,976.07,Other,100% of Medicaid,976.07,,,976.07,Other,100% of Medicaid,976.07,,,976.07,Other,100% of Medicaid,976.07,,,976.07,Other,100% of Medicaid,2196.16,,,2196.16,Other,225% of Medicaid,1493.39,,,1493.39,Other,153% of Medicaid,2196.16,,,2196.16,Other,225% of Medicaid,1366.5,,,1366.5,Other,140% of Medicaid,1400.8,34,"If Charge > 2,000, then 34 percent",1400.8,percent of total billed charges,Implants,2537.78,,,2537.78,Other,260% of Medicaid,3162.47,,,3162.47,Other,324% of Medicaid,2098.55,,,2098.55,Other,215% of Medicaid,2098.55,,,2098.55,Other,215% of Medicaid,1220.09,,,1220.09,Other,125% of Medicaid,976.07,3162.47,
ZIMMER 8143-11-400 HIP FRAC NAIL 11X400,C1889,HCPCS,,79012506,CDM,278,RC,,,both,,,7290,5394.62,,,5394.62,Other,150% of Medicare + 9.63% HCRA Surcharge,3280.5,45,,3280.5,percent of total billed charges,Critical Access Hospital RCC factor,2478.6,34,,2478.6,percent of total billed charges,Implant Device,2478.6,34,,2478.6,percent of total billed charges,Implant Device,2478.6,34,,2478.6,percent of total billed charges,Implant Device,2478.6,34,,2478.6,percent of total billed charges,Implant Device,2478.6,34,,2478.6,percent of total billed charges,Implant Device,3608.55,,,3608.55,Other,110% of Medicare,2551.5,35,,2551.5,percent of total billed charges,Implant Device,2478.6,34,"Charges > $500, x 34%",2478.6,percent of total billed charges,Implant Device,2551.5,35,,2551.5,percent of total billed charges,Implant Device,2551.5,35,,2551.5,percent of total billed charges,Implant Device,2551.5,35,,2551.5,percent of total billed charges,Implant Device,2551.5,35,,2551.5,percent of total billed charges,Implant Device,2551.5,35,,2551.5,percent of total billed charges,Implant Device,2916,40,,2916,percent of total billed charges,Implant Device,2551.5,70,,2551.5,percent of total billed charges,All Other,2478.6,34,,2478.6,percent of total billed charges,Implant Device,2478.6,34,,2478.6,percent of total billed charges,Implant Device,2551.5,35,,2551.5,percent of total billed charges,Implant Device,2551.5,35,,2551.5,percent of total billed charges,Implant Device,2551.5,35,,2551.5,percent of total billed charges,Implant Device,2551.5,35,,2551.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2478.6,34,"If Charge > 2,000, then 34 percent",2478.6,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5394.62,
ZIMMER 8145-50-060 CORTICAL SCREW 5X60MM,C1713,HCPCS,,79012507,CDM,278,RC,,,both,,,594,439.56,,,439.56,Other,150% of Medicare + 9.63% HCRA Surcharge,267.3,45,,267.3,percent of total billed charges,Critical Access Hospital RCC factor,201.96,34,,201.96,percent of total billed charges,Implant Device,201.96,34,,201.96,percent of total billed charges,Implant Device,201.96,34,,201.96,percent of total billed charges,Implant Device,201.96,34,,201.96,percent of total billed charges,Implant Device,201.96,34,,201.96,percent of total billed charges,Implant Device,294.03,,,294.03,Other,110% of Medicare,207.9,35,,207.9,percent of total billed charges,Implant Device,201.96,34,"Charges > $500, x 34%",201.96,percent of total billed charges,Implant Device,207.9,35,,207.9,percent of total billed charges,Implant Device,207.9,35,,207.9,percent of total billed charges,Implant Device,207.9,35,,207.9,percent of total billed charges,Implant Device,207.9,35,,207.9,percent of total billed charges,Implant Device,207.9,35,,207.9,percent of total billed charges,Implant Device,237.6,40,,237.6,percent of total billed charges,Implant Device,207.9,70,,207.9,percent of total billed charges,All Other,201.96,34,,201.96,percent of total billed charges,Implant Device,201.96,34,,201.96,percent of total billed charges,Implant Device,207.9,35,,207.9,percent of total billed charges,Implant Device,207.9,35,,207.9,percent of total billed charges,Implant Device,207.9,35,,207.9,percent of total billed charges,Implant Device,207.9,35,,207.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,439.56,
ZIMMER 8145-10-085 LAG SCREW 105X85MM,C1713,HCPCS,,79012508,CDM,278,RC,,,both,,,1786,1321.64,,,1321.64,Other,150% of Medicare + 9.63% HCRA Surcharge,803.7,45,,803.7,percent of total billed charges,Critical Access Hospital RCC factor,607.24,34,,607.24,percent of total billed charges,Implant Device,607.24,34,,607.24,percent of total billed charges,Implant Device,607.24,34,,607.24,percent of total billed charges,Implant Device,607.24,34,,607.24,percent of total billed charges,Implant Device,607.24,34,,607.24,percent of total billed charges,Implant Device,884.07,,,884.07,Other,110% of Medicare,625.1,35,,625.1,percent of total billed charges,Implant Device,607.24,34,"Charges > $500, x 34%",607.24,percent of total billed charges,Implant Device,625.1,35,,625.1,percent of total billed charges,Implant Device,625.1,35,,625.1,percent of total billed charges,Implant Device,625.1,35,,625.1,percent of total billed charges,Implant Device,625.1,35,,625.1,percent of total billed charges,Implant Device,625.1,35,,625.1,percent of total billed charges,Implant Device,714.4,40,,714.4,percent of total billed charges,Implant Device,625.1,70,,625.1,percent of total billed charges,All Other,607.24,34,,607.24,percent of total billed charges,Implant Device,607.24,34,,607.24,percent of total billed charges,Implant Device,625.1,35,,625.1,percent of total billed charges,Implant Device,625.1,35,,625.1,percent of total billed charges,Implant Device,625.1,35,,625.1,percent of total billed charges,Implant Device,625.1,35,,625.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1321.64,
ZIMMER 8145-01-075 SCRW ANTI-ROTATION 75,C1713,HCPCS,,79012509,CDM,278,RC,,,both,,,846,626.04,,,626.04,Other,150% of Medicare + 9.63% HCRA Surcharge,380.7,45,,380.7,percent of total billed charges,Critical Access Hospital RCC factor,287.64,34,,287.64,percent of total billed charges,Implant Device,287.64,34,,287.64,percent of total billed charges,Implant Device,287.64,34,,287.64,percent of total billed charges,Implant Device,287.64,34,,287.64,percent of total billed charges,Implant Device,287.64,34,,287.64,percent of total billed charges,Implant Device,418.77,,,418.77,Other,110% of Medicare,296.1,35,,296.1,percent of total billed charges,Implant Device,287.64,34,"Charges > $500, x 34%",287.64,percent of total billed charges,Implant Device,296.1,35,,296.1,percent of total billed charges,Implant Device,296.1,35,,296.1,percent of total billed charges,Implant Device,296.1,35,,296.1,percent of total billed charges,Implant Device,296.1,35,,296.1,percent of total billed charges,Implant Device,296.1,35,,296.1,percent of total billed charges,Implant Device,338.4,40,,338.4,percent of total billed charges,Implant Device,296.1,70,,296.1,percent of total billed charges,All Other,287.64,34,,287.64,percent of total billed charges,Implant Device,287.64,34,,287.64,percent of total billed charges,Implant Device,296.1,35,,296.1,percent of total billed charges,Implant Device,296.1,35,,296.1,percent of total billed charges,Implant Device,296.1,35,,296.1,percent of total billed charges,Implant Device,296.1,35,,296.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,626.04,
ZIMMER 8145-50-056 CORTICAL SCREW 5X56MM,C1713,HCPCS,,79012510,CDM,278,RC,,,both,,,594,439.56,,,439.56,Other,150% of Medicare + 9.63% HCRA Surcharge,267.3,45,,267.3,percent of total billed charges,Critical Access Hospital RCC factor,201.96,34,,201.96,percent of total billed charges,Implant Device,201.96,34,,201.96,percent of total billed charges,Implant Device,201.96,34,,201.96,percent of total billed charges,Implant Device,201.96,34,,201.96,percent of total billed charges,Implant Device,201.96,34,,201.96,percent of total billed charges,Implant Device,294.03,,,294.03,Other,110% of Medicare,207.9,35,,207.9,percent of total billed charges,Implant Device,201.96,34,"Charges > $500, x 34%",201.96,percent of total billed charges,Implant Device,207.9,35,,207.9,percent of total billed charges,Implant Device,207.9,35,,207.9,percent of total billed charges,Implant Device,207.9,35,,207.9,percent of total billed charges,Implant Device,207.9,35,,207.9,percent of total billed charges,Implant Device,207.9,35,,207.9,percent of total billed charges,Implant Device,237.6,40,,237.6,percent of total billed charges,Implant Device,207.9,70,,207.9,percent of total billed charges,All Other,201.96,34,,201.96,percent of total billed charges,Implant Device,201.96,34,,201.96,percent of total billed charges,Implant Device,207.9,35,,207.9,percent of total billed charges,Implant Device,207.9,35,,207.9,percent of total billed charges,Implant Device,207.9,35,,207.9,percent of total billed charges,Implant Device,207.9,35,,207.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,439.56,
J&J 02.127.140 LOCKING SCREW 3.5X40MM,C1713,HCPCS,,79012511,CDM,278,RC,,,both,,,414,306.36,,,306.36,Other,150% of Medicare + 9.63% HCRA Surcharge,186.3,45,,186.3,percent of total billed charges,Critical Access Hospital RCC factor,140.76,34,,140.76,percent of total billed charges,Implant Device,140.76,34,,140.76,percent of total billed charges,Implant Device,140.76,34,,140.76,percent of total billed charges,Implant Device,140.76,34,,140.76,percent of total billed charges,Implant Device,140.76,34,,140.76,percent of total billed charges,Implant Device,204.93,,,204.93,Other,110% of Medicare,144.9,35,,144.9,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,144.9,35,,144.9,percent of total billed charges,Implant Device,144.9,35,,144.9,percent of total billed charges,Implant Device,144.9,35,,144.9,percent of total billed charges,Implant Device,144.9,35,,144.9,percent of total billed charges,Implant Device,144.9,35,,144.9,percent of total billed charges,Implant Device,165.6,40,,165.6,percent of total billed charges,Implant Device,144.9,70,,144.9,percent of total billed charges,All Other,140.76,34,,140.76,percent of total billed charges,Implant Device,140.76,34,,140.76,percent of total billed charges,Implant Device,144.9,35,,144.9,percent of total billed charges,Implant Device,144.9,35,,144.9,percent of total billed charges,Implant Device,144.9,35,,144.9,percent of total billed charges,Implant Device,144.9,35,,144.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,306.36,
J&J 02.127.138 LOCKING SCREW 3.5X38MM,C1713,HCPCS,,79012512,CDM,278,RC,,,both,,,414,306.36,,,306.36,Other,150% of Medicare + 9.63% HCRA Surcharge,186.3,45,,186.3,percent of total billed charges,Critical Access Hospital RCC factor,140.76,34,,140.76,percent of total billed charges,Implant Device,140.76,34,,140.76,percent of total billed charges,Implant Device,140.76,34,,140.76,percent of total billed charges,Implant Device,140.76,34,,140.76,percent of total billed charges,Implant Device,140.76,34,,140.76,percent of total billed charges,Implant Device,204.93,,,204.93,Other,110% of Medicare,144.9,35,,144.9,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,144.9,35,,144.9,percent of total billed charges,Implant Device,144.9,35,,144.9,percent of total billed charges,Implant Device,144.9,35,,144.9,percent of total billed charges,Implant Device,144.9,35,,144.9,percent of total billed charges,Implant Device,144.9,35,,144.9,percent of total billed charges,Implant Device,165.6,40,,165.6,percent of total billed charges,Implant Device,144.9,70,,144.9,percent of total billed charges,All Other,140.76,34,,140.76,percent of total billed charges,Implant Device,140.76,34,,140.76,percent of total billed charges,Implant Device,144.9,35,,144.9,percent of total billed charges,Implant Device,144.9,35,,144.9,percent of total billed charges,Implant Device,144.9,35,,144.9,percent of total billed charges,Implant Device,144.9,35,,144.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,306.36,
J&J 02.127.150 LOCKING SCREW 3.5X50MM,C1713,HCPCS,,79012513,CDM,278,RC,,,both,,,414,306.36,,,306.36,Other,150% of Medicare + 9.63% HCRA Surcharge,186.3,45,,186.3,percent of total billed charges,Critical Access Hospital RCC factor,140.76,34,,140.76,percent of total billed charges,Implant Device,140.76,34,,140.76,percent of total billed charges,Implant Device,140.76,34,,140.76,percent of total billed charges,Implant Device,140.76,34,,140.76,percent of total billed charges,Implant Device,140.76,34,,140.76,percent of total billed charges,Implant Device,204.93,,,204.93,Other,110% of Medicare,144.9,35,,144.9,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,144.9,35,,144.9,percent of total billed charges,Implant Device,144.9,35,,144.9,percent of total billed charges,Implant Device,144.9,35,,144.9,percent of total billed charges,Implant Device,144.9,35,,144.9,percent of total billed charges,Implant Device,144.9,35,,144.9,percent of total billed charges,Implant Device,165.6,40,,165.6,percent of total billed charges,Implant Device,144.9,70,,144.9,percent of total billed charges,All Other,140.76,34,,140.76,percent of total billed charges,Implant Device,140.76,34,,140.76,percent of total billed charges,Implant Device,144.9,35,,144.9,percent of total billed charges,Implant Device,144.9,35,,144.9,percent of total billed charges,Implant Device,144.9,35,,144.9,percent of total billed charges,Implant Device,144.9,35,,144.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,306.36,
J&J 02.127.156 LOCKING SCREW 3.5X56MM,C1713,HCPCS,,79012514,CDM,278,RC,,,both,,,414,306.36,,,306.36,Other,150% of Medicare + 9.63% HCRA Surcharge,186.3,45,,186.3,percent of total billed charges,Critical Access Hospital RCC factor,140.76,34,,140.76,percent of total billed charges,Implant Device,140.76,34,,140.76,percent of total billed charges,Implant Device,140.76,34,,140.76,percent of total billed charges,Implant Device,140.76,34,,140.76,percent of total billed charges,Implant Device,140.76,34,,140.76,percent of total billed charges,Implant Device,204.93,,,204.93,Other,110% of Medicare,144.9,35,,144.9,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,144.9,35,,144.9,percent of total billed charges,Implant Device,144.9,35,,144.9,percent of total billed charges,Implant Device,144.9,35,,144.9,percent of total billed charges,Implant Device,144.9,35,,144.9,percent of total billed charges,Implant Device,144.9,35,,144.9,percent of total billed charges,Implant Device,165.6,40,,165.6,percent of total billed charges,Implant Device,144.9,70,,144.9,percent of total billed charges,All Other,140.76,34,,140.76,percent of total billed charges,Implant Device,140.76,34,,140.76,percent of total billed charges,Implant Device,144.9,35,,144.9,percent of total billed charges,Implant Device,144.9,35,,144.9,percent of total billed charges,Implant Device,144.9,35,,144.9,percent of total billed charges,Implant Device,144.9,35,,144.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,306.36,
J&J 02.221.101 TROCH RING PLT LT 3.5MM,C1713,HCPCS,,79012516,CDM,278,RC,,,both,,,5641,4174.35,,,4174.35,Other,150% of Medicare + 9.63% HCRA Surcharge,2538.45,45,,2538.45,percent of total billed charges,Critical Access Hospital RCC factor,1917.94,34,,1917.94,percent of total billed charges,Implant Device,1917.94,34,,1917.94,percent of total billed charges,Implant Device,1917.94,34,,1917.94,percent of total billed charges,Implant Device,1917.94,34,,1917.94,percent of total billed charges,Implant Device,1917.94,34,,1917.94,percent of total billed charges,Implant Device,2792.3,,,2792.3,Other,110% of Medicare,1974.35,35,,1974.35,percent of total billed charges,Implant Device,1917.94,34,"Charges > $500, x 34%",1917.94,percent of total billed charges,Implant Device,1974.35,35,,1974.35,percent of total billed charges,Implant Device,1974.35,35,,1974.35,percent of total billed charges,Implant Device,1974.35,35,,1974.35,percent of total billed charges,Implant Device,1974.35,35,,1974.35,percent of total billed charges,Implant Device,1974.35,35,,1974.35,percent of total billed charges,Implant Device,2256.4,40,,2256.4,percent of total billed charges,Implant Device,1974.35,70,,1974.35,percent of total billed charges,All Other,1917.94,34,,1917.94,percent of total billed charges,Implant Device,1917.94,34,,1917.94,percent of total billed charges,Implant Device,1974.35,35,,1974.35,percent of total billed charges,Implant Device,1974.35,35,,1974.35,percent of total billed charges,Implant Device,1974.35,35,,1974.35,percent of total billed charges,Implant Device,1974.35,35,,1974.35,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1917.94,34,"If Charge > 2,000, then 34 percent",1917.94,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4174.35,
J&J 02.221.115 PROX FEMUR PLT 8H LT 3.5,C1713,HCPCS,,79012518,CDM,278,RC,,,both,,,9227,6828,,,6828,Other,150% of Medicare + 9.63% HCRA Surcharge,4152.15,45,,4152.15,percent of total billed charges,Critical Access Hospital RCC factor,3137.18,34,,3137.18,percent of total billed charges,Implant Device,3137.18,34,,3137.18,percent of total billed charges,Implant Device,3137.18,34,,3137.18,percent of total billed charges,Implant Device,3137.18,34,,3137.18,percent of total billed charges,Implant Device,3137.18,34,,3137.18,percent of total billed charges,Implant Device,4567.37,,,4567.37,Other,110% of Medicare,3229.45,35,,3229.45,percent of total billed charges,Implant Device,3137.18,34,"Charges > $500, x 34%",3137.18,percent of total billed charges,Implant Device,3229.45,35,,3229.45,percent of total billed charges,Implant Device,3229.45,35,,3229.45,percent of total billed charges,Implant Device,3229.45,35,,3229.45,percent of total billed charges,Implant Device,3229.45,35,,3229.45,percent of total billed charges,Implant Device,3229.45,35,,3229.45,percent of total billed charges,Implant Device,3690.8,40,,3690.8,percent of total billed charges,Implant Device,3229.45,70,,3229.45,percent of total billed charges,All Other,3137.18,34,,3137.18,percent of total billed charges,Implant Device,3137.18,34,,3137.18,percent of total billed charges,Implant Device,3229.45,35,,3229.45,percent of total billed charges,Implant Device,3229.45,35,,3229.45,percent of total billed charges,Implant Device,3229.45,35,,3229.45,percent of total billed charges,Implant Device,3229.45,35,,3229.45,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3137.18,34,"If Charge > 2,000, then 34 percent",3137.18,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,6828,
J&J 02.221.180S CONNECTING SCREW,C1713,HCPCS,,79012519,CDM,278,RC,,,both,,,714,528.36,,,528.36,Other,150% of Medicare + 9.63% HCRA Surcharge,321.3,45,,321.3,percent of total billed charges,Critical Access Hospital RCC factor,242.76,34,,242.76,percent of total billed charges,Implant Device,242.76,34,,242.76,percent of total billed charges,Implant Device,242.76,34,,242.76,percent of total billed charges,Implant Device,242.76,34,,242.76,percent of total billed charges,Implant Device,242.76,34,,242.76,percent of total billed charges,Implant Device,353.43,,,353.43,Other,110% of Medicare,249.9,35,,249.9,percent of total billed charges,Implant Device,242.76,34,"Charges > $500, x 34%",242.76,percent of total billed charges,Implant Device,249.9,35,,249.9,percent of total billed charges,Implant Device,249.9,35,,249.9,percent of total billed charges,Implant Device,249.9,35,,249.9,percent of total billed charges,Implant Device,249.9,35,,249.9,percent of total billed charges,Implant Device,249.9,35,,249.9,percent of total billed charges,Implant Device,285.6,40,,285.6,percent of total billed charges,Implant Device,249.9,70,,249.9,percent of total billed charges,All Other,242.76,34,,242.76,percent of total billed charges,Implant Device,242.76,34,,242.76,percent of total billed charges,Implant Device,249.9,35,,249.9,percent of total billed charges,Implant Device,249.9,35,,249.9,percent of total billed charges,Implant Device,249.9,35,,249.9,percent of total billed charges,Implant Device,249.9,35,,249.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,528.36,
EXACTECH SPC0123 TAPERED WEDGE 54 SHORT,C1776,HCPCS,,79012522,CDM,278,RC,,,both,,,10085,7462.93,,,7462.93,Other,150% of Medicare + 9.63% HCRA Surcharge,4538.25,45,,4538.25,percent of total billed charges,Critical Access Hospital RCC factor,3428.9,34,,3428.9,percent of total billed charges,Implant Device,3428.9,34,,3428.9,percent of total billed charges,Implant Device,3428.9,34,,3428.9,percent of total billed charges,Implant Device,3428.9,34,,3428.9,percent of total billed charges,Implant Device,3428.9,34,,3428.9,percent of total billed charges,Implant Device,4992.08,,,4992.08,Other,110% of Medicare,3529.75,35,,3529.75,percent of total billed charges,Implant Device,3428.9,34,"Charges > $500, x 34%",3428.9,percent of total billed charges,Implant Device,3529.75,35,,3529.75,percent of total billed charges,Implant Device,3529.75,35,,3529.75,percent of total billed charges,Implant Device,3529.75,35,,3529.75,percent of total billed charges,Implant Device,3529.75,35,,3529.75,percent of total billed charges,Implant Device,3529.75,35,,3529.75,percent of total billed charges,Implant Device,4034,40,,4034,percent of total billed charges,Implant Device,3529.75,70,,3529.75,percent of total billed charges,All Other,3428.9,34,,3428.9,percent of total billed charges,Implant Device,3428.9,34,,3428.9,percent of total billed charges,Implant Device,3529.75,35,,3529.75,percent of total billed charges,Implant Device,3529.75,35,,3529.75,percent of total billed charges,Implant Device,3529.75,35,,3529.75,percent of total billed charges,Implant Device,3529.75,35,,3529.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3428.9,34,"If Charge > 2,000, then 34 percent",3428.9,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,7462.93,
ZIMMER 42-5121-009-10 ARTIC SURF LT 10MM,C1776,HCPCS,,79012523,CDM,278,RC,,,both,,,4116,3045.85,,,3045.85,Other,150% of Medicare + 9.63% HCRA Surcharge,1852.2,45,,1852.2,percent of total billed charges,Critical Access Hospital RCC factor,1399.44,34,,1399.44,percent of total billed charges,Implant Device,1399.44,34,,1399.44,percent of total billed charges,Implant Device,1399.44,34,,1399.44,percent of total billed charges,Implant Device,1399.44,34,,1399.44,percent of total billed charges,Implant Device,1399.44,34,,1399.44,percent of total billed charges,Implant Device,2037.42,,,2037.42,Other,110% of Medicare,1440.6,35,,1440.6,percent of total billed charges,Implant Device,1399.44,34,"Charges > $500, x 34%",1399.44,percent of total billed charges,Implant Device,1440.6,35,,1440.6,percent of total billed charges,Implant Device,1440.6,35,,1440.6,percent of total billed charges,Implant Device,1440.6,35,,1440.6,percent of total billed charges,Implant Device,1440.6,35,,1440.6,percent of total billed charges,Implant Device,1440.6,35,,1440.6,percent of total billed charges,Implant Device,1646.4,40,,1646.4,percent of total billed charges,Implant Device,1440.6,70,,1440.6,percent of total billed charges,All Other,1399.44,34,,1399.44,percent of total billed charges,Implant Device,1399.44,34,,1399.44,percent of total billed charges,Implant Device,1440.6,35,,1440.6,percent of total billed charges,Implant Device,1440.6,35,,1440.6,percent of total billed charges,Implant Device,1440.6,35,,1440.6,percent of total billed charges,Implant Device,1440.6,35,,1440.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1399.44,34,"If Charge > 2,000, then 34 percent",1399.44,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3045.85,
ZIMMER 574101075 FEMORAL STEM SIZE 7.5,C1776,HCPCS,,79012524,CDM,278,RC,,,both,,,6912,5114.9,,,5114.9,Other,150% of Medicare + 9.63% HCRA Surcharge,3110.4,45,,3110.4,percent of total billed charges,Critical Access Hospital RCC factor,2350.08,34,,2350.08,percent of total billed charges,Implant Device,2350.08,34,,2350.08,percent of total billed charges,Implant Device,2350.08,34,,2350.08,percent of total billed charges,Implant Device,2350.08,34,,2350.08,percent of total billed charges,Implant Device,2350.08,34,,2350.08,percent of total billed charges,Implant Device,3421.44,,,3421.44,Other,110% of Medicare,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2350.08,34,"Charges > $500, x 34%",2350.08,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2764.8,40,,2764.8,percent of total billed charges,Implant Device,2419.2,70,,2419.2,percent of total billed charges,All Other,2350.08,34,,2350.08,percent of total billed charges,Implant Device,2350.08,34,,2350.08,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2350.08,34,"If Charge > 2,000, then 34 percent",2350.08,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5114.9,
ZIMMER 8145-10-080 LAG SCREW 1.5X80MM,C1713,HCPCS,,79012525,CDM,278,RC,,,both,,,2052,1518.49,,,1518.49,Other,150% of Medicare + 9.63% HCRA Surcharge,923.4,45,,923.4,percent of total billed charges,Critical Access Hospital RCC factor,697.68,34,,697.68,percent of total billed charges,Implant Device,697.68,34,,697.68,percent of total billed charges,Implant Device,697.68,34,,697.68,percent of total billed charges,Implant Device,697.68,34,,697.68,percent of total billed charges,Implant Device,697.68,34,,697.68,percent of total billed charges,Implant Device,1015.74,,,1015.74,Other,110% of Medicare,718.2,35,,718.2,percent of total billed charges,Implant Device,697.68,34,"Charges > $500, x 34%",697.68,percent of total billed charges,Implant Device,718.2,35,,718.2,percent of total billed charges,Implant Device,718.2,35,,718.2,percent of total billed charges,Implant Device,718.2,35,,718.2,percent of total billed charges,Implant Device,718.2,35,,718.2,percent of total billed charges,Implant Device,718.2,35,,718.2,percent of total billed charges,Implant Device,820.8,40,,820.8,percent of total billed charges,Implant Device,718.2,70,,718.2,percent of total billed charges,All Other,697.68,34,,697.68,percent of total billed charges,Implant Device,697.68,34,,697.68,percent of total billed charges,Implant Device,718.2,35,,718.2,percent of total billed charges,Implant Device,718.2,35,,718.2,percent of total billed charges,Implant Device,718.2,35,,718.2,percent of total billed charges,Implant Device,718.2,35,,718.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,697.68,34,"If Charge > 2,000, then 34 percent",697.68,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1518.49,
ZIMMER 8145-01-070 HIP FRAC NAIL 11X180,C1713,HCPCS,,79012526,CDM,278,RC,,,both,,,846,626.04,,,626.04,Other,150% of Medicare + 9.63% HCRA Surcharge,380.7,45,,380.7,percent of total billed charges,Critical Access Hospital RCC factor,287.64,34,,287.64,percent of total billed charges,Implant Device,287.64,34,,287.64,percent of total billed charges,Implant Device,287.64,34,,287.64,percent of total billed charges,Implant Device,287.64,34,,287.64,percent of total billed charges,Implant Device,287.64,34,,287.64,percent of total billed charges,Implant Device,418.77,,,418.77,Other,110% of Medicare,296.1,35,,296.1,percent of total billed charges,Implant Device,287.64,34,"Charges > $500, x 34%",287.64,percent of total billed charges,Implant Device,296.1,35,,296.1,percent of total billed charges,Implant Device,296.1,35,,296.1,percent of total billed charges,Implant Device,296.1,35,,296.1,percent of total billed charges,Implant Device,296.1,35,,296.1,percent of total billed charges,Implant Device,296.1,35,,296.1,percent of total billed charges,Implant Device,338.4,40,,338.4,percent of total billed charges,Implant Device,296.1,70,,296.1,percent of total billed charges,All Other,287.64,34,,287.64,percent of total billed charges,Implant Device,287.64,34,,287.64,percent of total billed charges,Implant Device,296.1,35,,296.1,percent of total billed charges,Implant Device,296.1,35,,296.1,percent of total billed charges,Implant Device,296.1,35,,296.1,percent of total billed charges,Implant Device,296.1,35,,296.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,626.04,
ZIMMER 42-5221-007-10 ART SURFACE RT 10,C1776,HCPCS,,79012530,CDM,278,RC,,,both,,,3648,2699.53,,,2699.53,Other,150% of Medicare + 9.63% HCRA Surcharge,1641.6,45,,1641.6,percent of total billed charges,Critical Access Hospital RCC factor,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1805.76,,,1805.76,Other,110% of Medicare,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1240.32,34,"Charges > $500, x 34%",1240.32,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1459.2,40,,1459.2,percent of total billed charges,Implant Device,1276.8,70,,1276.8,percent of total billed charges,All Other,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1240.32,34,"If Charge > 2,000, then 34 percent",1240.32,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2699.53,
J&J 1504-11-107 FEMORAL COMP SZ 7 LT,C1776,HCPCS,,79012531,CDM,278,RC,,,both,,,6000,4440.02,,,4440.02,Other,150% of Medicare + 9.63% HCRA Surcharge,2700,45,,2700,percent of total billed charges,Critical Access Hospital RCC factor,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2970,,,2970,Other,110% of Medicare,2100,35,,2100,percent of total billed charges,Implant Device,2040,34,"Charges > $500, x 34%",2040,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2400,40,,2400,percent of total billed charges,Implant Device,2100,70,,2100,percent of total billed charges,All Other,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2040,34,"If Charge > 2,000, then 34 percent",2040,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4440.02,
J&J 1506-60-007 TIBIAL BASE SIZE 7,C1776,HCPCS,,79012535,CDM,278,RC,,,both,,,12965,9594.13,,,9594.13,Other,150% of Medicare + 9.63% HCRA Surcharge,5834.25,45,,5834.25,percent of total billed charges,Critical Access Hospital RCC factor,4408.1,34,,4408.1,percent of total billed charges,Implant Device,4408.1,34,,4408.1,percent of total billed charges,Implant Device,4408.1,34,,4408.1,percent of total billed charges,Implant Device,4408.1,34,,4408.1,percent of total billed charges,Implant Device,4408.1,34,,4408.1,percent of total billed charges,Implant Device,6417.68,,,6417.68,Other,110% of Medicare,4537.75,35,,4537.75,percent of total billed charges,Implant Device,4408.1,34,"Charges > $500, x 34%",4408.1,percent of total billed charges,Implant Device,4537.75,35,,4537.75,percent of total billed charges,Implant Device,4537.75,35,,4537.75,percent of total billed charges,Implant Device,4537.75,35,,4537.75,percent of total billed charges,Implant Device,4537.75,35,,4537.75,percent of total billed charges,Implant Device,4537.75,35,,4537.75,percent of total billed charges,Implant Device,5186,40,,5186,percent of total billed charges,Implant Device,4537.75,70,,4537.75,percent of total billed charges,All Other,4408.1,34,,4408.1,percent of total billed charges,Implant Device,4408.1,34,,4408.1,percent of total billed charges,Implant Device,4537.75,35,,4537.75,percent of total billed charges,Implant Device,4537.75,35,,4537.75,percent of total billed charges,Implant Device,4537.75,35,,4537.75,percent of total billed charges,Implant Device,4537.75,35,,4537.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,4408.1,34,"If Charge > 2,000, then 34 percent",4408.1,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,9594.13,
DJO 412-02-050 BIPOLAR MODULAR 50X28MM,C1776,HCPCS,,79012537,CDM,278,RC,,,both,,,1150,851,,,851,Other,150% of Medicare + 9.63% HCRA Surcharge,517.5,45,,517.5,percent of total billed charges,Critical Access Hospital RCC factor,391,34,,391,percent of total billed charges,Implant Device,391,34,,391,percent of total billed charges,Implant Device,391,34,,391,percent of total billed charges,Implant Device,391,34,,391,percent of total billed charges,Implant Device,391,34,,391,percent of total billed charges,Implant Device,569.25,,,569.25,Other,110% of Medicare,402.5,35,,402.5,percent of total billed charges,Implant Device,391,34,"Charges > $500, x 34%",391,percent of total billed charges,Implant Device,402.5,35,,402.5,percent of total billed charges,Implant Device,402.5,35,,402.5,percent of total billed charges,Implant Device,402.5,35,,402.5,percent of total billed charges,Implant Device,402.5,35,,402.5,percent of total billed charges,Implant Device,402.5,35,,402.5,percent of total billed charges,Implant Device,460,40,,460,percent of total billed charges,Implant Device,402.5,70,,402.5,percent of total billed charges,All Other,391,34,,391,percent of total billed charges,Implant Device,391,34,,391,percent of total billed charges,Implant Device,402.5,35,,402.5,percent of total billed charges,Implant Device,402.5,35,,402.5,percent of total billed charges,Implant Device,402.5,35,,402.5,percent of total billed charges,Implant Device,402.5,35,,402.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,851,
J&J 1504-11-126 FEMORAL COMP SIZE 6,C1776,HCPCS,,79012541,CDM,278,RC,,,both,,,6000,4440.02,,,4440.02,Other,150% of Medicare + 9.63% HCRA Surcharge,2700,45,,2700,percent of total billed charges,Critical Access Hospital RCC factor,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2970,,,2970,Other,110% of Medicare,2100,35,,2100,percent of total billed charges,Implant Device,2040,34,"Charges > $500, x 34%",2040,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2400,40,,2400,percent of total billed charges,Implant Device,2100,70,,2100,percent of total billed charges,All Other,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2040,34,"If Charge > 2,000, then 34 percent",2040,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4440.02,
J&J 1518-20-032 PATELLA 32MM,C1776,HCPCS,,79012542,CDM,278,RC,,,both,,,2100,1554.01,,,1554.01,Other,150% of Medicare + 9.63% HCRA Surcharge,945,45,,945,percent of total billed charges,Critical Access Hospital RCC factor,714,34,,714,percent of total billed charges,Implant Device,714,34,,714,percent of total billed charges,Implant Device,714,34,,714,percent of total billed charges,Implant Device,714,34,,714,percent of total billed charges,Implant Device,714,34,,714,percent of total billed charges,Implant Device,1039.5,,,1039.5,Other,110% of Medicare,735,35,,735,percent of total billed charges,Implant Device,714,34,"Charges > $500, x 34%",714,percent of total billed charges,Implant Device,735,35,,735,percent of total billed charges,Implant Device,735,35,,735,percent of total billed charges,Implant Device,735,35,,735,percent of total billed charges,Implant Device,735,35,,735,percent of total billed charges,Implant Device,735,35,,735,percent of total billed charges,Implant Device,840,40,,840,percent of total billed charges,Implant Device,735,70,,735,percent of total billed charges,All Other,714,34,,714,percent of total billed charges,Implant Device,714,34,,714,percent of total billed charges,Implant Device,735,35,,735,percent of total billed charges,Implant Device,735,35,,735,percent of total billed charges,Implant Device,735,35,,735,percent of total billed charges,Implant Device,735,35,,735,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,714,34,"If Charge > 2,000, then 34 percent",714,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1554.01,
ALLERGAN 1518320P ALLODERM MED 16X20CM,Q4116,HCPCS,,79012543,CDM,278,RC,,,both,,,22813,16881.68,,,16881.68,Other,150% of Medicare + 9.63% HCRA Surcharge,10265.85,45,,10265.85,percent of total billed charges,Critical Access Hospital RCC factor,7756.42,34,,7756.42,percent of total billed charges,Implant Device,7756.42,34,,7756.42,percent of total billed charges,Implant Device,7756.42,34,,7756.42,percent of total billed charges,Implant Device,7756.42,34,,7756.42,percent of total billed charges,Implant Device,7756.42,34,,7756.42,percent of total billed charges,Implant Device,11292.44,,,11292.44,Other,110% of Medicare,7984.55,35,,7984.55,percent of total billed charges,Implant Device,7756.42,34,"Charges > $500, x 34%",7756.42,percent of total billed charges,Implant Device,7984.55,35,,7984.55,percent of total billed charges,Implant Device,7984.55,35,,7984.55,percent of total billed charges,Implant Device,7984.55,35,,7984.55,percent of total billed charges,Implant Device,7984.55,35,,7984.55,percent of total billed charges,Implant Device,7984.55,35,,7984.55,percent of total billed charges,Implant Device,9125.2,40,,9125.2,percent of total billed charges,Implant Device,7984.55,70,,7984.55,percent of total billed charges,All Other,7756.42,34,,7756.42,percent of total billed charges,Implant Device,7756.42,34,,7756.42,percent of total billed charges,Implant Device,7984.55,35,,7984.55,percent of total billed charges,Implant Device,7984.55,35,,7984.55,percent of total billed charges,Implant Device,7984.55,35,,7984.55,percent of total billed charges,Implant Device,7984.55,35,,7984.55,percent of total billed charges,Implant Device,976.07,,,976.07,Other,100% of Medicaid,976.07,,,976.07,Other,100% of Medicaid,976.07,,,976.07,Other,100% of Medicaid,976.07,,,976.07,Other,100% of Medicaid,2196.15,,,2196.15,Other,225% of Medicaid,1493.38,,,1493.38,Other,153% of Medicaid,2196.15,,,2196.15,Other,225% of Medicaid,1366.49,,,1366.49,Other,140% of Medicaid,7756.42,34,"If Charge > 2,000, then 34 percent",7756.42,percent of total billed charges,Implants,2537.77,,,2537.77,Other,260% of Medicaid,3162.45,,,3162.45,Other,324% of Medicaid,2098.54,,,2098.54,Other,215% of Medicaid,2098.54,,,2098.54,Other,215% of Medicaid,1220.08,,,1220.08,Other,125% of Medicaid,976.07,16881.68,
J&J 202.826 CORTEX SCREW 2.7X26MM,C1713,HCPCS,,79012544,CDM,278,RC,,,both,,,85,62.9,,,62.9,Other,150% of Medicare + 9.63% HCRA Surcharge,38.25,45,,38.25,percent of total billed charges,Critical Access Hospital RCC factor,28.9,34,,28.9,percent of total billed charges,Implant Device,28.9,34,,28.9,percent of total billed charges,Implant Device,28.9,34,,28.9,percent of total billed charges,Implant Device,28.9,34,,28.9,percent of total billed charges,Implant Device,28.9,34,,28.9,percent of total billed charges,Implant Device,42.08,,,42.08,Other,110% of Medicare,29.75,35,,29.75,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,29.75,35,,29.75,percent of total billed charges,Implant Device,29.75,35,,29.75,percent of total billed charges,Implant Device,29.75,35,,29.75,percent of total billed charges,Implant Device,29.75,35,,29.75,percent of total billed charges,Implant Device,29.75,35,,29.75,percent of total billed charges,Implant Device,34,40,,34,percent of total billed charges,Implant Device,29.75,70,,29.75,percent of total billed charges,All Other,28.9,34,,28.9,percent of total billed charges,Implant Device,28.9,34,,28.9,percent of total billed charges,Implant Device,29.75,35,,29.75,percent of total billed charges,Implant Device,29.75,35,,29.75,percent of total billed charges,Implant Device,29.75,35,,29.75,percent of total billed charges,Implant Device,29.75,35,,29.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,62.9,
J&J 202.822 CORTEX SCREW 2.7X22MM,C1713,HCPCS,,79012545,CDM,278,RC,,,both,,,85,62.9,,,62.9,Other,150% of Medicare + 9.63% HCRA Surcharge,38.25,45,,38.25,percent of total billed charges,Critical Access Hospital RCC factor,28.9,34,,28.9,percent of total billed charges,Implant Device,28.9,34,,28.9,percent of total billed charges,Implant Device,28.9,34,,28.9,percent of total billed charges,Implant Device,28.9,34,,28.9,percent of total billed charges,Implant Device,28.9,34,,28.9,percent of total billed charges,Implant Device,42.08,,,42.08,Other,110% of Medicare,29.75,35,,29.75,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,29.75,35,,29.75,percent of total billed charges,Implant Device,29.75,35,,29.75,percent of total billed charges,Implant Device,29.75,35,,29.75,percent of total billed charges,Implant Device,29.75,35,,29.75,percent of total billed charges,Implant Device,29.75,35,,29.75,percent of total billed charges,Implant Device,34,40,,34,percent of total billed charges,Implant Device,29.75,70,,29.75,percent of total billed charges,All Other,28.9,34,,28.9,percent of total billed charges,Implant Device,28.9,34,,28.9,percent of total billed charges,Implant Device,29.75,35,,29.75,percent of total billed charges,Implant Device,29.75,35,,29.75,percent of total billed charges,Implant Device,29.75,35,,29.75,percent of total billed charges,Implant Device,29.75,35,,29.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,62.9,
J&J 02.123.027 PROX HUMERUS PLT 3.5MM,C1713,HCPCS,,79012546,CDM,278,RC,,,both,,,4431,3278.95,,,3278.95,Other,150% of Medicare + 9.63% HCRA Surcharge,1993.95,45,,1993.95,percent of total billed charges,Critical Access Hospital RCC factor,1506.54,34,,1506.54,percent of total billed charges,Implant Device,1506.54,34,,1506.54,percent of total billed charges,Implant Device,1506.54,34,,1506.54,percent of total billed charges,Implant Device,1506.54,34,,1506.54,percent of total billed charges,Implant Device,1506.54,34,,1506.54,percent of total billed charges,Implant Device,2193.35,,,2193.35,Other,110% of Medicare,1550.85,35,,1550.85,percent of total billed charges,Implant Device,1506.54,34,"Charges > $500, x 34%",1506.54,percent of total billed charges,Implant Device,1550.85,35,,1550.85,percent of total billed charges,Implant Device,1550.85,35,,1550.85,percent of total billed charges,Implant Device,1550.85,35,,1550.85,percent of total billed charges,Implant Device,1550.85,35,,1550.85,percent of total billed charges,Implant Device,1550.85,35,,1550.85,percent of total billed charges,Implant Device,1772.4,40,,1772.4,percent of total billed charges,Implant Device,1550.85,70,,1550.85,percent of total billed charges,All Other,1506.54,34,,1506.54,percent of total billed charges,Implant Device,1506.54,34,,1506.54,percent of total billed charges,Implant Device,1550.85,35,,1550.85,percent of total billed charges,Implant Device,1550.85,35,,1550.85,percent of total billed charges,Implant Device,1550.85,35,,1550.85,percent of total billed charges,Implant Device,1550.85,35,,1550.85,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1506.54,34,"If Charge > 2,000, then 34 percent",1506.54,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3278.95,
ZIMMER 183030 FEMORAL LEFT 67.5MM,C1776,HCPCS,,79012547,CDM,278,RC,,,both,,,6300,4662.02,,,4662.02,Other,150% of Medicare + 9.63% HCRA Surcharge,2835,45,,2835,percent of total billed charges,Critical Access Hospital RCC factor,2142,34,,2142,percent of total billed charges,Implant Device,2142,34,,2142,percent of total billed charges,Implant Device,2142,34,,2142,percent of total billed charges,Implant Device,2142,34,,2142,percent of total billed charges,Implant Device,2142,34,,2142,percent of total billed charges,Implant Device,3118.5,,,3118.5,Other,110% of Medicare,2205,35,,2205,percent of total billed charges,Implant Device,2142,34,"Charges > $500, x 34%",2142,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2520,40,,2520,percent of total billed charges,Implant Device,2205,70,,2205,percent of total billed charges,All Other,2142,34,,2142,percent of total billed charges,Implant Device,2142,34,,2142,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2142,34,"If Charge > 2,000, then 34 percent",2142,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4662.02,
J&J 02.124.414 CONDYLAR PLT 14H 4.5MM,C1713,HCPCS,,79012549,CDM,278,RC,,,both,,,4999,3699.27,,,3699.27,Other,150% of Medicare + 9.63% HCRA Surcharge,2249.55,45,,2249.55,percent of total billed charges,Critical Access Hospital RCC factor,1699.66,34,,1699.66,percent of total billed charges,Implant Device,1699.66,34,,1699.66,percent of total billed charges,Implant Device,1699.66,34,,1699.66,percent of total billed charges,Implant Device,1699.66,34,,1699.66,percent of total billed charges,Implant Device,1699.66,34,,1699.66,percent of total billed charges,Implant Device,2474.51,,,2474.51,Other,110% of Medicare,1749.65,35,,1749.65,percent of total billed charges,Implant Device,1699.66,34,"Charges > $500, x 34%",1699.66,percent of total billed charges,Implant Device,1749.65,35,,1749.65,percent of total billed charges,Implant Device,1749.65,35,,1749.65,percent of total billed charges,Implant Device,1749.65,35,,1749.65,percent of total billed charges,Implant Device,1749.65,35,,1749.65,percent of total billed charges,Implant Device,1749.65,35,,1749.65,percent of total billed charges,Implant Device,1999.6,40,,1999.6,percent of total billed charges,Implant Device,1749.65,70,,1749.65,percent of total billed charges,All Other,1699.66,34,,1699.66,percent of total billed charges,Implant Device,1699.66,34,,1699.66,percent of total billed charges,Implant Device,1749.65,35,,1749.65,percent of total billed charges,Implant Device,1749.65,35,,1749.65,percent of total billed charges,Implant Device,1749.65,35,,1749.65,percent of total billed charges,Implant Device,1749.65,35,,1749.65,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1699.66,34,"If Charge > 2,000, then 34 percent",1699.66,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3699.27,
J&J 78000110 FIBERGRAFT BG PUTTY 11CC,C1713,HCPCS,,79012550,CDM,278,RC,,,both,,,7032,5203.7,,,5203.7,Other,150% of Medicare + 9.63% HCRA Surcharge,3164.4,45,,3164.4,percent of total billed charges,Critical Access Hospital RCC factor,2390.88,34,,2390.88,percent of total billed charges,Implant Device,2390.88,34,,2390.88,percent of total billed charges,Implant Device,2390.88,34,,2390.88,percent of total billed charges,Implant Device,2390.88,34,,2390.88,percent of total billed charges,Implant Device,2390.88,34,,2390.88,percent of total billed charges,Implant Device,3480.84,,,3480.84,Other,110% of Medicare,2461.2,35,,2461.2,percent of total billed charges,Implant Device,2390.88,34,"Charges > $500, x 34%",2390.88,percent of total billed charges,Implant Device,2461.2,35,,2461.2,percent of total billed charges,Implant Device,2461.2,35,,2461.2,percent of total billed charges,Implant Device,2461.2,35,,2461.2,percent of total billed charges,Implant Device,2461.2,35,,2461.2,percent of total billed charges,Implant Device,2461.2,35,,2461.2,percent of total billed charges,Implant Device,2812.8,40,,2812.8,percent of total billed charges,Implant Device,2461.2,70,,2461.2,percent of total billed charges,All Other,2390.88,34,,2390.88,percent of total billed charges,Implant Device,2390.88,34,,2390.88,percent of total billed charges,Implant Device,2461.2,35,,2461.2,percent of total billed charges,Implant Device,2461.2,35,,2461.2,percent of total billed charges,Implant Device,2461.2,35,,2461.2,percent of total billed charges,Implant Device,2461.2,35,,2461.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2390.88,34,"If Charge > 2,000, then 34 percent",2390.88,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5203.7,
J&J 247.377 LCP PLATE 7 HOLE 2.4MM,C1713,HCPCS,,79012551,CDM,278,RC,,,both,,,1002,741.48,,,741.48,Other,150% of Medicare + 9.63% HCRA Surcharge,450.9,45,,450.9,percent of total billed charges,Critical Access Hospital RCC factor,340.68,34,,340.68,percent of total billed charges,Implant Device,340.68,34,,340.68,percent of total billed charges,Implant Device,340.68,34,,340.68,percent of total billed charges,Implant Device,340.68,34,,340.68,percent of total billed charges,Implant Device,340.68,34,,340.68,percent of total billed charges,Implant Device,495.99,,,495.99,Other,110% of Medicare,350.7,35,,350.7,percent of total billed charges,Implant Device,340.68,34,"Charges > $500, x 34%",340.68,percent of total billed charges,Implant Device,350.7,35,,350.7,percent of total billed charges,Implant Device,350.7,35,,350.7,percent of total billed charges,Implant Device,350.7,35,,350.7,percent of total billed charges,Implant Device,350.7,35,,350.7,percent of total billed charges,Implant Device,350.7,35,,350.7,percent of total billed charges,Implant Device,400.8,40,,400.8,percent of total billed charges,Implant Device,350.7,70,,350.7,percent of total billed charges,All Other,340.68,34,,340.68,percent of total billed charges,Implant Device,340.68,34,,340.68,percent of total billed charges,Implant Device,350.7,35,,350.7,percent of total billed charges,Implant Device,350.7,35,,350.7,percent of total billed charges,Implant Device,350.7,35,,350.7,percent of total billed charges,Implant Device,350.7,35,,350.7,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,741.48,
J&J 201.758 CORTEX SCREW 2.4X8MM,C1713,HCPCS,,79012552,CDM,278,RC,,,both,,,130,96.2,,,96.2,Other,150% of Medicare + 9.63% HCRA Surcharge,58.5,45,,58.5,percent of total billed charges,Critical Access Hospital RCC factor,44.2,34,,44.2,percent of total billed charges,Implant Device,44.2,34,,44.2,percent of total billed charges,Implant Device,44.2,34,,44.2,percent of total billed charges,Implant Device,44.2,34,,44.2,percent of total billed charges,Implant Device,44.2,34,,44.2,percent of total billed charges,Implant Device,64.35,,,64.35,Other,110% of Medicare,45.5,35,,45.5,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,45.5,35,,45.5,percent of total billed charges,Implant Device,45.5,35,,45.5,percent of total billed charges,Implant Device,45.5,35,,45.5,percent of total billed charges,Implant Device,45.5,35,,45.5,percent of total billed charges,Implant Device,45.5,35,,45.5,percent of total billed charges,Implant Device,52,40,,52,percent of total billed charges,Implant Device,45.5,70,,45.5,percent of total billed charges,All Other,44.2,34,,44.2,percent of total billed charges,Implant Device,44.2,34,,44.2,percent of total billed charges,Implant Device,45.5,35,,45.5,percent of total billed charges,Implant Device,45.5,35,,45.5,percent of total billed charges,Implant Device,45.5,35,,45.5,percent of total billed charges,Implant Device,45.5,35,,45.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,96.2,
J&J 201.780 CORTEX SCREW 2.4X30MM,C1713,HCPCS,,79012553,CDM,278,RC,,,both,,,130,96.2,,,96.2,Other,150% of Medicare + 9.63% HCRA Surcharge,58.5,45,,58.5,percent of total billed charges,Critical Access Hospital RCC factor,44.2,34,,44.2,percent of total billed charges,Implant Device,44.2,34,,44.2,percent of total billed charges,Implant Device,44.2,34,,44.2,percent of total billed charges,Implant Device,44.2,34,,44.2,percent of total billed charges,Implant Device,44.2,34,,44.2,percent of total billed charges,Implant Device,64.35,,,64.35,Other,110% of Medicare,45.5,35,,45.5,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,45.5,35,,45.5,percent of total billed charges,Implant Device,45.5,35,,45.5,percent of total billed charges,Implant Device,45.5,35,,45.5,percent of total billed charges,Implant Device,45.5,35,,45.5,percent of total billed charges,Implant Device,45.5,35,,45.5,percent of total billed charges,Implant Device,52,40,,52,percent of total billed charges,Implant Device,45.5,70,,45.5,percent of total billed charges,All Other,44.2,34,,44.2,percent of total billed charges,Implant Device,44.2,34,,44.2,percent of total billed charges,Implant Device,45.5,35,,45.5,percent of total billed charges,Implant Device,45.5,35,,45.5,percent of total billed charges,Implant Device,45.5,35,,45.5,percent of total billed charges,Implant Device,45.5,35,,45.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,96.2,
J&J 201.760 CORTEX SCREW 2.4X10MM,C1713,HCPCS,,79012554,CDM,278,RC,,,both,,,130,96.2,,,96.2,Other,150% of Medicare + 9.63% HCRA Surcharge,58.5,45,,58.5,percent of total billed charges,Critical Access Hospital RCC factor,44.2,34,,44.2,percent of total billed charges,Implant Device,44.2,34,,44.2,percent of total billed charges,Implant Device,44.2,34,,44.2,percent of total billed charges,Implant Device,44.2,34,,44.2,percent of total billed charges,Implant Device,44.2,34,,44.2,percent of total billed charges,Implant Device,64.35,,,64.35,Other,110% of Medicare,45.5,35,,45.5,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,45.5,35,,45.5,percent of total billed charges,Implant Device,45.5,35,,45.5,percent of total billed charges,Implant Device,45.5,35,,45.5,percent of total billed charges,Implant Device,45.5,35,,45.5,percent of total billed charges,Implant Device,45.5,35,,45.5,percent of total billed charges,Implant Device,52,40,,52,percent of total billed charges,Implant Device,45.5,70,,45.5,percent of total billed charges,All Other,44.2,34,,44.2,percent of total billed charges,Implant Device,44.2,34,,44.2,percent of total billed charges,Implant Device,45.5,35,,45.5,percent of total billed charges,Implant Device,45.5,35,,45.5,percent of total billed charges,Implant Device,45.5,35,,45.5,percent of total billed charges,Implant Device,45.5,35,,45.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,96.2,
J&J 04.005.566S LOCKING SCREW 5.0X76MM,C1713,HCPCS,,79012555,CDM,278,RC,,,both,,,412,304.88,,,304.88,Other,150% of Medicare + 9.63% HCRA Surcharge,185.4,45,,185.4,percent of total billed charges,Critical Access Hospital RCC factor,140.08,34,,140.08,percent of total billed charges,Implant Device,140.08,34,,140.08,percent of total billed charges,Implant Device,140.08,34,,140.08,percent of total billed charges,Implant Device,140.08,34,,140.08,percent of total billed charges,Implant Device,140.08,34,,140.08,percent of total billed charges,Implant Device,203.94,,,203.94,Other,110% of Medicare,144.2,35,,144.2,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,144.2,35,,144.2,percent of total billed charges,Implant Device,144.2,35,,144.2,percent of total billed charges,Implant Device,144.2,35,,144.2,percent of total billed charges,Implant Device,144.2,35,,144.2,percent of total billed charges,Implant Device,144.2,35,,144.2,percent of total billed charges,Implant Device,164.8,40,,164.8,percent of total billed charges,Implant Device,144.2,70,,144.2,percent of total billed charges,All Other,140.08,34,,140.08,percent of total billed charges,Implant Device,140.08,34,,140.08,percent of total billed charges,Implant Device,144.2,35,,144.2,percent of total billed charges,Implant Device,144.2,35,,144.2,percent of total billed charges,Implant Device,144.2,35,,144.2,percent of total billed charges,Implant Device,144.2,35,,144.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,304.88,
J&J 04.003.027S RECON SCREW 6.5X85MM,C1713,HCPCS,,79012556,CDM,278,RC,,,both,,,421,311.54,,,311.54,Other,150% of Medicare + 9.63% HCRA Surcharge,189.45,45,,189.45,percent of total billed charges,Critical Access Hospital RCC factor,143.14,34,,143.14,percent of total billed charges,Implant Device,143.14,34,,143.14,percent of total billed charges,Implant Device,143.14,34,,143.14,percent of total billed charges,Implant Device,143.14,34,,143.14,percent of total billed charges,Implant Device,143.14,34,,143.14,percent of total billed charges,Implant Device,208.4,,,208.4,Other,110% of Medicare,147.35,35,,147.35,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,147.35,35,,147.35,percent of total billed charges,Implant Device,147.35,35,,147.35,percent of total billed charges,Implant Device,147.35,35,,147.35,percent of total billed charges,Implant Device,147.35,35,,147.35,percent of total billed charges,Implant Device,147.35,35,,147.35,percent of total billed charges,Implant Device,168.4,40,,168.4,percent of total billed charges,Implant Device,147.35,70,,147.35,percent of total billed charges,All Other,143.14,34,,143.14,percent of total billed charges,Implant Device,143.14,34,,143.14,percent of total billed charges,Implant Device,147.35,35,,147.35,percent of total billed charges,Implant Device,147.35,35,,147.35,percent of total billed charges,Implant Device,147.35,35,,147.35,percent of total billed charges,Implant Device,147.35,35,,147.35,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,311.54,
J&J 04.003.026S RECON SCREW 6.5X80MM,C1713,HCPCS,,79012557,CDM,278,RC,,,both,,,421,311.54,,,311.54,Other,150% of Medicare + 9.63% HCRA Surcharge,189.45,45,,189.45,percent of total billed charges,Critical Access Hospital RCC factor,143.14,34,,143.14,percent of total billed charges,Implant Device,143.14,34,,143.14,percent of total billed charges,Implant Device,143.14,34,,143.14,percent of total billed charges,Implant Device,143.14,34,,143.14,percent of total billed charges,Implant Device,143.14,34,,143.14,percent of total billed charges,Implant Device,208.4,,,208.4,Other,110% of Medicare,147.35,35,,147.35,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,147.35,35,,147.35,percent of total billed charges,Implant Device,147.35,35,,147.35,percent of total billed charges,Implant Device,147.35,35,,147.35,percent of total billed charges,Implant Device,147.35,35,,147.35,percent of total billed charges,Implant Device,147.35,35,,147.35,percent of total billed charges,Implant Device,168.4,40,,168.4,percent of total billed charges,Implant Device,147.35,70,,147.35,percent of total billed charges,All Other,143.14,34,,143.14,percent of total billed charges,Implant Device,143.14,34,,143.14,percent of total billed charges,Implant Device,147.35,35,,147.35,percent of total billed charges,Implant Device,147.35,35,,147.35,percent of total billed charges,Implant Device,147.35,35,,147.35,percent of total billed charges,Implant Device,147.35,35,,147.35,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,311.54,
J&J 78000060 FIBERGRAFT BG PUTTY 6CC,C1713,HCPCS,,79012558,CDM,278,RC,,,both,,,4050,2997.01,,,2997.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1822.5,45,,1822.5,percent of total billed charges,Critical Access Hospital RCC factor,1377,34,,1377,percent of total billed charges,Implant Device,1377,34,,1377,percent of total billed charges,Implant Device,1377,34,,1377,percent of total billed charges,Implant Device,1377,34,,1377,percent of total billed charges,Implant Device,1377,34,,1377,percent of total billed charges,Implant Device,2004.75,,,2004.75,Other,110% of Medicare,1417.5,35,,1417.5,percent of total billed charges,Implant Device,1377,34,"Charges > $500, x 34%",1377,percent of total billed charges,Implant Device,1417.5,35,,1417.5,percent of total billed charges,Implant Device,1417.5,35,,1417.5,percent of total billed charges,Implant Device,1417.5,35,,1417.5,percent of total billed charges,Implant Device,1417.5,35,,1417.5,percent of total billed charges,Implant Device,1417.5,35,,1417.5,percent of total billed charges,Implant Device,1620,40,,1620,percent of total billed charges,Implant Device,1417.5,70,,1417.5,percent of total billed charges,All Other,1377,34,,1377,percent of total billed charges,Implant Device,1377,34,,1377,percent of total billed charges,Implant Device,1417.5,35,,1417.5,percent of total billed charges,Implant Device,1417.5,35,,1417.5,percent of total billed charges,Implant Device,1417.5,35,,1417.5,percent of total billed charges,Implant Device,1417.5,35,,1417.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1377,34,"If Charge > 2,000, then 34 percent",1377,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2997.01,
J&J 7800040 FIBERGRAFT BG PUTTY 4CC,C1713,HCPCS,,79012560,CDM,278,RC,,,both,,,2850,2109.01,,,2109.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1282.5,45,,1282.5,percent of total billed charges,Critical Access Hospital RCC factor,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,1410.75,,,1410.75,Other,110% of Medicare,997.5,35,,997.5,percent of total billed charges,Implant Device,969,34,"Charges > $500, x 34%",969,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,1140,40,,1140,percent of total billed charges,Implant Device,997.5,70,,997.5,percent of total billed charges,All Other,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,969,34,"If Charge > 2,000, then 34 percent",969,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2109.01,
J&J 04.033.067S FEMORAL NAIL SYS 10X360,C1713,HCPCS,,79012561,CDM,278,RC,,,both,,,5337,3949.39,,,3949.39,Other,150% of Medicare + 9.63% HCRA Surcharge,2401.65,45,,2401.65,percent of total billed charges,Critical Access Hospital RCC factor,1814.58,34,,1814.58,percent of total billed charges,Implant Device,1814.58,34,,1814.58,percent of total billed charges,Implant Device,1814.58,34,,1814.58,percent of total billed charges,Implant Device,1814.58,34,,1814.58,percent of total billed charges,Implant Device,1814.58,34,,1814.58,percent of total billed charges,Implant Device,2641.82,,,2641.82,Other,110% of Medicare,1867.95,35,,1867.95,percent of total billed charges,Implant Device,1814.58,34,"Charges > $500, x 34%",1814.58,percent of total billed charges,Implant Device,1867.95,35,,1867.95,percent of total billed charges,Implant Device,1867.95,35,,1867.95,percent of total billed charges,Implant Device,1867.95,35,,1867.95,percent of total billed charges,Implant Device,1867.95,35,,1867.95,percent of total billed charges,Implant Device,1867.95,35,,1867.95,percent of total billed charges,Implant Device,2134.8,40,,2134.8,percent of total billed charges,Implant Device,1867.95,70,,1867.95,percent of total billed charges,All Other,1814.58,34,,1814.58,percent of total billed charges,Implant Device,1814.58,34,,1814.58,percent of total billed charges,Implant Device,1867.95,35,,1867.95,percent of total billed charges,Implant Device,1867.95,35,,1867.95,percent of total billed charges,Implant Device,1867.95,35,,1867.95,percent of total billed charges,Implant Device,1867.95,35,,1867.95,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1814.58,34,"If Charge > 2,000, then 34 percent",1814.58,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3949.39,
WRIGHT 58820006 FIXATION PIN 1.1MM,C1713,HCPCS,,79012562,CDM,278,RC,,,both,,,341,252.34,,,252.34,Other,150% of Medicare + 9.63% HCRA Surcharge,153.45,45,,153.45,percent of total billed charges,Critical Access Hospital RCC factor,115.94,34,,115.94,percent of total billed charges,Implant Device,115.94,34,,115.94,percent of total billed charges,Implant Device,115.94,34,,115.94,percent of total billed charges,Implant Device,115.94,34,,115.94,percent of total billed charges,Implant Device,115.94,34,,115.94,percent of total billed charges,Implant Device,168.8,,,168.8,Other,110% of Medicare,119.35,35,,119.35,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,119.35,35,,119.35,percent of total billed charges,Implant Device,119.35,35,,119.35,percent of total billed charges,Implant Device,119.35,35,,119.35,percent of total billed charges,Implant Device,119.35,35,,119.35,percent of total billed charges,Implant Device,119.35,35,,119.35,percent of total billed charges,Implant Device,136.4,40,,136.4,percent of total billed charges,Implant Device,119.35,70,,119.35,percent of total billed charges,All Other,115.94,34,,115.94,percent of total billed charges,Implant Device,115.94,34,,115.94,percent of total billed charges,Implant Device,119.35,35,,119.35,percent of total billed charges,Implant Device,119.35,35,,119.35,percent of total billed charges,Implant Device,119.35,35,,119.35,percent of total billed charges,Implant Device,119.35,35,,119.35,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,252.34,
GORE BXA072901A VIABAHN 7X29X80CM STENT,C1874,HCPCS,,79012565,CDM,278,RC,,,both,,,11151,8251.77,,,8251.77,Other,150% of Medicare + 9.63% HCRA Surcharge,5017.95,45,,5017.95,percent of total billed charges,Critical Access Hospital RCC factor,3791.34,34,,3791.34,percent of total billed charges,Implant Device,3791.34,34,,3791.34,percent of total billed charges,Implant Device,3791.34,34,,3791.34,percent of total billed charges,Implant Device,3791.34,34,,3791.34,percent of total billed charges,Implant Device,3791.34,34,,3791.34,percent of total billed charges,Implant Device,5519.75,,,5519.75,Other,110% of Medicare,3902.85,35,,3902.85,percent of total billed charges,Implant Device,3791.34,34,"Charges > $500, x 34%",3791.34,percent of total billed charges,Implant Device,3902.85,35,,3902.85,percent of total billed charges,Implant Device,3902.85,35,,3902.85,percent of total billed charges,Implant Device,3902.85,35,,3902.85,percent of total billed charges,Implant Device,3902.85,35,,3902.85,percent of total billed charges,Implant Device,3902.85,35,,3902.85,percent of total billed charges,Implant Device,4460.4,40,,4460.4,percent of total billed charges,Implant Device,3902.85,70,,3902.85,percent of total billed charges,All Other,3791.34,34,,3791.34,percent of total billed charges,Implant Device,3791.34,34,,3791.34,percent of total billed charges,Implant Device,3902.85,35,,3902.85,percent of total billed charges,Implant Device,3902.85,35,,3902.85,percent of total billed charges,Implant Device,3902.85,35,,3902.85,percent of total billed charges,Implant Device,3902.85,35,,3902.85,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3791.34,34,"If Charge > 2,000, then 34 percent",3791.34,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,8251.77,
GORE BXA075901A VIABAHN 7X59X80CM STENT,C1874,HCPCS,,79012566,CDM,278,RC,,,both,,,11151,8251.77,,,8251.77,Other,150% of Medicare + 9.63% HCRA Surcharge,5017.95,45,,5017.95,percent of total billed charges,Critical Access Hospital RCC factor,3791.34,34,,3791.34,percent of total billed charges,Implant Device,3791.34,34,,3791.34,percent of total billed charges,Implant Device,3791.34,34,,3791.34,percent of total billed charges,Implant Device,3791.34,34,,3791.34,percent of total billed charges,Implant Device,3791.34,34,,3791.34,percent of total billed charges,Implant Device,5519.75,,,5519.75,Other,110% of Medicare,3902.85,35,,3902.85,percent of total billed charges,Implant Device,3791.34,34,"Charges > $500, x 34%",3791.34,percent of total billed charges,Implant Device,3902.85,35,,3902.85,percent of total billed charges,Implant Device,3902.85,35,,3902.85,percent of total billed charges,Implant Device,3902.85,35,,3902.85,percent of total billed charges,Implant Device,3902.85,35,,3902.85,percent of total billed charges,Implant Device,3902.85,35,,3902.85,percent of total billed charges,Implant Device,4460.4,40,,4460.4,percent of total billed charges,Implant Device,3902.85,70,,3902.85,percent of total billed charges,All Other,3791.34,34,,3791.34,percent of total billed charges,Implant Device,3791.34,34,,3791.34,percent of total billed charges,Implant Device,3902.85,35,,3902.85,percent of total billed charges,Implant Device,3902.85,35,,3902.85,percent of total billed charges,Implant Device,3902.85,35,,3902.85,percent of total billed charges,Implant Device,3902.85,35,,3902.85,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3791.34,34,"If Charge > 2,000, then 34 percent",3791.34,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,8251.77,
DJO 412-02-045 BIPOLAR MODULAR 45X28MM,C1776,HCPCS,,79012568,CDM,278,RC,,,both,,,1380,1021.2,,,1021.2,Other,150% of Medicare + 9.63% HCRA Surcharge,621,45,,621,percent of total billed charges,Critical Access Hospital RCC factor,469.2,34,,469.2,percent of total billed charges,Implant Device,469.2,34,,469.2,percent of total billed charges,Implant Device,469.2,34,,469.2,percent of total billed charges,Implant Device,469.2,34,,469.2,percent of total billed charges,Implant Device,469.2,34,,469.2,percent of total billed charges,Implant Device,683.1,,,683.1,Other,110% of Medicare,483,35,,483,percent of total billed charges,Implant Device,469.2,34,"Charges > $500, x 34%",469.2,percent of total billed charges,Implant Device,483,35,,483,percent of total billed charges,Implant Device,483,35,,483,percent of total billed charges,Implant Device,483,35,,483,percent of total billed charges,Implant Device,483,35,,483,percent of total billed charges,Implant Device,483,35,,483,percent of total billed charges,Implant Device,552,40,,552,percent of total billed charges,Implant Device,483,70,,483,percent of total billed charges,All Other,469.2,34,,469.2,percent of total billed charges,Implant Device,469.2,34,,469.2,percent of total billed charges,Implant Device,483,35,,483,percent of total billed charges,Implant Device,483,35,,483,percent of total billed charges,Implant Device,483,35,,483,percent of total billed charges,Implant Device,483,35,,483,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1021.2,
MEDTRONIC 97800 NEURO STIM IPG EXT KIT,C1778,HCPCS,,79012571,CDM,278,RC,,,both,,,30762,22763.96,,,22763.96,Other,150% of Medicare + 9.63% HCRA Surcharge,13842.9,45,,13842.9,percent of total billed charges,Critical Access Hospital RCC factor,10459.08,34,,10459.08,percent of total billed charges,Implant Device,10459.08,34,,10459.08,percent of total billed charges,Implant Device,10459.08,34,,10459.08,percent of total billed charges,Implant Device,10459.08,34,,10459.08,percent of total billed charges,Implant Device,10459.08,34,,10459.08,percent of total billed charges,Implant Device,15227.19,,,15227.19,Other,110% of Medicare,10766.7,35,,10766.7,percent of total billed charges,Implant Device,10459.08,34,"Charges > $500, x 34%",10459.08,percent of total billed charges,Implant Device,10766.7,35,,10766.7,percent of total billed charges,Implant Device,10766.7,35,,10766.7,percent of total billed charges,Implant Device,10766.7,35,,10766.7,percent of total billed charges,Implant Device,10766.7,35,,10766.7,percent of total billed charges,Implant Device,10766.7,35,,10766.7,percent of total billed charges,Implant Device,12304.8,40,,12304.8,percent of total billed charges,Implant Device,10766.7,70,,10766.7,percent of total billed charges,All Other,10459.08,34,,10459.08,percent of total billed charges,Implant Device,10459.08,34,,10459.08,percent of total billed charges,Implant Device,10766.7,35,,10766.7,percent of total billed charges,Implant Device,10766.7,35,,10766.7,percent of total billed charges,Implant Device,10766.7,35,,10766.7,percent of total billed charges,Implant Device,10766.7,35,,10766.7,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,10459.08,34,"If Charge > 2,000, then 34 percent",10459.08,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,22763.96,
MEDTRONIC TH90Q01 PATIENT PROGRAMMER,C1787,HCPCS,,79012572,CDM,278,RC,,,both,,,4722,3494.29,,,3494.29,Other,150% of Medicare + 9.63% HCRA Surcharge,2124.9,45,,2124.9,percent of total billed charges,Critical Access Hospital RCC factor,1605.48,34,,1605.48,percent of total billed charges,Implant Device,1605.48,34,,1605.48,percent of total billed charges,Implant Device,1605.48,34,,1605.48,percent of total billed charges,Implant Device,1605.48,34,,1605.48,percent of total billed charges,Implant Device,1605.48,34,,1605.48,percent of total billed charges,Implant Device,2337.39,,,2337.39,Other,110% of Medicare,1652.7,35,,1652.7,percent of total billed charges,Implant Device,1605.48,34,"Charges > $500, x 34%",1605.48,percent of total billed charges,Implant Device,1652.7,35,,1652.7,percent of total billed charges,Implant Device,1652.7,35,,1652.7,percent of total billed charges,Implant Device,1652.7,35,,1652.7,percent of total billed charges,Implant Device,1652.7,35,,1652.7,percent of total billed charges,Implant Device,1652.7,35,,1652.7,percent of total billed charges,Implant Device,1888.8,40,,1888.8,percent of total billed charges,Implant Device,1652.7,70,,1652.7,percent of total billed charges,All Other,1605.48,34,,1605.48,percent of total billed charges,Implant Device,1605.48,34,,1605.48,percent of total billed charges,Implant Device,1652.7,35,,1652.7,percent of total billed charges,Implant Device,1652.7,35,,1652.7,percent of total billed charges,Implant Device,1652.7,35,,1652.7,percent of total billed charges,Implant Device,1652.7,35,,1652.7,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1605.48,34,"If Charge > 2,000, then 34 percent",1605.48,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3494.29,
STRYKER 627214S PROX HUMERUS PLT LT 14H,C1713,HCPCS,,79012575,CDM,278,RC,,,both,,,8516,6301.86,,,6301.86,Other,150% of Medicare + 9.63% HCRA Surcharge,3832.2,45,,3832.2,percent of total billed charges,Critical Access Hospital RCC factor,2895.44,34,,2895.44,percent of total billed charges,Implant Device,2895.44,34,,2895.44,percent of total billed charges,Implant Device,2895.44,34,,2895.44,percent of total billed charges,Implant Device,2895.44,34,,2895.44,percent of total billed charges,Implant Device,2895.44,34,,2895.44,percent of total billed charges,Implant Device,4215.42,,,4215.42,Other,110% of Medicare,2980.6,35,,2980.6,percent of total billed charges,Implant Device,2895.44,34,"Charges > $500, x 34%",2895.44,percent of total billed charges,Implant Device,2980.6,35,,2980.6,percent of total billed charges,Implant Device,2980.6,35,,2980.6,percent of total billed charges,Implant Device,2980.6,35,,2980.6,percent of total billed charges,Implant Device,2980.6,35,,2980.6,percent of total billed charges,Implant Device,2980.6,35,,2980.6,percent of total billed charges,Implant Device,3406.4,40,,3406.4,percent of total billed charges,Implant Device,2980.6,70,,2980.6,percent of total billed charges,All Other,2895.44,34,,2895.44,percent of total billed charges,Implant Device,2895.44,34,,2895.44,percent of total billed charges,Implant Device,2980.6,35,,2980.6,percent of total billed charges,Implant Device,2980.6,35,,2980.6,percent of total billed charges,Implant Device,2980.6,35,,2980.6,percent of total billed charges,Implant Device,2980.6,35,,2980.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2895.44,34,"If Charge > 2,000, then 34 percent",2895.44,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,6301.86,
PARAGON P50-353-2722 LOCK SCREW 2.7X22MM,C1713,HCPCS,,79012576,CDM,278,RC,,,both,,,693,512.82,,,512.82,Other,150% of Medicare + 9.63% HCRA Surcharge,311.85,45,,311.85,percent of total billed charges,Critical Access Hospital RCC factor,235.62,34,,235.62,percent of total billed charges,Implant Device,235.62,34,,235.62,percent of total billed charges,Implant Device,235.62,34,,235.62,percent of total billed charges,Implant Device,235.62,34,,235.62,percent of total billed charges,Implant Device,235.62,34,,235.62,percent of total billed charges,Implant Device,343.04,,,343.04,Other,110% of Medicare,242.55,35,,242.55,percent of total billed charges,Implant Device,235.62,34,"Charges > $500, x 34%",235.62,percent of total billed charges,Implant Device,242.55,35,,242.55,percent of total billed charges,Implant Device,242.55,35,,242.55,percent of total billed charges,Implant Device,242.55,35,,242.55,percent of total billed charges,Implant Device,242.55,35,,242.55,percent of total billed charges,Implant Device,242.55,35,,242.55,percent of total billed charges,Implant Device,277.2,40,,277.2,percent of total billed charges,Implant Device,242.55,70,,242.55,percent of total billed charges,All Other,235.62,34,,235.62,percent of total billed charges,Implant Device,235.62,34,,235.62,percent of total billed charges,Implant Device,242.55,35,,242.55,percent of total billed charges,Implant Device,242.55,35,,242.55,percent of total billed charges,Implant Device,242.55,35,,242.55,percent of total billed charges,Implant Device,242.55,35,,242.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,512.82,
PARAGON P50-353-2720 LOCK SCREW 2.7X20MM,C1713,HCPCS,,79012577,CDM,278,RC,,,both,,,693,512.82,,,512.82,Other,150% of Medicare + 9.63% HCRA Surcharge,311.85,45,,311.85,percent of total billed charges,Critical Access Hospital RCC factor,235.62,34,,235.62,percent of total billed charges,Implant Device,235.62,34,,235.62,percent of total billed charges,Implant Device,235.62,34,,235.62,percent of total billed charges,Implant Device,235.62,34,,235.62,percent of total billed charges,Implant Device,235.62,34,,235.62,percent of total billed charges,Implant Device,343.04,,,343.04,Other,110% of Medicare,242.55,35,,242.55,percent of total billed charges,Implant Device,235.62,34,"Charges > $500, x 34%",235.62,percent of total billed charges,Implant Device,242.55,35,,242.55,percent of total billed charges,Implant Device,242.55,35,,242.55,percent of total billed charges,Implant Device,242.55,35,,242.55,percent of total billed charges,Implant Device,242.55,35,,242.55,percent of total billed charges,Implant Device,242.55,35,,242.55,percent of total billed charges,Implant Device,277.2,40,,277.2,percent of total billed charges,Implant Device,242.55,70,,242.55,percent of total billed charges,All Other,235.62,34,,235.62,percent of total billed charges,Implant Device,235.62,34,,235.62,percent of total billed charges,Implant Device,242.55,35,,242.55,percent of total billed charges,Implant Device,242.55,35,,242.55,percent of total billed charges,Implant Device,242.55,35,,242.55,percent of total billed charges,Implant Device,242.55,35,,242.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,512.82,
PARAGON P71-018-1818-S STAPLE 18X18X18MM,C1713,HCPCS,,79012578,CDM,278,RC,,,both,,,5450,4033.01,,,4033.01,Other,150% of Medicare + 9.63% HCRA Surcharge,2452.5,45,,2452.5,percent of total billed charges,Critical Access Hospital RCC factor,1853,34,,1853,percent of total billed charges,Implant Device,1853,34,,1853,percent of total billed charges,Implant Device,1853,34,,1853,percent of total billed charges,Implant Device,1853,34,,1853,percent of total billed charges,Implant Device,1853,34,,1853,percent of total billed charges,Implant Device,2697.75,,,2697.75,Other,110% of Medicare,1907.5,35,,1907.5,percent of total billed charges,Implant Device,1853,34,"Charges > $500, x 34%",1853,percent of total billed charges,Implant Device,1907.5,35,,1907.5,percent of total billed charges,Implant Device,1907.5,35,,1907.5,percent of total billed charges,Implant Device,1907.5,35,,1907.5,percent of total billed charges,Implant Device,1907.5,35,,1907.5,percent of total billed charges,Implant Device,1907.5,35,,1907.5,percent of total billed charges,Implant Device,2180,40,,2180,percent of total billed charges,Implant Device,1907.5,70,,1907.5,percent of total billed charges,All Other,1853,34,,1853,percent of total billed charges,Implant Device,1853,34,,1853,percent of total billed charges,Implant Device,1907.5,35,,1907.5,percent of total billed charges,Implant Device,1907.5,35,,1907.5,percent of total billed charges,Implant Device,1907.5,35,,1907.5,percent of total billed charges,Implant Device,1907.5,35,,1907.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1853,34,"If Charge > 2,000, then 34 percent",1853,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4033.01,
PARAGON P71-015-1515-S STAPLE 15X15X15MM,C1713,HCPCS,,79012579,CDM,278,RC,,,both,,,5450,4033.01,,,4033.01,Other,150% of Medicare + 9.63% HCRA Surcharge,2452.5,45,,2452.5,percent of total billed charges,Critical Access Hospital RCC factor,1853,34,,1853,percent of total billed charges,Implant Device,1853,34,,1853,percent of total billed charges,Implant Device,1853,34,,1853,percent of total billed charges,Implant Device,1853,34,,1853,percent of total billed charges,Implant Device,1853,34,,1853,percent of total billed charges,Implant Device,2697.75,,,2697.75,Other,110% of Medicare,1907.5,35,,1907.5,percent of total billed charges,Implant Device,1853,34,"Charges > $500, x 34%",1853,percent of total billed charges,Implant Device,1907.5,35,,1907.5,percent of total billed charges,Implant Device,1907.5,35,,1907.5,percent of total billed charges,Implant Device,1907.5,35,,1907.5,percent of total billed charges,Implant Device,1907.5,35,,1907.5,percent of total billed charges,Implant Device,1907.5,35,,1907.5,percent of total billed charges,Implant Device,2180,40,,2180,percent of total billed charges,Implant Device,1907.5,70,,1907.5,percent of total billed charges,All Other,1853,34,,1853,percent of total billed charges,Implant Device,1853,34,,1853,percent of total billed charges,Implant Device,1907.5,35,,1907.5,percent of total billed charges,Implant Device,1907.5,35,,1907.5,percent of total billed charges,Implant Device,1907.5,35,,1907.5,percent of total billed charges,Implant Device,1907.5,35,,1907.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1853,34,"If Charge > 2,000, then 34 percent",1853,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4033.01,
STRYKER 604740S CANNULATED SCREW 4X40MM,C1713,HCPCS,,79012580,CDM,278,RC,,,both,,,480,355.2,,,355.2,Other,150% of Medicare + 9.63% HCRA Surcharge,216,45,,216,percent of total billed charges,Critical Access Hospital RCC factor,163.2,34,,163.2,percent of total billed charges,Implant Device,163.2,34,,163.2,percent of total billed charges,Implant Device,163.2,34,,163.2,percent of total billed charges,Implant Device,163.2,34,,163.2,percent of total billed charges,Implant Device,163.2,34,,163.2,percent of total billed charges,Implant Device,237.6,,,237.6,Other,110% of Medicare,168,35,,168,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,192,40,,192,percent of total billed charges,Implant Device,168,70,,168,percent of total billed charges,All Other,163.2,34,,163.2,percent of total billed charges,Implant Device,163.2,34,,163.2,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,355.2,
STRYKER 604742S CANNULATED SCREW 4X42MM,C1713,HCPCS,,79012581,CDM,278,RC,,,both,,,480,355.2,,,355.2,Other,150% of Medicare + 9.63% HCRA Surcharge,216,45,,216,percent of total billed charges,Critical Access Hospital RCC factor,163.2,34,,163.2,percent of total billed charges,Implant Device,163.2,34,,163.2,percent of total billed charges,Implant Device,163.2,34,,163.2,percent of total billed charges,Implant Device,163.2,34,,163.2,percent of total billed charges,Implant Device,163.2,34,,163.2,percent of total billed charges,Implant Device,237.6,,,237.6,Other,110% of Medicare,168,35,,168,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,192,40,,192,percent of total billed charges,Implant Device,168,70,,168,percent of total billed charges,All Other,163.2,34,,163.2,percent of total billed charges,Implant Device,163.2,34,,163.2,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,355.2,
STRYKER 604744S CANNULATED SCREW 4X44MM,C1713,HCPCS,,79012582,CDM,278,RC,,,both,,,480,355.2,,,355.2,Other,150% of Medicare + 9.63% HCRA Surcharge,216,45,,216,percent of total billed charges,Critical Access Hospital RCC factor,163.2,34,,163.2,percent of total billed charges,Implant Device,163.2,34,,163.2,percent of total billed charges,Implant Device,163.2,34,,163.2,percent of total billed charges,Implant Device,163.2,34,,163.2,percent of total billed charges,Implant Device,163.2,34,,163.2,percent of total billed charges,Implant Device,237.6,,,237.6,Other,110% of Medicare,168,35,,168,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,192,40,,192,percent of total billed charges,Implant Device,168,70,,168,percent of total billed charges,All Other,163.2,34,,163.2,percent of total billed charges,Implant Device,163.2,34,,163.2,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,355.2,
STRYKER 604746S CANNULATED SCREW 4X46MM,C1713,HCPCS,,79012583,CDM,278,RC,,,both,,,487,360.38,,,360.38,Other,150% of Medicare + 9.63% HCRA Surcharge,219.15,45,,219.15,percent of total billed charges,Critical Access Hospital RCC factor,165.58,34,,165.58,percent of total billed charges,Implant Device,165.58,34,,165.58,percent of total billed charges,Implant Device,165.58,34,,165.58,percent of total billed charges,Implant Device,165.58,34,,165.58,percent of total billed charges,Implant Device,165.58,34,,165.58,percent of total billed charges,Implant Device,241.07,,,241.07,Other,110% of Medicare,170.45,35,,170.45,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,170.45,35,,170.45,percent of total billed charges,Implant Device,170.45,35,,170.45,percent of total billed charges,Implant Device,170.45,35,,170.45,percent of total billed charges,Implant Device,170.45,35,,170.45,percent of total billed charges,Implant Device,170.45,35,,170.45,percent of total billed charges,Implant Device,194.8,40,,194.8,percent of total billed charges,Implant Device,170.45,70,,170.45,percent of total billed charges,All Other,165.58,34,,165.58,percent of total billed charges,Implant Device,165.58,34,,165.58,percent of total billed charges,Implant Device,170.45,35,,170.45,percent of total billed charges,Implant Device,170.45,35,,170.45,percent of total billed charges,Implant Device,170.45,35,,170.45,percent of total billed charges,Implant Device,170.45,35,,170.45,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,360.38,
ZIMMER 8162-08-003 LOCK CALCANEUS PLT LT,C1713,HCPCS,,79012584,CDM,278,RC,,,both,,,2734,2023.17,,,2023.17,Other,150% of Medicare + 9.63% HCRA Surcharge,1230.3,45,,1230.3,percent of total billed charges,Critical Access Hospital RCC factor,929.56,34,,929.56,percent of total billed charges,Implant Device,929.56,34,,929.56,percent of total billed charges,Implant Device,929.56,34,,929.56,percent of total billed charges,Implant Device,929.56,34,,929.56,percent of total billed charges,Implant Device,929.56,34,,929.56,percent of total billed charges,Implant Device,1353.33,,,1353.33,Other,110% of Medicare,956.9,35,,956.9,percent of total billed charges,Implant Device,929.56,34,"Charges > $500, x 34%",929.56,percent of total billed charges,Implant Device,956.9,35,,956.9,percent of total billed charges,Implant Device,956.9,35,,956.9,percent of total billed charges,Implant Device,956.9,35,,956.9,percent of total billed charges,Implant Device,956.9,35,,956.9,percent of total billed charges,Implant Device,956.9,35,,956.9,percent of total billed charges,Implant Device,1093.6,40,,1093.6,percent of total billed charges,Implant Device,956.9,70,,956.9,percent of total billed charges,All Other,929.56,34,,929.56,percent of total billed charges,Implant Device,929.56,34,,929.56,percent of total billed charges,Implant Device,956.9,35,,956.9,percent of total billed charges,Implant Device,956.9,35,,956.9,percent of total billed charges,Implant Device,956.9,35,,956.9,percent of total billed charges,Implant Device,956.9,35,,956.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,929.56,34,"If Charge > 2,000, then 34 percent",929.56,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2023.17,
ZIMMER 1312-18-042 CORTICAL SCREW 3.5X42,C1713,HCPCS,,79012585,CDM,278,RC,,,both,,,216,159.84,,,159.84,Other,150% of Medicare + 9.63% HCRA Surcharge,97.2,45,,97.2,percent of total billed charges,Critical Access Hospital RCC factor,73.44,34,,73.44,percent of total billed charges,Implant Device,73.44,34,,73.44,percent of total billed charges,Implant Device,73.44,34,,73.44,percent of total billed charges,Implant Device,73.44,34,,73.44,percent of total billed charges,Implant Device,73.44,34,,73.44,percent of total billed charges,Implant Device,106.92,,,106.92,Other,110% of Medicare,75.6,35,,75.6,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,75.6,35,,75.6,percent of total billed charges,Implant Device,75.6,35,,75.6,percent of total billed charges,Implant Device,75.6,35,,75.6,percent of total billed charges,Implant Device,75.6,35,,75.6,percent of total billed charges,Implant Device,75.6,35,,75.6,percent of total billed charges,Implant Device,86.4,40,,86.4,percent of total billed charges,Implant Device,75.6,70,,75.6,percent of total billed charges,All Other,73.44,34,,73.44,percent of total billed charges,Implant Device,73.44,34,,73.44,percent of total billed charges,Implant Device,75.6,35,,75.6,percent of total billed charges,Implant Device,75.6,35,,75.6,percent of total billed charges,Implant Device,75.6,35,,75.6,percent of total billed charges,Implant Device,75.6,35,,75.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,159.84,
ZIMMER 8163-35-034 MULTIDIRECT SC 3.5X34,C1713,HCPCS,,79012586,CDM,278,RC,,,both,,,612,452.88,,,452.88,Other,150% of Medicare + 9.63% HCRA Surcharge,275.4,45,,275.4,percent of total billed charges,Critical Access Hospital RCC factor,208.08,34,,208.08,percent of total billed charges,Implant Device,208.08,34,,208.08,percent of total billed charges,Implant Device,208.08,34,,208.08,percent of total billed charges,Implant Device,208.08,34,,208.08,percent of total billed charges,Implant Device,208.08,34,,208.08,percent of total billed charges,Implant Device,302.94,,,302.94,Other,110% of Medicare,214.2,35,,214.2,percent of total billed charges,Implant Device,208.08,34,"Charges > $500, x 34%",208.08,percent of total billed charges,Implant Device,214.2,35,,214.2,percent of total billed charges,Implant Device,214.2,35,,214.2,percent of total billed charges,Implant Device,214.2,35,,214.2,percent of total billed charges,Implant Device,214.2,35,,214.2,percent of total billed charges,Implant Device,214.2,35,,214.2,percent of total billed charges,Implant Device,244.8,40,,244.8,percent of total billed charges,Implant Device,214.2,70,,214.2,percent of total billed charges,All Other,208.08,34,,208.08,percent of total billed charges,Implant Device,208.08,34,,208.08,percent of total billed charges,Implant Device,214.2,35,,214.2,percent of total billed charges,Implant Device,214.2,35,,214.2,percent of total billed charges,Implant Device,214.2,35,,214.2,percent of total billed charges,Implant Device,214.2,35,,214.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,452.88,
ZIMMER 8163-35-042 MULTIDIRECT SC 3.5X42,C1713,HCPCS,,79012587,CDM,278,RC,,,both,,,612,452.88,,,452.88,Other,150% of Medicare + 9.63% HCRA Surcharge,275.4,45,,275.4,percent of total billed charges,Critical Access Hospital RCC factor,208.08,34,,208.08,percent of total billed charges,Implant Device,208.08,34,,208.08,percent of total billed charges,Implant Device,208.08,34,,208.08,percent of total billed charges,Implant Device,208.08,34,,208.08,percent of total billed charges,Implant Device,208.08,34,,208.08,percent of total billed charges,Implant Device,302.94,,,302.94,Other,110% of Medicare,214.2,35,,214.2,percent of total billed charges,Implant Device,208.08,34,"Charges > $500, x 34%",208.08,percent of total billed charges,Implant Device,214.2,35,,214.2,percent of total billed charges,Implant Device,214.2,35,,214.2,percent of total billed charges,Implant Device,214.2,35,,214.2,percent of total billed charges,Implant Device,214.2,35,,214.2,percent of total billed charges,Implant Device,214.2,35,,214.2,percent of total billed charges,Implant Device,244.8,40,,244.8,percent of total billed charges,Implant Device,214.2,70,,214.2,percent of total billed charges,All Other,208.08,34,,208.08,percent of total billed charges,Implant Device,208.08,34,,208.08,percent of total billed charges,Implant Device,214.2,35,,214.2,percent of total billed charges,Implant Device,214.2,35,,214.2,percent of total billed charges,Implant Device,214.2,35,,214.2,percent of total billed charges,Implant Device,214.2,35,,214.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,452.88,
ZIMMER 8161-35-032 CORTICAL SCREW 3.5X32,C1713,HCPCS,,79012588,CDM,278,RC,,,both,,,432,319.68,,,319.68,Other,150% of Medicare + 9.63% HCRA Surcharge,194.4,45,,194.4,percent of total billed charges,Critical Access Hospital RCC factor,146.88,34,,146.88,percent of total billed charges,Implant Device,146.88,34,,146.88,percent of total billed charges,Implant Device,146.88,34,,146.88,percent of total billed charges,Implant Device,146.88,34,,146.88,percent of total billed charges,Implant Device,146.88,34,,146.88,percent of total billed charges,Implant Device,213.84,,,213.84,Other,110% of Medicare,151.2,35,,151.2,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,151.2,35,,151.2,percent of total billed charges,Implant Device,151.2,35,,151.2,percent of total billed charges,Implant Device,151.2,35,,151.2,percent of total billed charges,Implant Device,151.2,35,,151.2,percent of total billed charges,Implant Device,151.2,35,,151.2,percent of total billed charges,Implant Device,172.8,40,,172.8,percent of total billed charges,Implant Device,151.2,70,,151.2,percent of total billed charges,All Other,146.88,34,,146.88,percent of total billed charges,Implant Device,146.88,34,,146.88,percent of total billed charges,Implant Device,151.2,35,,151.2,percent of total billed charges,Implant Device,151.2,35,,151.2,percent of total billed charges,Implant Device,151.2,35,,151.2,percent of total billed charges,Implant Device,151.2,35,,151.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,319.68,
ZIMMER 8161-35-038 CORTICAL SCREW 3.5X38,C1713,HCPCS,,79012589,CDM,278,RC,,,both,,,432,319.68,,,319.68,Other,150% of Medicare + 9.63% HCRA Surcharge,194.4,45,,194.4,percent of total billed charges,Critical Access Hospital RCC factor,146.88,34,,146.88,percent of total billed charges,Implant Device,146.88,34,,146.88,percent of total billed charges,Implant Device,146.88,34,,146.88,percent of total billed charges,Implant Device,146.88,34,,146.88,percent of total billed charges,Implant Device,146.88,34,,146.88,percent of total billed charges,Implant Device,213.84,,,213.84,Other,110% of Medicare,151.2,35,,151.2,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,151.2,35,,151.2,percent of total billed charges,Implant Device,151.2,35,,151.2,percent of total billed charges,Implant Device,151.2,35,,151.2,percent of total billed charges,Implant Device,151.2,35,,151.2,percent of total billed charges,Implant Device,151.2,35,,151.2,percent of total billed charges,Implant Device,172.8,40,,172.8,percent of total billed charges,Implant Device,151.2,70,,151.2,percent of total billed charges,All Other,146.88,34,,146.88,percent of total billed charges,Implant Device,146.88,34,,146.88,percent of total billed charges,Implant Device,151.2,35,,151.2,percent of total billed charges,Implant Device,151.2,35,,151.2,percent of total billed charges,Implant Device,151.2,35,,151.2,percent of total billed charges,Implant Device,151.2,35,,151.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,319.68,
ZIMMER 8161-35-030 CORTICAL SCREW 3.5X30,C1713,HCPCS,,79012590,CDM,278,RC,,,both,,,432,319.68,,,319.68,Other,150% of Medicare + 9.63% HCRA Surcharge,194.4,45,,194.4,percent of total billed charges,Critical Access Hospital RCC factor,146.88,34,,146.88,percent of total billed charges,Implant Device,146.88,34,,146.88,percent of total billed charges,Implant Device,146.88,34,,146.88,percent of total billed charges,Implant Device,146.88,34,,146.88,percent of total billed charges,Implant Device,146.88,34,,146.88,percent of total billed charges,Implant Device,213.84,,,213.84,Other,110% of Medicare,151.2,35,,151.2,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,151.2,35,,151.2,percent of total billed charges,Implant Device,151.2,35,,151.2,percent of total billed charges,Implant Device,151.2,35,,151.2,percent of total billed charges,Implant Device,151.2,35,,151.2,percent of total billed charges,Implant Device,151.2,35,,151.2,percent of total billed charges,Implant Device,172.8,40,,172.8,percent of total billed charges,Implant Device,151.2,70,,151.2,percent of total billed charges,All Other,146.88,34,,146.88,percent of total billed charges,Implant Device,146.88,34,,146.88,percent of total billed charges,Implant Device,151.2,35,,151.2,percent of total billed charges,Implant Device,151.2,35,,151.2,percent of total billed charges,Implant Device,151.2,35,,151.2,percent of total billed charges,Implant Device,151.2,35,,151.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,319.68,
ZIMMER 574101010 FEMORAL STEM SIZE 1,C1776,HCPCS,,79012591,CDM,278,RC,,,both,,,6912,5114.9,,,5114.9,Other,150% of Medicare + 9.63% HCRA Surcharge,3110.4,45,,3110.4,percent of total billed charges,Critical Access Hospital RCC factor,2350.08,34,,2350.08,percent of total billed charges,Implant Device,2350.08,34,,2350.08,percent of total billed charges,Implant Device,2350.08,34,,2350.08,percent of total billed charges,Implant Device,2350.08,34,,2350.08,percent of total billed charges,Implant Device,2350.08,34,,2350.08,percent of total billed charges,Implant Device,3421.44,,,3421.44,Other,110% of Medicare,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2350.08,34,"Charges > $500, x 34%",2350.08,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2764.8,40,,2764.8,percent of total billed charges,Implant Device,2419.2,70,,2419.2,percent of total billed charges,All Other,2350.08,34,,2350.08,percent of total billed charges,Implant Device,2350.08,34,,2350.08,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2350.08,34,"If Charge > 2,000, then 34 percent",2350.08,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5114.9,
ZIMMER 110010243 ACETABULAR SHELL 50MM,C1776,HCPCS,,79012592,CDM,278,RC,,,both,,,8602,6365.5,,,6365.5,Other,150% of Medicare + 9.63% HCRA Surcharge,3870.9,45,,3870.9,percent of total billed charges,Critical Access Hospital RCC factor,2924.68,34,,2924.68,percent of total billed charges,Implant Device,2924.68,34,,2924.68,percent of total billed charges,Implant Device,2924.68,34,,2924.68,percent of total billed charges,Implant Device,2924.68,34,,2924.68,percent of total billed charges,Implant Device,2924.68,34,,2924.68,percent of total billed charges,Implant Device,4257.99,,,4257.99,Other,110% of Medicare,3010.7,35,,3010.7,percent of total billed charges,Implant Device,2924.68,34,"Charges > $500, x 34%",2924.68,percent of total billed charges,Implant Device,3010.7,35,,3010.7,percent of total billed charges,Implant Device,3010.7,35,,3010.7,percent of total billed charges,Implant Device,3010.7,35,,3010.7,percent of total billed charges,Implant Device,3010.7,35,,3010.7,percent of total billed charges,Implant Device,3010.7,35,,3010.7,percent of total billed charges,Implant Device,3440.8,40,,3440.8,percent of total billed charges,Implant Device,3010.7,70,,3010.7,percent of total billed charges,All Other,2924.68,34,,2924.68,percent of total billed charges,Implant Device,2924.68,34,,2924.68,percent of total billed charges,Implant Device,3010.7,35,,3010.7,percent of total billed charges,Implant Device,3010.7,35,,3010.7,percent of total billed charges,Implant Device,3010.7,35,,3010.7,percent of total billed charges,Implant Device,3010.7,35,,3010.7,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2924.68,34,"If Charge > 2,000, then 34 percent",2924.68,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,6365.5,
ZIMMER 30123604 LINER SIZE 3 36MM,C1776,HCPCS,,79012593,CDM,278,RC,,,both,,,3456,2557.45,,,2557.45,Other,150% of Medicare + 9.63% HCRA Surcharge,1555.2,45,,1555.2,percent of total billed charges,Critical Access Hospital RCC factor,1175.04,34,,1175.04,percent of total billed charges,Implant Device,1175.04,34,,1175.04,percent of total billed charges,Implant Device,1175.04,34,,1175.04,percent of total billed charges,Implant Device,1175.04,34,,1175.04,percent of total billed charges,Implant Device,1175.04,34,,1175.04,percent of total billed charges,Implant Device,1710.72,,,1710.72,Other,110% of Medicare,1209.6,35,,1209.6,percent of total billed charges,Implant Device,1175.04,34,"Charges > $500, x 34%",1175.04,percent of total billed charges,Implant Device,1209.6,35,,1209.6,percent of total billed charges,Implant Device,1209.6,35,,1209.6,percent of total billed charges,Implant Device,1209.6,35,,1209.6,percent of total billed charges,Implant Device,1209.6,35,,1209.6,percent of total billed charges,Implant Device,1209.6,35,,1209.6,percent of total billed charges,Implant Device,1382.4,40,,1382.4,percent of total billed charges,Implant Device,1209.6,70,,1209.6,percent of total billed charges,All Other,1175.04,34,,1175.04,percent of total billed charges,Implant Device,1175.04,34,,1175.04,percent of total billed charges,Implant Device,1209.6,35,,1209.6,percent of total billed charges,Implant Device,1209.6,35,,1209.6,percent of total billed charges,Implant Device,1209.6,35,,1209.6,percent of total billed charges,Implant Device,1209.6,35,,1209.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1175.04,34,"If Charge > 2,000, then 34 percent",1175.04,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2557.45,
J&J 02.112.813S HOOK PLT LONG 2.7X12 RT,C1713,HCPCS,,79012594,CDM,278,RC,,,both,,,3870,2863.81,,,2863.81,Other,150% of Medicare + 9.63% HCRA Surcharge,1741.5,45,,1741.5,percent of total billed charges,Critical Access Hospital RCC factor,1315.8,34,,1315.8,percent of total billed charges,Implant Device,1315.8,34,,1315.8,percent of total billed charges,Implant Device,1315.8,34,,1315.8,percent of total billed charges,Implant Device,1315.8,34,,1315.8,percent of total billed charges,Implant Device,1315.8,34,,1315.8,percent of total billed charges,Implant Device,1915.65,,,1915.65,Other,110% of Medicare,1354.5,35,,1354.5,percent of total billed charges,Implant Device,1315.8,34,"Charges > $500, x 34%",1315.8,percent of total billed charges,Implant Device,1354.5,35,,1354.5,percent of total billed charges,Implant Device,1354.5,35,,1354.5,percent of total billed charges,Implant Device,1354.5,35,,1354.5,percent of total billed charges,Implant Device,1354.5,35,,1354.5,percent of total billed charges,Implant Device,1354.5,35,,1354.5,percent of total billed charges,Implant Device,1548,40,,1548,percent of total billed charges,Implant Device,1354.5,70,,1354.5,percent of total billed charges,All Other,1315.8,34,,1315.8,percent of total billed charges,Implant Device,1315.8,34,,1315.8,percent of total billed charges,Implant Device,1354.5,35,,1354.5,percent of total billed charges,Implant Device,1354.5,35,,1354.5,percent of total billed charges,Implant Device,1354.5,35,,1354.5,percent of total billed charges,Implant Device,1354.5,35,,1354.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1315.8,34,"If Charge > 2,000, then 34 percent",1315.8,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2863.81,
J&J 02.112.811S HOOK PLT LONG 2.7X9MM RT,C1713,HCPCS,,79012595,CDM,278,RC,,,both,,,3870,2863.81,,,2863.81,Other,150% of Medicare + 9.63% HCRA Surcharge,1741.5,45,,1741.5,percent of total billed charges,Critical Access Hospital RCC factor,1315.8,34,,1315.8,percent of total billed charges,Implant Device,1315.8,34,,1315.8,percent of total billed charges,Implant Device,1315.8,34,,1315.8,percent of total billed charges,Implant Device,1315.8,34,,1315.8,percent of total billed charges,Implant Device,1315.8,34,,1315.8,percent of total billed charges,Implant Device,1915.65,,,1915.65,Other,110% of Medicare,1354.5,35,,1354.5,percent of total billed charges,Implant Device,1315.8,34,"Charges > $500, x 34%",1315.8,percent of total billed charges,Implant Device,1354.5,35,,1354.5,percent of total billed charges,Implant Device,1354.5,35,,1354.5,percent of total billed charges,Implant Device,1354.5,35,,1354.5,percent of total billed charges,Implant Device,1354.5,35,,1354.5,percent of total billed charges,Implant Device,1354.5,35,,1354.5,percent of total billed charges,Implant Device,1548,40,,1548,percent of total billed charges,Implant Device,1354.5,70,,1354.5,percent of total billed charges,All Other,1315.8,34,,1315.8,percent of total billed charges,Implant Device,1315.8,34,,1315.8,percent of total billed charges,Implant Device,1354.5,35,,1354.5,percent of total billed charges,Implant Device,1354.5,35,,1354.5,percent of total billed charges,Implant Device,1354.5,35,,1354.5,percent of total billed charges,Implant Device,1354.5,35,,1354.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1315.8,34,"If Charge > 2,000, then 34 percent",1315.8,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2863.81,
J&J 02.123.025 PROX HUMERUS PLT 3.5MM,C1713,HCPCS,,79012596,CDM,278,RC,,,both,,,4266,3156.85,,,3156.85,Other,150% of Medicare + 9.63% HCRA Surcharge,1919.7,45,,1919.7,percent of total billed charges,Critical Access Hospital RCC factor,1450.44,34,,1450.44,percent of total billed charges,Implant Device,1450.44,34,,1450.44,percent of total billed charges,Implant Device,1450.44,34,,1450.44,percent of total billed charges,Implant Device,1450.44,34,,1450.44,percent of total billed charges,Implant Device,1450.44,34,,1450.44,percent of total billed charges,Implant Device,2111.67,,,2111.67,Other,110% of Medicare,1493.1,35,,1493.1,percent of total billed charges,Implant Device,1450.44,34,"Charges > $500, x 34%",1450.44,percent of total billed charges,Implant Device,1493.1,35,,1493.1,percent of total billed charges,Implant Device,1493.1,35,,1493.1,percent of total billed charges,Implant Device,1493.1,35,,1493.1,percent of total billed charges,Implant Device,1493.1,35,,1493.1,percent of total billed charges,Implant Device,1493.1,35,,1493.1,percent of total billed charges,Implant Device,1706.4,40,,1706.4,percent of total billed charges,Implant Device,1493.1,70,,1493.1,percent of total billed charges,All Other,1450.44,34,,1450.44,percent of total billed charges,Implant Device,1450.44,34,,1450.44,percent of total billed charges,Implant Device,1493.1,35,,1493.1,percent of total billed charges,Implant Device,1493.1,35,,1493.1,percent of total billed charges,Implant Device,1493.1,35,,1493.1,percent of total billed charges,Implant Device,1493.1,35,,1493.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1450.44,34,"If Charge > 2,000, then 34 percent",1450.44,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3156.85,
J&J 206.035 CAN CELLOUS SCREW 4.0X35MM,C1713,HCPCS,,79012597,CDM,278,RC,,,both,,,47,34.78,,,34.78,Other,150% of Medicare + 9.63% HCRA Surcharge,21.15,45,,21.15,percent of total billed charges,Critical Access Hospital RCC factor,15.98,34,,15.98,percent of total billed charges,Implant Device,15.98,34,,15.98,percent of total billed charges,Implant Device,15.98,34,,15.98,percent of total billed charges,Implant Device,15.98,34,,15.98,percent of total billed charges,Implant Device,15.98,34,,15.98,percent of total billed charges,Implant Device,23.27,,,23.27,Other,110% of Medicare,16.45,35,,16.45,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,16.45,35,,16.45,percent of total billed charges,Implant Device,16.45,35,,16.45,percent of total billed charges,Implant Device,16.45,35,,16.45,percent of total billed charges,Implant Device,16.45,35,,16.45,percent of total billed charges,Implant Device,16.45,35,,16.45,percent of total billed charges,Implant Device,18.8,40,,18.8,percent of total billed charges,Implant Device,16.45,70,,16.45,percent of total billed charges,All Other,15.98,34,,15.98,percent of total billed charges,Implant Device,15.98,34,,15.98,percent of total billed charges,Implant Device,16.45,35,,16.45,percent of total billed charges,Implant Device,16.45,35,,16.45,percent of total billed charges,Implant Device,16.45,35,,16.45,percent of total billed charges,Implant Device,16.45,35,,16.45,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,34.78,
J&J 201.763 CORTEX SCREW 2.4X13MM,C1713,HCPCS,,79012598,CDM,278,RC,,,both,,,130,96.2,,,96.2,Other,150% of Medicare + 9.63% HCRA Surcharge,58.5,45,,58.5,percent of total billed charges,Critical Access Hospital RCC factor,44.2,34,,44.2,percent of total billed charges,Implant Device,44.2,34,,44.2,percent of total billed charges,Implant Device,44.2,34,,44.2,percent of total billed charges,Implant Device,44.2,34,,44.2,percent of total billed charges,Implant Device,44.2,34,,44.2,percent of total billed charges,Implant Device,64.35,,,64.35,Other,110% of Medicare,45.5,35,,45.5,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,45.5,35,,45.5,percent of total billed charges,Implant Device,45.5,35,,45.5,percent of total billed charges,Implant Device,45.5,35,,45.5,percent of total billed charges,Implant Device,45.5,35,,45.5,percent of total billed charges,Implant Device,45.5,35,,45.5,percent of total billed charges,Implant Device,52,40,,52,percent of total billed charges,Implant Device,45.5,70,,45.5,percent of total billed charges,All Other,44.2,34,,44.2,percent of total billed charges,Implant Device,44.2,34,,44.2,percent of total billed charges,Implant Device,45.5,35,,45.5,percent of total billed charges,Implant Device,45.5,35,,45.5,percent of total billed charges,Implant Device,45.5,35,,45.5,percent of total billed charges,Implant Device,45.5,35,,45.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,96.2,
J&J 02.112.623S CLAVICLE PLT RT 2.7MM,C1713,HCPCS,,79012599,CDM,278,RC,,,both,,,3434,2541.17,,,2541.17,Other,150% of Medicare + 9.63% HCRA Surcharge,1545.3,45,,1545.3,percent of total billed charges,Critical Access Hospital RCC factor,1167.56,34,,1167.56,percent of total billed charges,Implant Device,1167.56,34,,1167.56,percent of total billed charges,Implant Device,1167.56,34,,1167.56,percent of total billed charges,Implant Device,1167.56,34,,1167.56,percent of total billed charges,Implant Device,1167.56,34,,1167.56,percent of total billed charges,Implant Device,1699.83,,,1699.83,Other,110% of Medicare,1201.9,35,,1201.9,percent of total billed charges,Implant Device,1167.56,34,"Charges > $500, x 34%",1167.56,percent of total billed charges,Implant Device,1201.9,35,,1201.9,percent of total billed charges,Implant Device,1201.9,35,,1201.9,percent of total billed charges,Implant Device,1201.9,35,,1201.9,percent of total billed charges,Implant Device,1201.9,35,,1201.9,percent of total billed charges,Implant Device,1201.9,35,,1201.9,percent of total billed charges,Implant Device,1373.6,40,,1373.6,percent of total billed charges,Implant Device,1201.9,70,,1201.9,percent of total billed charges,All Other,1167.56,34,,1167.56,percent of total billed charges,Implant Device,1167.56,34,,1167.56,percent of total billed charges,Implant Device,1201.9,35,,1201.9,percent of total billed charges,Implant Device,1201.9,35,,1201.9,percent of total billed charges,Implant Device,1201.9,35,,1201.9,percent of total billed charges,Implant Device,1201.9,35,,1201.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1167.56,34,"If Charge > 2,000, then 34 percent",1167.56,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2541.17,
J&J 04.038.210S TFNA SCREW 110MM,C1713,HCPCS,,79012600,CDM,278,RC,,,both,,,1776,1314.24,,,1314.24,Other,150% of Medicare + 9.63% HCRA Surcharge,799.2,45,,799.2,percent of total billed charges,Critical Access Hospital RCC factor,603.84,34,,603.84,percent of total billed charges,Implant Device,603.84,34,,603.84,percent of total billed charges,Implant Device,603.84,34,,603.84,percent of total billed charges,Implant Device,603.84,34,,603.84,percent of total billed charges,Implant Device,603.84,34,,603.84,percent of total billed charges,Implant Device,879.12,,,879.12,Other,110% of Medicare,621.6,35,,621.6,percent of total billed charges,Implant Device,603.84,34,"Charges > $500, x 34%",603.84,percent of total billed charges,Implant Device,621.6,35,,621.6,percent of total billed charges,Implant Device,621.6,35,,621.6,percent of total billed charges,Implant Device,621.6,35,,621.6,percent of total billed charges,Implant Device,621.6,35,,621.6,percent of total billed charges,Implant Device,621.6,35,,621.6,percent of total billed charges,Implant Device,710.4,40,,710.4,percent of total billed charges,Implant Device,621.6,70,,621.6,percent of total billed charges,All Other,603.84,34,,603.84,percent of total billed charges,Implant Device,603.84,34,,603.84,percent of total billed charges,Implant Device,621.6,35,,621.6,percent of total billed charges,Implant Device,621.6,35,,621.6,percent of total billed charges,Implant Device,621.6,35,,621.6,percent of total billed charges,Implant Device,621.6,35,,621.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1314.24,
ZIMMER 42-5026-068-01 FEMUR LEFT SIZE 10,C1776,HCPCS,,79012601,CDM,278,RC,,,both,,,10200,7548.03,,,7548.03,Other,150% of Medicare + 9.63% HCRA Surcharge,4590,45,,4590,percent of total billed charges,Critical Access Hospital RCC factor,3468,34,,3468,percent of total billed charges,Implant Device,3468,34,,3468,percent of total billed charges,Implant Device,3468,34,,3468,percent of total billed charges,Implant Device,3468,34,,3468,percent of total billed charges,Implant Device,3468,34,,3468,percent of total billed charges,Implant Device,5049,,,5049,Other,110% of Medicare,3570,35,,3570,percent of total billed charges,Implant Device,3468,34,"Charges > $500, x 34%",3468,percent of total billed charges,Implant Device,3570,35,,3570,percent of total billed charges,Implant Device,3570,35,,3570,percent of total billed charges,Implant Device,3570,35,,3570,percent of total billed charges,Implant Device,3570,35,,3570,percent of total billed charges,Implant Device,3570,35,,3570,percent of total billed charges,Implant Device,4080,40,,4080,percent of total billed charges,Implant Device,3570,70,,3570,percent of total billed charges,All Other,3468,34,,3468,percent of total billed charges,Implant Device,3468,34,,3468,percent of total billed charges,Implant Device,3570,35,,3570,percent of total billed charges,Implant Device,3570,35,,3570,percent of total billed charges,Implant Device,3570,35,,3570,percent of total billed charges,Implant Device,3570,35,,3570,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3468,34,"If Charge > 2,000, then 34 percent",3468,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,7548.03,
ZIMMER 42-5221-007-16 ART SURF RT 16MM,C1776,HCPCS,,79012602,CDM,278,RC,,,both,,,3648,2699.53,,,2699.53,Other,150% of Medicare + 9.63% HCRA Surcharge,1641.6,45,,1641.6,percent of total billed charges,Critical Access Hospital RCC factor,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1805.76,,,1805.76,Other,110% of Medicare,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1240.32,34,"Charges > $500, x 34%",1240.32,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1459.2,40,,1459.2,percent of total billed charges,Implant Device,1276.8,70,,1276.8,percent of total billed charges,All Other,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1240.32,34,"If Charge > 2,000, then 34 percent",1240.32,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2699.53,
ZIMMER 574203050 FEMORAL STEM SIZE 5,C1776,HCPCS,,79012603,CDM,278,RC,,,both,,,6912,5114.9,,,5114.9,Other,150% of Medicare + 9.63% HCRA Surcharge,3110.4,45,,3110.4,percent of total billed charges,Critical Access Hospital RCC factor,2350.08,34,,2350.08,percent of total billed charges,Implant Device,2350.08,34,,2350.08,percent of total billed charges,Implant Device,2350.08,34,,2350.08,percent of total billed charges,Implant Device,2350.08,34,,2350.08,percent of total billed charges,Implant Device,2350.08,34,,2350.08,percent of total billed charges,Implant Device,3421.44,,,3421.44,Other,110% of Medicare,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2350.08,34,"Charges > $500, x 34%",2350.08,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2764.8,40,,2764.8,percent of total billed charges,Implant Device,2419.2,70,,2419.2,percent of total billed charges,All Other,2350.08,34,,2350.08,percent of total billed charges,Implant Device,2350.08,34,,2350.08,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2350.08,34,"If Charge > 2,000, then 34 percent",2350.08,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5114.9,
J&J 207.740 CANNULATED SCREW 4X40MM,C1713,HCPCS,,79012605,CDM,278,RC,,,both,,,491,363.34,,,363.34,Other,150% of Medicare + 9.63% HCRA Surcharge,220.95,45,,220.95,percent of total billed charges,Critical Access Hospital RCC factor,166.94,34,,166.94,percent of total billed charges,Implant Device,166.94,34,,166.94,percent of total billed charges,Implant Device,166.94,34,,166.94,percent of total billed charges,Implant Device,166.94,34,,166.94,percent of total billed charges,Implant Device,166.94,34,,166.94,percent of total billed charges,Implant Device,243.05,,,243.05,Other,110% of Medicare,171.85,35,,171.85,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,171.85,35,,171.85,percent of total billed charges,Implant Device,171.85,35,,171.85,percent of total billed charges,Implant Device,171.85,35,,171.85,percent of total billed charges,Implant Device,171.85,35,,171.85,percent of total billed charges,Implant Device,171.85,35,,171.85,percent of total billed charges,Implant Device,196.4,40,,196.4,percent of total billed charges,Implant Device,171.85,70,,171.85,percent of total billed charges,All Other,166.94,34,,166.94,percent of total billed charges,Implant Device,166.94,34,,166.94,percent of total billed charges,Implant Device,171.85,35,,171.85,percent of total billed charges,Implant Device,171.85,35,,171.85,percent of total billed charges,Implant Device,171.85,35,,171.85,percent of total billed charges,Implant Device,171.85,35,,171.85,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,363.34,
J&J 1506-11-004 TIBIAL BASEPLATE SZ 4,C1776,HCPCS,,79012606,CDM,278,RC,,,both,,,6300,4662.02,,,4662.02,Other,150% of Medicare + 9.63% HCRA Surcharge,2835,45,,2835,percent of total billed charges,Critical Access Hospital RCC factor,2142,34,,2142,percent of total billed charges,Implant Device,2142,34,,2142,percent of total billed charges,Implant Device,2142,34,,2142,percent of total billed charges,Implant Device,2142,34,,2142,percent of total billed charges,Implant Device,2142,34,,2142,percent of total billed charges,Implant Device,3118.5,,,3118.5,Other,110% of Medicare,2205,35,,2205,percent of total billed charges,Implant Device,2142,34,"Charges > $500, x 34%",2142,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2520,40,,2520,percent of total billed charges,Implant Device,2205,70,,2205,percent of total billed charges,All Other,2142,34,,2142,percent of total billed charges,Implant Device,2142,34,,2142,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2142,34,"If Charge > 2,000, then 34 percent",2142,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4662.02,
J&J 1504-10-106 FEMORAL COMP LT SZ 6,C1776,HCPCS,,79012607,CDM,278,RC,,,both,,,4800,3552.01,,,3552.01,Other,150% of Medicare + 9.63% HCRA Surcharge,2160,45,,2160,percent of total billed charges,Critical Access Hospital RCC factor,1632,34,,1632,percent of total billed charges,Implant Device,1632,34,,1632,percent of total billed charges,Implant Device,1632,34,,1632,percent of total billed charges,Implant Device,1632,34,,1632,percent of total billed charges,Implant Device,1632,34,,1632,percent of total billed charges,Implant Device,2376,,,2376,Other,110% of Medicare,1680,35,,1680,percent of total billed charges,Implant Device,1632,34,"Charges > $500, x 34%",1632,percent of total billed charges,Implant Device,1680,35,,1680,percent of total billed charges,Implant Device,1680,35,,1680,percent of total billed charges,Implant Device,1680,35,,1680,percent of total billed charges,Implant Device,1680,35,,1680,percent of total billed charges,Implant Device,1680,35,,1680,percent of total billed charges,Implant Device,1920,40,,1920,percent of total billed charges,Implant Device,1680,70,,1680,percent of total billed charges,All Other,1632,34,,1632,percent of total billed charges,Implant Device,1632,34,,1632,percent of total billed charges,Implant Device,1680,35,,1680,percent of total billed charges,Implant Device,1680,35,,1680,percent of total billed charges,Implant Device,1680,35,,1680,percent of total billed charges,Implant Device,1680,35,,1680,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1632,34,"If Charge > 2,000, then 34 percent",1632,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3552.01,
ARTHREX AR-5051-32 CANNULATED SCREW 4X32,C1713,HCPCS,,79012608,CDM,278,RC,,,both,,,495,366.3,,,366.3,Other,150% of Medicare + 9.63% HCRA Surcharge,222.75,45,,222.75,percent of total billed charges,Critical Access Hospital RCC factor,168.3,34,,168.3,percent of total billed charges,Implant Device,168.3,34,,168.3,percent of total billed charges,Implant Device,168.3,34,,168.3,percent of total billed charges,Implant Device,168.3,34,,168.3,percent of total billed charges,Implant Device,168.3,34,,168.3,percent of total billed charges,Implant Device,245.03,,,245.03,Other,110% of Medicare,173.25,35,,173.25,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,173.25,35,,173.25,percent of total billed charges,Implant Device,173.25,35,,173.25,percent of total billed charges,Implant Device,173.25,35,,173.25,percent of total billed charges,Implant Device,173.25,35,,173.25,percent of total billed charges,Implant Device,173.25,35,,173.25,percent of total billed charges,Implant Device,198,40,,198,percent of total billed charges,Implant Device,173.25,70,,173.25,percent of total billed charges,All Other,168.3,34,,168.3,percent of total billed charges,Implant Device,168.3,34,,168.3,percent of total billed charges,Implant Device,173.25,35,,173.25,percent of total billed charges,Implant Device,173.25,35,,173.25,percent of total billed charges,Implant Device,173.25,35,,173.25,percent of total billed charges,Implant Device,173.25,35,,173.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,366.3,
ARTHREX AR-5051-38 CANNULATED SCREW 4X38,C1713,HCPCS,,79012609,CDM,278,RC,,,both,,,495,366.3,,,366.3,Other,150% of Medicare + 9.63% HCRA Surcharge,222.75,45,,222.75,percent of total billed charges,Critical Access Hospital RCC factor,168.3,34,,168.3,percent of total billed charges,Implant Device,168.3,34,,168.3,percent of total billed charges,Implant Device,168.3,34,,168.3,percent of total billed charges,Implant Device,168.3,34,,168.3,percent of total billed charges,Implant Device,168.3,34,,168.3,percent of total billed charges,Implant Device,245.03,,,245.03,Other,110% of Medicare,173.25,35,,173.25,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,173.25,35,,173.25,percent of total billed charges,Implant Device,173.25,35,,173.25,percent of total billed charges,Implant Device,173.25,35,,173.25,percent of total billed charges,Implant Device,173.25,35,,173.25,percent of total billed charges,Implant Device,173.25,35,,173.25,percent of total billed charges,Implant Device,198,40,,198,percent of total billed charges,Implant Device,173.25,70,,173.25,percent of total billed charges,All Other,168.3,34,,168.3,percent of total billed charges,Implant Device,168.3,34,,168.3,percent of total billed charges,Implant Device,173.25,35,,173.25,percent of total billed charges,Implant Device,173.25,35,,173.25,percent of total billed charges,Implant Device,173.25,35,,173.25,percent of total billed charges,Implant Device,173.25,35,,173.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,366.3,
ARTHREX AR-5051-36 CANNULATED SCREW 4X36,C1713,HCPCS,,79012610,CDM,278,RC,,,both,,,495,366.3,,,366.3,Other,150% of Medicare + 9.63% HCRA Surcharge,222.75,45,,222.75,percent of total billed charges,Critical Access Hospital RCC factor,168.3,34,,168.3,percent of total billed charges,Implant Device,168.3,34,,168.3,percent of total billed charges,Implant Device,168.3,34,,168.3,percent of total billed charges,Implant Device,168.3,34,,168.3,percent of total billed charges,Implant Device,168.3,34,,168.3,percent of total billed charges,Implant Device,245.03,,,245.03,Other,110% of Medicare,173.25,35,,173.25,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,173.25,35,,173.25,percent of total billed charges,Implant Device,173.25,35,,173.25,percent of total billed charges,Implant Device,173.25,35,,173.25,percent of total billed charges,Implant Device,173.25,35,,173.25,percent of total billed charges,Implant Device,173.25,35,,173.25,percent of total billed charges,Implant Device,198,40,,198,percent of total billed charges,Implant Device,173.25,70,,173.25,percent of total billed charges,All Other,168.3,34,,168.3,percent of total billed charges,Implant Device,168.3,34,,168.3,percent of total billed charges,Implant Device,173.25,35,,173.25,percent of total billed charges,Implant Device,173.25,35,,173.25,percent of total billed charges,Implant Device,173.25,35,,173.25,percent of total billed charges,Implant Device,173.25,35,,173.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,366.3,
ARTHREX AR-5051-40 CANNULATED SCREW 4X40,C1713,HCPCS,,79012611,CDM,278,RC,,,both,,,495,366.3,,,366.3,Other,150% of Medicare + 9.63% HCRA Surcharge,222.75,45,,222.75,percent of total billed charges,Critical Access Hospital RCC factor,168.3,34,,168.3,percent of total billed charges,Implant Device,168.3,34,,168.3,percent of total billed charges,Implant Device,168.3,34,,168.3,percent of total billed charges,Implant Device,168.3,34,,168.3,percent of total billed charges,Implant Device,168.3,34,,168.3,percent of total billed charges,Implant Device,245.03,,,245.03,Other,110% of Medicare,173.25,35,,173.25,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,173.25,35,,173.25,percent of total billed charges,Implant Device,173.25,35,,173.25,percent of total billed charges,Implant Device,173.25,35,,173.25,percent of total billed charges,Implant Device,173.25,35,,173.25,percent of total billed charges,Implant Device,173.25,35,,173.25,percent of total billed charges,Implant Device,198,40,,198,percent of total billed charges,Implant Device,173.25,70,,173.25,percent of total billed charges,All Other,168.3,34,,168.3,percent of total billed charges,Implant Device,168.3,34,,168.3,percent of total billed charges,Implant Device,173.25,35,,173.25,percent of total billed charges,Implant Device,173.25,35,,173.25,percent of total billed charges,Implant Device,173.25,35,,173.25,percent of total billed charges,Implant Device,173.25,35,,173.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,366.3,
IN2BONES A80 ST100 SYNDESMOSIS IMP SYS,C1713,HCPCS,,79012614,CDM,278,RC,,,both,,,6885,5094.92,,,5094.92,Other,150% of Medicare + 9.63% HCRA Surcharge,3098.25,45,,3098.25,percent of total billed charges,Critical Access Hospital RCC factor,2340.9,34,,2340.9,percent of total billed charges,Implant Device,2340.9,34,,2340.9,percent of total billed charges,Implant Device,2340.9,34,,2340.9,percent of total billed charges,Implant Device,2340.9,34,,2340.9,percent of total billed charges,Implant Device,2340.9,34,,2340.9,percent of total billed charges,Implant Device,3408.08,,,3408.08,Other,110% of Medicare,2409.75,35,,2409.75,percent of total billed charges,Implant Device,2340.9,34,"Charges > $500, x 34%",2340.9,percent of total billed charges,Implant Device,2409.75,35,,2409.75,percent of total billed charges,Implant Device,2409.75,35,,2409.75,percent of total billed charges,Implant Device,2409.75,35,,2409.75,percent of total billed charges,Implant Device,2409.75,35,,2409.75,percent of total billed charges,Implant Device,2409.75,35,,2409.75,percent of total billed charges,Implant Device,2754,40,,2754,percent of total billed charges,Implant Device,2409.75,70,,2409.75,percent of total billed charges,All Other,2340.9,34,,2340.9,percent of total billed charges,Implant Device,2340.9,34,,2340.9,percent of total billed charges,Implant Device,2409.75,35,,2409.75,percent of total billed charges,Implant Device,2409.75,35,,2409.75,percent of total billed charges,Implant Device,2409.75,35,,2409.75,percent of total billed charges,Implant Device,2409.75,35,,2409.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2340.9,34,"If Charge > 2,000, then 34 percent",2340.9,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5094.92,
TRILLIANT 300-93-004 LAT FIBULA PLT RT,C1713,HCPCS,,79012615,CDM,278,RC,,,both,,,4875,3607.51,,,3607.51,Other,150% of Medicare + 9.63% HCRA Surcharge,2193.75,45,,2193.75,percent of total billed charges,Critical Access Hospital RCC factor,1657.5,34,,1657.5,percent of total billed charges,Implant Device,1657.5,34,,1657.5,percent of total billed charges,Implant Device,1657.5,34,,1657.5,percent of total billed charges,Implant Device,1657.5,34,,1657.5,percent of total billed charges,Implant Device,1657.5,34,,1657.5,percent of total billed charges,Implant Device,2413.13,,,2413.13,Other,110% of Medicare,1706.25,35,,1706.25,percent of total billed charges,Implant Device,1657.5,34,"Charges > $500, x 34%",1657.5,percent of total billed charges,Implant Device,1706.25,35,,1706.25,percent of total billed charges,Implant Device,1706.25,35,,1706.25,percent of total billed charges,Implant Device,1706.25,35,,1706.25,percent of total billed charges,Implant Device,1706.25,35,,1706.25,percent of total billed charges,Implant Device,1706.25,35,,1706.25,percent of total billed charges,Implant Device,1950,40,,1950,percent of total billed charges,Implant Device,1706.25,70,,1706.25,percent of total billed charges,All Other,1657.5,34,,1657.5,percent of total billed charges,Implant Device,1657.5,34,,1657.5,percent of total billed charges,Implant Device,1706.25,35,,1706.25,percent of total billed charges,Implant Device,1706.25,35,,1706.25,percent of total billed charges,Implant Device,1706.25,35,,1706.25,percent of total billed charges,Implant Device,1706.25,35,,1706.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1657.5,34,"If Charge > 2,000, then 34 percent",1657.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3607.51,
TRILLIANT 308-27-012 LOCK SCREW 2.7X12MM,C1713,HCPCS,,79012616,CDM,278,RC,,,both,,,780,577.2,,,577.2,Other,150% of Medicare + 9.63% HCRA Surcharge,351,45,,351,percent of total billed charges,Critical Access Hospital RCC factor,265.2,34,,265.2,percent of total billed charges,Implant Device,265.2,34,,265.2,percent of total billed charges,Implant Device,265.2,34,,265.2,percent of total billed charges,Implant Device,265.2,34,,265.2,percent of total billed charges,Implant Device,265.2,34,,265.2,percent of total billed charges,Implant Device,386.1,,,386.1,Other,110% of Medicare,273,35,,273,percent of total billed charges,Implant Device,265.2,34,"Charges > $500, x 34%",265.2,percent of total billed charges,Implant Device,273,35,,273,percent of total billed charges,Implant Device,273,35,,273,percent of total billed charges,Implant Device,273,35,,273,percent of total billed charges,Implant Device,273,35,,273,percent of total billed charges,Implant Device,273,35,,273,percent of total billed charges,Implant Device,312,40,,312,percent of total billed charges,Implant Device,273,70,,273,percent of total billed charges,All Other,265.2,34,,265.2,percent of total billed charges,Implant Device,265.2,34,,265.2,percent of total billed charges,Implant Device,273,35,,273,percent of total billed charges,Implant Device,273,35,,273,percent of total billed charges,Implant Device,273,35,,273,percent of total billed charges,Implant Device,273,35,,273,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,577.2,
TRILLIANT 308-27-014 LOCK SCREW 2.7X14MM,C1713,HCPCS,,79012617,CDM,278,RC,,,both,,,900,666,,,666,Other,150% of Medicare + 9.63% HCRA Surcharge,405,45,,405,percent of total billed charges,Critical Access Hospital RCC factor,306,34,,306,percent of total billed charges,Implant Device,306,34,,306,percent of total billed charges,Implant Device,306,34,,306,percent of total billed charges,Implant Device,306,34,,306,percent of total billed charges,Implant Device,306,34,,306,percent of total billed charges,Implant Device,445.5,,,445.5,Other,110% of Medicare,315,35,,315,percent of total billed charges,Implant Device,306,34,"Charges > $500, x 34%",306,percent of total billed charges,Implant Device,315,35,,315,percent of total billed charges,Implant Device,315,35,,315,percent of total billed charges,Implant Device,315,35,,315,percent of total billed charges,Implant Device,315,35,,315,percent of total billed charges,Implant Device,315,35,,315,percent of total billed charges,Implant Device,360,40,,360,percent of total billed charges,Implant Device,315,70,,315,percent of total billed charges,All Other,306,34,,306,percent of total billed charges,Implant Device,306,34,,306,percent of total billed charges,Implant Device,315,35,,315,percent of total billed charges,Implant Device,315,35,,315,percent of total billed charges,Implant Device,315,35,,315,percent of total billed charges,Implant Device,315,35,,315,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,666,
TRILLIANT 308-27-016 LOCK SCREW 2.7X16MM,C1713,HCPCS,,79012618,CDM,278,RC,,,both,,,900,666,,,666,Other,150% of Medicare + 9.63% HCRA Surcharge,405,45,,405,percent of total billed charges,Critical Access Hospital RCC factor,306,34,,306,percent of total billed charges,Implant Device,306,34,,306,percent of total billed charges,Implant Device,306,34,,306,percent of total billed charges,Implant Device,306,34,,306,percent of total billed charges,Implant Device,306,34,,306,percent of total billed charges,Implant Device,445.5,,,445.5,Other,110% of Medicare,315,35,,315,percent of total billed charges,Implant Device,306,34,"Charges > $500, x 34%",306,percent of total billed charges,Implant Device,315,35,,315,percent of total billed charges,Implant Device,315,35,,315,percent of total billed charges,Implant Device,315,35,,315,percent of total billed charges,Implant Device,315,35,,315,percent of total billed charges,Implant Device,315,35,,315,percent of total billed charges,Implant Device,360,40,,360,percent of total billed charges,Implant Device,315,70,,315,percent of total billed charges,All Other,306,34,,306,percent of total billed charges,Implant Device,306,34,,306,percent of total billed charges,Implant Device,315,35,,315,percent of total billed charges,Implant Device,315,35,,315,percent of total billed charges,Implant Device,315,35,,315,percent of total billed charges,Implant Device,315,35,,315,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,666,
TRILLIANT 308-35-012 LOCK SCREW 3.5X12MM,C1713,HCPCS,,79012619,CDM,278,RC,,,both,,,900,666,,,666,Other,150% of Medicare + 9.63% HCRA Surcharge,405,45,,405,percent of total billed charges,Critical Access Hospital RCC factor,306,34,,306,percent of total billed charges,Implant Device,306,34,,306,percent of total billed charges,Implant Device,306,34,,306,percent of total billed charges,Implant Device,306,34,,306,percent of total billed charges,Implant Device,306,34,,306,percent of total billed charges,Implant Device,445.5,,,445.5,Other,110% of Medicare,315,35,,315,percent of total billed charges,Implant Device,306,34,"Charges > $500, x 34%",306,percent of total billed charges,Implant Device,315,35,,315,percent of total billed charges,Implant Device,315,35,,315,percent of total billed charges,Implant Device,315,35,,315,percent of total billed charges,Implant Device,315,35,,315,percent of total billed charges,Implant Device,315,35,,315,percent of total billed charges,Implant Device,360,40,,360,percent of total billed charges,Implant Device,315,70,,315,percent of total billed charges,All Other,306,34,,306,percent of total billed charges,Implant Device,306,34,,306,percent of total billed charges,Implant Device,315,35,,315,percent of total billed charges,Implant Device,315,35,,315,percent of total billed charges,Implant Device,315,35,,315,percent of total billed charges,Implant Device,315,35,,315,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,666,
TRILLIANT 308-35-014 LOCK SCREW 3.5X14MM,C1713,HCPCS,,79012620,CDM,278,RC,,,both,,,900,666,,,666,Other,150% of Medicare + 9.63% HCRA Surcharge,405,45,,405,percent of total billed charges,Critical Access Hospital RCC factor,306,34,,306,percent of total billed charges,Implant Device,306,34,,306,percent of total billed charges,Implant Device,306,34,,306,percent of total billed charges,Implant Device,306,34,,306,percent of total billed charges,Implant Device,306,34,,306,percent of total billed charges,Implant Device,445.5,,,445.5,Other,110% of Medicare,315,35,,315,percent of total billed charges,Implant Device,306,34,"Charges > $500, x 34%",306,percent of total billed charges,Implant Device,315,35,,315,percent of total billed charges,Implant Device,315,35,,315,percent of total billed charges,Implant Device,315,35,,315,percent of total billed charges,Implant Device,315,35,,315,percent of total billed charges,Implant Device,315,35,,315,percent of total billed charges,Implant Device,360,40,,360,percent of total billed charges,Implant Device,315,70,,315,percent of total billed charges,All Other,306,34,,306,percent of total billed charges,Implant Device,306,34,,306,percent of total billed charges,Implant Device,315,35,,315,percent of total billed charges,Implant Device,315,35,,315,percent of total billed charges,Implant Device,315,35,,315,percent of total billed charges,Implant Device,315,35,,315,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,666,
TRILLIANT 307-27-022 NON-LOCK SRW 2.7X22,C1713,HCPCS,,79012621,CDM,278,RC,,,both,,,540,399.6,,,399.6,Other,150% of Medicare + 9.63% HCRA Surcharge,243,45,,243,percent of total billed charges,Critical Access Hospital RCC factor,183.6,34,,183.6,percent of total billed charges,Implant Device,183.6,34,,183.6,percent of total billed charges,Implant Device,183.6,34,,183.6,percent of total billed charges,Implant Device,183.6,34,,183.6,percent of total billed charges,Implant Device,183.6,34,,183.6,percent of total billed charges,Implant Device,267.3,,,267.3,Other,110% of Medicare,189,35,,189,percent of total billed charges,Implant Device,183.6,34,"Charges > $500, x 34%",183.6,percent of total billed charges,Implant Device,189,35,,189,percent of total billed charges,Implant Device,189,35,,189,percent of total billed charges,Implant Device,189,35,,189,percent of total billed charges,Implant Device,189,35,,189,percent of total billed charges,Implant Device,189,35,,189,percent of total billed charges,Implant Device,216,40,,216,percent of total billed charges,Implant Device,189,70,,189,percent of total billed charges,All Other,183.6,34,,183.6,percent of total billed charges,Implant Device,183.6,34,,183.6,percent of total billed charges,Implant Device,189,35,,189,percent of total billed charges,Implant Device,189,35,,189,percent of total billed charges,Implant Device,189,35,,189,percent of total billed charges,Implant Device,189,35,,189,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,399.6,
TRILLIANT 201-40-040 CANN SCREW 4.0X40MM,C1713,HCPCS,,79012622,CDM,278,RC,,,both,,,900,666,,,666,Other,150% of Medicare + 9.63% HCRA Surcharge,405,45,,405,percent of total billed charges,Critical Access Hospital RCC factor,306,34,,306,percent of total billed charges,Implant Device,306,34,,306,percent of total billed charges,Implant Device,306,34,,306,percent of total billed charges,Implant Device,306,34,,306,percent of total billed charges,Implant Device,306,34,,306,percent of total billed charges,Implant Device,445.5,,,445.5,Other,110% of Medicare,315,35,,315,percent of total billed charges,Implant Device,306,34,"Charges > $500, x 34%",306,percent of total billed charges,Implant Device,315,35,,315,percent of total billed charges,Implant Device,315,35,,315,percent of total billed charges,Implant Device,315,35,,315,percent of total billed charges,Implant Device,315,35,,315,percent of total billed charges,Implant Device,315,35,,315,percent of total billed charges,Implant Device,360,40,,360,percent of total billed charges,Implant Device,315,70,,315,percent of total billed charges,All Other,306,34,,306,percent of total billed charges,Implant Device,306,34,,306,percent of total billed charges,Implant Device,315,35,,315,percent of total billed charges,Implant Device,315,35,,315,percent of total billed charges,Implant Device,315,35,,315,percent of total billed charges,Implant Device,315,35,,315,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,666,
ZIMMER 574102060 FEMORAL STEM SIZE 6.5,C1776,HCPCS,,79012629,CDM,278,RC,,,both,,,6912,5114.9,,,5114.9,Other,150% of Medicare + 9.63% HCRA Surcharge,3110.4,45,,3110.4,percent of total billed charges,Critical Access Hospital RCC factor,2350.08,34,,2350.08,percent of total billed charges,Implant Device,2350.08,34,,2350.08,percent of total billed charges,Implant Device,2350.08,34,,2350.08,percent of total billed charges,Implant Device,2350.08,34,,2350.08,percent of total billed charges,Implant Device,2350.08,34,,2350.08,percent of total billed charges,Implant Device,3421.44,,,3421.44,Other,110% of Medicare,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2350.08,34,"Charges > $500, x 34%",2350.08,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2764.8,40,,2764.8,percent of total billed charges,Implant Device,2419.2,70,,2419.2,percent of total billed charges,All Other,2350.08,34,,2350.08,percent of total billed charges,Implant Device,2350.08,34,,2350.08,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2350.08,34,"If Charge > 2,000, then 34 percent",2350.08,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5114.9,
ZIMMER 183022 FEMORAL LEFT 57.5MM,C1776,HCPCS,,79012630,CDM,278,RC,,,both,,,6300,4662.02,,,4662.02,Other,150% of Medicare + 9.63% HCRA Surcharge,2835,45,,2835,percent of total billed charges,Critical Access Hospital RCC factor,2142,34,,2142,percent of total billed charges,Implant Device,2142,34,,2142,percent of total billed charges,Implant Device,2142,34,,2142,percent of total billed charges,Implant Device,2142,34,,2142,percent of total billed charges,Implant Device,2142,34,,2142,percent of total billed charges,Implant Device,3118.5,,,3118.5,Other,110% of Medicare,2205,35,,2205,percent of total billed charges,Implant Device,2142,34,"Charges > $500, x 34%",2142,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2520,40,,2520,percent of total billed charges,Implant Device,2205,70,,2205,percent of total billed charges,All Other,2142,34,,2142,percent of total billed charges,Implant Device,2142,34,,2142,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2142,34,"If Charge > 2,000, then 34 percent",2142,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4662.02,
STRYKER 658140 HEADLESS COMP SCREW 5X40,C1713,HCPCS,,79012631,CDM,278,RC,,,both,,,964,713.36,,,713.36,Other,150% of Medicare + 9.63% HCRA Surcharge,433.8,45,,433.8,percent of total billed charges,Critical Access Hospital RCC factor,327.76,34,,327.76,percent of total billed charges,Implant Device,327.76,34,,327.76,percent of total billed charges,Implant Device,327.76,34,,327.76,percent of total billed charges,Implant Device,327.76,34,,327.76,percent of total billed charges,Implant Device,327.76,34,,327.76,percent of total billed charges,Implant Device,477.18,,,477.18,Other,110% of Medicare,337.4,35,,337.4,percent of total billed charges,Implant Device,327.76,34,"Charges > $500, x 34%",327.76,percent of total billed charges,Implant Device,337.4,35,,337.4,percent of total billed charges,Implant Device,337.4,35,,337.4,percent of total billed charges,Implant Device,337.4,35,,337.4,percent of total billed charges,Implant Device,337.4,35,,337.4,percent of total billed charges,Implant Device,337.4,35,,337.4,percent of total billed charges,Implant Device,385.6,40,,385.6,percent of total billed charges,Implant Device,337.4,70,,337.4,percent of total billed charges,All Other,327.76,34,,327.76,percent of total billed charges,Implant Device,327.76,34,,327.76,percent of total billed charges,Implant Device,337.4,35,,337.4,percent of total billed charges,Implant Device,337.4,35,,337.4,percent of total billed charges,Implant Device,337.4,35,,337.4,percent of total billed charges,Implant Device,337.4,35,,337.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,713.36,
ZIMMER EP-189044 TIBIAL BEARING 14X67MM,C1776,HCPCS,,79012634,CDM,278,RC,,,both,,,3648,2699.53,,,2699.53,Other,150% of Medicare + 9.63% HCRA Surcharge,1641.6,45,,1641.6,percent of total billed charges,Critical Access Hospital RCC factor,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1805.76,,,1805.76,Other,110% of Medicare,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1240.32,34,"Charges > $500, x 34%",1240.32,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1459.2,40,,1459.2,percent of total billed charges,Implant Device,1276.8,70,,1276.8,percent of total billed charges,All Other,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1240.32,34,"If Charge > 2,000, then 34 percent",1240.32,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2699.53,
J&J 02.112.149S DISTAL FIBULAR PLATE,C1713,HCPCS,,79012635,CDM,278,RC,,,both,,,1791,1325.34,,,1325.34,Other,150% of Medicare + 9.63% HCRA Surcharge,805.95,45,,805.95,percent of total billed charges,Critical Access Hospital RCC factor,608.94,34,,608.94,percent of total billed charges,Implant Device,608.94,34,,608.94,percent of total billed charges,Implant Device,608.94,34,,608.94,percent of total billed charges,Implant Device,608.94,34,,608.94,percent of total billed charges,Implant Device,608.94,34,,608.94,percent of total billed charges,Implant Device,886.55,,,886.55,Other,110% of Medicare,626.85,35,,626.85,percent of total billed charges,Implant Device,608.94,34,"Charges > $500, x 34%",608.94,percent of total billed charges,Implant Device,626.85,35,,626.85,percent of total billed charges,Implant Device,626.85,35,,626.85,percent of total billed charges,Implant Device,626.85,35,,626.85,percent of total billed charges,Implant Device,626.85,35,,626.85,percent of total billed charges,Implant Device,626.85,35,,626.85,percent of total billed charges,Implant Device,716.4,40,,716.4,percent of total billed charges,Implant Device,626.85,70,,626.85,percent of total billed charges,All Other,608.94,34,,608.94,percent of total billed charges,Implant Device,608.94,34,,608.94,percent of total billed charges,Implant Device,626.85,35,,626.85,percent of total billed charges,Implant Device,626.85,35,,626.85,percent of total billed charges,Implant Device,626.85,35,,626.85,percent of total billed charges,Implant Device,626.85,35,,626.85,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1325.34,
J&J 243.234 T PLATE 2.0MM 3 HOLE,C1713,HCPCS,,79012636,CDM,278,RC,,,both,,,640,473.6,,,473.6,Other,150% of Medicare + 9.63% HCRA Surcharge,288,45,,288,percent of total billed charges,Critical Access Hospital RCC factor,217.6,34,,217.6,percent of total billed charges,Implant Device,217.6,34,,217.6,percent of total billed charges,Implant Device,217.6,34,,217.6,percent of total billed charges,Implant Device,217.6,34,,217.6,percent of total billed charges,Implant Device,217.6,34,,217.6,percent of total billed charges,Implant Device,316.8,,,316.8,Other,110% of Medicare,224,35,,224,percent of total billed charges,Implant Device,217.6,34,"Charges > $500, x 34%",217.6,percent of total billed charges,Implant Device,224,35,,224,percent of total billed charges,Implant Device,224,35,,224,percent of total billed charges,Implant Device,224,35,,224,percent of total billed charges,Implant Device,224,35,,224,percent of total billed charges,Implant Device,224,35,,224,percent of total billed charges,Implant Device,256,40,,256,percent of total billed charges,Implant Device,224,70,,224,percent of total billed charges,All Other,217.6,34,,217.6,percent of total billed charges,Implant Device,217.6,34,,217.6,percent of total billed charges,Implant Device,224,35,,224,percent of total billed charges,Implant Device,224,35,,224,percent of total billed charges,Implant Device,224,35,,224,percent of total billed charges,Implant Device,224,35,,224,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,473.6,
J&J 201.700 CORTEX SCREW 2.4X60MM,C1713,HCPCS,,79012637,CDM,278,RC,,,both,,,153,113.22,,,113.22,Other,150% of Medicare + 9.63% HCRA Surcharge,68.85,45,,68.85,percent of total billed charges,Critical Access Hospital RCC factor,52.02,34,,52.02,percent of total billed charges,Implant Device,52.02,34,,52.02,percent of total billed charges,Implant Device,52.02,34,,52.02,percent of total billed charges,Implant Device,52.02,34,,52.02,percent of total billed charges,Implant Device,52.02,34,,52.02,percent of total billed charges,Implant Device,75.74,,,75.74,Other,110% of Medicare,53.55,35,,53.55,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,53.55,35,,53.55,percent of total billed charges,Implant Device,53.55,35,,53.55,percent of total billed charges,Implant Device,53.55,35,,53.55,percent of total billed charges,Implant Device,53.55,35,,53.55,percent of total billed charges,Implant Device,53.55,35,,53.55,percent of total billed charges,Implant Device,61.2,40,,61.2,percent of total billed charges,Implant Device,53.55,70,,53.55,percent of total billed charges,All Other,52.02,34,,52.02,percent of total billed charges,Implant Device,52.02,34,,52.02,percent of total billed charges,Implant Device,53.55,35,,53.55,percent of total billed charges,Implant Device,53.55,35,,53.55,percent of total billed charges,Implant Device,53.55,35,,53.55,percent of total billed charges,Implant Device,53.55,35,,53.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,113.22,
J&J 201.670 CORTEX SCREW 2.4X40MM,C1713,HCPCS,,79012638,CDM,278,RC,,,both,,,121,89.54,,,89.54,Other,150% of Medicare + 9.63% HCRA Surcharge,54.45,45,,54.45,percent of total billed charges,Critical Access Hospital RCC factor,41.14,34,,41.14,percent of total billed charges,Implant Device,41.14,34,,41.14,percent of total billed charges,Implant Device,41.14,34,,41.14,percent of total billed charges,Implant Device,41.14,34,,41.14,percent of total billed charges,Implant Device,41.14,34,,41.14,percent of total billed charges,Implant Device,59.9,,,59.9,Other,110% of Medicare,42.35,35,,42.35,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,42.35,35,,42.35,percent of total billed charges,Implant Device,42.35,35,,42.35,percent of total billed charges,Implant Device,42.35,35,,42.35,percent of total billed charges,Implant Device,42.35,35,,42.35,percent of total billed charges,Implant Device,42.35,35,,42.35,percent of total billed charges,Implant Device,48.4,40,,48.4,percent of total billed charges,Implant Device,42.35,70,,42.35,percent of total billed charges,All Other,41.14,34,,41.14,percent of total billed charges,Implant Device,41.14,34,,41.14,percent of total billed charges,Implant Device,42.35,35,,42.35,percent of total billed charges,Implant Device,42.35,35,,42.35,percent of total billed charges,Implant Device,42.35,35,,42.35,percent of total billed charges,Implant Device,42.35,35,,42.35,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,89.54,
J&J 201.658 CORTEX SCREW 2.4X28MM,C1713,HCPCS,,79012639,CDM,278,RC,,,both,,,121,89.54,,,89.54,Other,150% of Medicare + 9.63% HCRA Surcharge,54.45,45,,54.45,percent of total billed charges,Critical Access Hospital RCC factor,41.14,34,,41.14,percent of total billed charges,Implant Device,41.14,34,,41.14,percent of total billed charges,Implant Device,41.14,34,,41.14,percent of total billed charges,Implant Device,41.14,34,,41.14,percent of total billed charges,Implant Device,41.14,34,,41.14,percent of total billed charges,Implant Device,59.9,,,59.9,Other,110% of Medicare,42.35,35,,42.35,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,42.35,35,,42.35,percent of total billed charges,Implant Device,42.35,35,,42.35,percent of total billed charges,Implant Device,42.35,35,,42.35,percent of total billed charges,Implant Device,42.35,35,,42.35,percent of total billed charges,Implant Device,42.35,35,,42.35,percent of total billed charges,Implant Device,48.4,40,,48.4,percent of total billed charges,Implant Device,42.35,70,,42.35,percent of total billed charges,All Other,41.14,34,,41.14,percent of total billed charges,Implant Device,41.14,34,,41.14,percent of total billed charges,Implant Device,42.35,35,,42.35,percent of total billed charges,Implant Device,42.35,35,,42.35,percent of total billed charges,Implant Device,42.35,35,,42.35,percent of total billed charges,Implant Device,42.35,35,,42.35,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,89.54,
J&J 201.656 CORTEX SCREW 2.4X26MM,C1713,HCPCS,,79012640,CDM,278,RC,,,both,,,121,89.54,,,89.54,Other,150% of Medicare + 9.63% HCRA Surcharge,54.45,45,,54.45,percent of total billed charges,Critical Access Hospital RCC factor,41.14,34,,41.14,percent of total billed charges,Implant Device,41.14,34,,41.14,percent of total billed charges,Implant Device,41.14,34,,41.14,percent of total billed charges,Implant Device,41.14,34,,41.14,percent of total billed charges,Implant Device,41.14,34,,41.14,percent of total billed charges,Implant Device,59.9,,,59.9,Other,110% of Medicare,42.35,35,,42.35,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,42.35,35,,42.35,percent of total billed charges,Implant Device,42.35,35,,42.35,percent of total billed charges,Implant Device,42.35,35,,42.35,percent of total billed charges,Implant Device,42.35,35,,42.35,percent of total billed charges,Implant Device,42.35,35,,42.35,percent of total billed charges,Implant Device,48.4,40,,48.4,percent of total billed charges,Implant Device,42.35,70,,42.35,percent of total billed charges,All Other,41.14,34,,41.14,percent of total billed charges,Implant Device,41.14,34,,41.14,percent of total billed charges,Implant Device,42.35,35,,42.35,percent of total billed charges,Implant Device,42.35,35,,42.35,percent of total billed charges,Implant Device,42.35,35,,42.35,percent of total billed charges,Implant Device,42.35,35,,42.35,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,89.54,
J&J 201.666 CORTEX SCREW 2.4X36MM,C1713,HCPCS,,79012641,CDM,278,RC,,,both,,,121,89.54,,,89.54,Other,150% of Medicare + 9.63% HCRA Surcharge,54.45,45,,54.45,percent of total billed charges,Critical Access Hospital RCC factor,41.14,34,,41.14,percent of total billed charges,Implant Device,41.14,34,,41.14,percent of total billed charges,Implant Device,41.14,34,,41.14,percent of total billed charges,Implant Device,41.14,34,,41.14,percent of total billed charges,Implant Device,41.14,34,,41.14,percent of total billed charges,Implant Device,59.9,,,59.9,Other,110% of Medicare,42.35,35,,42.35,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,42.35,35,,42.35,percent of total billed charges,Implant Device,42.35,35,,42.35,percent of total billed charges,Implant Device,42.35,35,,42.35,percent of total billed charges,Implant Device,42.35,35,,42.35,percent of total billed charges,Implant Device,42.35,35,,42.35,percent of total billed charges,Implant Device,48.4,40,,48.4,percent of total billed charges,Implant Device,42.35,70,,42.35,percent of total billed charges,All Other,41.14,34,,41.14,percent of total billed charges,Implant Device,41.14,34,,41.14,percent of total billed charges,Implant Device,42.35,35,,42.35,percent of total billed charges,Implant Device,42.35,35,,42.35,percent of total billed charges,Implant Device,42.35,35,,42.35,percent of total billed charges,Implant Device,42.35,35,,42.35,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,89.54,
J&J 201.699 CORTEX SCREW 2.4X58MM,C1713,HCPCS,,79012642,CDM,278,RC,,,both,,,153,113.22,,,113.22,Other,150% of Medicare + 9.63% HCRA Surcharge,68.85,45,,68.85,percent of total billed charges,Critical Access Hospital RCC factor,52.02,34,,52.02,percent of total billed charges,Implant Device,52.02,34,,52.02,percent of total billed charges,Implant Device,52.02,34,,52.02,percent of total billed charges,Implant Device,52.02,34,,52.02,percent of total billed charges,Implant Device,52.02,34,,52.02,percent of total billed charges,Implant Device,75.74,,,75.74,Other,110% of Medicare,53.55,35,,53.55,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,53.55,35,,53.55,percent of total billed charges,Implant Device,53.55,35,,53.55,percent of total billed charges,Implant Device,53.55,35,,53.55,percent of total billed charges,Implant Device,53.55,35,,53.55,percent of total billed charges,Implant Device,53.55,35,,53.55,percent of total billed charges,Implant Device,61.2,40,,61.2,percent of total billed charges,Implant Device,53.55,70,,53.55,percent of total billed charges,All Other,52.02,34,,52.02,percent of total billed charges,Implant Device,52.02,34,,52.02,percent of total billed charges,Implant Device,53.55,35,,53.55,percent of total billed charges,Implant Device,53.55,35,,53.55,percent of total billed charges,Implant Device,53.55,35,,53.55,percent of total billed charges,Implant Device,53.55,35,,53.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,113.22,
J&J 247.615 LCP T PLATE 2.0MM,C1713,HCPCS,,79012643,CDM,278,RC,,,both,,,1105,817.7,,,817.7,Other,150% of Medicare + 9.63% HCRA Surcharge,497.25,45,,497.25,percent of total billed charges,Critical Access Hospital RCC factor,375.7,34,,375.7,percent of total billed charges,Implant Device,375.7,34,,375.7,percent of total billed charges,Implant Device,375.7,34,,375.7,percent of total billed charges,Implant Device,375.7,34,,375.7,percent of total billed charges,Implant Device,375.7,34,,375.7,percent of total billed charges,Implant Device,546.98,,,546.98,Other,110% of Medicare,386.75,35,,386.75,percent of total billed charges,Implant Device,375.7,34,"Charges > $500, x 34%",375.7,percent of total billed charges,Implant Device,386.75,35,,386.75,percent of total billed charges,Implant Device,386.75,35,,386.75,percent of total billed charges,Implant Device,386.75,35,,386.75,percent of total billed charges,Implant Device,386.75,35,,386.75,percent of total billed charges,Implant Device,386.75,35,,386.75,percent of total billed charges,Implant Device,442,40,,442,percent of total billed charges,Implant Device,386.75,70,,386.75,percent of total billed charges,All Other,375.7,34,,375.7,percent of total billed charges,Implant Device,375.7,34,,375.7,percent of total billed charges,Implant Device,386.75,35,,386.75,percent of total billed charges,Implant Device,386.75,35,,386.75,percent of total billed charges,Implant Device,386.75,35,,386.75,percent of total billed charges,Implant Device,386.75,35,,386.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,817.7,
J&J 201.786 CORTEX SCREW 2.4X36MM,C1713,HCPCS,,79012644,CDM,278,RC,,,both,,,130,96.2,,,96.2,Other,150% of Medicare + 9.63% HCRA Surcharge,58.5,45,,58.5,percent of total billed charges,Critical Access Hospital RCC factor,44.2,34,,44.2,percent of total billed charges,Implant Device,44.2,34,,44.2,percent of total billed charges,Implant Device,44.2,34,,44.2,percent of total billed charges,Implant Device,44.2,34,,44.2,percent of total billed charges,Implant Device,44.2,34,,44.2,percent of total billed charges,Implant Device,64.35,,,64.35,Other,110% of Medicare,45.5,35,,45.5,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,45.5,35,,45.5,percent of total billed charges,Implant Device,45.5,35,,45.5,percent of total billed charges,Implant Device,45.5,35,,45.5,percent of total billed charges,Implant Device,45.5,35,,45.5,percent of total billed charges,Implant Device,45.5,35,,45.5,percent of total billed charges,Implant Device,52,40,,52,percent of total billed charges,Implant Device,45.5,70,,45.5,percent of total billed charges,All Other,44.2,34,,44.2,percent of total billed charges,Implant Device,44.2,34,,44.2,percent of total billed charges,Implant Device,45.5,35,,45.5,percent of total billed charges,Implant Device,45.5,35,,45.5,percent of total billed charges,Implant Device,45.5,35,,45.5,percent of total billed charges,Implant Device,45.5,35,,45.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,96.2,
J&J 02.112.144S LCP DISTAL FIB PLT 7H,C1713,HCPCS,,79012645,CDM,278,RC,,,both,,,1767,1307.58,,,1307.58,Other,150% of Medicare + 9.63% HCRA Surcharge,795.15,45,,795.15,percent of total billed charges,Critical Access Hospital RCC factor,600.78,34,,600.78,percent of total billed charges,Implant Device,600.78,34,,600.78,percent of total billed charges,Implant Device,600.78,34,,600.78,percent of total billed charges,Implant Device,600.78,34,,600.78,percent of total billed charges,Implant Device,600.78,34,,600.78,percent of total billed charges,Implant Device,874.67,,,874.67,Other,110% of Medicare,618.45,35,,618.45,percent of total billed charges,Implant Device,600.78,34,"Charges > $500, x 34%",600.78,percent of total billed charges,Implant Device,618.45,35,,618.45,percent of total billed charges,Implant Device,618.45,35,,618.45,percent of total billed charges,Implant Device,618.45,35,,618.45,percent of total billed charges,Implant Device,618.45,35,,618.45,percent of total billed charges,Implant Device,618.45,35,,618.45,percent of total billed charges,Implant Device,706.8,40,,706.8,percent of total billed charges,Implant Device,618.45,70,,618.45,percent of total billed charges,All Other,600.78,34,,600.78,percent of total billed charges,Implant Device,600.78,34,,600.78,percent of total billed charges,Implant Device,618.45,35,,618.45,percent of total billed charges,Implant Device,618.45,35,,618.45,percent of total billed charges,Implant Device,618.45,35,,618.45,percent of total billed charges,Implant Device,618.45,35,,618.45,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1307.58,
ANGIODYNAMICS H965458800 BIO-STABLE 4FR,C1751,HCPCS,,79012649,CDM,278,RC,,,both,,,816,603.84,,,603.84,Other,150% of Medicare + 9.63% HCRA Surcharge,367.2,45,,367.2,percent of total billed charges,Critical Access Hospital RCC factor,277.44,34,,277.44,percent of total billed charges,Implant Device,277.44,34,,277.44,percent of total billed charges,Implant Device,277.44,34,,277.44,percent of total billed charges,Implant Device,277.44,34,,277.44,percent of total billed charges,Implant Device,277.44,34,,277.44,percent of total billed charges,Implant Device,403.92,,,403.92,Other,110% of Medicare,285.6,35,,285.6,percent of total billed charges,Implant Device,277.44,34,"Charges > $500, x 34%",277.44,percent of total billed charges,Implant Device,285.6,35,,285.6,percent of total billed charges,Implant Device,285.6,35,,285.6,percent of total billed charges,Implant Device,285.6,35,,285.6,percent of total billed charges,Implant Device,285.6,35,,285.6,percent of total billed charges,Implant Device,285.6,35,,285.6,percent of total billed charges,Implant Device,326.4,40,,326.4,percent of total billed charges,Implant Device,285.6,70,,285.6,percent of total billed charges,All Other,277.44,34,,277.44,percent of total billed charges,Implant Device,277.44,34,,277.44,percent of total billed charges,Implant Device,285.6,35,,285.6,percent of total billed charges,Implant Device,285.6,35,,285.6,percent of total billed charges,Implant Device,285.6,35,,285.6,percent of total billed charges,Implant Device,285.6,35,,285.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,603.84,
ANGIODYNAMICS H965750171 BIOFLO PICC 55,C1751,HCPCS,,79012650,CDM,278,RC,,,both,,,599,443.26,,,443.26,Other,150% of Medicare + 9.63% HCRA Surcharge,269.55,45,,269.55,percent of total billed charges,Critical Access Hospital RCC factor,203.66,34,,203.66,percent of total billed charges,Implant Device,203.66,34,,203.66,percent of total billed charges,Implant Device,203.66,34,,203.66,percent of total billed charges,Implant Device,203.66,34,,203.66,percent of total billed charges,Implant Device,203.66,34,,203.66,percent of total billed charges,Implant Device,296.51,,,296.51,Other,110% of Medicare,209.65,35,,209.65,percent of total billed charges,Implant Device,203.66,34,"Charges > $500, x 34%",203.66,percent of total billed charges,Implant Device,209.65,35,,209.65,percent of total billed charges,Implant Device,209.65,35,,209.65,percent of total billed charges,Implant Device,209.65,35,,209.65,percent of total billed charges,Implant Device,209.65,35,,209.65,percent of total billed charges,Implant Device,209.65,35,,209.65,percent of total billed charges,Implant Device,239.6,40,,239.6,percent of total billed charges,Implant Device,209.65,70,,209.65,percent of total billed charges,All Other,203.66,34,,203.66,percent of total billed charges,Implant Device,203.66,34,,203.66,percent of total billed charges,Implant Device,209.65,35,,209.65,percent of total billed charges,Implant Device,209.65,35,,209.65,percent of total billed charges,Implant Device,209.65,35,,209.65,percent of total billed charges,Implant Device,209.65,35,,209.65,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,443.26,
J&J 02.104.010 LCP DIS HUMERUS PLT 3.5MM,C1713,HCPCS,,79012651,CDM,278,RC,,,both,,,3927,2905.99,,,2905.99,Other,150% of Medicare + 9.63% HCRA Surcharge,1767.15,45,,1767.15,percent of total billed charges,Critical Access Hospital RCC factor,1335.18,34,,1335.18,percent of total billed charges,Implant Device,1335.18,34,,1335.18,percent of total billed charges,Implant Device,1335.18,34,,1335.18,percent of total billed charges,Implant Device,1335.18,34,,1335.18,percent of total billed charges,Implant Device,1335.18,34,,1335.18,percent of total billed charges,Implant Device,1943.87,,,1943.87,Other,110% of Medicare,1374.45,35,,1374.45,percent of total billed charges,Implant Device,1335.18,34,"Charges > $500, x 34%",1335.18,percent of total billed charges,Implant Device,1374.45,35,,1374.45,percent of total billed charges,Implant Device,1374.45,35,,1374.45,percent of total billed charges,Implant Device,1374.45,35,,1374.45,percent of total billed charges,Implant Device,1374.45,35,,1374.45,percent of total billed charges,Implant Device,1374.45,35,,1374.45,percent of total billed charges,Implant Device,1570.8,40,,1570.8,percent of total billed charges,Implant Device,1374.45,70,,1374.45,percent of total billed charges,All Other,1335.18,34,,1335.18,percent of total billed charges,Implant Device,1335.18,34,,1335.18,percent of total billed charges,Implant Device,1374.45,35,,1374.45,percent of total billed charges,Implant Device,1374.45,35,,1374.45,percent of total billed charges,Implant Device,1374.45,35,,1374.45,percent of total billed charges,Implant Device,1374.45,35,,1374.45,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1335.18,34,"If Charge > 2,000, then 34 percent",1335.18,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2905.99,
J&J 02.115.151 DISTAL RADIUS 90 DEG PLT,C1713,HCPCS,,79012652,CDM,278,RC,,,both,,,1405,1039.7,,,1039.7,Other,150% of Medicare + 9.63% HCRA Surcharge,632.25,45,,632.25,percent of total billed charges,Critical Access Hospital RCC factor,477.7,34,,477.7,percent of total billed charges,Implant Device,477.7,34,,477.7,percent of total billed charges,Implant Device,477.7,34,,477.7,percent of total billed charges,Implant Device,477.7,34,,477.7,percent of total billed charges,Implant Device,477.7,34,,477.7,percent of total billed charges,Implant Device,695.48,,,695.48,Other,110% of Medicare,491.75,35,,491.75,percent of total billed charges,Implant Device,477.7,34,"Charges > $500, x 34%",477.7,percent of total billed charges,Implant Device,491.75,35,,491.75,percent of total billed charges,Implant Device,491.75,35,,491.75,percent of total billed charges,Implant Device,491.75,35,,491.75,percent of total billed charges,Implant Device,491.75,35,,491.75,percent of total billed charges,Implant Device,491.75,35,,491.75,percent of total billed charges,Implant Device,562,40,,562,percent of total billed charges,Implant Device,491.75,70,,491.75,percent of total billed charges,All Other,477.7,34,,477.7,percent of total billed charges,Implant Device,477.7,34,,477.7,percent of total billed charges,Implant Device,491.75,35,,491.75,percent of total billed charges,Implant Device,491.75,35,,491.75,percent of total billed charges,Implant Device,491.75,35,,491.75,percent of total billed charges,Implant Device,491.75,35,,491.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1039.7,
ZIMMER 183013 FEMORAL RIGHT 72.5MM,C1776,HCPCS,,79012653,CDM,278,RC,,,both,,,6300,4662.02,,,4662.02,Other,150% of Medicare + 9.63% HCRA Surcharge,2835,45,,2835,percent of total billed charges,Critical Access Hospital RCC factor,2142,34,,2142,percent of total billed charges,Implant Device,2142,34,,2142,percent of total billed charges,Implant Device,2142,34,,2142,percent of total billed charges,Implant Device,2142,34,,2142,percent of total billed charges,Implant Device,2142,34,,2142,percent of total billed charges,Implant Device,3118.5,,,3118.5,Other,110% of Medicare,2205,35,,2205,percent of total billed charges,Implant Device,2142,34,"Charges > $500, x 34%",2142,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2520,40,,2520,percent of total billed charges,Implant Device,2205,70,,2205,percent of total billed charges,All Other,2142,34,,2142,percent of total billed charges,Implant Device,2142,34,,2142,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2142,34,"If Charge > 2,000, then 34 percent",2142,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4662.02,
ARTHREX AR-8973R-30-130 FIBULOK NAIL RT,C1713,HCPCS,,79012654,CDM,278,RC,,,both,,,8985,6648.92,,,6648.92,Other,150% of Medicare + 9.63% HCRA Surcharge,4043.25,45,,4043.25,percent of total billed charges,Critical Access Hospital RCC factor,3054.9,34,,3054.9,percent of total billed charges,Implant Device,3054.9,34,,3054.9,percent of total billed charges,Implant Device,3054.9,34,,3054.9,percent of total billed charges,Implant Device,3054.9,34,,3054.9,percent of total billed charges,Implant Device,3054.9,34,,3054.9,percent of total billed charges,Implant Device,4447.58,,,4447.58,Other,110% of Medicare,3144.75,35,,3144.75,percent of total billed charges,Implant Device,3054.9,34,"Charges > $500, x 34%",3054.9,percent of total billed charges,Implant Device,3144.75,35,,3144.75,percent of total billed charges,Implant Device,3144.75,35,,3144.75,percent of total billed charges,Implant Device,3144.75,35,,3144.75,percent of total billed charges,Implant Device,3144.75,35,,3144.75,percent of total billed charges,Implant Device,3144.75,35,,3144.75,percent of total billed charges,Implant Device,3594,40,,3594,percent of total billed charges,Implant Device,3144.75,70,,3144.75,percent of total billed charges,All Other,3054.9,34,,3054.9,percent of total billed charges,Implant Device,3054.9,34,,3054.9,percent of total billed charges,Implant Device,3144.75,35,,3144.75,percent of total billed charges,Implant Device,3144.75,35,,3144.75,percent of total billed charges,Implant Device,3144.75,35,,3144.75,percent of total billed charges,Implant Device,3144.75,35,,3144.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3054.9,34,"If Charge > 2,000, then 34 percent",3054.9,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,6648.92,
ARTHREX AR-8827-16 CORT SCREW 2.7X16MM,C1713,HCPCS,,79012655,CDM,278,RC,,,both,,,135,99.9,,,99.9,Other,150% of Medicare + 9.63% HCRA Surcharge,60.75,45,,60.75,percent of total billed charges,Critical Access Hospital RCC factor,45.9,34,,45.9,percent of total billed charges,Implant Device,45.9,34,,45.9,percent of total billed charges,Implant Device,45.9,34,,45.9,percent of total billed charges,Implant Device,45.9,34,,45.9,percent of total billed charges,Implant Device,45.9,34,,45.9,percent of total billed charges,Implant Device,66.83,,,66.83,Other,110% of Medicare,47.25,35,,47.25,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,47.25,35,,47.25,percent of total billed charges,Implant Device,47.25,35,,47.25,percent of total billed charges,Implant Device,47.25,35,,47.25,percent of total billed charges,Implant Device,47.25,35,,47.25,percent of total billed charges,Implant Device,47.25,35,,47.25,percent of total billed charges,Implant Device,54,40,,54,percent of total billed charges,Implant Device,47.25,70,,47.25,percent of total billed charges,All Other,45.9,34,,45.9,percent of total billed charges,Implant Device,45.9,34,,45.9,percent of total billed charges,Implant Device,47.25,35,,47.25,percent of total billed charges,Implant Device,47.25,35,,47.25,percent of total billed charges,Implant Device,47.25,35,,47.25,percent of total billed charges,Implant Device,47.25,35,,47.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,99.9,
ARTHREX AR-8827-20 CORT SCREW 2.7X20MM,C1713,HCPCS,,79012656,CDM,278,RC,,,both,,,135,99.9,,,99.9,Other,150% of Medicare + 9.63% HCRA Surcharge,60.75,45,,60.75,percent of total billed charges,Critical Access Hospital RCC factor,45.9,34,,45.9,percent of total billed charges,Implant Device,45.9,34,,45.9,percent of total billed charges,Implant Device,45.9,34,,45.9,percent of total billed charges,Implant Device,45.9,34,,45.9,percent of total billed charges,Implant Device,45.9,34,,45.9,percent of total billed charges,Implant Device,66.83,,,66.83,Other,110% of Medicare,47.25,35,,47.25,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,47.25,35,,47.25,percent of total billed charges,Implant Device,47.25,35,,47.25,percent of total billed charges,Implant Device,47.25,35,,47.25,percent of total billed charges,Implant Device,47.25,35,,47.25,percent of total billed charges,Implant Device,47.25,35,,47.25,percent of total billed charges,Implant Device,54,40,,54,percent of total billed charges,Implant Device,47.25,70,,47.25,percent of total billed charges,All Other,45.9,34,,45.9,percent of total billed charges,Implant Device,45.9,34,,45.9,percent of total billed charges,Implant Device,47.25,35,,47.25,percent of total billed charges,Implant Device,47.25,35,,47.25,percent of total billed charges,Implant Device,47.25,35,,47.25,percent of total billed charges,Implant Device,47.25,35,,47.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,99.9,
ARTHREX AR-8827-22 CORT SCREW 2.6X22MM,C1713,HCPCS,,79012657,CDM,278,RC,,,both,,,135,99.9,,,99.9,Other,150% of Medicare + 9.63% HCRA Surcharge,60.75,45,,60.75,percent of total billed charges,Critical Access Hospital RCC factor,45.9,34,,45.9,percent of total billed charges,Implant Device,45.9,34,,45.9,percent of total billed charges,Implant Device,45.9,34,,45.9,percent of total billed charges,Implant Device,45.9,34,,45.9,percent of total billed charges,Implant Device,45.9,34,,45.9,percent of total billed charges,Implant Device,66.83,,,66.83,Other,110% of Medicare,47.25,35,,47.25,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,47.25,35,,47.25,percent of total billed charges,Implant Device,47.25,35,,47.25,percent of total billed charges,Implant Device,47.25,35,,47.25,percent of total billed charges,Implant Device,47.25,35,,47.25,percent of total billed charges,Implant Device,47.25,35,,47.25,percent of total billed charges,Implant Device,54,40,,54,percent of total billed charges,Implant Device,47.25,70,,47.25,percent of total billed charges,All Other,45.9,34,,45.9,percent of total billed charges,Implant Device,45.9,34,,45.9,percent of total billed charges,Implant Device,47.25,35,,47.25,percent of total billed charges,Implant Device,47.25,35,,47.25,percent of total billed charges,Implant Device,47.25,35,,47.25,percent of total billed charges,Implant Device,47.25,35,,47.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,99.9,
STRYKER 723-00-36D TRIDENT INSERT 36MM,C1776,HCPCS,,79012658,CDM,278,RC,,,both,,,2503,1852.23,,,1852.23,Other,150% of Medicare + 9.63% HCRA Surcharge,1126.35,45,,1126.35,percent of total billed charges,Critical Access Hospital RCC factor,851.02,34,,851.02,percent of total billed charges,Implant Device,851.02,34,,851.02,percent of total billed charges,Implant Device,851.02,34,,851.02,percent of total billed charges,Implant Device,851.02,34,,851.02,percent of total billed charges,Implant Device,851.02,34,,851.02,percent of total billed charges,Implant Device,1238.99,,,1238.99,Other,110% of Medicare,876.05,35,,876.05,percent of total billed charges,Implant Device,851.02,34,"Charges > $500, x 34%",851.02,percent of total billed charges,Implant Device,876.05,35,,876.05,percent of total billed charges,Implant Device,876.05,35,,876.05,percent of total billed charges,Implant Device,876.05,35,,876.05,percent of total billed charges,Implant Device,876.05,35,,876.05,percent of total billed charges,Implant Device,876.05,35,,876.05,percent of total billed charges,Implant Device,1001.2,40,,1001.2,percent of total billed charges,Implant Device,876.05,70,,876.05,percent of total billed charges,All Other,851.02,34,,851.02,percent of total billed charges,Implant Device,851.02,34,,851.02,percent of total billed charges,Implant Device,876.05,35,,876.05,percent of total billed charges,Implant Device,876.05,35,,876.05,percent of total billed charges,Implant Device,876.05,35,,876.05,percent of total billed charges,Implant Device,876.05,35,,876.05,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,851.02,34,"If Charge > 2,000, then 34 percent",851.02,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1852.23,
MEDTRONIC 2307-0110-N TAS IMPLANT 7 DEG,L8699,HCPCS,,79012660,CDM,278,RC,,,both,,,27150,20091.07,,,20091.07,Other,150% of Medicare + 9.63% HCRA Surcharge,12217.5,45,,12217.5,percent of total billed charges,Critical Access Hospital RCC factor,9231,34,,9231,percent of total billed charges,Implant Device,9231,34,,9231,percent of total billed charges,Implant Device,9231,34,,9231,percent of total billed charges,Implant Device,9231,34,,9231,percent of total billed charges,Implant Device,9231,34,,9231,percent of total billed charges,Implant Device,13439.25,,,13439.25,Other,110% of Medicare,9502.5,35,,9502.5,percent of total billed charges,Implant Device,9231,34,"Charges > $500, x 34%",9231,percent of total billed charges,Implant Device,9502.5,35,,9502.5,percent of total billed charges,Implant Device,9502.5,35,,9502.5,percent of total billed charges,Implant Device,9502.5,35,,9502.5,percent of total billed charges,Implant Device,9502.5,35,,9502.5,percent of total billed charges,Implant Device,9502.5,35,,9502.5,percent of total billed charges,Implant Device,10860,40,,10860,percent of total billed charges,Implant Device,9502.5,70,,9502.5,percent of total billed charges,All Other,9231,34,,9231,percent of total billed charges,Implant Device,9231,34,,9231,percent of total billed charges,Implant Device,9502.5,35,,9502.5,percent of total billed charges,Implant Device,9502.5,35,,9502.5,percent of total billed charges,Implant Device,9502.5,35,,9502.5,percent of total billed charges,Implant Device,9502.5,35,,9502.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,9231,34,"If Charge > 2,000, then 34 percent",9231,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,20091.07,
MEDTRONIC 2300-5525 TAS SCREW 5.5X25MM,C1713,HCPCS,,79012661,CDM,278,RC,,,both,,,525,388.5,,,388.5,Other,150% of Medicare + 9.63% HCRA Surcharge,236.25,45,,236.25,percent of total billed charges,Critical Access Hospital RCC factor,178.5,34,,178.5,percent of total billed charges,Implant Device,178.5,34,,178.5,percent of total billed charges,Implant Device,178.5,34,,178.5,percent of total billed charges,Implant Device,178.5,34,,178.5,percent of total billed charges,Implant Device,178.5,34,,178.5,percent of total billed charges,Implant Device,259.88,,,259.88,Other,110% of Medicare,183.75,35,,183.75,percent of total billed charges,Implant Device,178.5,34,"Charges > $500, x 34%",178.5,percent of total billed charges,Implant Device,183.75,35,,183.75,percent of total billed charges,Implant Device,183.75,35,,183.75,percent of total billed charges,Implant Device,183.75,35,,183.75,percent of total billed charges,Implant Device,183.75,35,,183.75,percent of total billed charges,Implant Device,183.75,35,,183.75,percent of total billed charges,Implant Device,210,40,,210,percent of total billed charges,Implant Device,183.75,70,,183.75,percent of total billed charges,All Other,178.5,34,,178.5,percent of total billed charges,Implant Device,178.5,34,,178.5,percent of total billed charges,Implant Device,183.75,35,,183.75,percent of total billed charges,Implant Device,183.75,35,,183.75,percent of total billed charges,Implant Device,183.75,35,,183.75,percent of total billed charges,Implant Device,183.75,35,,183.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,388.5,
J&J 202.828 CORTEX SCREW 2.7X28MM,C1713,HCPCS,,79012662,CDM,278,RC,,,both,,,85,62.9,,,62.9,Other,150% of Medicare + 9.63% HCRA Surcharge,38.25,45,,38.25,percent of total billed charges,Critical Access Hospital RCC factor,28.9,34,,28.9,percent of total billed charges,Implant Device,28.9,34,,28.9,percent of total billed charges,Implant Device,28.9,34,,28.9,percent of total billed charges,Implant Device,28.9,34,,28.9,percent of total billed charges,Implant Device,28.9,34,,28.9,percent of total billed charges,Implant Device,42.08,,,42.08,Other,110% of Medicare,29.75,35,,29.75,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,29.75,35,,29.75,percent of total billed charges,Implant Device,29.75,35,,29.75,percent of total billed charges,Implant Device,29.75,35,,29.75,percent of total billed charges,Implant Device,29.75,35,,29.75,percent of total billed charges,Implant Device,29.75,35,,29.75,percent of total billed charges,Implant Device,34,40,,34,percent of total billed charges,Implant Device,29.75,70,,29.75,percent of total billed charges,All Other,28.9,34,,28.9,percent of total billed charges,Implant Device,28.9,34,,28.9,percent of total billed charges,Implant Device,29.75,35,,29.75,percent of total billed charges,Implant Device,29.75,35,,29.75,percent of total billed charges,Implant Device,29.75,35,,29.75,percent of total billed charges,Implant Device,29.75,35,,29.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,62.9,
J&J 202.830 CORTEX SCREW 2.7X30MM,C1713,HCPCS,,79012663,CDM,278,RC,,,both,,,85,62.9,,,62.9,Other,150% of Medicare + 9.63% HCRA Surcharge,38.25,45,,38.25,percent of total billed charges,Critical Access Hospital RCC factor,28.9,34,,28.9,percent of total billed charges,Implant Device,28.9,34,,28.9,percent of total billed charges,Implant Device,28.9,34,,28.9,percent of total billed charges,Implant Device,28.9,34,,28.9,percent of total billed charges,Implant Device,28.9,34,,28.9,percent of total billed charges,Implant Device,42.08,,,42.08,Other,110% of Medicare,29.75,35,,29.75,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,29.75,35,,29.75,percent of total billed charges,Implant Device,29.75,35,,29.75,percent of total billed charges,Implant Device,29.75,35,,29.75,percent of total billed charges,Implant Device,29.75,35,,29.75,percent of total billed charges,Implant Device,29.75,35,,29.75,percent of total billed charges,Implant Device,34,40,,34,percent of total billed charges,Implant Device,29.75,70,,29.75,percent of total billed charges,All Other,28.9,34,,28.9,percent of total billed charges,Implant Device,28.9,34,,28.9,percent of total billed charges,Implant Device,29.75,35,,29.75,percent of total billed charges,Implant Device,29.75,35,,29.75,percent of total billed charges,Implant Device,29.75,35,,29.75,percent of total billed charges,Implant Device,29.75,35,,29.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,62.9,
J&J 02.104.008 LCP DIS RAD PLT 8H 3.5MM,C1713,HCPCS,,79012664,CDM,278,RC,,,both,,,3711,2746.15,,,2746.15,Other,150% of Medicare + 9.63% HCRA Surcharge,1669.95,45,,1669.95,percent of total billed charges,Critical Access Hospital RCC factor,1261.74,34,,1261.74,percent of total billed charges,Implant Device,1261.74,34,,1261.74,percent of total billed charges,Implant Device,1261.74,34,,1261.74,percent of total billed charges,Implant Device,1261.74,34,,1261.74,percent of total billed charges,Implant Device,1261.74,34,,1261.74,percent of total billed charges,Implant Device,1836.95,,,1836.95,Other,110% of Medicare,1298.85,35,,1298.85,percent of total billed charges,Implant Device,1261.74,34,"Charges > $500, x 34%",1261.74,percent of total billed charges,Implant Device,1298.85,35,,1298.85,percent of total billed charges,Implant Device,1298.85,35,,1298.85,percent of total billed charges,Implant Device,1298.85,35,,1298.85,percent of total billed charges,Implant Device,1298.85,35,,1298.85,percent of total billed charges,Implant Device,1298.85,35,,1298.85,percent of total billed charges,Implant Device,1484.4,40,,1484.4,percent of total billed charges,Implant Device,1298.85,70,,1298.85,percent of total billed charges,All Other,1261.74,34,,1261.74,percent of total billed charges,Implant Device,1261.74,34,,1261.74,percent of total billed charges,Implant Device,1298.85,35,,1298.85,percent of total billed charges,Implant Device,1298.85,35,,1298.85,percent of total billed charges,Implant Device,1298.85,35,,1298.85,percent of total billed charges,Implant Device,1298.85,35,,1298.85,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1261.74,34,"If Charge > 2,000, then 34 percent",1261.74,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2746.15,
J&J 294.772 SCHANZ SCREW 4.0X100MM,C1713,HCPCS,,79012665,CDM,278,RC,,,both,,,272,201.28,,,201.28,Other,150% of Medicare + 9.63% HCRA Surcharge,122.4,45,,122.4,percent of total billed charges,Critical Access Hospital RCC factor,92.48,34,,92.48,percent of total billed charges,Implant Device,92.48,34,,92.48,percent of total billed charges,Implant Device,92.48,34,,92.48,percent of total billed charges,Implant Device,92.48,34,,92.48,percent of total billed charges,Implant Device,92.48,34,,92.48,percent of total billed charges,Implant Device,134.64,,,134.64,Other,110% of Medicare,95.2,35,,95.2,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,95.2,35,,95.2,percent of total billed charges,Implant Device,95.2,35,,95.2,percent of total billed charges,Implant Device,95.2,35,,95.2,percent of total billed charges,Implant Device,95.2,35,,95.2,percent of total billed charges,Implant Device,95.2,35,,95.2,percent of total billed charges,Implant Device,108.8,40,,108.8,percent of total billed charges,Implant Device,95.2,70,,95.2,percent of total billed charges,All Other,92.48,34,,92.48,percent of total billed charges,Implant Device,92.48,34,,92.48,percent of total billed charges,Implant Device,95.2,35,,95.2,percent of total billed charges,Implant Device,95.2,35,,95.2,percent of total billed charges,Implant Device,95.2,35,,95.2,percent of total billed charges,Implant Device,95.2,35,,95.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,201.28,
J&J 02.111.651 DISTAL RADIUS PLT H 2.4MM,C1713,HCPCS,,79012668,CDM,278,RC,,,both,,,2499,1849.27,,,1849.27,Other,150% of Medicare + 9.63% HCRA Surcharge,1124.55,45,,1124.55,percent of total billed charges,Critical Access Hospital RCC factor,849.66,34,,849.66,percent of total billed charges,Implant Device,849.66,34,,849.66,percent of total billed charges,Implant Device,849.66,34,,849.66,percent of total billed charges,Implant Device,849.66,34,,849.66,percent of total billed charges,Implant Device,849.66,34,,849.66,percent of total billed charges,Implant Device,1237.01,,,1237.01,Other,110% of Medicare,874.65,35,,874.65,percent of total billed charges,Implant Device,849.66,34,"Charges > $500, x 34%",849.66,percent of total billed charges,Implant Device,874.65,35,,874.65,percent of total billed charges,Implant Device,874.65,35,,874.65,percent of total billed charges,Implant Device,874.65,35,,874.65,percent of total billed charges,Implant Device,874.65,35,,874.65,percent of total billed charges,Implant Device,874.65,35,,874.65,percent of total billed charges,Implant Device,999.6,40,,999.6,percent of total billed charges,Implant Device,874.65,70,,874.65,percent of total billed charges,All Other,849.66,34,,849.66,percent of total billed charges,Implant Device,849.66,34,,849.66,percent of total billed charges,Implant Device,874.65,35,,874.65,percent of total billed charges,Implant Device,874.65,35,,874.65,percent of total billed charges,Implant Device,874.65,35,,874.65,percent of total billed charges,Implant Device,874.65,35,,874.65,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,849.66,34,"If Charge > 2,000, then 34 percent",849.66,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1849.27,
J&J 249.679 LCP CONDYLAR PLT 7H 2.4MM,C1713,HCPCS,,79012669,CDM,278,RC,,,both,,,1504,1112.96,,,1112.96,Other,150% of Medicare + 9.63% HCRA Surcharge,676.8,45,,676.8,percent of total billed charges,Critical Access Hospital RCC factor,511.36,34,,511.36,percent of total billed charges,Implant Device,511.36,34,,511.36,percent of total billed charges,Implant Device,511.36,34,,511.36,percent of total billed charges,Implant Device,511.36,34,,511.36,percent of total billed charges,Implant Device,511.36,34,,511.36,percent of total billed charges,Implant Device,744.48,,,744.48,Other,110% of Medicare,526.4,35,,526.4,percent of total billed charges,Implant Device,511.36,34,"Charges > $500, x 34%",511.36,percent of total billed charges,Implant Device,526.4,35,,526.4,percent of total billed charges,Implant Device,526.4,35,,526.4,percent of total billed charges,Implant Device,526.4,35,,526.4,percent of total billed charges,Implant Device,526.4,35,,526.4,percent of total billed charges,Implant Device,526.4,35,,526.4,percent of total billed charges,Implant Device,601.6,40,,601.6,percent of total billed charges,Implant Device,526.4,70,,526.4,percent of total billed charges,All Other,511.36,34,,511.36,percent of total billed charges,Implant Device,511.36,34,,511.36,percent of total billed charges,Implant Device,526.4,35,,526.4,percent of total billed charges,Implant Device,526.4,35,,526.4,percent of total billed charges,Implant Device,526.4,35,,526.4,percent of total billed charges,Implant Device,526.4,35,,526.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1112.96,
J&J 247.366 LCP ADAPTION PLT 12H 2.4MM,C1713,HCPCS,,79012670,CDM,278,RC,,,both,,,1165,862.1,,,862.1,Other,150% of Medicare + 9.63% HCRA Surcharge,524.25,45,,524.25,percent of total billed charges,Critical Access Hospital RCC factor,396.1,34,,396.1,percent of total billed charges,Implant Device,396.1,34,,396.1,percent of total billed charges,Implant Device,396.1,34,,396.1,percent of total billed charges,Implant Device,396.1,34,,396.1,percent of total billed charges,Implant Device,396.1,34,,396.1,percent of total billed charges,Implant Device,576.68,,,576.68,Other,110% of Medicare,407.75,35,,407.75,percent of total billed charges,Implant Device,396.1,34,"Charges > $500, x 34%",396.1,percent of total billed charges,Implant Device,407.75,35,,407.75,percent of total billed charges,Implant Device,407.75,35,,407.75,percent of total billed charges,Implant Device,407.75,35,,407.75,percent of total billed charges,Implant Device,407.75,35,,407.75,percent of total billed charges,Implant Device,407.75,35,,407.75,percent of total billed charges,Implant Device,466,40,,466,percent of total billed charges,Implant Device,407.75,70,,407.75,percent of total billed charges,All Other,396.1,34,,396.1,percent of total billed charges,Implant Device,396.1,34,,396.1,percent of total billed charges,Implant Device,407.75,35,,407.75,percent of total billed charges,Implant Device,407.75,35,,407.75,percent of total billed charges,Implant Device,407.75,35,,407.75,percent of total billed charges,Implant Device,407.75,35,,407.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,862.1,
J&J 02.127.220 PROX TIBIA PLT 3.5X117MM,C1713,HCPCS,,79012673,CDM,278,RC,,,both,,,4260,3152.41,,,3152.41,Other,150% of Medicare + 9.63% HCRA Surcharge,1917,45,,1917,percent of total billed charges,Critical Access Hospital RCC factor,1448.4,34,,1448.4,percent of total billed charges,Implant Device,1448.4,34,,1448.4,percent of total billed charges,Implant Device,1448.4,34,,1448.4,percent of total billed charges,Implant Device,1448.4,34,,1448.4,percent of total billed charges,Implant Device,1448.4,34,,1448.4,percent of total billed charges,Implant Device,2108.7,,,2108.7,Other,110% of Medicare,1491,35,,1491,percent of total billed charges,Implant Device,1448.4,34,"Charges > $500, x 34%",1448.4,percent of total billed charges,Implant Device,1491,35,,1491,percent of total billed charges,Implant Device,1491,35,,1491,percent of total billed charges,Implant Device,1491,35,,1491,percent of total billed charges,Implant Device,1491,35,,1491,percent of total billed charges,Implant Device,1491,35,,1491,percent of total billed charges,Implant Device,1704,40,,1704,percent of total billed charges,Implant Device,1491,70,,1491,percent of total billed charges,All Other,1448.4,34,,1448.4,percent of total billed charges,Implant Device,1448.4,34,,1448.4,percent of total billed charges,Implant Device,1491,35,,1491,percent of total billed charges,Implant Device,1491,35,,1491,percent of total billed charges,Implant Device,1491,35,,1491,percent of total billed charges,Implant Device,1491,35,,1491,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1448.4,34,"If Charge > 2,000, then 34 percent",1448.4,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3152.41,
J&J 02.127.160 LOCKING SCREW 3.5X60MM,C1713,HCPCS,,79012674,CDM,278,RC,,,both,,,414,306.36,,,306.36,Other,150% of Medicare + 9.63% HCRA Surcharge,186.3,45,,186.3,percent of total billed charges,Critical Access Hospital RCC factor,140.76,34,,140.76,percent of total billed charges,Implant Device,140.76,34,,140.76,percent of total billed charges,Implant Device,140.76,34,,140.76,percent of total billed charges,Implant Device,140.76,34,,140.76,percent of total billed charges,Implant Device,140.76,34,,140.76,percent of total billed charges,Implant Device,204.93,,,204.93,Other,110% of Medicare,144.9,35,,144.9,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,144.9,35,,144.9,percent of total billed charges,Implant Device,144.9,35,,144.9,percent of total billed charges,Implant Device,144.9,35,,144.9,percent of total billed charges,Implant Device,144.9,35,,144.9,percent of total billed charges,Implant Device,144.9,35,,144.9,percent of total billed charges,Implant Device,165.6,40,,165.6,percent of total billed charges,Implant Device,144.9,70,,144.9,percent of total billed charges,All Other,140.76,34,,140.76,percent of total billed charges,Implant Device,140.76,34,,140.76,percent of total billed charges,Implant Device,144.9,35,,144.9,percent of total billed charges,Implant Device,144.9,35,,144.9,percent of total billed charges,Implant Device,144.9,35,,144.9,percent of total billed charges,Implant Device,144.9,35,,144.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,306.36,
STRYKER UH1-46-28 BIPOLAR COMP 28X+0MM,C1776,HCPCS,,79012675,CDM,278,RC,,,both,,,1391,1029.34,,,1029.34,Other,150% of Medicare + 9.63% HCRA Surcharge,625.95,45,,625.95,percent of total billed charges,Critical Access Hospital RCC factor,472.94,34,,472.94,percent of total billed charges,Implant Device,472.94,34,,472.94,percent of total billed charges,Implant Device,472.94,34,,472.94,percent of total billed charges,Implant Device,472.94,34,,472.94,percent of total billed charges,Implant Device,472.94,34,,472.94,percent of total billed charges,Implant Device,688.55,,,688.55,Other,110% of Medicare,486.85,35,,486.85,percent of total billed charges,Implant Device,472.94,34,"Charges > $500, x 34%",472.94,percent of total billed charges,Implant Device,486.85,35,,486.85,percent of total billed charges,Implant Device,486.85,35,,486.85,percent of total billed charges,Implant Device,486.85,35,,486.85,percent of total billed charges,Implant Device,486.85,35,,486.85,percent of total billed charges,Implant Device,486.85,35,,486.85,percent of total billed charges,Implant Device,556.4,40,,556.4,percent of total billed charges,Implant Device,486.85,70,,486.85,percent of total billed charges,All Other,472.94,34,,472.94,percent of total billed charges,Implant Device,472.94,34,,472.94,percent of total billed charges,Implant Device,486.85,35,,486.85,percent of total billed charges,Implant Device,486.85,35,,486.85,percent of total billed charges,Implant Device,486.85,35,,486.85,percent of total billed charges,Implant Device,486.85,35,,486.85,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1029.34,
J&J 02.118.411 FIBULAR PLT LT 9 HOLE,C1713,HCPCS,,79012676,CDM,278,RC,,,both,,,2775,2053.51,,,2053.51,Other,150% of Medicare + 9.63% HCRA Surcharge,1248.75,45,,1248.75,percent of total billed charges,Critical Access Hospital RCC factor,943.5,34,,943.5,percent of total billed charges,Implant Device,943.5,34,,943.5,percent of total billed charges,Implant Device,943.5,34,,943.5,percent of total billed charges,Implant Device,943.5,34,,943.5,percent of total billed charges,Implant Device,943.5,34,,943.5,percent of total billed charges,Implant Device,1373.63,,,1373.63,Other,110% of Medicare,971.25,35,,971.25,percent of total billed charges,Implant Device,943.5,34,"Charges > $500, x 34%",943.5,percent of total billed charges,Implant Device,971.25,35,,971.25,percent of total billed charges,Implant Device,971.25,35,,971.25,percent of total billed charges,Implant Device,971.25,35,,971.25,percent of total billed charges,Implant Device,971.25,35,,971.25,percent of total billed charges,Implant Device,971.25,35,,971.25,percent of total billed charges,Implant Device,1110,40,,1110,percent of total billed charges,Implant Device,971.25,70,,971.25,percent of total billed charges,All Other,943.5,34,,943.5,percent of total billed charges,Implant Device,943.5,34,,943.5,percent of total billed charges,Implant Device,971.25,35,,971.25,percent of total billed charges,Implant Device,971.25,35,,971.25,percent of total billed charges,Implant Device,971.25,35,,971.25,percent of total billed charges,Implant Device,971.25,35,,971.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,943.5,34,"If Charge > 2,000, then 34 percent",943.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2053.51,
J&J 02.206.230 CORTEX SCREW 2.5X30MM,C1713,HCPCS,,79012677,CDM,278,RC,,,both,,,79,58.46,,,58.46,Other,150% of Medicare + 9.63% HCRA Surcharge,35.55,45,,35.55,percent of total billed charges,Critical Access Hospital RCC factor,26.86,34,,26.86,percent of total billed charges,Implant Device,26.86,34,,26.86,percent of total billed charges,Implant Device,26.86,34,,26.86,percent of total billed charges,Implant Device,26.86,34,,26.86,percent of total billed charges,Implant Device,26.86,34,,26.86,percent of total billed charges,Implant Device,39.11,,,39.11,Other,110% of Medicare,27.65,35,,27.65,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,27.65,35,,27.65,percent of total billed charges,Implant Device,27.65,35,,27.65,percent of total billed charges,Implant Device,27.65,35,,27.65,percent of total billed charges,Implant Device,27.65,35,,27.65,percent of total billed charges,Implant Device,27.65,35,,27.65,percent of total billed charges,Implant Device,31.6,40,,31.6,percent of total billed charges,Implant Device,27.65,70,,27.65,percent of total billed charges,All Other,26.86,34,,26.86,percent of total billed charges,Implant Device,26.86,34,,26.86,percent of total billed charges,Implant Device,27.65,35,,27.65,percent of total billed charges,Implant Device,27.65,35,,27.65,percent of total billed charges,Implant Device,27.65,35,,27.65,percent of total billed charges,Implant Device,27.65,35,,27.65,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,58.46,
J&J 02.118.207 ANTEROLATERAL DIS PLT LT,C1713,HCPCS,,79012678,CDM,278,RC,,,both,,,4413,3265.63,,,3265.63,Other,150% of Medicare + 9.63% HCRA Surcharge,1985.85,45,,1985.85,percent of total billed charges,Critical Access Hospital RCC factor,1500.42,34,,1500.42,percent of total billed charges,Implant Device,1500.42,34,,1500.42,percent of total billed charges,Implant Device,1500.42,34,,1500.42,percent of total billed charges,Implant Device,1500.42,34,,1500.42,percent of total billed charges,Implant Device,1500.42,34,,1500.42,percent of total billed charges,Implant Device,2184.44,,,2184.44,Other,110% of Medicare,1544.55,35,,1544.55,percent of total billed charges,Implant Device,1500.42,34,"Charges > $500, x 34%",1500.42,percent of total billed charges,Implant Device,1544.55,35,,1544.55,percent of total billed charges,Implant Device,1544.55,35,,1544.55,percent of total billed charges,Implant Device,1544.55,35,,1544.55,percent of total billed charges,Implant Device,1544.55,35,,1544.55,percent of total billed charges,Implant Device,1544.55,35,,1544.55,percent of total billed charges,Implant Device,1765.2,40,,1765.2,percent of total billed charges,Implant Device,1544.55,70,,1544.55,percent of total billed charges,All Other,1500.42,34,,1500.42,percent of total billed charges,Implant Device,1500.42,34,,1500.42,percent of total billed charges,Implant Device,1544.55,35,,1544.55,percent of total billed charges,Implant Device,1544.55,35,,1544.55,percent of total billed charges,Implant Device,1544.55,35,,1544.55,percent of total billed charges,Implant Device,1544.55,35,,1544.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1500.42,34,"If Charge > 2,000, then 34 percent",1500.42,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3265.63,
J&J 202.967 CORTEX SCREW 2.7X50MM,C1713,HCPCS,,79012679,CDM,278,RC,,,both,,,88,65.12,,,65.12,Other,150% of Medicare + 9.63% HCRA Surcharge,39.6,45,,39.6,percent of total billed charges,Critical Access Hospital RCC factor,29.92,34,,29.92,percent of total billed charges,Implant Device,29.92,34,,29.92,percent of total billed charges,Implant Device,29.92,34,,29.92,percent of total billed charges,Implant Device,29.92,34,,29.92,percent of total billed charges,Implant Device,29.92,34,,29.92,percent of total billed charges,Implant Device,43.56,,,43.56,Other,110% of Medicare,30.8,35,,30.8,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,30.8,35,,30.8,percent of total billed charges,Implant Device,30.8,35,,30.8,percent of total billed charges,Implant Device,30.8,35,,30.8,percent of total billed charges,Implant Device,30.8,35,,30.8,percent of total billed charges,Implant Device,30.8,35,,30.8,percent of total billed charges,Implant Device,35.2,40,,35.2,percent of total billed charges,Implant Device,30.8,70,,30.8,percent of total billed charges,All Other,29.92,34,,29.92,percent of total billed charges,Implant Device,29.92,34,,29.92,percent of total billed charges,Implant Device,30.8,35,,30.8,percent of total billed charges,Implant Device,30.8,35,,30.8,percent of total billed charges,Implant Device,30.8,35,,30.8,percent of total billed charges,Implant Device,30.8,35,,30.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,65.12,
J&J 02.206.232 CORTEX SCREW 2.5X32MM,C1713,HCPCS,,79012680,CDM,278,RC,,,both,,,79,58.46,,,58.46,Other,150% of Medicare + 9.63% HCRA Surcharge,35.55,45,,35.55,percent of total billed charges,Critical Access Hospital RCC factor,26.86,34,,26.86,percent of total billed charges,Implant Device,26.86,34,,26.86,percent of total billed charges,Implant Device,26.86,34,,26.86,percent of total billed charges,Implant Device,26.86,34,,26.86,percent of total billed charges,Implant Device,26.86,34,,26.86,percent of total billed charges,Implant Device,39.11,,,39.11,Other,110% of Medicare,27.65,35,,27.65,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,27.65,35,,27.65,percent of total billed charges,Implant Device,27.65,35,,27.65,percent of total billed charges,Implant Device,27.65,35,,27.65,percent of total billed charges,Implant Device,27.65,35,,27.65,percent of total billed charges,Implant Device,27.65,35,,27.65,percent of total billed charges,Implant Device,31.6,40,,31.6,percent of total billed charges,Implant Device,27.65,70,,27.65,percent of total billed charges,All Other,26.86,34,,26.86,percent of total billed charges,Implant Device,26.86,34,,26.86,percent of total billed charges,Implant Device,27.65,35,,27.65,percent of total billed charges,Implant Device,27.65,35,,27.65,percent of total billed charges,Implant Device,27.65,35,,27.65,percent of total billed charges,Implant Device,27.65,35,,27.65,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,58.46,
J&J 02.206.240 CORTEX SCREW 3.5X40MM,C1713,HCPCS,,79012681,CDM,278,RC,,,both,,,79,58.46,,,58.46,Other,150% of Medicare + 9.63% HCRA Surcharge,35.55,45,,35.55,percent of total billed charges,Critical Access Hospital RCC factor,26.86,34,,26.86,percent of total billed charges,Implant Device,26.86,34,,26.86,percent of total billed charges,Implant Device,26.86,34,,26.86,percent of total billed charges,Implant Device,26.86,34,,26.86,percent of total billed charges,Implant Device,26.86,34,,26.86,percent of total billed charges,Implant Device,39.11,,,39.11,Other,110% of Medicare,27.65,35,,27.65,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,27.65,35,,27.65,percent of total billed charges,Implant Device,27.65,35,,27.65,percent of total billed charges,Implant Device,27.65,35,,27.65,percent of total billed charges,Implant Device,27.65,35,,27.65,percent of total billed charges,Implant Device,27.65,35,,27.65,percent of total billed charges,Implant Device,31.6,40,,31.6,percent of total billed charges,Implant Device,27.65,70,,27.65,percent of total billed charges,All Other,26.86,34,,26.86,percent of total billed charges,Implant Device,26.86,34,,26.86,percent of total billed charges,Implant Device,27.65,35,,27.65,percent of total billed charges,Implant Device,27.65,35,,27.65,percent of total billed charges,Implant Device,27.65,35,,27.65,percent of total billed charges,Implant Device,27.65,35,,27.65,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,58.46,
J&J 76000060 FIBERGRAFT BG PUTTY 6CC,C1713,HCPCS,,79012682,CDM,278,RC,,,both,,,4125,3052.51,,,3052.51,Other,150% of Medicare + 9.63% HCRA Surcharge,1856.25,45,,1856.25,percent of total billed charges,Critical Access Hospital RCC factor,1402.5,34,,1402.5,percent of total billed charges,Implant Device,1402.5,34,,1402.5,percent of total billed charges,Implant Device,1402.5,34,,1402.5,percent of total billed charges,Implant Device,1402.5,34,,1402.5,percent of total billed charges,Implant Device,1402.5,34,,1402.5,percent of total billed charges,Implant Device,2041.88,,,2041.88,Other,110% of Medicare,1443.75,35,,1443.75,percent of total billed charges,Implant Device,1402.5,34,"Charges > $500, x 34%",1402.5,percent of total billed charges,Implant Device,1443.75,35,,1443.75,percent of total billed charges,Implant Device,1443.75,35,,1443.75,percent of total billed charges,Implant Device,1443.75,35,,1443.75,percent of total billed charges,Implant Device,1443.75,35,,1443.75,percent of total billed charges,Implant Device,1443.75,35,,1443.75,percent of total billed charges,Implant Device,1650,40,,1650,percent of total billed charges,Implant Device,1443.75,70,,1443.75,percent of total billed charges,All Other,1402.5,34,,1402.5,percent of total billed charges,Implant Device,1402.5,34,,1402.5,percent of total billed charges,Implant Device,1443.75,35,,1443.75,percent of total billed charges,Implant Device,1443.75,35,,1443.75,percent of total billed charges,Implant Device,1443.75,35,,1443.75,percent of total billed charges,Implant Device,1443.75,35,,1443.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1402.5,34,"If Charge > 2,000, then 34 percent",1402.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3052.51,
ZIMMER EP-189060 TIBIAL BEARING 10X71MM,C1776,HCPCS,,79012683,CDM,278,RC,,,both,,,3648,2699.53,,,2699.53,Other,150% of Medicare + 9.63% HCRA Surcharge,1641.6,45,,1641.6,percent of total billed charges,Critical Access Hospital RCC factor,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1805.76,,,1805.76,Other,110% of Medicare,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1240.32,34,"Charges > $500, x 34%",1240.32,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1459.2,40,,1459.2,percent of total billed charges,Implant Device,1276.8,70,,1276.8,percent of total billed charges,All Other,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1240.32,34,"If Charge > 2,000, then 34 percent",1240.32,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2699.53,
J&J SE-2020TI SPEEDTITAN IMPLANT KIT,C1713,HCPCS,,79012684,CDM,278,RC,,,both,,,4512,3338.89,,,3338.89,Other,150% of Medicare + 9.63% HCRA Surcharge,2030.4,45,,2030.4,percent of total billed charges,Critical Access Hospital RCC factor,1534.08,34,,1534.08,percent of total billed charges,Implant Device,1534.08,34,,1534.08,percent of total billed charges,Implant Device,1534.08,34,,1534.08,percent of total billed charges,Implant Device,1534.08,34,,1534.08,percent of total billed charges,Implant Device,1534.08,34,,1534.08,percent of total billed charges,Implant Device,2233.44,,,2233.44,Other,110% of Medicare,1579.2,35,,1579.2,percent of total billed charges,Implant Device,1534.08,34,"Charges > $500, x 34%",1534.08,percent of total billed charges,Implant Device,1579.2,35,,1579.2,percent of total billed charges,Implant Device,1579.2,35,,1579.2,percent of total billed charges,Implant Device,1579.2,35,,1579.2,percent of total billed charges,Implant Device,1579.2,35,,1579.2,percent of total billed charges,Implant Device,1579.2,35,,1579.2,percent of total billed charges,Implant Device,1804.8,40,,1804.8,percent of total billed charges,Implant Device,1579.2,70,,1579.2,percent of total billed charges,All Other,1534.08,34,,1534.08,percent of total billed charges,Implant Device,1534.08,34,,1534.08,percent of total billed charges,Implant Device,1579.2,35,,1579.2,percent of total billed charges,Implant Device,1579.2,35,,1579.2,percent of total billed charges,Implant Device,1579.2,35,,1579.2,percent of total billed charges,Implant Device,1579.2,35,,1579.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1534.08,34,"If Charge > 2,000, then 34 percent",1534.08,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3338.89,
J&J 214.820 CORTEX SCREW 4.5X20MM,C1713,HCPCS,,79012685,CDM,278,RC,,,both,,,57,42.18,,,42.18,Other,150% of Medicare + 9.63% HCRA Surcharge,25.65,45,,25.65,percent of total billed charges,Critical Access Hospital RCC factor,19.38,34,,19.38,percent of total billed charges,Implant Device,19.38,34,,19.38,percent of total billed charges,Implant Device,19.38,34,,19.38,percent of total billed charges,Implant Device,19.38,34,,19.38,percent of total billed charges,Implant Device,19.38,34,,19.38,percent of total billed charges,Implant Device,28.22,,,28.22,Other,110% of Medicare,19.95,35,,19.95,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,19.95,35,,19.95,percent of total billed charges,Implant Device,19.95,35,,19.95,percent of total billed charges,Implant Device,19.95,35,,19.95,percent of total billed charges,Implant Device,19.95,35,,19.95,percent of total billed charges,Implant Device,19.95,35,,19.95,percent of total billed charges,Implant Device,22.8,40,,22.8,percent of total billed charges,Implant Device,19.95,70,,19.95,percent of total billed charges,All Other,19.38,34,,19.38,percent of total billed charges,Implant Device,19.38,34,,19.38,percent of total billed charges,Implant Device,19.95,35,,19.95,percent of total billed charges,Implant Device,19.95,35,,19.95,percent of total billed charges,Implant Device,19.95,35,,19.95,percent of total billed charges,Implant Device,19.95,35,,19.95,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,42.18,
ZIMMER 42-5221-007-14 ART SURF 14MM,C1776,HCPCS,,79012686,CDM,278,RC,,,both,,,3648,2699.53,,,2699.53,Other,150% of Medicare + 9.63% HCRA Surcharge,1641.6,45,,1641.6,percent of total billed charges,Critical Access Hospital RCC factor,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1805.76,,,1805.76,Other,110% of Medicare,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1240.32,34,"Charges > $500, x 34%",1240.32,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1459.2,40,,1459.2,percent of total billed charges,Implant Device,1276.8,70,,1276.8,percent of total billed charges,All Other,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1240.32,34,"If Charge > 2,000, then 34 percent",1240.32,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2699.53,
ZIMMER 42-5221-004-10 ART SURF 10MM,C1776,HCPCS,,79012687,CDM,278,RC,,,both,,,3648,2699.53,,,2699.53,Other,150% of Medicare + 9.63% HCRA Surcharge,1641.6,45,,1641.6,percent of total billed charges,Critical Access Hospital RCC factor,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1805.76,,,1805.76,Other,110% of Medicare,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1240.32,34,"Charges > $500, x 34%",1240.32,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1459.2,40,,1459.2,percent of total billed charges,Implant Device,1276.8,70,,1276.8,percent of total billed charges,All Other,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1240.32,34,"If Charge > 2,000, then 34 percent",1240.32,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2699.53,
ZIMMER 42-5020-060-02 FEMUR RIGHT SIZE 6,C1776,HCPCS,,79012688,CDM,278,RC,,,both,,,6300,4662.02,,,4662.02,Other,150% of Medicare + 9.63% HCRA Surcharge,2835,45,,2835,percent of total billed charges,Critical Access Hospital RCC factor,2142,34,,2142,percent of total billed charges,Implant Device,2142,34,,2142,percent of total billed charges,Implant Device,2142,34,,2142,percent of total billed charges,Implant Device,2142,34,,2142,percent of total billed charges,Implant Device,2142,34,,2142,percent of total billed charges,Implant Device,3118.5,,,3118.5,Other,110% of Medicare,2205,35,,2205,percent of total billed charges,Implant Device,2142,34,"Charges > $500, x 34%",2142,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2520,40,,2520,percent of total billed charges,Implant Device,2205,70,,2205,percent of total billed charges,All Other,2142,34,,2142,percent of total billed charges,Implant Device,2142,34,,2142,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2142,34,"If Charge > 2,000, then 34 percent",2142,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4662.02,
BOST 72404239 AMS 700 CX MS PUMP 12X24CM,C1813,HCPCS,,79012689,CDM,278,RC,,,both,,,34785,25740.99,,,25740.99,Other,150% of Medicare + 9.63% HCRA Surcharge,15653.25,45,,15653.25,percent of total billed charges,Critical Access Hospital RCC factor,11826.9,34,,11826.9,percent of total billed charges,Implant Device,11826.9,34,,11826.9,percent of total billed charges,Implant Device,11826.9,34,,11826.9,percent of total billed charges,Implant Device,11826.9,34,,11826.9,percent of total billed charges,Implant Device,11826.9,34,,11826.9,percent of total billed charges,Implant Device,17218.58,,,17218.58,Other,110% of Medicare,12174.75,35,,12174.75,percent of total billed charges,Implant Device,11826.9,34,"Charges > $500, x 34%",11826.9,percent of total billed charges,Implant Device,12174.75,35,,12174.75,percent of total billed charges,Implant Device,12174.75,35,,12174.75,percent of total billed charges,Implant Device,12174.75,35,,12174.75,percent of total billed charges,Implant Device,12174.75,35,,12174.75,percent of total billed charges,Implant Device,12174.75,35,,12174.75,percent of total billed charges,Implant Device,13914,40,,13914,percent of total billed charges,Implant Device,12174.75,70,,12174.75,percent of total billed charges,All Other,11826.9,34,,11826.9,percent of total billed charges,Implant Device,11826.9,34,,11826.9,percent of total billed charges,Implant Device,12174.75,35,,12174.75,percent of total billed charges,Implant Device,12174.75,35,,12174.75,percent of total billed charges,Implant Device,12174.75,35,,12174.75,percent of total billed charges,Implant Device,12174.75,35,,12174.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,11826.9,34,"If Charge > 2,000, then 34 percent",11826.9,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,25740.99,
ZIMMER 42-5121-003-12 ART SURF LT 12MM,C1776,HCPCS,,79012690,CDM,278,RC,,,both,,,3648,2699.53,,,2699.53,Other,150% of Medicare + 9.63% HCRA Surcharge,1641.6,45,,1641.6,percent of total billed charges,Critical Access Hospital RCC factor,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1805.76,,,1805.76,Other,110% of Medicare,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1240.32,34,"Charges > $500, x 34%",1240.32,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1459.2,40,,1459.2,percent of total billed charges,Implant Device,1276.8,70,,1276.8,percent of total billed charges,All Other,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1240.32,34,"If Charge > 2,000, then 34 percent",1240.32,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2699.53,
ZIMMER 42-5026-058-01 FEMUR LEFT SIZE 5,C1776,HCPCS,,79012691,CDM,278,RC,,,both,,,10200,7548.03,,,7548.03,Other,150% of Medicare + 9.63% HCRA Surcharge,4590,45,,4590,percent of total billed charges,Critical Access Hospital RCC factor,3468,34,,3468,percent of total billed charges,Implant Device,3468,34,,3468,percent of total billed charges,Implant Device,3468,34,,3468,percent of total billed charges,Implant Device,3468,34,,3468,percent of total billed charges,Implant Device,3468,34,,3468,percent of total billed charges,Implant Device,5049,,,5049,Other,110% of Medicare,3570,35,,3570,percent of total billed charges,Implant Device,3468,34,"Charges > $500, x 34%",3468,percent of total billed charges,Implant Device,3570,35,,3570,percent of total billed charges,Implant Device,3570,35,,3570,percent of total billed charges,Implant Device,3570,35,,3570,percent of total billed charges,Implant Device,3570,35,,3570,percent of total billed charges,Implant Device,3570,35,,3570,percent of total billed charges,Implant Device,4080,40,,4080,percent of total billed charges,Implant Device,3570,70,,3570,percent of total billed charges,All Other,3468,34,,3468,percent of total billed charges,Implant Device,3468,34,,3468,percent of total billed charges,Implant Device,3570,35,,3570,percent of total billed charges,Implant Device,3570,35,,3570,percent of total billed charges,Implant Device,3570,35,,3570,percent of total billed charges,Implant Device,3570,35,,3570,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3468,34,"If Charge > 2,000, then 34 percent",3468,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,7548.03,
ZIMMER 42-5320-067-01 TIBIA 5DEG LT SZ D,C1776,HCPCS,,79012692,CDM,278,RC,,,both,,,4433,3280.43,,,3280.43,Other,150% of Medicare + 9.63% HCRA Surcharge,1994.85,45,,1994.85,percent of total billed charges,Critical Access Hospital RCC factor,1507.22,34,,1507.22,percent of total billed charges,Implant Device,1507.22,34,,1507.22,percent of total billed charges,Implant Device,1507.22,34,,1507.22,percent of total billed charges,Implant Device,1507.22,34,,1507.22,percent of total billed charges,Implant Device,1507.22,34,,1507.22,percent of total billed charges,Implant Device,2194.34,,,2194.34,Other,110% of Medicare,1551.55,35,,1551.55,percent of total billed charges,Implant Device,1507.22,34,"Charges > $500, x 34%",1507.22,percent of total billed charges,Implant Device,1551.55,35,,1551.55,percent of total billed charges,Implant Device,1551.55,35,,1551.55,percent of total billed charges,Implant Device,1551.55,35,,1551.55,percent of total billed charges,Implant Device,1551.55,35,,1551.55,percent of total billed charges,Implant Device,1551.55,35,,1551.55,percent of total billed charges,Implant Device,1773.2,40,,1773.2,percent of total billed charges,Implant Device,1551.55,70,,1551.55,percent of total billed charges,All Other,1507.22,34,,1507.22,percent of total billed charges,Implant Device,1507.22,34,,1507.22,percent of total billed charges,Implant Device,1551.55,35,,1551.55,percent of total billed charges,Implant Device,1551.55,35,,1551.55,percent of total billed charges,Implant Device,1551.55,35,,1551.55,percent of total billed charges,Implant Device,1551.55,35,,1551.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1507.22,34,"If Charge > 2,000, then 34 percent",1507.22,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3280.43,
ZIMMER 189082 TIBIAL BEARING 12X75MM,C1776,HCPCS,,79012693,CDM,278,RC,,,both,,,1920,1420.8,,,1420.8,Other,150% of Medicare + 9.63% HCRA Surcharge,864,45,,864,percent of total billed charges,Critical Access Hospital RCC factor,652.8,34,,652.8,percent of total billed charges,Implant Device,652.8,34,,652.8,percent of total billed charges,Implant Device,652.8,34,,652.8,percent of total billed charges,Implant Device,652.8,34,,652.8,percent of total billed charges,Implant Device,652.8,34,,652.8,percent of total billed charges,Implant Device,950.4,,,950.4,Other,110% of Medicare,672,35,,672,percent of total billed charges,Implant Device,652.8,34,"Charges > $500, x 34%",652.8,percent of total billed charges,Implant Device,672,35,,672,percent of total billed charges,Implant Device,672,35,,672,percent of total billed charges,Implant Device,672,35,,672,percent of total billed charges,Implant Device,672,35,,672,percent of total billed charges,Implant Device,672,35,,672,percent of total billed charges,Implant Device,768,40,,768,percent of total billed charges,Implant Device,672,70,,672,percent of total billed charges,All Other,652.8,34,,652.8,percent of total billed charges,Implant Device,652.8,34,,652.8,percent of total billed charges,Implant Device,672,35,,672,percent of total billed charges,Implant Device,672,35,,672,percent of total billed charges,Implant Device,672,35,,672,percent of total billed charges,Implant Device,672,35,,672,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1420.8,
ZIMMER 42-5026-056-02 FEMUR RIGHT SZ 4,C1776,HCPCS,,79012694,CDM,278,RC,,,both,,,6300,4662.02,,,4662.02,Other,150% of Medicare + 9.63% HCRA Surcharge,2835,45,,2835,percent of total billed charges,Critical Access Hospital RCC factor,2142,34,,2142,percent of total billed charges,Implant Device,2142,34,,2142,percent of total billed charges,Implant Device,2142,34,,2142,percent of total billed charges,Implant Device,2142,34,,2142,percent of total billed charges,Implant Device,2142,34,,2142,percent of total billed charges,Implant Device,3118.5,,,3118.5,Other,110% of Medicare,2205,35,,2205,percent of total billed charges,Implant Device,2142,34,"Charges > $500, x 34%",2142,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2520,40,,2520,percent of total billed charges,Implant Device,2205,70,,2205,percent of total billed charges,All Other,2142,34,,2142,percent of total billed charges,Implant Device,2142,34,,2142,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2142,34,"If Charge > 2,000, then 34 percent",2142,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4662.02,
ZIMMER 42-5221-003-10 ART SURF RT 10MM,C1776,HCPCS,,79012695,CDM,278,RC,,,both,,,3648,2699.53,,,2699.53,Other,150% of Medicare + 9.63% HCRA Surcharge,1641.6,45,,1641.6,percent of total billed charges,Critical Access Hospital RCC factor,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1805.76,,,1805.76,Other,110% of Medicare,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1240.32,34,"Charges > $500, x 34%",1240.32,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1459.2,40,,1459.2,percent of total billed charges,Implant Device,1276.8,70,,1276.8,percent of total billed charges,All Other,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1240.32,34,"If Charge > 2,000, then 34 percent",1240.32,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2699.53,
J&J 04.111.631 DISTAL RADIUS PLT 2.4MM,C1713,HCPCS,,79012697,CDM,278,RC,,,both,,,2323,1719.03,,,1719.03,Other,150% of Medicare + 9.63% HCRA Surcharge,1045.35,45,,1045.35,percent of total billed charges,Critical Access Hospital RCC factor,789.82,34,,789.82,percent of total billed charges,Implant Device,789.82,34,,789.82,percent of total billed charges,Implant Device,789.82,34,,789.82,percent of total billed charges,Implant Device,789.82,34,,789.82,percent of total billed charges,Implant Device,789.82,34,,789.82,percent of total billed charges,Implant Device,1149.89,,,1149.89,Other,110% of Medicare,813.05,35,,813.05,percent of total billed charges,Implant Device,789.82,34,"Charges > $500, x 34%",789.82,percent of total billed charges,Implant Device,813.05,35,,813.05,percent of total billed charges,Implant Device,813.05,35,,813.05,percent of total billed charges,Implant Device,813.05,35,,813.05,percent of total billed charges,Implant Device,813.05,35,,813.05,percent of total billed charges,Implant Device,813.05,35,,813.05,percent of total billed charges,Implant Device,929.2,40,,929.2,percent of total billed charges,Implant Device,813.05,70,,813.05,percent of total billed charges,All Other,789.82,34,,789.82,percent of total billed charges,Implant Device,789.82,34,,789.82,percent of total billed charges,Implant Device,813.05,35,,813.05,percent of total billed charges,Implant Device,813.05,35,,813.05,percent of total billed charges,Implant Device,813.05,35,,813.05,percent of total billed charges,Implant Device,813.05,35,,813.05,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,789.82,34,"If Charge > 2,000, then 34 percent",789.82,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1719.03,
J&J 401.764 CORTEX SCREW 2.4X14MM,C1713,HCPCS,,79012698,CDM,278,RC,,,both,,,172,127.28,,,127.28,Other,150% of Medicare + 9.63% HCRA Surcharge,77.4,45,,77.4,percent of total billed charges,Critical Access Hospital RCC factor,58.48,34,,58.48,percent of total billed charges,Implant Device,58.48,34,,58.48,percent of total billed charges,Implant Device,58.48,34,,58.48,percent of total billed charges,Implant Device,58.48,34,,58.48,percent of total billed charges,Implant Device,58.48,34,,58.48,percent of total billed charges,Implant Device,85.14,,,85.14,Other,110% of Medicare,60.2,35,,60.2,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,60.2,35,,60.2,percent of total billed charges,Implant Device,60.2,35,,60.2,percent of total billed charges,Implant Device,60.2,35,,60.2,percent of total billed charges,Implant Device,60.2,35,,60.2,percent of total billed charges,Implant Device,60.2,35,,60.2,percent of total billed charges,Implant Device,68.8,40,,68.8,percent of total billed charges,Implant Device,60.2,70,,60.2,percent of total billed charges,All Other,58.48,34,,58.48,percent of total billed charges,Implant Device,58.48,34,,58.48,percent of total billed charges,Implant Device,60.2,35,,60.2,percent of total billed charges,Implant Device,60.2,35,,60.2,percent of total billed charges,Implant Device,60.2,35,,60.2,percent of total billed charges,Implant Device,60.2,35,,60.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,127.28,
J&J 04.210.122 LOCKING SCREW 2.4X22MM,C1713,HCPCS,,79012699,CDM,278,RC,,,both,,,330,244.2,,,244.2,Other,150% of Medicare + 9.63% HCRA Surcharge,148.5,45,,148.5,percent of total billed charges,Critical Access Hospital RCC factor,112.2,34,,112.2,percent of total billed charges,Implant Device,112.2,34,,112.2,percent of total billed charges,Implant Device,112.2,34,,112.2,percent of total billed charges,Implant Device,112.2,34,,112.2,percent of total billed charges,Implant Device,112.2,34,,112.2,percent of total billed charges,Implant Device,163.35,,,163.35,Other,110% of Medicare,115.5,35,,115.5,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,132,40,,132,percent of total billed charges,Implant Device,115.5,70,,115.5,percent of total billed charges,All Other,112.2,34,,112.2,percent of total billed charges,Implant Device,112.2,34,,112.2,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,244.2,
J&J 04.210.124 LOCKING SCREW 2.4X24MM,C1713,HCPCS,,79012700,CDM,278,RC,,,both,,,330,244.2,,,244.2,Other,150% of Medicare + 9.63% HCRA Surcharge,148.5,45,,148.5,percent of total billed charges,Critical Access Hospital RCC factor,112.2,34,,112.2,percent of total billed charges,Implant Device,112.2,34,,112.2,percent of total billed charges,Implant Device,112.2,34,,112.2,percent of total billed charges,Implant Device,112.2,34,,112.2,percent of total billed charges,Implant Device,112.2,34,,112.2,percent of total billed charges,Implant Device,163.35,,,163.35,Other,110% of Medicare,115.5,35,,115.5,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,132,40,,132,percent of total billed charges,Implant Device,115.5,70,,115.5,percent of total billed charges,All Other,112.2,34,,112.2,percent of total billed charges,Implant Device,112.2,34,,112.2,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,115.5,35,,115.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,244.2,
J&J 401.762 CORTEX SCREW 2.4X12MM,C1713,HCPCS,,79012701,CDM,278,RC,,,both,,,172,127.28,,,127.28,Other,150% of Medicare + 9.63% HCRA Surcharge,77.4,45,,77.4,percent of total billed charges,Critical Access Hospital RCC factor,58.48,34,,58.48,percent of total billed charges,Implant Device,58.48,34,,58.48,percent of total billed charges,Implant Device,58.48,34,,58.48,percent of total billed charges,Implant Device,58.48,34,,58.48,percent of total billed charges,Implant Device,58.48,34,,58.48,percent of total billed charges,Implant Device,85.14,,,85.14,Other,110% of Medicare,60.2,35,,60.2,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,60.2,35,,60.2,percent of total billed charges,Implant Device,60.2,35,,60.2,percent of total billed charges,Implant Device,60.2,35,,60.2,percent of total billed charges,Implant Device,60.2,35,,60.2,percent of total billed charges,Implant Device,60.2,35,,60.2,percent of total billed charges,Implant Device,68.8,40,,68.8,percent of total billed charges,Implant Device,60.2,70,,60.2,percent of total billed charges,All Other,58.48,34,,58.48,percent of total billed charges,Implant Device,58.48,34,,58.48,percent of total billed charges,Implant Device,60.2,35,,60.2,percent of total billed charges,Implant Device,60.2,35,,60.2,percent of total billed charges,Implant Device,60.2,35,,60.2,percent of total billed charges,Implant Device,60.2,35,,60.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,127.28,
J&J 402.874 CORTEX SCREW 2.7X14MM,C1713,HCPCS,,79012702,CDM,278,RC,,,both,,,136,100.64,,,100.64,Other,150% of Medicare + 9.63% HCRA Surcharge,61.2,45,,61.2,percent of total billed charges,Critical Access Hospital RCC factor,46.24,34,,46.24,percent of total billed charges,Implant Device,46.24,34,,46.24,percent of total billed charges,Implant Device,46.24,34,,46.24,percent of total billed charges,Implant Device,46.24,34,,46.24,percent of total billed charges,Implant Device,46.24,34,,46.24,percent of total billed charges,Implant Device,67.32,,,67.32,Other,110% of Medicare,47.6,35,,47.6,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,47.6,35,,47.6,percent of total billed charges,Implant Device,47.6,35,,47.6,percent of total billed charges,Implant Device,47.6,35,,47.6,percent of total billed charges,Implant Device,47.6,35,,47.6,percent of total billed charges,Implant Device,47.6,35,,47.6,percent of total billed charges,Implant Device,54.4,40,,54.4,percent of total billed charges,Implant Device,47.6,70,,47.6,percent of total billed charges,All Other,46.24,34,,46.24,percent of total billed charges,Implant Device,46.24,34,,46.24,percent of total billed charges,Implant Device,47.6,35,,47.6,percent of total billed charges,Implant Device,47.6,35,,47.6,percent of total billed charges,Implant Device,47.6,35,,47.6,percent of total billed charges,Implant Device,47.6,35,,47.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,100.64,
BOST SC-2408-56 AVISTA MRI 56CM LEAD KIT,C1778,HCPCS,,79012705,CDM,278,RC,,,both,,,4800,3552.01,,,3552.01,Other,150% of Medicare + 9.63% HCRA Surcharge,2160,45,,2160,percent of total billed charges,Critical Access Hospital RCC factor,1632,34,,1632,percent of total billed charges,Implant Device,1632,34,,1632,percent of total billed charges,Implant Device,1632,34,,1632,percent of total billed charges,Implant Device,1632,34,,1632,percent of total billed charges,Implant Device,1632,34,,1632,percent of total billed charges,Implant Device,2376,,,2376,Other,110% of Medicare,1680,35,,1680,percent of total billed charges,Implant Device,1632,34,"Charges > $500, x 34%",1632,percent of total billed charges,Implant Device,1680,35,,1680,percent of total billed charges,Implant Device,1680,35,,1680,percent of total billed charges,Implant Device,1680,35,,1680,percent of total billed charges,Implant Device,1680,35,,1680,percent of total billed charges,Implant Device,1680,35,,1680,percent of total billed charges,Implant Device,1920,40,,1920,percent of total billed charges,Implant Device,1680,70,,1680,percent of total billed charges,All Other,1632,34,,1632,percent of total billed charges,Implant Device,1632,34,,1632,percent of total billed charges,Implant Device,1680,35,,1680,percent of total billed charges,Implant Device,1680,35,,1680,percent of total billed charges,Implant Device,1680,35,,1680,percent of total billed charges,Implant Device,1680,35,,1680,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1632,34,"If Charge > 2,000, then 34 percent",1632,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3552.01,
BOST SCI SC-1232 ALPHA PULSE GENERTR KIT,L8679,HCPCS,,79012706,CDM,278,RC,,,both,,,51000,37740.13,,,37740.13,Other,150% of Medicare + 9.63% HCRA Surcharge,22950,45,,22950,percent of total billed charges,Critical Access Hospital RCC factor,17340,34,,17340,percent of total billed charges,Implant Device,17340,34,,17340,percent of total billed charges,Implant Device,17340,34,,17340,percent of total billed charges,Implant Device,17340,34,,17340,percent of total billed charges,Implant Device,17340,34,,17340,percent of total billed charges,Implant Device,25245,,,25245,Other,110% of Medicare,17850,35,,17850,percent of total billed charges,Implant Device,17340,34,"Charges > $500, x 34%",17340,percent of total billed charges,Implant Device,17850,35,,17850,percent of total billed charges,Implant Device,17850,35,,17850,percent of total billed charges,Implant Device,17850,35,,17850,percent of total billed charges,Implant Device,17850,35,,17850,percent of total billed charges,Implant Device,17850,35,,17850,percent of total billed charges,Implant Device,20400,40,,20400,percent of total billed charges,Implant Device,17850,70,,17850,percent of total billed charges,All Other,17340,34,,17340,percent of total billed charges,Implant Device,17340,34,,17340,percent of total billed charges,Implant Device,17850,35,,17850,percent of total billed charges,Implant Device,17850,35,,17850,percent of total billed charges,Implant Device,17850,35,,17850,percent of total billed charges,Implant Device,17850,35,,17850,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,17340,34,"If Charge > 2,000, then 34 percent",17340,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,37740.13,
BOST SCI SC-4319 CLIK X MRI ANCHOR,L8699,HCPCS,,79012709,CDM,278,RC,,,both,,,930,688.2,,,688.2,Other,150% of Medicare + 9.63% HCRA Surcharge,418.5,45,,418.5,percent of total billed charges,Critical Access Hospital RCC factor,316.2,34,,316.2,percent of total billed charges,Implant Device,316.2,34,,316.2,percent of total billed charges,Implant Device,316.2,34,,316.2,percent of total billed charges,Implant Device,316.2,34,,316.2,percent of total billed charges,Implant Device,316.2,34,,316.2,percent of total billed charges,Implant Device,460.35,,,460.35,Other,110% of Medicare,325.5,35,,325.5,percent of total billed charges,Implant Device,316.2,34,"Charges > $500, x 34%",316.2,percent of total billed charges,Implant Device,325.5,35,,325.5,percent of total billed charges,Implant Device,325.5,35,,325.5,percent of total billed charges,Implant Device,325.5,35,,325.5,percent of total billed charges,Implant Device,325.5,35,,325.5,percent of total billed charges,Implant Device,325.5,35,,325.5,percent of total billed charges,Implant Device,372,40,,372,percent of total billed charges,Implant Device,325.5,70,,325.5,percent of total billed charges,All Other,316.2,34,,316.2,percent of total billed charges,Implant Device,316.2,34,,316.2,percent of total billed charges,Implant Device,325.5,35,,325.5,percent of total billed charges,Implant Device,325.5,35,,325.5,percent of total billed charges,Implant Device,325.5,35,,325.5,percent of total billed charges,Implant Device,325.5,35,,325.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,688.2,
J&J 04.037.161S TFNA NAIL 11/130 DEG LT,C1889,HCPCS,,79012712,CDM,278,RC,,,both,,,5212,3856.89,,,3856.89,Other,150% of Medicare + 9.63% HCRA Surcharge,2345.4,45,,2345.4,percent of total billed charges,Critical Access Hospital RCC factor,1772.08,34,,1772.08,percent of total billed charges,Implant Device,1772.08,34,,1772.08,percent of total billed charges,Implant Device,1772.08,34,,1772.08,percent of total billed charges,Implant Device,1772.08,34,,1772.08,percent of total billed charges,Implant Device,1772.08,34,,1772.08,percent of total billed charges,Implant Device,2579.94,,,2579.94,Other,110% of Medicare,1824.2,35,,1824.2,percent of total billed charges,Implant Device,1772.08,34,"Charges > $500, x 34%",1772.08,percent of total billed charges,Implant Device,1824.2,35,,1824.2,percent of total billed charges,Implant Device,1824.2,35,,1824.2,percent of total billed charges,Implant Device,1824.2,35,,1824.2,percent of total billed charges,Implant Device,1824.2,35,,1824.2,percent of total billed charges,Implant Device,1824.2,35,,1824.2,percent of total billed charges,Implant Device,2084.8,40,,2084.8,percent of total billed charges,Implant Device,1824.2,70,,1824.2,percent of total billed charges,All Other,1772.08,34,,1772.08,percent of total billed charges,Implant Device,1772.08,34,,1772.08,percent of total billed charges,Implant Device,1824.2,35,,1824.2,percent of total billed charges,Implant Device,1824.2,35,,1824.2,percent of total billed charges,Implant Device,1824.2,35,,1824.2,percent of total billed charges,Implant Device,1824.2,35,,1824.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1772.08,34,"If Charge > 2,000, then 34 percent",1772.08,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3856.89,
J&J 02.117.801 LAT DISTAL HUMERUS PLT RT,C1713,HCPCS,,79012716,CDM,278,RC,,,both,,,3105,2297.71,,,2297.71,Other,150% of Medicare + 9.63% HCRA Surcharge,1397.25,45,,1397.25,percent of total billed charges,Critical Access Hospital RCC factor,1055.7,34,,1055.7,percent of total billed charges,Implant Device,1055.7,34,,1055.7,percent of total billed charges,Implant Device,1055.7,34,,1055.7,percent of total billed charges,Implant Device,1055.7,34,,1055.7,percent of total billed charges,Implant Device,1055.7,34,,1055.7,percent of total billed charges,Implant Device,1536.98,,,1536.98,Other,110% of Medicare,1086.75,35,,1086.75,percent of total billed charges,Implant Device,1055.7,34,"Charges > $500, x 34%",1055.7,percent of total billed charges,Implant Device,1086.75,35,,1086.75,percent of total billed charges,Implant Device,1086.75,35,,1086.75,percent of total billed charges,Implant Device,1086.75,35,,1086.75,percent of total billed charges,Implant Device,1086.75,35,,1086.75,percent of total billed charges,Implant Device,1086.75,35,,1086.75,percent of total billed charges,Implant Device,1242,40,,1242,percent of total billed charges,Implant Device,1086.75,70,,1086.75,percent of total billed charges,All Other,1055.7,34,,1055.7,percent of total billed charges,Implant Device,1055.7,34,,1055.7,percent of total billed charges,Implant Device,1086.75,35,,1086.75,percent of total billed charges,Implant Device,1086.75,35,,1086.75,percent of total billed charges,Implant Device,1086.75,35,,1086.75,percent of total billed charges,Implant Device,1086.75,35,,1086.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1055.7,34,"If Charge > 2,000, then 34 percent",1055.7,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2297.71,
J&J 02.211.048 LOCKING SCREW 2.7X48MM,C1713,HCPCS,,79012717,CDM,278,RC,,,both,,,343,253.82,,,253.82,Other,150% of Medicare + 9.63% HCRA Surcharge,154.35,45,,154.35,percent of total billed charges,Critical Access Hospital RCC factor,116.62,34,,116.62,percent of total billed charges,Implant Device,116.62,34,,116.62,percent of total billed charges,Implant Device,116.62,34,,116.62,percent of total billed charges,Implant Device,116.62,34,,116.62,percent of total billed charges,Implant Device,116.62,34,,116.62,percent of total billed charges,Implant Device,169.79,,,169.79,Other,110% of Medicare,120.05,35,,120.05,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,120.05,35,,120.05,percent of total billed charges,Implant Device,120.05,35,,120.05,percent of total billed charges,Implant Device,120.05,35,,120.05,percent of total billed charges,Implant Device,120.05,35,,120.05,percent of total billed charges,Implant Device,120.05,35,,120.05,percent of total billed charges,Implant Device,137.2,40,,137.2,percent of total billed charges,Implant Device,120.05,70,,120.05,percent of total billed charges,All Other,116.62,34,,116.62,percent of total billed charges,Implant Device,116.62,34,,116.62,percent of total billed charges,Implant Device,120.05,35,,120.05,percent of total billed charges,Implant Device,120.05,35,,120.05,percent of total billed charges,Implant Device,120.05,35,,120.05,percent of total billed charges,Implant Device,120.05,35,,120.05,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,253.82,
J&J 02.211.058 LOCKING SCREW 2.7X58MM,C1713,HCPCS,,79012718,CDM,278,RC,,,both,,,343,253.82,,,253.82,Other,150% of Medicare + 9.63% HCRA Surcharge,154.35,45,,154.35,percent of total billed charges,Critical Access Hospital RCC factor,116.62,34,,116.62,percent of total billed charges,Implant Device,116.62,34,,116.62,percent of total billed charges,Implant Device,116.62,34,,116.62,percent of total billed charges,Implant Device,116.62,34,,116.62,percent of total billed charges,Implant Device,116.62,34,,116.62,percent of total billed charges,Implant Device,169.79,,,169.79,Other,110% of Medicare,120.05,35,,120.05,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,120.05,35,,120.05,percent of total billed charges,Implant Device,120.05,35,,120.05,percent of total billed charges,Implant Device,120.05,35,,120.05,percent of total billed charges,Implant Device,120.05,35,,120.05,percent of total billed charges,Implant Device,120.05,35,,120.05,percent of total billed charges,Implant Device,137.2,40,,137.2,percent of total billed charges,Implant Device,120.05,70,,120.05,percent of total billed charges,All Other,116.62,34,,116.62,percent of total billed charges,Implant Device,116.62,34,,116.62,percent of total billed charges,Implant Device,120.05,35,,120.05,percent of total billed charges,Implant Device,120.05,35,,120.05,percent of total billed charges,Implant Device,120.05,35,,120.05,percent of total billed charges,Implant Device,120.05,35,,120.05,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,253.82,
J&J 02.117.604 MEDIAL DIS RADIUS PLT RT,C1713,HCPCS,,79012719,CDM,278,RC,,,both,,,3201,2368.75,,,2368.75,Other,150% of Medicare + 9.63% HCRA Surcharge,1440.45,45,,1440.45,percent of total billed charges,Critical Access Hospital RCC factor,1088.34,34,,1088.34,percent of total billed charges,Implant Device,1088.34,34,,1088.34,percent of total billed charges,Implant Device,1088.34,34,,1088.34,percent of total billed charges,Implant Device,1088.34,34,,1088.34,percent of total billed charges,Implant Device,1088.34,34,,1088.34,percent of total billed charges,Implant Device,1584.5,,,1584.5,Other,110% of Medicare,1120.35,35,,1120.35,percent of total billed charges,Implant Device,1088.34,34,"Charges > $500, x 34%",1088.34,percent of total billed charges,Implant Device,1120.35,35,,1120.35,percent of total billed charges,Implant Device,1120.35,35,,1120.35,percent of total billed charges,Implant Device,1120.35,35,,1120.35,percent of total billed charges,Implant Device,1120.35,35,,1120.35,percent of total billed charges,Implant Device,1120.35,35,,1120.35,percent of total billed charges,Implant Device,1280.4,40,,1280.4,percent of total billed charges,Implant Device,1120.35,70,,1120.35,percent of total billed charges,All Other,1088.34,34,,1088.34,percent of total billed charges,Implant Device,1088.34,34,,1088.34,percent of total billed charges,Implant Device,1120.35,35,,1120.35,percent of total billed charges,Implant Device,1120.35,35,,1120.35,percent of total billed charges,Implant Device,1120.35,35,,1120.35,percent of total billed charges,Implant Device,1120.35,35,,1120.35,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1088.34,34,"If Charge > 2,000, then 34 percent",1088.34,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2368.75,
J&J 02.117.204 LAT DISTAL HUMERUS PLT RT,C1713,HCPCS,,79012720,CDM,278,RC,,,both,,,3105,2297.71,,,2297.71,Other,150% of Medicare + 9.63% HCRA Surcharge,1397.25,45,,1397.25,percent of total billed charges,Critical Access Hospital RCC factor,1055.7,34,,1055.7,percent of total billed charges,Implant Device,1055.7,34,,1055.7,percent of total billed charges,Implant Device,1055.7,34,,1055.7,percent of total billed charges,Implant Device,1055.7,34,,1055.7,percent of total billed charges,Implant Device,1055.7,34,,1055.7,percent of total billed charges,Implant Device,1536.98,,,1536.98,Other,110% of Medicare,1086.75,35,,1086.75,percent of total billed charges,Implant Device,1055.7,34,"Charges > $500, x 34%",1055.7,percent of total billed charges,Implant Device,1086.75,35,,1086.75,percent of total billed charges,Implant Device,1086.75,35,,1086.75,percent of total billed charges,Implant Device,1086.75,35,,1086.75,percent of total billed charges,Implant Device,1086.75,35,,1086.75,percent of total billed charges,Implant Device,1086.75,35,,1086.75,percent of total billed charges,Implant Device,1242,40,,1242,percent of total billed charges,Implant Device,1086.75,70,,1086.75,percent of total billed charges,All Other,1055.7,34,,1055.7,percent of total billed charges,Implant Device,1055.7,34,,1055.7,percent of total billed charges,Implant Device,1086.75,35,,1086.75,percent of total billed charges,Implant Device,1086.75,35,,1086.75,percent of total billed charges,Implant Device,1086.75,35,,1086.75,percent of total billed charges,Implant Device,1086.75,35,,1086.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1055.7,34,"If Charge > 2,000, then 34 percent",1055.7,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2297.71,
J&J 249.676 LCP PLATE 2.4X52MM,C1713,HCPCS,,79012721,CDM,278,RC,,,both,,,1002,741.48,,,741.48,Other,150% of Medicare + 9.63% HCRA Surcharge,450.9,45,,450.9,percent of total billed charges,Critical Access Hospital RCC factor,340.68,34,,340.68,percent of total billed charges,Implant Device,340.68,34,,340.68,percent of total billed charges,Implant Device,340.68,34,,340.68,percent of total billed charges,Implant Device,340.68,34,,340.68,percent of total billed charges,Implant Device,340.68,34,,340.68,percent of total billed charges,Implant Device,495.99,,,495.99,Other,110% of Medicare,350.7,35,,350.7,percent of total billed charges,Implant Device,340.68,34,"Charges > $500, x 34%",340.68,percent of total billed charges,Implant Device,350.7,35,,350.7,percent of total billed charges,Implant Device,350.7,35,,350.7,percent of total billed charges,Implant Device,350.7,35,,350.7,percent of total billed charges,Implant Device,350.7,35,,350.7,percent of total billed charges,Implant Device,350.7,35,,350.7,percent of total billed charges,Implant Device,400.8,40,,400.8,percent of total billed charges,Implant Device,350.7,70,,350.7,percent of total billed charges,All Other,340.68,34,,340.68,percent of total billed charges,Implant Device,340.68,34,,340.68,percent of total billed charges,Implant Device,350.7,35,,350.7,percent of total billed charges,Implant Device,350.7,35,,350.7,percent of total billed charges,Implant Device,350.7,35,,350.7,percent of total billed charges,Implant Device,350.7,35,,350.7,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,741.48,
J&J 02.211.042 LOCKING SCREW 2.7X42MM,C1713,HCPCS,,79012722,CDM,278,RC,,,both,,,343,253.82,,,253.82,Other,150% of Medicare + 9.63% HCRA Surcharge,154.35,45,,154.35,percent of total billed charges,Critical Access Hospital RCC factor,116.62,34,,116.62,percent of total billed charges,Implant Device,116.62,34,,116.62,percent of total billed charges,Implant Device,116.62,34,,116.62,percent of total billed charges,Implant Device,116.62,34,,116.62,percent of total billed charges,Implant Device,116.62,34,,116.62,percent of total billed charges,Implant Device,169.79,,,169.79,Other,110% of Medicare,120.05,35,,120.05,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,120.05,35,,120.05,percent of total billed charges,Implant Device,120.05,35,,120.05,percent of total billed charges,Implant Device,120.05,35,,120.05,percent of total billed charges,Implant Device,120.05,35,,120.05,percent of total billed charges,Implant Device,120.05,35,,120.05,percent of total billed charges,Implant Device,137.2,40,,137.2,percent of total billed charges,Implant Device,120.05,70,,120.05,percent of total billed charges,All Other,116.62,34,,116.62,percent of total billed charges,Implant Device,116.62,34,,116.62,percent of total billed charges,Implant Device,120.05,35,,120.05,percent of total billed charges,Implant Device,120.05,35,,120.05,percent of total billed charges,Implant Device,120.05,35,,120.05,percent of total billed charges,Implant Device,120.05,35,,120.05,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,253.82,
J&J 02.118.530 METAPHYSEA SCREW 2.7X30MM,C1713,HCPCS,,79012723,CDM,278,RC,,,both,,,125,92.5,,,92.5,Other,150% of Medicare + 9.63% HCRA Surcharge,56.25,45,,56.25,percent of total billed charges,Critical Access Hospital RCC factor,42.5,34,,42.5,percent of total billed charges,Implant Device,42.5,34,,42.5,percent of total billed charges,Implant Device,42.5,34,,42.5,percent of total billed charges,Implant Device,42.5,34,,42.5,percent of total billed charges,Implant Device,42.5,34,,42.5,percent of total billed charges,Implant Device,61.88,,,61.88,Other,110% of Medicare,43.75,35,,43.75,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,43.75,35,,43.75,percent of total billed charges,Implant Device,43.75,35,,43.75,percent of total billed charges,Implant Device,43.75,35,,43.75,percent of total billed charges,Implant Device,43.75,35,,43.75,percent of total billed charges,Implant Device,43.75,35,,43.75,percent of total billed charges,Implant Device,50,40,,50,percent of total billed charges,Implant Device,43.75,70,,43.75,percent of total billed charges,All Other,42.5,34,,42.5,percent of total billed charges,Implant Device,42.5,34,,42.5,percent of total billed charges,Implant Device,43.75,35,,43.75,percent of total billed charges,Implant Device,43.75,35,,43.75,percent of total billed charges,Implant Device,43.75,35,,43.75,percent of total billed charges,Implant Device,43.75,35,,43.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,92.5,
STRYKER 629790 Y PLT NARROW 10H 2.4X81MM,C1713,HCPCS,,79012724,CDM,278,RC,,,both,,,3366,2490.85,,,2490.85,Other,150% of Medicare + 9.63% HCRA Surcharge,1514.7,45,,1514.7,percent of total billed charges,Critical Access Hospital RCC factor,1144.44,34,,1144.44,percent of total billed charges,Implant Device,1144.44,34,,1144.44,percent of total billed charges,Implant Device,1144.44,34,,1144.44,percent of total billed charges,Implant Device,1144.44,34,,1144.44,percent of total billed charges,Implant Device,1144.44,34,,1144.44,percent of total billed charges,Implant Device,1666.17,,,1666.17,Other,110% of Medicare,1178.1,35,,1178.1,percent of total billed charges,Implant Device,1144.44,34,"Charges > $500, x 34%",1144.44,percent of total billed charges,Implant Device,1178.1,35,,1178.1,percent of total billed charges,Implant Device,1178.1,35,,1178.1,percent of total billed charges,Implant Device,1178.1,35,,1178.1,percent of total billed charges,Implant Device,1178.1,35,,1178.1,percent of total billed charges,Implant Device,1178.1,35,,1178.1,percent of total billed charges,Implant Device,1346.4,40,,1346.4,percent of total billed charges,Implant Device,1178.1,70,,1178.1,percent of total billed charges,All Other,1144.44,34,,1144.44,percent of total billed charges,Implant Device,1144.44,34,,1144.44,percent of total billed charges,Implant Device,1178.1,35,,1178.1,percent of total billed charges,Implant Device,1178.1,35,,1178.1,percent of total billed charges,Implant Device,1178.1,35,,1178.1,percent of total billed charges,Implant Device,1178.1,35,,1178.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1144.44,34,"If Charge > 2,000, then 34 percent",1144.44,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2490.85,
STRYKER 656011 LOCKING SCREW 2.4X11MM,C1713,HCPCS,,79012725,CDM,278,RC,,,both,,,676,500.24,,,500.24,Other,150% of Medicare + 9.63% HCRA Surcharge,304.2,45,,304.2,percent of total billed charges,Critical Access Hospital RCC factor,229.84,34,,229.84,percent of total billed charges,Implant Device,229.84,34,,229.84,percent of total billed charges,Implant Device,229.84,34,,229.84,percent of total billed charges,Implant Device,229.84,34,,229.84,percent of total billed charges,Implant Device,229.84,34,,229.84,percent of total billed charges,Implant Device,334.62,,,334.62,Other,110% of Medicare,236.6,35,,236.6,percent of total billed charges,Implant Device,229.84,34,"Charges > $500, x 34%",229.84,percent of total billed charges,Implant Device,236.6,35,,236.6,percent of total billed charges,Implant Device,236.6,35,,236.6,percent of total billed charges,Implant Device,236.6,35,,236.6,percent of total billed charges,Implant Device,236.6,35,,236.6,percent of total billed charges,Implant Device,236.6,35,,236.6,percent of total billed charges,Implant Device,270.4,40,,270.4,percent of total billed charges,Implant Device,236.6,70,,236.6,percent of total billed charges,All Other,229.84,34,,229.84,percent of total billed charges,Implant Device,229.84,34,,229.84,percent of total billed charges,Implant Device,236.6,35,,236.6,percent of total billed charges,Implant Device,236.6,35,,236.6,percent of total billed charges,Implant Device,236.6,35,,236.6,percent of total billed charges,Implant Device,236.6,35,,236.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,500.24,
STRYKER 656128 BONE SCREW 2.4X28MM,C1713,HCPCS,,79012726,CDM,278,RC,,,both,,,282,208.68,,,208.68,Other,150% of Medicare + 9.63% HCRA Surcharge,126.9,45,,126.9,percent of total billed charges,Critical Access Hospital RCC factor,95.88,34,,95.88,percent of total billed charges,Implant Device,95.88,34,,95.88,percent of total billed charges,Implant Device,95.88,34,,95.88,percent of total billed charges,Implant Device,95.88,34,,95.88,percent of total billed charges,Implant Device,95.88,34,,95.88,percent of total billed charges,Implant Device,139.59,,,139.59,Other,110% of Medicare,98.7,35,,98.7,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,98.7,35,,98.7,percent of total billed charges,Implant Device,98.7,35,,98.7,percent of total billed charges,Implant Device,98.7,35,,98.7,percent of total billed charges,Implant Device,98.7,35,,98.7,percent of total billed charges,Implant Device,98.7,35,,98.7,percent of total billed charges,Implant Device,112.8,40,,112.8,percent of total billed charges,Implant Device,98.7,70,,98.7,percent of total billed charges,All Other,95.88,34,,95.88,percent of total billed charges,Implant Device,95.88,34,,95.88,percent of total billed charges,Implant Device,98.7,35,,98.7,percent of total billed charges,Implant Device,98.7,35,,98.7,percent of total billed charges,Implant Device,98.7,35,,98.7,percent of total billed charges,Implant Device,98.7,35,,98.7,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,208.68,
STRYKER 656134 BONE SCREW 2.4X34MM,C1713,HCPCS,,79012727,CDM,278,RC,,,both,,,282,208.68,,,208.68,Other,150% of Medicare + 9.63% HCRA Surcharge,126.9,45,,126.9,percent of total billed charges,Critical Access Hospital RCC factor,95.88,34,,95.88,percent of total billed charges,Implant Device,95.88,34,,95.88,percent of total billed charges,Implant Device,95.88,34,,95.88,percent of total billed charges,Implant Device,95.88,34,,95.88,percent of total billed charges,Implant Device,95.88,34,,95.88,percent of total billed charges,Implant Device,139.59,,,139.59,Other,110% of Medicare,98.7,35,,98.7,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,98.7,35,,98.7,percent of total billed charges,Implant Device,98.7,35,,98.7,percent of total billed charges,Implant Device,98.7,35,,98.7,percent of total billed charges,Implant Device,98.7,35,,98.7,percent of total billed charges,Implant Device,98.7,35,,98.7,percent of total billed charges,Implant Device,112.8,40,,112.8,percent of total billed charges,Implant Device,98.7,70,,98.7,percent of total billed charges,All Other,95.88,34,,95.88,percent of total billed charges,Implant Device,95.88,34,,95.88,percent of total billed charges,Implant Device,98.7,35,,98.7,percent of total billed charges,Implant Device,98.7,35,,98.7,percent of total billed charges,Implant Device,98.7,35,,98.7,percent of total billed charges,Implant Device,98.7,35,,98.7,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,208.68,
STRYKER 656136 BONE SCREW 2.4X36MM,C1713,HCPCS,,79012728,CDM,278,RC,,,both,,,282,208.68,,,208.68,Other,150% of Medicare + 9.63% HCRA Surcharge,126.9,45,,126.9,percent of total billed charges,Critical Access Hospital RCC factor,95.88,34,,95.88,percent of total billed charges,Implant Device,95.88,34,,95.88,percent of total billed charges,Implant Device,95.88,34,,95.88,percent of total billed charges,Implant Device,95.88,34,,95.88,percent of total billed charges,Implant Device,95.88,34,,95.88,percent of total billed charges,Implant Device,139.59,,,139.59,Other,110% of Medicare,98.7,35,,98.7,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,98.7,35,,98.7,percent of total billed charges,Implant Device,98.7,35,,98.7,percent of total billed charges,Implant Device,98.7,35,,98.7,percent of total billed charges,Implant Device,98.7,35,,98.7,percent of total billed charges,Implant Device,98.7,35,,98.7,percent of total billed charges,Implant Device,112.8,40,,112.8,percent of total billed charges,Implant Device,98.7,70,,98.7,percent of total billed charges,All Other,95.88,34,,95.88,percent of total billed charges,Implant Device,95.88,34,,95.88,percent of total billed charges,Implant Device,98.7,35,,98.7,percent of total billed charges,Implant Device,98.7,35,,98.7,percent of total billed charges,Implant Device,98.7,35,,98.7,percent of total billed charges,Implant Device,98.7,35,,98.7,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,208.68,
GORE BXA082901A 7FR 80CM VIABAHN STENTS,C1874,HCPCS,,79012729,CDM,278,RC,,,both,,,11151,8251.77,,,8251.77,Other,150% of Medicare + 9.63% HCRA Surcharge,5017.95,45,,5017.95,percent of total billed charges,Critical Access Hospital RCC factor,3791.34,34,,3791.34,percent of total billed charges,Implant Device,3791.34,34,,3791.34,percent of total billed charges,Implant Device,3791.34,34,,3791.34,percent of total billed charges,Implant Device,3791.34,34,,3791.34,percent of total billed charges,Implant Device,3791.34,34,,3791.34,percent of total billed charges,Implant Device,5519.75,,,5519.75,Other,110% of Medicare,3902.85,35,,3902.85,percent of total billed charges,Implant Device,3791.34,34,"Charges > $500, x 34%",3791.34,percent of total billed charges,Implant Device,3902.85,35,,3902.85,percent of total billed charges,Implant Device,3902.85,35,,3902.85,percent of total billed charges,Implant Device,3902.85,35,,3902.85,percent of total billed charges,Implant Device,3902.85,35,,3902.85,percent of total billed charges,Implant Device,3902.85,35,,3902.85,percent of total billed charges,Implant Device,4460.4,40,,4460.4,percent of total billed charges,Implant Device,3902.85,70,,3902.85,percent of total billed charges,All Other,3791.34,34,,3791.34,percent of total billed charges,Implant Device,3791.34,34,,3791.34,percent of total billed charges,Implant Device,3902.85,35,,3902.85,percent of total billed charges,Implant Device,3902.85,35,,3902.85,percent of total billed charges,Implant Device,3902.85,35,,3902.85,percent of total billed charges,Implant Device,3902.85,35,,3902.85,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3791.34,34,"If Charge > 2,000, then 34 percent",3791.34,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,8251.77,
STRYKER 6495-1-002 PROXIMAL FEM COMP V40,C1776,HCPCS,,79012731,CDM,278,RC,,,both,,,12998,9618.55,,,9618.55,Other,150% of Medicare + 9.63% HCRA Surcharge,5849.1,45,,5849.1,percent of total billed charges,Critical Access Hospital RCC factor,4419.32,34,,4419.32,percent of total billed charges,Implant Device,4419.32,34,,4419.32,percent of total billed charges,Implant Device,4419.32,34,,4419.32,percent of total billed charges,Implant Device,4419.32,34,,4419.32,percent of total billed charges,Implant Device,4419.32,34,,4419.32,percent of total billed charges,Implant Device,6434.01,,,6434.01,Other,110% of Medicare,4549.3,35,,4549.3,percent of total billed charges,Implant Device,4419.32,34,"Charges > $500, x 34%",4419.32,percent of total billed charges,Implant Device,4549.3,35,,4549.3,percent of total billed charges,Implant Device,4549.3,35,,4549.3,percent of total billed charges,Implant Device,4549.3,35,,4549.3,percent of total billed charges,Implant Device,4549.3,35,,4549.3,percent of total billed charges,Implant Device,4549.3,35,,4549.3,percent of total billed charges,Implant Device,5199.2,40,,5199.2,percent of total billed charges,Implant Device,4549.3,70,,4549.3,percent of total billed charges,All Other,4419.32,34,,4419.32,percent of total billed charges,Implant Device,4419.32,34,,4419.32,percent of total billed charges,Implant Device,4549.3,35,,4549.3,percent of total billed charges,Implant Device,4549.3,35,,4549.3,percent of total billed charges,Implant Device,4549.3,35,,4549.3,percent of total billed charges,Implant Device,4549.3,35,,4549.3,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,4419.32,34,"If Charge > 2,000, then 34 percent",4419.32,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,9618.55,
STRYKER UH1-48-26 BIPOLAR COMP 48X26MM,C1776,HCPCS,,79012732,CDM,278,RC,,,both,,,1391,1029.34,,,1029.34,Other,150% of Medicare + 9.63% HCRA Surcharge,625.95,45,,625.95,percent of total billed charges,Critical Access Hospital RCC factor,472.94,34,,472.94,percent of total billed charges,Implant Device,472.94,34,,472.94,percent of total billed charges,Implant Device,472.94,34,,472.94,percent of total billed charges,Implant Device,472.94,34,,472.94,percent of total billed charges,Implant Device,472.94,34,,472.94,percent of total billed charges,Implant Device,688.55,,,688.55,Other,110% of Medicare,486.85,35,,486.85,percent of total billed charges,Implant Device,472.94,34,"Charges > $500, x 34%",472.94,percent of total billed charges,Implant Device,486.85,35,,486.85,percent of total billed charges,Implant Device,486.85,35,,486.85,percent of total billed charges,Implant Device,486.85,35,,486.85,percent of total billed charges,Implant Device,486.85,35,,486.85,percent of total billed charges,Implant Device,486.85,35,,486.85,percent of total billed charges,Implant Device,556.4,40,,556.4,percent of total billed charges,Implant Device,486.85,70,,486.85,percent of total billed charges,All Other,472.94,34,,472.94,percent of total billed charges,Implant Device,472.94,34,,472.94,percent of total billed charges,Implant Device,486.85,35,,486.85,percent of total billed charges,Implant Device,486.85,35,,486.85,percent of total billed charges,Implant Device,486.85,35,,486.85,percent of total billed charges,Implant Device,486.85,35,,486.85,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1029.34,
STRYKER 6485-3-713 FEMORAL STEM 13X127MM,C1776,HCPCS,,79012733,CDM,278,RC,,,both,,,10014,7410.39,,,7410.39,Other,150% of Medicare + 9.63% HCRA Surcharge,4506.3,45,,4506.3,percent of total billed charges,Critical Access Hospital RCC factor,3404.76,34,,3404.76,percent of total billed charges,Implant Device,3404.76,34,,3404.76,percent of total billed charges,Implant Device,3404.76,34,,3404.76,percent of total billed charges,Implant Device,3404.76,34,,3404.76,percent of total billed charges,Implant Device,3404.76,34,,3404.76,percent of total billed charges,Implant Device,4956.93,,,4956.93,Other,110% of Medicare,3504.9,35,,3504.9,percent of total billed charges,Implant Device,3404.76,34,"Charges > $500, x 34%",3404.76,percent of total billed charges,Implant Device,3504.9,35,,3504.9,percent of total billed charges,Implant Device,3504.9,35,,3504.9,percent of total billed charges,Implant Device,3504.9,35,,3504.9,percent of total billed charges,Implant Device,3504.9,35,,3504.9,percent of total billed charges,Implant Device,3504.9,35,,3504.9,percent of total billed charges,Implant Device,4005.6,40,,4005.6,percent of total billed charges,Implant Device,3504.9,70,,3504.9,percent of total billed charges,All Other,3404.76,34,,3404.76,percent of total billed charges,Implant Device,3404.76,34,,3404.76,percent of total billed charges,Implant Device,3504.9,35,,3504.9,percent of total billed charges,Implant Device,3504.9,35,,3504.9,percent of total billed charges,Implant Device,3504.9,35,,3504.9,percent of total billed charges,Implant Device,3504.9,35,,3504.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3404.76,34,"If Charge > 2,000, then 34 percent",3404.76,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,7410.39,
J&J 1516-50-710 TIBAL INSERT SZ 7 10MM,C1776,HCPCS,,79012738,CDM,278,RC,,,both,,,4200,3108.01,,,3108.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1890,45,,1890,percent of total billed charges,Critical Access Hospital RCC factor,1428,34,,1428,percent of total billed charges,Implant Device,1428,34,,1428,percent of total billed charges,Implant Device,1428,34,,1428,percent of total billed charges,Implant Device,1428,34,,1428,percent of total billed charges,Implant Device,1428,34,,1428,percent of total billed charges,Implant Device,2079,,,2079,Other,110% of Medicare,1470,35,,1470,percent of total billed charges,Implant Device,1428,34,"Charges > $500, x 34%",1428,percent of total billed charges,Implant Device,1470,35,,1470,percent of total billed charges,Implant Device,1470,35,,1470,percent of total billed charges,Implant Device,1470,35,,1470,percent of total billed charges,Implant Device,1470,35,,1470,percent of total billed charges,Implant Device,1470,35,,1470,percent of total billed charges,Implant Device,1680,40,,1680,percent of total billed charges,Implant Device,1470,70,,1470,percent of total billed charges,All Other,1428,34,,1428,percent of total billed charges,Implant Device,1428,34,,1428,percent of total billed charges,Implant Device,1470,35,,1470,percent of total billed charges,Implant Device,1470,35,,1470,percent of total billed charges,Implant Device,1470,35,,1470,percent of total billed charges,Implant Device,1470,35,,1470,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1428,34,"If Charge > 2,000, then 34 percent",1428,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3108.01,
J&J 02.127.130 LOCKING SCREW 3.5X30MM,C1713,HCPCS,,79012739,CDM,278,RC,,,both,,,414,306.36,,,306.36,Other,150% of Medicare + 9.63% HCRA Surcharge,186.3,45,,186.3,percent of total billed charges,Critical Access Hospital RCC factor,140.76,34,,140.76,percent of total billed charges,Implant Device,140.76,34,,140.76,percent of total billed charges,Implant Device,140.76,34,,140.76,percent of total billed charges,Implant Device,140.76,34,,140.76,percent of total billed charges,Implant Device,140.76,34,,140.76,percent of total billed charges,Implant Device,204.93,,,204.93,Other,110% of Medicare,144.9,35,,144.9,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,144.9,35,,144.9,percent of total billed charges,Implant Device,144.9,35,,144.9,percent of total billed charges,Implant Device,144.9,35,,144.9,percent of total billed charges,Implant Device,144.9,35,,144.9,percent of total billed charges,Implant Device,144.9,35,,144.9,percent of total billed charges,Implant Device,165.6,40,,165.6,percent of total billed charges,Implant Device,144.9,70,,144.9,percent of total billed charges,All Other,140.76,34,,140.76,percent of total billed charges,Implant Device,140.76,34,,140.76,percent of total billed charges,Implant Device,144.9,35,,144.9,percent of total billed charges,Implant Device,144.9,35,,144.9,percent of total billed charges,Implant Device,144.9,35,,144.9,percent of total billed charges,Implant Device,144.9,35,,144.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,306.36,
J&J 02.127.221 PROX TIBIA PLT 3.5X117MM,C1713,HCPCS,,79012740,CDM,278,RC,,,both,,,4260,3152.41,,,3152.41,Other,150% of Medicare + 9.63% HCRA Surcharge,1917,45,,1917,percent of total billed charges,Critical Access Hospital RCC factor,1448.4,34,,1448.4,percent of total billed charges,Implant Device,1448.4,34,,1448.4,percent of total billed charges,Implant Device,1448.4,34,,1448.4,percent of total billed charges,Implant Device,1448.4,34,,1448.4,percent of total billed charges,Implant Device,1448.4,34,,1448.4,percent of total billed charges,Implant Device,2108.7,,,2108.7,Other,110% of Medicare,1491,35,,1491,percent of total billed charges,Implant Device,1448.4,34,"Charges > $500, x 34%",1448.4,percent of total billed charges,Implant Device,1491,35,,1491,percent of total billed charges,Implant Device,1491,35,,1491,percent of total billed charges,Implant Device,1491,35,,1491,percent of total billed charges,Implant Device,1491,35,,1491,percent of total billed charges,Implant Device,1491,35,,1491,percent of total billed charges,Implant Device,1704,40,,1704,percent of total billed charges,Implant Device,1491,70,,1491,percent of total billed charges,All Other,1448.4,34,,1448.4,percent of total billed charges,Implant Device,1448.4,34,,1448.4,percent of total billed charges,Implant Device,1491,35,,1491,percent of total billed charges,Implant Device,1491,35,,1491,percent of total billed charges,Implant Device,1491,35,,1491,percent of total billed charges,Implant Device,1491,35,,1491,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1448.4,34,"If Charge > 2,000, then 34 percent",1448.4,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3152.41,
J&J 223.601 LCP PLATE 10 HOLE,C1713,HCPCS,,79012742,CDM,278,RC,,,both,,,953,705.22,,,705.22,Other,150% of Medicare + 9.63% HCRA Surcharge,428.85,45,,428.85,percent of total billed charges,Critical Access Hospital RCC factor,324.02,34,,324.02,percent of total billed charges,Implant Device,324.02,34,,324.02,percent of total billed charges,Implant Device,324.02,34,,324.02,percent of total billed charges,Implant Device,324.02,34,,324.02,percent of total billed charges,Implant Device,324.02,34,,324.02,percent of total billed charges,Implant Device,471.74,,,471.74,Other,110% of Medicare,333.55,35,,333.55,percent of total billed charges,Implant Device,324.02,34,"Charges > $500, x 34%",324.02,percent of total billed charges,Implant Device,333.55,35,,333.55,percent of total billed charges,Implant Device,333.55,35,,333.55,percent of total billed charges,Implant Device,333.55,35,,333.55,percent of total billed charges,Implant Device,333.55,35,,333.55,percent of total billed charges,Implant Device,333.55,35,,333.55,percent of total billed charges,Implant Device,381.2,40,,381.2,percent of total billed charges,Implant Device,333.55,70,,333.55,percent of total billed charges,All Other,324.02,34,,324.02,percent of total billed charges,Implant Device,324.02,34,,324.02,percent of total billed charges,Implant Device,333.55,35,,333.55,percent of total billed charges,Implant Device,333.55,35,,333.55,percent of total billed charges,Implant Device,333.55,35,,333.55,percent of total billed charges,Implant Device,333.55,35,,333.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,705.22,
STRYKER 626677 TUBULAR PLATE 7 HOLE 83MM,C1713,HCPCS,,79012744,CDM,278,RC,,,both,,,889,657.86,,,657.86,Other,150% of Medicare + 9.63% HCRA Surcharge,400.05,45,,400.05,percent of total billed charges,Critical Access Hospital RCC factor,302.26,34,,302.26,percent of total billed charges,Implant Device,302.26,34,,302.26,percent of total billed charges,Implant Device,302.26,34,,302.26,percent of total billed charges,Implant Device,302.26,34,,302.26,percent of total billed charges,Implant Device,302.26,34,,302.26,percent of total billed charges,Implant Device,440.06,,,440.06,Other,110% of Medicare,311.15,35,,311.15,percent of total billed charges,Implant Device,302.26,34,"Charges > $500, x 34%",302.26,percent of total billed charges,Implant Device,311.15,35,,311.15,percent of total billed charges,Implant Device,311.15,35,,311.15,percent of total billed charges,Implant Device,311.15,35,,311.15,percent of total billed charges,Implant Device,311.15,35,,311.15,percent of total billed charges,Implant Device,311.15,35,,311.15,percent of total billed charges,Implant Device,355.6,40,,355.6,percent of total billed charges,Implant Device,311.15,70,,311.15,percent of total billed charges,All Other,302.26,34,,302.26,percent of total billed charges,Implant Device,302.26,34,,302.26,percent of total billed charges,Implant Device,311.15,35,,311.15,percent of total billed charges,Implant Device,311.15,35,,311.15,percent of total billed charges,Implant Device,311.15,35,,311.15,percent of total billed charges,Implant Device,311.15,35,,311.15,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,657.86,
J&J 02.112.622S LCP CLAVICLE PLT LT 2.7,C1713,HCPCS,,79012745,CDM,278,RC,,,both,,,3434,2541.17,,,2541.17,Other,150% of Medicare + 9.63% HCRA Surcharge,1545.3,45,,1545.3,percent of total billed charges,Critical Access Hospital RCC factor,1167.56,34,,1167.56,percent of total billed charges,Implant Device,1167.56,34,,1167.56,percent of total billed charges,Implant Device,1167.56,34,,1167.56,percent of total billed charges,Implant Device,1167.56,34,,1167.56,percent of total billed charges,Implant Device,1167.56,34,,1167.56,percent of total billed charges,Implant Device,1699.83,,,1699.83,Other,110% of Medicare,1201.9,35,,1201.9,percent of total billed charges,Implant Device,1167.56,34,"Charges > $500, x 34%",1167.56,percent of total billed charges,Implant Device,1201.9,35,,1201.9,percent of total billed charges,Implant Device,1201.9,35,,1201.9,percent of total billed charges,Implant Device,1201.9,35,,1201.9,percent of total billed charges,Implant Device,1201.9,35,,1201.9,percent of total billed charges,Implant Device,1201.9,35,,1201.9,percent of total billed charges,Implant Device,1373.6,40,,1373.6,percent of total billed charges,Implant Device,1201.9,70,,1201.9,percent of total billed charges,All Other,1167.56,34,,1167.56,percent of total billed charges,Implant Device,1167.56,34,,1167.56,percent of total billed charges,Implant Device,1201.9,35,,1201.9,percent of total billed charges,Implant Device,1201.9,35,,1201.9,percent of total billed charges,Implant Device,1201.9,35,,1201.9,percent of total billed charges,Implant Device,1201.9,35,,1201.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1167.56,34,"If Charge > 2,000, then 34 percent",1167.56,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2541.17,
J&J 239.954S PROX TIBIA PLT 4H 3.5X93MM,C1713,HCPCS,,79012746,CDM,278,RC,,,both,,,3765,2786.11,,,2786.11,Other,150% of Medicare + 9.63% HCRA Surcharge,1694.25,45,,1694.25,percent of total billed charges,Critical Access Hospital RCC factor,1280.1,34,,1280.1,percent of total billed charges,Implant Device,1280.1,34,,1280.1,percent of total billed charges,Implant Device,1280.1,34,,1280.1,percent of total billed charges,Implant Device,1280.1,34,,1280.1,percent of total billed charges,Implant Device,1280.1,34,,1280.1,percent of total billed charges,Implant Device,1863.68,,,1863.68,Other,110% of Medicare,1317.75,35,,1317.75,percent of total billed charges,Implant Device,1280.1,34,"Charges > $500, x 34%",1280.1,percent of total billed charges,Implant Device,1317.75,35,,1317.75,percent of total billed charges,Implant Device,1317.75,35,,1317.75,percent of total billed charges,Implant Device,1317.75,35,,1317.75,percent of total billed charges,Implant Device,1317.75,35,,1317.75,percent of total billed charges,Implant Device,1317.75,35,,1317.75,percent of total billed charges,Implant Device,1506,40,,1506,percent of total billed charges,Implant Device,1317.75,70,,1317.75,percent of total billed charges,All Other,1280.1,34,,1280.1,percent of total billed charges,Implant Device,1280.1,34,,1280.1,percent of total billed charges,Implant Device,1317.75,35,,1317.75,percent of total billed charges,Implant Device,1317.75,35,,1317.75,percent of total billed charges,Implant Device,1317.75,35,,1317.75,percent of total billed charges,Implant Device,1317.75,35,,1317.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1280.1,34,"If Charge > 2,000, then 34 percent",1280.1,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2786.11,
J&J 412.218S LOCKING SCREW 5.0X48MM,C1713,HCPCS,,79012748,CDM,278,RC,,,both,,,505,373.7,,,373.7,Other,150% of Medicare + 9.63% HCRA Surcharge,227.25,45,,227.25,percent of total billed charges,Critical Access Hospital RCC factor,171.7,34,,171.7,percent of total billed charges,Implant Device,171.7,34,,171.7,percent of total billed charges,Implant Device,171.7,34,,171.7,percent of total billed charges,Implant Device,171.7,34,,171.7,percent of total billed charges,Implant Device,171.7,34,,171.7,percent of total billed charges,Implant Device,249.98,,,249.98,Other,110% of Medicare,176.75,35,,176.75,percent of total billed charges,Implant Device,171.7,34,"Charges > $500, x 34%",171.7,percent of total billed charges,Implant Device,176.75,35,,176.75,percent of total billed charges,Implant Device,176.75,35,,176.75,percent of total billed charges,Implant Device,176.75,35,,176.75,percent of total billed charges,Implant Device,176.75,35,,176.75,percent of total billed charges,Implant Device,176.75,35,,176.75,percent of total billed charges,Implant Device,202,40,,202,percent of total billed charges,Implant Device,176.75,70,,176.75,percent of total billed charges,All Other,171.7,34,,171.7,percent of total billed charges,Implant Device,171.7,34,,171.7,percent of total billed charges,Implant Device,176.75,35,,176.75,percent of total billed charges,Implant Device,176.75,35,,176.75,percent of total billed charges,Implant Device,176.75,35,,176.75,percent of total billed charges,Implant Device,176.75,35,,176.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,373.7,
J&J 04.168.475S ANTIROTATION SCREW 75MM,C1713,HCPCS,,79012749,CDM,278,RC,,,both,,,633,468.42,,,468.42,Other,150% of Medicare + 9.63% HCRA Surcharge,284.85,45,,284.85,percent of total billed charges,Critical Access Hospital RCC factor,215.22,34,,215.22,percent of total billed charges,Implant Device,215.22,34,,215.22,percent of total billed charges,Implant Device,215.22,34,,215.22,percent of total billed charges,Implant Device,215.22,34,,215.22,percent of total billed charges,Implant Device,215.22,34,,215.22,percent of total billed charges,Implant Device,313.34,,,313.34,Other,110% of Medicare,221.55,35,,221.55,percent of total billed charges,Implant Device,215.22,34,"Charges > $500, x 34%",215.22,percent of total billed charges,Implant Device,221.55,35,,221.55,percent of total billed charges,Implant Device,221.55,35,,221.55,percent of total billed charges,Implant Device,221.55,35,,221.55,percent of total billed charges,Implant Device,221.55,35,,221.55,percent of total billed charges,Implant Device,221.55,35,,221.55,percent of total billed charges,Implant Device,253.2,40,,253.2,percent of total billed charges,Implant Device,221.55,70,,221.55,percent of total billed charges,All Other,215.22,34,,215.22,percent of total billed charges,Implant Device,215.22,34,,215.22,percent of total billed charges,Implant Device,221.55,35,,221.55,percent of total billed charges,Implant Device,221.55,35,,221.55,percent of total billed charges,Implant Device,221.55,35,,221.55,percent of total billed charges,Implant Device,221.55,35,,221.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,468.42,
J&J 04.168.275S BOLT FOR FEM NECK 75MM,C1713,HCPCS,,79012750,CDM,278,RC,,,both,,,938,694.12,,,694.12,Other,150% of Medicare + 9.63% HCRA Surcharge,422.1,45,,422.1,percent of total billed charges,Critical Access Hospital RCC factor,318.92,34,,318.92,percent of total billed charges,Implant Device,318.92,34,,318.92,percent of total billed charges,Implant Device,318.92,34,,318.92,percent of total billed charges,Implant Device,318.92,34,,318.92,percent of total billed charges,Implant Device,318.92,34,,318.92,percent of total billed charges,Implant Device,464.31,,,464.31,Other,110% of Medicare,328.3,35,,328.3,percent of total billed charges,Implant Device,318.92,34,"Charges > $500, x 34%",318.92,percent of total billed charges,Implant Device,328.3,35,,328.3,percent of total billed charges,Implant Device,328.3,35,,328.3,percent of total billed charges,Implant Device,328.3,35,,328.3,percent of total billed charges,Implant Device,328.3,35,,328.3,percent of total billed charges,Implant Device,328.3,35,,328.3,percent of total billed charges,Implant Device,375.2,40,,375.2,percent of total billed charges,Implant Device,328.3,70,,328.3,percent of total billed charges,All Other,318.92,34,,318.92,percent of total billed charges,Implant Device,318.92,34,,318.92,percent of total billed charges,Implant Device,328.3,35,,328.3,percent of total billed charges,Implant Device,328.3,35,,328.3,percent of total billed charges,Implant Device,328.3,35,,328.3,percent of total billed charges,Implant Device,328.3,35,,328.3,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,694.12,
ZIMMER 650-0662 CERAMIC HEAD 36MM +3,C1776,HCPCS,,79012751,CDM,278,RC,,,both,,,2880,2131.21,,,2131.21,Other,150% of Medicare + 9.63% HCRA Surcharge,1296,45,,1296,percent of total billed charges,Critical Access Hospital RCC factor,979.2,34,,979.2,percent of total billed charges,Implant Device,979.2,34,,979.2,percent of total billed charges,Implant Device,979.2,34,,979.2,percent of total billed charges,Implant Device,979.2,34,,979.2,percent of total billed charges,Implant Device,979.2,34,,979.2,percent of total billed charges,Implant Device,1425.6,,,1425.6,Other,110% of Medicare,1008,35,,1008,percent of total billed charges,Implant Device,979.2,34,"Charges > $500, x 34%",979.2,percent of total billed charges,Implant Device,1008,35,,1008,percent of total billed charges,Implant Device,1008,35,,1008,percent of total billed charges,Implant Device,1008,35,,1008,percent of total billed charges,Implant Device,1008,35,,1008,percent of total billed charges,Implant Device,1008,35,,1008,percent of total billed charges,Implant Device,1152,40,,1152,percent of total billed charges,Implant Device,1008,70,,1008,percent of total billed charges,All Other,979.2,34,,979.2,percent of total billed charges,Implant Device,979.2,34,,979.2,percent of total billed charges,Implant Device,1008,35,,1008,percent of total billed charges,Implant Device,1008,35,,1008,percent of total billed charges,Implant Device,1008,35,,1008,percent of total billed charges,Implant Device,1008,35,,1008,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,979.2,34,"If Charge > 2,000, then 34 percent",979.2,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2131.21,
STRYKER 5552-E-4017 HUMERAL HEAD 40X17,C1776,HCPCS,,79012752,CDM,278,RC,,,both,,,3675,2719.51,,,2719.51,Other,150% of Medicare + 9.63% HCRA Surcharge,1653.75,45,,1653.75,percent of total billed charges,Critical Access Hospital RCC factor,1249.5,34,,1249.5,percent of total billed charges,Implant Device,1249.5,34,,1249.5,percent of total billed charges,Implant Device,1249.5,34,,1249.5,percent of total billed charges,Implant Device,1249.5,34,,1249.5,percent of total billed charges,Implant Device,1249.5,34,,1249.5,percent of total billed charges,Implant Device,1819.13,,,1819.13,Other,110% of Medicare,1286.25,35,,1286.25,percent of total billed charges,Implant Device,1249.5,34,"Charges > $500, x 34%",1249.5,percent of total billed charges,Implant Device,1286.25,35,,1286.25,percent of total billed charges,Implant Device,1286.25,35,,1286.25,percent of total billed charges,Implant Device,1286.25,35,,1286.25,percent of total billed charges,Implant Device,1286.25,35,,1286.25,percent of total billed charges,Implant Device,1286.25,35,,1286.25,percent of total billed charges,Implant Device,1470,40,,1470,percent of total billed charges,Implant Device,1286.25,70,,1286.25,percent of total billed charges,All Other,1249.5,34,,1249.5,percent of total billed charges,Implant Device,1249.5,34,,1249.5,percent of total billed charges,Implant Device,1286.25,35,,1286.25,percent of total billed charges,Implant Device,1286.25,35,,1286.25,percent of total billed charges,Implant Device,1286.25,35,,1286.25,percent of total billed charges,Implant Device,1286.25,35,,1286.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1249.5,34,"If Charge > 2,000, then 34 percent",1249.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2719.51,
TELEFLEX UL2-C UROLIFT CARTRIDGES,L8699,HCPCS,,79012753,CDM,278,RC,,,both,,,3225,2386.51,,,2386.51,Other,150% of Medicare + 9.63% HCRA Surcharge,1451.25,45,,1451.25,percent of total billed charges,Critical Access Hospital RCC factor,1096.5,34,,1096.5,percent of total billed charges,Implant Device,1096.5,34,,1096.5,percent of total billed charges,Implant Device,1096.5,34,,1096.5,percent of total billed charges,Implant Device,1096.5,34,,1096.5,percent of total billed charges,Implant Device,1096.5,34,,1096.5,percent of total billed charges,Implant Device,1596.38,,,1596.38,Other,110% of Medicare,1128.75,35,,1128.75,percent of total billed charges,Implant Device,1096.5,34,"Charges > $500, x 34%",1096.5,percent of total billed charges,Implant Device,1128.75,35,,1128.75,percent of total billed charges,Implant Device,1128.75,35,,1128.75,percent of total billed charges,Implant Device,1128.75,35,,1128.75,percent of total billed charges,Implant Device,1128.75,35,,1128.75,percent of total billed charges,Implant Device,1128.75,35,,1128.75,percent of total billed charges,Implant Device,1290,40,,1290,percent of total billed charges,Implant Device,1128.75,70,,1128.75,percent of total billed charges,All Other,1096.5,34,,1096.5,percent of total billed charges,Implant Device,1096.5,34,,1096.5,percent of total billed charges,Implant Device,1128.75,35,,1128.75,percent of total billed charges,Implant Device,1128.75,35,,1128.75,percent of total billed charges,Implant Device,1128.75,35,,1128.75,percent of total billed charges,Implant Device,1128.75,35,,1128.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1096.5,34,"If Charge > 2,000, then 34 percent",1096.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2386.51,
ZIMMER VE189046 TIBIAL BEARING 67X16MM,C1776,HCPCS,,79012755,CDM,278,RC,,,both,,,3648,2699.53,,,2699.53,Other,150% of Medicare + 9.63% HCRA Surcharge,1641.6,45,,1641.6,percent of total billed charges,Critical Access Hospital RCC factor,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1805.76,,,1805.76,Other,110% of Medicare,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1240.32,34,"Charges > $500, x 34%",1240.32,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1459.2,40,,1459.2,percent of total billed charges,Implant Device,1276.8,70,,1276.8,percent of total billed charges,All Other,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1240.32,34,"If Charge > 2,000, then 34 percent",1240.32,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2699.53,
J&J 239.955S LCP PROX TIBIA PLT 3.5X93,C1713,HCPCS,,79012756,CDM,278,RC,,,both,,,3765,2786.11,,,2786.11,Other,150% of Medicare + 9.63% HCRA Surcharge,1694.25,45,,1694.25,percent of total billed charges,Critical Access Hospital RCC factor,1280.1,34,,1280.1,percent of total billed charges,Implant Device,1280.1,34,,1280.1,percent of total billed charges,Implant Device,1280.1,34,,1280.1,percent of total billed charges,Implant Device,1280.1,34,,1280.1,percent of total billed charges,Implant Device,1280.1,34,,1280.1,percent of total billed charges,Implant Device,1863.68,,,1863.68,Other,110% of Medicare,1317.75,35,,1317.75,percent of total billed charges,Implant Device,1280.1,34,"Charges > $500, x 34%",1280.1,percent of total billed charges,Implant Device,1317.75,35,,1317.75,percent of total billed charges,Implant Device,1317.75,35,,1317.75,percent of total billed charges,Implant Device,1317.75,35,,1317.75,percent of total billed charges,Implant Device,1317.75,35,,1317.75,percent of total billed charges,Implant Device,1317.75,35,,1317.75,percent of total billed charges,Implant Device,1506,40,,1506,percent of total billed charges,Implant Device,1317.75,70,,1317.75,percent of total billed charges,All Other,1280.1,34,,1280.1,percent of total billed charges,Implant Device,1280.1,34,,1280.1,percent of total billed charges,Implant Device,1317.75,35,,1317.75,percent of total billed charges,Implant Device,1317.75,35,,1317.75,percent of total billed charges,Implant Device,1317.75,35,,1317.75,percent of total billed charges,Implant Device,1317.75,35,,1317.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1280.1,34,"If Charge > 2,000, then 34 percent",1280.1,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2786.11,
J&J 04.005.428S LOCKING SCREW 4.0X38MM,C1713,HCPCS,,79012757,CDM,278,RC,,,both,,,412,304.88,,,304.88,Other,150% of Medicare + 9.63% HCRA Surcharge,185.4,45,,185.4,percent of total billed charges,Critical Access Hospital RCC factor,140.08,34,,140.08,percent of total billed charges,Implant Device,140.08,34,,140.08,percent of total billed charges,Implant Device,140.08,34,,140.08,percent of total billed charges,Implant Device,140.08,34,,140.08,percent of total billed charges,Implant Device,140.08,34,,140.08,percent of total billed charges,Implant Device,203.94,,,203.94,Other,110% of Medicare,144.2,35,,144.2,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,144.2,35,,144.2,percent of total billed charges,Implant Device,144.2,35,,144.2,percent of total billed charges,Implant Device,144.2,35,,144.2,percent of total billed charges,Implant Device,144.2,35,,144.2,percent of total billed charges,Implant Device,144.2,35,,144.2,percent of total billed charges,Implant Device,164.8,40,,164.8,percent of total billed charges,Implant Device,144.2,70,,144.2,percent of total billed charges,All Other,140.08,34,,140.08,percent of total billed charges,Implant Device,140.08,34,,140.08,percent of total billed charges,Implant Device,144.2,35,,144.2,percent of total billed charges,Implant Device,144.2,35,,144.2,percent of total billed charges,Implant Device,144.2,35,,144.2,percent of total billed charges,Implant Device,144.2,35,,144.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,304.88,
J&J 04.015.540S LOCKING SCREW 5.0X50MM,C1713,HCPCS,,79012758,CDM,278,RC,,,both,,,454,335.96,,,335.96,Other,150% of Medicare + 9.63% HCRA Surcharge,204.3,45,,204.3,percent of total billed charges,Critical Access Hospital RCC factor,154.36,34,,154.36,percent of total billed charges,Implant Device,154.36,34,,154.36,percent of total billed charges,Implant Device,154.36,34,,154.36,percent of total billed charges,Implant Device,154.36,34,,154.36,percent of total billed charges,Implant Device,154.36,34,,154.36,percent of total billed charges,Implant Device,224.73,,,224.73,Other,110% of Medicare,158.9,35,,158.9,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,158.9,35,,158.9,percent of total billed charges,Implant Device,158.9,35,,158.9,percent of total billed charges,Implant Device,158.9,35,,158.9,percent of total billed charges,Implant Device,158.9,35,,158.9,percent of total billed charges,Implant Device,158.9,35,,158.9,percent of total billed charges,Implant Device,181.6,40,,181.6,percent of total billed charges,Implant Device,158.9,70,,158.9,percent of total billed charges,All Other,154.36,34,,154.36,percent of total billed charges,Implant Device,154.36,34,,154.36,percent of total billed charges,Implant Device,158.9,35,,158.9,percent of total billed charges,Implant Device,158.9,35,,158.9,percent of total billed charges,Implant Device,158.9,35,,158.9,percent of total billed charges,Implant Device,158.9,35,,158.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,335.96,
J&J 04.034.352S CANN TIBIAL NAIL 360MM,C1889,HCPCS,,79012759,CDM,278,RC,,,both,,,2765,2046.11,,,2046.11,Other,150% of Medicare + 9.63% HCRA Surcharge,1244.25,45,,1244.25,percent of total billed charges,Critical Access Hospital RCC factor,940.1,34,,940.1,percent of total billed charges,Implant Device,940.1,34,,940.1,percent of total billed charges,Implant Device,940.1,34,,940.1,percent of total billed charges,Implant Device,940.1,34,,940.1,percent of total billed charges,Implant Device,940.1,34,,940.1,percent of total billed charges,Implant Device,1368.68,,,1368.68,Other,110% of Medicare,967.75,35,,967.75,percent of total billed charges,Implant Device,940.1,34,"Charges > $500, x 34%",940.1,percent of total billed charges,Implant Device,967.75,35,,967.75,percent of total billed charges,Implant Device,967.75,35,,967.75,percent of total billed charges,Implant Device,967.75,35,,967.75,percent of total billed charges,Implant Device,967.75,35,,967.75,percent of total billed charges,Implant Device,967.75,35,,967.75,percent of total billed charges,Implant Device,1106,40,,1106,percent of total billed charges,Implant Device,967.75,70,,967.75,percent of total billed charges,All Other,940.1,34,,940.1,percent of total billed charges,Implant Device,940.1,34,,940.1,percent of total billed charges,Implant Device,967.75,35,,967.75,percent of total billed charges,Implant Device,967.75,35,,967.75,percent of total billed charges,Implant Device,967.75,35,,967.75,percent of total billed charges,Implant Device,967.75,35,,967.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,940.1,34,"If Charge > 2,000, then 34 percent",940.1,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2046.11,
J&J 02.127.136 LOCKING SCREW 3.5X36MM,C1713,HCPCS,,79012760,CDM,278,RC,,,both,,,414,306.36,,,306.36,Other,150% of Medicare + 9.63% HCRA Surcharge,186.3,45,,186.3,percent of total billed charges,Critical Access Hospital RCC factor,140.76,34,,140.76,percent of total billed charges,Implant Device,140.76,34,,140.76,percent of total billed charges,Implant Device,140.76,34,,140.76,percent of total billed charges,Implant Device,140.76,34,,140.76,percent of total billed charges,Implant Device,140.76,34,,140.76,percent of total billed charges,Implant Device,204.93,,,204.93,Other,110% of Medicare,144.9,35,,144.9,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,144.9,35,,144.9,percent of total billed charges,Implant Device,144.9,35,,144.9,percent of total billed charges,Implant Device,144.9,35,,144.9,percent of total billed charges,Implant Device,144.9,35,,144.9,percent of total billed charges,Implant Device,144.9,35,,144.9,percent of total billed charges,Implant Device,165.6,40,,165.6,percent of total billed charges,Implant Device,144.9,70,,144.9,percent of total billed charges,All Other,140.76,34,,140.76,percent of total billed charges,Implant Device,140.76,34,,140.76,percent of total billed charges,Implant Device,144.9,35,,144.9,percent of total billed charges,Implant Device,144.9,35,,144.9,percent of total billed charges,Implant Device,144.9,35,,144.9,percent of total billed charges,Implant Device,144.9,35,,144.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,306.36,
J&J 02.117.502 MEDIAL PLATE 2.7/3.5MM 2H,C1713,HCPCS,,79012761,CDM,278,RC,,,both,,,3105,2297.71,,,2297.71,Other,150% of Medicare + 9.63% HCRA Surcharge,1397.25,45,,1397.25,percent of total billed charges,Critical Access Hospital RCC factor,1055.7,34,,1055.7,percent of total billed charges,Implant Device,1055.7,34,,1055.7,percent of total billed charges,Implant Device,1055.7,34,,1055.7,percent of total billed charges,Implant Device,1055.7,34,,1055.7,percent of total billed charges,Implant Device,1055.7,34,,1055.7,percent of total billed charges,Implant Device,1536.98,,,1536.98,Other,110% of Medicare,1086.75,35,,1086.75,percent of total billed charges,Implant Device,1055.7,34,"Charges > $500, x 34%",1055.7,percent of total billed charges,Implant Device,1086.75,35,,1086.75,percent of total billed charges,Implant Device,1086.75,35,,1086.75,percent of total billed charges,Implant Device,1086.75,35,,1086.75,percent of total billed charges,Implant Device,1086.75,35,,1086.75,percent of total billed charges,Implant Device,1086.75,35,,1086.75,percent of total billed charges,Implant Device,1242,40,,1242,percent of total billed charges,Implant Device,1086.75,70,,1086.75,percent of total billed charges,All Other,1055.7,34,,1055.7,percent of total billed charges,Implant Device,1055.7,34,,1055.7,percent of total billed charges,Implant Device,1086.75,35,,1086.75,percent of total billed charges,Implant Device,1086.75,35,,1086.75,percent of total billed charges,Implant Device,1086.75,35,,1086.75,percent of total billed charges,Implant Device,1086.75,35,,1086.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1055.7,34,"If Charge > 2,000, then 34 percent",1055.7,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2297.71,
J&J 02.118.526 SELF TAP SCREW 2.7X26MM,C1713,HCPCS,,79012762,CDM,278,RC,,,both,,,125,92.5,,,92.5,Other,150% of Medicare + 9.63% HCRA Surcharge,56.25,45,,56.25,percent of total billed charges,Critical Access Hospital RCC factor,42.5,34,,42.5,percent of total billed charges,Implant Device,42.5,34,,42.5,percent of total billed charges,Implant Device,42.5,34,,42.5,percent of total billed charges,Implant Device,42.5,34,,42.5,percent of total billed charges,Implant Device,42.5,34,,42.5,percent of total billed charges,Implant Device,61.88,,,61.88,Other,110% of Medicare,43.75,35,,43.75,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,43.75,35,,43.75,percent of total billed charges,Implant Device,43.75,35,,43.75,percent of total billed charges,Implant Device,43.75,35,,43.75,percent of total billed charges,Implant Device,43.75,35,,43.75,percent of total billed charges,Implant Device,43.75,35,,43.75,percent of total billed charges,Implant Device,50,40,,50,percent of total billed charges,Implant Device,43.75,70,,43.75,percent of total billed charges,All Other,42.5,34,,42.5,percent of total billed charges,Implant Device,42.5,34,,42.5,percent of total billed charges,Implant Device,43.75,35,,43.75,percent of total billed charges,Implant Device,43.75,35,,43.75,percent of total billed charges,Implant Device,43.75,35,,43.75,percent of total billed charges,Implant Device,43.75,35,,43.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,92.5,
J&J 02.118.540 SELF TAP SCREW 2.7X40MM,C1713,HCPCS,,79012763,CDM,278,RC,,,both,,,125,92.5,,,92.5,Other,150% of Medicare + 9.63% HCRA Surcharge,56.25,45,,56.25,percent of total billed charges,Critical Access Hospital RCC factor,42.5,34,,42.5,percent of total billed charges,Implant Device,42.5,34,,42.5,percent of total billed charges,Implant Device,42.5,34,,42.5,percent of total billed charges,Implant Device,42.5,34,,42.5,percent of total billed charges,Implant Device,42.5,34,,42.5,percent of total billed charges,Implant Device,61.88,,,61.88,Other,110% of Medicare,43.75,35,,43.75,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,43.75,35,,43.75,percent of total billed charges,Implant Device,43.75,35,,43.75,percent of total billed charges,Implant Device,43.75,35,,43.75,percent of total billed charges,Implant Device,43.75,35,,43.75,percent of total billed charges,Implant Device,43.75,35,,43.75,percent of total billed charges,Implant Device,50,40,,50,percent of total billed charges,Implant Device,43.75,70,,43.75,percent of total billed charges,All Other,42.5,34,,42.5,percent of total billed charges,Implant Device,42.5,34,,42.5,percent of total billed charges,Implant Device,43.75,35,,43.75,percent of total billed charges,Implant Device,43.75,35,,43.75,percent of total billed charges,Implant Device,43.75,35,,43.75,percent of total billed charges,Implant Device,43.75,35,,43.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,92.5,
J&J 02.117.303 LATERAL PLT 2.7/3.5MM 3H,C1713,HCPCS,,79012764,CDM,278,RC,,,both,,,3105,2297.71,,,2297.71,Other,150% of Medicare + 9.63% HCRA Surcharge,1397.25,45,,1397.25,percent of total billed charges,Critical Access Hospital RCC factor,1055.7,34,,1055.7,percent of total billed charges,Implant Device,1055.7,34,,1055.7,percent of total billed charges,Implant Device,1055.7,34,,1055.7,percent of total billed charges,Implant Device,1055.7,34,,1055.7,percent of total billed charges,Implant Device,1055.7,34,,1055.7,percent of total billed charges,Implant Device,1536.98,,,1536.98,Other,110% of Medicare,1086.75,35,,1086.75,percent of total billed charges,Implant Device,1055.7,34,"Charges > $500, x 34%",1055.7,percent of total billed charges,Implant Device,1086.75,35,,1086.75,percent of total billed charges,Implant Device,1086.75,35,,1086.75,percent of total billed charges,Implant Device,1086.75,35,,1086.75,percent of total billed charges,Implant Device,1086.75,35,,1086.75,percent of total billed charges,Implant Device,1086.75,35,,1086.75,percent of total billed charges,Implant Device,1242,40,,1242,percent of total billed charges,Implant Device,1086.75,70,,1086.75,percent of total billed charges,All Other,1055.7,34,,1055.7,percent of total billed charges,Implant Device,1055.7,34,,1055.7,percent of total billed charges,Implant Device,1086.75,35,,1086.75,percent of total billed charges,Implant Device,1086.75,35,,1086.75,percent of total billed charges,Implant Device,1086.75,35,,1086.75,percent of total billed charges,Implant Device,1086.75,35,,1086.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1055.7,34,"If Charge > 2,000, then 34 percent",1055.7,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2297.71,
STRYKER 626674 TUBULAR PLT 1/3 4H 47MM,C1713,HCPCS,,79012766,CDM,278,RC,,,both,,,890,658.6,,,658.6,Other,150% of Medicare + 9.63% HCRA Surcharge,400.5,45,,400.5,percent of total billed charges,Critical Access Hospital RCC factor,302.6,34,,302.6,percent of total billed charges,Implant Device,302.6,34,,302.6,percent of total billed charges,Implant Device,302.6,34,,302.6,percent of total billed charges,Implant Device,302.6,34,,302.6,percent of total billed charges,Implant Device,302.6,34,,302.6,percent of total billed charges,Implant Device,440.55,,,440.55,Other,110% of Medicare,311.5,35,,311.5,percent of total billed charges,Implant Device,302.6,34,"Charges > $500, x 34%",302.6,percent of total billed charges,Implant Device,311.5,35,,311.5,percent of total billed charges,Implant Device,311.5,35,,311.5,percent of total billed charges,Implant Device,311.5,35,,311.5,percent of total billed charges,Implant Device,311.5,35,,311.5,percent of total billed charges,Implant Device,311.5,35,,311.5,percent of total billed charges,Implant Device,356,40,,356,percent of total billed charges,Implant Device,311.5,70,,311.5,percent of total billed charges,All Other,302.6,34,,302.6,percent of total billed charges,Implant Device,302.6,34,,302.6,percent of total billed charges,Implant Device,311.5,35,,311.5,percent of total billed charges,Implant Device,311.5,35,,311.5,percent of total billed charges,Implant Device,311.5,35,,311.5,percent of total billed charges,Implant Device,311.5,35,,311.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,658.6,
STRYKER 626675 TUBULAR PLT 1/3 5H 59MM,C1713,HCPCS,,79012767,CDM,278,RC,,,both,,,890,658.6,,,658.6,Other,150% of Medicare + 9.63% HCRA Surcharge,400.5,45,,400.5,percent of total billed charges,Critical Access Hospital RCC factor,302.6,34,,302.6,percent of total billed charges,Implant Device,302.6,34,,302.6,percent of total billed charges,Implant Device,302.6,34,,302.6,percent of total billed charges,Implant Device,302.6,34,,302.6,percent of total billed charges,Implant Device,302.6,34,,302.6,percent of total billed charges,Implant Device,440.55,,,440.55,Other,110% of Medicare,311.5,35,,311.5,percent of total billed charges,Implant Device,302.6,34,"Charges > $500, x 34%",302.6,percent of total billed charges,Implant Device,311.5,35,,311.5,percent of total billed charges,Implant Device,311.5,35,,311.5,percent of total billed charges,Implant Device,311.5,35,,311.5,percent of total billed charges,Implant Device,311.5,35,,311.5,percent of total billed charges,Implant Device,311.5,35,,311.5,percent of total billed charges,Implant Device,356,40,,356,percent of total billed charges,Implant Device,311.5,70,,311.5,percent of total billed charges,All Other,302.6,34,,302.6,percent of total billed charges,Implant Device,302.6,34,,302.6,percent of total billed charges,Implant Device,311.5,35,,311.5,percent of total billed charges,Implant Device,311.5,35,,311.5,percent of total billed charges,Implant Device,311.5,35,,311.5,percent of total billed charges,Implant Device,311.5,35,,311.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,658.6,
STRYKER 626684 TUBULAR PLT 1/3 14H 167MM,C1713,HCPCS,,79012768,CDM,278,RC,,,both,,,1649,1220.26,,,1220.26,Other,150% of Medicare + 9.63% HCRA Surcharge,742.05,45,,742.05,percent of total billed charges,Critical Access Hospital RCC factor,560.66,34,,560.66,percent of total billed charges,Implant Device,560.66,34,,560.66,percent of total billed charges,Implant Device,560.66,34,,560.66,percent of total billed charges,Implant Device,560.66,34,,560.66,percent of total billed charges,Implant Device,560.66,34,,560.66,percent of total billed charges,Implant Device,816.26,,,816.26,Other,110% of Medicare,577.15,35,,577.15,percent of total billed charges,Implant Device,560.66,34,"Charges > $500, x 34%",560.66,percent of total billed charges,Implant Device,577.15,35,,577.15,percent of total billed charges,Implant Device,577.15,35,,577.15,percent of total billed charges,Implant Device,577.15,35,,577.15,percent of total billed charges,Implant Device,577.15,35,,577.15,percent of total billed charges,Implant Device,577.15,35,,577.15,percent of total billed charges,Implant Device,659.6,40,,659.6,percent of total billed charges,Implant Device,577.15,70,,577.15,percent of total billed charges,All Other,560.66,34,,560.66,percent of total billed charges,Implant Device,560.66,34,,560.66,percent of total billed charges,Implant Device,577.15,35,,577.15,percent of total billed charges,Implant Device,577.15,35,,577.15,percent of total billed charges,Implant Device,577.15,35,,577.15,percent of total billed charges,Implant Device,577.15,35,,577.15,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1220.26,
STRYKER 656424 BONE SCREW 2.7X24MM,C1713,HCPCS,,79012769,CDM,278,RC,,,both,,,282,208.68,,,208.68,Other,150% of Medicare + 9.63% HCRA Surcharge,126.9,45,,126.9,percent of total billed charges,Critical Access Hospital RCC factor,95.88,34,,95.88,percent of total billed charges,Implant Device,95.88,34,,95.88,percent of total billed charges,Implant Device,95.88,34,,95.88,percent of total billed charges,Implant Device,95.88,34,,95.88,percent of total billed charges,Implant Device,95.88,34,,95.88,percent of total billed charges,Implant Device,139.59,,,139.59,Other,110% of Medicare,98.7,35,,98.7,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,98.7,35,,98.7,percent of total billed charges,Implant Device,98.7,35,,98.7,percent of total billed charges,Implant Device,98.7,35,,98.7,percent of total billed charges,Implant Device,98.7,35,,98.7,percent of total billed charges,Implant Device,98.7,35,,98.7,percent of total billed charges,Implant Device,112.8,40,,112.8,percent of total billed charges,Implant Device,98.7,70,,98.7,percent of total billed charges,All Other,95.88,34,,95.88,percent of total billed charges,Implant Device,95.88,34,,95.88,percent of total billed charges,Implant Device,98.7,35,,98.7,percent of total billed charges,Implant Device,98.7,35,,98.7,percent of total billed charges,Implant Device,98.7,35,,98.7,percent of total billed charges,Implant Device,98.7,35,,98.7,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,208.68,
STRYKER 656430 BONE SCREW 2.7X30MM,C1713,HCPCS,,79012770,CDM,278,RC,,,both,,,282,208.68,,,208.68,Other,150% of Medicare + 9.63% HCRA Surcharge,126.9,45,,126.9,percent of total billed charges,Critical Access Hospital RCC factor,95.88,34,,95.88,percent of total billed charges,Implant Device,95.88,34,,95.88,percent of total billed charges,Implant Device,95.88,34,,95.88,percent of total billed charges,Implant Device,95.88,34,,95.88,percent of total billed charges,Implant Device,95.88,34,,95.88,percent of total billed charges,Implant Device,139.59,,,139.59,Other,110% of Medicare,98.7,35,,98.7,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,98.7,35,,98.7,percent of total billed charges,Implant Device,98.7,35,,98.7,percent of total billed charges,Implant Device,98.7,35,,98.7,percent of total billed charges,Implant Device,98.7,35,,98.7,percent of total billed charges,Implant Device,98.7,35,,98.7,percent of total billed charges,Implant Device,112.8,40,,112.8,percent of total billed charges,Implant Device,98.7,70,,98.7,percent of total billed charges,All Other,95.88,34,,95.88,percent of total billed charges,Implant Device,95.88,34,,95.88,percent of total billed charges,Implant Device,98.7,35,,98.7,percent of total billed charges,Implant Device,98.7,35,,98.7,percent of total billed charges,Implant Device,98.7,35,,98.7,percent of total billed charges,Implant Device,98.7,35,,98.7,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,208.68,
STRYKER 656446 BONE SCREW 2.7X46MM,C1713,HCPCS,,79012771,CDM,278,RC,,,both,,,306,226.44,,,226.44,Other,150% of Medicare + 9.63% HCRA Surcharge,137.7,45,,137.7,percent of total billed charges,Critical Access Hospital RCC factor,104.04,34,,104.04,percent of total billed charges,Implant Device,104.04,34,,104.04,percent of total billed charges,Implant Device,104.04,34,,104.04,percent of total billed charges,Implant Device,104.04,34,,104.04,percent of total billed charges,Implant Device,104.04,34,,104.04,percent of total billed charges,Implant Device,151.47,,,151.47,Other,110% of Medicare,107.1,35,,107.1,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,107.1,35,,107.1,percent of total billed charges,Implant Device,107.1,35,,107.1,percent of total billed charges,Implant Device,107.1,35,,107.1,percent of total billed charges,Implant Device,107.1,35,,107.1,percent of total billed charges,Implant Device,107.1,35,,107.1,percent of total billed charges,Implant Device,122.4,40,,122.4,percent of total billed charges,Implant Device,107.1,70,,107.1,percent of total billed charges,All Other,104.04,34,,104.04,percent of total billed charges,Implant Device,104.04,34,,104.04,percent of total billed charges,Implant Device,107.1,35,,107.1,percent of total billed charges,Implant Device,107.1,35,,107.1,percent of total billed charges,Implant Device,107.1,35,,107.1,percent of total billed charges,Implant Device,107.1,35,,107.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,226.44,
WRIGHT 86SYN005 GRAVITY SYNCHFIX SYNDES,C1713,HCPCS,,79012772,CDM,278,RC,,,both,,,3686,2727.65,,,2727.65,Other,150% of Medicare + 9.63% HCRA Surcharge,1658.7,45,,1658.7,percent of total billed charges,Critical Access Hospital RCC factor,1253.24,34,,1253.24,percent of total billed charges,Implant Device,1253.24,34,,1253.24,percent of total billed charges,Implant Device,1253.24,34,,1253.24,percent of total billed charges,Implant Device,1253.24,34,,1253.24,percent of total billed charges,Implant Device,1253.24,34,,1253.24,percent of total billed charges,Implant Device,1824.57,,,1824.57,Other,110% of Medicare,1290.1,35,,1290.1,percent of total billed charges,Implant Device,1253.24,34,"Charges > $500, x 34%",1253.24,percent of total billed charges,Implant Device,1290.1,35,,1290.1,percent of total billed charges,Implant Device,1290.1,35,,1290.1,percent of total billed charges,Implant Device,1290.1,35,,1290.1,percent of total billed charges,Implant Device,1290.1,35,,1290.1,percent of total billed charges,Implant Device,1290.1,35,,1290.1,percent of total billed charges,Implant Device,1474.4,40,,1474.4,percent of total billed charges,Implant Device,1290.1,70,,1290.1,percent of total billed charges,All Other,1253.24,34,,1253.24,percent of total billed charges,Implant Device,1253.24,34,,1253.24,percent of total billed charges,Implant Device,1290.1,35,,1290.1,percent of total billed charges,Implant Device,1290.1,35,,1290.1,percent of total billed charges,Implant Device,1290.1,35,,1290.1,percent of total billed charges,Implant Device,1290.1,35,,1290.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1253.24,34,"If Charge > 2,000, then 34 percent",1253.24,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2727.65,
ZIMMER 131218028 CORTICAL SCREW 3.5X28MM,C1713,HCPCS,,79012773,CDM,278,RC,,,both,,,187,138.38,,,138.38,Other,150% of Medicare + 9.63% HCRA Surcharge,84.15,45,,84.15,percent of total billed charges,Critical Access Hospital RCC factor,63.58,34,,63.58,percent of total billed charges,Implant Device,63.58,34,,63.58,percent of total billed charges,Implant Device,63.58,34,,63.58,percent of total billed charges,Implant Device,63.58,34,,63.58,percent of total billed charges,Implant Device,63.58,34,,63.58,percent of total billed charges,Implant Device,92.57,,,92.57,Other,110% of Medicare,65.45,35,,65.45,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,65.45,35,,65.45,percent of total billed charges,Implant Device,65.45,35,,65.45,percent of total billed charges,Implant Device,65.45,35,,65.45,percent of total billed charges,Implant Device,65.45,35,,65.45,percent of total billed charges,Implant Device,65.45,35,,65.45,percent of total billed charges,Implant Device,74.8,40,,74.8,percent of total billed charges,Implant Device,65.45,70,,65.45,percent of total billed charges,All Other,63.58,34,,63.58,percent of total billed charges,Implant Device,63.58,34,,63.58,percent of total billed charges,Implant Device,65.45,35,,65.45,percent of total billed charges,Implant Device,65.45,35,,65.45,percent of total billed charges,Implant Device,65.45,35,,65.45,percent of total billed charges,Implant Device,65.45,35,,65.45,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,138.38,
ZIMMER 131218026 CORTICAL SCREW 3.5X26MM,C1713,HCPCS,,79012774,CDM,278,RC,,,both,,,187,138.38,,,138.38,Other,150% of Medicare + 9.63% HCRA Surcharge,84.15,45,,84.15,percent of total billed charges,Critical Access Hospital RCC factor,63.58,34,,63.58,percent of total billed charges,Implant Device,63.58,34,,63.58,percent of total billed charges,Implant Device,63.58,34,,63.58,percent of total billed charges,Implant Device,63.58,34,,63.58,percent of total billed charges,Implant Device,63.58,34,,63.58,percent of total billed charges,Implant Device,92.57,,,92.57,Other,110% of Medicare,65.45,35,,65.45,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,65.45,35,,65.45,percent of total billed charges,Implant Device,65.45,35,,65.45,percent of total billed charges,Implant Device,65.45,35,,65.45,percent of total billed charges,Implant Device,65.45,35,,65.45,percent of total billed charges,Implant Device,65.45,35,,65.45,percent of total billed charges,Implant Device,74.8,40,,74.8,percent of total billed charges,Implant Device,65.45,70,,65.45,percent of total billed charges,All Other,63.58,34,,63.58,percent of total billed charges,Implant Device,63.58,34,,63.58,percent of total billed charges,Implant Device,65.45,35,,65.45,percent of total billed charges,Implant Device,65.45,35,,65.45,percent of total billed charges,Implant Device,65.45,35,,65.45,percent of total billed charges,Implant Device,65.45,35,,65.45,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,138.38,
ZIMMER 824074001 MIDFOOT FUSION PLT SM,C1713,HCPCS,,79012776,CDM,278,RC,,,both,,,2573,1904.03,,,1904.03,Other,150% of Medicare + 9.63% HCRA Surcharge,1157.85,45,,1157.85,percent of total billed charges,Critical Access Hospital RCC factor,874.82,34,,874.82,percent of total billed charges,Implant Device,874.82,34,,874.82,percent of total billed charges,Implant Device,874.82,34,,874.82,percent of total billed charges,Implant Device,874.82,34,,874.82,percent of total billed charges,Implant Device,874.82,34,,874.82,percent of total billed charges,Implant Device,1273.64,,,1273.64,Other,110% of Medicare,900.55,35,,900.55,percent of total billed charges,Implant Device,874.82,34,"Charges > $500, x 34%",874.82,percent of total billed charges,Implant Device,900.55,35,,900.55,percent of total billed charges,Implant Device,900.55,35,,900.55,percent of total billed charges,Implant Device,900.55,35,,900.55,percent of total billed charges,Implant Device,900.55,35,,900.55,percent of total billed charges,Implant Device,900.55,35,,900.55,percent of total billed charges,Implant Device,1029.2,40,,1029.2,percent of total billed charges,Implant Device,900.55,70,,900.55,percent of total billed charges,All Other,874.82,34,,874.82,percent of total billed charges,Implant Device,874.82,34,,874.82,percent of total billed charges,Implant Device,900.55,35,,900.55,percent of total billed charges,Implant Device,900.55,35,,900.55,percent of total billed charges,Implant Device,900.55,35,,900.55,percent of total billed charges,Implant Device,900.55,35,,900.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,874.82,34,"If Charge > 2,000, then 34 percent",874.82,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1904.03,
BOST SC-1216 WAVEWRITER GENERATOR KIT,C1820,HCPCS,,79012777,CDM,278,RC,,,both,,,49800,36852.12,,,36852.12,Other,150% of Medicare + 9.63% HCRA Surcharge,22410,45,,22410,percent of total billed charges,Critical Access Hospital RCC factor,16932,34,,16932,percent of total billed charges,Implant Device,16932,34,,16932,percent of total billed charges,Implant Device,16932,34,,16932,percent of total billed charges,Implant Device,16932,34,,16932,percent of total billed charges,Implant Device,16932,34,,16932,percent of total billed charges,Implant Device,24651,,,24651,Other,110% of Medicare,17430,35,,17430,percent of total billed charges,Implant Device,16932,34,"Charges > $500, x 34%",16932,percent of total billed charges,Implant Device,17430,35,,17430,percent of total billed charges,Implant Device,17430,35,,17430,percent of total billed charges,Implant Device,17430,35,,17430,percent of total billed charges,Implant Device,17430,35,,17430,percent of total billed charges,Implant Device,17430,35,,17430,percent of total billed charges,Implant Device,19920,40,,19920,percent of total billed charges,Implant Device,17430,70,,17430,percent of total billed charges,All Other,16932,34,,16932,percent of total billed charges,Implant Device,16932,34,,16932,percent of total billed charges,Implant Device,17430,35,,17430,percent of total billed charges,Implant Device,17430,35,,17430,percent of total billed charges,Implant Device,17430,35,,17430,percent of total billed charges,Implant Device,17430,35,,17430,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,16932,34,"If Charge > 2,000, then 34 percent",16932,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,36852.12,
ZIMMER 110027734 COMPREHEN VRS GLENOID,C1776,HCPCS,,79012779,CDM,278,RC,,,both,,,38815,28723.2,,,28723.2,Other,150% of Medicare + 9.63% HCRA Surcharge,17466.75,45,,17466.75,percent of total billed charges,Critical Access Hospital RCC factor,13197.1,34,,13197.1,percent of total billed charges,Implant Device,13197.1,34,,13197.1,percent of total billed charges,Implant Device,13197.1,34,,13197.1,percent of total billed charges,Implant Device,13197.1,34,,13197.1,percent of total billed charges,Implant Device,13197.1,34,,13197.1,percent of total billed charges,Implant Device,19213.43,,,19213.43,Other,110% of Medicare,13585.25,35,,13585.25,percent of total billed charges,Implant Device,13197.1,34,"Charges > $500, x 34%",13197.1,percent of total billed charges,Implant Device,13585.25,35,,13585.25,percent of total billed charges,Implant Device,13585.25,35,,13585.25,percent of total billed charges,Implant Device,13585.25,35,,13585.25,percent of total billed charges,Implant Device,13585.25,35,,13585.25,percent of total billed charges,Implant Device,13585.25,35,,13585.25,percent of total billed charges,Implant Device,15526,40,,15526,percent of total billed charges,Implant Device,13585.25,70,,13585.25,percent of total billed charges,All Other,13197.1,34,,13197.1,percent of total billed charges,Implant Device,13197.1,34,,13197.1,percent of total billed charges,Implant Device,13585.25,35,,13585.25,percent of total billed charges,Implant Device,13585.25,35,,13585.25,percent of total billed charges,Implant Device,13585.25,35,,13585.25,percent of total billed charges,Implant Device,13585.25,35,,13585.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,13197.1,34,"If Charge > 2,000, then 34 percent",13197.1,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,28723.2,
ZIMMER 141235 TIBIAL PLATE 79MM,C1776,HCPCS,,79012782,CDM,278,RC,,,both,,,2304,1704.97,,,1704.97,Other,150% of Medicare + 9.63% HCRA Surcharge,1036.8,45,,1036.8,percent of total billed charges,Critical Access Hospital RCC factor,783.36,34,,783.36,percent of total billed charges,Implant Device,783.36,34,,783.36,percent of total billed charges,Implant Device,783.36,34,,783.36,percent of total billed charges,Implant Device,783.36,34,,783.36,percent of total billed charges,Implant Device,783.36,34,,783.36,percent of total billed charges,Implant Device,1140.48,,,1140.48,Other,110% of Medicare,806.4,35,,806.4,percent of total billed charges,Implant Device,783.36,34,"Charges > $500, x 34%",783.36,percent of total billed charges,Implant Device,806.4,35,,806.4,percent of total billed charges,Implant Device,806.4,35,,806.4,percent of total billed charges,Implant Device,806.4,35,,806.4,percent of total billed charges,Implant Device,806.4,35,,806.4,percent of total billed charges,Implant Device,806.4,35,,806.4,percent of total billed charges,Implant Device,921.6,40,,921.6,percent of total billed charges,Implant Device,806.4,70,,806.4,percent of total billed charges,All Other,783.36,34,,783.36,percent of total billed charges,Implant Device,783.36,34,,783.36,percent of total billed charges,Implant Device,806.4,35,,806.4,percent of total billed charges,Implant Device,806.4,35,,806.4,percent of total billed charges,Implant Device,806.4,35,,806.4,percent of total billed charges,Implant Device,806.4,35,,806.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,783.36,34,"If Charge > 2,000, then 34 percent",783.36,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1704.97,
ZIMMER VE189100 TIBIAL BEARING 79X10MM,C1776,HCPCS,,79012783,CDM,278,RC,,,both,,,3648,2699.53,,,2699.53,Other,150% of Medicare + 9.63% HCRA Surcharge,1641.6,45,,1641.6,percent of total billed charges,Critical Access Hospital RCC factor,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1805.76,,,1805.76,Other,110% of Medicare,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1240.32,34,"Charges > $500, x 34%",1240.32,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1459.2,40,,1459.2,percent of total billed charges,Implant Device,1276.8,70,,1276.8,percent of total billed charges,All Other,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1240.32,34,"If Charge > 2,000, then 34 percent",1240.32,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2699.53,
"J&J 09.405.563S RADIAL HEAD 25, 6.5 STEM",C1776,HCPCS,,79012785,CDM,278,RC,,,both,,,9560,7074.42,,,7074.42,Other,150% of Medicare + 9.63% HCRA Surcharge,4302,45,,4302,percent of total billed charges,Critical Access Hospital RCC factor,3250.4,34,,3250.4,percent of total billed charges,Implant Device,3250.4,34,,3250.4,percent of total billed charges,Implant Device,3250.4,34,,3250.4,percent of total billed charges,Implant Device,3250.4,34,,3250.4,percent of total billed charges,Implant Device,3250.4,34,,3250.4,percent of total billed charges,Implant Device,4732.2,,,4732.2,Other,110% of Medicare,3346,35,,3346,percent of total billed charges,Implant Device,3250.4,34,"Charges > $500, x 34%",3250.4,percent of total billed charges,Implant Device,3346,35,,3346,percent of total billed charges,Implant Device,3346,35,,3346,percent of total billed charges,Implant Device,3346,35,,3346,percent of total billed charges,Implant Device,3346,35,,3346,percent of total billed charges,Implant Device,3346,35,,3346,percent of total billed charges,Implant Device,3824,40,,3824,percent of total billed charges,Implant Device,3346,70,,3346,percent of total billed charges,All Other,3250.4,34,,3250.4,percent of total billed charges,Implant Device,3250.4,34,,3250.4,percent of total billed charges,Implant Device,3346,35,,3346,percent of total billed charges,Implant Device,3346,35,,3346,percent of total billed charges,Implant Device,3346,35,,3346,percent of total billed charges,Implant Device,3346,35,,3346,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3250.4,34,"If Charge > 2,000, then 34 percent",3250.4,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,7074.42,
J&J 1024-56-407 TIBIAL INSERT 7MM SZ 4,C1776,HCPCS,,79012788,CDM,278,RC,,,both,,,2850,2109.01,,,2109.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1282.5,45,,1282.5,percent of total billed charges,Critical Access Hospital RCC factor,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,1410.75,,,1410.75,Other,110% of Medicare,997.5,35,,997.5,percent of total billed charges,Implant Device,969,34,"Charges > $500, x 34%",969,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,1140,40,,1140,percent of total billed charges,Implant Device,997.5,70,,997.5,percent of total billed charges,All Other,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,969,34,"If Charge > 2,000, then 34 percent",969,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2109.01,
J&J 1504-11-205 FEMORAL COMP RT SZ 5,C1776,HCPCS,,79012789,CDM,278,RC,,,both,,,6000,4440.02,,,4440.02,Other,150% of Medicare + 9.63% HCRA Surcharge,2700,45,,2700,percent of total billed charges,Critical Access Hospital RCC factor,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2970,,,2970,Other,110% of Medicare,2100,35,,2100,percent of total billed charges,Implant Device,2040,34,"Charges > $500, x 34%",2040,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2400,40,,2400,percent of total billed charges,Implant Device,2100,70,,2100,percent of total billed charges,All Other,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2040,34,"If Charge > 2,000, then 34 percent",2040,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4440.02,
ZIMMER 42-5026-060-02 FEMUR RT SZ 6,C1776,HCPCS,,79012790,CDM,278,RC,,,both,,,10200,7548.03,,,7548.03,Other,150% of Medicare + 9.63% HCRA Surcharge,4590,45,,4590,percent of total billed charges,Critical Access Hospital RCC factor,3468,34,,3468,percent of total billed charges,Implant Device,3468,34,,3468,percent of total billed charges,Implant Device,3468,34,,3468,percent of total billed charges,Implant Device,3468,34,,3468,percent of total billed charges,Implant Device,3468,34,,3468,percent of total billed charges,Implant Device,5049,,,5049,Other,110% of Medicare,3570,35,,3570,percent of total billed charges,Implant Device,3468,34,"Charges > $500, x 34%",3468,percent of total billed charges,Implant Device,3570,35,,3570,percent of total billed charges,Implant Device,3570,35,,3570,percent of total billed charges,Implant Device,3570,35,,3570,percent of total billed charges,Implant Device,3570,35,,3570,percent of total billed charges,Implant Device,3570,35,,3570,percent of total billed charges,Implant Device,4080,40,,4080,percent of total billed charges,Implant Device,3570,70,,3570,percent of total billed charges,All Other,3468,34,,3468,percent of total billed charges,Implant Device,3468,34,,3468,percent of total billed charges,Implant Device,3570,35,,3570,percent of total billed charges,Implant Device,3570,35,,3570,percent of total billed charges,Implant Device,3570,35,,3570,percent of total billed charges,Implant Device,3570,35,,3570,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3468,34,"If Charge > 2,000, then 34 percent",3468,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,7548.03,
EXACTECH 306-02-12 HUM LONG STEM 12X20,C1776,HCPCS,,79012791,CDM,278,RC,,,both,,,12672,9377.31,,,9377.31,Other,150% of Medicare + 9.63% HCRA Surcharge,5702.4,45,,5702.4,percent of total billed charges,Critical Access Hospital RCC factor,4308.48,34,,4308.48,percent of total billed charges,Implant Device,4308.48,34,,4308.48,percent of total billed charges,Implant Device,4308.48,34,,4308.48,percent of total billed charges,Implant Device,4308.48,34,,4308.48,percent of total billed charges,Implant Device,4308.48,34,,4308.48,percent of total billed charges,Implant Device,6272.64,,,6272.64,Other,110% of Medicare,4435.2,35,,4435.2,percent of total billed charges,Implant Device,4308.48,34,"Charges > $500, x 34%",4308.48,percent of total billed charges,Implant Device,4435.2,35,,4435.2,percent of total billed charges,Implant Device,4435.2,35,,4435.2,percent of total billed charges,Implant Device,4435.2,35,,4435.2,percent of total billed charges,Implant Device,4435.2,35,,4435.2,percent of total billed charges,Implant Device,4435.2,35,,4435.2,percent of total billed charges,Implant Device,5068.8,40,,5068.8,percent of total billed charges,Implant Device,4435.2,70,,4435.2,percent of total billed charges,All Other,4308.48,34,,4308.48,percent of total billed charges,Implant Device,4308.48,34,,4308.48,percent of total billed charges,Implant Device,4435.2,35,,4435.2,percent of total billed charges,Implant Device,4435.2,35,,4435.2,percent of total billed charges,Implant Device,4435.2,35,,4435.2,percent of total billed charges,Implant Device,4435.2,35,,4435.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,4308.48,34,"If Charge > 2,000, then 34 percent",4308.48,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,9377.31,
EXACTECH 320-00-12 LAT RT HUMERAL TRAY,C1776,HCPCS,,79012792,CDM,278,RC,,,both,,,13500,9990.03,,,9990.03,Other,150% of Medicare + 9.63% HCRA Surcharge,6075,45,,6075,percent of total billed charges,Critical Access Hospital RCC factor,4590,34,,4590,percent of total billed charges,Implant Device,4590,34,,4590,percent of total billed charges,Implant Device,4590,34,,4590,percent of total billed charges,Implant Device,4590,34,,4590,percent of total billed charges,Implant Device,4590,34,,4590,percent of total billed charges,Implant Device,6682.5,,,6682.5,Other,110% of Medicare,4725,35,,4725,percent of total billed charges,Implant Device,4590,34,"Charges > $500, x 34%",4590,percent of total billed charges,Implant Device,4725,35,,4725,percent of total billed charges,Implant Device,4725,35,,4725,percent of total billed charges,Implant Device,4725,35,,4725,percent of total billed charges,Implant Device,4725,35,,4725,percent of total billed charges,Implant Device,4725,35,,4725,percent of total billed charges,Implant Device,5400,40,,5400,percent of total billed charges,Implant Device,4725,70,,4725,percent of total billed charges,All Other,4590,34,,4590,percent of total billed charges,Implant Device,4590,34,,4590,percent of total billed charges,Implant Device,4725,35,,4725,percent of total billed charges,Implant Device,4725,35,,4725,percent of total billed charges,Implant Device,4725,35,,4725,percent of total billed charges,Implant Device,4725,35,,4725,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,4590,34,"If Charge > 2,000, then 34 percent",4590,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,9990.03,
J&J 206.045 CANCELLOUS SCREW 4X45MM,C1713,HCPCS,,79012793,CDM,278,RC,,,both,,,47,34.78,,,34.78,Other,150% of Medicare + 9.63% HCRA Surcharge,21.15,45,,21.15,percent of total billed charges,Critical Access Hospital RCC factor,15.98,34,,15.98,percent of total billed charges,Implant Device,15.98,34,,15.98,percent of total billed charges,Implant Device,15.98,34,,15.98,percent of total billed charges,Implant Device,15.98,34,,15.98,percent of total billed charges,Implant Device,15.98,34,,15.98,percent of total billed charges,Implant Device,23.27,,,23.27,Other,110% of Medicare,16.45,35,,16.45,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,16.45,35,,16.45,percent of total billed charges,Implant Device,16.45,35,,16.45,percent of total billed charges,Implant Device,16.45,35,,16.45,percent of total billed charges,Implant Device,16.45,35,,16.45,percent of total billed charges,Implant Device,16.45,35,,16.45,percent of total billed charges,Implant Device,18.8,40,,18.8,percent of total billed charges,Implant Device,16.45,70,,16.45,percent of total billed charges,All Other,15.98,34,,15.98,percent of total billed charges,Implant Device,15.98,34,,15.98,percent of total billed charges,Implant Device,16.45,35,,16.45,percent of total billed charges,Implant Device,16.45,35,,16.45,percent of total billed charges,Implant Device,16.45,35,,16.45,percent of total billed charges,Implant Device,16.45,35,,16.45,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,34.78,
ARTHREX AR-8970TT-04 TT PLATE 4 HOLE,C1713,HCPCS,,79012794,CDM,278,RC,,,both,,,6375,4717.52,,,4717.52,Other,150% of Medicare + 9.63% HCRA Surcharge,2868.75,45,,2868.75,percent of total billed charges,Critical Access Hospital RCC factor,2167.5,34,,2167.5,percent of total billed charges,Implant Device,2167.5,34,,2167.5,percent of total billed charges,Implant Device,2167.5,34,,2167.5,percent of total billed charges,Implant Device,2167.5,34,,2167.5,percent of total billed charges,Implant Device,2167.5,34,,2167.5,percent of total billed charges,Implant Device,3155.63,,,3155.63,Other,110% of Medicare,2231.25,35,,2231.25,percent of total billed charges,Implant Device,2167.5,34,"Charges > $500, x 34%",2167.5,percent of total billed charges,Implant Device,2231.25,35,,2231.25,percent of total billed charges,Implant Device,2231.25,35,,2231.25,percent of total billed charges,Implant Device,2231.25,35,,2231.25,percent of total billed charges,Implant Device,2231.25,35,,2231.25,percent of total billed charges,Implant Device,2231.25,35,,2231.25,percent of total billed charges,Implant Device,2550,40,,2550,percent of total billed charges,Implant Device,2231.25,70,,2231.25,percent of total billed charges,All Other,2167.5,34,,2167.5,percent of total billed charges,Implant Device,2167.5,34,,2167.5,percent of total billed charges,Implant Device,2231.25,35,,2231.25,percent of total billed charges,Implant Device,2231.25,35,,2231.25,percent of total billed charges,Implant Device,2231.25,35,,2231.25,percent of total billed charges,Implant Device,2231.25,35,,2231.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2167.5,34,"If Charge > 2,000, then 34 percent",2167.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4717.52,
ARTHREX AR-8770-60H FT SCREW 7.0X4.0MM,C1713,HCPCS,,79012795,CDM,278,RC,,,both,,,2085,1542.91,,,1542.91,Other,150% of Medicare + 9.63% HCRA Surcharge,938.25,45,,938.25,percent of total billed charges,Critical Access Hospital RCC factor,708.9,34,,708.9,percent of total billed charges,Implant Device,708.9,34,,708.9,percent of total billed charges,Implant Device,708.9,34,,708.9,percent of total billed charges,Implant Device,708.9,34,,708.9,percent of total billed charges,Implant Device,708.9,34,,708.9,percent of total billed charges,Implant Device,1032.08,,,1032.08,Other,110% of Medicare,729.75,35,,729.75,percent of total billed charges,Implant Device,708.9,34,"Charges > $500, x 34%",708.9,percent of total billed charges,Implant Device,729.75,35,,729.75,percent of total billed charges,Implant Device,729.75,35,,729.75,percent of total billed charges,Implant Device,729.75,35,,729.75,percent of total billed charges,Implant Device,729.75,35,,729.75,percent of total billed charges,Implant Device,729.75,35,,729.75,percent of total billed charges,Implant Device,834,40,,834,percent of total billed charges,Implant Device,729.75,70,,729.75,percent of total billed charges,All Other,708.9,34,,708.9,percent of total billed charges,Implant Device,708.9,34,,708.9,percent of total billed charges,Implant Device,729.75,35,,729.75,percent of total billed charges,Implant Device,729.75,35,,729.75,percent of total billed charges,Implant Device,729.75,35,,729.75,percent of total billed charges,Implant Device,729.75,35,,729.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,708.9,34,"If Charge > 2,000, then 34 percent",708.9,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1542.91,
ARTHREX AR-8545-42 CORT SCREW 4.5X42MM,C1713,HCPCS,,79012796,CDM,278,RC,,,both,,,225,166.5,,,166.5,Other,150% of Medicare + 9.63% HCRA Surcharge,101.25,45,,101.25,percent of total billed charges,Critical Access Hospital RCC factor,76.5,34,,76.5,percent of total billed charges,Implant Device,76.5,34,,76.5,percent of total billed charges,Implant Device,76.5,34,,76.5,percent of total billed charges,Implant Device,76.5,34,,76.5,percent of total billed charges,Implant Device,76.5,34,,76.5,percent of total billed charges,Implant Device,111.38,,,111.38,Other,110% of Medicare,78.75,35,,78.75,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,78.75,35,,78.75,percent of total billed charges,Implant Device,78.75,35,,78.75,percent of total billed charges,Implant Device,78.75,35,,78.75,percent of total billed charges,Implant Device,78.75,35,,78.75,percent of total billed charges,Implant Device,78.75,35,,78.75,percent of total billed charges,Implant Device,90,40,,90,percent of total billed charges,Implant Device,78.75,70,,78.75,percent of total billed charges,All Other,76.5,34,,76.5,percent of total billed charges,Implant Device,76.5,34,,76.5,percent of total billed charges,Implant Device,78.75,35,,78.75,percent of total billed charges,Implant Device,78.75,35,,78.75,percent of total billed charges,Implant Device,78.75,35,,78.75,percent of total billed charges,Implant Device,78.75,35,,78.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,166.5,
ARTHREX AR-8545L-50 LOCK SCREW 4.5X5MM,C1713,HCPCS,,79012797,CDM,278,RC,,,both,,,585,432.9,,,432.9,Other,150% of Medicare + 9.63% HCRA Surcharge,263.25,45,,263.25,percent of total billed charges,Critical Access Hospital RCC factor,198.9,34,,198.9,percent of total billed charges,Implant Device,198.9,34,,198.9,percent of total billed charges,Implant Device,198.9,34,,198.9,percent of total billed charges,Implant Device,198.9,34,,198.9,percent of total billed charges,Implant Device,198.9,34,,198.9,percent of total billed charges,Implant Device,289.58,,,289.58,Other,110% of Medicare,204.75,35,,204.75,percent of total billed charges,Implant Device,198.9,34,"Charges > $500, x 34%",198.9,percent of total billed charges,Implant Device,204.75,35,,204.75,percent of total billed charges,Implant Device,204.75,35,,204.75,percent of total billed charges,Implant Device,204.75,35,,204.75,percent of total billed charges,Implant Device,204.75,35,,204.75,percent of total billed charges,Implant Device,204.75,35,,204.75,percent of total billed charges,Implant Device,234,40,,234,percent of total billed charges,Implant Device,204.75,70,,204.75,percent of total billed charges,All Other,198.9,34,,198.9,percent of total billed charges,Implant Device,198.9,34,,198.9,percent of total billed charges,Implant Device,204.75,35,,204.75,percent of total billed charges,Implant Device,204.75,35,,204.75,percent of total billed charges,Implant Device,204.75,35,,204.75,percent of total billed charges,Implant Device,204.75,35,,204.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,432.9,
ZMMER 574101060 FEMORAL STEM SZ 6.5,C1776,HCPCS,,79012799,CDM,278,RC,,,both,,,6912,5114.9,,,5114.9,Other,150% of Medicare + 9.63% HCRA Surcharge,3110.4,45,,3110.4,percent of total billed charges,Critical Access Hospital RCC factor,2350.08,34,,2350.08,percent of total billed charges,Implant Device,2350.08,34,,2350.08,percent of total billed charges,Implant Device,2350.08,34,,2350.08,percent of total billed charges,Implant Device,2350.08,34,,2350.08,percent of total billed charges,Implant Device,2350.08,34,,2350.08,percent of total billed charges,Implant Device,3421.44,,,3421.44,Other,110% of Medicare,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2350.08,34,"Charges > $500, x 34%",2350.08,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2764.8,40,,2764.8,percent of total billed charges,Implant Device,2419.2,70,,2419.2,percent of total billed charges,All Other,2350.08,34,,2350.08,percent of total billed charges,Implant Device,2350.08,34,,2350.08,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2350.08,34,"If Charge > 2,000, then 34 percent",2350.08,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5114.9,
TELEFLEX UL400ATC UROLIFT DEVICE & IMPL,L8699,HCPCS,,79012808,CDM,278,RC,,,both,,,3525,2608.51,,,2608.51,Other,150% of Medicare + 9.63% HCRA Surcharge,1586.25,45,,1586.25,percent of total billed charges,Critical Access Hospital RCC factor,1198.5,34,,1198.5,percent of total billed charges,Implant Device,1198.5,34,,1198.5,percent of total billed charges,Implant Device,1198.5,34,,1198.5,percent of total billed charges,Implant Device,1198.5,34,,1198.5,percent of total billed charges,Implant Device,1198.5,34,,1198.5,percent of total billed charges,Implant Device,1744.88,,,1744.88,Other,110% of Medicare,1233.75,35,,1233.75,percent of total billed charges,Implant Device,1198.5,34,"Charges > $500, x 34%",1198.5,percent of total billed charges,Implant Device,1233.75,35,,1233.75,percent of total billed charges,Implant Device,1233.75,35,,1233.75,percent of total billed charges,Implant Device,1233.75,35,,1233.75,percent of total billed charges,Implant Device,1233.75,35,,1233.75,percent of total billed charges,Implant Device,1233.75,35,,1233.75,percent of total billed charges,Implant Device,1410,40,,1410,percent of total billed charges,Implant Device,1233.75,70,,1233.75,percent of total billed charges,All Other,1198.5,34,,1198.5,percent of total billed charges,Implant Device,1198.5,34,,1198.5,percent of total billed charges,Implant Device,1233.75,35,,1233.75,percent of total billed charges,Implant Device,1233.75,35,,1233.75,percent of total billed charges,Implant Device,1233.75,35,,1233.75,percent of total billed charges,Implant Device,1233.75,35,,1233.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1198.5,34,"If Charge > 2,000, then 34 percent",1198.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2608.51,
ZIMMER 183010 FEMORAL RIGHT 67.5MM,C1776,HCPCS,,79012809,CDM,278,RC,,,both,,,6300,4662.02,,,4662.02,Other,150% of Medicare + 9.63% HCRA Surcharge,2835,45,,2835,percent of total billed charges,Critical Access Hospital RCC factor,2142,34,,2142,percent of total billed charges,Implant Device,2142,34,,2142,percent of total billed charges,Implant Device,2142,34,,2142,percent of total billed charges,Implant Device,2142,34,,2142,percent of total billed charges,Implant Device,2142,34,,2142,percent of total billed charges,Implant Device,3118.5,,,3118.5,Other,110% of Medicare,2205,35,,2205,percent of total billed charges,Implant Device,2142,34,"Charges > $500, x 34%",2142,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2520,40,,2520,percent of total billed charges,Implant Device,2205,70,,2205,percent of total billed charges,All Other,2142,34,,2142,percent of total billed charges,Implant Device,2142,34,,2142,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2142,34,"If Charge > 2,000, then 34 percent",2142,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4662.02,
ZIMMER EP-189082 TIBIAL BEARING 12X75MM,C1776,HCPCS,,79012810,CDM,278,RC,,,both,,,3648,2699.53,,,2699.53,Other,150% of Medicare + 9.63% HCRA Surcharge,1641.6,45,,1641.6,percent of total billed charges,Critical Access Hospital RCC factor,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1805.76,,,1805.76,Other,110% of Medicare,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1240.32,34,"Charges > $500, x 34%",1240.32,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1459.2,40,,1459.2,percent of total billed charges,Implant Device,1276.8,70,,1276.8,percent of total billed charges,All Other,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1240.32,34,"If Charge > 2,000, then 34 percent",1240.32,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2699.53,
BOST SC-2408-74 AVISTA MRI 74CM LEAD KIT,C1778,HCPCS,,79012811,CDM,278,RC,,,both,,,4800,3552.01,,,3552.01,Other,150% of Medicare + 9.63% HCRA Surcharge,2160,45,,2160,percent of total billed charges,Critical Access Hospital RCC factor,1632,34,,1632,percent of total billed charges,Implant Device,1632,34,,1632,percent of total billed charges,Implant Device,1632,34,,1632,percent of total billed charges,Implant Device,1632,34,,1632,percent of total billed charges,Implant Device,1632,34,,1632,percent of total billed charges,Implant Device,2376,,,2376,Other,110% of Medicare,1680,35,,1680,percent of total billed charges,Implant Device,1632,34,"Charges > $500, x 34%",1632,percent of total billed charges,Implant Device,1680,35,,1680,percent of total billed charges,Implant Device,1680,35,,1680,percent of total billed charges,Implant Device,1680,35,,1680,percent of total billed charges,Implant Device,1680,35,,1680,percent of total billed charges,Implant Device,1680,35,,1680,percent of total billed charges,Implant Device,1920,40,,1920,percent of total billed charges,Implant Device,1680,70,,1680,percent of total billed charges,All Other,1632,34,,1632,percent of total billed charges,Implant Device,1632,34,,1632,percent of total billed charges,Implant Device,1680,35,,1680,percent of total billed charges,Implant Device,1680,35,,1680,percent of total billed charges,Implant Device,1680,35,,1680,percent of total billed charges,Implant Device,1680,35,,1680,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1632,34,"If Charge > 2,000, then 34 percent",1632,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3552.01,
J&J 02.118.544 METAPHYSEA SCREW 2.7X44MM,C1713,HCPCS,,79012812,CDM,278,RC,,,both,,,125,92.5,,,92.5,Other,150% of Medicare + 9.63% HCRA Surcharge,56.25,45,,56.25,percent of total billed charges,Critical Access Hospital RCC factor,42.5,34,,42.5,percent of total billed charges,Implant Device,42.5,34,,42.5,percent of total billed charges,Implant Device,42.5,34,,42.5,percent of total billed charges,Implant Device,42.5,34,,42.5,percent of total billed charges,Implant Device,42.5,34,,42.5,percent of total billed charges,Implant Device,61.88,,,61.88,Other,110% of Medicare,43.75,35,,43.75,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,43.75,35,,43.75,percent of total billed charges,Implant Device,43.75,35,,43.75,percent of total billed charges,Implant Device,43.75,35,,43.75,percent of total billed charges,Implant Device,43.75,35,,43.75,percent of total billed charges,Implant Device,43.75,35,,43.75,percent of total billed charges,Implant Device,50,40,,50,percent of total billed charges,Implant Device,43.75,70,,43.75,percent of total billed charges,All Other,42.5,34,,42.5,percent of total billed charges,Implant Device,42.5,34,,42.5,percent of total billed charges,Implant Device,43.75,35,,43.75,percent of total billed charges,Implant Device,43.75,35,,43.75,percent of total billed charges,Implant Device,43.75,35,,43.75,percent of total billed charges,Implant Device,43.75,35,,43.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,92.5,
J&J 09.405.260S RADIAL HEAD 22X6.5MM,C1776,HCPCS,,79012814,CDM,278,RC,,,both,,,10622,7860.31,,,7860.31,Other,150% of Medicare + 9.63% HCRA Surcharge,4779.9,45,,4779.9,percent of total billed charges,Critical Access Hospital RCC factor,3611.48,34,,3611.48,percent of total billed charges,Implant Device,3611.48,34,,3611.48,percent of total billed charges,Implant Device,3611.48,34,,3611.48,percent of total billed charges,Implant Device,3611.48,34,,3611.48,percent of total billed charges,Implant Device,3611.48,34,,3611.48,percent of total billed charges,Implant Device,5257.89,,,5257.89,Other,110% of Medicare,3717.7,35,,3717.7,percent of total billed charges,Implant Device,3611.48,34,"Charges > $500, x 34%",3611.48,percent of total billed charges,Implant Device,3717.7,35,,3717.7,percent of total billed charges,Implant Device,3717.7,35,,3717.7,percent of total billed charges,Implant Device,3717.7,35,,3717.7,percent of total billed charges,Implant Device,3717.7,35,,3717.7,percent of total billed charges,Implant Device,3717.7,35,,3717.7,percent of total billed charges,Implant Device,4248.8,40,,4248.8,percent of total billed charges,Implant Device,3717.7,70,,3717.7,percent of total billed charges,All Other,3611.48,34,,3611.48,percent of total billed charges,Implant Device,3611.48,34,,3611.48,percent of total billed charges,Implant Device,3717.7,35,,3717.7,percent of total billed charges,Implant Device,3717.7,35,,3717.7,percent of total billed charges,Implant Device,3717.7,35,,3717.7,percent of total billed charges,Implant Device,3717.7,35,,3717.7,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3611.48,34,"If Charge > 2,000, then 34 percent",3611.48,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,7860.31,
ZIMMER 00-8852-012-32 RIM LINER 32 SZ KK,C1776,HCPCS,,79012815,CDM,278,RC,,,both,,,3456,2557.45,,,2557.45,Other,150% of Medicare + 9.63% HCRA Surcharge,1555.2,45,,1555.2,percent of total billed charges,Critical Access Hospital RCC factor,1175.04,34,,1175.04,percent of total billed charges,Implant Device,1175.04,34,,1175.04,percent of total billed charges,Implant Device,1175.04,34,,1175.04,percent of total billed charges,Implant Device,1175.04,34,,1175.04,percent of total billed charges,Implant Device,1175.04,34,,1175.04,percent of total billed charges,Implant Device,1710.72,,,1710.72,Other,110% of Medicare,1209.6,35,,1209.6,percent of total billed charges,Implant Device,1175.04,34,"Charges > $500, x 34%",1175.04,percent of total billed charges,Implant Device,1209.6,35,,1209.6,percent of total billed charges,Implant Device,1209.6,35,,1209.6,percent of total billed charges,Implant Device,1209.6,35,,1209.6,percent of total billed charges,Implant Device,1209.6,35,,1209.6,percent of total billed charges,Implant Device,1209.6,35,,1209.6,percent of total billed charges,Implant Device,1382.4,40,,1382.4,percent of total billed charges,Implant Device,1209.6,70,,1209.6,percent of total billed charges,All Other,1175.04,34,,1175.04,percent of total billed charges,Implant Device,1175.04,34,,1175.04,percent of total billed charges,Implant Device,1209.6,35,,1209.6,percent of total billed charges,Implant Device,1209.6,35,,1209.6,percent of total billed charges,Implant Device,1209.6,35,,1209.6,percent of total billed charges,Implant Device,1209.6,35,,1209.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1175.04,34,"If Charge > 2,000, then 34 percent",1175.04,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2557.45,
ZIMMER VE189108 TIBIAL BEARING 79X18MM,C1776,HCPCS,,79012816,CDM,278,RC,,,both,,,3648,2699.53,,,2699.53,Other,150% of Medicare + 9.63% HCRA Surcharge,1641.6,45,,1641.6,percent of total billed charges,Critical Access Hospital RCC factor,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1805.76,,,1805.76,Other,110% of Medicare,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1240.32,34,"Charges > $500, x 34%",1240.32,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1459.2,40,,1459.2,percent of total billed charges,Implant Device,1276.8,70,,1276.8,percent of total billed charges,All Other,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1240.32,34,"If Charge > 2,000, then 34 percent",1240.32,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2699.53,
J&J 04.045.034S LOCKING SCREW 5X34MM,C1713,HCPCS,,79012817,CDM,278,RC,,,both,,,687,508.38,,,508.38,Other,150% of Medicare + 9.63% HCRA Surcharge,309.15,45,,309.15,percent of total billed charges,Critical Access Hospital RCC factor,233.58,34,,233.58,percent of total billed charges,Implant Device,233.58,34,,233.58,percent of total billed charges,Implant Device,233.58,34,,233.58,percent of total billed charges,Implant Device,233.58,34,,233.58,percent of total billed charges,Implant Device,233.58,34,,233.58,percent of total billed charges,Implant Device,340.07,,,340.07,Other,110% of Medicare,240.45,35,,240.45,percent of total billed charges,Implant Device,233.58,34,"Charges > $500, x 34%",233.58,percent of total billed charges,Implant Device,240.45,35,,240.45,percent of total billed charges,Implant Device,240.45,35,,240.45,percent of total billed charges,Implant Device,240.45,35,,240.45,percent of total billed charges,Implant Device,240.45,35,,240.45,percent of total billed charges,Implant Device,240.45,35,,240.45,percent of total billed charges,Implant Device,274.8,40,,274.8,percent of total billed charges,Implant Device,240.45,70,,240.45,percent of total billed charges,All Other,233.58,34,,233.58,percent of total billed charges,Implant Device,233.58,34,,233.58,percent of total billed charges,Implant Device,240.45,35,,240.45,percent of total billed charges,Implant Device,240.45,35,,240.45,percent of total billed charges,Implant Device,240.45,35,,240.45,percent of total billed charges,Implant Device,240.45,35,,240.45,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,508.38,
J&J 04.037.114S TFNA NAIL 11X125 125 DEG,C1713,HCPCS,,79012818,CDM,278,RC,,,both,,,4485,3318.91,,,3318.91,Other,150% of Medicare + 9.63% HCRA Surcharge,2018.25,45,,2018.25,percent of total billed charges,Critical Access Hospital RCC factor,1524.9,34,,1524.9,percent of total billed charges,Implant Device,1524.9,34,,1524.9,percent of total billed charges,Implant Device,1524.9,34,,1524.9,percent of total billed charges,Implant Device,1524.9,34,,1524.9,percent of total billed charges,Implant Device,1524.9,34,,1524.9,percent of total billed charges,Implant Device,2220.08,,,2220.08,Other,110% of Medicare,1569.75,35,,1569.75,percent of total billed charges,Implant Device,1524.9,34,"Charges > $500, x 34%",1524.9,percent of total billed charges,Implant Device,1569.75,35,,1569.75,percent of total billed charges,Implant Device,1569.75,35,,1569.75,percent of total billed charges,Implant Device,1569.75,35,,1569.75,percent of total billed charges,Implant Device,1569.75,35,,1569.75,percent of total billed charges,Implant Device,1569.75,35,,1569.75,percent of total billed charges,Implant Device,1794,40,,1794,percent of total billed charges,Implant Device,1569.75,70,,1569.75,percent of total billed charges,All Other,1524.9,34,,1524.9,percent of total billed charges,Implant Device,1524.9,34,,1524.9,percent of total billed charges,Implant Device,1569.75,35,,1569.75,percent of total billed charges,Implant Device,1569.75,35,,1569.75,percent of total billed charges,Implant Device,1569.75,35,,1569.75,percent of total billed charges,Implant Device,1569.75,35,,1569.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1524.9,34,"If Charge > 2,000, then 34 percent",1524.9,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3318.91,
J&J 1504-11-109 FEMORAL COMP LT SZ 9,C1776,HCPCS,,79012819,CDM,278,RC,,,both,,,6000,4440.02,,,4440.02,Other,150% of Medicare + 9.63% HCRA Surcharge,2700,45,,2700,percent of total billed charges,Critical Access Hospital RCC factor,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2970,,,2970,Other,110% of Medicare,2100,35,,2100,percent of total billed charges,Implant Device,2040,34,"Charges > $500, x 34%",2040,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2400,40,,2400,percent of total billed charges,Implant Device,2100,70,,2100,percent of total billed charges,All Other,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2040,34,"If Charge > 2,000, then 34 percent",2040,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4440.02,
STRYKER 6720-0127 HIP STEM SZ 1 27X96MM,C1776,HCPCS,,79012820,CDM,278,RC,,,both,,,6953,5145.24,,,5145.24,Other,150% of Medicare + 9.63% HCRA Surcharge,3128.85,45,,3128.85,percent of total billed charges,Critical Access Hospital RCC factor,2364.02,34,,2364.02,percent of total billed charges,Implant Device,2364.02,34,,2364.02,percent of total billed charges,Implant Device,2364.02,34,,2364.02,percent of total billed charges,Implant Device,2364.02,34,,2364.02,percent of total billed charges,Implant Device,2364.02,34,,2364.02,percent of total billed charges,Implant Device,3441.74,,,3441.74,Other,110% of Medicare,2433.55,35,,2433.55,percent of total billed charges,Implant Device,2364.02,34,"Charges > $500, x 34%",2364.02,percent of total billed charges,Implant Device,2433.55,35,,2433.55,percent of total billed charges,Implant Device,2433.55,35,,2433.55,percent of total billed charges,Implant Device,2433.55,35,,2433.55,percent of total billed charges,Implant Device,2433.55,35,,2433.55,percent of total billed charges,Implant Device,2433.55,35,,2433.55,percent of total billed charges,Implant Device,2781.2,40,,2781.2,percent of total billed charges,Implant Device,2433.55,70,,2433.55,percent of total billed charges,All Other,2364.02,34,,2364.02,percent of total billed charges,Implant Device,2364.02,34,,2364.02,percent of total billed charges,Implant Device,2433.55,35,,2433.55,percent of total billed charges,Implant Device,2433.55,35,,2433.55,percent of total billed charges,Implant Device,2433.55,35,,2433.55,percent of total billed charges,Implant Device,2433.55,35,,2433.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2364.02,34,"If Charge > 2,000, then 34 percent",2364.02,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5145.24,
ZIMMER 115397 CENTRAL SCREW 6.5X35MM,C1713,HCPCS,,79012821,CDM,278,RC,,,both,,,211,156.14,,,156.14,Other,150% of Medicare + 9.63% HCRA Surcharge,94.95,45,,94.95,percent of total billed charges,Critical Access Hospital RCC factor,71.74,34,,71.74,percent of total billed charges,Implant Device,71.74,34,,71.74,percent of total billed charges,Implant Device,71.74,34,,71.74,percent of total billed charges,Implant Device,71.74,34,,71.74,percent of total billed charges,Implant Device,71.74,34,,71.74,percent of total billed charges,Implant Device,104.45,,,104.45,Other,110% of Medicare,73.85,35,,73.85,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,73.85,35,,73.85,percent of total billed charges,Implant Device,73.85,35,,73.85,percent of total billed charges,Implant Device,73.85,35,,73.85,percent of total billed charges,Implant Device,73.85,35,,73.85,percent of total billed charges,Implant Device,73.85,35,,73.85,percent of total billed charges,Implant Device,84.4,40,,84.4,percent of total billed charges,Implant Device,73.85,70,,73.85,percent of total billed charges,All Other,71.74,34,,71.74,percent of total billed charges,Implant Device,71.74,34,,71.74,percent of total billed charges,Implant Device,73.85,35,,73.85,percent of total billed charges,Implant Device,73.85,35,,73.85,percent of total billed charges,Implant Device,73.85,35,,73.85,percent of total billed charges,Implant Device,73.85,35,,73.85,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,156.14,
ZIMMER 180553 LOCKING SCREW 4.75X30MM,C1713,HCPCS,,79012822,CDM,278,RC,,,both,,,211,156.14,,,156.14,Other,150% of Medicare + 9.63% HCRA Surcharge,94.95,45,,94.95,percent of total billed charges,Critical Access Hospital RCC factor,71.74,34,,71.74,percent of total billed charges,Implant Device,71.74,34,,71.74,percent of total billed charges,Implant Device,71.74,34,,71.74,percent of total billed charges,Implant Device,71.74,34,,71.74,percent of total billed charges,Implant Device,71.74,34,,71.74,percent of total billed charges,Implant Device,104.45,,,104.45,Other,110% of Medicare,73.85,35,,73.85,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,73.85,35,,73.85,percent of total billed charges,Implant Device,73.85,35,,73.85,percent of total billed charges,Implant Device,73.85,35,,73.85,percent of total billed charges,Implant Device,73.85,35,,73.85,percent of total billed charges,Implant Device,73.85,35,,73.85,percent of total billed charges,Implant Device,84.4,40,,84.4,percent of total billed charges,Implant Device,73.85,70,,73.85,percent of total billed charges,All Other,71.74,34,,71.74,percent of total billed charges,Implant Device,71.74,34,,71.74,percent of total billed charges,Implant Device,73.85,35,,73.85,percent of total billed charges,Implant Device,73.85,35,,73.85,percent of total billed charges,Implant Device,73.85,35,,73.85,percent of total billed charges,Implant Device,73.85,35,,73.85,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,156.14,
ZIMMER TI-115310 GLENOSPHERE 36MM,C1776,HCPCS,,79012823,CDM,278,RC,,,both,,,5261,3893.15,,,3893.15,Other,150% of Medicare + 9.63% HCRA Surcharge,2367.45,45,,2367.45,percent of total billed charges,Critical Access Hospital RCC factor,1788.74,34,,1788.74,percent of total billed charges,Implant Device,1788.74,34,,1788.74,percent of total billed charges,Implant Device,1788.74,34,,1788.74,percent of total billed charges,Implant Device,1788.74,34,,1788.74,percent of total billed charges,Implant Device,1788.74,34,,1788.74,percent of total billed charges,Implant Device,2604.2,,,2604.2,Other,110% of Medicare,1841.35,35,,1841.35,percent of total billed charges,Implant Device,1788.74,34,"Charges > $500, x 34%",1788.74,percent of total billed charges,Implant Device,1841.35,35,,1841.35,percent of total billed charges,Implant Device,1841.35,35,,1841.35,percent of total billed charges,Implant Device,1841.35,35,,1841.35,percent of total billed charges,Implant Device,1841.35,35,,1841.35,percent of total billed charges,Implant Device,1841.35,35,,1841.35,percent of total billed charges,Implant Device,2104.4,40,,2104.4,percent of total billed charges,Implant Device,1841.35,70,,1841.35,percent of total billed charges,All Other,1788.74,34,,1788.74,percent of total billed charges,Implant Device,1788.74,34,,1788.74,percent of total billed charges,Implant Device,1841.35,35,,1841.35,percent of total billed charges,Implant Device,1841.35,35,,1841.35,percent of total billed charges,Implant Device,1841.35,35,,1841.35,percent of total billed charges,Implant Device,1841.35,35,,1841.35,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1788.74,34,"If Charge > 2,000, then 34 percent",1788.74,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3893.15,
ZIMMER 113630 MINI HUMERAL STEM 10X83MM,C1776,HCPCS,,79012824,CDM,278,RC,,,both,,,9000,6660.02,,,6660.02,Other,150% of Medicare + 9.63% HCRA Surcharge,4050,45,,4050,percent of total billed charges,Critical Access Hospital RCC factor,3060,34,,3060,percent of total billed charges,Implant Device,3060,34,,3060,percent of total billed charges,Implant Device,3060,34,,3060,percent of total billed charges,Implant Device,3060,34,,3060,percent of total billed charges,Implant Device,3060,34,,3060,percent of total billed charges,Implant Device,4455,,,4455,Other,110% of Medicare,3150,35,,3150,percent of total billed charges,Implant Device,3060,34,"Charges > $500, x 34%",3060,percent of total billed charges,Implant Device,3150,35,,3150,percent of total billed charges,Implant Device,3150,35,,3150,percent of total billed charges,Implant Device,3150,35,,3150,percent of total billed charges,Implant Device,3150,35,,3150,percent of total billed charges,Implant Device,3150,35,,3150,percent of total billed charges,Implant Device,3600,40,,3600,percent of total billed charges,Implant Device,3150,70,,3150,percent of total billed charges,All Other,3060,34,,3060,percent of total billed charges,Implant Device,3060,34,,3060,percent of total billed charges,Implant Device,3150,35,,3150,percent of total billed charges,Implant Device,3150,35,,3150,percent of total billed charges,Implant Device,3150,35,,3150,percent of total billed charges,Implant Device,3150,35,,3150,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3060,34,"If Charge > 2,000, then 34 percent",3060,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,6660.02,
ZIMMER 110031408 MINI HUMERAL TRAY 40MM,C1776,HCPCS,,79012825,CDM,278,RC,,,both,,,4416,3267.85,,,3267.85,Other,150% of Medicare + 9.63% HCRA Surcharge,1987.2,45,,1987.2,percent of total billed charges,Critical Access Hospital RCC factor,1501.44,34,,1501.44,percent of total billed charges,Implant Device,1501.44,34,,1501.44,percent of total billed charges,Implant Device,1501.44,34,,1501.44,percent of total billed charges,Implant Device,1501.44,34,,1501.44,percent of total billed charges,Implant Device,1501.44,34,,1501.44,percent of total billed charges,Implant Device,2185.92,,,2185.92,Other,110% of Medicare,1545.6,35,,1545.6,percent of total billed charges,Implant Device,1501.44,34,"Charges > $500, x 34%",1501.44,percent of total billed charges,Implant Device,1545.6,35,,1545.6,percent of total billed charges,Implant Device,1545.6,35,,1545.6,percent of total billed charges,Implant Device,1545.6,35,,1545.6,percent of total billed charges,Implant Device,1545.6,35,,1545.6,percent of total billed charges,Implant Device,1545.6,35,,1545.6,percent of total billed charges,Implant Device,1766.4,40,,1766.4,percent of total billed charges,Implant Device,1545.6,70,,1545.6,percent of total billed charges,All Other,1501.44,34,,1501.44,percent of total billed charges,Implant Device,1501.44,34,,1501.44,percent of total billed charges,Implant Device,1545.6,35,,1545.6,percent of total billed charges,Implant Device,1545.6,35,,1545.6,percent of total billed charges,Implant Device,1545.6,35,,1545.6,percent of total billed charges,Implant Device,1545.6,35,,1545.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1501.44,34,"If Charge > 2,000, then 34 percent",1501.44,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3267.85,
ZIMMER 110031424 BEARING 36MM,C1776,HCPCS,,79012826,CDM,278,RC,,,both,,,4992,3694.09,,,3694.09,Other,150% of Medicare + 9.63% HCRA Surcharge,2246.4,45,,2246.4,percent of total billed charges,Critical Access Hospital RCC factor,1697.28,34,,1697.28,percent of total billed charges,Implant Device,1697.28,34,,1697.28,percent of total billed charges,Implant Device,1697.28,34,,1697.28,percent of total billed charges,Implant Device,1697.28,34,,1697.28,percent of total billed charges,Implant Device,1697.28,34,,1697.28,percent of total billed charges,Implant Device,2471.04,,,2471.04,Other,110% of Medicare,1747.2,35,,1747.2,percent of total billed charges,Implant Device,1697.28,34,"Charges > $500, x 34%",1697.28,percent of total billed charges,Implant Device,1747.2,35,,1747.2,percent of total billed charges,Implant Device,1747.2,35,,1747.2,percent of total billed charges,Implant Device,1747.2,35,,1747.2,percent of total billed charges,Implant Device,1747.2,35,,1747.2,percent of total billed charges,Implant Device,1747.2,35,,1747.2,percent of total billed charges,Implant Device,1996.8,40,,1996.8,percent of total billed charges,Implant Device,1747.2,70,,1747.2,percent of total billed charges,All Other,1697.28,34,,1697.28,percent of total billed charges,Implant Device,1697.28,34,,1697.28,percent of total billed charges,Implant Device,1747.2,35,,1747.2,percent of total billed charges,Implant Device,1747.2,35,,1747.2,percent of total billed charges,Implant Device,1747.2,35,,1747.2,percent of total billed charges,Implant Device,1747.2,35,,1747.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1697.28,34,"If Charge > 2,000, then 34 percent",1697.28,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3694.09,
STRYKER 57-10161 BONE PLATE 2.3MM 8 HOLE,C1713,HCPCS,,79012827,CDM,278,RC,,,both,,,799,591.26,,,591.26,Other,150% of Medicare + 9.63% HCRA Surcharge,359.55,45,,359.55,percent of total billed charges,Critical Access Hospital RCC factor,271.66,34,,271.66,percent of total billed charges,Implant Device,271.66,34,,271.66,percent of total billed charges,Implant Device,271.66,34,,271.66,percent of total billed charges,Implant Device,271.66,34,,271.66,percent of total billed charges,Implant Device,271.66,34,,271.66,percent of total billed charges,Implant Device,395.51,,,395.51,Other,110% of Medicare,279.65,35,,279.65,percent of total billed charges,Implant Device,271.66,34,"Charges > $500, x 34%",271.66,percent of total billed charges,Implant Device,279.65,35,,279.65,percent of total billed charges,Implant Device,279.65,35,,279.65,percent of total billed charges,Implant Device,279.65,35,,279.65,percent of total billed charges,Implant Device,279.65,35,,279.65,percent of total billed charges,Implant Device,279.65,35,,279.65,percent of total billed charges,Implant Device,319.6,40,,319.6,percent of total billed charges,Implant Device,279.65,70,,279.65,percent of total billed charges,All Other,271.66,34,,271.66,percent of total billed charges,Implant Device,271.66,34,,271.66,percent of total billed charges,Implant Device,279.65,35,,279.65,percent of total billed charges,Implant Device,279.65,35,,279.65,percent of total billed charges,Implant Device,279.65,35,,279.65,percent of total billed charges,Implant Device,279.65,35,,279.65,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,591.26,
J&J 245.051 LCP PLATE 3.5MM 5 HOLE,C1713,HCPCS,,79012830,CDM,278,RC,,,both,,,1125,832.5,,,832.5,Other,150% of Medicare + 9.63% HCRA Surcharge,506.25,45,,506.25,percent of total billed charges,Critical Access Hospital RCC factor,382.5,34,,382.5,percent of total billed charges,Implant Device,382.5,34,,382.5,percent of total billed charges,Implant Device,382.5,34,,382.5,percent of total billed charges,Implant Device,382.5,34,,382.5,percent of total billed charges,Implant Device,382.5,34,,382.5,percent of total billed charges,Implant Device,556.88,,,556.88,Other,110% of Medicare,393.75,35,,393.75,percent of total billed charges,Implant Device,382.5,34,"Charges > $500, x 34%",382.5,percent of total billed charges,Implant Device,393.75,35,,393.75,percent of total billed charges,Implant Device,393.75,35,,393.75,percent of total billed charges,Implant Device,393.75,35,,393.75,percent of total billed charges,Implant Device,393.75,35,,393.75,percent of total billed charges,Implant Device,393.75,35,,393.75,percent of total billed charges,Implant Device,450,40,,450,percent of total billed charges,Implant Device,393.75,70,,393.75,percent of total billed charges,All Other,382.5,34,,382.5,percent of total billed charges,Implant Device,382.5,34,,382.5,percent of total billed charges,Implant Device,393.75,35,,393.75,percent of total billed charges,Implant Device,393.75,35,,393.75,percent of total billed charges,Implant Device,393.75,35,,393.75,percent of total billed charges,Implant Device,393.75,35,,393.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,832.5,
J&J 245.061 LCP PLATE 3.5MM 6 HOLE,C1713,HCPCS,,79012831,CDM,278,RC,,,both,,,1301,962.74,,,962.74,Other,150% of Medicare + 9.63% HCRA Surcharge,585.45,45,,585.45,percent of total billed charges,Critical Access Hospital RCC factor,442.34,34,,442.34,percent of total billed charges,Implant Device,442.34,34,,442.34,percent of total billed charges,Implant Device,442.34,34,,442.34,percent of total billed charges,Implant Device,442.34,34,,442.34,percent of total billed charges,Implant Device,442.34,34,,442.34,percent of total billed charges,Implant Device,644,,,644,Other,110% of Medicare,455.35,35,,455.35,percent of total billed charges,Implant Device,442.34,34,"Charges > $500, x 34%",442.34,percent of total billed charges,Implant Device,455.35,35,,455.35,percent of total billed charges,Implant Device,455.35,35,,455.35,percent of total billed charges,Implant Device,455.35,35,,455.35,percent of total billed charges,Implant Device,455.35,35,,455.35,percent of total billed charges,Implant Device,455.35,35,,455.35,percent of total billed charges,Implant Device,520.4,40,,520.4,percent of total billed charges,Implant Device,455.35,70,,455.35,percent of total billed charges,All Other,442.34,34,,442.34,percent of total billed charges,Implant Device,442.34,34,,442.34,percent of total billed charges,Implant Device,455.35,35,,455.35,percent of total billed charges,Implant Device,455.35,35,,455.35,percent of total billed charges,Implant Device,455.35,35,,455.35,percent of total billed charges,Implant Device,455.35,35,,455.35,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,962.74,
DJO 509-02-036 SMALL SOCKET INSERT 36MM,C1776,HCPCS,,79012832,CDM,278,RC,,,both,,,3600,2664.01,,,2664.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1620,45,,1620,percent of total billed charges,Critical Access Hospital RCC factor,1224,34,,1224,percent of total billed charges,Implant Device,1224,34,,1224,percent of total billed charges,Implant Device,1224,34,,1224,percent of total billed charges,Implant Device,1224,34,,1224,percent of total billed charges,Implant Device,1224,34,,1224,percent of total billed charges,Implant Device,1782,,,1782,Other,110% of Medicare,1260,35,,1260,percent of total billed charges,Implant Device,1224,34,"Charges > $500, x 34%",1224,percent of total billed charges,Implant Device,1260,35,,1260,percent of total billed charges,Implant Device,1260,35,,1260,percent of total billed charges,Implant Device,1260,35,,1260,percent of total billed charges,Implant Device,1260,35,,1260,percent of total billed charges,Implant Device,1260,35,,1260,percent of total billed charges,Implant Device,1440,40,,1440,percent of total billed charges,Implant Device,1260,70,,1260,percent of total billed charges,All Other,1224,34,,1224,percent of total billed charges,Implant Device,1224,34,,1224,percent of total billed charges,Implant Device,1260,35,,1260,percent of total billed charges,Implant Device,1260,35,,1260,percent of total billed charges,Implant Device,1260,35,,1260,percent of total billed charges,Implant Device,1260,35,,1260,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1224,34,"If Charge > 2,000, then 34 percent",1224,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2664.01,
DJO 533-12-108 HUMERAL STEM 12X108MM,C1776,HCPCS,,79012833,CDM,278,RC,,,both,,,14400,10656.04,,,10656.04,Other,150% of Medicare + 9.63% HCRA Surcharge,6480,45,,6480,percent of total billed charges,Critical Access Hospital RCC factor,4896,34,,4896,percent of total billed charges,Implant Device,4896,34,,4896,percent of total billed charges,Implant Device,4896,34,,4896,percent of total billed charges,Implant Device,4896,34,,4896,percent of total billed charges,Implant Device,4896,34,,4896,percent of total billed charges,Implant Device,7128,,,7128,Other,110% of Medicare,5040,35,,5040,percent of total billed charges,Implant Device,4896,34,"Charges > $500, x 34%",4896,percent of total billed charges,Implant Device,5040,35,,5040,percent of total billed charges,Implant Device,5040,35,,5040,percent of total billed charges,Implant Device,5040,35,,5040,percent of total billed charges,Implant Device,5040,35,,5040,percent of total billed charges,Implant Device,5040,35,,5040,percent of total billed charges,Implant Device,5760,40,,5760,percent of total billed charges,Implant Device,5040,70,,5040,percent of total billed charges,All Other,4896,34,,4896,percent of total billed charges,Implant Device,4896,34,,4896,percent of total billed charges,Implant Device,5040,35,,5040,percent of total billed charges,Implant Device,5040,35,,5040,percent of total billed charges,Implant Device,5040,35,,5040,percent of total billed charges,Implant Device,5040,35,,5040,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,4896,34,"If Charge > 2,000, then 34 percent",4896,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,10656.04,
J&J 247.374 LCP PLATE 2.7X94MM 10 HOLE,C1713,HCPCS,,79012834,CDM,278,RC,,,both,,,1057,782.18,,,782.18,Other,150% of Medicare + 9.63% HCRA Surcharge,475.65,45,,475.65,percent of total billed charges,Critical Access Hospital RCC factor,359.38,34,,359.38,percent of total billed charges,Implant Device,359.38,34,,359.38,percent of total billed charges,Implant Device,359.38,34,,359.38,percent of total billed charges,Implant Device,359.38,34,,359.38,percent of total billed charges,Implant Device,359.38,34,,359.38,percent of total billed charges,Implant Device,523.22,,,523.22,Other,110% of Medicare,369.95,35,,369.95,percent of total billed charges,Implant Device,359.38,34,"Charges > $500, x 34%",359.38,percent of total billed charges,Implant Device,369.95,35,,369.95,percent of total billed charges,Implant Device,369.95,35,,369.95,percent of total billed charges,Implant Device,369.95,35,,369.95,percent of total billed charges,Implant Device,369.95,35,,369.95,percent of total billed charges,Implant Device,369.95,35,,369.95,percent of total billed charges,Implant Device,422.8,40,,422.8,percent of total billed charges,Implant Device,369.95,70,,369.95,percent of total billed charges,All Other,359.38,34,,359.38,percent of total billed charges,Implant Device,359.38,34,,359.38,percent of total billed charges,Implant Device,369.95,35,,369.95,percent of total billed charges,Implant Device,369.95,35,,369.95,percent of total billed charges,Implant Device,369.95,35,,369.95,percent of total billed charges,Implant Device,369.95,35,,369.95,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,782.18,
J&J 202.900 CORTEX SCREW 2.7X40MM,C1713,HCPCS,,79012835,CDM,278,RC,,,both,,,88,65.12,,,65.12,Other,150% of Medicare + 9.63% HCRA Surcharge,39.6,45,,39.6,percent of total billed charges,Critical Access Hospital RCC factor,29.92,34,,29.92,percent of total billed charges,Implant Device,29.92,34,,29.92,percent of total billed charges,Implant Device,29.92,34,,29.92,percent of total billed charges,Implant Device,29.92,34,,29.92,percent of total billed charges,Implant Device,29.92,34,,29.92,percent of total billed charges,Implant Device,43.56,,,43.56,Other,110% of Medicare,30.8,35,,30.8,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,30.8,35,,30.8,percent of total billed charges,Implant Device,30.8,35,,30.8,percent of total billed charges,Implant Device,30.8,35,,30.8,percent of total billed charges,Implant Device,30.8,35,,30.8,percent of total billed charges,Implant Device,30.8,35,,30.8,percent of total billed charges,Implant Device,35.2,40,,35.2,percent of total billed charges,Implant Device,30.8,70,,30.8,percent of total billed charges,All Other,29.92,34,,29.92,percent of total billed charges,Implant Device,29.92,34,,29.92,percent of total billed charges,Implant Device,30.8,35,,30.8,percent of total billed charges,Implant Device,30.8,35,,30.8,percent of total billed charges,Implant Device,30.8,35,,30.8,percent of total billed charges,Implant Device,30.8,35,,30.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,65.12,
J&J 02.247.390S LCP PLATE 2.7X161MM 20H,C1713,HCPCS,,79012836,CDM,278,RC,,,both,,,1901,1406.74,,,1406.74,Other,150% of Medicare + 9.63% HCRA Surcharge,855.45,45,,855.45,percent of total billed charges,Critical Access Hospital RCC factor,646.34,34,,646.34,percent of total billed charges,Implant Device,646.34,34,,646.34,percent of total billed charges,Implant Device,646.34,34,,646.34,percent of total billed charges,Implant Device,646.34,34,,646.34,percent of total billed charges,Implant Device,646.34,34,,646.34,percent of total billed charges,Implant Device,941,,,941,Other,110% of Medicare,665.35,35,,665.35,percent of total billed charges,Implant Device,646.34,34,"Charges > $500, x 34%",646.34,percent of total billed charges,Implant Device,665.35,35,,665.35,percent of total billed charges,Implant Device,665.35,35,,665.35,percent of total billed charges,Implant Device,665.35,35,,665.35,percent of total billed charges,Implant Device,665.35,35,,665.35,percent of total billed charges,Implant Device,665.35,35,,665.35,percent of total billed charges,Implant Device,760.4,40,,760.4,percent of total billed charges,Implant Device,665.35,70,,665.35,percent of total billed charges,All Other,646.34,34,,646.34,percent of total billed charges,Implant Device,646.34,34,,646.34,percent of total billed charges,Implant Device,665.35,35,,665.35,percent of total billed charges,Implant Device,665.35,35,,665.35,percent of total billed charges,Implant Device,665.35,35,,665.35,percent of total billed charges,Implant Device,665.35,35,,665.35,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1406.74,
J&J 02.118.211 VA PLATE 2.7/3.5MM 12H LT,C1713,HCPCS,,79012837,CDM,278,RC,,,both,,,5055,3740.71,,,3740.71,Other,150% of Medicare + 9.63% HCRA Surcharge,2274.75,45,,2274.75,percent of total billed charges,Critical Access Hospital RCC factor,1718.7,34,,1718.7,percent of total billed charges,Implant Device,1718.7,34,,1718.7,percent of total billed charges,Implant Device,1718.7,34,,1718.7,percent of total billed charges,Implant Device,1718.7,34,,1718.7,percent of total billed charges,Implant Device,1718.7,34,,1718.7,percent of total billed charges,Implant Device,2502.23,,,2502.23,Other,110% of Medicare,1769.25,35,,1769.25,percent of total billed charges,Implant Device,1718.7,34,"Charges > $500, x 34%",1718.7,percent of total billed charges,Implant Device,1769.25,35,,1769.25,percent of total billed charges,Implant Device,1769.25,35,,1769.25,percent of total billed charges,Implant Device,1769.25,35,,1769.25,percent of total billed charges,Implant Device,1769.25,35,,1769.25,percent of total billed charges,Implant Device,1769.25,35,,1769.25,percent of total billed charges,Implant Device,2022,40,,2022,percent of total billed charges,Implant Device,1769.25,70,,1769.25,percent of total billed charges,All Other,1718.7,34,,1718.7,percent of total billed charges,Implant Device,1718.7,34,,1718.7,percent of total billed charges,Implant Device,1769.25,35,,1769.25,percent of total billed charges,Implant Device,1769.25,35,,1769.25,percent of total billed charges,Implant Device,1769.25,35,,1769.25,percent of total billed charges,Implant Device,1769.25,35,,1769.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1718.7,34,"If Charge > 2,000, then 34 percent",1718.7,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3740.71,
J&J 02.206.234 CORTEX SCREW 3.5X34MM,C1713,HCPCS,,79012838,CDM,278,RC,,,both,,,79,58.46,,,58.46,Other,150% of Medicare + 9.63% HCRA Surcharge,35.55,45,,35.55,percent of total billed charges,Critical Access Hospital RCC factor,26.86,34,,26.86,percent of total billed charges,Implant Device,26.86,34,,26.86,percent of total billed charges,Implant Device,26.86,34,,26.86,percent of total billed charges,Implant Device,26.86,34,,26.86,percent of total billed charges,Implant Device,26.86,34,,26.86,percent of total billed charges,Implant Device,39.11,,,39.11,Other,110% of Medicare,27.65,35,,27.65,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,27.65,35,,27.65,percent of total billed charges,Implant Device,27.65,35,,27.65,percent of total billed charges,Implant Device,27.65,35,,27.65,percent of total billed charges,Implant Device,27.65,35,,27.65,percent of total billed charges,Implant Device,27.65,35,,27.65,percent of total billed charges,Implant Device,31.6,40,,31.6,percent of total billed charges,Implant Device,27.65,70,,27.65,percent of total billed charges,All Other,26.86,34,,26.86,percent of total billed charges,Implant Device,26.86,34,,26.86,percent of total billed charges,Implant Device,27.65,35,,27.65,percent of total billed charges,Implant Device,27.65,35,,27.65,percent of total billed charges,Implant Device,27.65,35,,27.65,percent of total billed charges,Implant Device,27.65,35,,27.65,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,58.46,
J&J 02.206.248 CORTEX SCREW 3.5X48MM,C1713,HCPCS,,79012839,CDM,278,RC,,,both,,,79,58.46,,,58.46,Other,150% of Medicare + 9.63% HCRA Surcharge,35.55,45,,35.55,percent of total billed charges,Critical Access Hospital RCC factor,26.86,34,,26.86,percent of total billed charges,Implant Device,26.86,34,,26.86,percent of total billed charges,Implant Device,26.86,34,,26.86,percent of total billed charges,Implant Device,26.86,34,,26.86,percent of total billed charges,Implant Device,26.86,34,,26.86,percent of total billed charges,Implant Device,39.11,,,39.11,Other,110% of Medicare,27.65,35,,27.65,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,27.65,35,,27.65,percent of total billed charges,Implant Device,27.65,35,,27.65,percent of total billed charges,Implant Device,27.65,35,,27.65,percent of total billed charges,Implant Device,27.65,35,,27.65,percent of total billed charges,Implant Device,27.65,35,,27.65,percent of total billed charges,Implant Device,31.6,40,,31.6,percent of total billed charges,Implant Device,27.65,70,,27.65,percent of total billed charges,All Other,26.86,34,,26.86,percent of total billed charges,Implant Device,26.86,34,,26.86,percent of total billed charges,Implant Device,27.65,35,,27.65,percent of total billed charges,Implant Device,27.65,35,,27.65,percent of total billed charges,Implant Device,27.65,35,,27.65,percent of total billed charges,Implant Device,27.65,35,,27.65,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,58.46,
J&J 02.206.242 CORTEX SCREW 3.5XC42MM,C1713,HCPCS,,79012840,CDM,278,RC,,,both,,,79,58.46,,,58.46,Other,150% of Medicare + 9.63% HCRA Surcharge,35.55,45,,35.55,percent of total billed charges,Critical Access Hospital RCC factor,26.86,34,,26.86,percent of total billed charges,Implant Device,26.86,34,,26.86,percent of total billed charges,Implant Device,26.86,34,,26.86,percent of total billed charges,Implant Device,26.86,34,,26.86,percent of total billed charges,Implant Device,26.86,34,,26.86,percent of total billed charges,Implant Device,39.11,,,39.11,Other,110% of Medicare,27.65,35,,27.65,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,27.65,35,,27.65,percent of total billed charges,Implant Device,27.65,35,,27.65,percent of total billed charges,Implant Device,27.65,35,,27.65,percent of total billed charges,Implant Device,27.65,35,,27.65,percent of total billed charges,Implant Device,27.65,35,,27.65,percent of total billed charges,Implant Device,31.6,40,,31.6,percent of total billed charges,Implant Device,27.65,70,,27.65,percent of total billed charges,All Other,26.86,34,,26.86,percent of total billed charges,Implant Device,26.86,34,,26.86,percent of total billed charges,Implant Device,27.65,35,,27.65,percent of total billed charges,Implant Device,27.65,35,,27.65,percent of total billed charges,Implant Device,27.65,35,,27.65,percent of total billed charges,Implant Device,27.65,35,,27.65,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,58.46,
J&J 02.206.250 CORTEX SCREW 3X50MM,C1713,HCPCS,,79012841,CDM,278,RC,,,both,,,79,58.46,,,58.46,Other,150% of Medicare + 9.63% HCRA Surcharge,35.55,45,,35.55,percent of total billed charges,Critical Access Hospital RCC factor,26.86,34,,26.86,percent of total billed charges,Implant Device,26.86,34,,26.86,percent of total billed charges,Implant Device,26.86,34,,26.86,percent of total billed charges,Implant Device,26.86,34,,26.86,percent of total billed charges,Implant Device,26.86,34,,26.86,percent of total billed charges,Implant Device,39.11,,,39.11,Other,110% of Medicare,27.65,35,,27.65,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,27.65,35,,27.65,percent of total billed charges,Implant Device,27.65,35,,27.65,percent of total billed charges,Implant Device,27.65,35,,27.65,percent of total billed charges,Implant Device,27.65,35,,27.65,percent of total billed charges,Implant Device,27.65,35,,27.65,percent of total billed charges,Implant Device,31.6,40,,31.6,percent of total billed charges,Implant Device,27.65,70,,27.65,percent of total billed charges,All Other,26.86,34,,26.86,percent of total billed charges,Implant Device,26.86,34,,26.86,percent of total billed charges,Implant Device,27.65,35,,27.65,percent of total billed charges,Implant Device,27.65,35,,27.65,percent of total billed charges,Implant Device,27.65,35,,27.65,percent of total billed charges,Implant Device,27.65,35,,27.65,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,58.46,
J&J 02.211.044 LOCKING SCREW 2.7X44MM,C1713,HCPCS,,79012842,CDM,278,RC,,,both,,,343,253.82,,,253.82,Other,150% of Medicare + 9.63% HCRA Surcharge,154.35,45,,154.35,percent of total billed charges,Critical Access Hospital RCC factor,116.62,34,,116.62,percent of total billed charges,Implant Device,116.62,34,,116.62,percent of total billed charges,Implant Device,116.62,34,,116.62,percent of total billed charges,Implant Device,116.62,34,,116.62,percent of total billed charges,Implant Device,116.62,34,,116.62,percent of total billed charges,Implant Device,169.79,,,169.79,Other,110% of Medicare,120.05,35,,120.05,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,120.05,35,,120.05,percent of total billed charges,Implant Device,120.05,35,,120.05,percent of total billed charges,Implant Device,120.05,35,,120.05,percent of total billed charges,Implant Device,120.05,35,,120.05,percent of total billed charges,Implant Device,120.05,35,,120.05,percent of total billed charges,Implant Device,137.2,40,,137.2,percent of total billed charges,Implant Device,120.05,70,,120.05,percent of total billed charges,All Other,116.62,34,,116.62,percent of total billed charges,Implant Device,116.62,34,,116.62,percent of total billed charges,Implant Device,120.05,35,,120.05,percent of total billed charges,Implant Device,120.05,35,,120.05,percent of total billed charges,Implant Device,120.05,35,,120.05,percent of total billed charges,Implant Device,120.05,35,,120.05,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,253.82,
J&J 02.206.236 CORTEX SCREW 3.5X36MM,C1713,HCPCS,,79012843,CDM,278,RC,,,both,,,79,58.46,,,58.46,Other,150% of Medicare + 9.63% HCRA Surcharge,35.55,45,,35.55,percent of total billed charges,Critical Access Hospital RCC factor,26.86,34,,26.86,percent of total billed charges,Implant Device,26.86,34,,26.86,percent of total billed charges,Implant Device,26.86,34,,26.86,percent of total billed charges,Implant Device,26.86,34,,26.86,percent of total billed charges,Implant Device,26.86,34,,26.86,percent of total billed charges,Implant Device,39.11,,,39.11,Other,110% of Medicare,27.65,35,,27.65,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,27.65,35,,27.65,percent of total billed charges,Implant Device,27.65,35,,27.65,percent of total billed charges,Implant Device,27.65,35,,27.65,percent of total billed charges,Implant Device,27.65,35,,27.65,percent of total billed charges,Implant Device,27.65,35,,27.65,percent of total billed charges,Implant Device,31.6,40,,31.6,percent of total billed charges,Implant Device,27.65,70,,27.65,percent of total billed charges,All Other,26.86,34,,26.86,percent of total billed charges,Implant Device,26.86,34,,26.86,percent of total billed charges,Implant Device,27.65,35,,27.65,percent of total billed charges,Implant Device,27.65,35,,27.65,percent of total billed charges,Implant Device,27.65,35,,27.65,percent of total billed charges,Implant Device,27.65,35,,27.65,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,58.46,
ZIMMER VE189040 TIBIAL BEARING 67X10MM,C1776,HCPCS,,79012844,CDM,278,RC,,,both,,,3648,2699.53,,,2699.53,Other,150% of Medicare + 9.63% HCRA Surcharge,1641.6,45,,1641.6,percent of total billed charges,Critical Access Hospital RCC factor,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1805.76,,,1805.76,Other,110% of Medicare,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1240.32,34,"Charges > $500, x 34%",1240.32,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1459.2,40,,1459.2,percent of total billed charges,Implant Device,1276.8,70,,1276.8,percent of total billed charges,All Other,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1240.32,34,"If Charge > 2,000, then 34 percent",1240.32,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2699.53,
ZIMMER 183028 FEMORAL LEFT 65MM,C1776,HCPCS,,79012845,CDM,278,RC,,,both,,,6300,4662.02,,,4662.02,Other,150% of Medicare + 9.63% HCRA Surcharge,2835,45,,2835,percent of total billed charges,Critical Access Hospital RCC factor,2142,34,,2142,percent of total billed charges,Implant Device,2142,34,,2142,percent of total billed charges,Implant Device,2142,34,,2142,percent of total billed charges,Implant Device,2142,34,,2142,percent of total billed charges,Implant Device,2142,34,,2142,percent of total billed charges,Implant Device,3118.5,,,3118.5,Other,110% of Medicare,2205,35,,2205,percent of total billed charges,Implant Device,2142,34,"Charges > $500, x 34%",2142,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2520,40,,2520,percent of total billed charges,Implant Device,2205,70,,2205,percent of total billed charges,All Other,2142,34,,2142,percent of total billed charges,Implant Device,2142,34,,2142,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2142,34,"If Charge > 2,000, then 34 percent",2142,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4662.02,
EXACTECH 320-05-12 HUM AUG TRAY +5 RT,C1776,HCPCS,,79012852,CDM,278,RC,,,both,,,13500,9990.03,,,9990.03,Other,150% of Medicare + 9.63% HCRA Surcharge,6075,45,,6075,percent of total billed charges,Critical Access Hospital RCC factor,4590,34,,4590,percent of total billed charges,Implant Device,4590,34,,4590,percent of total billed charges,Implant Device,4590,34,,4590,percent of total billed charges,Implant Device,4590,34,,4590,percent of total billed charges,Implant Device,4590,34,,4590,percent of total billed charges,Implant Device,6682.5,,,6682.5,Other,110% of Medicare,4725,35,,4725,percent of total billed charges,Implant Device,4590,34,"Charges > $500, x 34%",4590,percent of total billed charges,Implant Device,4725,35,,4725,percent of total billed charges,Implant Device,4725,35,,4725,percent of total billed charges,Implant Device,4725,35,,4725,percent of total billed charges,Implant Device,4725,35,,4725,percent of total billed charges,Implant Device,4725,35,,4725,percent of total billed charges,Implant Device,5400,40,,5400,percent of total billed charges,Implant Device,4725,70,,4725,percent of total billed charges,All Other,4590,34,,4590,percent of total billed charges,Implant Device,4590,34,,4590,percent of total billed charges,Implant Device,4725,35,,4725,percent of total billed charges,Implant Device,4725,35,,4725,percent of total billed charges,Implant Device,4725,35,,4725,percent of total billed charges,Implant Device,4725,35,,4725,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,4590,34,"If Charge > 2,000, then 34 percent",4590,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,9990.03,
ZIMMER 574101000 FEMORAL STEM SIZE 0,C1776,HCPCS,,79012853,CDM,278,RC,,,both,,,6912,5114.9,,,5114.9,Other,150% of Medicare + 9.63% HCRA Surcharge,3110.4,45,,3110.4,percent of total billed charges,Critical Access Hospital RCC factor,2350.08,34,,2350.08,percent of total billed charges,Implant Device,2350.08,34,,2350.08,percent of total billed charges,Implant Device,2350.08,34,,2350.08,percent of total billed charges,Implant Device,2350.08,34,,2350.08,percent of total billed charges,Implant Device,2350.08,34,,2350.08,percent of total billed charges,Implant Device,3421.44,,,3421.44,Other,110% of Medicare,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2350.08,34,"Charges > $500, x 34%",2350.08,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2764.8,40,,2764.8,percent of total billed charges,Implant Device,2419.2,70,,2419.2,percent of total billed charges,All Other,2350.08,34,,2350.08,percent of total billed charges,Implant Device,2350.08,34,,2350.08,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2350.08,34,"If Charge > 2,000, then 34 percent",2350.08,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5114.9,
STRYKER 629771 T PLATE NARROW 2X62MM 10H,C1713,HCPCS,,79012854,CDM,278,RC,,,both,,,2512,1858.89,,,1858.89,Other,150% of Medicare + 9.63% HCRA Surcharge,1130.4,45,,1130.4,percent of total billed charges,Critical Access Hospital RCC factor,854.08,34,,854.08,percent of total billed charges,Implant Device,854.08,34,,854.08,percent of total billed charges,Implant Device,854.08,34,,854.08,percent of total billed charges,Implant Device,854.08,34,,854.08,percent of total billed charges,Implant Device,854.08,34,,854.08,percent of total billed charges,Implant Device,1243.44,,,1243.44,Other,110% of Medicare,879.2,35,,879.2,percent of total billed charges,Implant Device,854.08,34,"Charges > $500, x 34%",854.08,percent of total billed charges,Implant Device,879.2,35,,879.2,percent of total billed charges,Implant Device,879.2,35,,879.2,percent of total billed charges,Implant Device,879.2,35,,879.2,percent of total billed charges,Implant Device,879.2,35,,879.2,percent of total billed charges,Implant Device,879.2,35,,879.2,percent of total billed charges,Implant Device,1004.8,40,,1004.8,percent of total billed charges,Implant Device,879.2,70,,879.2,percent of total billed charges,All Other,854.08,34,,854.08,percent of total billed charges,Implant Device,854.08,34,,854.08,percent of total billed charges,Implant Device,879.2,35,,879.2,percent of total billed charges,Implant Device,879.2,35,,879.2,percent of total billed charges,Implant Device,879.2,35,,879.2,percent of total billed charges,Implant Device,879.2,35,,879.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,854.08,34,"If Charge > 2,000, then 34 percent",854.08,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1858.89,
STRYKER 657611 LOCKING SCREW 2.0X11MM,C1713,HCPCS,,79012855,CDM,278,RC,,,both,,,676,500.24,,,500.24,Other,150% of Medicare + 9.63% HCRA Surcharge,304.2,45,,304.2,percent of total billed charges,Critical Access Hospital RCC factor,229.84,34,,229.84,percent of total billed charges,Implant Device,229.84,34,,229.84,percent of total billed charges,Implant Device,229.84,34,,229.84,percent of total billed charges,Implant Device,229.84,34,,229.84,percent of total billed charges,Implant Device,229.84,34,,229.84,percent of total billed charges,Implant Device,334.62,,,334.62,Other,110% of Medicare,236.6,35,,236.6,percent of total billed charges,Implant Device,229.84,34,"Charges > $500, x 34%",229.84,percent of total billed charges,Implant Device,236.6,35,,236.6,percent of total billed charges,Implant Device,236.6,35,,236.6,percent of total billed charges,Implant Device,236.6,35,,236.6,percent of total billed charges,Implant Device,236.6,35,,236.6,percent of total billed charges,Implant Device,236.6,35,,236.6,percent of total billed charges,Implant Device,270.4,40,,270.4,percent of total billed charges,Implant Device,236.6,70,,236.6,percent of total billed charges,All Other,229.84,34,,229.84,percent of total billed charges,Implant Device,229.84,34,,229.84,percent of total billed charges,Implant Device,236.6,35,,236.6,percent of total billed charges,Implant Device,236.6,35,,236.6,percent of total billed charges,Implant Device,236.6,35,,236.6,percent of total billed charges,Implant Device,236.6,35,,236.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,500.24,
STRYKER 657616 LOCKING SCREW 2.0X10MM,C1713,HCPCS,,79012856,CDM,278,RC,,,both,,,676,500.24,,,500.24,Other,150% of Medicare + 9.63% HCRA Surcharge,304.2,45,,304.2,percent of total billed charges,Critical Access Hospital RCC factor,229.84,34,,229.84,percent of total billed charges,Implant Device,229.84,34,,229.84,percent of total billed charges,Implant Device,229.84,34,,229.84,percent of total billed charges,Implant Device,229.84,34,,229.84,percent of total billed charges,Implant Device,229.84,34,,229.84,percent of total billed charges,Implant Device,334.62,,,334.62,Other,110% of Medicare,236.6,35,,236.6,percent of total billed charges,Implant Device,229.84,34,"Charges > $500, x 34%",229.84,percent of total billed charges,Implant Device,236.6,35,,236.6,percent of total billed charges,Implant Device,236.6,35,,236.6,percent of total billed charges,Implant Device,236.6,35,,236.6,percent of total billed charges,Implant Device,236.6,35,,236.6,percent of total billed charges,Implant Device,236.6,35,,236.6,percent of total billed charges,Implant Device,270.4,40,,270.4,percent of total billed charges,Implant Device,236.6,70,,236.6,percent of total billed charges,All Other,229.84,34,,229.84,percent of total billed charges,Implant Device,229.84,34,,229.84,percent of total billed charges,Implant Device,236.6,35,,236.6,percent of total billed charges,Implant Device,236.6,35,,236.6,percent of total billed charges,Implant Device,236.6,35,,236.6,percent of total billed charges,Implant Device,236.6,35,,236.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,500.24,
STRYKER 657710 BONE SCREW 2.0X10MM,C1713,HCPCS,,79012857,CDM,278,RC,,,both,,,395,292.3,,,292.3,Other,150% of Medicare + 9.63% HCRA Surcharge,177.75,45,,177.75,percent of total billed charges,Critical Access Hospital RCC factor,134.3,34,,134.3,percent of total billed charges,Implant Device,134.3,34,,134.3,percent of total billed charges,Implant Device,134.3,34,,134.3,percent of total billed charges,Implant Device,134.3,34,,134.3,percent of total billed charges,Implant Device,134.3,34,,134.3,percent of total billed charges,Implant Device,195.53,,,195.53,Other,110% of Medicare,138.25,35,,138.25,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,138.25,35,,138.25,percent of total billed charges,Implant Device,138.25,35,,138.25,percent of total billed charges,Implant Device,138.25,35,,138.25,percent of total billed charges,Implant Device,138.25,35,,138.25,percent of total billed charges,Implant Device,138.25,35,,138.25,percent of total billed charges,Implant Device,158,40,,158,percent of total billed charges,Implant Device,138.25,70,,138.25,percent of total billed charges,All Other,134.3,34,,134.3,percent of total billed charges,Implant Device,134.3,34,,134.3,percent of total billed charges,Implant Device,138.25,35,,138.25,percent of total billed charges,Implant Device,138.25,35,,138.25,percent of total billed charges,Implant Device,138.25,35,,138.25,percent of total billed charges,Implant Device,138.25,35,,138.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,292.3,
ZIMMER 51-106130 STEM 13X111MM,C1776,HCPCS,,79012858,CDM,278,RC,,,both,,,6912,5114.9,,,5114.9,Other,150% of Medicare + 9.63% HCRA Surcharge,3110.4,45,,3110.4,percent of total billed charges,Critical Access Hospital RCC factor,2350.08,34,,2350.08,percent of total billed charges,Implant Device,2350.08,34,,2350.08,percent of total billed charges,Implant Device,2350.08,34,,2350.08,percent of total billed charges,Implant Device,2350.08,34,,2350.08,percent of total billed charges,Implant Device,2350.08,34,,2350.08,percent of total billed charges,Implant Device,3421.44,,,3421.44,Other,110% of Medicare,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2350.08,34,"Charges > $500, x 34%",2350.08,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2764.8,40,,2764.8,percent of total billed charges,Implant Device,2419.2,70,,2419.2,percent of total billed charges,All Other,2350.08,34,,2350.08,percent of total billed charges,Implant Device,2350.08,34,,2350.08,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2350.08,34,"If Charge > 2,000, then 34 percent",2350.08,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5114.9,
J&J 09.405.560S RADIAL HEAD 25X6.5X11MM,C1776,HCPCS,,79012859,CDM,278,RC,,,both,,,10622,7860.31,,,7860.31,Other,150% of Medicare + 9.63% HCRA Surcharge,4779.9,45,,4779.9,percent of total billed charges,Critical Access Hospital RCC factor,3611.48,34,,3611.48,percent of total billed charges,Implant Device,3611.48,34,,3611.48,percent of total billed charges,Implant Device,3611.48,34,,3611.48,percent of total billed charges,Implant Device,3611.48,34,,3611.48,percent of total billed charges,Implant Device,3611.48,34,,3611.48,percent of total billed charges,Implant Device,5257.89,,,5257.89,Other,110% of Medicare,3717.7,35,,3717.7,percent of total billed charges,Implant Device,3611.48,34,"Charges > $500, x 34%",3611.48,percent of total billed charges,Implant Device,3717.7,35,,3717.7,percent of total billed charges,Implant Device,3717.7,35,,3717.7,percent of total billed charges,Implant Device,3717.7,35,,3717.7,percent of total billed charges,Implant Device,3717.7,35,,3717.7,percent of total billed charges,Implant Device,3717.7,35,,3717.7,percent of total billed charges,Implant Device,4248.8,40,,4248.8,percent of total billed charges,Implant Device,3717.7,70,,3717.7,percent of total billed charges,All Other,3611.48,34,,3611.48,percent of total billed charges,Implant Device,3611.48,34,,3611.48,percent of total billed charges,Implant Device,3717.7,35,,3717.7,percent of total billed charges,Implant Device,3717.7,35,,3717.7,percent of total billed charges,Implant Device,3717.7,35,,3717.7,percent of total billed charges,Implant Device,3717.7,35,,3717.7,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3611.48,34,"If Charge > 2,000, then 34 percent",3611.48,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,7860.31,
ZIMMER 42-5121-007-12 ART SURF LT 12MM,C1776,HCPCS,,79012860,CDM,278,RC,,,both,,,4116,3045.85,,,3045.85,Other,150% of Medicare + 9.63% HCRA Surcharge,1852.2,45,,1852.2,percent of total billed charges,Critical Access Hospital RCC factor,1399.44,34,,1399.44,percent of total billed charges,Implant Device,1399.44,34,,1399.44,percent of total billed charges,Implant Device,1399.44,34,,1399.44,percent of total billed charges,Implant Device,1399.44,34,,1399.44,percent of total billed charges,Implant Device,1399.44,34,,1399.44,percent of total billed charges,Implant Device,2037.42,,,2037.42,Other,110% of Medicare,1440.6,35,,1440.6,percent of total billed charges,Implant Device,1399.44,34,"Charges > $500, x 34%",1399.44,percent of total billed charges,Implant Device,1440.6,35,,1440.6,percent of total billed charges,Implant Device,1440.6,35,,1440.6,percent of total billed charges,Implant Device,1440.6,35,,1440.6,percent of total billed charges,Implant Device,1440.6,35,,1440.6,percent of total billed charges,Implant Device,1440.6,35,,1440.6,percent of total billed charges,Implant Device,1646.4,40,,1646.4,percent of total billed charges,Implant Device,1440.6,70,,1440.6,percent of total billed charges,All Other,1399.44,34,,1399.44,percent of total billed charges,Implant Device,1399.44,34,,1399.44,percent of total billed charges,Implant Device,1440.6,35,,1440.6,percent of total billed charges,Implant Device,1440.6,35,,1440.6,percent of total billed charges,Implant Device,1440.6,35,,1440.6,percent of total billed charges,Implant Device,1440.6,35,,1440.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1399.44,34,"If Charge > 2,000, then 34 percent",1399.44,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3045.85,
MEDLINE SWD890003 PED CATH 2 CUFF 37CM,C1750,HCPCS,,79012861,CDM,278,RC,,,both,,,138,102.12,,,102.12,Other,150% of Medicare + 9.63% HCRA Surcharge,62.1,45,,62.1,percent of total billed charges,Critical Access Hospital RCC factor,46.92,34,,46.92,percent of total billed charges,Implant Device,46.92,34,,46.92,percent of total billed charges,Implant Device,46.92,34,,46.92,percent of total billed charges,Implant Device,46.92,34,,46.92,percent of total billed charges,Implant Device,46.92,34,,46.92,percent of total billed charges,Implant Device,68.31,,,68.31,Other,110% of Medicare,48.3,35,,48.3,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,48.3,35,,48.3,percent of total billed charges,Implant Device,48.3,35,,48.3,percent of total billed charges,Implant Device,48.3,35,,48.3,percent of total billed charges,Implant Device,48.3,35,,48.3,percent of total billed charges,Implant Device,48.3,35,,48.3,percent of total billed charges,Implant Device,55.2,40,,55.2,percent of total billed charges,Implant Device,48.3,70,,48.3,percent of total billed charges,All Other,46.92,34,,46.92,percent of total billed charges,Implant Device,46.92,34,,46.92,percent of total billed charges,Implant Device,48.3,35,,48.3,percent of total billed charges,Implant Device,48.3,35,,48.3,percent of total billed charges,Implant Device,48.3,35,,48.3,percent of total billed charges,Implant Device,48.3,35,,48.3,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,102.12,
COVIDIEN 8810890003 PED CATH 2 CUFF 37CM,C1750,HCPCS,,79012862,CDM,278,RC,,,both,,,138,102.12,,,102.12,Other,150% of Medicare + 9.63% HCRA Surcharge,62.1,45,,62.1,percent of total billed charges,Critical Access Hospital RCC factor,46.92,34,,46.92,percent of total billed charges,Implant Device,46.92,34,,46.92,percent of total billed charges,Implant Device,46.92,34,,46.92,percent of total billed charges,Implant Device,46.92,34,,46.92,percent of total billed charges,Implant Device,46.92,34,,46.92,percent of total billed charges,Implant Device,68.31,,,68.31,Other,110% of Medicare,48.3,35,,48.3,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,48.3,35,,48.3,percent of total billed charges,Implant Device,48.3,35,,48.3,percent of total billed charges,Implant Device,48.3,35,,48.3,percent of total billed charges,Implant Device,48.3,35,,48.3,percent of total billed charges,Implant Device,48.3,35,,48.3,percent of total billed charges,Implant Device,55.2,40,,55.2,percent of total billed charges,Implant Device,48.3,70,,48.3,percent of total billed charges,All Other,46.92,34,,46.92,percent of total billed charges,Implant Device,46.92,34,,46.92,percent of total billed charges,Implant Device,48.3,35,,48.3,percent of total billed charges,Implant Device,48.3,35,,48.3,percent of total billed charges,Implant Device,48.3,35,,48.3,percent of total billed charges,Implant Device,48.3,35,,48.3,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,102.12,
ARTHREX AR-1588AU-CP GRAFTLINK ACL KIT,C1713,HCPCS,,79012864,CDM,278,RC,,,both,,,2040,1509.61,,,1509.61,Other,150% of Medicare + 9.63% HCRA Surcharge,918,45,,918,percent of total billed charges,Critical Access Hospital RCC factor,693.6,34,,693.6,percent of total billed charges,Implant Device,693.6,34,,693.6,percent of total billed charges,Implant Device,693.6,34,,693.6,percent of total billed charges,Implant Device,693.6,34,,693.6,percent of total billed charges,Implant Device,693.6,34,,693.6,percent of total billed charges,Implant Device,1009.8,,,1009.8,Other,110% of Medicare,714,35,,714,percent of total billed charges,Implant Device,693.6,34,"Charges > $500, x 34%",693.6,percent of total billed charges,Implant Device,714,35,,714,percent of total billed charges,Implant Device,714,35,,714,percent of total billed charges,Implant Device,714,35,,714,percent of total billed charges,Implant Device,714,35,,714,percent of total billed charges,Implant Device,714,35,,714,percent of total billed charges,Implant Device,816,40,,816,percent of total billed charges,Implant Device,714,70,,714,percent of total billed charges,All Other,693.6,34,,693.6,percent of total billed charges,Implant Device,693.6,34,,693.6,percent of total billed charges,Implant Device,714,35,,714,percent of total billed charges,Implant Device,714,35,,714,percent of total billed charges,Implant Device,714,35,,714,percent of total billed charges,Implant Device,714,35,,714,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,693.6,34,"If Charge > 2,000, then 34 percent",693.6,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1509.61,
ARTHREX AR-3641SP FIBERTAK KNOTLESS 2.6,C1713,HCPCS,,79012865,CDM,278,RC,,,both,,,1350,999,,,999,Other,150% of Medicare + 9.63% HCRA Surcharge,607.5,45,,607.5,percent of total billed charges,Critical Access Hospital RCC factor,459,34,,459,percent of total billed charges,Implant Device,459,34,,459,percent of total billed charges,Implant Device,459,34,,459,percent of total billed charges,Implant Device,459,34,,459,percent of total billed charges,Implant Device,459,34,,459,percent of total billed charges,Implant Device,668.25,,,668.25,Other,110% of Medicare,472.5,35,,472.5,percent of total billed charges,Implant Device,459,34,"Charges > $500, x 34%",459,percent of total billed charges,Implant Device,472.5,35,,472.5,percent of total billed charges,Implant Device,472.5,35,,472.5,percent of total billed charges,Implant Device,472.5,35,,472.5,percent of total billed charges,Implant Device,472.5,35,,472.5,percent of total billed charges,Implant Device,472.5,35,,472.5,percent of total billed charges,Implant Device,540,40,,540,percent of total billed charges,Implant Device,472.5,70,,472.5,percent of total billed charges,All Other,459,34,,459,percent of total billed charges,Implant Device,459,34,,459,percent of total billed charges,Implant Device,472.5,35,,472.5,percent of total billed charges,Implant Device,472.5,35,,472.5,percent of total billed charges,Implant Device,472.5,35,,472.5,percent of total billed charges,Implant Device,472.5,35,,472.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,999,
J&J 224.621 LCP PLATE 4.5MM 12 HOLE,C1713,HCPCS,,79012868,CDM,278,RC,,,both,,,1610,1191.4,,,1191.4,Other,150% of Medicare + 9.63% HCRA Surcharge,724.5,45,,724.5,percent of total billed charges,Critical Access Hospital RCC factor,547.4,34,,547.4,percent of total billed charges,Implant Device,547.4,34,,547.4,percent of total billed charges,Implant Device,547.4,34,,547.4,percent of total billed charges,Implant Device,547.4,34,,547.4,percent of total billed charges,Implant Device,547.4,34,,547.4,percent of total billed charges,Implant Device,796.95,,,796.95,Other,110% of Medicare,563.5,35,,563.5,percent of total billed charges,Implant Device,547.4,34,"Charges > $500, x 34%",547.4,percent of total billed charges,Implant Device,563.5,35,,563.5,percent of total billed charges,Implant Device,563.5,35,,563.5,percent of total billed charges,Implant Device,563.5,35,,563.5,percent of total billed charges,Implant Device,563.5,35,,563.5,percent of total billed charges,Implant Device,563.5,35,,563.5,percent of total billed charges,Implant Device,644,40,,644,percent of total billed charges,Implant Device,563.5,70,,563.5,percent of total billed charges,All Other,547.4,34,,547.4,percent of total billed charges,Implant Device,547.4,34,,547.4,percent of total billed charges,Implant Device,563.5,35,,563.5,percent of total billed charges,Implant Device,563.5,35,,563.5,percent of total billed charges,Implant Device,563.5,35,,563.5,percent of total billed charges,Implant Device,563.5,35,,563.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1191.4,
J&J 02.115.150 VA DORSAL PLATE 2.4MM,C1713,HCPCS,,79012869,CDM,278,RC,,,both,,,1405,1039.7,,,1039.7,Other,150% of Medicare + 9.63% HCRA Surcharge,632.25,45,,632.25,percent of total billed charges,Critical Access Hospital RCC factor,477.7,34,,477.7,percent of total billed charges,Implant Device,477.7,34,,477.7,percent of total billed charges,Implant Device,477.7,34,,477.7,percent of total billed charges,Implant Device,477.7,34,,477.7,percent of total billed charges,Implant Device,477.7,34,,477.7,percent of total billed charges,Implant Device,695.48,,,695.48,Other,110% of Medicare,491.75,35,,491.75,percent of total billed charges,Implant Device,477.7,34,"Charges > $500, x 34%",477.7,percent of total billed charges,Implant Device,491.75,35,,491.75,percent of total billed charges,Implant Device,491.75,35,,491.75,percent of total billed charges,Implant Device,491.75,35,,491.75,percent of total billed charges,Implant Device,491.75,35,,491.75,percent of total billed charges,Implant Device,491.75,35,,491.75,percent of total billed charges,Implant Device,562,40,,562,percent of total billed charges,Implant Device,491.75,70,,491.75,percent of total billed charges,All Other,477.7,34,,477.7,percent of total billed charges,Implant Device,477.7,34,,477.7,percent of total billed charges,Implant Device,491.75,35,,491.75,percent of total billed charges,Implant Device,491.75,35,,491.75,percent of total billed charges,Implant Device,491.75,35,,491.75,percent of total billed charges,Implant Device,491.75,35,,491.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1039.7,
ZIMMER 00-8757-050-02 SHELL 50MM SIZE HH,C1776,HCPCS,,79012870,CDM,278,RC,,,both,,,3450,2553.01,,,2553.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1552.5,45,,1552.5,percent of total billed charges,Critical Access Hospital RCC factor,1173,34,,1173,percent of total billed charges,Implant Device,1173,34,,1173,percent of total billed charges,Implant Device,1173,34,,1173,percent of total billed charges,Implant Device,1173,34,,1173,percent of total billed charges,Implant Device,1173,34,,1173,percent of total billed charges,Implant Device,1707.75,,,1707.75,Other,110% of Medicare,1207.5,35,,1207.5,percent of total billed charges,Implant Device,1173,34,"Charges > $500, x 34%",1173,percent of total billed charges,Implant Device,1207.5,35,,1207.5,percent of total billed charges,Implant Device,1207.5,35,,1207.5,percent of total billed charges,Implant Device,1207.5,35,,1207.5,percent of total billed charges,Implant Device,1207.5,35,,1207.5,percent of total billed charges,Implant Device,1207.5,35,,1207.5,percent of total billed charges,Implant Device,1380,40,,1380,percent of total billed charges,Implant Device,1207.5,70,,1207.5,percent of total billed charges,All Other,1173,34,,1173,percent of total billed charges,Implant Device,1173,34,,1173,percent of total billed charges,Implant Device,1207.5,35,,1207.5,percent of total billed charges,Implant Device,1207.5,35,,1207.5,percent of total billed charges,Implant Device,1207.5,35,,1207.5,percent of total billed charges,Implant Device,1207.5,35,,1207.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1173,34,"If Charge > 2,000, then 34 percent",1173,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2553.01,
BOST M00517240 ESOPHAGEAL STENT 18X59MM,C1874,HCPCS,,79012871,CDM,278,RC,,,both,,,8678,6421.74,,,6421.74,Other,150% of Medicare + 9.63% HCRA Surcharge,3905.1,45,,3905.1,percent of total billed charges,Critical Access Hospital RCC factor,2950.52,34,,2950.52,percent of total billed charges,Implant Device,2950.52,34,,2950.52,percent of total billed charges,Implant Device,2950.52,34,,2950.52,percent of total billed charges,Implant Device,2950.52,34,,2950.52,percent of total billed charges,Implant Device,2950.52,34,,2950.52,percent of total billed charges,Implant Device,4295.61,,,4295.61,Other,110% of Medicare,3037.3,35,,3037.3,percent of total billed charges,Implant Device,2950.52,34,"Charges > $500, x 34%",2950.52,percent of total billed charges,Implant Device,3037.3,35,,3037.3,percent of total billed charges,Implant Device,3037.3,35,,3037.3,percent of total billed charges,Implant Device,3037.3,35,,3037.3,percent of total billed charges,Implant Device,3037.3,35,,3037.3,percent of total billed charges,Implant Device,3037.3,35,,3037.3,percent of total billed charges,Implant Device,3471.2,40,,3471.2,percent of total billed charges,Implant Device,3037.3,70,,3037.3,percent of total billed charges,All Other,2950.52,34,,2950.52,percent of total billed charges,Implant Device,2950.52,34,,2950.52,percent of total billed charges,Implant Device,3037.3,35,,3037.3,percent of total billed charges,Implant Device,3037.3,35,,3037.3,percent of total billed charges,Implant Device,3037.3,35,,3037.3,percent of total billed charges,Implant Device,3037.3,35,,3037.3,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2950.52,34,"If Charge > 2,000, then 34 percent",2950.52,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,6421.74,
ZIMMER 42-5121-009-16 ART SURF LT 16MM,C1776,HCPCS,,79012872,CDM,278,RC,,,both,,,3648,2699.53,,,2699.53,Other,150% of Medicare + 9.63% HCRA Surcharge,1641.6,45,,1641.6,percent of total billed charges,Critical Access Hospital RCC factor,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1805.76,,,1805.76,Other,110% of Medicare,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1240.32,34,"Charges > $500, x 34%",1240.32,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1459.2,40,,1459.2,percent of total billed charges,Implant Device,1276.8,70,,1276.8,percent of total billed charges,All Other,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1240.32,34,"If Charge > 2,000, then 34 percent",1240.32,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2699.53,
INTEGRA DP1013 DURAGEN PLUS MATRIX 1X3',Q4100,HCPCS,,79012873,CDM,278,RC,,,both,,,960,710.4,,,710.4,Other,150% of Medicare + 9.63% HCRA Surcharge,432,45,,432,percent of total billed charges,Critical Access Hospital RCC factor,326.4,34,,326.4,percent of total billed charges,Implant Device,326.4,34,,326.4,percent of total billed charges,Implant Device,326.4,34,,326.4,percent of total billed charges,Implant Device,326.4,34,,326.4,percent of total billed charges,Implant Device,326.4,34,,326.4,percent of total billed charges,Implant Device,475.2,,,475.2,Other,110% of Medicare,336,35,,336,percent of total billed charges,Implant Device,326.4,34,"Charges > $500, x 34%",326.4,percent of total billed charges,Implant Device,336,35,,336,percent of total billed charges,Implant Device,336,35,,336,percent of total billed charges,Implant Device,336,35,,336,percent of total billed charges,Implant Device,336,35,,336,percent of total billed charges,Implant Device,336,35,,336,percent of total billed charges,Implant Device,384,40,,384,percent of total billed charges,Implant Device,336,70,,336,percent of total billed charges,All Other,326.4,34,,326.4,percent of total billed charges,Implant Device,326.4,34,,326.4,percent of total billed charges,Implant Device,336,35,,336,percent of total billed charges,Implant Device,336,35,,336,percent of total billed charges,Implant Device,336,35,,336,percent of total billed charges,Implant Device,336,35,,336,percent of total billed charges,Implant Device,976.07,,,976.07,Other,100% of Medicaid,976.07,,,976.07,Other,100% of Medicaid,976.07,,,976.07,Other,100% of Medicaid,976.07,,,976.07,Other,100% of Medicaid,2196.15,,,2196.15,Other,225% of Medicaid,1493.38,,,1493.38,Other,153% of Medicaid,2196.15,,,2196.15,Other,225% of Medicaid,1366.49,,,1366.49,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,2537.77,,,2537.77,Other,260% of Medicaid,3162.45,,,3162.45,Other,324% of Medicaid,2098.54,,,2098.54,Other,215% of Medicaid,2098.54,,,2098.54,Other,215% of Medicaid,1220.08,,,1220.08,Other,125% of Medicaid,0.01,3162.45,
GORE SBT-1602D BIFURCATED GRAFT 16X8X50,C1768,HCPCS,,79012874,CDM,278,RC,,,both,,,3246,2402.05,,,2402.05,Other,150% of Medicare + 9.63% HCRA Surcharge,1460.7,45,,1460.7,percent of total billed charges,Critical Access Hospital RCC factor,1103.64,34,,1103.64,percent of total billed charges,Implant Device,1103.64,34,,1103.64,percent of total billed charges,Implant Device,1103.64,34,,1103.64,percent of total billed charges,Implant Device,1103.64,34,,1103.64,percent of total billed charges,Implant Device,1103.64,34,,1103.64,percent of total billed charges,Implant Device,1606.77,,,1606.77,Other,110% of Medicare,1136.1,35,,1136.1,percent of total billed charges,Implant Device,1103.64,34,"Charges > $500, x 34%",1103.64,percent of total billed charges,Implant Device,1136.1,35,,1136.1,percent of total billed charges,Implant Device,1136.1,35,,1136.1,percent of total billed charges,Implant Device,1136.1,35,,1136.1,percent of total billed charges,Implant Device,1136.1,35,,1136.1,percent of total billed charges,Implant Device,1136.1,35,,1136.1,percent of total billed charges,Implant Device,1298.4,40,,1298.4,percent of total billed charges,Implant Device,1136.1,70,,1136.1,percent of total billed charges,All Other,1103.64,34,,1103.64,percent of total billed charges,Implant Device,1103.64,34,,1103.64,percent of total billed charges,Implant Device,1136.1,35,,1136.1,percent of total billed charges,Implant Device,1136.1,35,,1136.1,percent of total billed charges,Implant Device,1136.1,35,,1136.1,percent of total billed charges,Implant Device,1136.1,35,,1136.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1103.64,34,"If Charge > 2,000, then 34 percent",1103.64,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2402.05,
IN2BONES P72 ST118 LOCK SCREW 2.7X18MM,C1713,HCPCS,,79012875,CDM,278,RC,,,both,,,870,643.8,,,643.8,Other,150% of Medicare + 9.63% HCRA Surcharge,391.5,45,,391.5,percent of total billed charges,Critical Access Hospital RCC factor,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,430.65,,,430.65,Other,110% of Medicare,304.5,35,,304.5,percent of total billed charges,Implant Device,295.8,34,"Charges > $500, x 34%",295.8,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,348,40,,348,percent of total billed charges,Implant Device,304.5,70,,304.5,percent of total billed charges,All Other,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,643.8,
STRYKER 5567-P-3009 HUMERAL STEM 9X93MM,C1776,HCPCS,,79012885,CDM,278,RC,,,both,,,8925,6604.52,,,6604.52,Other,150% of Medicare + 9.63% HCRA Surcharge,4016.25,45,,4016.25,percent of total billed charges,Critical Access Hospital RCC factor,3034.5,34,,3034.5,percent of total billed charges,Implant Device,3034.5,34,,3034.5,percent of total billed charges,Implant Device,3034.5,34,,3034.5,percent of total billed charges,Implant Device,3034.5,34,,3034.5,percent of total billed charges,Implant Device,3034.5,34,,3034.5,percent of total billed charges,Implant Device,4417.88,,,4417.88,Other,110% of Medicare,3123.75,35,,3123.75,percent of total billed charges,Implant Device,3034.5,34,"Charges > $500, x 34%",3034.5,percent of total billed charges,Implant Device,3123.75,35,,3123.75,percent of total billed charges,Implant Device,3123.75,35,,3123.75,percent of total billed charges,Implant Device,3123.75,35,,3123.75,percent of total billed charges,Implant Device,3123.75,35,,3123.75,percent of total billed charges,Implant Device,3123.75,35,,3123.75,percent of total billed charges,Implant Device,3570,40,,3570,percent of total billed charges,Implant Device,3123.75,70,,3123.75,percent of total billed charges,All Other,3034.5,34,,3034.5,percent of total billed charges,Implant Device,3034.5,34,,3034.5,percent of total billed charges,Implant Device,3123.75,35,,3123.75,percent of total billed charges,Implant Device,3123.75,35,,3123.75,percent of total billed charges,Implant Device,3123.75,35,,3123.75,percent of total billed charges,Implant Device,3123.75,35,,3123.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3034.5,34,"If Charge > 2,000, then 34 percent",3034.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,6604.52,
STRYKER 5570-3202 HUMERAL CUP 32X2MM,C1776,HCPCS,,79012886,CDM,278,RC,,,both,,,4125,3052.51,,,3052.51,Other,150% of Medicare + 9.63% HCRA Surcharge,1856.25,45,,1856.25,percent of total billed charges,Critical Access Hospital RCC factor,1402.5,34,,1402.5,percent of total billed charges,Implant Device,1402.5,34,,1402.5,percent of total billed charges,Implant Device,1402.5,34,,1402.5,percent of total billed charges,Implant Device,1402.5,34,,1402.5,percent of total billed charges,Implant Device,1402.5,34,,1402.5,percent of total billed charges,Implant Device,2041.88,,,2041.88,Other,110% of Medicare,1443.75,35,,1443.75,percent of total billed charges,Implant Device,1402.5,34,"Charges > $500, x 34%",1402.5,percent of total billed charges,Implant Device,1443.75,35,,1443.75,percent of total billed charges,Implant Device,1443.75,35,,1443.75,percent of total billed charges,Implant Device,1443.75,35,,1443.75,percent of total billed charges,Implant Device,1443.75,35,,1443.75,percent of total billed charges,Implant Device,1443.75,35,,1443.75,percent of total billed charges,Implant Device,1650,40,,1650,percent of total billed charges,Implant Device,1443.75,70,,1443.75,percent of total billed charges,All Other,1402.5,34,,1402.5,percent of total billed charges,Implant Device,1402.5,34,,1402.5,percent of total billed charges,Implant Device,1443.75,35,,1443.75,percent of total billed charges,Implant Device,1443.75,35,,1443.75,percent of total billed charges,Implant Device,1443.75,35,,1443.75,percent of total billed charges,Implant Device,1443.75,35,,1443.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1402.5,34,"If Charge > 2,000, then 34 percent",1402.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3052.51,
STRYKER 5572-2802 BASEPLATE 28X10.05MM,C1776,HCPCS,,79012887,CDM,278,RC,,,both,,,6600,4884.02,,,4884.02,Other,150% of Medicare + 9.63% HCRA Surcharge,2970,45,,2970,percent of total billed charges,Critical Access Hospital RCC factor,2244,34,,2244,percent of total billed charges,Implant Device,2244,34,,2244,percent of total billed charges,Implant Device,2244,34,,2244,percent of total billed charges,Implant Device,2244,34,,2244,percent of total billed charges,Implant Device,2244,34,,2244,percent of total billed charges,Implant Device,3267,,,3267,Other,110% of Medicare,2310,35,,2310,percent of total billed charges,Implant Device,2244,34,"Charges > $500, x 34%",2244,percent of total billed charges,Implant Device,2310,35,,2310,percent of total billed charges,Implant Device,2310,35,,2310,percent of total billed charges,Implant Device,2310,35,,2310,percent of total billed charges,Implant Device,2310,35,,2310,percent of total billed charges,Implant Device,2310,35,,2310,percent of total billed charges,Implant Device,2640,40,,2640,percent of total billed charges,Implant Device,2310,70,,2310,percent of total billed charges,All Other,2244,34,,2244,percent of total billed charges,Implant Device,2244,34,,2244,percent of total billed charges,Implant Device,2310,35,,2310,percent of total billed charges,Implant Device,2310,35,,2310,percent of total billed charges,Implant Device,2310,35,,2310,percent of total billed charges,Implant Device,2310,35,,2310,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2244,34,"If Charge > 2,000, then 34 percent",2244,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4884.02,
ZIMMER 183070 FEMORAL LEFT 67.5MM,C1776,HCPCS,,79012888,CDM,278,RC,,,both,,,7104,5256.98,,,5256.98,Other,150% of Medicare + 9.63% HCRA Surcharge,3196.8,45,,3196.8,percent of total billed charges,Critical Access Hospital RCC factor,2415.36,34,,2415.36,percent of total billed charges,Implant Device,2415.36,34,,2415.36,percent of total billed charges,Implant Device,2415.36,34,,2415.36,percent of total billed charges,Implant Device,2415.36,34,,2415.36,percent of total billed charges,Implant Device,2415.36,34,,2415.36,percent of total billed charges,Implant Device,3516.48,,,3516.48,Other,110% of Medicare,2486.4,35,,2486.4,percent of total billed charges,Implant Device,2415.36,34,"Charges > $500, x 34%",2415.36,percent of total billed charges,Implant Device,2486.4,35,,2486.4,percent of total billed charges,Implant Device,2486.4,35,,2486.4,percent of total billed charges,Implant Device,2486.4,35,,2486.4,percent of total billed charges,Implant Device,2486.4,35,,2486.4,percent of total billed charges,Implant Device,2486.4,35,,2486.4,percent of total billed charges,Implant Device,2841.6,40,,2841.6,percent of total billed charges,Implant Device,2486.4,70,,2486.4,percent of total billed charges,All Other,2415.36,34,,2415.36,percent of total billed charges,Implant Device,2415.36,34,,2415.36,percent of total billed charges,Implant Device,2486.4,35,,2486.4,percent of total billed charges,Implant Device,2486.4,35,,2486.4,percent of total billed charges,Implant Device,2486.4,35,,2486.4,percent of total billed charges,Implant Device,2486.4,35,,2486.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2415.36,34,"If Charge > 2,000, then 34 percent",2415.36,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5256.98,
ZIMMER 184788 PATELLA 37X8.6MM,C1776,HCPCS,,79012889,CDM,278,RC,,,both,,,1152,852.48,,,852.48,Other,150% of Medicare + 9.63% HCRA Surcharge,518.4,45,,518.4,percent of total billed charges,Critical Access Hospital RCC factor,391.68,34,,391.68,percent of total billed charges,Implant Device,391.68,34,,391.68,percent of total billed charges,Implant Device,391.68,34,,391.68,percent of total billed charges,Implant Device,391.68,34,,391.68,percent of total billed charges,Implant Device,391.68,34,,391.68,percent of total billed charges,Implant Device,570.24,,,570.24,Other,110% of Medicare,403.2,35,,403.2,percent of total billed charges,Implant Device,391.68,34,"Charges > $500, x 34%",391.68,percent of total billed charges,Implant Device,403.2,35,,403.2,percent of total billed charges,Implant Device,403.2,35,,403.2,percent of total billed charges,Implant Device,403.2,35,,403.2,percent of total billed charges,Implant Device,403.2,35,,403.2,percent of total billed charges,Implant Device,403.2,35,,403.2,percent of total billed charges,Implant Device,460.8,40,,460.8,percent of total billed charges,Implant Device,403.2,70,,403.2,percent of total billed charges,All Other,391.68,34,,391.68,percent of total billed charges,Implant Device,391.68,34,,391.68,percent of total billed charges,Implant Device,403.2,35,,403.2,percent of total billed charges,Implant Device,403.2,35,,403.2,percent of total billed charges,Implant Device,403.2,35,,403.2,percent of total billed charges,Implant Device,403.2,35,,403.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,852.48,
ZIMMER EP-189084 TIBIAL BEARING 14X75MM,C1776,HCPCS,,79012890,CDM,278,RC,,,both,,,3648,2699.53,,,2699.53,Other,150% of Medicare + 9.63% HCRA Surcharge,1641.6,45,,1641.6,percent of total billed charges,Critical Access Hospital RCC factor,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1805.76,,,1805.76,Other,110% of Medicare,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1240.32,34,"Charges > $500, x 34%",1240.32,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1459.2,40,,1459.2,percent of total billed charges,Implant Device,1276.8,70,,1276.8,percent of total billed charges,All Other,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1240.32,34,"If Charge > 2,000, then 34 percent",1240.32,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2699.53,
J&J 02.211.036 LOCKING SCREW 2.7X36MM,C1713,HCPCS,,79012891,CDM,278,RC,,,both,,,343,253.82,,,253.82,Other,150% of Medicare + 9.63% HCRA Surcharge,154.35,45,,154.35,percent of total billed charges,Critical Access Hospital RCC factor,116.62,34,,116.62,percent of total billed charges,Implant Device,116.62,34,,116.62,percent of total billed charges,Implant Device,116.62,34,,116.62,percent of total billed charges,Implant Device,116.62,34,,116.62,percent of total billed charges,Implant Device,116.62,34,,116.62,percent of total billed charges,Implant Device,169.79,,,169.79,Other,110% of Medicare,120.05,35,,120.05,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,120.05,35,,120.05,percent of total billed charges,Implant Device,120.05,35,,120.05,percent of total billed charges,Implant Device,120.05,35,,120.05,percent of total billed charges,Implant Device,120.05,35,,120.05,percent of total billed charges,Implant Device,120.05,35,,120.05,percent of total billed charges,Implant Device,137.2,40,,137.2,percent of total billed charges,Implant Device,120.05,70,,120.05,percent of total billed charges,All Other,116.62,34,,116.62,percent of total billed charges,Implant Device,116.62,34,,116.62,percent of total billed charges,Implant Device,120.05,35,,120.05,percent of total billed charges,Implant Device,120.05,35,,120.05,percent of total billed charges,Implant Device,120.05,35,,120.05,percent of total billed charges,Implant Device,120.05,35,,120.05,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,253.82,
ZIMMER 00-8757-048-01 SHELL 48MM SIZE GG,C1776,HCPCS,,79012892,CDM,278,RC,,,both,,,3450,2553.01,,,2553.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1552.5,45,,1552.5,percent of total billed charges,Critical Access Hospital RCC factor,1173,34,,1173,percent of total billed charges,Implant Device,1173,34,,1173,percent of total billed charges,Implant Device,1173,34,,1173,percent of total billed charges,Implant Device,1173,34,,1173,percent of total billed charges,Implant Device,1173,34,,1173,percent of total billed charges,Implant Device,1707.75,,,1707.75,Other,110% of Medicare,1207.5,35,,1207.5,percent of total billed charges,Implant Device,1173,34,"Charges > $500, x 34%",1173,percent of total billed charges,Implant Device,1207.5,35,,1207.5,percent of total billed charges,Implant Device,1207.5,35,,1207.5,percent of total billed charges,Implant Device,1207.5,35,,1207.5,percent of total billed charges,Implant Device,1207.5,35,,1207.5,percent of total billed charges,Implant Device,1207.5,35,,1207.5,percent of total billed charges,Implant Device,1380,40,,1380,percent of total billed charges,Implant Device,1207.5,70,,1207.5,percent of total billed charges,All Other,1173,34,,1173,percent of total billed charges,Implant Device,1173,34,,1173,percent of total billed charges,Implant Device,1207.5,35,,1207.5,percent of total billed charges,Implant Device,1207.5,35,,1207.5,percent of total billed charges,Implant Device,1207.5,35,,1207.5,percent of total billed charges,Implant Device,1207.5,35,,1207.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1173,34,"If Charge > 2,000, then 34 percent",1173,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2553.01,
ZIMMER 00-8851-008-32 LINER 32MM SIZE GG,C1776,HCPCS,,79012893,CDM,278,RC,,,both,,,3456,2557.45,,,2557.45,Other,150% of Medicare + 9.63% HCRA Surcharge,1555.2,45,,1555.2,percent of total billed charges,Critical Access Hospital RCC factor,1175.04,34,,1175.04,percent of total billed charges,Implant Device,1175.04,34,,1175.04,percent of total billed charges,Implant Device,1175.04,34,,1175.04,percent of total billed charges,Implant Device,1175.04,34,,1175.04,percent of total billed charges,Implant Device,1175.04,34,,1175.04,percent of total billed charges,Implant Device,1710.72,,,1710.72,Other,110% of Medicare,1209.6,35,,1209.6,percent of total billed charges,Implant Device,1175.04,34,"Charges > $500, x 34%",1175.04,percent of total billed charges,Implant Device,1209.6,35,,1209.6,percent of total billed charges,Implant Device,1209.6,35,,1209.6,percent of total billed charges,Implant Device,1209.6,35,,1209.6,percent of total billed charges,Implant Device,1209.6,35,,1209.6,percent of total billed charges,Implant Device,1209.6,35,,1209.6,percent of total billed charges,Implant Device,1382.4,40,,1382.4,percent of total billed charges,Implant Device,1209.6,70,,1209.6,percent of total billed charges,All Other,1175.04,34,,1175.04,percent of total billed charges,Implant Device,1175.04,34,,1175.04,percent of total billed charges,Implant Device,1209.6,35,,1209.6,percent of total billed charges,Implant Device,1209.6,35,,1209.6,percent of total billed charges,Implant Device,1209.6,35,,1209.6,percent of total billed charges,Implant Device,1209.6,35,,1209.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1175.04,34,"If Charge > 2,000, then 34 percent",1175.04,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2557.45,
ZIMMER 183004 FEMORAL RIGHT 60MM,C1776,HCPCS,,79012895,CDM,278,RC,,,both,,,6300,4662.02,,,4662.02,Other,150% of Medicare + 9.63% HCRA Surcharge,2835,45,,2835,percent of total billed charges,Critical Access Hospital RCC factor,2142,34,,2142,percent of total billed charges,Implant Device,2142,34,,2142,percent of total billed charges,Implant Device,2142,34,,2142,percent of total billed charges,Implant Device,2142,34,,2142,percent of total billed charges,Implant Device,2142,34,,2142,percent of total billed charges,Implant Device,3118.5,,,3118.5,Other,110% of Medicare,2205,35,,2205,percent of total billed charges,Implant Device,2142,34,"Charges > $500, x 34%",2142,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2520,40,,2520,percent of total billed charges,Implant Device,2205,70,,2205,percent of total billed charges,All Other,2142,34,,2142,percent of total billed charges,Implant Device,2142,34,,2142,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2142,34,"If Charge > 2,000, then 34 percent",2142,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4662.02,
J&J 04.005.546S LOCKING SCREW 5.0X56MM,C1713,HCPCS,,79012901,CDM,278,RC,,,both,,,412,304.88,,,304.88,Other,150% of Medicare + 9.63% HCRA Surcharge,185.4,45,,185.4,percent of total billed charges,Critical Access Hospital RCC factor,140.08,34,,140.08,percent of total billed charges,Implant Device,140.08,34,,140.08,percent of total billed charges,Implant Device,140.08,34,,140.08,percent of total billed charges,Implant Device,140.08,34,,140.08,percent of total billed charges,Implant Device,140.08,34,,140.08,percent of total billed charges,Implant Device,203.94,,,203.94,Other,110% of Medicare,144.2,35,,144.2,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,144.2,35,,144.2,percent of total billed charges,Implant Device,144.2,35,,144.2,percent of total billed charges,Implant Device,144.2,35,,144.2,percent of total billed charges,Implant Device,144.2,35,,144.2,percent of total billed charges,Implant Device,144.2,35,,144.2,percent of total billed charges,Implant Device,164.8,40,,164.8,percent of total billed charges,Implant Device,144.2,70,,144.2,percent of total billed charges,All Other,140.08,34,,140.08,percent of total billed charges,Implant Device,140.08,34,,140.08,percent of total billed charges,Implant Device,144.2,35,,144.2,percent of total billed charges,Implant Device,144.2,35,,144.2,percent of total billed charges,Implant Device,144.2,35,,144.2,percent of total billed charges,Implant Device,144.2,35,,144.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,304.88,
J&J 04.037.129S TFNA NAIL 11X380 125 DEG,C1713,HCPCS,,79012902,CDM,278,RC,,,both,,,5467,4045.59,,,4045.59,Other,150% of Medicare + 9.63% HCRA Surcharge,2460.15,45,,2460.15,percent of total billed charges,Critical Access Hospital RCC factor,1858.78,34,,1858.78,percent of total billed charges,Implant Device,1858.78,34,,1858.78,percent of total billed charges,Implant Device,1858.78,34,,1858.78,percent of total billed charges,Implant Device,1858.78,34,,1858.78,percent of total billed charges,Implant Device,1858.78,34,,1858.78,percent of total billed charges,Implant Device,2706.17,,,2706.17,Other,110% of Medicare,1913.45,35,,1913.45,percent of total billed charges,Implant Device,1858.78,34,"Charges > $500, x 34%",1858.78,percent of total billed charges,Implant Device,1913.45,35,,1913.45,percent of total billed charges,Implant Device,1913.45,35,,1913.45,percent of total billed charges,Implant Device,1913.45,35,,1913.45,percent of total billed charges,Implant Device,1913.45,35,,1913.45,percent of total billed charges,Implant Device,1913.45,35,,1913.45,percent of total billed charges,Implant Device,2186.8,40,,2186.8,percent of total billed charges,Implant Device,1913.45,70,,1913.45,percent of total billed charges,All Other,1858.78,34,,1858.78,percent of total billed charges,Implant Device,1858.78,34,,1858.78,percent of total billed charges,Implant Device,1913.45,35,,1913.45,percent of total billed charges,Implant Device,1913.45,35,,1913.45,percent of total billed charges,Implant Device,1913.45,35,,1913.45,percent of total billed charges,Implant Device,1913.45,35,,1913.45,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1858.78,34,"If Charge > 2,000, then 34 percent",1858.78,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4045.59,
J&J 04.038.190S TFNA SCREW 90MM,C1713,HCPCS,,79012903,CDM,278,RC,,,both,,,1776,1314.24,,,1314.24,Other,150% of Medicare + 9.63% HCRA Surcharge,799.2,45,,799.2,percent of total billed charges,Critical Access Hospital RCC factor,603.84,34,,603.84,percent of total billed charges,Implant Device,603.84,34,,603.84,percent of total billed charges,Implant Device,603.84,34,,603.84,percent of total billed charges,Implant Device,603.84,34,,603.84,percent of total billed charges,Implant Device,603.84,34,,603.84,percent of total billed charges,Implant Device,879.12,,,879.12,Other,110% of Medicare,621.6,35,,621.6,percent of total billed charges,Implant Device,603.84,34,"Charges > $500, x 34%",603.84,percent of total billed charges,Implant Device,621.6,35,,621.6,percent of total billed charges,Implant Device,621.6,35,,621.6,percent of total billed charges,Implant Device,621.6,35,,621.6,percent of total billed charges,Implant Device,621.6,35,,621.6,percent of total billed charges,Implant Device,621.6,35,,621.6,percent of total billed charges,Implant Device,710.4,40,,710.4,percent of total billed charges,Implant Device,621.6,70,,621.6,percent of total billed charges,All Other,603.84,34,,603.84,percent of total billed charges,Implant Device,603.84,34,,603.84,percent of total billed charges,Implant Device,621.6,35,,621.6,percent of total billed charges,Implant Device,621.6,35,,621.6,percent of total billed charges,Implant Device,621.6,35,,621.6,percent of total billed charges,Implant Device,621.6,35,,621.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1314.24,
J&J 02.124.419 CONDYLAR PLT 4.5X370 18H,C1713,HCPCS,,79012904,CDM,278,RC,,,both,,,5428,4016.73,,,4016.73,Other,150% of Medicare + 9.63% HCRA Surcharge,2442.6,45,,2442.6,percent of total billed charges,Critical Access Hospital RCC factor,1845.52,34,,1845.52,percent of total billed charges,Implant Device,1845.52,34,,1845.52,percent of total billed charges,Implant Device,1845.52,34,,1845.52,percent of total billed charges,Implant Device,1845.52,34,,1845.52,percent of total billed charges,Implant Device,1845.52,34,,1845.52,percent of total billed charges,Implant Device,2686.86,,,2686.86,Other,110% of Medicare,1899.8,35,,1899.8,percent of total billed charges,Implant Device,1845.52,34,"Charges > $500, x 34%",1845.52,percent of total billed charges,Implant Device,1899.8,35,,1899.8,percent of total billed charges,Implant Device,1899.8,35,,1899.8,percent of total billed charges,Implant Device,1899.8,35,,1899.8,percent of total billed charges,Implant Device,1899.8,35,,1899.8,percent of total billed charges,Implant Device,1899.8,35,,1899.8,percent of total billed charges,Implant Device,2171.2,40,,2171.2,percent of total billed charges,Implant Device,1899.8,70,,1899.8,percent of total billed charges,All Other,1845.52,34,,1845.52,percent of total billed charges,Implant Device,1845.52,34,,1845.52,percent of total billed charges,Implant Device,1899.8,35,,1899.8,percent of total billed charges,Implant Device,1899.8,35,,1899.8,percent of total billed charges,Implant Device,1899.8,35,,1899.8,percent of total billed charges,Implant Device,1899.8,35,,1899.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1845.52,34,"If Charge > 2,000, then 34 percent",1845.52,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4016.73,
J&J 1504-10-206 FEMORAL RIGHT SIZE 6,C1776,HCPCS,,79012906,CDM,278,RC,,,both,,,4800,3552.01,,,3552.01,Other,150% of Medicare + 9.63% HCRA Surcharge,2160,45,,2160,percent of total billed charges,Critical Access Hospital RCC factor,1632,34,,1632,percent of total billed charges,Implant Device,1632,34,,1632,percent of total billed charges,Implant Device,1632,34,,1632,percent of total billed charges,Implant Device,1632,34,,1632,percent of total billed charges,Implant Device,1632,34,,1632,percent of total billed charges,Implant Device,2376,,,2376,Other,110% of Medicare,1680,35,,1680,percent of total billed charges,Implant Device,1632,34,"Charges > $500, x 34%",1632,percent of total billed charges,Implant Device,1680,35,,1680,percent of total billed charges,Implant Device,1680,35,,1680,percent of total billed charges,Implant Device,1680,35,,1680,percent of total billed charges,Implant Device,1680,35,,1680,percent of total billed charges,Implant Device,1680,35,,1680,percent of total billed charges,Implant Device,1920,40,,1920,percent of total billed charges,Implant Device,1680,70,,1680,percent of total billed charges,All Other,1632,34,,1632,percent of total billed charges,Implant Device,1632,34,,1632,percent of total billed charges,Implant Device,1680,35,,1680,percent of total billed charges,Implant Device,1680,35,,1680,percent of total billed charges,Implant Device,1680,35,,1680,percent of total billed charges,Implant Device,1680,35,,1680,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1632,34,"If Charge > 2,000, then 34 percent",1632,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3552.01,
J&J 3092040 BONE CEMENT 40G,C1713,HCPCS,,79012907,CDM,278,RC,,,both,,,711,526.14,,,526.14,Other,150% of Medicare + 9.63% HCRA Surcharge,319.95,45,,319.95,percent of total billed charges,Critical Access Hospital RCC factor,241.74,34,,241.74,percent of total billed charges,Implant Device,241.74,34,,241.74,percent of total billed charges,Implant Device,241.74,34,,241.74,percent of total billed charges,Implant Device,241.74,34,,241.74,percent of total billed charges,Implant Device,241.74,34,,241.74,percent of total billed charges,Implant Device,351.95,,,351.95,Other,110% of Medicare,248.85,35,,248.85,percent of total billed charges,Implant Device,241.74,34,"Charges > $500, x 34%",241.74,percent of total billed charges,Implant Device,248.85,35,,248.85,percent of total billed charges,Implant Device,248.85,35,,248.85,percent of total billed charges,Implant Device,248.85,35,,248.85,percent of total billed charges,Implant Device,248.85,35,,248.85,percent of total billed charges,Implant Device,248.85,35,,248.85,percent of total billed charges,Implant Device,284.4,40,,284.4,percent of total billed charges,Implant Device,248.85,70,,248.85,percent of total billed charges,All Other,241.74,34,,241.74,percent of total billed charges,Implant Device,241.74,34,,241.74,percent of total billed charges,Implant Device,248.85,35,,248.85,percent of total billed charges,Implant Device,248.85,35,,248.85,percent of total billed charges,Implant Device,248.85,35,,248.85,percent of total billed charges,Implant Device,248.85,35,,248.85,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,526.14,
J&J 04.038.185S TFNA FENESTATED SCREW 85,C1713,HCPCS,,79012908,CDM,278,RC,,,both,,,1693,1252.82,,,1252.82,Other,150% of Medicare + 9.63% HCRA Surcharge,761.85,45,,761.85,percent of total billed charges,Critical Access Hospital RCC factor,575.62,34,,575.62,percent of total billed charges,Implant Device,575.62,34,,575.62,percent of total billed charges,Implant Device,575.62,34,,575.62,percent of total billed charges,Implant Device,575.62,34,,575.62,percent of total billed charges,Implant Device,575.62,34,,575.62,percent of total billed charges,Implant Device,838.04,,,838.04,Other,110% of Medicare,592.55,35,,592.55,percent of total billed charges,Implant Device,575.62,34,"Charges > $500, x 34%",575.62,percent of total billed charges,Implant Device,592.55,35,,592.55,percent of total billed charges,Implant Device,592.55,35,,592.55,percent of total billed charges,Implant Device,592.55,35,,592.55,percent of total billed charges,Implant Device,592.55,35,,592.55,percent of total billed charges,Implant Device,592.55,35,,592.55,percent of total billed charges,Implant Device,677.2,40,,677.2,percent of total billed charges,Implant Device,592.55,70,,592.55,percent of total billed charges,All Other,575.62,34,,575.62,percent of total billed charges,Implant Device,575.62,34,,575.62,percent of total billed charges,Implant Device,592.55,35,,592.55,percent of total billed charges,Implant Device,592.55,35,,592.55,percent of total billed charges,Implant Device,592.55,35,,592.55,percent of total billed charges,Implant Device,592.55,35,,592.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1252.82,
BOST SC-2317-50 CONTACT LEAD KIT 50CM,C1778,HCPCS,,79012911,CDM,278,RC,,,both,,,7800,5772.02,,,5772.02,Other,150% of Medicare + 9.63% HCRA Surcharge,3510,45,,3510,percent of total billed charges,Critical Access Hospital RCC factor,2652,34,,2652,percent of total billed charges,Implant Device,2652,34,,2652,percent of total billed charges,Implant Device,2652,34,,2652,percent of total billed charges,Implant Device,2652,34,,2652,percent of total billed charges,Implant Device,2652,34,,2652,percent of total billed charges,Implant Device,3861,,,3861,Other,110% of Medicare,2730,35,,2730,percent of total billed charges,Implant Device,2652,34,"Charges > $500, x 34%",2652,percent of total billed charges,Implant Device,2730,35,,2730,percent of total billed charges,Implant Device,2730,35,,2730,percent of total billed charges,Implant Device,2730,35,,2730,percent of total billed charges,Implant Device,2730,35,,2730,percent of total billed charges,Implant Device,2730,35,,2730,percent of total billed charges,Implant Device,3120,40,,3120,percent of total billed charges,Implant Device,2730,70,,2730,percent of total billed charges,All Other,2652,34,,2652,percent of total billed charges,Implant Device,2652,34,,2652,percent of total billed charges,Implant Device,2730,35,,2730,percent of total billed charges,Implant Device,2730,35,,2730,percent of total billed charges,Implant Device,2730,35,,2730,percent of total billed charges,Implant Device,2730,35,,2730,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2652,34,"If Charge > 2,000, then 34 percent",2652,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5772.02,
BOST SCI SC-4318 CLIK X ANCHOR,L8699,HCPCS,,79012912,CDM,278,RC,,,both,,,930,688.2,,,688.2,Other,150% of Medicare + 9.63% HCRA Surcharge,418.5,45,,418.5,percent of total billed charges,Critical Access Hospital RCC factor,316.2,34,,316.2,percent of total billed charges,Implant Device,316.2,34,,316.2,percent of total billed charges,Implant Device,316.2,34,,316.2,percent of total billed charges,Implant Device,316.2,34,,316.2,percent of total billed charges,Implant Device,316.2,34,,316.2,percent of total billed charges,Implant Device,460.35,,,460.35,Other,110% of Medicare,325.5,35,,325.5,percent of total billed charges,Implant Device,316.2,34,"Charges > $500, x 34%",316.2,percent of total billed charges,Implant Device,325.5,35,,325.5,percent of total billed charges,Implant Device,325.5,35,,325.5,percent of total billed charges,Implant Device,325.5,35,,325.5,percent of total billed charges,Implant Device,325.5,35,,325.5,percent of total billed charges,Implant Device,325.5,35,,325.5,percent of total billed charges,Implant Device,372,40,,372,percent of total billed charges,Implant Device,325.5,70,,325.5,percent of total billed charges,All Other,316.2,34,,316.2,percent of total billed charges,Implant Device,316.2,34,,316.2,percent of total billed charges,Implant Device,325.5,35,,325.5,percent of total billed charges,Implant Device,325.5,35,,325.5,percent of total billed charges,Implant Device,325.5,35,,325.5,percent of total billed charges,Implant Device,325.5,35,,325.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,688.2,
ZIMMER 42-5020-068-01 FEMUR LT SZ 10,C1776,HCPCS,,79012913,CDM,278,RC,,,both,,,6300,4662.02,,,4662.02,Other,150% of Medicare + 9.63% HCRA Surcharge,2835,45,,2835,percent of total billed charges,Critical Access Hospital RCC factor,2142,34,,2142,percent of total billed charges,Implant Device,2142,34,,2142,percent of total billed charges,Implant Device,2142,34,,2142,percent of total billed charges,Implant Device,2142,34,,2142,percent of total billed charges,Implant Device,2142,34,,2142,percent of total billed charges,Implant Device,3118.5,,,3118.5,Other,110% of Medicare,2205,35,,2205,percent of total billed charges,Implant Device,2142,34,"Charges > $500, x 34%",2142,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2520,40,,2520,percent of total billed charges,Implant Device,2205,70,,2205,percent of total billed charges,All Other,2142,34,,2142,percent of total billed charges,Implant Device,2142,34,,2142,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2142,34,"If Charge > 2,000, then 34 percent",2142,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4662.02,
ZIMMER 42-5400-000-38 PATELLA 38X9.5MM,C1776,HCPCS,,79012914,CDM,278,RC,,,both,,,1539,1138.86,,,1138.86,Other,150% of Medicare + 9.63% HCRA Surcharge,692.55,45,,692.55,percent of total billed charges,Critical Access Hospital RCC factor,523.26,34,,523.26,percent of total billed charges,Implant Device,523.26,34,,523.26,percent of total billed charges,Implant Device,523.26,34,,523.26,percent of total billed charges,Implant Device,523.26,34,,523.26,percent of total billed charges,Implant Device,523.26,34,,523.26,percent of total billed charges,Implant Device,761.81,,,761.81,Other,110% of Medicare,538.65,35,,538.65,percent of total billed charges,Implant Device,523.26,34,"Charges > $500, x 34%",523.26,percent of total billed charges,Implant Device,538.65,35,,538.65,percent of total billed charges,Implant Device,538.65,35,,538.65,percent of total billed charges,Implant Device,538.65,35,,538.65,percent of total billed charges,Implant Device,538.65,35,,538.65,percent of total billed charges,Implant Device,538.65,35,,538.65,percent of total billed charges,Implant Device,615.6,40,,615.6,percent of total billed charges,Implant Device,538.65,70,,538.65,percent of total billed charges,All Other,523.26,34,,523.26,percent of total billed charges,Implant Device,523.26,34,,523.26,percent of total billed charges,Implant Device,538.65,35,,538.65,percent of total billed charges,Implant Device,538.65,35,,538.65,percent of total billed charges,Implant Device,538.65,35,,538.65,percent of total billed charges,Implant Device,538.65,35,,538.65,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1138.86,
ZIMMER 42-5221-003-13 ART SURF RT 13MM,C1776,HCPCS,,79012915,CDM,278,RC,,,both,,,3648,2699.53,,,2699.53,Other,150% of Medicare + 9.63% HCRA Surcharge,1641.6,45,,1641.6,percent of total billed charges,Critical Access Hospital RCC factor,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1805.76,,,1805.76,Other,110% of Medicare,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1240.32,34,"Charges > $500, x 34%",1240.32,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1459.2,40,,1459.2,percent of total billed charges,Implant Device,1276.8,70,,1276.8,percent of total billed charges,All Other,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1240.32,34,"If Charge > 2,000, then 34 percent",1240.32,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2699.53,
BOST M0068502110 ADVANTAGE FIT - CLEAR,C1771,HCPCS,,79012917,CDM,278,RC,,,both,,,3668,2714.33,,,2714.33,Other,150% of Medicare + 9.63% HCRA Surcharge,1650.6,45,,1650.6,percent of total billed charges,Critical Access Hospital RCC factor,1247.12,34,,1247.12,percent of total billed charges,Implant Device,1247.12,34,,1247.12,percent of total billed charges,Implant Device,1247.12,34,,1247.12,percent of total billed charges,Implant Device,1247.12,34,,1247.12,percent of total billed charges,Implant Device,1247.12,34,,1247.12,percent of total billed charges,Implant Device,1815.66,,,1815.66,Other,110% of Medicare,1283.8,35,,1283.8,percent of total billed charges,Implant Device,1247.12,34,"Charges > $500, x 34%",1247.12,percent of total billed charges,Implant Device,1283.8,35,,1283.8,percent of total billed charges,Implant Device,1283.8,35,,1283.8,percent of total billed charges,Implant Device,1283.8,35,,1283.8,percent of total billed charges,Implant Device,1283.8,35,,1283.8,percent of total billed charges,Implant Device,1283.8,35,,1283.8,percent of total billed charges,Implant Device,1467.2,40,,1467.2,percent of total billed charges,Implant Device,1283.8,70,,1283.8,percent of total billed charges,All Other,1247.12,34,,1247.12,percent of total billed charges,Implant Device,1247.12,34,,1247.12,percent of total billed charges,Implant Device,1283.8,35,,1283.8,percent of total billed charges,Implant Device,1283.8,35,,1283.8,percent of total billed charges,Implant Device,1283.8,35,,1283.8,percent of total billed charges,Implant Device,1283.8,35,,1283.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1247.12,34,"If Charge > 2,000, then 34 percent",1247.12,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2714.33,
PARAGON P50-453-2715 NON LOCK SRW 2.7X15,C1713,HCPCS,,79012918,CDM,278,RC,,,both,,,504,372.96,,,372.96,Other,150% of Medicare + 9.63% HCRA Surcharge,226.8,45,,226.8,percent of total billed charges,Critical Access Hospital RCC factor,171.36,34,,171.36,percent of total billed charges,Implant Device,171.36,34,,171.36,percent of total billed charges,Implant Device,171.36,34,,171.36,percent of total billed charges,Implant Device,171.36,34,,171.36,percent of total billed charges,Implant Device,171.36,34,,171.36,percent of total billed charges,Implant Device,249.48,,,249.48,Other,110% of Medicare,176.4,35,,176.4,percent of total billed charges,Implant Device,171.36,34,"Charges > $500, x 34%",171.36,percent of total billed charges,Implant Device,176.4,35,,176.4,percent of total billed charges,Implant Device,176.4,35,,176.4,percent of total billed charges,Implant Device,176.4,35,,176.4,percent of total billed charges,Implant Device,176.4,35,,176.4,percent of total billed charges,Implant Device,176.4,35,,176.4,percent of total billed charges,Implant Device,201.6,40,,201.6,percent of total billed charges,Implant Device,176.4,70,,176.4,percent of total billed charges,All Other,171.36,34,,171.36,percent of total billed charges,Implant Device,171.36,34,,171.36,percent of total billed charges,Implant Device,176.4,35,,176.4,percent of total billed charges,Implant Device,176.4,35,,176.4,percent of total billed charges,Implant Device,176.4,35,,176.4,percent of total billed charges,Implant Device,176.4,35,,176.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,372.96,
PARAGON P50-453-2724 NON LOCK SRW 2.7X24,C1713,HCPCS,,79012919,CDM,278,RC,,,both,,,504,372.96,,,372.96,Other,150% of Medicare + 9.63% HCRA Surcharge,226.8,45,,226.8,percent of total billed charges,Critical Access Hospital RCC factor,171.36,34,,171.36,percent of total billed charges,Implant Device,171.36,34,,171.36,percent of total billed charges,Implant Device,171.36,34,,171.36,percent of total billed charges,Implant Device,171.36,34,,171.36,percent of total billed charges,Implant Device,171.36,34,,171.36,percent of total billed charges,Implant Device,249.48,,,249.48,Other,110% of Medicare,176.4,35,,176.4,percent of total billed charges,Implant Device,171.36,34,"Charges > $500, x 34%",171.36,percent of total billed charges,Implant Device,176.4,35,,176.4,percent of total billed charges,Implant Device,176.4,35,,176.4,percent of total billed charges,Implant Device,176.4,35,,176.4,percent of total billed charges,Implant Device,176.4,35,,176.4,percent of total billed charges,Implant Device,176.4,35,,176.4,percent of total billed charges,Implant Device,201.6,40,,201.6,percent of total billed charges,Implant Device,176.4,70,,176.4,percent of total billed charges,All Other,171.36,34,,171.36,percent of total billed charges,Implant Device,171.36,34,,171.36,percent of total billed charges,Implant Device,176.4,35,,176.4,percent of total billed charges,Implant Device,176.4,35,,176.4,percent of total billed charges,Implant Device,176.4,35,,176.4,percent of total billed charges,Implant Device,176.4,35,,176.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,372.96,
PARAGON P53-203-R009 FIBULAR PLT RT 9H,C1713,HCPCS,,79012920,CDM,278,RC,,,both,,,5240,3877.61,,,3877.61,Other,150% of Medicare + 9.63% HCRA Surcharge,2358,45,,2358,percent of total billed charges,Critical Access Hospital RCC factor,1781.6,34,,1781.6,percent of total billed charges,Implant Device,1781.6,34,,1781.6,percent of total billed charges,Implant Device,1781.6,34,,1781.6,percent of total billed charges,Implant Device,1781.6,34,,1781.6,percent of total billed charges,Implant Device,1781.6,34,,1781.6,percent of total billed charges,Implant Device,2593.8,,,2593.8,Other,110% of Medicare,1834,35,,1834,percent of total billed charges,Implant Device,1781.6,34,"Charges > $500, x 34%",1781.6,percent of total billed charges,Implant Device,1834,35,,1834,percent of total billed charges,Implant Device,1834,35,,1834,percent of total billed charges,Implant Device,1834,35,,1834,percent of total billed charges,Implant Device,1834,35,,1834,percent of total billed charges,Implant Device,1834,35,,1834,percent of total billed charges,Implant Device,2096,40,,2096,percent of total billed charges,Implant Device,1834,70,,1834,percent of total billed charges,All Other,1781.6,34,,1781.6,percent of total billed charges,Implant Device,1781.6,34,,1781.6,percent of total billed charges,Implant Device,1834,35,,1834,percent of total billed charges,Implant Device,1834,35,,1834,percent of total billed charges,Implant Device,1834,35,,1834,percent of total billed charges,Implant Device,1834,35,,1834,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1781.6,34,"If Charge > 2,000, then 34 percent",1781.6,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3877.61,
PARAGON P50-453-3512 NON LOCK SRW 3.5X12,C1713,HCPCS,,79012921,CDM,278,RC,,,both,,,504,372.96,,,372.96,Other,150% of Medicare + 9.63% HCRA Surcharge,226.8,45,,226.8,percent of total billed charges,Critical Access Hospital RCC factor,171.36,34,,171.36,percent of total billed charges,Implant Device,171.36,34,,171.36,percent of total billed charges,Implant Device,171.36,34,,171.36,percent of total billed charges,Implant Device,171.36,34,,171.36,percent of total billed charges,Implant Device,171.36,34,,171.36,percent of total billed charges,Implant Device,249.48,,,249.48,Other,110% of Medicare,176.4,35,,176.4,percent of total billed charges,Implant Device,171.36,34,"Charges > $500, x 34%",171.36,percent of total billed charges,Implant Device,176.4,35,,176.4,percent of total billed charges,Implant Device,176.4,35,,176.4,percent of total billed charges,Implant Device,176.4,35,,176.4,percent of total billed charges,Implant Device,176.4,35,,176.4,percent of total billed charges,Implant Device,176.4,35,,176.4,percent of total billed charges,Implant Device,201.6,40,,201.6,percent of total billed charges,Implant Device,176.4,70,,176.4,percent of total billed charges,All Other,171.36,34,,171.36,percent of total billed charges,Implant Device,171.36,34,,171.36,percent of total billed charges,Implant Device,176.4,35,,176.4,percent of total billed charges,Implant Device,176.4,35,,176.4,percent of total billed charges,Implant Device,176.4,35,,176.4,percent of total billed charges,Implant Device,176.4,35,,176.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,372.96,
PARAGON P50-353-2715 LOCK SCREW 2.7X15,C1713,HCPCS,,79012922,CDM,278,RC,,,both,,,693,512.82,,,512.82,Other,150% of Medicare + 9.63% HCRA Surcharge,311.85,45,,311.85,percent of total billed charges,Critical Access Hospital RCC factor,235.62,34,,235.62,percent of total billed charges,Implant Device,235.62,34,,235.62,percent of total billed charges,Implant Device,235.62,34,,235.62,percent of total billed charges,Implant Device,235.62,34,,235.62,percent of total billed charges,Implant Device,235.62,34,,235.62,percent of total billed charges,Implant Device,343.04,,,343.04,Other,110% of Medicare,242.55,35,,242.55,percent of total billed charges,Implant Device,235.62,34,"Charges > $500, x 34%",235.62,percent of total billed charges,Implant Device,242.55,35,,242.55,percent of total billed charges,Implant Device,242.55,35,,242.55,percent of total billed charges,Implant Device,242.55,35,,242.55,percent of total billed charges,Implant Device,242.55,35,,242.55,percent of total billed charges,Implant Device,242.55,35,,242.55,percent of total billed charges,Implant Device,277.2,40,,277.2,percent of total billed charges,Implant Device,242.55,70,,242.55,percent of total billed charges,All Other,235.62,34,,235.62,percent of total billed charges,Implant Device,235.62,34,,235.62,percent of total billed charges,Implant Device,242.55,35,,242.55,percent of total billed charges,Implant Device,242.55,35,,242.55,percent of total billed charges,Implant Device,242.55,35,,242.55,percent of total billed charges,Implant Device,242.55,35,,242.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,512.82,
PARAGON P50-353-2711 LOCK SCREW 2.7X11MM,C1713,HCPCS,,79012923,CDM,278,RC,,,both,,,693,512.82,,,512.82,Other,150% of Medicare + 9.63% HCRA Surcharge,311.85,45,,311.85,percent of total billed charges,Critical Access Hospital RCC factor,235.62,34,,235.62,percent of total billed charges,Implant Device,235.62,34,,235.62,percent of total billed charges,Implant Device,235.62,34,,235.62,percent of total billed charges,Implant Device,235.62,34,,235.62,percent of total billed charges,Implant Device,235.62,34,,235.62,percent of total billed charges,Implant Device,343.04,,,343.04,Other,110% of Medicare,242.55,35,,242.55,percent of total billed charges,Implant Device,235.62,34,"Charges > $500, x 34%",235.62,percent of total billed charges,Implant Device,242.55,35,,242.55,percent of total billed charges,Implant Device,242.55,35,,242.55,percent of total billed charges,Implant Device,242.55,35,,242.55,percent of total billed charges,Implant Device,242.55,35,,242.55,percent of total billed charges,Implant Device,242.55,35,,242.55,percent of total billed charges,Implant Device,277.2,40,,277.2,percent of total billed charges,Implant Device,242.55,70,,242.55,percent of total billed charges,All Other,235.62,34,,235.62,percent of total billed charges,Implant Device,235.62,34,,235.62,percent of total billed charges,Implant Device,242.55,35,,242.55,percent of total billed charges,Implant Device,242.55,35,,242.55,percent of total billed charges,Implant Device,242.55,35,,242.55,percent of total billed charges,Implant Device,242.55,35,,242.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,512.82,
PARAGON P50-353-2714 LOCK SCREW 2.7X14MM,C1713,HCPCS,,79012924,CDM,278,RC,,,both,,,693,512.82,,,512.82,Other,150% of Medicare + 9.63% HCRA Surcharge,311.85,45,,311.85,percent of total billed charges,Critical Access Hospital RCC factor,235.62,34,,235.62,percent of total billed charges,Implant Device,235.62,34,,235.62,percent of total billed charges,Implant Device,235.62,34,,235.62,percent of total billed charges,Implant Device,235.62,34,,235.62,percent of total billed charges,Implant Device,235.62,34,,235.62,percent of total billed charges,Implant Device,343.04,,,343.04,Other,110% of Medicare,242.55,35,,242.55,percent of total billed charges,Implant Device,235.62,34,"Charges > $500, x 34%",235.62,percent of total billed charges,Implant Device,242.55,35,,242.55,percent of total billed charges,Implant Device,242.55,35,,242.55,percent of total billed charges,Implant Device,242.55,35,,242.55,percent of total billed charges,Implant Device,242.55,35,,242.55,percent of total billed charges,Implant Device,242.55,35,,242.55,percent of total billed charges,Implant Device,277.2,40,,277.2,percent of total billed charges,Implant Device,242.55,70,,242.55,percent of total billed charges,All Other,235.62,34,,235.62,percent of total billed charges,Implant Device,235.62,34,,235.62,percent of total billed charges,Implant Device,242.55,35,,242.55,percent of total billed charges,Implant Device,242.55,35,,242.55,percent of total billed charges,Implant Device,242.55,35,,242.55,percent of total billed charges,Implant Device,242.55,35,,242.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,512.82,
PARAGON P50-353-3512 LOCK SCREW 3.5X12MM,C1713,HCPCS,,79012925,CDM,278,RC,,,both,,,693,512.82,,,512.82,Other,150% of Medicare + 9.63% HCRA Surcharge,311.85,45,,311.85,percent of total billed charges,Critical Access Hospital RCC factor,235.62,34,,235.62,percent of total billed charges,Implant Device,235.62,34,,235.62,percent of total billed charges,Implant Device,235.62,34,,235.62,percent of total billed charges,Implant Device,235.62,34,,235.62,percent of total billed charges,Implant Device,235.62,34,,235.62,percent of total billed charges,Implant Device,343.04,,,343.04,Other,110% of Medicare,242.55,35,,242.55,percent of total billed charges,Implant Device,235.62,34,"Charges > $500, x 34%",235.62,percent of total billed charges,Implant Device,242.55,35,,242.55,percent of total billed charges,Implant Device,242.55,35,,242.55,percent of total billed charges,Implant Device,242.55,35,,242.55,percent of total billed charges,Implant Device,242.55,35,,242.55,percent of total billed charges,Implant Device,242.55,35,,242.55,percent of total billed charges,Implant Device,277.2,40,,277.2,percent of total billed charges,Implant Device,242.55,70,,242.55,percent of total billed charges,All Other,235.62,34,,235.62,percent of total billed charges,Implant Device,235.62,34,,235.62,percent of total billed charges,Implant Device,242.55,35,,242.55,percent of total billed charges,Implant Device,242.55,35,,242.55,percent of total billed charges,Implant Device,242.55,35,,242.55,percent of total billed charges,Implant Device,242.55,35,,242.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,512.82,
PARAGON P50-353-2713 LOCK SCREW 2.7X13MM,C1713,HCPCS,,79012926,CDM,278,RC,,,both,,,693,512.82,,,512.82,Other,150% of Medicare + 9.63% HCRA Surcharge,311.85,45,,311.85,percent of total billed charges,Critical Access Hospital RCC factor,235.62,34,,235.62,percent of total billed charges,Implant Device,235.62,34,,235.62,percent of total billed charges,Implant Device,235.62,34,,235.62,percent of total billed charges,Implant Device,235.62,34,,235.62,percent of total billed charges,Implant Device,235.62,34,,235.62,percent of total billed charges,Implant Device,343.04,,,343.04,Other,110% of Medicare,242.55,35,,242.55,percent of total billed charges,Implant Device,235.62,34,"Charges > $500, x 34%",235.62,percent of total billed charges,Implant Device,242.55,35,,242.55,percent of total billed charges,Implant Device,242.55,35,,242.55,percent of total billed charges,Implant Device,242.55,35,,242.55,percent of total billed charges,Implant Device,242.55,35,,242.55,percent of total billed charges,Implant Device,242.55,35,,242.55,percent of total billed charges,Implant Device,277.2,40,,277.2,percent of total billed charges,Implant Device,242.55,70,,242.55,percent of total billed charges,All Other,235.62,34,,235.62,percent of total billed charges,Implant Device,235.62,34,,235.62,percent of total billed charges,Implant Device,242.55,35,,242.55,percent of total billed charges,Implant Device,242.55,35,,242.55,percent of total billed charges,Implant Device,242.55,35,,242.55,percent of total billed charges,Implant Device,242.55,35,,242.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,512.82,
PARAGON P20-130-030S THREAD HEAD SC 3X30,C1713,HCPCS,,79012927,CDM,278,RC,,,both,,,735,543.9,,,543.9,Other,150% of Medicare + 9.63% HCRA Surcharge,330.75,45,,330.75,percent of total billed charges,Critical Access Hospital RCC factor,249.9,34,,249.9,percent of total billed charges,Implant Device,249.9,34,,249.9,percent of total billed charges,Implant Device,249.9,34,,249.9,percent of total billed charges,Implant Device,249.9,34,,249.9,percent of total billed charges,Implant Device,249.9,34,,249.9,percent of total billed charges,Implant Device,363.83,,,363.83,Other,110% of Medicare,257.25,35,,257.25,percent of total billed charges,Implant Device,249.9,34,"Charges > $500, x 34%",249.9,percent of total billed charges,Implant Device,257.25,35,,257.25,percent of total billed charges,Implant Device,257.25,35,,257.25,percent of total billed charges,Implant Device,257.25,35,,257.25,percent of total billed charges,Implant Device,257.25,35,,257.25,percent of total billed charges,Implant Device,257.25,35,,257.25,percent of total billed charges,Implant Device,294,40,,294,percent of total billed charges,Implant Device,257.25,70,,257.25,percent of total billed charges,All Other,249.9,34,,249.9,percent of total billed charges,Implant Device,249.9,34,,249.9,percent of total billed charges,Implant Device,257.25,35,,257.25,percent of total billed charges,Implant Device,257.25,35,,257.25,percent of total billed charges,Implant Device,257.25,35,,257.25,percent of total billed charges,Implant Device,257.25,35,,257.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,543.9,
PARAGON P20-030-DW00 WASHER 3.0MM,C1713,HCPCS,,79012929,CDM,278,RC,,,both,,,336,248.64,,,248.64,Other,150% of Medicare + 9.63% HCRA Surcharge,151.2,45,,151.2,percent of total billed charges,Critical Access Hospital RCC factor,114.24,34,,114.24,percent of total billed charges,Implant Device,114.24,34,,114.24,percent of total billed charges,Implant Device,114.24,34,,114.24,percent of total billed charges,Implant Device,114.24,34,,114.24,percent of total billed charges,Implant Device,114.24,34,,114.24,percent of total billed charges,Implant Device,166.32,,,166.32,Other,110% of Medicare,117.6,35,,117.6,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,117.6,35,,117.6,percent of total billed charges,Implant Device,117.6,35,,117.6,percent of total billed charges,Implant Device,117.6,35,,117.6,percent of total billed charges,Implant Device,117.6,35,,117.6,percent of total billed charges,Implant Device,117.6,35,,117.6,percent of total billed charges,Implant Device,134.4,40,,134.4,percent of total billed charges,Implant Device,117.6,70,,117.6,percent of total billed charges,All Other,114.24,34,,114.24,percent of total billed charges,Implant Device,114.24,34,,114.24,percent of total billed charges,Implant Device,117.6,35,,117.6,percent of total billed charges,Implant Device,117.6,35,,117.6,percent of total billed charges,Implant Device,117.6,35,,117.6,percent of total billed charges,Implant Device,117.6,35,,117.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,248.64,
PARAGON P50-353-3514 LOCK SCREW 3.5X14MM,C1713,HCPCS,,79012932,CDM,278,RC,,,both,,,693,512.82,,,512.82,Other,150% of Medicare + 9.63% HCRA Surcharge,311.85,45,,311.85,percent of total billed charges,Critical Access Hospital RCC factor,235.62,34,,235.62,percent of total billed charges,Implant Device,235.62,34,,235.62,percent of total billed charges,Implant Device,235.62,34,,235.62,percent of total billed charges,Implant Device,235.62,34,,235.62,percent of total billed charges,Implant Device,235.62,34,,235.62,percent of total billed charges,Implant Device,343.04,,,343.04,Other,110% of Medicare,242.55,35,,242.55,percent of total billed charges,Implant Device,235.62,34,"Charges > $500, x 34%",235.62,percent of total billed charges,Implant Device,242.55,35,,242.55,percent of total billed charges,Implant Device,242.55,35,,242.55,percent of total billed charges,Implant Device,242.55,35,,242.55,percent of total billed charges,Implant Device,242.55,35,,242.55,percent of total billed charges,Implant Device,242.55,35,,242.55,percent of total billed charges,Implant Device,277.2,40,,277.2,percent of total billed charges,Implant Device,242.55,70,,242.55,percent of total billed charges,All Other,235.62,34,,235.62,percent of total billed charges,Implant Device,235.62,34,,235.62,percent of total billed charges,Implant Device,242.55,35,,242.55,percent of total billed charges,Implant Device,242.55,35,,242.55,percent of total billed charges,Implant Device,242.55,35,,242.55,percent of total billed charges,Implant Device,242.55,35,,242.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,512.82,
ZIMMER 00-8755-008-32 LINER 32MM SIZE GG,C1776,HCPCS,,79012933,CDM,278,RC,,,both,,,2304,1704.97,,,1704.97,Other,150% of Medicare + 9.63% HCRA Surcharge,1036.8,45,,1036.8,percent of total billed charges,Critical Access Hospital RCC factor,783.36,34,,783.36,percent of total billed charges,Implant Device,783.36,34,,783.36,percent of total billed charges,Implant Device,783.36,34,,783.36,percent of total billed charges,Implant Device,783.36,34,,783.36,percent of total billed charges,Implant Device,783.36,34,,783.36,percent of total billed charges,Implant Device,1140.48,,,1140.48,Other,110% of Medicare,806.4,35,,806.4,percent of total billed charges,Implant Device,783.36,34,"Charges > $500, x 34%",783.36,percent of total billed charges,Implant Device,806.4,35,,806.4,percent of total billed charges,Implant Device,806.4,35,,806.4,percent of total billed charges,Implant Device,806.4,35,,806.4,percent of total billed charges,Implant Device,806.4,35,,806.4,percent of total billed charges,Implant Device,806.4,35,,806.4,percent of total billed charges,Implant Device,921.6,40,,921.6,percent of total billed charges,Implant Device,806.4,70,,806.4,percent of total billed charges,All Other,783.36,34,,783.36,percent of total billed charges,Implant Device,783.36,34,,783.36,percent of total billed charges,Implant Device,806.4,35,,806.4,percent of total billed charges,Implant Device,806.4,35,,806.4,percent of total billed charges,Implant Device,806.4,35,,806.4,percent of total billed charges,Implant Device,806.4,35,,806.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,783.36,34,"If Charge > 2,000, then 34 percent",783.36,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1704.97,
ZIMMER VE189022 TIBIAL BEARING 63X12MM,C1776,HCPCS,,79012934,CDM,278,RC,,,both,,,3648,2699.53,,,2699.53,Other,150% of Medicare + 9.63% HCRA Surcharge,1641.6,45,,1641.6,percent of total billed charges,Critical Access Hospital RCC factor,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1805.76,,,1805.76,Other,110% of Medicare,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1240.32,34,"Charges > $500, x 34%",1240.32,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1459.2,40,,1459.2,percent of total billed charges,Implant Device,1276.8,70,,1276.8,percent of total billed charges,All Other,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1240.32,34,"If Charge > 2,000, then 34 percent",1240.32,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2699.53,
STRYKER 662616 BONE SCREW 1.7X16MM,C1713,HCPCS,,79012936,CDM,278,RC,,,both,,,324,239.76,,,239.76,Other,150% of Medicare + 9.63% HCRA Surcharge,145.8,45,,145.8,percent of total billed charges,Critical Access Hospital RCC factor,110.16,34,,110.16,percent of total billed charges,Implant Device,110.16,34,,110.16,percent of total billed charges,Implant Device,110.16,34,,110.16,percent of total billed charges,Implant Device,110.16,34,,110.16,percent of total billed charges,Implant Device,110.16,34,,110.16,percent of total billed charges,Implant Device,160.38,,,160.38,Other,110% of Medicare,113.4,35,,113.4,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,129.6,40,,129.6,percent of total billed charges,Implant Device,113.4,70,,113.4,percent of total billed charges,All Other,110.16,34,,110.16,percent of total billed charges,Implant Device,110.16,34,,110.16,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,239.76,
STRYKER 6721-0027 HIP STEM SX 0 27X93MM,C1776,HCPCS,,79012937,CDM,278,RC,,,both,,,6953,5145.24,,,5145.24,Other,150% of Medicare + 9.63% HCRA Surcharge,3128.85,45,,3128.85,percent of total billed charges,Critical Access Hospital RCC factor,2364.02,34,,2364.02,percent of total billed charges,Implant Device,2364.02,34,,2364.02,percent of total billed charges,Implant Device,2364.02,34,,2364.02,percent of total billed charges,Implant Device,2364.02,34,,2364.02,percent of total billed charges,Implant Device,2364.02,34,,2364.02,percent of total billed charges,Implant Device,3441.74,,,3441.74,Other,110% of Medicare,2433.55,35,,2433.55,percent of total billed charges,Implant Device,2364.02,34,"Charges > $500, x 34%",2364.02,percent of total billed charges,Implant Device,2433.55,35,,2433.55,percent of total billed charges,Implant Device,2433.55,35,,2433.55,percent of total billed charges,Implant Device,2433.55,35,,2433.55,percent of total billed charges,Implant Device,2433.55,35,,2433.55,percent of total billed charges,Implant Device,2433.55,35,,2433.55,percent of total billed charges,Implant Device,2781.2,40,,2781.2,percent of total billed charges,Implant Device,2433.55,70,,2433.55,percent of total billed charges,All Other,2364.02,34,,2364.02,percent of total billed charges,Implant Device,2364.02,34,,2364.02,percent of total billed charges,Implant Device,2433.55,35,,2433.55,percent of total billed charges,Implant Device,2433.55,35,,2433.55,percent of total billed charges,Implant Device,2433.55,35,,2433.55,percent of total billed charges,Implant Device,2433.55,35,,2433.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2364.02,34,"If Charge > 2,000, then 34 percent",2364.02,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5145.24,
J&J 02.127.311 PROX TIBIAL PLT 3.5X87MM,C1713,HCPCS,,79012938,CDM,278,RC,,,both,,,4211,3116.15,,,3116.15,Other,150% of Medicare + 9.63% HCRA Surcharge,1894.95,45,,1894.95,percent of total billed charges,Critical Access Hospital RCC factor,1431.74,34,,1431.74,percent of total billed charges,Implant Device,1431.74,34,,1431.74,percent of total billed charges,Implant Device,1431.74,34,,1431.74,percent of total billed charges,Implant Device,1431.74,34,,1431.74,percent of total billed charges,Implant Device,1431.74,34,,1431.74,percent of total billed charges,Implant Device,2084.45,,,2084.45,Other,110% of Medicare,1473.85,35,,1473.85,percent of total billed charges,Implant Device,1431.74,34,"Charges > $500, x 34%",1431.74,percent of total billed charges,Implant Device,1473.85,35,,1473.85,percent of total billed charges,Implant Device,1473.85,35,,1473.85,percent of total billed charges,Implant Device,1473.85,35,,1473.85,percent of total billed charges,Implant Device,1473.85,35,,1473.85,percent of total billed charges,Implant Device,1473.85,35,,1473.85,percent of total billed charges,Implant Device,1684.4,40,,1684.4,percent of total billed charges,Implant Device,1473.85,70,,1473.85,percent of total billed charges,All Other,1431.74,34,,1431.74,percent of total billed charges,Implant Device,1431.74,34,,1431.74,percent of total billed charges,Implant Device,1473.85,35,,1473.85,percent of total billed charges,Implant Device,1473.85,35,,1473.85,percent of total billed charges,Implant Device,1473.85,35,,1473.85,percent of total billed charges,Implant Device,1473.85,35,,1473.85,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1431.74,34,"If Charge > 2,000, then 34 percent",1431.74,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3116.15,
J&J 204.842 CORTEX SCREW 3.5X42MM,C1713,HCPCS,,79012939,CDM,278,RC,,,both,,,57,42.18,,,42.18,Other,150% of Medicare + 9.63% HCRA Surcharge,25.65,45,,25.65,percent of total billed charges,Critical Access Hospital RCC factor,19.38,34,,19.38,percent of total billed charges,Implant Device,19.38,34,,19.38,percent of total billed charges,Implant Device,19.38,34,,19.38,percent of total billed charges,Implant Device,19.38,34,,19.38,percent of total billed charges,Implant Device,19.38,34,,19.38,percent of total billed charges,Implant Device,28.22,,,28.22,Other,110% of Medicare,19.95,35,,19.95,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,19.95,35,,19.95,percent of total billed charges,Implant Device,19.95,35,,19.95,percent of total billed charges,Implant Device,19.95,35,,19.95,percent of total billed charges,Implant Device,19.95,35,,19.95,percent of total billed charges,Implant Device,19.95,35,,19.95,percent of total billed charges,Implant Device,22.8,40,,22.8,percent of total billed charges,Implant Device,19.95,70,,19.95,percent of total billed charges,All Other,19.38,34,,19.38,percent of total billed charges,Implant Device,19.38,34,,19.38,percent of total billed charges,Implant Device,19.95,35,,19.95,percent of total billed charges,Implant Device,19.95,35,,19.95,percent of total billed charges,Implant Device,19.95,35,,19.95,percent of total billed charges,Implant Device,19.95,35,,19.95,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,42.18,
ZIMMER 42-5320-064-01 TIBIA 5DEG LT SZ C,C1776,HCPCS,,79012940,CDM,278,RC,,,both,,,2304,1704.97,,,1704.97,Other,150% of Medicare + 9.63% HCRA Surcharge,1036.8,45,,1036.8,percent of total billed charges,Critical Access Hospital RCC factor,783.36,34,,783.36,percent of total billed charges,Implant Device,783.36,34,,783.36,percent of total billed charges,Implant Device,783.36,34,,783.36,percent of total billed charges,Implant Device,783.36,34,,783.36,percent of total billed charges,Implant Device,783.36,34,,783.36,percent of total billed charges,Implant Device,1140.48,,,1140.48,Other,110% of Medicare,806.4,35,,806.4,percent of total billed charges,Implant Device,783.36,34,"Charges > $500, x 34%",783.36,percent of total billed charges,Implant Device,806.4,35,,806.4,percent of total billed charges,Implant Device,806.4,35,,806.4,percent of total billed charges,Implant Device,806.4,35,,806.4,percent of total billed charges,Implant Device,806.4,35,,806.4,percent of total billed charges,Implant Device,806.4,35,,806.4,percent of total billed charges,Implant Device,921.6,40,,921.6,percent of total billed charges,Implant Device,806.4,70,,806.4,percent of total billed charges,All Other,783.36,34,,783.36,percent of total billed charges,Implant Device,783.36,34,,783.36,percent of total billed charges,Implant Device,806.4,35,,806.4,percent of total billed charges,Implant Device,806.4,35,,806.4,percent of total billed charges,Implant Device,806.4,35,,806.4,percent of total billed charges,Implant Device,806.4,35,,806.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,783.36,34,"If Charge > 2,000, then 34 percent",783.36,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1704.97,
ZIMMER 42-5026-056-01 FEMUR LEFT SIZE 4,C1776,HCPCS,,79012941,CDM,278,RC,,,both,,,6300,4662.02,,,4662.02,Other,150% of Medicare + 9.63% HCRA Surcharge,2835,45,,2835,percent of total billed charges,Critical Access Hospital RCC factor,2142,34,,2142,percent of total billed charges,Implant Device,2142,34,,2142,percent of total billed charges,Implant Device,2142,34,,2142,percent of total billed charges,Implant Device,2142,34,,2142,percent of total billed charges,Implant Device,2142,34,,2142,percent of total billed charges,Implant Device,3118.5,,,3118.5,Other,110% of Medicare,2205,35,,2205,percent of total billed charges,Implant Device,2142,34,"Charges > $500, x 34%",2142,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2520,40,,2520,percent of total billed charges,Implant Device,2205,70,,2205,percent of total billed charges,All Other,2142,34,,2142,percent of total billed charges,Implant Device,2142,34,,2142,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2142,34,"If Charge > 2,000, then 34 percent",2142,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4662.02,
ZIMMER 42-5121-003-10 ART SURF LT 10MM,C1776,HCPCS,,79012942,CDM,278,RC,,,both,,,4116,3045.85,,,3045.85,Other,150% of Medicare + 9.63% HCRA Surcharge,1852.2,45,,1852.2,percent of total billed charges,Critical Access Hospital RCC factor,1399.44,34,,1399.44,percent of total billed charges,Implant Device,1399.44,34,,1399.44,percent of total billed charges,Implant Device,1399.44,34,,1399.44,percent of total billed charges,Implant Device,1399.44,34,,1399.44,percent of total billed charges,Implant Device,1399.44,34,,1399.44,percent of total billed charges,Implant Device,2037.42,,,2037.42,Other,110% of Medicare,1440.6,35,,1440.6,percent of total billed charges,Implant Device,1399.44,34,"Charges > $500, x 34%",1399.44,percent of total billed charges,Implant Device,1440.6,35,,1440.6,percent of total billed charges,Implant Device,1440.6,35,,1440.6,percent of total billed charges,Implant Device,1440.6,35,,1440.6,percent of total billed charges,Implant Device,1440.6,35,,1440.6,percent of total billed charges,Implant Device,1440.6,35,,1440.6,percent of total billed charges,Implant Device,1646.4,40,,1646.4,percent of total billed charges,Implant Device,1440.6,70,,1440.6,percent of total billed charges,All Other,1399.44,34,,1399.44,percent of total billed charges,Implant Device,1399.44,34,,1399.44,percent of total billed charges,Implant Device,1440.6,35,,1440.6,percent of total billed charges,Implant Device,1440.6,35,,1440.6,percent of total billed charges,Implant Device,1440.6,35,,1440.6,percent of total billed charges,Implant Device,1440.6,35,,1440.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1399.44,34,"If Charge > 2,000, then 34 percent",1399.44,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3045.85,
ARTHREX AR-1288QIS-110 QUAD IMPL SYS 11,C1713,HCPCS,,79012943,CDM,278,RC,,,both,,,6525,4828.52,,,4828.52,Other,150% of Medicare + 9.63% HCRA Surcharge,2936.25,45,,2936.25,percent of total billed charges,Critical Access Hospital RCC factor,2218.5,34,,2218.5,percent of total billed charges,Implant Device,2218.5,34,,2218.5,percent of total billed charges,Implant Device,2218.5,34,,2218.5,percent of total billed charges,Implant Device,2218.5,34,,2218.5,percent of total billed charges,Implant Device,2218.5,34,,2218.5,percent of total billed charges,Implant Device,3229.88,,,3229.88,Other,110% of Medicare,2283.75,35,,2283.75,percent of total billed charges,Implant Device,2218.5,34,"Charges > $500, x 34%",2218.5,percent of total billed charges,Implant Device,2283.75,35,,2283.75,percent of total billed charges,Implant Device,2283.75,35,,2283.75,percent of total billed charges,Implant Device,2283.75,35,,2283.75,percent of total billed charges,Implant Device,2283.75,35,,2283.75,percent of total billed charges,Implant Device,2283.75,35,,2283.75,percent of total billed charges,Implant Device,2610,40,,2610,percent of total billed charges,Implant Device,2283.75,70,,2283.75,percent of total billed charges,All Other,2218.5,34,,2218.5,percent of total billed charges,Implant Device,2218.5,34,,2218.5,percent of total billed charges,Implant Device,2283.75,35,,2283.75,percent of total billed charges,Implant Device,2283.75,35,,2283.75,percent of total billed charges,Implant Device,2283.75,35,,2283.75,percent of total billed charges,Implant Device,2283.75,35,,2283.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2218.5,34,"If Charge > 2,000, then 34 percent",2218.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4828.52,
ARTHREX AR-1588RT-2J ACL KIT,C1713,HCPCS,,79012944,CDM,278,RC,,,both,,,1395,1032.3,,,1032.3,Other,150% of Medicare + 9.63% HCRA Surcharge,627.75,45,,627.75,percent of total billed charges,Critical Access Hospital RCC factor,474.3,34,,474.3,percent of total billed charges,Implant Device,474.3,34,,474.3,percent of total billed charges,Implant Device,474.3,34,,474.3,percent of total billed charges,Implant Device,474.3,34,,474.3,percent of total billed charges,Implant Device,474.3,34,,474.3,percent of total billed charges,Implant Device,690.53,,,690.53,Other,110% of Medicare,488.25,35,,488.25,percent of total billed charges,Implant Device,474.3,34,"Charges > $500, x 34%",474.3,percent of total billed charges,Implant Device,488.25,35,,488.25,percent of total billed charges,Implant Device,488.25,35,,488.25,percent of total billed charges,Implant Device,488.25,35,,488.25,percent of total billed charges,Implant Device,488.25,35,,488.25,percent of total billed charges,Implant Device,488.25,35,,488.25,percent of total billed charges,Implant Device,558,40,,558,percent of total billed charges,Implant Device,488.25,70,,488.25,percent of total billed charges,All Other,474.3,34,,474.3,percent of total billed charges,Implant Device,474.3,34,,474.3,percent of total billed charges,Implant Device,488.25,35,,488.25,percent of total billed charges,Implant Device,488.25,35,,488.25,percent of total billed charges,Implant Device,488.25,35,,488.25,percent of total billed charges,Implant Device,488.25,35,,488.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1032.3,
ARTHREX AR-8555-60 CANC SCREW 5.5X60MM,C1713,HCPCS,,79012945,CDM,278,RC,,,both,,,324,239.76,,,239.76,Other,150% of Medicare + 9.63% HCRA Surcharge,145.8,45,,145.8,percent of total billed charges,Critical Access Hospital RCC factor,110.16,34,,110.16,percent of total billed charges,Implant Device,110.16,34,,110.16,percent of total billed charges,Implant Device,110.16,34,,110.16,percent of total billed charges,Implant Device,110.16,34,,110.16,percent of total billed charges,Implant Device,110.16,34,,110.16,percent of total billed charges,Implant Device,160.38,,,160.38,Other,110% of Medicare,113.4,35,,113.4,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,129.6,40,,129.6,percent of total billed charges,Implant Device,113.4,70,,113.4,percent of total billed charges,All Other,110.16,34,,110.16,percent of total billed charges,Implant Device,110.16,34,,110.16,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,239.76,
STRYKER 629728 LOCK PLATE 8H 2.7X64MM,C1713,HCPCS,,79012949,CDM,278,RC,,,both,,,3152,2332.49,,,2332.49,Other,150% of Medicare + 9.63% HCRA Surcharge,1418.4,45,,1418.4,percent of total billed charges,Critical Access Hospital RCC factor,1071.68,34,,1071.68,percent of total billed charges,Implant Device,1071.68,34,,1071.68,percent of total billed charges,Implant Device,1071.68,34,,1071.68,percent of total billed charges,Implant Device,1071.68,34,,1071.68,percent of total billed charges,Implant Device,1071.68,34,,1071.68,percent of total billed charges,Implant Device,1560.24,,,1560.24,Other,110% of Medicare,1103.2,35,,1103.2,percent of total billed charges,Implant Device,1071.68,34,"Charges > $500, x 34%",1071.68,percent of total billed charges,Implant Device,1103.2,35,,1103.2,percent of total billed charges,Implant Device,1103.2,35,,1103.2,percent of total billed charges,Implant Device,1103.2,35,,1103.2,percent of total billed charges,Implant Device,1103.2,35,,1103.2,percent of total billed charges,Implant Device,1103.2,35,,1103.2,percent of total billed charges,Implant Device,1260.8,40,,1260.8,percent of total billed charges,Implant Device,1103.2,70,,1103.2,percent of total billed charges,All Other,1071.68,34,,1071.68,percent of total billed charges,Implant Device,1071.68,34,,1071.68,percent of total billed charges,Implant Device,1103.2,35,,1103.2,percent of total billed charges,Implant Device,1103.2,35,,1103.2,percent of total billed charges,Implant Device,1103.2,35,,1103.2,percent of total billed charges,Implant Device,1103.2,35,,1103.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1071.68,34,"If Charge > 2,000, then 34 percent",1071.68,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2332.49,
STRYKER 629777 LOCK PLATE 10H 2.4X76MM,C1713,HCPCS,,79012950,CDM,278,RC,,,both,,,2938,2174.13,,,2174.13,Other,150% of Medicare + 9.63% HCRA Surcharge,1322.1,45,,1322.1,percent of total billed charges,Critical Access Hospital RCC factor,998.92,34,,998.92,percent of total billed charges,Implant Device,998.92,34,,998.92,percent of total billed charges,Implant Device,998.92,34,,998.92,percent of total billed charges,Implant Device,998.92,34,,998.92,percent of total billed charges,Implant Device,998.92,34,,998.92,percent of total billed charges,Implant Device,1454.31,,,1454.31,Other,110% of Medicare,1028.3,35,,1028.3,percent of total billed charges,Implant Device,998.92,34,"Charges > $500, x 34%",998.92,percent of total billed charges,Implant Device,1028.3,35,,1028.3,percent of total billed charges,Implant Device,1028.3,35,,1028.3,percent of total billed charges,Implant Device,1028.3,35,,1028.3,percent of total billed charges,Implant Device,1028.3,35,,1028.3,percent of total billed charges,Implant Device,1028.3,35,,1028.3,percent of total billed charges,Implant Device,1175.2,40,,1175.2,percent of total billed charges,Implant Device,1028.3,70,,1028.3,percent of total billed charges,All Other,998.92,34,,998.92,percent of total billed charges,Implant Device,998.92,34,,998.92,percent of total billed charges,Implant Device,1028.3,35,,1028.3,percent of total billed charges,Implant Device,1028.3,35,,1028.3,percent of total billed charges,Implant Device,1028.3,35,,1028.3,percent of total billed charges,Implant Device,1028.3,35,,1028.3,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,998.92,34,"If Charge > 2,000, then 34 percent",998.92,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2174.13,
STRYKER 656030 LOCKING SCREW 2.4X18MM,C1713,HCPCS,,79012951,CDM,278,RC,,,both,,,480,355.2,,,355.2,Other,150% of Medicare + 9.63% HCRA Surcharge,216,45,,216,percent of total billed charges,Critical Access Hospital RCC factor,163.2,34,,163.2,percent of total billed charges,Implant Device,163.2,34,,163.2,percent of total billed charges,Implant Device,163.2,34,,163.2,percent of total billed charges,Implant Device,163.2,34,,163.2,percent of total billed charges,Implant Device,163.2,34,,163.2,percent of total billed charges,Implant Device,237.6,,,237.6,Other,110% of Medicare,168,35,,168,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,192,40,,192,percent of total billed charges,Implant Device,168,70,,168,percent of total billed charges,All Other,163.2,34,,163.2,percent of total billed charges,Implant Device,163.2,34,,163.2,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,355.2,
STRYKER 656124 BONE SCREW 2.4X24MM,C1713,HCPCS,,79012952,CDM,278,RC,,,both,,,282,208.68,,,208.68,Other,150% of Medicare + 9.63% HCRA Surcharge,126.9,45,,126.9,percent of total billed charges,Critical Access Hospital RCC factor,95.88,34,,95.88,percent of total billed charges,Implant Device,95.88,34,,95.88,percent of total billed charges,Implant Device,95.88,34,,95.88,percent of total billed charges,Implant Device,95.88,34,,95.88,percent of total billed charges,Implant Device,95.88,34,,95.88,percent of total billed charges,Implant Device,139.59,,,139.59,Other,110% of Medicare,98.7,35,,98.7,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,98.7,35,,98.7,percent of total billed charges,Implant Device,98.7,35,,98.7,percent of total billed charges,Implant Device,98.7,35,,98.7,percent of total billed charges,Implant Device,98.7,35,,98.7,percent of total billed charges,Implant Device,98.7,35,,98.7,percent of total billed charges,Implant Device,112.8,40,,112.8,percent of total billed charges,Implant Device,98.7,70,,98.7,percent of total billed charges,All Other,95.88,34,,95.88,percent of total billed charges,Implant Device,95.88,34,,95.88,percent of total billed charges,Implant Device,98.7,35,,98.7,percent of total billed charges,Implant Device,98.7,35,,98.7,percent of total billed charges,Implant Device,98.7,35,,98.7,percent of total billed charges,Implant Device,98.7,35,,98.7,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,208.68,
STRYKER 656126 BONE SCREW 2.4X26MM,C1713,HCPCS,,79012953,CDM,278,RC,,,both,,,282,208.68,,,208.68,Other,150% of Medicare + 9.63% HCRA Surcharge,126.9,45,,126.9,percent of total billed charges,Critical Access Hospital RCC factor,95.88,34,,95.88,percent of total billed charges,Implant Device,95.88,34,,95.88,percent of total billed charges,Implant Device,95.88,34,,95.88,percent of total billed charges,Implant Device,95.88,34,,95.88,percent of total billed charges,Implant Device,95.88,34,,95.88,percent of total billed charges,Implant Device,139.59,,,139.59,Other,110% of Medicare,98.7,35,,98.7,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,98.7,35,,98.7,percent of total billed charges,Implant Device,98.7,35,,98.7,percent of total billed charges,Implant Device,98.7,35,,98.7,percent of total billed charges,Implant Device,98.7,35,,98.7,percent of total billed charges,Implant Device,98.7,35,,98.7,percent of total billed charges,Implant Device,112.8,40,,112.8,percent of total billed charges,Implant Device,98.7,70,,98.7,percent of total billed charges,All Other,95.88,34,,95.88,percent of total billed charges,Implant Device,95.88,34,,95.88,percent of total billed charges,Implant Device,98.7,35,,98.7,percent of total billed charges,Implant Device,98.7,35,,98.7,percent of total billed charges,Implant Device,98.7,35,,98.7,percent of total billed charges,Implant Device,98.7,35,,98.7,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,208.68,
STRYKER 656130 BONE SCREW 2.4X30MM,C1713,HCPCS,,79012954,CDM,278,RC,,,both,,,282,208.68,,,208.68,Other,150% of Medicare + 9.63% HCRA Surcharge,126.9,45,,126.9,percent of total billed charges,Critical Access Hospital RCC factor,95.88,34,,95.88,percent of total billed charges,Implant Device,95.88,34,,95.88,percent of total billed charges,Implant Device,95.88,34,,95.88,percent of total billed charges,Implant Device,95.88,34,,95.88,percent of total billed charges,Implant Device,95.88,34,,95.88,percent of total billed charges,Implant Device,139.59,,,139.59,Other,110% of Medicare,98.7,35,,98.7,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,98.7,35,,98.7,percent of total billed charges,Implant Device,98.7,35,,98.7,percent of total billed charges,Implant Device,98.7,35,,98.7,percent of total billed charges,Implant Device,98.7,35,,98.7,percent of total billed charges,Implant Device,98.7,35,,98.7,percent of total billed charges,Implant Device,112.8,40,,112.8,percent of total billed charges,Implant Device,98.7,70,,98.7,percent of total billed charges,All Other,95.88,34,,95.88,percent of total billed charges,Implant Device,95.88,34,,95.88,percent of total billed charges,Implant Device,98.7,35,,98.7,percent of total billed charges,Implant Device,98.7,35,,98.7,percent of total billed charges,Implant Device,98.7,35,,98.7,percent of total billed charges,Implant Device,98.7,35,,98.7,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,208.68,
STRYKER 656432 BONE SCREW 2.7X32MM,C1713,HCPCS,,79012955,CDM,278,RC,,,both,,,282,208.68,,,208.68,Other,150% of Medicare + 9.63% HCRA Surcharge,126.9,45,,126.9,percent of total billed charges,Critical Access Hospital RCC factor,95.88,34,,95.88,percent of total billed charges,Implant Device,95.88,34,,95.88,percent of total billed charges,Implant Device,95.88,34,,95.88,percent of total billed charges,Implant Device,95.88,34,,95.88,percent of total billed charges,Implant Device,95.88,34,,95.88,percent of total billed charges,Implant Device,139.59,,,139.59,Other,110% of Medicare,98.7,35,,98.7,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,98.7,35,,98.7,percent of total billed charges,Implant Device,98.7,35,,98.7,percent of total billed charges,Implant Device,98.7,35,,98.7,percent of total billed charges,Implant Device,98.7,35,,98.7,percent of total billed charges,Implant Device,98.7,35,,98.7,percent of total billed charges,Implant Device,112.8,40,,112.8,percent of total billed charges,Implant Device,98.7,70,,98.7,percent of total billed charges,All Other,95.88,34,,95.88,percent of total billed charges,Implant Device,95.88,34,,95.88,percent of total billed charges,Implant Device,98.7,35,,98.7,percent of total billed charges,Implant Device,98.7,35,,98.7,percent of total billed charges,Implant Device,98.7,35,,98.7,percent of total billed charges,Implant Device,98.7,35,,98.7,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,208.68,
STRYKER 656442 BONE SCREW 2.7X42MM,C1713,HCPCS,,79012956,CDM,278,RC,,,both,,,282,208.68,,,208.68,Other,150% of Medicare + 9.63% HCRA Surcharge,126.9,45,,126.9,percent of total billed charges,Critical Access Hospital RCC factor,95.88,34,,95.88,percent of total billed charges,Implant Device,95.88,34,,95.88,percent of total billed charges,Implant Device,95.88,34,,95.88,percent of total billed charges,Implant Device,95.88,34,,95.88,percent of total billed charges,Implant Device,95.88,34,,95.88,percent of total billed charges,Implant Device,139.59,,,139.59,Other,110% of Medicare,98.7,35,,98.7,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,98.7,35,,98.7,percent of total billed charges,Implant Device,98.7,35,,98.7,percent of total billed charges,Implant Device,98.7,35,,98.7,percent of total billed charges,Implant Device,98.7,35,,98.7,percent of total billed charges,Implant Device,98.7,35,,98.7,percent of total billed charges,Implant Device,112.8,40,,112.8,percent of total billed charges,Implant Device,98.7,70,,98.7,percent of total billed charges,All Other,95.88,34,,95.88,percent of total billed charges,Implant Device,95.88,34,,95.88,percent of total billed charges,Implant Device,98.7,35,,98.7,percent of total billed charges,Implant Device,98.7,35,,98.7,percent of total billed charges,Implant Device,98.7,35,,98.7,percent of total billed charges,Implant Device,98.7,35,,98.7,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,208.68,
STRYKER 656460 BONE SCREW 2.7X60MM,C1713,HCPCS,,79012957,CDM,278,RC,,,both,,,395,292.3,,,292.3,Other,150% of Medicare + 9.63% HCRA Surcharge,177.75,45,,177.75,percent of total billed charges,Critical Access Hospital RCC factor,134.3,34,,134.3,percent of total billed charges,Implant Device,134.3,34,,134.3,percent of total billed charges,Implant Device,134.3,34,,134.3,percent of total billed charges,Implant Device,134.3,34,,134.3,percent of total billed charges,Implant Device,134.3,34,,134.3,percent of total billed charges,Implant Device,195.53,,,195.53,Other,110% of Medicare,138.25,35,,138.25,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,138.25,35,,138.25,percent of total billed charges,Implant Device,138.25,35,,138.25,percent of total billed charges,Implant Device,138.25,35,,138.25,percent of total billed charges,Implant Device,138.25,35,,138.25,percent of total billed charges,Implant Device,138.25,35,,138.25,percent of total billed charges,Implant Device,158,40,,158,percent of total billed charges,Implant Device,138.25,70,,138.25,percent of total billed charges,All Other,134.3,34,,134.3,percent of total billed charges,Implant Device,134.3,34,,134.3,percent of total billed charges,Implant Device,138.25,35,,138.25,percent of total billed charges,Implant Device,138.25,35,,138.25,percent of total billed charges,Implant Device,138.25,35,,138.25,percent of total billed charges,Implant Device,138.25,35,,138.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,292.3,
STRYKER 6485-3-813 STEM 13X127MM,C1776,HCPCS,,79012958,CDM,278,RC,,,both,,,7254,5367.98,,,5367.98,Other,150% of Medicare + 9.63% HCRA Surcharge,3264.3,45,,3264.3,percent of total billed charges,Critical Access Hospital RCC factor,2466.36,34,,2466.36,percent of total billed charges,Implant Device,2466.36,34,,2466.36,percent of total billed charges,Implant Device,2466.36,34,,2466.36,percent of total billed charges,Implant Device,2466.36,34,,2466.36,percent of total billed charges,Implant Device,2466.36,34,,2466.36,percent of total billed charges,Implant Device,3590.73,,,3590.73,Other,110% of Medicare,2538.9,35,,2538.9,percent of total billed charges,Implant Device,2466.36,34,"Charges > $500, x 34%",2466.36,percent of total billed charges,Implant Device,2538.9,35,,2538.9,percent of total billed charges,Implant Device,2538.9,35,,2538.9,percent of total billed charges,Implant Device,2538.9,35,,2538.9,percent of total billed charges,Implant Device,2538.9,35,,2538.9,percent of total billed charges,Implant Device,2538.9,35,,2538.9,percent of total billed charges,Implant Device,2901.6,40,,2901.6,percent of total billed charges,Implant Device,2538.9,70,,2538.9,percent of total billed charges,All Other,2466.36,34,,2466.36,percent of total billed charges,Implant Device,2466.36,34,,2466.36,percent of total billed charges,Implant Device,2538.9,35,,2538.9,percent of total billed charges,Implant Device,2538.9,35,,2538.9,percent of total billed charges,Implant Device,2538.9,35,,2538.9,percent of total billed charges,Implant Device,2538.9,35,,2538.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2466.36,34,"If Charge > 2,000, then 34 percent",2466.36,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5367.98,
"STRYKER 6481-2-150 BUSHING, SLEEVE",C1776,HCPCS,,79012959,CDM,278,RC,,,both,,,4203,3110.23,,,3110.23,Other,150% of Medicare + 9.63% HCRA Surcharge,1891.35,45,,1891.35,percent of total billed charges,Critical Access Hospital RCC factor,1429.02,34,,1429.02,percent of total billed charges,Implant Device,1429.02,34,,1429.02,percent of total billed charges,Implant Device,1429.02,34,,1429.02,percent of total billed charges,Implant Device,1429.02,34,,1429.02,percent of total billed charges,Implant Device,1429.02,34,,1429.02,percent of total billed charges,Implant Device,2080.49,,,2080.49,Other,110% of Medicare,1471.05,35,,1471.05,percent of total billed charges,Implant Device,1429.02,34,"Charges > $500, x 34%",1429.02,percent of total billed charges,Implant Device,1471.05,35,,1471.05,percent of total billed charges,Implant Device,1471.05,35,,1471.05,percent of total billed charges,Implant Device,1471.05,35,,1471.05,percent of total billed charges,Implant Device,1471.05,35,,1471.05,percent of total billed charges,Implant Device,1471.05,35,,1471.05,percent of total billed charges,Implant Device,1681.2,40,,1681.2,percent of total billed charges,Implant Device,1471.05,70,,1471.05,percent of total billed charges,All Other,1429.02,34,,1429.02,percent of total billed charges,Implant Device,1429.02,34,,1429.02,percent of total billed charges,Implant Device,1471.05,35,,1471.05,percent of total billed charges,Implant Device,1471.05,35,,1471.05,percent of total billed charges,Implant Device,1471.05,35,,1471.05,percent of total billed charges,Implant Device,1471.05,35,,1471.05,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1429.02,34,"If Charge > 2,000, then 34 percent",1429.02,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3110.23,
STRYKER 6481-3-310 TIBIAL INSERT 10MM,C1776,HCPCS,,79012960,CDM,278,RC,,,both,,,2997,2217.79,,,2217.79,Other,150% of Medicare + 9.63% HCRA Surcharge,1348.65,45,,1348.65,percent of total billed charges,Critical Access Hospital RCC factor,1018.98,34,,1018.98,percent of total billed charges,Implant Device,1018.98,34,,1018.98,percent of total billed charges,Implant Device,1018.98,34,,1018.98,percent of total billed charges,Implant Device,1018.98,34,,1018.98,percent of total billed charges,Implant Device,1018.98,34,,1018.98,percent of total billed charges,Implant Device,1483.52,,,1483.52,Other,110% of Medicare,1048.95,35,,1048.95,percent of total billed charges,Implant Device,1018.98,34,"Charges > $500, x 34%",1018.98,percent of total billed charges,Implant Device,1048.95,35,,1048.95,percent of total billed charges,Implant Device,1048.95,35,,1048.95,percent of total billed charges,Implant Device,1048.95,35,,1048.95,percent of total billed charges,Implant Device,1048.95,35,,1048.95,percent of total billed charges,Implant Device,1048.95,35,,1048.95,percent of total billed charges,Implant Device,1198.8,40,,1198.8,percent of total billed charges,Implant Device,1048.95,70,,1048.95,percent of total billed charges,All Other,1018.98,34,,1018.98,percent of total billed charges,Implant Device,1018.98,34,,1018.98,percent of total billed charges,Implant Device,1048.95,35,,1048.95,percent of total billed charges,Implant Device,1048.95,35,,1048.95,percent of total billed charges,Implant Device,1048.95,35,,1048.95,percent of total billed charges,Implant Device,1048.95,35,,1048.95,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1018.98,34,"If Charge > 2,000, then 34 percent",1018.98,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2217.79,
STRYKER 6481-3-112 TIBIAL BASEPLT SZ M-2,C1776,HCPCS,,79012961,CDM,278,RC,,,both,,,8597,6361.8,,,6361.8,Other,150% of Medicare + 9.63% HCRA Surcharge,3868.65,45,,3868.65,percent of total billed charges,Critical Access Hospital RCC factor,2922.98,34,,2922.98,percent of total billed charges,Implant Device,2922.98,34,,2922.98,percent of total billed charges,Implant Device,2922.98,34,,2922.98,percent of total billed charges,Implant Device,2922.98,34,,2922.98,percent of total billed charges,Implant Device,2922.98,34,,2922.98,percent of total billed charges,Implant Device,4255.52,,,4255.52,Other,110% of Medicare,3008.95,35,,3008.95,percent of total billed charges,Implant Device,2922.98,34,"Charges > $500, x 34%",2922.98,percent of total billed charges,Implant Device,3008.95,35,,3008.95,percent of total billed charges,Implant Device,3008.95,35,,3008.95,percent of total billed charges,Implant Device,3008.95,35,,3008.95,percent of total billed charges,Implant Device,3008.95,35,,3008.95,percent of total billed charges,Implant Device,3008.95,35,,3008.95,percent of total billed charges,Implant Device,3438.8,40,,3438.8,percent of total billed charges,Implant Device,3008.95,70,,3008.95,percent of total billed charges,All Other,2922.98,34,,2922.98,percent of total billed charges,Implant Device,2922.98,34,,2922.98,percent of total billed charges,Implant Device,3008.95,35,,3008.95,percent of total billed charges,Implant Device,3008.95,35,,3008.95,percent of total billed charges,Implant Device,3008.95,35,,3008.95,percent of total billed charges,Implant Device,3008.95,35,,3008.95,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2922.98,34,"If Charge > 2,000, then 34 percent",2922.98,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,6361.8,
GORE ECH470045A ACUSEAL VASCULAR GRAFT,C1768,HCPCS,,79012963,CDM,278,RC,,,both,,,4404,3258.97,,,3258.97,Other,150% of Medicare + 9.63% HCRA Surcharge,1981.8,45,,1981.8,percent of total billed charges,Critical Access Hospital RCC factor,1497.36,34,,1497.36,percent of total billed charges,Implant Device,1497.36,34,,1497.36,percent of total billed charges,Implant Device,1497.36,34,,1497.36,percent of total billed charges,Implant Device,1497.36,34,,1497.36,percent of total billed charges,Implant Device,1497.36,34,,1497.36,percent of total billed charges,Implant Device,2179.98,,,2179.98,Other,110% of Medicare,1541.4,35,,1541.4,percent of total billed charges,Implant Device,1497.36,34,"Charges > $500, x 34%",1497.36,percent of total billed charges,Implant Device,1541.4,35,,1541.4,percent of total billed charges,Implant Device,1541.4,35,,1541.4,percent of total billed charges,Implant Device,1541.4,35,,1541.4,percent of total billed charges,Implant Device,1541.4,35,,1541.4,percent of total billed charges,Implant Device,1541.4,35,,1541.4,percent of total billed charges,Implant Device,1761.6,40,,1761.6,percent of total billed charges,Implant Device,1541.4,70,,1541.4,percent of total billed charges,All Other,1497.36,34,,1497.36,percent of total billed charges,Implant Device,1497.36,34,,1497.36,percent of total billed charges,Implant Device,1541.4,35,,1541.4,percent of total billed charges,Implant Device,1541.4,35,,1541.4,percent of total billed charges,Implant Device,1541.4,35,,1541.4,percent of total billed charges,Implant Device,1541.4,35,,1541.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1497.36,34,"If Charge > 2,000, then 34 percent",1497.36,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3258.97,
STRYKER 2339-1332S FEMORAL NAIL 13X320MM,C1889,HCPCS,,79012964,CDM,278,RC,,,both,,,6585,4872.92,,,4872.92,Other,150% of Medicare + 9.63% HCRA Surcharge,2963.25,45,,2963.25,percent of total billed charges,Critical Access Hospital RCC factor,2238.9,34,,2238.9,percent of total billed charges,Implant Device,2238.9,34,,2238.9,percent of total billed charges,Implant Device,2238.9,34,,2238.9,percent of total billed charges,Implant Device,2238.9,34,,2238.9,percent of total billed charges,Implant Device,2238.9,34,,2238.9,percent of total billed charges,Implant Device,3259.58,,,3259.58,Other,110% of Medicare,2304.75,35,,2304.75,percent of total billed charges,Implant Device,2238.9,34,"Charges > $500, x 34%",2238.9,percent of total billed charges,Implant Device,2304.75,35,,2304.75,percent of total billed charges,Implant Device,2304.75,35,,2304.75,percent of total billed charges,Implant Device,2304.75,35,,2304.75,percent of total billed charges,Implant Device,2304.75,35,,2304.75,percent of total billed charges,Implant Device,2304.75,35,,2304.75,percent of total billed charges,Implant Device,2634,40,,2634,percent of total billed charges,Implant Device,2304.75,70,,2304.75,percent of total billed charges,All Other,2238.9,34,,2238.9,percent of total billed charges,Implant Device,2238.9,34,,2238.9,percent of total billed charges,Implant Device,2304.75,35,,2304.75,percent of total billed charges,Implant Device,2304.75,35,,2304.75,percent of total billed charges,Implant Device,2304.75,35,,2304.75,percent of total billed charges,Implant Device,2304.75,35,,2304.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2238.9,34,"If Charge > 2,000, then 34 percent",2238.9,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4872.92,
STRYKER 2361-5070S LOCKING SCREW 5X55MM,C1713,HCPCS,,79012965,CDM,278,RC,,,both,,,887,656.38,,,656.38,Other,150% of Medicare + 9.63% HCRA Surcharge,399.15,45,,399.15,percent of total billed charges,Critical Access Hospital RCC factor,301.58,34,,301.58,percent of total billed charges,Implant Device,301.58,34,,301.58,percent of total billed charges,Implant Device,301.58,34,,301.58,percent of total billed charges,Implant Device,301.58,34,,301.58,percent of total billed charges,Implant Device,301.58,34,,301.58,percent of total billed charges,Implant Device,439.07,,,439.07,Other,110% of Medicare,310.45,35,,310.45,percent of total billed charges,Implant Device,301.58,34,"Charges > $500, x 34%",301.58,percent of total billed charges,Implant Device,310.45,35,,310.45,percent of total billed charges,Implant Device,310.45,35,,310.45,percent of total billed charges,Implant Device,310.45,35,,310.45,percent of total billed charges,Implant Device,310.45,35,,310.45,percent of total billed charges,Implant Device,310.45,35,,310.45,percent of total billed charges,Implant Device,354.8,40,,354.8,percent of total billed charges,Implant Device,310.45,70,,310.45,percent of total billed charges,All Other,301.58,34,,301.58,percent of total billed charges,Implant Device,301.58,34,,301.58,percent of total billed charges,Implant Device,310.45,35,,310.45,percent of total billed charges,Implant Device,310.45,35,,310.45,percent of total billed charges,Implant Device,310.45,35,,310.45,percent of total billed charges,Implant Device,310.45,35,,310.45,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,656.38,
STRYKER 2361-5085S LOCKING SCREW 5X85MM,C1713,HCPCS,,79012966,CDM,278,RC,,,both,,,887,656.38,,,656.38,Other,150% of Medicare + 9.63% HCRA Surcharge,399.15,45,,399.15,percent of total billed charges,Critical Access Hospital RCC factor,301.58,34,,301.58,percent of total billed charges,Implant Device,301.58,34,,301.58,percent of total billed charges,Implant Device,301.58,34,,301.58,percent of total billed charges,Implant Device,301.58,34,,301.58,percent of total billed charges,Implant Device,301.58,34,,301.58,percent of total billed charges,Implant Device,439.07,,,439.07,Other,110% of Medicare,310.45,35,,310.45,percent of total billed charges,Implant Device,301.58,34,"Charges > $500, x 34%",301.58,percent of total billed charges,Implant Device,310.45,35,,310.45,percent of total billed charges,Implant Device,310.45,35,,310.45,percent of total billed charges,Implant Device,310.45,35,,310.45,percent of total billed charges,Implant Device,310.45,35,,310.45,percent of total billed charges,Implant Device,310.45,35,,310.45,percent of total billed charges,Implant Device,354.8,40,,354.8,percent of total billed charges,Implant Device,310.45,70,,310.45,percent of total billed charges,All Other,301.58,34,,301.58,percent of total billed charges,Implant Device,301.58,34,,301.58,percent of total billed charges,Implant Device,310.45,35,,310.45,percent of total billed charges,Implant Device,310.45,35,,310.45,percent of total billed charges,Implant Device,310.45,35,,310.45,percent of total billed charges,Implant Device,310.45,35,,310.45,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,656.38,
J&J 02.112.148S 2.7/3.5 LCP PLATE RT 9H,C1713,HCPCS,,79012967,CDM,278,RC,,,both,,,1791,1325.34,,,1325.34,Other,150% of Medicare + 9.63% HCRA Surcharge,805.95,45,,805.95,percent of total billed charges,Critical Access Hospital RCC factor,608.94,34,,608.94,percent of total billed charges,Implant Device,608.94,34,,608.94,percent of total billed charges,Implant Device,608.94,34,,608.94,percent of total billed charges,Implant Device,608.94,34,,608.94,percent of total billed charges,Implant Device,608.94,34,,608.94,percent of total billed charges,Implant Device,886.55,,,886.55,Other,110% of Medicare,626.85,35,,626.85,percent of total billed charges,Implant Device,608.94,34,"Charges > $500, x 34%",608.94,percent of total billed charges,Implant Device,626.85,35,,626.85,percent of total billed charges,Implant Device,626.85,35,,626.85,percent of total billed charges,Implant Device,626.85,35,,626.85,percent of total billed charges,Implant Device,626.85,35,,626.85,percent of total billed charges,Implant Device,626.85,35,,626.85,percent of total billed charges,Implant Device,716.4,40,,716.4,percent of total billed charges,Implant Device,626.85,70,,626.85,percent of total billed charges,All Other,608.94,34,,608.94,percent of total billed charges,Implant Device,608.94,34,,608.94,percent of total billed charges,Implant Device,626.85,35,,626.85,percent of total billed charges,Implant Device,626.85,35,,626.85,percent of total billed charges,Implant Device,626.85,35,,626.85,percent of total billed charges,Implant Device,626.85,35,,626.85,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1325.34,
J&J 247.364 2.4 LCP PLATE 10 HOLE,C1713,HCPCS,,79012969,CDM,278,RC,,,both,,,1002,741.48,,,741.48,Other,150% of Medicare + 9.63% HCRA Surcharge,450.9,45,,450.9,percent of total billed charges,Critical Access Hospital RCC factor,340.68,34,,340.68,percent of total billed charges,Implant Device,340.68,34,,340.68,percent of total billed charges,Implant Device,340.68,34,,340.68,percent of total billed charges,Implant Device,340.68,34,,340.68,percent of total billed charges,Implant Device,340.68,34,,340.68,percent of total billed charges,Implant Device,495.99,,,495.99,Other,110% of Medicare,350.7,35,,350.7,percent of total billed charges,Implant Device,340.68,34,"Charges > $500, x 34%",340.68,percent of total billed charges,Implant Device,350.7,35,,350.7,percent of total billed charges,Implant Device,350.7,35,,350.7,percent of total billed charges,Implant Device,350.7,35,,350.7,percent of total billed charges,Implant Device,350.7,35,,350.7,percent of total billed charges,Implant Device,350.7,35,,350.7,percent of total billed charges,Implant Device,400.8,40,,400.8,percent of total billed charges,Implant Device,350.7,70,,350.7,percent of total billed charges,All Other,340.68,34,,340.68,percent of total billed charges,Implant Device,340.68,34,,340.68,percent of total billed charges,Implant Device,350.7,35,,350.7,percent of total billed charges,Implant Device,350.7,35,,350.7,percent of total billed charges,Implant Device,350.7,35,,350.7,percent of total billed charges,Implant Device,350.7,35,,350.7,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,741.48,
J&J 02.188.206 2.7/3.5 8 HOLE PLT RT,C1713,HCPCS,,79012970,CDM,278,RC,,,both,,,4413,3265.63,,,3265.63,Other,150% of Medicare + 9.63% HCRA Surcharge,1985.85,45,,1985.85,percent of total billed charges,Critical Access Hospital RCC factor,1500.42,34,,1500.42,percent of total billed charges,Implant Device,1500.42,34,,1500.42,percent of total billed charges,Implant Device,1500.42,34,,1500.42,percent of total billed charges,Implant Device,1500.42,34,,1500.42,percent of total billed charges,Implant Device,1500.42,34,,1500.42,percent of total billed charges,Implant Device,2184.44,,,2184.44,Other,110% of Medicare,1544.55,35,,1544.55,percent of total billed charges,Implant Device,1500.42,34,"Charges > $500, x 34%",1500.42,percent of total billed charges,Implant Device,1544.55,35,,1544.55,percent of total billed charges,Implant Device,1544.55,35,,1544.55,percent of total billed charges,Implant Device,1544.55,35,,1544.55,percent of total billed charges,Implant Device,1544.55,35,,1544.55,percent of total billed charges,Implant Device,1544.55,35,,1544.55,percent of total billed charges,Implant Device,1765.2,40,,1765.2,percent of total billed charges,Implant Device,1544.55,70,,1544.55,percent of total billed charges,All Other,1500.42,34,,1500.42,percent of total billed charges,Implant Device,1500.42,34,,1500.42,percent of total billed charges,Implant Device,1544.55,35,,1544.55,percent of total billed charges,Implant Device,1544.55,35,,1544.55,percent of total billed charges,Implant Device,1544.55,35,,1544.55,percent of total billed charges,Implant Device,1544.55,35,,1544.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1500.42,34,"If Charge > 2,000, then 34 percent",1500.42,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3265.63,
J&J 02.211.054 2.7 LOCK SCREW 54MM,C1713,HCPCS,,79012971,CDM,278,RC,,,both,,,343,253.82,,,253.82,Other,150% of Medicare + 9.63% HCRA Surcharge,154.35,45,,154.35,percent of total billed charges,Critical Access Hospital RCC factor,116.62,34,,116.62,percent of total billed charges,Implant Device,116.62,34,,116.62,percent of total billed charges,Implant Device,116.62,34,,116.62,percent of total billed charges,Implant Device,116.62,34,,116.62,percent of total billed charges,Implant Device,116.62,34,,116.62,percent of total billed charges,Implant Device,169.79,,,169.79,Other,110% of Medicare,120.05,35,,120.05,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,120.05,35,,120.05,percent of total billed charges,Implant Device,120.05,35,,120.05,percent of total billed charges,Implant Device,120.05,35,,120.05,percent of total billed charges,Implant Device,120.05,35,,120.05,percent of total billed charges,Implant Device,120.05,35,,120.05,percent of total billed charges,Implant Device,137.2,40,,137.2,percent of total billed charges,Implant Device,120.05,70,,120.05,percent of total billed charges,All Other,116.62,34,,116.62,percent of total billed charges,Implant Device,116.62,34,,116.62,percent of total billed charges,Implant Device,120.05,35,,120.05,percent of total billed charges,Implant Device,120.05,35,,120.05,percent of total billed charges,Implant Device,120.05,35,,120.05,percent of total billed charges,Implant Device,120.05,35,,120.05,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,253.82,
J&J 02.211.048 2.7 LOCK SCREW 48MM,C1713,HCPCS,,79012972,CDM,278,RC,,,both,,,343,253.82,,,253.82,Other,150% of Medicare + 9.63% HCRA Surcharge,154.35,45,,154.35,percent of total billed charges,Critical Access Hospital RCC factor,116.62,34,,116.62,percent of total billed charges,Implant Device,116.62,34,,116.62,percent of total billed charges,Implant Device,116.62,34,,116.62,percent of total billed charges,Implant Device,116.62,34,,116.62,percent of total billed charges,Implant Device,116.62,34,,116.62,percent of total billed charges,Implant Device,169.79,,,169.79,Other,110% of Medicare,120.05,35,,120.05,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,120.05,35,,120.05,percent of total billed charges,Implant Device,120.05,35,,120.05,percent of total billed charges,Implant Device,120.05,35,,120.05,percent of total billed charges,Implant Device,120.05,35,,120.05,percent of total billed charges,Implant Device,120.05,35,,120.05,percent of total billed charges,Implant Device,137.2,40,,137.2,percent of total billed charges,Implant Device,120.05,70,,120.05,percent of total billed charges,All Other,116.62,34,,116.62,percent of total billed charges,Implant Device,116.62,34,,116.62,percent of total billed charges,Implant Device,120.05,35,,120.05,percent of total billed charges,Implant Device,120.05,35,,120.05,percent of total billed charges,Implant Device,120.05,35,,120.05,percent of total billed charges,Implant Device,120.05,35,,120.05,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,253.82,
J&J 02.123.022 3.5 RT LCP PLATE 4H,C1713,HCPCS,,79012973,CDM,278,RC,,,both,,,4050,2997.01,,,2997.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1822.5,45,,1822.5,percent of total billed charges,Critical Access Hospital RCC factor,1377,34,,1377,percent of total billed charges,Implant Device,1377,34,,1377,percent of total billed charges,Implant Device,1377,34,,1377,percent of total billed charges,Implant Device,1377,34,,1377,percent of total billed charges,Implant Device,1377,34,,1377,percent of total billed charges,Implant Device,2004.75,,,2004.75,Other,110% of Medicare,1417.5,35,,1417.5,percent of total billed charges,Implant Device,1377,34,"Charges > $500, x 34%",1377,percent of total billed charges,Implant Device,1417.5,35,,1417.5,percent of total billed charges,Implant Device,1417.5,35,,1417.5,percent of total billed charges,Implant Device,1417.5,35,,1417.5,percent of total billed charges,Implant Device,1417.5,35,,1417.5,percent of total billed charges,Implant Device,1417.5,35,,1417.5,percent of total billed charges,Implant Device,1620,40,,1620,percent of total billed charges,Implant Device,1417.5,70,,1417.5,percent of total billed charges,All Other,1377,34,,1377,percent of total billed charges,Implant Device,1377,34,,1377,percent of total billed charges,Implant Device,1417.5,35,,1417.5,percent of total billed charges,Implant Device,1417.5,35,,1417.5,percent of total billed charges,Implant Device,1417.5,35,,1417.5,percent of total billed charges,Implant Device,1417.5,35,,1417.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1377,34,"If Charge > 2,000, then 34 percent",1377,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2997.01,
J&J 09.405.263S RADIAL HEAD 10 +3,C1776,HCPCS,,79012974,CDM,278,RC,,,both,,,9560,7074.42,,,7074.42,Other,150% of Medicare + 9.63% HCRA Surcharge,4302,45,,4302,percent of total billed charges,Critical Access Hospital RCC factor,3250.4,34,,3250.4,percent of total billed charges,Implant Device,3250.4,34,,3250.4,percent of total billed charges,Implant Device,3250.4,34,,3250.4,percent of total billed charges,Implant Device,3250.4,34,,3250.4,percent of total billed charges,Implant Device,3250.4,34,,3250.4,percent of total billed charges,Implant Device,4732.2,,,4732.2,Other,110% of Medicare,3346,35,,3346,percent of total billed charges,Implant Device,3250.4,34,"Charges > $500, x 34%",3250.4,percent of total billed charges,Implant Device,3346,35,,3346,percent of total billed charges,Implant Device,3346,35,,3346,percent of total billed charges,Implant Device,3346,35,,3346,percent of total billed charges,Implant Device,3346,35,,3346,percent of total billed charges,Implant Device,3346,35,,3346,percent of total billed charges,Implant Device,3824,40,,3824,percent of total billed charges,Implant Device,3346,70,,3346,percent of total billed charges,All Other,3250.4,34,,3250.4,percent of total billed charges,Implant Device,3250.4,34,,3250.4,percent of total billed charges,Implant Device,3346,35,,3346,percent of total billed charges,Implant Device,3346,35,,3346,percent of total billed charges,Implant Device,3346,35,,3346,percent of total billed charges,Implant Device,3346,35,,3346,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3250.4,34,"If Charge > 2,000, then 34 percent",3250.4,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,7074.42,
MEDLINE MPP22001L LAPIDUS LEFT PLATE,C1713,HCPCS,,79012977,CDM,278,RC,,,both,,,6720,4972.82,,,4972.82,Other,150% of Medicare + 9.63% HCRA Surcharge,3024,45,,3024,percent of total billed charges,Critical Access Hospital RCC factor,2284.8,34,,2284.8,percent of total billed charges,Implant Device,2284.8,34,,2284.8,percent of total billed charges,Implant Device,2284.8,34,,2284.8,percent of total billed charges,Implant Device,2284.8,34,,2284.8,percent of total billed charges,Implant Device,2284.8,34,,2284.8,percent of total billed charges,Implant Device,3326.4,,,3326.4,Other,110% of Medicare,2352,35,,2352,percent of total billed charges,Implant Device,2284.8,34,"Charges > $500, x 34%",2284.8,percent of total billed charges,Implant Device,2352,35,,2352,percent of total billed charges,Implant Device,2352,35,,2352,percent of total billed charges,Implant Device,2352,35,,2352,percent of total billed charges,Implant Device,2352,35,,2352,percent of total billed charges,Implant Device,2352,35,,2352,percent of total billed charges,Implant Device,2688,40,,2688,percent of total billed charges,Implant Device,2352,70,,2352,percent of total billed charges,All Other,2284.8,34,,2284.8,percent of total billed charges,Implant Device,2284.8,34,,2284.8,percent of total billed charges,Implant Device,2352,35,,2352,percent of total billed charges,Implant Device,2352,35,,2352,percent of total billed charges,Implant Device,2352,35,,2352,percent of total billed charges,Implant Device,2352,35,,2352,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2284.8,34,"If Charge > 2,000, then 34 percent",2284.8,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4972.82,
MEDLINE MPSL3516 LOCK SCREW 3.5X16MM,C1713,HCPCS,,79012981,CDM,278,RC,,,both,,,795,588.3,,,588.3,Other,150% of Medicare + 9.63% HCRA Surcharge,357.75,45,,357.75,percent of total billed charges,Critical Access Hospital RCC factor,270.3,34,,270.3,percent of total billed charges,Implant Device,270.3,34,,270.3,percent of total billed charges,Implant Device,270.3,34,,270.3,percent of total billed charges,Implant Device,270.3,34,,270.3,percent of total billed charges,Implant Device,270.3,34,,270.3,percent of total billed charges,Implant Device,393.53,,,393.53,Other,110% of Medicare,278.25,35,,278.25,percent of total billed charges,Implant Device,270.3,34,"Charges > $500, x 34%",270.3,percent of total billed charges,Implant Device,278.25,35,,278.25,percent of total billed charges,Implant Device,278.25,35,,278.25,percent of total billed charges,Implant Device,278.25,35,,278.25,percent of total billed charges,Implant Device,278.25,35,,278.25,percent of total billed charges,Implant Device,278.25,35,,278.25,percent of total billed charges,Implant Device,318,40,,318,percent of total billed charges,Implant Device,278.25,70,,278.25,percent of total billed charges,All Other,270.3,34,,270.3,percent of total billed charges,Implant Device,270.3,34,,270.3,percent of total billed charges,Implant Device,278.25,35,,278.25,percent of total billed charges,Implant Device,278.25,35,,278.25,percent of total billed charges,Implant Device,278.25,35,,278.25,percent of total billed charges,Implant Device,278.25,35,,278.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,588.3,
MEDLINE MPSL3518 LOCK SCREW 3.5X18MM,C1713,HCPCS,,79012982,CDM,278,RC,,,both,,,795,588.3,,,588.3,Other,150% of Medicare + 9.63% HCRA Surcharge,357.75,45,,357.75,percent of total billed charges,Critical Access Hospital RCC factor,270.3,34,,270.3,percent of total billed charges,Implant Device,270.3,34,,270.3,percent of total billed charges,Implant Device,270.3,34,,270.3,percent of total billed charges,Implant Device,270.3,34,,270.3,percent of total billed charges,Implant Device,270.3,34,,270.3,percent of total billed charges,Implant Device,393.53,,,393.53,Other,110% of Medicare,278.25,35,,278.25,percent of total billed charges,Implant Device,270.3,34,"Charges > $500, x 34%",270.3,percent of total billed charges,Implant Device,278.25,35,,278.25,percent of total billed charges,Implant Device,278.25,35,,278.25,percent of total billed charges,Implant Device,278.25,35,,278.25,percent of total billed charges,Implant Device,278.25,35,,278.25,percent of total billed charges,Implant Device,278.25,35,,278.25,percent of total billed charges,Implant Device,318,40,,318,percent of total billed charges,Implant Device,278.25,70,,278.25,percent of total billed charges,All Other,270.3,34,,270.3,percent of total billed charges,Implant Device,270.3,34,,270.3,percent of total billed charges,Implant Device,278.25,35,,278.25,percent of total billed charges,Implant Device,278.25,35,,278.25,percent of total billed charges,Implant Device,278.25,35,,278.25,percent of total billed charges,Implant Device,278.25,35,,278.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,588.3,
MEDLINE MPSX3534 CROSSPLATE SCREW 3.5X34,C1713,HCPCS,,79012983,CDM,278,RC,,,both,,,1065,788.1,,,788.1,Other,150% of Medicare + 9.63% HCRA Surcharge,479.25,45,,479.25,percent of total billed charges,Critical Access Hospital RCC factor,362.1,34,,362.1,percent of total billed charges,Implant Device,362.1,34,,362.1,percent of total billed charges,Implant Device,362.1,34,,362.1,percent of total billed charges,Implant Device,362.1,34,,362.1,percent of total billed charges,Implant Device,362.1,34,,362.1,percent of total billed charges,Implant Device,527.18,,,527.18,Other,110% of Medicare,372.75,35,,372.75,percent of total billed charges,Implant Device,362.1,34,"Charges > $500, x 34%",362.1,percent of total billed charges,Implant Device,372.75,35,,372.75,percent of total billed charges,Implant Device,372.75,35,,372.75,percent of total billed charges,Implant Device,372.75,35,,372.75,percent of total billed charges,Implant Device,372.75,35,,372.75,percent of total billed charges,Implant Device,372.75,35,,372.75,percent of total billed charges,Implant Device,426,40,,426,percent of total billed charges,Implant Device,372.75,70,,372.75,percent of total billed charges,All Other,362.1,34,,362.1,percent of total billed charges,Implant Device,362.1,34,,362.1,percent of total billed charges,Implant Device,372.75,35,,372.75,percent of total billed charges,Implant Device,372.75,35,,372.75,percent of total billed charges,Implant Device,372.75,35,,372.75,percent of total billed charges,Implant Device,372.75,35,,372.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,788.1,
ARTHREX AR-8933VCL-14 KREULOCK SCRW 3X14,C1713,HCPCS,,79012985,CDM,278,RC,,,both,,,959,709.66,,,709.66,Other,150% of Medicare + 9.63% HCRA Surcharge,431.55,45,,431.55,percent of total billed charges,Critical Access Hospital RCC factor,326.06,34,,326.06,percent of total billed charges,Implant Device,326.06,34,,326.06,percent of total billed charges,Implant Device,326.06,34,,326.06,percent of total billed charges,Implant Device,326.06,34,,326.06,percent of total billed charges,Implant Device,326.06,34,,326.06,percent of total billed charges,Implant Device,474.71,,,474.71,Other,110% of Medicare,335.65,35,,335.65,percent of total billed charges,Implant Device,326.06,34,"Charges > $500, x 34%",326.06,percent of total billed charges,Implant Device,335.65,35,,335.65,percent of total billed charges,Implant Device,335.65,35,,335.65,percent of total billed charges,Implant Device,335.65,35,,335.65,percent of total billed charges,Implant Device,335.65,35,,335.65,percent of total billed charges,Implant Device,335.65,35,,335.65,percent of total billed charges,Implant Device,383.6,40,,383.6,percent of total billed charges,Implant Device,335.65,70,,335.65,percent of total billed charges,All Other,326.06,34,,326.06,percent of total billed charges,Implant Device,326.06,34,,326.06,percent of total billed charges,Implant Device,335.65,35,,335.65,percent of total billed charges,Implant Device,335.65,35,,335.65,percent of total billed charges,Implant Device,335.65,35,,335.65,percent of total billed charges,Implant Device,335.65,35,,335.65,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,709.66,
ARTHREX AR-8933VCL-16 KREULOCK SCRW 3X16,C1713,HCPCS,,79012986,CDM,278,RC,,,both,,,959,709.66,,,709.66,Other,150% of Medicare + 9.63% HCRA Surcharge,431.55,45,,431.55,percent of total billed charges,Critical Access Hospital RCC factor,326.06,34,,326.06,percent of total billed charges,Implant Device,326.06,34,,326.06,percent of total billed charges,Implant Device,326.06,34,,326.06,percent of total billed charges,Implant Device,326.06,34,,326.06,percent of total billed charges,Implant Device,326.06,34,,326.06,percent of total billed charges,Implant Device,474.71,,,474.71,Other,110% of Medicare,335.65,35,,335.65,percent of total billed charges,Implant Device,326.06,34,"Charges > $500, x 34%",326.06,percent of total billed charges,Implant Device,335.65,35,,335.65,percent of total billed charges,Implant Device,335.65,35,,335.65,percent of total billed charges,Implant Device,335.65,35,,335.65,percent of total billed charges,Implant Device,335.65,35,,335.65,percent of total billed charges,Implant Device,335.65,35,,335.65,percent of total billed charges,Implant Device,383.6,40,,383.6,percent of total billed charges,Implant Device,335.65,70,,335.65,percent of total billed charges,All Other,326.06,34,,326.06,percent of total billed charges,Implant Device,326.06,34,,326.06,percent of total billed charges,Implant Device,335.65,35,,335.65,percent of total billed charges,Implant Device,335.65,35,,335.65,percent of total billed charges,Implant Device,335.65,35,,335.65,percent of total billed charges,Implant Device,335.65,35,,335.65,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,709.66,
ARTHREX AR-8933VCL-18 KREULOCK SCRW 3X18,C1713,HCPCS,,79012987,CDM,278,RC,,,both,,,885,654.9,,,654.9,Other,150% of Medicare + 9.63% HCRA Surcharge,398.25,45,,398.25,percent of total billed charges,Critical Access Hospital RCC factor,300.9,34,,300.9,percent of total billed charges,Implant Device,300.9,34,,300.9,percent of total billed charges,Implant Device,300.9,34,,300.9,percent of total billed charges,Implant Device,300.9,34,,300.9,percent of total billed charges,Implant Device,300.9,34,,300.9,percent of total billed charges,Implant Device,438.08,,,438.08,Other,110% of Medicare,309.75,35,,309.75,percent of total billed charges,Implant Device,300.9,34,"Charges > $500, x 34%",300.9,percent of total billed charges,Implant Device,309.75,35,,309.75,percent of total billed charges,Implant Device,309.75,35,,309.75,percent of total billed charges,Implant Device,309.75,35,,309.75,percent of total billed charges,Implant Device,309.75,35,,309.75,percent of total billed charges,Implant Device,309.75,35,,309.75,percent of total billed charges,Implant Device,354,40,,354,percent of total billed charges,Implant Device,309.75,70,,309.75,percent of total billed charges,All Other,300.9,34,,300.9,percent of total billed charges,Implant Device,300.9,34,,300.9,percent of total billed charges,Implant Device,309.75,35,,309.75,percent of total billed charges,Implant Device,309.75,35,,309.75,percent of total billed charges,Implant Device,309.75,35,,309.75,percent of total billed charges,Implant Device,309.75,35,,309.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,654.9,
ARTHREX AR-8935CL-14 KREULOCK SRW 3.5X14,C1713,HCPCS,,79012988,CDM,278,RC,,,both,,,959,709.66,,,709.66,Other,150% of Medicare + 9.63% HCRA Surcharge,431.55,45,,431.55,percent of total billed charges,Critical Access Hospital RCC factor,326.06,34,,326.06,percent of total billed charges,Implant Device,326.06,34,,326.06,percent of total billed charges,Implant Device,326.06,34,,326.06,percent of total billed charges,Implant Device,326.06,34,,326.06,percent of total billed charges,Implant Device,326.06,34,,326.06,percent of total billed charges,Implant Device,474.71,,,474.71,Other,110% of Medicare,335.65,35,,335.65,percent of total billed charges,Implant Device,326.06,34,"Charges > $500, x 34%",326.06,percent of total billed charges,Implant Device,335.65,35,,335.65,percent of total billed charges,Implant Device,335.65,35,,335.65,percent of total billed charges,Implant Device,335.65,35,,335.65,percent of total billed charges,Implant Device,335.65,35,,335.65,percent of total billed charges,Implant Device,335.65,35,,335.65,percent of total billed charges,Implant Device,383.6,40,,383.6,percent of total billed charges,Implant Device,335.65,70,,335.65,percent of total billed charges,All Other,326.06,34,,326.06,percent of total billed charges,Implant Device,326.06,34,,326.06,percent of total billed charges,Implant Device,335.65,35,,335.65,percent of total billed charges,Implant Device,335.65,35,,335.65,percent of total billed charges,Implant Device,335.65,35,,335.65,percent of total billed charges,Implant Device,335.65,35,,335.65,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,709.66,
ARTHREX AR-8935CL-18 KREULOCK SRW 3.5X18,C1713,HCPCS,,79012989,CDM,278,RC,,,both,,,885,654.9,,,654.9,Other,150% of Medicare + 9.63% HCRA Surcharge,398.25,45,,398.25,percent of total billed charges,Critical Access Hospital RCC factor,300.9,34,,300.9,percent of total billed charges,Implant Device,300.9,34,,300.9,percent of total billed charges,Implant Device,300.9,34,,300.9,percent of total billed charges,Implant Device,300.9,34,,300.9,percent of total billed charges,Implant Device,300.9,34,,300.9,percent of total billed charges,Implant Device,438.08,,,438.08,Other,110% of Medicare,309.75,35,,309.75,percent of total billed charges,Implant Device,300.9,34,"Charges > $500, x 34%",300.9,percent of total billed charges,Implant Device,309.75,35,,309.75,percent of total billed charges,Implant Device,309.75,35,,309.75,percent of total billed charges,Implant Device,309.75,35,,309.75,percent of total billed charges,Implant Device,309.75,35,,309.75,percent of total billed charges,Implant Device,309.75,35,,309.75,percent of total billed charges,Implant Device,354,40,,354,percent of total billed charges,Implant Device,309.75,70,,309.75,percent of total billed charges,All Other,300.9,34,,300.9,percent of total billed charges,Implant Device,300.9,34,,300.9,percent of total billed charges,Implant Device,309.75,35,,309.75,percent of total billed charges,Implant Device,309.75,35,,309.75,percent of total billed charges,Implant Device,309.75,35,,309.75,percent of total billed charges,Implant Device,309.75,35,,309.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,654.9,
ARTHREX AR-8935CL-16 KREULOCK SRW 3.5X16,C1713,HCPCS,,79012990,CDM,278,RC,,,both,,,959,709.66,,,709.66,Other,150% of Medicare + 9.63% HCRA Surcharge,431.55,45,,431.55,percent of total billed charges,Critical Access Hospital RCC factor,326.06,34,,326.06,percent of total billed charges,Implant Device,326.06,34,,326.06,percent of total billed charges,Implant Device,326.06,34,,326.06,percent of total billed charges,Implant Device,326.06,34,,326.06,percent of total billed charges,Implant Device,326.06,34,,326.06,percent of total billed charges,Implant Device,474.71,,,474.71,Other,110% of Medicare,335.65,35,,335.65,percent of total billed charges,Implant Device,326.06,34,"Charges > $500, x 34%",326.06,percent of total billed charges,Implant Device,335.65,35,,335.65,percent of total billed charges,Implant Device,335.65,35,,335.65,percent of total billed charges,Implant Device,335.65,35,,335.65,percent of total billed charges,Implant Device,335.65,35,,335.65,percent of total billed charges,Implant Device,335.65,35,,335.65,percent of total billed charges,Implant Device,383.6,40,,383.6,percent of total billed charges,Implant Device,335.65,70,,335.65,percent of total billed charges,All Other,326.06,34,,326.06,percent of total billed charges,Implant Device,326.06,34,,326.06,percent of total billed charges,Implant Device,335.65,35,,335.65,percent of total billed charges,Implant Device,335.65,35,,335.65,percent of total billed charges,Implant Device,335.65,35,,335.65,percent of total billed charges,Implant Device,335.65,35,,335.65,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,709.66,
IN2BONES P07 ST207 AFX PLATE LEFT 7 HOLE,C1713,HCPCS,,79012992,CDM,278,RC,,,both,,,6000,4440.02,,,4440.02,Other,150% of Medicare + 9.63% HCRA Surcharge,2700,45,,2700,percent of total billed charges,Critical Access Hospital RCC factor,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2970,,,2970,Other,110% of Medicare,2100,35,,2100,percent of total billed charges,Implant Device,2040,34,"Charges > $500, x 34%",2040,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2400,40,,2400,percent of total billed charges,Implant Device,2100,70,,2100,percent of total billed charges,All Other,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2040,34,"If Charge > 2,000, then 34 percent",2040,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4440.02,
IN2BONES C20 ST211 LIS FRANC PLATE,C1713,HCPCS,,79012993,CDM,278,RC,,,both,,,6000,4440.02,,,4440.02,Other,150% of Medicare + 9.63% HCRA Surcharge,2700,45,,2700,percent of total billed charges,Critical Access Hospital RCC factor,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2970,,,2970,Other,110% of Medicare,2100,35,,2100,percent of total billed charges,Implant Device,2040,34,"Charges > $500, x 34%",2040,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2400,40,,2400,percent of total billed charges,Implant Device,2100,70,,2100,percent of total billed charges,All Other,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2040,34,"If Charge > 2,000, then 34 percent",2040,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4440.02,
MEDLINE MSD14020 HEADED SCREW 4.0X20MM,C1713,HCPCS,,79012994,CDM,278,RC,,,both,,,825,610.5,,,610.5,Other,150% of Medicare + 9.63% HCRA Surcharge,371.25,45,,371.25,percent of total billed charges,Critical Access Hospital RCC factor,280.5,34,,280.5,percent of total billed charges,Implant Device,280.5,34,,280.5,percent of total billed charges,Implant Device,280.5,34,,280.5,percent of total billed charges,Implant Device,280.5,34,,280.5,percent of total billed charges,Implant Device,280.5,34,,280.5,percent of total billed charges,Implant Device,408.38,,,408.38,Other,110% of Medicare,288.75,35,,288.75,percent of total billed charges,Implant Device,280.5,34,"Charges > $500, x 34%",280.5,percent of total billed charges,Implant Device,288.75,35,,288.75,percent of total billed charges,Implant Device,288.75,35,,288.75,percent of total billed charges,Implant Device,288.75,35,,288.75,percent of total billed charges,Implant Device,288.75,35,,288.75,percent of total billed charges,Implant Device,288.75,35,,288.75,percent of total billed charges,Implant Device,330,40,,330,percent of total billed charges,Implant Device,288.75,70,,288.75,percent of total billed charges,All Other,280.5,34,,280.5,percent of total billed charges,Implant Device,280.5,34,,280.5,percent of total billed charges,Implant Device,288.75,35,,288.75,percent of total billed charges,Implant Device,288.75,35,,288.75,percent of total billed charges,Implant Device,288.75,35,,288.75,percent of total billed charges,Implant Device,288.75,35,,288.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,610.5,
MEDLINE MSD14022 HEADED SCREW 4.0X22MM,C1713,HCPCS,,79012995,CDM,278,RC,,,both,,,825,610.5,,,610.5,Other,150% of Medicare + 9.63% HCRA Surcharge,371.25,45,,371.25,percent of total billed charges,Critical Access Hospital RCC factor,280.5,34,,280.5,percent of total billed charges,Implant Device,280.5,34,,280.5,percent of total billed charges,Implant Device,280.5,34,,280.5,percent of total billed charges,Implant Device,280.5,34,,280.5,percent of total billed charges,Implant Device,280.5,34,,280.5,percent of total billed charges,Implant Device,408.38,,,408.38,Other,110% of Medicare,288.75,35,,288.75,percent of total billed charges,Implant Device,280.5,34,"Charges > $500, x 34%",280.5,percent of total billed charges,Implant Device,288.75,35,,288.75,percent of total billed charges,Implant Device,288.75,35,,288.75,percent of total billed charges,Implant Device,288.75,35,,288.75,percent of total billed charges,Implant Device,288.75,35,,288.75,percent of total billed charges,Implant Device,288.75,35,,288.75,percent of total billed charges,Implant Device,330,40,,330,percent of total billed charges,Implant Device,288.75,70,,288.75,percent of total billed charges,All Other,280.5,34,,280.5,percent of total billed charges,Implant Device,280.5,34,,280.5,percent of total billed charges,Implant Device,288.75,35,,288.75,percent of total billed charges,Implant Device,288.75,35,,288.75,percent of total billed charges,Implant Device,288.75,35,,288.75,percent of total billed charges,Implant Device,288.75,35,,288.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,610.5,
MEDLINE MSD14030 HEADED SCREW 4.0X30MM,C1713,HCPCS,,79012996,CDM,278,RC,,,both,,,825,610.5,,,610.5,Other,150% of Medicare + 9.63% HCRA Surcharge,371.25,45,,371.25,percent of total billed charges,Critical Access Hospital RCC factor,280.5,34,,280.5,percent of total billed charges,Implant Device,280.5,34,,280.5,percent of total billed charges,Implant Device,280.5,34,,280.5,percent of total billed charges,Implant Device,280.5,34,,280.5,percent of total billed charges,Implant Device,280.5,34,,280.5,percent of total billed charges,Implant Device,408.38,,,408.38,Other,110% of Medicare,288.75,35,,288.75,percent of total billed charges,Implant Device,280.5,34,"Charges > $500, x 34%",280.5,percent of total billed charges,Implant Device,288.75,35,,288.75,percent of total billed charges,Implant Device,288.75,35,,288.75,percent of total billed charges,Implant Device,288.75,35,,288.75,percent of total billed charges,Implant Device,288.75,35,,288.75,percent of total billed charges,Implant Device,288.75,35,,288.75,percent of total billed charges,Implant Device,330,40,,330,percent of total billed charges,Implant Device,288.75,70,,288.75,percent of total billed charges,All Other,280.5,34,,280.5,percent of total billed charges,Implant Device,280.5,34,,280.5,percent of total billed charges,Implant Device,288.75,35,,288.75,percent of total billed charges,Implant Device,288.75,35,,288.75,percent of total billed charges,Implant Device,288.75,35,,288.75,percent of total billed charges,Implant Device,288.75,35,,288.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,610.5,
MEDLINE MSD14034 HEADED SCREW 4.0X34MM,C1713,HCPCS,,79012997,CDM,278,RC,,,both,,,825,610.5,,,610.5,Other,150% of Medicare + 9.63% HCRA Surcharge,371.25,45,,371.25,percent of total billed charges,Critical Access Hospital RCC factor,280.5,34,,280.5,percent of total billed charges,Implant Device,280.5,34,,280.5,percent of total billed charges,Implant Device,280.5,34,,280.5,percent of total billed charges,Implant Device,280.5,34,,280.5,percent of total billed charges,Implant Device,280.5,34,,280.5,percent of total billed charges,Implant Device,408.38,,,408.38,Other,110% of Medicare,288.75,35,,288.75,percent of total billed charges,Implant Device,280.5,34,"Charges > $500, x 34%",280.5,percent of total billed charges,Implant Device,288.75,35,,288.75,percent of total billed charges,Implant Device,288.75,35,,288.75,percent of total billed charges,Implant Device,288.75,35,,288.75,percent of total billed charges,Implant Device,288.75,35,,288.75,percent of total billed charges,Implant Device,288.75,35,,288.75,percent of total billed charges,Implant Device,330,40,,330,percent of total billed charges,Implant Device,288.75,70,,288.75,percent of total billed charges,All Other,280.5,34,,280.5,percent of total billed charges,Implant Device,280.5,34,,280.5,percent of total billed charges,Implant Device,288.75,35,,288.75,percent of total billed charges,Implant Device,288.75,35,,288.75,percent of total billed charges,Implant Device,288.75,35,,288.75,percent of total billed charges,Implant Device,288.75,35,,288.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,610.5,
MEDLINE MSD14038 HEADED SCREW 4.0X38MM,C1713,HCPCS,,79012998,CDM,278,RC,,,both,,,825,610.5,,,610.5,Other,150% of Medicare + 9.63% HCRA Surcharge,371.25,45,,371.25,percent of total billed charges,Critical Access Hospital RCC factor,280.5,34,,280.5,percent of total billed charges,Implant Device,280.5,34,,280.5,percent of total billed charges,Implant Device,280.5,34,,280.5,percent of total billed charges,Implant Device,280.5,34,,280.5,percent of total billed charges,Implant Device,280.5,34,,280.5,percent of total billed charges,Implant Device,408.38,,,408.38,Other,110% of Medicare,288.75,35,,288.75,percent of total billed charges,Implant Device,280.5,34,"Charges > $500, x 34%",280.5,percent of total billed charges,Implant Device,288.75,35,,288.75,percent of total billed charges,Implant Device,288.75,35,,288.75,percent of total billed charges,Implant Device,288.75,35,,288.75,percent of total billed charges,Implant Device,288.75,35,,288.75,percent of total billed charges,Implant Device,288.75,35,,288.75,percent of total billed charges,Implant Device,330,40,,330,percent of total billed charges,Implant Device,288.75,70,,288.75,percent of total billed charges,All Other,280.5,34,,280.5,percent of total billed charges,Implant Device,280.5,34,,280.5,percent of total billed charges,Implant Device,288.75,35,,288.75,percent of total billed charges,Implant Device,288.75,35,,288.75,percent of total billed charges,Implant Device,288.75,35,,288.75,percent of total billed charges,Implant Device,288.75,35,,288.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,610.5,
IMPLANT/ INSERT DEVICE,C1889,HCPCS,,79013001,CDM,278,RC,,,both,,,840,621.6,,,621.6,Other,150% of Medicare + 9.63% HCRA Surcharge,378,45,,378,percent of total billed charges,Critical Access Hospital RCC factor,285.6,34,,285.6,percent of total billed charges,Implant Device,285.6,34,,285.6,percent of total billed charges,Implant Device,285.6,34,,285.6,percent of total billed charges,Implant Device,285.6,34,,285.6,percent of total billed charges,Implant Device,285.6,34,,285.6,percent of total billed charges,Implant Device,415.8,,,415.8,Other,110% of Medicare,294,35,,294,percent of total billed charges,Implant Device,285.6,34,"Charges > $500, x 34%",285.6,percent of total billed charges,Implant Device,294,35,,294,percent of total billed charges,Implant Device,294,35,,294,percent of total billed charges,Implant Device,294,35,,294,percent of total billed charges,Implant Device,294,35,,294,percent of total billed charges,Implant Device,294,35,,294,percent of total billed charges,Implant Device,336,40,,336,percent of total billed charges,Implant Device,294,70,,294,percent of total billed charges,All Other,285.6,34,,285.6,percent of total billed charges,Implant Device,285.6,34,,285.6,percent of total billed charges,Implant Device,294,35,,294,percent of total billed charges,Implant Device,294,35,,294,percent of total billed charges,Implant Device,294,35,,294,percent of total billed charges,Implant Device,294,35,,294,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,621.6,
STRYKER 607340 CANCELLOUS SCREW 4.0X40MM,C1713,HCPCS,,79013002,CDM,278,RC,,,both,,,144,106.56,,,106.56,Other,150% of Medicare + 9.63% HCRA Surcharge,64.8,45,,64.8,percent of total billed charges,Critical Access Hospital RCC factor,48.96,34,,48.96,percent of total billed charges,Implant Device,48.96,34,,48.96,percent of total billed charges,Implant Device,48.96,34,,48.96,percent of total billed charges,Implant Device,48.96,34,,48.96,percent of total billed charges,Implant Device,48.96,34,,48.96,percent of total billed charges,Implant Device,71.28,,,71.28,Other,110% of Medicare,50.4,35,,50.4,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,50.4,35,,50.4,percent of total billed charges,Implant Device,50.4,35,,50.4,percent of total billed charges,Implant Device,50.4,35,,50.4,percent of total billed charges,Implant Device,50.4,35,,50.4,percent of total billed charges,Implant Device,50.4,35,,50.4,percent of total billed charges,Implant Device,57.6,40,,57.6,percent of total billed charges,Implant Device,50.4,70,,50.4,percent of total billed charges,All Other,48.96,34,,48.96,percent of total billed charges,Implant Device,48.96,34,,48.96,percent of total billed charges,Implant Device,50.4,35,,50.4,percent of total billed charges,Implant Device,50.4,35,,50.4,percent of total billed charges,Implant Device,50.4,35,,50.4,percent of total billed charges,Implant Device,50.4,35,,50.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,106.56,
STRYKER 607344 CANCELLOUS SCREW 4.0X44MM,C1713,HCPCS,,79013003,CDM,278,RC,,,both,,,144,106.56,,,106.56,Other,150% of Medicare + 9.63% HCRA Surcharge,64.8,45,,64.8,percent of total billed charges,Critical Access Hospital RCC factor,48.96,34,,48.96,percent of total billed charges,Implant Device,48.96,34,,48.96,percent of total billed charges,Implant Device,48.96,34,,48.96,percent of total billed charges,Implant Device,48.96,34,,48.96,percent of total billed charges,Implant Device,48.96,34,,48.96,percent of total billed charges,Implant Device,71.28,,,71.28,Other,110% of Medicare,50.4,35,,50.4,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,50.4,35,,50.4,percent of total billed charges,Implant Device,50.4,35,,50.4,percent of total billed charges,Implant Device,50.4,35,,50.4,percent of total billed charges,Implant Device,50.4,35,,50.4,percent of total billed charges,Implant Device,50.4,35,,50.4,percent of total billed charges,Implant Device,57.6,40,,57.6,percent of total billed charges,Implant Device,50.4,70,,50.4,percent of total billed charges,All Other,48.96,34,,48.96,percent of total billed charges,Implant Device,48.96,34,,48.96,percent of total billed charges,Implant Device,50.4,35,,50.4,percent of total billed charges,Implant Device,50.4,35,,50.4,percent of total billed charges,Implant Device,50.4,35,,50.4,percent of total billed charges,Implant Device,50.4,35,,50.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,106.56,
STRYKER 663816 BONE SCREW 2.3X16MM,C1713,HCPCS,,79013005,CDM,278,RC,,,both,,,324,239.76,,,239.76,Other,150% of Medicare + 9.63% HCRA Surcharge,145.8,45,,145.8,percent of total billed charges,Critical Access Hospital RCC factor,110.16,34,,110.16,percent of total billed charges,Implant Device,110.16,34,,110.16,percent of total billed charges,Implant Device,110.16,34,,110.16,percent of total billed charges,Implant Device,110.16,34,,110.16,percent of total billed charges,Implant Device,110.16,34,,110.16,percent of total billed charges,Implant Device,160.38,,,160.38,Other,110% of Medicare,113.4,35,,113.4,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,129.6,40,,129.6,percent of total billed charges,Implant Device,113.4,70,,113.4,percent of total billed charges,All Other,110.16,34,,110.16,percent of total billed charges,Implant Device,110.16,34,,110.16,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,239.76,
J&J 202.898 CORTEX SCREW 2.7X38MM,C1713,HCPCS,,79013009,CDM,278,RC,,,both,,,88,65.12,,,65.12,Other,150% of Medicare + 9.63% HCRA Surcharge,39.6,45,,39.6,percent of total billed charges,Critical Access Hospital RCC factor,29.92,34,,29.92,percent of total billed charges,Implant Device,29.92,34,,29.92,percent of total billed charges,Implant Device,29.92,34,,29.92,percent of total billed charges,Implant Device,29.92,34,,29.92,percent of total billed charges,Implant Device,29.92,34,,29.92,percent of total billed charges,Implant Device,43.56,,,43.56,Other,110% of Medicare,30.8,35,,30.8,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,30.8,35,,30.8,percent of total billed charges,Implant Device,30.8,35,,30.8,percent of total billed charges,Implant Device,30.8,35,,30.8,percent of total billed charges,Implant Device,30.8,35,,30.8,percent of total billed charges,Implant Device,30.8,35,,30.8,percent of total billed charges,Implant Device,35.2,40,,35.2,percent of total billed charges,Implant Device,30.8,70,,30.8,percent of total billed charges,All Other,29.92,34,,29.92,percent of total billed charges,Implant Device,29.92,34,,29.92,percent of total billed charges,Implant Device,30.8,35,,30.8,percent of total billed charges,Implant Device,30.8,35,,30.8,percent of total billed charges,Implant Device,30.8,35,,30.8,percent of total billed charges,Implant Device,30.8,35,,30.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,65.12,
STRYKER 40100479 LPL BONE PLTE ULNAR,C1713,HCPCS,,79013010,CDM,278,RC,,,both,,,3926,2905.25,,,2905.25,Other,150% of Medicare + 9.63% HCRA Surcharge,1766.7,45,,1766.7,percent of total billed charges,Critical Access Hospital RCC factor,1334.84,34,,1334.84,percent of total billed charges,Implant Device,1334.84,34,,1334.84,percent of total billed charges,Implant Device,1334.84,34,,1334.84,percent of total billed charges,Implant Device,1334.84,34,,1334.84,percent of total billed charges,Implant Device,1334.84,34,,1334.84,percent of total billed charges,Implant Device,1943.37,,,1943.37,Other,110% of Medicare,1374.1,35,,1374.1,percent of total billed charges,Implant Device,1334.84,34,"Charges > $500, x 34%",1334.84,percent of total billed charges,Implant Device,1374.1,35,,1374.1,percent of total billed charges,Implant Device,1374.1,35,,1374.1,percent of total billed charges,Implant Device,1374.1,35,,1374.1,percent of total billed charges,Implant Device,1374.1,35,,1374.1,percent of total billed charges,Implant Device,1374.1,35,,1374.1,percent of total billed charges,Implant Device,1570.4,40,,1570.4,percent of total billed charges,Implant Device,1374.1,70,,1374.1,percent of total billed charges,All Other,1334.84,34,,1334.84,percent of total billed charges,Implant Device,1334.84,34,,1334.84,percent of total billed charges,Implant Device,1374.1,35,,1374.1,percent of total billed charges,Implant Device,1374.1,35,,1374.1,percent of total billed charges,Implant Device,1374.1,35,,1374.1,percent of total billed charges,Implant Device,1374.1,35,,1374.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1334.84,34,"If Charge > 2,000, then 34 percent",1334.84,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2905.25,
STRYKER 40100778 LOCKING SCREW 2.7X18MM,C1713,HCPCS,,79013016,CDM,278,RC,,,both,,,584,432.16,,,432.16,Other,150% of Medicare + 9.63% HCRA Surcharge,262.8,45,,262.8,percent of total billed charges,Critical Access Hospital RCC factor,198.56,34,,198.56,percent of total billed charges,Implant Device,198.56,34,,198.56,percent of total billed charges,Implant Device,198.56,34,,198.56,percent of total billed charges,Implant Device,198.56,34,,198.56,percent of total billed charges,Implant Device,198.56,34,,198.56,percent of total billed charges,Implant Device,289.08,,,289.08,Other,110% of Medicare,204.4,35,,204.4,percent of total billed charges,Implant Device,198.56,34,"Charges > $500, x 34%",198.56,percent of total billed charges,Implant Device,204.4,35,,204.4,percent of total billed charges,Implant Device,204.4,35,,204.4,percent of total billed charges,Implant Device,204.4,35,,204.4,percent of total billed charges,Implant Device,204.4,35,,204.4,percent of total billed charges,Implant Device,204.4,35,,204.4,percent of total billed charges,Implant Device,233.6,40,,233.6,percent of total billed charges,Implant Device,204.4,70,,204.4,percent of total billed charges,All Other,198.56,34,,198.56,percent of total billed charges,Implant Device,198.56,34,,198.56,percent of total billed charges,Implant Device,204.4,35,,204.4,percent of total billed charges,Implant Device,204.4,35,,204.4,percent of total billed charges,Implant Device,204.4,35,,204.4,percent of total billed charges,Implant Device,204.4,35,,204.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,432.16,
STRYKER 40100782 LOCKING SCREW 2.7X22MM,C1713,HCPCS,,79013017,CDM,278,RC,,,both,,,584,432.16,,,432.16,Other,150% of Medicare + 9.63% HCRA Surcharge,262.8,45,,262.8,percent of total billed charges,Critical Access Hospital RCC factor,198.56,34,,198.56,percent of total billed charges,Implant Device,198.56,34,,198.56,percent of total billed charges,Implant Device,198.56,34,,198.56,percent of total billed charges,Implant Device,198.56,34,,198.56,percent of total billed charges,Implant Device,198.56,34,,198.56,percent of total billed charges,Implant Device,289.08,,,289.08,Other,110% of Medicare,204.4,35,,204.4,percent of total billed charges,Implant Device,198.56,34,"Charges > $500, x 34%",198.56,percent of total billed charges,Implant Device,204.4,35,,204.4,percent of total billed charges,Implant Device,204.4,35,,204.4,percent of total billed charges,Implant Device,204.4,35,,204.4,percent of total billed charges,Implant Device,204.4,35,,204.4,percent of total billed charges,Implant Device,204.4,35,,204.4,percent of total billed charges,Implant Device,233.6,40,,233.6,percent of total billed charges,Implant Device,204.4,70,,204.4,percent of total billed charges,All Other,198.56,34,,198.56,percent of total billed charges,Implant Device,198.56,34,,198.56,percent of total billed charges,Implant Device,204.4,35,,204.4,percent of total billed charges,Implant Device,204.4,35,,204.4,percent of total billed charges,Implant Device,204.4,35,,204.4,percent of total billed charges,Implant Device,204.4,35,,204.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,432.16,
STRYKER 40100916 CORTICAL SCREW 3.5X16MM,C1713,HCPCS,,79013018,CDM,278,RC,,,both,,,303,224.22,,,224.22,Other,150% of Medicare + 9.63% HCRA Surcharge,136.35,45,,136.35,percent of total billed charges,Critical Access Hospital RCC factor,103.02,34,,103.02,percent of total billed charges,Implant Device,103.02,34,,103.02,percent of total billed charges,Implant Device,103.02,34,,103.02,percent of total billed charges,Implant Device,103.02,34,,103.02,percent of total billed charges,Implant Device,103.02,34,,103.02,percent of total billed charges,Implant Device,149.99,,,149.99,Other,110% of Medicare,106.05,35,,106.05,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,106.05,35,,106.05,percent of total billed charges,Implant Device,106.05,35,,106.05,percent of total billed charges,Implant Device,106.05,35,,106.05,percent of total billed charges,Implant Device,106.05,35,,106.05,percent of total billed charges,Implant Device,106.05,35,,106.05,percent of total billed charges,Implant Device,121.2,40,,121.2,percent of total billed charges,Implant Device,106.05,70,,106.05,percent of total billed charges,All Other,103.02,34,,103.02,percent of total billed charges,Implant Device,103.02,34,,103.02,percent of total billed charges,Implant Device,106.05,35,,106.05,percent of total billed charges,Implant Device,106.05,35,,106.05,percent of total billed charges,Implant Device,106.05,35,,106.05,percent of total billed charges,Implant Device,106.05,35,,106.05,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,224.22,
STRYKER 40100918 CORTICAL SCREW 3.5X18MM,C1713,HCPCS,,79013019,CDM,278,RC,,,both,,,303,224.22,,,224.22,Other,150% of Medicare + 9.63% HCRA Surcharge,136.35,45,,136.35,percent of total billed charges,Critical Access Hospital RCC factor,103.02,34,,103.02,percent of total billed charges,Implant Device,103.02,34,,103.02,percent of total billed charges,Implant Device,103.02,34,,103.02,percent of total billed charges,Implant Device,103.02,34,,103.02,percent of total billed charges,Implant Device,103.02,34,,103.02,percent of total billed charges,Implant Device,149.99,,,149.99,Other,110% of Medicare,106.05,35,,106.05,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,106.05,35,,106.05,percent of total billed charges,Implant Device,106.05,35,,106.05,percent of total billed charges,Implant Device,106.05,35,,106.05,percent of total billed charges,Implant Device,106.05,35,,106.05,percent of total billed charges,Implant Device,106.05,35,,106.05,percent of total billed charges,Implant Device,121.2,40,,121.2,percent of total billed charges,Implant Device,106.05,70,,106.05,percent of total billed charges,All Other,103.02,34,,103.02,percent of total billed charges,Implant Device,103.02,34,,103.02,percent of total billed charges,Implant Device,106.05,35,,106.05,percent of total billed charges,Implant Device,106.05,35,,106.05,percent of total billed charges,Implant Device,106.05,35,,106.05,percent of total billed charges,Implant Device,106.05,35,,106.05,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,224.22,
STRYKER 40100920 CORTICAL SCREW 3.5X20MM,C1713,HCPCS,,79013020,CDM,278,RC,,,both,,,303,224.22,,,224.22,Other,150% of Medicare + 9.63% HCRA Surcharge,136.35,45,,136.35,percent of total billed charges,Critical Access Hospital RCC factor,103.02,34,,103.02,percent of total billed charges,Implant Device,103.02,34,,103.02,percent of total billed charges,Implant Device,103.02,34,,103.02,percent of total billed charges,Implant Device,103.02,34,,103.02,percent of total billed charges,Implant Device,103.02,34,,103.02,percent of total billed charges,Implant Device,149.99,,,149.99,Other,110% of Medicare,106.05,35,,106.05,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,106.05,35,,106.05,percent of total billed charges,Implant Device,106.05,35,,106.05,percent of total billed charges,Implant Device,106.05,35,,106.05,percent of total billed charges,Implant Device,106.05,35,,106.05,percent of total billed charges,Implant Device,106.05,35,,106.05,percent of total billed charges,Implant Device,121.2,40,,121.2,percent of total billed charges,Implant Device,106.05,70,,106.05,percent of total billed charges,All Other,103.02,34,,103.02,percent of total billed charges,Implant Device,103.02,34,,103.02,percent of total billed charges,Implant Device,106.05,35,,106.05,percent of total billed charges,Implant Device,106.05,35,,106.05,percent of total billed charges,Implant Device,106.05,35,,106.05,percent of total billed charges,Implant Device,106.05,35,,106.05,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,224.22,
STRYKER 40100922 CORTICAL SCREW 3.5X22MM,C1713,HCPCS,,79013021,CDM,278,RC,,,both,,,303,224.22,,,224.22,Other,150% of Medicare + 9.63% HCRA Surcharge,136.35,45,,136.35,percent of total billed charges,Critical Access Hospital RCC factor,103.02,34,,103.02,percent of total billed charges,Implant Device,103.02,34,,103.02,percent of total billed charges,Implant Device,103.02,34,,103.02,percent of total billed charges,Implant Device,103.02,34,,103.02,percent of total billed charges,Implant Device,103.02,34,,103.02,percent of total billed charges,Implant Device,149.99,,,149.99,Other,110% of Medicare,106.05,35,,106.05,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,106.05,35,,106.05,percent of total billed charges,Implant Device,106.05,35,,106.05,percent of total billed charges,Implant Device,106.05,35,,106.05,percent of total billed charges,Implant Device,106.05,35,,106.05,percent of total billed charges,Implant Device,106.05,35,,106.05,percent of total billed charges,Implant Device,121.2,40,,121.2,percent of total billed charges,Implant Device,106.05,70,,106.05,percent of total billed charges,All Other,103.02,34,,103.02,percent of total billed charges,Implant Device,103.02,34,,103.02,percent of total billed charges,Implant Device,106.05,35,,106.05,percent of total billed charges,Implant Device,106.05,35,,106.05,percent of total billed charges,Implant Device,106.05,35,,106.05,percent of total billed charges,Implant Device,106.05,35,,106.05,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,224.22,
STRYKER 40100924 CORTICAL SCREW 3.5X24MM,C1713,HCPCS,,79013022,CDM,278,RC,,,both,,,303,224.22,,,224.22,Other,150% of Medicare + 9.63% HCRA Surcharge,136.35,45,,136.35,percent of total billed charges,Critical Access Hospital RCC factor,103.02,34,,103.02,percent of total billed charges,Implant Device,103.02,34,,103.02,percent of total billed charges,Implant Device,103.02,34,,103.02,percent of total billed charges,Implant Device,103.02,34,,103.02,percent of total billed charges,Implant Device,103.02,34,,103.02,percent of total billed charges,Implant Device,149.99,,,149.99,Other,110% of Medicare,106.05,35,,106.05,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,106.05,35,,106.05,percent of total billed charges,Implant Device,106.05,35,,106.05,percent of total billed charges,Implant Device,106.05,35,,106.05,percent of total billed charges,Implant Device,106.05,35,,106.05,percent of total billed charges,Implant Device,106.05,35,,106.05,percent of total billed charges,Implant Device,121.2,40,,121.2,percent of total billed charges,Implant Device,106.05,70,,106.05,percent of total billed charges,All Other,103.02,34,,103.02,percent of total billed charges,Implant Device,103.02,34,,103.02,percent of total billed charges,Implant Device,106.05,35,,106.05,percent of total billed charges,Implant Device,106.05,35,,106.05,percent of total billed charges,Implant Device,106.05,35,,106.05,percent of total billed charges,Implant Device,106.05,35,,106.05,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,224.22,
STRYKER 40100960 CORTICAL SCREW 2.7X20MM,C1713,HCPCS,,79013023,CDM,278,RC,,,both,,,303,224.22,,,224.22,Other,150% of Medicare + 9.63% HCRA Surcharge,136.35,45,,136.35,percent of total billed charges,Critical Access Hospital RCC factor,103.02,34,,103.02,percent of total billed charges,Implant Device,103.02,34,,103.02,percent of total billed charges,Implant Device,103.02,34,,103.02,percent of total billed charges,Implant Device,103.02,34,,103.02,percent of total billed charges,Implant Device,103.02,34,,103.02,percent of total billed charges,Implant Device,149.99,,,149.99,Other,110% of Medicare,106.05,35,,106.05,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,106.05,35,,106.05,percent of total billed charges,Implant Device,106.05,35,,106.05,percent of total billed charges,Implant Device,106.05,35,,106.05,percent of total billed charges,Implant Device,106.05,35,,106.05,percent of total billed charges,Implant Device,106.05,35,,106.05,percent of total billed charges,Implant Device,121.2,40,,121.2,percent of total billed charges,Implant Device,106.05,70,,106.05,percent of total billed charges,All Other,103.02,34,,103.02,percent of total billed charges,Implant Device,103.02,34,,103.02,percent of total billed charges,Implant Device,106.05,35,,106.05,percent of total billed charges,Implant Device,106.05,35,,106.05,percent of total billed charges,Implant Device,106.05,35,,106.05,percent of total billed charges,Implant Device,106.05,35,,106.05,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,224.22,
ZIMMER 110031013 BEARING 28X46MM SIZE G,C1776,HCPCS,,79013024,CDM,278,RC,,,both,,,3456,2557.45,,,2557.45,Other,150% of Medicare + 9.63% HCRA Surcharge,1555.2,45,,1555.2,percent of total billed charges,Critical Access Hospital RCC factor,1175.04,34,,1175.04,percent of total billed charges,Implant Device,1175.04,34,,1175.04,percent of total billed charges,Implant Device,1175.04,34,,1175.04,percent of total billed charges,Implant Device,1175.04,34,,1175.04,percent of total billed charges,Implant Device,1175.04,34,,1175.04,percent of total billed charges,Implant Device,1710.72,,,1710.72,Other,110% of Medicare,1209.6,35,,1209.6,percent of total billed charges,Implant Device,1175.04,34,"Charges > $500, x 34%",1175.04,percent of total billed charges,Implant Device,1209.6,35,,1209.6,percent of total billed charges,Implant Device,1209.6,35,,1209.6,percent of total billed charges,Implant Device,1209.6,35,,1209.6,percent of total billed charges,Implant Device,1209.6,35,,1209.6,percent of total billed charges,Implant Device,1209.6,35,,1209.6,percent of total billed charges,Implant Device,1382.4,40,,1382.4,percent of total billed charges,Implant Device,1209.6,70,,1209.6,percent of total billed charges,All Other,1175.04,34,,1175.04,percent of total billed charges,Implant Device,1175.04,34,,1175.04,percent of total billed charges,Implant Device,1209.6,35,,1209.6,percent of total billed charges,Implant Device,1209.6,35,,1209.6,percent of total billed charges,Implant Device,1209.6,35,,1209.6,percent of total billed charges,Implant Device,1209.6,35,,1209.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1175.04,34,"If Charge > 2,000, then 34 percent",1175.04,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2557.45,
ZIMMER 110024465 ACETABU LINER 46MM SZ G,C1776,HCPCS,,79013025,CDM,278,RC,,,both,,,3840,2841.61,,,2841.61,Other,150% of Medicare + 9.63% HCRA Surcharge,1728,45,,1728,percent of total billed charges,Critical Access Hospital RCC factor,1305.6,34,,1305.6,percent of total billed charges,Implant Device,1305.6,34,,1305.6,percent of total billed charges,Implant Device,1305.6,34,,1305.6,percent of total billed charges,Implant Device,1305.6,34,,1305.6,percent of total billed charges,Implant Device,1305.6,34,,1305.6,percent of total billed charges,Implant Device,1900.8,,,1900.8,Other,110% of Medicare,1344,35,,1344,percent of total billed charges,Implant Device,1305.6,34,"Charges > $500, x 34%",1305.6,percent of total billed charges,Implant Device,1344,35,,1344,percent of total billed charges,Implant Device,1344,35,,1344,percent of total billed charges,Implant Device,1344,35,,1344,percent of total billed charges,Implant Device,1344,35,,1344,percent of total billed charges,Implant Device,1344,35,,1344,percent of total billed charges,Implant Device,1536,40,,1536,percent of total billed charges,Implant Device,1344,70,,1344,percent of total billed charges,All Other,1305.6,34,,1305.6,percent of total billed charges,Implant Device,1305.6,34,,1305.6,percent of total billed charges,Implant Device,1344,35,,1344,percent of total billed charges,Implant Device,1344,35,,1344,percent of total billed charges,Implant Device,1344,35,,1344,percent of total billed charges,Implant Device,1344,35,,1344,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1305.6,34,"If Charge > 2,000, then 34 percent",1305.6,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2841.61,
ZIMMER 183014 FEMORAL RIGHT 75MM,C1776,HCPCS,,79013026,CDM,278,RC,,,both,,,6300,4662.02,,,4662.02,Other,150% of Medicare + 9.63% HCRA Surcharge,2835,45,,2835,percent of total billed charges,Critical Access Hospital RCC factor,2142,34,,2142,percent of total billed charges,Implant Device,2142,34,,2142,percent of total billed charges,Implant Device,2142,34,,2142,percent of total billed charges,Implant Device,2142,34,,2142,percent of total billed charges,Implant Device,2142,34,,2142,percent of total billed charges,Implant Device,3118.5,,,3118.5,Other,110% of Medicare,2205,35,,2205,percent of total billed charges,Implant Device,2142,34,"Charges > $500, x 34%",2142,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2520,40,,2520,percent of total billed charges,Implant Device,2205,70,,2205,percent of total billed charges,All Other,2142,34,,2142,percent of total billed charges,Implant Device,2142,34,,2142,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2142,34,"If Charge > 2,000, then 34 percent",2142,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4662.02,
J&J 208.439 CANNULATED SCREW 6.5X85MM,C1713,HCPCS,,79013027,CDM,278,RC,,,both,,,683,505.42,,,505.42,Other,150% of Medicare + 9.63% HCRA Surcharge,307.35,45,,307.35,percent of total billed charges,Critical Access Hospital RCC factor,232.22,34,,232.22,percent of total billed charges,Implant Device,232.22,34,,232.22,percent of total billed charges,Implant Device,232.22,34,,232.22,percent of total billed charges,Implant Device,232.22,34,,232.22,percent of total billed charges,Implant Device,232.22,34,,232.22,percent of total billed charges,Implant Device,338.09,,,338.09,Other,110% of Medicare,239.05,35,,239.05,percent of total billed charges,Implant Device,232.22,34,"Charges > $500, x 34%",232.22,percent of total billed charges,Implant Device,239.05,35,,239.05,percent of total billed charges,Implant Device,239.05,35,,239.05,percent of total billed charges,Implant Device,239.05,35,,239.05,percent of total billed charges,Implant Device,239.05,35,,239.05,percent of total billed charges,Implant Device,239.05,35,,239.05,percent of total billed charges,Implant Device,273.2,40,,273.2,percent of total billed charges,Implant Device,239.05,70,,239.05,percent of total billed charges,All Other,232.22,34,,232.22,percent of total billed charges,Implant Device,232.22,34,,232.22,percent of total billed charges,Implant Device,239.05,35,,239.05,percent of total billed charges,Implant Device,239.05,35,,239.05,percent of total billed charges,Implant Device,239.05,35,,239.05,percent of total billed charges,Implant Device,239.05,35,,239.05,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,505.42,
ZIMMER 42-5121-009-14 ART SURF LT 14,C1776,HCPCS,,79013028,CDM,278,RC,,,both,,,4116,3045.85,,,3045.85,Other,150% of Medicare + 9.63% HCRA Surcharge,1852.2,45,,1852.2,percent of total billed charges,Critical Access Hospital RCC factor,1399.44,34,,1399.44,percent of total billed charges,Implant Device,1399.44,34,,1399.44,percent of total billed charges,Implant Device,1399.44,34,,1399.44,percent of total billed charges,Implant Device,1399.44,34,,1399.44,percent of total billed charges,Implant Device,1399.44,34,,1399.44,percent of total billed charges,Implant Device,2037.42,,,2037.42,Other,110% of Medicare,1440.6,35,,1440.6,percent of total billed charges,Implant Device,1399.44,34,"Charges > $500, x 34%",1399.44,percent of total billed charges,Implant Device,1440.6,35,,1440.6,percent of total billed charges,Implant Device,1440.6,35,,1440.6,percent of total billed charges,Implant Device,1440.6,35,,1440.6,percent of total billed charges,Implant Device,1440.6,35,,1440.6,percent of total billed charges,Implant Device,1440.6,35,,1440.6,percent of total billed charges,Implant Device,1646.4,40,,1646.4,percent of total billed charges,Implant Device,1440.6,70,,1440.6,percent of total billed charges,All Other,1399.44,34,,1399.44,percent of total billed charges,Implant Device,1399.44,34,,1399.44,percent of total billed charges,Implant Device,1440.6,35,,1440.6,percent of total billed charges,Implant Device,1440.6,35,,1440.6,percent of total billed charges,Implant Device,1440.6,35,,1440.6,percent of total billed charges,Implant Device,1440.6,35,,1440.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1399.44,34,"If Charge > 2,000, then 34 percent",1399.44,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3045.85,
ZIMMER 11-300819 DISTAL STEM 19X150MM,C1776,HCPCS,,79013030,CDM,278,RC,,,both,,,10199,7547.29,,,7547.29,Other,150% of Medicare + 9.63% HCRA Surcharge,4589.55,45,,4589.55,percent of total billed charges,Critical Access Hospital RCC factor,3467.66,34,,3467.66,percent of total billed charges,Implant Device,3467.66,34,,3467.66,percent of total billed charges,Implant Device,3467.66,34,,3467.66,percent of total billed charges,Implant Device,3467.66,34,,3467.66,percent of total billed charges,Implant Device,3467.66,34,,3467.66,percent of total billed charges,Implant Device,5048.51,,,5048.51,Other,110% of Medicare,3569.65,35,,3569.65,percent of total billed charges,Implant Device,3467.66,34,"Charges > $500, x 34%",3467.66,percent of total billed charges,Implant Device,3569.65,35,,3569.65,percent of total billed charges,Implant Device,3569.65,35,,3569.65,percent of total billed charges,Implant Device,3569.65,35,,3569.65,percent of total billed charges,Implant Device,3569.65,35,,3569.65,percent of total billed charges,Implant Device,3569.65,35,,3569.65,percent of total billed charges,Implant Device,4079.6,40,,4079.6,percent of total billed charges,Implant Device,3569.65,70,,3569.65,percent of total billed charges,All Other,3467.66,34,,3467.66,percent of total billed charges,Implant Device,3467.66,34,,3467.66,percent of total billed charges,Implant Device,3569.65,35,,3569.65,percent of total billed charges,Implant Device,3569.65,35,,3569.65,percent of total billed charges,Implant Device,3569.65,35,,3569.65,percent of total billed charges,Implant Device,3569.65,35,,3569.65,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3467.66,34,"If Charge > 2,000, then 34 percent",3467.66,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,7547.29,
STRYKER 2339-1334S FEMORAL NAIL 13X340MM,C1889,HCPCS,,79013031,CDM,278,RC,,,both,,,6585,4872.92,,,4872.92,Other,150% of Medicare + 9.63% HCRA Surcharge,2963.25,45,,2963.25,percent of total billed charges,Critical Access Hospital RCC factor,2238.9,34,,2238.9,percent of total billed charges,Implant Device,2238.9,34,,2238.9,percent of total billed charges,Implant Device,2238.9,34,,2238.9,percent of total billed charges,Implant Device,2238.9,34,,2238.9,percent of total billed charges,Implant Device,2238.9,34,,2238.9,percent of total billed charges,Implant Device,3259.58,,,3259.58,Other,110% of Medicare,2304.75,35,,2304.75,percent of total billed charges,Implant Device,2238.9,34,"Charges > $500, x 34%",2238.9,percent of total billed charges,Implant Device,2304.75,35,,2304.75,percent of total billed charges,Implant Device,2304.75,35,,2304.75,percent of total billed charges,Implant Device,2304.75,35,,2304.75,percent of total billed charges,Implant Device,2304.75,35,,2304.75,percent of total billed charges,Implant Device,2304.75,35,,2304.75,percent of total billed charges,Implant Device,2634,40,,2634,percent of total billed charges,Implant Device,2304.75,70,,2304.75,percent of total billed charges,All Other,2238.9,34,,2238.9,percent of total billed charges,Implant Device,2238.9,34,,2238.9,percent of total billed charges,Implant Device,2304.75,35,,2304.75,percent of total billed charges,Implant Device,2304.75,35,,2304.75,percent of total billed charges,Implant Device,2304.75,35,,2304.75,percent of total billed charges,Implant Device,2304.75,35,,2304.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2238.9,34,"If Charge > 2,000, then 34 percent",2238.9,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4872.92,
ZIMMER 42-5121-004-11 ARTIC SURF LT 11MM,C1776,HCPCS,,79013032,CDM,278,RC,,,both,,,3648,2699.53,,,2699.53,Other,150% of Medicare + 9.63% HCRA Surcharge,1641.6,45,,1641.6,percent of total billed charges,Critical Access Hospital RCC factor,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1805.76,,,1805.76,Other,110% of Medicare,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1240.32,34,"Charges > $500, x 34%",1240.32,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1459.2,40,,1459.2,percent of total billed charges,Implant Device,1276.8,70,,1276.8,percent of total billed charges,All Other,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1240.32,34,"If Charge > 2,000, then 34 percent",1240.32,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2699.53,
STRYKER 657022 LOCKING SCREW 2.7X22MM,C1713,HCPCS,,79013033,CDM,278,RC,,,both,,,539,398.86,,,398.86,Other,150% of Medicare + 9.63% HCRA Surcharge,242.55,45,,242.55,percent of total billed charges,Critical Access Hospital RCC factor,183.26,34,,183.26,percent of total billed charges,Implant Device,183.26,34,,183.26,percent of total billed charges,Implant Device,183.26,34,,183.26,percent of total billed charges,Implant Device,183.26,34,,183.26,percent of total billed charges,Implant Device,183.26,34,,183.26,percent of total billed charges,Implant Device,266.81,,,266.81,Other,110% of Medicare,188.65,35,,188.65,percent of total billed charges,Implant Device,183.26,34,"Charges > $500, x 34%",183.26,percent of total billed charges,Implant Device,188.65,35,,188.65,percent of total billed charges,Implant Device,188.65,35,,188.65,percent of total billed charges,Implant Device,188.65,35,,188.65,percent of total billed charges,Implant Device,188.65,35,,188.65,percent of total billed charges,Implant Device,188.65,35,,188.65,percent of total billed charges,Implant Device,215.6,40,,215.6,percent of total billed charges,Implant Device,188.65,70,,188.65,percent of total billed charges,All Other,183.26,34,,183.26,percent of total billed charges,Implant Device,183.26,34,,183.26,percent of total billed charges,Implant Device,188.65,35,,188.65,percent of total billed charges,Implant Device,188.65,35,,188.65,percent of total billed charges,Implant Device,188.65,35,,188.65,percent of total billed charges,Implant Device,188.65,35,,188.65,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,398.86,
STRYKER 5065-9-015 HALF PIN 15MM,C1713,HCPCS,,79013040,CDM,278,RC,,,both,,,159,117.66,,,117.66,Other,150% of Medicare + 9.63% HCRA Surcharge,71.55,45,,71.55,percent of total billed charges,Critical Access Hospital RCC factor,54.06,34,,54.06,percent of total billed charges,Implant Device,54.06,34,,54.06,percent of total billed charges,Implant Device,54.06,34,,54.06,percent of total billed charges,Implant Device,54.06,34,,54.06,percent of total billed charges,Implant Device,54.06,34,,54.06,percent of total billed charges,Implant Device,78.71,,,78.71,Other,110% of Medicare,55.65,35,,55.65,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,55.65,35,,55.65,percent of total billed charges,Implant Device,55.65,35,,55.65,percent of total billed charges,Implant Device,55.65,35,,55.65,percent of total billed charges,Implant Device,55.65,35,,55.65,percent of total billed charges,Implant Device,55.65,35,,55.65,percent of total billed charges,Implant Device,63.6,40,,63.6,percent of total billed charges,Implant Device,55.65,70,,55.65,percent of total billed charges,All Other,54.06,34,,54.06,percent of total billed charges,Implant Device,54.06,34,,54.06,percent of total billed charges,Implant Device,55.65,35,,55.65,percent of total billed charges,Implant Device,55.65,35,,55.65,percent of total billed charges,Implant Device,55.65,35,,55.65,percent of total billed charges,Implant Device,55.65,35,,55.65,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,117.66,
STRYKER 5080-1-620 HALF PIN 1.65X45,C1713,HCPCS,,79013041,CDM,278,RC,,,both,,,184,136.16,,,136.16,Other,150% of Medicare + 9.63% HCRA Surcharge,82.8,45,,82.8,percent of total billed charges,Critical Access Hospital RCC factor,62.56,34,,62.56,percent of total billed charges,Implant Device,62.56,34,,62.56,percent of total billed charges,Implant Device,62.56,34,,62.56,percent of total billed charges,Implant Device,62.56,34,,62.56,percent of total billed charges,Implant Device,62.56,34,,62.56,percent of total billed charges,Implant Device,91.08,,,91.08,Other,110% of Medicare,64.4,35,,64.4,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,64.4,35,,64.4,percent of total billed charges,Implant Device,64.4,35,,64.4,percent of total billed charges,Implant Device,64.4,35,,64.4,percent of total billed charges,Implant Device,64.4,35,,64.4,percent of total billed charges,Implant Device,64.4,35,,64.4,percent of total billed charges,Implant Device,73.6,40,,73.6,percent of total billed charges,Implant Device,64.4,70,,64.4,percent of total billed charges,All Other,62.56,34,,62.56,percent of total billed charges,Implant Device,62.56,34,,62.56,percent of total billed charges,Implant Device,64.4,35,,64.4,percent of total billed charges,Implant Device,64.4,35,,64.4,percent of total billed charges,Implant Device,64.4,35,,64.4,percent of total billed charges,Implant Device,64.4,35,,64.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,136.16,
STRYKER 2360-4025S LOCKING SCREW 4X25MM,C1713,HCPCS,,79013042,CDM,278,RC,,,both,,,566,418.84,,,418.84,Other,150% of Medicare + 9.63% HCRA Surcharge,254.7,45,,254.7,percent of total billed charges,Critical Access Hospital RCC factor,192.44,34,,192.44,percent of total billed charges,Implant Device,192.44,34,,192.44,percent of total billed charges,Implant Device,192.44,34,,192.44,percent of total billed charges,Implant Device,192.44,34,,192.44,percent of total billed charges,Implant Device,192.44,34,,192.44,percent of total billed charges,Implant Device,280.17,,,280.17,Other,110% of Medicare,198.1,35,,198.1,percent of total billed charges,Implant Device,192.44,34,"Charges > $500, x 34%",192.44,percent of total billed charges,Implant Device,198.1,35,,198.1,percent of total billed charges,Implant Device,198.1,35,,198.1,percent of total billed charges,Implant Device,198.1,35,,198.1,percent of total billed charges,Implant Device,198.1,35,,198.1,percent of total billed charges,Implant Device,198.1,35,,198.1,percent of total billed charges,Implant Device,226.4,40,,226.4,percent of total billed charges,Implant Device,198.1,70,,198.1,percent of total billed charges,All Other,192.44,34,,192.44,percent of total billed charges,Implant Device,192.44,34,,192.44,percent of total billed charges,Implant Device,198.1,35,,198.1,percent of total billed charges,Implant Device,198.1,35,,198.1,percent of total billed charges,Implant Device,198.1,35,,198.1,percent of total billed charges,Implant Device,198.1,35,,198.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,418.84,
J&J 214.876 CORTEX SCREW 4.5X76MM,C1713,HCPCS,,79013044,CDM,278,RC,,,both,,,93,68.82,,,68.82,Other,150% of Medicare + 9.63% HCRA Surcharge,41.85,45,,41.85,percent of total billed charges,Critical Access Hospital RCC factor,31.62,34,,31.62,percent of total billed charges,Implant Device,31.62,34,,31.62,percent of total billed charges,Implant Device,31.62,34,,31.62,percent of total billed charges,Implant Device,31.62,34,,31.62,percent of total billed charges,Implant Device,31.62,34,,31.62,percent of total billed charges,Implant Device,46.04,,,46.04,Other,110% of Medicare,32.55,35,,32.55,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,32.55,35,,32.55,percent of total billed charges,Implant Device,32.55,35,,32.55,percent of total billed charges,Implant Device,32.55,35,,32.55,percent of total billed charges,Implant Device,32.55,35,,32.55,percent of total billed charges,Implant Device,32.55,35,,32.55,percent of total billed charges,Implant Device,37.2,40,,37.2,percent of total billed charges,Implant Device,32.55,70,,32.55,percent of total billed charges,All Other,31.62,34,,31.62,percent of total billed charges,Implant Device,31.62,34,,31.62,percent of total billed charges,Implant Device,32.55,35,,32.55,percent of total billed charges,Implant Device,32.55,35,,32.55,percent of total billed charges,Implant Device,32.55,35,,32.55,percent of total billed charges,Implant Device,32.55,35,,32.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,68.82,
J&J 04.038.180S FENESTRATED SCREW 80MM,C1713,HCPCS,,79013045,CDM,278,RC,,,both,,,1776,1314.24,,,1314.24,Other,150% of Medicare + 9.63% HCRA Surcharge,799.2,45,,799.2,percent of total billed charges,Critical Access Hospital RCC factor,603.84,34,,603.84,percent of total billed charges,Implant Device,603.84,34,,603.84,percent of total billed charges,Implant Device,603.84,34,,603.84,percent of total billed charges,Implant Device,603.84,34,,603.84,percent of total billed charges,Implant Device,603.84,34,,603.84,percent of total billed charges,Implant Device,879.12,,,879.12,Other,110% of Medicare,621.6,35,,621.6,percent of total billed charges,Implant Device,603.84,34,"Charges > $500, x 34%",603.84,percent of total billed charges,Implant Device,621.6,35,,621.6,percent of total billed charges,Implant Device,621.6,35,,621.6,percent of total billed charges,Implant Device,621.6,35,,621.6,percent of total billed charges,Implant Device,621.6,35,,621.6,percent of total billed charges,Implant Device,621.6,35,,621.6,percent of total billed charges,Implant Device,710.4,40,,710.4,percent of total billed charges,Implant Device,621.6,70,,621.6,percent of total billed charges,All Other,603.84,34,,603.84,percent of total billed charges,Implant Device,603.84,34,,603.84,percent of total billed charges,Implant Device,621.6,35,,621.6,percent of total billed charges,Implant Device,621.6,35,,621.6,percent of total billed charges,Implant Device,621.6,35,,621.6,percent of total billed charges,Implant Device,621.6,35,,621.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1314.24,
J&J 04.045.032S LOCKING SCREW 5X32MM,C1713,HCPCS,,79013046,CDM,278,RC,,,both,,,687,508.38,,,508.38,Other,150% of Medicare + 9.63% HCRA Surcharge,309.15,45,,309.15,percent of total billed charges,Critical Access Hospital RCC factor,233.58,34,,233.58,percent of total billed charges,Implant Device,233.58,34,,233.58,percent of total billed charges,Implant Device,233.58,34,,233.58,percent of total billed charges,Implant Device,233.58,34,,233.58,percent of total billed charges,Implant Device,233.58,34,,233.58,percent of total billed charges,Implant Device,340.07,,,340.07,Other,110% of Medicare,240.45,35,,240.45,percent of total billed charges,Implant Device,233.58,34,"Charges > $500, x 34%",233.58,percent of total billed charges,Implant Device,240.45,35,,240.45,percent of total billed charges,Implant Device,240.45,35,,240.45,percent of total billed charges,Implant Device,240.45,35,,240.45,percent of total billed charges,Implant Device,240.45,35,,240.45,percent of total billed charges,Implant Device,240.45,35,,240.45,percent of total billed charges,Implant Device,274.8,40,,274.8,percent of total billed charges,Implant Device,240.45,70,,240.45,percent of total billed charges,All Other,233.58,34,,233.58,percent of total billed charges,Implant Device,233.58,34,,233.58,percent of total billed charges,Implant Device,240.45,35,,240.45,percent of total billed charges,Implant Device,240.45,35,,240.45,percent of total billed charges,Implant Device,240.45,35,,240.45,percent of total billed charges,Implant Device,240.45,35,,240.45,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,508.38,
ARTHREX AR-1288QT-100 FIBERTAG TIGHTROPE,C1713,HCPCS,,79013047,CDM,278,RC,,,both,,,2925,2164.51,,,2164.51,Other,150% of Medicare + 9.63% HCRA Surcharge,1316.25,45,,1316.25,percent of total billed charges,Critical Access Hospital RCC factor,994.5,34,,994.5,percent of total billed charges,Implant Device,994.5,34,,994.5,percent of total billed charges,Implant Device,994.5,34,,994.5,percent of total billed charges,Implant Device,994.5,34,,994.5,percent of total billed charges,Implant Device,994.5,34,,994.5,percent of total billed charges,Implant Device,1447.88,,,1447.88,Other,110% of Medicare,1023.75,35,,1023.75,percent of total billed charges,Implant Device,994.5,34,"Charges > $500, x 34%",994.5,percent of total billed charges,Implant Device,1023.75,35,,1023.75,percent of total billed charges,Implant Device,1023.75,35,,1023.75,percent of total billed charges,Implant Device,1023.75,35,,1023.75,percent of total billed charges,Implant Device,1023.75,35,,1023.75,percent of total billed charges,Implant Device,1023.75,35,,1023.75,percent of total billed charges,Implant Device,1170,40,,1170,percent of total billed charges,Implant Device,1023.75,70,,1023.75,percent of total billed charges,All Other,994.5,34,,994.5,percent of total billed charges,Implant Device,994.5,34,,994.5,percent of total billed charges,Implant Device,1023.75,35,,1023.75,percent of total billed charges,Implant Device,1023.75,35,,1023.75,percent of total billed charges,Implant Device,1023.75,35,,1023.75,percent of total billed charges,Implant Device,1023.75,35,,1023.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,994.5,34,"If Charge > 2,000, then 34 percent",994.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2164.51,
ARTHREX AR-1588TB-31B BUTTON FOR ACL'S,C1713,HCPCS,,79013048,CDM,278,RC,,,both,,,825,610.5,,,610.5,Other,150% of Medicare + 9.63% HCRA Surcharge,371.25,45,,371.25,percent of total billed charges,Critical Access Hospital RCC factor,280.5,34,,280.5,percent of total billed charges,Implant Device,280.5,34,,280.5,percent of total billed charges,Implant Device,280.5,34,,280.5,percent of total billed charges,Implant Device,280.5,34,,280.5,percent of total billed charges,Implant Device,280.5,34,,280.5,percent of total billed charges,Implant Device,408.38,,,408.38,Other,110% of Medicare,288.75,35,,288.75,percent of total billed charges,Implant Device,280.5,34,"Charges > $500, x 34%",280.5,percent of total billed charges,Implant Device,288.75,35,,288.75,percent of total billed charges,Implant Device,288.75,35,,288.75,percent of total billed charges,Implant Device,288.75,35,,288.75,percent of total billed charges,Implant Device,288.75,35,,288.75,percent of total billed charges,Implant Device,288.75,35,,288.75,percent of total billed charges,Implant Device,330,40,,330,percent of total billed charges,Implant Device,288.75,70,,288.75,percent of total billed charges,All Other,280.5,34,,280.5,percent of total billed charges,Implant Device,280.5,34,,280.5,percent of total billed charges,Implant Device,288.75,35,,288.75,percent of total billed charges,Implant Device,288.75,35,,288.75,percent of total billed charges,Implant Device,288.75,35,,288.75,percent of total billed charges,Implant Device,288.75,35,,288.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,610.5,
STRYKER 5569-P-2016 HUMERAL STEM 16MM,C1776,HCPCS,,79013049,CDM,278,RC,,,both,,,8925,6604.52,,,6604.52,Other,150% of Medicare + 9.63% HCRA Surcharge,4016.25,45,,4016.25,percent of total billed charges,Critical Access Hospital RCC factor,3034.5,34,,3034.5,percent of total billed charges,Implant Device,3034.5,34,,3034.5,percent of total billed charges,Implant Device,3034.5,34,,3034.5,percent of total billed charges,Implant Device,3034.5,34,,3034.5,percent of total billed charges,Implant Device,3034.5,34,,3034.5,percent of total billed charges,Implant Device,4417.88,,,4417.88,Other,110% of Medicare,3123.75,35,,3123.75,percent of total billed charges,Implant Device,3034.5,34,"Charges > $500, x 34%",3034.5,percent of total billed charges,Implant Device,3123.75,35,,3123.75,percent of total billed charges,Implant Device,3123.75,35,,3123.75,percent of total billed charges,Implant Device,3123.75,35,,3123.75,percent of total billed charges,Implant Device,3123.75,35,,3123.75,percent of total billed charges,Implant Device,3123.75,35,,3123.75,percent of total billed charges,Implant Device,3570,40,,3570,percent of total billed charges,Implant Device,3123.75,70,,3123.75,percent of total billed charges,All Other,3034.5,34,,3034.5,percent of total billed charges,Implant Device,3034.5,34,,3034.5,percent of total billed charges,Implant Device,3123.75,35,,3123.75,percent of total billed charges,Implant Device,3123.75,35,,3123.75,percent of total billed charges,Implant Device,3123.75,35,,3123.75,percent of total billed charges,Implant Device,3123.75,35,,3123.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3034.5,34,"If Charge > 2,000, then 34 percent",3034.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,6604.52,
STRYKER 5571-S-3604-E HUM INSERT 36X4MM,C1776,HCPCS,,79013050,CDM,278,RC,,,both,,,4800,3552.01,,,3552.01,Other,150% of Medicare + 9.63% HCRA Surcharge,2160,45,,2160,percent of total billed charges,Critical Access Hospital RCC factor,1632,34,,1632,percent of total billed charges,Implant Device,1632,34,,1632,percent of total billed charges,Implant Device,1632,34,,1632,percent of total billed charges,Implant Device,1632,34,,1632,percent of total billed charges,Implant Device,1632,34,,1632,percent of total billed charges,Implant Device,2376,,,2376,Other,110% of Medicare,1680,35,,1680,percent of total billed charges,Implant Device,1632,34,"Charges > $500, x 34%",1632,percent of total billed charges,Implant Device,1680,35,,1680,percent of total billed charges,Implant Device,1680,35,,1680,percent of total billed charges,Implant Device,1680,35,,1680,percent of total billed charges,Implant Device,1680,35,,1680,percent of total billed charges,Implant Device,1680,35,,1680,percent of total billed charges,Implant Device,1920,40,,1920,percent of total billed charges,Implant Device,1680,70,,1680,percent of total billed charges,All Other,1632,34,,1632,percent of total billed charges,Implant Device,1632,34,,1632,percent of total billed charges,Implant Device,1680,35,,1680,percent of total billed charges,Implant Device,1680,35,,1680,percent of total billed charges,Implant Device,1680,35,,1680,percent of total billed charges,Implant Device,1680,35,,1680,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1632,34,"If Charge > 2,000, then 34 percent",1632,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3552.01,
STRYKER 5573-C-3606 GLENOSPHERE 36X6MM,C1776,HCPCS,,79013051,CDM,278,RC,,,both,,,6000,4440.02,,,4440.02,Other,150% of Medicare + 9.63% HCRA Surcharge,2700,45,,2700,percent of total billed charges,Critical Access Hospital RCC factor,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2970,,,2970,Other,110% of Medicare,2100,35,,2100,percent of total billed charges,Implant Device,2040,34,"Charges > $500, x 34%",2040,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2400,40,,2400,percent of total billed charges,Implant Device,2100,70,,2100,percent of total billed charges,All Other,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2040,34,"If Charge > 2,000, then 34 percent",2040,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4440.02,
J&J 04.038.195S FENESTRATED SCREW 95MM,C1713,HCPCS,,79013053,CDM,278,RC,,,both,,,1693,1252.82,,,1252.82,Other,150% of Medicare + 9.63% HCRA Surcharge,761.85,45,,761.85,percent of total billed charges,Critical Access Hospital RCC factor,575.62,34,,575.62,percent of total billed charges,Implant Device,575.62,34,,575.62,percent of total billed charges,Implant Device,575.62,34,,575.62,percent of total billed charges,Implant Device,575.62,34,,575.62,percent of total billed charges,Implant Device,575.62,34,,575.62,percent of total billed charges,Implant Device,838.04,,,838.04,Other,110% of Medicare,592.55,35,,592.55,percent of total billed charges,Implant Device,575.62,34,"Charges > $500, x 34%",575.62,percent of total billed charges,Implant Device,592.55,35,,592.55,percent of total billed charges,Implant Device,592.55,35,,592.55,percent of total billed charges,Implant Device,592.55,35,,592.55,percent of total billed charges,Implant Device,592.55,35,,592.55,percent of total billed charges,Implant Device,592.55,35,,592.55,percent of total billed charges,Implant Device,677.2,40,,677.2,percent of total billed charges,Implant Device,592.55,70,,592.55,percent of total billed charges,All Other,575.62,34,,575.62,percent of total billed charges,Implant Device,575.62,34,,575.62,percent of total billed charges,Implant Device,592.55,35,,592.55,percent of total billed charges,Implant Device,592.55,35,,592.55,percent of total billed charges,Implant Device,592.55,35,,592.55,percent of total billed charges,Implant Device,592.55,35,,592.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1252.82,
J&J 04.005.542S LOCKING SCREW 5.0X52MM,C1713,HCPCS,,79013054,CDM,278,RC,,,both,,,412,304.88,,,304.88,Other,150% of Medicare + 9.63% HCRA Surcharge,185.4,45,,185.4,percent of total billed charges,Critical Access Hospital RCC factor,140.08,34,,140.08,percent of total billed charges,Implant Device,140.08,34,,140.08,percent of total billed charges,Implant Device,140.08,34,,140.08,percent of total billed charges,Implant Device,140.08,34,,140.08,percent of total billed charges,Implant Device,140.08,34,,140.08,percent of total billed charges,Implant Device,203.94,,,203.94,Other,110% of Medicare,144.2,35,,144.2,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,144.2,35,,144.2,percent of total billed charges,Implant Device,144.2,35,,144.2,percent of total billed charges,Implant Device,144.2,35,,144.2,percent of total billed charges,Implant Device,144.2,35,,144.2,percent of total billed charges,Implant Device,144.2,35,,144.2,percent of total billed charges,Implant Device,164.8,40,,164.8,percent of total billed charges,Implant Device,144.2,70,,144.2,percent of total billed charges,All Other,140.08,34,,140.08,percent of total billed charges,Implant Device,140.08,34,,140.08,percent of total billed charges,Implant Device,144.2,35,,144.2,percent of total billed charges,Implant Device,144.2,35,,144.2,percent of total billed charges,Implant Device,144.2,35,,144.2,percent of total billed charges,Implant Device,144.2,35,,144.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,304.88,
J&J 04.005.562S LOCKING SCREW 5.0X72MM,C1713,HCPCS,,79013055,CDM,278,RC,,,both,,,412,304.88,,,304.88,Other,150% of Medicare + 9.63% HCRA Surcharge,185.4,45,,185.4,percent of total billed charges,Critical Access Hospital RCC factor,140.08,34,,140.08,percent of total billed charges,Implant Device,140.08,34,,140.08,percent of total billed charges,Implant Device,140.08,34,,140.08,percent of total billed charges,Implant Device,140.08,34,,140.08,percent of total billed charges,Implant Device,140.08,34,,140.08,percent of total billed charges,Implant Device,203.94,,,203.94,Other,110% of Medicare,144.2,35,,144.2,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,144.2,35,,144.2,percent of total billed charges,Implant Device,144.2,35,,144.2,percent of total billed charges,Implant Device,144.2,35,,144.2,percent of total billed charges,Implant Device,144.2,35,,144.2,percent of total billed charges,Implant Device,144.2,35,,144.2,percent of total billed charges,Implant Device,164.8,40,,164.8,percent of total billed charges,Implant Device,144.2,70,,144.2,percent of total billed charges,All Other,140.08,34,,140.08,percent of total billed charges,Implant Device,140.08,34,,140.08,percent of total billed charges,Implant Device,144.2,35,,144.2,percent of total billed charges,Implant Device,144.2,35,,144.2,percent of total billed charges,Implant Device,144.2,35,,144.2,percent of total billed charges,Implant Device,144.2,35,,144.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,304.88,
J&J 04.037.230S TFNA NAIL 12X400 125 DEG,C1889,HCPCS,,79013056,CDM,278,RC,,,both,,,5467,4045.59,,,4045.59,Other,150% of Medicare + 9.63% HCRA Surcharge,2460.15,45,,2460.15,percent of total billed charges,Critical Access Hospital RCC factor,1858.78,34,,1858.78,percent of total billed charges,Implant Device,1858.78,34,,1858.78,percent of total billed charges,Implant Device,1858.78,34,,1858.78,percent of total billed charges,Implant Device,1858.78,34,,1858.78,percent of total billed charges,Implant Device,1858.78,34,,1858.78,percent of total billed charges,Implant Device,2706.17,,,2706.17,Other,110% of Medicare,1913.45,35,,1913.45,percent of total billed charges,Implant Device,1858.78,34,"Charges > $500, x 34%",1858.78,percent of total billed charges,Implant Device,1913.45,35,,1913.45,percent of total billed charges,Implant Device,1913.45,35,,1913.45,percent of total billed charges,Implant Device,1913.45,35,,1913.45,percent of total billed charges,Implant Device,1913.45,35,,1913.45,percent of total billed charges,Implant Device,1913.45,35,,1913.45,percent of total billed charges,Implant Device,2186.8,40,,2186.8,percent of total billed charges,Implant Device,1913.45,70,,1913.45,percent of total billed charges,All Other,1858.78,34,,1858.78,percent of total billed charges,Implant Device,1858.78,34,,1858.78,percent of total billed charges,Implant Device,1913.45,35,,1913.45,percent of total billed charges,Implant Device,1913.45,35,,1913.45,percent of total billed charges,Implant Device,1913.45,35,,1913.45,percent of total billed charges,Implant Device,1913.45,35,,1913.45,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1858.78,34,"If Charge > 2,000, then 34 percent",1858.78,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4045.59,
ZIMMER 00-8777-028-04 FEM HEAD 28X+7MM,C1776,HCPCS,,79013062,CDM,278,RC,,,both,,,4950,3663.01,,,3663.01,Other,150% of Medicare + 9.63% HCRA Surcharge,2227.5,45,,2227.5,percent of total billed charges,Critical Access Hospital RCC factor,1683,34,,1683,percent of total billed charges,Implant Device,1683,34,,1683,percent of total billed charges,Implant Device,1683,34,,1683,percent of total billed charges,Implant Device,1683,34,,1683,percent of total billed charges,Implant Device,1683,34,,1683,percent of total billed charges,Implant Device,2450.25,,,2450.25,Other,110% of Medicare,1732.5,35,,1732.5,percent of total billed charges,Implant Device,1683,34,"Charges > $500, x 34%",1683,percent of total billed charges,Implant Device,1732.5,35,,1732.5,percent of total billed charges,Implant Device,1732.5,35,,1732.5,percent of total billed charges,Implant Device,1732.5,35,,1732.5,percent of total billed charges,Implant Device,1732.5,35,,1732.5,percent of total billed charges,Implant Device,1732.5,35,,1732.5,percent of total billed charges,Implant Device,1980,40,,1980,percent of total billed charges,Implant Device,1732.5,70,,1732.5,percent of total billed charges,All Other,1683,34,,1683,percent of total billed charges,Implant Device,1683,34,,1683,percent of total billed charges,Implant Device,1732.5,35,,1732.5,percent of total billed charges,Implant Device,1732.5,35,,1732.5,percent of total billed charges,Implant Device,1732.5,35,,1732.5,percent of total billed charges,Implant Device,1732.5,35,,1732.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1683,34,"If Charge > 2,000, then 34 percent",1683,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3663.01,
ZIMMER 110031001 BEARING 28X46MM,C1776,HCPCS,,79013063,CDM,278,RC,,,both,,,2304,1704.97,,,1704.97,Other,150% of Medicare + 9.63% HCRA Surcharge,1036.8,45,,1036.8,percent of total billed charges,Critical Access Hospital RCC factor,783.36,34,,783.36,percent of total billed charges,Implant Device,783.36,34,,783.36,percent of total billed charges,Implant Device,783.36,34,,783.36,percent of total billed charges,Implant Device,783.36,34,,783.36,percent of total billed charges,Implant Device,783.36,34,,783.36,percent of total billed charges,Implant Device,1140.48,,,1140.48,Other,110% of Medicare,806.4,35,,806.4,percent of total billed charges,Implant Device,783.36,34,"Charges > $500, x 34%",783.36,percent of total billed charges,Implant Device,806.4,35,,806.4,percent of total billed charges,Implant Device,806.4,35,,806.4,percent of total billed charges,Implant Device,806.4,35,,806.4,percent of total billed charges,Implant Device,806.4,35,,806.4,percent of total billed charges,Implant Device,806.4,35,,806.4,percent of total billed charges,Implant Device,921.6,40,,921.6,percent of total billed charges,Implant Device,806.4,70,,806.4,percent of total billed charges,All Other,783.36,34,,783.36,percent of total billed charges,Implant Device,783.36,34,,783.36,percent of total billed charges,Implant Device,806.4,35,,806.4,percent of total billed charges,Implant Device,806.4,35,,806.4,percent of total billed charges,Implant Device,806.4,35,,806.4,percent of total billed charges,Implant Device,806.4,35,,806.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,783.36,34,"If Charge > 2,000, then 34 percent",783.36,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1704.97,
J&J 76000040 FIBERGRAFT PUTTY 4CC,C1713,HCPCS,,79013064,CDM,278,RC,,,both,,,2850,2109.01,,,2109.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1282.5,45,,1282.5,percent of total billed charges,Critical Access Hospital RCC factor,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,1410.75,,,1410.75,Other,110% of Medicare,997.5,35,,997.5,percent of total billed charges,Implant Device,969,34,"Charges > $500, x 34%",969,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,1140,40,,1140,percent of total billed charges,Implant Device,997.5,70,,997.5,percent of total billed charges,All Other,969,34,,969,percent of total billed charges,Implant Device,969,34,,969,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,997.5,35,,997.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,969,34,"If Charge > 2,000, then 34 percent",969,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2109.01,
ALLERGAN SCF-325 BREAST IMPLANT 325CC,C1789,HCPCS,,79013065,CDM,278,RC,,,both,,,3975,2941.51,,,2941.51,Other,150% of Medicare + 9.63% HCRA Surcharge,1788.75,45,,1788.75,percent of total billed charges,Critical Access Hospital RCC factor,1351.5,34,,1351.5,percent of total billed charges,Implant Device,1351.5,34,,1351.5,percent of total billed charges,Implant Device,1351.5,34,,1351.5,percent of total billed charges,Implant Device,1351.5,34,,1351.5,percent of total billed charges,Implant Device,1351.5,34,,1351.5,percent of total billed charges,Implant Device,1967.63,,,1967.63,Other,110% of Medicare,1391.25,35,,1391.25,percent of total billed charges,Implant Device,1351.5,34,"Charges > $500, x 34%",1351.5,percent of total billed charges,Implant Device,1391.25,35,,1391.25,percent of total billed charges,Implant Device,1391.25,35,,1391.25,percent of total billed charges,Implant Device,1391.25,35,,1391.25,percent of total billed charges,Implant Device,1391.25,35,,1391.25,percent of total billed charges,Implant Device,1391.25,35,,1391.25,percent of total billed charges,Implant Device,1590,40,,1590,percent of total billed charges,Implant Device,1391.25,70,,1391.25,percent of total billed charges,All Other,1351.5,34,,1351.5,percent of total billed charges,Implant Device,1351.5,34,,1351.5,percent of total billed charges,Implant Device,1391.25,35,,1391.25,percent of total billed charges,Implant Device,1391.25,35,,1391.25,percent of total billed charges,Implant Device,1391.25,35,,1391.25,percent of total billed charges,Implant Device,1391.25,35,,1391.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1351.5,34,"If Charge > 2,000, then 34 percent",1351.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2941.51,
ALLERGAN SCF-335 BREAST IMPLANT 335CC,C1789,HCPCS,,79013066,CDM,278,RC,,,both,,,3975,2941.51,,,2941.51,Other,150% of Medicare + 9.63% HCRA Surcharge,1788.75,45,,1788.75,percent of total billed charges,Critical Access Hospital RCC factor,1351.5,34,,1351.5,percent of total billed charges,Implant Device,1351.5,34,,1351.5,percent of total billed charges,Implant Device,1351.5,34,,1351.5,percent of total billed charges,Implant Device,1351.5,34,,1351.5,percent of total billed charges,Implant Device,1351.5,34,,1351.5,percent of total billed charges,Implant Device,1967.63,,,1967.63,Other,110% of Medicare,1391.25,35,,1391.25,percent of total billed charges,Implant Device,1351.5,34,"Charges > $500, x 34%",1351.5,percent of total billed charges,Implant Device,1391.25,35,,1391.25,percent of total billed charges,Implant Device,1391.25,35,,1391.25,percent of total billed charges,Implant Device,1391.25,35,,1391.25,percent of total billed charges,Implant Device,1391.25,35,,1391.25,percent of total billed charges,Implant Device,1391.25,35,,1391.25,percent of total billed charges,Implant Device,1590,40,,1590,percent of total billed charges,Implant Device,1391.25,70,,1391.25,percent of total billed charges,All Other,1351.5,34,,1351.5,percent of total billed charges,Implant Device,1351.5,34,,1351.5,percent of total billed charges,Implant Device,1391.25,35,,1391.25,percent of total billed charges,Implant Device,1391.25,35,,1391.25,percent of total billed charges,Implant Device,1391.25,35,,1391.25,percent of total billed charges,Implant Device,1391.25,35,,1391.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1351.5,34,"If Charge > 2,000, then 34 percent",1351.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2941.51,
ALLERGAN SCF-345 BREAST IMPLANT 345CC,C1789,HCPCS,,79013067,CDM,278,RC,,,both,,,3975,2941.51,,,2941.51,Other,150% of Medicare + 9.63% HCRA Surcharge,1788.75,45,,1788.75,percent of total billed charges,Critical Access Hospital RCC factor,1351.5,34,,1351.5,percent of total billed charges,Implant Device,1351.5,34,,1351.5,percent of total billed charges,Implant Device,1351.5,34,,1351.5,percent of total billed charges,Implant Device,1351.5,34,,1351.5,percent of total billed charges,Implant Device,1351.5,34,,1351.5,percent of total billed charges,Implant Device,1967.63,,,1967.63,Other,110% of Medicare,1391.25,35,,1391.25,percent of total billed charges,Implant Device,1351.5,34,"Charges > $500, x 34%",1351.5,percent of total billed charges,Implant Device,1391.25,35,,1391.25,percent of total billed charges,Implant Device,1391.25,35,,1391.25,percent of total billed charges,Implant Device,1391.25,35,,1391.25,percent of total billed charges,Implant Device,1391.25,35,,1391.25,percent of total billed charges,Implant Device,1391.25,35,,1391.25,percent of total billed charges,Implant Device,1590,40,,1590,percent of total billed charges,Implant Device,1391.25,70,,1391.25,percent of total billed charges,All Other,1351.5,34,,1351.5,percent of total billed charges,Implant Device,1351.5,34,,1351.5,percent of total billed charges,Implant Device,1391.25,35,,1391.25,percent of total billed charges,Implant Device,1391.25,35,,1391.25,percent of total billed charges,Implant Device,1391.25,35,,1391.25,percent of total billed charges,Implant Device,1391.25,35,,1391.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1351.5,34,"If Charge > 2,000, then 34 percent",1351.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2941.51,
ALLERGAN SCM-295 BREAST IMPLANT 295CC,C1789,HCPCS,,79013071,CDM,278,RC,,,both,,,3975,2941.51,,,2941.51,Other,150% of Medicare + 9.63% HCRA Surcharge,1788.75,45,,1788.75,percent of total billed charges,Critical Access Hospital RCC factor,1351.5,34,,1351.5,percent of total billed charges,Implant Device,1351.5,34,,1351.5,percent of total billed charges,Implant Device,1351.5,34,,1351.5,percent of total billed charges,Implant Device,1351.5,34,,1351.5,percent of total billed charges,Implant Device,1351.5,34,,1351.5,percent of total billed charges,Implant Device,1967.63,,,1967.63,Other,110% of Medicare,1391.25,35,,1391.25,percent of total billed charges,Implant Device,1351.5,34,"Charges > $500, x 34%",1351.5,percent of total billed charges,Implant Device,1391.25,35,,1391.25,percent of total billed charges,Implant Device,1391.25,35,,1391.25,percent of total billed charges,Implant Device,1391.25,35,,1391.25,percent of total billed charges,Implant Device,1391.25,35,,1391.25,percent of total billed charges,Implant Device,1391.25,35,,1391.25,percent of total billed charges,Implant Device,1590,40,,1590,percent of total billed charges,Implant Device,1391.25,70,,1391.25,percent of total billed charges,All Other,1351.5,34,,1351.5,percent of total billed charges,Implant Device,1351.5,34,,1351.5,percent of total billed charges,Implant Device,1391.25,35,,1391.25,percent of total billed charges,Implant Device,1391.25,35,,1391.25,percent of total billed charges,Implant Device,1391.25,35,,1391.25,percent of total billed charges,Implant Device,1391.25,35,,1391.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1351.5,34,"If Charge > 2,000, then 34 percent",1351.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2941.51,
ALLERGAN SCM-310 BREAST IMPLANT 310CC,C1789,HCPCS,,79013072,CDM,278,RC,,,both,,,3975,2941.51,,,2941.51,Other,150% of Medicare + 9.63% HCRA Surcharge,1788.75,45,,1788.75,percent of total billed charges,Critical Access Hospital RCC factor,1351.5,34,,1351.5,percent of total billed charges,Implant Device,1351.5,34,,1351.5,percent of total billed charges,Implant Device,1351.5,34,,1351.5,percent of total billed charges,Implant Device,1351.5,34,,1351.5,percent of total billed charges,Implant Device,1351.5,34,,1351.5,percent of total billed charges,Implant Device,1967.63,,,1967.63,Other,110% of Medicare,1391.25,35,,1391.25,percent of total billed charges,Implant Device,1351.5,34,"Charges > $500, x 34%",1351.5,percent of total billed charges,Implant Device,1391.25,35,,1391.25,percent of total billed charges,Implant Device,1391.25,35,,1391.25,percent of total billed charges,Implant Device,1391.25,35,,1391.25,percent of total billed charges,Implant Device,1391.25,35,,1391.25,percent of total billed charges,Implant Device,1391.25,35,,1391.25,percent of total billed charges,Implant Device,1590,40,,1590,percent of total billed charges,Implant Device,1391.25,70,,1391.25,percent of total billed charges,All Other,1351.5,34,,1351.5,percent of total billed charges,Implant Device,1351.5,34,,1351.5,percent of total billed charges,Implant Device,1391.25,35,,1391.25,percent of total billed charges,Implant Device,1391.25,35,,1391.25,percent of total billed charges,Implant Device,1391.25,35,,1391.25,percent of total billed charges,Implant Device,1391.25,35,,1391.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1351.5,34,"If Charge > 2,000, then 34 percent",1351.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2941.51,
ZIMMER 574203000 FEMORAL STEM SIZE 0,C1776,HCPCS,,79013076,CDM,278,RC,,,both,,,6912,5114.9,,,5114.9,Other,150% of Medicare + 9.63% HCRA Surcharge,3110.4,45,,3110.4,percent of total billed charges,Critical Access Hospital RCC factor,2350.08,34,,2350.08,percent of total billed charges,Implant Device,2350.08,34,,2350.08,percent of total billed charges,Implant Device,2350.08,34,,2350.08,percent of total billed charges,Implant Device,2350.08,34,,2350.08,percent of total billed charges,Implant Device,2350.08,34,,2350.08,percent of total billed charges,Implant Device,3421.44,,,3421.44,Other,110% of Medicare,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2350.08,34,"Charges > $500, x 34%",2350.08,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2764.8,40,,2764.8,percent of total billed charges,Implant Device,2419.2,70,,2419.2,percent of total billed charges,All Other,2350.08,34,,2350.08,percent of total billed charges,Implant Device,2350.08,34,,2350.08,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2350.08,34,"If Charge > 2,000, then 34 percent",2350.08,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5114.9,
ZIMMER 802202201 FEMORAL HEAD 22MM,C1776,HCPCS,,79013077,CDM,278,RC,,,both,,,1445,1069.3,,,1069.3,Other,150% of Medicare + 9.63% HCRA Surcharge,650.25,45,,650.25,percent of total billed charges,Critical Access Hospital RCC factor,491.3,34,,491.3,percent of total billed charges,Implant Device,491.3,34,,491.3,percent of total billed charges,Implant Device,491.3,34,,491.3,percent of total billed charges,Implant Device,491.3,34,,491.3,percent of total billed charges,Implant Device,491.3,34,,491.3,percent of total billed charges,Implant Device,715.28,,,715.28,Other,110% of Medicare,505.75,35,,505.75,percent of total billed charges,Implant Device,491.3,34,"Charges > $500, x 34%",491.3,percent of total billed charges,Implant Device,505.75,35,,505.75,percent of total billed charges,Implant Device,505.75,35,,505.75,percent of total billed charges,Implant Device,505.75,35,,505.75,percent of total billed charges,Implant Device,505.75,35,,505.75,percent of total billed charges,Implant Device,505.75,35,,505.75,percent of total billed charges,Implant Device,578,40,,578,percent of total billed charges,Implant Device,505.75,70,,505.75,percent of total billed charges,All Other,491.3,34,,491.3,percent of total billed charges,Implant Device,491.3,34,,491.3,percent of total billed charges,Implant Device,505.75,35,,505.75,percent of total billed charges,Implant Device,505.75,35,,505.75,percent of total billed charges,Implant Device,505.75,35,,505.75,percent of total billed charges,Implant Device,505.75,35,,505.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1069.3,
ARTHREX AR-8933VCL-12 KREULOCK SRW 3X12,C1713,HCPCS,,79013080,CDM,278,RC,,,both,,,959,709.66,,,709.66,Other,150% of Medicare + 9.63% HCRA Surcharge,431.55,45,,431.55,percent of total billed charges,Critical Access Hospital RCC factor,326.06,34,,326.06,percent of total billed charges,Implant Device,326.06,34,,326.06,percent of total billed charges,Implant Device,326.06,34,,326.06,percent of total billed charges,Implant Device,326.06,34,,326.06,percent of total billed charges,Implant Device,326.06,34,,326.06,percent of total billed charges,Implant Device,474.71,,,474.71,Other,110% of Medicare,335.65,35,,335.65,percent of total billed charges,Implant Device,326.06,34,"Charges > $500, x 34%",326.06,percent of total billed charges,Implant Device,335.65,35,,335.65,percent of total billed charges,Implant Device,335.65,35,,335.65,percent of total billed charges,Implant Device,335.65,35,,335.65,percent of total billed charges,Implant Device,335.65,35,,335.65,percent of total billed charges,Implant Device,335.65,35,,335.65,percent of total billed charges,Implant Device,383.6,40,,383.6,percent of total billed charges,Implant Device,335.65,70,,335.65,percent of total billed charges,All Other,326.06,34,,326.06,percent of total billed charges,Implant Device,326.06,34,,326.06,percent of total billed charges,Implant Device,335.65,35,,335.65,percent of total billed charges,Implant Device,335.65,35,,335.65,percent of total billed charges,Implant Device,335.65,35,,335.65,percent of total billed charges,Implant Device,335.65,35,,335.65,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,709.66,
ARTHREX AR-8935CLC-12 KREULOCK SR 3.5X12,C1713,HCPCS,,79013081,CDM,278,RC,,,both,,,885,654.9,,,654.9,Other,150% of Medicare + 9.63% HCRA Surcharge,398.25,45,,398.25,percent of total billed charges,Critical Access Hospital RCC factor,300.9,34,,300.9,percent of total billed charges,Implant Device,300.9,34,,300.9,percent of total billed charges,Implant Device,300.9,34,,300.9,percent of total billed charges,Implant Device,300.9,34,,300.9,percent of total billed charges,Implant Device,300.9,34,,300.9,percent of total billed charges,Implant Device,438.08,,,438.08,Other,110% of Medicare,309.75,35,,309.75,percent of total billed charges,Implant Device,300.9,34,"Charges > $500, x 34%",300.9,percent of total billed charges,Implant Device,309.75,35,,309.75,percent of total billed charges,Implant Device,309.75,35,,309.75,percent of total billed charges,Implant Device,309.75,35,,309.75,percent of total billed charges,Implant Device,309.75,35,,309.75,percent of total billed charges,Implant Device,309.75,35,,309.75,percent of total billed charges,Implant Device,354,40,,354,percent of total billed charges,Implant Device,309.75,70,,309.75,percent of total billed charges,All Other,300.9,34,,300.9,percent of total billed charges,Implant Device,300.9,34,,300.9,percent of total billed charges,Implant Device,309.75,35,,309.75,percent of total billed charges,Implant Device,309.75,35,,309.75,percent of total billed charges,Implant Device,309.75,35,,309.75,percent of total billed charges,Implant Device,309.75,35,,309.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,654.9,
ARTHREX AR-8935CLC-16 KREULOCK SR 3.5X16,C1713,HCPCS,,79013082,CDM,278,RC,,,both,,,885,654.9,,,654.9,Other,150% of Medicare + 9.63% HCRA Surcharge,398.25,45,,398.25,percent of total billed charges,Critical Access Hospital RCC factor,300.9,34,,300.9,percent of total billed charges,Implant Device,300.9,34,,300.9,percent of total billed charges,Implant Device,300.9,34,,300.9,percent of total billed charges,Implant Device,300.9,34,,300.9,percent of total billed charges,Implant Device,300.9,34,,300.9,percent of total billed charges,Implant Device,438.08,,,438.08,Other,110% of Medicare,309.75,35,,309.75,percent of total billed charges,Implant Device,300.9,34,"Charges > $500, x 34%",300.9,percent of total billed charges,Implant Device,309.75,35,,309.75,percent of total billed charges,Implant Device,309.75,35,,309.75,percent of total billed charges,Implant Device,309.75,35,,309.75,percent of total billed charges,Implant Device,309.75,35,,309.75,percent of total billed charges,Implant Device,309.75,35,,309.75,percent of total billed charges,Implant Device,354,40,,354,percent of total billed charges,Implant Device,309.75,70,,309.75,percent of total billed charges,All Other,300.9,34,,300.9,percent of total billed charges,Implant Device,300.9,34,,300.9,percent of total billed charges,Implant Device,309.75,35,,309.75,percent of total billed charges,Implant Device,309.75,35,,309.75,percent of total billed charges,Implant Device,309.75,35,,309.75,percent of total billed charges,Implant Device,309.75,35,,309.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,654.9,
ARTHREX AR-9943BR-05 PLATE 5 HOLE,C1713,HCPCS,,79013083,CDM,278,RC,,,both,,,2100,1554.01,,,1554.01,Other,150% of Medicare + 9.63% HCRA Surcharge,945,45,,945,percent of total billed charges,Critical Access Hospital RCC factor,714,34,,714,percent of total billed charges,Implant Device,714,34,,714,percent of total billed charges,Implant Device,714,34,,714,percent of total billed charges,Implant Device,714,34,,714,percent of total billed charges,Implant Device,714,34,,714,percent of total billed charges,Implant Device,1039.5,,,1039.5,Other,110% of Medicare,735,35,,735,percent of total billed charges,Implant Device,714,34,"Charges > $500, x 34%",714,percent of total billed charges,Implant Device,735,35,,735,percent of total billed charges,Implant Device,735,35,,735,percent of total billed charges,Implant Device,735,35,,735,percent of total billed charges,Implant Device,735,35,,735,percent of total billed charges,Implant Device,735,35,,735,percent of total billed charges,Implant Device,840,40,,840,percent of total billed charges,Implant Device,735,70,,735,percent of total billed charges,All Other,714,34,,714,percent of total billed charges,Implant Device,714,34,,714,percent of total billed charges,Implant Device,735,35,,735,percent of total billed charges,Implant Device,735,35,,735,percent of total billed charges,Implant Device,735,35,,735,percent of total billed charges,Implant Device,735,35,,735,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,714,34,"If Charge > 2,000, then 34 percent",714,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1554.01,
ZIMMER 42-5221-009-18 ART SURF RT 18MM,C1776,HCPCS,,79013084,CDM,278,RC,,,both,,,3648,2699.53,,,2699.53,Other,150% of Medicare + 9.63% HCRA Surcharge,1641.6,45,,1641.6,percent of total billed charges,Critical Access Hospital RCC factor,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1805.76,,,1805.76,Other,110% of Medicare,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1240.32,34,"Charges > $500, x 34%",1240.32,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1459.2,40,,1459.2,percent of total billed charges,Implant Device,1276.8,70,,1276.8,percent of total billed charges,All Other,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1240.32,34,"If Charge > 2,000, then 34 percent",1240.32,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2699.53,
STRYKER 326080 CANNULATED SCREW 6.5X80MM,C1713,HCPCS,,79013085,CDM,278,RC,,,both,,,765,566.1,,,566.1,Other,150% of Medicare + 9.63% HCRA Surcharge,344.25,45,,344.25,percent of total billed charges,Critical Access Hospital RCC factor,260.1,34,,260.1,percent of total billed charges,Implant Device,260.1,34,,260.1,percent of total billed charges,Implant Device,260.1,34,,260.1,percent of total billed charges,Implant Device,260.1,34,,260.1,percent of total billed charges,Implant Device,260.1,34,,260.1,percent of total billed charges,Implant Device,378.68,,,378.68,Other,110% of Medicare,267.75,35,,267.75,percent of total billed charges,Implant Device,260.1,34,"Charges > $500, x 34%",260.1,percent of total billed charges,Implant Device,267.75,35,,267.75,percent of total billed charges,Implant Device,267.75,35,,267.75,percent of total billed charges,Implant Device,267.75,35,,267.75,percent of total billed charges,Implant Device,267.75,35,,267.75,percent of total billed charges,Implant Device,267.75,35,,267.75,percent of total billed charges,Implant Device,306,40,,306,percent of total billed charges,Implant Device,267.75,70,,267.75,percent of total billed charges,All Other,260.1,34,,260.1,percent of total billed charges,Implant Device,260.1,34,,260.1,percent of total billed charges,Implant Device,267.75,35,,267.75,percent of total billed charges,Implant Device,267.75,35,,267.75,percent of total billed charges,Implant Device,267.75,35,,267.75,percent of total billed charges,Implant Device,267.75,35,,267.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,566.1,
J&J 04.045.038S LOCKING SCREW 5X38MM,C1713,HCPCS,,79013086,CDM,278,RC,,,both,,,687,508.38,,,508.38,Other,150% of Medicare + 9.63% HCRA Surcharge,309.15,45,,309.15,percent of total billed charges,Critical Access Hospital RCC factor,233.58,34,,233.58,percent of total billed charges,Implant Device,233.58,34,,233.58,percent of total billed charges,Implant Device,233.58,34,,233.58,percent of total billed charges,Implant Device,233.58,34,,233.58,percent of total billed charges,Implant Device,233.58,34,,233.58,percent of total billed charges,Implant Device,340.07,,,340.07,Other,110% of Medicare,240.45,35,,240.45,percent of total billed charges,Implant Device,233.58,34,"Charges > $500, x 34%",233.58,percent of total billed charges,Implant Device,240.45,35,,240.45,percent of total billed charges,Implant Device,240.45,35,,240.45,percent of total billed charges,Implant Device,240.45,35,,240.45,percent of total billed charges,Implant Device,240.45,35,,240.45,percent of total billed charges,Implant Device,240.45,35,,240.45,percent of total billed charges,Implant Device,274.8,40,,274.8,percent of total billed charges,Implant Device,240.45,70,,240.45,percent of total billed charges,All Other,233.58,34,,233.58,percent of total billed charges,Implant Device,233.58,34,,233.58,percent of total billed charges,Implant Device,240.45,35,,240.45,percent of total billed charges,Implant Device,240.45,35,,240.45,percent of total billed charges,Implant Device,240.45,35,,240.45,percent of total billed charges,Implant Device,240.45,35,,240.45,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,508.38,
ZIMMER 574102085 FEMORAL HEAD 36X3.5MM,C1776,HCPCS,,79013087,CDM,278,RC,,,both,,,6912,5114.9,,,5114.9,Other,150% of Medicare + 9.63% HCRA Surcharge,3110.4,45,,3110.4,percent of total billed charges,Critical Access Hospital RCC factor,2350.08,34,,2350.08,percent of total billed charges,Implant Device,2350.08,34,,2350.08,percent of total billed charges,Implant Device,2350.08,34,,2350.08,percent of total billed charges,Implant Device,2350.08,34,,2350.08,percent of total billed charges,Implant Device,2350.08,34,,2350.08,percent of total billed charges,Implant Device,3421.44,,,3421.44,Other,110% of Medicare,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2350.08,34,"Charges > $500, x 34%",2350.08,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2764.8,40,,2764.8,percent of total billed charges,Implant Device,2419.2,70,,2419.2,percent of total billed charges,All Other,2350.08,34,,2350.08,percent of total billed charges,Implant Device,2350.08,34,,2350.08,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,2419.2,35,,2419.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2350.08,34,"If Charge > 2,000, then 34 percent",2350.08,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5114.9,
ARTHREX AR-8935-121 KREULOCK SRW 3.5X12,C1713,HCPCS,,79013088,CDM,278,RC,,,both,,,180,133.2,,,133.2,Other,150% of Medicare + 9.63% HCRA Surcharge,81,45,,81,percent of total billed charges,Critical Access Hospital RCC factor,61.2,34,,61.2,percent of total billed charges,Implant Device,61.2,34,,61.2,percent of total billed charges,Implant Device,61.2,34,,61.2,percent of total billed charges,Implant Device,61.2,34,,61.2,percent of total billed charges,Implant Device,61.2,34,,61.2,percent of total billed charges,Implant Device,89.1,,,89.1,Other,110% of Medicare,63,35,,63,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,63,35,,63,percent of total billed charges,Implant Device,63,35,,63,percent of total billed charges,Implant Device,63,35,,63,percent of total billed charges,Implant Device,63,35,,63,percent of total billed charges,Implant Device,63,35,,63,percent of total billed charges,Implant Device,72,40,,72,percent of total billed charges,Implant Device,63,70,,63,percent of total billed charges,All Other,61.2,34,,61.2,percent of total billed charges,Implant Device,61.2,34,,61.2,percent of total billed charges,Implant Device,63,35,,63,percent of total billed charges,Implant Device,63,35,,63,percent of total billed charges,Implant Device,63,35,,63,percent of total billed charges,Implant Device,63,35,,63,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,133.2,
STRYKER 1059-4513 DISTAL SPACER MED 13MM,C1776,HCPCS,,79013091,CDM,278,RC,,,both,,,168,124.32,,,124.32,Other,150% of Medicare + 9.63% HCRA Surcharge,75.6,45,,75.6,percent of total billed charges,Critical Access Hospital RCC factor,57.12,34,,57.12,percent of total billed charges,Implant Device,57.12,34,,57.12,percent of total billed charges,Implant Device,57.12,34,,57.12,percent of total billed charges,Implant Device,57.12,34,,57.12,percent of total billed charges,Implant Device,57.12,34,,57.12,percent of total billed charges,Implant Device,83.16,,,83.16,Other,110% of Medicare,58.8,35,,58.8,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,58.8,35,,58.8,percent of total billed charges,Implant Device,58.8,35,,58.8,percent of total billed charges,Implant Device,58.8,35,,58.8,percent of total billed charges,Implant Device,58.8,35,,58.8,percent of total billed charges,Implant Device,58.8,35,,58.8,percent of total billed charges,Implant Device,67.2,40,,67.2,percent of total billed charges,Implant Device,58.8,70,,58.8,percent of total billed charges,All Other,57.12,34,,57.12,percent of total billed charges,Implant Device,57.12,34,,57.12,percent of total billed charges,Implant Device,58.8,35,,58.8,percent of total billed charges,Implant Device,58.8,35,,58.8,percent of total billed charges,Implant Device,58.8,35,,58.8,percent of total billed charges,Implant Device,58.8,35,,58.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,124.32,
STRYKER 6364-2-126 FEMORAL HEAD 26X0MM,C1776,HCPCS,,79013092,CDM,278,RC,,,both,,,1391,1029.34,,,1029.34,Other,150% of Medicare + 9.63% HCRA Surcharge,625.95,45,,625.95,percent of total billed charges,Critical Access Hospital RCC factor,472.94,34,,472.94,percent of total billed charges,Implant Device,472.94,34,,472.94,percent of total billed charges,Implant Device,472.94,34,,472.94,percent of total billed charges,Implant Device,472.94,34,,472.94,percent of total billed charges,Implant Device,472.94,34,,472.94,percent of total billed charges,Implant Device,688.55,,,688.55,Other,110% of Medicare,486.85,35,,486.85,percent of total billed charges,Implant Device,472.94,34,"Charges > $500, x 34%",472.94,percent of total billed charges,Implant Device,486.85,35,,486.85,percent of total billed charges,Implant Device,486.85,35,,486.85,percent of total billed charges,Implant Device,486.85,35,,486.85,percent of total billed charges,Implant Device,486.85,35,,486.85,percent of total billed charges,Implant Device,486.85,35,,486.85,percent of total billed charges,Implant Device,556.4,40,,556.4,percent of total billed charges,Implant Device,486.85,70,,486.85,percent of total billed charges,All Other,472.94,34,,472.94,percent of total billed charges,Implant Device,472.94,34,,472.94,percent of total billed charges,Implant Device,486.85,35,,486.85,percent of total billed charges,Implant Device,486.85,35,,486.85,percent of total billed charges,Implant Device,486.85,35,,486.85,percent of total billed charges,Implant Device,486.85,35,,486.85,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1029.34,
STRYKER 6485-3-817 FEMORAL STEM 17X127,C1776,HCPCS,,79013093,CDM,278,RC,,,both,,,7254,5367.98,,,5367.98,Other,150% of Medicare + 9.63% HCRA Surcharge,3264.3,45,,3264.3,percent of total billed charges,Critical Access Hospital RCC factor,2466.36,34,,2466.36,percent of total billed charges,Implant Device,2466.36,34,,2466.36,percent of total billed charges,Implant Device,2466.36,34,,2466.36,percent of total billed charges,Implant Device,2466.36,34,,2466.36,percent of total billed charges,Implant Device,2466.36,34,,2466.36,percent of total billed charges,Implant Device,3590.73,,,3590.73,Other,110% of Medicare,2538.9,35,,2538.9,percent of total billed charges,Implant Device,2466.36,34,"Charges > $500, x 34%",2466.36,percent of total billed charges,Implant Device,2538.9,35,,2538.9,percent of total billed charges,Implant Device,2538.9,35,,2538.9,percent of total billed charges,Implant Device,2538.9,35,,2538.9,percent of total billed charges,Implant Device,2538.9,35,,2538.9,percent of total billed charges,Implant Device,2538.9,35,,2538.9,percent of total billed charges,Implant Device,2901.6,40,,2901.6,percent of total billed charges,Implant Device,2538.9,70,,2538.9,percent of total billed charges,All Other,2466.36,34,,2466.36,percent of total billed charges,Implant Device,2466.36,34,,2466.36,percent of total billed charges,Implant Device,2538.9,35,,2538.9,percent of total billed charges,Implant Device,2538.9,35,,2538.9,percent of total billed charges,Implant Device,2538.9,35,,2538.9,percent of total billed charges,Implant Device,2538.9,35,,2538.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2466.36,34,"If Charge > 2,000, then 34 percent",2466.36,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5367.98,
J&J 1504-00-204 FEMORAL SIZE 4 RIGHT,C1776,HCPCS,,79013094,CDM,278,RC,,,both,,,4800,3552.01,,,3552.01,Other,150% of Medicare + 9.63% HCRA Surcharge,2160,45,,2160,percent of total billed charges,Critical Access Hospital RCC factor,1632,34,,1632,percent of total billed charges,Implant Device,1632,34,,1632,percent of total billed charges,Implant Device,1632,34,,1632,percent of total billed charges,Implant Device,1632,34,,1632,percent of total billed charges,Implant Device,1632,34,,1632,percent of total billed charges,Implant Device,2376,,,2376,Other,110% of Medicare,1680,35,,1680,percent of total billed charges,Implant Device,1632,34,"Charges > $500, x 34%",1632,percent of total billed charges,Implant Device,1680,35,,1680,percent of total billed charges,Implant Device,1680,35,,1680,percent of total billed charges,Implant Device,1680,35,,1680,percent of total billed charges,Implant Device,1680,35,,1680,percent of total billed charges,Implant Device,1680,35,,1680,percent of total billed charges,Implant Device,1920,40,,1920,percent of total billed charges,Implant Device,1680,70,,1680,percent of total billed charges,All Other,1632,34,,1632,percent of total billed charges,Implant Device,1632,34,,1632,percent of total billed charges,Implant Device,1680,35,,1680,percent of total billed charges,Implant Device,1680,35,,1680,percent of total billed charges,Implant Device,1680,35,,1680,percent of total billed charges,Implant Device,1680,35,,1680,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1632,34,"If Charge > 2,000, then 34 percent",1632,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3552.01,
J&J  1506-80-003 TIBIAL BASE SIZE 3,C1776,HCPCS,,79013095,CDM,278,RC,,,both,,,3900,2886.01,,,2886.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1755,45,,1755,percent of total billed charges,Critical Access Hospital RCC factor,1326,34,,1326,percent of total billed charges,Implant Device,1326,34,,1326,percent of total billed charges,Implant Device,1326,34,,1326,percent of total billed charges,Implant Device,1326,34,,1326,percent of total billed charges,Implant Device,1326,34,,1326,percent of total billed charges,Implant Device,1930.5,,,1930.5,Other,110% of Medicare,1365,35,,1365,percent of total billed charges,Implant Device,1326,34,"Charges > $500, x 34%",1326,percent of total billed charges,Implant Device,1365,35,,1365,percent of total billed charges,Implant Device,1365,35,,1365,percent of total billed charges,Implant Device,1365,35,,1365,percent of total billed charges,Implant Device,1365,35,,1365,percent of total billed charges,Implant Device,1365,35,,1365,percent of total billed charges,Implant Device,1560,40,,1560,percent of total billed charges,Implant Device,1365,70,,1365,percent of total billed charges,All Other,1326,34,,1326,percent of total billed charges,Implant Device,1326,34,,1326,percent of total billed charges,Implant Device,1365,35,,1365,percent of total billed charges,Implant Device,1365,35,,1365,percent of total billed charges,Implant Device,1365,35,,1365,percent of total billed charges,Implant Device,1365,35,,1365,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1326,34,"If Charge > 2,000, then 34 percent",1326,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2886.01,
J&J 1516-30-405 TIBIAL INSERT SIZE 4 5MM,C1776,HCPCS,,79013096,CDM,278,RC,,,both,,,5400,3996.01,,,3996.01,Other,150% of Medicare + 9.63% HCRA Surcharge,2430,45,,2430,percent of total billed charges,Critical Access Hospital RCC factor,1836,34,,1836,percent of total billed charges,Implant Device,1836,34,,1836,percent of total billed charges,Implant Device,1836,34,,1836,percent of total billed charges,Implant Device,1836,34,,1836,percent of total billed charges,Implant Device,1836,34,,1836,percent of total billed charges,Implant Device,2673,,,2673,Other,110% of Medicare,1890,35,,1890,percent of total billed charges,Implant Device,1836,34,"Charges > $500, x 34%",1836,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,2160,40,,2160,percent of total billed charges,Implant Device,1890,70,,1890,percent of total billed charges,All Other,1836,34,,1836,percent of total billed charges,Implant Device,1836,34,,1836,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1836,34,"If Charge > 2,000, then 34 percent",1836,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3996.01,
J&J 1516-30-408 TIBIAL INSERT SZIE 4 8MM,C1776,HCPCS,,79013097,CDM,278,RC,,,both,,,5400,3996.01,,,3996.01,Other,150% of Medicare + 9.63% HCRA Surcharge,2430,45,,2430,percent of total billed charges,Critical Access Hospital RCC factor,1836,34,,1836,percent of total billed charges,Implant Device,1836,34,,1836,percent of total billed charges,Implant Device,1836,34,,1836,percent of total billed charges,Implant Device,1836,34,,1836,percent of total billed charges,Implant Device,1836,34,,1836,percent of total billed charges,Implant Device,2673,,,2673,Other,110% of Medicare,1890,35,,1890,percent of total billed charges,Implant Device,1836,34,"Charges > $500, x 34%",1836,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,2160,40,,2160,percent of total billed charges,Implant Device,1890,70,,1890,percent of total billed charges,All Other,1836,34,,1836,percent of total billed charges,Implant Device,1836,34,,1836,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1836,34,"If Charge > 2,000, then 34 percent",1836,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3996.01,
J&J 1504-00-205 FEMORAL SIZE 5 RIGHT,C1776,HCPCS,,79013098,CDM,278,RC,,,both,,,4800,3552.01,,,3552.01,Other,150% of Medicare + 9.63% HCRA Surcharge,2160,45,,2160,percent of total billed charges,Critical Access Hospital RCC factor,1632,34,,1632,percent of total billed charges,Implant Device,1632,34,,1632,percent of total billed charges,Implant Device,1632,34,,1632,percent of total billed charges,Implant Device,1632,34,,1632,percent of total billed charges,Implant Device,1632,34,,1632,percent of total billed charges,Implant Device,2376,,,2376,Other,110% of Medicare,1680,35,,1680,percent of total billed charges,Implant Device,1632,34,"Charges > $500, x 34%",1632,percent of total billed charges,Implant Device,1680,35,,1680,percent of total billed charges,Implant Device,1680,35,,1680,percent of total billed charges,Implant Device,1680,35,,1680,percent of total billed charges,Implant Device,1680,35,,1680,percent of total billed charges,Implant Device,1680,35,,1680,percent of total billed charges,Implant Device,1920,40,,1920,percent of total billed charges,Implant Device,1680,70,,1680,percent of total billed charges,All Other,1632,34,,1632,percent of total billed charges,Implant Device,1632,34,,1632,percent of total billed charges,Implant Device,1680,35,,1680,percent of total billed charges,Implant Device,1680,35,,1680,percent of total billed charges,Implant Device,1680,35,,1680,percent of total billed charges,Implant Device,1680,35,,1680,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1632,34,"If Charge > 2,000, then 34 percent",1632,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3552.01,
J&J 1506-80-004 TIBAL BASE SIZE 4,C1776,HCPCS,,79013099,CDM,278,RC,,,both,,,3900,2886.01,,,2886.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1755,45,,1755,percent of total billed charges,Critical Access Hospital RCC factor,1326,34,,1326,percent of total billed charges,Implant Device,1326,34,,1326,percent of total billed charges,Implant Device,1326,34,,1326,percent of total billed charges,Implant Device,1326,34,,1326,percent of total billed charges,Implant Device,1326,34,,1326,percent of total billed charges,Implant Device,1930.5,,,1930.5,Other,110% of Medicare,1365,35,,1365,percent of total billed charges,Implant Device,1326,34,"Charges > $500, x 34%",1326,percent of total billed charges,Implant Device,1365,35,,1365,percent of total billed charges,Implant Device,1365,35,,1365,percent of total billed charges,Implant Device,1365,35,,1365,percent of total billed charges,Implant Device,1365,35,,1365,percent of total billed charges,Implant Device,1365,35,,1365,percent of total billed charges,Implant Device,1560,40,,1560,percent of total billed charges,Implant Device,1365,70,,1365,percent of total billed charges,All Other,1326,34,,1326,percent of total billed charges,Implant Device,1326,34,,1326,percent of total billed charges,Implant Device,1365,35,,1365,percent of total billed charges,Implant Device,1365,35,,1365,percent of total billed charges,Implant Device,1365,35,,1365,percent of total billed charges,Implant Device,1365,35,,1365,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1326,34,"If Charge > 2,000, then 34 percent",1326,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2886.01,
J&J 1516-30-505 TIBIAL INSERT SIZE 5 5MM,C1776,HCPCS,,79013100,CDM,278,RC,,,both,,,5400,3996.01,,,3996.01,Other,150% of Medicare + 9.63% HCRA Surcharge,2430,45,,2430,percent of total billed charges,Critical Access Hospital RCC factor,1836,34,,1836,percent of total billed charges,Implant Device,1836,34,,1836,percent of total billed charges,Implant Device,1836,34,,1836,percent of total billed charges,Implant Device,1836,34,,1836,percent of total billed charges,Implant Device,1836,34,,1836,percent of total billed charges,Implant Device,2673,,,2673,Other,110% of Medicare,1890,35,,1890,percent of total billed charges,Implant Device,1836,34,"Charges > $500, x 34%",1836,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,2160,40,,2160,percent of total billed charges,Implant Device,1890,70,,1890,percent of total billed charges,All Other,1836,34,,1836,percent of total billed charges,Implant Device,1836,34,,1836,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1836,34,"If Charge > 2,000, then 34 percent",1836,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3996.01,
ZIMMER 42-5221-006-10 ARTIC SURF RT 10MM,C1776,HCPCS,,79013101,CDM,278,RC,,,both,,,3648,2699.53,,,2699.53,Other,150% of Medicare + 9.63% HCRA Surcharge,1641.6,45,,1641.6,percent of total billed charges,Critical Access Hospital RCC factor,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1805.76,,,1805.76,Other,110% of Medicare,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1240.32,34,"Charges > $500, x 34%",1240.32,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1459.2,40,,1459.2,percent of total billed charges,Implant Device,1276.8,70,,1276.8,percent of total billed charges,All Other,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1240.32,34,"If Charge > 2,000, then 34 percent",1240.32,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2699.53,
J&J 1010-11-020 FEMORAL STEM SIZE 2,C1776,HCPCS,,79013102,CDM,278,RC,,,both,,,7410,5483.42,,,5483.42,Other,150% of Medicare + 9.63% HCRA Surcharge,3334.5,45,,3334.5,percent of total billed charges,Critical Access Hospital RCC factor,2519.4,34,,2519.4,percent of total billed charges,Implant Device,2519.4,34,,2519.4,percent of total billed charges,Implant Device,2519.4,34,,2519.4,percent of total billed charges,Implant Device,2519.4,34,,2519.4,percent of total billed charges,Implant Device,2519.4,34,,2519.4,percent of total billed charges,Implant Device,3667.95,,,3667.95,Other,110% of Medicare,2593.5,35,,2593.5,percent of total billed charges,Implant Device,2519.4,34,"Charges > $500, x 34%",2519.4,percent of total billed charges,Implant Device,2593.5,35,,2593.5,percent of total billed charges,Implant Device,2593.5,35,,2593.5,percent of total billed charges,Implant Device,2593.5,35,,2593.5,percent of total billed charges,Implant Device,2593.5,35,,2593.5,percent of total billed charges,Implant Device,2593.5,35,,2593.5,percent of total billed charges,Implant Device,2964,40,,2964,percent of total billed charges,Implant Device,2593.5,70,,2593.5,percent of total billed charges,All Other,2519.4,34,,2519.4,percent of total billed charges,Implant Device,2519.4,34,,2519.4,percent of total billed charges,Implant Device,2593.5,35,,2593.5,percent of total billed charges,Implant Device,2593.5,35,,2593.5,percent of total billed charges,Implant Device,2593.5,35,,2593.5,percent of total billed charges,Implant Device,2593.5,35,,2593.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2519.4,34,"If Charge > 2,000, then 34 percent",2519.4,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5483.42,
J&J 1217-32-048 ACETABULAR SHELL 48MM,C1776,HCPCS,,79013103,CDM,278,RC,,,both,,,3420,2530.81,,,2530.81,Other,150% of Medicare + 9.63% HCRA Surcharge,1539,45,,1539,percent of total billed charges,Critical Access Hospital RCC factor,1162.8,34,,1162.8,percent of total billed charges,Implant Device,1162.8,34,,1162.8,percent of total billed charges,Implant Device,1162.8,34,,1162.8,percent of total billed charges,Implant Device,1162.8,34,,1162.8,percent of total billed charges,Implant Device,1162.8,34,,1162.8,percent of total billed charges,Implant Device,1692.9,,,1692.9,Other,110% of Medicare,1197,35,,1197,percent of total billed charges,Implant Device,1162.8,34,"Charges > $500, x 34%",1162.8,percent of total billed charges,Implant Device,1197,35,,1197,percent of total billed charges,Implant Device,1197,35,,1197,percent of total billed charges,Implant Device,1197,35,,1197,percent of total billed charges,Implant Device,1197,35,,1197,percent of total billed charges,Implant Device,1197,35,,1197,percent of total billed charges,Implant Device,1368,40,,1368,percent of total billed charges,Implant Device,1197,70,,1197,percent of total billed charges,All Other,1162.8,34,,1162.8,percent of total billed charges,Implant Device,1162.8,34,,1162.8,percent of total billed charges,Implant Device,1197,35,,1197,percent of total billed charges,Implant Device,1197,35,,1197,percent of total billed charges,Implant Device,1197,35,,1197,percent of total billed charges,Implant Device,1197,35,,1197,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1162.8,34,"If Charge > 2,000, then 34 percent",1162.8,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2530.81,
J&J 1221-32-048 ACETABULAR LINER 48MM,C1776,HCPCS,,79013104,CDM,278,RC,,,both,,,2565,1898.11,,,1898.11,Other,150% of Medicare + 9.63% HCRA Surcharge,1154.25,45,,1154.25,percent of total billed charges,Critical Access Hospital RCC factor,872.1,34,,872.1,percent of total billed charges,Implant Device,872.1,34,,872.1,percent of total billed charges,Implant Device,872.1,34,,872.1,percent of total billed charges,Implant Device,872.1,34,,872.1,percent of total billed charges,Implant Device,872.1,34,,872.1,percent of total billed charges,Implant Device,1269.68,,,1269.68,Other,110% of Medicare,897.75,35,,897.75,percent of total billed charges,Implant Device,872.1,34,"Charges > $500, x 34%",872.1,percent of total billed charges,Implant Device,897.75,35,,897.75,percent of total billed charges,Implant Device,897.75,35,,897.75,percent of total billed charges,Implant Device,897.75,35,,897.75,percent of total billed charges,Implant Device,897.75,35,,897.75,percent of total billed charges,Implant Device,897.75,35,,897.75,percent of total billed charges,Implant Device,1026,40,,1026,percent of total billed charges,Implant Device,897.75,70,,897.75,percent of total billed charges,All Other,872.1,34,,872.1,percent of total billed charges,Implant Device,872.1,34,,872.1,percent of total billed charges,Implant Device,897.75,35,,897.75,percent of total billed charges,Implant Device,897.75,35,,897.75,percent of total billed charges,Implant Device,897.75,35,,897.75,percent of total billed charges,Implant Device,897.75,35,,897.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,872.1,34,"If Charge > 2,000, then 34 percent",872.1,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1898.11,
J&J 1365-32-310 FEMORAL HEAD 32MM,C1776,HCPCS,,79013105,CDM,278,RC,,,both,,,2636,1950.65,,,1950.65,Other,150% of Medicare + 9.63% HCRA Surcharge,1186.2,45,,1186.2,percent of total billed charges,Critical Access Hospital RCC factor,896.24,34,,896.24,percent of total billed charges,Implant Device,896.24,34,,896.24,percent of total billed charges,Implant Device,896.24,34,,896.24,percent of total billed charges,Implant Device,896.24,34,,896.24,percent of total billed charges,Implant Device,896.24,34,,896.24,percent of total billed charges,Implant Device,1304.82,,,1304.82,Other,110% of Medicare,922.6,35,,922.6,percent of total billed charges,Implant Device,896.24,34,"Charges > $500, x 34%",896.24,percent of total billed charges,Implant Device,922.6,35,,922.6,percent of total billed charges,Implant Device,922.6,35,,922.6,percent of total billed charges,Implant Device,922.6,35,,922.6,percent of total billed charges,Implant Device,922.6,35,,922.6,percent of total billed charges,Implant Device,922.6,35,,922.6,percent of total billed charges,Implant Device,1054.4,40,,1054.4,percent of total billed charges,Implant Device,922.6,70,,922.6,percent of total billed charges,All Other,896.24,34,,896.24,percent of total billed charges,Implant Device,896.24,34,,896.24,percent of total billed charges,Implant Device,922.6,35,,922.6,percent of total billed charges,Implant Device,922.6,35,,922.6,percent of total billed charges,Implant Device,922.6,35,,922.6,percent of total billed charges,Implant Device,922.6,35,,922.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,896.24,34,"If Charge > 2,000, then 34 percent",896.24,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1950.65,
ZIMMER 42-5121-003-13 ARTIC SURF 13MM,C1776,HCPCS,,79013106,CDM,278,RC,,,both,,,3648,2699.53,,,2699.53,Other,150% of Medicare + 9.63% HCRA Surcharge,1641.6,45,,1641.6,percent of total billed charges,Critical Access Hospital RCC factor,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1805.76,,,1805.76,Other,110% of Medicare,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1240.32,34,"Charges > $500, x 34%",1240.32,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1459.2,40,,1459.2,percent of total billed charges,Implant Device,1276.8,70,,1276.8,percent of total billed charges,All Other,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1240.32,34,"If Charge > 2,000, then 34 percent",1240.32,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2699.53,
J & J 1010-11-060 FEMORAL STEM SIZE 6,C1776,HCPCS,,79013107,CDM,278,RC,,,both,,,7410,5483.42,,,5483.42,Other,150% of Medicare + 9.63% HCRA Surcharge,3334.5,45,,3334.5,percent of total billed charges,Critical Access Hospital RCC factor,2519.4,34,,2519.4,percent of total billed charges,Implant Device,2519.4,34,,2519.4,percent of total billed charges,Implant Device,2519.4,34,,2519.4,percent of total billed charges,Implant Device,2519.4,34,,2519.4,percent of total billed charges,Implant Device,2519.4,34,,2519.4,percent of total billed charges,Implant Device,3667.95,,,3667.95,Other,110% of Medicare,2593.5,35,,2593.5,percent of total billed charges,Implant Device,2519.4,34,"Charges > $500, x 34%",2519.4,percent of total billed charges,Implant Device,2593.5,35,,2593.5,percent of total billed charges,Implant Device,2593.5,35,,2593.5,percent of total billed charges,Implant Device,2593.5,35,,2593.5,percent of total billed charges,Implant Device,2593.5,35,,2593.5,percent of total billed charges,Implant Device,2593.5,35,,2593.5,percent of total billed charges,Implant Device,2964,40,,2964,percent of total billed charges,Implant Device,2593.5,70,,2593.5,percent of total billed charges,All Other,2519.4,34,,2519.4,percent of total billed charges,Implant Device,2519.4,34,,2519.4,percent of total billed charges,Implant Device,2593.5,35,,2593.5,percent of total billed charges,Implant Device,2593.5,35,,2593.5,percent of total billed charges,Implant Device,2593.5,35,,2593.5,percent of total billed charges,Implant Device,2593.5,35,,2593.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2519.4,34,"If Charge > 2,000, then 34 percent",2519.4,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5483.42,
J & J 1010-21-060 FEMORAL STEM SIZE 6,C1776,HCPCS,,79013108,CDM,278,RC,,,both,,,7410,5483.42,,,5483.42,Other,150% of Medicare + 9.63% HCRA Surcharge,3334.5,45,,3334.5,percent of total billed charges,Critical Access Hospital RCC factor,2519.4,34,,2519.4,percent of total billed charges,Implant Device,2519.4,34,,2519.4,percent of total billed charges,Implant Device,2519.4,34,,2519.4,percent of total billed charges,Implant Device,2519.4,34,,2519.4,percent of total billed charges,Implant Device,2519.4,34,,2519.4,percent of total billed charges,Implant Device,3667.95,,,3667.95,Other,110% of Medicare,2593.5,35,,2593.5,percent of total billed charges,Implant Device,2519.4,34,"Charges > $500, x 34%",2519.4,percent of total billed charges,Implant Device,2593.5,35,,2593.5,percent of total billed charges,Implant Device,2593.5,35,,2593.5,percent of total billed charges,Implant Device,2593.5,35,,2593.5,percent of total billed charges,Implant Device,2593.5,35,,2593.5,percent of total billed charges,Implant Device,2593.5,35,,2593.5,percent of total billed charges,Implant Device,2964,40,,2964,percent of total billed charges,Implant Device,2593.5,70,,2593.5,percent of total billed charges,All Other,2519.4,34,,2519.4,percent of total billed charges,Implant Device,2519.4,34,,2519.4,percent of total billed charges,Implant Device,2593.5,35,,2593.5,percent of total billed charges,Implant Device,2593.5,35,,2593.5,percent of total billed charges,Implant Device,2593.5,35,,2593.5,percent of total billed charges,Implant Device,2593.5,35,,2593.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2519.4,34,"If Charge > 2,000, then 34 percent",2519.4,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5483.42,
J&J 1217-32-056 ACETABULAR SHELL 56MM,C1776,HCPCS,,79013109,CDM,278,RC,,,both,,,3420,2530.81,,,2530.81,Other,150% of Medicare + 9.63% HCRA Surcharge,1539,45,,1539,percent of total billed charges,Critical Access Hospital RCC factor,1162.8,34,,1162.8,percent of total billed charges,Implant Device,1162.8,34,,1162.8,percent of total billed charges,Implant Device,1162.8,34,,1162.8,percent of total billed charges,Implant Device,1162.8,34,,1162.8,percent of total billed charges,Implant Device,1162.8,34,,1162.8,percent of total billed charges,Implant Device,1692.9,,,1692.9,Other,110% of Medicare,1197,35,,1197,percent of total billed charges,Implant Device,1162.8,34,"Charges > $500, x 34%",1162.8,percent of total billed charges,Implant Device,1197,35,,1197,percent of total billed charges,Implant Device,1197,35,,1197,percent of total billed charges,Implant Device,1197,35,,1197,percent of total billed charges,Implant Device,1197,35,,1197,percent of total billed charges,Implant Device,1197,35,,1197,percent of total billed charges,Implant Device,1368,40,,1368,percent of total billed charges,Implant Device,1197,70,,1197,percent of total billed charges,All Other,1162.8,34,,1162.8,percent of total billed charges,Implant Device,1162.8,34,,1162.8,percent of total billed charges,Implant Device,1197,35,,1197,percent of total billed charges,Implant Device,1197,35,,1197,percent of total billed charges,Implant Device,1197,35,,1197,percent of total billed charges,Implant Device,1197,35,,1197,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1162.8,34,"If Charge > 2,000, then 34 percent",1162.8,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2530.81,
J&J 1221-40-056 ACETABULAR LINER 40X56MM,C1776,HCPCS,,79013110,CDM,278,RC,,,both,,,2565,1898.11,,,1898.11,Other,150% of Medicare + 9.63% HCRA Surcharge,1154.25,45,,1154.25,percent of total billed charges,Critical Access Hospital RCC factor,872.1,34,,872.1,percent of total billed charges,Implant Device,872.1,34,,872.1,percent of total billed charges,Implant Device,872.1,34,,872.1,percent of total billed charges,Implant Device,872.1,34,,872.1,percent of total billed charges,Implant Device,872.1,34,,872.1,percent of total billed charges,Implant Device,1269.68,,,1269.68,Other,110% of Medicare,897.75,35,,897.75,percent of total billed charges,Implant Device,872.1,34,"Charges > $500, x 34%",872.1,percent of total billed charges,Implant Device,897.75,35,,897.75,percent of total billed charges,Implant Device,897.75,35,,897.75,percent of total billed charges,Implant Device,897.75,35,,897.75,percent of total billed charges,Implant Device,897.75,35,,897.75,percent of total billed charges,Implant Device,897.75,35,,897.75,percent of total billed charges,Implant Device,1026,40,,1026,percent of total billed charges,Implant Device,897.75,70,,897.75,percent of total billed charges,All Other,872.1,34,,872.1,percent of total billed charges,Implant Device,872.1,34,,872.1,percent of total billed charges,Implant Device,897.75,35,,897.75,percent of total billed charges,Implant Device,897.75,35,,897.75,percent of total billed charges,Implant Device,897.75,35,,897.75,percent of total billed charges,Implant Device,897.75,35,,897.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,872.1,34,"If Charge > 2,000, then 34 percent",872.1,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1898.11,
J & J 1365-54-710 FEMORAL HEAD 40MM,C1776,HCPCS,,79013111,CDM,278,RC,,,both,,,2636,1950.65,,,1950.65,Other,150% of Medicare + 9.63% HCRA Surcharge,1186.2,45,,1186.2,percent of total billed charges,Critical Access Hospital RCC factor,896.24,34,,896.24,percent of total billed charges,Implant Device,896.24,34,,896.24,percent of total billed charges,Implant Device,896.24,34,,896.24,percent of total billed charges,Implant Device,896.24,34,,896.24,percent of total billed charges,Implant Device,896.24,34,,896.24,percent of total billed charges,Implant Device,1304.82,,,1304.82,Other,110% of Medicare,922.6,35,,922.6,percent of total billed charges,Implant Device,896.24,34,"Charges > $500, x 34%",896.24,percent of total billed charges,Implant Device,922.6,35,,922.6,percent of total billed charges,Implant Device,922.6,35,,922.6,percent of total billed charges,Implant Device,922.6,35,,922.6,percent of total billed charges,Implant Device,922.6,35,,922.6,percent of total billed charges,Implant Device,922.6,35,,922.6,percent of total billed charges,Implant Device,1054.4,40,,1054.4,percent of total billed charges,Implant Device,922.6,70,,922.6,percent of total billed charges,All Other,896.24,34,,896.24,percent of total billed charges,Implant Device,896.24,34,,896.24,percent of total billed charges,Implant Device,922.6,35,,922.6,percent of total billed charges,Implant Device,922.6,35,,922.6,percent of total billed charges,Implant Device,922.6,35,,922.6,percent of total billed charges,Implant Device,922.6,35,,922.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,896.24,34,"If Charge > 2,000, then 34 percent",896.24,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1950.65,
J & J 04.037.156S TFNA CAN NAIL 11X130MM,C1889,HCPCS,,79013112,CDM,278,RC,,,both,,,5212,3856.89,,,3856.89,Other,150% of Medicare + 9.63% HCRA Surcharge,2345.4,45,,2345.4,percent of total billed charges,Critical Access Hospital RCC factor,1772.08,34,,1772.08,percent of total billed charges,Implant Device,1772.08,34,,1772.08,percent of total billed charges,Implant Device,1772.08,34,,1772.08,percent of total billed charges,Implant Device,1772.08,34,,1772.08,percent of total billed charges,Implant Device,1772.08,34,,1772.08,percent of total billed charges,Implant Device,2579.94,,,2579.94,Other,110% of Medicare,1824.2,35,,1824.2,percent of total billed charges,Implant Device,1772.08,34,"Charges > $500, x 34%",1772.08,percent of total billed charges,Implant Device,1824.2,35,,1824.2,percent of total billed charges,Implant Device,1824.2,35,,1824.2,percent of total billed charges,Implant Device,1824.2,35,,1824.2,percent of total billed charges,Implant Device,1824.2,35,,1824.2,percent of total billed charges,Implant Device,1824.2,35,,1824.2,percent of total billed charges,Implant Device,2084.8,40,,2084.8,percent of total billed charges,Implant Device,1824.2,70,,1824.2,percent of total billed charges,All Other,1772.08,34,,1772.08,percent of total billed charges,Implant Device,1772.08,34,,1772.08,percent of total billed charges,Implant Device,1824.2,35,,1824.2,percent of total billed charges,Implant Device,1824.2,35,,1824.2,percent of total billed charges,Implant Device,1824.2,35,,1824.2,percent of total billed charges,Implant Device,1824.2,35,,1824.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1772.08,34,"If Charge > 2,000, then 34 percent",1772.08,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3856.89,
J & J 04.015.525S LOCKING SCREW 5.0X35MM,C1713,HCPCS,,79013113,CDM,278,RC,,,both,,,454,335.96,,,335.96,Other,150% of Medicare + 9.63% HCRA Surcharge,204.3,45,,204.3,percent of total billed charges,Critical Access Hospital RCC factor,154.36,34,,154.36,percent of total billed charges,Implant Device,154.36,34,,154.36,percent of total billed charges,Implant Device,154.36,34,,154.36,percent of total billed charges,Implant Device,154.36,34,,154.36,percent of total billed charges,Implant Device,154.36,34,,154.36,percent of total billed charges,Implant Device,224.73,,,224.73,Other,110% of Medicare,158.9,35,,158.9,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,158.9,35,,158.9,percent of total billed charges,Implant Device,158.9,35,,158.9,percent of total billed charges,Implant Device,158.9,35,,158.9,percent of total billed charges,Implant Device,158.9,35,,158.9,percent of total billed charges,Implant Device,158.9,35,,158.9,percent of total billed charges,Implant Device,181.6,40,,181.6,percent of total billed charges,Implant Device,158.9,70,,158.9,percent of total billed charges,All Other,154.36,34,,154.36,percent of total billed charges,Implant Device,154.36,34,,154.36,percent of total billed charges,Implant Device,158.9,35,,158.9,percent of total billed charges,Implant Device,158.9,35,,158.9,percent of total billed charges,Implant Device,158.9,35,,158.9,percent of total billed charges,Implant Device,158.9,35,,158.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,335.96,
J&J 02.112.140S DISTAL FIB PLT 2.7/3.5MM,C1713,HCPCS,,79013114,CDM,278,RC,,,both,,,1718,1271.32,,,1271.32,Other,150% of Medicare + 9.63% HCRA Surcharge,773.1,45,,773.1,percent of total billed charges,Critical Access Hospital RCC factor,584.12,34,,584.12,percent of total billed charges,Implant Device,584.12,34,,584.12,percent of total billed charges,Implant Device,584.12,34,,584.12,percent of total billed charges,Implant Device,584.12,34,,584.12,percent of total billed charges,Implant Device,584.12,34,,584.12,percent of total billed charges,Implant Device,850.41,,,850.41,Other,110% of Medicare,601.3,35,,601.3,percent of total billed charges,Implant Device,584.12,34,"Charges > $500, x 34%",584.12,percent of total billed charges,Implant Device,601.3,35,,601.3,percent of total billed charges,Implant Device,601.3,35,,601.3,percent of total billed charges,Implant Device,601.3,35,,601.3,percent of total billed charges,Implant Device,601.3,35,,601.3,percent of total billed charges,Implant Device,601.3,35,,601.3,percent of total billed charges,Implant Device,687.2,40,,687.2,percent of total billed charges,Implant Device,601.3,70,,601.3,percent of total billed charges,All Other,584.12,34,,584.12,percent of total billed charges,Implant Device,584.12,34,,584.12,percent of total billed charges,Implant Device,601.3,35,,601.3,percent of total billed charges,Implant Device,601.3,35,,601.3,percent of total billed charges,Implant Device,601.3,35,,601.3,percent of total billed charges,Implant Device,601.3,35,,601.3,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1271.32,
J & J 04.034.443S TIBIAL NAIL 10X315MM,C1889,HCPCS,,79013115,CDM,278,RC,,,both,,,2765,2046.11,,,2046.11,Other,150% of Medicare + 9.63% HCRA Surcharge,1244.25,45,,1244.25,percent of total billed charges,Critical Access Hospital RCC factor,940.1,34,,940.1,percent of total billed charges,Implant Device,940.1,34,,940.1,percent of total billed charges,Implant Device,940.1,34,,940.1,percent of total billed charges,Implant Device,940.1,34,,940.1,percent of total billed charges,Implant Device,940.1,34,,940.1,percent of total billed charges,Implant Device,1368.68,,,1368.68,Other,110% of Medicare,967.75,35,,967.75,percent of total billed charges,Implant Device,940.1,34,"Charges > $500, x 34%",940.1,percent of total billed charges,Implant Device,967.75,35,,967.75,percent of total billed charges,Implant Device,967.75,35,,967.75,percent of total billed charges,Implant Device,967.75,35,,967.75,percent of total billed charges,Implant Device,967.75,35,,967.75,percent of total billed charges,Implant Device,967.75,35,,967.75,percent of total billed charges,Implant Device,1106,40,,1106,percent of total billed charges,Implant Device,967.75,70,,967.75,percent of total billed charges,All Other,940.1,34,,940.1,percent of total billed charges,Implant Device,940.1,34,,940.1,percent of total billed charges,Implant Device,967.75,35,,967.75,percent of total billed charges,Implant Device,967.75,35,,967.75,percent of total billed charges,Implant Device,967.75,35,,967.75,percent of total billed charges,Implant Device,967.75,35,,967.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,940.1,34,"If Charge > 2,000, then 34 percent",940.1,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2046.11,
STRYKER 3430-0380S GAM NAIL RT 10X380MM,C1889,HCPCS,,79013116,CDM,278,RC,,,both,,,4969,3677.07,,,3677.07,Other,150% of Medicare + 9.63% HCRA Surcharge,2236.05,45,,2236.05,percent of total billed charges,Critical Access Hospital RCC factor,1689.46,34,,1689.46,percent of total billed charges,Implant Device,1689.46,34,,1689.46,percent of total billed charges,Implant Device,1689.46,34,,1689.46,percent of total billed charges,Implant Device,1689.46,34,,1689.46,percent of total billed charges,Implant Device,1689.46,34,,1689.46,percent of total billed charges,Implant Device,2459.66,,,2459.66,Other,110% of Medicare,1739.15,35,,1739.15,percent of total billed charges,Implant Device,1689.46,34,"Charges > $500, x 34%",1689.46,percent of total billed charges,Implant Device,1739.15,35,,1739.15,percent of total billed charges,Implant Device,1739.15,35,,1739.15,percent of total billed charges,Implant Device,1739.15,35,,1739.15,percent of total billed charges,Implant Device,1739.15,35,,1739.15,percent of total billed charges,Implant Device,1739.15,35,,1739.15,percent of total billed charges,Implant Device,1987.6,40,,1987.6,percent of total billed charges,Implant Device,1739.15,70,,1739.15,percent of total billed charges,All Other,1689.46,34,,1689.46,percent of total billed charges,Implant Device,1689.46,34,,1689.46,percent of total billed charges,Implant Device,1739.15,35,,1739.15,percent of total billed charges,Implant Device,1739.15,35,,1739.15,percent of total billed charges,Implant Device,1739.15,35,,1739.15,percent of total billed charges,Implant Device,1739.15,35,,1739.15,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1689.46,34,"If Charge > 2,000, then 34 percent",1689.46,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3677.07,
J&J 04.037.245S TFNA CANN NAIL 12X235MM,C1889,HCPCS,,79013119,CDM,278,RC,,,both,,,4485,3318.91,,,3318.91,Other,150% of Medicare + 9.63% HCRA Surcharge,2018.25,45,,2018.25,percent of total billed charges,Critical Access Hospital RCC factor,1524.9,34,,1524.9,percent of total billed charges,Implant Device,1524.9,34,,1524.9,percent of total billed charges,Implant Device,1524.9,34,,1524.9,percent of total billed charges,Implant Device,1524.9,34,,1524.9,percent of total billed charges,Implant Device,1524.9,34,,1524.9,percent of total billed charges,Implant Device,2220.08,,,2220.08,Other,110% of Medicare,1569.75,35,,1569.75,percent of total billed charges,Implant Device,1524.9,34,"Charges > $500, x 34%",1524.9,percent of total billed charges,Implant Device,1569.75,35,,1569.75,percent of total billed charges,Implant Device,1569.75,35,,1569.75,percent of total billed charges,Implant Device,1569.75,35,,1569.75,percent of total billed charges,Implant Device,1569.75,35,,1569.75,percent of total billed charges,Implant Device,1569.75,35,,1569.75,percent of total billed charges,Implant Device,1794,40,,1794,percent of total billed charges,Implant Device,1569.75,70,,1569.75,percent of total billed charges,All Other,1524.9,34,,1524.9,percent of total billed charges,Implant Device,1524.9,34,,1524.9,percent of total billed charges,Implant Device,1569.75,35,,1569.75,percent of total billed charges,Implant Device,1569.75,35,,1569.75,percent of total billed charges,Implant Device,1569.75,35,,1569.75,percent of total billed charges,Implant Device,1569.75,35,,1569.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1524.9,34,"If Charge > 2,000, then 34 percent",1524.9,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3318.91,
J&J 04.045.036S LOCKING SCREW 5X36MM,C1713,HCPCS,,79013120,CDM,278,RC,,,both,,,687,508.38,,,508.38,Other,150% of Medicare + 9.63% HCRA Surcharge,309.15,45,,309.15,percent of total billed charges,Critical Access Hospital RCC factor,233.58,34,,233.58,percent of total billed charges,Implant Device,233.58,34,,233.58,percent of total billed charges,Implant Device,233.58,34,,233.58,percent of total billed charges,Implant Device,233.58,34,,233.58,percent of total billed charges,Implant Device,233.58,34,,233.58,percent of total billed charges,Implant Device,340.07,,,340.07,Other,110% of Medicare,240.45,35,,240.45,percent of total billed charges,Implant Device,233.58,34,"Charges > $500, x 34%",233.58,percent of total billed charges,Implant Device,240.45,35,,240.45,percent of total billed charges,Implant Device,240.45,35,,240.45,percent of total billed charges,Implant Device,240.45,35,,240.45,percent of total billed charges,Implant Device,240.45,35,,240.45,percent of total billed charges,Implant Device,240.45,35,,240.45,percent of total billed charges,Implant Device,274.8,40,,274.8,percent of total billed charges,Implant Device,240.45,70,,240.45,percent of total billed charges,All Other,233.58,34,,233.58,percent of total billed charges,Implant Device,233.58,34,,233.58,percent of total billed charges,Implant Device,240.45,35,,240.45,percent of total billed charges,Implant Device,240.45,35,,240.45,percent of total billed charges,Implant Device,240.45,35,,240.45,percent of total billed charges,Implant Device,240.45,35,,240.45,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,508.38,
J&J 02.112.139S DIST FIB PLATE 2.7/3.5MM,C1713,HCPCS,,79013121,CDM,278,RC,,,both,,,1696,1255.04,,,1255.04,Other,150% of Medicare + 9.63% HCRA Surcharge,763.2,45,,763.2,percent of total billed charges,Critical Access Hospital RCC factor,576.64,34,,576.64,percent of total billed charges,Implant Device,576.64,34,,576.64,percent of total billed charges,Implant Device,576.64,34,,576.64,percent of total billed charges,Implant Device,576.64,34,,576.64,percent of total billed charges,Implant Device,576.64,34,,576.64,percent of total billed charges,Implant Device,839.52,,,839.52,Other,110% of Medicare,593.6,35,,593.6,percent of total billed charges,Implant Device,576.64,34,"Charges > $500, x 34%",576.64,percent of total billed charges,Implant Device,593.6,35,,593.6,percent of total billed charges,Implant Device,593.6,35,,593.6,percent of total billed charges,Implant Device,593.6,35,,593.6,percent of total billed charges,Implant Device,593.6,35,,593.6,percent of total billed charges,Implant Device,593.6,35,,593.6,percent of total billed charges,Implant Device,678.4,40,,678.4,percent of total billed charges,Implant Device,593.6,70,,593.6,percent of total billed charges,All Other,576.64,34,,576.64,percent of total billed charges,Implant Device,576.64,34,,576.64,percent of total billed charges,Implant Device,593.6,35,,593.6,percent of total billed charges,Implant Device,593.6,35,,593.6,percent of total billed charges,Implant Device,593.6,35,,593.6,percent of total billed charges,Implant Device,593.6,35,,593.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1255.04,
STRYKER UH1-52-28 BIPOLAR COMP 52X28MM,C1776,HCPCS,,79013122,CDM,278,RC,,,both,,,1391,1029.34,,,1029.34,Other,150% of Medicare + 9.63% HCRA Surcharge,625.95,45,,625.95,percent of total billed charges,Critical Access Hospital RCC factor,472.94,34,,472.94,percent of total billed charges,Implant Device,472.94,34,,472.94,percent of total billed charges,Implant Device,472.94,34,,472.94,percent of total billed charges,Implant Device,472.94,34,,472.94,percent of total billed charges,Implant Device,472.94,34,,472.94,percent of total billed charges,Implant Device,688.55,,,688.55,Other,110% of Medicare,486.85,35,,486.85,percent of total billed charges,Implant Device,472.94,34,"Charges > $500, x 34%",472.94,percent of total billed charges,Implant Device,486.85,35,,486.85,percent of total billed charges,Implant Device,486.85,35,,486.85,percent of total billed charges,Implant Device,486.85,35,,486.85,percent of total billed charges,Implant Device,486.85,35,,486.85,percent of total billed charges,Implant Device,486.85,35,,486.85,percent of total billed charges,Implant Device,556.4,40,,556.4,percent of total billed charges,Implant Device,486.85,70,,486.85,percent of total billed charges,All Other,472.94,34,,472.94,percent of total billed charges,Implant Device,472.94,34,,472.94,percent of total billed charges,Implant Device,486.85,35,,486.85,percent of total billed charges,Implant Device,486.85,35,,486.85,percent of total billed charges,Implant Device,486.85,35,,486.85,percent of total billed charges,Implant Device,486.85,35,,486.85,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1029.34,
STRYKER 2341-1027S TIBIAL NAIL 10X270MM,C1889,HCPCS,,79013123,CDM,278,RC,,,both,,,4792,3546.09,,,3546.09,Other,150% of Medicare + 9.63% HCRA Surcharge,2156.4,45,,2156.4,percent of total billed charges,Critical Access Hospital RCC factor,1629.28,34,,1629.28,percent of total billed charges,Implant Device,1629.28,34,,1629.28,percent of total billed charges,Implant Device,1629.28,34,,1629.28,percent of total billed charges,Implant Device,1629.28,34,,1629.28,percent of total billed charges,Implant Device,1629.28,34,,1629.28,percent of total billed charges,Implant Device,2372.04,,,2372.04,Other,110% of Medicare,1677.2,35,,1677.2,percent of total billed charges,Implant Device,1629.28,34,"Charges > $500, x 34%",1629.28,percent of total billed charges,Implant Device,1677.2,35,,1677.2,percent of total billed charges,Implant Device,1677.2,35,,1677.2,percent of total billed charges,Implant Device,1677.2,35,,1677.2,percent of total billed charges,Implant Device,1677.2,35,,1677.2,percent of total billed charges,Implant Device,1677.2,35,,1677.2,percent of total billed charges,Implant Device,1916.8,40,,1916.8,percent of total billed charges,Implant Device,1677.2,70,,1677.2,percent of total billed charges,All Other,1629.28,34,,1629.28,percent of total billed charges,Implant Device,1629.28,34,,1629.28,percent of total billed charges,Implant Device,1677.2,35,,1677.2,percent of total billed charges,Implant Device,1677.2,35,,1677.2,percent of total billed charges,Implant Device,1677.2,35,,1677.2,percent of total billed charges,Implant Device,1677.2,35,,1677.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1629.28,34,"If Charge > 2,000, then 34 percent",1629.28,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3546.09,
STRYKER 2360-5030S LOCKING SCREW 5X30MM,C1713,HCPCS,,79013124,CDM,278,RC,,,both,,,682,504.68,,,504.68,Other,150% of Medicare + 9.63% HCRA Surcharge,306.9,45,,306.9,percent of total billed charges,Critical Access Hospital RCC factor,231.88,34,,231.88,percent of total billed charges,Implant Device,231.88,34,,231.88,percent of total billed charges,Implant Device,231.88,34,,231.88,percent of total billed charges,Implant Device,231.88,34,,231.88,percent of total billed charges,Implant Device,231.88,34,,231.88,percent of total billed charges,Implant Device,337.59,,,337.59,Other,110% of Medicare,238.7,35,,238.7,percent of total billed charges,Implant Device,231.88,34,"Charges > $500, x 34%",231.88,percent of total billed charges,Implant Device,238.7,35,,238.7,percent of total billed charges,Implant Device,238.7,35,,238.7,percent of total billed charges,Implant Device,238.7,35,,238.7,percent of total billed charges,Implant Device,238.7,35,,238.7,percent of total billed charges,Implant Device,238.7,35,,238.7,percent of total billed charges,Implant Device,272.8,40,,272.8,percent of total billed charges,Implant Device,238.7,70,,238.7,percent of total billed charges,All Other,231.88,34,,231.88,percent of total billed charges,Implant Device,231.88,34,,231.88,percent of total billed charges,Implant Device,238.7,35,,238.7,percent of total billed charges,Implant Device,238.7,35,,238.7,percent of total billed charges,Implant Device,238.7,35,,238.7,percent of total billed charges,Implant Device,238.7,35,,238.7,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,504.68,
J&J 03.045.018 GWIRE W/DRILL TIP 3.2MM,C1769,HCPCS,,79013125,CDM,278,RC,,,both,,,300,222,,,222,Other,150% of Medicare + 9.63% HCRA Surcharge,135,45,,135,percent of total billed charges,Critical Access Hospital RCC factor,102,34,,102,percent of total billed charges,Implant Device,102,34,,102,percent of total billed charges,Implant Device,102,34,,102,percent of total billed charges,Implant Device,102,34,,102,percent of total billed charges,Implant Device,102,34,,102,percent of total billed charges,Implant Device,148.5,,,148.5,Other,110% of Medicare,105,35,,105,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,105,35,,105,percent of total billed charges,Implant Device,105,35,,105,percent of total billed charges,Implant Device,105,35,,105,percent of total billed charges,Implant Device,105,35,,105,percent of total billed charges,Implant Device,105,35,,105,percent of total billed charges,Implant Device,120,40,,120,percent of total billed charges,Implant Device,105,70,,105,percent of total billed charges,All Other,102,34,,102,percent of total billed charges,Implant Device,102,34,,102,percent of total billed charges,Implant Device,105,35,,105,percent of total billed charges,Implant Device,105,35,,105,percent of total billed charges,Implant Device,105,35,,105,percent of total billed charges,Implant Device,105,35,,105,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,222,
J&J 04.045.376S LOCKING SCREW 5.0X76MM,C1713,HCPCS,,79013126,CDM,278,RC,,,both,,,813,601.62,,,601.62,Other,150% of Medicare + 9.63% HCRA Surcharge,365.85,45,,365.85,percent of total billed charges,Critical Access Hospital RCC factor,276.42,34,,276.42,percent of total billed charges,Implant Device,276.42,34,,276.42,percent of total billed charges,Implant Device,276.42,34,,276.42,percent of total billed charges,Implant Device,276.42,34,,276.42,percent of total billed charges,Implant Device,276.42,34,,276.42,percent of total billed charges,Implant Device,402.44,,,402.44,Other,110% of Medicare,284.55,35,,284.55,percent of total billed charges,Implant Device,276.42,34,"Charges > $500, x 34%",276.42,percent of total billed charges,Implant Device,284.55,35,,284.55,percent of total billed charges,Implant Device,284.55,35,,284.55,percent of total billed charges,Implant Device,284.55,35,,284.55,percent of total billed charges,Implant Device,284.55,35,,284.55,percent of total billed charges,Implant Device,284.55,35,,284.55,percent of total billed charges,Implant Device,325.2,40,,325.2,percent of total billed charges,Implant Device,284.55,70,,284.55,percent of total billed charges,All Other,276.42,34,,276.42,percent of total billed charges,Implant Device,276.42,34,,276.42,percent of total billed charges,Implant Device,284.55,35,,284.55,percent of total billed charges,Implant Device,284.55,35,,284.55,percent of total billed charges,Implant Device,284.55,35,,284.55,percent of total billed charges,Implant Device,284.55,35,,284.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,601.62,
J & J 04.045.360S LOCKING SCREW 5.0X60MM,C1713,HCPCS,,79013127,CDM,278,RC,,,both,,,813,601.62,,,601.62,Other,150% of Medicare + 9.63% HCRA Surcharge,365.85,45,,365.85,percent of total billed charges,Critical Access Hospital RCC factor,276.42,34,,276.42,percent of total billed charges,Implant Device,276.42,34,,276.42,percent of total billed charges,Implant Device,276.42,34,,276.42,percent of total billed charges,Implant Device,276.42,34,,276.42,percent of total billed charges,Implant Device,276.42,34,,276.42,percent of total billed charges,Implant Device,402.44,,,402.44,Other,110% of Medicare,284.55,35,,284.55,percent of total billed charges,Implant Device,276.42,34,"Charges > $500, x 34%",276.42,percent of total billed charges,Implant Device,284.55,35,,284.55,percent of total billed charges,Implant Device,284.55,35,,284.55,percent of total billed charges,Implant Device,284.55,35,,284.55,percent of total billed charges,Implant Device,284.55,35,,284.55,percent of total billed charges,Implant Device,284.55,35,,284.55,percent of total billed charges,Implant Device,325.2,40,,325.2,percent of total billed charges,Implant Device,284.55,70,,284.55,percent of total billed charges,All Other,276.42,34,,276.42,percent of total billed charges,Implant Device,276.42,34,,276.42,percent of total billed charges,Implant Device,284.55,35,,284.55,percent of total billed charges,Implant Device,284.55,35,,284.55,percent of total billed charges,Implant Device,284.55,35,,284.55,percent of total billed charges,Implant Device,284.55,35,,284.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,601.62,
J&J 02.124.411 COND PLATE 4.5MM 10 HOLE,C1713,HCPCS,,79013128,CDM,278,RC,,,both,,,4588,3395.13,,,3395.13,Other,150% of Medicare + 9.63% HCRA Surcharge,2064.6,45,,2064.6,percent of total billed charges,Critical Access Hospital RCC factor,1559.92,34,,1559.92,percent of total billed charges,Implant Device,1559.92,34,,1559.92,percent of total billed charges,Implant Device,1559.92,34,,1559.92,percent of total billed charges,Implant Device,1559.92,34,,1559.92,percent of total billed charges,Implant Device,1559.92,34,,1559.92,percent of total billed charges,Implant Device,2271.06,,,2271.06,Other,110% of Medicare,1605.8,35,,1605.8,percent of total billed charges,Implant Device,1559.92,34,"Charges > $500, x 34%",1559.92,percent of total billed charges,Implant Device,1605.8,35,,1605.8,percent of total billed charges,Implant Device,1605.8,35,,1605.8,percent of total billed charges,Implant Device,1605.8,35,,1605.8,percent of total billed charges,Implant Device,1605.8,35,,1605.8,percent of total billed charges,Implant Device,1605.8,35,,1605.8,percent of total billed charges,Implant Device,1835.2,40,,1835.2,percent of total billed charges,Implant Device,1605.8,70,,1605.8,percent of total billed charges,All Other,1559.92,34,,1559.92,percent of total billed charges,Implant Device,1559.92,34,,1559.92,percent of total billed charges,Implant Device,1605.8,35,,1605.8,percent of total billed charges,Implant Device,1605.8,35,,1605.8,percent of total billed charges,Implant Device,1605.8,35,,1605.8,percent of total billed charges,Implant Device,1605.8,35,,1605.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1559.92,34,"If Charge > 2,000, then 34 percent",1559.92,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3395.13,
J&J 04.045.040S LOCK SCREW 5.0X40MM,C1713,HCPCS,,79013129,CDM,278,RC,,,both,,,687,508.38,,,508.38,Other,150% of Medicare + 9.63% HCRA Surcharge,309.15,45,,309.15,percent of total billed charges,Critical Access Hospital RCC factor,233.58,34,,233.58,percent of total billed charges,Implant Device,233.58,34,,233.58,percent of total billed charges,Implant Device,233.58,34,,233.58,percent of total billed charges,Implant Device,233.58,34,,233.58,percent of total billed charges,Implant Device,233.58,34,,233.58,percent of total billed charges,Implant Device,340.07,,,340.07,Other,110% of Medicare,240.45,35,,240.45,percent of total billed charges,Implant Device,233.58,34,"Charges > $500, x 34%",233.58,percent of total billed charges,Implant Device,240.45,35,,240.45,percent of total billed charges,Implant Device,240.45,35,,240.45,percent of total billed charges,Implant Device,240.45,35,,240.45,percent of total billed charges,Implant Device,240.45,35,,240.45,percent of total billed charges,Implant Device,240.45,35,,240.45,percent of total billed charges,Implant Device,274.8,40,,274.8,percent of total billed charges,Implant Device,240.45,70,,240.45,percent of total billed charges,All Other,233.58,34,,233.58,percent of total billed charges,Implant Device,233.58,34,,233.58,percent of total billed charges,Implant Device,240.45,35,,240.45,percent of total billed charges,Implant Device,240.45,35,,240.45,percent of total billed charges,Implant Device,240.45,35,,240.45,percent of total billed charges,Implant Device,240.45,35,,240.45,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,508.38,
J & J 04.233.036S RFNA NAIL 10X360MM,C1889,HCPCS,,79013130,CDM,278,RC,,,both,,,5409,4002.67,,,4002.67,Other,150% of Medicare + 9.63% HCRA Surcharge,2434.05,45,,2434.05,percent of total billed charges,Critical Access Hospital RCC factor,1839.06,34,,1839.06,percent of total billed charges,Implant Device,1839.06,34,,1839.06,percent of total billed charges,Implant Device,1839.06,34,,1839.06,percent of total billed charges,Implant Device,1839.06,34,,1839.06,percent of total billed charges,Implant Device,1839.06,34,,1839.06,percent of total billed charges,Implant Device,2677.46,,,2677.46,Other,110% of Medicare,1893.15,35,,1893.15,percent of total billed charges,Implant Device,1839.06,34,"Charges > $500, x 34%",1839.06,percent of total billed charges,Implant Device,1893.15,35,,1893.15,percent of total billed charges,Implant Device,1893.15,35,,1893.15,percent of total billed charges,Implant Device,1893.15,35,,1893.15,percent of total billed charges,Implant Device,1893.15,35,,1893.15,percent of total billed charges,Implant Device,1893.15,35,,1893.15,percent of total billed charges,Implant Device,2163.6,40,,2163.6,percent of total billed charges,Implant Device,1893.15,70,,1893.15,percent of total billed charges,All Other,1839.06,34,,1839.06,percent of total billed charges,Implant Device,1839.06,34,,1839.06,percent of total billed charges,Implant Device,1893.15,35,,1893.15,percent of total billed charges,Implant Device,1893.15,35,,1893.15,percent of total billed charges,Implant Device,1893.15,35,,1893.15,percent of total billed charges,Implant Device,1893.15,35,,1893.15,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1839.06,34,"If Charge > 2,000, then 34 percent",1839.06,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4002.67,
J & J 1504-40-104 FEMORAL LEFT SIZE 4,C1776,HCPCS,,79013131,CDM,278,RC,,,both,,,21434,15861.21,,,15861.21,Other,150% of Medicare + 9.63% HCRA Surcharge,9645.3,45,,9645.3,percent of total billed charges,Critical Access Hospital RCC factor,7287.56,34,,7287.56,percent of total billed charges,Implant Device,7287.56,34,,7287.56,percent of total billed charges,Implant Device,7287.56,34,,7287.56,percent of total billed charges,Implant Device,7287.56,34,,7287.56,percent of total billed charges,Implant Device,7287.56,34,,7287.56,percent of total billed charges,Implant Device,10609.83,,,10609.83,Other,110% of Medicare,7501.9,35,,7501.9,percent of total billed charges,Implant Device,7287.56,34,"Charges > $500, x 34%",7287.56,percent of total billed charges,Implant Device,7501.9,35,,7501.9,percent of total billed charges,Implant Device,7501.9,35,,7501.9,percent of total billed charges,Implant Device,7501.9,35,,7501.9,percent of total billed charges,Implant Device,7501.9,35,,7501.9,percent of total billed charges,Implant Device,7501.9,35,,7501.9,percent of total billed charges,Implant Device,8573.6,40,,8573.6,percent of total billed charges,Implant Device,7501.9,70,,7501.9,percent of total billed charges,All Other,7287.56,34,,7287.56,percent of total billed charges,Implant Device,7287.56,34,,7287.56,percent of total billed charges,Implant Device,7501.9,35,,7501.9,percent of total billed charges,Implant Device,7501.9,35,,7501.9,percent of total billed charges,Implant Device,7501.9,35,,7501.9,percent of total billed charges,Implant Device,7501.9,35,,7501.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,7287.56,34,"If Charge > 2,000, then 34 percent",7287.56,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,15861.21,
J & J 1506-60-003 TIBAIL BASE SIZE 3,C1776,HCPCS,,79013132,CDM,278,RC,,,both,,,15558,11512.96,,,11512.96,Other,150% of Medicare + 9.63% HCRA Surcharge,7001.1,45,,7001.1,percent of total billed charges,Critical Access Hospital RCC factor,5289.72,34,,5289.72,percent of total billed charges,Implant Device,5289.72,34,,5289.72,percent of total billed charges,Implant Device,5289.72,34,,5289.72,percent of total billed charges,Implant Device,5289.72,34,,5289.72,percent of total billed charges,Implant Device,5289.72,34,,5289.72,percent of total billed charges,Implant Device,7701.21,,,7701.21,Other,110% of Medicare,5445.3,35,,5445.3,percent of total billed charges,Implant Device,5289.72,34,"Charges > $500, x 34%",5289.72,percent of total billed charges,Implant Device,5445.3,35,,5445.3,percent of total billed charges,Implant Device,5445.3,35,,5445.3,percent of total billed charges,Implant Device,5445.3,35,,5445.3,percent of total billed charges,Implant Device,5445.3,35,,5445.3,percent of total billed charges,Implant Device,5445.3,35,,5445.3,percent of total billed charges,Implant Device,6223.2,40,,6223.2,percent of total billed charges,Implant Device,5445.3,70,,5445.3,percent of total billed charges,All Other,5289.72,34,,5289.72,percent of total billed charges,Implant Device,5289.72,34,,5289.72,percent of total billed charges,Implant Device,5445.3,35,,5445.3,percent of total billed charges,Implant Device,5445.3,35,,5445.3,percent of total billed charges,Implant Device,5445.3,35,,5445.3,percent of total billed charges,Implant Device,5445.3,35,,5445.3,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,5289.72,34,"If Charge > 2,000, then 34 percent",5289.72,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,11512.96,
J & J 1512-14-050 STEM 14X50MM,C1776,HCPCS,,79013133,CDM,278,RC,,,both,,,3315,2453.11,,,2453.11,Other,150% of Medicare + 9.63% HCRA Surcharge,1491.75,45,,1491.75,percent of total billed charges,Critical Access Hospital RCC factor,1127.1,34,,1127.1,percent of total billed charges,Implant Device,1127.1,34,,1127.1,percent of total billed charges,Implant Device,1127.1,34,,1127.1,percent of total billed charges,Implant Device,1127.1,34,,1127.1,percent of total billed charges,Implant Device,1127.1,34,,1127.1,percent of total billed charges,Implant Device,1640.93,,,1640.93,Other,110% of Medicare,1160.25,35,,1160.25,percent of total billed charges,Implant Device,1127.1,34,"Charges > $500, x 34%",1127.1,percent of total billed charges,Implant Device,1160.25,35,,1160.25,percent of total billed charges,Implant Device,1160.25,35,,1160.25,percent of total billed charges,Implant Device,1160.25,35,,1160.25,percent of total billed charges,Implant Device,1160.25,35,,1160.25,percent of total billed charges,Implant Device,1160.25,35,,1160.25,percent of total billed charges,Implant Device,1326,40,,1326,percent of total billed charges,Implant Device,1160.25,70,,1160.25,percent of total billed charges,All Other,1127.1,34,,1127.1,percent of total billed charges,Implant Device,1127.1,34,,1127.1,percent of total billed charges,Implant Device,1160.25,35,,1160.25,percent of total billed charges,Implant Device,1160.25,35,,1160.25,percent of total billed charges,Implant Device,1160.25,35,,1160.25,percent of total billed charges,Implant Device,1160.25,35,,1160.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1127.1,34,"If Charge > 2,000, then 34 percent",1127.1,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2453.11,
J & J 1010-12-060 FEMORAL STEM SIZE 6,C1776,HCPCS,,79013135,CDM,278,RC,,,both,,,7410,5483.42,,,5483.42,Other,150% of Medicare + 9.63% HCRA Surcharge,3334.5,45,,3334.5,percent of total billed charges,Critical Access Hospital RCC factor,2519.4,34,,2519.4,percent of total billed charges,Implant Device,2519.4,34,,2519.4,percent of total billed charges,Implant Device,2519.4,34,,2519.4,percent of total billed charges,Implant Device,2519.4,34,,2519.4,percent of total billed charges,Implant Device,2519.4,34,,2519.4,percent of total billed charges,Implant Device,3667.95,,,3667.95,Other,110% of Medicare,2593.5,35,,2593.5,percent of total billed charges,Implant Device,2519.4,34,"Charges > $500, x 34%",2519.4,percent of total billed charges,Implant Device,2593.5,35,,2593.5,percent of total billed charges,Implant Device,2593.5,35,,2593.5,percent of total billed charges,Implant Device,2593.5,35,,2593.5,percent of total billed charges,Implant Device,2593.5,35,,2593.5,percent of total billed charges,Implant Device,2593.5,35,,2593.5,percent of total billed charges,Implant Device,2964,40,,2964,percent of total billed charges,Implant Device,2593.5,70,,2593.5,percent of total billed charges,All Other,2519.4,34,,2519.4,percent of total billed charges,Implant Device,2519.4,34,,2519.4,percent of total billed charges,Implant Device,2593.5,35,,2593.5,percent of total billed charges,Implant Device,2593.5,35,,2593.5,percent of total billed charges,Implant Device,2593.5,35,,2593.5,percent of total billed charges,Implant Device,2593.5,35,,2593.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2519.4,34,"If Charge > 2,000, then 34 percent",2519.4,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5483.42,
J & J 1217-32-058 ACETABULAR SHELL 58MM,C1776,HCPCS,,79013136,CDM,278,RC,,,both,,,3420,2530.81,,,2530.81,Other,150% of Medicare + 9.63% HCRA Surcharge,1539,45,,1539,percent of total billed charges,Critical Access Hospital RCC factor,1162.8,34,,1162.8,percent of total billed charges,Implant Device,1162.8,34,,1162.8,percent of total billed charges,Implant Device,1162.8,34,,1162.8,percent of total billed charges,Implant Device,1162.8,34,,1162.8,percent of total billed charges,Implant Device,1162.8,34,,1162.8,percent of total billed charges,Implant Device,1692.9,,,1692.9,Other,110% of Medicare,1197,35,,1197,percent of total billed charges,Implant Device,1162.8,34,"Charges > $500, x 34%",1162.8,percent of total billed charges,Implant Device,1197,35,,1197,percent of total billed charges,Implant Device,1197,35,,1197,percent of total billed charges,Implant Device,1197,35,,1197,percent of total billed charges,Implant Device,1197,35,,1197,percent of total billed charges,Implant Device,1197,35,,1197,percent of total billed charges,Implant Device,1368,40,,1368,percent of total billed charges,Implant Device,1197,70,,1197,percent of total billed charges,All Other,1162.8,34,,1162.8,percent of total billed charges,Implant Device,1162.8,34,,1162.8,percent of total billed charges,Implant Device,1197,35,,1197,percent of total billed charges,Implant Device,1197,35,,1197,percent of total billed charges,Implant Device,1197,35,,1197,percent of total billed charges,Implant Device,1197,35,,1197,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1162.8,34,"If Charge > 2,000, then 34 percent",1162.8,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2530.81,
J&J 1217-35-500 CANC BONE SCREW 6.5X35MM,C1713,HCPCS,,79013137,CDM,278,RC,,,both,,,228,168.72,,,168.72,Other,150% of Medicare + 9.63% HCRA Surcharge,102.6,45,,102.6,percent of total billed charges,Critical Access Hospital RCC factor,77.52,34,,77.52,percent of total billed charges,Implant Device,77.52,34,,77.52,percent of total billed charges,Implant Device,77.52,34,,77.52,percent of total billed charges,Implant Device,77.52,34,,77.52,percent of total billed charges,Implant Device,77.52,34,,77.52,percent of total billed charges,Implant Device,112.86,,,112.86,Other,110% of Medicare,79.8,35,,79.8,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,79.8,35,,79.8,percent of total billed charges,Implant Device,79.8,35,,79.8,percent of total billed charges,Implant Device,79.8,35,,79.8,percent of total billed charges,Implant Device,79.8,35,,79.8,percent of total billed charges,Implant Device,79.8,35,,79.8,percent of total billed charges,Implant Device,91.2,40,,91.2,percent of total billed charges,Implant Device,79.8,70,,79.8,percent of total billed charges,All Other,77.52,34,,77.52,percent of total billed charges,Implant Device,77.52,34,,77.52,percent of total billed charges,Implant Device,79.8,35,,79.8,percent of total billed charges,Implant Device,79.8,35,,79.8,percent of total billed charges,Implant Device,79.8,35,,79.8,percent of total billed charges,Implant Device,79.8,35,,79.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,168.72,
J&J 1217-40-500 CANC BONE SCREW 6.5X40MM,C1713,HCPCS,,79013138,CDM,278,RC,,,both,,,228,168.72,,,168.72,Other,150% of Medicare + 9.63% HCRA Surcharge,102.6,45,,102.6,percent of total billed charges,Critical Access Hospital RCC factor,77.52,34,,77.52,percent of total billed charges,Implant Device,77.52,34,,77.52,percent of total billed charges,Implant Device,77.52,34,,77.52,percent of total billed charges,Implant Device,77.52,34,,77.52,percent of total billed charges,Implant Device,77.52,34,,77.52,percent of total billed charges,Implant Device,112.86,,,112.86,Other,110% of Medicare,79.8,35,,79.8,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,79.8,35,,79.8,percent of total billed charges,Implant Device,79.8,35,,79.8,percent of total billed charges,Implant Device,79.8,35,,79.8,percent of total billed charges,Implant Device,79.8,35,,79.8,percent of total billed charges,Implant Device,79.8,35,,79.8,percent of total billed charges,Implant Device,91.2,40,,91.2,percent of total billed charges,Implant Device,79.8,70,,79.8,percent of total billed charges,All Other,77.52,34,,77.52,percent of total billed charges,Implant Device,77.52,34,,77.52,percent of total billed charges,Implant Device,79.8,35,,79.8,percent of total billed charges,Implant Device,79.8,35,,79.8,percent of total billed charges,Implant Device,79.8,35,,79.8,percent of total billed charges,Implant Device,79.8,35,,79.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,168.72,
J&J 1221-40-058 ACETABULAR LINER 40X58MM,C1776,HCPCS,,79013139,CDM,278,RC,,,both,,,2565,1898.11,,,1898.11,Other,150% of Medicare + 9.63% HCRA Surcharge,1154.25,45,,1154.25,percent of total billed charges,Critical Access Hospital RCC factor,872.1,34,,872.1,percent of total billed charges,Implant Device,872.1,34,,872.1,percent of total billed charges,Implant Device,872.1,34,,872.1,percent of total billed charges,Implant Device,872.1,34,,872.1,percent of total billed charges,Implant Device,872.1,34,,872.1,percent of total billed charges,Implant Device,1269.68,,,1269.68,Other,110% of Medicare,897.75,35,,897.75,percent of total billed charges,Implant Device,872.1,34,"Charges > $500, x 34%",872.1,percent of total billed charges,Implant Device,897.75,35,,897.75,percent of total billed charges,Implant Device,897.75,35,,897.75,percent of total billed charges,Implant Device,897.75,35,,897.75,percent of total billed charges,Implant Device,897.75,35,,897.75,percent of total billed charges,Implant Device,897.75,35,,897.75,percent of total billed charges,Implant Device,1026,40,,1026,percent of total billed charges,Implant Device,897.75,70,,897.75,percent of total billed charges,All Other,872.1,34,,872.1,percent of total billed charges,Implant Device,872.1,34,,872.1,percent of total billed charges,Implant Device,897.75,35,,897.75,percent of total billed charges,Implant Device,897.75,35,,897.75,percent of total billed charges,Implant Device,897.75,35,,897.75,percent of total billed charges,Implant Device,897.75,35,,897.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,872.1,34,"If Charge > 2,000, then 34 percent",872.1,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1898.11,
J & J 1365-40-710 FEMORAL HEAD 40MM,C1776,HCPCS,,79013140,CDM,278,RC,,,both,,,2636,1950.65,,,1950.65,Other,150% of Medicare + 9.63% HCRA Surcharge,1186.2,45,,1186.2,percent of total billed charges,Critical Access Hospital RCC factor,896.24,34,,896.24,percent of total billed charges,Implant Device,896.24,34,,896.24,percent of total billed charges,Implant Device,896.24,34,,896.24,percent of total billed charges,Implant Device,896.24,34,,896.24,percent of total billed charges,Implant Device,896.24,34,,896.24,percent of total billed charges,Implant Device,1304.82,,,1304.82,Other,110% of Medicare,922.6,35,,922.6,percent of total billed charges,Implant Device,896.24,34,"Charges > $500, x 34%",896.24,percent of total billed charges,Implant Device,922.6,35,,922.6,percent of total billed charges,Implant Device,922.6,35,,922.6,percent of total billed charges,Implant Device,922.6,35,,922.6,percent of total billed charges,Implant Device,922.6,35,,922.6,percent of total billed charges,Implant Device,922.6,35,,922.6,percent of total billed charges,Implant Device,1054.4,40,,1054.4,percent of total billed charges,Implant Device,922.6,70,,922.6,percent of total billed charges,All Other,896.24,34,,896.24,percent of total billed charges,Implant Device,896.24,34,,896.24,percent of total billed charges,Implant Device,922.6,35,,922.6,percent of total billed charges,Implant Device,922.6,35,,922.6,percent of total billed charges,Implant Device,922.6,35,,922.6,percent of total billed charges,Implant Device,922.6,35,,922.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,896.24,34,"If Charge > 2,000, then 34 percent",896.24,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1950.65,
STRYKER ORT IC4046 HEADED SCREW 4.0X46MM,C1713,HCPCS,,79013142,CDM,278,RC,,,both,,,961,711.14,,,711.14,Other,150% of Medicare + 9.63% HCRA Surcharge,432.45,45,,432.45,percent of total billed charges,Critical Access Hospital RCC factor,326.74,34,,326.74,percent of total billed charges,Implant Device,326.74,34,,326.74,percent of total billed charges,Implant Device,326.74,34,,326.74,percent of total billed charges,Implant Device,326.74,34,,326.74,percent of total billed charges,Implant Device,326.74,34,,326.74,percent of total billed charges,Implant Device,475.7,,,475.7,Other,110% of Medicare,336.35,35,,336.35,percent of total billed charges,Implant Device,326.74,34,"Charges > $500, x 34%",326.74,percent of total billed charges,Implant Device,336.35,35,,336.35,percent of total billed charges,Implant Device,336.35,35,,336.35,percent of total billed charges,Implant Device,336.35,35,,336.35,percent of total billed charges,Implant Device,336.35,35,,336.35,percent of total billed charges,Implant Device,336.35,35,,336.35,percent of total billed charges,Implant Device,384.4,40,,384.4,percent of total billed charges,Implant Device,336.35,70,,336.35,percent of total billed charges,All Other,326.74,34,,326.74,percent of total billed charges,Implant Device,326.74,34,,326.74,percent of total billed charges,Implant Device,336.35,35,,336.35,percent of total billed charges,Implant Device,336.35,35,,336.35,percent of total billed charges,Implant Device,336.35,35,,336.35,percent of total billed charges,Implant Device,336.35,35,,336.35,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,711.14,
DJO SURG 533-06-108 HUM STEM 6X108MM,C1776,HCPCS,,79013146,CDM,278,RC,,,both,,,14400,10656.04,,,10656.04,Other,150% of Medicare + 9.63% HCRA Surcharge,6480,45,,6480,percent of total billed charges,Critical Access Hospital RCC factor,4896,34,,4896,percent of total billed charges,Implant Device,4896,34,,4896,percent of total billed charges,Implant Device,4896,34,,4896,percent of total billed charges,Implant Device,4896,34,,4896,percent of total billed charges,Implant Device,4896,34,,4896,percent of total billed charges,Implant Device,7128,,,7128,Other,110% of Medicare,5040,35,,5040,percent of total billed charges,Implant Device,4896,34,"Charges > $500, x 34%",4896,percent of total billed charges,Implant Device,5040,35,,5040,percent of total billed charges,Implant Device,5040,35,,5040,percent of total billed charges,Implant Device,5040,35,,5040,percent of total billed charges,Implant Device,5040,35,,5040,percent of total billed charges,Implant Device,5040,35,,5040,percent of total billed charges,Implant Device,5760,40,,5760,percent of total billed charges,Implant Device,5040,70,,5040,percent of total billed charges,All Other,4896,34,,4896,percent of total billed charges,Implant Device,4896,34,,4896,percent of total billed charges,Implant Device,5040,35,,5040,percent of total billed charges,Implant Device,5040,35,,5040,percent of total billed charges,Implant Device,5040,35,,5040,percent of total billed charges,Implant Device,5040,35,,5040,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,4896,34,"If Charge > 2,000, then 34 percent",4896,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,10656.04,
STRYKER ORTHO 326105 CAN SCREW 6.5X105MM,C1713,HCPCS,,79013147,CDM,278,RC,,,both,,,765,566.1,,,566.1,Other,150% of Medicare + 9.63% HCRA Surcharge,344.25,45,,344.25,percent of total billed charges,Critical Access Hospital RCC factor,260.1,34,,260.1,percent of total billed charges,Implant Device,260.1,34,,260.1,percent of total billed charges,Implant Device,260.1,34,,260.1,percent of total billed charges,Implant Device,260.1,34,,260.1,percent of total billed charges,Implant Device,260.1,34,,260.1,percent of total billed charges,Implant Device,378.68,,,378.68,Other,110% of Medicare,267.75,35,,267.75,percent of total billed charges,Implant Device,260.1,34,"Charges > $500, x 34%",260.1,percent of total billed charges,Implant Device,267.75,35,,267.75,percent of total billed charges,Implant Device,267.75,35,,267.75,percent of total billed charges,Implant Device,267.75,35,,267.75,percent of total billed charges,Implant Device,267.75,35,,267.75,percent of total billed charges,Implant Device,267.75,35,,267.75,percent of total billed charges,Implant Device,306,40,,306,percent of total billed charges,Implant Device,267.75,70,,267.75,percent of total billed charges,All Other,260.1,34,,260.1,percent of total billed charges,Implant Device,260.1,34,,260.1,percent of total billed charges,Implant Device,267.75,35,,267.75,percent of total billed charges,Implant Device,267.75,35,,267.75,percent of total billed charges,Implant Device,267.75,35,,267.75,percent of total billed charges,Implant Device,267.75,35,,267.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,566.1,
J & J 1010-11-010 FEMORAL STEM SIZE 1,C1776,HCPCS,,79013148,CDM,278,RC,,,both,,,7410,5483.42,,,5483.42,Other,150% of Medicare + 9.63% HCRA Surcharge,3334.5,45,,3334.5,percent of total billed charges,Critical Access Hospital RCC factor,2519.4,34,,2519.4,percent of total billed charges,Implant Device,2519.4,34,,2519.4,percent of total billed charges,Implant Device,2519.4,34,,2519.4,percent of total billed charges,Implant Device,2519.4,34,,2519.4,percent of total billed charges,Implant Device,2519.4,34,,2519.4,percent of total billed charges,Implant Device,3667.95,,,3667.95,Other,110% of Medicare,2593.5,35,,2593.5,percent of total billed charges,Implant Device,2519.4,34,"Charges > $500, x 34%",2519.4,percent of total billed charges,Implant Device,2593.5,35,,2593.5,percent of total billed charges,Implant Device,2593.5,35,,2593.5,percent of total billed charges,Implant Device,2593.5,35,,2593.5,percent of total billed charges,Implant Device,2593.5,35,,2593.5,percent of total billed charges,Implant Device,2593.5,35,,2593.5,percent of total billed charges,Implant Device,2964,40,,2964,percent of total billed charges,Implant Device,2593.5,70,,2593.5,percent of total billed charges,All Other,2519.4,34,,2519.4,percent of total billed charges,Implant Device,2519.4,34,,2519.4,percent of total billed charges,Implant Device,2593.5,35,,2593.5,percent of total billed charges,Implant Device,2593.5,35,,2593.5,percent of total billed charges,Implant Device,2593.5,35,,2593.5,percent of total billed charges,Implant Device,2593.5,35,,2593.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2519.4,34,"If Charge > 2,000, then 34 percent",2519.4,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5483.42,
J&J 1506-60-005 TIBIAL BASE SIZE 5,C1776,HCPCS,,79013149,CDM,278,RC,,,both,,,15558,11512.96,,,11512.96,Other,150% of Medicare + 9.63% HCRA Surcharge,7001.1,45,,7001.1,percent of total billed charges,Critical Access Hospital RCC factor,5289.72,34,,5289.72,percent of total billed charges,Implant Device,5289.72,34,,5289.72,percent of total billed charges,Implant Device,5289.72,34,,5289.72,percent of total billed charges,Implant Device,5289.72,34,,5289.72,percent of total billed charges,Implant Device,5289.72,34,,5289.72,percent of total billed charges,Implant Device,7701.21,,,7701.21,Other,110% of Medicare,5445.3,35,,5445.3,percent of total billed charges,Implant Device,5289.72,34,"Charges > $500, x 34%",5289.72,percent of total billed charges,Implant Device,5445.3,35,,5445.3,percent of total billed charges,Implant Device,5445.3,35,,5445.3,percent of total billed charges,Implant Device,5445.3,35,,5445.3,percent of total billed charges,Implant Device,5445.3,35,,5445.3,percent of total billed charges,Implant Device,5445.3,35,,5445.3,percent of total billed charges,Implant Device,6223.2,40,,6223.2,percent of total billed charges,Implant Device,5445.3,70,,5445.3,percent of total billed charges,All Other,5289.72,34,,5289.72,percent of total billed charges,Implant Device,5289.72,34,,5289.72,percent of total billed charges,Implant Device,5445.3,35,,5445.3,percent of total billed charges,Implant Device,5445.3,35,,5445.3,percent of total billed charges,Implant Device,5445.3,35,,5445.3,percent of total billed charges,Implant Device,5445.3,35,,5445.3,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,5289.72,34,"If Charge > 2,000, then 34 percent",5289.72,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,11512.96,
J&J 1516-50-614 INSERT 14MM SIZE 6,C1776,HCPCS,,79013150,CDM,278,RC,,,both,,,5400,3996.01,,,3996.01,Other,150% of Medicare + 9.63% HCRA Surcharge,2430,45,,2430,percent of total billed charges,Critical Access Hospital RCC factor,1836,34,,1836,percent of total billed charges,Implant Device,1836,34,,1836,percent of total billed charges,Implant Device,1836,34,,1836,percent of total billed charges,Implant Device,1836,34,,1836,percent of total billed charges,Implant Device,1836,34,,1836,percent of total billed charges,Implant Device,2673,,,2673,Other,110% of Medicare,1890,35,,1890,percent of total billed charges,Implant Device,1836,34,"Charges > $500, x 34%",1836,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,2160,40,,2160,percent of total billed charges,Implant Device,1890,70,,1890,percent of total billed charges,All Other,1836,34,,1836,percent of total billed charges,Implant Device,1836,34,,1836,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1836,34,"If Charge > 2,000, then 34 percent",1836,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3996.01,
ARTHREX AR-3636 KNOTLESS FIBERTAK 1.8MM,C1713,HCPCS,,79013151,CDM,278,RC,,,both,,,1320,976.8,,,976.8,Other,150% of Medicare + 9.63% HCRA Surcharge,594,45,,594,percent of total billed charges,Critical Access Hospital RCC factor,448.8,34,,448.8,percent of total billed charges,Implant Device,448.8,34,,448.8,percent of total billed charges,Implant Device,448.8,34,,448.8,percent of total billed charges,Implant Device,448.8,34,,448.8,percent of total billed charges,Implant Device,448.8,34,,448.8,percent of total billed charges,Implant Device,653.4,,,653.4,Other,110% of Medicare,462,35,,462,percent of total billed charges,Implant Device,448.8,34,"Charges > $500, x 34%",448.8,percent of total billed charges,Implant Device,462,35,,462,percent of total billed charges,Implant Device,462,35,,462,percent of total billed charges,Implant Device,462,35,,462,percent of total billed charges,Implant Device,462,35,,462,percent of total billed charges,Implant Device,462,35,,462,percent of total billed charges,Implant Device,528,40,,528,percent of total billed charges,Implant Device,462,70,,462,percent of total billed charges,All Other,448.8,34,,448.8,percent of total billed charges,Implant Device,448.8,34,,448.8,percent of total billed charges,Implant Device,462,35,,462,percent of total billed charges,Implant Device,462,35,,462,percent of total billed charges,Implant Device,462,35,,462,percent of total billed charges,Implant Device,462,35,,462,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,976.8,
DJO 415-00-080 CEMENT RESTRICTOR 8MM,C1889,HCPCS,,79013154,CDM,278,RC,,,both,,,240,177.6,,,177.6,Other,150% of Medicare + 9.63% HCRA Surcharge,108,45,,108,percent of total billed charges,Critical Access Hospital RCC factor,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,118.8,,,118.8,Other,110% of Medicare,84,35,,84,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,96,40,,96,percent of total billed charges,Implant Device,84,70,,84,percent of total billed charges,All Other,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,177.6,
LIFENET AFLEX402 DECELLUR DERMIS 20X25MM,Q4125,HCPCS,,79013155,CDM,278,RC,,,both,,,3135,2319.91,,,2319.91,Other,150% of Medicare + 9.63% HCRA Surcharge,1410.75,45,,1410.75,percent of total billed charges,Critical Access Hospital RCC factor,1065.9,34,,1065.9,percent of total billed charges,Implant Device,1065.9,34,,1065.9,percent of total billed charges,Implant Device,1065.9,34,,1065.9,percent of total billed charges,Implant Device,1065.9,34,,1065.9,percent of total billed charges,Implant Device,1065.9,34,,1065.9,percent of total billed charges,Implant Device,1551.83,,,1551.83,Other,110% of Medicare,1097.25,35,,1097.25,percent of total billed charges,Implant Device,1065.9,34,"Charges > $500, x 34%",1065.9,percent of total billed charges,Implant Device,1097.25,35,,1097.25,percent of total billed charges,Implant Device,1097.25,35,,1097.25,percent of total billed charges,Implant Device,1097.25,35,,1097.25,percent of total billed charges,Implant Device,1097.25,35,,1097.25,percent of total billed charges,Implant Device,1097.25,35,,1097.25,percent of total billed charges,Implant Device,1254,40,,1254,percent of total billed charges,Implant Device,1097.25,70,,1097.25,percent of total billed charges,All Other,1065.9,34,,1065.9,percent of total billed charges,Implant Device,1065.9,34,,1065.9,percent of total billed charges,Implant Device,1097.25,35,,1097.25,percent of total billed charges,Implant Device,1097.25,35,,1097.25,percent of total billed charges,Implant Device,1097.25,35,,1097.25,percent of total billed charges,Implant Device,1097.25,35,,1097.25,percent of total billed charges,Implant Device,976.07,,,976.07,Other,100% of Medicaid,976.07,,,976.07,Other,100% of Medicaid,976.07,,,976.07,Other,100% of Medicaid,976.07,,,976.07,Other,100% of Medicaid,2196.16,,,2196.16,Other,225% of Medicaid,1493.39,,,1493.39,Other,153% of Medicaid,2196.16,,,2196.16,Other,225% of Medicaid,1366.5,,,1366.5,Other,140% of Medicaid,1065.9,34,"If Charge > 2,000, then 34 percent",1065.9,percent of total billed charges,Implants,2537.78,,,2537.78,Other,260% of Medicaid,3162.47,,,3162.47,Other,324% of Medicaid,2098.55,,,2098.55,Other,215% of Medicaid,2098.55,,,2098.55,Other,215% of Medicaid,1220.09,,,1220.09,Other,125% of Medicaid,976.07,3162.47,
LIFENET AFLEX403 DECELLUR DERMIS 25X30MM,Q4125,HCPCS,,79013156,CDM,278,RC,,,both,,,3420,2530.81,,,2530.81,Other,150% of Medicare + 9.63% HCRA Surcharge,1539,45,,1539,percent of total billed charges,Critical Access Hospital RCC factor,1162.8,34,,1162.8,percent of total billed charges,Implant Device,1162.8,34,,1162.8,percent of total billed charges,Implant Device,1162.8,34,,1162.8,percent of total billed charges,Implant Device,1162.8,34,,1162.8,percent of total billed charges,Implant Device,1162.8,34,,1162.8,percent of total billed charges,Implant Device,1692.9,,,1692.9,Other,110% of Medicare,1197,35,,1197,percent of total billed charges,Implant Device,1162.8,34,"Charges > $500, x 34%",1162.8,percent of total billed charges,Implant Device,1197,35,,1197,percent of total billed charges,Implant Device,1197,35,,1197,percent of total billed charges,Implant Device,1197,35,,1197,percent of total billed charges,Implant Device,1197,35,,1197,percent of total billed charges,Implant Device,1197,35,,1197,percent of total billed charges,Implant Device,1368,40,,1368,percent of total billed charges,Implant Device,1197,70,,1197,percent of total billed charges,All Other,1162.8,34,,1162.8,percent of total billed charges,Implant Device,1162.8,34,,1162.8,percent of total billed charges,Implant Device,1197,35,,1197,percent of total billed charges,Implant Device,1197,35,,1197,percent of total billed charges,Implant Device,1197,35,,1197,percent of total billed charges,Implant Device,1197,35,,1197,percent of total billed charges,Implant Device,976.07,,,976.07,Other,100% of Medicaid,976.07,,,976.07,Other,100% of Medicaid,976.07,,,976.07,Other,100% of Medicaid,976.07,,,976.07,Other,100% of Medicaid,2196.16,,,2196.16,Other,225% of Medicaid,1493.39,,,1493.39,Other,153% of Medicaid,2196.16,,,2196.16,Other,225% of Medicaid,1366.5,,,1366.5,Other,140% of Medicaid,1162.8,34,"If Charge > 2,000, then 34 percent",1162.8,percent of total billed charges,Implants,2537.78,,,2537.78,Other,260% of Medicaid,3162.47,,,3162.47,Other,324% of Medicaid,2098.55,,,2098.55,Other,215% of Medicaid,2098.55,,,2098.55,Other,215% of Medicaid,1220.09,,,1220.09,Other,125% of Medicaid,976.07,3162.47,
J&J 04.005.548S LOCKING SCREW 5X58MM,C1713,HCPCS,,79013161,CDM,278,RC,,,both,,,412,304.88,,,304.88,Other,150% of Medicare + 9.63% HCRA Surcharge,185.4,45,,185.4,percent of total billed charges,Critical Access Hospital RCC factor,140.08,34,,140.08,percent of total billed charges,Implant Device,140.08,34,,140.08,percent of total billed charges,Implant Device,140.08,34,,140.08,percent of total billed charges,Implant Device,140.08,34,,140.08,percent of total billed charges,Implant Device,140.08,34,,140.08,percent of total billed charges,Implant Device,203.94,,,203.94,Other,110% of Medicare,144.2,35,,144.2,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,144.2,35,,144.2,percent of total billed charges,Implant Device,144.2,35,,144.2,percent of total billed charges,Implant Device,144.2,35,,144.2,percent of total billed charges,Implant Device,144.2,35,,144.2,percent of total billed charges,Implant Device,144.2,35,,144.2,percent of total billed charges,Implant Device,164.8,40,,164.8,percent of total billed charges,Implant Device,144.2,70,,144.2,percent of total billed charges,All Other,140.08,34,,140.08,percent of total billed charges,Implant Device,140.08,34,,140.08,percent of total billed charges,Implant Device,144.2,35,,144.2,percent of total billed charges,Implant Device,144.2,35,,144.2,percent of total billed charges,Implant Device,144.2,35,,144.2,percent of total billed charges,Implant Device,144.2,35,,144.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,304.88,
J&J 04.005.558S LOCKING SCREW 5X68MM,C1713,HCPCS,,79013162,CDM,278,RC,,,both,,,412,304.88,,,304.88,Other,150% of Medicare + 9.63% HCRA Surcharge,185.4,45,,185.4,percent of total billed charges,Critical Access Hospital RCC factor,140.08,34,,140.08,percent of total billed charges,Implant Device,140.08,34,,140.08,percent of total billed charges,Implant Device,140.08,34,,140.08,percent of total billed charges,Implant Device,140.08,34,,140.08,percent of total billed charges,Implant Device,140.08,34,,140.08,percent of total billed charges,Implant Device,203.94,,,203.94,Other,110% of Medicare,144.2,35,,144.2,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,144.2,35,,144.2,percent of total billed charges,Implant Device,144.2,35,,144.2,percent of total billed charges,Implant Device,144.2,35,,144.2,percent of total billed charges,Implant Device,144.2,35,,144.2,percent of total billed charges,Implant Device,144.2,35,,144.2,percent of total billed charges,Implant Device,164.8,40,,164.8,percent of total billed charges,Implant Device,144.2,70,,144.2,percent of total billed charges,All Other,140.08,34,,140.08,percent of total billed charges,Implant Device,140.08,34,,140.08,percent of total billed charges,Implant Device,144.2,35,,144.2,percent of total billed charges,Implant Device,144.2,35,,144.2,percent of total billed charges,Implant Device,144.2,35,,144.2,percent of total billed charges,Implant Device,144.2,35,,144.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,304.88,
J&J 04.037.233S TFNA CANN NAIL 12X420MM,C1889,HCPCS,,79013163,CDM,278,RC,,,both,,,5467,4045.59,,,4045.59,Other,150% of Medicare + 9.63% HCRA Surcharge,2460.15,45,,2460.15,percent of total billed charges,Critical Access Hospital RCC factor,1858.78,34,,1858.78,percent of total billed charges,Implant Device,1858.78,34,,1858.78,percent of total billed charges,Implant Device,1858.78,34,,1858.78,percent of total billed charges,Implant Device,1858.78,34,,1858.78,percent of total billed charges,Implant Device,1858.78,34,,1858.78,percent of total billed charges,Implant Device,2706.17,,,2706.17,Other,110% of Medicare,1913.45,35,,1913.45,percent of total billed charges,Implant Device,1858.78,34,"Charges > $500, x 34%",1858.78,percent of total billed charges,Implant Device,1913.45,35,,1913.45,percent of total billed charges,Implant Device,1913.45,35,,1913.45,percent of total billed charges,Implant Device,1913.45,35,,1913.45,percent of total billed charges,Implant Device,1913.45,35,,1913.45,percent of total billed charges,Implant Device,1913.45,35,,1913.45,percent of total billed charges,Implant Device,2186.8,40,,2186.8,percent of total billed charges,Implant Device,1913.45,70,,1913.45,percent of total billed charges,All Other,1858.78,34,,1858.78,percent of total billed charges,Implant Device,1858.78,34,,1858.78,percent of total billed charges,Implant Device,1913.45,35,,1913.45,percent of total billed charges,Implant Device,1913.45,35,,1913.45,percent of total billed charges,Implant Device,1913.45,35,,1913.45,percent of total billed charges,Implant Device,1913.45,35,,1913.45,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1858.78,34,"If Charge > 2,000, then 34 percent",1858.78,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4045.59,
STRYKER 2341-1036S TIBIAL NAIL 10X360MM,C1713,HCPCS,,79013164,CDM,278,RC,,,both,,,4792,3546.09,,,3546.09,Other,150% of Medicare + 9.63% HCRA Surcharge,2156.4,45,,2156.4,percent of total billed charges,Critical Access Hospital RCC factor,1629.28,34,,1629.28,percent of total billed charges,Implant Device,1629.28,34,,1629.28,percent of total billed charges,Implant Device,1629.28,34,,1629.28,percent of total billed charges,Implant Device,1629.28,34,,1629.28,percent of total billed charges,Implant Device,1629.28,34,,1629.28,percent of total billed charges,Implant Device,2372.04,,,2372.04,Other,110% of Medicare,1677.2,35,,1677.2,percent of total billed charges,Implant Device,1629.28,34,"Charges > $500, x 34%",1629.28,percent of total billed charges,Implant Device,1677.2,35,,1677.2,percent of total billed charges,Implant Device,1677.2,35,,1677.2,percent of total billed charges,Implant Device,1677.2,35,,1677.2,percent of total billed charges,Implant Device,1677.2,35,,1677.2,percent of total billed charges,Implant Device,1677.2,35,,1677.2,percent of total billed charges,Implant Device,1916.8,40,,1916.8,percent of total billed charges,Implant Device,1677.2,70,,1677.2,percent of total billed charges,All Other,1629.28,34,,1629.28,percent of total billed charges,Implant Device,1629.28,34,,1629.28,percent of total billed charges,Implant Device,1677.2,35,,1677.2,percent of total billed charges,Implant Device,1677.2,35,,1677.2,percent of total billed charges,Implant Device,1677.2,35,,1677.2,percent of total billed charges,Implant Device,1677.2,35,,1677.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1629.28,34,"If Charge > 2,000, then 34 percent",1629.28,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3546.09,
BARD 0700515 POWERLINE LUMEN CATH 5FR,C1751,HCPCS,,79013166,CDM,278,RC,,,both,,,774,572.76,,,572.76,Other,150% of Medicare + 9.63% HCRA Surcharge,348.3,45,,348.3,percent of total billed charges,Critical Access Hospital RCC factor,263.16,34,,263.16,percent of total billed charges,Implant Device,263.16,34,,263.16,percent of total billed charges,Implant Device,263.16,34,,263.16,percent of total billed charges,Implant Device,263.16,34,,263.16,percent of total billed charges,Implant Device,263.16,34,,263.16,percent of total billed charges,Implant Device,383.13,,,383.13,Other,110% of Medicare,270.9,35,,270.9,percent of total billed charges,Implant Device,263.16,34,"Charges > $500, x 34%",263.16,percent of total billed charges,Implant Device,270.9,35,,270.9,percent of total billed charges,Implant Device,270.9,35,,270.9,percent of total billed charges,Implant Device,270.9,35,,270.9,percent of total billed charges,Implant Device,270.9,35,,270.9,percent of total billed charges,Implant Device,270.9,35,,270.9,percent of total billed charges,Implant Device,309.6,40,,309.6,percent of total billed charges,Implant Device,270.9,70,,270.9,percent of total billed charges,All Other,263.16,34,,263.16,percent of total billed charges,Implant Device,263.16,34,,263.16,percent of total billed charges,Implant Device,270.9,35,,270.9,percent of total billed charges,Implant Device,270.9,35,,270.9,percent of total billed charges,Implant Device,270.9,35,,270.9,percent of total billed charges,Implant Device,270.9,35,,270.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,572.76,
STRYKER 5567-P-3014 HUMERAL STEM 14X98MM,C1776,HCPCS,,79013167,CDM,278,RC,,,both,,,8925,6604.52,,,6604.52,Other,150% of Medicare + 9.63% HCRA Surcharge,4016.25,45,,4016.25,percent of total billed charges,Critical Access Hospital RCC factor,3034.5,34,,3034.5,percent of total billed charges,Implant Device,3034.5,34,,3034.5,percent of total billed charges,Implant Device,3034.5,34,,3034.5,percent of total billed charges,Implant Device,3034.5,34,,3034.5,percent of total billed charges,Implant Device,3034.5,34,,3034.5,percent of total billed charges,Implant Device,4417.88,,,4417.88,Other,110% of Medicare,3123.75,35,,3123.75,percent of total billed charges,Implant Device,3034.5,34,"Charges > $500, x 34%",3034.5,percent of total billed charges,Implant Device,3123.75,35,,3123.75,percent of total billed charges,Implant Device,3123.75,35,,3123.75,percent of total billed charges,Implant Device,3123.75,35,,3123.75,percent of total billed charges,Implant Device,3123.75,35,,3123.75,percent of total billed charges,Implant Device,3123.75,35,,3123.75,percent of total billed charges,Implant Device,3570,40,,3570,percent of total billed charges,Implant Device,3123.75,70,,3123.75,percent of total billed charges,All Other,3034.5,34,,3034.5,percent of total billed charges,Implant Device,3034.5,34,,3034.5,percent of total billed charges,Implant Device,3123.75,35,,3123.75,percent of total billed charges,Implant Device,3123.75,35,,3123.75,percent of total billed charges,Implant Device,3123.75,35,,3123.75,percent of total billed charges,Implant Device,3123.75,35,,3123.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3034.5,34,"If Charge > 2,000, then 34 percent",3034.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,6604.52,
STRYKER 5571-S-3206-E HUM INSERT 32XC6MM,C1776,HCPCS,,79013168,CDM,278,RC,,,both,,,3525,2608.51,,,2608.51,Other,150% of Medicare + 9.63% HCRA Surcharge,1586.25,45,,1586.25,percent of total billed charges,Critical Access Hospital RCC factor,1198.5,34,,1198.5,percent of total billed charges,Implant Device,1198.5,34,,1198.5,percent of total billed charges,Implant Device,1198.5,34,,1198.5,percent of total billed charges,Implant Device,1198.5,34,,1198.5,percent of total billed charges,Implant Device,1198.5,34,,1198.5,percent of total billed charges,Implant Device,1744.88,,,1744.88,Other,110% of Medicare,1233.75,35,,1233.75,percent of total billed charges,Implant Device,1198.5,34,"Charges > $500, x 34%",1198.5,percent of total billed charges,Implant Device,1233.75,35,,1233.75,percent of total billed charges,Implant Device,1233.75,35,,1233.75,percent of total billed charges,Implant Device,1233.75,35,,1233.75,percent of total billed charges,Implant Device,1233.75,35,,1233.75,percent of total billed charges,Implant Device,1233.75,35,,1233.75,percent of total billed charges,Implant Device,1410,40,,1410,percent of total billed charges,Implant Device,1233.75,70,,1233.75,percent of total billed charges,All Other,1198.5,34,,1198.5,percent of total billed charges,Implant Device,1198.5,34,,1198.5,percent of total billed charges,Implant Device,1233.75,35,,1233.75,percent of total billed charges,Implant Device,1233.75,35,,1233.75,percent of total billed charges,Implant Device,1233.75,35,,1233.75,percent of total billed charges,Implant Device,1233.75,35,,1233.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1198.5,34,"If Charge > 2,000, then 34 percent",1198.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2608.51,
STRYKER 5573-C-3206 GLENOSPHERE 32X6MM,C1776,HCPCS,,79013169,CDM,278,RC,,,both,,,4125,3052.51,,,3052.51,Other,150% of Medicare + 9.63% HCRA Surcharge,1856.25,45,,1856.25,percent of total billed charges,Critical Access Hospital RCC factor,1402.5,34,,1402.5,percent of total billed charges,Implant Device,1402.5,34,,1402.5,percent of total billed charges,Implant Device,1402.5,34,,1402.5,percent of total billed charges,Implant Device,1402.5,34,,1402.5,percent of total billed charges,Implant Device,1402.5,34,,1402.5,percent of total billed charges,Implant Device,2041.88,,,2041.88,Other,110% of Medicare,1443.75,35,,1443.75,percent of total billed charges,Implant Device,1402.5,34,"Charges > $500, x 34%",1402.5,percent of total billed charges,Implant Device,1443.75,35,,1443.75,percent of total billed charges,Implant Device,1443.75,35,,1443.75,percent of total billed charges,Implant Device,1443.75,35,,1443.75,percent of total billed charges,Implant Device,1443.75,35,,1443.75,percent of total billed charges,Implant Device,1443.75,35,,1443.75,percent of total billed charges,Implant Device,1650,40,,1650,percent of total billed charges,Implant Device,1443.75,70,,1443.75,percent of total billed charges,All Other,1402.5,34,,1402.5,percent of total billed charges,Implant Device,1402.5,34,,1402.5,percent of total billed charges,Implant Device,1443.75,35,,1443.75,percent of total billed charges,Implant Device,1443.75,35,,1443.75,percent of total billed charges,Implant Device,1443.75,35,,1443.75,percent of total billed charges,Implant Device,1443.75,35,,1443.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1402.5,34,"If Charge > 2,000, then 34 percent",1402.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3052.51,
J&J 1217-32-054 ACETAB SHELL 54MM SZ F,C1776,HCPCS,,79013170,CDM,278,RC,,,both,,,3420,2530.81,,,2530.81,Other,150% of Medicare + 9.63% HCRA Surcharge,1539,45,,1539,percent of total billed charges,Critical Access Hospital RCC factor,1162.8,34,,1162.8,percent of total billed charges,Implant Device,1162.8,34,,1162.8,percent of total billed charges,Implant Device,1162.8,34,,1162.8,percent of total billed charges,Implant Device,1162.8,34,,1162.8,percent of total billed charges,Implant Device,1162.8,34,,1162.8,percent of total billed charges,Implant Device,1692.9,,,1692.9,Other,110% of Medicare,1197,35,,1197,percent of total billed charges,Implant Device,1162.8,34,"Charges > $500, x 34%",1162.8,percent of total billed charges,Implant Device,1197,35,,1197,percent of total billed charges,Implant Device,1197,35,,1197,percent of total billed charges,Implant Device,1197,35,,1197,percent of total billed charges,Implant Device,1197,35,,1197,percent of total billed charges,Implant Device,1197,35,,1197,percent of total billed charges,Implant Device,1368,40,,1368,percent of total billed charges,Implant Device,1197,70,,1197,percent of total billed charges,All Other,1162.8,34,,1162.8,percent of total billed charges,Implant Device,1162.8,34,,1162.8,percent of total billed charges,Implant Device,1197,35,,1197,percent of total billed charges,Implant Device,1197,35,,1197,percent of total billed charges,Implant Device,1197,35,,1197,percent of total billed charges,Implant Device,1197,35,,1197,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1162.8,34,"If Charge > 2,000, then 34 percent",1162.8,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2530.81,
J&J 1010-11-040 FEMORAL STEM SIZE 4,C1776,HCPCS,,79013171,CDM,278,RC,,,both,,,7410,5483.42,,,5483.42,Other,150% of Medicare + 9.63% HCRA Surcharge,3334.5,45,,3334.5,percent of total billed charges,Critical Access Hospital RCC factor,2519.4,34,,2519.4,percent of total billed charges,Implant Device,2519.4,34,,2519.4,percent of total billed charges,Implant Device,2519.4,34,,2519.4,percent of total billed charges,Implant Device,2519.4,34,,2519.4,percent of total billed charges,Implant Device,2519.4,34,,2519.4,percent of total billed charges,Implant Device,3667.95,,,3667.95,Other,110% of Medicare,2593.5,35,,2593.5,percent of total billed charges,Implant Device,2519.4,34,"Charges > $500, x 34%",2519.4,percent of total billed charges,Implant Device,2593.5,35,,2593.5,percent of total billed charges,Implant Device,2593.5,35,,2593.5,percent of total billed charges,Implant Device,2593.5,35,,2593.5,percent of total billed charges,Implant Device,2593.5,35,,2593.5,percent of total billed charges,Implant Device,2593.5,35,,2593.5,percent of total billed charges,Implant Device,2964,40,,2964,percent of total billed charges,Implant Device,2593.5,70,,2593.5,percent of total billed charges,All Other,2519.4,34,,2519.4,percent of total billed charges,Implant Device,2519.4,34,,2519.4,percent of total billed charges,Implant Device,2593.5,35,,2593.5,percent of total billed charges,Implant Device,2593.5,35,,2593.5,percent of total billed charges,Implant Device,2593.5,35,,2593.5,percent of total billed charges,Implant Device,2593.5,35,,2593.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2519.4,34,"If Charge > 2,000, then 34 percent",2519.4,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5483.42,
J&J 1217-30-046 ACETABULAR SHELL 46MM,C1776,HCPCS,,79013172,CDM,278,RC,,,both,,,3420,2530.81,,,2530.81,Other,150% of Medicare + 9.63% HCRA Surcharge,1539,45,,1539,percent of total billed charges,Critical Access Hospital RCC factor,1162.8,34,,1162.8,percent of total billed charges,Implant Device,1162.8,34,,1162.8,percent of total billed charges,Implant Device,1162.8,34,,1162.8,percent of total billed charges,Implant Device,1162.8,34,,1162.8,percent of total billed charges,Implant Device,1162.8,34,,1162.8,percent of total billed charges,Implant Device,1692.9,,,1692.9,Other,110% of Medicare,1197,35,,1197,percent of total billed charges,Implant Device,1162.8,34,"Charges > $500, x 34%",1162.8,percent of total billed charges,Implant Device,1197,35,,1197,percent of total billed charges,Implant Device,1197,35,,1197,percent of total billed charges,Implant Device,1197,35,,1197,percent of total billed charges,Implant Device,1197,35,,1197,percent of total billed charges,Implant Device,1197,35,,1197,percent of total billed charges,Implant Device,1368,40,,1368,percent of total billed charges,Implant Device,1197,70,,1197,percent of total billed charges,All Other,1162.8,34,,1162.8,percent of total billed charges,Implant Device,1162.8,34,,1162.8,percent of total billed charges,Implant Device,1197,35,,1197,percent of total billed charges,Implant Device,1197,35,,1197,percent of total billed charges,Implant Device,1197,35,,1197,percent of total billed charges,Implant Device,1197,35,,1197,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1162.8,34,"If Charge > 2,000, then 34 percent",1162.8,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2530.81,
J&J 1221-28-046 ACETABULAR LINER 28X46MM,C1776,HCPCS,,79013173,CDM,278,RC,,,both,,,2565,1898.11,,,1898.11,Other,150% of Medicare + 9.63% HCRA Surcharge,1154.25,45,,1154.25,percent of total billed charges,Critical Access Hospital RCC factor,872.1,34,,872.1,percent of total billed charges,Implant Device,872.1,34,,872.1,percent of total billed charges,Implant Device,872.1,34,,872.1,percent of total billed charges,Implant Device,872.1,34,,872.1,percent of total billed charges,Implant Device,872.1,34,,872.1,percent of total billed charges,Implant Device,1269.68,,,1269.68,Other,110% of Medicare,897.75,35,,897.75,percent of total billed charges,Implant Device,872.1,34,"Charges > $500, x 34%",872.1,percent of total billed charges,Implant Device,897.75,35,,897.75,percent of total billed charges,Implant Device,897.75,35,,897.75,percent of total billed charges,Implant Device,897.75,35,,897.75,percent of total billed charges,Implant Device,897.75,35,,897.75,percent of total billed charges,Implant Device,897.75,35,,897.75,percent of total billed charges,Implant Device,1026,40,,1026,percent of total billed charges,Implant Device,897.75,70,,897.75,percent of total billed charges,All Other,872.1,34,,872.1,percent of total billed charges,Implant Device,872.1,34,,872.1,percent of total billed charges,Implant Device,897.75,35,,897.75,percent of total billed charges,Implant Device,897.75,35,,897.75,percent of total billed charges,Implant Device,897.75,35,,897.75,percent of total billed charges,Implant Device,897.75,35,,897.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,872.1,34,"If Charge > 2,000, then 34 percent",872.1,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1898.11,
ZIMMER 42-5020-068-02 FEMUR RIGHT SZ 10,C1776,HCPCS,,79013174,CDM,278,RC,,,both,,,6300,4662.02,,,4662.02,Other,150% of Medicare + 9.63% HCRA Surcharge,2835,45,,2835,percent of total billed charges,Critical Access Hospital RCC factor,2142,34,,2142,percent of total billed charges,Implant Device,2142,34,,2142,percent of total billed charges,Implant Device,2142,34,,2142,percent of total billed charges,Implant Device,2142,34,,2142,percent of total billed charges,Implant Device,2142,34,,2142,percent of total billed charges,Implant Device,3118.5,,,3118.5,Other,110% of Medicare,2205,35,,2205,percent of total billed charges,Implant Device,2142,34,"Charges > $500, x 34%",2142,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2520,40,,2520,percent of total billed charges,Implant Device,2205,70,,2205,percent of total billed charges,All Other,2142,34,,2142,percent of total billed charges,Implant Device,2142,34,,2142,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2142,34,"If Charge > 2,000, then 34 percent",2142,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4662.02,
J&J 1010-12-050 FEMORAL STEM SIZE 5,C1776,HCPCS,,79013175,CDM,278,RC,,,both,,,7410,5483.42,,,5483.42,Other,150% of Medicare + 9.63% HCRA Surcharge,3334.5,45,,3334.5,percent of total billed charges,Critical Access Hospital RCC factor,2519.4,34,,2519.4,percent of total billed charges,Implant Device,2519.4,34,,2519.4,percent of total billed charges,Implant Device,2519.4,34,,2519.4,percent of total billed charges,Implant Device,2519.4,34,,2519.4,percent of total billed charges,Implant Device,2519.4,34,,2519.4,percent of total billed charges,Implant Device,3667.95,,,3667.95,Other,110% of Medicare,2593.5,35,,2593.5,percent of total billed charges,Implant Device,2519.4,34,"Charges > $500, x 34%",2519.4,percent of total billed charges,Implant Device,2593.5,35,,2593.5,percent of total billed charges,Implant Device,2593.5,35,,2593.5,percent of total billed charges,Implant Device,2593.5,35,,2593.5,percent of total billed charges,Implant Device,2593.5,35,,2593.5,percent of total billed charges,Implant Device,2593.5,35,,2593.5,percent of total billed charges,Implant Device,2964,40,,2964,percent of total billed charges,Implant Device,2593.5,70,,2593.5,percent of total billed charges,All Other,2519.4,34,,2519.4,percent of total billed charges,Implant Device,2519.4,34,,2519.4,percent of total billed charges,Implant Device,2593.5,35,,2593.5,percent of total billed charges,Implant Device,2593.5,35,,2593.5,percent of total billed charges,Implant Device,2593.5,35,,2593.5,percent of total billed charges,Implant Device,2593.5,35,,2593.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2519.4,34,"If Charge > 2,000, then 34 percent",2519.4,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5483.42,
ZIMMER 42-5221-008-16 ART SURF RT 16MM,C1776,HCPCS,,79013176,CDM,278,RC,,,both,,,3648,2699.53,,,2699.53,Other,150% of Medicare + 9.63% HCRA Surcharge,1641.6,45,,1641.6,percent of total billed charges,Critical Access Hospital RCC factor,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1805.76,,,1805.76,Other,110% of Medicare,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1240.32,34,"Charges > $500, x 34%",1240.32,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1459.2,40,,1459.2,percent of total billed charges,Implant Device,1276.8,70,,1276.8,percent of total billed charges,All Other,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1240.32,34,"If Charge > 2,000, then 34 percent",1240.32,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2699.53,
IN2BONES P67 ST438 CANN SCREW 4X38MM,C1713,HCPCS,,79013177,CDM,278,RC,,,both,,,870,643.8,,,643.8,Other,150% of Medicare + 9.63% HCRA Surcharge,391.5,45,,391.5,percent of total billed charges,Critical Access Hospital RCC factor,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,430.65,,,430.65,Other,110% of Medicare,304.5,35,,304.5,percent of total billed charges,Implant Device,295.8,34,"Charges > $500, x 34%",295.8,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,348,40,,348,percent of total billed charges,Implant Device,304.5,70,,304.5,percent of total billed charges,All Other,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,643.8,
ARTHREX AR-8935CL-22 KREULOCK SRW 3.5X22,C1713,HCPCS,,79013178,CDM,278,RC,,,both,,,885,654.9,,,654.9,Other,150% of Medicare + 9.63% HCRA Surcharge,398.25,45,,398.25,percent of total billed charges,Critical Access Hospital RCC factor,300.9,34,,300.9,percent of total billed charges,Implant Device,300.9,34,,300.9,percent of total billed charges,Implant Device,300.9,34,,300.9,percent of total billed charges,Implant Device,300.9,34,,300.9,percent of total billed charges,Implant Device,300.9,34,,300.9,percent of total billed charges,Implant Device,438.08,,,438.08,Other,110% of Medicare,309.75,35,,309.75,percent of total billed charges,Implant Device,300.9,34,"Charges > $500, x 34%",300.9,percent of total billed charges,Implant Device,309.75,35,,309.75,percent of total billed charges,Implant Device,309.75,35,,309.75,percent of total billed charges,Implant Device,309.75,35,,309.75,percent of total billed charges,Implant Device,309.75,35,,309.75,percent of total billed charges,Implant Device,309.75,35,,309.75,percent of total billed charges,Implant Device,354,40,,354,percent of total billed charges,Implant Device,309.75,70,,309.75,percent of total billed charges,All Other,300.9,34,,300.9,percent of total billed charges,Implant Device,300.9,34,,300.9,percent of total billed charges,Implant Device,309.75,35,,309.75,percent of total billed charges,Implant Device,309.75,35,,309.75,percent of total billed charges,Implant Device,309.75,35,,309.75,percent of total billed charges,Implant Device,309.75,35,,309.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,654.9,
ARTHREX AR-8935L-22 LOCK SCREW 3.5X22MM,C1713,HCPCS,,79013179,CDM,278,RC,,,both,,,488,361.12,,,361.12,Other,150% of Medicare + 9.63% HCRA Surcharge,219.6,45,,219.6,percent of total billed charges,Critical Access Hospital RCC factor,165.92,34,,165.92,percent of total billed charges,Implant Device,165.92,34,,165.92,percent of total billed charges,Implant Device,165.92,34,,165.92,percent of total billed charges,Implant Device,165.92,34,,165.92,percent of total billed charges,Implant Device,165.92,34,,165.92,percent of total billed charges,Implant Device,241.56,,,241.56,Other,110% of Medicare,170.8,35,,170.8,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,170.8,35,,170.8,percent of total billed charges,Implant Device,170.8,35,,170.8,percent of total billed charges,Implant Device,170.8,35,,170.8,percent of total billed charges,Implant Device,170.8,35,,170.8,percent of total billed charges,Implant Device,170.8,35,,170.8,percent of total billed charges,Implant Device,195.2,40,,195.2,percent of total billed charges,Implant Device,170.8,70,,170.8,percent of total billed charges,All Other,165.92,34,,165.92,percent of total billed charges,Implant Device,165.92,34,,165.92,percent of total billed charges,Implant Device,170.8,35,,170.8,percent of total billed charges,Implant Device,170.8,35,,170.8,percent of total billed charges,Implant Device,170.8,35,,170.8,percent of total billed charges,Implant Device,170.8,35,,170.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,361.12,
ZIMMER 00-5994-032-20 ART SURFACE 20MM,C1776,HCPCS,,79013181,CDM,278,RC,,,both,,,6257,4630.2,,,4630.2,Other,150% of Medicare + 9.63% HCRA Surcharge,2815.65,45,,2815.65,percent of total billed charges,Critical Access Hospital RCC factor,2127.38,34,,2127.38,percent of total billed charges,Implant Device,2127.38,34,,2127.38,percent of total billed charges,Implant Device,2127.38,34,,2127.38,percent of total billed charges,Implant Device,2127.38,34,,2127.38,percent of total billed charges,Implant Device,2127.38,34,,2127.38,percent of total billed charges,Implant Device,3097.22,,,3097.22,Other,110% of Medicare,2189.95,35,,2189.95,percent of total billed charges,Implant Device,2127.38,34,"Charges > $500, x 34%",2127.38,percent of total billed charges,Implant Device,2189.95,35,,2189.95,percent of total billed charges,Implant Device,2189.95,35,,2189.95,percent of total billed charges,Implant Device,2189.95,35,,2189.95,percent of total billed charges,Implant Device,2189.95,35,,2189.95,percent of total billed charges,Implant Device,2189.95,35,,2189.95,percent of total billed charges,Implant Device,2502.8,40,,2502.8,percent of total billed charges,Implant Device,2189.95,70,,2189.95,percent of total billed charges,All Other,2127.38,34,,2127.38,percent of total billed charges,Implant Device,2127.38,34,,2127.38,percent of total billed charges,Implant Device,2189.95,35,,2189.95,percent of total billed charges,Implant Device,2189.95,35,,2189.95,percent of total billed charges,Implant Device,2189.95,35,,2189.95,percent of total billed charges,Implant Device,2189.95,35,,2189.95,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2127.38,34,"If Charge > 2,000, then 34 percent",2127.38,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4630.2,
ZIMMER 42-5121-004-10 ART SURFACE 10 LT,C1776,HCPCS,,79013182,CDM,278,RC,,,both,,,3648,2699.53,,,2699.53,Other,150% of Medicare + 9.63% HCRA Surcharge,1641.6,45,,1641.6,percent of total billed charges,Critical Access Hospital RCC factor,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1805.76,,,1805.76,Other,110% of Medicare,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1240.32,34,"Charges > $500, x 34%",1240.32,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1459.2,40,,1459.2,percent of total billed charges,Implant Device,1276.8,70,,1276.8,percent of total billed charges,All Other,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1240.32,34,"If Charge > 2,000, then 34 percent",1240.32,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2699.53,
ZIMMER 42-5026-060-01 FEMUR LEFT SIZE 6,C1776,HCPCS,,79013183,CDM,278,RC,,,both,,,10200,7548.03,,,7548.03,Other,150% of Medicare + 9.63% HCRA Surcharge,4590,45,,4590,percent of total billed charges,Critical Access Hospital RCC factor,3468,34,,3468,percent of total billed charges,Implant Device,3468,34,,3468,percent of total billed charges,Implant Device,3468,34,,3468,percent of total billed charges,Implant Device,3468,34,,3468,percent of total billed charges,Implant Device,3468,34,,3468,percent of total billed charges,Implant Device,5049,,,5049,Other,110% of Medicare,3570,35,,3570,percent of total billed charges,Implant Device,3468,34,"Charges > $500, x 34%",3468,percent of total billed charges,Implant Device,3570,35,,3570,percent of total billed charges,Implant Device,3570,35,,3570,percent of total billed charges,Implant Device,3570,35,,3570,percent of total billed charges,Implant Device,3570,35,,3570,percent of total billed charges,Implant Device,3570,35,,3570,percent of total billed charges,Implant Device,4080,40,,4080,percent of total billed charges,Implant Device,3570,70,,3570,percent of total billed charges,All Other,3468,34,,3468,percent of total billed charges,Implant Device,3468,34,,3468,percent of total billed charges,Implant Device,3570,35,,3570,percent of total billed charges,Implant Device,3570,35,,3570,percent of total billed charges,Implant Device,3570,35,,3570,percent of total billed charges,Implant Device,3570,35,,3570,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3468,34,"If Charge > 2,000, then 34 percent",3468,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,7548.03,
PARAGON P50-353-2718 LOCK PLT SRW 2.7X18,C1713,HCPCS,,79013186,CDM,278,RC,,,both,,,693,512.82,,,512.82,Other,150% of Medicare + 9.63% HCRA Surcharge,311.85,45,,311.85,percent of total billed charges,Critical Access Hospital RCC factor,235.62,34,,235.62,percent of total billed charges,Implant Device,235.62,34,,235.62,percent of total billed charges,Implant Device,235.62,34,,235.62,percent of total billed charges,Implant Device,235.62,34,,235.62,percent of total billed charges,Implant Device,235.62,34,,235.62,percent of total billed charges,Implant Device,343.04,,,343.04,Other,110% of Medicare,242.55,35,,242.55,percent of total billed charges,Implant Device,235.62,34,"Charges > $500, x 34%",235.62,percent of total billed charges,Implant Device,242.55,35,,242.55,percent of total billed charges,Implant Device,242.55,35,,242.55,percent of total billed charges,Implant Device,242.55,35,,242.55,percent of total billed charges,Implant Device,242.55,35,,242.55,percent of total billed charges,Implant Device,242.55,35,,242.55,percent of total billed charges,Implant Device,277.2,40,,277.2,percent of total billed charges,Implant Device,242.55,70,,242.55,percent of total billed charges,All Other,235.62,34,,235.62,percent of total billed charges,Implant Device,235.62,34,,235.62,percent of total billed charges,Implant Device,242.55,35,,242.55,percent of total billed charges,Implant Device,242.55,35,,242.55,percent of total billed charges,Implant Device,242.55,35,,242.55,percent of total billed charges,Implant Device,242.55,35,,242.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,512.82,
ARTHREX AR-1665KBCSL LOOP N TAK KIT,C1713,HCPCS,,79013187,CDM,278,RC,,,both,,,2796,2069.05,,,2069.05,Other,150% of Medicare + 9.63% HCRA Surcharge,1258.2,45,,1258.2,percent of total billed charges,Critical Access Hospital RCC factor,950.64,34,,950.64,percent of total billed charges,Implant Device,950.64,34,,950.64,percent of total billed charges,Implant Device,950.64,34,,950.64,percent of total billed charges,Implant Device,950.64,34,,950.64,percent of total billed charges,Implant Device,950.64,34,,950.64,percent of total billed charges,Implant Device,1384.02,,,1384.02,Other,110% of Medicare,978.6,35,,978.6,percent of total billed charges,Implant Device,950.64,34,"Charges > $500, x 34%",950.64,percent of total billed charges,Implant Device,978.6,35,,978.6,percent of total billed charges,Implant Device,978.6,35,,978.6,percent of total billed charges,Implant Device,978.6,35,,978.6,percent of total billed charges,Implant Device,978.6,35,,978.6,percent of total billed charges,Implant Device,978.6,35,,978.6,percent of total billed charges,Implant Device,1118.4,40,,1118.4,percent of total billed charges,Implant Device,978.6,70,,978.6,percent of total billed charges,All Other,950.64,34,,950.64,percent of total billed charges,Implant Device,950.64,34,,950.64,percent of total billed charges,Implant Device,978.6,35,,978.6,percent of total billed charges,Implant Device,978.6,35,,978.6,percent of total billed charges,Implant Device,978.6,35,,978.6,percent of total billed charges,Implant Device,978.6,35,,978.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,950.64,34,"If Charge > 2,000, then 34 percent",950.64,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2069.05,
J&J 02.112.111S DIS FIBULA PLT 2.7/3.5,C1713,HCPCS,,79013188,CDM,278,RC,,,both,,,1718,1271.32,,,1271.32,Other,150% of Medicare + 9.63% HCRA Surcharge,773.1,45,,773.1,percent of total billed charges,Critical Access Hospital RCC factor,584.12,34,,584.12,percent of total billed charges,Implant Device,584.12,34,,584.12,percent of total billed charges,Implant Device,584.12,34,,584.12,percent of total billed charges,Implant Device,584.12,34,,584.12,percent of total billed charges,Implant Device,584.12,34,,584.12,percent of total billed charges,Implant Device,850.41,,,850.41,Other,110% of Medicare,601.3,35,,601.3,percent of total billed charges,Implant Device,584.12,34,"Charges > $500, x 34%",584.12,percent of total billed charges,Implant Device,601.3,35,,601.3,percent of total billed charges,Implant Device,601.3,35,,601.3,percent of total billed charges,Implant Device,601.3,35,,601.3,percent of total billed charges,Implant Device,601.3,35,,601.3,percent of total billed charges,Implant Device,601.3,35,,601.3,percent of total billed charges,Implant Device,687.2,40,,687.2,percent of total billed charges,Implant Device,601.3,70,,601.3,percent of total billed charges,All Other,584.12,34,,584.12,percent of total billed charges,Implant Device,584.12,34,,584.12,percent of total billed charges,Implant Device,601.3,35,,601.3,percent of total billed charges,Implant Device,601.3,35,,601.3,percent of total billed charges,Implant Device,601.3,35,,601.3,percent of total billed charges,Implant Device,601.3,35,,601.3,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1271.32,
J&J 201.691 CORTEX SCREW 2.4X42MM,C1713,HCPCS,,79013190,CDM,278,RC,,,both,,,153,113.22,,,113.22,Other,150% of Medicare + 9.63% HCRA Surcharge,68.85,45,,68.85,percent of total billed charges,Critical Access Hospital RCC factor,52.02,34,,52.02,percent of total billed charges,Implant Device,52.02,34,,52.02,percent of total billed charges,Implant Device,52.02,34,,52.02,percent of total billed charges,Implant Device,52.02,34,,52.02,percent of total billed charges,Implant Device,52.02,34,,52.02,percent of total billed charges,Implant Device,75.74,,,75.74,Other,110% of Medicare,53.55,35,,53.55,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,53.55,35,,53.55,percent of total billed charges,Implant Device,53.55,35,,53.55,percent of total billed charges,Implant Device,53.55,35,,53.55,percent of total billed charges,Implant Device,53.55,35,,53.55,percent of total billed charges,Implant Device,53.55,35,,53.55,percent of total billed charges,Implant Device,61.2,40,,61.2,percent of total billed charges,Implant Device,53.55,70,,53.55,percent of total billed charges,All Other,52.02,34,,52.02,percent of total billed charges,Implant Device,52.02,34,,52.02,percent of total billed charges,Implant Device,53.55,35,,53.55,percent of total billed charges,Implant Device,53.55,35,,53.55,percent of total billed charges,Implant Device,53.55,35,,53.55,percent of total billed charges,Implant Device,53.55,35,,53.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,113.22,
J&J 201.668 CORTEX SCREW 2.4X38MM,C1713,HCPCS,,79013191,CDM,278,RC,,,both,,,121,89.54,,,89.54,Other,150% of Medicare + 9.63% HCRA Surcharge,54.45,45,,54.45,percent of total billed charges,Critical Access Hospital RCC factor,41.14,34,,41.14,percent of total billed charges,Implant Device,41.14,34,,41.14,percent of total billed charges,Implant Device,41.14,34,,41.14,percent of total billed charges,Implant Device,41.14,34,,41.14,percent of total billed charges,Implant Device,41.14,34,,41.14,percent of total billed charges,Implant Device,59.9,,,59.9,Other,110% of Medicare,42.35,35,,42.35,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,42.35,35,,42.35,percent of total billed charges,Implant Device,42.35,35,,42.35,percent of total billed charges,Implant Device,42.35,35,,42.35,percent of total billed charges,Implant Device,42.35,35,,42.35,percent of total billed charges,Implant Device,42.35,35,,42.35,percent of total billed charges,Implant Device,48.4,40,,48.4,percent of total billed charges,Implant Device,42.35,70,,42.35,percent of total billed charges,All Other,41.14,34,,41.14,percent of total billed charges,Implant Device,41.14,34,,41.14,percent of total billed charges,Implant Device,42.35,35,,42.35,percent of total billed charges,Implant Device,42.35,35,,42.35,percent of total billed charges,Implant Device,42.35,35,,42.35,percent of total billed charges,Implant Device,42.35,35,,42.35,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,89.54,
J&J 201.662 CORTEX SCREW 2.4X32MM,C1713,HCPCS,,79013192,CDM,278,RC,,,both,,,121,89.54,,,89.54,Other,150% of Medicare + 9.63% HCRA Surcharge,54.45,45,,54.45,percent of total billed charges,Critical Access Hospital RCC factor,41.14,34,,41.14,percent of total billed charges,Implant Device,41.14,34,,41.14,percent of total billed charges,Implant Device,41.14,34,,41.14,percent of total billed charges,Implant Device,41.14,34,,41.14,percent of total billed charges,Implant Device,41.14,34,,41.14,percent of total billed charges,Implant Device,59.9,,,59.9,Other,110% of Medicare,42.35,35,,42.35,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,42.35,35,,42.35,percent of total billed charges,Implant Device,42.35,35,,42.35,percent of total billed charges,Implant Device,42.35,35,,42.35,percent of total billed charges,Implant Device,42.35,35,,42.35,percent of total billed charges,Implant Device,42.35,35,,42.35,percent of total billed charges,Implant Device,48.4,40,,48.4,percent of total billed charges,Implant Device,42.35,70,,42.35,percent of total billed charges,All Other,41.14,34,,41.14,percent of total billed charges,Implant Device,41.14,34,,41.14,percent of total billed charges,Implant Device,42.35,35,,42.35,percent of total billed charges,Implant Device,42.35,35,,42.35,percent of total billed charges,Implant Device,42.35,35,,42.35,percent of total billed charges,Implant Device,42.35,35,,42.35,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,89.54,
J&J 1218-52-045 PINNACLE LINER 52/45,C1776,HCPCS,,79013193,CDM,278,RC,,,both,,,3465,2564.11,,,2564.11,Other,150% of Medicare + 9.63% HCRA Surcharge,1559.25,45,,1559.25,percent of total billed charges,Critical Access Hospital RCC factor,1178.1,34,,1178.1,percent of total billed charges,Implant Device,1178.1,34,,1178.1,percent of total billed charges,Implant Device,1178.1,34,,1178.1,percent of total billed charges,Implant Device,1178.1,34,,1178.1,percent of total billed charges,Implant Device,1178.1,34,,1178.1,percent of total billed charges,Implant Device,1715.18,,,1715.18,Other,110% of Medicare,1212.75,35,,1212.75,percent of total billed charges,Implant Device,1178.1,34,"Charges > $500, x 34%",1178.1,percent of total billed charges,Implant Device,1212.75,35,,1212.75,percent of total billed charges,Implant Device,1212.75,35,,1212.75,percent of total billed charges,Implant Device,1212.75,35,,1212.75,percent of total billed charges,Implant Device,1212.75,35,,1212.75,percent of total billed charges,Implant Device,1212.75,35,,1212.75,percent of total billed charges,Implant Device,1386,40,,1386,percent of total billed charges,Implant Device,1212.75,70,,1212.75,percent of total billed charges,All Other,1178.1,34,,1178.1,percent of total billed charges,Implant Device,1178.1,34,,1178.1,percent of total billed charges,Implant Device,1212.75,35,,1212.75,percent of total billed charges,Implant Device,1212.75,35,,1212.75,percent of total billed charges,Implant Device,1212.75,35,,1212.75,percent of total billed charges,Implant Device,1212.75,35,,1212.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1178.1,34,"If Charge > 2,000, then 34 percent",1178.1,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2564.11,
J&J 1365-29-000 FEMORAL HEAD 225MM,C1776,HCPCS,,79013194,CDM,278,RC,,,both,,,1710,1265.4,,,1265.4,Other,150% of Medicare + 9.63% HCRA Surcharge,769.5,45,,769.5,percent of total billed charges,Critical Access Hospital RCC factor,581.4,34,,581.4,percent of total billed charges,Implant Device,581.4,34,,581.4,percent of total billed charges,Implant Device,581.4,34,,581.4,percent of total billed charges,Implant Device,581.4,34,,581.4,percent of total billed charges,Implant Device,581.4,34,,581.4,percent of total billed charges,Implant Device,846.45,,,846.45,Other,110% of Medicare,598.5,35,,598.5,percent of total billed charges,Implant Device,581.4,34,"Charges > $500, x 34%",581.4,percent of total billed charges,Implant Device,598.5,35,,598.5,percent of total billed charges,Implant Device,598.5,35,,598.5,percent of total billed charges,Implant Device,598.5,35,,598.5,percent of total billed charges,Implant Device,598.5,35,,598.5,percent of total billed charges,Implant Device,598.5,35,,598.5,percent of total billed charges,Implant Device,684,40,,684,percent of total billed charges,Implant Device,598.5,70,,598.5,percent of total billed charges,All Other,581.4,34,,581.4,percent of total billed charges,Implant Device,581.4,34,,581.4,percent of total billed charges,Implant Device,598.5,35,,598.5,percent of total billed charges,Implant Device,598.5,35,,598.5,percent of total billed charges,Implant Device,598.5,35,,598.5,percent of total billed charges,Implant Device,598.5,35,,598.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1265.4,
"J&J DS10014522 LINER 22,2/45",C1776,HCPCS,,79013195,CDM,278,RC,,,both,,,3465,2564.11,,,2564.11,Other,150% of Medicare + 9.63% HCRA Surcharge,1559.25,45,,1559.25,percent of total billed charges,Critical Access Hospital RCC factor,1178.1,34,,1178.1,percent of total billed charges,Implant Device,1178.1,34,,1178.1,percent of total billed charges,Implant Device,1178.1,34,,1178.1,percent of total billed charges,Implant Device,1178.1,34,,1178.1,percent of total billed charges,Implant Device,1178.1,34,,1178.1,percent of total billed charges,Implant Device,1715.18,,,1715.18,Other,110% of Medicare,1212.75,35,,1212.75,percent of total billed charges,Implant Device,1178.1,34,"Charges > $500, x 34%",1178.1,percent of total billed charges,Implant Device,1212.75,35,,1212.75,percent of total billed charges,Implant Device,1212.75,35,,1212.75,percent of total billed charges,Implant Device,1212.75,35,,1212.75,percent of total billed charges,Implant Device,1212.75,35,,1212.75,percent of total billed charges,Implant Device,1212.75,35,,1212.75,percent of total billed charges,Implant Device,1386,40,,1386,percent of total billed charges,Implant Device,1212.75,70,,1212.75,percent of total billed charges,All Other,1178.1,34,,1178.1,percent of total billed charges,Implant Device,1178.1,34,,1178.1,percent of total billed charges,Implant Device,1212.75,35,,1212.75,percent of total billed charges,Implant Device,1212.75,35,,1212.75,percent of total billed charges,Implant Device,1212.75,35,,1212.75,percent of total billed charges,Implant Device,1212.75,35,,1212.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1178.1,34,"If Charge > 2,000, then 34 percent",1178.1,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2564.11,
J&J 1010-11-090 FEMORAL STEM SIZE 9,C1776,HCPCS,,79013196,CDM,278,RC,,,both,,,7410,5483.42,,,5483.42,Other,150% of Medicare + 9.63% HCRA Surcharge,3334.5,45,,3334.5,percent of total billed charges,Critical Access Hospital RCC factor,2519.4,34,,2519.4,percent of total billed charges,Implant Device,2519.4,34,,2519.4,percent of total billed charges,Implant Device,2519.4,34,,2519.4,percent of total billed charges,Implant Device,2519.4,34,,2519.4,percent of total billed charges,Implant Device,2519.4,34,,2519.4,percent of total billed charges,Implant Device,3667.95,,,3667.95,Other,110% of Medicare,2593.5,35,,2593.5,percent of total billed charges,Implant Device,2519.4,34,"Charges > $500, x 34%",2519.4,percent of total billed charges,Implant Device,2593.5,35,,2593.5,percent of total billed charges,Implant Device,2593.5,35,,2593.5,percent of total billed charges,Implant Device,2593.5,35,,2593.5,percent of total billed charges,Implant Device,2593.5,35,,2593.5,percent of total billed charges,Implant Device,2593.5,35,,2593.5,percent of total billed charges,Implant Device,2964,40,,2964,percent of total billed charges,Implant Device,2593.5,70,,2593.5,percent of total billed charges,All Other,2519.4,34,,2519.4,percent of total billed charges,Implant Device,2519.4,34,,2519.4,percent of total billed charges,Implant Device,2593.5,35,,2593.5,percent of total billed charges,Implant Device,2593.5,35,,2593.5,percent of total billed charges,Implant Device,2593.5,35,,2593.5,percent of total billed charges,Implant Device,2593.5,35,,2593.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2519.4,34,"If Charge > 2,000, then 34 percent",2519.4,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5483.42,
J&J 1217-25-500 CAN BONE SCREW 6.5X25MM,C1713,HCPCS,,79013197,CDM,278,RC,,,both,,,228,168.72,,,168.72,Other,150% of Medicare + 9.63% HCRA Surcharge,102.6,45,,102.6,percent of total billed charges,Critical Access Hospital RCC factor,77.52,34,,77.52,percent of total billed charges,Implant Device,77.52,34,,77.52,percent of total billed charges,Implant Device,77.52,34,,77.52,percent of total billed charges,Implant Device,77.52,34,,77.52,percent of total billed charges,Implant Device,77.52,34,,77.52,percent of total billed charges,Implant Device,112.86,,,112.86,Other,110% of Medicare,79.8,35,,79.8,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,79.8,35,,79.8,percent of total billed charges,Implant Device,79.8,35,,79.8,percent of total billed charges,Implant Device,79.8,35,,79.8,percent of total billed charges,Implant Device,79.8,35,,79.8,percent of total billed charges,Implant Device,79.8,35,,79.8,percent of total billed charges,Implant Device,91.2,40,,91.2,percent of total billed charges,Implant Device,79.8,70,,79.8,percent of total billed charges,All Other,77.52,34,,77.52,percent of total billed charges,Implant Device,77.52,34,,77.52,percent of total billed charges,Implant Device,79.8,35,,79.8,percent of total billed charges,Implant Device,79.8,35,,79.8,percent of total billed charges,Implant Device,79.8,35,,79.8,percent of total billed charges,Implant Device,79.8,35,,79.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,168.72,
J&J 1217-32-062 ACETABULAR SHELL 62MM,C1776,HCPCS,,79013198,CDM,278,RC,,,both,,,3420,2530.81,,,2530.81,Other,150% of Medicare + 9.63% HCRA Surcharge,1539,45,,1539,percent of total billed charges,Critical Access Hospital RCC factor,1162.8,34,,1162.8,percent of total billed charges,Implant Device,1162.8,34,,1162.8,percent of total billed charges,Implant Device,1162.8,34,,1162.8,percent of total billed charges,Implant Device,1162.8,34,,1162.8,percent of total billed charges,Implant Device,1162.8,34,,1162.8,percent of total billed charges,Implant Device,1692.9,,,1692.9,Other,110% of Medicare,1197,35,,1197,percent of total billed charges,Implant Device,1162.8,34,"Charges > $500, x 34%",1162.8,percent of total billed charges,Implant Device,1197,35,,1197,percent of total billed charges,Implant Device,1197,35,,1197,percent of total billed charges,Implant Device,1197,35,,1197,percent of total billed charges,Implant Device,1197,35,,1197,percent of total billed charges,Implant Device,1197,35,,1197,percent of total billed charges,Implant Device,1368,40,,1368,percent of total billed charges,Implant Device,1197,70,,1197,percent of total billed charges,All Other,1162.8,34,,1162.8,percent of total billed charges,Implant Device,1162.8,34,,1162.8,percent of total billed charges,Implant Device,1197,35,,1197,percent of total billed charges,Implant Device,1197,35,,1197,percent of total billed charges,Implant Device,1197,35,,1197,percent of total billed charges,Implant Device,1197,35,,1197,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1162.8,34,"If Charge > 2,000, then 34 percent",1162.8,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2530.81,
J&J 1221-40-062 ACETABULAR LINER 40X62MM,C1776,HCPCS,,79013199,CDM,278,RC,,,both,,,2565,1898.11,,,1898.11,Other,150% of Medicare + 9.63% HCRA Surcharge,1154.25,45,,1154.25,percent of total billed charges,Critical Access Hospital RCC factor,872.1,34,,872.1,percent of total billed charges,Implant Device,872.1,34,,872.1,percent of total billed charges,Implant Device,872.1,34,,872.1,percent of total billed charges,Implant Device,872.1,34,,872.1,percent of total billed charges,Implant Device,872.1,34,,872.1,percent of total billed charges,Implant Device,1269.68,,,1269.68,Other,110% of Medicare,897.75,35,,897.75,percent of total billed charges,Implant Device,872.1,34,"Charges > $500, x 34%",872.1,percent of total billed charges,Implant Device,897.75,35,,897.75,percent of total billed charges,Implant Device,897.75,35,,897.75,percent of total billed charges,Implant Device,897.75,35,,897.75,percent of total billed charges,Implant Device,897.75,35,,897.75,percent of total billed charges,Implant Device,897.75,35,,897.75,percent of total billed charges,Implant Device,1026,40,,1026,percent of total billed charges,Implant Device,897.75,70,,897.75,percent of total billed charges,All Other,872.1,34,,872.1,percent of total billed charges,Implant Device,872.1,34,,872.1,percent of total billed charges,Implant Device,897.75,35,,897.75,percent of total billed charges,Implant Device,897.75,35,,897.75,percent of total billed charges,Implant Device,897.75,35,,897.75,percent of total billed charges,Implant Device,897.75,35,,897.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,872.1,34,"If Charge > 2,000, then 34 percent",872.1,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1898.11,
ZIMMER 1100-31-012 BEARING 28X44MM,C1776,HCPCS,,79013200,CDM,278,RC,,,both,,,3456,2557.45,,,2557.45,Other,150% of Medicare + 9.63% HCRA Surcharge,1555.2,45,,1555.2,percent of total billed charges,Critical Access Hospital RCC factor,1175.04,34,,1175.04,percent of total billed charges,Implant Device,1175.04,34,,1175.04,percent of total billed charges,Implant Device,1175.04,34,,1175.04,percent of total billed charges,Implant Device,1175.04,34,,1175.04,percent of total billed charges,Implant Device,1175.04,34,,1175.04,percent of total billed charges,Implant Device,1710.72,,,1710.72,Other,110% of Medicare,1209.6,35,,1209.6,percent of total billed charges,Implant Device,1175.04,34,"Charges > $500, x 34%",1175.04,percent of total billed charges,Implant Device,1209.6,35,,1209.6,percent of total billed charges,Implant Device,1209.6,35,,1209.6,percent of total billed charges,Implant Device,1209.6,35,,1209.6,percent of total billed charges,Implant Device,1209.6,35,,1209.6,percent of total billed charges,Implant Device,1209.6,35,,1209.6,percent of total billed charges,Implant Device,1382.4,40,,1382.4,percent of total billed charges,Implant Device,1209.6,70,,1209.6,percent of total billed charges,All Other,1175.04,34,,1175.04,percent of total billed charges,Implant Device,1175.04,34,,1175.04,percent of total billed charges,Implant Device,1209.6,35,,1209.6,percent of total billed charges,Implant Device,1209.6,35,,1209.6,percent of total billed charges,Implant Device,1209.6,35,,1209.6,percent of total billed charges,Implant Device,1209.6,35,,1209.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1175.04,34,"If Charge > 2,000, then 34 percent",1175.04,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2557.45,
ZIMMER 11-301351 PROXIMAL BODY SZ 1 80MM,C1776,HCPCS,,79013201,CDM,278,RC,,,both,,,19784,14640.21,,,14640.21,Other,150% of Medicare + 9.63% HCRA Surcharge,8902.8,45,,8902.8,percent of total billed charges,Critical Access Hospital RCC factor,6726.56,34,,6726.56,percent of total billed charges,Implant Device,6726.56,34,,6726.56,percent of total billed charges,Implant Device,6726.56,34,,6726.56,percent of total billed charges,Implant Device,6726.56,34,,6726.56,percent of total billed charges,Implant Device,6726.56,34,,6726.56,percent of total billed charges,Implant Device,9793.08,,,9793.08,Other,110% of Medicare,6924.4,35,,6924.4,percent of total billed charges,Implant Device,6726.56,34,"Charges > $500, x 34%",6726.56,percent of total billed charges,Implant Device,6924.4,35,,6924.4,percent of total billed charges,Implant Device,6924.4,35,,6924.4,percent of total billed charges,Implant Device,6924.4,35,,6924.4,percent of total billed charges,Implant Device,6924.4,35,,6924.4,percent of total billed charges,Implant Device,6924.4,35,,6924.4,percent of total billed charges,Implant Device,7913.6,40,,7913.6,percent of total billed charges,Implant Device,6924.4,70,,6924.4,percent of total billed charges,All Other,6726.56,34,,6726.56,percent of total billed charges,Implant Device,6726.56,34,,6726.56,percent of total billed charges,Implant Device,6924.4,35,,6924.4,percent of total billed charges,Implant Device,6924.4,35,,6924.4,percent of total billed charges,Implant Device,6924.4,35,,6924.4,percent of total billed charges,Implant Device,6924.4,35,,6924.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,6726.56,34,"If Charge > 2,000, then 34 percent",6726.56,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,14640.21,
ARTHRO 9M52-2535-W ARTICULAR COMP 15MM,L8642,HCPCS,,79013203,CDM,278,RC,,,both,,,5205,3851.71,,,3851.71,Other,150% of Medicare + 9.63% HCRA Surcharge,2342.25,45,,2342.25,percent of total billed charges,Critical Access Hospital RCC factor,1769.7,34,,1769.7,percent of total billed charges,Implant Device,1769.7,34,,1769.7,percent of total billed charges,Implant Device,1769.7,34,,1769.7,percent of total billed charges,Implant Device,1769.7,34,,1769.7,percent of total billed charges,Implant Device,1769.7,34,,1769.7,percent of total billed charges,Implant Device,2576.48,,,2576.48,Other,110% of Medicare,1821.75,35,,1821.75,percent of total billed charges,Implant Device,1769.7,34,"Charges > $500, x 34%",1769.7,percent of total billed charges,Implant Device,1821.75,35,,1821.75,percent of total billed charges,Implant Device,1821.75,35,,1821.75,percent of total billed charges,Implant Device,1821.75,35,,1821.75,percent of total billed charges,Implant Device,1821.75,35,,1821.75,percent of total billed charges,Implant Device,1821.75,35,,1821.75,percent of total billed charges,Implant Device,2082,40,,2082,percent of total billed charges,Implant Device,1821.75,70,,1821.75,percent of total billed charges,All Other,1769.7,34,,1769.7,percent of total billed charges,Implant Device,1769.7,34,,1769.7,percent of total billed charges,Implant Device,1821.75,35,,1821.75,percent of total billed charges,Implant Device,1821.75,35,,1821.75,percent of total billed charges,Implant Device,1821.75,35,,1821.75,percent of total billed charges,Implant Device,1821.75,35,,1821.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1769.7,34,"If Charge > 2,000, then 34 percent",1769.7,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3851.71,
BIOTRONIK 434899 PK PAPYRUS 3MMX26MM,C1874,HCPCS,,79013204,CDM,278,RC,,,both,,,8910,6593.42,,,6593.42,Other,150% of Medicare + 9.63% HCRA Surcharge,4009.5,45,,4009.5,percent of total billed charges,Critical Access Hospital RCC factor,3029.4,34,,3029.4,percent of total billed charges,Implant Device,3029.4,34,,3029.4,percent of total billed charges,Implant Device,3029.4,34,,3029.4,percent of total billed charges,Implant Device,3029.4,34,,3029.4,percent of total billed charges,Implant Device,3029.4,34,,3029.4,percent of total billed charges,Implant Device,4410.45,,,4410.45,Other,110% of Medicare,3118.5,35,,3118.5,percent of total billed charges,Implant Device,3029.4,34,"Charges > $500, x 34%",3029.4,percent of total billed charges,Implant Device,3118.5,35,,3118.5,percent of total billed charges,Implant Device,3118.5,35,,3118.5,percent of total billed charges,Implant Device,3118.5,35,,3118.5,percent of total billed charges,Implant Device,3118.5,35,,3118.5,percent of total billed charges,Implant Device,3118.5,35,,3118.5,percent of total billed charges,Implant Device,3564,40,,3564,percent of total billed charges,Implant Device,3118.5,70,,3118.5,percent of total billed charges,All Other,3029.4,34,,3029.4,percent of total billed charges,Implant Device,3029.4,34,,3029.4,percent of total billed charges,Implant Device,3118.5,35,,3118.5,percent of total billed charges,Implant Device,3118.5,35,,3118.5,percent of total billed charges,Implant Device,3118.5,35,,3118.5,percent of total billed charges,Implant Device,3118.5,35,,3118.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3029.4,34,"If Charge > 2,000, then 34 percent",3029.4,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,6593.42,
BIOTRONIK 434901 PK PAPYRUS 4MMX26MM,C1874,HCPCS,,79013205,CDM,278,RC,,,both,,,8910,6593.42,,,6593.42,Other,150% of Medicare + 9.63% HCRA Surcharge,4009.5,45,,4009.5,percent of total billed charges,Critical Access Hospital RCC factor,3029.4,34,,3029.4,percent of total billed charges,Implant Device,3029.4,34,,3029.4,percent of total billed charges,Implant Device,3029.4,34,,3029.4,percent of total billed charges,Implant Device,3029.4,34,,3029.4,percent of total billed charges,Implant Device,3029.4,34,,3029.4,percent of total billed charges,Implant Device,4410.45,,,4410.45,Other,110% of Medicare,3118.5,35,,3118.5,percent of total billed charges,Implant Device,3029.4,34,"Charges > $500, x 34%",3029.4,percent of total billed charges,Implant Device,3118.5,35,,3118.5,percent of total billed charges,Implant Device,3118.5,35,,3118.5,percent of total billed charges,Implant Device,3118.5,35,,3118.5,percent of total billed charges,Implant Device,3118.5,35,,3118.5,percent of total billed charges,Implant Device,3118.5,35,,3118.5,percent of total billed charges,Implant Device,3564,40,,3564,percent of total billed charges,Implant Device,3118.5,70,,3118.5,percent of total billed charges,All Other,3029.4,34,,3029.4,percent of total billed charges,Implant Device,3029.4,34,,3029.4,percent of total billed charges,Implant Device,3118.5,35,,3118.5,percent of total billed charges,Implant Device,3118.5,35,,3118.5,percent of total billed charges,Implant Device,3118.5,35,,3118.5,percent of total billed charges,Implant Device,3118.5,35,,3118.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3029.4,34,"If Charge > 2,000, then 34 percent",3029.4,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,6593.42,
BIOTRONIK 434897 PK PAPYRUS 4.5MMX20MM,C1874,HCPCS,,79013206,CDM,278,RC,,,both,,,8910,6593.42,,,6593.42,Other,150% of Medicare + 9.63% HCRA Surcharge,4009.5,45,,4009.5,percent of total billed charges,Critical Access Hospital RCC factor,3029.4,34,,3029.4,percent of total billed charges,Implant Device,3029.4,34,,3029.4,percent of total billed charges,Implant Device,3029.4,34,,3029.4,percent of total billed charges,Implant Device,3029.4,34,,3029.4,percent of total billed charges,Implant Device,3029.4,34,,3029.4,percent of total billed charges,Implant Device,4410.45,,,4410.45,Other,110% of Medicare,3118.5,35,,3118.5,percent of total billed charges,Implant Device,3029.4,34,"Charges > $500, x 34%",3029.4,percent of total billed charges,Implant Device,3118.5,35,,3118.5,percent of total billed charges,Implant Device,3118.5,35,,3118.5,percent of total billed charges,Implant Device,3118.5,35,,3118.5,percent of total billed charges,Implant Device,3118.5,35,,3118.5,percent of total billed charges,Implant Device,3118.5,35,,3118.5,percent of total billed charges,Implant Device,3564,40,,3564,percent of total billed charges,Implant Device,3118.5,70,,3118.5,percent of total billed charges,All Other,3029.4,34,,3029.4,percent of total billed charges,Implant Device,3029.4,34,,3029.4,percent of total billed charges,Implant Device,3118.5,35,,3118.5,percent of total billed charges,Implant Device,3118.5,35,,3118.5,percent of total billed charges,Implant Device,3118.5,35,,3118.5,percent of total billed charges,Implant Device,3118.5,35,,3118.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3029.4,34,"If Charge > 2,000, then 34 percent",3029.4,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,6593.42,
BIOTRONIK 434903 PK PAPYRUS 5MMX26MM,C1874,HCPCS,,79013207,CDM,278,RC,,,both,,,8910,6593.42,,,6593.42,Other,150% of Medicare + 9.63% HCRA Surcharge,4009.5,45,,4009.5,percent of total billed charges,Critical Access Hospital RCC factor,3029.4,34,,3029.4,percent of total billed charges,Implant Device,3029.4,34,,3029.4,percent of total billed charges,Implant Device,3029.4,34,,3029.4,percent of total billed charges,Implant Device,3029.4,34,,3029.4,percent of total billed charges,Implant Device,3029.4,34,,3029.4,percent of total billed charges,Implant Device,4410.45,,,4410.45,Other,110% of Medicare,3118.5,35,,3118.5,percent of total billed charges,Implant Device,3029.4,34,"Charges > $500, x 34%",3029.4,percent of total billed charges,Implant Device,3118.5,35,,3118.5,percent of total billed charges,Implant Device,3118.5,35,,3118.5,percent of total billed charges,Implant Device,3118.5,35,,3118.5,percent of total billed charges,Implant Device,3118.5,35,,3118.5,percent of total billed charges,Implant Device,3118.5,35,,3118.5,percent of total billed charges,Implant Device,3564,40,,3564,percent of total billed charges,Implant Device,3118.5,70,,3118.5,percent of total billed charges,All Other,3029.4,34,,3029.4,percent of total billed charges,Implant Device,3029.4,34,,3029.4,percent of total billed charges,Implant Device,3118.5,35,,3118.5,percent of total billed charges,Implant Device,3118.5,35,,3118.5,percent of total billed charges,Implant Device,3118.5,35,,3118.5,percent of total billed charges,Implant Device,3118.5,35,,3118.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3029.4,34,"If Charge > 2,000, then 34 percent",3029.4,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,6593.42,
J&J 02.112.610 LCP CLAVICLE PLATE 2.7MM,C1713,HCPCS,,79013208,CDM,278,RC,,,both,,,3383,2503.43,,,2503.43,Other,150% of Medicare + 9.63% HCRA Surcharge,1522.35,45,,1522.35,percent of total billed charges,Critical Access Hospital RCC factor,1150.22,34,,1150.22,percent of total billed charges,Implant Device,1150.22,34,,1150.22,percent of total billed charges,Implant Device,1150.22,34,,1150.22,percent of total billed charges,Implant Device,1150.22,34,,1150.22,percent of total billed charges,Implant Device,1150.22,34,,1150.22,percent of total billed charges,Implant Device,1674.59,,,1674.59,Other,110% of Medicare,1184.05,35,,1184.05,percent of total billed charges,Implant Device,1150.22,34,"Charges > $500, x 34%",1150.22,percent of total billed charges,Implant Device,1184.05,35,,1184.05,percent of total billed charges,Implant Device,1184.05,35,,1184.05,percent of total billed charges,Implant Device,1184.05,35,,1184.05,percent of total billed charges,Implant Device,1184.05,35,,1184.05,percent of total billed charges,Implant Device,1184.05,35,,1184.05,percent of total billed charges,Implant Device,1353.2,40,,1353.2,percent of total billed charges,Implant Device,1184.05,70,,1184.05,percent of total billed charges,All Other,1150.22,34,,1150.22,percent of total billed charges,Implant Device,1150.22,34,,1150.22,percent of total billed charges,Implant Device,1184.05,35,,1184.05,percent of total billed charges,Implant Device,1184.05,35,,1184.05,percent of total billed charges,Implant Device,1184.05,35,,1184.05,percent of total billed charges,Implant Device,1184.05,35,,1184.05,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1150.22,34,"If Charge > 2,000, then 34 percent",1150.22,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2503.43,
J&J 412.212S LOCKING SCREW 5.0X36MM,C1713,HCPCS,,79013209,CDM,278,RC,,,both,,,505,373.7,,,373.7,Other,150% of Medicare + 9.63% HCRA Surcharge,227.25,45,,227.25,percent of total billed charges,Critical Access Hospital RCC factor,171.7,34,,171.7,percent of total billed charges,Implant Device,171.7,34,,171.7,percent of total billed charges,Implant Device,171.7,34,,171.7,percent of total billed charges,Implant Device,171.7,34,,171.7,percent of total billed charges,Implant Device,171.7,34,,171.7,percent of total billed charges,Implant Device,249.98,,,249.98,Other,110% of Medicare,176.75,35,,176.75,percent of total billed charges,Implant Device,171.7,34,"Charges > $500, x 34%",171.7,percent of total billed charges,Implant Device,176.75,35,,176.75,percent of total billed charges,Implant Device,176.75,35,,176.75,percent of total billed charges,Implant Device,176.75,35,,176.75,percent of total billed charges,Implant Device,176.75,35,,176.75,percent of total billed charges,Implant Device,176.75,35,,176.75,percent of total billed charges,Implant Device,202,40,,202,percent of total billed charges,Implant Device,176.75,70,,176.75,percent of total billed charges,All Other,171.7,34,,171.7,percent of total billed charges,Implant Device,171.7,34,,171.7,percent of total billed charges,Implant Device,176.75,35,,176.75,percent of total billed charges,Implant Device,176.75,35,,176.75,percent of total billed charges,Implant Device,176.75,35,,176.75,percent of total billed charges,Implant Device,176.75,35,,176.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,373.7,
J&J 412.211S LOCKING SCREW 5.0X34MM,C1713,HCPCS,,79013210,CDM,278,RC,,,both,,,505,373.7,,,373.7,Other,150% of Medicare + 9.63% HCRA Surcharge,227.25,45,,227.25,percent of total billed charges,Critical Access Hospital RCC factor,171.7,34,,171.7,percent of total billed charges,Implant Device,171.7,34,,171.7,percent of total billed charges,Implant Device,171.7,34,,171.7,percent of total billed charges,Implant Device,171.7,34,,171.7,percent of total billed charges,Implant Device,171.7,34,,171.7,percent of total billed charges,Implant Device,249.98,,,249.98,Other,110% of Medicare,176.75,35,,176.75,percent of total billed charges,Implant Device,171.7,34,"Charges > $500, x 34%",171.7,percent of total billed charges,Implant Device,176.75,35,,176.75,percent of total billed charges,Implant Device,176.75,35,,176.75,percent of total billed charges,Implant Device,176.75,35,,176.75,percent of total billed charges,Implant Device,176.75,35,,176.75,percent of total billed charges,Implant Device,176.75,35,,176.75,percent of total billed charges,Implant Device,202,40,,202,percent of total billed charges,Implant Device,176.75,70,,176.75,percent of total billed charges,All Other,171.7,34,,171.7,percent of total billed charges,Implant Device,171.7,34,,171.7,percent of total billed charges,Implant Device,176.75,35,,176.75,percent of total billed charges,Implant Device,176.75,35,,176.75,percent of total billed charges,Implant Device,176.75,35,,176.75,percent of total billed charges,Implant Device,176.75,35,,176.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,373.7,
J&J 1504-01-107 ATTUNE FEMORAL LEFT SZ 7,C1776,HCPCS,,79013211,CDM,278,RC,,,both,,,6000,4440.02,,,4440.02,Other,150% of Medicare + 9.63% HCRA Surcharge,2700,45,,2700,percent of total billed charges,Critical Access Hospital RCC factor,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2970,,,2970,Other,110% of Medicare,2100,35,,2100,percent of total billed charges,Implant Device,2040,34,"Charges > $500, x 34%",2040,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2400,40,,2400,percent of total billed charges,Implant Device,2100,70,,2100,percent of total billed charges,All Other,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2040,34,"If Charge > 2,000, then 34 percent",2040,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4440.02,
J&J 1516-30-705 TIBIAL INSERT SZ 7 5MM,C1776,HCPCS,,79013212,CDM,278,RC,,,both,,,5400,3996.01,,,3996.01,Other,150% of Medicare + 9.63% HCRA Surcharge,2430,45,,2430,percent of total billed charges,Critical Access Hospital RCC factor,1836,34,,1836,percent of total billed charges,Implant Device,1836,34,,1836,percent of total billed charges,Implant Device,1836,34,,1836,percent of total billed charges,Implant Device,1836,34,,1836,percent of total billed charges,Implant Device,1836,34,,1836,percent of total billed charges,Implant Device,2673,,,2673,Other,110% of Medicare,1890,35,,1890,percent of total billed charges,Implant Device,1836,34,"Charges > $500, x 34%",1836,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,2160,40,,2160,percent of total billed charges,Implant Device,1890,70,,1890,percent of total billed charges,All Other,1836,34,,1836,percent of total billed charges,Implant Device,1836,34,,1836,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1836,34,"If Charge > 2,000, then 34 percent",1836,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3996.01,
J&J 1504-01-105 ATTUNE FEMORAL LEFT SZ 5,C1776,HCPCS,,79013213,CDM,278,RC,,,both,,,6000,4440.02,,,4440.02,Other,150% of Medicare + 9.63% HCRA Surcharge,2700,45,,2700,percent of total billed charges,Critical Access Hospital RCC factor,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2970,,,2970,Other,110% of Medicare,2100,35,,2100,percent of total billed charges,Implant Device,2040,34,"Charges > $500, x 34%",2040,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2400,40,,2400,percent of total billed charges,Implant Device,2100,70,,2100,percent of total billed charges,All Other,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2040,34,"If Charge > 2,000, then 34 percent",2040,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4440.02,
J&J 1516-30-512 TIBAIL INSERT SZ 5 12MM,C1776,HCPCS,,79013214,CDM,278,RC,,,both,,,5400,3996.01,,,3996.01,Other,150% of Medicare + 9.63% HCRA Surcharge,2430,45,,2430,percent of total billed charges,Critical Access Hospital RCC factor,1836,34,,1836,percent of total billed charges,Implant Device,1836,34,,1836,percent of total billed charges,Implant Device,1836,34,,1836,percent of total billed charges,Implant Device,1836,34,,1836,percent of total billed charges,Implant Device,1836,34,,1836,percent of total billed charges,Implant Device,2673,,,2673,Other,110% of Medicare,1890,35,,1890,percent of total billed charges,Implant Device,1836,34,"Charges > $500, x 34%",1836,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,2160,40,,2160,percent of total billed charges,Implant Device,1890,70,,1890,percent of total billed charges,All Other,1836,34,,1836,percent of total billed charges,Implant Device,1836,34,,1836,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1836,34,"If Charge > 2,000, then 34 percent",1836,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3996.01,
J&J 1516-50-806 TIBIAL INSERT SIZE 8 6MM,C1776,HCPCS,,79013215,CDM,278,RC,,,both,,,5400,3996.01,,,3996.01,Other,150% of Medicare + 9.63% HCRA Surcharge,2430,45,,2430,percent of total billed charges,Critical Access Hospital RCC factor,1836,34,,1836,percent of total billed charges,Implant Device,1836,34,,1836,percent of total billed charges,Implant Device,1836,34,,1836,percent of total billed charges,Implant Device,1836,34,,1836,percent of total billed charges,Implant Device,1836,34,,1836,percent of total billed charges,Implant Device,2673,,,2673,Other,110% of Medicare,1890,35,,1890,percent of total billed charges,Implant Device,1836,34,"Charges > $500, x 34%",1836,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,2160,40,,2160,percent of total billed charges,Implant Device,1890,70,,1890,percent of total billed charges,All Other,1836,34,,1836,percent of total billed charges,Implant Device,1836,34,,1836,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1836,34,"If Charge > 2,000, then 34 percent",1836,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3996.01,
J&J 04.043.225S TIBIAL NAIL 10X315MM,C1889,HCPCS,,79013216,CDM,278,RC,,,both,,,4527,3349.99,,,3349.99,Other,150% of Medicare + 9.63% HCRA Surcharge,2037.15,45,,2037.15,percent of total billed charges,Critical Access Hospital RCC factor,1539.18,34,,1539.18,percent of total billed charges,Implant Device,1539.18,34,,1539.18,percent of total billed charges,Implant Device,1539.18,34,,1539.18,percent of total billed charges,Implant Device,1539.18,34,,1539.18,percent of total billed charges,Implant Device,1539.18,34,,1539.18,percent of total billed charges,Implant Device,2240.87,,,2240.87,Other,110% of Medicare,1584.45,35,,1584.45,percent of total billed charges,Implant Device,1539.18,34,"Charges > $500, x 34%",1539.18,percent of total billed charges,Implant Device,1584.45,35,,1584.45,percent of total billed charges,Implant Device,1584.45,35,,1584.45,percent of total billed charges,Implant Device,1584.45,35,,1584.45,percent of total billed charges,Implant Device,1584.45,35,,1584.45,percent of total billed charges,Implant Device,1584.45,35,,1584.45,percent of total billed charges,Implant Device,1810.8,40,,1810.8,percent of total billed charges,Implant Device,1584.45,70,,1584.45,percent of total billed charges,All Other,1539.18,34,,1539.18,percent of total billed charges,Implant Device,1539.18,34,,1539.18,percent of total billed charges,Implant Device,1584.45,35,,1584.45,percent of total billed charges,Implant Device,1584.45,35,,1584.45,percent of total billed charges,Implant Device,1584.45,35,,1584.45,percent of total billed charges,Implant Device,1584.45,35,,1584.45,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1539.18,34,"If Charge > 2,000, then 34 percent",1539.18,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3349.99,
J&J 04.043.220S TIBIAL NAIL 10X300MM,C1889,HCPCS,,79013217,CDM,278,RC,,,both,,,4527,3349.99,,,3349.99,Other,150% of Medicare + 9.63% HCRA Surcharge,2037.15,45,,2037.15,percent of total billed charges,Critical Access Hospital RCC factor,1539.18,34,,1539.18,percent of total billed charges,Implant Device,1539.18,34,,1539.18,percent of total billed charges,Implant Device,1539.18,34,,1539.18,percent of total billed charges,Implant Device,1539.18,34,,1539.18,percent of total billed charges,Implant Device,1539.18,34,,1539.18,percent of total billed charges,Implant Device,2240.87,,,2240.87,Other,110% of Medicare,1584.45,35,,1584.45,percent of total billed charges,Implant Device,1539.18,34,"Charges > $500, x 34%",1539.18,percent of total billed charges,Implant Device,1584.45,35,,1584.45,percent of total billed charges,Implant Device,1584.45,35,,1584.45,percent of total billed charges,Implant Device,1584.45,35,,1584.45,percent of total billed charges,Implant Device,1584.45,35,,1584.45,percent of total billed charges,Implant Device,1584.45,35,,1584.45,percent of total billed charges,Implant Device,1810.8,40,,1810.8,percent of total billed charges,Implant Device,1584.45,70,,1584.45,percent of total billed charges,All Other,1539.18,34,,1539.18,percent of total billed charges,Implant Device,1539.18,34,,1539.18,percent of total billed charges,Implant Device,1584.45,35,,1584.45,percent of total billed charges,Implant Device,1584.45,35,,1584.45,percent of total billed charges,Implant Device,1584.45,35,,1584.45,percent of total billed charges,Implant Device,1584.45,35,,1584.45,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1539.18,34,"If Charge > 2,000, then 34 percent",1539.18,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3349.99,
J&J 04.045.048S LOCKING SCREW 5.0X48MM,C1713,HCPCS,,79013218,CDM,278,RC,,,both,,,687,508.38,,,508.38,Other,150% of Medicare + 9.63% HCRA Surcharge,309.15,45,,309.15,percent of total billed charges,Critical Access Hospital RCC factor,233.58,34,,233.58,percent of total billed charges,Implant Device,233.58,34,,233.58,percent of total billed charges,Implant Device,233.58,34,,233.58,percent of total billed charges,Implant Device,233.58,34,,233.58,percent of total billed charges,Implant Device,233.58,34,,233.58,percent of total billed charges,Implant Device,340.07,,,340.07,Other,110% of Medicare,240.45,35,,240.45,percent of total billed charges,Implant Device,233.58,34,"Charges > $500, x 34%",233.58,percent of total billed charges,Implant Device,240.45,35,,240.45,percent of total billed charges,Implant Device,240.45,35,,240.45,percent of total billed charges,Implant Device,240.45,35,,240.45,percent of total billed charges,Implant Device,240.45,35,,240.45,percent of total billed charges,Implant Device,240.45,35,,240.45,percent of total billed charges,Implant Device,274.8,40,,274.8,percent of total billed charges,Implant Device,240.45,70,,240.45,percent of total billed charges,All Other,233.58,34,,233.58,percent of total billed charges,Implant Device,233.58,34,,233.58,percent of total billed charges,Implant Device,240.45,35,,240.45,percent of total billed charges,Implant Device,240.45,35,,240.45,percent of total billed charges,Implant Device,240.45,35,,240.45,percent of total billed charges,Implant Device,240.45,35,,240.45,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,508.38,
J&J 04.045.336S LOCKING SCREW 5.0X36MM,C1713,HCPCS,,79013219,CDM,278,RC,,,both,,,813,601.62,,,601.62,Other,150% of Medicare + 9.63% HCRA Surcharge,365.85,45,,365.85,percent of total billed charges,Critical Access Hospital RCC factor,276.42,34,,276.42,percent of total billed charges,Implant Device,276.42,34,,276.42,percent of total billed charges,Implant Device,276.42,34,,276.42,percent of total billed charges,Implant Device,276.42,34,,276.42,percent of total billed charges,Implant Device,276.42,34,,276.42,percent of total billed charges,Implant Device,402.44,,,402.44,Other,110% of Medicare,284.55,35,,284.55,percent of total billed charges,Implant Device,276.42,34,"Charges > $500, x 34%",276.42,percent of total billed charges,Implant Device,284.55,35,,284.55,percent of total billed charges,Implant Device,284.55,35,,284.55,percent of total billed charges,Implant Device,284.55,35,,284.55,percent of total billed charges,Implant Device,284.55,35,,284.55,percent of total billed charges,Implant Device,284.55,35,,284.55,percent of total billed charges,Implant Device,325.2,40,,325.2,percent of total billed charges,Implant Device,284.55,70,,284.55,percent of total billed charges,All Other,276.42,34,,276.42,percent of total billed charges,Implant Device,276.42,34,,276.42,percent of total billed charges,Implant Device,284.55,35,,284.55,percent of total billed charges,Implant Device,284.55,35,,284.55,percent of total billed charges,Implant Device,284.55,35,,284.55,percent of total billed charges,Implant Device,284.55,35,,284.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,601.62,
J&J 04.045.330S LOCKING SCREW 5.0X30MM,C1713,HCPCS,,79013220,CDM,278,RC,,,both,,,813,601.62,,,601.62,Other,150% of Medicare + 9.63% HCRA Surcharge,365.85,45,,365.85,percent of total billed charges,Critical Access Hospital RCC factor,276.42,34,,276.42,percent of total billed charges,Implant Device,276.42,34,,276.42,percent of total billed charges,Implant Device,276.42,34,,276.42,percent of total billed charges,Implant Device,276.42,34,,276.42,percent of total billed charges,Implant Device,276.42,34,,276.42,percent of total billed charges,Implant Device,402.44,,,402.44,Other,110% of Medicare,284.55,35,,284.55,percent of total billed charges,Implant Device,276.42,34,"Charges > $500, x 34%",276.42,percent of total billed charges,Implant Device,284.55,35,,284.55,percent of total billed charges,Implant Device,284.55,35,,284.55,percent of total billed charges,Implant Device,284.55,35,,284.55,percent of total billed charges,Implant Device,284.55,35,,284.55,percent of total billed charges,Implant Device,284.55,35,,284.55,percent of total billed charges,Implant Device,325.2,40,,325.2,percent of total billed charges,Implant Device,284.55,70,,284.55,percent of total billed charges,All Other,276.42,34,,276.42,percent of total billed charges,Implant Device,276.42,34,,276.42,percent of total billed charges,Implant Device,284.55,35,,284.55,percent of total billed charges,Implant Device,284.55,35,,284.55,percent of total billed charges,Implant Device,284.55,35,,284.55,percent of total billed charges,Implant Device,284.55,35,,284.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,601.62,
STRYKER 604655 CANNULATED SCREW 4.0X55MM,C1713,HCPCS,,79013221,CDM,278,RC,,,both,,,480,355.2,,,355.2,Other,150% of Medicare + 9.63% HCRA Surcharge,216,45,,216,percent of total billed charges,Critical Access Hospital RCC factor,163.2,34,,163.2,percent of total billed charges,Implant Device,163.2,34,,163.2,percent of total billed charges,Implant Device,163.2,34,,163.2,percent of total billed charges,Implant Device,163.2,34,,163.2,percent of total billed charges,Implant Device,163.2,34,,163.2,percent of total billed charges,Implant Device,237.6,,,237.6,Other,110% of Medicare,168,35,,168,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,192,40,,192,percent of total billed charges,Implant Device,168,70,,168,percent of total billed charges,All Other,163.2,34,,163.2,percent of total billed charges,Implant Device,163.2,34,,163.2,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,355.2,
STRYKER 629785 NARROW LOCK T-PLT 2.7X87,C1713,HCPCS,,79013222,CDM,278,RC,,,both,,,3366,2490.85,,,2490.85,Other,150% of Medicare + 9.63% HCRA Surcharge,1514.7,45,,1514.7,percent of total billed charges,Critical Access Hospital RCC factor,1144.44,34,,1144.44,percent of total billed charges,Implant Device,1144.44,34,,1144.44,percent of total billed charges,Implant Device,1144.44,34,,1144.44,percent of total billed charges,Implant Device,1144.44,34,,1144.44,percent of total billed charges,Implant Device,1144.44,34,,1144.44,percent of total billed charges,Implant Device,1666.17,,,1666.17,Other,110% of Medicare,1178.1,35,,1178.1,percent of total billed charges,Implant Device,1144.44,34,"Charges > $500, x 34%",1144.44,percent of total billed charges,Implant Device,1178.1,35,,1178.1,percent of total billed charges,Implant Device,1178.1,35,,1178.1,percent of total billed charges,Implant Device,1178.1,35,,1178.1,percent of total billed charges,Implant Device,1178.1,35,,1178.1,percent of total billed charges,Implant Device,1178.1,35,,1178.1,percent of total billed charges,Implant Device,1346.4,40,,1346.4,percent of total billed charges,Implant Device,1178.1,70,,1178.1,percent of total billed charges,All Other,1144.44,34,,1144.44,percent of total billed charges,Implant Device,1144.44,34,,1144.44,percent of total billed charges,Implant Device,1178.1,35,,1178.1,percent of total billed charges,Implant Device,1178.1,35,,1178.1,percent of total billed charges,Implant Device,1178.1,35,,1178.1,percent of total billed charges,Implant Device,1178.1,35,,1178.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1144.44,34,"If Charge > 2,000, then 34 percent",1144.44,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2490.85,
STRYKER 656340 LOCKING SCREW 2.7X40MM,C1713,HCPCS,,79013223,CDM,278,RC,,,both,,,480,355.2,,,355.2,Other,150% of Medicare + 9.63% HCRA Surcharge,216,45,,216,percent of total billed charges,Critical Access Hospital RCC factor,163.2,34,,163.2,percent of total billed charges,Implant Device,163.2,34,,163.2,percent of total billed charges,Implant Device,163.2,34,,163.2,percent of total billed charges,Implant Device,163.2,34,,163.2,percent of total billed charges,Implant Device,163.2,34,,163.2,percent of total billed charges,Implant Device,237.6,,,237.6,Other,110% of Medicare,168,35,,168,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,192,40,,192,percent of total billed charges,Implant Device,168,70,,168,percent of total billed charges,All Other,163.2,34,,163.2,percent of total billed charges,Implant Device,163.2,34,,163.2,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,168,35,,168,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,355.2,
STRYKER 656346 LOCKING SCREW 2.7X46MM,C1713,HCPCS,,79013224,CDM,278,RC,,,both,,,676,500.24,,,500.24,Other,150% of Medicare + 9.63% HCRA Surcharge,304.2,45,,304.2,percent of total billed charges,Critical Access Hospital RCC factor,229.84,34,,229.84,percent of total billed charges,Implant Device,229.84,34,,229.84,percent of total billed charges,Implant Device,229.84,34,,229.84,percent of total billed charges,Implant Device,229.84,34,,229.84,percent of total billed charges,Implant Device,229.84,34,,229.84,percent of total billed charges,Implant Device,334.62,,,334.62,Other,110% of Medicare,236.6,35,,236.6,percent of total billed charges,Implant Device,229.84,34,"Charges > $500, x 34%",229.84,percent of total billed charges,Implant Device,236.6,35,,236.6,percent of total billed charges,Implant Device,236.6,35,,236.6,percent of total billed charges,Implant Device,236.6,35,,236.6,percent of total billed charges,Implant Device,236.6,35,,236.6,percent of total billed charges,Implant Device,236.6,35,,236.6,percent of total billed charges,Implant Device,270.4,40,,270.4,percent of total billed charges,Implant Device,236.6,70,,236.6,percent of total billed charges,All Other,229.84,34,,229.84,percent of total billed charges,Implant Device,229.84,34,,229.84,percent of total billed charges,Implant Device,236.6,35,,236.6,percent of total billed charges,Implant Device,236.6,35,,236.6,percent of total billed charges,Implant Device,236.6,35,,236.6,percent of total billed charges,Implant Device,236.6,35,,236.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,500.24,
DJO 533-10-108 HUMERAL STEM SM 10X108MM,C1713,HCPCS,,79013225,CDM,278,RC,,,both,,,3600,2664.01,,,2664.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1620,45,,1620,percent of total billed charges,Critical Access Hospital RCC factor,1224,34,,1224,percent of total billed charges,Implant Device,1224,34,,1224,percent of total billed charges,Implant Device,1224,34,,1224,percent of total billed charges,Implant Device,1224,34,,1224,percent of total billed charges,Implant Device,1224,34,,1224,percent of total billed charges,Implant Device,1782,,,1782,Other,110% of Medicare,1260,35,,1260,percent of total billed charges,Implant Device,1224,34,"Charges > $500, x 34%",1224,percent of total billed charges,Implant Device,1260,35,,1260,percent of total billed charges,Implant Device,1260,35,,1260,percent of total billed charges,Implant Device,1260,35,,1260,percent of total billed charges,Implant Device,1260,35,,1260,percent of total billed charges,Implant Device,1260,35,,1260,percent of total billed charges,Implant Device,1440,40,,1440,percent of total billed charges,Implant Device,1260,70,,1260,percent of total billed charges,All Other,1224,34,,1224,percent of total billed charges,Implant Device,1224,34,,1224,percent of total billed charges,Implant Device,1260,35,,1260,percent of total billed charges,Implant Device,1260,35,,1260,percent of total billed charges,Implant Device,1260,35,,1260,percent of total billed charges,Implant Device,1260,35,,1260,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1224,34,"If Charge > 2,000, then 34 percent",1224,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2664.01,
DJO 415-00-120 CEMENT RESTRICTOR 12MM,C1889,HCPCS,,79013226,CDM,278,RC,,,both,,,240,177.6,,,177.6,Other,150% of Medicare + 9.63% HCRA Surcharge,108,45,,108,percent of total billed charges,Critical Access Hospital RCC factor,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,118.8,,,118.8,Other,110% of Medicare,84,35,,84,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,96,40,,96,percent of total billed charges,Implant Device,84,70,,84,percent of total billed charges,All Other,81.6,34,,81.6,percent of total billed charges,Implant Device,81.6,34,,81.6,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,84,35,,84,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,177.6,
J&J 1504-40-207 REVISION FEMORAL RT SZ 7,C1776,HCPCS,,79013227,CDM,278,RC,,,both,,,21434,15861.21,,,15861.21,Other,150% of Medicare + 9.63% HCRA Surcharge,9645.3,45,,9645.3,percent of total billed charges,Critical Access Hospital RCC factor,7287.56,34,,7287.56,percent of total billed charges,Implant Device,7287.56,34,,7287.56,percent of total billed charges,Implant Device,7287.56,34,,7287.56,percent of total billed charges,Implant Device,7287.56,34,,7287.56,percent of total billed charges,Implant Device,7287.56,34,,7287.56,percent of total billed charges,Implant Device,10609.83,,,10609.83,Other,110% of Medicare,7501.9,35,,7501.9,percent of total billed charges,Implant Device,7287.56,34,"Charges > $500, x 34%",7287.56,percent of total billed charges,Implant Device,7501.9,35,,7501.9,percent of total billed charges,Implant Device,7501.9,35,,7501.9,percent of total billed charges,Implant Device,7501.9,35,,7501.9,percent of total billed charges,Implant Device,7501.9,35,,7501.9,percent of total billed charges,Implant Device,7501.9,35,,7501.9,percent of total billed charges,Implant Device,8573.6,40,,8573.6,percent of total billed charges,Implant Device,7501.9,70,,7501.9,percent of total billed charges,All Other,7287.56,34,,7287.56,percent of total billed charges,Implant Device,7287.56,34,,7287.56,percent of total billed charges,Implant Device,7501.9,35,,7501.9,percent of total billed charges,Implant Device,7501.9,35,,7501.9,percent of total billed charges,Implant Device,7501.9,35,,7501.9,percent of total billed charges,Implant Device,7501.9,35,,7501.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,7287.56,34,"If Charge > 2,000, then 34 percent",7287.56,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,15861.21,
J&J 1506-60-006 REVISION TIBIAL BASE SZ6,C1776,HCPCS,,79013228,CDM,278,RC,,,both,,,15558,11512.96,,,11512.96,Other,150% of Medicare + 9.63% HCRA Surcharge,7001.1,45,,7001.1,percent of total billed charges,Critical Access Hospital RCC factor,5289.72,34,,5289.72,percent of total billed charges,Implant Device,5289.72,34,,5289.72,percent of total billed charges,Implant Device,5289.72,34,,5289.72,percent of total billed charges,Implant Device,5289.72,34,,5289.72,percent of total billed charges,Implant Device,5289.72,34,,5289.72,percent of total billed charges,Implant Device,7701.21,,,7701.21,Other,110% of Medicare,5445.3,35,,5445.3,percent of total billed charges,Implant Device,5289.72,34,"Charges > $500, x 34%",5289.72,percent of total billed charges,Implant Device,5445.3,35,,5445.3,percent of total billed charges,Implant Device,5445.3,35,,5445.3,percent of total billed charges,Implant Device,5445.3,35,,5445.3,percent of total billed charges,Implant Device,5445.3,35,,5445.3,percent of total billed charges,Implant Device,5445.3,35,,5445.3,percent of total billed charges,Implant Device,6223.2,40,,6223.2,percent of total billed charges,Implant Device,5445.3,70,,5445.3,percent of total billed charges,All Other,5289.72,34,,5289.72,percent of total billed charges,Implant Device,5289.72,34,,5289.72,percent of total billed charges,Implant Device,5445.3,35,,5445.3,percent of total billed charges,Implant Device,5445.3,35,,5445.3,percent of total billed charges,Implant Device,5445.3,35,,5445.3,percent of total billed charges,Implant Device,5445.3,35,,5445.3,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,5289.72,34,"If Charge > 2,000, then 34 percent",5289.72,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,11512.96,
J&J 1512-16-080 CEMENTED STEM RT SZ 7,C1776,HCPCS,,79013229,CDM,278,RC,,,both,,,3315,2453.11,,,2453.11,Other,150% of Medicare + 9.63% HCRA Surcharge,1491.75,45,,1491.75,percent of total billed charges,Critical Access Hospital RCC factor,1127.1,34,,1127.1,percent of total billed charges,Implant Device,1127.1,34,,1127.1,percent of total billed charges,Implant Device,1127.1,34,,1127.1,percent of total billed charges,Implant Device,1127.1,34,,1127.1,percent of total billed charges,Implant Device,1127.1,34,,1127.1,percent of total billed charges,Implant Device,1640.93,,,1640.93,Other,110% of Medicare,1160.25,35,,1160.25,percent of total billed charges,Implant Device,1127.1,34,"Charges > $500, x 34%",1127.1,percent of total billed charges,Implant Device,1160.25,35,,1160.25,percent of total billed charges,Implant Device,1160.25,35,,1160.25,percent of total billed charges,Implant Device,1160.25,35,,1160.25,percent of total billed charges,Implant Device,1160.25,35,,1160.25,percent of total billed charges,Implant Device,1160.25,35,,1160.25,percent of total billed charges,Implant Device,1326,40,,1326,percent of total billed charges,Implant Device,1160.25,70,,1160.25,percent of total billed charges,All Other,1127.1,34,,1127.1,percent of total billed charges,Implant Device,1127.1,34,,1127.1,percent of total billed charges,Implant Device,1160.25,35,,1160.25,percent of total billed charges,Implant Device,1160.25,35,,1160.25,percent of total billed charges,Implant Device,1160.25,35,,1160.25,percent of total billed charges,Implant Device,1160.25,35,,1160.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1127.1,34,"If Charge > 2,000, then 34 percent",1127.1,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2453.11,
J&J 1517-10-710 REVISION INSERT SZ7 10,C1776,HCPCS,,79013230,CDM,278,RC,,,both,,,9286,6871.66,,,6871.66,Other,150% of Medicare + 9.63% HCRA Surcharge,4178.7,45,,4178.7,percent of total billed charges,Critical Access Hospital RCC factor,3157.24,34,,3157.24,percent of total billed charges,Implant Device,3157.24,34,,3157.24,percent of total billed charges,Implant Device,3157.24,34,,3157.24,percent of total billed charges,Implant Device,3157.24,34,,3157.24,percent of total billed charges,Implant Device,3157.24,34,,3157.24,percent of total billed charges,Implant Device,4596.57,,,4596.57,Other,110% of Medicare,3250.1,35,,3250.1,percent of total billed charges,Implant Device,3157.24,34,"Charges > $500, x 34%",3157.24,percent of total billed charges,Implant Device,3250.1,35,,3250.1,percent of total billed charges,Implant Device,3250.1,35,,3250.1,percent of total billed charges,Implant Device,3250.1,35,,3250.1,percent of total billed charges,Implant Device,3250.1,35,,3250.1,percent of total billed charges,Implant Device,3250.1,35,,3250.1,percent of total billed charges,Implant Device,3714.4,40,,3714.4,percent of total billed charges,Implant Device,3250.1,70,,3250.1,percent of total billed charges,All Other,3157.24,34,,3157.24,percent of total billed charges,Implant Device,3157.24,34,,3157.24,percent of total billed charges,Implant Device,3250.1,35,,3250.1,percent of total billed charges,Implant Device,3250.1,35,,3250.1,percent of total billed charges,Implant Device,3250.1,35,,3250.1,percent of total billed charges,Implant Device,3250.1,35,,3250.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3157.24,34,"If Charge > 2,000, then 34 percent",3157.24,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,6871.66,
J&J 1547-07-001 DISTAL FEM SZ 7 4MM,C1776,HCPCS,,79013231,CDM,278,RC,,,both,,,3848,2847.53,,,2847.53,Other,150% of Medicare + 9.63% HCRA Surcharge,1731.6,45,,1731.6,percent of total billed charges,Critical Access Hospital RCC factor,1308.32,34,,1308.32,percent of total billed charges,Implant Device,1308.32,34,,1308.32,percent of total billed charges,Implant Device,1308.32,34,,1308.32,percent of total billed charges,Implant Device,1308.32,34,,1308.32,percent of total billed charges,Implant Device,1308.32,34,,1308.32,percent of total billed charges,Implant Device,1904.76,,,1904.76,Other,110% of Medicare,1346.8,35,,1346.8,percent of total billed charges,Implant Device,1308.32,34,"Charges > $500, x 34%",1308.32,percent of total billed charges,Implant Device,1346.8,35,,1346.8,percent of total billed charges,Implant Device,1346.8,35,,1346.8,percent of total billed charges,Implant Device,1346.8,35,,1346.8,percent of total billed charges,Implant Device,1346.8,35,,1346.8,percent of total billed charges,Implant Device,1346.8,35,,1346.8,percent of total billed charges,Implant Device,1539.2,40,,1539.2,percent of total billed charges,Implant Device,1346.8,70,,1346.8,percent of total billed charges,All Other,1308.32,34,,1308.32,percent of total billed charges,Implant Device,1308.32,34,,1308.32,percent of total billed charges,Implant Device,1346.8,35,,1346.8,percent of total billed charges,Implant Device,1346.8,35,,1346.8,percent of total billed charges,Implant Device,1346.8,35,,1346.8,percent of total billed charges,Implant Device,1346.8,35,,1346.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1308.32,34,"If Charge > 2,000, then 34 percent",1308.32,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2847.53,
J&J 1547-07-002 DISTAL FEM SZ 7 8MM,C1776,HCPCS,,79013232,CDM,278,RC,,,both,,,3848,2847.53,,,2847.53,Other,150% of Medicare + 9.63% HCRA Surcharge,1731.6,45,,1731.6,percent of total billed charges,Critical Access Hospital RCC factor,1308.32,34,,1308.32,percent of total billed charges,Implant Device,1308.32,34,,1308.32,percent of total billed charges,Implant Device,1308.32,34,,1308.32,percent of total billed charges,Implant Device,1308.32,34,,1308.32,percent of total billed charges,Implant Device,1308.32,34,,1308.32,percent of total billed charges,Implant Device,1904.76,,,1904.76,Other,110% of Medicare,1346.8,35,,1346.8,percent of total billed charges,Implant Device,1308.32,34,"Charges > $500, x 34%",1308.32,percent of total billed charges,Implant Device,1346.8,35,,1346.8,percent of total billed charges,Implant Device,1346.8,35,,1346.8,percent of total billed charges,Implant Device,1346.8,35,,1346.8,percent of total billed charges,Implant Device,1346.8,35,,1346.8,percent of total billed charges,Implant Device,1346.8,35,,1346.8,percent of total billed charges,Implant Device,1539.2,40,,1539.2,percent of total billed charges,Implant Device,1346.8,70,,1346.8,percent of total billed charges,All Other,1308.32,34,,1308.32,percent of total billed charges,Implant Device,1308.32,34,,1308.32,percent of total billed charges,Implant Device,1346.8,35,,1346.8,percent of total billed charges,Implant Device,1346.8,35,,1346.8,percent of total billed charges,Implant Device,1346.8,35,,1346.8,percent of total billed charges,Implant Device,1346.8,35,,1346.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1308.32,34,"If Charge > 2,000, then 34 percent",1308.32,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2847.53,
J&J 1549-07-001 FEMORAL SIZE 7 4MM,C1776,HCPCS,,79013233,CDM,278,RC,,,both,,,3848,2847.53,,,2847.53,Other,150% of Medicare + 9.63% HCRA Surcharge,1731.6,45,,1731.6,percent of total billed charges,Critical Access Hospital RCC factor,1308.32,34,,1308.32,percent of total billed charges,Implant Device,1308.32,34,,1308.32,percent of total billed charges,Implant Device,1308.32,34,,1308.32,percent of total billed charges,Implant Device,1308.32,34,,1308.32,percent of total billed charges,Implant Device,1308.32,34,,1308.32,percent of total billed charges,Implant Device,1904.76,,,1904.76,Other,110% of Medicare,1346.8,35,,1346.8,percent of total billed charges,Implant Device,1308.32,34,"Charges > $500, x 34%",1308.32,percent of total billed charges,Implant Device,1346.8,35,,1346.8,percent of total billed charges,Implant Device,1346.8,35,,1346.8,percent of total billed charges,Implant Device,1346.8,35,,1346.8,percent of total billed charges,Implant Device,1346.8,35,,1346.8,percent of total billed charges,Implant Device,1346.8,35,,1346.8,percent of total billed charges,Implant Device,1539.2,40,,1539.2,percent of total billed charges,Implant Device,1346.8,70,,1346.8,percent of total billed charges,All Other,1308.32,34,,1308.32,percent of total billed charges,Implant Device,1308.32,34,,1308.32,percent of total billed charges,Implant Device,1346.8,35,,1346.8,percent of total billed charges,Implant Device,1346.8,35,,1346.8,percent of total billed charges,Implant Device,1346.8,35,,1346.8,percent of total billed charges,Implant Device,1346.8,35,,1346.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1308.32,34,"If Charge > 2,000, then 34 percent",1308.32,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2847.53,
OSTEOREMEDIES GVHDLG GV FEM HEAD 60MM,L8699,HCPCS,,79013237,CDM,278,RC,,,both,,,5444,4028.57,,,4028.57,Other,150% of Medicare + 9.63% HCRA Surcharge,2449.8,45,,2449.8,percent of total billed charges,Critical Access Hospital RCC factor,1850.96,34,,1850.96,percent of total billed charges,Implant Device,1850.96,34,,1850.96,percent of total billed charges,Implant Device,1850.96,34,,1850.96,percent of total billed charges,Implant Device,1850.96,34,,1850.96,percent of total billed charges,Implant Device,1850.96,34,,1850.96,percent of total billed charges,Implant Device,2694.78,,,2694.78,Other,110% of Medicare,1905.4,35,,1905.4,percent of total billed charges,Implant Device,1850.96,34,"Charges > $500, x 34%",1850.96,percent of total billed charges,Implant Device,1905.4,35,,1905.4,percent of total billed charges,Implant Device,1905.4,35,,1905.4,percent of total billed charges,Implant Device,1905.4,35,,1905.4,percent of total billed charges,Implant Device,1905.4,35,,1905.4,percent of total billed charges,Implant Device,1905.4,35,,1905.4,percent of total billed charges,Implant Device,2177.6,40,,2177.6,percent of total billed charges,Implant Device,1905.4,70,,1905.4,percent of total billed charges,All Other,1850.96,34,,1850.96,percent of total billed charges,Implant Device,1850.96,34,,1850.96,percent of total billed charges,Implant Device,1905.4,35,,1905.4,percent of total billed charges,Implant Device,1905.4,35,,1905.4,percent of total billed charges,Implant Device,1905.4,35,,1905.4,percent of total billed charges,Implant Device,1905.4,35,,1905.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1850.96,34,"If Charge > 2,000, then 34 percent",1850.96,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4028.57,
OSTEOREMEDIES GVHDMD GV FEM HEAD 54MM,L8699,HCPCS,,79013238,CDM,278,RC,,,both,,,5444,4028.57,,,4028.57,Other,150% of Medicare + 9.63% HCRA Surcharge,2449.8,45,,2449.8,percent of total billed charges,Critical Access Hospital RCC factor,1850.96,34,,1850.96,percent of total billed charges,Implant Device,1850.96,34,,1850.96,percent of total billed charges,Implant Device,1850.96,34,,1850.96,percent of total billed charges,Implant Device,1850.96,34,,1850.96,percent of total billed charges,Implant Device,1850.96,34,,1850.96,percent of total billed charges,Implant Device,2694.78,,,2694.78,Other,110% of Medicare,1905.4,35,,1905.4,percent of total billed charges,Implant Device,1850.96,34,"Charges > $500, x 34%",1850.96,percent of total billed charges,Implant Device,1905.4,35,,1905.4,percent of total billed charges,Implant Device,1905.4,35,,1905.4,percent of total billed charges,Implant Device,1905.4,35,,1905.4,percent of total billed charges,Implant Device,1905.4,35,,1905.4,percent of total billed charges,Implant Device,1905.4,35,,1905.4,percent of total billed charges,Implant Device,2177.6,40,,2177.6,percent of total billed charges,Implant Device,1905.4,70,,1905.4,percent of total billed charges,All Other,1850.96,34,,1850.96,percent of total billed charges,Implant Device,1850.96,34,,1850.96,percent of total billed charges,Implant Device,1905.4,35,,1905.4,percent of total billed charges,Implant Device,1905.4,35,,1905.4,percent of total billed charges,Implant Device,1905.4,35,,1905.4,percent of total billed charges,Implant Device,1905.4,35,,1905.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1850.96,34,"If Charge > 2,000, then 34 percent",1850.96,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4028.57,
OSTEOREMEDIES GVHDSM GV FEM HEAD 46MM,L8699,HCPCS,,79013239,CDM,278,RC,,,both,,,5444,4028.57,,,4028.57,Other,150% of Medicare + 9.63% HCRA Surcharge,2449.8,45,,2449.8,percent of total billed charges,Critical Access Hospital RCC factor,1850.96,34,,1850.96,percent of total billed charges,Implant Device,1850.96,34,,1850.96,percent of total billed charges,Implant Device,1850.96,34,,1850.96,percent of total billed charges,Implant Device,1850.96,34,,1850.96,percent of total billed charges,Implant Device,1850.96,34,,1850.96,percent of total billed charges,Implant Device,2694.78,,,2694.78,Other,110% of Medicare,1905.4,35,,1905.4,percent of total billed charges,Implant Device,1850.96,34,"Charges > $500, x 34%",1850.96,percent of total billed charges,Implant Device,1905.4,35,,1905.4,percent of total billed charges,Implant Device,1905.4,35,,1905.4,percent of total billed charges,Implant Device,1905.4,35,,1905.4,percent of total billed charges,Implant Device,1905.4,35,,1905.4,percent of total billed charges,Implant Device,1905.4,35,,1905.4,percent of total billed charges,Implant Device,2177.6,40,,2177.6,percent of total billed charges,Implant Device,1905.4,70,,1905.4,percent of total billed charges,All Other,1850.96,34,,1850.96,percent of total billed charges,Implant Device,1850.96,34,,1850.96,percent of total billed charges,Implant Device,1905.4,35,,1905.4,percent of total billed charges,Implant Device,1905.4,35,,1905.4,percent of total billed charges,Implant Device,1905.4,35,,1905.4,percent of total billed charges,Implant Device,1905.4,35,,1905.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1850.96,34,"If Charge > 2,000, then 34 percent",1850.96,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4028.57,
OSTEOREMEDIES GVHDXS GV FEM HEAD 40MM,L8699,HCPCS,,79013240,CDM,278,RC,,,both,,,5444,4028.57,,,4028.57,Other,150% of Medicare + 9.63% HCRA Surcharge,2449.8,45,,2449.8,percent of total billed charges,Critical Access Hospital RCC factor,1850.96,34,,1850.96,percent of total billed charges,Implant Device,1850.96,34,,1850.96,percent of total billed charges,Implant Device,1850.96,34,,1850.96,percent of total billed charges,Implant Device,1850.96,34,,1850.96,percent of total billed charges,Implant Device,1850.96,34,,1850.96,percent of total billed charges,Implant Device,2694.78,,,2694.78,Other,110% of Medicare,1905.4,35,,1905.4,percent of total billed charges,Implant Device,1850.96,34,"Charges > $500, x 34%",1850.96,percent of total billed charges,Implant Device,1905.4,35,,1905.4,percent of total billed charges,Implant Device,1905.4,35,,1905.4,percent of total billed charges,Implant Device,1905.4,35,,1905.4,percent of total billed charges,Implant Device,1905.4,35,,1905.4,percent of total billed charges,Implant Device,1905.4,35,,1905.4,percent of total billed charges,Implant Device,2177.6,40,,2177.6,percent of total billed charges,Implant Device,1905.4,70,,1905.4,percent of total billed charges,All Other,1850.96,34,,1850.96,percent of total billed charges,Implant Device,1850.96,34,,1850.96,percent of total billed charges,Implant Device,1905.4,35,,1905.4,percent of total billed charges,Implant Device,1905.4,35,,1905.4,percent of total billed charges,Implant Device,1905.4,35,,1905.4,percent of total billed charges,Implant Device,1905.4,35,,1905.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1850.96,34,"If Charge > 2,000, then 34 percent",1850.96,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4028.57,
OSTEOREMEDIES GVLSLG GV FEM LONG STEM LG,L8699,HCPCS,,79013241,CDM,278,RC,,,both,,,7991,5913.36,,,5913.36,Other,150% of Medicare + 9.63% HCRA Surcharge,3595.95,45,,3595.95,percent of total billed charges,Critical Access Hospital RCC factor,2716.94,34,,2716.94,percent of total billed charges,Implant Device,2716.94,34,,2716.94,percent of total billed charges,Implant Device,2716.94,34,,2716.94,percent of total billed charges,Implant Device,2716.94,34,,2716.94,percent of total billed charges,Implant Device,2716.94,34,,2716.94,percent of total billed charges,Implant Device,3955.55,,,3955.55,Other,110% of Medicare,2796.85,35,,2796.85,percent of total billed charges,Implant Device,2716.94,34,"Charges > $500, x 34%",2716.94,percent of total billed charges,Implant Device,2796.85,35,,2796.85,percent of total billed charges,Implant Device,2796.85,35,,2796.85,percent of total billed charges,Implant Device,2796.85,35,,2796.85,percent of total billed charges,Implant Device,2796.85,35,,2796.85,percent of total billed charges,Implant Device,2796.85,35,,2796.85,percent of total billed charges,Implant Device,3196.4,40,,3196.4,percent of total billed charges,Implant Device,2796.85,70,,2796.85,percent of total billed charges,All Other,2716.94,34,,2716.94,percent of total billed charges,Implant Device,2716.94,34,,2716.94,percent of total billed charges,Implant Device,2796.85,35,,2796.85,percent of total billed charges,Implant Device,2796.85,35,,2796.85,percent of total billed charges,Implant Device,2796.85,35,,2796.85,percent of total billed charges,Implant Device,2796.85,35,,2796.85,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2716.94,34,"If Charge > 2,000, then 34 percent",2716.94,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5913.36,
OSTEOREMEDIES GVLSMD GV FEM LONG STEM MD,L8699,HCPCS,,79013242,CDM,278,RC,,,both,,,7991,5913.36,,,5913.36,Other,150% of Medicare + 9.63% HCRA Surcharge,3595.95,45,,3595.95,percent of total billed charges,Critical Access Hospital RCC factor,2716.94,34,,2716.94,percent of total billed charges,Implant Device,2716.94,34,,2716.94,percent of total billed charges,Implant Device,2716.94,34,,2716.94,percent of total billed charges,Implant Device,2716.94,34,,2716.94,percent of total billed charges,Implant Device,2716.94,34,,2716.94,percent of total billed charges,Implant Device,3955.55,,,3955.55,Other,110% of Medicare,2796.85,35,,2796.85,percent of total billed charges,Implant Device,2716.94,34,"Charges > $500, x 34%",2716.94,percent of total billed charges,Implant Device,2796.85,35,,2796.85,percent of total billed charges,Implant Device,2796.85,35,,2796.85,percent of total billed charges,Implant Device,2796.85,35,,2796.85,percent of total billed charges,Implant Device,2796.85,35,,2796.85,percent of total billed charges,Implant Device,2796.85,35,,2796.85,percent of total billed charges,Implant Device,3196.4,40,,3196.4,percent of total billed charges,Implant Device,2796.85,70,,2796.85,percent of total billed charges,All Other,2716.94,34,,2716.94,percent of total billed charges,Implant Device,2716.94,34,,2716.94,percent of total billed charges,Implant Device,2796.85,35,,2796.85,percent of total billed charges,Implant Device,2796.85,35,,2796.85,percent of total billed charges,Implant Device,2796.85,35,,2796.85,percent of total billed charges,Implant Device,2796.85,35,,2796.85,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2716.94,34,"If Charge > 2,000, then 34 percent",2716.94,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5913.36,
OSTEOREMEDIES GVLSSM GV FEM LONG STEM SM,L8699,HCPCS,,79013243,CDM,278,RC,,,both,,,7991,5913.36,,,5913.36,Other,150% of Medicare + 9.63% HCRA Surcharge,3595.95,45,,3595.95,percent of total billed charges,Critical Access Hospital RCC factor,2716.94,34,,2716.94,percent of total billed charges,Implant Device,2716.94,34,,2716.94,percent of total billed charges,Implant Device,2716.94,34,,2716.94,percent of total billed charges,Implant Device,2716.94,34,,2716.94,percent of total billed charges,Implant Device,2716.94,34,,2716.94,percent of total billed charges,Implant Device,3955.55,,,3955.55,Other,110% of Medicare,2796.85,35,,2796.85,percent of total billed charges,Implant Device,2716.94,34,"Charges > $500, x 34%",2716.94,percent of total billed charges,Implant Device,2796.85,35,,2796.85,percent of total billed charges,Implant Device,2796.85,35,,2796.85,percent of total billed charges,Implant Device,2796.85,35,,2796.85,percent of total billed charges,Implant Device,2796.85,35,,2796.85,percent of total billed charges,Implant Device,2796.85,35,,2796.85,percent of total billed charges,Implant Device,3196.4,40,,3196.4,percent of total billed charges,Implant Device,2796.85,70,,2796.85,percent of total billed charges,All Other,2716.94,34,,2716.94,percent of total billed charges,Implant Device,2716.94,34,,2716.94,percent of total billed charges,Implant Device,2796.85,35,,2796.85,percent of total billed charges,Implant Device,2796.85,35,,2796.85,percent of total billed charges,Implant Device,2796.85,35,,2796.85,percent of total billed charges,Implant Device,2796.85,35,,2796.85,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2716.94,34,"If Charge > 2,000, then 34 percent",2716.94,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5913.36,
OSTEOREMEDIES GVSTLG GV FEMORAL STEM LG,L8699,HCPCS,,79013244,CDM,278,RC,,,both,,,7691,5691.36,,,5691.36,Other,150% of Medicare + 9.63% HCRA Surcharge,3460.95,45,,3460.95,percent of total billed charges,Critical Access Hospital RCC factor,2614.94,34,,2614.94,percent of total billed charges,Implant Device,2614.94,34,,2614.94,percent of total billed charges,Implant Device,2614.94,34,,2614.94,percent of total billed charges,Implant Device,2614.94,34,,2614.94,percent of total billed charges,Implant Device,2614.94,34,,2614.94,percent of total billed charges,Implant Device,3807.05,,,3807.05,Other,110% of Medicare,2691.85,35,,2691.85,percent of total billed charges,Implant Device,2614.94,34,"Charges > $500, x 34%",2614.94,percent of total billed charges,Implant Device,2691.85,35,,2691.85,percent of total billed charges,Implant Device,2691.85,35,,2691.85,percent of total billed charges,Implant Device,2691.85,35,,2691.85,percent of total billed charges,Implant Device,2691.85,35,,2691.85,percent of total billed charges,Implant Device,2691.85,35,,2691.85,percent of total billed charges,Implant Device,3076.4,40,,3076.4,percent of total billed charges,Implant Device,2691.85,70,,2691.85,percent of total billed charges,All Other,2614.94,34,,2614.94,percent of total billed charges,Implant Device,2614.94,34,,2614.94,percent of total billed charges,Implant Device,2691.85,35,,2691.85,percent of total billed charges,Implant Device,2691.85,35,,2691.85,percent of total billed charges,Implant Device,2691.85,35,,2691.85,percent of total billed charges,Implant Device,2691.85,35,,2691.85,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2614.94,34,"If Charge > 2,000, then 34 percent",2614.94,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5691.36,
OSTEOREMEDIES GVSTMD GV FEMORAL STEM MD,L8699,HCPCS,,79013245,CDM,278,RC,,,both,,,7691,5691.36,,,5691.36,Other,150% of Medicare + 9.63% HCRA Surcharge,3460.95,45,,3460.95,percent of total billed charges,Critical Access Hospital RCC factor,2614.94,34,,2614.94,percent of total billed charges,Implant Device,2614.94,34,,2614.94,percent of total billed charges,Implant Device,2614.94,34,,2614.94,percent of total billed charges,Implant Device,2614.94,34,,2614.94,percent of total billed charges,Implant Device,2614.94,34,,2614.94,percent of total billed charges,Implant Device,3807.05,,,3807.05,Other,110% of Medicare,2691.85,35,,2691.85,percent of total billed charges,Implant Device,2614.94,34,"Charges > $500, x 34%",2614.94,percent of total billed charges,Implant Device,2691.85,35,,2691.85,percent of total billed charges,Implant Device,2691.85,35,,2691.85,percent of total billed charges,Implant Device,2691.85,35,,2691.85,percent of total billed charges,Implant Device,2691.85,35,,2691.85,percent of total billed charges,Implant Device,2691.85,35,,2691.85,percent of total billed charges,Implant Device,3076.4,40,,3076.4,percent of total billed charges,Implant Device,2691.85,70,,2691.85,percent of total billed charges,All Other,2614.94,34,,2614.94,percent of total billed charges,Implant Device,2614.94,34,,2614.94,percent of total billed charges,Implant Device,2691.85,35,,2691.85,percent of total billed charges,Implant Device,2691.85,35,,2691.85,percent of total billed charges,Implant Device,2691.85,35,,2691.85,percent of total billed charges,Implant Device,2691.85,35,,2691.85,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2614.94,34,"If Charge > 2,000, then 34 percent",2614.94,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5691.36,
OSTEOREMEDIES GVSTSM GV FEMORAL STEM SM,L8699,HCPCS,,79013246,CDM,278,RC,,,both,,,7691,5691.36,,,5691.36,Other,150% of Medicare + 9.63% HCRA Surcharge,3460.95,45,,3460.95,percent of total billed charges,Critical Access Hospital RCC factor,2614.94,34,,2614.94,percent of total billed charges,Implant Device,2614.94,34,,2614.94,percent of total billed charges,Implant Device,2614.94,34,,2614.94,percent of total billed charges,Implant Device,2614.94,34,,2614.94,percent of total billed charges,Implant Device,2614.94,34,,2614.94,percent of total billed charges,Implant Device,3807.05,,,3807.05,Other,110% of Medicare,2691.85,35,,2691.85,percent of total billed charges,Implant Device,2614.94,34,"Charges > $500, x 34%",2614.94,percent of total billed charges,Implant Device,2691.85,35,,2691.85,percent of total billed charges,Implant Device,2691.85,35,,2691.85,percent of total billed charges,Implant Device,2691.85,35,,2691.85,percent of total billed charges,Implant Device,2691.85,35,,2691.85,percent of total billed charges,Implant Device,2691.85,35,,2691.85,percent of total billed charges,Implant Device,3076.4,40,,3076.4,percent of total billed charges,Implant Device,2691.85,70,,2691.85,percent of total billed charges,All Other,2614.94,34,,2614.94,percent of total billed charges,Implant Device,2614.94,34,,2614.94,percent of total billed charges,Implant Device,2691.85,35,,2691.85,percent of total billed charges,Implant Device,2691.85,35,,2691.85,percent of total billed charges,Implant Device,2691.85,35,,2691.85,percent of total billed charges,Implant Device,2691.85,35,,2691.85,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2614.94,34,"If Charge > 2,000, then 34 percent",2614.94,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5691.36,
OSTEOREMEDIES RHACSM ACETAB CUP 46/54MM,C1776,HCPCS,,79013247,CDM,278,RC,,,both,,,4190,3100.61,,,3100.61,Other,150% of Medicare + 9.63% HCRA Surcharge,1885.5,45,,1885.5,percent of total billed charges,Critical Access Hospital RCC factor,1424.6,34,,1424.6,percent of total billed charges,Implant Device,1424.6,34,,1424.6,percent of total billed charges,Implant Device,1424.6,34,,1424.6,percent of total billed charges,Implant Device,1424.6,34,,1424.6,percent of total billed charges,Implant Device,1424.6,34,,1424.6,percent of total billed charges,Implant Device,2074.05,,,2074.05,Other,110% of Medicare,1466.5,35,,1466.5,percent of total billed charges,Implant Device,1424.6,34,"Charges > $500, x 34%",1424.6,percent of total billed charges,Implant Device,1466.5,35,,1466.5,percent of total billed charges,Implant Device,1466.5,35,,1466.5,percent of total billed charges,Implant Device,1466.5,35,,1466.5,percent of total billed charges,Implant Device,1466.5,35,,1466.5,percent of total billed charges,Implant Device,1466.5,35,,1466.5,percent of total billed charges,Implant Device,1676,40,,1676,percent of total billed charges,Implant Device,1466.5,70,,1466.5,percent of total billed charges,All Other,1424.6,34,,1424.6,percent of total billed charges,Implant Device,1424.6,34,,1424.6,percent of total billed charges,Implant Device,1466.5,35,,1466.5,percent of total billed charges,Implant Device,1466.5,35,,1466.5,percent of total billed charges,Implant Device,1466.5,35,,1466.5,percent of total billed charges,Implant Device,1466.5,35,,1466.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1424.6,34,"If Charge > 2,000, then 34 percent",1424.6,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3100.61,
OSTEOREMEDIES RHACXS ACETAB CUP 40/48MM,C1776,HCPCS,,79013248,CDM,278,RC,,,both,,,4190,3100.61,,,3100.61,Other,150% of Medicare + 9.63% HCRA Surcharge,1885.5,45,,1885.5,percent of total billed charges,Critical Access Hospital RCC factor,1424.6,34,,1424.6,percent of total billed charges,Implant Device,1424.6,34,,1424.6,percent of total billed charges,Implant Device,1424.6,34,,1424.6,percent of total billed charges,Implant Device,1424.6,34,,1424.6,percent of total billed charges,Implant Device,1424.6,34,,1424.6,percent of total billed charges,Implant Device,2074.05,,,2074.05,Other,110% of Medicare,1466.5,35,,1466.5,percent of total billed charges,Implant Device,1424.6,34,"Charges > $500, x 34%",1424.6,percent of total billed charges,Implant Device,1466.5,35,,1466.5,percent of total billed charges,Implant Device,1466.5,35,,1466.5,percent of total billed charges,Implant Device,1466.5,35,,1466.5,percent of total billed charges,Implant Device,1466.5,35,,1466.5,percent of total billed charges,Implant Device,1466.5,35,,1466.5,percent of total billed charges,Implant Device,1676,40,,1676,percent of total billed charges,Implant Device,1466.5,70,,1466.5,percent of total billed charges,All Other,1424.6,34,,1424.6,percent of total billed charges,Implant Device,1424.6,34,,1424.6,percent of total billed charges,Implant Device,1466.5,35,,1466.5,percent of total billed charges,Implant Device,1466.5,35,,1466.5,percent of total billed charges,Implant Device,1466.5,35,,1466.5,percent of total billed charges,Implant Device,1466.5,35,,1466.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1424.6,34,"If Charge > 2,000, then 34 percent",1424.6,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3100.61,
OSTEOREMEDIES RHHDLG MODULAR HEAD 60MM,C1776,HCPCS,,79013249,CDM,278,RC,,,both,,,4794,3547.57,,,3547.57,Other,150% of Medicare + 9.63% HCRA Surcharge,2157.3,45,,2157.3,percent of total billed charges,Critical Access Hospital RCC factor,1629.96,34,,1629.96,percent of total billed charges,Implant Device,1629.96,34,,1629.96,percent of total billed charges,Implant Device,1629.96,34,,1629.96,percent of total billed charges,Implant Device,1629.96,34,,1629.96,percent of total billed charges,Implant Device,1629.96,34,,1629.96,percent of total billed charges,Implant Device,2373.03,,,2373.03,Other,110% of Medicare,1677.9,35,,1677.9,percent of total billed charges,Implant Device,1629.96,34,"Charges > $500, x 34%",1629.96,percent of total billed charges,Implant Device,1677.9,35,,1677.9,percent of total billed charges,Implant Device,1677.9,35,,1677.9,percent of total billed charges,Implant Device,1677.9,35,,1677.9,percent of total billed charges,Implant Device,1677.9,35,,1677.9,percent of total billed charges,Implant Device,1677.9,35,,1677.9,percent of total billed charges,Implant Device,1917.6,40,,1917.6,percent of total billed charges,Implant Device,1677.9,70,,1677.9,percent of total billed charges,All Other,1629.96,34,,1629.96,percent of total billed charges,Implant Device,1629.96,34,,1629.96,percent of total billed charges,Implant Device,1677.9,35,,1677.9,percent of total billed charges,Implant Device,1677.9,35,,1677.9,percent of total billed charges,Implant Device,1677.9,35,,1677.9,percent of total billed charges,Implant Device,1677.9,35,,1677.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1629.96,34,"If Charge > 2,000, then 34 percent",1629.96,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3547.57,
OSTEOREMEDIES RHHDMD MODULAR HEAD 54MM,C1776,HCPCS,,79013250,CDM,278,RC,,,both,,,4794,3547.57,,,3547.57,Other,150% of Medicare + 9.63% HCRA Surcharge,2157.3,45,,2157.3,percent of total billed charges,Critical Access Hospital RCC factor,1629.96,34,,1629.96,percent of total billed charges,Implant Device,1629.96,34,,1629.96,percent of total billed charges,Implant Device,1629.96,34,,1629.96,percent of total billed charges,Implant Device,1629.96,34,,1629.96,percent of total billed charges,Implant Device,1629.96,34,,1629.96,percent of total billed charges,Implant Device,2373.03,,,2373.03,Other,110% of Medicare,1677.9,35,,1677.9,percent of total billed charges,Implant Device,1629.96,34,"Charges > $500, x 34%",1629.96,percent of total billed charges,Implant Device,1677.9,35,,1677.9,percent of total billed charges,Implant Device,1677.9,35,,1677.9,percent of total billed charges,Implant Device,1677.9,35,,1677.9,percent of total billed charges,Implant Device,1677.9,35,,1677.9,percent of total billed charges,Implant Device,1677.9,35,,1677.9,percent of total billed charges,Implant Device,1917.6,40,,1917.6,percent of total billed charges,Implant Device,1677.9,70,,1677.9,percent of total billed charges,All Other,1629.96,34,,1629.96,percent of total billed charges,Implant Device,1629.96,34,,1629.96,percent of total billed charges,Implant Device,1677.9,35,,1677.9,percent of total billed charges,Implant Device,1677.9,35,,1677.9,percent of total billed charges,Implant Device,1677.9,35,,1677.9,percent of total billed charges,Implant Device,1677.9,35,,1677.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1629.96,34,"If Charge > 2,000, then 34 percent",1629.96,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3547.57,
OSTEOREMEDIES RHHDSM MODULAR HEAD 46MM,C1776,HCPCS,,79013251,CDM,278,RC,,,both,,,4794,3547.57,,,3547.57,Other,150% of Medicare + 9.63% HCRA Surcharge,2157.3,45,,2157.3,percent of total billed charges,Critical Access Hospital RCC factor,1629.96,34,,1629.96,percent of total billed charges,Implant Device,1629.96,34,,1629.96,percent of total billed charges,Implant Device,1629.96,34,,1629.96,percent of total billed charges,Implant Device,1629.96,34,,1629.96,percent of total billed charges,Implant Device,1629.96,34,,1629.96,percent of total billed charges,Implant Device,2373.03,,,2373.03,Other,110% of Medicare,1677.9,35,,1677.9,percent of total billed charges,Implant Device,1629.96,34,"Charges > $500, x 34%",1629.96,percent of total billed charges,Implant Device,1677.9,35,,1677.9,percent of total billed charges,Implant Device,1677.9,35,,1677.9,percent of total billed charges,Implant Device,1677.9,35,,1677.9,percent of total billed charges,Implant Device,1677.9,35,,1677.9,percent of total billed charges,Implant Device,1677.9,35,,1677.9,percent of total billed charges,Implant Device,1917.6,40,,1917.6,percent of total billed charges,Implant Device,1677.9,70,,1677.9,percent of total billed charges,All Other,1629.96,34,,1629.96,percent of total billed charges,Implant Device,1629.96,34,,1629.96,percent of total billed charges,Implant Device,1677.9,35,,1677.9,percent of total billed charges,Implant Device,1677.9,35,,1677.9,percent of total billed charges,Implant Device,1677.9,35,,1677.9,percent of total billed charges,Implant Device,1677.9,35,,1677.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1629.96,34,"If Charge > 2,000, then 34 percent",1629.96,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3547.57,
OSTEOREMEDIES RHLSLG MOD LONG STEM LG,C1776,HCPCS,,79013252,CDM,278,RC,,,both,,,7020,5194.82,,,5194.82,Other,150% of Medicare + 9.63% HCRA Surcharge,3159,45,,3159,percent of total billed charges,Critical Access Hospital RCC factor,2386.8,34,,2386.8,percent of total billed charges,Implant Device,2386.8,34,,2386.8,percent of total billed charges,Implant Device,2386.8,34,,2386.8,percent of total billed charges,Implant Device,2386.8,34,,2386.8,percent of total billed charges,Implant Device,2386.8,34,,2386.8,percent of total billed charges,Implant Device,3474.9,,,3474.9,Other,110% of Medicare,2457,35,,2457,percent of total billed charges,Implant Device,2386.8,34,"Charges > $500, x 34%",2386.8,percent of total billed charges,Implant Device,2457,35,,2457,percent of total billed charges,Implant Device,2457,35,,2457,percent of total billed charges,Implant Device,2457,35,,2457,percent of total billed charges,Implant Device,2457,35,,2457,percent of total billed charges,Implant Device,2457,35,,2457,percent of total billed charges,Implant Device,2808,40,,2808,percent of total billed charges,Implant Device,2457,70,,2457,percent of total billed charges,All Other,2386.8,34,,2386.8,percent of total billed charges,Implant Device,2386.8,34,,2386.8,percent of total billed charges,Implant Device,2457,35,,2457,percent of total billed charges,Implant Device,2457,35,,2457,percent of total billed charges,Implant Device,2457,35,,2457,percent of total billed charges,Implant Device,2457,35,,2457,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2386.8,34,"If Charge > 2,000, then 34 percent",2386.8,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5194.82,
OSTEOREMEDIES RHLSMD MOD LONG STEM MED,C1776,HCPCS,,79013253,CDM,278,RC,,,both,,,7020,5194.82,,,5194.82,Other,150% of Medicare + 9.63% HCRA Surcharge,3159,45,,3159,percent of total billed charges,Critical Access Hospital RCC factor,2386.8,34,,2386.8,percent of total billed charges,Implant Device,2386.8,34,,2386.8,percent of total billed charges,Implant Device,2386.8,34,,2386.8,percent of total billed charges,Implant Device,2386.8,34,,2386.8,percent of total billed charges,Implant Device,2386.8,34,,2386.8,percent of total billed charges,Implant Device,3474.9,,,3474.9,Other,110% of Medicare,2457,35,,2457,percent of total billed charges,Implant Device,2386.8,34,"Charges > $500, x 34%",2386.8,percent of total billed charges,Implant Device,2457,35,,2457,percent of total billed charges,Implant Device,2457,35,,2457,percent of total billed charges,Implant Device,2457,35,,2457,percent of total billed charges,Implant Device,2457,35,,2457,percent of total billed charges,Implant Device,2457,35,,2457,percent of total billed charges,Implant Device,2808,40,,2808,percent of total billed charges,Implant Device,2457,70,,2457,percent of total billed charges,All Other,2386.8,34,,2386.8,percent of total billed charges,Implant Device,2386.8,34,,2386.8,percent of total billed charges,Implant Device,2457,35,,2457,percent of total billed charges,Implant Device,2457,35,,2457,percent of total billed charges,Implant Device,2457,35,,2457,percent of total billed charges,Implant Device,2457,35,,2457,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2386.8,34,"If Charge > 2,000, then 34 percent",2386.8,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5194.82,
OSTEOREMEDIES RHLSSM MOD LONG STEM SM,C1776,HCPCS,,79013254,CDM,278,RC,,,both,,,7020,5194.82,,,5194.82,Other,150% of Medicare + 9.63% HCRA Surcharge,3159,45,,3159,percent of total billed charges,Critical Access Hospital RCC factor,2386.8,34,,2386.8,percent of total billed charges,Implant Device,2386.8,34,,2386.8,percent of total billed charges,Implant Device,2386.8,34,,2386.8,percent of total billed charges,Implant Device,2386.8,34,,2386.8,percent of total billed charges,Implant Device,2386.8,34,,2386.8,percent of total billed charges,Implant Device,3474.9,,,3474.9,Other,110% of Medicare,2457,35,,2457,percent of total billed charges,Implant Device,2386.8,34,"Charges > $500, x 34%",2386.8,percent of total billed charges,Implant Device,2457,35,,2457,percent of total billed charges,Implant Device,2457,35,,2457,percent of total billed charges,Implant Device,2457,35,,2457,percent of total billed charges,Implant Device,2457,35,,2457,percent of total billed charges,Implant Device,2457,35,,2457,percent of total billed charges,Implant Device,2808,40,,2808,percent of total billed charges,Implant Device,2457,70,,2457,percent of total billed charges,All Other,2386.8,34,,2386.8,percent of total billed charges,Implant Device,2386.8,34,,2386.8,percent of total billed charges,Implant Device,2457,35,,2457,percent of total billed charges,Implant Device,2457,35,,2457,percent of total billed charges,Implant Device,2457,35,,2457,percent of total billed charges,Implant Device,2457,35,,2457,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2386.8,34,"If Charge > 2,000, then 34 percent",2386.8,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5194.82,
OSTEOREMEDIES RHSTLG MODULAR STEM LARGE,C1776,HCPCS,,79013255,CDM,278,RC,,,both,,,6762,5003.9,,,5003.9,Other,150% of Medicare + 9.63% HCRA Surcharge,3042.9,45,,3042.9,percent of total billed charges,Critical Access Hospital RCC factor,2299.08,34,,2299.08,percent of total billed charges,Implant Device,2299.08,34,,2299.08,percent of total billed charges,Implant Device,2299.08,34,,2299.08,percent of total billed charges,Implant Device,2299.08,34,,2299.08,percent of total billed charges,Implant Device,2299.08,34,,2299.08,percent of total billed charges,Implant Device,3347.19,,,3347.19,Other,110% of Medicare,2366.7,35,,2366.7,percent of total billed charges,Implant Device,2299.08,34,"Charges > $500, x 34%",2299.08,percent of total billed charges,Implant Device,2366.7,35,,2366.7,percent of total billed charges,Implant Device,2366.7,35,,2366.7,percent of total billed charges,Implant Device,2366.7,35,,2366.7,percent of total billed charges,Implant Device,2366.7,35,,2366.7,percent of total billed charges,Implant Device,2366.7,35,,2366.7,percent of total billed charges,Implant Device,2704.8,40,,2704.8,percent of total billed charges,Implant Device,2366.7,70,,2366.7,percent of total billed charges,All Other,2299.08,34,,2299.08,percent of total billed charges,Implant Device,2299.08,34,,2299.08,percent of total billed charges,Implant Device,2366.7,35,,2366.7,percent of total billed charges,Implant Device,2366.7,35,,2366.7,percent of total billed charges,Implant Device,2366.7,35,,2366.7,percent of total billed charges,Implant Device,2366.7,35,,2366.7,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2299.08,34,"If Charge > 2,000, then 34 percent",2299.08,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5003.9,
OSTEOREMEDIES RHSTMD MODULAR STEM MEDIUM,C1776,HCPCS,,79013256,CDM,278,RC,,,both,,,6762,5003.9,,,5003.9,Other,150% of Medicare + 9.63% HCRA Surcharge,3042.9,45,,3042.9,percent of total billed charges,Critical Access Hospital RCC factor,2299.08,34,,2299.08,percent of total billed charges,Implant Device,2299.08,34,,2299.08,percent of total billed charges,Implant Device,2299.08,34,,2299.08,percent of total billed charges,Implant Device,2299.08,34,,2299.08,percent of total billed charges,Implant Device,2299.08,34,,2299.08,percent of total billed charges,Implant Device,3347.19,,,3347.19,Other,110% of Medicare,2366.7,35,,2366.7,percent of total billed charges,Implant Device,2299.08,34,"Charges > $500, x 34%",2299.08,percent of total billed charges,Implant Device,2366.7,35,,2366.7,percent of total billed charges,Implant Device,2366.7,35,,2366.7,percent of total billed charges,Implant Device,2366.7,35,,2366.7,percent of total billed charges,Implant Device,2366.7,35,,2366.7,percent of total billed charges,Implant Device,2366.7,35,,2366.7,percent of total billed charges,Implant Device,2704.8,40,,2704.8,percent of total billed charges,Implant Device,2366.7,70,,2366.7,percent of total billed charges,All Other,2299.08,34,,2299.08,percent of total billed charges,Implant Device,2299.08,34,,2299.08,percent of total billed charges,Implant Device,2366.7,35,,2366.7,percent of total billed charges,Implant Device,2366.7,35,,2366.7,percent of total billed charges,Implant Device,2366.7,35,,2366.7,percent of total billed charges,Implant Device,2366.7,35,,2366.7,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2299.08,34,"If Charge > 2,000, then 34 percent",2299.08,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5003.9,
OSTEOREMEDIES RHSTSM MODULAR STEM SMALL,C1776,HCPCS,,79013257,CDM,278,RC,,,both,,,6762,5003.9,,,5003.9,Other,150% of Medicare + 9.63% HCRA Surcharge,3042.9,45,,3042.9,percent of total billed charges,Critical Access Hospital RCC factor,2299.08,34,,2299.08,percent of total billed charges,Implant Device,2299.08,34,,2299.08,percent of total billed charges,Implant Device,2299.08,34,,2299.08,percent of total billed charges,Implant Device,2299.08,34,,2299.08,percent of total billed charges,Implant Device,2299.08,34,,2299.08,percent of total billed charges,Implant Device,3347.19,,,3347.19,Other,110% of Medicare,2366.7,35,,2366.7,percent of total billed charges,Implant Device,2299.08,34,"Charges > $500, x 34%",2299.08,percent of total billed charges,Implant Device,2366.7,35,,2366.7,percent of total billed charges,Implant Device,2366.7,35,,2366.7,percent of total billed charges,Implant Device,2366.7,35,,2366.7,percent of total billed charges,Implant Device,2366.7,35,,2366.7,percent of total billed charges,Implant Device,2366.7,35,,2366.7,percent of total billed charges,Implant Device,2704.8,40,,2704.8,percent of total billed charges,Implant Device,2366.7,70,,2366.7,percent of total billed charges,All Other,2299.08,34,,2299.08,percent of total billed charges,Implant Device,2299.08,34,,2299.08,percent of total billed charges,Implant Device,2366.7,35,,2366.7,percent of total billed charges,Implant Device,2366.7,35,,2366.7,percent of total billed charges,Implant Device,2366.7,35,,2366.7,percent of total billed charges,Implant Device,2366.7,35,,2366.7,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2299.08,34,"If Charge > 2,000, then 34 percent",2299.08,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5003.9,
OSTEOREMEDIES RKFMLG FEMORAL COMP LARGE,C1776,HCPCS,,79013258,CDM,278,RC,,,both,,,6006,4444.46,,,4444.46,Other,150% of Medicare + 9.63% HCRA Surcharge,2702.7,45,,2702.7,percent of total billed charges,Critical Access Hospital RCC factor,2042.04,34,,2042.04,percent of total billed charges,Implant Device,2042.04,34,,2042.04,percent of total billed charges,Implant Device,2042.04,34,,2042.04,percent of total billed charges,Implant Device,2042.04,34,,2042.04,percent of total billed charges,Implant Device,2042.04,34,,2042.04,percent of total billed charges,Implant Device,2972.97,,,2972.97,Other,110% of Medicare,2102.1,35,,2102.1,percent of total billed charges,Implant Device,2042.04,34,"Charges > $500, x 34%",2042.04,percent of total billed charges,Implant Device,2102.1,35,,2102.1,percent of total billed charges,Implant Device,2102.1,35,,2102.1,percent of total billed charges,Implant Device,2102.1,35,,2102.1,percent of total billed charges,Implant Device,2102.1,35,,2102.1,percent of total billed charges,Implant Device,2102.1,35,,2102.1,percent of total billed charges,Implant Device,2402.4,40,,2402.4,percent of total billed charges,Implant Device,2102.1,70,,2102.1,percent of total billed charges,All Other,2042.04,34,,2042.04,percent of total billed charges,Implant Device,2042.04,34,,2042.04,percent of total billed charges,Implant Device,2102.1,35,,2102.1,percent of total billed charges,Implant Device,2102.1,35,,2102.1,percent of total billed charges,Implant Device,2102.1,35,,2102.1,percent of total billed charges,Implant Device,2102.1,35,,2102.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2042.04,34,"If Charge > 2,000, then 34 percent",2042.04,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4444.46,
OSTEOREMEDIES RKFMMD FEMORAL COMP MEDIUM,C1776,HCPCS,,79013259,CDM,278,RC,,,both,,,6006,4444.46,,,4444.46,Other,150% of Medicare + 9.63% HCRA Surcharge,2702.7,45,,2702.7,percent of total billed charges,Critical Access Hospital RCC factor,2042.04,34,,2042.04,percent of total billed charges,Implant Device,2042.04,34,,2042.04,percent of total billed charges,Implant Device,2042.04,34,,2042.04,percent of total billed charges,Implant Device,2042.04,34,,2042.04,percent of total billed charges,Implant Device,2042.04,34,,2042.04,percent of total billed charges,Implant Device,2972.97,,,2972.97,Other,110% of Medicare,2102.1,35,,2102.1,percent of total billed charges,Implant Device,2042.04,34,"Charges > $500, x 34%",2042.04,percent of total billed charges,Implant Device,2102.1,35,,2102.1,percent of total billed charges,Implant Device,2102.1,35,,2102.1,percent of total billed charges,Implant Device,2102.1,35,,2102.1,percent of total billed charges,Implant Device,2102.1,35,,2102.1,percent of total billed charges,Implant Device,2102.1,35,,2102.1,percent of total billed charges,Implant Device,2402.4,40,,2402.4,percent of total billed charges,Implant Device,2102.1,70,,2102.1,percent of total billed charges,All Other,2042.04,34,,2042.04,percent of total billed charges,Implant Device,2042.04,34,,2042.04,percent of total billed charges,Implant Device,2102.1,35,,2102.1,percent of total billed charges,Implant Device,2102.1,35,,2102.1,percent of total billed charges,Implant Device,2102.1,35,,2102.1,percent of total billed charges,Implant Device,2102.1,35,,2102.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2042.04,34,"If Charge > 2,000, then 34 percent",2042.04,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4444.46,
OSTEOREMEDIES RKFMSM FEMORAL COMP SMALL,C1776,HCPCS,,79013260,CDM,278,RC,,,both,,,6006,4444.46,,,4444.46,Other,150% of Medicare + 9.63% HCRA Surcharge,2702.7,45,,2702.7,percent of total billed charges,Critical Access Hospital RCC factor,2042.04,34,,2042.04,percent of total billed charges,Implant Device,2042.04,34,,2042.04,percent of total billed charges,Implant Device,2042.04,34,,2042.04,percent of total billed charges,Implant Device,2042.04,34,,2042.04,percent of total billed charges,Implant Device,2042.04,34,,2042.04,percent of total billed charges,Implant Device,2972.97,,,2972.97,Other,110% of Medicare,2102.1,35,,2102.1,percent of total billed charges,Implant Device,2042.04,34,"Charges > $500, x 34%",2042.04,percent of total billed charges,Implant Device,2102.1,35,,2102.1,percent of total billed charges,Implant Device,2102.1,35,,2102.1,percent of total billed charges,Implant Device,2102.1,35,,2102.1,percent of total billed charges,Implant Device,2102.1,35,,2102.1,percent of total billed charges,Implant Device,2102.1,35,,2102.1,percent of total billed charges,Implant Device,2402.4,40,,2402.4,percent of total billed charges,Implant Device,2102.1,70,,2102.1,percent of total billed charges,All Other,2042.04,34,,2042.04,percent of total billed charges,Implant Device,2042.04,34,,2042.04,percent of total billed charges,Implant Device,2102.1,35,,2102.1,percent of total billed charges,Implant Device,2102.1,35,,2102.1,percent of total billed charges,Implant Device,2102.1,35,,2102.1,percent of total billed charges,Implant Device,2102.1,35,,2102.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2042.04,34,"If Charge > 2,000, then 34 percent",2042.04,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4444.46,
OSTEOREMEDIES RKINLG TIB INSERT WEDGE LG,C1776,HCPCS,,79013261,CDM,278,RC,,,both,,,1650,1221,,,1221,Other,150% of Medicare + 9.63% HCRA Surcharge,742.5,45,,742.5,percent of total billed charges,Critical Access Hospital RCC factor,561,34,,561,percent of total billed charges,Implant Device,561,34,,561,percent of total billed charges,Implant Device,561,34,,561,percent of total billed charges,Implant Device,561,34,,561,percent of total billed charges,Implant Device,561,34,,561,percent of total billed charges,Implant Device,816.75,,,816.75,Other,110% of Medicare,577.5,35,,577.5,percent of total billed charges,Implant Device,561,34,"Charges > $500, x 34%",561,percent of total billed charges,Implant Device,577.5,35,,577.5,percent of total billed charges,Implant Device,577.5,35,,577.5,percent of total billed charges,Implant Device,577.5,35,,577.5,percent of total billed charges,Implant Device,577.5,35,,577.5,percent of total billed charges,Implant Device,577.5,35,,577.5,percent of total billed charges,Implant Device,660,40,,660,percent of total billed charges,Implant Device,577.5,70,,577.5,percent of total billed charges,All Other,561,34,,561,percent of total billed charges,Implant Device,561,34,,561,percent of total billed charges,Implant Device,577.5,35,,577.5,percent of total billed charges,Implant Device,577.5,35,,577.5,percent of total billed charges,Implant Device,577.5,35,,577.5,percent of total billed charges,Implant Device,577.5,35,,577.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1221,
OSTEOREMEDIES RKINMD TIB INS WEDGE MED,C1776,HCPCS,,79013262,CDM,278,RC,,,both,,,1650,1221,,,1221,Other,150% of Medicare + 9.63% HCRA Surcharge,742.5,45,,742.5,percent of total billed charges,Critical Access Hospital RCC factor,561,34,,561,percent of total billed charges,Implant Device,561,34,,561,percent of total billed charges,Implant Device,561,34,,561,percent of total billed charges,Implant Device,561,34,,561,percent of total billed charges,Implant Device,561,34,,561,percent of total billed charges,Implant Device,816.75,,,816.75,Other,110% of Medicare,577.5,35,,577.5,percent of total billed charges,Implant Device,561,34,"Charges > $500, x 34%",561,percent of total billed charges,Implant Device,577.5,35,,577.5,percent of total billed charges,Implant Device,577.5,35,,577.5,percent of total billed charges,Implant Device,577.5,35,,577.5,percent of total billed charges,Implant Device,577.5,35,,577.5,percent of total billed charges,Implant Device,577.5,35,,577.5,percent of total billed charges,Implant Device,660,40,,660,percent of total billed charges,Implant Device,577.5,70,,577.5,percent of total billed charges,All Other,561,34,,561,percent of total billed charges,Implant Device,561,34,,561,percent of total billed charges,Implant Device,577.5,35,,577.5,percent of total billed charges,Implant Device,577.5,35,,577.5,percent of total billed charges,Implant Device,577.5,35,,577.5,percent of total billed charges,Implant Device,577.5,35,,577.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1221,
OSTEOREMEDIES RKINSM TIB INSERT WEDGE SM,C1776,HCPCS,,79013263,CDM,278,RC,,,both,,,1650,1221,,,1221,Other,150% of Medicare + 9.63% HCRA Surcharge,742.5,45,,742.5,percent of total billed charges,Critical Access Hospital RCC factor,561,34,,561,percent of total billed charges,Implant Device,561,34,,561,percent of total billed charges,Implant Device,561,34,,561,percent of total billed charges,Implant Device,561,34,,561,percent of total billed charges,Implant Device,561,34,,561,percent of total billed charges,Implant Device,816.75,,,816.75,Other,110% of Medicare,577.5,35,,577.5,percent of total billed charges,Implant Device,561,34,"Charges > $500, x 34%",561,percent of total billed charges,Implant Device,577.5,35,,577.5,percent of total billed charges,Implant Device,577.5,35,,577.5,percent of total billed charges,Implant Device,577.5,35,,577.5,percent of total billed charges,Implant Device,577.5,35,,577.5,percent of total billed charges,Implant Device,577.5,35,,577.5,percent of total billed charges,Implant Device,660,40,,660,percent of total billed charges,Implant Device,577.5,70,,577.5,percent of total billed charges,All Other,561,34,,561,percent of total billed charges,Implant Device,561,34,,561,percent of total billed charges,Implant Device,577.5,35,,577.5,percent of total billed charges,Implant Device,577.5,35,,577.5,percent of total billed charges,Implant Device,577.5,35,,577.5,percent of total billed charges,Implant Device,577.5,35,,577.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1221,
OSTEOREMEDIES RKTBLG TIBIAL COMP LARGE,C1776,HCPCS,,79013264,CDM,278,RC,,,both,,,5814,4302.37,,,4302.37,Other,150% of Medicare + 9.63% HCRA Surcharge,2616.3,45,,2616.3,percent of total billed charges,Critical Access Hospital RCC factor,1976.76,34,,1976.76,percent of total billed charges,Implant Device,1976.76,34,,1976.76,percent of total billed charges,Implant Device,1976.76,34,,1976.76,percent of total billed charges,Implant Device,1976.76,34,,1976.76,percent of total billed charges,Implant Device,1976.76,34,,1976.76,percent of total billed charges,Implant Device,2877.93,,,2877.93,Other,110% of Medicare,2034.9,35,,2034.9,percent of total billed charges,Implant Device,1976.76,34,"Charges > $500, x 34%",1976.76,percent of total billed charges,Implant Device,2034.9,35,,2034.9,percent of total billed charges,Implant Device,2034.9,35,,2034.9,percent of total billed charges,Implant Device,2034.9,35,,2034.9,percent of total billed charges,Implant Device,2034.9,35,,2034.9,percent of total billed charges,Implant Device,2034.9,35,,2034.9,percent of total billed charges,Implant Device,2325.6,40,,2325.6,percent of total billed charges,Implant Device,2034.9,70,,2034.9,percent of total billed charges,All Other,1976.76,34,,1976.76,percent of total billed charges,Implant Device,1976.76,34,,1976.76,percent of total billed charges,Implant Device,2034.9,35,,2034.9,percent of total billed charges,Implant Device,2034.9,35,,2034.9,percent of total billed charges,Implant Device,2034.9,35,,2034.9,percent of total billed charges,Implant Device,2034.9,35,,2034.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1976.76,34,"If Charge > 2,000, then 34 percent",1976.76,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4302.37,
OSTEOREMEDIES RKTBMD TIBIAL COMP MED,C1776,HCPCS,,79013265,CDM,278,RC,,,both,,,5814,4302.37,,,4302.37,Other,150% of Medicare + 9.63% HCRA Surcharge,2616.3,45,,2616.3,percent of total billed charges,Critical Access Hospital RCC factor,1976.76,34,,1976.76,percent of total billed charges,Implant Device,1976.76,34,,1976.76,percent of total billed charges,Implant Device,1976.76,34,,1976.76,percent of total billed charges,Implant Device,1976.76,34,,1976.76,percent of total billed charges,Implant Device,1976.76,34,,1976.76,percent of total billed charges,Implant Device,2877.93,,,2877.93,Other,110% of Medicare,2034.9,35,,2034.9,percent of total billed charges,Implant Device,1976.76,34,"Charges > $500, x 34%",1976.76,percent of total billed charges,Implant Device,2034.9,35,,2034.9,percent of total billed charges,Implant Device,2034.9,35,,2034.9,percent of total billed charges,Implant Device,2034.9,35,,2034.9,percent of total billed charges,Implant Device,2034.9,35,,2034.9,percent of total billed charges,Implant Device,2034.9,35,,2034.9,percent of total billed charges,Implant Device,2325.6,40,,2325.6,percent of total billed charges,Implant Device,2034.9,70,,2034.9,percent of total billed charges,All Other,1976.76,34,,1976.76,percent of total billed charges,Implant Device,1976.76,34,,1976.76,percent of total billed charges,Implant Device,2034.9,35,,2034.9,percent of total billed charges,Implant Device,2034.9,35,,2034.9,percent of total billed charges,Implant Device,2034.9,35,,2034.9,percent of total billed charges,Implant Device,2034.9,35,,2034.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1976.76,34,"If Charge > 2,000, then 34 percent",1976.76,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4302.37,
OSTEOREMEDIES RKTBSM TIBIAL COMP SM,C1776,HCPCS,,79013266,CDM,278,RC,,,both,,,5814,4302.37,,,4302.37,Other,150% of Medicare + 9.63% HCRA Surcharge,2616.3,45,,2616.3,percent of total billed charges,Critical Access Hospital RCC factor,1976.76,34,,1976.76,percent of total billed charges,Implant Device,1976.76,34,,1976.76,percent of total billed charges,Implant Device,1976.76,34,,1976.76,percent of total billed charges,Implant Device,1976.76,34,,1976.76,percent of total billed charges,Implant Device,1976.76,34,,1976.76,percent of total billed charges,Implant Device,2877.93,,,2877.93,Other,110% of Medicare,2034.9,35,,2034.9,percent of total billed charges,Implant Device,1976.76,34,"Charges > $500, x 34%",1976.76,percent of total billed charges,Implant Device,2034.9,35,,2034.9,percent of total billed charges,Implant Device,2034.9,35,,2034.9,percent of total billed charges,Implant Device,2034.9,35,,2034.9,percent of total billed charges,Implant Device,2034.9,35,,2034.9,percent of total billed charges,Implant Device,2034.9,35,,2034.9,percent of total billed charges,Implant Device,2325.6,40,,2325.6,percent of total billed charges,Implant Device,2034.9,70,,2034.9,percent of total billed charges,All Other,1976.76,34,,1976.76,percent of total billed charges,Implant Device,1976.76,34,,1976.76,percent of total billed charges,Implant Device,2034.9,35,,2034.9,percent of total billed charges,Implant Device,2034.9,35,,2034.9,percent of total billed charges,Implant Device,2034.9,35,,2034.9,percent of total billed charges,Implant Device,2034.9,35,,2034.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1976.76,34,"If Charge > 2,000, then 34 percent",1976.76,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4302.37,
OSTEOREMEDIES RSK100 STEM EXTENSION 100,C1776,HCPCS,,79013267,CDM,278,RC,,,both,,,2873,2126.03,,,2126.03,Other,150% of Medicare + 9.63% HCRA Surcharge,1292.85,45,,1292.85,percent of total billed charges,Critical Access Hospital RCC factor,976.82,34,,976.82,percent of total billed charges,Implant Device,976.82,34,,976.82,percent of total billed charges,Implant Device,976.82,34,,976.82,percent of total billed charges,Implant Device,976.82,34,,976.82,percent of total billed charges,Implant Device,976.82,34,,976.82,percent of total billed charges,Implant Device,1422.14,,,1422.14,Other,110% of Medicare,1005.55,35,,1005.55,percent of total billed charges,Implant Device,976.82,34,"Charges > $500, x 34%",976.82,percent of total billed charges,Implant Device,1005.55,35,,1005.55,percent of total billed charges,Implant Device,1005.55,35,,1005.55,percent of total billed charges,Implant Device,1005.55,35,,1005.55,percent of total billed charges,Implant Device,1005.55,35,,1005.55,percent of total billed charges,Implant Device,1005.55,35,,1005.55,percent of total billed charges,Implant Device,1149.2,40,,1149.2,percent of total billed charges,Implant Device,1005.55,70,,1005.55,percent of total billed charges,All Other,976.82,34,,976.82,percent of total billed charges,Implant Device,976.82,34,,976.82,percent of total billed charges,Implant Device,1005.55,35,,1005.55,percent of total billed charges,Implant Device,1005.55,35,,1005.55,percent of total billed charges,Implant Device,1005.55,35,,1005.55,percent of total billed charges,Implant Device,1005.55,35,,1005.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,976.82,34,"If Charge > 2,000, then 34 percent",976.82,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2126.03,
OSTEOREMEDIES RSK175 STEM EXTENSION 175,C1776,HCPCS,,79013268,CDM,278,RC,,,both,,,3030,2242.21,,,2242.21,Other,150% of Medicare + 9.63% HCRA Surcharge,1363.5,45,,1363.5,percent of total billed charges,Critical Access Hospital RCC factor,1030.2,34,,1030.2,percent of total billed charges,Implant Device,1030.2,34,,1030.2,percent of total billed charges,Implant Device,1030.2,34,,1030.2,percent of total billed charges,Implant Device,1030.2,34,,1030.2,percent of total billed charges,Implant Device,1030.2,34,,1030.2,percent of total billed charges,Implant Device,1499.85,,,1499.85,Other,110% of Medicare,1060.5,35,,1060.5,percent of total billed charges,Implant Device,1030.2,34,"Charges > $500, x 34%",1030.2,percent of total billed charges,Implant Device,1060.5,35,,1060.5,percent of total billed charges,Implant Device,1060.5,35,,1060.5,percent of total billed charges,Implant Device,1060.5,35,,1060.5,percent of total billed charges,Implant Device,1060.5,35,,1060.5,percent of total billed charges,Implant Device,1060.5,35,,1060.5,percent of total billed charges,Implant Device,1212,40,,1212,percent of total billed charges,Implant Device,1060.5,70,,1060.5,percent of total billed charges,All Other,1030.2,34,,1030.2,percent of total billed charges,Implant Device,1030.2,34,,1030.2,percent of total billed charges,Implant Device,1060.5,35,,1060.5,percent of total billed charges,Implant Device,1060.5,35,,1060.5,percent of total billed charges,Implant Device,1060.5,35,,1060.5,percent of total billed charges,Implant Device,1060.5,35,,1060.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1030.2,34,"If Charge > 2,000, then 34 percent",1030.2,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2242.21,
OSTEOREMEDIES RSKFLG STEMMED FEM COMP LG,C1776,HCPCS,,79013269,CDM,278,RC,,,both,,,6400,4736.02,,,4736.02,Other,150% of Medicare + 9.63% HCRA Surcharge,2880,45,,2880,percent of total billed charges,Critical Access Hospital RCC factor,2176,34,,2176,percent of total billed charges,Implant Device,2176,34,,2176,percent of total billed charges,Implant Device,2176,34,,2176,percent of total billed charges,Implant Device,2176,34,,2176,percent of total billed charges,Implant Device,2176,34,,2176,percent of total billed charges,Implant Device,3168,,,3168,Other,110% of Medicare,2240,35,,2240,percent of total billed charges,Implant Device,2176,34,"Charges > $500, x 34%",2176,percent of total billed charges,Implant Device,2240,35,,2240,percent of total billed charges,Implant Device,2240,35,,2240,percent of total billed charges,Implant Device,2240,35,,2240,percent of total billed charges,Implant Device,2240,35,,2240,percent of total billed charges,Implant Device,2240,35,,2240,percent of total billed charges,Implant Device,2560,40,,2560,percent of total billed charges,Implant Device,2240,70,,2240,percent of total billed charges,All Other,2176,34,,2176,percent of total billed charges,Implant Device,2176,34,,2176,percent of total billed charges,Implant Device,2240,35,,2240,percent of total billed charges,Implant Device,2240,35,,2240,percent of total billed charges,Implant Device,2240,35,,2240,percent of total billed charges,Implant Device,2240,35,,2240,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2176,34,"If Charge > 2,000, then 34 percent",2176,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4736.02,
OSTEOREMEDIES RSKFMD STEM FEM COMP MED,C1776,HCPCS,,79013270,CDM,278,RC,,,both,,,6400,4736.02,,,4736.02,Other,150% of Medicare + 9.63% HCRA Surcharge,2880,45,,2880,percent of total billed charges,Critical Access Hospital RCC factor,2176,34,,2176,percent of total billed charges,Implant Device,2176,34,,2176,percent of total billed charges,Implant Device,2176,34,,2176,percent of total billed charges,Implant Device,2176,34,,2176,percent of total billed charges,Implant Device,2176,34,,2176,percent of total billed charges,Implant Device,3168,,,3168,Other,110% of Medicare,2240,35,,2240,percent of total billed charges,Implant Device,2176,34,"Charges > $500, x 34%",2176,percent of total billed charges,Implant Device,2240,35,,2240,percent of total billed charges,Implant Device,2240,35,,2240,percent of total billed charges,Implant Device,2240,35,,2240,percent of total billed charges,Implant Device,2240,35,,2240,percent of total billed charges,Implant Device,2240,35,,2240,percent of total billed charges,Implant Device,2560,40,,2560,percent of total billed charges,Implant Device,2240,70,,2240,percent of total billed charges,All Other,2176,34,,2176,percent of total billed charges,Implant Device,2176,34,,2176,percent of total billed charges,Implant Device,2240,35,,2240,percent of total billed charges,Implant Device,2240,35,,2240,percent of total billed charges,Implant Device,2240,35,,2240,percent of total billed charges,Implant Device,2240,35,,2240,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2176,34,"If Charge > 2,000, then 34 percent",2176,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4736.02,
OSTEOREMEDIES RSKFSM STEM FEM COMP SM,C1776,HCPCS,,79013271,CDM,278,RC,,,both,,,6400,4736.02,,,4736.02,Other,150% of Medicare + 9.63% HCRA Surcharge,2880,45,,2880,percent of total billed charges,Critical Access Hospital RCC factor,2176,34,,2176,percent of total billed charges,Implant Device,2176,34,,2176,percent of total billed charges,Implant Device,2176,34,,2176,percent of total billed charges,Implant Device,2176,34,,2176,percent of total billed charges,Implant Device,2176,34,,2176,percent of total billed charges,Implant Device,3168,,,3168,Other,110% of Medicare,2240,35,,2240,percent of total billed charges,Implant Device,2176,34,"Charges > $500, x 34%",2176,percent of total billed charges,Implant Device,2240,35,,2240,percent of total billed charges,Implant Device,2240,35,,2240,percent of total billed charges,Implant Device,2240,35,,2240,percent of total billed charges,Implant Device,2240,35,,2240,percent of total billed charges,Implant Device,2240,35,,2240,percent of total billed charges,Implant Device,2560,40,,2560,percent of total billed charges,Implant Device,2240,70,,2240,percent of total billed charges,All Other,2176,34,,2176,percent of total billed charges,Implant Device,2176,34,,2176,percent of total billed charges,Implant Device,2240,35,,2240,percent of total billed charges,Implant Device,2240,35,,2240,percent of total billed charges,Implant Device,2240,35,,2240,percent of total billed charges,Implant Device,2240,35,,2240,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2176,34,"If Charge > 2,000, then 34 percent",2176,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4736.02,
OSTEOREMEDIES RSKFXL STEM FEM COMP EX LG,C1776,HCPCS,,79013272,CDM,278,RC,,,both,,,6400,4736.02,,,4736.02,Other,150% of Medicare + 9.63% HCRA Surcharge,2880,45,,2880,percent of total billed charges,Critical Access Hospital RCC factor,2176,34,,2176,percent of total billed charges,Implant Device,2176,34,,2176,percent of total billed charges,Implant Device,2176,34,,2176,percent of total billed charges,Implant Device,2176,34,,2176,percent of total billed charges,Implant Device,2176,34,,2176,percent of total billed charges,Implant Device,3168,,,3168,Other,110% of Medicare,2240,35,,2240,percent of total billed charges,Implant Device,2176,34,"Charges > $500, x 34%",2176,percent of total billed charges,Implant Device,2240,35,,2240,percent of total billed charges,Implant Device,2240,35,,2240,percent of total billed charges,Implant Device,2240,35,,2240,percent of total billed charges,Implant Device,2240,35,,2240,percent of total billed charges,Implant Device,2240,35,,2240,percent of total billed charges,Implant Device,2560,40,,2560,percent of total billed charges,Implant Device,2240,70,,2240,percent of total billed charges,All Other,2176,34,,2176,percent of total billed charges,Implant Device,2176,34,,2176,percent of total billed charges,Implant Device,2240,35,,2240,percent of total billed charges,Implant Device,2240,35,,2240,percent of total billed charges,Implant Device,2240,35,,2240,percent of total billed charges,Implant Device,2240,35,,2240,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2176,34,"If Charge > 2,000, then 34 percent",2176,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4736.02,
OSTEOREMEDIES RSKTLG STEM TIBIAL COMP LG,C1776,HCPCS,,79013273,CDM,278,RC,,,both,,,6200,4588.02,,,4588.02,Other,150% of Medicare + 9.63% HCRA Surcharge,2790,45,,2790,percent of total billed charges,Critical Access Hospital RCC factor,2108,34,,2108,percent of total billed charges,Implant Device,2108,34,,2108,percent of total billed charges,Implant Device,2108,34,,2108,percent of total billed charges,Implant Device,2108,34,,2108,percent of total billed charges,Implant Device,2108,34,,2108,percent of total billed charges,Implant Device,3069,,,3069,Other,110% of Medicare,2170,35,,2170,percent of total billed charges,Implant Device,2108,34,"Charges > $500, x 34%",2108,percent of total billed charges,Implant Device,2170,35,,2170,percent of total billed charges,Implant Device,2170,35,,2170,percent of total billed charges,Implant Device,2170,35,,2170,percent of total billed charges,Implant Device,2170,35,,2170,percent of total billed charges,Implant Device,2170,35,,2170,percent of total billed charges,Implant Device,2480,40,,2480,percent of total billed charges,Implant Device,2170,70,,2170,percent of total billed charges,All Other,2108,34,,2108,percent of total billed charges,Implant Device,2108,34,,2108,percent of total billed charges,Implant Device,2170,35,,2170,percent of total billed charges,Implant Device,2170,35,,2170,percent of total billed charges,Implant Device,2170,35,,2170,percent of total billed charges,Implant Device,2170,35,,2170,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2108,34,"If Charge > 2,000, then 34 percent",2108,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4588.02,
OSTEOREMEDIES RSKTMD STEM TIB COMP MED,C1776,HCPCS,,79013274,CDM,278,RC,,,both,,,6200,4588.02,,,4588.02,Other,150% of Medicare + 9.63% HCRA Surcharge,2790,45,,2790,percent of total billed charges,Critical Access Hospital RCC factor,2108,34,,2108,percent of total billed charges,Implant Device,2108,34,,2108,percent of total billed charges,Implant Device,2108,34,,2108,percent of total billed charges,Implant Device,2108,34,,2108,percent of total billed charges,Implant Device,2108,34,,2108,percent of total billed charges,Implant Device,3069,,,3069,Other,110% of Medicare,2170,35,,2170,percent of total billed charges,Implant Device,2108,34,"Charges > $500, x 34%",2108,percent of total billed charges,Implant Device,2170,35,,2170,percent of total billed charges,Implant Device,2170,35,,2170,percent of total billed charges,Implant Device,2170,35,,2170,percent of total billed charges,Implant Device,2170,35,,2170,percent of total billed charges,Implant Device,2170,35,,2170,percent of total billed charges,Implant Device,2480,40,,2480,percent of total billed charges,Implant Device,2170,70,,2170,percent of total billed charges,All Other,2108,34,,2108,percent of total billed charges,Implant Device,2108,34,,2108,percent of total billed charges,Implant Device,2170,35,,2170,percent of total billed charges,Implant Device,2170,35,,2170,percent of total billed charges,Implant Device,2170,35,,2170,percent of total billed charges,Implant Device,2170,35,,2170,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2108,34,"If Charge > 2,000, then 34 percent",2108,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4588.02,
OSTEOREMEDIES RSKTSM STEM TIB COMP SM,C1776,HCPCS,,79013275,CDM,278,RC,,,both,,,6200,4588.02,,,4588.02,Other,150% of Medicare + 9.63% HCRA Surcharge,2790,45,,2790,percent of total billed charges,Critical Access Hospital RCC factor,2108,34,,2108,percent of total billed charges,Implant Device,2108,34,,2108,percent of total billed charges,Implant Device,2108,34,,2108,percent of total billed charges,Implant Device,2108,34,,2108,percent of total billed charges,Implant Device,2108,34,,2108,percent of total billed charges,Implant Device,3069,,,3069,Other,110% of Medicare,2170,35,,2170,percent of total billed charges,Implant Device,2108,34,"Charges > $500, x 34%",2108,percent of total billed charges,Implant Device,2170,35,,2170,percent of total billed charges,Implant Device,2170,35,,2170,percent of total billed charges,Implant Device,2170,35,,2170,percent of total billed charges,Implant Device,2170,35,,2170,percent of total billed charges,Implant Device,2170,35,,2170,percent of total billed charges,Implant Device,2480,40,,2480,percent of total billed charges,Implant Device,2170,70,,2170,percent of total billed charges,All Other,2108,34,,2108,percent of total billed charges,Implant Device,2108,34,,2108,percent of total billed charges,Implant Device,2170,35,,2170,percent of total billed charges,Implant Device,2170,35,,2170,percent of total billed charges,Implant Device,2170,35,,2170,percent of total billed charges,Implant Device,2170,35,,2170,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2108,34,"If Charge > 2,000, then 34 percent",2108,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4588.02,
IN2BONES S22 ST014 SNAP OFF SCREW 22X14,C1713,HCPCS,,79013277,CDM,278,RC,,,both,,,1275,943.5,,,943.5,Other,150% of Medicare + 9.63% HCRA Surcharge,573.75,45,,573.75,percent of total billed charges,Critical Access Hospital RCC factor,433.5,34,,433.5,percent of total billed charges,Implant Device,433.5,34,,433.5,percent of total billed charges,Implant Device,433.5,34,,433.5,percent of total billed charges,Implant Device,433.5,34,,433.5,percent of total billed charges,Implant Device,433.5,34,,433.5,percent of total billed charges,Implant Device,631.13,,,631.13,Other,110% of Medicare,446.25,35,,446.25,percent of total billed charges,Implant Device,433.5,34,"Charges > $500, x 34%",433.5,percent of total billed charges,Implant Device,446.25,35,,446.25,percent of total billed charges,Implant Device,446.25,35,,446.25,percent of total billed charges,Implant Device,446.25,35,,446.25,percent of total billed charges,Implant Device,446.25,35,,446.25,percent of total billed charges,Implant Device,446.25,35,,446.25,percent of total billed charges,Implant Device,510,40,,510,percent of total billed charges,Implant Device,446.25,70,,446.25,percent of total billed charges,All Other,433.5,34,,433.5,percent of total billed charges,Implant Device,433.5,34,,433.5,percent of total billed charges,Implant Device,446.25,35,,446.25,percent of total billed charges,Implant Device,446.25,35,,446.25,percent of total billed charges,Implant Device,446.25,35,,446.25,percent of total billed charges,Implant Device,446.25,35,,446.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,943.5,
STRYKER 626985 SLIM Y-PLATE 5 SHAFT HOLE,C1713,HCPCS,,79013278,CDM,278,RC,,,both,,,3516,2601.85,,,2601.85,Other,150% of Medicare + 9.63% HCRA Surcharge,1582.2,45,,1582.2,percent of total billed charges,Critical Access Hospital RCC factor,1195.44,34,,1195.44,percent of total billed charges,Implant Device,1195.44,34,,1195.44,percent of total billed charges,Implant Device,1195.44,34,,1195.44,percent of total billed charges,Implant Device,1195.44,34,,1195.44,percent of total billed charges,Implant Device,1195.44,34,,1195.44,percent of total billed charges,Implant Device,1740.42,,,1740.42,Other,110% of Medicare,1230.6,35,,1230.6,percent of total billed charges,Implant Device,1195.44,34,"Charges > $500, x 34%",1195.44,percent of total billed charges,Implant Device,1230.6,35,,1230.6,percent of total billed charges,Implant Device,1230.6,35,,1230.6,percent of total billed charges,Implant Device,1230.6,35,,1230.6,percent of total billed charges,Implant Device,1230.6,35,,1230.6,percent of total billed charges,Implant Device,1230.6,35,,1230.6,percent of total billed charges,Implant Device,1406.4,40,,1406.4,percent of total billed charges,Implant Device,1230.6,70,,1230.6,percent of total billed charges,All Other,1195.44,34,,1195.44,percent of total billed charges,Implant Device,1195.44,34,,1195.44,percent of total billed charges,Implant Device,1230.6,35,,1230.6,percent of total billed charges,Implant Device,1230.6,35,,1230.6,percent of total billed charges,Implant Device,1230.6,35,,1230.6,percent of total billed charges,Implant Device,1230.6,35,,1230.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1195.44,34,"If Charge > 2,000, then 34 percent",1195.44,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2601.85,
J&J 02.118.542 SELF TAP SCREW 2.7X42MM,C1713,HCPCS,,79013279,CDM,278,RC,,,both,,,125,92.5,,,92.5,Other,150% of Medicare + 9.63% HCRA Surcharge,56.25,45,,56.25,percent of total billed charges,Critical Access Hospital RCC factor,42.5,34,,42.5,percent of total billed charges,Implant Device,42.5,34,,42.5,percent of total billed charges,Implant Device,42.5,34,,42.5,percent of total billed charges,Implant Device,42.5,34,,42.5,percent of total billed charges,Implant Device,42.5,34,,42.5,percent of total billed charges,Implant Device,61.88,,,61.88,Other,110% of Medicare,43.75,35,,43.75,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,43.75,35,,43.75,percent of total billed charges,Implant Device,43.75,35,,43.75,percent of total billed charges,Implant Device,43.75,35,,43.75,percent of total billed charges,Implant Device,43.75,35,,43.75,percent of total billed charges,Implant Device,43.75,35,,43.75,percent of total billed charges,Implant Device,50,40,,50,percent of total billed charges,Implant Device,43.75,70,,43.75,percent of total billed charges,All Other,42.5,34,,42.5,percent of total billed charges,Implant Device,42.5,34,,42.5,percent of total billed charges,Implant Device,43.75,35,,43.75,percent of total billed charges,Implant Device,43.75,35,,43.75,percent of total billed charges,Implant Device,43.75,35,,43.75,percent of total billed charges,Implant Device,43.75,35,,43.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,92.5,
J&J 02.118.534 SELF TAP SCREW 2.7X34MM,C1713,HCPCS,,79013280,CDM,278,RC,,,both,,,125,92.5,,,92.5,Other,150% of Medicare + 9.63% HCRA Surcharge,56.25,45,,56.25,percent of total billed charges,Critical Access Hospital RCC factor,42.5,34,,42.5,percent of total billed charges,Implant Device,42.5,34,,42.5,percent of total billed charges,Implant Device,42.5,34,,42.5,percent of total billed charges,Implant Device,42.5,34,,42.5,percent of total billed charges,Implant Device,42.5,34,,42.5,percent of total billed charges,Implant Device,61.88,,,61.88,Other,110% of Medicare,43.75,35,,43.75,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,43.75,35,,43.75,percent of total billed charges,Implant Device,43.75,35,,43.75,percent of total billed charges,Implant Device,43.75,35,,43.75,percent of total billed charges,Implant Device,43.75,35,,43.75,percent of total billed charges,Implant Device,43.75,35,,43.75,percent of total billed charges,Implant Device,50,40,,50,percent of total billed charges,Implant Device,43.75,70,,43.75,percent of total billed charges,All Other,42.5,34,,42.5,percent of total billed charges,Implant Device,42.5,34,,42.5,percent of total billed charges,Implant Device,43.75,35,,43.75,percent of total billed charges,Implant Device,43.75,35,,43.75,percent of total billed charges,Implant Device,43.75,35,,43.75,percent of total billed charges,Implant Device,43.75,35,,43.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,92.5,
J&J 02.137.001S PATELLA PLT 2.78MM 3H,C1713,HCPCS,,79013282,CDM,278,RC,,,both,,,6252,4626.5,,,4626.5,Other,150% of Medicare + 9.63% HCRA Surcharge,2813.4,45,,2813.4,percent of total billed charges,Critical Access Hospital RCC factor,2125.68,34,,2125.68,percent of total billed charges,Implant Device,2125.68,34,,2125.68,percent of total billed charges,Implant Device,2125.68,34,,2125.68,percent of total billed charges,Implant Device,2125.68,34,,2125.68,percent of total billed charges,Implant Device,2125.68,34,,2125.68,percent of total billed charges,Implant Device,3094.74,,,3094.74,Other,110% of Medicare,2188.2,35,,2188.2,percent of total billed charges,Implant Device,2125.68,34,"Charges > $500, x 34%",2125.68,percent of total billed charges,Implant Device,2188.2,35,,2188.2,percent of total billed charges,Implant Device,2188.2,35,,2188.2,percent of total billed charges,Implant Device,2188.2,35,,2188.2,percent of total billed charges,Implant Device,2188.2,35,,2188.2,percent of total billed charges,Implant Device,2188.2,35,,2188.2,percent of total billed charges,Implant Device,2500.8,40,,2500.8,percent of total billed charges,Implant Device,2188.2,70,,2188.2,percent of total billed charges,All Other,2125.68,34,,2125.68,percent of total billed charges,Implant Device,2125.68,34,,2125.68,percent of total billed charges,Implant Device,2188.2,35,,2188.2,percent of total billed charges,Implant Device,2188.2,35,,2188.2,percent of total billed charges,Implant Device,2188.2,35,,2188.2,percent of total billed charges,Implant Device,2188.2,35,,2188.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2125.68,34,"If Charge > 2,000, then 34 percent",2125.68,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4626.5,
J&J 1010-12-040 FEMORAL STEM SIZE 4,C1776,HCPCS,,79013283,CDM,278,RC,,,both,,,7410,5483.42,,,5483.42,Other,150% of Medicare + 9.63% HCRA Surcharge,3334.5,45,,3334.5,percent of total billed charges,Critical Access Hospital RCC factor,2519.4,34,,2519.4,percent of total billed charges,Implant Device,2519.4,34,,2519.4,percent of total billed charges,Implant Device,2519.4,34,,2519.4,percent of total billed charges,Implant Device,2519.4,34,,2519.4,percent of total billed charges,Implant Device,2519.4,34,,2519.4,percent of total billed charges,Implant Device,3667.95,,,3667.95,Other,110% of Medicare,2593.5,35,,2593.5,percent of total billed charges,Implant Device,2519.4,34,"Charges > $500, x 34%",2519.4,percent of total billed charges,Implant Device,2593.5,35,,2593.5,percent of total billed charges,Implant Device,2593.5,35,,2593.5,percent of total billed charges,Implant Device,2593.5,35,,2593.5,percent of total billed charges,Implant Device,2593.5,35,,2593.5,percent of total billed charges,Implant Device,2593.5,35,,2593.5,percent of total billed charges,Implant Device,2964,40,,2964,percent of total billed charges,Implant Device,2593.5,70,,2593.5,percent of total billed charges,All Other,2519.4,34,,2519.4,percent of total billed charges,Implant Device,2519.4,34,,2519.4,percent of total billed charges,Implant Device,2593.5,35,,2593.5,percent of total billed charges,Implant Device,2593.5,35,,2593.5,percent of total billed charges,Implant Device,2593.5,35,,2593.5,percent of total billed charges,Implant Device,2593.5,35,,2593.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2519.4,34,"If Charge > 2,000, then 34 percent",2519.4,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5483.42,
J&J 1217-15-500 BONE SCREW 6.5X15MM,C1776,HCPCS,,79013284,CDM,278,RC,,,both,,,228,168.72,,,168.72,Other,150% of Medicare + 9.63% HCRA Surcharge,102.6,45,,102.6,percent of total billed charges,Critical Access Hospital RCC factor,77.52,34,,77.52,percent of total billed charges,Implant Device,77.52,34,,77.52,percent of total billed charges,Implant Device,77.52,34,,77.52,percent of total billed charges,Implant Device,77.52,34,,77.52,percent of total billed charges,Implant Device,77.52,34,,77.52,percent of total billed charges,Implant Device,112.86,,,112.86,Other,110% of Medicare,79.8,35,,79.8,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,79.8,35,,79.8,percent of total billed charges,Implant Device,79.8,35,,79.8,percent of total billed charges,Implant Device,79.8,35,,79.8,percent of total billed charges,Implant Device,79.8,35,,79.8,percent of total billed charges,Implant Device,79.8,35,,79.8,percent of total billed charges,Implant Device,91.2,40,,91.2,percent of total billed charges,Implant Device,79.8,70,,79.8,percent of total billed charges,All Other,77.52,34,,77.52,percent of total billed charges,Implant Device,77.52,34,,77.52,percent of total billed charges,Implant Device,79.8,35,,79.8,percent of total billed charges,Implant Device,79.8,35,,79.8,percent of total billed charges,Implant Device,79.8,35,,79.8,percent of total billed charges,Implant Device,79.8,35,,79.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,168.72,
J&J 1975-20-075 CONICAL PROX BODY 20X75,C1713,HCPCS,,79013285,CDM,278,RC,,,both,,,19322,14298.33,,,14298.33,Other,150% of Medicare + 9.63% HCRA Surcharge,8694.9,45,,8694.9,percent of total billed charges,Critical Access Hospital RCC factor,6569.48,34,,6569.48,percent of total billed charges,Implant Device,6569.48,34,,6569.48,percent of total billed charges,Implant Device,6569.48,34,,6569.48,percent of total billed charges,Implant Device,6569.48,34,,6569.48,percent of total billed charges,Implant Device,6569.48,34,,6569.48,percent of total billed charges,Implant Device,9564.39,,,9564.39,Other,110% of Medicare,6762.7,35,,6762.7,percent of total billed charges,Implant Device,6569.48,34,"Charges > $500, x 34%",6569.48,percent of total billed charges,Implant Device,6762.7,35,,6762.7,percent of total billed charges,Implant Device,6762.7,35,,6762.7,percent of total billed charges,Implant Device,6762.7,35,,6762.7,percent of total billed charges,Implant Device,6762.7,35,,6762.7,percent of total billed charges,Implant Device,6762.7,35,,6762.7,percent of total billed charges,Implant Device,7728.8,40,,7728.8,percent of total billed charges,Implant Device,6762.7,70,,6762.7,percent of total billed charges,All Other,6569.48,34,,6569.48,percent of total billed charges,Implant Device,6569.48,34,,6569.48,percent of total billed charges,Implant Device,6762.7,35,,6762.7,percent of total billed charges,Implant Device,6762.7,35,,6762.7,percent of total billed charges,Implant Device,6762.7,35,,6762.7,percent of total billed charges,Implant Device,6762.7,35,,6762.7,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,6569.48,34,"If Charge > 2,000, then 34 percent",6569.48,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,14298.33,
J&J 1976-16-190 DIS TAPERED STEM 16X190,C1776,HCPCS,,79013286,CDM,278,RC,,,both,,,16454,12176,,,12176,Other,150% of Medicare + 9.63% HCRA Surcharge,7404.3,45,,7404.3,percent of total billed charges,Critical Access Hospital RCC factor,5594.36,34,,5594.36,percent of total billed charges,Implant Device,5594.36,34,,5594.36,percent of total billed charges,Implant Device,5594.36,34,,5594.36,percent of total billed charges,Implant Device,5594.36,34,,5594.36,percent of total billed charges,Implant Device,5594.36,34,,5594.36,percent of total billed charges,Implant Device,8144.73,,,8144.73,Other,110% of Medicare,5758.9,35,,5758.9,percent of total billed charges,Implant Device,5594.36,34,"Charges > $500, x 34%",5594.36,percent of total billed charges,Implant Device,5758.9,35,,5758.9,percent of total billed charges,Implant Device,5758.9,35,,5758.9,percent of total billed charges,Implant Device,5758.9,35,,5758.9,percent of total billed charges,Implant Device,5758.9,35,,5758.9,percent of total billed charges,Implant Device,5758.9,35,,5758.9,percent of total billed charges,Implant Device,6581.6,40,,6581.6,percent of total billed charges,Implant Device,5758.9,70,,5758.9,percent of total billed charges,All Other,5594.36,34,,5594.36,percent of total billed charges,Implant Device,5594.36,34,,5594.36,percent of total billed charges,Implant Device,5758.9,35,,5758.9,percent of total billed charges,Implant Device,5758.9,35,,5758.9,percent of total billed charges,Implant Device,5758.9,35,,5758.9,percent of total billed charges,Implant Device,5758.9,35,,5758.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,5594.36,34,"If Charge > 2,000, then 34 percent",5594.36,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,12176,
STRYKER 663818 BONE SCREW 2.3X18MM,C1713,HCPCS,,79013287,CDM,278,RC,,,both,,,324,239.76,,,239.76,Other,150% of Medicare + 9.63% HCRA Surcharge,145.8,45,,145.8,percent of total billed charges,Critical Access Hospital RCC factor,110.16,34,,110.16,percent of total billed charges,Implant Device,110.16,34,,110.16,percent of total billed charges,Implant Device,110.16,34,,110.16,percent of total billed charges,Implant Device,110.16,34,,110.16,percent of total billed charges,Implant Device,110.16,34,,110.16,percent of total billed charges,Implant Device,160.38,,,160.38,Other,110% of Medicare,113.4,35,,113.4,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,129.6,40,,129.6,percent of total billed charges,Implant Device,113.4,70,,113.4,percent of total billed charges,All Other,110.16,34,,110.16,percent of total billed charges,Implant Device,110.16,34,,110.16,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,239.76,
ZIMMER 115398 CENTRAL SCREW 6.5X40MM,C1713,HCPCS,,79013288,CDM,278,RC,,,both,,,211,156.14,,,156.14,Other,150% of Medicare + 9.63% HCRA Surcharge,94.95,45,,94.95,percent of total billed charges,Critical Access Hospital RCC factor,71.74,34,,71.74,percent of total billed charges,Implant Device,71.74,34,,71.74,percent of total billed charges,Implant Device,71.74,34,,71.74,percent of total billed charges,Implant Device,71.74,34,,71.74,percent of total billed charges,Implant Device,71.74,34,,71.74,percent of total billed charges,Implant Device,104.45,,,104.45,Other,110% of Medicare,73.85,35,,73.85,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,73.85,35,,73.85,percent of total billed charges,Implant Device,73.85,35,,73.85,percent of total billed charges,Implant Device,73.85,35,,73.85,percent of total billed charges,Implant Device,73.85,35,,73.85,percent of total billed charges,Implant Device,73.85,35,,73.85,percent of total billed charges,Implant Device,84.4,40,,84.4,percent of total billed charges,Implant Device,73.85,70,,73.85,percent of total billed charges,All Other,71.74,34,,71.74,percent of total billed charges,Implant Device,71.74,34,,71.74,percent of total billed charges,Implant Device,73.85,35,,73.85,percent of total billed charges,Implant Device,73.85,35,,73.85,percent of total billed charges,Implant Device,73.85,35,,73.85,percent of total billed charges,Implant Device,73.85,35,,73.85,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,156.14,
ZIMMER 115310 GLENOSPHERE 36MM,C1776,HCPCS,,79013289,CDM,278,RC,,,both,,,3300,2442.01,,,2442.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1485,45,,1485,percent of total billed charges,Critical Access Hospital RCC factor,1122,34,,1122,percent of total billed charges,Implant Device,1122,34,,1122,percent of total billed charges,Implant Device,1122,34,,1122,percent of total billed charges,Implant Device,1122,34,,1122,percent of total billed charges,Implant Device,1122,34,,1122,percent of total billed charges,Implant Device,1633.5,,,1633.5,Other,110% of Medicare,1155,35,,1155,percent of total billed charges,Implant Device,1122,34,"Charges > $500, x 34%",1122,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,1320,40,,1320,percent of total billed charges,Implant Device,1155,70,,1155,percent of total billed charges,All Other,1122,34,,1122,percent of total billed charges,Implant Device,1122,34,,1122,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1122,34,"If Charge > 2,000, then 34 percent",1122,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2442.01,
ZIMMER 110031403 MINI HUMERAL TRAY 40MM,C1776,HCPCS,,79013290,CDM,278,RC,,,both,,,4416,3267.85,,,3267.85,Other,150% of Medicare + 9.63% HCRA Surcharge,1987.2,45,,1987.2,percent of total billed charges,Critical Access Hospital RCC factor,1501.44,34,,1501.44,percent of total billed charges,Implant Device,1501.44,34,,1501.44,percent of total billed charges,Implant Device,1501.44,34,,1501.44,percent of total billed charges,Implant Device,1501.44,34,,1501.44,percent of total billed charges,Implant Device,1501.44,34,,1501.44,percent of total billed charges,Implant Device,2185.92,,,2185.92,Other,110% of Medicare,1545.6,35,,1545.6,percent of total billed charges,Implant Device,1501.44,34,"Charges > $500, x 34%",1501.44,percent of total billed charges,Implant Device,1545.6,35,,1545.6,percent of total billed charges,Implant Device,1545.6,35,,1545.6,percent of total billed charges,Implant Device,1545.6,35,,1545.6,percent of total billed charges,Implant Device,1545.6,35,,1545.6,percent of total billed charges,Implant Device,1545.6,35,,1545.6,percent of total billed charges,Implant Device,1766.4,40,,1766.4,percent of total billed charges,Implant Device,1545.6,70,,1545.6,percent of total billed charges,All Other,1501.44,34,,1501.44,percent of total billed charges,Implant Device,1501.44,34,,1501.44,percent of total billed charges,Implant Device,1545.6,35,,1545.6,percent of total billed charges,Implant Device,1545.6,35,,1545.6,percent of total billed charges,Implant Device,1545.6,35,,1545.6,percent of total billed charges,Implant Device,1545.6,35,,1545.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1501.44,34,"If Charge > 2,000, then 34 percent",1501.44,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3267.85,
J&J 02.221.088 PROX FEMUR PLT 4.5MM 8H,C1713,HCPCS,,79013291,CDM,278,RC,,,both,,,8692,6432.1,,,6432.1,Other,150% of Medicare + 9.63% HCRA Surcharge,3911.4,45,,3911.4,percent of total billed charges,Critical Access Hospital RCC factor,2955.28,34,,2955.28,percent of total billed charges,Implant Device,2955.28,34,,2955.28,percent of total billed charges,Implant Device,2955.28,34,,2955.28,percent of total billed charges,Implant Device,2955.28,34,,2955.28,percent of total billed charges,Implant Device,2955.28,34,,2955.28,percent of total billed charges,Implant Device,4302.54,,,4302.54,Other,110% of Medicare,3042.2,35,,3042.2,percent of total billed charges,Implant Device,2955.28,34,"Charges > $500, x 34%",2955.28,percent of total billed charges,Implant Device,3042.2,35,,3042.2,percent of total billed charges,Implant Device,3042.2,35,,3042.2,percent of total billed charges,Implant Device,3042.2,35,,3042.2,percent of total billed charges,Implant Device,3042.2,35,,3042.2,percent of total billed charges,Implant Device,3042.2,35,,3042.2,percent of total billed charges,Implant Device,3476.8,40,,3476.8,percent of total billed charges,Implant Device,3042.2,70,,3042.2,percent of total billed charges,All Other,2955.28,34,,2955.28,percent of total billed charges,Implant Device,2955.28,34,,2955.28,percent of total billed charges,Implant Device,3042.2,35,,3042.2,percent of total billed charges,Implant Device,3042.2,35,,3042.2,percent of total billed charges,Implant Device,3042.2,35,,3042.2,percent of total billed charges,Implant Device,3042.2,35,,3042.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2955.28,34,"If Charge > 2,000, then 34 percent",2955.28,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,6432.1,
J&J 02.127.116 LOCK SCREW 3.5X16MM,C1713,HCPCS,,79013292,CDM,278,RC,,,both,,,414,306.36,,,306.36,Other,150% of Medicare + 9.63% HCRA Surcharge,186.3,45,,186.3,percent of total billed charges,Critical Access Hospital RCC factor,140.76,34,,140.76,percent of total billed charges,Implant Device,140.76,34,,140.76,percent of total billed charges,Implant Device,140.76,34,,140.76,percent of total billed charges,Implant Device,140.76,34,,140.76,percent of total billed charges,Implant Device,140.76,34,,140.76,percent of total billed charges,Implant Device,204.93,,,204.93,Other,110% of Medicare,144.9,35,,144.9,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,144.9,35,,144.9,percent of total billed charges,Implant Device,144.9,35,,144.9,percent of total billed charges,Implant Device,144.9,35,,144.9,percent of total billed charges,Implant Device,144.9,35,,144.9,percent of total billed charges,Implant Device,144.9,35,,144.9,percent of total billed charges,Implant Device,165.6,40,,165.6,percent of total billed charges,Implant Device,144.9,70,,144.9,percent of total billed charges,All Other,140.76,34,,140.76,percent of total billed charges,Implant Device,140.76,34,,140.76,percent of total billed charges,Implant Device,144.9,35,,144.9,percent of total billed charges,Implant Device,144.9,35,,144.9,percent of total billed charges,Implant Device,144.9,35,,144.9,percent of total billed charges,Implant Device,144.9,35,,144.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,306.36,
J&J 136532710 FEMORAL HEAD 32MM,C1713,HCPCS,,79013293,CDM,278,RC,,,both,,,10476,7752.27,,,7752.27,Other,150% of Medicare + 9.63% HCRA Surcharge,4714.2,45,,4714.2,percent of total billed charges,Critical Access Hospital RCC factor,3561.84,34,,3561.84,percent of total billed charges,Implant Device,3561.84,34,,3561.84,percent of total billed charges,Implant Device,3561.84,34,,3561.84,percent of total billed charges,Implant Device,3561.84,34,,3561.84,percent of total billed charges,Implant Device,3561.84,34,,3561.84,percent of total billed charges,Implant Device,5185.62,,,5185.62,Other,110% of Medicare,3666.6,35,,3666.6,percent of total billed charges,Implant Device,3561.84,34,"Charges > $500, x 34%",3561.84,percent of total billed charges,Implant Device,3666.6,35,,3666.6,percent of total billed charges,Implant Device,3666.6,35,,3666.6,percent of total billed charges,Implant Device,3666.6,35,,3666.6,percent of total billed charges,Implant Device,3666.6,35,,3666.6,percent of total billed charges,Implant Device,3666.6,35,,3666.6,percent of total billed charges,Implant Device,4190.4,40,,4190.4,percent of total billed charges,Implant Device,3666.6,70,,3666.6,percent of total billed charges,All Other,3561.84,34,,3561.84,percent of total billed charges,Implant Device,3561.84,34,,3561.84,percent of total billed charges,Implant Device,3666.6,35,,3666.6,percent of total billed charges,Implant Device,3666.6,35,,3666.6,percent of total billed charges,Implant Device,3666.6,35,,3666.6,percent of total billed charges,Implant Device,3666.6,35,,3666.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3561.84,34,"If Charge > 2,000, then 34 percent",3561.84,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,7752.27,
J&J 1506-11-003 TIBIAL BASE SIZE 3,C1776,HCPCS,,79013294,CDM,278,RC,,,both,,,6300,4662.02,,,4662.02,Other,150% of Medicare + 9.63% HCRA Surcharge,2835,45,,2835,percent of total billed charges,Critical Access Hospital RCC factor,2142,34,,2142,percent of total billed charges,Implant Device,2142,34,,2142,percent of total billed charges,Implant Device,2142,34,,2142,percent of total billed charges,Implant Device,2142,34,,2142,percent of total billed charges,Implant Device,2142,34,,2142,percent of total billed charges,Implant Device,3118.5,,,3118.5,Other,110% of Medicare,2205,35,,2205,percent of total billed charges,Implant Device,2142,34,"Charges > $500, x 34%",2142,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2520,40,,2520,percent of total billed charges,Implant Device,2205,70,,2205,percent of total billed charges,All Other,2142,34,,2142,percent of total billed charges,Implant Device,2142,34,,2142,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2142,34,"If Charge > 2,000, then 34 percent",2142,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4662.02,
J&J 1504-11-224 FEM COMP SIZE 4N RIGHT,C1776,HCPCS,,79013295,CDM,278,RC,,,both,,,6000,4440.02,,,4440.02,Other,150% of Medicare + 9.63% HCRA Surcharge,2700,45,,2700,percent of total billed charges,Critical Access Hospital RCC factor,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2970,,,2970,Other,110% of Medicare,2100,35,,2100,percent of total billed charges,Implant Device,2040,34,"Charges > $500, x 34%",2040,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2400,40,,2400,percent of total billed charges,Implant Device,2100,70,,2100,percent of total billed charges,All Other,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2040,34,"If Charge > 2,000, then 34 percent",2040,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4440.02,
J&J 1516-50-405 TIBIAL INSERT 5MM SZ 4,C1776,HCPCS,,79013296,CDM,278,RC,,,both,,,5400,3996.01,,,3996.01,Other,150% of Medicare + 9.63% HCRA Surcharge,2430,45,,2430,percent of total billed charges,Critical Access Hospital RCC factor,1836,34,,1836,percent of total billed charges,Implant Device,1836,34,,1836,percent of total billed charges,Implant Device,1836,34,,1836,percent of total billed charges,Implant Device,1836,34,,1836,percent of total billed charges,Implant Device,1836,34,,1836,percent of total billed charges,Implant Device,2673,,,2673,Other,110% of Medicare,1890,35,,1890,percent of total billed charges,Implant Device,1836,34,"Charges > $500, x 34%",1836,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,2160,40,,2160,percent of total billed charges,Implant Device,1890,70,,1890,percent of total billed charges,All Other,1836,34,,1836,percent of total billed charges,Implant Device,1836,34,,1836,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1836,34,"If Charge > 2,000, then 34 percent",1836,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3996.01,
EXACTECH 300-30-13 HUMERAL STEM 13MM,C1776,HCPCS,,79013298,CDM,278,RC,,,both,,,6000,4440.02,,,4440.02,Other,150% of Medicare + 9.63% HCRA Surcharge,2700,45,,2700,percent of total billed charges,Critical Access Hospital RCC factor,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2970,,,2970,Other,110% of Medicare,2100,35,,2100,percent of total billed charges,Implant Device,2040,34,"Charges > $500, x 34%",2040,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2400,40,,2400,percent of total billed charges,Implant Device,2100,70,,2100,percent of total billed charges,All Other,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2040,34,"If Charge > 2,000, then 34 percent",2040,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4440.02,
J&J 101011080 FEMORAL STEM SIZE 8,C1776,HCPCS,,79013299,CDM,278,RC,,,both,,,7410,5483.42,,,5483.42,Other,150% of Medicare + 9.63% HCRA Surcharge,3334.5,45,,3334.5,percent of total billed charges,Critical Access Hospital RCC factor,2519.4,34,,2519.4,percent of total billed charges,Implant Device,2519.4,34,,2519.4,percent of total billed charges,Implant Device,2519.4,34,,2519.4,percent of total billed charges,Implant Device,2519.4,34,,2519.4,percent of total billed charges,Implant Device,2519.4,34,,2519.4,percent of total billed charges,Implant Device,3667.95,,,3667.95,Other,110% of Medicare,2593.5,35,,2593.5,percent of total billed charges,Implant Device,2519.4,34,"Charges > $500, x 34%",2519.4,percent of total billed charges,Implant Device,2593.5,35,,2593.5,percent of total billed charges,Implant Device,2593.5,35,,2593.5,percent of total billed charges,Implant Device,2593.5,35,,2593.5,percent of total billed charges,Implant Device,2593.5,35,,2593.5,percent of total billed charges,Implant Device,2593.5,35,,2593.5,percent of total billed charges,Implant Device,2964,40,,2964,percent of total billed charges,Implant Device,2593.5,70,,2593.5,percent of total billed charges,All Other,2519.4,34,,2519.4,percent of total billed charges,Implant Device,2519.4,34,,2519.4,percent of total billed charges,Implant Device,2593.5,35,,2593.5,percent of total billed charges,Implant Device,2593.5,35,,2593.5,percent of total billed charges,Implant Device,2593.5,35,,2593.5,percent of total billed charges,Implant Device,2593.5,35,,2593.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2519.4,34,"If Charge > 2,000, then 34 percent",2519.4,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5483.42,
J&J 1365-28-310 CERAMIC FEM HEAD 28MM,C1713,HCPCS,,79013300,CDM,278,RC,,,both,,,1766,1306.84,,,1306.84,Other,150% of Medicare + 9.63% HCRA Surcharge,794.7,45,,794.7,percent of total billed charges,Critical Access Hospital RCC factor,600.44,34,,600.44,percent of total billed charges,Implant Device,600.44,34,,600.44,percent of total billed charges,Implant Device,600.44,34,,600.44,percent of total billed charges,Implant Device,600.44,34,,600.44,percent of total billed charges,Implant Device,600.44,34,,600.44,percent of total billed charges,Implant Device,874.17,,,874.17,Other,110% of Medicare,618.1,35,,618.1,percent of total billed charges,Implant Device,600.44,34,"Charges > $500, x 34%",600.44,percent of total billed charges,Implant Device,618.1,35,,618.1,percent of total billed charges,Implant Device,618.1,35,,618.1,percent of total billed charges,Implant Device,618.1,35,,618.1,percent of total billed charges,Implant Device,618.1,35,,618.1,percent of total billed charges,Implant Device,618.1,35,,618.1,percent of total billed charges,Implant Device,706.4,40,,706.4,percent of total billed charges,Implant Device,618.1,70,,618.1,percent of total billed charges,All Other,600.44,34,,600.44,percent of total billed charges,Implant Device,600.44,34,,600.44,percent of total billed charges,Implant Device,618.1,35,,618.1,percent of total billed charges,Implant Device,618.1,35,,618.1,percent of total billed charges,Implant Device,618.1,35,,618.1,percent of total billed charges,Implant Device,618.1,35,,618.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1306.84,
J&J 76000110 FIBERGRAFT BG PUTTY 11CC,C1713,HCPCS,,79013316,CDM,278,RC,,,both,,,18105,13397.75,,,13397.75,Other,150% of Medicare + 9.63% HCRA Surcharge,8147.25,45,,8147.25,percent of total billed charges,Critical Access Hospital RCC factor,6155.7,34,,6155.7,percent of total billed charges,Implant Device,6155.7,34,,6155.7,percent of total billed charges,Implant Device,6155.7,34,,6155.7,percent of total billed charges,Implant Device,6155.7,34,,6155.7,percent of total billed charges,Implant Device,6155.7,34,,6155.7,percent of total billed charges,Implant Device,8961.98,,,8961.98,Other,110% of Medicare,6336.75,35,,6336.75,percent of total billed charges,Implant Device,6155.7,34,"Charges > $500, x 34%",6155.7,percent of total billed charges,Implant Device,6336.75,35,,6336.75,percent of total billed charges,Implant Device,6336.75,35,,6336.75,percent of total billed charges,Implant Device,6336.75,35,,6336.75,percent of total billed charges,Implant Device,6336.75,35,,6336.75,percent of total billed charges,Implant Device,6336.75,35,,6336.75,percent of total billed charges,Implant Device,7242,40,,7242,percent of total billed charges,Implant Device,6336.75,70,,6336.75,percent of total billed charges,All Other,6155.7,34,,6155.7,percent of total billed charges,Implant Device,6155.7,34,,6155.7,percent of total billed charges,Implant Device,6336.75,35,,6336.75,percent of total billed charges,Implant Device,6336.75,35,,6336.75,percent of total billed charges,Implant Device,6336.75,35,,6336.75,percent of total billed charges,Implant Device,6336.75,35,,6336.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,6155.7,34,"If Charge > 2,000, then 34 percent",6155.7,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,13397.75,
STRYKER 608065 CANCELLOUS SCREW 6.0X65MM,C1713,HCPCS,,79013317,CDM,278,RC,,,both,,,168,124.32,,,124.32,Other,150% of Medicare + 9.63% HCRA Surcharge,75.6,45,,75.6,percent of total billed charges,Critical Access Hospital RCC factor,57.12,34,,57.12,percent of total billed charges,Implant Device,57.12,34,,57.12,percent of total billed charges,Implant Device,57.12,34,,57.12,percent of total billed charges,Implant Device,57.12,34,,57.12,percent of total billed charges,Implant Device,57.12,34,,57.12,percent of total billed charges,Implant Device,83.16,,,83.16,Other,110% of Medicare,58.8,35,,58.8,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,58.8,35,,58.8,percent of total billed charges,Implant Device,58.8,35,,58.8,percent of total billed charges,Implant Device,58.8,35,,58.8,percent of total billed charges,Implant Device,58.8,35,,58.8,percent of total billed charges,Implant Device,58.8,35,,58.8,percent of total billed charges,Implant Device,67.2,40,,67.2,percent of total billed charges,Implant Device,58.8,70,,58.8,percent of total billed charges,All Other,57.12,34,,57.12,percent of total billed charges,Implant Device,57.12,34,,57.12,percent of total billed charges,Implant Device,58.8,35,,58.8,percent of total billed charges,Implant Device,58.8,35,,58.8,percent of total billed charges,Implant Device,58.8,35,,58.8,percent of total billed charges,Implant Device,58.8,35,,58.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,124.32,
STRYKER 627640 DIS LAT FEMUR PLT 10H 238,C1713,HCPCS,,79013318,CDM,278,RC,,,both,,,8271,6120.56,,,6120.56,Other,150% of Medicare + 9.63% HCRA Surcharge,3721.95,45,,3721.95,percent of total billed charges,Critical Access Hospital RCC factor,2812.14,34,,2812.14,percent of total billed charges,Implant Device,2812.14,34,,2812.14,percent of total billed charges,Implant Device,2812.14,34,,2812.14,percent of total billed charges,Implant Device,2812.14,34,,2812.14,percent of total billed charges,Implant Device,2812.14,34,,2812.14,percent of total billed charges,Implant Device,4094.15,,,4094.15,Other,110% of Medicare,2894.85,35,,2894.85,percent of total billed charges,Implant Device,2812.14,34,"Charges > $500, x 34%",2812.14,percent of total billed charges,Implant Device,2894.85,35,,2894.85,percent of total billed charges,Implant Device,2894.85,35,,2894.85,percent of total billed charges,Implant Device,2894.85,35,,2894.85,percent of total billed charges,Implant Device,2894.85,35,,2894.85,percent of total billed charges,Implant Device,2894.85,35,,2894.85,percent of total billed charges,Implant Device,3308.4,40,,3308.4,percent of total billed charges,Implant Device,2894.85,70,,2894.85,percent of total billed charges,All Other,2812.14,34,,2812.14,percent of total billed charges,Implant Device,2812.14,34,,2812.14,percent of total billed charges,Implant Device,2894.85,35,,2894.85,percent of total billed charges,Implant Device,2894.85,35,,2894.85,percent of total billed charges,Implant Device,2894.85,35,,2894.85,percent of total billed charges,Implant Device,2894.85,35,,2894.85,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2812.14,34,"If Charge > 2,000, then 34 percent",2812.14,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,6120.56,
STRYKER 661128 LOCKING SCREW 5.0X28MM,C1713,HCPCS,,79013319,CDM,278,RC,,,both,,,664,491.36,,,491.36,Other,150% of Medicare + 9.63% HCRA Surcharge,298.8,45,,298.8,percent of total billed charges,Critical Access Hospital RCC factor,225.76,34,,225.76,percent of total billed charges,Implant Device,225.76,34,,225.76,percent of total billed charges,Implant Device,225.76,34,,225.76,percent of total billed charges,Implant Device,225.76,34,,225.76,percent of total billed charges,Implant Device,225.76,34,,225.76,percent of total billed charges,Implant Device,328.68,,,328.68,Other,110% of Medicare,232.4,35,,232.4,percent of total billed charges,Implant Device,225.76,34,"Charges > $500, x 34%",225.76,percent of total billed charges,Implant Device,232.4,35,,232.4,percent of total billed charges,Implant Device,232.4,35,,232.4,percent of total billed charges,Implant Device,232.4,35,,232.4,percent of total billed charges,Implant Device,232.4,35,,232.4,percent of total billed charges,Implant Device,232.4,35,,232.4,percent of total billed charges,Implant Device,265.6,40,,265.6,percent of total billed charges,Implant Device,232.4,70,,232.4,percent of total billed charges,All Other,225.76,34,,225.76,percent of total billed charges,Implant Device,225.76,34,,225.76,percent of total billed charges,Implant Device,232.4,35,,232.4,percent of total billed charges,Implant Device,232.4,35,,232.4,percent of total billed charges,Implant Device,232.4,35,,232.4,percent of total billed charges,Implant Device,232.4,35,,232.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,491.36,
STRYKER 5571-S-3204-E HUM INSERT 32X4MM,C1776,HCPCS,,79013320,CDM,278,RC,,,both,,,3525,2608.51,,,2608.51,Other,150% of Medicare + 9.63% HCRA Surcharge,1586.25,45,,1586.25,percent of total billed charges,Critical Access Hospital RCC factor,1198.5,34,,1198.5,percent of total billed charges,Implant Device,1198.5,34,,1198.5,percent of total billed charges,Implant Device,1198.5,34,,1198.5,percent of total billed charges,Implant Device,1198.5,34,,1198.5,percent of total billed charges,Implant Device,1198.5,34,,1198.5,percent of total billed charges,Implant Device,1744.88,,,1744.88,Other,110% of Medicare,1233.75,35,,1233.75,percent of total billed charges,Implant Device,1198.5,34,"Charges > $500, x 34%",1198.5,percent of total billed charges,Implant Device,1233.75,35,,1233.75,percent of total billed charges,Implant Device,1233.75,35,,1233.75,percent of total billed charges,Implant Device,1233.75,35,,1233.75,percent of total billed charges,Implant Device,1233.75,35,,1233.75,percent of total billed charges,Implant Device,1233.75,35,,1233.75,percent of total billed charges,Implant Device,1410,40,,1410,percent of total billed charges,Implant Device,1233.75,70,,1233.75,percent of total billed charges,All Other,1198.5,34,,1198.5,percent of total billed charges,Implant Device,1198.5,34,,1198.5,percent of total billed charges,Implant Device,1233.75,35,,1233.75,percent of total billed charges,Implant Device,1233.75,35,,1233.75,percent of total billed charges,Implant Device,1233.75,35,,1233.75,percent of total billed charges,Implant Device,1233.75,35,,1233.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1198.5,34,"If Charge > 2,000, then 34 percent",1198.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2608.51,
J&J 1504-00-108 ATTUNE FEMORAL LT SIZE 8,C1776,HCPCS,,79013321,CDM,278,RC,,,both,,,4800,3552.01,,,3552.01,Other,150% of Medicare + 9.63% HCRA Surcharge,2160,45,,2160,percent of total billed charges,Critical Access Hospital RCC factor,1632,34,,1632,percent of total billed charges,Implant Device,1632,34,,1632,percent of total billed charges,Implant Device,1632,34,,1632,percent of total billed charges,Implant Device,1632,34,,1632,percent of total billed charges,Implant Device,1632,34,,1632,percent of total billed charges,Implant Device,2376,,,2376,Other,110% of Medicare,1680,35,,1680,percent of total billed charges,Implant Device,1632,34,"Charges > $500, x 34%",1632,percent of total billed charges,Implant Device,1680,35,,1680,percent of total billed charges,Implant Device,1680,35,,1680,percent of total billed charges,Implant Device,1680,35,,1680,percent of total billed charges,Implant Device,1680,35,,1680,percent of total billed charges,Implant Device,1680,35,,1680,percent of total billed charges,Implant Device,1920,40,,1920,percent of total billed charges,Implant Device,1680,70,,1680,percent of total billed charges,All Other,1632,34,,1632,percent of total billed charges,Implant Device,1632,34,,1632,percent of total billed charges,Implant Device,1680,35,,1680,percent of total billed charges,Implant Device,1680,35,,1680,percent of total billed charges,Implant Device,1680,35,,1680,percent of total billed charges,Implant Device,1680,35,,1680,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1632,34,"If Charge > 2,000, then 34 percent",1632,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3552.01,
J&J 1516-30-806 TIBIAL INSERT SIZE 8 6MM,C1776,HCPCS,,79013322,CDM,278,RC,,,both,,,5400,3996.01,,,3996.01,Other,150% of Medicare + 9.63% HCRA Surcharge,2430,45,,2430,percent of total billed charges,Critical Access Hospital RCC factor,1836,34,,1836,percent of total billed charges,Implant Device,1836,34,,1836,percent of total billed charges,Implant Device,1836,34,,1836,percent of total billed charges,Implant Device,1836,34,,1836,percent of total billed charges,Implant Device,1836,34,,1836,percent of total billed charges,Implant Device,2673,,,2673,Other,110% of Medicare,1890,35,,1890,percent of total billed charges,Implant Device,1836,34,"Charges > $500, x 34%",1836,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,2160,40,,2160,percent of total billed charges,Implant Device,1890,70,,1890,percent of total billed charges,All Other,1836,34,,1836,percent of total billed charges,Implant Device,1836,34,,1836,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1836,34,"If Charge > 2,000, then 34 percent",1836,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3996.01,
J&J 201.691 CORTEX SCREW 2.4X42MM,C1713,HCPCS,,79013324,CDM,278,RC,,,both,,,153,113.22,,,113.22,Other,150% of Medicare + 9.63% HCRA Surcharge,68.85,45,,68.85,percent of total billed charges,Critical Access Hospital RCC factor,52.02,34,,52.02,percent of total billed charges,Implant Device,52.02,34,,52.02,percent of total billed charges,Implant Device,52.02,34,,52.02,percent of total billed charges,Implant Device,52.02,34,,52.02,percent of total billed charges,Implant Device,52.02,34,,52.02,percent of total billed charges,Implant Device,75.74,,,75.74,Other,110% of Medicare,53.55,35,,53.55,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,53.55,35,,53.55,percent of total billed charges,Implant Device,53.55,35,,53.55,percent of total billed charges,Implant Device,53.55,35,,53.55,percent of total billed charges,Implant Device,53.55,35,,53.55,percent of total billed charges,Implant Device,53.55,35,,53.55,percent of total billed charges,Implant Device,61.2,40,,61.2,percent of total billed charges,Implant Device,53.55,70,,53.55,percent of total billed charges,All Other,52.02,34,,52.02,percent of total billed charges,Implant Device,52.02,34,,52.02,percent of total billed charges,Implant Device,53.55,35,,53.55,percent of total billed charges,Implant Device,53.55,35,,53.55,percent of total billed charges,Implant Device,53.55,35,,53.55,percent of total billed charges,Implant Device,53.55,35,,53.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,113.22,
J&J 02.123.042 PROX HUMERUS PLT 5H 145MM,C1713,HCPCS,,79013325,CDM,278,RC,,,both,,,4148,3069.53,,,3069.53,Other,150% of Medicare + 9.63% HCRA Surcharge,1866.6,45,,1866.6,percent of total billed charges,Critical Access Hospital RCC factor,1410.32,34,,1410.32,percent of total billed charges,Implant Device,1410.32,34,,1410.32,percent of total billed charges,Implant Device,1410.32,34,,1410.32,percent of total billed charges,Implant Device,1410.32,34,,1410.32,percent of total billed charges,Implant Device,1410.32,34,,1410.32,percent of total billed charges,Implant Device,2053.26,,,2053.26,Other,110% of Medicare,1451.8,35,,1451.8,percent of total billed charges,Implant Device,1410.32,34,"Charges > $500, x 34%",1410.32,percent of total billed charges,Implant Device,1451.8,35,,1451.8,percent of total billed charges,Implant Device,1451.8,35,,1451.8,percent of total billed charges,Implant Device,1451.8,35,,1451.8,percent of total billed charges,Implant Device,1451.8,35,,1451.8,percent of total billed charges,Implant Device,1451.8,35,,1451.8,percent of total billed charges,Implant Device,1659.2,40,,1659.2,percent of total billed charges,Implant Device,1451.8,70,,1451.8,percent of total billed charges,All Other,1410.32,34,,1410.32,percent of total billed charges,Implant Device,1410.32,34,,1410.32,percent of total billed charges,Implant Device,1451.8,35,,1451.8,percent of total billed charges,Implant Device,1451.8,35,,1451.8,percent of total billed charges,Implant Device,1451.8,35,,1451.8,percent of total billed charges,Implant Device,1451.8,35,,1451.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1410.32,34,"If Charge > 2,000, then 34 percent",1410.32,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3069.53,
STRYKER 2341-1128S TIBIAL NAIL 11X285MM,C1713,HCPCS,,79013326,CDM,278,RC,,,both,,,4792,3546.09,,,3546.09,Other,150% of Medicare + 9.63% HCRA Surcharge,2156.4,45,,2156.4,percent of total billed charges,Critical Access Hospital RCC factor,1629.28,34,,1629.28,percent of total billed charges,Implant Device,1629.28,34,,1629.28,percent of total billed charges,Implant Device,1629.28,34,,1629.28,percent of total billed charges,Implant Device,1629.28,34,,1629.28,percent of total billed charges,Implant Device,1629.28,34,,1629.28,percent of total billed charges,Implant Device,2372.04,,,2372.04,Other,110% of Medicare,1677.2,35,,1677.2,percent of total billed charges,Implant Device,1629.28,34,"Charges > $500, x 34%",1629.28,percent of total billed charges,Implant Device,1677.2,35,,1677.2,percent of total billed charges,Implant Device,1677.2,35,,1677.2,percent of total billed charges,Implant Device,1677.2,35,,1677.2,percent of total billed charges,Implant Device,1677.2,35,,1677.2,percent of total billed charges,Implant Device,1677.2,35,,1677.2,percent of total billed charges,Implant Device,1916.8,40,,1916.8,percent of total billed charges,Implant Device,1677.2,70,,1677.2,percent of total billed charges,All Other,1629.28,34,,1629.28,percent of total billed charges,Implant Device,1629.28,34,,1629.28,percent of total billed charges,Implant Device,1677.2,35,,1677.2,percent of total billed charges,Implant Device,1677.2,35,,1677.2,percent of total billed charges,Implant Device,1677.2,35,,1677.2,percent of total billed charges,Implant Device,1677.2,35,,1677.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1629.28,34,"If Charge > 2,000, then 34 percent",1629.28,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3546.09,
DJO 940-01-48D ACETABULAR CUP 48MM,C1776,HCPCS,,79013327,CDM,278,RC,,,both,,,4362,3227.89,,,3227.89,Other,150% of Medicare + 9.63% HCRA Surcharge,1962.9,45,,1962.9,percent of total billed charges,Critical Access Hospital RCC factor,1483.08,34,,1483.08,percent of total billed charges,Implant Device,1483.08,34,,1483.08,percent of total billed charges,Implant Device,1483.08,34,,1483.08,percent of total billed charges,Implant Device,1483.08,34,,1483.08,percent of total billed charges,Implant Device,1483.08,34,,1483.08,percent of total billed charges,Implant Device,2159.19,,,2159.19,Other,110% of Medicare,1526.7,35,,1526.7,percent of total billed charges,Implant Device,1483.08,34,"Charges > $500, x 34%",1483.08,percent of total billed charges,Implant Device,1526.7,35,,1526.7,percent of total billed charges,Implant Device,1526.7,35,,1526.7,percent of total billed charges,Implant Device,1526.7,35,,1526.7,percent of total billed charges,Implant Device,1526.7,35,,1526.7,percent of total billed charges,Implant Device,1526.7,35,,1526.7,percent of total billed charges,Implant Device,1744.8,40,,1744.8,percent of total billed charges,Implant Device,1526.7,70,,1526.7,percent of total billed charges,All Other,1483.08,34,,1483.08,percent of total billed charges,Implant Device,1483.08,34,,1483.08,percent of total billed charges,Implant Device,1526.7,35,,1526.7,percent of total billed charges,Implant Device,1526.7,35,,1526.7,percent of total billed charges,Implant Device,1526.7,35,,1526.7,percent of total billed charges,Implant Device,1526.7,35,,1526.7,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1483.08,34,"If Charge > 2,000, then 34 percent",1483.08,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3227.89,
DJO 951-01-38D LINER METAL 38D,C1776,HCPCS,,79013328,CDM,278,RC,,,both,,,3600,2664.01,,,2664.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1620,45,,1620,percent of total billed charges,Critical Access Hospital RCC factor,1224,34,,1224,percent of total billed charges,Implant Device,1224,34,,1224,percent of total billed charges,Implant Device,1224,34,,1224,percent of total billed charges,Implant Device,1224,34,,1224,percent of total billed charges,Implant Device,1224,34,,1224,percent of total billed charges,Implant Device,1782,,,1782,Other,110% of Medicare,1260,35,,1260,percent of total billed charges,Implant Device,1224,34,"Charges > $500, x 34%",1224,percent of total billed charges,Implant Device,1260,35,,1260,percent of total billed charges,Implant Device,1260,35,,1260,percent of total billed charges,Implant Device,1260,35,,1260,percent of total billed charges,Implant Device,1260,35,,1260,percent of total billed charges,Implant Device,1260,35,,1260,percent of total billed charges,Implant Device,1440,40,,1440,percent of total billed charges,Implant Device,1260,70,,1260,percent of total billed charges,All Other,1224,34,,1224,percent of total billed charges,Implant Device,1224,34,,1224,percent of total billed charges,Implant Device,1260,35,,1260,percent of total billed charges,Implant Device,1260,35,,1260,percent of total billed charges,Implant Device,1260,35,,1260,percent of total billed charges,Implant Device,1260,35,,1260,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1224,34,"If Charge > 2,000, then 34 percent",1224,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2664.01,
J&J 04.334.128 CANN SCREW 2.5X28MM,C1713,HCPCS,,79013330,CDM,278,RC,,,both,,,1105,817.7,,,817.7,Other,150% of Medicare + 9.63% HCRA Surcharge,497.25,45,,497.25,percent of total billed charges,Critical Access Hospital RCC factor,375.7,34,,375.7,percent of total billed charges,Implant Device,375.7,34,,375.7,percent of total billed charges,Implant Device,375.7,34,,375.7,percent of total billed charges,Implant Device,375.7,34,,375.7,percent of total billed charges,Implant Device,375.7,34,,375.7,percent of total billed charges,Implant Device,546.98,,,546.98,Other,110% of Medicare,386.75,35,,386.75,percent of total billed charges,Implant Device,375.7,34,"Charges > $500, x 34%",375.7,percent of total billed charges,Implant Device,386.75,35,,386.75,percent of total billed charges,Implant Device,386.75,35,,386.75,percent of total billed charges,Implant Device,386.75,35,,386.75,percent of total billed charges,Implant Device,386.75,35,,386.75,percent of total billed charges,Implant Device,386.75,35,,386.75,percent of total billed charges,Implant Device,442,40,,442,percent of total billed charges,Implant Device,386.75,70,,386.75,percent of total billed charges,All Other,375.7,34,,375.7,percent of total billed charges,Implant Device,375.7,34,,375.7,percent of total billed charges,Implant Device,386.75,35,,386.75,percent of total billed charges,Implant Device,386.75,35,,386.75,percent of total billed charges,Implant Device,386.75,35,,386.75,percent of total billed charges,Implant Device,386.75,35,,386.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,817.7,
J&J 04.334.1124 CANN SCREW 2.5X24MM,C1713,HCPCS,,79013331,CDM,278,RC,,,both,,,1105,817.7,,,817.7,Other,150% of Medicare + 9.63% HCRA Surcharge,497.25,45,,497.25,percent of total billed charges,Critical Access Hospital RCC factor,375.7,34,,375.7,percent of total billed charges,Implant Device,375.7,34,,375.7,percent of total billed charges,Implant Device,375.7,34,,375.7,percent of total billed charges,Implant Device,375.7,34,,375.7,percent of total billed charges,Implant Device,375.7,34,,375.7,percent of total billed charges,Implant Device,546.98,,,546.98,Other,110% of Medicare,386.75,35,,386.75,percent of total billed charges,Implant Device,375.7,34,"Charges > $500, x 34%",375.7,percent of total billed charges,Implant Device,386.75,35,,386.75,percent of total billed charges,Implant Device,386.75,35,,386.75,percent of total billed charges,Implant Device,386.75,35,,386.75,percent of total billed charges,Implant Device,386.75,35,,386.75,percent of total billed charges,Implant Device,386.75,35,,386.75,percent of total billed charges,Implant Device,442,40,,442,percent of total billed charges,Implant Device,386.75,70,,386.75,percent of total billed charges,All Other,375.7,34,,375.7,percent of total billed charges,Implant Device,375.7,34,,375.7,percent of total billed charges,Implant Device,386.75,35,,386.75,percent of total billed charges,Implant Device,386.75,35,,386.75,percent of total billed charges,Implant Device,386.75,35,,386.75,percent of total billed charges,Implant Device,386.75,35,,386.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,817.7,
J&J 04.334.130 CANN SCREW 2.5X30MM,C1713,HCPCS,,79013332,CDM,278,RC,,,both,,,1105,817.7,,,817.7,Other,150% of Medicare + 9.63% HCRA Surcharge,497.25,45,,497.25,percent of total billed charges,Critical Access Hospital RCC factor,375.7,34,,375.7,percent of total billed charges,Implant Device,375.7,34,,375.7,percent of total billed charges,Implant Device,375.7,34,,375.7,percent of total billed charges,Implant Device,375.7,34,,375.7,percent of total billed charges,Implant Device,375.7,34,,375.7,percent of total billed charges,Implant Device,546.98,,,546.98,Other,110% of Medicare,386.75,35,,386.75,percent of total billed charges,Implant Device,375.7,34,"Charges > $500, x 34%",375.7,percent of total billed charges,Implant Device,386.75,35,,386.75,percent of total billed charges,Implant Device,386.75,35,,386.75,percent of total billed charges,Implant Device,386.75,35,,386.75,percent of total billed charges,Implant Device,386.75,35,,386.75,percent of total billed charges,Implant Device,386.75,35,,386.75,percent of total billed charges,Implant Device,442,40,,442,percent of total billed charges,Implant Device,386.75,70,,386.75,percent of total billed charges,All Other,375.7,34,,375.7,percent of total billed charges,Implant Device,375.7,34,,375.7,percent of total billed charges,Implant Device,386.75,35,,386.75,percent of total billed charges,Implant Device,386.75,35,,386.75,percent of total billed charges,Implant Device,386.75,35,,386.75,percent of total billed charges,Implant Device,386.75,35,,386.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,817.7,
J&J 1504-00-104 FEMORAL SIZE 4 LEFT,C1776,HCPCS,,79013333,CDM,278,RC,,,both,,,4800,3552.01,,,3552.01,Other,150% of Medicare + 9.63% HCRA Surcharge,2160,45,,2160,percent of total billed charges,Critical Access Hospital RCC factor,1632,34,,1632,percent of total billed charges,Implant Device,1632,34,,1632,percent of total billed charges,Implant Device,1632,34,,1632,percent of total billed charges,Implant Device,1632,34,,1632,percent of total billed charges,Implant Device,1632,34,,1632,percent of total billed charges,Implant Device,2376,,,2376,Other,110% of Medicare,1680,35,,1680,percent of total billed charges,Implant Device,1632,34,"Charges > $500, x 34%",1632,percent of total billed charges,Implant Device,1680,35,,1680,percent of total billed charges,Implant Device,1680,35,,1680,percent of total billed charges,Implant Device,1680,35,,1680,percent of total billed charges,Implant Device,1680,35,,1680,percent of total billed charges,Implant Device,1680,35,,1680,percent of total billed charges,Implant Device,1920,40,,1920,percent of total billed charges,Implant Device,1680,70,,1680,percent of total billed charges,All Other,1632,34,,1632,percent of total billed charges,Implant Device,1632,34,,1632,percent of total billed charges,Implant Device,1680,35,,1680,percent of total billed charges,Implant Device,1680,35,,1680,percent of total billed charges,Implant Device,1680,35,,1680,percent of total billed charges,Implant Device,1680,35,,1680,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1632,34,"If Charge > 2,000, then 34 percent",1632,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3552.01,
J&J 1010-11-070 FEMORAL STEM SIZE 7,C1776,HCPCS,,79013334,CDM,278,RC,,,both,,,7410,5483.42,,,5483.42,Other,150% of Medicare + 9.63% HCRA Surcharge,3334.5,45,,3334.5,percent of total billed charges,Critical Access Hospital RCC factor,2519.4,34,,2519.4,percent of total billed charges,Implant Device,2519.4,34,,2519.4,percent of total billed charges,Implant Device,2519.4,34,,2519.4,percent of total billed charges,Implant Device,2519.4,34,,2519.4,percent of total billed charges,Implant Device,2519.4,34,,2519.4,percent of total billed charges,Implant Device,3667.95,,,3667.95,Other,110% of Medicare,2593.5,35,,2593.5,percent of total billed charges,Implant Device,2519.4,34,"Charges > $500, x 34%",2519.4,percent of total billed charges,Implant Device,2593.5,35,,2593.5,percent of total billed charges,Implant Device,2593.5,35,,2593.5,percent of total billed charges,Implant Device,2593.5,35,,2593.5,percent of total billed charges,Implant Device,2593.5,35,,2593.5,percent of total billed charges,Implant Device,2593.5,35,,2593.5,percent of total billed charges,Implant Device,2964,40,,2964,percent of total billed charges,Implant Device,2593.5,70,,2593.5,percent of total billed charges,All Other,2519.4,34,,2519.4,percent of total billed charges,Implant Device,2519.4,34,,2519.4,percent of total billed charges,Implant Device,2593.5,35,,2593.5,percent of total billed charges,Implant Device,2593.5,35,,2593.5,percent of total billed charges,Implant Device,2593.5,35,,2593.5,percent of total billed charges,Implant Device,2593.5,35,,2593.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2519.4,34,"If Charge > 2,000, then 34 percent",2519.4,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5483.42,
J&J 04.037.033S CANN TFNA NAIL 10X420MM,C1713,HCPCS,,79013335,CDM,278,RC,,,both,,,5467,4045.59,,,4045.59,Other,150% of Medicare + 9.63% HCRA Surcharge,2460.15,45,,2460.15,percent of total billed charges,Critical Access Hospital RCC factor,1858.78,34,,1858.78,percent of total billed charges,Implant Device,1858.78,34,,1858.78,percent of total billed charges,Implant Device,1858.78,34,,1858.78,percent of total billed charges,Implant Device,1858.78,34,,1858.78,percent of total billed charges,Implant Device,1858.78,34,,1858.78,percent of total billed charges,Implant Device,2706.17,,,2706.17,Other,110% of Medicare,1913.45,35,,1913.45,percent of total billed charges,Implant Device,1858.78,34,"Charges > $500, x 34%",1858.78,percent of total billed charges,Implant Device,1913.45,35,,1913.45,percent of total billed charges,Implant Device,1913.45,35,,1913.45,percent of total billed charges,Implant Device,1913.45,35,,1913.45,percent of total billed charges,Implant Device,1913.45,35,,1913.45,percent of total billed charges,Implant Device,1913.45,35,,1913.45,percent of total billed charges,Implant Device,2186.8,40,,2186.8,percent of total billed charges,Implant Device,1913.45,70,,1913.45,percent of total billed charges,All Other,1858.78,34,,1858.78,percent of total billed charges,Implant Device,1858.78,34,,1858.78,percent of total billed charges,Implant Device,1913.45,35,,1913.45,percent of total billed charges,Implant Device,1913.45,35,,1913.45,percent of total billed charges,Implant Device,1913.45,35,,1913.45,percent of total billed charges,Implant Device,1913.45,35,,1913.45,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1858.78,34,"If Charge > 2,000, then 34 percent",1858.78,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4045.59,
J&J 04.045.358S LOCKING SCREW 5X58MM,C1713,HCPCS,,79013336,CDM,278,RC,,,both,,,813,601.62,,,601.62,Other,150% of Medicare + 9.63% HCRA Surcharge,365.85,45,,365.85,percent of total billed charges,Critical Access Hospital RCC factor,276.42,34,,276.42,percent of total billed charges,Implant Device,276.42,34,,276.42,percent of total billed charges,Implant Device,276.42,34,,276.42,percent of total billed charges,Implant Device,276.42,34,,276.42,percent of total billed charges,Implant Device,276.42,34,,276.42,percent of total billed charges,Implant Device,402.44,,,402.44,Other,110% of Medicare,284.55,35,,284.55,percent of total billed charges,Implant Device,276.42,34,"Charges > $500, x 34%",276.42,percent of total billed charges,Implant Device,284.55,35,,284.55,percent of total billed charges,Implant Device,284.55,35,,284.55,percent of total billed charges,Implant Device,284.55,35,,284.55,percent of total billed charges,Implant Device,284.55,35,,284.55,percent of total billed charges,Implant Device,284.55,35,,284.55,percent of total billed charges,Implant Device,325.2,40,,325.2,percent of total billed charges,Implant Device,284.55,70,,284.55,percent of total billed charges,All Other,276.42,34,,276.42,percent of total billed charges,Implant Device,276.42,34,,276.42,percent of total billed charges,Implant Device,284.55,35,,284.55,percent of total billed charges,Implant Device,284.55,35,,284.55,percent of total billed charges,Implant Device,284.55,35,,284.55,percent of total billed charges,Implant Device,284.55,35,,284.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,601.62,
ZIMMER 42-5121-010-13 ARTI SURF LT 13MM,C1776,HCPCS,,79013337,CDM,278,RC,,,both,,,3648,2699.53,,,2699.53,Other,150% of Medicare + 9.63% HCRA Surcharge,1641.6,45,,1641.6,percent of total billed charges,Critical Access Hospital RCC factor,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1805.76,,,1805.76,Other,110% of Medicare,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1240.32,34,"Charges > $500, x 34%",1240.32,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1459.2,40,,1459.2,percent of total billed charges,Implant Device,1276.8,70,,1276.8,percent of total billed charges,All Other,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1240.32,34,"If Charge > 2,000, then 34 percent",1240.32,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2699.53,
ZIMMER 42-5320-083-01 TIB 5 DEG LT SZ H,C1776,HCPCS,,79013338,CDM,278,RC,,,both,,,4433,3280.43,,,3280.43,Other,150% of Medicare + 9.63% HCRA Surcharge,1994.85,45,,1994.85,percent of total billed charges,Critical Access Hospital RCC factor,1507.22,34,,1507.22,percent of total billed charges,Implant Device,1507.22,34,,1507.22,percent of total billed charges,Implant Device,1507.22,34,,1507.22,percent of total billed charges,Implant Device,1507.22,34,,1507.22,percent of total billed charges,Implant Device,1507.22,34,,1507.22,percent of total billed charges,Implant Device,2194.34,,,2194.34,Other,110% of Medicare,1551.55,35,,1551.55,percent of total billed charges,Implant Device,1507.22,34,"Charges > $500, x 34%",1507.22,percent of total billed charges,Implant Device,1551.55,35,,1551.55,percent of total billed charges,Implant Device,1551.55,35,,1551.55,percent of total billed charges,Implant Device,1551.55,35,,1551.55,percent of total billed charges,Implant Device,1551.55,35,,1551.55,percent of total billed charges,Implant Device,1551.55,35,,1551.55,percent of total billed charges,Implant Device,1773.2,40,,1773.2,percent of total billed charges,Implant Device,1551.55,70,,1551.55,percent of total billed charges,All Other,1507.22,34,,1507.22,percent of total billed charges,Implant Device,1507.22,34,,1507.22,percent of total billed charges,Implant Device,1551.55,35,,1551.55,percent of total billed charges,Implant Device,1551.55,35,,1551.55,percent of total billed charges,Implant Device,1551.55,35,,1551.55,percent of total billed charges,Implant Device,1551.55,35,,1551.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1507.22,34,"If Charge > 2,000, then 34 percent",1507.22,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3280.43,
ZIMMER 42-5026-074-01 FEMUR LT SIZE 12,C1776,HCPCS,,79013339,CDM,278,RC,,,both,,,6300,4662.02,,,4662.02,Other,150% of Medicare + 9.63% HCRA Surcharge,2835,45,,2835,percent of total billed charges,Critical Access Hospital RCC factor,2142,34,,2142,percent of total billed charges,Implant Device,2142,34,,2142,percent of total billed charges,Implant Device,2142,34,,2142,percent of total billed charges,Implant Device,2142,34,,2142,percent of total billed charges,Implant Device,2142,34,,2142,percent of total billed charges,Implant Device,3118.5,,,3118.5,Other,110% of Medicare,2205,35,,2205,percent of total billed charges,Implant Device,2142,34,"Charges > $500, x 34%",2142,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2520,40,,2520,percent of total billed charges,Implant Device,2205,70,,2205,percent of total billed charges,All Other,2142,34,,2142,percent of total billed charges,Implant Device,2142,34,,2142,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2142,34,"If Charge > 2,000, then 34 percent",2142,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4662.02,
ZIMMER 42-5121-004-12 ART SURF LT 12MM,C1776,HCPCS,,79013340,CDM,278,RC,,,both,,,3648,2699.53,,,2699.53,Other,150% of Medicare + 9.63% HCRA Surcharge,1641.6,45,,1641.6,percent of total billed charges,Critical Access Hospital RCC factor,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1805.76,,,1805.76,Other,110% of Medicare,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1240.32,34,"Charges > $500, x 34%",1240.32,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1459.2,40,,1459.2,percent of total billed charges,Implant Device,1276.8,70,,1276.8,percent of total billed charges,All Other,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1240.32,34,"If Charge > 2,000, then 34 percent",1240.32,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2699.53,
ZIMMER 42-5601-135-14 STEM EXT 11MM,C1776,HCPCS,,79013341,CDM,278,RC,,,both,,,5299,3921.27,,,3921.27,Other,150% of Medicare + 9.63% HCRA Surcharge,2384.55,45,,2384.55,percent of total billed charges,Critical Access Hospital RCC factor,1801.66,34,,1801.66,percent of total billed charges,Implant Device,1801.66,34,,1801.66,percent of total billed charges,Implant Device,1801.66,34,,1801.66,percent of total billed charges,Implant Device,1801.66,34,,1801.66,percent of total billed charges,Implant Device,1801.66,34,,1801.66,percent of total billed charges,Implant Device,2623.01,,,2623.01,Other,110% of Medicare,1854.65,35,,1854.65,percent of total billed charges,Implant Device,1801.66,34,"Charges > $500, x 34%",1801.66,percent of total billed charges,Implant Device,1854.65,35,,1854.65,percent of total billed charges,Implant Device,1854.65,35,,1854.65,percent of total billed charges,Implant Device,1854.65,35,,1854.65,percent of total billed charges,Implant Device,1854.65,35,,1854.65,percent of total billed charges,Implant Device,1854.65,35,,1854.65,percent of total billed charges,Implant Device,2119.6,40,,2119.6,percent of total billed charges,Implant Device,1854.65,70,,1854.65,percent of total billed charges,All Other,1801.66,34,,1801.66,percent of total billed charges,Implant Device,1801.66,34,,1801.66,percent of total billed charges,Implant Device,1854.65,35,,1854.65,percent of total billed charges,Implant Device,1854.65,35,,1854.65,percent of total billed charges,Implant Device,1854.65,35,,1854.65,percent of total billed charges,Implant Device,1854.65,35,,1854.65,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1801.66,34,"If Charge > 2,000, then 34 percent",1801.66,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3921.27,
ZIMMER 42-5566-058-05 FEM DIS AUG SZ 5 5,C1776,HCPCS,,79013342,CDM,278,RC,,,both,,,3379,2500.47,,,2500.47,Other,150% of Medicare + 9.63% HCRA Surcharge,1520.55,45,,1520.55,percent of total billed charges,Critical Access Hospital RCC factor,1148.86,34,,1148.86,percent of total billed charges,Implant Device,1148.86,34,,1148.86,percent of total billed charges,Implant Device,1148.86,34,,1148.86,percent of total billed charges,Implant Device,1148.86,34,,1148.86,percent of total billed charges,Implant Device,1148.86,34,,1148.86,percent of total billed charges,Implant Device,1672.61,,,1672.61,Other,110% of Medicare,1182.65,35,,1182.65,percent of total billed charges,Implant Device,1148.86,34,"Charges > $500, x 34%",1148.86,percent of total billed charges,Implant Device,1182.65,35,,1182.65,percent of total billed charges,Implant Device,1182.65,35,,1182.65,percent of total billed charges,Implant Device,1182.65,35,,1182.65,percent of total billed charges,Implant Device,1182.65,35,,1182.65,percent of total billed charges,Implant Device,1182.65,35,,1182.65,percent of total billed charges,Implant Device,1351.6,40,,1351.6,percent of total billed charges,Implant Device,1182.65,70,,1182.65,percent of total billed charges,All Other,1148.86,34,,1148.86,percent of total billed charges,Implant Device,1148.86,34,,1148.86,percent of total billed charges,Implant Device,1182.65,35,,1182.65,percent of total billed charges,Implant Device,1182.65,35,,1182.65,percent of total billed charges,Implant Device,1182.65,35,,1182.65,percent of total billed charges,Implant Device,1182.65,35,,1182.65,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1148.86,34,"If Charge > 2,000, then 34 percent",1148.86,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2500.47,
ZIMMER 42-5420-071-01 TIBIA LEFT SIZE E,C1776,HCPCS,,79013343,CDM,278,RC,,,both,,,7834,5797.18,,,5797.18,Other,150% of Medicare + 9.63% HCRA Surcharge,3525.3,45,,3525.3,percent of total billed charges,Critical Access Hospital RCC factor,2663.56,34,,2663.56,percent of total billed charges,Implant Device,2663.56,34,,2663.56,percent of total billed charges,Implant Device,2663.56,34,,2663.56,percent of total billed charges,Implant Device,2663.56,34,,2663.56,percent of total billed charges,Implant Device,2663.56,34,,2663.56,percent of total billed charges,Implant Device,3877.83,,,3877.83,Other,110% of Medicare,2741.9,35,,2741.9,percent of total billed charges,Implant Device,2663.56,34,"Charges > $500, x 34%",2663.56,percent of total billed charges,Implant Device,2741.9,35,,2741.9,percent of total billed charges,Implant Device,2741.9,35,,2741.9,percent of total billed charges,Implant Device,2741.9,35,,2741.9,percent of total billed charges,Implant Device,2741.9,35,,2741.9,percent of total billed charges,Implant Device,2741.9,35,,2741.9,percent of total billed charges,Implant Device,3133.6,40,,3133.6,percent of total billed charges,Implant Device,2741.9,70,,2741.9,percent of total billed charges,All Other,2663.56,34,,2663.56,percent of total billed charges,Implant Device,2663.56,34,,2663.56,percent of total billed charges,Implant Device,2741.9,35,,2741.9,percent of total billed charges,Implant Device,2741.9,35,,2741.9,percent of total billed charges,Implant Device,2741.9,35,,2741.9,percent of total billed charges,Implant Device,2741.9,35,,2741.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2663.56,34,"If Charge > 2,000, then 34 percent",2663.56,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5797.18,
ZIMMER 42-5601-135-11 STEM EXTEN 11MM,C1776,HCPCS,,79013344,CDM,278,RC,,,both,,,5299,3921.27,,,3921.27,Other,150% of Medicare + 9.63% HCRA Surcharge,2384.55,45,,2384.55,percent of total billed charges,Critical Access Hospital RCC factor,1801.66,34,,1801.66,percent of total billed charges,Implant Device,1801.66,34,,1801.66,percent of total billed charges,Implant Device,1801.66,34,,1801.66,percent of total billed charges,Implant Device,1801.66,34,,1801.66,percent of total billed charges,Implant Device,1801.66,34,,1801.66,percent of total billed charges,Implant Device,2623.01,,,2623.01,Other,110% of Medicare,1854.65,35,,1854.65,percent of total billed charges,Implant Device,1801.66,34,"Charges > $500, x 34%",1801.66,percent of total billed charges,Implant Device,1854.65,35,,1854.65,percent of total billed charges,Implant Device,1854.65,35,,1854.65,percent of total billed charges,Implant Device,1854.65,35,,1854.65,percent of total billed charges,Implant Device,1854.65,35,,1854.65,percent of total billed charges,Implant Device,1854.65,35,,1854.65,percent of total billed charges,Implant Device,2119.6,40,,2119.6,percent of total billed charges,Implant Device,1854.65,70,,1854.65,percent of total billed charges,All Other,1801.66,34,,1801.66,percent of total billed charges,Implant Device,1801.66,34,,1801.66,percent of total billed charges,Implant Device,1854.65,35,,1854.65,percent of total billed charges,Implant Device,1854.65,35,,1854.65,percent of total billed charges,Implant Device,1854.65,35,,1854.65,percent of total billed charges,Implant Device,1854.65,35,,1854.65,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1801.66,34,"If Charge > 2,000, then 34 percent",1801.66,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3921.27,
ZIMMER 42-5128-006-14 ART SURF LT 14MM,C1776,HCPCS,,79013345,CDM,278,RC,,,both,,,7680,5683.22,,,5683.22,Other,150% of Medicare + 9.63% HCRA Surcharge,3456,45,,3456,percent of total billed charges,Critical Access Hospital RCC factor,2611.2,34,,2611.2,percent of total billed charges,Implant Device,2611.2,34,,2611.2,percent of total billed charges,Implant Device,2611.2,34,,2611.2,percent of total billed charges,Implant Device,2611.2,34,,2611.2,percent of total billed charges,Implant Device,2611.2,34,,2611.2,percent of total billed charges,Implant Device,3801.6,,,3801.6,Other,110% of Medicare,2688,35,,2688,percent of total billed charges,Implant Device,2611.2,34,"Charges > $500, x 34%",2611.2,percent of total billed charges,Implant Device,2688,35,,2688,percent of total billed charges,Implant Device,2688,35,,2688,percent of total billed charges,Implant Device,2688,35,,2688,percent of total billed charges,Implant Device,2688,35,,2688,percent of total billed charges,Implant Device,2688,35,,2688,percent of total billed charges,Implant Device,3072,40,,3072,percent of total billed charges,Implant Device,2688,70,,2688,percent of total billed charges,All Other,2611.2,34,,2611.2,percent of total billed charges,Implant Device,2611.2,34,,2611.2,percent of total billed charges,Implant Device,2688,35,,2688,percent of total billed charges,Implant Device,2688,35,,2688,percent of total billed charges,Implant Device,2688,35,,2688,percent of total billed charges,Implant Device,2688,35,,2688,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2611.2,34,"If Charge > 2,000, then 34 percent",2611.2,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5683.22,
ZIMMER 42-5450-005-08 TRAB METAL CONE,C1776,HCPCS,,79013346,CDM,278,RC,,,both,,,22176,16410.3,,,16410.3,Other,150% of Medicare + 9.63% HCRA Surcharge,9979.2,45,,9979.2,percent of total billed charges,Critical Access Hospital RCC factor,7539.84,34,,7539.84,percent of total billed charges,Implant Device,7539.84,34,,7539.84,percent of total billed charges,Implant Device,7539.84,34,,7539.84,percent of total billed charges,Implant Device,7539.84,34,,7539.84,percent of total billed charges,Implant Device,7539.84,34,,7539.84,percent of total billed charges,Implant Device,10977.12,,,10977.12,Other,110% of Medicare,7761.6,35,,7761.6,percent of total billed charges,Implant Device,7539.84,34,"Charges > $500, x 34%",7539.84,percent of total billed charges,Implant Device,7761.6,35,,7761.6,percent of total billed charges,Implant Device,7761.6,35,,7761.6,percent of total billed charges,Implant Device,7761.6,35,,7761.6,percent of total billed charges,Implant Device,7761.6,35,,7761.6,percent of total billed charges,Implant Device,7761.6,35,,7761.6,percent of total billed charges,Implant Device,8870.4,40,,8870.4,percent of total billed charges,Implant Device,7761.6,70,,7761.6,percent of total billed charges,All Other,7539.84,34,,7539.84,percent of total billed charges,Implant Device,7539.84,34,,7539.84,percent of total billed charges,Implant Device,7761.6,35,,7761.6,percent of total billed charges,Implant Device,7761.6,35,,7761.6,percent of total billed charges,Implant Device,7761.6,35,,7761.6,percent of total billed charges,Implant Device,7761.6,35,,7761.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,7539.84,34,"If Charge > 2,000, then 34 percent",7539.84,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,16410.3,
ZIMMER 42-5046-058-11 FEMUR LEFT SIZE 5+,C1776,HCPCS,,79013347,CDM,278,RC,,,both,,,23424,17333.82,,,17333.82,Other,150% of Medicare + 9.63% HCRA Surcharge,10540.8,45,,10540.8,percent of total billed charges,Critical Access Hospital RCC factor,7964.16,34,,7964.16,percent of total billed charges,Implant Device,7964.16,34,,7964.16,percent of total billed charges,Implant Device,7964.16,34,,7964.16,percent of total billed charges,Implant Device,7964.16,34,,7964.16,percent of total billed charges,Implant Device,7964.16,34,,7964.16,percent of total billed charges,Implant Device,11594.88,,,11594.88,Other,110% of Medicare,8198.4,35,,8198.4,percent of total billed charges,Implant Device,7964.16,34,"Charges > $500, x 34%",7964.16,percent of total billed charges,Implant Device,8198.4,35,,8198.4,percent of total billed charges,Implant Device,8198.4,35,,8198.4,percent of total billed charges,Implant Device,8198.4,35,,8198.4,percent of total billed charges,Implant Device,8198.4,35,,8198.4,percent of total billed charges,Implant Device,8198.4,35,,8198.4,percent of total billed charges,Implant Device,9369.6,40,,9369.6,percent of total billed charges,Implant Device,8198.4,70,,8198.4,percent of total billed charges,All Other,7964.16,34,,7964.16,percent of total billed charges,Implant Device,7964.16,34,,7964.16,percent of total billed charges,Implant Device,8198.4,35,,8198.4,percent of total billed charges,Implant Device,8198.4,35,,8198.4,percent of total billed charges,Implant Device,8198.4,35,,8198.4,percent of total billed charges,Implant Device,8198.4,35,,8198.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,7964.16,34,"If Charge > 2,000, then 34 percent",7964.16,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,17333.82,
STRYKER 326050 CANN SCREW 6.5X50MM,C1713,HCPCS,,79013348,CDM,278,RC,,,both,,,765,566.1,,,566.1,Other,150% of Medicare + 9.63% HCRA Surcharge,344.25,45,,344.25,percent of total billed charges,Critical Access Hospital RCC factor,260.1,34,,260.1,percent of total billed charges,Implant Device,260.1,34,,260.1,percent of total billed charges,Implant Device,260.1,34,,260.1,percent of total billed charges,Implant Device,260.1,34,,260.1,percent of total billed charges,Implant Device,260.1,34,,260.1,percent of total billed charges,Implant Device,378.68,,,378.68,Other,110% of Medicare,267.75,35,,267.75,percent of total billed charges,Implant Device,260.1,34,"Charges > $500, x 34%",260.1,percent of total billed charges,Implant Device,267.75,35,,267.75,percent of total billed charges,Implant Device,267.75,35,,267.75,percent of total billed charges,Implant Device,267.75,35,,267.75,percent of total billed charges,Implant Device,267.75,35,,267.75,percent of total billed charges,Implant Device,267.75,35,,267.75,percent of total billed charges,Implant Device,306,40,,306,percent of total billed charges,Implant Device,267.75,70,,267.75,percent of total billed charges,All Other,260.1,34,,260.1,percent of total billed charges,Implant Device,260.1,34,,260.1,percent of total billed charges,Implant Device,267.75,35,,267.75,percent of total billed charges,Implant Device,267.75,35,,267.75,percent of total billed charges,Implant Device,267.75,35,,267.75,percent of total billed charges,Implant Device,267.75,35,,267.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,566.1,
STRYKER 626800 LOCKING PLATE LATERAL,C1713,HCPCS,,79013353,CDM,278,RC,,,both,,,3589,2655.87,,,2655.87,Other,150% of Medicare + 9.63% HCRA Surcharge,1615.05,45,,1615.05,percent of total billed charges,Critical Access Hospital RCC factor,1220.26,34,,1220.26,percent of total billed charges,Implant Device,1220.26,34,,1220.26,percent of total billed charges,Implant Device,1220.26,34,,1220.26,percent of total billed charges,Implant Device,1220.26,34,,1220.26,percent of total billed charges,Implant Device,1220.26,34,,1220.26,percent of total billed charges,Implant Device,1776.56,,,1776.56,Other,110% of Medicare,1256.15,35,,1256.15,percent of total billed charges,Implant Device,1220.26,34,"Charges > $500, x 34%",1220.26,percent of total billed charges,Implant Device,1256.15,35,,1256.15,percent of total billed charges,Implant Device,1256.15,35,,1256.15,percent of total billed charges,Implant Device,1256.15,35,,1256.15,percent of total billed charges,Implant Device,1256.15,35,,1256.15,percent of total billed charges,Implant Device,1256.15,35,,1256.15,percent of total billed charges,Implant Device,1435.6,40,,1435.6,percent of total billed charges,Implant Device,1256.15,70,,1256.15,percent of total billed charges,All Other,1220.26,34,,1220.26,percent of total billed charges,Implant Device,1220.26,34,,1220.26,percent of total billed charges,Implant Device,1256.15,35,,1256.15,percent of total billed charges,Implant Device,1256.15,35,,1256.15,percent of total billed charges,Implant Device,1256.15,35,,1256.15,percent of total billed charges,Implant Device,1256.15,35,,1256.15,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1220.26,34,"If Charge > 2,000, then 34 percent",1220.26,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2655.87,
STRYKER 70-812-0515 IMPLANT SYS 5X15MM,C1713,HCPCS,,79013354,CDM,278,RC,,,both,,,4200,3108.01,,,3108.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1890,45,,1890,percent of total billed charges,Critical Access Hospital RCC factor,1428,34,,1428,percent of total billed charges,Implant Device,1428,34,,1428,percent of total billed charges,Implant Device,1428,34,,1428,percent of total billed charges,Implant Device,1428,34,,1428,percent of total billed charges,Implant Device,1428,34,,1428,percent of total billed charges,Implant Device,2079,,,2079,Other,110% of Medicare,1470,35,,1470,percent of total billed charges,Implant Device,1428,34,"Charges > $500, x 34%",1428,percent of total billed charges,Implant Device,1470,35,,1470,percent of total billed charges,Implant Device,1470,35,,1470,percent of total billed charges,Implant Device,1470,35,,1470,percent of total billed charges,Implant Device,1470,35,,1470,percent of total billed charges,Implant Device,1470,35,,1470,percent of total billed charges,Implant Device,1680,40,,1680,percent of total billed charges,Implant Device,1470,70,,1470,percent of total billed charges,All Other,1428,34,,1428,percent of total billed charges,Implant Device,1428,34,,1428,percent of total billed charges,Implant Device,1470,35,,1470,percent of total billed charges,Implant Device,1470,35,,1470,percent of total billed charges,Implant Device,1470,35,,1470,percent of total billed charges,Implant Device,1470,35,,1470,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1428,34,"If Charge > 2,000, then 34 percent",1428,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3108.01,
STRYKER 58A91000 ORTHOLOC 3DI PLAT SYS,C1713,HCPCS,,79013355,CDM,278,RC,,,both,,,4500,3330.01,,,3330.01,Other,150% of Medicare + 9.63% HCRA Surcharge,2025,45,,2025,percent of total billed charges,Critical Access Hospital RCC factor,1530,34,,1530,percent of total billed charges,Implant Device,1530,34,,1530,percent of total billed charges,Implant Device,1530,34,,1530,percent of total billed charges,Implant Device,1530,34,,1530,percent of total billed charges,Implant Device,1530,34,,1530,percent of total billed charges,Implant Device,2227.5,,,2227.5,Other,110% of Medicare,1575,35,,1575,percent of total billed charges,Implant Device,1530,34,"Charges > $500, x 34%",1530,percent of total billed charges,Implant Device,1575,35,,1575,percent of total billed charges,Implant Device,1575,35,,1575,percent of total billed charges,Implant Device,1575,35,,1575,percent of total billed charges,Implant Device,1575,35,,1575,percent of total billed charges,Implant Device,1575,35,,1575,percent of total billed charges,Implant Device,1800,40,,1800,percent of total billed charges,Implant Device,1575,70,,1575,percent of total billed charges,All Other,1530,34,,1530,percent of total billed charges,Implant Device,1530,34,,1530,percent of total billed charges,Implant Device,1575,35,,1575,percent of total billed charges,Implant Device,1575,35,,1575,percent of total billed charges,Implant Device,1575,35,,1575,percent of total billed charges,Implant Device,1575,35,,1575,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1530,34,"If Charge > 2,000, then 34 percent",1530,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3330.01,
STRYKER 86660800 BICORTICAL 8 EVANS WED,C1713,HCPCS,,79013356,CDM,278,RC,,,both,,,12114,8964.39,,,8964.39,Other,150% of Medicare + 9.63% HCRA Surcharge,5451.3,45,,5451.3,percent of total billed charges,Critical Access Hospital RCC factor,4118.76,34,,4118.76,percent of total billed charges,Implant Device,4118.76,34,,4118.76,percent of total billed charges,Implant Device,4118.76,34,,4118.76,percent of total billed charges,Implant Device,4118.76,34,,4118.76,percent of total billed charges,Implant Device,4118.76,34,,4118.76,percent of total billed charges,Implant Device,5996.43,,,5996.43,Other,110% of Medicare,4239.9,35,,4239.9,percent of total billed charges,Implant Device,4118.76,34,"Charges > $500, x 34%",4118.76,percent of total billed charges,Implant Device,4239.9,35,,4239.9,percent of total billed charges,Implant Device,4239.9,35,,4239.9,percent of total billed charges,Implant Device,4239.9,35,,4239.9,percent of total billed charges,Implant Device,4239.9,35,,4239.9,percent of total billed charges,Implant Device,4239.9,35,,4239.9,percent of total billed charges,Implant Device,4845.6,40,,4845.6,percent of total billed charges,Implant Device,4239.9,70,,4239.9,percent of total billed charges,All Other,4118.76,34,,4118.76,percent of total billed charges,Implant Device,4118.76,34,,4118.76,percent of total billed charges,Implant Device,4239.9,35,,4239.9,percent of total billed charges,Implant Device,4239.9,35,,4239.9,percent of total billed charges,Implant Device,4239.9,35,,4239.9,percent of total billed charges,Implant Device,4239.9,35,,4239.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,4118.76,34,"If Charge > 2,000, then 34 percent",4118.76,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,8964.39,
STRYKER 8160-0095S LAG SCREW 10.5X95MM,C1713,HCPCS,,79013358,CDM,278,RC,,,both,,,1777,1314.98,,,1314.98,Other,150% of Medicare + 9.63% HCRA Surcharge,799.65,45,,799.65,percent of total billed charges,Critical Access Hospital RCC factor,604.18,34,,604.18,percent of total billed charges,Implant Device,604.18,34,,604.18,percent of total billed charges,Implant Device,604.18,34,,604.18,percent of total billed charges,Implant Device,604.18,34,,604.18,percent of total billed charges,Implant Device,604.18,34,,604.18,percent of total billed charges,Implant Device,879.62,,,879.62,Other,110% of Medicare,621.95,35,,621.95,percent of total billed charges,Implant Device,604.18,34,"Charges > $500, x 34%",604.18,percent of total billed charges,Implant Device,621.95,35,,621.95,percent of total billed charges,Implant Device,621.95,35,,621.95,percent of total billed charges,Implant Device,621.95,35,,621.95,percent of total billed charges,Implant Device,621.95,35,,621.95,percent of total billed charges,Implant Device,621.95,35,,621.95,percent of total billed charges,Implant Device,710.8,40,,710.8,percent of total billed charges,Implant Device,621.95,70,,621.95,percent of total billed charges,All Other,604.18,34,,604.18,percent of total billed charges,Implant Device,604.18,34,,604.18,percent of total billed charges,Implant Device,621.95,35,,621.95,percent of total billed charges,Implant Device,621.95,35,,621.95,percent of total billed charges,Implant Device,621.95,35,,621.95,percent of total billed charges,Implant Device,621.95,35,,621.95,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1314.98,
STRYKER 8160-0100S LAG SCREW 10.5X100MM,C1713,HCPCS,,79013359,CDM,278,RC,,,both,,,1777,1314.98,,,1314.98,Other,150% of Medicare + 9.63% HCRA Surcharge,799.65,45,,799.65,percent of total billed charges,Critical Access Hospital RCC factor,604.18,34,,604.18,percent of total billed charges,Implant Device,604.18,34,,604.18,percent of total billed charges,Implant Device,604.18,34,,604.18,percent of total billed charges,Implant Device,604.18,34,,604.18,percent of total billed charges,Implant Device,604.18,34,,604.18,percent of total billed charges,Implant Device,879.62,,,879.62,Other,110% of Medicare,621.95,35,,621.95,percent of total billed charges,Implant Device,604.18,34,"Charges > $500, x 34%",604.18,percent of total billed charges,Implant Device,621.95,35,,621.95,percent of total billed charges,Implant Device,621.95,35,,621.95,percent of total billed charges,Implant Device,621.95,35,,621.95,percent of total billed charges,Implant Device,621.95,35,,621.95,percent of total billed charges,Implant Device,621.95,35,,621.95,percent of total billed charges,Implant Device,710.8,40,,710.8,percent of total billed charges,Implant Device,621.95,70,,621.95,percent of total billed charges,All Other,604.18,34,,604.18,percent of total billed charges,Implant Device,604.18,34,,604.18,percent of total billed charges,Implant Device,621.95,35,,621.95,percent of total billed charges,Implant Device,621.95,35,,621.95,percent of total billed charges,Implant Device,621.95,35,,621.95,percent of total billed charges,Implant Device,621.95,35,,621.95,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1314.98,
STRYKER 8425-0360S NAIL RT 10X360X125DEG,C1713,HCPCS,,79013360,CDM,278,RC,,,both,,,7227,5348,,,5348,Other,150% of Medicare + 9.63% HCRA Surcharge,3252.15,45,,3252.15,percent of total billed charges,Critical Access Hospital RCC factor,2457.18,34,,2457.18,percent of total billed charges,Implant Device,2457.18,34,,2457.18,percent of total billed charges,Implant Device,2457.18,34,,2457.18,percent of total billed charges,Implant Device,2457.18,34,,2457.18,percent of total billed charges,Implant Device,2457.18,34,,2457.18,percent of total billed charges,Implant Device,3577.37,,,3577.37,Other,110% of Medicare,2529.45,35,,2529.45,percent of total billed charges,Implant Device,2457.18,34,"Charges > $500, x 34%",2457.18,percent of total billed charges,Implant Device,2529.45,35,,2529.45,percent of total billed charges,Implant Device,2529.45,35,,2529.45,percent of total billed charges,Implant Device,2529.45,35,,2529.45,percent of total billed charges,Implant Device,2529.45,35,,2529.45,percent of total billed charges,Implant Device,2529.45,35,,2529.45,percent of total billed charges,Implant Device,2890.8,40,,2890.8,percent of total billed charges,Implant Device,2529.45,70,,2529.45,percent of total billed charges,All Other,2457.18,34,,2457.18,percent of total billed charges,Implant Device,2457.18,34,,2457.18,percent of total billed charges,Implant Device,2529.45,35,,2529.45,percent of total billed charges,Implant Device,2529.45,35,,2529.45,percent of total billed charges,Implant Device,2529.45,35,,2529.45,percent of total billed charges,Implant Device,2529.45,35,,2529.45,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2457.18,34,"If Charge > 2,000, then 34 percent",2457.18,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5348,
STRYKER 8525-0360S NAIL LT 10X360X125DEG,C1713,HCPCS,,79013361,CDM,278,RC,,,both,,,7227,5348,,,5348,Other,150% of Medicare + 9.63% HCRA Surcharge,3252.15,45,,3252.15,percent of total billed charges,Critical Access Hospital RCC factor,2457.18,34,,2457.18,percent of total billed charges,Implant Device,2457.18,34,,2457.18,percent of total billed charges,Implant Device,2457.18,34,,2457.18,percent of total billed charges,Implant Device,2457.18,34,,2457.18,percent of total billed charges,Implant Device,2457.18,34,,2457.18,percent of total billed charges,Implant Device,3577.37,,,3577.37,Other,110% of Medicare,2529.45,35,,2529.45,percent of total billed charges,Implant Device,2457.18,34,"Charges > $500, x 34%",2457.18,percent of total billed charges,Implant Device,2529.45,35,,2529.45,percent of total billed charges,Implant Device,2529.45,35,,2529.45,percent of total billed charges,Implant Device,2529.45,35,,2529.45,percent of total billed charges,Implant Device,2529.45,35,,2529.45,percent of total billed charges,Implant Device,2529.45,35,,2529.45,percent of total billed charges,Implant Device,2890.8,40,,2890.8,percent of total billed charges,Implant Device,2529.45,70,,2529.45,percent of total billed charges,All Other,2457.18,34,,2457.18,percent of total billed charges,Implant Device,2457.18,34,,2457.18,percent of total billed charges,Implant Device,2529.45,35,,2529.45,percent of total billed charges,Implant Device,2529.45,35,,2529.45,percent of total billed charges,Implant Device,2529.45,35,,2529.45,percent of total billed charges,Implant Device,2529.45,35,,2529.45,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2457.18,34,"If Charge > 2,000, then 34 percent",2457.18,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5348,
STRYKER 1217-32-050 ACETAB SHELL 50MM,C1776,HCPCS,,79013362,CDM,278,RC,,,both,,,3420,2530.81,,,2530.81,Other,150% of Medicare + 9.63% HCRA Surcharge,1539,45,,1539,percent of total billed charges,Critical Access Hospital RCC factor,1162.8,34,,1162.8,percent of total billed charges,Implant Device,1162.8,34,,1162.8,percent of total billed charges,Implant Device,1162.8,34,,1162.8,percent of total billed charges,Implant Device,1162.8,34,,1162.8,percent of total billed charges,Implant Device,1162.8,34,,1162.8,percent of total billed charges,Implant Device,1692.9,,,1692.9,Other,110% of Medicare,1197,35,,1197,percent of total billed charges,Implant Device,1162.8,34,"Charges > $500, x 34%",1162.8,percent of total billed charges,Implant Device,1197,35,,1197,percent of total billed charges,Implant Device,1197,35,,1197,percent of total billed charges,Implant Device,1197,35,,1197,percent of total billed charges,Implant Device,1197,35,,1197,percent of total billed charges,Implant Device,1197,35,,1197,percent of total billed charges,Implant Device,1368,40,,1368,percent of total billed charges,Implant Device,1197,70,,1197,percent of total billed charges,All Other,1162.8,34,,1162.8,percent of total billed charges,Implant Device,1162.8,34,,1162.8,percent of total billed charges,Implant Device,1197,35,,1197,percent of total billed charges,Implant Device,1197,35,,1197,percent of total billed charges,Implant Device,1197,35,,1197,percent of total billed charges,Implant Device,1197,35,,1197,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1162.8,34,"If Charge > 2,000, then 34 percent",1162.8,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2530.81,
J&J 04.168.285S BOLT FOR FEM NECK SYS 85,C1713,HCPCS,,79013365,CDM,278,RC,,,both,,,938,694.12,,,694.12,Other,150% of Medicare + 9.63% HCRA Surcharge,422.1,45,,422.1,percent of total billed charges,Critical Access Hospital RCC factor,318.92,34,,318.92,percent of total billed charges,Implant Device,318.92,34,,318.92,percent of total billed charges,Implant Device,318.92,34,,318.92,percent of total billed charges,Implant Device,318.92,34,,318.92,percent of total billed charges,Implant Device,318.92,34,,318.92,percent of total billed charges,Implant Device,464.31,,,464.31,Other,110% of Medicare,328.3,35,,328.3,percent of total billed charges,Implant Device,318.92,34,"Charges > $500, x 34%",318.92,percent of total billed charges,Implant Device,328.3,35,,328.3,percent of total billed charges,Implant Device,328.3,35,,328.3,percent of total billed charges,Implant Device,328.3,35,,328.3,percent of total billed charges,Implant Device,328.3,35,,328.3,percent of total billed charges,Implant Device,328.3,35,,328.3,percent of total billed charges,Implant Device,375.2,40,,375.2,percent of total billed charges,Implant Device,328.3,70,,328.3,percent of total billed charges,All Other,318.92,34,,318.92,percent of total billed charges,Implant Device,318.92,34,,318.92,percent of total billed charges,Implant Device,328.3,35,,328.3,percent of total billed charges,Implant Device,328.3,35,,328.3,percent of total billed charges,Implant Device,328.3,35,,328.3,percent of total billed charges,Implant Device,328.3,35,,328.3,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,694.12,
J&J 04.168.485S ANTIROTATION SCREW 85LEN,C1713,HCPCS,,79013366,CDM,278,RC,,,both,,,633,468.42,,,468.42,Other,150% of Medicare + 9.63% HCRA Surcharge,284.85,45,,284.85,percent of total billed charges,Critical Access Hospital RCC factor,215.22,34,,215.22,percent of total billed charges,Implant Device,215.22,34,,215.22,percent of total billed charges,Implant Device,215.22,34,,215.22,percent of total billed charges,Implant Device,215.22,34,,215.22,percent of total billed charges,Implant Device,215.22,34,,215.22,percent of total billed charges,Implant Device,313.34,,,313.34,Other,110% of Medicare,221.55,35,,221.55,percent of total billed charges,Implant Device,215.22,34,"Charges > $500, x 34%",215.22,percent of total billed charges,Implant Device,221.55,35,,221.55,percent of total billed charges,Implant Device,221.55,35,,221.55,percent of total billed charges,Implant Device,221.55,35,,221.55,percent of total billed charges,Implant Device,221.55,35,,221.55,percent of total billed charges,Implant Device,221.55,35,,221.55,percent of total billed charges,Implant Device,253.2,40,,253.2,percent of total billed charges,Implant Device,221.55,70,,221.55,percent of total billed charges,All Other,215.22,34,,215.22,percent of total billed charges,Implant Device,215.22,34,,215.22,percent of total billed charges,Implant Device,221.55,35,,221.55,percent of total billed charges,Implant Device,221.55,35,,221.55,percent of total billed charges,Implant Device,221.55,35,,221.55,percent of total billed charges,Implant Device,221.55,35,,221.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,468.42,
J&J 1010-11-050 FEM STEM 12/14 TAPER SZ5,C1776,HCPCS,,79013367,CDM,278,RC,,,both,,,7410,5483.42,,,5483.42,Other,150% of Medicare + 9.63% HCRA Surcharge,3334.5,45,,3334.5,percent of total billed charges,Critical Access Hospital RCC factor,2519.4,34,,2519.4,percent of total billed charges,Implant Device,2519.4,34,,2519.4,percent of total billed charges,Implant Device,2519.4,34,,2519.4,percent of total billed charges,Implant Device,2519.4,34,,2519.4,percent of total billed charges,Implant Device,2519.4,34,,2519.4,percent of total billed charges,Implant Device,3667.95,,,3667.95,Other,110% of Medicare,2593.5,35,,2593.5,percent of total billed charges,Implant Device,2519.4,34,"Charges > $500, x 34%",2519.4,percent of total billed charges,Implant Device,2593.5,35,,2593.5,percent of total billed charges,Implant Device,2593.5,35,,2593.5,percent of total billed charges,Implant Device,2593.5,35,,2593.5,percent of total billed charges,Implant Device,2593.5,35,,2593.5,percent of total billed charges,Implant Device,2593.5,35,,2593.5,percent of total billed charges,Implant Device,2964,40,,2964,percent of total billed charges,Implant Device,2593.5,70,,2593.5,percent of total billed charges,All Other,2519.4,34,,2519.4,percent of total billed charges,Implant Device,2519.4,34,,2519.4,percent of total billed charges,Implant Device,2593.5,35,,2593.5,percent of total billed charges,Implant Device,2593.5,35,,2593.5,percent of total billed charges,Implant Device,2593.5,35,,2593.5,percent of total billed charges,Implant Device,2593.5,35,,2593.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2519.4,34,"If Charge > 2,000, then 34 percent",2519.4,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5483.42,
J&J 1504-01-225 ATTUNE FEM SZ 5 5MM,C1776,HCPCS,,79013368,CDM,278,RC,,,both,,,6000,4440.02,,,4440.02,Other,150% of Medicare + 9.63% HCRA Surcharge,2700,45,,2700,percent of total billed charges,Critical Access Hospital RCC factor,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2970,,,2970,Other,110% of Medicare,2100,35,,2100,percent of total billed charges,Implant Device,2040,34,"Charges > $500, x 34%",2040,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2400,40,,2400,percent of total billed charges,Implant Device,2100,70,,2100,percent of total billed charges,All Other,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2040,34,"If Charge > 2,000, then 34 percent",2040,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4440.02,
J&J 1504-00-208 FEM SIZE 8 RT,C1776,HCPCS,,79013369,CDM,278,RC,,,both,,,4800,3552.01,,,3552.01,Other,150% of Medicare + 9.63% HCRA Surcharge,2160,45,,2160,percent of total billed charges,Critical Access Hospital RCC factor,1632,34,,1632,percent of total billed charges,Implant Device,1632,34,,1632,percent of total billed charges,Implant Device,1632,34,,1632,percent of total billed charges,Implant Device,1632,34,,1632,percent of total billed charges,Implant Device,1632,34,,1632,percent of total billed charges,Implant Device,2376,,,2376,Other,110% of Medicare,1680,35,,1680,percent of total billed charges,Implant Device,1632,34,"Charges > $500, x 34%",1632,percent of total billed charges,Implant Device,1680,35,,1680,percent of total billed charges,Implant Device,1680,35,,1680,percent of total billed charges,Implant Device,1680,35,,1680,percent of total billed charges,Implant Device,1680,35,,1680,percent of total billed charges,Implant Device,1680,35,,1680,percent of total billed charges,Implant Device,1920,40,,1920,percent of total billed charges,Implant Device,1680,70,,1680,percent of total billed charges,All Other,1632,34,,1632,percent of total billed charges,Implant Device,1632,34,,1632,percent of total billed charges,Implant Device,1680,35,,1680,percent of total billed charges,Implant Device,1680,35,,1680,percent of total billed charges,Implant Device,1680,35,,1680,percent of total billed charges,Implant Device,1680,35,,1680,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1632,34,"If Charge > 2,000, then 34 percent",1632,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3552.01,
J&J 1516-30-805 TIBIAL INSERT SZ 8 5MM,C1776,HCPCS,,79013370,CDM,278,RC,,,both,,,5400,3996.01,,,3996.01,Other,150% of Medicare + 9.63% HCRA Surcharge,2430,45,,2430,percent of total billed charges,Critical Access Hospital RCC factor,1836,34,,1836,percent of total billed charges,Implant Device,1836,34,,1836,percent of total billed charges,Implant Device,1836,34,,1836,percent of total billed charges,Implant Device,1836,34,,1836,percent of total billed charges,Implant Device,1836,34,,1836,percent of total billed charges,Implant Device,2673,,,2673,Other,110% of Medicare,1890,35,,1890,percent of total billed charges,Implant Device,1836,34,"Charges > $500, x 34%",1836,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,2160,40,,2160,percent of total billed charges,Implant Device,1890,70,,1890,percent of total billed charges,All Other,1836,34,,1836,percent of total billed charges,Implant Device,1836,34,,1836,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1836,34,"If Charge > 2,000, then 34 percent",1836,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3996.01,
ARGON 231050G HOMER BLN 20GX5CM,A4648,HCPCS,,79013372,CDM,278,RC,,,both,,,99,73.26,,,73.26,Other,150% of Medicare + 9.63% HCRA Surcharge,44.55,45,,44.55,percent of total billed charges,Critical Access Hospital RCC factor,33.66,34,,33.66,percent of total billed charges,Implant Device,33.66,34,,33.66,percent of total billed charges,Implant Device,33.66,34,,33.66,percent of total billed charges,Implant Device,33.66,34,,33.66,percent of total billed charges,Implant Device,33.66,34,,33.66,percent of total billed charges,Implant Device,49.01,,,49.01,Other,110% of Medicare,34.65,35,,34.65,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,34.65,35,,34.65,percent of total billed charges,Implant Device,34.65,35,,34.65,percent of total billed charges,Implant Device,34.65,35,,34.65,percent of total billed charges,Implant Device,34.65,35,,34.65,percent of total billed charges,Implant Device,34.65,35,,34.65,percent of total billed charges,Implant Device,39.6,40,,39.6,percent of total billed charges,Implant Device,34.65,70,,34.65,percent of total billed charges,All Other,33.66,34,,33.66,percent of total billed charges,Implant Device,33.66,34,,33.66,percent of total billed charges,Implant Device,34.65,35,,34.65,percent of total billed charges,Implant Device,34.65,35,,34.65,percent of total billed charges,Implant Device,34.65,35,,34.65,percent of total billed charges,Implant Device,34.65,35,,34.65,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,73.26,
ARGON 231075G HOMER BLN 20GX7.5CM,A4648,HCPCS,,79013373,CDM,278,RC,,,both,,,99,73.26,,,73.26,Other,150% of Medicare + 9.63% HCRA Surcharge,44.55,45,,44.55,percent of total billed charges,Critical Access Hospital RCC factor,33.66,34,,33.66,percent of total billed charges,Implant Device,33.66,34,,33.66,percent of total billed charges,Implant Device,33.66,34,,33.66,percent of total billed charges,Implant Device,33.66,34,,33.66,percent of total billed charges,Implant Device,33.66,34,,33.66,percent of total billed charges,Implant Device,49.01,,,49.01,Other,110% of Medicare,34.65,35,,34.65,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,34.65,35,,34.65,percent of total billed charges,Implant Device,34.65,35,,34.65,percent of total billed charges,Implant Device,34.65,35,,34.65,percent of total billed charges,Implant Device,34.65,35,,34.65,percent of total billed charges,Implant Device,34.65,35,,34.65,percent of total billed charges,Implant Device,39.6,40,,39.6,percent of total billed charges,Implant Device,34.65,70,,34.65,percent of total billed charges,All Other,33.66,34,,33.66,percent of total billed charges,Implant Device,33.66,34,,33.66,percent of total billed charges,Implant Device,34.65,35,,34.65,percent of total billed charges,Implant Device,34.65,35,,34.65,percent of total billed charges,Implant Device,34.65,35,,34.65,percent of total billed charges,Implant Device,34.65,35,,34.65,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,73.26,
ARGON 231100G HOMER BLN 20GX10CM,A4648,HCPCS,,79013374,CDM,278,RC,,,both,,,99,73.26,,,73.26,Other,150% of Medicare + 9.63% HCRA Surcharge,44.55,45,,44.55,percent of total billed charges,Critical Access Hospital RCC factor,33.66,34,,33.66,percent of total billed charges,Implant Device,33.66,34,,33.66,percent of total billed charges,Implant Device,33.66,34,,33.66,percent of total billed charges,Implant Device,33.66,34,,33.66,percent of total billed charges,Implant Device,33.66,34,,33.66,percent of total billed charges,Implant Device,49.01,,,49.01,Other,110% of Medicare,34.65,35,,34.65,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,34.65,35,,34.65,percent of total billed charges,Implant Device,34.65,35,,34.65,percent of total billed charges,Implant Device,34.65,35,,34.65,percent of total billed charges,Implant Device,34.65,35,,34.65,percent of total billed charges,Implant Device,34.65,35,,34.65,percent of total billed charges,Implant Device,39.6,40,,39.6,percent of total billed charges,Implant Device,34.65,70,,34.65,percent of total billed charges,All Other,33.66,34,,33.66,percent of total billed charges,Implant Device,33.66,34,,33.66,percent of total billed charges,Implant Device,34.65,35,,34.65,percent of total billed charges,Implant Device,34.65,35,,34.65,percent of total billed charges,Implant Device,34.65,35,,34.65,percent of total billed charges,Implant Device,34.65,35,,34.65,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,73.26,
J&J 04.333.018 CANN HEADLESS SCREW 2X18,C1713,HCPCS,,79013377,CDM,278,RC,,,both,,,1105,817.7,,,817.7,Other,150% of Medicare + 9.63% HCRA Surcharge,497.25,45,,497.25,percent of total billed charges,Critical Access Hospital RCC factor,375.7,34,,375.7,percent of total billed charges,Implant Device,375.7,34,,375.7,percent of total billed charges,Implant Device,375.7,34,,375.7,percent of total billed charges,Implant Device,375.7,34,,375.7,percent of total billed charges,Implant Device,375.7,34,,375.7,percent of total billed charges,Implant Device,546.98,,,546.98,Other,110% of Medicare,386.75,35,,386.75,percent of total billed charges,Implant Device,375.7,34,"Charges > $500, x 34%",375.7,percent of total billed charges,Implant Device,386.75,35,,386.75,percent of total billed charges,Implant Device,386.75,35,,386.75,percent of total billed charges,Implant Device,386.75,35,,386.75,percent of total billed charges,Implant Device,386.75,35,,386.75,percent of total billed charges,Implant Device,386.75,35,,386.75,percent of total billed charges,Implant Device,442,40,,442,percent of total billed charges,Implant Device,386.75,70,,386.75,percent of total billed charges,All Other,375.7,34,,375.7,percent of total billed charges,Implant Device,375.7,34,,375.7,percent of total billed charges,Implant Device,386.75,35,,386.75,percent of total billed charges,Implant Device,386.75,35,,386.75,percent of total billed charges,Implant Device,386.75,35,,386.75,percent of total billed charges,Implant Device,386.75,35,,386.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,817.7,
J&J 04.333.020 HEADLESS SCREW 2X20,C1713,HCPCS,,79013378,CDM,278,RC,,,both,,,1105,817.7,,,817.7,Other,150% of Medicare + 9.63% HCRA Surcharge,497.25,45,,497.25,percent of total billed charges,Critical Access Hospital RCC factor,375.7,34,,375.7,percent of total billed charges,Implant Device,375.7,34,,375.7,percent of total billed charges,Implant Device,375.7,34,,375.7,percent of total billed charges,Implant Device,375.7,34,,375.7,percent of total billed charges,Implant Device,375.7,34,,375.7,percent of total billed charges,Implant Device,546.98,,,546.98,Other,110% of Medicare,386.75,35,,386.75,percent of total billed charges,Implant Device,375.7,34,"Charges > $500, x 34%",375.7,percent of total billed charges,Implant Device,386.75,35,,386.75,percent of total billed charges,Implant Device,386.75,35,,386.75,percent of total billed charges,Implant Device,386.75,35,,386.75,percent of total billed charges,Implant Device,386.75,35,,386.75,percent of total billed charges,Implant Device,386.75,35,,386.75,percent of total billed charges,Implant Device,442,40,,442,percent of total billed charges,Implant Device,386.75,70,,386.75,percent of total billed charges,All Other,375.7,34,,375.7,percent of total billed charges,Implant Device,375.7,34,,375.7,percent of total billed charges,Implant Device,386.75,35,,386.75,percent of total billed charges,Implant Device,386.75,35,,386.75,percent of total billed charges,Implant Device,386.75,35,,386.75,percent of total billed charges,Implant Device,386.75,35,,386.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,817.7,
J&J 02.112.142S LCP FIBULA PLT 2.7/3.5MM,C1713,HCPCS,,79013379,CDM,278,RC,,,both,,,1743,1289.82,,,1289.82,Other,150% of Medicare + 9.63% HCRA Surcharge,784.35,45,,784.35,percent of total billed charges,Critical Access Hospital RCC factor,592.62,34,,592.62,percent of total billed charges,Implant Device,592.62,34,,592.62,percent of total billed charges,Implant Device,592.62,34,,592.62,percent of total billed charges,Implant Device,592.62,34,,592.62,percent of total billed charges,Implant Device,592.62,34,,592.62,percent of total billed charges,Implant Device,862.79,,,862.79,Other,110% of Medicare,610.05,35,,610.05,percent of total billed charges,Implant Device,592.62,34,"Charges > $500, x 34%",592.62,percent of total billed charges,Implant Device,610.05,35,,610.05,percent of total billed charges,Implant Device,610.05,35,,610.05,percent of total billed charges,Implant Device,610.05,35,,610.05,percent of total billed charges,Implant Device,610.05,35,,610.05,percent of total billed charges,Implant Device,610.05,35,,610.05,percent of total billed charges,Implant Device,697.2,40,,697.2,percent of total billed charges,Implant Device,610.05,70,,610.05,percent of total billed charges,All Other,592.62,34,,592.62,percent of total billed charges,Implant Device,592.62,34,,592.62,percent of total billed charges,Implant Device,610.05,35,,610.05,percent of total billed charges,Implant Device,610.05,35,,610.05,percent of total billed charges,Implant Device,610.05,35,,610.05,percent of total billed charges,Implant Device,610.05,35,,610.05,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1289.82,
J&J 201.695 CORTEX SCREW 2.4X50MM,C1713,HCPCS,,79013380,CDM,278,RC,,,both,,,153,113.22,,,113.22,Other,150% of Medicare + 9.63% HCRA Surcharge,68.85,45,,68.85,percent of total billed charges,Critical Access Hospital RCC factor,52.02,34,,52.02,percent of total billed charges,Implant Device,52.02,34,,52.02,percent of total billed charges,Implant Device,52.02,34,,52.02,percent of total billed charges,Implant Device,52.02,34,,52.02,percent of total billed charges,Implant Device,52.02,34,,52.02,percent of total billed charges,Implant Device,75.74,,,75.74,Other,110% of Medicare,53.55,35,,53.55,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,53.55,35,,53.55,percent of total billed charges,Implant Device,53.55,35,,53.55,percent of total billed charges,Implant Device,53.55,35,,53.55,percent of total billed charges,Implant Device,53.55,35,,53.55,percent of total billed charges,Implant Device,53.55,35,,53.55,percent of total billed charges,Implant Device,61.2,40,,61.2,percent of total billed charges,Implant Device,53.55,70,,53.55,percent of total billed charges,All Other,52.02,34,,52.02,percent of total billed charges,Implant Device,52.02,34,,52.02,percent of total billed charges,Implant Device,53.55,35,,53.55,percent of total billed charges,Implant Device,53.55,35,,53.55,percent of total billed charges,Implant Device,53.55,35,,53.55,percent of total billed charges,Implant Device,53.55,35,,53.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,113.22,
J&J 02.221.087 HOOK PLATE 3.5/4.5MM,C1713,HCPCS,,79013381,CDM,278,RC,,,both,,,7897,5843.8,,,5843.8,Other,150% of Medicare + 9.63% HCRA Surcharge,3553.65,45,,3553.65,percent of total billed charges,Critical Access Hospital RCC factor,2684.98,34,,2684.98,percent of total billed charges,Implant Device,2684.98,34,,2684.98,percent of total billed charges,Implant Device,2684.98,34,,2684.98,percent of total billed charges,Implant Device,2684.98,34,,2684.98,percent of total billed charges,Implant Device,2684.98,34,,2684.98,percent of total billed charges,Implant Device,3909.02,,,3909.02,Other,110% of Medicare,2763.95,35,,2763.95,percent of total billed charges,Implant Device,2684.98,34,"Charges > $500, x 34%",2684.98,percent of total billed charges,Implant Device,2763.95,35,,2763.95,percent of total billed charges,Implant Device,2763.95,35,,2763.95,percent of total billed charges,Implant Device,2763.95,35,,2763.95,percent of total billed charges,Implant Device,2763.95,35,,2763.95,percent of total billed charges,Implant Device,2763.95,35,,2763.95,percent of total billed charges,Implant Device,3158.8,40,,3158.8,percent of total billed charges,Implant Device,2763.95,70,,2763.95,percent of total billed charges,All Other,2684.98,34,,2684.98,percent of total billed charges,Implant Device,2684.98,34,,2684.98,percent of total billed charges,Implant Device,2763.95,35,,2763.95,percent of total billed charges,Implant Device,2763.95,35,,2763.95,percent of total billed charges,Implant Device,2763.95,35,,2763.95,percent of total billed charges,Implant Device,2763.95,35,,2763.95,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2684.98,34,"If Charge > 2,000, then 34 percent",2684.98,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5843.8,
J&J 02.127.132 LOCKING SCREW 3.5X32MM,C1713,HCPCS,,79013382,CDM,278,RC,,,both,,,414,306.36,,,306.36,Other,150% of Medicare + 9.63% HCRA Surcharge,186.3,45,,186.3,percent of total billed charges,Critical Access Hospital RCC factor,140.76,34,,140.76,percent of total billed charges,Implant Device,140.76,34,,140.76,percent of total billed charges,Implant Device,140.76,34,,140.76,percent of total billed charges,Implant Device,140.76,34,,140.76,percent of total billed charges,Implant Device,140.76,34,,140.76,percent of total billed charges,Implant Device,204.93,,,204.93,Other,110% of Medicare,144.9,35,,144.9,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,144.9,35,,144.9,percent of total billed charges,Implant Device,144.9,35,,144.9,percent of total billed charges,Implant Device,144.9,35,,144.9,percent of total billed charges,Implant Device,144.9,35,,144.9,percent of total billed charges,Implant Device,144.9,35,,144.9,percent of total billed charges,Implant Device,165.6,40,,165.6,percent of total billed charges,Implant Device,144.9,70,,144.9,percent of total billed charges,All Other,140.76,34,,140.76,percent of total billed charges,Implant Device,140.76,34,,140.76,percent of total billed charges,Implant Device,144.9,35,,144.9,percent of total billed charges,Implant Device,144.9,35,,144.9,percent of total billed charges,Implant Device,144.9,35,,144.9,percent of total billed charges,Implant Device,144.9,35,,144.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,306.36,
J&J 201.660 CORTEX SCREW 2.4X30MM,C1713,HCPCS,,79013383,CDM,278,RC,,,both,,,121,89.54,,,89.54,Other,150% of Medicare + 9.63% HCRA Surcharge,54.45,45,,54.45,percent of total billed charges,Critical Access Hospital RCC factor,41.14,34,,41.14,percent of total billed charges,Implant Device,41.14,34,,41.14,percent of total billed charges,Implant Device,41.14,34,,41.14,percent of total billed charges,Implant Device,41.14,34,,41.14,percent of total billed charges,Implant Device,41.14,34,,41.14,percent of total billed charges,Implant Device,59.9,,,59.9,Other,110% of Medicare,42.35,35,,42.35,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,42.35,35,,42.35,percent of total billed charges,Implant Device,42.35,35,,42.35,percent of total billed charges,Implant Device,42.35,35,,42.35,percent of total billed charges,Implant Device,42.35,35,,42.35,percent of total billed charges,Implant Device,42.35,35,,42.35,percent of total billed charges,Implant Device,48.4,40,,48.4,percent of total billed charges,Implant Device,42.35,70,,42.35,percent of total billed charges,All Other,41.14,34,,41.14,percent of total billed charges,Implant Device,41.14,34,,41.14,percent of total billed charges,Implant Device,42.35,35,,42.35,percent of total billed charges,Implant Device,42.35,35,,42.35,percent of total billed charges,Implant Device,42.35,35,,42.35,percent of total billed charges,Implant Device,42.35,35,,42.35,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,89.54,
"DJO 952-28-38D BEARING ID28, OD38",C1776,HCPCS,,79013384,CDM,278,RC,,,both,,,2100,1554.01,,,1554.01,Other,150% of Medicare + 9.63% HCRA Surcharge,945,45,,945,percent of total billed charges,Critical Access Hospital RCC factor,714,34,,714,percent of total billed charges,Implant Device,714,34,,714,percent of total billed charges,Implant Device,714,34,,714,percent of total billed charges,Implant Device,714,34,,714,percent of total billed charges,Implant Device,714,34,,714,percent of total billed charges,Implant Device,1039.5,,,1039.5,Other,110% of Medicare,735,35,,735,percent of total billed charges,Implant Device,714,34,"Charges > $500, x 34%",714,percent of total billed charges,Implant Device,735,35,,735,percent of total billed charges,Implant Device,735,35,,735,percent of total billed charges,Implant Device,735,35,,735,percent of total billed charges,Implant Device,735,35,,735,percent of total billed charges,Implant Device,735,35,,735,percent of total billed charges,Implant Device,840,40,,840,percent of total billed charges,Implant Device,735,70,,735,percent of total billed charges,All Other,714,34,,714,percent of total billed charges,Implant Device,714,34,,714,percent of total billed charges,Implant Device,735,35,,735,percent of total billed charges,Implant Device,735,35,,735,percent of total billed charges,Implant Device,735,35,,735,percent of total billed charges,Implant Device,735,35,,735,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,714,34,"If Charge > 2,000, then 34 percent",714,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1554.01,
STRYKER 6720-0330 132 NECK ANGLE HIP STE,C1776,HCPCS,,79013386,CDM,278,RC,,,both,,,6953,5145.24,,,5145.24,Other,150% of Medicare + 9.63% HCRA Surcharge,3128.85,45,,3128.85,percent of total billed charges,Critical Access Hospital RCC factor,2364.02,34,,2364.02,percent of total billed charges,Implant Device,2364.02,34,,2364.02,percent of total billed charges,Implant Device,2364.02,34,,2364.02,percent of total billed charges,Implant Device,2364.02,34,,2364.02,percent of total billed charges,Implant Device,2364.02,34,,2364.02,percent of total billed charges,Implant Device,3441.74,,,3441.74,Other,110% of Medicare,2433.55,35,,2433.55,percent of total billed charges,Implant Device,2364.02,34,"Charges > $500, x 34%",2364.02,percent of total billed charges,Implant Device,2433.55,35,,2433.55,percent of total billed charges,Implant Device,2433.55,35,,2433.55,percent of total billed charges,Implant Device,2433.55,35,,2433.55,percent of total billed charges,Implant Device,2433.55,35,,2433.55,percent of total billed charges,Implant Device,2433.55,35,,2433.55,percent of total billed charges,Implant Device,2781.2,40,,2781.2,percent of total billed charges,Implant Device,2433.55,70,,2433.55,percent of total billed charges,All Other,2364.02,34,,2364.02,percent of total billed charges,Implant Device,2364.02,34,,2364.02,percent of total billed charges,Implant Device,2433.55,35,,2433.55,percent of total billed charges,Implant Device,2433.55,35,,2433.55,percent of total billed charges,Implant Device,2433.55,35,,2433.55,percent of total billed charges,Implant Device,2433.55,35,,2433.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2364.02,34,"If Charge > 2,000, then 34 percent",2364.02,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5145.24,
STRYKER 6260-5-226 FEMORAL HEAD 26X4MM,C1776,HCPCS,,79013387,CDM,278,RC,,,both,,,1391,1029.34,,,1029.34,Other,150% of Medicare + 9.63% HCRA Surcharge,625.95,45,,625.95,percent of total billed charges,Critical Access Hospital RCC factor,472.94,34,,472.94,percent of total billed charges,Implant Device,472.94,34,,472.94,percent of total billed charges,Implant Device,472.94,34,,472.94,percent of total billed charges,Implant Device,472.94,34,,472.94,percent of total billed charges,Implant Device,472.94,34,,472.94,percent of total billed charges,Implant Device,688.55,,,688.55,Other,110% of Medicare,486.85,35,,486.85,percent of total billed charges,Implant Device,472.94,34,"Charges > $500, x 34%",472.94,percent of total billed charges,Implant Device,486.85,35,,486.85,percent of total billed charges,Implant Device,486.85,35,,486.85,percent of total billed charges,Implant Device,486.85,35,,486.85,percent of total billed charges,Implant Device,486.85,35,,486.85,percent of total billed charges,Implant Device,486.85,35,,486.85,percent of total billed charges,Implant Device,556.4,40,,556.4,percent of total billed charges,Implant Device,486.85,70,,486.85,percent of total billed charges,All Other,472.94,34,,472.94,percent of total billed charges,Implant Device,472.94,34,,472.94,percent of total billed charges,Implant Device,486.85,35,,486.85,percent of total billed charges,Implant Device,486.85,35,,486.85,percent of total billed charges,Implant Device,486.85,35,,486.85,percent of total billed charges,Implant Device,486.85,35,,486.85,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1029.34,
ZIMMER 42-5600-075-14 STEM EXT 14X75MM,C1776,HCPCS,,79013388,CDM,278,RC,,,both,,,4946,3660.05,,,3660.05,Other,150% of Medicare + 9.63% HCRA Surcharge,2225.7,45,,2225.7,percent of total billed charges,Critical Access Hospital RCC factor,1681.64,34,,1681.64,percent of total billed charges,Implant Device,1681.64,34,,1681.64,percent of total billed charges,Implant Device,1681.64,34,,1681.64,percent of total billed charges,Implant Device,1681.64,34,,1681.64,percent of total billed charges,Implant Device,1681.64,34,,1681.64,percent of total billed charges,Implant Device,2448.27,,,2448.27,Other,110% of Medicare,1731.1,35,,1731.1,percent of total billed charges,Implant Device,1681.64,34,"Charges > $500, x 34%",1681.64,percent of total billed charges,Implant Device,1731.1,35,,1731.1,percent of total billed charges,Implant Device,1731.1,35,,1731.1,percent of total billed charges,Implant Device,1731.1,35,,1731.1,percent of total billed charges,Implant Device,1731.1,35,,1731.1,percent of total billed charges,Implant Device,1731.1,35,,1731.1,percent of total billed charges,Implant Device,1978.4,40,,1978.4,percent of total billed charges,Implant Device,1731.1,70,,1731.1,percent of total billed charges,All Other,1681.64,34,,1681.64,percent of total billed charges,Implant Device,1681.64,34,,1681.64,percent of total billed charges,Implant Device,1731.1,35,,1731.1,percent of total billed charges,Implant Device,1731.1,35,,1731.1,percent of total billed charges,Implant Device,1731.1,35,,1731.1,percent of total billed charges,Implant Device,1731.1,35,,1731.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1681.64,34,"If Charge > 2,000, then 34 percent",1681.64,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3660.05,
ZIMMER 42-5128-007-12 ART SURF LT 12MM,C1776,HCPCS,,79013389,CDM,278,RC,,,both,,,7680,5683.22,,,5683.22,Other,150% of Medicare + 9.63% HCRA Surcharge,3456,45,,3456,percent of total billed charges,Critical Access Hospital RCC factor,2611.2,34,,2611.2,percent of total billed charges,Implant Device,2611.2,34,,2611.2,percent of total billed charges,Implant Device,2611.2,34,,2611.2,percent of total billed charges,Implant Device,2611.2,34,,2611.2,percent of total billed charges,Implant Device,2611.2,34,,2611.2,percent of total billed charges,Implant Device,3801.6,,,3801.6,Other,110% of Medicare,2688,35,,2688,percent of total billed charges,Implant Device,2611.2,34,"Charges > $500, x 34%",2611.2,percent of total billed charges,Implant Device,2688,35,,2688,percent of total billed charges,Implant Device,2688,35,,2688,percent of total billed charges,Implant Device,2688,35,,2688,percent of total billed charges,Implant Device,2688,35,,2688,percent of total billed charges,Implant Device,2688,35,,2688,percent of total billed charges,Implant Device,3072,40,,3072,percent of total billed charges,Implant Device,2688,70,,2688,percent of total billed charges,All Other,2611.2,34,,2611.2,percent of total billed charges,Implant Device,2611.2,34,,2611.2,percent of total billed charges,Implant Device,2688,35,,2688,percent of total billed charges,Implant Device,2688,35,,2688,percent of total billed charges,Implant Device,2688,35,,2688,percent of total billed charges,Implant Device,2688,35,,2688,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2611.2,34,"If Charge > 2,000, then 34 percent",2611.2,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5683.22,
ZIMMER 42-5046-062-01 FEMUR LEFT SIZE 7,C1776,HCPCS,,79013390,CDM,278,RC,,,both,,,21888,16197.17,,,16197.17,Other,150% of Medicare + 9.63% HCRA Surcharge,9849.6,45,,9849.6,percent of total billed charges,Critical Access Hospital RCC factor,7441.92,34,,7441.92,percent of total billed charges,Implant Device,7441.92,34,,7441.92,percent of total billed charges,Implant Device,7441.92,34,,7441.92,percent of total billed charges,Implant Device,7441.92,34,,7441.92,percent of total billed charges,Implant Device,7441.92,34,,7441.92,percent of total billed charges,Implant Device,10834.56,,,10834.56,Other,110% of Medicare,7660.8,35,,7660.8,percent of total billed charges,Implant Device,7441.92,34,"Charges > $500, x 34%",7441.92,percent of total billed charges,Implant Device,7660.8,35,,7660.8,percent of total billed charges,Implant Device,7660.8,35,,7660.8,percent of total billed charges,Implant Device,7660.8,35,,7660.8,percent of total billed charges,Implant Device,7660.8,35,,7660.8,percent of total billed charges,Implant Device,7660.8,35,,7660.8,percent of total billed charges,Implant Device,8755.2,40,,8755.2,percent of total billed charges,Implant Device,7660.8,70,,7660.8,percent of total billed charges,All Other,7441.92,34,,7441.92,percent of total billed charges,Implant Device,7441.92,34,,7441.92,percent of total billed charges,Implant Device,7660.8,35,,7660.8,percent of total billed charges,Implant Device,7660.8,35,,7660.8,percent of total billed charges,Implant Device,7660.8,35,,7660.8,percent of total billed charges,Implant Device,7660.8,35,,7660.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,7441.92,34,"If Charge > 2,000, then 34 percent",7441.92,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,16197.17,
ZIMMER 42-5420-075-01 TIB FIXED LT SZ F,C1776,HCPCS,,79013391,CDM,278,RC,,,both,,,7834,5797.18,,,5797.18,Other,150% of Medicare + 9.63% HCRA Surcharge,3525.3,45,,3525.3,percent of total billed charges,Critical Access Hospital RCC factor,2663.56,34,,2663.56,percent of total billed charges,Implant Device,2663.56,34,,2663.56,percent of total billed charges,Implant Device,2663.56,34,,2663.56,percent of total billed charges,Implant Device,2663.56,34,,2663.56,percent of total billed charges,Implant Device,2663.56,34,,2663.56,percent of total billed charges,Implant Device,3877.83,,,3877.83,Other,110% of Medicare,2741.9,35,,2741.9,percent of total billed charges,Implant Device,2663.56,34,"Charges > $500, x 34%",2663.56,percent of total billed charges,Implant Device,2741.9,35,,2741.9,percent of total billed charges,Implant Device,2741.9,35,,2741.9,percent of total billed charges,Implant Device,2741.9,35,,2741.9,percent of total billed charges,Implant Device,2741.9,35,,2741.9,percent of total billed charges,Implant Device,2741.9,35,,2741.9,percent of total billed charges,Implant Device,3133.6,40,,3133.6,percent of total billed charges,Implant Device,2741.9,70,,2741.9,percent of total billed charges,All Other,2663.56,34,,2663.56,percent of total billed charges,Implant Device,2663.56,34,,2663.56,percent of total billed charges,Implant Device,2741.9,35,,2741.9,percent of total billed charges,Implant Device,2741.9,35,,2741.9,percent of total billed charges,Implant Device,2741.9,35,,2741.9,percent of total billed charges,Implant Device,2741.9,35,,2741.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2663.56,34,"If Charge > 2,000, then 34 percent",2663.56,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5797.18,
ZIMMER 42-5601-135-12 STEM EXT 12X135MM,C1776,HCPCS,,79013392,CDM,278,RC,,,both,,,5299,3921.27,,,3921.27,Other,150% of Medicare + 9.63% HCRA Surcharge,2384.55,45,,2384.55,percent of total billed charges,Critical Access Hospital RCC factor,1801.66,34,,1801.66,percent of total billed charges,Implant Device,1801.66,34,,1801.66,percent of total billed charges,Implant Device,1801.66,34,,1801.66,percent of total billed charges,Implant Device,1801.66,34,,1801.66,percent of total billed charges,Implant Device,1801.66,34,,1801.66,percent of total billed charges,Implant Device,2623.01,,,2623.01,Other,110% of Medicare,1854.65,35,,1854.65,percent of total billed charges,Implant Device,1801.66,34,"Charges > $500, x 34%",1801.66,percent of total billed charges,Implant Device,1854.65,35,,1854.65,percent of total billed charges,Implant Device,1854.65,35,,1854.65,percent of total billed charges,Implant Device,1854.65,35,,1854.65,percent of total billed charges,Implant Device,1854.65,35,,1854.65,percent of total billed charges,Implant Device,1854.65,35,,1854.65,percent of total billed charges,Implant Device,2119.6,40,,2119.6,percent of total billed charges,Implant Device,1854.65,70,,1854.65,percent of total billed charges,All Other,1801.66,34,,1801.66,percent of total billed charges,Implant Device,1801.66,34,,1801.66,percent of total billed charges,Implant Device,1854.65,35,,1854.65,percent of total billed charges,Implant Device,1854.65,35,,1854.65,percent of total billed charges,Implant Device,1854.65,35,,1854.65,percent of total billed charges,Implant Device,1854.65,35,,1854.65,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1801.66,34,"If Charge > 2,000, then 34 percent",1801.66,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3921.27,
ZIMMER 42-5601-135-10 STEM EXT 10X135MM,C1776,HCPCS,,79013393,CDM,278,RC,,,both,,,5299,3921.27,,,3921.27,Other,150% of Medicare + 9.63% HCRA Surcharge,2384.55,45,,2384.55,percent of total billed charges,Critical Access Hospital RCC factor,1801.66,34,,1801.66,percent of total billed charges,Implant Device,1801.66,34,,1801.66,percent of total billed charges,Implant Device,1801.66,34,,1801.66,percent of total billed charges,Implant Device,1801.66,34,,1801.66,percent of total billed charges,Implant Device,1801.66,34,,1801.66,percent of total billed charges,Implant Device,2623.01,,,2623.01,Other,110% of Medicare,1854.65,35,,1854.65,percent of total billed charges,Implant Device,1801.66,34,"Charges > $500, x 34%",1801.66,percent of total billed charges,Implant Device,1854.65,35,,1854.65,percent of total billed charges,Implant Device,1854.65,35,,1854.65,percent of total billed charges,Implant Device,1854.65,35,,1854.65,percent of total billed charges,Implant Device,1854.65,35,,1854.65,percent of total billed charges,Implant Device,1854.65,35,,1854.65,percent of total billed charges,Implant Device,2119.6,40,,2119.6,percent of total billed charges,Implant Device,1854.65,70,,1854.65,percent of total billed charges,All Other,1801.66,34,,1801.66,percent of total billed charges,Implant Device,1801.66,34,,1801.66,percent of total billed charges,Implant Device,1854.65,35,,1854.65,percent of total billed charges,Implant Device,1854.65,35,,1854.65,percent of total billed charges,Implant Device,1854.65,35,,1854.65,percent of total billed charges,Implant Device,1854.65,35,,1854.65,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1801.66,34,"If Charge > 2,000, then 34 percent",1801.66,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3921.27,
STRYKER IC3022 HEADED SCREW 3.0X22MM,C1713,HCPCS,,79013396,CDM,278,RC,,,both,,,964,713.36,,,713.36,Other,150% of Medicare + 9.63% HCRA Surcharge,433.8,45,,433.8,percent of total billed charges,Critical Access Hospital RCC factor,327.76,34,,327.76,percent of total billed charges,Implant Device,327.76,34,,327.76,percent of total billed charges,Implant Device,327.76,34,,327.76,percent of total billed charges,Implant Device,327.76,34,,327.76,percent of total billed charges,Implant Device,327.76,34,,327.76,percent of total billed charges,Implant Device,477.18,,,477.18,Other,110% of Medicare,337.4,35,,337.4,percent of total billed charges,Implant Device,327.76,34,"Charges > $500, x 34%",327.76,percent of total billed charges,Implant Device,337.4,35,,337.4,percent of total billed charges,Implant Device,337.4,35,,337.4,percent of total billed charges,Implant Device,337.4,35,,337.4,percent of total billed charges,Implant Device,337.4,35,,337.4,percent of total billed charges,Implant Device,337.4,35,,337.4,percent of total billed charges,Implant Device,385.6,40,,385.6,percent of total billed charges,Implant Device,337.4,70,,337.4,percent of total billed charges,All Other,327.76,34,,327.76,percent of total billed charges,Implant Device,327.76,34,,327.76,percent of total billed charges,Implant Device,337.4,35,,337.4,percent of total billed charges,Implant Device,337.4,35,,337.4,percent of total billed charges,Implant Device,337.4,35,,337.4,percent of total billed charges,Implant Device,337.4,35,,337.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,713.36,
STRYKER IC3032 HEADED SCREW 3.0X32MM,C1713,HCPCS,,79013397,CDM,278,RC,,,both,,,964,713.36,,,713.36,Other,150% of Medicare + 9.63% HCRA Surcharge,433.8,45,,433.8,percent of total billed charges,Critical Access Hospital RCC factor,327.76,34,,327.76,percent of total billed charges,Implant Device,327.76,34,,327.76,percent of total billed charges,Implant Device,327.76,34,,327.76,percent of total billed charges,Implant Device,327.76,34,,327.76,percent of total billed charges,Implant Device,327.76,34,,327.76,percent of total billed charges,Implant Device,477.18,,,477.18,Other,110% of Medicare,337.4,35,,337.4,percent of total billed charges,Implant Device,327.76,34,"Charges > $500, x 34%",327.76,percent of total billed charges,Implant Device,337.4,35,,337.4,percent of total billed charges,Implant Device,337.4,35,,337.4,percent of total billed charges,Implant Device,337.4,35,,337.4,percent of total billed charges,Implant Device,337.4,35,,337.4,percent of total billed charges,Implant Device,337.4,35,,337.4,percent of total billed charges,Implant Device,385.6,40,,385.6,percent of total billed charges,Implant Device,337.4,70,,337.4,percent of total billed charges,All Other,327.76,34,,327.76,percent of total billed charges,Implant Device,327.76,34,,327.76,percent of total billed charges,Implant Device,337.4,35,,337.4,percent of total billed charges,Implant Device,337.4,35,,337.4,percent of total billed charges,Implant Device,337.4,35,,337.4,percent of total billed charges,Implant Device,337.4,35,,337.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,713.36,
STRYKER 587338RT RT ORTHOLOC PLNTING SYS,C1713,HCPCS,,79013398,CDM,278,RC,,,both,,,8494,6285.58,,,6285.58,Other,150% of Medicare + 9.63% HCRA Surcharge,3822.3,45,,3822.3,percent of total billed charges,Critical Access Hospital RCC factor,2887.96,34,,2887.96,percent of total billed charges,Implant Device,2887.96,34,,2887.96,percent of total billed charges,Implant Device,2887.96,34,,2887.96,percent of total billed charges,Implant Device,2887.96,34,,2887.96,percent of total billed charges,Implant Device,2887.96,34,,2887.96,percent of total billed charges,Implant Device,4204.53,,,4204.53,Other,110% of Medicare,2972.9,35,,2972.9,percent of total billed charges,Implant Device,2887.96,34,"Charges > $500, x 34%",2887.96,percent of total billed charges,Implant Device,2972.9,35,,2972.9,percent of total billed charges,Implant Device,2972.9,35,,2972.9,percent of total billed charges,Implant Device,2972.9,35,,2972.9,percent of total billed charges,Implant Device,2972.9,35,,2972.9,percent of total billed charges,Implant Device,2972.9,35,,2972.9,percent of total billed charges,Implant Device,3397.6,40,,3397.6,percent of total billed charges,Implant Device,2972.9,70,,2972.9,percent of total billed charges,All Other,2887.96,34,,2887.96,percent of total billed charges,Implant Device,2887.96,34,,2887.96,percent of total billed charges,Implant Device,2972.9,35,,2972.9,percent of total billed charges,Implant Device,2972.9,35,,2972.9,percent of total billed charges,Implant Device,2972.9,35,,2972.9,percent of total billed charges,Implant Device,2972.9,35,,2972.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2887.96,34,"If Charge > 2,000, then 34 percent",2887.96,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,6285.58,
STRYKER 58803510 LOCKING SCREW 3.5X10MM,C1713,HCPCS,,79013399,CDM,278,RC,,,both,,,1536,1136.64,,,1136.64,Other,150% of Medicare + 9.63% HCRA Surcharge,691.2,45,,691.2,percent of total billed charges,Critical Access Hospital RCC factor,522.24,34,,522.24,percent of total billed charges,Implant Device,522.24,34,,522.24,percent of total billed charges,Implant Device,522.24,34,,522.24,percent of total billed charges,Implant Device,522.24,34,,522.24,percent of total billed charges,Implant Device,522.24,34,,522.24,percent of total billed charges,Implant Device,760.32,,,760.32,Other,110% of Medicare,537.6,35,,537.6,percent of total billed charges,Implant Device,522.24,34,"Charges > $500, x 34%",522.24,percent of total billed charges,Implant Device,537.6,35,,537.6,percent of total billed charges,Implant Device,537.6,35,,537.6,percent of total billed charges,Implant Device,537.6,35,,537.6,percent of total billed charges,Implant Device,537.6,35,,537.6,percent of total billed charges,Implant Device,537.6,35,,537.6,percent of total billed charges,Implant Device,614.4,40,,614.4,percent of total billed charges,Implant Device,537.6,70,,537.6,percent of total billed charges,All Other,522.24,34,,522.24,percent of total billed charges,Implant Device,522.24,34,,522.24,percent of total billed charges,Implant Device,537.6,35,,537.6,percent of total billed charges,Implant Device,537.6,35,,537.6,percent of total billed charges,Implant Device,537.6,35,,537.6,percent of total billed charges,Implant Device,537.6,35,,537.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1136.64,
STRYKER 58803514 LOCKING SCREW 3.5X14MM,C1713,HCPCS,,79013400,CDM,278,RC,,,both,,,1536,1136.64,,,1136.64,Other,150% of Medicare + 9.63% HCRA Surcharge,691.2,45,,691.2,percent of total billed charges,Critical Access Hospital RCC factor,522.24,34,,522.24,percent of total billed charges,Implant Device,522.24,34,,522.24,percent of total billed charges,Implant Device,522.24,34,,522.24,percent of total billed charges,Implant Device,522.24,34,,522.24,percent of total billed charges,Implant Device,522.24,34,,522.24,percent of total billed charges,Implant Device,760.32,,,760.32,Other,110% of Medicare,537.6,35,,537.6,percent of total billed charges,Implant Device,522.24,34,"Charges > $500, x 34%",522.24,percent of total billed charges,Implant Device,537.6,35,,537.6,percent of total billed charges,Implant Device,537.6,35,,537.6,percent of total billed charges,Implant Device,537.6,35,,537.6,percent of total billed charges,Implant Device,537.6,35,,537.6,percent of total billed charges,Implant Device,537.6,35,,537.6,percent of total billed charges,Implant Device,614.4,40,,614.4,percent of total billed charges,Implant Device,537.6,70,,537.6,percent of total billed charges,All Other,522.24,34,,522.24,percent of total billed charges,Implant Device,522.24,34,,522.24,percent of total billed charges,Implant Device,537.6,35,,537.6,percent of total billed charges,Implant Device,537.6,35,,537.6,percent of total billed charges,Implant Device,537.6,35,,537.6,percent of total billed charges,Implant Device,537.6,35,,537.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1136.64,
EXACTECH 300-01-08 HUMERAL STEM 8MM,C1776,HCPCS,,79013402,CDM,278,RC,,,both,,,4425,3274.51,,,3274.51,Other,150% of Medicare + 9.63% HCRA Surcharge,1991.25,45,,1991.25,percent of total billed charges,Critical Access Hospital RCC factor,1504.5,34,,1504.5,percent of total billed charges,Implant Device,1504.5,34,,1504.5,percent of total billed charges,Implant Device,1504.5,34,,1504.5,percent of total billed charges,Implant Device,1504.5,34,,1504.5,percent of total billed charges,Implant Device,1504.5,34,,1504.5,percent of total billed charges,Implant Device,2190.38,,,2190.38,Other,110% of Medicare,1548.75,35,,1548.75,percent of total billed charges,Implant Device,1504.5,34,"Charges > $500, x 34%",1504.5,percent of total billed charges,Implant Device,1548.75,35,,1548.75,percent of total billed charges,Implant Device,1548.75,35,,1548.75,percent of total billed charges,Implant Device,1548.75,35,,1548.75,percent of total billed charges,Implant Device,1548.75,35,,1548.75,percent of total billed charges,Implant Device,1548.75,35,,1548.75,percent of total billed charges,Implant Device,1770,40,,1770,percent of total billed charges,Implant Device,1548.75,70,,1548.75,percent of total billed charges,All Other,1504.5,34,,1504.5,percent of total billed charges,Implant Device,1504.5,34,,1504.5,percent of total billed charges,Implant Device,1548.75,35,,1548.75,percent of total billed charges,Implant Device,1548.75,35,,1548.75,percent of total billed charges,Implant Device,1548.75,35,,1548.75,percent of total billed charges,Implant Device,1548.75,35,,1548.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1504.5,34,"If Charge > 2,000, then 34 percent",1504.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3274.51,
GORE BXA093901A VBX VIABAHN 9X38MM STENT,C1874,HCPCS,,79013403,CDM,278,RC,,,both,,,11541,8540.37,,,8540.37,Other,150% of Medicare + 9.63% HCRA Surcharge,5193.45,45,,5193.45,percent of total billed charges,Critical Access Hospital RCC factor,3923.94,34,,3923.94,percent of total billed charges,Implant Device,3923.94,34,,3923.94,percent of total billed charges,Implant Device,3923.94,34,,3923.94,percent of total billed charges,Implant Device,3923.94,34,,3923.94,percent of total billed charges,Implant Device,3923.94,34,,3923.94,percent of total billed charges,Implant Device,5712.8,,,5712.8,Other,110% of Medicare,4039.35,35,,4039.35,percent of total billed charges,Implant Device,3923.94,34,"Charges > $500, x 34%",3923.94,percent of total billed charges,Implant Device,4039.35,35,,4039.35,percent of total billed charges,Implant Device,4039.35,35,,4039.35,percent of total billed charges,Implant Device,4039.35,35,,4039.35,percent of total billed charges,Implant Device,4039.35,35,,4039.35,percent of total billed charges,Implant Device,4039.35,35,,4039.35,percent of total billed charges,Implant Device,4616.4,40,,4616.4,percent of total billed charges,Implant Device,4039.35,70,,4039.35,percent of total billed charges,All Other,3923.94,34,,3923.94,percent of total billed charges,Implant Device,3923.94,34,,3923.94,percent of total billed charges,Implant Device,4039.35,35,,4039.35,percent of total billed charges,Implant Device,4039.35,35,,4039.35,percent of total billed charges,Implant Device,4039.35,35,,4039.35,percent of total billed charges,Implant Device,4039.35,35,,4039.35,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3923.94,34,"If Charge > 2,000, then 34 percent",3923.94,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,8540.37,
GORE BXA095901A VBX VIABAHN 9X59MM STENT,C1874,HCPCS,,79013404,CDM,278,RC,,,both,,,11541,8540.37,,,8540.37,Other,150% of Medicare + 9.63% HCRA Surcharge,5193.45,45,,5193.45,percent of total billed charges,Critical Access Hospital RCC factor,3923.94,34,,3923.94,percent of total billed charges,Implant Device,3923.94,34,,3923.94,percent of total billed charges,Implant Device,3923.94,34,,3923.94,percent of total billed charges,Implant Device,3923.94,34,,3923.94,percent of total billed charges,Implant Device,3923.94,34,,3923.94,percent of total billed charges,Implant Device,5712.8,,,5712.8,Other,110% of Medicare,4039.35,35,,4039.35,percent of total billed charges,Implant Device,3923.94,34,"Charges > $500, x 34%",3923.94,percent of total billed charges,Implant Device,4039.35,35,,4039.35,percent of total billed charges,Implant Device,4039.35,35,,4039.35,percent of total billed charges,Implant Device,4039.35,35,,4039.35,percent of total billed charges,Implant Device,4039.35,35,,4039.35,percent of total billed charges,Implant Device,4039.35,35,,4039.35,percent of total billed charges,Implant Device,4616.4,40,,4616.4,percent of total billed charges,Implant Device,4039.35,70,,4039.35,percent of total billed charges,All Other,3923.94,34,,3923.94,percent of total billed charges,Implant Device,3923.94,34,,3923.94,percent of total billed charges,Implant Device,4039.35,35,,4039.35,percent of total billed charges,Implant Device,4039.35,35,,4039.35,percent of total billed charges,Implant Device,4039.35,35,,4039.35,percent of total billed charges,Implant Device,4039.35,35,,4039.35,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3923.94,34,"If Charge > 2,000, then 34 percent",3923.94,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,8540.37,
GORE BXA113901A VIABAHN 11X39MM STENT,C1874,HCPCS,,79013405,CDM,278,RC,,,both,,,11541,8540.37,,,8540.37,Other,150% of Medicare + 9.63% HCRA Surcharge,5193.45,45,,5193.45,percent of total billed charges,Critical Access Hospital RCC factor,3923.94,34,,3923.94,percent of total billed charges,Implant Device,3923.94,34,,3923.94,percent of total billed charges,Implant Device,3923.94,34,,3923.94,percent of total billed charges,Implant Device,3923.94,34,,3923.94,percent of total billed charges,Implant Device,3923.94,34,,3923.94,percent of total billed charges,Implant Device,5712.8,,,5712.8,Other,110% of Medicare,4039.35,35,,4039.35,percent of total billed charges,Implant Device,3923.94,34,"Charges > $500, x 34%",3923.94,percent of total billed charges,Implant Device,4039.35,35,,4039.35,percent of total billed charges,Implant Device,4039.35,35,,4039.35,percent of total billed charges,Implant Device,4039.35,35,,4039.35,percent of total billed charges,Implant Device,4039.35,35,,4039.35,percent of total billed charges,Implant Device,4039.35,35,,4039.35,percent of total billed charges,Implant Device,4616.4,40,,4616.4,percent of total billed charges,Implant Device,4039.35,70,,4039.35,percent of total billed charges,All Other,3923.94,34,,3923.94,percent of total billed charges,Implant Device,3923.94,34,,3923.94,percent of total billed charges,Implant Device,4039.35,35,,4039.35,percent of total billed charges,Implant Device,4039.35,35,,4039.35,percent of total billed charges,Implant Device,4039.35,35,,4039.35,percent of total billed charges,Implant Device,4039.35,35,,4039.35,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3923.94,34,"If Charge > 2,000, then 34 percent",3923.94,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,8540.37,
GORE BXA115901A VIABAHN 11X59MM STENT,C1874,HCPCS,,79013406,CDM,278,RC,,,both,,,11541,8540.37,,,8540.37,Other,150% of Medicare + 9.63% HCRA Surcharge,5193.45,45,,5193.45,percent of total billed charges,Critical Access Hospital RCC factor,3923.94,34,,3923.94,percent of total billed charges,Implant Device,3923.94,34,,3923.94,percent of total billed charges,Implant Device,3923.94,34,,3923.94,percent of total billed charges,Implant Device,3923.94,34,,3923.94,percent of total billed charges,Implant Device,3923.94,34,,3923.94,percent of total billed charges,Implant Device,5712.8,,,5712.8,Other,110% of Medicare,4039.35,35,,4039.35,percent of total billed charges,Implant Device,3923.94,34,"Charges > $500, x 34%",3923.94,percent of total billed charges,Implant Device,4039.35,35,,4039.35,percent of total billed charges,Implant Device,4039.35,35,,4039.35,percent of total billed charges,Implant Device,4039.35,35,,4039.35,percent of total billed charges,Implant Device,4039.35,35,,4039.35,percent of total billed charges,Implant Device,4039.35,35,,4039.35,percent of total billed charges,Implant Device,4616.4,40,,4616.4,percent of total billed charges,Implant Device,4039.35,70,,4039.35,percent of total billed charges,All Other,3923.94,34,,3923.94,percent of total billed charges,Implant Device,3923.94,34,,3923.94,percent of total billed charges,Implant Device,4039.35,35,,4039.35,percent of total billed charges,Implant Device,4039.35,35,,4039.35,percent of total billed charges,Implant Device,4039.35,35,,4039.35,percent of total billed charges,Implant Device,4039.35,35,,4039.35,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3923.94,34,"If Charge > 2,000, then 34 percent",3923.94,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,8540.37,
J&J 1516-30-506 ATTUNE TIB INS SZ 5 6MM,C1776,HCPCS,,79013411,CDM,278,RC,,,both,,,5400,3996.01,,,3996.01,Other,150% of Medicare + 9.63% HCRA Surcharge,2430,45,,2430,percent of total billed charges,Critical Access Hospital RCC factor,1836,34,,1836,percent of total billed charges,Implant Device,1836,34,,1836,percent of total billed charges,Implant Device,1836,34,,1836,percent of total billed charges,Implant Device,1836,34,,1836,percent of total billed charges,Implant Device,1836,34,,1836,percent of total billed charges,Implant Device,2673,,,2673,Other,110% of Medicare,1890,35,,1890,percent of total billed charges,Implant Device,1836,34,"Charges > $500, x 34%",1836,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,2160,40,,2160,percent of total billed charges,Implant Device,1890,70,,1890,percent of total billed charges,All Other,1836,34,,1836,percent of total billed charges,Implant Device,1836,34,,1836,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1836,34,"If Charge > 2,000, then 34 percent",1836,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3996.01,
J&J 1504-00-124 ATTUNE FEMORAL SZ 4N LT,C1776,HCPCS,,79013412,CDM,278,RC,,,both,,,4800,3552.01,,,3552.01,Other,150% of Medicare + 9.63% HCRA Surcharge,2160,45,,2160,percent of total billed charges,Critical Access Hospital RCC factor,1632,34,,1632,percent of total billed charges,Implant Device,1632,34,,1632,percent of total billed charges,Implant Device,1632,34,,1632,percent of total billed charges,Implant Device,1632,34,,1632,percent of total billed charges,Implant Device,1632,34,,1632,percent of total billed charges,Implant Device,2376,,,2376,Other,110% of Medicare,1680,35,,1680,percent of total billed charges,Implant Device,1632,34,"Charges > $500, x 34%",1632,percent of total billed charges,Implant Device,1680,35,,1680,percent of total billed charges,Implant Device,1680,35,,1680,percent of total billed charges,Implant Device,1680,35,,1680,percent of total billed charges,Implant Device,1680,35,,1680,percent of total billed charges,Implant Device,1680,35,,1680,percent of total billed charges,Implant Device,1920,40,,1920,percent of total billed charges,Implant Device,1680,70,,1680,percent of total billed charges,All Other,1632,34,,1632,percent of total billed charges,Implant Device,1632,34,,1632,percent of total billed charges,Implant Device,1680,35,,1680,percent of total billed charges,Implant Device,1680,35,,1680,percent of total billed charges,Implant Device,1680,35,,1680,percent of total billed charges,Implant Device,1680,35,,1680,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1632,34,"If Charge > 2,000, then 34 percent",1632,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3552.01,
J&J 1506-80-002 ATTUNE TIB INS SZ 4 8MM,C1776,HCPCS,,79013413,CDM,278,RC,,,both,,,3900,2886.01,,,2886.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1755,45,,1755,percent of total billed charges,Critical Access Hospital RCC factor,1326,34,,1326,percent of total billed charges,Implant Device,1326,34,,1326,percent of total billed charges,Implant Device,1326,34,,1326,percent of total billed charges,Implant Device,1326,34,,1326,percent of total billed charges,Implant Device,1326,34,,1326,percent of total billed charges,Implant Device,1930.5,,,1930.5,Other,110% of Medicare,1365,35,,1365,percent of total billed charges,Implant Device,1326,34,"Charges > $500, x 34%",1326,percent of total billed charges,Implant Device,1365,35,,1365,percent of total billed charges,Implant Device,1365,35,,1365,percent of total billed charges,Implant Device,1365,35,,1365,percent of total billed charges,Implant Device,1365,35,,1365,percent of total billed charges,Implant Device,1365,35,,1365,percent of total billed charges,Implant Device,1560,40,,1560,percent of total billed charges,Implant Device,1365,70,,1365,percent of total billed charges,All Other,1326,34,,1326,percent of total billed charges,Implant Device,1326,34,,1326,percent of total billed charges,Implant Device,1365,35,,1365,percent of total billed charges,Implant Device,1365,35,,1365,percent of total billed charges,Implant Device,1365,35,,1365,percent of total billed charges,Implant Device,1365,35,,1365,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1326,34,"If Charge > 2,000, then 34 percent",1326,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2886.01,
ZIMMER 14-444224 FEMORAL NAIL 10.5X240MM,C1713,HCPCS,,79013414,CDM,278,RC,,,both,,,5715,4229.11,,,4229.11,Other,150% of Medicare + 9.63% HCRA Surcharge,2571.75,45,,2571.75,percent of total billed charges,Critical Access Hospital RCC factor,1943.1,34,,1943.1,percent of total billed charges,Implant Device,1943.1,34,,1943.1,percent of total billed charges,Implant Device,1943.1,34,,1943.1,percent of total billed charges,Implant Device,1943.1,34,,1943.1,percent of total billed charges,Implant Device,1943.1,34,,1943.1,percent of total billed charges,Implant Device,2828.93,,,2828.93,Other,110% of Medicare,2000.25,35,,2000.25,percent of total billed charges,Implant Device,1943.1,34,"Charges > $500, x 34%",1943.1,percent of total billed charges,Implant Device,2000.25,35,,2000.25,percent of total billed charges,Implant Device,2000.25,35,,2000.25,percent of total billed charges,Implant Device,2000.25,35,,2000.25,percent of total billed charges,Implant Device,2000.25,35,,2000.25,percent of total billed charges,Implant Device,2000.25,35,,2000.25,percent of total billed charges,Implant Device,2286,40,,2286,percent of total billed charges,Implant Device,2000.25,70,,2000.25,percent of total billed charges,All Other,1943.1,34,,1943.1,percent of total billed charges,Implant Device,1943.1,34,,1943.1,percent of total billed charges,Implant Device,2000.25,35,,2000.25,percent of total billed charges,Implant Device,2000.25,35,,2000.25,percent of total billed charges,Implant Device,2000.25,35,,2000.25,percent of total billed charges,Implant Device,2000.25,35,,2000.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1943.1,34,"If Charge > 2,000, then 34 percent",1943.1,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4229.11,
ZIMMER 14-405050 CORTICAL SCREW 5.0X50MM,C1713,HCPCS,,79013415,CDM,278,RC,,,both,,,634,469.16,,,469.16,Other,150% of Medicare + 9.63% HCRA Surcharge,285.3,45,,285.3,percent of total billed charges,Critical Access Hospital RCC factor,215.56,34,,215.56,percent of total billed charges,Implant Device,215.56,34,,215.56,percent of total billed charges,Implant Device,215.56,34,,215.56,percent of total billed charges,Implant Device,215.56,34,,215.56,percent of total billed charges,Implant Device,215.56,34,,215.56,percent of total billed charges,Implant Device,313.83,,,313.83,Other,110% of Medicare,221.9,35,,221.9,percent of total billed charges,Implant Device,215.56,34,"Charges > $500, x 34%",215.56,percent of total billed charges,Implant Device,221.9,35,,221.9,percent of total billed charges,Implant Device,221.9,35,,221.9,percent of total billed charges,Implant Device,221.9,35,,221.9,percent of total billed charges,Implant Device,221.9,35,,221.9,percent of total billed charges,Implant Device,221.9,35,,221.9,percent of total billed charges,Implant Device,253.6,40,,253.6,percent of total billed charges,Implant Device,221.9,70,,221.9,percent of total billed charges,All Other,215.56,34,,215.56,percent of total billed charges,Implant Device,215.56,34,,215.56,percent of total billed charges,Implant Device,221.9,35,,221.9,percent of total billed charges,Implant Device,221.9,35,,221.9,percent of total billed charges,Implant Device,221.9,35,,221.9,percent of total billed charges,Implant Device,221.9,35,,221.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,469.16,
ZIMMER 14-405070 CORTICAL SCREW 5.0X70MM,C1713,HCPCS,,79013416,CDM,278,RC,,,both,,,634,469.16,,,469.16,Other,150% of Medicare + 9.63% HCRA Surcharge,285.3,45,,285.3,percent of total billed charges,Critical Access Hospital RCC factor,215.56,34,,215.56,percent of total billed charges,Implant Device,215.56,34,,215.56,percent of total billed charges,Implant Device,215.56,34,,215.56,percent of total billed charges,Implant Device,215.56,34,,215.56,percent of total billed charges,Implant Device,215.56,34,,215.56,percent of total billed charges,Implant Device,313.83,,,313.83,Other,110% of Medicare,221.9,35,,221.9,percent of total billed charges,Implant Device,215.56,34,"Charges > $500, x 34%",215.56,percent of total billed charges,Implant Device,221.9,35,,221.9,percent of total billed charges,Implant Device,221.9,35,,221.9,percent of total billed charges,Implant Device,221.9,35,,221.9,percent of total billed charges,Implant Device,221.9,35,,221.9,percent of total billed charges,Implant Device,221.9,35,,221.9,percent of total billed charges,Implant Device,253.6,40,,253.6,percent of total billed charges,Implant Device,221.9,70,,221.9,percent of total billed charges,All Other,215.56,34,,215.56,percent of total billed charges,Implant Device,215.56,34,,215.56,percent of total billed charges,Implant Device,221.9,35,,221.9,percent of total billed charges,Implant Device,221.9,35,,221.9,percent of total billed charges,Implant Device,221.9,35,,221.9,percent of total billed charges,Implant Device,221.9,35,,221.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,469.16,
ZIMMER 14-405090 CORTICAL SCREW 5X90MM,C1713,HCPCS,,79013417,CDM,278,RC,,,both,,,634,469.16,,,469.16,Other,150% of Medicare + 9.63% HCRA Surcharge,285.3,45,,285.3,percent of total billed charges,Critical Access Hospital RCC factor,215.56,34,,215.56,percent of total billed charges,Implant Device,215.56,34,,215.56,percent of total billed charges,Implant Device,215.56,34,,215.56,percent of total billed charges,Implant Device,215.56,34,,215.56,percent of total billed charges,Implant Device,215.56,34,,215.56,percent of total billed charges,Implant Device,313.83,,,313.83,Other,110% of Medicare,221.9,35,,221.9,percent of total billed charges,Implant Device,215.56,34,"Charges > $500, x 34%",215.56,percent of total billed charges,Implant Device,221.9,35,,221.9,percent of total billed charges,Implant Device,221.9,35,,221.9,percent of total billed charges,Implant Device,221.9,35,,221.9,percent of total billed charges,Implant Device,221.9,35,,221.9,percent of total billed charges,Implant Device,221.9,35,,221.9,percent of total billed charges,Implant Device,253.6,40,,253.6,percent of total billed charges,Implant Device,221.9,70,,221.9,percent of total billed charges,All Other,215.56,34,,215.56,percent of total billed charges,Implant Device,215.56,34,,215.56,percent of total billed charges,Implant Device,221.9,35,,221.9,percent of total billed charges,Implant Device,221.9,35,,221.9,percent of total billed charges,Implant Device,221.9,35,,221.9,percent of total billed charges,Implant Device,221.9,35,,221.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,469.16,
ZIMMER 02.03264.112 NCB DIS FEM PLT 278,C1713,HCPCS,,79013418,CDM,278,RC,,,both,,,3859,2855.67,,,2855.67,Other,150% of Medicare + 9.63% HCRA Surcharge,1736.55,45,,1736.55,percent of total billed charges,Critical Access Hospital RCC factor,1312.06,34,,1312.06,percent of total billed charges,Implant Device,1312.06,34,,1312.06,percent of total billed charges,Implant Device,1312.06,34,,1312.06,percent of total billed charges,Implant Device,1312.06,34,,1312.06,percent of total billed charges,Implant Device,1312.06,34,,1312.06,percent of total billed charges,Implant Device,1910.21,,,1910.21,Other,110% of Medicare,1350.65,35,,1350.65,percent of total billed charges,Implant Device,1312.06,34,"Charges > $500, x 34%",1312.06,percent of total billed charges,Implant Device,1350.65,35,,1350.65,percent of total billed charges,Implant Device,1350.65,35,,1350.65,percent of total billed charges,Implant Device,1350.65,35,,1350.65,percent of total billed charges,Implant Device,1350.65,35,,1350.65,percent of total billed charges,Implant Device,1350.65,35,,1350.65,percent of total billed charges,Implant Device,1543.6,40,,1543.6,percent of total billed charges,Implant Device,1350.65,70,,1350.65,percent of total billed charges,All Other,1312.06,34,,1312.06,percent of total billed charges,Implant Device,1312.06,34,,1312.06,percent of total billed charges,Implant Device,1350.65,35,,1350.65,percent of total billed charges,Implant Device,1350.65,35,,1350.65,percent of total billed charges,Implant Device,1350.65,35,,1350.65,percent of total billed charges,Implant Device,1350.65,35,,1350.65,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1312.06,34,"If Charge > 2,000, then 34 percent",1312.06,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2855.67,
ZIMMER 02.03152.050 CAN SCREW 5X50MM,C1713,HCPCS,,79013419,CDM,278,RC,,,both,,,403,298.22,,,298.22,Other,150% of Medicare + 9.63% HCRA Surcharge,181.35,45,,181.35,percent of total billed charges,Critical Access Hospital RCC factor,137.02,34,,137.02,percent of total billed charges,Implant Device,137.02,34,,137.02,percent of total billed charges,Implant Device,137.02,34,,137.02,percent of total billed charges,Implant Device,137.02,34,,137.02,percent of total billed charges,Implant Device,137.02,34,,137.02,percent of total billed charges,Implant Device,199.49,,,199.49,Other,110% of Medicare,141.05,35,,141.05,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,141.05,35,,141.05,percent of total billed charges,Implant Device,141.05,35,,141.05,percent of total billed charges,Implant Device,141.05,35,,141.05,percent of total billed charges,Implant Device,141.05,35,,141.05,percent of total billed charges,Implant Device,141.05,35,,141.05,percent of total billed charges,Implant Device,161.2,40,,161.2,percent of total billed charges,Implant Device,141.05,70,,141.05,percent of total billed charges,All Other,137.02,34,,137.02,percent of total billed charges,Implant Device,137.02,34,,137.02,percent of total billed charges,Implant Device,141.05,35,,141.05,percent of total billed charges,Implant Device,141.05,35,,141.05,percent of total billed charges,Implant Device,141.05,35,,141.05,percent of total billed charges,Implant Device,141.05,35,,141.05,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,298.22,
ZIMMER 02.03150.060 CORT SCREW 5X60MM,C1713,HCPCS,,79013420,CDM,278,RC,,,both,,,475,351.5,,,351.5,Other,150% of Medicare + 9.63% HCRA Surcharge,213.75,45,,213.75,percent of total billed charges,Critical Access Hospital RCC factor,161.5,34,,161.5,percent of total billed charges,Implant Device,161.5,34,,161.5,percent of total billed charges,Implant Device,161.5,34,,161.5,percent of total billed charges,Implant Device,161.5,34,,161.5,percent of total billed charges,Implant Device,161.5,34,,161.5,percent of total billed charges,Implant Device,235.13,,,235.13,Other,110% of Medicare,166.25,35,,166.25,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,166.25,35,,166.25,percent of total billed charges,Implant Device,166.25,35,,166.25,percent of total billed charges,Implant Device,166.25,35,,166.25,percent of total billed charges,Implant Device,166.25,35,,166.25,percent of total billed charges,Implant Device,166.25,35,,166.25,percent of total billed charges,Implant Device,190,40,,190,percent of total billed charges,Implant Device,166.25,70,,166.25,percent of total billed charges,All Other,161.5,34,,161.5,percent of total billed charges,Implant Device,161.5,34,,161.5,percent of total billed charges,Implant Device,166.25,35,,166.25,percent of total billed charges,Implant Device,166.25,35,,166.25,percent of total billed charges,Implant Device,166.25,35,,166.25,percent of total billed charges,Implant Device,166.25,35,,166.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,351.5,
ZIMMER 02.03150.055 CORT SCREW 5X55MM,C1713,HCPCS,,79013421,CDM,278,RC,,,both,,,475,351.5,,,351.5,Other,150% of Medicare + 9.63% HCRA Surcharge,213.75,45,,213.75,percent of total billed charges,Critical Access Hospital RCC factor,161.5,34,,161.5,percent of total billed charges,Implant Device,161.5,34,,161.5,percent of total billed charges,Implant Device,161.5,34,,161.5,percent of total billed charges,Implant Device,161.5,34,,161.5,percent of total billed charges,Implant Device,161.5,34,,161.5,percent of total billed charges,Implant Device,235.13,,,235.13,Other,110% of Medicare,166.25,35,,166.25,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,166.25,35,,166.25,percent of total billed charges,Implant Device,166.25,35,,166.25,percent of total billed charges,Implant Device,166.25,35,,166.25,percent of total billed charges,Implant Device,166.25,35,,166.25,percent of total billed charges,Implant Device,166.25,35,,166.25,percent of total billed charges,Implant Device,190,40,,190,percent of total billed charges,Implant Device,166.25,70,,166.25,percent of total billed charges,All Other,161.5,34,,161.5,percent of total billed charges,Implant Device,161.5,34,,161.5,percent of total billed charges,Implant Device,166.25,35,,166.25,percent of total billed charges,Implant Device,166.25,35,,166.25,percent of total billed charges,Implant Device,166.25,35,,166.25,percent of total billed charges,Implant Device,166.25,35,,166.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,351.5,
ZIMMER 02.03151.020 UNCORT SCREW 5X20MM,C1713,HCPCS,,79013422,CDM,278,RC,,,both,,,446,330.04,,,330.04,Other,150% of Medicare + 9.63% HCRA Surcharge,200.7,45,,200.7,percent of total billed charges,Critical Access Hospital RCC factor,151.64,34,,151.64,percent of total billed charges,Implant Device,151.64,34,,151.64,percent of total billed charges,Implant Device,151.64,34,,151.64,percent of total billed charges,Implant Device,151.64,34,,151.64,percent of total billed charges,Implant Device,151.64,34,,151.64,percent of total billed charges,Implant Device,220.77,,,220.77,Other,110% of Medicare,156.1,35,,156.1,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,156.1,35,,156.1,percent of total billed charges,Implant Device,156.1,35,,156.1,percent of total billed charges,Implant Device,156.1,35,,156.1,percent of total billed charges,Implant Device,156.1,35,,156.1,percent of total billed charges,Implant Device,156.1,35,,156.1,percent of total billed charges,Implant Device,178.4,40,,178.4,percent of total billed charges,Implant Device,156.1,70,,156.1,percent of total billed charges,All Other,151.64,34,,151.64,percent of total billed charges,Implant Device,151.64,34,,151.64,percent of total billed charges,Implant Device,156.1,35,,156.1,percent of total billed charges,Implant Device,156.1,35,,156.1,percent of total billed charges,Implant Device,156.1,35,,156.1,percent of total billed charges,Implant Device,156.1,35,,156.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,330.04,
ZIMMER 02.03150.038 CORT SCREW 5X38MM,C1713,HCPCS,,79013423,CDM,278,RC,,,both,,,475,351.5,,,351.5,Other,150% of Medicare + 9.63% HCRA Surcharge,213.75,45,,213.75,percent of total billed charges,Critical Access Hospital RCC factor,161.5,34,,161.5,percent of total billed charges,Implant Device,161.5,34,,161.5,percent of total billed charges,Implant Device,161.5,34,,161.5,percent of total billed charges,Implant Device,161.5,34,,161.5,percent of total billed charges,Implant Device,161.5,34,,161.5,percent of total billed charges,Implant Device,235.13,,,235.13,Other,110% of Medicare,166.25,35,,166.25,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,166.25,35,,166.25,percent of total billed charges,Implant Device,166.25,35,,166.25,percent of total billed charges,Implant Device,166.25,35,,166.25,percent of total billed charges,Implant Device,166.25,35,,166.25,percent of total billed charges,Implant Device,166.25,35,,166.25,percent of total billed charges,Implant Device,190,40,,190,percent of total billed charges,Implant Device,166.25,70,,166.25,percent of total billed charges,All Other,161.5,34,,161.5,percent of total billed charges,Implant Device,161.5,34,,161.5,percent of total billed charges,Implant Device,166.25,35,,166.25,percent of total billed charges,Implant Device,166.25,35,,166.25,percent of total billed charges,Implant Device,166.25,35,,166.25,percent of total billed charges,Implant Device,166.25,35,,166.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,351.5,
STRYKER 625094 DORSAL PLT NARROW RT 58MM,C1713,HCPCS,,79013424,CDM,278,RC,,,both,,,3083,2281.43,,,2281.43,Other,150% of Medicare + 9.63% HCRA Surcharge,1387.35,45,,1387.35,percent of total billed charges,Critical Access Hospital RCC factor,1048.22,34,,1048.22,percent of total billed charges,Implant Device,1048.22,34,,1048.22,percent of total billed charges,Implant Device,1048.22,34,,1048.22,percent of total billed charges,Implant Device,1048.22,34,,1048.22,percent of total billed charges,Implant Device,1048.22,34,,1048.22,percent of total billed charges,Implant Device,1526.09,,,1526.09,Other,110% of Medicare,1079.05,35,,1079.05,percent of total billed charges,Implant Device,1048.22,34,"Charges > $500, x 34%",1048.22,percent of total billed charges,Implant Device,1079.05,35,,1079.05,percent of total billed charges,Implant Device,1079.05,35,,1079.05,percent of total billed charges,Implant Device,1079.05,35,,1079.05,percent of total billed charges,Implant Device,1079.05,35,,1079.05,percent of total billed charges,Implant Device,1079.05,35,,1079.05,percent of total billed charges,Implant Device,1233.2,40,,1233.2,percent of total billed charges,Implant Device,1079.05,70,,1079.05,percent of total billed charges,All Other,1048.22,34,,1048.22,percent of total billed charges,Implant Device,1048.22,34,,1048.22,percent of total billed charges,Implant Device,1079.05,35,,1079.05,percent of total billed charges,Implant Device,1079.05,35,,1079.05,percent of total billed charges,Implant Device,1079.05,35,,1079.05,percent of total billed charges,Implant Device,1079.05,35,,1079.05,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1048.22,34,"If Charge > 2,000, then 34 percent",1048.22,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2281.43,
J&J 1010-11-110 FEMORAL STEM SIZE 11,C1776,HCPCS,,79013425,CDM,278,RC,,,both,,,7410,5483.42,,,5483.42,Other,150% of Medicare + 9.63% HCRA Surcharge,3334.5,45,,3334.5,percent of total billed charges,Critical Access Hospital RCC factor,2519.4,34,,2519.4,percent of total billed charges,Implant Device,2519.4,34,,2519.4,percent of total billed charges,Implant Device,2519.4,34,,2519.4,percent of total billed charges,Implant Device,2519.4,34,,2519.4,percent of total billed charges,Implant Device,2519.4,34,,2519.4,percent of total billed charges,Implant Device,3667.95,,,3667.95,Other,110% of Medicare,2593.5,35,,2593.5,percent of total billed charges,Implant Device,2519.4,34,"Charges > $500, x 34%",2519.4,percent of total billed charges,Implant Device,2593.5,35,,2593.5,percent of total billed charges,Implant Device,2593.5,35,,2593.5,percent of total billed charges,Implant Device,2593.5,35,,2593.5,percent of total billed charges,Implant Device,2593.5,35,,2593.5,percent of total billed charges,Implant Device,2593.5,35,,2593.5,percent of total billed charges,Implant Device,2964,40,,2964,percent of total billed charges,Implant Device,2593.5,70,,2593.5,percent of total billed charges,All Other,2519.4,34,,2519.4,percent of total billed charges,Implant Device,2519.4,34,,2519.4,percent of total billed charges,Implant Device,2593.5,35,,2593.5,percent of total billed charges,Implant Device,2593.5,35,,2593.5,percent of total billed charges,Implant Device,2593.5,35,,2593.5,percent of total billed charges,Implant Device,2593.5,35,,2593.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2519.4,34,"If Charge > 2,000, then 34 percent",2519.4,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5483.42,
J&J 1504-10-108 ATTUNE FEMORAL SIZE 8 LT,C1776,HCPCS,,79013426,CDM,278,RC,,,both,,,4800,3552.01,,,3552.01,Other,150% of Medicare + 9.63% HCRA Surcharge,2160,45,,2160,percent of total billed charges,Critical Access Hospital RCC factor,1632,34,,1632,percent of total billed charges,Implant Device,1632,34,,1632,percent of total billed charges,Implant Device,1632,34,,1632,percent of total billed charges,Implant Device,1632,34,,1632,percent of total billed charges,Implant Device,1632,34,,1632,percent of total billed charges,Implant Device,2376,,,2376,Other,110% of Medicare,1680,35,,1680,percent of total billed charges,Implant Device,1632,34,"Charges > $500, x 34%",1632,percent of total billed charges,Implant Device,1680,35,,1680,percent of total billed charges,Implant Device,1680,35,,1680,percent of total billed charges,Implant Device,1680,35,,1680,percent of total billed charges,Implant Device,1680,35,,1680,percent of total billed charges,Implant Device,1680,35,,1680,percent of total billed charges,Implant Device,1920,40,,1920,percent of total billed charges,Implant Device,1680,70,,1680,percent of total billed charges,All Other,1632,34,,1632,percent of total billed charges,Implant Device,1632,34,,1632,percent of total billed charges,Implant Device,1680,35,,1680,percent of total billed charges,Implant Device,1680,35,,1680,percent of total billed charges,Implant Device,1680,35,,1680,percent of total billed charges,Implant Device,1680,35,,1680,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1632,34,"If Charge > 2,000, then 34 percent",1632,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3552.01,
J&J 1516-50-810 TIBIAL INSERT SZ 8 10MM,C1776,HCPCS,,79013427,CDM,278,RC,,,both,,,5400,3996.01,,,3996.01,Other,150% of Medicare + 9.63% HCRA Surcharge,2430,45,,2430,percent of total billed charges,Critical Access Hospital RCC factor,1836,34,,1836,percent of total billed charges,Implant Device,1836,34,,1836,percent of total billed charges,Implant Device,1836,34,,1836,percent of total billed charges,Implant Device,1836,34,,1836,percent of total billed charges,Implant Device,1836,34,,1836,percent of total billed charges,Implant Device,2673,,,2673,Other,110% of Medicare,1890,35,,1890,percent of total billed charges,Implant Device,1836,34,"Charges > $500, x 34%",1836,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,2160,40,,2160,percent of total billed charges,Implant Device,1890,70,,1890,percent of total billed charges,All Other,1836,34,,1836,percent of total billed charges,Implant Device,1836,34,,1836,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1836,34,"If Charge > 2,000, then 34 percent",1836,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3996.01,
BOST H7493929460061 6X60X130 ELU STENT,C1874,HCPCS,,79013428,CDM,278,RC,,,both,,,6825,5050.52,,,5050.52,Other,150% of Medicare + 9.63% HCRA Surcharge,3071.25,45,,3071.25,percent of total billed charges,Critical Access Hospital RCC factor,2320.5,34,,2320.5,percent of total billed charges,Implant Device,2320.5,34,,2320.5,percent of total billed charges,Implant Device,2320.5,34,,2320.5,percent of total billed charges,Implant Device,2320.5,34,,2320.5,percent of total billed charges,Implant Device,2320.5,34,,2320.5,percent of total billed charges,Implant Device,3378.38,,,3378.38,Other,110% of Medicare,2388.75,35,,2388.75,percent of total billed charges,Implant Device,2320.5,34,"Charges > $500, x 34%",2320.5,percent of total billed charges,Implant Device,2388.75,35,,2388.75,percent of total billed charges,Implant Device,2388.75,35,,2388.75,percent of total billed charges,Implant Device,2388.75,35,,2388.75,percent of total billed charges,Implant Device,2388.75,35,,2388.75,percent of total billed charges,Implant Device,2388.75,35,,2388.75,percent of total billed charges,Implant Device,2730,40,,2730,percent of total billed charges,Implant Device,2388.75,70,,2388.75,percent of total billed charges,All Other,2320.5,34,,2320.5,percent of total billed charges,Implant Device,2320.5,34,,2320.5,percent of total billed charges,Implant Device,2388.75,35,,2388.75,percent of total billed charges,Implant Device,2388.75,35,,2388.75,percent of total billed charges,Implant Device,2388.75,35,,2388.75,percent of total billed charges,Implant Device,2388.75,35,,2388.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2320.5,34,"If Charge > 2,000, then 34 percent",2320.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5050.52,
BOST H7493929460151 6X150X130 ELU STENT,C1874,HCPCS,,79013429,CDM,278,RC,,,both,,,11085,8202.93,,,8202.93,Other,150% of Medicare + 9.63% HCRA Surcharge,4988.25,45,,4988.25,percent of total billed charges,Critical Access Hospital RCC factor,3768.9,34,,3768.9,percent of total billed charges,Implant Device,3768.9,34,,3768.9,percent of total billed charges,Implant Device,3768.9,34,,3768.9,percent of total billed charges,Implant Device,3768.9,34,,3768.9,percent of total billed charges,Implant Device,3768.9,34,,3768.9,percent of total billed charges,Implant Device,5487.08,,,5487.08,Other,110% of Medicare,3879.75,35,,3879.75,percent of total billed charges,Implant Device,3768.9,34,"Charges > $500, x 34%",3768.9,percent of total billed charges,Implant Device,3879.75,35,,3879.75,percent of total billed charges,Implant Device,3879.75,35,,3879.75,percent of total billed charges,Implant Device,3879.75,35,,3879.75,percent of total billed charges,Implant Device,3879.75,35,,3879.75,percent of total billed charges,Implant Device,3879.75,35,,3879.75,percent of total billed charges,Implant Device,4434,40,,4434,percent of total billed charges,Implant Device,3879.75,70,,3879.75,percent of total billed charges,All Other,3768.9,34,,3768.9,percent of total billed charges,Implant Device,3768.9,34,,3768.9,percent of total billed charges,Implant Device,3879.75,35,,3879.75,percent of total billed charges,Implant Device,3879.75,35,,3879.75,percent of total billed charges,Implant Device,3879.75,35,,3879.75,percent of total billed charges,Implant Device,3879.75,35,,3879.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3768.9,34,"If Charge > 2,000, then 34 percent",3768.9,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,8202.93,
BOST H7493929470061 7X60X130 ELU STENT,C1874,HCPCS,,79013430,CDM,278,RC,,,both,,,6825,5050.52,,,5050.52,Other,150% of Medicare + 9.63% HCRA Surcharge,3071.25,45,,3071.25,percent of total billed charges,Critical Access Hospital RCC factor,2320.5,34,,2320.5,percent of total billed charges,Implant Device,2320.5,34,,2320.5,percent of total billed charges,Implant Device,2320.5,34,,2320.5,percent of total billed charges,Implant Device,2320.5,34,,2320.5,percent of total billed charges,Implant Device,2320.5,34,,2320.5,percent of total billed charges,Implant Device,3378.38,,,3378.38,Other,110% of Medicare,2388.75,35,,2388.75,percent of total billed charges,Implant Device,2320.5,34,"Charges > $500, x 34%",2320.5,percent of total billed charges,Implant Device,2388.75,35,,2388.75,percent of total billed charges,Implant Device,2388.75,35,,2388.75,percent of total billed charges,Implant Device,2388.75,35,,2388.75,percent of total billed charges,Implant Device,2388.75,35,,2388.75,percent of total billed charges,Implant Device,2388.75,35,,2388.75,percent of total billed charges,Implant Device,2730,40,,2730,percent of total billed charges,Implant Device,2388.75,70,,2388.75,percent of total billed charges,All Other,2320.5,34,,2320.5,percent of total billed charges,Implant Device,2320.5,34,,2320.5,percent of total billed charges,Implant Device,2388.75,35,,2388.75,percent of total billed charges,Implant Device,2388.75,35,,2388.75,percent of total billed charges,Implant Device,2388.75,35,,2388.75,percent of total billed charges,Implant Device,2388.75,35,,2388.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2320.5,34,"If Charge > 2,000, then 34 percent",2320.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5050.52,
BOST H74938046640750 EXP LD 6X37X75CM,C1876,HCPCS,,79013431,CDM,278,RC,,,both,,,1976,1462.24,,,1462.24,Other,150% of Medicare + 9.63% HCRA Surcharge,889.2,45,,889.2,percent of total billed charges,Critical Access Hospital RCC factor,671.84,34,,671.84,percent of total billed charges,Implant Device,671.84,34,,671.84,percent of total billed charges,Implant Device,671.84,34,,671.84,percent of total billed charges,Implant Device,671.84,34,,671.84,percent of total billed charges,Implant Device,671.84,34,,671.84,percent of total billed charges,Implant Device,978.12,,,978.12,Other,110% of Medicare,691.6,35,,691.6,percent of total billed charges,Implant Device,671.84,34,"Charges > $500, x 34%",671.84,percent of total billed charges,Implant Device,691.6,35,,691.6,percent of total billed charges,Implant Device,691.6,35,,691.6,percent of total billed charges,Implant Device,691.6,35,,691.6,percent of total billed charges,Implant Device,691.6,35,,691.6,percent of total billed charges,Implant Device,691.6,35,,691.6,percent of total billed charges,Implant Device,790.4,40,,790.4,percent of total billed charges,Implant Device,691.6,70,,691.6,percent of total billed charges,All Other,671.84,34,,671.84,percent of total billed charges,Implant Device,671.84,34,,671.84,percent of total billed charges,Implant Device,691.6,35,,691.6,percent of total billed charges,Implant Device,691.6,35,,691.6,percent of total billed charges,Implant Device,691.6,35,,691.6,percent of total billed charges,Implant Device,691.6,35,,691.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1462.24,
BOST H74938046830750 EXP LD 8X27X75CM,C1876,HCPCS,,79013432,CDM,278,RC,,,both,,,1976,1462.24,,,1462.24,Other,150% of Medicare + 9.63% HCRA Surcharge,889.2,45,,889.2,percent of total billed charges,Critical Access Hospital RCC factor,671.84,34,,671.84,percent of total billed charges,Implant Device,671.84,34,,671.84,percent of total billed charges,Implant Device,671.84,34,,671.84,percent of total billed charges,Implant Device,671.84,34,,671.84,percent of total billed charges,Implant Device,671.84,34,,671.84,percent of total billed charges,Implant Device,978.12,,,978.12,Other,110% of Medicare,691.6,35,,691.6,percent of total billed charges,Implant Device,671.84,34,"Charges > $500, x 34%",671.84,percent of total billed charges,Implant Device,691.6,35,,691.6,percent of total billed charges,Implant Device,691.6,35,,691.6,percent of total billed charges,Implant Device,691.6,35,,691.6,percent of total billed charges,Implant Device,691.6,35,,691.6,percent of total billed charges,Implant Device,691.6,35,,691.6,percent of total billed charges,Implant Device,790.4,40,,790.4,percent of total billed charges,Implant Device,691.6,70,,691.6,percent of total billed charges,All Other,671.84,34,,671.84,percent of total billed charges,Implant Device,671.84,34,,671.84,percent of total billed charges,Implant Device,691.6,35,,691.6,percent of total billed charges,Implant Device,691.6,35,,691.6,percent of total billed charges,Implant Device,691.6,35,,691.6,percent of total billed charges,Implant Device,691.6,35,,691.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1462.24,
BOST H74938046760750 EXP LD 7X57X75CM,C1876,HCPCS,,79013433,CDM,278,RC,,,both,,,1976,1462.24,,,1462.24,Other,150% of Medicare + 9.63% HCRA Surcharge,889.2,45,,889.2,percent of total billed charges,Critical Access Hospital RCC factor,671.84,34,,671.84,percent of total billed charges,Implant Device,671.84,34,,671.84,percent of total billed charges,Implant Device,671.84,34,,671.84,percent of total billed charges,Implant Device,671.84,34,,671.84,percent of total billed charges,Implant Device,671.84,34,,671.84,percent of total billed charges,Implant Device,978.12,,,978.12,Other,110% of Medicare,691.6,35,,691.6,percent of total billed charges,Implant Device,671.84,34,"Charges > $500, x 34%",671.84,percent of total billed charges,Implant Device,691.6,35,,691.6,percent of total billed charges,Implant Device,691.6,35,,691.6,percent of total billed charges,Implant Device,691.6,35,,691.6,percent of total billed charges,Implant Device,691.6,35,,691.6,percent of total billed charges,Implant Device,691.6,35,,691.6,percent of total billed charges,Implant Device,790.4,40,,790.4,percent of total billed charges,Implant Device,691.6,70,,691.6,percent of total billed charges,All Other,671.84,34,,671.84,percent of total billed charges,Implant Device,671.84,34,,671.84,percent of total billed charges,Implant Device,691.6,35,,691.6,percent of total billed charges,Implant Device,691.6,35,,691.6,percent of total billed charges,Implant Device,691.6,35,,691.6,percent of total billed charges,Implant Device,691.6,35,,691.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1462.24,
BOST H47937911715150 7X15X150 EXP STENT,C1876,HCPCS,,79013434,CDM,278,RC,,,both,,,1976,1462.24,,,1462.24,Other,150% of Medicare + 9.63% HCRA Surcharge,889.2,45,,889.2,percent of total billed charges,Critical Access Hospital RCC factor,671.84,34,,671.84,percent of total billed charges,Implant Device,671.84,34,,671.84,percent of total billed charges,Implant Device,671.84,34,,671.84,percent of total billed charges,Implant Device,671.84,34,,671.84,percent of total billed charges,Implant Device,671.84,34,,671.84,percent of total billed charges,Implant Device,978.12,,,978.12,Other,110% of Medicare,691.6,35,,691.6,percent of total billed charges,Implant Device,671.84,34,"Charges > $500, x 34%",671.84,percent of total billed charges,Implant Device,691.6,35,,691.6,percent of total billed charges,Implant Device,691.6,35,,691.6,percent of total billed charges,Implant Device,691.6,35,,691.6,percent of total billed charges,Implant Device,691.6,35,,691.6,percent of total billed charges,Implant Device,691.6,35,,691.6,percent of total billed charges,Implant Device,790.4,40,,790.4,percent of total billed charges,Implant Device,691.6,70,,691.6,percent of total billed charges,All Other,671.84,34,,671.84,percent of total billed charges,Implant Device,671.84,34,,671.84,percent of total billed charges,Implant Device,691.6,35,,691.6,percent of total billed charges,Implant Device,691.6,35,,691.6,percent of total billed charges,Implant Device,691.6,35,,691.6,percent of total billed charges,Implant Device,691.6,35,,691.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1462.24,
J&J 1010-11-030 FEMORAL STEM SIZE 3,C1776,HCPCS,,79013435,CDM,278,RC,,,both,,,7410,5483.42,,,5483.42,Other,150% of Medicare + 9.63% HCRA Surcharge,3334.5,45,,3334.5,percent of total billed charges,Critical Access Hospital RCC factor,2519.4,34,,2519.4,percent of total billed charges,Implant Device,2519.4,34,,2519.4,percent of total billed charges,Implant Device,2519.4,34,,2519.4,percent of total billed charges,Implant Device,2519.4,34,,2519.4,percent of total billed charges,Implant Device,2519.4,34,,2519.4,percent of total billed charges,Implant Device,3667.95,,,3667.95,Other,110% of Medicare,2593.5,35,,2593.5,percent of total billed charges,Implant Device,2519.4,34,"Charges > $500, x 34%",2519.4,percent of total billed charges,Implant Device,2593.5,35,,2593.5,percent of total billed charges,Implant Device,2593.5,35,,2593.5,percent of total billed charges,Implant Device,2593.5,35,,2593.5,percent of total billed charges,Implant Device,2593.5,35,,2593.5,percent of total billed charges,Implant Device,2593.5,35,,2593.5,percent of total billed charges,Implant Device,2964,40,,2964,percent of total billed charges,Implant Device,2593.5,70,,2593.5,percent of total billed charges,All Other,2519.4,34,,2519.4,percent of total billed charges,Implant Device,2519.4,34,,2519.4,percent of total billed charges,Implant Device,2593.5,35,,2593.5,percent of total billed charges,Implant Device,2593.5,35,,2593.5,percent of total billed charges,Implant Device,2593.5,35,,2593.5,percent of total billed charges,Implant Device,2593.5,35,,2593.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2519.4,34,"If Charge > 2,000, then 34 percent",2519.4,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5483.42,
STRYKER 662511 LOCKING SCREW 1.7X11MM,C1713,HCPCS,,79013436,CDM,278,RC,,,both,,,413,305.62,,,305.62,Other,150% of Medicare + 9.63% HCRA Surcharge,185.85,45,,185.85,percent of total billed charges,Critical Access Hospital RCC factor,140.42,34,,140.42,percent of total billed charges,Implant Device,140.42,34,,140.42,percent of total billed charges,Implant Device,140.42,34,,140.42,percent of total billed charges,Implant Device,140.42,34,,140.42,percent of total billed charges,Implant Device,140.42,34,,140.42,percent of total billed charges,Implant Device,204.44,,,204.44,Other,110% of Medicare,144.55,35,,144.55,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,144.55,35,,144.55,percent of total billed charges,Implant Device,144.55,35,,144.55,percent of total billed charges,Implant Device,144.55,35,,144.55,percent of total billed charges,Implant Device,144.55,35,,144.55,percent of total billed charges,Implant Device,144.55,35,,144.55,percent of total billed charges,Implant Device,165.2,40,,165.2,percent of total billed charges,Implant Device,144.55,70,,144.55,percent of total billed charges,All Other,140.42,34,,140.42,percent of total billed charges,Implant Device,140.42,34,,140.42,percent of total billed charges,Implant Device,144.55,35,,144.55,percent of total billed charges,Implant Device,144.55,35,,144.55,percent of total billed charges,Implant Device,144.55,35,,144.55,percent of total billed charges,Implant Device,144.55,35,,144.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,305.62,
STRYKER 662512 LOCKING SCREW 1.7X12MM,C1713,HCPCS,,79013437,CDM,278,RC,,,both,,,413,305.62,,,305.62,Other,150% of Medicare + 9.63% HCRA Surcharge,185.85,45,,185.85,percent of total billed charges,Critical Access Hospital RCC factor,140.42,34,,140.42,percent of total billed charges,Implant Device,140.42,34,,140.42,percent of total billed charges,Implant Device,140.42,34,,140.42,percent of total billed charges,Implant Device,140.42,34,,140.42,percent of total billed charges,Implant Device,140.42,34,,140.42,percent of total billed charges,Implant Device,204.44,,,204.44,Other,110% of Medicare,144.55,35,,144.55,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,144.55,35,,144.55,percent of total billed charges,Implant Device,144.55,35,,144.55,percent of total billed charges,Implant Device,144.55,35,,144.55,percent of total billed charges,Implant Device,144.55,35,,144.55,percent of total billed charges,Implant Device,144.55,35,,144.55,percent of total billed charges,Implant Device,165.2,40,,165.2,percent of total billed charges,Implant Device,144.55,70,,144.55,percent of total billed charges,All Other,140.42,34,,140.42,percent of total billed charges,Implant Device,140.42,34,,140.42,percent of total billed charges,Implant Device,144.55,35,,144.55,percent of total billed charges,Implant Device,144.55,35,,144.55,percent of total billed charges,Implant Device,144.55,35,,144.55,percent of total billed charges,Implant Device,144.55,35,,144.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,305.62,
STRYKER 662611 LOCKING SCREW 1.7X11MM,C1713,HCPCS,,79013438,CDM,278,RC,,,both,,,324,239.76,,,239.76,Other,150% of Medicare + 9.63% HCRA Surcharge,145.8,45,,145.8,percent of total billed charges,Critical Access Hospital RCC factor,110.16,34,,110.16,percent of total billed charges,Implant Device,110.16,34,,110.16,percent of total billed charges,Implant Device,110.16,34,,110.16,percent of total billed charges,Implant Device,110.16,34,,110.16,percent of total billed charges,Implant Device,110.16,34,,110.16,percent of total billed charges,Implant Device,160.38,,,160.38,Other,110% of Medicare,113.4,35,,113.4,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,129.6,40,,129.6,percent of total billed charges,Implant Device,113.4,70,,113.4,percent of total billed charges,All Other,110.16,34,,110.16,percent of total billed charges,Implant Device,110.16,34,,110.16,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,239.76,
ARTHREX AR-8933VCL-20 KREULOCK SCRW 3X20,C1713,HCPCS,,79013443,CDM,278,RC,,,both,,,885,654.9,,,654.9,Other,150% of Medicare + 9.63% HCRA Surcharge,398.25,45,,398.25,percent of total billed charges,Critical Access Hospital RCC factor,300.9,34,,300.9,percent of total billed charges,Implant Device,300.9,34,,300.9,percent of total billed charges,Implant Device,300.9,34,,300.9,percent of total billed charges,Implant Device,300.9,34,,300.9,percent of total billed charges,Implant Device,300.9,34,,300.9,percent of total billed charges,Implant Device,438.08,,,438.08,Other,110% of Medicare,309.75,35,,309.75,percent of total billed charges,Implant Device,300.9,34,"Charges > $500, x 34%",300.9,percent of total billed charges,Implant Device,309.75,35,,309.75,percent of total billed charges,Implant Device,309.75,35,,309.75,percent of total billed charges,Implant Device,309.75,35,,309.75,percent of total billed charges,Implant Device,309.75,35,,309.75,percent of total billed charges,Implant Device,309.75,35,,309.75,percent of total billed charges,Implant Device,354,40,,354,percent of total billed charges,Implant Device,309.75,70,,309.75,percent of total billed charges,All Other,300.9,34,,300.9,percent of total billed charges,Implant Device,300.9,34,,300.9,percent of total billed charges,Implant Device,309.75,35,,309.75,percent of total billed charges,Implant Device,309.75,35,,309.75,percent of total billed charges,Implant Device,309.75,35,,309.75,percent of total billed charges,Implant Device,309.75,35,,309.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,654.9,
ARTHREX AR-9933-22 CORT SCREW 3X22MM,C1713,HCPCS,,79013444,CDM,278,RC,,,both,,,375,277.5,,,277.5,Other,150% of Medicare + 9.63% HCRA Surcharge,168.75,45,,168.75,percent of total billed charges,Critical Access Hospital RCC factor,127.5,34,,127.5,percent of total billed charges,Implant Device,127.5,34,,127.5,percent of total billed charges,Implant Device,127.5,34,,127.5,percent of total billed charges,Implant Device,127.5,34,,127.5,percent of total billed charges,Implant Device,127.5,34,,127.5,percent of total billed charges,Implant Device,185.63,,,185.63,Other,110% of Medicare,131.25,35,,131.25,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,131.25,35,,131.25,percent of total billed charges,Implant Device,131.25,35,,131.25,percent of total billed charges,Implant Device,131.25,35,,131.25,percent of total billed charges,Implant Device,131.25,35,,131.25,percent of total billed charges,Implant Device,131.25,35,,131.25,percent of total billed charges,Implant Device,150,40,,150,percent of total billed charges,Implant Device,131.25,70,,131.25,percent of total billed charges,All Other,127.5,34,,127.5,percent of total billed charges,Implant Device,127.5,34,,127.5,percent of total billed charges,Implant Device,131.25,35,,131.25,percent of total billed charges,Implant Device,131.25,35,,131.25,percent of total billed charges,Implant Device,131.25,35,,131.25,percent of total billed charges,Implant Device,131.25,35,,131.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,277.5,
STRYKER 8160-0105S LAG SCREW 10.5X105MM,C1713,HCPCS,,79013483,CDM,278,RC,,,both,,,1777,1314.98,,,1314.98,Other,150% of Medicare + 9.63% HCRA Surcharge,799.65,45,,799.65,percent of total billed charges,Critical Access Hospital RCC factor,604.18,34,,604.18,percent of total billed charges,Implant Device,604.18,34,,604.18,percent of total billed charges,Implant Device,604.18,34,,604.18,percent of total billed charges,Implant Device,604.18,34,,604.18,percent of total billed charges,Implant Device,604.18,34,,604.18,percent of total billed charges,Implant Device,879.62,,,879.62,Other,110% of Medicare,621.95,35,,621.95,percent of total billed charges,Implant Device,604.18,34,"Charges > $500, x 34%",604.18,percent of total billed charges,Implant Device,621.95,35,,621.95,percent of total billed charges,Implant Device,621.95,35,,621.95,percent of total billed charges,Implant Device,621.95,35,,621.95,percent of total billed charges,Implant Device,621.95,35,,621.95,percent of total billed charges,Implant Device,621.95,35,,621.95,percent of total billed charges,Implant Device,710.8,40,,710.8,percent of total billed charges,Implant Device,621.95,70,,621.95,percent of total billed charges,All Other,604.18,34,,604.18,percent of total billed charges,Implant Device,604.18,34,,604.18,percent of total billed charges,Implant Device,621.95,35,,621.95,percent of total billed charges,Implant Device,621.95,35,,621.95,percent of total billed charges,Implant Device,621.95,35,,621.95,percent of total billed charges,Implant Device,621.95,35,,621.95,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1314.98,
STRYKER 8425-1380S NAIL RT 11X380X125DEG,C1713,HCPCS,,79013484,CDM,278,RC,,,both,,,7227,5348,,,5348,Other,150% of Medicare + 9.63% HCRA Surcharge,3252.15,45,,3252.15,percent of total billed charges,Critical Access Hospital RCC factor,2457.18,34,,2457.18,percent of total billed charges,Implant Device,2457.18,34,,2457.18,percent of total billed charges,Implant Device,2457.18,34,,2457.18,percent of total billed charges,Implant Device,2457.18,34,,2457.18,percent of total billed charges,Implant Device,2457.18,34,,2457.18,percent of total billed charges,Implant Device,3577.37,,,3577.37,Other,110% of Medicare,2529.45,35,,2529.45,percent of total billed charges,Implant Device,2457.18,34,"Charges > $500, x 34%",2457.18,percent of total billed charges,Implant Device,2529.45,35,,2529.45,percent of total billed charges,Implant Device,2529.45,35,,2529.45,percent of total billed charges,Implant Device,2529.45,35,,2529.45,percent of total billed charges,Implant Device,2529.45,35,,2529.45,percent of total billed charges,Implant Device,2529.45,35,,2529.45,percent of total billed charges,Implant Device,2890.8,40,,2890.8,percent of total billed charges,Implant Device,2529.45,70,,2529.45,percent of total billed charges,All Other,2457.18,34,,2457.18,percent of total billed charges,Implant Device,2457.18,34,,2457.18,percent of total billed charges,Implant Device,2529.45,35,,2529.45,percent of total billed charges,Implant Device,2529.45,35,,2529.45,percent of total billed charges,Implant Device,2529.45,35,,2529.45,percent of total billed charges,Implant Device,2529.45,35,,2529.45,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2457.18,34,"If Charge > 2,000, then 34 percent",2457.18,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5348,
DJO 940-01-50E ACETABULAR CUP 50MM,C1776,HCPCS,,79013486,CDM,278,RC,,,both,,,4362,3227.89,,,3227.89,Other,150% of Medicare + 9.63% HCRA Surcharge,1962.9,45,,1962.9,percent of total billed charges,Critical Access Hospital RCC factor,1483.08,34,,1483.08,percent of total billed charges,Implant Device,1483.08,34,,1483.08,percent of total billed charges,Implant Device,1483.08,34,,1483.08,percent of total billed charges,Implant Device,1483.08,34,,1483.08,percent of total billed charges,Implant Device,1483.08,34,,1483.08,percent of total billed charges,Implant Device,2159.19,,,2159.19,Other,110% of Medicare,1526.7,35,,1526.7,percent of total billed charges,Implant Device,1483.08,34,"Charges > $500, x 34%",1483.08,percent of total billed charges,Implant Device,1526.7,35,,1526.7,percent of total billed charges,Implant Device,1526.7,35,,1526.7,percent of total billed charges,Implant Device,1526.7,35,,1526.7,percent of total billed charges,Implant Device,1526.7,35,,1526.7,percent of total billed charges,Implant Device,1526.7,35,,1526.7,percent of total billed charges,Implant Device,1744.8,40,,1744.8,percent of total billed charges,Implant Device,1526.7,70,,1526.7,percent of total billed charges,All Other,1483.08,34,,1483.08,percent of total billed charges,Implant Device,1483.08,34,,1483.08,percent of total billed charges,Implant Device,1526.7,35,,1526.7,percent of total billed charges,Implant Device,1526.7,35,,1526.7,percent of total billed charges,Implant Device,1526.7,35,,1526.7,percent of total billed charges,Implant Device,1526.7,35,,1526.7,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1483.08,34,"If Charge > 2,000, then 34 percent",1483.08,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3227.89,
DJO 951-01-40E EMPOWER METAL LINER,C1776,HCPCS,,79013487,CDM,278,RC,,,both,,,3600,2664.01,,,2664.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1620,45,,1620,percent of total billed charges,Critical Access Hospital RCC factor,1224,34,,1224,percent of total billed charges,Implant Device,1224,34,,1224,percent of total billed charges,Implant Device,1224,34,,1224,percent of total billed charges,Implant Device,1224,34,,1224,percent of total billed charges,Implant Device,1224,34,,1224,percent of total billed charges,Implant Device,1782,,,1782,Other,110% of Medicare,1260,35,,1260,percent of total billed charges,Implant Device,1224,34,"Charges > $500, x 34%",1224,percent of total billed charges,Implant Device,1260,35,,1260,percent of total billed charges,Implant Device,1260,35,,1260,percent of total billed charges,Implant Device,1260,35,,1260,percent of total billed charges,Implant Device,1260,35,,1260,percent of total billed charges,Implant Device,1260,35,,1260,percent of total billed charges,Implant Device,1440,40,,1440,percent of total billed charges,Implant Device,1260,70,,1260,percent of total billed charges,All Other,1224,34,,1224,percent of total billed charges,Implant Device,1224,34,,1224,percent of total billed charges,Implant Device,1260,35,,1260,percent of total billed charges,Implant Device,1260,35,,1260,percent of total billed charges,Implant Device,1260,35,,1260,percent of total billed charges,Implant Device,1260,35,,1260,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1224,34,"If Charge > 2,000, then 34 percent",1224,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2664.01,
DJO 952-28-40E EMPOWER POLY BEARING,C1776,HCPCS,,79013488,CDM,278,RC,,,both,,,2100,1554.01,,,1554.01,Other,150% of Medicare + 9.63% HCRA Surcharge,945,45,,945,percent of total billed charges,Critical Access Hospital RCC factor,714,34,,714,percent of total billed charges,Implant Device,714,34,,714,percent of total billed charges,Implant Device,714,34,,714,percent of total billed charges,Implant Device,714,34,,714,percent of total billed charges,Implant Device,714,34,,714,percent of total billed charges,Implant Device,1039.5,,,1039.5,Other,110% of Medicare,735,35,,735,percent of total billed charges,Implant Device,714,34,"Charges > $500, x 34%",714,percent of total billed charges,Implant Device,735,35,,735,percent of total billed charges,Implant Device,735,35,,735,percent of total billed charges,Implant Device,735,35,,735,percent of total billed charges,Implant Device,735,35,,735,percent of total billed charges,Implant Device,735,35,,735,percent of total billed charges,Implant Device,840,40,,840,percent of total billed charges,Implant Device,735,70,,735,percent of total billed charges,All Other,714,34,,714,percent of total billed charges,Implant Device,714,34,,714,percent of total billed charges,Implant Device,735,35,,735,percent of total billed charges,Implant Device,735,35,,735,percent of total billed charges,Implant Device,735,35,,735,percent of total billed charges,Implant Device,735,35,,735,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,714,34,"If Charge > 2,000, then 34 percent",714,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1554.01,
DJO D111-18-1104 ORIGIN HIP STEM SIZE 11,C1776,HCPCS,,79013489,CDM,278,RC,,,both,,,7320,5416.82,,,5416.82,Other,150% of Medicare + 9.63% HCRA Surcharge,3294,45,,3294,percent of total billed charges,Critical Access Hospital RCC factor,2488.8,34,,2488.8,percent of total billed charges,Implant Device,2488.8,34,,2488.8,percent of total billed charges,Implant Device,2488.8,34,,2488.8,percent of total billed charges,Implant Device,2488.8,34,,2488.8,percent of total billed charges,Implant Device,2488.8,34,,2488.8,percent of total billed charges,Implant Device,3623.4,,,3623.4,Other,110% of Medicare,2562,35,,2562,percent of total billed charges,Implant Device,2488.8,34,"Charges > $500, x 34%",2488.8,percent of total billed charges,Implant Device,2562,35,,2562,percent of total billed charges,Implant Device,2562,35,,2562,percent of total billed charges,Implant Device,2562,35,,2562,percent of total billed charges,Implant Device,2562,35,,2562,percent of total billed charges,Implant Device,2562,35,,2562,percent of total billed charges,Implant Device,2928,40,,2928,percent of total billed charges,Implant Device,2562,70,,2562,percent of total billed charges,All Other,2488.8,34,,2488.8,percent of total billed charges,Implant Device,2488.8,34,,2488.8,percent of total billed charges,Implant Device,2562,35,,2562,percent of total billed charges,Implant Device,2562,35,,2562,percent of total billed charges,Implant Device,2562,35,,2562,percent of total billed charges,Implant Device,2562,35,,2562,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2488.8,34,"If Charge > 2,000, then 34 percent",2488.8,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5416.82,
J&J 1504-01-106 FEMORAL POROCOAT LT SZ 6,C1776,HCPCS,,79013490,CDM,278,RC,,,both,,,6000,4440.02,,,4440.02,Other,150% of Medicare + 9.63% HCRA Surcharge,2700,45,,2700,percent of total billed charges,Critical Access Hospital RCC factor,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2970,,,2970,Other,110% of Medicare,2100,35,,2100,percent of total billed charges,Implant Device,2040,34,"Charges > $500, x 34%",2040,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2400,40,,2400,percent of total billed charges,Implant Device,2100,70,,2100,percent of total billed charges,All Other,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2040,34,"If Charge > 2,000, then 34 percent",2040,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4440.02,
J&J 1516-30-605 TIBIAL INSERT 5MM SIZE 6,C1776,HCPCS,,79013491,CDM,278,RC,,,both,,,5400,3996.01,,,3996.01,Other,150% of Medicare + 9.63% HCRA Surcharge,2430,45,,2430,percent of total billed charges,Critical Access Hospital RCC factor,1836,34,,1836,percent of total billed charges,Implant Device,1836,34,,1836,percent of total billed charges,Implant Device,1836,34,,1836,percent of total billed charges,Implant Device,1836,34,,1836,percent of total billed charges,Implant Device,1836,34,,1836,percent of total billed charges,Implant Device,2673,,,2673,Other,110% of Medicare,1890,35,,1890,percent of total billed charges,Implant Device,1836,34,"Charges > $500, x 34%",1836,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,2160,40,,2160,percent of total billed charges,Implant Device,1890,70,,1890,percent of total billed charges,All Other,1836,34,,1836,percent of total billed charges,Implant Device,1836,34,,1836,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1836,34,"If Charge > 2,000, then 34 percent",1836,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3996.01,
J&J 04.354.432 CANNULATED 4.0X32MM,C1713,HCPCS,,79013494,CDM,278,RC,,,both,,,947,700.78,,,700.78,Other,150% of Medicare + 9.63% HCRA Surcharge,426.15,45,,426.15,percent of total billed charges,Critical Access Hospital RCC factor,321.98,34,,321.98,percent of total billed charges,Implant Device,321.98,34,,321.98,percent of total billed charges,Implant Device,321.98,34,,321.98,percent of total billed charges,Implant Device,321.98,34,,321.98,percent of total billed charges,Implant Device,321.98,34,,321.98,percent of total billed charges,Implant Device,468.77,,,468.77,Other,110% of Medicare,331.45,35,,331.45,percent of total billed charges,Implant Device,321.98,34,"Charges > $500, x 34%",321.98,percent of total billed charges,Implant Device,331.45,35,,331.45,percent of total billed charges,Implant Device,331.45,35,,331.45,percent of total billed charges,Implant Device,331.45,35,,331.45,percent of total billed charges,Implant Device,331.45,35,,331.45,percent of total billed charges,Implant Device,331.45,35,,331.45,percent of total billed charges,Implant Device,378.8,40,,378.8,percent of total billed charges,Implant Device,331.45,70,,331.45,percent of total billed charges,All Other,321.98,34,,321.98,percent of total billed charges,Implant Device,321.98,34,,321.98,percent of total billed charges,Implant Device,331.45,35,,331.45,percent of total billed charges,Implant Device,331.45,35,,331.45,percent of total billed charges,Implant Device,331.45,35,,331.45,percent of total billed charges,Implant Device,331.45,35,,331.45,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,700.78,
J&J 04.354.450 CANNULATED SCREW 4.0X50MM,C1713,HCPCS,,79013495,CDM,278,RC,,,both,,,947,700.78,,,700.78,Other,150% of Medicare + 9.63% HCRA Surcharge,426.15,45,,426.15,percent of total billed charges,Critical Access Hospital RCC factor,321.98,34,,321.98,percent of total billed charges,Implant Device,321.98,34,,321.98,percent of total billed charges,Implant Device,321.98,34,,321.98,percent of total billed charges,Implant Device,321.98,34,,321.98,percent of total billed charges,Implant Device,321.98,34,,321.98,percent of total billed charges,Implant Device,468.77,,,468.77,Other,110% of Medicare,331.45,35,,331.45,percent of total billed charges,Implant Device,321.98,34,"Charges > $500, x 34%",321.98,percent of total billed charges,Implant Device,331.45,35,,331.45,percent of total billed charges,Implant Device,331.45,35,,331.45,percent of total billed charges,Implant Device,331.45,35,,331.45,percent of total billed charges,Implant Device,331.45,35,,331.45,percent of total billed charges,Implant Device,331.45,35,,331.45,percent of total billed charges,Implant Device,378.8,40,,378.8,percent of total billed charges,Implant Device,331.45,70,,331.45,percent of total billed charges,All Other,321.98,34,,321.98,percent of total billed charges,Implant Device,321.98,34,,321.98,percent of total billed charges,Implant Device,331.45,35,,331.45,percent of total billed charges,Implant Device,331.45,35,,331.45,percent of total billed charges,Implant Device,331.45,35,,331.45,percent of total billed charges,Implant Device,331.45,35,,331.45,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,700.78,
J&J 04.354.438 CANNULATED SCREW 4.0X38MM,C1713,HCPCS,,79013497,CDM,278,RC,,,both,,,947,700.78,,,700.78,Other,150% of Medicare + 9.63% HCRA Surcharge,426.15,45,,426.15,percent of total billed charges,Critical Access Hospital RCC factor,321.98,34,,321.98,percent of total billed charges,Implant Device,321.98,34,,321.98,percent of total billed charges,Implant Device,321.98,34,,321.98,percent of total billed charges,Implant Device,321.98,34,,321.98,percent of total billed charges,Implant Device,321.98,34,,321.98,percent of total billed charges,Implant Device,468.77,,,468.77,Other,110% of Medicare,331.45,35,,331.45,percent of total billed charges,Implant Device,321.98,34,"Charges > $500, x 34%",321.98,percent of total billed charges,Implant Device,331.45,35,,331.45,percent of total billed charges,Implant Device,331.45,35,,331.45,percent of total billed charges,Implant Device,331.45,35,,331.45,percent of total billed charges,Implant Device,331.45,35,,331.45,percent of total billed charges,Implant Device,331.45,35,,331.45,percent of total billed charges,Implant Device,378.8,40,,378.8,percent of total billed charges,Implant Device,331.45,70,,331.45,percent of total billed charges,All Other,321.98,34,,321.98,percent of total billed charges,Implant Device,321.98,34,,321.98,percent of total billed charges,Implant Device,331.45,35,,331.45,percent of total billed charges,Implant Device,331.45,35,,331.45,percent of total billed charges,Implant Device,331.45,35,,331.45,percent of total billed charges,Implant Device,331.45,35,,331.45,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,700.78,
J&J 04.354.454 CANNULATED SCREW 4.0X54MM,C1713,HCPCS,,79013498,CDM,278,RC,,,both,,,947,700.78,,,700.78,Other,150% of Medicare + 9.63% HCRA Surcharge,426.15,45,,426.15,percent of total billed charges,Critical Access Hospital RCC factor,321.98,34,,321.98,percent of total billed charges,Implant Device,321.98,34,,321.98,percent of total billed charges,Implant Device,321.98,34,,321.98,percent of total billed charges,Implant Device,321.98,34,,321.98,percent of total billed charges,Implant Device,321.98,34,,321.98,percent of total billed charges,Implant Device,468.77,,,468.77,Other,110% of Medicare,331.45,35,,331.45,percent of total billed charges,Implant Device,321.98,34,"Charges > $500, x 34%",321.98,percent of total billed charges,Implant Device,331.45,35,,331.45,percent of total billed charges,Implant Device,331.45,35,,331.45,percent of total billed charges,Implant Device,331.45,35,,331.45,percent of total billed charges,Implant Device,331.45,35,,331.45,percent of total billed charges,Implant Device,331.45,35,,331.45,percent of total billed charges,Implant Device,378.8,40,,378.8,percent of total billed charges,Implant Device,331.45,70,,331.45,percent of total billed charges,All Other,321.98,34,,321.98,percent of total billed charges,Implant Device,321.98,34,,321.98,percent of total billed charges,Implant Device,331.45,35,,331.45,percent of total billed charges,Implant Device,331.45,35,,331.45,percent of total billed charges,Implant Device,331.45,35,,331.45,percent of total billed charges,Implant Device,331.45,35,,331.45,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,700.78,
J&J 04.354.456 CANNULATED SCREW 4.0X56MM,C1713,HCPCS,,79013499,CDM,278,RC,,,both,,,947,700.78,,,700.78,Other,150% of Medicare + 9.63% HCRA Surcharge,426.15,45,,426.15,percent of total billed charges,Critical Access Hospital RCC factor,321.98,34,,321.98,percent of total billed charges,Implant Device,321.98,34,,321.98,percent of total billed charges,Implant Device,321.98,34,,321.98,percent of total billed charges,Implant Device,321.98,34,,321.98,percent of total billed charges,Implant Device,321.98,34,,321.98,percent of total billed charges,Implant Device,468.77,,,468.77,Other,110% of Medicare,331.45,35,,331.45,percent of total billed charges,Implant Device,321.98,34,"Charges > $500, x 34%",321.98,percent of total billed charges,Implant Device,331.45,35,,331.45,percent of total billed charges,Implant Device,331.45,35,,331.45,percent of total billed charges,Implant Device,331.45,35,,331.45,percent of total billed charges,Implant Device,331.45,35,,331.45,percent of total billed charges,Implant Device,331.45,35,,331.45,percent of total billed charges,Implant Device,378.8,40,,378.8,percent of total billed charges,Implant Device,331.45,70,,331.45,percent of total billed charges,All Other,321.98,34,,321.98,percent of total billed charges,Implant Device,321.98,34,,321.98,percent of total billed charges,Implant Device,331.45,35,,331.45,percent of total billed charges,Implant Device,331.45,35,,331.45,percent of total billed charges,Implant Device,331.45,35,,331.45,percent of total billed charges,Implant Device,331.45,35,,331.45,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,700.78,
J&J 04.353.904S WASHER FOR 4 CANN SCREW,C1713,HCPCS,,79013500,CDM,278,RC,,,both,,,117,86.58,,,86.58,Other,150% of Medicare + 9.63% HCRA Surcharge,52.65,45,,52.65,percent of total billed charges,Critical Access Hospital RCC factor,39.78,34,,39.78,percent of total billed charges,Implant Device,39.78,34,,39.78,percent of total billed charges,Implant Device,39.78,34,,39.78,percent of total billed charges,Implant Device,39.78,34,,39.78,percent of total billed charges,Implant Device,39.78,34,,39.78,percent of total billed charges,Implant Device,57.92,,,57.92,Other,110% of Medicare,40.95,35,,40.95,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,40.95,35,,40.95,percent of total billed charges,Implant Device,40.95,35,,40.95,percent of total billed charges,Implant Device,40.95,35,,40.95,percent of total billed charges,Implant Device,40.95,35,,40.95,percent of total billed charges,Implant Device,40.95,35,,40.95,percent of total billed charges,Implant Device,46.8,40,,46.8,percent of total billed charges,Implant Device,40.95,70,,40.95,percent of total billed charges,All Other,39.78,34,,39.78,percent of total billed charges,Implant Device,39.78,34,,39.78,percent of total billed charges,Implant Device,40.95,35,,40.95,percent of total billed charges,Implant Device,40.95,35,,40.95,percent of total billed charges,Implant Device,40.95,35,,40.95,percent of total billed charges,Implant Device,40.95,35,,40.95,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,86.58,
J&J 1365-32-720 CERAMIC FEMORAL HEAD 32,C1776,HCPCS,,79013502,CDM,278,RC,,,both,,,10476,7752.27,,,7752.27,Other,150% of Medicare + 9.63% HCRA Surcharge,4714.2,45,,4714.2,percent of total billed charges,Critical Access Hospital RCC factor,3561.84,34,,3561.84,percent of total billed charges,Implant Device,3561.84,34,,3561.84,percent of total billed charges,Implant Device,3561.84,34,,3561.84,percent of total billed charges,Implant Device,3561.84,34,,3561.84,percent of total billed charges,Implant Device,3561.84,34,,3561.84,percent of total billed charges,Implant Device,5185.62,,,5185.62,Other,110% of Medicare,3666.6,35,,3666.6,percent of total billed charges,Implant Device,3561.84,34,"Charges > $500, x 34%",3561.84,percent of total billed charges,Implant Device,3666.6,35,,3666.6,percent of total billed charges,Implant Device,3666.6,35,,3666.6,percent of total billed charges,Implant Device,3666.6,35,,3666.6,percent of total billed charges,Implant Device,3666.6,35,,3666.6,percent of total billed charges,Implant Device,3666.6,35,,3666.6,percent of total billed charges,Implant Device,4190.4,40,,4190.4,percent of total billed charges,Implant Device,3666.6,70,,3666.6,percent of total billed charges,All Other,3561.84,34,,3561.84,percent of total billed charges,Implant Device,3561.84,34,,3561.84,percent of total billed charges,Implant Device,3666.6,35,,3666.6,percent of total billed charges,Implant Device,3666.6,35,,3666.6,percent of total billed charges,Implant Device,3666.6,35,,3666.6,percent of total billed charges,Implant Device,3666.6,35,,3666.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3561.84,34,"If Charge > 2,000, then 34 percent",3561.84,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,7752.27,
EXACTECH 320-00-11 HUM AUG TRAY +0MM LT,C1776,HCPCS,,79013503,CDM,278,RC,,,both,,,13500,9990.03,,,9990.03,Other,150% of Medicare + 9.63% HCRA Surcharge,6075,45,,6075,percent of total billed charges,Critical Access Hospital RCC factor,4590,34,,4590,percent of total billed charges,Implant Device,4590,34,,4590,percent of total billed charges,Implant Device,4590,34,,4590,percent of total billed charges,Implant Device,4590,34,,4590,percent of total billed charges,Implant Device,4590,34,,4590,percent of total billed charges,Implant Device,6682.5,,,6682.5,Other,110% of Medicare,4725,35,,4725,percent of total billed charges,Implant Device,4590,34,"Charges > $500, x 34%",4590,percent of total billed charges,Implant Device,4725,35,,4725,percent of total billed charges,Implant Device,4725,35,,4725,percent of total billed charges,Implant Device,4725,35,,4725,percent of total billed charges,Implant Device,4725,35,,4725,percent of total billed charges,Implant Device,4725,35,,4725,percent of total billed charges,Implant Device,5400,40,,5400,percent of total billed charges,Implant Device,4725,70,,4725,percent of total billed charges,All Other,4590,34,,4590,percent of total billed charges,Implant Device,4590,34,,4590,percent of total billed charges,Implant Device,4725,35,,4725,percent of total billed charges,Implant Device,4725,35,,4725,percent of total billed charges,Implant Device,4725,35,,4725,percent of total billed charges,Implant Device,4725,35,,4725,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,4590,34,"If Charge > 2,000, then 34 percent",4590,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,9990.03,
J&J 1975-20-095 CONICAL PROZ BODY 20X95,C1776,HCPCS,,79013504,CDM,278,RC,,,both,,,19322,14298.33,,,14298.33,Other,150% of Medicare + 9.63% HCRA Surcharge,8694.9,45,,8694.9,percent of total billed charges,Critical Access Hospital RCC factor,6569.48,34,,6569.48,percent of total billed charges,Implant Device,6569.48,34,,6569.48,percent of total billed charges,Implant Device,6569.48,34,,6569.48,percent of total billed charges,Implant Device,6569.48,34,,6569.48,percent of total billed charges,Implant Device,6569.48,34,,6569.48,percent of total billed charges,Implant Device,9564.39,,,9564.39,Other,110% of Medicare,6762.7,35,,6762.7,percent of total billed charges,Implant Device,6569.48,34,"Charges > $500, x 34%",6569.48,percent of total billed charges,Implant Device,6762.7,35,,6762.7,percent of total billed charges,Implant Device,6762.7,35,,6762.7,percent of total billed charges,Implant Device,6762.7,35,,6762.7,percent of total billed charges,Implant Device,6762.7,35,,6762.7,percent of total billed charges,Implant Device,6762.7,35,,6762.7,percent of total billed charges,Implant Device,7728.8,40,,7728.8,percent of total billed charges,Implant Device,6762.7,70,,6762.7,percent of total billed charges,All Other,6569.48,34,,6569.48,percent of total billed charges,Implant Device,6569.48,34,,6569.48,percent of total billed charges,Implant Device,6762.7,35,,6762.7,percent of total billed charges,Implant Device,6762.7,35,,6762.7,percent of total billed charges,Implant Device,6762.7,35,,6762.7,percent of total billed charges,Implant Device,6762.7,35,,6762.7,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,6569.48,34,"If Charge > 2,000, then 34 percent",6569.48,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,14298.33,
J&J 1976-16-140 DIS TAPERED STEM 16X140,C1776,HCPCS,,79013505,CDM,278,RC,,,both,,,15708,11623.96,,,11623.96,Other,150% of Medicare + 9.63% HCRA Surcharge,7068.6,45,,7068.6,percent of total billed charges,Critical Access Hospital RCC factor,5340.72,34,,5340.72,percent of total billed charges,Implant Device,5340.72,34,,5340.72,percent of total billed charges,Implant Device,5340.72,34,,5340.72,percent of total billed charges,Implant Device,5340.72,34,,5340.72,percent of total billed charges,Implant Device,5340.72,34,,5340.72,percent of total billed charges,Implant Device,7775.46,,,7775.46,Other,110% of Medicare,5497.8,35,,5497.8,percent of total billed charges,Implant Device,5340.72,34,"Charges > $500, x 34%",5340.72,percent of total billed charges,Implant Device,5497.8,35,,5497.8,percent of total billed charges,Implant Device,5497.8,35,,5497.8,percent of total billed charges,Implant Device,5497.8,35,,5497.8,percent of total billed charges,Implant Device,5497.8,35,,5497.8,percent of total billed charges,Implant Device,5497.8,35,,5497.8,percent of total billed charges,Implant Device,6283.2,40,,6283.2,percent of total billed charges,Implant Device,5497.8,70,,5497.8,percent of total billed charges,All Other,5340.72,34,,5340.72,percent of total billed charges,Implant Device,5340.72,34,,5340.72,percent of total billed charges,Implant Device,5497.8,35,,5497.8,percent of total billed charges,Implant Device,5497.8,35,,5497.8,percent of total billed charges,Implant Device,5497.8,35,,5497.8,percent of total billed charges,Implant Device,5497.8,35,,5497.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,5340.72,34,"If Charge > 2,000, then 34 percent",5340.72,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,11623.96,
J&J 1504-10-103 ATTUNE FEMORAL SIZE 3 LT,C1776,HCPCS,,79013508,CDM,278,RC,,,both,,,4800,3552.01,,,3552.01,Other,150% of Medicare + 9.63% HCRA Surcharge,2160,45,,2160,percent of total billed charges,Critical Access Hospital RCC factor,1632,34,,1632,percent of total billed charges,Implant Device,1632,34,,1632,percent of total billed charges,Implant Device,1632,34,,1632,percent of total billed charges,Implant Device,1632,34,,1632,percent of total billed charges,Implant Device,1632,34,,1632,percent of total billed charges,Implant Device,2376,,,2376,Other,110% of Medicare,1680,35,,1680,percent of total billed charges,Implant Device,1632,34,"Charges > $500, x 34%",1632,percent of total billed charges,Implant Device,1680,35,,1680,percent of total billed charges,Implant Device,1680,35,,1680,percent of total billed charges,Implant Device,1680,35,,1680,percent of total billed charges,Implant Device,1680,35,,1680,percent of total billed charges,Implant Device,1680,35,,1680,percent of total billed charges,Implant Device,1920,40,,1920,percent of total billed charges,Implant Device,1680,70,,1680,percent of total billed charges,All Other,1632,34,,1632,percent of total billed charges,Implant Device,1632,34,,1632,percent of total billed charges,Implant Device,1680,35,,1680,percent of total billed charges,Implant Device,1680,35,,1680,percent of total billed charges,Implant Device,1680,35,,1680,percent of total billed charges,Implant Device,1680,35,,1680,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1632,34,"If Charge > 2,000, then 34 percent",1632,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3552.01,
J&J 1516-50-312 ATTUNE TIB INS SZ 3 12MM,C1776,HCPCS,,79013509,CDM,278,RC,,,both,,,5400,3996.01,,,3996.01,Other,150% of Medicare + 9.63% HCRA Surcharge,2430,45,,2430,percent of total billed charges,Critical Access Hospital RCC factor,1836,34,,1836,percent of total billed charges,Implant Device,1836,34,,1836,percent of total billed charges,Implant Device,1836,34,,1836,percent of total billed charges,Implant Device,1836,34,,1836,percent of total billed charges,Implant Device,1836,34,,1836,percent of total billed charges,Implant Device,2673,,,2673,Other,110% of Medicare,1890,35,,1890,percent of total billed charges,Implant Device,1836,34,"Charges > $500, x 34%",1836,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,2160,40,,2160,percent of total billed charges,Implant Device,1890,70,,1890,percent of total billed charges,All Other,1836,34,,1836,percent of total billed charges,Implant Device,1836,34,,1836,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1836,34,"If Charge > 2,000, then 34 percent",1836,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3996.01,
J&J 1504-40-205 ATTUNE REV CRS FEM SZ 5,C1776,HCPCS,,79013510,CDM,278,RC,,,both,,,21434,15861.21,,,15861.21,Other,150% of Medicare + 9.63% HCRA Surcharge,9645.3,45,,9645.3,percent of total billed charges,Critical Access Hospital RCC factor,7287.56,34,,7287.56,percent of total billed charges,Implant Device,7287.56,34,,7287.56,percent of total billed charges,Implant Device,7287.56,34,,7287.56,percent of total billed charges,Implant Device,7287.56,34,,7287.56,percent of total billed charges,Implant Device,7287.56,34,,7287.56,percent of total billed charges,Implant Device,10609.83,,,10609.83,Other,110% of Medicare,7501.9,35,,7501.9,percent of total billed charges,Implant Device,7287.56,34,"Charges > $500, x 34%",7287.56,percent of total billed charges,Implant Device,7501.9,35,,7501.9,percent of total billed charges,Implant Device,7501.9,35,,7501.9,percent of total billed charges,Implant Device,7501.9,35,,7501.9,percent of total billed charges,Implant Device,7501.9,35,,7501.9,percent of total billed charges,Implant Device,7501.9,35,,7501.9,percent of total billed charges,Implant Device,8573.6,40,,8573.6,percent of total billed charges,Implant Device,7501.9,70,,7501.9,percent of total billed charges,All Other,7287.56,34,,7287.56,percent of total billed charges,Implant Device,7287.56,34,,7287.56,percent of total billed charges,Implant Device,7501.9,35,,7501.9,percent of total billed charges,Implant Device,7501.9,35,,7501.9,percent of total billed charges,Implant Device,7501.9,35,,7501.9,percent of total billed charges,Implant Device,7501.9,35,,7501.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,7287.56,34,"If Charge > 2,000, then 34 percent",7287.56,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,15861.21,
J&J 1506-60-004 ATTUNE REV TIB BASE SZ 4,C1776,HCPCS,,79013511,CDM,278,RC,,,both,,,15558,11512.96,,,11512.96,Other,150% of Medicare + 9.63% HCRA Surcharge,7001.1,45,,7001.1,percent of total billed charges,Critical Access Hospital RCC factor,5289.72,34,,5289.72,percent of total billed charges,Implant Device,5289.72,34,,5289.72,percent of total billed charges,Implant Device,5289.72,34,,5289.72,percent of total billed charges,Implant Device,5289.72,34,,5289.72,percent of total billed charges,Implant Device,5289.72,34,,5289.72,percent of total billed charges,Implant Device,7701.21,,,7701.21,Other,110% of Medicare,5445.3,35,,5445.3,percent of total billed charges,Implant Device,5289.72,34,"Charges > $500, x 34%",5289.72,percent of total billed charges,Implant Device,5445.3,35,,5445.3,percent of total billed charges,Implant Device,5445.3,35,,5445.3,percent of total billed charges,Implant Device,5445.3,35,,5445.3,percent of total billed charges,Implant Device,5445.3,35,,5445.3,percent of total billed charges,Implant Device,5445.3,35,,5445.3,percent of total billed charges,Implant Device,6223.2,40,,6223.2,percent of total billed charges,Implant Device,5445.3,70,,5445.3,percent of total billed charges,All Other,5289.72,34,,5289.72,percent of total billed charges,Implant Device,5289.72,34,,5289.72,percent of total billed charges,Implant Device,5445.3,35,,5445.3,percent of total billed charges,Implant Device,5445.3,35,,5445.3,percent of total billed charges,Implant Device,5445.3,35,,5445.3,percent of total billed charges,Implant Device,5445.3,35,,5445.3,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,5289.72,34,"If Charge > 2,000, then 34 percent",5289.72,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,11512.96,
J&J 1511-11-102 ATTUNE REV TIB SLEEVE 37,C1776,HCPCS,,79013512,CDM,278,RC,,,both,,,11771,8710.57,,,8710.57,Other,150% of Medicare + 9.63% HCRA Surcharge,5296.95,45,,5296.95,percent of total billed charges,Critical Access Hospital RCC factor,4002.14,34,,4002.14,percent of total billed charges,Implant Device,4002.14,34,,4002.14,percent of total billed charges,Implant Device,4002.14,34,,4002.14,percent of total billed charges,Implant Device,4002.14,34,,4002.14,percent of total billed charges,Implant Device,4002.14,34,,4002.14,percent of total billed charges,Implant Device,5826.65,,,5826.65,Other,110% of Medicare,4119.85,35,,4119.85,percent of total billed charges,Implant Device,4002.14,34,"Charges > $500, x 34%",4002.14,percent of total billed charges,Implant Device,4119.85,35,,4119.85,percent of total billed charges,Implant Device,4119.85,35,,4119.85,percent of total billed charges,Implant Device,4119.85,35,,4119.85,percent of total billed charges,Implant Device,4119.85,35,,4119.85,percent of total billed charges,Implant Device,4119.85,35,,4119.85,percent of total billed charges,Implant Device,4708.4,40,,4708.4,percent of total billed charges,Implant Device,4119.85,70,,4119.85,percent of total billed charges,All Other,4002.14,34,,4002.14,percent of total billed charges,Implant Device,4002.14,34,,4002.14,percent of total billed charges,Implant Device,4119.85,35,,4119.85,percent of total billed charges,Implant Device,4119.85,35,,4119.85,percent of total billed charges,Implant Device,4119.85,35,,4119.85,percent of total billed charges,Implant Device,4119.85,35,,4119.85,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,4002.14,34,"If Charge > 2,000, then 34 percent",4002.14,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,8710.57,
J&J 1512-14-080 ATTUNE REV CEMENT STEM,C1776,HCPCS,,79013513,CDM,278,RC,,,both,,,3315,2453.11,,,2453.11,Other,150% of Medicare + 9.63% HCRA Surcharge,1491.75,45,,1491.75,percent of total billed charges,Critical Access Hospital RCC factor,1127.1,34,,1127.1,percent of total billed charges,Implant Device,1127.1,34,,1127.1,percent of total billed charges,Implant Device,1127.1,34,,1127.1,percent of total billed charges,Implant Device,1127.1,34,,1127.1,percent of total billed charges,Implant Device,1127.1,34,,1127.1,percent of total billed charges,Implant Device,1640.93,,,1640.93,Other,110% of Medicare,1160.25,35,,1160.25,percent of total billed charges,Implant Device,1127.1,34,"Charges > $500, x 34%",1127.1,percent of total billed charges,Implant Device,1160.25,35,,1160.25,percent of total billed charges,Implant Device,1160.25,35,,1160.25,percent of total billed charges,Implant Device,1160.25,35,,1160.25,percent of total billed charges,Implant Device,1160.25,35,,1160.25,percent of total billed charges,Implant Device,1160.25,35,,1160.25,percent of total billed charges,Implant Device,1326,40,,1326,percent of total billed charges,Implant Device,1160.25,70,,1160.25,percent of total billed charges,All Other,1127.1,34,,1127.1,percent of total billed charges,Implant Device,1127.1,34,,1127.1,percent of total billed charges,Implant Device,1160.25,35,,1160.25,percent of total billed charges,Implant Device,1160.25,35,,1160.25,percent of total billed charges,Implant Device,1160.25,35,,1160.25,percent of total billed charges,Implant Device,1160.25,35,,1160.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1127.1,34,"If Charge > 2,000, then 34 percent",1127.1,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2453.11,
J&J 1513-18-060 ATTUNE REV PRESSFIT STEM,C1776,HCPCS,,79013514,CDM,278,RC,,,both,,,5239,3876.87,,,3876.87,Other,150% of Medicare + 9.63% HCRA Surcharge,2357.55,45,,2357.55,percent of total billed charges,Critical Access Hospital RCC factor,1781.26,34,,1781.26,percent of total billed charges,Implant Device,1781.26,34,,1781.26,percent of total billed charges,Implant Device,1781.26,34,,1781.26,percent of total billed charges,Implant Device,1781.26,34,,1781.26,percent of total billed charges,Implant Device,1781.26,34,,1781.26,percent of total billed charges,Implant Device,2593.31,,,2593.31,Other,110% of Medicare,1833.65,35,,1833.65,percent of total billed charges,Implant Device,1781.26,34,"Charges > $500, x 34%",1781.26,percent of total billed charges,Implant Device,1833.65,35,,1833.65,percent of total billed charges,Implant Device,1833.65,35,,1833.65,percent of total billed charges,Implant Device,1833.65,35,,1833.65,percent of total billed charges,Implant Device,1833.65,35,,1833.65,percent of total billed charges,Implant Device,1833.65,35,,1833.65,percent of total billed charges,Implant Device,2095.6,40,,2095.6,percent of total billed charges,Implant Device,1833.65,70,,1833.65,percent of total billed charges,All Other,1781.26,34,,1781.26,percent of total billed charges,Implant Device,1781.26,34,,1781.26,percent of total billed charges,Implant Device,1833.65,35,,1833.65,percent of total billed charges,Implant Device,1833.65,35,,1833.65,percent of total billed charges,Implant Device,1833.65,35,,1833.65,percent of total billed charges,Implant Device,1833.65,35,,1833.65,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1781.26,34,"If Charge > 2,000, then 34 percent",1781.26,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3876.87,
J&J 1504-10-125 ATTUNE FEM SZ 5N LEFT,C1776,HCPCS,,79013515,CDM,278,RC,,,both,,,4800,3552.01,,,3552.01,Other,150% of Medicare + 9.63% HCRA Surcharge,2160,45,,2160,percent of total billed charges,Critical Access Hospital RCC factor,1632,34,,1632,percent of total billed charges,Implant Device,1632,34,,1632,percent of total billed charges,Implant Device,1632,34,,1632,percent of total billed charges,Implant Device,1632,34,,1632,percent of total billed charges,Implant Device,1632,34,,1632,percent of total billed charges,Implant Device,2376,,,2376,Other,110% of Medicare,1680,35,,1680,percent of total billed charges,Implant Device,1632,34,"Charges > $500, x 34%",1632,percent of total billed charges,Implant Device,1680,35,,1680,percent of total billed charges,Implant Device,1680,35,,1680,percent of total billed charges,Implant Device,1680,35,,1680,percent of total billed charges,Implant Device,1680,35,,1680,percent of total billed charges,Implant Device,1680,35,,1680,percent of total billed charges,Implant Device,1920,40,,1920,percent of total billed charges,Implant Device,1680,70,,1680,percent of total billed charges,All Other,1632,34,,1632,percent of total billed charges,Implant Device,1632,34,,1632,percent of total billed charges,Implant Device,1680,35,,1680,percent of total billed charges,Implant Device,1680,35,,1680,percent of total billed charges,Implant Device,1680,35,,1680,percent of total billed charges,Implant Device,1680,35,,1680,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1632,34,"If Charge > 2,000, then 34 percent",1632,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3552.01,
J&J 1517-10-512 ATTUNE REV CRS INS SZ 5,C1776,HCPCS,,79013516,CDM,278,RC,,,both,,,9286,6871.66,,,6871.66,Other,150% of Medicare + 9.63% HCRA Surcharge,4178.7,45,,4178.7,percent of total billed charges,Critical Access Hospital RCC factor,3157.24,34,,3157.24,percent of total billed charges,Implant Device,3157.24,34,,3157.24,percent of total billed charges,Implant Device,3157.24,34,,3157.24,percent of total billed charges,Implant Device,3157.24,34,,3157.24,percent of total billed charges,Implant Device,3157.24,34,,3157.24,percent of total billed charges,Implant Device,4596.57,,,4596.57,Other,110% of Medicare,3250.1,35,,3250.1,percent of total billed charges,Implant Device,3157.24,34,"Charges > $500, x 34%",3157.24,percent of total billed charges,Implant Device,3250.1,35,,3250.1,percent of total billed charges,Implant Device,3250.1,35,,3250.1,percent of total billed charges,Implant Device,3250.1,35,,3250.1,percent of total billed charges,Implant Device,3250.1,35,,3250.1,percent of total billed charges,Implant Device,3250.1,35,,3250.1,percent of total billed charges,Implant Device,3714.4,40,,3714.4,percent of total billed charges,Implant Device,3250.1,70,,3250.1,percent of total billed charges,All Other,3157.24,34,,3157.24,percent of total billed charges,Implant Device,3157.24,34,,3157.24,percent of total billed charges,Implant Device,3250.1,35,,3250.1,percent of total billed charges,Implant Device,3250.1,35,,3250.1,percent of total billed charges,Implant Device,3250.1,35,,3250.1,percent of total billed charges,Implant Device,3250.1,35,,3250.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3157.24,34,"If Charge > 2,000, then 34 percent",3157.24,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,6871.66,
J&J 1517-10-518 ATTUNE REVISION INS SZ 5,C1776,HCPCS,,79013517,CDM,278,RC,,,both,,,9286,6871.66,,,6871.66,Other,150% of Medicare + 9.63% HCRA Surcharge,4178.7,45,,4178.7,percent of total billed charges,Critical Access Hospital RCC factor,3157.24,34,,3157.24,percent of total billed charges,Implant Device,3157.24,34,,3157.24,percent of total billed charges,Implant Device,3157.24,34,,3157.24,percent of total billed charges,Implant Device,3157.24,34,,3157.24,percent of total billed charges,Implant Device,3157.24,34,,3157.24,percent of total billed charges,Implant Device,4596.57,,,4596.57,Other,110% of Medicare,3250.1,35,,3250.1,percent of total billed charges,Implant Device,3157.24,34,"Charges > $500, x 34%",3157.24,percent of total billed charges,Implant Device,3250.1,35,,3250.1,percent of total billed charges,Implant Device,3250.1,35,,3250.1,percent of total billed charges,Implant Device,3250.1,35,,3250.1,percent of total billed charges,Implant Device,3250.1,35,,3250.1,percent of total billed charges,Implant Device,3250.1,35,,3250.1,percent of total billed charges,Implant Device,3714.4,40,,3714.4,percent of total billed charges,Implant Device,3250.1,70,,3250.1,percent of total billed charges,All Other,3157.24,34,,3157.24,percent of total billed charges,Implant Device,3157.24,34,,3157.24,percent of total billed charges,Implant Device,3250.1,35,,3250.1,percent of total billed charges,Implant Device,3250.1,35,,3250.1,percent of total billed charges,Implant Device,3250.1,35,,3250.1,percent of total billed charges,Implant Device,3250.1,35,,3250.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3157.24,34,"If Charge > 2,000, then 34 percent",3157.24,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,6871.66,
ARTHREX ABS-2010-05 ALLOSYNC PURE 5CC,C1713,HCPCS,,79013520,CDM,278,RC,,,both,,,3000,2220.01,,,2220.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1350,45,,1350,percent of total billed charges,Critical Access Hospital RCC factor,1020,34,,1020,percent of total billed charges,Implant Device,1020,34,,1020,percent of total billed charges,Implant Device,1020,34,,1020,percent of total billed charges,Implant Device,1020,34,,1020,percent of total billed charges,Implant Device,1020,34,,1020,percent of total billed charges,Implant Device,1485,,,1485,Other,110% of Medicare,1050,35,,1050,percent of total billed charges,Implant Device,1020,34,"Charges > $500, x 34%",1020,percent of total billed charges,Implant Device,1050,35,,1050,percent of total billed charges,Implant Device,1050,35,,1050,percent of total billed charges,Implant Device,1050,35,,1050,percent of total billed charges,Implant Device,1050,35,,1050,percent of total billed charges,Implant Device,1050,35,,1050,percent of total billed charges,Implant Device,1200,40,,1200,percent of total billed charges,Implant Device,1050,70,,1050,percent of total billed charges,All Other,1020,34,,1020,percent of total billed charges,Implant Device,1020,34,,1020,percent of total billed charges,Implant Device,1050,35,,1050,percent of total billed charges,Implant Device,1050,35,,1050,percent of total billed charges,Implant Device,1050,35,,1050,percent of total billed charges,Implant Device,1050,35,,1050,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1020,34,"If Charge > 2,000, then 34 percent",1020,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2220.01,
STRYKER 8125-1170S TROCHANT NAIL 11X170,C1713,HCPCS,,79013521,CDM,278,RC,,,both,,,4797,3549.79,,,3549.79,Other,150% of Medicare + 9.63% HCRA Surcharge,2158.65,45,,2158.65,percent of total billed charges,Critical Access Hospital RCC factor,1630.98,34,,1630.98,percent of total billed charges,Implant Device,1630.98,34,,1630.98,percent of total billed charges,Implant Device,1630.98,34,,1630.98,percent of total billed charges,Implant Device,1630.98,34,,1630.98,percent of total billed charges,Implant Device,1630.98,34,,1630.98,percent of total billed charges,Implant Device,2374.52,,,2374.52,Other,110% of Medicare,1678.95,35,,1678.95,percent of total billed charges,Implant Device,1630.98,34,"Charges > $500, x 34%",1630.98,percent of total billed charges,Implant Device,1678.95,35,,1678.95,percent of total billed charges,Implant Device,1678.95,35,,1678.95,percent of total billed charges,Implant Device,1678.95,35,,1678.95,percent of total billed charges,Implant Device,1678.95,35,,1678.95,percent of total billed charges,Implant Device,1678.95,35,,1678.95,percent of total billed charges,Implant Device,1918.8,40,,1918.8,percent of total billed charges,Implant Device,1678.95,70,,1678.95,percent of total billed charges,All Other,1630.98,34,,1630.98,percent of total billed charges,Implant Device,1630.98,34,,1630.98,percent of total billed charges,Implant Device,1678.95,35,,1678.95,percent of total billed charges,Implant Device,1678.95,35,,1678.95,percent of total billed charges,Implant Device,1678.95,35,,1678.95,percent of total billed charges,Implant Device,1678.95,35,,1678.95,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1630.98,34,"If Charge > 2,000, then 34 percent",1630.98,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3549.79,
STRYKER 8160-0085S LAG SCREW 10.5X85MM,C1713,HCPCS,,79013522,CDM,278,RC,,,both,,,1777,1314.98,,,1314.98,Other,150% of Medicare + 9.63% HCRA Surcharge,799.65,45,,799.65,percent of total billed charges,Critical Access Hospital RCC factor,604.18,34,,604.18,percent of total billed charges,Implant Device,604.18,34,,604.18,percent of total billed charges,Implant Device,604.18,34,,604.18,percent of total billed charges,Implant Device,604.18,34,,604.18,percent of total billed charges,Implant Device,604.18,34,,604.18,percent of total billed charges,Implant Device,879.62,,,879.62,Other,110% of Medicare,621.95,35,,621.95,percent of total billed charges,Implant Device,604.18,34,"Charges > $500, x 34%",604.18,percent of total billed charges,Implant Device,621.95,35,,621.95,percent of total billed charges,Implant Device,621.95,35,,621.95,percent of total billed charges,Implant Device,621.95,35,,621.95,percent of total billed charges,Implant Device,621.95,35,,621.95,percent of total billed charges,Implant Device,621.95,35,,621.95,percent of total billed charges,Implant Device,710.8,40,,710.8,percent of total billed charges,Implant Device,621.95,70,,621.95,percent of total billed charges,All Other,604.18,34,,604.18,percent of total billed charges,Implant Device,604.18,34,,604.18,percent of total billed charges,Implant Device,621.95,35,,621.95,percent of total billed charges,Implant Device,621.95,35,,621.95,percent of total billed charges,Implant Device,621.95,35,,621.95,percent of total billed charges,Implant Device,621.95,35,,621.95,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1314.98,
STRYKER 8125-0170S TROCHANT NAIL 10X170,C1713,HCPCS,,79013523,CDM,278,RC,,,both,,,4797,3549.79,,,3549.79,Other,150% of Medicare + 9.63% HCRA Surcharge,2158.65,45,,2158.65,percent of total billed charges,Critical Access Hospital RCC factor,1630.98,34,,1630.98,percent of total billed charges,Implant Device,1630.98,34,,1630.98,percent of total billed charges,Implant Device,1630.98,34,,1630.98,percent of total billed charges,Implant Device,1630.98,34,,1630.98,percent of total billed charges,Implant Device,1630.98,34,,1630.98,percent of total billed charges,Implant Device,2374.52,,,2374.52,Other,110% of Medicare,1678.95,35,,1678.95,percent of total billed charges,Implant Device,1630.98,34,"Charges > $500, x 34%",1630.98,percent of total billed charges,Implant Device,1678.95,35,,1678.95,percent of total billed charges,Implant Device,1678.95,35,,1678.95,percent of total billed charges,Implant Device,1678.95,35,,1678.95,percent of total billed charges,Implant Device,1678.95,35,,1678.95,percent of total billed charges,Implant Device,1678.95,35,,1678.95,percent of total billed charges,Implant Device,1918.8,40,,1918.8,percent of total billed charges,Implant Device,1678.95,70,,1678.95,percent of total billed charges,All Other,1630.98,34,,1630.98,percent of total billed charges,Implant Device,1630.98,34,,1630.98,percent of total billed charges,Implant Device,1678.95,35,,1678.95,percent of total billed charges,Implant Device,1678.95,35,,1678.95,percent of total billed charges,Implant Device,1678.95,35,,1678.95,percent of total billed charges,Implant Device,1678.95,35,,1678.95,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1630.98,34,"If Charge > 2,000, then 34 percent",1630.98,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3549.79,
ARTHREX AR-7000-28FT CANN SCREW 3.75X28,C1713,HCPCS,,79013525,CDM,278,RC,,,both,,,651,481.74,,,481.74,Other,150% of Medicare + 9.63% HCRA Surcharge,292.95,45,,292.95,percent of total billed charges,Critical Access Hospital RCC factor,221.34,34,,221.34,percent of total billed charges,Implant Device,221.34,34,,221.34,percent of total billed charges,Implant Device,221.34,34,,221.34,percent of total billed charges,Implant Device,221.34,34,,221.34,percent of total billed charges,Implant Device,221.34,34,,221.34,percent of total billed charges,Implant Device,322.25,,,322.25,Other,110% of Medicare,227.85,35,,227.85,percent of total billed charges,Implant Device,221.34,34,"Charges > $500, x 34%",221.34,percent of total billed charges,Implant Device,227.85,35,,227.85,percent of total billed charges,Implant Device,227.85,35,,227.85,percent of total billed charges,Implant Device,227.85,35,,227.85,percent of total billed charges,Implant Device,227.85,35,,227.85,percent of total billed charges,Implant Device,227.85,35,,227.85,percent of total billed charges,Implant Device,260.4,40,,260.4,percent of total billed charges,Implant Device,227.85,70,,227.85,percent of total billed charges,All Other,221.34,34,,221.34,percent of total billed charges,Implant Device,221.34,34,,221.34,percent of total billed charges,Implant Device,227.85,35,,227.85,percent of total billed charges,Implant Device,227.85,35,,227.85,percent of total billed charges,Implant Device,227.85,35,,227.85,percent of total billed charges,Implant Device,227.85,35,,227.85,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,481.74,
STR 8525-01360S LG NL LT 11X360MMX125 DG,C1713,HCPCS,,79013527,CDM,278,RC,,,both,,,7227,5348,,,5348,Other,150% of Medicare + 9.63% HCRA Surcharge,3252.15,45,,3252.15,percent of total billed charges,Critical Access Hospital RCC factor,2457.18,34,,2457.18,percent of total billed charges,Implant Device,2457.18,34,,2457.18,percent of total billed charges,Implant Device,2457.18,34,,2457.18,percent of total billed charges,Implant Device,2457.18,34,,2457.18,percent of total billed charges,Implant Device,2457.18,34,,2457.18,percent of total billed charges,Implant Device,3577.37,,,3577.37,Other,110% of Medicare,2529.45,35,,2529.45,percent of total billed charges,Implant Device,2457.18,34,"Charges > $500, x 34%",2457.18,percent of total billed charges,Implant Device,2529.45,35,,2529.45,percent of total billed charges,Implant Device,2529.45,35,,2529.45,percent of total billed charges,Implant Device,2529.45,35,,2529.45,percent of total billed charges,Implant Device,2529.45,35,,2529.45,percent of total billed charges,Implant Device,2529.45,35,,2529.45,percent of total billed charges,Implant Device,2890.8,40,,2890.8,percent of total billed charges,Implant Device,2529.45,70,,2529.45,percent of total billed charges,All Other,2457.18,34,,2457.18,percent of total billed charges,Implant Device,2457.18,34,,2457.18,percent of total billed charges,Implant Device,2529.45,35,,2529.45,percent of total billed charges,Implant Device,2529.45,35,,2529.45,percent of total billed charges,Implant Device,2529.45,35,,2529.45,percent of total billed charges,Implant Device,2529.45,35,,2529.45,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2457.18,34,"If Charge > 2,000, then 34 percent",2457.18,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5348,
ZIM US INC 14-405075 DB LD CRT 5.0X75MM,C1713,HCPCS,,79013528,CDM,278,RC,,,both,,,634,469.16,,,469.16,Other,150% of Medicare + 9.63% HCRA Surcharge,285.3,45,,285.3,percent of total billed charges,Critical Access Hospital RCC factor,215.56,34,,215.56,percent of total billed charges,Implant Device,215.56,34,,215.56,percent of total billed charges,Implant Device,215.56,34,,215.56,percent of total billed charges,Implant Device,215.56,34,,215.56,percent of total billed charges,Implant Device,215.56,34,,215.56,percent of total billed charges,Implant Device,313.83,,,313.83,Other,110% of Medicare,221.9,35,,221.9,percent of total billed charges,Implant Device,215.56,34,"Charges > $500, x 34%",215.56,percent of total billed charges,Implant Device,221.9,35,,221.9,percent of total billed charges,Implant Device,221.9,35,,221.9,percent of total billed charges,Implant Device,221.9,35,,221.9,percent of total billed charges,Implant Device,221.9,35,,221.9,percent of total billed charges,Implant Device,221.9,35,,221.9,percent of total billed charges,Implant Device,253.6,40,,253.6,percent of total billed charges,Implant Device,221.9,70,,221.9,percent of total billed charges,All Other,215.56,34,,215.56,percent of total billed charges,Implant Device,215.56,34,,215.56,percent of total billed charges,Implant Device,221.9,35,,221.9,percent of total billed charges,Implant Device,221.9,35,,221.9,percent of total billed charges,Implant Device,221.9,35,,221.9,percent of total billed charges,Implant Device,221.9,35,,221.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,469.16,
ZIM US INC 14-444230 FM NL RE 10.5X300MM,C1713,HCPCS,,79013529,CDM,278,RC,,,both,,,5717,4230.59,,,4230.59,Other,150% of Medicare + 9.63% HCRA Surcharge,2572.65,45,,2572.65,percent of total billed charges,Critical Access Hospital RCC factor,1943.78,34,,1943.78,percent of total billed charges,Implant Device,1943.78,34,,1943.78,percent of total billed charges,Implant Device,1943.78,34,,1943.78,percent of total billed charges,Implant Device,1943.78,34,,1943.78,percent of total billed charges,Implant Device,1943.78,34,,1943.78,percent of total billed charges,Implant Device,2829.92,,,2829.92,Other,110% of Medicare,2000.95,35,,2000.95,percent of total billed charges,Implant Device,1943.78,34,"Charges > $500, x 34%",1943.78,percent of total billed charges,Implant Device,2000.95,35,,2000.95,percent of total billed charges,Implant Device,2000.95,35,,2000.95,percent of total billed charges,Implant Device,2000.95,35,,2000.95,percent of total billed charges,Implant Device,2000.95,35,,2000.95,percent of total billed charges,Implant Device,2000.95,35,,2000.95,percent of total billed charges,Implant Device,2286.8,40,,2286.8,percent of total billed charges,Implant Device,2000.95,70,,2000.95,percent of total billed charges,All Other,1943.78,34,,1943.78,percent of total billed charges,Implant Device,1943.78,34,,1943.78,percent of total billed charges,Implant Device,2000.95,35,,2000.95,percent of total billed charges,Implant Device,2000.95,35,,2000.95,percent of total billed charges,Implant Device,2000.95,35,,2000.95,percent of total billed charges,Implant Device,2000.95,35,,2000.95,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1943.78,34,"If Charge > 2,000, then 34 percent",1943.78,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4230.59,
ZIM US INC 14-405058 DB LD CORT 5.0X58MM,C1713,HCPCS,,79013530,CDM,278,RC,,,both,,,634,469.16,,,469.16,Other,150% of Medicare + 9.63% HCRA Surcharge,285.3,45,,285.3,percent of total billed charges,Critical Access Hospital RCC factor,215.56,34,,215.56,percent of total billed charges,Implant Device,215.56,34,,215.56,percent of total billed charges,Implant Device,215.56,34,,215.56,percent of total billed charges,Implant Device,215.56,34,,215.56,percent of total billed charges,Implant Device,215.56,34,,215.56,percent of total billed charges,Implant Device,313.83,,,313.83,Other,110% of Medicare,221.9,35,,221.9,percent of total billed charges,Implant Device,215.56,34,"Charges > $500, x 34%",215.56,percent of total billed charges,Implant Device,221.9,35,,221.9,percent of total billed charges,Implant Device,221.9,35,,221.9,percent of total billed charges,Implant Device,221.9,35,,221.9,percent of total billed charges,Implant Device,221.9,35,,221.9,percent of total billed charges,Implant Device,221.9,35,,221.9,percent of total billed charges,Implant Device,253.6,40,,253.6,percent of total billed charges,Implant Device,221.9,70,,221.9,percent of total billed charges,All Other,215.56,34,,215.56,percent of total billed charges,Implant Device,215.56,34,,215.56,percent of total billed charges,Implant Device,221.9,35,,221.9,percent of total billed charges,Implant Device,221.9,35,,221.9,percent of total billed charges,Implant Device,221.9,35,,221.9,percent of total billed charges,Implant Device,221.9,35,,221.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,469.16,
ZIM US INC 02.03150.050 COR SCR 5.0X50MM,C1713,HCPCS,,79013531,CDM,278,RC,,,both,,,475,351.5,,,351.5,Other,150% of Medicare + 9.63% HCRA Surcharge,213.75,45,,213.75,percent of total billed charges,Critical Access Hospital RCC factor,161.5,34,,161.5,percent of total billed charges,Implant Device,161.5,34,,161.5,percent of total billed charges,Implant Device,161.5,34,,161.5,percent of total billed charges,Implant Device,161.5,34,,161.5,percent of total billed charges,Implant Device,161.5,34,,161.5,percent of total billed charges,Implant Device,235.13,,,235.13,Other,110% of Medicare,166.25,35,,166.25,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,166.25,35,,166.25,percent of total billed charges,Implant Device,166.25,35,,166.25,percent of total billed charges,Implant Device,166.25,35,,166.25,percent of total billed charges,Implant Device,166.25,35,,166.25,percent of total billed charges,Implant Device,166.25,35,,166.25,percent of total billed charges,Implant Device,190,40,,190,percent of total billed charges,Implant Device,166.25,70,,166.25,percent of total billed charges,All Other,161.5,34,,161.5,percent of total billed charges,Implant Device,161.5,34,,161.5,percent of total billed charges,Implant Device,166.25,35,,166.25,percent of total billed charges,Implant Device,166.25,35,,166.25,percent of total billed charges,Implant Device,166.25,35,,166.25,percent of total billed charges,Implant Device,166.25,35,,166.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,351.5,
ZIM US INC 02.03150.065 COR SCR 5.0X65MM,C1713,HCPCS,,79013532,CDM,278,RC,,,both,,,475,351.5,,,351.5,Other,150% of Medicare + 9.63% HCRA Surcharge,213.75,45,,213.75,percent of total billed charges,Critical Access Hospital RCC factor,161.5,34,,161.5,percent of total billed charges,Implant Device,161.5,34,,161.5,percent of total billed charges,Implant Device,161.5,34,,161.5,percent of total billed charges,Implant Device,161.5,34,,161.5,percent of total billed charges,Implant Device,161.5,34,,161.5,percent of total billed charges,Implant Device,235.13,,,235.13,Other,110% of Medicare,166.25,35,,166.25,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,166.25,35,,166.25,percent of total billed charges,Implant Device,166.25,35,,166.25,percent of total billed charges,Implant Device,166.25,35,,166.25,percent of total billed charges,Implant Device,166.25,35,,166.25,percent of total billed charges,Implant Device,166.25,35,,166.25,percent of total billed charges,Implant Device,190,40,,190,percent of total billed charges,Implant Device,166.25,70,,166.25,percent of total billed charges,All Other,161.5,34,,161.5,percent of total billed charges,Implant Device,161.5,34,,161.5,percent of total billed charges,Implant Device,166.25,35,,166.25,percent of total billed charges,Implant Device,166.25,35,,166.25,percent of total billed charges,Implant Device,166.25,35,,166.25,percent of total billed charges,Implant Device,166.25,35,,166.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,351.5,
ZIM US INC 02.03263.018 PRX FEM PL 363MM,C1713,HCPCS,,79013533,CDM,278,RC,,,both,,,4291,3175.35,,,3175.35,Other,150% of Medicare + 9.63% HCRA Surcharge,1930.95,45,,1930.95,percent of total billed charges,Critical Access Hospital RCC factor,1458.94,34,,1458.94,percent of total billed charges,Implant Device,1458.94,34,,1458.94,percent of total billed charges,Implant Device,1458.94,34,,1458.94,percent of total billed charges,Implant Device,1458.94,34,,1458.94,percent of total billed charges,Implant Device,1458.94,34,,1458.94,percent of total billed charges,Implant Device,2124.05,,,2124.05,Other,110% of Medicare,1501.85,35,,1501.85,percent of total billed charges,Implant Device,1458.94,34,"Charges > $500, x 34%",1458.94,percent of total billed charges,Implant Device,1501.85,35,,1501.85,percent of total billed charges,Implant Device,1501.85,35,,1501.85,percent of total billed charges,Implant Device,1501.85,35,,1501.85,percent of total billed charges,Implant Device,1501.85,35,,1501.85,percent of total billed charges,Implant Device,1501.85,35,,1501.85,percent of total billed charges,Implant Device,1716.4,40,,1716.4,percent of total billed charges,Implant Device,1501.85,70,,1501.85,percent of total billed charges,All Other,1458.94,34,,1458.94,percent of total billed charges,Implant Device,1458.94,34,,1458.94,percent of total billed charges,Implant Device,1501.85,35,,1501.85,percent of total billed charges,Implant Device,1501.85,35,,1501.85,percent of total billed charges,Implant Device,1501.85,35,,1501.85,percent of total billed charges,Implant Device,1501.85,35,,1501.85,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1458.94,34,"If Charge > 2,000, then 34 percent",1458.94,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3175.35,
J&J 02.130.251 STRGHT PLT 12 HOLES 1.5MM,C1713,HCPCS,,79013534,CDM,278,RC,,,both,,,1350,999,,,999,Other,150% of Medicare + 9.63% HCRA Surcharge,607.5,45,,607.5,percent of total billed charges,Critical Access Hospital RCC factor,459,34,,459,percent of total billed charges,Implant Device,459,34,,459,percent of total billed charges,Implant Device,459,34,,459,percent of total billed charges,Implant Device,459,34,,459,percent of total billed charges,Implant Device,459,34,,459,percent of total billed charges,Implant Device,668.25,,,668.25,Other,110% of Medicare,472.5,35,,472.5,percent of total billed charges,Implant Device,459,34,"Charges > $500, x 34%",459,percent of total billed charges,Implant Device,472.5,35,,472.5,percent of total billed charges,Implant Device,472.5,35,,472.5,percent of total billed charges,Implant Device,472.5,35,,472.5,percent of total billed charges,Implant Device,472.5,35,,472.5,percent of total billed charges,Implant Device,472.5,35,,472.5,percent of total billed charges,Implant Device,540,40,,540,percent of total billed charges,Implant Device,472.5,70,,472.5,percent of total billed charges,All Other,459,34,,459,percent of total billed charges,Implant Device,459,34,,459,percent of total billed charges,Implant Device,472.5,35,,472.5,percent of total billed charges,Implant Device,472.5,35,,472.5,percent of total billed charges,Implant Device,472.5,35,,472.5,percent of total billed charges,Implant Device,472.5,35,,472.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,999,
J&J 02.214.111 CORTEX SCREW 1.5X11MM,C1713,HCPCS,,79013535,CDM,278,RC,,,both,,,110,81.4,,,81.4,Other,150% of Medicare + 9.63% HCRA Surcharge,49.5,45,,49.5,percent of total billed charges,Critical Access Hospital RCC factor,37.4,34,,37.4,percent of total billed charges,Implant Device,37.4,34,,37.4,percent of total billed charges,Implant Device,37.4,34,,37.4,percent of total billed charges,Implant Device,37.4,34,,37.4,percent of total billed charges,Implant Device,37.4,34,,37.4,percent of total billed charges,Implant Device,54.45,,,54.45,Other,110% of Medicare,38.5,35,,38.5,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,38.5,35,,38.5,percent of total billed charges,Implant Device,38.5,35,,38.5,percent of total billed charges,Implant Device,38.5,35,,38.5,percent of total billed charges,Implant Device,38.5,35,,38.5,percent of total billed charges,Implant Device,38.5,35,,38.5,percent of total billed charges,Implant Device,44,40,,44,percent of total billed charges,Implant Device,38.5,70,,38.5,percent of total billed charges,All Other,37.4,34,,37.4,percent of total billed charges,Implant Device,37.4,34,,37.4,percent of total billed charges,Implant Device,38.5,35,,38.5,percent of total billed charges,Implant Device,38.5,35,,38.5,percent of total billed charges,Implant Device,38.5,35,,38.5,percent of total billed charges,Implant Device,38.5,35,,38.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,81.4,
J&J 02.214.110 CORTEX SCREW 1.5X10MM,C1713,HCPCS,,79013536,CDM,278,RC,,,both,,,110,81.4,,,81.4,Other,150% of Medicare + 9.63% HCRA Surcharge,49.5,45,,49.5,percent of total billed charges,Critical Access Hospital RCC factor,37.4,34,,37.4,percent of total billed charges,Implant Device,37.4,34,,37.4,percent of total billed charges,Implant Device,37.4,34,,37.4,percent of total billed charges,Implant Device,37.4,34,,37.4,percent of total billed charges,Implant Device,37.4,34,,37.4,percent of total billed charges,Implant Device,54.45,,,54.45,Other,110% of Medicare,38.5,35,,38.5,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,38.5,35,,38.5,percent of total billed charges,Implant Device,38.5,35,,38.5,percent of total billed charges,Implant Device,38.5,35,,38.5,percent of total billed charges,Implant Device,38.5,35,,38.5,percent of total billed charges,Implant Device,38.5,35,,38.5,percent of total billed charges,Implant Device,44,40,,44,percent of total billed charges,Implant Device,38.5,70,,38.5,percent of total billed charges,All Other,37.4,34,,37.4,percent of total billed charges,Implant Device,37.4,34,,37.4,percent of total billed charges,Implant Device,38.5,35,,38.5,percent of total billed charges,Implant Device,38.5,35,,38.5,percent of total billed charges,Implant Device,38.5,35,,38.5,percent of total billed charges,Implant Device,38.5,35,,38.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,81.4,
J&J 02.214.112 CORTEX SCREW 1.5X12MM,C1713,HCPCS,,79013537,CDM,278,RC,,,both,,,110,81.4,,,81.4,Other,150% of Medicare + 9.63% HCRA Surcharge,49.5,45,,49.5,percent of total billed charges,Critical Access Hospital RCC factor,37.4,34,,37.4,percent of total billed charges,Implant Device,37.4,34,,37.4,percent of total billed charges,Implant Device,37.4,34,,37.4,percent of total billed charges,Implant Device,37.4,34,,37.4,percent of total billed charges,Implant Device,37.4,34,,37.4,percent of total billed charges,Implant Device,54.45,,,54.45,Other,110% of Medicare,38.5,35,,38.5,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,38.5,35,,38.5,percent of total billed charges,Implant Device,38.5,35,,38.5,percent of total billed charges,Implant Device,38.5,35,,38.5,percent of total billed charges,Implant Device,38.5,35,,38.5,percent of total billed charges,Implant Device,38.5,35,,38.5,percent of total billed charges,Implant Device,44,40,,44,percent of total billed charges,Implant Device,38.5,70,,38.5,percent of total billed charges,All Other,37.4,34,,37.4,percent of total billed charges,Implant Device,37.4,34,,37.4,percent of total billed charges,Implant Device,38.5,35,,38.5,percent of total billed charges,Implant Device,38.5,35,,38.5,percent of total billed charges,Implant Device,38.5,35,,38.5,percent of total billed charges,Implant Device,38.5,35,,38.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,81.4,
J&J 02.130.211 LOCKING SCREW 1.5X11MM,C1713,HCPCS,,79013538,CDM,278,RC,,,both,,,365,270.1,,,270.1,Other,150% of Medicare + 9.63% HCRA Surcharge,164.25,45,,164.25,percent of total billed charges,Critical Access Hospital RCC factor,124.1,34,,124.1,percent of total billed charges,Implant Device,124.1,34,,124.1,percent of total billed charges,Implant Device,124.1,34,,124.1,percent of total billed charges,Implant Device,124.1,34,,124.1,percent of total billed charges,Implant Device,124.1,34,,124.1,percent of total billed charges,Implant Device,180.68,,,180.68,Other,110% of Medicare,127.75,35,,127.75,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,127.75,35,,127.75,percent of total billed charges,Implant Device,127.75,35,,127.75,percent of total billed charges,Implant Device,127.75,35,,127.75,percent of total billed charges,Implant Device,127.75,35,,127.75,percent of total billed charges,Implant Device,127.75,35,,127.75,percent of total billed charges,Implant Device,146,40,,146,percent of total billed charges,Implant Device,127.75,70,,127.75,percent of total billed charges,All Other,124.1,34,,124.1,percent of total billed charges,Implant Device,124.1,34,,124.1,percent of total billed charges,Implant Device,127.75,35,,127.75,percent of total billed charges,Implant Device,127.75,35,,127.75,percent of total billed charges,Implant Device,127.75,35,,127.75,percent of total billed charges,Implant Device,127.75,35,,127.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,270.1,
J&J 412.210S LOCKING SCREW 5.0X32MM,C1713,HCPCS,,79013539,CDM,278,RC,,,both,,,384,284.16,,,284.16,Other,150% of Medicare + 9.63% HCRA Surcharge,172.8,45,,172.8,percent of total billed charges,Critical Access Hospital RCC factor,130.56,34,,130.56,percent of total billed charges,Implant Device,130.56,34,,130.56,percent of total billed charges,Implant Device,130.56,34,,130.56,percent of total billed charges,Implant Device,130.56,34,,130.56,percent of total billed charges,Implant Device,130.56,34,,130.56,percent of total billed charges,Implant Device,190.08,,,190.08,Other,110% of Medicare,134.4,35,,134.4,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,134.4,35,,134.4,percent of total billed charges,Implant Device,134.4,35,,134.4,percent of total billed charges,Implant Device,134.4,35,,134.4,percent of total billed charges,Implant Device,134.4,35,,134.4,percent of total billed charges,Implant Device,134.4,35,,134.4,percent of total billed charges,Implant Device,153.6,40,,153.6,percent of total billed charges,Implant Device,134.4,70,,134.4,percent of total billed charges,All Other,130.56,34,,130.56,percent of total billed charges,Implant Device,130.56,34,,130.56,percent of total billed charges,Implant Device,134.4,35,,134.4,percent of total billed charges,Implant Device,134.4,35,,134.4,percent of total billed charges,Implant Device,134.4,35,,134.4,percent of total billed charges,Implant Device,134.4,35,,134.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,284.16,
EXACTECH 320-20-02 MOD EXT & SCREW RIGHT,C1713,HCPCS,,79013540,CDM,278,RC,,,both,,,5999,4439.27,,,4439.27,Other,150% of Medicare + 9.63% HCRA Surcharge,2699.55,45,,2699.55,percent of total billed charges,Critical Access Hospital RCC factor,2039.66,34,,2039.66,percent of total billed charges,Implant Device,2039.66,34,,2039.66,percent of total billed charges,Implant Device,2039.66,34,,2039.66,percent of total billed charges,Implant Device,2039.66,34,,2039.66,percent of total billed charges,Implant Device,2039.66,34,,2039.66,percent of total billed charges,Implant Device,2969.51,,,2969.51,Other,110% of Medicare,2099.65,35,,2099.65,percent of total billed charges,Implant Device,2039.66,34,"Charges > $500, x 34%",2039.66,percent of total billed charges,Implant Device,2099.65,35,,2099.65,percent of total billed charges,Implant Device,2099.65,35,,2099.65,percent of total billed charges,Implant Device,2099.65,35,,2099.65,percent of total billed charges,Implant Device,2099.65,35,,2099.65,percent of total billed charges,Implant Device,2099.65,35,,2099.65,percent of total billed charges,Implant Device,2399.6,40,,2399.6,percent of total billed charges,Implant Device,2099.65,70,,2099.65,percent of total billed charges,All Other,2039.66,34,,2039.66,percent of total billed charges,Implant Device,2039.66,34,,2039.66,percent of total billed charges,Implant Device,2099.65,35,,2099.65,percent of total billed charges,Implant Device,2099.65,35,,2099.65,percent of total billed charges,Implant Device,2099.65,35,,2099.65,percent of total billed charges,Implant Device,2099.65,35,,2099.65,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2039.66,34,"If Charge > 2,000, then 34 percent",2039.66,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4439.27,
EXACTECH 320-05-22 HML AUGMT TRY +5MM RT,C1776,HCPCS,,79013541,CDM,278,RC,,,both,,,13500,9990.03,,,9990.03,Other,150% of Medicare + 9.63% HCRA Surcharge,6075,45,,6075,percent of total billed charges,Critical Access Hospital RCC factor,4590,34,,4590,percent of total billed charges,Implant Device,4590,34,,4590,percent of total billed charges,Implant Device,4590,34,,4590,percent of total billed charges,Implant Device,4590,34,,4590,percent of total billed charges,Implant Device,4590,34,,4590,percent of total billed charges,Implant Device,6682.5,,,6682.5,Other,110% of Medicare,4725,35,,4725,percent of total billed charges,Implant Device,4590,34,"Charges > $500, x 34%",4590,percent of total billed charges,Implant Device,4725,35,,4725,percent of total billed charges,Implant Device,4725,35,,4725,percent of total billed charges,Implant Device,4725,35,,4725,percent of total billed charges,Implant Device,4725,35,,4725,percent of total billed charges,Implant Device,4725,35,,4725,percent of total billed charges,Implant Device,5400,40,,5400,percent of total billed charges,Implant Device,4725,70,,4725,percent of total billed charges,All Other,4590,34,,4590,percent of total billed charges,Implant Device,4590,34,,4590,percent of total billed charges,Implant Device,4725,35,,4725,percent of total billed charges,Implant Device,4725,35,,4725,percent of total billed charges,Implant Device,4725,35,,4725,percent of total billed charges,Implant Device,4725,35,,4725,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,4590,34,"If Charge > 2,000, then 34 percent",4590,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,9990.03,
ZIM US INC 42-5221-007-11 ART SF RT 11MM,C1776,HCPCS,,79013542,CDM,278,RC,,,both,,,4116,3045.85,,,3045.85,Other,150% of Medicare + 9.63% HCRA Surcharge,1852.2,45,,1852.2,percent of total billed charges,Critical Access Hospital RCC factor,1399.44,34,,1399.44,percent of total billed charges,Implant Device,1399.44,34,,1399.44,percent of total billed charges,Implant Device,1399.44,34,,1399.44,percent of total billed charges,Implant Device,1399.44,34,,1399.44,percent of total billed charges,Implant Device,1399.44,34,,1399.44,percent of total billed charges,Implant Device,2037.42,,,2037.42,Other,110% of Medicare,1440.6,35,,1440.6,percent of total billed charges,Implant Device,1399.44,34,"Charges > $500, x 34%",1399.44,percent of total billed charges,Implant Device,1440.6,35,,1440.6,percent of total billed charges,Implant Device,1440.6,35,,1440.6,percent of total billed charges,Implant Device,1440.6,35,,1440.6,percent of total billed charges,Implant Device,1440.6,35,,1440.6,percent of total billed charges,Implant Device,1440.6,35,,1440.6,percent of total billed charges,Implant Device,1646.4,40,,1646.4,percent of total billed charges,Implant Device,1440.6,70,,1440.6,percent of total billed charges,All Other,1399.44,34,,1399.44,percent of total billed charges,Implant Device,1399.44,34,,1399.44,percent of total billed charges,Implant Device,1440.6,35,,1440.6,percent of total billed charges,Implant Device,1440.6,35,,1440.6,percent of total billed charges,Implant Device,1440.6,35,,1440.6,percent of total billed charges,Implant Device,1440.6,35,,1440.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1399.44,34,"If Charge > 2,000, then 34 percent",1399.44,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3045.85,
ZIM US INC 42-5726-062-02 FEM RT SIZE 7,C1776,HCPCS,,79013543,CDM,278,RC,,,both,,,7104,5256.98,,,5256.98,Other,150% of Medicare + 9.63% HCRA Surcharge,3196.8,45,,3196.8,percent of total billed charges,Critical Access Hospital RCC factor,2415.36,34,,2415.36,percent of total billed charges,Implant Device,2415.36,34,,2415.36,percent of total billed charges,Implant Device,2415.36,34,,2415.36,percent of total billed charges,Implant Device,2415.36,34,,2415.36,percent of total billed charges,Implant Device,2415.36,34,,2415.36,percent of total billed charges,Implant Device,3516.48,,,3516.48,Other,110% of Medicare,2486.4,35,,2486.4,percent of total billed charges,Implant Device,2415.36,34,"Charges > $500, x 34%",2415.36,percent of total billed charges,Implant Device,2486.4,35,,2486.4,percent of total billed charges,Implant Device,2486.4,35,,2486.4,percent of total billed charges,Implant Device,2486.4,35,,2486.4,percent of total billed charges,Implant Device,2486.4,35,,2486.4,percent of total billed charges,Implant Device,2486.4,35,,2486.4,percent of total billed charges,Implant Device,2841.6,40,,2841.6,percent of total billed charges,Implant Device,2486.4,70,,2486.4,percent of total billed charges,All Other,2415.36,34,,2415.36,percent of total billed charges,Implant Device,2415.36,34,,2415.36,percent of total billed charges,Implant Device,2486.4,35,,2486.4,percent of total billed charges,Implant Device,2486.4,35,,2486.4,percent of total billed charges,Implant Device,2486.4,35,,2486.4,percent of total billed charges,Implant Device,2486.4,35,,2486.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2415.36,34,"If Charge > 2,000, then 34 percent",2415.36,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5256.98,
J&J 1504-00-206 ATTUNE FEMORAL RT SZ 6,C1776,HCPCS,,79013544,CDM,278,RC,,,both,,,4800,3552.01,,,3552.01,Other,150% of Medicare + 9.63% HCRA Surcharge,2160,45,,2160,percent of total billed charges,Critical Access Hospital RCC factor,1632,34,,1632,percent of total billed charges,Implant Device,1632,34,,1632,percent of total billed charges,Implant Device,1632,34,,1632,percent of total billed charges,Implant Device,1632,34,,1632,percent of total billed charges,Implant Device,1632,34,,1632,percent of total billed charges,Implant Device,2376,,,2376,Other,110% of Medicare,1680,35,,1680,percent of total billed charges,Implant Device,1632,34,"Charges > $500, x 34%",1632,percent of total billed charges,Implant Device,1680,35,,1680,percent of total billed charges,Implant Device,1680,35,,1680,percent of total billed charges,Implant Device,1680,35,,1680,percent of total billed charges,Implant Device,1680,35,,1680,percent of total billed charges,Implant Device,1680,35,,1680,percent of total billed charges,Implant Device,1920,40,,1920,percent of total billed charges,Implant Device,1680,70,,1680,percent of total billed charges,All Other,1632,34,,1632,percent of total billed charges,Implant Device,1632,34,,1632,percent of total billed charges,Implant Device,1680,35,,1680,percent of total billed charges,Implant Device,1680,35,,1680,percent of total billed charges,Implant Device,1680,35,,1680,percent of total billed charges,Implant Device,1680,35,,1680,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1632,34,"If Charge > 2,000, then 34 percent",1632,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3552.01,
J&J 1010-12-030 FEMORAL STEM SIZE 3,C1776,HCPCS,,79013548,CDM,278,RC,,,both,,,7410,5483.42,,,5483.42,Other,150% of Medicare + 9.63% HCRA Surcharge,3334.5,45,,3334.5,percent of total billed charges,Critical Access Hospital RCC factor,2519.4,34,,2519.4,percent of total billed charges,Implant Device,2519.4,34,,2519.4,percent of total billed charges,Implant Device,2519.4,34,,2519.4,percent of total billed charges,Implant Device,2519.4,34,,2519.4,percent of total billed charges,Implant Device,2519.4,34,,2519.4,percent of total billed charges,Implant Device,3667.95,,,3667.95,Other,110% of Medicare,2593.5,35,,2593.5,percent of total billed charges,Implant Device,2519.4,34,"Charges > $500, x 34%",2519.4,percent of total billed charges,Implant Device,2593.5,35,,2593.5,percent of total billed charges,Implant Device,2593.5,35,,2593.5,percent of total billed charges,Implant Device,2593.5,35,,2593.5,percent of total billed charges,Implant Device,2593.5,35,,2593.5,percent of total billed charges,Implant Device,2593.5,35,,2593.5,percent of total billed charges,Implant Device,2964,40,,2964,percent of total billed charges,Implant Device,2593.5,70,,2593.5,percent of total billed charges,All Other,2519.4,34,,2519.4,percent of total billed charges,Implant Device,2519.4,34,,2519.4,percent of total billed charges,Implant Device,2593.5,35,,2593.5,percent of total billed charges,Implant Device,2593.5,35,,2593.5,percent of total billed charges,Implant Device,2593.5,35,,2593.5,percent of total billed charges,Implant Device,2593.5,35,,2593.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2519.4,34,"If Charge > 2,000, then 34 percent",2519.4,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5483.42,
J&J 1516-30-606 TIBIAL INSERT 6MM SIZE 6,C1776,HCPCS,,79013549,CDM,278,RC,,,both,,,5400,3996.01,,,3996.01,Other,150% of Medicare + 9.63% HCRA Surcharge,2430,45,,2430,percent of total billed charges,Critical Access Hospital RCC factor,1836,34,,1836,percent of total billed charges,Implant Device,1836,34,,1836,percent of total billed charges,Implant Device,1836,34,,1836,percent of total billed charges,Implant Device,1836,34,,1836,percent of total billed charges,Implant Device,1836,34,,1836,percent of total billed charges,Implant Device,2673,,,2673,Other,110% of Medicare,1890,35,,1890,percent of total billed charges,Implant Device,1836,34,"Charges > $500, x 34%",1836,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,2160,40,,2160,percent of total billed charges,Implant Device,1890,70,,1890,percent of total billed charges,All Other,1836,34,,1836,percent of total billed charges,Implant Device,1836,34,,1836,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1836,34,"If Charge > 2,000, then 34 percent",1836,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3996.01,
J&J 1504-01-104 ATTUNE FEMORAL LT SZ 4,C1776,HCPCS,,79013550,CDM,278,RC,,,both,,,6000,4440.02,,,4440.02,Other,150% of Medicare + 9.63% HCRA Surcharge,2700,45,,2700,percent of total billed charges,Critical Access Hospital RCC factor,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2970,,,2970,Other,110% of Medicare,2100,35,,2100,percent of total billed charges,Implant Device,2040,34,"Charges > $500, x 34%",2040,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2400,40,,2400,percent of total billed charges,Implant Device,2100,70,,2100,percent of total billed charges,All Other,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2040,34,"If Charge > 2,000, then 34 percent",2040,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4440.02,
BARD LSMU1350616 5X26X135 COVERED STENT,C1874,HCPCS,,79013553,CDM,278,RC,,,both,,,7350,5439.02,,,5439.02,Other,150% of Medicare + 9.63% HCRA Surcharge,3307.5,45,,3307.5,percent of total billed charges,Critical Access Hospital RCC factor,2499,34,,2499,percent of total billed charges,Implant Device,2499,34,,2499,percent of total billed charges,Implant Device,2499,34,,2499,percent of total billed charges,Implant Device,2499,34,,2499,percent of total billed charges,Implant Device,2499,34,,2499,percent of total billed charges,Implant Device,3638.25,,,3638.25,Other,110% of Medicare,2572.5,35,,2572.5,percent of total billed charges,Implant Device,2499,34,"Charges > $500, x 34%",2499,percent of total billed charges,Implant Device,2572.5,35,,2572.5,percent of total billed charges,Implant Device,2572.5,35,,2572.5,percent of total billed charges,Implant Device,2572.5,35,,2572.5,percent of total billed charges,Implant Device,2572.5,35,,2572.5,percent of total billed charges,Implant Device,2572.5,35,,2572.5,percent of total billed charges,Implant Device,2940,40,,2940,percent of total billed charges,Implant Device,2572.5,70,,2572.5,percent of total billed charges,All Other,2499,34,,2499,percent of total billed charges,Implant Device,2499,34,,2499,percent of total billed charges,Implant Device,2572.5,35,,2572.5,percent of total billed charges,Implant Device,2572.5,35,,2572.5,percent of total billed charges,Implant Device,2572.5,35,,2572.5,percent of total billed charges,Implant Device,2572.5,35,,2572.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2499,34,"If Charge > 2,000, then 34 percent",2499,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5439.02,
BARD LSMU1350526 6X16X135 COVERED STENT,C1874,HCPCS,,79013554,CDM,278,RC,,,both,,,7350,5439.02,,,5439.02,Other,150% of Medicare + 9.63% HCRA Surcharge,3307.5,45,,3307.5,percent of total billed charges,Critical Access Hospital RCC factor,2499,34,,2499,percent of total billed charges,Implant Device,2499,34,,2499,percent of total billed charges,Implant Device,2499,34,,2499,percent of total billed charges,Implant Device,2499,34,,2499,percent of total billed charges,Implant Device,2499,34,,2499,percent of total billed charges,Implant Device,3638.25,,,3638.25,Other,110% of Medicare,2572.5,35,,2572.5,percent of total billed charges,Implant Device,2499,34,"Charges > $500, x 34%",2499,percent of total billed charges,Implant Device,2572.5,35,,2572.5,percent of total billed charges,Implant Device,2572.5,35,,2572.5,percent of total billed charges,Implant Device,2572.5,35,,2572.5,percent of total billed charges,Implant Device,2572.5,35,,2572.5,percent of total billed charges,Implant Device,2572.5,35,,2572.5,percent of total billed charges,Implant Device,2940,40,,2940,percent of total billed charges,Implant Device,2572.5,70,,2572.5,percent of total billed charges,All Other,2499,34,,2499,percent of total billed charges,Implant Device,2499,34,,2499,percent of total billed charges,Implant Device,2572.5,35,,2572.5,percent of total billed charges,Implant Device,2572.5,35,,2572.5,percent of total billed charges,Implant Device,2572.5,35,,2572.5,percent of total billed charges,Implant Device,2572.5,35,,2572.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2499,34,"If Charge > 2,000, then 34 percent",2499,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5439.02,
PARAGON PCPT-181408 COTTON WEDGE 8MM,C1713,HCPCS,,79013558,CDM,278,RC,,,both,,,5198,3846.53,,,3846.53,Other,150% of Medicare + 9.63% HCRA Surcharge,2339.1,45,,2339.1,percent of total billed charges,Critical Access Hospital RCC factor,1767.32,34,,1767.32,percent of total billed charges,Implant Device,1767.32,34,,1767.32,percent of total billed charges,Implant Device,1767.32,34,,1767.32,percent of total billed charges,Implant Device,1767.32,34,,1767.32,percent of total billed charges,Implant Device,1767.32,34,,1767.32,percent of total billed charges,Implant Device,2573.01,,,2573.01,Other,110% of Medicare,1819.3,35,,1819.3,percent of total billed charges,Implant Device,1767.32,34,"Charges > $500, x 34%",1767.32,percent of total billed charges,Implant Device,1819.3,35,,1819.3,percent of total billed charges,Implant Device,1819.3,35,,1819.3,percent of total billed charges,Implant Device,1819.3,35,,1819.3,percent of total billed charges,Implant Device,1819.3,35,,1819.3,percent of total billed charges,Implant Device,1819.3,35,,1819.3,percent of total billed charges,Implant Device,2079.2,40,,2079.2,percent of total billed charges,Implant Device,1819.3,70,,1819.3,percent of total billed charges,All Other,1767.32,34,,1767.32,percent of total billed charges,Implant Device,1767.32,34,,1767.32,percent of total billed charges,Implant Device,1819.3,35,,1819.3,percent of total billed charges,Implant Device,1819.3,35,,1819.3,percent of total billed charges,Implant Device,1819.3,35,,1819.3,percent of total billed charges,Implant Device,1819.3,35,,1819.3,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1767.32,34,"If Charge > 2,000, then 34 percent",1767.32,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3846.53,
J&J 247.345 LCP PLATE 2.0X38MM 5 HOLES,C1713,HCPCS,,79013559,CDM,278,RC,,,both,,,624,461.76,,,461.76,Other,150% of Medicare + 9.63% HCRA Surcharge,280.8,45,,280.8,percent of total billed charges,Critical Access Hospital RCC factor,212.16,34,,212.16,percent of total billed charges,Implant Device,212.16,34,,212.16,percent of total billed charges,Implant Device,212.16,34,,212.16,percent of total billed charges,Implant Device,212.16,34,,212.16,percent of total billed charges,Implant Device,212.16,34,,212.16,percent of total billed charges,Implant Device,308.88,,,308.88,Other,110% of Medicare,218.4,35,,218.4,percent of total billed charges,Implant Device,212.16,34,"Charges > $500, x 34%",212.16,percent of total billed charges,Implant Device,218.4,35,,218.4,percent of total billed charges,Implant Device,218.4,35,,218.4,percent of total billed charges,Implant Device,218.4,35,,218.4,percent of total billed charges,Implant Device,218.4,35,,218.4,percent of total billed charges,Implant Device,218.4,35,,218.4,percent of total billed charges,Implant Device,249.6,40,,249.6,percent of total billed charges,Implant Device,218.4,70,,218.4,percent of total billed charges,All Other,212.16,34,,212.16,percent of total billed charges,Implant Device,212.16,34,,212.16,percent of total billed charges,Implant Device,218.4,35,,218.4,percent of total billed charges,Implant Device,218.4,35,,218.4,percent of total billed charges,Implant Device,218.4,35,,218.4,percent of total billed charges,Implant Device,218.4,35,,218.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,461.76,
J&J 201.362.97 CORTEX SCREW 2.0X12MM,C1713,HCPCS,,79013560,CDM,278,RC,,,both,,,90,66.6,,,66.6,Other,150% of Medicare + 9.63% HCRA Surcharge,40.5,45,,40.5,percent of total billed charges,Critical Access Hospital RCC factor,30.6,34,,30.6,percent of total billed charges,Implant Device,30.6,34,,30.6,percent of total billed charges,Implant Device,30.6,34,,30.6,percent of total billed charges,Implant Device,30.6,34,,30.6,percent of total billed charges,Implant Device,30.6,34,,30.6,percent of total billed charges,Implant Device,44.55,,,44.55,Other,110% of Medicare,31.5,35,,31.5,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,31.5,35,,31.5,percent of total billed charges,Implant Device,31.5,35,,31.5,percent of total billed charges,Implant Device,31.5,35,,31.5,percent of total billed charges,Implant Device,31.5,35,,31.5,percent of total billed charges,Implant Device,31.5,35,,31.5,percent of total billed charges,Implant Device,36,40,,36,percent of total billed charges,Implant Device,31.5,70,,31.5,percent of total billed charges,All Other,30.6,34,,30.6,percent of total billed charges,Implant Device,30.6,34,,30.6,percent of total billed charges,Implant Device,31.5,35,,31.5,percent of total billed charges,Implant Device,31.5,35,,31.5,percent of total billed charges,Implant Device,31.5,35,,31.5,percent of total billed charges,Implant Device,31.5,35,,31.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,66.6,
J&J 201.364.97 CORTEX SCREW 2.0X14MM,C1713,HCPCS,,79013561,CDM,278,RC,,,both,,,90,66.6,,,66.6,Other,150% of Medicare + 9.63% HCRA Surcharge,40.5,45,,40.5,percent of total billed charges,Critical Access Hospital RCC factor,30.6,34,,30.6,percent of total billed charges,Implant Device,30.6,34,,30.6,percent of total billed charges,Implant Device,30.6,34,,30.6,percent of total billed charges,Implant Device,30.6,34,,30.6,percent of total billed charges,Implant Device,30.6,34,,30.6,percent of total billed charges,Implant Device,44.55,,,44.55,Other,110% of Medicare,31.5,35,,31.5,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,31.5,35,,31.5,percent of total billed charges,Implant Device,31.5,35,,31.5,percent of total billed charges,Implant Device,31.5,35,,31.5,percent of total billed charges,Implant Device,31.5,35,,31.5,percent of total billed charges,Implant Device,31.5,35,,31.5,percent of total billed charges,Implant Device,36,40,,36,percent of total billed charges,Implant Device,31.5,70,,31.5,percent of total billed charges,All Other,30.6,34,,30.6,percent of total billed charges,Implant Device,30.6,34,,30.6,percent of total billed charges,Implant Device,31.5,35,,31.5,percent of total billed charges,Implant Device,31.5,35,,31.5,percent of total billed charges,Implant Device,31.5,35,,31.5,percent of total billed charges,Implant Device,31.5,35,,31.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,66.6,
J&J 1218-50-043 DUAL LINER W/ACE SHELL,C1776,HCPCS,,79013563,CDM,278,RC,,,both,,,3465,2564.11,,,2564.11,Other,150% of Medicare + 9.63% HCRA Surcharge,1559.25,45,,1559.25,percent of total billed charges,Critical Access Hospital RCC factor,1178.1,34,,1178.1,percent of total billed charges,Implant Device,1178.1,34,,1178.1,percent of total billed charges,Implant Device,1178.1,34,,1178.1,percent of total billed charges,Implant Device,1178.1,34,,1178.1,percent of total billed charges,Implant Device,1178.1,34,,1178.1,percent of total billed charges,Implant Device,1715.18,,,1715.18,Other,110% of Medicare,1212.75,35,,1212.75,percent of total billed charges,Implant Device,1178.1,34,"Charges > $500, x 34%",1178.1,percent of total billed charges,Implant Device,1212.75,35,,1212.75,percent of total billed charges,Implant Device,1212.75,35,,1212.75,percent of total billed charges,Implant Device,1212.75,35,,1212.75,percent of total billed charges,Implant Device,1212.75,35,,1212.75,percent of total billed charges,Implant Device,1212.75,35,,1212.75,percent of total billed charges,Implant Device,1386,40,,1386,percent of total billed charges,Implant Device,1212.75,70,,1212.75,percent of total billed charges,All Other,1178.1,34,,1178.1,percent of total billed charges,Implant Device,1178.1,34,,1178.1,percent of total billed charges,Implant Device,1212.75,35,,1212.75,percent of total billed charges,Implant Device,1212.75,35,,1212.75,percent of total billed charges,Implant Device,1212.75,35,,1212.75,percent of total billed charges,Implant Device,1212.75,35,,1212.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1178.1,34,"If Charge > 2,000, then 34 percent",1178.1,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2564.11,
J&J 1221-22-043 ALTRX LINER 43/22,C1776,HCPCS,,79013564,CDM,278,RC,,,both,,,3506,2594.45,,,2594.45,Other,150% of Medicare + 9.63% HCRA Surcharge,1577.7,45,,1577.7,percent of total billed charges,Critical Access Hospital RCC factor,1192.04,34,,1192.04,percent of total billed charges,Implant Device,1192.04,34,,1192.04,percent of total billed charges,Implant Device,1192.04,34,,1192.04,percent of total billed charges,Implant Device,1192.04,34,,1192.04,percent of total billed charges,Implant Device,1192.04,34,,1192.04,percent of total billed charges,Implant Device,1735.47,,,1735.47,Other,110% of Medicare,1227.1,35,,1227.1,percent of total billed charges,Implant Device,1192.04,34,"Charges > $500, x 34%",1192.04,percent of total billed charges,Implant Device,1227.1,35,,1227.1,percent of total billed charges,Implant Device,1227.1,35,,1227.1,percent of total billed charges,Implant Device,1227.1,35,,1227.1,percent of total billed charges,Implant Device,1227.1,35,,1227.1,percent of total billed charges,Implant Device,1227.1,35,,1227.1,percent of total billed charges,Implant Device,1402.4,40,,1402.4,percent of total billed charges,Implant Device,1227.1,70,,1227.1,percent of total billed charges,All Other,1192.04,34,,1192.04,percent of total billed charges,Implant Device,1192.04,34,,1192.04,percent of total billed charges,Implant Device,1227.1,35,,1227.1,percent of total billed charges,Implant Device,1227.1,35,,1227.1,percent of total billed charges,Implant Device,1227.1,35,,1227.1,percent of total billed charges,Implant Device,1227.1,35,,1227.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1192.04,34,"If Charge > 2,000, then 34 percent",1192.04,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2594.45,
J&J 1365-30-000 FEMORAL HEAD 12/14 TAPER,C1776,HCPCS,,79013565,CDM,278,RC,,,both,,,1710,1265.4,,,1265.4,Other,150% of Medicare + 9.63% HCRA Surcharge,769.5,45,,769.5,percent of total billed charges,Critical Access Hospital RCC factor,581.4,34,,581.4,percent of total billed charges,Implant Device,581.4,34,,581.4,percent of total billed charges,Implant Device,581.4,34,,581.4,percent of total billed charges,Implant Device,581.4,34,,581.4,percent of total billed charges,Implant Device,581.4,34,,581.4,percent of total billed charges,Implant Device,846.45,,,846.45,Other,110% of Medicare,598.5,35,,598.5,percent of total billed charges,Implant Device,581.4,34,"Charges > $500, x 34%",581.4,percent of total billed charges,Implant Device,598.5,35,,598.5,percent of total billed charges,Implant Device,598.5,35,,598.5,percent of total billed charges,Implant Device,598.5,35,,598.5,percent of total billed charges,Implant Device,598.5,35,,598.5,percent of total billed charges,Implant Device,598.5,35,,598.5,percent of total billed charges,Implant Device,684,40,,684,percent of total billed charges,Implant Device,598.5,70,,598.5,percent of total billed charges,All Other,581.4,34,,581.4,percent of total billed charges,Implant Device,581.4,34,,581.4,percent of total billed charges,Implant Device,598.5,35,,598.5,percent of total billed charges,Implant Device,598.5,35,,598.5,percent of total billed charges,Implant Device,598.5,35,,598.5,percent of total billed charges,Implant Device,598.5,35,,598.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1265.4,
J&J 1516-30-708 TIBIAL INSERT SZ 7 8MM,C1776,HCPCS,,79013566,CDM,278,RC,,,both,,,5400,3996.01,,,3996.01,Other,150% of Medicare + 9.63% HCRA Surcharge,2430,45,,2430,percent of total billed charges,Critical Access Hospital RCC factor,1836,34,,1836,percent of total billed charges,Implant Device,1836,34,,1836,percent of total billed charges,Implant Device,1836,34,,1836,percent of total billed charges,Implant Device,1836,34,,1836,percent of total billed charges,Implant Device,1836,34,,1836,percent of total billed charges,Implant Device,2673,,,2673,Other,110% of Medicare,1890,35,,1890,percent of total billed charges,Implant Device,1836,34,"Charges > $500, x 34%",1836,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,2160,40,,2160,percent of total billed charges,Implant Device,1890,70,,1890,percent of total billed charges,All Other,1836,34,,1836,percent of total billed charges,Implant Device,1836,34,,1836,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1836,34,"If Charge > 2,000, then 34 percent",1836,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3996.01,
J&J 02.112.138S LCP FIBULA PLT 2.7/3.5MM,C1713,HCPCS,,79013567,CDM,278,RC,,,both,,,1696,1255.04,,,1255.04,Other,150% of Medicare + 9.63% HCRA Surcharge,763.2,45,,763.2,percent of total billed charges,Critical Access Hospital RCC factor,576.64,34,,576.64,percent of total billed charges,Implant Device,576.64,34,,576.64,percent of total billed charges,Implant Device,576.64,34,,576.64,percent of total billed charges,Implant Device,576.64,34,,576.64,percent of total billed charges,Implant Device,576.64,34,,576.64,percent of total billed charges,Implant Device,839.52,,,839.52,Other,110% of Medicare,593.6,35,,593.6,percent of total billed charges,Implant Device,576.64,34,"Charges > $500, x 34%",576.64,percent of total billed charges,Implant Device,593.6,35,,593.6,percent of total billed charges,Implant Device,593.6,35,,593.6,percent of total billed charges,Implant Device,593.6,35,,593.6,percent of total billed charges,Implant Device,593.6,35,,593.6,percent of total billed charges,Implant Device,593.6,35,,593.6,percent of total billed charges,Implant Device,678.4,40,,678.4,percent of total billed charges,Implant Device,593.6,70,,593.6,percent of total billed charges,All Other,576.64,34,,576.64,percent of total billed charges,Implant Device,576.64,34,,576.64,percent of total billed charges,Implant Device,593.6,35,,593.6,percent of total billed charges,Implant Device,593.6,35,,593.6,percent of total billed charges,Implant Device,593.6,35,,593.6,percent of total billed charges,Implant Device,593.6,35,,593.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1255.04,
STRYKER 58802712 LOCKING SCREW 2.7X12MM,C1713,HCPCS,,79013579,CDM,278,RC,,,both,,,1145,847.3,,,847.3,Other,150% of Medicare + 9.63% HCRA Surcharge,515.25,45,,515.25,percent of total billed charges,Critical Access Hospital RCC factor,389.3,34,,389.3,percent of total billed charges,Implant Device,389.3,34,,389.3,percent of total billed charges,Implant Device,389.3,34,,389.3,percent of total billed charges,Implant Device,389.3,34,,389.3,percent of total billed charges,Implant Device,389.3,34,,389.3,percent of total billed charges,Implant Device,566.78,,,566.78,Other,110% of Medicare,400.75,35,,400.75,percent of total billed charges,Implant Device,389.3,34,"Charges > $500, x 34%",389.3,percent of total billed charges,Implant Device,400.75,35,,400.75,percent of total billed charges,Implant Device,400.75,35,,400.75,percent of total billed charges,Implant Device,400.75,35,,400.75,percent of total billed charges,Implant Device,400.75,35,,400.75,percent of total billed charges,Implant Device,400.75,35,,400.75,percent of total billed charges,Implant Device,458,40,,458,percent of total billed charges,Implant Device,400.75,70,,400.75,percent of total billed charges,All Other,389.3,34,,389.3,percent of total billed charges,Implant Device,389.3,34,,389.3,percent of total billed charges,Implant Device,400.75,35,,400.75,percent of total billed charges,Implant Device,400.75,35,,400.75,percent of total billed charges,Implant Device,400.75,35,,400.75,percent of total billed charges,Implant Device,400.75,35,,400.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,847.3,
STRYKER 58802714 LOCKING SCREW 2.7X14MM,C1713,HCPCS,,79013580,CDM,278,RC,,,both,,,1536,1136.64,,,1136.64,Other,150% of Medicare + 9.63% HCRA Surcharge,691.2,45,,691.2,percent of total billed charges,Critical Access Hospital RCC factor,522.24,34,,522.24,percent of total billed charges,Implant Device,522.24,34,,522.24,percent of total billed charges,Implant Device,522.24,34,,522.24,percent of total billed charges,Implant Device,522.24,34,,522.24,percent of total billed charges,Implant Device,522.24,34,,522.24,percent of total billed charges,Implant Device,760.32,,,760.32,Other,110% of Medicare,537.6,35,,537.6,percent of total billed charges,Implant Device,522.24,34,"Charges > $500, x 34%",522.24,percent of total billed charges,Implant Device,537.6,35,,537.6,percent of total billed charges,Implant Device,537.6,35,,537.6,percent of total billed charges,Implant Device,537.6,35,,537.6,percent of total billed charges,Implant Device,537.6,35,,537.6,percent of total billed charges,Implant Device,537.6,35,,537.6,percent of total billed charges,Implant Device,614.4,40,,614.4,percent of total billed charges,Implant Device,537.6,70,,537.6,percent of total billed charges,All Other,522.24,34,,522.24,percent of total billed charges,Implant Device,522.24,34,,522.24,percent of total billed charges,Implant Device,537.6,35,,537.6,percent of total billed charges,Implant Device,537.6,35,,537.6,percent of total billed charges,Implant Device,537.6,35,,537.6,percent of total billed charges,Implant Device,537.6,35,,537.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1136.64,
STRYKER 58803518 LOCKING SCREW 3.5X18MM,C1713,HCPCS,,79013581,CDM,278,RC,,,both,,,1145,847.3,,,847.3,Other,150% of Medicare + 9.63% HCRA Surcharge,515.25,45,,515.25,percent of total billed charges,Critical Access Hospital RCC factor,389.3,34,,389.3,percent of total billed charges,Implant Device,389.3,34,,389.3,percent of total billed charges,Implant Device,389.3,34,,389.3,percent of total billed charges,Implant Device,389.3,34,,389.3,percent of total billed charges,Implant Device,389.3,34,,389.3,percent of total billed charges,Implant Device,566.78,,,566.78,Other,110% of Medicare,400.75,35,,400.75,percent of total billed charges,Implant Device,389.3,34,"Charges > $500, x 34%",389.3,percent of total billed charges,Implant Device,400.75,35,,400.75,percent of total billed charges,Implant Device,400.75,35,,400.75,percent of total billed charges,Implant Device,400.75,35,,400.75,percent of total billed charges,Implant Device,400.75,35,,400.75,percent of total billed charges,Implant Device,400.75,35,,400.75,percent of total billed charges,Implant Device,458,40,,458,percent of total billed charges,Implant Device,400.75,70,,400.75,percent of total billed charges,All Other,389.3,34,,389.3,percent of total billed charges,Implant Device,389.3,34,,389.3,percent of total billed charges,Implant Device,400.75,35,,400.75,percent of total billed charges,Implant Device,400.75,35,,400.75,percent of total billed charges,Implant Device,400.75,35,,400.75,percent of total billed charges,Implant Device,400.75,35,,400.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,847.3,
STRYKER D1140028 DART-FIRE EDGE COMP SCW,C1713,HCPCS,,79013584,CDM,278,RC,,,both,,,1845,1365.3,,,1365.3,Other,150% of Medicare + 9.63% HCRA Surcharge,830.25,45,,830.25,percent of total billed charges,Critical Access Hospital RCC factor,627.3,34,,627.3,percent of total billed charges,Implant Device,627.3,34,,627.3,percent of total billed charges,Implant Device,627.3,34,,627.3,percent of total billed charges,Implant Device,627.3,34,,627.3,percent of total billed charges,Implant Device,627.3,34,,627.3,percent of total billed charges,Implant Device,913.28,,,913.28,Other,110% of Medicare,645.75,35,,645.75,percent of total billed charges,Implant Device,627.3,34,"Charges > $500, x 34%",627.3,percent of total billed charges,Implant Device,645.75,35,,645.75,percent of total billed charges,Implant Device,645.75,35,,645.75,percent of total billed charges,Implant Device,645.75,35,,645.75,percent of total billed charges,Implant Device,645.75,35,,645.75,percent of total billed charges,Implant Device,645.75,35,,645.75,percent of total billed charges,Implant Device,738,40,,738,percent of total billed charges,Implant Device,645.75,70,,645.75,percent of total billed charges,All Other,627.3,34,,627.3,percent of total billed charges,Implant Device,627.3,34,,627.3,percent of total billed charges,Implant Device,645.75,35,,645.75,percent of total billed charges,Implant Device,645.75,35,,645.75,percent of total billed charges,Implant Device,645.75,35,,645.75,percent of total billed charges,Implant Device,645.75,35,,645.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1365.3,
STRYKER D1140034 DART-FIRE EDGE COMP SRW,C1713,HCPCS,,79013585,CDM,278,RC,,,both,,,1845,1365.3,,,1365.3,Other,150% of Medicare + 9.63% HCRA Surcharge,830.25,45,,830.25,percent of total billed charges,Critical Access Hospital RCC factor,627.3,34,,627.3,percent of total billed charges,Implant Device,627.3,34,,627.3,percent of total billed charges,Implant Device,627.3,34,,627.3,percent of total billed charges,Implant Device,627.3,34,,627.3,percent of total billed charges,Implant Device,627.3,34,,627.3,percent of total billed charges,Implant Device,913.28,,,913.28,Other,110% of Medicare,645.75,35,,645.75,percent of total billed charges,Implant Device,627.3,34,"Charges > $500, x 34%",627.3,percent of total billed charges,Implant Device,645.75,35,,645.75,percent of total billed charges,Implant Device,645.75,35,,645.75,percent of total billed charges,Implant Device,645.75,35,,645.75,percent of total billed charges,Implant Device,645.75,35,,645.75,percent of total billed charges,Implant Device,645.75,35,,645.75,percent of total billed charges,Implant Device,738,40,,738,percent of total billed charges,Implant Device,645.75,70,,645.75,percent of total billed charges,All Other,627.3,34,,627.3,percent of total billed charges,Implant Device,627.3,34,,627.3,percent of total billed charges,Implant Device,645.75,35,,645.75,percent of total billed charges,Implant Device,645.75,35,,645.75,percent of total billed charges,Implant Device,645.75,35,,645.75,percent of total billed charges,Implant Device,645.75,35,,645.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1365.3,
STRYKER 326075 ASNIS CANN SCREW 6.5X75MM,C1713,HCPCS,,79013592,CDM,278,RC,,,both,,,765,566.1,,,566.1,Other,150% of Medicare + 9.63% HCRA Surcharge,344.25,45,,344.25,percent of total billed charges,Critical Access Hospital RCC factor,260.1,34,,260.1,percent of total billed charges,Implant Device,260.1,34,,260.1,percent of total billed charges,Implant Device,260.1,34,,260.1,percent of total billed charges,Implant Device,260.1,34,,260.1,percent of total billed charges,Implant Device,260.1,34,,260.1,percent of total billed charges,Implant Device,378.68,,,378.68,Other,110% of Medicare,267.75,35,,267.75,percent of total billed charges,Implant Device,260.1,34,"Charges > $500, x 34%",260.1,percent of total billed charges,Implant Device,267.75,35,,267.75,percent of total billed charges,Implant Device,267.75,35,,267.75,percent of total billed charges,Implant Device,267.75,35,,267.75,percent of total billed charges,Implant Device,267.75,35,,267.75,percent of total billed charges,Implant Device,267.75,35,,267.75,percent of total billed charges,Implant Device,306,40,,306,percent of total billed charges,Implant Device,267.75,70,,267.75,percent of total billed charges,All Other,260.1,34,,260.1,percent of total billed charges,Implant Device,260.1,34,,260.1,percent of total billed charges,Implant Device,267.75,35,,267.75,percent of total billed charges,Implant Device,267.75,35,,267.75,percent of total billed charges,Implant Device,267.75,35,,267.75,percent of total billed charges,Implant Device,267.75,35,,267.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,566.1,
STRYKER 326675 ASNIS CANN SCREW 8X75MM,C1713,HCPCS,,79013593,CDM,278,RC,,,both,,,765,566.1,,,566.1,Other,150% of Medicare + 9.63% HCRA Surcharge,344.25,45,,344.25,percent of total billed charges,Critical Access Hospital RCC factor,260.1,34,,260.1,percent of total billed charges,Implant Device,260.1,34,,260.1,percent of total billed charges,Implant Device,260.1,34,,260.1,percent of total billed charges,Implant Device,260.1,34,,260.1,percent of total billed charges,Implant Device,260.1,34,,260.1,percent of total billed charges,Implant Device,378.68,,,378.68,Other,110% of Medicare,267.75,35,,267.75,percent of total billed charges,Implant Device,260.1,34,"Charges > $500, x 34%",260.1,percent of total billed charges,Implant Device,267.75,35,,267.75,percent of total billed charges,Implant Device,267.75,35,,267.75,percent of total billed charges,Implant Device,267.75,35,,267.75,percent of total billed charges,Implant Device,267.75,35,,267.75,percent of total billed charges,Implant Device,267.75,35,,267.75,percent of total billed charges,Implant Device,306,40,,306,percent of total billed charges,Implant Device,267.75,70,,267.75,percent of total billed charges,All Other,260.1,34,,260.1,percent of total billed charges,Implant Device,260.1,34,,260.1,percent of total billed charges,Implant Device,267.75,35,,267.75,percent of total billed charges,Implant Device,267.75,35,,267.75,percent of total billed charges,Implant Device,267.75,35,,267.75,percent of total billed charges,Implant Device,267.75,35,,267.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,566.1,
STRYKER 326680 ASNIS CANN SCREW 8X80MM,C1713,HCPCS,,79013594,CDM,278,RC,,,both,,,765,566.1,,,566.1,Other,150% of Medicare + 9.63% HCRA Surcharge,344.25,45,,344.25,percent of total billed charges,Critical Access Hospital RCC factor,260.1,34,,260.1,percent of total billed charges,Implant Device,260.1,34,,260.1,percent of total billed charges,Implant Device,260.1,34,,260.1,percent of total billed charges,Implant Device,260.1,34,,260.1,percent of total billed charges,Implant Device,260.1,34,,260.1,percent of total billed charges,Implant Device,378.68,,,378.68,Other,110% of Medicare,267.75,35,,267.75,percent of total billed charges,Implant Device,260.1,34,"Charges > $500, x 34%",260.1,percent of total billed charges,Implant Device,267.75,35,,267.75,percent of total billed charges,Implant Device,267.75,35,,267.75,percent of total billed charges,Implant Device,267.75,35,,267.75,percent of total billed charges,Implant Device,267.75,35,,267.75,percent of total billed charges,Implant Device,267.75,35,,267.75,percent of total billed charges,Implant Device,306,40,,306,percent of total billed charges,Implant Device,267.75,70,,267.75,percent of total billed charges,All Other,260.1,34,,260.1,percent of total billed charges,Implant Device,260.1,34,,260.1,percent of total billed charges,Implant Device,267.75,35,,267.75,percent of total billed charges,Implant Device,267.75,35,,267.75,percent of total billed charges,Implant Device,267.75,35,,267.75,percent of total billed charges,Implant Device,267.75,35,,267.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,566.1,
STRYKER 390016 ASNIS WASHER FOR 6.5/8MM,C1713,HCPCS,,79013595,CDM,278,RC,,,both,,,113,83.62,,,83.62,Other,150% of Medicare + 9.63% HCRA Surcharge,50.85,45,,50.85,percent of total billed charges,Critical Access Hospital RCC factor,38.42,34,,38.42,percent of total billed charges,Implant Device,38.42,34,,38.42,percent of total billed charges,Implant Device,38.42,34,,38.42,percent of total billed charges,Implant Device,38.42,34,,38.42,percent of total billed charges,Implant Device,38.42,34,,38.42,percent of total billed charges,Implant Device,55.94,,,55.94,Other,110% of Medicare,39.55,35,,39.55,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,39.55,35,,39.55,percent of total billed charges,Implant Device,39.55,35,,39.55,percent of total billed charges,Implant Device,39.55,35,,39.55,percent of total billed charges,Implant Device,39.55,35,,39.55,percent of total billed charges,Implant Device,39.55,35,,39.55,percent of total billed charges,Implant Device,45.2,40,,45.2,percent of total billed charges,Implant Device,39.55,70,,39.55,percent of total billed charges,All Other,38.42,34,,38.42,percent of total billed charges,Implant Device,38.42,34,,38.42,percent of total billed charges,Implant Device,39.55,35,,39.55,percent of total billed charges,Implant Device,39.55,35,,39.55,percent of total billed charges,Implant Device,39.55,35,,39.55,percent of total billed charges,Implant Device,39.55,35,,39.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,83.62,
J&J 201.564 CORTEX SCREW 2.4X24MM,C1713,HCPCS,,79013596,CDM,278,RC,,,both,,,121,89.54,,,89.54,Other,150% of Medicare + 9.63% HCRA Surcharge,54.45,45,,54.45,percent of total billed charges,Critical Access Hospital RCC factor,41.14,34,,41.14,percent of total billed charges,Implant Device,41.14,34,,41.14,percent of total billed charges,Implant Device,41.14,34,,41.14,percent of total billed charges,Implant Device,41.14,34,,41.14,percent of total billed charges,Implant Device,41.14,34,,41.14,percent of total billed charges,Implant Device,59.9,,,59.9,Other,110% of Medicare,42.35,35,,42.35,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,42.35,35,,42.35,percent of total billed charges,Implant Device,42.35,35,,42.35,percent of total billed charges,Implant Device,42.35,35,,42.35,percent of total billed charges,Implant Device,42.35,35,,42.35,percent of total billed charges,Implant Device,42.35,35,,42.35,percent of total billed charges,Implant Device,48.4,40,,48.4,percent of total billed charges,Implant Device,42.35,70,,42.35,percent of total billed charges,All Other,41.14,34,,41.14,percent of total billed charges,Implant Device,41.14,34,,41.14,percent of total billed charges,Implant Device,42.35,35,,42.35,percent of total billed charges,Implant Device,42.35,35,,42.35,percent of total billed charges,Implant Device,42.35,35,,42.35,percent of total billed charges,Implant Device,42.35,35,,42.35,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,89.54,
STRYKER D1140040 EDGE CANN SCREW 4X40MM,C1713,HCPCS,,79013597,CDM,278,RC,,,both,,,1381,1021.94,,,1021.94,Other,150% of Medicare + 9.63% HCRA Surcharge,621.45,45,,621.45,percent of total billed charges,Critical Access Hospital RCC factor,469.54,34,,469.54,percent of total billed charges,Implant Device,469.54,34,,469.54,percent of total billed charges,Implant Device,469.54,34,,469.54,percent of total billed charges,Implant Device,469.54,34,,469.54,percent of total billed charges,Implant Device,469.54,34,,469.54,percent of total billed charges,Implant Device,683.6,,,683.6,Other,110% of Medicare,483.35,35,,483.35,percent of total billed charges,Implant Device,469.54,34,"Charges > $500, x 34%",469.54,percent of total billed charges,Implant Device,483.35,35,,483.35,percent of total billed charges,Implant Device,483.35,35,,483.35,percent of total billed charges,Implant Device,483.35,35,,483.35,percent of total billed charges,Implant Device,483.35,35,,483.35,percent of total billed charges,Implant Device,483.35,35,,483.35,percent of total billed charges,Implant Device,552.4,40,,552.4,percent of total billed charges,Implant Device,483.35,70,,483.35,percent of total billed charges,All Other,469.54,34,,469.54,percent of total billed charges,Implant Device,469.54,34,,469.54,percent of total billed charges,Implant Device,483.35,35,,483.35,percent of total billed charges,Implant Device,483.35,35,,483.35,percent of total billed charges,Implant Device,483.35,35,,483.35,percent of total billed charges,Implant Device,483.35,35,,483.35,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1021.94,
STRYKER D1140042 EDGE CANN SCREW 4X42MM,C1713,HCPCS,,79013598,CDM,278,RC,,,both,,,1381,1021.94,,,1021.94,Other,150% of Medicare + 9.63% HCRA Surcharge,621.45,45,,621.45,percent of total billed charges,Critical Access Hospital RCC factor,469.54,34,,469.54,percent of total billed charges,Implant Device,469.54,34,,469.54,percent of total billed charges,Implant Device,469.54,34,,469.54,percent of total billed charges,Implant Device,469.54,34,,469.54,percent of total billed charges,Implant Device,469.54,34,,469.54,percent of total billed charges,Implant Device,683.6,,,683.6,Other,110% of Medicare,483.35,35,,483.35,percent of total billed charges,Implant Device,469.54,34,"Charges > $500, x 34%",469.54,percent of total billed charges,Implant Device,483.35,35,,483.35,percent of total billed charges,Implant Device,483.35,35,,483.35,percent of total billed charges,Implant Device,483.35,35,,483.35,percent of total billed charges,Implant Device,483.35,35,,483.35,percent of total billed charges,Implant Device,483.35,35,,483.35,percent of total billed charges,Implant Device,552.4,40,,552.4,percent of total billed charges,Implant Device,483.35,70,,483.35,percent of total billed charges,All Other,469.54,34,,469.54,percent of total billed charges,Implant Device,469.54,34,,469.54,percent of total billed charges,Implant Device,483.35,35,,483.35,percent of total billed charges,Implant Device,483.35,35,,483.35,percent of total billed charges,Implant Device,483.35,35,,483.35,percent of total billed charges,Implant Device,483.35,35,,483.35,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1021.94,
STRYKER D1140046 EDGE CANN SCREW 4X46MM,C1713,HCPCS,,79013599,CDM,278,RC,,,both,,,1381,1021.94,,,1021.94,Other,150% of Medicare + 9.63% HCRA Surcharge,621.45,45,,621.45,percent of total billed charges,Critical Access Hospital RCC factor,469.54,34,,469.54,percent of total billed charges,Implant Device,469.54,34,,469.54,percent of total billed charges,Implant Device,469.54,34,,469.54,percent of total billed charges,Implant Device,469.54,34,,469.54,percent of total billed charges,Implant Device,469.54,34,,469.54,percent of total billed charges,Implant Device,683.6,,,683.6,Other,110% of Medicare,483.35,35,,483.35,percent of total billed charges,Implant Device,469.54,34,"Charges > $500, x 34%",469.54,percent of total billed charges,Implant Device,483.35,35,,483.35,percent of total billed charges,Implant Device,483.35,35,,483.35,percent of total billed charges,Implant Device,483.35,35,,483.35,percent of total billed charges,Implant Device,483.35,35,,483.35,percent of total billed charges,Implant Device,483.35,35,,483.35,percent of total billed charges,Implant Device,552.4,40,,552.4,percent of total billed charges,Implant Device,483.35,70,,483.35,percent of total billed charges,All Other,469.54,34,,469.54,percent of total billed charges,Implant Device,469.54,34,,469.54,percent of total billed charges,Implant Device,483.35,35,,483.35,percent of total billed charges,Implant Device,483.35,35,,483.35,percent of total billed charges,Implant Device,483.35,35,,483.35,percent of total billed charges,Implant Device,483.35,35,,483.35,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1021.94,
ZIMMER 11-300913 DIS STEM 13X190 W/ SRW,C1776,HCPCS,,79013600,CDM,278,RC,,,both,,,10199,7547.29,,,7547.29,Other,150% of Medicare + 9.63% HCRA Surcharge,4589.55,45,,4589.55,percent of total billed charges,Critical Access Hospital RCC factor,3467.66,34,,3467.66,percent of total billed charges,Implant Device,3467.66,34,,3467.66,percent of total billed charges,Implant Device,3467.66,34,,3467.66,percent of total billed charges,Implant Device,3467.66,34,,3467.66,percent of total billed charges,Implant Device,3467.66,34,,3467.66,percent of total billed charges,Implant Device,5048.51,,,5048.51,Other,110% of Medicare,3569.65,35,,3569.65,percent of total billed charges,Implant Device,3467.66,34,"Charges > $500, x 34%",3467.66,percent of total billed charges,Implant Device,3569.65,35,,3569.65,percent of total billed charges,Implant Device,3569.65,35,,3569.65,percent of total billed charges,Implant Device,3569.65,35,,3569.65,percent of total billed charges,Implant Device,3569.65,35,,3569.65,percent of total billed charges,Implant Device,3569.65,35,,3569.65,percent of total billed charges,Implant Device,4079.6,40,,4079.6,percent of total billed charges,Implant Device,3569.65,70,,3569.65,percent of total billed charges,All Other,3467.66,34,,3467.66,percent of total billed charges,Implant Device,3467.66,34,,3467.66,percent of total billed charges,Implant Device,3569.65,35,,3569.65,percent of total billed charges,Implant Device,3569.65,35,,3569.65,percent of total billed charges,Implant Device,3569.65,35,,3569.65,percent of total billed charges,Implant Device,3569.65,35,,3569.65,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3467.66,34,"If Charge > 2,000, then 34 percent",3467.66,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,7547.29,
ZIMMER 11-301322 CONE PROX BODY SZ B 70,C1776,HCPCS,,79013601,CDM,278,RC,,,both,,,1152,852.48,,,852.48,Other,150% of Medicare + 9.63% HCRA Surcharge,518.4,45,,518.4,percent of total billed charges,Critical Access Hospital RCC factor,391.68,34,,391.68,percent of total billed charges,Implant Device,391.68,34,,391.68,percent of total billed charges,Implant Device,391.68,34,,391.68,percent of total billed charges,Implant Device,391.68,34,,391.68,percent of total billed charges,Implant Device,391.68,34,,391.68,percent of total billed charges,Implant Device,570.24,,,570.24,Other,110% of Medicare,403.2,35,,403.2,percent of total billed charges,Implant Device,391.68,34,"Charges > $500, x 34%",391.68,percent of total billed charges,Implant Device,403.2,35,,403.2,percent of total billed charges,Implant Device,403.2,35,,403.2,percent of total billed charges,Implant Device,403.2,35,,403.2,percent of total billed charges,Implant Device,403.2,35,,403.2,percent of total billed charges,Implant Device,403.2,35,,403.2,percent of total billed charges,Implant Device,460.8,40,,460.8,percent of total billed charges,Implant Device,403.2,70,,403.2,percent of total billed charges,All Other,391.68,34,,391.68,percent of total billed charges,Implant Device,391.68,34,,391.68,percent of total billed charges,Implant Device,403.2,35,,403.2,percent of total billed charges,Implant Device,403.2,35,,403.2,percent of total billed charges,Implant Device,403.2,35,,403.2,percent of total billed charges,Implant Device,403.2,35,,403.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,852.48,
J&J 212.123 LOCKING SCREW 3.5MMX55MM,C1713,HCPCS,,79013602,CDM,278,RC,,,both,,,315,233.1,,,233.1,Other,150% of Medicare + 9.63% HCRA Surcharge,141.75,45,,141.75,percent of total billed charges,Critical Access Hospital RCC factor,107.1,34,,107.1,percent of total billed charges,Implant Device,107.1,34,,107.1,percent of total billed charges,Implant Device,107.1,34,,107.1,percent of total billed charges,Implant Device,107.1,34,,107.1,percent of total billed charges,Implant Device,107.1,34,,107.1,percent of total billed charges,Implant Device,155.93,,,155.93,Other,110% of Medicare,110.25,35,,110.25,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,110.25,35,,110.25,percent of total billed charges,Implant Device,110.25,35,,110.25,percent of total billed charges,Implant Device,110.25,35,,110.25,percent of total billed charges,Implant Device,110.25,35,,110.25,percent of total billed charges,Implant Device,110.25,35,,110.25,percent of total billed charges,Implant Device,126,40,,126,percent of total billed charges,Implant Device,110.25,70,,110.25,percent of total billed charges,All Other,107.1,34,,107.1,percent of total billed charges,Implant Device,107.1,34,,107.1,percent of total billed charges,Implant Device,110.25,35,,110.25,percent of total billed charges,Implant Device,110.25,35,,110.25,percent of total billed charges,Implant Device,110.25,35,,110.25,percent of total billed charges,Implant Device,110.25,35,,110.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,233.1,
DJO 506-03-126 LOCKING SCREW 5X28MM,C1776,HCPCS,,79013603,CDM,278,RC,,,both,,,360,266.4,,,266.4,Other,150% of Medicare + 9.63% HCRA Surcharge,162,45,,162,percent of total billed charges,Critical Access Hospital RCC factor,122.4,34,,122.4,percent of total billed charges,Implant Device,122.4,34,,122.4,percent of total billed charges,Implant Device,122.4,34,,122.4,percent of total billed charges,Implant Device,122.4,34,,122.4,percent of total billed charges,Implant Device,122.4,34,,122.4,percent of total billed charges,Implant Device,178.2,,,178.2,Other,110% of Medicare,126,35,,126,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,126,35,,126,percent of total billed charges,Implant Device,126,35,,126,percent of total billed charges,Implant Device,126,35,,126,percent of total billed charges,Implant Device,126,35,,126,percent of total billed charges,Implant Device,126,35,,126,percent of total billed charges,Implant Device,144,40,,144,percent of total billed charges,Implant Device,126,70,,126,percent of total billed charges,All Other,122.4,34,,122.4,percent of total billed charges,Implant Device,122.4,34,,122.4,percent of total billed charges,Implant Device,126,35,,126,percent of total billed charges,Implant Device,126,35,,126,percent of total billed charges,Implant Device,126,35,,126,percent of total billed charges,Implant Device,126,35,,126,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,266.4,
DJO 509-02-432 SOCKET INSERT 32MM,C1776,HCPCS,,79013604,CDM,278,RC,,,both,,,3600,2664.01,,,2664.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1620,45,,1620,percent of total billed charges,Critical Access Hospital RCC factor,1224,34,,1224,percent of total billed charges,Implant Device,1224,34,,1224,percent of total billed charges,Implant Device,1224,34,,1224,percent of total billed charges,Implant Device,1224,34,,1224,percent of total billed charges,Implant Device,1224,34,,1224,percent of total billed charges,Implant Device,1782,,,1782,Other,110% of Medicare,1260,35,,1260,percent of total billed charges,Implant Device,1224,34,"Charges > $500, x 34%",1224,percent of total billed charges,Implant Device,1260,35,,1260,percent of total billed charges,Implant Device,1260,35,,1260,percent of total billed charges,Implant Device,1260,35,,1260,percent of total billed charges,Implant Device,1260,35,,1260,percent of total billed charges,Implant Device,1260,35,,1260,percent of total billed charges,Implant Device,1440,40,,1440,percent of total billed charges,Implant Device,1260,70,,1260,percent of total billed charges,All Other,1224,34,,1224,percent of total billed charges,Implant Device,1224,34,,1224,percent of total billed charges,Implant Device,1260,35,,1260,percent of total billed charges,Implant Device,1260,35,,1260,percent of total billed charges,Implant Device,1260,35,,1260,percent of total billed charges,Implant Device,1260,35,,1260,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1224,34,"If Charge > 2,000, then 34 percent",1224,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2664.01,
STRYKER 587220RT FUSION MED RT PLAT SYS,C1713,HCPCS,,79013605,CDM,278,RC,,,both,,,7776,5754.26,,,5754.26,Other,150% of Medicare + 9.63% HCRA Surcharge,3499.2,45,,3499.2,percent of total billed charges,Critical Access Hospital RCC factor,2643.84,34,,2643.84,percent of total billed charges,Implant Device,2643.84,34,,2643.84,percent of total billed charges,Implant Device,2643.84,34,,2643.84,percent of total billed charges,Implant Device,2643.84,34,,2643.84,percent of total billed charges,Implant Device,2643.84,34,,2643.84,percent of total billed charges,Implant Device,3849.12,,,3849.12,Other,110% of Medicare,2721.6,35,,2721.6,percent of total billed charges,Implant Device,2643.84,34,"Charges > $500, x 34%",2643.84,percent of total billed charges,Implant Device,2721.6,35,,2721.6,percent of total billed charges,Implant Device,2721.6,35,,2721.6,percent of total billed charges,Implant Device,2721.6,35,,2721.6,percent of total billed charges,Implant Device,2721.6,35,,2721.6,percent of total billed charges,Implant Device,2721.6,35,,2721.6,percent of total billed charges,Implant Device,3110.4,40,,3110.4,percent of total billed charges,Implant Device,2721.6,70,,2721.6,percent of total billed charges,All Other,2643.84,34,,2643.84,percent of total billed charges,Implant Device,2643.84,34,,2643.84,percent of total billed charges,Implant Device,2721.6,35,,2721.6,percent of total billed charges,Implant Device,2721.6,35,,2721.6,percent of total billed charges,Implant Device,2721.6,35,,2721.6,percent of total billed charges,Implant Device,2721.6,35,,2721.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2643.84,34,"If Charge > 2,000, then 34 percent",2643.84,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5754.26,
STRYKER 58AOMPX1R CROSSCHECK RT ORTHOLOC,C1713,HCPCS,,79013608,CDM,278,RC,,,both,,,9644,7136.58,,,7136.58,Other,150% of Medicare + 9.63% HCRA Surcharge,4339.8,45,,4339.8,percent of total billed charges,Critical Access Hospital RCC factor,3278.96,34,,3278.96,percent of total billed charges,Implant Device,3278.96,34,,3278.96,percent of total billed charges,Implant Device,3278.96,34,,3278.96,percent of total billed charges,Implant Device,3278.96,34,,3278.96,percent of total billed charges,Implant Device,3278.96,34,,3278.96,percent of total billed charges,Implant Device,4773.78,,,4773.78,Other,110% of Medicare,3375.4,35,,3375.4,percent of total billed charges,Implant Device,3278.96,34,"Charges > $500, x 34%",3278.96,percent of total billed charges,Implant Device,3375.4,35,,3375.4,percent of total billed charges,Implant Device,3375.4,35,,3375.4,percent of total billed charges,Implant Device,3375.4,35,,3375.4,percent of total billed charges,Implant Device,3375.4,35,,3375.4,percent of total billed charges,Implant Device,3375.4,35,,3375.4,percent of total billed charges,Implant Device,3857.6,40,,3857.6,percent of total billed charges,Implant Device,3375.4,70,,3375.4,percent of total billed charges,All Other,3278.96,34,,3278.96,percent of total billed charges,Implant Device,3278.96,34,,3278.96,percent of total billed charges,Implant Device,3375.4,35,,3375.4,percent of total billed charges,Implant Device,3375.4,35,,3375.4,percent of total billed charges,Implant Device,3375.4,35,,3375.4,percent of total billed charges,Implant Device,3375.4,35,,3375.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3278.96,34,"If Charge > 2,000, then 34 percent",3278.96,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,7136.58,
J&J 1504-00-107 ATTUNE FEMORAL SIZE 7 LT,C1776,HCPCS,,79013609,CDM,278,RC,,,both,,,4800,3552.01,,,3552.01,Other,150% of Medicare + 9.63% HCRA Surcharge,2160,45,,2160,percent of total billed charges,Critical Access Hospital RCC factor,1632,34,,1632,percent of total billed charges,Implant Device,1632,34,,1632,percent of total billed charges,Implant Device,1632,34,,1632,percent of total billed charges,Implant Device,1632,34,,1632,percent of total billed charges,Implant Device,1632,34,,1632,percent of total billed charges,Implant Device,2376,,,2376,Other,110% of Medicare,1680,35,,1680,percent of total billed charges,Implant Device,1632,34,"Charges > $500, x 34%",1632,percent of total billed charges,Implant Device,1680,35,,1680,percent of total billed charges,Implant Device,1680,35,,1680,percent of total billed charges,Implant Device,1680,35,,1680,percent of total billed charges,Implant Device,1680,35,,1680,percent of total billed charges,Implant Device,1680,35,,1680,percent of total billed charges,Implant Device,1920,40,,1920,percent of total billed charges,Implant Device,1680,70,,1680,percent of total billed charges,All Other,1632,34,,1632,percent of total billed charges,Implant Device,1632,34,,1632,percent of total billed charges,Implant Device,1680,35,,1680,percent of total billed charges,Implant Device,1680,35,,1680,percent of total billed charges,Implant Device,1680,35,,1680,percent of total billed charges,Implant Device,1680,35,,1680,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1632,34,"If Charge > 2,000, then 34 percent",1632,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3552.01,
ARTHREX AR-8940-38 CANN SCREW 4X38MM,C1713,HCPCS,,79013610,CDM,278,RC,,,both,,,195,144.3,,,144.3,Other,150% of Medicare + 9.63% HCRA Surcharge,87.75,45,,87.75,percent of total billed charges,Critical Access Hospital RCC factor,66.3,34,,66.3,percent of total billed charges,Implant Device,66.3,34,,66.3,percent of total billed charges,Implant Device,66.3,34,,66.3,percent of total billed charges,Implant Device,66.3,34,,66.3,percent of total billed charges,Implant Device,66.3,34,,66.3,percent of total billed charges,Implant Device,96.53,,,96.53,Other,110% of Medicare,68.25,35,,68.25,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,68.25,35,,68.25,percent of total billed charges,Implant Device,68.25,35,,68.25,percent of total billed charges,Implant Device,68.25,35,,68.25,percent of total billed charges,Implant Device,68.25,35,,68.25,percent of total billed charges,Implant Device,68.25,35,,68.25,percent of total billed charges,Implant Device,78,40,,78,percent of total billed charges,Implant Device,68.25,70,,68.25,percent of total billed charges,All Other,66.3,34,,66.3,percent of total billed charges,Implant Device,66.3,34,,66.3,percent of total billed charges,Implant Device,68.25,35,,68.25,percent of total billed charges,Implant Device,68.25,35,,68.25,percent of total billed charges,Implant Device,68.25,35,,68.25,percent of total billed charges,Implant Device,68.25,35,,68.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,144.3,
STRYKER 629604 PROFILE PLATE 4 H 2X22MM,C1713,HCPCS,,79013611,CDM,278,RC,,,both,,,1619,1198.06,,,1198.06,Other,150% of Medicare + 9.63% HCRA Surcharge,728.55,45,,728.55,percent of total billed charges,Critical Access Hospital RCC factor,550.46,34,,550.46,percent of total billed charges,Implant Device,550.46,34,,550.46,percent of total billed charges,Implant Device,550.46,34,,550.46,percent of total billed charges,Implant Device,550.46,34,,550.46,percent of total billed charges,Implant Device,550.46,34,,550.46,percent of total billed charges,Implant Device,801.41,,,801.41,Other,110% of Medicare,566.65,35,,566.65,percent of total billed charges,Implant Device,550.46,34,"Charges > $500, x 34%",550.46,percent of total billed charges,Implant Device,566.65,35,,566.65,percent of total billed charges,Implant Device,566.65,35,,566.65,percent of total billed charges,Implant Device,566.65,35,,566.65,percent of total billed charges,Implant Device,566.65,35,,566.65,percent of total billed charges,Implant Device,566.65,35,,566.65,percent of total billed charges,Implant Device,647.6,40,,647.6,percent of total billed charges,Implant Device,566.65,70,,566.65,percent of total billed charges,All Other,550.46,34,,550.46,percent of total billed charges,Implant Device,550.46,34,,550.46,percent of total billed charges,Implant Device,566.65,35,,566.65,percent of total billed charges,Implant Device,566.65,35,,566.65,percent of total billed charges,Implant Device,566.65,35,,566.65,percent of total billed charges,Implant Device,566.65,35,,566.65,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1198.06,
STRYKER 629606 PROFILE PLATE 6 H 2X33MM,C1713,HCPCS,,79013612,CDM,278,RC,,,both,,,1619,1198.06,,,1198.06,Other,150% of Medicare + 9.63% HCRA Surcharge,728.55,45,,728.55,percent of total billed charges,Critical Access Hospital RCC factor,550.46,34,,550.46,percent of total billed charges,Implant Device,550.46,34,,550.46,percent of total billed charges,Implant Device,550.46,34,,550.46,percent of total billed charges,Implant Device,550.46,34,,550.46,percent of total billed charges,Implant Device,550.46,34,,550.46,percent of total billed charges,Implant Device,801.41,,,801.41,Other,110% of Medicare,566.65,35,,566.65,percent of total billed charges,Implant Device,550.46,34,"Charges > $500, x 34%",550.46,percent of total billed charges,Implant Device,566.65,35,,566.65,percent of total billed charges,Implant Device,566.65,35,,566.65,percent of total billed charges,Implant Device,566.65,35,,566.65,percent of total billed charges,Implant Device,566.65,35,,566.65,percent of total billed charges,Implant Device,566.65,35,,566.65,percent of total billed charges,Implant Device,647.6,40,,647.6,percent of total billed charges,Implant Device,566.65,70,,566.65,percent of total billed charges,All Other,550.46,34,,550.46,percent of total billed charges,Implant Device,550.46,34,,550.46,percent of total billed charges,Implant Device,566.65,35,,566.65,percent of total billed charges,Implant Device,566.65,35,,566.65,percent of total billed charges,Implant Device,566.65,35,,566.65,percent of total billed charges,Implant Device,566.65,35,,566.65,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1198.06,
STRYKER 657606 LOCKING SCREW 2X6MM,C1713,HCPCS,,79013613,CDM,278,RC,,,both,,,676,500.24,,,500.24,Other,150% of Medicare + 9.63% HCRA Surcharge,304.2,45,,304.2,percent of total billed charges,Critical Access Hospital RCC factor,229.84,34,,229.84,percent of total billed charges,Implant Device,229.84,34,,229.84,percent of total billed charges,Implant Device,229.84,34,,229.84,percent of total billed charges,Implant Device,229.84,34,,229.84,percent of total billed charges,Implant Device,229.84,34,,229.84,percent of total billed charges,Implant Device,334.62,,,334.62,Other,110% of Medicare,236.6,35,,236.6,percent of total billed charges,Implant Device,229.84,34,"Charges > $500, x 34%",229.84,percent of total billed charges,Implant Device,236.6,35,,236.6,percent of total billed charges,Implant Device,236.6,35,,236.6,percent of total billed charges,Implant Device,236.6,35,,236.6,percent of total billed charges,Implant Device,236.6,35,,236.6,percent of total billed charges,Implant Device,236.6,35,,236.6,percent of total billed charges,Implant Device,270.4,40,,270.4,percent of total billed charges,Implant Device,236.6,70,,236.6,percent of total billed charges,All Other,229.84,34,,229.84,percent of total billed charges,Implant Device,229.84,34,,229.84,percent of total billed charges,Implant Device,236.6,35,,236.6,percent of total billed charges,Implant Device,236.6,35,,236.6,percent of total billed charges,Implant Device,236.6,35,,236.6,percent of total billed charges,Implant Device,236.6,35,,236.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,500.24,
STRYKER 657608 LOCKING SCREW 2.0X8MM,C1713,HCPCS,,79013614,CDM,278,RC,,,both,,,676,500.24,,,500.24,Other,150% of Medicare + 9.63% HCRA Surcharge,304.2,45,,304.2,percent of total billed charges,Critical Access Hospital RCC factor,229.84,34,,229.84,percent of total billed charges,Implant Device,229.84,34,,229.84,percent of total billed charges,Implant Device,229.84,34,,229.84,percent of total billed charges,Implant Device,229.84,34,,229.84,percent of total billed charges,Implant Device,229.84,34,,229.84,percent of total billed charges,Implant Device,334.62,,,334.62,Other,110% of Medicare,236.6,35,,236.6,percent of total billed charges,Implant Device,229.84,34,"Charges > $500, x 34%",229.84,percent of total billed charges,Implant Device,236.6,35,,236.6,percent of total billed charges,Implant Device,236.6,35,,236.6,percent of total billed charges,Implant Device,236.6,35,,236.6,percent of total billed charges,Implant Device,236.6,35,,236.6,percent of total billed charges,Implant Device,236.6,35,,236.6,percent of total billed charges,Implant Device,270.4,40,,270.4,percent of total billed charges,Implant Device,236.6,70,,236.6,percent of total billed charges,All Other,229.84,34,,229.84,percent of total billed charges,Implant Device,229.84,34,,229.84,percent of total billed charges,Implant Device,236.6,35,,236.6,percent of total billed charges,Implant Device,236.6,35,,236.6,percent of total billed charges,Implant Device,236.6,35,,236.6,percent of total billed charges,Implant Device,236.6,35,,236.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,500.24,
STRYKER 657609 LOCKING SCREW 2.0X9MM,C1713,HCPCS,,79013615,CDM,278,RC,,,both,,,676,500.24,,,500.24,Other,150% of Medicare + 9.63% HCRA Surcharge,304.2,45,,304.2,percent of total billed charges,Critical Access Hospital RCC factor,229.84,34,,229.84,percent of total billed charges,Implant Device,229.84,34,,229.84,percent of total billed charges,Implant Device,229.84,34,,229.84,percent of total billed charges,Implant Device,229.84,34,,229.84,percent of total billed charges,Implant Device,229.84,34,,229.84,percent of total billed charges,Implant Device,334.62,,,334.62,Other,110% of Medicare,236.6,35,,236.6,percent of total billed charges,Implant Device,229.84,34,"Charges > $500, x 34%",229.84,percent of total billed charges,Implant Device,236.6,35,,236.6,percent of total billed charges,Implant Device,236.6,35,,236.6,percent of total billed charges,Implant Device,236.6,35,,236.6,percent of total billed charges,Implant Device,236.6,35,,236.6,percent of total billed charges,Implant Device,236.6,35,,236.6,percent of total billed charges,Implant Device,270.4,40,,270.4,percent of total billed charges,Implant Device,236.6,70,,236.6,percent of total billed charges,All Other,229.84,34,,229.84,percent of total billed charges,Implant Device,229.84,34,,229.84,percent of total billed charges,Implant Device,236.6,35,,236.6,percent of total billed charges,Implant Device,236.6,35,,236.6,percent of total billed charges,Implant Device,236.6,35,,236.6,percent of total billed charges,Implant Device,236.6,35,,236.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,500.24,
STRYKER 657706 BONE SCREW 2.0X6MM,C1713,HCPCS,,79013616,CDM,278,RC,,,both,,,395,292.3,,,292.3,Other,150% of Medicare + 9.63% HCRA Surcharge,177.75,45,,177.75,percent of total billed charges,Critical Access Hospital RCC factor,134.3,34,,134.3,percent of total billed charges,Implant Device,134.3,34,,134.3,percent of total billed charges,Implant Device,134.3,34,,134.3,percent of total billed charges,Implant Device,134.3,34,,134.3,percent of total billed charges,Implant Device,134.3,34,,134.3,percent of total billed charges,Implant Device,195.53,,,195.53,Other,110% of Medicare,138.25,35,,138.25,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,138.25,35,,138.25,percent of total billed charges,Implant Device,138.25,35,,138.25,percent of total billed charges,Implant Device,138.25,35,,138.25,percent of total billed charges,Implant Device,138.25,35,,138.25,percent of total billed charges,Implant Device,138.25,35,,138.25,percent of total billed charges,Implant Device,158,40,,158,percent of total billed charges,Implant Device,138.25,70,,138.25,percent of total billed charges,All Other,134.3,34,,134.3,percent of total billed charges,Implant Device,134.3,34,,134.3,percent of total billed charges,Implant Device,138.25,35,,138.25,percent of total billed charges,Implant Device,138.25,35,,138.25,percent of total billed charges,Implant Device,138.25,35,,138.25,percent of total billed charges,Implant Device,138.25,35,,138.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,292.3,
STRYKER 657708 BONE SCREW 2.0X8MM,C1713,HCPCS,,79013617,CDM,278,RC,,,both,,,395,292.3,,,292.3,Other,150% of Medicare + 9.63% HCRA Surcharge,177.75,45,,177.75,percent of total billed charges,Critical Access Hospital RCC factor,134.3,34,,134.3,percent of total billed charges,Implant Device,134.3,34,,134.3,percent of total billed charges,Implant Device,134.3,34,,134.3,percent of total billed charges,Implant Device,134.3,34,,134.3,percent of total billed charges,Implant Device,134.3,34,,134.3,percent of total billed charges,Implant Device,195.53,,,195.53,Other,110% of Medicare,138.25,35,,138.25,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,138.25,35,,138.25,percent of total billed charges,Implant Device,138.25,35,,138.25,percent of total billed charges,Implant Device,138.25,35,,138.25,percent of total billed charges,Implant Device,138.25,35,,138.25,percent of total billed charges,Implant Device,138.25,35,,138.25,percent of total billed charges,Implant Device,158,40,,158,percent of total billed charges,Implant Device,138.25,70,,138.25,percent of total billed charges,All Other,134.3,34,,134.3,percent of total billed charges,Implant Device,134.3,34,,134.3,percent of total billed charges,Implant Device,138.25,35,,138.25,percent of total billed charges,Implant Device,138.25,35,,138.25,percent of total billed charges,Implant Device,138.25,35,,138.25,percent of total billed charges,Implant Device,138.25,35,,138.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,292.3,
STRYKER 662612 BONE SCREW 1.7X12MM,C1713,HCPCS,,79013618,CDM,278,RC,,,both,,,324,239.76,,,239.76,Other,150% of Medicare + 9.63% HCRA Surcharge,145.8,45,,145.8,percent of total billed charges,Critical Access Hospital RCC factor,110.16,34,,110.16,percent of total billed charges,Implant Device,110.16,34,,110.16,percent of total billed charges,Implant Device,110.16,34,,110.16,percent of total billed charges,Implant Device,110.16,34,,110.16,percent of total billed charges,Implant Device,110.16,34,,110.16,percent of total billed charges,Implant Device,160.38,,,160.38,Other,110% of Medicare,113.4,35,,113.4,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,129.6,40,,129.6,percent of total billed charges,Implant Device,113.4,70,,113.4,percent of total billed charges,All Other,110.16,34,,110.16,percent of total billed charges,Implant Device,110.16,34,,110.16,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,239.76,
STRYKER 662614 BONE SCREW 1.7X14MM,C1713,HCPCS,,79013619,CDM,278,RC,,,both,,,324,239.76,,,239.76,Other,150% of Medicare + 9.63% HCRA Surcharge,145.8,45,,145.8,percent of total billed charges,Critical Access Hospital RCC factor,110.16,34,,110.16,percent of total billed charges,Implant Device,110.16,34,,110.16,percent of total billed charges,Implant Device,110.16,34,,110.16,percent of total billed charges,Implant Device,110.16,34,,110.16,percent of total billed charges,Implant Device,110.16,34,,110.16,percent of total billed charges,Implant Device,160.38,,,160.38,Other,110% of Medicare,113.4,35,,113.4,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,129.6,40,,129.6,percent of total billed charges,Implant Device,113.4,70,,113.4,percent of total billed charges,All Other,110.16,34,,110.16,percent of total billed charges,Implant Device,110.16,34,,110.16,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,239.76,
ZIMMER 42-5020-060-01 FEMUR NARW LT SZ 6,C1776,HCPCS,,79013620,CDM,278,RC,,,both,,,6300,4662.02,,,4662.02,Other,150% of Medicare + 9.63% HCRA Surcharge,2835,45,,2835,percent of total billed charges,Critical Access Hospital RCC factor,2142,34,,2142,percent of total billed charges,Implant Device,2142,34,,2142,percent of total billed charges,Implant Device,2142,34,,2142,percent of total billed charges,Implant Device,2142,34,,2142,percent of total billed charges,Implant Device,2142,34,,2142,percent of total billed charges,Implant Device,3118.5,,,3118.5,Other,110% of Medicare,2205,35,,2205,percent of total billed charges,Implant Device,2142,34,"Charges > $500, x 34%",2142,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2520,40,,2520,percent of total billed charges,Implant Device,2205,70,,2205,percent of total billed charges,All Other,2142,34,,2142,percent of total billed charges,Implant Device,2142,34,,2142,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,2205,35,,2205,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2142,34,"If Charge > 2,000, then 34 percent",2142,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4662.02,
ZIMMER 02.03264.015 DISTAL FEMOR PLATE,C1713,HCPCS,,79013637,CDM,278,RC,,,both,,,4075,3015.51,,,3015.51,Other,150% of Medicare + 9.63% HCRA Surcharge,1833.75,45,,1833.75,percent of total billed charges,Critical Access Hospital RCC factor,1385.5,34,,1385.5,percent of total billed charges,Implant Device,1385.5,34,,1385.5,percent of total billed charges,Implant Device,1385.5,34,,1385.5,percent of total billed charges,Implant Device,1385.5,34,,1385.5,percent of total billed charges,Implant Device,1385.5,34,,1385.5,percent of total billed charges,Implant Device,2017.13,,,2017.13,Other,110% of Medicare,1426.25,35,,1426.25,percent of total billed charges,Implant Device,1385.5,34,"Charges > $500, x 34%",1385.5,percent of total billed charges,Implant Device,1426.25,35,,1426.25,percent of total billed charges,Implant Device,1426.25,35,,1426.25,percent of total billed charges,Implant Device,1426.25,35,,1426.25,percent of total billed charges,Implant Device,1426.25,35,,1426.25,percent of total billed charges,Implant Device,1426.25,35,,1426.25,percent of total billed charges,Implant Device,1630,40,,1630,percent of total billed charges,Implant Device,1426.25,70,,1426.25,percent of total billed charges,All Other,1385.5,34,,1385.5,percent of total billed charges,Implant Device,1385.5,34,,1385.5,percent of total billed charges,Implant Device,1426.25,35,,1426.25,percent of total billed charges,Implant Device,1426.25,35,,1426.25,percent of total billed charges,Implant Device,1426.25,35,,1426.25,percent of total billed charges,Implant Device,1426.25,35,,1426.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1385.5,34,"If Charge > 2,000, then 34 percent",1385.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3015.51,
ZIMMER 02.03150.040 CORTICAL SCRW 5X40MM,C1713,HCPCS,,79013638,CDM,278,RC,,,both,,,475,351.5,,,351.5,Other,150% of Medicare + 9.63% HCRA Surcharge,213.75,45,,213.75,percent of total billed charges,Critical Access Hospital RCC factor,161.5,34,,161.5,percent of total billed charges,Implant Device,161.5,34,,161.5,percent of total billed charges,Implant Device,161.5,34,,161.5,percent of total billed charges,Implant Device,161.5,34,,161.5,percent of total billed charges,Implant Device,161.5,34,,161.5,percent of total billed charges,Implant Device,235.13,,,235.13,Other,110% of Medicare,166.25,35,,166.25,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,166.25,35,,166.25,percent of total billed charges,Implant Device,166.25,35,,166.25,percent of total billed charges,Implant Device,166.25,35,,166.25,percent of total billed charges,Implant Device,166.25,35,,166.25,percent of total billed charges,Implant Device,166.25,35,,166.25,percent of total billed charges,Implant Device,190,40,,190,percent of total billed charges,Implant Device,166.25,70,,166.25,percent of total billed charges,All Other,161.5,34,,161.5,percent of total billed charges,Implant Device,161.5,34,,161.5,percent of total billed charges,Implant Device,166.25,35,,166.25,percent of total billed charges,Implant Device,166.25,35,,166.25,percent of total billed charges,Implant Device,166.25,35,,166.25,percent of total billed charges,Implant Device,166.25,35,,166.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,351.5,
ZIMMER 02.03150.046 CORTICAL SCRW 5X46MM,C1713,HCPCS,,79013639,CDM,278,RC,,,both,,,475,351.5,,,351.5,Other,150% of Medicare + 9.63% HCRA Surcharge,213.75,45,,213.75,percent of total billed charges,Critical Access Hospital RCC factor,161.5,34,,161.5,percent of total billed charges,Implant Device,161.5,34,,161.5,percent of total billed charges,Implant Device,161.5,34,,161.5,percent of total billed charges,Implant Device,161.5,34,,161.5,percent of total billed charges,Implant Device,161.5,34,,161.5,percent of total billed charges,Implant Device,235.13,,,235.13,Other,110% of Medicare,166.25,35,,166.25,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,166.25,35,,166.25,percent of total billed charges,Implant Device,166.25,35,,166.25,percent of total billed charges,Implant Device,166.25,35,,166.25,percent of total billed charges,Implant Device,166.25,35,,166.25,percent of total billed charges,Implant Device,166.25,35,,166.25,percent of total billed charges,Implant Device,190,40,,190,percent of total billed charges,Implant Device,166.25,70,,166.25,percent of total billed charges,All Other,161.5,34,,161.5,percent of total billed charges,Implant Device,161.5,34,,161.5,percent of total billed charges,Implant Device,166.25,35,,166.25,percent of total billed charges,Implant Device,166.25,35,,166.25,percent of total billed charges,Implant Device,166.25,35,,166.25,percent of total billed charges,Implant Device,166.25,35,,166.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,351.5,
ZIMMER 02.03150.060 CORTICAL SCRW 5X60MM,C1713,HCPCS,,79013640,CDM,278,RC,,,both,,,475,351.5,,,351.5,Other,150% of Medicare + 9.63% HCRA Surcharge,213.75,45,,213.75,percent of total billed charges,Critical Access Hospital RCC factor,161.5,34,,161.5,percent of total billed charges,Implant Device,161.5,34,,161.5,percent of total billed charges,Implant Device,161.5,34,,161.5,percent of total billed charges,Implant Device,161.5,34,,161.5,percent of total billed charges,Implant Device,161.5,34,,161.5,percent of total billed charges,Implant Device,235.13,,,235.13,Other,110% of Medicare,166.25,35,,166.25,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,166.25,35,,166.25,percent of total billed charges,Implant Device,166.25,35,,166.25,percent of total billed charges,Implant Device,166.25,35,,166.25,percent of total billed charges,Implant Device,166.25,35,,166.25,percent of total billed charges,Implant Device,166.25,35,,166.25,percent of total billed charges,Implant Device,190,40,,190,percent of total billed charges,Implant Device,166.25,70,,166.25,percent of total billed charges,All Other,161.5,34,,161.5,percent of total billed charges,Implant Device,161.5,34,,161.5,percent of total billed charges,Implant Device,166.25,35,,166.25,percent of total billed charges,Implant Device,166.25,35,,166.25,percent of total billed charges,Implant Device,166.25,35,,166.25,percent of total billed charges,Implant Device,166.25,35,,166.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,351.5,
ZIMMER 290.20.280 2.0MM WIRE,C1713,HCPCS,,79013641,CDM,278,RC,,,both,,,101,74.74,,,74.74,Other,150% of Medicare + 9.63% HCRA Surcharge,45.45,45,,45.45,percent of total billed charges,Critical Access Hospital RCC factor,34.34,34,,34.34,percent of total billed charges,Implant Device,34.34,34,,34.34,percent of total billed charges,Implant Device,34.34,34,,34.34,percent of total billed charges,Implant Device,34.34,34,,34.34,percent of total billed charges,Implant Device,34.34,34,,34.34,percent of total billed charges,Implant Device,50,,,50,Other,110% of Medicare,35.35,35,,35.35,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,35.35,35,,35.35,percent of total billed charges,Implant Device,35.35,35,,35.35,percent of total billed charges,Implant Device,35.35,35,,35.35,percent of total billed charges,Implant Device,35.35,35,,35.35,percent of total billed charges,Implant Device,35.35,35,,35.35,percent of total billed charges,Implant Device,40.4,40,,40.4,percent of total billed charges,Implant Device,35.35,70,,35.35,percent of total billed charges,All Other,34.34,34,,34.34,percent of total billed charges,Implant Device,34.34,34,,34.34,percent of total billed charges,Implant Device,35.35,35,,35.35,percent of total billed charges,Implant Device,35.35,35,,35.35,percent of total billed charges,Implant Device,35.35,35,,35.35,percent of total billed charges,Implant Device,35.35,35,,35.35,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,74.74,
ZIMMER 47-2232-060-01 CABLE BUTTON,C1713,HCPCS,,79013643,CDM,278,RC,,,both,,,500,370,,,370,Other,150% of Medicare + 9.63% HCRA Surcharge,225,45,,225,percent of total billed charges,Critical Access Hospital RCC factor,170,34,,170,percent of total billed charges,Implant Device,170,34,,170,percent of total billed charges,Implant Device,170,34,,170,percent of total billed charges,Implant Device,170,34,,170,percent of total billed charges,Implant Device,170,34,,170,percent of total billed charges,Implant Device,247.5,,,247.5,Other,110% of Medicare,175,35,,175,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,175,35,,175,percent of total billed charges,Implant Device,175,35,,175,percent of total billed charges,Implant Device,175,35,,175,percent of total billed charges,Implant Device,175,35,,175,percent of total billed charges,Implant Device,175,35,,175,percent of total billed charges,Implant Device,200,40,,200,percent of total billed charges,Implant Device,175,70,,175,percent of total billed charges,All Other,170,34,,170,percent of total billed charges,Implant Device,170,34,,170,percent of total billed charges,Implant Device,175,35,,175,percent of total billed charges,Implant Device,175,35,,175,percent of total billed charges,Implant Device,175,35,,175,percent of total billed charges,Implant Device,175,35,,175,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,370,
ZIMMER 814550030 CORT BONE SCREW 5X30MM,C1713,HCPCS,,79013644,CDM,278,RC,,,both,,,533,394.42,,,394.42,Other,150% of Medicare + 9.63% HCRA Surcharge,239.85,45,,239.85,percent of total billed charges,Critical Access Hospital RCC factor,181.22,34,,181.22,percent of total billed charges,Implant Device,181.22,34,,181.22,percent of total billed charges,Implant Device,181.22,34,,181.22,percent of total billed charges,Implant Device,181.22,34,,181.22,percent of total billed charges,Implant Device,181.22,34,,181.22,percent of total billed charges,Implant Device,263.84,,,263.84,Other,110% of Medicare,186.55,35,,186.55,percent of total billed charges,Implant Device,181.22,34,"Charges > $500, x 34%",181.22,percent of total billed charges,Implant Device,186.55,35,,186.55,percent of total billed charges,Implant Device,186.55,35,,186.55,percent of total billed charges,Implant Device,186.55,35,,186.55,percent of total billed charges,Implant Device,186.55,35,,186.55,percent of total billed charges,Implant Device,186.55,35,,186.55,percent of total billed charges,Implant Device,213.2,40,,213.2,percent of total billed charges,Implant Device,186.55,70,,186.55,percent of total billed charges,All Other,181.22,34,,181.22,percent of total billed charges,Implant Device,181.22,34,,181.22,percent of total billed charges,Implant Device,186.55,35,,186.55,percent of total billed charges,Implant Device,186.55,35,,186.55,percent of total billed charges,Implant Device,186.55,35,,186.55,percent of total billed charges,Implant Device,186.55,35,,186.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,394.42,
BOST H74912044146070 14X60X75CM STENT,C1876,HCPCS,,79013648,CDM,278,RC,,,both,,,2665,1972.11,,,1972.11,Other,150% of Medicare + 9.63% HCRA Surcharge,1199.25,45,,1199.25,percent of total billed charges,Critical Access Hospital RCC factor,906.1,34,,906.1,percent of total billed charges,Implant Device,906.1,34,,906.1,percent of total billed charges,Implant Device,906.1,34,,906.1,percent of total billed charges,Implant Device,906.1,34,,906.1,percent of total billed charges,Implant Device,906.1,34,,906.1,percent of total billed charges,Implant Device,1319.18,,,1319.18,Other,110% of Medicare,932.75,35,,932.75,percent of total billed charges,Implant Device,906.1,34,"Charges > $500, x 34%",906.1,percent of total billed charges,Implant Device,932.75,35,,932.75,percent of total billed charges,Implant Device,932.75,35,,932.75,percent of total billed charges,Implant Device,932.75,35,,932.75,percent of total billed charges,Implant Device,932.75,35,,932.75,percent of total billed charges,Implant Device,932.75,35,,932.75,percent of total billed charges,Implant Device,1066,40,,1066,percent of total billed charges,Implant Device,932.75,70,,932.75,percent of total billed charges,All Other,906.1,34,,906.1,percent of total billed charges,Implant Device,906.1,34,,906.1,percent of total billed charges,Implant Device,932.75,35,,932.75,percent of total billed charges,Implant Device,932.75,35,,932.75,percent of total billed charges,Implant Device,932.75,35,,932.75,percent of total billed charges,Implant Device,932.75,35,,932.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,906.1,34,"If Charge > 2,000, then 34 percent",906.1,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1972.11,
BOST H74912044166070 16X60X75CM STENT,C1876,HCPCS,,79013649,CDM,278,RC,,,both,,,2665,1972.11,,,1972.11,Other,150% of Medicare + 9.63% HCRA Surcharge,1199.25,45,,1199.25,percent of total billed charges,Critical Access Hospital RCC factor,906.1,34,,906.1,percent of total billed charges,Implant Device,906.1,34,,906.1,percent of total billed charges,Implant Device,906.1,34,,906.1,percent of total billed charges,Implant Device,906.1,34,,906.1,percent of total billed charges,Implant Device,906.1,34,,906.1,percent of total billed charges,Implant Device,1319.18,,,1319.18,Other,110% of Medicare,932.75,35,,932.75,percent of total billed charges,Implant Device,906.1,34,"Charges > $500, x 34%",906.1,percent of total billed charges,Implant Device,932.75,35,,932.75,percent of total billed charges,Implant Device,932.75,35,,932.75,percent of total billed charges,Implant Device,932.75,35,,932.75,percent of total billed charges,Implant Device,932.75,35,,932.75,percent of total billed charges,Implant Device,932.75,35,,932.75,percent of total billed charges,Implant Device,1066,40,,1066,percent of total billed charges,Implant Device,932.75,70,,932.75,percent of total billed charges,All Other,906.1,34,,906.1,percent of total billed charges,Implant Device,906.1,34,,906.1,percent of total billed charges,Implant Device,932.75,35,,932.75,percent of total billed charges,Implant Device,932.75,35,,932.75,percent of total billed charges,Implant Device,932.75,35,,932.75,percent of total billed charges,Implant Device,932.75,35,,932.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,906.1,34,"If Charge > 2,000, then 34 percent",906.1,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1972.11,
BOST H74912044169070 16X90X75CM STENT,C1876,HCPCS,,79013650,CDM,278,RC,,,both,,,2665,1972.11,,,1972.11,Other,150% of Medicare + 9.63% HCRA Surcharge,1199.25,45,,1199.25,percent of total billed charges,Critical Access Hospital RCC factor,906.1,34,,906.1,percent of total billed charges,Implant Device,906.1,34,,906.1,percent of total billed charges,Implant Device,906.1,34,,906.1,percent of total billed charges,Implant Device,906.1,34,,906.1,percent of total billed charges,Implant Device,906.1,34,,906.1,percent of total billed charges,Implant Device,1319.18,,,1319.18,Other,110% of Medicare,932.75,35,,932.75,percent of total billed charges,Implant Device,906.1,34,"Charges > $500, x 34%",906.1,percent of total billed charges,Implant Device,932.75,35,,932.75,percent of total billed charges,Implant Device,932.75,35,,932.75,percent of total billed charges,Implant Device,932.75,35,,932.75,percent of total billed charges,Implant Device,932.75,35,,932.75,percent of total billed charges,Implant Device,932.75,35,,932.75,percent of total billed charges,Implant Device,1066,40,,1066,percent of total billed charges,Implant Device,932.75,70,,932.75,percent of total billed charges,All Other,906.1,34,,906.1,percent of total billed charges,Implant Device,906.1,34,,906.1,percent of total billed charges,Implant Device,932.75,35,,932.75,percent of total billed charges,Implant Device,932.75,35,,932.75,percent of total billed charges,Implant Device,932.75,35,,932.75,percent of total billed charges,Implant Device,932.75,35,,932.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,906.1,34,"If Charge > 2,000, then 34 percent",906.1,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1972.11,
BOST H74912044186070 18X60X75CM STENT,C1876,HCPCS,,79013651,CDM,278,RC,,,both,,,2665,1972.11,,,1972.11,Other,150% of Medicare + 9.63% HCRA Surcharge,1199.25,45,,1199.25,percent of total billed charges,Critical Access Hospital RCC factor,906.1,34,,906.1,percent of total billed charges,Implant Device,906.1,34,,906.1,percent of total billed charges,Implant Device,906.1,34,,906.1,percent of total billed charges,Implant Device,906.1,34,,906.1,percent of total billed charges,Implant Device,906.1,34,,906.1,percent of total billed charges,Implant Device,1319.18,,,1319.18,Other,110% of Medicare,932.75,35,,932.75,percent of total billed charges,Implant Device,906.1,34,"Charges > $500, x 34%",906.1,percent of total billed charges,Implant Device,932.75,35,,932.75,percent of total billed charges,Implant Device,932.75,35,,932.75,percent of total billed charges,Implant Device,932.75,35,,932.75,percent of total billed charges,Implant Device,932.75,35,,932.75,percent of total billed charges,Implant Device,932.75,35,,932.75,percent of total billed charges,Implant Device,1066,40,,1066,percent of total billed charges,Implant Device,932.75,70,,932.75,percent of total billed charges,All Other,906.1,34,,906.1,percent of total billed charges,Implant Device,906.1,34,,906.1,percent of total billed charges,Implant Device,932.75,35,,932.75,percent of total billed charges,Implant Device,932.75,35,,932.75,percent of total billed charges,Implant Device,932.75,35,,932.75,percent of total billed charges,Implant Device,932.75,35,,932.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,906.1,34,"If Charge > 2,000, then 34 percent",906.1,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1972.11,
ARTHREX AR-8730-26PT CAN SCREW 3X26MM,C1713,HCPCS,,79013657,CDM,278,RC,,,both,,,488,361.12,,,361.12,Other,150% of Medicare + 9.63% HCRA Surcharge,219.6,45,,219.6,percent of total billed charges,Critical Access Hospital RCC factor,165.92,34,,165.92,percent of total billed charges,Implant Device,165.92,34,,165.92,percent of total billed charges,Implant Device,165.92,34,,165.92,percent of total billed charges,Implant Device,165.92,34,,165.92,percent of total billed charges,Implant Device,165.92,34,,165.92,percent of total billed charges,Implant Device,241.56,,,241.56,Other,110% of Medicare,170.8,35,,170.8,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,170.8,35,,170.8,percent of total billed charges,Implant Device,170.8,35,,170.8,percent of total billed charges,Implant Device,170.8,35,,170.8,percent of total billed charges,Implant Device,170.8,35,,170.8,percent of total billed charges,Implant Device,170.8,35,,170.8,percent of total billed charges,Implant Device,195.2,40,,195.2,percent of total billed charges,Implant Device,170.8,70,,170.8,percent of total billed charges,All Other,165.92,34,,165.92,percent of total billed charges,Implant Device,165.92,34,,165.92,percent of total billed charges,Implant Device,170.8,35,,170.8,percent of total billed charges,Implant Device,170.8,35,,170.8,percent of total billed charges,Implant Device,170.8,35,,170.8,percent of total billed charges,Implant Device,170.8,35,,170.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,361.12,
ARTHREX AR-8933VCL-10 KREULOCK SRW 3X10,C1713,HCPCS,,79013658,CDM,278,RC,,,both,,,959,709.66,,,709.66,Other,150% of Medicare + 9.63% HCRA Surcharge,431.55,45,,431.55,percent of total billed charges,Critical Access Hospital RCC factor,326.06,34,,326.06,percent of total billed charges,Implant Device,326.06,34,,326.06,percent of total billed charges,Implant Device,326.06,34,,326.06,percent of total billed charges,Implant Device,326.06,34,,326.06,percent of total billed charges,Implant Device,326.06,34,,326.06,percent of total billed charges,Implant Device,474.71,,,474.71,Other,110% of Medicare,335.65,35,,335.65,percent of total billed charges,Implant Device,326.06,34,"Charges > $500, x 34%",326.06,percent of total billed charges,Implant Device,335.65,35,,335.65,percent of total billed charges,Implant Device,335.65,35,,335.65,percent of total billed charges,Implant Device,335.65,35,,335.65,percent of total billed charges,Implant Device,335.65,35,,335.65,percent of total billed charges,Implant Device,335.65,35,,335.65,percent of total billed charges,Implant Device,383.6,40,,383.6,percent of total billed charges,Implant Device,335.65,70,,335.65,percent of total billed charges,All Other,326.06,34,,326.06,percent of total billed charges,Implant Device,326.06,34,,326.06,percent of total billed charges,Implant Device,335.65,35,,335.65,percent of total billed charges,Implant Device,335.65,35,,335.65,percent of total billed charges,Implant Device,335.65,35,,335.65,percent of total billed charges,Implant Device,335.65,35,,335.65,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,709.66,
EXACTECH 310-02-44 HUM HEAD TALL 44MM,C1776,HCPCS,,79013659,CDM,278,RC,,,both,,,3150,2331.01,,,2331.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1417.5,45,,1417.5,percent of total billed charges,Critical Access Hospital RCC factor,1071,34,,1071,percent of total billed charges,Implant Device,1071,34,,1071,percent of total billed charges,Implant Device,1071,34,,1071,percent of total billed charges,Implant Device,1071,34,,1071,percent of total billed charges,Implant Device,1071,34,,1071,percent of total billed charges,Implant Device,1559.25,,,1559.25,Other,110% of Medicare,1102.5,35,,1102.5,percent of total billed charges,Implant Device,1071,34,"Charges > $500, x 34%",1071,percent of total billed charges,Implant Device,1102.5,35,,1102.5,percent of total billed charges,Implant Device,1102.5,35,,1102.5,percent of total billed charges,Implant Device,1102.5,35,,1102.5,percent of total billed charges,Implant Device,1102.5,35,,1102.5,percent of total billed charges,Implant Device,1102.5,35,,1102.5,percent of total billed charges,Implant Device,1260,40,,1260,percent of total billed charges,Implant Device,1102.5,70,,1102.5,percent of total billed charges,All Other,1071,34,,1071,percent of total billed charges,Implant Device,1071,34,,1071,percent of total billed charges,Implant Device,1102.5,35,,1102.5,percent of total billed charges,Implant Device,1102.5,35,,1102.5,percent of total billed charges,Implant Device,1102.5,35,,1102.5,percent of total billed charges,Implant Device,1102.5,35,,1102.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1071,34,"If Charge > 2,000, then 34 percent",1071,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2331.01,
J&J 224.601 NARROW LCP PLATE 4.5X188 10H,C1713,HCPCS,,79013660,CDM,278,RC,,,both,,,1392,1030.08,,,1030.08,Other,150% of Medicare + 9.63% HCRA Surcharge,626.4,45,,626.4,percent of total billed charges,Critical Access Hospital RCC factor,473.28,34,,473.28,percent of total billed charges,Implant Device,473.28,34,,473.28,percent of total billed charges,Implant Device,473.28,34,,473.28,percent of total billed charges,Implant Device,473.28,34,,473.28,percent of total billed charges,Implant Device,473.28,34,,473.28,percent of total billed charges,Implant Device,689.04,,,689.04,Other,110% of Medicare,487.2,35,,487.2,percent of total billed charges,Implant Device,473.28,34,"Charges > $500, x 34%",473.28,percent of total billed charges,Implant Device,487.2,35,,487.2,percent of total billed charges,Implant Device,487.2,35,,487.2,percent of total billed charges,Implant Device,487.2,35,,487.2,percent of total billed charges,Implant Device,487.2,35,,487.2,percent of total billed charges,Implant Device,487.2,35,,487.2,percent of total billed charges,Implant Device,556.8,40,,556.8,percent of total billed charges,Implant Device,487.2,70,,487.2,percent of total billed charges,All Other,473.28,34,,473.28,percent of total billed charges,Implant Device,473.28,34,,473.28,percent of total billed charges,Implant Device,487.2,35,,487.2,percent of total billed charges,Implant Device,487.2,35,,487.2,percent of total billed charges,Implant Device,487.2,35,,487.2,percent of total billed charges,Implant Device,487.2,35,,487.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1030.08,
J&J 150401204 ATTUNE FEMORAL RIGHT SZ 4,C1776,HCPCS,,79013661,CDM,278,RC,,,both,,,6000,4440.02,,,4440.02,Other,150% of Medicare + 9.63% HCRA Surcharge,2700,45,,2700,percent of total billed charges,Critical Access Hospital RCC factor,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2970,,,2970,Other,110% of Medicare,2100,35,,2100,percent of total billed charges,Implant Device,2040,34,"Charges > $500, x 34%",2040,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2400,40,,2400,percent of total billed charges,Implant Device,2100,70,,2100,percent of total billed charges,All Other,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2040,34,"If Charge > 2,000, then 34 percent",2040,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4440.02,
J&J 151630406 ATTUNE TIBIAL INSERT SZ 4,C1776,HCPCS,,79013662,CDM,278,RC,,,both,,,5400,3996.01,,,3996.01,Other,150% of Medicare + 9.63% HCRA Surcharge,2430,45,,2430,percent of total billed charges,Critical Access Hospital RCC factor,1836,34,,1836,percent of total billed charges,Implant Device,1836,34,,1836,percent of total billed charges,Implant Device,1836,34,,1836,percent of total billed charges,Implant Device,1836,34,,1836,percent of total billed charges,Implant Device,1836,34,,1836,percent of total billed charges,Implant Device,2673,,,2673,Other,110% of Medicare,1890,35,,1890,percent of total billed charges,Implant Device,1836,34,"Charges > $500, x 34%",1836,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,2160,40,,2160,percent of total billed charges,Implant Device,1890,70,,1890,percent of total billed charges,All Other,1836,34,,1836,percent of total billed charges,Implant Device,1836,34,,1836,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1836,34,"If Charge > 2,000, then 34 percent",1836,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3996.01,
J&J 150400105 ATTUNE FEMORAL LT SIZE 5,C1776,HCPCS,,79013663,CDM,278,RC,,,both,,,4800,3552.01,,,3552.01,Other,150% of Medicare + 9.63% HCRA Surcharge,2160,45,,2160,percent of total billed charges,Critical Access Hospital RCC factor,1632,34,,1632,percent of total billed charges,Implant Device,1632,34,,1632,percent of total billed charges,Implant Device,1632,34,,1632,percent of total billed charges,Implant Device,1632,34,,1632,percent of total billed charges,Implant Device,1632,34,,1632,percent of total billed charges,Implant Device,2376,,,2376,Other,110% of Medicare,1680,35,,1680,percent of total billed charges,Implant Device,1632,34,"Charges > $500, x 34%",1632,percent of total billed charges,Implant Device,1680,35,,1680,percent of total billed charges,Implant Device,1680,35,,1680,percent of total billed charges,Implant Device,1680,35,,1680,percent of total billed charges,Implant Device,1680,35,,1680,percent of total billed charges,Implant Device,1680,35,,1680,percent of total billed charges,Implant Device,1920,40,,1920,percent of total billed charges,Implant Device,1680,70,,1680,percent of total billed charges,All Other,1632,34,,1632,percent of total billed charges,Implant Device,1632,34,,1632,percent of total billed charges,Implant Device,1680,35,,1680,percent of total billed charges,Implant Device,1680,35,,1680,percent of total billed charges,Implant Device,1680,35,,1680,percent of total billed charges,Implant Device,1680,35,,1680,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1632,34,"If Charge > 2,000, then 34 percent",1632,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3552.01,
J&J 101012080 ACTIS FEMORAL STEM SIZE 8,C1776,HCPCS,,79013664,CDM,278,RC,,,both,,,7410,5483.42,,,5483.42,Other,150% of Medicare + 9.63% HCRA Surcharge,3334.5,45,,3334.5,percent of total billed charges,Critical Access Hospital RCC factor,2519.4,34,,2519.4,percent of total billed charges,Implant Device,2519.4,34,,2519.4,percent of total billed charges,Implant Device,2519.4,34,,2519.4,percent of total billed charges,Implant Device,2519.4,34,,2519.4,percent of total billed charges,Implant Device,2519.4,34,,2519.4,percent of total billed charges,Implant Device,3667.95,,,3667.95,Other,110% of Medicare,2593.5,35,,2593.5,percent of total billed charges,Implant Device,2519.4,34,"Charges > $500, x 34%",2519.4,percent of total billed charges,Implant Device,2593.5,35,,2593.5,percent of total billed charges,Implant Device,2593.5,35,,2593.5,percent of total billed charges,Implant Device,2593.5,35,,2593.5,percent of total billed charges,Implant Device,2593.5,35,,2593.5,percent of total billed charges,Implant Device,2593.5,35,,2593.5,percent of total billed charges,Implant Device,2964,40,,2964,percent of total billed charges,Implant Device,2593.5,70,,2593.5,percent of total billed charges,All Other,2519.4,34,,2519.4,percent of total billed charges,Implant Device,2519.4,34,,2519.4,percent of total billed charges,Implant Device,2593.5,35,,2593.5,percent of total billed charges,Implant Device,2593.5,35,,2593.5,percent of total billed charges,Implant Device,2593.5,35,,2593.5,percent of total billed charges,Implant Device,2593.5,35,,2593.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2519.4,34,"If Charge > 2,000, then 34 percent",2519.4,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5483.42,
J&J 121732060 ACEBULAR SHELL 60MM,C1776,HCPCS,,79013665,CDM,278,RC,,,both,,,3420,2530.81,,,2530.81,Other,150% of Medicare + 9.63% HCRA Surcharge,1539,45,,1539,percent of total billed charges,Critical Access Hospital RCC factor,1162.8,34,,1162.8,percent of total billed charges,Implant Device,1162.8,34,,1162.8,percent of total billed charges,Implant Device,1162.8,34,,1162.8,percent of total billed charges,Implant Device,1162.8,34,,1162.8,percent of total billed charges,Implant Device,1162.8,34,,1162.8,percent of total billed charges,Implant Device,1692.9,,,1692.9,Other,110% of Medicare,1197,35,,1197,percent of total billed charges,Implant Device,1162.8,34,"Charges > $500, x 34%",1162.8,percent of total billed charges,Implant Device,1197,35,,1197,percent of total billed charges,Implant Device,1197,35,,1197,percent of total billed charges,Implant Device,1197,35,,1197,percent of total billed charges,Implant Device,1197,35,,1197,percent of total billed charges,Implant Device,1197,35,,1197,percent of total billed charges,Implant Device,1368,40,,1368,percent of total billed charges,Implant Device,1197,70,,1197,percent of total billed charges,All Other,1162.8,34,,1162.8,percent of total billed charges,Implant Device,1162.8,34,,1162.8,percent of total billed charges,Implant Device,1197,35,,1197,percent of total billed charges,Implant Device,1197,35,,1197,percent of total billed charges,Implant Device,1197,35,,1197,percent of total billed charges,Implant Device,1197,35,,1197,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1162.8,34,"If Charge > 2,000, then 34 percent",1162.8,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2530.81,
J&J 122140060 ACETABULAR LINER 40X60MM,C1776,HCPCS,,79013666,CDM,278,RC,,,both,,,2565,1898.11,,,1898.11,Other,150% of Medicare + 9.63% HCRA Surcharge,1154.25,45,,1154.25,percent of total billed charges,Critical Access Hospital RCC factor,872.1,34,,872.1,percent of total billed charges,Implant Device,872.1,34,,872.1,percent of total billed charges,Implant Device,872.1,34,,872.1,percent of total billed charges,Implant Device,872.1,34,,872.1,percent of total billed charges,Implant Device,872.1,34,,872.1,percent of total billed charges,Implant Device,1269.68,,,1269.68,Other,110% of Medicare,897.75,35,,897.75,percent of total billed charges,Implant Device,872.1,34,"Charges > $500, x 34%",872.1,percent of total billed charges,Implant Device,897.75,35,,897.75,percent of total billed charges,Implant Device,897.75,35,,897.75,percent of total billed charges,Implant Device,897.75,35,,897.75,percent of total billed charges,Implant Device,897.75,35,,897.75,percent of total billed charges,Implant Device,897.75,35,,897.75,percent of total billed charges,Implant Device,1026,40,,1026,percent of total billed charges,Implant Device,897.75,70,,897.75,percent of total billed charges,All Other,872.1,34,,872.1,percent of total billed charges,Implant Device,872.1,34,,872.1,percent of total billed charges,Implant Device,897.75,35,,897.75,percent of total billed charges,Implant Device,897.75,35,,897.75,percent of total billed charges,Implant Device,897.75,35,,897.75,percent of total billed charges,Implant Device,897.75,35,,897.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,872.1,34,"If Charge > 2,000, then 34 percent",872.1,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1898.11,
STRYKER 326285 ASNIS CANN SCREW 6.5X85MM,C1713,HCPCS,,79013667,CDM,278,RC,,,both,,,765,566.1,,,566.1,Other,150% of Medicare + 9.63% HCRA Surcharge,344.25,45,,344.25,percent of total billed charges,Critical Access Hospital RCC factor,260.1,34,,260.1,percent of total billed charges,Implant Device,260.1,34,,260.1,percent of total billed charges,Implant Device,260.1,34,,260.1,percent of total billed charges,Implant Device,260.1,34,,260.1,percent of total billed charges,Implant Device,260.1,34,,260.1,percent of total billed charges,Implant Device,378.68,,,378.68,Other,110% of Medicare,267.75,35,,267.75,percent of total billed charges,Implant Device,260.1,34,"Charges > $500, x 34%",260.1,percent of total billed charges,Implant Device,267.75,35,,267.75,percent of total billed charges,Implant Device,267.75,35,,267.75,percent of total billed charges,Implant Device,267.75,35,,267.75,percent of total billed charges,Implant Device,267.75,35,,267.75,percent of total billed charges,Implant Device,267.75,35,,267.75,percent of total billed charges,Implant Device,306,40,,306,percent of total billed charges,Implant Device,267.75,70,,267.75,percent of total billed charges,All Other,260.1,34,,260.1,percent of total billed charges,Implant Device,260.1,34,,260.1,percent of total billed charges,Implant Device,267.75,35,,267.75,percent of total billed charges,Implant Device,267.75,35,,267.75,percent of total billed charges,Implant Device,267.75,35,,267.75,percent of total billed charges,Implant Device,267.75,35,,267.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,566.1,
STRYKER 5048-5-300 CONNECT ROD 5X300MM,C1713,HCPCS,,79013668,CDM,278,RC,,,both,,,334,247.16,,,247.16,Other,150% of Medicare + 9.63% HCRA Surcharge,150.3,45,,150.3,percent of total billed charges,Critical Access Hospital RCC factor,113.56,34,,113.56,percent of total billed charges,Implant Device,113.56,34,,113.56,percent of total billed charges,Implant Device,113.56,34,,113.56,percent of total billed charges,Implant Device,113.56,34,,113.56,percent of total billed charges,Implant Device,113.56,34,,113.56,percent of total billed charges,Implant Device,165.33,,,165.33,Other,110% of Medicare,116.9,35,,116.9,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,116.9,35,,116.9,percent of total billed charges,Implant Device,116.9,35,,116.9,percent of total billed charges,Implant Device,116.9,35,,116.9,percent of total billed charges,Implant Device,116.9,35,,116.9,percent of total billed charges,Implant Device,116.9,35,,116.9,percent of total billed charges,Implant Device,133.6,40,,133.6,percent of total billed charges,Implant Device,116.9,70,,116.9,percent of total billed charges,All Other,113.56,34,,113.56,percent of total billed charges,Implant Device,113.56,34,,113.56,percent of total billed charges,Implant Device,116.9,35,,116.9,percent of total billed charges,Implant Device,116.9,35,,116.9,percent of total billed charges,Implant Device,116.9,35,,116.9,percent of total billed charges,Implant Device,116.9,35,,116.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,247.16,
STRYKER 8125-2170S TROCHANT NAIL 12X170,C1713,HCPCS,,79013669,CDM,278,RC,,,both,,,4797,3549.79,,,3549.79,Other,150% of Medicare + 9.63% HCRA Surcharge,2158.65,45,,2158.65,percent of total billed charges,Critical Access Hospital RCC factor,1630.98,34,,1630.98,percent of total billed charges,Implant Device,1630.98,34,,1630.98,percent of total billed charges,Implant Device,1630.98,34,,1630.98,percent of total billed charges,Implant Device,1630.98,34,,1630.98,percent of total billed charges,Implant Device,1630.98,34,,1630.98,percent of total billed charges,Implant Device,2374.52,,,2374.52,Other,110% of Medicare,1678.95,35,,1678.95,percent of total billed charges,Implant Device,1630.98,34,"Charges > $500, x 34%",1630.98,percent of total billed charges,Implant Device,1678.95,35,,1678.95,percent of total billed charges,Implant Device,1678.95,35,,1678.95,percent of total billed charges,Implant Device,1678.95,35,,1678.95,percent of total billed charges,Implant Device,1678.95,35,,1678.95,percent of total billed charges,Implant Device,1678.95,35,,1678.95,percent of total billed charges,Implant Device,1918.8,40,,1918.8,percent of total billed charges,Implant Device,1678.95,70,,1678.95,percent of total billed charges,All Other,1630.98,34,,1630.98,percent of total billed charges,Implant Device,1630.98,34,,1630.98,percent of total billed charges,Implant Device,1678.95,35,,1678.95,percent of total billed charges,Implant Device,1678.95,35,,1678.95,percent of total billed charges,Implant Device,1678.95,35,,1678.95,percent of total billed charges,Implant Device,1678.95,35,,1678.95,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1630.98,34,"If Charge > 2,000, then 34 percent",1630.98,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3549.79,
STRYKER 2341-1233S TIBIAL NAIL 12X330MM,C1713,HCPCS,,79013670,CDM,278,RC,,,both,,,4792,3546.09,,,3546.09,Other,150% of Medicare + 9.63% HCRA Surcharge,2156.4,45,,2156.4,percent of total billed charges,Critical Access Hospital RCC factor,1629.28,34,,1629.28,percent of total billed charges,Implant Device,1629.28,34,,1629.28,percent of total billed charges,Implant Device,1629.28,34,,1629.28,percent of total billed charges,Implant Device,1629.28,34,,1629.28,percent of total billed charges,Implant Device,1629.28,34,,1629.28,percent of total billed charges,Implant Device,2372.04,,,2372.04,Other,110% of Medicare,1677.2,35,,1677.2,percent of total billed charges,Implant Device,1629.28,34,"Charges > $500, x 34%",1629.28,percent of total billed charges,Implant Device,1677.2,35,,1677.2,percent of total billed charges,Implant Device,1677.2,35,,1677.2,percent of total billed charges,Implant Device,1677.2,35,,1677.2,percent of total billed charges,Implant Device,1677.2,35,,1677.2,percent of total billed charges,Implant Device,1677.2,35,,1677.2,percent of total billed charges,Implant Device,1916.8,40,,1916.8,percent of total billed charges,Implant Device,1677.2,70,,1677.2,percent of total billed charges,All Other,1629.28,34,,1629.28,percent of total billed charges,Implant Device,1629.28,34,,1629.28,percent of total billed charges,Implant Device,1677.2,35,,1677.2,percent of total billed charges,Implant Device,1677.2,35,,1677.2,percent of total billed charges,Implant Device,1677.2,35,,1677.2,percent of total billed charges,Implant Device,1677.2,35,,1677.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1629.28,34,"If Charge > 2,000, then 34 percent",1629.28,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3546.09,
STRYKER 2341-1234S TIBIAL NAIL 12X345MM,C1713,HCPCS,,79013671,CDM,278,RC,,,both,,,4792,3546.09,,,3546.09,Other,150% of Medicare + 9.63% HCRA Surcharge,2156.4,45,,2156.4,percent of total billed charges,Critical Access Hospital RCC factor,1629.28,34,,1629.28,percent of total billed charges,Implant Device,1629.28,34,,1629.28,percent of total billed charges,Implant Device,1629.28,34,,1629.28,percent of total billed charges,Implant Device,1629.28,34,,1629.28,percent of total billed charges,Implant Device,1629.28,34,,1629.28,percent of total billed charges,Implant Device,2372.04,,,2372.04,Other,110% of Medicare,1677.2,35,,1677.2,percent of total billed charges,Implant Device,1629.28,34,"Charges > $500, x 34%",1629.28,percent of total billed charges,Implant Device,1677.2,35,,1677.2,percent of total billed charges,Implant Device,1677.2,35,,1677.2,percent of total billed charges,Implant Device,1677.2,35,,1677.2,percent of total billed charges,Implant Device,1677.2,35,,1677.2,percent of total billed charges,Implant Device,1677.2,35,,1677.2,percent of total billed charges,Implant Device,1916.8,40,,1916.8,percent of total billed charges,Implant Device,1677.2,70,,1677.2,percent of total billed charges,All Other,1629.28,34,,1629.28,percent of total billed charges,Implant Device,1629.28,34,,1629.28,percent of total billed charges,Implant Device,1677.2,35,,1677.2,percent of total billed charges,Implant Device,1677.2,35,,1677.2,percent of total billed charges,Implant Device,1677.2,35,,1677.2,percent of total billed charges,Implant Device,1677.2,35,,1677.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1629.28,34,"If Charge > 2,000, then 34 percent",1629.28,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3546.09,
ZIMMER 110031010 CROSSLINK BEARING 28X40,C1776,HCPCS,,79013672,CDM,278,RC,,,both,,,3456,2557.45,,,2557.45,Other,150% of Medicare + 9.63% HCRA Surcharge,1555.2,45,,1555.2,percent of total billed charges,Critical Access Hospital RCC factor,1175.04,34,,1175.04,percent of total billed charges,Implant Device,1175.04,34,,1175.04,percent of total billed charges,Implant Device,1175.04,34,,1175.04,percent of total billed charges,Implant Device,1175.04,34,,1175.04,percent of total billed charges,Implant Device,1175.04,34,,1175.04,percent of total billed charges,Implant Device,1710.72,,,1710.72,Other,110% of Medicare,1209.6,35,,1209.6,percent of total billed charges,Implant Device,1175.04,34,"Charges > $500, x 34%",1175.04,percent of total billed charges,Implant Device,1209.6,35,,1209.6,percent of total billed charges,Implant Device,1209.6,35,,1209.6,percent of total billed charges,Implant Device,1209.6,35,,1209.6,percent of total billed charges,Implant Device,1209.6,35,,1209.6,percent of total billed charges,Implant Device,1209.6,35,,1209.6,percent of total billed charges,Implant Device,1382.4,40,,1382.4,percent of total billed charges,Implant Device,1209.6,70,,1209.6,percent of total billed charges,All Other,1175.04,34,,1175.04,percent of total billed charges,Implant Device,1175.04,34,,1175.04,percent of total billed charges,Implant Device,1209.6,35,,1209.6,percent of total billed charges,Implant Device,1209.6,35,,1209.6,percent of total billed charges,Implant Device,1209.6,35,,1209.6,percent of total billed charges,Implant Device,1209.6,35,,1209.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1175.04,34,"If Charge > 2,000, then 34 percent",1175.04,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2557.45,
ZIMMER 650-1159 CERAMIC HEAD 28-3MM NECK,C1776,HCPCS,,79013673,CDM,278,RC,,,both,,,2880,2131.21,,,2131.21,Other,150% of Medicare + 9.63% HCRA Surcharge,1296,45,,1296,percent of total billed charges,Critical Access Hospital RCC factor,979.2,34,,979.2,percent of total billed charges,Implant Device,979.2,34,,979.2,percent of total billed charges,Implant Device,979.2,34,,979.2,percent of total billed charges,Implant Device,979.2,34,,979.2,percent of total billed charges,Implant Device,979.2,34,,979.2,percent of total billed charges,Implant Device,1425.6,,,1425.6,Other,110% of Medicare,1008,35,,1008,percent of total billed charges,Implant Device,979.2,34,"Charges > $500, x 34%",979.2,percent of total billed charges,Implant Device,1008,35,,1008,percent of total billed charges,Implant Device,1008,35,,1008,percent of total billed charges,Implant Device,1008,35,,1008,percent of total billed charges,Implant Device,1008,35,,1008,percent of total billed charges,Implant Device,1008,35,,1008,percent of total billed charges,Implant Device,1152,40,,1152,percent of total billed charges,Implant Device,1008,70,,1008,percent of total billed charges,All Other,979.2,34,,979.2,percent of total billed charges,Implant Device,979.2,34,,979.2,percent of total billed charges,Implant Device,1008,35,,1008,percent of total billed charges,Implant Device,1008,35,,1008,percent of total billed charges,Implant Device,1008,35,,1008,percent of total billed charges,Implant Device,1008,35,,1008,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,979.2,34,"If Charge > 2,000, then 34 percent",979.2,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2131.21,
ZIMMER 110024462 ACETAULAR LINER 40 SZD,C1776,HCPCS,,79013674,CDM,278,RC,,,both,,,3840,2841.61,,,2841.61,Other,150% of Medicare + 9.63% HCRA Surcharge,1728,45,,1728,percent of total billed charges,Critical Access Hospital RCC factor,1305.6,34,,1305.6,percent of total billed charges,Implant Device,1305.6,34,,1305.6,percent of total billed charges,Implant Device,1305.6,34,,1305.6,percent of total billed charges,Implant Device,1305.6,34,,1305.6,percent of total billed charges,Implant Device,1305.6,34,,1305.6,percent of total billed charges,Implant Device,1900.8,,,1900.8,Other,110% of Medicare,1344,35,,1344,percent of total billed charges,Implant Device,1305.6,34,"Charges > $500, x 34%",1305.6,percent of total billed charges,Implant Device,1344,35,,1344,percent of total billed charges,Implant Device,1344,35,,1344,percent of total billed charges,Implant Device,1344,35,,1344,percent of total billed charges,Implant Device,1344,35,,1344,percent of total billed charges,Implant Device,1344,35,,1344,percent of total billed charges,Implant Device,1536,40,,1536,percent of total billed charges,Implant Device,1344,70,,1344,percent of total billed charges,All Other,1305.6,34,,1305.6,percent of total billed charges,Implant Device,1305.6,34,,1305.6,percent of total billed charges,Implant Device,1344,35,,1344,percent of total billed charges,Implant Device,1344,35,,1344,percent of total billed charges,Implant Device,1344,35,,1344,percent of total billed charges,Implant Device,1344,35,,1344,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1305.6,34,"If Charge > 2,000, then 34 percent",1305.6,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2841.61,
STRYKER 2341-1030S TIBIAL NAIL 10X300MM,C1713,HCPCS,,79013679,CDM,278,RC,,,both,,,4792,3546.09,,,3546.09,Other,150% of Medicare + 9.63% HCRA Surcharge,2156.4,45,,2156.4,percent of total billed charges,Critical Access Hospital RCC factor,1629.28,34,,1629.28,percent of total billed charges,Implant Device,1629.28,34,,1629.28,percent of total billed charges,Implant Device,1629.28,34,,1629.28,percent of total billed charges,Implant Device,1629.28,34,,1629.28,percent of total billed charges,Implant Device,1629.28,34,,1629.28,percent of total billed charges,Implant Device,2372.04,,,2372.04,Other,110% of Medicare,1677.2,35,,1677.2,percent of total billed charges,Implant Device,1629.28,34,"Charges > $500, x 34%",1629.28,percent of total billed charges,Implant Device,1677.2,35,,1677.2,percent of total billed charges,Implant Device,1677.2,35,,1677.2,percent of total billed charges,Implant Device,1677.2,35,,1677.2,percent of total billed charges,Implant Device,1677.2,35,,1677.2,percent of total billed charges,Implant Device,1677.2,35,,1677.2,percent of total billed charges,Implant Device,1916.8,40,,1916.8,percent of total billed charges,Implant Device,1677.2,70,,1677.2,percent of total billed charges,All Other,1629.28,34,,1629.28,percent of total billed charges,Implant Device,1629.28,34,,1629.28,percent of total billed charges,Implant Device,1677.2,35,,1677.2,percent of total billed charges,Implant Device,1677.2,35,,1677.2,percent of total billed charges,Implant Device,1677.2,35,,1677.2,percent of total billed charges,Implant Device,1677.2,35,,1677.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1629.28,34,"If Charge > 2,000, then 34 percent",1629.28,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3546.09,
J&J 1221-32-148 ACETAB SHELL SECTOR 48MM,C1776,HCPCS,,79013680,CDM,278,RC,,,both,,,2565,1898.11,,,1898.11,Other,150% of Medicare + 9.63% HCRA Surcharge,1154.25,45,,1154.25,percent of total billed charges,Critical Access Hospital RCC factor,872.1,34,,872.1,percent of total billed charges,Implant Device,872.1,34,,872.1,percent of total billed charges,Implant Device,872.1,34,,872.1,percent of total billed charges,Implant Device,872.1,34,,872.1,percent of total billed charges,Implant Device,872.1,34,,872.1,percent of total billed charges,Implant Device,1269.68,,,1269.68,Other,110% of Medicare,897.75,35,,897.75,percent of total billed charges,Implant Device,872.1,34,"Charges > $500, x 34%",872.1,percent of total billed charges,Implant Device,897.75,35,,897.75,percent of total billed charges,Implant Device,897.75,35,,897.75,percent of total billed charges,Implant Device,897.75,35,,897.75,percent of total billed charges,Implant Device,897.75,35,,897.75,percent of total billed charges,Implant Device,897.75,35,,897.75,percent of total billed charges,Implant Device,1026,40,,1026,percent of total billed charges,Implant Device,897.75,70,,897.75,percent of total billed charges,All Other,872.1,34,,872.1,percent of total billed charges,Implant Device,872.1,34,,872.1,percent of total billed charges,Implant Device,897.75,35,,897.75,percent of total billed charges,Implant Device,897.75,35,,897.75,percent of total billed charges,Implant Device,897.75,35,,897.75,percent of total billed charges,Implant Device,897.75,35,,897.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,872.1,34,"If Charge > 2,000, then 34 percent",872.1,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1898.11,
J&J 02.124.408 CONDYLAR PLT 8H 4.5X185MM,C1713,HCPCS,,79013681,CDM,278,RC,,,both,,,4381,3241.95,,,3241.95,Other,150% of Medicare + 9.63% HCRA Surcharge,1971.45,45,,1971.45,percent of total billed charges,Critical Access Hospital RCC factor,1489.54,34,,1489.54,percent of total billed charges,Implant Device,1489.54,34,,1489.54,percent of total billed charges,Implant Device,1489.54,34,,1489.54,percent of total billed charges,Implant Device,1489.54,34,,1489.54,percent of total billed charges,Implant Device,1489.54,34,,1489.54,percent of total billed charges,Implant Device,2168.6,,,2168.6,Other,110% of Medicare,1533.35,35,,1533.35,percent of total billed charges,Implant Device,1489.54,34,"Charges > $500, x 34%",1489.54,percent of total billed charges,Implant Device,1533.35,35,,1533.35,percent of total billed charges,Implant Device,1533.35,35,,1533.35,percent of total billed charges,Implant Device,1533.35,35,,1533.35,percent of total billed charges,Implant Device,1533.35,35,,1533.35,percent of total billed charges,Implant Device,1533.35,35,,1533.35,percent of total billed charges,Implant Device,1752.4,40,,1752.4,percent of total billed charges,Implant Device,1533.35,70,,1533.35,percent of total billed charges,All Other,1489.54,34,,1489.54,percent of total billed charges,Implant Device,1489.54,34,,1489.54,percent of total billed charges,Implant Device,1533.35,35,,1533.35,percent of total billed charges,Implant Device,1533.35,35,,1533.35,percent of total billed charges,Implant Device,1533.35,35,,1533.35,percent of total billed charges,Implant Device,1533.35,35,,1533.35,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1489.54,34,"If Charge > 2,000, then 34 percent",1489.54,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3241.95,
J&J 42.231.244 LOCKING SCREW 5.0X60MM,C1713,HCPCS,,79013682,CDM,278,RC,,,both,,,513,379.62,,,379.62,Other,150% of Medicare + 9.63% HCRA Surcharge,230.85,45,,230.85,percent of total billed charges,Critical Access Hospital RCC factor,174.42,34,,174.42,percent of total billed charges,Implant Device,174.42,34,,174.42,percent of total billed charges,Implant Device,174.42,34,,174.42,percent of total billed charges,Implant Device,174.42,34,,174.42,percent of total billed charges,Implant Device,174.42,34,,174.42,percent of total billed charges,Implant Device,253.94,,,253.94,Other,110% of Medicare,179.55,35,,179.55,percent of total billed charges,Implant Device,174.42,34,"Charges > $500, x 34%",174.42,percent of total billed charges,Implant Device,179.55,35,,179.55,percent of total billed charges,Implant Device,179.55,35,,179.55,percent of total billed charges,Implant Device,179.55,35,,179.55,percent of total billed charges,Implant Device,179.55,35,,179.55,percent of total billed charges,Implant Device,179.55,35,,179.55,percent of total billed charges,Implant Device,205.2,40,,205.2,percent of total billed charges,Implant Device,179.55,70,,179.55,percent of total billed charges,All Other,174.42,34,,174.42,percent of total billed charges,Implant Device,174.42,34,,174.42,percent of total billed charges,Implant Device,179.55,35,,179.55,percent of total billed charges,Implant Device,179.55,35,,179.55,percent of total billed charges,Implant Device,179.55,35,,179.55,percent of total billed charges,Implant Device,179.55,35,,179.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,379.62,
IN2BONES P60 ST032 LAT NECK PLT RT 6H,C1713,HCPCS,,79013683,CDM,278,RC,,,both,,,6000,4440.02,,,4440.02,Other,150% of Medicare + 9.63% HCRA Surcharge,2700,45,,2700,percent of total billed charges,Critical Access Hospital RCC factor,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2970,,,2970,Other,110% of Medicare,2100,35,,2100,percent of total billed charges,Implant Device,2040,34,"Charges > $500, x 34%",2040,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2400,40,,2400,percent of total billed charges,Implant Device,2100,70,,2100,percent of total billed charges,All Other,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2040,34,"If Charge > 2,000, then 34 percent",2040,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4440.02,
IN2BONES P62 ST416 NON LOCK SCREW 2.4X16,C1713,HCPCS,,79013684,CDM,278,RC,,,both,,,870,643.8,,,643.8,Other,150% of Medicare + 9.63% HCRA Surcharge,391.5,45,,391.5,percent of total billed charges,Critical Access Hospital RCC factor,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,430.65,,,430.65,Other,110% of Medicare,304.5,35,,304.5,percent of total billed charges,Implant Device,295.8,34,"Charges > $500, x 34%",295.8,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,348,40,,348,percent of total billed charges,Implant Device,304.5,70,,304.5,percent of total billed charges,All Other,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,643.8,
ALLOSOURCE 16517015 FIBULAR SEG/SHAFT,C1713,HCPCS,,79013685,CDM,278,RC,,,both,,,2940,2175.61,,,2175.61,Other,150% of Medicare + 9.63% HCRA Surcharge,1323,45,,1323,percent of total billed charges,Critical Access Hospital RCC factor,999.6,34,,999.6,percent of total billed charges,Implant Device,999.6,34,,999.6,percent of total billed charges,Implant Device,999.6,34,,999.6,percent of total billed charges,Implant Device,999.6,34,,999.6,percent of total billed charges,Implant Device,999.6,34,,999.6,percent of total billed charges,Implant Device,1455.3,,,1455.3,Other,110% of Medicare,1029,35,,1029,percent of total billed charges,Implant Device,999.6,34,"Charges > $500, x 34%",999.6,percent of total billed charges,Implant Device,1029,35,,1029,percent of total billed charges,Implant Device,1029,35,,1029,percent of total billed charges,Implant Device,1029,35,,1029,percent of total billed charges,Implant Device,1029,35,,1029,percent of total billed charges,Implant Device,1029,35,,1029,percent of total billed charges,Implant Device,1176,40,,1176,percent of total billed charges,Implant Device,1029,70,,1029,percent of total billed charges,All Other,999.6,34,,999.6,percent of total billed charges,Implant Device,999.6,34,,999.6,percent of total billed charges,Implant Device,1029,35,,1029,percent of total billed charges,Implant Device,1029,35,,1029,percent of total billed charges,Implant Device,1029,35,,1029,percent of total billed charges,Implant Device,1029,35,,1029,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,999.6,34,"If Charge > 2,000, then 34 percent",999.6,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2175.61,
ARTHREX AR-1934BCT-2 SUTURE ANCH 3X14.5,C1713,HCPCS,,79013687,CDM,278,RC,,,both,,,1170,865.8,,,865.8,Other,150% of Medicare + 9.63% HCRA Surcharge,526.5,45,,526.5,percent of total billed charges,Critical Access Hospital RCC factor,397.8,34,,397.8,percent of total billed charges,Implant Device,397.8,34,,397.8,percent of total billed charges,Implant Device,397.8,34,,397.8,percent of total billed charges,Implant Device,397.8,34,,397.8,percent of total billed charges,Implant Device,397.8,34,,397.8,percent of total billed charges,Implant Device,579.15,,,579.15,Other,110% of Medicare,409.5,35,,409.5,percent of total billed charges,Implant Device,397.8,34,"Charges > $500, x 34%",397.8,percent of total billed charges,Implant Device,409.5,35,,409.5,percent of total billed charges,Implant Device,409.5,35,,409.5,percent of total billed charges,Implant Device,409.5,35,,409.5,percent of total billed charges,Implant Device,409.5,35,,409.5,percent of total billed charges,Implant Device,409.5,35,,409.5,percent of total billed charges,Implant Device,468,40,,468,percent of total billed charges,Implant Device,409.5,70,,409.5,percent of total billed charges,All Other,397.8,34,,397.8,percent of total billed charges,Implant Device,397.8,34,,397.8,percent of total billed charges,Implant Device,409.5,35,,409.5,percent of total billed charges,Implant Device,409.5,35,,409.5,percent of total billed charges,Implant Device,409.5,35,,409.5,percent of total billed charges,Implant Device,409.5,35,,409.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,865.8,
J&J 02.111.650 DIS RADIUS PLT 2.4MM RT,C1713,HCPCS,,79013689,CDM,278,RC,,,both,,,2499,1849.27,,,1849.27,Other,150% of Medicare + 9.63% HCRA Surcharge,1124.55,45,,1124.55,percent of total billed charges,Critical Access Hospital RCC factor,849.66,34,,849.66,percent of total billed charges,Implant Device,849.66,34,,849.66,percent of total billed charges,Implant Device,849.66,34,,849.66,percent of total billed charges,Implant Device,849.66,34,,849.66,percent of total billed charges,Implant Device,849.66,34,,849.66,percent of total billed charges,Implant Device,1237.01,,,1237.01,Other,110% of Medicare,874.65,35,,874.65,percent of total billed charges,Implant Device,849.66,34,"Charges > $500, x 34%",849.66,percent of total billed charges,Implant Device,874.65,35,,874.65,percent of total billed charges,Implant Device,874.65,35,,874.65,percent of total billed charges,Implant Device,874.65,35,,874.65,percent of total billed charges,Implant Device,874.65,35,,874.65,percent of total billed charges,Implant Device,874.65,35,,874.65,percent of total billed charges,Implant Device,999.6,40,,999.6,percent of total billed charges,Implant Device,874.65,70,,874.65,percent of total billed charges,All Other,849.66,34,,849.66,percent of total billed charges,Implant Device,849.66,34,,849.66,percent of total billed charges,Implant Device,874.65,35,,874.65,percent of total billed charges,Implant Device,874.65,35,,874.65,percent of total billed charges,Implant Device,874.65,35,,874.65,percent of total billed charges,Implant Device,874.65,35,,874.65,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,849.66,34,"If Charge > 2,000, then 34 percent",849.66,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1849.27,
J&J 1504-00-207 ATTUNE FEMORAL SZ 7 RT,C1776,HCPCS,,79013690,CDM,278,RC,,,both,,,4800,3552.01,,,3552.01,Other,150% of Medicare + 9.63% HCRA Surcharge,2160,45,,2160,percent of total billed charges,Critical Access Hospital RCC factor,1632,34,,1632,percent of total billed charges,Implant Device,1632,34,,1632,percent of total billed charges,Implant Device,1632,34,,1632,percent of total billed charges,Implant Device,1632,34,,1632,percent of total billed charges,Implant Device,1632,34,,1632,percent of total billed charges,Implant Device,2376,,,2376,Other,110% of Medicare,1680,35,,1680,percent of total billed charges,Implant Device,1632,34,"Charges > $500, x 34%",1632,percent of total billed charges,Implant Device,1680,35,,1680,percent of total billed charges,Implant Device,1680,35,,1680,percent of total billed charges,Implant Device,1680,35,,1680,percent of total billed charges,Implant Device,1680,35,,1680,percent of total billed charges,Implant Device,1680,35,,1680,percent of total billed charges,Implant Device,1920,40,,1920,percent of total billed charges,Implant Device,1680,70,,1680,percent of total billed charges,All Other,1632,34,,1632,percent of total billed charges,Implant Device,1632,34,,1632,percent of total billed charges,Implant Device,1680,35,,1680,percent of total billed charges,Implant Device,1680,35,,1680,percent of total billed charges,Implant Device,1680,35,,1680,percent of total billed charges,Implant Device,1680,35,,1680,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1632,34,"If Charge > 2,000, then 34 percent",1632,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3552.01,
J&J 1504-01-206 ATTUNE FEMORAL SZ 6 RT,C1776,HCPCS,,79013691,CDM,278,RC,,,both,,,6000,4440.02,,,4440.02,Other,150% of Medicare + 9.63% HCRA Surcharge,2700,45,,2700,percent of total billed charges,Critical Access Hospital RCC factor,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2970,,,2970,Other,110% of Medicare,2100,35,,2100,percent of total billed charges,Implant Device,2040,34,"Charges > $500, x 34%",2040,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2400,40,,2400,percent of total billed charges,Implant Device,2100,70,,2100,percent of total billed charges,All Other,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2040,34,"If Charge > 2,000, then 34 percent",2040,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4440.02,
J&J 202.892 CORTEX SCREW 2.7X32MM,C1713,HCPCS,,79013692,CDM,278,RC,,,both,,,88,65.12,,,65.12,Other,150% of Medicare + 9.63% HCRA Surcharge,39.6,45,,39.6,percent of total billed charges,Critical Access Hospital RCC factor,29.92,34,,29.92,percent of total billed charges,Implant Device,29.92,34,,29.92,percent of total billed charges,Implant Device,29.92,34,,29.92,percent of total billed charges,Implant Device,29.92,34,,29.92,percent of total billed charges,Implant Device,29.92,34,,29.92,percent of total billed charges,Implant Device,43.56,,,43.56,Other,110% of Medicare,30.8,35,,30.8,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,30.8,35,,30.8,percent of total billed charges,Implant Device,30.8,35,,30.8,percent of total billed charges,Implant Device,30.8,35,,30.8,percent of total billed charges,Implant Device,30.8,35,,30.8,percent of total billed charges,Implant Device,30.8,35,,30.8,percent of total billed charges,Implant Device,35.2,40,,35.2,percent of total billed charges,Implant Device,30.8,70,,30.8,percent of total billed charges,All Other,29.92,34,,29.92,percent of total billed charges,Implant Device,29.92,34,,29.92,percent of total billed charges,Implant Device,30.8,35,,30.8,percent of total billed charges,Implant Device,30.8,35,,30.8,percent of total billed charges,Implant Device,30.8,35,,30.8,percent of total billed charges,Implant Device,30.8,35,,30.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,65.12,
ARTHREX AR-7822 FIBERTAPE CERCLAGE-LG,C1713,HCPCS,,79013693,CDM,278,RC,,,both,,,675,499.5,,,499.5,Other,150% of Medicare + 9.63% HCRA Surcharge,303.75,45,,303.75,percent of total billed charges,Critical Access Hospital RCC factor,229.5,34,,229.5,percent of total billed charges,Implant Device,229.5,34,,229.5,percent of total billed charges,Implant Device,229.5,34,,229.5,percent of total billed charges,Implant Device,229.5,34,,229.5,percent of total billed charges,Implant Device,229.5,34,,229.5,percent of total billed charges,Implant Device,334.13,,,334.13,Other,110% of Medicare,236.25,35,,236.25,percent of total billed charges,Implant Device,229.5,34,"Charges > $500, x 34%",229.5,percent of total billed charges,Implant Device,236.25,35,,236.25,percent of total billed charges,Implant Device,236.25,35,,236.25,percent of total billed charges,Implant Device,236.25,35,,236.25,percent of total billed charges,Implant Device,236.25,35,,236.25,percent of total billed charges,Implant Device,236.25,35,,236.25,percent of total billed charges,Implant Device,270,40,,270,percent of total billed charges,Implant Device,236.25,70,,236.25,percent of total billed charges,All Other,229.5,34,,229.5,percent of total billed charges,Implant Device,229.5,34,,229.5,percent of total billed charges,Implant Device,236.25,35,,236.25,percent of total billed charges,Implant Device,236.25,35,,236.25,percent of total billed charges,Implant Device,236.25,35,,236.25,percent of total billed charges,Implant Device,236.25,35,,236.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,499.5,
J&J 150401207 ATTUNE FEMORAL SIZE 7 RT,C1776,HCPCS,,79013695,CDM,278,RC,,,both,,,6000,4440.02,,,4440.02,Other,150% of Medicare + 9.63% HCRA Surcharge,2700,45,,2700,percent of total billed charges,Critical Access Hospital RCC factor,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2970,,,2970,Other,110% of Medicare,2100,35,,2100,percent of total billed charges,Implant Device,2040,34,"Charges > $500, x 34%",2040,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2400,40,,2400,percent of total billed charges,Implant Device,2100,70,,2100,percent of total billed charges,All Other,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2040,34,"If Charge > 2,000, then 34 percent",2040,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4440.02,
STRYKER 663912 EMERGENCY SCREW 2.5X12MM,C1713,HCPCS,,79013697,CDM,278,RC,,,both,,,324,239.76,,,239.76,Other,150% of Medicare + 9.63% HCRA Surcharge,145.8,45,,145.8,percent of total billed charges,Critical Access Hospital RCC factor,110.16,34,,110.16,percent of total billed charges,Implant Device,110.16,34,,110.16,percent of total billed charges,Implant Device,110.16,34,,110.16,percent of total billed charges,Implant Device,110.16,34,,110.16,percent of total billed charges,Implant Device,110.16,34,,110.16,percent of total billed charges,Implant Device,160.38,,,160.38,Other,110% of Medicare,113.4,35,,113.4,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,129.6,40,,129.6,percent of total billed charges,Implant Device,113.4,70,,113.4,percent of total billed charges,All Other,110.16,34,,110.16,percent of total billed charges,Implant Device,110.16,34,,110.16,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,239.76,
J&J 1504-01-205 ATTUNE FEMORAL SIZE 5 RT,C1776,HCPCS,,79013698,CDM,278,RC,,,both,,,6000,4440.02,,,4440.02,Other,150% of Medicare + 9.63% HCRA Surcharge,2700,45,,2700,percent of total billed charges,Critical Access Hospital RCC factor,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2970,,,2970,Other,110% of Medicare,2100,35,,2100,percent of total billed charges,Implant Device,2040,34,"Charges > $500, x 34%",2040,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2400,40,,2400,percent of total billed charges,Implant Device,2100,70,,2100,percent of total billed charges,All Other,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2040,34,"If Charge > 2,000, then 34 percent",2040,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4440.02,
J&J 1516-30-608 TIBIAL INSERT SIZE 6 8MM,C1776,HCPCS,,79013699,CDM,278,RC,,,both,,,5400,3996.01,,,3996.01,Other,150% of Medicare + 9.63% HCRA Surcharge,2430,45,,2430,percent of total billed charges,Critical Access Hospital RCC factor,1836,34,,1836,percent of total billed charges,Implant Device,1836,34,,1836,percent of total billed charges,Implant Device,1836,34,,1836,percent of total billed charges,Implant Device,1836,34,,1836,percent of total billed charges,Implant Device,1836,34,,1836,percent of total billed charges,Implant Device,2673,,,2673,Other,110% of Medicare,1890,35,,1890,percent of total billed charges,Implant Device,1836,34,"Charges > $500, x 34%",1836,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,2160,40,,2160,percent of total billed charges,Implant Device,1890,70,,1890,percent of total billed charges,All Other,1836,34,,1836,percent of total billed charges,Implant Device,1836,34,,1836,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1836,34,"If Charge > 2,000, then 34 percent",1836,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3996.01,
EXACTECH 320-00-02 HUM AUGMENTED TRAY,C1776,HCPCS,,79013700,CDM,278,RC,,,both,,,13500,9990.03,,,9990.03,Other,150% of Medicare + 9.63% HCRA Surcharge,6075,45,,6075,percent of total billed charges,Critical Access Hospital RCC factor,4590,34,,4590,percent of total billed charges,Implant Device,4590,34,,4590,percent of total billed charges,Implant Device,4590,34,,4590,percent of total billed charges,Implant Device,4590,34,,4590,percent of total billed charges,Implant Device,4590,34,,4590,percent of total billed charges,Implant Device,6682.5,,,6682.5,Other,110% of Medicare,4725,35,,4725,percent of total billed charges,Implant Device,4590,34,"Charges > $500, x 34%",4590,percent of total billed charges,Implant Device,4725,35,,4725,percent of total billed charges,Implant Device,4725,35,,4725,percent of total billed charges,Implant Device,4725,35,,4725,percent of total billed charges,Implant Device,4725,35,,4725,percent of total billed charges,Implant Device,4725,35,,4725,percent of total billed charges,Implant Device,5400,40,,5400,percent of total billed charges,Implant Device,4725,70,,4725,percent of total billed charges,All Other,4590,34,,4590,percent of total billed charges,Implant Device,4590,34,,4590,percent of total billed charges,Implant Device,4725,35,,4725,percent of total billed charges,Implant Device,4725,35,,4725,percent of total billed charges,Implant Device,4725,35,,4725,percent of total billed charges,Implant Device,4725,35,,4725,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,4590,34,"If Charge > 2,000, then 34 percent",4590,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,9990.03,
J&J 151630508 ATTUNE TIB INSERT SZ 5 8MM,C1776,HCPCS,,79013701,CDM,278,RC,,,both,,,5400,3996.01,,,3996.01,Other,150% of Medicare + 9.63% HCRA Surcharge,2430,45,,2430,percent of total billed charges,Critical Access Hospital RCC factor,1836,34,,1836,percent of total billed charges,Implant Device,1836,34,,1836,percent of total billed charges,Implant Device,1836,34,,1836,percent of total billed charges,Implant Device,1836,34,,1836,percent of total billed charges,Implant Device,1836,34,,1836,percent of total billed charges,Implant Device,2673,,,2673,Other,110% of Medicare,1890,35,,1890,percent of total billed charges,Implant Device,1836,34,"Charges > $500, x 34%",1836,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,2160,40,,2160,percent of total billed charges,Implant Device,1890,70,,1890,percent of total billed charges,All Other,1836,34,,1836,percent of total billed charges,Implant Device,1836,34,,1836,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1836,34,"If Charge > 2,000, then 34 percent",1836,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3996.01,
J&J 1516-50-712 TIBIAL INSERT SZ 7 12MM,C1776,HCPCS,,79013704,CDM,278,RC,,,both,,,5400,3996.01,,,3996.01,Other,150% of Medicare + 9.63% HCRA Surcharge,2430,45,,2430,percent of total billed charges,Critical Access Hospital RCC factor,1836,34,,1836,percent of total billed charges,Implant Device,1836,34,,1836,percent of total billed charges,Implant Device,1836,34,,1836,percent of total billed charges,Implant Device,1836,34,,1836,percent of total billed charges,Implant Device,1836,34,,1836,percent of total billed charges,Implant Device,2673,,,2673,Other,110% of Medicare,1890,35,,1890,percent of total billed charges,Implant Device,1836,34,"Charges > $500, x 34%",1836,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,2160,40,,2160,percent of total billed charges,Implant Device,1890,70,,1890,percent of total billed charges,All Other,1836,34,,1836,percent of total billed charges,Implant Device,1836,34,,1836,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1836,34,"If Charge > 2,000, then 34 percent",1836,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3996.01,
ARTHREX AR-8730-18PT CANN SCREW 3.0X18MM,C1713,HCPCS,,79013706,CDM,278,RC,,,both,,,488,361.12,,,361.12,Other,150% of Medicare + 9.63% HCRA Surcharge,219.6,45,,219.6,percent of total billed charges,Critical Access Hospital RCC factor,165.92,34,,165.92,percent of total billed charges,Implant Device,165.92,34,,165.92,percent of total billed charges,Implant Device,165.92,34,,165.92,percent of total billed charges,Implant Device,165.92,34,,165.92,percent of total billed charges,Implant Device,165.92,34,,165.92,percent of total billed charges,Implant Device,241.56,,,241.56,Other,110% of Medicare,170.8,35,,170.8,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,170.8,35,,170.8,percent of total billed charges,Implant Device,170.8,35,,170.8,percent of total billed charges,Implant Device,170.8,35,,170.8,percent of total billed charges,Implant Device,170.8,35,,170.8,percent of total billed charges,Implant Device,170.8,35,,170.8,percent of total billed charges,Implant Device,195.2,40,,195.2,percent of total billed charges,Implant Device,170.8,70,,170.8,percent of total billed charges,All Other,165.92,34,,165.92,percent of total billed charges,Implant Device,165.92,34,,165.92,percent of total billed charges,Implant Device,170.8,35,,170.8,percent of total billed charges,Implant Device,170.8,35,,170.8,percent of total billed charges,Implant Device,170.8,35,,170.8,percent of total billed charges,Implant Device,170.8,35,,170.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,361.12,
STRYKER 2339-1336S DEM NAIL RETRO 13X360,C1889,HCPCS,,79013707,CDM,278,RC,,,both,,,6585,4872.92,,,4872.92,Other,150% of Medicare + 9.63% HCRA Surcharge,2963.25,45,,2963.25,percent of total billed charges,Critical Access Hospital RCC factor,2238.9,34,,2238.9,percent of total billed charges,Implant Device,2238.9,34,,2238.9,percent of total billed charges,Implant Device,2238.9,34,,2238.9,percent of total billed charges,Implant Device,2238.9,34,,2238.9,percent of total billed charges,Implant Device,2238.9,34,,2238.9,percent of total billed charges,Implant Device,3259.58,,,3259.58,Other,110% of Medicare,2304.75,35,,2304.75,percent of total billed charges,Implant Device,2238.9,34,"Charges > $500, x 34%",2238.9,percent of total billed charges,Implant Device,2304.75,35,,2304.75,percent of total billed charges,Implant Device,2304.75,35,,2304.75,percent of total billed charges,Implant Device,2304.75,35,,2304.75,percent of total billed charges,Implant Device,2304.75,35,,2304.75,percent of total billed charges,Implant Device,2304.75,35,,2304.75,percent of total billed charges,Implant Device,2634,40,,2634,percent of total billed charges,Implant Device,2304.75,70,,2304.75,percent of total billed charges,All Other,2238.9,34,,2238.9,percent of total billed charges,Implant Device,2238.9,34,,2238.9,percent of total billed charges,Implant Device,2304.75,35,,2304.75,percent of total billed charges,Implant Device,2304.75,35,,2304.75,percent of total billed charges,Implant Device,2304.75,35,,2304.75,percent of total billed charges,Implant Device,2304.75,35,,2304.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2238.9,34,"If Charge > 2,000, then 34 percent",2238.9,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4872.92,
STRYKER 2361-5080S LOCKING SCREW 5X80MM,C1713,HCPCS,,79013708,CDM,278,RC,,,both,,,887,656.38,,,656.38,Other,150% of Medicare + 9.63% HCRA Surcharge,399.15,45,,399.15,percent of total billed charges,Critical Access Hospital RCC factor,301.58,34,,301.58,percent of total billed charges,Implant Device,301.58,34,,301.58,percent of total billed charges,Implant Device,301.58,34,,301.58,percent of total billed charges,Implant Device,301.58,34,,301.58,percent of total billed charges,Implant Device,301.58,34,,301.58,percent of total billed charges,Implant Device,439.07,,,439.07,Other,110% of Medicare,310.45,35,,310.45,percent of total billed charges,Implant Device,301.58,34,"Charges > $500, x 34%",301.58,percent of total billed charges,Implant Device,310.45,35,,310.45,percent of total billed charges,Implant Device,310.45,35,,310.45,percent of total billed charges,Implant Device,310.45,35,,310.45,percent of total billed charges,Implant Device,310.45,35,,310.45,percent of total billed charges,Implant Device,310.45,35,,310.45,percent of total billed charges,Implant Device,354.8,40,,354.8,percent of total billed charges,Implant Device,310.45,70,,310.45,percent of total billed charges,All Other,301.58,34,,301.58,percent of total billed charges,Implant Device,301.58,34,,301.58,percent of total billed charges,Implant Device,310.45,35,,310.45,percent of total billed charges,Implant Device,310.45,35,,310.45,percent of total billed charges,Implant Device,310.45,35,,310.45,percent of total billed charges,Implant Device,310.45,35,,310.45,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,656.38,
STRYKER 2361-5090S LOCKING SCREW 5X90MM,C1713,HCPCS,,79013709,CDM,278,RC,,,both,,,887,656.38,,,656.38,Other,150% of Medicare + 9.63% HCRA Surcharge,399.15,45,,399.15,percent of total billed charges,Critical Access Hospital RCC factor,301.58,34,,301.58,percent of total billed charges,Implant Device,301.58,34,,301.58,percent of total billed charges,Implant Device,301.58,34,,301.58,percent of total billed charges,Implant Device,301.58,34,,301.58,percent of total billed charges,Implant Device,301.58,34,,301.58,percent of total billed charges,Implant Device,439.07,,,439.07,Other,110% of Medicare,310.45,35,,310.45,percent of total billed charges,Implant Device,301.58,34,"Charges > $500, x 34%",301.58,percent of total billed charges,Implant Device,310.45,35,,310.45,percent of total billed charges,Implant Device,310.45,35,,310.45,percent of total billed charges,Implant Device,310.45,35,,310.45,percent of total billed charges,Implant Device,310.45,35,,310.45,percent of total billed charges,Implant Device,310.45,35,,310.45,percent of total billed charges,Implant Device,354.8,40,,354.8,percent of total billed charges,Implant Device,310.45,70,,310.45,percent of total billed charges,All Other,301.58,34,,301.58,percent of total billed charges,Implant Device,301.58,34,,301.58,percent of total billed charges,Implant Device,310.45,35,,310.45,percent of total billed charges,Implant Device,310.45,35,,310.45,percent of total billed charges,Implant Device,310.45,35,,310.45,percent of total billed charges,Implant Device,310.45,35,,310.45,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,656.38,
J&J 1516-50-906 TIBIAL INSERT SZ 9 6MM,C1776,HCPCS,,79013710,CDM,278,RC,,,both,,,5400,3996.01,,,3996.01,Other,150% of Medicare + 9.63% HCRA Surcharge,2430,45,,2430,percent of total billed charges,Critical Access Hospital RCC factor,1836,34,,1836,percent of total billed charges,Implant Device,1836,34,,1836,percent of total billed charges,Implant Device,1836,34,,1836,percent of total billed charges,Implant Device,1836,34,,1836,percent of total billed charges,Implant Device,1836,34,,1836,percent of total billed charges,Implant Device,2673,,,2673,Other,110% of Medicare,1890,35,,1890,percent of total billed charges,Implant Device,1836,34,"Charges > $500, x 34%",1836,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,2160,40,,2160,percent of total billed charges,Implant Device,1890,70,,1890,percent of total billed charges,All Other,1836,34,,1836,percent of total billed charges,Implant Device,1836,34,,1836,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1836,34,"If Charge > 2,000, then 34 percent",1836,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3996.01,
J&J 02.104.006 ART DIS HUM PLT 3.5X158MM,C1713,HCPCS,,79013713,CDM,278,RC,,,both,,,3495,2586.31,,,2586.31,Other,150% of Medicare + 9.63% HCRA Surcharge,1572.75,45,,1572.75,percent of total billed charges,Critical Access Hospital RCC factor,1188.3,34,,1188.3,percent of total billed charges,Implant Device,1188.3,34,,1188.3,percent of total billed charges,Implant Device,1188.3,34,,1188.3,percent of total billed charges,Implant Device,1188.3,34,,1188.3,percent of total billed charges,Implant Device,1188.3,34,,1188.3,percent of total billed charges,Implant Device,1730.03,,,1730.03,Other,110% of Medicare,1223.25,35,,1223.25,percent of total billed charges,Implant Device,1188.3,34,"Charges > $500, x 34%",1188.3,percent of total billed charges,Implant Device,1223.25,35,,1223.25,percent of total billed charges,Implant Device,1223.25,35,,1223.25,percent of total billed charges,Implant Device,1223.25,35,,1223.25,percent of total billed charges,Implant Device,1223.25,35,,1223.25,percent of total billed charges,Implant Device,1223.25,35,,1223.25,percent of total billed charges,Implant Device,1398,40,,1398,percent of total billed charges,Implant Device,1223.25,70,,1223.25,percent of total billed charges,All Other,1188.3,34,,1188.3,percent of total billed charges,Implant Device,1188.3,34,,1188.3,percent of total billed charges,Implant Device,1223.25,35,,1223.25,percent of total billed charges,Implant Device,1223.25,35,,1223.25,percent of total billed charges,Implant Device,1223.25,35,,1223.25,percent of total billed charges,Implant Device,1223.25,35,,1223.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1188.3,34,"If Charge > 2,000, then 34 percent",1188.3,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2586.31,
MEDLINE MPP1005L MTP FUSION PLT 5 DEG LT,C1713,HCPCS,,79013715,CDM,278,RC,,,both,,,6000,4440.02,,,4440.02,Other,150% of Medicare + 9.63% HCRA Surcharge,2700,45,,2700,percent of total billed charges,Critical Access Hospital RCC factor,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2970,,,2970,Other,110% of Medicare,2100,35,,2100,percent of total billed charges,Implant Device,2040,34,"Charges > $500, x 34%",2040,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2400,40,,2400,percent of total billed charges,Implant Device,2100,70,,2100,percent of total billed charges,All Other,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2040,34,"If Charge > 2,000, then 34 percent",2040,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4440.02,
MEDLINE MPSL2710 LOCKING SCREW 2.7X10MM,C1713,HCPCS,,79013716,CDM,278,RC,,,both,,,870,643.8,,,643.8,Other,150% of Medicare + 9.63% HCRA Surcharge,391.5,45,,391.5,percent of total billed charges,Critical Access Hospital RCC factor,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,430.65,,,430.65,Other,110% of Medicare,304.5,35,,304.5,percent of total billed charges,Implant Device,295.8,34,"Charges > $500, x 34%",295.8,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,348,40,,348,percent of total billed charges,Implant Device,304.5,70,,304.5,percent of total billed charges,All Other,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,643.8,
MEDLINE MPSL2712 LOCKING SCREW 2.7X12MM,C1713,HCPCS,,79013717,CDM,278,RC,,,both,,,870,643.8,,,643.8,Other,150% of Medicare + 9.63% HCRA Surcharge,391.5,45,,391.5,percent of total billed charges,Critical Access Hospital RCC factor,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,430.65,,,430.65,Other,110% of Medicare,304.5,35,,304.5,percent of total billed charges,Implant Device,295.8,34,"Charges > $500, x 34%",295.8,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,348,40,,348,percent of total billed charges,Implant Device,304.5,70,,304.5,percent of total billed charges,All Other,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,643.8,
MEDLINE MPSN3518 NON LOCK SCREW 3.5X18MM,C1713,HCPCS,,79013718,CDM,278,RC,,,both,,,870,643.8,,,643.8,Other,150% of Medicare + 9.63% HCRA Surcharge,391.5,45,,391.5,percent of total billed charges,Critical Access Hospital RCC factor,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,430.65,,,430.65,Other,110% of Medicare,304.5,35,,304.5,percent of total billed charges,Implant Device,295.8,34,"Charges > $500, x 34%",295.8,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,348,40,,348,percent of total billed charges,Implant Device,304.5,70,,304.5,percent of total billed charges,All Other,295.8,34,,295.8,percent of total billed charges,Implant Device,295.8,34,,295.8,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,304.5,35,,304.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,643.8,
MEDLINE MSD14026 CANN SCREW 4.0X26MM,C1713,HCPCS,,79013719,CDM,278,RC,,,both,,,1275,943.5,,,943.5,Other,150% of Medicare + 9.63% HCRA Surcharge,573.75,45,,573.75,percent of total billed charges,Critical Access Hospital RCC factor,433.5,34,,433.5,percent of total billed charges,Implant Device,433.5,34,,433.5,percent of total billed charges,Implant Device,433.5,34,,433.5,percent of total billed charges,Implant Device,433.5,34,,433.5,percent of total billed charges,Implant Device,433.5,34,,433.5,percent of total billed charges,Implant Device,631.13,,,631.13,Other,110% of Medicare,446.25,35,,446.25,percent of total billed charges,Implant Device,433.5,34,"Charges > $500, x 34%",433.5,percent of total billed charges,Implant Device,446.25,35,,446.25,percent of total billed charges,Implant Device,446.25,35,,446.25,percent of total billed charges,Implant Device,446.25,35,,446.25,percent of total billed charges,Implant Device,446.25,35,,446.25,percent of total billed charges,Implant Device,446.25,35,,446.25,percent of total billed charges,Implant Device,510,40,,510,percent of total billed charges,Implant Device,446.25,70,,446.25,percent of total billed charges,All Other,433.5,34,,433.5,percent of total billed charges,Implant Device,433.5,34,,433.5,percent of total billed charges,Implant Device,446.25,35,,446.25,percent of total billed charges,Implant Device,446.25,35,,446.25,percent of total billed charges,Implant Device,446.25,35,,446.25,percent of total billed charges,Implant Device,446.25,35,,446.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,943.5,
BOST H74938046830750 8X27X75CM EXP STENT,C1876,HCPCS,,79013725,CDM,278,RC,,,both,,,1976,1462.24,,,1462.24,Other,150% of Medicare + 9.63% HCRA Surcharge,889.2,45,,889.2,percent of total billed charges,Critical Access Hospital RCC factor,671.84,34,,671.84,percent of total billed charges,Implant Device,671.84,34,,671.84,percent of total billed charges,Implant Device,671.84,34,,671.84,percent of total billed charges,Implant Device,671.84,34,,671.84,percent of total billed charges,Implant Device,671.84,34,,671.84,percent of total billed charges,Implant Device,978.12,,,978.12,Other,110% of Medicare,691.6,35,,691.6,percent of total billed charges,Implant Device,671.84,34,"Charges > $500, x 34%",671.84,percent of total billed charges,Implant Device,691.6,35,,691.6,percent of total billed charges,Implant Device,691.6,35,,691.6,percent of total billed charges,Implant Device,691.6,35,,691.6,percent of total billed charges,Implant Device,691.6,35,,691.6,percent of total billed charges,Implant Device,691.6,35,,691.6,percent of total billed charges,Implant Device,790.4,40,,790.4,percent of total billed charges,Implant Device,691.6,70,,691.6,percent of total billed charges,All Other,671.84,34,,671.84,percent of total billed charges,Implant Device,671.84,34,,671.84,percent of total billed charges,Implant Device,691.6,35,,691.6,percent of total billed charges,Implant Device,691.6,35,,691.6,percent of total billed charges,Implant Device,691.6,35,,691.6,percent of total billed charges,Implant Device,691.6,35,,691.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1462.24,
STRYKER IH2510 HEADLESS SCREW 2.5X10MM,C1713,HCPCS,,79013726,CDM,278,RC,,,both,,,1679,1242.46,,,1242.46,Other,150% of Medicare + 9.63% HCRA Surcharge,755.55,45,,755.55,percent of total billed charges,Critical Access Hospital RCC factor,570.86,34,,570.86,percent of total billed charges,Implant Device,570.86,34,,570.86,percent of total billed charges,Implant Device,570.86,34,,570.86,percent of total billed charges,Implant Device,570.86,34,,570.86,percent of total billed charges,Implant Device,570.86,34,,570.86,percent of total billed charges,Implant Device,831.11,,,831.11,Other,110% of Medicare,587.65,35,,587.65,percent of total billed charges,Implant Device,570.86,34,"Charges > $500, x 34%",570.86,percent of total billed charges,Implant Device,587.65,35,,587.65,percent of total billed charges,Implant Device,587.65,35,,587.65,percent of total billed charges,Implant Device,587.65,35,,587.65,percent of total billed charges,Implant Device,587.65,35,,587.65,percent of total billed charges,Implant Device,587.65,35,,587.65,percent of total billed charges,Implant Device,671.6,40,,671.6,percent of total billed charges,Implant Device,587.65,70,,587.65,percent of total billed charges,All Other,570.86,34,,570.86,percent of total billed charges,Implant Device,570.86,34,,570.86,percent of total billed charges,Implant Device,587.65,35,,587.65,percent of total billed charges,Implant Device,587.65,35,,587.65,percent of total billed charges,Implant Device,587.65,35,,587.65,percent of total billed charges,Implant Device,587.65,35,,587.65,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1242.46,
STRYKER IH3010 HEADLESS SCREW 3.0X10MM,C1713,HCPCS,,79013727,CDM,278,RC,,,both,,,1679,1242.46,,,1242.46,Other,150% of Medicare + 9.63% HCRA Surcharge,755.55,45,,755.55,percent of total billed charges,Critical Access Hospital RCC factor,570.86,34,,570.86,percent of total billed charges,Implant Device,570.86,34,,570.86,percent of total billed charges,Implant Device,570.86,34,,570.86,percent of total billed charges,Implant Device,570.86,34,,570.86,percent of total billed charges,Implant Device,570.86,34,,570.86,percent of total billed charges,Implant Device,831.11,,,831.11,Other,110% of Medicare,587.65,35,,587.65,percent of total billed charges,Implant Device,570.86,34,"Charges > $500, x 34%",570.86,percent of total billed charges,Implant Device,587.65,35,,587.65,percent of total billed charges,Implant Device,587.65,35,,587.65,percent of total billed charges,Implant Device,587.65,35,,587.65,percent of total billed charges,Implant Device,587.65,35,,587.65,percent of total billed charges,Implant Device,587.65,35,,587.65,percent of total billed charges,Implant Device,671.6,40,,671.6,percent of total billed charges,Implant Device,587.65,70,,587.65,percent of total billed charges,All Other,570.86,34,,570.86,percent of total billed charges,Implant Device,570.86,34,,570.86,percent of total billed charges,Implant Device,587.65,35,,587.65,percent of total billed charges,Implant Device,587.65,35,,587.65,percent of total billed charges,Implant Device,587.65,35,,587.65,percent of total billed charges,Implant Device,587.65,35,,587.65,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1242.46,
STRYKER IH3012 HEADLESS SCREW 3.0X12MM,C1713,HCPCS,,79013728,CDM,278,RC,,,both,,,1679,1242.46,,,1242.46,Other,150% of Medicare + 9.63% HCRA Surcharge,755.55,45,,755.55,percent of total billed charges,Critical Access Hospital RCC factor,570.86,34,,570.86,percent of total billed charges,Implant Device,570.86,34,,570.86,percent of total billed charges,Implant Device,570.86,34,,570.86,percent of total billed charges,Implant Device,570.86,34,,570.86,percent of total billed charges,Implant Device,570.86,34,,570.86,percent of total billed charges,Implant Device,831.11,,,831.11,Other,110% of Medicare,587.65,35,,587.65,percent of total billed charges,Implant Device,570.86,34,"Charges > $500, x 34%",570.86,percent of total billed charges,Implant Device,587.65,35,,587.65,percent of total billed charges,Implant Device,587.65,35,,587.65,percent of total billed charges,Implant Device,587.65,35,,587.65,percent of total billed charges,Implant Device,587.65,35,,587.65,percent of total billed charges,Implant Device,587.65,35,,587.65,percent of total billed charges,Implant Device,671.6,40,,671.6,percent of total billed charges,Implant Device,587.65,70,,587.65,percent of total billed charges,All Other,570.86,34,,570.86,percent of total billed charges,Implant Device,570.86,34,,570.86,percent of total billed charges,Implant Device,587.65,35,,587.65,percent of total billed charges,Implant Device,587.65,35,,587.65,percent of total billed charges,Implant Device,587.65,35,,587.65,percent of total billed charges,Implant Device,587.65,35,,587.65,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1242.46,
SYNTHES 245.071 PLATE LCP 7 HOLE,C1713,HCPCS,,79013729,CDM,278,RC,,,both,,,1417,1048.58,,,1048.58,Other,150% of Medicare + 9.63% HCRA Surcharge,637.65,45,,637.65,percent of total billed charges,Critical Access Hospital RCC factor,481.78,34,,481.78,percent of total billed charges,Implant Device,481.78,34,,481.78,percent of total billed charges,Implant Device,481.78,34,,481.78,percent of total billed charges,Implant Device,481.78,34,,481.78,percent of total billed charges,Implant Device,481.78,34,,481.78,percent of total billed charges,Implant Device,701.42,,,701.42,Other,110% of Medicare,495.95,35,,495.95,percent of total billed charges,Implant Device,481.78,34,"Charges > $500, x 34%",481.78,percent of total billed charges,Implant Device,495.95,35,,495.95,percent of total billed charges,Implant Device,495.95,35,,495.95,percent of total billed charges,Implant Device,495.95,35,,495.95,percent of total billed charges,Implant Device,495.95,35,,495.95,percent of total billed charges,Implant Device,495.95,35,,495.95,percent of total billed charges,Implant Device,566.8,40,,566.8,percent of total billed charges,Implant Device,495.95,70,,495.95,percent of total billed charges,All Other,481.78,34,,481.78,percent of total billed charges,Implant Device,481.78,34,,481.78,percent of total billed charges,Implant Device,495.95,35,,495.95,percent of total billed charges,Implant Device,495.95,35,,495.95,percent of total billed charges,Implant Device,495.95,35,,495.95,percent of total billed charges,Implant Device,495.95,35,,495.95,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1048.58,
J&J 1010-11-100 FEMORAL STEM SIZE 10,C1776,HCPCS,,79013730,CDM,278,RC,,,both,,,7410,5483.42,,,5483.42,Other,150% of Medicare + 9.63% HCRA Surcharge,3334.5,45,,3334.5,percent of total billed charges,Critical Access Hospital RCC factor,2519.4,34,,2519.4,percent of total billed charges,Implant Device,2519.4,34,,2519.4,percent of total billed charges,Implant Device,2519.4,34,,2519.4,percent of total billed charges,Implant Device,2519.4,34,,2519.4,percent of total billed charges,Implant Device,2519.4,34,,2519.4,percent of total billed charges,Implant Device,3667.95,,,3667.95,Other,110% of Medicare,2593.5,35,,2593.5,percent of total billed charges,Implant Device,2519.4,34,"Charges > $500, x 34%",2519.4,percent of total billed charges,Implant Device,2593.5,35,,2593.5,percent of total billed charges,Implant Device,2593.5,35,,2593.5,percent of total billed charges,Implant Device,2593.5,35,,2593.5,percent of total billed charges,Implant Device,2593.5,35,,2593.5,percent of total billed charges,Implant Device,2593.5,35,,2593.5,percent of total billed charges,Implant Device,2964,40,,2964,percent of total billed charges,Implant Device,2593.5,70,,2593.5,percent of total billed charges,All Other,2519.4,34,,2519.4,percent of total billed charges,Implant Device,2519.4,34,,2519.4,percent of total billed charges,Implant Device,2593.5,35,,2593.5,percent of total billed charges,Implant Device,2593.5,35,,2593.5,percent of total billed charges,Implant Device,2593.5,35,,2593.5,percent of total billed charges,Implant Device,2593.5,35,,2593.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2519.4,34,"If Charge > 2,000, then 34 percent",2519.4,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5483.42,
STRYKER 601636S CANNULATED SCREW 5X36MM,C1713,HCPCS,,79013749,CDM,278,RC,,,both,,,529,391.46,,,391.46,Other,150% of Medicare + 9.63% HCRA Surcharge,238.05,45,,238.05,percent of total billed charges,Critical Access Hospital RCC factor,179.86,34,,179.86,percent of total billed charges,Implant Device,179.86,34,,179.86,percent of total billed charges,Implant Device,179.86,34,,179.86,percent of total billed charges,Implant Device,179.86,34,,179.86,percent of total billed charges,Implant Device,179.86,34,,179.86,percent of total billed charges,Implant Device,261.86,,,261.86,Other,110% of Medicare,185.15,35,,185.15,percent of total billed charges,Implant Device,179.86,34,"Charges > $500, x 34%",179.86,percent of total billed charges,Implant Device,185.15,35,,185.15,percent of total billed charges,Implant Device,185.15,35,,185.15,percent of total billed charges,Implant Device,185.15,35,,185.15,percent of total billed charges,Implant Device,185.15,35,,185.15,percent of total billed charges,Implant Device,185.15,35,,185.15,percent of total billed charges,Implant Device,211.6,40,,211.6,percent of total billed charges,Implant Device,185.15,70,,185.15,percent of total billed charges,All Other,179.86,34,,179.86,percent of total billed charges,Implant Device,179.86,34,,179.86,percent of total billed charges,Implant Device,185.15,35,,185.15,percent of total billed charges,Implant Device,185.15,35,,185.15,percent of total billed charges,Implant Device,185.15,35,,185.15,percent of total billed charges,Implant Device,185.15,35,,185.15,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,391.46,
WRIGHT FFS21815 STAPLE 18X15NITINOL 2LEG,C1713,HCPCS,,79013751,CDM,278,RC,,,both,,,6000,4440.02,,,4440.02,Other,150% of Medicare + 9.63% HCRA Surcharge,2700,45,,2700,percent of total billed charges,Critical Access Hospital RCC factor,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2970,,,2970,Other,110% of Medicare,2100,35,,2100,percent of total billed charges,Implant Device,2040,34,"Charges > $500, x 34%",2040,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2400,40,,2400,percent of total billed charges,Implant Device,2100,70,,2100,percent of total billed charges,All Other,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2040,34,"If Charge > 2,000, then 34 percent",2040,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4440.02,
STRYKER 5901-6056 HUM CUP TRAIL ADAPTOR,C1776,HCPCS,,79013752,CDM,278,RC,,,both,,,1767,1307.58,,,1307.58,Other,150% of Medicare + 9.63% HCRA Surcharge,795.15,45,,795.15,percent of total billed charges,Critical Access Hospital RCC factor,600.78,34,,600.78,percent of total billed charges,Implant Device,600.78,34,,600.78,percent of total billed charges,Implant Device,600.78,34,,600.78,percent of total billed charges,Implant Device,600.78,34,,600.78,percent of total billed charges,Implant Device,600.78,34,,600.78,percent of total billed charges,Implant Device,874.67,,,874.67,Other,110% of Medicare,618.45,35,,618.45,percent of total billed charges,Implant Device,600.78,34,"Charges > $500, x 34%",600.78,percent of total billed charges,Implant Device,618.45,35,,618.45,percent of total billed charges,Implant Device,618.45,35,,618.45,percent of total billed charges,Implant Device,618.45,35,,618.45,percent of total billed charges,Implant Device,618.45,35,,618.45,percent of total billed charges,Implant Device,618.45,35,,618.45,percent of total billed charges,Implant Device,706.8,40,,706.8,percent of total billed charges,Implant Device,618.45,70,,618.45,percent of total billed charges,All Other,600.78,34,,600.78,percent of total billed charges,Implant Device,600.78,34,,600.78,percent of total billed charges,Implant Device,618.45,35,,618.45,percent of total billed charges,Implant Device,618.45,35,,618.45,percent of total billed charges,Implant Device,618.45,35,,618.45,percent of total billed charges,Implant Device,618.45,35,,618.45,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1307.58,
STRYKER 5571-S-3210 HUMERAL INS 32X10MM,C1776,HCPCS,,79013753,CDM,278,RC,,,both,,,3525,2608.51,,,2608.51,Other,150% of Medicare + 9.63% HCRA Surcharge,1586.25,45,,1586.25,percent of total billed charges,Critical Access Hospital RCC factor,1198.5,34,,1198.5,percent of total billed charges,Implant Device,1198.5,34,,1198.5,percent of total billed charges,Implant Device,1198.5,34,,1198.5,percent of total billed charges,Implant Device,1198.5,34,,1198.5,percent of total billed charges,Implant Device,1198.5,34,,1198.5,percent of total billed charges,Implant Device,1744.88,,,1744.88,Other,110% of Medicare,1233.75,35,,1233.75,percent of total billed charges,Implant Device,1198.5,34,"Charges > $500, x 34%",1198.5,percent of total billed charges,Implant Device,1233.75,35,,1233.75,percent of total billed charges,Implant Device,1233.75,35,,1233.75,percent of total billed charges,Implant Device,1233.75,35,,1233.75,percent of total billed charges,Implant Device,1233.75,35,,1233.75,percent of total billed charges,Implant Device,1233.75,35,,1233.75,percent of total billed charges,Implant Device,1410,40,,1410,percent of total billed charges,Implant Device,1233.75,70,,1233.75,percent of total billed charges,All Other,1198.5,34,,1198.5,percent of total billed charges,Implant Device,1198.5,34,,1198.5,percent of total billed charges,Implant Device,1233.75,35,,1233.75,percent of total billed charges,Implant Device,1233.75,35,,1233.75,percent of total billed charges,Implant Device,1233.75,35,,1233.75,percent of total billed charges,Implant Device,1233.75,35,,1233.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1198.5,34,"If Charge > 2,000, then 34 percent",1198.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2608.51,
J&J 1504-00-106 ATTUNE FEMORAL SZ 6 LT,C1776,HCPCS,,79013754,CDM,278,RC,,,both,,,4800,3552.01,,,3552.01,Other,150% of Medicare + 9.63% HCRA Surcharge,2160,45,,2160,percent of total billed charges,Critical Access Hospital RCC factor,1632,34,,1632,percent of total billed charges,Implant Device,1632,34,,1632,percent of total billed charges,Implant Device,1632,34,,1632,percent of total billed charges,Implant Device,1632,34,,1632,percent of total billed charges,Implant Device,1632,34,,1632,percent of total billed charges,Implant Device,2376,,,2376,Other,110% of Medicare,1680,35,,1680,percent of total billed charges,Implant Device,1632,34,"Charges > $500, x 34%",1632,percent of total billed charges,Implant Device,1680,35,,1680,percent of total billed charges,Implant Device,1680,35,,1680,percent of total billed charges,Implant Device,1680,35,,1680,percent of total billed charges,Implant Device,1680,35,,1680,percent of total billed charges,Implant Device,1680,35,,1680,percent of total billed charges,Implant Device,1920,40,,1920,percent of total billed charges,Implant Device,1680,70,,1680,percent of total billed charges,All Other,1632,34,,1632,percent of total billed charges,Implant Device,1632,34,,1632,percent of total billed charges,Implant Device,1680,35,,1680,percent of total billed charges,Implant Device,1680,35,,1680,percent of total billed charges,Implant Device,1680,35,,1680,percent of total billed charges,Implant Device,1680,35,,1680,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1632,34,"If Charge > 2,000, then 34 percent",1632,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3552.01,
J&J 1516-30-612 ATTUNE TIB INS SZ 6 12MM,C1776,HCPCS,,79013755,CDM,278,RC,,,both,,,5400,3996.01,,,3996.01,Other,150% of Medicare + 9.63% HCRA Surcharge,2430,45,,2430,percent of total billed charges,Critical Access Hospital RCC factor,1836,34,,1836,percent of total billed charges,Implant Device,1836,34,,1836,percent of total billed charges,Implant Device,1836,34,,1836,percent of total billed charges,Implant Device,1836,34,,1836,percent of total billed charges,Implant Device,1836,34,,1836,percent of total billed charges,Implant Device,2673,,,2673,Other,110% of Medicare,1890,35,,1890,percent of total billed charges,Implant Device,1836,34,"Charges > $500, x 34%",1836,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,2160,40,,2160,percent of total billed charges,Implant Device,1890,70,,1890,percent of total billed charges,All Other,1836,34,,1836,percent of total billed charges,Implant Device,1836,34,,1836,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1836,34,"If Charge > 2,000, then 34 percent",1836,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3996.01,
J&J 1504-01-108 ATTUNE FEMORAL SZ 8 LT,C1776,HCPCS,,79013756,CDM,278,RC,,,both,,,6000,4440.02,,,4440.02,Other,150% of Medicare + 9.63% HCRA Surcharge,2700,45,,2700,percent of total billed charges,Critical Access Hospital RCC factor,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2970,,,2970,Other,110% of Medicare,2100,35,,2100,percent of total billed charges,Implant Device,2040,34,"Charges > $500, x 34%",2040,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2400,40,,2400,percent of total billed charges,Implant Device,2100,70,,2100,percent of total billed charges,All Other,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2040,34,"If Charge > 2,000, then 34 percent",2040,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4440.02,
J&J 1516-30-807 ATTUNE TIB INS SZ 8 7MM,C1776,HCPCS,,79013757,CDM,278,RC,,,both,,,5400,3996.01,,,3996.01,Other,150% of Medicare + 9.63% HCRA Surcharge,2430,45,,2430,percent of total billed charges,Critical Access Hospital RCC factor,1836,34,,1836,percent of total billed charges,Implant Device,1836,34,,1836,percent of total billed charges,Implant Device,1836,34,,1836,percent of total billed charges,Implant Device,1836,34,,1836,percent of total billed charges,Implant Device,1836,34,,1836,percent of total billed charges,Implant Device,2673,,,2673,Other,110% of Medicare,1890,35,,1890,percent of total billed charges,Implant Device,1836,34,"Charges > $500, x 34%",1836,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,2160,40,,2160,percent of total billed charges,Implant Device,1890,70,,1890,percent of total billed charges,All Other,1836,34,,1836,percent of total billed charges,Implant Device,1836,34,,1836,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1836,34,"If Charge > 2,000, then 34 percent",1836,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3996.01,
J&J 02.111.551 DIS RADIUS PLT 5H 2.4MM,C1713,HCPCS,,79013758,CDM,278,RC,,,both,,,2499,1849.27,,,1849.27,Other,150% of Medicare + 9.63% HCRA Surcharge,1124.55,45,,1124.55,percent of total billed charges,Critical Access Hospital RCC factor,849.66,34,,849.66,percent of total billed charges,Implant Device,849.66,34,,849.66,percent of total billed charges,Implant Device,849.66,34,,849.66,percent of total billed charges,Implant Device,849.66,34,,849.66,percent of total billed charges,Implant Device,849.66,34,,849.66,percent of total billed charges,Implant Device,1237.01,,,1237.01,Other,110% of Medicare,874.65,35,,874.65,percent of total billed charges,Implant Device,849.66,34,"Charges > $500, x 34%",849.66,percent of total billed charges,Implant Device,874.65,35,,874.65,percent of total billed charges,Implant Device,874.65,35,,874.65,percent of total billed charges,Implant Device,874.65,35,,874.65,percent of total billed charges,Implant Device,874.65,35,,874.65,percent of total billed charges,Implant Device,874.65,35,,874.65,percent of total billed charges,Implant Device,999.6,40,,999.6,percent of total billed charges,Implant Device,874.65,70,,874.65,percent of total billed charges,All Other,849.66,34,,849.66,percent of total billed charges,Implant Device,849.66,34,,849.66,percent of total billed charges,Implant Device,874.65,35,,874.65,percent of total billed charges,Implant Device,874.65,35,,874.65,percent of total billed charges,Implant Device,874.65,35,,874.65,percent of total billed charges,Implant Device,874.65,35,,874.65,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,849.66,34,"If Charge > 2,000, then 34 percent",849.66,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1849.27,
J&J 04.333.222 HEADLESS SCREW 3.0X22MM,C1713,HCPCS,,79013760,CDM,278,RC,,,both,,,1105,817.7,,,817.7,Other,150% of Medicare + 9.63% HCRA Surcharge,497.25,45,,497.25,percent of total billed charges,Critical Access Hospital RCC factor,375.7,34,,375.7,percent of total billed charges,Implant Device,375.7,34,,375.7,percent of total billed charges,Implant Device,375.7,34,,375.7,percent of total billed charges,Implant Device,375.7,34,,375.7,percent of total billed charges,Implant Device,375.7,34,,375.7,percent of total billed charges,Implant Device,546.98,,,546.98,Other,110% of Medicare,386.75,35,,386.75,percent of total billed charges,Implant Device,375.7,34,"Charges > $500, x 34%",375.7,percent of total billed charges,Implant Device,386.75,35,,386.75,percent of total billed charges,Implant Device,386.75,35,,386.75,percent of total billed charges,Implant Device,386.75,35,,386.75,percent of total billed charges,Implant Device,386.75,35,,386.75,percent of total billed charges,Implant Device,386.75,35,,386.75,percent of total billed charges,Implant Device,442,40,,442,percent of total billed charges,Implant Device,386.75,70,,386.75,percent of total billed charges,All Other,375.7,34,,375.7,percent of total billed charges,Implant Device,375.7,34,,375.7,percent of total billed charges,Implant Device,386.75,35,,386.75,percent of total billed charges,Implant Device,386.75,35,,386.75,percent of total billed charges,Implant Device,386.75,35,,386.75,percent of total billed charges,Implant Device,386.75,35,,386.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,817.7,
J&J 04.333.232 HEADLESS SCREW 3.0X32MM,C1713,HCPCS,,79013761,CDM,278,RC,,,both,,,1105,817.7,,,817.7,Other,150% of Medicare + 9.63% HCRA Surcharge,497.25,45,,497.25,percent of total billed charges,Critical Access Hospital RCC factor,375.7,34,,375.7,percent of total billed charges,Implant Device,375.7,34,,375.7,percent of total billed charges,Implant Device,375.7,34,,375.7,percent of total billed charges,Implant Device,375.7,34,,375.7,percent of total billed charges,Implant Device,375.7,34,,375.7,percent of total billed charges,Implant Device,546.98,,,546.98,Other,110% of Medicare,386.75,35,,386.75,percent of total billed charges,Implant Device,375.7,34,"Charges > $500, x 34%",375.7,percent of total billed charges,Implant Device,386.75,35,,386.75,percent of total billed charges,Implant Device,386.75,35,,386.75,percent of total billed charges,Implant Device,386.75,35,,386.75,percent of total billed charges,Implant Device,386.75,35,,386.75,percent of total billed charges,Implant Device,386.75,35,,386.75,percent of total billed charges,Implant Device,442,40,,442,percent of total billed charges,Implant Device,386.75,70,,386.75,percent of total billed charges,All Other,375.7,34,,375.7,percent of total billed charges,Implant Device,375.7,34,,375.7,percent of total billed charges,Implant Device,386.75,35,,386.75,percent of total billed charges,Implant Device,386.75,35,,386.75,percent of total billed charges,Implant Device,386.75,35,,386.75,percent of total billed charges,Implant Device,386.75,35,,386.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,817.7,
J&J 04.333.224 HEADLESS SCREW 3.0X24MM,C1713,HCPCS,,79013762,CDM,278,RC,,,both,,,1105,817.7,,,817.7,Other,150% of Medicare + 9.63% HCRA Surcharge,497.25,45,,497.25,percent of total billed charges,Critical Access Hospital RCC factor,375.7,34,,375.7,percent of total billed charges,Implant Device,375.7,34,,375.7,percent of total billed charges,Implant Device,375.7,34,,375.7,percent of total billed charges,Implant Device,375.7,34,,375.7,percent of total billed charges,Implant Device,375.7,34,,375.7,percent of total billed charges,Implant Device,546.98,,,546.98,Other,110% of Medicare,386.75,35,,386.75,percent of total billed charges,Implant Device,375.7,34,"Charges > $500, x 34%",375.7,percent of total billed charges,Implant Device,386.75,35,,386.75,percent of total billed charges,Implant Device,386.75,35,,386.75,percent of total billed charges,Implant Device,386.75,35,,386.75,percent of total billed charges,Implant Device,386.75,35,,386.75,percent of total billed charges,Implant Device,386.75,35,,386.75,percent of total billed charges,Implant Device,442,40,,442,percent of total billed charges,Implant Device,386.75,70,,386.75,percent of total billed charges,All Other,375.7,34,,375.7,percent of total billed charges,Implant Device,375.7,34,,375.7,percent of total billed charges,Implant Device,386.75,35,,386.75,percent of total billed charges,Implant Device,386.75,35,,386.75,percent of total billed charges,Implant Device,386.75,35,,386.75,percent of total billed charges,Implant Device,386.75,35,,386.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,817.7,
J&J 04.334.232 HEADLESS SCREW 3.0X32MM,C1713,HCPCS,,79013763,CDM,278,RC,,,both,,,1105,817.7,,,817.7,Other,150% of Medicare + 9.63% HCRA Surcharge,497.25,45,,497.25,percent of total billed charges,Critical Access Hospital RCC factor,375.7,34,,375.7,percent of total billed charges,Implant Device,375.7,34,,375.7,percent of total billed charges,Implant Device,375.7,34,,375.7,percent of total billed charges,Implant Device,375.7,34,,375.7,percent of total billed charges,Implant Device,375.7,34,,375.7,percent of total billed charges,Implant Device,546.98,,,546.98,Other,110% of Medicare,386.75,35,,386.75,percent of total billed charges,Implant Device,375.7,34,"Charges > $500, x 34%",375.7,percent of total billed charges,Implant Device,386.75,35,,386.75,percent of total billed charges,Implant Device,386.75,35,,386.75,percent of total billed charges,Implant Device,386.75,35,,386.75,percent of total billed charges,Implant Device,386.75,35,,386.75,percent of total billed charges,Implant Device,386.75,35,,386.75,percent of total billed charges,Implant Device,442,40,,442,percent of total billed charges,Implant Device,386.75,70,,386.75,percent of total billed charges,All Other,375.7,34,,375.7,percent of total billed charges,Implant Device,375.7,34,,375.7,percent of total billed charges,Implant Device,386.75,35,,386.75,percent of total billed charges,Implant Device,386.75,35,,386.75,percent of total billed charges,Implant Device,386.75,35,,386.75,percent of total billed charges,Implant Device,386.75,35,,386.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,817.7,
J&J 02.221.151 DISTAL FEM PLT 4 HOLE 3.5,C1713,HCPCS,,79013764,CDM,278,RC,,,both,,,4110,3041.41,,,3041.41,Other,150% of Medicare + 9.63% HCRA Surcharge,1849.5,45,,1849.5,percent of total billed charges,Critical Access Hospital RCC factor,1397.4,34,,1397.4,percent of total billed charges,Implant Device,1397.4,34,,1397.4,percent of total billed charges,Implant Device,1397.4,34,,1397.4,percent of total billed charges,Implant Device,1397.4,34,,1397.4,percent of total billed charges,Implant Device,1397.4,34,,1397.4,percent of total billed charges,Implant Device,2034.45,,,2034.45,Other,110% of Medicare,1438.5,35,,1438.5,percent of total billed charges,Implant Device,1397.4,34,"Charges > $500, x 34%",1397.4,percent of total billed charges,Implant Device,1438.5,35,,1438.5,percent of total billed charges,Implant Device,1438.5,35,,1438.5,percent of total billed charges,Implant Device,1438.5,35,,1438.5,percent of total billed charges,Implant Device,1438.5,35,,1438.5,percent of total billed charges,Implant Device,1438.5,35,,1438.5,percent of total billed charges,Implant Device,1644,40,,1644,percent of total billed charges,Implant Device,1438.5,70,,1438.5,percent of total billed charges,All Other,1397.4,34,,1397.4,percent of total billed charges,Implant Device,1397.4,34,,1397.4,percent of total billed charges,Implant Device,1438.5,35,,1438.5,percent of total billed charges,Implant Device,1438.5,35,,1438.5,percent of total billed charges,Implant Device,1438.5,35,,1438.5,percent of total billed charges,Implant Device,1438.5,35,,1438.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1397.4,34,"If Charge > 2,000, then 34 percent",1397.4,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3041.41,
J&J 02.221.123 PROX FEMUR PLT 4.5X32 LT,C1713,HCPCS,,79013765,CDM,278,RC,,,both,,,8752,6476.5,,,6476.5,Other,150% of Medicare + 9.63% HCRA Surcharge,3938.4,45,,3938.4,percent of total billed charges,Critical Access Hospital RCC factor,2975.68,34,,2975.68,percent of total billed charges,Implant Device,2975.68,34,,2975.68,percent of total billed charges,Implant Device,2975.68,34,,2975.68,percent of total billed charges,Implant Device,2975.68,34,,2975.68,percent of total billed charges,Implant Device,2975.68,34,,2975.68,percent of total billed charges,Implant Device,4332.24,,,4332.24,Other,110% of Medicare,3063.2,35,,3063.2,percent of total billed charges,Implant Device,2975.68,34,"Charges > $500, x 34%",2975.68,percent of total billed charges,Implant Device,3063.2,35,,3063.2,percent of total billed charges,Implant Device,3063.2,35,,3063.2,percent of total billed charges,Implant Device,3063.2,35,,3063.2,percent of total billed charges,Implant Device,3063.2,35,,3063.2,percent of total billed charges,Implant Device,3063.2,35,,3063.2,percent of total billed charges,Implant Device,3500.8,40,,3500.8,percent of total billed charges,Implant Device,3063.2,70,,3063.2,percent of total billed charges,All Other,2975.68,34,,2975.68,percent of total billed charges,Implant Device,2975.68,34,,2975.68,percent of total billed charges,Implant Device,3063.2,35,,3063.2,percent of total billed charges,Implant Device,3063.2,35,,3063.2,percent of total billed charges,Implant Device,3063.2,35,,3063.2,percent of total billed charges,Implant Device,3063.2,35,,3063.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2975.68,34,"If Charge > 2,000, then 34 percent",2975.68,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,6476.5,
J&J 02.120.606 CONNECTING SCREW,C1713,HCPCS,,79013766,CDM,278,RC,,,both,,,419,310.06,,,310.06,Other,150% of Medicare + 9.63% HCRA Surcharge,188.55,45,,188.55,percent of total billed charges,Critical Access Hospital RCC factor,142.46,34,,142.46,percent of total billed charges,Implant Device,142.46,34,,142.46,percent of total billed charges,Implant Device,142.46,34,,142.46,percent of total billed charges,Implant Device,142.46,34,,142.46,percent of total billed charges,Implant Device,142.46,34,,142.46,percent of total billed charges,Implant Device,207.41,,,207.41,Other,110% of Medicare,146.65,35,,146.65,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,146.65,35,,146.65,percent of total billed charges,Implant Device,146.65,35,,146.65,percent of total billed charges,Implant Device,146.65,35,,146.65,percent of total billed charges,Implant Device,146.65,35,,146.65,percent of total billed charges,Implant Device,146.65,35,,146.65,percent of total billed charges,Implant Device,167.6,40,,167.6,percent of total billed charges,Implant Device,146.65,70,,146.65,percent of total billed charges,All Other,142.46,34,,142.46,percent of total billed charges,Implant Device,142.46,34,,142.46,percent of total billed charges,Implant Device,146.65,35,,146.65,percent of total billed charges,Implant Device,146.65,35,,146.65,percent of total billed charges,Implant Device,146.65,35,,146.65,percent of total billed charges,Implant Device,146.65,35,,146.65,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,310.06,
J&J 02.200.034 CORTEX SCREW 3.5X34MM,C1713,HCPCS,,79013768,CDM,278,RC,,,both,,,63,46.62,,,46.62,Other,150% of Medicare + 9.63% HCRA Surcharge,28.35,45,,28.35,percent of total billed charges,Critical Access Hospital RCC factor,21.42,34,,21.42,percent of total billed charges,Implant Device,21.42,34,,21.42,percent of total billed charges,Implant Device,21.42,34,,21.42,percent of total billed charges,Implant Device,21.42,34,,21.42,percent of total billed charges,Implant Device,21.42,34,,21.42,percent of total billed charges,Implant Device,31.19,,,31.19,Other,110% of Medicare,22.05,35,,22.05,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,22.05,35,,22.05,percent of total billed charges,Implant Device,22.05,35,,22.05,percent of total billed charges,Implant Device,22.05,35,,22.05,percent of total billed charges,Implant Device,22.05,35,,22.05,percent of total billed charges,Implant Device,22.05,35,,22.05,percent of total billed charges,Implant Device,25.2,40,,25.2,percent of total billed charges,Implant Device,22.05,70,,22.05,percent of total billed charges,All Other,21.42,34,,21.42,percent of total billed charges,Implant Device,21.42,34,,21.42,percent of total billed charges,Implant Device,22.05,35,,22.05,percent of total billed charges,Implant Device,22.05,35,,22.05,percent of total billed charges,Implant Device,22.05,35,,22.05,percent of total billed charges,Implant Device,22.05,35,,22.05,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,46.62,
J&J 02.200.040 CORTEX SCREW 3.5X40MM,C1713,HCPCS,,79013770,CDM,278,RC,,,both,,,63,46.62,,,46.62,Other,150% of Medicare + 9.63% HCRA Surcharge,28.35,45,,28.35,percent of total billed charges,Critical Access Hospital RCC factor,21.42,34,,21.42,percent of total billed charges,Implant Device,21.42,34,,21.42,percent of total billed charges,Implant Device,21.42,34,,21.42,percent of total billed charges,Implant Device,21.42,34,,21.42,percent of total billed charges,Implant Device,21.42,34,,21.42,percent of total billed charges,Implant Device,31.19,,,31.19,Other,110% of Medicare,22.05,35,,22.05,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,22.05,35,,22.05,percent of total billed charges,Implant Device,22.05,35,,22.05,percent of total billed charges,Implant Device,22.05,35,,22.05,percent of total billed charges,Implant Device,22.05,35,,22.05,percent of total billed charges,Implant Device,22.05,35,,22.05,percent of total billed charges,Implant Device,25.2,40,,25.2,percent of total billed charges,Implant Device,22.05,70,,22.05,percent of total billed charges,All Other,21.42,34,,21.42,percent of total billed charges,Implant Device,21.42,34,,21.42,percent of total billed charges,Implant Device,22.05,35,,22.05,percent of total billed charges,Implant Device,22.05,35,,22.05,percent of total billed charges,Implant Device,22.05,35,,22.05,percent of total billed charges,Implant Device,22.05,35,,22.05,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,46.62,
J&J 02.200.044 CORTEX SCREW 3.5X44MM,C1713,HCPCS,,79013771,CDM,278,RC,,,both,,,63,46.62,,,46.62,Other,150% of Medicare + 9.63% HCRA Surcharge,28.35,45,,28.35,percent of total billed charges,Critical Access Hospital RCC factor,21.42,34,,21.42,percent of total billed charges,Implant Device,21.42,34,,21.42,percent of total billed charges,Implant Device,21.42,34,,21.42,percent of total billed charges,Implant Device,21.42,34,,21.42,percent of total billed charges,Implant Device,21.42,34,,21.42,percent of total billed charges,Implant Device,31.19,,,31.19,Other,110% of Medicare,22.05,35,,22.05,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,22.05,35,,22.05,percent of total billed charges,Implant Device,22.05,35,,22.05,percent of total billed charges,Implant Device,22.05,35,,22.05,percent of total billed charges,Implant Device,22.05,35,,22.05,percent of total billed charges,Implant Device,22.05,35,,22.05,percent of total billed charges,Implant Device,25.2,40,,25.2,percent of total billed charges,Implant Device,22.05,70,,22.05,percent of total billed charges,All Other,21.42,34,,21.42,percent of total billed charges,Implant Device,21.42,34,,21.42,percent of total billed charges,Implant Device,22.05,35,,22.05,percent of total billed charges,Implant Device,22.05,35,,22.05,percent of total billed charges,Implant Device,22.05,35,,22.05,percent of total billed charges,Implant Device,22.05,35,,22.05,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,46.62,
J&J 214.860 CORTEX SCREW 4.5X60MM,C1713,HCPCS,,79013772,CDM,278,RC,,,both,,,57,42.18,,,42.18,Other,150% of Medicare + 9.63% HCRA Surcharge,25.65,45,,25.65,percent of total billed charges,Critical Access Hospital RCC factor,19.38,34,,19.38,percent of total billed charges,Implant Device,19.38,34,,19.38,percent of total billed charges,Implant Device,19.38,34,,19.38,percent of total billed charges,Implant Device,19.38,34,,19.38,percent of total billed charges,Implant Device,19.38,34,,19.38,percent of total billed charges,Implant Device,28.22,,,28.22,Other,110% of Medicare,19.95,35,,19.95,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,19.95,35,,19.95,percent of total billed charges,Implant Device,19.95,35,,19.95,percent of total billed charges,Implant Device,19.95,35,,19.95,percent of total billed charges,Implant Device,19.95,35,,19.95,percent of total billed charges,Implant Device,19.95,35,,19.95,percent of total billed charges,Implant Device,22.8,40,,22.8,percent of total billed charges,Implant Device,19.95,70,,19.95,percent of total billed charges,All Other,19.38,34,,19.38,percent of total billed charges,Implant Device,19.38,34,,19.38,percent of total billed charges,Implant Device,19.95,35,,19.95,percent of total billed charges,Implant Device,19.95,35,,19.95,percent of total billed charges,Implant Device,19.95,35,,19.95,percent of total billed charges,Implant Device,19.95,35,,19.95,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,42.18,
J&J 04.045.030S LOCKING SCREW 5X30MM,C1713,HCPCS,,79013773,CDM,278,RC,,,both,,,687,508.38,,,508.38,Other,150% of Medicare + 9.63% HCRA Surcharge,309.15,45,,309.15,percent of total billed charges,Critical Access Hospital RCC factor,233.58,34,,233.58,percent of total billed charges,Implant Device,233.58,34,,233.58,percent of total billed charges,Implant Device,233.58,34,,233.58,percent of total billed charges,Implant Device,233.58,34,,233.58,percent of total billed charges,Implant Device,233.58,34,,233.58,percent of total billed charges,Implant Device,340.07,,,340.07,Other,110% of Medicare,240.45,35,,240.45,percent of total billed charges,Implant Device,233.58,34,"Charges > $500, x 34%",233.58,percent of total billed charges,Implant Device,240.45,35,,240.45,percent of total billed charges,Implant Device,240.45,35,,240.45,percent of total billed charges,Implant Device,240.45,35,,240.45,percent of total billed charges,Implant Device,240.45,35,,240.45,percent of total billed charges,Implant Device,240.45,35,,240.45,percent of total billed charges,Implant Device,274.8,40,,274.8,percent of total billed charges,Implant Device,240.45,70,,240.45,percent of total billed charges,All Other,233.58,34,,233.58,percent of total billed charges,Implant Device,233.58,34,,233.58,percent of total billed charges,Implant Device,240.45,35,,240.45,percent of total billed charges,Implant Device,240.45,35,,240.45,percent of total billed charges,Implant Device,240.45,35,,240.45,percent of total billed charges,Implant Device,240.45,35,,240.45,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,508.38,
ZIMMER 42-5221-008-13 ART SURF RT 13MM,C1776,HCPCS,,79013774,CDM,278,RC,,,both,,,3648,2699.53,,,2699.53,Other,150% of Medicare + 9.63% HCRA Surcharge,1641.6,45,,1641.6,percent of total billed charges,Critical Access Hospital RCC factor,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1805.76,,,1805.76,Other,110% of Medicare,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1240.32,34,"Charges > $500, x 34%",1240.32,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1459.2,40,,1459.2,percent of total billed charges,Implant Device,1276.8,70,,1276.8,percent of total billed charges,All Other,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1240.32,34,"If Charge > 2,000, then 34 percent",1240.32,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2699.53,
ZIMMER 42-5121-008-16 ART SURF LT 18MM,C1776,HCPCS,,79013775,CDM,278,RC,,,both,,,3648,2699.53,,,2699.53,Other,150% of Medicare + 9.63% HCRA Surcharge,1641.6,45,,1641.6,percent of total billed charges,Critical Access Hospital RCC factor,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1805.76,,,1805.76,Other,110% of Medicare,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1240.32,34,"Charges > $500, x 34%",1240.32,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1459.2,40,,1459.2,percent of total billed charges,Implant Device,1276.8,70,,1276.8,percent of total billed charges,All Other,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1240.32,34,,1240.32,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,1276.8,35,,1276.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1240.32,34,"If Charge > 2,000, then 34 percent",1240.32,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2699.53,
IN2BONES M80 SB008 COLLAGEN IMP 7.5X40,C1763,HCPCS,,79013777,CDM,278,RC,,,both,,,4485,3318.91,,,3318.91,Other,150% of Medicare + 9.63% HCRA Surcharge,2018.25,45,,2018.25,percent of total billed charges,Critical Access Hospital RCC factor,1524.9,34,,1524.9,percent of total billed charges,Implant Device,1524.9,34,,1524.9,percent of total billed charges,Implant Device,1524.9,34,,1524.9,percent of total billed charges,Implant Device,1524.9,34,,1524.9,percent of total billed charges,Implant Device,1524.9,34,,1524.9,percent of total billed charges,Implant Device,2220.08,,,2220.08,Other,110% of Medicare,1569.75,35,,1569.75,percent of total billed charges,Implant Device,1524.9,34,"Charges > $500, x 34%",1524.9,percent of total billed charges,Implant Device,1569.75,35,,1569.75,percent of total billed charges,Implant Device,1569.75,35,,1569.75,percent of total billed charges,Implant Device,1569.75,35,,1569.75,percent of total billed charges,Implant Device,1569.75,35,,1569.75,percent of total billed charges,Implant Device,1569.75,35,,1569.75,percent of total billed charges,Implant Device,1794,40,,1794,percent of total billed charges,Implant Device,1569.75,70,,1569.75,percent of total billed charges,All Other,1524.9,34,,1524.9,percent of total billed charges,Implant Device,1524.9,34,,1524.9,percent of total billed charges,Implant Device,1569.75,35,,1569.75,percent of total billed charges,Implant Device,1569.75,35,,1569.75,percent of total billed charges,Implant Device,1569.75,35,,1569.75,percent of total billed charges,Implant Device,1569.75,35,,1569.75,percent of total billed charges,Implant Device,976.07,,,976.07,Other,100% of Medicaid,976.07,,,976.07,Other,100% of Medicaid,976.07,,,976.07,Other,100% of Medicaid,976.07,,,976.07,Other,100% of Medicaid,2196.16,,,2196.16,Other,225% of Medicaid,1493.39,,,1493.39,Other,153% of Medicaid,2196.16,,,2196.16,Other,225% of Medicaid,1366.5,,,1366.5,Other,140% of Medicaid,1524.9,34,"If Charge > 2,000, then 34 percent",1524.9,percent of total billed charges,Implants,2537.78,,,2537.78,Other,260% of Medicaid,3162.47,,,3162.47,Other,324% of Medicaid,2098.55,,,2098.55,Other,215% of Medicaid,2098.55,,,2098.55,Other,215% of Medicaid,1220.09,,,1220.09,Other,125% of Medicaid,976.07,3318.91,
ARTHREX AR-9055-50PT FX SCREW 5.5X50MM,C1713,HCPCS,,79013778,CDM,278,RC,,,both,,,2584,1912.17,,,1912.17,Other,150% of Medicare + 9.63% HCRA Surcharge,1162.8,45,,1162.8,percent of total billed charges,Critical Access Hospital RCC factor,878.56,34,,878.56,percent of total billed charges,Implant Device,878.56,34,,878.56,percent of total billed charges,Implant Device,878.56,34,,878.56,percent of total billed charges,Implant Device,878.56,34,,878.56,percent of total billed charges,Implant Device,878.56,34,,878.56,percent of total billed charges,Implant Device,1279.08,,,1279.08,Other,110% of Medicare,904.4,35,,904.4,percent of total billed charges,Implant Device,878.56,34,"Charges > $500, x 34%",878.56,percent of total billed charges,Implant Device,904.4,35,,904.4,percent of total billed charges,Implant Device,904.4,35,,904.4,percent of total billed charges,Implant Device,904.4,35,,904.4,percent of total billed charges,Implant Device,904.4,35,,904.4,percent of total billed charges,Implant Device,904.4,35,,904.4,percent of total billed charges,Implant Device,1033.6,40,,1033.6,percent of total billed charges,Implant Device,904.4,70,,904.4,percent of total billed charges,All Other,878.56,34,,878.56,percent of total billed charges,Implant Device,878.56,34,,878.56,percent of total billed charges,Implant Device,904.4,35,,904.4,percent of total billed charges,Implant Device,904.4,35,,904.4,percent of total billed charges,Implant Device,904.4,35,,904.4,percent of total billed charges,Implant Device,904.4,35,,904.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,878.56,34,"If Charge > 2,000, then 34 percent",878.56,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1912.17,
ARTHREX AR-8750-55H HEADLESS SCREW 5X55,C1713,HCPCS,,79013781,CDM,278,RC,,,both,,,1544,1142.56,,,1142.56,Other,150% of Medicare + 9.63% HCRA Surcharge,694.8,45,,694.8,percent of total billed charges,Critical Access Hospital RCC factor,524.96,34,,524.96,percent of total billed charges,Implant Device,524.96,34,,524.96,percent of total billed charges,Implant Device,524.96,34,,524.96,percent of total billed charges,Implant Device,524.96,34,,524.96,percent of total billed charges,Implant Device,524.96,34,,524.96,percent of total billed charges,Implant Device,764.28,,,764.28,Other,110% of Medicare,540.4,35,,540.4,percent of total billed charges,Implant Device,524.96,34,"Charges > $500, x 34%",524.96,percent of total billed charges,Implant Device,540.4,35,,540.4,percent of total billed charges,Implant Device,540.4,35,,540.4,percent of total billed charges,Implant Device,540.4,35,,540.4,percent of total billed charges,Implant Device,540.4,35,,540.4,percent of total billed charges,Implant Device,540.4,35,,540.4,percent of total billed charges,Implant Device,617.6,40,,617.6,percent of total billed charges,Implant Device,540.4,70,,540.4,percent of total billed charges,All Other,524.96,34,,524.96,percent of total billed charges,Implant Device,524.96,34,,524.96,percent of total billed charges,Implant Device,540.4,35,,540.4,percent of total billed charges,Implant Device,540.4,35,,540.4,percent of total billed charges,Implant Device,540.4,35,,540.4,percent of total billed charges,Implant Device,540.4,35,,540.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1142.56,
ARTHREX AR-8750-50H HEADLESS SCREW 5X50,C1713,HCPCS,,79013782,CDM,278,RC,,,both,,,1544,1142.56,,,1142.56,Other,150% of Medicare + 9.63% HCRA Surcharge,694.8,45,,694.8,percent of total billed charges,Critical Access Hospital RCC factor,524.96,34,,524.96,percent of total billed charges,Implant Device,524.96,34,,524.96,percent of total billed charges,Implant Device,524.96,34,,524.96,percent of total billed charges,Implant Device,524.96,34,,524.96,percent of total billed charges,Implant Device,524.96,34,,524.96,percent of total billed charges,Implant Device,764.28,,,764.28,Other,110% of Medicare,540.4,35,,540.4,percent of total billed charges,Implant Device,524.96,34,"Charges > $500, x 34%",524.96,percent of total billed charges,Implant Device,540.4,35,,540.4,percent of total billed charges,Implant Device,540.4,35,,540.4,percent of total billed charges,Implant Device,540.4,35,,540.4,percent of total billed charges,Implant Device,540.4,35,,540.4,percent of total billed charges,Implant Device,540.4,35,,540.4,percent of total billed charges,Implant Device,617.6,40,,617.6,percent of total billed charges,Implant Device,540.4,70,,540.4,percent of total billed charges,All Other,524.96,34,,524.96,percent of total billed charges,Implant Device,524.96,34,,524.96,percent of total billed charges,Implant Device,540.4,35,,540.4,percent of total billed charges,Implant Device,540.4,35,,540.4,percent of total billed charges,Implant Device,540.4,35,,540.4,percent of total billed charges,Implant Device,540.4,35,,540.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1142.56,
ARTHREX AR-8770-50H HEADLESS SCREW 7X50,C1713,HCPCS,,79013783,CDM,278,RC,,,both,,,2260,1672.41,,,1672.41,Other,150% of Medicare + 9.63% HCRA Surcharge,1017,45,,1017,percent of total billed charges,Critical Access Hospital RCC factor,768.4,34,,768.4,percent of total billed charges,Implant Device,768.4,34,,768.4,percent of total billed charges,Implant Device,768.4,34,,768.4,percent of total billed charges,Implant Device,768.4,34,,768.4,percent of total billed charges,Implant Device,768.4,34,,768.4,percent of total billed charges,Implant Device,1118.7,,,1118.7,Other,110% of Medicare,791,35,,791,percent of total billed charges,Implant Device,768.4,34,"Charges > $500, x 34%",768.4,percent of total billed charges,Implant Device,791,35,,791,percent of total billed charges,Implant Device,791,35,,791,percent of total billed charges,Implant Device,791,35,,791,percent of total billed charges,Implant Device,791,35,,791,percent of total billed charges,Implant Device,791,35,,791,percent of total billed charges,Implant Device,904,40,,904,percent of total billed charges,Implant Device,791,70,,791,percent of total billed charges,All Other,768.4,34,,768.4,percent of total billed charges,Implant Device,768.4,34,,768.4,percent of total billed charges,Implant Device,791,35,,791,percent of total billed charges,Implant Device,791,35,,791,percent of total billed charges,Implant Device,791,35,,791,percent of total billed charges,Implant Device,791,35,,791,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,768.4,34,"If Charge > 2,000, then 34 percent",768.4,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1672.41,
STRYKER 8425-0380S LONG NAIL RT 10X380MM,C1713,HCPCS,,79013786,CDM,278,RC,,,both,,,7227,5348,,,5348,Other,150% of Medicare + 9.63% HCRA Surcharge,3252.15,45,,3252.15,percent of total billed charges,Critical Access Hospital RCC factor,2457.18,34,,2457.18,percent of total billed charges,Implant Device,2457.18,34,,2457.18,percent of total billed charges,Implant Device,2457.18,34,,2457.18,percent of total billed charges,Implant Device,2457.18,34,,2457.18,percent of total billed charges,Implant Device,2457.18,34,,2457.18,percent of total billed charges,Implant Device,3577.37,,,3577.37,Other,110% of Medicare,2529.45,35,,2529.45,percent of total billed charges,Implant Device,2457.18,34,"Charges > $500, x 34%",2457.18,percent of total billed charges,Implant Device,2529.45,35,,2529.45,percent of total billed charges,Implant Device,2529.45,35,,2529.45,percent of total billed charges,Implant Device,2529.45,35,,2529.45,percent of total billed charges,Implant Device,2529.45,35,,2529.45,percent of total billed charges,Implant Device,2529.45,35,,2529.45,percent of total billed charges,Implant Device,2890.8,40,,2890.8,percent of total billed charges,Implant Device,2529.45,70,,2529.45,percent of total billed charges,All Other,2457.18,34,,2457.18,percent of total billed charges,Implant Device,2457.18,34,,2457.18,percent of total billed charges,Implant Device,2529.45,35,,2529.45,percent of total billed charges,Implant Device,2529.45,35,,2529.45,percent of total billed charges,Implant Device,2529.45,35,,2529.45,percent of total billed charges,Implant Device,2529.45,35,,2529.45,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2457.18,34,"If Charge > 2,000, then 34 percent",2457.18,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5348,
MEDTRONIC AB9U16060090 16X60 STENT SYS,C1876,HCPCS,,79013790,CDM,278,RC,,,both,,,5685,4206.91,,,4206.91,Other,150% of Medicare + 9.63% HCRA Surcharge,2558.25,45,,2558.25,percent of total billed charges,Critical Access Hospital RCC factor,1932.9,34,,1932.9,percent of total billed charges,Implant Device,1932.9,34,,1932.9,percent of total billed charges,Implant Device,1932.9,34,,1932.9,percent of total billed charges,Implant Device,1932.9,34,,1932.9,percent of total billed charges,Implant Device,1932.9,34,,1932.9,percent of total billed charges,Implant Device,2814.08,,,2814.08,Other,110% of Medicare,1989.75,35,,1989.75,percent of total billed charges,Implant Device,1932.9,34,"Charges > $500, x 34%",1932.9,percent of total billed charges,Implant Device,1989.75,35,,1989.75,percent of total billed charges,Implant Device,1989.75,35,,1989.75,percent of total billed charges,Implant Device,1989.75,35,,1989.75,percent of total billed charges,Implant Device,1989.75,35,,1989.75,percent of total billed charges,Implant Device,1989.75,35,,1989.75,percent of total billed charges,Implant Device,2274,40,,2274,percent of total billed charges,Implant Device,1989.75,70,,1989.75,percent of total billed charges,All Other,1932.9,34,,1932.9,percent of total billed charges,Implant Device,1932.9,34,,1932.9,percent of total billed charges,Implant Device,1989.75,35,,1989.75,percent of total billed charges,Implant Device,1989.75,35,,1989.75,percent of total billed charges,Implant Device,1989.75,35,,1989.75,percent of total billed charges,Implant Device,1989.75,35,,1989.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1932.9,34,"If Charge > 2,000, then 34 percent",1932.9,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4206.91,
MEDTRONIC AB9U16080090 16X80 STENT SYS,C1876,HCPCS,,79013791,CDM,278,RC,,,both,,,5685,4206.91,,,4206.91,Other,150% of Medicare + 9.63% HCRA Surcharge,2558.25,45,,2558.25,percent of total billed charges,Critical Access Hospital RCC factor,1932.9,34,,1932.9,percent of total billed charges,Implant Device,1932.9,34,,1932.9,percent of total billed charges,Implant Device,1932.9,34,,1932.9,percent of total billed charges,Implant Device,1932.9,34,,1932.9,percent of total billed charges,Implant Device,1932.9,34,,1932.9,percent of total billed charges,Implant Device,2814.08,,,2814.08,Other,110% of Medicare,1989.75,35,,1989.75,percent of total billed charges,Implant Device,1932.9,34,"Charges > $500, x 34%",1932.9,percent of total billed charges,Implant Device,1989.75,35,,1989.75,percent of total billed charges,Implant Device,1989.75,35,,1989.75,percent of total billed charges,Implant Device,1989.75,35,,1989.75,percent of total billed charges,Implant Device,1989.75,35,,1989.75,percent of total billed charges,Implant Device,1989.75,35,,1989.75,percent of total billed charges,Implant Device,2274,40,,2274,percent of total billed charges,Implant Device,1989.75,70,,1989.75,percent of total billed charges,All Other,1932.9,34,,1932.9,percent of total billed charges,Implant Device,1932.9,34,,1932.9,percent of total billed charges,Implant Device,1989.75,35,,1989.75,percent of total billed charges,Implant Device,1989.75,35,,1989.75,percent of total billed charges,Implant Device,1989.75,35,,1989.75,percent of total billed charges,Implant Device,1989.75,35,,1989.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1932.9,34,"If Charge > 2,000, then 34 percent",1932.9,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4206.91,
DJO 307-27-016 2.7X16MM NL SCREW,C1713,HCPCS,,79013793,CDM,278,RC,,,both,,,540,399.6,,,399.6,Other,150% of Medicare + 9.63% HCRA Surcharge,243,45,,243,percent of total billed charges,Critical Access Hospital RCC factor,183.6,34,,183.6,percent of total billed charges,Implant Device,183.6,34,,183.6,percent of total billed charges,Implant Device,183.6,34,,183.6,percent of total billed charges,Implant Device,183.6,34,,183.6,percent of total billed charges,Implant Device,183.6,34,,183.6,percent of total billed charges,Implant Device,267.3,,,267.3,Other,110% of Medicare,189,35,,189,percent of total billed charges,Implant Device,183.6,34,"Charges > $500, x 34%",183.6,percent of total billed charges,Implant Device,189,35,,189,percent of total billed charges,Implant Device,189,35,,189,percent of total billed charges,Implant Device,189,35,,189,percent of total billed charges,Implant Device,189,35,,189,percent of total billed charges,Implant Device,189,35,,189,percent of total billed charges,Implant Device,216,40,,216,percent of total billed charges,Implant Device,189,70,,189,percent of total billed charges,All Other,183.6,34,,183.6,percent of total billed charges,Implant Device,183.6,34,,183.6,percent of total billed charges,Implant Device,189,35,,189,percent of total billed charges,Implant Device,189,35,,189,percent of total billed charges,Implant Device,189,35,,189,percent of total billed charges,Implant Device,189,35,,189,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,399.6,
DJO 307-27-018 2.7X18MM NL SCREW,C1713,HCPCS,,79013794,CDM,278,RC,,,both,,,540,399.6,,,399.6,Other,150% of Medicare + 9.63% HCRA Surcharge,243,45,,243,percent of total billed charges,Critical Access Hospital RCC factor,183.6,34,,183.6,percent of total billed charges,Implant Device,183.6,34,,183.6,percent of total billed charges,Implant Device,183.6,34,,183.6,percent of total billed charges,Implant Device,183.6,34,,183.6,percent of total billed charges,Implant Device,183.6,34,,183.6,percent of total billed charges,Implant Device,267.3,,,267.3,Other,110% of Medicare,189,35,,189,percent of total billed charges,Implant Device,183.6,34,"Charges > $500, x 34%",183.6,percent of total billed charges,Implant Device,189,35,,189,percent of total billed charges,Implant Device,189,35,,189,percent of total billed charges,Implant Device,189,35,,189,percent of total billed charges,Implant Device,189,35,,189,percent of total billed charges,Implant Device,189,35,,189,percent of total billed charges,Implant Device,216,40,,216,percent of total billed charges,Implant Device,189,70,,189,percent of total billed charges,All Other,183.6,34,,183.6,percent of total billed charges,Implant Device,183.6,34,,183.6,percent of total billed charges,Implant Device,189,35,,189,percent of total billed charges,Implant Device,189,35,,189,percent of total billed charges,Implant Device,189,35,,189,percent of total billed charges,Implant Device,189,35,,189,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,399.6,
DJO 308-27-010 2.7X10MM L SCREW,C1713,HCPCS,,79013795,CDM,278,RC,,,both,,,900,666,,,666,Other,150% of Medicare + 9.63% HCRA Surcharge,405,45,,405,percent of total billed charges,Critical Access Hospital RCC factor,306,34,,306,percent of total billed charges,Implant Device,306,34,,306,percent of total billed charges,Implant Device,306,34,,306,percent of total billed charges,Implant Device,306,34,,306,percent of total billed charges,Implant Device,306,34,,306,percent of total billed charges,Implant Device,445.5,,,445.5,Other,110% of Medicare,315,35,,315,percent of total billed charges,Implant Device,306,34,"Charges > $500, x 34%",306,percent of total billed charges,Implant Device,315,35,,315,percent of total billed charges,Implant Device,315,35,,315,percent of total billed charges,Implant Device,315,35,,315,percent of total billed charges,Implant Device,315,35,,315,percent of total billed charges,Implant Device,315,35,,315,percent of total billed charges,Implant Device,360,40,,360,percent of total billed charges,Implant Device,315,70,,315,percent of total billed charges,All Other,306,34,,306,percent of total billed charges,Implant Device,306,34,,306,percent of total billed charges,Implant Device,315,35,,315,percent of total billed charges,Implant Device,315,35,,315,percent of total billed charges,Implant Device,315,35,,315,percent of total billed charges,Implant Device,315,35,,315,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,666,
DJO 307-35-012 3.5X12MM NL SCREW,C1713,HCPCS,,79013796,CDM,278,RC,,,both,,,540,399.6,,,399.6,Other,150% of Medicare + 9.63% HCRA Surcharge,243,45,,243,percent of total billed charges,Critical Access Hospital RCC factor,183.6,34,,183.6,percent of total billed charges,Implant Device,183.6,34,,183.6,percent of total billed charges,Implant Device,183.6,34,,183.6,percent of total billed charges,Implant Device,183.6,34,,183.6,percent of total billed charges,Implant Device,183.6,34,,183.6,percent of total billed charges,Implant Device,267.3,,,267.3,Other,110% of Medicare,189,35,,189,percent of total billed charges,Implant Device,183.6,34,"Charges > $500, x 34%",183.6,percent of total billed charges,Implant Device,189,35,,189,percent of total billed charges,Implant Device,189,35,,189,percent of total billed charges,Implant Device,189,35,,189,percent of total billed charges,Implant Device,189,35,,189,percent of total billed charges,Implant Device,189,35,,189,percent of total billed charges,Implant Device,216,40,,216,percent of total billed charges,Implant Device,189,70,,189,percent of total billed charges,All Other,183.6,34,,183.6,percent of total billed charges,Implant Device,183.6,34,,183.6,percent of total billed charges,Implant Device,189,35,,189,percent of total billed charges,Implant Device,189,35,,189,percent of total billed charges,Implant Device,189,35,,189,percent of total billed charges,Implant Device,189,35,,189,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,399.6,
DJO 307-35-014 3.5X14MM NL SCREW,C1713,HCPCS,,79013797,CDM,278,RC,,,both,,,540,399.6,,,399.6,Other,150% of Medicare + 9.63% HCRA Surcharge,243,45,,243,percent of total billed charges,Critical Access Hospital RCC factor,183.6,34,,183.6,percent of total billed charges,Implant Device,183.6,34,,183.6,percent of total billed charges,Implant Device,183.6,34,,183.6,percent of total billed charges,Implant Device,183.6,34,,183.6,percent of total billed charges,Implant Device,183.6,34,,183.6,percent of total billed charges,Implant Device,267.3,,,267.3,Other,110% of Medicare,189,35,,189,percent of total billed charges,Implant Device,183.6,34,"Charges > $500, x 34%",183.6,percent of total billed charges,Implant Device,189,35,,189,percent of total billed charges,Implant Device,189,35,,189,percent of total billed charges,Implant Device,189,35,,189,percent of total billed charges,Implant Device,189,35,,189,percent of total billed charges,Implant Device,189,35,,189,percent of total billed charges,Implant Device,216,40,,216,percent of total billed charges,Implant Device,189,70,,189,percent of total billed charges,All Other,183.6,34,,183.6,percent of total billed charges,Implant Device,183.6,34,,183.6,percent of total billed charges,Implant Device,189,35,,189,percent of total billed charges,Implant Device,189,35,,189,percent of total billed charges,Implant Device,189,35,,189,percent of total billed charges,Implant Device,189,35,,189,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,399.6,
DJO 300-92-002 FIBULA PLATE 10 HOLE,C1713,HCPCS,,79013798,CDM,278,RC,,,both,,,4797,3549.79,,,3549.79,Other,150% of Medicare + 9.63% HCRA Surcharge,2158.65,45,,2158.65,percent of total billed charges,Critical Access Hospital RCC factor,1630.98,34,,1630.98,percent of total billed charges,Implant Device,1630.98,34,,1630.98,percent of total billed charges,Implant Device,1630.98,34,,1630.98,percent of total billed charges,Implant Device,1630.98,34,,1630.98,percent of total billed charges,Implant Device,1630.98,34,,1630.98,percent of total billed charges,Implant Device,2374.52,,,2374.52,Other,110% of Medicare,1678.95,35,,1678.95,percent of total billed charges,Implant Device,1630.98,34,"Charges > $500, x 34%",1630.98,percent of total billed charges,Implant Device,1678.95,35,,1678.95,percent of total billed charges,Implant Device,1678.95,35,,1678.95,percent of total billed charges,Implant Device,1678.95,35,,1678.95,percent of total billed charges,Implant Device,1678.95,35,,1678.95,percent of total billed charges,Implant Device,1678.95,35,,1678.95,percent of total billed charges,Implant Device,1918.8,40,,1918.8,percent of total billed charges,Implant Device,1678.95,70,,1678.95,percent of total billed charges,All Other,1630.98,34,,1630.98,percent of total billed charges,Implant Device,1630.98,34,,1630.98,percent of total billed charges,Implant Device,1678.95,35,,1678.95,percent of total billed charges,Implant Device,1678.95,35,,1678.95,percent of total billed charges,Implant Device,1678.95,35,,1678.95,percent of total billed charges,Implant Device,1678.95,35,,1678.95,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1630.98,34,"If Charge > 2,000, then 34 percent",1630.98,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3549.79,
STRYKER 8130-1170S TROCH NAIL 1.5X100MM,C1713,HCPCS,,79013799,CDM,278,RC,,,both,,,4797,3549.79,,,3549.79,Other,150% of Medicare + 9.63% HCRA Surcharge,2158.65,45,,2158.65,percent of total billed charges,Critical Access Hospital RCC factor,1630.98,34,,1630.98,percent of total billed charges,Implant Device,1630.98,34,,1630.98,percent of total billed charges,Implant Device,1630.98,34,,1630.98,percent of total billed charges,Implant Device,1630.98,34,,1630.98,percent of total billed charges,Implant Device,1630.98,34,,1630.98,percent of total billed charges,Implant Device,2374.52,,,2374.52,Other,110% of Medicare,1678.95,35,,1678.95,percent of total billed charges,Implant Device,1630.98,34,"Charges > $500, x 34%",1630.98,percent of total billed charges,Implant Device,1678.95,35,,1678.95,percent of total billed charges,Implant Device,1678.95,35,,1678.95,percent of total billed charges,Implant Device,1678.95,35,,1678.95,percent of total billed charges,Implant Device,1678.95,35,,1678.95,percent of total billed charges,Implant Device,1678.95,35,,1678.95,percent of total billed charges,Implant Device,1918.8,40,,1918.8,percent of total billed charges,Implant Device,1678.95,70,,1678.95,percent of total billed charges,All Other,1630.98,34,,1630.98,percent of total billed charges,Implant Device,1630.98,34,,1630.98,percent of total billed charges,Implant Device,1678.95,35,,1678.95,percent of total billed charges,Implant Device,1678.95,35,,1678.95,percent of total billed charges,Implant Device,1678.95,35,,1678.95,percent of total billed charges,Implant Device,1678.95,35,,1678.95,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1630.98,34,"If Charge > 2,000, then 34 percent",1630.98,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3549.79,
LIFENET PCDXL14 CANN REVISION DOWEL 14MM,C1762,HCPCS,,79013801,CDM,278,RC,,,both,,,3443,2547.83,,,2547.83,Other,150% of Medicare + 9.63% HCRA Surcharge,1549.35,45,,1549.35,percent of total billed charges,Critical Access Hospital RCC factor,1170.62,34,,1170.62,percent of total billed charges,Implant Device,1170.62,34,,1170.62,percent of total billed charges,Implant Device,1170.62,34,,1170.62,percent of total billed charges,Implant Device,1170.62,34,,1170.62,percent of total billed charges,Implant Device,1170.62,34,,1170.62,percent of total billed charges,Implant Device,1704.29,,,1704.29,Other,110% of Medicare,1205.05,35,,1205.05,percent of total billed charges,Implant Device,1170.62,34,"Charges > $500, x 34%",1170.62,percent of total billed charges,Implant Device,1205.05,35,,1205.05,percent of total billed charges,Implant Device,1205.05,35,,1205.05,percent of total billed charges,Implant Device,1205.05,35,,1205.05,percent of total billed charges,Implant Device,1205.05,35,,1205.05,percent of total billed charges,Implant Device,1205.05,35,,1205.05,percent of total billed charges,Implant Device,1377.2,40,,1377.2,percent of total billed charges,Implant Device,1205.05,70,,1205.05,percent of total billed charges,All Other,1170.62,34,,1170.62,percent of total billed charges,Implant Device,1170.62,34,,1170.62,percent of total billed charges,Implant Device,1205.05,35,,1205.05,percent of total billed charges,Implant Device,1205.05,35,,1205.05,percent of total billed charges,Implant Device,1205.05,35,,1205.05,percent of total billed charges,Implant Device,1205.05,35,,1205.05,percent of total billed charges,Implant Device,976.07,,,976.07,Other,100% of Medicaid,976.07,,,976.07,Other,100% of Medicaid,976.07,,,976.07,Other,100% of Medicaid,976.07,,,976.07,Other,100% of Medicaid,2196.16,,,2196.16,Other,225% of Medicaid,1493.39,,,1493.39,Other,153% of Medicaid,2196.16,,,2196.16,Other,225% of Medicaid,1366.5,,,1366.5,Other,140% of Medicaid,1170.62,34,"If Charge > 2,000, then 34 percent",1170.62,percent of total billed charges,Implants,2537.78,,,2537.78,Other,260% of Medicaid,3162.47,,,3162.47,Other,324% of Medicaid,2098.55,,,2098.55,Other,215% of Medicaid,2098.55,,,2098.55,Other,215% of Medicaid,1220.09,,,1220.09,Other,125% of Medicaid,976.07,3162.47,
STRYKER 5612-P-511 HINGE INS SZ 5 11MM,C1713,HCPCS,,79013802,CDM,278,RC,,,both,,,11739,8686.89,,,8686.89,Other,150% of Medicare + 9.63% HCRA Surcharge,5282.55,45,,5282.55,percent of total billed charges,Critical Access Hospital RCC factor,3991.26,34,,3991.26,percent of total billed charges,Implant Device,3991.26,34,,3991.26,percent of total billed charges,Implant Device,3991.26,34,,3991.26,percent of total billed charges,Implant Device,3991.26,34,,3991.26,percent of total billed charges,Implant Device,3991.26,34,,3991.26,percent of total billed charges,Implant Device,5810.81,,,5810.81,Other,110% of Medicare,4108.65,35,,4108.65,percent of total billed charges,Implant Device,3991.26,34,"Charges > $500, x 34%",3991.26,percent of total billed charges,Implant Device,4108.65,35,,4108.65,percent of total billed charges,Implant Device,4108.65,35,,4108.65,percent of total billed charges,Implant Device,4108.65,35,,4108.65,percent of total billed charges,Implant Device,4108.65,35,,4108.65,percent of total billed charges,Implant Device,4108.65,35,,4108.65,percent of total billed charges,Implant Device,4695.6,40,,4695.6,percent of total billed charges,Implant Device,4108.65,70,,4108.65,percent of total billed charges,All Other,3991.26,34,,3991.26,percent of total billed charges,Implant Device,3991.26,34,,3991.26,percent of total billed charges,Implant Device,4108.65,35,,4108.65,percent of total billed charges,Implant Device,4108.65,35,,4108.65,percent of total billed charges,Implant Device,4108.65,35,,4108.65,percent of total billed charges,Implant Device,4108.65,35,,4108.65,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3991.26,34,"If Charge > 2,000, then 34 percent",3991.26,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,8686.89,
STRYKER 6495-2-115 GMRS AXLE SMALL,C1776,HCPCS,,79013803,CDM,278,RC,,,both,,,2670,1975.81,,,1975.81,Other,150% of Medicare + 9.63% HCRA Surcharge,1201.5,45,,1201.5,percent of total billed charges,Critical Access Hospital RCC factor,907.8,34,,907.8,percent of total billed charges,Implant Device,907.8,34,,907.8,percent of total billed charges,Implant Device,907.8,34,,907.8,percent of total billed charges,Implant Device,907.8,34,,907.8,percent of total billed charges,Implant Device,907.8,34,,907.8,percent of total billed charges,Implant Device,1321.65,,,1321.65,Other,110% of Medicare,934.5,35,,934.5,percent of total billed charges,Implant Device,907.8,34,"Charges > $500, x 34%",907.8,percent of total billed charges,Implant Device,934.5,35,,934.5,percent of total billed charges,Implant Device,934.5,35,,934.5,percent of total billed charges,Implant Device,934.5,35,,934.5,percent of total billed charges,Implant Device,934.5,35,,934.5,percent of total billed charges,Implant Device,934.5,35,,934.5,percent of total billed charges,Implant Device,1068,40,,1068,percent of total billed charges,Implant Device,934.5,70,,934.5,percent of total billed charges,All Other,907.8,34,,907.8,percent of total billed charges,Implant Device,907.8,34,,907.8,percent of total billed charges,Implant Device,934.5,35,,934.5,percent of total billed charges,Implant Device,934.5,35,,934.5,percent of total billed charges,Implant Device,934.5,35,,934.5,percent of total billed charges,Implant Device,934.5,35,,934.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,907.8,34,"If Charge > 2,000, then 34 percent",907.8,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1975.81,
STRYKER 5612-005 HINGE TIB COMP SZ 5-6,C1713,HCPCS,,79013804,CDM,278,RC,,,both,,,17060,12624.44,,,12624.44,Other,150% of Medicare + 9.63% HCRA Surcharge,7677,45,,7677,percent of total billed charges,Critical Access Hospital RCC factor,5800.4,34,,5800.4,percent of total billed charges,Implant Device,5800.4,34,,5800.4,percent of total billed charges,Implant Device,5800.4,34,,5800.4,percent of total billed charges,Implant Device,5800.4,34,,5800.4,percent of total billed charges,Implant Device,5800.4,34,,5800.4,percent of total billed charges,Implant Device,8444.7,,,8444.7,Other,110% of Medicare,5971,35,,5971,percent of total billed charges,Implant Device,5800.4,34,"Charges > $500, x 34%",5800.4,percent of total billed charges,Implant Device,5971,35,,5971,percent of total billed charges,Implant Device,5971,35,,5971,percent of total billed charges,Implant Device,5971,35,,5971,percent of total billed charges,Implant Device,5971,35,,5971,percent of total billed charges,Implant Device,5971,35,,5971,percent of total billed charges,Implant Device,6824,40,,6824,percent of total billed charges,Implant Device,5971,70,,5971,percent of total billed charges,All Other,5800.4,34,,5800.4,percent of total billed charges,Implant Device,5800.4,34,,5800.4,percent of total billed charges,Implant Device,5971,35,,5971,percent of total billed charges,Implant Device,5971,35,,5971,percent of total billed charges,Implant Device,5971,35,,5971,percent of total billed charges,Implant Device,5971,35,,5971,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,5800.4,34,"If Charge > 2,000, then 34 percent",5800.4,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,12624.44,
STRYKER 5612-4-003 HINGE BUMPER +3 DEG,C1776,HCPCS,,79013805,CDM,278,RC,,,both,,,3263,2414.63,,,2414.63,Other,150% of Medicare + 9.63% HCRA Surcharge,1468.35,45,,1468.35,percent of total billed charges,Critical Access Hospital RCC factor,1109.42,34,,1109.42,percent of total billed charges,Implant Device,1109.42,34,,1109.42,percent of total billed charges,Implant Device,1109.42,34,,1109.42,percent of total billed charges,Implant Device,1109.42,34,,1109.42,percent of total billed charges,Implant Device,1109.42,34,,1109.42,percent of total billed charges,Implant Device,1615.19,,,1615.19,Other,110% of Medicare,1142.05,35,,1142.05,percent of total billed charges,Implant Device,1109.42,34,"Charges > $500, x 34%",1109.42,percent of total billed charges,Implant Device,1142.05,35,,1142.05,percent of total billed charges,Implant Device,1142.05,35,,1142.05,percent of total billed charges,Implant Device,1142.05,35,,1142.05,percent of total billed charges,Implant Device,1142.05,35,,1142.05,percent of total billed charges,Implant Device,1142.05,35,,1142.05,percent of total billed charges,Implant Device,1305.2,40,,1305.2,percent of total billed charges,Implant Device,1142.05,70,,1142.05,percent of total billed charges,All Other,1109.42,34,,1109.42,percent of total billed charges,Implant Device,1109.42,34,,1109.42,percent of total billed charges,Implant Device,1142.05,35,,1142.05,percent of total billed charges,Implant Device,1142.05,35,,1142.05,percent of total billed charges,Implant Device,1142.05,35,,1142.05,percent of total billed charges,Implant Device,1142.05,35,,1142.05,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1109.42,34,"If Charge > 2,000, then 34 percent",1109.42,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2414.63,
STRYKER 5612-B-500 REV TIB BASEPLT SZ 5,C1776,HCPCS,,79013806,CDM,278,RC,,,both,,,15530,11492.24,,,11492.24,Other,150% of Medicare + 9.63% HCRA Surcharge,6988.5,45,,6988.5,percent of total billed charges,Critical Access Hospital RCC factor,5280.2,34,,5280.2,percent of total billed charges,Implant Device,5280.2,34,,5280.2,percent of total billed charges,Implant Device,5280.2,34,,5280.2,percent of total billed charges,Implant Device,5280.2,34,,5280.2,percent of total billed charges,Implant Device,5280.2,34,,5280.2,percent of total billed charges,Implant Device,7687.35,,,7687.35,Other,110% of Medicare,5435.5,35,,5435.5,percent of total billed charges,Implant Device,5280.2,34,"Charges > $500, x 34%",5280.2,percent of total billed charges,Implant Device,5435.5,35,,5435.5,percent of total billed charges,Implant Device,5435.5,35,,5435.5,percent of total billed charges,Implant Device,5435.5,35,,5435.5,percent of total billed charges,Implant Device,5435.5,35,,5435.5,percent of total billed charges,Implant Device,5435.5,35,,5435.5,percent of total billed charges,Implant Device,6212,40,,6212,percent of total billed charges,Implant Device,5435.5,70,,5435.5,percent of total billed charges,All Other,5280.2,34,,5280.2,percent of total billed charges,Implant Device,5280.2,34,,5280.2,percent of total billed charges,Implant Device,5435.5,35,,5435.5,percent of total billed charges,Implant Device,5435.5,35,,5435.5,percent of total billed charges,Implant Device,5435.5,35,,5435.5,percent of total billed charges,Implant Device,5435.5,35,,5435.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,5280.2,34,"If Charge > 2,000, then 34 percent",5280.2,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,11492.24,
DJO 200-30-036 TIGER SCREW 3.0X36MM,C1713,HCPCS,,79013807,CDM,278,RC,,,both,,,495,366.3,,,366.3,Other,150% of Medicare + 9.63% HCRA Surcharge,222.75,45,,222.75,percent of total billed charges,Critical Access Hospital RCC factor,168.3,34,,168.3,percent of total billed charges,Implant Device,168.3,34,,168.3,percent of total billed charges,Implant Device,168.3,34,,168.3,percent of total billed charges,Implant Device,168.3,34,,168.3,percent of total billed charges,Implant Device,168.3,34,,168.3,percent of total billed charges,Implant Device,245.03,,,245.03,Other,110% of Medicare,173.25,35,,173.25,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,173.25,35,,173.25,percent of total billed charges,Implant Device,173.25,35,,173.25,percent of total billed charges,Implant Device,173.25,35,,173.25,percent of total billed charges,Implant Device,173.25,35,,173.25,percent of total billed charges,Implant Device,173.25,35,,173.25,percent of total billed charges,Implant Device,198,40,,198,percent of total billed charges,Implant Device,173.25,70,,173.25,percent of total billed charges,All Other,168.3,34,,168.3,percent of total billed charges,Implant Device,168.3,34,,168.3,percent of total billed charges,Implant Device,173.25,35,,173.25,percent of total billed charges,Implant Device,173.25,35,,173.25,percent of total billed charges,Implant Device,173.25,35,,173.25,percent of total billed charges,Implant Device,173.25,35,,173.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,366.3,
DJO 200-40-034 TIGER SCREW 4.0X34MM,C1713,HCPCS,,79013808,CDM,278,RC,,,both,,,495,366.3,,,366.3,Other,150% of Medicare + 9.63% HCRA Surcharge,222.75,45,,222.75,percent of total billed charges,Critical Access Hospital RCC factor,168.3,34,,168.3,percent of total billed charges,Implant Device,168.3,34,,168.3,percent of total billed charges,Implant Device,168.3,34,,168.3,percent of total billed charges,Implant Device,168.3,34,,168.3,percent of total billed charges,Implant Device,168.3,34,,168.3,percent of total billed charges,Implant Device,245.03,,,245.03,Other,110% of Medicare,173.25,35,,173.25,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,173.25,35,,173.25,percent of total billed charges,Implant Device,173.25,35,,173.25,percent of total billed charges,Implant Device,173.25,35,,173.25,percent of total billed charges,Implant Device,173.25,35,,173.25,percent of total billed charges,Implant Device,173.25,35,,173.25,percent of total billed charges,Implant Device,198,40,,198,percent of total billed charges,Implant Device,173.25,70,,173.25,percent of total billed charges,All Other,168.3,34,,168.3,percent of total billed charges,Implant Device,168.3,34,,168.3,percent of total billed charges,Implant Device,173.25,35,,173.25,percent of total billed charges,Implant Device,173.25,35,,173.25,percent of total billed charges,Implant Device,173.25,35,,173.25,percent of total billed charges,Implant Device,173.25,35,,173.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,366.3,
STRYKER 5531-G-711-E TIB BEAR INS 11MM,C1776,HCPCS,,79013810,CDM,278,RC,,,both,,,2781,2057.95,,,2057.95,Other,150% of Medicare + 9.63% HCRA Surcharge,1251.45,45,,1251.45,percent of total billed charges,Critical Access Hospital RCC factor,945.54,34,,945.54,percent of total billed charges,Implant Device,945.54,34,,945.54,percent of total billed charges,Implant Device,945.54,34,,945.54,percent of total billed charges,Implant Device,945.54,34,,945.54,percent of total billed charges,Implant Device,945.54,34,,945.54,percent of total billed charges,Implant Device,1376.6,,,1376.6,Other,110% of Medicare,973.35,35,,973.35,percent of total billed charges,Implant Device,945.54,34,"Charges > $500, x 34%",945.54,percent of total billed charges,Implant Device,973.35,35,,973.35,percent of total billed charges,Implant Device,973.35,35,,973.35,percent of total billed charges,Implant Device,973.35,35,,973.35,percent of total billed charges,Implant Device,973.35,35,,973.35,percent of total billed charges,Implant Device,973.35,35,,973.35,percent of total billed charges,Implant Device,1112.4,40,,1112.4,percent of total billed charges,Implant Device,973.35,70,,973.35,percent of total billed charges,All Other,945.54,34,,945.54,percent of total billed charges,Implant Device,945.54,34,,945.54,percent of total billed charges,Implant Device,973.35,35,,973.35,percent of total billed charges,Implant Device,973.35,35,,973.35,percent of total billed charges,Implant Device,973.35,35,,973.35,percent of total billed charges,Implant Device,973.35,35,,973.35,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,945.54,34,"If Charge > 2,000, then 34 percent",945.54,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2057.95,
EXACTECH 312-01-44 RESURFACING HUM HEAD,C1776,HCPCS,,79013811,CDM,278,RC,,,both,,,9240,6837.62,,,6837.62,Other,150% of Medicare + 9.63% HCRA Surcharge,4158,45,,4158,percent of total billed charges,Critical Access Hospital RCC factor,3141.6,34,,3141.6,percent of total billed charges,Implant Device,3141.6,34,,3141.6,percent of total billed charges,Implant Device,3141.6,34,,3141.6,percent of total billed charges,Implant Device,3141.6,34,,3141.6,percent of total billed charges,Implant Device,3141.6,34,,3141.6,percent of total billed charges,Implant Device,4573.8,,,4573.8,Other,110% of Medicare,3234,35,,3234,percent of total billed charges,Implant Device,3141.6,34,"Charges > $500, x 34%",3141.6,percent of total billed charges,Implant Device,3234,35,,3234,percent of total billed charges,Implant Device,3234,35,,3234,percent of total billed charges,Implant Device,3234,35,,3234,percent of total billed charges,Implant Device,3234,35,,3234,percent of total billed charges,Implant Device,3234,35,,3234,percent of total billed charges,Implant Device,3696,40,,3696,percent of total billed charges,Implant Device,3234,70,,3234,percent of total billed charges,All Other,3141.6,34,,3141.6,percent of total billed charges,Implant Device,3141.6,34,,3141.6,percent of total billed charges,Implant Device,3234,35,,3234,percent of total billed charges,Implant Device,3234,35,,3234,percent of total billed charges,Implant Device,3234,35,,3234,percent of total billed charges,Implant Device,3234,35,,3234,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3141.6,34,"If Charge > 2,000, then 34 percent",3141.6,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,6837.62,
EXACTECH 312-01-01 RESURFACING CAGE 25MM,C1776,HCPCS,,79013812,CDM,278,RC,,,both,,,1665,1232.1,,,1232.1,Other,150% of Medicare + 9.63% HCRA Surcharge,749.25,45,,749.25,percent of total billed charges,Critical Access Hospital RCC factor,566.1,34,,566.1,percent of total billed charges,Implant Device,566.1,34,,566.1,percent of total billed charges,Implant Device,566.1,34,,566.1,percent of total billed charges,Implant Device,566.1,34,,566.1,percent of total billed charges,Implant Device,566.1,34,,566.1,percent of total billed charges,Implant Device,824.18,,,824.18,Other,110% of Medicare,582.75,35,,582.75,percent of total billed charges,Implant Device,566.1,34,"Charges > $500, x 34%",566.1,percent of total billed charges,Implant Device,582.75,35,,582.75,percent of total billed charges,Implant Device,582.75,35,,582.75,percent of total billed charges,Implant Device,582.75,35,,582.75,percent of total billed charges,Implant Device,582.75,35,,582.75,percent of total billed charges,Implant Device,582.75,35,,582.75,percent of total billed charges,Implant Device,666,40,,666,percent of total billed charges,Implant Device,582.75,70,,582.75,percent of total billed charges,All Other,566.1,34,,566.1,percent of total billed charges,Implant Device,566.1,34,,566.1,percent of total billed charges,Implant Device,582.75,35,,582.75,percent of total billed charges,Implant Device,582.75,35,,582.75,percent of total billed charges,Implant Device,582.75,35,,582.75,percent of total billed charges,Implant Device,582.75,35,,582.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1232.1,
EXACTECH 313-35-00 K WIRE 3X250MM,C1713,HCPCS,,79013813,CDM,278,RC,,,both,,,150,111,,,111,Other,150% of Medicare + 9.63% HCRA Surcharge,67.5,45,,67.5,percent of total billed charges,Critical Access Hospital RCC factor,51,34,,51,percent of total billed charges,Implant Device,51,34,,51,percent of total billed charges,Implant Device,51,34,,51,percent of total billed charges,Implant Device,51,34,,51,percent of total billed charges,Implant Device,51,34,,51,percent of total billed charges,Implant Device,74.25,,,74.25,Other,110% of Medicare,52.5,35,,52.5,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,52.5,35,,52.5,percent of total billed charges,Implant Device,52.5,35,,52.5,percent of total billed charges,Implant Device,52.5,35,,52.5,percent of total billed charges,Implant Device,52.5,35,,52.5,percent of total billed charges,Implant Device,52.5,35,,52.5,percent of total billed charges,Implant Device,60,40,,60,percent of total billed charges,Implant Device,52.5,70,,52.5,percent of total billed charges,All Other,51,34,,51,percent of total billed charges,Implant Device,51,34,,51,percent of total billed charges,Implant Device,52.5,35,,52.5,percent of total billed charges,Implant Device,52.5,35,,52.5,percent of total billed charges,Implant Device,52.5,35,,52.5,percent of total billed charges,Implant Device,52.5,35,,52.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,111,
DAVOL 5950040 VENTRIO ST HERNIA PATCH,C1781,HCPCS,,79013814,CDM,278,RC,,,both,,,2671,1976.55,,,1976.55,Other,150% of Medicare + 9.63% HCRA Surcharge,1201.95,45,,1201.95,percent of total billed charges,Critical Access Hospital RCC factor,908.14,34,,908.14,percent of total billed charges,Implant Device,908.14,34,,908.14,percent of total billed charges,Implant Device,908.14,34,,908.14,percent of total billed charges,Implant Device,908.14,34,,908.14,percent of total billed charges,Implant Device,908.14,34,,908.14,percent of total billed charges,Implant Device,1322.15,,,1322.15,Other,110% of Medicare,934.85,35,,934.85,percent of total billed charges,Implant Device,908.14,34,"Charges > $500, x 34%",908.14,percent of total billed charges,Implant Device,934.85,35,,934.85,percent of total billed charges,Implant Device,934.85,35,,934.85,percent of total billed charges,Implant Device,934.85,35,,934.85,percent of total billed charges,Implant Device,934.85,35,,934.85,percent of total billed charges,Implant Device,934.85,35,,934.85,percent of total billed charges,Implant Device,1068.4,40,,1068.4,percent of total billed charges,Implant Device,934.85,70,,934.85,percent of total billed charges,All Other,908.14,34,,908.14,percent of total billed charges,Implant Device,908.14,34,,908.14,percent of total billed charges,Implant Device,934.85,35,,934.85,percent of total billed charges,Implant Device,934.85,35,,934.85,percent of total billed charges,Implant Device,934.85,35,,934.85,percent of total billed charges,Implant Device,934.85,35,,934.85,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,908.14,34,"If Charge > 2,000, then 34 percent",908.14,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1976.55,
J&J 1504-10-209 ATTUNE FEMORAL SIZE 9,C1776,HCPCS,,79013815,CDM,278,RC,,,both,,,4800,3552.01,,,3552.01,Other,150% of Medicare + 9.63% HCRA Surcharge,2160,45,,2160,percent of total billed charges,Critical Access Hospital RCC factor,1632,34,,1632,percent of total billed charges,Implant Device,1632,34,,1632,percent of total billed charges,Implant Device,1632,34,,1632,percent of total billed charges,Implant Device,1632,34,,1632,percent of total billed charges,Implant Device,1632,34,,1632,percent of total billed charges,Implant Device,2376,,,2376,Other,110% of Medicare,1680,35,,1680,percent of total billed charges,Implant Device,1632,34,"Charges > $500, x 34%",1632,percent of total billed charges,Implant Device,1680,35,,1680,percent of total billed charges,Implant Device,1680,35,,1680,percent of total billed charges,Implant Device,1680,35,,1680,percent of total billed charges,Implant Device,1680,35,,1680,percent of total billed charges,Implant Device,1680,35,,1680,percent of total billed charges,Implant Device,1920,40,,1920,percent of total billed charges,Implant Device,1680,70,,1680,percent of total billed charges,All Other,1632,34,,1632,percent of total billed charges,Implant Device,1632,34,,1632,percent of total billed charges,Implant Device,1680,35,,1680,percent of total billed charges,Implant Device,1680,35,,1680,percent of total billed charges,Implant Device,1680,35,,1680,percent of total billed charges,Implant Device,1680,35,,1680,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1632,34,"If Charge > 2,000, then 34 percent",1632,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3552.01,
J&J 1506-80-009 ATTUNE TIBIAL BASE SZ 9,C1776,HCPCS,,79013816,CDM,278,RC,,,both,,,3900,2886.01,,,2886.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1755,45,,1755,percent of total billed charges,Critical Access Hospital RCC factor,1326,34,,1326,percent of total billed charges,Implant Device,1326,34,,1326,percent of total billed charges,Implant Device,1326,34,,1326,percent of total billed charges,Implant Device,1326,34,,1326,percent of total billed charges,Implant Device,1326,34,,1326,percent of total billed charges,Implant Device,1930.5,,,1930.5,Other,110% of Medicare,1365,35,,1365,percent of total billed charges,Implant Device,1326,34,"Charges > $500, x 34%",1326,percent of total billed charges,Implant Device,1365,35,,1365,percent of total billed charges,Implant Device,1365,35,,1365,percent of total billed charges,Implant Device,1365,35,,1365,percent of total billed charges,Implant Device,1365,35,,1365,percent of total billed charges,Implant Device,1365,35,,1365,percent of total billed charges,Implant Device,1560,40,,1560,percent of total billed charges,Implant Device,1365,70,,1365,percent of total billed charges,All Other,1326,34,,1326,percent of total billed charges,Implant Device,1326,34,,1326,percent of total billed charges,Implant Device,1365,35,,1365,percent of total billed charges,Implant Device,1365,35,,1365,percent of total billed charges,Implant Device,1365,35,,1365,percent of total billed charges,Implant Device,1365,35,,1365,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1326,34,"If Charge > 2,000, then 34 percent",1326,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2886.01,
J&J 1010-12-020 FEMORAL STEM SIZE 2,C1776,HCPCS,,79013820,CDM,278,RC,,,both,,,7410,5483.42,,,5483.42,Other,150% of Medicare + 9.63% HCRA Surcharge,3334.5,45,,3334.5,percent of total billed charges,Critical Access Hospital RCC factor,2519.4,34,,2519.4,percent of total billed charges,Implant Device,2519.4,34,,2519.4,percent of total billed charges,Implant Device,2519.4,34,,2519.4,percent of total billed charges,Implant Device,2519.4,34,,2519.4,percent of total billed charges,Implant Device,2519.4,34,,2519.4,percent of total billed charges,Implant Device,3667.95,,,3667.95,Other,110% of Medicare,2593.5,35,,2593.5,percent of total billed charges,Implant Device,2519.4,34,"Charges > $500, x 34%",2519.4,percent of total billed charges,Implant Device,2593.5,35,,2593.5,percent of total billed charges,Implant Device,2593.5,35,,2593.5,percent of total billed charges,Implant Device,2593.5,35,,2593.5,percent of total billed charges,Implant Device,2593.5,35,,2593.5,percent of total billed charges,Implant Device,2593.5,35,,2593.5,percent of total billed charges,Implant Device,2964,40,,2964,percent of total billed charges,Implant Device,2593.5,70,,2593.5,percent of total billed charges,All Other,2519.4,34,,2519.4,percent of total billed charges,Implant Device,2519.4,34,,2519.4,percent of total billed charges,Implant Device,2593.5,35,,2593.5,percent of total billed charges,Implant Device,2593.5,35,,2593.5,percent of total billed charges,Implant Device,2593.5,35,,2593.5,percent of total billed charges,Implant Device,2593.5,35,,2593.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2519.4,34,"If Charge > 2,000, then 34 percent",2519.4,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5483.42,
STRYKER 8130-0170S TROCH NAIL 10X170MM,C1713,HCPCS,,79013823,CDM,278,RC,,,both,,,4797,3549.79,,,3549.79,Other,150% of Medicare + 9.63% HCRA Surcharge,2158.65,45,,2158.65,percent of total billed charges,Critical Access Hospital RCC factor,1630.98,34,,1630.98,percent of total billed charges,Implant Device,1630.98,34,,1630.98,percent of total billed charges,Implant Device,1630.98,34,,1630.98,percent of total billed charges,Implant Device,1630.98,34,,1630.98,percent of total billed charges,Implant Device,1630.98,34,,1630.98,percent of total billed charges,Implant Device,2374.52,,,2374.52,Other,110% of Medicare,1678.95,35,,1678.95,percent of total billed charges,Implant Device,1630.98,34,"Charges > $500, x 34%",1630.98,percent of total billed charges,Implant Device,1678.95,35,,1678.95,percent of total billed charges,Implant Device,1678.95,35,,1678.95,percent of total billed charges,Implant Device,1678.95,35,,1678.95,percent of total billed charges,Implant Device,1678.95,35,,1678.95,percent of total billed charges,Implant Device,1678.95,35,,1678.95,percent of total billed charges,Implant Device,1918.8,40,,1918.8,percent of total billed charges,Implant Device,1678.95,70,,1678.95,percent of total billed charges,All Other,1630.98,34,,1630.98,percent of total billed charges,Implant Device,1630.98,34,,1630.98,percent of total billed charges,Implant Device,1678.95,35,,1678.95,percent of total billed charges,Implant Device,1678.95,35,,1678.95,percent of total billed charges,Implant Device,1678.95,35,,1678.95,percent of total billed charges,Implant Device,1678.95,35,,1678.95,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1630.98,34,"If Charge > 2,000, then 34 percent",1630.98,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3549.79,
STRYKER 8160-0110S LAG SCREW 10.5X110MM,C1713,HCPCS,,79013824,CDM,278,RC,,,both,,,1777,1314.98,,,1314.98,Other,150% of Medicare + 9.63% HCRA Surcharge,799.65,45,,799.65,percent of total billed charges,Critical Access Hospital RCC factor,604.18,34,,604.18,percent of total billed charges,Implant Device,604.18,34,,604.18,percent of total billed charges,Implant Device,604.18,34,,604.18,percent of total billed charges,Implant Device,604.18,34,,604.18,percent of total billed charges,Implant Device,604.18,34,,604.18,percent of total billed charges,Implant Device,879.62,,,879.62,Other,110% of Medicare,621.95,35,,621.95,percent of total billed charges,Implant Device,604.18,34,"Charges > $500, x 34%",604.18,percent of total billed charges,Implant Device,621.95,35,,621.95,percent of total billed charges,Implant Device,621.95,35,,621.95,percent of total billed charges,Implant Device,621.95,35,,621.95,percent of total billed charges,Implant Device,621.95,35,,621.95,percent of total billed charges,Implant Device,621.95,35,,621.95,percent of total billed charges,Implant Device,710.8,40,,710.8,percent of total billed charges,Implant Device,621.95,70,,621.95,percent of total billed charges,All Other,604.18,34,,604.18,percent of total billed charges,Implant Device,604.18,34,,604.18,percent of total billed charges,Implant Device,621.95,35,,621.95,percent of total billed charges,Implant Device,621.95,35,,621.95,percent of total billed charges,Implant Device,621.95,35,,621.95,percent of total billed charges,Implant Device,621.95,35,,621.95,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1314.98,
ZIMMER 42-5121-008-11 ART SURF LT 11MM,C1776,HCPCS,,79013825,CDM,278,RC,,,both,,,4116,3045.85,,,3045.85,Other,150% of Medicare + 9.63% HCRA Surcharge,1852.2,45,,1852.2,percent of total billed charges,Critical Access Hospital RCC factor,1399.44,34,,1399.44,percent of total billed charges,Implant Device,1399.44,34,,1399.44,percent of total billed charges,Implant Device,1399.44,34,,1399.44,percent of total billed charges,Implant Device,1399.44,34,,1399.44,percent of total billed charges,Implant Device,1399.44,34,,1399.44,percent of total billed charges,Implant Device,2037.42,,,2037.42,Other,110% of Medicare,1440.6,35,,1440.6,percent of total billed charges,Implant Device,1399.44,34,"Charges > $500, x 34%",1399.44,percent of total billed charges,Implant Device,1440.6,35,,1440.6,percent of total billed charges,Implant Device,1440.6,35,,1440.6,percent of total billed charges,Implant Device,1440.6,35,,1440.6,percent of total billed charges,Implant Device,1440.6,35,,1440.6,percent of total billed charges,Implant Device,1440.6,35,,1440.6,percent of total billed charges,Implant Device,1646.4,40,,1646.4,percent of total billed charges,Implant Device,1440.6,70,,1440.6,percent of total billed charges,All Other,1399.44,34,,1399.44,percent of total billed charges,Implant Device,1399.44,34,,1399.44,percent of total billed charges,Implant Device,1440.6,35,,1440.6,percent of total billed charges,Implant Device,1440.6,35,,1440.6,percent of total billed charges,Implant Device,1440.6,35,,1440.6,percent of total billed charges,Implant Device,1440.6,35,,1440.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1399.44,34,"If Charge > 2,000, then 34 percent",1399.44,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3045.85,
AMERISOURCE 10263069 BARRIGEL PROC PACK,C1889,HCPCS,,79013826,CDM,278,RC,,,both,,,10050,7437.03,,,7437.03,Other,150% of Medicare + 9.63% HCRA Surcharge,4522.5,45,,4522.5,percent of total billed charges,Critical Access Hospital RCC factor,3417,34,,3417,percent of total billed charges,Implant Device,3417,34,,3417,percent of total billed charges,Implant Device,3417,34,,3417,percent of total billed charges,Implant Device,3417,34,,3417,percent of total billed charges,Implant Device,3417,34,,3417,percent of total billed charges,Implant Device,4974.75,,,4974.75,Other,110% of Medicare,3517.5,35,,3517.5,percent of total billed charges,Implant Device,3417,34,"Charges > $500, x 34%",3417,percent of total billed charges,Implant Device,3517.5,35,,3517.5,percent of total billed charges,Implant Device,3517.5,35,,3517.5,percent of total billed charges,Implant Device,3517.5,35,,3517.5,percent of total billed charges,Implant Device,3517.5,35,,3517.5,percent of total billed charges,Implant Device,3517.5,35,,3517.5,percent of total billed charges,Implant Device,4020,40,,4020,percent of total billed charges,Implant Device,3517.5,70,,3517.5,percent of total billed charges,All Other,3417,34,,3417,percent of total billed charges,Implant Device,3417,34,,3417,percent of total billed charges,Implant Device,3517.5,35,,3517.5,percent of total billed charges,Implant Device,3517.5,35,,3517.5,percent of total billed charges,Implant Device,3517.5,35,,3517.5,percent of total billed charges,Implant Device,3517.5,35,,3517.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3417,34,"If Charge > 2,000, then 34 percent",3417,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,7437.03,
ZIMMER 42-5121-007-13 ART SURF LT 13MM,C1776,HCPCS,,79013827,CDM,278,RC,,,both,,,4116,3045.85,,,3045.85,Other,150% of Medicare + 9.63% HCRA Surcharge,1852.2,45,,1852.2,percent of total billed charges,Critical Access Hospital RCC factor,1399.44,34,,1399.44,percent of total billed charges,Implant Device,1399.44,34,,1399.44,percent of total billed charges,Implant Device,1399.44,34,,1399.44,percent of total billed charges,Implant Device,1399.44,34,,1399.44,percent of total billed charges,Implant Device,1399.44,34,,1399.44,percent of total billed charges,Implant Device,2037.42,,,2037.42,Other,110% of Medicare,1440.6,35,,1440.6,percent of total billed charges,Implant Device,1399.44,34,"Charges > $500, x 34%",1399.44,percent of total billed charges,Implant Device,1440.6,35,,1440.6,percent of total billed charges,Implant Device,1440.6,35,,1440.6,percent of total billed charges,Implant Device,1440.6,35,,1440.6,percent of total billed charges,Implant Device,1440.6,35,,1440.6,percent of total billed charges,Implant Device,1440.6,35,,1440.6,percent of total billed charges,Implant Device,1646.4,40,,1646.4,percent of total billed charges,Implant Device,1440.6,70,,1440.6,percent of total billed charges,All Other,1399.44,34,,1399.44,percent of total billed charges,Implant Device,1399.44,34,,1399.44,percent of total billed charges,Implant Device,1440.6,35,,1440.6,percent of total billed charges,Implant Device,1440.6,35,,1440.6,percent of total billed charges,Implant Device,1440.6,35,,1440.6,percent of total billed charges,Implant Device,1440.6,35,,1440.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1399.44,34,"If Charge > 2,000, then 34 percent",1399.44,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3045.85,
ZIMMER 42-5121-007-16 ART SURF LT 16MM,C1776,HCPCS,,79013828,CDM,278,RC,,,both,,,4116,3045.85,,,3045.85,Other,150% of Medicare + 9.63% HCRA Surcharge,1852.2,45,,1852.2,percent of total billed charges,Critical Access Hospital RCC factor,1399.44,34,,1399.44,percent of total billed charges,Implant Device,1399.44,34,,1399.44,percent of total billed charges,Implant Device,1399.44,34,,1399.44,percent of total billed charges,Implant Device,1399.44,34,,1399.44,percent of total billed charges,Implant Device,1399.44,34,,1399.44,percent of total billed charges,Implant Device,2037.42,,,2037.42,Other,110% of Medicare,1440.6,35,,1440.6,percent of total billed charges,Implant Device,1399.44,34,"Charges > $500, x 34%",1399.44,percent of total billed charges,Implant Device,1440.6,35,,1440.6,percent of total billed charges,Implant Device,1440.6,35,,1440.6,percent of total billed charges,Implant Device,1440.6,35,,1440.6,percent of total billed charges,Implant Device,1440.6,35,,1440.6,percent of total billed charges,Implant Device,1440.6,35,,1440.6,percent of total billed charges,Implant Device,1646.4,40,,1646.4,percent of total billed charges,Implant Device,1440.6,70,,1440.6,percent of total billed charges,All Other,1399.44,34,,1399.44,percent of total billed charges,Implant Device,1399.44,34,,1399.44,percent of total billed charges,Implant Device,1440.6,35,,1440.6,percent of total billed charges,Implant Device,1440.6,35,,1440.6,percent of total billed charges,Implant Device,1440.6,35,,1440.6,percent of total billed charges,Implant Device,1440.6,35,,1440.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1399.44,34,"If Charge > 2,000, then 34 percent",1399.44,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3045.85,
ARTHREX AR-1288QIS-110 4.75 SWIVELOCK,C1713,HCPCS,,79013829,CDM,278,RC,,,both,,,1529,1131.46,,,1131.46,Other,150% of Medicare + 9.63% HCRA Surcharge,688.05,45,,688.05,percent of total billed charges,Critical Access Hospital RCC factor,519.86,34,,519.86,percent of total billed charges,Implant Device,519.86,34,,519.86,percent of total billed charges,Implant Device,519.86,34,,519.86,percent of total billed charges,Implant Device,519.86,34,,519.86,percent of total billed charges,Implant Device,519.86,34,,519.86,percent of total billed charges,Implant Device,756.86,,,756.86,Other,110% of Medicare,535.15,35,,535.15,percent of total billed charges,Implant Device,519.86,34,"Charges > $500, x 34%",519.86,percent of total billed charges,Implant Device,535.15,35,,535.15,percent of total billed charges,Implant Device,535.15,35,,535.15,percent of total billed charges,Implant Device,535.15,35,,535.15,percent of total billed charges,Implant Device,535.15,35,,535.15,percent of total billed charges,Implant Device,535.15,35,,535.15,percent of total billed charges,Implant Device,611.6,40,,611.6,percent of total billed charges,Implant Device,535.15,70,,535.15,percent of total billed charges,All Other,519.86,34,,519.86,percent of total billed charges,Implant Device,519.86,34,,519.86,percent of total billed charges,Implant Device,535.15,35,,535.15,percent of total billed charges,Implant Device,535.15,35,,535.15,percent of total billed charges,Implant Device,535.15,35,,535.15,percent of total billed charges,Implant Device,535.15,35,,535.15,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1131.46,
ARTHREX AR-2600FSB-2 2.6 SPEEDBRIDGE,C1713,HCPCS,,79013830,CDM,278,RC,,,both,,,9019,6674.08,,,6674.08,Other,150% of Medicare + 9.63% HCRA Surcharge,4058.55,45,,4058.55,percent of total billed charges,Critical Access Hospital RCC factor,3066.46,34,,3066.46,percent of total billed charges,Implant Device,3066.46,34,,3066.46,percent of total billed charges,Implant Device,3066.46,34,,3066.46,percent of total billed charges,Implant Device,3066.46,34,,3066.46,percent of total billed charges,Implant Device,3066.46,34,,3066.46,percent of total billed charges,Implant Device,4464.41,,,4464.41,Other,110% of Medicare,3156.65,35,,3156.65,percent of total billed charges,Implant Device,3066.46,34,"Charges > $500, x 34%",3066.46,percent of total billed charges,Implant Device,3156.65,35,,3156.65,percent of total billed charges,Implant Device,3156.65,35,,3156.65,percent of total billed charges,Implant Device,3156.65,35,,3156.65,percent of total billed charges,Implant Device,3156.65,35,,3156.65,percent of total billed charges,Implant Device,3156.65,35,,3156.65,percent of total billed charges,Implant Device,3607.6,40,,3607.6,percent of total billed charges,Implant Device,3156.65,70,,3156.65,percent of total billed charges,All Other,3066.46,34,,3066.46,percent of total billed charges,Implant Device,3066.46,34,,3066.46,percent of total billed charges,Implant Device,3156.65,35,,3156.65,percent of total billed charges,Implant Device,3156.65,35,,3156.65,percent of total billed charges,Implant Device,3156.65,35,,3156.65,percent of total billed charges,Implant Device,3156.65,35,,3156.65,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3066.46,34,"If Charge > 2,000, then 34 percent",3066.46,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,6674.08,
J&J 1010-12-070 FEM STEM 12.14 TAP SZ 7,C1776,HCPCS,,79013831,CDM,278,RC,,,both,,,7410,5483.42,,,5483.42,Other,150% of Medicare + 9.63% HCRA Surcharge,3334.5,45,,3334.5,percent of total billed charges,Critical Access Hospital RCC factor,2519.4,34,,2519.4,percent of total billed charges,Implant Device,2519.4,34,,2519.4,percent of total billed charges,Implant Device,2519.4,34,,2519.4,percent of total billed charges,Implant Device,2519.4,34,,2519.4,percent of total billed charges,Implant Device,2519.4,34,,2519.4,percent of total billed charges,Implant Device,3667.95,,,3667.95,Other,110% of Medicare,2593.5,35,,2593.5,percent of total billed charges,Implant Device,2519.4,34,"Charges > $500, x 34%",2519.4,percent of total billed charges,Implant Device,2593.5,35,,2593.5,percent of total billed charges,Implant Device,2593.5,35,,2593.5,percent of total billed charges,Implant Device,2593.5,35,,2593.5,percent of total billed charges,Implant Device,2593.5,35,,2593.5,percent of total billed charges,Implant Device,2593.5,35,,2593.5,percent of total billed charges,Implant Device,2964,40,,2964,percent of total billed charges,Implant Device,2593.5,70,,2593.5,percent of total billed charges,All Other,2519.4,34,,2519.4,percent of total billed charges,Implant Device,2519.4,34,,2519.4,percent of total billed charges,Implant Device,2593.5,35,,2593.5,percent of total billed charges,Implant Device,2593.5,35,,2593.5,percent of total billed charges,Implant Device,2593.5,35,,2593.5,percent of total billed charges,Implant Device,2593.5,35,,2593.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2519.4,34,"If Charge > 2,000, then 34 percent",2519.4,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5483.42,
J&J 136540730 FEMORAL HEAD 40MM +8.5,C1776,HCPCS,,79013832,CDM,278,RC,,,both,,,2636,1950.65,,,1950.65,Other,150% of Medicare + 9.63% HCRA Surcharge,1186.2,45,,1186.2,percent of total billed charges,Critical Access Hospital RCC factor,896.24,34,,896.24,percent of total billed charges,Implant Device,896.24,34,,896.24,percent of total billed charges,Implant Device,896.24,34,,896.24,percent of total billed charges,Implant Device,896.24,34,,896.24,percent of total billed charges,Implant Device,896.24,34,,896.24,percent of total billed charges,Implant Device,1304.82,,,1304.82,Other,110% of Medicare,922.6,35,,922.6,percent of total billed charges,Implant Device,896.24,34,"Charges > $500, x 34%",896.24,percent of total billed charges,Implant Device,922.6,35,,922.6,percent of total billed charges,Implant Device,922.6,35,,922.6,percent of total billed charges,Implant Device,922.6,35,,922.6,percent of total billed charges,Implant Device,922.6,35,,922.6,percent of total billed charges,Implant Device,922.6,35,,922.6,percent of total billed charges,Implant Device,1054.4,40,,1054.4,percent of total billed charges,Implant Device,922.6,70,,922.6,percent of total billed charges,All Other,896.24,34,,896.24,percent of total billed charges,Implant Device,896.24,34,,896.24,percent of total billed charges,Implant Device,922.6,35,,922.6,percent of total billed charges,Implant Device,922.6,35,,922.6,percent of total billed charges,Implant Device,922.6,35,,922.6,percent of total billed charges,Implant Device,922.6,35,,922.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,896.24,34,"If Charge > 2,000, then 34 percent",896.24,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1950.65,
J&J 1010-12-110 FEM STEM 12/14 TAP SZ 11,C1776,HCPCS,,79013833,CDM,278,RC,,,both,,,7410,5483.42,,,5483.42,Other,150% of Medicare + 9.63% HCRA Surcharge,3334.5,45,,3334.5,percent of total billed charges,Critical Access Hospital RCC factor,2519.4,34,,2519.4,percent of total billed charges,Implant Device,2519.4,34,,2519.4,percent of total billed charges,Implant Device,2519.4,34,,2519.4,percent of total billed charges,Implant Device,2519.4,34,,2519.4,percent of total billed charges,Implant Device,2519.4,34,,2519.4,percent of total billed charges,Implant Device,3667.95,,,3667.95,Other,110% of Medicare,2593.5,35,,2593.5,percent of total billed charges,Implant Device,2519.4,34,"Charges > $500, x 34%",2519.4,percent of total billed charges,Implant Device,2593.5,35,,2593.5,percent of total billed charges,Implant Device,2593.5,35,,2593.5,percent of total billed charges,Implant Device,2593.5,35,,2593.5,percent of total billed charges,Implant Device,2593.5,35,,2593.5,percent of total billed charges,Implant Device,2593.5,35,,2593.5,percent of total billed charges,Implant Device,2964,40,,2964,percent of total billed charges,Implant Device,2593.5,70,,2593.5,percent of total billed charges,All Other,2519.4,34,,2519.4,percent of total billed charges,Implant Device,2519.4,34,,2519.4,percent of total billed charges,Implant Device,2593.5,35,,2593.5,percent of total billed charges,Implant Device,2593.5,35,,2593.5,percent of total billed charges,Implant Device,2593.5,35,,2593.5,percent of total billed charges,Implant Device,2593.5,35,,2593.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2519.4,34,"If Charge > 2,000, then 34 percent",2519.4,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5483.42,
J&J 1221-40-158 ACE LINER +4 10DEG 40X58,C1776,HCPCS,,79013834,CDM,278,RC,,,both,,,2565,1898.11,,,1898.11,Other,150% of Medicare + 9.63% HCRA Surcharge,1154.25,45,,1154.25,percent of total billed charges,Critical Access Hospital RCC factor,872.1,34,,872.1,percent of total billed charges,Implant Device,872.1,34,,872.1,percent of total billed charges,Implant Device,872.1,34,,872.1,percent of total billed charges,Implant Device,872.1,34,,872.1,percent of total billed charges,Implant Device,872.1,34,,872.1,percent of total billed charges,Implant Device,1269.68,,,1269.68,Other,110% of Medicare,897.75,35,,897.75,percent of total billed charges,Implant Device,872.1,34,"Charges > $500, x 34%",872.1,percent of total billed charges,Implant Device,897.75,35,,897.75,percent of total billed charges,Implant Device,897.75,35,,897.75,percent of total billed charges,Implant Device,897.75,35,,897.75,percent of total billed charges,Implant Device,897.75,35,,897.75,percent of total billed charges,Implant Device,897.75,35,,897.75,percent of total billed charges,Implant Device,1026,40,,1026,percent of total billed charges,Implant Device,897.75,70,,897.75,percent of total billed charges,All Other,872.1,34,,872.1,percent of total billed charges,Implant Device,872.1,34,,872.1,percent of total billed charges,Implant Device,897.75,35,,897.75,percent of total billed charges,Implant Device,897.75,35,,897.75,percent of total billed charges,Implant Device,897.75,35,,897.75,percent of total billed charges,Implant Device,897.75,35,,897.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,872.1,34,"If Charge > 2,000, then 34 percent",872.1,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1898.11,
STRYKER 2339-0932S FEMORAL NAIL 9X320MM,C1889,HCPCS,,79013835,CDM,278,RC,,,both,,,6585,4872.92,,,4872.92,Other,150% of Medicare + 9.63% HCRA Surcharge,2963.25,45,,2963.25,percent of total billed charges,Critical Access Hospital RCC factor,2238.9,34,,2238.9,percent of total billed charges,Implant Device,2238.9,34,,2238.9,percent of total billed charges,Implant Device,2238.9,34,,2238.9,percent of total billed charges,Implant Device,2238.9,34,,2238.9,percent of total billed charges,Implant Device,2238.9,34,,2238.9,percent of total billed charges,Implant Device,3259.58,,,3259.58,Other,110% of Medicare,2304.75,35,,2304.75,percent of total billed charges,Implant Device,2238.9,34,"Charges > $500, x 34%",2238.9,percent of total billed charges,Implant Device,2304.75,35,,2304.75,percent of total billed charges,Implant Device,2304.75,35,,2304.75,percent of total billed charges,Implant Device,2304.75,35,,2304.75,percent of total billed charges,Implant Device,2304.75,35,,2304.75,percent of total billed charges,Implant Device,2304.75,35,,2304.75,percent of total billed charges,Implant Device,2634,40,,2634,percent of total billed charges,Implant Device,2304.75,70,,2304.75,percent of total billed charges,All Other,2238.9,34,,2238.9,percent of total billed charges,Implant Device,2238.9,34,,2238.9,percent of total billed charges,Implant Device,2304.75,35,,2304.75,percent of total billed charges,Implant Device,2304.75,35,,2304.75,percent of total billed charges,Implant Device,2304.75,35,,2304.75,percent of total billed charges,Implant Device,2304.75,35,,2304.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2238.9,34,"If Charge > 2,000, then 34 percent",2238.9,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4872.92,
BIOTRONIK 471155 BIOMONITOR IV,C1764,HCPCS,,79013838,CDM,278,RC,,,both,,,12600,9324.03,,,9324.03,Other,150% of Medicare + 9.63% HCRA Surcharge,5670,45,,5670,percent of total billed charges,Critical Access Hospital RCC factor,4284,34,,4284,percent of total billed charges,Implant Device,4284,34,,4284,percent of total billed charges,Implant Device,4284,34,,4284,percent of total billed charges,Implant Device,4284,34,,4284,percent of total billed charges,Implant Device,4284,34,,4284,percent of total billed charges,Implant Device,6237,,,6237,Other,110% of Medicare,4410,35,,4410,percent of total billed charges,Implant Device,4284,34,"Charges > $500, x 34%",4284,percent of total billed charges,Implant Device,4410,35,,4410,percent of total billed charges,Implant Device,4410,35,,4410,percent of total billed charges,Implant Device,4410,35,,4410,percent of total billed charges,Implant Device,4410,35,,4410,percent of total billed charges,Implant Device,4410,35,,4410,percent of total billed charges,Implant Device,5040,40,,5040,percent of total billed charges,Implant Device,4410,70,,4410,percent of total billed charges,All Other,4284,34,,4284,percent of total billed charges,Implant Device,4284,34,,4284,percent of total billed charges,Implant Device,4410,35,,4410,percent of total billed charges,Implant Device,4410,35,,4410,percent of total billed charges,Implant Device,4410,35,,4410,percent of total billed charges,Implant Device,4410,35,,4410,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,4284,34,"If Charge > 2,000, then 34 percent",4284,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,9324.03,
ARTHREX 1035-40-000 BI-POLAR HEAD 40X28,C1776,HCPCS,,79013839,CDM,278,RC,,,both,,,1733,1282.42,,,1282.42,Other,150% of Medicare + 9.63% HCRA Surcharge,779.85,45,,779.85,percent of total billed charges,Critical Access Hospital RCC factor,589.22,34,,589.22,percent of total billed charges,Implant Device,589.22,34,,589.22,percent of total billed charges,Implant Device,589.22,34,,589.22,percent of total billed charges,Implant Device,589.22,34,,589.22,percent of total billed charges,Implant Device,589.22,34,,589.22,percent of total billed charges,Implant Device,857.84,,,857.84,Other,110% of Medicare,606.55,35,,606.55,percent of total billed charges,Implant Device,589.22,34,"Charges > $500, x 34%",589.22,percent of total billed charges,Implant Device,606.55,35,,606.55,percent of total billed charges,Implant Device,606.55,35,,606.55,percent of total billed charges,Implant Device,606.55,35,,606.55,percent of total billed charges,Implant Device,606.55,35,,606.55,percent of total billed charges,Implant Device,606.55,35,,606.55,percent of total billed charges,Implant Device,693.2,40,,693.2,percent of total billed charges,Implant Device,606.55,70,,606.55,percent of total billed charges,All Other,589.22,34,,589.22,percent of total billed charges,Implant Device,589.22,34,,589.22,percent of total billed charges,Implant Device,606.55,35,,606.55,percent of total billed charges,Implant Device,606.55,35,,606.55,percent of total billed charges,Implant Device,606.55,35,,606.55,percent of total billed charges,Implant Device,606.55,35,,606.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1282.42,
PARAGON P53-203-R011 FIBULAR PLT 11H RT,C1713,HCPCS,,79013841,CDM,278,RC,,,both,,,5240,3877.61,,,3877.61,Other,150% of Medicare + 9.63% HCRA Surcharge,2358,45,,2358,percent of total billed charges,Critical Access Hospital RCC factor,1781.6,34,,1781.6,percent of total billed charges,Implant Device,1781.6,34,,1781.6,percent of total billed charges,Implant Device,1781.6,34,,1781.6,percent of total billed charges,Implant Device,1781.6,34,,1781.6,percent of total billed charges,Implant Device,1781.6,34,,1781.6,percent of total billed charges,Implant Device,2593.8,,,2593.8,Other,110% of Medicare,1834,35,,1834,percent of total billed charges,Implant Device,1781.6,34,"Charges > $500, x 34%",1781.6,percent of total billed charges,Implant Device,1834,35,,1834,percent of total billed charges,Implant Device,1834,35,,1834,percent of total billed charges,Implant Device,1834,35,,1834,percent of total billed charges,Implant Device,1834,35,,1834,percent of total billed charges,Implant Device,1834,35,,1834,percent of total billed charges,Implant Device,2096,40,,2096,percent of total billed charges,Implant Device,1834,70,,1834,percent of total billed charges,All Other,1781.6,34,,1781.6,percent of total billed charges,Implant Device,1781.6,34,,1781.6,percent of total billed charges,Implant Device,1834,35,,1834,percent of total billed charges,Implant Device,1834,35,,1834,percent of total billed charges,Implant Device,1834,35,,1834,percent of total billed charges,Implant Device,1834,35,,1834,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1781.6,34,"If Charge > 2,000, then 34 percent",1781.6,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3877.61,
PARAGON P50-453-2714 NON LOCK SRW 2.7X14,C1713,HCPCS,,79013842,CDM,278,RC,,,both,,,504,372.96,,,372.96,Other,150% of Medicare + 9.63% HCRA Surcharge,226.8,45,,226.8,percent of total billed charges,Critical Access Hospital RCC factor,171.36,34,,171.36,percent of total billed charges,Implant Device,171.36,34,,171.36,percent of total billed charges,Implant Device,171.36,34,,171.36,percent of total billed charges,Implant Device,171.36,34,,171.36,percent of total billed charges,Implant Device,171.36,34,,171.36,percent of total billed charges,Implant Device,249.48,,,249.48,Other,110% of Medicare,176.4,35,,176.4,percent of total billed charges,Implant Device,171.36,34,"Charges > $500, x 34%",171.36,percent of total billed charges,Implant Device,176.4,35,,176.4,percent of total billed charges,Implant Device,176.4,35,,176.4,percent of total billed charges,Implant Device,176.4,35,,176.4,percent of total billed charges,Implant Device,176.4,35,,176.4,percent of total billed charges,Implant Device,176.4,35,,176.4,percent of total billed charges,Implant Device,201.6,40,,201.6,percent of total billed charges,Implant Device,176.4,70,,176.4,percent of total billed charges,All Other,171.36,34,,171.36,percent of total billed charges,Implant Device,171.36,34,,171.36,percent of total billed charges,Implant Device,176.4,35,,176.4,percent of total billed charges,Implant Device,176.4,35,,176.4,percent of total billed charges,Implant Device,176.4,35,,176.4,percent of total billed charges,Implant Device,176.4,35,,176.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,372.96,
PARAGON P50-453-2713 NON LOCK SRW 2.7X13,C1713,HCPCS,,79013843,CDM,278,RC,,,both,,,504,372.96,,,372.96,Other,150% of Medicare + 9.63% HCRA Surcharge,226.8,45,,226.8,percent of total billed charges,Critical Access Hospital RCC factor,171.36,34,,171.36,percent of total billed charges,Implant Device,171.36,34,,171.36,percent of total billed charges,Implant Device,171.36,34,,171.36,percent of total billed charges,Implant Device,171.36,34,,171.36,percent of total billed charges,Implant Device,171.36,34,,171.36,percent of total billed charges,Implant Device,249.48,,,249.48,Other,110% of Medicare,176.4,35,,176.4,percent of total billed charges,Implant Device,171.36,34,"Charges > $500, x 34%",171.36,percent of total billed charges,Implant Device,176.4,35,,176.4,percent of total billed charges,Implant Device,176.4,35,,176.4,percent of total billed charges,Implant Device,176.4,35,,176.4,percent of total billed charges,Implant Device,176.4,35,,176.4,percent of total billed charges,Implant Device,176.4,35,,176.4,percent of total billed charges,Implant Device,201.6,40,,201.6,percent of total billed charges,Implant Device,176.4,70,,176.4,percent of total billed charges,All Other,171.36,34,,171.36,percent of total billed charges,Implant Device,171.36,34,,171.36,percent of total billed charges,Implant Device,176.4,35,,176.4,percent of total billed charges,Implant Device,176.4,35,,176.4,percent of total billed charges,Implant Device,176.4,35,,176.4,percent of total billed charges,Implant Device,176.4,35,,176.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,372.96,
PARAGON P20-140-040L LONG THRED 4X40,C1713,HCPCS,,79013844,CDM,278,RC,,,both,,,830,614.2,,,614.2,Other,150% of Medicare + 9.63% HCRA Surcharge,373.5,45,,373.5,percent of total billed charges,Critical Access Hospital RCC factor,282.2,34,,282.2,percent of total billed charges,Implant Device,282.2,34,,282.2,percent of total billed charges,Implant Device,282.2,34,,282.2,percent of total billed charges,Implant Device,282.2,34,,282.2,percent of total billed charges,Implant Device,282.2,34,,282.2,percent of total billed charges,Implant Device,410.85,,,410.85,Other,110% of Medicare,290.5,35,,290.5,percent of total billed charges,Implant Device,282.2,34,"Charges > $500, x 34%",282.2,percent of total billed charges,Implant Device,290.5,35,,290.5,percent of total billed charges,Implant Device,290.5,35,,290.5,percent of total billed charges,Implant Device,290.5,35,,290.5,percent of total billed charges,Implant Device,290.5,35,,290.5,percent of total billed charges,Implant Device,290.5,35,,290.5,percent of total billed charges,Implant Device,332,40,,332,percent of total billed charges,Implant Device,290.5,70,,290.5,percent of total billed charges,All Other,282.2,34,,282.2,percent of total billed charges,Implant Device,282.2,34,,282.2,percent of total billed charges,Implant Device,290.5,35,,290.5,percent of total billed charges,Implant Device,290.5,35,,290.5,percent of total billed charges,Implant Device,290.5,35,,290.5,percent of total billed charges,Implant Device,290.5,35,,290.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,614.2,
PARAGON P20-140-038L LONG THRED SRW 4X38,C1713,HCPCS,,79013845,CDM,278,RC,,,both,,,830,614.2,,,614.2,Other,150% of Medicare + 9.63% HCRA Surcharge,373.5,45,,373.5,percent of total billed charges,Critical Access Hospital RCC factor,282.2,34,,282.2,percent of total billed charges,Implant Device,282.2,34,,282.2,percent of total billed charges,Implant Device,282.2,34,,282.2,percent of total billed charges,Implant Device,282.2,34,,282.2,percent of total billed charges,Implant Device,282.2,34,,282.2,percent of total billed charges,Implant Device,410.85,,,410.85,Other,110% of Medicare,290.5,35,,290.5,percent of total billed charges,Implant Device,282.2,34,"Charges > $500, x 34%",282.2,percent of total billed charges,Implant Device,290.5,35,,290.5,percent of total billed charges,Implant Device,290.5,35,,290.5,percent of total billed charges,Implant Device,290.5,35,,290.5,percent of total billed charges,Implant Device,290.5,35,,290.5,percent of total billed charges,Implant Device,290.5,35,,290.5,percent of total billed charges,Implant Device,332,40,,332,percent of total billed charges,Implant Device,290.5,70,,290.5,percent of total billed charges,All Other,282.2,34,,282.2,percent of total billed charges,Implant Device,282.2,34,,282.2,percent of total billed charges,Implant Device,290.5,35,,290.5,percent of total billed charges,Implant Device,290.5,35,,290.5,percent of total billed charges,Implant Device,290.5,35,,290.5,percent of total billed charges,Implant Device,290.5,35,,290.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,614.2,
PARAGON P53-102-L101 SUPPORT PLT LT SM,C1713,HCPCS,,79013846,CDM,278,RC,,,both,,,4568,3380.33,,,3380.33,Other,150% of Medicare + 9.63% HCRA Surcharge,2055.6,45,,2055.6,percent of total billed charges,Critical Access Hospital RCC factor,1553.12,34,,1553.12,percent of total billed charges,Implant Device,1553.12,34,,1553.12,percent of total billed charges,Implant Device,1553.12,34,,1553.12,percent of total billed charges,Implant Device,1553.12,34,,1553.12,percent of total billed charges,Implant Device,1553.12,34,,1553.12,percent of total billed charges,Implant Device,2261.16,,,2261.16,Other,110% of Medicare,1598.8,35,,1598.8,percent of total billed charges,Implant Device,1553.12,34,"Charges > $500, x 34%",1553.12,percent of total billed charges,Implant Device,1598.8,35,,1598.8,percent of total billed charges,Implant Device,1598.8,35,,1598.8,percent of total billed charges,Implant Device,1598.8,35,,1598.8,percent of total billed charges,Implant Device,1598.8,35,,1598.8,percent of total billed charges,Implant Device,1598.8,35,,1598.8,percent of total billed charges,Implant Device,1827.2,40,,1827.2,percent of total billed charges,Implant Device,1598.8,70,,1598.8,percent of total billed charges,All Other,1553.12,34,,1553.12,percent of total billed charges,Implant Device,1553.12,34,,1553.12,percent of total billed charges,Implant Device,1598.8,35,,1598.8,percent of total billed charges,Implant Device,1598.8,35,,1598.8,percent of total billed charges,Implant Device,1598.8,35,,1598.8,percent of total billed charges,Implant Device,1598.8,35,,1598.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1553.12,34,"If Charge > 2,000, then 34 percent",1553.12,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3380.33,
PARAGON P50-353-3524 LOCK PLT SRW 3.5X24,C1713,HCPCS,,79013847,CDM,278,RC,,,both,,,693,512.82,,,512.82,Other,150% of Medicare + 9.63% HCRA Surcharge,311.85,45,,311.85,percent of total billed charges,Critical Access Hospital RCC factor,235.62,34,,235.62,percent of total billed charges,Implant Device,235.62,34,,235.62,percent of total billed charges,Implant Device,235.62,34,,235.62,percent of total billed charges,Implant Device,235.62,34,,235.62,percent of total billed charges,Implant Device,235.62,34,,235.62,percent of total billed charges,Implant Device,343.04,,,343.04,Other,110% of Medicare,242.55,35,,242.55,percent of total billed charges,Implant Device,235.62,34,"Charges > $500, x 34%",235.62,percent of total billed charges,Implant Device,242.55,35,,242.55,percent of total billed charges,Implant Device,242.55,35,,242.55,percent of total billed charges,Implant Device,242.55,35,,242.55,percent of total billed charges,Implant Device,242.55,35,,242.55,percent of total billed charges,Implant Device,242.55,35,,242.55,percent of total billed charges,Implant Device,277.2,40,,277.2,percent of total billed charges,Implant Device,242.55,70,,242.55,percent of total billed charges,All Other,235.62,34,,235.62,percent of total billed charges,Implant Device,235.62,34,,235.62,percent of total billed charges,Implant Device,242.55,35,,242.55,percent of total billed charges,Implant Device,242.55,35,,242.55,percent of total billed charges,Implant Device,242.55,35,,242.55,percent of total billed charges,Implant Device,242.55,35,,242.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,512.82,
PARAGON P50-353-3526 LOCK PLT SRW 3.5X26,C1713,HCPCS,,79013848,CDM,278,RC,,,both,,,693,512.82,,,512.82,Other,150% of Medicare + 9.63% HCRA Surcharge,311.85,45,,311.85,percent of total billed charges,Critical Access Hospital RCC factor,235.62,34,,235.62,percent of total billed charges,Implant Device,235.62,34,,235.62,percent of total billed charges,Implant Device,235.62,34,,235.62,percent of total billed charges,Implant Device,235.62,34,,235.62,percent of total billed charges,Implant Device,235.62,34,,235.62,percent of total billed charges,Implant Device,343.04,,,343.04,Other,110% of Medicare,242.55,35,,242.55,percent of total billed charges,Implant Device,235.62,34,"Charges > $500, x 34%",235.62,percent of total billed charges,Implant Device,242.55,35,,242.55,percent of total billed charges,Implant Device,242.55,35,,242.55,percent of total billed charges,Implant Device,242.55,35,,242.55,percent of total billed charges,Implant Device,242.55,35,,242.55,percent of total billed charges,Implant Device,242.55,35,,242.55,percent of total billed charges,Implant Device,277.2,40,,277.2,percent of total billed charges,Implant Device,242.55,70,,242.55,percent of total billed charges,All Other,235.62,34,,235.62,percent of total billed charges,Implant Device,235.62,34,,235.62,percent of total billed charges,Implant Device,242.55,35,,242.55,percent of total billed charges,Implant Device,242.55,35,,242.55,percent of total billed charges,Implant Device,242.55,35,,242.55,percent of total billed charges,Implant Device,242.55,35,,242.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,512.82,
PARAGON P50-353-3532 LOCK PLT SRW 3.5X32,C1713,HCPCS,,79013849,CDM,278,RC,,,both,,,693,512.82,,,512.82,Other,150% of Medicare + 9.63% HCRA Surcharge,311.85,45,,311.85,percent of total billed charges,Critical Access Hospital RCC factor,235.62,34,,235.62,percent of total billed charges,Implant Device,235.62,34,,235.62,percent of total billed charges,Implant Device,235.62,34,,235.62,percent of total billed charges,Implant Device,235.62,34,,235.62,percent of total billed charges,Implant Device,235.62,34,,235.62,percent of total billed charges,Implant Device,343.04,,,343.04,Other,110% of Medicare,242.55,35,,242.55,percent of total billed charges,Implant Device,235.62,34,"Charges > $500, x 34%",235.62,percent of total billed charges,Implant Device,242.55,35,,242.55,percent of total billed charges,Implant Device,242.55,35,,242.55,percent of total billed charges,Implant Device,242.55,35,,242.55,percent of total billed charges,Implant Device,242.55,35,,242.55,percent of total billed charges,Implant Device,242.55,35,,242.55,percent of total billed charges,Implant Device,277.2,40,,277.2,percent of total billed charges,Implant Device,242.55,70,,242.55,percent of total billed charges,All Other,235.62,34,,235.62,percent of total billed charges,Implant Device,235.62,34,,235.62,percent of total billed charges,Implant Device,242.55,35,,242.55,percent of total billed charges,Implant Device,242.55,35,,242.55,percent of total billed charges,Implant Device,242.55,35,,242.55,percent of total billed charges,Implant Device,242.55,35,,242.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,512.82,
STRYKER 629203 DIS LAT HUM PLT LT 3H 84,C1713,HCPCS,,79013850,CDM,278,RC,,,both,,,2766,2046.85,,,2046.85,Other,150% of Medicare + 9.63% HCRA Surcharge,1244.7,45,,1244.7,percent of total billed charges,Critical Access Hospital RCC factor,940.44,34,,940.44,percent of total billed charges,Implant Device,940.44,34,,940.44,percent of total billed charges,Implant Device,940.44,34,,940.44,percent of total billed charges,Implant Device,940.44,34,,940.44,percent of total billed charges,Implant Device,940.44,34,,940.44,percent of total billed charges,Implant Device,1369.17,,,1369.17,Other,110% of Medicare,968.1,35,,968.1,percent of total billed charges,Implant Device,940.44,34,"Charges > $500, x 34%",940.44,percent of total billed charges,Implant Device,968.1,35,,968.1,percent of total billed charges,Implant Device,968.1,35,,968.1,percent of total billed charges,Implant Device,968.1,35,,968.1,percent of total billed charges,Implant Device,968.1,35,,968.1,percent of total billed charges,Implant Device,968.1,35,,968.1,percent of total billed charges,Implant Device,1106.4,40,,1106.4,percent of total billed charges,Implant Device,968.1,70,,968.1,percent of total billed charges,All Other,940.44,34,,940.44,percent of total billed charges,Implant Device,940.44,34,,940.44,percent of total billed charges,Implant Device,968.1,35,,968.1,percent of total billed charges,Implant Device,968.1,35,,968.1,percent of total billed charges,Implant Device,968.1,35,,968.1,percent of total billed charges,Implant Device,968.1,35,,968.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,940.44,34,"If Charge > 2,000, then 34 percent",940.44,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2046.85,
STRYKER 657340 LOCKING SCREW 3.5X40MM,C1713,HCPCS,,79013851,CDM,278,RC,,,both,,,539,398.86,,,398.86,Other,150% of Medicare + 9.63% HCRA Surcharge,242.55,45,,242.55,percent of total billed charges,Critical Access Hospital RCC factor,183.26,34,,183.26,percent of total billed charges,Implant Device,183.26,34,,183.26,percent of total billed charges,Implant Device,183.26,34,,183.26,percent of total billed charges,Implant Device,183.26,34,,183.26,percent of total billed charges,Implant Device,183.26,34,,183.26,percent of total billed charges,Implant Device,266.81,,,266.81,Other,110% of Medicare,188.65,35,,188.65,percent of total billed charges,Implant Device,183.26,34,"Charges > $500, x 34%",183.26,percent of total billed charges,Implant Device,188.65,35,,188.65,percent of total billed charges,Implant Device,188.65,35,,188.65,percent of total billed charges,Implant Device,188.65,35,,188.65,percent of total billed charges,Implant Device,188.65,35,,188.65,percent of total billed charges,Implant Device,188.65,35,,188.65,percent of total billed charges,Implant Device,215.6,40,,215.6,percent of total billed charges,Implant Device,188.65,70,,188.65,percent of total billed charges,All Other,183.26,34,,183.26,percent of total billed charges,Implant Device,183.26,34,,183.26,percent of total billed charges,Implant Device,188.65,35,,188.65,percent of total billed charges,Implant Device,188.65,35,,188.65,percent of total billed charges,Implant Device,188.65,35,,188.65,percent of total billed charges,Implant Device,188.65,35,,188.65,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,398.86,
ABBOTT DM5500 ASSERT-IQ EL+,C1764,HCPCS,,79013852,CDM,278,RC,,,both,,,13800,10212.03,,,10212.03,Other,150% of Medicare + 9.63% HCRA Surcharge,6210,45,,6210,percent of total billed charges,Critical Access Hospital RCC factor,4692,34,,4692,percent of total billed charges,Implant Device,4692,34,,4692,percent of total billed charges,Implant Device,4692,34,,4692,percent of total billed charges,Implant Device,4692,34,,4692,percent of total billed charges,Implant Device,4692,34,,4692,percent of total billed charges,Implant Device,6831,,,6831,Other,110% of Medicare,4830,35,,4830,percent of total billed charges,Implant Device,4692,34,"Charges > $500, x 34%",4692,percent of total billed charges,Implant Device,4830,35,,4830,percent of total billed charges,Implant Device,4830,35,,4830,percent of total billed charges,Implant Device,4830,35,,4830,percent of total billed charges,Implant Device,4830,35,,4830,percent of total billed charges,Implant Device,4830,35,,4830,percent of total billed charges,Implant Device,5520,40,,5520,percent of total billed charges,Implant Device,4830,70,,4830,percent of total billed charges,All Other,4692,34,,4692,percent of total billed charges,Implant Device,4692,34,,4692,percent of total billed charges,Implant Device,4830,35,,4830,percent of total billed charges,Implant Device,4830,35,,4830,percent of total billed charges,Implant Device,4830,35,,4830,percent of total billed charges,Implant Device,4830,35,,4830,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,4692,34,"If Charge > 2,000, then 34 percent",4692,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,10212.03,
J&J 150440106 ATTUNE REV CRS FEM LT SZ 6,C1776,HCPCS,,79013853,CDM,278,RC,,,both,,,21434,15861.21,,,15861.21,Other,150% of Medicare + 9.63% HCRA Surcharge,9645.3,45,,9645.3,percent of total billed charges,Critical Access Hospital RCC factor,7287.56,34,,7287.56,percent of total billed charges,Implant Device,7287.56,34,,7287.56,percent of total billed charges,Implant Device,7287.56,34,,7287.56,percent of total billed charges,Implant Device,7287.56,34,,7287.56,percent of total billed charges,Implant Device,7287.56,34,,7287.56,percent of total billed charges,Implant Device,10609.83,,,10609.83,Other,110% of Medicare,7501.9,35,,7501.9,percent of total billed charges,Implant Device,7287.56,34,"Charges > $500, x 34%",7287.56,percent of total billed charges,Implant Device,7501.9,35,,7501.9,percent of total billed charges,Implant Device,7501.9,35,,7501.9,percent of total billed charges,Implant Device,7501.9,35,,7501.9,percent of total billed charges,Implant Device,7501.9,35,,7501.9,percent of total billed charges,Implant Device,7501.9,35,,7501.9,percent of total billed charges,Implant Device,8573.6,40,,8573.6,percent of total billed charges,Implant Device,7501.9,70,,7501.9,percent of total billed charges,All Other,7287.56,34,,7287.56,percent of total billed charges,Implant Device,7287.56,34,,7287.56,percent of total billed charges,Implant Device,7501.9,35,,7501.9,percent of total billed charges,Implant Device,7501.9,35,,7501.9,percent of total billed charges,Implant Device,7501.9,35,,7501.9,percent of total billed charges,Implant Device,7501.9,35,,7501.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,7287.56,34,"If Charge > 2,000, then 34 percent",7287.56,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,15861.21,
J&J 151101204 ATTUNE REV FEM SLEEVE 40MM,C1776,HCPCS,,79013854,CDM,278,RC,,,both,,,10428,7716.75,,,7716.75,Other,150% of Medicare + 9.63% HCRA Surcharge,4692.6,45,,4692.6,percent of total billed charges,Critical Access Hospital RCC factor,3545.52,34,,3545.52,percent of total billed charges,Implant Device,3545.52,34,,3545.52,percent of total billed charges,Implant Device,3545.52,34,,3545.52,percent of total billed charges,Implant Device,3545.52,34,,3545.52,percent of total billed charges,Implant Device,3545.52,34,,3545.52,percent of total billed charges,Implant Device,5161.86,,,5161.86,Other,110% of Medicare,3649.8,35,,3649.8,percent of total billed charges,Implant Device,3545.52,34,"Charges > $500, x 34%",3545.52,percent of total billed charges,Implant Device,3649.8,35,,3649.8,percent of total billed charges,Implant Device,3649.8,35,,3649.8,percent of total billed charges,Implant Device,3649.8,35,,3649.8,percent of total billed charges,Implant Device,3649.8,35,,3649.8,percent of total billed charges,Implant Device,3649.8,35,,3649.8,percent of total billed charges,Implant Device,4171.2,40,,4171.2,percent of total billed charges,Implant Device,3649.8,70,,3649.8,percent of total billed charges,All Other,3545.52,34,,3545.52,percent of total billed charges,Implant Device,3545.52,34,,3545.52,percent of total billed charges,Implant Device,3649.8,35,,3649.8,percent of total billed charges,Implant Device,3649.8,35,,3649.8,percent of total billed charges,Implant Device,3649.8,35,,3649.8,percent of total billed charges,Implant Device,3649.8,35,,3649.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3545.52,34,"If Charge > 2,000, then 34 percent",3545.52,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,7716.75,
J&J 151111202 ATTUNE REV TIB SLEEVE 37MM,C1776,HCPCS,,79013855,CDM,278,RC,,,both,,,11771,8710.57,,,8710.57,Other,150% of Medicare + 9.63% HCRA Surcharge,5296.95,45,,5296.95,percent of total billed charges,Critical Access Hospital RCC factor,4002.14,34,,4002.14,percent of total billed charges,Implant Device,4002.14,34,,4002.14,percent of total billed charges,Implant Device,4002.14,34,,4002.14,percent of total billed charges,Implant Device,4002.14,34,,4002.14,percent of total billed charges,Implant Device,4002.14,34,,4002.14,percent of total billed charges,Implant Device,5826.65,,,5826.65,Other,110% of Medicare,4119.85,35,,4119.85,percent of total billed charges,Implant Device,4002.14,34,"Charges > $500, x 34%",4002.14,percent of total billed charges,Implant Device,4119.85,35,,4119.85,percent of total billed charges,Implant Device,4119.85,35,,4119.85,percent of total billed charges,Implant Device,4119.85,35,,4119.85,percent of total billed charges,Implant Device,4119.85,35,,4119.85,percent of total billed charges,Implant Device,4119.85,35,,4119.85,percent of total billed charges,Implant Device,4708.4,40,,4708.4,percent of total billed charges,Implant Device,4119.85,70,,4119.85,percent of total billed charges,All Other,4002.14,34,,4002.14,percent of total billed charges,Implant Device,4002.14,34,,4002.14,percent of total billed charges,Implant Device,4119.85,35,,4119.85,percent of total billed charges,Implant Device,4119.85,35,,4119.85,percent of total billed charges,Implant Device,4119.85,35,,4119.85,percent of total billed charges,Implant Device,4119.85,35,,4119.85,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,4002.14,34,"If Charge > 2,000, then 34 percent",4002.14,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,8710.57,
J&J 151314060 REV PRESSFIT STEM 14X60MM,C1776,HCPCS,,79013856,CDM,278,RC,,,both,,,5239,3876.87,,,3876.87,Other,150% of Medicare + 9.63% HCRA Surcharge,2357.55,45,,2357.55,percent of total billed charges,Critical Access Hospital RCC factor,1781.26,34,,1781.26,percent of total billed charges,Implant Device,1781.26,34,,1781.26,percent of total billed charges,Implant Device,1781.26,34,,1781.26,percent of total billed charges,Implant Device,1781.26,34,,1781.26,percent of total billed charges,Implant Device,1781.26,34,,1781.26,percent of total billed charges,Implant Device,2593.31,,,2593.31,Other,110% of Medicare,1833.65,35,,1833.65,percent of total billed charges,Implant Device,1781.26,34,"Charges > $500, x 34%",1781.26,percent of total billed charges,Implant Device,1833.65,35,,1833.65,percent of total billed charges,Implant Device,1833.65,35,,1833.65,percent of total billed charges,Implant Device,1833.65,35,,1833.65,percent of total billed charges,Implant Device,1833.65,35,,1833.65,percent of total billed charges,Implant Device,1833.65,35,,1833.65,percent of total billed charges,Implant Device,2095.6,40,,2095.6,percent of total billed charges,Implant Device,1833.65,70,,1833.65,percent of total billed charges,All Other,1781.26,34,,1781.26,percent of total billed charges,Implant Device,1781.26,34,,1781.26,percent of total billed charges,Implant Device,1833.65,35,,1833.65,percent of total billed charges,Implant Device,1833.65,35,,1833.65,percent of total billed charges,Implant Device,1833.65,35,,1833.65,percent of total billed charges,Implant Device,1833.65,35,,1833.65,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1781.26,34,"If Charge > 2,000, then 34 percent",1781.26,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3876.87,
J&J 151316060 REV PRESSFIT STEM 16X60MM,C1776,HCPCS,,79013857,CDM,278,RC,,,both,,,5239,3876.87,,,3876.87,Other,150% of Medicare + 9.63% HCRA Surcharge,2357.55,45,,2357.55,percent of total billed charges,Critical Access Hospital RCC factor,1781.26,34,,1781.26,percent of total billed charges,Implant Device,1781.26,34,,1781.26,percent of total billed charges,Implant Device,1781.26,34,,1781.26,percent of total billed charges,Implant Device,1781.26,34,,1781.26,percent of total billed charges,Implant Device,1781.26,34,,1781.26,percent of total billed charges,Implant Device,2593.31,,,2593.31,Other,110% of Medicare,1833.65,35,,1833.65,percent of total billed charges,Implant Device,1781.26,34,"Charges > $500, x 34%",1781.26,percent of total billed charges,Implant Device,1833.65,35,,1833.65,percent of total billed charges,Implant Device,1833.65,35,,1833.65,percent of total billed charges,Implant Device,1833.65,35,,1833.65,percent of total billed charges,Implant Device,1833.65,35,,1833.65,percent of total billed charges,Implant Device,1833.65,35,,1833.65,percent of total billed charges,Implant Device,2095.6,40,,2095.6,percent of total billed charges,Implant Device,1833.65,70,,1833.65,percent of total billed charges,All Other,1781.26,34,,1781.26,percent of total billed charges,Implant Device,1781.26,34,,1781.26,percent of total billed charges,Implant Device,1833.65,35,,1833.65,percent of total billed charges,Implant Device,1833.65,35,,1833.65,percent of total billed charges,Implant Device,1833.65,35,,1833.65,percent of total billed charges,Implant Device,1833.65,35,,1833.65,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1781.26,34,"If Charge > 2,000, then 34 percent",1781.26,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3876.87,
J&J 151710608 REV ROTATING PLATFORM INS,C1776,HCPCS,,79013858,CDM,278,RC,,,both,,,9286,6871.66,,,6871.66,Other,150% of Medicare + 9.63% HCRA Surcharge,4178.7,45,,4178.7,percent of total billed charges,Critical Access Hospital RCC factor,3157.24,34,,3157.24,percent of total billed charges,Implant Device,3157.24,34,,3157.24,percent of total billed charges,Implant Device,3157.24,34,,3157.24,percent of total billed charges,Implant Device,3157.24,34,,3157.24,percent of total billed charges,Implant Device,3157.24,34,,3157.24,percent of total billed charges,Implant Device,4596.57,,,4596.57,Other,110% of Medicare,3250.1,35,,3250.1,percent of total billed charges,Implant Device,3157.24,34,"Charges > $500, x 34%",3157.24,percent of total billed charges,Implant Device,3250.1,35,,3250.1,percent of total billed charges,Implant Device,3250.1,35,,3250.1,percent of total billed charges,Implant Device,3250.1,35,,3250.1,percent of total billed charges,Implant Device,3250.1,35,,3250.1,percent of total billed charges,Implant Device,3250.1,35,,3250.1,percent of total billed charges,Implant Device,3714.4,40,,3714.4,percent of total billed charges,Implant Device,3250.1,70,,3250.1,percent of total billed charges,All Other,3157.24,34,,3157.24,percent of total billed charges,Implant Device,3157.24,34,,3157.24,percent of total billed charges,Implant Device,3250.1,35,,3250.1,percent of total billed charges,Implant Device,3250.1,35,,3250.1,percent of total billed charges,Implant Device,3250.1,35,,3250.1,percent of total billed charges,Implant Device,3250.1,35,,3250.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3157.24,34,"If Charge > 2,000, then 34 percent",3157.24,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,6871.66,
J&J 154706002 ATTUNE REV DIS FEM SZ6 8MM,C1776,HCPCS,,79013859,CDM,278,RC,,,both,,,3848,2847.53,,,2847.53,Other,150% of Medicare + 9.63% HCRA Surcharge,1731.6,45,,1731.6,percent of total billed charges,Critical Access Hospital RCC factor,1308.32,34,,1308.32,percent of total billed charges,Implant Device,1308.32,34,,1308.32,percent of total billed charges,Implant Device,1308.32,34,,1308.32,percent of total billed charges,Implant Device,1308.32,34,,1308.32,percent of total billed charges,Implant Device,1308.32,34,,1308.32,percent of total billed charges,Implant Device,1904.76,,,1904.76,Other,110% of Medicare,1346.8,35,,1346.8,percent of total billed charges,Implant Device,1308.32,34,"Charges > $500, x 34%",1308.32,percent of total billed charges,Implant Device,1346.8,35,,1346.8,percent of total billed charges,Implant Device,1346.8,35,,1346.8,percent of total billed charges,Implant Device,1346.8,35,,1346.8,percent of total billed charges,Implant Device,1346.8,35,,1346.8,percent of total billed charges,Implant Device,1346.8,35,,1346.8,percent of total billed charges,Implant Device,1539.2,40,,1539.2,percent of total billed charges,Implant Device,1346.8,70,,1346.8,percent of total billed charges,All Other,1308.32,34,,1308.32,percent of total billed charges,Implant Device,1308.32,34,,1308.32,percent of total billed charges,Implant Device,1346.8,35,,1346.8,percent of total billed charges,Implant Device,1346.8,35,,1346.8,percent of total billed charges,Implant Device,1346.8,35,,1346.8,percent of total billed charges,Implant Device,1346.8,35,,1346.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1308.32,34,"If Charge > 2,000, then 34 percent",1308.32,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2847.53,
J&J 154906001 ATTUNE POSTER FEM SZ6 4MM,C1776,HCPCS,,79013860,CDM,278,RC,,,both,,,3848,2847.53,,,2847.53,Other,150% of Medicare + 9.63% HCRA Surcharge,1731.6,45,,1731.6,percent of total billed charges,Critical Access Hospital RCC factor,1308.32,34,,1308.32,percent of total billed charges,Implant Device,1308.32,34,,1308.32,percent of total billed charges,Implant Device,1308.32,34,,1308.32,percent of total billed charges,Implant Device,1308.32,34,,1308.32,percent of total billed charges,Implant Device,1308.32,34,,1308.32,percent of total billed charges,Implant Device,1904.76,,,1904.76,Other,110% of Medicare,1346.8,35,,1346.8,percent of total billed charges,Implant Device,1308.32,34,"Charges > $500, x 34%",1308.32,percent of total billed charges,Implant Device,1346.8,35,,1346.8,percent of total billed charges,Implant Device,1346.8,35,,1346.8,percent of total billed charges,Implant Device,1346.8,35,,1346.8,percent of total billed charges,Implant Device,1346.8,35,,1346.8,percent of total billed charges,Implant Device,1346.8,35,,1346.8,percent of total billed charges,Implant Device,1539.2,40,,1539.2,percent of total billed charges,Implant Device,1346.8,70,,1346.8,percent of total billed charges,All Other,1308.32,34,,1308.32,percent of total billed charges,Implant Device,1308.32,34,,1308.32,percent of total billed charges,Implant Device,1346.8,35,,1346.8,percent of total billed charges,Implant Device,1346.8,35,,1346.8,percent of total billed charges,Implant Device,1346.8,35,,1346.8,percent of total billed charges,Implant Device,1346.8,35,,1346.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1308.32,34,"If Charge > 2,000, then 34 percent",1308.32,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2847.53,
ZIMMER 110031399 MINI HUM TRAY 40MM,C1776,HCPCS,,79013862,CDM,278,RC,,,both,,,6000,4440.02,,,4440.02,Other,150% of Medicare + 9.63% HCRA Surcharge,2700,45,,2700,percent of total billed charges,Critical Access Hospital RCC factor,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2970,,,2970,Other,110% of Medicare,2100,35,,2100,percent of total billed charges,Implant Device,2040,34,"Charges > $500, x 34%",2040,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2400,40,,2400,percent of total billed charges,Implant Device,2100,70,,2100,percent of total billed charges,All Other,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2040,34,"If Charge > 2,000, then 34 percent",2040,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4440.02,
ZIMMER 113628 MINI HUM STEM 8X83MM LONG,C1776,HCPCS,,79013863,CDM,278,RC,,,both,,,13200,9768.03,,,9768.03,Other,150% of Medicare + 9.63% HCRA Surcharge,5940,45,,5940,percent of total billed charges,Critical Access Hospital RCC factor,4488,34,,4488,percent of total billed charges,Implant Device,4488,34,,4488,percent of total billed charges,Implant Device,4488,34,,4488,percent of total billed charges,Implant Device,4488,34,,4488,percent of total billed charges,Implant Device,4488,34,,4488,percent of total billed charges,Implant Device,6534,,,6534,Other,110% of Medicare,4620,35,,4620,percent of total billed charges,Implant Device,4488,34,"Charges > $500, x 34%",4488,percent of total billed charges,Implant Device,4620,35,,4620,percent of total billed charges,Implant Device,4620,35,,4620,percent of total billed charges,Implant Device,4620,35,,4620,percent of total billed charges,Implant Device,4620,35,,4620,percent of total billed charges,Implant Device,4620,35,,4620,percent of total billed charges,Implant Device,5280,40,,5280,percent of total billed charges,Implant Device,4620,70,,4620,percent of total billed charges,All Other,4488,34,,4488,percent of total billed charges,Implant Device,4488,34,,4488,percent of total billed charges,Implant Device,4620,35,,4620,percent of total billed charges,Implant Device,4620,35,,4620,percent of total billed charges,Implant Device,4620,35,,4620,percent of total billed charges,Implant Device,4620,35,,4620,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,4488,34,"If Charge > 2,000, then 34 percent",4488,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,9768.03,
J&J 04.045.042S LOCKING SCREW 5X42MM,C1713,HCPCS,,79013865,CDM,278,RC,,,both,,,687,508.38,,,508.38,Other,150% of Medicare + 9.63% HCRA Surcharge,309.15,45,,309.15,percent of total billed charges,Critical Access Hospital RCC factor,233.58,34,,233.58,percent of total billed charges,Implant Device,233.58,34,,233.58,percent of total billed charges,Implant Device,233.58,34,,233.58,percent of total billed charges,Implant Device,233.58,34,,233.58,percent of total billed charges,Implant Device,233.58,34,,233.58,percent of total billed charges,Implant Device,340.07,,,340.07,Other,110% of Medicare,240.45,35,,240.45,percent of total billed charges,Implant Device,233.58,34,"Charges > $500, x 34%",233.58,percent of total billed charges,Implant Device,240.45,35,,240.45,percent of total billed charges,Implant Device,240.45,35,,240.45,percent of total billed charges,Implant Device,240.45,35,,240.45,percent of total billed charges,Implant Device,240.45,35,,240.45,percent of total billed charges,Implant Device,240.45,35,,240.45,percent of total billed charges,Implant Device,274.8,40,,274.8,percent of total billed charges,Implant Device,240.45,70,,240.45,percent of total billed charges,All Other,233.58,34,,233.58,percent of total billed charges,Implant Device,233.58,34,,233.58,percent of total billed charges,Implant Device,240.45,35,,240.45,percent of total billed charges,Implant Device,240.45,35,,240.45,percent of total billed charges,Implant Device,240.45,35,,240.45,percent of total billed charges,Implant Device,240.45,35,,240.45,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,508.38,
ZIMMER 42560113513 STEM EXT 13X135MM,C1776,HCPCS,,79013890,CDM,278,RC,,,both,,,7476,5532.26,,,5532.26,Other,150% of Medicare + 9.63% HCRA Surcharge,3364.2,45,,3364.2,percent of total billed charges,Critical Access Hospital RCC factor,2541.84,34,,2541.84,percent of total billed charges,Implant Device,2541.84,34,,2541.84,percent of total billed charges,Implant Device,2541.84,34,,2541.84,percent of total billed charges,Implant Device,2541.84,34,,2541.84,percent of total billed charges,Implant Device,2541.84,34,,2541.84,percent of total billed charges,Implant Device,3700.62,,,3700.62,Other,110% of Medicare,2616.6,35,,2616.6,percent of total billed charges,Implant Device,2541.84,34,"Charges > $500, x 34%",2541.84,percent of total billed charges,Implant Device,2616.6,35,,2616.6,percent of total billed charges,Implant Device,2616.6,35,,2616.6,percent of total billed charges,Implant Device,2616.6,35,,2616.6,percent of total billed charges,Implant Device,2616.6,35,,2616.6,percent of total billed charges,Implant Device,2616.6,35,,2616.6,percent of total billed charges,Implant Device,2990.4,40,,2990.4,percent of total billed charges,Implant Device,2616.6,70,,2616.6,percent of total billed charges,All Other,2541.84,34,,2541.84,percent of total billed charges,Implant Device,2541.84,34,,2541.84,percent of total billed charges,Implant Device,2616.6,35,,2616.6,percent of total billed charges,Implant Device,2616.6,35,,2616.6,percent of total billed charges,Implant Device,2616.6,35,,2616.6,percent of total billed charges,Implant Device,2616.6,35,,2616.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2541.84,34,"If Charge > 2,000, then 34 percent",2541.84,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5532.26,
ZIMMER 42522800420 ART SURF RT 20MM,C1776,HCPCS,,79013891,CDM,278,RC,,,both,,,10815,8003.13,,,8003.13,Other,150% of Medicare + 9.63% HCRA Surcharge,4866.75,45,,4866.75,percent of total billed charges,Critical Access Hospital RCC factor,3677.1,34,,3677.1,percent of total billed charges,Implant Device,3677.1,34,,3677.1,percent of total billed charges,Implant Device,3677.1,34,,3677.1,percent of total billed charges,Implant Device,3677.1,34,,3677.1,percent of total billed charges,Implant Device,3677.1,34,,3677.1,percent of total billed charges,Implant Device,5353.43,,,5353.43,Other,110% of Medicare,3785.25,35,,3785.25,percent of total billed charges,Implant Device,3677.1,34,"Charges > $500, x 34%",3677.1,percent of total billed charges,Implant Device,3785.25,35,,3785.25,percent of total billed charges,Implant Device,3785.25,35,,3785.25,percent of total billed charges,Implant Device,3785.25,35,,3785.25,percent of total billed charges,Implant Device,3785.25,35,,3785.25,percent of total billed charges,Implant Device,3785.25,35,,3785.25,percent of total billed charges,Implant Device,4326,40,,4326,percent of total billed charges,Implant Device,3785.25,70,,3785.25,percent of total billed charges,All Other,3677.1,34,,3677.1,percent of total billed charges,Implant Device,3677.1,34,,3677.1,percent of total billed charges,Implant Device,3785.25,35,,3785.25,percent of total billed charges,Implant Device,3785.25,35,,3785.25,percent of total billed charges,Implant Device,3785.25,35,,3785.25,percent of total billed charges,Implant Device,3785.25,35,,3785.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3677.1,34,"If Charge > 2,000, then 34 percent",3677.1,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,8003.13,
ZIMMER 42504605802 FEMUR RT SIZE 5,C1713,HCPCS,,79013892,CDM,278,RC,,,both,,,30828,22812.8,,,22812.8,Other,150% of Medicare + 9.63% HCRA Surcharge,13872.6,45,,13872.6,percent of total billed charges,Critical Access Hospital RCC factor,10481.52,34,,10481.52,percent of total billed charges,Implant Device,10481.52,34,,10481.52,percent of total billed charges,Implant Device,10481.52,34,,10481.52,percent of total billed charges,Implant Device,10481.52,34,,10481.52,percent of total billed charges,Implant Device,10481.52,34,,10481.52,percent of total billed charges,Implant Device,15259.86,,,15259.86,Other,110% of Medicare,10789.8,35,,10789.8,percent of total billed charges,Implant Device,10481.52,34,"Charges > $500, x 34%",10481.52,percent of total billed charges,Implant Device,10789.8,35,,10789.8,percent of total billed charges,Implant Device,10789.8,35,,10789.8,percent of total billed charges,Implant Device,10789.8,35,,10789.8,percent of total billed charges,Implant Device,10789.8,35,,10789.8,percent of total billed charges,Implant Device,10789.8,35,,10789.8,percent of total billed charges,Implant Device,12331.2,40,,12331.2,percent of total billed charges,Implant Device,10789.8,70,,10789.8,percent of total billed charges,All Other,10481.52,34,,10481.52,percent of total billed charges,Implant Device,10481.52,34,,10481.52,percent of total billed charges,Implant Device,10789.8,35,,10789.8,percent of total billed charges,Implant Device,10789.8,35,,10789.8,percent of total billed charges,Implant Device,10789.8,35,,10789.8,percent of total billed charges,Implant Device,10789.8,35,,10789.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,10481.52,34,"If Charge > 2,000, then 34 percent",10481.52,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,22812.8,
ZIMMER 42556605810 FEM DIS AUG SZ 5 10MM,C1776,HCPCS,,79013893,CDM,278,RC,,,both,,,4767,3527.59,,,3527.59,Other,150% of Medicare + 9.63% HCRA Surcharge,2145.15,45,,2145.15,percent of total billed charges,Critical Access Hospital RCC factor,1620.78,34,,1620.78,percent of total billed charges,Implant Device,1620.78,34,,1620.78,percent of total billed charges,Implant Device,1620.78,34,,1620.78,percent of total billed charges,Implant Device,1620.78,34,,1620.78,percent of total billed charges,Implant Device,1620.78,34,,1620.78,percent of total billed charges,Implant Device,2359.67,,,2359.67,Other,110% of Medicare,1668.45,35,,1668.45,percent of total billed charges,Implant Device,1620.78,34,"Charges > $500, x 34%",1620.78,percent of total billed charges,Implant Device,1668.45,35,,1668.45,percent of total billed charges,Implant Device,1668.45,35,,1668.45,percent of total billed charges,Implant Device,1668.45,35,,1668.45,percent of total billed charges,Implant Device,1668.45,35,,1668.45,percent of total billed charges,Implant Device,1668.45,35,,1668.45,percent of total billed charges,Implant Device,1906.8,40,,1906.8,percent of total billed charges,Implant Device,1668.45,70,,1668.45,percent of total billed charges,All Other,1620.78,34,,1620.78,percent of total billed charges,Implant Device,1620.78,34,,1620.78,percent of total billed charges,Implant Device,1668.45,35,,1668.45,percent of total billed charges,Implant Device,1668.45,35,,1668.45,percent of total billed charges,Implant Device,1668.45,35,,1668.45,percent of total billed charges,Implant Device,1668.45,35,,1668.45,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1620.78,34,"If Charge > 2,000, then 34 percent",1620.78,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3527.59,
ZIMMER 42556605815 FEM DIS AUG SZ 5 15MM,C1776,HCPCS,,79013894,CDM,278,RC,,,both,,,4767,3527.59,,,3527.59,Other,150% of Medicare + 9.63% HCRA Surcharge,2145.15,45,,2145.15,percent of total billed charges,Critical Access Hospital RCC factor,1620.78,34,,1620.78,percent of total billed charges,Implant Device,1620.78,34,,1620.78,percent of total billed charges,Implant Device,1620.78,34,,1620.78,percent of total billed charges,Implant Device,1620.78,34,,1620.78,percent of total billed charges,Implant Device,1620.78,34,,1620.78,percent of total billed charges,Implant Device,2359.67,,,2359.67,Other,110% of Medicare,1668.45,35,,1668.45,percent of total billed charges,Implant Device,1620.78,34,"Charges > $500, x 34%",1620.78,percent of total billed charges,Implant Device,1668.45,35,,1668.45,percent of total billed charges,Implant Device,1668.45,35,,1668.45,percent of total billed charges,Implant Device,1668.45,35,,1668.45,percent of total billed charges,Implant Device,1668.45,35,,1668.45,percent of total billed charges,Implant Device,1668.45,35,,1668.45,percent of total billed charges,Implant Device,1906.8,40,,1906.8,percent of total billed charges,Implant Device,1668.45,70,,1668.45,percent of total billed charges,All Other,1620.78,34,,1620.78,percent of total billed charges,Implant Device,1620.78,34,,1620.78,percent of total billed charges,Implant Device,1668.45,35,,1668.45,percent of total billed charges,Implant Device,1668.45,35,,1668.45,percent of total billed charges,Implant Device,1668.45,35,,1668.45,percent of total billed charges,Implant Device,1668.45,35,,1668.45,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1620.78,34,"If Charge > 2,000, then 34 percent",1620.78,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3527.59,
ZIMMER 42542006702 TIBIA RT SIZE D,C1776,HCPCS,,79013895,CDM,278,RC,,,both,,,11046,8174.07,,,8174.07,Other,150% of Medicare + 9.63% HCRA Surcharge,4970.7,45,,4970.7,percent of total billed charges,Critical Access Hospital RCC factor,3755.64,34,,3755.64,percent of total billed charges,Implant Device,3755.64,34,,3755.64,percent of total billed charges,Implant Device,3755.64,34,,3755.64,percent of total billed charges,Implant Device,3755.64,34,,3755.64,percent of total billed charges,Implant Device,3755.64,34,,3755.64,percent of total billed charges,Implant Device,5467.77,,,5467.77,Other,110% of Medicare,3866.1,35,,3866.1,percent of total billed charges,Implant Device,3755.64,34,"Charges > $500, x 34%",3755.64,percent of total billed charges,Implant Device,3866.1,35,,3866.1,percent of total billed charges,Implant Device,3866.1,35,,3866.1,percent of total billed charges,Implant Device,3866.1,35,,3866.1,percent of total billed charges,Implant Device,3866.1,35,,3866.1,percent of total billed charges,Implant Device,3866.1,35,,3866.1,percent of total billed charges,Implant Device,4418.4,40,,4418.4,percent of total billed charges,Implant Device,3866.1,70,,3866.1,percent of total billed charges,All Other,3755.64,34,,3755.64,percent of total billed charges,Implant Device,3755.64,34,,3755.64,percent of total billed charges,Implant Device,3866.1,35,,3866.1,percent of total billed charges,Implant Device,3866.1,35,,3866.1,percent of total billed charges,Implant Device,3866.1,35,,3866.1,percent of total billed charges,Implant Device,3866.1,35,,3866.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3755.64,34,"If Charge > 2,000, then 34 percent",3755.64,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,8174.07,
STRYKER 628010 SUPER PLT DECREASE 10H LT,C1713,HCPCS,,79013896,CDM,278,RC,,,both,,,3342,2473.09,,,2473.09,Other,150% of Medicare + 9.63% HCRA Surcharge,1503.9,45,,1503.9,percent of total billed charges,Critical Access Hospital RCC factor,1136.28,34,,1136.28,percent of total billed charges,Implant Device,1136.28,34,,1136.28,percent of total billed charges,Implant Device,1136.28,34,,1136.28,percent of total billed charges,Implant Device,1136.28,34,,1136.28,percent of total billed charges,Implant Device,1136.28,34,,1136.28,percent of total billed charges,Implant Device,1654.29,,,1654.29,Other,110% of Medicare,1169.7,35,,1169.7,percent of total billed charges,Implant Device,1136.28,34,"Charges > $500, x 34%",1136.28,percent of total billed charges,Implant Device,1169.7,35,,1169.7,percent of total billed charges,Implant Device,1169.7,35,,1169.7,percent of total billed charges,Implant Device,1169.7,35,,1169.7,percent of total billed charges,Implant Device,1169.7,35,,1169.7,percent of total billed charges,Implant Device,1169.7,35,,1169.7,percent of total billed charges,Implant Device,1336.8,40,,1336.8,percent of total billed charges,Implant Device,1169.7,70,,1169.7,percent of total billed charges,All Other,1136.28,34,,1136.28,percent of total billed charges,Implant Device,1136.28,34,,1136.28,percent of total billed charges,Implant Device,1169.7,35,,1169.7,percent of total billed charges,Implant Device,1169.7,35,,1169.7,percent of total billed charges,Implant Device,1169.7,35,,1169.7,percent of total billed charges,Implant Device,1169.7,35,,1169.7,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1136.28,34,"If Charge > 2,000, then 34 percent",1136.28,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2473.09,
J&J 04.045.350S LOCKING SCREWS 5.0X50MM,C1713,HCPCS,,79013899,CDM,278,RC,,,both,,,813,601.62,,,601.62,Other,150% of Medicare + 9.63% HCRA Surcharge,365.85,45,,365.85,percent of total billed charges,Critical Access Hospital RCC factor,276.42,34,,276.42,percent of total billed charges,Implant Device,276.42,34,,276.42,percent of total billed charges,Implant Device,276.42,34,,276.42,percent of total billed charges,Implant Device,276.42,34,,276.42,percent of total billed charges,Implant Device,276.42,34,,276.42,percent of total billed charges,Implant Device,402.44,,,402.44,Other,110% of Medicare,284.55,35,,284.55,percent of total billed charges,Implant Device,276.42,34,"Charges > $500, x 34%",276.42,percent of total billed charges,Implant Device,284.55,35,,284.55,percent of total billed charges,Implant Device,284.55,35,,284.55,percent of total billed charges,Implant Device,284.55,35,,284.55,percent of total billed charges,Implant Device,284.55,35,,284.55,percent of total billed charges,Implant Device,284.55,35,,284.55,percent of total billed charges,Implant Device,325.2,40,,325.2,percent of total billed charges,Implant Device,284.55,70,,284.55,percent of total billed charges,All Other,276.42,34,,276.42,percent of total billed charges,Implant Device,276.42,34,,276.42,percent of total billed charges,Implant Device,284.55,35,,284.55,percent of total billed charges,Implant Device,284.55,35,,284.55,percent of total billed charges,Implant Device,284.55,35,,284.55,percent of total billed charges,Implant Device,284.55,35,,284.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,601.62,
J&J 04.045.372S LOCKING SCREW 5.0X72MM,C1713,HCPCS,,79013900,CDM,278,RC,,,both,,,813,601.62,,,601.62,Other,150% of Medicare + 9.63% HCRA Surcharge,365.85,45,,365.85,percent of total billed charges,Critical Access Hospital RCC factor,276.42,34,,276.42,percent of total billed charges,Implant Device,276.42,34,,276.42,percent of total billed charges,Implant Device,276.42,34,,276.42,percent of total billed charges,Implant Device,276.42,34,,276.42,percent of total billed charges,Implant Device,276.42,34,,276.42,percent of total billed charges,Implant Device,402.44,,,402.44,Other,110% of Medicare,284.55,35,,284.55,percent of total billed charges,Implant Device,276.42,34,"Charges > $500, x 34%",276.42,percent of total billed charges,Implant Device,284.55,35,,284.55,percent of total billed charges,Implant Device,284.55,35,,284.55,percent of total billed charges,Implant Device,284.55,35,,284.55,percent of total billed charges,Implant Device,284.55,35,,284.55,percent of total billed charges,Implant Device,284.55,35,,284.55,percent of total billed charges,Implant Device,325.2,40,,325.2,percent of total billed charges,Implant Device,284.55,70,,284.55,percent of total billed charges,All Other,276.42,34,,276.42,percent of total billed charges,Implant Device,276.42,34,,276.42,percent of total billed charges,Implant Device,284.55,35,,284.55,percent of total billed charges,Implant Device,284.55,35,,284.55,percent of total billed charges,Implant Device,284.55,35,,284.55,percent of total billed charges,Implant Device,284.55,35,,284.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,601.62,
J&J 04.045.340S LOCKING SCREW 5.0X40MM,C1713,HCPCS,,79013901,CDM,278,RC,,,both,,,813,601.62,,,601.62,Other,150% of Medicare + 9.63% HCRA Surcharge,365.85,45,,365.85,percent of total billed charges,Critical Access Hospital RCC factor,276.42,34,,276.42,percent of total billed charges,Implant Device,276.42,34,,276.42,percent of total billed charges,Implant Device,276.42,34,,276.42,percent of total billed charges,Implant Device,276.42,34,,276.42,percent of total billed charges,Implant Device,276.42,34,,276.42,percent of total billed charges,Implant Device,402.44,,,402.44,Other,110% of Medicare,284.55,35,,284.55,percent of total billed charges,Implant Device,276.42,34,"Charges > $500, x 34%",276.42,percent of total billed charges,Implant Device,284.55,35,,284.55,percent of total billed charges,Implant Device,284.55,35,,284.55,percent of total billed charges,Implant Device,284.55,35,,284.55,percent of total billed charges,Implant Device,284.55,35,,284.55,percent of total billed charges,Implant Device,284.55,35,,284.55,percent of total billed charges,Implant Device,325.2,40,,325.2,percent of total billed charges,Implant Device,284.55,70,,284.55,percent of total billed charges,All Other,276.42,34,,276.42,percent of total billed charges,Implant Device,276.42,34,,276.42,percent of total billed charges,Implant Device,284.55,35,,284.55,percent of total billed charges,Implant Device,284.55,35,,284.55,percent of total billed charges,Implant Device,284.55,35,,284.55,percent of total billed charges,Implant Device,284.55,35,,284.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,601.62,
J&J 245.121 LCP RECON PLATE 3.5MM,C1713,HCPCS,,79013902,CDM,278,RC,,,both,,,1606,1188.44,,,1188.44,Other,150% of Medicare + 9.63% HCRA Surcharge,722.7,45,,722.7,percent of total billed charges,Critical Access Hospital RCC factor,546.04,34,,546.04,percent of total billed charges,Implant Device,546.04,34,,546.04,percent of total billed charges,Implant Device,546.04,34,,546.04,percent of total billed charges,Implant Device,546.04,34,,546.04,percent of total billed charges,Implant Device,546.04,34,,546.04,percent of total billed charges,Implant Device,794.97,,,794.97,Other,110% of Medicare,562.1,35,,562.1,percent of total billed charges,Implant Device,546.04,34,"Charges > $500, x 34%",546.04,percent of total billed charges,Implant Device,562.1,35,,562.1,percent of total billed charges,Implant Device,562.1,35,,562.1,percent of total billed charges,Implant Device,562.1,35,,562.1,percent of total billed charges,Implant Device,562.1,35,,562.1,percent of total billed charges,Implant Device,562.1,35,,562.1,percent of total billed charges,Implant Device,642.4,40,,642.4,percent of total billed charges,Implant Device,562.1,70,,562.1,percent of total billed charges,All Other,546.04,34,,546.04,percent of total billed charges,Implant Device,546.04,34,,546.04,percent of total billed charges,Implant Device,562.1,35,,562.1,percent of total billed charges,Implant Device,562.1,35,,562.1,percent of total billed charges,Implant Device,562.1,35,,562.1,percent of total billed charges,Implant Device,562.1,35,,562.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1188.44,
STRYKER 657350 LOCKING SCREW 3.5X50MM,C1713,HCPCS,,79013903,CDM,278,RC,,,both,,,539,398.86,,,398.86,Other,150% of Medicare + 9.63% HCRA Surcharge,242.55,45,,242.55,percent of total billed charges,Critical Access Hospital RCC factor,183.26,34,,183.26,percent of total billed charges,Implant Device,183.26,34,,183.26,percent of total billed charges,Implant Device,183.26,34,,183.26,percent of total billed charges,Implant Device,183.26,34,,183.26,percent of total billed charges,Implant Device,183.26,34,,183.26,percent of total billed charges,Implant Device,266.81,,,266.81,Other,110% of Medicare,188.65,35,,188.65,percent of total billed charges,Implant Device,183.26,34,"Charges > $500, x 34%",183.26,percent of total billed charges,Implant Device,188.65,35,,188.65,percent of total billed charges,Implant Device,188.65,35,,188.65,percent of total billed charges,Implant Device,188.65,35,,188.65,percent of total billed charges,Implant Device,188.65,35,,188.65,percent of total billed charges,Implant Device,188.65,35,,188.65,percent of total billed charges,Implant Device,215.6,40,,215.6,percent of total billed charges,Implant Device,188.65,70,,188.65,percent of total billed charges,All Other,183.26,34,,183.26,percent of total billed charges,Implant Device,183.26,34,,183.26,percent of total billed charges,Implant Device,188.65,35,,188.65,percent of total billed charges,Implant Device,188.65,35,,188.65,percent of total billed charges,Implant Device,188.65,35,,188.65,percent of total billed charges,Implant Device,188.65,35,,188.65,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,398.86,
MEDLINE MMSL2412 LOCKING SCREW 2.4X12MM,C1713,HCPCS,,79013904,CDM,278,RC,,,both,,,1125,832.5,,,832.5,Other,150% of Medicare + 9.63% HCRA Surcharge,506.25,45,,506.25,percent of total billed charges,Critical Access Hospital RCC factor,382.5,34,,382.5,percent of total billed charges,Implant Device,382.5,34,,382.5,percent of total billed charges,Implant Device,382.5,34,,382.5,percent of total billed charges,Implant Device,382.5,34,,382.5,percent of total billed charges,Implant Device,382.5,34,,382.5,percent of total billed charges,Implant Device,556.88,,,556.88,Other,110% of Medicare,393.75,35,,393.75,percent of total billed charges,Implant Device,382.5,34,"Charges > $500, x 34%",382.5,percent of total billed charges,Implant Device,393.75,35,,393.75,percent of total billed charges,Implant Device,393.75,35,,393.75,percent of total billed charges,Implant Device,393.75,35,,393.75,percent of total billed charges,Implant Device,393.75,35,,393.75,percent of total billed charges,Implant Device,393.75,35,,393.75,percent of total billed charges,Implant Device,450,40,,450,percent of total billed charges,Implant Device,393.75,70,,393.75,percent of total billed charges,All Other,382.5,34,,382.5,percent of total billed charges,Implant Device,382.5,34,,382.5,percent of total billed charges,Implant Device,393.75,35,,393.75,percent of total billed charges,Implant Device,393.75,35,,393.75,percent of total billed charges,Implant Device,393.75,35,,393.75,percent of total billed charges,Implant Device,393.75,35,,393.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,832.5,
MEDLINE MPPM301U PLATE 4 HOLE,C1713,HCPCS,,79013905,CDM,278,RC,,,both,,,5400,3996.01,,,3996.01,Other,150% of Medicare + 9.63% HCRA Surcharge,2430,45,,2430,percent of total billed charges,Critical Access Hospital RCC factor,1836,34,,1836,percent of total billed charges,Implant Device,1836,34,,1836,percent of total billed charges,Implant Device,1836,34,,1836,percent of total billed charges,Implant Device,1836,34,,1836,percent of total billed charges,Implant Device,1836,34,,1836,percent of total billed charges,Implant Device,2673,,,2673,Other,110% of Medicare,1890,35,,1890,percent of total billed charges,Implant Device,1836,34,"Charges > $500, x 34%",1836,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,2160,40,,2160,percent of total billed charges,Implant Device,1890,70,,1890,percent of total billed charges,All Other,1836,34,,1836,percent of total billed charges,Implant Device,1836,34,,1836,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1836,34,"If Charge > 2,000, then 34 percent",1836,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3996.01,
MEDLINE MSD03520 CANN SCREW 3.5X20MM,C1713,HCPCS,,79013906,CDM,278,RC,,,both,,,1125,832.5,,,832.5,Other,150% of Medicare + 9.63% HCRA Surcharge,506.25,45,,506.25,percent of total billed charges,Critical Access Hospital RCC factor,382.5,34,,382.5,percent of total billed charges,Implant Device,382.5,34,,382.5,percent of total billed charges,Implant Device,382.5,34,,382.5,percent of total billed charges,Implant Device,382.5,34,,382.5,percent of total billed charges,Implant Device,382.5,34,,382.5,percent of total billed charges,Implant Device,556.88,,,556.88,Other,110% of Medicare,393.75,35,,393.75,percent of total billed charges,Implant Device,382.5,34,"Charges > $500, x 34%",382.5,percent of total billed charges,Implant Device,393.75,35,,393.75,percent of total billed charges,Implant Device,393.75,35,,393.75,percent of total billed charges,Implant Device,393.75,35,,393.75,percent of total billed charges,Implant Device,393.75,35,,393.75,percent of total billed charges,Implant Device,393.75,35,,393.75,percent of total billed charges,Implant Device,450,40,,450,percent of total billed charges,Implant Device,393.75,70,,393.75,percent of total billed charges,All Other,382.5,34,,382.5,percent of total billed charges,Implant Device,382.5,34,,382.5,percent of total billed charges,Implant Device,393.75,35,,393.75,percent of total billed charges,Implant Device,393.75,35,,393.75,percent of total billed charges,Implant Device,393.75,35,,393.75,percent of total billed charges,Implant Device,393.75,35,,393.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,832.5,
J&J 42.231.220 SELF TAP LOCK SCREW 5X20,C1713,HCPCS,,79013910,CDM,278,RC,,,both,,,513,379.62,,,379.62,Other,150% of Medicare + 9.63% HCRA Surcharge,230.85,45,,230.85,percent of total billed charges,Critical Access Hospital RCC factor,174.42,34,,174.42,percent of total billed charges,Implant Device,174.42,34,,174.42,percent of total billed charges,Implant Device,174.42,34,,174.42,percent of total billed charges,Implant Device,174.42,34,,174.42,percent of total billed charges,Implant Device,174.42,34,,174.42,percent of total billed charges,Implant Device,253.94,,,253.94,Other,110% of Medicare,179.55,35,,179.55,percent of total billed charges,Implant Device,174.42,34,"Charges > $500, x 34%",174.42,percent of total billed charges,Implant Device,179.55,35,,179.55,percent of total billed charges,Implant Device,179.55,35,,179.55,percent of total billed charges,Implant Device,179.55,35,,179.55,percent of total billed charges,Implant Device,179.55,35,,179.55,percent of total billed charges,Implant Device,179.55,35,,179.55,percent of total billed charges,Implant Device,205.2,40,,205.2,percent of total billed charges,Implant Device,179.55,70,,179.55,percent of total billed charges,All Other,174.42,34,,174.42,percent of total billed charges,Implant Device,174.42,34,,174.42,percent of total billed charges,Implant Device,179.55,35,,179.55,percent of total billed charges,Implant Device,179.55,35,,179.55,percent of total billed charges,Implant Device,179.55,35,,179.55,percent of total billed charges,Implant Device,179.55,35,,179.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,379.62,
J&J 42.231.010 VA LOCKING SCREW 5.0X10MM,C1713,HCPCS,,79013911,CDM,278,RC,,,both,,,733,542.42,,,542.42,Other,150% of Medicare + 9.63% HCRA Surcharge,329.85,45,,329.85,percent of total billed charges,Critical Access Hospital RCC factor,249.22,34,,249.22,percent of total billed charges,Implant Device,249.22,34,,249.22,percent of total billed charges,Implant Device,249.22,34,,249.22,percent of total billed charges,Implant Device,249.22,34,,249.22,percent of total billed charges,Implant Device,249.22,34,,249.22,percent of total billed charges,Implant Device,362.84,,,362.84,Other,110% of Medicare,256.55,35,,256.55,percent of total billed charges,Implant Device,249.22,34,"Charges > $500, x 34%",249.22,percent of total billed charges,Implant Device,256.55,35,,256.55,percent of total billed charges,Implant Device,256.55,35,,256.55,percent of total billed charges,Implant Device,256.55,35,,256.55,percent of total billed charges,Implant Device,256.55,35,,256.55,percent of total billed charges,Implant Device,256.55,35,,256.55,percent of total billed charges,Implant Device,293.2,40,,293.2,percent of total billed charges,Implant Device,256.55,70,,256.55,percent of total billed charges,All Other,249.22,34,,249.22,percent of total billed charges,Implant Device,249.22,34,,249.22,percent of total billed charges,Implant Device,256.55,35,,256.55,percent of total billed charges,Implant Device,256.55,35,,256.55,percent of total billed charges,Implant Device,256.55,35,,256.55,percent of total billed charges,Implant Device,256.55,35,,256.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,542.42,
J&J 1010-12-090 FEMORAL STEM SIZE 9,C1776,HCPCS,,79013912,CDM,278,RC,,,both,,,7410,5483.42,,,5483.42,Other,150% of Medicare + 9.63% HCRA Surcharge,3334.5,45,,3334.5,percent of total billed charges,Critical Access Hospital RCC factor,2519.4,34,,2519.4,percent of total billed charges,Implant Device,2519.4,34,,2519.4,percent of total billed charges,Implant Device,2519.4,34,,2519.4,percent of total billed charges,Implant Device,2519.4,34,,2519.4,percent of total billed charges,Implant Device,2519.4,34,,2519.4,percent of total billed charges,Implant Device,3667.95,,,3667.95,Other,110% of Medicare,2593.5,35,,2593.5,percent of total billed charges,Implant Device,2519.4,34,"Charges > $500, x 34%",2519.4,percent of total billed charges,Implant Device,2593.5,35,,2593.5,percent of total billed charges,Implant Device,2593.5,35,,2593.5,percent of total billed charges,Implant Device,2593.5,35,,2593.5,percent of total billed charges,Implant Device,2593.5,35,,2593.5,percent of total billed charges,Implant Device,2593.5,35,,2593.5,percent of total billed charges,Implant Device,2964,40,,2964,percent of total billed charges,Implant Device,2593.5,70,,2593.5,percent of total billed charges,All Other,2519.4,34,,2519.4,percent of total billed charges,Implant Device,2519.4,34,,2519.4,percent of total billed charges,Implant Device,2593.5,35,,2593.5,percent of total billed charges,Implant Device,2593.5,35,,2593.5,percent of total billed charges,Implant Device,2593.5,35,,2593.5,percent of total billed charges,Implant Device,2593.5,35,,2593.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2519.4,34,"If Charge > 2,000, then 34 percent",2519.4,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5483.42,
J&J 1516-30-808 TIBIAL INSERT 8MM SIZE 8,C1776,HCPCS,,79013913,CDM,278,RC,,,both,,,5400,3996.01,,,3996.01,Other,150% of Medicare + 9.63% HCRA Surcharge,2430,45,,2430,percent of total billed charges,Critical Access Hospital RCC factor,1836,34,,1836,percent of total billed charges,Implant Device,1836,34,,1836,percent of total billed charges,Implant Device,1836,34,,1836,percent of total billed charges,Implant Device,1836,34,,1836,percent of total billed charges,Implant Device,1836,34,,1836,percent of total billed charges,Implant Device,2673,,,2673,Other,110% of Medicare,1890,35,,1890,percent of total billed charges,Implant Device,1836,34,"Charges > $500, x 34%",1836,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,2160,40,,2160,percent of total billed charges,Implant Device,1890,70,,1890,percent of total billed charges,All Other,1836,34,,1836,percent of total billed charges,Implant Device,1836,34,,1836,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1836,34,"If Charge > 2,000, then 34 percent",1836,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3996.01,
STRYKER 5532-G-509-E TIB BEARING INS 9MM,C1776,HCPCS,,79013914,CDM,278,RC,,,both,,,2781,2057.95,,,2057.95,Other,150% of Medicare + 9.63% HCRA Surcharge,1251.45,45,,1251.45,percent of total billed charges,Critical Access Hospital RCC factor,945.54,34,,945.54,percent of total billed charges,Implant Device,945.54,34,,945.54,percent of total billed charges,Implant Device,945.54,34,,945.54,percent of total billed charges,Implant Device,945.54,34,,945.54,percent of total billed charges,Implant Device,945.54,34,,945.54,percent of total billed charges,Implant Device,1376.6,,,1376.6,Other,110% of Medicare,973.35,35,,973.35,percent of total billed charges,Implant Device,945.54,34,"Charges > $500, x 34%",945.54,percent of total billed charges,Implant Device,973.35,35,,973.35,percent of total billed charges,Implant Device,973.35,35,,973.35,percent of total billed charges,Implant Device,973.35,35,,973.35,percent of total billed charges,Implant Device,973.35,35,,973.35,percent of total billed charges,Implant Device,973.35,35,,973.35,percent of total billed charges,Implant Device,1112.4,40,,1112.4,percent of total billed charges,Implant Device,973.35,70,,973.35,percent of total billed charges,All Other,945.54,34,,945.54,percent of total billed charges,Implant Device,945.54,34,,945.54,percent of total billed charges,Implant Device,973.35,35,,973.35,percent of total billed charges,Implant Device,973.35,35,,973.35,percent of total billed charges,Implant Device,973.35,35,,973.35,percent of total billed charges,Implant Device,973.35,35,,973.35,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,945.54,34,"If Charge > 2,000, then 34 percent",945.54,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2057.95,
GLOBUS 51422 BMAC KIT 60CC,C1713,HCPCS,,79013916,CDM,278,RC,,,both,,,5700,4218.01,,,4218.01,Other,150% of Medicare + 9.63% HCRA Surcharge,2565,45,,2565,percent of total billed charges,Critical Access Hospital RCC factor,1938,34,,1938,percent of total billed charges,Implant Device,1938,34,,1938,percent of total billed charges,Implant Device,1938,34,,1938,percent of total billed charges,Implant Device,1938,34,,1938,percent of total billed charges,Implant Device,1938,34,,1938,percent of total billed charges,Implant Device,2821.5,,,2821.5,Other,110% of Medicare,1995,35,,1995,percent of total billed charges,Implant Device,1938,34,"Charges > $500, x 34%",1938,percent of total billed charges,Implant Device,1995,35,,1995,percent of total billed charges,Implant Device,1995,35,,1995,percent of total billed charges,Implant Device,1995,35,,1995,percent of total billed charges,Implant Device,1995,35,,1995,percent of total billed charges,Implant Device,1995,35,,1995,percent of total billed charges,Implant Device,2280,40,,2280,percent of total billed charges,Implant Device,1995,70,,1995,percent of total billed charges,All Other,1938,34,,1938,percent of total billed charges,Implant Device,1938,34,,1938,percent of total billed charges,Implant Device,1995,35,,1995,percent of total billed charges,Implant Device,1995,35,,1995,percent of total billed charges,Implant Device,1995,35,,1995,percent of total billed charges,Implant Device,1995,35,,1995,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1938,34,"If Charge > 2,000, then 34 percent",1938,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4218.01,
TRILLIANT 3200-01-7080 DYNANAIL HALIX,L8699,HCPCS,,79013917,CDM,278,RC,,,both,,,15285,11310.94,,,11310.94,Other,150% of Medicare + 9.63% HCRA Surcharge,6878.25,45,,6878.25,percent of total billed charges,Critical Access Hospital RCC factor,5196.9,34,,5196.9,percent of total billed charges,Implant Device,5196.9,34,,5196.9,percent of total billed charges,Implant Device,5196.9,34,,5196.9,percent of total billed charges,Implant Device,5196.9,34,,5196.9,percent of total billed charges,Implant Device,5196.9,34,,5196.9,percent of total billed charges,Implant Device,7566.08,,,7566.08,Other,110% of Medicare,5349.75,35,,5349.75,percent of total billed charges,Implant Device,5196.9,34,"Charges > $500, x 34%",5196.9,percent of total billed charges,Implant Device,5349.75,35,,5349.75,percent of total billed charges,Implant Device,5349.75,35,,5349.75,percent of total billed charges,Implant Device,5349.75,35,,5349.75,percent of total billed charges,Implant Device,5349.75,35,,5349.75,percent of total billed charges,Implant Device,5349.75,35,,5349.75,percent of total billed charges,Implant Device,6114,40,,6114,percent of total billed charges,Implant Device,5349.75,70,,5349.75,percent of total billed charges,All Other,5196.9,34,,5196.9,percent of total billed charges,Implant Device,5196.9,34,,5196.9,percent of total billed charges,Implant Device,5349.75,35,,5349.75,percent of total billed charges,Implant Device,5349.75,35,,5349.75,percent of total billed charges,Implant Device,5349.75,35,,5349.75,percent of total billed charges,Implant Device,5349.75,35,,5349.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,5196.9,34,"If Charge > 2,000, then 34 percent",5196.9,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,11310.94,
STRYKER 633820 BONE SCREW 2.3X20MM,C1713,HCPCS,,79013918,CDM,278,RC,,,both,,,324,239.76,,,239.76,Other,150% of Medicare + 9.63% HCRA Surcharge,145.8,45,,145.8,percent of total billed charges,Critical Access Hospital RCC factor,110.16,34,,110.16,percent of total billed charges,Implant Device,110.16,34,,110.16,percent of total billed charges,Implant Device,110.16,34,,110.16,percent of total billed charges,Implant Device,110.16,34,,110.16,percent of total billed charges,Implant Device,110.16,34,,110.16,percent of total billed charges,Implant Device,160.38,,,160.38,Other,110% of Medicare,113.4,35,,113.4,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,129.6,40,,129.6,percent of total billed charges,Implant Device,113.4,70,,113.4,percent of total billed charges,All Other,110.16,34,,110.16,percent of total billed charges,Implant Device,110.16,34,,110.16,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,239.76,
J&J 04.112.625 LCP CLAVICLE PLT 2.7MM RT,C1713,HCPCS,,79013919,CDM,278,RC,,,both,,,3495,2586.31,,,2586.31,Other,150% of Medicare + 9.63% HCRA Surcharge,1572.75,45,,1572.75,percent of total billed charges,Critical Access Hospital RCC factor,1188.3,34,,1188.3,percent of total billed charges,Implant Device,1188.3,34,,1188.3,percent of total billed charges,Implant Device,1188.3,34,,1188.3,percent of total billed charges,Implant Device,1188.3,34,,1188.3,percent of total billed charges,Implant Device,1188.3,34,,1188.3,percent of total billed charges,Implant Device,1730.03,,,1730.03,Other,110% of Medicare,1223.25,35,,1223.25,percent of total billed charges,Implant Device,1188.3,34,"Charges > $500, x 34%",1188.3,percent of total billed charges,Implant Device,1223.25,35,,1223.25,percent of total billed charges,Implant Device,1223.25,35,,1223.25,percent of total billed charges,Implant Device,1223.25,35,,1223.25,percent of total billed charges,Implant Device,1223.25,35,,1223.25,percent of total billed charges,Implant Device,1223.25,35,,1223.25,percent of total billed charges,Implant Device,1398,40,,1398,percent of total billed charges,Implant Device,1223.25,70,,1223.25,percent of total billed charges,All Other,1188.3,34,,1188.3,percent of total billed charges,Implant Device,1188.3,34,,1188.3,percent of total billed charges,Implant Device,1223.25,35,,1223.25,percent of total billed charges,Implant Device,1223.25,35,,1223.25,percent of total billed charges,Implant Device,1223.25,35,,1223.25,percent of total billed charges,Implant Device,1223.25,35,,1223.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1188.3,34,"If Charge > 2,000, then 34 percent",1188.3,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2586.31,
J&J 402.876 CORTEX SCREW 2.7X16MM,C1713,HCPCS,,79013920,CDM,278,RC,,,both,,,136,100.64,,,100.64,Other,150% of Medicare + 9.63% HCRA Surcharge,61.2,45,,61.2,percent of total billed charges,Critical Access Hospital RCC factor,46.24,34,,46.24,percent of total billed charges,Implant Device,46.24,34,,46.24,percent of total billed charges,Implant Device,46.24,34,,46.24,percent of total billed charges,Implant Device,46.24,34,,46.24,percent of total billed charges,Implant Device,46.24,34,,46.24,percent of total billed charges,Implant Device,67.32,,,67.32,Other,110% of Medicare,47.6,35,,47.6,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,47.6,35,,47.6,percent of total billed charges,Implant Device,47.6,35,,47.6,percent of total billed charges,Implant Device,47.6,35,,47.6,percent of total billed charges,Implant Device,47.6,35,,47.6,percent of total billed charges,Implant Device,47.6,35,,47.6,percent of total billed charges,Implant Device,54.4,40,,54.4,percent of total billed charges,Implant Device,47.6,70,,47.6,percent of total billed charges,All Other,46.24,34,,46.24,percent of total billed charges,Implant Device,46.24,34,,46.24,percent of total billed charges,Implant Device,47.6,35,,47.6,percent of total billed charges,Implant Device,47.6,35,,47.6,percent of total billed charges,Implant Device,47.6,35,,47.6,percent of total billed charges,Implant Device,47.6,35,,47.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,100.64,
J&J 402.880 CORTEX SCREW 2.7X20MM,C1713,HCPCS,,79013921,CDM,278,RC,,,both,,,136,100.64,,,100.64,Other,150% of Medicare + 9.63% HCRA Surcharge,61.2,45,,61.2,percent of total billed charges,Critical Access Hospital RCC factor,46.24,34,,46.24,percent of total billed charges,Implant Device,46.24,34,,46.24,percent of total billed charges,Implant Device,46.24,34,,46.24,percent of total billed charges,Implant Device,46.24,34,,46.24,percent of total billed charges,Implant Device,46.24,34,,46.24,percent of total billed charges,Implant Device,67.32,,,67.32,Other,110% of Medicare,47.6,35,,47.6,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,47.6,35,,47.6,percent of total billed charges,Implant Device,47.6,35,,47.6,percent of total billed charges,Implant Device,47.6,35,,47.6,percent of total billed charges,Implant Device,47.6,35,,47.6,percent of total billed charges,Implant Device,47.6,35,,47.6,percent of total billed charges,Implant Device,54.4,40,,54.4,percent of total billed charges,Implant Device,47.6,70,,47.6,percent of total billed charges,All Other,46.24,34,,46.24,percent of total billed charges,Implant Device,46.24,34,,46.24,percent of total billed charges,Implant Device,47.6,35,,47.6,percent of total billed charges,Implant Device,47.6,35,,47.6,percent of total billed charges,Implant Device,47.6,35,,47.6,percent of total billed charges,Implant Device,47.6,35,,47.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,100.64,
J&J 402.878 CORTEX SCREW 2.7X18MM,C1713,HCPCS,,79013922,CDM,278,RC,,,both,,,136,100.64,,,100.64,Other,150% of Medicare + 9.63% HCRA Surcharge,61.2,45,,61.2,percent of total billed charges,Critical Access Hospital RCC factor,46.24,34,,46.24,percent of total billed charges,Implant Device,46.24,34,,46.24,percent of total billed charges,Implant Device,46.24,34,,46.24,percent of total billed charges,Implant Device,46.24,34,,46.24,percent of total billed charges,Implant Device,46.24,34,,46.24,percent of total billed charges,Implant Device,67.32,,,67.32,Other,110% of Medicare,47.6,35,,47.6,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,47.6,35,,47.6,percent of total billed charges,Implant Device,47.6,35,,47.6,percent of total billed charges,Implant Device,47.6,35,,47.6,percent of total billed charges,Implant Device,47.6,35,,47.6,percent of total billed charges,Implant Device,47.6,35,,47.6,percent of total billed charges,Implant Device,54.4,40,,54.4,percent of total billed charges,Implant Device,47.6,70,,47.6,percent of total billed charges,All Other,46.24,34,,46.24,percent of total billed charges,Implant Device,46.24,34,,46.24,percent of total billed charges,Implant Device,47.6,35,,47.6,percent of total billed charges,Implant Device,47.6,35,,47.6,percent of total billed charges,Implant Device,47.6,35,,47.6,percent of total billed charges,Implant Device,47.6,35,,47.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,100.64,
J&J 04.211.014 VAL SELF TAP SCREW 2.7X14,C1713,HCPCS,,79013924,CDM,278,RC,,,both,,,343,253.82,,,253.82,Other,150% of Medicare + 9.63% HCRA Surcharge,154.35,45,,154.35,percent of total billed charges,Critical Access Hospital RCC factor,116.62,34,,116.62,percent of total billed charges,Implant Device,116.62,34,,116.62,percent of total billed charges,Implant Device,116.62,34,,116.62,percent of total billed charges,Implant Device,116.62,34,,116.62,percent of total billed charges,Implant Device,116.62,34,,116.62,percent of total billed charges,Implant Device,169.79,,,169.79,Other,110% of Medicare,120.05,35,,120.05,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,120.05,35,,120.05,percent of total billed charges,Implant Device,120.05,35,,120.05,percent of total billed charges,Implant Device,120.05,35,,120.05,percent of total billed charges,Implant Device,120.05,35,,120.05,percent of total billed charges,Implant Device,120.05,35,,120.05,percent of total billed charges,Implant Device,137.2,40,,137.2,percent of total billed charges,Implant Device,120.05,70,,120.05,percent of total billed charges,All Other,116.62,34,,116.62,percent of total billed charges,Implant Device,116.62,34,,116.62,percent of total billed charges,Implant Device,120.05,35,,120.05,percent of total billed charges,Implant Device,120.05,35,,120.05,percent of total billed charges,Implant Device,120.05,35,,120.05,percent of total billed charges,Implant Device,120.05,35,,120.05,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,253.82,
ZIMMER 574203065 FEMORAL STEM SIZE 6.5,C1776,HCPCS,,79013926,CDM,278,RC,,,both,,,8573,6344.04,,,6344.04,Other,150% of Medicare + 9.63% HCRA Surcharge,3857.85,45,,3857.85,percent of total billed charges,Critical Access Hospital RCC factor,2914.82,34,,2914.82,percent of total billed charges,Implant Device,2914.82,34,,2914.82,percent of total billed charges,Implant Device,2914.82,34,,2914.82,percent of total billed charges,Implant Device,2914.82,34,,2914.82,percent of total billed charges,Implant Device,2914.82,34,,2914.82,percent of total billed charges,Implant Device,4243.64,,,4243.64,Other,110% of Medicare,3000.55,35,,3000.55,percent of total billed charges,Implant Device,2914.82,34,"Charges > $500, x 34%",2914.82,percent of total billed charges,Implant Device,3000.55,35,,3000.55,percent of total billed charges,Implant Device,3000.55,35,,3000.55,percent of total billed charges,Implant Device,3000.55,35,,3000.55,percent of total billed charges,Implant Device,3000.55,35,,3000.55,percent of total billed charges,Implant Device,3000.55,35,,3000.55,percent of total billed charges,Implant Device,3429.2,40,,3429.2,percent of total billed charges,Implant Device,3000.55,70,,3000.55,percent of total billed charges,All Other,2914.82,34,,2914.82,percent of total billed charges,Implant Device,2914.82,34,,2914.82,percent of total billed charges,Implant Device,3000.55,35,,3000.55,percent of total billed charges,Implant Device,3000.55,35,,3000.55,percent of total billed charges,Implant Device,3000.55,35,,3000.55,percent of total billed charges,Implant Device,3000.55,35,,3000.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2914.82,34,"If Charge > 2,000, then 34 percent",2914.82,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,6344.04,
J&J 02.104.030 ARTI DIS HUM PLT 3.5.230,C1713,HCPCS,,79013927,CDM,278,RC,,,both,,,3927,2905.99,,,2905.99,Other,150% of Medicare + 9.63% HCRA Surcharge,1767.15,45,,1767.15,percent of total billed charges,Critical Access Hospital RCC factor,1335.18,34,,1335.18,percent of total billed charges,Implant Device,1335.18,34,,1335.18,percent of total billed charges,Implant Device,1335.18,34,,1335.18,percent of total billed charges,Implant Device,1335.18,34,,1335.18,percent of total billed charges,Implant Device,1335.18,34,,1335.18,percent of total billed charges,Implant Device,1943.87,,,1943.87,Other,110% of Medicare,1374.45,35,,1374.45,percent of total billed charges,Implant Device,1335.18,34,"Charges > $500, x 34%",1335.18,percent of total billed charges,Implant Device,1374.45,35,,1374.45,percent of total billed charges,Implant Device,1374.45,35,,1374.45,percent of total billed charges,Implant Device,1374.45,35,,1374.45,percent of total billed charges,Implant Device,1374.45,35,,1374.45,percent of total billed charges,Implant Device,1374.45,35,,1374.45,percent of total billed charges,Implant Device,1570.8,40,,1570.8,percent of total billed charges,Implant Device,1374.45,70,,1374.45,percent of total billed charges,All Other,1335.18,34,,1335.18,percent of total billed charges,Implant Device,1335.18,34,,1335.18,percent of total billed charges,Implant Device,1374.45,35,,1374.45,percent of total billed charges,Implant Device,1374.45,35,,1374.45,percent of total billed charges,Implant Device,1374.45,35,,1374.45,percent of total billed charges,Implant Device,1374.45,35,,1374.45,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1335.18,34,"If Charge > 2,000, then 34 percent",1335.18,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2905.99,
J&J 1516-30-507 TIBIAL INSERT SIZE 5 7MM,C1776,HCPCS,,79013928,CDM,278,RC,,,both,,,5400,3996.01,,,3996.01,Other,150% of Medicare + 9.63% HCRA Surcharge,2430,45,,2430,percent of total billed charges,Critical Access Hospital RCC factor,1836,34,,1836,percent of total billed charges,Implant Device,1836,34,,1836,percent of total billed charges,Implant Device,1836,34,,1836,percent of total billed charges,Implant Device,1836,34,,1836,percent of total billed charges,Implant Device,1836,34,,1836,percent of total billed charges,Implant Device,2673,,,2673,Other,110% of Medicare,1890,35,,1890,percent of total billed charges,Implant Device,1836,34,"Charges > $500, x 34%",1836,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,2160,40,,2160,percent of total billed charges,Implant Device,1890,70,,1890,percent of total billed charges,All Other,1836,34,,1836,percent of total billed charges,Implant Device,1836,34,,1836,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1836,34,"If Charge > 2,000, then 34 percent",1836,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3996.01,
J&J 1221-40-162 ACETABULAR LINER 40X62MM,C1776,HCPCS,,79013929,CDM,278,RC,,,both,,,2565,1898.11,,,1898.11,Other,150% of Medicare + 9.63% HCRA Surcharge,1154.25,45,,1154.25,percent of total billed charges,Critical Access Hospital RCC factor,872.1,34,,872.1,percent of total billed charges,Implant Device,872.1,34,,872.1,percent of total billed charges,Implant Device,872.1,34,,872.1,percent of total billed charges,Implant Device,872.1,34,,872.1,percent of total billed charges,Implant Device,872.1,34,,872.1,percent of total billed charges,Implant Device,1269.68,,,1269.68,Other,110% of Medicare,897.75,35,,897.75,percent of total billed charges,Implant Device,872.1,34,"Charges > $500, x 34%",872.1,percent of total billed charges,Implant Device,897.75,35,,897.75,percent of total billed charges,Implant Device,897.75,35,,897.75,percent of total billed charges,Implant Device,897.75,35,,897.75,percent of total billed charges,Implant Device,897.75,35,,897.75,percent of total billed charges,Implant Device,897.75,35,,897.75,percent of total billed charges,Implant Device,1026,40,,1026,percent of total billed charges,Implant Device,897.75,70,,897.75,percent of total billed charges,All Other,872.1,34,,872.1,percent of total billed charges,Implant Device,872.1,34,,872.1,percent of total billed charges,Implant Device,897.75,35,,897.75,percent of total billed charges,Implant Device,897.75,35,,897.75,percent of total billed charges,Implant Device,897.75,35,,897.75,percent of total billed charges,Implant Device,897.75,35,,897.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,872.1,34,"If Charge > 2,000, then 34 percent",872.1,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1898.11,
J&J 1365-40-720 FEMORAL HEAD 40MM +5,C1776,HCPCS,,79013930,CDM,278,RC,,,both,,,2636,1950.65,,,1950.65,Other,150% of Medicare + 9.63% HCRA Surcharge,1186.2,45,,1186.2,percent of total billed charges,Critical Access Hospital RCC factor,896.24,34,,896.24,percent of total billed charges,Implant Device,896.24,34,,896.24,percent of total billed charges,Implant Device,896.24,34,,896.24,percent of total billed charges,Implant Device,896.24,34,,896.24,percent of total billed charges,Implant Device,896.24,34,,896.24,percent of total billed charges,Implant Device,1304.82,,,1304.82,Other,110% of Medicare,922.6,35,,922.6,percent of total billed charges,Implant Device,896.24,34,"Charges > $500, x 34%",896.24,percent of total billed charges,Implant Device,922.6,35,,922.6,percent of total billed charges,Implant Device,922.6,35,,922.6,percent of total billed charges,Implant Device,922.6,35,,922.6,percent of total billed charges,Implant Device,922.6,35,,922.6,percent of total billed charges,Implant Device,922.6,35,,922.6,percent of total billed charges,Implant Device,1054.4,40,,1054.4,percent of total billed charges,Implant Device,922.6,70,,922.6,percent of total billed charges,All Other,896.24,34,,896.24,percent of total billed charges,Implant Device,896.24,34,,896.24,percent of total billed charges,Implant Device,922.6,35,,922.6,percent of total billed charges,Implant Device,922.6,35,,922.6,percent of total billed charges,Implant Device,922.6,35,,922.6,percent of total billed charges,Implant Device,922.6,35,,922.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,896.24,34,"If Charge > 2,000, then 34 percent",896.24,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1950.65,
PARAGON P50-453-2718 LOCK PLT SCRW 2.7X1,C1713,HCPCS,,79013931,CDM,278,RC,,,both,,,504,372.96,,,372.96,Other,150% of Medicare + 9.63% HCRA Surcharge,226.8,45,,226.8,percent of total billed charges,Critical Access Hospital RCC factor,171.36,34,,171.36,percent of total billed charges,Implant Device,171.36,34,,171.36,percent of total billed charges,Implant Device,171.36,34,,171.36,percent of total billed charges,Implant Device,171.36,34,,171.36,percent of total billed charges,Implant Device,171.36,34,,171.36,percent of total billed charges,Implant Device,249.48,,,249.48,Other,110% of Medicare,176.4,35,,176.4,percent of total billed charges,Implant Device,171.36,34,"Charges > $500, x 34%",171.36,percent of total billed charges,Implant Device,176.4,35,,176.4,percent of total billed charges,Implant Device,176.4,35,,176.4,percent of total billed charges,Implant Device,176.4,35,,176.4,percent of total billed charges,Implant Device,176.4,35,,176.4,percent of total billed charges,Implant Device,176.4,35,,176.4,percent of total billed charges,Implant Device,201.6,40,,201.6,percent of total billed charges,Implant Device,176.4,70,,176.4,percent of total billed charges,All Other,171.36,34,,171.36,percent of total billed charges,Implant Device,171.36,34,,171.36,percent of total billed charges,Implant Device,176.4,35,,176.4,percent of total billed charges,Implant Device,176.4,35,,176.4,percent of total billed charges,Implant Device,176.4,35,,176.4,percent of total billed charges,Implant Device,176.4,35,,176.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,372.96,
PARAGON P50-353-3510 LOCK PLT SRW 3.5X10,C1713,HCPCS,,79013932,CDM,278,RC,,,both,,,693,512.82,,,512.82,Other,150% of Medicare + 9.63% HCRA Surcharge,311.85,45,,311.85,percent of total billed charges,Critical Access Hospital RCC factor,235.62,34,,235.62,percent of total billed charges,Implant Device,235.62,34,,235.62,percent of total billed charges,Implant Device,235.62,34,,235.62,percent of total billed charges,Implant Device,235.62,34,,235.62,percent of total billed charges,Implant Device,235.62,34,,235.62,percent of total billed charges,Implant Device,343.04,,,343.04,Other,110% of Medicare,242.55,35,,242.55,percent of total billed charges,Implant Device,235.62,34,"Charges > $500, x 34%",235.62,percent of total billed charges,Implant Device,242.55,35,,242.55,percent of total billed charges,Implant Device,242.55,35,,242.55,percent of total billed charges,Implant Device,242.55,35,,242.55,percent of total billed charges,Implant Device,242.55,35,,242.55,percent of total billed charges,Implant Device,242.55,35,,242.55,percent of total billed charges,Implant Device,277.2,40,,277.2,percent of total billed charges,Implant Device,242.55,70,,242.55,percent of total billed charges,All Other,235.62,34,,235.62,percent of total billed charges,Implant Device,235.62,34,,235.62,percent of total billed charges,Implant Device,242.55,35,,242.55,percent of total billed charges,Implant Device,242.55,35,,242.55,percent of total billed charges,Implant Device,242.55,35,,242.55,percent of total billed charges,Implant Device,242.55,35,,242.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,512.82,
PARAGON P50-353-27112 LOCK PL SRW 2.7X12,C1713,HCPCS,,79013933,CDM,278,RC,,,both,,,693,512.82,,,512.82,Other,150% of Medicare + 9.63% HCRA Surcharge,311.85,45,,311.85,percent of total billed charges,Critical Access Hospital RCC factor,235.62,34,,235.62,percent of total billed charges,Implant Device,235.62,34,,235.62,percent of total billed charges,Implant Device,235.62,34,,235.62,percent of total billed charges,Implant Device,235.62,34,,235.62,percent of total billed charges,Implant Device,235.62,34,,235.62,percent of total billed charges,Implant Device,343.04,,,343.04,Other,110% of Medicare,242.55,35,,242.55,percent of total billed charges,Implant Device,235.62,34,"Charges > $500, x 34%",235.62,percent of total billed charges,Implant Device,242.55,35,,242.55,percent of total billed charges,Implant Device,242.55,35,,242.55,percent of total billed charges,Implant Device,242.55,35,,242.55,percent of total billed charges,Implant Device,242.55,35,,242.55,percent of total billed charges,Implant Device,242.55,35,,242.55,percent of total billed charges,Implant Device,277.2,40,,277.2,percent of total billed charges,Implant Device,242.55,70,,242.55,percent of total billed charges,All Other,235.62,34,,235.62,percent of total billed charges,Implant Device,235.62,34,,235.62,percent of total billed charges,Implant Device,242.55,35,,242.55,percent of total billed charges,Implant Device,242.55,35,,242.55,percent of total billed charges,Implant Device,242.55,35,,242.55,percent of total billed charges,Implant Device,242.55,35,,242.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,512.82,
ZIMMER 42-5221-007-13 ARTI SURF RT 13MM,C1776,HCPCS,,79013935,CDM,278,RC,,,both,,,4116,3045.85,,,3045.85,Other,150% of Medicare + 9.63% HCRA Surcharge,1852.2,45,,1852.2,percent of total billed charges,Critical Access Hospital RCC factor,1399.44,34,,1399.44,percent of total billed charges,Implant Device,1399.44,34,,1399.44,percent of total billed charges,Implant Device,1399.44,34,,1399.44,percent of total billed charges,Implant Device,1399.44,34,,1399.44,percent of total billed charges,Implant Device,1399.44,34,,1399.44,percent of total billed charges,Implant Device,2037.42,,,2037.42,Other,110% of Medicare,1440.6,35,,1440.6,percent of total billed charges,Implant Device,1399.44,34,"Charges > $500, x 34%",1399.44,percent of total billed charges,Implant Device,1440.6,35,,1440.6,percent of total billed charges,Implant Device,1440.6,35,,1440.6,percent of total billed charges,Implant Device,1440.6,35,,1440.6,percent of total billed charges,Implant Device,1440.6,35,,1440.6,percent of total billed charges,Implant Device,1440.6,35,,1440.6,percent of total billed charges,Implant Device,1646.4,40,,1646.4,percent of total billed charges,Implant Device,1440.6,70,,1440.6,percent of total billed charges,All Other,1399.44,34,,1399.44,percent of total billed charges,Implant Device,1399.44,34,,1399.44,percent of total billed charges,Implant Device,1440.6,35,,1440.6,percent of total billed charges,Implant Device,1440.6,35,,1440.6,percent of total billed charges,Implant Device,1440.6,35,,1440.6,percent of total billed charges,Implant Device,1440.6,35,,1440.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1399.44,34,"If Charge > 2,000, then 34 percent",1399.44,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3045.85,
J&J 3092020 SMARTSET BONE CEMENT 20G,C1713,HCPCS,,79013936,CDM,278,RC,,,both,,,627,463.98,,,463.98,Other,150% of Medicare + 9.63% HCRA Surcharge,282.15,45,,282.15,percent of total billed charges,Critical Access Hospital RCC factor,213.18,34,,213.18,percent of total billed charges,Implant Device,213.18,34,,213.18,percent of total billed charges,Implant Device,213.18,34,,213.18,percent of total billed charges,Implant Device,213.18,34,,213.18,percent of total billed charges,Implant Device,213.18,34,,213.18,percent of total billed charges,Implant Device,310.37,,,310.37,Other,110% of Medicare,219.45,35,,219.45,percent of total billed charges,Implant Device,213.18,34,"Charges > $500, x 34%",213.18,percent of total billed charges,Implant Device,219.45,35,,219.45,percent of total billed charges,Implant Device,219.45,35,,219.45,percent of total billed charges,Implant Device,219.45,35,,219.45,percent of total billed charges,Implant Device,219.45,35,,219.45,percent of total billed charges,Implant Device,219.45,35,,219.45,percent of total billed charges,Implant Device,250.8,40,,250.8,percent of total billed charges,Implant Device,219.45,70,,219.45,percent of total billed charges,All Other,213.18,34,,213.18,percent of total billed charges,Implant Device,213.18,34,,213.18,percent of total billed charges,Implant Device,219.45,35,,219.45,percent of total billed charges,Implant Device,219.45,35,,219.45,percent of total billed charges,Implant Device,219.45,35,,219.45,percent of total billed charges,Implant Device,219.45,35,,219.45,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,463.98,
J&J 04.037.215S TFNA NAIL 125DEG 12X235,C1889,HCPCS,,79013937,CDM,278,RC,,,both,,,4485,3318.91,,,3318.91,Other,150% of Medicare + 9.63% HCRA Surcharge,2018.25,45,,2018.25,percent of total billed charges,Critical Access Hospital RCC factor,1524.9,34,,1524.9,percent of total billed charges,Implant Device,1524.9,34,,1524.9,percent of total billed charges,Implant Device,1524.9,34,,1524.9,percent of total billed charges,Implant Device,1524.9,34,,1524.9,percent of total billed charges,Implant Device,1524.9,34,,1524.9,percent of total billed charges,Implant Device,2220.08,,,2220.08,Other,110% of Medicare,1569.75,35,,1569.75,percent of total billed charges,Implant Device,1524.9,34,"Charges > $500, x 34%",1524.9,percent of total billed charges,Implant Device,1569.75,35,,1569.75,percent of total billed charges,Implant Device,1569.75,35,,1569.75,percent of total billed charges,Implant Device,1569.75,35,,1569.75,percent of total billed charges,Implant Device,1569.75,35,,1569.75,percent of total billed charges,Implant Device,1569.75,35,,1569.75,percent of total billed charges,Implant Device,1794,40,,1794,percent of total billed charges,Implant Device,1569.75,70,,1569.75,percent of total billed charges,All Other,1524.9,34,,1524.9,percent of total billed charges,Implant Device,1524.9,34,,1524.9,percent of total billed charges,Implant Device,1569.75,35,,1569.75,percent of total billed charges,Implant Device,1569.75,35,,1569.75,percent of total billed charges,Implant Device,1569.75,35,,1569.75,percent of total billed charges,Implant Device,1569.75,35,,1569.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1524.9,34,"If Charge > 2,000, then 34 percent",1524.9,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3318.91,
J&J 1010-112-100 FEMORAL STEM SIZE 10,C1776,HCPCS,,79013939,CDM,278,RC,,,both,,,7410,5483.42,,,5483.42,Other,150% of Medicare + 9.63% HCRA Surcharge,3334.5,45,,3334.5,percent of total billed charges,Critical Access Hospital RCC factor,2519.4,34,,2519.4,percent of total billed charges,Implant Device,2519.4,34,,2519.4,percent of total billed charges,Implant Device,2519.4,34,,2519.4,percent of total billed charges,Implant Device,2519.4,34,,2519.4,percent of total billed charges,Implant Device,2519.4,34,,2519.4,percent of total billed charges,Implant Device,3667.95,,,3667.95,Other,110% of Medicare,2593.5,35,,2593.5,percent of total billed charges,Implant Device,2519.4,34,"Charges > $500, x 34%",2519.4,percent of total billed charges,Implant Device,2593.5,35,,2593.5,percent of total billed charges,Implant Device,2593.5,35,,2593.5,percent of total billed charges,Implant Device,2593.5,35,,2593.5,percent of total billed charges,Implant Device,2593.5,35,,2593.5,percent of total billed charges,Implant Device,2593.5,35,,2593.5,percent of total billed charges,Implant Device,2964,40,,2964,percent of total billed charges,Implant Device,2593.5,70,,2593.5,percent of total billed charges,All Other,2519.4,34,,2519.4,percent of total billed charges,Implant Device,2519.4,34,,2519.4,percent of total billed charges,Implant Device,2593.5,35,,2593.5,percent of total billed charges,Implant Device,2593.5,35,,2593.5,percent of total billed charges,Implant Device,2593.5,35,,2593.5,percent of total billed charges,Implant Device,2593.5,35,,2593.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2519.4,34,"If Charge > 2,000, then 34 percent",2519.4,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5483.42,
BIOCOMP 660-001 BULLET MAT & INTRODUCER,C1713,HCPCS,,79013940,CDM,278,RC,,,both,,,3300,2442.01,,,2442.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1485,45,,1485,percent of total billed charges,Critical Access Hospital RCC factor,1122,34,,1122,percent of total billed charges,Implant Device,1122,34,,1122,percent of total billed charges,Implant Device,1122,34,,1122,percent of total billed charges,Implant Device,1122,34,,1122,percent of total billed charges,Implant Device,1122,34,,1122,percent of total billed charges,Implant Device,1633.5,,,1633.5,Other,110% of Medicare,1155,35,,1155,percent of total billed charges,Implant Device,1122,34,"Charges > $500, x 34%",1122,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,1320,40,,1320,percent of total billed charges,Implant Device,1155,70,,1155,percent of total billed charges,All Other,1122,34,,1122,percent of total billed charges,Implant Device,1122,34,,1122,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,1155,35,,1155,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1122,34,"If Charge > 2,000, then 34 percent",1122,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2442.01,
J&J 1516-30-706 TIBIAL INSERT SIZE 7 6MM,C1776,HCPCS,,79013941,CDM,278,RC,,,both,,,5400,3996.01,,,3996.01,Other,150% of Medicare + 9.63% HCRA Surcharge,2430,45,,2430,percent of total billed charges,Critical Access Hospital RCC factor,1836,34,,1836,percent of total billed charges,Implant Device,1836,34,,1836,percent of total billed charges,Implant Device,1836,34,,1836,percent of total billed charges,Implant Device,1836,34,,1836,percent of total billed charges,Implant Device,1836,34,,1836,percent of total billed charges,Implant Device,2673,,,2673,Other,110% of Medicare,1890,35,,1890,percent of total billed charges,Implant Device,1836,34,"Charges > $500, x 34%",1836,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,2160,40,,2160,percent of total billed charges,Implant Device,1890,70,,1890,percent of total billed charges,All Other,1836,34,,1836,percent of total billed charges,Implant Device,1836,34,,1836,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1836,34,"If Charge > 2,000, then 34 percent",1836,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3996.01,
J&J 1518-20-029 PATELLA DOME 29MM,C1776,HCPCS,,79013942,CDM,278,RC,,,both,,,2100,1554.01,,,1554.01,Other,150% of Medicare + 9.63% HCRA Surcharge,945,45,,945,percent of total billed charges,Critical Access Hospital RCC factor,714,34,,714,percent of total billed charges,Implant Device,714,34,,714,percent of total billed charges,Implant Device,714,34,,714,percent of total billed charges,Implant Device,714,34,,714,percent of total billed charges,Implant Device,714,34,,714,percent of total billed charges,Implant Device,1039.5,,,1039.5,Other,110% of Medicare,735,35,,735,percent of total billed charges,Implant Device,714,34,"Charges > $500, x 34%",714,percent of total billed charges,Implant Device,735,35,,735,percent of total billed charges,Implant Device,735,35,,735,percent of total billed charges,Implant Device,735,35,,735,percent of total billed charges,Implant Device,735,35,,735,percent of total billed charges,Implant Device,735,35,,735,percent of total billed charges,Implant Device,840,40,,840,percent of total billed charges,Implant Device,735,70,,735,percent of total billed charges,All Other,714,34,,714,percent of total billed charges,Implant Device,714,34,,714,percent of total billed charges,Implant Device,735,35,,735,percent of total billed charges,Implant Device,735,35,,735,percent of total billed charges,Implant Device,735,35,,735,percent of total billed charges,Implant Device,735,35,,735,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,714,34,"If Charge > 2,000, then 34 percent",714,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1554.01,
J&J 1504-00-203 ATTUNE FEMORAL SZ 3 RT,C1776,HCPCS,,79013943,CDM,278,RC,,,both,,,4800,3552.01,,,3552.01,Other,150% of Medicare + 9.63% HCRA Surcharge,2160,45,,2160,percent of total billed charges,Critical Access Hospital RCC factor,1632,34,,1632,percent of total billed charges,Implant Device,1632,34,,1632,percent of total billed charges,Implant Device,1632,34,,1632,percent of total billed charges,Implant Device,1632,34,,1632,percent of total billed charges,Implant Device,1632,34,,1632,percent of total billed charges,Implant Device,2376,,,2376,Other,110% of Medicare,1680,35,,1680,percent of total billed charges,Implant Device,1632,34,"Charges > $500, x 34%",1632,percent of total billed charges,Implant Device,1680,35,,1680,percent of total billed charges,Implant Device,1680,35,,1680,percent of total billed charges,Implant Device,1680,35,,1680,percent of total billed charges,Implant Device,1680,35,,1680,percent of total billed charges,Implant Device,1680,35,,1680,percent of total billed charges,Implant Device,1920,40,,1920,percent of total billed charges,Implant Device,1680,70,,1680,percent of total billed charges,All Other,1632,34,,1632,percent of total billed charges,Implant Device,1632,34,,1632,percent of total billed charges,Implant Device,1680,35,,1680,percent of total billed charges,Implant Device,1680,35,,1680,percent of total billed charges,Implant Device,1680,35,,1680,percent of total billed charges,Implant Device,1680,35,,1680,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1632,34,"If Charge > 2,000, then 34 percent",1632,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3552.01,
J&J 1516-30-306 ATTUNE TIB INS SZ 3 6MM,C1776,HCPCS,,79013944,CDM,278,RC,,,both,,,5400,3996.01,,,3996.01,Other,150% of Medicare + 9.63% HCRA Surcharge,2430,45,,2430,percent of total billed charges,Critical Access Hospital RCC factor,1836,34,,1836,percent of total billed charges,Implant Device,1836,34,,1836,percent of total billed charges,Implant Device,1836,34,,1836,percent of total billed charges,Implant Device,1836,34,,1836,percent of total billed charges,Implant Device,1836,34,,1836,percent of total billed charges,Implant Device,2673,,,2673,Other,110% of Medicare,1890,35,,1890,percent of total billed charges,Implant Device,1836,34,"Charges > $500, x 34%",1836,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,2160,40,,2160,percent of total billed charges,Implant Device,1890,70,,1890,percent of total billed charges,All Other,1836,34,,1836,percent of total billed charges,Implant Device,1836,34,,1836,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1836,34,"If Charge > 2,000, then 34 percent",1836,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3996.01,
STRYKER 5542-P-0052 PEG GLENOID SZ 52,C1776,HCPCS,,79013946,CDM,278,RC,,,both,,,3675,2719.51,,,2719.51,Other,150% of Medicare + 9.63% HCRA Surcharge,1653.75,45,,1653.75,percent of total billed charges,Critical Access Hospital RCC factor,1249.5,34,,1249.5,percent of total billed charges,Implant Device,1249.5,34,,1249.5,percent of total billed charges,Implant Device,1249.5,34,,1249.5,percent of total billed charges,Implant Device,1249.5,34,,1249.5,percent of total billed charges,Implant Device,1249.5,34,,1249.5,percent of total billed charges,Implant Device,1819.13,,,1819.13,Other,110% of Medicare,1286.25,35,,1286.25,percent of total billed charges,Implant Device,1249.5,34,"Charges > $500, x 34%",1249.5,percent of total billed charges,Implant Device,1286.25,35,,1286.25,percent of total billed charges,Implant Device,1286.25,35,,1286.25,percent of total billed charges,Implant Device,1286.25,35,,1286.25,percent of total billed charges,Implant Device,1286.25,35,,1286.25,percent of total billed charges,Implant Device,1286.25,35,,1286.25,percent of total billed charges,Implant Device,1470,40,,1470,percent of total billed charges,Implant Device,1286.25,70,,1286.25,percent of total billed charges,All Other,1249.5,34,,1249.5,percent of total billed charges,Implant Device,1249.5,34,,1249.5,percent of total billed charges,Implant Device,1286.25,35,,1286.25,percent of total billed charges,Implant Device,1286.25,35,,1286.25,percent of total billed charges,Implant Device,1286.25,35,,1286.25,percent of total billed charges,Implant Device,1286.25,35,,1286.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1249.5,34,"If Charge > 2,000, then 34 percent",1249.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2719.51,
STRYKER 8160-0115S LAG SCREW 1.5X15MM,C1713,HCPCS,,79013947,CDM,278,RC,,,both,,,1777,1314.98,,,1314.98,Other,150% of Medicare + 9.63% HCRA Surcharge,799.65,45,,799.65,percent of total billed charges,Critical Access Hospital RCC factor,604.18,34,,604.18,percent of total billed charges,Implant Device,604.18,34,,604.18,percent of total billed charges,Implant Device,604.18,34,,604.18,percent of total billed charges,Implant Device,604.18,34,,604.18,percent of total billed charges,Implant Device,604.18,34,,604.18,percent of total billed charges,Implant Device,879.62,,,879.62,Other,110% of Medicare,621.95,35,,621.95,percent of total billed charges,Implant Device,604.18,34,"Charges > $500, x 34%",604.18,percent of total billed charges,Implant Device,621.95,35,,621.95,percent of total billed charges,Implant Device,621.95,35,,621.95,percent of total billed charges,Implant Device,621.95,35,,621.95,percent of total billed charges,Implant Device,621.95,35,,621.95,percent of total billed charges,Implant Device,621.95,35,,621.95,percent of total billed charges,Implant Device,710.8,40,,710.8,percent of total billed charges,Implant Device,621.95,70,,621.95,percent of total billed charges,All Other,604.18,34,,604.18,percent of total billed charges,Implant Device,604.18,34,,604.18,percent of total billed charges,Implant Device,621.95,35,,621.95,percent of total billed charges,Implant Device,621.95,35,,621.95,percent of total billed charges,Implant Device,621.95,35,,621.95,percent of total billed charges,Implant Device,621.95,35,,621.95,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1314.98,
STRYKER 6721-0937 HIP STEM 127DEG 37X120,C1776,HCPCS,,79013948,CDM,278,RC,,,both,,,6953,5145.24,,,5145.24,Other,150% of Medicare + 9.63% HCRA Surcharge,3128.85,45,,3128.85,percent of total billed charges,Critical Access Hospital RCC factor,2364.02,34,,2364.02,percent of total billed charges,Implant Device,2364.02,34,,2364.02,percent of total billed charges,Implant Device,2364.02,34,,2364.02,percent of total billed charges,Implant Device,2364.02,34,,2364.02,percent of total billed charges,Implant Device,2364.02,34,,2364.02,percent of total billed charges,Implant Device,3441.74,,,3441.74,Other,110% of Medicare,2433.55,35,,2433.55,percent of total billed charges,Implant Device,2364.02,34,"Charges > $500, x 34%",2364.02,percent of total billed charges,Implant Device,2433.55,35,,2433.55,percent of total billed charges,Implant Device,2433.55,35,,2433.55,percent of total billed charges,Implant Device,2433.55,35,,2433.55,percent of total billed charges,Implant Device,2433.55,35,,2433.55,percent of total billed charges,Implant Device,2433.55,35,,2433.55,percent of total billed charges,Implant Device,2781.2,40,,2781.2,percent of total billed charges,Implant Device,2433.55,70,,2433.55,percent of total billed charges,All Other,2364.02,34,,2364.02,percent of total billed charges,Implant Device,2364.02,34,,2364.02,percent of total billed charges,Implant Device,2433.55,35,,2433.55,percent of total billed charges,Implant Device,2433.55,35,,2433.55,percent of total billed charges,Implant Device,2433.55,35,,2433.55,percent of total billed charges,Implant Device,2433.55,35,,2433.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2364.02,34,"If Charge > 2,000, then 34 percent",2364.02,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5145.24,
STRYKER 5901-6053 HUM HEAD TRIAL ADAPTOR,C1776,HCPCS,,79013951,CDM,278,RC,,,both,,,2481,1835.95,,,1835.95,Other,150% of Medicare + 9.63% HCRA Surcharge,1116.45,45,,1116.45,percent of total billed charges,Critical Access Hospital RCC factor,843.54,34,,843.54,percent of total billed charges,Implant Device,843.54,34,,843.54,percent of total billed charges,Implant Device,843.54,34,,843.54,percent of total billed charges,Implant Device,843.54,34,,843.54,percent of total billed charges,Implant Device,843.54,34,,843.54,percent of total billed charges,Implant Device,1228.1,,,1228.1,Other,110% of Medicare,868.35,35,,868.35,percent of total billed charges,Implant Device,843.54,34,"Charges > $500, x 34%",843.54,percent of total billed charges,Implant Device,868.35,35,,868.35,percent of total billed charges,Implant Device,868.35,35,,868.35,percent of total billed charges,Implant Device,868.35,35,,868.35,percent of total billed charges,Implant Device,868.35,35,,868.35,percent of total billed charges,Implant Device,868.35,35,,868.35,percent of total billed charges,Implant Device,992.4,40,,992.4,percent of total billed charges,Implant Device,868.35,70,,868.35,percent of total billed charges,All Other,843.54,34,,843.54,percent of total billed charges,Implant Device,843.54,34,,843.54,percent of total billed charges,Implant Device,868.35,35,,868.35,percent of total billed charges,Implant Device,868.35,35,,868.35,percent of total billed charges,Implant Device,868.35,35,,868.35,percent of total billed charges,Implant Device,868.35,35,,868.35,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,843.54,34,"If Charge > 2,000, then 34 percent",843.54,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1835.95,
STRYKER 1516-30-905 ATTUNE INS SZ 9 5MM,C1776,HCPCS,,79013952,CDM,278,RC,,,both,,,5400,3996.01,,,3996.01,Other,150% of Medicare + 9.63% HCRA Surcharge,2430,45,,2430,percent of total billed charges,Critical Access Hospital RCC factor,1836,34,,1836,percent of total billed charges,Implant Device,1836,34,,1836,percent of total billed charges,Implant Device,1836,34,,1836,percent of total billed charges,Implant Device,1836,34,,1836,percent of total billed charges,Implant Device,1836,34,,1836,percent of total billed charges,Implant Device,2673,,,2673,Other,110% of Medicare,1890,35,,1890,percent of total billed charges,Implant Device,1836,34,"Charges > $500, x 34%",1836,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,2160,40,,2160,percent of total billed charges,Implant Device,1890,70,,1890,percent of total billed charges,All Other,1836,34,,1836,percent of total billed charges,Implant Device,1836,34,,1836,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1836,34,"If Charge > 2,000, then 34 percent",1836,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3996.01,
STRYKER 5820X3528 CROSSCHECK SCRW 3.5X28,C1713,HCPCS,,79013953,CDM,278,RC,,,both,,,1299,961.26,,,961.26,Other,150% of Medicare + 9.63% HCRA Surcharge,584.55,45,,584.55,percent of total billed charges,Critical Access Hospital RCC factor,441.66,34,,441.66,percent of total billed charges,Implant Device,441.66,34,,441.66,percent of total billed charges,Implant Device,441.66,34,,441.66,percent of total billed charges,Implant Device,441.66,34,,441.66,percent of total billed charges,Implant Device,441.66,34,,441.66,percent of total billed charges,Implant Device,643.01,,,643.01,Other,110% of Medicare,454.65,35,,454.65,percent of total billed charges,Implant Device,441.66,34,"Charges > $500, x 34%",441.66,percent of total billed charges,Implant Device,454.65,35,,454.65,percent of total billed charges,Implant Device,454.65,35,,454.65,percent of total billed charges,Implant Device,454.65,35,,454.65,percent of total billed charges,Implant Device,454.65,35,,454.65,percent of total billed charges,Implant Device,454.65,35,,454.65,percent of total billed charges,Implant Device,519.6,40,,519.6,percent of total billed charges,Implant Device,454.65,70,,454.65,percent of total billed charges,All Other,441.66,34,,441.66,percent of total billed charges,Implant Device,441.66,34,,441.66,percent of total billed charges,Implant Device,454.65,35,,454.65,percent of total billed charges,Implant Device,454.65,35,,454.65,percent of total billed charges,Implant Device,454.65,35,,454.65,percent of total billed charges,Implant Device,454.65,35,,454.65,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,961.26,
STRYKER 5820X3530 CROSSCHECK SCRW 3.5X30,C1713,HCPCS,,79013954,CDM,278,RC,,,both,,,1299,961.26,,,961.26,Other,150% of Medicare + 9.63% HCRA Surcharge,584.55,45,,584.55,percent of total billed charges,Critical Access Hospital RCC factor,441.66,34,,441.66,percent of total billed charges,Implant Device,441.66,34,,441.66,percent of total billed charges,Implant Device,441.66,34,,441.66,percent of total billed charges,Implant Device,441.66,34,,441.66,percent of total billed charges,Implant Device,441.66,34,,441.66,percent of total billed charges,Implant Device,643.01,,,643.01,Other,110% of Medicare,454.65,35,,454.65,percent of total billed charges,Implant Device,441.66,34,"Charges > $500, x 34%",441.66,percent of total billed charges,Implant Device,454.65,35,,454.65,percent of total billed charges,Implant Device,454.65,35,,454.65,percent of total billed charges,Implant Device,454.65,35,,454.65,percent of total billed charges,Implant Device,454.65,35,,454.65,percent of total billed charges,Implant Device,454.65,35,,454.65,percent of total billed charges,Implant Device,519.6,40,,519.6,percent of total billed charges,Implant Device,454.65,70,,454.65,percent of total billed charges,All Other,441.66,34,,441.66,percent of total billed charges,Implant Device,441.66,34,,441.66,percent of total billed charges,Implant Device,454.65,35,,454.65,percent of total billed charges,Implant Device,454.65,35,,454.65,percent of total billed charges,Implant Device,454.65,35,,454.65,percent of total billed charges,Implant Device,454.65,35,,454.65,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,961.26,
STRYKER 628168 PT 8 HOLE BRIDGE/RIGHT,C1713,HCPCS,,79013960,CDM,278,RC,,,both,,,3672,2717.29,,,2717.29,Other,150% of Medicare + 9.63% HCRA Surcharge,1652.4,45,,1652.4,percent of total billed charges,Critical Access Hospital RCC factor,1248.48,34,,1248.48,percent of total billed charges,Implant Device,1248.48,34,,1248.48,percent of total billed charges,Implant Device,1248.48,34,,1248.48,percent of total billed charges,Implant Device,1248.48,34,,1248.48,percent of total billed charges,Implant Device,1248.48,34,,1248.48,percent of total billed charges,Implant Device,1817.64,,,1817.64,Other,110% of Medicare,1285.2,35,,1285.2,percent of total billed charges,Implant Device,1248.48,34,"Charges > $500, x 34%",1248.48,percent of total billed charges,Implant Device,1285.2,35,,1285.2,percent of total billed charges,Implant Device,1285.2,35,,1285.2,percent of total billed charges,Implant Device,1285.2,35,,1285.2,percent of total billed charges,Implant Device,1285.2,35,,1285.2,percent of total billed charges,Implant Device,1285.2,35,,1285.2,percent of total billed charges,Implant Device,1468.8,40,,1468.8,percent of total billed charges,Implant Device,1285.2,70,,1285.2,percent of total billed charges,All Other,1248.48,34,,1248.48,percent of total billed charges,Implant Device,1248.48,34,,1248.48,percent of total billed charges,Implant Device,1285.2,35,,1285.2,percent of total billed charges,Implant Device,1285.2,35,,1285.2,percent of total billed charges,Implant Device,1285.2,35,,1285.2,percent of total billed charges,Implant Device,1285.2,35,,1285.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1248.48,34,"If Charge > 2,000, then 34 percent",1248.48,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2717.29,
STRYKER 629740 NARROW LOCK PLT 20 HOLE,C1713,HCPCS,,79013961,CDM,278,RC,,,both,,,3366,2490.85,,,2490.85,Other,150% of Medicare + 9.63% HCRA Surcharge,1514.7,45,,1514.7,percent of total billed charges,Critical Access Hospital RCC factor,1144.44,34,,1144.44,percent of total billed charges,Implant Device,1144.44,34,,1144.44,percent of total billed charges,Implant Device,1144.44,34,,1144.44,percent of total billed charges,Implant Device,1144.44,34,,1144.44,percent of total billed charges,Implant Device,1144.44,34,,1144.44,percent of total billed charges,Implant Device,1666.17,,,1666.17,Other,110% of Medicare,1178.1,35,,1178.1,percent of total billed charges,Implant Device,1144.44,34,"Charges > $500, x 34%",1144.44,percent of total billed charges,Implant Device,1178.1,35,,1178.1,percent of total billed charges,Implant Device,1178.1,35,,1178.1,percent of total billed charges,Implant Device,1178.1,35,,1178.1,percent of total billed charges,Implant Device,1178.1,35,,1178.1,percent of total billed charges,Implant Device,1178.1,35,,1178.1,percent of total billed charges,Implant Device,1346.4,40,,1346.4,percent of total billed charges,Implant Device,1178.1,70,,1178.1,percent of total billed charges,All Other,1144.44,34,,1144.44,percent of total billed charges,Implant Device,1144.44,34,,1144.44,percent of total billed charges,Implant Device,1178.1,35,,1178.1,percent of total billed charges,Implant Device,1178.1,35,,1178.1,percent of total billed charges,Implant Device,1178.1,35,,1178.1,percent of total billed charges,Implant Device,1178.1,35,,1178.1,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1144.44,34,"If Charge > 2,000, then 34 percent",1144.44,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2490.85,
STRYKER 627210 HUMERUS PLATE 10 HOLE,C1713,HCPCS,,79013962,CDM,278,RC,,,both,,,7656,5665.46,,,5665.46,Other,150% of Medicare + 9.63% HCRA Surcharge,3445.2,45,,3445.2,percent of total billed charges,Critical Access Hospital RCC factor,2603.04,34,,2603.04,percent of total billed charges,Implant Device,2603.04,34,,2603.04,percent of total billed charges,Implant Device,2603.04,34,,2603.04,percent of total billed charges,Implant Device,2603.04,34,,2603.04,percent of total billed charges,Implant Device,2603.04,34,,2603.04,percent of total billed charges,Implant Device,3789.72,,,3789.72,Other,110% of Medicare,2679.6,35,,2679.6,percent of total billed charges,Implant Device,2603.04,34,"Charges > $500, x 34%",2603.04,percent of total billed charges,Implant Device,2679.6,35,,2679.6,percent of total billed charges,Implant Device,2679.6,35,,2679.6,percent of total billed charges,Implant Device,2679.6,35,,2679.6,percent of total billed charges,Implant Device,2679.6,35,,2679.6,percent of total billed charges,Implant Device,2679.6,35,,2679.6,percent of total billed charges,Implant Device,3062.4,40,,3062.4,percent of total billed charges,Implant Device,2679.6,70,,2679.6,percent of total billed charges,All Other,2603.04,34,,2603.04,percent of total billed charges,Implant Device,2603.04,34,,2603.04,percent of total billed charges,Implant Device,2679.6,35,,2679.6,percent of total billed charges,Implant Device,2679.6,35,,2679.6,percent of total billed charges,Implant Device,2679.6,35,,2679.6,percent of total billed charges,Implant Device,2679.6,35,,2679.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2603.04,34,"If Charge > 2,000, then 34 percent",2603.04,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5665.46,
STRYKER 1516-30-710 ATTUNE SIZE 7 10MM,C1776,HCPCS,,79013963,CDM,278,RC,,,both,,,5400,3996.01,,,3996.01,Other,150% of Medicare + 9.63% HCRA Surcharge,2430,45,,2430,percent of total billed charges,Critical Access Hospital RCC factor,1836,34,,1836,percent of total billed charges,Implant Device,1836,34,,1836,percent of total billed charges,Implant Device,1836,34,,1836,percent of total billed charges,Implant Device,1836,34,,1836,percent of total billed charges,Implant Device,1836,34,,1836,percent of total billed charges,Implant Device,2673,,,2673,Other,110% of Medicare,1890,35,,1890,percent of total billed charges,Implant Device,1836,34,"Charges > $500, x 34%",1836,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,2160,40,,2160,percent of total billed charges,Implant Device,1890,70,,1890,percent of total billed charges,All Other,1836,34,,1836,percent of total billed charges,Implant Device,1836,34,,1836,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1836,34,"If Charge > 2,000, then 34 percent",1836,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3996.01,
STRYKER 8160-0090S LAG SCREW 10.5X90MM,C1713,HCPCS,,79013964,CDM,278,RC,,,both,,,1777,1314.98,,,1314.98,Other,150% of Medicare + 9.63% HCRA Surcharge,799.65,45,,799.65,percent of total billed charges,Critical Access Hospital RCC factor,604.18,34,,604.18,percent of total billed charges,Implant Device,604.18,34,,604.18,percent of total billed charges,Implant Device,604.18,34,,604.18,percent of total billed charges,Implant Device,604.18,34,,604.18,percent of total billed charges,Implant Device,604.18,34,,604.18,percent of total billed charges,Implant Device,879.62,,,879.62,Other,110% of Medicare,621.95,35,,621.95,percent of total billed charges,Implant Device,604.18,34,"Charges > $500, x 34%",604.18,percent of total billed charges,Implant Device,621.95,35,,621.95,percent of total billed charges,Implant Device,621.95,35,,621.95,percent of total billed charges,Implant Device,621.95,35,,621.95,percent of total billed charges,Implant Device,621.95,35,,621.95,percent of total billed charges,Implant Device,621.95,35,,621.95,percent of total billed charges,Implant Device,710.8,40,,710.8,percent of total billed charges,Implant Device,621.95,70,,621.95,percent of total billed charges,All Other,604.18,34,,604.18,percent of total billed charges,Implant Device,604.18,34,,604.18,percent of total billed charges,Implant Device,621.95,35,,621.95,percent of total billed charges,Implant Device,621.95,35,,621.95,percent of total billed charges,Implant Device,621.95,35,,621.95,percent of total billed charges,Implant Device,621.95,35,,621.95,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1314.98,
EXACTECH 314-23-13 LASER CAGE GLENOID MD,C1776,HCPCS,,79013965,CDM,278,RC,,,both,,,4725,3496.51,,,3496.51,Other,150% of Medicare + 9.63% HCRA Surcharge,2126.25,45,,2126.25,percent of total billed charges,Critical Access Hospital RCC factor,1606.5,34,,1606.5,percent of total billed charges,Implant Device,1606.5,34,,1606.5,percent of total billed charges,Implant Device,1606.5,34,,1606.5,percent of total billed charges,Implant Device,1606.5,34,,1606.5,percent of total billed charges,Implant Device,1606.5,34,,1606.5,percent of total billed charges,Implant Device,2338.88,,,2338.88,Other,110% of Medicare,1653.75,35,,1653.75,percent of total billed charges,Implant Device,1606.5,34,"Charges > $500, x 34%",1606.5,percent of total billed charges,Implant Device,1653.75,35,,1653.75,percent of total billed charges,Implant Device,1653.75,35,,1653.75,percent of total billed charges,Implant Device,1653.75,35,,1653.75,percent of total billed charges,Implant Device,1653.75,35,,1653.75,percent of total billed charges,Implant Device,1653.75,35,,1653.75,percent of total billed charges,Implant Device,1890,40,,1890,percent of total billed charges,Implant Device,1653.75,70,,1653.75,percent of total billed charges,All Other,1606.5,34,,1606.5,percent of total billed charges,Implant Device,1606.5,34,,1606.5,percent of total billed charges,Implant Device,1653.75,35,,1653.75,percent of total billed charges,Implant Device,1653.75,35,,1653.75,percent of total billed charges,Implant Device,1653.75,35,,1653.75,percent of total billed charges,Implant Device,1653.75,35,,1653.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1606.5,34,"If Charge > 2,000, then 34 percent",1606.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3496.51,
STRYKER 6260-5-126 FEMORAL HEAD 26MM,C1776,HCPCS,,79013966,CDM,278,RC,,,both,,,1391,1029.34,,,1029.34,Other,150% of Medicare + 9.63% HCRA Surcharge,625.95,45,,625.95,percent of total billed charges,Critical Access Hospital RCC factor,472.94,34,,472.94,percent of total billed charges,Implant Device,472.94,34,,472.94,percent of total billed charges,Implant Device,472.94,34,,472.94,percent of total billed charges,Implant Device,472.94,34,,472.94,percent of total billed charges,Implant Device,472.94,34,,472.94,percent of total billed charges,Implant Device,688.55,,,688.55,Other,110% of Medicare,486.85,35,,486.85,percent of total billed charges,Implant Device,472.94,34,"Charges > $500, x 34%",472.94,percent of total billed charges,Implant Device,486.85,35,,486.85,percent of total billed charges,Implant Device,486.85,35,,486.85,percent of total billed charges,Implant Device,486.85,35,,486.85,percent of total billed charges,Implant Device,486.85,35,,486.85,percent of total billed charges,Implant Device,486.85,35,,486.85,percent of total billed charges,Implant Device,556.4,40,,556.4,percent of total billed charges,Implant Device,486.85,70,,486.85,percent of total billed charges,All Other,472.94,34,,472.94,percent of total billed charges,Implant Device,472.94,34,,472.94,percent of total billed charges,Implant Device,486.85,35,,486.85,percent of total billed charges,Implant Device,486.85,35,,486.85,percent of total billed charges,Implant Device,486.85,35,,486.85,percent of total billed charges,Implant Device,486.85,35,,486.85,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1029.34,
J&J 1516-50-607 ATTUNE INSERT SIZE 6 7MM,C1776,HCPCS,,79013967,CDM,278,RC,,,both,,,5400,3996.01,,,3996.01,Other,150% of Medicare + 9.63% HCRA Surcharge,2430,45,,2430,percent of total billed charges,Critical Access Hospital RCC factor,1836,34,,1836,percent of total billed charges,Implant Device,1836,34,,1836,percent of total billed charges,Implant Device,1836,34,,1836,percent of total billed charges,Implant Device,1836,34,,1836,percent of total billed charges,Implant Device,1836,34,,1836,percent of total billed charges,Implant Device,2673,,,2673,Other,110% of Medicare,1890,35,,1890,percent of total billed charges,Implant Device,1836,34,"Charges > $500, x 34%",1836,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,2160,40,,2160,percent of total billed charges,Implant Device,1890,70,,1890,percent of total billed charges,All Other,1836,34,,1836,percent of total billed charges,Implant Device,1836,34,,1836,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1836,34,"If Charge > 2,000, then 34 percent",1836,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3996.01,
STRYKER IH2512 HEADLESS SCREW 2.5X12MM,C1713,HCPCS,,79013968,CDM,278,RC,,,both,,,1679,1242.46,,,1242.46,Other,150% of Medicare + 9.63% HCRA Surcharge,755.55,45,,755.55,percent of total billed charges,Critical Access Hospital RCC factor,570.86,34,,570.86,percent of total billed charges,Implant Device,570.86,34,,570.86,percent of total billed charges,Implant Device,570.86,34,,570.86,percent of total billed charges,Implant Device,570.86,34,,570.86,percent of total billed charges,Implant Device,570.86,34,,570.86,percent of total billed charges,Implant Device,831.11,,,831.11,Other,110% of Medicare,587.65,35,,587.65,percent of total billed charges,Implant Device,570.86,34,"Charges > $500, x 34%",570.86,percent of total billed charges,Implant Device,587.65,35,,587.65,percent of total billed charges,Implant Device,587.65,35,,587.65,percent of total billed charges,Implant Device,587.65,35,,587.65,percent of total billed charges,Implant Device,587.65,35,,587.65,percent of total billed charges,Implant Device,587.65,35,,587.65,percent of total billed charges,Implant Device,671.6,40,,671.6,percent of total billed charges,Implant Device,587.65,70,,587.65,percent of total billed charges,All Other,570.86,34,,570.86,percent of total billed charges,Implant Device,570.86,34,,570.86,percent of total billed charges,Implant Device,587.65,35,,587.65,percent of total billed charges,Implant Device,587.65,35,,587.65,percent of total billed charges,Implant Device,587.65,35,,587.65,percent of total billed charges,Implant Device,587.65,35,,587.65,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1242.46,
STRYKER 8160-0120S LAG SCREW 10.5X120MM,C1713,HCPCS,,79013969,CDM,278,RC,,,both,,,1777,1314.98,,,1314.98,Other,150% of Medicare + 9.63% HCRA Surcharge,799.65,45,,799.65,percent of total billed charges,Critical Access Hospital RCC factor,604.18,34,,604.18,percent of total billed charges,Implant Device,604.18,34,,604.18,percent of total billed charges,Implant Device,604.18,34,,604.18,percent of total billed charges,Implant Device,604.18,34,,604.18,percent of total billed charges,Implant Device,604.18,34,,604.18,percent of total billed charges,Implant Device,879.62,,,879.62,Other,110% of Medicare,621.95,35,,621.95,percent of total billed charges,Implant Device,604.18,34,"Charges > $500, x 34%",604.18,percent of total billed charges,Implant Device,621.95,35,,621.95,percent of total billed charges,Implant Device,621.95,35,,621.95,percent of total billed charges,Implant Device,621.95,35,,621.95,percent of total billed charges,Implant Device,621.95,35,,621.95,percent of total billed charges,Implant Device,621.95,35,,621.95,percent of total billed charges,Implant Device,710.8,40,,710.8,percent of total billed charges,Implant Device,621.95,70,,621.95,percent of total billed charges,All Other,604.18,34,,604.18,percent of total billed charges,Implant Device,604.18,34,,604.18,percent of total billed charges,Implant Device,621.95,35,,621.95,percent of total billed charges,Implant Device,621.95,35,,621.95,percent of total billed charges,Implant Device,621.95,35,,621.95,percent of total billed charges,Implant Device,621.95,35,,621.95,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1314.98,
STRYKER 8525-0420S NAIL LT 10X420X125DEG,C1713,HCPCS,,79013970,CDM,278,RC,,,both,,,7227,5348,,,5348,Other,150% of Medicare + 9.63% HCRA Surcharge,3252.15,45,,3252.15,percent of total billed charges,Critical Access Hospital RCC factor,2457.18,34,,2457.18,percent of total billed charges,Implant Device,2457.18,34,,2457.18,percent of total billed charges,Implant Device,2457.18,34,,2457.18,percent of total billed charges,Implant Device,2457.18,34,,2457.18,percent of total billed charges,Implant Device,2457.18,34,,2457.18,percent of total billed charges,Implant Device,3577.37,,,3577.37,Other,110% of Medicare,2529.45,35,,2529.45,percent of total billed charges,Implant Device,2457.18,34,"Charges > $500, x 34%",2457.18,percent of total billed charges,Implant Device,2529.45,35,,2529.45,percent of total billed charges,Implant Device,2529.45,35,,2529.45,percent of total billed charges,Implant Device,2529.45,35,,2529.45,percent of total billed charges,Implant Device,2529.45,35,,2529.45,percent of total billed charges,Implant Device,2529.45,35,,2529.45,percent of total billed charges,Implant Device,2890.8,40,,2890.8,percent of total billed charges,Implant Device,2529.45,70,,2529.45,percent of total billed charges,All Other,2457.18,34,,2457.18,percent of total billed charges,Implant Device,2457.18,34,,2457.18,percent of total billed charges,Implant Device,2529.45,35,,2529.45,percent of total billed charges,Implant Device,2529.45,35,,2529.45,percent of total billed charges,Implant Device,2529.45,35,,2529.45,percent of total billed charges,Implant Device,2529.45,35,,2529.45,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2457.18,34,"If Charge > 2,000, then 34 percent",2457.18,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5348,
STRYKER 663810 BONE SCREW 2.3X19MM,C1713,HCPCS,,79013971,CDM,278,RC,,,both,,,324,239.76,,,239.76,Other,150% of Medicare + 9.63% HCRA Surcharge,145.8,45,,145.8,percent of total billed charges,Critical Access Hospital RCC factor,110.16,34,,110.16,percent of total billed charges,Implant Device,110.16,34,,110.16,percent of total billed charges,Implant Device,110.16,34,,110.16,percent of total billed charges,Implant Device,110.16,34,,110.16,percent of total billed charges,Implant Device,110.16,34,,110.16,percent of total billed charges,Implant Device,160.38,,,160.38,Other,110% of Medicare,113.4,35,,113.4,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,129.6,40,,129.6,percent of total billed charges,Implant Device,113.4,70,,113.4,percent of total billed charges,All Other,110.16,34,,110.16,percent of total billed charges,Implant Device,110.16,34,,110.16,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,113.4,35,,113.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,239.76,
STRYKER 663715 LOCKING SCREW 2.3X15MM,C1713,HCPCS,,79013972,CDM,278,RC,,,both,,,413,305.62,,,305.62,Other,150% of Medicare + 9.63% HCRA Surcharge,185.85,45,,185.85,percent of total billed charges,Critical Access Hospital RCC factor,140.42,34,,140.42,percent of total billed charges,Implant Device,140.42,34,,140.42,percent of total billed charges,Implant Device,140.42,34,,140.42,percent of total billed charges,Implant Device,140.42,34,,140.42,percent of total billed charges,Implant Device,140.42,34,,140.42,percent of total billed charges,Implant Device,204.44,,,204.44,Other,110% of Medicare,144.55,35,,144.55,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,144.55,35,,144.55,percent of total billed charges,Implant Device,144.55,35,,144.55,percent of total billed charges,Implant Device,144.55,35,,144.55,percent of total billed charges,Implant Device,144.55,35,,144.55,percent of total billed charges,Implant Device,144.55,35,,144.55,percent of total billed charges,Implant Device,165.2,40,,165.2,percent of total billed charges,Implant Device,144.55,70,,144.55,percent of total billed charges,All Other,140.42,34,,140.42,percent of total billed charges,Implant Device,140.42,34,,140.42,percent of total billed charges,Implant Device,144.55,35,,144.55,percent of total billed charges,Implant Device,144.55,35,,144.55,percent of total billed charges,Implant Device,144.55,35,,144.55,percent of total billed charges,Implant Device,144.55,35,,144.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,305.62,
J&J 249.682 LCP PLATE 6 HOLE 2.7MM,C1713,HCPCS,,79013978,CDM,278,RC,,,both,,,1057,782.18,,,782.18,Other,150% of Medicare + 9.63% HCRA Surcharge,475.65,45,,475.65,percent of total billed charges,Critical Access Hospital RCC factor,359.38,34,,359.38,percent of total billed charges,Implant Device,359.38,34,,359.38,percent of total billed charges,Implant Device,359.38,34,,359.38,percent of total billed charges,Implant Device,359.38,34,,359.38,percent of total billed charges,Implant Device,359.38,34,,359.38,percent of total billed charges,Implant Device,523.22,,,523.22,Other,110% of Medicare,369.95,35,,369.95,percent of total billed charges,Implant Device,359.38,34,"Charges > $500, x 34%",359.38,percent of total billed charges,Implant Device,369.95,35,,369.95,percent of total billed charges,Implant Device,369.95,35,,369.95,percent of total billed charges,Implant Device,369.95,35,,369.95,percent of total billed charges,Implant Device,369.95,35,,369.95,percent of total billed charges,Implant Device,369.95,35,,369.95,percent of total billed charges,Implant Device,422.8,40,,422.8,percent of total billed charges,Implant Device,369.95,70,,369.95,percent of total billed charges,All Other,359.38,34,,359.38,percent of total billed charges,Implant Device,359.38,34,,359.38,percent of total billed charges,Implant Device,369.95,35,,369.95,percent of total billed charges,Implant Device,369.95,35,,369.95,percent of total billed charges,Implant Device,369.95,35,,369.95,percent of total billed charges,Implant Device,369.95,35,,369.95,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,782.18,
J&J 02.247.380S LCP PLATE 16 HOLE 2.7MM,C1713,HCPCS,,79013979,CDM,278,RC,,,both,,,1590,1176.6,,,1176.6,Other,150% of Medicare + 9.63% HCRA Surcharge,715.5,45,,715.5,percent of total billed charges,Critical Access Hospital RCC factor,540.6,34,,540.6,percent of total billed charges,Implant Device,540.6,34,,540.6,percent of total billed charges,Implant Device,540.6,34,,540.6,percent of total billed charges,Implant Device,540.6,34,,540.6,percent of total billed charges,Implant Device,540.6,34,,540.6,percent of total billed charges,Implant Device,787.05,,,787.05,Other,110% of Medicare,556.5,35,,556.5,percent of total billed charges,Implant Device,540.6,34,"Charges > $500, x 34%",540.6,percent of total billed charges,Implant Device,556.5,35,,556.5,percent of total billed charges,Implant Device,556.5,35,,556.5,percent of total billed charges,Implant Device,556.5,35,,556.5,percent of total billed charges,Implant Device,556.5,35,,556.5,percent of total billed charges,Implant Device,556.5,35,,556.5,percent of total billed charges,Implant Device,636,40,,636,percent of total billed charges,Implant Device,556.5,70,,556.5,percent of total billed charges,All Other,540.6,34,,540.6,percent of total billed charges,Implant Device,540.6,34,,540.6,percent of total billed charges,Implant Device,556.5,35,,556.5,percent of total billed charges,Implant Device,556.5,35,,556.5,percent of total billed charges,Implant Device,556.5,35,,556.5,percent of total billed charges,Implant Device,556.5,35,,556.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1176.6,
DJO 392-09-704 TIB KNEE INS E-PLUS SZ 4,C1776,HCPCS,,79013980,CDM,278,RC,,,both,,,2100,1554.01,,,1554.01,Other,150% of Medicare + 9.63% HCRA Surcharge,945,45,,945,percent of total billed charges,Critical Access Hospital RCC factor,714,34,,714,percent of total billed charges,Implant Device,714,34,,714,percent of total billed charges,Implant Device,714,34,,714,percent of total billed charges,Implant Device,714,34,,714,percent of total billed charges,Implant Device,714,34,,714,percent of total billed charges,Implant Device,1039.5,,,1039.5,Other,110% of Medicare,735,35,,735,percent of total billed charges,Implant Device,714,34,"Charges > $500, x 34%",714,percent of total billed charges,Implant Device,735,35,,735,percent of total billed charges,Implant Device,735,35,,735,percent of total billed charges,Implant Device,735,35,,735,percent of total billed charges,Implant Device,735,35,,735,percent of total billed charges,Implant Device,735,35,,735,percent of total billed charges,Implant Device,840,40,,840,percent of total billed charges,Implant Device,735,70,,735,percent of total billed charges,All Other,714,34,,714,percent of total billed charges,Implant Device,714,34,,714,percent of total billed charges,Implant Device,735,35,,735,percent of total billed charges,Implant Device,735,35,,735,percent of total billed charges,Implant Device,735,35,,735,percent of total billed charges,Implant Device,735,35,,735,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,714,34,"If Charge > 2,000, then 34 percent",714,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1554.01,
J&J 96-0087 FEMORAL TC3 CEMENTED SZ 2 RT,C1776,HCPCS,,79013983,CDM,278,RC,,,both,,,18244,13500.61,,,13500.61,Other,150% of Medicare + 9.63% HCRA Surcharge,8209.8,45,,8209.8,percent of total billed charges,Critical Access Hospital RCC factor,6202.96,34,,6202.96,percent of total billed charges,Implant Device,6202.96,34,,6202.96,percent of total billed charges,Implant Device,6202.96,34,,6202.96,percent of total billed charges,Implant Device,6202.96,34,,6202.96,percent of total billed charges,Implant Device,6202.96,34,,6202.96,percent of total billed charges,Implant Device,9030.78,,,9030.78,Other,110% of Medicare,6385.4,35,,6385.4,percent of total billed charges,Implant Device,6202.96,34,"Charges > $500, x 34%",6202.96,percent of total billed charges,Implant Device,6385.4,35,,6385.4,percent of total billed charges,Implant Device,6385.4,35,,6385.4,percent of total billed charges,Implant Device,6385.4,35,,6385.4,percent of total billed charges,Implant Device,6385.4,35,,6385.4,percent of total billed charges,Implant Device,6385.4,35,,6385.4,percent of total billed charges,Implant Device,7297.6,40,,7297.6,percent of total billed charges,Implant Device,6385.4,70,,6385.4,percent of total billed charges,All Other,6202.96,34,,6202.96,percent of total billed charges,Implant Device,6202.96,34,,6202.96,percent of total billed charges,Implant Device,6385.4,35,,6385.4,percent of total billed charges,Implant Device,6385.4,35,,6385.4,percent of total billed charges,Implant Device,6385.4,35,,6385.4,percent of total billed charges,Implant Device,6385.4,35,,6385.4,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,6202.96,34,"If Charge > 2,000, then 34 percent",6202.96,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,13500.61,
J&J 96-0822 DISTAL AUGMENT SIZE 2 8MM LT,C1776,HCPCS,,79013984,CDM,278,RC,,,both,,,3099,2293.27,,,2293.27,Other,150% of Medicare + 9.63% HCRA Surcharge,1394.55,45,,1394.55,percent of total billed charges,Critical Access Hospital RCC factor,1053.66,34,,1053.66,percent of total billed charges,Implant Device,1053.66,34,,1053.66,percent of total billed charges,Implant Device,1053.66,34,,1053.66,percent of total billed charges,Implant Device,1053.66,34,,1053.66,percent of total billed charges,Implant Device,1053.66,34,,1053.66,percent of total billed charges,Implant Device,1534.01,,,1534.01,Other,110% of Medicare,1084.65,35,,1084.65,percent of total billed charges,Implant Device,1053.66,34,"Charges > $500, x 34%",1053.66,percent of total billed charges,Implant Device,1084.65,35,,1084.65,percent of total billed charges,Implant Device,1084.65,35,,1084.65,percent of total billed charges,Implant Device,1084.65,35,,1084.65,percent of total billed charges,Implant Device,1084.65,35,,1084.65,percent of total billed charges,Implant Device,1084.65,35,,1084.65,percent of total billed charges,Implant Device,1239.6,40,,1239.6,percent of total billed charges,Implant Device,1084.65,70,,1084.65,percent of total billed charges,All Other,1053.66,34,,1053.66,percent of total billed charges,Implant Device,1053.66,34,,1053.66,percent of total billed charges,Implant Device,1084.65,35,,1084.65,percent of total billed charges,Implant Device,1084.65,35,,1084.65,percent of total billed charges,Implant Device,1084.65,35,,1084.65,percent of total billed charges,Implant Device,1084.65,35,,1084.65,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1053.66,34,"If Charge > 2,000, then 34 percent",1053.66,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2293.27,
J&J 96-2321 TIBIAL INSERT SIZE 2 10MM,C1776,HCPCS,,79013985,CDM,278,RC,,,both,,,8758,6480.94,,,6480.94,Other,150% of Medicare + 9.63% HCRA Surcharge,3941.1,45,,3941.1,percent of total billed charges,Critical Access Hospital RCC factor,2977.72,34,,2977.72,percent of total billed charges,Implant Device,2977.72,34,,2977.72,percent of total billed charges,Implant Device,2977.72,34,,2977.72,percent of total billed charges,Implant Device,2977.72,34,,2977.72,percent of total billed charges,Implant Device,2977.72,34,,2977.72,percent of total billed charges,Implant Device,4335.21,,,4335.21,Other,110% of Medicare,3065.3,35,,3065.3,percent of total billed charges,Implant Device,2977.72,34,"Charges > $500, x 34%",2977.72,percent of total billed charges,Implant Device,3065.3,35,,3065.3,percent of total billed charges,Implant Device,3065.3,35,,3065.3,percent of total billed charges,Implant Device,3065.3,35,,3065.3,percent of total billed charges,Implant Device,3065.3,35,,3065.3,percent of total billed charges,Implant Device,3065.3,35,,3065.3,percent of total billed charges,Implant Device,3503.2,40,,3503.2,percent of total billed charges,Implant Device,3065.3,70,,3065.3,percent of total billed charges,All Other,2977.72,34,,2977.72,percent of total billed charges,Implant Device,2977.72,34,,2977.72,percent of total billed charges,Implant Device,3065.3,35,,3065.3,percent of total billed charges,Implant Device,3065.3,35,,3065.3,percent of total billed charges,Implant Device,3065.3,35,,3065.3,percent of total billed charges,Implant Device,3065.3,35,,3065.3,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2977.72,34,"If Charge > 2,000, then 34 percent",2977.72,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,6480.94,
STRYKER 3102-1415 CANCELLOUS CHIPS 15CC,C1713,HCPCS,,79013986,CDM,278,RC,,,both,,,615,455.1,,,455.1,Other,150% of Medicare + 9.63% HCRA Surcharge,276.75,45,,276.75,percent of total billed charges,Critical Access Hospital RCC factor,209.1,34,,209.1,percent of total billed charges,Implant Device,209.1,34,,209.1,percent of total billed charges,Implant Device,209.1,34,,209.1,percent of total billed charges,Implant Device,209.1,34,,209.1,percent of total billed charges,Implant Device,209.1,34,,209.1,percent of total billed charges,Implant Device,304.43,,,304.43,Other,110% of Medicare,215.25,35,,215.25,percent of total billed charges,Implant Device,209.1,34,"Charges > $500, x 34%",209.1,percent of total billed charges,Implant Device,215.25,35,,215.25,percent of total billed charges,Implant Device,215.25,35,,215.25,percent of total billed charges,Implant Device,215.25,35,,215.25,percent of total billed charges,Implant Device,215.25,35,,215.25,percent of total billed charges,Implant Device,215.25,35,,215.25,percent of total billed charges,Implant Device,246,40,,246,percent of total billed charges,Implant Device,215.25,70,,215.25,percent of total billed charges,All Other,209.1,34,,209.1,percent of total billed charges,Implant Device,209.1,34,,209.1,percent of total billed charges,Implant Device,215.25,35,,215.25,percent of total billed charges,Implant Device,215.25,35,,215.25,percent of total billed charges,Implant Device,215.25,35,,215.25,percent of total billed charges,Implant Device,215.25,35,,215.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,455.1,
STRYKER 3102-1430 CANCELLOUS CHIPS 30CC,C1713,HCPCS,,79013987,CDM,278,RC,,,both,,,989,731.86,,,731.86,Other,150% of Medicare + 9.63% HCRA Surcharge,445.05,45,,445.05,percent of total billed charges,Critical Access Hospital RCC factor,336.26,34,,336.26,percent of total billed charges,Implant Device,336.26,34,,336.26,percent of total billed charges,Implant Device,336.26,34,,336.26,percent of total billed charges,Implant Device,336.26,34,,336.26,percent of total billed charges,Implant Device,336.26,34,,336.26,percent of total billed charges,Implant Device,489.56,,,489.56,Other,110% of Medicare,346.15,35,,346.15,percent of total billed charges,Implant Device,336.26,34,"Charges > $500, x 34%",336.26,percent of total billed charges,Implant Device,346.15,35,,346.15,percent of total billed charges,Implant Device,346.15,35,,346.15,percent of total billed charges,Implant Device,346.15,35,,346.15,percent of total billed charges,Implant Device,346.15,35,,346.15,percent of total billed charges,Implant Device,346.15,35,,346.15,percent of total billed charges,Implant Device,395.6,40,,395.6,percent of total billed charges,Implant Device,346.15,70,,346.15,percent of total billed charges,All Other,336.26,34,,336.26,percent of total billed charges,Implant Device,336.26,34,,336.26,percent of total billed charges,Implant Device,346.15,35,,346.15,percent of total billed charges,Implant Device,346.15,35,,346.15,percent of total billed charges,Implant Device,346.15,35,,346.15,percent of total billed charges,Implant Device,346.15,35,,346.15,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,731.86,
STRYKER 3102-1460 CANCELLOUS CHIPS 60CC,C1713,HCPCS,,79013988,CDM,278,RC,,,both,,,1620,1198.8,,,1198.8,Other,150% of Medicare + 9.63% HCRA Surcharge,729,45,,729,percent of total billed charges,Critical Access Hospital RCC factor,550.8,34,,550.8,percent of total billed charges,Implant Device,550.8,34,,550.8,percent of total billed charges,Implant Device,550.8,34,,550.8,percent of total billed charges,Implant Device,550.8,34,,550.8,percent of total billed charges,Implant Device,550.8,34,,550.8,percent of total billed charges,Implant Device,801.9,,,801.9,Other,110% of Medicare,567,35,,567,percent of total billed charges,Implant Device,550.8,34,"Charges > $500, x 34%",550.8,percent of total billed charges,Implant Device,567,35,,567,percent of total billed charges,Implant Device,567,35,,567,percent of total billed charges,Implant Device,567,35,,567,percent of total billed charges,Implant Device,567,35,,567,percent of total billed charges,Implant Device,567,35,,567,percent of total billed charges,Implant Device,648,40,,648,percent of total billed charges,Implant Device,567,70,,567,percent of total billed charges,All Other,550.8,34,,550.8,percent of total billed charges,Implant Device,550.8,34,,550.8,percent of total billed charges,Implant Device,567,35,,567,percent of total billed charges,Implant Device,567,35,,567,percent of total billed charges,Implant Device,567,35,,567,percent of total billed charges,Implant Device,567,35,,567,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1198.8,
MEDLINE MSD14028 CANN SCREW 4.0X28MM,C1713,HCPCS,,79013989,CDM,278,RC,,,both,,,1305,965.7,,,965.7,Other,150% of Medicare + 9.63% HCRA Surcharge,587.25,45,,587.25,percent of total billed charges,Critical Access Hospital RCC factor,443.7,34,,443.7,percent of total billed charges,Implant Device,443.7,34,,443.7,percent of total billed charges,Implant Device,443.7,34,,443.7,percent of total billed charges,Implant Device,443.7,34,,443.7,percent of total billed charges,Implant Device,443.7,34,,443.7,percent of total billed charges,Implant Device,645.98,,,645.98,Other,110% of Medicare,456.75,35,,456.75,percent of total billed charges,Implant Device,443.7,34,"Charges > $500, x 34%",443.7,percent of total billed charges,Implant Device,456.75,35,,456.75,percent of total billed charges,Implant Device,456.75,35,,456.75,percent of total billed charges,Implant Device,456.75,35,,456.75,percent of total billed charges,Implant Device,456.75,35,,456.75,percent of total billed charges,Implant Device,456.75,35,,456.75,percent of total billed charges,Implant Device,522,40,,522,percent of total billed charges,Implant Device,456.75,70,,456.75,percent of total billed charges,All Other,443.7,34,,443.7,percent of total billed charges,Implant Device,443.7,34,,443.7,percent of total billed charges,Implant Device,456.75,35,,456.75,percent of total billed charges,Implant Device,456.75,35,,456.75,percent of total billed charges,Implant Device,456.75,35,,456.75,percent of total billed charges,Implant Device,456.75,35,,456.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,965.7,
MENTOR 350-5480BC BREAST IMPLANT 480CC,C1789,HCPCS,,79013990,CDM,278,RC,,,both,,,3225,2386.51,,,2386.51,Other,150% of Medicare + 9.63% HCRA Surcharge,1451.25,45,,1451.25,percent of total billed charges,Critical Access Hospital RCC factor,1096.5,34,,1096.5,percent of total billed charges,Implant Device,1096.5,34,,1096.5,percent of total billed charges,Implant Device,1096.5,34,,1096.5,percent of total billed charges,Implant Device,1096.5,34,,1096.5,percent of total billed charges,Implant Device,1096.5,34,,1096.5,percent of total billed charges,Implant Device,1596.38,,,1596.38,Other,110% of Medicare,1128.75,35,,1128.75,percent of total billed charges,Implant Device,1096.5,34,"Charges > $500, x 34%",1096.5,percent of total billed charges,Implant Device,1128.75,35,,1128.75,percent of total billed charges,Implant Device,1128.75,35,,1128.75,percent of total billed charges,Implant Device,1128.75,35,,1128.75,percent of total billed charges,Implant Device,1128.75,35,,1128.75,percent of total billed charges,Implant Device,1128.75,35,,1128.75,percent of total billed charges,Implant Device,1290,40,,1290,percent of total billed charges,Implant Device,1128.75,70,,1128.75,percent of total billed charges,All Other,1096.5,34,,1096.5,percent of total billed charges,Implant Device,1096.5,34,,1096.5,percent of total billed charges,Implant Device,1128.75,35,,1128.75,percent of total billed charges,Implant Device,1128.75,35,,1128.75,percent of total billed charges,Implant Device,1128.75,35,,1128.75,percent of total billed charges,Implant Device,1128.75,35,,1128.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1096.5,34,"If Charge > 2,000, then 34 percent",1096.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2386.51,
MENTOR 350-3460BC BREAST IMPLANT 460CC,C1789,HCPCS,,79013991,CDM,278,RC,,,both,,,3225,2386.51,,,2386.51,Other,150% of Medicare + 9.63% HCRA Surcharge,1451.25,45,,1451.25,percent of total billed charges,Critical Access Hospital RCC factor,1096.5,34,,1096.5,percent of total billed charges,Implant Device,1096.5,34,,1096.5,percent of total billed charges,Implant Device,1096.5,34,,1096.5,percent of total billed charges,Implant Device,1096.5,34,,1096.5,percent of total billed charges,Implant Device,1096.5,34,,1096.5,percent of total billed charges,Implant Device,1596.38,,,1596.38,Other,110% of Medicare,1128.75,35,,1128.75,percent of total billed charges,Implant Device,1096.5,34,"Charges > $500, x 34%",1096.5,percent of total billed charges,Implant Device,1128.75,35,,1128.75,percent of total billed charges,Implant Device,1128.75,35,,1128.75,percent of total billed charges,Implant Device,1128.75,35,,1128.75,percent of total billed charges,Implant Device,1128.75,35,,1128.75,percent of total billed charges,Implant Device,1128.75,35,,1128.75,percent of total billed charges,Implant Device,1290,40,,1290,percent of total billed charges,Implant Device,1128.75,70,,1128.75,percent of total billed charges,All Other,1096.5,34,,1096.5,percent of total billed charges,Implant Device,1096.5,34,,1096.5,percent of total billed charges,Implant Device,1128.75,35,,1128.75,percent of total billed charges,Implant Device,1128.75,35,,1128.75,percent of total billed charges,Implant Device,1128.75,35,,1128.75,percent of total billed charges,Implant Device,1128.75,35,,1128.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1096.5,34,"If Charge > 2,000, then 34 percent",1096.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2386.51,
MENTOR 350-3460 BREAST IMPLANT 460CC,C1789,HCPCS,,79013993,CDM,278,RC,,,both,,,1545,1143.3,,,1143.3,Other,150% of Medicare + 9.63% HCRA Surcharge,695.25,45,,695.25,percent of total billed charges,Critical Access Hospital RCC factor,525.3,34,,525.3,percent of total billed charges,Implant Device,525.3,34,,525.3,percent of total billed charges,Implant Device,525.3,34,,525.3,percent of total billed charges,Implant Device,525.3,34,,525.3,percent of total billed charges,Implant Device,525.3,34,,525.3,percent of total billed charges,Implant Device,764.78,,,764.78,Other,110% of Medicare,540.75,35,,540.75,percent of total billed charges,Implant Device,525.3,34,"Charges > $500, x 34%",525.3,percent of total billed charges,Implant Device,540.75,35,,540.75,percent of total billed charges,Implant Device,540.75,35,,540.75,percent of total billed charges,Implant Device,540.75,35,,540.75,percent of total billed charges,Implant Device,540.75,35,,540.75,percent of total billed charges,Implant Device,540.75,35,,540.75,percent of total billed charges,Implant Device,618,40,,618,percent of total billed charges,Implant Device,540.75,70,,540.75,percent of total billed charges,All Other,525.3,34,,525.3,percent of total billed charges,Implant Device,525.3,34,,525.3,percent of total billed charges,Implant Device,540.75,35,,540.75,percent of total billed charges,Implant Device,540.75,35,,540.75,percent of total billed charges,Implant Device,540.75,35,,540.75,percent of total billed charges,Implant Device,540.75,35,,540.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1143.3,
WRIGHT 58510000 LAPIDUS PLATE 0MM,C1713,HCPCS,,79013995,CDM,278,RC,,,both,,,7776,5754.26,,,5754.26,Other,150% of Medicare + 9.63% HCRA Surcharge,3499.2,45,,3499.2,percent of total billed charges,Critical Access Hospital RCC factor,2643.84,34,,2643.84,percent of total billed charges,Implant Device,2643.84,34,,2643.84,percent of total billed charges,Implant Device,2643.84,34,,2643.84,percent of total billed charges,Implant Device,2643.84,34,,2643.84,percent of total billed charges,Implant Device,2643.84,34,,2643.84,percent of total billed charges,Implant Device,3849.12,,,3849.12,Other,110% of Medicare,2721.6,35,,2721.6,percent of total billed charges,Implant Device,2643.84,34,"Charges > $500, x 34%",2643.84,percent of total billed charges,Implant Device,2721.6,35,,2721.6,percent of total billed charges,Implant Device,2721.6,35,,2721.6,percent of total billed charges,Implant Device,2721.6,35,,2721.6,percent of total billed charges,Implant Device,2721.6,35,,2721.6,percent of total billed charges,Implant Device,2721.6,35,,2721.6,percent of total billed charges,Implant Device,3110.4,40,,3110.4,percent of total billed charges,Implant Device,2721.6,70,,2721.6,percent of total billed charges,All Other,2643.84,34,,2643.84,percent of total billed charges,Implant Device,2643.84,34,,2643.84,percent of total billed charges,Implant Device,2721.6,35,,2721.6,percent of total billed charges,Implant Device,2721.6,35,,2721.6,percent of total billed charges,Implant Device,2721.6,35,,2721.6,percent of total billed charges,Implant Device,2721.6,35,,2721.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2643.84,34,"If Charge > 2,000, then 34 percent",2643.84,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5754.26,
WRIGHT 58812710 CORTICAL SCREW 2.7X10MM,C1713,HCPCS,,79013996,CDM,278,RC,,,both,,,583,431.42,,,431.42,Other,150% of Medicare + 9.63% HCRA Surcharge,262.35,45,,262.35,percent of total billed charges,Critical Access Hospital RCC factor,198.22,34,,198.22,percent of total billed charges,Implant Device,198.22,34,,198.22,percent of total billed charges,Implant Device,198.22,34,,198.22,percent of total billed charges,Implant Device,198.22,34,,198.22,percent of total billed charges,Implant Device,198.22,34,,198.22,percent of total billed charges,Implant Device,288.59,,,288.59,Other,110% of Medicare,204.05,35,,204.05,percent of total billed charges,Implant Device,198.22,34,"Charges > $500, x 34%",198.22,percent of total billed charges,Implant Device,204.05,35,,204.05,percent of total billed charges,Implant Device,204.05,35,,204.05,percent of total billed charges,Implant Device,204.05,35,,204.05,percent of total billed charges,Implant Device,204.05,35,,204.05,percent of total billed charges,Implant Device,204.05,35,,204.05,percent of total billed charges,Implant Device,233.2,40,,233.2,percent of total billed charges,Implant Device,204.05,70,,204.05,percent of total billed charges,All Other,198.22,34,,198.22,percent of total billed charges,Implant Device,198.22,34,,198.22,percent of total billed charges,Implant Device,204.05,35,,204.05,percent of total billed charges,Implant Device,204.05,35,,204.05,percent of total billed charges,Implant Device,204.05,35,,204.05,percent of total billed charges,Implant Device,204.05,35,,204.05,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,431.42,
WRIGHT 58812714 CORTICAL SCREW 2.7X14MM,C1713,HCPCS,,79013997,CDM,278,RC,,,both,,,583,431.42,,,431.42,Other,150% of Medicare + 9.63% HCRA Surcharge,262.35,45,,262.35,percent of total billed charges,Critical Access Hospital RCC factor,198.22,34,,198.22,percent of total billed charges,Implant Device,198.22,34,,198.22,percent of total billed charges,Implant Device,198.22,34,,198.22,percent of total billed charges,Implant Device,198.22,34,,198.22,percent of total billed charges,Implant Device,198.22,34,,198.22,percent of total billed charges,Implant Device,288.59,,,288.59,Other,110% of Medicare,204.05,35,,204.05,percent of total billed charges,Implant Device,198.22,34,"Charges > $500, x 34%",198.22,percent of total billed charges,Implant Device,204.05,35,,204.05,percent of total billed charges,Implant Device,204.05,35,,204.05,percent of total billed charges,Implant Device,204.05,35,,204.05,percent of total billed charges,Implant Device,204.05,35,,204.05,percent of total billed charges,Implant Device,204.05,35,,204.05,percent of total billed charges,Implant Device,233.2,40,,233.2,percent of total billed charges,Implant Device,204.05,70,,204.05,percent of total billed charges,All Other,198.22,34,,198.22,percent of total billed charges,Implant Device,198.22,34,,198.22,percent of total billed charges,Implant Device,204.05,35,,204.05,percent of total billed charges,Implant Device,204.05,35,,204.05,percent of total billed charges,Implant Device,204.05,35,,204.05,percent of total billed charges,Implant Device,204.05,35,,204.05,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,431.42,
J&J 42.231.018 LOCKING SCREW 5.018MM,C1713,HCPCS,,79013998,CDM,278,RC,,,both,,,733,542.42,,,542.42,Other,150% of Medicare + 9.63% HCRA Surcharge,329.85,45,,329.85,percent of total billed charges,Critical Access Hospital RCC factor,249.22,34,,249.22,percent of total billed charges,Implant Device,249.22,34,,249.22,percent of total billed charges,Implant Device,249.22,34,,249.22,percent of total billed charges,Implant Device,249.22,34,,249.22,percent of total billed charges,Implant Device,249.22,34,,249.22,percent of total billed charges,Implant Device,362.84,,,362.84,Other,110% of Medicare,256.55,35,,256.55,percent of total billed charges,Implant Device,249.22,34,"Charges > $500, x 34%",249.22,percent of total billed charges,Implant Device,256.55,35,,256.55,percent of total billed charges,Implant Device,256.55,35,,256.55,percent of total billed charges,Implant Device,256.55,35,,256.55,percent of total billed charges,Implant Device,256.55,35,,256.55,percent of total billed charges,Implant Device,256.55,35,,256.55,percent of total billed charges,Implant Device,293.2,40,,293.2,percent of total billed charges,Implant Device,256.55,70,,256.55,percent of total billed charges,All Other,249.22,34,,249.22,percent of total billed charges,Implant Device,249.22,34,,249.22,percent of total billed charges,Implant Device,256.55,35,,256.55,percent of total billed charges,Implant Device,256.55,35,,256.55,percent of total billed charges,Implant Device,256.55,35,,256.55,percent of total billed charges,Implant Device,256.55,35,,256.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,542.42,
J&J 42.231.014 LOCKING SCREW 5.0X14MM,C1713,HCPCS,,79013999,CDM,278,RC,,,both,,,733,542.42,,,542.42,Other,150% of Medicare + 9.63% HCRA Surcharge,329.85,45,,329.85,percent of total billed charges,Critical Access Hospital RCC factor,249.22,34,,249.22,percent of total billed charges,Implant Device,249.22,34,,249.22,percent of total billed charges,Implant Device,249.22,34,,249.22,percent of total billed charges,Implant Device,249.22,34,,249.22,percent of total billed charges,Implant Device,249.22,34,,249.22,percent of total billed charges,Implant Device,362.84,,,362.84,Other,110% of Medicare,256.55,35,,256.55,percent of total billed charges,Implant Device,249.22,34,"Charges > $500, x 34%",249.22,percent of total billed charges,Implant Device,256.55,35,,256.55,percent of total billed charges,Implant Device,256.55,35,,256.55,percent of total billed charges,Implant Device,256.55,35,,256.55,percent of total billed charges,Implant Device,256.55,35,,256.55,percent of total billed charges,Implant Device,256.55,35,,256.55,percent of total billed charges,Implant Device,293.2,40,,293.2,percent of total billed charges,Implant Device,256.55,70,,256.55,percent of total billed charges,All Other,249.22,34,,249.22,percent of total billed charges,Implant Device,249.22,34,,249.22,percent of total billed charges,Implant Device,256.55,35,,256.55,percent of total billed charges,Implant Device,256.55,35,,256.55,percent of total billed charges,Implant Device,256.55,35,,256.55,percent of total billed charges,Implant Device,256.55,35,,256.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,542.42,
J&J 224.561 LCP PLATE 4.5X116MM 6 HOLE,C1713,HCPCS,,79014000,CDM,278,RC,,,both,,,999,739.26,,,739.26,Other,150% of Medicare + 9.63% HCRA Surcharge,449.55,45,,449.55,percent of total billed charges,Critical Access Hospital RCC factor,339.66,34,,339.66,percent of total billed charges,Implant Device,339.66,34,,339.66,percent of total billed charges,Implant Device,339.66,34,,339.66,percent of total billed charges,Implant Device,339.66,34,,339.66,percent of total billed charges,Implant Device,339.66,34,,339.66,percent of total billed charges,Implant Device,494.51,,,494.51,Other,110% of Medicare,349.65,35,,349.65,percent of total billed charges,Implant Device,339.66,34,"Charges > $500, x 34%",339.66,percent of total billed charges,Implant Device,349.65,35,,349.65,percent of total billed charges,Implant Device,349.65,35,,349.65,percent of total billed charges,Implant Device,349.65,35,,349.65,percent of total billed charges,Implant Device,349.65,35,,349.65,percent of total billed charges,Implant Device,349.65,35,,349.65,percent of total billed charges,Implant Device,399.6,40,,399.6,percent of total billed charges,Implant Device,349.65,70,,349.65,percent of total billed charges,All Other,339.66,34,,339.66,percent of total billed charges,Implant Device,339.66,34,,339.66,percent of total billed charges,Implant Device,349.65,35,,349.65,percent of total billed charges,Implant Device,349.65,35,,349.65,percent of total billed charges,Implant Device,349.65,35,,349.65,percent of total billed charges,Implant Device,349.65,35,,349.65,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,739.26,
J&J 02.206.224 CORTEX SCREW 3.5X24MM,C1713,HCPCS,,79014001,CDM,278,RC,,,both,,,79,58.46,,,58.46,Other,150% of Medicare + 9.63% HCRA Surcharge,35.55,45,,35.55,percent of total billed charges,Critical Access Hospital RCC factor,26.86,34,,26.86,percent of total billed charges,Implant Device,26.86,34,,26.86,percent of total billed charges,Implant Device,26.86,34,,26.86,percent of total billed charges,Implant Device,26.86,34,,26.86,percent of total billed charges,Implant Device,26.86,34,,26.86,percent of total billed charges,Implant Device,39.11,,,39.11,Other,110% of Medicare,27.65,35,,27.65,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,27.65,35,,27.65,percent of total billed charges,Implant Device,27.65,35,,27.65,percent of total billed charges,Implant Device,27.65,35,,27.65,percent of total billed charges,Implant Device,27.65,35,,27.65,percent of total billed charges,Implant Device,27.65,35,,27.65,percent of total billed charges,Implant Device,31.6,40,,31.6,percent of total billed charges,Implant Device,27.65,70,,27.65,percent of total billed charges,All Other,26.86,34,,26.86,percent of total billed charges,Implant Device,26.86,34,,26.86,percent of total billed charges,Implant Device,27.65,35,,27.65,percent of total billed charges,Implant Device,27.65,35,,27.65,percent of total billed charges,Implant Device,27.65,35,,27.65,percent of total billed charges,Implant Device,27.65,35,,27.65,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,58.46,
J&J 02.118.217S DIS TIB PLT 18H 2.7/3.5,C1713,HCPCS,,79014002,CDM,278,RC,,,both,,,6033,4464.44,,,4464.44,Other,150% of Medicare + 9.63% HCRA Surcharge,2714.85,45,,2714.85,percent of total billed charges,Critical Access Hospital RCC factor,2051.22,34,,2051.22,percent of total billed charges,Implant Device,2051.22,34,,2051.22,percent of total billed charges,Implant Device,2051.22,34,,2051.22,percent of total billed charges,Implant Device,2051.22,34,,2051.22,percent of total billed charges,Implant Device,2051.22,34,,2051.22,percent of total billed charges,Implant Device,2986.34,,,2986.34,Other,110% of Medicare,2111.55,35,,2111.55,percent of total billed charges,Implant Device,2051.22,34,"Charges > $500, x 34%",2051.22,percent of total billed charges,Implant Device,2111.55,35,,2111.55,percent of total billed charges,Implant Device,2111.55,35,,2111.55,percent of total billed charges,Implant Device,2111.55,35,,2111.55,percent of total billed charges,Implant Device,2111.55,35,,2111.55,percent of total billed charges,Implant Device,2111.55,35,,2111.55,percent of total billed charges,Implant Device,2413.2,40,,2413.2,percent of total billed charges,Implant Device,2111.55,70,,2111.55,percent of total billed charges,All Other,2051.22,34,,2051.22,percent of total billed charges,Implant Device,2051.22,34,,2051.22,percent of total billed charges,Implant Device,2111.55,35,,2111.55,percent of total billed charges,Implant Device,2111.55,35,,2111.55,percent of total billed charges,Implant Device,2111.55,35,,2111.55,percent of total billed charges,Implant Device,2111.55,35,,2111.55,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2051.22,34,"If Charge > 2,000, then 34 percent",2051.22,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4464.44,
J&J 04.037.031S CAN NAIL LT 10/125 DEG,C1713,HCPCS,,79014006,CDM,278,RC,,,both,,,98,72.52,,,72.52,Other,150% of Medicare + 9.63% HCRA Surcharge,44.1,45,,44.1,percent of total billed charges,Critical Access Hospital RCC factor,33.32,34,,33.32,percent of total billed charges,Implant Device,33.32,34,,33.32,percent of total billed charges,Implant Device,33.32,34,,33.32,percent of total billed charges,Implant Device,33.32,34,,33.32,percent of total billed charges,Implant Device,33.32,34,,33.32,percent of total billed charges,Implant Device,48.51,,,48.51,Other,110% of Medicare,34.3,35,,34.3,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,34.3,35,,34.3,percent of total billed charges,Implant Device,34.3,35,,34.3,percent of total billed charges,Implant Device,34.3,35,,34.3,percent of total billed charges,Implant Device,34.3,35,,34.3,percent of total billed charges,Implant Device,34.3,35,,34.3,percent of total billed charges,Implant Device,39.2,40,,39.2,percent of total billed charges,Implant Device,34.3,70,,34.3,percent of total billed charges,All Other,33.32,34,,33.32,percent of total billed charges,Implant Device,33.32,34,,33.32,percent of total billed charges,Implant Device,34.3,35,,34.3,percent of total billed charges,Implant Device,34.3,35,,34.3,percent of total billed charges,Implant Device,34.3,35,,34.3,percent of total billed charges,Implant Device,34.3,35,,34.3,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,72.52,
J&J 1217-22-052 ACETABULAR SHELL 52MM,C1713,HCPCS,,79014008,CDM,278,RC,,,both,,,2636,1950.65,,,1950.65,Other,150% of Medicare + 9.63% HCRA Surcharge,1186.2,45,,1186.2,percent of total billed charges,Critical Access Hospital RCC factor,896.24,34,,896.24,percent of total billed charges,Implant Device,896.24,34,,896.24,percent of total billed charges,Implant Device,896.24,34,,896.24,percent of total billed charges,Implant Device,896.24,34,,896.24,percent of total billed charges,Implant Device,896.24,34,,896.24,percent of total billed charges,Implant Device,1304.82,,,1304.82,Other,110% of Medicare,922.6,35,,922.6,percent of total billed charges,Implant Device,896.24,34,"Charges > $500, x 34%",896.24,percent of total billed charges,Implant Device,922.6,35,,922.6,percent of total billed charges,Implant Device,922.6,35,,922.6,percent of total billed charges,Implant Device,922.6,35,,922.6,percent of total billed charges,Implant Device,922.6,35,,922.6,percent of total billed charges,Implant Device,922.6,35,,922.6,percent of total billed charges,Implant Device,1054.4,40,,1054.4,percent of total billed charges,Implant Device,922.6,70,,922.6,percent of total billed charges,All Other,896.24,34,,896.24,percent of total billed charges,Implant Device,896.24,34,,896.24,percent of total billed charges,Implant Device,922.6,35,,922.6,percent of total billed charges,Implant Device,922.6,35,,922.6,percent of total billed charges,Implant Device,922.6,35,,922.6,percent of total billed charges,Implant Device,922.6,35,,922.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,896.24,34,"If Charge > 2,000, then 34 percent",896.24,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1950.65,
J&J 02.118.528 METAPHYSEA SCREW 2.7X28,C1713,HCPCS,,79014009,CDM,278,RC,,,both,,,125,92.5,,,92.5,Other,150% of Medicare + 9.63% HCRA Surcharge,56.25,45,,56.25,percent of total billed charges,Critical Access Hospital RCC factor,42.5,34,,42.5,percent of total billed charges,Implant Device,42.5,34,,42.5,percent of total billed charges,Implant Device,42.5,34,,42.5,percent of total billed charges,Implant Device,42.5,34,,42.5,percent of total billed charges,Implant Device,42.5,34,,42.5,percent of total billed charges,Implant Device,61.88,,,61.88,Other,110% of Medicare,43.75,35,,43.75,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,43.75,35,,43.75,percent of total billed charges,Implant Device,43.75,35,,43.75,percent of total billed charges,Implant Device,43.75,35,,43.75,percent of total billed charges,Implant Device,43.75,35,,43.75,percent of total billed charges,Implant Device,43.75,35,,43.75,percent of total billed charges,Implant Device,50,40,,50,percent of total billed charges,Implant Device,43.75,70,,43.75,percent of total billed charges,All Other,42.5,34,,42.5,percent of total billed charges,Implant Device,42.5,34,,42.5,percent of total billed charges,Implant Device,43.75,35,,43.75,percent of total billed charges,Implant Device,43.75,35,,43.75,percent of total billed charges,Implant Device,43.75,35,,43.75,percent of total billed charges,Implant Device,43.75,35,,43.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,92.5,
DJO 530-06-108 HUM STEM REVERSE 6X108,C1776,HCPCS,,79014010,CDM,278,RC,,,both,,,14400,10656.04,,,10656.04,Other,150% of Medicare + 9.63% HCRA Surcharge,6480,45,,6480,percent of total billed charges,Critical Access Hospital RCC factor,4896,34,,4896,percent of total billed charges,Implant Device,4896,34,,4896,percent of total billed charges,Implant Device,4896,34,,4896,percent of total billed charges,Implant Device,4896,34,,4896,percent of total billed charges,Implant Device,4896,34,,4896,percent of total billed charges,Implant Device,7128,,,7128,Other,110% of Medicare,5040,35,,5040,percent of total billed charges,Implant Device,4896,34,"Charges > $500, x 34%",4896,percent of total billed charges,Implant Device,5040,35,,5040,percent of total billed charges,Implant Device,5040,35,,5040,percent of total billed charges,Implant Device,5040,35,,5040,percent of total billed charges,Implant Device,5040,35,,5040,percent of total billed charges,Implant Device,5040,35,,5040,percent of total billed charges,Implant Device,5760,40,,5760,percent of total billed charges,Implant Device,5040,70,,5040,percent of total billed charges,All Other,4896,34,,4896,percent of total billed charges,Implant Device,4896,34,,4896,percent of total billed charges,Implant Device,5040,35,,5040,percent of total billed charges,Implant Device,5040,35,,5040,percent of total billed charges,Implant Device,5040,35,,5040,percent of total billed charges,Implant Device,5040,35,,5040,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,4896,34,"If Charge > 2,000, then 34 percent",4896,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,10656.04,
J&J 1516-30-516 INSERT SIZE 5 16MM,C1776,HCPCS,,79014011,CDM,278,RC,,,both,,,5400,3996.01,,,3996.01,Other,150% of Medicare + 9.63% HCRA Surcharge,2430,45,,2430,percent of total billed charges,Critical Access Hospital RCC factor,1836,34,,1836,percent of total billed charges,Implant Device,1836,34,,1836,percent of total billed charges,Implant Device,1836,34,,1836,percent of total billed charges,Implant Device,1836,34,,1836,percent of total billed charges,Implant Device,1836,34,,1836,percent of total billed charges,Implant Device,2673,,,2673,Other,110% of Medicare,1890,35,,1890,percent of total billed charges,Implant Device,1836,34,"Charges > $500, x 34%",1836,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,2160,40,,2160,percent of total billed charges,Implant Device,1890,70,,1890,percent of total billed charges,All Other,1836,34,,1836,percent of total billed charges,Implant Device,1836,34,,1836,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,1890,35,,1890,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1836,34,"If Charge > 2,000, then 34 percent",1836,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3996.01,
J&J 1217-22-052 PINNACLE SECTOR II CUP52,C1776,HCPCS,,79014012,CDM,278,RC,,,both,,,2636,1950.65,,,1950.65,Other,150% of Medicare + 9.63% HCRA Surcharge,1186.2,45,,1186.2,percent of total billed charges,Critical Access Hospital RCC factor,896.24,34,,896.24,percent of total billed charges,Implant Device,896.24,34,,896.24,percent of total billed charges,Implant Device,896.24,34,,896.24,percent of total billed charges,Implant Device,896.24,34,,896.24,percent of total billed charges,Implant Device,896.24,34,,896.24,percent of total billed charges,Implant Device,1304.82,,,1304.82,Other,110% of Medicare,922.6,35,,922.6,percent of total billed charges,Implant Device,896.24,34,"Charges > $500, x 34%",896.24,percent of total billed charges,Implant Device,922.6,35,,922.6,percent of total billed charges,Implant Device,922.6,35,,922.6,percent of total billed charges,Implant Device,922.6,35,,922.6,percent of total billed charges,Implant Device,922.6,35,,922.6,percent of total billed charges,Implant Device,922.6,35,,922.6,percent of total billed charges,Implant Device,1054.4,40,,1054.4,percent of total billed charges,Implant Device,922.6,70,,922.6,percent of total billed charges,All Other,896.24,34,,896.24,percent of total billed charges,Implant Device,896.24,34,,896.24,percent of total billed charges,Implant Device,922.6,35,,922.6,percent of total billed charges,Implant Device,922.6,35,,922.6,percent of total billed charges,Implant Device,922.6,35,,922.6,percent of total billed charges,Implant Device,922.6,35,,922.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,896.24,34,"If Charge > 2,000, then 34 percent",896.24,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1950.65,
EXACTECH 314-24-24 LASER CAGE GLENOID 8,C1776,HCPCS,,79014013,CDM,278,RC,,,both,,,7725,5716.52,,,5716.52,Other,150% of Medicare + 9.63% HCRA Surcharge,3476.25,45,,3476.25,percent of total billed charges,Critical Access Hospital RCC factor,2626.5,34,,2626.5,percent of total billed charges,Implant Device,2626.5,34,,2626.5,percent of total billed charges,Implant Device,2626.5,34,,2626.5,percent of total billed charges,Implant Device,2626.5,34,,2626.5,percent of total billed charges,Implant Device,2626.5,34,,2626.5,percent of total billed charges,Implant Device,3823.88,,,3823.88,Other,110% of Medicare,2703.75,35,,2703.75,percent of total billed charges,Implant Device,2626.5,34,"Charges > $500, x 34%",2626.5,percent of total billed charges,Implant Device,2703.75,35,,2703.75,percent of total billed charges,Implant Device,2703.75,35,,2703.75,percent of total billed charges,Implant Device,2703.75,35,,2703.75,percent of total billed charges,Implant Device,2703.75,35,,2703.75,percent of total billed charges,Implant Device,2703.75,35,,2703.75,percent of total billed charges,Implant Device,3090,40,,3090,percent of total billed charges,Implant Device,2703.75,70,,2703.75,percent of total billed charges,All Other,2626.5,34,,2626.5,percent of total billed charges,Implant Device,2626.5,34,,2626.5,percent of total billed charges,Implant Device,2703.75,35,,2703.75,percent of total billed charges,Implant Device,2703.75,35,,2703.75,percent of total billed charges,Implant Device,2703.75,35,,2703.75,percent of total billed charges,Implant Device,2703.75,35,,2703.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2626.5,34,"If Charge > 2,000, then 34 percent",2626.5,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5716.52,
PAR 28 P20-140-036S CANN THREAD SRW 4X36,C1713,HCPCS,,79014014,CDM,278,RC,,,both,,,830,614.2,,,614.2,Other,150% of Medicare + 9.63% HCRA Surcharge,373.5,45,,373.5,percent of total billed charges,Critical Access Hospital RCC factor,282.2,34,,282.2,percent of total billed charges,Implant Device,282.2,34,,282.2,percent of total billed charges,Implant Device,282.2,34,,282.2,percent of total billed charges,Implant Device,282.2,34,,282.2,percent of total billed charges,Implant Device,282.2,34,,282.2,percent of total billed charges,Implant Device,410.85,,,410.85,Other,110% of Medicare,290.5,35,,290.5,percent of total billed charges,Implant Device,282.2,34,"Charges > $500, x 34%",282.2,percent of total billed charges,Implant Device,290.5,35,,290.5,percent of total billed charges,Implant Device,290.5,35,,290.5,percent of total billed charges,Implant Device,290.5,35,,290.5,percent of total billed charges,Implant Device,290.5,35,,290.5,percent of total billed charges,Implant Device,290.5,35,,290.5,percent of total billed charges,Implant Device,332,40,,332,percent of total billed charges,Implant Device,290.5,70,,290.5,percent of total billed charges,All Other,282.2,34,,282.2,percent of total billed charges,Implant Device,282.2,34,,282.2,percent of total billed charges,Implant Device,290.5,35,,290.5,percent of total billed charges,Implant Device,290.5,35,,290.5,percent of total billed charges,Implant Device,290.5,35,,290.5,percent of total billed charges,Implant Device,290.5,35,,290.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,614.2,
PAR28 P72-018-1818-S STAPLE KIT 18X18X18,C1713,HCPCS,,79014015,CDM,278,RC,,,both,,,8235,6093.92,,,6093.92,Other,150% of Medicare + 9.63% HCRA Surcharge,3705.75,45,,3705.75,percent of total billed charges,Critical Access Hospital RCC factor,2799.9,34,,2799.9,percent of total billed charges,Implant Device,2799.9,34,,2799.9,percent of total billed charges,Implant Device,2799.9,34,,2799.9,percent of total billed charges,Implant Device,2799.9,34,,2799.9,percent of total billed charges,Implant Device,2799.9,34,,2799.9,percent of total billed charges,Implant Device,4076.33,,,4076.33,Other,110% of Medicare,2882.25,35,,2882.25,percent of total billed charges,Implant Device,2799.9,34,"Charges > $500, x 34%",2799.9,percent of total billed charges,Implant Device,2882.25,35,,2882.25,percent of total billed charges,Implant Device,2882.25,35,,2882.25,percent of total billed charges,Implant Device,2882.25,35,,2882.25,percent of total billed charges,Implant Device,2882.25,35,,2882.25,percent of total billed charges,Implant Device,2882.25,35,,2882.25,percent of total billed charges,Implant Device,3294,40,,3294,percent of total billed charges,Implant Device,2882.25,70,,2882.25,percent of total billed charges,All Other,2799.9,34,,2799.9,percent of total billed charges,Implant Device,2799.9,34,,2799.9,percent of total billed charges,Implant Device,2882.25,35,,2882.25,percent of total billed charges,Implant Device,2882.25,35,,2882.25,percent of total billed charges,Implant Device,2882.25,35,,2882.25,percent of total billed charges,Implant Device,2882.25,35,,2882.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2799.9,34,"If Charge > 2,000, then 34 percent",2799.9,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,6093.92,
EXACTECH 320-10-10 EQUINOX REV TRAY ADA,C1776,HCPCS,,79014017,CDM,278,RC,,,both,,,4950,3663.01,,,3663.01,Other,150% of Medicare + 9.63% HCRA Surcharge,2227.5,45,,2227.5,percent of total billed charges,Critical Access Hospital RCC factor,1683,34,,1683,percent of total billed charges,Implant Device,1683,34,,1683,percent of total billed charges,Implant Device,1683,34,,1683,percent of total billed charges,Implant Device,1683,34,,1683,percent of total billed charges,Implant Device,1683,34,,1683,percent of total billed charges,Implant Device,2450.25,,,2450.25,Other,110% of Medicare,1732.5,35,,1732.5,percent of total billed charges,Implant Device,1683,34,"Charges > $500, x 34%",1683,percent of total billed charges,Implant Device,1732.5,35,,1732.5,percent of total billed charges,Implant Device,1732.5,35,,1732.5,percent of total billed charges,Implant Device,1732.5,35,,1732.5,percent of total billed charges,Implant Device,1732.5,35,,1732.5,percent of total billed charges,Implant Device,1732.5,35,,1732.5,percent of total billed charges,Implant Device,1980,40,,1980,percent of total billed charges,Implant Device,1732.5,70,,1732.5,percent of total billed charges,All Other,1683,34,,1683,percent of total billed charges,Implant Device,1683,34,,1683,percent of total billed charges,Implant Device,1732.5,35,,1732.5,percent of total billed charges,Implant Device,1732.5,35,,1732.5,percent of total billed charges,Implant Device,1732.5,35,,1732.5,percent of total billed charges,Implant Device,1732.5,35,,1732.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1683,34,"If Charge > 2,000, then 34 percent",1683,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3663.01,
ARTHREX AR-8935CL-12 KREULOCK SRW 3.5X12,C1713,HCPCS,,79014018,CDM,278,RC,,,both,,,959,709.66,,,709.66,Other,150% of Medicare + 9.63% HCRA Surcharge,431.55,45,,431.55,percent of total billed charges,Critical Access Hospital RCC factor,326.06,34,,326.06,percent of total billed charges,Implant Device,326.06,34,,326.06,percent of total billed charges,Implant Device,326.06,34,,326.06,percent of total billed charges,Implant Device,326.06,34,,326.06,percent of total billed charges,Implant Device,326.06,34,,326.06,percent of total billed charges,Implant Device,474.71,,,474.71,Other,110% of Medicare,335.65,35,,335.65,percent of total billed charges,Implant Device,326.06,34,"Charges > $500, x 34%",326.06,percent of total billed charges,Implant Device,335.65,35,,335.65,percent of total billed charges,Implant Device,335.65,35,,335.65,percent of total billed charges,Implant Device,335.65,35,,335.65,percent of total billed charges,Implant Device,335.65,35,,335.65,percent of total billed charges,Implant Device,335.65,35,,335.65,percent of total billed charges,Implant Device,383.6,40,,383.6,percent of total billed charges,Implant Device,335.65,70,,335.65,percent of total billed charges,All Other,326.06,34,,326.06,percent of total billed charges,Implant Device,326.06,34,,326.06,percent of total billed charges,Implant Device,335.65,35,,335.65,percent of total billed charges,Implant Device,335.65,35,,335.65,percent of total billed charges,Implant Device,335.65,35,,335.65,percent of total billed charges,Implant Device,335.65,35,,335.65,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,709.66,
STRYKER 5570-3602 HUMERAL CUP 36X2MM,C1776,HCPCS,,79014020,CDM,278,RC,,,both,,,6000,4440.02,,,4440.02,Other,150% of Medicare + 9.63% HCRA Surcharge,2700,45,,2700,percent of total billed charges,Critical Access Hospital RCC factor,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2970,,,2970,Other,110% of Medicare,2100,35,,2100,percent of total billed charges,Implant Device,2040,34,"Charges > $500, x 34%",2040,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2400,40,,2400,percent of total billed charges,Implant Device,2100,70,,2100,percent of total billed charges,All Other,2040,34,,2040,percent of total billed charges,Implant Device,2040,34,,2040,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,2100,35,,2100,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2040,34,"If Charge > 2,000, then 34 percent",2040,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4440.02,
STRYKER 5817001R MIDFOOT FUSION U PLT RT,C1713,HCPCS,,79014021,CDM,278,RC,,,both,,,8932,6609.7,,,6609.7,Other,150% of Medicare + 9.63% HCRA Surcharge,4019.4,45,,4019.4,percent of total billed charges,Critical Access Hospital RCC factor,3036.88,34,,3036.88,percent of total billed charges,Implant Device,3036.88,34,,3036.88,percent of total billed charges,Implant Device,3036.88,34,,3036.88,percent of total billed charges,Implant Device,3036.88,34,,3036.88,percent of total billed charges,Implant Device,3036.88,34,,3036.88,percent of total billed charges,Implant Device,4421.34,,,4421.34,Other,110% of Medicare,3126.2,35,,3126.2,percent of total billed charges,Implant Device,3036.88,34,"Charges > $500, x 34%",3036.88,percent of total billed charges,Implant Device,3126.2,35,,3126.2,percent of total billed charges,Implant Device,3126.2,35,,3126.2,percent of total billed charges,Implant Device,3126.2,35,,3126.2,percent of total billed charges,Implant Device,3126.2,35,,3126.2,percent of total billed charges,Implant Device,3126.2,35,,3126.2,percent of total billed charges,Implant Device,3572.8,40,,3572.8,percent of total billed charges,Implant Device,3126.2,70,,3126.2,percent of total billed charges,All Other,3036.88,34,,3036.88,percent of total billed charges,Implant Device,3036.88,34,,3036.88,percent of total billed charges,Implant Device,3126.2,35,,3126.2,percent of total billed charges,Implant Device,3126.2,35,,3126.2,percent of total billed charges,Implant Device,3126.2,35,,3126.2,percent of total billed charges,Implant Device,3126.2,35,,3126.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,3036.88,34,"If Charge > 2,000, then 34 percent",3036.88,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,6609.7,
STRYKER 58180000 MIDFOOT FUSION STGT PLT,C1713,HCPCS,,79014022,CDM,278,RC,,,both,,,5608,4149.93,,,4149.93,Other,150% of Medicare + 9.63% HCRA Surcharge,2523.6,45,,2523.6,percent of total billed charges,Critical Access Hospital RCC factor,1906.72,34,,1906.72,percent of total billed charges,Implant Device,1906.72,34,,1906.72,percent of total billed charges,Implant Device,1906.72,34,,1906.72,percent of total billed charges,Implant Device,1906.72,34,,1906.72,percent of total billed charges,Implant Device,1906.72,34,,1906.72,percent of total billed charges,Implant Device,2775.96,,,2775.96,Other,110% of Medicare,1962.8,35,,1962.8,percent of total billed charges,Implant Device,1906.72,34,"Charges > $500, x 34%",1906.72,percent of total billed charges,Implant Device,1962.8,35,,1962.8,percent of total billed charges,Implant Device,1962.8,35,,1962.8,percent of total billed charges,Implant Device,1962.8,35,,1962.8,percent of total billed charges,Implant Device,1962.8,35,,1962.8,percent of total billed charges,Implant Device,1962.8,35,,1962.8,percent of total billed charges,Implant Device,2243.2,40,,2243.2,percent of total billed charges,Implant Device,1962.8,70,,1962.8,percent of total billed charges,All Other,1906.72,34,,1906.72,percent of total billed charges,Implant Device,1906.72,34,,1906.72,percent of total billed charges,Implant Device,1962.8,35,,1962.8,percent of total billed charges,Implant Device,1962.8,35,,1962.8,percent of total billed charges,Implant Device,1962.8,35,,1962.8,percent of total billed charges,Implant Device,1962.8,35,,1962.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1906.72,34,"If Charge > 2,000, then 34 percent",1906.72,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4149.93,
STRYKER 58802716 LOCKING SCREW 2.7X16MM,C1713,HCPCS,,79014023,CDM,278,RC,,,both,,,1145,847.3,,,847.3,Other,150% of Medicare + 9.63% HCRA Surcharge,515.25,45,,515.25,percent of total billed charges,Critical Access Hospital RCC factor,389.3,34,,389.3,percent of total billed charges,Implant Device,389.3,34,,389.3,percent of total billed charges,Implant Device,389.3,34,,389.3,percent of total billed charges,Implant Device,389.3,34,,389.3,percent of total billed charges,Implant Device,389.3,34,,389.3,percent of total billed charges,Implant Device,566.78,,,566.78,Other,110% of Medicare,400.75,35,,400.75,percent of total billed charges,Implant Device,389.3,34,"Charges > $500, x 34%",389.3,percent of total billed charges,Implant Device,400.75,35,,400.75,percent of total billed charges,Implant Device,400.75,35,,400.75,percent of total billed charges,Implant Device,400.75,35,,400.75,percent of total billed charges,Implant Device,400.75,35,,400.75,percent of total billed charges,Implant Device,400.75,35,,400.75,percent of total billed charges,Implant Device,458,40,,458,percent of total billed charges,Implant Device,400.75,70,,400.75,percent of total billed charges,All Other,389.3,34,,389.3,percent of total billed charges,Implant Device,389.3,34,,389.3,percent of total billed charges,Implant Device,400.75,35,,400.75,percent of total billed charges,Implant Device,400.75,35,,400.75,percent of total billed charges,Implant Device,400.75,35,,400.75,percent of total billed charges,Implant Device,400.75,35,,400.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,847.3,
STRYKER 58802718 LOCKING SCREW 2.7X18MM,C1713,HCPCS,,79014024,CDM,278,RC,,,both,,,1145,847.3,,,847.3,Other,150% of Medicare + 9.63% HCRA Surcharge,515.25,45,,515.25,percent of total billed charges,Critical Access Hospital RCC factor,389.3,34,,389.3,percent of total billed charges,Implant Device,389.3,34,,389.3,percent of total billed charges,Implant Device,389.3,34,,389.3,percent of total billed charges,Implant Device,389.3,34,,389.3,percent of total billed charges,Implant Device,389.3,34,,389.3,percent of total billed charges,Implant Device,566.78,,,566.78,Other,110% of Medicare,400.75,35,,400.75,percent of total billed charges,Implant Device,389.3,34,"Charges > $500, x 34%",389.3,percent of total billed charges,Implant Device,400.75,35,,400.75,percent of total billed charges,Implant Device,400.75,35,,400.75,percent of total billed charges,Implant Device,400.75,35,,400.75,percent of total billed charges,Implant Device,400.75,35,,400.75,percent of total billed charges,Implant Device,400.75,35,,400.75,percent of total billed charges,Implant Device,458,40,,458,percent of total billed charges,Implant Device,400.75,70,,400.75,percent of total billed charges,All Other,389.3,34,,389.3,percent of total billed charges,Implant Device,389.3,34,,389.3,percent of total billed charges,Implant Device,400.75,35,,400.75,percent of total billed charges,Implant Device,400.75,35,,400.75,percent of total billed charges,Implant Device,400.75,35,,400.75,percent of total billed charges,Implant Device,400.75,35,,400.75,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,847.3,
STRYKER 58812718 CORTICAL SCREW 2.7X18MM,C1713,HCPCS,,79014025,CDM,278,RC,,,both,,,583,431.42,,,431.42,Other,150% of Medicare + 9.63% HCRA Surcharge,262.35,45,,262.35,percent of total billed charges,Critical Access Hospital RCC factor,198.22,34,,198.22,percent of total billed charges,Implant Device,198.22,34,,198.22,percent of total billed charges,Implant Device,198.22,34,,198.22,percent of total billed charges,Implant Device,198.22,34,,198.22,percent of total billed charges,Implant Device,198.22,34,,198.22,percent of total billed charges,Implant Device,288.59,,,288.59,Other,110% of Medicare,204.05,35,,204.05,percent of total billed charges,Implant Device,198.22,34,"Charges > $500, x 34%",198.22,percent of total billed charges,Implant Device,204.05,35,,204.05,percent of total billed charges,Implant Device,204.05,35,,204.05,percent of total billed charges,Implant Device,204.05,35,,204.05,percent of total billed charges,Implant Device,204.05,35,,204.05,percent of total billed charges,Implant Device,204.05,35,,204.05,percent of total billed charges,Implant Device,233.2,40,,233.2,percent of total billed charges,Implant Device,204.05,70,,204.05,percent of total billed charges,All Other,198.22,34,,198.22,percent of total billed charges,Implant Device,198.22,34,,198.22,percent of total billed charges,Implant Device,204.05,35,,204.05,percent of total billed charges,Implant Device,204.05,35,,204.05,percent of total billed charges,Implant Device,204.05,35,,204.05,percent of total billed charges,Implant Device,204.05,35,,204.05,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,431.42,
STRYKER 58812720 CORTICAL SCREW 2.7X20MM,C1713,HCPCS,,79014026,CDM,278,RC,,,both,,,583,431.42,,,431.42,Other,150% of Medicare + 9.63% HCRA Surcharge,262.35,45,,262.35,percent of total billed charges,Critical Access Hospital RCC factor,198.22,34,,198.22,percent of total billed charges,Implant Device,198.22,34,,198.22,percent of total billed charges,Implant Device,198.22,34,,198.22,percent of total billed charges,Implant Device,198.22,34,,198.22,percent of total billed charges,Implant Device,198.22,34,,198.22,percent of total billed charges,Implant Device,288.59,,,288.59,Other,110% of Medicare,204.05,35,,204.05,percent of total billed charges,Implant Device,198.22,34,"Charges > $500, x 34%",198.22,percent of total billed charges,Implant Device,204.05,35,,204.05,percent of total billed charges,Implant Device,204.05,35,,204.05,percent of total billed charges,Implant Device,204.05,35,,204.05,percent of total billed charges,Implant Device,204.05,35,,204.05,percent of total billed charges,Implant Device,204.05,35,,204.05,percent of total billed charges,Implant Device,233.2,40,,233.2,percent of total billed charges,Implant Device,204.05,70,,204.05,percent of total billed charges,All Other,198.22,34,,198.22,percent of total billed charges,Implant Device,198.22,34,,198.22,percent of total billed charges,Implant Device,204.05,35,,204.05,percent of total billed charges,Implant Device,204.05,35,,204.05,percent of total billed charges,Implant Device,204.05,35,,204.05,percent of total billed charges,Implant Device,204.05,35,,204.05,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,431.42,
STRYKER 58812722 CORTICAL SCREW 2.7X22MM,C1713,HCPCS,,79014027,CDM,278,RC,,,both,,,583,431.42,,,431.42,Other,150% of Medicare + 9.63% HCRA Surcharge,262.35,45,,262.35,percent of total billed charges,Critical Access Hospital RCC factor,198.22,34,,198.22,percent of total billed charges,Implant Device,198.22,34,,198.22,percent of total billed charges,Implant Device,198.22,34,,198.22,percent of total billed charges,Implant Device,198.22,34,,198.22,percent of total billed charges,Implant Device,198.22,34,,198.22,percent of total billed charges,Implant Device,288.59,,,288.59,Other,110% of Medicare,204.05,35,,204.05,percent of total billed charges,Implant Device,198.22,34,"Charges > $500, x 34%",198.22,percent of total billed charges,Implant Device,204.05,35,,204.05,percent of total billed charges,Implant Device,204.05,35,,204.05,percent of total billed charges,Implant Device,204.05,35,,204.05,percent of total billed charges,Implant Device,204.05,35,,204.05,percent of total billed charges,Implant Device,204.05,35,,204.05,percent of total billed charges,Implant Device,233.2,40,,233.2,percent of total billed charges,Implant Device,204.05,70,,204.05,percent of total billed charges,All Other,198.22,34,,198.22,percent of total billed charges,Implant Device,198.22,34,,198.22,percent of total billed charges,Implant Device,204.05,35,,204.05,percent of total billed charges,Implant Device,204.05,35,,204.05,percent of total billed charges,Implant Device,204.05,35,,204.05,percent of total billed charges,Implant Device,204.05,35,,204.05,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,431.42,
STRYKER 58812724 CORTICAL SCREW 2.7X24MM,C1713,HCPCS,,79014028,CDM,278,RC,,,both,,,583,431.42,,,431.42,Other,150% of Medicare + 9.63% HCRA Surcharge,262.35,45,,262.35,percent of total billed charges,Critical Access Hospital RCC factor,198.22,34,,198.22,percent of total billed charges,Implant Device,198.22,34,,198.22,percent of total billed charges,Implant Device,198.22,34,,198.22,percent of total billed charges,Implant Device,198.22,34,,198.22,percent of total billed charges,Implant Device,198.22,34,,198.22,percent of total billed charges,Implant Device,288.59,,,288.59,Other,110% of Medicare,204.05,35,,204.05,percent of total billed charges,Implant Device,198.22,34,"Charges > $500, x 34%",198.22,percent of total billed charges,Implant Device,204.05,35,,204.05,percent of total billed charges,Implant Device,204.05,35,,204.05,percent of total billed charges,Implant Device,204.05,35,,204.05,percent of total billed charges,Implant Device,204.05,35,,204.05,percent of total billed charges,Implant Device,204.05,35,,204.05,percent of total billed charges,Implant Device,233.2,40,,233.2,percent of total billed charges,Implant Device,204.05,70,,204.05,percent of total billed charges,All Other,198.22,34,,198.22,percent of total billed charges,Implant Device,198.22,34,,198.22,percent of total billed charges,Implant Device,204.05,35,,204.05,percent of total billed charges,Implant Device,204.05,35,,204.05,percent of total billed charges,Implant Device,204.05,35,,204.05,percent of total billed charges,Implant Device,204.05,35,,204.05,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,431.42,
STRTKER K30001510 AUGMENT INJECT KIT 1.5,C1734,HCPCS,,79014031,CDM,278,RC,,,both,,,7669,5675.08,,,5675.08,Other,150% of Medicare + 9.63% HCRA Surcharge,3451.05,45,,3451.05,percent of total billed charges,Critical Access Hospital RCC factor,2607.46,34,,2607.46,percent of total billed charges,Implant Device,2607.46,34,,2607.46,percent of total billed charges,Implant Device,2607.46,34,,2607.46,percent of total billed charges,Implant Device,2607.46,34,,2607.46,percent of total billed charges,Implant Device,2607.46,34,,2607.46,percent of total billed charges,Implant Device,3796.16,,,3796.16,Other,110% of Medicare,2684.15,35,,2684.15,percent of total billed charges,Implant Device,2607.46,34,"Charges > $500, x 34%",2607.46,percent of total billed charges,Implant Device,2684.15,35,,2684.15,percent of total billed charges,Implant Device,2684.15,35,,2684.15,percent of total billed charges,Implant Device,2684.15,35,,2684.15,percent of total billed charges,Implant Device,2684.15,35,,2684.15,percent of total billed charges,Implant Device,2684.15,35,,2684.15,percent of total billed charges,Implant Device,3067.6,40,,3067.6,percent of total billed charges,Implant Device,2684.15,70,,2684.15,percent of total billed charges,All Other,2607.46,34,,2607.46,percent of total billed charges,Implant Device,2607.46,34,,2607.46,percent of total billed charges,Implant Device,2684.15,35,,2684.15,percent of total billed charges,Implant Device,2684.15,35,,2684.15,percent of total billed charges,Implant Device,2684.15,35,,2684.15,percent of total billed charges,Implant Device,2684.15,35,,2684.15,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,2607.46,34,"If Charge > 2,000, then 34 percent",2607.46,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5675.08,
GORE SRRT06060080L VASC GRAFT RING 6X40,C1768,HCPCS,,79014033,CDM,278,RC,,,both,,,4074,3014.77,,,3014.77,Other,150% of Medicare + 9.63% HCRA Surcharge,1833.3,45,,1833.3,percent of total billed charges,Critical Access Hospital RCC factor,1385.16,34,,1385.16,percent of total billed charges,Implant Device,1385.16,34,,1385.16,percent of total billed charges,Implant Device,1385.16,34,,1385.16,percent of total billed charges,Implant Device,1385.16,34,,1385.16,percent of total billed charges,Implant Device,1385.16,34,,1385.16,percent of total billed charges,Implant Device,2016.63,,,2016.63,Other,110% of Medicare,1425.9,35,,1425.9,percent of total billed charges,Implant Device,1385.16,34,"Charges > $500, x 34%",1385.16,percent of total billed charges,Implant Device,1425.9,35,,1425.9,percent of total billed charges,Implant Device,1425.9,35,,1425.9,percent of total billed charges,Implant Device,1425.9,35,,1425.9,percent of total billed charges,Implant Device,1425.9,35,,1425.9,percent of total billed charges,Implant Device,1425.9,35,,1425.9,percent of total billed charges,Implant Device,1629.6,40,,1629.6,percent of total billed charges,Implant Device,1425.9,70,,1425.9,percent of total billed charges,All Other,1385.16,34,,1385.16,percent of total billed charges,Implant Device,1385.16,34,,1385.16,percent of total billed charges,Implant Device,1425.9,35,,1425.9,percent of total billed charges,Implant Device,1425.9,35,,1425.9,percent of total billed charges,Implant Device,1425.9,35,,1425.9,percent of total billed charges,Implant Device,1425.9,35,,1425.9,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1385.16,34,"If Charge > 2,000, then 34 percent",1385.16,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3014.77,
GORE SRRT08070080L VASC GRAFT RING 8X80,C1768,HCPCS,,79014034,CDM,278,RC,,,both,,,4899,3625.27,,,3625.27,Other,150% of Medicare + 9.63% HCRA Surcharge,2204.55,45,,2204.55,percent of total billed charges,Critical Access Hospital RCC factor,1665.66,34,,1665.66,percent of total billed charges,Implant Device,1665.66,34,,1665.66,percent of total billed charges,Implant Device,1665.66,34,,1665.66,percent of total billed charges,Implant Device,1665.66,34,,1665.66,percent of total billed charges,Implant Device,1665.66,34,,1665.66,percent of total billed charges,Implant Device,2425.01,,,2425.01,Other,110% of Medicare,1714.65,35,,1714.65,percent of total billed charges,Implant Device,1665.66,34,"Charges > $500, x 34%",1665.66,percent of total billed charges,Implant Device,1714.65,35,,1714.65,percent of total billed charges,Implant Device,1714.65,35,,1714.65,percent of total billed charges,Implant Device,1714.65,35,,1714.65,percent of total billed charges,Implant Device,1714.65,35,,1714.65,percent of total billed charges,Implant Device,1714.65,35,,1714.65,percent of total billed charges,Implant Device,1959.6,40,,1959.6,percent of total billed charges,Implant Device,1714.65,70,,1714.65,percent of total billed charges,All Other,1665.66,34,,1665.66,percent of total billed charges,Implant Device,1665.66,34,,1665.66,percent of total billed charges,Implant Device,1714.65,35,,1714.65,percent of total billed charges,Implant Device,1714.65,35,,1714.65,percent of total billed charges,Implant Device,1714.65,35,,1714.65,percent of total billed charges,Implant Device,1714.65,35,,1714.65,percent of total billed charges,Implant Device,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1665.66,34,"If Charge > 2,000, then 34 percent",1665.66,percent of total billed charges,Implants,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3625.27,
EMERG RESPONSE MONTHLY FEE,S5161,HCPCS,,84000001,CDM,291,RC,,,both,,,40,29.6,,,29.6,Other,150% of Medicare + 9.63% HCRA Surcharge,18,45,,18,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,19.8,,,19.8,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,28,70,,28,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,29.6,
EMERG RESP INSTALL & TEST,S5160,HCPCS,,84000002,CDM,291,RC,,,both,,,90,66.6,,,66.6,Other,150% of Medicare + 9.63% HCRA Surcharge,40.5,45,,40.5,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,44.55,,,44.55,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,63,70,,63,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,66.6,
EMERG RESPONSE MONTHLY FEE WIRELESS,S5161,HCPCS,U1,84000003,CDM,291,RC,,,both,,,40,29.6,,,29.6,Other,150% of Medicare + 9.63% HCRA Surcharge,18,45,,18,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,19.8,,,19.8,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,28,70,,28,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,29.6,
ROUTINE VENIPUNCTURE,36415,CPT,,30036415,CDM,300,RC,,,both,,,21,15.54,,,15.54,Other,150% of Medicare + 9.63% HCRA Surcharge,9.45,45,,9.45,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,15.81,,,15.81,Fee Schedule,,14.22,,,14.22,Fee Schedule,,13.44,,,13.44,Fee Schedule,,10.4,,,10.4,Other,110% of Medicare,27.81,,,27.81,Fee Schedule,,61,,,61,Other,186% of Medicaid,32.76,,,32.76,Fee Schedule,,13.02,,,13.02,Fee Schedule,,18.54,,,18.54,Fee Schedule,,32.76,,,32.76,Fee Schedule,,13.02,,,13.02,Fee Schedule,,34.88,,,34.88,Fee Schedule,,14.7,70,,14.7,percent of total billed charges,All Other,14.22,,,14.22,Fee Schedule,,12.05,,,12.05,Fee Schedule,,4.5,,,4.5,Fee Schedule,,4.5,,,4.5,Fee Schedule,,4.5,,,4.5,Fee Schedule,,4.5,,,4.5,Fee Schedule,,32.83,,,32.83,Other,100% of Medicaid,32.83,,,32.83,Other,100% of Medicaid,32.83,,,32.83,Other,100% of Medicaid,32.83,,,32.83,Other,100% of Medicaid,73.87,,,73.87,Other,225% of Medicaid,50.23,,,50.23,Other,153% of Medicaid,73.87,,,73.87,Other,225% of Medicaid,45.96,,,45.96,Other,140% of Medicaid,73.87,,,73.87,Other,225% of Medicaid,85.36,,,85.36,Other,260% of Medicaid,106.38,,,106.38,Other,324% of Medicaid,70.59,,,70.59,Other,215% of Medicaid,70.59,,,70.59,Other,215% of Medicaid,41.04,,,41.04,Other,125% of Medicaid,0.01,106.38,
REAGENT STRIP/BLOOD GLUCOSE,82948,CPT,,30082948,CDM,300,RC,,,both,,,29,21.46,,,21.46,Other,150% of Medicare + 9.63% HCRA Surcharge,13.05,45,,13.05,percent of total billed charges,Critical Access Hospital RCC factor,15.17,,,15.17,Fee Schedule,,13.66,,,13.66,Fee Schedule,,23.45,,,23.45,Fee Schedule,,21.09,,,21.09,Fee Schedule,,19.94,,,19.94,Fee Schedule,,14.36,,,14.36,Other,110% of Medicare,15.88,,,15.88,Fee Schedule,,4,,,4,Other,186% of Medicaid,18.7,,,18.7,Fee Schedule,,17.98,,,17.98,Fee Schedule,,10.58,,,10.58,Fee Schedule,,18.7,,,18.7,Fee Schedule,,17.98,,,17.98,Fee Schedule,,19.91,,,19.91,Fee Schedule,,20.3,70,,20.3,percent of total billed charges,All Other,23.88,,,23.88,Fee Schedule,,20.24,,,20.24,Fee Schedule,,7.56,,,7.56,Fee Schedule,,7.56,,,7.56,Fee Schedule,,7.56,,,7.56,Fee Schedule,,7.56,,,7.56,Fee Schedule,,2.02,,,2.02,Other,100% of Medicaid,2.02,,,2.02,Other,100% of Medicaid,2.02,,,2.02,Other,100% of Medicaid,2.02,,,2.02,Other,100% of Medicaid,4.55,,,4.55,Other,225% of Medicaid,3.09,,,3.09,Other,153% of Medicaid,4.55,,,4.55,Other,225% of Medicaid,2.83,,,2.83,Other,140% of Medicaid,4.55,,,4.55,Other,225% of Medicaid,5.25,,,5.25,Other,260% of Medicaid,6.54,,,6.54,Other,324% of Medicaid,4.34,,,4.34,Other,215% of Medicaid,4.34,,,4.34,Other,215% of Medicaid,2.53,,,2.53,Other,125% of Medicaid,2.02,23.88,
NURSE VENIPUNCTURE,36415,CPT,,34036415,CDM,300,RC,,,both,,,21,15.54,,,15.54,Other,150% of Medicare + 9.63% HCRA Surcharge,9.45,45,,9.45,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,15.81,,,15.81,Fee Schedule,,14.22,,,14.22,Fee Schedule,,13.44,,,13.44,Fee Schedule,,10.4,,,10.4,Other,110% of Medicare,27.81,,,27.81,Fee Schedule,,61,,,61,Other,186% of Medicaid,32.76,,,32.76,Fee Schedule,,13.02,,,13.02,Fee Schedule,,18.54,,,18.54,Fee Schedule,,32.76,,,32.76,Fee Schedule,,13.02,,,13.02,Fee Schedule,,34.88,,,34.88,Fee Schedule,,14.7,70,,14.7,percent of total billed charges,All Other,14.22,,,14.22,Fee Schedule,,12.05,,,12.05,Fee Schedule,,4.5,,,4.5,Fee Schedule,,4.5,,,4.5,Fee Schedule,,4.5,,,4.5,Fee Schedule,,4.5,,,4.5,Fee Schedule,,32.83,,,32.83,Other,100% of Medicaid,32.83,,,32.83,Other,100% of Medicaid,32.83,,,32.83,Other,100% of Medicaid,32.83,,,32.83,Other,100% of Medicaid,73.87,,,73.87,Other,225% of Medicaid,50.23,,,50.23,Other,153% of Medicaid,73.87,,,73.87,Other,225% of Medicaid,45.96,,,45.96,Other,140% of Medicaid,73.87,,,73.87,Other,225% of Medicaid,85.36,,,85.36,Other,260% of Medicaid,106.38,,,106.38,Other,324% of Medicaid,70.59,,,70.59,Other,215% of Medicaid,70.59,,,70.59,Other,215% of Medicaid,41.04,,,41.04,Other,125% of Medicaid,0.01,106.38,
CAPILLARY BLOOD DRAW,36416,CPT,,34036416,CDM,300,RC,,,both,,,41,30.34,,,30.34,Other,150% of Medicare + 9.63% HCRA Surcharge,18.45,45,,18.45,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1.22,,,1.22,Fee Schedule,,1.22,,,1.22,Fee Schedule,,1.22,,,1.22,Fee Schedule,,20.3,,,20.3,Other,110% of Medicare,27.88,68,,27.88,percent of total billed charges,All Other,61,,,61,Other,186% of Medicaid,34.03,83,,34.03,percent of total billed charges,All Other,25.42,62,,25.42,percent of total billed charges,Lab and Radiology,22.55,55,,22.55,percent of total billed charges,Default if not on Fee Schedule,32.8,80,,32.8,percent of total billed charges,All Other,25.42,62,,25.42,percent of total billed charges,Lab and Radiology,32.8,80,,32.8,percent of total billed charges,All Other,28.7,70,,28.7,percent of total billed charges,All Other,26.65,65,,26.65,percent of total billed charges,Default if not in Fee Schedule,26.65,65,,26.65,percent of total billed charges,Default if not in Fee Schedule,4.34,,,4.34,Fee Schedule,,4.34,,,4.34,Fee Schedule,,4.34,,,4.34,Fee Schedule,,4.34,,,4.34,Fee Schedule,,32.83,,,32.83,Other,100% of Medicaid,32.83,,,32.83,Other,100% of Medicaid,32.83,,,32.83,Other,100% of Medicaid,32.83,,,32.83,Other,100% of Medicaid,73.87,,,73.87,Other,225% of Medicaid,50.23,,,50.23,Other,153% of Medicaid,73.87,,,73.87,Other,225% of Medicaid,45.96,,,45.96,Other,140% of Medicaid,73.87,,,73.87,Other,225% of Medicaid,85.36,,,85.36,Other,260% of Medicaid,106.38,,,106.38,Other,324% of Medicaid,70.59,,,70.59,Other,215% of Medicaid,70.59,,,70.59,Other,215% of Medicaid,41.04,,,41.04,Other,125% of Medicaid,0.01,106.38,
COLLECT BLOOD FROM PICC,36592,CPT,,34036592,CDM,300,RC,,,both,,,263,194.62,,,194.62,Other,150% of Medicare + 9.63% HCRA Surcharge,118.35,45,,118.35,percent of total billed charges,Critical Access Hospital RCC factor,98.28,,,98.28,Fee Schedule,,88.48,,,88.48,Fee Schedule,,174.02,,,174.02,Fee Schedule,,156.51,,,156.51,Fee Schedule,,147.93,,,147.93,Fee Schedule,,130.19,,,130.19,Other,110% of Medicare,102.85,,,102.85,Fee Schedule,,49,,,49,Other,186% of Medicaid,121.13,,,121.13,Fee Schedule,,163.06,,,163.06,Fee Schedule,,68.57,,,68.57,Fee Schedule,,121.13,,,121.13,Fee Schedule,,163.06,,,163.06,Fee Schedule,,128.97,,,128.97,Fee Schedule,,184.1,70,,184.1,percent of total billed charges,All Other,144.32,,,144.32,Fee Schedule,,122.32,,,122.32,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,26.36,,,26.36,Other,100% of Medicaid,26.36,,,26.36,Other,100% of Medicaid,26.36,,,26.36,Other,100% of Medicaid,26.36,,,26.36,Other,100% of Medicaid,59.32,,,59.32,Other,225% of Medicaid,40.33,,,40.33,Other,153% of Medicaid,59.32,,,59.32,Other,225% of Medicaid,36.91,,,36.91,Other,140% of Medicaid,59.32,,,59.32,Other,225% of Medicaid,68.54,,,68.54,Other,260% of Medicaid,85.41,,,85.41,Other,324% of Medicaid,56.68,,,56.68,Other,215% of Medicaid,56.68,,,56.68,Other,215% of Medicaid,32.95,,,32.95,Other,125% of Medicaid,0.01,194.62,
GLUCOSE; BLD BY MONITOR DEVICE,82962,CPT,,34082962,CDM,300,RC,,,both,,,31,22.94,,,22.94,Other,150% of Medicare + 9.63% HCRA Surcharge,13.95,45,,13.95,percent of total billed charges,Critical Access Hospital RCC factor,9.87,,,9.87,Fee Schedule,,8.89,,,8.89,Fee Schedule,,16.13,,,16.13,Fee Schedule,,14.5,,,14.5,Fee Schedule,,13.71,,,13.71,Fee Schedule,,15.35,,,15.35,Other,110% of Medicare,10.33,,,10.33,Fee Schedule,,12,,,12,Other,186% of Medicaid,12.17,,,12.17,Fee Schedule,,19.22,,,19.22,Fee Schedule,,6.89,,,6.89,Fee Schedule,,12.17,,,12.17,Fee Schedule,,19.22,,,19.22,Fee Schedule,,12.96,,,12.96,Fee Schedule,,21.7,70,,21.7,percent of total billed charges,All Other,15.54,,,15.54,Fee Schedule,,13.17,,,13.17,Fee Schedule,,4.92,,,4.92,Fee Schedule,,4.92,,,4.92,Fee Schedule,,4.92,,,4.92,Fee Schedule,,4.92,,,4.92,Fee Schedule,,6.31,,,6.31,Other,100% of Medicaid,6.31,,,6.31,Other,100% of Medicaid,6.31,,,6.31,Other,100% of Medicaid,6.31,,,6.31,Other,100% of Medicaid,14.2,,,14.2,Other,225% of Medicaid,9.65,,,9.65,Other,153% of Medicaid,14.2,,,14.2,Other,225% of Medicaid,8.83,,,8.83,Other,140% of Medicaid,14.2,,,14.2,Other,225% of Medicaid,16.41,,,16.41,Other,260% of Medicaid,20.45,,,20.45,Other,324% of Medicaid,13.57,,,13.57,Other,215% of Medicaid,13.57,,,13.57,Other,215% of Medicaid,7.89,,,7.89,Other,125% of Medicaid,4.92,22.94,
ROUTINE VENIPUNCTURE,36415,CPT,,46036415,CDM,300,RC,,,both,,,21,15.54,,,15.54,Other,150% of Medicare + 9.63% HCRA Surcharge,9.45,45,,9.45,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,15.81,,,15.81,Fee Schedule,,14.22,,,14.22,Fee Schedule,,13.44,,,13.44,Fee Schedule,,10.4,,,10.4,Other,110% of Medicare,27.81,,,27.81,Fee Schedule,,61,,,61,Other,186% of Medicaid,32.76,,,32.76,Fee Schedule,,13.02,,,13.02,Fee Schedule,,18.54,,,18.54,Fee Schedule,,32.76,,,32.76,Fee Schedule,,13.02,,,13.02,Fee Schedule,,34.88,,,34.88,Fee Schedule,,14.7,70,,14.7,percent of total billed charges,All Other,14.22,,,14.22,Fee Schedule,,12.05,,,12.05,Fee Schedule,,4.5,,,4.5,Fee Schedule,,4.5,,,4.5,Fee Schedule,,4.5,,,4.5,Fee Schedule,,4.5,,,4.5,Fee Schedule,,32.83,,,32.83,Other,100% of Medicaid,32.83,,,32.83,Other,100% of Medicaid,32.83,,,32.83,Other,100% of Medicaid,32.83,,,32.83,Other,100% of Medicaid,73.87,,,73.87,Other,225% of Medicaid,50.23,,,50.23,Other,153% of Medicaid,73.87,,,73.87,Other,225% of Medicaid,45.96,,,45.96,Other,140% of Medicaid,73.87,,,73.87,Other,225% of Medicaid,85.36,,,85.36,Other,260% of Medicaid,106.38,,,106.38,Other,324% of Medicaid,70.59,,,70.59,Other,215% of Medicaid,70.59,,,70.59,Other,215% of Medicaid,41.04,,,41.04,Other,125% of Medicaid,0.01,106.38,
ROUTINE VENIPUNCTURE,36415,CPT,,47036415,CDM,300,RC,,,both,,,21,15.54,,,15.54,Other,150% of Medicare + 9.63% HCRA Surcharge,9.45,45,,9.45,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,15.81,,,15.81,Fee Schedule,,14.22,,,14.22,Fee Schedule,,13.44,,,13.44,Fee Schedule,,10.4,,,10.4,Other,110% of Medicare,27.81,,,27.81,Fee Schedule,,61,,,61,Other,186% of Medicaid,32.76,,,32.76,Fee Schedule,,13.02,,,13.02,Fee Schedule,,18.54,,,18.54,Fee Schedule,,32.76,,,32.76,Fee Schedule,,13.02,,,13.02,Fee Schedule,,34.88,,,34.88,Fee Schedule,,14.7,70,,14.7,percent of total billed charges,All Other,14.22,,,14.22,Fee Schedule,,12.05,,,12.05,Fee Schedule,,4.5,,,4.5,Fee Schedule,,4.5,,,4.5,Fee Schedule,,4.5,,,4.5,Fee Schedule,,4.5,,,4.5,Fee Schedule,,32.83,,,32.83,Other,100% of Medicaid,32.83,,,32.83,Other,100% of Medicaid,32.83,,,32.83,Other,100% of Medicaid,32.83,,,32.83,Other,100% of Medicaid,73.87,,,73.87,Other,225% of Medicaid,50.23,,,50.23,Other,153% of Medicaid,73.87,,,73.87,Other,225% of Medicaid,45.96,,,45.96,Other,140% of Medicaid,73.87,,,73.87,Other,225% of Medicaid,85.36,,,85.36,Other,260% of Medicaid,106.38,,,106.38,Other,324% of Medicaid,70.59,,,70.59,Other,215% of Medicaid,70.59,,,70.59,Other,215% of Medicaid,41.04,,,41.04,Other,125% of Medicaid,0.01,106.38,
BLOOD GASES O2 SAT ONLY,82810,CPT,,49082810,CDM,300,RC,,,both,,,51,37.74,,,37.74,Other,150% of Medicare + 9.63% HCRA Surcharge,22.95,45,,22.95,percent of total billed charges,Critical Access Hospital RCC factor,29.41,,,29.41,Fee Schedule,,26.48,,,26.48,Fee Schedule,,64.72,,,64.72,Fee Schedule,,58.21,,,58.21,Fee Schedule,,55.01,,,55.01,Fee Schedule,,25.25,,,25.25,Other,110% of Medicare,30.78,,,30.78,Fee Schedule,,18,,,18,Other,186% of Medicaid,36.25,,,36.25,Fee Schedule,,31.62,,,31.62,Fee Schedule,,20.52,,,20.52,Fee Schedule,,36.25,,,36.25,Fee Schedule,,31.62,,,31.62,Fee Schedule,,38.59,,,38.59,Fee Schedule,,35.7,70,,35.7,percent of total billed charges,All Other,46.3,,,46.3,Fee Schedule,,39.24,,,39.24,Fee Schedule,,14.66,,,14.66,Fee Schedule,,14.66,,,14.66,Fee Schedule,,14.66,,,14.66,Fee Schedule,,14.66,,,14.66,Fee Schedule,,9.77,,,9.77,Other,100% of Medicaid,9.77,,,9.77,Other,100% of Medicaid,9.77,,,9.77,Other,100% of Medicaid,9.77,,,9.77,Other,100% of Medicaid,21.98,,,21.98,Other,225% of Medicaid,14.95,,,14.95,Other,153% of Medicaid,21.98,,,21.98,Other,225% of Medicaid,13.68,,,13.68,Other,140% of Medicaid,21.98,,,21.98,Other,225% of Medicaid,25.4,,,25.4,Other,260% of Medicaid,31.65,,,31.65,Other,324% of Medicaid,21.01,,,21.01,Other,215% of Medicaid,21.01,,,21.01,Other,215% of Medicaid,12.21,,,12.21,Other,125% of Medicaid,9.77,64.72,
GLUCOSE; BLD BY MONITOR DEVICE,82962,CPT,,73082962,CDM,300,RC,,,both,,,31,22.94,,,22.94,Other,150% of Medicare + 9.63% HCRA Surcharge,13.95,45,,13.95,percent of total billed charges,Critical Access Hospital RCC factor,9.87,,,9.87,Fee Schedule,,8.89,,,8.89,Fee Schedule,,16.13,,,16.13,Fee Schedule,,14.5,,,14.5,Fee Schedule,,13.71,,,13.71,Fee Schedule,,15.35,,,15.35,Other,110% of Medicare,10.33,,,10.33,Fee Schedule,,12,,,12,Other,186% of Medicaid,12.17,,,12.17,Fee Schedule,,19.22,,,19.22,Fee Schedule,,6.89,,,6.89,Fee Schedule,,12.17,,,12.17,Fee Schedule,,19.22,,,19.22,Fee Schedule,,12.96,,,12.96,Fee Schedule,,21.7,70,,21.7,percent of total billed charges,All Other,15.54,,,15.54,Fee Schedule,,13.17,,,13.17,Fee Schedule,,4.92,,,4.92,Fee Schedule,,4.92,,,4.92,Fee Schedule,,4.92,,,4.92,Fee Schedule,,4.92,,,4.92,Fee Schedule,,6.31,,,6.31,Other,100% of Medicaid,6.31,,,6.31,Other,100% of Medicaid,6.31,,,6.31,Other,100% of Medicaid,6.31,,,6.31,Other,100% of Medicaid,14.2,,,14.2,Other,225% of Medicaid,9.65,,,9.65,Other,153% of Medicaid,14.2,,,14.2,Other,225% of Medicaid,8.83,,,8.83,Other,140% of Medicaid,14.2,,,14.2,Other,225% of Medicaid,16.41,,,16.41,Other,260% of Medicaid,20.45,,,20.45,Other,324% of Medicaid,13.57,,,13.57,Other,215% of Medicaid,13.57,,,13.57,Other,215% of Medicaid,7.89,,,7.89,Other,125% of Medicaid,4.92,22.94,
GLUCOSE; BLD BY MONITOR DEVICE,82962,CPT,,74082962,CDM,300,RC,,,both,,,31,22.94,,,22.94,Other,150% of Medicare + 9.63% HCRA Surcharge,13.95,45,,13.95,percent of total billed charges,Critical Access Hospital RCC factor,9.87,,,9.87,Fee Schedule,,8.89,,,8.89,Fee Schedule,,16.13,,,16.13,Fee Schedule,,14.5,,,14.5,Fee Schedule,,13.71,,,13.71,Fee Schedule,,15.35,,,15.35,Other,110% of Medicare,10.33,,,10.33,Fee Schedule,,12,,,12,Other,186% of Medicaid,12.17,,,12.17,Fee Schedule,,19.22,,,19.22,Fee Schedule,,6.89,,,6.89,Fee Schedule,,12.17,,,12.17,Fee Schedule,,19.22,,,19.22,Fee Schedule,,12.96,,,12.96,Fee Schedule,,21.7,70,,21.7,percent of total billed charges,All Other,15.54,,,15.54,Fee Schedule,,13.17,,,13.17,Fee Schedule,,4.92,,,4.92,Fee Schedule,,4.92,,,4.92,Fee Schedule,,4.92,,,4.92,Fee Schedule,,4.92,,,4.92,Fee Schedule,,6.31,,,6.31,Other,100% of Medicaid,6.31,,,6.31,Other,100% of Medicaid,6.31,,,6.31,Other,100% of Medicaid,6.31,,,6.31,Other,100% of Medicaid,14.2,,,14.2,Other,225% of Medicaid,9.65,,,9.65,Other,153% of Medicaid,14.2,,,14.2,Other,225% of Medicaid,8.83,,,8.83,Other,140% of Medicaid,14.2,,,14.2,Other,225% of Medicaid,16.41,,,16.41,Other,260% of Medicaid,20.45,,,20.45,Other,324% of Medicaid,13.57,,,13.57,Other,215% of Medicaid,13.57,,,13.57,Other,215% of Medicaid,7.89,,,7.89,Other,125% of Medicaid,4.92,22.94,
NURSE VENIPUNCTURE,36415,CPT,,75036415,CDM,300,RC,,,both,,,21,15.54,,,15.54,Other,150% of Medicare + 9.63% HCRA Surcharge,9.45,45,,9.45,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,15.81,,,15.81,Fee Schedule,,14.22,,,14.22,Fee Schedule,,13.44,,,13.44,Fee Schedule,,10.4,,,10.4,Other,110% of Medicare,27.81,,,27.81,Fee Schedule,,61,,,61,Other,186% of Medicaid,32.76,,,32.76,Fee Schedule,,13.02,,,13.02,Fee Schedule,,18.54,,,18.54,Fee Schedule,,32.76,,,32.76,Fee Schedule,,13.02,,,13.02,Fee Schedule,,34.88,,,34.88,Fee Schedule,,14.7,70,,14.7,percent of total billed charges,All Other,14.22,,,14.22,Fee Schedule,,12.05,,,12.05,Fee Schedule,,4.5,,,4.5,Fee Schedule,,4.5,,,4.5,Fee Schedule,,4.5,,,4.5,Fee Schedule,,4.5,,,4.5,Fee Schedule,,32.83,,,32.83,Other,100% of Medicaid,32.83,,,32.83,Other,100% of Medicaid,32.83,,,32.83,Other,100% of Medicaid,32.83,,,32.83,Other,100% of Medicaid,73.87,,,73.87,Other,225% of Medicaid,50.23,,,50.23,Other,153% of Medicaid,73.87,,,73.87,Other,225% of Medicaid,45.96,,,45.96,Other,140% of Medicaid,73.87,,,73.87,Other,225% of Medicaid,85.36,,,85.36,Other,260% of Medicaid,106.38,,,106.38,Other,324% of Medicaid,70.59,,,70.59,Other,215% of Medicaid,70.59,,,70.59,Other,215% of Medicaid,41.04,,,41.04,Other,125% of Medicaid,0.01,106.38,
RBC ANTIBODY SCREEN,86850,CPT,,77086850,CDM,300,RC,,,both,,,184,136.16,,,136.16,Other,150% of Medicare + 9.63% HCRA Surcharge,82.8,45,,82.8,percent of total billed charges,Critical Access Hospital RCC factor,29.41,,,29.41,Fee Schedule,,26.48,,,26.48,Fee Schedule,,6.54,,,6.54,Fee Schedule,,6.54,,,6.54,Fee Schedule,,6.54,,,6.54,Fee Schedule,,91.08,,,91.08,Other,110% of Medicare,30.78,,,30.78,Fee Schedule,,10,,,10,Other,186% of Medicaid,36.25,,,36.25,Fee Schedule,,114.08,,,114.08,Fee Schedule,,20.52,,,20.52,Fee Schedule,,36.25,,,36.25,Fee Schedule,,114.08,,,114.08,Fee Schedule,,38.59,,,38.59,Fee Schedule,,128.8,70,,128.8,percent of total billed charges,All Other,46.3,,,46.3,Fee Schedule,,39.24,,,39.24,Fee Schedule,,14.66,,,14.66,Fee Schedule,,14.66,,,14.66,Fee Schedule,,14.66,,,14.66,Fee Schedule,,14.66,,,14.66,Fee Schedule,,5.61,,,5.61,Other,100% of Medicaid,5.61,,,5.61,Other,100% of Medicaid,5.61,,,5.61,Other,100% of Medicaid,5.61,,,5.61,Other,100% of Medicaid,12.61,,,12.61,Other,225% of Medicaid,8.58,,,8.58,Other,153% of Medicaid,12.61,,,12.61,Other,225% of Medicaid,7.85,,,7.85,Other,140% of Medicaid,12.61,,,12.61,Other,225% of Medicaid,14.57,,,14.57,Other,260% of Medicaid,18.16,,,18.16,Other,324% of Medicaid,12.05,,,12.05,Other,215% of Medicaid,12.05,,,12.05,Other,215% of Medicaid,7.01,,,7.01,Other,125% of Medicaid,5.61,136.16,
AUTOLOG BLOOD PREDEPOSITED,86890,CPT,,77086890,CDM,300,RC,,,both,,,355,262.7,,,262.7,Other,150% of Medicare + 9.63% HCRA Surcharge,159.75,45,,159.75,percent of total billed charges,Critical Access Hospital RCC factor,230.75,65,,230.75,percent of total billed charges,All Other,209.45,65,,209.45,percent of total billed charges,All Other,271.58,76.5,,271.58,percent of total billed charges,All Other,252.05,69,,252.05,percent of total billed charges,All Other,244.95,65,,244.95,percent of total billed charges,All Other,175.73,,,175.73,Other,110% of Medicare,241.4,68,,241.4,percent of total billed charges,All Other,71,,,71,Other,186% of Medicaid,294.65,83,,294.65,percent of total billed charges,All Other,220.1,62,,220.1,percent of total billed charges,Lab and Radiology,195.25,55,,195.25,percent of total billed charges,Default if not on Fee Schedule,284,80,,284,percent of total billed charges,All Other,220.1,62,,220.1,percent of total billed charges,Lab and Radiology,284,80,,284,percent of total billed charges,All Other,248.5,70,,248.5,percent of total billed charges,All Other,230.75,65,,230.75,percent of total billed charges,Default if not in Fee Schedule,230.75,65,,230.75,percent of total billed charges,Default if not in Fee Schedule,215.25,,,215.25,Fee Schedule,,215.25,,,215.25,Fee Schedule,,215.25,,,215.25,Fee Schedule,,215.25,,,215.25,Fee Schedule,,38.29,,,38.29,Other,100% of Medicaid,38.29,,,38.29,Other,100% of Medicaid,38.29,,,38.29,Other,100% of Medicaid,38.29,,,38.29,Other,100% of Medicaid,86.15,,,86.15,Other,225% of Medicaid,58.58,,,58.58,Other,153% of Medicaid,86.15,,,86.15,Other,225% of Medicaid,53.6,,,53.6,Other,140% of Medicaid,86.15,,,86.15,Other,225% of Medicaid,99.55,,,99.55,Other,260% of Medicaid,124.06,,,124.06,Other,324% of Medicaid,82.32,,,82.32,Other,215% of Medicaid,82.32,,,82.32,Other,215% of Medicaid,47.86,,,47.86,Other,125% of Medicaid,38.29,294.65,
AUTOLOG BLOOD OP SALVAGE,86891,CPT,,77086891,CDM,300,RC,,,both,,,1749,1294.26,,,1294.26,Other,150% of Medicare + 9.63% HCRA Surcharge,787.05,45,,787.05,percent of total billed charges,Critical Access Hospital RCC factor,1136.85,65,,1136.85,percent of total billed charges,All Other,1031.91,65,,1031.91,percent of total billed charges,All Other,1337.99,76.5,,1337.99,percent of total billed charges,All Other,1241.79,69,,1241.79,percent of total billed charges,All Other,1206.81,65,,1206.81,percent of total billed charges,All Other,865.76,,,865.76,Other,110% of Medicare,1189.32,68,,1189.32,percent of total billed charges,All Other,71,,,71,Other,186% of Medicaid,1451.67,83,,1451.67,percent of total billed charges,All Other,1084.38,62,,1084.38,percent of total billed charges,Lab and Radiology,961.95,55,,961.95,percent of total billed charges,Default if not on Fee Schedule,1399.2,80,,1399.2,percent of total billed charges,All Other,1084.38,62,,1084.38,percent of total billed charges,Lab and Radiology,1399.2,80,,1399.2,percent of total billed charges,All Other,1224.3,70,,1224.3,percent of total billed charges,All Other,1136.85,65,,1136.85,percent of total billed charges,Default if not in Fee Schedule,1136.85,65,,1136.85,percent of total billed charges,Default if not in Fee Schedule,942.3,,,942.3,Fee Schedule,,942.3,,,942.3,Fee Schedule,,942.3,,,942.3,Fee Schedule,,942.3,,,942.3,Fee Schedule,,38.29,,,38.29,Other,100% of Medicaid,38.29,,,38.29,Other,100% of Medicaid,38.29,,,38.29,Other,100% of Medicaid,38.29,,,38.29,Other,100% of Medicaid,86.15,,,86.15,Other,225% of Medicaid,58.58,,,58.58,Other,153% of Medicaid,86.15,,,86.15,Other,225% of Medicaid,53.6,,,53.6,Other,140% of Medicaid,86.15,,,86.15,Other,225% of Medicaid,99.55,,,99.55,Other,260% of Medicaid,124.06,,,124.06,Other,324% of Medicaid,82.32,,,82.32,Other,215% of Medicaid,82.32,,,82.32,Other,215% of Medicaid,47.86,,,47.86,Other,125% of Medicaid,38.29,1451.67,
BLOOD TYPING; ABO,86900,CPT,,77086900,CDM,300,RC,,,both,,,263,194.62,,,194.62,Other,150% of Medicare + 9.63% HCRA Surcharge,118.35,45,,118.35,percent of total billed charges,Critical Access Hospital RCC factor,9,,,9,Fee Schedule,,8.1,,,8.1,Fee Schedule,,22.13,,,22.13,Fee Schedule,,19.91,,,19.91,Fee Schedule,,18.82,,,18.82,Fee Schedule,,130.19,,,130.19,Other,110% of Medicare,9.42,,,9.42,Fee Schedule,,6,,,6,Other,186% of Medicaid,11.09,,,11.09,Fee Schedule,,163.06,,,163.06,Fee Schedule,,6.28,,,6.28,Fee Schedule,,11.09,,,11.09,Fee Schedule,,163.06,,,163.06,Fee Schedule,,11.81,,,11.81,Fee Schedule,,184.1,70,,184.1,percent of total billed charges,All Other,14.17,,,14.17,Fee Schedule,,12.01,,,12.01,Fee Schedule,,4.49,,,4.49,Fee Schedule,,4.49,,,4.49,Fee Schedule,,4.49,,,4.49,Fee Schedule,,4.49,,,4.49,Fee Schedule,,2.99,,,2.99,Other,100% of Medicaid,2.99,,,2.99,Other,100% of Medicaid,2.99,,,2.99,Other,100% of Medicaid,2.99,,,2.99,Other,100% of Medicaid,6.73,,,6.73,Other,225% of Medicaid,4.57,,,4.57,Other,153% of Medicaid,6.73,,,6.73,Other,225% of Medicaid,4.19,,,4.19,Other,140% of Medicaid,6.73,,,6.73,Other,225% of Medicaid,7.77,,,7.77,Other,260% of Medicaid,9.69,,,9.69,Other,324% of Medicaid,6.43,,,6.43,Other,215% of Medicaid,6.43,,,6.43,Other,215% of Medicaid,3.74,,,3.74,Other,125% of Medicaid,2.99,194.62,
BLOOD TYPING RH(D),86901,CPT,,77086901,CDM,300,RC,,,both,,,138,102.12,,,102.12,Other,150% of Medicare + 9.63% HCRA Surcharge,62.1,45,,62.1,percent of total billed charges,Critical Access Hospital RCC factor,9,,,9,Fee Schedule,,8.1,,,8.1,Fee Schedule,,22.13,,,22.13,Fee Schedule,,19.91,,,19.91,Fee Schedule,,18.82,,,18.82,Fee Schedule,,68.31,,,68.31,Other,110% of Medicare,9.42,,,9.42,Fee Schedule,,6,,,6,Other,186% of Medicaid,11.09,,,11.09,Fee Schedule,,85.56,,,85.56,Fee Schedule,,6.28,,,6.28,Fee Schedule,,11.09,,,11.09,Fee Schedule,,85.56,,,85.56,Fee Schedule,,11.81,,,11.81,Fee Schedule,,96.6,70,,96.6,percent of total billed charges,All Other,14.17,,,14.17,Fee Schedule,,12.01,,,12.01,Fee Schedule,,4.49,,,4.49,Fee Schedule,,4.49,,,4.49,Fee Schedule,,4.49,,,4.49,Fee Schedule,,4.49,,,4.49,Fee Schedule,,2.99,,,2.99,Other,100% of Medicaid,2.99,,,2.99,Other,100% of Medicaid,2.99,,,2.99,Other,100% of Medicaid,2.99,,,2.99,Other,100% of Medicaid,6.73,,,6.73,Other,225% of Medicaid,4.57,,,4.57,Other,153% of Medicaid,6.73,,,6.73,Other,225% of Medicaid,4.19,,,4.19,Other,140% of Medicaid,6.73,,,6.73,Other,225% of Medicaid,7.77,,,7.77,Other,260% of Medicaid,9.69,,,9.69,Other,324% of Medicaid,6.43,,,6.43,Other,215% of Medicaid,6.43,,,6.43,Other,215% of Medicaid,3.74,,,3.74,Other,125% of Medicaid,2.99,102.12,
BLD TYPE; RBC AG NOT ABO/RHD,86905,CPT,,77086905,CDM,300,RC,,,both,,,731,540.94,,,540.94,Other,150% of Medicare + 9.63% HCRA Surcharge,328.95,45,,328.95,percent of total billed charges,Critical Access Hospital RCC factor,11.53,,,11.53,Fee Schedule,,10.38,,,10.38,Fee Schedule,,28.35,,,28.35,Fee Schedule,,25.5,,,25.5,Fee Schedule,,24.1,,,24.1,Fee Schedule,,361.85,,,361.85,Other,110% of Medicare,12.06,,,12.06,Fee Schedule,,7,,,7,Other,186% of Medicaid,14.21,,,14.21,Fee Schedule,,453.22,,,453.22,Fee Schedule,,8.04,,,8.04,Fee Schedule,,14.21,,,14.21,Fee Schedule,,453.22,,,453.22,Fee Schedule,,15.13,,,15.13,Fee Schedule,,511.7,70,,511.7,percent of total billed charges,All Other,18.15,,,18.15,Fee Schedule,,15.38,,,15.38,Fee Schedule,,5.75,,,5.75,Fee Schedule,,5.75,,,5.75,Fee Schedule,,5.75,,,5.75,Fee Schedule,,5.75,,,5.75,Fee Schedule,,3.83,,,3.83,Other,100% of Medicaid,3.83,,,3.83,Other,100% of Medicaid,3.83,,,3.83,Other,100% of Medicaid,3.83,,,3.83,Other,100% of Medicaid,8.62,,,8.62,Other,225% of Medicaid,5.86,,,5.86,Other,153% of Medicaid,8.62,,,8.62,Other,225% of Medicaid,5.36,,,5.36,Other,140% of Medicaid,8.62,,,8.62,Other,225% of Medicaid,9.96,,,9.96,Other,260% of Medicaid,12.41,,,12.41,Other,324% of Medicaid,8.23,,,8.23,Other,215% of Medicaid,8.23,,,8.23,Other,215% of Medicaid,4.79,,,4.79,Other,125% of Medicaid,3.83,540.94,
COMPATIBILITY TEST SPIN,86920,CPT,,77086920,CDM,300,RC,,,both,,,357,264.18,,,264.18,Other,150% of Medicare + 9.63% HCRA Surcharge,160.65,45,,160.65,percent of total billed charges,Critical Access Hospital RCC factor,232.05,65,,232.05,percent of total billed charges,All Other,210.63,65,,210.63,percent of total billed charges,All Other,9.4,,,9.4,Fee Schedule,,9.4,,,9.4,Fee Schedule,,9.4,,,9.4,Fee Schedule,,176.72,,,176.72,Other,110% of Medicare,242.76,68,,242.76,percent of total billed charges,All Other,72,,,72,Other,186% of Medicaid,296.31,83,,296.31,percent of total billed charges,All Other,221.34,62,,221.34,percent of total billed charges,Lab and Radiology,196.35,55,,196.35,percent of total billed charges,Default if not on Fee Schedule,285.6,80,,285.6,percent of total billed charges,All Other,221.34,62,,221.34,percent of total billed charges,Lab and Radiology,285.6,80,,285.6,percent of total billed charges,All Other,249.9,70,,249.9,percent of total billed charges,All Other,232.05,65,,232.05,percent of total billed charges,Default if not in Fee Schedule,232.05,65,,232.05,percent of total billed charges,Default if not in Fee Schedule,215.25,,,215.25,Fee Schedule,,215.25,,,215.25,Fee Schedule,,215.25,,,215.25,Fee Schedule,,215.25,,,215.25,Fee Schedule,,38.8,,,38.8,Other,100% of Medicaid,38.8,,,38.8,Other,100% of Medicaid,38.8,,,38.8,Other,100% of Medicaid,38.8,,,38.8,Other,100% of Medicaid,87.31,,,87.31,Other,225% of Medicaid,59.37,,,59.37,Other,153% of Medicaid,87.31,,,87.31,Other,225% of Medicaid,54.32,,,54.32,Other,140% of Medicaid,87.31,,,87.31,Other,225% of Medicaid,100.89,,,100.89,Other,260% of Medicaid,125.72,,,125.72,Other,324% of Medicaid,83.43,,,83.43,Other,215% of Medicaid,83.43,,,83.43,Other,215% of Medicaid,48.5,,,48.5,Other,125% of Medicaid,9.4,296.31,
COMPATIBILITY TEST INCUBATE,86921,CPT,,77086921,CDM,300,RC,,,both,,,355,262.7,,,262.7,Other,150% of Medicare + 9.63% HCRA Surcharge,159.75,45,,159.75,percent of total billed charges,Critical Access Hospital RCC factor,230.75,65,,230.75,percent of total billed charges,All Other,209.45,65,,209.45,percent of total billed charges,All Other,8.44,,,8.44,Fee Schedule,,8.44,,,8.44,Fee Schedule,,8.44,,,8.44,Fee Schedule,,175.73,,,175.73,Other,110% of Medicare,241.4,68,,241.4,percent of total billed charges,All Other,72,,,72,Other,186% of Medicaid,294.65,83,,294.65,percent of total billed charges,All Other,220.1,62,,220.1,percent of total billed charges,Lab and Radiology,195.25,55,,195.25,percent of total billed charges,Default if not on Fee Schedule,284,80,,284,percent of total billed charges,All Other,220.1,62,,220.1,percent of total billed charges,Lab and Radiology,284,80,,284,percent of total billed charges,All Other,248.5,70,,248.5,percent of total billed charges,All Other,230.75,65,,230.75,percent of total billed charges,Default if not in Fee Schedule,230.75,65,,230.75,percent of total billed charges,Default if not in Fee Schedule,215.25,,,215.25,Fee Schedule,,215.25,,,215.25,Fee Schedule,,215.25,,,215.25,Fee Schedule,,215.25,,,215.25,Fee Schedule,,38.8,,,38.8,Other,100% of Medicaid,38.8,,,38.8,Other,100% of Medicaid,38.8,,,38.8,Other,100% of Medicaid,38.8,,,38.8,Other,100% of Medicaid,87.31,,,87.31,Other,225% of Medicaid,59.37,,,59.37,Other,153% of Medicaid,87.31,,,87.31,Other,225% of Medicaid,54.32,,,54.32,Other,140% of Medicaid,87.31,,,87.31,Other,225% of Medicaid,100.89,,,100.89,Other,260% of Medicaid,125.72,,,125.72,Other,324% of Medicaid,83.43,,,83.43,Other,215% of Medicaid,83.43,,,83.43,Other,215% of Medicaid,48.5,,,48.5,Other,125% of Medicaid,8.44,294.65,
FFP THAWING EA UNIT,86927,CPT,,77086927,CDM,300,RC,,,both,,,355,262.7,,,262.7,Other,150% of Medicare + 9.63% HCRA Surcharge,159.75,45,,159.75,percent of total billed charges,Critical Access Hospital RCC factor,230.75,65,,230.75,percent of total billed charges,All Other,209.45,65,,209.45,percent of total billed charges,All Other,271.58,76.5,,271.58,percent of total billed charges,All Other,252.05,69,,252.05,percent of total billed charges,All Other,244.95,65,,244.95,percent of total billed charges,All Other,175.73,,,175.73,Other,110% of Medicare,241.4,68,,241.4,percent of total billed charges,All Other,71,,,71,Other,186% of Medicaid,294.65,83,,294.65,percent of total billed charges,All Other,220.1,62,,220.1,percent of total billed charges,Lab and Radiology,195.25,55,,195.25,percent of total billed charges,Default if not on Fee Schedule,284,80,,284,percent of total billed charges,All Other,220.1,62,,220.1,percent of total billed charges,Lab and Radiology,284,80,,284,percent of total billed charges,All Other,248.5,70,,248.5,percent of total billed charges,All Other,230.75,65,,230.75,percent of total billed charges,Default if not in Fee Schedule,230.75,65,,230.75,percent of total billed charges,Default if not in Fee Schedule,215.25,,,215.25,Fee Schedule,,215.25,,,215.25,Fee Schedule,,215.25,,,215.25,Fee Schedule,,215.25,,,215.25,Fee Schedule,,38.29,,,38.29,Other,100% of Medicaid,38.29,,,38.29,Other,100% of Medicaid,38.29,,,38.29,Other,100% of Medicaid,38.29,,,38.29,Other,100% of Medicaid,86.15,,,86.15,Other,225% of Medicaid,58.58,,,58.58,Other,153% of Medicaid,86.15,,,86.15,Other,225% of Medicaid,53.6,,,53.6,Other,140% of Medicaid,86.15,,,86.15,Other,225% of Medicaid,99.55,,,99.55,Other,260% of Medicaid,124.06,,,124.06,Other,324% of Medicaid,82.32,,,82.32,Other,215% of Medicaid,82.32,,,82.32,Other,215% of Medicaid,47.86,,,47.86,Other,125% of Medicaid,38.29,294.65,
FROZEN BLOOD PREP,86930,CPT,,77086930,CDM,300,RC,,,both,,,731,540.94,,,540.94,Other,150% of Medicare + 9.63% HCRA Surcharge,328.95,45,,328.95,percent of total billed charges,Critical Access Hospital RCC factor,475.15,65,,475.15,percent of total billed charges,All Other,431.29,65,,431.29,percent of total billed charges,All Other,559.22,76.5,,559.22,percent of total billed charges,All Other,519.01,69,,519.01,percent of total billed charges,All Other,504.39,65,,504.39,percent of total billed charges,All Other,361.85,,,361.85,Other,110% of Medicare,497.08,68,,497.08,percent of total billed charges,All Other,71,,,71,Other,186% of Medicaid,606.73,83,,606.73,percent of total billed charges,All Other,453.22,62,,453.22,percent of total billed charges,Lab and Radiology,402.05,55,,402.05,percent of total billed charges,Default if not on Fee Schedule,584.8,80,,584.8,percent of total billed charges,All Other,453.22,62,,453.22,percent of total billed charges,Lab and Radiology,584.8,80,,584.8,percent of total billed charges,All Other,511.7,70,,511.7,percent of total billed charges,All Other,475.15,65,,475.15,percent of total billed charges,Default if not in Fee Schedule,475.15,65,,475.15,percent of total billed charges,Default if not in Fee Schedule,425.12,,,425.12,Fee Schedule,,425.12,,,425.12,Fee Schedule,,425.12,,,425.12,Fee Schedule,,425.12,,,425.12,Fee Schedule,,38.29,,,38.29,Other,100% of Medicaid,38.29,,,38.29,Other,100% of Medicaid,38.29,,,38.29,Other,100% of Medicaid,38.29,,,38.29,Other,100% of Medicaid,86.15,,,86.15,Other,225% of Medicaid,58.58,,,58.58,Other,153% of Medicaid,86.15,,,86.15,Other,225% of Medicaid,53.6,,,53.6,Other,140% of Medicaid,86.15,,,86.15,Other,225% of Medicaid,99.55,,,99.55,Other,260% of Medicaid,124.06,,,124.06,Other,324% of Medicaid,82.32,,,82.32,Other,215% of Medicaid,82.32,,,82.32,Other,215% of Medicaid,47.86,,,47.86,Other,125% of Medicaid,38.29,606.73,
FROZEN BLOOD THAW,86931,CPT,,77086931,CDM,300,RC,,,both,,,731,540.94,,,540.94,Other,150% of Medicare + 9.63% HCRA Surcharge,328.95,45,,328.95,percent of total billed charges,Critical Access Hospital RCC factor,475.15,65,,475.15,percent of total billed charges,All Other,431.29,65,,431.29,percent of total billed charges,All Other,559.22,76.5,,559.22,percent of total billed charges,All Other,519.01,69,,519.01,percent of total billed charges,All Other,504.39,65,,504.39,percent of total billed charges,All Other,361.85,,,361.85,Other,110% of Medicare,497.08,68,,497.08,percent of total billed charges,All Other,71,,,71,Other,186% of Medicaid,606.73,83,,606.73,percent of total billed charges,All Other,453.22,62,,453.22,percent of total billed charges,Lab and Radiology,402.05,55,,402.05,percent of total billed charges,Default if not on Fee Schedule,584.8,80,,584.8,percent of total billed charges,All Other,453.22,62,,453.22,percent of total billed charges,Lab and Radiology,584.8,80,,584.8,percent of total billed charges,All Other,511.7,70,,511.7,percent of total billed charges,All Other,475.15,65,,475.15,percent of total billed charges,Default if not in Fee Schedule,475.15,65,,475.15,percent of total billed charges,Default if not in Fee Schedule,425.12,,,425.12,Fee Schedule,,425.12,,,425.12,Fee Schedule,,425.12,,,425.12,Fee Schedule,,425.12,,,425.12,Fee Schedule,,38.29,,,38.29,Other,100% of Medicaid,38.29,,,38.29,Other,100% of Medicaid,38.29,,,38.29,Other,100% of Medicaid,38.29,,,38.29,Other,100% of Medicaid,86.15,,,86.15,Other,225% of Medicaid,58.58,,,58.58,Other,153% of Medicaid,86.15,,,86.15,Other,225% of Medicaid,53.6,,,53.6,Other,140% of Medicaid,86.15,,,86.15,Other,225% of Medicaid,99.55,,,99.55,Other,260% of Medicaid,124.06,,,124.06,Other,324% of Medicaid,82.32,,,82.32,Other,215% of Medicaid,82.32,,,82.32,Other,215% of Medicaid,47.86,,,47.86,Other,125% of Medicaid,38.29,606.73,
FROZEN BLOOD FREEZE & THAW,86932,CPT,,77086932,CDM,300,RC,,,both,,,78,57.72,,,57.72,Other,150% of Medicare + 9.63% HCRA Surcharge,35.1,45,,35.1,percent of total billed charges,Critical Access Hospital RCC factor,50.7,65,,50.7,percent of total billed charges,All Other,46.02,65,,46.02,percent of total billed charges,All Other,59.67,76.5,,59.67,percent of total billed charges,All Other,55.38,69,,55.38,percent of total billed charges,All Other,53.82,65,,53.82,percent of total billed charges,All Other,38.61,,,38.61,Other,110% of Medicare,53.04,68,,53.04,percent of total billed charges,All Other,71,,,71,Other,186% of Medicaid,64.74,83,,64.74,percent of total billed charges,All Other,48.36,62,,48.36,percent of total billed charges,Lab and Radiology,42.9,55,,42.9,percent of total billed charges,Default if not on Fee Schedule,62.4,80,,62.4,percent of total billed charges,All Other,48.36,62,,48.36,percent of total billed charges,Lab and Radiology,62.4,80,,62.4,percent of total billed charges,All Other,54.6,70,,54.6,percent of total billed charges,All Other,50.7,65,,50.7,percent of total billed charges,Default if not in Fee Schedule,50.7,65,,50.7,percent of total billed charges,Default if not in Fee Schedule,50.15,,,50.15,Fee Schedule,,50.15,,,50.15,Fee Schedule,,50.15,,,50.15,Fee Schedule,,50.15,,,50.15,Fee Schedule,,38.29,,,38.29,Other,100% of Medicaid,38.29,,,38.29,Other,100% of Medicaid,38.29,,,38.29,Other,100% of Medicaid,38.29,,,38.29,Other,100% of Medicaid,86.15,,,86.15,Other,225% of Medicaid,58.58,,,58.58,Other,153% of Medicaid,86.15,,,86.15,Other,225% of Medicaid,53.6,,,53.6,Other,140% of Medicaid,86.15,,,86.15,Other,225% of Medicaid,99.55,,,99.55,Other,260% of Medicaid,124.06,,,124.06,Other,324% of Medicaid,82.32,,,82.32,Other,215% of Medicaid,82.32,,,82.32,Other,215% of Medicaid,47.86,,,47.86,Other,125% of Medicaid,35.1,124.06,
IRRADIATE BLD PRODUCT EA UNIT,86945,CPT,,77086945,CDM,300,RC,,,both,,,78,57.72,,,57.72,Other,150% of Medicare + 9.63% HCRA Surcharge,35.1,45,,35.1,percent of total billed charges,Critical Access Hospital RCC factor,50.7,65,,50.7,percent of total billed charges,All Other,46.02,65,,46.02,percent of total billed charges,All Other,7.9,,,7.9,Fee Schedule,,7.9,,,7.9,Fee Schedule,,7.9,,,7.9,Fee Schedule,,38.61,,,38.61,Other,110% of Medicare,53.04,68,,53.04,percent of total billed charges,All Other,71,,,71,Other,186% of Medicaid,64.74,83,,64.74,percent of total billed charges,All Other,48.36,62,,48.36,percent of total billed charges,Lab and Radiology,42.9,55,,42.9,percent of total billed charges,Default if not on Fee Schedule,62.4,80,,62.4,percent of total billed charges,All Other,48.36,62,,48.36,percent of total billed charges,Lab and Radiology,62.4,80,,62.4,percent of total billed charges,All Other,54.6,70,,54.6,percent of total billed charges,All Other,50.7,65,,50.7,percent of total billed charges,Default if not in Fee Schedule,50.7,65,,50.7,percent of total billed charges,Default if not in Fee Schedule,50.15,,,50.15,Fee Schedule,,50.15,,,50.15,Fee Schedule,,50.15,,,50.15,Fee Schedule,,50.15,,,50.15,Fee Schedule,,38.29,,,38.29,Other,100% of Medicaid,38.29,,,38.29,Other,100% of Medicaid,38.29,,,38.29,Other,100% of Medicaid,38.29,,,38.29,Other,100% of Medicaid,86.15,,,86.15,Other,225% of Medicaid,58.58,,,58.58,Other,153% of Medicaid,86.15,,,86.15,Other,225% of Medicaid,53.6,,,53.6,Other,140% of Medicaid,86.15,,,86.15,Other,225% of Medicaid,99.55,,,99.55,Other,260% of Medicaid,124.06,,,124.06,Other,324% of Medicaid,82.32,,,82.32,Other,215% of Medicaid,82.32,,,82.32,Other,215% of Medicaid,47.86,,,47.86,Other,125% of Medicaid,7.9,124.06,
PROSTATE CANCER SCREENING PSA,G0103,HCPCS,,78000002,CDM,300,RC,,,both,,,137,101.38,,,101.38,Other,150% of Medicare + 9.63% HCRA Surcharge,61.65,45,,61.65,percent of total billed charges,Critical Access Hospital RCC factor,58.12,,,58.12,Fee Schedule,,52.33,,,52.33,Fee Schedule,,136.44,,,136.44,Fee Schedule,,122.72,,,122.72,Fee Schedule,,115.99,,,115.99,Fee Schedule,,67.82,,,67.82,Other,110% of Medicare,60.83,,,60.83,Fee Schedule,,18,,,18,Other,186% of Medicaid,71.64,,,71.64,Fee Schedule,,84.94,,,84.94,Fee Schedule,,40.55,,,40.55,Fee Schedule,,71.64,,,71.64,Fee Schedule,,84.94,,,84.94,Fee Schedule,,76.27,,,76.27,Fee Schedule,,95.9,70,,95.9,percent of total billed charges,All Other,91.51,,,91.51,Fee Schedule,,77.56,,,77.56,Fee Schedule,,28.97,,,28.97,Fee Schedule,,28.97,,,28.97,Fee Schedule,,28.97,,,28.97,Fee Schedule,,28.97,,,28.97,Fee Schedule,,9.88,,,9.88,Other,100% of Medicaid,9.88,,,9.88,Other,100% of Medicaid,9.88,,,9.88,Other,100% of Medicaid,9.88,,,9.88,Other,100% of Medicaid,22.23,,,22.23,Other,225% of Medicaid,15.11,,,15.11,Other,153% of Medicaid,22.23,,,22.23,Other,225% of Medicaid,13.83,,,13.83,Other,140% of Medicaid,22.23,,,22.23,Other,225% of Medicaid,25.68,,,25.68,Other,260% of Medicaid,32.01,,,32.01,Other,324% of Medicaid,21.24,,,21.24,Other,215% of Medicaid,21.24,,,21.24,Other,215% of Medicaid,12.35,,,12.35,Other,125% of Medicaid,9.88,136.44,
CATH CLCT SPEC 1 PT ALL PLACES,P9612,HCPCS,,78000010,CDM,300,RC,,,both,,,60,44.4,,,44.4,Other,150% of Medicare + 9.63% HCRA Surcharge,27,45,,27,percent of total billed charges,Critical Access Hospital RCC factor,26.58,,,26.58,Fee Schedule,,23.93,,,23.93,Fee Schedule,,45.9,76.5,,45.9,percent of total billed charges,All Other,42.6,69,,42.6,percent of total billed charges,All Other,41.4,65,,41.4,percent of total billed charges,All Other,29.7,,,29.7,Other,110% of Medicare,27.81,,,27.81,Fee Schedule,,61,,,61,Other,186% of Medicaid,32.76,,,32.76,Fee Schedule,,37.2,,,37.2,Fee Schedule,,18.54,,,18.54,Fee Schedule,,32.76,,,32.76,Fee Schedule,,37.2,,,37.2,Fee Schedule,,34.88,,,34.88,Fee Schedule,,42,70,,42,percent of total billed charges,All Other,14.22,,,14.22,Fee Schedule,,12.05,,,12.05,Fee Schedule,,4.5,,,4.5,Fee Schedule,,4.5,,,4.5,Fee Schedule,,4.5,,,4.5,Fee Schedule,,4.5,,,4.5,Fee Schedule,,32.83,,,32.83,Other,100% of Medicaid,32.83,,,32.83,Other,100% of Medicaid,32.83,,,32.83,Other,100% of Medicaid,32.83,,,32.83,Other,100% of Medicaid,73.87,,,73.87,Other,225% of Medicaid,50.23,,,50.23,Other,153% of Medicaid,73.87,,,73.87,Other,225% of Medicaid,45.96,,,45.96,Other,140% of Medicaid,73.87,,,73.87,Other,225% of Medicaid,85.36,,,85.36,Other,260% of Medicaid,106.38,,,106.38,Other,324% of Medicaid,70.59,,,70.59,Other,215% of Medicaid,70.59,,,70.59,Other,215% of Medicaid,41.04,,,41.04,Other,125% of Medicaid,4.5,106.38,
LIVER DIS 10 ASSAYS W/NASH,0003M,HCPCS,,78000019,CDM,300,RC,,,both,,,1587,1174.38,,,1174.38,Other,150% of Medicare + 9.63% HCRA Surcharge,714.15,45,,714.15,percent of total billed charges,Critical Access Hospital RCC factor,1515.23,,,1515.23,Fee Schedule,,1364.21,,,1364.21,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,785.57,,,785.57,Other,110% of Medicare,1585.71,,,1585.71,Fee Schedule,,0.01,,,0.01,Other,186% of Medicaid,1867.61,,,1867.61,Fee Schedule,,983.94,,,983.94,Fee Schedule,,1057.14,,,1057.14,Fee Schedule,,1867.61,,,1867.61,Fee Schedule,,983.94,,,983.94,Fee Schedule,,1988.43,,,1988.43,Fee Schedule,,1110.9,70,,1110.9,percent of total billed charges,All Other,2385.63,,,2385.63,Fee Schedule,,2021.97,,,2021.97,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2385.63,
NFCT DS VIR RESP RNA 4 TRGT,0241U,HCPCS,,78000020,CDM,300,RC,,,both,,,450,333,,,333,Other,150% of Medicare + 9.63% HCRA Surcharge,202.5,45,,202.5,percent of total billed charges,Critical Access Hospital RCC factor,429.32,,,429.32,Fee Schedule,,386.53,,,386.53,Fee Schedule,,142.63,,,142.63,Fee Schedule,,142.63,,,142.63,Fee Schedule,,142.63,,,142.63,Fee Schedule,,222.75,,,222.75,Other,110% of Medicare,449.28,,,449.28,Fee Schedule,,67,,,67,Other,186% of Medicaid,529.16,,,529.16,Fee Schedule,,279,,,279,Fee Schedule,,299.52,,,299.52,Fee Schedule,,529.16,,,529.16,Fee Schedule,,279,,,279,Fee Schedule,,563.39,,,563.39,Fee Schedule,,315,70,,315,percent of total billed charges,All Other,675.93,,,675.93,Fee Schedule,,572.89,,,572.89,Fee Schedule,,213.9,,,213.9,Fee Schedule,,213.9,,,213.9,Fee Schedule,,213.9,,,213.9,Fee Schedule,,213.9,,,213.9,Fee Schedule,,36.17,,,36.17,Other,100% of Medicaid,36.17,,,36.17,Other,100% of Medicaid,36.17,,,36.17,Other,100% of Medicaid,36.17,,,36.17,Other,100% of Medicaid,81.38,,,81.38,Other,225% of Medicaid,55.34,,,55.34,Other,153% of Medicaid,81.38,,,81.38,Other,225% of Medicaid,50.64,,,50.64,Other,140% of Medicaid,81.38,,,81.38,Other,225% of Medicaid,94.04,,,94.04,Other,260% of Medicaid,117.19,,,117.19,Other,324% of Medicaid,77.77,,,77.77,Other,215% of Medicaid,77.77,,,77.77,Other,215% of Medicaid,45.21,,,45.21,Other,125% of Medicaid,36.17,675.93,
ROUTINE VENIPUNCTURE,36415,CPT,,78036415,CDM,300,RC,,,both,,,21,15.54,,,15.54,Other,150% of Medicare + 9.63% HCRA Surcharge,9.45,45,,9.45,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,15.81,,,15.81,Fee Schedule,,14.22,,,14.22,Fee Schedule,,13.44,,,13.44,Fee Schedule,,10.4,,,10.4,Other,110% of Medicare,27.81,,,27.81,Fee Schedule,,61,,,61,Other,186% of Medicaid,32.76,,,32.76,Fee Schedule,,13.02,,,13.02,Fee Schedule,,18.54,,,18.54,Fee Schedule,,32.76,,,32.76,Fee Schedule,,13.02,,,13.02,Fee Schedule,,34.88,,,34.88,Fee Schedule,,14.7,70,,14.7,percent of total billed charges,All Other,14.22,,,14.22,Fee Schedule,,12.05,,,12.05,Fee Schedule,,4.5,,,4.5,Fee Schedule,,4.5,,,4.5,Fee Schedule,,4.5,,,4.5,Fee Schedule,,4.5,,,4.5,Fee Schedule,,32.83,,,32.83,Other,100% of Medicaid,32.83,,,32.83,Other,100% of Medicaid,32.83,,,32.83,Other,100% of Medicaid,32.83,,,32.83,Other,100% of Medicaid,73.87,,,73.87,Other,225% of Medicaid,50.23,,,50.23,Other,153% of Medicaid,73.87,,,73.87,Other,225% of Medicaid,45.96,,,45.96,Other,140% of Medicaid,73.87,,,73.87,Other,225% of Medicaid,85.36,,,85.36,Other,260% of Medicaid,106.38,,,106.38,Other,324% of Medicaid,70.59,,,70.59,Other,215% of Medicaid,70.59,,,70.59,Other,215% of Medicaid,41.04,,,41.04,Other,125% of Medicaid,0.01,106.38,
CAPILLARY BLOOD DRAW,36416,CPT,,78036416,CDM,300,RC,,,both,,,41,30.34,,,30.34,Other,150% of Medicare + 9.63% HCRA Surcharge,18.45,45,,18.45,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1.22,,,1.22,Fee Schedule,,1.22,,,1.22,Fee Schedule,,1.22,,,1.22,Fee Schedule,,20.3,,,20.3,Other,110% of Medicare,27.88,68,,27.88,percent of total billed charges,All Other,61,,,61,Other,186% of Medicaid,34.03,83,,34.03,percent of total billed charges,All Other,25.42,62,,25.42,percent of total billed charges,Lab and Radiology,22.55,55,,22.55,percent of total billed charges,Default if not on Fee Schedule,32.8,80,,32.8,percent of total billed charges,All Other,25.42,62,,25.42,percent of total billed charges,Lab and Radiology,32.8,80,,32.8,percent of total billed charges,All Other,28.7,70,,28.7,percent of total billed charges,All Other,26.65,65,,26.65,percent of total billed charges,Default if not in Fee Schedule,26.65,65,,26.65,percent of total billed charges,Default if not in Fee Schedule,4.34,,,4.34,Fee Schedule,,4.34,,,4.34,Fee Schedule,,4.34,,,4.34,Fee Schedule,,4.34,,,4.34,Fee Schedule,,32.83,,,32.83,Other,100% of Medicaid,32.83,,,32.83,Other,100% of Medicaid,32.83,,,32.83,Other,100% of Medicaid,32.83,,,32.83,Other,100% of Medicaid,73.87,,,73.87,Other,225% of Medicaid,50.23,,,50.23,Other,153% of Medicaid,73.87,,,73.87,Other,225% of Medicaid,45.96,,,45.96,Other,140% of Medicaid,73.87,,,73.87,Other,225% of Medicaid,85.36,,,85.36,Other,260% of Medicaid,106.38,,,106.38,Other,324% of Medicaid,70.59,,,70.59,Other,215% of Medicaid,70.59,,,70.59,Other,215% of Medicaid,41.04,,,41.04,Other,125% of Medicaid,0.01,106.38,
COLLECT BLOOD FROM VAD,36591,CPT,,78036591,CDM,300,RC,,,both,,,263,194.62,,,194.62,Other,150% of Medicare + 9.63% HCRA Surcharge,118.35,45,,118.35,percent of total billed charges,Critical Access Hospital RCC factor,90.63,,,90.63,Fee Schedule,,81.6,,,81.6,Fee Schedule,,155.73,,,155.73,Fee Schedule,,140.07,,,140.07,Fee Schedule,,132.38,,,132.38,Fee Schedule,,130.19,,,130.19,Other,110% of Medicare,94.85,,,94.85,Fee Schedule,,49,,,49,Other,186% of Medicaid,111.71,,,111.71,Fee Schedule,,163.06,,,163.06,Fee Schedule,,63.23,,,63.23,Fee Schedule,,111.71,,,111.71,Fee Schedule,,163.06,,,163.06,Fee Schedule,,118.93,,,118.93,Fee Schedule,,184.1,70,,184.1,percent of total billed charges,All Other,129.56,,,129.56,Fee Schedule,,109.81,,,109.81,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,26.36,,,26.36,Other,100% of Medicaid,26.36,,,26.36,Other,100% of Medicaid,26.36,,,26.36,Other,100% of Medicaid,26.36,,,26.36,Other,100% of Medicaid,59.32,,,59.32,Other,225% of Medicaid,40.33,,,40.33,Other,153% of Medicaid,59.32,,,59.32,Other,225% of Medicaid,36.91,,,36.91,Other,140% of Medicaid,59.32,,,59.32,Other,225% of Medicaid,68.54,,,68.54,Other,260% of Medicaid,85.41,,,85.41,Other,324% of Medicaid,56.68,,,56.68,Other,215% of Medicaid,56.68,,,56.68,Other,215% of Medicaid,32.95,,,32.95,Other,125% of Medicaid,0.01,194.62,
COLLECT BLOOD FROM PICC,36592,CPT,,78036592,CDM,300,RC,,,both,,,263,194.62,,,194.62,Other,150% of Medicare + 9.63% HCRA Surcharge,118.35,45,,118.35,percent of total billed charges,Critical Access Hospital RCC factor,98.28,,,98.28,Fee Schedule,,88.48,,,88.48,Fee Schedule,,174.02,,,174.02,Fee Schedule,,156.51,,,156.51,Fee Schedule,,147.93,,,147.93,Fee Schedule,,130.19,,,130.19,Other,110% of Medicare,102.85,,,102.85,Fee Schedule,,49,,,49,Other,186% of Medicaid,121.13,,,121.13,Fee Schedule,,163.06,,,163.06,Fee Schedule,,68.57,,,68.57,Fee Schedule,,121.13,,,121.13,Fee Schedule,,163.06,,,163.06,Fee Schedule,,128.97,,,128.97,Fee Schedule,,184.1,70,,184.1,percent of total billed charges,All Other,144.32,,,144.32,Fee Schedule,,122.32,,,122.32,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,26.36,,,26.36,Other,100% of Medicaid,26.36,,,26.36,Other,100% of Medicaid,26.36,,,26.36,Other,100% of Medicaid,26.36,,,26.36,Other,100% of Medicaid,59.32,,,59.32,Other,225% of Medicaid,40.33,,,40.33,Other,153% of Medicaid,59.32,,,59.32,Other,225% of Medicaid,36.91,,,36.91,Other,140% of Medicaid,59.32,,,59.32,Other,225% of Medicaid,68.54,,,68.54,Other,260% of Medicaid,85.41,,,85.41,Other,324% of Medicaid,56.68,,,56.68,Other,215% of Medicaid,56.68,,,56.68,Other,215% of Medicaid,32.95,,,32.95,Other,125% of Medicaid,0.01,194.62,
ASSAY OF AMIKACIN,80150,CPT,,78080150,CDM,300,RC,,,both,,,260,192.4,,,192.4,Other,150% of Medicare + 9.63% HCRA Surcharge,117,45,,117,percent of total billed charges,Critical Access Hospital RCC factor,45.39,,,45.39,Fee Schedule,,40.87,,,40.87,Fee Schedule,,111.78,,,111.78,Fee Schedule,,100.54,,,100.54,Fee Schedule,,95.02,,,95.02,Fee Schedule,,128.7,,,128.7,Other,110% of Medicare,47.5,,,47.5,Fee Schedule,,20,,,20,Other,186% of Medicaid,55.95,,,55.95,Fee Schedule,,161.2,,,161.2,Fee Schedule,,31.67,,,31.67,Fee Schedule,,55.95,,,55.95,Fee Schedule,,161.2,,,161.2,Fee Schedule,,59.57,,,59.57,Fee Schedule,,182,70,,182,percent of total billed charges,All Other,71.46,,,71.46,Fee Schedule,,60.57,,,60.57,Fee Schedule,,22.62,,,22.62,Fee Schedule,,22.62,,,22.62,Fee Schedule,,22.62,,,22.62,Fee Schedule,,22.62,,,22.62,Fee Schedule,,10.61,,,10.61,Other,100% of Medicaid,10.61,,,10.61,Other,100% of Medicaid,10.61,,,10.61,Other,100% of Medicaid,10.61,,,10.61,Other,100% of Medicaid,23.86,,,23.86,Other,225% of Medicaid,16.23,,,16.23,Other,153% of Medicaid,23.86,,,23.86,Other,225% of Medicaid,14.85,,,14.85,Other,140% of Medicaid,23.86,,,23.86,Other,225% of Medicaid,27.57,,,27.57,Other,260% of Medicaid,34.36,,,34.36,Other,324% of Medicaid,22.8,,,22.8,Other,215% of Medicaid,22.8,,,22.8,Other,215% of Medicaid,13.26,,,13.26,Other,125% of Medicaid,10.61,192.4,
ASSAY OF DIGOXIN,80162,CPT,,78080162,CDM,300,RC,,,both,,,168,124.32,,,124.32,Other,150% of Medicare + 9.63% HCRA Surcharge,75.6,45,,75.6,percent of total billed charges,Critical Access Hospital RCC factor,39.97,,,39.97,Fee Schedule,,35.99,,,35.99,Fee Schedule,,98.5,,,98.5,Fee Schedule,,88.59,,,88.59,Fee Schedule,,83.73,,,83.73,Fee Schedule,,83.16,,,83.16,Other,110% of Medicare,41.83,,,41.83,Fee Schedule,,20,,,20,Other,186% of Medicaid,49.27,,,49.27,Fee Schedule,,104.16,,,104.16,Fee Schedule,,27.89,,,27.89,Fee Schedule,,49.27,,,49.27,Fee Schedule,,104.16,,,104.16,Fee Schedule,,52.46,,,52.46,Fee Schedule,,117.6,70,,117.6,percent of total billed charges,All Other,62.93,,,62.93,Fee Schedule,,53.34,,,53.34,Fee Schedule,,19.92,,,19.92,Fee Schedule,,19.92,,,19.92,Fee Schedule,,19.92,,,19.92,Fee Schedule,,19.92,,,19.92,Fee Schedule,,10.61,,,10.61,Other,100% of Medicaid,10.61,,,10.61,Other,100% of Medicaid,10.61,,,10.61,Other,100% of Medicaid,10.61,,,10.61,Other,100% of Medicaid,23.86,,,23.86,Other,225% of Medicaid,16.23,,,16.23,Other,153% of Medicaid,23.86,,,23.86,Other,225% of Medicaid,14.85,,,14.85,Other,140% of Medicaid,23.86,,,23.86,Other,225% of Medicaid,27.57,,,27.57,Other,260% of Medicaid,34.36,,,34.36,Other,324% of Medicaid,22.8,,,22.8,Other,215% of Medicaid,22.8,,,22.8,Other,215% of Medicaid,13.26,,,13.26,Other,125% of Medicaid,10.61,124.32,
ASSAY OF PHENYTOIN TOTAL,80185,CPT,,78080185,CDM,300,RC,,,both,,,196,145.04,,,145.04,Other,150% of Medicare + 9.63% HCRA Surcharge,88.2,45,,88.2,percent of total billed charges,Critical Access Hospital RCC factor,39.88,,,39.88,Fee Schedule,,35.91,,,35.91,Fee Schedule,,98.34,,,98.34,Fee Schedule,,88.45,,,88.45,Fee Schedule,,83.6,,,83.6,Fee Schedule,,97.02,,,97.02,Other,110% of Medicare,41.74,,,41.74,Fee Schedule,,20,,,20,Other,186% of Medicaid,49.16,,,49.16,Fee Schedule,,121.52,,,121.52,Fee Schedule,,27.83,,,27.83,Fee Schedule,,49.16,,,49.16,Fee Schedule,,121.52,,,121.52,Fee Schedule,,52.34,,,52.34,Fee Schedule,,137.2,70,,137.2,percent of total billed charges,All Other,62.79,,,62.79,Fee Schedule,,53.22,,,53.22,Fee Schedule,,19.88,,,19.88,Fee Schedule,,19.88,,,19.88,Fee Schedule,,19.88,,,19.88,Fee Schedule,,19.88,,,19.88,Fee Schedule,,10.61,,,10.61,Other,100% of Medicaid,10.61,,,10.61,Other,100% of Medicaid,10.61,,,10.61,Other,100% of Medicaid,10.61,,,10.61,Other,100% of Medicaid,23.86,,,23.86,Other,225% of Medicaid,16.23,,,16.23,Other,153% of Medicaid,23.86,,,23.86,Other,225% of Medicaid,14.85,,,14.85,Other,140% of Medicaid,23.86,,,23.86,Other,225% of Medicaid,27.57,,,27.57,Other,260% of Medicaid,34.36,,,34.36,Other,324% of Medicaid,22.8,,,22.8,Other,215% of Medicaid,22.8,,,22.8,Other,215% of Medicaid,13.26,,,13.26,Other,125% of Medicaid,10.61,145.04,
ASSAY OF TACROLIMUS,80197,CPT,,78080197,CDM,300,RC,,,both,,,315,233.1,,,233.1,Other,150% of Medicare + 9.63% HCRA Surcharge,141.75,45,,141.75,percent of total billed charges,Critical Access Hospital RCC factor,41.33,,,41.33,Fee Schedule,,37.21,,,37.21,Fee Schedule,,101.82,,,101.82,Fee Schedule,,91.58,,,91.58,Fee Schedule,,86.55,,,86.55,Fee Schedule,,155.93,,,155.93,Other,110% of Medicare,43.25,,,43.25,Fee Schedule,,20,,,20,Other,186% of Medicaid,50.94,,,50.94,Fee Schedule,,195.3,,,195.3,Fee Schedule,,28.83,,,28.83,Fee Schedule,,50.94,,,50.94,Fee Schedule,,195.3,,,195.3,Fee Schedule,,54.23,,,54.23,Fee Schedule,,220.5,70,,220.5,percent of total billed charges,All Other,65.07,,,65.07,Fee Schedule,,55.15,,,55.15,Fee Schedule,,20.6,,,20.6,Fee Schedule,,20.6,,,20.6,Fee Schedule,,20.6,,,20.6,Fee Schedule,,20.6,,,20.6,Fee Schedule,,10.61,,,10.61,Other,100% of Medicaid,10.61,,,10.61,Other,100% of Medicaid,10.61,,,10.61,Other,100% of Medicaid,10.61,,,10.61,Other,100% of Medicaid,23.86,,,23.86,Other,225% of Medicaid,16.23,,,16.23,Other,153% of Medicaid,23.86,,,23.86,Other,225% of Medicaid,14.85,,,14.85,Other,140% of Medicaid,23.86,,,23.86,Other,225% of Medicaid,27.57,,,27.57,Other,260% of Medicaid,34.36,,,34.36,Other,324% of Medicaid,22.8,,,22.8,Other,215% of Medicaid,22.8,,,22.8,Other,215% of Medicaid,13.26,,,13.26,Other,125% of Medicaid,10.61,233.1,
URINALYSIS AUTO W/O SCOPE,81003,CPT,,78081003,CDM,300,RC,,,both,,,41,30.34,,,30.34,Other,150% of Medicare + 9.63% HCRA Surcharge,18.45,45,,18.45,percent of total billed charges,Critical Access Hospital RCC factor,6.77,,,6.77,Fee Schedule,,6.1,,,6.1,Fee Schedule,,16.65,,,16.65,Fee Schedule,,14.98,,,14.98,Fee Schedule,,14.16,,,14.16,Fee Schedule,,20.3,,,20.3,Other,110% of Medicare,7.09,,,7.09,Fee Schedule,,4,,,4,Other,186% of Medicaid,8.35,,,8.35,Fee Schedule,,25.42,,,25.42,Fee Schedule,,4.73,,,4.73,Fee Schedule,,8.35,,,8.35,Fee Schedule,,25.42,,,25.42,Fee Schedule,,8.89,,,8.89,Fee Schedule,,28.7,70,,28.7,percent of total billed charges,All Other,10.66,,,10.66,Fee Schedule,,9.04,,,9.04,Fee Schedule,,3.38,,,3.38,Fee Schedule,,3.38,,,3.38,Fee Schedule,,3.38,,,3.38,Fee Schedule,,3.38,,,3.38,Fee Schedule,,2.02,,,2.02,Other,100% of Medicaid,2.02,,,2.02,Other,100% of Medicaid,2.02,,,2.02,Other,100% of Medicaid,2.02,,,2.02,Other,100% of Medicaid,4.55,,,4.55,Other,225% of Medicaid,3.09,,,3.09,Other,153% of Medicaid,4.55,,,4.55,Other,225% of Medicaid,2.83,,,2.83,Other,140% of Medicaid,4.55,,,4.55,Other,225% of Medicaid,5.25,,,5.25,Other,260% of Medicaid,6.54,,,6.54,Other,324% of Medicaid,4.34,,,4.34,Other,215% of Medicaid,4.34,,,4.34,Other,215% of Medicaid,2.53,,,2.53,Other,125% of Medicaid,2.02,30.34,
URINE PREGNANCY TEST,81025,CPT,,78081025,CDM,300,RC,,,both,,,57,42.18,,,42.18,Other,150% of Medicare + 9.63% HCRA Surcharge,25.65,45,,25.65,percent of total billed charges,Critical Access Hospital RCC factor,25.92,,,25.92,Fee Schedule,,23.33,,,23.33,Fee Schedule,,46.9,,,46.9,Fee Schedule,,42.19,,,42.19,Fee Schedule,,39.87,,,39.87,Fee Schedule,,28.22,,,28.22,Other,110% of Medicare,27.12,,,27.12,Fee Schedule,,4,,,4,Other,186% of Medicaid,31.94,,,31.94,Fee Schedule,,35.34,,,35.34,Fee Schedule,,18.08,,,18.08,Fee Schedule,,31.94,,,31.94,Fee Schedule,,35.34,,,35.34,Fee Schedule,,34.01,,,34.01,Fee Schedule,,39.9,70,,39.9,percent of total billed charges,All Other,40.8,,,40.8,Fee Schedule,,34.58,,,34.58,Fee Schedule,,12.92,,,12.92,Fee Schedule,,12.92,,,12.92,Fee Schedule,,12.92,,,12.92,Fee Schedule,,12.92,,,12.92,Fee Schedule,,2.02,,,2.02,Other,100% of Medicaid,2.02,,,2.02,Other,100% of Medicaid,2.02,,,2.02,Other,100% of Medicaid,2.02,,,2.02,Other,100% of Medicaid,4.55,,,4.55,Other,225% of Medicaid,3.09,,,3.09,Other,153% of Medicaid,4.55,,,4.55,Other,225% of Medicaid,2.83,,,2.83,Other,140% of Medicaid,4.55,,,4.55,Other,225% of Medicaid,5.25,,,5.25,Other,260% of Medicaid,6.54,,,6.54,Other,324% of Medicaid,4.34,,,4.34,Other,215% of Medicaid,4.34,,,4.34,Other,215% of Medicaid,2.53,,,2.53,Other,125% of Medicaid,2.02,46.9,
CALR GENE COM VARIANTS,81219,CPT,,78081219,CDM,300,RC,,,both,,,348,257.52,,,257.52,Other,150% of Medicare + 9.63% HCRA Surcharge,156.6,45,,156.6,percent of total billed charges,Critical Access Hospital RCC factor,366.11,,,366.11,Fee Schedule,,329.62,,,329.62,Fee Schedule,,66.27,,,66.27,Fee Schedule,,66.27,,,66.27,Fee Schedule,,66.27,,,66.27,Fee Schedule,,172.26,,,172.26,Other,110% of Medicare,383.13,,,383.13,Fee Schedule,,0.01,,,0.01,Other,186% of Medicaid,451.25,,,451.25,Fee Schedule,,215.76,,,215.76,Fee Schedule,,255.42,,,255.42,Fee Schedule,,451.25,,,451.25,Fee Schedule,,215.76,,,215.76,Fee Schedule,,480.44,,,480.44,Fee Schedule,,243.6,70,,243.6,percent of total billed charges,All Other,576.41,,,576.41,Fee Schedule,,488.54,,,488.54,Fee Schedule,,182.45,,,182.45,Fee Schedule,,182.45,,,182.45,Fee Schedule,,182.45,,,182.45,Fee Schedule,,182.45,,,182.45,Fee Schedule,,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,576.41,
IGH VARI REGIONAL MUTATION,81263,CPT,,78081263,CDM,300,RC,,,both,,,900,666,,,666,Other,150% of Medicare + 9.63% HCRA Surcharge,405,45,,405,percent of total billed charges,Critical Access Hospital RCC factor,886.51,,,886.51,Fee Schedule,,798.15,,,798.15,Fee Schedule,,51.44,,,51.44,Fee Schedule,,51.44,,,51.44,Fee Schedule,,51.44,,,51.44,Fee Schedule,,445.5,,,445.5,Other,110% of Medicare,927.74,,,927.74,Fee Schedule,,0.01,,,0.01,Other,186% of Medicaid,1092.67,,,1092.67,Fee Schedule,,558,,,558,Fee Schedule,,618.49,,,618.49,Fee Schedule,,1092.67,,,1092.67,Fee Schedule,,558,,,558,Fee Schedule,,1163.35,,,1163.35,Fee Schedule,,630,70,,630,percent of total billed charges,All Other,1395.74,,,1395.74,Fee Schedule,,1182.98,,,1182.98,Fee Schedule,,441.78,,,441.78,Fee Schedule,,441.78,,,441.78,Fee Schedule,,441.78,,,441.78,Fee Schedule,,441.78,,,441.78,Fee Schedule,,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1395.74,
STR MARKERS SPECIMEN ANAL,81265,CPT,,78081265,CDM,300,RC,,,both,,,735,543.9,,,543.9,Other,150% of Medicare + 9.63% HCRA Surcharge,330.75,45,,330.75,percent of total billed charges,Critical Access Hospital RCC factor,701.54,,,701.54,Fee Schedule,,631.62,,,631.62,Fee Schedule,,76.58,,,76.58,Fee Schedule,,76.58,,,76.58,Fee Schedule,,76.58,,,76.58,Fee Schedule,,363.83,,,363.83,Other,110% of Medicare,734.17,,,734.17,Fee Schedule,,0.01,,,0.01,Other,186% of Medicaid,864.69,,,864.69,Fee Schedule,,455.7,,,455.7,Fee Schedule,,489.45,,,489.45,Fee Schedule,,864.69,,,864.69,Fee Schedule,,455.7,,,455.7,Fee Schedule,,920.63,,,920.63,Fee Schedule,,514.5,70,,514.5,percent of total billed charges,All Other,1104.53,,,1104.53,Fee Schedule,,936.15,,,936.15,Fee Schedule,,349.61,,,349.61,Fee Schedule,,349.61,,,349.61,Fee Schedule,,349.61,,,349.61,Fee Schedule,,349.61,,,349.61,Fee Schedule,,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1104.53,
KIT GENE TARGETED SEQ ANALYS,81272,CPT,,78081272,CDM,300,RC,,,both,,,918,679.32,,,679.32,Other,150% of Medicare + 9.63% HCRA Surcharge,413.1,45,,413.1,percent of total billed charges,Critical Access Hospital RCC factor,991.83,,,991.83,Fee Schedule,,892.97,,,892.97,Fee Schedule,,131.8,,,131.8,Fee Schedule,,131.8,,,131.8,Fee Schedule,,131.8,,,131.8,Fee Schedule,,454.41,,,454.41,Other,110% of Medicare,1037.96,,,1037.96,Fee Schedule,,0.01,,,0.01,Other,186% of Medicaid,1222.48,,,1222.48,Fee Schedule,,569.16,,,569.16,Fee Schedule,,691.97,,,691.97,Fee Schedule,,1222.48,,,1222.48,Fee Schedule,,569.16,,,569.16,Fee Schedule,,1301.56,,,1301.56,Fee Schedule,,642.6,70,,642.6,percent of total billed charges,All Other,1561.56,,,1561.56,Fee Schedule,,1323.52,,,1323.52,Fee Schedule,,494.27,,,494.27,Fee Schedule,,494.27,,,494.27,Fee Schedule,,494.27,,,494.27,Fee Schedule,,494.27,,,494.27,Fee Schedule,,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1561.56,
SMN1 GENE DOS/DELETION ALYS,81329,CPT,,78081329,CDM,300,RC,,,both,,,364,269.36,,,269.36,Other,150% of Medicare + 9.63% HCRA Surcharge,163.8,45,,163.8,percent of total billed charges,Critical Access Hospital RCC factor,412.37,,,412.37,Fee Schedule,,371.27,,,371.27,Fee Schedule,,137,,,137,Fee Schedule,,137,,,137,Fee Schedule,,137,,,137,Fee Schedule,,180.18,,,180.18,Other,110% of Medicare,431.55,,,431.55,Fee Schedule,,156,,,156,Other,186% of Medicaid,508.27,,,508.27,Fee Schedule,,225.68,,,225.68,Fee Schedule,,287.7,,,287.7,Fee Schedule,,508.27,,,508.27,Fee Schedule,,225.68,,,225.68,Fee Schedule,,541.15,,,541.15,Fee Schedule,,254.8,70,,254.8,percent of total billed charges,All Other,649.25,,,649.25,Fee Schedule,,550.28,,,550.28,Fee Schedule,,205.5,,,205.5,Fee Schedule,,205.5,,,205.5,Fee Schedule,,205.5,,,205.5,Fee Schedule,,205.5,,,205.5,Fee Schedule,,83.83,,,83.83,Other,100% of Medicaid,83.83,,,83.83,Other,100% of Medicaid,83.83,,,83.83,Other,100% of Medicaid,83.83,,,83.83,Other,100% of Medicaid,188.62,,,188.62,Other,225% of Medicaid,128.26,,,128.26,Other,153% of Medicaid,188.62,,,188.62,Other,225% of Medicaid,117.36,,,117.36,Other,140% of Medicaid,188.62,,,188.62,Other,225% of Medicaid,217.96,,,217.96,Other,260% of Medicaid,271.61,,,271.61,Other,324% of Medicaid,180.23,,,180.23,Other,215% of Medicaid,180.23,,,180.23,Other,215% of Medicaid,104.79,,,104.79,Other,125% of Medicaid,83.83,649.25,
MOPATH PROCEDURE LEVEL 3,81402,CPT,,78081402,CDM,300,RC,,,both,,,417,308.58,,,308.58,Other,150% of Medicare + 9.63% HCRA Surcharge,187.65,45,,187.65,percent of total billed charges,Critical Access Hospital RCC factor,452.49,,,452.49,Fee Schedule,,407.39,,,407.39,Fee Schedule,,51.6,,,51.6,Fee Schedule,,51.6,,,51.6,Fee Schedule,,51.6,,,51.6,Fee Schedule,,206.42,,,206.42,Other,110% of Medicare,473.54,,,473.54,Fee Schedule,,0.01,,,0.01,Other,186% of Medicaid,557.72,,,557.72,Fee Schedule,,258.54,,,258.54,Fee Schedule,,315.69,,,315.69,Fee Schedule,,557.72,,,557.72,Fee Schedule,,258.54,,,258.54,Fee Schedule,,593.8,,,593.8,Fee Schedule,,291.9,70,,291.9,percent of total billed charges,All Other,712.42,,,712.42,Fee Schedule,,603.82,,,603.82,Fee Schedule,,225.5,,,225.5,Fee Schedule,,225.5,,,225.5,Fee Schedule,,225.5,,,225.5,Fee Schedule,,225.5,,,225.5,Fee Schedule,,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,712.42,
AUTOIMMUNE RHEMATOID ARTHR,81490,CPT,,78081490,CDM,300,RC,,,both,,,2118,1567.33,,,1567.33,Other,150% of Medicare + 9.63% HCRA Surcharge,953.1,45,,953.1,percent of total billed charges,Critical Access Hospital RCC factor,2530.36,,,2530.36,Fee Schedule,,2278.16,,,2278.16,Fee Schedule,,420.33,,,420.33,Fee Schedule,,420.33,,,420.33,Fee Schedule,,420.33,,,420.33,Fee Schedule,,1048.41,,,1048.41,Other,110% of Medicare,2648.05,,,2648.05,Fee Schedule,,0.01,,,0.01,Other,186% of Medicaid,3118.81,,,3118.81,Fee Schedule,,1313.16,,,1313.16,Fee Schedule,,1765.37,,,1765.37,Fee Schedule,,3118.81,,,3118.81,Fee Schedule,,1313.16,,,1313.16,Fee Schedule,,3320.57,,,3320.57,Fee Schedule,,1482.6,70,,1482.6,percent of total billed charges,All Other,3983.87,,,3983.87,Fee Schedule,,3376.57,,,3376.57,Fee Schedule,,1260.98,,,1260.98,Fee Schedule,,1260.98,,,1260.98,Fee Schedule,,1260.98,,,1260.98,Fee Schedule,,1260.98,,,1260.98,Fee Schedule,,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3983.87,
ALPHA-1-ANTITRYPSIN TOTAL,82103,CPT,,78082103,CDM,300,RC,,,both,,,224,165.76,,,165.76,Other,150% of Medicare + 9.63% HCRA Surcharge,100.8,45,,100.8,percent of total billed charges,Critical Access Hospital RCC factor,40.45,,,40.45,Fee Schedule,,36.42,,,36.42,Fee Schedule,,99.66,,,99.66,Fee Schedule,,89.63,,,89.63,Fee Schedule,,84.72,,,84.72,Fee Schedule,,110.88,,,110.88,Other,110% of Medicare,42.34,,,42.34,Fee Schedule,,23,,,23,Other,186% of Medicaid,49.86,,,49.86,Fee Schedule,,138.88,,,138.88,Fee Schedule,,28.22,,,28.22,Fee Schedule,,49.86,,,49.86,Fee Schedule,,138.88,,,138.88,Fee Schedule,,53.09,,,53.09,Fee Schedule,,156.8,70,,156.8,percent of total billed charges,All Other,63.69,,,63.69,Fee Schedule,,53.98,,,53.98,Fee Schedule,,20.16,,,20.16,Fee Schedule,,20.16,,,20.16,Fee Schedule,,20.16,,,20.16,Fee Schedule,,20.16,,,20.16,Fee Schedule,,12.63,,,12.63,Other,100% of Medicaid,12.63,,,12.63,Other,100% of Medicaid,12.63,,,12.63,Other,100% of Medicaid,12.63,,,12.63,Other,100% of Medicaid,28.41,,,28.41,Other,225% of Medicaid,19.32,,,19.32,Other,153% of Medicaid,28.41,,,28.41,Other,225% of Medicaid,17.68,,,17.68,Other,140% of Medicaid,28.41,,,28.41,Other,225% of Medicaid,32.83,,,32.83,Other,260% of Medicaid,40.91,,,40.91,Other,324% of Medicaid,27.14,,,27.14,Other,215% of Medicaid,27.14,,,27.14,Other,215% of Medicaid,15.78,,,15.78,Other,125% of Medicaid,12.63,165.76,
ASSAY TEST FOR BLOOD FECAL,82274,CPT,,78082274,CDM,300,RC,,,both,,,103,76.22,,,76.22,Other,150% of Medicare + 9.63% HCRA Surcharge,46.35,45,,46.35,percent of total billed charges,Critical Access Hospital RCC factor,47.92,,,47.92,Fee Schedule,,43.14,,,43.14,Fee Schedule,,117.94,,,117.94,Fee Schedule,,106.08,,,106.08,Fee Schedule,,100.26,,,100.26,Fee Schedule,,50.99,,,50.99,Other,110% of Medicare,50.15,,,50.15,Fee Schedule,,6,,,6,Other,186% of Medicaid,59.06,,,59.06,Fee Schedule,,63.86,,,63.86,Fee Schedule,,33.43,,,33.43,Fee Schedule,,59.06,,,59.06,Fee Schedule,,63.86,,,63.86,Fee Schedule,,62.88,,,62.88,Fee Schedule,,72.1,70,,72.1,percent of total billed charges,All Other,75.45,,,75.45,Fee Schedule,,63.94,,,63.94,Fee Schedule,,23.88,,,23.88,Fee Schedule,,23.88,,,23.88,Fee Schedule,,23.88,,,23.88,Fee Schedule,,23.88,,,23.88,Fee Schedule,,3.43,,,3.43,Other,100% of Medicaid,3.43,,,3.43,Other,100% of Medicaid,3.43,,,3.43,Other,100% of Medicaid,3.43,,,3.43,Other,100% of Medicaid,7.73,,,7.73,Other,225% of Medicaid,5.25,,,5.25,Other,153% of Medicaid,7.73,,,7.73,Other,225% of Medicaid,4.81,,,4.81,Other,140% of Medicaid,7.73,,,7.73,Other,225% of Medicaid,8.93,,,8.93,Other,260% of Medicaid,11.13,,,11.13,Other,324% of Medicaid,7.38,,,7.38,Other,215% of Medicaid,7.38,,,7.38,Other,215% of Medicaid,4.29,,,4.29,Other,125% of Medicaid,3.43,117.94,
ASSAY CARBOXYHB QUANT,82375,CPT,,78082375,CDM,300,RC,,,both,,,160,118.4,,,118.4,Other,150% of Medicare + 9.63% HCRA Surcharge,72,45,,72,percent of total billed charges,Critical Access Hospital RCC factor,37.08,,,37.08,Fee Schedule,,33.39,,,33.39,Fee Schedule,,91.43,,,91.43,Fee Schedule,,82.24,,,82.24,Fee Schedule,,77.73,,,77.73,Fee Schedule,,79.2,,,79.2,Other,110% of Medicare,38.81,,,38.81,Fee Schedule,,21,,,21,Other,186% of Medicaid,45.71,,,45.71,Fee Schedule,,99.2,,,99.2,Fee Schedule,,25.87,,,25.87,Fee Schedule,,45.71,,,45.71,Fee Schedule,,99.2,,,99.2,Fee Schedule,,48.66,,,48.66,Fee Schedule,,112,70,,112,percent of total billed charges,All Other,58.38,,,58.38,Fee Schedule,,49.48,,,49.48,Fee Schedule,,18.48,,,18.48,Fee Schedule,,18.48,,,18.48,Fee Schedule,,18.48,,,18.48,Fee Schedule,,18.48,,,18.48,Fee Schedule,,11.11,,,11.11,Other,100% of Medicaid,11.11,,,11.11,Other,100% of Medicaid,11.11,,,11.11,Other,100% of Medicaid,11.11,,,11.11,Other,100% of Medicaid,25,,,25,Other,225% of Medicaid,17,,,17,Other,153% of Medicaid,25,,,25,Other,225% of Medicaid,15.55,,,15.55,Other,140% of Medicaid,25,,,25,Other,225% of Medicaid,28.89,,,28.89,Other,260% of Medicaid,36,,,36,Other,324% of Medicaid,23.89,,,23.89,Other,215% of Medicaid,23.89,,,23.89,Other,215% of Medicaid,13.89,,,13.89,Other,125% of Medicaid,11.11,118.4,
ASSAY OF CARNITINE,82379,CPT,,78082379,CDM,300,RC,,,both,,,105,77.7,,,77.7,Other,150% of Medicare + 9.63% HCRA Surcharge,47.25,45,,47.25,percent of total billed charges,Critical Access Hospital RCC factor,50.78,,,50.78,Fee Schedule,,45.72,,,45.72,Fee Schedule,,106.88,,,106.88,Fee Schedule,,96.13,,,96.13,Fee Schedule,,90.85,,,90.85,Fee Schedule,,51.98,,,51.98,Other,110% of Medicare,53.14,,,53.14,Fee Schedule,,20,,,20,Other,186% of Medicaid,62.59,,,62.59,Fee Schedule,,65.1,,,65.1,Fee Schedule,,35.43,,,35.43,Fee Schedule,,62.59,,,62.59,Fee Schedule,,65.1,,,65.1,Fee Schedule,,66.64,,,66.64,Fee Schedule,,73.5,70,,73.5,percent of total billed charges,All Other,79.95,,,79.95,Fee Schedule,,67.76,,,67.76,Fee Schedule,,25.31,,,25.31,Fee Schedule,,25.31,,,25.31,Fee Schedule,,25.31,,,25.31,Fee Schedule,,25.31,,,25.31,Fee Schedule,,10.61,,,10.61,Other,100% of Medicaid,10.61,,,10.61,Other,100% of Medicaid,10.61,,,10.61,Other,100% of Medicaid,10.61,,,10.61,Other,100% of Medicaid,23.86,,,23.86,Other,225% of Medicaid,16.23,,,16.23,Other,153% of Medicaid,23.86,,,23.86,Other,225% of Medicaid,14.85,,,14.85,Other,140% of Medicaid,23.86,,,23.86,Other,225% of Medicaid,27.57,,,27.57,Other,260% of Medicaid,34.36,,,34.36,Other,324% of Medicaid,22.8,,,22.8,Other,215% of Medicaid,22.8,,,22.8,Other,215% of Medicaid,13.26,,,13.26,Other,125% of Medicaid,10.61,106.88,
ENZYME CELL ACTIVITY,82657,CPT,,78082657,CDM,300,RC,,,both,,,108,79.92,,,79.92,Other,150% of Medicare + 9.63% HCRA Surcharge,48.6,45,,48.6,percent of total billed charges,Critical Access Hospital RCC factor,66.73,,,66.73,Fee Schedule,,60.08,,,60.08,Fee Schedule,,133.91,,,133.91,Fee Schedule,,120.44,,,120.44,Fee Schedule,,113.84,,,113.84,Fee Schedule,,53.46,,,53.46,Other,110% of Medicare,69.84,,,69.84,Fee Schedule,,19,,,19,Other,186% of Medicaid,82.25,,,82.25,Fee Schedule,,66.96,,,66.96,Fee Schedule,,46.56,,,46.56,Fee Schedule,,82.25,,,82.25,Fee Schedule,,66.96,,,66.96,Fee Schedule,,87.57,,,87.57,Fee Schedule,,75.6,70,,75.6,percent of total billed charges,All Other,105.06,,,105.06,Fee Schedule,,89.05,,,89.05,Fee Schedule,,33.26,,,33.26,Fee Schedule,,33.26,,,33.26,Fee Schedule,,33.26,,,33.26,Fee Schedule,,33.26,,,33.26,Fee Schedule,,10.16,,,10.16,Other,100% of Medicaid,10.16,,,10.16,Other,100% of Medicaid,10.16,,,10.16,Other,100% of Medicaid,10.16,,,10.16,Other,100% of Medicaid,22.85,,,22.85,Other,225% of Medicaid,15.54,,,15.54,Other,153% of Medicaid,22.85,,,22.85,Other,225% of Medicaid,14.22,,,14.22,Other,140% of Medicaid,22.85,,,22.85,Other,225% of Medicaid,26.4,,,26.4,Other,260% of Medicaid,32.9,,,32.9,Other,324% of Medicaid,21.83,,,21.83,Other,215% of Medicaid,21.83,,,21.83,Other,215% of Medicaid,12.69,,,12.69,Other,125% of Medicaid,10.16,133.91,
ELECTROPHORETIC TEST,82664,CPT,,78082664,CDM,300,RC,,,both,,,412,304.88,,,304.88,Other,150% of Medicare + 9.63% HCRA Surcharge,185.4,45,,185.4,percent of total billed charges,Critical Access Hospital RCC factor,185.12,,,185.12,Fee Schedule,,166.67,,,166.67,Fee Schedule,,220.13,,,220.13,Fee Schedule,,197.99,,,197.99,Fee Schedule,,187.13,,,187.13,Fee Schedule,,203.94,,,203.94,Other,110% of Medicare,193.73,,,193.73,Fee Schedule,,59,,,59,Other,186% of Medicaid,228.17,,,228.17,Fee Schedule,,255.44,,,255.44,Fee Schedule,,129.15,,,129.15,Fee Schedule,,228.17,,,228.17,Fee Schedule,,255.44,,,255.44,Fee Schedule,,242.93,,,242.93,Fee Schedule,,288.4,70,,288.4,percent of total billed charges,All Other,291.45,,,291.45,Fee Schedule,,247.02,,,247.02,Fee Schedule,,92.25,,,92.25,Fee Schedule,,92.25,,,92.25,Fee Schedule,,92.25,,,92.25,Fee Schedule,,92.25,,,92.25,Fee Schedule,,31.7,,,31.7,Other,100% of Medicaid,31.7,,,31.7,Other,100% of Medicaid,31.7,,,31.7,Other,100% of Medicaid,31.7,,,31.7,Other,100% of Medicaid,71.33,,,71.33,Other,225% of Medicaid,48.51,,,48.51,Other,153% of Medicaid,71.33,,,71.33,Other,225% of Medicaid,44.38,,,44.38,Other,140% of Medicaid,71.33,,,71.33,Other,225% of Medicaid,82.43,,,82.43,Other,260% of Medicaid,102.72,,,102.72,Other,324% of Medicaid,68.16,,,68.16,Other,215% of Medicaid,68.16,,,68.16,Other,215% of Medicaid,39.63,,,39.63,Other,125% of Medicaid,31.7,304.88,
ASSAY IGA/IGD/IGG/IGM EACH,82784,CPT,,78082784,CDM,300,RC,,,both,,,119,88.06,,,88.06,Other,150% of Medicare + 9.63% HCRA Surcharge,53.55,45,,53.55,percent of total billed charges,Critical Access Hospital RCC factor,27.99,,,27.99,Fee Schedule,,25.2,,,25.2,Fee Schedule,,68.98,,,68.98,Fee Schedule,,62.05,,,62.05,Fee Schedule,,58.64,,,58.64,Fee Schedule,,58.91,,,58.91,Other,110% of Medicare,29.3,,,29.3,Fee Schedule,,17,,,17,Other,186% of Medicaid,34.5,,,34.5,Fee Schedule,,73.78,,,73.78,Fee Schedule,,19.53,,,19.53,Fee Schedule,,34.5,,,34.5,Fee Schedule,,73.78,,,73.78,Fee Schedule,,36.74,,,36.74,Fee Schedule,,83.3,70,,83.3,percent of total billed charges,All Other,44.07,,,44.07,Fee Schedule,,37.35,,,37.35,Fee Schedule,,13.95,,,13.95,Fee Schedule,,13.95,,,13.95,Fee Schedule,,13.95,,,13.95,Fee Schedule,,13.95,,,13.95,Fee Schedule,,9.3,,,9.3,Other,100% of Medicaid,9.3,,,9.3,Other,100% of Medicaid,9.3,,,9.3,Other,100% of Medicaid,9.3,,,9.3,Other,100% of Medicaid,20.93,,,20.93,Other,225% of Medicaid,14.23,,,14.23,Other,153% of Medicaid,20.93,,,20.93,Other,225% of Medicaid,13.02,,,13.02,Other,140% of Medicaid,20.93,,,20.93,Other,225% of Medicaid,24.18,,,24.18,Other,260% of Medicaid,30.13,,,30.13,Other,324% of Medicaid,20,,,20,Other,215% of Medicaid,20,,,20,Other,215% of Medicaid,11.63,,,11.63,Other,125% of Medicaid,9.3,88.06,
IGG 1 2 3 OR 4 EACH,82787,CPT,,78082787,CDM,300,RC,,,both,,,192,142.08,,,142.08,Other,150% of Medicare + 9.63% HCRA Surcharge,86.4,45,,86.4,percent of total billed charges,Critical Access Hospital RCC factor,24.14,,,24.14,Fee Schedule,,21.73,,,21.73,Fee Schedule,,31.04,,,31.04,Fee Schedule,,27.92,,,27.92,Fee Schedule,,26.39,,,26.39,Fee Schedule,,95.04,,,95.04,Other,110% of Medicare,25.26,,,25.26,Fee Schedule,,11,,,11,Other,186% of Medicaid,29.75,,,29.75,Fee Schedule,,119.04,,,119.04,Fee Schedule,,16.84,,,16.84,Fee Schedule,,29.75,,,29.75,Fee Schedule,,119.04,,,119.04,Fee Schedule,,31.68,,,31.68,Fee Schedule,,134.4,70,,134.4,percent of total billed charges,All Other,38.01,,,38.01,Fee Schedule,,32.21,,,32.21,Fee Schedule,,12.03,,,12.03,Fee Schedule,,12.03,,,12.03,Fee Schedule,,12.03,,,12.03,Fee Schedule,,12.03,,,12.03,Fee Schedule,,5.96,,,5.96,Other,100% of Medicaid,5.96,,,5.96,Other,100% of Medicaid,5.96,,,5.96,Other,100% of Medicaid,5.96,,,5.96,Other,100% of Medicaid,13.41,,,13.41,Other,225% of Medicaid,9.12,,,9.12,Other,153% of Medicaid,13.41,,,13.41,Other,225% of Medicaid,8.34,,,8.34,Other,140% of Medicaid,13.41,,,13.41,Other,225% of Medicaid,15.49,,,15.49,Other,260% of Medicaid,19.31,,,19.31,Other,324% of Medicaid,12.81,,,12.81,Other,215% of Medicaid,12.81,,,12.81,Other,215% of Medicaid,7.45,,,7.45,Other,125% of Medicaid,5.96,142.08,
REAGENT STRIP/BLOOD GLUCOSE,82948,CPT,,78082948,CDM,300,RC,,,both,,,29,21.46,,,21.46,Other,150% of Medicare + 9.63% HCRA Surcharge,13.05,45,,13.05,percent of total billed charges,Critical Access Hospital RCC factor,15.17,,,15.17,Fee Schedule,,13.66,,,13.66,Fee Schedule,,23.45,,,23.45,Fee Schedule,,21.09,,,21.09,Fee Schedule,,19.94,,,19.94,Fee Schedule,,14.36,,,14.36,Other,110% of Medicare,15.88,,,15.88,Fee Schedule,,4,,,4,Other,186% of Medicaid,18.7,,,18.7,Fee Schedule,,17.98,,,17.98,Fee Schedule,,10.58,,,10.58,Fee Schedule,,18.7,,,18.7,Fee Schedule,,17.98,,,17.98,Fee Schedule,,19.91,,,19.91,Fee Schedule,,20.3,70,,20.3,percent of total billed charges,All Other,23.88,,,23.88,Fee Schedule,,20.24,,,20.24,Fee Schedule,,7.56,,,7.56,Fee Schedule,,7.56,,,7.56,Fee Schedule,,7.56,,,7.56,Fee Schedule,,7.56,,,7.56,Fee Schedule,,2.02,,,2.02,Other,100% of Medicaid,2.02,,,2.02,Other,100% of Medicaid,2.02,,,2.02,Other,100% of Medicaid,2.02,,,2.02,Other,100% of Medicaid,4.55,,,4.55,Other,225% of Medicaid,3.09,,,3.09,Other,153% of Medicaid,4.55,,,4.55,Other,225% of Medicaid,2.83,,,2.83,Other,140% of Medicaid,4.55,,,4.55,Other,225% of Medicaid,5.25,,,5.25,Other,260% of Medicaid,6.54,,,6.54,Other,324% of Medicaid,4.34,,,4.34,Other,215% of Medicaid,4.34,,,4.34,Other,215% of Medicaid,2.53,,,2.53,Other,125% of Medicaid,2.02,23.88,
ASSAY TOTAL HYDROXYPROLINE,83505,CPT,,78083505,CDM,300,RC,,,both,,,382,282.68,,,282.68,Other,150% of Medicare + 9.63% HCRA Surcharge,171.9,45,,171.9,percent of total billed charges,Critical Access Hospital RCC factor,73.14,,,73.14,Fee Schedule,,65.85,,,65.85,Fee Schedule,,180.29,,,180.29,Fee Schedule,,162.16,,,162.16,Fee Schedule,,153.26,,,153.26,Fee Schedule,,189.09,,,189.09,Other,110% of Medicare,76.55,,,76.55,Fee Schedule,,45,,,45,Other,186% of Medicaid,90.15,,,90.15,Fee Schedule,,236.84,,,236.84,Fee Schedule,,51.03,,,51.03,Fee Schedule,,90.15,,,90.15,Fee Schedule,,236.84,,,236.84,Fee Schedule,,95.99,,,95.99,Fee Schedule,,267.4,70,,267.4,percent of total billed charges,All Other,115.16,,,115.16,Fee Schedule,,97.6,,,97.6,Fee Schedule,,36.45,,,36.45,Fee Schedule,,36.45,,,36.45,Fee Schedule,,36.45,,,36.45,Fee Schedule,,36.45,,,36.45,Fee Schedule,,24.3,,,24.3,Other,100% of Medicaid,24.3,,,24.3,Other,100% of Medicaid,24.3,,,24.3,Other,100% of Medicaid,24.3,,,24.3,Other,100% of Medicaid,54.68,,,54.68,Other,225% of Medicaid,37.18,,,37.18,Other,153% of Medicaid,54.68,,,54.68,Other,225% of Medicaid,34.02,,,34.02,Other,140% of Medicaid,54.68,,,54.68,Other,225% of Medicaid,63.18,,,63.18,Other,260% of Medicaid,78.73,,,78.73,Other,324% of Medicaid,52.25,,,52.25,Other,215% of Medicaid,52.25,,,52.25,Other,215% of Medicaid,30.38,,,30.38,Other,125% of Medicaid,24.3,282.68,
IMMUNOASSAY QUANT NOS NONAB,83520,CPT,,78083520,CDM,300,RC,,,both,,,348,257.52,,,257.52,Other,150% of Medicare + 9.63% HCRA Surcharge,156.6,45,,156.6,percent of total billed charges,Critical Access Hospital RCC factor,51.98,,,51.98,Fee Schedule,,46.8,,,46.8,Fee Schedule,,96.02,,,96.02,Fee Schedule,,86.36,,,86.36,Fee Schedule,,81.63,,,81.63,Fee Schedule,,172.26,,,172.26,Other,110% of Medicare,54.4,,,54.4,Fee Schedule,,19,,,19,Other,186% of Medicaid,64.07,,,64.07,Fee Schedule,,215.76,,,215.76,Fee Schedule,,36.27,,,36.27,Fee Schedule,,64.07,,,64.07,Fee Schedule,,215.76,,,215.76,Fee Schedule,,68.22,,,68.22,Fee Schedule,,243.6,70,,243.6,percent of total billed charges,All Other,81.84,,,81.84,Fee Schedule,,69.37,,,69.37,Fee Schedule,,25.91,,,25.91,Fee Schedule,,25.91,,,25.91,Fee Schedule,,25.91,,,25.91,Fee Schedule,,25.91,,,25.91,Fee Schedule,,10.16,,,10.16,Other,100% of Medicaid,10.16,,,10.16,Other,100% of Medicaid,10.16,,,10.16,Other,100% of Medicaid,10.16,,,10.16,Other,100% of Medicaid,22.85,,,22.85,Other,225% of Medicaid,15.54,,,15.54,Other,153% of Medicaid,22.85,,,22.85,Other,225% of Medicaid,14.22,,,14.22,Other,140% of Medicaid,22.85,,,22.85,Other,225% of Medicaid,26.4,,,26.4,Other,260% of Medicaid,32.9,,,32.9,Other,324% of Medicaid,21.83,,,21.83,Other,215% of Medicaid,21.83,,,21.83,Other,215% of Medicaid,12.69,,,12.69,Other,125% of Medicaid,10.16,257.52,
ASSAY OF LACTIC ACID,83605,CPT,,78083605,CDM,300,RC,,,both,,,193,142.82,,,142.82,Other,150% of Medicare + 9.63% HCRA Surcharge,86.85,45,,86.85,percent of total billed charges,Critical Access Hospital RCC factor,34.83,,,34.83,Fee Schedule,,31.35,,,31.35,Fee Schedule,,64.08,,,64.08,Fee Schedule,,57.64,,,57.64,Fee Schedule,,54.48,,,54.48,Fee Schedule,,95.54,,,95.54,Other,110% of Medicare,36.45,,,36.45,Fee Schedule,,17,,,17,Other,186% of Medicaid,42.92,,,42.92,Fee Schedule,,119.66,,,119.66,Fee Schedule,,24.3,,,24.3,Fee Schedule,,42.92,,,42.92,Fee Schedule,,119.66,,,119.66,Fee Schedule,,45.7,,,45.7,Fee Schedule,,135.1,70,,135.1,percent of total billed charges,All Other,54.83,,,54.83,Fee Schedule,,46.47,,,46.47,Fee Schedule,,17.36,,,17.36,Fee Schedule,,17.36,,,17.36,Fee Schedule,,17.36,,,17.36,Fee Schedule,,17.36,,,17.36,Fee Schedule,,9.39,,,9.39,Other,100% of Medicaid,9.39,,,9.39,Other,100% of Medicaid,9.39,,,9.39,Other,100% of Medicaid,9.39,,,9.39,Other,100% of Medicaid,21.13,,,21.13,Other,225% of Medicaid,14.37,,,14.37,Other,153% of Medicaid,21.13,,,21.13,Other,225% of Medicaid,13.15,,,13.15,Other,140% of Medicaid,21.13,,,21.13,Other,225% of Medicaid,24.42,,,24.42,Other,260% of Medicaid,30.43,,,30.43,Other,324% of Medicaid,20.19,,,20.19,Other,215% of Medicaid,20.19,,,20.19,Other,215% of Medicaid,11.74,,,11.74,Other,125% of Medicaid,9.39,142.82,
ASSAY LIPOPROTEIN PLA2,83698,CPT,,78083698,CDM,300,RC,,,both,,,202,149.48,,,149.48,Other,150% of Medicare + 9.63% HCRA Surcharge,90.9,45,,90.9,percent of total billed charges,Critical Access Hospital RCC factor,139.39,,,139.39,Fee Schedule,,125.5,,,125.5,Fee Schedule,,251.75,,,251.75,Fee Schedule,,226.43,,,226.43,Fee Schedule,,214.01,,,214.01,Fee Schedule,,99.99,,,99.99,Other,110% of Medicare,145.88,,,145.88,Fee Schedule,,59,,,59,Other,186% of Medicaid,171.81,,,171.81,Fee Schedule,,125.24,,,125.24,Fee Schedule,,97.25,,,97.25,Fee Schedule,,171.81,,,171.81,Fee Schedule,,125.24,,,125.24,Fee Schedule,,182.92,,,182.92,Fee Schedule,,141.4,70,,141.4,percent of total billed charges,All Other,219.46,,,219.46,Fee Schedule,,186.01,,,186.01,Fee Schedule,,69.47,,,69.47,Fee Schedule,,69.47,,,69.47,Fee Schedule,,69.47,,,69.47,Fee Schedule,,69.47,,,69.47,Fee Schedule,,31.7,,,31.7,Other,100% of Medicaid,31.7,,,31.7,Other,100% of Medicaid,31.7,,,31.7,Other,100% of Medicaid,31.7,,,31.7,Other,100% of Medicaid,71.33,,,71.33,Other,225% of Medicaid,48.51,,,48.51,Other,153% of Medicaid,71.33,,,71.33,Other,225% of Medicaid,44.38,,,44.38,Other,140% of Medicaid,71.33,,,71.33,Other,225% of Medicaid,82.43,,,82.43,Other,260% of Medicaid,102.72,,,102.72,Other,324% of Medicaid,68.16,,,68.16,Other,215% of Medicaid,68.16,,,68.16,Other,215% of Medicaid,39.63,,,39.63,Other,125% of Medicaid,31.7,251.75,
LIPOPROTEIN BLD HR FRACTION,83701,CPT,,78083701,CDM,300,RC,,,both,,,131,96.94,,,96.94,Other,150% of Medicare + 9.63% HCRA Surcharge,58.95,45,,58.95,percent of total billed charges,Critical Access Hospital RCC factor,101.92,,,101.92,Fee Schedule,,91.76,,,91.76,Fee Schedule,,107.67,,,107.67,Fee Schedule,,96.84,,,96.84,Fee Schedule,,91.53,,,91.53,Fee Schedule,,64.85,,,64.85,Other,110% of Medicare,106.66,,,106.66,Fee Schedule,,59,,,59,Other,186% of Medicaid,125.62,,,125.62,Fee Schedule,,81.22,,,81.22,Fee Schedule,,71.11,,,71.11,Fee Schedule,,125.62,,,125.62,Fee Schedule,,81.22,,,81.22,Fee Schedule,,133.75,,,133.75,Fee Schedule,,91.7,70,,91.7,percent of total billed charges,All Other,160.46,,,160.46,Fee Schedule,,136,,,136,Fee Schedule,,50.79,,,50.79,Fee Schedule,,50.79,,,50.79,Fee Schedule,,50.79,,,50.79,Fee Schedule,,50.79,,,50.79,Fee Schedule,,31.7,,,31.7,Other,100% of Medicaid,31.7,,,31.7,Other,100% of Medicaid,31.7,,,31.7,Other,100% of Medicaid,31.7,,,31.7,Other,100% of Medicaid,71.33,,,71.33,Other,225% of Medicaid,48.51,,,48.51,Other,153% of Medicaid,71.33,,,71.33,Other,225% of Medicaid,44.38,,,44.38,Other,140% of Medicaid,71.33,,,71.33,Other,225% of Medicaid,82.43,,,82.43,Other,260% of Medicaid,102.72,,,102.72,Other,324% of Medicaid,68.16,,,68.16,Other,215% of Medicaid,68.16,,,68.16,Other,215% of Medicaid,39.63,,,39.63,Other,125% of Medicaid,31.7,160.46,
ASSAY OF PARATHORMONE,83970,CPT,,78083970,CDM,300,RC,,,both,,,566,418.84,,,418.84,Other,150% of Medicare + 9.63% HCRA Surcharge,254.7,45,,254.7,percent of total billed charges,Critical Access Hospital RCC factor,124.25,,,124.25,Fee Schedule,,111.87,,,111.87,Fee Schedule,,306.08,,,306.08,Fee Schedule,,275.3,,,275.3,Fee Schedule,,260.2,,,260.2,Fee Schedule,,280.17,,,280.17,Other,110% of Medicare,130.03,,,130.03,Fee Schedule,,77,,,77,Other,186% of Medicaid,153.15,,,153.15,Fee Schedule,,350.92,,,350.92,Fee Schedule,,86.69,,,86.69,Fee Schedule,,153.15,,,153.15,Fee Schedule,,350.92,,,350.92,Fee Schedule,,163.06,,,163.06,Fee Schedule,,396.2,70,,396.2,percent of total billed charges,All Other,195.63,,,195.63,Fee Schedule,,165.81,,,165.81,Fee Schedule,,61.92,,,61.92,Fee Schedule,,61.92,,,61.92,Fee Schedule,,61.92,,,61.92,Fee Schedule,,61.92,,,61.92,Fee Schedule,,41.28,,,41.28,Other,100% of Medicaid,41.28,,,41.28,Other,100% of Medicaid,41.28,,,41.28,Other,100% of Medicaid,41.28,,,41.28,Other,100% of Medicaid,92.88,,,92.88,Other,225% of Medicaid,63.16,,,63.16,Other,153% of Medicaid,92.88,,,92.88,Other,225% of Medicaid,57.79,,,57.79,Other,140% of Medicaid,92.88,,,92.88,Other,225% of Medicaid,107.33,,,107.33,Other,260% of Medicaid,133.75,,,133.75,Other,324% of Medicaid,88.75,,,88.75,Other,215% of Medicaid,88.75,,,88.75,Other,215% of Medicaid,51.6,,,51.6,Other,125% of Medicaid,41.28,418.84,
ASSAY OF PSA COMPLEXED,84152,CPT,,78084152,CDM,300,RC,,,both,,,135,99.9,,,99.9,Other,150% of Medicare + 9.63% HCRA Surcharge,60.75,45,,60.75,percent of total billed charges,Critical Access Hospital RCC factor,55.35,,,55.35,Fee Schedule,,49.84,,,49.84,Fee Schedule,,136.44,,,136.44,Fee Schedule,,122.72,,,122.72,Fee Schedule,,115.99,,,115.99,Fee Schedule,,66.83,,,66.83,Other,110% of Medicare,57.93,,,57.93,Fee Schedule,,34,,,34,Other,186% of Medicaid,68.23,,,68.23,Fee Schedule,,83.7,,,83.7,Fee Schedule,,38.62,,,38.62,Fee Schedule,,68.23,,,68.23,Fee Schedule,,83.7,,,83.7,Fee Schedule,,72.64,,,72.64,Fee Schedule,,94.5,70,,94.5,percent of total billed charges,All Other,87.15,,,87.15,Fee Schedule,,73.87,,,73.87,Fee Schedule,,27.59,,,27.59,Fee Schedule,,27.59,,,27.59,Fee Schedule,,27.59,,,27.59,Fee Schedule,,27.59,,,27.59,Fee Schedule,,18.39,,,18.39,Other,100% of Medicaid,18.39,,,18.39,Other,100% of Medicaid,18.39,,,18.39,Other,100% of Medicaid,18.39,,,18.39,Other,100% of Medicaid,41.38,,,41.38,Other,225% of Medicaid,28.14,,,28.14,Other,153% of Medicaid,41.38,,,41.38,Other,225% of Medicaid,25.75,,,25.75,Other,140% of Medicaid,41.38,,,41.38,Other,225% of Medicaid,47.81,,,47.81,Other,260% of Medicaid,59.58,,,59.58,Other,324% of Medicaid,39.54,,,39.54,Other,215% of Medicaid,39.54,,,39.54,Other,215% of Medicaid,22.99,,,22.99,Other,125% of Medicaid,18.39,136.44,
ASSAY OF PROTEIN OTHER,84157,CPT,,78084157,CDM,300,RC,,,both,,,65,48.1,,,48.1,Other,150% of Medicare + 9.63% HCRA Surcharge,29.25,45,,29.25,percent of total billed charges,Critical Access Hospital RCC factor,12.04,,,12.04,Fee Schedule,,10.84,,,10.84,Fee Schedule,,27.19,,,27.19,Fee Schedule,,24.46,,,24.46,Fee Schedule,,23.12,,,23.12,Fee Schedule,,32.18,,,32.18,Other,110% of Medicare,12.6,,,12.6,Fee Schedule,,7,,,7,Other,186% of Medicaid,14.84,,,14.84,Fee Schedule,,40.3,,,40.3,Fee Schedule,,8.4,,,8.4,Fee Schedule,,14.84,,,14.84,Fee Schedule,,40.3,,,40.3,Fee Schedule,,15.8,,,15.8,Fee Schedule,,45.5,70,,45.5,percent of total billed charges,All Other,18.96,,,18.96,Fee Schedule,,16.07,,,16.07,Fee Schedule,,6,,,6,Fee Schedule,,6,,,6,Fee Schedule,,6,,,6,Fee Schedule,,6,,,6,Fee Schedule,,4,,,4,Other,100% of Medicaid,4,,,4,Other,100% of Medicaid,4,,,4,Other,100% of Medicaid,4,,,4,Other,100% of Medicaid,9,,,9,Other,225% of Medicaid,6.12,,,6.12,Other,153% of Medicaid,9,,,9,Other,225% of Medicaid,5.6,,,5.6,Other,140% of Medicaid,9,,,9,Other,225% of Medicaid,10.4,,,10.4,Other,260% of Medicaid,12.96,,,12.96,Other,324% of Medicaid,8.6,,,8.6,Other,215% of Medicaid,8.6,,,8.6,Other,215% of Medicaid,5,,,5,Other,125% of Medicaid,4,48.1,
ASSAY OF PROINSULIN,84206,CPT,,78084206,CDM,300,RC,,,both,,,115,85.1,,,85.1,Other,150% of Medicare + 9.63% HCRA Surcharge,51.75,45,,51.75,percent of total billed charges,Critical Access Hospital RCC factor,80.34,,,80.34,Fee Schedule,,72.33,,,72.33,Fee Schedule,,132.12,,,132.12,Fee Schedule,,118.83,,,118.83,Fee Schedule,,112.31,,,112.31,Fee Schedule,,56.93,,,56.93,Other,110% of Medicare,84.07,,,84.07,Fee Schedule,,44,,,44,Other,186% of Medicaid,99.02,,,99.02,Fee Schedule,,71.3,,,71.3,Fee Schedule,,56.05,,,56.05,Fee Schedule,,99.02,,,99.02,Fee Schedule,,71.3,,,71.3,Fee Schedule,,105.43,,,105.43,Fee Schedule,,80.5,70,,80.5,percent of total billed charges,All Other,126.48,,,126.48,Fee Schedule,,107.2,,,107.2,Fee Schedule,,40.04,,,40.04,Fee Schedule,,40.04,,,40.04,Fee Schedule,,40.04,,,40.04,Fee Schedule,,40.04,,,40.04,Fee Schedule,,23.84,,,23.84,Other,100% of Medicaid,23.84,,,23.84,Other,100% of Medicaid,23.84,,,23.84,Other,100% of Medicaid,23.84,,,23.84,Other,100% of Medicaid,53.64,,,53.64,Other,225% of Medicaid,36.47,,,36.47,Other,153% of Medicaid,53.64,,,53.64,Other,225% of Medicaid,33.37,,,33.37,Other,140% of Medicaid,53.64,,,53.64,Other,225% of Medicaid,61.98,,,61.98,Other,260% of Medicaid,77.24,,,77.24,Other,324% of Medicaid,51.25,,,51.25,Other,215% of Medicaid,51.25,,,51.25,Other,215% of Medicaid,29.8,,,29.8,Other,125% of Medicaid,23.84,132.12,
ASSAY OF SEX HORMONE GLOBUL,84270,CPT,,78084270,CDM,300,RC,,,both,,,139,102.86,,,102.86,Other,150% of Medicare + 9.63% HCRA Surcharge,62.55,45,,62.55,percent of total billed charges,Critical Access Hospital RCC factor,65.41,,,65.41,Fee Schedule,,58.89,,,58.89,Fee Schedule,,161.16,,,161.16,Fee Schedule,,144.95,,,144.95,Fee Schedule,,137,,,137,Fee Schedule,,68.81,,,68.81,Other,110% of Medicare,68.45,,,68.45,Fee Schedule,,19,,,19,Other,186% of Medicaid,80.62,,,80.62,Fee Schedule,,86.18,,,86.18,Fee Schedule,,45.63,,,45.63,Fee Schedule,,80.62,,,80.62,Fee Schedule,,86.18,,,86.18,Fee Schedule,,85.83,,,85.83,Fee Schedule,,97.3,70,,97.3,percent of total billed charges,All Other,102.98,,,102.98,Fee Schedule,,87.28,,,87.28,Fee Schedule,,32.6,,,32.6,Fee Schedule,,32.6,,,32.6,Fee Schedule,,32.6,,,32.6,Fee Schedule,,32.6,,,32.6,Fee Schedule,,10.16,,,10.16,Other,100% of Medicaid,10.16,,,10.16,Other,100% of Medicaid,10.16,,,10.16,Other,100% of Medicaid,10.16,,,10.16,Other,100% of Medicaid,22.85,,,22.85,Other,225% of Medicaid,15.54,,,15.54,Other,153% of Medicaid,22.85,,,22.85,Other,225% of Medicaid,14.22,,,14.22,Other,140% of Medicaid,22.85,,,22.85,Other,225% of Medicaid,26.4,,,26.4,Other,260% of Medicaid,32.9,,,32.9,Other,324% of Medicaid,21.83,,,21.83,Other,215% of Medicaid,21.83,,,21.83,Other,215% of Medicaid,12.69,,,12.69,Other,125% of Medicaid,10.16,161.16,
CLINICAL CHEMISTRY TEST,84999,CPT,,78084999,CDM,300,RC,,,both,,,105,77.7,,,77.7,Other,150% of Medicare + 9.63% HCRA Surcharge,47.25,45,,47.25,percent of total billed charges,Critical Access Hospital RCC factor,68.25,65,,68.25,percent of total billed charges,All Other,61.95,65,,61.95,percent of total billed charges,All Other,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,51.98,,,51.98,Other,110% of Medicare,71.4,68,,71.4,percent of total billed charges,All Other,19,,,19,Other,186% of Medicaid,87.15,83,,87.15,percent of total billed charges,All Other,65.1,62,,65.1,percent of total billed charges,Lab and Radiology,57.75,55,,57.75,percent of total billed charges,Default if not on Fee Schedule,84,80,,84,percent of total billed charges,All Other,65.1,62,,65.1,percent of total billed charges,Lab and Radiology,84,80,,84,percent of total billed charges,All Other,73.5,70,,73.5,percent of total billed charges,All Other,68.25,65,,68.25,percent of total billed charges,Default if not in Fee Schedule,68.25,65,,68.25,percent of total billed charges,Default if not in Fee Schedule,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,10.16,,,10.16,Other,100% of Medicaid,10.16,,,10.16,Other,100% of Medicaid,10.16,,,10.16,Other,100% of Medicaid,10.16,,,10.16,Other,100% of Medicaid,22.85,,,22.85,Other,225% of Medicaid,15.54,,,15.54,Other,153% of Medicaid,22.85,,,22.85,Other,225% of Medicaid,14.22,,,14.22,Other,140% of Medicaid,22.85,,,22.85,Other,225% of Medicaid,26.4,,,26.4,Other,260% of Medicaid,32.9,,,32.9,Other,324% of Medicaid,21.83,,,21.83,Other,215% of Medicaid,21.83,,,21.83,Other,215% of Medicaid,12.69,,,12.69,Other,125% of Medicaid,0.01,87.15,
SPUN MICROHEMATOCRIT,85013,CPT,,78085013,CDM,300,RC,,,both,,,30,22.2,,,22.2,Other,150% of Medicare + 9.63% HCRA Surcharge,13.5,45,,13.5,percent of total billed charges,Critical Access Hospital RCC factor,21.07,,,21.07,Fee Schedule,,18.97,,,18.97,Fee Schedule,,17.55,,,17.55,Fee Schedule,,15.78,,,15.78,Fee Schedule,,14.92,,,14.92,Fee Schedule,,14.85,,,14.85,Other,110% of Medicare,22.05,,,22.05,Fee Schedule,,4,,,4,Other,186% of Medicaid,25.97,,,25.97,Fee Schedule,,18.6,,,18.6,Fee Schedule,,14.7,,,14.7,Fee Schedule,,25.97,,,25.97,Fee Schedule,,18.6,,,18.6,Fee Schedule,,27.65,,,27.65,Fee Schedule,,21,70,,21,percent of total billed charges,All Other,33.17,,,33.17,Fee Schedule,,28.12,,,28.12,Fee Schedule,,10.5,,,10.5,Fee Schedule,,10.5,,,10.5,Fee Schedule,,10.5,,,10.5,Fee Schedule,,10.5,,,10.5,Fee Schedule,,2.02,,,2.02,Other,100% of Medicaid,2.02,,,2.02,Other,100% of Medicaid,2.02,,,2.02,Other,100% of Medicaid,2.02,,,2.02,Other,100% of Medicaid,4.55,,,4.55,Other,225% of Medicaid,3.09,,,3.09,Other,153% of Medicaid,4.55,,,4.55,Other,225% of Medicaid,2.83,,,2.83,Other,140% of Medicaid,4.55,,,4.55,Other,225% of Medicaid,5.25,,,5.25,Other,260% of Medicaid,6.54,,,6.54,Other,324% of Medicaid,4.34,,,4.34,Other,215% of Medicaid,4.34,,,4.34,Other,215% of Medicaid,2.53,,,2.53,Other,125% of Medicaid,2.02,33.17,
HEMATOCRIT,85014,CPT,,78085014,CDM,300,RC,,,both,,,40,29.6,,,29.6,Other,150% of Medicare + 9.63% HCRA Surcharge,18,45,,18,percent of total billed charges,Critical Access Hospital RCC factor,7.13,,,7.13,Fee Schedule,,6.42,,,6.42,Fee Schedule,,17.55,,,17.55,Fee Schedule,,15.78,,,15.78,Fee Schedule,,14.92,,,14.92,Fee Schedule,,19.8,,,19.8,Other,110% of Medicare,7.47,,,7.47,Fee Schedule,,4,,,4,Other,186% of Medicaid,8.79,,,8.79,Fee Schedule,,24.8,,,24.8,Fee Schedule,,4.98,,,4.98,Fee Schedule,,8.79,,,8.79,Fee Schedule,,24.8,,,24.8,Fee Schedule,,9.36,,,9.36,Fee Schedule,,28,70,,28,percent of total billed charges,All Other,11.23,,,11.23,Fee Schedule,,9.52,,,9.52,Fee Schedule,,3.56,,,3.56,Fee Schedule,,3.56,,,3.56,Fee Schedule,,3.56,,,3.56,Fee Schedule,,3.56,,,3.56,Fee Schedule,,2.02,,,2.02,Other,100% of Medicaid,2.02,,,2.02,Other,100% of Medicaid,2.02,,,2.02,Other,100% of Medicaid,2.02,,,2.02,Other,100% of Medicaid,4.55,,,4.55,Other,225% of Medicaid,3.09,,,3.09,Other,153% of Medicaid,4.55,,,4.55,Other,225% of Medicaid,2.83,,,2.83,Other,140% of Medicaid,4.55,,,4.55,Other,225% of Medicaid,5.25,,,5.25,Other,260% of Medicaid,6.54,,,6.54,Other,324% of Medicaid,4.34,,,4.34,Other,215% of Medicaid,4.34,,,4.34,Other,215% of Medicaid,2.53,,,2.53,Other,125% of Medicaid,2.02,29.6,
AUTOMATED PLATELET COUNT,85049,CPT,,78085049,CDM,300,RC,,,both,,,45,33.3,,,33.3,Other,150% of Medicare + 9.63% HCRA Surcharge,20.25,45,,20.25,percent of total billed charges,Critical Access Hospital RCC factor,13.48,,,13.48,Fee Schedule,,12.14,,,12.14,Fee Schedule,,33.15,,,33.15,Fee Schedule,,29.81,,,29.81,Fee Schedule,,28.18,,,28.18,Fee Schedule,,22.28,,,22.28,Other,110% of Medicare,14.11,,,14.11,Fee Schedule,,6,,,6,Other,186% of Medicaid,16.62,,,16.62,Fee Schedule,,27.9,,,27.9,Fee Schedule,,9.41,,,9.41,Fee Schedule,,16.62,,,16.62,Fee Schedule,,27.9,,,27.9,Fee Schedule,,17.7,,,17.7,Fee Schedule,,31.5,70,,31.5,percent of total billed charges,All Other,21.23,,,21.23,Fee Schedule,,17.99,,,17.99,Fee Schedule,,6.72,,,6.72,Fee Schedule,,6.72,,,6.72,Fee Schedule,,6.72,,,6.72,Fee Schedule,,6.72,,,6.72,Fee Schedule,,3.2,,,3.2,Other,100% of Medicaid,3.2,,,3.2,Other,100% of Medicaid,3.2,,,3.2,Other,100% of Medicaid,3.2,,,3.2,Other,100% of Medicaid,7.2,,,7.2,Other,225% of Medicaid,4.9,,,4.9,Other,153% of Medicaid,7.2,,,7.2,Other,225% of Medicaid,4.48,,,4.48,Other,140% of Medicaid,7.2,,,7.2,Other,225% of Medicaid,8.32,,,8.32,Other,260% of Medicaid,10.37,,,10.37,Other,324% of Medicaid,6.88,,,6.88,Other,215% of Medicaid,6.88,,,6.88,Other,215% of Medicaid,4,,,4,Other,125% of Medicaid,3.2,33.3,
BLOOD SMEAR INTERPRETATION,85060,CPT,,78085060,CDM,300,RC,,,both,,,119,88.06,,,88.06,Other,150% of Medicare + 9.63% HCRA Surcharge,53.55,45,,53.55,percent of total billed charges,Critical Access Hospital RCC factor,74.14,,,74.14,Fee Schedule,,66.75,,,66.75,Fee Schedule,,137.55,,,137.55,Fee Schedule,,123.71,,,123.71,Fee Schedule,,116.93,,,116.93,Fee Schedule,,58.91,,,58.91,Other,110% of Medicare,77.58,,,77.58,Fee Schedule,,38,,,38,Other,186% of Medicaid,91.38,,,91.38,Fee Schedule,,73.78,,,73.78,Fee Schedule,,51.72,,,51.72,Fee Schedule,,91.38,,,91.38,Fee Schedule,,73.78,,,73.78,Fee Schedule,,97.29,,,97.29,Fee Schedule,,83.3,70,,83.3,percent of total billed charges,All Other,116.44,,,116.44,Fee Schedule,,98.69,,,98.69,Fee Schedule,,37.89,,,37.89,Fee Schedule,,37.89,,,37.89,Fee Schedule,,37.89,,,37.89,Fee Schedule,,37.89,,,37.89,Fee Schedule,,20.42,,,20.42,Other,100% of Medicaid,20.42,,,20.42,Other,100% of Medicaid,20.42,,,20.42,Other,100% of Medicaid,20.42,,,20.42,Other,100% of Medicaid,45.95,,,45.95,Other,225% of Medicaid,31.25,,,31.25,Other,153% of Medicaid,45.95,,,45.95,Other,225% of Medicaid,28.59,,,28.59,Other,140% of Medicaid,45.95,,,45.95,Other,225% of Medicaid,53.1,,,53.1,Other,260% of Medicaid,66.17,,,66.17,Other,324% of Medicaid,43.91,,,43.91,Other,215% of Medicaid,43.91,,,43.91,Other,215% of Medicaid,25.53,,,25.53,Other,125% of Medicaid,20.42,137.55,
PHOSPHOLIPID PLTLT NEUTRALIZ,85597,CPT,,78085597,CDM,300,RC,,,both,,,88,65.12,,,65.12,Other,150% of Medicare + 9.63% HCRA Surcharge,39.6,45,,39.6,percent of total billed charges,Critical Access Hospital RCC factor,54.12,,,54.12,Fee Schedule,,48.73,,,48.73,Fee Schedule,,100.13,,,100.13,Fee Schedule,,90.06,,,90.06,Fee Schedule,,85.12,,,85.12,Fee Schedule,,43.56,,,43.56,Other,110% of Medicare,56.64,,,56.64,Fee Schedule,,23,,,23,Other,186% of Medicaid,66.71,,,66.71,Fee Schedule,,54.56,,,54.56,Fee Schedule,,37.76,,,37.76,Fee Schedule,,66.71,,,66.71,Fee Schedule,,54.56,,,54.56,Fee Schedule,,71.02,,,71.02,Fee Schedule,,61.6,70,,61.6,percent of total billed charges,All Other,85.21,,,85.21,Fee Schedule,,72.22,,,72.22,Fee Schedule,,26.97,,,26.97,Fee Schedule,,26.97,,,26.97,Fee Schedule,,26.97,,,26.97,Fee Schedule,,26.97,,,26.97,Fee Schedule,,12.56,,,12.56,Other,100% of Medicaid,12.56,,,12.56,Other,100% of Medicaid,12.56,,,12.56,Other,100% of Medicaid,12.56,,,12.56,Other,100% of Medicaid,28.27,,,28.27,Other,225% of Medicaid,19.22,,,19.22,Other,153% of Medicaid,28.27,,,28.27,Other,225% of Medicaid,17.59,,,17.59,Other,140% of Medicaid,28.27,,,28.27,Other,225% of Medicaid,32.67,,,32.67,Other,260% of Medicaid,40.71,,,40.71,Other,324% of Medicaid,27.01,,,27.01,Other,215% of Medicaid,27.01,,,27.01,Other,215% of Medicaid,15.7,,,15.7,Other,125% of Medicaid,12.56,100.13,
PROTHROMBIN TEST,85611,CPT,,78085611,CDM,300,RC,,,both,,,38,28.12,,,28.12,Other,150% of Medicare + 9.63% HCRA Surcharge,17.1,45,,17.1,percent of total billed charges,Critical Access Hospital RCC factor,11.86,,,11.86,Fee Schedule,,10.68,,,10.68,Fee Schedule,,29.2,,,29.2,Fee Schedule,,26.26,,,26.26,Fee Schedule,,24.82,,,24.82,Fee Schedule,,18.81,,,18.81,Other,110% of Medicare,12.41,,,12.41,Fee Schedule,,23,,,23,Other,186% of Medicaid,14.62,,,14.62,Fee Schedule,,23.56,,,23.56,Fee Schedule,,8.27,,,8.27,Fee Schedule,,14.62,,,14.62,Fee Schedule,,23.56,,,23.56,Fee Schedule,,15.56,,,15.56,Fee Schedule,,26.6,70,,26.6,percent of total billed charges,All Other,18.67,,,18.67,Fee Schedule,,15.83,,,15.83,Fee Schedule,,5.91,,,5.91,Fee Schedule,,5.91,,,5.91,Fee Schedule,,5.91,,,5.91,Fee Schedule,,5.91,,,5.91,Fee Schedule,,12.56,,,12.56,Other,100% of Medicaid,12.56,,,12.56,Other,100% of Medicaid,12.56,,,12.56,Other,100% of Medicaid,12.56,,,12.56,Other,100% of Medicaid,28.27,,,28.27,Other,225% of Medicaid,19.22,,,19.22,Other,153% of Medicaid,28.27,,,28.27,Other,225% of Medicaid,17.59,,,17.59,Other,140% of Medicaid,28.27,,,28.27,Other,225% of Medicaid,32.67,,,32.67,Other,260% of Medicaid,40.71,,,40.71,Other,324% of Medicaid,27.01,,,27.01,Other,215% of Medicaid,27.01,,,27.01,Other,215% of Medicaid,15.7,,,15.7,Other,125% of Medicaid,5.91,40.71,
THROMBOPLASTIN TIME PARTIAL,85730,CPT,,78085730,CDM,300,RC,,,both,,,155,114.7,,,114.7,Other,150% of Medicare + 9.63% HCRA Surcharge,69.75,45,,69.75,percent of total billed charges,Critical Access Hospital RCC factor,18.09,,,18.09,Fee Schedule,,16.29,,,16.29,Fee Schedule,,44.53,,,44.53,Fee Schedule,,40.05,,,40.05,Fee Schedule,,37.86,,,37.86,Fee Schedule,,76.73,,,76.73,Other,110% of Medicare,18.93,,,18.93,Fee Schedule,,11,,,11,Other,186% of Medicaid,22.3,,,22.3,Fee Schedule,,96.1,,,96.1,Fee Schedule,,12.62,,,12.62,Fee Schedule,,22.3,,,22.3,Fee Schedule,,96.1,,,96.1,Fee Schedule,,23.74,,,23.74,Fee Schedule,,108.5,70,,108.5,percent of total billed charges,All Other,28.48,,,28.48,Fee Schedule,,24.14,,,24.14,Fee Schedule,,9.02,,,9.02,Fee Schedule,,9.02,,,9.02,Fee Schedule,,9.02,,,9.02,Fee Schedule,,9.02,,,9.02,Fee Schedule,,6.01,,,6.01,Other,100% of Medicaid,6.01,,,6.01,Other,100% of Medicaid,6.01,,,6.01,Other,100% of Medicaid,6.01,,,6.01,Other,100% of Medicaid,13.52,,,13.52,Other,225% of Medicaid,9.2,,,9.2,Other,153% of Medicaid,13.52,,,13.52,Other,225% of Medicaid,8.41,,,8.41,Other,140% of Medicaid,13.52,,,13.52,Other,225% of Medicaid,15.63,,,15.63,Other,260% of Medicaid,19.47,,,19.47,Other,324% of Medicaid,12.92,,,12.92,Other,215% of Medicaid,12.92,,,12.92,Other,215% of Medicaid,7.51,,,7.51,Other,125% of Medicaid,6.01,114.7,
THROMBOPLASTIN TIME PARTIAL,85732,CPT,,78085732,CDM,300,RC,,,both,,,155,114.7,,,114.7,Other,150% of Medicare + 9.63% HCRA Surcharge,69.75,45,,69.75,percent of total billed charges,Critical Access Hospital RCC factor,19.47,,,19.47,Fee Schedule,,17.53,,,17.53,Fee Schedule,,48.01,,,48.01,Fee Schedule,,43.18,,,43.18,Fee Schedule,,40.81,,,40.81,Fee Schedule,,76.73,,,76.73,Other,110% of Medicare,20.38,,,20.38,Fee Schedule,,12,,,12,Other,186% of Medicaid,24,,,24,Fee Schedule,,96.1,,,96.1,Fee Schedule,,13.59,,,13.59,Fee Schedule,,24,,,24,Fee Schedule,,96.1,,,96.1,Fee Schedule,,25.56,,,25.56,Fee Schedule,,108.5,70,,108.5,percent of total billed charges,All Other,30.66,,,30.66,Fee Schedule,,25.99,,,25.99,Fee Schedule,,9.71,,,9.71,Fee Schedule,,9.71,,,9.71,Fee Schedule,,9.71,,,9.71,Fee Schedule,,9.71,,,9.71,Fee Schedule,,6.25,,,6.25,Other,100% of Medicaid,6.25,,,6.25,Other,100% of Medicaid,6.25,,,6.25,Other,100% of Medicaid,6.25,,,6.25,Other,100% of Medicaid,14.07,,,14.07,Other,225% of Medicaid,9.57,,,9.57,Other,153% of Medicaid,14.07,,,14.07,Other,225% of Medicaid,8.75,,,8.75,Other,140% of Medicaid,14.07,,,14.07,Other,225% of Medicaid,16.25,,,16.25,Other,260% of Medicaid,20.26,,,20.26,Other,324% of Medicaid,13.44,,,13.44,Other,215% of Medicaid,13.44,,,13.44,Other,215% of Medicaid,7.81,,,7.81,Other,125% of Medicaid,6.25,114.7,
AGGLUTININS FEBRILE,86000,CPT,,78086000,CDM,300,RC,,,both,,,278,205.72,,,205.72,Other,150% of Medicare + 9.63% HCRA Surcharge,125.1,45,,125.1,percent of total billed charges,Critical Access Hospital RCC factor,21.01,,,21.01,Fee Schedule,,18.92,,,18.92,Fee Schedule,,51.75,,,51.75,Fee Schedule,,46.55,,,46.55,Fee Schedule,,43.99,,,43.99,Fee Schedule,,137.61,,,137.61,Other,110% of Medicare,21.99,,,21.99,Fee Schedule,,18,,,18,Other,186% of Medicaid,25.9,,,25.9,Fee Schedule,,172.36,,,172.36,Fee Schedule,,14.66,,,14.66,Fee Schedule,,25.9,,,25.9,Fee Schedule,,172.36,,,172.36,Fee Schedule,,27.57,,,27.57,Fee Schedule,,194.6,70,,194.6,percent of total billed charges,All Other,33.08,,,33.08,Fee Schedule,,28.04,,,28.04,Fee Schedule,,10.47,,,10.47,Fee Schedule,,10.47,,,10.47,Fee Schedule,,10.47,,,10.47,Fee Schedule,,10.47,,,10.47,Fee Schedule,,9.88,,,9.88,Other,100% of Medicaid,9.88,,,9.88,Other,100% of Medicaid,9.88,,,9.88,Other,100% of Medicaid,9.88,,,9.88,Other,100% of Medicaid,22.23,,,22.23,Other,225% of Medicaid,15.11,,,15.11,Other,153% of Medicaid,22.23,,,22.23,Other,225% of Medicaid,13.83,,,13.83,Other,140% of Medicaid,22.23,,,22.23,Other,225% of Medicaid,25.68,,,25.68,Other,260% of Medicaid,32.01,,,32.01,Other,324% of Medicaid,21.24,,,21.24,Other,215% of Medicaid,21.24,,,21.24,Other,215% of Medicaid,12.35,,,12.35,Other,125% of Medicaid,9.88,205.72,
GLYCOPROTEIN ANTIBODY,86146,CPT,,78086146,CDM,300,RC,,,both,,,157,116.18,,,116.18,Other,150% of Medicare + 9.63% HCRA Surcharge,70.65,45,,70.65,percent of total billed charges,Critical Access Hospital RCC factor,76.6,,,76.6,Fee Schedule,,68.97,,,68.97,Fee Schedule,,43.11,,,43.11,Fee Schedule,,38.77,,,38.77,Fee Schedule,,36.65,,,36.65,Fee Schedule,,77.72,,,77.72,Other,110% of Medicare,80.17,,,80.17,Fee Schedule,,15,,,15,Other,186% of Medicaid,94.42,,,94.42,Fee Schedule,,97.34,,,97.34,Fee Schedule,,53.45,,,53.45,Fee Schedule,,94.42,,,94.42,Fee Schedule,,97.34,,,97.34,Fee Schedule,,100.53,,,100.53,Fee Schedule,,109.9,70,,109.9,percent of total billed charges,All Other,120.61,,,120.61,Fee Schedule,,102.22,,,102.22,Fee Schedule,,38.18,,,38.18,Fee Schedule,,38.18,,,38.18,Fee Schedule,,38.18,,,38.18,Fee Schedule,,38.18,,,38.18,Fee Schedule,,7.9,,,7.9,Other,100% of Medicaid,7.9,,,7.9,Other,100% of Medicaid,7.9,,,7.9,Other,100% of Medicaid,7.9,,,7.9,Other,100% of Medicaid,17.77,,,17.77,Other,225% of Medicaid,12.08,,,12.08,Other,153% of Medicaid,17.77,,,17.77,Other,225% of Medicaid,11.06,,,11.06,Other,140% of Medicaid,17.77,,,17.77,Other,225% of Medicaid,20.54,,,20.54,Other,260% of Medicaid,25.59,,,25.59,Other,324% of Medicaid,16.98,,,16.98,Other,215% of Medicaid,16.98,,,16.98,Other,215% of Medicaid,9.87,,,9.87,Other,125% of Medicaid,7.9,120.61,
CARDIOLIPIN ANTIBODY,86147,CPT,,78086147,CDM,300,RC,,,both,,,157,116.18,,,116.18,Other,150% of Medicare + 9.63% HCRA Surcharge,70.65,45,,70.65,percent of total billed charges,Critical Access Hospital RCC factor,76.6,,,76.6,Fee Schedule,,68.97,,,68.97,Fee Schedule,,43.11,,,43.11,Fee Schedule,,38.77,,,38.77,Fee Schedule,,36.65,,,36.65,Fee Schedule,,77.72,,,77.72,Other,110% of Medicare,80.17,,,80.17,Fee Schedule,,15,,,15,Other,186% of Medicaid,94.42,,,94.42,Fee Schedule,,97.34,,,97.34,Fee Schedule,,53.45,,,53.45,Fee Schedule,,94.42,,,94.42,Fee Schedule,,97.34,,,97.34,Fee Schedule,,100.53,,,100.53,Fee Schedule,,109.9,70,,109.9,percent of total billed charges,All Other,120.61,,,120.61,Fee Schedule,,102.22,,,102.22,Fee Schedule,,38.18,,,38.18,Fee Schedule,,38.18,,,38.18,Fee Schedule,,38.18,,,38.18,Fee Schedule,,38.18,,,38.18,Fee Schedule,,7.9,,,7.9,Other,100% of Medicaid,7.9,,,7.9,Other,100% of Medicaid,7.9,,,7.9,Other,100% of Medicaid,7.9,,,7.9,Other,100% of Medicaid,17.77,,,17.77,Other,225% of Medicaid,12.08,,,12.08,Other,153% of Medicaid,17.77,,,17.77,Other,225% of Medicaid,11.06,,,11.06,Other,140% of Medicaid,17.77,,,17.77,Other,225% of Medicaid,20.54,,,20.54,Other,260% of Medicaid,25.59,,,25.59,Other,324% of Medicaid,16.98,,,16.98,Other,215% of Medicaid,16.98,,,16.98,Other,215% of Medicaid,9.87,,,9.87,Other,125% of Medicaid,7.9,120.61,
NUCLEAR ANTIGEN ANTIBODY,86235,CPT,,78086235,CDM,300,RC,,,both,,,218,161.32,,,161.32,Other,150% of Medicare + 9.63% HCRA Surcharge,98.1,45,,98.1,percent of total billed charges,Critical Access Hospital RCC factor,53.97,,,53.97,Fee Schedule,,48.59,,,48.59,Fee Schedule,,132.96,,,132.96,Fee Schedule,,119.59,,,119.59,Fee Schedule,,113.03,,,113.03,Fee Schedule,,107.91,,,107.91,Other,110% of Medicare,56.48,,,56.48,Fee Schedule,,10,,,10,Other,186% of Medicaid,66.52,,,66.52,Fee Schedule,,135.16,,,135.16,Fee Schedule,,37.65,,,37.65,Fee Schedule,,66.52,,,66.52,Fee Schedule,,135.16,,,135.16,Fee Schedule,,70.82,,,70.82,Fee Schedule,,152.6,70,,152.6,percent of total billed charges,All Other,84.97,,,84.97,Fee Schedule,,72.02,,,72.02,Fee Schedule,,26.9,,,26.9,Fee Schedule,,26.9,,,26.9,Fee Schedule,,26.9,,,26.9,Fee Schedule,,26.9,,,26.9,Fee Schedule,,5.25,,,5.25,Other,100% of Medicaid,5.25,,,5.25,Other,100% of Medicaid,5.25,,,5.25,Other,100% of Medicaid,5.25,,,5.25,Other,100% of Medicaid,11.82,,,11.82,Other,225% of Medicaid,8.04,,,8.04,Other,153% of Medicaid,11.82,,,11.82,Other,225% of Medicaid,7.35,,,7.35,Other,140% of Medicaid,11.82,,,11.82,Other,225% of Medicaid,13.66,,,13.66,Other,260% of Medicaid,17.02,,,17.02,Other,324% of Medicaid,11.29,,,11.29,Other,215% of Medicaid,11.29,,,11.29,Other,215% of Medicaid,6.57,,,6.57,Other,125% of Medicaid,5.25,161.32,
FLUORESCENT ANTIBODY SCREEN,86255,CPT,,78086255,CDM,300,RC,,,both,,,216,159.84,,,159.84,Other,150% of Medicare + 9.63% HCRA Surcharge,97.2,45,,97.2,percent of total billed charges,Critical Access Hospital RCC factor,36.27,,,36.27,Fee Schedule,,32.66,,,32.66,Fee Schedule,,89.38,,,89.38,Fee Schedule,,80.39,,,80.39,Fee Schedule,,75.98,,,75.98,Fee Schedule,,106.92,,,106.92,Other,110% of Medicare,37.96,,,37.96,Fee Schedule,,10,,,10,Other,186% of Medicaid,44.71,,,44.71,Fee Schedule,,133.92,,,133.92,Fee Schedule,,25.31,,,25.31,Fee Schedule,,44.71,,,44.71,Fee Schedule,,133.92,,,133.92,Fee Schedule,,47.6,,,47.6,Fee Schedule,,151.2,70,,151.2,percent of total billed charges,All Other,57.11,,,57.11,Fee Schedule,,48.4,,,48.4,Fee Schedule,,18.08,,,18.08,Fee Schedule,,18.08,,,18.08,Fee Schedule,,18.08,,,18.08,Fee Schedule,,18.08,,,18.08,Fee Schedule,,5.25,,,5.25,Other,100% of Medicaid,5.25,,,5.25,Other,100% of Medicaid,5.25,,,5.25,Other,100% of Medicaid,5.25,,,5.25,Other,100% of Medicaid,11.82,,,11.82,Other,225% of Medicaid,8.04,,,8.04,Other,153% of Medicaid,11.82,,,11.82,Other,225% of Medicaid,7.35,,,7.35,Other,140% of Medicaid,11.82,,,11.82,Other,225% of Medicaid,13.66,,,13.66,Other,260% of Medicaid,17.02,,,17.02,Other,324% of Medicaid,11.29,,,11.29,Other,215% of Medicaid,11.29,,,11.29,Other,215% of Medicaid,6.57,,,6.57,Other,125% of Medicaid,5.25,159.84,
FLUORESCENT ANTIBODY TITER,86256,CPT,,78086256,CDM,300,RC,,,both,,,216,159.84,,,159.84,Other,150% of Medicare + 9.63% HCRA Surcharge,97.2,45,,97.2,percent of total billed charges,Critical Access Hospital RCC factor,36.27,,,36.27,Fee Schedule,,32.66,,,32.66,Fee Schedule,,89.38,,,89.38,Fee Schedule,,80.39,,,80.39,Fee Schedule,,75.98,,,75.98,Fee Schedule,,106.92,,,106.92,Other,110% of Medicare,37.96,,,37.96,Fee Schedule,,0.01,,,0.01,Other,186% of Medicaid,44.71,,,44.71,Fee Schedule,,133.92,,,133.92,Fee Schedule,,25.31,,,25.31,Fee Schedule,,44.71,,,44.71,Fee Schedule,,133.92,,,133.92,Fee Schedule,,47.6,,,47.6,Fee Schedule,,151.2,70,,151.2,percent of total billed charges,All Other,57.11,,,57.11,Fee Schedule,,48.4,,,48.4,Fee Schedule,,18.08,,,18.08,Fee Schedule,,18.08,,,18.08,Fee Schedule,,18.08,,,18.08,Fee Schedule,,18.08,,,18.08,Fee Schedule,,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,159.84,
IMMUNFIX E-PHORSIS/URINE/CSF,86335,CPT,,78086335,CDM,300,RC,,,both,,,187,138.38,,,138.38,Other,150% of Medicare + 9.63% HCRA Surcharge,84.15,45,,84.15,percent of total billed charges,Critical Access Hospital RCC factor,88.34,,,88.34,Fee Schedule,,79.54,,,79.54,Fee Schedule,,217.65,,,217.65,Fee Schedule,,195.76,,,195.76,Fee Schedule,,185.02,,,185.02,Fee Schedule,,92.57,,,92.57,Other,110% of Medicare,92.45,,,92.45,Fee Schedule,,55,,,55,Other,186% of Medicaid,108.89,,,108.89,Fee Schedule,,115.94,,,115.94,Fee Schedule,,61.64,,,61.64,Fee Schedule,,108.89,,,108.89,Fee Schedule,,115.94,,,115.94,Fee Schedule,,115.93,,,115.93,Fee Schedule,,130.9,70,,130.9,percent of total billed charges,All Other,139.09,,,139.09,Fee Schedule,,117.89,,,117.89,Fee Schedule,,44.03,,,44.03,Fee Schedule,,44.03,,,44.03,Fee Schedule,,44.03,,,44.03,Fee Schedule,,44.03,,,44.03,Fee Schedule,,29.35,,,29.35,Other,100% of Medicaid,29.35,,,29.35,Other,100% of Medicaid,29.35,,,29.35,Other,100% of Medicaid,29.35,,,29.35,Other,100% of Medicaid,66.04,,,66.04,Other,225% of Medicaid,44.91,,,44.91,Other,153% of Medicaid,66.04,,,66.04,Other,225% of Medicaid,41.09,,,41.09,Other,140% of Medicaid,66.04,,,66.04,Other,225% of Medicaid,76.31,,,76.31,Other,260% of Medicaid,95.09,,,95.09,Other,324% of Medicaid,63.1,,,63.1,Other,215% of Medicaid,63.1,,,63.1,Other,215% of Medicaid,36.69,,,36.69,Other,125% of Medicaid,29.35,217.65,
TB AG RESPONSE T-CELL SUSP,86481,CPT,,78086481,CDM,300,RC,,,both,,,315,233.1,,,233.1,Other,150% of Medicare + 9.63% HCRA Surcharge,141.75,45,,141.75,percent of total billed charges,Critical Access Hospital RCC factor,301,,,301,Fee Schedule,,271,,,271,Fee Schedule,,459.65,,,459.65,Fee Schedule,,413.42,,,413.42,Fee Schedule,,390.75,,,390.75,Fee Schedule,,155.93,,,155.93,Other,110% of Medicare,315,,,315,Fee Schedule,,94,,,94,Other,186% of Medicaid,371,,,371,Fee Schedule,,195.3,,,195.3,Fee Schedule,,210,,,210,Fee Schedule,,371,,,371,Fee Schedule,,195.3,,,195.3,Fee Schedule,,395,,,395,Fee Schedule,,220.5,70,,220.5,percent of total billed charges,All Other,473.9,,,473.9,Fee Schedule,,401.66,,,401.66,Fee Schedule,,150,,,150,Fee Schedule,,150,,,150,Fee Schedule,,150,,,150,Fee Schedule,,150,,,150,Fee Schedule,,50.5,,,50.5,Other,100% of Medicaid,50.5,,,50.5,Other,100% of Medicaid,50.5,,,50.5,Other,100% of Medicaid,50.5,,,50.5,Other,100% of Medicaid,113.63,,,113.63,Other,225% of Medicaid,77.27,,,77.27,Other,153% of Medicaid,113.63,,,113.63,Other,225% of Medicaid,70.7,,,70.7,Other,140% of Medicaid,113.63,,,113.63,Other,225% of Medicaid,131.3,,,131.3,Other,260% of Medicaid,163.62,,,163.62,Other,324% of Medicaid,108.58,,,108.58,Other,215% of Medicaid,108.58,,,108.58,Other,215% of Medicaid,63.13,,,63.13,Other,125% of Medicaid,50.5,473.9,
ADENOVIRUS ANTIBODY,86603,CPT,,78086603,CDM,300,RC,,,both,,,254,187.96,,,187.96,Other,150% of Medicare + 9.63% HCRA Surcharge,114.3,45,,114.3,percent of total billed charges,Critical Access Hospital RCC factor,38.74,,,38.74,Fee Schedule,,34.88,,,34.88,Fee Schedule,,43.11,,,43.11,Fee Schedule,,38.77,,,38.77,Fee Schedule,,36.65,,,36.65,Fee Schedule,,125.73,,,125.73,Other,110% of Medicare,40.54,,,40.54,Fee Schedule,,15,,,15,Other,186% of Medicaid,47.75,,,47.75,Fee Schedule,,157.48,,,157.48,Fee Schedule,,27.03,,,27.03,Fee Schedule,,47.75,,,47.75,Fee Schedule,,157.48,,,157.48,Fee Schedule,,50.84,,,50.84,Fee Schedule,,177.8,70,,177.8,percent of total billed charges,All Other,60.99,,,60.99,Fee Schedule,,51.69,,,51.69,Fee Schedule,,19.31,,,19.31,Fee Schedule,,19.31,,,19.31,Fee Schedule,,19.31,,,19.31,Fee Schedule,,19.31,,,19.31,Fee Schedule,,8.11,,,8.11,Other,100% of Medicaid,8.11,,,8.11,Other,100% of Medicaid,8.11,,,8.11,Other,100% of Medicaid,8.11,,,8.11,Other,100% of Medicaid,18.25,,,18.25,Other,225% of Medicaid,12.41,,,12.41,Other,153% of Medicaid,18.25,,,18.25,Other,225% of Medicaid,11.35,,,11.35,Other,140% of Medicaid,18.25,,,18.25,Other,225% of Medicaid,21.09,,,21.09,Other,260% of Medicaid,26.28,,,26.28,Other,324% of Medicaid,17.44,,,17.44,Other,215% of Medicaid,17.44,,,17.44,Other,215% of Medicaid,10.14,,,10.14,Other,125% of Medicaid,8.11,187.96,
LYME DISEASE ANTIBODY,86617,CPT,,78086617,CDM,300,RC,,,both,,,466,344.84,,,344.84,Other,150% of Medicare + 9.63% HCRA Surcharge,209.7,45,,209.7,percent of total billed charges,Critical Access Hospital RCC factor,46.62,,,46.62,Fee Schedule,,41.98,,,41.98,Fee Schedule,,114.89,,,114.89,Fee Schedule,,103.33,,,103.33,Fee Schedule,,97.66,,,97.66,Fee Schedule,,230.67,,,230.67,Other,110% of Medicare,48.79,,,48.79,Fee Schedule,,29,,,29,Other,186% of Medicaid,57.47,,,57.47,Fee Schedule,,288.92,,,288.92,Fee Schedule,,32.53,,,32.53,Fee Schedule,,57.47,,,57.47,Fee Schedule,,288.92,,,288.92,Fee Schedule,,61.19,,,61.19,Fee Schedule,,326.2,70,,326.2,percent of total billed charges,All Other,73.41,,,73.41,Fee Schedule,,62.22,,,62.22,Fee Schedule,,23.24,,,23.24,Fee Schedule,,23.24,,,23.24,Fee Schedule,,23.24,,,23.24,Fee Schedule,,23.24,,,23.24,Fee Schedule,,15.49,,,15.49,Other,100% of Medicaid,15.49,,,15.49,Other,100% of Medicaid,15.49,,,15.49,Other,100% of Medicaid,15.49,,,15.49,Other,100% of Medicaid,34.85,,,34.85,Other,225% of Medicaid,23.7,,,23.7,Other,153% of Medicaid,34.85,,,34.85,Other,225% of Medicaid,21.69,,,21.69,Other,140% of Medicaid,34.85,,,34.85,Other,225% of Medicaid,40.27,,,40.27,Other,260% of Medicaid,50.19,,,50.19,Other,324% of Medicaid,33.3,,,33.3,Other,215% of Medicaid,33.3,,,33.3,Other,215% of Medicaid,19.36,,,19.36,Other,125% of Medicaid,15.49,344.84,
BRUCELLA ANTIBODY,86622,CPT,,78086622,CDM,300,RC,,,both,,,55,40.7,,,40.7,Other,150% of Medicare + 9.63% HCRA Surcharge,24.75,45,,24.75,percent of total billed charges,Critical Access Hospital RCC factor,26.88,,,26.88,Fee Schedule,,24.2,,,24.2,Fee Schedule,,43.11,,,43.11,Fee Schedule,,38.77,,,38.77,Fee Schedule,,36.65,,,36.65,Fee Schedule,,27.23,,,27.23,Other,110% of Medicare,28.13,,,28.13,Fee Schedule,,15,,,15,Other,186% of Medicaid,33.13,,,33.13,Fee Schedule,,34.1,,,34.1,Fee Schedule,,18.75,,,18.75,Fee Schedule,,33.13,,,33.13,Fee Schedule,,34.1,,,34.1,Fee Schedule,,35.27,,,35.27,Fee Schedule,,38.5,70,,38.5,percent of total billed charges,All Other,42.32,,,42.32,Fee Schedule,,35.87,,,35.87,Fee Schedule,,13.4,,,13.4,Fee Schedule,,13.4,,,13.4,Fee Schedule,,13.4,,,13.4,Fee Schedule,,13.4,,,13.4,Fee Schedule,,8.11,,,8.11,Other,100% of Medicaid,8.11,,,8.11,Other,100% of Medicaid,8.11,,,8.11,Other,100% of Medicaid,8.11,,,8.11,Other,100% of Medicaid,18.25,,,18.25,Other,225% of Medicaid,12.41,,,12.41,Other,153% of Medicaid,18.25,,,18.25,Other,225% of Medicaid,11.35,,,11.35,Other,140% of Medicaid,18.25,,,18.25,Other,225% of Medicaid,21.09,,,21.09,Other,260% of Medicaid,26.28,,,26.28,Other,324% of Medicaid,17.44,,,17.44,Other,215% of Medicaid,17.44,,,17.44,Other,215% of Medicaid,10.14,,,10.14,Other,125% of Medicaid,8.11,43.11,
ENCEPHALITIS ANTIBODY,86652,CPT,,78086652,CDM,300,RC,,,both,,,83,61.42,,,61.42,Other,150% of Medicare + 9.63% HCRA Surcharge,37.35,45,,37.35,percent of total billed charges,Critical Access Hospital RCC factor,39.7,,,39.7,Fee Schedule,,35.74,,,35.74,Fee Schedule,,43.11,,,43.11,Fee Schedule,,38.77,,,38.77,Fee Schedule,,36.65,,,36.65,Fee Schedule,,41.09,,,41.09,Other,110% of Medicare,41.55,,,41.55,Fee Schedule,,15,,,15,Other,186% of Medicaid,48.93,,,48.93,Fee Schedule,,51.46,,,51.46,Fee Schedule,,27.7,,,27.7,Fee Schedule,,48.93,,,48.93,Fee Schedule,,51.46,,,51.46,Fee Schedule,,52.1,,,52.1,Fee Schedule,,58.1,70,,58.1,percent of total billed charges,All Other,62.51,,,62.51,Fee Schedule,,52.98,,,52.98,Fee Schedule,,19.79,,,19.79,Fee Schedule,,19.79,,,19.79,Fee Schedule,,19.79,,,19.79,Fee Schedule,,19.79,,,19.79,Fee Schedule,,8.11,,,8.11,Other,100% of Medicaid,8.11,,,8.11,Other,100% of Medicaid,8.11,,,8.11,Other,100% of Medicaid,8.11,,,8.11,Other,100% of Medicaid,18.25,,,18.25,Other,225% of Medicaid,12.41,,,12.41,Other,153% of Medicaid,18.25,,,18.25,Other,225% of Medicaid,11.35,,,11.35,Other,140% of Medicaid,18.25,,,18.25,Other,225% of Medicaid,21.09,,,21.09,Other,260% of Medicaid,26.28,,,26.28,Other,324% of Medicaid,17.44,,,17.44,Other,215% of Medicaid,17.44,,,17.44,Other,215% of Medicaid,10.14,,,10.14,Other,125% of Medicaid,8.11,62.51,
EHRLICHIA ANTIBODY,86666,CPT,,78086666,CDM,300,RC,,,both,,,41,30.34,,,30.34,Other,150% of Medicare + 9.63% HCRA Surcharge,18.45,45,,18.45,percent of total billed charges,Critical Access Hospital RCC factor,30.64,,,30.64,Fee Schedule,,27.59,,,27.59,Fee Schedule,,43.11,,,43.11,Fee Schedule,,38.77,,,38.77,Fee Schedule,,36.65,,,36.65,Fee Schedule,,20.3,,,20.3,Other,110% of Medicare,32.07,,,32.07,Fee Schedule,,15,,,15,Other,186% of Medicaid,37.77,,,37.77,Fee Schedule,,25.42,,,25.42,Fee Schedule,,21.38,,,21.38,Fee Schedule,,37.77,,,37.77,Fee Schedule,,25.42,,,25.42,Fee Schedule,,40.21,,,40.21,Fee Schedule,,28.7,70,,28.7,percent of total billed charges,All Other,48.24,,,48.24,Fee Schedule,,40.89,,,40.89,Fee Schedule,,15.27,,,15.27,Fee Schedule,,15.27,,,15.27,Fee Schedule,,15.27,,,15.27,Fee Schedule,,15.27,,,15.27,Fee Schedule,,8.11,,,8.11,Other,100% of Medicaid,8.11,,,8.11,Other,100% of Medicaid,8.11,,,8.11,Other,100% of Medicaid,8.11,,,8.11,Other,100% of Medicaid,18.25,,,18.25,Other,225% of Medicaid,12.41,,,12.41,Other,153% of Medicaid,18.25,,,18.25,Other,225% of Medicaid,11.35,,,11.35,Other,140% of Medicaid,18.25,,,18.25,Other,225% of Medicaid,21.09,,,21.09,Other,260% of Medicaid,26.28,,,26.28,Other,324% of Medicaid,17.44,,,17.44,Other,215% of Medicaid,17.44,,,17.44,Other,215% of Medicaid,10.14,,,10.14,Other,125% of Medicaid,8.11,48.24,
HELICOBACTER PYHLORI,86677,CPT,,78086677,CDM,300,RC,,,both,,,420,310.8,,,310.8,Other,150% of Medicare + 9.63% HCRA Surcharge,189,45,,189,percent of total billed charges,Critical Access Hospital RCC factor,50.72,,,50.72,Fee Schedule,,45.66,,,45.66,Fee Schedule,,43.11,,,43.11,Fee Schedule,,38.77,,,38.77,Fee Schedule,,36.65,,,36.65,Fee Schedule,,207.9,,,207.9,Other,110% of Medicare,53.08,,,53.08,Fee Schedule,,15,,,15,Other,186% of Medicaid,62.51,,,62.51,Fee Schedule,,260.4,,,260.4,Fee Schedule,,35.39,,,35.39,Fee Schedule,,62.51,,,62.51,Fee Schedule,,260.4,,,260.4,Fee Schedule,,66.56,,,66.56,Fee Schedule,,294,70,,294,percent of total billed charges,All Other,79.85,,,79.85,Fee Schedule,,67.68,,,67.68,Fee Schedule,,25.28,,,25.28,Fee Schedule,,25.28,,,25.28,Fee Schedule,,25.28,,,25.28,Fee Schedule,,25.28,,,25.28,Fee Schedule,,8.11,,,8.11,Other,100% of Medicaid,8.11,,,8.11,Other,100% of Medicaid,8.11,,,8.11,Other,100% of Medicaid,8.11,,,8.11,Other,100% of Medicaid,18.25,,,18.25,Other,225% of Medicaid,12.41,,,12.41,Other,153% of Medicaid,18.25,,,18.25,Other,225% of Medicaid,11.35,,,11.35,Other,140% of Medicaid,18.25,,,18.25,Other,225% of Medicaid,21.09,,,21.09,Other,260% of Medicaid,26.28,,,26.28,Other,324% of Medicaid,17.44,,,17.44,Other,215% of Medicaid,17.44,,,17.44,Other,215% of Medicaid,10.14,,,10.14,Other,125% of Medicaid,8.11,310.8,
HERPES SIMPLEX TEST,86695,CPT,,78086695,CDM,300,RC,,,both,,,271,200.54,,,200.54,Other,150% of Medicare + 9.63% HCRA Surcharge,121.95,45,,121.95,percent of total billed charges,Critical Access Hospital RCC factor,39.7,,,39.7,Fee Schedule,,35.74,,,35.74,Fee Schedule,,97.81,,,97.81,Fee Schedule,,87.97,,,87.97,Fee Schedule,,83.15,,,83.15,Fee Schedule,,134.15,,,134.15,Other,110% of Medicare,41.55,,,41.55,Fee Schedule,,18,,,18,Other,186% of Medicaid,48.93,,,48.93,Fee Schedule,,168.02,,,168.02,Fee Schedule,,27.7,,,27.7,Fee Schedule,,48.93,,,48.93,Fee Schedule,,168.02,,,168.02,Fee Schedule,,52.1,,,52.1,Fee Schedule,,189.7,70,,189.7,percent of total billed charges,All Other,62.51,,,62.51,Fee Schedule,,52.98,,,52.98,Fee Schedule,,19.79,,,19.79,Fee Schedule,,19.79,,,19.79,Fee Schedule,,19.79,,,19.79,Fee Schedule,,19.79,,,19.79,Fee Schedule,,9.88,,,9.88,Other,100% of Medicaid,9.88,,,9.88,Other,100% of Medicaid,9.88,,,9.88,Other,100% of Medicaid,9.88,,,9.88,Other,100% of Medicaid,22.23,,,22.23,Other,225% of Medicaid,15.11,,,15.11,Other,153% of Medicaid,22.23,,,22.23,Other,225% of Medicaid,13.83,,,13.83,Other,140% of Medicaid,22.23,,,22.23,Other,225% of Medicaid,25.68,,,25.68,Other,260% of Medicaid,32.01,,,32.01,Other,324% of Medicaid,21.24,,,21.24,Other,215% of Medicaid,21.24,,,21.24,Other,215% of Medicaid,12.35,,,12.35,Other,125% of Medicaid,9.88,200.54,
HERPES SIMPLEX TYPE 2,86696,CPT,,78086696,CDM,300,RC,,,both,,,271,200.54,,,200.54,Other,150% of Medicare + 9.63% HCRA Surcharge,121.95,45,,121.95,percent of total billed charges,Critical Access Hospital RCC factor,58.24,,,58.24,Fee Schedule,,52.44,,,52.44,Fee Schedule,,143.5,,,143.5,Fee Schedule,,129.07,,,129.07,Fee Schedule,,121.99,,,121.99,Fee Schedule,,134.15,,,134.15,Other,110% of Medicare,60.95,,,60.95,Fee Schedule,,27,,,27,Other,186% of Medicaid,71.79,,,71.79,Fee Schedule,,168.02,,,168.02,Fee Schedule,,40.64,,,40.64,Fee Schedule,,71.79,,,71.79,Fee Schedule,,168.02,,,168.02,Fee Schedule,,76.43,,,76.43,Fee Schedule,,189.7,70,,189.7,percent of total billed charges,All Other,91.7,,,91.7,Fee Schedule,,77.72,,,77.72,Fee Schedule,,29.03,,,29.03,Fee Schedule,,29.03,,,29.03,Fee Schedule,,29.03,,,29.03,Fee Schedule,,29.03,,,29.03,Fee Schedule,,14.65,,,14.65,Other,100% of Medicaid,14.65,,,14.65,Other,100% of Medicaid,14.65,,,14.65,Other,100% of Medicaid,14.65,,,14.65,Other,100% of Medicaid,32.95,,,32.95,Other,225% of Medicaid,22.41,,,22.41,Other,153% of Medicaid,32.95,,,32.95,Other,225% of Medicaid,20.5,,,20.5,Other,140% of Medicaid,32.95,,,32.95,Other,225% of Medicaid,38.08,,,38.08,Other,260% of Medicaid,47.45,,,47.45,Other,324% of Medicaid,31.49,,,31.49,Other,215% of Medicaid,31.49,,,31.49,Other,215% of Medicaid,18.31,,,18.31,Other,125% of Medicaid,14.65,200.54,
HIV-1,86701,CPT,,78086701,CDM,300,RC,,,both,,,294,217.56,,,217.56,Other,150% of Medicare + 9.63% HCRA Surcharge,132.3,45,,132.3,percent of total billed charges,Critical Access Hospital RCC factor,26.76,,,26.76,Fee Schedule,,24.09,,,24.09,Fee Schedule,,65.88,,,65.88,Fee Schedule,,59.25,,,59.25,Fee Schedule,,56,,,56,Fee Schedule,,145.53,,,145.53,Other,110% of Medicare,28,,,28,Fee Schedule,,17,,,17,Other,186% of Medicaid,32.98,,,32.98,Fee Schedule,,182.28,,,182.28,Fee Schedule,,18.67,,,18.67,Fee Schedule,,32.98,,,32.98,Fee Schedule,,182.28,,,182.28,Fee Schedule,,35.12,,,35.12,Fee Schedule,,205.8,70,,205.8,percent of total billed charges,All Other,42.13,,,42.13,Fee Schedule,,35.71,,,35.71,Fee Schedule,,13.34,,,13.34,Fee Schedule,,13.34,,,13.34,Fee Schedule,,13.34,,,13.34,Fee Schedule,,13.34,,,13.34,Fee Schedule,,8.89,,,8.89,Other,100% of Medicaid,8.89,,,8.89,Other,100% of Medicaid,8.89,,,8.89,Other,100% of Medicaid,8.89,,,8.89,Other,100% of Medicaid,20,,,20,Other,225% of Medicaid,13.6,,,13.6,Other,153% of Medicaid,20,,,20,Other,225% of Medicaid,12.45,,,12.45,Other,140% of Medicaid,20,,,20,Other,225% of Medicaid,23.11,,,23.11,Other,260% of Medicaid,28.8,,,28.8,Other,324% of Medicaid,19.11,,,19.11,Other,215% of Medicaid,19.11,,,19.11,Other,215% of Medicaid,11.11,,,11.11,Other,125% of Medicaid,8.89,217.56,
MUMPS ANTIBODY,86735,CPT,,78086735,CDM,300,RC,,,both,,,198,146.52,,,146.52,Other,150% of Medicare + 9.63% HCRA Surcharge,89.1,45,,89.1,percent of total billed charges,Critical Access Hospital RCC factor,39.28,,,39.28,Fee Schedule,,35.37,,,35.37,Fee Schedule,,43.11,,,43.11,Fee Schedule,,38.77,,,38.77,Fee Schedule,,36.65,,,36.65,Fee Schedule,,98.01,,,98.01,Other,110% of Medicare,41.11,,,41.11,Fee Schedule,,15,,,15,Other,186% of Medicaid,48.42,,,48.42,Fee Schedule,,122.76,,,122.76,Fee Schedule,,27.41,,,27.41,Fee Schedule,,48.42,,,48.42,Fee Schedule,,122.76,,,122.76,Fee Schedule,,51.55,,,51.55,Fee Schedule,,138.6,70,,138.6,percent of total billed charges,All Other,61.84,,,61.84,Fee Schedule,,52.42,,,52.42,Fee Schedule,,19.58,,,19.58,Fee Schedule,,19.58,,,19.58,Fee Schedule,,19.58,,,19.58,Fee Schedule,,19.58,,,19.58,Fee Schedule,,8.11,,,8.11,Other,100% of Medicaid,8.11,,,8.11,Other,100% of Medicaid,8.11,,,8.11,Other,100% of Medicaid,8.11,,,8.11,Other,100% of Medicaid,18.25,,,18.25,Other,225% of Medicaid,12.41,,,12.41,Other,153% of Medicaid,18.25,,,18.25,Other,225% of Medicaid,11.35,,,11.35,Other,140% of Medicaid,18.25,,,18.25,Other,225% of Medicaid,21.09,,,21.09,Other,260% of Medicaid,26.28,,,26.28,Other,324% of Medicaid,17.44,,,17.44,Other,215% of Medicaid,17.44,,,17.44,Other,215% of Medicaid,10.14,,,10.14,Other,125% of Medicaid,8.11,146.52,
PROTOZOA ANTIBODY NOS,86753,CPT,,78086753,CDM,300,RC,,,both,,,76,56.24,,,56.24,Other,150% of Medicare + 9.63% HCRA Surcharge,34.2,45,,34.2,percent of total billed charges,Critical Access Hospital RCC factor,37.29,,,37.29,Fee Schedule,,33.58,,,33.58,Fee Schedule,,43.11,,,43.11,Fee Schedule,,38.77,,,38.77,Fee Schedule,,36.65,,,36.65,Fee Schedule,,37.62,,,37.62,Other,110% of Medicare,39.03,,,39.03,Fee Schedule,,0.01,,,0.01,Other,186% of Medicaid,45.97,,,45.97,Fee Schedule,,47.12,,,47.12,Fee Schedule,,26.02,,,26.02,Fee Schedule,,45.97,,,45.97,Fee Schedule,,47.12,,,47.12,Fee Schedule,,48.94,,,48.94,Fee Schedule,,53.2,70,,53.2,percent of total billed charges,All Other,58.72,,,58.72,Fee Schedule,,49.77,,,49.77,Fee Schedule,,18.59,,,18.59,Fee Schedule,,18.59,,,18.59,Fee Schedule,,18.59,,,18.59,Fee Schedule,,18.59,,,18.59,Fee Schedule,,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,58.72,
TOXOPLASMA,86777,CPT,,78086777,CDM,300,RC,,,both,,,210,155.4,,,155.4,Other,150% of Medicare + 9.63% HCRA Surcharge,94.5,45,,94.5,percent of total billed charges,Critical Access Hospital RCC factor,43.31,,,43.31,Fee Schedule,,39,,,39,Fee Schedule,,106.72,,,106.72,Fee Schedule,,95.99,,,95.99,Fee Schedule,,90.72,,,90.72,Fee Schedule,,103.95,,,103.95,Other,110% of Medicare,45.33,,,45.33,Fee Schedule,,27,,,27,Other,186% of Medicaid,53.39,,,53.39,Fee Schedule,,130.2,,,130.2,Fee Schedule,,30.22,,,30.22,Fee Schedule,,53.39,,,53.39,Fee Schedule,,130.2,,,130.2,Fee Schedule,,56.84,,,56.84,Fee Schedule,,147,70,,147,percent of total billed charges,All Other,68.19,,,68.19,Fee Schedule,,57.8,,,57.8,Fee Schedule,,21.59,,,21.59,Fee Schedule,,21.59,,,21.59,Fee Schedule,,21.59,,,21.59,Fee Schedule,,21.59,,,21.59,Fee Schedule,,14.39,,,14.39,Other,100% of Medicaid,14.39,,,14.39,Other,100% of Medicaid,14.39,,,14.39,Other,100% of Medicaid,14.39,,,14.39,Other,100% of Medicaid,32.38,,,32.38,Other,225% of Medicaid,22.02,,,22.02,Other,153% of Medicaid,32.38,,,32.38,Other,225% of Medicaid,20.15,,,20.15,Other,140% of Medicaid,32.38,,,32.38,Other,225% of Medicaid,37.41,,,37.41,Other,260% of Medicaid,46.62,,,46.62,Other,324% of Medicaid,30.94,,,30.94,Other,215% of Medicaid,30.94,,,30.94,Other,215% of Medicaid,17.99,,,17.99,Other,125% of Medicaid,14.39,155.4,
RBC ANTIBODY SCREEN,86850,CPT,,78086850,CDM,300,RC,,,both,,,184,136.16,,,136.16,Other,150% of Medicare + 9.63% HCRA Surcharge,82.8,45,,82.8,percent of total billed charges,Critical Access Hospital RCC factor,29.41,,,29.41,Fee Schedule,,26.48,,,26.48,Fee Schedule,,6.54,,,6.54,Fee Schedule,,6.54,,,6.54,Fee Schedule,,6.54,,,6.54,Fee Schedule,,91.08,,,91.08,Other,110% of Medicare,30.78,,,30.78,Fee Schedule,,10,,,10,Other,186% of Medicaid,36.25,,,36.25,Fee Schedule,,114.08,,,114.08,Fee Schedule,,20.52,,,20.52,Fee Schedule,,36.25,,,36.25,Fee Schedule,,114.08,,,114.08,Fee Schedule,,38.59,,,38.59,Fee Schedule,,128.8,70,,128.8,percent of total billed charges,All Other,46.3,,,46.3,Fee Schedule,,39.24,,,39.24,Fee Schedule,,14.66,,,14.66,Fee Schedule,,14.66,,,14.66,Fee Schedule,,14.66,,,14.66,Fee Schedule,,14.66,,,14.66,Fee Schedule,,5.61,,,5.61,Other,100% of Medicaid,5.61,,,5.61,Other,100% of Medicaid,5.61,,,5.61,Other,100% of Medicaid,5.61,,,5.61,Other,100% of Medicaid,12.61,,,12.61,Other,225% of Medicaid,8.58,,,8.58,Other,153% of Medicaid,12.61,,,12.61,Other,225% of Medicaid,7.85,,,7.85,Other,140% of Medicaid,12.61,,,12.61,Other,225% of Medicaid,14.57,,,14.57,Other,260% of Medicaid,18.16,,,18.16,Other,324% of Medicaid,12.05,,,12.05,Other,215% of Medicaid,12.05,,,12.05,Other,215% of Medicaid,7.01,,,7.01,Other,125% of Medicaid,5.61,136.16,
BLOOD TYPING RH (D),86901,CPT,,78086901,CDM,300,RC,,,both,,,138,102.12,,,102.12,Other,150% of Medicare + 9.63% HCRA Surcharge,62.1,45,,62.1,percent of total billed charges,Critical Access Hospital RCC factor,9,,,9,Fee Schedule,,8.1,,,8.1,Fee Schedule,,22.13,,,22.13,Fee Schedule,,19.91,,,19.91,Fee Schedule,,18.82,,,18.82,Fee Schedule,,68.31,,,68.31,Other,110% of Medicare,9.42,,,9.42,Fee Schedule,,6,,,6,Other,186% of Medicaid,11.09,,,11.09,Fee Schedule,,85.56,,,85.56,Fee Schedule,,6.28,,,6.28,Fee Schedule,,11.09,,,11.09,Fee Schedule,,85.56,,,85.56,Fee Schedule,,11.81,,,11.81,Fee Schedule,,96.6,70,,96.6,percent of total billed charges,All Other,14.17,,,14.17,Fee Schedule,,12.01,,,12.01,Fee Schedule,,4.49,,,4.49,Fee Schedule,,4.49,,,4.49,Fee Schedule,,4.49,,,4.49,Fee Schedule,,4.49,,,4.49,Fee Schedule,,2.99,,,2.99,Other,100% of Medicaid,2.99,,,2.99,Other,100% of Medicaid,2.99,,,2.99,Other,100% of Medicaid,2.99,,,2.99,Other,100% of Medicaid,6.73,,,6.73,Other,225% of Medicaid,4.57,,,4.57,Other,153% of Medicaid,6.73,,,6.73,Other,225% of Medicaid,4.19,,,4.19,Other,140% of Medicaid,6.73,,,6.73,Other,225% of Medicaid,7.77,,,7.77,Other,260% of Medicaid,9.69,,,9.69,Other,324% of Medicaid,6.43,,,6.43,Other,215% of Medicaid,6.43,,,6.43,Other,215% of Medicaid,3.74,,,3.74,Other,125% of Medicaid,2.99,102.12,
COMPATIBILITY TEST SPIN,86920,CPT,,78086920,CDM,300,RC,,,both,,,357,264.18,,,264.18,Other,150% of Medicare + 9.63% HCRA Surcharge,160.65,45,,160.65,percent of total billed charges,Critical Access Hospital RCC factor,232.05,65,,232.05,percent of total billed charges,All Other,210.63,65,,210.63,percent of total billed charges,All Other,9.4,,,9.4,Fee Schedule,,9.4,,,9.4,Fee Schedule,,9.4,,,9.4,Fee Schedule,,176.72,,,176.72,Other,110% of Medicare,242.76,68,,242.76,percent of total billed charges,All Other,72,,,72,Other,186% of Medicaid,296.31,83,,296.31,percent of total billed charges,All Other,221.34,62,,221.34,percent of total billed charges,Lab and Radiology,196.35,55,,196.35,percent of total billed charges,Default if not on Fee Schedule,285.6,80,,285.6,percent of total billed charges,All Other,221.34,62,,221.34,percent of total billed charges,Lab and Radiology,285.6,80,,285.6,percent of total billed charges,All Other,249.9,70,,249.9,percent of total billed charges,All Other,232.05,65,,232.05,percent of total billed charges,Default if not in Fee Schedule,232.05,65,,232.05,percent of total billed charges,Default if not in Fee Schedule,215.25,,,215.25,Fee Schedule,,215.25,,,215.25,Fee Schedule,,215.25,,,215.25,Fee Schedule,,215.25,,,215.25,Fee Schedule,,38.8,,,38.8,Other,100% of Medicaid,38.8,,,38.8,Other,100% of Medicaid,38.8,,,38.8,Other,100% of Medicaid,38.8,,,38.8,Other,100% of Medicaid,87.31,,,87.31,Other,225% of Medicaid,59.37,,,59.37,Other,153% of Medicaid,87.31,,,87.31,Other,225% of Medicaid,54.32,,,54.32,Other,140% of Medicaid,87.31,,,87.31,Other,225% of Medicaid,100.89,,,100.89,Other,260% of Medicaid,125.72,,,125.72,Other,324% of Medicaid,83.43,,,83.43,Other,215% of Medicaid,83.43,,,83.43,Other,215% of Medicaid,48.5,,,48.5,Other,125% of Medicaid,9.4,296.31,
COMPATIBILITY TEST INCUBATE,86921,CPT,,78086921,CDM,300,RC,,,both,,,355,262.7,,,262.7,Other,150% of Medicare + 9.63% HCRA Surcharge,159.75,45,,159.75,percent of total billed charges,Critical Access Hospital RCC factor,230.75,65,,230.75,percent of total billed charges,All Other,209.45,65,,209.45,percent of total billed charges,All Other,8.44,,,8.44,Fee Schedule,,8.44,,,8.44,Fee Schedule,,8.44,,,8.44,Fee Schedule,,175.73,,,175.73,Other,110% of Medicare,241.4,68,,241.4,percent of total billed charges,All Other,72,,,72,Other,186% of Medicaid,294.65,83,,294.65,percent of total billed charges,All Other,220.1,62,,220.1,percent of total billed charges,Lab and Radiology,195.25,55,,195.25,percent of total billed charges,Default if not on Fee Schedule,284,80,,284,percent of total billed charges,All Other,220.1,62,,220.1,percent of total billed charges,Lab and Radiology,284,80,,284,percent of total billed charges,All Other,248.5,70,,248.5,percent of total billed charges,All Other,230.75,65,,230.75,percent of total billed charges,Default if not in Fee Schedule,230.75,65,,230.75,percent of total billed charges,Default if not in Fee Schedule,215.25,,,215.25,Fee Schedule,,215.25,,,215.25,Fee Schedule,,215.25,,,215.25,Fee Schedule,,215.25,,,215.25,Fee Schedule,,38.8,,,38.8,Other,100% of Medicaid,38.8,,,38.8,Other,100% of Medicaid,38.8,,,38.8,Other,100% of Medicaid,38.8,,,38.8,Other,100% of Medicaid,87.31,,,87.31,Other,225% of Medicaid,59.37,,,59.37,Other,153% of Medicaid,87.31,,,87.31,Other,225% of Medicaid,54.32,,,54.32,Other,140% of Medicaid,87.31,,,87.31,Other,225% of Medicaid,100.89,,,100.89,Other,260% of Medicaid,125.72,,,125.72,Other,324% of Medicaid,83.43,,,83.43,Other,215% of Medicaid,83.43,,,83.43,Other,215% of Medicaid,48.5,,,48.5,Other,125% of Medicaid,8.44,294.65,
HEMOLYSINS/AGGLLUTININS,86941,CPT,,78086941,CDM,300,RC,,,both,,,74,54.76,,,54.76,Other,150% of Medicare + 9.63% HCRA Surcharge,33.3,45,,33.3,percent of total billed charges,Critical Access Hospital RCC factor,36.45,,,36.45,Fee Schedule,,32.82,,,32.82,Fee Schedule,,89.8,,,89.8,Fee Schedule,,80.77,,,80.77,Fee Schedule,,76.34,,,76.34,Fee Schedule,,36.63,,,36.63,Other,110% of Medicare,38.15,,,38.15,Fee Schedule,,19,,,19,Other,186% of Medicaid,44.93,,,44.93,Fee Schedule,,45.88,,,45.88,Fee Schedule,,25.43,,,25.43,Fee Schedule,,44.93,,,44.93,Fee Schedule,,45.88,,,45.88,Fee Schedule,,47.83,,,47.83,Fee Schedule,,51.8,70,,51.8,percent of total billed charges,All Other,57.39,,,57.39,Fee Schedule,,48.64,,,48.64,Fee Schedule,,18.17,,,18.17,Fee Schedule,,18.17,,,18.17,Fee Schedule,,18.17,,,18.17,Fee Schedule,,18.17,,,18.17,Fee Schedule,,10.37,,,10.37,Other,100% of Medicaid,10.37,,,10.37,Other,100% of Medicaid,10.37,,,10.37,Other,100% of Medicaid,10.37,,,10.37,Other,100% of Medicaid,23.34,,,23.34,Other,225% of Medicaid,15.87,,,15.87,Other,153% of Medicaid,23.34,,,23.34,Other,225% of Medicaid,14.52,,,14.52,Other,140% of Medicaid,23.34,,,23.34,Other,225% of Medicaid,26.97,,,26.97,Other,260% of Medicaid,33.61,,,33.61,Other,324% of Medicaid,22.3,,,22.3,Other,215% of Medicaid,22.3,,,22.3,Other,215% of Medicaid,12.97,,,12.97,Other,125% of Medicaid,10.37,89.8,
POOLING BLOOD PLATELETS,86965,CPT,,78086965,CDM,300,RC,,,both,,,355,262.7,,,262.7,Other,150% of Medicare + 9.63% HCRA Surcharge,159.75,45,,159.75,percent of total billed charges,Critical Access Hospital RCC factor,248.5,70,,248.5,percent of total billed charges,Blood Products,248.5,70,,248.5,percent of total billed charges,Blood Products,248.5,76.5,,248.5,percent of total billed charges,All Other,248.5,69,,248.5,percent of total billed charges,All Other,248.5,65,,248.5,percent of total billed charges,All Other,175.73,,,175.73,Other,110% of Medicare,241.4,68,,241.4,percent of total billed charges,All Other,71,,,71,Other,186% of Medicaid,294.65,83,,294.65,percent of total billed charges,All Other,220.1,62,,220.1,percent of total billed charges,Lab and Radiology,195.25,55,,195.25,percent of total billed charges,Default if not on Fee Schedule,284,80,,284,percent of total billed charges,All Other,220.1,62,,220.1,percent of total billed charges,Lab and Radiology,284,80,,284,percent of total billed charges,All Other,248.5,70,,248.5,percent of total billed charges,All Other,230.75,65,,230.75,percent of total billed charges,Default if not in Fee Schedule,230.75,65,,230.75,percent of total billed charges,Default if not in Fee Schedule,237.85,,,237.85,Fee Schedule,,237.85,,,237.85,Fee Schedule,,237.85,,,237.85,Fee Schedule,,237.85,,,237.85,Fee Schedule,,38.29,,,38.29,Other,100% of Medicaid,38.29,,,38.29,Other,100% of Medicaid,38.29,,,38.29,Other,100% of Medicaid,38.29,,,38.29,Other,100% of Medicaid,86.15,,,86.15,Other,225% of Medicaid,58.58,,,58.58,Other,153% of Medicaid,86.15,,,86.15,Other,225% of Medicaid,53.6,,,53.6,Other,140% of Medicaid,86.15,,,86.15,Other,225% of Medicaid,99.55,,,99.55,Other,260% of Medicaid,124.06,,,124.06,Other,324% of Medicaid,82.32,,,82.32,Other,215% of Medicaid,82.32,,,82.32,Other,215% of Medicaid,47.86,,,47.86,Other,125% of Medicaid,38.29,294.65,
RBC PRETREATMENT SERUM,86978,CPT,,78086978,CDM,300,RC,,,both,,,122,90.28,,,90.28,Other,150% of Medicare + 9.63% HCRA Surcharge,54.9,45,,54.9,percent of total billed charges,Critical Access Hospital RCC factor,79.3,65,,79.3,percent of total billed charges,All Other,71.98,65,,71.98,percent of total billed charges,All Other,93.33,76.5,,93.33,percent of total billed charges,All Other,86.62,69,,86.62,percent of total billed charges,All Other,84.18,65,,84.18,percent of total billed charges,All Other,60.39,,,60.39,Other,110% of Medicare,82.96,68,,82.96,percent of total billed charges,All Other,71,,,71,Other,186% of Medicaid,101.26,83,,101.26,percent of total billed charges,All Other,75.64,62,,75.64,percent of total billed charges,Lab and Radiology,67.1,55,,67.1,percent of total billed charges,Default if not on Fee Schedule,97.6,80,,97.6,percent of total billed charges,All Other,75.64,62,,75.64,percent of total billed charges,Lab and Radiology,97.6,80,,97.6,percent of total billed charges,All Other,85.4,70,,85.4,percent of total billed charges,All Other,79.3,65,,79.3,percent of total billed charges,Default if not in Fee Schedule,79.3,65,,79.3,percent of total billed charges,Default if not in Fee Schedule,50.15,,,50.15,Fee Schedule,,50.15,,,50.15,Fee Schedule,,50.15,,,50.15,Fee Schedule,,50.15,,,50.15,Fee Schedule,,38.29,,,38.29,Other,100% of Medicaid,38.29,,,38.29,Other,100% of Medicaid,38.29,,,38.29,Other,100% of Medicaid,38.29,,,38.29,Other,100% of Medicaid,86.15,,,86.15,Other,225% of Medicaid,58.58,,,58.58,Other,153% of Medicaid,86.15,,,86.15,Other,225% of Medicaid,53.6,,,53.6,Other,140% of Medicaid,86.15,,,86.15,Other,225% of Medicaid,99.55,,,99.55,Other,260% of Medicaid,124.06,,,124.06,Other,324% of Medicaid,82.32,,,82.32,Other,215% of Medicaid,82.32,,,82.32,Other,215% of Medicaid,47.86,,,47.86,Other,125% of Medicaid,38.29,124.06,
SPLIT BLOOD OR PRODUCTS,86985,CPT,,78086985,CDM,300,RC,,,both,,,355,262.7,,,262.7,Other,150% of Medicare + 9.63% HCRA Surcharge,159.75,45,,159.75,percent of total billed charges,Critical Access Hospital RCC factor,230.75,65,,230.75,percent of total billed charges,All Other,209.45,65,,209.45,percent of total billed charges,All Other,271.58,76.5,,271.58,percent of total billed charges,All Other,252.05,69,,252.05,percent of total billed charges,All Other,244.95,65,,244.95,percent of total billed charges,All Other,175.73,,,175.73,Other,110% of Medicare,241.4,68,,241.4,percent of total billed charges,All Other,71,,,71,Other,186% of Medicaid,294.65,83,,294.65,percent of total billed charges,All Other,220.1,62,,220.1,percent of total billed charges,Lab and Radiology,195.25,55,,195.25,percent of total billed charges,Default if not on Fee Schedule,284,80,,284,percent of total billed charges,All Other,220.1,62,,220.1,percent of total billed charges,Lab and Radiology,284,80,,284,percent of total billed charges,All Other,248.5,70,,248.5,percent of total billed charges,All Other,230.75,65,,230.75,percent of total billed charges,Default if not in Fee Schedule,230.75,65,,230.75,percent of total billed charges,Default if not in Fee Schedule,215.25,,,215.25,Fee Schedule,,215.25,,,215.25,Fee Schedule,,215.25,,,215.25,Fee Schedule,,215.25,,,215.25,Fee Schedule,,38.29,,,38.29,Other,100% of Medicaid,38.29,,,38.29,Other,100% of Medicaid,38.29,,,38.29,Other,100% of Medicaid,38.29,,,38.29,Other,100% of Medicaid,86.15,,,86.15,Other,225% of Medicaid,58.58,,,58.58,Other,153% of Medicaid,86.15,,,86.15,Other,225% of Medicaid,53.6,,,53.6,Other,140% of Medicaid,86.15,,,86.15,Other,225% of Medicaid,99.55,,,99.55,Other,260% of Medicaid,124.06,,,124.06,Other,324% of Medicaid,82.32,,,82.32,Other,215% of Medicaid,82.32,,,82.32,Other,215% of Medicaid,47.86,,,47.86,Other,125% of Medicaid,38.29,294.65,
CULTURE AEROBIC IDENTIFY,87077,CPT,,78087077,CDM,300,RC,,,both,,,94,69.56,,,69.56,Other,150% of Medicare + 9.63% HCRA Surcharge,42.3,45,,42.3,percent of total billed charges,Critical Access Hospital RCC factor,24.32,,,24.32,Fee Schedule,,21.9,,,21.9,Fee Schedule,,59.92,,,59.92,Fee Schedule,,53.89,,,53.89,Fee Schedule,,50.94,,,50.94,Fee Schedule,,46.53,,,46.53,Other,110% of Medicare,25.45,,,25.45,Fee Schedule,,15,,,15,Other,186% of Medicaid,29.98,,,29.98,Fee Schedule,,58.28,,,58.28,Fee Schedule,,16.97,,,16.97,Fee Schedule,,29.98,,,29.98,Fee Schedule,,58.28,,,58.28,Fee Schedule,,31.92,,,31.92,Fee Schedule,,65.8,70,,65.8,percent of total billed charges,All Other,38.29,,,38.29,Fee Schedule,,32.45,,,32.45,Fee Schedule,,12.12,,,12.12,Fee Schedule,,12.12,,,12.12,Fee Schedule,,12.12,,,12.12,Fee Schedule,,12.12,,,12.12,Fee Schedule,,8.08,,,8.08,Other,100% of Medicaid,8.08,,,8.08,Other,100% of Medicaid,8.08,,,8.08,Other,100% of Medicaid,8.08,,,8.08,Other,100% of Medicaid,18.18,,,18.18,Other,225% of Medicaid,12.36,,,12.36,Other,153% of Medicaid,18.18,,,18.18,Other,225% of Medicaid,11.31,,,11.31,Other,140% of Medicaid,18.18,,,18.18,Other,225% of Medicaid,21.01,,,21.01,Other,260% of Medicaid,26.18,,,26.18,Other,324% of Medicaid,17.37,,,17.37,Other,215% of Medicaid,17.37,,,17.37,Other,215% of Medicaid,10.1,,,10.1,Other,125% of Medicaid,8.08,69.56,
MYCOPLASMA,87109,CPT,,78087109,CDM,300,RC,,,both,,,291,215.34,,,215.34,Other,150% of Medicare + 9.63% HCRA Surcharge,130.95,45,,130.95,percent of total billed charges,Critical Access Hospital RCC factor,46.32,,,46.32,Fee Schedule,,41.71,,,41.71,Fee Schedule,,107.67,,,107.67,Fee Schedule,,96.84,,,96.84,Fee Schedule,,91.53,,,91.53,Fee Schedule,,144.05,,,144.05,Other,110% of Medicare,48.48,,,48.48,Fee Schedule,,15,,,15,Other,186% of Medicaid,57.1,,,57.1,Fee Schedule,,180.42,,,180.42,Fee Schedule,,32.32,,,32.32,Fee Schedule,,57.1,,,57.1,Fee Schedule,,180.42,,,180.42,Fee Schedule,,60.79,,,60.79,Fee Schedule,,203.7,70,,203.7,percent of total billed charges,All Other,72.93,,,72.93,Fee Schedule,,61.82,,,61.82,Fee Schedule,,23.09,,,23.09,Fee Schedule,,23.09,,,23.09,Fee Schedule,,23.09,,,23.09,Fee Schedule,,23.09,,,23.09,Fee Schedule,,8.23,,,8.23,Other,100% of Medicaid,8.23,,,8.23,Other,100% of Medicaid,8.23,,,8.23,Other,100% of Medicaid,8.23,,,8.23,Other,100% of Medicaid,18.52,,,18.52,Other,225% of Medicaid,12.59,,,12.59,Other,153% of Medicaid,18.52,,,18.52,Other,225% of Medicaid,11.52,,,11.52,Other,140% of Medicaid,18.52,,,18.52,Other,225% of Medicaid,21.4,,,21.4,Other,260% of Medicaid,26.67,,,26.67,Other,324% of Medicaid,17.7,,,17.7,Other,215% of Medicaid,17.7,,,17.7,Other,215% of Medicaid,10.29,,,10.29,Other,125% of Medicaid,8.23,215.34,
OVA AND PARASITES SMEARS,87177,CPT,,78087177,CDM,300,RC,,,both,,,382,282.68,,,282.68,Other,150% of Medicare + 9.63% HCRA Surcharge,171.9,45,,171.9,percent of total billed charges,Critical Access Hospital RCC factor,26.79,,,26.79,Fee Schedule,,24.12,,,24.12,Fee Schedule,,65.98,,,65.98,Fee Schedule,,59.34,,,59.34,Fee Schedule,,56.09,,,56.09,Fee Schedule,,189.09,,,189.09,Other,110% of Medicare,28.04,,,28.04,Fee Schedule,,17,,,17,Other,186% of Medicaid,33.02,,,33.02,Fee Schedule,,236.84,,,236.84,Fee Schedule,,18.69,,,18.69,Fee Schedule,,33.02,,,33.02,Fee Schedule,,236.84,,,236.84,Fee Schedule,,35.16,,,35.16,Fee Schedule,,267.4,70,,267.4,percent of total billed charges,All Other,42.18,,,42.18,Fee Schedule,,35.75,,,35.75,Fee Schedule,,13.35,,,13.35,Fee Schedule,,13.35,,,13.35,Fee Schedule,,13.35,,,13.35,Fee Schedule,,13.35,,,13.35,Fee Schedule,,8.9,,,8.9,Other,100% of Medicaid,8.9,,,8.9,Other,100% of Medicaid,8.9,,,8.9,Other,100% of Medicaid,8.9,,,8.9,Other,100% of Medicaid,20.03,,,20.03,Other,225% of Medicaid,13.62,,,13.62,Other,153% of Medicaid,20.03,,,20.03,Other,225% of Medicaid,12.46,,,12.46,Other,140% of Medicaid,20.03,,,20.03,Other,225% of Medicaid,23.14,,,23.14,Other,260% of Medicaid,28.84,,,28.84,Other,324% of Medicaid,19.14,,,19.14,Other,215% of Medicaid,19.14,,,19.14,Other,215% of Medicaid,11.13,,,11.13,Other,125% of Medicaid,8.9,282.68,
MICROBE SUSCEPT MYCOBACTERI,87190,CPT,,78087190,CDM,300,RC,,,both,,,74,54.76,,,54.76,Other,150% of Medicare + 9.63% HCRA Surcharge,33.3,45,,33.3,percent of total billed charges,Critical Access Hospital RCC factor,22,,,22,Fee Schedule,,19.81,,,19.81,Fee Schedule,,41.95,,,41.95,Fee Schedule,,37.73,,,37.73,Fee Schedule,,35.66,,,35.66,Fee Schedule,,36.63,,,36.63,Other,110% of Medicare,23.03,,,23.03,Fee Schedule,,14,,,14,Other,186% of Medicaid,27.12,,,27.12,Fee Schedule,,45.88,,,45.88,Fee Schedule,,15.35,,,15.35,Fee Schedule,,27.12,,,27.12,Fee Schedule,,45.88,,,45.88,Fee Schedule,,28.87,,,28.87,Fee Schedule,,51.8,70,,51.8,percent of total billed charges,All Other,34.64,,,34.64,Fee Schedule,,29.36,,,29.36,Fee Schedule,,10.97,,,10.97,Fee Schedule,,10.97,,,10.97,Fee Schedule,,10.97,,,10.97,Fee Schedule,,10.97,,,10.97,Fee Schedule,,7.31,,,7.31,Other,100% of Medicaid,7.31,,,7.31,Other,100% of Medicaid,7.31,,,7.31,Other,100% of Medicaid,7.31,,,7.31,Other,100% of Medicaid,16.45,,,16.45,Other,225% of Medicaid,11.18,,,11.18,Other,153% of Medicaid,16.45,,,16.45,Other,225% of Medicaid,10.23,,,10.23,Other,140% of Medicaid,16.45,,,16.45,Other,225% of Medicaid,19.01,,,19.01,Other,260% of Medicaid,23.68,,,23.68,Other,324% of Medicaid,15.72,,,15.72,Other,215% of Medicaid,15.72,,,15.72,Other,215% of Medicaid,9.14,,,9.14,Other,125% of Medicaid,7.31,54.76,
VIRUS INOCULATION SHELL VIA,87254,CPT,,78087254,CDM,300,RC,,,both,,,125,92.5,,,92.5,Other,150% of Medicare + 9.63% HCRA Surcharge,56.25,45,,56.25,percent of total billed charges,Critical Access Hospital RCC factor,58.88,,,58.88,Fee Schedule,,53.01,,,53.01,Fee Schedule,,145.03,,,145.03,Fee Schedule,,130.44,,,130.44,Fee Schedule,,123.29,,,123.29,Fee Schedule,,61.88,,,61.88,Other,110% of Medicare,61.61,,,61.61,Fee Schedule,,13,,,13,Other,186% of Medicaid,72.57,,,72.57,Fee Schedule,,77.5,,,77.5,Fee Schedule,,41.08,,,41.08,Fee Schedule,,72.57,,,72.57,Fee Schedule,,77.5,,,77.5,Fee Schedule,,77.26,,,77.26,Fee Schedule,,87.5,70,,87.5,percent of total billed charges,All Other,92.7,,,92.7,Fee Schedule,,78.57,,,78.57,Fee Schedule,,29.34,,,29.34,Fee Schedule,,29.34,,,29.34,Fee Schedule,,29.34,,,29.34,Fee Schedule,,29.34,,,29.34,Fee Schedule,,6.83,,,6.83,Other,100% of Medicaid,6.83,,,6.83,Other,100% of Medicaid,6.83,,,6.83,Other,100% of Medicaid,6.83,,,6.83,Other,100% of Medicaid,15.36,,,15.36,Other,225% of Medicaid,10.45,,,10.45,Other,153% of Medicaid,15.36,,,15.36,Other,225% of Medicaid,9.56,,,9.56,Other,140% of Medicaid,15.36,,,15.36,Other,225% of Medicaid,17.75,,,17.75,Other,260% of Medicaid,22.12,,,22.12,Other,324% of Medicaid,14.68,,,14.68,Other,215% of Medicaid,14.68,,,14.68,Other,215% of Medicaid,8.53,,,8.53,Other,125% of Medicaid,6.83,145.03,
LEGION PNEUMOPHILIA AG IF,87278,CPT,,78087278,CDM,300,RC,,,both,,,74,54.76,,,54.76,Other,150% of Medicare + 9.63% HCRA Surcharge,33.3,45,,33.3,percent of total billed charges,Critical Access Hospital RCC factor,46.96,,,46.96,Fee Schedule,,42.28,,,42.28,Fee Schedule,,64.87,,,64.87,Fee Schedule,,58.35,,,58.35,Fee Schedule,,55.15,,,55.15,Fee Schedule,,36.63,,,36.63,Other,110% of Medicare,49.14,,,49.14,Fee Schedule,,29,,,29,Other,186% of Medicaid,57.88,,,57.88,Fee Schedule,,45.88,,,45.88,Fee Schedule,,32.76,,,32.76,Fee Schedule,,57.88,,,57.88,Fee Schedule,,45.88,,,45.88,Fee Schedule,,61.62,,,61.62,Fee Schedule,,51.8,70,,51.8,percent of total billed charges,All Other,73.93,,,73.93,Fee Schedule,,62.66,,,62.66,Fee Schedule,,23.4,,,23.4,Fee Schedule,,23.4,,,23.4,Fee Schedule,,23.4,,,23.4,Fee Schedule,,23.4,,,23.4,Fee Schedule,,15.6,,,15.6,Other,100% of Medicaid,15.6,,,15.6,Other,100% of Medicaid,15.6,,,15.6,Other,100% of Medicaid,15.6,,,15.6,Other,100% of Medicaid,35.1,,,35.1,Other,225% of Medicaid,23.87,,,23.87,Other,153% of Medicaid,35.1,,,35.1,Other,225% of Medicaid,21.84,,,21.84,Other,140% of Medicaid,35.1,,,35.1,Other,225% of Medicaid,40.56,,,40.56,Other,260% of Medicaid,50.54,,,50.54,Other,324% of Medicaid,33.54,,,33.54,Other,215% of Medicaid,33.54,,,33.54,Other,215% of Medicaid,19.5,,,19.5,Other,125% of Medicaid,15.6,73.93,
ASPERGILLUS AG EIA,87305,CPT,,78087305,CDM,300,RC,,,both,,,69,51.06,,,51.06,Other,150% of Medicare + 9.63% HCRA Surcharge,31.05,45,,31.05,percent of total billed charges,Critical Access Hospital RCC factor,36.06,,,36.06,Fee Schedule,,32.47,,,32.47,Fee Schedule,,64.87,,,64.87,Fee Schedule,,58.35,,,58.35,Fee Schedule,,55.15,,,55.15,Fee Schedule,,34.16,,,34.16,Other,110% of Medicare,37.74,,,37.74,Fee Schedule,,15,,,15,Other,186% of Medicaid,44.45,,,44.45,Fee Schedule,,42.78,,,42.78,Fee Schedule,,25.16,,,25.16,Fee Schedule,,44.45,,,44.45,Fee Schedule,,42.78,,,42.78,Fee Schedule,,47.32,,,47.32,Fee Schedule,,48.3,70,,48.3,percent of total billed charges,All Other,56.77,,,56.77,Fee Schedule,,48.12,,,48.12,Fee Schedule,,17.97,,,17.97,Fee Schedule,,17.97,,,17.97,Fee Schedule,,17.97,,,17.97,Fee Schedule,,17.97,,,17.97,Fee Schedule,,8.11,,,8.11,Other,100% of Medicaid,8.11,,,8.11,Other,100% of Medicaid,8.11,,,8.11,Other,100% of Medicaid,8.11,,,8.11,Other,100% of Medicaid,18.25,,,18.25,Other,225% of Medicaid,12.41,,,12.41,Other,153% of Medicaid,18.25,,,18.25,Other,225% of Medicaid,11.35,,,11.35,Other,140% of Medicaid,18.25,,,18.25,Other,225% of Medicaid,21.09,,,21.09,Other,260% of Medicaid,26.28,,,26.28,Other,324% of Medicaid,17.44,,,17.44,Other,215% of Medicaid,17.44,,,17.44,Other,215% of Medicaid,10.14,,,10.14,Other,125% of Medicaid,8.11,64.87,
STREP A AG EIA,87430,CPT,,78087430,CDM,300,RC,,,both,,,74,54.76,,,54.76,Other,150% of Medicare + 9.63% HCRA Surcharge,33.3,45,,33.3,percent of total billed charges,Critical Access Hospital RCC factor,50.6,,,50.6,Fee Schedule,,45.56,,,45.56,Fee Schedule,,64.87,,,64.87,Fee Schedule,,58.35,,,58.35,Fee Schedule,,55.15,,,55.15,Fee Schedule,,36.63,,,36.63,Other,110% of Medicare,52.95,,,52.95,Fee Schedule,,10,,,10,Other,186% of Medicaid,62.37,,,62.37,Fee Schedule,,45.88,,,45.88,Fee Schedule,,35.3,,,35.3,Fee Schedule,,62.37,,,62.37,Fee Schedule,,45.88,,,45.88,Fee Schedule,,66.4,,,66.4,Fee Schedule,,51.8,70,,51.8,percent of total billed charges,All Other,79.66,,,79.66,Fee Schedule,,67.52,,,67.52,Fee Schedule,,25.22,,,25.22,Fee Schedule,,25.22,,,25.22,Fee Schedule,,25.22,,,25.22,Fee Schedule,,25.22,,,25.22,Fee Schedule,,5.25,,,5.25,Other,100% of Medicaid,5.25,,,5.25,Other,100% of Medicaid,5.25,,,5.25,Other,100% of Medicaid,5.25,,,5.25,Other,100% of Medicaid,11.82,,,11.82,Other,225% of Medicaid,8.04,,,8.04,Other,153% of Medicaid,11.82,,,11.82,Other,225% of Medicaid,7.35,,,7.35,Other,140% of Medicaid,11.82,,,11.82,Other,225% of Medicaid,13.66,,,13.66,Other,260% of Medicaid,17.02,,,17.02,Other,324% of Medicaid,11.29,,,11.29,Other,215% of Medicaid,11.29,,,11.29,Other,215% of Medicaid,6.57,,,6.57,Other,125% of Medicaid,5.25,79.66,
BARTONELLA DNA AMP PROBE,87471,CPT,,78087471,CDM,300,RC,,,both,,,223,165.02,,,165.02,Other,150% of Medicare + 9.63% HCRA Surcharge,100.35,45,,100.35,percent of total billed charges,Critical Access Hospital RCC factor,105.62,,,105.62,Fee Schedule,,95.09,,,95.09,Fee Schedule,,260.29,,,260.29,Fee Schedule,,234.11,,,234.11,Fee Schedule,,221.27,,,221.27,Fee Schedule,,110.39,,,110.39,Other,110% of Medicare,110.53,,,110.53,Fee Schedule,,67,,,67,Other,186% of Medicaid,130.18,,,130.18,Fee Schedule,,138.26,,,138.26,Fee Schedule,,73.69,,,73.69,Fee Schedule,,130.18,,,130.18,Fee Schedule,,138.26,,,138.26,Fee Schedule,,138.61,,,138.61,Fee Schedule,,156.1,70,,156.1,percent of total billed charges,All Other,166.29,,,166.29,Fee Schedule,,140.94,,,140.94,Fee Schedule,,52.64,,,52.64,Fee Schedule,,52.64,,,52.64,Fee Schedule,,52.64,,,52.64,Fee Schedule,,52.64,,,52.64,Fee Schedule,,36.17,,,36.17,Other,100% of Medicaid,36.17,,,36.17,Other,100% of Medicaid,36.17,,,36.17,Other,100% of Medicaid,36.17,,,36.17,Other,100% of Medicaid,81.38,,,81.38,Other,225% of Medicaid,55.34,,,55.34,Other,153% of Medicaid,81.38,,,81.38,Other,225% of Medicaid,50.64,,,50.64,Other,140% of Medicaid,81.38,,,81.38,Other,225% of Medicaid,94.04,,,94.04,Other,260% of Medicaid,117.19,,,117.19,Other,324% of Medicaid,77.77,,,77.77,Other,215% of Medicaid,77.77,,,77.77,Other,215% of Medicaid,45.21,,,45.21,Other,125% of Medicaid,36.17,260.29,
CYTOMEG DNA QUANT,87497,CPT,,78087497,CDM,300,RC,,,both,,,304,224.96,,,224.96,Other,150% of Medicare + 9.63% HCRA Surcharge,136.8,45,,136.8,percent of total billed charges,Critical Access Hospital RCC factor,128.95,,,128.95,Fee Schedule,,116.1,,,116.1,Fee Schedule,,317.68,,,317.68,Fee Schedule,,285.73,,,285.73,Fee Schedule,,270.05,,,270.05,Fee Schedule,,150.48,,,150.48,Other,110% of Medicare,134.95,,,134.95,Fee Schedule,,54,,,54,Other,186% of Medicaid,158.94,,,158.94,Fee Schedule,,188.48,,,188.48,Fee Schedule,,89.96,,,89.96,Fee Schedule,,158.94,,,158.94,Fee Schedule,,188.48,,,188.48,Fee Schedule,,169.22,,,169.22,Fee Schedule,,212.8,70,,212.8,percent of total billed charges,All Other,203.02,,,203.02,Fee Schedule,,172.07,,,172.07,Fee Schedule,,64.26,,,64.26,Fee Schedule,,64.26,,,64.26,Fee Schedule,,64.26,,,64.26,Fee Schedule,,64.26,,,64.26,Fee Schedule,,28.85,,,28.85,Other,100% of Medicaid,28.85,,,28.85,Other,100% of Medicaid,28.85,,,28.85,Other,100% of Medicaid,28.85,,,28.85,Other,100% of Medicaid,64.9,,,64.9,Other,225% of Medicaid,44.13,,,44.13,Other,153% of Medicaid,64.9,,,64.9,Other,225% of Medicaid,40.38,,,40.38,Other,140% of Medicaid,64.9,,,64.9,Other,225% of Medicaid,75,,,75,Other,260% of Medicaid,93.46,,,93.46,Other,324% of Medicaid,62.02,,,62.02,Other,215% of Medicaid,62.02,,,62.02,Other,215% of Medicaid,36.06,,,36.06,Other,125% of Medicaid,28.85,317.68,
HEPATITIS C RNA AMP PROBE,87521,CPT,,78087521,CDM,300,RC,,,both,,,586,433.64,,,433.64,Other,150% of Medicare + 9.63% HCRA Surcharge,263.7,45,,263.7,percent of total billed charges,Critical Access Hospital RCC factor,105.62,,,105.62,Fee Schedule,,95.09,,,95.09,Fee Schedule,,260.29,,,260.29,Fee Schedule,,234.11,,,234.11,Fee Schedule,,221.27,,,221.27,Fee Schedule,,290.07,,,290.07,Other,110% of Medicare,110.53,,,110.53,Fee Schedule,,65,,,65,Other,186% of Medicaid,130.18,,,130.18,Fee Schedule,,363.32,,,363.32,Fee Schedule,,73.69,,,73.69,Fee Schedule,,130.18,,,130.18,Fee Schedule,,363.32,,,363.32,Fee Schedule,,138.61,,,138.61,Fee Schedule,,410.2,70,,410.2,percent of total billed charges,All Other,166.29,,,166.29,Fee Schedule,,140.94,,,140.94,Fee Schedule,,52.64,,,52.64,Fee Schedule,,52.64,,,52.64,Fee Schedule,,52.64,,,52.64,Fee Schedule,,52.64,,,52.64,Fee Schedule,,35.09,,,35.09,Other,100% of Medicaid,35.09,,,35.09,Other,100% of Medicaid,35.09,,,35.09,Other,100% of Medicaid,35.09,,,35.09,Other,100% of Medicaid,78.95,,,78.95,Other,225% of Medicaid,53.69,,,53.69,Other,153% of Medicaid,78.95,,,78.95,Other,225% of Medicaid,49.13,,,49.13,Other,140% of Medicaid,78.95,,,78.95,Other,225% of Medicaid,91.23,,,91.23,Other,260% of Medicaid,113.69,,,113.69,Other,324% of Medicaid,75.44,,,75.44,Other,215% of Medicaid,75.44,,,75.44,Other,215% of Medicaid,43.86,,,43.86,Other,125% of Medicaid,35.09,433.64,
HIV-L DNA QUANT,87536,CPT,,78087536,CDM,300,RC,,,both,,,538,398.12,,,398.12,Other,150% of Medicare + 9.63% HCRA Surcharge,242.1,45,,242.1,percent of total billed charges,Critical Access Hospital RCC factor,256.15,,,256.15,Fee Schedule,,230.62,,,230.62,Fee Schedule,,631.08,,,631.08,Fee Schedule,,567.62,,,567.62,Fee Schedule,,536.48,,,536.48,Fee Schedule,,266.31,,,266.31,Other,110% of Medicare,268.07,,,268.07,Fee Schedule,,158,,,158,Other,186% of Medicaid,315.72,,,315.72,Fee Schedule,,333.56,,,333.56,Fee Schedule,,178.71,,,178.71,Fee Schedule,,315.72,,,315.72,Fee Schedule,,333.56,,,333.56,Fee Schedule,,336.15,,,336.15,Fee Schedule,,376.6,70,,376.6,percent of total billed charges,All Other,403.29,,,403.29,Fee Schedule,,341.81,,,341.81,Fee Schedule,,127.65,,,127.65,Fee Schedule,,127.65,,,127.65,Fee Schedule,,127.65,,,127.65,Fee Schedule,,127.65,,,127.65,Fee Schedule,,85.1,,,85.1,Other,100% of Medicaid,85.1,,,85.1,Other,100% of Medicaid,85.1,,,85.1,Other,100% of Medicaid,85.1,,,85.1,Other,100% of Medicaid,191.48,,,191.48,Other,225% of Medicaid,130.2,,,130.2,Other,153% of Medicaid,191.48,,,191.48,Other,225% of Medicaid,119.14,,,119.14,Other,140% of Medicaid,191.48,,,191.48,Other,225% of Medicaid,221.26,,,221.26,Other,260% of Medicaid,275.72,,,275.72,Other,324% of Medicaid,182.97,,,182.97,Other,215% of Medicaid,182.97,,,182.97,Other,215% of Medicaid,106.38,,,106.38,Other,125% of Medicaid,85.1,631.08,
HIV-2 DNA AMP PROBE,87538,CPT,,78087538,CDM,300,RC,,,both,,,208,153.92,,,153.92,Other,150% of Medicare + 9.63% HCRA Surcharge,93.6,45,,93.6,percent of total billed charges,Critical Access Hospital RCC factor,105.62,,,105.62,Fee Schedule,,95.09,,,95.09,Fee Schedule,,260.29,,,260.29,Fee Schedule,,234.11,,,234.11,Fee Schedule,,221.27,,,221.27,Fee Schedule,,102.96,,,102.96,Other,110% of Medicare,110.53,,,110.53,Fee Schedule,,67,,,67,Other,186% of Medicaid,130.18,,,130.18,Fee Schedule,,128.96,,,128.96,Fee Schedule,,73.69,,,73.69,Fee Schedule,,130.18,,,130.18,Fee Schedule,,128.96,,,128.96,Fee Schedule,,138.61,,,138.61,Fee Schedule,,145.6,70,,145.6,percent of total billed charges,All Other,166.29,,,166.29,Fee Schedule,,140.94,,,140.94,Fee Schedule,,52.64,,,52.64,Fee Schedule,,52.64,,,52.64,Fee Schedule,,52.64,,,52.64,Fee Schedule,,52.64,,,52.64,Fee Schedule,,36.17,,,36.17,Other,100% of Medicaid,36.17,,,36.17,Other,100% of Medicaid,36.17,,,36.17,Other,100% of Medicaid,36.17,,,36.17,Other,100% of Medicaid,81.38,,,81.38,Other,225% of Medicaid,55.34,,,55.34,Other,153% of Medicaid,81.38,,,81.38,Other,225% of Medicaid,50.64,,,50.64,Other,140% of Medicaid,81.38,,,81.38,Other,225% of Medicaid,94.04,,,94.04,Other,260% of Medicaid,117.19,,,117.19,Other,324% of Medicaid,77.77,,,77.77,Other,215% of Medicaid,77.77,,,77.77,Other,215% of Medicaid,45.21,,,45.21,Other,125% of Medicaid,36.17,260.29,
DETECT AGENT NOS DNA AMP,87798,CPT,,78087798,CDM,300,RC,,,both,,,369,273.06,,,273.06,Other,150% of Medicare + 9.63% HCRA Surcharge,166.05,45,,166.05,percent of total billed charges,Critical Access Hospital RCC factor,105.62,,,105.62,Fee Schedule,,95.09,,,95.09,Fee Schedule,,260.29,,,260.29,Fee Schedule,,234.11,,,234.11,Fee Schedule,,221.27,,,221.27,Fee Schedule,,182.66,,,182.66,Other,110% of Medicare,110.53,,,110.53,Fee Schedule,,0.01,,,0.01,Other,186% of Medicaid,130.18,,,130.18,Fee Schedule,,228.78,,,228.78,Fee Schedule,,73.69,,,73.69,Fee Schedule,,130.18,,,130.18,Fee Schedule,,228.78,,,228.78,Fee Schedule,,138.61,,,138.61,Fee Schedule,,258.3,70,,258.3,percent of total billed charges,All Other,166.29,,,166.29,Fee Schedule,,140.94,,,140.94,Fee Schedule,,52.64,,,52.64,Fee Schedule,,52.64,,,52.64,Fee Schedule,,52.64,,,52.64,Fee Schedule,,52.64,,,52.64,Fee Schedule,,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,273.06,
RSV ASSAY W/OPTIC,87807,CPT,,78087807,CDM,300,RC,,,both,,,69,51.06,,,51.06,Other,150% of Medicare + 9.63% HCRA Surcharge,31.05,45,,31.05,percent of total billed charges,Critical Access Hospital RCC factor,39.43,,,39.43,Fee Schedule,,35.5,,,35.5,Fee Schedule,,64.87,,,64.87,Fee Schedule,,58.35,,,58.35,Fee Schedule,,55.15,,,55.15,Fee Schedule,,34.16,,,34.16,Other,110% of Medicare,41.27,,,41.27,Fee Schedule,,24,,,24,Other,186% of Medicaid,48.6,,,48.6,Fee Schedule,,42.78,,,42.78,Fee Schedule,,27.51,,,27.51,Fee Schedule,,48.6,,,48.6,Fee Schedule,,42.78,,,42.78,Fee Schedule,,51.75,,,51.75,Fee Schedule,,48.3,70,,48.3,percent of total billed charges,All Other,62.08,,,62.08,Fee Schedule,,52.62,,,52.62,Fee Schedule,,19.65,,,19.65,Fee Schedule,,19.65,,,19.65,Fee Schedule,,19.65,,,19.65,Fee Schedule,,19.65,,,19.65,Fee Schedule,,13.1,,,13.1,Other,100% of Medicaid,13.1,,,13.1,Other,100% of Medicaid,13.1,,,13.1,Other,100% of Medicaid,13.1,,,13.1,Other,100% of Medicaid,29.48,,,29.48,Other,225% of Medicaid,20.04,,,20.04,Other,153% of Medicaid,29.48,,,29.48,Other,225% of Medicaid,18.34,,,18.34,Other,140% of Medicaid,29.48,,,29.48,Other,225% of Medicaid,34.06,,,34.06,Other,260% of Medicaid,42.44,,,42.44,Other,324% of Medicaid,28.17,,,28.17,Other,215% of Medicaid,28.17,,,28.17,Other,215% of Medicaid,16.38,,,16.38,Other,125% of Medicaid,13.1,64.87,
GENOTYPE DNA HIV REVERSE T,87901,CPT,,78087901,CDM,300,RC,,,both,,,888,657.12,,,657.12,Other,150% of Medicare + 9.63% HCRA Surcharge,399.6,45,,399.6,percent of total billed charges,Critical Access Hospital RCC factor,774.92,,,774.92,Fee Schedule,,697.69,,,697.69,Fee Schedule,,1909.22,,,1909.22,Fee Schedule,,1717.21,,,1717.21,Fee Schedule,,1623.01,,,1623.01,Fee Schedule,,439.56,,,439.56,Other,110% of Medicare,810.97,,,810.97,Fee Schedule,,479,,,479,Other,186% of Medicaid,955.14,,,955.14,Fee Schedule,,550.56,,,550.56,Fee Schedule,,540.65,,,540.65,Fee Schedule,,955.14,,,955.14,Fee Schedule,,550.56,,,550.56,Fee Schedule,,1016.93,,,1016.93,Fee Schedule,,621.6,70,,621.6,percent of total billed charges,All Other,1220.06,,,1220.06,Fee Schedule,,1034.08,,,1034.08,Fee Schedule,,386.18,,,386.18,Fee Schedule,,386.18,,,386.18,Fee Schedule,,386.18,,,386.18,Fee Schedule,,386.18,,,386.18,Fee Schedule,,257.45,,,257.45,Other,100% of Medicaid,257.45,,,257.45,Other,100% of Medicaid,257.45,,,257.45,Other,100% of Medicaid,257.45,,,257.45,Other,100% of Medicaid,579.26,,,579.26,Other,225% of Medicaid,393.9,,,393.9,Other,153% of Medicaid,579.26,,,579.26,Other,225% of Medicaid,360.43,,,360.43,Other,140% of Medicaid,579.26,,,579.26,Other,225% of Medicaid,669.37,,,669.37,Other,260% of Medicaid,834.14,,,834.14,Other,324% of Medicaid,553.52,,,553.52,Other,215% of Medicaid,553.52,,,553.52,Other,215% of Medicaid,321.81,,,321.81,Other,125% of Medicaid,257.45,1909.22,
GENOTYPE DNA HEPATITIS C,87902,CPT,,78087902,CDM,300,RC,,,both,,,1948,1441.52,,,1441.52,Other,150% of Medicare + 9.63% HCRA Surcharge,876.6,45,,876.6,percent of total billed charges,Critical Access Hospital RCC factor,774.92,,,774.92,Fee Schedule,,697.69,,,697.69,Fee Schedule,,1909.22,,,1909.22,Fee Schedule,,1717.21,,,1717.21,Fee Schedule,,1623.01,,,1623.01,Fee Schedule,,964.26,,,964.26,Other,110% of Medicare,810.97,,,810.97,Fee Schedule,,479,,,479,Other,186% of Medicaid,955.14,,,955.14,Fee Schedule,,1207.76,,,1207.76,Fee Schedule,,540.65,,,540.65,Fee Schedule,,955.14,,,955.14,Fee Schedule,,1207.76,,,1207.76,Fee Schedule,,1016.93,,,1016.93,Fee Schedule,,1363.6,70,,1363.6,percent of total billed charges,All Other,1220.06,,,1220.06,Fee Schedule,,1034.08,,,1034.08,Fee Schedule,,386.18,,,386.18,Fee Schedule,,386.18,,,386.18,Fee Schedule,,386.18,,,386.18,Fee Schedule,,386.18,,,386.18,Fee Schedule,,257.45,,,257.45,Other,100% of Medicaid,257.45,,,257.45,Other,100% of Medicaid,257.45,,,257.45,Other,100% of Medicaid,257.45,,,257.45,Other,100% of Medicaid,579.26,,,579.26,Other,225% of Medicaid,393.9,,,393.9,Other,153% of Medicaid,579.26,,,579.26,Other,225% of Medicaid,360.43,,,360.43,Other,140% of Medicaid,579.26,,,579.26,Other,225% of Medicaid,669.37,,,669.37,Other,260% of Medicaid,834.14,,,834.14,Other,324% of Medicaid,553.52,,,553.52,Other,215% of Medicaid,553.52,,,553.52,Other,215% of Medicaid,321.81,,,321.81,Other,125% of Medicaid,257.45,1909.22,
BODY FLUID CELL COUNT,89050,CPT,,78089050,CDM,300,RC,,,both,,,26,19.24,,,19.24,Other,150% of Medicare + 9.63% HCRA Surcharge,11.7,45,,11.7,percent of total billed charges,Critical Access Hospital RCC factor,14.21,,,14.21,Fee Schedule,,12.79,,,12.79,Fee Schedule,,31.83,,,31.83,Fee Schedule,,28.63,,,28.63,Fee Schedule,,27.06,,,27.06,Fee Schedule,,12.87,,,12.87,Other,110% of Medicare,14.87,,,14.87,Fee Schedule,,5,,,5,Other,186% of Medicaid,17.51,,,17.51,Fee Schedule,,16.12,,,16.12,Fee Schedule,,9.91,,,9.91,Fee Schedule,,17.51,,,17.51,Fee Schedule,,16.12,,,16.12,Fee Schedule,,18.64,,,18.64,Fee Schedule,,18.2,70,,18.2,percent of total billed charges,All Other,22.37,,,22.37,Fee Schedule,,18.96,,,18.96,Fee Schedule,,7.08,,,7.08,Fee Schedule,,7.08,,,7.08,Fee Schedule,,7.08,,,7.08,Fee Schedule,,7.08,,,7.08,Fee Schedule,,2.83,,,2.83,Other,100% of Medicaid,2.83,,,2.83,Other,100% of Medicaid,2.83,,,2.83,Other,100% of Medicaid,2.83,,,2.83,Other,100% of Medicaid,6.36,,,6.36,Other,225% of Medicaid,4.33,,,4.33,Other,153% of Medicaid,6.36,,,6.36,Other,225% of Medicaid,3.96,,,3.96,Other,140% of Medicaid,6.36,,,6.36,Other,225% of Medicaid,7.35,,,7.35,Other,260% of Medicaid,9.16,,,9.16,Other,324% of Medicaid,6.08,,,6.08,Other,215% of Medicaid,6.08,,,6.08,Other,215% of Medicaid,3.54,,,3.54,Other,125% of Medicaid,2.83,31.83,
LEUKOCYTE ASSESSMENT FECAL,89055,CPT,,78089055,CDM,300,RC,,,both,,,65,48.1,,,48.1,Other,150% of Medicare + 9.63% HCRA Surcharge,29.25,45,,29.25,percent of total billed charges,Critical Access Hospital RCC factor,12.85,,,12.85,Fee Schedule,,11.57,,,11.57,Fee Schedule,,31.67,,,31.67,Fee Schedule,,28.49,,,28.49,Fee Schedule,,26.92,,,26.92,Fee Schedule,,32.18,,,32.18,Other,110% of Medicare,13.45,,,13.45,Fee Schedule,,6,,,6,Other,186% of Medicaid,15.84,,,15.84,Fee Schedule,,40.3,,,40.3,Fee Schedule,,8.97,,,8.97,Fee Schedule,,15.84,,,15.84,Fee Schedule,,40.3,,,40.3,Fee Schedule,,16.87,,,16.87,Fee Schedule,,45.5,70,,45.5,percent of total billed charges,All Other,20.24,,,20.24,Fee Schedule,,17.15,,,17.15,Fee Schedule,,6.41,,,6.41,Fee Schedule,,6.41,,,6.41,Fee Schedule,,6.41,,,6.41,Fee Schedule,,6.41,,,6.41,Fee Schedule,,3.43,,,3.43,Other,100% of Medicaid,3.43,,,3.43,Other,100% of Medicaid,3.43,,,3.43,Other,100% of Medicaid,3.43,,,3.43,Other,100% of Medicaid,7.73,,,7.73,Other,225% of Medicaid,5.25,,,5.25,Other,153% of Medicaid,7.73,,,7.73,Other,225% of Medicaid,4.81,,,4.81,Other,140% of Medicaid,7.73,,,7.73,Other,225% of Medicaid,8.93,,,8.93,Other,260% of Medicaid,11.13,,,11.13,Other,324% of Medicaid,7.38,,,7.38,Other,215% of Medicaid,7.38,,,7.38,Other,215% of Medicaid,4.29,,,4.29,Other,125% of Medicaid,3.43,48.1,
MEAT FIBERS FECES,89160,CPT,,78089160,CDM,300,RC,,,both,,,24,17.76,,,17.76,Other,150% of Medicare + 9.63% HCRA Surcharge,10.8,45,,10.8,percent of total billed charges,Critical Access Hospital RCC factor,14.6,,,14.6,Fee Schedule,,13.14,,,13.14,Fee Schedule,,27.35,,,27.35,Fee Schedule,,24.6,,,24.6,Fee Schedule,,23.25,,,23.25,Fee Schedule,,11.88,,,11.88,Other,110% of Medicare,15.28,,,15.28,Fee Schedule,,65,,,65,Other,186% of Medicaid,17.99,,,17.99,Fee Schedule,,14.88,,,14.88,Fee Schedule,,10.19,,,10.19,Fee Schedule,,17.99,,,17.99,Fee Schedule,,14.88,,,14.88,Fee Schedule,,19.16,,,19.16,Fee Schedule,,16.8,70,,16.8,percent of total billed charges,All Other,22.98,,,22.98,Fee Schedule,,19.48,,,19.48,Fee Schedule,,7.28,,,7.28,Fee Schedule,,7.28,,,7.28,Fee Schedule,,7.28,,,7.28,Fee Schedule,,7.28,,,7.28,Fee Schedule,,35.14,,,35.14,Other,100% of Medicaid,35.14,,,35.14,Other,100% of Medicaid,35.14,,,35.14,Other,100% of Medicaid,35.14,,,35.14,Other,100% of Medicaid,79.05,,,79.05,Other,225% of Medicaid,53.76,,,53.76,Other,153% of Medicaid,79.05,,,79.05,Other,225% of Medicaid,49.19,,,49.19,Other,140% of Medicaid,79.05,,,79.05,Other,225% of Medicaid,91.35,,,91.35,Other,260% of Medicaid,113.84,,,113.84,Other,324% of Medicaid,75.54,,,75.54,Other,215% of Medicaid,75.54,,,75.54,Other,215% of Medicaid,43.92,,,43.92,Other,125% of Medicaid,7.28,113.84,
HEMATOCRIT,85014,CPT,QW,78185014,CDM,300,RC,,,both,,,40,29.6,,,29.6,Other,150% of Medicare + 9.63% HCRA Surcharge,18,45,,18,percent of total billed charges,Critical Access Hospital RCC factor,7.13,,,7.13,Fee Schedule,,6.42,,,6.42,Fee Schedule,,17.55,,,17.55,Fee Schedule,,15.78,,,15.78,Fee Schedule,,14.92,,,14.92,Fee Schedule,,19.8,,,19.8,Other,110% of Medicare,7.47,,,7.47,Fee Schedule,,4,,,4,Other,186% of Medicaid,8.79,,,8.79,Fee Schedule,,24.8,,,24.8,Fee Schedule,,4.98,,,4.98,Fee Schedule,,8.79,,,8.79,Fee Schedule,,24.8,,,24.8,Fee Schedule,,9.36,,,9.36,Fee Schedule,,28,70,,28,percent of total billed charges,All Other,11.23,,,11.23,Fee Schedule,,9.52,,,9.52,Fee Schedule,,3.56,,,3.56,Fee Schedule,,3.56,,,3.56,Fee Schedule,,3.56,,,3.56,Fee Schedule,,3.56,,,3.56,Fee Schedule,,2.02,,,2.02,Other,100% of Medicaid,2.02,,,2.02,Other,100% of Medicaid,2.02,,,2.02,Other,100% of Medicaid,2.02,,,2.02,Other,100% of Medicaid,4.55,,,4.55,Other,225% of Medicaid,3.09,,,3.09,Other,153% of Medicaid,4.55,,,4.55,Other,225% of Medicaid,2.83,,,2.83,Other,140% of Medicaid,4.55,,,4.55,Other,225% of Medicaid,5.25,,,5.25,Other,260% of Medicaid,6.54,,,6.54,Other,324% of Medicaid,4.34,,,4.34,Other,215% of Medicaid,4.34,,,4.34,Other,215% of Medicaid,2.53,,,2.53,Other,125% of Medicaid,2.02,29.6,
ROUTINE VENIPUNCTURE,36415,CPT,,82036415,CDM,300,RC,,,both,,,21,15.54,,,15.54,Other,150% of Medicare + 9.63% HCRA Surcharge,9.45,45,,9.45,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,15.81,,,15.81,Fee Schedule,,14.22,,,14.22,Fee Schedule,,13.44,,,13.44,Fee Schedule,,10.4,,,10.4,Other,110% of Medicare,27.81,,,27.81,Fee Schedule,,61,,,61,Other,186% of Medicaid,32.76,,,32.76,Fee Schedule,,13.02,,,13.02,Fee Schedule,,18.54,,,18.54,Fee Schedule,,32.76,,,32.76,Fee Schedule,,13.02,,,13.02,Fee Schedule,,34.88,,,34.88,Fee Schedule,,14.7,70,,14.7,percent of total billed charges,All Other,14.22,,,14.22,Fee Schedule,,12.05,,,12.05,Fee Schedule,,4.5,,,4.5,Fee Schedule,,4.5,,,4.5,Fee Schedule,,4.5,,,4.5,Fee Schedule,,4.5,,,4.5,Fee Schedule,,32.83,,,32.83,Other,100% of Medicaid,32.83,,,32.83,Other,100% of Medicaid,32.83,,,32.83,Other,100% of Medicaid,32.83,,,32.83,Other,100% of Medicaid,73.87,,,73.87,Other,225% of Medicaid,50.23,,,50.23,Other,153% of Medicaid,73.87,,,73.87,Other,225% of Medicaid,45.96,,,45.96,Other,140% of Medicaid,73.87,,,73.87,Other,225% of Medicaid,85.36,,,85.36,Other,260% of Medicaid,106.38,,,106.38,Other,324% of Medicaid,70.59,,,70.59,Other,215% of Medicaid,70.59,,,70.59,Other,215% of Medicaid,41.04,,,41.04,Other,125% of Medicaid,0.01,106.38,
CAPILLARY BLOOD DRAW,36416,CPT,,82036416,CDM,300,RC,,,both,,,41,30.34,,,30.34,Other,150% of Medicare + 9.63% HCRA Surcharge,18.45,45,,18.45,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1.22,,,1.22,Fee Schedule,,1.22,,,1.22,Fee Schedule,,1.22,,,1.22,Fee Schedule,,20.3,,,20.3,Other,110% of Medicare,27.88,68,,27.88,percent of total billed charges,All Other,61,,,61,Other,186% of Medicaid,34.03,83,,34.03,percent of total billed charges,All Other,25.42,62,,25.42,percent of total billed charges,Lab and Radiology,22.55,55,,22.55,percent of total billed charges,Default if not on Fee Schedule,32.8,80,,32.8,percent of total billed charges,All Other,25.42,62,,25.42,percent of total billed charges,Lab and Radiology,32.8,80,,32.8,percent of total billed charges,All Other,28.7,70,,28.7,percent of total billed charges,All Other,26.65,65,,26.65,percent of total billed charges,Default if not in Fee Schedule,26.65,65,,26.65,percent of total billed charges,Default if not in Fee Schedule,4.34,,,4.34,Fee Schedule,,4.34,,,4.34,Fee Schedule,,4.34,,,4.34,Fee Schedule,,4.34,,,4.34,Fee Schedule,,32.83,,,32.83,Other,100% of Medicaid,32.83,,,32.83,Other,100% of Medicaid,32.83,,,32.83,Other,100% of Medicaid,32.83,,,32.83,Other,100% of Medicaid,73.87,,,73.87,Other,225% of Medicaid,50.23,,,50.23,Other,153% of Medicaid,73.87,,,73.87,Other,225% of Medicaid,45.96,,,45.96,Other,140% of Medicaid,73.87,,,73.87,Other,225% of Medicaid,85.36,,,85.36,Other,260% of Medicaid,106.38,,,106.38,Other,324% of Medicaid,70.59,,,70.59,Other,215% of Medicaid,70.59,,,70.59,Other,215% of Medicaid,41.04,,,41.04,Other,125% of Medicaid,0.01,106.38,
COLLECT BLOOD FROM PICC,36592,CPT,,82036592,CDM,300,RC,,,both,,,263,194.62,,,194.62,Other,150% of Medicare + 9.63% HCRA Surcharge,118.35,45,,118.35,percent of total billed charges,Critical Access Hospital RCC factor,98.28,,,98.28,Fee Schedule,,88.48,,,88.48,Fee Schedule,,174.02,,,174.02,Fee Schedule,,156.51,,,156.51,Fee Schedule,,147.93,,,147.93,Fee Schedule,,130.19,,,130.19,Other,110% of Medicare,102.85,,,102.85,Fee Schedule,,49,,,49,Other,186% of Medicaid,121.13,,,121.13,Fee Schedule,,163.06,,,163.06,Fee Schedule,,68.57,,,68.57,Fee Schedule,,121.13,,,121.13,Fee Schedule,,163.06,,,163.06,Fee Schedule,,128.97,,,128.97,Fee Schedule,,184.1,70,,184.1,percent of total billed charges,All Other,144.32,,,144.32,Fee Schedule,,122.32,,,122.32,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,26.36,,,26.36,Other,100% of Medicaid,26.36,,,26.36,Other,100% of Medicaid,26.36,,,26.36,Other,100% of Medicaid,26.36,,,26.36,Other,100% of Medicaid,59.32,,,59.32,Other,225% of Medicaid,40.33,,,40.33,Other,153% of Medicaid,59.32,,,59.32,Other,225% of Medicaid,36.91,,,36.91,Other,140% of Medicaid,59.32,,,59.32,Other,225% of Medicaid,68.54,,,68.54,Other,260% of Medicaid,85.41,,,85.41,Other,324% of Medicaid,56.68,,,56.68,Other,215% of Medicaid,56.68,,,56.68,Other,215% of Medicaid,32.95,,,32.95,Other,125% of Medicaid,0.01,194.62,
REAGENT STRIP/BLOOD GLUCOSE,82948,CPT,,82082948,CDM,300,RC,,,both,,,29,21.46,,,21.46,Other,150% of Medicare + 9.63% HCRA Surcharge,13.05,45,,13.05,percent of total billed charges,Critical Access Hospital RCC factor,15.17,,,15.17,Fee Schedule,,13.66,,,13.66,Fee Schedule,,23.45,,,23.45,Fee Schedule,,21.09,,,21.09,Fee Schedule,,19.94,,,19.94,Fee Schedule,,14.36,,,14.36,Other,110% of Medicare,15.88,,,15.88,Fee Schedule,,4,,,4,Other,186% of Medicaid,18.7,,,18.7,Fee Schedule,,17.98,,,17.98,Fee Schedule,,10.58,,,10.58,Fee Schedule,,18.7,,,18.7,Fee Schedule,,17.98,,,17.98,Fee Schedule,,19.91,,,19.91,Fee Schedule,,20.3,70,,20.3,percent of total billed charges,All Other,23.88,,,23.88,Fee Schedule,,20.24,,,20.24,Fee Schedule,,7.56,,,7.56,Fee Schedule,,7.56,,,7.56,Fee Schedule,,7.56,,,7.56,Fee Schedule,,7.56,,,7.56,Fee Schedule,,2.02,,,2.02,Other,100% of Medicaid,2.02,,,2.02,Other,100% of Medicaid,2.02,,,2.02,Other,100% of Medicaid,2.02,,,2.02,Other,100% of Medicaid,4.55,,,4.55,Other,225% of Medicaid,3.09,,,3.09,Other,153% of Medicaid,4.55,,,4.55,Other,225% of Medicaid,2.83,,,2.83,Other,140% of Medicaid,4.55,,,4.55,Other,225% of Medicaid,5.25,,,5.25,Other,260% of Medicaid,6.54,,,6.54,Other,324% of Medicaid,4.34,,,4.34,Other,215% of Medicaid,4.34,,,4.34,Other,215% of Medicaid,2.53,,,2.53,Other,125% of Medicaid,2.02,23.88,
BILIRUBIN TOTAL TRANSCUT,88720,CPT,TC,85088720,CDM,300,RC,,,both,,,30,22.2,,,22.2,Other,150% of Medicare + 9.63% HCRA Surcharge,13.5,45,,13.5,percent of total billed charges,Critical Access Hospital RCC factor,15.11,,,15.11,Fee Schedule,,13.6,,,13.6,Fee Schedule,,37.21,,,37.21,Fee Schedule,,33.46,,,33.46,Fee Schedule,,31.63,,,31.63,Fee Schedule,,14.85,,,14.85,Other,110% of Medicare,15.81,,,15.81,Fee Schedule,,19,,,19,Other,186% of Medicaid,18.62,,,18.62,Fee Schedule,,18.6,,,18.6,Fee Schedule,,10.54,,,10.54,Fee Schedule,,18.62,,,18.62,Fee Schedule,,18.6,,,18.6,Fee Schedule,,19.83,,,19.83,Fee Schedule,,21,70,,21,percent of total billed charges,All Other,23.79,,,23.79,Fee Schedule,,20.16,,,20.16,Fee Schedule,,7.53,,,7.53,Fee Schedule,,7.53,,,7.53,Fee Schedule,,7.53,,,7.53,Fee Schedule,,7.53,,,7.53,Fee Schedule,,10.45,,,10.45,Other,100% of Medicaid,10.45,,,10.45,Other,100% of Medicaid,10.45,,,10.45,Other,100% of Medicaid,10.45,,,10.45,Other,100% of Medicaid,23.51,,,23.51,Other,225% of Medicaid,15.99,,,15.99,Other,153% of Medicaid,23.51,,,23.51,Other,225% of Medicaid,14.63,,,14.63,Other,140% of Medicaid,23.51,,,23.51,Other,225% of Medicaid,27.16,,,27.16,Other,260% of Medicaid,33.85,,,33.85,Other,324% of Medicaid,22.46,,,22.46,Other,215% of Medicaid,22.46,,,22.46,Other,215% of Medicaid,13.06,,,13.06,Other,125% of Medicaid,7.53,37.21,
EXAM SYNOVIAL FLUID CRYSTALS,89060,CPT,TC,85089060,CDM,300,RC,,,both,,,80,59.2,,,59.2,Other,150% of Medicare + 9.63% HCRA Surcharge,36,45,,36,percent of total billed charges,Critical Access Hospital RCC factor,22.06,,,22.06,Fee Schedule,,19.86,,,19.86,Fee Schedule,,53.02,,,53.02,Fee Schedule,,47.68,,,47.68,Fee Schedule,,45.07,,,45.07,Fee Schedule,,39.6,,,39.6,Other,110% of Medicare,23.09,,,23.09,Fee Schedule,,11,,,11,Other,186% of Medicaid,27.19,,,27.19,Fee Schedule,,49.6,,,49.6,Fee Schedule,,15.39,,,15.39,Fee Schedule,,27.19,,,27.19,Fee Schedule,,49.6,,,49.6,Fee Schedule,,28.95,,,28.95,Fee Schedule,,56,70,,56,percent of total billed charges,All Other,34.74,,,34.74,Fee Schedule,,29.44,,,29.44,Fee Schedule,,11,,,11,Fee Schedule,,11,,,11,Fee Schedule,,11,,,11,Fee Schedule,,11,,,11,Fee Schedule,,6.06,,,6.06,Other,100% of Medicaid,6.06,,,6.06,Other,100% of Medicaid,6.06,,,6.06,Other,100% of Medicaid,6.06,,,6.06,Other,100% of Medicaid,13.64,,,13.64,Other,225% of Medicaid,9.27,,,9.27,Other,153% of Medicaid,13.64,,,13.64,Other,225% of Medicaid,8.48,,,8.48,Other,140% of Medicaid,13.64,,,13.64,Other,225% of Medicaid,15.76,,,15.76,Other,260% of Medicaid,19.63,,,19.63,Other,324% of Medicaid,13.03,,,13.03,Other,215% of Medicaid,13.03,,,13.03,Other,215% of Medicaid,7.58,,,7.58,Other,125% of Medicaid,6.06,59.2,
DRUG TEST PRSMV CHEM ANLYZR,80307,CPT,,38080307,CDM,301,RC,,,both,,,405,299.7,,,299.7,Other,150% of Medicare + 9.63% HCRA Surcharge,182.25,45,,182.25,percent of total billed charges,Critical Access Hospital RCC factor,187.04,,,187.04,Fee Schedule,,168.4,,,168.4,Fee Schedule,,31.92,,,31.92,Fee Schedule,,31.92,,,31.92,Fee Schedule,,31.92,,,31.92,Fee Schedule,,200.48,,,200.48,Other,110% of Medicare,195.74,,,195.74,Fee Schedule,,14,,,14,Other,186% of Medicaid,230.54,,,230.54,Fee Schedule,,251.1,,,251.1,Fee Schedule,,130.49,,,130.49,Fee Schedule,,230.54,,,230.54,Fee Schedule,,251.1,,,251.1,Fee Schedule,,245.45,,,245.45,Fee Schedule,,283.5,70,,283.5,percent of total billed charges,All Other,294.48,,,294.48,Fee Schedule,,249.59,,,249.59,Fee Schedule,,93.21,,,93.21,Fee Schedule,,93.21,,,93.21,Fee Schedule,,93.21,,,93.21,Fee Schedule,,93.21,,,93.21,Fee Schedule,,7.58,,,7.58,Other,100% of Medicaid,7.58,,,7.58,Other,100% of Medicaid,7.58,,,7.58,Other,100% of Medicaid,7.58,,,7.58,Other,100% of Medicaid,17.04,,,17.04,Other,225% of Medicaid,11.59,,,11.59,Other,153% of Medicaid,17.04,,,17.04,Other,225% of Medicaid,10.61,,,10.61,Other,140% of Medicaid,17.04,,,17.04,Other,225% of Medicaid,19.7,,,19.7,Other,260% of Medicaid,24.54,,,24.54,Other,324% of Medicaid,16.29,,,16.29,Other,215% of Medicaid,16.29,,,16.29,Other,215% of Medicaid,9.47,,,9.47,Other,125% of Medicaid,7.58,299.7,
ASSAY CARBOXYHB QUANT,82375,CPT,,71082375,CDM,301,RC,,,both,,,160,118.4,,,118.4,Other,150% of Medicare + 9.63% HCRA Surcharge,72,45,,72,percent of total billed charges,Critical Access Hospital RCC factor,37.08,,,37.08,Fee Schedule,,33.39,,,33.39,Fee Schedule,,91.43,,,91.43,Fee Schedule,,82.24,,,82.24,Fee Schedule,,77.73,,,77.73,Fee Schedule,,79.2,,,79.2,Other,110% of Medicare,38.81,,,38.81,Fee Schedule,,21,,,21,Other,186% of Medicaid,45.71,,,45.71,Fee Schedule,,99.2,,,99.2,Fee Schedule,,25.87,,,25.87,Fee Schedule,,45.71,,,45.71,Fee Schedule,,99.2,,,99.2,Fee Schedule,,48.66,,,48.66,Fee Schedule,,112,70,,112,percent of total billed charges,All Other,58.38,,,58.38,Fee Schedule,,49.48,,,49.48,Fee Schedule,,18.48,,,18.48,Fee Schedule,,18.48,,,18.48,Fee Schedule,,18.48,,,18.48,Fee Schedule,,18.48,,,18.48,Fee Schedule,,11.11,,,11.11,Other,100% of Medicaid,11.11,,,11.11,Other,100% of Medicaid,11.11,,,11.11,Other,100% of Medicaid,11.11,,,11.11,Other,100% of Medicaid,25,,,25,Other,225% of Medicaid,17,,,17,Other,153% of Medicaid,25,,,25,Other,225% of Medicaid,15.55,,,15.55,Other,140% of Medicaid,25,,,25,Other,225% of Medicaid,28.89,,,28.89,Other,260% of Medicaid,36,,,36,Other,324% of Medicaid,23.89,,,23.89,Other,215% of Medicaid,23.89,,,23.89,Other,215% of Medicaid,13.89,,,13.89,Other,125% of Medicaid,11.11,118.4,
BLOOD GASES CALCULATED O2,82803,CPT,,71082803,CDM,301,RC,,,both,,,377,278.98,,,278.98,Other,150% of Medicare + 9.63% HCRA Surcharge,169.65,45,,169.65,percent of total billed charges,Critical Access Hospital RCC factor,78.47,,,78.47,Fee Schedule,,70.65,,,70.65,Fee Schedule,,143.45,,,143.45,Fee Schedule,,129.02,,,129.02,Fee Schedule,,121.95,,,121.95,Fee Schedule,,186.62,,,186.62,Other,110% of Medicare,82.12,,,82.12,Fee Schedule,,30,,,30,Other,186% of Medicaid,96.72,,,96.72,Fee Schedule,,233.74,,,233.74,Fee Schedule,,54.75,,,54.75,Fee Schedule,,96.72,,,96.72,Fee Schedule,,233.74,,,233.74,Fee Schedule,,102.98,,,102.98,Fee Schedule,,263.9,70,,263.9,percent of total billed charges,All Other,123.55,,,123.55,Fee Schedule,,104.71,,,104.71,Fee Schedule,,39.11,,,39.11,Fee Schedule,,39.11,,,39.11,Fee Schedule,,39.11,,,39.11,Fee Schedule,,39.11,,,39.11,Fee Schedule,,16.36,,,16.36,Other,100% of Medicaid,16.36,,,16.36,Other,100% of Medicaid,16.36,,,16.36,Other,100% of Medicaid,16.36,,,16.36,Other,100% of Medicaid,36.81,,,36.81,Other,225% of Medicaid,25.03,,,25.03,Other,153% of Medicaid,36.81,,,36.81,Other,225% of Medicaid,22.91,,,22.91,Other,140% of Medicaid,36.81,,,36.81,Other,225% of Medicaid,42.54,,,42.54,Other,260% of Medicaid,53.01,,,53.01,Other,324% of Medicaid,35.18,,,35.18,Other,215% of Medicaid,35.18,,,35.18,Other,215% of Medicaid,20.45,,,20.45,Other,125% of Medicaid,16.36,278.98,
BLOOD GASES W/O2 SATURATION,82805,CPT,,71082805,CDM,301,RC,,,both,,,294,217.56,,,217.56,Other,150% of Medicare + 9.63% HCRA Surcharge,132.3,45,,132.3,percent of total billed charges,Critical Access Hospital RCC factor,237.1,,,237.1,Fee Schedule,,213.47,,,213.47,Fee Schedule,,210.48,,,210.48,Fee Schedule,,189.32,,,189.32,Fee Schedule,,178.93,,,178.93,Fee Schedule,,145.53,,,145.53,Other,110% of Medicare,248.13,,,248.13,Fee Schedule,,45,,,45,Other,186% of Medicaid,292.24,,,292.24,Fee Schedule,,182.28,,,182.28,Fee Schedule,,165.42,,,165.42,Fee Schedule,,292.24,,,292.24,Fee Schedule,,182.28,,,182.28,Fee Schedule,,311.14,,,311.14,Fee Schedule,,205.8,70,,205.8,percent of total billed charges,All Other,373.29,,,373.29,Fee Schedule,,316.39,,,316.39,Fee Schedule,,118.16,,,118.16,Fee Schedule,,118.16,,,118.16,Fee Schedule,,118.16,,,118.16,Fee Schedule,,118.16,,,118.16,Fee Schedule,,24.13,,,24.13,Other,100% of Medicaid,24.13,,,24.13,Other,100% of Medicaid,24.13,,,24.13,Other,100% of Medicaid,24.13,,,24.13,Other,100% of Medicaid,54.29,,,54.29,Other,225% of Medicaid,36.92,,,36.92,Other,153% of Medicaid,54.29,,,54.29,Other,225% of Medicaid,33.78,,,33.78,Other,140% of Medicaid,54.29,,,54.29,Other,225% of Medicaid,62.74,,,62.74,Other,260% of Medicaid,78.18,,,78.18,Other,324% of Medicaid,51.88,,,51.88,Other,215% of Medicaid,51.88,,,51.88,Other,215% of Medicaid,30.16,,,30.16,Other,125% of Medicaid,24.13,373.29,
BLOOD METHEMOGLOBIN ASSAY,83050,CPT,,71083050,CDM,301,RC,,,both,,,180,133.2,,,133.2,Other,150% of Medicare + 9.63% HCRA Surcharge,81,45,,81,percent of total billed charges,Critical Access Hospital RCC factor,24.68,,,24.68,Fee Schedule,,22.22,,,22.22,Fee Schedule,,25.88,,,25.88,Fee Schedule,,23.27,,,23.27,Fee Schedule,,22,,,22,Fee Schedule,,89.1,,,89.1,Other,110% of Medicare,25.83,,,25.83,Fee Schedule,,7,,,7,Other,186% of Medicaid,30.42,,,30.42,Fee Schedule,,111.6,,,111.6,Fee Schedule,,17.22,,,17.22,Fee Schedule,,30.42,,,30.42,Fee Schedule,,111.6,,,111.6,Fee Schedule,,32.39,,,32.39,Fee Schedule,,126,70,,126,percent of total billed charges,All Other,38.86,,,38.86,Fee Schedule,,32.94,,,32.94,Fee Schedule,,12.3,,,12.3,Fee Schedule,,12.3,,,12.3,Fee Schedule,,12.3,,,12.3,Fee Schedule,,12.3,,,12.3,Fee Schedule,,3.79,,,3.79,Other,100% of Medicaid,3.79,,,3.79,Other,100% of Medicaid,3.79,,,3.79,Other,100% of Medicaid,3.79,,,3.79,Other,100% of Medicaid,8.52,,,8.52,Other,225% of Medicaid,5.79,,,5.79,Other,153% of Medicaid,8.52,,,8.52,Other,225% of Medicaid,5.3,,,5.3,Other,140% of Medicaid,8.52,,,8.52,Other,225% of Medicaid,9.85,,,9.85,Other,260% of Medicaid,12.27,,,12.27,Other,324% of Medicaid,8.14,,,8.14,Other,215% of Medicaid,8.14,,,8.14,Other,215% of Medicaid,4.73,,,4.73,Other,125% of Medicaid,3.79,133.2,
CHORIONIC GONADOTROPIN TEST,84702,CPT,,77084702,CDM,301,RC,,,both,,,109,80.66,,,80.66,Other,150% of Medicare + 9.63% HCRA Surcharge,49.05,45,,49.05,percent of total billed charges,Critical Access Hospital RCC factor,45.3,,,45.3,Fee Schedule,,40.79,,,40.79,Fee Schedule,,111.67,,,111.67,Fee Schedule,,100.44,,,100.44,Fee Schedule,,94.93,,,94.93,Fee Schedule,,53.96,,,53.96,Other,110% of Medicare,47.41,,,47.41,Fee Schedule,,23,,,23,Other,186% of Medicaid,55.84,,,55.84,Fee Schedule,,67.58,,,67.58,Fee Schedule,,31.61,,,31.61,Fee Schedule,,55.84,,,55.84,Fee Schedule,,67.58,,,67.58,Fee Schedule,,59.45,,,59.45,Fee Schedule,,76.3,70,,76.3,percent of total billed charges,All Other,71.32,,,71.32,Fee Schedule,,60.45,,,60.45,Fee Schedule,,22.58,,,22.58,Fee Schedule,,22.58,,,22.58,Fee Schedule,,22.58,,,22.58,Fee Schedule,,22.58,,,22.58,Fee Schedule,,12.49,,,12.49,Other,100% of Medicaid,12.49,,,12.49,Other,100% of Medicaid,12.49,,,12.49,Other,100% of Medicaid,12.49,,,12.49,Other,100% of Medicaid,28.11,,,28.11,Other,225% of Medicaid,19.12,,,19.12,Other,153% of Medicaid,28.11,,,28.11,Other,225% of Medicaid,17.49,,,17.49,Other,140% of Medicaid,28.11,,,28.11,Other,225% of Medicaid,32.48,,,32.48,Other,260% of Medicaid,40.48,,,40.48,Other,324% of Medicaid,26.86,,,26.86,Other,215% of Medicaid,26.86,,,26.86,Other,215% of Medicaid,15.62,,,15.62,Other,125% of Medicaid,12.49,111.67,
DRUG TEST DEF 1-7 CLASSES,G0480,HCPCS,,78000013,CDM,301,RC,,,both,,,504,372.96,,,372.96,Other,150% of Medicare + 9.63% HCRA Surcharge,226.8,45,,226.8,percent of total billed charges,Critical Access Hospital RCC factor,344.43,,,344.43,Fee Schedule,,310.11,,,310.11,Fee Schedule,,57.22,,,57.22,Fee Schedule,,57.22,,,57.22,Fee Schedule,,57.22,,,57.22,Fee Schedule,,249.48,,,249.48,Other,110% of Medicare,360.45,,,360.45,Fee Schedule,,28,,,28,Other,186% of Medicaid,424.54,,,424.54,Fee Schedule,,312.48,,,312.48,Fee Schedule,,240.3,,,240.3,Fee Schedule,,424.54,,,424.54,Fee Schedule,,312.48,,,312.48,Fee Schedule,,452,,,452,Fee Schedule,,352.8,70,,352.8,percent of total billed charges,All Other,542.29,,,542.29,Fee Schedule,,459.62,,,459.62,Fee Schedule,,171.65,,,171.65,Fee Schedule,,171.65,,,171.65,Fee Schedule,,171.65,,,171.65,Fee Schedule,,171.65,,,171.65,Fee Schedule,,15.15,,,15.15,Other,100% of Medicaid,15.15,,,15.15,Other,100% of Medicaid,15.15,,,15.15,Other,100% of Medicaid,15.15,,,15.15,Other,100% of Medicaid,34.09,,,34.09,Other,225% of Medicaid,23.18,,,23.18,Other,153% of Medicaid,34.09,,,34.09,Other,225% of Medicaid,21.21,,,21.21,Other,140% of Medicaid,34.09,,,34.09,Other,225% of Medicaid,39.39,,,39.39,Other,260% of Medicaid,49.09,,,49.09,Other,324% of Medicaid,32.57,,,32.57,Other,215% of Medicaid,32.57,,,32.57,Other,215% of Medicaid,18.94,,,18.94,Other,125% of Medicaid,15.15,542.29,
METABOLIC PANEL IONIZED CA,80047,CPT,QW,78080047,CDM,301,RC,,,both,,,39,28.86,,,28.86,Other,150% of Medicare + 9.63% HCRA Surcharge,17.55,45,,17.55,percent of total billed charges,Critical Access Hospital RCC factor,41.33,,,41.33,Fee Schedule,,37.21,,,37.21,Fee Schedule,,47.38,,,47.38,Fee Schedule,,42.61,,,42.61,Fee Schedule,,40.28,,,40.28,Fee Schedule,,19.31,,,19.31,Other,110% of Medicare,43.25,,,43.25,Fee Schedule,,14,,,14,Other,186% of Medicaid,50.94,,,50.94,Fee Schedule,,24.18,,,24.18,Fee Schedule,,28.83,,,28.83,Fee Schedule,,50.94,,,50.94,Fee Schedule,,24.18,,,24.18,Fee Schedule,,54.23,,,54.23,Fee Schedule,,27.3,70,,27.3,percent of total billed charges,All Other,65.07,,,65.07,Fee Schedule,,55.15,,,55.15,Fee Schedule,,20.6,,,20.6,Fee Schedule,,20.6,,,20.6,Fee Schedule,,20.6,,,20.6,Fee Schedule,,20.6,,,20.6,Fee Schedule,,7.32,,,7.32,Other,100% of Medicaid,7.32,,,7.32,Other,100% of Medicaid,7.32,,,7.32,Other,100% of Medicaid,7.32,,,7.32,Other,100% of Medicaid,16.48,,,16.48,Other,225% of Medicaid,11.2,,,11.2,Other,153% of Medicaid,16.48,,,16.48,Other,225% of Medicaid,10.25,,,10.25,Other,140% of Medicaid,16.48,,,16.48,Other,225% of Medicaid,19.04,,,19.04,Other,260% of Medicaid,23.72,,,23.72,Other,324% of Medicaid,15.74,,,15.74,Other,215% of Medicaid,15.74,,,15.74,Other,215% of Medicaid,9.15,,,9.15,Other,125% of Medicaid,7.32,65.07,
METABOLIC PANEL TOTAL CA,80048,CPT,,78080048,CDM,301,RC,,,both,,,210,155.4,,,155.4,Other,150% of Medicare + 9.63% HCRA Surcharge,94.5,45,,94.5,percent of total billed charges,Critical Access Hospital RCC factor,25.46,,,25.46,Fee Schedule,,22.93,,,22.93,Fee Schedule,,47.38,,,47.38,Fee Schedule,,42.61,,,42.61,Fee Schedule,,40.28,,,40.28,Fee Schedule,,103.95,,,103.95,Other,110% of Medicare,26.65,,,26.65,Fee Schedule,,14,,,14,Other,186% of Medicaid,31.39,,,31.39,Fee Schedule,,130.2,,,130.2,Fee Schedule,,17.77,,,17.77,Fee Schedule,,31.39,,,31.39,Fee Schedule,,130.2,,,130.2,Fee Schedule,,33.42,,,33.42,Fee Schedule,,147,70,,147,percent of total billed charges,All Other,40.09,,,40.09,Fee Schedule,,33.98,,,33.98,Fee Schedule,,12.69,,,12.69,Fee Schedule,,12.69,,,12.69,Fee Schedule,,12.69,,,12.69,Fee Schedule,,12.69,,,12.69,Fee Schedule,,7.32,,,7.32,Other,100% of Medicaid,7.32,,,7.32,Other,100% of Medicaid,7.32,,,7.32,Other,100% of Medicaid,7.32,,,7.32,Other,100% of Medicaid,16.48,,,16.48,Other,225% of Medicaid,11.2,,,11.2,Other,153% of Medicaid,16.48,,,16.48,Other,225% of Medicaid,10.25,,,10.25,Other,140% of Medicaid,16.48,,,16.48,Other,225% of Medicaid,19.04,,,19.04,Other,260% of Medicaid,23.72,,,23.72,Other,324% of Medicaid,15.74,,,15.74,Other,215% of Medicaid,15.74,,,15.74,Other,215% of Medicaid,9.15,,,9.15,Other,125% of Medicaid,7.32,155.4,
GENERAL HEALTH PANEL,80050,CPT,,78080050,CDM,301,RC,,,both,,,258,190.92,,,190.92,Other,150% of Medicare + 9.63% HCRA Surcharge,116.1,45,,116.1,percent of total billed charges,Critical Access Hospital RCC factor,167.7,65,,167.7,percent of total billed charges,All Other,152.22,65,,152.22,percent of total billed charges,All Other,15.79,,,15.79,Fee Schedule,,15.79,,,15.79,Fee Schedule,,15.79,,,15.79,Fee Schedule,,127.71,,,127.71,Other,110% of Medicare,175.44,68,,175.44,percent of total billed charges,All Other,45,,,45,Other,186% of Medicaid,214.14,83,,214.14,percent of total billed charges,All Other,159.96,62,,159.96,percent of total billed charges,Lab and Radiology,141.9,55,,141.9,percent of total billed charges,Default if not on Fee Schedule,206.4,80,,206.4,percent of total billed charges,All Other,159.96,62,,159.96,percent of total billed charges,Lab and Radiology,206.4,80,,206.4,percent of total billed charges,All Other,180.6,70,,180.6,percent of total billed charges,All Other,167.28,,,167.28,Fee Schedule,,141.78,,,141.78,Fee Schedule,,70.92,,,70.92,Fee Schedule,,70.92,,,70.92,Fee Schedule,,70.92,,,70.92,Fee Schedule,,70.92,,,70.92,Fee Schedule,,24.4,,,24.4,Other,100% of Medicaid,24.4,,,24.4,Other,100% of Medicaid,24.4,,,24.4,Other,100% of Medicaid,24.4,,,24.4,Other,100% of Medicaid,54.89,,,54.89,Other,225% of Medicaid,37.33,,,37.33,Other,153% of Medicaid,54.89,,,54.89,Other,225% of Medicaid,34.15,,,34.15,Other,140% of Medicaid,54.89,,,54.89,Other,225% of Medicaid,63.43,,,63.43,Other,260% of Medicaid,79.04,,,79.04,Other,324% of Medicaid,52.45,,,52.45,Other,215% of Medicaid,52.45,,,52.45,Other,215% of Medicaid,30.5,,,30.5,Other,125% of Medicaid,15.79,214.14,
ELECTROLYTE PANEL,80051,CPT,,78080051,CDM,301,RC,,,both,,,90,66.6,,,66.6,Other,150% of Medicare + 9.63% HCRA Surcharge,40.5,45,,40.5,percent of total billed charges,Critical Access Hospital RCC factor,21.1,,,21.1,Fee Schedule,,19,,,19,Fee Schedule,,39.58,,,39.58,Fee Schedule,,35.6,,,35.6,Fee Schedule,,33.64,,,33.64,Fee Schedule,,44.55,,,44.55,Other,110% of Medicare,22.08,,,22.08,Fee Schedule,,11,,,11,Other,186% of Medicaid,26.01,,,26.01,Fee Schedule,,55.8,,,55.8,Fee Schedule,,14.72,,,14.72,Fee Schedule,,26.01,,,26.01,Fee Schedule,,55.8,,,55.8,Fee Schedule,,27.69,,,27.69,Fee Schedule,,63,70,,63,percent of total billed charges,All Other,33.22,,,33.22,Fee Schedule,,28.16,,,28.16,Fee Schedule,,10.52,,,10.52,Fee Schedule,,10.52,,,10.52,Fee Schedule,,10.52,,,10.52,Fee Schedule,,10.52,,,10.52,Fee Schedule,,6.1,,,6.1,Other,100% of Medicaid,6.1,,,6.1,Other,100% of Medicaid,6.1,,,6.1,Other,100% of Medicaid,6.1,,,6.1,Other,100% of Medicaid,13.73,,,13.73,Other,225% of Medicaid,9.33,,,9.33,Other,153% of Medicaid,13.73,,,13.73,Other,225% of Medicaid,8.54,,,8.54,Other,140% of Medicaid,13.73,,,13.73,Other,225% of Medicaid,15.86,,,15.86,Other,260% of Medicaid,19.77,,,19.77,Other,324% of Medicaid,13.12,,,13.12,Other,215% of Medicaid,13.12,,,13.12,Other,215% of Medicaid,7.63,,,7.63,Other,125% of Medicaid,6.1,66.6,
COMPREHEN METABOLIC PANEL,80053,CPT,,78080053,CDM,301,RC,,,both,,,245,181.3,,,181.3,Other,150% of Medicare + 9.63% HCRA Surcharge,110.25,45,,110.25,percent of total billed charges,Critical Access Hospital RCC factor,31.79,,,31.79,Fee Schedule,,28.62,,,28.62,Fee Schedule,,70.88,,,70.88,Fee Schedule,,63.75,,,63.75,Fee Schedule,,60.26,,,60.26,Fee Schedule,,121.28,,,121.28,Other,110% of Medicare,33.26,,,33.26,Fee Schedule,,19,,,19,Other,186% of Medicaid,39.18,,,39.18,Fee Schedule,,151.9,,,151.9,Fee Schedule,,22.18,,,22.18,Fee Schedule,,39.18,,,39.18,Fee Schedule,,151.9,,,151.9,Fee Schedule,,41.71,,,41.71,Fee Schedule,,171.5,70,,171.5,percent of total billed charges,All Other,50.04,,,50.04,Fee Schedule,,42.42,,,42.42,Fee Schedule,,15.84,,,15.84,Fee Schedule,,15.84,,,15.84,Fee Schedule,,15.84,,,15.84,Fee Schedule,,15.84,,,15.84,Fee Schedule,,10.1,,,10.1,Other,100% of Medicaid,10.1,,,10.1,Other,100% of Medicaid,10.1,,,10.1,Other,100% of Medicaid,10.1,,,10.1,Other,100% of Medicaid,22.73,,,22.73,Other,225% of Medicaid,15.45,,,15.45,Other,153% of Medicaid,22.73,,,22.73,Other,225% of Medicaid,14.14,,,14.14,Other,140% of Medicaid,22.73,,,22.73,Other,225% of Medicaid,26.26,,,26.26,Other,260% of Medicaid,32.72,,,32.72,Other,324% of Medicaid,21.72,,,21.72,Other,215% of Medicaid,21.72,,,21.72,Other,215% of Medicaid,12.63,,,12.63,Other,125% of Medicaid,10.1,181.3,
LIPID PANEL,80061,CPT,,78080061,CDM,301,RC,,,both,,,227,167.98,,,167.98,Other,150% of Medicare + 9.63% HCRA Surcharge,102.15,45,,102.15,percent of total billed charges,Critical Access Hospital RCC factor,40.3,,,40.3,Fee Schedule,,36.29,,,36.29,Fee Schedule,,99.34,,,99.34,Fee Schedule,,89.35,,,89.35,Fee Schedule,,84.45,,,84.45,Fee Schedule,,112.37,,,112.37,Other,110% of Medicare,42.18,,,42.18,Fee Schedule,,11,,,11,Other,186% of Medicaid,49.68,,,49.68,Fee Schedule,,140.74,,,140.74,Fee Schedule,,28.12,,,28.12,Fee Schedule,,49.68,,,49.68,Fee Schedule,,140.74,,,140.74,Fee Schedule,,52.89,,,52.89,Fee Schedule,,158.9,70,,158.9,percent of total billed charges,All Other,63.46,,,63.46,Fee Schedule,,53.78,,,53.78,Fee Schedule,,20.09,,,20.09,Fee Schedule,,20.09,,,20.09,Fee Schedule,,20.09,,,20.09,Fee Schedule,,20.09,,,20.09,Fee Schedule,,6.1,,,6.1,Other,100% of Medicaid,6.1,,,6.1,Other,100% of Medicaid,6.1,,,6.1,Other,100% of Medicaid,6.1,,,6.1,Other,100% of Medicaid,13.73,,,13.73,Other,225% of Medicaid,9.33,,,9.33,Other,153% of Medicaid,13.73,,,13.73,Other,225% of Medicaid,8.54,,,8.54,Other,140% of Medicaid,13.73,,,13.73,Other,225% of Medicaid,15.86,,,15.86,Other,260% of Medicaid,19.77,,,19.77,Other,324% of Medicaid,13.12,,,13.12,Other,215% of Medicaid,13.12,,,13.12,Other,215% of Medicaid,7.63,,,7.63,Other,125% of Medicaid,6.1,167.98,
RENAL FUNCTION PANEL,80069,CPT,,78080069,CDM,301,RC,,,both,,,90,66.6,,,66.6,Other,150% of Medicare + 9.63% HCRA Surcharge,40.5,45,,40.5,percent of total billed charges,Critical Access Hospital RCC factor,26.13,,,26.13,Fee Schedule,,23.52,,,23.52,Fee Schedule,,59.45,,,59.45,Fee Schedule,,53.47,,,53.47,Fee Schedule,,50.53,,,50.53,Fee Schedule,,44.55,,,44.55,Other,110% of Medicare,27.34,,,27.34,Fee Schedule,,16,,,16,Other,186% of Medicaid,32.2,,,32.2,Fee Schedule,,55.8,,,55.8,Fee Schedule,,18.23,,,18.23,Fee Schedule,,32.2,,,32.2,Fee Schedule,,55.8,,,55.8,Fee Schedule,,34.29,,,34.29,Fee Schedule,,63,70,,63,percent of total billed charges,All Other,41.13,,,41.13,Fee Schedule,,34.86,,,34.86,Fee Schedule,,13.02,,,13.02,Fee Schedule,,13.02,,,13.02,Fee Schedule,,13.02,,,13.02,Fee Schedule,,13.02,,,13.02,Fee Schedule,,8.68,,,8.68,Other,100% of Medicaid,8.68,,,8.68,Other,100% of Medicaid,8.68,,,8.68,Other,100% of Medicaid,8.68,,,8.68,Other,100% of Medicaid,19.53,,,19.53,Other,225% of Medicaid,13.28,,,13.28,Other,153% of Medicaid,19.53,,,19.53,Other,225% of Medicaid,12.15,,,12.15,Other,140% of Medicaid,19.53,,,19.53,Other,225% of Medicaid,22.57,,,22.57,Other,260% of Medicaid,28.12,,,28.12,Other,324% of Medicaid,18.66,,,18.66,Other,215% of Medicaid,18.66,,,18.66,Other,215% of Medicaid,10.85,,,10.85,Other,125% of Medicaid,8.68,66.6,
ACUTE HEPATITIS PANEL,80074,CPT,,78080074,CDM,301,RC,,,both,,,395,292.3,,,292.3,Other,150% of Medicare + 9.63% HCRA Surcharge,177.75,45,,177.75,percent of total billed charges,Critical Access Hospital RCC factor,143.37,,,143.37,Fee Schedule,,129.08,,,129.08,Fee Schedule,,353.14,,,353.14,Fee Schedule,,317.63,,,317.63,Fee Schedule,,300.2,,,300.2,Fee Schedule,,195.53,,,195.53,Other,110% of Medicare,150.03,,,150.03,Fee Schedule,,45,,,45,Other,186% of Medicaid,176.71,,,176.71,Fee Schedule,,244.9,,,244.9,Fee Schedule,,100.02,,,100.02,Fee Schedule,,176.71,,,176.71,Fee Schedule,,244.9,,,244.9,Fee Schedule,,188.14,,,188.14,Fee Schedule,,276.5,70,,276.5,percent of total billed charges,All Other,225.72,,,225.72,Fee Schedule,,191.31,,,191.31,Fee Schedule,,71.45,,,71.45,Fee Schedule,,71.45,,,71.45,Fee Schedule,,71.45,,,71.45,Fee Schedule,,71.45,,,71.45,Fee Schedule,,24.4,,,24.4,Other,100% of Medicaid,24.4,,,24.4,Other,100% of Medicaid,24.4,,,24.4,Other,100% of Medicaid,24.4,,,24.4,Other,100% of Medicaid,54.89,,,54.89,Other,225% of Medicaid,37.33,,,37.33,Other,153% of Medicaid,54.89,,,54.89,Other,225% of Medicaid,34.15,,,34.15,Other,140% of Medicaid,54.89,,,54.89,Other,225% of Medicaid,63.43,,,63.43,Other,260% of Medicaid,79.04,,,79.04,Other,324% of Medicaid,52.45,,,52.45,Other,215% of Medicaid,52.45,,,52.45,Other,215% of Medicaid,30.5,,,30.5,Other,125% of Medicaid,24.4,353.14,
HEPATIC FUNCTION PANEL,80076,CPT,,78080076,CDM,301,RC,,,both,,,224,165.76,,,165.76,Other,150% of Medicare + 9.63% HCRA Surcharge,100.8,45,,100.8,percent of total billed charges,Critical Access Hospital RCC factor,24.59,,,24.59,Fee Schedule,,22.14,,,22.14,Fee Schedule,,47.38,,,47.38,Fee Schedule,,42.61,,,42.61,Fee Schedule,,40.28,,,40.28,Fee Schedule,,110.88,,,110.88,Other,110% of Medicare,25.74,,,25.74,Fee Schedule,,14,,,14,Other,186% of Medicaid,30.31,,,30.31,Fee Schedule,,138.88,,,138.88,Fee Schedule,,17.16,,,17.16,Fee Schedule,,30.31,,,30.31,Fee Schedule,,138.88,,,138.88,Fee Schedule,,32.27,,,32.27,Fee Schedule,,156.8,70,,156.8,percent of total billed charges,All Other,38.72,,,38.72,Fee Schedule,,32.82,,,32.82,Fee Schedule,,12.26,,,12.26,Fee Schedule,,12.26,,,12.26,Fee Schedule,,12.26,,,12.26,Fee Schedule,,12.26,,,12.26,Fee Schedule,,7.32,,,7.32,Other,100% of Medicaid,7.32,,,7.32,Other,100% of Medicaid,7.32,,,7.32,Other,100% of Medicaid,7.32,,,7.32,Other,100% of Medicaid,16.48,,,16.48,Other,225% of Medicaid,11.2,,,11.2,Other,153% of Medicaid,16.48,,,16.48,Other,225% of Medicaid,10.25,,,10.25,Other,140% of Medicaid,16.48,,,16.48,Other,225% of Medicaid,19.04,,,19.04,Other,260% of Medicaid,23.72,,,23.72,Other,324% of Medicaid,15.74,,,15.74,Other,215% of Medicaid,15.74,,,15.74,Other,215% of Medicaid,9.15,,,9.15,Other,125% of Medicaid,7.32,165.76,
DRUG ASSAY ADALIMUMAB,80145,CPT,,78080145,CDM,301,RC,,,both,,,122,90.28,,,90.28,Other,150% of Medicare + 9.63% HCRA Surcharge,54.9,45,,54.9,percent of total billed charges,Critical Access Hospital RCC factor,116.1,,,116.1,Fee Schedule,,104.52,,,104.52,Fee Schedule,,30.86,,,30.86,Fee Schedule,,30.86,,,30.86,Fee Schedule,,30.86,,,30.86,Fee Schedule,,60.39,,,60.39,Other,110% of Medicare,121.5,,,121.5,Fee Schedule,,20,,,20,Other,186% of Medicaid,143.09,,,143.09,Fee Schedule,,75.64,,,75.64,Fee Schedule,,81,,,81,Fee Schedule,,143.09,,,143.09,Fee Schedule,,75.64,,,75.64,Fee Schedule,,152.35,,,152.35,Fee Schedule,,85.4,70,,85.4,percent of total billed charges,All Other,182.78,,,182.78,Fee Schedule,,154.92,,,154.92,Fee Schedule,,57.86,,,57.86,Fee Schedule,,57.86,,,57.86,Fee Schedule,,57.86,,,57.86,Fee Schedule,,57.86,,,57.86,Fee Schedule,,10.61,,,10.61,Other,100% of Medicaid,10.61,,,10.61,Other,100% of Medicaid,10.61,,,10.61,Other,100% of Medicaid,10.61,,,10.61,Other,100% of Medicaid,23.86,,,23.86,Other,225% of Medicaid,16.23,,,16.23,Other,153% of Medicaid,23.86,,,23.86,Other,225% of Medicaid,14.85,,,14.85,Other,140% of Medicaid,23.86,,,23.86,Other,225% of Medicaid,27.57,,,27.57,Other,260% of Medicaid,34.36,,,34.36,Other,324% of Medicaid,22.8,,,22.8,Other,215% of Medicaid,22.8,,,22.8,Other,215% of Medicaid,13.26,,,13.26,Other,125% of Medicaid,10.61,182.78,
DRUG ASSAY CAFFEINE,80155,CPT,,78080155,CDM,301,RC,,,both,,,122,90.28,,,90.28,Other,150% of Medicare + 9.63% HCRA Surcharge,54.9,45,,54.9,percent of total billed charges,Critical Access Hospital RCC factor,116.1,,,116.1,Fee Schedule,,104.52,,,104.52,Fee Schedule,,7.72,,,7.72,Fee Schedule,,7.72,,,7.72,Fee Schedule,,7.72,,,7.72,Fee Schedule,,60.39,,,60.39,Other,110% of Medicare,121.5,,,121.5,Fee Schedule,,30,,,30,Other,186% of Medicaid,143.09,,,143.09,Fee Schedule,,75.64,,,75.64,Fee Schedule,,81,,,81,Fee Schedule,,143.09,,,143.09,Fee Schedule,,75.64,,,75.64,Fee Schedule,,152.35,,,152.35,Fee Schedule,,85.4,70,,85.4,percent of total billed charges,All Other,182.78,,,182.78,Fee Schedule,,154.92,,,154.92,Fee Schedule,,57.86,,,57.86,Fee Schedule,,57.86,,,57.86,Fee Schedule,,57.86,,,57.86,Fee Schedule,,57.86,,,57.86,Fee Schedule,,16.02,,,16.02,Other,100% of Medicaid,16.02,,,16.02,Other,100% of Medicaid,16.02,,,16.02,Other,100% of Medicaid,16.02,,,16.02,Other,100% of Medicaid,36.04,,,36.04,Other,225% of Medicaid,24.51,,,24.51,Other,153% of Medicaid,36.04,,,36.04,Other,225% of Medicaid,22.43,,,22.43,Other,140% of Medicaid,36.04,,,36.04,Other,225% of Medicaid,41.65,,,41.65,Other,260% of Medicaid,51.9,,,51.9,Other,324% of Medicaid,34.44,,,34.44,Other,215% of Medicaid,34.44,,,34.44,Other,215% of Medicaid,20.02,,,20.02,Other,125% of Medicaid,7.72,182.78,
ASSAY CARBAMAZEPINE TOTAL,80156,CPT,,78080156,CDM,301,RC,,,both,,,210,155.4,,,155.4,Other,150% of Medicare + 9.63% HCRA Surcharge,94.5,45,,94.5,percent of total billed charges,Critical Access Hospital RCC factor,43.86,,,43.86,Fee Schedule,,39.48,,,39.48,Fee Schedule,,87.01,,,87.01,Fee Schedule,,78.26,,,78.26,Fee Schedule,,73.96,,,73.96,Fee Schedule,,103.95,,,103.95,Other,110% of Medicare,45.9,,,45.9,Fee Schedule,,20,,,20,Other,186% of Medicaid,54.05,,,54.05,Fee Schedule,,130.2,,,130.2,Fee Schedule,,30.6,,,30.6,Fee Schedule,,54.05,,,54.05,Fee Schedule,,130.2,,,130.2,Fee Schedule,,57.55,,,57.55,Fee Schedule,,147,70,,147,percent of total billed charges,All Other,69.05,,,69.05,Fee Schedule,,58.52,,,58.52,Fee Schedule,,21.86,,,21.86,Fee Schedule,,21.86,,,21.86,Fee Schedule,,21.86,,,21.86,Fee Schedule,,21.86,,,21.86,Fee Schedule,,10.61,,,10.61,Other,100% of Medicaid,10.61,,,10.61,Other,100% of Medicaid,10.61,,,10.61,Other,100% of Medicaid,10.61,,,10.61,Other,100% of Medicaid,23.86,,,23.86,Other,225% of Medicaid,16.23,,,16.23,Other,153% of Medicaid,23.86,,,23.86,Other,225% of Medicaid,14.85,,,14.85,Other,140% of Medicaid,23.86,,,23.86,Other,225% of Medicaid,27.57,,,27.57,Other,260% of Medicaid,34.36,,,34.36,Other,324% of Medicaid,22.8,,,22.8,Other,215% of Medicaid,22.8,,,22.8,Other,215% of Medicaid,13.26,,,13.26,Other,125% of Medicaid,10.61,155.4,
ASSAY CARBAMAZEPINE FREE,80157,CPT,,78080157,CDM,301,RC,,,both,,,42,31.08,,,31.08,Other,150% of Medicare + 9.63% HCRA Surcharge,18.9,45,,18.9,percent of total billed charges,Critical Access Hospital RCC factor,39.88,,,39.88,Fee Schedule,,35.91,,,35.91,Fee Schedule,,98.34,,,98.34,Fee Schedule,,88.45,,,88.45,Fee Schedule,,83.6,,,83.6,Fee Schedule,,20.79,,,20.79,Other,110% of Medicare,41.74,,,41.74,Fee Schedule,,20,,,20,Other,186% of Medicaid,49.16,,,49.16,Fee Schedule,,26.04,,,26.04,Fee Schedule,,27.83,,,27.83,Fee Schedule,,49.16,,,49.16,Fee Schedule,,26.04,,,26.04,Fee Schedule,,52.34,,,52.34,Fee Schedule,,29.4,70,,29.4,percent of total billed charges,All Other,62.79,,,62.79,Fee Schedule,,53.22,,,53.22,Fee Schedule,,19.88,,,19.88,Fee Schedule,,19.88,,,19.88,Fee Schedule,,19.88,,,19.88,Fee Schedule,,19.88,,,19.88,Fee Schedule,,10.61,,,10.61,Other,100% of Medicaid,10.61,,,10.61,Other,100% of Medicaid,10.61,,,10.61,Other,100% of Medicaid,10.61,,,10.61,Other,100% of Medicaid,23.86,,,23.86,Other,225% of Medicaid,16.23,,,16.23,Other,153% of Medicaid,23.86,,,23.86,Other,225% of Medicaid,14.85,,,14.85,Other,140% of Medicaid,23.86,,,23.86,Other,225% of Medicaid,27.57,,,27.57,Other,260% of Medicaid,34.36,,,34.36,Other,324% of Medicaid,22.8,,,22.8,Other,215% of Medicaid,22.8,,,22.8,Other,215% of Medicaid,13.26,,,13.26,Other,125% of Medicaid,10.61,98.34,
ASSAY OF CYCLOSPORINE,80158,CPT,,78080158,CDM,301,RC,,,both,,,275,203.5,,,203.5,Other,150% of Medicare + 9.63% HCRA Surcharge,123.75,45,,123.75,percent of total billed charges,Critical Access Hospital RCC factor,54.33,,,54.33,Fee Schedule,,48.92,,,48.92,Fee Schedule,,133.86,,,133.86,Fee Schedule,,120.4,,,120.4,Fee Schedule,,113.79,,,113.79,Fee Schedule,,136.13,,,136.13,Other,110% of Medicare,56.86,,,56.86,Fee Schedule,,20,,,20,Other,186% of Medicaid,66.97,,,66.97,Fee Schedule,,170.5,,,170.5,Fee Schedule,,37.91,,,37.91,Fee Schedule,,66.97,,,66.97,Fee Schedule,,170.5,,,170.5,Fee Schedule,,71.3,,,71.3,Fee Schedule,,192.5,70,,192.5,percent of total billed charges,All Other,85.54,,,85.54,Fee Schedule,,72.5,,,72.5,Fee Schedule,,27.08,,,27.08,Fee Schedule,,27.08,,,27.08,Fee Schedule,,27.08,,,27.08,Fee Schedule,,27.08,,,27.08,Fee Schedule,,10.61,,,10.61,Other,100% of Medicaid,10.61,,,10.61,Other,100% of Medicaid,10.61,,,10.61,Other,100% of Medicaid,10.61,,,10.61,Other,100% of Medicaid,23.86,,,23.86,Other,225% of Medicaid,16.23,,,16.23,Other,153% of Medicaid,23.86,,,23.86,Other,225% of Medicaid,14.85,,,14.85,Other,140% of Medicaid,23.86,,,23.86,Other,225% of Medicaid,27.57,,,27.57,Other,260% of Medicaid,34.36,,,34.36,Other,324% of Medicaid,22.8,,,22.8,Other,215% of Medicaid,22.8,,,22.8,Other,215% of Medicaid,13.26,,,13.26,Other,125% of Medicaid,10.61,203.5,
DRUG SCREEN QUANT CLOZAPINE,80159,CPT,,78080159,CDM,301,RC,,,both,,,100,74,,,74,Other,150% of Medicare + 9.63% HCRA Surcharge,45,45,,45,percent of total billed charges,Critical Access Hospital RCC factor,60.65,,,60.65,Fee Schedule,,54.61,,,54.61,Fee Schedule,,10.09,,,10.09,Fee Schedule,,10.09,,,10.09,Fee Schedule,,10.09,,,10.09,Fee Schedule,,49.5,,,49.5,Other,110% of Medicare,63.47,,,63.47,Fee Schedule,,20,,,20,Other,186% of Medicaid,74.76,,,74.76,Fee Schedule,,62,,,62,Fee Schedule,,42.32,,,42.32,Fee Schedule,,74.76,,,74.76,Fee Schedule,,62,,,62,Fee Schedule,,79.59,,,79.59,Fee Schedule,,70,70,,70,percent of total billed charges,All Other,95.49,,,95.49,Fee Schedule,,80.93,,,80.93,Fee Schedule,,30.23,,,30.23,Fee Schedule,,30.23,,,30.23,Fee Schedule,,30.23,,,30.23,Fee Schedule,,30.23,,,30.23,Fee Schedule,,10.61,,,10.61,Other,100% of Medicaid,10.61,,,10.61,Other,100% of Medicaid,10.61,,,10.61,Other,100% of Medicaid,10.61,,,10.61,Other,100% of Medicaid,23.86,,,23.86,Other,225% of Medicaid,16.23,,,16.23,Other,153% of Medicaid,23.86,,,23.86,Other,225% of Medicaid,14.85,,,14.85,Other,140% of Medicaid,23.86,,,23.86,Other,225% of Medicaid,27.57,,,27.57,Other,260% of Medicaid,34.36,,,34.36,Other,324% of Medicaid,22.8,,,22.8,Other,215% of Medicaid,22.8,,,22.8,Other,215% of Medicaid,13.26,,,13.26,Other,125% of Medicaid,10.09,95.49,
ASSAY DIPROPYLACETIC ACID,80164,CPT,,78080164,CDM,301,RC,,,both,,,182,134.68,,,134.68,Other,150% of Medicare + 9.63% HCRA Surcharge,81.9,45,,81.9,percent of total billed charges,Critical Access Hospital RCC factor,40.76,,,40.76,Fee Schedule,,36.69,,,36.69,Fee Schedule,,100.45,,,100.45,Fee Schedule,,90.34,,,90.34,Fee Schedule,,85.39,,,85.39,Fee Schedule,,90.09,,,90.09,Other,110% of Medicare,42.65,,,42.65,Fee Schedule,,20,,,20,Other,186% of Medicaid,50.23,,,50.23,Fee Schedule,,112.84,,,112.84,Fee Schedule,,28.43,,,28.43,Fee Schedule,,50.23,,,50.23,Fee Schedule,,112.84,,,112.84,Fee Schedule,,53.48,,,53.48,Fee Schedule,,127.4,70,,127.4,percent of total billed charges,All Other,64.17,,,64.17,Fee Schedule,,54.39,,,54.39,Fee Schedule,,20.31,,,20.31,Fee Schedule,,20.31,,,20.31,Fee Schedule,,20.31,,,20.31,Fee Schedule,,20.31,,,20.31,Fee Schedule,,10.61,,,10.61,Other,100% of Medicaid,10.61,,,10.61,Other,100% of Medicaid,10.61,,,10.61,Other,100% of Medicaid,10.61,,,10.61,Other,100% of Medicaid,23.86,,,23.86,Other,225% of Medicaid,16.23,,,16.23,Other,153% of Medicaid,23.86,,,23.86,Other,225% of Medicaid,14.85,,,14.85,Other,140% of Medicaid,23.86,,,23.86,Other,225% of Medicaid,27.57,,,27.57,Other,260% of Medicaid,34.36,,,34.36,Other,324% of Medicaid,22.8,,,22.8,Other,215% of Medicaid,22.8,,,22.8,Other,215% of Medicaid,13.26,,,13.26,Other,125% of Medicaid,10.61,134.68,
ASSAY OF ETHOSUXIMIDE,80168,CPT,,78080168,CDM,301,RC,,,both,,,160,118.4,,,118.4,Other,150% of Medicare + 9.63% HCRA Surcharge,72,45,,72,percent of total billed charges,Critical Access Hospital RCC factor,49.18,,,49.18,Fee Schedule,,44.28,,,44.28,Fee Schedule,,121.21,,,121.21,Fee Schedule,,109.02,,,109.02,Fee Schedule,,103.04,,,103.04,Fee Schedule,,79.2,,,79.2,Other,110% of Medicare,51.47,,,51.47,Fee Schedule,,20,,,20,Other,186% of Medicaid,60.62,,,60.62,Fee Schedule,,99.2,,,99.2,Fee Schedule,,34.31,,,34.31,Fee Schedule,,60.62,,,60.62,Fee Schedule,,99.2,,,99.2,Fee Schedule,,64.54,,,64.54,Fee Schedule,,112,70,,112,percent of total billed charges,All Other,77.44,,,77.44,Fee Schedule,,65.63,,,65.63,Fee Schedule,,24.51,,,24.51,Fee Schedule,,24.51,,,24.51,Fee Schedule,,24.51,,,24.51,Fee Schedule,,24.51,,,24.51,Fee Schedule,,10.61,,,10.61,Other,100% of Medicaid,10.61,,,10.61,Other,100% of Medicaid,10.61,,,10.61,Other,100% of Medicaid,10.61,,,10.61,Other,100% of Medicaid,23.86,,,23.86,Other,225% of Medicaid,16.23,,,16.23,Other,153% of Medicaid,23.86,,,23.86,Other,225% of Medicaid,14.85,,,14.85,Other,140% of Medicaid,23.86,,,23.86,Other,225% of Medicaid,27.57,,,27.57,Other,260% of Medicaid,34.36,,,34.36,Other,324% of Medicaid,22.8,,,22.8,Other,215% of Medicaid,22.8,,,22.8,Other,215% of Medicaid,13.26,,,13.26,Other,125% of Medicaid,10.61,121.21,
ASSAY OF GENTAMICIN,80170,CPT,,78080170,CDM,301,RC,,,both,,,233,172.42,,,172.42,Other,150% of Medicare + 9.63% HCRA Surcharge,104.85,45,,104.85,percent of total billed charges,Critical Access Hospital RCC factor,49.3,,,49.3,Fee Schedule,,44.39,,,44.39,Fee Schedule,,121.58,,,121.58,Fee Schedule,,109.35,,,109.35,Fee Schedule,,103.35,,,103.35,Fee Schedule,,115.34,,,115.34,Other,110% of Medicare,51.6,,,51.6,Fee Schedule,,20,,,20,Other,186% of Medicaid,60.77,,,60.77,Fee Schedule,,144.46,,,144.46,Fee Schedule,,34.4,,,34.4,Fee Schedule,,60.77,,,60.77,Fee Schedule,,144.46,,,144.46,Fee Schedule,,64.7,,,64.7,Fee Schedule,,163.1,70,,163.1,percent of total billed charges,All Other,77.63,,,77.63,Fee Schedule,,65.79,,,65.79,Fee Schedule,,24.57,,,24.57,Fee Schedule,,24.57,,,24.57,Fee Schedule,,24.57,,,24.57,Fee Schedule,,24.57,,,24.57,Fee Schedule,,10.61,,,10.61,Other,100% of Medicaid,10.61,,,10.61,Other,100% of Medicaid,10.61,,,10.61,Other,100% of Medicaid,10.61,,,10.61,Other,100% of Medicaid,23.86,,,23.86,Other,225% of Medicaid,16.23,,,16.23,Other,153% of Medicaid,23.86,,,23.86,Other,225% of Medicaid,14.85,,,14.85,Other,140% of Medicaid,23.86,,,23.86,Other,225% of Medicaid,27.57,,,27.57,Other,260% of Medicaid,34.36,,,34.36,Other,324% of Medicaid,22.8,,,22.8,Other,215% of Medicaid,22.8,,,22.8,Other,215% of Medicaid,13.26,,,13.26,Other,125% of Medicaid,10.61,172.42,
ASSAY OF HALOPERIDOL,80173,CPT,,78080173,CDM,301,RC,,,both,,,209,154.66,,,154.66,Other,150% of Medicare + 9.63% HCRA Surcharge,94.05,45,,94.05,percent of total billed charges,Critical Access Hospital RCC factor,47.5,,,47.5,Fee Schedule,,42.76,,,42.76,Fee Schedule,,87.01,,,87.01,Fee Schedule,,78.26,,,78.26,Fee Schedule,,73.96,,,73.96,Fee Schedule,,103.46,,,103.46,Other,110% of Medicare,49.71,,,49.71,Fee Schedule,,20,,,20,Other,186% of Medicaid,58.54,,,58.54,Fee Schedule,,129.58,,,129.58,Fee Schedule,,33.14,,,33.14,Fee Schedule,,58.54,,,58.54,Fee Schedule,,129.58,,,129.58,Fee Schedule,,62.33,,,62.33,Fee Schedule,,146.3,70,,146.3,percent of total billed charges,All Other,74.78,,,74.78,Fee Schedule,,63.38,,,63.38,Fee Schedule,,23.67,,,23.67,Fee Schedule,,23.67,,,23.67,Fee Schedule,,23.67,,,23.67,Fee Schedule,,23.67,,,23.67,Fee Schedule,,10.61,,,10.61,Other,100% of Medicaid,10.61,,,10.61,Other,100% of Medicaid,10.61,,,10.61,Other,100% of Medicaid,10.61,,,10.61,Other,100% of Medicaid,23.86,,,23.86,Other,225% of Medicaid,16.23,,,16.23,Other,153% of Medicaid,23.86,,,23.86,Other,225% of Medicaid,14.85,,,14.85,Other,140% of Medicaid,23.86,,,23.86,Other,225% of Medicaid,27.57,,,27.57,Other,260% of Medicaid,34.36,,,34.36,Other,324% of Medicaid,22.8,,,22.8,Other,215% of Medicaid,22.8,,,22.8,Other,215% of Medicaid,13.26,,,13.26,Other,125% of Medicaid,10.61,154.66,
DRUG SCREEN QUAN LAMOTRIGINE,80175,CPT,,78080175,CDM,301,RC,,,both,,,31,22.94,,,22.94,Other,150% of Medicare + 9.63% HCRA Surcharge,13.95,45,,13.95,percent of total billed charges,Critical Access Hospital RCC factor,39.88,,,39.88,Fee Schedule,,35.91,,,35.91,Fee Schedule,,7.24,,,7.24,Fee Schedule,,7.24,,,7.24,Fee Schedule,,7.24,,,7.24,Fee Schedule,,15.35,,,15.35,Other,110% of Medicare,41.74,,,41.74,Fee Schedule,,20,,,20,Other,186% of Medicaid,49.16,,,49.16,Fee Schedule,,19.22,,,19.22,Fee Schedule,,27.83,,,27.83,Fee Schedule,,49.16,,,49.16,Fee Schedule,,19.22,,,19.22,Fee Schedule,,52.34,,,52.34,Fee Schedule,,21.7,70,,21.7,percent of total billed charges,All Other,62.79,,,62.79,Fee Schedule,,53.22,,,53.22,Fee Schedule,,19.88,,,19.88,Fee Schedule,,19.88,,,19.88,Fee Schedule,,19.88,,,19.88,Fee Schedule,,19.88,,,19.88,Fee Schedule,,10.61,,,10.61,Other,100% of Medicaid,10.61,,,10.61,Other,100% of Medicaid,10.61,,,10.61,Other,100% of Medicaid,10.61,,,10.61,Other,100% of Medicaid,23.86,,,23.86,Other,225% of Medicaid,16.23,,,16.23,Other,153% of Medicaid,23.86,,,23.86,Other,225% of Medicaid,14.85,,,14.85,Other,140% of Medicaid,23.86,,,23.86,Other,225% of Medicaid,27.57,,,27.57,Other,260% of Medicaid,34.36,,,34.36,Other,324% of Medicaid,22.8,,,22.8,Other,215% of Medicaid,22.8,,,22.8,Other,215% of Medicaid,13.26,,,13.26,Other,125% of Medicaid,7.24,62.79,
ASSAY OF LIDOCAINE,80176,CPT,,78080176,CDM,301,RC,,,both,,,180,133.2,,,133.2,Other,150% of Medicare + 9.63% HCRA Surcharge,81,45,,81,percent of total billed charges,Critical Access Hospital RCC factor,44.22,,,44.22,Fee Schedule,,39.81,,,39.81,Fee Schedule,,108.93,,,108.93,Fee Schedule,,97.98,,,97.98,Fee Schedule,,92.6,,,92.6,Fee Schedule,,89.1,,,89.1,Other,110% of Medicare,46.27,,,46.27,Fee Schedule,,30,,,30,Other,186% of Medicaid,54.5,,,54.5,Fee Schedule,,111.6,,,111.6,Fee Schedule,,30.85,,,30.85,Fee Schedule,,54.5,,,54.5,Fee Schedule,,111.6,,,111.6,Fee Schedule,,58.03,,,58.03,Fee Schedule,,126,70,,126,percent of total billed charges,All Other,69.62,,,69.62,Fee Schedule,,59,,,59,Fee Schedule,,22.04,,,22.04,Fee Schedule,,22.04,,,22.04,Fee Schedule,,22.04,,,22.04,Fee Schedule,,22.04,,,22.04,Fee Schedule,,16.02,,,16.02,Other,100% of Medicaid,16.02,,,16.02,Other,100% of Medicaid,16.02,,,16.02,Other,100% of Medicaid,16.02,,,16.02,Other,100% of Medicaid,36.04,,,36.04,Other,225% of Medicaid,24.51,,,24.51,Other,153% of Medicaid,36.04,,,36.04,Other,225% of Medicaid,22.43,,,22.43,Other,140% of Medicaid,36.04,,,36.04,Other,225% of Medicaid,41.65,,,41.65,Other,260% of Medicaid,51.9,,,51.9,Other,324% of Medicaid,34.44,,,34.44,Other,215% of Medicaid,34.44,,,34.44,Other,215% of Medicaid,20.02,,,20.02,Other,125% of Medicaid,16.02,133.2,
DRUG SCRN QUAN LEVETIRACETAM,80177,CPT,,78080177,CDM,301,RC,,,both,,,180,133.2,,,133.2,Other,150% of Medicare + 9.63% HCRA Surcharge,81,45,,81,percent of total billed charges,Critical Access Hospital RCC factor,39.88,,,39.88,Fee Schedule,,35.91,,,35.91,Fee Schedule,,7.24,,,7.24,Fee Schedule,,7.24,,,7.24,Fee Schedule,,7.24,,,7.24,Fee Schedule,,89.1,,,89.1,Other,110% of Medicare,41.74,,,41.74,Fee Schedule,,20,,,20,Other,186% of Medicaid,49.16,,,49.16,Fee Schedule,,111.6,,,111.6,Fee Schedule,,27.83,,,27.83,Fee Schedule,,49.16,,,49.16,Fee Schedule,,111.6,,,111.6,Fee Schedule,,52.34,,,52.34,Fee Schedule,,126,70,,126,percent of total billed charges,All Other,62.79,,,62.79,Fee Schedule,,53.22,,,53.22,Fee Schedule,,19.88,,,19.88,Fee Schedule,,19.88,,,19.88,Fee Schedule,,19.88,,,19.88,Fee Schedule,,19.88,,,19.88,Fee Schedule,,10.61,,,10.61,Other,100% of Medicaid,10.61,,,10.61,Other,100% of Medicaid,10.61,,,10.61,Other,100% of Medicaid,10.61,,,10.61,Other,100% of Medicaid,23.86,,,23.86,Other,225% of Medicaid,16.23,,,16.23,Other,153% of Medicaid,23.86,,,23.86,Other,225% of Medicaid,14.85,,,14.85,Other,140% of Medicaid,23.86,,,23.86,Other,225% of Medicaid,27.57,,,27.57,Other,260% of Medicaid,34.36,,,34.36,Other,324% of Medicaid,22.8,,,22.8,Other,215% of Medicaid,22.8,,,22.8,Other,215% of Medicaid,13.26,,,13.26,Other,125% of Medicaid,7.24,133.2,
ASSAY OF LITHIUM,80178,CPT,,78080178,CDM,301,RC,,,both,,,93,68.82,,,68.82,Other,150% of Medicare + 9.63% HCRA Surcharge,41.85,45,,41.85,percent of total billed charges,Critical Access Hospital RCC factor,19.9,,,19.9,Fee Schedule,,17.91,,,17.91,Fee Schedule,,49.01,,,49.01,Fee Schedule,,44.08,,,44.08,Fee Schedule,,41.66,,,41.66,Fee Schedule,,46.04,,,46.04,Other,110% of Medicare,20.82,,,20.82,Fee Schedule,,12,,,12,Other,186% of Medicaid,24.52,,,24.52,Fee Schedule,,57.66,,,57.66,Fee Schedule,,13.88,,,13.88,Fee Schedule,,24.52,,,24.52,Fee Schedule,,57.66,,,57.66,Fee Schedule,,26.11,,,26.11,Fee Schedule,,65.1,70,,65.1,percent of total billed charges,All Other,31.33,,,31.33,Fee Schedule,,26.55,,,26.55,Fee Schedule,,9.92,,,9.92,Fee Schedule,,9.92,,,9.92,Fee Schedule,,9.92,,,9.92,Fee Schedule,,9.92,,,9.92,Fee Schedule,,6.61,,,6.61,Other,100% of Medicaid,6.61,,,6.61,Other,100% of Medicaid,6.61,,,6.61,Other,100% of Medicaid,6.61,,,6.61,Other,100% of Medicaid,14.87,,,14.87,Other,225% of Medicaid,10.11,,,10.11,Other,153% of Medicaid,14.87,,,14.87,Other,225% of Medicaid,9.25,,,9.25,Other,140% of Medicaid,14.87,,,14.87,Other,225% of Medicaid,17.19,,,17.19,Other,260% of Medicaid,21.42,,,21.42,Other,324% of Medicaid,14.21,,,14.21,Other,215% of Medicaid,14.21,,,14.21,Other,215% of Medicaid,8.26,,,8.26,Other,125% of Medicaid,6.61,68.82,
DRUG SCRN QUAN MYCOPHENOLATE,80180,CPT,,78080180,CDM,301,RC,,,both,,,58,42.92,,,42.92,Other,150% of Medicare + 9.63% HCRA Surcharge,26.1,45,,26.1,percent of total billed charges,Critical Access Hospital RCC factor,54.33,,,54.33,Fee Schedule,,48.92,,,48.92,Fee Schedule,,9.85,,,9.85,Fee Schedule,,9.85,,,9.85,Fee Schedule,,9.85,,,9.85,Fee Schedule,,28.71,,,28.71,Other,110% of Medicare,56.86,,,56.86,Fee Schedule,,20,,,20,Other,186% of Medicaid,66.97,,,66.97,Fee Schedule,,35.96,,,35.96,Fee Schedule,,37.91,,,37.91,Fee Schedule,,66.97,,,66.97,Fee Schedule,,35.96,,,35.96,Fee Schedule,,71.3,,,71.3,Fee Schedule,,40.6,70,,40.6,percent of total billed charges,All Other,85.54,,,85.54,Fee Schedule,,72.5,,,72.5,Fee Schedule,,27.08,,,27.08,Fee Schedule,,27.08,,,27.08,Fee Schedule,,27.08,,,27.08,Fee Schedule,,27.08,,,27.08,Fee Schedule,,10.61,,,10.61,Other,100% of Medicaid,10.61,,,10.61,Other,100% of Medicaid,10.61,,,10.61,Other,100% of Medicaid,10.61,,,10.61,Other,100% of Medicaid,23.86,,,23.86,Other,225% of Medicaid,16.23,,,16.23,Other,153% of Medicaid,23.86,,,23.86,Other,225% of Medicaid,14.85,,,14.85,Other,140% of Medicaid,23.86,,,23.86,Other,225% of Medicaid,27.57,,,27.57,Other,260% of Medicaid,34.36,,,34.36,Other,324% of Medicaid,22.8,,,22.8,Other,215% of Medicaid,22.8,,,22.8,Other,215% of Medicaid,13.26,,,13.26,Other,125% of Medicaid,9.85,85.54,
DRUG SCRN QUANT OXCARBAZEPIN,80183,CPT,,78080183,CDM,301,RC,,,both,,,42,31.08,,,31.08,Other,150% of Medicare + 9.63% HCRA Surcharge,18.9,45,,18.9,percent of total billed charges,Critical Access Hospital RCC factor,39.88,,,39.88,Fee Schedule,,35.91,,,35.91,Fee Schedule,,7.24,,,7.24,Fee Schedule,,7.24,,,7.24,Fee Schedule,,7.24,,,7.24,Fee Schedule,,20.79,,,20.79,Other,110% of Medicare,41.74,,,41.74,Fee Schedule,,20,,,20,Other,186% of Medicaid,49.16,,,49.16,Fee Schedule,,26.04,,,26.04,Fee Schedule,,27.83,,,27.83,Fee Schedule,,49.16,,,49.16,Fee Schedule,,26.04,,,26.04,Fee Schedule,,52.34,,,52.34,Fee Schedule,,29.4,70,,29.4,percent of total billed charges,All Other,62.79,,,62.79,Fee Schedule,,53.22,,,53.22,Fee Schedule,,19.88,,,19.88,Fee Schedule,,19.88,,,19.88,Fee Schedule,,19.88,,,19.88,Fee Schedule,,19.88,,,19.88,Fee Schedule,,10.61,,,10.61,Other,100% of Medicaid,10.61,,,10.61,Other,100% of Medicaid,10.61,,,10.61,Other,100% of Medicaid,10.61,,,10.61,Other,100% of Medicaid,23.86,,,23.86,Other,225% of Medicaid,16.23,,,16.23,Other,153% of Medicaid,23.86,,,23.86,Other,225% of Medicaid,14.85,,,14.85,Other,140% of Medicaid,23.86,,,23.86,Other,225% of Medicaid,27.57,,,27.57,Other,260% of Medicaid,34.36,,,34.36,Other,324% of Medicaid,22.8,,,22.8,Other,215% of Medicaid,22.8,,,22.8,Other,215% of Medicaid,13.26,,,13.26,Other,125% of Medicaid,7.24,62.79,
ASSAY OF PHENOBARBITAL,80184,CPT,,78080184,CDM,301,RC,,,both,,,174,128.76,,,128.76,Other,150% of Medicare + 9.63% HCRA Surcharge,78.3,45,,78.3,percent of total billed charges,Critical Access Hospital RCC factor,46.05,,,46.05,Fee Schedule,,41.46,,,41.46,Fee Schedule,,84.95,,,84.95,Fee Schedule,,76.41,,,76.41,Fee Schedule,,72.22,,,72.22,Fee Schedule,,86.13,,,86.13,Other,110% of Medicare,48.2,,,48.2,Fee Schedule,,20,,,20,Other,186% of Medicaid,56.76,,,56.76,Fee Schedule,,107.88,,,107.88,Fee Schedule,,32.13,,,32.13,Fee Schedule,,56.76,,,56.76,Fee Schedule,,107.88,,,107.88,Fee Schedule,,60.44,,,60.44,Fee Schedule,,121.8,70,,121.8,percent of total billed charges,All Other,72.51,,,72.51,Fee Schedule,,61.45,,,61.45,Fee Schedule,,22.95,,,22.95,Fee Schedule,,22.95,,,22.95,Fee Schedule,,22.95,,,22.95,Fee Schedule,,22.95,,,22.95,Fee Schedule,,10.61,,,10.61,Other,100% of Medicaid,10.61,,,10.61,Other,100% of Medicaid,10.61,,,10.61,Other,100% of Medicaid,10.61,,,10.61,Other,100% of Medicaid,23.86,,,23.86,Other,225% of Medicaid,16.23,,,16.23,Other,153% of Medicaid,23.86,,,23.86,Other,225% of Medicaid,14.85,,,14.85,Other,140% of Medicaid,23.86,,,23.86,Other,225% of Medicaid,27.57,,,27.57,Other,260% of Medicaid,34.36,,,34.36,Other,324% of Medicaid,22.8,,,22.8,Other,215% of Medicaid,22.8,,,22.8,Other,215% of Medicaid,13.26,,,13.26,Other,125% of Medicaid,10.61,128.76,
ASSAY OF PHENYTOIN FREE,80186,CPT,,78080186,CDM,301,RC,,,both,,,147,108.78,,,108.78,Other,150% of Medicare + 9.63% HCRA Surcharge,66.15,45,,66.15,percent of total billed charges,Critical Access Hospital RCC factor,41.42,,,41.42,Fee Schedule,,37.29,,,37.29,Fee Schedule,,87.01,,,87.01,Fee Schedule,,78.26,,,78.26,Fee Schedule,,73.96,,,73.96,Fee Schedule,,72.77,,,72.77,Other,110% of Medicare,43.34,,,43.34,Fee Schedule,,20,,,20,Other,186% of Medicaid,51.05,,,51.05,Fee Schedule,,91.14,,,91.14,Fee Schedule,,28.9,,,28.9,Fee Schedule,,51.05,,,51.05,Fee Schedule,,91.14,,,91.14,Fee Schedule,,54.35,,,54.35,Fee Schedule,,102.9,70,,102.9,percent of total billed charges,All Other,65.21,,,65.21,Fee Schedule,,55.27,,,55.27,Fee Schedule,,20.64,,,20.64,Fee Schedule,,20.64,,,20.64,Fee Schedule,,20.64,,,20.64,Fee Schedule,,20.64,,,20.64,Fee Schedule,,10.61,,,10.61,Other,100% of Medicaid,10.61,,,10.61,Other,100% of Medicaid,10.61,,,10.61,Other,100% of Medicaid,10.61,,,10.61,Other,100% of Medicaid,23.86,,,23.86,Other,225% of Medicaid,16.23,,,16.23,Other,153% of Medicaid,23.86,,,23.86,Other,225% of Medicaid,14.85,,,14.85,Other,140% of Medicaid,23.86,,,23.86,Other,225% of Medicaid,27.57,,,27.57,Other,260% of Medicaid,34.36,,,34.36,Other,324% of Medicaid,22.8,,,22.8,Other,215% of Medicaid,22.8,,,22.8,Other,215% of Medicaid,13.26,,,13.26,Other,125% of Medicaid,10.61,108.78,
ASSAY OF PRIMIDONE,80188,CPT,,78080188,CDM,301,RC,,,both,,,223,165.02,,,165.02,Other,150% of Medicare + 9.63% HCRA Surcharge,100.35,45,,100.35,percent of total billed charges,Critical Access Hospital RCC factor,49.94,,,49.94,Fee Schedule,,44.96,,,44.96,Fee Schedule,,123.05,,,123.05,Fee Schedule,,110.68,,,110.68,Fee Schedule,,104.61,,,104.61,Fee Schedule,,110.39,,,110.39,Other,110% of Medicare,52.26,,,52.26,Fee Schedule,,20,,,20,Other,186% of Medicaid,61.55,,,61.55,Fee Schedule,,138.26,,,138.26,Fee Schedule,,34.84,,,34.84,Fee Schedule,,61.55,,,61.55,Fee Schedule,,138.26,,,138.26,Fee Schedule,,65.53,,,65.53,Fee Schedule,,156.1,70,,156.1,percent of total billed charges,All Other,78.62,,,78.62,Fee Schedule,,66.64,,,66.64,Fee Schedule,,24.89,,,24.89,Fee Schedule,,24.89,,,24.89,Fee Schedule,,24.89,,,24.89,Fee Schedule,,24.89,,,24.89,Fee Schedule,,10.61,,,10.61,Other,100% of Medicaid,10.61,,,10.61,Other,100% of Medicaid,10.61,,,10.61,Other,100% of Medicaid,10.61,,,10.61,Other,100% of Medicaid,23.86,,,23.86,Other,225% of Medicaid,16.23,,,16.23,Other,153% of Medicaid,23.86,,,23.86,Other,225% of Medicaid,14.85,,,14.85,Other,140% of Medicaid,23.86,,,23.86,Other,225% of Medicaid,27.57,,,27.57,Other,260% of Medicaid,34.36,,,34.36,Other,324% of Medicaid,22.8,,,22.8,Other,215% of Medicaid,22.8,,,22.8,Other,215% of Medicaid,13.26,,,13.26,Other,125% of Medicaid,10.61,165.02,
ASSAY OF PROCAINAMIDE,80190,CPT,,78080190,CDM,301,RC,,,both,,,194,143.56,,,143.56,Other,150% of Medicare + 9.63% HCRA Surcharge,87.3,45,,87.3,percent of total billed charges,Critical Access Hospital RCC factor,180.6,,,180.6,Fee Schedule,,162.6,,,162.6,Fee Schedule,,124.21,,,124.21,Fee Schedule,,111.72,,,111.72,Fee Schedule,,105.59,,,105.59,Fee Schedule,,96.03,,,96.03,Other,110% of Medicare,189,,,189,Fee Schedule,,30,,,30,Other,186% of Medicaid,222.6,,,222.6,Fee Schedule,,120.28,,,120.28,Fee Schedule,,126,,,126,Fee Schedule,,222.6,,,222.6,Fee Schedule,,120.28,,,120.28,Fee Schedule,,237,,,237,Fee Schedule,,135.8,70,,135.8,percent of total billed charges,All Other,284.34,,,284.34,Fee Schedule,,241,,,241,Fee Schedule,,90,,,90,Fee Schedule,,90,,,90,Fee Schedule,,90,,,90,Fee Schedule,,90,,,90,Fee Schedule,,16.02,,,16.02,Other,100% of Medicaid,16.02,,,16.02,Other,100% of Medicaid,16.02,,,16.02,Other,100% of Medicaid,16.02,,,16.02,Other,100% of Medicaid,36.04,,,36.04,Other,225% of Medicaid,24.51,,,24.51,Other,153% of Medicaid,36.04,,,36.04,Other,225% of Medicaid,22.43,,,22.43,Other,140% of Medicaid,36.04,,,36.04,Other,225% of Medicaid,41.65,,,41.65,Other,260% of Medicaid,51.9,,,51.9,Other,324% of Medicaid,34.44,,,34.44,Other,215% of Medicaid,34.44,,,34.44,Other,215% of Medicaid,20.02,,,20.02,Other,125% of Medicaid,16.02,284.34,
ASSAY OF PROCAINAMIDE,80192,CPT,,78080192,CDM,301,RC,,,both,,,194,143.56,,,143.56,Other,150% of Medicare + 9.63% HCRA Surcharge,87.3,45,,87.3,percent of total billed charges,Critical Access Hospital RCC factor,50.42,,,50.42,Fee Schedule,,45.39,,,45.39,Fee Schedule,,124.21,,,124.21,Fee Schedule,,111.72,,,111.72,Fee Schedule,,105.59,,,105.59,Fee Schedule,,96.03,,,96.03,Other,110% of Medicare,52.76,,,52.76,Fee Schedule,,30,,,30,Other,186% of Medicaid,62.14,,,62.14,Fee Schedule,,120.28,,,120.28,Fee Schedule,,35.18,,,35.18,Fee Schedule,,62.14,,,62.14,Fee Schedule,,120.28,,,120.28,Fee Schedule,,66.16,,,66.16,Fee Schedule,,135.8,70,,135.8,percent of total billed charges,All Other,79.38,,,79.38,Fee Schedule,,67.28,,,67.28,Fee Schedule,,25.13,,,25.13,Fee Schedule,,25.13,,,25.13,Fee Schedule,,25.13,,,25.13,Fee Schedule,,25.13,,,25.13,Fee Schedule,,16.02,,,16.02,Other,100% of Medicaid,16.02,,,16.02,Other,100% of Medicaid,16.02,,,16.02,Other,100% of Medicaid,16.02,,,16.02,Other,100% of Medicaid,36.04,,,36.04,Other,225% of Medicaid,24.51,,,24.51,Other,153% of Medicaid,36.04,,,36.04,Other,225% of Medicaid,22.43,,,22.43,Other,140% of Medicaid,36.04,,,36.04,Other,225% of Medicaid,41.65,,,41.65,Other,260% of Medicaid,51.9,,,51.9,Other,324% of Medicaid,34.44,,,34.44,Other,215% of Medicaid,34.44,,,34.44,Other,215% of Medicaid,20.02,,,20.02,Other,125% of Medicaid,16.02,143.56,
ASSAY OF QUINIDINE,80194,CPT,,78080194,CDM,301,RC,,,both,,,174,128.76,,,128.76,Other,150% of Medicare + 9.63% HCRA Surcharge,78.3,45,,78.3,percent of total billed charges,Critical Access Hospital RCC factor,43.95,,,43.95,Fee Schedule,,39.57,,,39.57,Fee Schedule,,108.25,,,108.25,Fee Schedule,,97.36,,,97.36,Fee Schedule,,92.02,,,92.02,Fee Schedule,,86.13,,,86.13,Other,110% of Medicare,45.99,,,45.99,Fee Schedule,,20,,,20,Other,186% of Medicaid,54.17,,,54.17,Fee Schedule,,107.88,,,107.88,Fee Schedule,,30.66,,,30.66,Fee Schedule,,54.17,,,54.17,Fee Schedule,,107.88,,,107.88,Fee Schedule,,57.67,,,57.67,Fee Schedule,,121.8,70,,121.8,percent of total billed charges,All Other,69.19,,,69.19,Fee Schedule,,58.64,,,58.64,Fee Schedule,,21.9,,,21.9,Fee Schedule,,21.9,,,21.9,Fee Schedule,,21.9,,,21.9,Fee Schedule,,21.9,,,21.9,Fee Schedule,,10.61,,,10.61,Other,100% of Medicaid,10.61,,,10.61,Other,100% of Medicaid,10.61,,,10.61,Other,100% of Medicaid,10.61,,,10.61,Other,100% of Medicaid,23.86,,,23.86,Other,225% of Medicaid,16.23,,,16.23,Other,153% of Medicaid,23.86,,,23.86,Other,225% of Medicaid,14.85,,,14.85,Other,140% of Medicaid,23.86,,,23.86,Other,225% of Medicaid,27.57,,,27.57,Other,260% of Medicaid,34.36,,,34.36,Other,324% of Medicaid,22.8,,,22.8,Other,215% of Medicaid,22.8,,,22.8,Other,215% of Medicaid,13.26,,,13.26,Other,125% of Medicaid,10.61,128.76,
ASSAY OF SIROLIMUS,80195,CPT,,78080195,CDM,301,RC,,,both,,,82,60.68,,,60.68,Other,150% of Medicare + 9.63% HCRA Surcharge,36.9,45,,36.9,percent of total billed charges,Critical Access Hospital RCC factor,41.33,,,41.33,Fee Schedule,,37.21,,,37.21,Fee Schedule,,101.82,,,101.82,Fee Schedule,,91.58,,,91.58,Fee Schedule,,86.55,,,86.55,Fee Schedule,,40.59,,,40.59,Other,110% of Medicare,43.25,,,43.25,Fee Schedule,,20,,,20,Other,186% of Medicaid,50.94,,,50.94,Fee Schedule,,50.84,,,50.84,Fee Schedule,,28.83,,,28.83,Fee Schedule,,50.94,,,50.94,Fee Schedule,,50.84,,,50.84,Fee Schedule,,54.23,,,54.23,Fee Schedule,,57.4,70,,57.4,percent of total billed charges,All Other,65.07,,,65.07,Fee Schedule,,55.15,,,55.15,Fee Schedule,,20.6,,,20.6,Fee Schedule,,20.6,,,20.6,Fee Schedule,,20.6,,,20.6,Fee Schedule,,20.6,,,20.6,Fee Schedule,,10.61,,,10.61,Other,100% of Medicaid,10.61,,,10.61,Other,100% of Medicaid,10.61,,,10.61,Other,100% of Medicaid,10.61,,,10.61,Other,100% of Medicaid,23.86,,,23.86,Other,225% of Medicaid,16.23,,,16.23,Other,153% of Medicaid,23.86,,,23.86,Other,225% of Medicaid,14.85,,,14.85,Other,140% of Medicaid,23.86,,,23.86,Other,225% of Medicaid,27.57,,,27.57,Other,260% of Medicaid,34.36,,,34.36,Other,324% of Medicaid,22.8,,,22.8,Other,215% of Medicaid,22.8,,,22.8,Other,215% of Medicaid,13.26,,,13.26,Other,125% of Medicaid,10.61,101.82,
ASSAY OF THEOPHYLLINE,80198,CPT,,78080198,CDM,301,RC,,,both,,,170,125.8,,,125.8,Other,150% of Medicare + 9.63% HCRA Surcharge,76.5,45,,76.5,percent of total billed charges,Critical Access Hospital RCC factor,42.56,,,42.56,Fee Schedule,,38.32,,,38.32,Fee Schedule,,104.93,,,104.93,Fee Schedule,,94.37,,,94.37,Fee Schedule,,89.2,,,89.2,Fee Schedule,,84.15,,,84.15,Other,110% of Medicare,44.54,,,44.54,Fee Schedule,,15,,,15,Other,186% of Medicaid,52.46,,,52.46,Fee Schedule,,105.4,,,105.4,Fee Schedule,,29.69,,,29.69,Fee Schedule,,52.46,,,52.46,Fee Schedule,,105.4,,,105.4,Fee Schedule,,55.85,,,55.85,Fee Schedule,,119,70,,119,percent of total billed charges,All Other,67.01,,,67.01,Fee Schedule,,56.8,,,56.8,Fee Schedule,,21.21,,,21.21,Fee Schedule,,21.21,,,21.21,Fee Schedule,,21.21,,,21.21,Fee Schedule,,21.21,,,21.21,Fee Schedule,,8.08,,,8.08,Other,100% of Medicaid,8.08,,,8.08,Other,100% of Medicaid,8.08,,,8.08,Other,100% of Medicaid,8.08,,,8.08,Other,100% of Medicaid,18.18,,,18.18,Other,225% of Medicaid,12.36,,,12.36,Other,153% of Medicaid,18.18,,,18.18,Other,225% of Medicaid,11.31,,,11.31,Other,140% of Medicaid,18.18,,,18.18,Other,225% of Medicaid,21.01,,,21.01,Other,260% of Medicaid,26.18,,,26.18,Other,324% of Medicaid,17.37,,,17.37,Other,215% of Medicaid,17.37,,,17.37,Other,215% of Medicaid,10.1,,,10.1,Other,125% of Medicaid,8.08,125.8,
ASSAY OF TOBRAMYCIN,80200,CPT,,78080200,CDM,301,RC,,,both,,,242,179.08,,,179.08,Other,150% of Medicare + 9.63% HCRA Surcharge,108.9,45,,108.9,percent of total billed charges,Critical Access Hospital RCC factor,48.55,,,48.55,Fee Schedule,,43.71,,,43.71,Fee Schedule,,119.52,,,119.52,Fee Schedule,,107.5,,,107.5,Fee Schedule,,101.61,,,101.61,Fee Schedule,,119.79,,,119.79,Other,110% of Medicare,50.81,,,50.81,Fee Schedule,,20,,,20,Other,186% of Medicaid,59.84,,,59.84,Fee Schedule,,150.04,,,150.04,Fee Schedule,,33.87,,,33.87,Fee Schedule,,59.84,,,59.84,Fee Schedule,,150.04,,,150.04,Fee Schedule,,63.71,,,63.71,Fee Schedule,,169.4,70,,169.4,percent of total billed charges,All Other,76.44,,,76.44,Fee Schedule,,64.79,,,64.79,Fee Schedule,,24.2,,,24.2,Fee Schedule,,24.2,,,24.2,Fee Schedule,,24.2,,,24.2,Fee Schedule,,24.2,,,24.2,Fee Schedule,,10.61,,,10.61,Other,100% of Medicaid,10.61,,,10.61,Other,100% of Medicaid,10.61,,,10.61,Other,100% of Medicaid,10.61,,,10.61,Other,100% of Medicaid,23.86,,,23.86,Other,225% of Medicaid,16.23,,,16.23,Other,153% of Medicaid,23.86,,,23.86,Other,225% of Medicaid,14.85,,,14.85,Other,140% of Medicaid,23.86,,,23.86,Other,225% of Medicaid,27.57,,,27.57,Other,260% of Medicaid,34.36,,,34.36,Other,324% of Medicaid,22.8,,,22.8,Other,215% of Medicaid,22.8,,,22.8,Other,215% of Medicaid,13.26,,,13.26,Other,125% of Medicaid,10.61,179.08,
ASSAY OF TOPIRAMATE,80201,CPT,,78080201,CDM,301,RC,,,both,,,112,82.88,,,82.88,Other,150% of Medicare + 9.63% HCRA Surcharge,50.4,45,,50.4,percent of total billed charges,Critical Access Hospital RCC factor,35.88,,,35.88,Fee Schedule,,32.3,,,32.3,Fee Schedule,,88.43,,,88.43,Fee Schedule,,79.54,,,79.54,Fee Schedule,,75.17,,,75.17,Fee Schedule,,55.44,,,55.44,Other,110% of Medicare,37.55,,,37.55,Fee Schedule,,30,,,30,Other,186% of Medicaid,44.22,,,44.22,Fee Schedule,,69.44,,,69.44,Fee Schedule,,25.03,,,25.03,Fee Schedule,,44.22,,,44.22,Fee Schedule,,69.44,,,69.44,Fee Schedule,,47.08,,,47.08,Fee Schedule,,78.4,70,,78.4,percent of total billed charges,All Other,56.49,,,56.49,Fee Schedule,,47.88,,,47.88,Fee Schedule,,17.88,,,17.88,Fee Schedule,,17.88,,,17.88,Fee Schedule,,17.88,,,17.88,Fee Schedule,,17.88,,,17.88,Fee Schedule,,16.02,,,16.02,Other,100% of Medicaid,16.02,,,16.02,Other,100% of Medicaid,16.02,,,16.02,Other,100% of Medicaid,16.02,,,16.02,Other,100% of Medicaid,36.04,,,36.04,Other,225% of Medicaid,24.51,,,24.51,Other,153% of Medicaid,36.04,,,36.04,Other,225% of Medicaid,22.43,,,22.43,Other,140% of Medicaid,36.04,,,36.04,Other,225% of Medicaid,41.65,,,41.65,Other,260% of Medicaid,51.9,,,51.9,Other,324% of Medicaid,34.44,,,34.44,Other,215% of Medicaid,34.44,,,34.44,Other,215% of Medicaid,20.02,,,20.02,Other,125% of Medicaid,16.02,88.43,
ASSAY OF VANCOMYCIN,80202,CPT,,78080202,CDM,301,RC,,,both,,,187,138.38,,,138.38,Other,150% of Medicare + 9.63% HCRA Surcharge,84.15,45,,84.15,percent of total billed charges,Critical Access Hospital RCC factor,40.76,,,40.76,Fee Schedule,,36.69,,,36.69,Fee Schedule,,100.45,,,100.45,Fee Schedule,,90.34,,,90.34,Fee Schedule,,85.39,,,85.39,Fee Schedule,,92.57,,,92.57,Other,110% of Medicare,42.65,,,42.65,Fee Schedule,,20,,,20,Other,186% of Medicaid,50.23,,,50.23,Fee Schedule,,115.94,,,115.94,Fee Schedule,,28.43,,,28.43,Fee Schedule,,50.23,,,50.23,Fee Schedule,,115.94,,,115.94,Fee Schedule,,53.48,,,53.48,Fee Schedule,,130.9,70,,130.9,percent of total billed charges,All Other,64.17,,,64.17,Fee Schedule,,54.39,,,54.39,Fee Schedule,,20.31,,,20.31,Fee Schedule,,20.31,,,20.31,Fee Schedule,,20.31,,,20.31,Fee Schedule,,20.31,,,20.31,Fee Schedule,,10.61,,,10.61,Other,100% of Medicaid,10.61,,,10.61,Other,100% of Medicaid,10.61,,,10.61,Other,100% of Medicaid,10.61,,,10.61,Other,100% of Medicaid,23.86,,,23.86,Other,225% of Medicaid,16.23,,,16.23,Other,153% of Medicaid,23.86,,,23.86,Other,225% of Medicaid,14.85,,,14.85,Other,140% of Medicaid,23.86,,,23.86,Other,225% of Medicaid,27.57,,,27.57,Other,260% of Medicaid,34.36,,,34.36,Other,324% of Medicaid,22.8,,,22.8,Other,215% of Medicaid,22.8,,,22.8,Other,215% of Medicaid,13.26,,,13.26,Other,125% of Medicaid,10.61,138.38,
DRUG SCREEN QUANT ZONISAMIDE,80203,CPT,,78080203,CDM,301,RC,,,both,,,70,51.8,,,51.8,Other,150% of Medicare + 9.63% HCRA Surcharge,31.5,45,,31.5,percent of total billed charges,Critical Access Hospital RCC factor,39.88,,,39.88,Fee Schedule,,35.91,,,35.91,Fee Schedule,,7.24,,,7.24,Fee Schedule,,7.24,,,7.24,Fee Schedule,,7.24,,,7.24,Fee Schedule,,34.65,,,34.65,Other,110% of Medicare,41.74,,,41.74,Fee Schedule,,20,,,20,Other,186% of Medicaid,49.16,,,49.16,Fee Schedule,,43.4,,,43.4,Fee Schedule,,27.83,,,27.83,Fee Schedule,,49.16,,,49.16,Fee Schedule,,43.4,,,43.4,Fee Schedule,,52.34,,,52.34,Fee Schedule,,49,70,,49,percent of total billed charges,All Other,62.79,,,62.79,Fee Schedule,,53.22,,,53.22,Fee Schedule,,19.88,,,19.88,Fee Schedule,,19.88,,,19.88,Fee Schedule,,19.88,,,19.88,Fee Schedule,,19.88,,,19.88,Fee Schedule,,10.61,,,10.61,Other,100% of Medicaid,10.61,,,10.61,Other,100% of Medicaid,10.61,,,10.61,Other,100% of Medicaid,10.61,,,10.61,Other,100% of Medicaid,23.86,,,23.86,Other,225% of Medicaid,16.23,,,16.23,Other,153% of Medicaid,23.86,,,23.86,Other,225% of Medicaid,14.85,,,14.85,Other,140% of Medicaid,23.86,,,23.86,Other,225% of Medicaid,27.57,,,27.57,Other,260% of Medicaid,34.36,,,34.36,Other,324% of Medicaid,22.8,,,22.8,Other,215% of Medicaid,22.8,,,22.8,Other,215% of Medicaid,13.26,,,13.26,Other,125% of Medicaid,7.24,62.79,
DRUG ASY HYDROXYCHLOROQUINE,80220,CPT,,78080220,CDM,301,RC,,,both,,,59,43.66,,,43.66,Other,150% of Medicare + 9.63% HCRA Surcharge,26.55,45,,26.55,percent of total billed charges,Critical Access Hospital RCC factor,56.11,,,56.11,Fee Schedule,,50.51,,,50.51,Fee Schedule,,18.64,,,18.64,Fee Schedule,,18.64,,,18.64,Fee Schedule,,18.64,,,18.64,Fee Schedule,,29.21,,,29.21,Other,110% of Medicare,58.72,,,58.72,Fee Schedule,,20,,,20,Other,186% of Medicaid,69.15,,,69.15,Fee Schedule,,36.58,,,36.58,Fee Schedule,,39.14,,,39.14,Fee Schedule,,69.15,,,69.15,Fee Schedule,,36.58,,,36.58,Fee Schedule,,73.63,,,73.63,Fee Schedule,,41.3,70,,41.3,percent of total billed charges,All Other,88.34,,,88.34,Fee Schedule,,74.87,,,74.87,Fee Schedule,,27.96,,,27.96,Fee Schedule,,27.96,,,27.96,Fee Schedule,,27.96,,,27.96,Fee Schedule,,27.96,,,27.96,Fee Schedule,,10.61,,,10.61,Other,100% of Medicaid,10.61,,,10.61,Other,100% of Medicaid,10.61,,,10.61,Other,100% of Medicaid,10.61,,,10.61,Other,100% of Medicaid,23.86,,,23.86,Other,225% of Medicaid,16.23,,,16.23,Other,153% of Medicaid,23.86,,,23.86,Other,225% of Medicaid,14.85,,,14.85,Other,140% of Medicaid,23.86,,,23.86,Other,225% of Medicaid,27.57,,,27.57,Other,260% of Medicaid,34.36,,,34.36,Other,324% of Medicaid,22.8,,,22.8,Other,215% of Medicaid,22.8,,,22.8,Other,215% of Medicaid,13.26,,,13.26,Other,125% of Medicaid,10.61,88.34,
DRUG ASSAY INFLIXIMAB,80230,CPT,,78080230,CDM,301,RC,,,both,,,122,90.28,,,90.28,Other,150% of Medicare + 9.63% HCRA Surcharge,54.9,45,,54.9,percent of total billed charges,Critical Access Hospital RCC factor,116.1,,,116.1,Fee Schedule,,104.52,,,104.52,Fee Schedule,,7.39,,,7.39,Fee Schedule,,7.39,,,7.39,Fee Schedule,,7.39,,,7.39,Fee Schedule,,60.39,,,60.39,Other,110% of Medicare,121.5,,,121.5,Fee Schedule,,20,,,20,Other,186% of Medicaid,143.09,,,143.09,Fee Schedule,,75.64,,,75.64,Fee Schedule,,81,,,81,Fee Schedule,,143.09,,,143.09,Fee Schedule,,75.64,,,75.64,Fee Schedule,,152.35,,,152.35,Fee Schedule,,85.4,70,,85.4,percent of total billed charges,All Other,182.78,,,182.78,Fee Schedule,,154.92,,,154.92,Fee Schedule,,57.86,,,57.86,Fee Schedule,,57.86,,,57.86,Fee Schedule,,57.86,,,57.86,Fee Schedule,,57.86,,,57.86,Fee Schedule,,10.61,,,10.61,Other,100% of Medicaid,10.61,,,10.61,Other,100% of Medicaid,10.61,,,10.61,Other,100% of Medicaid,10.61,,,10.61,Other,100% of Medicaid,23.86,,,23.86,Other,225% of Medicaid,16.23,,,16.23,Other,153% of Medicaid,23.86,,,23.86,Other,225% of Medicaid,14.85,,,14.85,Other,140% of Medicaid,23.86,,,23.86,Other,225% of Medicaid,27.57,,,27.57,Other,260% of Medicaid,34.36,,,34.36,Other,324% of Medicaid,22.8,,,22.8,Other,215% of Medicaid,22.8,,,22.8,Other,215% of Medicaid,13.26,,,13.26,Other,125% of Medicaid,7.39,182.78,
DRUG ASSAY LACOSAMIDE,80235,CPT,,78080235,CDM,301,RC,,,both,,,87,64.38,,,64.38,Other,150% of Medicare + 9.63% HCRA Surcharge,39.15,45,,39.15,percent of total billed charges,Critical Access Hospital RCC factor,81.6,,,81.6,Fee Schedule,,73.47,,,73.47,Fee Schedule,,21.69,,,21.69,Fee Schedule,,21.69,,,21.69,Fee Schedule,,21.69,,,21.69,Fee Schedule,,43.07,,,43.07,Other,110% of Medicare,85.4,,,85.4,Fee Schedule,,20,,,20,Other,186% of Medicaid,100.58,,,100.58,Fee Schedule,,53.94,,,53.94,Fee Schedule,,56.93,,,56.93,Fee Schedule,,100.58,,,100.58,Fee Schedule,,53.94,,,53.94,Fee Schedule,,107.08,,,107.08,Fee Schedule,,60.9,70,,60.9,percent of total billed charges,All Other,128.48,,,128.48,Fee Schedule,,108.89,,,108.89,Fee Schedule,,40.67,,,40.67,Fee Schedule,,40.67,,,40.67,Fee Schedule,,40.67,,,40.67,Fee Schedule,,40.67,,,40.67,Fee Schedule,,10.61,,,10.61,Other,100% of Medicaid,10.61,,,10.61,Other,100% of Medicaid,10.61,,,10.61,Other,100% of Medicaid,10.61,,,10.61,Other,100% of Medicaid,23.86,,,23.86,Other,225% of Medicaid,16.23,,,16.23,Other,153% of Medicaid,23.86,,,23.86,Other,225% of Medicaid,14.85,,,14.85,Other,140% of Medicaid,23.86,,,23.86,Other,225% of Medicaid,27.57,,,27.57,Other,260% of Medicaid,34.36,,,34.36,Other,324% of Medicaid,22.8,,,22.8,Other,215% of Medicaid,22.8,,,22.8,Other,215% of Medicaid,13.26,,,13.26,Other,125% of Medicaid,10.61,128.48,
QUANTITATIVE ASSAY DRUG,80299,CPT,,78080299,CDM,301,RC,,,both,,,343,253.82,,,253.82,Other,150% of Medicare + 9.63% HCRA Surcharge,154.35,45,,154.35,percent of total billed charges,Critical Access Hospital RCC factor,56.11,,,56.11,Fee Schedule,,50.51,,,50.51,Fee Schedule,,101.55,,,101.55,Fee Schedule,,91.34,,,91.34,Fee Schedule,,86.33,,,86.33,Fee Schedule,,169.79,,,169.79,Other,110% of Medicare,58.72,,,58.72,Fee Schedule,,0.01,,,0.01,Other,186% of Medicaid,69.15,,,69.15,Fee Schedule,,212.66,,,212.66,Fee Schedule,,39.14,,,39.14,Fee Schedule,,69.15,,,69.15,Fee Schedule,,212.66,,,212.66,Fee Schedule,,73.63,,,73.63,Fee Schedule,,240.1,70,,240.1,percent of total billed charges,All Other,88.34,,,88.34,Fee Schedule,,74.87,,,74.87,Fee Schedule,,27.96,,,27.96,Fee Schedule,,27.96,,,27.96,Fee Schedule,,27.96,,,27.96,Fee Schedule,,27.96,,,27.96,Fee Schedule,,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,253.82,
DRUG TEST PRSMV DIR OPT OBS,80305,CPT,,78080305,CDM,301,RC,,,both,,,346,256.04,,,256.04,Other,150% of Medicare + 9.63% HCRA Surcharge,155.7,45,,155.7,percent of total billed charges,Critical Access Hospital RCC factor,37.93,,,37.93,Fee Schedule,,34.15,,,34.15,Fee Schedule,,5.98,,,5.98,Fee Schedule,,5.98,,,5.98,Fee Schedule,,5.98,,,5.98,Fee Schedule,,171.27,,,171.27,Other,110% of Medicare,39.69,,,39.69,Fee Schedule,,9,,,9,Other,186% of Medicaid,46.75,,,46.75,Fee Schedule,,214.52,,,214.52,Fee Schedule,,26.46,,,26.46,Fee Schedule,,46.75,,,46.75,Fee Schedule,,214.52,,,214.52,Fee Schedule,,49.77,,,49.77,Fee Schedule,,242.2,70,,242.2,percent of total billed charges,All Other,59.71,,,59.71,Fee Schedule,,50.61,,,50.61,Fee Schedule,,18.9,,,18.9,Fee Schedule,,18.9,,,18.9,Fee Schedule,,18.9,,,18.9,Fee Schedule,,18.9,,,18.9,Fee Schedule,,5.05,,,5.05,Other,100% of Medicaid,5.05,,,5.05,Other,100% of Medicaid,5.05,,,5.05,Other,100% of Medicaid,5.05,,,5.05,Other,100% of Medicaid,11.36,,,11.36,Other,225% of Medicaid,7.73,,,7.73,Other,153% of Medicaid,11.36,,,11.36,Other,225% of Medicaid,7.07,,,7.07,Other,140% of Medicaid,11.36,,,11.36,Other,225% of Medicaid,13.13,,,13.13,Other,260% of Medicaid,16.36,,,16.36,Other,324% of Medicaid,10.86,,,10.86,Other,215% of Medicaid,10.86,,,10.86,Other,215% of Medicaid,6.31,,,6.31,Other,125% of Medicaid,5.05,256.04,
DRUG TEST PRSMV INSTRMNT,80306,CPT,,78080306,CDM,301,RC,,,both,,,377,278.98,,,278.98,Other,150% of Medicare + 9.63% HCRA Surcharge,169.65,45,,169.65,percent of total billed charges,Critical Access Hospital RCC factor,51.59,,,51.59,Fee Schedule,,46.45,,,46.45,Fee Schedule,,7.98,,,7.98,Fee Schedule,,7.98,,,7.98,Fee Schedule,,7.98,,,7.98,Fee Schedule,,186.62,,,186.62,Other,110% of Medicare,53.99,,,53.99,Fee Schedule,,9,,,9,Other,186% of Medicaid,63.59,,,63.59,Fee Schedule,,233.74,,,233.74,Fee Schedule,,35.99,,,35.99,Fee Schedule,,63.59,,,63.59,Fee Schedule,,233.74,,,233.74,Fee Schedule,,67.7,,,67.7,Fee Schedule,,263.9,70,,263.9,percent of total billed charges,All Other,81.23,,,81.23,Fee Schedule,,68.84,,,68.84,Fee Schedule,,25.71,,,25.71,Fee Schedule,,25.71,,,25.71,Fee Schedule,,25.71,,,25.71,Fee Schedule,,25.71,,,25.71,Fee Schedule,,5.05,,,5.05,Other,100% of Medicaid,5.05,,,5.05,Other,100% of Medicaid,5.05,,,5.05,Other,100% of Medicaid,5.05,,,5.05,Other,100% of Medicaid,11.36,,,11.36,Other,225% of Medicaid,7.73,,,7.73,Other,153% of Medicaid,11.36,,,11.36,Other,225% of Medicaid,7.07,,,7.07,Other,140% of Medicaid,11.36,,,11.36,Other,225% of Medicaid,13.13,,,13.13,Other,260% of Medicaid,16.36,,,16.36,Other,324% of Medicaid,10.86,,,10.86,Other,215% of Medicaid,10.86,,,10.86,Other,215% of Medicaid,6.31,,,6.31,Other,125% of Medicaid,5.05,278.98,
DRUG TEST PRSMV CHEM ANLYZR,80307,CPT,,78080307,CDM,301,RC,,,both,,,405,299.7,,,299.7,Other,150% of Medicare + 9.63% HCRA Surcharge,182.25,45,,182.25,percent of total billed charges,Critical Access Hospital RCC factor,187.04,,,187.04,Fee Schedule,,168.4,,,168.4,Fee Schedule,,31.92,,,31.92,Fee Schedule,,31.92,,,31.92,Fee Schedule,,31.92,,,31.92,Fee Schedule,,200.48,,,200.48,Other,110% of Medicare,195.74,,,195.74,Fee Schedule,,14,,,14,Other,186% of Medicaid,230.54,,,230.54,Fee Schedule,,251.1,,,251.1,Fee Schedule,,130.49,,,130.49,Fee Schedule,,230.54,,,230.54,Fee Schedule,,251.1,,,251.1,Fee Schedule,,245.45,,,245.45,Fee Schedule,,283.5,70,,283.5,percent of total billed charges,All Other,294.48,,,294.48,Fee Schedule,,249.59,,,249.59,Fee Schedule,,93.21,,,93.21,Fee Schedule,,93.21,,,93.21,Fee Schedule,,93.21,,,93.21,Fee Schedule,,93.21,,,93.21,Fee Schedule,,7.58,,,7.58,Other,100% of Medicaid,7.58,,,7.58,Other,100% of Medicaid,7.58,,,7.58,Other,100% of Medicaid,7.58,,,7.58,Other,100% of Medicaid,17.04,,,17.04,Other,225% of Medicaid,11.59,,,11.59,Other,153% of Medicaid,17.04,,,17.04,Other,225% of Medicaid,10.61,,,10.61,Other,140% of Medicaid,17.04,,,17.04,Other,225% of Medicaid,19.7,,,19.7,Other,260% of Medicaid,24.54,,,24.54,Other,324% of Medicaid,16.29,,,16.29,Other,215% of Medicaid,16.29,,,16.29,Other,215% of Medicaid,9.47,,,9.47,Other,125% of Medicaid,7.58,299.7,
DRUG SCREEN QUANTALCOHOLS,80320,CPT,,78080320,CDM,301,RC,,,both,,,100,74,,,74,Other,150% of Medicare + 9.63% HCRA Surcharge,45,45,,45,percent of total billed charges,Critical Access Hospital RCC factor,65,65,,65,percent of total billed charges,All Other,59,65,,59,percent of total billed charges,All Other,6.12,,,6.12,Fee Schedule,,6.12,,,6.12,Fee Schedule,,6.12,,,6.12,Fee Schedule,,49.5,,,49.5,Other,110% of Medicare,68,68,,68,percent of total billed charges,All Other,9,,,9,Other,186% of Medicaid,83,83,,83,percent of total billed charges,All Other,62,62,,62,percent of total billed charges,Lab and Radiology,55,55,,55,percent of total billed charges,Default if not on Fee Schedule,80,80,,80,percent of total billed charges,All Other,62,62,,62,percent of total billed charges,Lab and Radiology,80,80,,80,percent of total billed charges,All Other,70,70,,70,percent of total billed charges,All Other,65,65,,65,percent of total billed charges,Default if not in Fee Schedule,65,65,,65,percent of total billed charges,Default if not in Fee Schedule,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,5.05,,,5.05,Other,100% of Medicaid,5.05,,,5.05,Other,100% of Medicaid,5.05,,,5.05,Other,100% of Medicaid,5.05,,,5.05,Other,100% of Medicaid,11.36,,,11.36,Other,225% of Medicaid,7.73,,,7.73,Other,153% of Medicaid,11.36,,,11.36,Other,225% of Medicaid,7.07,,,7.07,Other,140% of Medicaid,11.36,,,11.36,Other,225% of Medicaid,13.13,,,13.13,Other,260% of Medicaid,16.36,,,16.36,Other,324% of Medicaid,10.86,,,10.86,Other,215% of Medicaid,10.86,,,10.86,Other,215% of Medicaid,6.31,,,6.31,Other,125% of Medicaid,0.01,83,
ALCOHOLS BIOMARKERS 1OR 2,80321,CPT,,78080321,CDM,301,RC,,,both,,,92,68.08,,,68.08,Other,150% of Medicare + 9.63% HCRA Surcharge,41.4,45,,41.4,percent of total billed charges,Critical Access Hospital RCC factor,59.8,65,,59.8,percent of total billed charges,All Other,54.28,65,,54.28,percent of total billed charges,All Other,6.12,,,6.12,Fee Schedule,,6.12,,,6.12,Fee Schedule,,6.12,,,6.12,Fee Schedule,,45.54,,,45.54,Other,110% of Medicare,62.56,68,,62.56,percent of total billed charges,All Other,0.01,,,0.01,Other,186% of Medicaid,76.36,83,,76.36,percent of total billed charges,All Other,57.04,62,,57.04,percent of total billed charges,Lab and Radiology,50.6,55,,50.6,percent of total billed charges,Default if not on Fee Schedule,73.6,80,,73.6,percent of total billed charges,All Other,57.04,62,,57.04,percent of total billed charges,Lab and Radiology,73.6,80,,73.6,percent of total billed charges,All Other,64.4,70,,64.4,percent of total billed charges,All Other,59.8,65,,59.8,percent of total billed charges,Default if not in Fee Schedule,59.8,65,,59.8,percent of total billed charges,Default if not in Fee Schedule,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,76.36,
ALCOHOLS BIOMARKERS 3/MORE,80322,CPT,,78080322,CDM,301,RC,,,both,,,107,79.18,,,79.18,Other,150% of Medicare + 9.63% HCRA Surcharge,48.15,45,,48.15,percent of total billed charges,Critical Access Hospital RCC factor,69.55,65,,69.55,percent of total billed charges,All Other,63.13,65,,63.13,percent of total billed charges,All Other,6.73,,,6.73,Fee Schedule,,6.73,,,6.73,Fee Schedule,,6.73,,,6.73,Fee Schedule,,52.97,,,52.97,Other,110% of Medicare,72.76,68,,72.76,percent of total billed charges,All Other,0.01,,,0.01,Other,186% of Medicaid,88.81,83,,88.81,percent of total billed charges,All Other,66.34,62,,66.34,percent of total billed charges,Lab and Radiology,58.85,55,,58.85,percent of total billed charges,Default if not on Fee Schedule,85.6,80,,85.6,percent of total billed charges,All Other,66.34,62,,66.34,percent of total billed charges,Lab and Radiology,85.6,80,,85.6,percent of total billed charges,All Other,74.9,70,,74.9,percent of total billed charges,All Other,69.55,65,,69.55,percent of total billed charges,Default if not in Fee Schedule,69.55,65,,69.55,percent of total billed charges,Default if not in Fee Schedule,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,88.81,
ALKALOIDS NOS,80323,CPT,,78080323,CDM,301,RC,,,both,,,100,74,,,74,Other,150% of Medicare + 9.63% HCRA Surcharge,45,45,,45,percent of total billed charges,Critical Access Hospital RCC factor,65,65,,65,percent of total billed charges,All Other,59,65,,59,percent of total billed charges,All Other,17,,,17,Fee Schedule,,17,,,17,Fee Schedule,,17,,,17,Fee Schedule,,49.5,,,49.5,Other,110% of Medicare,68,68,,68,percent of total billed charges,All Other,9,,,9,Other,186% of Medicaid,83,83,,83,percent of total billed charges,All Other,62,62,,62,percent of total billed charges,Lab and Radiology,55,55,,55,percent of total billed charges,Default if not on Fee Schedule,80,80,,80,percent of total billed charges,All Other,62,62,,62,percent of total billed charges,Lab and Radiology,80,80,,80,percent of total billed charges,All Other,70,70,,70,percent of total billed charges,All Other,65,65,,65,percent of total billed charges,Default if not in Fee Schedule,65,65,,65,percent of total billed charges,Default if not in Fee Schedule,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,5.05,,,5.05,Other,100% of Medicaid,5.05,,,5.05,Other,100% of Medicaid,5.05,,,5.05,Other,100% of Medicaid,5.05,,,5.05,Other,100% of Medicaid,11.36,,,11.36,Other,225% of Medicaid,7.73,,,7.73,Other,153% of Medicaid,11.36,,,11.36,Other,225% of Medicaid,7.07,,,7.07,Other,140% of Medicaid,11.36,,,11.36,Other,225% of Medicaid,13.13,,,13.13,Other,260% of Medicaid,16.36,,,16.36,Other,324% of Medicaid,10.86,,,10.86,Other,215% of Medicaid,10.86,,,10.86,Other,215% of Medicaid,6.31,,,6.31,Other,125% of Medicaid,0.01,83,
DRUG SCREEN AMPHETAMINES 1/2,80324,CPT,,78080324,CDM,301,RC,,,both,,,100,74,,,74,Other,150% of Medicare + 9.63% HCRA Surcharge,45,45,,45,percent of total billed charges,Critical Access Hospital RCC factor,65,65,,65,percent of total billed charges,All Other,59,65,,59,percent of total billed charges,All Other,8.81,,,8.81,Fee Schedule,,8.81,,,8.81,Fee Schedule,,8.81,,,8.81,Fee Schedule,,49.5,,,49.5,Other,110% of Medicare,68,68,,68,percent of total billed charges,All Other,9,,,9,Other,186% of Medicaid,83,83,,83,percent of total billed charges,All Other,62,62,,62,percent of total billed charges,Lab and Radiology,55,55,,55,percent of total billed charges,Default if not on Fee Schedule,80,80,,80,percent of total billed charges,All Other,62,62,,62,percent of total billed charges,Lab and Radiology,80,80,,80,percent of total billed charges,All Other,70,70,,70,percent of total billed charges,All Other,65,65,,65,percent of total billed charges,Default if not in Fee Schedule,65,65,,65,percent of total billed charges,Default if not in Fee Schedule,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,5.05,,,5.05,Other,100% of Medicaid,5.05,,,5.05,Other,100% of Medicaid,5.05,,,5.05,Other,100% of Medicaid,5.05,,,5.05,Other,100% of Medicaid,11.36,,,11.36,Other,225% of Medicaid,7.73,,,7.73,Other,153% of Medicaid,11.36,,,11.36,Other,225% of Medicaid,7.07,,,7.07,Other,140% of Medicaid,11.36,,,11.36,Other,225% of Medicaid,13.13,,,13.13,Other,260% of Medicaid,16.36,,,16.36,Other,324% of Medicaid,10.86,,,10.86,Other,215% of Medicaid,10.86,,,10.86,Other,215% of Medicaid,6.31,,,6.31,Other,125% of Medicaid,0.01,83,
AMPHETAMINES 3OR 4,80325,CPT,,78080325,CDM,301,RC,,,both,,,107,79.18,,,79.18,Other,150% of Medicare + 9.63% HCRA Surcharge,48.15,45,,48.15,percent of total billed charges,Critical Access Hospital RCC factor,69.55,65,,69.55,percent of total billed charges,All Other,63.13,65,,63.13,percent of total billed charges,All Other,9.69,,,9.69,Fee Schedule,,9.69,,,9.69,Fee Schedule,,9.69,,,9.69,Fee Schedule,,52.97,,,52.97,Other,110% of Medicare,72.76,68,,72.76,percent of total billed charges,All Other,9,,,9,Other,186% of Medicaid,88.81,83,,88.81,percent of total billed charges,All Other,66.34,62,,66.34,percent of total billed charges,Lab and Radiology,58.85,55,,58.85,percent of total billed charges,Default if not on Fee Schedule,85.6,80,,85.6,percent of total billed charges,All Other,66.34,62,,66.34,percent of total billed charges,Lab and Radiology,85.6,80,,85.6,percent of total billed charges,All Other,74.9,70,,74.9,percent of total billed charges,All Other,69.55,65,,69.55,percent of total billed charges,Default if not in Fee Schedule,69.55,65,,69.55,percent of total billed charges,Default if not in Fee Schedule,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,5.05,,,5.05,Other,100% of Medicaid,5.05,,,5.05,Other,100% of Medicaid,5.05,,,5.05,Other,100% of Medicaid,5.05,,,5.05,Other,100% of Medicaid,11.36,,,11.36,Other,225% of Medicaid,7.73,,,7.73,Other,153% of Medicaid,11.36,,,11.36,Other,225% of Medicaid,7.07,,,7.07,Other,140% of Medicaid,11.36,,,11.36,Other,225% of Medicaid,13.13,,,13.13,Other,260% of Medicaid,16.36,,,16.36,Other,324% of Medicaid,10.86,,,10.86,Other,215% of Medicaid,10.86,,,10.86,Other,215% of Medicaid,6.31,,,6.31,Other,125% of Medicaid,0.01,88.81,
AMPHETAMINES 5 OR MORE,80326,CPT,,78080326,CDM,301,RC,,,both,,,133,98.42,,,98.42,Other,150% of Medicare + 9.63% HCRA Surcharge,59.85,45,,59.85,percent of total billed charges,Critical Access Hospital RCC factor,86.45,65,,86.45,percent of total billed charges,All Other,78.47,65,,78.47,percent of total billed charges,All Other,10.57,,,10.57,Fee Schedule,,10.57,,,10.57,Fee Schedule,,10.57,,,10.57,Fee Schedule,,65.84,,,65.84,Other,110% of Medicare,90.44,68,,90.44,percent of total billed charges,All Other,9,,,9,Other,186% of Medicaid,110.39,83,,110.39,percent of total billed charges,All Other,82.46,62,,82.46,percent of total billed charges,Lab and Radiology,73.15,55,,73.15,percent of total billed charges,Default if not on Fee Schedule,106.4,80,,106.4,percent of total billed charges,All Other,82.46,62,,82.46,percent of total billed charges,Lab and Radiology,106.4,80,,106.4,percent of total billed charges,All Other,93.1,70,,93.1,percent of total billed charges,All Other,86.45,65,,86.45,percent of total billed charges,Default if not in Fee Schedule,86.45,65,,86.45,percent of total billed charges,Default if not in Fee Schedule,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,5.05,,,5.05,Other,100% of Medicaid,5.05,,,5.05,Other,100% of Medicaid,5.05,,,5.05,Other,100% of Medicaid,5.05,,,5.05,Other,100% of Medicaid,11.36,,,11.36,Other,225% of Medicaid,7.73,,,7.73,Other,153% of Medicaid,11.36,,,11.36,Other,225% of Medicaid,7.07,,,7.07,Other,140% of Medicaid,11.36,,,11.36,Other,225% of Medicaid,13.13,,,13.13,Other,260% of Medicaid,16.36,,,16.36,Other,324% of Medicaid,10.86,,,10.86,Other,215% of Medicaid,10.86,,,10.86,Other,215% of Medicaid,6.31,,,6.31,Other,125% of Medicaid,0.01,110.39,
ANABOLIC STEROID 1 OR 2,80327,CPT,,78080327,CDM,301,RC,,,both,,,93,68.82,,,68.82,Other,150% of Medicare + 9.63% HCRA Surcharge,41.85,45,,41.85,percent of total billed charges,Critical Access Hospital RCC factor,60.45,65,,60.45,percent of total billed charges,All Other,54.87,65,,54.87,percent of total billed charges,All Other,14.62,,,14.62,Fee Schedule,,14.62,,,14.62,Fee Schedule,,14.62,,,14.62,Fee Schedule,,46.04,,,46.04,Other,110% of Medicare,63.24,68,,63.24,percent of total billed charges,All Other,0.01,,,0.01,Other,186% of Medicaid,77.19,83,,77.19,percent of total billed charges,All Other,57.66,62,,57.66,percent of total billed charges,Lab and Radiology,51.15,55,,51.15,percent of total billed charges,Default if not on Fee Schedule,74.4,80,,74.4,percent of total billed charges,All Other,57.66,62,,57.66,percent of total billed charges,Lab and Radiology,74.4,80,,74.4,percent of total billed charges,All Other,65.1,70,,65.1,percent of total billed charges,All Other,60.45,65,,60.45,percent of total billed charges,Default if not in Fee Schedule,60.45,65,,60.45,percent of total billed charges,Default if not in Fee Schedule,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,77.19,
ANABOLIC STEROID 3 OR MORE,80328,CPT,,78080328,CDM,301,RC,,,both,,,107,79.18,,,79.18,Other,150% of Medicare + 9.63% HCRA Surcharge,48.15,45,,48.15,percent of total billed charges,Critical Access Hospital RCC factor,69.55,65,,69.55,percent of total billed charges,All Other,63.13,65,,63.13,percent of total billed charges,All Other,16.08,,,16.08,Fee Schedule,,16.08,,,16.08,Fee Schedule,,16.08,,,16.08,Fee Schedule,,52.97,,,52.97,Other,110% of Medicare,72.76,68,,72.76,percent of total billed charges,All Other,0.01,,,0.01,Other,186% of Medicaid,88.81,83,,88.81,percent of total billed charges,All Other,66.34,62,,66.34,percent of total billed charges,Lab and Radiology,58.85,55,,58.85,percent of total billed charges,Default if not on Fee Schedule,85.6,80,,85.6,percent of total billed charges,All Other,66.34,62,,66.34,percent of total billed charges,Lab and Radiology,85.6,80,,85.6,percent of total billed charges,All Other,74.9,70,,74.9,percent of total billed charges,All Other,69.55,65,,69.55,percent of total billed charges,Default if not in Fee Schedule,69.55,65,,69.55,percent of total billed charges,Default if not in Fee Schedule,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,88.81,
ANALGESICS NON-OPIOID 1 OR 2 SALICYLATE,80329,CPT,,78080329,CDM,301,RC,,,both,,,90,66.6,,,66.6,Other,150% of Medicare + 9.63% HCRA Surcharge,40.5,45,,40.5,percent of total billed charges,Critical Access Hospital RCC factor,58.5,65,,58.5,percent of total billed charges,All Other,53.1,65,,53.1,percent of total billed charges,All Other,11.46,,,11.46,Fee Schedule,,11.46,,,11.46,Fee Schedule,,11.46,,,11.46,Fee Schedule,,44.55,,,44.55,Other,110% of Medicare,61.2,68,,61.2,percent of total billed charges,All Other,0.01,,,0.01,Other,186% of Medicaid,74.7,83,,74.7,percent of total billed charges,All Other,55.8,62,,55.8,percent of total billed charges,Lab and Radiology,49.5,55,,49.5,percent of total billed charges,Default if not on Fee Schedule,72,80,,72,percent of total billed charges,All Other,55.8,62,,55.8,percent of total billed charges,Lab and Radiology,72,80,,72,percent of total billed charges,All Other,63,70,,63,percent of total billed charges,All Other,58.5,65,,58.5,percent of total billed charges,Default if not in Fee Schedule,58.5,65,,58.5,percent of total billed charges,Default if not in Fee Schedule,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,74.7,
ANALGESICS NON-OPIOID 3-5,80330,CPT,,78080330,CDM,301,RC,,,both,,,107,79.18,,,79.18,Other,150% of Medicare + 9.63% HCRA Surcharge,48.15,45,,48.15,percent of total billed charges,Critical Access Hospital RCC factor,69.55,65,,69.55,percent of total billed charges,All Other,63.13,65,,63.13,percent of total billed charges,All Other,12.61,,,12.61,Fee Schedule,,12.61,,,12.61,Fee Schedule,,12.61,,,12.61,Fee Schedule,,52.97,,,52.97,Other,110% of Medicare,72.76,68,,72.76,percent of total billed charges,All Other,0.01,,,0.01,Other,186% of Medicaid,88.81,83,,88.81,percent of total billed charges,All Other,66.34,62,,66.34,percent of total billed charges,Lab and Radiology,58.85,55,,58.85,percent of total billed charges,Default if not on Fee Schedule,85.6,80,,85.6,percent of total billed charges,All Other,66.34,62,,66.34,percent of total billed charges,Lab and Radiology,85.6,80,,85.6,percent of total billed charges,All Other,74.9,70,,74.9,percent of total billed charges,All Other,69.55,65,,69.55,percent of total billed charges,Default if not in Fee Schedule,69.55,65,,69.55,percent of total billed charges,Default if not in Fee Schedule,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,88.81,
ANALGESICS NON-OPIOID 6/MORE,80331,CPT,,78080331,CDM,301,RC,,,both,,,133,98.42,,,98.42,Other,150% of Medicare + 9.63% HCRA Surcharge,59.85,45,,59.85,percent of total billed charges,Critical Access Hospital RCC factor,86.45,65,,86.45,percent of total billed charges,All Other,78.47,65,,78.47,percent of total billed charges,All Other,13.75,,,13.75,Fee Schedule,,13.75,,,13.75,Fee Schedule,,13.75,,,13.75,Fee Schedule,,65.84,,,65.84,Other,110% of Medicare,90.44,68,,90.44,percent of total billed charges,All Other,0.01,,,0.01,Other,186% of Medicaid,110.39,83,,110.39,percent of total billed charges,All Other,82.46,62,,82.46,percent of total billed charges,Lab and Radiology,73.15,55,,73.15,percent of total billed charges,Default if not on Fee Schedule,106.4,80,,106.4,percent of total billed charges,All Other,82.46,62,,82.46,percent of total billed charges,Lab and Radiology,106.4,80,,106.4,percent of total billed charges,All Other,93.1,70,,93.1,percent of total billed charges,All Other,86.45,65,,86.45,percent of total billed charges,Default if not in Fee Schedule,86.45,65,,86.45,percent of total billed charges,Default if not in Fee Schedule,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,110.39,
ANTIDEPRESSANTS CLASS 1 OR 2,80332,CPT,,78080332,CDM,301,RC,,,both,,,86,63.64,,,63.64,Other,150% of Medicare + 9.63% HCRA Surcharge,38.7,45,,38.7,percent of total billed charges,Critical Access Hospital RCC factor,55.9,65,,55.9,percent of total billed charges,All Other,50.74,65,,50.74,percent of total billed charges,All Other,10.14,,,10.14,Fee Schedule,,10.14,,,10.14,Fee Schedule,,10.14,,,10.14,Fee Schedule,,42.57,,,42.57,Other,110% of Medicare,58.48,68,,58.48,percent of total billed charges,All Other,0.01,,,0.01,Other,186% of Medicaid,71.38,83,,71.38,percent of total billed charges,All Other,53.32,62,,53.32,percent of total billed charges,Lab and Radiology,47.3,55,,47.3,percent of total billed charges,Default if not on Fee Schedule,68.8,80,,68.8,percent of total billed charges,All Other,53.32,62,,53.32,percent of total billed charges,Lab and Radiology,68.8,80,,68.8,percent of total billed charges,All Other,60.2,70,,60.2,percent of total billed charges,All Other,55.9,65,,55.9,percent of total billed charges,Default if not in Fee Schedule,55.9,65,,55.9,percent of total billed charges,Default if not in Fee Schedule,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,71.38,
ANTIDEPRESSANTS CLASS 3-5,80333,CPT,,78080333,CDM,301,RC,,,both,,,107,79.18,,,79.18,Other,150% of Medicare + 9.63% HCRA Surcharge,48.15,45,,48.15,percent of total billed charges,Critical Access Hospital RCC factor,69.55,65,,69.55,percent of total billed charges,All Other,63.13,65,,63.13,percent of total billed charges,All Other,11.15,,,11.15,Fee Schedule,,11.15,,,11.15,Fee Schedule,,11.15,,,11.15,Fee Schedule,,52.97,,,52.97,Other,110% of Medicare,72.76,68,,72.76,percent of total billed charges,All Other,0.01,,,0.01,Other,186% of Medicaid,88.81,83,,88.81,percent of total billed charges,All Other,66.34,62,,66.34,percent of total billed charges,Lab and Radiology,58.85,55,,58.85,percent of total billed charges,Default if not on Fee Schedule,85.6,80,,85.6,percent of total billed charges,All Other,66.34,62,,66.34,percent of total billed charges,Lab and Radiology,85.6,80,,85.6,percent of total billed charges,All Other,74.9,70,,74.9,percent of total billed charges,All Other,69.55,65,,69.55,percent of total billed charges,Default if not in Fee Schedule,69.55,65,,69.55,percent of total billed charges,Default if not in Fee Schedule,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,88.81,
ANTIDEPRESSANTS CLASS 6/MORE,80334,CPT,,78080334,CDM,301,RC,,,both,,,133,98.42,,,98.42,Other,150% of Medicare + 9.63% HCRA Surcharge,59.85,45,,59.85,percent of total billed charges,Critical Access Hospital RCC factor,86.45,65,,86.45,percent of total billed charges,All Other,78.47,65,,78.47,percent of total billed charges,All Other,12.17,,,12.17,Fee Schedule,,12.17,,,12.17,Fee Schedule,,12.17,,,12.17,Fee Schedule,,65.84,,,65.84,Other,110% of Medicare,90.44,68,,90.44,percent of total billed charges,All Other,0.01,,,0.01,Other,186% of Medicaid,110.39,83,,110.39,percent of total billed charges,All Other,82.46,62,,82.46,percent of total billed charges,Lab and Radiology,73.15,55,,73.15,percent of total billed charges,Default if not on Fee Schedule,106.4,80,,106.4,percent of total billed charges,All Other,82.46,62,,82.46,percent of total billed charges,Lab and Radiology,106.4,80,,106.4,percent of total billed charges,All Other,93.1,70,,93.1,percent of total billed charges,All Other,86.45,65,,86.45,percent of total billed charges,Default if not in Fee Schedule,86.45,65,,86.45,percent of total billed charges,Default if not in Fee Schedule,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,110.39,
ANTIDEPRESSANT TRICYCLIC 1/2,80335,CPT,,78080335,CDM,301,RC,,,both,,,100,74,,,74,Other,150% of Medicare + 9.63% HCRA Surcharge,45,45,,45,percent of total billed charges,Critical Access Hospital RCC factor,65,65,,65,percent of total billed charges,All Other,59,65,,59,percent of total billed charges,All Other,10.14,,,10.14,Fee Schedule,,10.14,,,10.14,Fee Schedule,,10.14,,,10.14,Fee Schedule,,49.5,,,49.5,Other,110% of Medicare,68,68,,68,percent of total billed charges,All Other,9,,,9,Other,186% of Medicaid,83,83,,83,percent of total billed charges,All Other,62,62,,62,percent of total billed charges,Lab and Radiology,55,55,,55,percent of total billed charges,Default if not on Fee Schedule,80,80,,80,percent of total billed charges,All Other,62,62,,62,percent of total billed charges,Lab and Radiology,80,80,,80,percent of total billed charges,All Other,70,70,,70,percent of total billed charges,All Other,65,65,,65,percent of total billed charges,Default if not in Fee Schedule,65,65,,65,percent of total billed charges,Default if not in Fee Schedule,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,5.05,,,5.05,Other,100% of Medicaid,5.05,,,5.05,Other,100% of Medicaid,5.05,,,5.05,Other,100% of Medicaid,5.05,,,5.05,Other,100% of Medicaid,11.36,,,11.36,Other,225% of Medicaid,7.73,,,7.73,Other,153% of Medicaid,11.36,,,11.36,Other,225% of Medicaid,7.07,,,7.07,Other,140% of Medicaid,11.36,,,11.36,Other,225% of Medicaid,13.13,,,13.13,Other,260% of Medicaid,16.36,,,16.36,Other,324% of Medicaid,10.86,,,10.86,Other,215% of Medicaid,10.86,,,10.86,Other,215% of Medicaid,6.31,,,6.31,Other,125% of Medicaid,0.01,83,
ANTIDEPRESSANT TRICYCLIC 3-5,80336,CPT,,78080336,CDM,301,RC,,,both,,,107,79.18,,,79.18,Other,150% of Medicare + 9.63% HCRA Surcharge,48.15,45,,48.15,percent of total billed charges,Critical Access Hospital RCC factor,69.55,65,,69.55,percent of total billed charges,All Other,63.13,65,,63.13,percent of total billed charges,All Other,11.15,,,11.15,Fee Schedule,,11.15,,,11.15,Fee Schedule,,11.15,,,11.15,Fee Schedule,,52.97,,,52.97,Other,110% of Medicare,72.76,68,,72.76,percent of total billed charges,All Other,9,,,9,Other,186% of Medicaid,88.81,83,,88.81,percent of total billed charges,All Other,66.34,62,,66.34,percent of total billed charges,Lab and Radiology,58.85,55,,58.85,percent of total billed charges,Default if not on Fee Schedule,85.6,80,,85.6,percent of total billed charges,All Other,66.34,62,,66.34,percent of total billed charges,Lab and Radiology,85.6,80,,85.6,percent of total billed charges,All Other,74.9,70,,74.9,percent of total billed charges,All Other,69.55,65,,69.55,percent of total billed charges,Default if not in Fee Schedule,69.55,65,,69.55,percent of total billed charges,Default if not in Fee Schedule,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,5.05,,,5.05,Other,100% of Medicaid,5.05,,,5.05,Other,100% of Medicaid,5.05,,,5.05,Other,100% of Medicaid,5.05,,,5.05,Other,100% of Medicaid,11.36,,,11.36,Other,225% of Medicaid,7.73,,,7.73,Other,153% of Medicaid,11.36,,,11.36,Other,225% of Medicaid,7.07,,,7.07,Other,140% of Medicaid,11.36,,,11.36,Other,225% of Medicaid,13.13,,,13.13,Other,260% of Medicaid,16.36,,,16.36,Other,324% of Medicaid,10.86,,,10.86,Other,215% of Medicaid,10.86,,,10.86,Other,215% of Medicaid,6.31,,,6.31,Other,125% of Medicaid,0.01,88.81,
TRICYCLIC & CYCLICALS 6/MORE,80337,CPT,,78080337,CDM,301,RC,,,both,,,133,98.42,,,98.42,Other,150% of Medicare + 9.63% HCRA Surcharge,59.85,45,,59.85,percent of total billed charges,Critical Access Hospital RCC factor,86.45,65,,86.45,percent of total billed charges,All Other,78.47,65,,78.47,percent of total billed charges,All Other,12.17,,,12.17,Fee Schedule,,12.17,,,12.17,Fee Schedule,,12.17,,,12.17,Fee Schedule,,65.84,,,65.84,Other,110% of Medicare,90.44,68,,90.44,percent of total billed charges,All Other,9,,,9,Other,186% of Medicaid,110.39,83,,110.39,percent of total billed charges,All Other,82.46,62,,82.46,percent of total billed charges,Lab and Radiology,73.15,55,,73.15,percent of total billed charges,Default if not on Fee Schedule,106.4,80,,106.4,percent of total billed charges,All Other,82.46,62,,82.46,percent of total billed charges,Lab and Radiology,106.4,80,,106.4,percent of total billed charges,All Other,93.1,70,,93.1,percent of total billed charges,All Other,86.45,65,,86.45,percent of total billed charges,Default if not in Fee Schedule,86.45,65,,86.45,percent of total billed charges,Default if not in Fee Schedule,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,5.05,,,5.05,Other,100% of Medicaid,5.05,,,5.05,Other,100% of Medicaid,5.05,,,5.05,Other,100% of Medicaid,5.05,,,5.05,Other,100% of Medicaid,11.36,,,11.36,Other,225% of Medicaid,7.73,,,7.73,Other,153% of Medicaid,11.36,,,11.36,Other,225% of Medicaid,7.07,,,7.07,Other,140% of Medicaid,11.36,,,11.36,Other,225% of Medicaid,13.13,,,13.13,Other,260% of Medicaid,16.36,,,16.36,Other,324% of Medicaid,10.86,,,10.86,Other,215% of Medicaid,10.86,,,10.86,Other,215% of Medicaid,6.31,,,6.31,Other,125% of Medicaid,0.01,110.39,
ANTIDEPRESSANT NOT SPECIFIED,80338,CPT,,78080338,CDM,301,RC,,,both,,,86,63.64,,,63.64,Other,150% of Medicare + 9.63% HCRA Surcharge,38.7,45,,38.7,percent of total billed charges,Critical Access Hospital RCC factor,55.9,65,,55.9,percent of total billed charges,All Other,50.74,65,,50.74,percent of total billed charges,All Other,10.14,,,10.14,Fee Schedule,,10.14,,,10.14,Fee Schedule,,10.14,,,10.14,Fee Schedule,,42.57,,,42.57,Other,110% of Medicare,58.48,68,,58.48,percent of total billed charges,All Other,0.01,,,0.01,Other,186% of Medicaid,71.38,83,,71.38,percent of total billed charges,All Other,53.32,62,,53.32,percent of total billed charges,Lab and Radiology,47.3,55,,47.3,percent of total billed charges,Default if not on Fee Schedule,68.8,80,,68.8,percent of total billed charges,All Other,53.32,62,,53.32,percent of total billed charges,Lab and Radiology,68.8,80,,68.8,percent of total billed charges,All Other,60.2,70,,60.2,percent of total billed charges,All Other,55.9,65,,55.9,percent of total billed charges,Default if not in Fee Schedule,55.9,65,,55.9,percent of total billed charges,Default if not in Fee Schedule,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,71.38,
ANTIEPILEPTICS NOS 1-3,80339,CPT,,78080339,CDM,301,RC,,,both,,,86,63.64,,,63.64,Other,150% of Medicare + 9.63% HCRA Surcharge,38.7,45,,38.7,percent of total billed charges,Critical Access Hospital RCC factor,55.9,65,,55.9,percent of total billed charges,All Other,50.74,65,,50.74,percent of total billed charges,All Other,7.84,,,7.84,Fee Schedule,,7.84,,,7.84,Fee Schedule,,7.84,,,7.84,Fee Schedule,,42.57,,,42.57,Other,110% of Medicare,58.48,68,,58.48,percent of total billed charges,All Other,0.01,,,0.01,Other,186% of Medicaid,71.38,83,,71.38,percent of total billed charges,All Other,53.32,62,,53.32,percent of total billed charges,Lab and Radiology,47.3,55,,47.3,percent of total billed charges,Default if not on Fee Schedule,68.8,80,,68.8,percent of total billed charges,All Other,53.32,62,,53.32,percent of total billed charges,Lab and Radiology,68.8,80,,68.8,percent of total billed charges,All Other,60.2,70,,60.2,percent of total billed charges,All Other,55.9,65,,55.9,percent of total billed charges,Default if not in Fee Schedule,55.9,65,,55.9,percent of total billed charges,Default if not in Fee Schedule,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,71.38,
ANTIEPILEPTICS NOS 4-6,80340,CPT,,78080340,CDM,301,RC,,,both,,,107,79.18,,,79.18,Other,150% of Medicare + 9.63% HCRA Surcharge,48.15,45,,48.15,percent of total billed charges,Critical Access Hospital RCC factor,69.55,65,,69.55,percent of total billed charges,All Other,63.13,65,,63.13,percent of total billed charges,All Other,8.62,,,8.62,Fee Schedule,,8.62,,,8.62,Fee Schedule,,8.62,,,8.62,Fee Schedule,,52.97,,,52.97,Other,110% of Medicare,72.76,68,,72.76,percent of total billed charges,All Other,0.01,,,0.01,Other,186% of Medicaid,88.81,83,,88.81,percent of total billed charges,All Other,66.34,62,,66.34,percent of total billed charges,Lab and Radiology,58.85,55,,58.85,percent of total billed charges,Default if not on Fee Schedule,85.6,80,,85.6,percent of total billed charges,All Other,66.34,62,,66.34,percent of total billed charges,Lab and Radiology,85.6,80,,85.6,percent of total billed charges,All Other,74.9,70,,74.9,percent of total billed charges,All Other,69.55,65,,69.55,percent of total billed charges,Default if not in Fee Schedule,69.55,65,,69.55,percent of total billed charges,Default if not in Fee Schedule,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,88.81,
ANTIEPILEPTICS NOS 7/MORE,80341,CPT,,78080341,CDM,301,RC,,,both,,,133,98.42,,,98.42,Other,150% of Medicare + 9.63% HCRA Surcharge,59.85,45,,59.85,percent of total billed charges,Critical Access Hospital RCC factor,86.45,65,,86.45,percent of total billed charges,All Other,78.47,65,,78.47,percent of total billed charges,All Other,9.41,,,9.41,Fee Schedule,,9.41,,,9.41,Fee Schedule,,9.41,,,9.41,Fee Schedule,,65.84,,,65.84,Other,110% of Medicare,90.44,68,,90.44,percent of total billed charges,All Other,0.01,,,0.01,Other,186% of Medicaid,110.39,83,,110.39,percent of total billed charges,All Other,82.46,62,,82.46,percent of total billed charges,Lab and Radiology,73.15,55,,73.15,percent of total billed charges,Default if not on Fee Schedule,106.4,80,,106.4,percent of total billed charges,All Other,82.46,62,,82.46,percent of total billed charges,Lab and Radiology,106.4,80,,106.4,percent of total billed charges,All Other,93.1,70,,93.1,percent of total billed charges,All Other,86.45,65,,86.45,percent of total billed charges,Default if not in Fee Schedule,86.45,65,,86.45,percent of total billed charges,Default if not in Fee Schedule,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,110.39,
ANTIPSYCHOTICS NOS 1-3,80342,CPT,,78080342,CDM,301,RC,,,both,,,100,74,,,74,Other,150% of Medicare + 9.63% HCRA Surcharge,45,45,,45,percent of total billed charges,Critical Access Hospital RCC factor,65,65,,65,percent of total billed charges,All Other,59,65,,59,percent of total billed charges,All Other,8.82,,,8.82,Fee Schedule,,8.82,,,8.82,Fee Schedule,,8.82,,,8.82,Fee Schedule,,49.5,,,49.5,Other,110% of Medicare,68,68,,68,percent of total billed charges,All Other,0.01,,,0.01,Other,186% of Medicaid,83,83,,83,percent of total billed charges,All Other,62,62,,62,percent of total billed charges,Lab and Radiology,55,55,,55,percent of total billed charges,Default if not on Fee Schedule,80,80,,80,percent of total billed charges,All Other,62,62,,62,percent of total billed charges,Lab and Radiology,80,80,,80,percent of total billed charges,All Other,70,70,,70,percent of total billed charges,All Other,65,65,,65,percent of total billed charges,Default if not in Fee Schedule,65,65,,65,percent of total billed charges,Default if not in Fee Schedule,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,83,
ANTIPSYCHOTICS NOS 4-6,80343,CPT,,78080343,CDM,301,RC,,,both,,,107,79.18,,,79.18,Other,150% of Medicare + 9.63% HCRA Surcharge,48.15,45,,48.15,percent of total billed charges,Critical Access Hospital RCC factor,69.55,65,,69.55,percent of total billed charges,All Other,63.13,65,,63.13,percent of total billed charges,All Other,9.7,,,9.7,Fee Schedule,,9.7,,,9.7,Fee Schedule,,9.7,,,9.7,Fee Schedule,,52.97,,,52.97,Other,110% of Medicare,72.76,68,,72.76,percent of total billed charges,All Other,0.01,,,0.01,Other,186% of Medicaid,88.81,83,,88.81,percent of total billed charges,All Other,66.34,62,,66.34,percent of total billed charges,Lab and Radiology,58.85,55,,58.85,percent of total billed charges,Default if not on Fee Schedule,85.6,80,,85.6,percent of total billed charges,All Other,66.34,62,,66.34,percent of total billed charges,Lab and Radiology,85.6,80,,85.6,percent of total billed charges,All Other,74.9,70,,74.9,percent of total billed charges,All Other,69.55,65,,69.55,percent of total billed charges,Default if not in Fee Schedule,69.55,65,,69.55,percent of total billed charges,Default if not in Fee Schedule,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,88.81,
ANTIPSYCHOTICS NOS 7/MORE,80344,CPT,,78080344,CDM,301,RC,,,both,,,133,98.42,,,98.42,Other,150% of Medicare + 9.63% HCRA Surcharge,59.85,45,,59.85,percent of total billed charges,Critical Access Hospital RCC factor,86.45,65,,86.45,percent of total billed charges,All Other,78.47,65,,78.47,percent of total billed charges,All Other,10.58,,,10.58,Fee Schedule,,10.58,,,10.58,Fee Schedule,,10.58,,,10.58,Fee Schedule,,65.84,,,65.84,Other,110% of Medicare,90.44,68,,90.44,percent of total billed charges,All Other,0.01,,,0.01,Other,186% of Medicaid,110.39,83,,110.39,percent of total billed charges,All Other,82.46,62,,82.46,percent of total billed charges,Lab and Radiology,73.15,55,,73.15,percent of total billed charges,Default if not on Fee Schedule,106.4,80,,106.4,percent of total billed charges,All Other,82.46,62,,82.46,percent of total billed charges,Lab and Radiology,106.4,80,,106.4,percent of total billed charges,All Other,93.1,70,,93.1,percent of total billed charges,All Other,86.45,65,,86.45,percent of total billed charges,Default if not in Fee Schedule,86.45,65,,86.45,percent of total billed charges,Default if not in Fee Schedule,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,110.39,
DRUG SCREENING BARBITURATES,80345,CPT,,78080345,CDM,301,RC,,,both,,,100,74,,,74,Other,150% of Medicare + 9.63% HCRA Surcharge,45,45,,45,percent of total billed charges,Critical Access Hospital RCC factor,65,65,,65,percent of total billed charges,All Other,59,65,,59,percent of total billed charges,All Other,6.49,,,6.49,Fee Schedule,,6.49,,,6.49,Fee Schedule,,6.49,,,6.49,Fee Schedule,,49.5,,,49.5,Other,110% of Medicare,68,68,,68,percent of total billed charges,All Other,9,,,9,Other,186% of Medicaid,83,83,,83,percent of total billed charges,All Other,62,62,,62,percent of total billed charges,Lab and Radiology,55,55,,55,percent of total billed charges,Default if not on Fee Schedule,80,80,,80,percent of total billed charges,All Other,62,62,,62,percent of total billed charges,Lab and Radiology,80,80,,80,percent of total billed charges,All Other,70,70,,70,percent of total billed charges,All Other,65,65,,65,percent of total billed charges,Default if not in Fee Schedule,65,65,,65,percent of total billed charges,Default if not in Fee Schedule,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,5.05,,,5.05,Other,100% of Medicaid,5.05,,,5.05,Other,100% of Medicaid,5.05,,,5.05,Other,100% of Medicaid,5.05,,,5.05,Other,100% of Medicaid,11.36,,,11.36,Other,225% of Medicaid,7.73,,,7.73,Other,153% of Medicaid,11.36,,,11.36,Other,225% of Medicaid,7.07,,,7.07,Other,140% of Medicaid,11.36,,,11.36,Other,225% of Medicaid,13.13,,,13.13,Other,260% of Medicaid,16.36,,,16.36,Other,324% of Medicaid,10.86,,,10.86,Other,215% of Medicaid,10.86,,,10.86,Other,215% of Medicaid,6.31,,,6.31,Other,125% of Medicaid,0.01,83,
BENZODIAZEPINES1-12,80346,CPT,,78080346,CDM,301,RC,,,both,,,100,74,,,74,Other,150% of Medicare + 9.63% HCRA Surcharge,45,45,,45,percent of total billed charges,Critical Access Hospital RCC factor,65,65,,65,percent of total billed charges,All Other,59,65,,59,percent of total billed charges,All Other,10.48,,,10.48,Fee Schedule,,10.48,,,10.48,Fee Schedule,,10.48,,,10.48,Fee Schedule,,49.5,,,49.5,Other,110% of Medicare,68,68,,68,percent of total billed charges,All Other,9,,,9,Other,186% of Medicaid,83,83,,83,percent of total billed charges,All Other,62,62,,62,percent of total billed charges,Lab and Radiology,55,55,,55,percent of total billed charges,Default if not on Fee Schedule,80,80,,80,percent of total billed charges,All Other,62,62,,62,percent of total billed charges,Lab and Radiology,80,80,,80,percent of total billed charges,All Other,70,70,,70,percent of total billed charges,All Other,65,65,,65,percent of total billed charges,Default if not in Fee Schedule,65,65,,65,percent of total billed charges,Default if not in Fee Schedule,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,5.05,,,5.05,Other,100% of Medicaid,5.05,,,5.05,Other,100% of Medicaid,5.05,,,5.05,Other,100% of Medicaid,5.05,,,5.05,Other,100% of Medicaid,11.36,,,11.36,Other,225% of Medicaid,7.73,,,7.73,Other,153% of Medicaid,11.36,,,11.36,Other,225% of Medicaid,7.07,,,7.07,Other,140% of Medicaid,11.36,,,11.36,Other,225% of Medicaid,13.13,,,13.13,Other,260% of Medicaid,16.36,,,16.36,Other,324% of Medicaid,10.86,,,10.86,Other,215% of Medicaid,10.86,,,10.86,Other,215% of Medicaid,6.31,,,6.31,Other,125% of Medicaid,0.01,83,
BENZODIAZEPINES 13 OR MORE,80347,CPT,,78080347,CDM,301,RC,,,both,,,124,91.76,,,91.76,Other,150% of Medicare + 9.63% HCRA Surcharge,55.8,45,,55.8,percent of total billed charges,Critical Access Hospital RCC factor,80.6,65,,80.6,percent of total billed charges,All Other,73.16,65,,73.16,percent of total billed charges,All Other,11.53,,,11.53,Fee Schedule,,11.53,,,11.53,Fee Schedule,,11.53,,,11.53,Fee Schedule,,61.38,,,61.38,Other,110% of Medicare,84.32,68,,84.32,percent of total billed charges,All Other,9,,,9,Other,186% of Medicaid,102.92,83,,102.92,percent of total billed charges,All Other,76.88,62,,76.88,percent of total billed charges,Lab and Radiology,68.2,55,,68.2,percent of total billed charges,Default if not on Fee Schedule,99.2,80,,99.2,percent of total billed charges,All Other,76.88,62,,76.88,percent of total billed charges,Lab and Radiology,99.2,80,,99.2,percent of total billed charges,All Other,86.8,70,,86.8,percent of total billed charges,All Other,80.6,65,,80.6,percent of total billed charges,Default if not in Fee Schedule,80.6,65,,80.6,percent of total billed charges,Default if not in Fee Schedule,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,5.05,,,5.05,Other,100% of Medicaid,5.05,,,5.05,Other,100% of Medicaid,5.05,,,5.05,Other,100% of Medicaid,5.05,,,5.05,Other,100% of Medicaid,11.36,,,11.36,Other,225% of Medicaid,7.73,,,7.73,Other,153% of Medicaid,11.36,,,11.36,Other,225% of Medicaid,7.07,,,7.07,Other,140% of Medicaid,11.36,,,11.36,Other,225% of Medicaid,13.13,,,13.13,Other,260% of Medicaid,16.36,,,16.36,Other,324% of Medicaid,10.86,,,10.86,Other,215% of Medicaid,10.86,,,10.86,Other,215% of Medicaid,6.31,,,6.31,Other,125% of Medicaid,0.01,102.92,
DRUG SCREENING BUPRENORPHINE,80348,CPT,,78080348,CDM,301,RC,,,both,,,100,74,,,74,Other,150% of Medicare + 9.63% HCRA Surcharge,45,45,,45,percent of total billed charges,Critical Access Hospital RCC factor,65,65,,65,percent of total billed charges,All Other,59,65,,59,percent of total billed charges,All Other,11.02,,,11.02,Fee Schedule,,11.02,,,11.02,Fee Schedule,,11.02,,,11.02,Fee Schedule,,49.5,,,49.5,Other,110% of Medicare,68,68,,68,percent of total billed charges,All Other,9,,,9,Other,186% of Medicaid,83,83,,83,percent of total billed charges,All Other,62,62,,62,percent of total billed charges,Lab and Radiology,55,55,,55,percent of total billed charges,Default if not on Fee Schedule,80,80,,80,percent of total billed charges,All Other,62,62,,62,percent of total billed charges,Lab and Radiology,80,80,,80,percent of total billed charges,All Other,70,70,,70,percent of total billed charges,All Other,65,65,,65,percent of total billed charges,Default if not in Fee Schedule,65,65,,65,percent of total billed charges,Default if not in Fee Schedule,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,5.05,,,5.05,Other,100% of Medicaid,5.05,,,5.05,Other,100% of Medicaid,5.05,,,5.05,Other,100% of Medicaid,5.05,,,5.05,Other,100% of Medicaid,11.36,,,11.36,Other,225% of Medicaid,7.73,,,7.73,Other,153% of Medicaid,11.36,,,11.36,Other,225% of Medicaid,7.07,,,7.07,Other,140% of Medicaid,11.36,,,11.36,Other,225% of Medicaid,13.13,,,13.13,Other,260% of Medicaid,16.36,,,16.36,Other,324% of Medicaid,10.86,,,10.86,Other,215% of Medicaid,10.86,,,10.86,Other,215% of Medicaid,6.31,,,6.31,Other,125% of Medicaid,0.01,83,
CANNABINOIDS NATURAL,80349,CPT,,78080349,CDM,301,RC,,,both,,,100,74,,,74,Other,150% of Medicare + 9.63% HCRA Surcharge,45,45,,45,percent of total billed charges,Critical Access Hospital RCC factor,65,65,,65,percent of total billed charges,All Other,59,65,,59,percent of total billed charges,All Other,13.42,,,13.42,Fee Schedule,,13.42,,,13.42,Fee Schedule,,13.42,,,13.42,Fee Schedule,,49.5,,,49.5,Other,110% of Medicare,68,68,,68,percent of total billed charges,All Other,9,,,9,Other,186% of Medicaid,83,83,,83,percent of total billed charges,All Other,62,62,,62,percent of total billed charges,Lab and Radiology,55,55,,55,percent of total billed charges,Default if not on Fee Schedule,80,80,,80,percent of total billed charges,All Other,62,62,,62,percent of total billed charges,Lab and Radiology,80,80,,80,percent of total billed charges,All Other,70,70,,70,percent of total billed charges,All Other,65,65,,65,percent of total billed charges,Default if not in Fee Schedule,65,65,,65,percent of total billed charges,Default if not in Fee Schedule,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,5.05,,,5.05,Other,100% of Medicaid,5.05,,,5.05,Other,100% of Medicaid,5.05,,,5.05,Other,100% of Medicaid,5.05,,,5.05,Other,100% of Medicaid,11.36,,,11.36,Other,225% of Medicaid,7.73,,,7.73,Other,153% of Medicaid,11.36,,,11.36,Other,225% of Medicaid,7.07,,,7.07,Other,140% of Medicaid,11.36,,,11.36,Other,225% of Medicaid,13.13,,,13.13,Other,260% of Medicaid,16.36,,,16.36,Other,324% of Medicaid,10.86,,,10.86,Other,215% of Medicaid,10.86,,,10.86,Other,215% of Medicaid,6.31,,,6.31,Other,125% of Medicaid,0.01,83,
CANNABINOIDS SYNTHETIC 1-3,80350,CPT,,78080350,CDM,301,RC,,,both,,,86,63.64,,,63.64,Other,150% of Medicare + 9.63% HCRA Surcharge,38.7,45,,38.7,percent of total billed charges,Critical Access Hospital RCC factor,55.9,65,,55.9,percent of total billed charges,All Other,50.74,65,,50.74,percent of total billed charges,All Other,13.42,,,13.42,Fee Schedule,,13.42,,,13.42,Fee Schedule,,13.42,,,13.42,Fee Schedule,,42.57,,,42.57,Other,110% of Medicare,58.48,68,,58.48,percent of total billed charges,All Other,9,,,9,Other,186% of Medicaid,71.38,83,,71.38,percent of total billed charges,All Other,53.32,62,,53.32,percent of total billed charges,Lab and Radiology,47.3,55,,47.3,percent of total billed charges,Default if not on Fee Schedule,68.8,80,,68.8,percent of total billed charges,All Other,53.32,62,,53.32,percent of total billed charges,Lab and Radiology,68.8,80,,68.8,percent of total billed charges,All Other,60.2,70,,60.2,percent of total billed charges,All Other,55.9,65,,55.9,percent of total billed charges,Default if not in Fee Schedule,55.9,65,,55.9,percent of total billed charges,Default if not in Fee Schedule,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,5.05,,,5.05,Other,100% of Medicaid,5.05,,,5.05,Other,100% of Medicaid,5.05,,,5.05,Other,100% of Medicaid,5.05,,,5.05,Other,100% of Medicaid,11.36,,,11.36,Other,225% of Medicaid,7.73,,,7.73,Other,153% of Medicaid,11.36,,,11.36,Other,225% of Medicaid,7.07,,,7.07,Other,140% of Medicaid,11.36,,,11.36,Other,225% of Medicaid,13.13,,,13.13,Other,260% of Medicaid,16.36,,,16.36,Other,324% of Medicaid,10.86,,,10.86,Other,215% of Medicaid,10.86,,,10.86,Other,215% of Medicaid,6.31,,,6.31,Other,125% of Medicaid,0.01,71.38,
CANNABINOIDS SYNTHETIC 4-6,80351,CPT,,78080351,CDM,301,RC,,,both,,,107,79.18,,,79.18,Other,150% of Medicare + 9.63% HCRA Surcharge,48.15,45,,48.15,percent of total billed charges,Critical Access Hospital RCC factor,69.55,65,,69.55,percent of total billed charges,All Other,63.13,65,,63.13,percent of total billed charges,All Other,14.76,,,14.76,Fee Schedule,,14.76,,,14.76,Fee Schedule,,14.76,,,14.76,Fee Schedule,,52.97,,,52.97,Other,110% of Medicare,72.76,68,,72.76,percent of total billed charges,All Other,9,,,9,Other,186% of Medicaid,88.81,83,,88.81,percent of total billed charges,All Other,66.34,62,,66.34,percent of total billed charges,Lab and Radiology,58.85,55,,58.85,percent of total billed charges,Default if not on Fee Schedule,85.6,80,,85.6,percent of total billed charges,All Other,66.34,62,,66.34,percent of total billed charges,Lab and Radiology,85.6,80,,85.6,percent of total billed charges,All Other,74.9,70,,74.9,percent of total billed charges,All Other,69.55,65,,69.55,percent of total billed charges,Default if not in Fee Schedule,69.55,65,,69.55,percent of total billed charges,Default if not in Fee Schedule,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,5.05,,,5.05,Other,100% of Medicaid,5.05,,,5.05,Other,100% of Medicaid,5.05,,,5.05,Other,100% of Medicaid,5.05,,,5.05,Other,100% of Medicaid,11.36,,,11.36,Other,225% of Medicaid,7.73,,,7.73,Other,153% of Medicaid,11.36,,,11.36,Other,225% of Medicaid,7.07,,,7.07,Other,140% of Medicaid,11.36,,,11.36,Other,225% of Medicaid,13.13,,,13.13,Other,260% of Medicaid,16.36,,,16.36,Other,324% of Medicaid,10.86,,,10.86,Other,215% of Medicaid,10.86,,,10.86,Other,215% of Medicaid,6.31,,,6.31,Other,125% of Medicaid,0.01,88.81,
CANNABINOID SYNTHETIC 7/MORE,80352,CPT,,78080352,CDM,301,RC,,,both,,,133,98.42,,,98.42,Other,150% of Medicare + 9.63% HCRA Surcharge,59.85,45,,59.85,percent of total billed charges,Critical Access Hospital RCC factor,86.45,65,,86.45,percent of total billed charges,All Other,78.47,65,,78.47,percent of total billed charges,All Other,16.1,,,16.1,Fee Schedule,,16.1,,,16.1,Fee Schedule,,16.1,,,16.1,Fee Schedule,,65.84,,,65.84,Other,110% of Medicare,90.44,68,,90.44,percent of total billed charges,All Other,9,,,9,Other,186% of Medicaid,110.39,83,,110.39,percent of total billed charges,All Other,82.46,62,,82.46,percent of total billed charges,Lab and Radiology,73.15,55,,73.15,percent of total billed charges,Default if not on Fee Schedule,106.4,80,,106.4,percent of total billed charges,All Other,82.46,62,,82.46,percent of total billed charges,Lab and Radiology,106.4,80,,106.4,percent of total billed charges,All Other,93.1,70,,93.1,percent of total billed charges,All Other,86.45,65,,86.45,percent of total billed charges,Default if not in Fee Schedule,86.45,65,,86.45,percent of total billed charges,Default if not in Fee Schedule,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,5.05,,,5.05,Other,100% of Medicaid,5.05,,,5.05,Other,100% of Medicaid,5.05,,,5.05,Other,100% of Medicaid,5.05,,,5.05,Other,100% of Medicaid,11.36,,,11.36,Other,225% of Medicaid,7.73,,,7.73,Other,153% of Medicaid,11.36,,,11.36,Other,225% of Medicaid,7.07,,,7.07,Other,140% of Medicaid,11.36,,,11.36,Other,225% of Medicaid,13.13,,,13.13,Other,260% of Medicaid,16.36,,,16.36,Other,324% of Medicaid,10.86,,,10.86,Other,215% of Medicaid,10.86,,,10.86,Other,215% of Medicaid,6.31,,,6.31,Other,125% of Medicaid,0.01,110.39,
DRUG SCREENING COCAINE,80353,CPT,,78080353,CDM,301,RC,,,both,,,100,74,,,74,Other,150% of Medicare + 9.63% HCRA Surcharge,45,45,,45,percent of total billed charges,Critical Access Hospital RCC factor,65,65,,65,percent of total billed charges,All Other,59,65,,59,percent of total billed charges,All Other,8.59,,,8.59,Fee Schedule,,8.59,,,8.59,Fee Schedule,,8.59,,,8.59,Fee Schedule,,49.5,,,49.5,Other,110% of Medicare,68,68,,68,percent of total billed charges,All Other,9,,,9,Other,186% of Medicaid,83,83,,83,percent of total billed charges,All Other,62,62,,62,percent of total billed charges,Lab and Radiology,55,55,,55,percent of total billed charges,Default if not on Fee Schedule,80,80,,80,percent of total billed charges,All Other,62,62,,62,percent of total billed charges,Lab and Radiology,80,80,,80,percent of total billed charges,All Other,70,70,,70,percent of total billed charges,All Other,65,65,,65,percent of total billed charges,Default if not in Fee Schedule,65,65,,65,percent of total billed charges,Default if not in Fee Schedule,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,5.05,,,5.05,Other,100% of Medicaid,5.05,,,5.05,Other,100% of Medicaid,5.05,,,5.05,Other,100% of Medicaid,5.05,,,5.05,Other,100% of Medicaid,11.36,,,11.36,Other,225% of Medicaid,7.73,,,7.73,Other,153% of Medicaid,11.36,,,11.36,Other,225% of Medicaid,7.07,,,7.07,Other,140% of Medicaid,11.36,,,11.36,Other,225% of Medicaid,13.13,,,13.13,Other,260% of Medicaid,16.36,,,16.36,Other,324% of Medicaid,10.86,,,10.86,Other,215% of Medicaid,10.86,,,10.86,Other,215% of Medicaid,6.31,,,6.31,Other,125% of Medicaid,0.01,83,
DRUG SCREENING FENTANYL,80354,CPT,,78080354,CDM,301,RC,,,both,,,100,74,,,74,Other,150% of Medicare + 9.63% HCRA Surcharge,45,45,,45,percent of total billed charges,Critical Access Hospital RCC factor,65,65,,65,percent of total billed charges,All Other,59,65,,59,percent of total billed charges,All Other,11.02,,,11.02,Fee Schedule,,11.02,,,11.02,Fee Schedule,,11.02,,,11.02,Fee Schedule,,49.5,,,49.5,Other,110% of Medicare,68,68,,68,percent of total billed charges,All Other,9,,,9,Other,186% of Medicaid,83,83,,83,percent of total billed charges,All Other,62,62,,62,percent of total billed charges,Lab and Radiology,55,55,,55,percent of total billed charges,Default if not on Fee Schedule,80,80,,80,percent of total billed charges,All Other,62,62,,62,percent of total billed charges,Lab and Radiology,80,80,,80,percent of total billed charges,All Other,70,70,,70,percent of total billed charges,All Other,65,65,,65,percent of total billed charges,Default if not in Fee Schedule,65,65,,65,percent of total billed charges,Default if not in Fee Schedule,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,5.05,,,5.05,Other,100% of Medicaid,5.05,,,5.05,Other,100% of Medicaid,5.05,,,5.05,Other,100% of Medicaid,5.05,,,5.05,Other,100% of Medicaid,11.36,,,11.36,Other,225% of Medicaid,7.73,,,7.73,Other,153% of Medicaid,11.36,,,11.36,Other,225% of Medicaid,7.07,,,7.07,Other,140% of Medicaid,11.36,,,11.36,Other,225% of Medicaid,13.13,,,13.13,Other,260% of Medicaid,16.36,,,16.36,Other,324% of Medicaid,10.86,,,10.86,Other,215% of Medicaid,10.86,,,10.86,Other,215% of Medicaid,6.31,,,6.31,Other,125% of Medicaid,0.01,83,
GABAPENTIN NON-BLOOD,80355,CPT,,78080355,CDM,301,RC,,,both,,,86,63.64,,,63.64,Other,150% of Medicare + 9.63% HCRA Surcharge,38.7,45,,38.7,percent of total billed charges,Critical Access Hospital RCC factor,55.9,65,,55.9,percent of total billed charges,All Other,50.74,65,,50.74,percent of total billed charges,All Other,7.24,,,7.24,Fee Schedule,,7.24,,,7.24,Fee Schedule,,7.24,,,7.24,Fee Schedule,,42.57,,,42.57,Other,110% of Medicare,58.48,68,,58.48,percent of total billed charges,All Other,0.01,,,0.01,Other,186% of Medicaid,71.38,83,,71.38,percent of total billed charges,All Other,53.32,62,,53.32,percent of total billed charges,Lab and Radiology,47.3,55,,47.3,percent of total billed charges,Default if not on Fee Schedule,68.8,80,,68.8,percent of total billed charges,All Other,53.32,62,,53.32,percent of total billed charges,Lab and Radiology,68.8,80,,68.8,percent of total billed charges,All Other,60.2,70,,60.2,percent of total billed charges,All Other,55.9,65,,55.9,percent of total billed charges,Default if not in Fee Schedule,55.9,65,,55.9,percent of total billed charges,Default if not in Fee Schedule,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,71.38,
HEROIN METABOLITE,80356,CPT,,78080356,CDM,301,RC,,,both,,,100,74,,,74,Other,150% of Medicare + 9.63% HCRA Surcharge,45,45,,45,percent of total billed charges,Critical Access Hospital RCC factor,65,65,,65,percent of total billed charges,All Other,59,65,,59,percent of total billed charges,All Other,11.02,,,11.02,Fee Schedule,,11.02,,,11.02,Fee Schedule,,11.02,,,11.02,Fee Schedule,,49.5,,,49.5,Other,110% of Medicare,68,68,,68,percent of total billed charges,All Other,9,,,9,Other,186% of Medicaid,83,83,,83,percent of total billed charges,All Other,62,62,,62,percent of total billed charges,Lab and Radiology,55,55,,55,percent of total billed charges,Default if not on Fee Schedule,80,80,,80,percent of total billed charges,All Other,62,62,,62,percent of total billed charges,Lab and Radiology,80,80,,80,percent of total billed charges,All Other,70,70,,70,percent of total billed charges,All Other,65,65,,65,percent of total billed charges,Default if not in Fee Schedule,65,65,,65,percent of total billed charges,Default if not in Fee Schedule,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,5.05,,,5.05,Other,100% of Medicaid,5.05,,,5.05,Other,100% of Medicaid,5.05,,,5.05,Other,100% of Medicaid,5.05,,,5.05,Other,100% of Medicaid,11.36,,,11.36,Other,225% of Medicaid,7.73,,,7.73,Other,153% of Medicaid,11.36,,,11.36,Other,225% of Medicaid,7.07,,,7.07,Other,140% of Medicaid,11.36,,,11.36,Other,225% of Medicaid,13.13,,,13.13,Other,260% of Medicaid,16.36,,,16.36,Other,324% of Medicaid,10.86,,,10.86,Other,215% of Medicaid,10.86,,,10.86,Other,215% of Medicaid,6.31,,,6.31,Other,125% of Medicaid,0.01,83,
KETAMINE AND NORKETAMINE,80357,CPT,,78080357,CDM,301,RC,,,both,,,86,63.64,,,63.64,Other,150% of Medicare + 9.63% HCRA Surcharge,38.7,45,,38.7,percent of total billed charges,Critical Access Hospital RCC factor,55.9,65,,55.9,percent of total billed charges,All Other,50.74,65,,50.74,percent of total billed charges,All Other,8.33,,,8.33,Fee Schedule,,8.33,,,8.33,Fee Schedule,,8.33,,,8.33,Fee Schedule,,42.57,,,42.57,Other,110% of Medicare,58.48,68,,58.48,percent of total billed charges,All Other,0.01,,,0.01,Other,186% of Medicaid,71.38,83,,71.38,percent of total billed charges,All Other,53.32,62,,53.32,percent of total billed charges,Lab and Radiology,47.3,55,,47.3,percent of total billed charges,Default if not on Fee Schedule,68.8,80,,68.8,percent of total billed charges,All Other,53.32,62,,53.32,percent of total billed charges,Lab and Radiology,68.8,80,,68.8,percent of total billed charges,All Other,60.2,70,,60.2,percent of total billed charges,All Other,55.9,65,,55.9,percent of total billed charges,Default if not in Fee Schedule,55.9,65,,55.9,percent of total billed charges,Default if not in Fee Schedule,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,71.38,
DRUG SCREENING METHADONE,80358,CPT,,78080358,CDM,301,RC,,,both,,,100,74,,,74,Other,150% of Medicare + 9.63% HCRA Surcharge,45,45,,45,percent of total billed charges,Critical Access Hospital RCC factor,65,65,,65,percent of total billed charges,All Other,59,65,,59,percent of total billed charges,All Other,9.25,,,9.25,Fee Schedule,,9.25,,,9.25,Fee Schedule,,9.25,,,9.25,Fee Schedule,,49.5,,,49.5,Other,110% of Medicare,68,68,,68,percent of total billed charges,All Other,9,,,9,Other,186% of Medicaid,83,83,,83,percent of total billed charges,All Other,62,62,,62,percent of total billed charges,Lab and Radiology,55,55,,55,percent of total billed charges,Default if not on Fee Schedule,80,80,,80,percent of total billed charges,All Other,62,62,,62,percent of total billed charges,Lab and Radiology,80,80,,80,percent of total billed charges,All Other,70,70,,70,percent of total billed charges,All Other,65,65,,65,percent of total billed charges,Default if not in Fee Schedule,65,65,,65,percent of total billed charges,Default if not in Fee Schedule,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,5.05,,,5.05,Other,100% of Medicaid,5.05,,,5.05,Other,100% of Medicaid,5.05,,,5.05,Other,100% of Medicaid,5.05,,,5.05,Other,100% of Medicaid,11.36,,,11.36,Other,225% of Medicaid,7.73,,,7.73,Other,153% of Medicaid,11.36,,,11.36,Other,225% of Medicaid,7.07,,,7.07,Other,140% of Medicaid,11.36,,,11.36,Other,225% of Medicaid,13.13,,,13.13,Other,260% of Medicaid,16.36,,,16.36,Other,324% of Medicaid,10.86,,,10.86,Other,215% of Medicaid,10.86,,,10.86,Other,215% of Medicaid,6.31,,,6.31,Other,125% of Medicaid,0.01,83,
METHYLENEDIOXYAMPHETAMINES,80359,CPT,,78080359,CDM,301,RC,,,both,,,86,63.64,,,63.64,Other,150% of Medicare + 9.63% HCRA Surcharge,38.7,45,,38.7,percent of total billed charges,Critical Access Hospital RCC factor,55.9,65,,55.9,percent of total billed charges,All Other,50.74,65,,50.74,percent of total billed charges,All Other,8.81,,,8.81,Fee Schedule,,8.81,,,8.81,Fee Schedule,,8.81,,,8.81,Fee Schedule,,42.57,,,42.57,Other,110% of Medicare,58.48,68,,58.48,percent of total billed charges,All Other,9,,,9,Other,186% of Medicaid,71.38,83,,71.38,percent of total billed charges,All Other,53.32,62,,53.32,percent of total billed charges,Lab and Radiology,47.3,55,,47.3,percent of total billed charges,Default if not on Fee Schedule,68.8,80,,68.8,percent of total billed charges,All Other,53.32,62,,53.32,percent of total billed charges,Lab and Radiology,68.8,80,,68.8,percent of total billed charges,All Other,60.2,70,,60.2,percent of total billed charges,All Other,55.9,65,,55.9,percent of total billed charges,Default if not in Fee Schedule,55.9,65,,55.9,percent of total billed charges,Default if not in Fee Schedule,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,5.05,,,5.05,Other,100% of Medicaid,5.05,,,5.05,Other,100% of Medicaid,5.05,,,5.05,Other,100% of Medicaid,5.05,,,5.05,Other,100% of Medicaid,11.36,,,11.36,Other,225% of Medicaid,7.73,,,7.73,Other,153% of Medicaid,11.36,,,11.36,Other,225% of Medicaid,7.07,,,7.07,Other,140% of Medicaid,11.36,,,11.36,Other,225% of Medicaid,13.13,,,13.13,Other,260% of Medicaid,16.36,,,16.36,Other,324% of Medicaid,10.86,,,10.86,Other,215% of Medicaid,10.86,,,10.86,Other,215% of Medicaid,6.31,,,6.31,Other,125% of Medicaid,0.01,71.38,
METHYLPHENIDATE,80360,CPT,,78080360,CDM,301,RC,,,both,,,86,63.64,,,63.64,Other,150% of Medicare + 9.63% HCRA Surcharge,38.7,45,,38.7,percent of total billed charges,Critical Access Hospital RCC factor,55.9,65,,55.9,percent of total billed charges,All Other,50.74,65,,50.74,percent of total billed charges,All Other,8.81,,,8.81,Fee Schedule,,8.81,,,8.81,Fee Schedule,,8.81,,,8.81,Fee Schedule,,42.57,,,42.57,Other,110% of Medicare,58.48,68,,58.48,percent of total billed charges,All Other,0.01,,,0.01,Other,186% of Medicaid,71.38,83,,71.38,percent of total billed charges,All Other,53.32,62,,53.32,percent of total billed charges,Lab and Radiology,47.3,55,,47.3,percent of total billed charges,Default if not on Fee Schedule,68.8,80,,68.8,percent of total billed charges,All Other,53.32,62,,53.32,percent of total billed charges,Lab and Radiology,68.8,80,,68.8,percent of total billed charges,All Other,60.2,70,,60.2,percent of total billed charges,All Other,55.9,65,,55.9,percent of total billed charges,Default if not in Fee Schedule,55.9,65,,55.9,percent of total billed charges,Default if not in Fee Schedule,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,71.38,
OPIATES 1 OR MORE,80361,CPT,,78080361,CDM,301,RC,,,both,,,100,74,,,74,Other,150% of Medicare + 9.63% HCRA Surcharge,45,45,,45,percent of total billed charges,Critical Access Hospital RCC factor,65,65,,65,percent of total billed charges,All Other,59,65,,59,percent of total billed charges,All Other,11.02,,,11.02,Fee Schedule,,11.02,,,11.02,Fee Schedule,,11.02,,,11.02,Fee Schedule,,49.5,,,49.5,Other,110% of Medicare,68,68,,68,percent of total billed charges,All Other,9,,,9,Other,186% of Medicaid,83,83,,83,percent of total billed charges,All Other,62,62,,62,percent of total billed charges,Lab and Radiology,55,55,,55,percent of total billed charges,Default if not on Fee Schedule,80,80,,80,percent of total billed charges,All Other,62,62,,62,percent of total billed charges,Lab and Radiology,80,80,,80,percent of total billed charges,All Other,70,70,,70,percent of total billed charges,All Other,65,65,,65,percent of total billed charges,Default if not in Fee Schedule,65,65,,65,percent of total billed charges,Default if not in Fee Schedule,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,5.05,,,5.05,Other,100% of Medicaid,5.05,,,5.05,Other,100% of Medicaid,5.05,,,5.05,Other,100% of Medicaid,5.05,,,5.05,Other,100% of Medicaid,11.36,,,11.36,Other,225% of Medicaid,7.73,,,7.73,Other,153% of Medicaid,11.36,,,11.36,Other,225% of Medicaid,7.07,,,7.07,Other,140% of Medicaid,11.36,,,11.36,Other,225% of Medicaid,13.13,,,13.13,Other,260% of Medicaid,16.36,,,16.36,Other,324% of Medicaid,10.86,,,10.86,Other,215% of Medicaid,10.86,,,10.86,Other,215% of Medicaid,6.31,,,6.31,Other,125% of Medicaid,0.01,83,
OPIOIDS & OPIATE ANALOGS 1/2,80362,CPT,,78080362,CDM,301,RC,,,both,,,86,63.64,,,63.64,Other,150% of Medicare + 9.63% HCRA Surcharge,38.7,45,,38.7,percent of total billed charges,Critical Access Hospital RCC factor,55.9,65,,55.9,percent of total billed charges,All Other,50.74,65,,50.74,percent of total billed charges,All Other,11.02,,,11.02,Fee Schedule,,11.02,,,11.02,Fee Schedule,,11.02,,,11.02,Fee Schedule,,42.57,,,42.57,Other,110% of Medicare,58.48,68,,58.48,percent of total billed charges,All Other,9,,,9,Other,186% of Medicaid,71.38,83,,71.38,percent of total billed charges,All Other,53.32,62,,53.32,percent of total billed charges,Lab and Radiology,47.3,55,,47.3,percent of total billed charges,Default if not on Fee Schedule,68.8,80,,68.8,percent of total billed charges,All Other,53.32,62,,53.32,percent of total billed charges,Lab and Radiology,68.8,80,,68.8,percent of total billed charges,All Other,60.2,70,,60.2,percent of total billed charges,All Other,55.9,65,,55.9,percent of total billed charges,Default if not in Fee Schedule,55.9,65,,55.9,percent of total billed charges,Default if not in Fee Schedule,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,5.05,,,5.05,Other,100% of Medicaid,5.05,,,5.05,Other,100% of Medicaid,5.05,,,5.05,Other,100% of Medicaid,5.05,,,5.05,Other,100% of Medicaid,11.36,,,11.36,Other,225% of Medicaid,7.73,,,7.73,Other,153% of Medicaid,11.36,,,11.36,Other,225% of Medicaid,7.07,,,7.07,Other,140% of Medicaid,11.36,,,11.36,Other,225% of Medicaid,13.13,,,13.13,Other,260% of Medicaid,16.36,,,16.36,Other,324% of Medicaid,10.86,,,10.86,Other,215% of Medicaid,10.86,,,10.86,Other,215% of Medicaid,6.31,,,6.31,Other,125% of Medicaid,0.01,71.38,
OPIOIDS & OPIATE ANALOGS 3/4,80363,CPT,,78080363,CDM,301,RC,,,both,,,107,79.18,,,79.18,Other,150% of Medicare + 9.63% HCRA Surcharge,48.15,45,,48.15,percent of total billed charges,Critical Access Hospital RCC factor,69.55,65,,69.55,percent of total billed charges,All Other,63.13,65,,63.13,percent of total billed charges,All Other,12.12,,,12.12,Fee Schedule,,12.12,,,12.12,Fee Schedule,,12.12,,,12.12,Fee Schedule,,52.97,,,52.97,Other,110% of Medicare,72.76,68,,72.76,percent of total billed charges,All Other,9,,,9,Other,186% of Medicaid,88.81,83,,88.81,percent of total billed charges,All Other,66.34,62,,66.34,percent of total billed charges,Lab and Radiology,58.85,55,,58.85,percent of total billed charges,Default if not on Fee Schedule,85.6,80,,85.6,percent of total billed charges,All Other,66.34,62,,66.34,percent of total billed charges,Lab and Radiology,85.6,80,,85.6,percent of total billed charges,All Other,74.9,70,,74.9,percent of total billed charges,All Other,69.55,65,,69.55,percent of total billed charges,Default if not in Fee Schedule,69.55,65,,69.55,percent of total billed charges,Default if not in Fee Schedule,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,5.05,,,5.05,Other,100% of Medicaid,5.05,,,5.05,Other,100% of Medicaid,5.05,,,5.05,Other,100% of Medicaid,5.05,,,5.05,Other,100% of Medicaid,11.36,,,11.36,Other,225% of Medicaid,7.73,,,7.73,Other,153% of Medicaid,11.36,,,11.36,Other,225% of Medicaid,7.07,,,7.07,Other,140% of Medicaid,11.36,,,11.36,Other,225% of Medicaid,13.13,,,13.13,Other,260% of Medicaid,16.36,,,16.36,Other,324% of Medicaid,10.86,,,10.86,Other,215% of Medicaid,10.86,,,10.86,Other,215% of Medicaid,6.31,,,6.31,Other,125% of Medicaid,0.01,88.81,
OPIOID &OPIATE ANALOG 5/MORE,80364,CPT,,78080364,CDM,301,RC,,,both,,,133,98.42,,,98.42,Other,150% of Medicare + 9.63% HCRA Surcharge,59.85,45,,59.85,percent of total billed charges,Critical Access Hospital RCC factor,86.45,65,,86.45,percent of total billed charges,All Other,78.47,65,,78.47,percent of total billed charges,All Other,13.22,,,13.22,Fee Schedule,,13.22,,,13.22,Fee Schedule,,13.22,,,13.22,Fee Schedule,,65.84,,,65.84,Other,110% of Medicare,90.44,68,,90.44,percent of total billed charges,All Other,9,,,9,Other,186% of Medicaid,110.39,83,,110.39,percent of total billed charges,All Other,82.46,62,,82.46,percent of total billed charges,Lab and Radiology,73.15,55,,73.15,percent of total billed charges,Default if not on Fee Schedule,106.4,80,,106.4,percent of total billed charges,All Other,82.46,62,,82.46,percent of total billed charges,Lab and Radiology,106.4,80,,106.4,percent of total billed charges,All Other,93.1,70,,93.1,percent of total billed charges,All Other,86.45,65,,86.45,percent of total billed charges,Default if not in Fee Schedule,86.45,65,,86.45,percent of total billed charges,Default if not in Fee Schedule,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,5.05,,,5.05,Other,100% of Medicaid,5.05,,,5.05,Other,100% of Medicaid,5.05,,,5.05,Other,100% of Medicaid,5.05,,,5.05,Other,100% of Medicaid,11.36,,,11.36,Other,225% of Medicaid,7.73,,,7.73,Other,153% of Medicaid,11.36,,,11.36,Other,225% of Medicaid,7.07,,,7.07,Other,140% of Medicaid,11.36,,,11.36,Other,225% of Medicaid,13.13,,,13.13,Other,260% of Medicaid,16.36,,,16.36,Other,324% of Medicaid,10.86,,,10.86,Other,215% of Medicaid,10.86,,,10.86,Other,215% of Medicaid,6.31,,,6.31,Other,125% of Medicaid,0.01,110.39,
DRUG SCREENING OXYCODONE,80365,CPT,,78080365,CDM,301,RC,,,both,,,100,74,,,74,Other,150% of Medicare + 9.63% HCRA Surcharge,45,45,,45,percent of total billed charges,Critical Access Hospital RCC factor,65,65,,65,percent of total billed charges,All Other,59,65,,59,percent of total billed charges,All Other,11.02,,,11.02,Fee Schedule,,11.02,,,11.02,Fee Schedule,,11.02,,,11.02,Fee Schedule,,49.5,,,49.5,Other,110% of Medicare,68,68,,68,percent of total billed charges,All Other,9,,,9,Other,186% of Medicaid,83,83,,83,percent of total billed charges,All Other,62,62,,62,percent of total billed charges,Lab and Radiology,55,55,,55,percent of total billed charges,Default if not on Fee Schedule,80,80,,80,percent of total billed charges,All Other,62,62,,62,percent of total billed charges,Lab and Radiology,80,80,,80,percent of total billed charges,All Other,70,70,,70,percent of total billed charges,All Other,65,65,,65,percent of total billed charges,Default if not in Fee Schedule,65,65,,65,percent of total billed charges,Default if not in Fee Schedule,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,5.05,,,5.05,Other,100% of Medicaid,5.05,,,5.05,Other,100% of Medicaid,5.05,,,5.05,Other,100% of Medicaid,5.05,,,5.05,Other,100% of Medicaid,11.36,,,11.36,Other,225% of Medicaid,7.73,,,7.73,Other,153% of Medicaid,11.36,,,11.36,Other,225% of Medicaid,7.07,,,7.07,Other,140% of Medicaid,11.36,,,11.36,Other,225% of Medicaid,13.13,,,13.13,Other,260% of Medicaid,16.36,,,16.36,Other,324% of Medicaid,10.86,,,10.86,Other,215% of Medicaid,10.86,,,10.86,Other,215% of Medicaid,6.31,,,6.31,Other,125% of Medicaid,0.01,83,
DRUG SCREENING PREGABALIN,80366,CPT,,78080366,CDM,301,RC,,,both,,,86,63.64,,,63.64,Other,150% of Medicare + 9.63% HCRA Surcharge,38.7,45,,38.7,percent of total billed charges,Critical Access Hospital RCC factor,55.9,65,,55.9,percent of total billed charges,All Other,50.74,65,,50.74,percent of total billed charges,All Other,7.84,,,7.84,Fee Schedule,,7.84,,,7.84,Fee Schedule,,7.84,,,7.84,Fee Schedule,,42.57,,,42.57,Other,110% of Medicare,58.48,68,,58.48,percent of total billed charges,All Other,0.01,,,0.01,Other,186% of Medicaid,71.38,83,,71.38,percent of total billed charges,All Other,53.32,62,,53.32,percent of total billed charges,Lab and Radiology,47.3,55,,47.3,percent of total billed charges,Default if not on Fee Schedule,68.8,80,,68.8,percent of total billed charges,All Other,53.32,62,,53.32,percent of total billed charges,Lab and Radiology,68.8,80,,68.8,percent of total billed charges,All Other,60.2,70,,60.2,percent of total billed charges,All Other,55.9,65,,55.9,percent of total billed charges,Default if not in Fee Schedule,55.9,65,,55.9,percent of total billed charges,Default if not in Fee Schedule,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,71.38,
DRUG SCREENING PROPOXYPHENE,80367,CPT,,78080367,CDM,301,RC,,,both,,,86,63.64,,,63.64,Other,150% of Medicare + 9.63% HCRA Surcharge,38.7,45,,38.7,percent of total billed charges,Critical Access Hospital RCC factor,55.9,65,,55.9,percent of total billed charges,All Other,50.74,65,,50.74,percent of total billed charges,All Other,11.02,,,11.02,Fee Schedule,,11.02,,,11.02,Fee Schedule,,11.02,,,11.02,Fee Schedule,,42.57,,,42.57,Other,110% of Medicare,58.48,68,,58.48,percent of total billed charges,All Other,9,,,9,Other,186% of Medicaid,71.38,83,,71.38,percent of total billed charges,All Other,53.32,62,,53.32,percent of total billed charges,Lab and Radiology,47.3,55,,47.3,percent of total billed charges,Default if not on Fee Schedule,68.8,80,,68.8,percent of total billed charges,All Other,53.32,62,,53.32,percent of total billed charges,Lab and Radiology,68.8,80,,68.8,percent of total billed charges,All Other,60.2,70,,60.2,percent of total billed charges,All Other,55.9,65,,55.9,percent of total billed charges,Default if not in Fee Schedule,55.9,65,,55.9,percent of total billed charges,Default if not in Fee Schedule,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,5.05,,,5.05,Other,100% of Medicaid,5.05,,,5.05,Other,100% of Medicaid,5.05,,,5.05,Other,100% of Medicaid,5.05,,,5.05,Other,100% of Medicaid,11.36,,,11.36,Other,225% of Medicaid,7.73,,,7.73,Other,153% of Medicaid,11.36,,,11.36,Other,225% of Medicaid,7.07,,,7.07,Other,140% of Medicaid,11.36,,,11.36,Other,225% of Medicaid,13.13,,,13.13,Other,260% of Medicaid,16.36,,,16.36,Other,324% of Medicaid,10.86,,,10.86,Other,215% of Medicaid,10.86,,,10.86,Other,215% of Medicaid,6.31,,,6.31,Other,125% of Medicaid,0.01,71.38,
SEDATIVE HYPNOTICS,80368,CPT,,78080368,CDM,301,RC,,,both,,,92,68.08,,,68.08,Other,150% of Medicare + 9.63% HCRA Surcharge,41.4,45,,41.4,percent of total billed charges,Critical Access Hospital RCC factor,59.8,65,,59.8,percent of total billed charges,All Other,54.28,65,,54.28,percent of total billed charges,All Other,10.48,,,10.48,Fee Schedule,,10.48,,,10.48,Fee Schedule,,10.48,,,10.48,Fee Schedule,,45.54,,,45.54,Other,110% of Medicare,62.56,68,,62.56,percent of total billed charges,All Other,0.01,,,0.01,Other,186% of Medicaid,76.36,83,,76.36,percent of total billed charges,All Other,57.04,62,,57.04,percent of total billed charges,Lab and Radiology,50.6,55,,50.6,percent of total billed charges,Default if not on Fee Schedule,73.6,80,,73.6,percent of total billed charges,All Other,57.04,62,,57.04,percent of total billed charges,Lab and Radiology,73.6,80,,73.6,percent of total billed charges,All Other,64.4,70,,64.4,percent of total billed charges,All Other,59.8,65,,59.8,percent of total billed charges,Default if not in Fee Schedule,59.8,65,,59.8,percent of total billed charges,Default if not in Fee Schedule,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,76.36,
SKELETAL MUSCLE RELAXANT 1/2,80369,CPT,,78080369,CDM,301,RC,,,both,,,100,74,,,74,Other,150% of Medicare + 9.63% HCRA Surcharge,45,45,,45,percent of total billed charges,Critical Access Hospital RCC factor,65,65,,65,percent of total billed charges,All Other,59,65,,59,percent of total billed charges,All Other,9.99,,,9.99,Fee Schedule,,9.99,,,9.99,Fee Schedule,,9.99,,,9.99,Fee Schedule,,49.5,,,49.5,Other,110% of Medicare,68,68,,68,percent of total billed charges,All Other,0.01,,,0.01,Other,186% of Medicaid,83,83,,83,percent of total billed charges,All Other,62,62,,62,percent of total billed charges,Lab and Radiology,55,55,,55,percent of total billed charges,Default if not on Fee Schedule,80,80,,80,percent of total billed charges,All Other,62,62,,62,percent of total billed charges,Lab and Radiology,80,80,,80,percent of total billed charges,All Other,70,70,,70,percent of total billed charges,All Other,65,65,,65,percent of total billed charges,Default if not in Fee Schedule,65,65,,65,percent of total billed charges,Default if not in Fee Schedule,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,83,
SKEL MUSC RELAXANT 3 OR MORE,80370,CPT,,78080370,CDM,301,RC,,,both,,,107,79.18,,,79.18,Other,150% of Medicare + 9.63% HCRA Surcharge,48.15,45,,48.15,percent of total billed charges,Critical Access Hospital RCC factor,69.55,65,,69.55,percent of total billed charges,All Other,63.13,65,,63.13,percent of total billed charges,All Other,10.99,,,10.99,Fee Schedule,,10.99,,,10.99,Fee Schedule,,10.99,,,10.99,Fee Schedule,,52.97,,,52.97,Other,110% of Medicare,72.76,68,,72.76,percent of total billed charges,All Other,0.01,,,0.01,Other,186% of Medicaid,88.81,83,,88.81,percent of total billed charges,All Other,66.34,62,,66.34,percent of total billed charges,Lab and Radiology,58.85,55,,58.85,percent of total billed charges,Default if not on Fee Schedule,85.6,80,,85.6,percent of total billed charges,All Other,66.34,62,,66.34,percent of total billed charges,Lab and Radiology,85.6,80,,85.6,percent of total billed charges,All Other,74.9,70,,74.9,percent of total billed charges,All Other,69.55,65,,69.55,percent of total billed charges,Default if not in Fee Schedule,69.55,65,,69.55,percent of total billed charges,Default if not in Fee Schedule,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,88.81,
STIMULANTS SYNTHETIC,80371,CPT,,78080371,CDM,301,RC,,,both,,,86,63.64,,,63.64,Other,150% of Medicare + 9.63% HCRA Surcharge,38.7,45,,38.7,percent of total billed charges,Critical Access Hospital RCC factor,55.9,65,,55.9,percent of total billed charges,All Other,50.74,65,,50.74,percent of total billed charges,All Other,8.81,,,8.81,Fee Schedule,,8.81,,,8.81,Fee Schedule,,8.81,,,8.81,Fee Schedule,,42.57,,,42.57,Other,110% of Medicare,58.48,68,,58.48,percent of total billed charges,All Other,0.01,,,0.01,Other,186% of Medicaid,71.38,83,,71.38,percent of total billed charges,All Other,53.32,62,,53.32,percent of total billed charges,Lab and Radiology,47.3,55,,47.3,percent of total billed charges,Default if not on Fee Schedule,68.8,80,,68.8,percent of total billed charges,All Other,53.32,62,,53.32,percent of total billed charges,Lab and Radiology,68.8,80,,68.8,percent of total billed charges,All Other,60.2,70,,60.2,percent of total billed charges,All Other,55.9,65,,55.9,percent of total billed charges,Default if not in Fee Schedule,55.9,65,,55.9,percent of total billed charges,Default if not in Fee Schedule,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,71.38,
DRUG SCREENING TAPENTADOL,80372,CPT,,78080372,CDM,301,RC,,,both,,,86,63.64,,,63.64,Other,150% of Medicare + 9.63% HCRA Surcharge,38.7,45,,38.7,percent of total billed charges,Critical Access Hospital RCC factor,55.9,65,,55.9,percent of total billed charges,All Other,50.74,65,,50.74,percent of total billed charges,All Other,11.46,,,11.46,Fee Schedule,,11.46,,,11.46,Fee Schedule,,11.46,,,11.46,Fee Schedule,,42.57,,,42.57,Other,110% of Medicare,58.48,68,,58.48,percent of total billed charges,All Other,0.01,,,0.01,Other,186% of Medicaid,71.38,83,,71.38,percent of total billed charges,All Other,53.32,62,,53.32,percent of total billed charges,Lab and Radiology,47.3,55,,47.3,percent of total billed charges,Default if not on Fee Schedule,68.8,80,,68.8,percent of total billed charges,All Other,53.32,62,,53.32,percent of total billed charges,Lab and Radiology,68.8,80,,68.8,percent of total billed charges,All Other,60.2,70,,60.2,percent of total billed charges,All Other,55.9,65,,55.9,percent of total billed charges,Default if not in Fee Schedule,55.9,65,,55.9,percent of total billed charges,Default if not in Fee Schedule,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,71.38,
DRUG SCREENING TRAMADOL,80373,CPT,,78080373,CDM,301,RC,,,both,,,92,68.08,,,68.08,Other,150% of Medicare + 9.63% HCRA Surcharge,41.4,45,,41.4,percent of total billed charges,Critical Access Hospital RCC factor,59.8,65,,59.8,percent of total billed charges,All Other,54.28,65,,54.28,percent of total billed charges,All Other,11.02,,,11.02,Fee Schedule,,11.02,,,11.02,Fee Schedule,,11.02,,,11.02,Fee Schedule,,45.54,,,45.54,Other,110% of Medicare,62.56,68,,62.56,percent of total billed charges,All Other,0.01,,,0.01,Other,186% of Medicaid,76.36,83,,76.36,percent of total billed charges,All Other,57.04,62,,57.04,percent of total billed charges,Lab and Radiology,50.6,55,,50.6,percent of total billed charges,Default if not on Fee Schedule,73.6,80,,73.6,percent of total billed charges,All Other,57.04,62,,57.04,percent of total billed charges,Lab and Radiology,73.6,80,,73.6,percent of total billed charges,All Other,64.4,70,,64.4,percent of total billed charges,All Other,59.8,65,,59.8,percent of total billed charges,Default if not in Fee Schedule,59.8,65,,59.8,percent of total billed charges,Default if not in Fee Schedule,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,76.36,
STEREOISOMER ANALYSIS,80374,CPT,,78080374,CDM,301,RC,,,both,,,86,63.64,,,63.64,Other,150% of Medicare + 9.63% HCRA Surcharge,38.7,45,,38.7,percent of total billed charges,Critical Access Hospital RCC factor,55.9,65,,55.9,percent of total billed charges,All Other,50.74,65,,50.74,percent of total billed charges,All Other,10.23,,,10.23,Fee Schedule,,10.23,,,10.23,Fee Schedule,,10.23,,,10.23,Fee Schedule,,42.57,,,42.57,Other,110% of Medicare,58.48,68,,58.48,percent of total billed charges,All Other,0.01,,,0.01,Other,186% of Medicaid,71.38,83,,71.38,percent of total billed charges,All Other,53.32,62,,53.32,percent of total billed charges,Lab and Radiology,47.3,55,,47.3,percent of total billed charges,Default if not on Fee Schedule,68.8,80,,68.8,percent of total billed charges,All Other,53.32,62,,53.32,percent of total billed charges,Lab and Radiology,68.8,80,,68.8,percent of total billed charges,All Other,60.2,70,,60.2,percent of total billed charges,All Other,55.9,65,,55.9,percent of total billed charges,Default if not in Fee Schedule,55.9,65,,55.9,percent of total billed charges,Default if not in Fee Schedule,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,71.38,
DRUG/SUBSTANCE NOS 1-3,80375,CPT,,78080375,CDM,301,RC,,,both,,,93,68.82,,,68.82,Other,150% of Medicare + 9.63% HCRA Surcharge,41.85,45,,41.85,percent of total billed charges,Critical Access Hospital RCC factor,60.45,65,,60.45,percent of total billed charges,All Other,54.87,65,,54.87,percent of total billed charges,All Other,10.23,,,10.23,Fee Schedule,,10.23,,,10.23,Fee Schedule,,10.23,,,10.23,Fee Schedule,,46.04,,,46.04,Other,110% of Medicare,63.24,68,,63.24,percent of total billed charges,All Other,0.01,,,0.01,Other,186% of Medicaid,77.19,83,,77.19,percent of total billed charges,All Other,57.66,62,,57.66,percent of total billed charges,Lab and Radiology,51.15,55,,51.15,percent of total billed charges,Default if not on Fee Schedule,74.4,80,,74.4,percent of total billed charges,All Other,57.66,62,,57.66,percent of total billed charges,Lab and Radiology,74.4,80,,74.4,percent of total billed charges,All Other,65.1,70,,65.1,percent of total billed charges,All Other,60.45,65,,60.45,percent of total billed charges,Default if not in Fee Schedule,60.45,65,,60.45,percent of total billed charges,Default if not in Fee Schedule,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,77.19,
DRUG/SUBSTANCE NOS 4-6,80376,CPT,,78080376,CDM,301,RC,,,both,,,107,79.18,,,79.18,Other,150% of Medicare + 9.63% HCRA Surcharge,48.15,45,,48.15,percent of total billed charges,Critical Access Hospital RCC factor,69.55,65,,69.55,percent of total billed charges,All Other,63.13,65,,63.13,percent of total billed charges,All Other,11.25,,,11.25,Fee Schedule,,11.25,,,11.25,Fee Schedule,,11.25,,,11.25,Fee Schedule,,52.97,,,52.97,Other,110% of Medicare,72.76,68,,72.76,percent of total billed charges,All Other,0.01,,,0.01,Other,186% of Medicaid,88.81,83,,88.81,percent of total billed charges,All Other,66.34,62,,66.34,percent of total billed charges,Lab and Radiology,58.85,55,,58.85,percent of total billed charges,Default if not on Fee Schedule,85.6,80,,85.6,percent of total billed charges,All Other,66.34,62,,66.34,percent of total billed charges,Lab and Radiology,85.6,80,,85.6,percent of total billed charges,All Other,74.9,70,,74.9,percent of total billed charges,All Other,69.55,65,,69.55,percent of total billed charges,Default if not in Fee Schedule,69.55,65,,69.55,percent of total billed charges,Default if not in Fee Schedule,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,88.81,
DRUG/SUBSTANCE NOS 7/MORE,80377,CPT,,78080377,CDM,301,RC,,,both,,,133,98.42,,,98.42,Other,150% of Medicare + 9.63% HCRA Surcharge,59.85,45,,59.85,percent of total billed charges,Critical Access Hospital RCC factor,86.45,65,,86.45,percent of total billed charges,All Other,78.47,65,,78.47,percent of total billed charges,All Other,12.28,,,12.28,Fee Schedule,,12.28,,,12.28,Fee Schedule,,12.28,,,12.28,Fee Schedule,,65.84,,,65.84,Other,110% of Medicare,90.44,68,,90.44,percent of total billed charges,All Other,0.01,,,0.01,Other,186% of Medicaid,110.39,83,,110.39,percent of total billed charges,All Other,82.46,62,,82.46,percent of total billed charges,Lab and Radiology,73.15,55,,73.15,percent of total billed charges,Default if not on Fee Schedule,106.4,80,,106.4,percent of total billed charges,All Other,82.46,62,,82.46,percent of total billed charges,Lab and Radiology,106.4,80,,106.4,percent of total billed charges,All Other,93.1,70,,93.1,percent of total billed charges,All Other,86.45,65,,86.45,percent of total billed charges,Default if not in Fee Schedule,86.45,65,,86.45,percent of total billed charges,Default if not in Fee Schedule,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,110.39,
INSULIN TOLERANCE PANEL,80434,CPT,,78080434,CDM,301,RC,,,both,,,718,531.32,,,531.32,Other,150% of Medicare + 9.63% HCRA Surcharge,323.1,45,,323.1,percent of total billed charges,Critical Access Hospital RCC factor,857.94,,,857.94,Fee Schedule,,772.43,,,772.43,Fee Schedule,,750.18,,,750.18,Fee Schedule,,674.74,,,674.74,Fee Schedule,,637.73,,,637.73,Fee Schedule,,355.41,,,355.41,Other,110% of Medicare,897.84,,,897.84,Fee Schedule,,0.01,,,0.01,Other,186% of Medicaid,1057.46,,,1057.46,Fee Schedule,,445.16,,,445.16,Fee Schedule,,598.56,,,598.56,Fee Schedule,,1057.46,,,1057.46,Fee Schedule,,445.16,,,445.16,Fee Schedule,,1125.87,,,1125.87,Fee Schedule,,502.6,70,,502.6,percent of total billed charges,All Other,1350.77,,,1350.77,Fee Schedule,,1144.86,,,1144.86,Fee Schedule,,427.55,,,427.55,Fee Schedule,,427.55,,,427.55,Fee Schedule,,427.55,,,427.55,Fee Schedule,,427.55,,,427.55,Fee Schedule,,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1350.77,
TRH STIMULATION PANEL,80438,CPT,,78080438,CDM,301,RC,,,both,,,291,215.34,,,215.34,Other,150% of Medicare + 9.63% HCRA Surcharge,130.95,45,,130.95,percent of total billed charges,Critical Access Hospital RCC factor,151.73,,,151.73,Fee Schedule,,136.61,,,136.61,Fee Schedule,,373.75,,,373.75,Fee Schedule,,336.16,,,336.16,Fee Schedule,,317.72,,,317.72,Fee Schedule,,144.05,,,144.05,Other,110% of Medicare,158.79,,,158.79,Fee Schedule,,34,,,34,Other,186% of Medicaid,187.02,,,187.02,Fee Schedule,,180.42,,,180.42,Fee Schedule,,105.86,,,105.86,Fee Schedule,,187.02,,,187.02,Fee Schedule,,180.42,,,180.42,Fee Schedule,,199.12,,,199.12,Fee Schedule,,203.7,70,,203.7,percent of total billed charges,All Other,238.89,,,238.89,Fee Schedule,,202.48,,,202.48,Fee Schedule,,75.62,,,75.62,Fee Schedule,,75.62,,,75.62,Fee Schedule,,75.62,,,75.62,Fee Schedule,,75.62,,,75.62,Fee Schedule,,18.18,,,18.18,Other,100% of Medicaid,18.18,,,18.18,Other,100% of Medicaid,18.18,,,18.18,Other,100% of Medicaid,18.18,,,18.18,Other,100% of Medicaid,40.91,,,40.91,Other,225% of Medicaid,27.82,,,27.82,Other,153% of Medicaid,40.91,,,40.91,Other,225% of Medicaid,25.45,,,25.45,Other,140% of Medicaid,40.91,,,40.91,Other,225% of Medicaid,47.27,,,47.27,Other,260% of Medicaid,58.9,,,58.9,Other,324% of Medicaid,39.09,,,39.09,Other,215% of Medicaid,39.09,,,39.09,Other,215% of Medicaid,22.73,,,22.73,Other,125% of Medicaid,18.18,373.75,
HPA-1 GENOTYPING,81105,CPT,,78081105,CDM,301,RC,,,both,,,386,285.64,,,285.64,Other,150% of Medicare + 9.63% HCRA Surcharge,173.7,45,,173.7,percent of total billed charges,Critical Access Hospital RCC factor,367.88,,,367.88,Fee Schedule,,331.22,,,331.22,Fee Schedule,,295.29,76.5,,295.29,percent of total billed charges,All Other,274.06,69,,274.06,percent of total billed charges,All Other,266.34,65,,266.34,percent of total billed charges,All Other,191.07,,,191.07,Other,110% of Medicare,384.99,,,384.99,Fee Schedule,,0.01,,,0.01,Other,186% of Medicaid,453.44,,,453.44,Fee Schedule,,239.32,,,239.32,Fee Schedule,,256.66,,,256.66,Fee Schedule,,453.44,,,453.44,Fee Schedule,,239.32,,,239.32,Fee Schedule,,482.77,,,482.77,Fee Schedule,,270.2,70,,270.2,percent of total billed charges,All Other,579.2,,,579.2,Fee Schedule,,490.91,,,490.91,Fee Schedule,,183.33,,,183.33,Fee Schedule,,183.33,,,183.33,Fee Schedule,,183.33,,,183.33,Fee Schedule,,183.33,,,183.33,Fee Schedule,,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,579.2,
IDH1 COMMON VARIANTS,81120,CPT,,78081120,CDM,301,RC,,,both,,,609,450.66,,,450.66,Other,150% of Medicare + 9.63% HCRA Surcharge,274.05,45,,274.05,percent of total billed charges,Critical Access Hospital RCC factor,581.68,,,581.68,Fee Schedule,,523.71,,,523.71,Fee Schedule,,77.3,,,77.3,Fee Schedule,,77.3,,,77.3,Fee Schedule,,77.3,,,77.3,Fee Schedule,,301.46,,,301.46,Other,110% of Medicare,608.74,,,608.74,Fee Schedule,,0.01,,,0.01,Other,186% of Medicaid,716.96,,,716.96,Fee Schedule,,377.58,,,377.58,Fee Schedule,,405.83,,,405.83,Fee Schedule,,716.96,,,716.96,Fee Schedule,,377.58,,,377.58,Fee Schedule,,763.34,,,763.34,Fee Schedule,,426.3,70,,426.3,percent of total billed charges,All Other,915.82,,,915.82,Fee Schedule,,776.21,,,776.21,Fee Schedule,,289.88,,,289.88,Fee Schedule,,289.88,,,289.88,Fee Schedule,,289.88,,,289.88,Fee Schedule,,289.88,,,289.88,Fee Schedule,,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,915.82,
IDH2 COMMON VARIANTS,81121,CPT,,78081121,CDM,301,RC,,,both,,,933,690.42,,,690.42,Other,150% of Medicare + 9.63% HCRA Surcharge,419.85,45,,419.85,percent of total billed charges,Critical Access Hospital RCC factor,890.33,,,890.33,Fee Schedule,,801.59,,,801.59,Fee Schedule,,713.75,76.5,,713.75,percent of total billed charges,All Other,662.43,69,,662.43,percent of total billed charges,All Other,643.77,65,,643.77,percent of total billed charges,All Other,461.84,,,461.84,Other,110% of Medicare,931.74,,,931.74,Fee Schedule,,0.01,,,0.01,Other,186% of Medicaid,1097.38,,,1097.38,Fee Schedule,,578.46,,,578.46,Fee Schedule,,621.16,,,621.16,Fee Schedule,,1097.38,,,1097.38,Fee Schedule,,578.46,,,578.46,Fee Schedule,,1168.37,,,1168.37,Fee Schedule,,653.1,70,,653.1,percent of total billed charges,All Other,1401.76,,,1401.76,Fee Schedule,,1188.08,,,1188.08,Fee Schedule,,443.69,,,443.69,Fee Schedule,,443.69,,,443.69,Fee Schedule,,443.69,,,443.69,Fee Schedule,,443.69,,,443.69,Fee Schedule,,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1401.76,
BRCA1&2 SEQ & FULL DUP/DEL,81162,CPT,,78081162,CDM,301,RC,,,both,,,8236,6094.66,,,6094.66,Other,150% of Medicare + 9.63% HCRA Surcharge,3706.2,45,,3706.2,percent of total billed charges,Critical Access Hospital RCC factor,5492.89,,,5492.89,Fee Schedule,,4945.42,,,4945.42,Fee Schedule,,994.34,,,994.34,Fee Schedule,,994.34,,,994.34,Fee Schedule,,994.34,,,994.34,Fee Schedule,,4076.82,,,4076.82,Other,110% of Medicare,5748.37,,,5748.37,Fee Schedule,,0.01,,,0.01,Other,186% of Medicaid,6770.3,,,6770.3,Fee Schedule,,5106.32,,,5106.32,Fee Schedule,,3832.25,,,3832.25,Fee Schedule,,6770.3,,,6770.3,Fee Schedule,,5106.32,,,5106.32,Fee Schedule,,7208.28,,,7208.28,Fee Schedule,,5765.2,70,,5765.2,percent of total billed charges,All Other,8648.17,,,8648.17,Fee Schedule,,7329.85,,,7329.85,Fee Schedule,,2737.32,,,2737.32,Fee Schedule,,2737.32,,,2737.32,Fee Schedule,,2737.32,,,2737.32,Fee Schedule,,2737.32,,,2737.32,Fee Schedule,,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,8648.17,
ABL 1 GENE,81170,CPT,,78081170,CDM,301,RC,,,both,,,910,673.4,,,673.4,Other,150% of Medicare + 9.63% HCRA Surcharge,409.5,45,,409.5,percent of total billed charges,Critical Access Hospital RCC factor,903,,,903,Fee Schedule,,813,,,813,Fee Schedule,,131.8,,,131.8,Fee Schedule,,131.8,,,131.8,Fee Schedule,,131.8,,,131.8,Fee Schedule,,450.45,,,450.45,Other,110% of Medicare,945,,,945,Fee Schedule,,371,,,371,Other,186% of Medicaid,1113,,,1113,Fee Schedule,,564.2,,,564.2,Fee Schedule,,630,,,630,Fee Schedule,,1113,,,1113,Fee Schedule,,564.2,,,564.2,Fee Schedule,,1185,,,1185,Fee Schedule,,637,70,,637,percent of total billed charges,All Other,1421.71,,,1421.71,Fee Schedule,,1204.99,,,1204.99,Fee Schedule,,450,,,450,Fee Schedule,,450,,,450,Fee Schedule,,450,,,450,Fee Schedule,,450,,,450,Fee Schedule,,199.69,,,199.69,Other,100% of Medicaid,199.69,,,199.69,Other,100% of Medicaid,199.69,,,199.69,Other,100% of Medicaid,199.69,,,199.69,Other,100% of Medicaid,449.3,,,449.3,Other,225% of Medicaid,305.52,,,305.52,Other,153% of Medicaid,449.3,,,449.3,Other,225% of Medicaid,279.56,,,279.56,Other,140% of Medicaid,449.3,,,449.3,Other,225% of Medicaid,519.19,,,519.19,Other,260% of Medicaid,646.99,,,646.99,Other,324% of Medicaid,429.33,,,429.33,Other,215% of Medicaid,429.33,,,429.33,Other,215% of Medicaid,249.61,,,249.61,Other,125% of Medicaid,131.8,1421.71,
BCR/ABL1 GENE MAJOR BP,81206,CPT,,78081206,CDM,301,RC,,,both,,,849,628.26,,,628.26,Other,150% of Medicare + 9.63% HCRA Surcharge,382.05,45,,382.05,percent of total billed charges,Critical Access Hospital RCC factor,493.52,,,493.52,Fee Schedule,,444.33,,,444.33,Fee Schedule,,24.24,,,24.24,Fee Schedule,,24.24,,,24.24,Fee Schedule,,24.24,,,24.24,Fee Schedule,,420.26,,,420.26,Other,110% of Medicare,516.47,,,516.47,Fee Schedule,,305,,,305,Other,186% of Medicaid,608.29,,,608.29,Fee Schedule,,526.38,,,526.38,Fee Schedule,,344.32,,,344.32,Fee Schedule,,608.29,,,608.29,Fee Schedule,,526.38,,,526.38,Fee Schedule,,647.64,,,647.64,Fee Schedule,,594.3,70,,594.3,percent of total billed charges,All Other,777.01,,,777.01,Fee Schedule,,658.57,,,658.57,Fee Schedule,,245.94,,,245.94,Fee Schedule,,245.94,,,245.94,Fee Schedule,,245.94,,,245.94,Fee Schedule,,245.94,,,245.94,Fee Schedule,,163.96,,,163.96,Other,100% of Medicaid,163.96,,,163.96,Other,100% of Medicaid,163.96,,,163.96,Other,100% of Medicaid,163.96,,,163.96,Other,100% of Medicaid,368.91,,,368.91,Other,225% of Medicaid,250.86,,,250.86,Other,153% of Medicaid,368.91,,,368.91,Other,225% of Medicaid,229.54,,,229.54,Other,140% of Medicaid,368.91,,,368.91,Other,225% of Medicaid,426.3,,,426.3,Other,260% of Medicaid,531.23,,,531.23,Other,324% of Medicaid,352.51,,,352.51,Other,215% of Medicaid,352.51,,,352.51,Other,215% of Medicaid,204.95,,,204.95,Other,125% of Medicaid,24.24,777.01,
BCR/ABL1 GENE MINOR BP,81207,CPT,,78081207,CDM,301,RC,,,both,,,750,555,,,555,Other,150% of Medicare + 9.63% HCRA Surcharge,337.5,45,,337.5,percent of total billed charges,Critical Access Hospital RCC factor,435.97,,,435.97,Fee Schedule,,392.52,,,392.52,Fee Schedule,,24.24,,,24.24,Fee Schedule,,24.24,,,24.24,Fee Schedule,,24.24,,,24.24,Fee Schedule,,371.25,,,371.25,Other,110% of Medicare,456.25,,,456.25,Fee Schedule,,269,,,269,Other,186% of Medicaid,537.36,,,537.36,Fee Schedule,,465,,,465,Fee Schedule,,304.16,,,304.16,Fee Schedule,,537.36,,,537.36,Fee Schedule,,465,,,465,Fee Schedule,,572.12,,,572.12,Fee Schedule,,525,70,,525,percent of total billed charges,All Other,686.4,,,686.4,Fee Schedule,,581.77,,,581.77,Fee Schedule,,217.26,,,217.26,Fee Schedule,,217.26,,,217.26,Fee Schedule,,217.26,,,217.26,Fee Schedule,,217.26,,,217.26,Fee Schedule,,144.84,,,144.84,Other,100% of Medicaid,144.84,,,144.84,Other,100% of Medicaid,144.84,,,144.84,Other,100% of Medicaid,144.84,,,144.84,Other,100% of Medicaid,325.89,,,325.89,Other,225% of Medicaid,221.61,,,221.61,Other,153% of Medicaid,325.89,,,325.89,Other,225% of Medicaid,202.78,,,202.78,Other,140% of Medicaid,325.89,,,325.89,Other,225% of Medicaid,376.58,,,376.58,Other,260% of Medicaid,469.28,,,469.28,Other,324% of Medicaid,311.41,,,311.41,Other,215% of Medicaid,311.41,,,311.41,Other,215% of Medicaid,181.05,,,181.05,Other,125% of Medicaid,24.24,686.4,
BRAF GENE,81210,CPT,,78081210,CDM,301,RC,,,both,,,659,487.66,,,487.66,Other,150% of Medicare + 9.63% HCRA Surcharge,296.55,45,,296.55,percent of total billed charges,Critical Access Hospital RCC factor,527.95,,,527.95,Fee Schedule,,475.33,,,475.33,Fee Schedule,,35.94,,,35.94,Fee Schedule,,35.94,,,35.94,Fee Schedule,,35.94,,,35.94,Fee Schedule,,326.21,,,326.21,Other,110% of Medicare,552.51,,,552.51,Fee Schedule,,326,,,326,Other,186% of Medicaid,650.73,,,650.73,Fee Schedule,,408.58,,,408.58,Fee Schedule,,368.34,,,368.34,Fee Schedule,,650.73,,,650.73,Fee Schedule,,408.58,,,408.58,Fee Schedule,,692.83,,,692.83,Fee Schedule,,461.3,70,,461.3,percent of total billed charges,All Other,831.23,,,831.23,Fee Schedule,,704.52,,,704.52,Fee Schedule,,263.1,,,263.1,Fee Schedule,,263.1,,,263.1,Fee Schedule,,263.1,,,263.1,Fee Schedule,,263.1,,,263.1,Fee Schedule,,175.4,,,175.4,Other,100% of Medicaid,175.4,,,175.4,Other,100% of Medicaid,175.4,,,175.4,Other,100% of Medicaid,175.4,,,175.4,Other,100% of Medicaid,394.65,,,394.65,Other,225% of Medicaid,268.36,,,268.36,Other,153% of Medicaid,394.65,,,394.65,Other,225% of Medicaid,245.56,,,245.56,Other,140% of Medicaid,394.65,,,394.65,Other,225% of Medicaid,456.04,,,456.04,Other,260% of Medicaid,568.3,,,568.3,Other,324% of Medicaid,377.11,,,377.11,Other,215% of Medicaid,377.11,,,377.11,Other,215% of Medicaid,219.25,,,219.25,Other,125% of Medicaid,35.94,831.23,
BRCA1 GENE KNOWN FAM VARIANT,81215,CPT,,78081215,CDM,301,RC,,,both,,,752,556.48,,,556.48,Other,150% of Medicare + 9.63% HCRA Surcharge,338.4,45,,338.4,percent of total billed charges,Critical Access Hospital RCC factor,1129.5,,,1129.5,Fee Schedule,,1016.93,,,1016.93,Fee Schedule,,167.2,,,167.2,Fee Schedule,,167.2,,,167.2,Fee Schedule,,167.2,,,167.2,Fee Schedule,,372.24,,,372.24,Other,110% of Medicare,1182.04,,,1182.04,Fee Schedule,,175,,,175,Other,186% of Medicaid,1392.18,,,1392.18,Fee Schedule,,466.24,,,466.24,Fee Schedule,,788.03,,,788.03,Fee Schedule,,1392.18,,,1392.18,Fee Schedule,,466.24,,,466.24,Fee Schedule,,1482.24,,,1482.24,Fee Schedule,,526.4,70,,526.4,percent of total billed charges,All Other,1778.32,,,1778.32,Fee Schedule,,1507.24,,,1507.24,Fee Schedule,,562.88,,,562.88,Fee Schedule,,562.88,,,562.88,Fee Schedule,,562.88,,,562.88,Fee Schedule,,562.88,,,562.88,Fee Schedule,,94.17,,,94.17,Other,100% of Medicaid,94.17,,,94.17,Other,100% of Medicaid,94.17,,,94.17,Other,100% of Medicaid,94.17,,,94.17,Other,100% of Medicaid,211.89,,,211.89,Other,225% of Medicaid,144.08,,,144.08,Other,153% of Medicaid,211.89,,,211.89,Other,225% of Medicaid,131.84,,,131.84,Other,140% of Medicaid,211.89,,,211.89,Other,225% of Medicaid,244.85,,,244.85,Other,260% of Medicaid,305.12,,,305.12,Other,324% of Medicaid,202.47,,,202.47,Other,215% of Medicaid,202.47,,,202.47,Other,215% of Medicaid,117.72,,,117.72,Other,125% of Medicaid,94.17,1778.32,
CFTR GENE COM VARIANTS,81220,CPT,,78081220,CDM,301,RC,,,both,,,1115,825.1,,,825.1,Other,150% of Medicare + 9.63% HCRA Surcharge,501.75,45,,501.75,percent of total billed charges,Critical Access Hospital RCC factor,1675.37,,,1675.37,Fee Schedule,,1508.39,,,1508.39,Fee Schedule,,179.18,,,179.18,Fee Schedule,,179.18,,,179.18,Fee Schedule,,179.18,,,179.18,Fee Schedule,,551.93,,,551.93,Other,110% of Medicare,1753.29,,,1753.29,Fee Schedule,,611,,,611,Other,186% of Medicaid,2064.99,,,2064.99,Fee Schedule,,691.3,,,691.3,Fee Schedule,,1168.86,,,1168.86,Fee Schedule,,2064.99,,,2064.99,Fee Schedule,,691.3,,,691.3,Fee Schedule,,2198.57,,,2198.57,Fee Schedule,,780.5,70,,780.5,percent of total billed charges,All Other,2637.75,,,2637.75,Fee Schedule,,2235.65,,,2235.65,Fee Schedule,,834.9,,,834.9,Fee Schedule,,834.9,,,834.9,Fee Schedule,,834.9,,,834.9,Fee Schedule,,834.9,,,834.9,Fee Schedule,,328.25,,,328.25,Other,100% of Medicaid,328.25,,,328.25,Other,100% of Medicaid,328.25,,,328.25,Other,100% of Medicaid,328.25,,,328.25,Other,100% of Medicaid,738.56,,,738.56,Other,225% of Medicaid,502.22,,,502.22,Other,153% of Medicaid,738.56,,,738.56,Other,225% of Medicaid,459.55,,,459.55,Other,140% of Medicaid,738.56,,,738.56,Other,225% of Medicaid,853.45,,,853.45,Other,260% of Medicaid,1063.53,,,1063.53,Other,324% of Medicaid,705.74,,,705.74,Other,215% of Medicaid,705.74,,,705.74,Other,215% of Medicaid,410.31,,,410.31,Other,125% of Medicaid,179.18,2637.75,
CFTR GENE DUP/DELET VARIANTS,81222,CPT,,78081222,CDM,301,RC,,,both,,,1372,1015.28,,,1015.28,Other,150% of Medicare + 9.63% HCRA Surcharge,617.4,45,,617.4,percent of total billed charges,Critical Access Hospital RCC factor,1309.56,,,1309.56,Fee Schedule,,1179.04,,,1179.04,Fee Schedule,,48.31,,,48.31,Fee Schedule,,48.31,,,48.31,Fee Schedule,,48.31,,,48.31,Fee Schedule,,679.14,,,679.14,Other,110% of Medicare,1370.47,,,1370.47,Fee Schedule,,0.01,,,0.01,Other,186% of Medicaid,1614.11,,,1614.11,Fee Schedule,,850.64,,,850.64,Fee Schedule,,913.65,,,913.65,Fee Schedule,,1614.11,,,1614.11,Fee Schedule,,850.64,,,850.64,Fee Schedule,,1718.53,,,1718.53,Fee Schedule,,960.4,70,,960.4,percent of total billed charges,All Other,2061.81,,,2061.81,Fee Schedule,,1747.51,,,1747.51,Fee Schedule,,652.61,,,652.61,Fee Schedule,,652.61,,,652.61,Fee Schedule,,652.61,,,652.61,Fee Schedule,,652.61,,,652.61,Fee Schedule,,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2061.81,
CFTR GENE FULL SEQUENCE,81223,CPT,,78081223,CDM,301,RC,,,both,,,6520,4824.82,,,4824.82,Other,150% of Medicare + 9.63% HCRA Surcharge,2934,45,,2934,percent of total billed charges,Critical Access Hospital RCC factor,1501.99,,,1501.99,Fee Schedule,,1352.29,,,1352.29,Fee Schedule,,243.71,,,243.71,Fee Schedule,,243.71,,,243.71,Fee Schedule,,243.71,,,243.71,Fee Schedule,,3227.4,,,3227.4,Other,110% of Medicare,1571.85,,,1571.85,Fee Schedule,,0.01,,,0.01,Other,186% of Medicaid,1851.29,,,1851.29,Fee Schedule,,4042.4,,,4042.4,Fee Schedule,,1047.9,,,1047.9,Fee Schedule,,1851.29,,,1851.29,Fee Schedule,,4042.4,,,4042.4,Fee Schedule,,1971.05,,,1971.05,Fee Schedule,,4564,70,,4564,percent of total billed charges,All Other,2364.78,,,2364.78,Fee Schedule,,2004.29,,,2004.29,Fee Schedule,,748.5,,,748.5,Fee Schedule,,748.5,,,748.5,Fee Schedule,,748.5,,,748.5,Fee Schedule,,748.5,,,748.5,Fee Schedule,,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4824.82,
CYP2C19 GENE COM VARIANTS,81225,CPT,,78081225,CDM,301,RC,,,both,,,876,648.24,,,648.24,Other,150% of Medicare + 9.63% HCRA Surcharge,394.2,45,,394.2,percent of total billed charges,Critical Access Hospital RCC factor,876.99,,,876.99,Fee Schedule,,789.59,,,789.59,Fee Schedule,,40.48,,,40.48,Fee Schedule,,40.48,,,40.48,Fee Schedule,,40.48,,,40.48,Fee Schedule,,433.62,,,433.62,Other,110% of Medicare,917.78,,,917.78,Fee Schedule,,0.01,,,0.01,Other,186% of Medicaid,1080.95,,,1080.95,Fee Schedule,,543.12,,,543.12,Fee Schedule,,611.86,,,611.86,Fee Schedule,,1080.95,,,1080.95,Fee Schedule,,543.12,,,543.12,Fee Schedule,,1150.87,,,1150.87,Fee Schedule,,613.2,70,,613.2,percent of total billed charges,All Other,1380.77,,,1380.77,Fee Schedule,,1170.28,,,1170.28,Fee Schedule,,437.04,,,437.04,Fee Schedule,,437.04,,,437.04,Fee Schedule,,437.04,,,437.04,Fee Schedule,,437.04,,,437.04,Fee Schedule,,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1380.77,
CYTOGEN M ARRAY COPY NO&SNP,81229,CPT,,78081229,CDM,301,RC,,,both,,,3654,2703.97,,,2703.97,Other,150% of Medicare + 9.63% HCRA Surcharge,1644.3,45,,1644.3,percent of total billed charges,Critical Access Hospital RCC factor,3491.6,,,3491.6,Fee Schedule,,3143.6,,,3143.6,Fee Schedule,,14.7,,,14.7,Fee Schedule,,14.7,,,14.7,Fee Schedule,,14.7,,,14.7,Fee Schedule,,1808.73,,,1808.73,Other,110% of Medicare,3654,,,3654,Fee Schedule,,0.01,,,0.01,Other,186% of Medicaid,4303.6,,,4303.6,Fee Schedule,,2265.48,,,2265.48,Fee Schedule,,2436,,,2436,Fee Schedule,,4303.6,,,4303.6,Fee Schedule,,2265.48,,,2265.48,Fee Schedule,,4582,,,4582,Fee Schedule,,2557.8,70,,2557.8,percent of total billed charges,All Other,5497.28,,,5497.28,Fee Schedule,,4659.28,,,4659.28,Fee Schedule,,1740,,,1740,Fee Schedule,,1740,,,1740,Fee Schedule,,1740,,,1740,Fee Schedule,,1740,,,1740,Fee Schedule,,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5497.28,
F2 GENE,81240,CPT,,78081240,CDM,301,RC,,,both,,,429,317.46,,,317.46,Other,150% of Medicare + 9.63% HCRA Surcharge,193.05,45,,193.05,percent of total billed charges,Critical Access Hospital RCC factor,197.73,,,197.73,Fee Schedule,,178.02,,,178.02,Fee Schedule,,20.27,,,20.27,Fee Schedule,,20.27,,,20.27,Fee Schedule,,20.27,,,20.27,Fee Schedule,,212.36,,,212.36,Other,110% of Medicare,206.92,,,206.92,Fee Schedule,,122,,,122,Other,186% of Medicaid,243.71,,,243.71,Fee Schedule,,265.98,,,265.98,Fee Schedule,,137.95,,,137.95,Fee Schedule,,243.71,,,243.71,Fee Schedule,,265.98,,,265.98,Fee Schedule,,259.48,,,259.48,Fee Schedule,,300.3,70,,300.3,percent of total billed charges,All Other,311.31,,,311.31,Fee Schedule,,263.85,,,263.85,Fee Schedule,,98.54,,,98.54,Fee Schedule,,98.54,,,98.54,Fee Schedule,,98.54,,,98.54,Fee Schedule,,98.54,,,98.54,Fee Schedule,,65.69,,,65.69,Other,100% of Medicaid,65.69,,,65.69,Other,100% of Medicaid,65.69,,,65.69,Other,100% of Medicaid,65.69,,,65.69,Other,100% of Medicaid,147.8,,,147.8,Other,225% of Medicaid,100.51,,,100.51,Other,153% of Medicaid,147.8,,,147.8,Other,225% of Medicaid,91.97,,,91.97,Other,140% of Medicaid,147.8,,,147.8,Other,225% of Medicaid,170.79,,,170.79,Other,260% of Medicaid,212.84,,,212.84,Other,324% of Medicaid,141.23,,,141.23,Other,215% of Medicaid,141.23,,,141.23,Other,215% of Medicaid,82.11,,,82.11,Other,125% of Medicaid,20.27,317.46,
F5 GENE,81241,CPT,,78081241,CDM,301,RC,,,both,,,429,317.46,,,317.46,Other,150% of Medicare + 9.63% HCRA Surcharge,193.05,45,,193.05,percent of total billed charges,Critical Access Hospital RCC factor,220.84,,,220.84,Fee Schedule,,198.83,,,198.83,Fee Schedule,,21.16,,,21.16,Fee Schedule,,21.16,,,21.16,Fee Schedule,,21.16,,,21.16,Fee Schedule,,212.36,,,212.36,Other,110% of Medicare,231.12,,,231.12,Fee Schedule,,136,,,136,Other,186% of Medicaid,272.2,,,272.2,Fee Schedule,,265.98,,,265.98,Fee Schedule,,154.08,,,154.08,Fee Schedule,,272.2,,,272.2,Fee Schedule,,265.98,,,265.98,Fee Schedule,,289.81,,,289.81,Fee Schedule,,300.3,70,,300.3,percent of total billed charges,All Other,347.7,,,347.7,Fee Schedule,,294.7,,,294.7,Fee Schedule,,110.06,,,110.06,Fee Schedule,,110.06,,,110.06,Fee Schedule,,110.06,,,110.06,Fee Schedule,,110.06,,,110.06,Fee Schedule,,73.37,,,73.37,Other,100% of Medicaid,73.37,,,73.37,Other,100% of Medicaid,73.37,,,73.37,Other,100% of Medicaid,73.37,,,73.37,Other,100% of Medicaid,165.08,,,165.08,Other,225% of Medicaid,112.26,,,112.26,Other,153% of Medicaid,165.08,,,165.08,Other,225% of Medicaid,102.72,,,102.72,Other,140% of Medicaid,165.08,,,165.08,Other,225% of Medicaid,190.76,,,190.76,Other,260% of Medicaid,237.72,,,237.72,Other,324% of Medicaid,157.75,,,157.75,Other,215% of Medicaid,157.75,,,157.75,Other,215% of Medicaid,91.71,,,91.71,Other,125% of Medicaid,21.16,347.7,
FMR1 GENE DETECTION,81243,CPT,,78081243,CDM,301,RC,,,both,,,908,671.92,,,671.92,Other,150% of Medicare + 9.63% HCRA Surcharge,408.6,45,,408.6,percent of total billed charges,Critical Access Hospital RCC factor,171.69,,,171.69,Fee Schedule,,154.58,,,154.58,Fee Schedule,,24.41,,,24.41,Fee Schedule,,24.41,,,24.41,Fee Schedule,,24.41,,,24.41,Fee Schedule,,449.46,,,449.46,Other,110% of Medicare,179.68,,,179.68,Fee Schedule,,0.01,,,0.01,Other,186% of Medicaid,211.62,,,211.62,Fee Schedule,,562.96,,,562.96,Fee Schedule,,119.78,,,119.78,Fee Schedule,,211.62,,,211.62,Fee Schedule,,562.96,,,562.96,Fee Schedule,,225.31,,,225.31,Fee Schedule,,635.6,70,,635.6,percent of total billed charges,All Other,270.31,,,270.31,Fee Schedule,,229.11,,,229.11,Fee Schedule,,85.56,,,85.56,Fee Schedule,,85.56,,,85.56,Fee Schedule,,85.56,,,85.56,Fee Schedule,,85.56,,,85.56,Fee Schedule,,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,671.92,
FMR1 GENE CHARACTERIZATION,81244,CPT,,78081244,CDM,301,RC,,,both,,,518,383.32,,,383.32,Other,150% of Medicare + 9.63% HCRA Surcharge,233.1,45,,233.1,percent of total billed charges,Critical Access Hospital RCC factor,135.12,,,135.12,Fee Schedule,,121.65,,,121.65,Fee Schedule,,24.11,,,24.11,Fee Schedule,,24.11,,,24.11,Fee Schedule,,24.11,,,24.11,Fee Schedule,,256.41,,,256.41,Other,110% of Medicare,141.4,,,141.4,Fee Schedule,,0.01,,,0.01,Other,186% of Medicaid,166.54,,,166.54,Fee Schedule,,321.16,,,321.16,Fee Schedule,,94.27,,,94.27,Fee Schedule,,166.54,,,166.54,Fee Schedule,,321.16,,,321.16,Fee Schedule,,177.32,,,177.32,Fee Schedule,,362.6,70,,362.6,percent of total billed charges,All Other,212.74,,,212.74,Fee Schedule,,180.31,,,180.31,Fee Schedule,,67.34,,,67.34,Fee Schedule,,67.34,,,67.34,Fee Schedule,,67.34,,,67.34,Fee Schedule,,67.34,,,67.34,Fee Schedule,,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,383.32,
FLT3 GENE ANALYSIS,81246,CPT,,78081246,CDM,301,RC,,,both,,,212,156.88,,,156.88,Other,150% of Medicare + 9.63% HCRA Surcharge,95.4,45,,95.4,percent of total billed charges,Critical Access Hospital RCC factor,249.83,,,249.83,Fee Schedule,,224.93,,,224.93,Fee Schedule,,31.12,,,31.12,Fee Schedule,,31.12,,,31.12,Fee Schedule,,31.12,,,31.12,Fee Schedule,,104.94,,,104.94,Other,110% of Medicare,261.45,,,261.45,Fee Schedule,,154,,,154,Other,186% of Medicaid,307.93,,,307.93,Fee Schedule,,131.44,,,131.44,Fee Schedule,,174.3,,,174.3,Fee Schedule,,307.93,,,307.93,Fee Schedule,,131.44,,,131.44,Fee Schedule,,327.85,,,327.85,Fee Schedule,,148.4,70,,148.4,percent of total billed charges,All Other,393.34,,,393.34,Fee Schedule,,333.38,,,333.38,Fee Schedule,,124.5,,,124.5,Fee Schedule,,124.5,,,124.5,Fee Schedule,,124.5,,,124.5,Fee Schedule,,124.5,,,124.5,Fee Schedule,,83,,,83,Other,100% of Medicaid,83,,,83,Other,100% of Medicaid,83,,,83,Other,100% of Medicaid,83,,,83,Other,100% of Medicaid,186.75,,,186.75,Other,225% of Medicaid,126.99,,,126.99,Other,153% of Medicaid,186.75,,,186.75,Other,225% of Medicaid,116.2,,,116.2,Other,140% of Medicaid,186.75,,,186.75,Other,225% of Medicaid,215.8,,,215.8,Other,260% of Medicaid,268.92,,,268.92,Other,324% of Medicaid,178.45,,,178.45,Other,215% of Medicaid,178.45,,,178.45,Other,215% of Medicaid,103.75,,,103.75,Other,125% of Medicaid,31.12,393.34,
HFE GENE,81256,CPT,,78081256,CDM,301,RC,,,both,,,1626,1203.24,,,1203.24,Other,150% of Medicare + 9.63% HCRA Surcharge,731.7,45,,731.7,percent of total billed charges,Critical Access Hospital RCC factor,196.73,,,196.73,Fee Schedule,,177.13,,,177.13,Fee Schedule,,25.42,,,25.42,Fee Schedule,,25.42,,,25.42,Fee Schedule,,25.42,,,25.42,Fee Schedule,,804.87,,,804.87,Other,110% of Medicare,205.88,,,205.88,Fee Schedule,,0.01,,,0.01,Other,186% of Medicaid,242.49,,,242.49,Fee Schedule,,1008.12,,,1008.12,Fee Schedule,,137.26,,,137.26,Fee Schedule,,242.49,,,242.49,Fee Schedule,,1008.12,,,1008.12,Fee Schedule,,258.17,,,258.17,Fee Schedule,,1138.2,70,,1138.2,percent of total billed charges,All Other,309.74,,,309.74,Fee Schedule,,262.53,,,262.53,Fee Schedule,,98.04,,,98.04,Fee Schedule,,98.04,,,98.04,Fee Schedule,,98.04,,,98.04,Fee Schedule,,98.04,,,98.04,Fee Schedule,,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1203.24,
IGH GENE REARRANGE AMP METH,81261,CPT,,78081261,CDM,301,RC,,,both,,,624,461.76,,,461.76,Other,150% of Medicare + 9.63% HCRA Surcharge,280.8,45,,280.8,percent of total billed charges,Critical Access Hospital RCC factor,595.95,,,595.95,Fee Schedule,,536.55,,,536.55,Fee Schedule,,28.82,,,28.82,Fee Schedule,,28.82,,,28.82,Fee Schedule,,28.82,,,28.82,Fee Schedule,,308.88,,,308.88,Other,110% of Medicare,623.67,,,623.67,Fee Schedule,,0.01,,,0.01,Other,186% of Medicaid,734.54,,,734.54,Fee Schedule,,386.88,,,386.88,Fee Schedule,,415.78,,,415.78,Fee Schedule,,734.54,,,734.54,Fee Schedule,,386.88,,,386.88,Fee Schedule,,782.06,,,782.06,Fee Schedule,,436.8,70,,436.8,percent of total billed charges,All Other,938.28,,,938.28,Fee Schedule,,795.25,,,795.25,Fee Schedule,,296.99,,,296.99,Fee Schedule,,296.99,,,296.99,Fee Schedule,,296.99,,,296.99,Fee Schedule,,296.99,,,296.99,Fee Schedule,,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,938.28,
CHIMERISM ANAL NO CELL SELEC,81267,CPT,,78081267,CDM,301,RC,,,both,,,655,484.7,,,484.7,Other,150% of Medicare + 9.63% HCRA Surcharge,294.75,45,,294.75,percent of total billed charges,Critical Access Hospital RCC factor,624.45,,,624.45,Fee Schedule,,562.22,,,562.22,Fee Schedule,,175.69,,,175.69,Fee Schedule,,175.69,,,175.69,Fee Schedule,,175.69,,,175.69,Fee Schedule,,324.23,,,324.23,Other,110% of Medicare,653.5,,,653.5,Fee Schedule,,0.01,,,0.01,Other,186% of Medicaid,769.68,,,769.68,Fee Schedule,,406.1,,,406.1,Fee Schedule,,435.67,,,435.67,Fee Schedule,,769.68,,,769.68,Fee Schedule,,406.1,,,406.1,Fee Schedule,,819.47,,,819.47,Fee Schedule,,458.5,70,,458.5,percent of total billed charges,All Other,983.16,,,983.16,Fee Schedule,,833.29,,,833.29,Fee Schedule,,311.19,,,311.19,Fee Schedule,,311.19,,,311.19,Fee Schedule,,311.19,,,311.19,Fee Schedule,,311.19,,,311.19,Fee Schedule,,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,983.16,
CHIMERISM ANAL W/CELL SELECT,81268,CPT,,78081268,CDM,301,RC,,,both,,,823,609.02,,,609.02,Other,150% of Medicare + 9.63% HCRA Surcharge,370.35,45,,370.35,percent of total billed charges,Critical Access Hospital RCC factor,784.98,,,784.98,Fee Schedule,,706.74,,,706.74,Fee Schedule,,169.45,,,169.45,Fee Schedule,,169.45,,,169.45,Fee Schedule,,169.45,,,169.45,Fee Schedule,,407.39,,,407.39,Other,110% of Medicare,821.49,,,821.49,Fee Schedule,,0.01,,,0.01,Other,186% of Medicaid,967.53,,,967.53,Fee Schedule,,510.26,,,510.26,Fee Schedule,,547.66,,,547.66,Fee Schedule,,967.53,,,967.53,Fee Schedule,,510.26,,,510.26,Fee Schedule,,1030.12,,,1030.12,Fee Schedule,,576.1,70,,576.1,percent of total billed charges,All Other,1235.89,,,1235.89,Fee Schedule,,1047.49,,,1047.49,Fee Schedule,,391.19,,,391.19,Fee Schedule,,391.19,,,391.19,Fee Schedule,,391.19,,,391.19,Fee Schedule,,391.19,,,391.19,Fee Schedule,,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1235.89,
HBA1/HBA2 GENE DUP/DEL VRNTS,81269,CPT,,78081269,CDM,301,RC,,,both,,,639,472.86,,,472.86,Other,150% of Medicare + 9.63% HCRA Surcharge,287.55,45,,287.55,percent of total billed charges,Critical Access Hospital RCC factor,609.22,,,609.22,Fee Schedule,,548.5,,,548.5,Fee Schedule,,80.96,,,80.96,Fee Schedule,,80.96,,,80.96,Fee Schedule,,80.96,,,80.96,Fee Schedule,,316.31,,,316.31,Other,110% of Medicare,637.56,,,637.56,Fee Schedule,,358,,,358,Other,186% of Medicaid,750.9,,,750.9,Fee Schedule,,396.18,,,396.18,Fee Schedule,,425.04,,,425.04,Fee Schedule,,750.9,,,750.9,Fee Schedule,,396.18,,,396.18,Fee Schedule,,799.48,,,799.48,Fee Schedule,,447.3,70,,447.3,percent of total billed charges,All Other,959.18,,,959.18,Fee Schedule,,812.96,,,812.96,Fee Schedule,,303.6,,,303.6,Fee Schedule,,303.6,,,303.6,Fee Schedule,,303.6,,,303.6,Fee Schedule,,303.6,,,303.6,Fee Schedule,,192.59,,,192.59,Other,100% of Medicaid,192.59,,,192.59,Other,100% of Medicaid,192.59,,,192.59,Other,100% of Medicaid,192.59,,,192.59,Other,100% of Medicaid,433.32,,,433.32,Other,225% of Medicaid,294.66,,,294.66,Other,153% of Medicaid,433.32,,,433.32,Other,225% of Medicaid,269.62,,,269.62,Other,140% of Medicaid,433.32,,,433.32,Other,225% of Medicaid,500.73,,,500.73,Other,260% of Medicaid,623.98,,,623.98,Other,324% of Medicaid,414.06,,,414.06,Other,215% of Medicaid,414.06,,,414.06,Other,215% of Medicaid,240.73,,,240.73,Other,125% of Medicaid,80.96,959.18,
JAK2 GENE,81270,CPT,,78081270,CDM,301,RC,,,both,,,511,378.14,,,378.14,Other,150% of Medicare + 9.63% HCRA Surcharge,229.95,45,,229.95,percent of total billed charges,Critical Access Hospital RCC factor,275.9,,,275.9,Fee Schedule,,248.4,,,248.4,Fee Schedule,,21.53,,,21.53,Fee Schedule,,21.53,,,21.53,Fee Schedule,,21.53,,,21.53,Fee Schedule,,252.95,,,252.95,Other,110% of Medicare,288.73,,,288.73,Fee Schedule,,0.01,,,0.01,Other,186% of Medicaid,340.06,,,340.06,Fee Schedule,,316.82,,,316.82,Fee Schedule,,192.49,,,192.49,Fee Schedule,,340.06,,,340.06,Fee Schedule,,316.82,,,316.82,Fee Schedule,,362.06,,,362.06,Fee Schedule,,357.7,70,,357.7,percent of total billed charges,All Other,434.38,,,434.38,Fee Schedule,,368.16,,,368.16,Fee Schedule,,137.49,,,137.49,Fee Schedule,,137.49,,,137.49,Fee Schedule,,137.49,,,137.49,Fee Schedule,,137.49,,,137.49,Fee Schedule,,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,434.38,
KRAS GENE VARIANTS EXON 2,81275,CPT,,78081275,CDM,301,RC,,,both,,,726,537.24,,,537.24,Other,150% of Medicare + 9.63% HCRA Surcharge,326.7,45,,326.7,percent of total billed charges,Critical Access Hospital RCC factor,581.68,,,581.68,Fee Schedule,,523.71,,,523.71,Fee Schedule,,43.32,,,43.32,Fee Schedule,,43.32,,,43.32,Fee Schedule,,43.32,,,43.32,Fee Schedule,,359.37,,,359.37,Other,110% of Medicare,608.74,,,608.74,Fee Schedule,,359,,,359,Other,186% of Medicaid,716.96,,,716.96,Fee Schedule,,450.12,,,450.12,Fee Schedule,,405.83,,,405.83,Fee Schedule,,716.96,,,716.96,Fee Schedule,,450.12,,,450.12,Fee Schedule,,763.34,,,763.34,Fee Schedule,,508.2,70,,508.2,percent of total billed charges,All Other,915.82,,,915.82,Fee Schedule,,776.21,,,776.21,Fee Schedule,,289.88,,,289.88,Fee Schedule,,289.88,,,289.88,Fee Schedule,,289.88,,,289.88,Fee Schedule,,289.88,,,289.88,Fee Schedule,,193.25,,,193.25,Other,100% of Medicaid,193.25,,,193.25,Other,100% of Medicaid,193.25,,,193.25,Other,100% of Medicaid,193.25,,,193.25,Other,100% of Medicaid,434.81,,,434.81,Other,225% of Medicaid,295.67,,,295.67,Other,153% of Medicaid,434.81,,,434.81,Other,225% of Medicaid,270.55,,,270.55,Other,140% of Medicaid,434.81,,,434.81,Other,225% of Medicaid,502.45,,,502.45,Other,260% of Medicaid,626.13,,,626.13,Other,324% of Medicaid,415.49,,,415.49,Other,215% of Medicaid,415.49,,,415.49,Other,215% of Medicaid,241.56,,,241.56,Other,125% of Medicaid,43.32,915.82,
IFNL3 GENE,81283,CPT,,78081283,CDM,301,RC,,,both,,,233,172.42,,,172.42,Other,150% of Medicare + 9.63% HCRA Surcharge,104.85,45,,104.85,percent of total billed charges,Critical Access Hospital RCC factor,220.84,,,220.84,Fee Schedule,,198.83,,,198.83,Fee Schedule,,178.25,76.5,,178.25,percent of total billed charges,All Other,165.43,69,,165.43,percent of total billed charges,All Other,160.77,65,,160.77,percent of total billed charges,All Other,115.34,,,115.34,Other,110% of Medicare,231.12,,,231.12,Fee Schedule,,0.01,,,0.01,Other,186% of Medicaid,272.2,,,272.2,Fee Schedule,,144.46,,,144.46,Fee Schedule,,154.08,,,154.08,Fee Schedule,,272.2,,,272.2,Fee Schedule,,144.46,,,144.46,Fee Schedule,,289.81,,,289.81,Fee Schedule,,163.1,70,,163.1,percent of total billed charges,All Other,347.7,,,347.7,Fee Schedule,,294.7,,,294.7,Fee Schedule,,110.06,,,110.06,Fee Schedule,,110.06,,,110.06,Fee Schedule,,110.06,,,110.06,Fee Schedule,,110.06,,,110.06,Fee Schedule,,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,347.7,
MGMT GENE PRMTR MTHYLTN ALYS,81287,CPT,,78081287,CDM,301,RC,,,both,,,393,290.82,,,290.82,Other,150% of Medicare + 9.63% HCRA Surcharge,176.85,45,,176.85,percent of total billed charges,Critical Access Hospital RCC factor,375.17,,,375.17,Fee Schedule,,337.77,,,337.77,Fee Schedule,,35.94,,,35.94,Fee Schedule,,35.94,,,35.94,Fee Schedule,,35.94,,,35.94,Fee Schedule,,194.54,,,194.54,Other,110% of Medicare,392.62,,,392.62,Fee Schedule,,0.01,,,0.01,Other,186% of Medicaid,462.41,,,462.41,Fee Schedule,,243.66,,,243.66,Fee Schedule,,261.74,,,261.74,Fee Schedule,,462.41,,,462.41,Fee Schedule,,243.66,,,243.66,Fee Schedule,,492.33,,,492.33,Fee Schedule,,275.1,70,,275.1,percent of total billed charges,All Other,590.67,,,590.67,Fee Schedule,,500.63,,,500.63,Fee Schedule,,186.96,,,186.96,Fee Schedule,,186.96,,,186.96,Fee Schedule,,186.96,,,186.96,Fee Schedule,,186.96,,,186.96,Fee Schedule,,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,590.67,
MTHFR GENE,81291,CPT,,78081291,CDM,301,RC,,,both,,,132,97.68,,,97.68,Other,150% of Medicare + 9.63% HCRA Surcharge,59.4,45,,59.4,percent of total billed charges,Critical Access Hospital RCC factor,196.67,,,196.67,Fee Schedule,,177.07,,,177.07,Fee Schedule,,24.37,,,24.37,Fee Schedule,,24.37,,,24.37,Fee Schedule,,24.37,,,24.37,Fee Schedule,,65.34,,,65.34,Other,110% of Medicare,205.82,,,205.82,Fee Schedule,,0.01,,,0.01,Other,186% of Medicaid,242.41,,,242.41,Fee Schedule,,81.84,,,81.84,Fee Schedule,,137.21,,,137.21,Fee Schedule,,242.41,,,242.41,Fee Schedule,,81.84,,,81.84,Fee Schedule,,258.09,,,258.09,Fee Schedule,,92.4,70,,92.4,percent of total billed charges,All Other,309.65,,,309.65,Fee Schedule,,262.45,,,262.45,Fee Schedule,,98.01,,,98.01,Fee Schedule,,98.01,,,98.01,Fee Schedule,,98.01,,,98.01,Fee Schedule,,98.01,,,98.01,Fee Schedule,,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,309.65,
NPM1 GENE,81310,CPT,,78081310,CDM,301,RC,,,both,,,777,574.98,,,574.98,Other,150% of Medicare + 9.63% HCRA Surcharge,349.65,45,,349.65,percent of total billed charges,Critical Access Hospital RCC factor,742.03,,,742.03,Fee Schedule,,668.07,,,668.07,Fee Schedule,,14.5,,,14.5,Fee Schedule,,14.5,,,14.5,Fee Schedule,,14.5,,,14.5,Fee Schedule,,384.62,,,384.62,Other,110% of Medicare,776.54,,,776.54,Fee Schedule,,459,,,459,Other,186% of Medicaid,914.59,,,914.59,Fee Schedule,,481.74,,,481.74,Fee Schedule,,517.69,,,517.69,Fee Schedule,,914.59,,,914.59,Fee Schedule,,481.74,,,481.74,Fee Schedule,,973.75,,,973.75,Fee Schedule,,543.9,70,,543.9,percent of total billed charges,All Other,1168.27,,,1168.27,Fee Schedule,,990.18,,,990.18,Fee Schedule,,369.78,,,369.78,Fee Schedule,,369.78,,,369.78,Fee Schedule,,369.78,,,369.78,Fee Schedule,,369.78,,,369.78,Fee Schedule,,246.52,,,246.52,Other,100% of Medicaid,246.52,,,246.52,Other,100% of Medicaid,246.52,,,246.52,Other,100% of Medicaid,246.52,,,246.52,Other,100% of Medicaid,554.67,,,554.67,Other,225% of Medicaid,377.18,,,377.18,Other,153% of Medicaid,554.67,,,554.67,Other,225% of Medicaid,345.13,,,345.13,Other,140% of Medicaid,554.67,,,554.67,Other,225% of Medicaid,640.95,,,640.95,Other,260% of Medicaid,798.72,,,798.72,Other,324% of Medicaid,530.02,,,530.02,Other,215% of Medicaid,530.02,,,530.02,Other,215% of Medicaid,308.15,,,308.15,Other,125% of Medicaid,14.5,1168.27,
PML/RARALPHA COM BREAKPOINTS,81315,CPT,,78081315,CDM,301,RC,,,both,,,654,483.96,,,483.96,Other,150% of Medicare + 9.63% HCRA Surcharge,294.3,45,,294.3,percent of total billed charges,Critical Access Hospital RCC factor,624,,,624,Fee Schedule,,561.81,,,561.81,Fee Schedule,,39.53,,,39.53,Fee Schedule,,39.53,,,39.53,Fee Schedule,,39.53,,,39.53,Fee Schedule,,323.73,,,323.73,Other,110% of Medicare,653.03,,,653.03,Fee Schedule,,386,,,386,Other,186% of Medicaid,769.12,,,769.12,Fee Schedule,,405.48,,,405.48,Fee Schedule,,435.35,,,435.35,Fee Schedule,,769.12,,,769.12,Fee Schedule,,405.48,,,405.48,Fee Schedule,,818.87,,,818.87,Fee Schedule,,457.8,70,,457.8,percent of total billed charges,All Other,982.45,,,982.45,Fee Schedule,,832.69,,,832.69,Fee Schedule,,310.97,,,310.97,Fee Schedule,,310.97,,,310.97,Fee Schedule,,310.97,,,310.97,Fee Schedule,,310.97,,,310.97,Fee Schedule,,207.31,,,207.31,Other,100% of Medicaid,207.31,,,207.31,Other,100% of Medicaid,207.31,,,207.31,Other,100% of Medicaid,207.31,,,207.31,Other,100% of Medicaid,466.45,,,466.45,Other,225% of Medicaid,317.18,,,317.18,Other,153% of Medicaid,466.45,,,466.45,Other,225% of Medicaid,290.23,,,290.23,Other,140% of Medicaid,466.45,,,466.45,Other,225% of Medicaid,539.01,,,539.01,Other,260% of Medicaid,671.68,,,671.68,Other,324% of Medicaid,445.72,,,445.72,Other,215% of Medicaid,445.72,,,445.72,Other,215% of Medicaid,259.14,,,259.14,Other,125% of Medicaid,39.53,982.45,
SERPINA1 GENE,81332,CPT,,78081332,CDM,301,RC,,,both,,,244,180.56,,,180.56,Other,150% of Medicare + 9.63% HCRA Surcharge,109.8,45,,109.8,percent of total billed charges,Critical Access Hospital RCC factor,131.39,,,131.39,Fee Schedule,,118.29,,,118.29,Fee Schedule,,25.42,,,25.42,Fee Schedule,,25.42,,,25.42,Fee Schedule,,25.42,,,25.42,Fee Schedule,,120.78,,,120.78,Other,110% of Medicare,137.5,,,137.5,Fee Schedule,,81,,,81,Other,186% of Medicaid,161.94,,,161.94,Fee Schedule,,151.28,,,151.28,Fee Schedule,,91.67,,,91.67,Fee Schedule,,161.94,,,161.94,Fee Schedule,,151.28,,,151.28,Fee Schedule,,172.42,,,172.42,Fee Schedule,,170.8,70,,170.8,percent of total billed charges,All Other,206.86,,,206.86,Fee Schedule,,175.33,,,175.33,Fee Schedule,,65.48,,,65.48,Fee Schedule,,65.48,,,65.48,Fee Schedule,,65.48,,,65.48,Fee Schedule,,65.48,,,65.48,Fee Schedule,,43.65,,,43.65,Other,100% of Medicaid,43.65,,,43.65,Other,100% of Medicaid,43.65,,,43.65,Other,100% of Medicaid,43.65,,,43.65,Other,100% of Medicaid,98.21,,,98.21,Other,225% of Medicaid,66.78,,,66.78,Other,153% of Medicaid,98.21,,,98.21,Other,225% of Medicaid,61.11,,,61.11,Other,140% of Medicaid,98.21,,,98.21,Other,225% of Medicaid,113.49,,,113.49,Other,260% of Medicaid,141.43,,,141.43,Other,324% of Medicaid,93.85,,,93.85,Other,215% of Medicaid,93.85,,,93.85,Other,215% of Medicaid,54.56,,,54.56,Other,125% of Medicaid,25.42,206.86,
TPMT GENE COM VARIANTS,81335,CPT,,78081335,CDM,301,RC,,,both,,,552,408.48,,,408.48,Other,150% of Medicare + 9.63% HCRA Surcharge,248.4,45,,248.4,percent of total billed charges,Critical Access Hospital RCC factor,526.18,,,526.18,Fee Schedule,,473.74,,,473.74,Fee Schedule,,69.92,,,69.92,Fee Schedule,,69.92,,,69.92,Fee Schedule,,69.92,,,69.92,Fee Schedule,,273.24,,,273.24,Other,110% of Medicare,550.65,,,550.65,Fee Schedule,,0.01,,,0.01,Other,186% of Medicaid,648.55,,,648.55,Fee Schedule,,342.24,,,342.24,Fee Schedule,,367.1,,,367.1,Fee Schedule,,648.55,,,648.55,Fee Schedule,,342.24,,,342.24,Fee Schedule,,690.5,,,690.5,Fee Schedule,,386.4,70,,386.4,percent of total billed charges,All Other,828.43,,,828.43,Fee Schedule,,702.15,,,702.15,Fee Schedule,,262.22,,,262.22,Fee Schedule,,262.22,,,262.22,Fee Schedule,,262.22,,,262.22,Fee Schedule,,262.22,,,262.22,Fee Schedule,,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,828.43,
HBB FULL GENE SEQUENCE,81364,CPT,,78081364,CDM,301,RC,,,both,,,1023,757.02,,,757.02,Other,150% of Medicare + 9.63% HCRA Surcharge,460.35,45,,460.35,percent of total billed charges,Critical Access Hospital RCC factor,976.99,,,976.99,Fee Schedule,,879.61,,,879.61,Fee Schedule,,782.6,76.5,,782.6,percent of total billed charges,All Other,726.33,69,,726.33,percent of total billed charges,All Other,705.87,65,,705.87,percent of total billed charges,All Other,506.39,,,506.39,Other,110% of Medicare,1022.43,,,1022.43,Fee Schedule,,0.01,,,0.01,Other,186% of Medicaid,1204.19,,,1204.19,Fee Schedule,,634.26,,,634.26,Fee Schedule,,681.62,,,681.62,Fee Schedule,,1204.19,,,1204.19,Fee Schedule,,634.26,,,634.26,Fee Schedule,,1282.09,,,1282.09,Fee Schedule,,716.1,70,,716.1,percent of total billed charges,All Other,1538.2,,,1538.2,Fee Schedule,,1303.71,,,1303.71,Fee Schedule,,486.87,,,486.87,Fee Schedule,,486.87,,,486.87,Fee Schedule,,486.87,,,486.87,Fee Schedule,,486.87,,,486.87,Fee Schedule,,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1538.2,
HLA I TYPING COMPLETE LR,81372,CPT,,78081372,CDM,301,RC,,,both,,,2610,1931.41,,,1931.41,Other,150% of Medicare + 9.63% HCRA Surcharge,1174.5,45,,1174.5,percent of total billed charges,Critical Access Hospital RCC factor,1214.81,,,1214.81,Fee Schedule,,1093.73,,,1093.73,Fee Schedule,,366.46,,,366.46,Fee Schedule,,366.46,,,366.46,Fee Schedule,,366.46,,,366.46,Fee Schedule,,1291.95,,,1291.95,Other,110% of Medicare,1271.31,,,1271.31,Fee Schedule,,0.01,,,0.01,Other,186% of Medicaid,1497.32,,,1497.32,Fee Schedule,,1618.2,,,1618.2,Fee Schedule,,847.54,,,847.54,Fee Schedule,,1497.32,,,1497.32,Fee Schedule,,1618.2,,,1618.2,Fee Schedule,,1594.18,,,1594.18,Fee Schedule,,1827,70,,1827,percent of total billed charges,All Other,1912.63,,,1912.63,Fee Schedule,,1621.07,,,1621.07,Fee Schedule,,605.39,,,605.39,Fee Schedule,,605.39,,,605.39,Fee Schedule,,605.39,,,605.39,Fee Schedule,,605.39,,,605.39,Fee Schedule,,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1931.41,
HLA I TYPING 1 LOCUS LR,81373,CPT,,78081373,CDM,301,RC,,,both,,,534,395.16,,,395.16,Other,150% of Medicare + 9.63% HCRA Surcharge,240.3,45,,240.3,percent of total billed charges,Critical Access Hospital RCC factor,383.56,,,383.56,Fee Schedule,,345.34,,,345.34,Fee Schedule,,124.6,,,124.6,Fee Schedule,,124.6,,,124.6,Fee Schedule,,124.6,,,124.6,Fee Schedule,,264.33,,,264.33,Other,110% of Medicare,401.4,,,401.4,Fee Schedule,,0.01,,,0.01,Other,186% of Medicaid,472.77,,,472.77,Fee Schedule,,331.08,,,331.08,Fee Schedule,,267.6,,,267.6,Fee Schedule,,472.77,,,472.77,Fee Schedule,,331.08,,,331.08,Fee Schedule,,503.35,,,503.35,Fee Schedule,,373.8,70,,373.8,percent of total billed charges,All Other,603.9,,,603.9,Fee Schedule,,511.84,,,511.84,Fee Schedule,,191.15,,,191.15,Fee Schedule,,191.15,,,191.15,Fee Schedule,,191.15,,,191.15,Fee Schedule,,191.15,,,191.15,Fee Schedule,,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,603.9,
HLA I TYPING 1 ANTIGEN LR,81374,CPT,,78081374,CDM,301,RC,,,both,,,405,299.7,,,299.7,Other,150% of Medicare + 9.63% HCRA Surcharge,182.25,45,,182.25,percent of total billed charges,Critical Access Hospital RCC factor,223.73,,,223.73,Fee Schedule,,201.43,,,201.43,Fee Schedule,,124.6,,,124.6,Fee Schedule,,124.6,,,124.6,Fee Schedule,,124.6,,,124.6,Fee Schedule,,200.48,,,200.48,Other,110% of Medicare,234.14,,,234.14,Fee Schedule,,0.01,,,0.01,Other,186% of Medicaid,275.76,,,275.76,Fee Schedule,,251.1,,,251.1,Fee Schedule,,156.09,,,156.09,Fee Schedule,,275.76,,,275.76,Fee Schedule,,251.1,,,251.1,Fee Schedule,,293.6,,,293.6,Fee Schedule,,283.5,70,,283.5,percent of total billed charges,All Other,352.25,,,352.25,Fee Schedule,,298.56,,,298.56,Fee Schedule,,111.5,,,111.5,Fee Schedule,,111.5,,,111.5,Fee Schedule,,111.5,,,111.5,Fee Schedule,,111.5,,,111.5,Fee Schedule,,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,352.25,
HLA II TYPING AG EQUIV LR,81375,CPT,,78081375,CDM,301,RC,,,both,,,1047,774.78,,,774.78,Other,150% of Medicare + 9.63% HCRA Surcharge,471.15,45,,471.15,percent of total billed charges,Critical Access Hospital RCC factor,664.43,,,664.43,Fee Schedule,,598.21,,,598.21,Fee Schedule,,128.18,,,128.18,Fee Schedule,,128.18,,,128.18,Fee Schedule,,128.18,,,128.18,Fee Schedule,,518.27,,,518.27,Other,110% of Medicare,695.33,,,695.33,Fee Schedule,,0.01,,,0.01,Other,186% of Medicaid,818.95,,,818.95,Fee Schedule,,649.14,,,649.14,Fee Schedule,,463.55,,,463.55,Fee Schedule,,818.95,,,818.95,Fee Schedule,,649.14,,,649.14,Fee Schedule,,871.92,,,871.92,Fee Schedule,,732.9,70,,732.9,percent of total billed charges,All Other,1046.09,,,1046.09,Fee Schedule,,886.63,,,886.63,Fee Schedule,,331.11,,,331.11,Fee Schedule,,331.11,,,331.11,Fee Schedule,,331.11,,,331.11,Fee Schedule,,331.11,,,331.11,Fee Schedule,,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1046.09,
HLA II TYPING 1 LOCUS LR,81376,CPT,,78081376,CDM,301,RC,,,both,,,386,285.64,,,285.64,Other,150% of Medicare + 9.63% HCRA Surcharge,173.7,45,,173.7,percent of total billed charges,Critical Access Hospital RCC factor,367.88,,,367.88,Fee Schedule,,331.22,,,331.22,Fee Schedule,,68.66,,,68.66,Fee Schedule,,68.66,,,68.66,Fee Schedule,,68.66,,,68.66,Fee Schedule,,191.07,,,191.07,Other,110% of Medicare,384.99,,,384.99,Fee Schedule,,0.01,,,0.01,Other,186% of Medicaid,453.44,,,453.44,Fee Schedule,,239.32,,,239.32,Fee Schedule,,256.66,,,256.66,Fee Schedule,,453.44,,,453.44,Fee Schedule,,239.32,,,239.32,Fee Schedule,,482.77,,,482.77,Fee Schedule,,270.2,70,,270.2,percent of total billed charges,All Other,579.2,,,579.2,Fee Schedule,,490.91,,,490.91,Fee Schedule,,183.33,,,183.33,Fee Schedule,,183.33,,,183.33,Fee Schedule,,183.33,,,183.33,Fee Schedule,,183.33,,,183.33,Fee Schedule,,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,579.2,
HLA II TYPE 1 AG EQUIV LR,81377,CPT,,78081377,CDM,301,RC,,,both,,,436,322.64,,,322.64,Other,150% of Medicare + 9.63% HCRA Surcharge,196.2,45,,196.2,percent of total billed charges,Critical Access Hospital RCC factor,285.17,,,285.17,Fee Schedule,,256.75,,,256.75,Fee Schedule,,58.63,,,58.63,Fee Schedule,,58.63,,,58.63,Fee Schedule,,58.63,,,58.63,Fee Schedule,,215.82,,,215.82,Other,110% of Medicare,298.43,,,298.43,Fee Schedule,,0.01,,,0.01,Other,186% of Medicaid,351.49,,,351.49,Fee Schedule,,270.32,,,270.32,Fee Schedule,,198.95,,,198.95,Fee Schedule,,351.49,,,351.49,Fee Schedule,,270.32,,,270.32,Fee Schedule,,374.22,,,374.22,Fee Schedule,,305.2,70,,305.2,percent of total billed charges,All Other,448.98,,,448.98,Fee Schedule,,380.53,,,380.53,Fee Schedule,,142.11,,,142.11,Fee Schedule,,142.11,,,142.11,Fee Schedule,,142.11,,,142.11,Fee Schedule,,142.11,,,142.11,Fee Schedule,,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,448.98,
HLA I TYPING 1 LOCUS HR,81380,CPT,,78081380,CDM,301,RC,,,both,,,559,413.66,,,413.66,Other,150% of Medicare + 9.63% HCRA Surcharge,251.55,45,,251.55,percent of total billed charges,Critical Access Hospital RCC factor,533.52,,,533.52,Fee Schedule,,480.35,,,480.35,Fee Schedule,,35.98,,,35.98,Fee Schedule,,35.98,,,35.98,Fee Schedule,,35.98,,,35.98,Fee Schedule,,276.71,,,276.71,Other,110% of Medicare,558.34,,,558.34,Fee Schedule,,0.01,,,0.01,Other,186% of Medicaid,657.6,,,657.6,Fee Schedule,,346.58,,,346.58,Fee Schedule,,372.23,,,372.23,Fee Schedule,,657.6,,,657.6,Fee Schedule,,346.58,,,346.58,Fee Schedule,,700.14,,,700.14,Fee Schedule,,391.3,70,,391.3,percent of total billed charges,All Other,839.99,,,839.99,Fee Schedule,,711.95,,,711.95,Fee Schedule,,265.88,,,265.88,Fee Schedule,,265.88,,,265.88,Fee Schedule,,265.88,,,265.88,Fee Schedule,,265.88,,,265.88,Fee Schedule,,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,839.99,
HLA I TYPING 1 ALLELE HR,81381,CPT,,78081381,CDM,301,RC,,,both,,,659,487.66,,,487.66,Other,150% of Medicare + 9.63% HCRA Surcharge,296.55,45,,296.55,percent of total billed charges,Critical Access Hospital RCC factor,511.4,,,511.4,Fee Schedule,,460.43,,,460.43,Fee Schedule,,124.6,,,124.6,Fee Schedule,,124.6,,,124.6,Fee Schedule,,124.6,,,124.6,Fee Schedule,,326.21,,,326.21,Other,110% of Medicare,535.19,,,535.19,Fee Schedule,,0.01,,,0.01,Other,186% of Medicaid,630.33,,,630.33,Fee Schedule,,408.58,,,408.58,Fee Schedule,,356.79,,,356.79,Fee Schedule,,630.33,,,630.33,Fee Schedule,,408.58,,,408.58,Fee Schedule,,671.11,,,671.11,Fee Schedule,,461.3,70,,461.3,percent of total billed charges,All Other,805.16,,,805.16,Fee Schedule,,682.42,,,682.42,Fee Schedule,,254.85,,,254.85,Fee Schedule,,254.85,,,254.85,Fee Schedule,,254.85,,,254.85,Fee Schedule,,254.85,,,254.85,Fee Schedule,,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,805.16,
HLA II TYPING 1 LOC HR,81382,CPT,,78081382,CDM,301,RC,,,both,,,391,289.34,,,289.34,Other,150% of Medicare + 9.63% HCRA Surcharge,175.95,45,,175.95,percent of total billed charges,Critical Access Hospital RCC factor,372.28,,,372.28,Fee Schedule,,335.17,,,335.17,Fee Schedule,,25.24,,,25.24,Fee Schedule,,25.24,,,25.24,Fee Schedule,,25.24,,,25.24,Fee Schedule,,193.55,,,193.55,Other,110% of Medicare,389.59,,,389.59,Fee Schedule,,0.01,,,0.01,Other,186% of Medicaid,458.85,,,458.85,Fee Schedule,,242.42,,,242.42,Fee Schedule,,259.73,,,259.73,Fee Schedule,,458.85,,,458.85,Fee Schedule,,242.42,,,242.42,Fee Schedule,,488.54,,,488.54,Fee Schedule,,273.7,70,,273.7,percent of total billed charges,All Other,586.12,,,586.12,Fee Schedule,,496.78,,,496.78,Fee Schedule,,185.52,,,185.52,Fee Schedule,,185.52,,,185.52,Fee Schedule,,185.52,,,185.52,Fee Schedule,,185.52,,,185.52,Fee Schedule,,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,586.12,
HLA II TYPING 1 ALLELE HR,81383,CPT,,78081383,CDM,301,RC,,,both,,,518,383.32,,,383.32,Other,150% of Medicare + 9.63% HCRA Surcharge,233.1,45,,233.1,percent of total billed charges,Critical Access Hospital RCC factor,328.48,,,328.48,Fee Schedule,,295.74,,,295.74,Fee Schedule,,45.74,,,45.74,Fee Schedule,,45.74,,,45.74,Fee Schedule,,45.74,,,45.74,Fee Schedule,,256.41,,,256.41,Other,110% of Medicare,343.76,,,343.76,Fee Schedule,,0.01,,,0.01,Other,186% of Medicaid,404.87,,,404.87,Fee Schedule,,321.16,,,321.16,Fee Schedule,,229.17,,,229.17,Fee Schedule,,404.87,,,404.87,Fee Schedule,,321.16,,,321.16,Fee Schedule,,431.06,,,431.06,Fee Schedule,,362.6,70,,362.6,percent of total billed charges,All Other,517.17,,,517.17,Fee Schedule,,438.33,,,438.33,Fee Schedule,,163.7,,,163.7,Fee Schedule,,163.7,,,163.7,Fee Schedule,,163.7,,,163.7,Fee Schedule,,163.7,,,163.7,Fee Schedule,,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,517.17,
MOPATH PROCEDURE LEVEL 1,81400,CPT,,78081400,CDM,301,RC,,,both,,,498,368.52,,,368.52,Other,150% of Medicare + 9.63% HCRA Surcharge,224.1,45,,224.1,percent of total billed charges,Critical Access Hospital RCC factor,192.52,,,192.52,Fee Schedule,,173.33,,,173.33,Fee Schedule,,20.51,,,20.51,Fee Schedule,,20.51,,,20.51,Fee Schedule,,20.51,,,20.51,Fee Schedule,,246.51,,,246.51,Other,110% of Medicare,201.47,,,201.47,Fee Schedule,,0.01,,,0.01,Other,186% of Medicaid,237.29,,,237.29,Fee Schedule,,308.76,,,308.76,Fee Schedule,,134.32,,,134.32,Fee Schedule,,237.29,,,237.29,Fee Schedule,,308.76,,,308.76,Fee Schedule,,252.64,,,252.64,Fee Schedule,,348.6,70,,348.6,percent of total billed charges,All Other,303.11,,,303.11,Fee Schedule,,256.9,,,256.9,Fee Schedule,,95.94,,,95.94,Fee Schedule,,95.94,,,95.94,Fee Schedule,,95.94,,,95.94,Fee Schedule,,95.94,,,95.94,Fee Schedule,,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,368.52,
MOPATH PROCEDURE LEVEL 2,81401,CPT,,78081401,CDM,301,RC,,,both,,,498,368.52,,,368.52,Other,150% of Medicare + 9.63% HCRA Surcharge,224.1,45,,224.1,percent of total billed charges,Critical Access Hospital RCC factor,412.37,,,412.37,Fee Schedule,,371.27,,,371.27,Fee Schedule,,20.51,,,20.51,Fee Schedule,,20.51,,,20.51,Fee Schedule,,20.51,,,20.51,Fee Schedule,,246.51,,,246.51,Other,110% of Medicare,431.55,,,431.55,Fee Schedule,,0.01,,,0.01,Other,186% of Medicaid,508.27,,,508.27,Fee Schedule,,308.76,,,308.76,Fee Schedule,,287.7,,,287.7,Fee Schedule,,508.27,,,508.27,Fee Schedule,,308.76,,,308.76,Fee Schedule,,541.15,,,541.15,Fee Schedule,,348.6,70,,348.6,percent of total billed charges,All Other,649.25,,,649.25,Fee Schedule,,550.28,,,550.28,Fee Schedule,,205.5,,,205.5,Fee Schedule,,205.5,,,205.5,Fee Schedule,,205.5,,,205.5,Fee Schedule,,205.5,,,205.5,Fee Schedule,,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,649.25,
MOPATH PROCEDURE LEVEL 4,81403,CPT,,78081403,CDM,301,RC,,,both,,,603,446.22,,,446.22,Other,150% of Medicare + 9.63% HCRA Surcharge,271.35,45,,271.35,percent of total billed charges,Critical Access Hospital RCC factor,557.45,,,557.45,Fee Schedule,,501.89,,,501.89,Fee Schedule,,67.55,,,67.55,Fee Schedule,,67.55,,,67.55,Fee Schedule,,67.55,,,67.55,Fee Schedule,,298.49,,,298.49,Other,110% of Medicare,583.38,,,583.38,Fee Schedule,,0.01,,,0.01,Other,186% of Medicaid,687.09,,,687.09,Fee Schedule,,373.86,,,373.86,Fee Schedule,,388.92,,,388.92,Fee Schedule,,687.09,,,687.09,Fee Schedule,,373.86,,,373.86,Fee Schedule,,731.54,,,731.54,Fee Schedule,,422.1,70,,422.1,percent of total billed charges,All Other,877.67,,,877.67,Fee Schedule,,743.88,,,743.88,Fee Schedule,,277.8,,,277.8,Fee Schedule,,277.8,,,277.8,Fee Schedule,,277.8,,,277.8,Fee Schedule,,277.8,,,277.8,Fee Schedule,,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,877.67,
MOPATH PROCEDURE LEVEL 5,81404,CPT,,78081404,CDM,301,RC,,,both,,,551,407.74,,,407.74,Other,150% of Medicare + 9.63% HCRA Surcharge,247.95,45,,247.95,percent of total billed charges,Critical Access Hospital RCC factor,827.24,,,827.24,Fee Schedule,,744.79,,,744.79,Fee Schedule,,60.5,,,60.5,Fee Schedule,,60.5,,,60.5,Fee Schedule,,60.5,,,60.5,Fee Schedule,,272.75,,,272.75,Other,110% of Medicare,865.71,,,865.71,Fee Schedule,,0.01,,,0.01,Other,186% of Medicaid,1019.62,,,1019.62,Fee Schedule,,341.62,,,341.62,Fee Schedule,,577.14,,,577.14,Fee Schedule,,1019.62,,,1019.62,Fee Schedule,,341.62,,,341.62,Fee Schedule,,1085.58,,,1085.58,Fee Schedule,,385.7,70,,385.7,percent of total billed charges,All Other,1302.43,,,1302.43,Fee Schedule,,1103.89,,,1103.89,Fee Schedule,,412.25,,,412.25,Fee Schedule,,412.25,,,412.25,Fee Schedule,,412.25,,,412.25,Fee Schedule,,412.25,,,412.25,Fee Schedule,,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1302.43,
MOPATH PROCEDURE LEVEL 6,81405,CPT,,78081405,CDM,301,RC,,,both,,,3201,2368.75,,,2368.75,Other,150% of Medicare + 9.63% HCRA Surcharge,1440.45,45,,1440.45,percent of total billed charges,Critical Access Hospital RCC factor,907.06,,,907.06,Fee Schedule,,816.66,,,816.66,Fee Schedule,,87.56,,,87.56,Fee Schedule,,87.56,,,87.56,Fee Schedule,,87.56,,,87.56,Fee Schedule,,1584.5,,,1584.5,Other,110% of Medicare,949.25,,,949.25,Fee Schedule,,0.01,,,0.01,Other,186% of Medicaid,1118.01,,,1118.01,Fee Schedule,,1984.62,,,1984.62,Fee Schedule,,632.84,,,632.84,Fee Schedule,,1118.01,,,1118.01,Fee Schedule,,1984.62,,,1984.62,Fee Schedule,,1190.33,,,1190.33,Fee Schedule,,2240.7,70,,2240.7,percent of total billed charges,All Other,1428.11,,,1428.11,Fee Schedule,,1210.41,,,1210.41,Fee Schedule,,452.03,,,452.03,Fee Schedule,,452.03,,,452.03,Fee Schedule,,452.03,,,452.03,Fee Schedule,,452.03,,,452.03,Fee Schedule,,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2368.75,
MOPATH PROCEDURE LEVEL 7,81406,CPT,,78081406,CDM,301,RC,,,both,,,750,555,,,555,Other,150% of Medicare + 9.63% HCRA Surcharge,337.5,45,,337.5,percent of total billed charges,Critical Access Hospital RCC factor,851.47,,,851.47,Fee Schedule,,766.6,,,766.6,Fee Schedule,,46.9,,,46.9,Fee Schedule,,46.9,,,46.9,Fee Schedule,,46.9,,,46.9,Fee Schedule,,371.25,,,371.25,Other,110% of Medicare,891.07,,,891.07,Fee Schedule,,0.01,,,0.01,Other,186% of Medicaid,1049.48,,,1049.48,Fee Schedule,,465,,,465,Fee Schedule,,594.05,,,594.05,Fee Schedule,,1049.48,,,1049.48,Fee Schedule,,465,,,465,Fee Schedule,,1117.38,,,1117.38,Fee Schedule,,525,70,,525,percent of total billed charges,All Other,1340.58,,,1340.58,Fee Schedule,,1136.22,,,1136.22,Fee Schedule,,424.32,,,424.32,Fee Schedule,,424.32,,,424.32,Fee Schedule,,424.32,,,424.32,Fee Schedule,,424.32,,,424.32,Fee Schedule,,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1340.58,
MOPATH PROCEDURE LEVEL 9,81408,CPT,,78081408,CDM,301,RC,,,both,,,4917,3638.59,,,3638.59,Other,150% of Medicare + 9.63% HCRA Surcharge,2212.65,45,,2212.65,percent of total billed charges,Critical Access Hospital RCC factor,6020,,,6020,Fee Schedule,,5420,,,5420,Fee Schedule,,964.59,,,964.59,Fee Schedule,,964.59,,,964.59,Fee Schedule,,964.59,,,964.59,Fee Schedule,,2433.92,,,2433.92,Other,110% of Medicare,6300,,,6300,Fee Schedule,,0.01,,,0.01,Other,186% of Medicaid,7420,,,7420,Fee Schedule,,3048.54,,,3048.54,Fee Schedule,,4200,,,4200,Fee Schedule,,7420,,,7420,Fee Schedule,,3048.54,,,3048.54,Fee Schedule,,7900,,,7900,Fee Schedule,,3441.9,70,,3441.9,percent of total billed charges,All Other,9478.07,,,9478.07,Fee Schedule,,8033.24,,,8033.24,Fee Schedule,,3000,,,3000,Fee Schedule,,3000,,,3000,Fee Schedule,,3000,,,3000,Fee Schedule,,3000,,,3000,Fee Schedule,,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,9478.07,
TARGETED GENOMIC SEQ ANALYS,81445,CPT,,78081445,CDM,301,RC,,,both,,,1884,1394.16,,,1394.16,Other,150% of Medicare + 9.63% HCRA Surcharge,847.8,45,,847.8,percent of total billed charges,Critical Access Hospital RCC factor,1799.71,,,1799.71,Fee Schedule,,1620.34,,,1620.34,Fee Schedule,,846.27,,,846.27,Fee Schedule,,846.27,,,846.27,Fee Schedule,,846.27,,,846.27,Fee Schedule,,932.58,,,932.58,Other,110% of Medicare,1883.42,,,1883.42,Fee Schedule,,0.01,,,0.01,Other,186% of Medicaid,2218.25,,,2218.25,Fee Schedule,,1168.08,,,1168.08,Fee Schedule,,1255.61,,,1255.61,Fee Schedule,,2218.25,,,2218.25,Fee Schedule,,1168.08,,,1168.08,Fee Schedule,,2361.74,,,2361.74,Fee Schedule,,1318.8,70,,1318.8,percent of total billed charges,All Other,2833.52,,,2833.52,Fee Schedule,,2401.58,,,2401.58,Fee Schedule,,896.87,,,896.87,Fee Schedule,,896.87,,,896.87,Fee Schedule,,896.87,,,896.87,Fee Schedule,,896.87,,,896.87,Fee Schedule,,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2833.52,
TARGETED GENOMIC SEQ ANALYS,81450,CPT,,78081450,CDM,301,RC,,,both,,,1596,1181.04,,,1181.04,Other,150% of Medicare + 9.63% HCRA Surcharge,718.2,45,,718.2,percent of total billed charges,Critical Access Hospital RCC factor,2286.19,,,2286.19,Fee Schedule,,2058.33,,,2058.33,Fee Schedule,,846.27,,,846.27,Fee Schedule,,846.27,,,846.27,Fee Schedule,,846.27,,,846.27,Fee Schedule,,790.02,,,790.02,Other,110% of Medicare,2392.52,,,2392.52,Fee Schedule,,0.01,,,0.01,Other,186% of Medicaid,2817.86,,,2817.86,Fee Schedule,,989.52,,,989.52,Fee Schedule,,1595.01,,,1595.01,Fee Schedule,,2817.86,,,2817.86,Fee Schedule,,989.52,,,989.52,Fee Schedule,,3000.14,,,3000.14,Fee Schedule,,1117.2,70,,1117.2,percent of total billed charges,All Other,3599.44,,,3599.44,Fee Schedule,,3050.74,,,3050.74,Fee Schedule,,1139.3,,,1139.3,Fee Schedule,,1139.3,,,1139.3,Fee Schedule,,1139.3,,,1139.3,Fee Schedule,,1139.3,,,1139.3,Fee Schedule,,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3599.44,
TARGETED GENOMIC SEQ ANALYS 51/<GEN,81455,CPT,,78081455,CDM,301,RC,,,both,,,9197,6805.8,,,6805.8,Other,150% of Medicare + 9.63% HCRA Surcharge,4138.65,45,,4138.65,percent of total billed charges,Critical Access Hospital RCC factor,8788,,,8788,Fee Schedule,,7912.12,,,7912.12,Fee Schedule,,846.27,,,846.27,Fee Schedule,,846.27,,,846.27,Fee Schedule,,846.27,,,846.27,Fee Schedule,,4552.52,,,4552.52,Other,110% of Medicare,9196.74,,,9196.74,Fee Schedule,,0.01,,,0.01,Other,186% of Medicaid,10831.72,,,10831.72,Fee Schedule,,5702.14,,,5702.14,Fee Schedule,,6131.16,,,6131.16,Fee Schedule,,10831.72,,,10831.72,Fee Schedule,,5702.14,,,5702.14,Fee Schedule,,11532.42,,,11532.42,Fee Schedule,,6437.9,70,,6437.9,percent of total billed charges,All Other,13836.09,,,13836.09,Fee Schedule,,11726.93,,,11726.93,Fee Schedule,,4379.4,,,4379.4,Fee Schedule,,4379.4,,,4379.4,Fee Schedule,,4379.4,,,4379.4,Fee Schedule,,4379.4,,,4379.4,Fee Schedule,,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,13836.09,
UNLISTED MOLECULAR PATHOLOGY,81479,CPT,,78081479,CDM,301,RC,,,both,,,604,446.96,,,446.96,Other,150% of Medicare + 9.63% HCRA Surcharge,271.8,45,,271.8,percent of total billed charges,Critical Access Hospital RCC factor,392.6,65,,392.6,percent of total billed charges,All Other,356.36,65,,356.36,percent of total billed charges,All Other,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,298.98,,,298.98,Other,110% of Medicare,410.72,68,,410.72,percent of total billed charges,All Other,0.01,,,0.01,Other,186% of Medicaid,501.32,83,,501.32,percent of total billed charges,All Other,374.48,62,,374.48,percent of total billed charges,Lab and Radiology,332.2,55,,332.2,percent of total billed charges,Default if not on Fee Schedule,483.2,80,,483.2,percent of total billed charges,All Other,374.48,62,,374.48,percent of total billed charges,Lab and Radiology,483.2,80,,483.2,percent of total billed charges,All Other,422.8,70,,422.8,percent of total billed charges,All Other,392.6,65,,392.6,percent of total billed charges,Default if not in Fee Schedule,392.6,65,,392.6,percent of total billed charges,Default if not in Fee Schedule,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,501.32,
FTL CGEN ABNOR FOUR ANAL,81511,CPT,,78081511,CDM,301,RC,,,both,,,485,358.9,,,358.9,Other,150% of Medicare + 9.63% HCRA Surcharge,218.25,45,,218.25,percent of total billed charges,Critical Access Hospital RCC factor,462.04,,,462.04,Fee Schedule,,415.99,,,415.99,Fee Schedule,,40.56,,,40.56,Fee Schedule,,40.56,,,40.56,Fee Schedule,,40.56,,,40.56,Fee Schedule,,240.08,,,240.08,Other,110% of Medicare,483.53,,,483.53,Fee Schedule,,81,,,81,Other,186% of Medicaid,569.49,,,569.49,Fee Schedule,,300.7,,,300.7,Fee Schedule,,322.35,,,322.35,Fee Schedule,,569.49,,,569.49,Fee Schedule,,300.7,,,300.7,Fee Schedule,,606.33,,,606.33,Fee Schedule,,339.5,70,,339.5,percent of total billed charges,All Other,727.44,,,727.44,Fee Schedule,,616.55,,,616.55,Fee Schedule,,230.25,,,230.25,Fee Schedule,,230.25,,,230.25,Fee Schedule,,230.25,,,230.25,Fee Schedule,,230.25,,,230.25,Fee Schedule,,43.3,,,43.3,Other,100% of Medicaid,43.3,,,43.3,Other,100% of Medicaid,43.3,,,43.3,Other,100% of Medicaid,43.3,,,43.3,Other,100% of Medicaid,97.42,,,97.42,Other,225% of Medicaid,66.25,,,66.25,Other,153% of Medicaid,97.42,,,97.42,Other,225% of Medicaid,60.62,,,60.62,Other,140% of Medicaid,97.42,,,97.42,Other,225% of Medicaid,112.58,,,112.58,Other,260% of Medicaid,140.29,,,140.29,Other,324% of Medicaid,93.09,,,93.09,Other,215% of Medicaid,93.09,,,93.09,Other,215% of Medicaid,54.12,,,54.12,Other,125% of Medicaid,40.56,727.44,
TEST FOR ACETONE/KETONES,82009,CPT,,78082009,CDM,301,RC,,,both,,,97,71.78,,,71.78,Other,150% of Medicare + 9.63% HCRA Surcharge,43.65,45,,43.65,percent of total billed charges,Critical Access Hospital RCC factor,13.61,,,13.61,Fee Schedule,,12.25,,,12.25,Fee Schedule,,33.52,,,33.52,Fee Schedule,,30.15,,,30.15,Fee Schedule,,28.49,,,28.49,Fee Schedule,,48.02,,,48.02,Other,110% of Medicare,14.24,,,14.24,Fee Schedule,,1,,,1,Other,186% of Medicaid,16.77,,,16.77,Fee Schedule,,60.14,,,60.14,Fee Schedule,,9.49,,,9.49,Fee Schedule,,16.77,,,16.77,Fee Schedule,,60.14,,,60.14,Fee Schedule,,17.85,,,17.85,Fee Schedule,,67.9,70,,67.9,percent of total billed charges,All Other,21.42,,,21.42,Fee Schedule,,18.16,,,18.16,Fee Schedule,,6.78,,,6.78,Fee Schedule,,6.78,,,6.78,Fee Schedule,,6.78,,,6.78,Fee Schedule,,6.78,,,6.78,Fee Schedule,,0.51,,,0.51,Other,100% of Medicaid,0.51,,,0.51,Other,100% of Medicaid,0.51,,,0.51,Other,100% of Medicaid,0.51,,,0.51,Other,100% of Medicaid,1.14,,,1.14,Other,225% of Medicaid,0.77,,,0.77,Other,153% of Medicaid,1.14,,,1.14,Other,225% of Medicaid,0.71,,,0.71,Other,140% of Medicaid,1.14,,,1.14,Other,225% of Medicaid,1.31,,,1.31,Other,260% of Medicaid,1.64,,,1.64,Other,324% of Medicaid,1.09,,,1.09,Other,215% of Medicaid,1.09,,,1.09,Other,215% of Medicaid,0.63,,,0.63,Other,125% of Medicaid,0.51,71.78,
ACETONE ASSAY,82010,CPT,,78082010,CDM,301,RC,,,both,,,137,101.38,,,101.38,Other,150% of Medicare + 9.63% HCRA Surcharge,61.65,45,,61.65,percent of total billed charges,Critical Access Hospital RCC factor,24.59,,,24.59,Fee Schedule,,22.14,,,22.14,Fee Schedule,,60.61,,,60.61,Fee Schedule,,54.51,,,54.51,Fee Schedule,,51.52,,,51.52,Fee Schedule,,67.82,,,67.82,Other,110% of Medicare,25.74,,,25.74,Fee Schedule,,12,,,12,Other,186% of Medicaid,30.31,,,30.31,Fee Schedule,,84.94,,,84.94,Fee Schedule,,17.16,,,17.16,Fee Schedule,,30.31,,,30.31,Fee Schedule,,84.94,,,84.94,Fee Schedule,,32.27,,,32.27,Fee Schedule,,95.9,70,,95.9,percent of total billed charges,All Other,38.72,,,38.72,Fee Schedule,,32.82,,,32.82,Fee Schedule,,12.26,,,12.26,Fee Schedule,,12.26,,,12.26,Fee Schedule,,12.26,,,12.26,Fee Schedule,,12.26,,,12.26,Fee Schedule,,6.31,,,6.31,Other,100% of Medicaid,6.31,,,6.31,Other,100% of Medicaid,6.31,,,6.31,Other,100% of Medicaid,6.31,,,6.31,Other,100% of Medicaid,14.2,,,14.2,Other,225% of Medicaid,9.65,,,9.65,Other,153% of Medicaid,14.2,,,14.2,Other,225% of Medicaid,8.83,,,8.83,Other,140% of Medicaid,14.2,,,14.2,Other,225% of Medicaid,16.41,,,16.41,Other,260% of Medicaid,20.45,,,20.45,Other,324% of Medicaid,13.57,,,13.57,Other,215% of Medicaid,13.57,,,13.57,Other,215% of Medicaid,7.89,,,7.89,Other,125% of Medicaid,6.31,101.38,
ACYLCARNITINES QUANT,82017,CPT,,78082017,CDM,301,RC,,,both,,,54,39.96,,,39.96,Other,150% of Medicare + 9.63% HCRA Surcharge,24.3,45,,24.3,percent of total billed charges,Critical Access Hospital RCC factor,50.78,,,50.78,Fee Schedule,,45.72,,,45.72,Fee Schedule,,106.88,,,106.88,Fee Schedule,,96.13,,,96.13,Fee Schedule,,90.85,,,90.85,Fee Schedule,,26.73,,,26.73,Other,110% of Medicare,53.14,,,53.14,Fee Schedule,,31,,,31,Other,186% of Medicaid,62.59,,,62.59,Fee Schedule,,33.48,,,33.48,Fee Schedule,,35.43,,,35.43,Fee Schedule,,62.59,,,62.59,Fee Schedule,,33.48,,,33.48,Fee Schedule,,66.64,,,66.64,Fee Schedule,,37.8,70,,37.8,percent of total billed charges,All Other,79.95,,,79.95,Fee Schedule,,67.76,,,67.76,Fee Schedule,,25.31,,,25.31,Fee Schedule,,25.31,,,25.31,Fee Schedule,,25.31,,,25.31,Fee Schedule,,25.31,,,25.31,Fee Schedule,,16.87,,,16.87,Other,100% of Medicaid,16.87,,,16.87,Other,100% of Medicaid,16.87,,,16.87,Other,100% of Medicaid,16.87,,,16.87,Other,100% of Medicaid,37.96,,,37.96,Other,225% of Medicaid,25.81,,,25.81,Other,153% of Medicaid,37.96,,,37.96,Other,225% of Medicaid,23.62,,,23.62,Other,140% of Medicaid,37.96,,,37.96,Other,225% of Medicaid,43.86,,,43.86,Other,260% of Medicaid,54.66,,,54.66,Other,324% of Medicaid,36.27,,,36.27,Other,215% of Medicaid,36.27,,,36.27,Other,215% of Medicaid,21.09,,,21.09,Other,125% of Medicaid,16.87,106.88,
ASSAY OF ACTH,82024,CPT,,78082024,CDM,301,RC,,,both,,,534,395.16,,,395.16,Other,150% of Medicare + 9.63% HCRA Surcharge,240.3,45,,240.3,percent of total billed charges,Critical Access Hospital RCC factor,116.25,,,116.25,Fee Schedule,,104.66,,,104.66,Fee Schedule,,286.42,,,286.42,Fee Schedule,,257.62,,,257.62,Fee Schedule,,243.49,,,243.49,Fee Schedule,,264.33,,,264.33,Other,110% of Medicare,121.65,,,121.65,Fee Schedule,,72,,,72,Other,186% of Medicaid,143.28,,,143.28,Fee Schedule,,331.08,,,331.08,Fee Schedule,,81.1,,,81.1,Fee Schedule,,143.28,,,143.28,Fee Schedule,,331.08,,,331.08,Fee Schedule,,152.55,,,152.55,Fee Schedule,,373.8,70,,373.8,percent of total billed charges,All Other,183.02,,,183.02,Fee Schedule,,155.12,,,155.12,Fee Schedule,,57.93,,,57.93,Fee Schedule,,57.93,,,57.93,Fee Schedule,,57.93,,,57.93,Fee Schedule,,57.93,,,57.93,Fee Schedule,,38.62,,,38.62,Other,100% of Medicaid,38.62,,,38.62,Other,100% of Medicaid,38.62,,,38.62,Other,100% of Medicaid,38.62,,,38.62,Other,100% of Medicaid,86.9,,,86.9,Other,225% of Medicaid,59.09,,,59.09,Other,153% of Medicaid,86.9,,,86.9,Other,225% of Medicaid,54.07,,,54.07,Other,140% of Medicaid,86.9,,,86.9,Other,225% of Medicaid,100.41,,,100.41,Other,260% of Medicaid,125.13,,,125.13,Other,324% of Medicaid,83.03,,,83.03,Other,215% of Medicaid,83.03,,,83.03,Other,215% of Medicaid,48.28,,,48.28,Other,125% of Medicaid,38.62,395.16,
ASSAY OF ADP & AMP,82030,CPT,,78082030,CDM,301,RC,,,both,,,382,282.68,,,282.68,Other,150% of Medicare + 9.63% HCRA Surcharge,171.9,45,,171.9,percent of total billed charges,Critical Access Hospital RCC factor,77.66,,,77.66,Fee Schedule,,69.92,,,69.92,Fee Schedule,,191.3,,,191.3,Fee Schedule,,172.06,,,172.06,Fee Schedule,,162.62,,,162.62,Fee Schedule,,189.09,,,189.09,Other,110% of Medicare,81.27,,,81.27,Fee Schedule,,44,,,44,Other,186% of Medicaid,95.72,,,95.72,Fee Schedule,,236.84,,,236.84,Fee Schedule,,54.18,,,54.18,Fee Schedule,,95.72,,,95.72,Fee Schedule,,236.84,,,236.84,Fee Schedule,,101.91,,,101.91,Fee Schedule,,267.4,70,,267.4,percent of total billed charges,All Other,122.27,,,122.27,Fee Schedule,,103.63,,,103.63,Fee Schedule,,38.7,,,38.7,Fee Schedule,,38.7,,,38.7,Fee Schedule,,38.7,,,38.7,Fee Schedule,,38.7,,,38.7,Fee Schedule,,23.84,,,23.84,Other,100% of Medicaid,23.84,,,23.84,Other,100% of Medicaid,23.84,,,23.84,Other,100% of Medicaid,23.84,,,23.84,Other,100% of Medicaid,53.64,,,53.64,Other,225% of Medicaid,36.47,,,36.47,Other,153% of Medicaid,53.64,,,53.64,Other,225% of Medicaid,33.37,,,33.37,Other,140% of Medicaid,53.64,,,53.64,Other,225% of Medicaid,61.98,,,61.98,Other,260% of Medicaid,77.24,,,77.24,Other,324% of Medicaid,51.25,,,51.25,Other,215% of Medicaid,51.25,,,51.25,Other,215% of Medicaid,29.8,,,29.8,Other,125% of Medicaid,23.84,282.68,
ASSAY OF SERUM ALBUMIN,82040,CPT,,78082040,CDM,301,RC,,,both,,,69,51.06,,,51.06,Other,150% of Medicare + 9.63% HCRA Surcharge,31.05,45,,31.05,percent of total billed charges,Critical Access Hospital RCC factor,14.9,,,14.9,Fee Schedule,,13.41,,,13.41,Fee Schedule,,36.68,,,36.68,Fee Schedule,,32.99,,,32.99,Fee Schedule,,31.18,,,31.18,Fee Schedule,,34.16,,,34.16,Other,110% of Medicare,15.59,,,15.59,Fee Schedule,,9,,,9,Other,186% of Medicaid,18.36,,,18.36,Fee Schedule,,42.78,,,42.78,Fee Schedule,,10.4,,,10.4,Fee Schedule,,18.36,,,18.36,Fee Schedule,,42.78,,,42.78,Fee Schedule,,19.55,,,19.55,Fee Schedule,,48.3,70,,48.3,percent of total billed charges,All Other,23.46,,,23.46,Fee Schedule,,19.88,,,19.88,Fee Schedule,,7.43,,,7.43,Fee Schedule,,7.43,,,7.43,Fee Schedule,,7.43,,,7.43,Fee Schedule,,7.43,,,7.43,Fee Schedule,,4.95,,,4.95,Other,100% of Medicaid,4.95,,,4.95,Other,100% of Medicaid,4.95,,,4.95,Other,100% of Medicaid,4.95,,,4.95,Other,100% of Medicaid,11.14,,,11.14,Other,225% of Medicaid,7.57,,,7.57,Other,153% of Medicaid,11.14,,,11.14,Other,225% of Medicaid,6.93,,,6.93,Other,140% of Medicaid,11.14,,,11.14,Other,225% of Medicaid,12.87,,,12.87,Other,260% of Medicaid,16.04,,,16.04,Other,324% of Medicaid,10.64,,,10.64,Other,215% of Medicaid,10.64,,,10.64,Other,215% of Medicaid,6.19,,,6.19,Other,125% of Medicaid,4.95,51.06,
ASSAY OF URINE ALBUMIN,82042,CPT,,78082042,CDM,301,RC,,,both,,,65,48.1,,,48.1,Other,150% of Medicare + 9.63% HCRA Surcharge,29.25,45,,29.25,percent of total billed charges,Critical Access Hospital RCC factor,23.42,,,23.42,Fee Schedule,,21.08,,,21.08,Fee Schedule,,21.34,,,21.34,Fee Schedule,,19.2,,,19.2,Fee Schedule,,18.14,,,18.14,Fee Schedule,,32.18,,,32.18,Other,110% of Medicare,24.51,,,24.51,Fee Schedule,,9,,,9,Other,186% of Medicaid,28.86,,,28.86,Fee Schedule,,40.3,,,40.3,Fee Schedule,,16.34,,,16.34,Fee Schedule,,28.86,,,28.86,Fee Schedule,,40.3,,,40.3,Fee Schedule,,30.73,,,30.73,Fee Schedule,,45.5,70,,45.5,percent of total billed charges,All Other,36.87,,,36.87,Fee Schedule,,31.25,,,31.25,Fee Schedule,,11.67,,,11.67,Fee Schedule,,11.67,,,11.67,Fee Schedule,,11.67,,,11.67,Fee Schedule,,11.67,,,11.67,Fee Schedule,,5.08,,,5.08,Other,100% of Medicaid,5.08,,,5.08,Other,100% of Medicaid,5.08,,,5.08,Other,100% of Medicaid,5.08,,,5.08,Other,100% of Medicaid,11.43,,,11.43,Other,225% of Medicaid,7.77,,,7.77,Other,153% of Medicaid,11.43,,,11.43,Other,225% of Medicaid,7.11,,,7.11,Other,140% of Medicaid,11.43,,,11.43,Other,225% of Medicaid,13.21,,,13.21,Other,260% of Medicaid,16.46,,,16.46,Other,324% of Medicaid,10.92,,,10.92,Other,215% of Medicaid,10.92,,,10.92,Other,215% of Medicaid,6.35,,,6.35,Other,125% of Medicaid,5.08,48.1,
MICROALBUMIN QUANTITATIVE,82043,CPT,,78082043,CDM,301,RC,,,both,,,137,101.38,,,101.38,Other,150% of Medicare + 9.63% HCRA Surcharge,61.65,45,,61.65,percent of total billed charges,Critical Access Hospital RCC factor,17.4,,,17.4,Fee Schedule,,15.66,,,15.66,Fee Schedule,,42.9,,,42.9,Fee Schedule,,38.58,,,38.58,Fee Schedule,,36.47,,,36.47,Fee Schedule,,67.82,,,67.82,Other,110% of Medicare,18.21,,,18.21,Fee Schedule,,9,,,9,Other,186% of Medicaid,21.44,,,21.44,Fee Schedule,,84.94,,,84.94,Fee Schedule,,12.14,,,12.14,Fee Schedule,,21.44,,,21.44,Fee Schedule,,84.94,,,84.94,Fee Schedule,,22.83,,,22.83,Fee Schedule,,95.9,70,,95.9,percent of total billed charges,All Other,27.39,,,27.39,Fee Schedule,,23.22,,,23.22,Fee Schedule,,8.67,,,8.67,Fee Schedule,,8.67,,,8.67,Fee Schedule,,8.67,,,8.67,Fee Schedule,,8.67,,,8.67,Fee Schedule,,5.08,,,5.08,Other,100% of Medicaid,5.08,,,5.08,Other,100% of Medicaid,5.08,,,5.08,Other,100% of Medicaid,5.08,,,5.08,Other,100% of Medicaid,11.43,,,11.43,Other,225% of Medicaid,7.77,,,7.77,Other,153% of Medicaid,11.43,,,11.43,Other,225% of Medicaid,7.11,,,7.11,Other,140% of Medicaid,11.43,,,11.43,Other,225% of Medicaid,13.21,,,13.21,Other,260% of Medicaid,16.46,,,16.46,Other,324% of Medicaid,10.92,,,10.92,Other,215% of Medicaid,10.92,,,10.92,Other,215% of Medicaid,6.35,,,6.35,Other,125% of Medicaid,5.08,101.38,
ASSAY OF ALDOLASE,82085,CPT,,78082085,CDM,301,RC,,,both,,,129,95.46,,,95.46,Other,150% of Medicare + 9.63% HCRA Surcharge,58.05,45,,58.05,percent of total billed charges,Critical Access Hospital RCC factor,29.23,,,29.23,Fee Schedule,,26.31,,,26.31,Fee Schedule,,71.99,,,71.99,Fee Schedule,,64.75,,,64.75,Fee Schedule,,61.2,,,61.2,Fee Schedule,,63.86,,,63.86,Other,110% of Medicare,30.59,,,30.59,Fee Schedule,,12,,,12,Other,186% of Medicaid,36.02,,,36.02,Fee Schedule,,79.98,,,79.98,Fee Schedule,,20.39,,,20.39,Fee Schedule,,36.02,,,36.02,Fee Schedule,,79.98,,,79.98,Fee Schedule,,38.35,,,38.35,Fee Schedule,,90.3,70,,90.3,percent of total billed charges,All Other,46.02,,,46.02,Fee Schedule,,39,,,39,Fee Schedule,,14.57,,,14.57,Fee Schedule,,14.57,,,14.57,Fee Schedule,,14.57,,,14.57,Fee Schedule,,14.57,,,14.57,Fee Schedule,,6.31,,,6.31,Other,100% of Medicaid,6.31,,,6.31,Other,100% of Medicaid,6.31,,,6.31,Other,100% of Medicaid,6.31,,,6.31,Other,100% of Medicaid,14.2,,,14.2,Other,225% of Medicaid,9.65,,,9.65,Other,153% of Medicaid,14.2,,,14.2,Other,225% of Medicaid,8.83,,,8.83,Other,140% of Medicaid,14.2,,,14.2,Other,225% of Medicaid,16.41,,,16.41,Other,260% of Medicaid,20.45,,,20.45,Other,324% of Medicaid,13.57,,,13.57,Other,215% of Medicaid,13.57,,,13.57,Other,215% of Medicaid,7.89,,,7.89,Other,125% of Medicaid,6.31,95.46,
ASSAY OF ALDOSTERONE,82088,CPT,,78082088,CDM,301,RC,,,both,,,514,380.36,,,380.36,Other,150% of Medicare + 9.63% HCRA Surcharge,231.3,45,,231.3,percent of total billed charges,Critical Access Hospital RCC factor,122.66,,,122.66,Fee Schedule,,110.43,,,110.43,Fee Schedule,,302.23,,,302.23,Fee Schedule,,271.84,,,271.84,Fee Schedule,,256.93,,,256.93,Fee Schedule,,254.43,,,254.43,Other,110% of Medicare,128.36,,,128.36,Fee Schedule,,76,,,76,Other,186% of Medicaid,151.18,,,151.18,Fee Schedule,,318.68,,,318.68,Fee Schedule,,85.58,,,85.58,Fee Schedule,,151.18,,,151.18,Fee Schedule,,318.68,,,318.68,Fee Schedule,,160.96,,,160.96,Fee Schedule,,359.8,70,,359.8,percent of total billed charges,All Other,193.12,,,193.12,Fee Schedule,,163.68,,,163.68,Fee Schedule,,61.13,,,61.13,Fee Schedule,,61.13,,,61.13,Fee Schedule,,61.13,,,61.13,Fee Schedule,,61.13,,,61.13,Fee Schedule,,40.75,,,40.75,Other,100% of Medicaid,40.75,,,40.75,Other,100% of Medicaid,40.75,,,40.75,Other,100% of Medicaid,40.75,,,40.75,Other,100% of Medicaid,91.69,,,91.69,Other,225% of Medicaid,62.35,,,62.35,Other,153% of Medicaid,91.69,,,91.69,Other,225% of Medicaid,57.05,,,57.05,Other,140% of Medicaid,91.69,,,91.69,Other,225% of Medicaid,105.95,,,105.95,Other,260% of Medicaid,132.03,,,132.03,Other,324% of Medicaid,87.61,,,87.61,Other,215% of Medicaid,87.61,,,87.61,Other,215% of Medicaid,50.94,,,50.94,Other,125% of Medicaid,40.75,380.36,
ALPHA-1-ANTITRYPSIN PHENO,82104,CPT,,78082104,CDM,301,RC,,,both,,,193,142.82,,,142.82,Other,150% of Medicare + 9.63% HCRA Surcharge,86.85,45,,86.85,percent of total billed charges,Critical Access Hospital RCC factor,43.52,,,43.52,Fee Schedule,,39.19,,,39.19,Fee Schedule,,107.24,,,107.24,Fee Schedule,,96.46,,,96.46,Fee Schedule,,91.17,,,91.17,Fee Schedule,,95.54,,,95.54,Other,110% of Medicare,45.55,,,45.55,Fee Schedule,,26,,,26,Other,186% of Medicaid,53.65,,,53.65,Fee Schedule,,119.66,,,119.66,Fee Schedule,,30.37,,,30.37,Fee Schedule,,53.65,,,53.65,Fee Schedule,,119.66,,,119.66,Fee Schedule,,57.12,,,57.12,Fee Schedule,,135.1,70,,135.1,percent of total billed charges,All Other,68.53,,,68.53,Fee Schedule,,58.08,,,58.08,Fee Schedule,,21.69,,,21.69,Fee Schedule,,21.69,,,21.69,Fee Schedule,,21.69,,,21.69,Fee Schedule,,21.69,,,21.69,Fee Schedule,,13.86,,,13.86,Other,100% of Medicaid,13.86,,,13.86,Other,100% of Medicaid,13.86,,,13.86,Other,100% of Medicaid,13.86,,,13.86,Other,100% of Medicaid,31.18,,,31.18,Other,225% of Medicaid,21.2,,,21.2,Other,153% of Medicaid,31.18,,,31.18,Other,225% of Medicaid,19.4,,,19.4,Other,140% of Medicaid,31.18,,,31.18,Other,225% of Medicaid,36.03,,,36.03,Other,260% of Medicaid,44.9,,,44.9,Other,324% of Medicaid,29.79,,,29.79,Other,215% of Medicaid,29.79,,,29.79,Other,215% of Medicaid,17.32,,,17.32,Other,125% of Medicaid,13.86,142.82,
ALPHA-FETOPROTEIN SERUM,82105,CPT,,78082105,CDM,301,RC,,,both,,,240,177.6,,,177.6,Other,150% of Medicare + 9.63% HCRA Surcharge,108,45,,108,percent of total billed charges,Critical Access Hospital RCC factor,50.48,,,50.48,Fee Schedule,,45.45,,,45.45,Fee Schedule,,124.42,,,124.42,Fee Schedule,,111.91,,,111.91,Fee Schedule,,105.77,,,105.77,Fee Schedule,,118.8,,,118.8,Other,110% of Medicare,52.83,,,52.83,Fee Schedule,,12,,,12,Other,186% of Medicaid,62.22,,,62.22,Fee Schedule,,148.8,,,148.8,Fee Schedule,,35.22,,,35.22,Fee Schedule,,62.22,,,62.22,Fee Schedule,,148.8,,,148.8,Fee Schedule,,66.24,,,66.24,Fee Schedule,,168,70,,168,percent of total billed charges,All Other,79.47,,,79.47,Fee Schedule,,67.36,,,67.36,Fee Schedule,,25.16,,,25.16,Fee Schedule,,25.16,,,25.16,Fee Schedule,,25.16,,,25.16,Fee Schedule,,25.16,,,25.16,Fee Schedule,,6.57,,,6.57,Other,100% of Medicaid,6.57,,,6.57,Other,100% of Medicaid,6.57,,,6.57,Other,100% of Medicaid,6.57,,,6.57,Other,100% of Medicaid,14.77,,,14.77,Other,225% of Medicaid,10.04,,,10.04,Other,153% of Medicaid,14.77,,,14.77,Other,225% of Medicaid,9.19,,,9.19,Other,140% of Medicaid,14.77,,,14.77,Other,225% of Medicaid,17.07,,,17.07,Other,260% of Medicaid,21.27,,,21.27,Other,324% of Medicaid,14.11,,,14.11,Other,215% of Medicaid,14.11,,,14.11,Other,215% of Medicaid,8.21,,,8.21,Other,125% of Medicaid,6.57,177.6,
ALPHA-FETOPROTEIN AMNIOTIC,82106,CPT,,78082106,CDM,301,RC,,,both,,,199,147.26,,,147.26,Other,150% of Medicare + 9.63% HCRA Surcharge,89.55,45,,89.55,percent of total billed charges,Critical Access Hospital RCC factor,51.17,,,51.17,Fee Schedule,,46.07,,,46.07,Fee Schedule,,124.42,,,124.42,Fee Schedule,,111.91,,,111.91,Fee Schedule,,105.77,,,105.77,Fee Schedule,,98.51,,,98.51,Other,110% of Medicare,53.55,,,53.55,Fee Schedule,,19,,,19,Other,186% of Medicaid,63.07,,,63.07,Fee Schedule,,123.38,,,123.38,Fee Schedule,,35.7,,,35.7,Fee Schedule,,63.07,,,63.07,Fee Schedule,,123.38,,,123.38,Fee Schedule,,67.15,,,67.15,Fee Schedule,,139.3,70,,139.3,percent of total billed charges,All Other,80.56,,,80.56,Fee Schedule,,68.28,,,68.28,Fee Schedule,,25.5,,,25.5,Fee Schedule,,25.5,,,25.5,Fee Schedule,,25.5,,,25.5,Fee Schedule,,25.5,,,25.5,Fee Schedule,,10.1,,,10.1,Other,100% of Medicaid,10.1,,,10.1,Other,100% of Medicaid,10.1,,,10.1,Other,100% of Medicaid,10.1,,,10.1,Other,100% of Medicaid,22.73,,,22.73,Other,225% of Medicaid,15.45,,,15.45,Other,153% of Medicaid,22.73,,,22.73,Other,225% of Medicaid,14.14,,,14.14,Other,140% of Medicaid,22.73,,,22.73,Other,225% of Medicaid,26.26,,,26.26,Other,260% of Medicaid,32.72,,,32.72,Other,324% of Medicaid,21.72,,,21.72,Other,215% of Medicaid,21.72,,,21.72,Other,215% of Medicaid,12.63,,,12.63,Other,125% of Medicaid,10.1,147.26,
ALPHA-FETOPROTEIN L3,82107,CPT,,78082107,CDM,301,RC,,,both,,,146,108.04,,,108.04,Other,150% of Medicare + 9.63% HCRA Surcharge,65.7,45,,65.7,percent of total billed charges,Critical Access Hospital RCC factor,193.87,,,193.87,Fee Schedule,,174.55,,,174.55,Fee Schedule,,466.55,,,466.55,Fee Schedule,,419.63,,,419.63,Fee Schedule,,396.61,,,396.61,Fee Schedule,,72.27,,,72.27,Other,110% of Medicare,202.89,,,202.89,Fee Schedule,,120,,,120,Other,186% of Medicaid,238.96,,,238.96,Fee Schedule,,90.52,,,90.52,Fee Schedule,,135.26,,,135.26,Fee Schedule,,238.96,,,238.96,Fee Schedule,,90.52,,,90.52,Fee Schedule,,254.42,,,254.42,Fee Schedule,,102.2,70,,102.2,percent of total billed charges,All Other,305.24,,,305.24,Fee Schedule,,258.71,,,258.71,Fee Schedule,,96.62,,,96.62,Fee Schedule,,96.62,,,96.62,Fee Schedule,,96.62,,,96.62,Fee Schedule,,96.62,,,96.62,Fee Schedule,,64.41,,,64.41,Other,100% of Medicaid,64.41,,,64.41,Other,100% of Medicaid,64.41,,,64.41,Other,100% of Medicaid,64.41,,,64.41,Other,100% of Medicaid,144.92,,,144.92,Other,225% of Medicaid,98.55,,,98.55,Other,153% of Medicaid,144.92,,,144.92,Other,225% of Medicaid,90.17,,,90.17,Other,140% of Medicaid,144.92,,,144.92,Other,225% of Medicaid,167.47,,,167.47,Other,260% of Medicaid,208.69,,,208.69,Other,324% of Medicaid,138.48,,,138.48,Other,215% of Medicaid,138.48,,,138.48,Other,215% of Medicaid,80.51,,,80.51,Other,125% of Medicaid,64.41,466.55,
ASSAY OF ALUMINUM,82108,CPT,,78082108,CDM,301,RC,,,both,,,240,177.6,,,177.6,Other,150% of Medicare + 9.63% HCRA Surcharge,108,45,,108,percent of total billed charges,Critical Access Hospital RCC factor,76.69,,,76.69,Fee Schedule,,69.05,,,69.05,Fee Schedule,,188.93,,,188.93,Fee Schedule,,169.93,,,169.93,Fee Schedule,,160.61,,,160.61,Fee Schedule,,118.8,,,118.8,Other,110% of Medicare,80.26,,,80.26,Fee Schedule,,47,,,47,Other,186% of Medicaid,94.53,,,94.53,Fee Schedule,,148.8,,,148.8,Fee Schedule,,53.51,,,53.51,Fee Schedule,,94.53,,,94.53,Fee Schedule,,148.8,,,148.8,Fee Schedule,,100.65,,,100.65,Fee Schedule,,168,70,,168,percent of total billed charges,All Other,120.75,,,120.75,Fee Schedule,,102.34,,,102.34,Fee Schedule,,38.22,,,38.22,Fee Schedule,,38.22,,,38.22,Fee Schedule,,38.22,,,38.22,Fee Schedule,,38.22,,,38.22,Fee Schedule,,25.48,,,25.48,Other,100% of Medicaid,25.48,,,25.48,Other,100% of Medicaid,25.48,,,25.48,Other,100% of Medicaid,25.48,,,25.48,Other,100% of Medicaid,57.33,,,57.33,Other,225% of Medicaid,38.98,,,38.98,Other,153% of Medicaid,57.33,,,57.33,Other,225% of Medicaid,35.67,,,35.67,Other,140% of Medicaid,57.33,,,57.33,Other,225% of Medicaid,66.25,,,66.25,Other,260% of Medicaid,82.56,,,82.56,Other,324% of Medicaid,54.78,,,54.78,Other,215% of Medicaid,54.78,,,54.78,Other,215% of Medicaid,31.85,,,31.85,Other,125% of Medicaid,25.48,188.93,
AMINO ACIDS MULT QUAL,82128,CPT,,78082128,CDM,301,RC,,,both,,,167,123.58,,,123.58,Other,150% of Medicare + 9.63% HCRA Surcharge,75.15,45,,75.15,percent of total billed charges,Critical Access Hospital RCC factor,41.75,,,41.75,Fee Schedule,,37.59,,,37.59,Fee Schedule,,79.95,,,79.95,Fee Schedule,,71.91,,,71.91,Fee Schedule,,67.96,,,67.96,Fee Schedule,,82.67,,,82.67,Other,110% of Medicare,43.69,,,43.69,Fee Schedule,,17,,,17,Other,186% of Medicaid,51.46,,,51.46,Fee Schedule,,103.54,,,103.54,Fee Schedule,,29.13,,,29.13,Fee Schedule,,51.46,,,51.46,Fee Schedule,,103.54,,,103.54,Fee Schedule,,54.79,,,54.79,Fee Schedule,,116.9,70,,116.9,percent of total billed charges,All Other,65.73,,,65.73,Fee Schedule,,55.71,,,55.71,Fee Schedule,,20.81,,,20.81,Fee Schedule,,20.81,,,20.81,Fee Schedule,,20.81,,,20.81,Fee Schedule,,20.81,,,20.81,Fee Schedule,,9.29,,,9.29,Other,100% of Medicaid,9.29,,,9.29,Other,100% of Medicaid,9.29,,,9.29,Other,100% of Medicaid,9.29,,,9.29,Other,100% of Medicaid,20.91,,,20.91,Other,225% of Medicaid,14.22,,,14.22,Other,153% of Medicaid,20.91,,,20.91,Other,225% of Medicaid,13.01,,,13.01,Other,140% of Medicaid,20.91,,,20.91,Other,225% of Medicaid,24.16,,,24.16,Other,260% of Medicaid,30.11,,,30.11,Other,324% of Medicaid,19.98,,,19.98,Other,215% of Medicaid,19.98,,,19.98,Other,215% of Medicaid,11.62,,,11.62,Other,125% of Medicaid,9.29,123.58,
AMINO ACIDS SINGLE QUANT,82131,CPT,,78082131,CDM,301,RC,,,both,,,275,203.5,,,203.5,Other,150% of Medicare + 9.63% HCRA Surcharge,123.75,45,,123.75,percent of total billed charges,Critical Access Hospital RCC factor,69.17,,,69.17,Fee Schedule,,62.28,,,62.28,Fee Schedule,,125.11,,,125.11,Fee Schedule,,112.53,,,112.53,Fee Schedule,,106.36,,,106.36,Fee Schedule,,136.13,,,136.13,Other,110% of Medicare,72.39,,,72.39,Fee Schedule,,26,,,26,Other,186% of Medicaid,85.26,,,85.26,Fee Schedule,,170.5,,,170.5,Fee Schedule,,48.26,,,48.26,Fee Schedule,,85.26,,,85.26,Fee Schedule,,170.5,,,170.5,Fee Schedule,,90.77,,,90.77,Fee Schedule,,192.5,70,,192.5,percent of total billed charges,All Other,108.9,,,108.9,Fee Schedule,,92.3,,,92.3,Fee Schedule,,34.47,,,34.47,Fee Schedule,,34.47,,,34.47,Fee Schedule,,34.47,,,34.47,Fee Schedule,,34.47,,,34.47,Fee Schedule,,14.14,,,14.14,Other,100% of Medicaid,14.14,,,14.14,Other,100% of Medicaid,14.14,,,14.14,Other,100% of Medicaid,14.14,,,14.14,Other,100% of Medicaid,31.82,,,31.82,Other,225% of Medicaid,21.63,,,21.63,Other,153% of Medicaid,31.82,,,31.82,Other,225% of Medicaid,19.8,,,19.8,Other,140% of Medicaid,31.82,,,31.82,Other,225% of Medicaid,36.76,,,36.76,Other,260% of Medicaid,45.81,,,45.81,Other,324% of Medicaid,30.4,,,30.4,Other,215% of Medicaid,30.4,,,30.4,Other,215% of Medicaid,17.68,,,17.68,Other,125% of Medicaid,14.14,203.5,
ASSAY AMINOLEVULINIC ACID,82135,CPT,,78082135,CDM,301,RC,,,both,,,218,161.32,,,161.32,Other,150% of Medicare + 9.63% HCRA Surcharge,98.1,45,,98.1,percent of total billed charges,Critical Access Hospital RCC factor,49.51,,,49.51,Fee Schedule,,44.58,,,44.58,Fee Schedule,,122.05,,,122.05,Fee Schedule,,109.78,,,109.78,Fee Schedule,,103.76,,,103.76,Fee Schedule,,107.91,,,107.91,Other,110% of Medicare,51.82,,,51.82,Fee Schedule,,19,,,19,Other,186% of Medicaid,61.03,,,61.03,Fee Schedule,,135.16,,,135.16,Fee Schedule,,34.55,,,34.55,Fee Schedule,,61.03,,,61.03,Fee Schedule,,135.16,,,135.16,Fee Schedule,,64.98,,,64.98,Fee Schedule,,152.6,70,,152.6,percent of total billed charges,All Other,77.96,,,77.96,Fee Schedule,,66.07,,,66.07,Fee Schedule,,24.68,,,24.68,Fee Schedule,,24.68,,,24.68,Fee Schedule,,24.68,,,24.68,Fee Schedule,,24.68,,,24.68,Fee Schedule,,10.16,,,10.16,Other,100% of Medicaid,10.16,,,10.16,Other,100% of Medicaid,10.16,,,10.16,Other,100% of Medicaid,10.16,,,10.16,Other,100% of Medicaid,22.85,,,22.85,Other,225% of Medicaid,15.54,,,15.54,Other,153% of Medicaid,22.85,,,22.85,Other,225% of Medicaid,14.22,,,14.22,Other,140% of Medicaid,22.85,,,22.85,Other,225% of Medicaid,26.4,,,26.4,Other,260% of Medicaid,32.9,,,32.9,Other,324% of Medicaid,21.83,,,21.83,Other,215% of Medicaid,21.83,,,21.83,Other,215% of Medicaid,12.69,,,12.69,Other,125% of Medicaid,10.16,161.32,
AMINO ACIDS QUANT 2-5,82136,CPT,,78082136,CDM,301,RC,,,both,,,511,378.14,,,378.14,Other,150% of Medicare + 9.63% HCRA Surcharge,229.95,45,,229.95,percent of total billed charges,Critical Access Hospital RCC factor,59.03,,,59.03,Fee Schedule,,53.14,,,53.14,Fee Schedule,,106.88,,,106.88,Fee Schedule,,96.13,,,96.13,Fee Schedule,,90.85,,,90.85,Fee Schedule,,252.95,,,252.95,Other,110% of Medicare,61.77,,,61.77,Fee Schedule,,26,,,26,Other,186% of Medicaid,72.75,,,72.75,Fee Schedule,,316.82,,,316.82,Fee Schedule,,41.18,,,41.18,Fee Schedule,,72.75,,,72.75,Fee Schedule,,316.82,,,316.82,Fee Schedule,,77.46,,,77.46,Fee Schedule,,357.7,70,,357.7,percent of total billed charges,All Other,92.93,,,92.93,Fee Schedule,,78.77,,,78.77,Fee Schedule,,29.42,,,29.42,Fee Schedule,,29.42,,,29.42,Fee Schedule,,29.42,,,29.42,Fee Schedule,,29.42,,,29.42,Fee Schedule,,14.14,,,14.14,Other,100% of Medicaid,14.14,,,14.14,Other,100% of Medicaid,14.14,,,14.14,Other,100% of Medicaid,14.14,,,14.14,Other,100% of Medicaid,31.82,,,31.82,Other,225% of Medicaid,21.63,,,21.63,Other,153% of Medicaid,31.82,,,31.82,Other,225% of Medicaid,19.8,,,19.8,Other,140% of Medicaid,31.82,,,31.82,Other,225% of Medicaid,36.76,,,36.76,Other,260% of Medicaid,45.81,,,45.81,Other,324% of Medicaid,30.4,,,30.4,Other,215% of Medicaid,30.4,,,30.4,Other,215% of Medicaid,17.68,,,17.68,Other,125% of Medicaid,14.14,378.14,
AMINO ACIDS QUAN 6 OR MORE,82139,CPT,,78082139,CDM,301,RC,,,both,,,1181,873.94,,,873.94,Other,150% of Medicare + 9.63% HCRA Surcharge,531.45,45,,531.45,percent of total billed charges,Critical Access Hospital RCC factor,50.78,,,50.78,Fee Schedule,,45.72,,,45.72,Fee Schedule,,106.88,,,106.88,Fee Schedule,,96.13,,,96.13,Fee Schedule,,90.85,,,90.85,Fee Schedule,,584.6,,,584.6,Other,110% of Medicare,53.14,,,53.14,Fee Schedule,,26,,,26,Other,186% of Medicaid,62.59,,,62.59,Fee Schedule,,732.22,,,732.22,Fee Schedule,,35.43,,,35.43,Fee Schedule,,62.59,,,62.59,Fee Schedule,,732.22,,,732.22,Fee Schedule,,66.64,,,66.64,Fee Schedule,,826.7,70,,826.7,percent of total billed charges,All Other,79.95,,,79.95,Fee Schedule,,67.76,,,67.76,Fee Schedule,,25.31,,,25.31,Fee Schedule,,25.31,,,25.31,Fee Schedule,,25.31,,,25.31,Fee Schedule,,25.31,,,25.31,Fee Schedule,,14.14,,,14.14,Other,100% of Medicaid,14.14,,,14.14,Other,100% of Medicaid,14.14,,,14.14,Other,100% of Medicaid,14.14,,,14.14,Other,100% of Medicaid,31.82,,,31.82,Other,225% of Medicaid,21.63,,,21.63,Other,153% of Medicaid,31.82,,,31.82,Other,225% of Medicaid,19.8,,,19.8,Other,140% of Medicaid,31.82,,,31.82,Other,225% of Medicaid,36.76,,,36.76,Other,260% of Medicaid,45.81,,,45.81,Other,324% of Medicaid,30.4,,,30.4,Other,215% of Medicaid,30.4,,,30.4,Other,215% of Medicaid,17.68,,,17.68,Other,125% of Medicaid,14.14,873.94,
ASSAY OF AMMONIA,82140,CPT,,78082140,CDM,301,RC,,,both,,,233,172.42,,,172.42,Other,150% of Medicare + 9.63% HCRA Surcharge,104.85,45,,104.85,percent of total billed charges,Critical Access Hospital RCC factor,43.86,,,43.86,Fee Schedule,,39.48,,,39.48,Fee Schedule,,108.09,,,108.09,Fee Schedule,,97.22,,,97.22,Fee Schedule,,91.88,,,91.88,Fee Schedule,,115.34,,,115.34,Other,110% of Medicare,45.9,,,45.9,Fee Schedule,,27,,,27,Other,186% of Medicaid,54.05,,,54.05,Fee Schedule,,144.46,,,144.46,Fee Schedule,,30.6,,,30.6,Fee Schedule,,54.05,,,54.05,Fee Schedule,,144.46,,,144.46,Fee Schedule,,57.55,,,57.55,Fee Schedule,,163.1,70,,163.1,percent of total billed charges,All Other,69.05,,,69.05,Fee Schedule,,58.52,,,58.52,Fee Schedule,,21.86,,,21.86,Fee Schedule,,21.86,,,21.86,Fee Schedule,,21.86,,,21.86,Fee Schedule,,21.86,,,21.86,Fee Schedule,,14.57,,,14.57,Other,100% of Medicaid,14.57,,,14.57,Other,100% of Medicaid,14.57,,,14.57,Other,100% of Medicaid,14.57,,,14.57,Other,100% of Medicaid,32.78,,,32.78,Other,225% of Medicaid,22.29,,,22.29,Other,153% of Medicaid,32.78,,,32.78,Other,225% of Medicaid,20.4,,,20.4,Other,140% of Medicaid,32.78,,,32.78,Other,225% of Medicaid,37.88,,,37.88,Other,260% of Medicaid,47.21,,,47.21,Other,324% of Medicaid,31.33,,,31.33,Other,215% of Medicaid,31.33,,,31.33,Other,215% of Medicaid,18.21,,,18.21,Other,125% of Medicaid,14.57,172.42,
ASSAY OF AMYLASE,82150,CPT,,78082150,CDM,301,RC,,,both,,,125,92.5,,,92.5,Other,150% of Medicare + 9.63% HCRA Surcharge,56.25,45,,56.25,percent of total billed charges,Critical Access Hospital RCC factor,19.5,,,19.5,Fee Schedule,,17.56,,,17.56,Fee Schedule,,48.06,,,48.06,Fee Schedule,,43.23,,,43.23,Fee Schedule,,40.86,,,40.86,Fee Schedule,,61.88,,,61.88,Other,110% of Medicare,20.41,,,20.41,Fee Schedule,,9,,,9,Other,186% of Medicaid,24.04,,,24.04,Fee Schedule,,77.5,,,77.5,Fee Schedule,,13.61,,,13.61,Fee Schedule,,24.04,,,24.04,Fee Schedule,,77.5,,,77.5,Fee Schedule,,25.6,,,25.6,Fee Schedule,,87.5,70,,87.5,percent of total billed charges,All Other,30.71,,,30.71,Fee Schedule,,26.03,,,26.03,Fee Schedule,,9.72,,,9.72,Fee Schedule,,9.72,,,9.72,Fee Schedule,,9.72,,,9.72,Fee Schedule,,9.72,,,9.72,Fee Schedule,,5.08,,,5.08,Other,100% of Medicaid,5.08,,,5.08,Other,100% of Medicaid,5.08,,,5.08,Other,100% of Medicaid,5.08,,,5.08,Other,100% of Medicaid,11.43,,,11.43,Other,225% of Medicaid,7.77,,,7.77,Other,153% of Medicaid,11.43,,,11.43,Other,225% of Medicaid,7.11,,,7.11,Other,140% of Medicaid,11.43,,,11.43,Other,225% of Medicaid,13.21,,,13.21,Other,260% of Medicaid,16.46,,,16.46,Other,324% of Medicaid,10.92,,,10.92,Other,215% of Medicaid,10.92,,,10.92,Other,215% of Medicaid,6.35,,,6.35,Other,125% of Medicaid,5.08,92.5,
ASSAY OF ANDROSTENEDIONE,82157,CPT,,78082157,CDM,301,RC,,,both,,,446,330.04,,,330.04,Other,150% of Medicare + 9.63% HCRA Surcharge,200.7,45,,200.7,percent of total billed charges,Critical Access Hospital RCC factor,88.13,,,88.13,Fee Schedule,,79.35,,,79.35,Fee Schedule,,217.12,,,217.12,Fee Schedule,,195.29,,,195.29,Fee Schedule,,184.58,,,184.58,Fee Schedule,,220.77,,,220.77,Other,110% of Medicare,92.23,,,92.23,Fee Schedule,,54,,,54,Other,186% of Medicaid,108.63,,,108.63,Fee Schedule,,276.52,,,276.52,Fee Schedule,,61.49,,,61.49,Fee Schedule,,108.63,,,108.63,Fee Schedule,,276.52,,,276.52,Fee Schedule,,115.66,,,115.66,Fee Schedule,,312.2,70,,312.2,percent of total billed charges,All Other,138.76,,,138.76,Fee Schedule,,117.61,,,117.61,Fee Schedule,,43.92,,,43.92,Fee Schedule,,43.92,,,43.92,Fee Schedule,,43.92,,,43.92,Fee Schedule,,43.92,,,43.92,Fee Schedule,,29.28,,,29.28,Other,100% of Medicaid,29.28,,,29.28,Other,100% of Medicaid,29.28,,,29.28,Other,100% of Medicaid,29.28,,,29.28,Other,100% of Medicaid,65.88,,,65.88,Other,225% of Medicaid,44.8,,,44.8,Other,153% of Medicaid,65.88,,,65.88,Other,225% of Medicaid,40.99,,,40.99,Other,140% of Medicaid,65.88,,,65.88,Other,225% of Medicaid,76.13,,,76.13,Other,260% of Medicaid,94.87,,,94.87,Other,324% of Medicaid,62.95,,,62.95,Other,215% of Medicaid,62.95,,,62.95,Other,215% of Medicaid,36.6,,,36.6,Other,125% of Medicaid,29.28,330.04,
ANGIOTENSIN I ENZYME TEST,82164,CPT,,78082164,CDM,301,RC,,,both,,,227,167.98,,,167.98,Other,150% of Medicare + 9.63% HCRA Surcharge,102.15,45,,102.15,percent of total billed charges,Critical Access Hospital RCC factor,43.95,,,43.95,Fee Schedule,,39.57,,,39.57,Fee Schedule,,108.25,,,108.25,Fee Schedule,,97.36,,,97.36,Fee Schedule,,92.02,,,92.02,Fee Schedule,,112.37,,,112.37,Other,110% of Medicare,45.99,,,45.99,Fee Schedule,,19,,,19,Other,186% of Medicaid,54.17,,,54.17,Fee Schedule,,140.74,,,140.74,Fee Schedule,,30.66,,,30.66,Fee Schedule,,54.17,,,54.17,Fee Schedule,,140.74,,,140.74,Fee Schedule,,57.67,,,57.67,Fee Schedule,,158.9,70,,158.9,percent of total billed charges,All Other,69.19,,,69.19,Fee Schedule,,58.64,,,58.64,Fee Schedule,,21.9,,,21.9,Fee Schedule,,21.9,,,21.9,Fee Schedule,,21.9,,,21.9,Fee Schedule,,21.9,,,21.9,Fee Schedule,,10.16,,,10.16,Other,100% of Medicaid,10.16,,,10.16,Other,100% of Medicaid,10.16,,,10.16,Other,100% of Medicaid,10.16,,,10.16,Other,100% of Medicaid,22.85,,,22.85,Other,225% of Medicaid,15.54,,,15.54,Other,153% of Medicaid,22.85,,,22.85,Other,225% of Medicaid,14.22,,,14.22,Other,140% of Medicaid,22.85,,,22.85,Other,225% of Medicaid,26.4,,,26.4,Other,260% of Medicaid,32.9,,,32.9,Other,324% of Medicaid,21.83,,,21.83,Other,215% of Medicaid,21.83,,,21.83,Other,215% of Medicaid,12.69,,,12.69,Other,125% of Medicaid,10.16,167.98,
ASSAY OF APOLIPOPROTEIN,82172,CPT,,78082172,CDM,301,RC,,,both,,,182,134.68,,,134.68,Other,150% of Medicare + 9.63% HCRA Surcharge,81.9,45,,81.9,percent of total billed charges,Critical Access Hospital RCC factor,63.48,,,63.48,Fee Schedule,,57.15,,,57.15,Fee Schedule,,114.94,,,114.94,Fee Schedule,,103.38,,,103.38,Fee Schedule,,97.71,,,97.71,Fee Schedule,,90.09,,,90.09,Other,110% of Medicare,66.43,,,66.43,Fee Schedule,,30,,,30,Other,186% of Medicaid,78.24,,,78.24,Fee Schedule,,112.84,,,112.84,Fee Schedule,,44.29,,,44.29,Fee Schedule,,78.24,,,78.24,Fee Schedule,,112.84,,,112.84,Fee Schedule,,83.31,,,83.31,Fee Schedule,,127.4,70,,127.4,percent of total billed charges,All Other,99.95,,,99.95,Fee Schedule,,84.71,,,84.71,Fee Schedule,,31.64,,,31.64,Fee Schedule,,31.64,,,31.64,Fee Schedule,,31.64,,,31.64,Fee Schedule,,31.64,,,31.64,Fee Schedule,,16.09,,,16.09,Other,100% of Medicaid,16.09,,,16.09,Other,100% of Medicaid,16.09,,,16.09,Other,100% of Medicaid,16.09,,,16.09,Other,100% of Medicaid,36.2,,,36.2,Other,225% of Medicaid,24.62,,,24.62,Other,153% of Medicaid,36.2,,,36.2,Other,225% of Medicaid,22.53,,,22.53,Other,140% of Medicaid,36.2,,,36.2,Other,225% of Medicaid,41.83,,,41.83,Other,260% of Medicaid,52.13,,,52.13,Other,324% of Medicaid,34.59,,,34.59,Other,215% of Medicaid,34.59,,,34.59,Other,215% of Medicaid,20.11,,,20.11,Other,125% of Medicaid,16.09,134.68,
ASSAY OF ARSENIC,82175,CPT,,78082175,CDM,301,RC,,,both,,,192,142.08,,,142.08,Other,150% of Medicare + 9.63% HCRA Surcharge,86.4,45,,86.4,percent of total billed charges,Critical Access Hospital RCC factor,57.1,,,57.1,Fee Schedule,,51.41,,,51.41,Fee Schedule,,140.71,,,140.71,Fee Schedule,,126.56,,,126.56,Fee Schedule,,119.62,,,119.62,Fee Schedule,,95.04,,,95.04,Other,110% of Medicare,59.76,,,59.76,Fee Schedule,,35,,,35,Other,186% of Medicaid,70.38,,,70.38,Fee Schedule,,119.04,,,119.04,Fee Schedule,,39.84,,,39.84,Fee Schedule,,70.38,,,70.38,Fee Schedule,,119.04,,,119.04,Fee Schedule,,74.93,,,74.93,Fee Schedule,,134.4,70,,134.4,percent of total billed charges,All Other,89.9,,,89.9,Fee Schedule,,76.2,,,76.2,Fee Schedule,,28.46,,,28.46,Fee Schedule,,28.46,,,28.46,Fee Schedule,,28.46,,,28.46,Fee Schedule,,28.46,,,28.46,Fee Schedule,,18.97,,,18.97,Other,100% of Medicaid,18.97,,,18.97,Other,100% of Medicaid,18.97,,,18.97,Other,100% of Medicaid,18.97,,,18.97,Other,100% of Medicaid,42.68,,,42.68,Other,225% of Medicaid,29.02,,,29.02,Other,153% of Medicaid,42.68,,,42.68,Other,225% of Medicaid,26.56,,,26.56,Other,140% of Medicaid,42.68,,,42.68,Other,225% of Medicaid,49.32,,,49.32,Other,260% of Medicaid,61.46,,,61.46,Other,324% of Medicaid,40.79,,,40.79,Other,215% of Medicaid,40.79,,,40.79,Other,215% of Medicaid,23.71,,,23.71,Other,125% of Medicaid,18.97,142.08,
ASSAY OF ASCORBIC ACID,82180,CPT,,78082180,CDM,301,RC,,,both,,,163,120.62,,,120.62,Other,150% of Medicare + 9.63% HCRA Surcharge,73.35,45,,73.35,percent of total billed charges,Critical Access Hospital RCC factor,29.77,,,29.77,Fee Schedule,,26.8,,,26.8,Fee Schedule,,68.3,,,68.3,Fee Schedule,,61.43,,,61.43,Fee Schedule,,58.06,,,58.06,Fee Schedule,,80.69,,,80.69,Other,110% of Medicare,31.15,,,31.15,Fee Schedule,,18,,,18,Other,186% of Medicaid,36.69,,,36.69,Fee Schedule,,101.06,,,101.06,Fee Schedule,,20.77,,,20.77,Fee Schedule,,36.69,,,36.69,Fee Schedule,,101.06,,,101.06,Fee Schedule,,39.07,,,39.07,Fee Schedule,,114.1,70,,114.1,percent of total billed charges,All Other,46.87,,,46.87,Fee Schedule,,39.72,,,39.72,Fee Schedule,,14.84,,,14.84,Fee Schedule,,14.84,,,14.84,Fee Schedule,,14.84,,,14.84,Fee Schedule,,14.84,,,14.84,Fee Schedule,,9.89,,,9.89,Other,100% of Medicaid,9.89,,,9.89,Other,100% of Medicaid,9.89,,,9.89,Other,100% of Medicaid,9.89,,,9.89,Other,100% of Medicaid,22.25,,,22.25,Other,225% of Medicaid,15.13,,,15.13,Other,153% of Medicaid,22.25,,,22.25,Other,225% of Medicaid,13.85,,,13.85,Other,140% of Medicaid,22.25,,,22.25,Other,225% of Medicaid,25.71,,,25.71,Other,260% of Medicaid,32.04,,,32.04,Other,324% of Medicaid,21.26,,,21.26,Other,215% of Medicaid,21.26,,,21.26,Other,215% of Medicaid,12.36,,,12.36,Other,125% of Medicaid,9.89,120.62,
ATOMIC ABSORPTION,82190,CPT,,78082190,CDM,301,RC,,,both,,,63,46.62,,,46.62,Other,150% of Medicare + 9.63% HCRA Surcharge,28.35,45,,28.35,percent of total billed charges,Critical Access Hospital RCC factor,47.86,,,47.86,Fee Schedule,,43.09,,,43.09,Fee Schedule,,40.37,,,40.37,Fee Schedule,,36.31,,,36.31,Fee Schedule,,34.32,,,34.32,Fee Schedule,,31.19,,,31.19,Other,110% of Medicare,50.09,,,50.09,Fee Schedule,,19,,,19,Other,186% of Medicaid,58.99,,,58.99,Fee Schedule,,39.06,,,39.06,Fee Schedule,,33.39,,,33.39,Fee Schedule,,58.99,,,58.99,Fee Schedule,,39.06,,,39.06,Fee Schedule,,62.81,,,62.81,Fee Schedule,,44.1,70,,44.1,percent of total billed charges,All Other,75.35,,,75.35,Fee Schedule,,63.86,,,63.86,Fee Schedule,,23.85,,,23.85,Fee Schedule,,23.85,,,23.85,Fee Schedule,,23.85,,,23.85,Fee Schedule,,23.85,,,23.85,Fee Schedule,,10.16,,,10.16,Other,100% of Medicaid,10.16,,,10.16,Other,100% of Medicaid,10.16,,,10.16,Other,100% of Medicaid,10.16,,,10.16,Other,100% of Medicaid,22.85,,,22.85,Other,225% of Medicaid,15.54,,,15.54,Other,153% of Medicaid,22.85,,,22.85,Other,225% of Medicaid,14.22,,,14.22,Other,140% of Medicaid,22.85,,,22.85,Other,225% of Medicaid,26.4,,,26.4,Other,260% of Medicaid,32.9,,,32.9,Other,324% of Medicaid,21.83,,,21.83,Other,215% of Medicaid,21.83,,,21.83,Other,215% of Medicaid,12.69,,,12.69,Other,125% of Medicaid,10.16,75.35,
ASSAY OF BETA-2 PROTEIN,82232,CPT,,78082232,CDM,301,RC,,,both,,,270,199.8,,,199.8,Other,150% of Medicare + 9.63% HCRA Surcharge,121.5,45,,121.5,percent of total billed charges,Critical Access Hospital RCC factor,48.7,,,48.7,Fee Schedule,,43.85,,,43.85,Fee Schedule,,119.95,,,119.95,Fee Schedule,,107.88,,,107.88,Fee Schedule,,101.96,,,101.96,Fee Schedule,,133.65,,,133.65,Other,110% of Medicare,50.97,,,50.97,Fee Schedule,,23,,,23,Other,186% of Medicaid,60.03,,,60.03,Fee Schedule,,167.4,,,167.4,Fee Schedule,,33.98,,,33.98,Fee Schedule,,60.03,,,60.03,Fee Schedule,,167.4,,,167.4,Fee Schedule,,63.91,,,63.91,Fee Schedule,,189,70,,189,percent of total billed charges,All Other,76.68,,,76.68,Fee Schedule,,64.99,,,64.99,Fee Schedule,,24.27,,,24.27,Fee Schedule,,24.27,,,24.27,Fee Schedule,,24.27,,,24.27,Fee Schedule,,24.27,,,24.27,Fee Schedule,,12.63,,,12.63,Other,100% of Medicaid,12.63,,,12.63,Other,100% of Medicaid,12.63,,,12.63,Other,100% of Medicaid,12.63,,,12.63,Other,100% of Medicaid,28.41,,,28.41,Other,225% of Medicaid,19.32,,,19.32,Other,153% of Medicaid,28.41,,,28.41,Other,225% of Medicaid,17.68,,,17.68,Other,140% of Medicaid,28.41,,,28.41,Other,225% of Medicaid,32.83,,,32.83,Other,260% of Medicaid,40.91,,,40.91,Other,324% of Medicaid,27.14,,,27.14,Other,215% of Medicaid,27.14,,,27.14,Other,215% of Medicaid,15.78,,,15.78,Other,125% of Medicaid,12.63,199.8,
BILE ACIDS TOTAL,82239,CPT,,78082239,CDM,301,RC,,,both,,,111,82.14,,,82.14,Other,150% of Medicare + 9.63% HCRA Surcharge,49.95,45,,49.95,percent of total billed charges,Critical Access Hospital RCC factor,51.53,,,51.53,Fee Schedule,,46.4,,,46.4,Fee Schedule,,104.87,,,104.87,Fee Schedule,,94.33,,,94.33,Fee Schedule,,89.15,,,89.15,Fee Schedule,,54.95,,,54.95,Other,110% of Medicare,53.93,,,53.93,Fee Schedule,,25,,,25,Other,186% of Medicaid,63.52,,,63.52,Fee Schedule,,68.82,,,68.82,Fee Schedule,,35.95,,,35.95,Fee Schedule,,63.52,,,63.52,Fee Schedule,,68.82,,,68.82,Fee Schedule,,67.62,,,67.62,Fee Schedule,,77.7,70,,77.7,percent of total billed charges,All Other,81.13,,,81.13,Fee Schedule,,68.76,,,68.76,Fee Schedule,,25.68,,,25.68,Fee Schedule,,25.68,,,25.68,Fee Schedule,,25.68,,,25.68,Fee Schedule,,25.68,,,25.68,Fee Schedule,,13.18,,,13.18,Other,100% of Medicaid,13.18,,,13.18,Other,100% of Medicaid,13.18,,,13.18,Other,100% of Medicaid,13.18,,,13.18,Other,100% of Medicaid,29.66,,,29.66,Other,225% of Medicaid,20.17,,,20.17,Other,153% of Medicaid,29.66,,,29.66,Other,225% of Medicaid,18.45,,,18.45,Other,140% of Medicaid,29.66,,,29.66,Other,225% of Medicaid,34.27,,,34.27,Other,260% of Medicaid,42.7,,,42.7,Other,324% of Medicaid,28.34,,,28.34,Other,215% of Medicaid,28.34,,,28.34,Other,215% of Medicaid,16.48,,,16.48,Other,125% of Medicaid,13.18,104.87,
BILIRUBIN TOTAL,82247,CPT,,78082247,CDM,301,RC,,,both,,,74,54.76,,,54.76,Other,150% of Medicare + 9.63% HCRA Surcharge,33.3,45,,33.3,percent of total billed charges,Critical Access Hospital RCC factor,15.11,,,15.11,Fee Schedule,,13.6,,,13.6,Fee Schedule,,37.21,,,37.21,Fee Schedule,,33.46,,,33.46,Fee Schedule,,31.63,,,31.63,Fee Schedule,,36.63,,,36.63,Other,110% of Medicare,15.81,,,15.81,Fee Schedule,,9,,,9,Other,186% of Medicaid,18.62,,,18.62,Fee Schedule,,45.88,,,45.88,Fee Schedule,,10.54,,,10.54,Fee Schedule,,18.62,,,18.62,Fee Schedule,,45.88,,,45.88,Fee Schedule,,19.83,,,19.83,Fee Schedule,,51.8,70,,51.8,percent of total billed charges,All Other,23.79,,,23.79,Fee Schedule,,20.16,,,20.16,Fee Schedule,,7.53,,,7.53,Fee Schedule,,7.53,,,7.53,Fee Schedule,,7.53,,,7.53,Fee Schedule,,7.53,,,7.53,Fee Schedule,,5.02,,,5.02,Other,100% of Medicaid,5.02,,,5.02,Other,100% of Medicaid,5.02,,,5.02,Other,100% of Medicaid,5.02,,,5.02,Other,100% of Medicaid,11.3,,,11.3,Other,225% of Medicaid,7.68,,,7.68,Other,153% of Medicaid,11.3,,,11.3,Other,225% of Medicaid,7.03,,,7.03,Other,140% of Medicaid,11.3,,,11.3,Other,225% of Medicaid,13.05,,,13.05,Other,260% of Medicaid,16.26,,,16.26,Other,324% of Medicaid,10.79,,,10.79,Other,215% of Medicaid,10.79,,,10.79,Other,215% of Medicaid,6.28,,,6.28,Other,125% of Medicaid,5.02,54.76,
BILIRUBIN DIRECT,82248,CPT,,78082248,CDM,301,RC,,,both,,,74,54.76,,,54.76,Other,150% of Medicare + 9.63% HCRA Surcharge,33.3,45,,33.3,percent of total billed charges,Critical Access Hospital RCC factor,15.11,,,15.11,Fee Schedule,,13.6,,,13.6,Fee Schedule,,37.21,,,37.21,Fee Schedule,,33.46,,,33.46,Fee Schedule,,31.63,,,31.63,Fee Schedule,,36.63,,,36.63,Other,110% of Medicare,15.81,,,15.81,Fee Schedule,,9,,,9,Other,186% of Medicaid,18.62,,,18.62,Fee Schedule,,45.88,,,45.88,Fee Schedule,,10.54,,,10.54,Fee Schedule,,18.62,,,18.62,Fee Schedule,,45.88,,,45.88,Fee Schedule,,19.83,,,19.83,Fee Schedule,,51.8,70,,51.8,percent of total billed charges,All Other,23.79,,,23.79,Fee Schedule,,20.16,,,20.16,Fee Schedule,,7.53,,,7.53,Fee Schedule,,7.53,,,7.53,Fee Schedule,,7.53,,,7.53,Fee Schedule,,7.53,,,7.53,Fee Schedule,,5.02,,,5.02,Other,100% of Medicaid,5.02,,,5.02,Other,100% of Medicaid,5.02,,,5.02,Other,100% of Medicaid,5.02,,,5.02,Other,100% of Medicaid,11.3,,,11.3,Other,225% of Medicaid,7.68,,,7.68,Other,153% of Medicaid,11.3,,,11.3,Other,225% of Medicaid,7.03,,,7.03,Other,140% of Medicaid,11.3,,,11.3,Other,225% of Medicaid,13.05,,,13.05,Other,260% of Medicaid,16.26,,,16.26,Other,324% of Medicaid,10.79,,,10.79,Other,215% of Medicaid,10.79,,,10.79,Other,215% of Medicaid,6.28,,,6.28,Other,125% of Medicaid,5.02,54.76,
ASSAY OF BIOTINIDASE,82261,CPT,,78082261,CDM,301,RC,,,both,,,54,39.96,,,39.96,Other,150% of Medicare + 9.63% HCRA Surcharge,24.3,45,,24.3,percent of total billed charges,Critical Access Hospital RCC factor,50.78,,,50.78,Fee Schedule,,45.72,,,45.72,Fee Schedule,,106.88,,,106.88,Fee Schedule,,96.13,,,96.13,Fee Schedule,,90.85,,,90.85,Fee Schedule,,26.73,,,26.73,Other,110% of Medicare,53.14,,,53.14,Fee Schedule,,30,,,30,Other,186% of Medicaid,62.59,,,62.59,Fee Schedule,,33.48,,,33.48,Fee Schedule,,35.43,,,35.43,Fee Schedule,,62.59,,,62.59,Fee Schedule,,33.48,,,33.48,Fee Schedule,,66.64,,,66.64,Fee Schedule,,37.8,70,,37.8,percent of total billed charges,All Other,79.95,,,79.95,Fee Schedule,,67.76,,,67.76,Fee Schedule,,25.31,,,25.31,Fee Schedule,,25.31,,,25.31,Fee Schedule,,25.31,,,25.31,Fee Schedule,,25.31,,,25.31,Fee Schedule,,16.09,,,16.09,Other,100% of Medicaid,16.09,,,16.09,Other,100% of Medicaid,16.09,,,16.09,Other,100% of Medicaid,16.09,,,16.09,Other,100% of Medicaid,36.2,,,36.2,Other,225% of Medicaid,24.62,,,24.62,Other,153% of Medicaid,36.2,,,36.2,Other,225% of Medicaid,22.53,,,22.53,Other,140% of Medicaid,36.2,,,36.2,Other,225% of Medicaid,41.83,,,41.83,Other,260% of Medicaid,52.13,,,52.13,Other,324% of Medicaid,34.59,,,34.59,Other,215% of Medicaid,34.59,,,34.59,Other,215% of Medicaid,20.11,,,20.11,Other,125% of Medicaid,16.09,106.88,
OCCULT BLOOD FECES,82270,CPT,,78082270,CDM,301,RC,,,both,,,44,32.56,,,32.56,Other,150% of Medicare + 9.63% HCRA Surcharge,19.8,45,,19.8,percent of total billed charges,Critical Access Hospital RCC factor,13.18,,,13.18,Fee Schedule,,11.87,,,11.87,Fee Schedule,,24.14,,,24.14,Fee Schedule,,21.71,,,21.71,Fee Schedule,,20.52,,,20.52,Fee Schedule,,21.78,,,21.78,Other,110% of Medicare,13.8,,,13.8,Fee Schedule,,6,,,6,Other,186% of Medicaid,16.25,,,16.25,Fee Schedule,,27.28,,,27.28,Fee Schedule,,9.2,,,9.2,Fee Schedule,,16.25,,,16.25,Fee Schedule,,27.28,,,27.28,Fee Schedule,,17.3,,,17.3,Fee Schedule,,30.8,70,,30.8,percent of total billed charges,All Other,20.76,,,20.76,Fee Schedule,,17.59,,,17.59,Fee Schedule,,6.57,,,6.57,Fee Schedule,,6.57,,,6.57,Fee Schedule,,6.57,,,6.57,Fee Schedule,,6.57,,,6.57,Fee Schedule,,3.43,,,3.43,Other,100% of Medicaid,3.43,,,3.43,Other,100% of Medicaid,3.43,,,3.43,Other,100% of Medicaid,3.43,,,3.43,Other,100% of Medicaid,7.73,,,7.73,Other,225% of Medicaid,5.25,,,5.25,Other,153% of Medicaid,7.73,,,7.73,Other,225% of Medicaid,4.81,,,4.81,Other,140% of Medicaid,7.73,,,7.73,Other,225% of Medicaid,8.93,,,8.93,Other,260% of Medicaid,11.13,,,11.13,Other,324% of Medicaid,7.38,,,7.38,Other,215% of Medicaid,7.38,,,7.38,Other,215% of Medicaid,4.29,,,4.29,Other,125% of Medicaid,3.43,32.56,
OCCULT BLOOD OTHER SOURCES,82271,CPT,,78082271,CDM,301,RC,,,both,,,53,39.22,,,39.22,Other,150% of Medicare + 9.63% HCRA Surcharge,23.85,45,,23.85,percent of total billed charges,Critical Access Hospital RCC factor,16.01,,,16.01,Fee Schedule,,14.42,,,14.42,Fee Schedule,,24.14,,,24.14,Fee Schedule,,21.71,,,21.71,Fee Schedule,,20.52,,,20.52,Fee Schedule,,26.24,,,26.24,Other,110% of Medicare,16.76,,,16.76,Fee Schedule,,12,,,12,Other,186% of Medicaid,19.74,,,19.74,Fee Schedule,,32.86,,,32.86,Fee Schedule,,11.17,,,11.17,Fee Schedule,,19.74,,,19.74,Fee Schedule,,32.86,,,32.86,Fee Schedule,,21.01,,,21.01,Fee Schedule,,37.1,70,,37.1,percent of total billed charges,All Other,25.21,,,25.21,Fee Schedule,,21.37,,,21.37,Fee Schedule,,7.98,,,7.98,Fee Schedule,,7.98,,,7.98,Fee Schedule,,7.98,,,7.98,Fee Schedule,,7.98,,,7.98,Fee Schedule,,6.31,,,6.31,Other,100% of Medicaid,6.31,,,6.31,Other,100% of Medicaid,6.31,,,6.31,Other,100% of Medicaid,6.31,,,6.31,Other,100% of Medicaid,14.2,,,14.2,Other,225% of Medicaid,9.65,,,9.65,Other,153% of Medicaid,14.2,,,14.2,Other,225% of Medicaid,8.83,,,8.83,Other,140% of Medicaid,14.2,,,14.2,Other,225% of Medicaid,16.41,,,16.41,Other,260% of Medicaid,20.45,,,20.45,Other,324% of Medicaid,13.57,,,13.57,Other,215% of Medicaid,13.57,,,13.57,Other,215% of Medicaid,7.89,,,7.89,Other,125% of Medicaid,6.31,39.22,
OCCULT BLD FECES 1-3 TESTS,82272,CPT,,78082272,CDM,301,RC,,,both,,,37,27.38,,,27.38,Other,150% of Medicare + 9.63% HCRA Surcharge,16.65,45,,16.65,percent of total billed charges,Critical Access Hospital RCC factor,12.73,,,12.73,Fee Schedule,,11.46,,,11.46,Fee Schedule,,24.14,,,24.14,Fee Schedule,,21.71,,,21.71,Fee Schedule,,20.52,,,20.52,Fee Schedule,,18.32,,,18.32,Other,110% of Medicare,13.32,,,13.32,Fee Schedule,,12,,,12,Other,186% of Medicaid,15.69,,,15.69,Fee Schedule,,22.94,,,22.94,Fee Schedule,,8.88,,,8.88,Fee Schedule,,15.69,,,15.69,Fee Schedule,,22.94,,,22.94,Fee Schedule,,16.71,,,16.71,Fee Schedule,,25.9,70,,25.9,percent of total billed charges,All Other,20.05,,,20.05,Fee Schedule,,16.99,,,16.99,Fee Schedule,,6.35,,,6.35,Fee Schedule,,6.35,,,6.35,Fee Schedule,,6.35,,,6.35,Fee Schedule,,6.35,,,6.35,Fee Schedule,,6.31,,,6.31,Other,100% of Medicaid,6.31,,,6.31,Other,100% of Medicaid,6.31,,,6.31,Other,100% of Medicaid,6.31,,,6.31,Other,100% of Medicaid,14.2,,,14.2,Other,225% of Medicaid,9.65,,,9.65,Other,153% of Medicaid,14.2,,,14.2,Other,225% of Medicaid,8.83,,,8.83,Other,140% of Medicaid,14.2,,,14.2,Other,225% of Medicaid,16.41,,,16.41,Other,260% of Medicaid,20.45,,,20.45,Other,324% of Medicaid,13.57,,,13.57,Other,215% of Medicaid,13.57,,,13.57,Other,215% of Medicaid,7.89,,,7.89,Other,125% of Medicaid,6.31,27.38,
ASSAY OF CADMIUM,82300,CPT,,78082300,CDM,301,RC,,,both,,,213,157.62,,,157.62,Other,150% of Medicare + 9.63% HCRA Surcharge,95.85,45,,95.85,percent of total billed charges,Critical Access Hospital RCC factor,71.16,,,71.16,Fee Schedule,,64.06,,,64.06,Fee Schedule,,108.93,,,108.93,Fee Schedule,,97.98,,,97.98,Fee Schedule,,92.6,,,92.6,Fee Schedule,,105.44,,,105.44,Other,110% of Medicare,74.47,,,74.47,Fee Schedule,,30,,,30,Other,186% of Medicaid,87.7,,,87.7,Fee Schedule,,132.06,,,132.06,Fee Schedule,,49.64,,,49.64,Fee Schedule,,87.7,,,87.7,Fee Schedule,,132.06,,,132.06,Fee Schedule,,93.38,,,93.38,Fee Schedule,,149.1,70,,149.1,percent of total billed charges,All Other,112.03,,,112.03,Fee Schedule,,94.95,,,94.95,Fee Schedule,,35.46,,,35.46,Fee Schedule,,35.46,,,35.46,Fee Schedule,,35.46,,,35.46,Fee Schedule,,35.46,,,35.46,Fee Schedule,,15.96,,,15.96,Other,100% of Medicaid,15.96,,,15.96,Other,100% of Medicaid,15.96,,,15.96,Other,100% of Medicaid,15.96,,,15.96,Other,100% of Medicaid,35.91,,,35.91,Other,225% of Medicaid,24.42,,,24.42,Other,153% of Medicaid,35.91,,,35.91,Other,225% of Medicaid,22.34,,,22.34,Other,140% of Medicaid,35.91,,,35.91,Other,225% of Medicaid,41.49,,,41.49,Other,260% of Medicaid,51.7,,,51.7,Other,324% of Medicaid,34.31,,,34.31,Other,215% of Medicaid,34.31,,,34.31,Other,215% of Medicaid,19.95,,,19.95,Other,125% of Medicaid,15.96,157.62,
VITAMIN D 25 HYDROXY,82306,CPT,,78082306,CDM,301,RC,,,both,,,556,411.44,,,411.44,Other,150% of Medicare + 9.63% HCRA Surcharge,250.2,45,,250.2,percent of total billed charges,Critical Access Hospital RCC factor,89.1,,,89.1,Fee Schedule,,80.22,,,80.22,Fee Schedule,,219.55,,,219.55,Fee Schedule,,197.47,,,197.47,Fee Schedule,,186.64,,,186.64,Fee Schedule,,275.22,,,275.22,Other,110% of Medicare,93.24,,,93.24,Fee Schedule,,55,,,55,Other,186% of Medicaid,109.82,,,109.82,Fee Schedule,,344.72,,,344.72,Fee Schedule,,62.16,,,62.16,Fee Schedule,,109.82,,,109.82,Fee Schedule,,344.72,,,344.72,Fee Schedule,,116.92,,,116.92,Fee Schedule,,389.2,70,,389.2,percent of total billed charges,All Other,140.28,,,140.28,Fee Schedule,,118.89,,,118.89,Fee Schedule,,44.4,,,44.4,Fee Schedule,,44.4,,,44.4,Fee Schedule,,44.4,,,44.4,Fee Schedule,,44.4,,,44.4,Fee Schedule,,29.6,,,29.6,Other,100% of Medicaid,29.6,,,29.6,Other,100% of Medicaid,29.6,,,29.6,Other,100% of Medicaid,29.6,,,29.6,Other,100% of Medicaid,66.6,,,66.6,Other,225% of Medicaid,45.29,,,45.29,Other,153% of Medicaid,66.6,,,66.6,Other,225% of Medicaid,41.44,,,41.44,Other,140% of Medicaid,66.6,,,66.6,Other,225% of Medicaid,76.96,,,76.96,Other,260% of Medicaid,95.9,,,95.9,Other,324% of Medicaid,63.64,,,63.64,Other,215% of Medicaid,63.64,,,63.64,Other,215% of Medicaid,37,,,37,Other,125% of Medicaid,29.6,411.44,
ASSAY OF CALCITONIN,82308,CPT,,78082308,CDM,301,RC,,,both,,,549,406.26,,,406.26,Other,150% of Medicare + 9.63% HCRA Surcharge,247.05,45,,247.05,percent of total billed charges,Critical Access Hospital RCC factor,80.64,,,80.64,Fee Schedule,,72.6,,,72.6,Fee Schedule,,198.63,,,198.63,Fee Schedule,,178.65,,,178.65,Fee Schedule,,168.85,,,168.85,Fee Schedule,,271.76,,,271.76,Other,110% of Medicare,84.39,,,84.39,Fee Schedule,,50,,,50,Other,186% of Medicaid,99.39,,,99.39,Fee Schedule,,340.38,,,340.38,Fee Schedule,,56.26,,,56.26,Fee Schedule,,99.39,,,99.39,Fee Schedule,,340.38,,,340.38,Fee Schedule,,105.82,,,105.82,Fee Schedule,,384.3,70,,384.3,percent of total billed charges,All Other,126.96,,,126.96,Fee Schedule,,107.61,,,107.61,Fee Schedule,,40.19,,,40.19,Fee Schedule,,40.19,,,40.19,Fee Schedule,,40.19,,,40.19,Fee Schedule,,40.19,,,40.19,Fee Schedule,,26.79,,,26.79,Other,100% of Medicaid,26.79,,,26.79,Other,100% of Medicaid,26.79,,,26.79,Other,100% of Medicaid,26.79,,,26.79,Other,100% of Medicaid,60.28,,,60.28,Other,225% of Medicaid,40.99,,,40.99,Other,153% of Medicaid,60.28,,,60.28,Other,225% of Medicaid,37.51,,,37.51,Other,140% of Medicaid,60.28,,,60.28,Other,225% of Medicaid,69.65,,,69.65,Other,260% of Medicaid,86.8,,,86.8,Other,324% of Medicaid,57.6,,,57.6,Other,215% of Medicaid,57.6,,,57.6,Other,215% of Medicaid,33.49,,,33.49,Other,125% of Medicaid,26.79,406.26,
ASSAY OF CALCIUM,82310,CPT,,78082310,CDM,301,RC,,,both,,,234,173.16,,,173.16,Other,150% of Medicare + 9.63% HCRA Surcharge,105.3,45,,105.3,percent of total billed charges,Critical Access Hospital RCC factor,15.53,,,15.53,Fee Schedule,,13.98,,,13.98,Fee Schedule,,38.26,,,38.26,Fee Schedule,,34.41,,,34.41,Fee Schedule,,32.52,,,32.52,Fee Schedule,,115.83,,,115.83,Other,110% of Medicare,16.25,,,16.25,Fee Schedule,,9,,,9,Other,186% of Medicaid,19.14,,,19.14,Fee Schedule,,145.08,,,145.08,Fee Schedule,,10.84,,,10.84,Fee Schedule,,19.14,,,19.14,Fee Schedule,,145.08,,,145.08,Fee Schedule,,20.38,,,20.38,Fee Schedule,,163.8,70,,163.8,percent of total billed charges,All Other,24.45,,,24.45,Fee Schedule,,20.73,,,20.73,Fee Schedule,,7.74,,,7.74,Fee Schedule,,7.74,,,7.74,Fee Schedule,,7.74,,,7.74,Fee Schedule,,7.74,,,7.74,Fee Schedule,,5.08,,,5.08,Other,100% of Medicaid,5.08,,,5.08,Other,100% of Medicaid,5.08,,,5.08,Other,100% of Medicaid,5.08,,,5.08,Other,100% of Medicaid,11.43,,,11.43,Other,225% of Medicaid,7.77,,,7.77,Other,153% of Medicaid,11.43,,,11.43,Other,225% of Medicaid,7.11,,,7.11,Other,140% of Medicaid,11.43,,,11.43,Other,225% of Medicaid,13.21,,,13.21,Other,260% of Medicaid,16.46,,,16.46,Other,324% of Medicaid,10.92,,,10.92,Other,215% of Medicaid,10.92,,,10.92,Other,215% of Medicaid,6.35,,,6.35,Other,125% of Medicaid,5.08,173.16,
ASSAY OF CALCIUM,82330,CPT,,78082330,CDM,301,RC,,,both,,,233,172.42,,,172.42,Other,150% of Medicare + 9.63% HCRA Surcharge,104.85,45,,104.85,percent of total billed charges,Critical Access Hospital RCC factor,41.18,,,41.18,Fee Schedule,,37.07,,,37.07,Fee Schedule,,51.86,,,51.86,Fee Schedule,,46.64,,,46.64,Fee Schedule,,44.08,,,44.08,Fee Schedule,,115.34,,,115.34,Other,110% of Medicare,43.09,,,43.09,Fee Schedule,,9,,,9,Other,186% of Medicaid,50.75,,,50.75,Fee Schedule,,144.46,,,144.46,Fee Schedule,,28.73,,,28.73,Fee Schedule,,50.75,,,50.75,Fee Schedule,,144.46,,,144.46,Fee Schedule,,54.04,,,54.04,Fee Schedule,,163.1,70,,163.1,percent of total billed charges,All Other,64.83,,,64.83,Fee Schedule,,54.95,,,54.95,Fee Schedule,,20.52,,,20.52,Fee Schedule,,20.52,,,20.52,Fee Schedule,,20.52,,,20.52,Fee Schedule,,20.52,,,20.52,Fee Schedule,,5.08,,,5.08,Other,100% of Medicaid,5.08,,,5.08,Other,100% of Medicaid,5.08,,,5.08,Other,100% of Medicaid,5.08,,,5.08,Other,100% of Medicaid,11.43,,,11.43,Other,225% of Medicaid,7.77,,,7.77,Other,153% of Medicaid,11.43,,,11.43,Other,225% of Medicaid,7.11,,,7.11,Other,140% of Medicaid,11.43,,,11.43,Other,225% of Medicaid,13.21,,,13.21,Other,260% of Medicaid,16.46,,,16.46,Other,324% of Medicaid,10.92,,,10.92,Other,215% of Medicaid,10.92,,,10.92,Other,215% of Medicaid,6.35,,,6.35,Other,125% of Medicaid,5.08,172.42,
ASSAY OF CALCIUM IN URINE,82340,CPT,,78082340,CDM,301,RC,,,both,,,74,54.76,,,54.76,Other,150% of Medicare + 9.63% HCRA Surcharge,33.3,45,,33.3,percent of total billed charges,Critical Access Hospital RCC factor,18.15,,,18.15,Fee Schedule,,16.34,,,16.34,Fee Schedule,,44.74,,,44.74,Fee Schedule,,40.24,,,40.24,Fee Schedule,,38.04,,,38.04,Fee Schedule,,36.63,,,36.63,Other,110% of Medicare,18.99,,,18.99,Fee Schedule,,11,,,11,Other,186% of Medicaid,22.37,,,22.37,Fee Schedule,,45.88,,,45.88,Fee Schedule,,12.66,,,12.66,Fee Schedule,,22.37,,,22.37,Fee Schedule,,45.88,,,45.88,Fee Schedule,,23.82,,,23.82,Fee Schedule,,51.8,70,,51.8,percent of total billed charges,All Other,28.58,,,28.58,Fee Schedule,,24.22,,,24.22,Fee Schedule,,9.05,,,9.05,Fee Schedule,,9.05,,,9.05,Fee Schedule,,9.05,,,9.05,Fee Schedule,,9.05,,,9.05,Fee Schedule,,6.03,,,6.03,Other,100% of Medicaid,6.03,,,6.03,Other,100% of Medicaid,6.03,,,6.03,Other,100% of Medicaid,6.03,,,6.03,Other,100% of Medicaid,13.57,,,13.57,Other,225% of Medicaid,9.23,,,9.23,Other,153% of Medicaid,13.57,,,13.57,Other,225% of Medicaid,8.44,,,8.44,Other,140% of Medicaid,13.57,,,13.57,Other,225% of Medicaid,15.68,,,15.68,Other,260% of Medicaid,19.54,,,19.54,Other,324% of Medicaid,12.96,,,12.96,Other,215% of Medicaid,12.96,,,12.96,Other,215% of Medicaid,7.54,,,7.54,Other,125% of Medicaid,6.03,54.76,
CALCULUS ANALYSIS QUAL,82355,CPT,,78082355,CDM,301,RC,,,both,,,151,111.74,,,111.74,Other,150% of Medicare + 9.63% HCRA Surcharge,67.95,45,,67.95,percent of total billed charges,Critical Access Hospital RCC factor,34.86,,,34.86,Fee Schedule,,31.38,,,31.38,Fee Schedule,,85.85,,,85.85,Fee Schedule,,77.21,,,77.21,Fee Schedule,,72.98,,,72.98,Fee Schedule,,74.75,,,74.75,Other,110% of Medicare,36.48,,,36.48,Fee Schedule,,22,,,22,Other,186% of Medicaid,42.96,,,42.96,Fee Schedule,,93.62,,,93.62,Fee Schedule,,24.32,,,24.32,Fee Schedule,,42.96,,,42.96,Fee Schedule,,93.62,,,93.62,Fee Schedule,,45.74,,,45.74,Fee Schedule,,105.7,70,,105.7,percent of total billed charges,All Other,54.88,,,54.88,Fee Schedule,,46.51,,,46.51,Fee Schedule,,17.37,,,17.37,Fee Schedule,,17.37,,,17.37,Fee Schedule,,17.37,,,17.37,Fee Schedule,,17.37,,,17.37,Fee Schedule,,11.58,,,11.58,Other,100% of Medicaid,11.58,,,11.58,Other,100% of Medicaid,11.58,,,11.58,Other,100% of Medicaid,11.58,,,11.58,Other,100% of Medicaid,26.06,,,26.06,Other,225% of Medicaid,17.72,,,17.72,Other,153% of Medicaid,26.06,,,26.06,Other,225% of Medicaid,16.21,,,16.21,Other,140% of Medicaid,26.06,,,26.06,Other,225% of Medicaid,30.11,,,30.11,Other,260% of Medicaid,37.52,,,37.52,Other,324% of Medicaid,24.9,,,24.9,Other,215% of Medicaid,24.9,,,24.9,Other,215% of Medicaid,14.48,,,14.48,Other,125% of Medicaid,11.58,111.74,
CALCULUS ASSAY QUANT,82360,CPT,,78082360,CDM,301,RC,,,both,,,138,102.12,,,102.12,Other,150% of Medicare + 9.63% HCRA Surcharge,62.1,45,,62.1,percent of total billed charges,Critical Access Hospital RCC factor,38.74,,,38.74,Fee Schedule,,34.88,,,34.88,Fee Schedule,,95.49,,,95.49,Fee Schedule,,85.89,,,85.89,Fee Schedule,,81.18,,,81.18,Fee Schedule,,68.31,,,68.31,Other,110% of Medicare,40.54,,,40.54,Fee Schedule,,24,,,24,Other,186% of Medicaid,47.75,,,47.75,Fee Schedule,,85.56,,,85.56,Fee Schedule,,27.03,,,27.03,Fee Schedule,,47.75,,,47.75,Fee Schedule,,85.56,,,85.56,Fee Schedule,,50.84,,,50.84,Fee Schedule,,96.6,70,,96.6,percent of total billed charges,All Other,60.99,,,60.99,Fee Schedule,,51.69,,,51.69,Fee Schedule,,19.31,,,19.31,Fee Schedule,,19.31,,,19.31,Fee Schedule,,19.31,,,19.31,Fee Schedule,,19.31,,,19.31,Fee Schedule,,12.87,,,12.87,Other,100% of Medicaid,12.87,,,12.87,Other,100% of Medicaid,12.87,,,12.87,Other,100% of Medicaid,12.87,,,12.87,Other,100% of Medicaid,28.96,,,28.96,Other,225% of Medicaid,19.69,,,19.69,Other,153% of Medicaid,28.96,,,28.96,Other,225% of Medicaid,18.02,,,18.02,Other,140% of Medicaid,28.96,,,28.96,Other,225% of Medicaid,33.46,,,33.46,Other,260% of Medicaid,41.7,,,41.7,Other,324% of Medicaid,27.67,,,27.67,Other,215% of Medicaid,27.67,,,27.67,Other,215% of Medicaid,16.09,,,16.09,Other,125% of Medicaid,12.87,102.12,
CALCULUS SPECTROSCOPY,82365,CPT,,78082365,CDM,301,RC,,,both,,,41,30.34,,,30.34,Other,150% of Medicare + 9.63% HCRA Surcharge,18.45,45,,18.45,percent of total billed charges,Critical Access Hospital RCC factor,38.83,,,38.83,Fee Schedule,,34.96,,,34.96,Fee Schedule,,95.6,,,95.6,Fee Schedule,,85.98,,,85.98,Fee Schedule,,81.27,,,81.27,Fee Schedule,,20.3,,,20.3,Other,110% of Medicare,40.64,,,40.64,Fee Schedule,,23,,,23,Other,186% of Medicaid,47.86,,,47.86,Fee Schedule,,25.42,,,25.42,Fee Schedule,,27.09,,,27.09,Fee Schedule,,47.86,,,47.86,Fee Schedule,,25.42,,,25.42,Fee Schedule,,50.96,,,50.96,Fee Schedule,,28.7,70,,28.7,percent of total billed charges,All Other,61.13,,,61.13,Fee Schedule,,51.81,,,51.81,Fee Schedule,,19.35,,,19.35,Fee Schedule,,19.35,,,19.35,Fee Schedule,,19.35,,,19.35,Fee Schedule,,19.35,,,19.35,Fee Schedule,,12.51,,,12.51,Other,100% of Medicaid,12.51,,,12.51,Other,100% of Medicaid,12.51,,,12.51,Other,100% of Medicaid,12.51,,,12.51,Other,100% of Medicaid,28.16,,,28.16,Other,225% of Medicaid,19.15,,,19.15,Other,153% of Medicaid,28.16,,,28.16,Other,225% of Medicaid,17.52,,,17.52,Other,140% of Medicaid,28.16,,,28.16,Other,225% of Medicaid,32.54,,,32.54,Other,260% of Medicaid,40.55,,,40.55,Other,324% of Medicaid,26.9,,,26.9,Other,215% of Medicaid,26.9,,,26.9,Other,215% of Medicaid,15.64,,,15.64,Other,125% of Medicaid,12.51,95.6,
X-RAY ASSAY CALCULUS,82370,CPT,,78082370,CDM,301,RC,,,both,,,114,84.36,,,84.36,Other,150% of Medicare + 9.63% HCRA Surcharge,51.3,45,,51.3,percent of total billed charges,Critical Access Hospital RCC factor,37.69,,,37.69,Fee Schedule,,33.93,,,33.93,Fee Schedule,,91.12,,,91.12,Fee Schedule,,81.95,,,81.95,Fee Schedule,,77.46,,,77.46,Fee Schedule,,56.43,,,56.43,Other,110% of Medicare,39.44,,,39.44,Fee Schedule,,23,,,23,Other,186% of Medicaid,46.45,,,46.45,Fee Schedule,,70.68,,,70.68,Fee Schedule,,26.29,,,26.29,Fee Schedule,,46.45,,,46.45,Fee Schedule,,70.68,,,70.68,Fee Schedule,,49.45,,,49.45,Fee Schedule,,79.8,70,,79.8,percent of total billed charges,All Other,59.33,,,59.33,Fee Schedule,,50.29,,,50.29,Fee Schedule,,18.78,,,18.78,Fee Schedule,,18.78,,,18.78,Fee Schedule,,18.78,,,18.78,Fee Schedule,,18.78,,,18.78,Fee Schedule,,12.52,,,12.52,Other,100% of Medicaid,12.52,,,12.52,Other,100% of Medicaid,12.52,,,12.52,Other,100% of Medicaid,12.52,,,12.52,Other,100% of Medicaid,28.17,,,28.17,Other,225% of Medicaid,19.16,,,19.16,Other,153% of Medicaid,28.17,,,28.17,Other,225% of Medicaid,17.53,,,17.53,Other,140% of Medicaid,28.17,,,28.17,Other,225% of Medicaid,32.55,,,32.55,Other,260% of Medicaid,40.56,,,40.56,Other,324% of Medicaid,26.92,,,26.92,Other,215% of Medicaid,26.92,,,26.92,Other,215% of Medicaid,15.65,,,15.65,Other,125% of Medicaid,12.52,91.12,
ASSAY C-D TRANSFER MEASURE,82373,CPT,,78082373,CDM,301,RC,,,both,,,108,79.92,,,79.92,Other,150% of Medicare + 9.63% HCRA Surcharge,48.6,45,,48.6,percent of total billed charges,Critical Access Hospital RCC factor,54.36,,,54.36,Fee Schedule,,48.94,,,48.94,Fee Schedule,,133.91,,,133.91,Fee Schedule,,120.44,,,120.44,Fee Schedule,,113.84,,,113.84,Fee Schedule,,53.46,,,53.46,Other,110% of Medicare,56.89,,,56.89,Fee Schedule,,15,,,15,Other,186% of Medicaid,67,,,67,Fee Schedule,,66.96,,,66.96,Fee Schedule,,37.93,,,37.93,Fee Schedule,,67,,,67,Fee Schedule,,66.96,,,66.96,Fee Schedule,,71.34,,,71.34,Fee Schedule,,75.6,70,,75.6,percent of total billed charges,All Other,85.59,,,85.59,Fee Schedule,,72.54,,,72.54,Fee Schedule,,27.09,,,27.09,Fee Schedule,,27.09,,,27.09,Fee Schedule,,27.09,,,27.09,Fee Schedule,,27.09,,,27.09,Fee Schedule,,7.97,,,7.97,Other,100% of Medicaid,7.97,,,7.97,Other,100% of Medicaid,7.97,,,7.97,Other,100% of Medicaid,7.97,,,7.97,Other,100% of Medicaid,17.93,,,17.93,Other,225% of Medicaid,12.19,,,12.19,Other,153% of Medicaid,17.93,,,17.93,Other,225% of Medicaid,11.16,,,11.16,Other,140% of Medicaid,17.93,,,17.93,Other,225% of Medicaid,20.72,,,20.72,Other,260% of Medicaid,25.82,,,25.82,Other,324% of Medicaid,17.13,,,17.13,Other,215% of Medicaid,17.13,,,17.13,Other,215% of Medicaid,9.96,,,9.96,Other,125% of Medicaid,7.97,133.91,
ASSAY BLOOD CARBON DIOXIDE,82374,CPT,,78082374,CDM,301,RC,,,both,,,69,51.06,,,51.06,Other,150% of Medicare + 9.63% HCRA Surcharge,31.05,45,,31.05,percent of total billed charges,Critical Access Hospital RCC factor,14.69,,,14.69,Fee Schedule,,13.22,,,13.22,Fee Schedule,,36.26,,,36.26,Fee Schedule,,32.61,,,32.61,Fee Schedule,,30.82,,,30.82,Fee Schedule,,34.16,,,34.16,Other,110% of Medicare,15.37,,,15.37,Fee Schedule,,9,,,9,Other,186% of Medicaid,18.1,,,18.1,Fee Schedule,,42.78,,,42.78,Fee Schedule,,10.25,,,10.25,Fee Schedule,,18.1,,,18.1,Fee Schedule,,42.78,,,42.78,Fee Schedule,,19.28,,,19.28,Fee Schedule,,48.3,70,,48.3,percent of total billed charges,All Other,23.13,,,23.13,Fee Schedule,,19.6,,,19.6,Fee Schedule,,7.32,,,7.32,Fee Schedule,,7.32,,,7.32,Fee Schedule,,7.32,,,7.32,Fee Schedule,,7.32,,,7.32,Fee Schedule,,4.88,,,4.88,Other,100% of Medicaid,4.88,,,4.88,Other,100% of Medicaid,4.88,,,4.88,Other,100% of Medicaid,4.88,,,4.88,Other,100% of Medicaid,10.98,,,10.98,Other,225% of Medicaid,7.47,,,7.47,Other,153% of Medicaid,10.98,,,10.98,Other,225% of Medicaid,6.83,,,6.83,Other,140% of Medicaid,10.98,,,10.98,Other,225% of Medicaid,12.69,,,12.69,Other,260% of Medicaid,15.81,,,15.81,Other,324% of Medicaid,10.49,,,10.49,Other,215% of Medicaid,10.49,,,10.49,Other,215% of Medicaid,6.1,,,6.1,Other,125% of Medicaid,4.88,51.06,
CARCINOEMBRYONIC ANTIGEN,82378,CPT,,78082378,CDM,301,RC,,,both,,,230,170.2,,,170.2,Other,150% of Medicare + 9.63% HCRA Surcharge,103.5,45,,103.5,percent of total billed charges,Critical Access Hospital RCC factor,57.07,,,57.07,Fee Schedule,,51.38,,,51.38,Fee Schedule,,140.71,,,140.71,Fee Schedule,,126.56,,,126.56,Fee Schedule,,119.62,,,119.62,Fee Schedule,,113.85,,,113.85,Other,110% of Medicare,59.72,,,59.72,Fee Schedule,,35,,,35,Other,186% of Medicaid,70.34,,,70.34,Fee Schedule,,142.6,,,142.6,Fee Schedule,,39.82,,,39.82,Fee Schedule,,70.34,,,70.34,Fee Schedule,,142.6,,,142.6,Fee Schedule,,74.89,,,74.89,Fee Schedule,,161,70,,161,percent of total billed charges,All Other,89.85,,,89.85,Fee Schedule,,76.16,,,76.16,Fee Schedule,,28.44,,,28.44,Fee Schedule,,28.44,,,28.44,Fee Schedule,,28.44,,,28.44,Fee Schedule,,28.44,,,28.44,Fee Schedule,,18.96,,,18.96,Other,100% of Medicaid,18.96,,,18.96,Other,100% of Medicaid,18.96,,,18.96,Other,100% of Medicaid,18.96,,,18.96,Other,100% of Medicaid,42.66,,,42.66,Other,225% of Medicaid,29.01,,,29.01,Other,153% of Medicaid,42.66,,,42.66,Other,225% of Medicaid,26.54,,,26.54,Other,140% of Medicaid,42.66,,,42.66,Other,225% of Medicaid,49.3,,,49.3,Other,260% of Medicaid,61.43,,,61.43,Other,324% of Medicaid,40.76,,,40.76,Other,215% of Medicaid,40.76,,,40.76,Other,215% of Medicaid,23.7,,,23.7,Other,125% of Medicaid,18.96,170.2,
ASSAY OF CAROTENE,82380,CPT,,78082380,CDM,301,RC,,,both,,,117,86.58,,,86.58,Other,150% of Medicare + 9.63% HCRA Surcharge,52.65,45,,52.65,percent of total billed charges,Critical Access Hospital RCC factor,27.75,,,27.75,Fee Schedule,,24.99,,,24.99,Fee Schedule,,68.4,,,68.4,Fee Schedule,,61.53,,,61.53,Fee Schedule,,58.15,,,58.15,Fee Schedule,,57.92,,,57.92,Other,110% of Medicare,29.04,,,29.04,Fee Schedule,,12,,,12,Other,186% of Medicaid,34.21,,,34.21,Fee Schedule,,72.54,,,72.54,Fee Schedule,,19.36,,,19.36,Fee Schedule,,34.21,,,34.21,Fee Schedule,,72.54,,,72.54,Fee Schedule,,36.42,,,36.42,Fee Schedule,,81.9,70,,81.9,percent of total billed charges,All Other,43.69,,,43.69,Fee Schedule,,37.03,,,37.03,Fee Schedule,,13.83,,,13.83,Fee Schedule,,13.83,,,13.83,Fee Schedule,,13.83,,,13.83,Fee Schedule,,13.83,,,13.83,Fee Schedule,,6.31,,,6.31,Other,100% of Medicaid,6.31,,,6.31,Other,100% of Medicaid,6.31,,,6.31,Other,100% of Medicaid,6.31,,,6.31,Other,100% of Medicaid,14.2,,,14.2,Other,225% of Medicaid,9.65,,,9.65,Other,153% of Medicaid,14.2,,,14.2,Other,225% of Medicaid,8.83,,,8.83,Other,140% of Medicaid,14.2,,,14.2,Other,225% of Medicaid,16.41,,,16.41,Other,260% of Medicaid,20.45,,,20.45,Other,324% of Medicaid,13.57,,,13.57,Other,215% of Medicaid,13.57,,,13.57,Other,215% of Medicaid,7.89,,,7.89,Other,125% of Medicaid,6.31,86.58,
ASSAY URINE CATECHOLAMINES,82382,CPT,,78082382,CDM,301,RC,,,both,,,186,137.64,,,137.64,Other,150% of Medicare + 9.63% HCRA Surcharge,83.7,45,,83.7,percent of total billed charges,Critical Access Hospital RCC factor,82.17,,,82.17,Fee Schedule,,73.98,,,73.98,Fee Schedule,,127.01,,,127.01,Fee Schedule,,114.23,,,114.23,Fee Schedule,,107.97,,,107.97,Fee Schedule,,92.07,,,92.07,Other,110% of Medicare,86,,,86,Fee Schedule,,35,,,35,Other,186% of Medicaid,101.28,,,101.28,Fee Schedule,,115.32,,,115.32,Fee Schedule,,57.33,,,57.33,Fee Schedule,,101.28,,,101.28,Fee Schedule,,115.32,,,115.32,Fee Schedule,,107.84,,,107.84,Fee Schedule,,130.2,70,,130.2,percent of total billed charges,All Other,129.38,,,129.38,Fee Schedule,,109.65,,,109.65,Fee Schedule,,40.95,,,40.95,Fee Schedule,,40.95,,,40.95,Fee Schedule,,40.95,,,40.95,Fee Schedule,,40.95,,,40.95,Fee Schedule,,18.58,,,18.58,Other,100% of Medicaid,18.58,,,18.58,Other,100% of Medicaid,18.58,,,18.58,Other,100% of Medicaid,18.58,,,18.58,Other,100% of Medicaid,41.81,,,41.81,Other,225% of Medicaid,28.43,,,28.43,Other,153% of Medicaid,41.81,,,41.81,Other,225% of Medicaid,26.02,,,26.02,Other,140% of Medicaid,41.81,,,41.81,Other,225% of Medicaid,48.32,,,48.32,Other,260% of Medicaid,60.21,,,60.21,Other,324% of Medicaid,39.96,,,39.96,Other,215% of Medicaid,39.96,,,39.96,Other,215% of Medicaid,23.23,,,23.23,Other,125% of Medicaid,18.58,137.64,
ASSAY BLOOD CATECHOLAMINES,82383,CPT,,78082383,CDM,301,RC,,,both,,,414,306.36,,,306.36,Other,150% of Medicare + 9.63% HCRA Surcharge,186.3,45,,186.3,percent of total billed charges,Critical Access Hospital RCC factor,87.53,,,87.53,Fee Schedule,,78.81,,,78.81,Fee Schedule,,127.01,,,127.01,Fee Schedule,,114.23,,,114.23,Fee Schedule,,107.97,,,107.97,Fee Schedule,,204.93,,,204.93,Other,110% of Medicare,91.6,,,91.6,Fee Schedule,,35,,,35,Other,186% of Medicaid,107.89,,,107.89,Fee Schedule,,256.68,,,256.68,Fee Schedule,,61.07,,,61.07,Fee Schedule,,107.89,,,107.89,Fee Schedule,,256.68,,,256.68,Fee Schedule,,114.87,,,114.87,Fee Schedule,,289.8,70,,289.8,percent of total billed charges,All Other,137.81,,,137.81,Fee Schedule,,116.8,,,116.8,Fee Schedule,,43.62,,,43.62,Fee Schedule,,43.62,,,43.62,Fee Schedule,,43.62,,,43.62,Fee Schedule,,43.62,,,43.62,Fee Schedule,,18.58,,,18.58,Other,100% of Medicaid,18.58,,,18.58,Other,100% of Medicaid,18.58,,,18.58,Other,100% of Medicaid,18.58,,,18.58,Other,100% of Medicaid,41.81,,,41.81,Other,225% of Medicaid,28.43,,,28.43,Other,153% of Medicaid,41.81,,,41.81,Other,225% of Medicaid,26.02,,,26.02,Other,140% of Medicaid,41.81,,,41.81,Other,225% of Medicaid,48.32,,,48.32,Other,260% of Medicaid,60.21,,,60.21,Other,324% of Medicaid,39.96,,,39.96,Other,215% of Medicaid,39.96,,,39.96,Other,215% of Medicaid,23.23,,,23.23,Other,125% of Medicaid,18.58,306.36,
ASSAY THREE CATECHOLAMINES,82384,CPT,,78082384,CDM,301,RC,,,both,,,284,210.16,,,210.16,Other,150% of Medicare + 9.63% HCRA Surcharge,127.8,45,,127.8,percent of total billed charges,Critical Access Hospital RCC factor,76,,,76,Fee Schedule,,68.43,,,68.43,Fee Schedule,,127.01,,,127.01,Fee Schedule,,114.23,,,114.23,Fee Schedule,,107.97,,,107.97,Fee Schedule,,140.58,,,140.58,Other,110% of Medicare,79.54,,,79.54,Fee Schedule,,35,,,35,Other,186% of Medicaid,93.68,,,93.68,Fee Schedule,,176.08,,,176.08,Fee Schedule,,53.03,,,53.03,Fee Schedule,,93.68,,,93.68,Fee Schedule,,176.08,,,176.08,Fee Schedule,,99.74,,,99.74,Fee Schedule,,198.8,70,,198.8,percent of total billed charges,All Other,119.66,,,119.66,Fee Schedule,,101.42,,,101.42,Fee Schedule,,37.88,,,37.88,Fee Schedule,,37.88,,,37.88,Fee Schedule,,37.88,,,37.88,Fee Schedule,,37.88,,,37.88,Fee Schedule,,18.58,,,18.58,Other,100% of Medicaid,18.58,,,18.58,Other,100% of Medicaid,18.58,,,18.58,Other,100% of Medicaid,18.58,,,18.58,Other,100% of Medicaid,41.81,,,41.81,Other,225% of Medicaid,28.43,,,28.43,Other,153% of Medicaid,41.81,,,41.81,Other,225% of Medicaid,26.02,,,26.02,Other,140% of Medicaid,41.81,,,41.81,Other,225% of Medicaid,48.32,,,48.32,Other,260% of Medicaid,60.21,,,60.21,Other,324% of Medicaid,39.96,,,39.96,Other,215% of Medicaid,39.96,,,39.96,Other,215% of Medicaid,23.23,,,23.23,Other,125% of Medicaid,18.58,210.16,
ASSAY OF CERULOPLASMIN,82390,CPT,,78082390,CDM,301,RC,,,both,,,141,104.34,,,104.34,Other,150% of Medicare + 9.63% HCRA Surcharge,63.45,45,,63.45,percent of total billed charges,Critical Access Hospital RCC factor,32.33,,,32.33,Fee Schedule,,29.11,,,29.11,Fee Schedule,,55.86,,,55.86,Fee Schedule,,50.24,,,50.24,Fee Schedule,,47.49,,,47.49,Fee Schedule,,69.8,,,69.8,Other,110% of Medicare,33.83,,,33.83,Fee Schedule,,15,,,15,Other,186% of Medicaid,39.85,,,39.85,Fee Schedule,,87.42,,,87.42,Fee Schedule,,22.55,,,22.55,Fee Schedule,,39.85,,,39.85,Fee Schedule,,87.42,,,87.42,Fee Schedule,,42.42,,,42.42,Fee Schedule,,98.7,70,,98.7,percent of total billed charges,All Other,50.9,,,50.9,Fee Schedule,,43.14,,,43.14,Fee Schedule,,16.11,,,16.11,Fee Schedule,,16.11,,,16.11,Fee Schedule,,16.11,,,16.11,Fee Schedule,,16.11,,,16.11,Fee Schedule,,8.18,,,8.18,Other,100% of Medicaid,8.18,,,8.18,Other,100% of Medicaid,8.18,,,8.18,Other,100% of Medicaid,8.18,,,8.18,Other,100% of Medicaid,18.41,,,18.41,Other,225% of Medicaid,12.52,,,12.52,Other,153% of Medicaid,18.41,,,18.41,Other,225% of Medicaid,11.45,,,11.45,Other,140% of Medicaid,18.41,,,18.41,Other,225% of Medicaid,21.27,,,21.27,Other,260% of Medicaid,26.51,,,26.51,Other,324% of Medicaid,17.59,,,17.59,Other,215% of Medicaid,17.59,,,17.59,Other,215% of Medicaid,10.23,,,10.23,Other,125% of Medicaid,8.18,104.34,
ASSAY OF CHLORAMPHENICOL,82415,CPT,,78082415,CDM,301,RC,,,both,,,143,105.82,,,105.82,Other,150% of Medicare + 9.63% HCRA Surcharge,64.35,45,,64.35,percent of total billed charges,Critical Access Hospital RCC factor,38.14,,,38.14,Fee Schedule,,34.34,,,34.34,Fee Schedule,,87.01,,,87.01,Fee Schedule,,78.26,,,78.26,Fee Schedule,,73.96,,,73.96,Fee Schedule,,70.79,,,70.79,Other,110% of Medicare,39.91,,,39.91,Fee Schedule,,30,,,30,Other,186% of Medicaid,47.01,,,47.01,Fee Schedule,,88.66,,,88.66,Fee Schedule,,26.61,,,26.61,Fee Schedule,,47.01,,,47.01,Fee Schedule,,88.66,,,88.66,Fee Schedule,,50.05,,,50.05,Fee Schedule,,100.1,70,,100.1,percent of total billed charges,All Other,60.04,,,60.04,Fee Schedule,,50.89,,,50.89,Fee Schedule,,19.01,,,19.01,Fee Schedule,,19.01,,,19.01,Fee Schedule,,19.01,,,19.01,Fee Schedule,,19.01,,,19.01,Fee Schedule,,16.02,,,16.02,Other,100% of Medicaid,16.02,,,16.02,Other,100% of Medicaid,16.02,,,16.02,Other,100% of Medicaid,16.02,,,16.02,Other,100% of Medicaid,36.04,,,36.04,Other,225% of Medicaid,24.51,,,24.51,Other,153% of Medicaid,36.04,,,36.04,Other,225% of Medicaid,22.43,,,22.43,Other,140% of Medicaid,36.04,,,36.04,Other,225% of Medicaid,41.65,,,41.65,Other,260% of Medicaid,51.9,,,51.9,Other,324% of Medicaid,34.44,,,34.44,Other,215% of Medicaid,34.44,,,34.44,Other,215% of Medicaid,20.02,,,20.02,Other,125% of Medicaid,16.02,105.82,
ASSAY OF BLOOD CHLORIDE,82435,CPT,,78082435,CDM,301,RC,,,both,,,55,40.7,,,40.7,Other,150% of Medicare + 9.63% HCRA Surcharge,24.75,45,,24.75,percent of total billed charges,Critical Access Hospital RCC factor,13.85,,,13.85,Fee Schedule,,12.47,,,12.47,Fee Schedule,,34.1,,,34.1,Fee Schedule,,30.67,,,30.67,Fee Schedule,,28.99,,,28.99,Fee Schedule,,27.23,,,27.23,Other,110% of Medicare,14.49,,,14.49,Fee Schedule,,9,,,9,Other,186% of Medicaid,17.07,,,17.07,Fee Schedule,,34.1,,,34.1,Fee Schedule,,9.66,,,9.66,Fee Schedule,,17.07,,,17.07,Fee Schedule,,34.1,,,34.1,Fee Schedule,,18.17,,,18.17,Fee Schedule,,38.5,70,,38.5,percent of total billed charges,All Other,21.8,,,21.8,Fee Schedule,,18.48,,,18.48,Fee Schedule,,6.9,,,6.9,Fee Schedule,,6.9,,,6.9,Fee Schedule,,6.9,,,6.9,Fee Schedule,,6.9,,,6.9,Fee Schedule,,4.6,,,4.6,Other,100% of Medicaid,4.6,,,4.6,Other,100% of Medicaid,4.6,,,4.6,Other,100% of Medicaid,4.6,,,4.6,Other,100% of Medicaid,10.35,,,10.35,Other,225% of Medicaid,7.04,,,7.04,Other,153% of Medicaid,10.35,,,10.35,Other,225% of Medicaid,6.44,,,6.44,Other,140% of Medicaid,10.35,,,10.35,Other,225% of Medicaid,11.96,,,11.96,Other,260% of Medicaid,14.9,,,14.9,Other,324% of Medicaid,9.89,,,9.89,Other,215% of Medicaid,9.89,,,9.89,Other,215% of Medicaid,5.75,,,5.75,Other,125% of Medicaid,4.6,40.7,
ASSAY OF URINE CHLORIDE,82436,CPT,,78082436,CDM,301,RC,,,both,,,90,66.6,,,66.6,Other,150% of Medicare + 9.63% HCRA Surcharge,40.5,45,,40.5,percent of total billed charges,Critical Access Hospital RCC factor,17.31,,,17.31,Fee Schedule,,15.58,,,15.58,Fee Schedule,,17.92,,,17.92,Fee Schedule,,16.12,,,16.12,Fee Schedule,,15.23,,,15.23,Fee Schedule,,44.55,,,44.55,Other,110% of Medicare,18.11,,,18.11,Fee Schedule,,9,,,9,Other,186% of Medicaid,21.33,,,21.33,Fee Schedule,,55.8,,,55.8,Fee Schedule,,12.08,,,12.08,Fee Schedule,,21.33,,,21.33,Fee Schedule,,55.8,,,55.8,Fee Schedule,,22.71,,,22.71,Fee Schedule,,63,70,,63,percent of total billed charges,All Other,27.25,,,27.25,Fee Schedule,,23.1,,,23.1,Fee Schedule,,8.63,,,8.63,Fee Schedule,,8.63,,,8.63,Fee Schedule,,8.63,,,8.63,Fee Schedule,,8.63,,,8.63,Fee Schedule,,5.08,,,5.08,Other,100% of Medicaid,5.08,,,5.08,Other,100% of Medicaid,5.08,,,5.08,Other,100% of Medicaid,5.08,,,5.08,Other,100% of Medicaid,11.43,,,11.43,Other,225% of Medicaid,7.77,,,7.77,Other,153% of Medicaid,11.43,,,11.43,Other,225% of Medicaid,7.11,,,7.11,Other,140% of Medicaid,11.43,,,11.43,Other,225% of Medicaid,13.21,,,13.21,Other,260% of Medicaid,16.46,,,16.46,Other,324% of Medicaid,10.92,,,10.92,Other,215% of Medicaid,10.92,,,10.92,Other,215% of Medicaid,6.35,,,6.35,Other,125% of Medicaid,5.08,66.6,
ASSAY OTHER FLUID CHLORIDES,82438,CPT,,78082438,CDM,301,RC,,,both,,,44,32.56,,,32.56,Other,150% of Medicare + 9.63% HCRA Surcharge,19.8,45,,19.8,percent of total billed charges,Critical Access Hospital RCC factor,15.05,,,15.05,Fee Schedule,,13.55,,,13.55,Fee Schedule,,17.92,,,17.92,Fee Schedule,,16.12,,,16.12,Fee Schedule,,15.23,,,15.23,Fee Schedule,,21.78,,,21.78,Other,110% of Medicare,15.75,,,15.75,Fee Schedule,,9,,,9,Other,186% of Medicaid,18.55,,,18.55,Fee Schedule,,27.28,,,27.28,Fee Schedule,,10.5,,,10.5,Fee Schedule,,18.55,,,18.55,Fee Schedule,,27.28,,,27.28,Fee Schedule,,19.75,,,19.75,Fee Schedule,,30.8,70,,30.8,percent of total billed charges,All Other,23.7,,,23.7,Fee Schedule,,20.08,,,20.08,Fee Schedule,,7.5,,,7.5,Fee Schedule,,7.5,,,7.5,Fee Schedule,,7.5,,,7.5,Fee Schedule,,7.5,,,7.5,Fee Schedule,,5,,,5,Other,100% of Medicaid,5,,,5,Other,100% of Medicaid,5,,,5,Other,100% of Medicaid,5,,,5,Other,100% of Medicaid,11.25,,,11.25,Other,225% of Medicaid,7.65,,,7.65,Other,153% of Medicaid,11.25,,,11.25,Other,225% of Medicaid,7,,,7,Other,140% of Medicaid,11.25,,,11.25,Other,225% of Medicaid,13,,,13,Other,260% of Medicaid,16.2,,,16.2,Other,324% of Medicaid,10.75,,,10.75,Other,215% of Medicaid,10.75,,,10.75,Other,215% of Medicaid,6.25,,,6.25,Other,125% of Medicaid,5,32.56,
ASSAY BLD/SERUM CHOLESTEROL,82465,CPT,,78082465,CDM,301,RC,,,both,,,46,34.04,,,34.04,Other,150% of Medicare + 9.63% HCRA Surcharge,20.7,45,,20.7,percent of total billed charges,Critical Access Hospital RCC factor,13.09,,,13.09,Fee Schedule,,11.79,,,11.79,Fee Schedule,,32.31,,,32.31,Fee Schedule,,29.06,,,29.06,Fee Schedule,,27.46,,,27.46,Fee Schedule,,22.77,,,22.77,Other,110% of Medicare,13.7,,,13.7,Fee Schedule,,8,,,8,Other,186% of Medicaid,16.14,,,16.14,Fee Schedule,,28.52,,,28.52,Fee Schedule,,9.14,,,9.14,Fee Schedule,,16.14,,,16.14,Fee Schedule,,28.52,,,28.52,Fee Schedule,,17.18,,,17.18,Fee Schedule,,32.2,70,,32.2,percent of total billed charges,All Other,20.61,,,20.61,Fee Schedule,,17.47,,,17.47,Fee Schedule,,6.53,,,6.53,Fee Schedule,,6.53,,,6.53,Fee Schedule,,6.53,,,6.53,Fee Schedule,,6.53,,,6.53,Fee Schedule,,4.35,,,4.35,Other,100% of Medicaid,4.35,,,4.35,Other,100% of Medicaid,4.35,,,4.35,Other,100% of Medicaid,4.35,,,4.35,Other,100% of Medicaid,9.79,,,9.79,Other,225% of Medicaid,6.66,,,6.66,Other,153% of Medicaid,9.79,,,9.79,Other,225% of Medicaid,6.09,,,6.09,Other,140% of Medicaid,9.79,,,9.79,Other,225% of Medicaid,11.31,,,11.31,Other,260% of Medicaid,14.09,,,14.09,Other,324% of Medicaid,9.35,,,9.35,Other,215% of Medicaid,9.35,,,9.35,Other,215% of Medicaid,5.44,,,5.44,Other,125% of Medicaid,4.35,34.04,
ASSAY SERUM CHOLINESTERASE,82480,CPT,,78082480,CDM,301,RC,,,both,,,108,79.92,,,79.92,Other,150% of Medicare + 9.63% HCRA Surcharge,48.6,45,,48.6,percent of total billed charges,Critical Access Hospital RCC factor,23.69,,,23.69,Fee Schedule,,21.33,,,21.33,Fee Schedule,,58.44,,,58.44,Fee Schedule,,52.57,,,52.57,Fee Schedule,,49.68,,,49.68,Fee Schedule,,53.46,,,53.46,Other,110% of Medicare,24.79,,,24.79,Fee Schedule,,15,,,15,Other,186% of Medicaid,29.2,,,29.2,Fee Schedule,,66.96,,,66.96,Fee Schedule,,16.53,,,16.53,Fee Schedule,,29.2,,,29.2,Fee Schedule,,66.96,,,66.96,Fee Schedule,,31.09,,,31.09,Fee Schedule,,75.6,70,,75.6,percent of total billed charges,All Other,37.3,,,37.3,Fee Schedule,,31.61,,,31.61,Fee Schedule,,11.81,,,11.81,Fee Schedule,,11.81,,,11.81,Fee Schedule,,11.81,,,11.81,Fee Schedule,,11.81,,,11.81,Fee Schedule,,7.87,,,7.87,Other,100% of Medicaid,7.87,,,7.87,Other,100% of Medicaid,7.87,,,7.87,Other,100% of Medicaid,7.87,,,7.87,Other,100% of Medicaid,17.71,,,17.71,Other,225% of Medicaid,12.04,,,12.04,Other,153% of Medicaid,17.71,,,17.71,Other,225% of Medicaid,11.02,,,11.02,Other,140% of Medicaid,17.71,,,17.71,Other,225% of Medicaid,20.46,,,20.46,Other,260% of Medicaid,25.5,,,25.5,Other,324% of Medicaid,16.92,,,16.92,Other,215% of Medicaid,16.92,,,16.92,Other,215% of Medicaid,9.84,,,9.84,Other,125% of Medicaid,7.87,79.92,
ASSAY RBC CHOLINESTERASE,82482,CPT,,78082482,CDM,301,RC,,,both,,,135,99.9,,,99.9,Other,150% of Medicare + 9.63% HCRA Surcharge,60.75,45,,60.75,percent of total billed charges,Critical Access Hospital RCC factor,29.53,,,29.53,Fee Schedule,,26.59,,,26.59,Fee Schedule,,56.97,,,56.97,Fee Schedule,,51.24,,,51.24,Fee Schedule,,48.43,,,48.43,Fee Schedule,,66.83,,,66.83,Other,110% of Medicare,30.9,,,30.9,Fee Schedule,,12,,,12,Other,186% of Medicaid,36.4,,,36.4,Fee Schedule,,83.7,,,83.7,Fee Schedule,,20.6,,,20.6,Fee Schedule,,36.4,,,36.4,Fee Schedule,,83.7,,,83.7,Fee Schedule,,38.75,,,38.75,Fee Schedule,,94.5,70,,94.5,percent of total billed charges,All Other,46.49,,,46.49,Fee Schedule,,39.4,,,39.4,Fee Schedule,,14.72,,,14.72,Fee Schedule,,14.72,,,14.72,Fee Schedule,,14.72,,,14.72,Fee Schedule,,14.72,,,14.72,Fee Schedule,,6.31,,,6.31,Other,100% of Medicaid,6.31,,,6.31,Other,100% of Medicaid,6.31,,,6.31,Other,100% of Medicaid,6.31,,,6.31,Other,100% of Medicaid,14.2,,,14.2,Other,225% of Medicaid,9.65,,,9.65,Other,153% of Medicaid,14.2,,,14.2,Other,225% of Medicaid,8.83,,,8.83,Other,140% of Medicaid,14.2,,,14.2,Other,225% of Medicaid,16.41,,,16.41,Other,260% of Medicaid,20.45,,,20.45,Other,324% of Medicaid,13.57,,,13.57,Other,215% of Medicaid,13.57,,,13.57,Other,215% of Medicaid,7.89,,,7.89,Other,125% of Medicaid,6.31,99.9,
ASSAY OF CHROMIUM,82495,CPT,,78082495,CDM,301,RC,,,both,,,208,153.92,,,153.92,Other,150% of Medicare + 9.63% HCRA Surcharge,93.6,45,,93.6,percent of total billed charges,Critical Access Hospital RCC factor,61.04,,,61.04,Fee Schedule,,54.96,,,54.96,Fee Schedule,,150.41,,,150.41,Fee Schedule,,135.28,,,135.28,Fee Schedule,,127.86,,,127.86,Fee Schedule,,102.96,,,102.96,Other,110% of Medicare,63.88,,,63.88,Fee Schedule,,38,,,38,Other,186% of Medicaid,75.24,,,75.24,Fee Schedule,,128.96,,,128.96,Fee Schedule,,42.59,,,42.59,Fee Schedule,,75.24,,,75.24,Fee Schedule,,128.96,,,128.96,Fee Schedule,,80.11,,,80.11,Fee Schedule,,145.6,70,,145.6,percent of total billed charges,All Other,96.11,,,96.11,Fee Schedule,,81.46,,,81.46,Fee Schedule,,30.42,,,30.42,Fee Schedule,,30.42,,,30.42,Fee Schedule,,30.42,,,30.42,Fee Schedule,,30.42,,,30.42,Fee Schedule,,20.28,,,20.28,Other,100% of Medicaid,20.28,,,20.28,Other,100% of Medicaid,20.28,,,20.28,Other,100% of Medicaid,20.28,,,20.28,Other,100% of Medicaid,45.63,,,45.63,Other,225% of Medicaid,31.03,,,31.03,Other,153% of Medicaid,45.63,,,45.63,Other,225% of Medicaid,28.39,,,28.39,Other,140% of Medicaid,45.63,,,45.63,Other,225% of Medicaid,52.73,,,52.73,Other,260% of Medicaid,65.71,,,65.71,Other,324% of Medicaid,43.6,,,43.6,Other,215% of Medicaid,43.6,,,43.6,Other,215% of Medicaid,25.35,,,25.35,Other,125% of Medicaid,20.28,153.92,
ASSAY OF CITRATE,82507,CPT,,78082507,CDM,301,RC,,,both,,,237,175.38,,,175.38,Other,150% of Medicare + 9.63% HCRA Surcharge,106.65,45,,106.65,percent of total billed charges,Critical Access Hospital RCC factor,83.68,,,83.68,Fee Schedule,,75.34,,,75.34,Fee Schedule,,206.22,,,206.22,Fee Schedule,,185.48,,,185.48,Fee Schedule,,175.3,,,175.3,Fee Schedule,,117.32,,,117.32,Other,110% of Medicare,87.57,,,87.57,Fee Schedule,,48,,,48,Other,186% of Medicaid,103.14,,,103.14,Fee Schedule,,146.94,,,146.94,Fee Schedule,,58.38,,,58.38,Fee Schedule,,103.14,,,103.14,Fee Schedule,,146.94,,,146.94,Fee Schedule,,109.81,,,109.81,Fee Schedule,,165.9,70,,165.9,percent of total billed charges,All Other,131.75,,,131.75,Fee Schedule,,111.66,,,111.66,Fee Schedule,,41.7,,,41.7,Fee Schedule,,41.7,,,41.7,Fee Schedule,,41.7,,,41.7,Fee Schedule,,41.7,,,41.7,Fee Schedule,,25.55,,,25.55,Other,100% of Medicaid,25.55,,,25.55,Other,100% of Medicaid,25.55,,,25.55,Other,100% of Medicaid,25.55,,,25.55,Other,100% of Medicaid,57.49,,,57.49,Other,225% of Medicaid,39.1,,,39.1,Other,153% of Medicaid,57.49,,,57.49,Other,225% of Medicaid,35.77,,,35.77,Other,140% of Medicaid,57.49,,,57.49,Other,225% of Medicaid,66.44,,,66.44,Other,260% of Medicaid,82.79,,,82.79,Other,324% of Medicaid,54.94,,,54.94,Other,215% of Medicaid,54.94,,,54.94,Other,215% of Medicaid,31.94,,,31.94,Other,125% of Medicaid,25.55,206.22,
COLLAGEN CROSSLINKS,82523,CPT,,78082523,CDM,301,RC,,,both,,,239,176.86,,,176.86,Other,150% of Medicare + 9.63% HCRA Surcharge,107.55,45,,107.55,percent of total billed charges,Critical Access Hospital RCC factor,56.23,,,56.23,Fee Schedule,,50.62,,,50.62,Fee Schedule,,138.65,,,138.65,Fee Schedule,,124.71,,,124.71,Fee Schedule,,117.87,,,117.87,Fee Schedule,,118.31,,,118.31,Other,110% of Medicare,58.84,,,58.84,Fee Schedule,,35,,,35,Other,186% of Medicaid,69.3,,,69.3,Fee Schedule,,148.18,,,148.18,Fee Schedule,,39.23,,,39.23,Fee Schedule,,69.3,,,69.3,Fee Schedule,,148.18,,,148.18,Fee Schedule,,73.79,,,73.79,Fee Schedule,,167.3,70,,167.3,percent of total billed charges,All Other,88.53,,,88.53,Fee Schedule,,75.03,,,75.03,Fee Schedule,,28.02,,,28.02,Fee Schedule,,28.02,,,28.02,Fee Schedule,,28.02,,,28.02,Fee Schedule,,28.02,,,28.02,Fee Schedule,,18.68,,,18.68,Other,100% of Medicaid,18.68,,,18.68,Other,100% of Medicaid,18.68,,,18.68,Other,100% of Medicaid,18.68,,,18.68,Other,100% of Medicaid,42.03,,,42.03,Other,225% of Medicaid,28.58,,,28.58,Other,153% of Medicaid,42.03,,,42.03,Other,225% of Medicaid,26.15,,,26.15,Other,140% of Medicaid,42.03,,,42.03,Other,225% of Medicaid,48.57,,,48.57,Other,260% of Medicaid,60.52,,,60.52,Other,324% of Medicaid,40.16,,,40.16,Other,215% of Medicaid,40.16,,,40.16,Other,215% of Medicaid,23.35,,,23.35,Other,125% of Medicaid,18.68,176.86,
ASSAY OF COPPER,82525,CPT,,78082525,CDM,301,RC,,,both,,,271,200.54,,,200.54,Other,150% of Medicare + 9.63% HCRA Surcharge,121.95,45,,121.95,percent of total billed charges,Critical Access Hospital RCC factor,37.35,,,37.35,Fee Schedule,,33.63,,,33.63,Fee Schedule,,92.01,,,92.01,Fee Schedule,,82.76,,,82.76,Fee Schedule,,78.22,,,78.22,Fee Schedule,,134.15,,,134.15,Other,110% of Medicare,39.09,,,39.09,Fee Schedule,,23,,,23,Other,186% of Medicaid,46.04,,,46.04,Fee Schedule,,168.02,,,168.02,Fee Schedule,,26.06,,,26.06,Fee Schedule,,46.04,,,46.04,Fee Schedule,,168.02,,,168.02,Fee Schedule,,49.02,,,49.02,Fee Schedule,,189.7,70,,189.7,percent of total billed charges,All Other,58.81,,,58.81,Fee Schedule,,49.85,,,49.85,Fee Schedule,,18.62,,,18.62,Fee Schedule,,18.62,,,18.62,Fee Schedule,,18.62,,,18.62,Fee Schedule,,18.62,,,18.62,Fee Schedule,,12.41,,,12.41,Other,100% of Medicaid,12.41,,,12.41,Other,100% of Medicaid,12.41,,,12.41,Other,100% of Medicaid,12.41,,,12.41,Other,100% of Medicaid,27.92,,,27.92,Other,225% of Medicaid,18.99,,,18.99,Other,153% of Medicaid,27.92,,,27.92,Other,225% of Medicaid,17.37,,,17.37,Other,140% of Medicaid,27.92,,,27.92,Other,225% of Medicaid,32.27,,,32.27,Other,260% of Medicaid,40.21,,,40.21,Other,324% of Medicaid,26.68,,,26.68,Other,215% of Medicaid,26.68,,,26.68,Other,215% of Medicaid,15.51,,,15.51,Other,125% of Medicaid,12.41,200.54,
CORTISOL FREE,82530,CPT,,78082530,CDM,301,RC,,,both,,,246,182.04,,,182.04,Other,150% of Medicare + 9.63% HCRA Surcharge,110.7,45,,110.7,percent of total billed charges,Critical Access Hospital RCC factor,50.3,,,50.3,Fee Schedule,,45.28,,,45.28,Fee Schedule,,123.95,,,123.95,Fee Schedule,,111.48,,,111.48,Fee Schedule,,105.37,,,105.37,Fee Schedule,,121.77,,,121.77,Other,110% of Medicare,52.64,,,52.64,Fee Schedule,,31,,,31,Other,186% of Medicaid,61.99,,,61.99,Fee Schedule,,152.52,,,152.52,Fee Schedule,,35.09,,,35.09,Fee Schedule,,61.99,,,61.99,Fee Schedule,,152.52,,,152.52,Fee Schedule,,66,,,66,Fee Schedule,,172.2,70,,172.2,percent of total billed charges,All Other,79.19,,,79.19,Fee Schedule,,67.12,,,67.12,Fee Schedule,,25.07,,,25.07,Fee Schedule,,25.07,,,25.07,Fee Schedule,,25.07,,,25.07,Fee Schedule,,25.07,,,25.07,Fee Schedule,,16.71,,,16.71,Other,100% of Medicaid,16.71,,,16.71,Other,100% of Medicaid,16.71,,,16.71,Other,100% of Medicaid,16.71,,,16.71,Other,100% of Medicaid,37.6,,,37.6,Other,225% of Medicaid,25.57,,,25.57,Other,153% of Medicaid,37.6,,,37.6,Other,225% of Medicaid,23.39,,,23.39,Other,140% of Medicaid,37.6,,,37.6,Other,225% of Medicaid,43.45,,,43.45,Other,260% of Medicaid,54.14,,,54.14,Other,324% of Medicaid,35.93,,,35.93,Other,215% of Medicaid,35.93,,,35.93,Other,215% of Medicaid,20.89,,,20.89,Other,125% of Medicaid,16.71,182.04,
TOTAL CORTISOL,82533,CPT,,78082533,CDM,301,RC,,,both,,,224,165.76,,,165.76,Other,150% of Medicare + 9.63% HCRA Surcharge,100.8,45,,100.8,percent of total billed charges,Critical Access Hospital RCC factor,49.06,,,49.06,Fee Schedule,,44.17,,,44.17,Fee Schedule,,120.95,,,120.95,Fee Schedule,,108.78,,,108.78,Fee Schedule,,102.82,,,102.82,Fee Schedule,,110.88,,,110.88,Other,110% of Medicare,51.35,,,51.35,Fee Schedule,,30,,,30,Other,186% of Medicaid,60.47,,,60.47,Fee Schedule,,138.88,,,138.88,Fee Schedule,,34.23,,,34.23,Fee Schedule,,60.47,,,60.47,Fee Schedule,,138.88,,,138.88,Fee Schedule,,64.39,,,64.39,Fee Schedule,,156.8,70,,156.8,percent of total billed charges,All Other,77.25,,,77.25,Fee Schedule,,65.47,,,65.47,Fee Schedule,,24.45,,,24.45,Fee Schedule,,24.45,,,24.45,Fee Schedule,,24.45,,,24.45,Fee Schedule,,24.45,,,24.45,Fee Schedule,,16.3,,,16.3,Other,100% of Medicaid,16.3,,,16.3,Other,100% of Medicaid,16.3,,,16.3,Other,100% of Medicaid,16.3,,,16.3,Other,100% of Medicaid,36.68,,,36.68,Other,225% of Medicaid,24.94,,,24.94,Other,153% of Medicaid,36.68,,,36.68,Other,225% of Medicaid,22.82,,,22.82,Other,140% of Medicaid,36.68,,,36.68,Other,225% of Medicaid,42.38,,,42.38,Other,260% of Medicaid,52.81,,,52.81,Other,324% of Medicaid,35.05,,,35.05,Other,215% of Medicaid,35.05,,,35.05,Other,215% of Medicaid,20.38,,,20.38,Other,125% of Medicaid,16.3,165.76,
ASSAY OF CREATINE,82540,CPT,,78082540,CDM,301,RC,,,both,,,107,79.18,,,79.18,Other,150% of Medicare + 9.63% HCRA Surcharge,48.15,45,,48.15,percent of total billed charges,Critical Access Hospital RCC factor,13.97,,,13.97,Fee Schedule,,12.57,,,12.57,Fee Schedule,,34.36,,,34.36,Fee Schedule,,30.9,,,30.9,Fee Schedule,,29.21,,,29.21,Fee Schedule,,52.97,,,52.97,Other,110% of Medicare,14.62,,,14.62,Fee Schedule,,12,,,12,Other,186% of Medicaid,17.21,,,17.21,Fee Schedule,,66.34,,,66.34,Fee Schedule,,9.74,,,9.74,Fee Schedule,,17.21,,,17.21,Fee Schedule,,66.34,,,66.34,Fee Schedule,,18.33,,,18.33,Fee Schedule,,74.9,70,,74.9,percent of total billed charges,All Other,21.99,,,21.99,Fee Schedule,,18.64,,,18.64,Fee Schedule,,6.96,,,6.96,Fee Schedule,,6.96,,,6.96,Fee Schedule,,6.96,,,6.96,Fee Schedule,,6.96,,,6.96,Fee Schedule,,6.31,,,6.31,Other,100% of Medicaid,6.31,,,6.31,Other,100% of Medicaid,6.31,,,6.31,Other,100% of Medicaid,6.31,,,6.31,Other,100% of Medicaid,14.2,,,14.2,Other,225% of Medicaid,9.65,,,9.65,Other,153% of Medicaid,14.2,,,14.2,Other,225% of Medicaid,8.83,,,8.83,Other,140% of Medicaid,14.2,,,14.2,Other,225% of Medicaid,16.41,,,16.41,Other,260% of Medicaid,20.45,,,20.45,Other,324% of Medicaid,13.57,,,13.57,Other,215% of Medicaid,13.57,,,13.57,Other,215% of Medicaid,7.89,,,7.89,Other,125% of Medicaid,6.31,79.18,
COLUMN CHROMOTOGRAPHY QUANT,82542,CPT,,78082542,CDM,301,RC,,,both,,,160,118.4,,,118.4,Other,150% of Medicare + 9.63% HCRA Surcharge,72,45,,72,percent of total billed charges,Critical Access Hospital RCC factor,72.51,,,72.51,Fee Schedule,,65.28,,,65.28,Fee Schedule,,133.91,,,133.91,Fee Schedule,,120.44,,,120.44,Fee Schedule,,113.84,,,113.84,Fee Schedule,,79.2,,,79.2,Other,110% of Medicare,75.88,,,75.88,Fee Schedule,,19,,,19,Other,186% of Medicaid,89.37,,,89.37,Fee Schedule,,99.2,,,99.2,Fee Schedule,,50.59,,,50.59,Fee Schedule,,89.37,,,89.37,Fee Schedule,,99.2,,,99.2,Fee Schedule,,95.16,,,95.16,Fee Schedule,,112,70,,112,percent of total billed charges,All Other,114.16,,,114.16,Fee Schedule,,96.76,,,96.76,Fee Schedule,,36.14,,,36.14,Fee Schedule,,36.14,,,36.14,Fee Schedule,,36.14,,,36.14,Fee Schedule,,36.14,,,36.14,Fee Schedule,,10.16,,,10.16,Other,100% of Medicaid,10.16,,,10.16,Other,100% of Medicaid,10.16,,,10.16,Other,100% of Medicaid,10.16,,,10.16,Other,100% of Medicaid,22.85,,,22.85,Other,225% of Medicaid,15.54,,,15.54,Other,153% of Medicaid,22.85,,,22.85,Other,225% of Medicaid,14.22,,,14.22,Other,140% of Medicaid,22.85,,,22.85,Other,225% of Medicaid,26.4,,,26.4,Other,260% of Medicaid,32.9,,,32.9,Other,324% of Medicaid,21.83,,,21.83,Other,215% of Medicaid,21.83,,,21.83,Other,215% of Medicaid,12.69,,,12.69,Other,125% of Medicaid,10.16,133.91,
ASSAY OF CK (CPK),82550,CPT,,78082550,CDM,301,RC,,,both,,,87,64.38,,,64.38,Other,150% of Medicare + 9.63% HCRA Surcharge,39.15,45,,39.15,percent of total billed charges,Critical Access Hospital RCC factor,19.6,,,19.6,Fee Schedule,,17.64,,,17.64,Fee Schedule,,48.33,,,48.33,Fee Schedule,,43.47,,,43.47,Fee Schedule,,41.08,,,41.08,Fee Schedule,,43.07,,,43.07,Other,110% of Medicare,20.51,,,20.51,Fee Schedule,,9,,,9,Other,186% of Medicaid,24.15,,,24.15,Fee Schedule,,53.94,,,53.94,Fee Schedule,,13.67,,,13.67,Fee Schedule,,24.15,,,24.15,Fee Schedule,,53.94,,,53.94,Fee Schedule,,25.71,,,25.71,Fee Schedule,,60.9,70,,60.9,percent of total billed charges,All Other,30.85,,,30.85,Fee Schedule,,26.15,,,26.15,Fee Schedule,,9.77,,,9.77,Fee Schedule,,9.77,,,9.77,Fee Schedule,,9.77,,,9.77,Fee Schedule,,9.77,,,9.77,Fee Schedule,,5.08,,,5.08,Other,100% of Medicaid,5.08,,,5.08,Other,100% of Medicaid,5.08,,,5.08,Other,100% of Medicaid,5.08,,,5.08,Other,100% of Medicaid,11.43,,,11.43,Other,225% of Medicaid,7.77,,,7.77,Other,153% of Medicaid,11.43,,,11.43,Other,225% of Medicaid,7.11,,,7.11,Other,140% of Medicaid,11.43,,,11.43,Other,225% of Medicaid,13.21,,,13.21,Other,260% of Medicaid,16.46,,,16.46,Other,324% of Medicaid,10.92,,,10.92,Other,215% of Medicaid,10.92,,,10.92,Other,215% of Medicaid,6.35,,,6.35,Other,125% of Medicaid,5.08,64.38,
ASSAY OF CPK IN BLOOD,82552,CPT,,78082552,CDM,301,RC,,,both,,,166,122.84,,,122.84,Other,150% of Medicare + 9.63% HCRA Surcharge,74.7,45,,74.7,percent of total billed charges,Critical Access Hospital RCC factor,40.3,,,40.3,Fee Schedule,,36.29,,,36.29,Fee Schedule,,64.87,,,64.87,Fee Schedule,,58.35,,,58.35,Fee Schedule,,55.15,,,55.15,Fee Schedule,,82.17,,,82.17,Other,110% of Medicare,42.18,,,42.18,Fee Schedule,,18,,,18,Other,186% of Medicaid,49.68,,,49.68,Fee Schedule,,102.92,,,102.92,Fee Schedule,,28.12,,,28.12,Fee Schedule,,49.68,,,49.68,Fee Schedule,,102.92,,,102.92,Fee Schedule,,52.89,,,52.89,Fee Schedule,,116.2,70,,116.2,percent of total billed charges,All Other,63.46,,,63.46,Fee Schedule,,53.78,,,53.78,Fee Schedule,,20.09,,,20.09,Fee Schedule,,20.09,,,20.09,Fee Schedule,,20.09,,,20.09,Fee Schedule,,20.09,,,20.09,Fee Schedule,,9.49,,,9.49,Other,100% of Medicaid,9.49,,,9.49,Other,100% of Medicaid,9.49,,,9.49,Other,100% of Medicaid,9.49,,,9.49,Other,100% of Medicaid,21.36,,,21.36,Other,225% of Medicaid,14.53,,,14.53,Other,153% of Medicaid,21.36,,,21.36,Other,225% of Medicaid,13.29,,,13.29,Other,140% of Medicaid,21.36,,,21.36,Other,225% of Medicaid,24.68,,,24.68,Other,260% of Medicaid,30.76,,,30.76,Other,324% of Medicaid,20.41,,,20.41,Other,215% of Medicaid,20.41,,,20.41,Other,215% of Medicaid,11.87,,,11.87,Other,125% of Medicaid,9.49,122.84,
CREATINE MB FRACTION,82553,CPT,,78082553,CDM,301,RC,,,both,,,244,180.56,,,180.56,Other,150% of Medicare + 9.63% HCRA Surcharge,109.8,45,,109.8,percent of total billed charges,Critical Access Hospital RCC factor,34.77,,,34.77,Fee Schedule,,31.3,,,31.3,Fee Schedule,,45.64,,,45.64,Fee Schedule,,41.05,,,41.05,Fee Schedule,,38.8,,,38.8,Fee Schedule,,120.78,,,120.78,Other,110% of Medicare,36.38,,,36.38,Fee Schedule,,15,,,15,Other,186% of Medicaid,42.85,,,42.85,Fee Schedule,,151.28,,,151.28,Fee Schedule,,24.26,,,24.26,Fee Schedule,,42.85,,,42.85,Fee Schedule,,151.28,,,151.28,Fee Schedule,,45.62,,,45.62,Fee Schedule,,170.8,70,,170.8,percent of total billed charges,All Other,54.74,,,54.74,Fee Schedule,,46.39,,,46.39,Fee Schedule,,17.33,,,17.33,Fee Schedule,,17.33,,,17.33,Fee Schedule,,17.33,,,17.33,Fee Schedule,,17.33,,,17.33,Fee Schedule,,8.13,,,8.13,Other,100% of Medicaid,8.13,,,8.13,Other,100% of Medicaid,8.13,,,8.13,Other,100% of Medicaid,8.13,,,8.13,Other,100% of Medicaid,18.29,,,18.29,Other,225% of Medicaid,12.44,,,12.44,Other,153% of Medicaid,18.29,,,18.29,Other,225% of Medicaid,11.38,,,11.38,Other,140% of Medicaid,18.29,,,18.29,Other,225% of Medicaid,21.14,,,21.14,Other,260% of Medicaid,26.34,,,26.34,Other,324% of Medicaid,17.48,,,17.48,Other,215% of Medicaid,17.48,,,17.48,Other,215% of Medicaid,10.16,,,10.16,Other,125% of Medicaid,8.13,180.56,
ASSAY OF CREATININE,82565,CPT,,78082565,CDM,301,RC,,,both,,,99,73.26,,,73.26,Other,150% of Medicare + 9.63% HCRA Surcharge,44.55,45,,44.55,percent of total billed charges,Critical Access Hospital RCC factor,15.41,,,15.41,Fee Schedule,,13.88,,,13.88,Fee Schedule,,38.05,,,38.05,Fee Schedule,,34.22,,,34.22,Fee Schedule,,32.35,,,32.35,Fee Schedule,,49.01,,,49.01,Other,110% of Medicare,16.13,,,16.13,Fee Schedule,,9,,,9,Other,186% of Medicaid,19,,,19,Fee Schedule,,61.38,,,61.38,Fee Schedule,,10.75,,,10.75,Fee Schedule,,19,,,19,Fee Schedule,,61.38,,,61.38,Fee Schedule,,20.22,,,20.22,Fee Schedule,,69.3,70,,69.3,percent of total billed charges,All Other,24.26,,,24.26,Fee Schedule,,20.57,,,20.57,Fee Schedule,,7.68,,,7.68,Fee Schedule,,7.68,,,7.68,Fee Schedule,,7.68,,,7.68,Fee Schedule,,7.68,,,7.68,Fee Schedule,,5.08,,,5.08,Other,100% of Medicaid,5.08,,,5.08,Other,100% of Medicaid,5.08,,,5.08,Other,100% of Medicaid,5.08,,,5.08,Other,100% of Medicaid,11.43,,,11.43,Other,225% of Medicaid,7.77,,,7.77,Other,153% of Medicaid,11.43,,,11.43,Other,225% of Medicaid,7.11,,,7.11,Other,140% of Medicaid,11.43,,,11.43,Other,225% of Medicaid,13.21,,,13.21,Other,260% of Medicaid,16.46,,,16.46,Other,324% of Medicaid,10.92,,,10.92,Other,215% of Medicaid,10.92,,,10.92,Other,215% of Medicaid,6.35,,,6.35,Other,125% of Medicaid,5.08,73.26,
ASSAY OF URINE CREATININE,82570,CPT,,78082570,CDM,301,RC,,,both,,,78,57.72,,,57.72,Other,150% of Medicare + 9.63% HCRA Surcharge,35.1,45,,35.1,percent of total billed charges,Critical Access Hospital RCC factor,15.59,,,15.59,Fee Schedule,,14.04,,,14.04,Fee Schedule,,38.37,,,38.37,Fee Schedule,,34.51,,,34.51,Fee Schedule,,32.61,,,32.61,Fee Schedule,,38.61,,,38.61,Other,110% of Medicare,16.32,,,16.32,Fee Schedule,,9,,,9,Other,186% of Medicaid,19.22,,,19.22,Fee Schedule,,48.36,,,48.36,Fee Schedule,,10.88,,,10.88,Fee Schedule,,19.22,,,19.22,Fee Schedule,,48.36,,,48.36,Fee Schedule,,20.46,,,20.46,Fee Schedule,,54.6,70,,54.6,percent of total billed charges,All Other,24.55,,,24.55,Fee Schedule,,20.81,,,20.81,Fee Schedule,,7.77,,,7.77,Fee Schedule,,7.77,,,7.77,Fee Schedule,,7.77,,,7.77,Fee Schedule,,7.77,,,7.77,Fee Schedule,,5.08,,,5.08,Other,100% of Medicaid,5.08,,,5.08,Other,100% of Medicaid,5.08,,,5.08,Other,100% of Medicaid,5.08,,,5.08,Other,100% of Medicaid,11.43,,,11.43,Other,225% of Medicaid,7.77,,,7.77,Other,153% of Medicaid,11.43,,,11.43,Other,225% of Medicaid,7.11,,,7.11,Other,140% of Medicaid,11.43,,,11.43,Other,225% of Medicaid,13.21,,,13.21,Other,260% of Medicaid,16.46,,,16.46,Other,324% of Medicaid,10.92,,,10.92,Other,215% of Medicaid,10.92,,,10.92,Other,215% of Medicaid,6.35,,,6.35,Other,125% of Medicaid,5.08,57.72,
CREATININE CLEARANCE TEST,82575,CPT,,78082575,CDM,301,RC,,,both,,,129,95.46,,,95.46,Other,150% of Medicare + 9.63% HCRA Surcharge,58.05,45,,58.05,percent of total billed charges,Critical Access Hospital RCC factor,28.47,,,28.47,Fee Schedule,,25.64,,,25.64,Fee Schedule,,70.09,,,70.09,Fee Schedule,,63.04,,,63.04,Fee Schedule,,59.58,,,59.58,Fee Schedule,,63.86,,,63.86,Other,110% of Medicare,29.8,,,29.8,Fee Schedule,,11,,,11,Other,186% of Medicaid,35.1,,,35.1,Fee Schedule,,79.98,,,79.98,Fee Schedule,,19.87,,,19.87,Fee Schedule,,35.1,,,35.1,Fee Schedule,,79.98,,,79.98,Fee Schedule,,37.37,,,37.37,Fee Schedule,,90.3,70,,90.3,percent of total billed charges,All Other,44.83,,,44.83,Fee Schedule,,38,,,38,Fee Schedule,,14.19,,,14.19,Fee Schedule,,14.19,,,14.19,Fee Schedule,,14.19,,,14.19,Fee Schedule,,14.19,,,14.19,Fee Schedule,,5.89,,,5.89,Other,100% of Medicaid,5.89,,,5.89,Other,100% of Medicaid,5.89,,,5.89,Other,100% of Medicaid,5.89,,,5.89,Other,100% of Medicaid,13.25,,,13.25,Other,225% of Medicaid,9.01,,,9.01,Other,153% of Medicaid,13.25,,,13.25,Other,225% of Medicaid,8.24,,,8.24,Other,140% of Medicaid,13.25,,,13.25,Other,225% of Medicaid,15.31,,,15.31,Other,260% of Medicaid,19.08,,,19.08,Other,324% of Medicaid,12.66,,,12.66,Other,215% of Medicaid,12.66,,,12.66,Other,215% of Medicaid,7.36,,,7.36,Other,125% of Medicaid,5.89,95.46,
ASSAY OF CRYOFIBRINOGEN,82585,CPT,,78082585,CDM,301,RC,,,both,,,277,204.98,,,204.98,Other,150% of Medicare + 9.63% HCRA Surcharge,124.65,45,,124.65,percent of total billed charges,Critical Access Hospital RCC factor,42.56,,,42.56,Fee Schedule,,38.32,,,38.32,Fee Schedule,,38.68,,,38.68,Fee Schedule,,34.79,,,34.79,Fee Schedule,,32.88,,,32.88,Fee Schedule,,137.12,,,137.12,Other,110% of Medicare,44.54,,,44.54,Fee Schedule,,19,,,19,Other,186% of Medicaid,52.46,,,52.46,Fee Schedule,,171.74,,,171.74,Fee Schedule,,29.69,,,29.69,Fee Schedule,,52.46,,,52.46,Fee Schedule,,171.74,,,171.74,Fee Schedule,,55.85,,,55.85,Fee Schedule,,193.9,70,,193.9,percent of total billed charges,All Other,67.01,,,67.01,Fee Schedule,,56.8,,,56.8,Fee Schedule,,21.21,,,21.21,Fee Schedule,,21.21,,,21.21,Fee Schedule,,21.21,,,21.21,Fee Schedule,,21.21,,,21.21,Fee Schedule,,10.16,,,10.16,Other,100% of Medicaid,10.16,,,10.16,Other,100% of Medicaid,10.16,,,10.16,Other,100% of Medicaid,10.16,,,10.16,Other,100% of Medicaid,22.85,,,22.85,Other,225% of Medicaid,15.54,,,15.54,Other,153% of Medicaid,22.85,,,22.85,Other,225% of Medicaid,14.22,,,14.22,Other,140% of Medicaid,22.85,,,22.85,Other,225% of Medicaid,26.4,,,26.4,Other,260% of Medicaid,32.9,,,32.9,Other,324% of Medicaid,21.83,,,21.83,Other,215% of Medicaid,21.83,,,21.83,Other,215% of Medicaid,12.69,,,12.69,Other,125% of Medicaid,10.16,204.98,
ASSAY OF CRYOGLOBULIN,82595,CPT,,78082595,CDM,301,RC,,,both,,,124,91.76,,,91.76,Other,150% of Medicare + 9.63% HCRA Surcharge,55.8,45,,55.8,percent of total billed charges,Critical Access Hospital RCC factor,19.47,,,19.47,Fee Schedule,,17.53,,,17.53,Fee Schedule,,48.01,,,48.01,Fee Schedule,,43.18,,,43.18,Fee Schedule,,40.81,,,40.81,Fee Schedule,,61.38,,,61.38,Other,110% of Medicare,20.38,,,20.38,Fee Schedule,,10,,,10,Other,186% of Medicaid,24,,,24,Fee Schedule,,76.88,,,76.88,Fee Schedule,,13.59,,,13.59,Fee Schedule,,24,,,24,Fee Schedule,,76.88,,,76.88,Fee Schedule,,25.56,,,25.56,Fee Schedule,,86.8,70,,86.8,percent of total billed charges,All Other,30.66,,,30.66,Fee Schedule,,25.99,,,25.99,Fee Schedule,,9.71,,,9.71,Fee Schedule,,9.71,,,9.71,Fee Schedule,,9.71,,,9.71,Fee Schedule,,9.71,,,9.71,Fee Schedule,,5.53,,,5.53,Other,100% of Medicaid,5.53,,,5.53,Other,100% of Medicaid,5.53,,,5.53,Other,100% of Medicaid,5.53,,,5.53,Other,100% of Medicaid,12.45,,,12.45,Other,225% of Medicaid,8.47,,,8.47,Other,153% of Medicaid,12.45,,,12.45,Other,225% of Medicaid,7.75,,,7.75,Other,140% of Medicaid,12.45,,,12.45,Other,225% of Medicaid,14.39,,,14.39,Other,260% of Medicaid,17.93,,,17.93,Other,324% of Medicaid,11.9,,,11.9,Other,215% of Medicaid,11.9,,,11.9,Other,215% of Medicaid,6.92,,,6.92,Other,125% of Medicaid,5.53,91.76,
ASSAY OF CYANIDE,82600,CPT,,78082600,CDM,301,RC,,,both,,,194,143.56,,,143.56,Other,150% of Medicare + 9.63% HCRA Surcharge,87.3,45,,87.3,percent of total billed charges,Critical Access Hospital RCC factor,58.39,,,58.39,Fee Schedule,,52.57,,,52.57,Fee Schedule,,143.87,,,143.87,Fee Schedule,,129.4,,,129.4,Fee Schedule,,122.3,,,122.3,Fee Schedule,,96.03,,,96.03,Other,110% of Medicare,61.11,,,61.11,Fee Schedule,,33,,,33,Other,186% of Medicaid,71.97,,,71.97,Fee Schedule,,120.28,,,120.28,Fee Schedule,,40.74,,,40.74,Fee Schedule,,71.97,,,71.97,Fee Schedule,,120.28,,,120.28,Fee Schedule,,76.63,,,76.63,Fee Schedule,,135.8,70,,135.8,percent of total billed charges,All Other,91.94,,,91.94,Fee Schedule,,77.92,,,77.92,Fee Schedule,,29.1,,,29.1,Fee Schedule,,29.1,,,29.1,Fee Schedule,,29.1,,,29.1,Fee Schedule,,29.1,,,29.1,Fee Schedule,,17.86,,,17.86,Other,100% of Medicaid,17.86,,,17.86,Other,100% of Medicaid,17.86,,,17.86,Other,100% of Medicaid,17.86,,,17.86,Other,100% of Medicaid,40.19,,,40.19,Other,225% of Medicaid,27.33,,,27.33,Other,153% of Medicaid,40.19,,,40.19,Other,225% of Medicaid,25.01,,,25.01,Other,140% of Medicaid,40.19,,,40.19,Other,225% of Medicaid,46.45,,,46.45,Other,260% of Medicaid,57.88,,,57.88,Other,324% of Medicaid,38.41,,,38.41,Other,215% of Medicaid,38.41,,,38.41,Other,215% of Medicaid,22.33,,,22.33,Other,125% of Medicaid,17.86,143.87,
VITAMIN B-12,82607,CPT,,78082607,CDM,301,RC,,,both,,,227,167.98,,,167.98,Other,150% of Medicare + 9.63% HCRA Surcharge,102.15,45,,102.15,percent of total billed charges,Critical Access Hospital RCC factor,45.39,,,45.39,Fee Schedule,,40.87,,,40.87,Fee Schedule,,111.78,,,111.78,Fee Schedule,,100.54,,,100.54,Fee Schedule,,95.02,,,95.02,Fee Schedule,,112.37,,,112.37,Other,110% of Medicare,47.5,,,47.5,Fee Schedule,,23,,,23,Other,186% of Medicaid,55.95,,,55.95,Fee Schedule,,140.74,,,140.74,Fee Schedule,,31.67,,,31.67,Fee Schedule,,55.95,,,55.95,Fee Schedule,,140.74,,,140.74,Fee Schedule,,59.57,,,59.57,Fee Schedule,,158.9,70,,158.9,percent of total billed charges,All Other,71.46,,,71.46,Fee Schedule,,60.57,,,60.57,Fee Schedule,,22.62,,,22.62,Fee Schedule,,22.62,,,22.62,Fee Schedule,,22.62,,,22.62,Fee Schedule,,22.62,,,22.62,Fee Schedule,,12.63,,,12.63,Other,100% of Medicaid,12.63,,,12.63,Other,100% of Medicaid,12.63,,,12.63,Other,100% of Medicaid,12.63,,,12.63,Other,100% of Medicaid,28.41,,,28.41,Other,225% of Medicaid,19.32,,,19.32,Other,153% of Medicaid,28.41,,,28.41,Other,225% of Medicaid,17.68,,,17.68,Other,140% of Medicaid,28.41,,,28.41,Other,225% of Medicaid,32.83,,,32.83,Other,260% of Medicaid,40.91,,,40.91,Other,324% of Medicaid,27.14,,,27.14,Other,215% of Medicaid,27.14,,,27.14,Other,215% of Medicaid,15.78,,,15.78,Other,125% of Medicaid,12.63,167.98,
B-12 BINDING CAPACITY,82608,CPT,,78082608,CDM,301,RC,,,both,,,201,148.74,,,148.74,Other,150% of Medicare + 9.63% HCRA Surcharge,90.45,45,,90.45,percent of total billed charges,Critical Access Hospital RCC factor,43.1,,,43.1,Fee Schedule,,38.81,,,38.81,Fee Schedule,,106.19,,,106.19,Fee Schedule,,95.51,,,95.51,Fee Schedule,,90.27,,,90.27,Fee Schedule,,99.5,,,99.5,Other,110% of Medicare,45.11,,,45.11,Fee Schedule,,27,,,27,Other,186% of Medicaid,53.13,,,53.13,Fee Schedule,,124.62,,,124.62,Fee Schedule,,30.07,,,30.07,Fee Schedule,,53.13,,,53.13,Fee Schedule,,124.62,,,124.62,Fee Schedule,,56.56,,,56.56,Fee Schedule,,140.7,70,,140.7,percent of total billed charges,All Other,67.86,,,67.86,Fee Schedule,,57.52,,,57.52,Fee Schedule,,21.48,,,21.48,Fee Schedule,,21.48,,,21.48,Fee Schedule,,21.48,,,21.48,Fee Schedule,,21.48,,,21.48,Fee Schedule,,14.32,,,14.32,Other,100% of Medicaid,14.32,,,14.32,Other,100% of Medicaid,14.32,,,14.32,Other,100% of Medicaid,14.32,,,14.32,Other,100% of Medicaid,32.22,,,32.22,Other,225% of Medicaid,21.91,,,21.91,Other,153% of Medicaid,32.22,,,32.22,Other,225% of Medicaid,20.05,,,20.05,Other,140% of Medicaid,32.22,,,32.22,Other,225% of Medicaid,37.23,,,37.23,Other,260% of Medicaid,46.4,,,46.4,Other,324% of Medicaid,30.79,,,30.79,Other,215% of Medicaid,30.79,,,30.79,Other,215% of Medicaid,17.9,,,17.9,Other,125% of Medicaid,14.32,148.74,
CYSTATIN C,82610,CPT,,78082610,CDM,301,RC,,,both,,,71,52.54,,,52.54,Other,150% of Medicare + 9.63% HCRA Surcharge,31.95,45,,31.95,percent of total billed charges,Critical Access Hospital RCC factor,55.75,,,55.75,Fee Schedule,,50.19,,,50.19,Fee Schedule,,84.21,,,84.21,Fee Schedule,,75.75,,,75.75,Fee Schedule,,71.59,,,71.59,Fee Schedule,,35.15,,,35.15,Other,110% of Medicare,58.34,,,58.34,Fee Schedule,,19,,,19,Other,186% of Medicaid,68.71,,,68.71,Fee Schedule,,44.02,,,44.02,Fee Schedule,,38.89,,,38.89,Fee Schedule,,68.71,,,68.71,Fee Schedule,,44.02,,,44.02,Fee Schedule,,73.15,,,73.15,Fee Schedule,,49.7,70,,49.7,percent of total billed charges,All Other,87.77,,,87.77,Fee Schedule,,74.39,,,74.39,Fee Schedule,,27.78,,,27.78,Fee Schedule,,27.78,,,27.78,Fee Schedule,,27.78,,,27.78,Fee Schedule,,27.78,,,27.78,Fee Schedule,,10.16,,,10.16,Other,100% of Medicaid,10.16,,,10.16,Other,100% of Medicaid,10.16,,,10.16,Other,100% of Medicaid,10.16,,,10.16,Other,100% of Medicaid,22.85,,,22.85,Other,225% of Medicaid,15.54,,,15.54,Other,153% of Medicaid,22.85,,,22.85,Other,225% of Medicaid,14.22,,,14.22,Other,140% of Medicaid,22.85,,,22.85,Other,225% of Medicaid,26.4,,,26.4,Other,260% of Medicaid,32.9,,,32.9,Other,324% of Medicaid,21.83,,,21.83,Other,215% of Medicaid,21.83,,,21.83,Other,215% of Medicaid,12.69,,,12.69,Other,125% of Medicaid,10.16,87.77,
TEST FOR URINE CYSTINES,82615,CPT,,78082615,CDM,301,RC,,,both,,,78,57.72,,,57.72,Other,150% of Medicare + 9.63% HCRA Surcharge,35.1,45,,35.1,percent of total billed charges,Critical Access Hospital RCC factor,28.75,,,28.75,Fee Schedule,,25.88,,,25.88,Fee Schedule,,60.5,,,60.5,Fee Schedule,,54.42,,,54.42,Fee Schedule,,51.43,,,51.43,Fee Schedule,,38.61,,,38.61,Other,110% of Medicare,30.08,,,30.08,Fee Schedule,,13,,,13,Other,186% of Medicaid,35.43,,,35.43,Fee Schedule,,48.36,,,48.36,Fee Schedule,,20.06,,,20.06,Fee Schedule,,35.43,,,35.43,Fee Schedule,,48.36,,,48.36,Fee Schedule,,37.72,,,37.72,Fee Schedule,,54.6,70,,54.6,percent of total billed charges,All Other,45.26,,,45.26,Fee Schedule,,38.36,,,38.36,Fee Schedule,,14.33,,,14.33,Fee Schedule,,14.33,,,14.33,Fee Schedule,,14.33,,,14.33,Fee Schedule,,14.33,,,14.33,Fee Schedule,,7.07,,,7.07,Other,100% of Medicaid,7.07,,,7.07,Other,100% of Medicaid,7.07,,,7.07,Other,100% of Medicaid,7.07,,,7.07,Other,100% of Medicaid,15.91,,,15.91,Other,225% of Medicaid,10.82,,,10.82,Other,153% of Medicaid,15.91,,,15.91,Other,225% of Medicaid,9.9,,,9.9,Other,140% of Medicaid,15.91,,,15.91,Other,225% of Medicaid,18.38,,,18.38,Other,260% of Medicaid,22.91,,,22.91,Other,324% of Medicaid,15.2,,,15.2,Other,215% of Medicaid,15.2,,,15.2,Other,215% of Medicaid,8.84,,,8.84,Other,125% of Medicaid,7.07,60.5,
DHEA,82626,CPT,,78082626,CDM,301,RC,,,both,,,384,284.16,,,284.16,Other,150% of Medicare + 9.63% HCRA Surcharge,172.8,45,,172.8,percent of total billed charges,Critical Access Hospital RCC factor,76.06,,,76.06,Fee Schedule,,68.48,,,68.48,Fee Schedule,,187.4,,,187.4,Fee Schedule,,168.55,,,168.55,Fee Schedule,,159.31,,,159.31,Fee Schedule,,190.08,,,190.08,Other,110% of Medicare,79.6,,,79.6,Fee Schedule,,45,,,45,Other,186% of Medicaid,93.75,,,93.75,Fee Schedule,,238.08,,,238.08,Fee Schedule,,53.07,,,53.07,Fee Schedule,,93.75,,,93.75,Fee Schedule,,238.08,,,238.08,Fee Schedule,,99.82,,,99.82,Fee Schedule,,268.8,70,,268.8,percent of total billed charges,All Other,119.76,,,119.76,Fee Schedule,,101.5,,,101.5,Fee Schedule,,37.91,,,37.91,Fee Schedule,,37.91,,,37.91,Fee Schedule,,37.91,,,37.91,Fee Schedule,,37.91,,,37.91,Fee Schedule,,24.06,,,24.06,Other,100% of Medicaid,24.06,,,24.06,Other,100% of Medicaid,24.06,,,24.06,Other,100% of Medicaid,24.06,,,24.06,Other,100% of Medicaid,54.13,,,54.13,Other,225% of Medicaid,36.81,,,36.81,Other,153% of Medicaid,54.13,,,54.13,Other,225% of Medicaid,33.68,,,33.68,Other,140% of Medicaid,54.13,,,54.13,Other,225% of Medicaid,62.55,,,62.55,Other,260% of Medicaid,77.95,,,77.95,Other,324% of Medicaid,51.73,,,51.73,Other,215% of Medicaid,51.73,,,51.73,Other,215% of Medicaid,30.07,,,30.07,Other,125% of Medicaid,24.06,284.16,
DHEA-S,82627,CPT,,78082627,CDM,301,RC,,,both,,,384,284.16,,,284.16,Other,150% of Medicare + 9.63% HCRA Surcharge,172.8,45,,172.8,percent of total billed charges,Critical Access Hospital RCC factor,66.91,,,66.91,Fee Schedule,,60.24,,,60.24,Fee Schedule,,164.9,,,164.9,Fee Schedule,,148.31,,,148.31,Fee Schedule,,140.18,,,140.18,Fee Schedule,,190.08,,,190.08,Other,110% of Medicare,70.02,,,70.02,Fee Schedule,,41,,,41,Other,186% of Medicaid,82.47,,,82.47,Fee Schedule,,238.08,,,238.08,Fee Schedule,,46.68,,,46.68,Fee Schedule,,82.47,,,82.47,Fee Schedule,,238.08,,,238.08,Fee Schedule,,87.81,,,87.81,Fee Schedule,,268.8,70,,268.8,percent of total billed charges,All Other,105.35,,,105.35,Fee Schedule,,89.29,,,89.29,Fee Schedule,,33.35,,,33.35,Fee Schedule,,33.35,,,33.35,Fee Schedule,,33.35,,,33.35,Fee Schedule,,33.35,,,33.35,Fee Schedule,,22.23,,,22.23,Other,100% of Medicaid,22.23,,,22.23,Other,100% of Medicaid,22.23,,,22.23,Other,100% of Medicaid,22.23,,,22.23,Other,100% of Medicaid,50.02,,,50.02,Other,225% of Medicaid,34.01,,,34.01,Other,153% of Medicaid,50.02,,,50.02,Other,225% of Medicaid,31.12,,,31.12,Other,140% of Medicaid,50.02,,,50.02,Other,225% of Medicaid,57.8,,,57.8,Other,260% of Medicaid,72.03,,,72.03,Other,324% of Medicaid,47.79,,,47.79,Other,215% of Medicaid,47.79,,,47.79,Other,215% of Medicaid,27.79,,,27.79,Other,125% of Medicaid,22.23,284.16,
DESOXYCORTICOSTERONE,82633,CPT,,78082633,CDM,301,RC,,,both,,,98,72.52,,,72.52,Other,150% of Medicare + 9.63% HCRA Surcharge,44.1,45,,44.1,percent of total billed charges,Critical Access Hospital RCC factor,93.25,,,93.25,Fee Schedule,,83.96,,,83.96,Fee Schedule,,229.72,,,229.72,Fee Schedule,,206.62,,,206.62,Fee Schedule,,195.28,,,195.28,Fee Schedule,,48.51,,,48.51,Other,110% of Medicare,97.59,,,97.59,Fee Schedule,,62,,,62,Other,186% of Medicaid,114.94,,,114.94,Fee Schedule,,60.76,,,60.76,Fee Schedule,,65.06,,,65.06,Fee Schedule,,114.94,,,114.94,Fee Schedule,,60.76,,,60.76,Fee Schedule,,122.37,,,122.37,Fee Schedule,,68.6,70,,68.6,percent of total billed charges,All Other,146.82,,,146.82,Fee Schedule,,124.43,,,124.43,Fee Schedule,,46.47,,,46.47,Fee Schedule,,46.47,,,46.47,Fee Schedule,,46.47,,,46.47,Fee Schedule,,46.47,,,46.47,Fee Schedule,,33.57,,,33.57,Other,100% of Medicaid,33.57,,,33.57,Other,100% of Medicaid,33.57,,,33.57,Other,100% of Medicaid,33.57,,,33.57,Other,100% of Medicaid,75.53,,,75.53,Other,225% of Medicaid,51.36,,,51.36,Other,153% of Medicaid,75.53,,,75.53,Other,225% of Medicaid,47,,,47,Other,140% of Medicaid,75.53,,,75.53,Other,225% of Medicaid,87.28,,,87.28,Other,260% of Medicaid,108.76,,,108.76,Other,324% of Medicaid,72.17,,,72.17,Other,215% of Medicaid,72.17,,,72.17,Other,215% of Medicaid,41.96,,,41.96,Other,125% of Medicaid,33.57,229.72,
DEOXYCORTISOL,82634,CPT,,78082634,CDM,301,RC,,,both,,,429,317.46,,,317.46,Other,150% of Medicare + 9.63% HCRA Surcharge,193.05,45,,193.05,percent of total billed charges,Critical Access Hospital RCC factor,88.13,,,88.13,Fee Schedule,,79.35,,,79.35,Fee Schedule,,217.12,,,217.12,Fee Schedule,,195.29,,,195.29,Fee Schedule,,184.58,,,184.58,Fee Schedule,,212.36,,,212.36,Other,110% of Medicare,92.23,,,92.23,Fee Schedule,,28,,,28,Other,186% of Medicaid,108.63,,,108.63,Fee Schedule,,265.98,,,265.98,Fee Schedule,,61.49,,,61.49,Fee Schedule,,108.63,,,108.63,Fee Schedule,,265.98,,,265.98,Fee Schedule,,115.66,,,115.66,Fee Schedule,,300.3,70,,300.3,percent of total billed charges,All Other,138.76,,,138.76,Fee Schedule,,117.61,,,117.61,Fee Schedule,,43.92,,,43.92,Fee Schedule,,43.92,,,43.92,Fee Schedule,,43.92,,,43.92,Fee Schedule,,43.92,,,43.92,Fee Schedule,,15.15,,,15.15,Other,100% of Medicaid,15.15,,,15.15,Other,100% of Medicaid,15.15,,,15.15,Other,100% of Medicaid,15.15,,,15.15,Other,100% of Medicaid,34.09,,,34.09,Other,225% of Medicaid,23.18,,,23.18,Other,153% of Medicaid,34.09,,,34.09,Other,225% of Medicaid,21.21,,,21.21,Other,140% of Medicaid,34.09,,,34.09,Other,225% of Medicaid,39.39,,,39.39,Other,260% of Medicaid,49.09,,,49.09,Other,324% of Medicaid,32.57,,,32.57,Other,215% of Medicaid,32.57,,,32.57,Other,215% of Medicaid,18.94,,,18.94,Other,125% of Medicaid,15.15,317.46,
ASSAY OF DIBUCAINE NUMBER,82638,CPT,,78082638,CDM,301,RC,,,both,,,139,102.86,,,102.86,Other,150% of Medicare + 9.63% HCRA Surcharge,62.55,45,,62.55,percent of total billed charges,Critical Access Hospital RCC factor,36.87,,,36.87,Fee Schedule,,33.2,,,33.2,Fee Schedule,,90.8,,,90.8,Fee Schedule,,81.67,,,81.67,Fee Schedule,,77.19,,,77.19,Fee Schedule,,68.81,,,68.81,Other,110% of Medicare,38.59,,,38.59,Fee Schedule,,19,,,19,Other,186% of Medicaid,45.45,,,45.45,Fee Schedule,,86.18,,,86.18,Fee Schedule,,25.73,,,25.73,Fee Schedule,,45.45,,,45.45,Fee Schedule,,86.18,,,86.18,Fee Schedule,,48.39,,,48.39,Fee Schedule,,97.3,70,,97.3,percent of total billed charges,All Other,58.05,,,58.05,Fee Schedule,,49.2,,,49.2,Fee Schedule,,18.38,,,18.38,Fee Schedule,,18.38,,,18.38,Fee Schedule,,18.38,,,18.38,Fee Schedule,,18.38,,,18.38,Fee Schedule,,10.16,,,10.16,Other,100% of Medicaid,10.16,,,10.16,Other,100% of Medicaid,10.16,,,10.16,Other,100% of Medicaid,10.16,,,10.16,Other,100% of Medicaid,22.85,,,22.85,Other,225% of Medicaid,15.54,,,15.54,Other,153% of Medicaid,22.85,,,22.85,Other,225% of Medicaid,14.22,,,14.22,Other,140% of Medicaid,22.85,,,22.85,Other,225% of Medicaid,26.4,,,26.4,Other,260% of Medicaid,32.9,,,32.9,Other,324% of Medicaid,21.83,,,21.83,Other,215% of Medicaid,21.83,,,21.83,Other,215% of Medicaid,12.69,,,12.69,Other,125% of Medicaid,10.16,102.86,
DIHYDROTESTOSTERONE,82642,CPT,,78082642,CDM,301,RC,,,both,,,93,68.82,,,68.82,Other,150% of Medicare + 9.63% HCRA Surcharge,41.85,45,,41.85,percent of total billed charges,Critical Access Hospital RCC factor,88.13,,,88.13,Fee Schedule,,79.35,,,79.35,Fee Schedule,,32.53,,,32.53,Fee Schedule,,32.53,,,32.53,Fee Schedule,,32.53,,,32.53,Fee Schedule,,46.04,,,46.04,Other,110% of Medicare,92.23,,,92.23,Fee Schedule,,44,,,44,Other,186% of Medicaid,108.63,,,108.63,Fee Schedule,,57.66,,,57.66,Fee Schedule,,61.49,,,61.49,Fee Schedule,,108.63,,,108.63,Fee Schedule,,57.66,,,57.66,Fee Schedule,,115.66,,,115.66,Fee Schedule,,65.1,70,,65.1,percent of total billed charges,All Other,138.76,,,138.76,Fee Schedule,,117.61,,,117.61,Fee Schedule,,43.92,,,43.92,Fee Schedule,,43.92,,,43.92,Fee Schedule,,43.92,,,43.92,Fee Schedule,,43.92,,,43.92,Fee Schedule,,23.84,,,23.84,Other,100% of Medicaid,23.84,,,23.84,Other,100% of Medicaid,23.84,,,23.84,Other,100% of Medicaid,23.84,,,23.84,Other,100% of Medicaid,53.64,,,53.64,Other,225% of Medicaid,36.47,,,36.47,Other,153% of Medicaid,53.64,,,53.64,Other,225% of Medicaid,33.37,,,33.37,Other,140% of Medicaid,53.64,,,53.64,Other,225% of Medicaid,61.98,,,61.98,Other,260% of Medicaid,77.24,,,77.24,Other,324% of Medicaid,51.25,,,51.25,Other,215% of Medicaid,51.25,,,51.25,Other,215% of Medicaid,29.8,,,29.8,Other,125% of Medicaid,23.84,138.76,
VIT D 1 25-DIHYDROXY,82652,CPT,,78082652,CDM,301,RC,,,both,,,760,562.4,,,562.4,Other,150% of Medicare + 9.63% HCRA Surcharge,342,45,,342,percent of total billed charges,Critical Access Hospital RCC factor,115.89,,,115.89,Fee Schedule,,104.34,,,104.34,Fee Schedule,,285.53,,,285.53,Fee Schedule,,256.81,,,256.81,Fee Schedule,,242.73,,,242.73,Fee Schedule,,376.2,,,376.2,Other,110% of Medicare,121.28,,,121.28,Fee Schedule,,59,,,59,Other,186% of Medicaid,142.84,,,142.84,Fee Schedule,,471.2,,,471.2,Fee Schedule,,80.85,,,80.85,Fee Schedule,,142.84,,,142.84,Fee Schedule,,471.2,,,471.2,Fee Schedule,,152.08,,,152.08,Fee Schedule,,532,70,,532,percent of total billed charges,All Other,182.45,,,182.45,Fee Schedule,,154.64,,,154.64,Fee Schedule,,57.75,,,57.75,Fee Schedule,,57.75,,,57.75,Fee Schedule,,57.75,,,57.75,Fee Schedule,,57.75,,,57.75,Fee Schedule,,31.7,,,31.7,Other,100% of Medicaid,31.7,,,31.7,Other,100% of Medicaid,31.7,,,31.7,Other,100% of Medicaid,31.7,,,31.7,Other,100% of Medicaid,71.33,,,71.33,Other,225% of Medicaid,48.51,,,48.51,Other,153% of Medicaid,71.33,,,71.33,Other,225% of Medicaid,44.38,,,44.38,Other,140% of Medicaid,71.33,,,71.33,Other,225% of Medicaid,82.43,,,82.43,Other,260% of Medicaid,102.72,,,102.72,Other,324% of Medicaid,68.16,,,68.16,Other,215% of Medicaid,68.16,,,68.16,Other,215% of Medicaid,39.63,,,39.63,Other,125% of Medicaid,31.7,562.4,
PANCREATIC ELASTASE FECAL,82656,CPT,,78082656,CDM,301,RC,,,both,,,67,49.58,,,49.58,Other,150% of Medicare + 9.63% HCRA Surcharge,30.15,45,,30.15,percent of total billed charges,Critical Access Hospital RCC factor,34.71,,,34.71,Fee Schedule,,31.25,,,31.25,Fee Schedule,,64.87,,,64.87,Fee Schedule,,58.35,,,58.35,Fee Schedule,,55.15,,,55.15,Fee Schedule,,33.17,,,33.17,Other,110% of Medicare,36.32,,,36.32,Fee Schedule,,10,,,10,Other,186% of Medicaid,42.78,,,42.78,Fee Schedule,,41.54,,,41.54,Fee Schedule,,24.21,,,24.21,Fee Schedule,,42.78,,,42.78,Fee Schedule,,41.54,,,41.54,Fee Schedule,,45.54,,,45.54,Fee Schedule,,46.9,70,,46.9,percent of total billed charges,All Other,54.64,,,54.64,Fee Schedule,,46.31,,,46.31,Fee Schedule,,17.3,,,17.3,Fee Schedule,,17.3,,,17.3,Fee Schedule,,17.3,,,17.3,Fee Schedule,,17.3,,,17.3,Fee Schedule,,5.25,,,5.25,Other,100% of Medicaid,5.25,,,5.25,Other,100% of Medicaid,5.25,,,5.25,Other,100% of Medicaid,5.25,,,5.25,Other,100% of Medicaid,11.82,,,11.82,Other,225% of Medicaid,8.04,,,8.04,Other,153% of Medicaid,11.82,,,11.82,Other,225% of Medicaid,7.35,,,7.35,Other,140% of Medicaid,11.82,,,11.82,Other,225% of Medicaid,13.66,,,13.66,Other,260% of Medicaid,17.02,,,17.02,Other,324% of Medicaid,11.29,,,11.29,Other,215% of Medicaid,11.29,,,11.29,Other,215% of Medicaid,6.57,,,6.57,Other,125% of Medicaid,5.25,64.87,
ASSAY OF ERYTHROPOIETIN,82668,CPT,,78082668,CDM,301,RC,,,both,,,312,230.88,,,230.88,Other,150% of Medicare + 9.63% HCRA Surcharge,140.4,45,,140.4,percent of total billed charges,Critical Access Hospital RCC factor,56.56,,,56.56,Fee Schedule,,50.92,,,50.92,Fee Schedule,,139.44,,,139.44,Fee Schedule,,125.42,,,125.42,Fee Schedule,,118.54,,,118.54,Fee Schedule,,154.44,,,154.44,Other,110% of Medicare,59.19,,,59.19,Fee Schedule,,32,,,32,Other,186% of Medicaid,69.71,,,69.71,Fee Schedule,,193.44,,,193.44,Fee Schedule,,39.46,,,39.46,Fee Schedule,,69.71,,,69.71,Fee Schedule,,193.44,,,193.44,Fee Schedule,,74.22,,,74.22,Fee Schedule,,218.4,70,,218.4,percent of total billed charges,All Other,89.05,,,89.05,Fee Schedule,,75.47,,,75.47,Fee Schedule,,28.19,,,28.19,Fee Schedule,,28.19,,,28.19,Fee Schedule,,28.19,,,28.19,Fee Schedule,,28.19,,,28.19,Fee Schedule,,17.23,,,17.23,Other,100% of Medicaid,17.23,,,17.23,Other,100% of Medicaid,17.23,,,17.23,Other,100% of Medicaid,17.23,,,17.23,Other,100% of Medicaid,38.77,,,38.77,Other,225% of Medicaid,26.36,,,26.36,Other,153% of Medicaid,38.77,,,38.77,Other,225% of Medicaid,24.12,,,24.12,Other,140% of Medicaid,38.77,,,38.77,Other,225% of Medicaid,44.8,,,44.8,Other,260% of Medicaid,55.83,,,55.83,Other,324% of Medicaid,37.05,,,37.05,Other,215% of Medicaid,37.05,,,37.05,Other,215% of Medicaid,21.54,,,21.54,Other,125% of Medicaid,17.23,230.88,
ASSAY OF ESTRADIOL,82670,CPT,,78082670,CDM,301,RC,,,both,,,373,276.02,,,276.02,Other,150% of Medicare + 9.63% HCRA Surcharge,167.85,45,,167.85,percent of total billed charges,Critical Access Hospital RCC factor,84.1,,,84.1,Fee Schedule,,75.72,,,75.72,Fee Schedule,,207.22,,,207.22,Fee Schedule,,186.38,,,186.38,Fee Schedule,,176.15,,,176.15,Fee Schedule,,184.64,,,184.64,Other,110% of Medicare,88.01,,,88.01,Fee Schedule,,52,,,52,Other,186% of Medicaid,103.66,,,103.66,Fee Schedule,,231.26,,,231.26,Fee Schedule,,58.67,,,58.67,Fee Schedule,,103.66,,,103.66,Fee Schedule,,231.26,,,231.26,Fee Schedule,,110.36,,,110.36,Fee Schedule,,261.1,70,,261.1,percent of total billed charges,All Other,132.41,,,132.41,Fee Schedule,,112.22,,,112.22,Fee Schedule,,41.91,,,41.91,Fee Schedule,,41.91,,,41.91,Fee Schedule,,41.91,,,41.91,Fee Schedule,,41.91,,,41.91,Fee Schedule,,27.94,,,27.94,Other,100% of Medicaid,27.94,,,27.94,Other,100% of Medicaid,27.94,,,27.94,Other,100% of Medicaid,27.94,,,27.94,Other,100% of Medicaid,62.87,,,62.87,Other,225% of Medicaid,42.75,,,42.75,Other,153% of Medicaid,62.87,,,62.87,Other,225% of Medicaid,39.12,,,39.12,Other,140% of Medicaid,62.87,,,62.87,Other,225% of Medicaid,72.64,,,72.64,Other,260% of Medicaid,90.53,,,90.53,Other,324% of Medicaid,60.07,,,60.07,Other,215% of Medicaid,60.07,,,60.07,Other,215% of Medicaid,34.93,,,34.93,Other,125% of Medicaid,27.94,276.02,
ASSAY OF ESTROGENS,82671,CPT,,78082671,CDM,301,RC,,,both,,,504,372.96,,,372.96,Other,150% of Medicare + 9.63% HCRA Surcharge,226.8,45,,226.8,percent of total billed charges,Critical Access Hospital RCC factor,97.22,,,97.22,Fee Schedule,,87.53,,,87.53,Fee Schedule,,239.52,,,239.52,Fee Schedule,,215.43,,,215.43,Fee Schedule,,203.62,,,203.62,Fee Schedule,,249.48,,,249.48,Other,110% of Medicare,101.75,,,101.75,Fee Schedule,,62,,,62,Other,186% of Medicaid,119.83,,,119.83,Fee Schedule,,312.48,,,312.48,Fee Schedule,,67.83,,,67.83,Fee Schedule,,119.83,,,119.83,Fee Schedule,,312.48,,,312.48,Fee Schedule,,127.59,,,127.59,Fee Schedule,,352.8,70,,352.8,percent of total billed charges,All Other,153.07,,,153.07,Fee Schedule,,129.74,,,129.74,Fee Schedule,,48.45,,,48.45,Fee Schedule,,48.45,,,48.45,Fee Schedule,,48.45,,,48.45,Fee Schedule,,48.45,,,48.45,Fee Schedule,,33.57,,,33.57,Other,100% of Medicaid,33.57,,,33.57,Other,100% of Medicaid,33.57,,,33.57,Other,100% of Medicaid,33.57,,,33.57,Other,100% of Medicaid,75.53,,,75.53,Other,225% of Medicaid,51.36,,,51.36,Other,153% of Medicaid,75.53,,,75.53,Other,225% of Medicaid,47,,,47,Other,140% of Medicaid,75.53,,,75.53,Other,225% of Medicaid,87.28,,,87.28,Other,260% of Medicaid,108.76,,,108.76,Other,324% of Medicaid,72.17,,,72.17,Other,215% of Medicaid,72.17,,,72.17,Other,215% of Medicaid,41.96,,,41.96,Other,125% of Medicaid,33.57,372.96,
ASSAY OF ESTROGEN,82672,CPT,,78082672,CDM,301,RC,,,both,,,352,260.48,,,260.48,Other,150% of Medicare + 9.63% HCRA Surcharge,158.4,45,,158.4,percent of total billed charges,Critical Access Hospital RCC factor,65.32,,,65.32,Fee Schedule,,58.81,,,58.81,Fee Schedule,,160.89,,,160.89,Fee Schedule,,144.71,,,144.71,Fee Schedule,,136.77,,,136.77,Fee Schedule,,174.24,,,174.24,Other,110% of Medicare,68.36,,,68.36,Fee Schedule,,40,,,40,Other,186% of Medicaid,80.51,,,80.51,Fee Schedule,,218.24,,,218.24,Fee Schedule,,45.57,,,45.57,Fee Schedule,,80.51,,,80.51,Fee Schedule,,218.24,,,218.24,Fee Schedule,,85.72,,,85.72,Fee Schedule,,246.4,70,,246.4,percent of total billed charges,All Other,102.84,,,102.84,Fee Schedule,,87.16,,,87.16,Fee Schedule,,32.55,,,32.55,Fee Schedule,,32.55,,,32.55,Fee Schedule,,32.55,,,32.55,Fee Schedule,,32.55,,,32.55,Fee Schedule,,21.7,,,21.7,Other,100% of Medicaid,21.7,,,21.7,Other,100% of Medicaid,21.7,,,21.7,Other,100% of Medicaid,21.7,,,21.7,Other,100% of Medicaid,48.83,,,48.83,Other,225% of Medicaid,33.2,,,33.2,Other,153% of Medicaid,48.83,,,48.83,Other,225% of Medicaid,30.38,,,30.38,Other,140% of Medicaid,48.83,,,48.83,Other,225% of Medicaid,56.42,,,56.42,Other,260% of Medicaid,70.31,,,70.31,Other,324% of Medicaid,46.66,,,46.66,Other,215% of Medicaid,46.66,,,46.66,Other,215% of Medicaid,27.13,,,27.13,Other,125% of Medicaid,21.7,260.48,
ASSAY OF ESTRIOL,82677,CPT,,78082677,CDM,301,RC,,,both,,,213,157.62,,,157.62,Other,150% of Medicare + 9.63% HCRA Surcharge,95.85,45,,95.85,percent of total billed charges,Critical Access Hospital RCC factor,72.78,,,72.78,Fee Schedule,,65.53,,,65.53,Fee Schedule,,179.34,,,179.34,Fee Schedule,,161.3,,,161.3,Fee Schedule,,152.45,,,152.45,Fee Schedule,,105.44,,,105.44,Other,110% of Medicare,76.17,,,76.17,Fee Schedule,,33,,,33,Other,186% of Medicaid,89.71,,,89.71,Fee Schedule,,132.06,,,132.06,Fee Schedule,,50.78,,,50.78,Fee Schedule,,89.71,,,89.71,Fee Schedule,,132.06,,,132.06,Fee Schedule,,95.51,,,95.51,Fee Schedule,,149.1,70,,149.1,percent of total billed charges,All Other,114.59,,,114.59,Fee Schedule,,97.12,,,97.12,Fee Schedule,,36.27,,,36.27,Fee Schedule,,36.27,,,36.27,Fee Schedule,,36.27,,,36.27,Fee Schedule,,36.27,,,36.27,Fee Schedule,,17.68,,,17.68,Other,100% of Medicaid,17.68,,,17.68,Other,100% of Medicaid,17.68,,,17.68,Other,100% of Medicaid,17.68,,,17.68,Other,100% of Medicaid,39.77,,,39.77,Other,225% of Medicaid,27.04,,,27.04,Other,153% of Medicaid,39.77,,,39.77,Other,225% of Medicaid,24.75,,,24.75,Other,140% of Medicaid,39.77,,,39.77,Other,225% of Medicaid,45.96,,,45.96,Other,260% of Medicaid,57.27,,,57.27,Other,324% of Medicaid,38,,,38,Other,215% of Medicaid,38,,,38,Other,215% of Medicaid,22.09,,,22.09,Other,125% of Medicaid,17.68,179.34,
ASSAY OF ESTRONE,82679,CPT,,78082679,CDM,301,RC,,,both,,,280,207.2,,,207.2,Other,150% of Medicare + 9.63% HCRA Surcharge,126,45,,126,percent of total billed charges,Critical Access Hospital RCC factor,75.1,,,75.1,Fee Schedule,,67.61,,,67.61,Fee Schedule,,185.08,,,185.08,Fee Schedule,,166.47,,,166.47,Fee Schedule,,157.34,,,157.34,Fee Schedule,,138.6,,,138.6,Other,110% of Medicare,78.59,,,78.59,Fee Schedule,,46,,,46,Other,186% of Medicaid,92.56,,,92.56,Fee Schedule,,173.6,,,173.6,Fee Schedule,,52.4,,,52.4,Fee Schedule,,92.56,,,92.56,Fee Schedule,,173.6,,,173.6,Fee Schedule,,98.55,,,98.55,Fee Schedule,,196,70,,196,percent of total billed charges,All Other,118.24,,,118.24,Fee Schedule,,100.21,,,100.21,Fee Schedule,,37.43,,,37.43,Fee Schedule,,37.43,,,37.43,Fee Schedule,,37.43,,,37.43,Fee Schedule,,37.43,,,37.43,Fee Schedule,,24.95,,,24.95,Other,100% of Medicaid,24.95,,,24.95,Other,100% of Medicaid,24.95,,,24.95,Other,100% of Medicaid,24.95,,,24.95,Other,100% of Medicaid,56.14,,,56.14,Other,225% of Medicaid,38.17,,,38.17,Other,153% of Medicaid,56.14,,,56.14,Other,225% of Medicaid,34.93,,,34.93,Other,140% of Medicaid,56.14,,,56.14,Other,225% of Medicaid,64.87,,,64.87,Other,260% of Medicaid,80.84,,,80.84,Other,324% of Medicaid,53.64,,,53.64,Other,215% of Medicaid,53.64,,,53.64,Other,215% of Medicaid,31.19,,,31.19,Other,125% of Medicaid,24.95,207.2,
ASSAY OF ETHYLENE GLYCOL,82693,CPT,,78082693,CDM,301,RC,,,both,,,210,155.4,,,155.4,Other,150% of Medicare + 9.63% HCRA Surcharge,94.5,45,,94.5,percent of total billed charges,Critical Access Hospital RCC factor,44.85,,,44.85,Fee Schedule,,40.38,,,40.38,Fee Schedule,,110.46,,,110.46,Fee Schedule,,99.35,,,99.35,Fee Schedule,,93.9,,,93.9,Fee Schedule,,103.95,,,103.95,Other,110% of Medicare,46.94,,,46.94,Fee Schedule,,33,,,33,Other,186% of Medicaid,55.28,,,55.28,Fee Schedule,,130.2,,,130.2,Fee Schedule,,31.29,,,31.29,Fee Schedule,,55.28,,,55.28,Fee Schedule,,130.2,,,130.2,Fee Schedule,,58.86,,,58.86,Fee Schedule,,147,70,,147,percent of total billed charges,All Other,70.61,,,70.61,Fee Schedule,,59.85,,,59.85,Fee Schedule,,22.35,,,22.35,Fee Schedule,,22.35,,,22.35,Fee Schedule,,22.35,,,22.35,Fee Schedule,,22.35,,,22.35,Fee Schedule,,17.86,,,17.86,Other,100% of Medicaid,17.86,,,17.86,Other,100% of Medicaid,17.86,,,17.86,Other,100% of Medicaid,17.86,,,17.86,Other,100% of Medicaid,40.19,,,40.19,Other,225% of Medicaid,27.33,,,27.33,Other,153% of Medicaid,40.19,,,40.19,Other,225% of Medicaid,25.01,,,25.01,Other,140% of Medicaid,40.19,,,40.19,Other,225% of Medicaid,46.45,,,46.45,Other,260% of Medicaid,57.88,,,57.88,Other,324% of Medicaid,38.41,,,38.41,Other,215% of Medicaid,38.41,,,38.41,Other,215% of Medicaid,22.33,,,22.33,Other,125% of Medicaid,17.86,155.4,
FATS/LIPIDS FECES QUAL,82705,CPT,,78082705,CDM,301,RC,,,both,,,87,64.38,,,64.38,Other,150% of Medicare + 9.63% HCRA Surcharge,39.15,45,,39.15,percent of total billed charges,Critical Access Hospital RCC factor,15.35,,,15.35,Fee Schedule,,13.82,,,13.82,Fee Schedule,,37.73,,,37.73,Fee Schedule,,33.94,,,33.94,Fee Schedule,,32.08,,,32.08,Fee Schedule,,43.07,,,43.07,Other,110% of Medicare,16.07,,,16.07,Fee Schedule,,9,,,9,Other,186% of Medicaid,18.92,,,18.92,Fee Schedule,,53.94,,,53.94,Fee Schedule,,10.71,,,10.71,Fee Schedule,,18.92,,,18.92,Fee Schedule,,53.94,,,53.94,Fee Schedule,,20.15,,,20.15,Fee Schedule,,60.9,70,,60.9,percent of total billed charges,All Other,24.17,,,24.17,Fee Schedule,,20.48,,,20.48,Fee Schedule,,7.65,,,7.65,Fee Schedule,,7.65,,,7.65,Fee Schedule,,7.65,,,7.65,Fee Schedule,,7.65,,,7.65,Fee Schedule,,5.1,,,5.1,Other,100% of Medicaid,5.1,,,5.1,Other,100% of Medicaid,5.1,,,5.1,Other,100% of Medicaid,5.1,,,5.1,Other,100% of Medicaid,11.48,,,11.48,Other,225% of Medicaid,7.8,,,7.8,Other,153% of Medicaid,11.48,,,11.48,Other,225% of Medicaid,7.14,,,7.14,Other,140% of Medicaid,11.48,,,11.48,Other,225% of Medicaid,13.26,,,13.26,Other,260% of Medicaid,16.52,,,16.52,Other,324% of Medicaid,10.97,,,10.97,Other,215% of Medicaid,10.97,,,10.97,Other,215% of Medicaid,6.38,,,6.38,Other,125% of Medicaid,5.1,64.38,
FATS/LIPIDS FECES QUANT,82710,CPT,,78082710,CDM,301,RC,,,both,,,239,176.86,,,176.86,Other,150% of Medicare + 9.63% HCRA Surcharge,107.55,45,,107.55,percent of total billed charges,Critical Access Hospital RCC factor,50.57,,,50.57,Fee Schedule,,45.53,,,45.53,Fee Schedule,,124.58,,,124.58,Fee Schedule,,112.05,,,112.05,Fee Schedule,,105.91,,,105.91,Fee Schedule,,118.31,,,118.31,Other,110% of Medicare,52.92,,,52.92,Fee Schedule,,31,,,31,Other,186% of Medicaid,62.33,,,62.33,Fee Schedule,,148.18,,,148.18,Fee Schedule,,35.28,,,35.28,Fee Schedule,,62.33,,,62.33,Fee Schedule,,148.18,,,148.18,Fee Schedule,,66.36,,,66.36,Fee Schedule,,167.3,70,,167.3,percent of total billed charges,All Other,79.62,,,79.62,Fee Schedule,,67.48,,,67.48,Fee Schedule,,25.2,,,25.2,Fee Schedule,,25.2,,,25.2,Fee Schedule,,25.2,,,25.2,Fee Schedule,,25.2,,,25.2,Fee Schedule,,16.8,,,16.8,Other,100% of Medicaid,16.8,,,16.8,Other,100% of Medicaid,16.8,,,16.8,Other,100% of Medicaid,16.8,,,16.8,Other,100% of Medicaid,37.8,,,37.8,Other,225% of Medicaid,25.7,,,25.7,Other,153% of Medicaid,37.8,,,37.8,Other,225% of Medicaid,23.52,,,23.52,Other,140% of Medicaid,37.8,,,37.8,Other,225% of Medicaid,43.68,,,43.68,Other,260% of Medicaid,54.43,,,54.43,Other,324% of Medicaid,36.12,,,36.12,Other,215% of Medicaid,36.12,,,36.12,Other,215% of Medicaid,21,,,21,Other,125% of Medicaid,16.8,176.86,
Fatty Acids Nonesterified,82725,CPT,,78082725,CDM,301,RC,,,both,,,350,259,,,259,Other,150% of Medicare + 9.63% HCRA Surcharge,157.5,45,,157.5,percent of total billed charges,Critical Access Hospital RCC factor,56.5,,,56.5,Fee Schedule,,50.87,,,50.87,Fee Schedule,,98.76,,,98.76,Fee Schedule,,88.83,,,88.83,Fee Schedule,,83.96,,,83.96,Fee Schedule,,173.25,,,173.25,Other,110% of Medicare,59.13,,,59.13,Fee Schedule,,19,,,19,Other,186% of Medicaid,69.64,,,69.64,Fee Schedule,,217,,,217,Fee Schedule,,39.42,,,39.42,Fee Schedule,,69.64,,,69.64,Fee Schedule,,217,,,217,Fee Schedule,,74.14,,,74.14,Fee Schedule,,245,70,,245,percent of total billed charges,All Other,88.95,,,88.95,Fee Schedule,,75.39,,,75.39,Fee Schedule,,28.16,,,28.16,Fee Schedule,,28.16,,,28.16,Fee Schedule,,28.16,,,28.16,Fee Schedule,,28.16,,,28.16,Fee Schedule,,10.16,,,10.16,Other,100% of Medicaid,10.16,,,10.16,Other,100% of Medicaid,10.16,,,10.16,Other,100% of Medicaid,10.16,,,10.16,Other,100% of Medicaid,22.85,,,22.85,Other,225% of Medicaid,15.54,,,15.54,Other,153% of Medicaid,22.85,,,22.85,Other,225% of Medicaid,14.22,,,14.22,Other,140% of Medicaid,22.85,,,22.85,Other,225% of Medicaid,26.4,,,26.4,Other,260% of Medicaid,32.9,,,32.9,Other,324% of Medicaid,21.83,,,21.83,Other,215% of Medicaid,21.83,,,21.83,Other,215% of Medicaid,12.69,,,12.69,Other,125% of Medicaid,10.16,259,
LONG CHAIN FATTY ACIDS,82726,CPT,,78082726,CDM,301,RC,,,both,,,63,46.62,,,46.62,Other,150% of Medicare + 9.63% HCRA Surcharge,28.35,45,,28.35,percent of total billed charges,Critical Access Hospital RCC factor,59.45,,,59.45,Fee Schedule,,53.52,,,53.52,Fee Schedule,,133.91,,,133.91,Fee Schedule,,120.44,,,120.44,Fee Schedule,,113.84,,,113.84,Fee Schedule,,31.19,,,31.19,Other,110% of Medicare,62.21,,,62.21,Fee Schedule,,37,,,37,Other,186% of Medicaid,73.27,,,73.27,Fee Schedule,,39.06,,,39.06,Fee Schedule,,41.48,,,41.48,Fee Schedule,,73.27,,,73.27,Fee Schedule,,39.06,,,39.06,Fee Schedule,,78.01,,,78.01,Fee Schedule,,44.1,70,,44.1,percent of total billed charges,All Other,93.6,,,93.6,Fee Schedule,,79.33,,,79.33,Fee Schedule,,29.63,,,29.63,Fee Schedule,,29.63,,,29.63,Fee Schedule,,29.63,,,29.63,Fee Schedule,,29.63,,,29.63,Fee Schedule,,19.75,,,19.75,Other,100% of Medicaid,19.75,,,19.75,Other,100% of Medicaid,19.75,,,19.75,Other,100% of Medicaid,19.75,,,19.75,Other,100% of Medicaid,44.44,,,44.44,Other,225% of Medicaid,30.22,,,30.22,Other,153% of Medicaid,44.44,,,44.44,Other,225% of Medicaid,27.65,,,27.65,Other,140% of Medicaid,44.44,,,44.44,Other,225% of Medicaid,51.35,,,51.35,Other,260% of Medicaid,63.99,,,63.99,Other,324% of Medicaid,42.46,,,42.46,Other,215% of Medicaid,42.46,,,42.46,Other,215% of Medicaid,24.69,,,24.69,Other,125% of Medicaid,19.75,133.91,
ASSAY OF FERRITIN,82728,CPT,,78082728,CDM,301,RC,,,both,,,196,145.04,,,145.04,Other,150% of Medicare + 9.63% HCRA Surcharge,88.2,45,,88.2,percent of total billed charges,Critical Access Hospital RCC factor,41.03,,,41.03,Fee Schedule,,36.94,,,36.94,Fee Schedule,,101.03,,,101.03,Fee Schedule,,90.87,,,90.87,Fee Schedule,,85.88,,,85.88,Fee Schedule,,97.02,,,97.02,Other,110% of Medicare,42.93,,,42.93,Fee Schedule,,25,,,25,Other,186% of Medicaid,50.57,,,50.57,Fee Schedule,,121.52,,,121.52,Fee Schedule,,28.62,,,28.62,Fee Schedule,,50.57,,,50.57,Fee Schedule,,121.52,,,121.52,Fee Schedule,,53.84,,,53.84,Fee Schedule,,137.2,70,,137.2,percent of total billed charges,All Other,64.59,,,64.59,Fee Schedule,,54.75,,,54.75,Fee Schedule,,20.45,,,20.45,Fee Schedule,,20.45,,,20.45,Fee Schedule,,20.45,,,20.45,Fee Schedule,,20.45,,,20.45,Fee Schedule,,13.63,,,13.63,Other,100% of Medicaid,13.63,,,13.63,Other,100% of Medicaid,13.63,,,13.63,Other,100% of Medicaid,13.63,,,13.63,Other,100% of Medicaid,30.67,,,30.67,Other,225% of Medicaid,20.85,,,20.85,Other,153% of Medicaid,30.67,,,30.67,Other,225% of Medicaid,19.08,,,19.08,Other,140% of Medicaid,30.67,,,30.67,Other,225% of Medicaid,35.44,,,35.44,Other,260% of Medicaid,44.16,,,44.16,Other,324% of Medicaid,29.3,,,29.3,Other,215% of Medicaid,29.3,,,29.3,Other,215% of Medicaid,17.04,,,17.04,Other,125% of Medicaid,13.63,145.04,
ASSAY OF FETAL FIBRONECTIN,82731,CPT,,78082731,CDM,301,RC,,,both,,,204,150.96,,,150.96,Other,150% of Medicare + 9.63% HCRA Surcharge,91.8,45,,91.8,percent of total billed charges,Critical Access Hospital RCC factor,193.87,,,193.87,Fee Schedule,,174.55,,,174.55,Fee Schedule,,466.55,,,466.55,Fee Schedule,,419.63,,,419.63,Fee Schedule,,396.61,,,396.61,Fee Schedule,,100.98,,,100.98,Other,110% of Medicare,202.89,,,202.89,Fee Schedule,,120,,,120,Other,186% of Medicaid,238.96,,,238.96,Fee Schedule,,126.48,,,126.48,Fee Schedule,,135.26,,,135.26,Fee Schedule,,238.96,,,238.96,Fee Schedule,,126.48,,,126.48,Fee Schedule,,254.42,,,254.42,Fee Schedule,,142.8,70,,142.8,percent of total billed charges,All Other,305.24,,,305.24,Fee Schedule,,258.71,,,258.71,Fee Schedule,,96.62,,,96.62,Fee Schedule,,96.62,,,96.62,Fee Schedule,,96.62,,,96.62,Fee Schedule,,96.62,,,96.62,Fee Schedule,,64.41,,,64.41,Other,100% of Medicaid,64.41,,,64.41,Other,100% of Medicaid,64.41,,,64.41,Other,100% of Medicaid,64.41,,,64.41,Other,100% of Medicaid,144.92,,,144.92,Other,225% of Medicaid,98.55,,,98.55,Other,153% of Medicaid,144.92,,,144.92,Other,225% of Medicaid,90.17,,,90.17,Other,140% of Medicaid,144.92,,,144.92,Other,225% of Medicaid,167.47,,,167.47,Other,260% of Medicaid,208.69,,,208.69,Other,324% of Medicaid,138.48,,,138.48,Other,215% of Medicaid,138.48,,,138.48,Other,215% of Medicaid,80.51,,,80.51,Other,125% of Medicaid,64.41,466.55,
BLOOD FOLIC ACID SERUM,82746,CPT,,78082746,CDM,301,RC,,,both,,,197,145.78,,,145.78,Other,150% of Medicare + 9.63% HCRA Surcharge,88.65,45,,88.65,percent of total billed charges,Critical Access Hospital RCC factor,44.25,,,44.25,Fee Schedule,,39.84,,,39.84,Fee Schedule,,109.04,,,109.04,Fee Schedule,,98.07,,,98.07,Fee Schedule,,92.69,,,92.69,Fee Schedule,,97.52,,,97.52,Other,110% of Medicare,46.31,,,46.31,Fee Schedule,,23,,,23,Other,186% of Medicaid,54.54,,,54.54,Fee Schedule,,122.14,,,122.14,Fee Schedule,,30.87,,,30.87,Fee Schedule,,54.54,,,54.54,Fee Schedule,,122.14,,,122.14,Fee Schedule,,58.07,,,58.07,Fee Schedule,,137.9,70,,137.9,percent of total billed charges,All Other,69.66,,,69.66,Fee Schedule,,59.04,,,59.04,Fee Schedule,,22.05,,,22.05,Fee Schedule,,22.05,,,22.05,Fee Schedule,,22.05,,,22.05,Fee Schedule,,22.05,,,22.05,Fee Schedule,,12.63,,,12.63,Other,100% of Medicaid,12.63,,,12.63,Other,100% of Medicaid,12.63,,,12.63,Other,100% of Medicaid,12.63,,,12.63,Other,100% of Medicaid,28.41,,,28.41,Other,225% of Medicaid,19.32,,,19.32,Other,153% of Medicaid,28.41,,,28.41,Other,225% of Medicaid,17.68,,,17.68,Other,140% of Medicaid,28.41,,,28.41,Other,225% of Medicaid,32.83,,,32.83,Other,260% of Medicaid,40.91,,,40.91,Other,324% of Medicaid,27.14,,,27.14,Other,215% of Medicaid,27.14,,,27.14,Other,215% of Medicaid,15.78,,,15.78,Other,125% of Medicaid,12.63,145.78,
ASSAY OF FOLIC ACID RBC,82747,CPT,,78082747,CDM,301,RC,,,both,,,298,220.52,,,220.52,Other,150% of Medicare + 9.63% HCRA Surcharge,134.1,45,,134.1,percent of total billed charges,Critical Access Hospital RCC factor,53.13,,,53.13,Fee Schedule,,47.83,,,47.83,Fee Schedule,,86.32,,,86.32,Fee Schedule,,77.64,,,77.64,Fee Schedule,,73.38,,,73.38,Fee Schedule,,147.51,,,147.51,Other,110% of Medicare,55.6,,,55.6,Fee Schedule,,23,,,23,Other,186% of Medicaid,65.48,,,65.48,Fee Schedule,,184.76,,,184.76,Fee Schedule,,37.07,,,37.07,Fee Schedule,,65.48,,,65.48,Fee Schedule,,184.76,,,184.76,Fee Schedule,,69.72,,,69.72,Fee Schedule,,208.6,70,,208.6,percent of total billed charges,All Other,83.64,,,83.64,Fee Schedule,,70.89,,,70.89,Fee Schedule,,26.48,,,26.48,Fee Schedule,,26.48,,,26.48,Fee Schedule,,26.48,,,26.48,Fee Schedule,,26.48,,,26.48,Fee Schedule,,12.63,,,12.63,Other,100% of Medicaid,12.63,,,12.63,Other,100% of Medicaid,12.63,,,12.63,Other,100% of Medicaid,12.63,,,12.63,Other,100% of Medicaid,28.41,,,28.41,Other,225% of Medicaid,19.32,,,19.32,Other,153% of Medicaid,28.41,,,28.41,Other,225% of Medicaid,17.68,,,17.68,Other,140% of Medicaid,28.41,,,28.41,Other,225% of Medicaid,32.83,,,32.83,Other,260% of Medicaid,40.91,,,40.91,Other,324% of Medicaid,27.14,,,27.14,Other,215% of Medicaid,27.14,,,27.14,Other,215% of Medicaid,15.78,,,15.78,Other,125% of Medicaid,12.63,220.52,
ASSAY OF SEMEN FRUCTOSE,82757,CPT,,78082757,CDM,301,RC,,,both,,,37,27.38,,,27.38,Other,150% of Medicare + 9.63% HCRA Surcharge,16.65,45,,16.65,percent of total billed charges,Critical Access Hospital RCC factor,52.19,,,52.19,Fee Schedule,,46.99,,,46.99,Fee Schedule,,128.64,,,128.64,Fee Schedule,,115.7,,,115.7,Fee Schedule,,109.36,,,109.36,Fee Schedule,,18.32,,,18.32,Other,110% of Medicare,54.62,,,54.62,Fee Schedule,,19,,,19,Other,186% of Medicaid,64.33,,,64.33,Fee Schedule,,22.94,,,22.94,Fee Schedule,,36.41,,,36.41,Fee Schedule,,64.33,,,64.33,Fee Schedule,,22.94,,,22.94,Fee Schedule,,68.49,,,68.49,Fee Schedule,,25.9,70,,25.9,percent of total billed charges,All Other,82.17,,,82.17,Fee Schedule,,69.65,,,69.65,Fee Schedule,,26.01,,,26.01,Fee Schedule,,26.01,,,26.01,Fee Schedule,,26.01,,,26.01,Fee Schedule,,26.01,,,26.01,Fee Schedule,,10.16,,,10.16,Other,100% of Medicaid,10.16,,,10.16,Other,100% of Medicaid,10.16,,,10.16,Other,100% of Medicaid,10.16,,,10.16,Other,100% of Medicaid,22.85,,,22.85,Other,225% of Medicaid,15.54,,,15.54,Other,153% of Medicaid,22.85,,,22.85,Other,225% of Medicaid,14.22,,,14.22,Other,140% of Medicaid,22.85,,,22.85,Other,225% of Medicaid,26.4,,,26.4,Other,260% of Medicaid,32.9,,,32.9,Other,324% of Medicaid,21.83,,,21.83,Other,215% of Medicaid,21.83,,,21.83,Other,215% of Medicaid,12.69,,,12.69,Other,125% of Medicaid,10.16,128.64,
ASSAY GALACTOSE TRANSFERASE,82775,CPT,,78082775,CDM,301,RC,,,both,,,68,50.32,,,50.32,Other,150% of Medicare + 9.63% HCRA Surcharge,30.6,45,,30.6,percent of total billed charges,Critical Access Hospital RCC factor,63.42,,,63.42,Fee Schedule,,57.1,,,57.1,Fee Schedule,,156.2,,,156.2,Fee Schedule,,140.49,,,140.49,Fee Schedule,,132.79,,,132.79,Fee Schedule,,33.66,,,33.66,Other,110% of Medicare,66.37,,,66.37,Fee Schedule,,39,,,39,Other,186% of Medicaid,78.17,,,78.17,Fee Schedule,,42.16,,,42.16,Fee Schedule,,44.25,,,44.25,Fee Schedule,,78.17,,,78.17,Fee Schedule,,42.16,,,42.16,Fee Schedule,,83.23,,,83.23,Fee Schedule,,47.6,70,,47.6,percent of total billed charges,All Other,99.85,,,99.85,Fee Schedule,,84.63,,,84.63,Fee Schedule,,31.61,,,31.61,Fee Schedule,,31.61,,,31.61,Fee Schedule,,31.61,,,31.61,Fee Schedule,,31.61,,,31.61,Fee Schedule,,21.07,,,21.07,Other,100% of Medicaid,21.07,,,21.07,Other,100% of Medicaid,21.07,,,21.07,Other,100% of Medicaid,21.07,,,21.07,Other,100% of Medicaid,47.41,,,47.41,Other,225% of Medicaid,32.24,,,32.24,Other,153% of Medicaid,47.41,,,47.41,Other,225% of Medicaid,29.5,,,29.5,Other,140% of Medicaid,47.41,,,47.41,Other,225% of Medicaid,54.78,,,54.78,Other,260% of Medicaid,68.27,,,68.27,Other,324% of Medicaid,45.3,,,45.3,Other,215% of Medicaid,45.3,,,45.3,Other,215% of Medicaid,26.34,,,26.34,Other,125% of Medicaid,21.07,156.2,
GALECTIN-3,82777,CPT,,78082777,CDM,301,RC,,,both,,,140,103.6,,,103.6,Other,150% of Medicare + 9.63% HCRA Surcharge,63,45,,63,percent of total billed charges,Critical Access Hospital RCC factor,133.19,,,133.19,Fee Schedule,,119.92,,,119.92,Fee Schedule,,7.12,,,7.12,Fee Schedule,,7.12,,,7.12,Fee Schedule,,7.12,,,7.12,Fee Schedule,,69.3,,,69.3,Other,110% of Medicare,139.39,,,139.39,Fee Schedule,,59,,,59,Other,186% of Medicaid,164.17,,,164.17,Fee Schedule,,86.8,,,86.8,Fee Schedule,,92.93,,,92.93,Fee Schedule,,164.17,,,164.17,Fee Schedule,,86.8,,,86.8,Fee Schedule,,174.79,,,174.79,Fee Schedule,,98,70,,98,percent of total billed charges,All Other,209.7,,,209.7,Fee Schedule,,177.74,,,177.74,Fee Schedule,,66.38,,,66.38,Fee Schedule,,66.38,,,66.38,Fee Schedule,,66.38,,,66.38,Fee Schedule,,66.38,,,66.38,Fee Schedule,,31.7,,,31.7,Other,100% of Medicaid,31.7,,,31.7,Other,100% of Medicaid,31.7,,,31.7,Other,100% of Medicaid,31.7,,,31.7,Other,100% of Medicaid,71.33,,,71.33,Other,225% of Medicaid,48.51,,,48.51,Other,153% of Medicaid,71.33,,,71.33,Other,225% of Medicaid,44.38,,,44.38,Other,140% of Medicaid,71.33,,,71.33,Other,225% of Medicaid,82.43,,,82.43,Other,260% of Medicaid,102.72,,,102.72,Other,324% of Medicaid,68.16,,,68.16,Other,215% of Medicaid,68.16,,,68.16,Other,215% of Medicaid,39.63,,,39.63,Other,125% of Medicaid,7.12,209.7,
BLOOD GAS MIXED WO O2 SAT,82803,CPT,,78082803,CDM,301,RC,,,both,,,377,278.98,,,278.98,Other,150% of Medicare + 9.63% HCRA Surcharge,169.65,45,,169.65,percent of total billed charges,Critical Access Hospital RCC factor,78.47,,,78.47,Fee Schedule,,70.65,,,70.65,Fee Schedule,,143.45,,,143.45,Fee Schedule,,129.02,,,129.02,Fee Schedule,,121.95,,,121.95,Fee Schedule,,186.62,,,186.62,Other,110% of Medicare,82.12,,,82.12,Fee Schedule,,30,,,30,Other,186% of Medicaid,96.72,,,96.72,Fee Schedule,,233.74,,,233.74,Fee Schedule,,54.75,,,54.75,Fee Schedule,,96.72,,,96.72,Fee Schedule,,233.74,,,233.74,Fee Schedule,,102.98,,,102.98,Fee Schedule,,263.9,70,,263.9,percent of total billed charges,All Other,123.55,,,123.55,Fee Schedule,,104.71,,,104.71,Fee Schedule,,39.11,,,39.11,Fee Schedule,,39.11,,,39.11,Fee Schedule,,39.11,,,39.11,Fee Schedule,,39.11,,,39.11,Fee Schedule,,16.36,,,16.36,Other,100% of Medicaid,16.36,,,16.36,Other,100% of Medicaid,16.36,,,16.36,Other,100% of Medicaid,16.36,,,16.36,Other,100% of Medicaid,36.81,,,36.81,Other,225% of Medicaid,25.03,,,25.03,Other,153% of Medicaid,36.81,,,36.81,Other,225% of Medicaid,22.91,,,22.91,Other,140% of Medicaid,36.81,,,36.81,Other,225% of Medicaid,42.54,,,42.54,Other,260% of Medicaid,53.01,,,53.01,Other,324% of Medicaid,35.18,,,35.18,Other,215% of Medicaid,35.18,,,35.18,Other,215% of Medicaid,20.45,,,20.45,Other,125% of Medicaid,16.36,278.98,
BLOOD GASES W/O2 SATURATION,82805,CPT,,78082805,CDM,301,RC,,,both,,,294,217.56,,,217.56,Other,150% of Medicare + 9.63% HCRA Surcharge,132.3,45,,132.3,percent of total billed charges,Critical Access Hospital RCC factor,237.1,,,237.1,Fee Schedule,,213.47,,,213.47,Fee Schedule,,210.48,,,210.48,Fee Schedule,,189.32,,,189.32,Fee Schedule,,178.93,,,178.93,Fee Schedule,,145.53,,,145.53,Other,110% of Medicare,248.13,,,248.13,Fee Schedule,,45,,,45,Other,186% of Medicaid,292.24,,,292.24,Fee Schedule,,182.28,,,182.28,Fee Schedule,,165.42,,,165.42,Fee Schedule,,292.24,,,292.24,Fee Schedule,,182.28,,,182.28,Fee Schedule,,311.14,,,311.14,Fee Schedule,,205.8,70,,205.8,percent of total billed charges,All Other,373.29,,,373.29,Fee Schedule,,316.39,,,316.39,Fee Schedule,,118.16,,,118.16,Fee Schedule,,118.16,,,118.16,Fee Schedule,,118.16,,,118.16,Fee Schedule,,118.16,,,118.16,Fee Schedule,,24.13,,,24.13,Other,100% of Medicaid,24.13,,,24.13,Other,100% of Medicaid,24.13,,,24.13,Other,100% of Medicaid,24.13,,,24.13,Other,100% of Medicaid,54.29,,,54.29,Other,225% of Medicaid,36.92,,,36.92,Other,153% of Medicaid,54.29,,,54.29,Other,225% of Medicaid,33.78,,,33.78,Other,140% of Medicaid,54.29,,,54.29,Other,225% of Medicaid,62.74,,,62.74,Other,260% of Medicaid,78.18,,,78.18,Other,324% of Medicaid,51.88,,,51.88,Other,215% of Medicaid,51.88,,,51.88,Other,215% of Medicaid,30.16,,,30.16,Other,125% of Medicaid,24.13,373.29,
GASTRIC ANALY W/PH EA SPEC,82930,CPT,,78082930,CDM,301,RC,,,both,,,92,68.08,,,68.08,Other,150% of Medicare + 9.63% HCRA Surcharge,41.4,45,,41.4,percent of total billed charges,Critical Access Hospital RCC factor,20.2,,,20.2,Fee Schedule,,18.18,,,18.18,Fee Schedule,,40.42,,,40.42,Fee Schedule,,36.36,,,36.36,Fee Schedule,,34.36,,,34.36,Fee Schedule,,45.54,,,45.54,Other,110% of Medicare,21.14,,,21.14,Fee Schedule,,12,,,12,Other,186% of Medicaid,24.89,,,24.89,Fee Schedule,,57.04,,,57.04,Fee Schedule,,14.09,,,14.09,Fee Schedule,,24.89,,,24.89,Fee Schedule,,57.04,,,57.04,Fee Schedule,,26.5,,,26.5,Fee Schedule,,64.4,70,,64.4,percent of total billed charges,All Other,31.8,,,31.8,Fee Schedule,,26.95,,,26.95,Fee Schedule,,10.07,,,10.07,Fee Schedule,,10.07,,,10.07,Fee Schedule,,10.07,,,10.07,Fee Schedule,,10.07,,,10.07,Fee Schedule,,6.31,,,6.31,Other,100% of Medicaid,6.31,,,6.31,Other,100% of Medicaid,6.31,,,6.31,Other,100% of Medicaid,6.31,,,6.31,Other,100% of Medicaid,14.2,,,14.2,Other,225% of Medicaid,9.65,,,9.65,Other,153% of Medicaid,14.2,,,14.2,Other,225% of Medicaid,8.83,,,8.83,Other,140% of Medicaid,14.2,,,14.2,Other,225% of Medicaid,16.41,,,16.41,Other,260% of Medicaid,20.45,,,20.45,Other,324% of Medicaid,13.57,,,13.57,Other,215% of Medicaid,13.57,,,13.57,Other,215% of Medicaid,7.89,,,7.89,Other,125% of Medicaid,6.31,68.08,
ASSAY OF GASTRIN,82941,CPT,,78082941,CDM,301,RC,,,both,,,207,153.18,,,153.18,Other,150% of Medicare + 9.63% HCRA Surcharge,93.15,45,,93.15,percent of total billed charges,Critical Access Hospital RCC factor,53.07,,,53.07,Fee Schedule,,47.78,,,47.78,Fee Schedule,,130.8,,,130.8,Fee Schedule,,117.65,,,117.65,Fee Schedule,,111.19,,,111.19,Fee Schedule,,102.47,,,102.47,Other,110% of Medicare,55.53,,,55.53,Fee Schedule,,33,,,33,Other,186% of Medicaid,65.41,,,65.41,Fee Schedule,,128.34,,,128.34,Fee Schedule,,37.02,,,37.02,Fee Schedule,,65.41,,,65.41,Fee Schedule,,128.34,,,128.34,Fee Schedule,,69.64,,,69.64,Fee Schedule,,144.9,70,,144.9,percent of total billed charges,All Other,83.55,,,83.55,Fee Schedule,,70.81,,,70.81,Fee Schedule,,26.45,,,26.45,Fee Schedule,,26.45,,,26.45,Fee Schedule,,26.45,,,26.45,Fee Schedule,,26.45,,,26.45,Fee Schedule,,17.63,,,17.63,Other,100% of Medicaid,17.63,,,17.63,Other,100% of Medicaid,17.63,,,17.63,Other,100% of Medicaid,17.63,,,17.63,Other,100% of Medicaid,39.67,,,39.67,Other,225% of Medicaid,26.97,,,26.97,Other,153% of Medicaid,39.67,,,39.67,Other,225% of Medicaid,24.68,,,24.68,Other,140% of Medicaid,39.67,,,39.67,Other,225% of Medicaid,45.84,,,45.84,Other,260% of Medicaid,57.12,,,57.12,Other,324% of Medicaid,37.9,,,37.9,Other,215% of Medicaid,37.9,,,37.9,Other,215% of Medicaid,22.04,,,22.04,Other,125% of Medicaid,17.63,153.18,
ASSAY OF GLUCAGON,82943,CPT,,78082943,CDM,301,RC,,,both,,,264,195.36,,,195.36,Other,150% of Medicare + 9.63% HCRA Surcharge,118.8,45,,118.8,percent of total billed charges,Critical Access Hospital RCC factor,43.01,,,43.01,Fee Schedule,,38.73,,,38.73,Fee Schedule,,105.98,,,105.98,Fee Schedule,,95.32,,,95.32,Fee Schedule,,90.09,,,90.09,Fee Schedule,,130.68,,,130.68,Other,110% of Medicare,45.01,,,45.01,Fee Schedule,,27,,,27,Other,186% of Medicaid,53.02,,,53.02,Fee Schedule,,163.68,,,163.68,Fee Schedule,,30.01,,,30.01,Fee Schedule,,53.02,,,53.02,Fee Schedule,,163.68,,,163.68,Fee Schedule,,56.45,,,56.45,Fee Schedule,,184.8,70,,184.8,percent of total billed charges,All Other,67.72,,,67.72,Fee Schedule,,57.4,,,57.4,Fee Schedule,,21.44,,,21.44,Fee Schedule,,21.44,,,21.44,Fee Schedule,,21.44,,,21.44,Fee Schedule,,21.44,,,21.44,Fee Schedule,,14.29,,,14.29,Other,100% of Medicaid,14.29,,,14.29,Other,100% of Medicaid,14.29,,,14.29,Other,100% of Medicaid,14.29,,,14.29,Other,100% of Medicaid,32.15,,,32.15,Other,225% of Medicaid,21.86,,,21.86,Other,153% of Medicaid,32.15,,,32.15,Other,225% of Medicaid,20.01,,,20.01,Other,140% of Medicaid,32.15,,,32.15,Other,225% of Medicaid,37.15,,,37.15,Other,260% of Medicaid,46.3,,,46.3,Other,324% of Medicaid,30.72,,,30.72,Other,215% of Medicaid,30.72,,,30.72,Other,215% of Medicaid,17.86,,,17.86,Other,125% of Medicaid,14.29,195.36,
GLUCOSE OTHER FLUID,82945,CPT,,78082945,CDM,301,RC,,,both,,,55,40.7,,,40.7,Other,150% of Medicare + 9.63% HCRA Surcharge,24.75,45,,24.75,percent of total billed charges,Critical Access Hospital RCC factor,11.83,,,11.83,Fee Schedule,,10.65,,,10.65,Fee Schedule,,29.09,,,29.09,Fee Schedule,,26.16,,,26.16,Fee Schedule,,24.73,,,24.73,Fee Schedule,,27.23,,,27.23,Other,110% of Medicare,12.38,,,12.38,Fee Schedule,,7,,,7,Other,186% of Medicaid,14.58,,,14.58,Fee Schedule,,34.1,,,34.1,Fee Schedule,,8.25,,,8.25,Fee Schedule,,14.58,,,14.58,Fee Schedule,,34.1,,,34.1,Fee Schedule,,15.52,,,15.52,Fee Schedule,,38.5,70,,38.5,percent of total billed charges,All Other,18.62,,,18.62,Fee Schedule,,15.79,,,15.79,Fee Schedule,,5.9,,,5.9,Fee Schedule,,5.9,,,5.9,Fee Schedule,,5.9,,,5.9,Fee Schedule,,5.9,,,5.9,Fee Schedule,,3.93,,,3.93,Other,100% of Medicaid,3.93,,,3.93,Other,100% of Medicaid,3.93,,,3.93,Other,100% of Medicaid,3.93,,,3.93,Other,100% of Medicaid,8.84,,,8.84,Other,225% of Medicaid,6.01,,,6.01,Other,153% of Medicaid,8.84,,,8.84,Other,225% of Medicaid,5.5,,,5.5,Other,140% of Medicaid,8.84,,,8.84,Other,225% of Medicaid,10.22,,,10.22,Other,260% of Medicaid,12.73,,,12.73,Other,324% of Medicaid,8.45,,,8.45,Other,215% of Medicaid,8.45,,,8.45,Other,215% of Medicaid,4.91,,,4.91,Other,125% of Medicaid,3.93,40.7,
ASSAY GLUCOSE BLOOD QUANT,82947,CPT,,78082947,CDM,301,RC,,,both,,,84,62.16,,,62.16,Other,150% of Medicare + 9.63% HCRA Surcharge,37.8,45,,37.8,percent of total billed charges,Critical Access Hospital RCC factor,11.83,,,11.83,Fee Schedule,,10.65,,,10.65,Fee Schedule,,29.09,,,29.09,Fee Schedule,,26.16,,,26.16,Fee Schedule,,24.73,,,24.73,Fee Schedule,,41.58,,,41.58,Other,110% of Medicare,12.38,,,12.38,Fee Schedule,,7,,,7,Other,186% of Medicaid,14.58,,,14.58,Fee Schedule,,52.08,,,52.08,Fee Schedule,,8.25,,,8.25,Fee Schedule,,14.58,,,14.58,Fee Schedule,,52.08,,,52.08,Fee Schedule,,15.52,,,15.52,Fee Schedule,,58.8,70,,58.8,percent of total billed charges,All Other,18.62,,,18.62,Fee Schedule,,15.79,,,15.79,Fee Schedule,,5.9,,,5.9,Fee Schedule,,5.9,,,5.9,Fee Schedule,,5.9,,,5.9,Fee Schedule,,5.9,,,5.9,Fee Schedule,,3.93,,,3.93,Other,100% of Medicaid,3.93,,,3.93,Other,100% of Medicaid,3.93,,,3.93,Other,100% of Medicaid,3.93,,,3.93,Other,100% of Medicaid,8.84,,,8.84,Other,225% of Medicaid,6.01,,,6.01,Other,153% of Medicaid,8.84,,,8.84,Other,225% of Medicaid,5.5,,,5.5,Other,140% of Medicaid,8.84,,,8.84,Other,225% of Medicaid,10.22,,,10.22,Other,260% of Medicaid,12.73,,,12.73,Other,324% of Medicaid,8.45,,,8.45,Other,215% of Medicaid,8.45,,,8.45,Other,215% of Medicaid,4.91,,,4.91,Other,125% of Medicaid,3.93,62.16,
GLUCOSE TEST,82950,CPT,,78082950,CDM,301,RC,,,both,,,94,69.56,,,69.56,Other,150% of Medicare + 9.63% HCRA Surcharge,42.3,45,,42.3,percent of total billed charges,Critical Access Hospital RCC factor,14.3,,,14.3,Fee Schedule,,12.87,,,12.87,Fee Schedule,,35.2,,,35.2,Fee Schedule,,31.66,,,31.66,Fee Schedule,,29.93,,,29.93,Fee Schedule,,46.53,,,46.53,Other,110% of Medicare,14.96,,,14.96,Fee Schedule,,9,,,9,Other,186% of Medicaid,17.62,,,17.62,Fee Schedule,,58.28,,,58.28,Fee Schedule,,9.98,,,9.98,Fee Schedule,,17.62,,,17.62,Fee Schedule,,58.28,,,58.28,Fee Schedule,,18.76,,,18.76,Fee Schedule,,65.8,70,,65.8,percent of total billed charges,All Other,22.51,,,22.51,Fee Schedule,,19.08,,,19.08,Fee Schedule,,7.13,,,7.13,Fee Schedule,,7.13,,,7.13,Fee Schedule,,7.13,,,7.13,Fee Schedule,,7.13,,,7.13,Fee Schedule,,4.75,,,4.75,Other,100% of Medicaid,4.75,,,4.75,Other,100% of Medicaid,4.75,,,4.75,Other,100% of Medicaid,4.75,,,4.75,Other,100% of Medicaid,10.69,,,10.69,Other,225% of Medicaid,7.27,,,7.27,Other,153% of Medicaid,10.69,,,10.69,Other,225% of Medicaid,6.65,,,6.65,Other,140% of Medicaid,10.69,,,10.69,Other,225% of Medicaid,12.35,,,12.35,Other,260% of Medicaid,15.39,,,15.39,Other,324% of Medicaid,10.21,,,10.21,Other,215% of Medicaid,10.21,,,10.21,Other,215% of Medicaid,5.94,,,5.94,Other,125% of Medicaid,4.75,69.56,
GLUCOSE TOLERANCE TEST (GTT),82951,CPT,,78082951,CDM,301,RC,,,both,,,220,162.8,,,162.8,Other,150% of Medicare + 9.63% HCRA Surcharge,99,45,,99,percent of total billed charges,Critical Access Hospital RCC factor,38.74,,,38.74,Fee Schedule,,34.88,,,34.88,Fee Schedule,,95.49,,,95.49,Fee Schedule,,85.89,,,85.89,Fee Schedule,,81.18,,,81.18,Fee Schedule,,108.9,,,108.9,Other,110% of Medicare,40.54,,,40.54,Fee Schedule,,13,,,13,Other,186% of Medicaid,47.75,,,47.75,Fee Schedule,,136.4,,,136.4,Fee Schedule,,27.03,,,27.03,Fee Schedule,,47.75,,,47.75,Fee Schedule,,136.4,,,136.4,Fee Schedule,,50.84,,,50.84,Fee Schedule,,154,70,,154,percent of total billed charges,All Other,60.99,,,60.99,Fee Schedule,,51.69,,,51.69,Fee Schedule,,19.31,,,19.31,Fee Schedule,,19.31,,,19.31,Fee Schedule,,19.31,,,19.31,Fee Schedule,,19.31,,,19.31,Fee Schedule,,6.91,,,6.91,Other,100% of Medicaid,6.91,,,6.91,Other,100% of Medicaid,6.91,,,6.91,Other,100% of Medicaid,6.91,,,6.91,Other,100% of Medicaid,15.54,,,15.54,Other,225% of Medicaid,10.57,,,10.57,Other,153% of Medicaid,15.54,,,15.54,Other,225% of Medicaid,9.67,,,9.67,Other,140% of Medicaid,15.54,,,15.54,Other,225% of Medicaid,17.96,,,17.96,Other,260% of Medicaid,22.38,,,22.38,Other,324% of Medicaid,14.85,,,14.85,Other,215% of Medicaid,14.85,,,14.85,Other,215% of Medicaid,8.64,,,8.64,Other,125% of Medicaid,6.91,162.8,
GTT-ADDED SAMPLES,82952,CPT,,78082952,CDM,301,RC,,,both,,,78,57.72,,,57.72,Other,150% of Medicare + 9.63% HCRA Surcharge,35.1,45,,35.1,percent of total billed charges,Critical Access Hospital RCC factor,11.8,,,11.8,Fee Schedule,,10.62,,,10.62,Fee Schedule,,21.34,,,21.34,Fee Schedule,,19.2,,,19.2,Fee Schedule,,18.14,,,18.14,Fee Schedule,,38.61,,,38.61,Other,110% of Medicare,12.35,,,12.35,Fee Schedule,,3,,,3,Other,186% of Medicaid,14.54,,,14.54,Fee Schedule,,48.36,,,48.36,Fee Schedule,,8.23,,,8.23,Fee Schedule,,14.54,,,14.54,Fee Schedule,,48.36,,,48.36,Fee Schedule,,15.48,,,15.48,Fee Schedule,,54.6,70,,54.6,percent of total billed charges,All Other,18.58,,,18.58,Fee Schedule,,15.75,,,15.75,Fee Schedule,,5.88,,,5.88,Fee Schedule,,5.88,,,5.88,Fee Schedule,,5.88,,,5.88,Fee Schedule,,5.88,,,5.88,Fee Schedule,,1.41,,,1.41,Other,100% of Medicaid,1.41,,,1.41,Other,100% of Medicaid,1.41,,,1.41,Other,100% of Medicaid,1.41,,,1.41,Other,100% of Medicaid,3.18,,,3.18,Other,225% of Medicaid,2.16,,,2.16,Other,153% of Medicaid,3.18,,,3.18,Other,225% of Medicaid,1.98,,,1.98,Other,140% of Medicaid,3.18,,,3.18,Other,225% of Medicaid,3.68,,,3.68,Other,260% of Medicaid,4.58,,,4.58,Other,324% of Medicaid,3.04,,,3.04,Other,215% of Medicaid,3.04,,,3.04,Other,215% of Medicaid,1.77,,,1.77,Other,125% of Medicaid,1.41,57.72,
ASSAY OF G6PD ENZYME,82955,CPT,,78082955,CDM,301,RC,,,both,,,143,105.82,,,105.82,Other,150% of Medicare + 9.63% HCRA Surcharge,64.35,45,,64.35,percent of total billed charges,Critical Access Hospital RCC factor,29.2,,,29.2,Fee Schedule,,26.29,,,26.29,Fee Schedule,,71.94,,,71.94,Fee Schedule,,64.7,,,64.7,Fee Schedule,,61.15,,,61.15,Fee Schedule,,70.79,,,70.79,Other,110% of Medicare,30.56,,,30.56,Fee Schedule,,18,,,18,Other,186% of Medicaid,35.99,,,35.99,Fee Schedule,,88.66,,,88.66,Fee Schedule,,20.37,,,20.37,Fee Schedule,,35.99,,,35.99,Fee Schedule,,88.66,,,88.66,Fee Schedule,,38.32,,,38.32,Fee Schedule,,100.1,70,,100.1,percent of total billed charges,All Other,45.97,,,45.97,Fee Schedule,,38.96,,,38.96,Fee Schedule,,14.55,,,14.55,Fee Schedule,,14.55,,,14.55,Fee Schedule,,14.55,,,14.55,Fee Schedule,,14.55,,,14.55,Fee Schedule,,9.7,,,9.7,Other,100% of Medicaid,9.7,,,9.7,Other,100% of Medicaid,9.7,,,9.7,Other,100% of Medicaid,9.7,,,9.7,Other,100% of Medicaid,21.83,,,21.83,Other,225% of Medicaid,14.84,,,14.84,Other,153% of Medicaid,21.83,,,21.83,Other,225% of Medicaid,13.58,,,13.58,Other,140% of Medicaid,21.83,,,21.83,Other,225% of Medicaid,25.22,,,25.22,Other,260% of Medicaid,31.43,,,31.43,Other,324% of Medicaid,20.86,,,20.86,Other,215% of Medicaid,20.86,,,20.86,Other,215% of Medicaid,12.13,,,12.13,Other,125% of Medicaid,9.7,105.82,
TEST FOR G6PD ENZYME,82960,CPT,,78082960,CDM,301,RC,,,both,,,155,114.7,,,114.7,Other,150% of Medicare + 9.63% HCRA Surcharge,69.75,45,,69.75,percent of total billed charges,Critical Access Hospital RCC factor,18.21,,,18.21,Fee Schedule,,16.4,,,16.4,Fee Schedule,,43.11,,,43.11,Fee Schedule,,38.77,,,38.77,Fee Schedule,,36.65,,,36.65,Fee Schedule,,76.73,,,76.73,Other,110% of Medicare,19.06,,,19.06,Fee Schedule,,6,,,6,Other,186% of Medicaid,22.45,,,22.45,Fee Schedule,,96.1,,,96.1,Fee Schedule,,12.71,,,12.71,Fee Schedule,,22.45,,,22.45,Fee Schedule,,96.1,,,96.1,Fee Schedule,,23.9,,,23.9,Fee Schedule,,108.5,70,,108.5,percent of total billed charges,All Other,28.67,,,28.67,Fee Schedule,,24.3,,,24.3,Fee Schedule,,9.08,,,9.08,Fee Schedule,,9.08,,,9.08,Fee Schedule,,9.08,,,9.08,Fee Schedule,,9.08,,,9.08,Fee Schedule,,3.03,,,3.03,Other,100% of Medicaid,3.03,,,3.03,Other,100% of Medicaid,3.03,,,3.03,Other,100% of Medicaid,3.03,,,3.03,Other,100% of Medicaid,6.82,,,6.82,Other,225% of Medicaid,4.64,,,4.64,Other,153% of Medicaid,6.82,,,6.82,Other,225% of Medicaid,4.24,,,4.24,Other,140% of Medicaid,6.82,,,6.82,Other,225% of Medicaid,7.88,,,7.88,Other,260% of Medicaid,9.82,,,9.82,Other,324% of Medicaid,6.51,,,6.51,Other,215% of Medicaid,6.51,,,6.51,Other,215% of Medicaid,3.79,,,3.79,Other,125% of Medicaid,3.03,114.7,
GLUCOSE BLOOD TEST,82962,CPT,,78082962,CDM,301,RC,,,both,,,31,22.94,,,22.94,Other,150% of Medicare + 9.63% HCRA Surcharge,13.95,45,,13.95,percent of total billed charges,Critical Access Hospital RCC factor,9.87,,,9.87,Fee Schedule,,8.89,,,8.89,Fee Schedule,,16.13,,,16.13,Fee Schedule,,14.5,,,14.5,Fee Schedule,,13.71,,,13.71,Fee Schedule,,15.35,,,15.35,Other,110% of Medicare,10.33,,,10.33,Fee Schedule,,12,,,12,Other,186% of Medicaid,12.17,,,12.17,Fee Schedule,,19.22,,,19.22,Fee Schedule,,6.89,,,6.89,Fee Schedule,,12.17,,,12.17,Fee Schedule,,19.22,,,19.22,Fee Schedule,,12.96,,,12.96,Fee Schedule,,21.7,70,,21.7,percent of total billed charges,All Other,15.54,,,15.54,Fee Schedule,,13.17,,,13.17,Fee Schedule,,4.92,,,4.92,Fee Schedule,,4.92,,,4.92,Fee Schedule,,4.92,,,4.92,Fee Schedule,,4.92,,,4.92,Fee Schedule,,6.31,,,6.31,Other,100% of Medicaid,6.31,,,6.31,Other,100% of Medicaid,6.31,,,6.31,Other,100% of Medicaid,6.31,,,6.31,Other,100% of Medicaid,14.2,,,14.2,Other,225% of Medicaid,9.65,,,9.65,Other,153% of Medicaid,14.2,,,14.2,Other,225% of Medicaid,8.83,,,8.83,Other,140% of Medicaid,14.2,,,14.2,Other,225% of Medicaid,16.41,,,16.41,Other,260% of Medicaid,20.45,,,20.45,Other,324% of Medicaid,13.57,,,13.57,Other,215% of Medicaid,13.57,,,13.57,Other,215% of Medicaid,7.89,,,7.89,Other,125% of Medicaid,4.92,22.94,
ASSAY OF GGT,82977,CPT,,78082977,CDM,301,RC,,,both,,,87,64.38,,,64.38,Other,150% of Medicare + 9.63% HCRA Surcharge,39.15,45,,39.15,percent of total billed charges,Critical Access Hospital RCC factor,21.67,,,21.67,Fee Schedule,,19.51,,,19.51,Fee Schedule,,53.39,,,53.39,Fee Schedule,,48.02,,,48.02,Fee Schedule,,45.38,,,45.38,Fee Schedule,,43.07,,,43.07,Other,110% of Medicare,22.68,,,22.68,Fee Schedule,,9,,,9,Other,186% of Medicaid,26.71,,,26.71,Fee Schedule,,53.94,,,53.94,Fee Schedule,,15.12,,,15.12,Fee Schedule,,26.71,,,26.71,Fee Schedule,,53.94,,,53.94,Fee Schedule,,28.44,,,28.44,Fee Schedule,,60.9,70,,60.9,percent of total billed charges,All Other,34.12,,,34.12,Fee Schedule,,28.92,,,28.92,Fee Schedule,,10.8,,,10.8,Fee Schedule,,10.8,,,10.8,Fee Schedule,,10.8,,,10.8,Fee Schedule,,10.8,,,10.8,Fee Schedule,,5.08,,,5.08,Other,100% of Medicaid,5.08,,,5.08,Other,100% of Medicaid,5.08,,,5.08,Other,100% of Medicaid,5.08,,,5.08,Other,100% of Medicaid,11.43,,,11.43,Other,225% of Medicaid,7.77,,,7.77,Other,153% of Medicaid,11.43,,,11.43,Other,225% of Medicaid,7.11,,,7.11,Other,140% of Medicaid,11.43,,,11.43,Other,225% of Medicaid,13.21,,,13.21,Other,260% of Medicaid,16.46,,,16.46,Other,324% of Medicaid,10.92,,,10.92,Other,215% of Medicaid,10.92,,,10.92,Other,215% of Medicaid,6.35,,,6.35,Other,125% of Medicaid,5.08,64.38,
GLUTATHIONE,82978,CPT,,78082978,CDM,301,RC,,,both,,,86,63.64,,,63.64,Other,150% of Medicare + 9.63% HCRA Surcharge,38.7,45,,38.7,percent of total billed charges,Critical Access Hospital RCC factor,46.5,,,46.5,Fee Schedule,,41.87,,,41.87,Fee Schedule,,105.72,,,105.72,Fee Schedule,,95.08,,,95.08,Fee Schedule,,89.87,,,89.87,Fee Schedule,,42.57,,,42.57,Other,110% of Medicare,48.67,,,48.67,Fee Schedule,,19,,,19,Other,186% of Medicaid,57.32,,,57.32,Fee Schedule,,53.32,,,53.32,Fee Schedule,,32.45,,,32.45,Fee Schedule,,57.32,,,57.32,Fee Schedule,,53.32,,,53.32,Fee Schedule,,61.03,,,61.03,Fee Schedule,,60.2,70,,60.2,percent of total billed charges,All Other,73.22,,,73.22,Fee Schedule,,62.06,,,62.06,Fee Schedule,,23.18,,,23.18,Fee Schedule,,23.18,,,23.18,Fee Schedule,,23.18,,,23.18,Fee Schedule,,23.18,,,23.18,Fee Schedule,,10.16,,,10.16,Other,100% of Medicaid,10.16,,,10.16,Other,100% of Medicaid,10.16,,,10.16,Other,100% of Medicaid,10.16,,,10.16,Other,100% of Medicaid,22.85,,,22.85,Other,225% of Medicaid,15.54,,,15.54,Other,153% of Medicaid,22.85,,,22.85,Other,225% of Medicaid,14.22,,,14.22,Other,140% of Medicaid,22.85,,,22.85,Other,225% of Medicaid,26.4,,,26.4,Other,260% of Medicaid,32.9,,,32.9,Other,324% of Medicaid,21.83,,,21.83,Other,215% of Medicaid,21.83,,,21.83,Other,215% of Medicaid,12.69,,,12.69,Other,125% of Medicaid,10.16,105.72,
ASSAY RBC GLUTATHIONE,82979,CPT,,78082979,CDM,301,RC,,,both,,,213,157.62,,,157.62,Other,150% of Medicare + 9.63% HCRA Surcharge,95.85,45,,95.85,percent of total billed charges,Critical Access Hospital RCC factor,28.41,,,28.41,Fee Schedule,,25.58,,,25.58,Fee Schedule,,51.07,,,51.07,Fee Schedule,,45.93,,,45.93,Fee Schedule,,43.41,,,43.41,Fee Schedule,,105.44,,,105.44,Other,110% of Medicare,29.74,,,29.74,Fee Schedule,,12,,,12,Other,186% of Medicaid,35.02,,,35.02,Fee Schedule,,132.06,,,132.06,Fee Schedule,,19.82,,,19.82,Fee Schedule,,35.02,,,35.02,Fee Schedule,,132.06,,,132.06,Fee Schedule,,37.29,,,37.29,Fee Schedule,,149.1,70,,149.1,percent of total billed charges,All Other,44.74,,,44.74,Fee Schedule,,37.92,,,37.92,Fee Schedule,,14.16,,,14.16,Fee Schedule,,14.16,,,14.16,Fee Schedule,,14.16,,,14.16,Fee Schedule,,14.16,,,14.16,Fee Schedule,,6.31,,,6.31,Other,100% of Medicaid,6.31,,,6.31,Other,100% of Medicaid,6.31,,,6.31,Other,100% of Medicaid,6.31,,,6.31,Other,100% of Medicaid,14.2,,,14.2,Other,225% of Medicaid,9.65,,,9.65,Other,153% of Medicaid,14.2,,,14.2,Other,225% of Medicaid,8.83,,,8.83,Other,140% of Medicaid,14.2,,,14.2,Other,225% of Medicaid,16.41,,,16.41,Other,260% of Medicaid,20.45,,,20.45,Other,324% of Medicaid,13.57,,,13.57,Other,215% of Medicaid,13.57,,,13.57,Other,215% of Medicaid,7.89,,,7.89,Other,125% of Medicaid,6.31,157.62,
GLYCATED PROTEIN,82985,CPT,,78082985,CDM,301,RC,,,both,,,129,95.46,,,95.46,Other,150% of Medicare + 9.63% HCRA Surcharge,58.05,45,,58.05,percent of total billed charges,Critical Access Hospital RCC factor,50.45,,,50.45,Fee Schedule,,45.42,,,45.42,Fee Schedule,,111.78,,,111.78,Fee Schedule,,100.54,,,100.54,Fee Schedule,,95.02,,,95.02,Fee Schedule,,63.86,,,63.86,Other,110% of Medicare,52.79,,,52.79,Fee Schedule,,20,,,20,Other,186% of Medicaid,62.18,,,62.18,Fee Schedule,,79.98,,,79.98,Fee Schedule,,35.2,,,35.2,Fee Schedule,,62.18,,,62.18,Fee Schedule,,79.98,,,79.98,Fee Schedule,,66.2,,,66.2,Fee Schedule,,90.3,70,,90.3,percent of total billed charges,All Other,79.43,,,79.43,Fee Schedule,,67.32,,,67.32,Fee Schedule,,25.14,,,25.14,Fee Schedule,,25.14,,,25.14,Fee Schedule,,25.14,,,25.14,Fee Schedule,,25.14,,,25.14,Fee Schedule,,10.75,,,10.75,Other,100% of Medicaid,10.75,,,10.75,Other,100% of Medicaid,10.75,,,10.75,Other,100% of Medicaid,10.75,,,10.75,Other,100% of Medicaid,24.18,,,24.18,Other,225% of Medicaid,16.44,,,16.44,Other,153% of Medicaid,24.18,,,24.18,Other,225% of Medicaid,15.04,,,15.04,Other,140% of Medicaid,24.18,,,24.18,Other,225% of Medicaid,27.94,,,27.94,Other,260% of Medicaid,34.82,,,34.82,Other,324% of Medicaid,23.1,,,23.1,Other,215% of Medicaid,23.1,,,23.1,Other,215% of Medicaid,13.43,,,13.43,Other,125% of Medicaid,10.75,111.78,
GONADOTROPIN (FSH),83001,CPT,,78083001,CDM,301,RC,,,both,,,263,194.62,,,194.62,Other,150% of Medicare + 9.63% HCRA Surcharge,118.35,45,,118.35,percent of total billed charges,Critical Access Hospital RCC factor,55.93,,,55.93,Fee Schedule,,50.35,,,50.35,Fee Schedule,,137.81,,,137.81,Fee Schedule,,123.95,,,123.95,Fee Schedule,,117.15,,,117.15,Fee Schedule,,130.19,,,130.19,Other,110% of Medicare,58.53,,,58.53,Fee Schedule,,35,,,35,Other,186% of Medicaid,68.93,,,68.93,Fee Schedule,,163.06,,,163.06,Fee Schedule,,39.02,,,39.02,Fee Schedule,,68.93,,,68.93,Fee Schedule,,163.06,,,163.06,Fee Schedule,,73.39,,,73.39,Fee Schedule,,184.1,70,,184.1,percent of total billed charges,All Other,88.05,,,88.05,Fee Schedule,,74.63,,,74.63,Fee Schedule,,27.87,,,27.87,Fee Schedule,,27.87,,,27.87,Fee Schedule,,27.87,,,27.87,Fee Schedule,,27.87,,,27.87,Fee Schedule,,18.58,,,18.58,Other,100% of Medicaid,18.58,,,18.58,Other,100% of Medicaid,18.58,,,18.58,Other,100% of Medicaid,18.58,,,18.58,Other,100% of Medicaid,41.81,,,41.81,Other,225% of Medicaid,28.43,,,28.43,Other,153% of Medicaid,41.81,,,41.81,Other,225% of Medicaid,26.01,,,26.01,Other,140% of Medicaid,41.81,,,41.81,Other,225% of Medicaid,48.31,,,48.31,Other,260% of Medicaid,60.2,,,60.2,Other,324% of Medicaid,39.95,,,39.95,Other,215% of Medicaid,39.95,,,39.95,Other,215% of Medicaid,23.23,,,23.23,Other,125% of Medicaid,18.58,194.62,
GONADOTROPIN (LH),83002,CPT,,78083002,CDM,301,RC,,,both,,,271,200.54,,,200.54,Other,150% of Medicare + 9.63% HCRA Surcharge,121.95,45,,121.95,percent of total billed charges,Critical Access Hospital RCC factor,55.75,,,55.75,Fee Schedule,,50.19,,,50.19,Fee Schedule,,137.34,,,137.34,Fee Schedule,,123.52,,,123.52,Fee Schedule,,116.75,,,116.75,Fee Schedule,,134.15,,,134.15,Other,110% of Medicare,58.34,,,58.34,Fee Schedule,,34,,,34,Other,186% of Medicaid,68.71,,,68.71,Fee Schedule,,168.02,,,168.02,Fee Schedule,,38.89,,,38.89,Fee Schedule,,68.71,,,68.71,Fee Schedule,,168.02,,,168.02,Fee Schedule,,73.15,,,73.15,Fee Schedule,,189.7,70,,189.7,percent of total billed charges,All Other,87.77,,,87.77,Fee Schedule,,74.39,,,74.39,Fee Schedule,,27.78,,,27.78,Fee Schedule,,27.78,,,27.78,Fee Schedule,,27.78,,,27.78,Fee Schedule,,27.78,,,27.78,Fee Schedule,,18.52,,,18.52,Other,100% of Medicaid,18.52,,,18.52,Other,100% of Medicaid,18.52,,,18.52,Other,100% of Medicaid,18.52,,,18.52,Other,100% of Medicaid,41.67,,,41.67,Other,225% of Medicaid,28.34,,,28.34,Other,153% of Medicaid,41.67,,,41.67,Other,225% of Medicaid,25.93,,,25.93,Other,140% of Medicaid,41.67,,,41.67,Other,225% of Medicaid,48.15,,,48.15,Other,260% of Medicaid,60,,,60,Other,324% of Medicaid,39.82,,,39.82,Other,215% of Medicaid,39.82,,,39.82,Other,215% of Medicaid,23.15,,,23.15,Other,125% of Medicaid,18.52,200.54,
ASSAY GROWTH HORMONE (HGH),83003,CPT,,78083003,CDM,301,RC,,,both,,,196,145.04,,,145.04,Other,150% of Medicare + 9.63% HCRA Surcharge,88.2,45,,88.2,percent of total billed charges,Critical Access Hospital RCC factor,50.18,,,50.18,Fee Schedule,,45.18,,,45.18,Fee Schedule,,123.69,,,123.69,Fee Schedule,,111.25,,,111.25,Fee Schedule,,105.15,,,105.15,Fee Schedule,,97.02,,,97.02,Other,110% of Medicare,52.51,,,52.51,Fee Schedule,,31,,,31,Other,186% of Medicaid,61.85,,,61.85,Fee Schedule,,121.52,,,121.52,Fee Schedule,,35.01,,,35.01,Fee Schedule,,61.85,,,61.85,Fee Schedule,,121.52,,,121.52,Fee Schedule,,65.85,,,65.85,Fee Schedule,,137.2,70,,137.2,percent of total billed charges,All Other,79,,,79,Fee Schedule,,66.96,,,66.96,Fee Schedule,,25.01,,,25.01,Fee Schedule,,25.01,,,25.01,Fee Schedule,,25.01,,,25.01,Fee Schedule,,25.01,,,25.01,Fee Schedule,,16.67,,,16.67,Other,100% of Medicaid,16.67,,,16.67,Other,100% of Medicaid,16.67,,,16.67,Other,100% of Medicaid,16.67,,,16.67,Other,100% of Medicaid,37.51,,,37.51,Other,225% of Medicaid,25.51,,,25.51,Other,153% of Medicaid,37.51,,,37.51,Other,225% of Medicaid,23.34,,,23.34,Other,140% of Medicaid,37.51,,,37.51,Other,225% of Medicaid,43.34,,,43.34,Other,260% of Medicaid,54.01,,,54.01,Other,324% of Medicaid,35.84,,,35.84,Other,215% of Medicaid,35.84,,,35.84,Other,215% of Medicaid,20.84,,,20.84,Other,125% of Medicaid,16.67,145.04,
ASSAY OF HAPTOGLOBIN QUANT,83010,CPT,,78083010,CDM,301,RC,,,both,,,203,150.22,,,150.22,Other,150% of Medicare + 9.63% HCRA Surcharge,91.35,45,,91.35,percent of total billed charges,Critical Access Hospital RCC factor,37.87,,,37.87,Fee Schedule,,34.09,,,34.09,Fee Schedule,,93.28,,,93.28,Fee Schedule,,83.9,,,83.9,Fee Schedule,,79.3,,,79.3,Fee Schedule,,100.49,,,100.49,Other,110% of Medicare,39.63,,,39.63,Fee Schedule,,23,,,23,Other,186% of Medicaid,46.67,,,46.67,Fee Schedule,,125.86,,,125.86,Fee Schedule,,26.42,,,26.42,Fee Schedule,,46.67,,,46.67,Fee Schedule,,125.86,,,125.86,Fee Schedule,,49.69,,,49.69,Fee Schedule,,142.1,70,,142.1,percent of total billed charges,All Other,59.62,,,59.62,Fee Schedule,,50.53,,,50.53,Fee Schedule,,18.87,,,18.87,Fee Schedule,,18.87,,,18.87,Fee Schedule,,18.87,,,18.87,Fee Schedule,,18.87,,,18.87,Fee Schedule,,12.58,,,12.58,Other,100% of Medicaid,12.58,,,12.58,Other,100% of Medicaid,12.58,,,12.58,Other,100% of Medicaid,12.58,,,12.58,Other,100% of Medicaid,28.31,,,28.31,Other,225% of Medicaid,19.25,,,19.25,Other,153% of Medicaid,28.31,,,28.31,Other,225% of Medicaid,17.61,,,17.61,Other,140% of Medicaid,28.31,,,28.31,Other,225% of Medicaid,32.71,,,32.71,Other,260% of Medicaid,40.76,,,40.76,Other,324% of Medicaid,27.05,,,27.05,Other,215% of Medicaid,27.05,,,27.05,Other,215% of Medicaid,15.73,,,15.73,Other,125% of Medicaid,12.58,150.22,
H PYLORI (C-13) BREATH TEST,83013,CPT,,78083013,CDM,301,RC,,,both,,,449,332.26,,,332.26,Other,150% of Medicare + 9.63% HCRA Surcharge,202.05,45,,202.05,percent of total billed charges,Critical Access Hospital RCC factor,202.75,,,202.75,Fee Schedule,,182.55,,,182.55,Fee Schedule,,499.54,,,499.54,Fee Schedule,,449.3,,,449.3,Fee Schedule,,424.66,,,424.66,Fee Schedule,,222.26,,,222.26,Other,110% of Medicare,212.18,,,212.18,Fee Schedule,,125,,,125,Other,186% of Medicaid,249.91,,,249.91,Fee Schedule,,278.38,,,278.38,Fee Schedule,,141.46,,,141.46,Fee Schedule,,249.91,,,249.91,Fee Schedule,,278.38,,,278.38,Fee Schedule,,266.07,,,266.07,Fee Schedule,,314.3,70,,314.3,percent of total billed charges,All Other,319.22,,,319.22,Fee Schedule,,270.56,,,270.56,Fee Schedule,,101.04,,,101.04,Fee Schedule,,101.04,,,101.04,Fee Schedule,,101.04,,,101.04,Fee Schedule,,101.04,,,101.04,Fee Schedule,,67.36,,,67.36,Other,100% of Medicaid,67.36,,,67.36,Other,100% of Medicaid,67.36,,,67.36,Other,100% of Medicaid,67.36,,,67.36,Other,100% of Medicaid,151.56,,,151.56,Other,225% of Medicaid,103.06,,,103.06,Other,153% of Medicaid,151.56,,,151.56,Other,225% of Medicaid,94.3,,,94.3,Other,140% of Medicaid,151.56,,,151.56,Other,225% of Medicaid,175.14,,,175.14,Other,260% of Medicaid,218.25,,,218.25,Other,324% of Medicaid,144.82,,,144.82,Other,215% of Medicaid,144.82,,,144.82,Other,215% of Medicaid,84.2,,,84.2,Other,125% of Medicaid,67.36,499.54,
HEAVY METAL SCREEN,83015,CPT,,78083015,CDM,301,RC,,,both,,,299,221.26,,,221.26,Other,150% of Medicare + 9.63% HCRA Surcharge,134.55,45,,134.55,percent of total billed charges,Critical Access Hospital RCC factor,63.03,,,63.03,Fee Schedule,,56.75,,,56.75,Fee Schedule,,139.66,,,139.66,Fee Schedule,,125.61,,,125.61,Fee Schedule,,118.72,,,118.72,Fee Schedule,,148.01,,,148.01,Other,110% of Medicare,65.96,,,65.96,Fee Schedule,,39,,,39,Other,186% of Medicaid,77.69,,,77.69,Fee Schedule,,185.38,,,185.38,Fee Schedule,,43.97,,,43.97,Fee Schedule,,77.69,,,77.69,Fee Schedule,,185.38,,,185.38,Fee Schedule,,82.71,,,82.71,Fee Schedule,,209.3,70,,209.3,percent of total billed charges,All Other,99.24,,,99.24,Fee Schedule,,84.11,,,84.11,Fee Schedule,,31.41,,,31.41,Fee Schedule,,31.41,,,31.41,Fee Schedule,,31.41,,,31.41,Fee Schedule,,31.41,,,31.41,Fee Schedule,,20.94,,,20.94,Other,100% of Medicaid,20.94,,,20.94,Other,100% of Medicaid,20.94,,,20.94,Other,100% of Medicaid,20.94,,,20.94,Other,100% of Medicaid,47.12,,,47.12,Other,225% of Medicaid,32.04,,,32.04,Other,153% of Medicaid,47.12,,,47.12,Other,225% of Medicaid,29.32,,,29.32,Other,140% of Medicaid,47.12,,,47.12,Other,225% of Medicaid,54.44,,,54.44,Other,260% of Medicaid,67.85,,,67.85,Other,324% of Medicaid,45.02,,,45.02,Other,215% of Medicaid,45.02,,,45.02,Other,215% of Medicaid,26.18,,,26.18,Other,125% of Medicaid,20.94,221.26,
QUANTITATIVE SCREEN METALS,83018,CPT,,78083018,CDM,301,RC,,,both,,,254,187.96,,,187.96,Other,150% of Medicare + 9.63% HCRA Surcharge,114.3,45,,114.3,percent of total billed charges,Critical Access Hospital RCC factor,66.1,,,66.1,Fee Schedule,,59.51,,,59.51,Fee Schedule,,162.9,,,162.9,Fee Schedule,,146.51,,,146.51,Fee Schedule,,138.48,,,138.48,Fee Schedule,,125.73,,,125.73,Other,110% of Medicare,69.17,,,69.17,Fee Schedule,,33,,,33,Other,186% of Medicaid,81.47,,,81.47,Fee Schedule,,157.48,,,157.48,Fee Schedule,,46.12,,,46.12,Fee Schedule,,81.47,,,81.47,Fee Schedule,,157.48,,,157.48,Fee Schedule,,86.74,,,86.74,Fee Schedule,,177.8,70,,177.8,percent of total billed charges,All Other,104.07,,,104.07,Fee Schedule,,88.21,,,88.21,Fee Schedule,,32.94,,,32.94,Fee Schedule,,32.94,,,32.94,Fee Schedule,,32.94,,,32.94,Fee Schedule,,32.94,,,32.94,Fee Schedule,,17.86,,,17.86,Other,100% of Medicaid,17.86,,,17.86,Other,100% of Medicaid,17.86,,,17.86,Other,100% of Medicaid,17.86,,,17.86,Other,100% of Medicaid,40.19,,,40.19,Other,225% of Medicaid,27.33,,,27.33,Other,153% of Medicaid,40.19,,,40.19,Other,225% of Medicaid,25.01,,,25.01,Other,140% of Medicaid,40.19,,,40.19,Other,225% of Medicaid,46.45,,,46.45,Other,260% of Medicaid,57.88,,,57.88,Other,324% of Medicaid,38.41,,,38.41,Other,215% of Medicaid,38.41,,,38.41,Other,215% of Medicaid,22.33,,,22.33,Other,125% of Medicaid,17.86,187.96,
HEMOGLOBIN ELECTROPHORESIS,83020,CPT,,78083020,CDM,301,RC,,,both,,,83,61.42,,,61.42,Other,150% of Medicare + 9.63% HCRA Surcharge,37.35,45,,37.35,percent of total billed charges,Critical Access Hospital RCC factor,38.74,,,38.74,Fee Schedule,,34.88,,,34.88,Fee Schedule,,95.49,,,95.49,Fee Schedule,,85.89,,,85.89,Fee Schedule,,81.18,,,81.18,Fee Schedule,,41.09,,,41.09,Other,110% of Medicare,40.54,,,40.54,Fee Schedule,,24,,,24,Other,186% of Medicaid,47.75,,,47.75,Fee Schedule,,51.46,,,51.46,Fee Schedule,,27.03,,,27.03,Fee Schedule,,47.75,,,47.75,Fee Schedule,,51.46,,,51.46,Fee Schedule,,50.84,,,50.84,Fee Schedule,,58.1,70,,58.1,percent of total billed charges,All Other,60.99,,,60.99,Fee Schedule,,51.69,,,51.69,Fee Schedule,,19.31,,,19.31,Fee Schedule,,19.31,,,19.31,Fee Schedule,,19.31,,,19.31,Fee Schedule,,19.31,,,19.31,Fee Schedule,,12.87,,,12.87,Other,100% of Medicaid,12.87,,,12.87,Other,100% of Medicaid,12.87,,,12.87,Other,100% of Medicaid,12.87,,,12.87,Other,100% of Medicaid,28.96,,,28.96,Other,225% of Medicaid,19.69,,,19.69,Other,153% of Medicaid,28.96,,,28.96,Other,225% of Medicaid,18.02,,,18.02,Other,140% of Medicaid,28.96,,,28.96,Other,225% of Medicaid,33.46,,,33.46,Other,260% of Medicaid,41.7,,,41.7,Other,324% of Medicaid,27.67,,,27.67,Other,215% of Medicaid,27.67,,,27.67,Other,215% of Medicaid,16.09,,,16.09,Other,125% of Medicaid,12.87,95.49,
HEMOGLOBIN CHROMOTOGRAPHY,83021,CPT,,78083021,CDM,301,RC,,,both,,,186,137.64,,,137.64,Other,150% of Medicare + 9.63% HCRA Surcharge,83.7,45,,83.7,percent of total billed charges,Critical Access Hospital RCC factor,54.36,,,54.36,Fee Schedule,,48.94,,,48.94,Fee Schedule,,133.91,,,133.91,Fee Schedule,,120.44,,,120.44,Fee Schedule,,113.84,,,113.84,Fee Schedule,,92.07,,,92.07,Other,110% of Medicare,56.89,,,56.89,Fee Schedule,,34,,,34,Other,186% of Medicaid,67,,,67,Fee Schedule,,115.32,,,115.32,Fee Schedule,,37.93,,,37.93,Fee Schedule,,67,,,67,Fee Schedule,,115.32,,,115.32,Fee Schedule,,71.34,,,71.34,Fee Schedule,,130.2,70,,130.2,percent of total billed charges,All Other,85.59,,,85.59,Fee Schedule,,72.54,,,72.54,Fee Schedule,,27.09,,,27.09,Fee Schedule,,27.09,,,27.09,Fee Schedule,,27.09,,,27.09,Fee Schedule,,27.09,,,27.09,Fee Schedule,,18.06,,,18.06,Other,100% of Medicaid,18.06,,,18.06,Other,100% of Medicaid,18.06,,,18.06,Other,100% of Medicaid,18.06,,,18.06,Other,100% of Medicaid,40.64,,,40.64,Other,225% of Medicaid,27.63,,,27.63,Other,153% of Medicaid,40.64,,,40.64,Other,225% of Medicaid,25.28,,,25.28,Other,140% of Medicaid,40.64,,,40.64,Other,225% of Medicaid,46.96,,,46.96,Other,260% of Medicaid,58.51,,,58.51,Other,324% of Medicaid,38.83,,,38.83,Other,215% of Medicaid,38.83,,,38.83,Other,215% of Medicaid,22.58,,,22.58,Other,125% of Medicaid,18.06,137.64,
FETAL HEMOGLOBIN CHEMICAL,83030,CPT,,78083030,CDM,301,RC,,,both,,,79,58.46,,,58.46,Other,150% of Medicare + 9.63% HCRA Surcharge,35.55,45,,35.55,percent of total billed charges,Critical Access Hospital RCC factor,32.33,,,32.33,Fee Schedule,,29.11,,,29.11,Fee Schedule,,25.88,,,25.88,Fee Schedule,,23.27,,,23.27,Fee Schedule,,22,,,22,Fee Schedule,,39.11,,,39.11,Other,110% of Medicare,33.83,,,33.83,Fee Schedule,,7,,,7,Other,186% of Medicaid,39.85,,,39.85,Fee Schedule,,48.98,,,48.98,Fee Schedule,,22.55,,,22.55,Fee Schedule,,39.85,,,39.85,Fee Schedule,,48.98,,,48.98,Fee Schedule,,42.42,,,42.42,Fee Schedule,,55.3,70,,55.3,percent of total billed charges,All Other,50.9,,,50.9,Fee Schedule,,43.14,,,43.14,Fee Schedule,,16.11,,,16.11,Fee Schedule,,16.11,,,16.11,Fee Schedule,,16.11,,,16.11,Fee Schedule,,16.11,,,16.11,Fee Schedule,,3.79,,,3.79,Other,100% of Medicaid,3.79,,,3.79,Other,100% of Medicaid,3.79,,,3.79,Other,100% of Medicaid,3.79,,,3.79,Other,100% of Medicaid,8.52,,,8.52,Other,225% of Medicaid,5.79,,,5.79,Other,153% of Medicaid,8.52,,,8.52,Other,225% of Medicaid,5.3,,,5.3,Other,140% of Medicaid,8.52,,,8.52,Other,225% of Medicaid,9.85,,,9.85,Other,260% of Medicaid,12.27,,,12.27,Other,324% of Medicaid,8.14,,,8.14,Other,215% of Medicaid,8.14,,,8.14,Other,215% of Medicaid,4.73,,,4.73,Other,125% of Medicaid,3.79,58.46,
FETAL HEMOGLOBIN ASSAY QUAL,83033,CPT,,78083033,CDM,301,RC,,,both,,,92,68.08,,,68.08,Other,150% of Medicare + 9.63% HCRA Surcharge,41.4,45,,41.4,percent of total billed charges,Critical Access Hospital RCC factor,24.08,,,24.08,Fee Schedule,,21.68,,,21.68,Fee Schedule,,25.88,,,25.88,Fee Schedule,,23.27,,,23.27,Fee Schedule,,22,,,22,Fee Schedule,,45.54,,,45.54,Other,110% of Medicare,25.2,,,25.2,Fee Schedule,,12,,,12,Other,186% of Medicaid,29.68,,,29.68,Fee Schedule,,57.04,,,57.04,Fee Schedule,,16.8,,,16.8,Fee Schedule,,29.68,,,29.68,Fee Schedule,,57.04,,,57.04,Fee Schedule,,31.6,,,31.6,Fee Schedule,,64.4,70,,64.4,percent of total billed charges,All Other,37.91,,,37.91,Fee Schedule,,32.13,,,32.13,Fee Schedule,,12,,,12,Fee Schedule,,12,,,12,Fee Schedule,,12,,,12,Fee Schedule,,12,,,12,Fee Schedule,,6.31,,,6.31,Other,100% of Medicaid,6.31,,,6.31,Other,100% of Medicaid,6.31,,,6.31,Other,100% of Medicaid,6.31,,,6.31,Other,100% of Medicaid,14.2,,,14.2,Other,225% of Medicaid,9.65,,,9.65,Other,153% of Medicaid,14.2,,,14.2,Other,225% of Medicaid,8.83,,,8.83,Other,140% of Medicaid,14.2,,,14.2,Other,225% of Medicaid,16.41,,,16.41,Other,260% of Medicaid,20.45,,,20.45,Other,324% of Medicaid,13.57,,,13.57,Other,215% of Medicaid,13.57,,,13.57,Other,215% of Medicaid,7.89,,,7.89,Other,125% of Medicaid,6.31,68.08,
GLYCOSYLATED HEMOGLOBIN TEST,83036,CPT,,78083036,CDM,301,RC,,,both,,,138,102.12,,,102.12,Other,150% of Medicare + 9.63% HCRA Surcharge,62.1,45,,62.1,percent of total billed charges,Critical Access Hospital RCC factor,29.23,,,29.23,Fee Schedule,,26.31,,,26.31,Fee Schedule,,71.99,,,71.99,Fee Schedule,,64.75,,,64.75,Fee Schedule,,61.2,,,61.2,Fee Schedule,,68.31,,,68.31,Other,110% of Medicare,30.59,,,30.59,Fee Schedule,,18,,,18,Other,186% of Medicaid,36.02,,,36.02,Fee Schedule,,85.56,,,85.56,Fee Schedule,,20.39,,,20.39,Fee Schedule,,36.02,,,36.02,Fee Schedule,,85.56,,,85.56,Fee Schedule,,38.35,,,38.35,Fee Schedule,,96.6,70,,96.6,percent of total billed charges,All Other,46.02,,,46.02,Fee Schedule,,39,,,39,Fee Schedule,,14.57,,,14.57,Fee Schedule,,14.57,,,14.57,Fee Schedule,,14.57,,,14.57,Fee Schedule,,14.57,,,14.57,Fee Schedule,,9.71,,,9.71,Other,100% of Medicaid,9.71,,,9.71,Other,100% of Medicaid,9.71,,,9.71,Other,100% of Medicaid,9.71,,,9.71,Other,100% of Medicaid,21.85,,,21.85,Other,225% of Medicaid,14.86,,,14.86,Other,153% of Medicaid,21.85,,,21.85,Other,225% of Medicaid,13.59,,,13.59,Other,140% of Medicaid,21.85,,,21.85,Other,225% of Medicaid,25.25,,,25.25,Other,260% of Medicaid,31.46,,,31.46,Other,324% of Medicaid,20.88,,,20.88,Other,215% of Medicaid,20.88,,,20.88,Other,215% of Medicaid,12.14,,,12.14,Other,125% of Medicaid,9.71,102.12,
BLOOD METHEMOGLOBIN ASSAY,83050,CPT,,78083050,CDM,301,RC,,,both,,,180,133.2,,,133.2,Other,150% of Medicare + 9.63% HCRA Surcharge,81,45,,81,percent of total billed charges,Critical Access Hospital RCC factor,24.68,,,24.68,Fee Schedule,,22.22,,,22.22,Fee Schedule,,25.88,,,25.88,Fee Schedule,,23.27,,,23.27,Fee Schedule,,22,,,22,Fee Schedule,,89.1,,,89.1,Other,110% of Medicare,25.83,,,25.83,Fee Schedule,,7,,,7,Other,186% of Medicaid,30.42,,,30.42,Fee Schedule,,111.6,,,111.6,Fee Schedule,,17.22,,,17.22,Fee Schedule,,30.42,,,30.42,Fee Schedule,,111.6,,,111.6,Fee Schedule,,32.39,,,32.39,Fee Schedule,,126,70,,126,percent of total billed charges,All Other,38.86,,,38.86,Fee Schedule,,32.94,,,32.94,Fee Schedule,,12.3,,,12.3,Fee Schedule,,12.3,,,12.3,Fee Schedule,,12.3,,,12.3,Fee Schedule,,12.3,,,12.3,Fee Schedule,,3.79,,,3.79,Other,100% of Medicaid,3.79,,,3.79,Other,100% of Medicaid,3.79,,,3.79,Other,100% of Medicaid,3.79,,,3.79,Other,100% of Medicaid,8.52,,,8.52,Other,225% of Medicaid,5.79,,,5.79,Other,153% of Medicaid,8.52,,,8.52,Other,225% of Medicaid,5.3,,,5.3,Other,140% of Medicaid,8.52,,,8.52,Other,225% of Medicaid,9.85,,,9.85,Other,260% of Medicaid,12.27,,,12.27,Other,324% of Medicaid,8.14,,,8.14,Other,215% of Medicaid,8.14,,,8.14,Other,215% of Medicaid,4.73,,,4.73,Other,125% of Medicaid,3.79,133.2,
ASSAY OF PLASMA HEMOGLOBIN,83051,CPT,,78083051,CDM,301,RC,,,both,,,125,92.5,,,92.5,Other,150% of Medicare + 9.63% HCRA Surcharge,56.25,45,,56.25,percent of total billed charges,Critical Access Hospital RCC factor,22,,,22,Fee Schedule,,19.81,,,19.81,Fee Schedule,,25.88,,,25.88,Fee Schedule,,23.27,,,23.27,Fee Schedule,,22,,,22,Fee Schedule,,61.88,,,61.88,Other,110% of Medicare,23.03,,,23.03,Fee Schedule,,7,,,7,Other,186% of Medicaid,27.12,,,27.12,Fee Schedule,,77.5,,,77.5,Fee Schedule,,15.35,,,15.35,Fee Schedule,,27.12,,,27.12,Fee Schedule,,77.5,,,77.5,Fee Schedule,,28.87,,,28.87,Fee Schedule,,87.5,70,,87.5,percent of total billed charges,All Other,34.64,,,34.64,Fee Schedule,,29.36,,,29.36,Fee Schedule,,10.97,,,10.97,Fee Schedule,,10.97,,,10.97,Fee Schedule,,10.97,,,10.97,Fee Schedule,,10.97,,,10.97,Fee Schedule,,3.79,,,3.79,Other,100% of Medicaid,3.79,,,3.79,Other,100% of Medicaid,3.79,,,3.79,Other,100% of Medicaid,3.79,,,3.79,Other,100% of Medicaid,8.52,,,8.52,Other,225% of Medicaid,5.79,,,5.79,Other,153% of Medicaid,8.52,,,8.52,Other,225% of Medicaid,5.3,,,5.3,Other,140% of Medicaid,8.52,,,8.52,Other,225% of Medicaid,9.85,,,9.85,Other,260% of Medicaid,12.27,,,12.27,Other,324% of Medicaid,8.14,,,8.14,Other,215% of Medicaid,8.14,,,8.14,Other,215% of Medicaid,4.73,,,4.73,Other,125% of Medicaid,3.79,92.5,
HEMOGLOBIN STABILITY SCREEN,83068,CPT,,78083068,CDM,301,RC,,,both,,,31,22.94,,,22.94,Other,150% of Medicare + 9.63% HCRA Surcharge,13.95,45,,13.95,percent of total billed charges,Critical Access Hospital RCC factor,28.5,,,28.5,Fee Schedule,,25.66,,,25.66,Fee Schedule,,25.88,,,25.88,Fee Schedule,,23.27,,,23.27,Fee Schedule,,22,,,22,Fee Schedule,,15.35,,,15.35,Other,110% of Medicare,29.83,,,29.83,Fee Schedule,,12,,,12,Other,186% of Medicaid,35.13,,,35.13,Fee Schedule,,19.22,,,19.22,Fee Schedule,,19.89,,,19.89,Fee Schedule,,35.13,,,35.13,Fee Schedule,,19.22,,,19.22,Fee Schedule,,37.41,,,37.41,Fee Schedule,,21.7,70,,21.7,percent of total billed charges,All Other,44.88,,,44.88,Fee Schedule,,38.04,,,38.04,Fee Schedule,,14.21,,,14.21,Fee Schedule,,14.21,,,14.21,Fee Schedule,,14.21,,,14.21,Fee Schedule,,14.21,,,14.21,Fee Schedule,,6.31,,,6.31,Other,100% of Medicaid,6.31,,,6.31,Other,100% of Medicaid,6.31,,,6.31,Other,100% of Medicaid,6.31,,,6.31,Other,100% of Medicaid,14.2,,,14.2,Other,225% of Medicaid,9.65,,,9.65,Other,153% of Medicaid,14.2,,,14.2,Other,225% of Medicaid,8.83,,,8.83,Other,140% of Medicaid,14.2,,,14.2,Other,225% of Medicaid,16.41,,,16.41,Other,260% of Medicaid,20.45,,,20.45,Other,324% of Medicaid,13.57,,,13.57,Other,215% of Medicaid,13.57,,,13.57,Other,215% of Medicaid,7.89,,,7.89,Other,125% of Medicaid,6.31,44.88,
ASSAY OF URINE HEMOGLOBIN,83069,CPT,,78083069,CDM,301,RC,,,both,,,30,22.2,,,22.2,Other,150% of Medicare + 9.63% HCRA Surcharge,13.5,45,,13.5,percent of total billed charges,Critical Access Hospital RCC factor,11.89,,,11.89,Fee Schedule,,10.7,,,10.7,Fee Schedule,,25.88,,,25.88,Fee Schedule,,23.27,,,23.27,Fee Schedule,,22,,,22,Fee Schedule,,14.85,,,14.85,Other,110% of Medicare,12.44,,,12.44,Fee Schedule,,12,,,12,Other,186% of Medicaid,14.65,,,14.65,Fee Schedule,,18.6,,,18.6,Fee Schedule,,8.3,,,8.3,Fee Schedule,,14.65,,,14.65,Fee Schedule,,18.6,,,18.6,Fee Schedule,,15.6,,,15.6,Fee Schedule,,21,70,,21,percent of total billed charges,All Other,18.72,,,18.72,Fee Schedule,,15.87,,,15.87,Fee Schedule,,5.93,,,5.93,Fee Schedule,,5.93,,,5.93,Fee Schedule,,5.93,,,5.93,Fee Schedule,,5.93,,,5.93,Fee Schedule,,6.31,,,6.31,Other,100% of Medicaid,6.31,,,6.31,Other,100% of Medicaid,6.31,,,6.31,Other,100% of Medicaid,6.31,,,6.31,Other,100% of Medicaid,14.2,,,14.2,Other,225% of Medicaid,9.65,,,9.65,Other,153% of Medicaid,14.2,,,14.2,Other,225% of Medicaid,8.83,,,8.83,Other,140% of Medicaid,14.2,,,14.2,Other,225% of Medicaid,16.41,,,16.41,Other,260% of Medicaid,20.45,,,20.45,Other,324% of Medicaid,13.57,,,13.57,Other,215% of Medicaid,13.57,,,13.57,Other,215% of Medicaid,7.89,,,7.89,Other,125% of Medicaid,5.93,25.88,
ASSAY OF HEMOSIDERIN QUAL,83070,CPT,,78083070,CDM,301,RC,,,both,,,87,64.38,,,64.38,Other,150% of Medicare + 9.63% HCRA Surcharge,39.15,45,,39.15,percent of total billed charges,Critical Access Hospital RCC factor,14.3,,,14.3,Fee Schedule,,12.87,,,12.87,Fee Schedule,,35.2,,,35.2,Fee Schedule,,31.66,,,31.66,Fee Schedule,,29.93,,,29.93,Fee Schedule,,43.07,,,43.07,Other,110% of Medicare,14.96,,,14.96,Fee Schedule,,12,,,12,Other,186% of Medicaid,17.62,,,17.62,Fee Schedule,,53.94,,,53.94,Fee Schedule,,9.98,,,9.98,Fee Schedule,,17.62,,,17.62,Fee Schedule,,53.94,,,53.94,Fee Schedule,,18.76,,,18.76,Fee Schedule,,60.9,70,,60.9,percent of total billed charges,All Other,22.51,,,22.51,Fee Schedule,,19.08,,,19.08,Fee Schedule,,7.13,,,7.13,Fee Schedule,,7.13,,,7.13,Fee Schedule,,7.13,,,7.13,Fee Schedule,,7.13,,,7.13,Fee Schedule,,6.31,,,6.31,Other,100% of Medicaid,6.31,,,6.31,Other,100% of Medicaid,6.31,,,6.31,Other,100% of Medicaid,6.31,,,6.31,Other,100% of Medicaid,14.2,,,14.2,Other,225% of Medicaid,9.65,,,9.65,Other,153% of Medicaid,14.2,,,14.2,Other,225% of Medicaid,8.83,,,8.83,Other,140% of Medicaid,14.2,,,14.2,Other,225% of Medicaid,16.41,,,16.41,Other,260% of Medicaid,20.45,,,20.45,Other,324% of Medicaid,13.57,,,13.57,Other,215% of Medicaid,13.57,,,13.57,Other,215% of Medicaid,7.89,,,7.89,Other,125% of Medicaid,6.31,64.38,
ASSAY OF HISTAMINE,83088,CPT,,78083088,CDM,301,RC,,,both,,,582,430.68,,,430.68,Other,150% of Medicare + 9.63% HCRA Surcharge,261.9,45,,261.9,percent of total billed charges,Critical Access Hospital RCC factor,88.89,,,88.89,Fee Schedule,,80.03,,,80.03,Fee Schedule,,219.02,,,219.02,Fee Schedule,,196.99,,,196.99,Fee Schedule,,186.19,,,186.19,Fee Schedule,,288.09,,,288.09,Other,110% of Medicare,93.02,,,93.02,Fee Schedule,,59,,,59,Other,186% of Medicaid,109.56,,,109.56,Fee Schedule,,360.84,,,360.84,Fee Schedule,,62.01,,,62.01,Fee Schedule,,109.56,,,109.56,Fee Schedule,,360.84,,,360.84,Fee Schedule,,116.64,,,116.64,Fee Schedule,,407.4,70,,407.4,percent of total billed charges,All Other,139.94,,,139.94,Fee Schedule,,118.61,,,118.61,Fee Schedule,,44.3,,,44.3,Fee Schedule,,44.3,,,44.3,Fee Schedule,,44.3,,,44.3,Fee Schedule,,44.3,,,44.3,Fee Schedule,,31.7,,,31.7,Other,100% of Medicaid,31.7,,,31.7,Other,100% of Medicaid,31.7,,,31.7,Other,100% of Medicaid,31.7,,,31.7,Other,100% of Medicaid,71.33,,,71.33,Other,225% of Medicaid,48.51,,,48.51,Other,153% of Medicaid,71.33,,,71.33,Other,225% of Medicaid,44.38,,,44.38,Other,140% of Medicaid,71.33,,,71.33,Other,225% of Medicaid,82.43,,,82.43,Other,260% of Medicaid,102.72,,,102.72,Other,324% of Medicaid,68.16,,,68.16,Other,215% of Medicaid,68.16,,,68.16,Other,215% of Medicaid,39.63,,,39.63,Other,125% of Medicaid,31.7,430.68,
ASSAY OF FOR HVA,83150,CPT,,78083150,CDM,301,RC,,,both,,,184,136.16,,,136.16,Other,150% of Medicare + 9.63% HCRA Surcharge,82.8,45,,82.8,percent of total billed charges,Critical Access Hospital RCC factor,67.45,,,67.45,Fee Schedule,,60.73,,,60.73,Fee Schedule,,43.11,,,43.11,Fee Schedule,,38.77,,,38.77,Fee Schedule,,36.65,,,36.65,Fee Schedule,,91.08,,,91.08,Other,110% of Medicare,70.59,,,70.59,Fee Schedule,,12,,,12,Other,186% of Medicaid,83.14,,,83.14,Fee Schedule,,114.08,,,114.08,Fee Schedule,,47.06,,,47.06,Fee Schedule,,83.14,,,83.14,Fee Schedule,,114.08,,,114.08,Fee Schedule,,88.52,,,88.52,Fee Schedule,,128.8,70,,128.8,percent of total billed charges,All Other,106.2,,,106.2,Fee Schedule,,90.01,,,90.01,Fee Schedule,,33.62,,,33.62,Fee Schedule,,33.62,,,33.62,Fee Schedule,,33.62,,,33.62,Fee Schedule,,33.62,,,33.62,Fee Schedule,,6.31,,,6.31,Other,100% of Medicaid,6.31,,,6.31,Other,100% of Medicaid,6.31,,,6.31,Other,100% of Medicaid,6.31,,,6.31,Other,100% of Medicaid,14.2,,,14.2,Other,225% of Medicaid,9.66,,,9.66,Other,153% of Medicaid,14.2,,,14.2,Other,225% of Medicaid,8.84,,,8.84,Other,140% of Medicaid,14.2,,,14.2,Other,225% of Medicaid,16.41,,,16.41,Other,260% of Medicaid,20.45,,,20.45,Other,324% of Medicaid,13.57,,,13.57,Other,215% of Medicaid,13.57,,,13.57,Other,215% of Medicaid,7.89,,,7.89,Other,125% of Medicaid,6.31,136.16,
ASSAY OF CORTICOSTEROIDS,83491,CPT,,78083491,CDM,301,RC,,,both,,,226,167.24,,,167.24,Other,150% of Medicare + 9.63% HCRA Surcharge,101.7,45,,101.7,percent of total billed charges,Critical Access Hospital RCC factor,53.88,,,53.88,Fee Schedule,,48.51,,,48.51,Fee Schedule,,129.91,,,129.91,Fee Schedule,,116.84,,,116.84,Fee Schedule,,110.43,,,110.43,Fee Schedule,,111.87,,,111.87,Other,110% of Medicare,56.39,,,56.39,Fee Schedule,,44,,,44,Other,186% of Medicaid,66.41,,,66.41,Fee Schedule,,140.12,,,140.12,Fee Schedule,,37.59,,,37.59,Fee Schedule,,66.41,,,66.41,Fee Schedule,,140.12,,,140.12,Fee Schedule,,70.71,,,70.71,Fee Schedule,,158.2,70,,158.2,percent of total billed charges,All Other,84.83,,,84.83,Fee Schedule,,71.9,,,71.9,Fee Schedule,,26.85,,,26.85,Fee Schedule,,26.85,,,26.85,Fee Schedule,,26.85,,,26.85,Fee Schedule,,26.85,,,26.85,Fee Schedule,,23.84,,,23.84,Other,100% of Medicaid,23.84,,,23.84,Other,100% of Medicaid,23.84,,,23.84,Other,100% of Medicaid,23.84,,,23.84,Other,100% of Medicaid,53.64,,,53.64,Other,225% of Medicaid,36.47,,,36.47,Other,153% of Medicaid,53.64,,,53.64,Other,225% of Medicaid,33.37,,,33.37,Other,140% of Medicaid,53.64,,,53.64,Other,225% of Medicaid,61.98,,,61.98,Other,260% of Medicaid,77.24,,,77.24,Other,324% of Medicaid,51.25,,,51.25,Other,215% of Medicaid,51.25,,,51.25,Other,215% of Medicaid,29.8,,,29.8,Other,125% of Medicaid,23.84,167.24,
ASSAY OF 5-HIAA,83497,CPT,,78083497,CDM,301,RC,,,both,,,171,126.54,,,126.54,Other,150% of Medicare + 9.63% HCRA Surcharge,76.95,45,,76.95,percent of total billed charges,Critical Access Hospital RCC factor,38.83,,,38.83,Fee Schedule,,34.96,,,34.96,Fee Schedule,,95.6,,,95.6,Fee Schedule,,85.98,,,85.98,Fee Schedule,,81.27,,,81.27,Fee Schedule,,84.65,,,84.65,Other,110% of Medicare,40.64,,,40.64,Fee Schedule,,24,,,24,Other,186% of Medicaid,47.86,,,47.86,Fee Schedule,,106.02,,,106.02,Fee Schedule,,27.09,,,27.09,Fee Schedule,,47.86,,,47.86,Fee Schedule,,106.02,,,106.02,Fee Schedule,,50.96,,,50.96,Fee Schedule,,119.7,70,,119.7,percent of total billed charges,All Other,61.13,,,61.13,Fee Schedule,,51.81,,,51.81,Fee Schedule,,19.35,,,19.35,Fee Schedule,,19.35,,,19.35,Fee Schedule,,19.35,,,19.35,Fee Schedule,,19.35,,,19.35,Fee Schedule,,12.9,,,12.9,Other,100% of Medicaid,12.9,,,12.9,Other,100% of Medicaid,12.9,,,12.9,Other,100% of Medicaid,12.9,,,12.9,Other,100% of Medicaid,29.03,,,29.03,Other,225% of Medicaid,19.74,,,19.74,Other,153% of Medicaid,29.03,,,29.03,Other,225% of Medicaid,18.06,,,18.06,Other,140% of Medicaid,29.03,,,29.03,Other,225% of Medicaid,33.54,,,33.54,Other,260% of Medicaid,41.8,,,41.8,Other,324% of Medicaid,27.74,,,27.74,Other,215% of Medicaid,27.74,,,27.74,Other,215% of Medicaid,16.13,,,16.13,Other,125% of Medicaid,12.9,126.54,
ASSAY OF PROGESTERONE,83498,CPT,,78083498,CDM,301,RC,,,both,,,298,220.52,,,220.52,Other,150% of Medicare + 9.63% HCRA Surcharge,134.1,45,,134.1,percent of total billed charges,Critical Access Hospital RCC factor,81.78,,,81.78,Fee Schedule,,73.63,,,73.63,Fee Schedule,,201.47,,,201.47,Fee Schedule,,181.21,,,181.21,Fee Schedule,,171.27,,,171.27,Fee Schedule,,147.51,,,147.51,Other,110% of Medicare,85.59,,,85.59,Fee Schedule,,51,,,51,Other,186% of Medicaid,100.8,,,100.8,Fee Schedule,,184.76,,,184.76,Fee Schedule,,57.06,,,57.06,Fee Schedule,,100.8,,,100.8,Fee Schedule,,184.76,,,184.76,Fee Schedule,,107.32,,,107.32,Fee Schedule,,208.6,70,,208.6,percent of total billed charges,All Other,128.76,,,128.76,Fee Schedule,,109.13,,,109.13,Fee Schedule,,40.76,,,40.76,Fee Schedule,,40.76,,,40.76,Fee Schedule,,40.76,,,40.76,Fee Schedule,,40.76,,,40.76,Fee Schedule,,27.17,,,27.17,Other,100% of Medicaid,27.17,,,27.17,Other,100% of Medicaid,27.17,,,27.17,Other,100% of Medicaid,27.17,,,27.17,Other,100% of Medicaid,61.13,,,61.13,Other,225% of Medicaid,41.57,,,41.57,Other,153% of Medicaid,61.13,,,61.13,Other,225% of Medicaid,38.04,,,38.04,Other,140% of Medicaid,61.13,,,61.13,Other,225% of Medicaid,70.64,,,70.64,Other,260% of Medicaid,88.03,,,88.03,Other,324% of Medicaid,58.42,,,58.42,Other,215% of Medicaid,58.42,,,58.42,Other,215% of Medicaid,33.96,,,33.96,Other,125% of Medicaid,27.17,220.52,
ASSAY FREE HYDROXYPROLINE,83500,CPT,,78083500,CDM,301,RC,,,both,,,293,216.82,,,216.82,Other,150% of Medicare + 9.63% HCRA Surcharge,131.85,45,,131.85,percent of total billed charges,Critical Access Hospital RCC factor,68.18,,,68.18,Fee Schedule,,61.38,,,61.38,Fee Schedule,,167.95,,,167.95,Fee Schedule,,151.06,,,151.06,Fee Schedule,,142.78,,,142.78,Fee Schedule,,145.04,,,145.04,Other,110% of Medicare,71.35,,,71.35,Fee Schedule,,42,,,42,Other,186% of Medicaid,84.03,,,84.03,Fee Schedule,,181.66,,,181.66,Fee Schedule,,47.57,,,47.57,Fee Schedule,,84.03,,,84.03,Fee Schedule,,181.66,,,181.66,Fee Schedule,,89.47,,,89.47,Fee Schedule,,205.1,70,,205.1,percent of total billed charges,All Other,107.34,,,107.34,Fee Schedule,,90.98,,,90.98,Fee Schedule,,33.98,,,33.98,Fee Schedule,,33.98,,,33.98,Fee Schedule,,33.98,,,33.98,Fee Schedule,,33.98,,,33.98,Fee Schedule,,22.65,,,22.65,Other,100% of Medicaid,22.65,,,22.65,Other,100% of Medicaid,22.65,,,22.65,Other,100% of Medicaid,22.65,,,22.65,Other,100% of Medicaid,50.96,,,50.96,Other,225% of Medicaid,34.65,,,34.65,Other,153% of Medicaid,50.96,,,50.96,Other,225% of Medicaid,31.71,,,31.71,Other,140% of Medicaid,50.96,,,50.96,Other,225% of Medicaid,58.89,,,58.89,Other,260% of Medicaid,73.39,,,73.39,Other,324% of Medicaid,48.7,,,48.7,Other,215% of Medicaid,48.7,,,48.7,Other,215% of Medicaid,28.31,,,28.31,Other,125% of Medicaid,22.65,216.82,
IMMUNOASSAY NONANTIBODY,83516,CPT,,78083516,CDM,301,RC,,,both,,,132,97.68,,,97.68,Other,150% of Medicare + 9.63% HCRA Surcharge,59.4,45,,59.4,percent of total billed charges,Critical Access Hospital RCC factor,34.71,,,34.71,Fee Schedule,,31.25,,,31.25,Fee Schedule,,64.87,,,64.87,Fee Schedule,,58.35,,,58.35,Fee Schedule,,55.15,,,55.15,Fee Schedule,,65.34,,,65.34,Other,110% of Medicare,36.32,,,36.32,Fee Schedule,,19,,,19,Other,186% of Medicaid,42.78,,,42.78,Fee Schedule,,81.84,,,81.84,Fee Schedule,,24.21,,,24.21,Fee Schedule,,42.78,,,42.78,Fee Schedule,,81.84,,,81.84,Fee Schedule,,45.54,,,45.54,Fee Schedule,,92.4,70,,92.4,percent of total billed charges,All Other,54.64,,,54.64,Fee Schedule,,46.31,,,46.31,Fee Schedule,,17.3,,,17.3,Fee Schedule,,17.3,,,17.3,Fee Schedule,,17.3,,,17.3,Fee Schedule,,17.3,,,17.3,Fee Schedule,,10.16,,,10.16,Other,100% of Medicaid,10.16,,,10.16,Other,100% of Medicaid,10.16,,,10.16,Other,100% of Medicaid,10.16,,,10.16,Other,100% of Medicaid,22.85,,,22.85,Other,225% of Medicaid,15.54,,,15.54,Other,153% of Medicaid,22.85,,,22.85,Other,225% of Medicaid,14.22,,,14.22,Other,140% of Medicaid,22.85,,,22.85,Other,225% of Medicaid,26.4,,,26.4,Other,260% of Medicaid,32.9,,,32.9,Other,324% of Medicaid,21.83,,,21.83,Other,215% of Medicaid,21.83,,,21.83,Other,215% of Medicaid,12.69,,,12.69,Other,125% of Medicaid,10.16,97.68,
RIA NONANTIBODY,83519,CPT,,78083519,CDM,301,RC,,,both,,,343,253.82,,,253.82,Other,150% of Medicare + 9.63% HCRA Surcharge,154.35,45,,154.35,percent of total billed charges,Critical Access Hospital RCC factor,55.38,,,55.38,Fee Schedule,,49.86,,,49.86,Fee Schedule,,100.18,,,100.18,Fee Schedule,,90.11,,,90.11,Fee Schedule,,85.16,,,85.16,Fee Schedule,,169.79,,,169.79,Other,110% of Medicare,57.96,,,57.96,Fee Schedule,,19,,,19,Other,186% of Medicaid,68.26,,,68.26,Fee Schedule,,212.66,,,212.66,Fee Schedule,,38.64,,,38.64,Fee Schedule,,68.26,,,68.26,Fee Schedule,,212.66,,,212.66,Fee Schedule,,72.68,,,72.68,Fee Schedule,,240.1,70,,240.1,percent of total billed charges,All Other,87.2,,,87.2,Fee Schedule,,73.91,,,73.91,Fee Schedule,,27.6,,,27.6,Fee Schedule,,27.6,,,27.6,Fee Schedule,,27.6,,,27.6,Fee Schedule,,27.6,,,27.6,Fee Schedule,,10.16,,,10.16,Other,100% of Medicaid,10.16,,,10.16,Other,100% of Medicaid,10.16,,,10.16,Other,100% of Medicaid,10.16,,,10.16,Other,100% of Medicaid,22.85,,,22.85,Other,225% of Medicaid,15.54,,,15.54,Other,153% of Medicaid,22.85,,,22.85,Other,225% of Medicaid,14.22,,,14.22,Other,140% of Medicaid,22.85,,,22.85,Other,225% of Medicaid,26.4,,,26.4,Other,260% of Medicaid,32.9,,,32.9,Other,324% of Medicaid,21.83,,,21.83,Other,215% of Medicaid,21.83,,,21.83,Other,215% of Medicaid,12.69,,,12.69,Other,125% of Medicaid,10.16,253.82,
ASSAY OF INSULIN,83525,CPT,,78083525,CDM,301,RC,,,both,,,168,124.32,,,124.32,Other,150% of Medicare + 9.63% HCRA Surcharge,75.6,45,,75.6,percent of total billed charges,Critical Access Hospital RCC factor,34.4,,,34.4,Fee Schedule,,30.98,,,30.98,Fee Schedule,,84.79,,,84.79,Fee Schedule,,76.27,,,76.27,Fee Schedule,,72.08,,,72.08,Fee Schedule,,83.16,,,83.16,Other,110% of Medicare,36,,,36,Fee Schedule,,21,,,21,Other,186% of Medicaid,42.41,,,42.41,Fee Schedule,,104.16,,,104.16,Fee Schedule,,24,,,24,Fee Schedule,,42.41,,,42.41,Fee Schedule,,104.16,,,104.16,Fee Schedule,,45.15,,,45.15,Fee Schedule,,117.6,70,,117.6,percent of total billed charges,All Other,54.17,,,54.17,Fee Schedule,,45.91,,,45.91,Fee Schedule,,17.15,,,17.15,Fee Schedule,,17.15,,,17.15,Fee Schedule,,17.15,,,17.15,Fee Schedule,,17.15,,,17.15,Fee Schedule,,11.43,,,11.43,Other,100% of Medicaid,11.43,,,11.43,Other,100% of Medicaid,11.43,,,11.43,Other,100% of Medicaid,11.43,,,11.43,Other,100% of Medicaid,25.72,,,25.72,Other,225% of Medicaid,17.49,,,17.49,Other,153% of Medicaid,25.72,,,25.72,Other,225% of Medicaid,16,,,16,Other,140% of Medicaid,25.72,,,25.72,Other,225% of Medicaid,29.72,,,29.72,Other,260% of Medicaid,37.03,,,37.03,Other,324% of Medicaid,24.57,,,24.57,Other,215% of Medicaid,24.57,,,24.57,Other,215% of Medicaid,14.29,,,14.29,Other,125% of Medicaid,11.43,124.32,
ASSAY OF IRON,83540,CPT,,78083540,CDM,301,RC,,,both,,,82,60.68,,,60.68,Other,150% of Medicare + 9.63% HCRA Surcharge,36.9,45,,36.9,percent of total billed charges,Critical Access Hospital RCC factor,19.47,,,19.47,Fee Schedule,,17.53,,,17.53,Fee Schedule,,48.06,,,48.06,Fee Schedule,,43.23,,,43.23,Fee Schedule,,40.86,,,40.86,Fee Schedule,,40.59,,,40.59,Other,110% of Medicare,20.38,,,20.38,Fee Schedule,,9,,,9,Other,186% of Medicaid,24,,,24,Fee Schedule,,50.84,,,50.84,Fee Schedule,,13.59,,,13.59,Fee Schedule,,24,,,24,Fee Schedule,,50.84,,,50.84,Fee Schedule,,25.56,,,25.56,Fee Schedule,,57.4,70,,57.4,percent of total billed charges,All Other,30.66,,,30.66,Fee Schedule,,25.99,,,25.99,Fee Schedule,,9.71,,,9.71,Fee Schedule,,9.71,,,9.71,Fee Schedule,,9.71,,,9.71,Fee Schedule,,9.71,,,9.71,Fee Schedule,,5.08,,,5.08,Other,100% of Medicaid,5.08,,,5.08,Other,100% of Medicaid,5.08,,,5.08,Other,100% of Medicaid,5.08,,,5.08,Other,100% of Medicaid,11.43,,,11.43,Other,225% of Medicaid,7.77,,,7.77,Other,153% of Medicaid,11.43,,,11.43,Other,225% of Medicaid,7.11,,,7.11,Other,140% of Medicaid,11.43,,,11.43,Other,225% of Medicaid,13.21,,,13.21,Other,260% of Medicaid,16.46,,,16.46,Other,324% of Medicaid,10.92,,,10.92,Other,215% of Medicaid,10.92,,,10.92,Other,215% of Medicaid,6.35,,,6.35,Other,125% of Medicaid,5.08,60.68,
IRON BINDING TEST,83550,CPT,,78083550,CDM,301,RC,,,both,,,91,67.34,,,67.34,Other,150% of Medicare + 9.63% HCRA Surcharge,40.95,45,,40.95,percent of total billed charges,Critical Access Hospital RCC factor,26.31,,,26.31,Fee Schedule,,23.69,,,23.69,Fee Schedule,,64.82,,,64.82,Fee Schedule,,58.3,,,58.3,Fee Schedule,,55.1,,,55.1,Fee Schedule,,45.05,,,45.05,Other,110% of Medicare,27.53,,,27.53,Fee Schedule,,9,,,9,Other,186% of Medicaid,32.43,,,32.43,Fee Schedule,,56.42,,,56.42,Fee Schedule,,18.35,,,18.35,Fee Schedule,,32.43,,,32.43,Fee Schedule,,56.42,,,56.42,Fee Schedule,,34.52,,,34.52,Fee Schedule,,63.7,70,,63.7,percent of total billed charges,All Other,41.42,,,41.42,Fee Schedule,,35.11,,,35.11,Fee Schedule,,13.11,,,13.11,Fee Schedule,,13.11,,,13.11,Fee Schedule,,13.11,,,13.11,Fee Schedule,,13.11,,,13.11,Fee Schedule,,5.08,,,5.08,Other,100% of Medicaid,5.08,,,5.08,Other,100% of Medicaid,5.08,,,5.08,Other,100% of Medicaid,5.08,,,5.08,Other,100% of Medicaid,11.43,,,11.43,Other,225% of Medicaid,7.77,,,7.77,Other,153% of Medicaid,11.43,,,11.43,Other,225% of Medicaid,7.11,,,7.11,Other,140% of Medicaid,11.43,,,11.43,Other,225% of Medicaid,13.21,,,13.21,Other,260% of Medicaid,16.46,,,16.46,Other,324% of Medicaid,10.92,,,10.92,Other,215% of Medicaid,10.92,,,10.92,Other,215% of Medicaid,6.35,,,6.35,Other,125% of Medicaid,5.08,67.34,
ASSAY OF IDH ENZYME,83570,CPT,,78083570,CDM,301,RC,,,both,,,50,37,,,37,Other,150% of Medicare + 9.63% HCRA Surcharge,22.5,45,,22.5,percent of total billed charges,Critical Access Hospital RCC factor,26.64,,,26.64,Fee Schedule,,23.98,,,23.98,Fee Schedule,,65.61,,,65.61,Fee Schedule,,59.01,,,59.01,Fee Schedule,,55.78,,,55.78,Fee Schedule,,24.75,,,24.75,Other,110% of Medicare,27.88,,,27.88,Fee Schedule,,12,,,12,Other,186% of Medicaid,32.83,,,32.83,Fee Schedule,,31,,,31,Fee Schedule,,18.59,,,18.59,Fee Schedule,,32.83,,,32.83,Fee Schedule,,31,,,31,Fee Schedule,,34.96,,,34.96,Fee Schedule,,35,70,,35,percent of total billed charges,All Other,41.94,,,41.94,Fee Schedule,,35.55,,,35.55,Fee Schedule,,13.28,,,13.28,Fee Schedule,,13.28,,,13.28,Fee Schedule,,13.28,,,13.28,Fee Schedule,,13.28,,,13.28,Fee Schedule,,6.31,,,6.31,Other,100% of Medicaid,6.31,,,6.31,Other,100% of Medicaid,6.31,,,6.31,Other,100% of Medicaid,6.31,,,6.31,Other,100% of Medicaid,14.2,,,14.2,Other,225% of Medicaid,9.65,,,9.65,Other,153% of Medicaid,14.2,,,14.2,Other,225% of Medicaid,8.83,,,8.83,Other,140% of Medicaid,14.2,,,14.2,Other,225% of Medicaid,16.41,,,16.41,Other,260% of Medicaid,20.45,,,20.45,Other,324% of Medicaid,13.57,,,13.57,Other,215% of Medicaid,13.57,,,13.57,Other,215% of Medicaid,7.89,,,7.89,Other,125% of Medicaid,6.31,65.61,
ASSAY OF KETOGENIC STEROIDS,83582,CPT,,78083582,CDM,301,RC,,,both,,,186,137.64,,,137.64,Other,150% of Medicare + 9.63% HCRA Surcharge,83.7,45,,83.7,percent of total billed charges,Critical Access Hospital RCC factor,46.56,,,46.56,Fee Schedule,,41.92,,,41.92,Fee Schedule,,105.08,,,105.08,Fee Schedule,,94.52,,,94.52,Fee Schedule,,89.33,,,89.33,Fee Schedule,,92.07,,,92.07,Other,110% of Medicare,48.73,,,48.73,Fee Schedule,,44,,,44,Other,186% of Medicaid,57.39,,,57.39,Fee Schedule,,115.32,,,115.32,Fee Schedule,,32.49,,,32.49,Fee Schedule,,57.39,,,57.39,Fee Schedule,,115.32,,,115.32,Fee Schedule,,61.11,,,61.11,Fee Schedule,,130.2,70,,130.2,percent of total billed charges,All Other,73.31,,,73.31,Fee Schedule,,62.14,,,62.14,Fee Schedule,,23.21,,,23.21,Fee Schedule,,23.21,,,23.21,Fee Schedule,,23.21,,,23.21,Fee Schedule,,23.21,,,23.21,Fee Schedule,,23.84,,,23.84,Other,100% of Medicaid,23.84,,,23.84,Other,100% of Medicaid,23.84,,,23.84,Other,100% of Medicaid,23.84,,,23.84,Other,100% of Medicaid,53.64,,,53.64,Other,225% of Medicaid,36.47,,,36.47,Other,153% of Medicaid,53.64,,,53.64,Other,225% of Medicaid,33.37,,,33.37,Other,140% of Medicaid,53.64,,,53.64,Other,225% of Medicaid,61.98,,,61.98,Other,260% of Medicaid,77.24,,,77.24,Other,324% of Medicaid,51.25,,,51.25,Other,215% of Medicaid,51.25,,,51.25,Other,215% of Medicaid,29.8,,,29.8,Other,125% of Medicaid,23.21,137.64,
ASSAY 17- KETOSTEROIDS,83586,CPT,,78083586,CDM,301,RC,,,both,,,155,114.7,,,114.7,Other,150% of Medicare + 9.63% HCRA Surcharge,69.75,45,,69.75,percent of total billed charges,Critical Access Hospital RCC factor,38.53,,,38.53,Fee Schedule,,34.69,,,34.69,Fee Schedule,,69.04,,,69.04,Fee Schedule,,62.09,,,62.09,Fee Schedule,,58.69,,,58.69,Fee Schedule,,76.73,,,76.73,Other,110% of Medicare,40.32,,,40.32,Fee Schedule,,18,,,18,Other,186% of Medicaid,47.49,,,47.49,Fee Schedule,,96.1,,,96.1,Fee Schedule,,26.88,,,26.88,Fee Schedule,,47.49,,,47.49,Fee Schedule,,96.1,,,96.1,Fee Schedule,,50.56,,,50.56,Fee Schedule,,108.5,70,,108.5,percent of total billed charges,All Other,60.66,,,60.66,Fee Schedule,,51.41,,,51.41,Fee Schedule,,19.2,,,19.2,Fee Schedule,,19.2,,,19.2,Fee Schedule,,19.2,,,19.2,Fee Schedule,,19.2,,,19.2,Fee Schedule,,9.49,,,9.49,Other,100% of Medicaid,9.49,,,9.49,Other,100% of Medicaid,9.49,,,9.49,Other,100% of Medicaid,9.49,,,9.49,Other,100% of Medicaid,21.36,,,21.36,Other,225% of Medicaid,14.53,,,14.53,Other,153% of Medicaid,21.36,,,21.36,Other,225% of Medicaid,13.29,,,13.29,Other,140% of Medicaid,21.36,,,21.36,Other,225% of Medicaid,24.68,,,24.68,Other,260% of Medicaid,30.76,,,30.76,Other,324% of Medicaid,20.41,,,20.41,Other,215% of Medicaid,20.41,,,20.41,Other,215% of Medicaid,11.87,,,11.87,Other,125% of Medicaid,9.49,114.7,
FRACTIONATION KETOSTEROIDS,83593,CPT,,78083593,CDM,301,RC,,,both,,,147,108.78,,,108.78,Other,150% of Medicare + 9.63% HCRA Surcharge,66.15,45,,66.15,percent of total billed charges,Critical Access Hospital RCC factor,85.79,,,85.79,Fee Schedule,,77.24,,,77.24,Fee Schedule,,64.87,,,64.87,Fee Schedule,,58.35,,,58.35,Fee Schedule,,55.15,,,55.15,Fee Schedule,,72.77,,,72.77,Other,110% of Medicare,89.78,,,89.78,Fee Schedule,,22,,,22,Other,186% of Medicaid,105.74,,,105.74,Fee Schedule,,91.14,,,91.14,Fee Schedule,,59.85,,,59.85,Fee Schedule,,105.74,,,105.74,Fee Schedule,,91.14,,,91.14,Fee Schedule,,112.58,,,112.58,Fee Schedule,,102.9,70,,102.9,percent of total billed charges,All Other,135.06,,,135.06,Fee Schedule,,114.47,,,114.47,Fee Schedule,,42.75,,,42.75,Fee Schedule,,42.75,,,42.75,Fee Schedule,,42.75,,,42.75,Fee Schedule,,42.75,,,42.75,Fee Schedule,,11.56,,,11.56,Other,100% of Medicaid,11.56,,,11.56,Other,100% of Medicaid,11.56,,,11.56,Other,100% of Medicaid,11.56,,,11.56,Other,100% of Medicaid,26.02,,,26.02,Other,225% of Medicaid,17.69,,,17.69,Other,153% of Medicaid,26.02,,,26.02,Other,225% of Medicaid,16.19,,,16.19,Other,140% of Medicaid,26.02,,,26.02,Other,225% of Medicaid,30.07,,,30.07,Other,260% of Medicaid,37.47,,,37.47,Other,324% of Medicaid,24.86,,,24.86,Other,215% of Medicaid,24.86,,,24.86,Other,215% of Medicaid,14.46,,,14.46,Other,125% of Medicaid,11.56,135.06,
LACTATE (LD) (LDH) ENZYME,83615,CPT,,78083615,CDM,301,RC,,,both,,,87,64.38,,,64.38,Other,150% of Medicare + 9.63% HCRA Surcharge,39.15,45,,39.15,percent of total billed charges,Critical Access Hospital RCC factor,18.18,,,18.18,Fee Schedule,,16.37,,,16.37,Fee Schedule,,44.8,,,44.8,Fee Schedule,,40.29,,,40.29,Fee Schedule,,38.08,,,38.08,Fee Schedule,,43.07,,,43.07,Other,110% of Medicare,19.03,,,19.03,Fee Schedule,,9,,,9,Other,186% of Medicaid,22.41,,,22.41,Fee Schedule,,53.94,,,53.94,Fee Schedule,,12.68,,,12.68,Fee Schedule,,22.41,,,22.41,Fee Schedule,,53.94,,,53.94,Fee Schedule,,23.86,,,23.86,Fee Schedule,,60.9,70,,60.9,percent of total billed charges,All Other,28.62,,,28.62,Fee Schedule,,24.26,,,24.26,Fee Schedule,,9.06,,,9.06,Fee Schedule,,9.06,,,9.06,Fee Schedule,,9.06,,,9.06,Fee Schedule,,9.06,,,9.06,Fee Schedule,,5.08,,,5.08,Other,100% of Medicaid,5.08,,,5.08,Other,100% of Medicaid,5.08,,,5.08,Other,100% of Medicaid,5.08,,,5.08,Other,100% of Medicaid,11.43,,,11.43,Other,225% of Medicaid,7.77,,,7.77,Other,153% of Medicaid,11.43,,,11.43,Other,225% of Medicaid,7.11,,,7.11,Other,140% of Medicaid,11.43,,,11.43,Other,225% of Medicaid,13.21,,,13.21,Other,260% of Medicaid,16.46,,,16.46,Other,324% of Medicaid,10.92,,,10.92,Other,215% of Medicaid,10.92,,,10.92,Other,215% of Medicaid,6.35,,,6.35,Other,125% of Medicaid,5.08,64.38,
ASSAY OF LDH ENZYMES,83625,CPT,,78083625,CDM,301,RC,,,both,,,180,133.2,,,133.2,Other,150% of Medicare + 9.63% HCRA Surcharge,81,45,,81,percent of total billed charges,Critical Access Hospital RCC factor,38.5,,,38.5,Fee Schedule,,34.66,,,34.66,Fee Schedule,,64.87,,,64.87,Fee Schedule,,58.35,,,58.35,Fee Schedule,,55.15,,,55.15,Fee Schedule,,89.1,,,89.1,Other,110% of Medicare,40.29,,,40.29,Fee Schedule,,18,,,18,Other,186% of Medicaid,47.45,,,47.45,Fee Schedule,,111.6,,,111.6,Fee Schedule,,26.86,,,26.86,Fee Schedule,,47.45,,,47.45,Fee Schedule,,111.6,,,111.6,Fee Schedule,,50.52,,,50.52,Fee Schedule,,126,70,,126,percent of total billed charges,All Other,60.61,,,60.61,Fee Schedule,,51.37,,,51.37,Fee Schedule,,19.19,,,19.19,Fee Schedule,,19.19,,,19.19,Fee Schedule,,19.19,,,19.19,Fee Schedule,,19.19,,,19.19,Fee Schedule,,9.49,,,9.49,Other,100% of Medicaid,9.49,,,9.49,Other,100% of Medicaid,9.49,,,9.49,Other,100% of Medicaid,9.49,,,9.49,Other,100% of Medicaid,21.36,,,21.36,Other,225% of Medicaid,14.53,,,14.53,Other,153% of Medicaid,21.36,,,21.36,Other,225% of Medicaid,13.29,,,13.29,Other,140% of Medicaid,21.36,,,21.36,Other,225% of Medicaid,24.68,,,24.68,Other,260% of Medicaid,30.76,,,30.76,Other,324% of Medicaid,20.41,,,20.41,Other,215% of Medicaid,20.41,,,20.41,Other,215% of Medicaid,11.87,,,11.87,Other,125% of Medicaid,9.49,133.2,
"LACTOFERRIN, FECAL, QUANT",83631,CPT,,78083631,CDM,301,RC,,,both,,,154,113.96,,,113.96,Other,150% of Medicare + 9.63% HCRA Surcharge,69.3,45,,69.3,percent of total billed charges,Critical Access Hospital RCC factor,59.09,,,59.09,Fee Schedule,,53.2,,,53.2,Fee Schedule,,145.56,,,145.56,Fee Schedule,,130.92,,,130.92,Fee Schedule,,123.74,,,123.74,Fee Schedule,,76.23,,,76.23,Other,110% of Medicare,61.83,,,61.83,Fee Schedule,,21,,,21,Other,186% of Medicaid,72.83,,,72.83,Fee Schedule,,95.48,,,95.48,Fee Schedule,,41.22,,,41.22,Fee Schedule,,72.83,,,72.83,Fee Schedule,,95.48,,,95.48,Fee Schedule,,77.54,,,77.54,Fee Schedule,,107.8,70,,107.8,percent of total billed charges,All Other,93.03,,,93.03,Fee Schedule,,78.85,,,78.85,Fee Schedule,,29.45,,,29.45,Fee Schedule,,29.45,,,29.45,Fee Schedule,,29.45,,,29.45,Fee Schedule,,29.45,,,29.45,Fee Schedule,,11.39,,,11.39,Other,100% of Medicaid,11.39,,,11.39,Other,100% of Medicaid,11.39,,,11.39,Other,100% of Medicaid,11.39,,,11.39,Other,100% of Medicaid,25.63,,,25.63,Other,225% of Medicaid,17.43,,,17.43,Other,153% of Medicaid,25.63,,,25.63,Other,225% of Medicaid,15.95,,,15.95,Other,140% of Medicaid,25.63,,,25.63,Other,225% of Medicaid,29.62,,,29.62,Other,260% of Medicaid,36.91,,,36.91,Other,324% of Medicaid,24.49,,,24.49,Other,215% of Medicaid,24.49,,,24.49,Other,215% of Medicaid,14.24,,,14.24,Other,125% of Medicaid,11.39,145.56,
PLACENTAL LACTOGEN,83632,CPT,,78083632,CDM,301,RC,,,both,,,202,149.48,,,149.48,Other,150% of Medicare + 9.63% HCRA Surcharge,90.9,45,,90.9,percent of total billed charges,Critical Access Hospital RCC factor,60.86,,,60.86,Fee Schedule,,54.8,,,54.8,Fee Schedule,,149.93,,,149.93,Fee Schedule,,134.85,,,134.85,Fee Schedule,,127.46,,,127.46,Fee Schedule,,99.99,,,99.99,Other,110% of Medicare,63.69,,,63.69,Fee Schedule,,19,,,19,Other,186% of Medicaid,75.02,,,75.02,Fee Schedule,,125.24,,,125.24,Fee Schedule,,42.46,,,42.46,Fee Schedule,,75.02,,,75.02,Fee Schedule,,125.24,,,125.24,Fee Schedule,,79.87,,,79.87,Fee Schedule,,141.4,70,,141.4,percent of total billed charges,All Other,95.82,,,95.82,Fee Schedule,,81.22,,,81.22,Fee Schedule,,30.33,,,30.33,Fee Schedule,,30.33,,,30.33,Fee Schedule,,30.33,,,30.33,Fee Schedule,,30.33,,,30.33,Fee Schedule,,10.16,,,10.16,Other,100% of Medicaid,10.16,,,10.16,Other,100% of Medicaid,10.16,,,10.16,Other,100% of Medicaid,10.16,,,10.16,Other,100% of Medicaid,22.85,,,22.85,Other,225% of Medicaid,15.54,,,15.54,Other,153% of Medicaid,22.85,,,22.85,Other,225% of Medicaid,14.22,,,14.22,Other,140% of Medicaid,22.85,,,22.85,Other,225% of Medicaid,26.4,,,26.4,Other,260% of Medicaid,32.9,,,32.9,Other,324% of Medicaid,21.83,,,21.83,Other,215% of Medicaid,21.83,,,21.83,Other,215% of Medicaid,12.69,,,12.69,Other,125% of Medicaid,10.16,149.93,
ASSAY OF LEAD,83655,CPT,,78083655,CDM,301,RC,,,both,,,160,118.4,,,118.4,Other,150% of Medicare + 9.63% HCRA Surcharge,72,45,,72,percent of total billed charges,Critical Access Hospital RCC factor,36.45,,,36.45,Fee Schedule,,32.82,,,32.82,Fee Schedule,,89.75,,,89.75,Fee Schedule,,80.72,,,80.72,Fee Schedule,,76.29,,,76.29,Fee Schedule,,79.2,,,79.2,Other,110% of Medicare,38.15,,,38.15,Fee Schedule,,23,,,23,Other,186% of Medicaid,44.93,,,44.93,Fee Schedule,,99.2,,,99.2,Fee Schedule,,25.43,,,25.43,Fee Schedule,,44.93,,,44.93,Fee Schedule,,99.2,,,99.2,Fee Schedule,,47.83,,,47.83,Fee Schedule,,112,70,,112,percent of total billed charges,All Other,57.39,,,57.39,Fee Schedule,,48.64,,,48.64,Fee Schedule,,18.17,,,18.17,Fee Schedule,,18.17,,,18.17,Fee Schedule,,18.17,,,18.17,Fee Schedule,,18.17,,,18.17,Fee Schedule,,12.11,,,12.11,Other,100% of Medicaid,12.11,,,12.11,Other,100% of Medicaid,12.11,,,12.11,Other,100% of Medicaid,12.11,,,12.11,Other,100% of Medicaid,27.25,,,27.25,Other,225% of Medicaid,18.53,,,18.53,Other,153% of Medicaid,27.25,,,27.25,Other,225% of Medicaid,16.95,,,16.95,Other,140% of Medicaid,27.25,,,27.25,Other,225% of Medicaid,31.49,,,31.49,Other,260% of Medicaid,39.24,,,39.24,Other,324% of Medicaid,26.04,,,26.04,Other,215% of Medicaid,26.04,,,26.04,Other,215% of Medicaid,15.14,,,15.14,Other,125% of Medicaid,12.11,118.4,
L/S RATIO FETAL LUNG,83661,CPT,,78083661,CDM,301,RC,,,both,,,328,242.72,,,242.72,Other,150% of Medicare + 9.63% HCRA Surcharge,147.6,45,,147.6,percent of total billed charges,Critical Access Hospital RCC factor,66.19,,,66.19,Fee Schedule,,59.59,,,59.59,Fee Schedule,,163.05,,,163.05,Fee Schedule,,146.66,,,146.66,Fee Schedule,,138.61,,,138.61,Fee Schedule,,162.36,,,162.36,Other,110% of Medicare,69.27,,,69.27,Fee Schedule,,41,,,41,Other,186% of Medicaid,81.58,,,81.58,Fee Schedule,,203.36,,,203.36,Fee Schedule,,46.18,,,46.18,Fee Schedule,,81.58,,,81.58,Fee Schedule,,203.36,,,203.36,Fee Schedule,,86.86,,,86.86,Fee Schedule,,229.6,70,,229.6,percent of total billed charges,All Other,104.21,,,104.21,Fee Schedule,,88.33,,,88.33,Fee Schedule,,32.99,,,32.99,Fee Schedule,,32.99,,,32.99,Fee Schedule,,32.99,,,32.99,Fee Schedule,,32.99,,,32.99,Fee Schedule,,21.99,,,21.99,Other,100% of Medicaid,21.99,,,21.99,Other,100% of Medicaid,21.99,,,21.99,Other,100% of Medicaid,21.99,,,21.99,Other,100% of Medicaid,49.48,,,49.48,Other,225% of Medicaid,33.64,,,33.64,Other,153% of Medicaid,49.48,,,49.48,Other,225% of Medicaid,30.79,,,30.79,Other,140% of Medicaid,49.48,,,49.48,Other,225% of Medicaid,57.17,,,57.17,Other,260% of Medicaid,71.25,,,71.25,Other,324% of Medicaid,47.28,,,47.28,Other,215% of Medicaid,47.28,,,47.28,Other,215% of Medicaid,27.49,,,27.49,Other,125% of Medicaid,21.99,242.72,
ASSAY OF LAP ENZYME,83670,CPT,,78083670,CDM,301,RC,,,both,,,92,68.08,,,68.08,Other,150% of Medicare + 9.63% HCRA Surcharge,41.4,45,,41.4,percent of total billed charges,Critical Access Hospital RCC factor,29.53,,,29.53,Fee Schedule,,26.59,,,26.59,Fee Schedule,,53.07,,,53.07,Fee Schedule,,47.73,,,47.73,Fee Schedule,,45.11,,,45.11,Fee Schedule,,45.54,,,45.54,Other,110% of Medicare,30.9,,,30.9,Fee Schedule,,12,,,12,Other,186% of Medicaid,36.4,,,36.4,Fee Schedule,,57.04,,,57.04,Fee Schedule,,20.6,,,20.6,Fee Schedule,,36.4,,,36.4,Fee Schedule,,57.04,,,57.04,Fee Schedule,,38.75,,,38.75,Fee Schedule,,64.4,70,,64.4,percent of total billed charges,All Other,46.49,,,46.49,Fee Schedule,,39.4,,,39.4,Fee Schedule,,14.72,,,14.72,Fee Schedule,,14.72,,,14.72,Fee Schedule,,14.72,,,14.72,Fee Schedule,,14.72,,,14.72,Fee Schedule,,6.31,,,6.31,Other,100% of Medicaid,6.31,,,6.31,Other,100% of Medicaid,6.31,,,6.31,Other,100% of Medicaid,6.31,,,6.31,Other,100% of Medicaid,14.2,,,14.2,Other,225% of Medicaid,9.65,,,9.65,Other,153% of Medicaid,14.2,,,14.2,Other,225% of Medicaid,8.83,,,8.83,Other,140% of Medicaid,14.2,,,14.2,Other,225% of Medicaid,16.41,,,16.41,Other,260% of Medicaid,20.45,,,20.45,Other,324% of Medicaid,13.57,,,13.57,Other,215% of Medicaid,13.57,,,13.57,Other,215% of Medicaid,7.89,,,7.89,Other,125% of Medicaid,6.31,68.08,
ASSAY OF LIPASE,83690,CPT,,78083690,CDM,301,RC,,,both,,,100,74,,,74,Other,150% of Medicare + 9.63% HCRA Surcharge,45,45,,45,percent of total billed charges,Critical Access Hospital RCC factor,20.74,,,20.74,Fee Schedule,,18.67,,,18.67,Fee Schedule,,43.11,,,43.11,Fee Schedule,,38.77,,,38.77,Fee Schedule,,36.65,,,36.65,Fee Schedule,,49.5,,,49.5,Other,110% of Medicare,21.7,,,21.7,Fee Schedule,,11,,,11,Other,186% of Medicaid,25.56,,,25.56,Fee Schedule,,62,,,62,Fee Schedule,,14.47,,,14.47,Fee Schedule,,25.56,,,25.56,Fee Schedule,,62,,,62,Fee Schedule,,27.22,,,27.22,Fee Schedule,,70,70,,70,percent of total billed charges,All Other,32.65,,,32.65,Fee Schedule,,27.67,,,27.67,Fee Schedule,,10.34,,,10.34,Fee Schedule,,10.34,,,10.34,Fee Schedule,,10.34,,,10.34,Fee Schedule,,10.34,,,10.34,Fee Schedule,,5.81,,,5.81,Other,100% of Medicaid,5.81,,,5.81,Other,100% of Medicaid,5.81,,,5.81,Other,100% of Medicaid,5.81,,,5.81,Other,100% of Medicaid,13.07,,,13.07,Other,225% of Medicaid,8.89,,,8.89,Other,153% of Medicaid,13.07,,,13.07,Other,225% of Medicaid,8.13,,,8.13,Other,140% of Medicaid,13.07,,,13.07,Other,225% of Medicaid,15.1,,,15.1,Other,260% of Medicaid,18.82,,,18.82,Other,324% of Medicaid,12.49,,,12.49,Other,215% of Medicaid,12.49,,,12.49,Other,215% of Medicaid,7.26,,,7.26,Other,125% of Medicaid,5.81,74,
ASSAY OF LIPOPROTEIN(A),83695,CPT,,78083695,CDM,301,RC,,,both,,,109,80.66,,,80.66,Other,150% of Medicare + 9.63% HCRA Surcharge,49.05,45,,49.05,percent of total billed charges,Critical Access Hospital RCC factor,43.1,,,43.1,Fee Schedule,,38.81,,,38.81,Fee Schedule,,96.02,,,96.02,Fee Schedule,,86.36,,,86.36,Fee Schedule,,81.63,,,81.63,Fee Schedule,,53.96,,,53.96,Other,110% of Medicare,45.11,,,45.11,Fee Schedule,,19,,,19,Other,186% of Medicaid,53.13,,,53.13,Fee Schedule,,67.58,,,67.58,Fee Schedule,,30.07,,,30.07,Fee Schedule,,53.13,,,53.13,Fee Schedule,,67.58,,,67.58,Fee Schedule,,56.56,,,56.56,Fee Schedule,,76.3,70,,76.3,percent of total billed charges,All Other,67.86,,,67.86,Fee Schedule,,57.52,,,57.52,Fee Schedule,,21.48,,,21.48,Fee Schedule,,21.48,,,21.48,Fee Schedule,,21.48,,,21.48,Fee Schedule,,21.48,,,21.48,Fee Schedule,,10.16,,,10.16,Other,100% of Medicaid,10.16,,,10.16,Other,100% of Medicaid,10.16,,,10.16,Other,100% of Medicaid,10.16,,,10.16,Other,100% of Medicaid,22.85,,,22.85,Other,225% of Medicaid,15.54,,,15.54,Other,153% of Medicaid,22.85,,,22.85,Other,225% of Medicaid,14.22,,,14.22,Other,140% of Medicaid,22.85,,,22.85,Other,225% of Medicaid,26.4,,,26.4,Other,260% of Medicaid,32.9,,,32.9,Other,324% of Medicaid,21.83,,,21.83,Other,215% of Medicaid,21.83,,,21.83,Other,215% of Medicaid,12.69,,,12.69,Other,125% of Medicaid,10.16,96.02,
LIPOPRO BLD ELECTROPHORETIC,83700,CPT,,78083700,CDM,301,RC,,,both,,,137,101.38,,,101.38,Other,150% of Medicare + 9.63% HCRA Surcharge,61.65,45,,61.65,percent of total billed charges,Critical Access Hospital RCC factor,33.89,,,33.89,Fee Schedule,,30.51,,,30.51,Fee Schedule,,83.48,,,83.48,Fee Schedule,,75.08,,,75.08,Fee Schedule,,70.96,,,70.96,Fee Schedule,,67.82,,,67.82,Other,110% of Medicare,35.47,,,35.47,Fee Schedule,,19,,,19,Other,186% of Medicaid,41.77,,,41.77,Fee Schedule,,84.94,,,84.94,Fee Schedule,,23.65,,,23.65,Fee Schedule,,41.77,,,41.77,Fee Schedule,,84.94,,,84.94,Fee Schedule,,44.48,,,44.48,Fee Schedule,,95.9,70,,95.9,percent of total billed charges,All Other,53.36,,,53.36,Fee Schedule,,45.23,,,45.23,Fee Schedule,,16.89,,,16.89,Fee Schedule,,16.89,,,16.89,Fee Schedule,,16.89,,,16.89,Fee Schedule,,16.89,,,16.89,Fee Schedule,,10.16,,,10.16,Other,100% of Medicaid,10.16,,,10.16,Other,100% of Medicaid,10.16,,,10.16,Other,100% of Medicaid,10.16,,,10.16,Other,100% of Medicaid,22.85,,,22.85,Other,225% of Medicaid,15.54,,,15.54,Other,153% of Medicaid,22.85,,,22.85,Other,225% of Medicaid,14.22,,,14.22,Other,140% of Medicaid,22.85,,,22.85,Other,225% of Medicaid,26.4,,,26.4,Other,260% of Medicaid,32.9,,,32.9,Other,324% of Medicaid,21.83,,,21.83,Other,215% of Medicaid,21.83,,,21.83,Other,215% of Medicaid,12.69,,,12.69,Other,125% of Medicaid,10.16,101.38,
LIPOPROTEIN BLD BY NMR,83704,CPT,,78083704,CDM,301,RC,,,both,,,193,142.82,,,142.82,Other,150% of Medicare + 9.63% HCRA Surcharge,86.85,45,,86.85,percent of total billed charges,Critical Access Hospital RCC factor,102.91,,,102.91,Fee Schedule,,92.65,,,92.65,Fee Schedule,,150.77,,,150.77,Fee Schedule,,135.61,,,135.61,Fee Schedule,,128.17,,,128.17,Fee Schedule,,95.54,,,95.54,Other,110% of Medicare,107.7,,,107.7,Fee Schedule,,59,,,59,Other,186% of Medicaid,126.84,,,126.84,Fee Schedule,,119.66,,,119.66,Fee Schedule,,71.8,,,71.8,Fee Schedule,,126.84,,,126.84,Fee Schedule,,119.66,,,119.66,Fee Schedule,,135.05,,,135.05,Fee Schedule,,135.1,70,,135.1,percent of total billed charges,All Other,162.03,,,162.03,Fee Schedule,,137.33,,,137.33,Fee Schedule,,51.29,,,51.29,Fee Schedule,,51.29,,,51.29,Fee Schedule,,51.29,,,51.29,Fee Schedule,,51.29,,,51.29,Fee Schedule,,31.7,,,31.7,Other,100% of Medicaid,31.7,,,31.7,Other,100% of Medicaid,31.7,,,31.7,Other,100% of Medicaid,31.7,,,31.7,Other,100% of Medicaid,71.33,,,71.33,Other,225% of Medicaid,48.51,,,48.51,Other,153% of Medicaid,71.33,,,71.33,Other,225% of Medicaid,44.38,,,44.38,Other,140% of Medicaid,71.33,,,71.33,Other,225% of Medicaid,82.43,,,82.43,Other,260% of Medicaid,102.72,,,102.72,Other,324% of Medicaid,68.16,,,68.16,Other,215% of Medicaid,68.16,,,68.16,Other,215% of Medicaid,39.63,,,39.63,Other,125% of Medicaid,31.7,162.03,
ASSAY OF LIPOPROTEIN,83718,CPT,,78083718,CDM,301,RC,,,both,,,92,68.08,,,68.08,Other,150% of Medicare + 9.63% HCRA Surcharge,41.4,45,,41.4,percent of total billed charges,Critical Access Hospital RCC factor,24.65,,,24.65,Fee Schedule,,22.19,,,22.19,Fee Schedule,,60.71,,,60.71,Fee Schedule,,54.6,,,54.6,Fee Schedule,,51.61,,,51.61,Fee Schedule,,45.54,,,45.54,Other,110% of Medicare,25.8,,,25.8,Fee Schedule,,9,,,9,Other,186% of Medicaid,30.38,,,30.38,Fee Schedule,,57.04,,,57.04,Fee Schedule,,17.2,,,17.2,Fee Schedule,,30.38,,,30.38,Fee Schedule,,57.04,,,57.04,Fee Schedule,,32.35,,,32.35,Fee Schedule,,64.4,70,,64.4,percent of total billed charges,All Other,38.81,,,38.81,Fee Schedule,,32.9,,,32.9,Fee Schedule,,12.29,,,12.29,Fee Schedule,,12.29,,,12.29,Fee Schedule,,12.29,,,12.29,Fee Schedule,,12.29,,,12.29,Fee Schedule,,5.08,,,5.08,Other,100% of Medicaid,5.08,,,5.08,Other,100% of Medicaid,5.08,,,5.08,Other,100% of Medicaid,5.08,,,5.08,Other,100% of Medicaid,11.43,,,11.43,Other,225% of Medicaid,7.77,,,7.77,Other,153% of Medicaid,11.43,,,11.43,Other,225% of Medicaid,7.11,,,7.11,Other,140% of Medicaid,11.43,,,11.43,Other,225% of Medicaid,13.21,,,13.21,Other,260% of Medicaid,16.46,,,16.46,Other,324% of Medicaid,10.92,,,10.92,Other,215% of Medicaid,10.92,,,10.92,Other,215% of Medicaid,6.35,,,6.35,Other,125% of Medicaid,5.08,68.08,
ASSAY OF BLOOD LIPOPROTEIN,83721,CPT,,78083721,CDM,301,RC,,,both,,,264,195.36,,,195.36,Other,150% of Medicare + 9.63% HCRA Surcharge,118.8,45,,118.8,percent of total billed charges,Critical Access Hospital RCC factor,31.61,,,31.61,Fee Schedule,,28.46,,,28.46,Fee Schedule,,70.72,,,70.72,Fee Schedule,,63.61,,,63.61,Fee Schedule,,60.12,,,60.12,Fee Schedule,,130.68,,,130.68,Other,110% of Medicare,33.08,,,33.08,Fee Schedule,,12,,,12,Other,186% of Medicaid,38.96,,,38.96,Fee Schedule,,163.68,,,163.68,Fee Schedule,,22.05,,,22.05,Fee Schedule,,38.96,,,38.96,Fee Schedule,,163.68,,,163.68,Fee Schedule,,41.48,,,41.48,Fee Schedule,,184.8,70,,184.8,percent of total billed charges,All Other,49.76,,,49.76,Fee Schedule,,42.17,,,42.17,Fee Schedule,,15.75,,,15.75,Fee Schedule,,15.75,,,15.75,Fee Schedule,,15.75,,,15.75,Fee Schedule,,15.75,,,15.75,Fee Schedule,,6.31,,,6.31,Other,100% of Medicaid,6.31,,,6.31,Other,100% of Medicaid,6.31,,,6.31,Other,100% of Medicaid,6.31,,,6.31,Other,100% of Medicaid,14.2,,,14.2,Other,225% of Medicaid,9.65,,,9.65,Other,153% of Medicaid,14.2,,,14.2,Other,225% of Medicaid,8.83,,,8.83,Other,140% of Medicaid,14.2,,,14.2,Other,225% of Medicaid,16.41,,,16.41,Other,260% of Medicaid,20.45,,,20.45,Other,324% of Medicaid,13.57,,,13.57,Other,215% of Medicaid,13.57,,,13.57,Other,215% of Medicaid,7.89,,,7.89,Other,125% of Medicaid,6.31,195.36,
ASSAY OF MAGNESIUM,83735,CPT,,78083735,CDM,301,RC,,,both,,,119,88.06,,,88.06,Other,150% of Medicare + 9.63% HCRA Surcharge,53.55,45,,53.55,percent of total billed charges,Critical Access Hospital RCC factor,20.17,,,20.17,Fee Schedule,,18.16,,,18.16,Fee Schedule,,49.7,,,49.7,Fee Schedule,,44.7,,,44.7,Fee Schedule,,42.25,,,42.25,Fee Schedule,,58.91,,,58.91,Other,110% of Medicare,21.11,,,21.11,Fee Schedule,,9,,,9,Other,186% of Medicaid,24.86,,,24.86,Fee Schedule,,73.78,,,73.78,Fee Schedule,,14.07,,,14.07,Fee Schedule,,24.86,,,24.86,Fee Schedule,,73.78,,,73.78,Fee Schedule,,26.47,,,26.47,Fee Schedule,,83.3,70,,83.3,percent of total billed charges,All Other,31.75,,,31.75,Fee Schedule,,26.91,,,26.91,Fee Schedule,,10.05,,,10.05,Fee Schedule,,10.05,,,10.05,Fee Schedule,,10.05,,,10.05,Fee Schedule,,10.05,,,10.05,Fee Schedule,,5.08,,,5.08,Other,100% of Medicaid,5.08,,,5.08,Other,100% of Medicaid,5.08,,,5.08,Other,100% of Medicaid,5.08,,,5.08,Other,100% of Medicaid,11.43,,,11.43,Other,225% of Medicaid,7.77,,,7.77,Other,153% of Medicaid,11.43,,,11.43,Other,225% of Medicaid,7.11,,,7.11,Other,140% of Medicaid,11.43,,,11.43,Other,225% of Medicaid,13.21,,,13.21,Other,260% of Medicaid,16.46,,,16.46,Other,324% of Medicaid,10.92,,,10.92,Other,215% of Medicaid,10.92,,,10.92,Other,215% of Medicaid,6.35,,,6.35,Other,125% of Medicaid,5.08,88.06,
ASSAY OF MANGANESE,83785,CPT,,78083785,CDM,301,RC,,,both,,,205,151.7,,,151.7,Other,150% of Medicare + 9.63% HCRA Surcharge,92.25,45,,92.25,percent of total billed charges,Critical Access Hospital RCC factor,80.22,,,80.22,Fee Schedule,,72.22,,,72.22,Fee Schedule,,182.39,,,182.39,Fee Schedule,,164.05,,,164.05,Fee Schedule,,155.05,,,155.05,Fee Schedule,,101.48,,,101.48,Other,110% of Medicare,83.95,,,83.95,Fee Schedule,,50,,,50,Other,186% of Medicaid,98.87,,,98.87,Fee Schedule,,127.1,,,127.1,Fee Schedule,,55.97,,,55.97,Fee Schedule,,98.87,,,98.87,Fee Schedule,,127.1,,,127.1,Fee Schedule,,105.27,,,105.27,Fee Schedule,,143.5,70,,143.5,percent of total billed charges,All Other,126.3,,,126.3,Fee Schedule,,107.04,,,107.04,Fee Schedule,,39.98,,,39.98,Fee Schedule,,39.98,,,39.98,Fee Schedule,,39.98,,,39.98,Fee Schedule,,39.98,,,39.98,Fee Schedule,,26.65,,,26.65,Other,100% of Medicaid,26.65,,,26.65,Other,100% of Medicaid,26.65,,,26.65,Other,100% of Medicaid,26.65,,,26.65,Other,100% of Medicaid,59.96,,,59.96,Other,225% of Medicaid,40.77,,,40.77,Other,153% of Medicaid,59.96,,,59.96,Other,225% of Medicaid,37.31,,,37.31,Other,140% of Medicaid,59.96,,,59.96,Other,225% of Medicaid,69.29,,,69.29,Other,260% of Medicaid,86.35,,,86.35,Other,324% of Medicaid,57.3,,,57.3,Other,215% of Medicaid,57.3,,,57.3,Other,215% of Medicaid,33.31,,,33.31,Other,125% of Medicaid,26.65,182.39,
QUAN MASS SPECT EA SPECIM,83789,CPT,,78083789,CDM,301,RC,,,both,,,116,85.84,,,85.84,Other,150% of Medicare + 9.63% HCRA Surcharge,52.2,45,,52.2,percent of total billed charges,Critical Access Hospital RCC factor,72.57,,,72.57,Fee Schedule,,65.34,,,65.34,Fee Schedule,,133.91,,,133.91,Fee Schedule,,120.44,,,120.44,Fee Schedule,,113.84,,,113.84,Fee Schedule,,57.42,,,57.42,Other,110% of Medicare,75.95,,,75.95,Fee Schedule,,19,,,19,Other,186% of Medicaid,89.45,,,89.45,Fee Schedule,,71.92,,,71.92,Fee Schedule,,50.63,,,50.63,Fee Schedule,,89.45,,,89.45,Fee Schedule,,71.92,,,71.92,Fee Schedule,,95.23,,,95.23,Fee Schedule,,81.2,70,,81.2,percent of total billed charges,All Other,114.26,,,114.26,Fee Schedule,,96.84,,,96.84,Fee Schedule,,36.17,,,36.17,Fee Schedule,,36.17,,,36.17,Fee Schedule,,36.17,,,36.17,Fee Schedule,,36.17,,,36.17,Fee Schedule,,10.16,,,10.16,Other,100% of Medicaid,10.16,,,10.16,Other,100% of Medicaid,10.16,,,10.16,Other,100% of Medicaid,10.16,,,10.16,Other,100% of Medicaid,22.85,,,22.85,Other,225% of Medicaid,15.54,,,15.54,Other,153% of Medicaid,22.85,,,22.85,Other,225% of Medicaid,14.22,,,14.22,Other,140% of Medicaid,22.85,,,22.85,Other,225% of Medicaid,26.4,,,26.4,Other,260% of Medicaid,32.9,,,32.9,Other,324% of Medicaid,21.83,,,21.83,Other,215% of Medicaid,21.83,,,21.83,Other,215% of Medicaid,12.69,,,12.69,Other,125% of Medicaid,10.16,133.91,
ASSAY OF MERCURY,83825,CPT,,78083825,CDM,301,RC,,,both,,,241,178.34,,,178.34,Other,150% of Medicare + 9.63% HCRA Surcharge,108.45,45,,108.45,percent of total billed charges,Critical Access Hospital RCC factor,48.94,,,48.94,Fee Schedule,,44.06,,,44.06,Fee Schedule,,120.58,,,120.58,Fee Schedule,,108.45,,,108.45,Fee Schedule,,102.5,,,102.5,Fee Schedule,,119.3,,,119.3,Other,110% of Medicare,51.22,,,51.22,Fee Schedule,,30,,,30,Other,186% of Medicaid,60.32,,,60.32,Fee Schedule,,149.42,,,149.42,Fee Schedule,,34.15,,,34.15,Fee Schedule,,60.32,,,60.32,Fee Schedule,,149.42,,,149.42,Fee Schedule,,64.23,,,64.23,Fee Schedule,,168.7,70,,168.7,percent of total billed charges,All Other,77.06,,,77.06,Fee Schedule,,65.31,,,65.31,Fee Schedule,,24.39,,,24.39,Fee Schedule,,24.39,,,24.39,Fee Schedule,,24.39,,,24.39,Fee Schedule,,24.39,,,24.39,Fee Schedule,,16.26,,,16.26,Other,100% of Medicaid,16.26,,,16.26,Other,100% of Medicaid,16.26,,,16.26,Other,100% of Medicaid,16.26,,,16.26,Other,100% of Medicaid,36.59,,,36.59,Other,225% of Medicaid,24.88,,,24.88,Other,153% of Medicaid,36.59,,,36.59,Other,225% of Medicaid,22.76,,,22.76,Other,140% of Medicaid,36.59,,,36.59,Other,225% of Medicaid,42.28,,,42.28,Other,260% of Medicaid,52.68,,,52.68,Other,324% of Medicaid,34.96,,,34.96,Other,215% of Medicaid,34.96,,,34.96,Other,215% of Medicaid,20.33,,,20.33,Other,125% of Medicaid,16.26,178.34,
ASSAY OF METANEPHRINES,83835,CPT,,78083835,CDM,301,RC,,,both,,,395,292.3,,,292.3,Other,150% of Medicare + 9.63% HCRA Surcharge,177.75,45,,177.75,percent of total billed charges,Critical Access Hospital RCC factor,50.99,,,50.99,Fee Schedule,,45.91,,,45.91,Fee Schedule,,125.64,,,125.64,Fee Schedule,,113,,,113,Fee Schedule,,106.8,,,106.8,Fee Schedule,,195.53,,,195.53,Other,110% of Medicare,53.36,,,53.36,Fee Schedule,,32,,,32,Other,186% of Medicaid,62.85,,,62.85,Fee Schedule,,244.9,,,244.9,Fee Schedule,,35.57,,,35.57,Fee Schedule,,62.85,,,62.85,Fee Schedule,,244.9,,,244.9,Fee Schedule,,66.91,,,66.91,Fee Schedule,,276.5,70,,276.5,percent of total billed charges,All Other,80.28,,,80.28,Fee Schedule,,68.04,,,68.04,Fee Schedule,,25.41,,,25.41,Fee Schedule,,25.41,,,25.41,Fee Schedule,,25.41,,,25.41,Fee Schedule,,25.41,,,25.41,Fee Schedule,,16.94,,,16.94,Other,100% of Medicaid,16.94,,,16.94,Other,100% of Medicaid,16.94,,,16.94,Other,100% of Medicaid,16.94,,,16.94,Other,100% of Medicaid,38.12,,,38.12,Other,225% of Medicaid,25.92,,,25.92,Other,153% of Medicaid,38.12,,,38.12,Other,225% of Medicaid,23.72,,,23.72,Other,140% of Medicaid,38.12,,,38.12,Other,225% of Medicaid,44.04,,,44.04,Other,260% of Medicaid,54.89,,,54.89,Other,324% of Medicaid,36.42,,,36.42,Other,215% of Medicaid,36.42,,,36.42,Other,215% of Medicaid,21.18,,,21.18,Other,125% of Medicaid,16.94,292.3,
ASSAY OF METHEMALBUMIN,83857,CPT,,78083857,CDM,301,RC,,,both,,,55,40.7,,,40.7,Other,150% of Medicare + 9.63% HCRA Surcharge,24.75,45,,24.75,percent of total billed charges,Critical Access Hospital RCC factor,32.33,,,32.33,Fee Schedule,,29.11,,,29.11,Fee Schedule,,64.08,,,64.08,Fee Schedule,,57.64,,,57.64,Fee Schedule,,54.48,,,54.48,Fee Schedule,,27.23,,,27.23,Other,110% of Medicare,33.83,,,33.83,Fee Schedule,,12,,,12,Other,186% of Medicaid,39.85,,,39.85,Fee Schedule,,34.1,,,34.1,Fee Schedule,,22.55,,,22.55,Fee Schedule,,39.85,,,39.85,Fee Schedule,,34.1,,,34.1,Fee Schedule,,42.42,,,42.42,Fee Schedule,,38.5,70,,38.5,percent of total billed charges,All Other,50.9,,,50.9,Fee Schedule,,43.14,,,43.14,Fee Schedule,,16.11,,,16.11,Fee Schedule,,16.11,,,16.11,Fee Schedule,,16.11,,,16.11,Fee Schedule,,16.11,,,16.11,Fee Schedule,,6.31,,,6.31,Other,100% of Medicaid,6.31,,,6.31,Other,100% of Medicaid,6.31,,,6.31,Other,100% of Medicaid,6.31,,,6.31,Other,100% of Medicaid,14.2,,,14.2,Other,225% of Medicaid,9.65,,,9.65,Other,153% of Medicaid,14.2,,,14.2,Other,225% of Medicaid,8.83,,,8.83,Other,140% of Medicaid,14.2,,,14.2,Other,225% of Medicaid,16.41,,,16.41,Other,260% of Medicaid,20.45,,,20.45,Other,324% of Medicaid,13.57,,,13.57,Other,215% of Medicaid,13.57,,,13.57,Other,215% of Medicaid,7.89,,,7.89,Other,125% of Medicaid,6.31,64.08,
MUCOPOLYSACCHARIDES,83864,CPT,,78083864,CDM,301,RC,,,both,,,313,231.62,,,231.62,Other,150% of Medicare + 9.63% HCRA Surcharge,140.85,45,,140.85,percent of total billed charges,Critical Access Hospital RCC factor,85.79,,,85.79,Fee Schedule,,77.24,,,77.24,Fee Schedule,,118.79,,,118.79,Fee Schedule,,106.84,,,106.84,Fee Schedule,,100.98,,,100.98,Fee Schedule,,154.94,,,154.94,Other,110% of Medicare,89.78,,,89.78,Fee Schedule,,38,,,38,Other,186% of Medicaid,105.74,,,105.74,Fee Schedule,,194.06,,,194.06,Fee Schedule,,59.85,,,59.85,Fee Schedule,,105.74,,,105.74,Fee Schedule,,194.06,,,194.06,Fee Schedule,,112.58,,,112.58,Fee Schedule,,219.1,70,,219.1,percent of total billed charges,All Other,135.06,,,135.06,Fee Schedule,,114.47,,,114.47,Fee Schedule,,42.75,,,42.75,Fee Schedule,,42.75,,,42.75,Fee Schedule,,42.75,,,42.75,Fee Schedule,,42.75,,,42.75,Fee Schedule,,20.35,,,20.35,Other,100% of Medicaid,20.35,,,20.35,Other,100% of Medicaid,20.35,,,20.35,Other,100% of Medicaid,20.35,,,20.35,Other,100% of Medicaid,45.79,,,45.79,Other,225% of Medicaid,31.14,,,31.14,Other,153% of Medicaid,45.79,,,45.79,Other,225% of Medicaid,28.49,,,28.49,Other,140% of Medicaid,45.79,,,45.79,Other,225% of Medicaid,52.91,,,52.91,Other,260% of Medicaid,65.94,,,65.94,Other,324% of Medicaid,43.76,,,43.76,Other,215% of Medicaid,43.76,,,43.76,Other,215% of Medicaid,25.44,,,25.44,Other,125% of Medicaid,20.35,231.62,
ASSAY SYNOVIAL FLUID MUCIN,83872,CPT,,78083872,CDM,301,RC,,,both,,,47,34.78,,,34.78,Other,150% of Medicare + 9.63% HCRA Surcharge,21.15,45,,21.15,percent of total billed charges,Critical Access Hospital RCC factor,17.64,,,17.64,Fee Schedule,,15.88,,,15.88,Fee Schedule,,31.83,,,31.83,Fee Schedule,,28.63,,,28.63,Fee Schedule,,27.06,,,27.06,Fee Schedule,,23.27,,,23.27,Other,110% of Medicare,18.46,,,18.46,Fee Schedule,,12,,,12,Other,186% of Medicaid,21.74,,,21.74,Fee Schedule,,29.14,,,29.14,Fee Schedule,,12.31,,,12.31,Fee Schedule,,21.74,,,21.74,Fee Schedule,,29.14,,,29.14,Fee Schedule,,23.15,,,23.15,Fee Schedule,,32.9,70,,32.9,percent of total billed charges,All Other,27.77,,,27.77,Fee Schedule,,23.54,,,23.54,Fee Schedule,,8.79,,,8.79,Fee Schedule,,8.79,,,8.79,Fee Schedule,,8.79,,,8.79,Fee Schedule,,8.79,,,8.79,Fee Schedule,,6.31,,,6.31,Other,100% of Medicaid,6.31,,,6.31,Other,100% of Medicaid,6.31,,,6.31,Other,100% of Medicaid,6.31,,,6.31,Other,100% of Medicaid,14.2,,,14.2,Other,225% of Medicaid,9.65,,,9.65,Other,153% of Medicaid,14.2,,,14.2,Other,225% of Medicaid,8.83,,,8.83,Other,140% of Medicaid,14.2,,,14.2,Other,225% of Medicaid,16.41,,,16.41,Other,260% of Medicaid,20.45,,,20.45,Other,324% of Medicaid,13.57,,,13.57,Other,215% of Medicaid,13.57,,,13.57,Other,215% of Medicaid,7.89,,,7.89,Other,125% of Medicaid,6.31,34.78,
ASSAY OF CSF PROTEIN,83873,CPT,,78083873,CDM,301,RC,,,both,,,334,247.16,,,247.16,Other,150% of Medicare + 9.63% HCRA Surcharge,150.3,45,,150.3,percent of total billed charges,Critical Access Hospital RCC factor,51.77,,,51.77,Fee Schedule,,46.61,,,46.61,Fee Schedule,,127.59,,,127.59,Fee Schedule,,114.76,,,114.76,Fee Schedule,,108.46,,,108.46,Fee Schedule,,165.33,,,165.33,Other,110% of Medicare,54.18,,,54.18,Fee Schedule,,19,,,19,Other,186% of Medicaid,63.81,,,63.81,Fee Schedule,,207.08,,,207.08,Fee Schedule,,36.12,,,36.12,Fee Schedule,,63.81,,,63.81,Fee Schedule,,207.08,,,207.08,Fee Schedule,,67.94,,,67.94,Fee Schedule,,233.8,70,,233.8,percent of total billed charges,All Other,81.51,,,81.51,Fee Schedule,,69.09,,,69.09,Fee Schedule,,25.8,,,25.8,Fee Schedule,,25.8,,,25.8,Fee Schedule,,25.8,,,25.8,Fee Schedule,,25.8,,,25.8,Fee Schedule,,10.16,,,10.16,Other,100% of Medicaid,10.16,,,10.16,Other,100% of Medicaid,10.16,,,10.16,Other,100% of Medicaid,10.16,,,10.16,Other,100% of Medicaid,22.85,,,22.85,Other,225% of Medicaid,15.54,,,15.54,Other,153% of Medicaid,22.85,,,22.85,Other,225% of Medicaid,14.22,,,14.22,Other,140% of Medicaid,22.85,,,22.85,Other,225% of Medicaid,26.4,,,26.4,Other,260% of Medicaid,32.9,,,32.9,Other,324% of Medicaid,21.83,,,21.83,Other,215% of Medicaid,21.83,,,21.83,Other,215% of Medicaid,12.69,,,12.69,Other,125% of Medicaid,10.16,247.16,
ASSAY OF MYOGLOBIN,83874,CPT,,78083874,CDM,301,RC,,,both,,,240,177.6,,,177.6,Other,150% of Medicare + 9.63% HCRA Surcharge,108,45,,108,percent of total billed charges,Critical Access Hospital RCC factor,38.89,,,38.89,Fee Schedule,,35.01,,,35.01,Fee Schedule,,88.33,,,88.33,Fee Schedule,,79.44,,,79.44,Fee Schedule,,75.08,,,75.08,Fee Schedule,,118.8,,,118.8,Other,110% of Medicare,40.7,,,40.7,Fee Schedule,,19,,,19,Other,186% of Medicaid,47.93,,,47.93,Fee Schedule,,148.8,,,148.8,Fee Schedule,,27.13,,,27.13,Fee Schedule,,47.93,,,47.93,Fee Schedule,,148.8,,,148.8,Fee Schedule,,51.03,,,51.03,Fee Schedule,,168,70,,168,percent of total billed charges,All Other,61.23,,,61.23,Fee Schedule,,51.89,,,51.89,Fee Schedule,,19.38,,,19.38,Fee Schedule,,19.38,,,19.38,Fee Schedule,,19.38,,,19.38,Fee Schedule,,19.38,,,19.38,Fee Schedule,,10.16,,,10.16,Other,100% of Medicaid,10.16,,,10.16,Other,100% of Medicaid,10.16,,,10.16,Other,100% of Medicaid,10.16,,,10.16,Other,100% of Medicaid,22.85,,,22.85,Other,225% of Medicaid,15.54,,,15.54,Other,153% of Medicaid,22.85,,,22.85,Other,225% of Medicaid,14.22,,,14.22,Other,140% of Medicaid,22.85,,,22.85,Other,225% of Medicaid,26.4,,,26.4,Other,260% of Medicaid,32.9,,,32.9,Other,324% of Medicaid,21.83,,,21.83,Other,215% of Medicaid,21.83,,,21.83,Other,215% of Medicaid,12.69,,,12.69,Other,125% of Medicaid,10.16,177.6,
NATRIURETIC PEPTIDE,83880,CPT,,78083880,CDM,301,RC,,,both,,,230,170.2,,,170.2,Other,150% of Medicare + 9.63% HCRA Surcharge,103.5,45,,103.5,percent of total billed charges,Critical Access Hospital RCC factor,118.17,,,118.17,Fee Schedule,,106.39,,,106.39,Fee Schedule,,251.75,,,251.75,Fee Schedule,,226.43,,,226.43,Fee Schedule,,214.01,,,214.01,Fee Schedule,,113.85,,,113.85,Other,110% of Medicare,123.67,,,123.67,Fee Schedule,,64,,,64,Other,186% of Medicaid,145.65,,,145.65,Fee Schedule,,142.6,,,142.6,Fee Schedule,,82.45,,,82.45,Fee Schedule,,145.65,,,145.65,Fee Schedule,,142.6,,,142.6,Fee Schedule,,155.08,,,155.08,Fee Schedule,,161,70,,161,percent of total billed charges,All Other,186.05,,,186.05,Fee Schedule,,157.69,,,157.69,Fee Schedule,,58.89,,,58.89,Fee Schedule,,58.89,,,58.89,Fee Schedule,,58.89,,,58.89,Fee Schedule,,58.89,,,58.89,Fee Schedule,,34.41,,,34.41,Other,100% of Medicaid,34.41,,,34.41,Other,100% of Medicaid,34.41,,,34.41,Other,100% of Medicaid,34.41,,,34.41,Other,100% of Medicaid,77.42,,,77.42,Other,225% of Medicaid,52.65,,,52.65,Other,153% of Medicaid,77.42,,,77.42,Other,225% of Medicaid,48.17,,,48.17,Other,140% of Medicaid,77.42,,,77.42,Other,225% of Medicaid,89.47,,,89.47,Other,260% of Medicaid,111.49,,,111.49,Other,324% of Medicaid,73.98,,,73.98,Other,215% of Medicaid,73.98,,,73.98,Other,215% of Medicaid,43.01,,,43.01,Other,125% of Medicaid,34.41,251.75,
ASSAY NEPHELOMETRY NOT SPEC,83883,CPT,,78083883,CDM,301,RC,,,both,,,222,164.28,,,164.28,Other,150% of Medicare + 9.63% HCRA Surcharge,99.9,45,,99.9,percent of total billed charges,Critical Access Hospital RCC factor,40.94,,,40.94,Fee Schedule,,36.86,,,36.86,Fee Schedule,,84.21,,,84.21,Fee Schedule,,75.75,,,75.75,Fee Schedule,,71.59,,,71.59,Fee Schedule,,109.89,,,109.89,Other,110% of Medicare,42.84,,,42.84,Fee Schedule,,18,,,18,Other,186% of Medicaid,50.46,,,50.46,Fee Schedule,,137.64,,,137.64,Fee Schedule,,28.56,,,28.56,Fee Schedule,,50.46,,,50.46,Fee Schedule,,137.64,,,137.64,Fee Schedule,,53.72,,,53.72,Fee Schedule,,155.4,70,,155.4,percent of total billed charges,All Other,64.45,,,64.45,Fee Schedule,,54.63,,,54.63,Fee Schedule,,20.4,,,20.4,Fee Schedule,,20.4,,,20.4,Fee Schedule,,20.4,,,20.4,Fee Schedule,,20.4,,,20.4,Fee Schedule,,9.88,,,9.88,Other,100% of Medicaid,9.88,,,9.88,Other,100% of Medicaid,9.88,,,9.88,Other,100% of Medicaid,9.88,,,9.88,Other,100% of Medicaid,22.23,,,22.23,Other,225% of Medicaid,15.11,,,15.11,Other,153% of Medicaid,22.23,,,22.23,Other,225% of Medicaid,13.83,,,13.83,Other,140% of Medicaid,22.23,,,22.23,Other,225% of Medicaid,25.68,,,25.68,Other,260% of Medicaid,32.01,,,32.01,Other,324% of Medicaid,21.24,,,21.24,Other,215% of Medicaid,21.24,,,21.24,Other,215% of Medicaid,12.35,,,12.35,Other,125% of Medicaid,9.88,164.28,
ASSAY OF NICKEL,83885,CPT,,78083885,CDM,301,RC,,,both,,,196,145.04,,,145.04,Other,150% of Medicare + 9.63% HCRA Surcharge,88.2,45,,88.2,percent of total billed charges,Critical Access Hospital RCC factor,73.78,,,73.78,Fee Schedule,,66.42,,,66.42,Fee Schedule,,151.88,,,151.88,Fee Schedule,,136.61,,,136.61,Fee Schedule,,129.11,,,129.11,Fee Schedule,,97.02,,,97.02,Other,110% of Medicare,77.21,,,77.21,Fee Schedule,,33,,,33,Other,186% of Medicaid,90.93,,,90.93,Fee Schedule,,121.52,,,121.52,Fee Schedule,,51.47,,,51.47,Fee Schedule,,90.93,,,90.93,Fee Schedule,,121.52,,,121.52,Fee Schedule,,96.81,,,96.81,Fee Schedule,,137.2,70,,137.2,percent of total billed charges,All Other,116.15,,,116.15,Fee Schedule,,98.45,,,98.45,Fee Schedule,,36.77,,,36.77,Fee Schedule,,36.77,,,36.77,Fee Schedule,,36.77,,,36.77,Fee Schedule,,36.77,,,36.77,Fee Schedule,,17.86,,,17.86,Other,100% of Medicaid,17.86,,,17.86,Other,100% of Medicaid,17.86,,,17.86,Other,100% of Medicaid,17.86,,,17.86,Other,100% of Medicaid,40.19,,,40.19,Other,225% of Medicaid,27.33,,,27.33,Other,153% of Medicaid,40.19,,,40.19,Other,225% of Medicaid,25.01,,,25.01,Other,140% of Medicaid,40.19,,,40.19,Other,225% of Medicaid,46.45,,,46.45,Other,260% of Medicaid,57.88,,,57.88,Other,324% of Medicaid,38.41,,,38.41,Other,215% of Medicaid,38.41,,,38.41,Other,215% of Medicaid,22.33,,,22.33,Other,125% of Medicaid,17.86,151.88,
ASSAY OF NUCLEOTIDASE,83915,CPT,,78083915,CDM,301,RC,,,both,,,144,106.56,,,106.56,Other,150% of Medicare + 9.63% HCRA Surcharge,64.8,45,,64.8,percent of total billed charges,Critical Access Hospital RCC factor,33.56,,,33.56,Fee Schedule,,30.22,,,30.22,Fee Schedule,,82.74,,,82.74,Fee Schedule,,74.42,,,74.42,Fee Schedule,,70.34,,,70.34,Fee Schedule,,71.28,,,71.28,Other,110% of Medicare,35.12,,,35.12,Fee Schedule,,19,,,19,Other,186% of Medicaid,41.37,,,41.37,Fee Schedule,,89.28,,,89.28,Fee Schedule,,23.42,,,23.42,Fee Schedule,,41.37,,,41.37,Fee Schedule,,89.28,,,89.28,Fee Schedule,,44.04,,,44.04,Fee Schedule,,100.8,70,,100.8,percent of total billed charges,All Other,52.84,,,52.84,Fee Schedule,,44.79,,,44.79,Fee Schedule,,16.73,,,16.73,Fee Schedule,,16.73,,,16.73,Fee Schedule,,16.73,,,16.73,Fee Schedule,,16.73,,,16.73,Fee Schedule,,10.16,,,10.16,Other,100% of Medicaid,10.16,,,10.16,Other,100% of Medicaid,10.16,,,10.16,Other,100% of Medicaid,10.16,,,10.16,Other,100% of Medicaid,22.85,,,22.85,Other,225% of Medicaid,15.54,,,15.54,Other,153% of Medicaid,22.85,,,22.85,Other,225% of Medicaid,14.22,,,14.22,Other,140% of Medicaid,22.85,,,22.85,Other,225% of Medicaid,26.4,,,26.4,Other,260% of Medicaid,32.9,,,32.9,Other,324% of Medicaid,21.83,,,21.83,Other,215% of Medicaid,21.83,,,21.83,Other,215% of Medicaid,12.69,,,12.69,Other,125% of Medicaid,10.16,106.56,
OLIGOCLONAL BANDS,83916,CPT,,78083916,CDM,301,RC,,,both,,,319,236.06,,,236.06,Other,150% of Medicare + 9.63% HCRA Surcharge,143.55,45,,143.55,percent of total billed charges,Critical Access Hospital RCC factor,82.44,,,82.44,Fee Schedule,,74.23,,,74.23,Fee Schedule,,149.14,,,149.14,Fee Schedule,,134.14,,,134.14,Fee Schedule,,126.78,,,126.78,Fee Schedule,,157.91,,,157.91,Other,110% of Medicare,86.28,,,86.28,Fee Schedule,,59,,,59,Other,186% of Medicaid,101.62,,,101.62,Fee Schedule,,197.78,,,197.78,Fee Schedule,,57.52,,,57.52,Fee Schedule,,101.62,,,101.62,Fee Schedule,,197.78,,,197.78,Fee Schedule,,108.19,,,108.19,Fee Schedule,,223.3,70,,223.3,percent of total billed charges,All Other,129.8,,,129.8,Fee Schedule,,110.02,,,110.02,Fee Schedule,,41.09,,,41.09,Fee Schedule,,41.09,,,41.09,Fee Schedule,,41.09,,,41.09,Fee Schedule,,41.09,,,41.09,Fee Schedule,,31.7,,,31.7,Other,100% of Medicaid,31.7,,,31.7,Other,100% of Medicaid,31.7,,,31.7,Other,100% of Medicaid,31.7,,,31.7,Other,100% of Medicaid,71.33,,,71.33,Other,225% of Medicaid,48.51,,,48.51,Other,153% of Medicaid,71.33,,,71.33,Other,225% of Medicaid,44.38,,,44.38,Other,140% of Medicaid,71.33,,,71.33,Other,225% of Medicaid,82.43,,,82.43,Other,260% of Medicaid,102.72,,,102.72,Other,324% of Medicaid,68.16,,,68.16,Other,215% of Medicaid,68.16,,,68.16,Other,215% of Medicaid,39.63,,,39.63,Other,125% of Medicaid,31.7,236.06,
QUANTIT ORGANIC ACIDS EA SPECIM,83918,CPT,,78083918,CDM,301,RC,,,both,,,99,73.26,,,73.26,Other,150% of Medicare + 9.63% HCRA Surcharge,44.55,45,,44.55,percent of total billed charges,Critical Access Hospital RCC factor,71.04,,,71.04,Fee Schedule,,63.96,,,63.96,Fee Schedule,,122.05,,,122.05,Fee Schedule,,109.78,,,109.78,Fee Schedule,,103.76,,,103.76,Fee Schedule,,49.01,,,49.01,Other,110% of Medicare,74.34,,,74.34,Fee Schedule,,43,,,43,Other,186% of Medicaid,87.56,,,87.56,Fee Schedule,,61.38,,,61.38,Fee Schedule,,49.56,,,49.56,Fee Schedule,,87.56,,,87.56,Fee Schedule,,61.38,,,61.38,Fee Schedule,,93.22,,,93.22,Fee Schedule,,69.3,70,,69.3,percent of total billed charges,All Other,111.84,,,111.84,Fee Schedule,,94.79,,,94.79,Fee Schedule,,35.4,,,35.4,Fee Schedule,,35.4,,,35.4,Fee Schedule,,35.4,,,35.4,Fee Schedule,,35.4,,,35.4,Fee Schedule,,22.98,,,22.98,Other,100% of Medicaid,22.98,,,22.98,Other,100% of Medicaid,22.98,,,22.98,Other,100% of Medicaid,22.98,,,22.98,Other,100% of Medicaid,51.7,,,51.7,Other,225% of Medicaid,35.16,,,35.16,Other,153% of Medicaid,51.7,,,51.7,Other,225% of Medicaid,32.17,,,32.17,Other,140% of Medicaid,51.7,,,51.7,Other,225% of Medicaid,59.74,,,59.74,Other,260% of Medicaid,74.45,,,74.45,Other,324% of Medicaid,49.4,,,49.4,Other,215% of Medicaid,49.4,,,49.4,Other,215% of Medicaid,28.72,,,28.72,Other,125% of Medicaid,22.98,122.05,
ORGANIC ACIDS EA SPEC QUAL,83919,CPT,,78083919,CDM,301,RC,,,both,,,107,79.18,,,79.18,Other,150% of Medicare + 9.63% HCRA Surcharge,48.15,45,,48.15,percent of total billed charges,Critical Access Hospital RCC factor,49.51,,,49.51,Fee Schedule,,44.58,,,44.58,Fee Schedule,,122.05,,,122.05,Fee Schedule,,109.78,,,109.78,Fee Schedule,,103.76,,,103.76,Fee Schedule,,52.97,,,52.97,Other,110% of Medicare,51.82,,,51.82,Fee Schedule,,31,,,31,Other,186% of Medicaid,61.03,,,61.03,Fee Schedule,,66.34,,,66.34,Fee Schedule,,34.55,,,34.55,Fee Schedule,,61.03,,,61.03,Fee Schedule,,66.34,,,66.34,Fee Schedule,,64.98,,,64.98,Fee Schedule,,74.9,70,,74.9,percent of total billed charges,All Other,77.96,,,77.96,Fee Schedule,,66.07,,,66.07,Fee Schedule,,24.68,,,24.68,Fee Schedule,,24.68,,,24.68,Fee Schedule,,24.68,,,24.68,Fee Schedule,,24.68,,,24.68,Fee Schedule,,16.45,,,16.45,Other,100% of Medicaid,16.45,,,16.45,Other,100% of Medicaid,16.45,,,16.45,Other,100% of Medicaid,16.45,,,16.45,Other,100% of Medicaid,37.01,,,37.01,Other,225% of Medicaid,25.17,,,25.17,Other,153% of Medicaid,37.01,,,37.01,Other,225% of Medicaid,23.03,,,23.03,Other,140% of Medicaid,37.01,,,37.01,Other,225% of Medicaid,42.77,,,42.77,Other,260% of Medicaid,53.3,,,53.3,Other,324% of Medicaid,35.37,,,35.37,Other,215% of Medicaid,35.37,,,35.37,Other,215% of Medicaid,20.56,,,20.56,Other,125% of Medicaid,16.45,122.05,
ORGANIC ACID SINGLE QUANT,83921,CPT,,78083921,CDM,301,RC,,,both,,,157,116.18,,,116.18,Other,150% of Medicare + 9.63% HCRA Surcharge,70.65,45,,70.65,percent of total billed charges,Critical Access Hospital RCC factor,63.84,,,63.84,Fee Schedule,,57.48,,,57.48,Fee Schedule,,122.05,,,122.05,Fee Schedule,,109.78,,,109.78,Fee Schedule,,103.76,,,103.76,Fee Schedule,,77.72,,,77.72,Other,110% of Medicare,66.81,,,66.81,Fee Schedule,,39,,,39,Other,186% of Medicaid,78.69,,,78.69,Fee Schedule,,97.34,,,97.34,Fee Schedule,,44.54,,,44.54,Fee Schedule,,78.69,,,78.69,Fee Schedule,,97.34,,,97.34,Fee Schedule,,83.78,,,83.78,Fee Schedule,,109.9,70,,109.9,percent of total billed charges,All Other,100.51,,,100.51,Fee Schedule,,85.19,,,85.19,Fee Schedule,,31.82,,,31.82,Fee Schedule,,31.82,,,31.82,Fee Schedule,,31.82,,,31.82,Fee Schedule,,31.82,,,31.82,Fee Schedule,,21.21,,,21.21,Other,100% of Medicaid,21.21,,,21.21,Other,100% of Medicaid,21.21,,,21.21,Other,100% of Medicaid,21.21,,,21.21,Other,100% of Medicaid,47.72,,,47.72,Other,225% of Medicaid,32.45,,,32.45,Other,153% of Medicaid,47.72,,,47.72,Other,225% of Medicaid,29.69,,,29.69,Other,140% of Medicaid,47.72,,,47.72,Other,225% of Medicaid,55.15,,,55.15,Other,260% of Medicaid,68.72,,,68.72,Other,324% of Medicaid,45.6,,,45.6,Other,215% of Medicaid,45.6,,,45.6,Other,215% of Medicaid,26.51,,,26.51,Other,125% of Medicaid,21.21,122.05,
ASSAY OF BLOOD OSMOLALITY,83930,CPT,,78083930,CDM,301,RC,,,both,,,129,95.46,,,95.46,Other,150% of Medicare + 9.63% HCRA Surcharge,58.05,45,,58.05,percent of total billed charges,Critical Access Hospital RCC factor,19.9,,,19.9,Fee Schedule,,17.91,,,17.91,Fee Schedule,,49.01,,,49.01,Fee Schedule,,44.08,,,44.08,Fee Schedule,,41.66,,,41.66,Fee Schedule,,63.86,,,63.86,Other,110% of Medicare,20.82,,,20.82,Fee Schedule,,11,,,11,Other,186% of Medicaid,24.52,,,24.52,Fee Schedule,,79.98,,,79.98,Fee Schedule,,13.88,,,13.88,Fee Schedule,,24.52,,,24.52,Fee Schedule,,79.98,,,79.98,Fee Schedule,,26.11,,,26.11,Fee Schedule,,90.3,70,,90.3,percent of total billed charges,All Other,31.33,,,31.33,Fee Schedule,,26.55,,,26.55,Fee Schedule,,9.92,,,9.92,Fee Schedule,,9.92,,,9.92,Fee Schedule,,9.92,,,9.92,Fee Schedule,,9.92,,,9.92,Fee Schedule,,6.1,,,6.1,Other,100% of Medicaid,6.1,,,6.1,Other,100% of Medicaid,6.1,,,6.1,Other,100% of Medicaid,6.1,,,6.1,Other,100% of Medicaid,13.73,,,13.73,Other,225% of Medicaid,9.33,,,9.33,Other,153% of Medicaid,13.73,,,13.73,Other,225% of Medicaid,8.54,,,8.54,Other,140% of Medicaid,13.73,,,13.73,Other,225% of Medicaid,15.86,,,15.86,Other,260% of Medicaid,19.77,,,19.77,Other,324% of Medicaid,13.12,,,13.12,Other,215% of Medicaid,13.12,,,13.12,Other,215% of Medicaid,7.63,,,7.63,Other,125% of Medicaid,6.1,95.46,
OSMOLALITY URINE,83935,CPT,,78083935,CDM,301,RC,,,both,,,42,31.08,,,31.08,Other,150% of Medicare + 9.63% HCRA Surcharge,18.9,45,,18.9,percent of total billed charges,Critical Access Hospital RCC factor,20.53,,,20.53,Fee Schedule,,18.48,,,18.48,Fee Schedule,,50.54,,,50.54,Fee Schedule,,45.46,,,45.46,Fee Schedule,,42.96,,,42.96,Fee Schedule,,20.79,,,20.79,Other,110% of Medicare,21.48,,,21.48,Fee Schedule,,11,,,11,Other,186% of Medicaid,25.3,,,25.3,Fee Schedule,,26.04,,,26.04,Fee Schedule,,14.32,,,14.32,Fee Schedule,,25.3,,,25.3,Fee Schedule,,26.04,,,26.04,Fee Schedule,,26.94,,,26.94,Fee Schedule,,29.4,70,,29.4,percent of total billed charges,All Other,32.32,,,32.32,Fee Schedule,,27.39,,,27.39,Fee Schedule,,10.23,,,10.23,Fee Schedule,,10.23,,,10.23,Fee Schedule,,10.23,,,10.23,Fee Schedule,,10.23,,,10.23,Fee Schedule,,6.1,,,6.1,Other,100% of Medicaid,6.1,,,6.1,Other,100% of Medicaid,6.1,,,6.1,Other,100% of Medicaid,6.1,,,6.1,Other,100% of Medicaid,13.73,,,13.73,Other,225% of Medicaid,9.33,,,9.33,Other,153% of Medicaid,13.73,,,13.73,Other,225% of Medicaid,8.54,,,8.54,Other,140% of Medicaid,13.73,,,13.73,Other,225% of Medicaid,15.86,,,15.86,Other,260% of Medicaid,19.77,,,19.77,Other,324% of Medicaid,13.12,,,13.12,Other,215% of Medicaid,13.12,,,13.12,Other,215% of Medicaid,7.63,,,7.63,Other,125% of Medicaid,6.1,50.54,
OSTEOCALCIN,83937,CPT,,78083937,CDM,301,RC,,,both,,,177,130.98,,,130.98,Other,150% of Medicare + 9.63% HCRA Surcharge,79.65,45,,79.65,percent of total billed charges,Critical Access Hospital RCC factor,89.85,,,89.85,Fee Schedule,,80.89,,,80.89,Fee Schedule,,221.39,,,221.39,Fee Schedule,,199.13,,,199.13,Fee Schedule,,188.2,,,188.2,Fee Schedule,,87.62,,,87.62,Other,110% of Medicare,94.03,,,94.03,Fee Schedule,,62,,,62,Other,186% of Medicaid,110.74,,,110.74,Fee Schedule,,109.74,,,109.74,Fee Schedule,,62.69,,,62.69,Fee Schedule,,110.74,,,110.74,Fee Schedule,,109.74,,,109.74,Fee Schedule,,117.91,,,117.91,Fee Schedule,,123.9,70,,123.9,percent of total billed charges,All Other,141.46,,,141.46,Fee Schedule,,119.9,,,119.9,Fee Schedule,,44.78,,,44.78,Fee Schedule,,44.78,,,44.78,Fee Schedule,,44.78,,,44.78,Fee Schedule,,44.78,,,44.78,Fee Schedule,,33.57,,,33.57,Other,100% of Medicaid,33.57,,,33.57,Other,100% of Medicaid,33.57,,,33.57,Other,100% of Medicaid,33.57,,,33.57,Other,100% of Medicaid,75.53,,,75.53,Other,225% of Medicaid,51.36,,,51.36,Other,153% of Medicaid,75.53,,,75.53,Other,225% of Medicaid,47,,,47,Other,140% of Medicaid,75.53,,,75.53,Other,225% of Medicaid,87.28,,,87.28,Other,260% of Medicaid,108.76,,,108.76,Other,324% of Medicaid,72.17,,,72.17,Other,215% of Medicaid,72.17,,,72.17,Other,215% of Medicaid,41.96,,,41.96,Other,125% of Medicaid,33.57,221.39,
ASSAY OF OXALATE,83945,CPT,,78083945,CDM,301,RC,,,both,,,174,128.76,,,128.76,Other,150% of Medicare + 9.63% HCRA Surcharge,78.3,45,,78.3,percent of total billed charges,Critical Access Hospital RCC factor,43.49,,,43.49,Fee Schedule,,39.16,,,39.16,Fee Schedule,,82.05,,,82.05,Fee Schedule,,73.8,,,73.8,Fee Schedule,,69.75,,,69.75,Fee Schedule,,86.13,,,86.13,Other,110% of Medicare,45.52,,,45.52,Fee Schedule,,22,,,22,Other,186% of Medicaid,53.61,,,53.61,Fee Schedule,,107.88,,,107.88,Fee Schedule,,30.35,,,30.35,Fee Schedule,,53.61,,,53.61,Fee Schedule,,107.88,,,107.88,Fee Schedule,,57.08,,,57.08,Fee Schedule,,121.8,70,,121.8,percent of total billed charges,All Other,68.48,,,68.48,Fee Schedule,,58.04,,,58.04,Fee Schedule,,21.68,,,21.68,Fee Schedule,,21.68,,,21.68,Fee Schedule,,21.68,,,21.68,Fee Schedule,,21.68,,,21.68,Fee Schedule,,12.02,,,12.02,Other,100% of Medicaid,12.02,,,12.02,Other,100% of Medicaid,12.02,,,12.02,Other,100% of Medicaid,12.02,,,12.02,Other,100% of Medicaid,27.04,,,27.04,Other,225% of Medicaid,18.39,,,18.39,Other,153% of Medicaid,27.04,,,27.04,Other,225% of Medicaid,16.83,,,16.83,Other,140% of Medicaid,27.04,,,27.04,Other,225% of Medicaid,31.25,,,31.25,Other,260% of Medicaid,38.94,,,38.94,Other,324% of Medicaid,25.84,,,25.84,Other,215% of Medicaid,25.84,,,25.84,Other,215% of Medicaid,15.02,,,15.02,Other,125% of Medicaid,12.02,128.76,
ONCOPROTEIN HER-2/NEU,83950,CPT,,78083950,CDM,301,RC,,,both,,,383,283.42,,,283.42,Other,150% of Medicare + 9.63% HCRA Surcharge,172.35,45,,172.35,percent of total billed charges,Critical Access Hospital RCC factor,193.87,,,193.87,Fee Schedule,,174.55,,,174.55,Fee Schedule,,466.55,,,466.55,Fee Schedule,,419.63,,,419.63,Fee Schedule,,396.61,,,396.61,Fee Schedule,,189.59,,,189.59,Other,110% of Medicare,202.89,,,202.89,Fee Schedule,,120,,,120,Other,186% of Medicaid,238.96,,,238.96,Fee Schedule,,237.46,,,237.46,Fee Schedule,,135.26,,,135.26,Fee Schedule,,238.96,,,238.96,Fee Schedule,,237.46,,,237.46,Fee Schedule,,254.42,,,254.42,Fee Schedule,,268.1,70,,268.1,percent of total billed charges,All Other,305.24,,,305.24,Fee Schedule,,258.71,,,258.71,Fee Schedule,,96.62,,,96.62,Fee Schedule,,96.62,,,96.62,Fee Schedule,,96.62,,,96.62,Fee Schedule,,96.62,,,96.62,Fee Schedule,,64.41,,,64.41,Other,100% of Medicaid,64.41,,,64.41,Other,100% of Medicaid,64.41,,,64.41,Other,100% of Medicaid,64.41,,,64.41,Other,100% of Medicaid,144.92,,,144.92,Other,225% of Medicaid,98.55,,,98.55,Other,153% of Medicaid,144.92,,,144.92,Other,225% of Medicaid,90.17,,,90.17,Other,140% of Medicaid,144.92,,,144.92,Other,225% of Medicaid,167.47,,,167.47,Other,260% of Medicaid,208.69,,,208.69,Other,324% of Medicaid,138.48,,,138.48,Other,215% of Medicaid,138.48,,,138.48,Other,215% of Medicaid,80.51,,,80.51,Other,125% of Medicaid,64.41,466.55,
ONCOPROTEIN DCP,83951,CPT,,78083951,CDM,301,RC,,,both,,,146,108.04,,,108.04,Other,150% of Medicare + 9.63% HCRA Surcharge,65.7,45,,65.7,percent of total billed charges,Critical Access Hospital RCC factor,193.87,,,193.87,Fee Schedule,,174.55,,,174.55,Fee Schedule,,466.55,,,466.55,Fee Schedule,,419.63,,,419.63,Fee Schedule,,396.61,,,396.61,Fee Schedule,,72.27,,,72.27,Other,110% of Medicare,202.89,,,202.89,Fee Schedule,,120,,,120,Other,186% of Medicaid,238.96,,,238.96,Fee Schedule,,90.52,,,90.52,Fee Schedule,,135.26,,,135.26,Fee Schedule,,238.96,,,238.96,Fee Schedule,,90.52,,,90.52,Fee Schedule,,254.42,,,254.42,Fee Schedule,,102.2,70,,102.2,percent of total billed charges,All Other,305.24,,,305.24,Fee Schedule,,258.71,,,258.71,Fee Schedule,,96.62,,,96.62,Fee Schedule,,96.62,,,96.62,Fee Schedule,,96.62,,,96.62,Fee Schedule,,96.62,,,96.62,Fee Schedule,,64.41,,,64.41,Other,100% of Medicaid,64.41,,,64.41,Other,100% of Medicaid,64.41,,,64.41,Other,100% of Medicaid,64.41,,,64.41,Other,100% of Medicaid,144.92,,,144.92,Other,225% of Medicaid,98.55,,,98.55,Other,153% of Medicaid,144.92,,,144.92,Other,225% of Medicaid,90.17,,,90.17,Other,140% of Medicaid,144.92,,,144.92,Other,225% of Medicaid,167.47,,,167.47,Other,260% of Medicaid,208.69,,,208.69,Other,324% of Medicaid,138.48,,,138.48,Other,215% of Medicaid,138.48,,,138.48,Other,215% of Medicaid,80.51,,,80.51,Other,125% of Medicaid,64.41,466.55,
ASSAY PH BODY FLUID NOS,83986,CPT,,78083986,CDM,301,RC,,,both,,,36,26.64,,,26.64,Other,150% of Medicare + 9.63% HCRA Surcharge,16.2,45,,16.2,percent of total billed charges,Critical Access Hospital RCC factor,10.78,,,10.78,Fee Schedule,,9.7,,,9.7,Fee Schedule,,24.82,,,24.82,Fee Schedule,,22.33,,,22.33,Fee Schedule,,21.1,,,21.1,Fee Schedule,,17.82,,,17.82,Other,110% of Medicare,11.28,,,11.28,Fee Schedule,,12,,,12,Other,186% of Medicaid,13.28,,,13.28,Fee Schedule,,22.32,,,22.32,Fee Schedule,,7.52,,,7.52,Fee Schedule,,13.28,,,13.28,Fee Schedule,,22.32,,,22.32,Fee Schedule,,14.14,,,14.14,Fee Schedule,,25.2,70,,25.2,percent of total billed charges,All Other,16.97,,,16.97,Fee Schedule,,14.38,,,14.38,Fee Schedule,,5.37,,,5.37,Fee Schedule,,5.37,,,5.37,Fee Schedule,,5.37,,,5.37,Fee Schedule,,5.37,,,5.37,Fee Schedule,,6.31,,,6.31,Other,100% of Medicaid,6.31,,,6.31,Other,100% of Medicaid,6.31,,,6.31,Other,100% of Medicaid,6.31,,,6.31,Other,100% of Medicaid,14.2,,,14.2,Other,225% of Medicaid,9.65,,,9.65,Other,153% of Medicaid,14.2,,,14.2,Other,225% of Medicaid,8.83,,,8.83,Other,140% of Medicaid,14.2,,,14.2,Other,225% of Medicaid,16.41,,,16.41,Other,260% of Medicaid,20.45,,,20.45,Other,324% of Medicaid,13.57,,,13.57,Other,215% of Medicaid,13.57,,,13.57,Other,215% of Medicaid,7.89,,,7.89,Other,125% of Medicaid,5.37,26.64,
ASSAY FOR PHENCYCLIDINE,83992,CPT,,78083992,CDM,301,RC,,,both,,,168,124.32,,,124.32,Other,150% of Medicare + 9.63% HCRA Surcharge,75.6,45,,75.6,percent of total billed charges,Critical Access Hospital RCC factor,109.2,65,,109.2,percent of total billed charges,All Other,99.12,65,,99.12,percent of total billed charges,All Other,108.98,,,108.98,Fee Schedule,,98.02,,,98.02,Fee Schedule,,92.65,,,92.65,Fee Schedule,,83.16,,,83.16,Other,110% of Medicare,114.24,68,,114.24,percent of total billed charges,All Other,33,,,33,Other,186% of Medicaid,139.44,83,,139.44,percent of total billed charges,All Other,104.16,62,,104.16,percent of total billed charges,Lab and Radiology,92.4,55,,92.4,percent of total billed charges,Default if not on Fee Schedule,134.4,80,,134.4,percent of total billed charges,All Other,104.16,62,,104.16,percent of total billed charges,Lab and Radiology,134.4,80,,134.4,percent of total billed charges,All Other,117.6,70,,117.6,percent of total billed charges,All Other,109.2,65,,109.2,percent of total billed charges,Default if not in Fee Schedule,109.2,65,,109.2,percent of total billed charges,Default if not in Fee Schedule,64.97,,,64.97,Fee Schedule,,64.97,,,64.97,Fee Schedule,,64.97,,,64.97,Fee Schedule,,64.97,,,64.97,Fee Schedule,,17.86,,,17.86,Other,100% of Medicaid,17.86,,,17.86,Other,100% of Medicaid,17.86,,,17.86,Other,100% of Medicaid,17.86,,,17.86,Other,100% of Medicaid,40.19,,,40.19,Other,225% of Medicaid,27.33,,,27.33,Other,153% of Medicaid,40.19,,,40.19,Other,225% of Medicaid,25.01,,,25.01,Other,140% of Medicaid,40.19,,,40.19,Other,225% of Medicaid,46.45,,,46.45,Other,260% of Medicaid,57.88,,,57.88,Other,324% of Medicaid,38.41,,,38.41,Other,215% of Medicaid,38.41,,,38.41,Other,215% of Medicaid,22.33,,,22.33,Other,125% of Medicaid,17.86,139.44,
ASSAY FOR CALPROTECTIN FECAL,83993,CPT,,78083993,CDM,301,RC,,,both,,,125,92.5,,,92.5,Other,150% of Medicare + 9.63% HCRA Surcharge,56.25,45,,56.25,percent of total billed charges,Critical Access Hospital RCC factor,59.09,,,59.09,Fee Schedule,,53.2,,,53.2,Fee Schedule,,145.56,,,145.56,Fee Schedule,,130.92,,,130.92,Fee Schedule,,123.74,,,123.74,Fee Schedule,,61.88,,,61.88,Other,110% of Medicare,61.83,,,61.83,Fee Schedule,,21,,,21,Other,186% of Medicaid,72.83,,,72.83,Fee Schedule,,77.5,,,77.5,Fee Schedule,,41.22,,,41.22,Fee Schedule,,72.83,,,72.83,Fee Schedule,,77.5,,,77.5,Fee Schedule,,77.54,,,77.54,Fee Schedule,,87.5,70,,87.5,percent of total billed charges,All Other,93.03,,,93.03,Fee Schedule,,78.85,,,78.85,Fee Schedule,,29.45,,,29.45,Fee Schedule,,29.45,,,29.45,Fee Schedule,,29.45,,,29.45,Fee Schedule,,29.45,,,29.45,Fee Schedule,,11.39,,,11.39,Other,100% of Medicaid,11.39,,,11.39,Other,100% of Medicaid,11.39,,,11.39,Other,100% of Medicaid,11.39,,,11.39,Other,100% of Medicaid,25.63,,,25.63,Other,225% of Medicaid,17.43,,,17.43,Other,153% of Medicaid,25.63,,,25.63,Other,225% of Medicaid,15.95,,,15.95,Other,140% of Medicaid,25.63,,,25.63,Other,225% of Medicaid,29.62,,,29.62,Other,260% of Medicaid,36.91,,,36.91,Other,324% of Medicaid,24.49,,,24.49,Other,215% of Medicaid,24.49,,,24.49,Other,215% of Medicaid,14.24,,,14.24,Other,125% of Medicaid,11.39,145.56,
ASSAY OF BLOOD PKU,84030,CPT,,78084030,CDM,301,RC,,,both,,,203,150.22,,,150.22,Other,150% of Medicare + 9.63% HCRA Surcharge,91.35,45,,91.35,percent of total billed charges,Critical Access Hospital RCC factor,16.56,,,16.56,Fee Schedule,,14.91,,,14.91,Fee Schedule,,40.79,,,40.79,Fee Schedule,,36.69,,,36.69,Fee Schedule,,34.68,,,34.68,Fee Schedule,,100.49,,,100.49,Other,110% of Medicare,17.33,,,17.33,Fee Schedule,,10,,,10,Other,186% of Medicaid,20.41,,,20.41,Fee Schedule,,125.86,,,125.86,Fee Schedule,,11.55,,,11.55,Fee Schedule,,20.41,,,20.41,Fee Schedule,,125.86,,,125.86,Fee Schedule,,21.73,,,21.73,Fee Schedule,,142.1,70,,142.1,percent of total billed charges,All Other,26.06,,,26.06,Fee Schedule,,22.09,,,22.09,Fee Schedule,,8.25,,,8.25,Fee Schedule,,8.25,,,8.25,Fee Schedule,,8.25,,,8.25,Fee Schedule,,8.25,,,8.25,Fee Schedule,,5.5,,,5.5,Other,100% of Medicaid,5.5,,,5.5,Other,100% of Medicaid,5.5,,,5.5,Other,100% of Medicaid,5.5,,,5.5,Other,100% of Medicaid,12.38,,,12.38,Other,225% of Medicaid,8.42,,,8.42,Other,153% of Medicaid,12.38,,,12.38,Other,225% of Medicaid,7.7,,,7.7,Other,140% of Medicaid,12.38,,,12.38,Other,225% of Medicaid,14.3,,,14.3,Other,260% of Medicaid,17.82,,,17.82,Other,324% of Medicaid,11.83,,,11.83,Other,215% of Medicaid,11.83,,,11.83,Other,215% of Medicaid,6.88,,,6.88,Other,125% of Medicaid,5.5,150.22,
ASSAY ACID PHOSPHATASE,84060,CPT,,78084060,CDM,301,RC,,,both,,,91,67.34,,,67.34,Other,150% of Medicare + 9.63% HCRA Surcharge,40.95,45,,40.95,percent of total billed charges,Critical Access Hospital RCC factor,23,,,23,Fee Schedule,,20.7,,,20.7,Fee Schedule,,54.76,,,54.76,Fee Schedule,,49.25,,,49.25,Fee Schedule,,46.55,,,46.55,Fee Schedule,,45.05,,,45.05,Other,110% of Medicare,24.07,,,24.07,Fee Schedule,,9,,,9,Other,186% of Medicaid,28.34,,,28.34,Fee Schedule,,56.42,,,56.42,Fee Schedule,,16.04,,,16.04,Fee Schedule,,28.34,,,28.34,Fee Schedule,,56.42,,,56.42,Fee Schedule,,30.18,,,30.18,Fee Schedule,,63.7,70,,63.7,percent of total billed charges,All Other,36.21,,,36.21,Fee Schedule,,30.69,,,30.69,Fee Schedule,,11.46,,,11.46,Fee Schedule,,11.46,,,11.46,Fee Schedule,,11.46,,,11.46,Fee Schedule,,11.46,,,11.46,Fee Schedule,,5.08,,,5.08,Other,100% of Medicaid,5.08,,,5.08,Other,100% of Medicaid,5.08,,,5.08,Other,100% of Medicaid,5.08,,,5.08,Other,100% of Medicaid,11.43,,,11.43,Other,225% of Medicaid,7.77,,,7.77,Other,153% of Medicaid,11.43,,,11.43,Other,225% of Medicaid,7.11,,,7.11,Other,140% of Medicaid,11.43,,,11.43,Other,225% of Medicaid,13.21,,,13.21,Other,260% of Medicaid,16.46,,,16.46,Other,324% of Medicaid,10.92,,,10.92,Other,215% of Medicaid,10.92,,,10.92,Other,215% of Medicaid,6.35,,,6.35,Other,125% of Medicaid,5.08,67.34,
ASSAY PROSTATE PHOSPHATASE,84066,CPT,,78084066,CDM,301,RC,,,both,,,133,98.42,,,98.42,Other,150% of Medicare + 9.63% HCRA Surcharge,59.85,45,,59.85,percent of total billed charges,Critical Access Hospital RCC factor,29.08,,,29.08,Fee Schedule,,26.18,,,26.18,Fee Schedule,,71.62,,,71.62,Fee Schedule,,64.42,,,64.42,Fee Schedule,,60.88,,,60.88,Fee Schedule,,65.84,,,65.84,Other,110% of Medicare,30.43,,,30.43,Fee Schedule,,18,,,18,Other,186% of Medicaid,35.84,,,35.84,Fee Schedule,,82.46,,,82.46,Fee Schedule,,20.29,,,20.29,Fee Schedule,,35.84,,,35.84,Fee Schedule,,82.46,,,82.46,Fee Schedule,,38.16,,,38.16,Fee Schedule,,93.1,70,,93.1,percent of total billed charges,All Other,45.78,,,45.78,Fee Schedule,,38.8,,,38.8,Fee Schedule,,14.49,,,14.49,Fee Schedule,,14.49,,,14.49,Fee Schedule,,14.49,,,14.49,Fee Schedule,,14.49,,,14.49,Fee Schedule,,9.66,,,9.66,Other,100% of Medicaid,9.66,,,9.66,Other,100% of Medicaid,9.66,,,9.66,Other,100% of Medicaid,9.66,,,9.66,Other,100% of Medicaid,21.74,,,21.74,Other,225% of Medicaid,14.78,,,14.78,Other,153% of Medicaid,21.74,,,21.74,Other,225% of Medicaid,13.52,,,13.52,Other,140% of Medicaid,21.74,,,21.74,Other,225% of Medicaid,25.12,,,25.12,Other,260% of Medicaid,31.3,,,31.3,Other,324% of Medicaid,20.77,,,20.77,Other,215% of Medicaid,20.77,,,20.77,Other,215% of Medicaid,12.08,,,12.08,Other,125% of Medicaid,9.66,98.42,
ASSAY ALKALINE PHOSPHATASE,84075,CPT,,78084075,CDM,301,RC,,,both,,,89,65.86,,,65.86,Other,150% of Medicare + 9.63% HCRA Surcharge,40.05,45,,40.05,percent of total billed charges,Critical Access Hospital RCC factor,15.59,,,15.59,Fee Schedule,,14.04,,,14.04,Fee Schedule,,38.37,,,38.37,Fee Schedule,,34.51,,,34.51,Fee Schedule,,32.61,,,32.61,Fee Schedule,,44.06,,,44.06,Other,110% of Medicare,16.32,,,16.32,Fee Schedule,,9,,,9,Other,186% of Medicaid,19.22,,,19.22,Fee Schedule,,55.18,,,55.18,Fee Schedule,,10.88,,,10.88,Fee Schedule,,19.22,,,19.22,Fee Schedule,,55.18,,,55.18,Fee Schedule,,20.46,,,20.46,Fee Schedule,,62.3,70,,62.3,percent of total billed charges,All Other,24.55,,,24.55,Fee Schedule,,20.81,,,20.81,Fee Schedule,,7.77,,,7.77,Fee Schedule,,7.77,,,7.77,Fee Schedule,,7.77,,,7.77,Fee Schedule,,7.77,,,7.77,Fee Schedule,,5.08,,,5.08,Other,100% of Medicaid,5.08,,,5.08,Other,100% of Medicaid,5.08,,,5.08,Other,100% of Medicaid,5.08,,,5.08,Other,100% of Medicaid,11.43,,,11.43,Other,225% of Medicaid,7.77,,,7.77,Other,153% of Medicaid,11.43,,,11.43,Other,225% of Medicaid,7.11,,,7.11,Other,140% of Medicaid,11.43,,,11.43,Other,225% of Medicaid,13.21,,,13.21,Other,260% of Medicaid,16.46,,,16.46,Other,324% of Medicaid,10.92,,,10.92,Other,215% of Medicaid,10.92,,,10.92,Other,215% of Medicaid,6.35,,,6.35,Other,125% of Medicaid,5.08,65.86,
ASSAY ALKALINE PHOSPHATASES,84080,CPT,,78084080,CDM,301,RC,,,both,,,95,70.3,,,70.3,Other,150% of Medicare + 9.63% HCRA Surcharge,42.75,45,,42.75,percent of total billed charges,Critical Access Hospital RCC factor,44.49,,,44.49,Fee Schedule,,40.05,,,40.05,Fee Schedule,,64.87,,,64.87,Fee Schedule,,58.35,,,58.35,Fee Schedule,,55.15,,,55.15,Fee Schedule,,47.03,,,47.03,Other,110% of Medicare,46.56,,,46.56,Fee Schedule,,19,,,19,Other,186% of Medicaid,54.83,,,54.83,Fee Schedule,,58.9,,,58.9,Fee Schedule,,31.04,,,31.04,Fee Schedule,,54.83,,,54.83,Fee Schedule,,58.9,,,58.9,Fee Schedule,,58.38,,,58.38,Fee Schedule,,66.5,70,,66.5,percent of total billed charges,All Other,70.04,,,70.04,Fee Schedule,,59.37,,,59.37,Fee Schedule,,22.17,,,22.17,Fee Schedule,,22.17,,,22.17,Fee Schedule,,22.17,,,22.17,Fee Schedule,,22.17,,,22.17,Fee Schedule,,10.01,,,10.01,Other,100% of Medicaid,10.01,,,10.01,Other,100% of Medicaid,10.01,,,10.01,Other,100% of Medicaid,10.01,,,10.01,Other,100% of Medicaid,22.52,,,22.52,Other,225% of Medicaid,15.31,,,15.31,Other,153% of Medicaid,22.52,,,22.52,Other,225% of Medicaid,14.01,,,14.01,Other,140% of Medicaid,22.52,,,22.52,Other,225% of Medicaid,26.02,,,26.02,Other,260% of Medicaid,32.43,,,32.43,Other,324% of Medicaid,21.52,,,21.52,Other,215% of Medicaid,21.52,,,21.52,Other,215% of Medicaid,12.51,,,12.51,Other,125% of Medicaid,10.01,70.3,
AMNIOTIC FLUID ENZYME TEST,84081,CPT,,78084081,CDM,301,RC,,,both,,,170,125.8,,,125.8,Other,150% of Medicare + 9.63% HCRA Surcharge,76.5,45,,76.5,percent of total billed charges,Critical Access Hospital RCC factor,49.73,,,49.73,Fee Schedule,,44.77,,,44.77,Fee Schedule,,122.53,,,122.53,Fee Schedule,,110.21,,,110.21,Fee Schedule,,104.16,,,104.16,Fee Schedule,,84.15,,,84.15,Other,110% of Medicare,52.04,,,52.04,Fee Schedule,,15,,,15,Other,186% of Medicaid,61.29,,,61.29,Fee Schedule,,105.4,,,105.4,Fee Schedule,,34.69,,,34.69,Fee Schedule,,61.29,,,61.29,Fee Schedule,,105.4,,,105.4,Fee Schedule,,65.25,,,65.25,Fee Schedule,,119,70,,119,percent of total billed charges,All Other,78.29,,,78.29,Fee Schedule,,66.35,,,66.35,Fee Schedule,,24.78,,,24.78,Fee Schedule,,24.78,,,24.78,Fee Schedule,,24.78,,,24.78,Fee Schedule,,24.78,,,24.78,Fee Schedule,,8.05,,,8.05,Other,100% of Medicaid,8.05,,,8.05,Other,100% of Medicaid,8.05,,,8.05,Other,100% of Medicaid,8.05,,,8.05,Other,100% of Medicaid,18.11,,,18.11,Other,225% of Medicaid,12.32,,,12.32,Other,153% of Medicaid,18.11,,,18.11,Other,225% of Medicaid,11.27,,,11.27,Other,140% of Medicaid,18.11,,,18.11,Other,225% of Medicaid,20.93,,,20.93,Other,260% of Medicaid,26.08,,,26.08,Other,324% of Medicaid,17.31,,,17.31,Other,215% of Medicaid,17.31,,,17.31,Other,215% of Medicaid,10.06,,,10.06,Other,125% of Medicaid,8.05,125.8,
ASSAY OF PHOSPHORUS,84100,CPT,,78084100,CDM,301,RC,,,both,,,100,74,,,74,Other,150% of Medicare + 9.63% HCRA Surcharge,45,45,,45,percent of total billed charges,Critical Access Hospital RCC factor,14.27,,,14.27,Fee Schedule,,12.85,,,12.85,Fee Schedule,,35.15,,,35.15,Fee Schedule,,31.62,,,31.62,Fee Schedule,,29.88,,,29.88,Fee Schedule,,49.5,,,49.5,Other,110% of Medicare,14.93,,,14.93,Fee Schedule,,9,,,9,Other,186% of Medicaid,17.59,,,17.59,Fee Schedule,,62,,,62,Fee Schedule,,9.95,,,9.95,Fee Schedule,,17.59,,,17.59,Fee Schedule,,62,,,62,Fee Schedule,,18.72,,,18.72,Fee Schedule,,70,70,,70,percent of total billed charges,All Other,22.46,,,22.46,Fee Schedule,,19.04,,,19.04,Fee Schedule,,7.11,,,7.11,Fee Schedule,,7.11,,,7.11,Fee Schedule,,7.11,,,7.11,Fee Schedule,,7.11,,,7.11,Fee Schedule,,4.74,,,4.74,Other,100% of Medicaid,4.74,,,4.74,Other,100% of Medicaid,4.74,,,4.74,Other,100% of Medicaid,4.74,,,4.74,Other,100% of Medicaid,10.67,,,10.67,Other,225% of Medicaid,7.25,,,7.25,Other,153% of Medicaid,10.67,,,10.67,Other,225% of Medicaid,6.64,,,6.64,Other,140% of Medicaid,10.67,,,10.67,Other,225% of Medicaid,12.32,,,12.32,Other,260% of Medicaid,15.36,,,15.36,Other,324% of Medicaid,10.19,,,10.19,Other,215% of Medicaid,10.19,,,10.19,Other,215% of Medicaid,5.93,,,5.93,Other,125% of Medicaid,4.74,74,
ASSAY OF URINE PHOSPHORUS,84105,CPT,,78084105,CDM,301,RC,,,both,,,72,53.28,,,53.28,Other,150% of Medicare + 9.63% HCRA Surcharge,32.4,45,,32.4,percent of total billed charges,Critical Access Hospital RCC factor,17.4,,,17.4,Fee Schedule,,15.66,,,15.66,Fee Schedule,,38.37,,,38.37,Fee Schedule,,34.51,,,34.51,Fee Schedule,,32.61,,,32.61,Fee Schedule,,35.64,,,35.64,Other,110% of Medicare,18.21,,,18.21,Fee Schedule,,9,,,9,Other,186% of Medicaid,21.44,,,21.44,Fee Schedule,,44.64,,,44.64,Fee Schedule,,12.14,,,12.14,Fee Schedule,,21.44,,,21.44,Fee Schedule,,44.64,,,44.64,Fee Schedule,,22.83,,,22.83,Fee Schedule,,50.4,70,,50.4,percent of total billed charges,All Other,27.39,,,27.39,Fee Schedule,,23.22,,,23.22,Fee Schedule,,8.67,,,8.67,Fee Schedule,,8.67,,,8.67,Fee Schedule,,8.67,,,8.67,Fee Schedule,,8.67,,,8.67,Fee Schedule,,5.08,,,5.08,Other,100% of Medicaid,5.08,,,5.08,Other,100% of Medicaid,5.08,,,5.08,Other,100% of Medicaid,5.08,,,5.08,Other,100% of Medicaid,11.43,,,11.43,Other,225% of Medicaid,7.77,,,7.77,Other,153% of Medicaid,11.43,,,11.43,Other,225% of Medicaid,7.11,,,7.11,Other,140% of Medicaid,11.43,,,11.43,Other,225% of Medicaid,13.21,,,13.21,Other,260% of Medicaid,16.46,,,16.46,Other,324% of Medicaid,10.92,,,10.92,Other,215% of Medicaid,10.92,,,10.92,Other,215% of Medicaid,6.35,,,6.35,Other,125% of Medicaid,5.08,53.28,
ASSAY OF PORPHOBILINOGEN,84110,CPT,,78084110,CDM,301,RC,,,both,,,138,102.12,,,102.12,Other,150% of Medicare + 9.63% HCRA Surcharge,62.1,45,,62.1,percent of total billed charges,Critical Access Hospital RCC factor,25.4,,,25.4,Fee Schedule,,22.87,,,22.87,Fee Schedule,,62.61,,,62.61,Fee Schedule,,56.31,,,56.31,Fee Schedule,,53.22,,,53.22,Fee Schedule,,68.31,,,68.31,Other,110% of Medicare,26.59,,,26.59,Fee Schedule,,16,,,16,Other,186% of Medicaid,31.31,,,31.31,Fee Schedule,,85.56,,,85.56,Fee Schedule,,17.72,,,17.72,Fee Schedule,,31.31,,,31.31,Fee Schedule,,85.56,,,85.56,Fee Schedule,,33.34,,,33.34,Fee Schedule,,96.6,70,,96.6,percent of total billed charges,All Other,40,,,40,Fee Schedule,,33.9,,,33.9,Fee Schedule,,12.66,,,12.66,Fee Schedule,,12.66,,,12.66,Fee Schedule,,12.66,,,12.66,Fee Schedule,,12.66,,,12.66,Fee Schedule,,8.44,,,8.44,Other,100% of Medicaid,8.44,,,8.44,Other,100% of Medicaid,8.44,,,8.44,Other,100% of Medicaid,8.44,,,8.44,Other,100% of Medicaid,18.99,,,18.99,Other,225% of Medicaid,12.91,,,12.91,Other,153% of Medicaid,18.99,,,18.99,Other,225% of Medicaid,11.82,,,11.82,Other,140% of Medicaid,18.99,,,18.99,Other,225% of Medicaid,21.94,,,21.94,Other,260% of Medicaid,27.35,,,27.35,Other,324% of Medicaid,18.15,,,18.15,Other,215% of Medicaid,18.15,,,18.15,Other,215% of Medicaid,10.55,,,10.55,Other,125% of Medicaid,8.44,102.12,
ASSAY OF URINE PORPHYRINS,84120,CPT,,78084120,CDM,301,RC,,,both,,,243,179.82,,,179.82,Other,150% of Medicare + 9.63% HCRA Surcharge,109.35,45,,109.35,percent of total billed charges,Critical Access Hospital RCC factor,44.28,,,44.28,Fee Schedule,,39.86,,,39.86,Fee Schedule,,93.7,,,93.7,Fee Schedule,,84.28,,,84.28,Fee Schedule,,79.65,,,79.65,Fee Schedule,,120.29,,,120.29,Other,110% of Medicare,46.34,,,46.34,Fee Schedule,,27,,,27,Other,186% of Medicaid,54.57,,,54.57,Fee Schedule,,150.66,,,150.66,Fee Schedule,,30.89,,,30.89,Fee Schedule,,54.57,,,54.57,Fee Schedule,,150.66,,,150.66,Fee Schedule,,58.1,,,58.1,Fee Schedule,,170.1,70,,170.1,percent of total billed charges,All Other,69.71,,,69.71,Fee Schedule,,59.08,,,59.08,Fee Schedule,,22.07,,,22.07,Fee Schedule,,22.07,,,22.07,Fee Schedule,,22.07,,,22.07,Fee Schedule,,22.07,,,22.07,Fee Schedule,,14.71,,,14.71,Other,100% of Medicaid,14.71,,,14.71,Other,100% of Medicaid,14.71,,,14.71,Other,100% of Medicaid,14.71,,,14.71,Other,100% of Medicaid,33.1,,,33.1,Other,225% of Medicaid,22.51,,,22.51,Other,153% of Medicaid,33.1,,,33.1,Other,225% of Medicaid,20.59,,,20.59,Other,140% of Medicaid,33.1,,,33.1,Other,225% of Medicaid,38.25,,,38.25,Other,260% of Medicaid,47.66,,,47.66,Other,324% of Medicaid,31.63,,,31.63,Other,215% of Medicaid,31.63,,,31.63,Other,215% of Medicaid,18.39,,,18.39,Other,125% of Medicaid,14.71,179.82,
ASSAY OF FECES PORPHYRINS,84126,CPT,,78084126,CDM,301,RC,,,both,,,306,226.44,,,226.44,Other,150% of Medicare + 9.63% HCRA Surcharge,137.7,45,,137.7,percent of total billed charges,Critical Access Hospital RCC factor,117.72,,,117.72,Fee Schedule,,105.99,,,105.99,Fee Schedule,,188.93,,,188.93,Fee Schedule,,169.93,,,169.93,Fee Schedule,,160.61,,,160.61,Fee Schedule,,151.47,,,151.47,Other,110% of Medicare,123.2,,,123.2,Fee Schedule,,59,,,59,Other,186% of Medicaid,145.1,,,145.1,Fee Schedule,,189.72,,,189.72,Fee Schedule,,82.13,,,82.13,Fee Schedule,,145.1,,,145.1,Fee Schedule,,189.72,,,189.72,Fee Schedule,,154.48,,,154.48,Fee Schedule,,214.2,70,,214.2,percent of total billed charges,All Other,185.34,,,185.34,Fee Schedule,,157.09,,,157.09,Fee Schedule,,58.67,,,58.67,Fee Schedule,,58.67,,,58.67,Fee Schedule,,58.67,,,58.67,Fee Schedule,,58.67,,,58.67,Fee Schedule,,31.7,,,31.7,Other,100% of Medicaid,31.7,,,31.7,Other,100% of Medicaid,31.7,,,31.7,Other,100% of Medicaid,31.7,,,31.7,Other,100% of Medicaid,71.33,,,71.33,Other,225% of Medicaid,48.51,,,48.51,Other,153% of Medicaid,71.33,,,71.33,Other,225% of Medicaid,44.38,,,44.38,Other,140% of Medicaid,71.33,,,71.33,Other,225% of Medicaid,82.43,,,82.43,Other,260% of Medicaid,102.72,,,102.72,Other,324% of Medicaid,68.16,,,68.16,Other,215% of Medicaid,68.16,,,68.16,Other,215% of Medicaid,39.63,,,39.63,Other,125% of Medicaid,31.7,226.44,
ASSAY OF SERUM POTASSIUM,84132,CPT,,78084132,CDM,301,RC,,,both,,,82,60.68,,,60.68,Other,150% of Medicare + 9.63% HCRA Surcharge,36.9,45,,36.9,percent of total billed charges,Critical Access Hospital RCC factor,14.33,,,14.33,Fee Schedule,,12.9,,,12.9,Fee Schedule,,34.1,,,34.1,Fee Schedule,,30.67,,,30.67,Fee Schedule,,28.99,,,28.99,Fee Schedule,,40.59,,,40.59,Other,110% of Medicare,14.99,,,14.99,Fee Schedule,,9,,,9,Other,186% of Medicaid,17.66,,,17.66,Fee Schedule,,50.84,,,50.84,Fee Schedule,,10,,,10,Fee Schedule,,17.66,,,17.66,Fee Schedule,,50.84,,,50.84,Fee Schedule,,18.8,,,18.8,Fee Schedule,,57.4,70,,57.4,percent of total billed charges,All Other,22.56,,,22.56,Fee Schedule,,19.12,,,19.12,Fee Schedule,,7.14,,,7.14,Fee Schedule,,7.14,,,7.14,Fee Schedule,,7.14,,,7.14,Fee Schedule,,7.14,,,7.14,Fee Schedule,,4.76,,,4.76,Other,100% of Medicaid,4.76,,,4.76,Other,100% of Medicaid,4.76,,,4.76,Other,100% of Medicaid,4.76,,,4.76,Other,100% of Medicaid,10.71,,,10.71,Other,225% of Medicaid,7.28,,,7.28,Other,153% of Medicaid,10.71,,,10.71,Other,225% of Medicaid,6.66,,,6.66,Other,140% of Medicaid,10.71,,,10.71,Other,225% of Medicaid,12.38,,,12.38,Other,260% of Medicaid,15.42,,,15.42,Other,324% of Medicaid,10.23,,,10.23,Other,215% of Medicaid,10.23,,,10.23,Other,215% of Medicaid,5.95,,,5.95,Other,125% of Medicaid,4.76,60.68,
ASSAY OF URINE POTASSIUM,84133,CPT,,78084133,CDM,301,RC,,,both,,,68,50.32,,,50.32,Other,150% of Medicare + 9.63% HCRA Surcharge,30.6,45,,30.6,percent of total billed charges,Critical Access Hospital RCC factor,14.24,,,14.24,Fee Schedule,,12.82,,,12.82,Fee Schedule,,31.88,,,31.88,Fee Schedule,,28.68,,,28.68,Fee Schedule,,27.1,,,27.1,Fee Schedule,,33.66,,,33.66,Other,110% of Medicare,14.9,,,14.9,Fee Schedule,,9,,,9,Other,186% of Medicaid,17.55,,,17.55,Fee Schedule,,42.16,,,42.16,Fee Schedule,,9.93,,,9.93,Fee Schedule,,17.55,,,17.55,Fee Schedule,,42.16,,,42.16,Fee Schedule,,18.68,,,18.68,Fee Schedule,,47.6,70,,47.6,percent of total billed charges,All Other,22.42,,,22.42,Fee Schedule,,19,,,19,Fee Schedule,,7.1,,,7.1,Fee Schedule,,7.1,,,7.1,Fee Schedule,,7.1,,,7.1,Fee Schedule,,7.1,,,7.1,Fee Schedule,,4.73,,,4.73,Other,100% of Medicaid,4.73,,,4.73,Other,100% of Medicaid,4.73,,,4.73,Other,100% of Medicaid,4.73,,,4.73,Other,100% of Medicaid,10.64,,,10.64,Other,225% of Medicaid,7.24,,,7.24,Other,153% of Medicaid,10.64,,,10.64,Other,225% of Medicaid,6.62,,,6.62,Other,140% of Medicaid,10.64,,,10.64,Other,225% of Medicaid,12.3,,,12.3,Other,260% of Medicaid,15.33,,,15.33,Other,324% of Medicaid,10.17,,,10.17,Other,215% of Medicaid,10.17,,,10.17,Other,215% of Medicaid,5.91,,,5.91,Other,125% of Medicaid,4.73,50.32,
ASSAY OF PREALBUMIN,84134,CPT,,78084134,CDM,301,RC,,,both,,,240,177.6,,,177.6,Other,150% of Medicare + 9.63% HCRA Surcharge,108,45,,108,percent of total billed charges,Critical Access Hospital RCC factor,43.92,,,43.92,Fee Schedule,,39.54,,,39.54,Fee Schedule,,41.42,,,41.42,Fee Schedule,,37.26,,,37.26,Fee Schedule,,35.21,,,35.21,Fee Schedule,,118.8,,,118.8,Other,110% of Medicare,45.96,,,45.96,Fee Schedule,,14,,,14,Other,186% of Medicaid,54.13,,,54.13,Fee Schedule,,148.8,,,148.8,Fee Schedule,,30.64,,,30.64,Fee Schedule,,54.13,,,54.13,Fee Schedule,,148.8,,,148.8,Fee Schedule,,57.63,,,57.63,Fee Schedule,,168,70,,168,percent of total billed charges,All Other,69.14,,,69.14,Fee Schedule,,58.6,,,58.6,Fee Schedule,,21.89,,,21.89,Fee Schedule,,21.89,,,21.89,Fee Schedule,,21.89,,,21.89,Fee Schedule,,21.89,,,21.89,Fee Schedule,,7.39,,,7.39,Other,100% of Medicaid,7.39,,,7.39,Other,100% of Medicaid,7.39,,,7.39,Other,100% of Medicaid,7.39,,,7.39,Other,100% of Medicaid,16.63,,,16.63,Other,225% of Medicaid,11.31,,,11.31,Other,153% of Medicaid,16.63,,,16.63,Other,225% of Medicaid,10.35,,,10.35,Other,140% of Medicaid,16.63,,,16.63,Other,225% of Medicaid,19.22,,,19.22,Other,260% of Medicaid,23.95,,,23.95,Other,324% of Medicaid,15.9,,,15.9,Other,215% of Medicaid,15.9,,,15.9,Other,215% of Medicaid,9.24,,,9.24,Other,125% of Medicaid,7.39,177.6,
ASSAY OF PREGNANEDIOL,84135,CPT,,78084135,CDM,301,RC,,,both,,,251,185.74,,,185.74,Other,150% of Medicare + 9.63% HCRA Surcharge,112.95,45,,112.95,percent of total billed charges,Critical Access Hospital RCC factor,64.02,,,64.02,Fee Schedule,,57.64,,,57.64,Fee Schedule,,141.87,,,141.87,Fee Schedule,,127.6,,,127.6,Fee Schedule,,120.6,,,120.6,Fee Schedule,,124.25,,,124.25,Other,110% of Medicare,67,,,67,Fee Schedule,,44,,,44,Other,186% of Medicaid,78.91,,,78.91,Fee Schedule,,155.62,,,155.62,Fee Schedule,,44.67,,,44.67,Fee Schedule,,78.91,,,78.91,Fee Schedule,,155.62,,,155.62,Fee Schedule,,84.02,,,84.02,Fee Schedule,,175.7,70,,175.7,percent of total billed charges,All Other,100.8,,,100.8,Fee Schedule,,85.43,,,85.43,Fee Schedule,,31.91,,,31.91,Fee Schedule,,31.91,,,31.91,Fee Schedule,,31.91,,,31.91,Fee Schedule,,31.91,,,31.91,Fee Schedule,,23.84,,,23.84,Other,100% of Medicaid,23.84,,,23.84,Other,100% of Medicaid,23.84,,,23.84,Other,100% of Medicaid,23.84,,,23.84,Other,100% of Medicaid,53.64,,,53.64,Other,225% of Medicaid,36.47,,,36.47,Other,153% of Medicaid,53.64,,,53.64,Other,225% of Medicaid,33.37,,,33.37,Other,140% of Medicaid,53.64,,,53.64,Other,225% of Medicaid,61.98,,,61.98,Other,260% of Medicaid,77.24,,,77.24,Other,324% of Medicaid,51.25,,,51.25,Other,215% of Medicaid,51.25,,,51.25,Other,215% of Medicaid,29.8,,,29.8,Other,125% of Medicaid,23.84,185.74,
ASSAY OF PREGNANETRIOL,84138,CPT,,78084138,CDM,301,RC,,,both,,,251,185.74,,,185.74,Other,150% of Medicare + 9.63% HCRA Surcharge,112.95,45,,112.95,percent of total billed charges,Critical Access Hospital RCC factor,63.36,,,63.36,Fee Schedule,,57.05,,,57.05,Fee Schedule,,140.45,,,140.45,Fee Schedule,,126.32,,,126.32,Fee Schedule,,119.39,,,119.39,Fee Schedule,,124.25,,,124.25,Other,110% of Medicare,66.31,,,66.31,Fee Schedule,,44,,,44,Other,186% of Medicaid,78.1,,,78.1,Fee Schedule,,155.62,,,155.62,Fee Schedule,,44.21,,,44.21,Fee Schedule,,78.1,,,78.1,Fee Schedule,,155.62,,,155.62,Fee Schedule,,83.15,,,83.15,Fee Schedule,,175.7,70,,175.7,percent of total billed charges,All Other,99.76,,,99.76,Fee Schedule,,84.55,,,84.55,Fee Schedule,,31.58,,,31.58,Fee Schedule,,31.58,,,31.58,Fee Schedule,,31.58,,,31.58,Fee Schedule,,31.58,,,31.58,Fee Schedule,,23.84,,,23.84,Other,100% of Medicaid,23.84,,,23.84,Other,100% of Medicaid,23.84,,,23.84,Other,100% of Medicaid,23.84,,,23.84,Other,100% of Medicaid,53.64,,,53.64,Other,225% of Medicaid,36.47,,,36.47,Other,153% of Medicaid,53.64,,,53.64,Other,225% of Medicaid,33.37,,,33.37,Other,140% of Medicaid,53.64,,,53.64,Other,225% of Medicaid,61.98,,,61.98,Other,260% of Medicaid,77.24,,,77.24,Other,324% of Medicaid,51.25,,,51.25,Other,215% of Medicaid,51.25,,,51.25,Other,215% of Medicaid,29.8,,,29.8,Other,125% of Medicaid,23.84,185.74,
PREGNENOLONE,84140,CPT,,78084140,CDM,301,RC,,,both,,,124,91.76,,,91.76,Other,150% of Medicare + 9.63% HCRA Surcharge,55.8,45,,55.8,percent of total billed charges,Critical Access Hospital RCC factor,62.22,,,62.22,Fee Schedule,,56.02,,,56.02,Fee Schedule,,153.36,,,153.36,Fee Schedule,,137.93,,,137.93,Fee Schedule,,130.37,,,130.37,Fee Schedule,,61.38,,,61.38,Other,110% of Medicare,65.11,,,65.11,Fee Schedule,,38,,,38,Other,186% of Medicaid,76.69,,,76.69,Fee Schedule,,76.88,,,76.88,Fee Schedule,,43.41,,,43.41,Fee Schedule,,76.69,,,76.69,Fee Schedule,,76.88,,,76.88,Fee Schedule,,81.65,,,81.65,Fee Schedule,,86.8,70,,86.8,percent of total billed charges,All Other,97.96,,,97.96,Fee Schedule,,83.02,,,83.02,Fee Schedule,,31.01,,,31.01,Fee Schedule,,31.01,,,31.01,Fee Schedule,,31.01,,,31.01,Fee Schedule,,31.01,,,31.01,Fee Schedule,,20.67,,,20.67,Other,100% of Medicaid,20.67,,,20.67,Other,100% of Medicaid,20.67,,,20.67,Other,100% of Medicaid,20.67,,,20.67,Other,100% of Medicaid,46.51,,,46.51,Other,225% of Medicaid,31.63,,,31.63,Other,153% of Medicaid,46.51,,,46.51,Other,225% of Medicaid,28.94,,,28.94,Other,140% of Medicaid,46.51,,,46.51,Other,225% of Medicaid,53.74,,,53.74,Other,260% of Medicaid,66.97,,,66.97,Other,324% of Medicaid,44.44,,,44.44,Other,215% of Medicaid,44.44,,,44.44,Other,215% of Medicaid,25.84,,,25.84,Other,125% of Medicaid,20.67,153.36,
ASSAY OF 17-HYDROXYPREGNENO,84143,CPT,,78084143,CDM,301,RC,,,both,,,73,54.02,,,54.02,Other,150% of Medicare + 9.63% HCRA Surcharge,32.85,45,,32.85,percent of total billed charges,Critical Access Hospital RCC factor,68.66,,,68.66,Fee Schedule,,61.82,,,61.82,Fee Schedule,,169.27,,,169.27,Fee Schedule,,152.25,,,152.25,Fee Schedule,,143.9,,,143.9,Fee Schedule,,36.14,,,36.14,Other,110% of Medicare,71.85,,,71.85,Fee Schedule,,42,,,42,Other,186% of Medicaid,84.63,,,84.63,Fee Schedule,,45.26,,,45.26,Fee Schedule,,47.9,,,47.9,Fee Schedule,,84.63,,,84.63,Fee Schedule,,45.26,,,45.26,Fee Schedule,,90.1,,,90.1,Fee Schedule,,51.1,70,,51.1,percent of total billed charges,All Other,108.1,,,108.1,Fee Schedule,,91.62,,,91.62,Fee Schedule,,34.22,,,34.22,Fee Schedule,,34.22,,,34.22,Fee Schedule,,34.22,,,34.22,Fee Schedule,,34.22,,,34.22,Fee Schedule,,22.81,,,22.81,Other,100% of Medicaid,22.81,,,22.81,Other,100% of Medicaid,22.81,,,22.81,Other,100% of Medicaid,22.81,,,22.81,Other,100% of Medicaid,51.32,,,51.32,Other,225% of Medicaid,34.9,,,34.9,Other,153% of Medicaid,51.32,,,51.32,Other,225% of Medicaid,31.93,,,31.93,Other,140% of Medicaid,51.32,,,51.32,Other,225% of Medicaid,59.31,,,59.31,Other,260% of Medicaid,73.9,,,73.9,Other,324% of Medicaid,49.04,,,49.04,Other,215% of Medicaid,49.04,,,49.04,Other,215% of Medicaid,28.51,,,28.51,Other,125% of Medicaid,22.81,169.27,
ASSAY OF PROGESTERONE,84144,CPT,,78084144,CDM,301,RC,,,both,,,266,196.84,,,196.84,Other,150% of Medicare + 9.63% HCRA Surcharge,119.7,45,,119.7,percent of total billed charges,Critical Access Hospital RCC factor,62.79,,,62.79,Fee Schedule,,56.53,,,56.53,Fee Schedule,,154.73,,,154.73,Fee Schedule,,139.17,,,139.17,Fee Schedule,,131.53,,,131.53,Fee Schedule,,131.67,,,131.67,Other,110% of Medicare,65.71,,,65.71,Fee Schedule,,39,,,39,Other,186% of Medicaid,77.39,,,77.39,Fee Schedule,,164.92,,,164.92,Fee Schedule,,43.81,,,43.81,Fee Schedule,,77.39,,,77.39,Fee Schedule,,164.92,,,164.92,Fee Schedule,,82.4,,,82.4,Fee Schedule,,186.2,70,,186.2,percent of total billed charges,All Other,98.86,,,98.86,Fee Schedule,,83.79,,,83.79,Fee Schedule,,31.29,,,31.29,Fee Schedule,,31.29,,,31.29,Fee Schedule,,31.29,,,31.29,Fee Schedule,,31.29,,,31.29,Fee Schedule,,20.86,,,20.86,Other,100% of Medicaid,20.86,,,20.86,Other,100% of Medicaid,20.86,,,20.86,Other,100% of Medicaid,20.86,,,20.86,Other,100% of Medicaid,46.94,,,46.94,Other,225% of Medicaid,31.92,,,31.92,Other,153% of Medicaid,46.94,,,46.94,Other,225% of Medicaid,29.2,,,29.2,Other,140% of Medicaid,46.94,,,46.94,Other,225% of Medicaid,54.24,,,54.24,Other,260% of Medicaid,67.59,,,67.59,Other,324% of Medicaid,44.85,,,44.85,Other,215% of Medicaid,44.85,,,44.85,Other,215% of Medicaid,26.08,,,26.08,Other,125% of Medicaid,20.86,196.84,
PROCALCITONIN (PCT),84145,CPT,,78084145,CDM,301,RC,,,both,,,172,127.28,,,127.28,Other,150% of Medicare + 9.63% HCRA Surcharge,77.4,45,,77.4,percent of total billed charges,Critical Access Hospital RCC factor,81.93,,,81.93,Fee Schedule,,73.77,,,73.77,Fee Schedule,,198.63,,,198.63,Fee Schedule,,178.65,,,178.65,Fee Schedule,,168.85,,,168.85,Fee Schedule,,85.14,,,85.14,Other,110% of Medicare,85.74,,,85.74,Fee Schedule,,44,,,44,Other,186% of Medicaid,100.99,,,100.99,Fee Schedule,,106.64,,,106.64,Fee Schedule,,57.16,,,57.16,Fee Schedule,,100.99,,,100.99,Fee Schedule,,106.64,,,106.64,Fee Schedule,,107.52,,,107.52,Fee Schedule,,120.4,70,,120.4,percent of total billed charges,All Other,129,,,129,Fee Schedule,,109.33,,,109.33,Fee Schedule,,40.83,,,40.83,Fee Schedule,,40.83,,,40.83,Fee Schedule,,40.83,,,40.83,Fee Schedule,,40.83,,,40.83,Fee Schedule,,23.84,,,23.84,Other,100% of Medicaid,23.84,,,23.84,Other,100% of Medicaid,23.84,,,23.84,Other,100% of Medicaid,23.84,,,23.84,Other,100% of Medicaid,53.64,,,53.64,Other,225% of Medicaid,36.47,,,36.47,Other,153% of Medicaid,53.64,,,53.64,Other,225% of Medicaid,33.37,,,33.37,Other,140% of Medicaid,53.64,,,53.64,Other,225% of Medicaid,61.98,,,61.98,Other,260% of Medicaid,77.24,,,77.24,Other,324% of Medicaid,51.25,,,51.25,Other,215% of Medicaid,51.25,,,51.25,Other,215% of Medicaid,29.8,,,29.8,Other,125% of Medicaid,23.84,198.63,
ASSAY OF PROLACTIN,84146,CPT,,78084146,CDM,301,RC,,,both,,,260,192.4,,,192.4,Other,150% of Medicare + 9.63% HCRA Surcharge,117,45,,117,percent of total billed charges,Critical Access Hospital RCC factor,58.33,,,58.33,Fee Schedule,,52.52,,,52.52,Fee Schedule,,143.71,,,143.71,Fee Schedule,,129.26,,,129.26,Fee Schedule,,122.17,,,122.17,Fee Schedule,,128.7,,,128.7,Other,110% of Medicare,61.05,,,61.05,Fee Schedule,,36,,,36,Other,186% of Medicaid,71.9,,,71.9,Fee Schedule,,161.2,,,161.2,Fee Schedule,,40.7,,,40.7,Fee Schedule,,71.9,,,71.9,Fee Schedule,,161.2,,,161.2,Fee Schedule,,76.55,,,76.55,Fee Schedule,,182,70,,182,percent of total billed charges,All Other,91.84,,,91.84,Fee Schedule,,77.84,,,77.84,Fee Schedule,,29.07,,,29.07,Fee Schedule,,29.07,,,29.07,Fee Schedule,,29.07,,,29.07,Fee Schedule,,29.07,,,29.07,Fee Schedule,,19.38,,,19.38,Other,100% of Medicaid,19.38,,,19.38,Other,100% of Medicaid,19.38,,,19.38,Other,100% of Medicaid,19.38,,,19.38,Other,100% of Medicaid,43.61,,,43.61,Other,225% of Medicaid,29.65,,,29.65,Other,153% of Medicaid,43.61,,,43.61,Other,225% of Medicaid,27.13,,,27.13,Other,140% of Medicaid,43.61,,,43.61,Other,225% of Medicaid,50.39,,,50.39,Other,260% of Medicaid,62.79,,,62.79,Other,324% of Medicaid,41.67,,,41.67,Other,215% of Medicaid,41.67,,,41.67,Other,215% of Medicaid,24.23,,,24.23,Other,125% of Medicaid,19.38,192.4,
PSA TOTAL,84153,CPT,,78084153,CDM,301,RC,,,both,,,119,88.06,,,88.06,Other,150% of Medicare + 9.63% HCRA Surcharge,53.55,45,,53.55,percent of total billed charges,Critical Access Hospital RCC factor,55.35,,,55.35,Fee Schedule,,49.84,,,49.84,Fee Schedule,,136.44,,,136.44,Fee Schedule,,122.72,,,122.72,Fee Schedule,,115.99,,,115.99,Fee Schedule,,58.91,,,58.91,Other,110% of Medicare,57.93,,,57.93,Fee Schedule,,34,,,34,Other,186% of Medicaid,68.23,,,68.23,Fee Schedule,,73.78,,,73.78,Fee Schedule,,38.62,,,38.62,Fee Schedule,,68.23,,,68.23,Fee Schedule,,73.78,,,73.78,Fee Schedule,,72.64,,,72.64,Fee Schedule,,83.3,70,,83.3,percent of total billed charges,All Other,87.15,,,87.15,Fee Schedule,,73.87,,,73.87,Fee Schedule,,27.59,,,27.59,Fee Schedule,,27.59,,,27.59,Fee Schedule,,27.59,,,27.59,Fee Schedule,,27.59,,,27.59,Fee Schedule,,18.39,,,18.39,Other,100% of Medicaid,18.39,,,18.39,Other,100% of Medicaid,18.39,,,18.39,Other,100% of Medicaid,18.39,,,18.39,Other,100% of Medicaid,41.38,,,41.38,Other,225% of Medicaid,28.14,,,28.14,Other,153% of Medicaid,41.38,,,41.38,Other,225% of Medicaid,25.75,,,25.75,Other,140% of Medicaid,41.38,,,41.38,Other,225% of Medicaid,47.81,,,47.81,Other,260% of Medicaid,59.58,,,59.58,Other,324% of Medicaid,39.54,,,39.54,Other,215% of Medicaid,39.54,,,39.54,Other,215% of Medicaid,22.99,,,22.99,Other,125% of Medicaid,18.39,136.44,
ASSAY OF PSA FREE,84154,CPT,,78084154,CDM,301,RC,,,both,,,275,203.5,,,203.5,Other,150% of Medicare + 9.63% HCRA Surcharge,123.75,45,,123.75,percent of total billed charges,Critical Access Hospital RCC factor,55.35,,,55.35,Fee Schedule,,49.84,,,49.84,Fee Schedule,,136.44,,,136.44,Fee Schedule,,122.72,,,122.72,Fee Schedule,,115.99,,,115.99,Fee Schedule,,136.13,,,136.13,Other,110% of Medicare,57.93,,,57.93,Fee Schedule,,34,,,34,Other,186% of Medicaid,68.23,,,68.23,Fee Schedule,,170.5,,,170.5,Fee Schedule,,38.62,,,38.62,Fee Schedule,,68.23,,,68.23,Fee Schedule,,170.5,,,170.5,Fee Schedule,,72.64,,,72.64,Fee Schedule,,192.5,70,,192.5,percent of total billed charges,All Other,87.15,,,87.15,Fee Schedule,,73.87,,,73.87,Fee Schedule,,27.59,,,27.59,Fee Schedule,,27.59,,,27.59,Fee Schedule,,27.59,,,27.59,Fee Schedule,,27.59,,,27.59,Fee Schedule,,18.39,,,18.39,Other,100% of Medicaid,18.39,,,18.39,Other,100% of Medicaid,18.39,,,18.39,Other,100% of Medicaid,18.39,,,18.39,Other,100% of Medicaid,41.38,,,41.38,Other,225% of Medicaid,28.14,,,28.14,Other,153% of Medicaid,41.38,,,41.38,Other,225% of Medicaid,25.75,,,25.75,Other,140% of Medicaid,41.38,,,41.38,Other,225% of Medicaid,47.81,,,47.81,Other,260% of Medicaid,59.58,,,59.58,Other,324% of Medicaid,39.54,,,39.54,Other,215% of Medicaid,39.54,,,39.54,Other,215% of Medicaid,22.99,,,22.99,Other,125% of Medicaid,18.39,203.5,
ASSAY OF PROTEIN SERUM,84155,CPT,,78084155,CDM,301,RC,,,both,,,94,69.56,,,69.56,Other,150% of Medicare + 9.63% HCRA Surcharge,42.3,45,,42.3,percent of total billed charges,Critical Access Hospital RCC factor,11.05,,,11.05,Fee Schedule,,9.95,,,9.95,Fee Schedule,,27.19,,,27.19,Fee Schedule,,24.46,,,24.46,Fee Schedule,,23.12,,,23.12,Fee Schedule,,46.53,,,46.53,Other,110% of Medicare,11.56,,,11.56,Fee Schedule,,7,,,7,Other,186% of Medicaid,13.62,,,13.62,Fee Schedule,,58.28,,,58.28,Fee Schedule,,7.71,,,7.71,Fee Schedule,,13.62,,,13.62,Fee Schedule,,58.28,,,58.28,Fee Schedule,,14.5,,,14.5,Fee Schedule,,65.8,70,,65.8,percent of total billed charges,All Other,17.39,,,17.39,Fee Schedule,,14.74,,,14.74,Fee Schedule,,5.51,,,5.51,Fee Schedule,,5.51,,,5.51,Fee Schedule,,5.51,,,5.51,Fee Schedule,,5.51,,,5.51,Fee Schedule,,3.67,,,3.67,Other,100% of Medicaid,3.67,,,3.67,Other,100% of Medicaid,3.67,,,3.67,Other,100% of Medicaid,3.67,,,3.67,Other,100% of Medicaid,8.26,,,8.26,Other,225% of Medicaid,5.62,,,5.62,Other,153% of Medicaid,8.26,,,8.26,Other,225% of Medicaid,5.14,,,5.14,Other,140% of Medicaid,8.26,,,8.26,Other,225% of Medicaid,9.54,,,9.54,Other,260% of Medicaid,11.89,,,11.89,Other,324% of Medicaid,7.89,,,7.89,Other,215% of Medicaid,7.89,,,7.89,Other,215% of Medicaid,4.59,,,4.59,Other,125% of Medicaid,3.67,69.56,
ASSAY OF PROTEIN URINE,84156,CPT,,78084156,CDM,301,RC,,,both,,,94,69.56,,,69.56,Other,150% of Medicare + 9.63% HCRA Surcharge,42.3,45,,42.3,percent of total billed charges,Critical Access Hospital RCC factor,11.05,,,11.05,Fee Schedule,,9.95,,,9.95,Fee Schedule,,27.19,,,27.19,Fee Schedule,,24.46,,,24.46,Fee Schedule,,23.12,,,23.12,Fee Schedule,,46.53,,,46.53,Other,110% of Medicare,11.56,,,11.56,Fee Schedule,,7,,,7,Other,186% of Medicaid,13.62,,,13.62,Fee Schedule,,58.28,,,58.28,Fee Schedule,,7.71,,,7.71,Fee Schedule,,13.62,,,13.62,Fee Schedule,,58.28,,,58.28,Fee Schedule,,14.5,,,14.5,Fee Schedule,,65.8,70,,65.8,percent of total billed charges,All Other,17.39,,,17.39,Fee Schedule,,14.74,,,14.74,Fee Schedule,,5.51,,,5.51,Fee Schedule,,5.51,,,5.51,Fee Schedule,,5.51,,,5.51,Fee Schedule,,5.51,,,5.51,Fee Schedule,,3.67,,,3.67,Other,100% of Medicaid,3.67,,,3.67,Other,100% of Medicaid,3.67,,,3.67,Other,100% of Medicaid,3.67,,,3.67,Other,100% of Medicaid,8.26,,,8.26,Other,225% of Medicaid,5.62,,,5.62,Other,153% of Medicaid,8.26,,,8.26,Other,225% of Medicaid,5.14,,,5.14,Other,140% of Medicaid,8.26,,,8.26,Other,225% of Medicaid,9.54,,,9.54,Other,260% of Medicaid,11.89,,,11.89,Other,324% of Medicaid,7.89,,,7.89,Other,215% of Medicaid,7.89,,,7.89,Other,215% of Medicaid,4.59,,,4.59,Other,125% of Medicaid,3.67,69.56,
PROTEIN E-PHORESIS SERUM,84165,CPT,,78084165,CDM,301,RC,,,both,,,241,178.34,,,178.34,Other,150% of Medicare + 9.63% HCRA Surcharge,108.45,45,,108.45,percent of total billed charges,Critical Access Hospital RCC factor,32.33,,,32.33,Fee Schedule,,29.11,,,29.11,Fee Schedule,,79.68,,,79.68,Fee Schedule,,71.67,,,71.67,Fee Schedule,,67.74,,,67.74,Fee Schedule,,119.3,,,119.3,Other,110% of Medicare,33.83,,,33.83,Fee Schedule,,15,,,15,Other,186% of Medicaid,39.85,,,39.85,Fee Schedule,,149.42,,,149.42,Fee Schedule,,22.55,,,22.55,Fee Schedule,,39.85,,,39.85,Fee Schedule,,149.42,,,149.42,Fee Schedule,,42.42,,,42.42,Fee Schedule,,168.7,70,,168.7,percent of total billed charges,All Other,50.9,,,50.9,Fee Schedule,,43.14,,,43.14,Fee Schedule,,16.11,,,16.11,Fee Schedule,,16.11,,,16.11,Fee Schedule,,16.11,,,16.11,Fee Schedule,,16.11,,,16.11,Fee Schedule,,8.08,,,8.08,Other,100% of Medicaid,8.08,,,8.08,Other,100% of Medicaid,8.08,,,8.08,Other,100% of Medicaid,8.08,,,8.08,Other,100% of Medicaid,18.18,,,18.18,Other,225% of Medicaid,12.36,,,12.36,Other,153% of Medicaid,18.18,,,18.18,Other,225% of Medicaid,11.31,,,11.31,Other,140% of Medicaid,18.18,,,18.18,Other,225% of Medicaid,21.01,,,21.01,Other,260% of Medicaid,26.18,,,26.18,Other,324% of Medicaid,17.37,,,17.37,Other,215% of Medicaid,17.37,,,17.37,Other,215% of Medicaid,10.1,,,10.1,Other,125% of Medicaid,8.08,178.34,
PROTEIN E-PHORESIS/URINE/CSF,84166,CPT,,78084166,CDM,301,RC,,,both,,,193,142.82,,,142.82,Other,150% of Medicare + 9.63% HCRA Surcharge,86.85,45,,86.85,percent of total billed charges,Critical Access Hospital RCC factor,53.67,,,53.67,Fee Schedule,,48.32,,,48.32,Fee Schedule,,132.22,,,132.22,Fee Schedule,,118.93,,,118.93,Fee Schedule,,112.4,,,112.4,Fee Schedule,,95.54,,,95.54,Other,110% of Medicare,56.16,,,56.16,Fee Schedule,,21,,,21,Other,186% of Medicaid,66.15,,,66.15,Fee Schedule,,119.66,,,119.66,Fee Schedule,,37.44,,,37.44,Fee Schedule,,66.15,,,66.15,Fee Schedule,,119.66,,,119.66,Fee Schedule,,70.43,,,70.43,Fee Schedule,,135.1,70,,135.1,percent of total billed charges,All Other,84.5,,,84.5,Fee Schedule,,71.62,,,71.62,Fee Schedule,,26.75,,,26.75,Fee Schedule,,26.75,,,26.75,Fee Schedule,,26.75,,,26.75,Fee Schedule,,26.75,,,26.75,Fee Schedule,,11.36,,,11.36,Other,100% of Medicaid,11.36,,,11.36,Other,100% of Medicaid,11.36,,,11.36,Other,100% of Medicaid,11.36,,,11.36,Other,100% of Medicaid,25.57,,,25.57,Other,225% of Medicaid,17.38,,,17.38,Other,153% of Medicaid,25.57,,,25.57,Other,225% of Medicaid,15.91,,,15.91,Other,140% of Medicaid,25.57,,,25.57,Other,225% of Medicaid,29.54,,,29.54,Other,260% of Medicaid,36.81,,,36.81,Other,324% of Medicaid,24.43,,,24.43,Other,215% of Medicaid,24.43,,,24.43,Other,215% of Medicaid,14.2,,,14.2,Other,125% of Medicaid,11.36,142.82,
WESTERN BLOT TEST,84181,CPT,,78084181,CDM,301,RC,,,both,,,245,181.3,,,181.3,Other,150% of Medicare + 9.63% HCRA Surcharge,110.25,45,,110.25,percent of total billed charges,Critical Access Hospital RCC factor,51.26,,,51.26,Fee Schedule,,46.15,,,46.15,Fee Schedule,,98.87,,,98.87,Fee Schedule,,88.92,,,88.92,Fee Schedule,,84.04,,,84.04,Fee Schedule,,121.28,,,121.28,Other,110% of Medicare,53.64,,,53.64,Fee Schedule,,18,,,18,Other,186% of Medicaid,63.18,,,63.18,Fee Schedule,,151.9,,,151.9,Fee Schedule,,35.76,,,35.76,Fee Schedule,,63.18,,,63.18,Fee Schedule,,151.9,,,151.9,Fee Schedule,,67.27,,,67.27,Fee Schedule,,171.5,70,,171.5,percent of total billed charges,All Other,80.71,,,80.71,Fee Schedule,,68.4,,,68.4,Fee Schedule,,25.55,,,25.55,Fee Schedule,,25.55,,,25.55,Fee Schedule,,25.55,,,25.55,Fee Schedule,,25.55,,,25.55,Fee Schedule,,9.88,,,9.88,Other,100% of Medicaid,9.88,,,9.88,Other,100% of Medicaid,9.88,,,9.88,Other,100% of Medicaid,9.88,,,9.88,Other,100% of Medicaid,22.23,,,22.23,Other,225% of Medicaid,15.11,,,15.11,Other,153% of Medicaid,22.23,,,22.23,Other,225% of Medicaid,13.83,,,13.83,Other,140% of Medicaid,22.23,,,22.23,Other,225% of Medicaid,25.68,,,25.68,Other,260% of Medicaid,32.01,,,32.01,Other,324% of Medicaid,21.24,,,21.24,Other,215% of Medicaid,21.24,,,21.24,Other,215% of Medicaid,12.35,,,12.35,Other,125% of Medicaid,9.88,181.3,
PROTEIN WESTERN BLOT TEST,84182,CPT,,78084182,CDM,301,RC,,,both,,,742,549.08,,,549.08,Other,150% of Medicare + 9.63% HCRA Surcharge,333.9,45,,333.9,percent of total billed charges,Critical Access Hospital RCC factor,87.92,,,87.92,Fee Schedule,,79.16,,,79.16,Fee Schedule,,133.49,,,133.49,Fee Schedule,,120.06,,,120.06,Fee Schedule,,113.48,,,113.48,Fee Schedule,,367.29,,,367.29,Other,110% of Medicare,92.01,,,92.01,Fee Schedule,,66,,,66,Other,186% of Medicaid,108.37,,,108.37,Fee Schedule,,460.04,,,460.04,Fee Schedule,,61.34,,,61.34,Fee Schedule,,108.37,,,108.37,Fee Schedule,,460.04,,,460.04,Fee Schedule,,115.38,,,115.38,Fee Schedule,,519.4,70,,519.4,percent of total billed charges,All Other,138.43,,,138.43,Fee Schedule,,117.33,,,117.33,Fee Schedule,,43.82,,,43.82,Fee Schedule,,43.82,,,43.82,Fee Schedule,,43.82,,,43.82,Fee Schedule,,43.82,,,43.82,Fee Schedule,,35.34,,,35.34,Other,100% of Medicaid,35.34,,,35.34,Other,100% of Medicaid,35.34,,,35.34,Other,100% of Medicaid,35.34,,,35.34,Other,100% of Medicaid,79.52,,,79.52,Other,225% of Medicaid,54.07,,,54.07,Other,153% of Medicaid,79.52,,,79.52,Other,225% of Medicaid,49.48,,,49.48,Other,140% of Medicaid,79.52,,,79.52,Other,225% of Medicaid,91.89,,,91.89,Other,260% of Medicaid,114.51,,,114.51,Other,324% of Medicaid,75.98,,,75.98,Other,215% of Medicaid,75.98,,,75.98,Other,215% of Medicaid,44.18,,,44.18,Other,125% of Medicaid,35.34,549.08,
ASSAY RBC PROTOPORPHYRIN,84202,CPT,,78084202,CDM,301,RC,,,both,,,141,104.34,,,104.34,Other,150% of Medicare + 9.63% HCRA Surcharge,63.45,45,,63.45,percent of total billed charges,Critical Access Hospital RCC factor,43.19,,,43.19,Fee Schedule,,38.89,,,38.89,Fee Schedule,,73.15,,,73.15,Fee Schedule,,65.79,,,65.79,Fee Schedule,,62.18,,,62.18,Fee Schedule,,69.8,,,69.8,Other,110% of Medicare,45.2,,,45.2,Fee Schedule,,17,,,17,Other,186% of Medicaid,53.24,,,53.24,Fee Schedule,,87.42,,,87.42,Fee Schedule,,30.14,,,30.14,Fee Schedule,,53.24,,,53.24,Fee Schedule,,87.42,,,87.42,Fee Schedule,,56.68,,,56.68,Fee Schedule,,98.7,70,,98.7,percent of total billed charges,All Other,68.01,,,68.01,Fee Schedule,,57.64,,,57.64,Fee Schedule,,21.53,,,21.53,Fee Schedule,,21.53,,,21.53,Fee Schedule,,21.53,,,21.53,Fee Schedule,,21.53,,,21.53,Fee Schedule,,9.09,,,9.09,Other,100% of Medicaid,9.09,,,9.09,Other,100% of Medicaid,9.09,,,9.09,Other,100% of Medicaid,9.09,,,9.09,Other,100% of Medicaid,20.45,,,20.45,Other,225% of Medicaid,13.91,,,13.91,Other,153% of Medicaid,20.45,,,20.45,Other,225% of Medicaid,12.73,,,12.73,Other,140% of Medicaid,20.45,,,20.45,Other,225% of Medicaid,23.63,,,23.63,Other,260% of Medicaid,29.45,,,29.45,Other,324% of Medicaid,19.54,,,19.54,Other,215% of Medicaid,19.54,,,19.54,Other,215% of Medicaid,11.36,,,11.36,Other,125% of Medicaid,9.09,104.34,
ASSAY OF VITAMIN B-6,84207,CPT,,78084207,CDM,301,RC,,,both,,,192,142.08,,,142.08,Other,150% of Medicare + 9.63% HCRA Surcharge,86.4,45,,86.4,percent of total billed charges,Critical Access Hospital RCC factor,84.58,,,84.58,Fee Schedule,,76.15,,,76.15,Fee Schedule,,208.38,,,208.38,Fee Schedule,,187.42,,,187.42,Fee Schedule,,177.14,,,177.14,Fee Schedule,,95.04,,,95.04,Other,110% of Medicare,88.52,,,88.52,Fee Schedule,,52,,,52,Other,186% of Medicaid,104.25,,,104.25,Fee Schedule,,119.04,,,119.04,Fee Schedule,,59.01,,,59.01,Fee Schedule,,104.25,,,104.25,Fee Schedule,,119.04,,,119.04,Fee Schedule,,111,,,111,Fee Schedule,,134.4,70,,134.4,percent of total billed charges,All Other,133.17,,,133.17,Fee Schedule,,112.87,,,112.87,Fee Schedule,,42.15,,,42.15,Fee Schedule,,42.15,,,42.15,Fee Schedule,,42.15,,,42.15,Fee Schedule,,42.15,,,42.15,Fee Schedule,,28.1,,,28.1,Other,100% of Medicaid,28.1,,,28.1,Other,100% of Medicaid,28.1,,,28.1,Other,100% of Medicaid,28.1,,,28.1,Other,100% of Medicaid,63.23,,,63.23,Other,225% of Medicaid,42.99,,,42.99,Other,153% of Medicaid,63.23,,,63.23,Other,225% of Medicaid,39.34,,,39.34,Other,140% of Medicaid,63.23,,,63.23,Other,225% of Medicaid,73.06,,,73.06,Other,260% of Medicaid,91.04,,,91.04,Other,324% of Medicaid,60.42,,,60.42,Other,215% of Medicaid,60.42,,,60.42,Other,215% of Medicaid,35.13,,,35.13,Other,125% of Medicaid,28.1,208.38,
ASSAY OF PYRUVATE,84210,CPT,,78084210,CDM,301,RC,,,both,,,66,48.84,,,48.84,Other,150% of Medicare + 9.63% HCRA Surcharge,29.7,45,,29.7,percent of total billed charges,Critical Access Hospital RCC factor,43.58,,,43.58,Fee Schedule,,39.24,,,39.24,Fee Schedule,,80.47,,,80.47,Fee Schedule,,72.38,,,72.38,Fee Schedule,,68.41,,,68.41,Fee Schedule,,32.67,,,32.67,Other,110% of Medicare,45.61,,,45.61,Fee Schedule,,19,,,19,Other,186% of Medicaid,53.72,,,53.72,Fee Schedule,,40.92,,,40.92,Fee Schedule,,30.41,,,30.41,Fee Schedule,,53.72,,,53.72,Fee Schedule,,40.92,,,40.92,Fee Schedule,,57.2,,,57.2,Fee Schedule,,46.2,70,,46.2,percent of total billed charges,All Other,68.62,,,68.62,Fee Schedule,,58.16,,,58.16,Fee Schedule,,21.72,,,21.72,Fee Schedule,,21.72,,,21.72,Fee Schedule,,21.72,,,21.72,Fee Schedule,,21.72,,,21.72,Fee Schedule,,10.16,,,10.16,Other,100% of Medicaid,10.16,,,10.16,Other,100% of Medicaid,10.16,,,10.16,Other,100% of Medicaid,10.16,,,10.16,Other,100% of Medicaid,22.85,,,22.85,Other,225% of Medicaid,15.54,,,15.54,Other,153% of Medicaid,22.85,,,22.85,Other,225% of Medicaid,14.22,,,14.22,Other,140% of Medicaid,22.85,,,22.85,Other,225% of Medicaid,26.4,,,26.4,Other,260% of Medicaid,32.9,,,32.9,Other,324% of Medicaid,21.83,,,21.83,Other,215% of Medicaid,21.83,,,21.83,Other,215% of Medicaid,12.69,,,12.69,Other,125% of Medicaid,10.16,80.47,
ASSAY OF PYRUVATE KINASE,84220,CPT,,78084220,CDM,301,RC,,,both,,,31,22.94,,,22.94,Other,150% of Medicare + 9.63% HCRA Surcharge,13.95,45,,13.95,percent of total billed charges,Critical Access Hospital RCC factor,28.41,,,28.41,Fee Schedule,,25.58,,,25.58,Fee Schedule,,69.99,,,69.99,Fee Schedule,,62.95,,,62.95,Fee Schedule,,59.49,,,59.49,Fee Schedule,,15.35,,,15.35,Other,110% of Medicare,29.74,,,29.74,Fee Schedule,,18,,,18,Other,186% of Medicaid,35.02,,,35.02,Fee Schedule,,19.22,,,19.22,Fee Schedule,,19.82,,,19.82,Fee Schedule,,35.02,,,35.02,Fee Schedule,,19.22,,,19.22,Fee Schedule,,37.29,,,37.29,Fee Schedule,,21.7,70,,21.7,percent of total billed charges,All Other,44.74,,,44.74,Fee Schedule,,37.92,,,37.92,Fee Schedule,,14.16,,,14.16,Fee Schedule,,14.16,,,14.16,Fee Schedule,,14.16,,,14.16,Fee Schedule,,14.16,,,14.16,Fee Schedule,,9.44,,,9.44,Other,100% of Medicaid,9.44,,,9.44,Other,100% of Medicaid,9.44,,,9.44,Other,100% of Medicaid,9.44,,,9.44,Other,100% of Medicaid,21.24,,,21.24,Other,225% of Medicaid,14.44,,,14.44,Other,153% of Medicaid,21.24,,,21.24,Other,225% of Medicaid,13.22,,,13.22,Other,140% of Medicaid,21.24,,,21.24,Other,225% of Medicaid,24.54,,,24.54,Other,260% of Medicaid,30.59,,,30.59,Other,324% of Medicaid,20.3,,,20.3,Other,215% of Medicaid,20.3,,,20.3,Other,215% of Medicaid,11.8,,,11.8,Other,125% of Medicaid,9.44,69.99,
ASSAY OF ESTROGEN,84233,CPT,,78084233,CDM,301,RC,,,both,,,486,359.64,,,359.64,Other,150% of Medicare + 9.63% HCRA Surcharge,218.7,45,,218.7,percent of total billed charges,Critical Access Hospital RCC factor,264.52,,,264.52,Fee Schedule,,238.15,,,238.15,Fee Schedule,,466.55,,,466.55,Fee Schedule,,419.63,,,419.63,Fee Schedule,,396.61,,,396.61,Fee Schedule,,240.57,,,240.57,Other,110% of Medicare,276.82,,,276.82,Fee Schedule,,70,,,70,Other,186% of Medicaid,326.03,,,326.03,Fee Schedule,,301.32,,,301.32,Fee Schedule,,184.55,,,184.55,Fee Schedule,,326.03,,,326.03,Fee Schedule,,301.32,,,301.32,Fee Schedule,,347.13,,,347.13,Fee Schedule,,340.2,70,,340.2,percent of total billed charges,All Other,416.47,,,416.47,Fee Schedule,,352.98,,,352.98,Fee Schedule,,131.82,,,131.82,Fee Schedule,,131.82,,,131.82,Fee Schedule,,131.82,,,131.82,Fee Schedule,,131.82,,,131.82,Fee Schedule,,37.88,,,37.88,Other,100% of Medicaid,37.88,,,37.88,Other,100% of Medicaid,37.88,,,37.88,Other,100% of Medicaid,37.88,,,37.88,Other,100% of Medicaid,85.22,,,85.22,Other,225% of Medicaid,57.95,,,57.95,Other,153% of Medicaid,85.22,,,85.22,Other,225% of Medicaid,53.03,,,53.03,Other,140% of Medicaid,85.22,,,85.22,Other,225% of Medicaid,98.48,,,98.48,Other,260% of Medicaid,122.72,,,122.72,Other,324% of Medicaid,81.43,,,81.43,Other,215% of Medicaid,81.43,,,81.43,Other,215% of Medicaid,47.34,,,47.34,Other,125% of Medicaid,37.88,466.55,
ASSAY OF PROGESTERONE,84234,CPT,,78084234,CDM,301,RC,,,both,,,440,325.6,,,325.6,Other,150% of Medicare + 9.63% HCRA Surcharge,198,45,,198,percent of total billed charges,Critical Access Hospital RCC factor,195.29,,,195.29,Fee Schedule,,175.82,,,175.82,Fee Schedule,,481.1,,,481.1,Fee Schedule,,432.71,,,432.71,Fee Schedule,,408.98,,,408.98,Fee Schedule,,217.8,,,217.8,Other,110% of Medicare,204.37,,,204.37,Fee Schedule,,46,,,46,Other,186% of Medicaid,240.7,,,240.7,Fee Schedule,,272.8,,,272.8,Fee Schedule,,136.25,,,136.25,Fee Schedule,,240.7,,,240.7,Fee Schedule,,272.8,,,272.8,Fee Schedule,,256.28,,,256.28,Fee Schedule,,308,70,,308,percent of total billed charges,All Other,307.47,,,307.47,Fee Schedule,,260.6,,,260.6,Fee Schedule,,97.32,,,97.32,Fee Schedule,,97.32,,,97.32,Fee Schedule,,97.32,,,97.32,Fee Schedule,,97.32,,,97.32,Fee Schedule,,24.69,,,24.69,Other,100% of Medicaid,24.69,,,24.69,Other,100% of Medicaid,24.69,,,24.69,Other,100% of Medicaid,24.69,,,24.69,Other,100% of Medicaid,55.56,,,55.56,Other,225% of Medicaid,37.78,,,37.78,Other,153% of Medicaid,55.56,,,55.56,Other,225% of Medicaid,34.57,,,34.57,Other,140% of Medicaid,55.56,,,55.56,Other,225% of Medicaid,64.21,,,64.21,Other,260% of Medicaid,80.01,,,80.01,Other,324% of Medicaid,53.09,,,53.09,Other,215% of Medicaid,53.09,,,53.09,Other,215% of Medicaid,30.87,,,30.87,Other,125% of Medicaid,24.69,481.1,
ASSAY OF ENDOCRINE HORMONE,84235,CPT,,78084235,CDM,301,RC,,,both,,,311,230.14,,,230.14,Other,150% of Medicare + 9.63% HCRA Surcharge,139.95,45,,139.95,percent of total billed charges,Critical Access Hospital RCC factor,214.4,,,214.4,Fee Schedule,,193.03,,,193.03,Fee Schedule,,388.14,,,388.14,Fee Schedule,,349.1,,,349.1,Fee Schedule,,329.95,,,329.95,Fee Schedule,,153.95,,,153.95,Other,110% of Medicare,224.37,,,224.37,Fee Schedule,,62,,,62,Other,186% of Medicaid,264.26,,,264.26,Fee Schedule,,192.82,,,192.82,Fee Schedule,,149.58,,,149.58,Fee Schedule,,264.26,,,264.26,Fee Schedule,,192.82,,,192.82,Fee Schedule,,281.36,,,281.36,Fee Schedule,,217.7,70,,217.7,percent of total billed charges,All Other,337.56,,,337.56,Fee Schedule,,286.1,,,286.1,Fee Schedule,,106.85,,,106.85,Fee Schedule,,106.85,,,106.85,Fee Schedule,,106.85,,,106.85,Fee Schedule,,106.85,,,106.85,Fee Schedule,,33.57,,,33.57,Other,100% of Medicaid,33.57,,,33.57,Other,100% of Medicaid,33.57,,,33.57,Other,100% of Medicaid,33.57,,,33.57,Other,100% of Medicaid,75.53,,,75.53,Other,225% of Medicaid,51.36,,,51.36,Other,153% of Medicaid,75.53,,,75.53,Other,225% of Medicaid,47,,,47,Other,140% of Medicaid,75.53,,,75.53,Other,225% of Medicaid,87.28,,,87.28,Other,260% of Medicaid,108.76,,,108.76,Other,324% of Medicaid,72.17,,,72.17,Other,215% of Medicaid,72.17,,,72.17,Other,215% of Medicaid,41.96,,,41.96,Other,125% of Medicaid,33.57,388.14,
ASSAY NONENDOCRINE RECEPTOR,84238,CPT,,78084238,CDM,301,RC,,,both,,,416,307.84,,,307.84,Other,150% of Medicare + 9.63% HCRA Surcharge,187.2,45,,187.2,percent of total billed charges,Critical Access Hospital RCC factor,110.08,,,110.08,Fee Schedule,,99.1,,,99.1,Fee Schedule,,271.19,,,271.19,Fee Schedule,,243.92,,,243.92,Fee Schedule,,230.54,,,230.54,Fee Schedule,,205.92,,,205.92,Other,110% of Medicare,115.2,,,115.2,Fee Schedule,,59,,,59,Other,186% of Medicaid,135.67,,,135.67,Fee Schedule,,257.92,,,257.92,Fee Schedule,,76.8,,,76.8,Fee Schedule,,135.67,,,135.67,Fee Schedule,,257.92,,,257.92,Fee Schedule,,144.45,,,144.45,Fee Schedule,,291.2,70,,291.2,percent of total billed charges,All Other,173.31,,,173.31,Fee Schedule,,146.89,,,146.89,Fee Schedule,,54.86,,,54.86,Fee Schedule,,54.86,,,54.86,Fee Schedule,,54.86,,,54.86,Fee Schedule,,54.86,,,54.86,Fee Schedule,,31.7,,,31.7,Other,100% of Medicaid,31.7,,,31.7,Other,100% of Medicaid,31.7,,,31.7,Other,100% of Medicaid,31.7,,,31.7,Other,100% of Medicaid,71.33,,,71.33,Other,225% of Medicaid,48.51,,,48.51,Other,153% of Medicaid,71.33,,,71.33,Other,225% of Medicaid,44.38,,,44.38,Other,140% of Medicaid,71.33,,,71.33,Other,225% of Medicaid,82.43,,,82.43,Other,260% of Medicaid,102.72,,,102.72,Other,324% of Medicaid,68.16,,,68.16,Other,215% of Medicaid,68.16,,,68.16,Other,215% of Medicaid,39.63,,,39.63,Other,125% of Medicaid,31.7,307.84,
ASSAY OF RENIN,84244,CPT,,78084244,CDM,301,RC,,,both,,,279,206.46,,,206.46,Other,150% of Medicare + 9.63% HCRA Surcharge,125.55,45,,125.55,percent of total billed charges,Critical Access Hospital RCC factor,66.19,,,66.19,Fee Schedule,,59.59,,,59.59,Fee Schedule,,163.11,,,163.11,Fee Schedule,,146.7,,,146.7,Fee Schedule,,138.66,,,138.66,Fee Schedule,,138.11,,,138.11,Other,110% of Medicare,69.27,,,69.27,Fee Schedule,,44,,,44,Other,186% of Medicaid,81.58,,,81.58,Fee Schedule,,172.98,,,172.98,Fee Schedule,,46.18,,,46.18,Fee Schedule,,81.58,,,81.58,Fee Schedule,,172.98,,,172.98,Fee Schedule,,86.86,,,86.86,Fee Schedule,,195.3,70,,195.3,percent of total billed charges,All Other,104.21,,,104.21,Fee Schedule,,88.33,,,88.33,Fee Schedule,,32.99,,,32.99,Fee Schedule,,32.99,,,32.99,Fee Schedule,,32.99,,,32.99,Fee Schedule,,32.99,,,32.99,Fee Schedule,,23.84,,,23.84,Other,100% of Medicaid,23.84,,,23.84,Other,100% of Medicaid,23.84,,,23.84,Other,100% of Medicaid,23.84,,,23.84,Other,100% of Medicaid,53.64,,,53.64,Other,225% of Medicaid,36.47,,,36.47,Other,153% of Medicaid,53.64,,,53.64,Other,225% of Medicaid,33.37,,,33.37,Other,140% of Medicaid,53.64,,,53.64,Other,225% of Medicaid,61.98,,,61.98,Other,260% of Medicaid,77.24,,,77.24,Other,324% of Medicaid,51.25,,,51.25,Other,215% of Medicaid,51.25,,,51.25,Other,215% of Medicaid,29.8,,,29.8,Other,125% of Medicaid,23.84,206.46,
ASSAY OF VITAMIN B-2,84252,CPT,,78084252,CDM,301,RC,,,both,,,179,132.46,,,132.46,Other,150% of Medicare + 9.63% HCRA Surcharge,80.55,45,,80.55,percent of total billed charges,Critical Access Hospital RCC factor,60.92,,,60.92,Fee Schedule,,54.85,,,54.85,Fee Schedule,,150.09,,,150.09,Fee Schedule,,135,,,135,Fee Schedule,,127.59,,,127.59,Fee Schedule,,88.61,,,88.61,Other,110% of Medicare,63.76,,,63.76,Fee Schedule,,19,,,19,Other,186% of Medicaid,75.09,,,75.09,Fee Schedule,,110.98,,,110.98,Fee Schedule,,42.5,,,42.5,Fee Schedule,,75.09,,,75.09,Fee Schedule,,110.98,,,110.98,Fee Schedule,,79.95,,,79.95,Fee Schedule,,125.3,70,,125.3,percent of total billed charges,All Other,95.92,,,95.92,Fee Schedule,,81.3,,,81.3,Fee Schedule,,30.36,,,30.36,Fee Schedule,,30.36,,,30.36,Fee Schedule,,30.36,,,30.36,Fee Schedule,,30.36,,,30.36,Fee Schedule,,10.16,,,10.16,Other,100% of Medicaid,10.16,,,10.16,Other,100% of Medicaid,10.16,,,10.16,Other,100% of Medicaid,10.16,,,10.16,Other,100% of Medicaid,22.85,,,22.85,Other,225% of Medicaid,15.54,,,15.54,Other,153% of Medicaid,22.85,,,22.85,Other,225% of Medicaid,14.22,,,14.22,Other,140% of Medicaid,22.85,,,22.85,Other,225% of Medicaid,26.4,,,26.4,Other,260% of Medicaid,32.9,,,32.9,Other,324% of Medicaid,21.83,,,21.83,Other,215% of Medicaid,21.83,,,21.83,Other,215% of Medicaid,12.69,,,12.69,Other,125% of Medicaid,10.16,150.09,
ASSAY OF SELENIUM,84255,CPT,,78084255,CDM,301,RC,,,both,,,260,192.4,,,192.4,Other,150% of Medicare + 9.63% HCRA Surcharge,117,45,,117,percent of total billed charges,Critical Access Hospital RCC factor,76.85,,,76.85,Fee Schedule,,69.19,,,69.19,Fee Schedule,,189.35,,,189.35,Fee Schedule,,170.31,,,170.31,Fee Schedule,,160.97,,,160.97,Fee Schedule,,128.7,,,128.7,Other,110% of Medicare,80.42,,,80.42,Fee Schedule,,33,,,33,Other,186% of Medicaid,94.72,,,94.72,Fee Schedule,,161.2,,,161.2,Fee Schedule,,53.61,,,53.61,Fee Schedule,,94.72,,,94.72,Fee Schedule,,161.2,,,161.2,Fee Schedule,,100.84,,,100.84,Fee Schedule,,182,70,,182,percent of total billed charges,All Other,120.99,,,120.99,Fee Schedule,,102.54,,,102.54,Fee Schedule,,38.3,,,38.3,Fee Schedule,,38.3,,,38.3,Fee Schedule,,38.3,,,38.3,Fee Schedule,,38.3,,,38.3,Fee Schedule,,17.86,,,17.86,Other,100% of Medicaid,17.86,,,17.86,Other,100% of Medicaid,17.86,,,17.86,Other,100% of Medicaid,17.86,,,17.86,Other,100% of Medicaid,40.19,,,40.19,Other,225% of Medicaid,27.33,,,27.33,Other,153% of Medicaid,40.19,,,40.19,Other,225% of Medicaid,25.01,,,25.01,Other,140% of Medicaid,40.19,,,40.19,Other,225% of Medicaid,46.45,,,46.45,Other,260% of Medicaid,57.88,,,57.88,Other,324% of Medicaid,38.41,,,38.41,Other,215% of Medicaid,38.41,,,38.41,Other,215% of Medicaid,22.33,,,22.33,Other,125% of Medicaid,17.86,192.4,
ASSAY OF SEROTONIN,84260,CPT,,78084260,CDM,301,RC,,,both,,,105,77.7,,,77.7,Other,150% of Medicare + 9.63% HCRA Surcharge,47.25,45,,47.25,percent of total billed charges,Critical Access Hospital RCC factor,93.25,,,93.25,Fee Schedule,,83.96,,,83.96,Fee Schedule,,127.01,,,127.01,Fee Schedule,,114.23,,,114.23,Fee Schedule,,107.97,,,107.97,Fee Schedule,,51.98,,,51.98,Other,110% of Medicare,97.59,,,97.59,Fee Schedule,,62,,,62,Other,186% of Medicaid,114.94,,,114.94,Fee Schedule,,65.1,,,65.1,Fee Schedule,,65.06,,,65.06,Fee Schedule,,114.94,,,114.94,Fee Schedule,,65.1,,,65.1,Fee Schedule,,122.37,,,122.37,Fee Schedule,,73.5,70,,73.5,percent of total billed charges,All Other,146.82,,,146.82,Fee Schedule,,124.43,,,124.43,Fee Schedule,,46.47,,,46.47,Fee Schedule,,46.47,,,46.47,Fee Schedule,,46.47,,,46.47,Fee Schedule,,46.47,,,46.47,Fee Schedule,,33.57,,,33.57,Other,100% of Medicaid,33.57,,,33.57,Other,100% of Medicaid,33.57,,,33.57,Other,100% of Medicaid,33.57,,,33.57,Other,100% of Medicaid,75.53,,,75.53,Other,225% of Medicaid,51.36,,,51.36,Other,153% of Medicaid,75.53,,,75.53,Other,225% of Medicaid,47,,,47,Other,140% of Medicaid,75.53,,,75.53,Other,225% of Medicaid,87.28,,,87.28,Other,260% of Medicaid,108.76,,,108.76,Other,324% of Medicaid,72.17,,,72.17,Other,215% of Medicaid,72.17,,,72.17,Other,215% of Medicaid,41.96,,,41.96,Other,125% of Medicaid,33.57,146.82,
ASSAY OF SIALIC ACID,84275,CPT,,78084275,CDM,301,RC,,,both,,,176,130.24,,,130.24,Other,150% of Medicare + 9.63% HCRA Surcharge,79.2,45,,79.2,percent of total billed charges,Critical Access Hospital RCC factor,40.45,,,40.45,Fee Schedule,,36.42,,,36.42,Fee Schedule,,99.66,,,99.66,Fee Schedule,,89.63,,,89.63,Fee Schedule,,84.72,,,84.72,Fee Schedule,,87.12,,,87.12,Other,110% of Medicare,42.34,,,42.34,Fee Schedule,,25,,,25,Other,186% of Medicaid,49.86,,,49.86,Fee Schedule,,109.12,,,109.12,Fee Schedule,,28.22,,,28.22,Fee Schedule,,49.86,,,49.86,Fee Schedule,,109.12,,,109.12,Fee Schedule,,53.09,,,53.09,Fee Schedule,,123.2,70,,123.2,percent of total billed charges,All Other,63.69,,,63.69,Fee Schedule,,53.98,,,53.98,Fee Schedule,,20.16,,,20.16,Fee Schedule,,20.16,,,20.16,Fee Schedule,,20.16,,,20.16,Fee Schedule,,20.16,,,20.16,Fee Schedule,,13.44,,,13.44,Other,100% of Medicaid,13.44,,,13.44,Other,100% of Medicaid,13.44,,,13.44,Other,100% of Medicaid,13.44,,,13.44,Other,100% of Medicaid,30.24,,,30.24,Other,225% of Medicaid,20.56,,,20.56,Other,153% of Medicaid,30.24,,,30.24,Other,225% of Medicaid,18.82,,,18.82,Other,140% of Medicaid,30.24,,,30.24,Other,225% of Medicaid,34.94,,,34.94,Other,260% of Medicaid,43.55,,,43.55,Other,324% of Medicaid,28.9,,,28.9,Other,215% of Medicaid,28.9,,,28.9,Other,215% of Medicaid,16.8,,,16.8,Other,125% of Medicaid,13.44,130.24,
ASSAY OF SERUM SODIUM,84295,CPT,,78084295,CDM,301,RC,,,both,,,72,53.28,,,53.28,Other,150% of Medicare + 9.63% HCRA Surcharge,32.4,45,,32.4,percent of total billed charges,Critical Access Hospital RCC factor,14.48,,,14.48,Fee Schedule,,13.04,,,13.04,Fee Schedule,,35.68,,,35.68,Fee Schedule,,32.09,,,32.09,Fee Schedule,,30.33,,,30.33,Fee Schedule,,35.64,,,35.64,Other,110% of Medicare,15.15,,,15.15,Fee Schedule,,9,,,9,Other,186% of Medicaid,17.85,,,17.85,Fee Schedule,,44.64,,,44.64,Fee Schedule,,10.1,,,10.1,Fee Schedule,,17.85,,,17.85,Fee Schedule,,44.64,,,44.64,Fee Schedule,,19,,,19,Fee Schedule,,50.4,70,,50.4,percent of total billed charges,All Other,22.79,,,22.79,Fee Schedule,,19.32,,,19.32,Fee Schedule,,7.22,,,7.22,Fee Schedule,,7.22,,,7.22,Fee Schedule,,7.22,,,7.22,Fee Schedule,,7.22,,,7.22,Fee Schedule,,4.81,,,4.81,Other,100% of Medicaid,4.81,,,4.81,Other,100% of Medicaid,4.81,,,4.81,Other,100% of Medicaid,4.81,,,4.81,Other,100% of Medicaid,10.82,,,10.82,Other,225% of Medicaid,7.36,,,7.36,Other,153% of Medicaid,10.82,,,10.82,Other,225% of Medicaid,6.73,,,6.73,Other,140% of Medicaid,10.82,,,10.82,Other,225% of Medicaid,12.51,,,12.51,Other,260% of Medicaid,15.58,,,15.58,Other,324% of Medicaid,10.34,,,10.34,Other,215% of Medicaid,10.34,,,10.34,Other,215% of Medicaid,6.01,,,6.01,Other,125% of Medicaid,4.81,53.28,
ASSAY OF URINE SODIUM,84300,CPT,,78084300,CDM,301,RC,,,both,,,65,48.1,,,48.1,Other,150% of Medicare + 9.63% HCRA Surcharge,29.25,45,,29.25,percent of total billed charges,Critical Access Hospital RCC factor,15.23,,,15.23,Fee Schedule,,13.71,,,13.71,Fee Schedule,,36.1,,,36.1,Fee Schedule,,32.47,,,32.47,Fee Schedule,,30.69,,,30.69,Fee Schedule,,32.18,,,32.18,Other,110% of Medicare,15.94,,,15.94,Fee Schedule,,9,,,9,Other,186% of Medicaid,18.77,,,18.77,Fee Schedule,,40.3,,,40.3,Fee Schedule,,10.63,,,10.63,Fee Schedule,,18.77,,,18.77,Fee Schedule,,40.3,,,40.3,Fee Schedule,,19.99,,,19.99,Fee Schedule,,45.5,70,,45.5,percent of total billed charges,All Other,23.98,,,23.98,Fee Schedule,,20.32,,,20.32,Fee Schedule,,7.59,,,7.59,Fee Schedule,,7.59,,,7.59,Fee Schedule,,7.59,,,7.59,Fee Schedule,,7.59,,,7.59,Fee Schedule,,5.03,,,5.03,Other,100% of Medicaid,5.03,,,5.03,Other,100% of Medicaid,5.03,,,5.03,Other,100% of Medicaid,5.03,,,5.03,Other,100% of Medicaid,11.32,,,11.32,Other,225% of Medicaid,7.7,,,7.7,Other,153% of Medicaid,11.32,,,11.32,Other,225% of Medicaid,7.04,,,7.04,Other,140% of Medicaid,11.32,,,11.32,Other,225% of Medicaid,13.08,,,13.08,Other,260% of Medicaid,16.3,,,16.3,Other,324% of Medicaid,10.81,,,10.81,Other,215% of Medicaid,10.81,,,10.81,Other,215% of Medicaid,6.29,,,6.29,Other,125% of Medicaid,5.03,48.1,
SODIUM OTHER  SOURCE,84302,CPT,,78084302,CDM,301,RC,,,both,,,29,21.46,,,21.46,Other,150% of Medicare + 9.63% HCRA Surcharge,13.05,45,,13.05,percent of total billed charges,Critical Access Hospital RCC factor,14.63,,,14.63,Fee Schedule,,13.17,,,13.17,Fee Schedule,,36.1,,,36.1,Fee Schedule,,32.47,,,32.47,Fee Schedule,,30.69,,,30.69,Fee Schedule,,14.36,,,14.36,Other,110% of Medicare,15.31,,,15.31,Fee Schedule,,9,,,9,Other,186% of Medicaid,18.03,,,18.03,Fee Schedule,,17.98,,,17.98,Fee Schedule,,10.21,,,10.21,Fee Schedule,,18.03,,,18.03,Fee Schedule,,17.98,,,17.98,Fee Schedule,,19.2,,,19.2,Fee Schedule,,20.3,70,,20.3,percent of total billed charges,All Other,23.03,,,23.03,Fee Schedule,,19.52,,,19.52,Fee Schedule,,7.29,,,7.29,Fee Schedule,,7.29,,,7.29,Fee Schedule,,7.29,,,7.29,Fee Schedule,,7.29,,,7.29,Fee Schedule,,4.86,,,4.86,Other,100% of Medicaid,4.86,,,4.86,Other,100% of Medicaid,4.86,,,4.86,Other,100% of Medicaid,4.86,,,4.86,Other,100% of Medicaid,10.94,,,10.94,Other,225% of Medicaid,7.44,,,7.44,Other,153% of Medicaid,10.94,,,10.94,Other,225% of Medicaid,6.8,,,6.8,Other,140% of Medicaid,10.94,,,10.94,Other,225% of Medicaid,12.64,,,12.64,Other,260% of Medicaid,15.75,,,15.75,Other,324% of Medicaid,10.45,,,10.45,Other,215% of Medicaid,10.45,,,10.45,Other,215% of Medicaid,6.08,,,6.08,Other,125% of Medicaid,4.86,36.1,
ASSAY OF SOMATOMEDIN,84305,CPT,,78084305,CDM,301,RC,,,both,,,254,187.96,,,187.96,Other,150% of Medicare + 9.63% HCRA Surcharge,114.3,45,,114.3,percent of total billed charges,Critical Access Hospital RCC factor,63.99,,,63.99,Fee Schedule,,57.61,,,57.61,Fee Schedule,,157.68,,,157.68,Fee Schedule,,141.82,,,141.82,Fee Schedule,,134.04,,,134.04,Fee Schedule,,125.73,,,125.73,Other,110% of Medicare,66.97,,,66.97,Fee Schedule,,39,,,39,Other,186% of Medicaid,78.87,,,78.87,Fee Schedule,,157.48,,,157.48,Fee Schedule,,44.65,,,44.65,Fee Schedule,,78.87,,,78.87,Fee Schedule,,157.48,,,157.48,Fee Schedule,,83.98,,,83.98,Fee Schedule,,177.8,70,,177.8,percent of total billed charges,All Other,100.75,,,100.75,Fee Schedule,,85.39,,,85.39,Fee Schedule,,31.89,,,31.89,Fee Schedule,,31.89,,,31.89,Fee Schedule,,31.89,,,31.89,Fee Schedule,,31.89,,,31.89,Fee Schedule,,20.71,,,20.71,Other,100% of Medicaid,20.71,,,20.71,Other,100% of Medicaid,20.71,,,20.71,Other,100% of Medicaid,20.71,,,20.71,Other,100% of Medicaid,46.59,,,46.59,Other,225% of Medicaid,31.68,,,31.68,Other,153% of Medicaid,46.59,,,46.59,Other,225% of Medicaid,28.99,,,28.99,Other,140% of Medicaid,46.59,,,46.59,Other,225% of Medicaid,53.83,,,53.83,Other,260% of Medicaid,67.08,,,67.08,Other,324% of Medicaid,44.52,,,44.52,Other,215% of Medicaid,44.52,,,44.52,Other,215% of Medicaid,25.88,,,25.88,Other,125% of Medicaid,20.71,187.96,
SPECTROPHOTOMETRY,84311,CPT,,78084311,CDM,301,RC,,,both,,,134,99.16,,,99.16,Other,150% of Medicare + 9.63% HCRA Surcharge,60.3,45,,60.3,percent of total billed charges,Critical Access Hospital RCC factor,24.38,,,24.38,Fee Schedule,,21.95,,,21.95,Fee Schedule,,51.8,,,51.8,Fee Schedule,,46.59,,,46.59,Fee Schedule,,44.04,,,44.04,Fee Schedule,,66.33,,,66.33,Other,110% of Medicare,25.52,,,25.52,Fee Schedule,,12,,,12,Other,186% of Medicaid,30.05,,,30.05,Fee Schedule,,83.08,,,83.08,Fee Schedule,,17.01,,,17.01,Fee Schedule,,30.05,,,30.05,Fee Schedule,,83.08,,,83.08,Fee Schedule,,32,,,32,Fee Schedule,,93.8,70,,93.8,percent of total billed charges,All Other,38.39,,,38.39,Fee Schedule,,32.53,,,32.53,Fee Schedule,,12.15,,,12.15,Fee Schedule,,12.15,,,12.15,Fee Schedule,,12.15,,,12.15,Fee Schedule,,12.15,,,12.15,Fee Schedule,,6.31,,,6.31,Other,100% of Medicaid,6.31,,,6.31,Other,100% of Medicaid,6.31,,,6.31,Other,100% of Medicaid,6.31,,,6.31,Other,100% of Medicaid,14.2,,,14.2,Other,225% of Medicaid,9.65,,,9.65,Other,153% of Medicaid,14.2,,,14.2,Other,225% of Medicaid,8.83,,,8.83,Other,140% of Medicaid,14.2,,,14.2,Other,225% of Medicaid,16.41,,,16.41,Other,260% of Medicaid,20.45,,,20.45,Other,324% of Medicaid,13.57,,,13.57,Other,215% of Medicaid,13.57,,,13.57,Other,215% of Medicaid,7.89,,,7.89,Other,125% of Medicaid,6.31,99.16,
BODY FLUID SPECIFIC GRAVITY,84315,CPT,,78084315,CDM,301,RC,,,both,,,54,39.96,,,39.96,Other,150% of Medicare + 9.63% HCRA Surcharge,24.3,45,,24.3,percent of total billed charges,Critical Access Hospital RCC factor,9.87,,,9.87,Fee Schedule,,8.89,,,8.89,Fee Schedule,,18.6,,,18.6,Fee Schedule,,16.73,,,16.73,Fee Schedule,,15.81,,,15.81,Fee Schedule,,26.73,,,26.73,Other,110% of Medicare,10.33,,,10.33,Fee Schedule,,12,,,12,Other,186% of Medicaid,12.17,,,12.17,Fee Schedule,,33.48,,,33.48,Fee Schedule,,6.89,,,6.89,Fee Schedule,,12.17,,,12.17,Fee Schedule,,33.48,,,33.48,Fee Schedule,,12.96,,,12.96,Fee Schedule,,37.8,70,,37.8,percent of total billed charges,All Other,15.54,,,15.54,Fee Schedule,,13.17,,,13.17,Fee Schedule,,4.92,,,4.92,Fee Schedule,,4.92,,,4.92,Fee Schedule,,4.92,,,4.92,Fee Schedule,,4.92,,,4.92,Fee Schedule,,6.31,,,6.31,Other,100% of Medicaid,6.31,,,6.31,Other,100% of Medicaid,6.31,,,6.31,Other,100% of Medicaid,6.31,,,6.31,Other,100% of Medicaid,14.2,,,14.2,Other,225% of Medicaid,9.65,,,9.65,Other,153% of Medicaid,14.2,,,14.2,Other,225% of Medicaid,8.83,,,8.83,Other,140% of Medicaid,14.2,,,14.2,Other,225% of Medicaid,16.41,,,16.41,Other,260% of Medicaid,20.45,,,20.45,Other,324% of Medicaid,13.57,,,13.57,Other,215% of Medicaid,13.57,,,13.57,Other,215% of Medicaid,7.89,,,7.89,Other,125% of Medicaid,4.92,39.96,
SUGARS SINGLE QUAL,84376,CPT,,78084376,CDM,301,RC,,,both,,,24,17.76,,,17.76,Other,150% of Medicare + 9.63% HCRA Surcharge,10.8,45,,10.8,percent of total billed charges,Critical Access Hospital RCC factor,16.56,,,16.56,Fee Schedule,,14.91,,,14.91,Fee Schedule,,40.79,,,40.79,Fee Schedule,,36.69,,,36.69,Fee Schedule,,34.68,,,34.68,Fee Schedule,,11.88,,,11.88,Other,110% of Medicare,17.33,,,17.33,Fee Schedule,,9,,,9,Other,186% of Medicaid,20.41,,,20.41,Fee Schedule,,14.88,,,14.88,Fee Schedule,,11.55,,,11.55,Fee Schedule,,20.41,,,20.41,Fee Schedule,,14.88,,,14.88,Fee Schedule,,21.73,,,21.73,Fee Schedule,,16.8,70,,16.8,percent of total billed charges,All Other,26.06,,,26.06,Fee Schedule,,22.09,,,22.09,Fee Schedule,,8.25,,,8.25,Fee Schedule,,8.25,,,8.25,Fee Schedule,,8.25,,,8.25,Fee Schedule,,8.25,,,8.25,Fee Schedule,,5.08,,,5.08,Other,100% of Medicaid,5.08,,,5.08,Other,100% of Medicaid,5.08,,,5.08,Other,100% of Medicaid,5.08,,,5.08,Other,100% of Medicaid,11.43,,,11.43,Other,225% of Medicaid,7.77,,,7.77,Other,153% of Medicaid,11.43,,,11.43,Other,225% of Medicaid,7.11,,,7.11,Other,140% of Medicaid,11.43,,,11.43,Other,225% of Medicaid,13.21,,,13.21,Other,260% of Medicaid,16.46,,,16.46,Other,324% of Medicaid,10.92,,,10.92,Other,215% of Medicaid,10.92,,,10.92,Other,215% of Medicaid,6.35,,,6.35,Other,125% of Medicaid,5.08,40.79,
SUGARS MULTI QUAL EA SPECIMEN,84377,CPT,,78084377,CDM,301,RC,,,both,,,32,23.68,,,23.68,Other,150% of Medicare + 9.63% HCRA Surcharge,14.4,45,,14.4,percent of total billed charges,Critical Access Hospital RCC factor,16.56,,,16.56,Fee Schedule,,14.91,,,14.91,Fee Schedule,,40.79,,,40.79,Fee Schedule,,36.69,,,36.69,Fee Schedule,,34.68,,,34.68,Fee Schedule,,15.84,,,15.84,Other,110% of Medicare,17.33,,,17.33,Fee Schedule,,10,,,10,Other,186% of Medicaid,20.41,,,20.41,Fee Schedule,,19.84,,,19.84,Fee Schedule,,11.55,,,11.55,Fee Schedule,,20.41,,,20.41,Fee Schedule,,19.84,,,19.84,Fee Schedule,,21.73,,,21.73,Fee Schedule,,22.4,70,,22.4,percent of total billed charges,All Other,26.06,,,26.06,Fee Schedule,,22.09,,,22.09,Fee Schedule,,8.25,,,8.25,Fee Schedule,,8.25,,,8.25,Fee Schedule,,8.25,,,8.25,Fee Schedule,,8.25,,,8.25,Fee Schedule,,5.5,,,5.5,Other,100% of Medicaid,5.5,,,5.5,Other,100% of Medicaid,5.5,,,5.5,Other,100% of Medicaid,5.5,,,5.5,Other,100% of Medicaid,12.38,,,12.38,Other,225% of Medicaid,8.42,,,8.42,Other,153% of Medicaid,12.38,,,12.38,Other,225% of Medicaid,7.7,,,7.7,Other,140% of Medicaid,12.38,,,12.38,Other,225% of Medicaid,14.3,,,14.3,Other,260% of Medicaid,17.82,,,17.82,Other,324% of Medicaid,11.83,,,11.83,Other,215% of Medicaid,11.83,,,11.83,Other,215% of Medicaid,6.88,,,6.88,Other,125% of Medicaid,5.5,40.79,
SUGARS; SINGLE QUAN EA SPECIMEN,84378,CPT,,78084378,CDM,301,RC,,,both,,,70,51.8,,,51.8,Other,150% of Medicare + 9.63% HCRA Surcharge,31.5,45,,31.5,percent of total billed charges,Critical Access Hospital RCC factor,34.71,,,34.71,Fee Schedule,,31.25,,,31.25,Fee Schedule,,85.48,,,85.48,Fee Schedule,,76.88,,,76.88,Fee Schedule,,72.67,,,72.67,Fee Schedule,,34.65,,,34.65,Other,110% of Medicare,36.32,,,36.32,Fee Schedule,,21,,,21,Other,186% of Medicaid,42.78,,,42.78,Fee Schedule,,43.4,,,43.4,Fee Schedule,,24.21,,,24.21,Fee Schedule,,42.78,,,42.78,Fee Schedule,,43.4,,,43.4,Fee Schedule,,45.54,,,45.54,Fee Schedule,,49,70,,49,percent of total billed charges,All Other,54.64,,,54.64,Fee Schedule,,46.31,,,46.31,Fee Schedule,,17.3,,,17.3,Fee Schedule,,17.3,,,17.3,Fee Schedule,,17.3,,,17.3,Fee Schedule,,17.3,,,17.3,Fee Schedule,,11.53,,,11.53,Other,100% of Medicaid,11.53,,,11.53,Other,100% of Medicaid,11.53,,,11.53,Other,100% of Medicaid,11.53,,,11.53,Other,100% of Medicaid,25.94,,,25.94,Other,225% of Medicaid,17.64,,,17.64,Other,153% of Medicaid,25.94,,,25.94,Other,225% of Medicaid,16.14,,,16.14,Other,140% of Medicaid,25.94,,,25.94,Other,225% of Medicaid,29.98,,,29.98,Other,260% of Medicaid,37.36,,,37.36,Other,324% of Medicaid,24.79,,,24.79,Other,215% of Medicaid,24.79,,,24.79,Other,215% of Medicaid,14.41,,,14.41,Other,125% of Medicaid,11.53,85.48,
URINE SULFATE,84392,CPT,,78084392,CDM,301,RC,,,both,,,29,21.46,,,21.46,Other,150% of Medicare + 9.63% HCRA Surcharge,13.05,45,,13.05,percent of total billed charges,Critical Access Hospital RCC factor,16.52,,,16.52,Fee Schedule,,14.88,,,14.88,Fee Schedule,,35.2,,,35.2,Fee Schedule,,31.66,,,31.66,Fee Schedule,,29.93,,,29.93,Fee Schedule,,14.36,,,14.36,Other,110% of Medicare,17.29,,,17.29,Fee Schedule,,19,,,19,Other,186% of Medicaid,20.37,,,20.37,Fee Schedule,,17.98,,,17.98,Fee Schedule,,11.53,,,11.53,Fee Schedule,,20.37,,,20.37,Fee Schedule,,17.98,,,17.98,Fee Schedule,,21.69,,,21.69,Fee Schedule,,20.3,70,,20.3,percent of total billed charges,All Other,26.02,,,26.02,Fee Schedule,,22.05,,,22.05,Fee Schedule,,8.24,,,8.24,Fee Schedule,,8.24,,,8.24,Fee Schedule,,8.24,,,8.24,Fee Schedule,,8.24,,,8.24,Fee Schedule,,9.96,,,9.96,Other,100% of Medicaid,9.96,,,9.96,Other,100% of Medicaid,9.96,,,9.96,Other,100% of Medicaid,9.96,,,9.96,Other,100% of Medicaid,22.4,,,22.4,Other,225% of Medicaid,15.23,,,15.23,Other,153% of Medicaid,22.4,,,22.4,Other,225% of Medicaid,13.94,,,13.94,Other,140% of Medicaid,22.4,,,22.4,Other,225% of Medicaid,25.88,,,25.88,Other,260% of Medicaid,32.25,,,32.25,Other,324% of Medicaid,21.4,,,21.4,Other,215% of Medicaid,21.4,,,21.4,Other,215% of Medicaid,12.44,,,12.44,Other,125% of Medicaid,8.24,35.2,
ASSAY OF TESTOSTERONE,84402,CPT,,78084402,CDM,301,RC,,,both,,,525,388.5,,,388.5,Other,150% of Medicare + 9.63% HCRA Surcharge,236.25,45,,236.25,percent of total billed charges,Critical Access Hospital RCC factor,76.66,,,76.66,Fee Schedule,,69.02,,,69.02,Fee Schedule,,188.88,,,188.88,Fee Schedule,,169.88,,,169.88,Fee Schedule,,160.56,,,160.56,Fee Schedule,,259.88,,,259.88,Other,110% of Medicare,80.23,,,80.23,Fee Schedule,,47,,,47,Other,186% of Medicaid,94.49,,,94.49,Fee Schedule,,325.5,,,325.5,Fee Schedule,,53.49,,,53.49,Fee Schedule,,94.49,,,94.49,Fee Schedule,,325.5,,,325.5,Fee Schedule,,100.61,,,100.61,Fee Schedule,,367.5,70,,367.5,percent of total billed charges,All Other,120.7,,,120.7,Fee Schedule,,102.3,,,102.3,Fee Schedule,,38.21,,,38.21,Fee Schedule,,38.21,,,38.21,Fee Schedule,,38.21,,,38.21,Fee Schedule,,38.21,,,38.21,Fee Schedule,,25.47,,,25.47,Other,100% of Medicaid,25.47,,,25.47,Other,100% of Medicaid,25.47,,,25.47,Other,100% of Medicaid,25.47,,,25.47,Other,100% of Medicaid,57.31,,,57.31,Other,225% of Medicaid,38.97,,,38.97,Other,153% of Medicaid,57.31,,,57.31,Other,225% of Medicaid,35.66,,,35.66,Other,140% of Medicaid,57.31,,,57.31,Other,225% of Medicaid,66.22,,,66.22,Other,260% of Medicaid,82.52,,,82.52,Other,324% of Medicaid,54.76,,,54.76,Other,215% of Medicaid,54.76,,,54.76,Other,215% of Medicaid,31.84,,,31.84,Other,125% of Medicaid,25.47,388.5,
ASSAY OF TOTAL TESTOSTERONE,84403,CPT,,78084403,CDM,301,RC,,,both,,,329,243.46,,,243.46,Other,150% of Medicare + 9.63% HCRA Surcharge,148.05,45,,148.05,percent of total billed charges,Critical Access Hospital RCC factor,77.69,,,77.69,Fee Schedule,,69.95,,,69.95,Fee Schedule,,191.46,,,191.46,Fee Schedule,,172.2,,,172.2,Fee Schedule,,162.76,,,162.76,Fee Schedule,,162.86,,,162.86,Other,110% of Medicare,81.3,,,81.3,Fee Schedule,,48,,,48,Other,186% of Medicaid,95.76,,,95.76,Fee Schedule,,203.98,,,203.98,Fee Schedule,,54.2,,,54.2,Fee Schedule,,95.76,,,95.76,Fee Schedule,,203.98,,,203.98,Fee Schedule,,101.95,,,101.95,Fee Schedule,,230.3,70,,230.3,percent of total billed charges,All Other,122.31,,,122.31,Fee Schedule,,103.67,,,103.67,Fee Schedule,,38.72,,,38.72,Fee Schedule,,38.72,,,38.72,Fee Schedule,,38.72,,,38.72,Fee Schedule,,38.72,,,38.72,Fee Schedule,,25.81,,,25.81,Other,100% of Medicaid,25.81,,,25.81,Other,100% of Medicaid,25.81,,,25.81,Other,100% of Medicaid,25.81,,,25.81,Other,100% of Medicaid,58.07,,,58.07,Other,225% of Medicaid,39.49,,,39.49,Other,153% of Medicaid,58.07,,,58.07,Other,225% of Medicaid,36.13,,,36.13,Other,140% of Medicaid,58.07,,,58.07,Other,225% of Medicaid,67.11,,,67.11,Other,260% of Medicaid,83.62,,,83.62,Other,324% of Medicaid,55.49,,,55.49,Other,215% of Medicaid,55.49,,,55.49,Other,215% of Medicaid,32.26,,,32.26,Other,125% of Medicaid,25.81,243.46,
ASSAY OF VITAMIN B-1,84425,CPT,,78084425,CDM,301,RC,,,both,,,192,142.08,,,142.08,Other,150% of Medicare + 9.63% HCRA Surcharge,86.4,45,,86.4,percent of total billed charges,Critical Access Hospital RCC factor,63.9,,,63.9,Fee Schedule,,57.53,,,57.53,Fee Schedule,,157.47,,,157.47,Fee Schedule,,141.63,,,141.63,Fee Schedule,,133.86,,,133.86,Fee Schedule,,95.04,,,95.04,Other,110% of Medicare,66.87,,,66.87,Fee Schedule,,28,,,28,Other,186% of Medicaid,78.76,,,78.76,Fee Schedule,,119.04,,,119.04,Fee Schedule,,44.58,,,44.58,Fee Schedule,,78.76,,,78.76,Fee Schedule,,119.04,,,119.04,Fee Schedule,,83.86,,,83.86,Fee Schedule,,134.4,70,,134.4,percent of total billed charges,All Other,100.61,,,100.61,Fee Schedule,,85.27,,,85.27,Fee Schedule,,31.85,,,31.85,Fee Schedule,,31.85,,,31.85,Fee Schedule,,31.85,,,31.85,Fee Schedule,,31.85,,,31.85,Fee Schedule,,15.15,,,15.15,Other,100% of Medicaid,15.15,,,15.15,Other,100% of Medicaid,15.15,,,15.15,Other,100% of Medicaid,15.15,,,15.15,Other,100% of Medicaid,34.09,,,34.09,Other,225% of Medicaid,23.18,,,23.18,Other,153% of Medicaid,34.09,,,34.09,Other,225% of Medicaid,21.21,,,21.21,Other,140% of Medicaid,34.09,,,34.09,Other,225% of Medicaid,39.39,,,39.39,Other,260% of Medicaid,49.09,,,49.09,Other,324% of Medicaid,32.57,,,32.57,Other,215% of Medicaid,32.57,,,32.57,Other,215% of Medicaid,18.94,,,18.94,Other,125% of Medicaid,15.15,157.47,
ASSAY OF THIOCYANATE,84430,CPT,,78084430,CDM,301,RC,,,both,,,170,125.8,,,125.8,Other,150% of Medicare + 9.63% HCRA Surcharge,76.5,45,,76.5,percent of total billed charges,Critical Access Hospital RCC factor,35.01,,,35.01,Fee Schedule,,31.52,,,31.52,Fee Schedule,,86.32,,,86.32,Fee Schedule,,77.64,,,77.64,Fee Schedule,,73.38,,,73.38,Fee Schedule,,84.15,,,84.15,Other,110% of Medicare,36.63,,,36.63,Fee Schedule,,33,,,33,Other,186% of Medicaid,43.15,,,43.15,Fee Schedule,,105.4,,,105.4,Fee Schedule,,24.42,,,24.42,Fee Schedule,,43.15,,,43.15,Fee Schedule,,105.4,,,105.4,Fee Schedule,,45.94,,,45.94,Fee Schedule,,119,70,,119,percent of total billed charges,All Other,55.11,,,55.11,Fee Schedule,,46.71,,,46.71,Fee Schedule,,17.45,,,17.45,Fee Schedule,,17.45,,,17.45,Fee Schedule,,17.45,,,17.45,Fee Schedule,,17.45,,,17.45,Fee Schedule,,17.86,,,17.86,Other,100% of Medicaid,17.86,,,17.86,Other,100% of Medicaid,17.86,,,17.86,Other,100% of Medicaid,17.86,,,17.86,Other,100% of Medicaid,40.19,,,40.19,Other,225% of Medicaid,27.33,,,27.33,Other,153% of Medicaid,40.19,,,40.19,Other,225% of Medicaid,25.01,,,25.01,Other,140% of Medicaid,40.19,,,40.19,Other,225% of Medicaid,46.45,,,46.45,Other,260% of Medicaid,57.88,,,57.88,Other,324% of Medicaid,38.41,,,38.41,Other,215% of Medicaid,38.41,,,38.41,Other,215% of Medicaid,22.33,,,22.33,Other,125% of Medicaid,17.45,125.8,
THYROGLOBULIN,84432,CPT,,78084432,CDM,301,RC,,,both,,,45,33.3,,,33.3,Other,150% of Medicare + 9.63% HCRA Surcharge,20.25,45,,20.25,percent of total billed charges,Critical Access Hospital RCC factor,48.34,,,48.34,Fee Schedule,,43.52,,,43.52,Fee Schedule,,119.15,,,119.15,Fee Schedule,,107.17,,,107.17,Fee Schedule,,101.29,,,101.29,Fee Schedule,,22.28,,,22.28,Other,110% of Medicare,50.59,,,50.59,Fee Schedule,,44,,,44,Other,186% of Medicaid,59.58,,,59.58,Fee Schedule,,27.9,,,27.9,Fee Schedule,,33.73,,,33.73,Fee Schedule,,59.58,,,59.58,Fee Schedule,,27.9,,,27.9,Fee Schedule,,63.44,,,63.44,Fee Schedule,,31.5,70,,31.5,percent of total billed charges,All Other,76.11,,,76.11,Fee Schedule,,64.51,,,64.51,Fee Schedule,,24.09,,,24.09,Fee Schedule,,24.09,,,24.09,Fee Schedule,,24.09,,,24.09,Fee Schedule,,24.09,,,24.09,Fee Schedule,,23.84,,,23.84,Other,100% of Medicaid,23.84,,,23.84,Other,100% of Medicaid,23.84,,,23.84,Other,100% of Medicaid,23.84,,,23.84,Other,100% of Medicaid,53.64,,,53.64,Other,225% of Medicaid,36.47,,,36.47,Other,153% of Medicaid,53.64,,,53.64,Other,225% of Medicaid,33.37,,,33.37,Other,140% of Medicaid,53.64,,,53.64,Other,225% of Medicaid,61.98,,,61.98,Other,260% of Medicaid,77.24,,,77.24,Other,324% of Medicaid,51.25,,,51.25,Other,215% of Medicaid,51.25,,,51.25,Other,215% of Medicaid,29.8,,,29.8,Other,125% of Medicaid,20.25,119.15,
ASSAY OF TOTAL THYROXINE,84436,CPT,,78084436,CDM,301,RC,,,both,,,99,73.26,,,73.26,Other,150% of Medicare + 9.63% HCRA Surcharge,44.55,45,,44.55,percent of total billed charges,Critical Access Hospital RCC factor,20.68,,,20.68,Fee Schedule,,18.62,,,18.62,Fee Schedule,,50.96,,,50.96,Fee Schedule,,45.84,,,45.84,Fee Schedule,,43.32,,,43.32,Fee Schedule,,49.01,,,49.01,Other,110% of Medicare,21.64,,,21.64,Fee Schedule,,11,,,11,Other,186% of Medicaid,25.49,,,25.49,Fee Schedule,,61.38,,,61.38,Fee Schedule,,14.43,,,14.43,Fee Schedule,,25.49,,,25.49,Fee Schedule,,61.38,,,61.38,Fee Schedule,,27.14,,,27.14,Fee Schedule,,69.3,70,,69.3,percent of total billed charges,All Other,32.56,,,32.56,Fee Schedule,,27.59,,,27.59,Fee Schedule,,10.31,,,10.31,Fee Schedule,,10.31,,,10.31,Fee Schedule,,10.31,,,10.31,Fee Schedule,,10.31,,,10.31,Fee Schedule,,5.76,,,5.76,Other,100% of Medicaid,5.76,,,5.76,Other,100% of Medicaid,5.76,,,5.76,Other,100% of Medicaid,5.76,,,5.76,Other,100% of Medicaid,12.95,,,12.95,Other,225% of Medicaid,8.81,,,8.81,Other,153% of Medicaid,12.95,,,12.95,Other,225% of Medicaid,8.06,,,8.06,Other,140% of Medicaid,12.95,,,12.95,Other,225% of Medicaid,14.97,,,14.97,Other,260% of Medicaid,18.65,,,18.65,Other,324% of Medicaid,12.38,,,12.38,Other,215% of Medicaid,12.38,,,12.38,Other,215% of Medicaid,7.2,,,7.2,Other,125% of Medicaid,5.76,73.26,
ASSAY OF FREE THYROXINE,84439,CPT,,78084439,CDM,301,RC,,,both,,,235,173.9,,,173.9,Other,150% of Medicare + 9.63% HCRA Surcharge,105.75,45,,105.75,percent of total billed charges,Critical Access Hospital RCC factor,27.15,,,27.15,Fee Schedule,,24.44,,,24.44,Fee Schedule,,66.88,,,66.88,Fee Schedule,,60.15,,,60.15,Fee Schedule,,56.85,,,56.85,Fee Schedule,,116.33,,,116.33,Other,110% of Medicare,28.41,,,28.41,Fee Schedule,,17,,,17,Other,186% of Medicaid,33.46,,,33.46,Fee Schedule,,145.7,,,145.7,Fee Schedule,,18.94,,,18.94,Fee Schedule,,33.46,,,33.46,Fee Schedule,,145.7,,,145.7,Fee Schedule,,35.63,,,35.63,Fee Schedule,,164.5,70,,164.5,percent of total billed charges,All Other,42.75,,,42.75,Fee Schedule,,36.23,,,36.23,Fee Schedule,,13.53,,,13.53,Fee Schedule,,13.53,,,13.53,Fee Schedule,,13.53,,,13.53,Fee Schedule,,13.53,,,13.53,Fee Schedule,,9,,,9,Other,100% of Medicaid,9,,,9,Other,100% of Medicaid,9,,,9,Other,100% of Medicaid,9,,,9,Other,100% of Medicaid,20.25,,,20.25,Other,225% of Medicaid,13.77,,,13.77,Other,153% of Medicaid,20.25,,,20.25,Other,225% of Medicaid,12.6,,,12.6,Other,140% of Medicaid,20.25,,,20.25,Other,225% of Medicaid,23.4,,,23.4,Other,260% of Medicaid,29.16,,,29.16,Other,324% of Medicaid,19.35,,,19.35,Other,215% of Medicaid,19.35,,,19.35,Other,215% of Medicaid,11.25,,,11.25,Other,125% of Medicaid,9,173.9,
ASSAY OF THYROID ACTIVITY,84442,CPT,,78084442,CDM,301,RC,,,both,,,237,175.38,,,175.38,Other,150% of Medicare + 9.63% HCRA Surcharge,106.65,45,,106.65,percent of total billed charges,Critical Access Hospital RCC factor,44.49,,,44.49,Fee Schedule,,40.05,,,40.05,Fee Schedule,,109.72,,,109.72,Fee Schedule,,98.69,,,98.69,Fee Schedule,,93.27,,,93.27,Fee Schedule,,117.32,,,117.32,Other,110% of Medicare,46.56,,,46.56,Fee Schedule,,17,,,17,Other,186% of Medicaid,54.83,,,54.83,Fee Schedule,,146.94,,,146.94,Fee Schedule,,31.04,,,31.04,Fee Schedule,,54.83,,,54.83,Fee Schedule,,146.94,,,146.94,Fee Schedule,,58.38,,,58.38,Fee Schedule,,165.9,70,,165.9,percent of total billed charges,All Other,70.04,,,70.04,Fee Schedule,,59.37,,,59.37,Fee Schedule,,22.17,,,22.17,Fee Schedule,,22.17,,,22.17,Fee Schedule,,22.17,,,22.17,Fee Schedule,,22.17,,,22.17,Fee Schedule,,9.09,,,9.09,Other,100% of Medicaid,9.09,,,9.09,Other,100% of Medicaid,9.09,,,9.09,Other,100% of Medicaid,9.09,,,9.09,Other,100% of Medicaid,20.45,,,20.45,Other,225% of Medicaid,13.91,,,13.91,Other,153% of Medicaid,20.45,,,20.45,Other,225% of Medicaid,12.73,,,12.73,Other,140% of Medicaid,20.45,,,20.45,Other,225% of Medicaid,23.63,,,23.63,Other,260% of Medicaid,29.45,,,29.45,Other,324% of Medicaid,19.54,,,19.54,Other,215% of Medicaid,19.54,,,19.54,Other,215% of Medicaid,11.36,,,11.36,Other,125% of Medicaid,9.09,175.38,
ASSAY THYROID STIM HORMONE,84443,CPT,,78084443,CDM,301,RC,,,both,,,210,155.4,,,155.4,Other,150% of Medicare + 9.63% HCRA Surcharge,94.5,45,,94.5,percent of total billed charges,Critical Access Hospital RCC factor,50.57,,,50.57,Fee Schedule,,45.53,,,45.53,Fee Schedule,,124.58,,,124.58,Fee Schedule,,112.05,,,112.05,Fee Schedule,,105.91,,,105.91,Fee Schedule,,103.95,,,103.95,Other,110% of Medicare,52.92,,,52.92,Fee Schedule,,17,,,17,Other,186% of Medicaid,62.33,,,62.33,Fee Schedule,,130.2,,,130.2,Fee Schedule,,35.28,,,35.28,Fee Schedule,,62.33,,,62.33,Fee Schedule,,130.2,,,130.2,Fee Schedule,,66.36,,,66.36,Fee Schedule,,147,70,,147,percent of total billed charges,All Other,79.62,,,79.62,Fee Schedule,,67.48,,,67.48,Fee Schedule,,25.2,,,25.2,Fee Schedule,,25.2,,,25.2,Fee Schedule,,25.2,,,25.2,Fee Schedule,,25.2,,,25.2,Fee Schedule,,9.09,,,9.09,Other,100% of Medicaid,9.09,,,9.09,Other,100% of Medicaid,9.09,,,9.09,Other,100% of Medicaid,9.09,,,9.09,Other,100% of Medicaid,20.45,,,20.45,Other,225% of Medicaid,13.91,,,13.91,Other,153% of Medicaid,20.45,,,20.45,Other,225% of Medicaid,12.73,,,12.73,Other,140% of Medicaid,20.45,,,20.45,Other,225% of Medicaid,23.63,,,23.63,Other,260% of Medicaid,29.45,,,29.45,Other,324% of Medicaid,19.54,,,19.54,Other,215% of Medicaid,19.54,,,19.54,Other,215% of Medicaid,11.36,,,11.36,Other,125% of Medicaid,9.09,155.4,
ASSAY OF TSI,84445,CPT,,78084445,CDM,301,RC,,,both,,,323,239.02,,,239.02,Other,150% of Medicare + 9.63% HCRA Surcharge,145.35,45,,145.35,percent of total billed charges,Critical Access Hospital RCC factor,153.09,,,153.09,Fee Schedule,,137.83,,,137.83,Fee Schedule,,377.12,,,377.12,Fee Schedule,,339.19,,,339.19,Fee Schedule,,320.59,,,320.59,Fee Schedule,,159.89,,,159.89,Other,110% of Medicare,160.21,,,160.21,Fee Schedule,,62,,,62,Other,186% of Medicaid,188.69,,,188.69,Fee Schedule,,200.26,,,200.26,Fee Schedule,,106.81,,,106.81,Fee Schedule,,188.69,,,188.69,Fee Schedule,,200.26,,,200.26,Fee Schedule,,200.9,,,200.9,Fee Schedule,,226.1,70,,226.1,percent of total billed charges,All Other,241.03,,,241.03,Fee Schedule,,204.29,,,204.29,Fee Schedule,,76.29,,,76.29,Fee Schedule,,76.29,,,76.29,Fee Schedule,,76.29,,,76.29,Fee Schedule,,76.29,,,76.29,Fee Schedule,,33.57,,,33.57,Other,100% of Medicaid,33.57,,,33.57,Other,100% of Medicaid,33.57,,,33.57,Other,100% of Medicaid,33.57,,,33.57,Other,100% of Medicaid,75.53,,,75.53,Other,225% of Medicaid,51.36,,,51.36,Other,153% of Medicaid,75.53,,,75.53,Other,225% of Medicaid,47,,,47,Other,140% of Medicaid,75.53,,,75.53,Other,225% of Medicaid,87.28,,,87.28,Other,260% of Medicaid,108.76,,,108.76,Other,324% of Medicaid,72.17,,,72.17,Other,215% of Medicaid,72.17,,,72.17,Other,215% of Medicaid,41.96,,,41.96,Other,125% of Medicaid,33.57,377.12,
ASSAY OF VITAMIN E,84446,CPT,,78084446,CDM,301,RC,,,both,,,192,142.08,,,142.08,Other,150% of Medicare + 9.63% HCRA Surcharge,86.4,45,,86.4,percent of total billed charges,Critical Access Hospital RCC factor,42.68,,,42.68,Fee Schedule,,38.43,,,38.43,Fee Schedule,,105.14,,,105.14,Fee Schedule,,94.56,,,94.56,Fee Schedule,,89.38,,,89.38,Fee Schedule,,95.04,,,95.04,Other,110% of Medicare,44.67,,,44.67,Fee Schedule,,26,,,26,Other,186% of Medicaid,52.61,,,52.61,Fee Schedule,,119.04,,,119.04,Fee Schedule,,29.78,,,29.78,Fee Schedule,,52.61,,,52.61,Fee Schedule,,119.04,,,119.04,Fee Schedule,,56.01,,,56.01,Fee Schedule,,134.4,70,,134.4,percent of total billed charges,All Other,67.2,,,67.2,Fee Schedule,,56.96,,,56.96,Fee Schedule,,21.27,,,21.27,Fee Schedule,,21.27,,,21.27,Fee Schedule,,21.27,,,21.27,Fee Schedule,,21.27,,,21.27,Fee Schedule,,14.18,,,14.18,Other,100% of Medicaid,14.18,,,14.18,Other,100% of Medicaid,14.18,,,14.18,Other,100% of Medicaid,14.18,,,14.18,Other,100% of Medicaid,31.91,,,31.91,Other,225% of Medicaid,21.7,,,21.7,Other,153% of Medicaid,31.91,,,31.91,Other,225% of Medicaid,19.85,,,19.85,Other,140% of Medicaid,31.91,,,31.91,Other,225% of Medicaid,36.87,,,36.87,Other,260% of Medicaid,45.94,,,45.94,Other,324% of Medicaid,30.49,,,30.49,Other,215% of Medicaid,30.49,,,30.49,Other,215% of Medicaid,17.73,,,17.73,Other,125% of Medicaid,14.18,142.08,
TRANSCORTIN,84449,CPT,,78084449,CDM,301,RC,,,both,,,108,79.92,,,79.92,Other,150% of Medicare + 9.63% HCRA Surcharge,48.6,45,,48.6,percent of total billed charges,Critical Access Hospital RCC factor,54.18,,,54.18,Fee Schedule,,48.78,,,48.78,Fee Schedule,,133.49,,,133.49,Fee Schedule,,120.06,,,120.06,Fee Schedule,,113.48,,,113.48,Fee Schedule,,53.46,,,53.46,Other,110% of Medicare,56.7,,,56.7,Fee Schedule,,33,,,33,Other,186% of Medicaid,66.78,,,66.78,Fee Schedule,,66.96,,,66.96,Fee Schedule,,37.8,,,37.8,Fee Schedule,,66.78,,,66.78,Fee Schedule,,66.96,,,66.96,Fee Schedule,,71.1,,,71.1,Fee Schedule,,75.6,70,,75.6,percent of total billed charges,All Other,85.3,,,85.3,Fee Schedule,,72.3,,,72.3,Fee Schedule,,27,,,27,Fee Schedule,,27,,,27,Fee Schedule,,27,,,27,Fee Schedule,,27,,,27,Fee Schedule,,18,,,18,Other,100% of Medicaid,18,,,18,Other,100% of Medicaid,18,,,18,Other,100% of Medicaid,18,,,18,Other,100% of Medicaid,40.5,,,40.5,Other,225% of Medicaid,27.54,,,27.54,Other,153% of Medicaid,40.5,,,40.5,Other,225% of Medicaid,25.2,,,25.2,Other,140% of Medicaid,40.5,,,40.5,Other,225% of Medicaid,46.8,,,46.8,Other,260% of Medicaid,58.32,,,58.32,Other,324% of Medicaid,38.7,,,38.7,Other,215% of Medicaid,38.7,,,38.7,Other,215% of Medicaid,22.5,,,22.5,Other,125% of Medicaid,18,133.49,
TRANSFERASE (AST) (SGOT),84450,CPT,,78084450,CDM,301,RC,,,both,,,100,74,,,74,Other,150% of Medicare + 9.63% HCRA Surcharge,45,45,,45,percent of total billed charges,Critical Access Hospital RCC factor,15.59,,,15.59,Fee Schedule,,14.04,,,14.04,Fee Schedule,,38.37,,,38.37,Fee Schedule,,34.51,,,34.51,Fee Schedule,,32.61,,,32.61,Fee Schedule,,49.5,,,49.5,Other,110% of Medicare,16.32,,,16.32,Fee Schedule,,9,,,9,Other,186% of Medicaid,19.22,,,19.22,Fee Schedule,,62,,,62,Fee Schedule,,10.88,,,10.88,Fee Schedule,,19.22,,,19.22,Fee Schedule,,62,,,62,Fee Schedule,,20.46,,,20.46,Fee Schedule,,70,70,,70,percent of total billed charges,All Other,24.55,,,24.55,Fee Schedule,,20.81,,,20.81,Fee Schedule,,7.77,,,7.77,Fee Schedule,,7.77,,,7.77,Fee Schedule,,7.77,,,7.77,Fee Schedule,,7.77,,,7.77,Fee Schedule,,5.08,,,5.08,Other,100% of Medicaid,5.08,,,5.08,Other,100% of Medicaid,5.08,,,5.08,Other,100% of Medicaid,5.08,,,5.08,Other,100% of Medicaid,11.43,,,11.43,Other,225% of Medicaid,7.77,,,7.77,Other,153% of Medicaid,11.43,,,11.43,Other,225% of Medicaid,7.11,,,7.11,Other,140% of Medicaid,11.43,,,11.43,Other,225% of Medicaid,13.21,,,13.21,Other,260% of Medicaid,16.46,,,16.46,Other,324% of Medicaid,10.92,,,10.92,Other,215% of Medicaid,10.92,,,10.92,Other,215% of Medicaid,6.35,,,6.35,Other,125% of Medicaid,5.08,74,
ALANINE AMINO (ALT) (SGPT),84460,CPT,,78084460,CDM,301,RC,,,both,,,107,79.18,,,79.18,Other,150% of Medicare + 9.63% HCRA Surcharge,48.15,45,,48.15,percent of total billed charges,Critical Access Hospital RCC factor,15.95,,,15.95,Fee Schedule,,14.36,,,14.36,Fee Schedule,,39.21,,,39.21,Fee Schedule,,35.27,,,35.27,Fee Schedule,,33.33,,,33.33,Fee Schedule,,52.97,,,52.97,Other,110% of Medicare,16.7,,,16.7,Fee Schedule,,9,,,9,Other,186% of Medicaid,19.66,,,19.66,Fee Schedule,,66.34,,,66.34,Fee Schedule,,11.13,,,11.13,Fee Schedule,,19.66,,,19.66,Fee Schedule,,66.34,,,66.34,Fee Schedule,,20.94,,,20.94,Fee Schedule,,74.9,70,,74.9,percent of total billed charges,All Other,25.12,,,25.12,Fee Schedule,,21.29,,,21.29,Fee Schedule,,7.95,,,7.95,Fee Schedule,,7.95,,,7.95,Fee Schedule,,7.95,,,7.95,Fee Schedule,,7.95,,,7.95,Fee Schedule,,5.08,,,5.08,Other,100% of Medicaid,5.08,,,5.08,Other,100% of Medicaid,5.08,,,5.08,Other,100% of Medicaid,5.08,,,5.08,Other,100% of Medicaid,11.43,,,11.43,Other,225% of Medicaid,7.77,,,7.77,Other,153% of Medicaid,11.43,,,11.43,Other,225% of Medicaid,7.11,,,7.11,Other,140% of Medicaid,11.43,,,11.43,Other,225% of Medicaid,13.21,,,13.21,Other,260% of Medicaid,16.46,,,16.46,Other,324% of Medicaid,10.92,,,10.92,Other,215% of Medicaid,10.92,,,10.92,Other,215% of Medicaid,6.35,,,6.35,Other,125% of Medicaid,5.08,79.18,
ASSAY OF TRANSFERRIN,84466,CPT,,78084466,CDM,301,RC,,,both,,,142,105.08,,,105.08,Other,150% of Medicare + 9.63% HCRA Surcharge,63.9,45,,63.9,percent of total billed charges,Critical Access Hospital RCC factor,38.41,,,38.41,Fee Schedule,,34.58,,,34.58,Fee Schedule,,94.7,,,94.7,Fee Schedule,,85.18,,,85.18,Fee Schedule,,80.51,,,80.51,Fee Schedule,,70.29,,,70.29,Other,110% of Medicare,40.19,,,40.19,Fee Schedule,,23,,,23,Other,186% of Medicaid,47.34,,,47.34,Fee Schedule,,88.04,,,88.04,Fee Schedule,,26.8,,,26.8,Fee Schedule,,47.34,,,47.34,Fee Schedule,,88.04,,,88.04,Fee Schedule,,50.4,,,50.4,Fee Schedule,,99.4,70,,99.4,percent of total billed charges,All Other,60.47,,,60.47,Fee Schedule,,51.25,,,51.25,Fee Schedule,,19.14,,,19.14,Fee Schedule,,19.14,,,19.14,Fee Schedule,,19.14,,,19.14,Fee Schedule,,19.14,,,19.14,Fee Schedule,,12.63,,,12.63,Other,100% of Medicaid,12.63,,,12.63,Other,100% of Medicaid,12.63,,,12.63,Other,100% of Medicaid,12.63,,,12.63,Other,100% of Medicaid,28.41,,,28.41,Other,225% of Medicaid,19.32,,,19.32,Other,153% of Medicaid,28.41,,,28.41,Other,225% of Medicaid,17.68,,,17.68,Other,140% of Medicaid,28.41,,,28.41,Other,225% of Medicaid,32.83,,,32.83,Other,260% of Medicaid,40.91,,,40.91,Other,324% of Medicaid,27.14,,,27.14,Other,215% of Medicaid,27.14,,,27.14,Other,215% of Medicaid,15.78,,,15.78,Other,125% of Medicaid,12.63,105.08,
ASSAY OF TRIGLYCERIDES,84478,CPT,,78084478,CDM,301,RC,,,both,,,107,79.18,,,79.18,Other,150% of Medicare + 9.63% HCRA Surcharge,48.15,45,,48.15,percent of total billed charges,Critical Access Hospital RCC factor,17.28,,,17.28,Fee Schedule,,15.56,,,15.56,Fee Schedule,,42.69,,,42.69,Fee Schedule,,38.39,,,38.39,Fee Schedule,,36.29,,,36.29,Fee Schedule,,52.97,,,52.97,Other,110% of Medicare,18.08,,,18.08,Fee Schedule,,9,,,9,Other,186% of Medicaid,21.3,,,21.3,Fee Schedule,,66.34,,,66.34,Fee Schedule,,12.05,,,12.05,Fee Schedule,,21.3,,,21.3,Fee Schedule,,66.34,,,66.34,Fee Schedule,,22.67,,,22.67,Fee Schedule,,74.9,70,,74.9,percent of total billed charges,All Other,27.2,,,27.2,Fee Schedule,,23.06,,,23.06,Fee Schedule,,8.61,,,8.61,Fee Schedule,,8.61,,,8.61,Fee Schedule,,8.61,,,8.61,Fee Schedule,,8.61,,,8.61,Fee Schedule,,5.08,,,5.08,Other,100% of Medicaid,5.08,,,5.08,Other,100% of Medicaid,5.08,,,5.08,Other,100% of Medicaid,5.08,,,5.08,Other,100% of Medicaid,11.43,,,11.43,Other,225% of Medicaid,7.77,,,7.77,Other,153% of Medicaid,11.43,,,11.43,Other,225% of Medicaid,7.11,,,7.11,Other,140% of Medicaid,11.43,,,11.43,Other,225% of Medicaid,13.21,,,13.21,Other,260% of Medicaid,16.46,,,16.46,Other,324% of Medicaid,10.92,,,10.92,Other,215% of Medicaid,10.92,,,10.92,Other,215% of Medicaid,6.35,,,6.35,Other,125% of Medicaid,5.08,79.18,
ASSAY OF THYROID (T3 OR T4),84479,CPT,,78084479,CDM,301,RC,,,both,,,235,173.9,,,173.9,Other,150% of Medicare + 9.63% HCRA Surcharge,105.75,45,,105.75,percent of total billed charges,Critical Access Hospital RCC factor,19.47,,,19.47,Fee Schedule,,17.53,,,17.53,Fee Schedule,,48.01,,,48.01,Fee Schedule,,43.18,,,43.18,Fee Schedule,,40.81,,,40.81,Fee Schedule,,116.33,,,116.33,Other,110% of Medicare,20.38,,,20.38,Fee Schedule,,6,,,6,Other,186% of Medicaid,24,,,24,Fee Schedule,,145.7,,,145.7,Fee Schedule,,13.59,,,13.59,Fee Schedule,,24,,,24,Fee Schedule,,145.7,,,145.7,Fee Schedule,,25.56,,,25.56,Fee Schedule,,164.5,70,,164.5,percent of total billed charges,All Other,30.66,,,30.66,Fee Schedule,,25.99,,,25.99,Fee Schedule,,9.71,,,9.71,Fee Schedule,,9.71,,,9.71,Fee Schedule,,9.71,,,9.71,Fee Schedule,,9.71,,,9.71,Fee Schedule,,3.33,,,3.33,Other,100% of Medicaid,3.33,,,3.33,Other,100% of Medicaid,3.33,,,3.33,Other,100% of Medicaid,3.33,,,3.33,Other,100% of Medicaid,7.5,,,7.5,Other,225% of Medicaid,5.1,,,5.1,Other,153% of Medicaid,7.5,,,7.5,Other,225% of Medicaid,4.67,,,4.67,Other,140% of Medicaid,7.5,,,7.5,Other,225% of Medicaid,8.67,,,8.67,Other,260% of Medicaid,10.8,,,10.8,Other,324% of Medicaid,7.17,,,7.17,Other,215% of Medicaid,7.17,,,7.17,Other,215% of Medicaid,4.17,,,4.17,Other,125% of Medicaid,3.33,173.9,
ASSAY TRIIODOTHYRONINE (T3),84480,CPT,,78084480,CDM,301,RC,,,both,,,173,128.02,,,128.02,Other,150% of Medicare + 9.63% HCRA Surcharge,77.85,45,,77.85,percent of total billed charges,Critical Access Hospital RCC factor,42.68,,,42.68,Fee Schedule,,38.43,,,38.43,Fee Schedule,,105.14,,,105.14,Fee Schedule,,94.56,,,94.56,Fee Schedule,,89.38,,,89.38,Fee Schedule,,85.64,,,85.64,Other,110% of Medicare,44.67,,,44.67,Fee Schedule,,11,,,11,Other,186% of Medicaid,52.61,,,52.61,Fee Schedule,,107.26,,,107.26,Fee Schedule,,29.78,,,29.78,Fee Schedule,,52.61,,,52.61,Fee Schedule,,107.26,,,107.26,Fee Schedule,,56.01,,,56.01,Fee Schedule,,121.1,70,,121.1,percent of total billed charges,All Other,67.2,,,67.2,Fee Schedule,,56.96,,,56.96,Fee Schedule,,21.27,,,21.27,Fee Schedule,,21.27,,,21.27,Fee Schedule,,21.27,,,21.27,Fee Schedule,,21.27,,,21.27,Fee Schedule,,5.76,,,5.76,Other,100% of Medicaid,5.76,,,5.76,Other,100% of Medicaid,5.76,,,5.76,Other,100% of Medicaid,5.76,,,5.76,Other,100% of Medicaid,12.95,,,12.95,Other,225% of Medicaid,8.81,,,8.81,Other,153% of Medicaid,12.95,,,12.95,Other,225% of Medicaid,8.06,,,8.06,Other,140% of Medicaid,12.95,,,12.95,Other,225% of Medicaid,14.97,,,14.97,Other,260% of Medicaid,18.65,,,18.65,Other,324% of Medicaid,12.38,,,12.38,Other,215% of Medicaid,12.38,,,12.38,Other,215% of Medicaid,7.2,,,7.2,Other,125% of Medicaid,5.76,128.02,
FREE ASSAY (FT-3),84481,CPT,,78084481,CDM,301,RC,,,both,,,532,393.68,,,393.68,Other,150% of Medicare + 9.63% HCRA Surcharge,239.4,45,,239.4,percent of total billed charges,Critical Access Hospital RCC factor,50.99,,,50.99,Fee Schedule,,45.91,,,45.91,Fee Schedule,,125.64,,,125.64,Fee Schedule,,113,,,113,Fee Schedule,,106.8,,,106.8,Fee Schedule,,263.34,,,263.34,Other,110% of Medicare,53.36,,,53.36,Fee Schedule,,17,,,17,Other,186% of Medicaid,62.85,,,62.85,Fee Schedule,,329.84,,,329.84,Fee Schedule,,35.57,,,35.57,Fee Schedule,,62.85,,,62.85,Fee Schedule,,329.84,,,329.84,Fee Schedule,,66.91,,,66.91,Fee Schedule,,372.4,70,,372.4,percent of total billed charges,All Other,80.28,,,80.28,Fee Schedule,,68.04,,,68.04,Fee Schedule,,25.41,,,25.41,Fee Schedule,,25.41,,,25.41,Fee Schedule,,25.41,,,25.41,Fee Schedule,,25.41,,,25.41,Fee Schedule,,9.09,,,9.09,Other,100% of Medicaid,9.09,,,9.09,Other,100% of Medicaid,9.09,,,9.09,Other,100% of Medicaid,9.09,,,9.09,Other,100% of Medicaid,20.45,,,20.45,Other,225% of Medicaid,13.91,,,13.91,Other,153% of Medicaid,20.45,,,20.45,Other,225% of Medicaid,12.73,,,12.73,Other,140% of Medicaid,20.45,,,20.45,Other,225% of Medicaid,23.63,,,23.63,Other,260% of Medicaid,29.45,,,29.45,Other,324% of Medicaid,19.54,,,19.54,Other,215% of Medicaid,19.54,,,19.54,Other,215% of Medicaid,11.36,,,11.36,Other,125% of Medicaid,9.09,393.68,
T3 REVERSE,84482,CPT,,78084482,CDM,301,RC,,,both,,,377,278.98,,,278.98,Other,150% of Medicare + 9.63% HCRA Surcharge,169.65,45,,169.65,percent of total billed charges,Critical Access Hospital RCC factor,47.44,,,47.44,Fee Schedule,,42.71,,,42.71,Fee Schedule,,57.07,,,57.07,Fee Schedule,,51.33,,,51.33,Fee Schedule,,48.52,,,48.52,Fee Schedule,,186.62,,,186.62,Other,110% of Medicare,49.64,,,49.64,Fee Schedule,,11,,,11,Other,186% of Medicaid,58.47,,,58.47,Fee Schedule,,233.74,,,233.74,Fee Schedule,,33.1,,,33.1,Fee Schedule,,58.47,,,58.47,Fee Schedule,,233.74,,,233.74,Fee Schedule,,62.25,,,62.25,Fee Schedule,,263.9,70,,263.9,percent of total billed charges,All Other,74.69,,,74.69,Fee Schedule,,63.3,,,63.3,Fee Schedule,,23.64,,,23.64,Fee Schedule,,23.64,,,23.64,Fee Schedule,,23.64,,,23.64,Fee Schedule,,23.64,,,23.64,Fee Schedule,,5.76,,,5.76,Other,100% of Medicaid,5.76,,,5.76,Other,100% of Medicaid,5.76,,,5.76,Other,100% of Medicaid,5.76,,,5.76,Other,100% of Medicaid,12.95,,,12.95,Other,225% of Medicaid,8.81,,,8.81,Other,153% of Medicaid,12.95,,,12.95,Other,225% of Medicaid,8.06,,,8.06,Other,140% of Medicaid,12.95,,,12.95,Other,225% of Medicaid,14.97,,,14.97,Other,260% of Medicaid,18.65,,,18.65,Other,324% of Medicaid,12.38,,,12.38,Other,215% of Medicaid,12.38,,,12.38,Other,215% of Medicaid,7.2,,,7.2,Other,125% of Medicaid,5.76,278.98,
ASSAY OF TROPONIN QUANT,84484,CPT,,78084484,CDM,301,RC,,,both,,,281,207.94,,,207.94,Other,150% of Medicare + 9.63% HCRA Surcharge,126.45,45,,126.45,percent of total billed charges,Critical Access Hospital RCC factor,37.53,,,37.53,Fee Schedule,,33.79,,,33.79,Fee Schedule,,45.64,,,45.64,Fee Schedule,,41.05,,,41.05,Fee Schedule,,38.8,,,38.8,Fee Schedule,,139.1,,,139.1,Other,110% of Medicare,39.28,,,39.28,Fee Schedule,,15,,,15,Other,186% of Medicaid,46.26,,,46.26,Fee Schedule,,174.22,,,174.22,Fee Schedule,,26.19,,,26.19,Fee Schedule,,46.26,,,46.26,Fee Schedule,,174.22,,,174.22,Fee Schedule,,49.26,,,49.26,Fee Schedule,,196.7,70,,196.7,percent of total billed charges,All Other,59.1,,,59.1,Fee Schedule,,50.09,,,50.09,Fee Schedule,,18.71,,,18.71,Fee Schedule,,18.71,,,18.71,Fee Schedule,,18.71,,,18.71,Fee Schedule,,18.71,,,18.71,Fee Schedule,,8.13,,,8.13,Other,100% of Medicaid,8.13,,,8.13,Other,100% of Medicaid,8.13,,,8.13,Other,100% of Medicaid,8.13,,,8.13,Other,100% of Medicaid,18.29,,,18.29,Other,225% of Medicaid,12.44,,,12.44,Other,153% of Medicaid,18.29,,,18.29,Other,225% of Medicaid,11.38,,,11.38,Other,140% of Medicaid,18.29,,,18.29,Other,225% of Medicaid,21.14,,,21.14,Other,260% of Medicaid,26.34,,,26.34,Other,324% of Medicaid,17.48,,,17.48,Other,215% of Medicaid,17.48,,,17.48,Other,215% of Medicaid,10.16,,,10.16,Other,125% of Medicaid,8.13,207.94,
ASSAY OF TYROSINE,84510,CPT,,78084510,CDM,301,RC,,,both,,,34,25.16,,,25.16,Other,150% of Medicare + 9.63% HCRA Surcharge,15.3,45,,15.3,percent of total billed charges,Critical Access Hospital RCC factor,32,,,32,Fee Schedule,,28.81,,,28.81,Fee Schedule,,77.15,,,77.15,Fee Schedule,,69.39,,,69.39,Fee Schedule,,65.59,,,65.59,Fee Schedule,,16.83,,,16.83,Other,110% of Medicare,33.48,,,33.48,Fee Schedule,,20,,,20,Other,186% of Medicaid,39.44,,,39.44,Fee Schedule,,21.08,,,21.08,Fee Schedule,,22.32,,,22.32,Fee Schedule,,39.44,,,39.44,Fee Schedule,,21.08,,,21.08,Fee Schedule,,41.99,,,41.99,Fee Schedule,,23.8,70,,23.8,percent of total billed charges,All Other,50.38,,,50.38,Fee Schedule,,42.7,,,42.7,Fee Schedule,,15.95,,,15.95,Fee Schedule,,15.95,,,15.95,Fee Schedule,,15.95,,,15.95,Fee Schedule,,15.95,,,15.95,Fee Schedule,,10.63,,,10.63,Other,100% of Medicaid,10.63,,,10.63,Other,100% of Medicaid,10.63,,,10.63,Other,100% of Medicaid,10.63,,,10.63,Other,100% of Medicaid,23.92,,,23.92,Other,225% of Medicaid,16.26,,,16.26,Other,153% of Medicaid,23.92,,,23.92,Other,225% of Medicaid,14.88,,,14.88,Other,140% of Medicaid,23.92,,,23.92,Other,225% of Medicaid,27.64,,,27.64,Other,260% of Medicaid,34.44,,,34.44,Other,324% of Medicaid,22.85,,,22.85,Other,215% of Medicaid,22.85,,,22.85,Other,215% of Medicaid,13.29,,,13.29,Other,125% of Medicaid,10.63,77.15,
ASSAY OF UREA NITROGEN,84520,CPT,,78084520,CDM,301,RC,,,both,,,84,62.16,,,62.16,Other,150% of Medicare + 9.63% HCRA Surcharge,37.8,45,,37.8,percent of total billed charges,Critical Access Hospital RCC factor,11.89,,,11.89,Fee Schedule,,10.7,,,10.7,Fee Schedule,,29.3,,,29.3,Fee Schedule,,26.35,,,26.35,Fee Schedule,,24.91,,,24.91,Fee Schedule,,41.58,,,41.58,Other,110% of Medicare,12.44,,,12.44,Fee Schedule,,7,,,7,Other,186% of Medicaid,14.65,,,14.65,Fee Schedule,,52.08,,,52.08,Fee Schedule,,8.3,,,8.3,Fee Schedule,,14.65,,,14.65,Fee Schedule,,52.08,,,52.08,Fee Schedule,,15.6,,,15.6,Fee Schedule,,58.8,70,,58.8,percent of total billed charges,All Other,18.72,,,18.72,Fee Schedule,,15.87,,,15.87,Fee Schedule,,5.93,,,5.93,Fee Schedule,,5.93,,,5.93,Fee Schedule,,5.93,,,5.93,Fee Schedule,,5.93,,,5.93,Fee Schedule,,3.95,,,3.95,Other,100% of Medicaid,3.95,,,3.95,Other,100% of Medicaid,3.95,,,3.95,Other,100% of Medicaid,3.95,,,3.95,Other,100% of Medicaid,8.89,,,8.89,Other,225% of Medicaid,6.04,,,6.04,Other,153% of Medicaid,8.89,,,8.89,Other,225% of Medicaid,5.53,,,5.53,Other,140% of Medicaid,8.89,,,8.89,Other,225% of Medicaid,10.27,,,10.27,Other,260% of Medicaid,12.8,,,12.8,Other,324% of Medicaid,8.49,,,8.49,Other,215% of Medicaid,8.49,,,8.49,Other,215% of Medicaid,4.94,,,4.94,Other,125% of Medicaid,3.95,62.16,
ASSAY OF URINE/UREA-N,84540,CPT,,78084540,CDM,301,RC,,,both,,,84,62.16,,,62.16,Other,150% of Medicare + 9.63% HCRA Surcharge,37.8,45,,37.8,percent of total billed charges,Critical Access Hospital RCC factor,16.74,,,16.74,Fee Schedule,,15.07,,,15.07,Fee Schedule,,35.2,,,35.2,Fee Schedule,,31.66,,,31.66,Fee Schedule,,29.93,,,29.93,Fee Schedule,,41.58,,,41.58,Other,110% of Medicare,17.51,,,17.51,Fee Schedule,,9,,,9,Other,186% of Medicaid,20.63,,,20.63,Fee Schedule,,52.08,,,52.08,Fee Schedule,,11.68,,,11.68,Fee Schedule,,20.63,,,20.63,Fee Schedule,,52.08,,,52.08,Fee Schedule,,21.96,,,21.96,Fee Schedule,,58.8,70,,58.8,percent of total billed charges,All Other,26.35,,,26.35,Fee Schedule,,22.33,,,22.33,Fee Schedule,,8.34,,,8.34,Fee Schedule,,8.34,,,8.34,Fee Schedule,,8.34,,,8.34,Fee Schedule,,8.34,,,8.34,Fee Schedule,,5.08,,,5.08,Other,100% of Medicaid,5.08,,,5.08,Other,100% of Medicaid,5.08,,,5.08,Other,100% of Medicaid,5.08,,,5.08,Other,100% of Medicaid,11.43,,,11.43,Other,225% of Medicaid,7.77,,,7.77,Other,153% of Medicaid,11.43,,,11.43,Other,225% of Medicaid,7.11,,,7.11,Other,140% of Medicaid,11.43,,,11.43,Other,225% of Medicaid,13.21,,,13.21,Other,260% of Medicaid,16.46,,,16.46,Other,324% of Medicaid,10.92,,,10.92,Other,215% of Medicaid,10.92,,,10.92,Other,215% of Medicaid,6.35,,,6.35,Other,125% of Medicaid,5.08,62.16,
UREA-N CLEARANCE TEST,84545,CPT,,78084545,CDM,301,RC,,,both,,,117,86.58,,,86.58,Other,150% of Medicare + 9.63% HCRA Surcharge,52.65,45,,52.65,percent of total billed charges,Critical Access Hospital RCC factor,21.67,,,21.67,Fee Schedule,,19.51,,,19.51,Fee Schedule,,48.96,,,48.96,Fee Schedule,,44.03,,,44.03,Fee Schedule,,41.62,,,41.62,Fee Schedule,,57.92,,,57.92,Other,110% of Medicare,22.68,,,22.68,Fee Schedule,,12,,,12,Other,186% of Medicaid,26.71,,,26.71,Fee Schedule,,72.54,,,72.54,Fee Schedule,,15.12,,,15.12,Fee Schedule,,26.71,,,26.71,Fee Schedule,,72.54,,,72.54,Fee Schedule,,28.44,,,28.44,Fee Schedule,,81.9,70,,81.9,percent of total billed charges,All Other,34.12,,,34.12,Fee Schedule,,28.92,,,28.92,Fee Schedule,,10.8,,,10.8,Fee Schedule,,10.8,,,10.8,Fee Schedule,,10.8,,,10.8,Fee Schedule,,10.8,,,10.8,Fee Schedule,,6.31,,,6.31,Other,100% of Medicaid,6.31,,,6.31,Other,100% of Medicaid,6.31,,,6.31,Other,100% of Medicaid,6.31,,,6.31,Other,100% of Medicaid,14.2,,,14.2,Other,225% of Medicaid,9.65,,,9.65,Other,153% of Medicaid,14.2,,,14.2,Other,225% of Medicaid,8.83,,,8.83,Other,140% of Medicaid,14.2,,,14.2,Other,225% of Medicaid,16.41,,,16.41,Other,260% of Medicaid,20.45,,,20.45,Other,324% of Medicaid,13.57,,,13.57,Other,215% of Medicaid,13.57,,,13.57,Other,215% of Medicaid,7.89,,,7.89,Other,125% of Medicaid,6.31,86.58,
ASSAY OF BLOOD/URIC ACID,84550,CPT,,78084550,CDM,301,RC,,,both,,,93,68.82,,,68.82,Other,150% of Medicare + 9.63% HCRA Surcharge,41.85,45,,41.85,percent of total billed charges,Critical Access Hospital RCC factor,13.61,,,13.61,Fee Schedule,,12.25,,,12.25,Fee Schedule,,33.52,,,33.52,Fee Schedule,,30.15,,,30.15,Fee Schedule,,28.49,,,28.49,Fee Schedule,,46.04,,,46.04,Other,110% of Medicare,14.24,,,14.24,Fee Schedule,,8,,,8,Other,186% of Medicaid,16.77,,,16.77,Fee Schedule,,57.66,,,57.66,Fee Schedule,,9.49,,,9.49,Fee Schedule,,16.77,,,16.77,Fee Schedule,,57.66,,,57.66,Fee Schedule,,17.85,,,17.85,Fee Schedule,,65.1,70,,65.1,percent of total billed charges,All Other,21.42,,,21.42,Fee Schedule,,18.16,,,18.16,Fee Schedule,,6.78,,,6.78,Fee Schedule,,6.78,,,6.78,Fee Schedule,,6.78,,,6.78,Fee Schedule,,6.78,,,6.78,Fee Schedule,,4.52,,,4.52,Other,100% of Medicaid,4.52,,,4.52,Other,100% of Medicaid,4.52,,,4.52,Other,100% of Medicaid,4.52,,,4.52,Other,100% of Medicaid,10.17,,,10.17,Other,225% of Medicaid,6.92,,,6.92,Other,153% of Medicaid,10.17,,,10.17,Other,225% of Medicaid,6.33,,,6.33,Other,140% of Medicaid,10.17,,,10.17,Other,225% of Medicaid,11.75,,,11.75,Other,260% of Medicaid,14.64,,,14.64,Other,324% of Medicaid,9.72,,,9.72,Other,215% of Medicaid,9.72,,,9.72,Other,215% of Medicaid,5.65,,,5.65,Other,125% of Medicaid,4.52,68.82,
ASSAY OF URINE/URIC ACID,84560,CPT,,78084560,CDM,301,RC,,,both,,,92,68.08,,,68.08,Other,150% of Medicare + 9.63% HCRA Surcharge,41.4,45,,41.4,percent of total billed charges,Critical Access Hospital RCC factor,15.29,,,15.29,Fee Schedule,,13.77,,,13.77,Fee Schedule,,35.2,,,35.2,Fee Schedule,,31.66,,,31.66,Fee Schedule,,29.93,,,29.93,Fee Schedule,,45.54,,,45.54,Other,110% of Medicare,16,,,16,Fee Schedule,,9,,,9,Other,186% of Medicaid,18.85,,,18.85,Fee Schedule,,57.04,,,57.04,Fee Schedule,,10.67,,,10.67,Fee Schedule,,18.85,,,18.85,Fee Schedule,,57.04,,,57.04,Fee Schedule,,20.07,,,20.07,Fee Schedule,,64.4,70,,64.4,percent of total billed charges,All Other,24.07,,,24.07,Fee Schedule,,20.4,,,20.4,Fee Schedule,,7.62,,,7.62,Fee Schedule,,7.62,,,7.62,Fee Schedule,,7.62,,,7.62,Fee Schedule,,7.62,,,7.62,Fee Schedule,,5.08,,,5.08,Other,100% of Medicaid,5.08,,,5.08,Other,100% of Medicaid,5.08,,,5.08,Other,100% of Medicaid,5.08,,,5.08,Other,100% of Medicaid,11.43,,,11.43,Other,225% of Medicaid,7.77,,,7.77,Other,153% of Medicaid,11.43,,,11.43,Other,225% of Medicaid,7.11,,,7.11,Other,140% of Medicaid,11.43,,,11.43,Other,225% of Medicaid,13.21,,,13.21,Other,260% of Medicaid,16.46,,,16.46,Other,324% of Medicaid,10.92,,,10.92,Other,215% of Medicaid,10.92,,,10.92,Other,215% of Medicaid,6.35,,,6.35,Other,125% of Medicaid,5.08,68.08,
ASSAY OF FECES/UROBILINOGEN,84577,CPT,,78084577,CDM,301,RC,,,both,,,77,56.98,,,56.98,Other,150% of Medicare + 9.63% HCRA Surcharge,34.65,45,,34.65,percent of total billed charges,Critical Access Hospital RCC factor,50.57,,,50.57,Fee Schedule,,45.53,,,45.53,Fee Schedule,,92.54,,,92.54,Fee Schedule,,83.23,,,83.23,Fee Schedule,,78.67,,,78.67,Fee Schedule,,38.12,,,38.12,Other,110% of Medicare,52.92,,,52.92,Fee Schedule,,19,,,19,Other,186% of Medicaid,62.33,,,62.33,Fee Schedule,,47.74,,,47.74,Fee Schedule,,35.28,,,35.28,Fee Schedule,,62.33,,,62.33,Fee Schedule,,47.74,,,47.74,Fee Schedule,,66.36,,,66.36,Fee Schedule,,53.9,70,,53.9,percent of total billed charges,All Other,79.62,,,79.62,Fee Schedule,,67.48,,,67.48,Fee Schedule,,25.2,,,25.2,Fee Schedule,,25.2,,,25.2,Fee Schedule,,25.2,,,25.2,Fee Schedule,,25.2,,,25.2,Fee Schedule,,10.16,,,10.16,Other,100% of Medicaid,10.16,,,10.16,Other,100% of Medicaid,10.16,,,10.16,Other,100% of Medicaid,10.16,,,10.16,Other,100% of Medicaid,22.85,,,22.85,Other,225% of Medicaid,15.54,,,15.54,Other,153% of Medicaid,22.85,,,22.85,Other,225% of Medicaid,14.22,,,14.22,Other,140% of Medicaid,22.85,,,22.85,Other,225% of Medicaid,26.4,,,26.4,Other,260% of Medicaid,32.9,,,32.9,Other,324% of Medicaid,21.83,,,21.83,Other,215% of Medicaid,21.83,,,21.83,Other,215% of Medicaid,12.69,,,12.69,Other,125% of Medicaid,10.16,92.54,
TEST URINE UROBILINOGEN,84578,CPT,,78084578,CDM,301,RC,,,both,,,20,14.8,,,14.8,Other,150% of Medicare + 9.63% HCRA Surcharge,9,45,,9,percent of total billed charges,Critical Access Hospital RCC factor,13.45,,,13.45,Fee Schedule,,12.11,,,12.11,Fee Schedule,,24.08,,,24.08,Fee Schedule,,21.66,,,21.66,Fee Schedule,,20.47,,,20.47,Fee Schedule,,9.9,,,9.9,Other,110% of Medicare,14.08,,,14.08,Fee Schedule,,12,,,12,Other,186% of Medicaid,16.58,,,16.58,Fee Schedule,,12.4,,,12.4,Fee Schedule,,9.39,,,9.39,Fee Schedule,,16.58,,,16.58,Fee Schedule,,12.4,,,12.4,Fee Schedule,,17.66,,,17.66,Fee Schedule,,14,70,,14,percent of total billed charges,All Other,21.18,,,21.18,Fee Schedule,,17.95,,,17.95,Fee Schedule,,6.71,,,6.71,Fee Schedule,,6.71,,,6.71,Fee Schedule,,6.71,,,6.71,Fee Schedule,,6.71,,,6.71,Fee Schedule,,6.31,,,6.31,Other,100% of Medicaid,6.31,,,6.31,Other,100% of Medicaid,6.31,,,6.31,Other,100% of Medicaid,6.31,,,6.31,Other,100% of Medicaid,14.2,,,14.2,Other,225% of Medicaid,9.65,,,9.65,Other,153% of Medicaid,14.2,,,14.2,Other,225% of Medicaid,8.83,,,8.83,Other,140% of Medicaid,14.2,,,14.2,Other,225% of Medicaid,16.41,,,16.41,Other,260% of Medicaid,20.45,,,20.45,Other,324% of Medicaid,13.57,,,13.57,Other,215% of Medicaid,13.57,,,13.57,Other,215% of Medicaid,7.89,,,7.89,Other,125% of Medicaid,6.31,24.08,
ASSAY OF URINE UROBILINOGEN,84583,CPT,,78084583,CDM,301,RC,,,both,,,37,27.38,,,27.38,Other,150% of Medicare + 9.63% HCRA Surcharge,16.65,45,,16.65,percent of total billed charges,Critical Access Hospital RCC factor,18.21,,,18.21,Fee Schedule,,16.4,,,16.4,Fee Schedule,,32.41,,,32.41,Fee Schedule,,29.15,,,29.15,Fee Schedule,,27.55,,,27.55,Fee Schedule,,18.32,,,18.32,Other,110% of Medicare,19.06,,,19.06,Fee Schedule,,12,,,12,Other,186% of Medicaid,22.45,,,22.45,Fee Schedule,,22.94,,,22.94,Fee Schedule,,12.71,,,12.71,Fee Schedule,,22.45,,,22.45,Fee Schedule,,22.94,,,22.94,Fee Schedule,,23.9,,,23.9,Fee Schedule,,25.9,70,,25.9,percent of total billed charges,All Other,28.67,,,28.67,Fee Schedule,,24.3,,,24.3,Fee Schedule,,9.08,,,9.08,Fee Schedule,,9.08,,,9.08,Fee Schedule,,9.08,,,9.08,Fee Schedule,,9.08,,,9.08,Fee Schedule,,6.31,,,6.31,Other,100% of Medicaid,6.31,,,6.31,Other,100% of Medicaid,6.31,,,6.31,Other,100% of Medicaid,6.31,,,6.31,Other,100% of Medicaid,14.2,,,14.2,Other,225% of Medicaid,9.65,,,9.65,Other,153% of Medicaid,14.2,,,14.2,Other,225% of Medicaid,8.83,,,8.83,Other,140% of Medicaid,14.2,,,14.2,Other,225% of Medicaid,16.41,,,16.41,Other,260% of Medicaid,20.45,,,20.45,Other,324% of Medicaid,13.57,,,13.57,Other,215% of Medicaid,13.57,,,13.57,Other,215% of Medicaid,7.89,,,7.89,Other,125% of Medicaid,6.31,32.41,
ASSAY OF URINE VMA,84585,CPT,,78084585,CDM,301,RC,,,both,,,164,121.36,,,121.36,Other,150% of Medicare + 9.63% HCRA Surcharge,73.8,45,,73.8,percent of total billed charges,Critical Access Hospital RCC factor,46.66,,,46.66,Fee Schedule,,42.01,,,42.01,Fee Schedule,,114.99,,,114.99,Fee Schedule,,103.43,,,103.43,Fee Schedule,,97.75,,,97.75,Fee Schedule,,81.18,,,81.18,Other,110% of Medicare,48.83,,,48.83,Fee Schedule,,29,,,29,Other,186% of Medicaid,57.51,,,57.51,Fee Schedule,,101.68,,,101.68,Fee Schedule,,32.55,,,32.55,Fee Schedule,,57.51,,,57.51,Fee Schedule,,101.68,,,101.68,Fee Schedule,,61.23,,,61.23,Fee Schedule,,114.8,70,,114.8,percent of total billed charges,All Other,73.46,,,73.46,Fee Schedule,,62.26,,,62.26,Fee Schedule,,23.25,,,23.25,Fee Schedule,,23.25,,,23.25,Fee Schedule,,23.25,,,23.25,Fee Schedule,,23.25,,,23.25,Fee Schedule,,15.5,,,15.5,Other,100% of Medicaid,15.5,,,15.5,Other,100% of Medicaid,15.5,,,15.5,Other,100% of Medicaid,15.5,,,15.5,Other,100% of Medicaid,34.88,,,34.88,Other,225% of Medicaid,23.72,,,23.72,Other,153% of Medicaid,34.88,,,34.88,Other,225% of Medicaid,21.7,,,21.7,Other,140% of Medicaid,34.88,,,34.88,Other,225% of Medicaid,40.3,,,40.3,Other,260% of Medicaid,50.22,,,50.22,Other,324% of Medicaid,33.33,,,33.33,Other,215% of Medicaid,33.33,,,33.33,Other,215% of Medicaid,19.38,,,19.38,Other,125% of Medicaid,15.5,121.36,
ASSAY OF VIP,84586,CPT,,78084586,CDM,301,RC,,,both,,,584,432.16,,,432.16,Other,150% of Medicare + 9.63% HCRA Surcharge,262.8,45,,262.8,percent of total billed charges,Critical Access Hospital RCC factor,106.34,,,106.34,Fee Schedule,,95.74,,,95.74,Fee Schedule,,262.02,,,262.02,Fee Schedule,,235.67,,,235.67,Fee Schedule,,222.75,,,222.75,Fee Schedule,,289.08,,,289.08,Other,110% of Medicare,111.29,,,111.29,Fee Schedule,,62,,,62,Other,186% of Medicaid,131.07,,,131.07,Fee Schedule,,362.08,,,362.08,Fee Schedule,,74.19,,,74.19,Fee Schedule,,131.07,,,131.07,Fee Schedule,,362.08,,,362.08,Fee Schedule,,139.55,,,139.55,Fee Schedule,,408.8,70,,408.8,percent of total billed charges,All Other,167.43,,,167.43,Fee Schedule,,141.91,,,141.91,Fee Schedule,,53,,,53,Fee Schedule,,53,,,53,Fee Schedule,,53,,,53,Fee Schedule,,53,,,53,Fee Schedule,,33.57,,,33.57,Other,100% of Medicaid,33.57,,,33.57,Other,100% of Medicaid,33.57,,,33.57,Other,100% of Medicaid,33.57,,,33.57,Other,100% of Medicaid,75.53,,,75.53,Other,225% of Medicaid,51.36,,,51.36,Other,153% of Medicaid,75.53,,,75.53,Other,225% of Medicaid,47,,,47,Other,140% of Medicaid,75.53,,,75.53,Other,225% of Medicaid,87.28,,,87.28,Other,260% of Medicaid,108.76,,,108.76,Other,324% of Medicaid,72.17,,,72.17,Other,215% of Medicaid,72.17,,,72.17,Other,215% of Medicaid,41.96,,,41.96,Other,125% of Medicaid,33.57,432.16,
ASSAY OF VASOPRESSIN,84588,CPT,,78084588,CDM,301,RC,,,both,,,641,474.34,,,474.34,Other,150% of Medicare + 9.63% HCRA Surcharge,288.45,45,,288.45,percent of total billed charges,Critical Access Hospital RCC factor,102.16,,,102.16,Fee Schedule,,91.98,,,91.98,Fee Schedule,,251.75,,,251.75,Fee Schedule,,226.43,,,226.43,Fee Schedule,,214.01,,,214.01,Fee Schedule,,317.3,,,317.3,Other,110% of Medicare,106.91,,,106.91,Fee Schedule,,63,,,63,Other,186% of Medicaid,125.92,,,125.92,Fee Schedule,,397.42,,,397.42,Fee Schedule,,71.27,,,71.27,Fee Schedule,,125.92,,,125.92,Fee Schedule,,397.42,,,397.42,Fee Schedule,,134.06,,,134.06,Fee Schedule,,448.7,70,,448.7,percent of total billed charges,All Other,160.84,,,160.84,Fee Schedule,,136.32,,,136.32,Fee Schedule,,50.91,,,50.91,Fee Schedule,,50.91,,,50.91,Fee Schedule,,50.91,,,50.91,Fee Schedule,,50.91,,,50.91,Fee Schedule,,33.94,,,33.94,Other,100% of Medicaid,33.94,,,33.94,Other,100% of Medicaid,33.94,,,33.94,Other,100% of Medicaid,33.94,,,33.94,Other,100% of Medicaid,76.37,,,76.37,Other,225% of Medicaid,51.93,,,51.93,Other,153% of Medicaid,76.37,,,76.37,Other,225% of Medicaid,47.52,,,47.52,Other,140% of Medicaid,76.37,,,76.37,Other,225% of Medicaid,88.24,,,88.24,Other,260% of Medicaid,109.97,,,109.97,Other,324% of Medicaid,72.97,,,72.97,Other,215% of Medicaid,72.97,,,72.97,Other,215% of Medicaid,42.43,,,42.43,Other,125% of Medicaid,33.94,474.34,
ASSAY OF VITAMIN A,84590,CPT,,78084590,CDM,301,RC,,,both,,,233,172.42,,,172.42,Other,150% of Medicare + 9.63% HCRA Surcharge,104.85,45,,104.85,percent of total billed charges,Critical Access Hospital RCC factor,34.95,,,34.95,Fee Schedule,,31.46,,,31.46,Fee Schedule,,86.01,,,86.01,Fee Schedule,,77.36,,,77.36,Fee Schedule,,73.11,,,73.11,Fee Schedule,,115.34,,,115.34,Other,110% of Medicare,36.57,,,36.57,Fee Schedule,,22,,,22,Other,186% of Medicaid,43.07,,,43.07,Fee Schedule,,144.46,,,144.46,Fee Schedule,,24.38,,,24.38,Fee Schedule,,43.07,,,43.07,Fee Schedule,,144.46,,,144.46,Fee Schedule,,45.86,,,45.86,Fee Schedule,,163.1,70,,163.1,percent of total billed charges,All Other,55.02,,,55.02,Fee Schedule,,46.63,,,46.63,Fee Schedule,,17.42,,,17.42,Fee Schedule,,17.42,,,17.42,Fee Schedule,,17.42,,,17.42,Fee Schedule,,17.42,,,17.42,Fee Schedule,,11.61,,,11.61,Other,100% of Medicaid,11.61,,,11.61,Other,100% of Medicaid,11.61,,,11.61,Other,100% of Medicaid,11.61,,,11.61,Other,100% of Medicaid,26.12,,,26.12,Other,225% of Medicaid,17.76,,,17.76,Other,153% of Medicaid,26.12,,,26.12,Other,225% of Medicaid,16.25,,,16.25,Other,140% of Medicaid,26.12,,,26.12,Other,225% of Medicaid,30.19,,,30.19,Other,260% of Medicaid,37.62,,,37.62,Other,324% of Medicaid,24.96,,,24.96,Other,215% of Medicaid,24.96,,,24.96,Other,215% of Medicaid,14.51,,,14.51,Other,125% of Medicaid,11.61,172.42,
ASSAY OF NOS VITAMIN,84591,CPT,,78084591,CDM,301,RC,,,both,,,70,51.8,,,51.8,Other,150% of Medicare + 9.63% HCRA Surcharge,31.5,45,,31.5,percent of total billed charges,Critical Access Hospital RCC factor,51.35,,,51.35,Fee Schedule,,46.23,,,46.23,Fee Schedule,,86.01,,,86.01,Fee Schedule,,77.36,,,77.36,Fee Schedule,,73.11,,,73.11,Fee Schedule,,34.65,,,34.65,Other,110% of Medicare,53.74,,,53.74,Fee Schedule,,0.01,,,0.01,Other,186% of Medicaid,63.29,,,63.29,Fee Schedule,,43.4,,,43.4,Fee Schedule,,35.83,,,35.83,Fee Schedule,,63.29,,,63.29,Fee Schedule,,43.4,,,43.4,Fee Schedule,,67.39,,,67.39,Fee Schedule,,49,70,,49,percent of total billed charges,All Other,80.85,,,80.85,Fee Schedule,,68.52,,,68.52,Fee Schedule,,25.59,,,25.59,Fee Schedule,,25.59,,,25.59,Fee Schedule,,25.59,,,25.59,Fee Schedule,,25.59,,,25.59,Fee Schedule,,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,86.01,
ASSAY OF VITAMIN K,84597,CPT,,78084597,CDM,301,RC,,,both,,,192,142.08,,,142.08,Other,150% of Medicare + 9.63% HCRA Surcharge,86.4,45,,86.4,percent of total billed charges,Critical Access Hospital RCC factor,41.3,,,41.3,Fee Schedule,,37.18,,,37.18,Fee Schedule,,101.66,,,101.66,Fee Schedule,,91.43,,,91.43,Fee Schedule,,86.42,,,86.42,Fee Schedule,,95.04,,,95.04,Other,110% of Medicare,43.22,,,43.22,Fee Schedule,,26,,,26,Other,186% of Medicaid,50.9,,,50.9,Fee Schedule,,119.04,,,119.04,Fee Schedule,,28.81,,,28.81,Fee Schedule,,50.9,,,50.9,Fee Schedule,,119.04,,,119.04,Fee Schedule,,54.19,,,54.19,Fee Schedule,,134.4,70,,134.4,percent of total billed charges,All Other,65.02,,,65.02,Fee Schedule,,55.11,,,55.11,Fee Schedule,,20.58,,,20.58,Fee Schedule,,20.58,,,20.58,Fee Schedule,,20.58,,,20.58,Fee Schedule,,20.58,,,20.58,Fee Schedule,,13.72,,,13.72,Other,100% of Medicaid,13.72,,,13.72,Other,100% of Medicaid,13.72,,,13.72,Other,100% of Medicaid,13.72,,,13.72,Other,100% of Medicaid,30.87,,,30.87,Other,225% of Medicaid,20.99,,,20.99,Other,153% of Medicaid,30.87,,,30.87,Other,225% of Medicaid,19.21,,,19.21,Other,140% of Medicaid,30.87,,,30.87,Other,225% of Medicaid,35.67,,,35.67,Other,260% of Medicaid,44.45,,,44.45,Other,324% of Medicaid,29.5,,,29.5,Other,215% of Medicaid,29.5,,,29.5,Other,215% of Medicaid,17.15,,,17.15,Other,125% of Medicaid,13.72,142.08,
ASSAY OF VOLATILES,84600,CPT,,78084600,CDM,301,RC,,,both,,,161,119.14,,,119.14,Other,150% of Medicare + 9.63% HCRA Surcharge,72.45,45,,72.45,percent of total billed charges,Critical Access Hospital RCC factor,51.5,,,51.5,Fee Schedule,,46.37,,,46.37,Fee Schedule,,110.93,,,110.93,Fee Schedule,,99.78,,,99.78,Fee Schedule,,94.3,,,94.3,Fee Schedule,,79.7,,,79.7,Other,110% of Medicare,53.9,,,53.9,Fee Schedule,,19,,,19,Other,186% of Medicaid,63.48,,,63.48,Fee Schedule,,99.82,,,99.82,Fee Schedule,,35.93,,,35.93,Fee Schedule,,63.48,,,63.48,Fee Schedule,,99.82,,,99.82,Fee Schedule,,67.58,,,67.58,Fee Schedule,,112.7,70,,112.7,percent of total billed charges,All Other,81.08,,,81.08,Fee Schedule,,68.72,,,68.72,Fee Schedule,,25.67,,,25.67,Fee Schedule,,25.67,,,25.67,Fee Schedule,,25.67,,,25.67,Fee Schedule,,25.67,,,25.67,Fee Schedule,,10.16,,,10.16,Other,100% of Medicaid,10.16,,,10.16,Other,100% of Medicaid,10.16,,,10.16,Other,100% of Medicaid,10.16,,,10.16,Other,100% of Medicaid,22.85,,,22.85,Other,225% of Medicaid,15.54,,,15.54,Other,153% of Medicaid,22.85,,,22.85,Other,225% of Medicaid,14.22,,,14.22,Other,140% of Medicaid,22.85,,,22.85,Other,225% of Medicaid,26.4,,,26.4,Other,260% of Medicaid,32.9,,,32.9,Other,324% of Medicaid,21.83,,,21.83,Other,215% of Medicaid,21.83,,,21.83,Other,215% of Medicaid,12.69,,,12.69,Other,125% of Medicaid,10.16,119.14,
XYLOSE TOLERANCE TEST,84620,CPT,,78084620,CDM,301,RC,,,both,,,165,122.1,,,122.1,Other,150% of Medicare + 9.63% HCRA Surcharge,74.25,45,,74.25,percent of total billed charges,Critical Access Hospital RCC factor,38.86,,,38.86,Fee Schedule,,34.99,,,34.99,Fee Schedule,,82.05,,,82.05,Fee Schedule,,73.8,,,73.8,Fee Schedule,,69.75,,,69.75,Fee Schedule,,81.68,,,81.68,Other,110% of Medicare,40.67,,,40.67,Fee Schedule,,24,,,24,Other,186% of Medicaid,47.9,,,47.9,Fee Schedule,,102.3,,,102.3,Fee Schedule,,27.11,,,27.11,Fee Schedule,,47.9,,,47.9,Fee Schedule,,102.3,,,102.3,Fee Schedule,,50.99,,,50.99,Fee Schedule,,115.5,70,,115.5,percent of total billed charges,All Other,61.18,,,61.18,Fee Schedule,,51.85,,,51.85,Fee Schedule,,19.37,,,19.37,Fee Schedule,,19.37,,,19.37,Fee Schedule,,19.37,,,19.37,Fee Schedule,,19.37,,,19.37,Fee Schedule,,12.91,,,12.91,Other,100% of Medicaid,12.91,,,12.91,Other,100% of Medicaid,12.91,,,12.91,Other,100% of Medicaid,12.91,,,12.91,Other,100% of Medicaid,29.05,,,29.05,Other,225% of Medicaid,19.75,,,19.75,Other,153% of Medicaid,29.05,,,29.05,Other,225% of Medicaid,18.07,,,18.07,Other,140% of Medicaid,29.05,,,29.05,Other,225% of Medicaid,33.57,,,33.57,Other,260% of Medicaid,41.83,,,41.83,Other,324% of Medicaid,27.76,,,27.76,Other,215% of Medicaid,27.76,,,27.76,Other,215% of Medicaid,16.14,,,16.14,Other,125% of Medicaid,12.91,122.1,
ASSAY OF ZINC,84630,CPT,,78084630,CDM,301,RC,,,both,,,192,142.08,,,142.08,Other,150% of Medicare + 9.63% HCRA Surcharge,86.4,45,,86.4,percent of total billed charges,Critical Access Hospital RCC factor,34.28,,,34.28,Fee Schedule,,30.87,,,30.87,Fee Schedule,,54.6,,,54.6,Fee Schedule,,49.11,,,49.11,Fee Schedule,,46.41,,,46.41,Fee Schedule,,95.04,,,95.04,Other,110% of Medicare,35.88,,,35.88,Fee Schedule,,15,,,15,Other,186% of Medicaid,42.26,,,42.26,Fee Schedule,,119.04,,,119.04,Fee Schedule,,23.92,,,23.92,Fee Schedule,,42.26,,,42.26,Fee Schedule,,119.04,,,119.04,Fee Schedule,,44.99,,,44.99,Fee Schedule,,134.4,70,,134.4,percent of total billed charges,All Other,53.98,,,53.98,Fee Schedule,,45.75,,,45.75,Fee Schedule,,17.09,,,17.09,Fee Schedule,,17.09,,,17.09,Fee Schedule,,17.09,,,17.09,Fee Schedule,,17.09,,,17.09,Fee Schedule,,7.98,,,7.98,Other,100% of Medicaid,7.98,,,7.98,Other,100% of Medicaid,7.98,,,7.98,Other,100% of Medicaid,7.98,,,7.98,Other,100% of Medicaid,17.95,,,17.95,Other,225% of Medicaid,12.21,,,12.21,Other,153% of Medicaid,17.95,,,17.95,Other,225% of Medicaid,11.17,,,11.17,Other,140% of Medicaid,17.95,,,17.95,Other,225% of Medicaid,20.75,,,20.75,Other,260% of Medicaid,25.85,,,25.85,Other,324% of Medicaid,17.15,,,17.15,Other,215% of Medicaid,17.15,,,17.15,Other,215% of Medicaid,9.97,,,9.97,Other,125% of Medicaid,7.98,142.08,
ASSAY OF C-PEPTIDE,84681,CPT,,78084681,CDM,301,RC,,,both,,,240,177.6,,,177.6,Other,150% of Medicare + 9.63% HCRA Surcharge,108,45,,108,percent of total billed charges,Critical Access Hospital RCC factor,62.64,,,62.64,Fee Schedule,,56.4,,,56.4,Fee Schedule,,154.31,,,154.31,Fee Schedule,,138.79,,,138.79,Fee Schedule,,131.17,,,131.17,Fee Schedule,,118.8,,,118.8,Other,110% of Medicare,65.55,,,65.55,Fee Schedule,,39,,,39,Other,186% of Medicaid,77.21,,,77.21,Fee Schedule,,148.8,,,148.8,Fee Schedule,,43.7,,,43.7,Fee Schedule,,77.21,,,77.21,Fee Schedule,,148.8,,,148.8,Fee Schedule,,82.2,,,82.2,Fee Schedule,,168,70,,168,percent of total billed charges,All Other,98.62,,,98.62,Fee Schedule,,83.59,,,83.59,Fee Schedule,,31.22,,,31.22,Fee Schedule,,31.22,,,31.22,Fee Schedule,,31.22,,,31.22,Fee Schedule,,31.22,,,31.22,Fee Schedule,,20.81,,,20.81,Other,100% of Medicaid,20.81,,,20.81,Other,100% of Medicaid,20.81,,,20.81,Other,100% of Medicaid,20.81,,,20.81,Other,100% of Medicaid,46.82,,,46.82,Other,225% of Medicaid,31.84,,,31.84,Other,153% of Medicaid,46.82,,,46.82,Other,225% of Medicaid,29.13,,,29.13,Other,140% of Medicaid,46.82,,,46.82,Other,225% of Medicaid,54.11,,,54.11,Other,260% of Medicaid,67.42,,,67.42,Other,324% of Medicaid,44.74,,,44.74,Other,215% of Medicaid,44.74,,,44.74,Other,215% of Medicaid,26.01,,,26.01,Other,125% of Medicaid,20.81,177.6,
CHORIONIC GONADOTROPIN TEST,84702,CPT,,78084702,CDM,301,RC,,,both,,,109,80.66,,,80.66,Other,150% of Medicare + 9.63% HCRA Surcharge,49.05,45,,49.05,percent of total billed charges,Critical Access Hospital RCC factor,45.3,,,45.3,Fee Schedule,,40.79,,,40.79,Fee Schedule,,111.67,,,111.67,Fee Schedule,,100.44,,,100.44,Fee Schedule,,94.93,,,94.93,Fee Schedule,,53.96,,,53.96,Other,110% of Medicare,47.41,,,47.41,Fee Schedule,,23,,,23,Other,186% of Medicaid,55.84,,,55.84,Fee Schedule,,67.58,,,67.58,Fee Schedule,,31.61,,,31.61,Fee Schedule,,55.84,,,55.84,Fee Schedule,,67.58,,,67.58,Fee Schedule,,59.45,,,59.45,Fee Schedule,,76.3,70,,76.3,percent of total billed charges,All Other,71.32,,,71.32,Fee Schedule,,60.45,,,60.45,Fee Schedule,,22.58,,,22.58,Fee Schedule,,22.58,,,22.58,Fee Schedule,,22.58,,,22.58,Fee Schedule,,22.58,,,22.58,Fee Schedule,,12.49,,,12.49,Other,100% of Medicaid,12.49,,,12.49,Other,100% of Medicaid,12.49,,,12.49,Other,100% of Medicaid,12.49,,,12.49,Other,100% of Medicaid,28.11,,,28.11,Other,225% of Medicaid,19.12,,,19.12,Other,153% of Medicaid,28.11,,,28.11,Other,225% of Medicaid,17.49,,,17.49,Other,140% of Medicaid,28.11,,,28.11,Other,225% of Medicaid,32.48,,,32.48,Other,260% of Medicaid,40.48,,,40.48,Other,324% of Medicaid,26.86,,,26.86,Other,215% of Medicaid,26.86,,,26.86,Other,215% of Medicaid,15.62,,,15.62,Other,125% of Medicaid,12.49,111.67,
CHORIONIC GONADOTROPIN ASSAY,84703,CPT,,78084703,CDM,301,RC,,,both,,,109,80.66,,,80.66,Other,150% of Medicare + 9.63% HCRA Surcharge,49.05,45,,49.05,percent of total billed charges,Critical Access Hospital RCC factor,22.64,,,22.64,Fee Schedule,,20.38,,,20.38,Fee Schedule,,55.7,,,55.7,Fee Schedule,,50.1,,,50.1,Fee Schedule,,47.35,,,47.35,Fee Schedule,,53.96,,,53.96,Other,110% of Medicare,23.69,,,23.69,Fee Schedule,,4,,,4,Other,186% of Medicaid,27.9,,,27.9,Fee Schedule,,67.58,,,67.58,Fee Schedule,,15.79,,,15.79,Fee Schedule,,27.9,,,27.9,Fee Schedule,,67.58,,,67.58,Fee Schedule,,29.7,,,29.7,Fee Schedule,,76.3,70,,76.3,percent of total billed charges,All Other,35.64,,,35.64,Fee Schedule,,30.2,,,30.2,Fee Schedule,,11.28,,,11.28,Fee Schedule,,11.28,,,11.28,Fee Schedule,,11.28,,,11.28,Fee Schedule,,11.28,,,11.28,Fee Schedule,,2.02,,,2.02,Other,100% of Medicaid,2.02,,,2.02,Other,100% of Medicaid,2.02,,,2.02,Other,100% of Medicaid,2.02,,,2.02,Other,100% of Medicaid,4.55,,,4.55,Other,225% of Medicaid,3.09,,,3.09,Other,153% of Medicaid,4.55,,,4.55,Other,225% of Medicaid,2.83,,,2.83,Other,140% of Medicaid,4.55,,,4.55,Other,225% of Medicaid,5.25,,,5.25,Other,260% of Medicaid,6.54,,,6.54,Other,324% of Medicaid,4.34,,,4.34,Other,215% of Medicaid,4.34,,,4.34,Other,215% of Medicaid,2.53,,,2.53,Other,125% of Medicaid,2.02,80.66,
FLT3 GENE,81245,CPT,,78181245,CDM,301,RC,,,both,,,611,452.14,,,452.14,Other,150% of Medicare + 9.63% HCRA Surcharge,274.95,45,,274.95,percent of total billed charges,Critical Access Hospital RCC factor,498.19,,,498.19,Fee Schedule,,448.53,,,448.53,Fee Schedule,,31.12,,,31.12,Fee Schedule,,31.12,,,31.12,Fee Schedule,,31.12,,,31.12,Fee Schedule,,302.45,,,302.45,Other,110% of Medicare,521.36,,,521.36,Fee Schedule,,308,,,308,Other,186% of Medicaid,614.04,,,614.04,Fee Schedule,,378.82,,,378.82,Fee Schedule,,347.57,,,347.57,Fee Schedule,,614.04,,,614.04,Fee Schedule,,378.82,,,378.82,Fee Schedule,,653.76,,,653.76,Fee Schedule,,427.7,70,,427.7,percent of total billed charges,All Other,784.36,,,784.36,Fee Schedule,,664.79,,,664.79,Fee Schedule,,248.27,,,248.27,Fee Schedule,,248.27,,,248.27,Fee Schedule,,248.27,,,248.27,Fee Schedule,,248.27,,,248.27,Fee Schedule,,165.51,,,165.51,Other,100% of Medicaid,165.51,,,165.51,Other,100% of Medicaid,165.51,,,165.51,Other,100% of Medicaid,165.51,,,165.51,Other,100% of Medicaid,372.4,,,372.4,Other,225% of Medicaid,253.23,,,253.23,Other,153% of Medicaid,372.4,,,372.4,Other,225% of Medicaid,231.71,,,231.71,Other,140% of Medicaid,372.4,,,372.4,Other,225% of Medicaid,430.33,,,430.33,Other,260% of Medicaid,536.25,,,536.25,Other,324% of Medicaid,355.85,,,355.85,Other,215% of Medicaid,355.85,,,355.85,Other,215% of Medicaid,206.89,,,206.89,Other,125% of Medicaid,31.12,784.36,
BCR/ABL1 GENE MAJOR BP,81206,CPT,TC,85081206,CDM,301,RC,,,both,,,849,628.26,,,628.26,Other,150% of Medicare + 9.63% HCRA Surcharge,382.05,45,,382.05,percent of total billed charges,Critical Access Hospital RCC factor,493.52,,,493.52,Fee Schedule,,444.33,,,444.33,Fee Schedule,,24.24,,,24.24,Fee Schedule,,24.24,,,24.24,Fee Schedule,,24.24,,,24.24,Fee Schedule,,420.26,,,420.26,Other,110% of Medicare,516.47,,,516.47,Fee Schedule,,305,,,305,Other,186% of Medicaid,608.29,,,608.29,Fee Schedule,,526.38,,,526.38,Fee Schedule,,344.32,,,344.32,Fee Schedule,,608.29,,,608.29,Fee Schedule,,526.38,,,526.38,Fee Schedule,,647.64,,,647.64,Fee Schedule,,594.3,70,,594.3,percent of total billed charges,All Other,777.01,,,777.01,Fee Schedule,,658.57,,,658.57,Fee Schedule,,245.94,,,245.94,Fee Schedule,,245.94,,,245.94,Fee Schedule,,245.94,,,245.94,Fee Schedule,,245.94,,,245.94,Fee Schedule,,163.96,,,163.96,Other,100% of Medicaid,163.96,,,163.96,Other,100% of Medicaid,163.96,,,163.96,Other,100% of Medicaid,163.96,,,163.96,Other,100% of Medicaid,368.91,,,368.91,Other,225% of Medicaid,250.86,,,250.86,Other,153% of Medicaid,368.91,,,368.91,Other,225% of Medicaid,229.54,,,229.54,Other,140% of Medicaid,368.91,,,368.91,Other,225% of Medicaid,426.3,,,426.3,Other,260% of Medicaid,531.23,,,531.23,Other,324% of Medicaid,352.51,,,352.51,Other,215% of Medicaid,352.51,,,352.51,Other,215% of Medicaid,204.95,,,204.95,Other,125% of Medicaid,24.24,777.01,
BCR/ABL1 GENE MINOR BP,81207,CPT,TC,85081207,CDM,301,RC,,,both,,,750,555,,,555,Other,150% of Medicare + 9.63% HCRA Surcharge,337.5,45,,337.5,percent of total billed charges,Critical Access Hospital RCC factor,435.97,,,435.97,Fee Schedule,,392.52,,,392.52,Fee Schedule,,24.24,,,24.24,Fee Schedule,,24.24,,,24.24,Fee Schedule,,24.24,,,24.24,Fee Schedule,,371.25,,,371.25,Other,110% of Medicare,456.25,,,456.25,Fee Schedule,,269,,,269,Other,186% of Medicaid,537.36,,,537.36,Fee Schedule,,465,,,465,Fee Schedule,,304.16,,,304.16,Fee Schedule,,537.36,,,537.36,Fee Schedule,,465,,,465,Fee Schedule,,572.12,,,572.12,Fee Schedule,,525,70,,525,percent of total billed charges,All Other,686.4,,,686.4,Fee Schedule,,581.77,,,581.77,Fee Schedule,,217.26,,,217.26,Fee Schedule,,217.26,,,217.26,Fee Schedule,,217.26,,,217.26,Fee Schedule,,217.26,,,217.26,Fee Schedule,,144.84,,,144.84,Other,100% of Medicaid,144.84,,,144.84,Other,100% of Medicaid,144.84,,,144.84,Other,100% of Medicaid,144.84,,,144.84,Other,100% of Medicaid,325.89,,,325.89,Other,225% of Medicaid,221.61,,,221.61,Other,153% of Medicaid,325.89,,,325.89,Other,225% of Medicaid,202.78,,,202.78,Other,140% of Medicaid,325.89,,,325.89,Other,225% of Medicaid,376.58,,,376.58,Other,260% of Medicaid,469.28,,,469.28,Other,324% of Medicaid,311.41,,,311.41,Other,215% of Medicaid,311.41,,,311.41,Other,215% of Medicaid,181.05,,,181.05,Other,125% of Medicaid,24.24,686.4,
BRAF GENE,81210,CPT,TC,85081210,CDM,301,RC,,,both,,,659,487.66,,,487.66,Other,150% of Medicare + 9.63% HCRA Surcharge,296.55,45,,296.55,percent of total billed charges,Critical Access Hospital RCC factor,527.95,,,527.95,Fee Schedule,,475.33,,,475.33,Fee Schedule,,35.94,,,35.94,Fee Schedule,,35.94,,,35.94,Fee Schedule,,35.94,,,35.94,Fee Schedule,,326.21,,,326.21,Other,110% of Medicare,552.51,,,552.51,Fee Schedule,,326,,,326,Other,186% of Medicaid,650.73,,,650.73,Fee Schedule,,408.58,,,408.58,Fee Schedule,,368.34,,,368.34,Fee Schedule,,650.73,,,650.73,Fee Schedule,,408.58,,,408.58,Fee Schedule,,692.83,,,692.83,Fee Schedule,,461.3,70,,461.3,percent of total billed charges,All Other,831.23,,,831.23,Fee Schedule,,704.52,,,704.52,Fee Schedule,,263.1,,,263.1,Fee Schedule,,263.1,,,263.1,Fee Schedule,,263.1,,,263.1,Fee Schedule,,263.1,,,263.1,Fee Schedule,,175.4,,,175.4,Other,100% of Medicaid,175.4,,,175.4,Other,100% of Medicaid,175.4,,,175.4,Other,100% of Medicaid,175.4,,,175.4,Other,100% of Medicaid,394.65,,,394.65,Other,225% of Medicaid,268.36,,,268.36,Other,153% of Medicaid,394.65,,,394.65,Other,225% of Medicaid,245.56,,,245.56,Other,140% of Medicaid,394.65,,,394.65,Other,225% of Medicaid,456.04,,,456.04,Other,260% of Medicaid,568.3,,,568.3,Other,324% of Medicaid,377.11,,,377.11,Other,215% of Medicaid,377.11,,,377.11,Other,215% of Medicaid,219.25,,,219.25,Other,125% of Medicaid,35.94,831.23,
EGFR GENE COM VARIANTS,81235,CPT,TC,85081235,CDM,301,RC,,,both,,,1210,895.4,,,895.4,Other,150% of Medicare + 9.63% HCRA Surcharge,544.5,45,,544.5,percent of total billed charges,Critical Access Hospital RCC factor,976.99,,,976.99,Fee Schedule,,879.61,,,879.61,Fee Schedule,,20.27,,,20.27,Fee Schedule,,20.27,,,20.27,Fee Schedule,,20.27,,,20.27,Fee Schedule,,598.95,,,598.95,Other,110% of Medicare,1022.43,,,1022.43,Fee Schedule,,0.01,,,0.01,Other,186% of Medicaid,1204.19,,,1204.19,Fee Schedule,,750.2,,,750.2,Fee Schedule,,681.62,,,681.62,Fee Schedule,,1204.19,,,1204.19,Fee Schedule,,750.2,,,750.2,Fee Schedule,,1282.09,,,1282.09,Fee Schedule,,847,70,,847,percent of total billed charges,All Other,1538.2,,,1538.2,Fee Schedule,,1303.71,,,1303.71,Fee Schedule,,486.87,,,486.87,Fee Schedule,,486.87,,,486.87,Fee Schedule,,486.87,,,486.87,Fee Schedule,,486.87,,,486.87,Fee Schedule,,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1538.2,
FLT3 GENE,81245,CPT,TC,85081245,CDM,301,RC,,,both,,,611,452.14,,,452.14,Other,150% of Medicare + 9.63% HCRA Surcharge,274.95,45,,274.95,percent of total billed charges,Critical Access Hospital RCC factor,498.19,,,498.19,Fee Schedule,,448.53,,,448.53,Fee Schedule,,31.12,,,31.12,Fee Schedule,,31.12,,,31.12,Fee Schedule,,31.12,,,31.12,Fee Schedule,,302.45,,,302.45,Other,110% of Medicare,521.36,,,521.36,Fee Schedule,,308,,,308,Other,186% of Medicaid,614.04,,,614.04,Fee Schedule,,378.82,,,378.82,Fee Schedule,,347.57,,,347.57,Fee Schedule,,614.04,,,614.04,Fee Schedule,,378.82,,,378.82,Fee Schedule,,653.76,,,653.76,Fee Schedule,,427.7,70,,427.7,percent of total billed charges,All Other,784.36,,,784.36,Fee Schedule,,664.79,,,664.79,Fee Schedule,,248.27,,,248.27,Fee Schedule,,248.27,,,248.27,Fee Schedule,,248.27,,,248.27,Fee Schedule,,248.27,,,248.27,Fee Schedule,,165.51,,,165.51,Other,100% of Medicaid,165.51,,,165.51,Other,100% of Medicaid,165.51,,,165.51,Other,100% of Medicaid,165.51,,,165.51,Other,100% of Medicaid,372.4,,,372.4,Other,225% of Medicaid,253.23,,,253.23,Other,153% of Medicaid,372.4,,,372.4,Other,225% of Medicaid,231.71,,,231.71,Other,140% of Medicaid,372.4,,,372.4,Other,225% of Medicaid,430.33,,,430.33,Other,260% of Medicaid,536.25,,,536.25,Other,324% of Medicaid,355.85,,,355.85,Other,215% of Medicaid,355.85,,,355.85,Other,215% of Medicaid,206.89,,,206.89,Other,125% of Medicaid,31.12,784.36,
IGH VARI REGIONAL MUTATION,81263,CPT,TC,85081263,CDM,301,RC,,,both,,,900,666,,,666,Other,150% of Medicare + 9.63% HCRA Surcharge,405,45,,405,percent of total billed charges,Critical Access Hospital RCC factor,886.51,,,886.51,Fee Schedule,,798.15,,,798.15,Fee Schedule,,51.44,,,51.44,Fee Schedule,,51.44,,,51.44,Fee Schedule,,51.44,,,51.44,Fee Schedule,,445.5,,,445.5,Other,110% of Medicare,927.74,,,927.74,Fee Schedule,,0.01,,,0.01,Other,186% of Medicaid,1092.67,,,1092.67,Fee Schedule,,558,,,558,Fee Schedule,,618.49,,,618.49,Fee Schedule,,1092.67,,,1092.67,Fee Schedule,,558,,,558,Fee Schedule,,1163.35,,,1163.35,Fee Schedule,,630,70,,630,percent of total billed charges,All Other,1395.74,,,1395.74,Fee Schedule,,1182.98,,,1182.98,Fee Schedule,,441.78,,,441.78,Fee Schedule,,441.78,,,441.78,Fee Schedule,,441.78,,,441.78,Fee Schedule,,441.78,,,441.78,Fee Schedule,,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1395.74,
JAK2 GENE,81270,CPT,TC,85081270,CDM,301,RC,,,both,,,511,378.14,,,378.14,Other,150% of Medicare + 9.63% HCRA Surcharge,229.95,45,,229.95,percent of total billed charges,Critical Access Hospital RCC factor,275.9,,,275.9,Fee Schedule,,248.4,,,248.4,Fee Schedule,,21.53,,,21.53,Fee Schedule,,21.53,,,21.53,Fee Schedule,,21.53,,,21.53,Fee Schedule,,252.95,,,252.95,Other,110% of Medicare,288.73,,,288.73,Fee Schedule,,0.01,,,0.01,Other,186% of Medicaid,340.06,,,340.06,Fee Schedule,,316.82,,,316.82,Fee Schedule,,192.49,,,192.49,Fee Schedule,,340.06,,,340.06,Fee Schedule,,316.82,,,316.82,Fee Schedule,,362.06,,,362.06,Fee Schedule,,357.7,70,,357.7,percent of total billed charges,All Other,434.38,,,434.38,Fee Schedule,,368.16,,,368.16,Fee Schedule,,137.49,,,137.49,Fee Schedule,,137.49,,,137.49,Fee Schedule,,137.49,,,137.49,Fee Schedule,,137.49,,,137.49,Fee Schedule,,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,434.38,
KRAS GENE VARIANTS EXON 2,81275,CPT,TC,85081275,CDM,301,RC,,,both,,,726,537.24,,,537.24,Other,150% of Medicare + 9.63% HCRA Surcharge,326.7,45,,326.7,percent of total billed charges,Critical Access Hospital RCC factor,581.68,,,581.68,Fee Schedule,,523.71,,,523.71,Fee Schedule,,43.32,,,43.32,Fee Schedule,,43.32,,,43.32,Fee Schedule,,43.32,,,43.32,Fee Schedule,,359.37,,,359.37,Other,110% of Medicare,608.74,,,608.74,Fee Schedule,,359,,,359,Other,186% of Medicaid,716.96,,,716.96,Fee Schedule,,450.12,,,450.12,Fee Schedule,,405.83,,,405.83,Fee Schedule,,716.96,,,716.96,Fee Schedule,,450.12,,,450.12,Fee Schedule,,763.34,,,763.34,Fee Schedule,,508.2,70,,508.2,percent of total billed charges,All Other,915.82,,,915.82,Fee Schedule,,776.21,,,776.21,Fee Schedule,,289.88,,,289.88,Fee Schedule,,289.88,,,289.88,Fee Schedule,,289.88,,,289.88,Fee Schedule,,289.88,,,289.88,Fee Schedule,,193.25,,,193.25,Other,100% of Medicaid,193.25,,,193.25,Other,100% of Medicaid,193.25,,,193.25,Other,100% of Medicaid,193.25,,,193.25,Other,100% of Medicaid,434.81,,,434.81,Other,225% of Medicaid,295.67,,,295.67,Other,153% of Medicaid,434.81,,,434.81,Other,225% of Medicaid,270.55,,,270.55,Other,140% of Medicaid,434.81,,,434.81,Other,225% of Medicaid,502.45,,,502.45,Other,260% of Medicaid,626.13,,,626.13,Other,324% of Medicaid,415.49,,,415.49,Other,215% of Medicaid,415.49,,,415.49,Other,215% of Medicaid,241.56,,,241.56,Other,125% of Medicaid,43.32,915.82,
TRG GENE REARRANGEMENT ANAL,81342,CPT,TC,85081342,CDM,301,RC,,,both,,,1008,745.92,,,745.92,Other,150% of Medicare + 9.63% HCRA Surcharge,453.6,45,,453.6,percent of total billed charges,Critical Access Hospital RCC factor,606.52,,,606.52,Fee Schedule,,546.07,,,546.07,Fee Schedule,,35.91,,,35.91,Fee Schedule,,35.91,,,35.91,Fee Schedule,,35.91,,,35.91,Fee Schedule,,498.96,,,498.96,Other,110% of Medicare,634.73,,,634.73,Fee Schedule,,0.01,,,0.01,Other,186% of Medicaid,747.57,,,747.57,Fee Schedule,,624.96,,,624.96,Fee Schedule,,423.15,,,423.15,Fee Schedule,,747.57,,,747.57,Fee Schedule,,624.96,,,624.96,Fee Schedule,,795.93,,,795.93,Fee Schedule,,705.6,70,,705.6,percent of total billed charges,All Other,954.92,,,954.92,Fee Schedule,,809.35,,,809.35,Fee Schedule,,302.25,,,302.25,Fee Schedule,,302.25,,,302.25,Fee Schedule,,302.25,,,302.25,Fee Schedule,,302.25,,,302.25,Fee Schedule,,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,954.92,
ASSAY OF IGE,82785,CPT,TC,85082785,CDM,301,RC,,,both,,,237,175.38,,,175.38,Other,150% of Medicare + 9.63% HCRA Surcharge,106.65,45,,106.65,percent of total billed charges,Critical Access Hospital RCC factor,49.54,,,49.54,Fee Schedule,,44.61,,,44.61,Fee Schedule,,122.16,,,122.16,Fee Schedule,,109.87,,,109.87,Fee Schedule,,103.85,,,103.85,Fee Schedule,,117.32,,,117.32,Other,110% of Medicare,51.85,,,51.85,Fee Schedule,,23,,,23,Other,186% of Medicaid,61.07,,,61.07,Fee Schedule,,146.94,,,146.94,Fee Schedule,,34.57,,,34.57,Fee Schedule,,61.07,,,61.07,Fee Schedule,,146.94,,,146.94,Fee Schedule,,65.02,,,65.02,Fee Schedule,,165.9,70,,165.9,percent of total billed charges,All Other,78,,,78,Fee Schedule,,66.11,,,66.11,Fee Schedule,,24.69,,,24.69,Fee Schedule,,24.69,,,24.69,Fee Schedule,,24.69,,,24.69,Fee Schedule,,24.69,,,24.69,Fee Schedule,,12.63,,,12.63,Other,100% of Medicaid,12.63,,,12.63,Other,100% of Medicaid,12.63,,,12.63,Other,100% of Medicaid,12.63,,,12.63,Other,100% of Medicaid,28.41,,,28.41,Other,225% of Medicaid,19.32,,,19.32,Other,153% of Medicaid,28.41,,,28.41,Other,225% of Medicaid,17.68,,,17.68,Other,140% of Medicaid,28.41,,,28.41,Other,225% of Medicaid,32.83,,,32.83,Other,260% of Medicaid,40.91,,,40.91,Other,324% of Medicaid,27.14,,,27.14,Other,215% of Medicaid,27.14,,,27.14,Other,215% of Medicaid,15.78,,,15.78,Other,125% of Medicaid,12.63,175.38,
SKIN TEST; TB ID,86580,CPT,,40086580,CDM,302,RC,,,both,,,58,42.92,,,42.92,Other,150% of Medicare + 9.63% HCRA Surcharge,26.1,45,,26.1,percent of total billed charges,Critical Access Hospital RCC factor,33.95,,,33.95,Fee Schedule,,30.57,,,30.57,Fee Schedule,,50.43,,,50.43,Fee Schedule,,45.36,,,45.36,Fee Schedule,,42.87,,,42.87,Fee Schedule,,28.71,,,28.71,Other,110% of Medicare,35.53,,,35.53,Fee Schedule,,18,,,18,Other,186% of Medicaid,41.85,,,41.85,Fee Schedule,,35.96,,,35.96,Fee Schedule,,23.69,,,23.69,Fee Schedule,,41.85,,,41.85,Fee Schedule,,35.96,,,35.96,Fee Schedule,,44.56,,,44.56,Fee Schedule,,40.6,70,,40.6,percent of total billed charges,All Other,50.84,,,50.84,Fee Schedule,,43.09,,,43.09,Fee Schedule,,34.49,,,34.49,Fee Schedule,,34.49,,,34.49,Fee Schedule,,34.49,,,34.49,Fee Schedule,,34.49,,,34.49,Fee Schedule,,9.88,,,9.88,Other,100% of Medicaid,9.88,,,9.88,Other,100% of Medicaid,9.88,,,9.88,Other,100% of Medicaid,9.88,,,9.88,Other,100% of Medicaid,22.23,,,22.23,Other,225% of Medicaid,15.11,,,15.11,Other,153% of Medicaid,22.23,,,22.23,Other,225% of Medicaid,13.83,,,13.83,Other,140% of Medicaid,22.23,,,22.23,Other,225% of Medicaid,25.68,,,25.68,Other,260% of Medicaid,32.01,,,32.01,Other,324% of Medicaid,21.24,,,21.24,Other,215% of Medicaid,21.24,,,21.24,Other,215% of Medicaid,12.35,,,12.35,Other,125% of Medicaid,9.88,50.84,
HLA TYPING A B OR C,86813,CPT,,77086813,CDM,302,RC,,,both,,,343,253.82,,,253.82,Other,150% of Medicare + 9.63% HCRA Surcharge,154.35,45,,154.35,percent of total billed charges,Critical Access Hospital RCC factor,174.58,,,174.58,Fee Schedule,,157.18,,,157.18,Fee Schedule,,430.08,,,430.08,Fee Schedule,,386.83,,,386.83,Fee Schedule,,365.61,,,365.61,Fee Schedule,,169.79,,,169.79,Other,110% of Medicare,182.7,,,182.7,Fee Schedule,,72,,,72,Other,186% of Medicaid,215.18,,,215.18,Fee Schedule,,212.66,,,212.66,Fee Schedule,,121.8,,,121.8,Fee Schedule,,215.18,,,215.18,Fee Schedule,,212.66,,,212.66,Fee Schedule,,229.1,,,229.1,Fee Schedule,,240.1,70,,240.1,percent of total billed charges,All Other,274.86,,,274.86,Fee Schedule,,232.96,,,232.96,Fee Schedule,,87,,,87,Fee Schedule,,87,,,87,Fee Schedule,,87,,,87,Fee Schedule,,87,,,87,Fee Schedule,,38.81,,,38.81,Other,100% of Medicaid,38.81,,,38.81,Other,100% of Medicaid,38.81,,,38.81,Other,100% of Medicaid,38.81,,,38.81,Other,100% of Medicaid,87.32,,,87.32,Other,225% of Medicaid,59.37,,,59.37,Other,153% of Medicaid,87.32,,,87.32,Other,225% of Medicaid,54.33,,,54.33,Other,140% of Medicaid,87.32,,,87.32,Other,225% of Medicaid,100.9,,,100.9,Other,260% of Medicaid,125.73,,,125.73,Other,324% of Medicaid,83.43,,,83.43,Other,215% of Medicaid,83.43,,,83.43,Other,215% of Medicaid,48.51,,,48.51,Other,125% of Medicaid,38.81,430.08,
RBC ANTIBODY ELUTION,86860,CPT,,77086860,CDM,302,RC,,,both,,,355,262.7,,,262.7,Other,150% of Medicare + 9.63% HCRA Surcharge,159.75,45,,159.75,percent of total billed charges,Critical Access Hospital RCC factor,230.75,65,,230.75,percent of total billed charges,All Other,209.45,65,,209.45,percent of total billed charges,All Other,8.44,,,8.44,Fee Schedule,,8.44,,,8.44,Fee Schedule,,8.44,,,8.44,Fee Schedule,,175.73,,,175.73,Other,110% of Medicare,241.4,68,,241.4,percent of total billed charges,All Other,22,,,22,Other,186% of Medicaid,294.65,83,,294.65,percent of total billed charges,All Other,220.1,62,,220.1,percent of total billed charges,Lab and Radiology,195.25,55,,195.25,percent of total billed charges,Default if not on Fee Schedule,284,80,,284,percent of total billed charges,All Other,220.1,62,,220.1,percent of total billed charges,Lab and Radiology,284,80,,284,percent of total billed charges,All Other,248.5,70,,248.5,percent of total billed charges,All Other,230.75,65,,230.75,percent of total billed charges,Default if not in Fee Schedule,230.75,65,,230.75,percent of total billed charges,Default if not in Fee Schedule,215.25,,,215.25,Fee Schedule,,215.25,,,215.25,Fee Schedule,,215.25,,,215.25,Fee Schedule,,215.25,,,215.25,Fee Schedule,,11.82,,,11.82,Other,100% of Medicaid,11.82,,,11.82,Other,100% of Medicaid,11.82,,,11.82,Other,100% of Medicaid,11.82,,,11.82,Other,100% of Medicaid,26.59,,,26.59,Other,225% of Medicaid,18.08,,,18.08,Other,153% of Medicaid,26.59,,,26.59,Other,225% of Medicaid,16.54,,,16.54,Other,140% of Medicaid,26.59,,,26.59,Other,225% of Medicaid,30.72,,,30.72,Other,260% of Medicaid,38.29,,,38.29,Other,324% of Medicaid,25.41,,,25.41,Other,215% of Medicaid,25.41,,,25.41,Other,215% of Medicaid,14.77,,,14.77,Other,125% of Medicaid,8.44,294.65,
RBC ANTIBODY IDENTIFICATION,86870,CPT,,77086870,CDM,302,RC,,,both,,,731,540.94,,,540.94,Other,150% of Medicare + 9.63% HCRA Surcharge,328.95,45,,328.95,percent of total billed charges,Critical Access Hospital RCC factor,475.15,65,,475.15,percent of total billed charges,All Other,431.29,65,,431.29,percent of total billed charges,All Other,11.57,,,11.57,Fee Schedule,,11.57,,,11.57,Fee Schedule,,11.57,,,11.57,Fee Schedule,,361.85,,,361.85,Other,110% of Medicare,497.08,68,,497.08,percent of total billed charges,All Other,26,,,26,Other,186% of Medicaid,606.73,83,,606.73,percent of total billed charges,All Other,453.22,62,,453.22,percent of total billed charges,Lab and Radiology,402.05,55,,402.05,percent of total billed charges,Default if not on Fee Schedule,584.8,80,,584.8,percent of total billed charges,All Other,453.22,62,,453.22,percent of total billed charges,Lab and Radiology,584.8,80,,584.8,percent of total billed charges,All Other,511.7,70,,511.7,percent of total billed charges,All Other,475.15,65,,475.15,percent of total billed charges,Default if not in Fee Schedule,475.15,65,,475.15,percent of total billed charges,Default if not in Fee Schedule,425.12,,,425.12,Fee Schedule,,425.12,,,425.12,Fee Schedule,,425.12,,,425.12,Fee Schedule,,425.12,,,425.12,Fee Schedule,,14.24,,,14.24,Other,100% of Medicaid,14.24,,,14.24,Other,100% of Medicaid,14.24,,,14.24,Other,100% of Medicaid,14.24,,,14.24,Other,100% of Medicaid,32.04,,,32.04,Other,225% of Medicaid,21.79,,,21.79,Other,153% of Medicaid,32.04,,,32.04,Other,225% of Medicaid,19.94,,,19.94,Other,140% of Medicaid,32.04,,,32.04,Other,225% of Medicaid,37.03,,,37.03,Other,260% of Medicaid,46.14,,,46.14,Other,324% of Medicaid,30.62,,,30.62,Other,215% of Medicaid,30.62,,,30.62,Other,215% of Medicaid,17.8,,,17.8,Other,125% of Medicaid,11.57,606.73,
COOMBS TEST DIRECT,86880,CPT,,77086880,CDM,302,RC,,,both,,,131,96.94,,,96.94,Other,150% of Medicare + 9.63% HCRA Surcharge,58.95,45,,58.95,percent of total billed charges,Critical Access Hospital RCC factor,16.22,,,16.22,Fee Schedule,,14.61,,,14.61,Fee Schedule,,39.84,,,39.84,Fee Schedule,,35.83,,,35.83,Fee Schedule,,33.87,,,33.87,Fee Schedule,,64.85,,,64.85,Other,110% of Medicare,16.98,,,16.98,Fee Schedule,,9,,,9,Other,186% of Medicaid,20,,,20,Fee Schedule,,81.22,,,81.22,Fee Schedule,,11.32,,,11.32,Fee Schedule,,20,,,20,Fee Schedule,,81.22,,,81.22,Fee Schedule,,21.29,,,21.29,Fee Schedule,,91.7,70,,91.7,percent of total billed charges,All Other,25.54,,,25.54,Fee Schedule,,21.65,,,21.65,Fee Schedule,,8.09,,,8.09,Fee Schedule,,8.09,,,8.09,Fee Schedule,,8.09,,,8.09,Fee Schedule,,8.09,,,8.09,Fee Schedule,,4.74,,,4.74,Other,100% of Medicaid,4.74,,,4.74,Other,100% of Medicaid,4.74,,,4.74,Other,100% of Medicaid,4.74,,,4.74,Other,100% of Medicaid,10.66,,,10.66,Other,225% of Medicaid,7.25,,,7.25,Other,153% of Medicaid,10.66,,,10.66,Other,225% of Medicaid,6.63,,,6.63,Other,140% of Medicaid,10.66,,,10.66,Other,225% of Medicaid,12.32,,,12.32,Other,260% of Medicaid,15.35,,,15.35,Other,324% of Medicaid,10.18,,,10.18,Other,215% of Medicaid,10.18,,,10.18,Other,215% of Medicaid,5.92,,,5.92,Other,125% of Medicaid,4.74,96.94,
BLOOD TYPE ANTIGEN DONOR EA,86902,CPT,,77086902,CDM,302,RC,,,both,,,731,540.94,,,540.94,Other,150% of Medicare + 9.63% HCRA Surcharge,328.95,45,,328.95,percent of total billed charges,Critical Access Hospital RCC factor,19.11,,,19.11,Fee Schedule,,17.21,,,17.21,Fee Schedule,,28.35,,,28.35,Fee Schedule,,25.5,,,25.5,Fee Schedule,,24.1,,,24.1,Fee Schedule,,361.85,,,361.85,Other,110% of Medicare,20,,,20,Fee Schedule,,72,,,72,Other,186% of Medicaid,23.56,,,23.56,Fee Schedule,,453.22,,,453.22,Fee Schedule,,13.34,,,13.34,Fee Schedule,,23.56,,,23.56,Fee Schedule,,453.22,,,453.22,Fee Schedule,,25.08,,,25.08,Fee Schedule,,511.7,70,,511.7,percent of total billed charges,All Other,30.09,,,30.09,Fee Schedule,,25.51,,,25.51,Fee Schedule,,9.53,,,9.53,Fee Schedule,,9.53,,,9.53,Fee Schedule,,9.53,,,9.53,Fee Schedule,,9.53,,,9.53,Fee Schedule,,38.81,,,38.81,Other,100% of Medicaid,38.81,,,38.81,Other,100% of Medicaid,38.81,,,38.81,Other,100% of Medicaid,38.81,,,38.81,Other,100% of Medicaid,87.32,,,87.32,Other,225% of Medicaid,59.37,,,59.37,Other,153% of Medicaid,87.32,,,87.32,Other,225% of Medicaid,54.33,,,54.33,Other,140% of Medicaid,87.32,,,87.32,Other,225% of Medicaid,100.9,,,100.9,Other,260% of Medicaid,125.73,,,125.73,Other,324% of Medicaid,83.43,,,83.43,Other,215% of Medicaid,83.43,,,83.43,Other,215% of Medicaid,48.51,,,48.51,Other,125% of Medicaid,9.53,540.94,
COMPATIBILITY TEST ANTIGLOB,86922,CPT,,77086922,CDM,302,RC,,,both,,,355,262.7,,,262.7,Other,150% of Medicare + 9.63% HCRA Surcharge,159.75,45,,159.75,percent of total billed charges,Critical Access Hospital RCC factor,230.75,65,,230.75,percent of total billed charges,All Other,209.45,65,,209.45,percent of total billed charges,All Other,10.08,,,10.08,Fee Schedule,,10.08,,,10.08,Fee Schedule,,10.08,,,10.08,Fee Schedule,,175.73,,,175.73,Other,110% of Medicare,241.4,68,,241.4,percent of total billed charges,All Other,72,,,72,Other,186% of Medicaid,294.65,83,,294.65,percent of total billed charges,All Other,220.1,62,,220.1,percent of total billed charges,Lab and Radiology,195.25,55,,195.25,percent of total billed charges,Default if not on Fee Schedule,284,80,,284,percent of total billed charges,All Other,220.1,62,,220.1,percent of total billed charges,Lab and Radiology,284,80,,284,percent of total billed charges,All Other,248.5,70,,248.5,percent of total billed charges,All Other,230.75,65,,230.75,percent of total billed charges,Default if not in Fee Schedule,230.75,65,,230.75,percent of total billed charges,Default if not in Fee Schedule,215.25,,,215.25,Fee Schedule,,215.25,,,215.25,Fee Schedule,,215.25,,,215.25,Fee Schedule,,215.25,,,215.25,Fee Schedule,,38.8,,,38.8,Other,100% of Medicaid,38.8,,,38.8,Other,100% of Medicaid,38.8,,,38.8,Other,100% of Medicaid,38.8,,,38.8,Other,100% of Medicaid,87.31,,,87.31,Other,225% of Medicaid,59.37,,,59.37,Other,153% of Medicaid,87.31,,,87.31,Other,225% of Medicaid,54.32,,,54.32,Other,140% of Medicaid,87.31,,,87.31,Other,225% of Medicaid,100.89,,,100.89,Other,260% of Medicaid,125.72,,,125.72,Other,324% of Medicaid,83.43,,,83.43,Other,215% of Medicaid,83.43,,,83.43,Other,215% of Medicaid,48.5,,,48.5,Other,125% of Medicaid,10.08,294.65,
ALLERGEN SPECIFIC IGG,86001,CPT,,78086001,CDM,302,RC,,,both,,,26,19.24,,,19.24,Other,150% of Medicare + 9.63% HCRA Surcharge,11.7,45,,11.7,percent of total billed charges,Critical Access Hospital RCC factor,23.54,,,23.54,Fee Schedule,,21.19,,,21.19,Fee Schedule,,37,,,37,Fee Schedule,,33.27,,,33.27,Fee Schedule,,31.45,,,31.45,Fee Schedule,,12.87,,,12.87,Other,110% of Medicare,24.63,,,24.63,Fee Schedule,,18,,,18,Other,186% of Medicaid,29.01,,,29.01,Fee Schedule,,16.12,,,16.12,Fee Schedule,,16.42,,,16.42,Fee Schedule,,29.01,,,29.01,Fee Schedule,,16.12,,,16.12,Fee Schedule,,30.89,,,30.89,Fee Schedule,,18.2,70,,18.2,percent of total billed charges,All Other,37.06,,,37.06,Fee Schedule,,31.41,,,31.41,Fee Schedule,,11.73,,,11.73,Fee Schedule,,11.73,,,11.73,Fee Schedule,,11.73,,,11.73,Fee Schedule,,11.73,,,11.73,Fee Schedule,,9.88,,,9.88,Other,100% of Medicaid,9.88,,,9.88,Other,100% of Medicaid,9.88,,,9.88,Other,100% of Medicaid,9.88,,,9.88,Other,100% of Medicaid,22.23,,,22.23,Other,225% of Medicaid,15.11,,,15.11,Other,153% of Medicaid,22.23,,,22.23,Other,225% of Medicaid,13.83,,,13.83,Other,140% of Medicaid,22.23,,,22.23,Other,225% of Medicaid,25.68,,,25.68,Other,260% of Medicaid,32.01,,,32.01,Other,324% of Medicaid,21.24,,,21.24,Other,215% of Medicaid,21.24,,,21.24,Other,215% of Medicaid,12.35,,,12.35,Other,125% of Medicaid,9.88,37.06,
ALLERGEN SPECIFIC IGE,86003,CPT,,78086003,CDM,302,RC,,,both,,,45,33.3,,,33.3,Other,150% of Medicare + 9.63% HCRA Surcharge,20.25,45,,20.25,percent of total billed charges,Critical Access Hospital RCC factor,15.71,,,15.71,Fee Schedule,,14.15,,,14.15,Fee Schedule,,37,,,37,Fee Schedule,,33.27,,,33.27,Fee Schedule,,31.45,,,31.45,Fee Schedule,,22.28,,,22.28,Other,110% of Medicare,16.44,,,16.44,Fee Schedule,,7,,,7,Other,186% of Medicaid,19.37,,,19.37,Fee Schedule,,27.9,,,27.9,Fee Schedule,,10.96,,,10.96,Fee Schedule,,19.37,,,19.37,Fee Schedule,,27.9,,,27.9,Fee Schedule,,20.62,,,20.62,Fee Schedule,,31.5,70,,31.5,percent of total billed charges,All Other,24.74,,,24.74,Fee Schedule,,20.97,,,20.97,Fee Schedule,,7.83,,,7.83,Fee Schedule,,7.83,,,7.83,Fee Schedule,,7.83,,,7.83,Fee Schedule,,7.83,,,7.83,Fee Schedule,,3.69,,,3.69,Other,100% of Medicaid,3.69,,,3.69,Other,100% of Medicaid,3.69,,,3.69,Other,100% of Medicaid,3.69,,,3.69,Other,100% of Medicaid,8.29,,,8.29,Other,225% of Medicaid,5.64,,,5.64,Other,153% of Medicaid,8.29,,,8.29,Other,225% of Medicaid,5.16,,,5.16,Other,140% of Medicaid,8.29,,,8.29,Other,225% of Medicaid,9.58,,,9.58,Other,260% of Medicaid,11.94,,,11.94,Other,324% of Medicaid,7.93,,,7.93,Other,215% of Medicaid,7.93,,,7.93,Other,215% of Medicaid,4.61,,,4.61,Other,125% of Medicaid,3.69,37,
ALLERGEN SPECIFIC IGE,86005,CPT,,78086005,CDM,302,RC,,,both,,,47,34.78,,,34.78,Other,150% of Medicare + 9.63% HCRA Surcharge,21.15,45,,21.15,percent of total billed charges,Critical Access Hospital RCC factor,23.99,,,23.99,Fee Schedule,,21.6,,,21.6,Fee Schedule,,59.13,,,59.13,Fee Schedule,,53.18,,,53.18,Fee Schedule,,50.27,,,50.27,Fee Schedule,,23.27,,,23.27,Other,110% of Medicare,25.11,,,25.11,Fee Schedule,,18,,,18,Other,186% of Medicaid,29.57,,,29.57,Fee Schedule,,29.14,,,29.14,Fee Schedule,,16.74,,,16.74,Fee Schedule,,29.57,,,29.57,Fee Schedule,,29.14,,,29.14,Fee Schedule,,31.48,,,31.48,Fee Schedule,,32.9,70,,32.9,percent of total billed charges,All Other,37.77,,,37.77,Fee Schedule,,32.01,,,32.01,Fee Schedule,,11.96,,,11.96,Fee Schedule,,11.96,,,11.96,Fee Schedule,,11.96,,,11.96,Fee Schedule,,11.96,,,11.96,Fee Schedule,,9.88,,,9.88,Other,100% of Medicaid,9.88,,,9.88,Other,100% of Medicaid,9.88,,,9.88,Other,100% of Medicaid,9.88,,,9.88,Other,100% of Medicaid,22.23,,,22.23,Other,225% of Medicaid,15.11,,,15.11,Other,153% of Medicaid,22.23,,,22.23,Other,225% of Medicaid,13.83,,,13.83,Other,140% of Medicaid,22.23,,,22.23,Other,225% of Medicaid,25.68,,,25.68,Other,260% of Medicaid,32.01,,,32.01,Other,324% of Medicaid,21.24,,,21.24,Other,215% of Medicaid,21.24,,,21.24,Other,215% of Medicaid,12.35,,,12.35,Other,125% of Medicaid,9.88,59.13,
ALLG SPEC IGE RECOMB EA,86008,CPT,,78086008,CDM,302,RC,,,both,,,57,42.18,,,42.18,Other,150% of Medicare + 9.63% HCRA Surcharge,25.65,45,,25.65,percent of total billed charges,Critical Access Hospital RCC factor,53.97,,,53.97,Fee Schedule,,48.59,,,48.59,Fee Schedule,,8.86,,,8.86,Fee Schedule,,8.86,,,8.86,Fee Schedule,,8.86,,,8.86,Fee Schedule,,28.22,,,28.22,Other,110% of Medicare,56.48,,,56.48,Fee Schedule,,7,,,7,Other,186% of Medicaid,66.52,,,66.52,Fee Schedule,,35.34,,,35.34,Fee Schedule,,37.65,,,37.65,Fee Schedule,,66.52,,,66.52,Fee Schedule,,35.34,,,35.34,Fee Schedule,,70.82,,,70.82,Fee Schedule,,39.9,70,,39.9,percent of total billed charges,All Other,84.97,,,84.97,Fee Schedule,,72.02,,,72.02,Fee Schedule,,26.9,,,26.9,Fee Schedule,,26.9,,,26.9,Fee Schedule,,26.9,,,26.9,Fee Schedule,,26.9,,,26.9,Fee Schedule,,3.69,,,3.69,Other,100% of Medicaid,3.69,,,3.69,Other,100% of Medicaid,3.69,,,3.69,Other,100% of Medicaid,3.69,,,3.69,Other,100% of Medicaid,8.29,,,8.29,Other,225% of Medicaid,5.64,,,5.64,Other,153% of Medicaid,8.29,,,8.29,Other,225% of Medicaid,5.16,,,5.16,Other,140% of Medicaid,8.29,,,8.29,Other,225% of Medicaid,9.58,,,9.58,Other,260% of Medicaid,11.94,,,11.94,Other,324% of Medicaid,7.93,,,7.93,Other,215% of Medicaid,7.93,,,7.93,Other,215% of Medicaid,4.61,,,4.61,Other,125% of Medicaid,3.69,84.97,
ACTINANTIBODY EACH,86015,CPT,,78086015,CDM,302,RC,,,both,,,37,27.38,,,27.38,Other,150% of Medicare + 9.63% HCRA Surcharge,16.65,45,,16.65,percent of total billed charges,Critical Access Hospital RCC factor,36.27,,,36.27,Fee Schedule,,32.66,,,32.66,Fee Schedule,,11.53,,,11.53,Fee Schedule,,11.53,,,11.53,Fee Schedule,,11.53,,,11.53,Fee Schedule,,18.32,,,18.32,Other,110% of Medicare,37.96,,,37.96,Fee Schedule,,13,,,13,Other,186% of Medicaid,44.71,,,44.71,Fee Schedule,,22.94,,,22.94,Fee Schedule,,25.31,,,25.31,Fee Schedule,,44.71,,,44.71,Fee Schedule,,22.94,,,22.94,Fee Schedule,,47.6,,,47.6,Fee Schedule,,25.9,70,,25.9,percent of total billed charges,All Other,54.64,,,54.64,Fee Schedule,,46.31,,,46.31,Fee Schedule,,17.3,,,17.3,Fee Schedule,,17.3,,,17.3,Fee Schedule,,17.3,,,17.3,Fee Schedule,,17.3,,,17.3,Fee Schedule,,6.98,,,6.98,Other,100% of Medicaid,6.98,,,6.98,Other,100% of Medicaid,6.98,,,6.98,Other,100% of Medicaid,6.98,,,6.98,Other,100% of Medicaid,15.7,,,15.7,Other,225% of Medicaid,10.68,,,10.68,Other,153% of Medicaid,15.7,,,15.7,Other,225% of Medicaid,9.77,,,9.77,Other,140% of Medicaid,15.7,,,15.7,Other,225% of Medicaid,18.15,,,18.15,Other,260% of Medicaid,22.61,,,22.61,Other,324% of Medicaid,15.01,,,15.01,Other,215% of Medicaid,15.01,,,15.01,Other,215% of Medicaid,8.72,,,8.72,Other,125% of Medicaid,6.98,54.64,
WBC ANTIBODY IDENTIFICATION,86021,CPT,,78086021,CDM,302,RC,,,both,,,342,253.08,,,253.08,Other,150% of Medicare + 9.63% HCRA Surcharge,153.9,45,,153.9,percent of total billed charges,Critical Access Hospital RCC factor,45.3,,,45.3,Fee Schedule,,40.79,,,40.79,Fee Schedule,,111.67,,,111.67,Fee Schedule,,100.44,,,100.44,Fee Schedule,,94.93,,,94.93,Fee Schedule,,169.29,,,169.29,Other,110% of Medicare,47.41,,,47.41,Fee Schedule,,18,,,18,Other,186% of Medicaid,55.84,,,55.84,Fee Schedule,,212.04,,,212.04,Fee Schedule,,31.61,,,31.61,Fee Schedule,,55.84,,,55.84,Fee Schedule,,212.04,,,212.04,Fee Schedule,,59.45,,,59.45,Fee Schedule,,239.4,70,,239.4,percent of total billed charges,All Other,71.32,,,71.32,Fee Schedule,,60.45,,,60.45,Fee Schedule,,22.58,,,22.58,Fee Schedule,,22.58,,,22.58,Fee Schedule,,22.58,,,22.58,Fee Schedule,,22.58,,,22.58,Fee Schedule,,9.88,,,9.88,Other,100% of Medicaid,9.88,,,9.88,Other,100% of Medicaid,9.88,,,9.88,Other,100% of Medicaid,9.88,,,9.88,Other,100% of Medicaid,22.23,,,22.23,Other,225% of Medicaid,15.11,,,15.11,Other,153% of Medicaid,22.23,,,22.23,Other,225% of Medicaid,13.83,,,13.83,Other,140% of Medicaid,22.23,,,22.23,Other,225% of Medicaid,25.68,,,25.68,Other,260% of Medicaid,32.01,,,32.01,Other,324% of Medicaid,21.24,,,21.24,Other,215% of Medicaid,21.24,,,21.24,Other,215% of Medicaid,12.35,,,12.35,Other,125% of Medicaid,9.88,253.08,
PLATELET ANTIBODIES,86022,CPT,,78086022,CDM,302,RC,,,both,,,409,302.66,,,302.66,Other,150% of Medicare + 9.63% HCRA Surcharge,184.05,45,,184.05,percent of total billed charges,Critical Access Hospital RCC factor,55.29,,,55.29,Fee Schedule,,49.78,,,49.78,Fee Schedule,,136.23,,,136.23,Fee Schedule,,122.53,,,122.53,Fee Schedule,,115.81,,,115.81,Fee Schedule,,202.46,,,202.46,Other,110% of Medicare,57.87,,,57.87,Fee Schedule,,18,,,18,Other,186% of Medicaid,68.15,,,68.15,Fee Schedule,,253.58,,,253.58,Fee Schedule,,38.58,,,38.58,Fee Schedule,,68.15,,,68.15,Fee Schedule,,253.58,,,253.58,Fee Schedule,,72.56,,,72.56,Fee Schedule,,286.3,70,,286.3,percent of total billed charges,All Other,87.06,,,87.06,Fee Schedule,,73.79,,,73.79,Fee Schedule,,27.56,,,27.56,Fee Schedule,,27.56,,,27.56,Fee Schedule,,27.56,,,27.56,Fee Schedule,,27.56,,,27.56,Fee Schedule,,9.88,,,9.88,Other,100% of Medicaid,9.88,,,9.88,Other,100% of Medicaid,9.88,,,9.88,Other,100% of Medicaid,9.88,,,9.88,Other,100% of Medicaid,22.23,,,22.23,Other,225% of Medicaid,15.11,,,15.11,Other,153% of Medicaid,22.23,,,22.23,Other,225% of Medicaid,13.83,,,13.83,Other,140% of Medicaid,22.23,,,22.23,Other,225% of Medicaid,25.68,,,25.68,Other,260% of Medicaid,32.01,,,32.01,Other,324% of Medicaid,21.24,,,21.24,Other,215% of Medicaid,21.24,,,21.24,Other,215% of Medicaid,12.35,,,12.35,Other,125% of Medicaid,9.88,302.66,
IMMUNOGLOBULIN ASSAY,86023,CPT,,78086023,CDM,302,RC,,,both,,,40,29.6,,,29.6,Other,150% of Medicare + 9.63% HCRA Surcharge,18,45,,18,percent of total billed charges,Critical Access Hospital RCC factor,37.5,,,37.5,Fee Schedule,,33.77,,,33.77,Fee Schedule,,92.38,,,92.38,Fee Schedule,,83.09,,,83.09,Fee Schedule,,78.53,,,78.53,Fee Schedule,,19.8,,,19.8,Other,110% of Medicare,39.25,,,39.25,Fee Schedule,,18,,,18,Other,186% of Medicaid,46.23,,,46.23,Fee Schedule,,24.8,,,24.8,Fee Schedule,,26.17,,,26.17,Fee Schedule,,46.23,,,46.23,Fee Schedule,,24.8,,,24.8,Fee Schedule,,49.22,,,49.22,Fee Schedule,,28,70,,28,percent of total billed charges,All Other,59.05,,,59.05,Fee Schedule,,50.05,,,50.05,Fee Schedule,,18.69,,,18.69,Fee Schedule,,18.69,,,18.69,Fee Schedule,,18.69,,,18.69,Fee Schedule,,18.69,,,18.69,Fee Schedule,,9.88,,,9.88,Other,100% of Medicaid,9.88,,,9.88,Other,100% of Medicaid,9.88,,,9.88,Other,100% of Medicaid,9.88,,,9.88,Other,100% of Medicaid,22.23,,,22.23,Other,225% of Medicaid,15.11,,,15.11,Other,153% of Medicaid,22.23,,,22.23,Other,225% of Medicaid,13.83,,,13.83,Other,140% of Medicaid,22.23,,,22.23,Other,225% of Medicaid,25.68,,,25.68,Other,260% of Medicaid,32.01,,,32.01,Other,324% of Medicaid,21.24,,,21.24,Other,215% of Medicaid,21.24,,,21.24,Other,215% of Medicaid,12.35,,,12.35,Other,125% of Medicaid,9.88,92.38,
ANCA SCREEN EACH ANTIBODY,86036,CPT,,78086036,CDM,302,RC,,,both,,,39,28.86,,,28.86,Other,150% of Medicare + 9.63% HCRA Surcharge,17.55,45,,17.55,percent of total billed charges,Critical Access Hospital RCC factor,36.27,,,36.27,Fee Schedule,,32.66,,,32.66,Fee Schedule,,12.05,,,12.05,Fee Schedule,,12.05,,,12.05,Fee Schedule,,12.05,,,12.05,Fee Schedule,,19.31,,,19.31,Other,110% of Medicare,37.96,,,37.96,Fee Schedule,,14,,,14,Other,186% of Medicaid,44.71,,,44.71,Fee Schedule,,24.18,,,24.18,Fee Schedule,,25.31,,,25.31,Fee Schedule,,44.71,,,44.71,Fee Schedule,,24.18,,,24.18,Fee Schedule,,47.6,,,47.6,Fee Schedule,,27.3,70,,27.3,percent of total billed charges,All Other,57.11,,,57.11,Fee Schedule,,48.4,,,48.4,Fee Schedule,,18.08,,,18.08,Fee Schedule,,18.08,,,18.08,Fee Schedule,,18.08,,,18.08,Fee Schedule,,18.08,,,18.08,Fee Schedule,,7.3,,,7.3,Other,100% of Medicaid,7.3,,,7.3,Other,100% of Medicaid,7.3,,,7.3,Other,100% of Medicaid,7.3,,,7.3,Other,100% of Medicaid,16.43,,,16.43,Other,225% of Medicaid,11.17,,,11.17,Other,153% of Medicaid,16.43,,,16.43,Other,225% of Medicaid,10.22,,,10.22,Other,140% of Medicaid,16.43,,,16.43,Other,225% of Medicaid,18.99,,,18.99,Other,260% of Medicaid,23.66,,,23.66,Other,324% of Medicaid,15.7,,,15.7,Other,215% of Medicaid,15.7,,,15.7,Other,215% of Medicaid,9.13,,,9.13,Other,125% of Medicaid,7.3,57.11,
ANCA TITER EACH ANTIBODY,86037,CPT,,78086037,CDM,302,RC,,,both,,,28,20.72,,,20.72,Other,150% of Medicare + 9.63% HCRA Surcharge,12.6,45,,12.6,percent of total billed charges,Critical Access Hospital RCC factor,36.27,,,36.27,Fee Schedule,,32.66,,,32.66,Fee Schedule,,12.05,,,12.05,Fee Schedule,,12.05,,,12.05,Fee Schedule,,12.05,,,12.05,Fee Schedule,,13.86,,,13.86,Other,110% of Medicare,37.96,,,37.96,Fee Schedule,,14,,,14,Other,186% of Medicaid,44.71,,,44.71,Fee Schedule,,17.36,,,17.36,Fee Schedule,,25.31,,,25.31,Fee Schedule,,44.71,,,44.71,Fee Schedule,,17.36,,,17.36,Fee Schedule,,47.6,,,47.6,Fee Schedule,,19.6,70,,19.6,percent of total billed charges,All Other,57.11,,,57.11,Fee Schedule,,48.4,,,48.4,Fee Schedule,,18.08,,,18.08,Fee Schedule,,18.08,,,18.08,Fee Schedule,,18.08,,,18.08,Fee Schedule,,18.08,,,18.08,Fee Schedule,,7.3,,,7.3,Other,100% of Medicaid,7.3,,,7.3,Other,100% of Medicaid,7.3,,,7.3,Other,100% of Medicaid,7.3,,,7.3,Other,100% of Medicaid,16.43,,,16.43,Other,225% of Medicaid,11.17,,,11.17,Other,153% of Medicaid,16.43,,,16.43,Other,225% of Medicaid,10.22,,,10.22,Other,140% of Medicaid,16.43,,,16.43,Other,225% of Medicaid,18.99,,,18.99,Other,260% of Medicaid,23.66,,,23.66,Other,324% of Medicaid,15.7,,,15.7,Other,215% of Medicaid,15.7,,,15.7,Other,215% of Medicaid,9.13,,,9.13,Other,125% of Medicaid,7.3,57.11,
ANTINUCLEAR ANTIBODIES,86038,CPT,,78086038,CDM,302,RC,,,both,,,218,161.32,,,161.32,Other,150% of Medicare + 9.63% HCRA Surcharge,98.1,45,,98.1,percent of total billed charges,Critical Access Hospital RCC factor,36.39,,,36.39,Fee Schedule,,32.76,,,32.76,Fee Schedule,,89.64,,,89.64,Fee Schedule,,80.63,,,80.63,Fee Schedule,,76.2,,,76.2,Fee Schedule,,107.91,,,107.91,Other,110% of Medicare,38.08,,,38.08,Fee Schedule,,10,,,10,Other,186% of Medicaid,44.85,,,44.85,Fee Schedule,,135.16,,,135.16,Fee Schedule,,25.39,,,25.39,Fee Schedule,,44.85,,,44.85,Fee Schedule,,135.16,,,135.16,Fee Schedule,,47.76,,,47.76,Fee Schedule,,152.6,70,,152.6,percent of total billed charges,All Other,57.29,,,57.29,Fee Schedule,,48.56,,,48.56,Fee Schedule,,18.14,,,18.14,Fee Schedule,,18.14,,,18.14,Fee Schedule,,18.14,,,18.14,Fee Schedule,,18.14,,,18.14,Fee Schedule,,5.25,,,5.25,Other,100% of Medicaid,5.25,,,5.25,Other,100% of Medicaid,5.25,,,5.25,Other,100% of Medicaid,5.25,,,5.25,Other,100% of Medicaid,11.82,,,11.82,Other,225% of Medicaid,8.04,,,8.04,Other,153% of Medicaid,11.82,,,11.82,Other,225% of Medicaid,7.35,,,7.35,Other,140% of Medicaid,11.82,,,11.82,Other,225% of Medicaid,13.66,,,13.66,Other,260% of Medicaid,17.02,,,17.02,Other,324% of Medicaid,11.29,,,11.29,Other,215% of Medicaid,11.29,,,11.29,Other,215% of Medicaid,6.57,,,6.57,Other,125% of Medicaid,5.25,161.32,
ANTINUCLEAR ANTIBODIES (ANA),86039,CPT,,78086039,CDM,302,RC,,,both,,,186,137.64,,,137.64,Other,150% of Medicare + 9.63% HCRA Surcharge,83.7,45,,83.7,percent of total billed charges,Critical Access Hospital RCC factor,33.59,,,33.59,Fee Schedule,,30.24,,,30.24,Fee Schedule,,82.79,,,82.79,Fee Schedule,,74.47,,,74.47,Fee Schedule,,70.38,,,70.38,Fee Schedule,,92.07,,,92.07,Other,110% of Medicare,35.15,,,35.15,Fee Schedule,,10,,,10,Other,186% of Medicaid,41.4,,,41.4,Fee Schedule,,115.32,,,115.32,Fee Schedule,,23.44,,,23.44,Fee Schedule,,41.4,,,41.4,Fee Schedule,,115.32,,,115.32,Fee Schedule,,44.08,,,44.08,Fee Schedule,,130.2,70,,130.2,percent of total billed charges,All Other,52.89,,,52.89,Fee Schedule,,44.83,,,44.83,Fee Schedule,,16.74,,,16.74,Fee Schedule,,16.74,,,16.74,Fee Schedule,,16.74,,,16.74,Fee Schedule,,16.74,,,16.74,Fee Schedule,,5.25,,,5.25,Other,100% of Medicaid,5.25,,,5.25,Other,100% of Medicaid,5.25,,,5.25,Other,100% of Medicaid,5.25,,,5.25,Other,100% of Medicaid,11.82,,,11.82,Other,225% of Medicaid,8.04,,,8.04,Other,153% of Medicaid,11.82,,,11.82,Other,225% of Medicaid,7.35,,,7.35,Other,140% of Medicaid,11.82,,,11.82,Other,225% of Medicaid,13.66,,,13.66,Other,260% of Medicaid,17.02,,,17.02,Other,324% of Medicaid,11.29,,,11.29,Other,215% of Medicaid,11.29,,,11.29,Other,215% of Medicaid,6.57,,,6.57,Other,125% of Medicaid,5.25,137.64,
AQUAPORIN-4 ANTB ELISA,86051,CPT,,78086051,CDM,302,RC,,,both,,,37,27.38,,,27.38,Other,150% of Medicare + 9.63% HCRA Surcharge,16.65,45,,16.65,percent of total billed charges,Critical Access Hospital RCC factor,34.71,,,34.71,Fee Schedule,,31.25,,,31.25,Fee Schedule,,11.53,,,11.53,Fee Schedule,,11.53,,,11.53,Fee Schedule,,11.53,,,11.53,Fee Schedule,,18.32,,,18.32,Other,110% of Medicare,36.32,,,36.32,Fee Schedule,,13,,,13,Other,186% of Medicaid,42.78,,,42.78,Fee Schedule,,22.94,,,22.94,Fee Schedule,,24.21,,,24.21,Fee Schedule,,42.78,,,42.78,Fee Schedule,,22.94,,,22.94,Fee Schedule,,45.54,,,45.54,Fee Schedule,,25.9,70,,25.9,percent of total billed charges,All Other,54.64,,,54.64,Fee Schedule,,46.31,,,46.31,Fee Schedule,,17.3,,,17.3,Fee Schedule,,17.3,,,17.3,Fee Schedule,,17.3,,,17.3,Fee Schedule,,17.3,,,17.3,Fee Schedule,,6.98,,,6.98,Other,100% of Medicaid,6.98,,,6.98,Other,100% of Medicaid,6.98,,,6.98,Other,100% of Medicaid,6.98,,,6.98,Other,100% of Medicaid,15.7,,,15.7,Other,225% of Medicaid,10.68,,,10.68,Other,153% of Medicaid,15.7,,,15.7,Other,225% of Medicaid,9.77,,,9.77,Other,140% of Medicaid,15.7,,,15.7,Other,225% of Medicaid,18.15,,,18.15,Other,260% of Medicaid,22.61,,,22.61,Other,324% of Medicaid,15.01,,,15.01,Other,215% of Medicaid,15.01,,,15.01,Other,215% of Medicaid,8.72,,,8.72,Other,125% of Medicaid,6.98,54.64,
AQUAPORIN-4 ANTB CBA EACH,86052,CPT,,78086052,CDM,302,RC,,,both,,,35,25.9,,,25.9,Other,150% of Medicare + 9.63% HCRA Surcharge,15.75,45,,15.75,percent of total billed charges,Critical Access Hospital RCC factor,36.27,,,36.27,Fee Schedule,,32.66,,,32.66,Fee Schedule,,12.05,,,12.05,Fee Schedule,,12.05,,,12.05,Fee Schedule,,12.05,,,12.05,Fee Schedule,,17.33,,,17.33,Other,110% of Medicare,37.96,,,37.96,Fee Schedule,,14,,,14,Other,186% of Medicaid,44.71,,,44.71,Fee Schedule,,21.7,,,21.7,Fee Schedule,,25.31,,,25.31,Fee Schedule,,44.71,,,44.71,Fee Schedule,,21.7,,,21.7,Fee Schedule,,47.6,,,47.6,Fee Schedule,,24.5,70,,24.5,percent of total billed charges,All Other,57.11,,,57.11,Fee Schedule,,48.4,,,48.4,Fee Schedule,,18.08,,,18.08,Fee Schedule,,18.08,,,18.08,Fee Schedule,,18.08,,,18.08,Fee Schedule,,18.08,,,18.08,Fee Schedule,,7.3,,,7.3,Other,100% of Medicaid,7.3,,,7.3,Other,100% of Medicaid,7.3,,,7.3,Other,100% of Medicaid,7.3,,,7.3,Other,100% of Medicaid,16.43,,,16.43,Other,225% of Medicaid,11.17,,,11.17,Other,153% of Medicaid,16.43,,,16.43,Other,225% of Medicaid,10.22,,,10.22,Other,140% of Medicaid,16.43,,,16.43,Other,225% of Medicaid,18.99,,,18.99,Other,260% of Medicaid,23.66,,,23.66,Other,324% of Medicaid,15.7,,,15.7,Other,215% of Medicaid,15.7,,,15.7,Other,215% of Medicaid,9.13,,,9.13,Other,125% of Medicaid,7.3,57.11,
AQAPRN-4 ANTB FLO CYTMTRY EA,86053,CPT,,78086053,CDM,302,RC,,,both,,,77,56.98,,,56.98,Other,150% of Medicare + 9.63% HCRA Surcharge,34.65,45,,34.65,percent of total billed charges,Critical Access Hospital RCC factor,113.57,,,113.57,Fee Schedule,,102.25,,,102.25,Fee Schedule,,12.05,,,12.05,Fee Schedule,,12.05,,,12.05,Fee Schedule,,12.05,,,12.05,Fee Schedule,,38.12,,,38.12,Other,110% of Medicare,118.85,,,118.85,Fee Schedule,,14,,,14,Other,186% of Medicaid,139.98,,,139.98,Fee Schedule,,47.74,,,47.74,Fee Schedule,,79.23,,,79.23,Fee Schedule,,139.98,,,139.98,Fee Schedule,,47.74,,,47.74,Fee Schedule,,149.03,,,149.03,Fee Schedule,,53.9,70,,53.9,percent of total billed charges,All Other,57.11,,,57.11,Fee Schedule,,48.4,,,48.4,Fee Schedule,,18.08,,,18.08,Fee Schedule,,18.08,,,18.08,Fee Schedule,,18.08,,,18.08,Fee Schedule,,18.08,,,18.08,Fee Schedule,,7.3,,,7.3,Other,100% of Medicaid,7.3,,,7.3,Other,100% of Medicaid,7.3,,,7.3,Other,100% of Medicaid,7.3,,,7.3,Other,100% of Medicaid,16.43,,,16.43,Other,225% of Medicaid,11.17,,,11.17,Other,153% of Medicaid,16.43,,,16.43,Other,225% of Medicaid,10.22,,,10.22,Other,140% of Medicaid,16.43,,,16.43,Other,225% of Medicaid,18.99,,,18.99,Other,260% of Medicaid,23.66,,,23.66,Other,324% of Medicaid,15.7,,,15.7,Other,215% of Medicaid,15.7,,,15.7,Other,215% of Medicaid,9.13,,,9.13,Other,125% of Medicaid,7.3,149.03,
ANTISTREPTOLYSIN O TITER,86060,CPT,,78086060,CDM,302,RC,,,both,,,107,79.18,,,79.18,Other,150% of Medicare + 9.63% HCRA Surcharge,48.15,45,,48.15,percent of total billed charges,Critical Access Hospital RCC factor,21.97,,,21.97,Fee Schedule,,19.78,,,19.78,Fee Schedule,,54.12,,,54.12,Fee Schedule,,48.68,,,48.68,Fee Schedule,,46.01,,,46.01,Fee Schedule,,52.97,,,52.97,Other,110% of Medicare,23,,,23,Fee Schedule,,10,,,10,Other,186% of Medicaid,27.08,,,27.08,Fee Schedule,,66.34,,,66.34,Fee Schedule,,15.33,,,15.33,Fee Schedule,,27.08,,,27.08,Fee Schedule,,66.34,,,66.34,Fee Schedule,,28.84,,,28.84,Fee Schedule,,74.9,70,,74.9,percent of total billed charges,All Other,34.59,,,34.59,Fee Schedule,,29.32,,,29.32,Fee Schedule,,10.95,,,10.95,Fee Schedule,,10.95,,,10.95,Fee Schedule,,10.95,,,10.95,Fee Schedule,,10.95,,,10.95,Fee Schedule,,5.25,,,5.25,Other,100% of Medicaid,5.25,,,5.25,Other,100% of Medicaid,5.25,,,5.25,Other,100% of Medicaid,5.25,,,5.25,Other,100% of Medicaid,11.82,,,11.82,Other,225% of Medicaid,8.04,,,8.04,Other,153% of Medicaid,11.82,,,11.82,Other,225% of Medicaid,7.35,,,7.35,Other,140% of Medicaid,11.82,,,11.82,Other,225% of Medicaid,13.66,,,13.66,Other,260% of Medicaid,17.02,,,17.02,Other,324% of Medicaid,11.29,,,11.29,Other,215% of Medicaid,11.29,,,11.29,Other,215% of Medicaid,6.57,,,6.57,Other,125% of Medicaid,5.25,79.18,
ANTISTREPTOLYSIN O SCREEN,86063,CPT,,78086063,CDM,302,RC,,,both,,,138,102.12,,,102.12,Other,150% of Medicare + 9.63% HCRA Surcharge,62.1,45,,62.1,percent of total billed charges,Critical Access Hospital RCC factor,17.37,,,17.37,Fee Schedule,,15.64,,,15.64,Fee Schedule,,38,,,38,Fee Schedule,,34.18,,,34.18,Fee Schedule,,32.3,,,32.3,Fee Schedule,,68.31,,,68.31,Other,110% of Medicare,18.18,,,18.18,Fee Schedule,,7,,,7,Other,186% of Medicaid,21.41,,,21.41,Fee Schedule,,85.56,,,85.56,Fee Schedule,,12.12,,,12.12,Fee Schedule,,21.41,,,21.41,Fee Schedule,,85.56,,,85.56,Fee Schedule,,22.79,,,22.79,Fee Schedule,,96.6,70,,96.6,percent of total billed charges,All Other,27.34,,,27.34,Fee Schedule,,23.18,,,23.18,Fee Schedule,,8.66,,,8.66,Fee Schedule,,8.66,,,8.66,Fee Schedule,,8.66,,,8.66,Fee Schedule,,8.66,,,8.66,Fee Schedule,,3.79,,,3.79,Other,100% of Medicaid,3.79,,,3.79,Other,100% of Medicaid,3.79,,,3.79,Other,100% of Medicaid,3.79,,,3.79,Other,100% of Medicaid,8.52,,,8.52,Other,225% of Medicaid,5.79,,,5.79,Other,153% of Medicaid,8.52,,,8.52,Other,225% of Medicaid,5.3,,,5.3,Other,140% of Medicaid,8.52,,,8.52,Other,225% of Medicaid,9.85,,,9.85,Other,260% of Medicaid,12.27,,,12.27,Other,324% of Medicaid,8.14,,,8.14,Other,215% of Medicaid,8.14,,,8.14,Other,215% of Medicaid,4.73,,,4.73,Other,125% of Medicaid,3.79,102.12,
C-REACTIVE PROTEIN,86140,CPT,,78086140,CDM,302,RC,,,both,,,83,61.42,,,61.42,Other,150% of Medicare + 9.63% HCRA Surcharge,37.35,45,,37.35,percent of total billed charges,Critical Access Hospital RCC factor,15.59,,,15.59,Fee Schedule,,14.04,,,14.04,Fee Schedule,,38.37,,,38.37,Fee Schedule,,34.51,,,34.51,Fee Schedule,,32.61,,,32.61,Fee Schedule,,41.09,,,41.09,Other,110% of Medicare,16.32,,,16.32,Fee Schedule,,8,,,8,Other,186% of Medicaid,19.22,,,19.22,Fee Schedule,,51.46,,,51.46,Fee Schedule,,10.88,,,10.88,Fee Schedule,,19.22,,,19.22,Fee Schedule,,51.46,,,51.46,Fee Schedule,,20.46,,,20.46,Fee Schedule,,58.1,70,,58.1,percent of total billed charges,All Other,24.55,,,24.55,Fee Schedule,,20.81,,,20.81,Fee Schedule,,7.77,,,7.77,Fee Schedule,,7.77,,,7.77,Fee Schedule,,7.77,,,7.77,Fee Schedule,,7.77,,,7.77,Fee Schedule,,4.14,,,4.14,Other,100% of Medicaid,4.14,,,4.14,Other,100% of Medicaid,4.14,,,4.14,Other,100% of Medicaid,4.14,,,4.14,Other,100% of Medicaid,9.32,,,9.32,Other,225% of Medicaid,6.34,,,6.34,Other,153% of Medicaid,9.32,,,9.32,Other,225% of Medicaid,5.8,,,5.8,Other,140% of Medicaid,9.32,,,9.32,Other,225% of Medicaid,10.77,,,10.77,Other,260% of Medicaid,13.42,,,13.42,Other,324% of Medicaid,8.9,,,8.9,Other,215% of Medicaid,8.9,,,8.9,Other,215% of Medicaid,5.18,,,5.18,Other,125% of Medicaid,4.14,61.42,
C-REACTIVE PROTEIN HS,86141,CPT,,78086141,CDM,302,RC,,,both,,,84,62.16,,,62.16,Other,150% of Medicare + 9.63% HCRA Surcharge,37.8,45,,37.8,percent of total billed charges,Critical Access Hospital RCC factor,38.98,,,38.98,Fee Schedule,,35.09,,,35.09,Fee Schedule,,96.02,,,96.02,Fee Schedule,,86.36,,,86.36,Fee Schedule,,81.63,,,81.63,Fee Schedule,,41.58,,,41.58,Other,110% of Medicare,40.79,,,40.79,Fee Schedule,,19,,,19,Other,186% of Medicaid,48.04,,,48.04,Fee Schedule,,52.08,,,52.08,Fee Schedule,,27.2,,,27.2,Fee Schedule,,48.04,,,48.04,Fee Schedule,,52.08,,,52.08,Fee Schedule,,51.15,,,51.15,Fee Schedule,,58.8,70,,58.8,percent of total billed charges,All Other,61.37,,,61.37,Fee Schedule,,52.02,,,52.02,Fee Schedule,,19.43,,,19.43,Fee Schedule,,19.43,,,19.43,Fee Schedule,,19.43,,,19.43,Fee Schedule,,19.43,,,19.43,Fee Schedule,,10.35,,,10.35,Other,100% of Medicaid,10.35,,,10.35,Other,100% of Medicaid,10.35,,,10.35,Other,100% of Medicaid,10.35,,,10.35,Other,100% of Medicaid,23.29,,,23.29,Other,225% of Medicaid,15.84,,,15.84,Other,153% of Medicaid,23.29,,,23.29,Other,225% of Medicaid,14.49,,,14.49,Other,140% of Medicaid,23.29,,,23.29,Other,225% of Medicaid,26.92,,,26.92,Other,260% of Medicaid,33.54,,,33.54,Other,324% of Medicaid,22.26,,,22.26,Other,215% of Medicaid,22.26,,,22.26,Other,215% of Medicaid,12.94,,,12.94,Other,125% of Medicaid,10.35,96.02,
PHOSPHOLIPID ANTIBODY,86148,CPT,,78086148,CDM,302,RC,,,both,,,260,192.4,,,192.4,Other,150% of Medicare + 9.63% HCRA Surcharge,117,45,,117,percent of total billed charges,Critical Access Hospital RCC factor,48.37,,,48.37,Fee Schedule,,43.55,,,43.55,Fee Schedule,,119.15,,,119.15,Fee Schedule,,107.17,,,107.17,Fee Schedule,,101.29,,,101.29,Fee Schedule,,128.7,,,128.7,Other,110% of Medicare,50.62,,,50.62,Fee Schedule,,15,,,15,Other,186% of Medicaid,59.62,,,59.62,Fee Schedule,,161.2,,,161.2,Fee Schedule,,33.75,,,33.75,Fee Schedule,,59.62,,,59.62,Fee Schedule,,161.2,,,161.2,Fee Schedule,,63.48,,,63.48,Fee Schedule,,182,70,,182,percent of total billed charges,All Other,76.16,,,76.16,Fee Schedule,,64.55,,,64.55,Fee Schedule,,24.11,,,24.11,Fee Schedule,,24.11,,,24.11,Fee Schedule,,24.11,,,24.11,Fee Schedule,,24.11,,,24.11,Fee Schedule,,7.9,,,7.9,Other,100% of Medicaid,7.9,,,7.9,Other,100% of Medicaid,7.9,,,7.9,Other,100% of Medicaid,7.9,,,7.9,Other,100% of Medicaid,17.77,,,17.77,Other,225% of Medicaid,12.08,,,12.08,Other,153% of Medicaid,17.77,,,17.77,Other,225% of Medicaid,11.06,,,11.06,Other,140% of Medicaid,17.77,,,17.77,Other,225% of Medicaid,20.54,,,20.54,Other,260% of Medicaid,25.59,,,25.59,Other,324% of Medicaid,16.98,,,16.98,Other,215% of Medicaid,16.98,,,16.98,Other,215% of Medicaid,9.87,,,9.87,Other,125% of Medicaid,7.9,192.4,
COLD AGGLUTININ TITER,86157,CPT,,78086157,CDM,302,RC,,,both,,,107,79.18,,,79.18,Other,150% of Medicare + 9.63% HCRA Surcharge,48.15,45,,48.15,percent of total billed charges,Critical Access Hospital RCC factor,24.26,,,24.26,Fee Schedule,,21.84,,,21.84,Fee Schedule,,43.11,,,43.11,Fee Schedule,,38.77,,,38.77,Fee Schedule,,36.65,,,36.65,Fee Schedule,,52.97,,,52.97,Other,110% of Medicare,25.39,,,25.39,Fee Schedule,,10,,,10,Other,186% of Medicaid,29.9,,,29.9,Fee Schedule,,66.34,,,66.34,Fee Schedule,,16.93,,,16.93,Fee Schedule,,29.9,,,29.9,Fee Schedule,,66.34,,,66.34,Fee Schedule,,31.84,,,31.84,Fee Schedule,,74.9,70,,74.9,percent of total billed charges,All Other,38.2,,,38.2,Fee Schedule,,32.37,,,32.37,Fee Schedule,,12.09,,,12.09,Fee Schedule,,12.09,,,12.09,Fee Schedule,,12.09,,,12.09,Fee Schedule,,12.09,,,12.09,Fee Schedule,,5.25,,,5.25,Other,100% of Medicaid,5.25,,,5.25,Other,100% of Medicaid,5.25,,,5.25,Other,100% of Medicaid,5.25,,,5.25,Other,100% of Medicaid,11.82,,,11.82,Other,225% of Medicaid,8.04,,,8.04,Other,153% of Medicaid,11.82,,,11.82,Other,225% of Medicaid,7.35,,,7.35,Other,140% of Medicaid,11.82,,,11.82,Other,225% of Medicaid,13.66,,,13.66,Other,260% of Medicaid,17.02,,,17.02,Other,324% of Medicaid,11.29,,,11.29,Other,215% of Medicaid,11.29,,,11.29,Other,215% of Medicaid,6.57,,,6.57,Other,125% of Medicaid,5.25,79.18,
COMPLEMENT ANTIGEN,86160,CPT,,78086160,CDM,302,RC,,,both,,,175,129.5,,,129.5,Other,150% of Medicare + 9.63% HCRA Surcharge,78.75,45,,78.75,percent of total billed charges,Critical Access Hospital RCC factor,36.12,,,36.12,Fee Schedule,,32.52,,,32.52,Fee Schedule,,89.01,,,89.01,Fee Schedule,,80.06,,,80.06,Fee Schedule,,75.67,,,75.67,Fee Schedule,,86.63,,,86.63,Other,110% of Medicare,37.8,,,37.8,Fee Schedule,,20,,,20,Other,186% of Medicaid,44.52,,,44.52,Fee Schedule,,108.5,,,108.5,Fee Schedule,,25.2,,,25.2,Fee Schedule,,44.52,,,44.52,Fee Schedule,,108.5,,,108.5,Fee Schedule,,47.4,,,47.4,Fee Schedule,,122.5,70,,122.5,percent of total billed charges,All Other,56.87,,,56.87,Fee Schedule,,48.2,,,48.2,Fee Schedule,,18,,,18,Fee Schedule,,18,,,18,Fee Schedule,,18,,,18,Fee Schedule,,18,,,18,Fee Schedule,,10.61,,,10.61,Other,100% of Medicaid,10.61,,,10.61,Other,100% of Medicaid,10.61,,,10.61,Other,100% of Medicaid,10.61,,,10.61,Other,100% of Medicaid,23.86,,,23.86,Other,225% of Medicaid,16.23,,,16.23,Other,153% of Medicaid,23.86,,,23.86,Other,225% of Medicaid,14.85,,,14.85,Other,140% of Medicaid,23.86,,,23.86,Other,225% of Medicaid,27.57,,,27.57,Other,260% of Medicaid,34.36,,,34.36,Other,324% of Medicaid,22.8,,,22.8,Other,215% of Medicaid,22.8,,,22.8,Other,215% of Medicaid,13.26,,,13.26,Other,125% of Medicaid,10.61,129.5,
COMPLEMENT/FUNCTION ACTIVITY,86161,CPT,,78086161,CDM,302,RC,,,both,,,182,134.68,,,134.68,Other,150% of Medicare + 9.63% HCRA Surcharge,81.9,45,,81.9,percent of total billed charges,Critical Access Hospital RCC factor,36.12,,,36.12,Fee Schedule,,32.52,,,32.52,Fee Schedule,,89.01,,,89.01,Fee Schedule,,80.06,,,80.06,Fee Schedule,,75.67,,,75.67,Fee Schedule,,90.09,,,90.09,Other,110% of Medicare,37.8,,,37.8,Fee Schedule,,22,,,22,Other,186% of Medicaid,44.52,,,44.52,Fee Schedule,,112.84,,,112.84,Fee Schedule,,25.2,,,25.2,Fee Schedule,,44.52,,,44.52,Fee Schedule,,112.84,,,112.84,Fee Schedule,,47.4,,,47.4,Fee Schedule,,127.4,70,,127.4,percent of total billed charges,All Other,56.87,,,56.87,Fee Schedule,,48.2,,,48.2,Fee Schedule,,18,,,18,Fee Schedule,,18,,,18,Fee Schedule,,18,,,18,Fee Schedule,,18,,,18,Fee Schedule,,12,,,12,Other,100% of Medicaid,12,,,12,Other,100% of Medicaid,12,,,12,Other,100% of Medicaid,12,,,12,Other,100% of Medicaid,27,,,27,Other,225% of Medicaid,18.36,,,18.36,Other,153% of Medicaid,27,,,27,Other,225% of Medicaid,16.8,,,16.8,Other,140% of Medicaid,27,,,27,Other,225% of Medicaid,31.2,,,31.2,Other,260% of Medicaid,38.88,,,38.88,Other,324% of Medicaid,25.8,,,25.8,Other,215% of Medicaid,25.8,,,25.8,Other,215% of Medicaid,15,,,15,Other,125% of Medicaid,12,134.68,
COMPLEMENT TOTAL (CH50),86162,CPT,,78086162,CDM,302,RC,,,both,,,343,253.82,,,253.82,Other,150% of Medicare + 9.63% HCRA Surcharge,154.35,45,,154.35,percent of total billed charges,Critical Access Hospital RCC factor,61.16,,,61.16,Fee Schedule,,55.07,,,55.07,Fee Schedule,,150.67,,,150.67,Fee Schedule,,135.52,,,135.52,Fee Schedule,,128.08,,,128.08,Fee Schedule,,169.79,,,169.79,Other,110% of Medicare,64.01,,,64.01,Fee Schedule,,36,,,36,Other,186% of Medicaid,75.39,,,75.39,Fee Schedule,,212.66,,,212.66,Fee Schedule,,42.67,,,42.67,Fee Schedule,,75.39,,,75.39,Fee Schedule,,212.66,,,212.66,Fee Schedule,,80.26,,,80.26,Fee Schedule,,240.1,70,,240.1,percent of total billed charges,All Other,96.3,,,96.3,Fee Schedule,,81.62,,,81.62,Fee Schedule,,30.48,,,30.48,Fee Schedule,,30.48,,,30.48,Fee Schedule,,30.48,,,30.48,Fee Schedule,,30.48,,,30.48,Fee Schedule,,19.58,,,19.58,Other,100% of Medicaid,19.58,,,19.58,Other,100% of Medicaid,19.58,,,19.58,Other,100% of Medicaid,19.58,,,19.58,Other,100% of Medicaid,44.06,,,44.06,Other,225% of Medicaid,29.96,,,29.96,Other,153% of Medicaid,44.06,,,44.06,Other,225% of Medicaid,27.42,,,27.42,Other,140% of Medicaid,44.06,,,44.06,Other,225% of Medicaid,50.92,,,50.92,Other,260% of Medicaid,63.45,,,63.45,Other,324% of Medicaid,42.11,,,42.11,Other,215% of Medicaid,42.11,,,42.11,Other,215% of Medicaid,24.48,,,24.48,Other,125% of Medicaid,19.58,253.82,
CCP ANTIBODY,86200,CPT,,78086200,CDM,302,RC,,,both,,,84,62.16,,,62.16,Other,150% of Medicare + 9.63% HCRA Surcharge,37.8,45,,37.8,percent of total billed charges,Critical Access Hospital RCC factor,38.98,,,38.98,Fee Schedule,,35.09,,,35.09,Fee Schedule,,96.02,,,96.02,Fee Schedule,,86.36,,,86.36,Fee Schedule,,81.63,,,81.63,Fee Schedule,,41.58,,,41.58,Other,110% of Medicare,40.79,,,40.79,Fee Schedule,,18,,,18,Other,186% of Medicaid,48.04,,,48.04,Fee Schedule,,52.08,,,52.08,Fee Schedule,,27.2,,,27.2,Fee Schedule,,48.04,,,48.04,Fee Schedule,,52.08,,,52.08,Fee Schedule,,51.15,,,51.15,Fee Schedule,,58.8,70,,58.8,percent of total billed charges,All Other,61.37,,,61.37,Fee Schedule,,52.02,,,52.02,Fee Schedule,,19.43,,,19.43,Fee Schedule,,19.43,,,19.43,Fee Schedule,,19.43,,,19.43,Fee Schedule,,19.43,,,19.43,Fee Schedule,,9.88,,,9.88,Other,100% of Medicaid,9.88,,,9.88,Other,100% of Medicaid,9.88,,,9.88,Other,100% of Medicaid,9.88,,,9.88,Other,100% of Medicaid,22.23,,,22.23,Other,225% of Medicaid,15.11,,,15.11,Other,153% of Medicaid,22.23,,,22.23,Other,225% of Medicaid,13.83,,,13.83,Other,140% of Medicaid,22.23,,,22.23,Other,225% of Medicaid,25.68,,,25.68,Other,260% of Medicaid,32.01,,,32.01,Other,324% of Medicaid,21.24,,,21.24,Other,215% of Medicaid,21.24,,,21.24,Other,215% of Medicaid,12.35,,,12.35,Other,125% of Medicaid,9.88,96.02,
DNA ANTIBODY,86215,CPT,,78086215,CDM,302,RC,,,both,,,182,134.68,,,134.68,Other,150% of Medicare + 9.63% HCRA Surcharge,81.9,45,,81.9,percent of total billed charges,Critical Access Hospital RCC factor,39.88,,,39.88,Fee Schedule,,35.91,,,35.91,Fee Schedule,,98.29,,,98.29,Fee Schedule,,88.4,,,88.4,Fee Schedule,,83.55,,,83.55,Fee Schedule,,90.09,,,90.09,Other,110% of Medicare,41.74,,,41.74,Fee Schedule,,10,,,10,Other,186% of Medicaid,49.16,,,49.16,Fee Schedule,,112.84,,,112.84,Fee Schedule,,27.83,,,27.83,Fee Schedule,,49.16,,,49.16,Fee Schedule,,112.84,,,112.84,Fee Schedule,,52.34,,,52.34,Fee Schedule,,127.4,70,,127.4,percent of total billed charges,All Other,62.79,,,62.79,Fee Schedule,,53.22,,,53.22,Fee Schedule,,19.88,,,19.88,Fee Schedule,,19.88,,,19.88,Fee Schedule,,19.88,,,19.88,Fee Schedule,,19.88,,,19.88,Fee Schedule,,5.25,,,5.25,Other,100% of Medicaid,5.25,,,5.25,Other,100% of Medicaid,5.25,,,5.25,Other,100% of Medicaid,5.25,,,5.25,Other,100% of Medicaid,11.82,,,11.82,Other,225% of Medicaid,8.04,,,8.04,Other,153% of Medicaid,11.82,,,11.82,Other,225% of Medicaid,7.35,,,7.35,Other,140% of Medicaid,11.82,,,11.82,Other,225% of Medicaid,13.66,,,13.66,Other,260% of Medicaid,17.02,,,17.02,Other,324% of Medicaid,11.29,,,11.29,Other,215% of Medicaid,11.29,,,11.29,Other,215% of Medicaid,6.57,,,6.57,Other,125% of Medicaid,5.25,134.68,
DNA AB; NATIVE OR DS,86225,CPT,,78086225,CDM,302,RC,,,both,,,185,136.9,,,136.9,Other,150% of Medicare + 9.63% HCRA Surcharge,83.25,45,,83.25,percent of total billed charges,Critical Access Hospital RCC factor,41.36,,,41.36,Fee Schedule,,37.24,,,37.24,Fee Schedule,,101.87,,,101.87,Fee Schedule,,91.62,,,91.62,Fee Schedule,,86.6,,,86.6,Fee Schedule,,91.58,,,91.58,Other,110% of Medicare,43.28,,,43.28,Fee Schedule,,10,,,10,Other,186% of Medicaid,50.98,,,50.98,Fee Schedule,,114.7,,,114.7,Fee Schedule,,28.85,,,28.85,Fee Schedule,,50.98,,,50.98,Fee Schedule,,114.7,,,114.7,Fee Schedule,,54.27,,,54.27,Fee Schedule,,129.5,70,,129.5,percent of total billed charges,All Other,65.11,,,65.11,Fee Schedule,,55.19,,,55.19,Fee Schedule,,20.61,,,20.61,Fee Schedule,,20.61,,,20.61,Fee Schedule,,20.61,,,20.61,Fee Schedule,,20.61,,,20.61,Fee Schedule,,5.25,,,5.25,Other,100% of Medicaid,5.25,,,5.25,Other,100% of Medicaid,5.25,,,5.25,Other,100% of Medicaid,5.25,,,5.25,Other,100% of Medicaid,11.82,,,11.82,Other,225% of Medicaid,8.04,,,8.04,Other,153% of Medicaid,11.82,,,11.82,Other,225% of Medicaid,7.35,,,7.35,Other,140% of Medicaid,11.82,,,11.82,Other,225% of Medicaid,13.66,,,13.66,Other,260% of Medicaid,17.02,,,17.02,Other,324% of Medicaid,11.29,,,11.29,Other,215% of Medicaid,11.29,,,11.29,Other,215% of Medicaid,6.57,,,6.57,Other,125% of Medicaid,5.25,136.9,
DNA ANTIBODY SINGLE STRAND,86226,CPT,,78086226,CDM,302,RC,,,both,,,225,166.5,,,166.5,Other,150% of Medicare + 9.63% HCRA Surcharge,101.25,45,,101.25,percent of total billed charges,Critical Access Hospital RCC factor,36.45,,,36.45,Fee Schedule,,32.82,,,32.82,Fee Schedule,,89.8,,,89.8,Fee Schedule,,80.77,,,80.77,Fee Schedule,,76.34,,,76.34,Fee Schedule,,111.38,,,111.38,Other,110% of Medicare,38.15,,,38.15,Fee Schedule,,18,,,18,Other,186% of Medicaid,44.93,,,44.93,Fee Schedule,,139.5,,,139.5,Fee Schedule,,25.43,,,25.43,Fee Schedule,,44.93,,,44.93,Fee Schedule,,139.5,,,139.5,Fee Schedule,,47.83,,,47.83,Fee Schedule,,157.5,70,,157.5,percent of total billed charges,All Other,57.39,,,57.39,Fee Schedule,,48.64,,,48.64,Fee Schedule,,18.17,,,18.17,Fee Schedule,,18.17,,,18.17,Fee Schedule,,18.17,,,18.17,Fee Schedule,,18.17,,,18.17,Fee Schedule,,9.88,,,9.88,Other,100% of Medicaid,9.88,,,9.88,Other,100% of Medicaid,9.88,,,9.88,Other,100% of Medicaid,9.88,,,9.88,Other,100% of Medicaid,22.23,,,22.23,Other,225% of Medicaid,15.11,,,15.11,Other,153% of Medicaid,22.23,,,22.23,Other,225% of Medicaid,13.83,,,13.83,Other,140% of Medicaid,22.23,,,22.23,Other,225% of Medicaid,25.68,,,25.68,Other,260% of Medicaid,32.01,,,32.01,Other,324% of Medicaid,21.24,,,21.24,Other,215% of Medicaid,21.24,,,21.24,Other,215% of Medicaid,12.35,,,12.35,Other,125% of Medicaid,9.88,166.5,
EMA EACH IG CLASS,86231,CPT,,78086231,CDM,302,RC,,,both,,,39,28.86,,,28.86,Other,150% of Medicare + 9.63% HCRA Surcharge,17.55,45,,17.55,percent of total billed charges,Critical Access Hospital RCC factor,36.39,,,36.39,Fee Schedule,,32.76,,,32.76,Fee Schedule,,12.09,,,12.09,Fee Schedule,,12.09,,,12.09,Fee Schedule,,12.09,,,12.09,Fee Schedule,,19.31,,,19.31,Other,110% of Medicare,38.08,,,38.08,Fee Schedule,,14,,,14,Other,186% of Medicaid,44.85,,,44.85,Fee Schedule,,24.18,,,24.18,Fee Schedule,,25.39,,,25.39,Fee Schedule,,44.85,,,44.85,Fee Schedule,,24.18,,,24.18,Fee Schedule,,47.76,,,47.76,Fee Schedule,,27.3,70,,27.3,percent of total billed charges,All Other,57.29,,,57.29,Fee Schedule,,48.56,,,48.56,Fee Schedule,,18.14,,,18.14,Fee Schedule,,18.14,,,18.14,Fee Schedule,,18.14,,,18.14,Fee Schedule,,18.14,,,18.14,Fee Schedule,,7.32,,,7.32,Other,100% of Medicaid,7.32,,,7.32,Other,100% of Medicaid,7.32,,,7.32,Other,100% of Medicaid,7.32,,,7.32,Other,100% of Medicaid,16.48,,,16.48,Other,225% of Medicaid,11.2,,,11.2,Other,153% of Medicaid,16.48,,,16.48,Other,225% of Medicaid,10.25,,,10.25,Other,140% of Medicaid,16.48,,,16.48,Other,225% of Medicaid,19.04,,,19.04,Other,260% of Medicaid,23.72,,,23.72,Other,324% of Medicaid,15.74,,,15.74,Other,215% of Medicaid,15.74,,,15.74,Other,215% of Medicaid,9.15,,,9.15,Other,125% of Medicaid,7.32,57.29,
DGP ANTIBODY EACH IG CLASS,86258,CPT,,78086258,CDM,302,RC,,,both,,,37,27.38,,,27.38,Other,150% of Medicare + 9.63% HCRA Surcharge,16.65,45,,16.65,percent of total billed charges,Critical Access Hospital RCC factor,36.27,,,36.27,Fee Schedule,,32.66,,,32.66,Fee Schedule,,11.53,,,11.53,Fee Schedule,,11.53,,,11.53,Fee Schedule,,11.53,,,11.53,Fee Schedule,,18.32,,,18.32,Other,110% of Medicare,37.96,,,37.96,Fee Schedule,,13,,,13,Other,186% of Medicaid,44.71,,,44.71,Fee Schedule,,22.94,,,22.94,Fee Schedule,,25.31,,,25.31,Fee Schedule,,44.71,,,44.71,Fee Schedule,,22.94,,,22.94,Fee Schedule,,47.6,,,47.6,Fee Schedule,,25.9,70,,25.9,percent of total billed charges,All Other,54.64,,,54.64,Fee Schedule,,46.31,,,46.31,Fee Schedule,,17.3,,,17.3,Fee Schedule,,17.3,,,17.3,Fee Schedule,,17.3,,,17.3,Fee Schedule,,17.3,,,17.3,Fee Schedule,,6.98,,,6.98,Other,100% of Medicaid,6.98,,,6.98,Other,100% of Medicaid,6.98,,,6.98,Other,100% of Medicaid,6.98,,,6.98,Other,100% of Medicaid,15.7,,,15.7,Other,225% of Medicaid,10.68,,,10.68,Other,153% of Medicaid,15.7,,,15.7,Other,225% of Medicaid,9.77,,,9.77,Other,140% of Medicaid,15.7,,,15.7,Other,225% of Medicaid,18.15,,,18.15,Other,260% of Medicaid,22.61,,,22.61,Other,324% of Medicaid,15.01,,,15.01,Other,215% of Medicaid,15.01,,,15.01,Other,215% of Medicaid,8.72,,,8.72,Other,125% of Medicaid,6.98,54.64,
IMMUNOASSAY TUMOR CA 15-3,86300,CPT,,78086300,CDM,302,RC,,,both,,,134,99.16,,,99.16,Other,150% of Medicare + 9.63% HCRA Surcharge,60.3,45,,60.3,percent of total billed charges,Critical Access Hospital RCC factor,62.64,,,62.64,Fee Schedule,,56.4,,,56.4,Fee Schedule,,154.36,,,154.36,Fee Schedule,,138.83,,,138.83,Fee Schedule,,131.22,,,131.22,Fee Schedule,,66.33,,,66.33,Other,110% of Medicare,65.55,,,65.55,Fee Schedule,,39,,,39,Other,186% of Medicaid,77.21,,,77.21,Fee Schedule,,83.08,,,83.08,Fee Schedule,,43.7,,,43.7,Fee Schedule,,77.21,,,77.21,Fee Schedule,,83.08,,,83.08,Fee Schedule,,82.2,,,82.2,Fee Schedule,,93.8,70,,93.8,percent of total billed charges,All Other,98.62,,,98.62,Fee Schedule,,83.59,,,83.59,Fee Schedule,,31.22,,,31.22,Fee Schedule,,31.22,,,31.22,Fee Schedule,,31.22,,,31.22,Fee Schedule,,31.22,,,31.22,Fee Schedule,,20.81,,,20.81,Other,100% of Medicaid,20.81,,,20.81,Other,100% of Medicaid,20.81,,,20.81,Other,100% of Medicaid,20.81,,,20.81,Other,100% of Medicaid,46.82,,,46.82,Other,225% of Medicaid,31.84,,,31.84,Other,153% of Medicaid,46.82,,,46.82,Other,225% of Medicaid,29.13,,,29.13,Other,140% of Medicaid,46.82,,,46.82,Other,225% of Medicaid,54.11,,,54.11,Other,260% of Medicaid,67.42,,,67.42,Other,324% of Medicaid,44.74,,,44.74,Other,215% of Medicaid,44.74,,,44.74,Other,215% of Medicaid,26.01,,,26.01,Other,125% of Medicaid,20.81,154.36,
IMMUNOASSAY TUMOR CA 19-9,86301,CPT,,78086301,CDM,302,RC,,,both,,,173,128.02,,,128.02,Other,150% of Medicare + 9.63% HCRA Surcharge,77.85,45,,77.85,percent of total billed charges,Critical Access Hospital RCC factor,62.64,,,62.64,Fee Schedule,,56.4,,,56.4,Fee Schedule,,154.36,,,154.36,Fee Schedule,,138.83,,,138.83,Fee Schedule,,131.22,,,131.22,Fee Schedule,,85.64,,,85.64,Other,110% of Medicare,65.55,,,65.55,Fee Schedule,,39,,,39,Other,186% of Medicaid,77.21,,,77.21,Fee Schedule,,107.26,,,107.26,Fee Schedule,,43.7,,,43.7,Fee Schedule,,77.21,,,77.21,Fee Schedule,,107.26,,,107.26,Fee Schedule,,82.2,,,82.2,Fee Schedule,,121.1,70,,121.1,percent of total billed charges,All Other,98.62,,,98.62,Fee Schedule,,83.59,,,83.59,Fee Schedule,,31.22,,,31.22,Fee Schedule,,31.22,,,31.22,Fee Schedule,,31.22,,,31.22,Fee Schedule,,31.22,,,31.22,Fee Schedule,,20.81,,,20.81,Other,100% of Medicaid,20.81,,,20.81,Other,100% of Medicaid,20.81,,,20.81,Other,100% of Medicaid,20.81,,,20.81,Other,100% of Medicaid,46.82,,,46.82,Other,225% of Medicaid,31.84,,,31.84,Other,153% of Medicaid,46.82,,,46.82,Other,225% of Medicaid,29.13,,,29.13,Other,140% of Medicaid,46.82,,,46.82,Other,225% of Medicaid,54.11,,,54.11,Other,260% of Medicaid,67.42,,,67.42,Other,324% of Medicaid,44.74,,,44.74,Other,215% of Medicaid,44.74,,,44.74,Other,215% of Medicaid,26.01,,,26.01,Other,125% of Medicaid,20.81,154.36,
IMMUNOASSAY TUMOR CA 125,86304,CPT,,78086304,CDM,302,RC,,,both,,,260,192.4,,,192.4,Other,150% of Medicare + 9.63% HCRA Surcharge,117,45,,117,percent of total billed charges,Critical Access Hospital RCC factor,62.64,,,62.64,Fee Schedule,,56.4,,,56.4,Fee Schedule,,154.36,,,154.36,Fee Schedule,,138.83,,,138.83,Fee Schedule,,131.22,,,131.22,Fee Schedule,,128.7,,,128.7,Other,110% of Medicare,65.55,,,65.55,Fee Schedule,,39,,,39,Other,186% of Medicaid,77.21,,,77.21,Fee Schedule,,161.2,,,161.2,Fee Schedule,,43.7,,,43.7,Fee Schedule,,77.21,,,77.21,Fee Schedule,,161.2,,,161.2,Fee Schedule,,82.2,,,82.2,Fee Schedule,,182,70,,182,percent of total billed charges,All Other,98.62,,,98.62,Fee Schedule,,83.59,,,83.59,Fee Schedule,,31.22,,,31.22,Fee Schedule,,31.22,,,31.22,Fee Schedule,,31.22,,,31.22,Fee Schedule,,31.22,,,31.22,Fee Schedule,,20.81,,,20.81,Other,100% of Medicaid,20.81,,,20.81,Other,100% of Medicaid,20.81,,,20.81,Other,100% of Medicaid,20.81,,,20.81,Other,100% of Medicaid,46.82,,,46.82,Other,225% of Medicaid,31.84,,,31.84,Other,153% of Medicaid,46.82,,,46.82,Other,225% of Medicaid,29.13,,,29.13,Other,140% of Medicaid,46.82,,,46.82,Other,225% of Medicaid,54.11,,,54.11,Other,260% of Medicaid,67.42,,,67.42,Other,324% of Medicaid,44.74,,,44.74,Other,215% of Medicaid,44.74,,,44.74,Other,215% of Medicaid,26.01,,,26.01,Other,125% of Medicaid,20.81,192.4,
HUMAN EPIDIDYMIS PROTEIN 4,86305,CPT,,78086305,CDM,302,RC,,,both,,,124,91.76,,,91.76,Other,150% of Medicare + 9.63% HCRA Surcharge,55.8,45,,55.8,percent of total billed charges,Critical Access Hospital RCC factor,62.64,,,62.64,Fee Schedule,,56.4,,,56.4,Fee Schedule,,154.36,,,154.36,Fee Schedule,,138.83,,,138.83,Fee Schedule,,131.22,,,131.22,Fee Schedule,,61.38,,,61.38,Other,110% of Medicare,65.55,,,65.55,Fee Schedule,,39,,,39,Other,186% of Medicaid,77.21,,,77.21,Fee Schedule,,76.88,,,76.88,Fee Schedule,,43.7,,,43.7,Fee Schedule,,77.21,,,77.21,Fee Schedule,,76.88,,,76.88,Fee Schedule,,82.2,,,82.2,Fee Schedule,,86.8,70,,86.8,percent of total billed charges,All Other,98.62,,,98.62,Fee Schedule,,83.59,,,83.59,Fee Schedule,,31.22,,,31.22,Fee Schedule,,31.22,,,31.22,Fee Schedule,,31.22,,,31.22,Fee Schedule,,31.22,,,31.22,Fee Schedule,,20.81,,,20.81,Other,100% of Medicaid,20.81,,,20.81,Other,100% of Medicaid,20.81,,,20.81,Other,100% of Medicaid,20.81,,,20.81,Other,100% of Medicaid,46.82,,,46.82,Other,225% of Medicaid,31.84,,,31.84,Other,153% of Medicaid,46.82,,,46.82,Other,225% of Medicaid,29.13,,,29.13,Other,140% of Medicaid,46.82,,,46.82,Other,225% of Medicaid,54.11,,,54.11,Other,260% of Medicaid,67.42,,,67.42,Other,324% of Medicaid,44.74,,,44.74,Other,215% of Medicaid,44.74,,,44.74,Other,215% of Medicaid,26.01,,,26.01,Other,125% of Medicaid,20.81,154.36,
HETEROPHILE ANTIBODIES,86308,CPT,,78086308,CDM,302,RC,,,both,,,118,87.32,,,87.32,Other,150% of Medicare + 9.63% HCRA Surcharge,53.1,45,,53.1,percent of total billed charges,Critical Access Hospital RCC factor,15.59,,,15.59,Fee Schedule,,14.04,,,14.04,Fee Schedule,,38.37,,,38.37,Fee Schedule,,34.51,,,34.51,Fee Schedule,,32.61,,,32.61,Fee Schedule,,58.41,,,58.41,Other,110% of Medicare,16.32,,,16.32,Fee Schedule,,9,,,9,Other,186% of Medicaid,19.22,,,19.22,Fee Schedule,,73.16,,,73.16,Fee Schedule,,10.88,,,10.88,Fee Schedule,,19.22,,,19.22,Fee Schedule,,73.16,,,73.16,Fee Schedule,,20.46,,,20.46,Fee Schedule,,82.6,70,,82.6,percent of total billed charges,All Other,24.55,,,24.55,Fee Schedule,,20.81,,,20.81,Fee Schedule,,7.77,,,7.77,Fee Schedule,,7.77,,,7.77,Fee Schedule,,7.77,,,7.77,Fee Schedule,,7.77,,,7.77,Fee Schedule,,4.78,,,4.78,Other,100% of Medicaid,4.78,,,4.78,Other,100% of Medicaid,4.78,,,4.78,Other,100% of Medicaid,4.78,,,4.78,Other,100% of Medicaid,10.75,,,10.75,Other,225% of Medicaid,7.31,,,7.31,Other,153% of Medicaid,10.75,,,10.75,Other,225% of Medicaid,6.69,,,6.69,Other,140% of Medicaid,10.75,,,10.75,Other,225% of Medicaid,12.42,,,12.42,Other,260% of Medicaid,15.48,,,15.48,Other,324% of Medicaid,10.27,,,10.27,Other,215% of Medicaid,10.27,,,10.27,Other,215% of Medicaid,5.97,,,5.97,Other,125% of Medicaid,4.78,87.32,
HETEROPHILE ANTIBODIES,86309,CPT,,78086309,CDM,302,RC,,,both,,,102,75.48,,,75.48,Other,150% of Medicare + 9.63% HCRA Surcharge,45.9,45,,45.9,percent of total billed charges,Critical Access Hospital RCC factor,19.47,,,19.47,Fee Schedule,,17.53,,,17.53,Fee Schedule,,48.01,,,48.01,Fee Schedule,,43.18,,,43.18,Fee Schedule,,40.81,,,40.81,Fee Schedule,,50.49,,,50.49,Other,110% of Medicare,20.38,,,20.38,Fee Schedule,,12,,,12,Other,186% of Medicaid,24,,,24,Fee Schedule,,63.24,,,63.24,Fee Schedule,,13.59,,,13.59,Fee Schedule,,24,,,24,Fee Schedule,,63.24,,,63.24,Fee Schedule,,25.56,,,25.56,Fee Schedule,,71.4,70,,71.4,percent of total billed charges,All Other,30.66,,,30.66,Fee Schedule,,25.99,,,25.99,Fee Schedule,,9.71,,,9.71,Fee Schedule,,9.71,,,9.71,Fee Schedule,,9.71,,,9.71,Fee Schedule,,9.71,,,9.71,Fee Schedule,,6.47,,,6.47,Other,100% of Medicaid,6.47,,,6.47,Other,100% of Medicaid,6.47,,,6.47,Other,100% of Medicaid,6.47,,,6.47,Other,100% of Medicaid,14.56,,,14.56,Other,225% of Medicaid,9.9,,,9.9,Other,153% of Medicaid,14.56,,,14.56,Other,225% of Medicaid,9.06,,,9.06,Other,140% of Medicaid,14.56,,,14.56,Other,225% of Medicaid,16.82,,,16.82,Other,260% of Medicaid,20.96,,,20.96,Other,324% of Medicaid,13.91,,,13.91,Other,215% of Medicaid,13.91,,,13.91,Other,215% of Medicaid,8.09,,,8.09,Other,125% of Medicaid,6.47,75.48,
IMMUNOASSAY TUMOR OTHER,86316,CPT,,78086316,CDM,302,RC,,,both,,,381,281.94,,,281.94,Other,150% of Medicare + 9.63% HCRA Surcharge,171.45,45,,171.45,percent of total billed charges,Critical Access Hospital RCC factor,62.64,,,62.64,Fee Schedule,,56.4,,,56.4,Fee Schedule,,154.36,,,154.36,Fee Schedule,,138.83,,,138.83,Fee Schedule,,131.22,,,131.22,Fee Schedule,,188.6,,,188.6,Other,110% of Medicare,65.55,,,65.55,Fee Schedule,,18,,,18,Other,186% of Medicaid,77.21,,,77.21,Fee Schedule,,236.22,,,236.22,Fee Schedule,,43.7,,,43.7,Fee Schedule,,77.21,,,77.21,Fee Schedule,,236.22,,,236.22,Fee Schedule,,82.2,,,82.2,Fee Schedule,,266.7,70,,266.7,percent of total billed charges,All Other,98.62,,,98.62,Fee Schedule,,83.59,,,83.59,Fee Schedule,,31.22,,,31.22,Fee Schedule,,31.22,,,31.22,Fee Schedule,,31.22,,,31.22,Fee Schedule,,31.22,,,31.22,Fee Schedule,,9.88,,,9.88,Other,100% of Medicaid,9.88,,,9.88,Other,100% of Medicaid,9.88,,,9.88,Other,100% of Medicaid,9.88,,,9.88,Other,100% of Medicaid,22.23,,,22.23,Other,225% of Medicaid,15.11,,,15.11,Other,153% of Medicaid,22.23,,,22.23,Other,225% of Medicaid,13.83,,,13.83,Other,140% of Medicaid,22.23,,,22.23,Other,225% of Medicaid,25.68,,,25.68,Other,260% of Medicaid,32.01,,,32.01,Other,324% of Medicaid,21.24,,,21.24,Other,215% of Medicaid,21.24,,,21.24,Other,215% of Medicaid,12.35,,,12.35,Other,125% of Medicaid,9.88,281.94,
IMMUNOASSAY INFECTIOUS AGENT,86317,CPT,,78086317,CDM,302,RC,,,both,,,141,104.34,,,104.34,Other,150% of Medicare + 9.63% HCRA Surcharge,63.45,45,,63.45,percent of total billed charges,Critical Access Hospital RCC factor,45.12,,,45.12,Fee Schedule,,40.62,,,40.62,Fee Schedule,,111.2,,,111.2,Fee Schedule,,100.01,,,100.01,Fee Schedule,,94.53,,,94.53,Fee Schedule,,69.8,,,69.8,Other,110% of Medicare,47.22,,,47.22,Fee Schedule,,18,,,18,Other,186% of Medicaid,55.61,,,55.61,Fee Schedule,,87.42,,,87.42,Fee Schedule,,31.48,,,31.48,Fee Schedule,,55.61,,,55.61,Fee Schedule,,87.42,,,87.42,Fee Schedule,,59.21,,,59.21,Fee Schedule,,98.7,70,,98.7,percent of total billed charges,All Other,71.04,,,71.04,Fee Schedule,,60.21,,,60.21,Fee Schedule,,22.49,,,22.49,Fee Schedule,,22.49,,,22.49,Fee Schedule,,22.49,,,22.49,Fee Schedule,,22.49,,,22.49,Fee Schedule,,9.88,,,9.88,Other,100% of Medicaid,9.88,,,9.88,Other,100% of Medicaid,9.88,,,9.88,Other,100% of Medicaid,9.88,,,9.88,Other,100% of Medicaid,22.23,,,22.23,Other,225% of Medicaid,15.11,,,15.11,Other,153% of Medicaid,22.23,,,22.23,Other,225% of Medicaid,13.83,,,13.83,Other,140% of Medicaid,22.23,,,22.23,Other,225% of Medicaid,25.68,,,25.68,Other,260% of Medicaid,32.01,,,32.01,Other,324% of Medicaid,21.24,,,21.24,Other,215% of Medicaid,21.24,,,21.24,Other,215% of Medicaid,12.35,,,12.35,Other,125% of Medicaid,9.88,111.2,
IMMUNOASSAY INFECTIOUS AGENT,86318,CPT,,78086318,CDM,302,RC,,,both,,,132,97.68,,,97.68,Other,150% of Medicare + 9.63% HCRA Surcharge,59.4,45,,59.4,percent of total billed charges,Critical Access Hospital RCC factor,54.45,,,54.45,Fee Schedule,,49.02,,,49.02,Fee Schedule,,96.02,,,96.02,Fee Schedule,,86.36,,,86.36,Fee Schedule,,81.63,,,81.63,Fee Schedule,,65.34,,,65.34,Other,110% of Medicare,56.98,,,56.98,Fee Schedule,,7,,,7,Other,186% of Medicaid,67.11,,,67.11,Fee Schedule,,81.84,,,81.84,Fee Schedule,,37.99,,,37.99,Fee Schedule,,67.11,,,67.11,Fee Schedule,,81.84,,,81.84,Fee Schedule,,71.46,,,71.46,Fee Schedule,,92.4,70,,92.4,percent of total billed charges,All Other,85.73,,,85.73,Fee Schedule,,72.66,,,72.66,Fee Schedule,,27.14,,,27.14,Fee Schedule,,27.14,,,27.14,Fee Schedule,,27.14,,,27.14,Fee Schedule,,27.14,,,27.14,Fee Schedule,,3.79,,,3.79,Other,100% of Medicaid,3.79,,,3.79,Other,100% of Medicaid,3.79,,,3.79,Other,100% of Medicaid,3.79,,,3.79,Other,100% of Medicaid,8.52,,,8.52,Other,225% of Medicaid,5.79,,,5.79,Other,153% of Medicaid,8.52,,,8.52,Other,225% of Medicaid,5.3,,,5.3,Other,140% of Medicaid,8.52,,,8.52,Other,225% of Medicaid,9.85,,,9.85,Other,260% of Medicaid,12.27,,,12.27,Other,324% of Medicaid,8.14,,,8.14,Other,215% of Medicaid,8.14,,,8.14,Other,215% of Medicaid,4.73,,,4.73,Other,125% of Medicaid,3.79,97.68,
SERUM IMMUNOELECTROPHORESIS,86320,CPT,,78086320,CDM,302,RC,,,both,,,320,236.8,,,236.8,Other,150% of Medicare + 9.63% HCRA Surcharge,144,45,,144,percent of total billed charges,Critical Access Hospital RCC factor,90.06,,,90.06,Fee Schedule,,81.08,,,81.08,Fee Schedule,,166.22,,,166.22,Fee Schedule,,149.5,,,149.5,Fee Schedule,,141.3,,,141.3,Fee Schedule,,158.4,,,158.4,Other,110% of Medicare,94.25,,,94.25,Fee Schedule,,52,,,52,Other,186% of Medicaid,111,,,111,Fee Schedule,,198.4,,,198.4,Fee Schedule,,62.83,,,62.83,Fee Schedule,,111,,,111,Fee Schedule,,198.4,,,198.4,Fee Schedule,,118.18,,,118.18,Fee Schedule,,224,70,,224,percent of total billed charges,All Other,141.79,,,141.79,Fee Schedule,,120.18,,,120.18,Fee Schedule,,44.88,,,44.88,Fee Schedule,,44.88,,,44.88,Fee Schedule,,44.88,,,44.88,Fee Schedule,,44.88,,,44.88,Fee Schedule,,27.69,,,27.69,Other,100% of Medicaid,27.69,,,27.69,Other,100% of Medicaid,27.69,,,27.69,Other,100% of Medicaid,27.69,,,27.69,Other,100% of Medicaid,62.31,,,62.31,Other,225% of Medicaid,42.37,,,42.37,Other,153% of Medicaid,62.31,,,62.31,Other,225% of Medicaid,38.77,,,38.77,Other,140% of Medicaid,62.31,,,62.31,Other,225% of Medicaid,72,,,72,Other,260% of Medicaid,89.73,,,89.73,Other,324% of Medicaid,59.54,,,59.54,Other,215% of Medicaid,59.54,,,59.54,Other,215% of Medicaid,34.62,,,34.62,Other,125% of Medicaid,27.69,236.8,
IMMUNOELECTROPHORESIS ASSAY,86327,CPT,,78086327,CDM,302,RC,,,both,,,365,270.1,,,270.1,Other,150% of Medicare + 9.63% HCRA Surcharge,164.25,45,,164.25,percent of total billed charges,Critical Access Hospital RCC factor,90.06,,,90.06,Fee Schedule,,81.08,,,81.08,Fee Schedule,,168.27,,,168.27,Fee Schedule,,151.35,,,151.35,Fee Schedule,,143.05,,,143.05,Fee Schedule,,180.68,,,180.68,Other,110% of Medicare,94.25,,,94.25,Fee Schedule,,66,,,66,Other,186% of Medicaid,111,,,111,Fee Schedule,,226.3,,,226.3,Fee Schedule,,62.83,,,62.83,Fee Schedule,,111,,,111,Fee Schedule,,226.3,,,226.3,Fee Schedule,,118.18,,,118.18,Fee Schedule,,255.5,70,,255.5,percent of total billed charges,All Other,141.79,,,141.79,Fee Schedule,,120.18,,,120.18,Fee Schedule,,44.88,,,44.88,Fee Schedule,,44.88,,,44.88,Fee Schedule,,44.88,,,44.88,Fee Schedule,,44.88,,,44.88,Fee Schedule,,35.34,,,35.34,Other,100% of Medicaid,35.34,,,35.34,Other,100% of Medicaid,35.34,,,35.34,Other,100% of Medicaid,35.34,,,35.34,Other,100% of Medicaid,79.52,,,79.52,Other,225% of Medicaid,54.07,,,54.07,Other,153% of Medicaid,79.52,,,79.52,Other,225% of Medicaid,49.48,,,49.48,Other,140% of Medicaid,79.52,,,79.52,Other,225% of Medicaid,91.89,,,91.89,Other,260% of Medicaid,114.51,,,114.51,Other,324% of Medicaid,75.98,,,75.98,Other,215% of Medicaid,75.98,,,75.98,Other,215% of Medicaid,44.18,,,44.18,Other,125% of Medicaid,35.34,270.1,
IA NFCT AB SARSCOV2 COVID19,86328,CPT,,78086328,CDM,302,RC,,,both,,,158,116.92,,,116.92,Other,150% of Medicare + 9.63% HCRA Surcharge,71.1,45,,71.1,percent of total billed charges,Critical Access Hospital RCC factor,136.29,,,136.29,Fee Schedule,,122.71,,,122.71,Fee Schedule,,18.09,,,18.09,Fee Schedule,,18.09,,,18.09,Fee Schedule,,18.09,,,18.09,Fee Schedule,,78.21,,,78.21,Other,110% of Medicare,142.63,,,142.63,Fee Schedule,,50,,,50,Other,186% of Medicaid,167.99,,,167.99,Fee Schedule,,97.96,,,97.96,Fee Schedule,,95.09,,,95.09,Fee Schedule,,167.99,,,167.99,Fee Schedule,,97.96,,,97.96,Fee Schedule,,178.86,,,178.86,Fee Schedule,,110.6,70,,110.6,percent of total billed charges,All Other,214.58,,,214.58,Fee Schedule,,181.87,,,181.87,Fee Schedule,,67.92,,,67.92,Fee Schedule,,67.92,,,67.92,Fee Schedule,,67.92,,,67.92,Fee Schedule,,67.92,,,67.92,Fee Schedule,,27.14,,,27.14,Other,100% of Medicaid,27.14,,,27.14,Other,100% of Medicaid,27.14,,,27.14,Other,100% of Medicaid,27.14,,,27.14,Other,100% of Medicaid,61.07,,,61.07,Other,225% of Medicaid,41.52,,,41.52,Other,153% of Medicaid,61.07,,,61.07,Other,225% of Medicaid,38,,,38,Other,140% of Medicaid,61.07,,,61.07,Other,225% of Medicaid,70.56,,,70.56,Other,260% of Medicaid,87.93,,,87.93,Other,324% of Medicaid,58.35,,,58.35,Other,215% of Medicaid,58.35,,,58.35,Other,215% of Medicaid,33.93,,,33.93,Other,125% of Medicaid,18.09,214.58,
IMMUNODIFFUSION,86329,CPT,,78086329,CDM,302,RC,,,both,,,147,108.78,,,108.78,Other,150% of Medicare + 9.63% HCRA Surcharge,66.15,45,,66.15,percent of total billed charges,Critical Access Hospital RCC factor,42.29,,,42.29,Fee Schedule,,38.08,,,38.08,Fee Schedule,,104.19,,,104.19,Fee Schedule,,93.71,,,93.71,Fee Schedule,,88.57,,,88.57,Fee Schedule,,72.77,,,72.77,Other,110% of Medicare,44.26,,,44.26,Fee Schedule,,23,,,23,Other,186% of Medicaid,52.13,,,52.13,Fee Schedule,,91.14,,,91.14,Fee Schedule,,29.51,,,29.51,Fee Schedule,,52.13,,,52.13,Fee Schedule,,91.14,,,91.14,Fee Schedule,,55.5,,,55.5,Fee Schedule,,102.9,70,,102.9,percent of total billed charges,All Other,66.58,,,66.58,Fee Schedule,,56.43,,,56.43,Fee Schedule,,21.08,,,21.08,Fee Schedule,,21.08,,,21.08,Fee Schedule,,21.08,,,21.08,Fee Schedule,,21.08,,,21.08,Fee Schedule,,12.63,,,12.63,Other,100% of Medicaid,12.63,,,12.63,Other,100% of Medicaid,12.63,,,12.63,Other,100% of Medicaid,12.63,,,12.63,Other,100% of Medicaid,28.41,,,28.41,Other,225% of Medicaid,19.32,,,19.32,Other,153% of Medicaid,28.41,,,28.41,Other,225% of Medicaid,17.68,,,17.68,Other,140% of Medicaid,28.41,,,28.41,Other,225% of Medicaid,32.83,,,32.83,Other,260% of Medicaid,40.91,,,40.91,Other,324% of Medicaid,27.14,,,27.14,Other,215% of Medicaid,27.14,,,27.14,Other,215% of Medicaid,15.78,,,15.78,Other,125% of Medicaid,12.63,108.78,
IMMUNODIFFUSION OUCHTERLONY,86331,CPT,,78086331,CDM,302,RC,,,both,,,147,108.78,,,108.78,Other,150% of Medicare + 9.63% HCRA Surcharge,66.15,45,,66.15,percent of total billed charges,Critical Access Hospital RCC factor,36.06,,,36.06,Fee Schedule,,32.47,,,32.47,Fee Schedule,,88.85,,,88.85,Fee Schedule,,79.92,,,79.92,Fee Schedule,,75.53,,,75.53,Fee Schedule,,72.77,,,72.77,Other,110% of Medicare,37.74,,,37.74,Fee Schedule,,18,,,18,Other,186% of Medicaid,44.45,,,44.45,Fee Schedule,,91.14,,,91.14,Fee Schedule,,25.16,,,25.16,Fee Schedule,,44.45,,,44.45,Fee Schedule,,91.14,,,91.14,Fee Schedule,,47.32,,,47.32,Fee Schedule,,102.9,70,,102.9,percent of total billed charges,All Other,56.77,,,56.77,Fee Schedule,,48.12,,,48.12,Fee Schedule,,17.97,,,17.97,Fee Schedule,,17.97,,,17.97,Fee Schedule,,17.97,,,17.97,Fee Schedule,,17.97,,,17.97,Fee Schedule,,9.88,,,9.88,Other,100% of Medicaid,9.88,,,9.88,Other,100% of Medicaid,9.88,,,9.88,Other,100% of Medicaid,9.88,,,9.88,Other,100% of Medicaid,22.23,,,22.23,Other,225% of Medicaid,15.11,,,15.11,Other,153% of Medicaid,22.23,,,22.23,Other,225% of Medicaid,13.83,,,13.83,Other,140% of Medicaid,22.23,,,22.23,Other,225% of Medicaid,25.68,,,25.68,Other,260% of Medicaid,32.01,,,32.01,Other,324% of Medicaid,21.24,,,21.24,Other,215% of Medicaid,21.24,,,21.24,Other,215% of Medicaid,12.35,,,12.35,Other,125% of Medicaid,9.88,108.78,
IMMUNE COMPLEX ASSAY,86332,CPT,,78086332,CDM,302,RC,,,both,,,196,145.04,,,145.04,Other,150% of Medicare + 9.63% HCRA Surcharge,88.2,45,,88.2,percent of total billed charges,Critical Access Hospital RCC factor,73.35,,,73.35,Fee Schedule,,66.04,,,66.04,Fee Schedule,,180.76,,,180.76,Fee Schedule,,162.58,,,162.58,Fee Schedule,,153.66,,,153.66,Fee Schedule,,97.02,,,97.02,Other,110% of Medicare,76.77,,,76.77,Fee Schedule,,18,,,18,Other,186% of Medicaid,90.41,,,90.41,Fee Schedule,,121.52,,,121.52,Fee Schedule,,51.18,,,51.18,Fee Schedule,,90.41,,,90.41,Fee Schedule,,121.52,,,121.52,Fee Schedule,,96.26,,,96.26,Fee Schedule,,137.2,70,,137.2,percent of total billed charges,All Other,115.49,,,115.49,Fee Schedule,,97.89,,,97.89,Fee Schedule,,36.56,,,36.56,Fee Schedule,,36.56,,,36.56,Fee Schedule,,36.56,,,36.56,Fee Schedule,,36.56,,,36.56,Fee Schedule,,9.88,,,9.88,Other,100% of Medicaid,9.88,,,9.88,Other,100% of Medicaid,9.88,,,9.88,Other,100% of Medicaid,9.88,,,9.88,Other,100% of Medicaid,22.23,,,22.23,Other,225% of Medicaid,15.11,,,15.11,Other,153% of Medicaid,22.23,,,22.23,Other,225% of Medicaid,13.83,,,13.83,Other,140% of Medicaid,22.23,,,22.23,Other,225% of Medicaid,25.68,,,25.68,Other,260% of Medicaid,32.01,,,32.01,Other,324% of Medicaid,21.24,,,21.24,Other,215% of Medicaid,21.24,,,21.24,Other,215% of Medicaid,12.35,,,12.35,Other,125% of Medicaid,9.88,180.76,
SERUM IMMUNOFIXATION ELECTROPH,86334,CPT,,78086334,CDM,302,RC,,,both,,,175,129.5,,,129.5,Other,150% of Medicare + 9.63% HCRA Surcharge,78.75,45,,78.75,percent of total billed charges,Critical Access Hospital RCC factor,67.24,,,67.24,Fee Schedule,,60.54,,,60.54,Fee Schedule,,165.69,,,165.69,Fee Schedule,,149.03,,,149.03,Fee Schedule,,140.85,,,140.85,Fee Schedule,,86.63,,,86.63,Other,110% of Medicare,70.37,,,70.37,Fee Schedule,,42,,,42,Other,186% of Medicaid,82.88,,,82.88,Fee Schedule,,108.5,,,108.5,Fee Schedule,,46.91,,,46.91,Fee Schedule,,82.88,,,82.88,Fee Schedule,,108.5,,,108.5,Fee Schedule,,88.24,,,88.24,Fee Schedule,,122.5,70,,122.5,percent of total billed charges,All Other,105.87,,,105.87,Fee Schedule,,89.73,,,89.73,Fee Schedule,,33.51,,,33.51,Fee Schedule,,33.51,,,33.51,Fee Schedule,,33.51,,,33.51,Fee Schedule,,33.51,,,33.51,Fee Schedule,,22.34,,,22.34,Other,100% of Medicaid,22.34,,,22.34,Other,100% of Medicaid,22.34,,,22.34,Other,100% of Medicaid,22.34,,,22.34,Other,100% of Medicaid,50.27,,,50.27,Other,225% of Medicaid,34.18,,,34.18,Other,153% of Medicaid,50.27,,,50.27,Other,225% of Medicaid,31.28,,,31.28,Other,140% of Medicaid,50.27,,,50.27,Other,225% of Medicaid,58.08,,,58.08,Other,260% of Medicaid,72.38,,,72.38,Other,324% of Medicaid,48.03,,,48.03,Other,215% of Medicaid,48.03,,,48.03,Other,215% of Medicaid,27.93,,,27.93,Other,125% of Medicaid,22.34,165.69,
INHIBIN A,86336,CPT,,78086336,CDM,302,RC,,,both,,,112,82.88,,,82.88,Other,150% of Medicare + 9.63% HCRA Surcharge,50.4,45,,50.4,percent of total billed charges,Critical Access Hospital RCC factor,46.93,,,46.93,Fee Schedule,,42.25,,,42.25,Fee Schedule,,115.57,,,115.57,Fee Schedule,,103.95,,,103.95,Fee Schedule,,98.25,,,98.25,Fee Schedule,,55.44,,,55.44,Other,110% of Medicare,49.11,,,49.11,Fee Schedule,,12,,,12,Other,186% of Medicaid,57.84,,,57.84,Fee Schedule,,69.44,,,69.44,Fee Schedule,,32.74,,,32.74,Fee Schedule,,57.84,,,57.84,Fee Schedule,,69.44,,,69.44,Fee Schedule,,61.58,,,61.58,Fee Schedule,,78.4,70,,78.4,percent of total billed charges,All Other,73.88,,,73.88,Fee Schedule,,62.62,,,62.62,Fee Schedule,,23.39,,,23.39,Fee Schedule,,23.39,,,23.39,Fee Schedule,,23.39,,,23.39,Fee Schedule,,23.39,,,23.39,Fee Schedule,,6.57,,,6.57,Other,100% of Medicaid,6.57,,,6.57,Other,100% of Medicaid,6.57,,,6.57,Other,100% of Medicaid,6.57,,,6.57,Other,100% of Medicaid,14.77,,,14.77,Other,225% of Medicaid,10.04,,,10.04,Other,153% of Medicaid,14.77,,,14.77,Other,225% of Medicaid,9.19,,,9.19,Other,140% of Medicaid,14.77,,,14.77,Other,225% of Medicaid,17.07,,,17.07,Other,260% of Medicaid,21.27,,,21.27,Other,324% of Medicaid,14.11,,,14.11,Other,215% of Medicaid,14.11,,,14.11,Other,215% of Medicaid,8.21,,,8.21,Other,125% of Medicaid,6.57,115.57,
INSULIN ANTIBODIES,86337,CPT,,78086337,CDM,302,RC,,,both,,,320,236.8,,,236.8,Other,150% of Medicare + 9.63% HCRA Surcharge,144,45,,144,percent of total billed charges,Critical Access Hospital RCC factor,64.44,,,64.44,Fee Schedule,,58.02,,,58.02,Fee Schedule,,158.79,,,158.79,Fee Schedule,,142.82,,,142.82,Fee Schedule,,134.98,,,134.98,Fee Schedule,,158.4,,,158.4,Other,110% of Medicare,67.44,,,67.44,Fee Schedule,,23,,,23,Other,186% of Medicaid,79.43,,,79.43,Fee Schedule,,198.4,,,198.4,Fee Schedule,,44.96,,,44.96,Fee Schedule,,79.43,,,79.43,Fee Schedule,,198.4,,,198.4,Fee Schedule,,84.57,,,84.57,Fee Schedule,,224,70,,224,percent of total billed charges,All Other,101.46,,,101.46,Fee Schedule,,86,,,86,Fee Schedule,,32.12,,,32.12,Fee Schedule,,32.12,,,32.12,Fee Schedule,,32.12,,,32.12,Fee Schedule,,32.12,,,32.12,Fee Schedule,,12.63,,,12.63,Other,100% of Medicaid,12.63,,,12.63,Other,100% of Medicaid,12.63,,,12.63,Other,100% of Medicaid,12.63,,,12.63,Other,100% of Medicaid,28.41,,,28.41,Other,225% of Medicaid,19.32,,,19.32,Other,153% of Medicaid,28.41,,,28.41,Other,225% of Medicaid,17.68,,,17.68,Other,140% of Medicaid,28.41,,,28.41,Other,225% of Medicaid,32.83,,,32.83,Other,260% of Medicaid,40.91,,,40.91,Other,324% of Medicaid,27.14,,,27.14,Other,215% of Medicaid,27.14,,,27.14,Other,215% of Medicaid,15.78,,,15.78,Other,125% of Medicaid,12.63,236.8,
INTRINSIC FACTOR ANTIBODY,86340,CPT,,78086340,CDM,302,RC,,,both,,,266,196.84,,,196.84,Other,150% of Medicare + 9.63% HCRA Surcharge,119.7,45,,119.7,percent of total billed charges,Critical Access Hospital RCC factor,45.39,,,45.39,Fee Schedule,,40.87,,,40.87,Fee Schedule,,111.78,,,111.78,Fee Schedule,,100.54,,,100.54,Fee Schedule,,95.02,,,95.02,Fee Schedule,,131.67,,,131.67,Other,110% of Medicare,47.5,,,47.5,Fee Schedule,,21,,,21,Other,186% of Medicaid,55.95,,,55.95,Fee Schedule,,164.92,,,164.92,Fee Schedule,,31.67,,,31.67,Fee Schedule,,55.95,,,55.95,Fee Schedule,,164.92,,,164.92,Fee Schedule,,59.57,,,59.57,Fee Schedule,,186.2,70,,186.2,percent of total billed charges,All Other,71.46,,,71.46,Fee Schedule,,60.57,,,60.57,Fee Schedule,,22.62,,,22.62,Fee Schedule,,22.62,,,22.62,Fee Schedule,,22.62,,,22.62,Fee Schedule,,22.62,,,22.62,Fee Schedule,,11.47,,,11.47,Other,100% of Medicaid,11.47,,,11.47,Other,100% of Medicaid,11.47,,,11.47,Other,100% of Medicaid,11.47,,,11.47,Other,100% of Medicaid,25.82,,,25.82,Other,225% of Medicaid,17.55,,,17.55,Other,153% of Medicaid,25.82,,,25.82,Other,225% of Medicaid,16.06,,,16.06,Other,140% of Medicaid,25.82,,,25.82,Other,225% of Medicaid,29.83,,,29.83,Other,260% of Medicaid,37.17,,,37.17,Other,324% of Medicaid,24.67,,,24.67,Other,215% of Medicaid,24.67,,,24.67,Other,215% of Medicaid,14.34,,,14.34,Other,125% of Medicaid,11.47,196.84,
ISLET CELL ANTIBODY,86341,CPT,,78086341,CDM,302,RC,,,both,,,314,232.36,,,232.36,Other,150% of Medicare + 9.63% HCRA Surcharge,141.3,45,,141.3,percent of total billed charges,Critical Access Hospital RCC factor,70.95,,,70.95,Fee Schedule,,63.87,,,63.87,Fee Schedule,,146.77,,,146.77,Fee Schedule,,132.01,,,132.01,Fee Schedule,,124.77,,,124.77,Fee Schedule,,155.43,,,155.43,Other,110% of Medicare,74.25,,,74.25,Fee Schedule,,23,,,23,Other,186% of Medicaid,87.44,,,87.44,Fee Schedule,,194.68,,,194.68,Fee Schedule,,49.5,,,49.5,Fee Schedule,,87.44,,,87.44,Fee Schedule,,194.68,,,194.68,Fee Schedule,,93.1,,,93.1,Fee Schedule,,219.8,70,,219.8,percent of total billed charges,All Other,111.7,,,111.7,Fee Schedule,,94.67,,,94.67,Fee Schedule,,35.36,,,35.36,Fee Schedule,,35.36,,,35.36,Fee Schedule,,35.36,,,35.36,Fee Schedule,,35.36,,,35.36,Fee Schedule,,12.63,,,12.63,Other,100% of Medicaid,12.63,,,12.63,Other,100% of Medicaid,12.63,,,12.63,Other,100% of Medicaid,12.63,,,12.63,Other,100% of Medicaid,28.41,,,28.41,Other,225% of Medicaid,19.32,,,19.32,Other,153% of Medicaid,28.41,,,28.41,Other,225% of Medicaid,17.68,,,17.68,Other,140% of Medicaid,28.41,,,28.41,Other,225% of Medicaid,32.83,,,32.83,Other,260% of Medicaid,40.91,,,40.91,Other,324% of Medicaid,27.14,,,27.14,Other,215% of Medicaid,27.14,,,27.14,Other,215% of Medicaid,15.78,,,15.78,Other,125% of Medicaid,12.63,232.36,
LHR TEST,86343,CPT,,78086343,CDM,302,RC,,,both,,,38,28.12,,,28.12,Other,150% of Medicare + 9.63% HCRA Surcharge,17.1,45,,17.1,percent of total billed charges,Critical Access Hospital RCC factor,37.5,,,37.5,Fee Schedule,,33.77,,,33.77,Fee Schedule,,47.59,,,47.59,Fee Schedule,,42.8,,,42.8,Fee Schedule,,40.45,,,40.45,Fee Schedule,,18.81,,,18.81,Other,110% of Medicare,39.25,,,39.25,Fee Schedule,,18,,,18,Other,186% of Medicaid,46.23,,,46.23,Fee Schedule,,23.56,,,23.56,Fee Schedule,,26.17,,,26.17,Fee Schedule,,46.23,,,46.23,Fee Schedule,,23.56,,,23.56,Fee Schedule,,49.22,,,49.22,Fee Schedule,,26.6,70,,26.6,percent of total billed charges,All Other,59.05,,,59.05,Fee Schedule,,50.05,,,50.05,Fee Schedule,,18.69,,,18.69,Fee Schedule,,18.69,,,18.69,Fee Schedule,,18.69,,,18.69,Fee Schedule,,18.69,,,18.69,Fee Schedule,,9.88,,,9.88,Other,100% of Medicaid,9.88,,,9.88,Other,100% of Medicaid,9.88,,,9.88,Other,100% of Medicaid,9.88,,,9.88,Other,100% of Medicaid,22.23,,,22.23,Other,225% of Medicaid,15.11,,,15.11,Other,153% of Medicaid,22.23,,,22.23,Other,225% of Medicaid,13.83,,,13.83,Other,140% of Medicaid,22.23,,,22.23,Other,225% of Medicaid,25.68,,,25.68,Other,260% of Medicaid,32.01,,,32.01,Other,324% of Medicaid,21.24,,,21.24,Other,215% of Medicaid,21.24,,,21.24,Other,215% of Medicaid,12.35,,,12.35,Other,125% of Medicaid,9.88,59.05,
CELL FUNCTION ASSAY W/STIM,86352,CPT,,78086352,CDM,302,RC,,,both,,,429,317.46,,,317.46,Other,150% of Medicare + 9.63% HCRA Surcharge,193.05,45,,193.05,percent of total billed charges,Critical Access Hospital RCC factor,408.94,,,408.94,Fee Schedule,,368.18,,,368.18,Fee Schedule,,1007.57,,,1007.57,Fee Schedule,,906.24,,,906.24,Fee Schedule,,856.53,,,856.53,Fee Schedule,,212.36,,,212.36,Other,110% of Medicare,427.96,,,427.96,Fee Schedule,,66,,,66,Other,186% of Medicaid,504.04,,,504.04,Fee Schedule,,265.98,,,265.98,Fee Schedule,,285.31,,,285.31,Fee Schedule,,504.04,,,504.04,Fee Schedule,,265.98,,,265.98,Fee Schedule,,536.65,,,536.65,Fee Schedule,,300.3,70,,300.3,percent of total billed charges,All Other,643.85,,,643.85,Fee Schedule,,545.7,,,545.7,Fee Schedule,,203.79,,,203.79,Fee Schedule,,203.79,,,203.79,Fee Schedule,,203.79,,,203.79,Fee Schedule,,203.79,,,203.79,Fee Schedule,,35.34,,,35.34,Other,100% of Medicaid,35.34,,,35.34,Other,100% of Medicaid,35.34,,,35.34,Other,100% of Medicaid,35.34,,,35.34,Other,100% of Medicaid,79.52,,,79.52,Other,225% of Medicaid,54.07,,,54.07,Other,153% of Medicaid,79.52,,,79.52,Other,225% of Medicaid,49.48,,,49.48,Other,140% of Medicaid,79.52,,,79.52,Other,225% of Medicaid,91.89,,,91.89,Other,260% of Medicaid,114.51,,,114.51,Other,324% of Medicaid,75.98,,,75.98,Other,215% of Medicaid,75.98,,,75.98,Other,215% of Medicaid,44.18,,,44.18,Other,125% of Medicaid,35.34,1007.57,
LYMPHOCYTE TRANSFORMATION,86353,CPT,,78086353,CDM,302,RC,,,both,,,156,115.44,,,115.44,Other,150% of Medicare + 9.63% HCRA Surcharge,70.2,45,,70.2,percent of total billed charges,Critical Access Hospital RCC factor,147.58,,,147.58,Fee Schedule,,132.87,,,132.87,Fee Schedule,,363.58,,,363.58,Fee Schedule,,327.01,,,327.01,Fee Schedule,,309.08,,,309.08,Fee Schedule,,77.22,,,77.22,Other,110% of Medicare,154.44,,,154.44,Fee Schedule,,66,,,66,Other,186% of Medicaid,181.9,,,181.9,Fee Schedule,,96.72,,,96.72,Fee Schedule,,102.96,,,102.96,Fee Schedule,,181.9,,,181.9,Fee Schedule,,96.72,,,96.72,Fee Schedule,,193.67,,,193.67,Fee Schedule,,109.2,70,,109.2,percent of total billed charges,All Other,232.35,,,232.35,Fee Schedule,,196.93,,,196.93,Fee Schedule,,73.55,,,73.55,Fee Schedule,,73.55,,,73.55,Fee Schedule,,73.55,,,73.55,Fee Schedule,,73.55,,,73.55,Fee Schedule,,35.34,,,35.34,Other,100% of Medicaid,35.34,,,35.34,Other,100% of Medicaid,35.34,,,35.34,Other,100% of Medicaid,35.34,,,35.34,Other,100% of Medicaid,79.52,,,79.52,Other,225% of Medicaid,54.07,,,54.07,Other,153% of Medicaid,79.52,,,79.52,Other,225% of Medicaid,49.48,,,49.48,Other,140% of Medicaid,79.52,,,79.52,Other,225% of Medicaid,91.89,,,91.89,Other,260% of Medicaid,114.51,,,114.51,Other,324% of Medicaid,75.98,,,75.98,Other,215% of Medicaid,75.98,,,75.98,Other,215% of Medicaid,44.18,,,44.18,Other,125% of Medicaid,35.34,363.58,
B CELLS TOTAL COUNT,86355,CPT,,78086355,CDM,302,RC,,,both,,,240,177.6,,,177.6,Other,150% of Medicare + 9.63% HCRA Surcharge,108,45,,108,percent of total billed charges,Critical Access Hospital RCC factor,113.57,,,113.57,Fee Schedule,,102.25,,,102.25,Fee Schedule,,279.73,,,279.73,Fee Schedule,,251.6,,,251.6,Fee Schedule,,237.8,,,237.8,Fee Schedule,,118.8,,,118.8,Other,110% of Medicare,118.85,,,118.85,Fee Schedule,,44,,,44,Other,186% of Medicaid,139.98,,,139.98,Fee Schedule,,148.8,,,148.8,Fee Schedule,,79.23,,,79.23,Fee Schedule,,139.98,,,139.98,Fee Schedule,,148.8,,,148.8,Fee Schedule,,149.03,,,149.03,Fee Schedule,,168,70,,168,percent of total billed charges,All Other,178.8,,,178.8,Fee Schedule,,151.55,,,151.55,Fee Schedule,,56.6,,,56.6,Fee Schedule,,56.6,,,56.6,Fee Schedule,,56.6,,,56.6,Fee Schedule,,56.6,,,56.6,Fee Schedule,,23.4,,,23.4,Other,100% of Medicaid,23.4,,,23.4,Other,100% of Medicaid,23.4,,,23.4,Other,100% of Medicaid,23.4,,,23.4,Other,100% of Medicaid,52.65,,,52.65,Other,225% of Medicaid,35.8,,,35.8,Other,153% of Medicaid,52.65,,,52.65,Other,225% of Medicaid,32.76,,,32.76,Other,140% of Medicaid,52.65,,,52.65,Other,225% of Medicaid,60.84,,,60.84,Other,260% of Medicaid,75.82,,,75.82,Other,324% of Medicaid,50.31,,,50.31,Other,215% of Medicaid,50.31,,,50.31,Other,215% of Medicaid,29.25,,,29.25,Other,125% of Medicaid,23.4,279.73,
MONONUCLEAR CELL ANTIGEN,86356,CPT,,78086356,CDM,302,RC,,,both,,,172,127.28,,,127.28,Other,150% of Medicare + 9.63% HCRA Surcharge,77.4,45,,77.4,percent of total billed charges,Critical Access Hospital RCC factor,80.61,,,80.61,Fee Schedule,,72.57,,,72.57,Fee Schedule,,198.52,,,198.52,Fee Schedule,,178.56,,,178.56,Fee Schedule,,168.76,,,168.76,Fee Schedule,,85.14,,,85.14,Other,110% of Medicare,84.36,,,84.36,Fee Schedule,,66,,,66,Other,186% of Medicaid,99.35,,,99.35,Fee Schedule,,106.64,,,106.64,Fee Schedule,,56.24,,,56.24,Fee Schedule,,99.35,,,99.35,Fee Schedule,,106.64,,,106.64,Fee Schedule,,105.78,,,105.78,Fee Schedule,,120.4,70,,120.4,percent of total billed charges,All Other,126.91,,,126.91,Fee Schedule,,107.57,,,107.57,Fee Schedule,,40.17,,,40.17,Fee Schedule,,40.17,,,40.17,Fee Schedule,,40.17,,,40.17,Fee Schedule,,40.17,,,40.17,Fee Schedule,,35.34,,,35.34,Other,100% of Medicaid,35.34,,,35.34,Other,100% of Medicaid,35.34,,,35.34,Other,100% of Medicaid,35.34,,,35.34,Other,100% of Medicaid,79.52,,,79.52,Other,225% of Medicaid,54.07,,,54.07,Other,153% of Medicaid,79.52,,,79.52,Other,225% of Medicaid,49.48,,,49.48,Other,140% of Medicaid,79.52,,,79.52,Other,225% of Medicaid,91.89,,,91.89,Other,260% of Medicaid,114.51,,,114.51,Other,324% of Medicaid,75.98,,,75.98,Other,215% of Medicaid,75.98,,,75.98,Other,215% of Medicaid,44.18,,,44.18,Other,125% of Medicaid,35.34,198.52,
NK CELLS TOTAL COUNT,86357,CPT,,78086357,CDM,302,RC,,,both,,,198,146.52,,,146.52,Other,150% of Medicare + 9.63% HCRA Surcharge,89.1,45,,89.1,percent of total billed charges,Critical Access Hospital RCC factor,113.57,,,113.57,Fee Schedule,,102.25,,,102.25,Fee Schedule,,279.73,,,279.73,Fee Schedule,,251.6,,,251.6,Fee Schedule,,237.8,,,237.8,Fee Schedule,,98.01,,,98.01,Other,110% of Medicare,118.85,,,118.85,Fee Schedule,,44,,,44,Other,186% of Medicaid,139.98,,,139.98,Fee Schedule,,122.76,,,122.76,Fee Schedule,,79.23,,,79.23,Fee Schedule,,139.98,,,139.98,Fee Schedule,,122.76,,,122.76,Fee Schedule,,149.03,,,149.03,Fee Schedule,,138.6,70,,138.6,percent of total billed charges,All Other,178.8,,,178.8,Fee Schedule,,151.55,,,151.55,Fee Schedule,,56.6,,,56.6,Fee Schedule,,56.6,,,56.6,Fee Schedule,,56.6,,,56.6,Fee Schedule,,56.6,,,56.6,Fee Schedule,,23.4,,,23.4,Other,100% of Medicaid,23.4,,,23.4,Other,100% of Medicaid,23.4,,,23.4,Other,100% of Medicaid,23.4,,,23.4,Other,100% of Medicaid,52.65,,,52.65,Other,225% of Medicaid,35.8,,,35.8,Other,153% of Medicaid,52.65,,,52.65,Other,225% of Medicaid,32.76,,,32.76,Other,140% of Medicaid,52.65,,,52.65,Other,225% of Medicaid,60.84,,,60.84,Other,260% of Medicaid,75.82,,,75.82,Other,324% of Medicaid,50.31,,,50.31,Other,215% of Medicaid,50.31,,,50.31,Other,215% of Medicaid,29.25,,,29.25,Other,125% of Medicaid,23.4,279.73,
T CELLS TOTAL COUNT,86359,CPT,,78086359,CDM,302,RC,,,both,,,240,177.6,,,177.6,Other,150% of Medicare + 9.63% HCRA Surcharge,108,45,,108,percent of total billed charges,Critical Access Hospital RCC factor,113.57,,,113.57,Fee Schedule,,102.25,,,102.25,Fee Schedule,,279.73,,,279.73,Fee Schedule,,251.6,,,251.6,Fee Schedule,,237.8,,,237.8,Fee Schedule,,118.8,,,118.8,Other,110% of Medicare,118.85,,,118.85,Fee Schedule,,44,,,44,Other,186% of Medicaid,139.98,,,139.98,Fee Schedule,,148.8,,,148.8,Fee Schedule,,79.23,,,79.23,Fee Schedule,,139.98,,,139.98,Fee Schedule,,148.8,,,148.8,Fee Schedule,,149.03,,,149.03,Fee Schedule,,168,70,,168,percent of total billed charges,All Other,178.8,,,178.8,Fee Schedule,,151.55,,,151.55,Fee Schedule,,56.6,,,56.6,Fee Schedule,,56.6,,,56.6,Fee Schedule,,56.6,,,56.6,Fee Schedule,,56.6,,,56.6,Fee Schedule,,23.4,,,23.4,Other,100% of Medicaid,23.4,,,23.4,Other,100% of Medicaid,23.4,,,23.4,Other,100% of Medicaid,23.4,,,23.4,Other,100% of Medicaid,52.65,,,52.65,Other,225% of Medicaid,35.8,,,35.8,Other,153% of Medicaid,52.65,,,52.65,Other,225% of Medicaid,32.76,,,32.76,Other,140% of Medicaid,52.65,,,52.65,Other,225% of Medicaid,60.84,,,60.84,Other,260% of Medicaid,75.82,,,75.82,Other,324% of Medicaid,50.31,,,50.31,Other,215% of Medicaid,50.31,,,50.31,Other,215% of Medicaid,29.25,,,29.25,Other,125% of Medicaid,23.4,279.73,
T CELL ABSOLUTE COUNT/RATIO,86360,CPT,,78086360,CDM,302,RC,,,both,,,365,270.1,,,270.1,Other,150% of Medicare + 9.63% HCRA Surcharge,164.25,45,,164.25,percent of total billed charges,Critical Access Hospital RCC factor,141.41,,,141.41,Fee Schedule,,127.32,,,127.32,Fee Schedule,,348.45,,,348.45,Fee Schedule,,313.41,,,313.41,Fee Schedule,,296.22,,,296.22,Fee Schedule,,180.68,,,180.68,Other,110% of Medicare,147.99,,,147.99,Fee Schedule,,87,,,87,Other,186% of Medicaid,174.3,,,174.3,Fee Schedule,,226.3,,,226.3,Fee Schedule,,98.66,,,98.66,Fee Schedule,,174.3,,,174.3,Fee Schedule,,226.3,,,226.3,Fee Schedule,,185.57,,,185.57,Fee Schedule,,255.5,70,,255.5,percent of total billed charges,All Other,222.64,,,222.64,Fee Schedule,,188.7,,,188.7,Fee Schedule,,70.47,,,70.47,Fee Schedule,,70.47,,,70.47,Fee Schedule,,70.47,,,70.47,Fee Schedule,,70.47,,,70.47,Fee Schedule,,46.98,,,46.98,Other,100% of Medicaid,46.98,,,46.98,Other,100% of Medicaid,46.98,,,46.98,Other,100% of Medicaid,46.98,,,46.98,Other,100% of Medicaid,105.71,,,105.71,Other,225% of Medicaid,71.88,,,71.88,Other,153% of Medicaid,105.71,,,105.71,Other,225% of Medicaid,65.77,,,65.77,Other,140% of Medicaid,105.71,,,105.71,Other,225% of Medicaid,122.15,,,122.15,Other,260% of Medicaid,152.22,,,152.22,Other,324% of Medicaid,101.01,,,101.01,Other,215% of Medicaid,101.01,,,101.01,Other,215% of Medicaid,58.73,,,58.73,Other,125% of Medicaid,46.98,348.45,
T CELL ABSOLUTE COUNT,86361,CPT,,78086361,CDM,302,RC,,,both,,,160,118.4,,,118.4,Other,150% of Medicare + 9.63% HCRA Surcharge,72,45,,72,percent of total billed charges,Critical Access Hospital RCC factor,80.61,,,80.61,Fee Schedule,,72.57,,,72.57,Fee Schedule,,198.52,,,198.52,Fee Schedule,,178.56,,,178.56,Fee Schedule,,168.76,,,168.76,Fee Schedule,,79.2,,,79.2,Other,110% of Medicare,84.36,,,84.36,Fee Schedule,,44,,,44,Other,186% of Medicaid,99.35,,,99.35,Fee Schedule,,99.2,,,99.2,Fee Schedule,,56.24,,,56.24,Fee Schedule,,99.35,,,99.35,Fee Schedule,,99.2,,,99.2,Fee Schedule,,105.78,,,105.78,Fee Schedule,,112,70,,112,percent of total billed charges,All Other,126.91,,,126.91,Fee Schedule,,107.57,,,107.57,Fee Schedule,,40.17,,,40.17,Fee Schedule,,40.17,,,40.17,Fee Schedule,,40.17,,,40.17,Fee Schedule,,40.17,,,40.17,Fee Schedule,,23.4,,,23.4,Other,100% of Medicaid,23.4,,,23.4,Other,100% of Medicaid,23.4,,,23.4,Other,100% of Medicaid,23.4,,,23.4,Other,100% of Medicaid,52.65,,,52.65,Other,225% of Medicaid,35.8,,,35.8,Other,153% of Medicaid,52.65,,,52.65,Other,225% of Medicaid,32.76,,,32.76,Other,140% of Medicaid,52.65,,,52.65,Other,225% of Medicaid,60.84,,,60.84,Other,260% of Medicaid,75.82,,,75.82,Other,324% of Medicaid,50.31,,,50.31,Other,215% of Medicaid,50.31,,,50.31,Other,215% of Medicaid,29.25,,,29.25,Other,125% of Medicaid,23.4,198.52,
MOG-IGG1 ANTB CBA EACH,86362,CPT,,78086362,CDM,302,RC,,,both,,,39,28.86,,,28.86,Other,150% of Medicare + 9.63% HCRA Surcharge,17.55,45,,17.55,percent of total billed charges,Critical Access Hospital RCC factor,36.27,,,36.27,Fee Schedule,,32.66,,,32.66,Fee Schedule,,12.05,,,12.05,Fee Schedule,,12.05,,,12.05,Fee Schedule,,12.05,,,12.05,Fee Schedule,,19.31,,,19.31,Other,110% of Medicare,37.96,,,37.96,Fee Schedule,,18,,,18,Other,186% of Medicaid,44.71,,,44.71,Fee Schedule,,24.18,,,24.18,Fee Schedule,,25.31,,,25.31,Fee Schedule,,44.71,,,44.71,Fee Schedule,,24.18,,,24.18,Fee Schedule,,47.6,,,47.6,Fee Schedule,,27.3,70,,27.3,percent of total billed charges,All Other,57.11,,,57.11,Fee Schedule,,48.4,,,48.4,Fee Schedule,,18.08,,,18.08,Fee Schedule,,18.08,,,18.08,Fee Schedule,,18.08,,,18.08,Fee Schedule,,18.08,,,18.08,Fee Schedule,,9.88,,,9.88,Other,100% of Medicaid,9.88,,,9.88,Other,100% of Medicaid,9.88,,,9.88,Other,100% of Medicaid,9.88,,,9.88,Other,100% of Medicaid,22.23,,,22.23,Other,225% of Medicaid,15.11,,,15.11,Other,153% of Medicaid,22.23,,,22.23,Other,225% of Medicaid,13.83,,,13.83,Other,140% of Medicaid,22.23,,,22.23,Other,225% of Medicaid,25.68,,,25.68,Other,260% of Medicaid,32.01,,,32.01,Other,324% of Medicaid,21.24,,,21.24,Other,215% of Medicaid,21.24,,,21.24,Other,215% of Medicaid,12.35,,,12.35,Other,125% of Medicaid,9.88,57.11,
MOG-IGG1 ANTB FLO CYTMTRY EA,86363,CPT,,78086363,CDM,302,RC,,,both,,,77,56.98,,,56.98,Other,150% of Medicare + 9.63% HCRA Surcharge,34.65,45,,34.65,percent of total billed charges,Critical Access Hospital RCC factor,113.57,,,113.57,Fee Schedule,,102.25,,,102.25,Fee Schedule,,12.05,,,12.05,Fee Schedule,,12.05,,,12.05,Fee Schedule,,12.05,,,12.05,Fee Schedule,,38.12,,,38.12,Other,110% of Medicare,118.85,,,118.85,Fee Schedule,,14,,,14,Other,186% of Medicaid,139.98,,,139.98,Fee Schedule,,47.74,,,47.74,Fee Schedule,,79.23,,,79.23,Fee Schedule,,139.98,,,139.98,Fee Schedule,,47.74,,,47.74,Fee Schedule,,149.03,,,149.03,Fee Schedule,,53.9,70,,53.9,percent of total billed charges,All Other,57.11,,,57.11,Fee Schedule,,48.4,,,48.4,Fee Schedule,,18.08,,,18.08,Fee Schedule,,18.08,,,18.08,Fee Schedule,,18.08,,,18.08,Fee Schedule,,18.08,,,18.08,Fee Schedule,,7.3,,,7.3,Other,100% of Medicaid,7.3,,,7.3,Other,100% of Medicaid,7.3,,,7.3,Other,100% of Medicaid,7.3,,,7.3,Other,100% of Medicaid,16.43,,,16.43,Other,225% of Medicaid,11.17,,,11.17,Other,153% of Medicaid,16.43,,,16.43,Other,225% of Medicaid,10.22,,,10.22,Other,140% of Medicaid,16.43,,,16.43,Other,225% of Medicaid,18.99,,,18.99,Other,260% of Medicaid,23.66,,,23.66,Other,324% of Medicaid,15.7,,,15.7,Other,215% of Medicaid,15.7,,,15.7,Other,215% of Medicaid,9.13,,,9.13,Other,125% of Medicaid,7.3,149.03,
STEM CELLS TOTAL COUNT,86367,CPT,,78086367,CDM,302,RC,,,both,,,246,182.04,,,182.04,Other,150% of Medicare + 9.63% HCRA Surcharge,110.7,45,,110.7,percent of total billed charges,Critical Access Hospital RCC factor,234.12,,,234.12,Fee Schedule,,210.78,,,210.78,Fee Schedule,,279.73,,,279.73,Fee Schedule,,251.6,,,251.6,Fee Schedule,,237.8,,,237.8,Fee Schedule,,121.77,,,121.77,Other,110% of Medicare,245.01,,,245.01,Fee Schedule,,44,,,44,Other,186% of Medicaid,288.56,,,288.56,Fee Schedule,,152.52,,,152.52,Fee Schedule,,163.34,,,163.34,Fee Schedule,,288.56,,,288.56,Fee Schedule,,152.52,,,152.52,Fee Schedule,,307.23,,,307.23,Fee Schedule,,172.2,70,,172.2,percent of total billed charges,All Other,368.6,,,368.6,Fee Schedule,,312.41,,,312.41,Fee Schedule,,116.67,,,116.67,Fee Schedule,,116.67,,,116.67,Fee Schedule,,116.67,,,116.67,Fee Schedule,,116.67,,,116.67,Fee Schedule,,23.4,,,23.4,Other,100% of Medicaid,23.4,,,23.4,Other,100% of Medicaid,23.4,,,23.4,Other,100% of Medicaid,23.4,,,23.4,Other,100% of Medicaid,52.65,,,52.65,Other,225% of Medicaid,35.8,,,35.8,Other,153% of Medicaid,52.65,,,52.65,Other,225% of Medicaid,32.76,,,32.76,Other,140% of Medicaid,52.65,,,52.65,Other,225% of Medicaid,60.84,,,60.84,Other,260% of Medicaid,75.82,,,75.82,Other,324% of Medicaid,50.31,,,50.31,Other,215% of Medicaid,50.31,,,50.31,Other,215% of Medicaid,29.25,,,29.25,Other,125% of Medicaid,23.4,368.6,
MICROSOMAL ATIBODY,86376,CPT,,78086376,CDM,302,RC,,,both,,,155,114.7,,,114.7,Other,150% of Medicare + 9.63% HCRA Surcharge,69.75,45,,69.75,percent of total billed charges,Critical Access Hospital RCC factor,43.8,,,43.8,Fee Schedule,,39.43,,,39.43,Fee Schedule,,107.93,,,107.93,Fee Schedule,,97.08,,,97.08,Fee Schedule,,91.75,,,91.75,Fee Schedule,,76.73,,,76.73,Other,110% of Medicare,45.83,,,45.83,Fee Schedule,,27,,,27,Other,186% of Medicaid,53.98,,,53.98,Fee Schedule,,96.1,,,96.1,Fee Schedule,,30.56,,,30.56,Fee Schedule,,53.98,,,53.98,Fee Schedule,,96.1,,,96.1,Fee Schedule,,57.47,,,57.47,Fee Schedule,,108.5,70,,108.5,percent of total billed charges,All Other,68.95,,,68.95,Fee Schedule,,58.44,,,58.44,Fee Schedule,,21.83,,,21.83,Fee Schedule,,21.83,,,21.83,Fee Schedule,,21.83,,,21.83,Fee Schedule,,21.83,,,21.83,Fee Schedule,,14.55,,,14.55,Other,100% of Medicaid,14.55,,,14.55,Other,100% of Medicaid,14.55,,,14.55,Other,100% of Medicaid,14.55,,,14.55,Other,100% of Medicaid,32.74,,,32.74,Other,225% of Medicaid,22.26,,,22.26,Other,153% of Medicaid,32.74,,,32.74,Other,225% of Medicaid,20.37,,,20.37,Other,140% of Medicaid,32.74,,,32.74,Other,225% of Medicaid,37.83,,,37.83,Other,260% of Medicaid,47.14,,,47.14,Other,324% of Medicaid,31.28,,,31.28,Other,215% of Medicaid,31.28,,,31.28,Other,215% of Medicaid,18.19,,,18.19,Other,125% of Medicaid,14.55,114.7,
MIGRATION INHIBITORY FACTOR,86378,CPT,,78086378,CDM,302,RC,,,both,,,138,102.12,,,102.12,Other,150% of Medicare + 9.63% HCRA Surcharge,62.1,45,,62.1,percent of total billed charges,Critical Access Hospital RCC factor,89.7,65,,89.7,percent of total billed charges,All Other,81.42,65,,81.42,percent of total billed charges,All Other,6.3,,,6.3,Fee Schedule,,6.3,,,6.3,Fee Schedule,,6.3,,,6.3,Fee Schedule,,68.31,,,68.31,Other,110% of Medicare,93.84,68,,93.84,percent of total billed charges,All Other,66,,,66,Other,186% of Medicaid,114.54,83,,114.54,percent of total billed charges,All Other,85.56,62,,85.56,percent of total billed charges,Lab and Radiology,75.9,55,,75.9,percent of total billed charges,Default if not on Fee Schedule,110.4,80,,110.4,percent of total billed charges,All Other,85.56,62,,85.56,percent of total billed charges,Lab and Radiology,110.4,80,,110.4,percent of total billed charges,All Other,96.6,70,,96.6,percent of total billed charges,All Other,89.7,65,,89.7,percent of total billed charges,Default if not in Fee Schedule,89.7,65,,89.7,percent of total billed charges,Default if not in Fee Schedule,69,,,69,Fee Schedule,,69,,,69,Fee Schedule,,69,,,69,Fee Schedule,,69,,,69,Fee Schedule,,35.34,,,35.34,Other,100% of Medicaid,35.34,,,35.34,Other,100% of Medicaid,35.34,,,35.34,Other,100% of Medicaid,35.34,,,35.34,Other,100% of Medicaid,79.52,,,79.52,Other,225% of Medicaid,54.07,,,54.07,Other,153% of Medicaid,79.52,,,79.52,Other,225% of Medicaid,49.48,,,49.48,Other,140% of Medicaid,79.52,,,79.52,Other,225% of Medicaid,91.89,,,91.89,Other,260% of Medicaid,114.51,,,114.51,Other,324% of Medicaid,75.98,,,75.98,Other,215% of Medicaid,75.98,,,75.98,Other,215% of Medicaid,44.18,,,44.18,Other,125% of Medicaid,6.3,114.54,
NEUTRALIZATION TEST VIRAL,86382,CPT,,78086382,CDM,302,RC,,,both,,,186,137.64,,,137.64,Other,150% of Medicare + 9.63% HCRA Surcharge,83.7,45,,83.7,percent of total billed charges,Critical Access Hospital RCC factor,50.9,,,50.9,Fee Schedule,,45.83,,,45.83,Fee Schedule,,125.43,,,125.43,Fee Schedule,,112.81,,,112.81,Fee Schedule,,106.62,,,106.62,Fee Schedule,,92.07,,,92.07,Other,110% of Medicare,53.27,,,53.27,Fee Schedule,,9,,,9,Other,186% of Medicaid,62.74,,,62.74,Fee Schedule,,115.32,,,115.32,Fee Schedule,,35.51,,,35.51,Fee Schedule,,62.74,,,62.74,Fee Schedule,,115.32,,,115.32,Fee Schedule,,66.79,,,66.79,Fee Schedule,,130.2,70,,130.2,percent of total billed charges,All Other,80.14,,,80.14,Fee Schedule,,67.92,,,67.92,Fee Schedule,,25.37,,,25.37,Fee Schedule,,25.37,,,25.37,Fee Schedule,,25.37,,,25.37,Fee Schedule,,25.37,,,25.37,Fee Schedule,,5.05,,,5.05,Other,100% of Medicaid,5.05,,,5.05,Other,100% of Medicaid,5.05,,,5.05,Other,100% of Medicaid,5.05,,,5.05,Other,100% of Medicaid,11.36,,,11.36,Other,225% of Medicaid,7.73,,,7.73,Other,153% of Medicaid,11.36,,,11.36,Other,225% of Medicaid,7.07,,,7.07,Other,140% of Medicaid,11.36,,,11.36,Other,225% of Medicaid,13.13,,,13.13,Other,260% of Medicaid,16.36,,,16.36,Other,324% of Medicaid,10.86,,,10.86,Other,215% of Medicaid,10.86,,,10.86,Other,215% of Medicaid,6.31,,,6.31,Other,125% of Medicaid,5.05,137.64,
PARTICLE AGGLUTINATION TEST,86403,CPT,,78086403,CDM,302,RC,,,both,,,194,143.56,,,143.56,Other,150% of Medicare + 9.63% HCRA Surcharge,87.3,45,,87.3,percent of total billed charges,Critical Access Hospital RCC factor,34.74,,,34.74,Fee Schedule,,31.27,,,31.27,Fee Schedule,,75.57,,,75.57,Fee Schedule,,67.97,,,67.97,Fee Schedule,,64.24,,,64.24,Fee Schedule,,96.03,,,96.03,Other,110% of Medicare,36.35,,,36.35,Fee Schedule,,7,,,7,Other,186% of Medicaid,42.81,,,42.81,Fee Schedule,,120.28,,,120.28,Fee Schedule,,24.23,,,24.23,Fee Schedule,,42.81,,,42.81,Fee Schedule,,120.28,,,120.28,Fee Schedule,,45.58,,,45.58,Fee Schedule,,135.8,70,,135.8,percent of total billed charges,All Other,54.69,,,54.69,Fee Schedule,,46.35,,,46.35,Fee Schedule,,17.31,,,17.31,Fee Schedule,,17.31,,,17.31,Fee Schedule,,17.31,,,17.31,Fee Schedule,,17.31,,,17.31,Fee Schedule,,3.79,,,3.79,Other,100% of Medicaid,3.79,,,3.79,Other,100% of Medicaid,3.79,,,3.79,Other,100% of Medicaid,3.79,,,3.79,Other,100% of Medicaid,8.52,,,8.52,Other,225% of Medicaid,5.79,,,5.79,Other,153% of Medicaid,8.52,,,8.52,Other,225% of Medicaid,5.3,,,5.3,Other,140% of Medicaid,8.52,,,8.52,Other,225% of Medicaid,9.85,,,9.85,Other,260% of Medicaid,12.27,,,12.27,Other,324% of Medicaid,8.14,,,8.14,Other,215% of Medicaid,8.14,,,8.14,Other,215% of Medicaid,4.73,,,4.73,Other,125% of Medicaid,3.79,143.56,
PARTICLE AGGLUT ANTBDY TITR,86406,CPT,,78086406,CDM,302,RC,,,both,,,34,25.16,,,25.16,Other,150% of Medicare + 9.63% HCRA Surcharge,15.3,45,,15.3,percent of total billed charges,Critical Access Hospital RCC factor,32.03,,,32.03,Fee Schedule,,28.83,,,28.83,Fee Schedule,,43.11,,,43.11,Fee Schedule,,38.77,,,38.77,Fee Schedule,,36.65,,,36.65,Fee Schedule,,16.83,,,16.83,Other,110% of Medicare,33.52,,,33.52,Fee Schedule,,18,,,18,Other,186% of Medicaid,39.47,,,39.47,Fee Schedule,,21.08,,,21.08,Fee Schedule,,22.34,,,22.34,Fee Schedule,,39.47,,,39.47,Fee Schedule,,21.08,,,21.08,Fee Schedule,,42.03,,,42.03,Fee Schedule,,23.8,70,,23.8,percent of total billed charges,All Other,50.42,,,50.42,Fee Schedule,,42.74,,,42.74,Fee Schedule,,15.96,,,15.96,Fee Schedule,,15.96,,,15.96,Fee Schedule,,15.96,,,15.96,Fee Schedule,,15.96,,,15.96,Fee Schedule,,9.88,,,9.88,Other,100% of Medicaid,9.88,,,9.88,Other,100% of Medicaid,9.88,,,9.88,Other,100% of Medicaid,9.88,,,9.88,Other,100% of Medicaid,22.23,,,22.23,Other,225% of Medicaid,15.11,,,15.11,Other,153% of Medicaid,22.23,,,22.23,Other,225% of Medicaid,13.83,,,13.83,Other,140% of Medicaid,22.23,,,22.23,Other,225% of Medicaid,25.68,,,25.68,Other,260% of Medicaid,32.01,,,32.01,Other,324% of Medicaid,21.24,,,21.24,Other,215% of Medicaid,21.24,,,21.24,Other,215% of Medicaid,12.35,,,12.35,Other,125% of Medicaid,9.88,50.42,
RHEUMATOID FACTOR TEST,86430,CPT,,78086430,CDM,302,RC,,,both,,,70,51.8,,,51.8,Other,150% of Medicare + 9.63% HCRA Surcharge,31.5,45,,31.5,percent of total billed charges,Critical Access Hospital RCC factor,18.48,,,18.48,Fee Schedule,,16.64,,,16.64,Fee Schedule,,42.05,,,42.05,Fee Schedule,,37.83,,,37.83,Fee Schedule,,35.75,,,35.75,Fee Schedule,,34.65,,,34.65,Other,110% of Medicare,19.34,,,19.34,Fee Schedule,,9,,,9,Other,186% of Medicaid,22.78,,,22.78,Fee Schedule,,43.4,,,43.4,Fee Schedule,,12.89,,,12.89,Fee Schedule,,22.78,,,22.78,Fee Schedule,,43.4,,,43.4,Fee Schedule,,24.25,,,24.25,Fee Schedule,,49,70,,49,percent of total billed charges,All Other,29.1,,,29.1,Fee Schedule,,24.66,,,24.66,Fee Schedule,,9.21,,,9.21,Fee Schedule,,9.21,,,9.21,Fee Schedule,,9.21,,,9.21,Fee Schedule,,9.21,,,9.21,Fee Schedule,,4.93,,,4.93,Other,100% of Medicaid,4.93,,,4.93,Other,100% of Medicaid,4.93,,,4.93,Other,100% of Medicaid,4.93,,,4.93,Other,100% of Medicaid,11.09,,,11.09,Other,225% of Medicaid,7.54,,,7.54,Other,153% of Medicaid,11.09,,,11.09,Other,225% of Medicaid,6.9,,,6.9,Other,140% of Medicaid,11.09,,,11.09,Other,225% of Medicaid,12.81,,,12.81,Other,260% of Medicaid,15.97,,,15.97,Other,324% of Medicaid,10.6,,,10.6,Other,215% of Medicaid,10.6,,,10.6,Other,215% of Medicaid,6.16,,,6.16,Other,125% of Medicaid,4.93,51.8,
RHEUMATOID FACTOR QUANT,86431,CPT,,78086431,CDM,302,RC,,,both,,,108,79.92,,,79.92,Other,150% of Medicare + 9.63% HCRA Surcharge,48.6,45,,48.6,percent of total billed charges,Critical Access Hospital RCC factor,17.07,,,17.07,Fee Schedule,,15.37,,,15.37,Fee Schedule,,42.05,,,42.05,Fee Schedule,,37.83,,,37.83,Fee Schedule,,35.75,,,35.75,Fee Schedule,,53.46,,,53.46,Other,110% of Medicare,17.86,,,17.86,Fee Schedule,,10,,,10,Other,186% of Medicaid,21.04,,,21.04,Fee Schedule,,66.96,,,66.96,Fee Schedule,,11.91,,,11.91,Fee Schedule,,21.04,,,21.04,Fee Schedule,,66.96,,,66.96,Fee Schedule,,22.4,,,22.4,Fee Schedule,,75.6,70,,75.6,percent of total billed charges,All Other,26.87,,,26.87,Fee Schedule,,22.77,,,22.77,Fee Schedule,,8.51,,,8.51,Fee Schedule,,8.51,,,8.51,Fee Schedule,,8.51,,,8.51,Fee Schedule,,8.51,,,8.51,Fee Schedule,,5.25,,,5.25,Other,100% of Medicaid,5.25,,,5.25,Other,100% of Medicaid,5.25,,,5.25,Other,100% of Medicaid,5.25,,,5.25,Other,100% of Medicaid,11.82,,,11.82,Other,225% of Medicaid,8.04,,,8.04,Other,153% of Medicaid,11.82,,,11.82,Other,225% of Medicaid,7.35,,,7.35,Other,140% of Medicaid,11.82,,,11.82,Other,225% of Medicaid,13.66,,,13.66,Other,260% of Medicaid,17.02,,,17.02,Other,324% of Medicaid,11.29,,,11.29,Other,215% of Medicaid,11.29,,,11.29,Other,215% of Medicaid,6.57,,,6.57,Other,125% of Medicaid,5.25,79.92,
TB TEST CELL IMMUN MEASURE,86480,CPT,,78086480,CDM,302,RC,,,both,,,393,290.82,,,290.82,Other,150% of Medicare + 9.63% HCRA Surcharge,176.85,45,,176.85,percent of total billed charges,Critical Access Hospital RCC factor,186.56,,,186.56,Fee Schedule,,167.97,,,167.97,Fee Schedule,,459.65,,,459.65,Fee Schedule,,413.42,,,413.42,Fee Schedule,,390.75,,,390.75,Fee Schedule,,194.54,,,194.54,Other,110% of Medicare,195.24,,,195.24,Fee Schedule,,94,,,94,Other,186% of Medicaid,229.95,,,229.95,Fee Schedule,,243.66,,,243.66,Fee Schedule,,130.16,,,130.16,Fee Schedule,,229.95,,,229.95,Fee Schedule,,243.66,,,243.66,Fee Schedule,,244.82,,,244.82,Fee Schedule,,275.1,70,,275.1,percent of total billed charges,All Other,293.73,,,293.73,Fee Schedule,,248.95,,,248.95,Fee Schedule,,92.97,,,92.97,Fee Schedule,,92.97,,,92.97,Fee Schedule,,92.97,,,92.97,Fee Schedule,,92.97,,,92.97,Fee Schedule,,50.5,,,50.5,Other,100% of Medicaid,50.5,,,50.5,Other,100% of Medicaid,50.5,,,50.5,Other,100% of Medicaid,50.5,,,50.5,Other,100% of Medicaid,113.63,,,113.63,Other,225% of Medicaid,77.27,,,77.27,Other,153% of Medicaid,113.63,,,113.63,Other,225% of Medicaid,70.7,,,70.7,Other,140% of Medicaid,113.63,,,113.63,Other,225% of Medicaid,131.3,,,131.3,Other,260% of Medicaid,163.62,,,163.62,Other,324% of Medicaid,108.58,,,108.58,Other,215% of Medicaid,108.58,,,108.58,Other,215% of Medicaid,63.13,,,63.13,Other,125% of Medicaid,50.5,459.65,
SYPHILIS TEST NON-TREP QUAL,86592,CPT,,78086592,CDM,302,RC,,,both,,,68,50.32,,,50.32,Other,150% of Medicare + 9.63% HCRA Surcharge,30.6,45,,30.6,percent of total billed charges,Critical Access Hospital RCC factor,12.85,,,12.85,Fee Schedule,,11.57,,,11.57,Fee Schedule,,31.67,,,31.67,Fee Schedule,,28.49,,,28.49,Fee Schedule,,26.92,,,26.92,Fee Schedule,,33.66,,,33.66,Other,110% of Medicare,13.45,,,13.45,Fee Schedule,,6,,,6,Other,186% of Medicaid,15.84,,,15.84,Fee Schedule,,42.16,,,42.16,Fee Schedule,,8.97,,,8.97,Fee Schedule,,15.84,,,15.84,Fee Schedule,,42.16,,,42.16,Fee Schedule,,16.87,,,16.87,Fee Schedule,,47.6,70,,47.6,percent of total billed charges,All Other,20.24,,,20.24,Fee Schedule,,17.15,,,17.15,Fee Schedule,,6.41,,,6.41,Fee Schedule,,6.41,,,6.41,Fee Schedule,,6.41,,,6.41,Fee Schedule,,6.41,,,6.41,Fee Schedule,,3.3,,,3.3,Other,100% of Medicaid,3.3,,,3.3,Other,100% of Medicaid,3.3,,,3.3,Other,100% of Medicaid,3.3,,,3.3,Other,100% of Medicaid,7.43,,,7.43,Other,225% of Medicaid,5.05,,,5.05,Other,153% of Medicaid,7.43,,,7.43,Other,225% of Medicaid,4.62,,,4.62,Other,140% of Medicaid,7.43,,,7.43,Other,225% of Medicaid,8.59,,,8.59,Other,260% of Medicaid,10.7,,,10.7,Other,324% of Medicaid,7.1,,,7.1,Other,215% of Medicaid,7.1,,,7.1,Other,215% of Medicaid,4.13,,,4.13,Other,125% of Medicaid,3.3,50.32,
SYPHILIS TEST NON-TREP QUANT,86593,CPT,,78086593,CDM,302,RC,,,both,,,93,68.82,,,68.82,Other,150% of Medicare + 9.63% HCRA Surcharge,41.85,45,,41.85,percent of total billed charges,Critical Access Hospital RCC factor,13.24,,,13.24,Fee Schedule,,11.92,,,11.92,Fee Schedule,,32.62,,,32.62,Fee Schedule,,29.34,,,29.34,Fee Schedule,,27.73,,,27.73,Fee Schedule,,46.04,,,46.04,Other,110% of Medicare,13.86,,,13.86,Fee Schedule,,7,,,7,Other,186% of Medicaid,16.32,,,16.32,Fee Schedule,,57.66,,,57.66,Fee Schedule,,9.24,,,9.24,Fee Schedule,,16.32,,,16.32,Fee Schedule,,57.66,,,57.66,Fee Schedule,,17.38,,,17.38,Fee Schedule,,65.1,70,,65.1,percent of total billed charges,All Other,20.85,,,20.85,Fee Schedule,,17.67,,,17.67,Fee Schedule,,6.6,,,6.6,Fee Schedule,,6.6,,,6.6,Fee Schedule,,6.6,,,6.6,Fee Schedule,,6.6,,,6.6,Fee Schedule,,3.74,,,3.74,Other,100% of Medicaid,3.74,,,3.74,Other,100% of Medicaid,3.74,,,3.74,Other,100% of Medicaid,3.74,,,3.74,Other,100% of Medicaid,8.41,,,8.41,Other,225% of Medicaid,5.72,,,5.72,Other,153% of Medicaid,8.41,,,8.41,Other,225% of Medicaid,5.23,,,5.23,Other,140% of Medicaid,8.41,,,8.41,Other,225% of Medicaid,9.72,,,9.72,Other,260% of Medicaid,12.11,,,12.11,Other,324% of Medicaid,8.03,,,8.03,Other,215% of Medicaid,8.03,,,8.03,Other,215% of Medicaid,4.67,,,4.67,Other,125% of Medicaid,3.74,68.82,
VOLTAGE-GTD CA CHNL ANTB EA,86596,CPT,,78086596,CDM,302,RC,,,both,,,59,43.66,,,43.66,Other,150% of Medicare + 9.63% HCRA Surcharge,26.55,45,,26.55,percent of total billed charges,Critical Access Hospital RCC factor,36.27,,,36.27,Fee Schedule,,32.66,,,32.66,Fee Schedule,,18.4,,,18.4,Fee Schedule,,18.4,,,18.4,Fee Schedule,,18.4,,,18.4,Fee Schedule,,29.21,,,29.21,Other,110% of Medicare,37.96,,,37.96,Fee Schedule,,21,,,21,Other,186% of Medicaid,44.71,,,44.71,Fee Schedule,,36.58,,,36.58,Fee Schedule,,25.31,,,25.31,Fee Schedule,,44.71,,,44.71,Fee Schedule,,36.58,,,36.58,Fee Schedule,,47.6,,,47.6,Fee Schedule,,41.3,70,,41.3,percent of total billed charges,All Other,87.2,,,87.2,Fee Schedule,,73.91,,,73.91,Fee Schedule,,27.6,,,27.6,Fee Schedule,,27.6,,,27.6,Fee Schedule,,27.6,,,27.6,Fee Schedule,,27.6,,,27.6,Fee Schedule,,11.15,,,11.15,Other,100% of Medicaid,11.15,,,11.15,Other,100% of Medicaid,11.15,,,11.15,Other,100% of Medicaid,11.15,,,11.15,Other,100% of Medicaid,25.09,,,25.09,Other,225% of Medicaid,17.06,,,17.06,Other,153% of Medicaid,25.09,,,25.09,Other,225% of Medicaid,15.61,,,15.61,Other,140% of Medicaid,25.09,,,25.09,Other,225% of Medicaid,28.99,,,28.99,Other,260% of Medicaid,36.13,,,36.13,Other,324% of Medicaid,23.97,,,23.97,Other,215% of Medicaid,23.97,,,23.97,Other,215% of Medicaid,13.94,,,13.94,Other,125% of Medicaid,11.15,87.2,
ANTIOMYCES ANTIBODY,86602,CPT,,78086602,CDM,302,RC,,,both,,,34,25.16,,,25.16,Other,150% of Medicare + 9.63% HCRA Surcharge,15.3,45,,15.3,percent of total billed charges,Critical Access Hospital RCC factor,30.64,,,30.64,Fee Schedule,,27.59,,,27.59,Fee Schedule,,43.11,,,43.11,Fee Schedule,,38.77,,,38.77,Fee Schedule,,36.65,,,36.65,Fee Schedule,,16.83,,,16.83,Other,110% of Medicare,32.07,,,32.07,Fee Schedule,,15,,,15,Other,186% of Medicaid,37.77,,,37.77,Fee Schedule,,21.08,,,21.08,Fee Schedule,,21.38,,,21.38,Fee Schedule,,37.77,,,37.77,Fee Schedule,,21.08,,,21.08,Fee Schedule,,40.21,,,40.21,Fee Schedule,,23.8,70,,23.8,percent of total billed charges,All Other,48.24,,,48.24,Fee Schedule,,40.89,,,40.89,Fee Schedule,,15.27,,,15.27,Fee Schedule,,15.27,,,15.27,Fee Schedule,,15.27,,,15.27,Fee Schedule,,15.27,,,15.27,Fee Schedule,,8.11,,,8.11,Other,100% of Medicaid,8.11,,,8.11,Other,100% of Medicaid,8.11,,,8.11,Other,100% of Medicaid,8.11,,,8.11,Other,100% of Medicaid,18.25,,,18.25,Other,225% of Medicaid,12.41,,,12.41,Other,153% of Medicaid,18.25,,,18.25,Other,225% of Medicaid,11.35,,,11.35,Other,140% of Medicaid,18.25,,,18.25,Other,225% of Medicaid,21.09,,,21.09,Other,260% of Medicaid,26.28,,,26.28,Other,324% of Medicaid,17.44,,,17.44,Other,215% of Medicaid,17.44,,,17.44,Other,215% of Medicaid,10.14,,,10.14,Other,125% of Medicaid,8.11,48.24,
ASPERGILLUS ANTIBODY,86606,CPT,,78086606,CDM,302,RC,,,both,,,201,148.74,,,148.74,Other,150% of Medicare + 9.63% HCRA Surcharge,90.45,45,,90.45,percent of total billed charges,Critical Access Hospital RCC factor,45.3,,,45.3,Fee Schedule,,40.79,,,40.79,Fee Schedule,,43.11,,,43.11,Fee Schedule,,38.77,,,38.77,Fee Schedule,,36.65,,,36.65,Fee Schedule,,99.5,,,99.5,Other,110% of Medicare,47.41,,,47.41,Fee Schedule,,15,,,15,Other,186% of Medicaid,55.84,,,55.84,Fee Schedule,,124.62,,,124.62,Fee Schedule,,31.61,,,31.61,Fee Schedule,,55.84,,,55.84,Fee Schedule,,124.62,,,124.62,Fee Schedule,,59.45,,,59.45,Fee Schedule,,140.7,70,,140.7,percent of total billed charges,All Other,71.32,,,71.32,Fee Schedule,,60.45,,,60.45,Fee Schedule,,22.58,,,22.58,Fee Schedule,,22.58,,,22.58,Fee Schedule,,22.58,,,22.58,Fee Schedule,,22.58,,,22.58,Fee Schedule,,8.11,,,8.11,Other,100% of Medicaid,8.11,,,8.11,Other,100% of Medicaid,8.11,,,8.11,Other,100% of Medicaid,8.11,,,8.11,Other,100% of Medicaid,18.25,,,18.25,Other,225% of Medicaid,12.41,,,12.41,Other,153% of Medicaid,18.25,,,18.25,Other,225% of Medicaid,11.35,,,11.35,Other,140% of Medicaid,18.25,,,18.25,Other,225% of Medicaid,21.09,,,21.09,Other,260% of Medicaid,26.28,,,26.28,Other,324% of Medicaid,17.44,,,17.44,Other,215% of Medicaid,17.44,,,17.44,Other,215% of Medicaid,10.14,,,10.14,Other,125% of Medicaid,8.11,148.74,
BACTERIUM ANTIBODY,86609,CPT,,78086609,CDM,302,RC,,,both,,,77,56.98,,,56.98,Other,150% of Medicare + 9.63% HCRA Surcharge,34.65,45,,34.65,percent of total billed charges,Critical Access Hospital RCC factor,38.77,,,38.77,Fee Schedule,,34.9,,,34.9,Fee Schedule,,43.11,,,43.11,Fee Schedule,,38.77,,,38.77,Fee Schedule,,36.65,,,36.65,Fee Schedule,,38.12,,,38.12,Other,110% of Medicare,40.57,,,40.57,Fee Schedule,,0.01,,,0.01,Other,186% of Medicaid,47.78,,,47.78,Fee Schedule,,47.74,,,47.74,Fee Schedule,,27.05,,,27.05,Fee Schedule,,47.78,,,47.78,Fee Schedule,,47.74,,,47.74,Fee Schedule,,50.88,,,50.88,Fee Schedule,,53.9,70,,53.9,percent of total billed charges,All Other,61.04,,,61.04,Fee Schedule,,51.73,,,51.73,Fee Schedule,,19.32,,,19.32,Fee Schedule,,19.32,,,19.32,Fee Schedule,,19.32,,,19.32,Fee Schedule,,19.32,,,19.32,Fee Schedule,,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,61.04,
BARTONELLA ANTIBODY,86611,CPT,,78086611,CDM,302,RC,,,both,,,37,27.38,,,27.38,Other,150% of Medicare + 9.63% HCRA Surcharge,16.65,45,,16.65,percent of total billed charges,Critical Access Hospital RCC factor,30.64,,,30.64,Fee Schedule,,27.59,,,27.59,Fee Schedule,,43.11,,,43.11,Fee Schedule,,38.77,,,38.77,Fee Schedule,,36.65,,,36.65,Fee Schedule,,18.32,,,18.32,Other,110% of Medicare,32.07,,,32.07,Fee Schedule,,15,,,15,Other,186% of Medicaid,37.77,,,37.77,Fee Schedule,,22.94,,,22.94,Fee Schedule,,21.38,,,21.38,Fee Schedule,,37.77,,,37.77,Fee Schedule,,22.94,,,22.94,Fee Schedule,,40.21,,,40.21,Fee Schedule,,25.9,70,,25.9,percent of total billed charges,All Other,48.24,,,48.24,Fee Schedule,,40.89,,,40.89,Fee Schedule,,15.27,,,15.27,Fee Schedule,,15.27,,,15.27,Fee Schedule,,15.27,,,15.27,Fee Schedule,,15.27,,,15.27,Fee Schedule,,8.11,,,8.11,Other,100% of Medicaid,8.11,,,8.11,Other,100% of Medicaid,8.11,,,8.11,Other,100% of Medicaid,8.11,,,8.11,Other,100% of Medicaid,18.25,,,18.25,Other,225% of Medicaid,12.41,,,12.41,Other,153% of Medicaid,18.25,,,18.25,Other,225% of Medicaid,11.35,,,11.35,Other,140% of Medicaid,18.25,,,18.25,Other,225% of Medicaid,21.09,,,21.09,Other,260% of Medicaid,26.28,,,26.28,Other,324% of Medicaid,17.44,,,17.44,Other,215% of Medicaid,17.44,,,17.44,Other,215% of Medicaid,10.14,,,10.14,Other,125% of Medicaid,8.11,48.24,
BLASTOMYCES ANTIBODY,86612,CPT,,78086612,CDM,302,RC,,,both,,,41,30.34,,,30.34,Other,150% of Medicare + 9.63% HCRA Surcharge,18.45,45,,18.45,percent of total billed charges,Critical Access Hospital RCC factor,38.83,,,38.83,Fee Schedule,,34.96,,,34.96,Fee Schedule,,43.11,,,43.11,Fee Schedule,,38.77,,,38.77,Fee Schedule,,36.65,,,36.65,Fee Schedule,,20.3,,,20.3,Other,110% of Medicare,40.64,,,40.64,Fee Schedule,,15,,,15,Other,186% of Medicaid,47.86,,,47.86,Fee Schedule,,25.42,,,25.42,Fee Schedule,,27.09,,,27.09,Fee Schedule,,47.86,,,47.86,Fee Schedule,,25.42,,,25.42,Fee Schedule,,50.96,,,50.96,Fee Schedule,,28.7,70,,28.7,percent of total billed charges,All Other,61.13,,,61.13,Fee Schedule,,51.81,,,51.81,Fee Schedule,,19.35,,,19.35,Fee Schedule,,19.35,,,19.35,Fee Schedule,,19.35,,,19.35,Fee Schedule,,19.35,,,19.35,Fee Schedule,,8.11,,,8.11,Other,100% of Medicaid,8.11,,,8.11,Other,100% of Medicaid,8.11,,,8.11,Other,100% of Medicaid,8.11,,,8.11,Other,100% of Medicaid,18.25,,,18.25,Other,225% of Medicaid,12.41,,,12.41,Other,153% of Medicaid,18.25,,,18.25,Other,225% of Medicaid,11.35,,,11.35,Other,140% of Medicaid,18.25,,,18.25,Other,225% of Medicaid,21.09,,,21.09,Other,260% of Medicaid,26.28,,,26.28,Other,324% of Medicaid,17.44,,,17.44,Other,215% of Medicaid,17.44,,,17.44,Other,215% of Medicaid,10.14,,,10.14,Other,125% of Medicaid,8.11,61.13,
BORDETELLA ANTIBODY,86615,CPT,,78086615,CDM,302,RC,,,both,,,225,166.5,,,166.5,Other,150% of Medicare + 9.63% HCRA Surcharge,101.25,45,,101.25,percent of total billed charges,Critical Access Hospital RCC factor,39.7,,,39.7,Fee Schedule,,35.74,,,35.74,Fee Schedule,,43.11,,,43.11,Fee Schedule,,38.77,,,38.77,Fee Schedule,,36.65,,,36.65,Fee Schedule,,111.38,,,111.38,Other,110% of Medicare,41.55,,,41.55,Fee Schedule,,15,,,15,Other,186% of Medicaid,48.93,,,48.93,Fee Schedule,,139.5,,,139.5,Fee Schedule,,27.7,,,27.7,Fee Schedule,,48.93,,,48.93,Fee Schedule,,139.5,,,139.5,Fee Schedule,,52.1,,,52.1,Fee Schedule,,157.5,70,,157.5,percent of total billed charges,All Other,62.51,,,62.51,Fee Schedule,,52.98,,,52.98,Fee Schedule,,19.79,,,19.79,Fee Schedule,,19.79,,,19.79,Fee Schedule,,19.79,,,19.79,Fee Schedule,,19.79,,,19.79,Fee Schedule,,8.11,,,8.11,Other,100% of Medicaid,8.11,,,8.11,Other,100% of Medicaid,8.11,,,8.11,Other,100% of Medicaid,8.11,,,8.11,Other,100% of Medicaid,18.25,,,18.25,Other,225% of Medicaid,12.41,,,12.41,Other,153% of Medicaid,18.25,,,18.25,Other,225% of Medicaid,11.35,,,11.35,Other,140% of Medicaid,18.25,,,18.25,Other,225% of Medicaid,21.09,,,21.09,Other,260% of Medicaid,26.28,,,26.28,Other,324% of Medicaid,17.44,,,17.44,Other,215% of Medicaid,17.44,,,17.44,Other,215% of Medicaid,10.14,,,10.14,Other,125% of Medicaid,8.11,166.5,
LYME DISEASE ANTIBODY,86618,CPT,,78086618,CDM,302,RC,,,both,,,105,77.7,,,77.7,Other,150% of Medicare + 9.63% HCRA Surcharge,47.25,45,,47.25,percent of total billed charges,Critical Access Hospital RCC factor,51.26,,,51.26,Fee Schedule,,46.15,,,46.15,Fee Schedule,,126.32,,,126.32,Fee Schedule,,113.62,,,113.62,Fee Schedule,,107.39,,,107.39,Fee Schedule,,51.98,,,51.98,Other,110% of Medicare,53.64,,,53.64,Fee Schedule,,32,,,32,Other,186% of Medicaid,63.18,,,63.18,Fee Schedule,,65.1,,,65.1,Fee Schedule,,35.76,,,35.76,Fee Schedule,,63.18,,,63.18,Fee Schedule,,65.1,,,65.1,Fee Schedule,,67.27,,,67.27,Fee Schedule,,73.5,70,,73.5,percent of total billed charges,All Other,80.71,,,80.71,Fee Schedule,,68.4,,,68.4,Fee Schedule,,25.55,,,25.55,Fee Schedule,,25.55,,,25.55,Fee Schedule,,25.55,,,25.55,Fee Schedule,,25.55,,,25.55,Fee Schedule,,17.03,,,17.03,Other,100% of Medicaid,17.03,,,17.03,Other,100% of Medicaid,17.03,,,17.03,Other,100% of Medicaid,17.03,,,17.03,Other,100% of Medicaid,38.32,,,38.32,Other,225% of Medicaid,26.06,,,26.06,Other,153% of Medicaid,38.32,,,38.32,Other,225% of Medicaid,23.84,,,23.84,Other,140% of Medicaid,38.32,,,38.32,Other,225% of Medicaid,44.28,,,44.28,Other,260% of Medicaid,55.18,,,55.18,Other,324% of Medicaid,36.61,,,36.61,Other,215% of Medicaid,36.61,,,36.61,Other,215% of Medicaid,21.29,,,21.29,Other,125% of Medicaid,17.03,126.32,
CAMPYLOBACTER ANTIBODY,86625,CPT,,78086625,CDM,302,RC,,,both,,,215,159.1,,,159.1,Other,150% of Medicare + 9.63% HCRA Surcharge,96.75,45,,96.75,percent of total billed charges,Critical Access Hospital RCC factor,39.49,,,39.49,Fee Schedule,,35.56,,,35.56,Fee Schedule,,43.11,,,43.11,Fee Schedule,,38.77,,,38.77,Fee Schedule,,36.65,,,36.65,Fee Schedule,,106.43,,,106.43,Other,110% of Medicare,41.33,,,41.33,Fee Schedule,,15,,,15,Other,186% of Medicaid,48.68,,,48.68,Fee Schedule,,133.3,,,133.3,Fee Schedule,,27.55,,,27.55,Fee Schedule,,48.68,,,48.68,Fee Schedule,,133.3,,,133.3,Fee Schedule,,51.82,,,51.82,Fee Schedule,,150.5,70,,150.5,percent of total billed charges,All Other,62.18,,,62.18,Fee Schedule,,52.7,,,52.7,Fee Schedule,,19.68,,,19.68,Fee Schedule,,19.68,,,19.68,Fee Schedule,,19.68,,,19.68,Fee Schedule,,19.68,,,19.68,Fee Schedule,,8.11,,,8.11,Other,100% of Medicaid,8.11,,,8.11,Other,100% of Medicaid,8.11,,,8.11,Other,100% of Medicaid,8.11,,,8.11,Other,100% of Medicaid,18.25,,,18.25,Other,225% of Medicaid,12.41,,,12.41,Other,153% of Medicaid,18.25,,,18.25,Other,225% of Medicaid,11.35,,,11.35,Other,140% of Medicaid,18.25,,,18.25,Other,225% of Medicaid,21.09,,,21.09,Other,260% of Medicaid,26.28,,,26.28,Other,324% of Medicaid,17.44,,,17.44,Other,215% of Medicaid,17.44,,,17.44,Other,215% of Medicaid,10.14,,,10.14,Other,125% of Medicaid,8.11,159.1,
CANDIDA ANTIBODY,86628,CPT,,78086628,CDM,302,RC,,,both,,,69,51.06,,,51.06,Other,150% of Medicare + 9.63% HCRA Surcharge,31.05,45,,31.05,percent of total billed charges,Critical Access Hospital RCC factor,36.15,,,36.15,Fee Schedule,,32.55,,,32.55,Fee Schedule,,43.11,,,43.11,Fee Schedule,,38.77,,,38.77,Fee Schedule,,36.65,,,36.65,Fee Schedule,,34.16,,,34.16,Other,110% of Medicare,37.83,,,37.83,Fee Schedule,,18,,,18,Other,186% of Medicaid,44.56,,,44.56,Fee Schedule,,42.78,,,42.78,Fee Schedule,,25.22,,,25.22,Fee Schedule,,44.56,,,44.56,Fee Schedule,,42.78,,,42.78,Fee Schedule,,47.44,,,47.44,Fee Schedule,,48.3,70,,48.3,percent of total billed charges,All Other,56.92,,,56.92,Fee Schedule,,48.24,,,48.24,Fee Schedule,,18.02,,,18.02,Fee Schedule,,18.02,,,18.02,Fee Schedule,,18.02,,,18.02,Fee Schedule,,18.02,,,18.02,Fee Schedule,,9.88,,,9.88,Other,100% of Medicaid,9.88,,,9.88,Other,100% of Medicaid,9.88,,,9.88,Other,100% of Medicaid,9.88,,,9.88,Other,100% of Medicaid,22.23,,,22.23,Other,225% of Medicaid,15.11,,,15.11,Other,153% of Medicaid,22.23,,,22.23,Other,225% of Medicaid,13.83,,,13.83,Other,140% of Medicaid,22.23,,,22.23,Other,225% of Medicaid,25.68,,,25.68,Other,260% of Medicaid,32.01,,,32.01,Other,324% of Medicaid,21.24,,,21.24,Other,215% of Medicaid,21.24,,,21.24,Other,215% of Medicaid,12.35,,,12.35,Other,125% of Medicaid,9.88,56.92,
CHLAMYDIA ANTIBODY,86631,CPT,,78086631,CDM,302,RC,,,both,,,257,190.18,,,190.18,Other,150% of Medicare + 9.63% HCRA Surcharge,115.65,45,,115.65,percent of total billed charges,Critical Access Hospital RCC factor,35.58,,,35.58,Fee Schedule,,32.03,,,32.03,Fee Schedule,,43.11,,,43.11,Fee Schedule,,38.77,,,38.77,Fee Schedule,,36.65,,,36.65,Fee Schedule,,127.22,,,127.22,Other,110% of Medicare,37.23,,,37.23,Fee Schedule,,15,,,15,Other,186% of Medicaid,43.85,,,43.85,Fee Schedule,,159.34,,,159.34,Fee Schedule,,24.82,,,24.82,Fee Schedule,,43.85,,,43.85,Fee Schedule,,159.34,,,159.34,Fee Schedule,,46.69,,,46.69,Fee Schedule,,179.9,70,,179.9,percent of total billed charges,All Other,56.02,,,56.02,Fee Schedule,,47.48,,,47.48,Fee Schedule,,17.73,,,17.73,Fee Schedule,,17.73,,,17.73,Fee Schedule,,17.73,,,17.73,Fee Schedule,,17.73,,,17.73,Fee Schedule,,8.11,,,8.11,Other,100% of Medicaid,8.11,,,8.11,Other,100% of Medicaid,8.11,,,8.11,Other,100% of Medicaid,8.11,,,8.11,Other,100% of Medicaid,18.25,,,18.25,Other,225% of Medicaid,12.41,,,12.41,Other,153% of Medicaid,18.25,,,18.25,Other,225% of Medicaid,11.35,,,11.35,Other,140% of Medicaid,18.25,,,18.25,Other,225% of Medicaid,21.09,,,21.09,Other,260% of Medicaid,26.28,,,26.28,Other,324% of Medicaid,17.44,,,17.44,Other,215% of Medicaid,17.44,,,17.44,Other,215% of Medicaid,10.14,,,10.14,Other,125% of Medicaid,8.11,190.18,
CHLAMYDIA IGM ANTIBODY,86632,CPT,,78086632,CDM,302,RC,,,both,,,257,190.18,,,190.18,Other,150% of Medicare + 9.63% HCRA Surcharge,115.65,45,,115.65,percent of total billed charges,Critical Access Hospital RCC factor,38.17,,,38.17,Fee Schedule,,34.36,,,34.36,Fee Schedule,,43.11,,,43.11,Fee Schedule,,38.77,,,38.77,Fee Schedule,,36.65,,,36.65,Fee Schedule,,127.22,,,127.22,Other,110% of Medicare,39.94,,,39.94,Fee Schedule,,15,,,15,Other,186% of Medicaid,47.04,,,47.04,Fee Schedule,,159.34,,,159.34,Fee Schedule,,26.63,,,26.63,Fee Schedule,,47.04,,,47.04,Fee Schedule,,159.34,,,159.34,Fee Schedule,,50.09,,,50.09,Fee Schedule,,179.9,70,,179.9,percent of total billed charges,All Other,60.09,,,60.09,Fee Schedule,,50.93,,,50.93,Fee Schedule,,19.02,,,19.02,Fee Schedule,,19.02,,,19.02,Fee Schedule,,19.02,,,19.02,Fee Schedule,,19.02,,,19.02,Fee Schedule,,8.11,,,8.11,Other,100% of Medicaid,8.11,,,8.11,Other,100% of Medicaid,8.11,,,8.11,Other,100% of Medicaid,8.11,,,8.11,Other,100% of Medicaid,18.25,,,18.25,Other,225% of Medicaid,12.41,,,12.41,Other,153% of Medicaid,18.25,,,18.25,Other,225% of Medicaid,11.35,,,11.35,Other,140% of Medicaid,18.25,,,18.25,Other,225% of Medicaid,21.09,,,21.09,Other,260% of Medicaid,26.28,,,26.28,Other,324% of Medicaid,17.44,,,17.44,Other,215% of Medicaid,17.44,,,17.44,Other,215% of Medicaid,10.14,,,10.14,Other,125% of Medicaid,8.11,190.18,
COCCIDIOIDES ANTIBODY,86635,CPT,,78086635,CDM,302,RC,,,both,,,212,156.88,,,156.88,Other,150% of Medicare + 9.63% HCRA Surcharge,95.4,45,,95.4,percent of total billed charges,Critical Access Hospital RCC factor,34.52,,,34.52,Fee Schedule,,31.08,,,31.08,Fee Schedule,,43.11,,,43.11,Fee Schedule,,38.77,,,38.77,Fee Schedule,,36.65,,,36.65,Fee Schedule,,104.94,,,104.94,Other,110% of Medicare,36.13,,,36.13,Fee Schedule,,15,,,15,Other,186% of Medicaid,42.55,,,42.55,Fee Schedule,,131.44,,,131.44,Fee Schedule,,24.09,,,24.09,Fee Schedule,,42.55,,,42.55,Fee Schedule,,131.44,,,131.44,Fee Schedule,,45.31,,,45.31,Fee Schedule,,148.4,70,,148.4,percent of total billed charges,All Other,54.36,,,54.36,Fee Schedule,,46.07,,,46.07,Fee Schedule,,17.21,,,17.21,Fee Schedule,,17.21,,,17.21,Fee Schedule,,17.21,,,17.21,Fee Schedule,,17.21,,,17.21,Fee Schedule,,8.11,,,8.11,Other,100% of Medicaid,8.11,,,8.11,Other,100% of Medicaid,8.11,,,8.11,Other,100% of Medicaid,8.11,,,8.11,Other,100% of Medicaid,18.25,,,18.25,Other,225% of Medicaid,12.41,,,12.41,Other,153% of Medicaid,18.25,,,18.25,Other,225% of Medicaid,11.35,,,11.35,Other,140% of Medicaid,18.25,,,18.25,Other,225% of Medicaid,21.09,,,21.09,Other,260% of Medicaid,26.28,,,26.28,Other,324% of Medicaid,17.44,,,17.44,Other,215% of Medicaid,17.44,,,17.44,Other,215% of Medicaid,10.14,,,10.14,Other,125% of Medicaid,8.11,156.88,
Q FEVER ANTIBODY,86638,CPT,,78086638,CDM,302,RC,,,both,,,93,68.82,,,68.82,Other,150% of Medicare + 9.63% HCRA Surcharge,41.85,45,,41.85,percent of total billed charges,Critical Access Hospital RCC factor,36.48,,,36.48,Fee Schedule,,32.85,,,32.85,Fee Schedule,,43.11,,,43.11,Fee Schedule,,38.77,,,38.77,Fee Schedule,,36.65,,,36.65,Fee Schedule,,46.04,,,46.04,Other,110% of Medicare,38.18,,,38.18,Fee Schedule,,15,,,15,Other,186% of Medicaid,44.97,,,44.97,Fee Schedule,,57.66,,,57.66,Fee Schedule,,25.45,,,25.45,Fee Schedule,,44.97,,,44.97,Fee Schedule,,57.66,,,57.66,Fee Schedule,,47.87,,,47.87,Fee Schedule,,65.1,70,,65.1,percent of total billed charges,All Other,57.44,,,57.44,Fee Schedule,,48.68,,,48.68,Fee Schedule,,18.18,,,18.18,Fee Schedule,,18.18,,,18.18,Fee Schedule,,18.18,,,18.18,Fee Schedule,,18.18,,,18.18,Fee Schedule,,8.11,,,8.11,Other,100% of Medicaid,8.11,,,8.11,Other,100% of Medicaid,8.11,,,8.11,Other,100% of Medicaid,8.11,,,8.11,Other,100% of Medicaid,18.25,,,18.25,Other,225% of Medicaid,12.41,,,12.41,Other,153% of Medicaid,18.25,,,18.25,Other,225% of Medicaid,11.35,,,11.35,Other,140% of Medicaid,18.25,,,18.25,Other,225% of Medicaid,21.09,,,21.09,Other,260% of Medicaid,26.28,,,26.28,Other,324% of Medicaid,17.44,,,17.44,Other,215% of Medicaid,17.44,,,17.44,Other,215% of Medicaid,10.14,,,10.14,Other,125% of Medicaid,8.11,68.82,
CRYPTOCOCCUS ANTIBODY,86641,CPT,,78086641,CDM,302,RC,,,both,,,116,85.84,,,85.84,Other,150% of Medicare + 9.63% HCRA Surcharge,52.2,45,,52.2,percent of total billed charges,Critical Access Hospital RCC factor,43.37,,,43.37,Fee Schedule,,39.05,,,39.05,Fee Schedule,,43.11,,,43.11,Fee Schedule,,38.77,,,38.77,Fee Schedule,,36.65,,,36.65,Fee Schedule,,57.42,,,57.42,Other,110% of Medicare,45.39,,,45.39,Fee Schedule,,15,,,15,Other,186% of Medicaid,53.46,,,53.46,Fee Schedule,,71.92,,,71.92,Fee Schedule,,30.26,,,30.26,Fee Schedule,,53.46,,,53.46,Fee Schedule,,71.92,,,71.92,Fee Schedule,,56.92,,,56.92,Fee Schedule,,81.2,70,,81.2,percent of total billed charges,All Other,68.29,,,68.29,Fee Schedule,,57.88,,,57.88,Fee Schedule,,21.62,,,21.62,Fee Schedule,,21.62,,,21.62,Fee Schedule,,21.62,,,21.62,Fee Schedule,,21.62,,,21.62,Fee Schedule,,8.11,,,8.11,Other,100% of Medicaid,8.11,,,8.11,Other,100% of Medicaid,8.11,,,8.11,Other,100% of Medicaid,8.11,,,8.11,Other,100% of Medicaid,18.25,,,18.25,Other,225% of Medicaid,12.41,,,12.41,Other,153% of Medicaid,18.25,,,18.25,Other,225% of Medicaid,11.35,,,11.35,Other,140% of Medicaid,18.25,,,18.25,Other,225% of Medicaid,21.09,,,21.09,Other,260% of Medicaid,26.28,,,26.28,Other,324% of Medicaid,17.44,,,17.44,Other,215% of Medicaid,17.44,,,17.44,Other,215% of Medicaid,10.14,,,10.14,Other,125% of Medicaid,8.11,85.84,
CMV ANTIBODY,86644,CPT,,78086644,CDM,302,RC,,,both,,,206,152.44,,,152.44,Other,150% of Medicare + 9.63% HCRA Surcharge,92.7,45,,92.7,percent of total billed charges,Critical Access Hospital RCC factor,43.31,,,43.31,Fee Schedule,,39,,,39,Fee Schedule,,106.72,,,106.72,Fee Schedule,,95.99,,,95.99,Fee Schedule,,90.72,,,90.72,Fee Schedule,,101.97,,,101.97,Other,110% of Medicare,45.33,,,45.33,Fee Schedule,,27,,,27,Other,186% of Medicaid,53.39,,,53.39,Fee Schedule,,127.72,,,127.72,Fee Schedule,,30.22,,,30.22,Fee Schedule,,53.39,,,53.39,Fee Schedule,,127.72,,,127.72,Fee Schedule,,56.84,,,56.84,Fee Schedule,,144.2,70,,144.2,percent of total billed charges,All Other,68.19,,,68.19,Fee Schedule,,57.8,,,57.8,Fee Schedule,,21.59,,,21.59,Fee Schedule,,21.59,,,21.59,Fee Schedule,,21.59,,,21.59,Fee Schedule,,21.59,,,21.59,Fee Schedule,,14.39,,,14.39,Other,100% of Medicaid,14.39,,,14.39,Other,100% of Medicaid,14.39,,,14.39,Other,100% of Medicaid,14.39,,,14.39,Other,100% of Medicaid,32.38,,,32.38,Other,225% of Medicaid,22.02,,,22.02,Other,153% of Medicaid,32.38,,,32.38,Other,225% of Medicaid,20.15,,,20.15,Other,140% of Medicaid,32.38,,,32.38,Other,225% of Medicaid,37.41,,,37.41,Other,260% of Medicaid,46.62,,,46.62,Other,324% of Medicaid,30.94,,,30.94,Other,215% of Medicaid,30.94,,,30.94,Other,215% of Medicaid,17.99,,,17.99,Other,125% of Medicaid,14.39,152.44,
CMV ANTIBODY IGM,86645,CPT,,78086645,CDM,302,RC,,,both,,,197,145.78,,,145.78,Other,150% of Medicare + 9.63% HCRA Surcharge,88.65,45,,88.65,percent of total billed charges,Critical Access Hospital RCC factor,50.72,,,50.72,Fee Schedule,,45.66,,,45.66,Fee Schedule,,43.11,,,43.11,Fee Schedule,,38.77,,,38.77,Fee Schedule,,36.65,,,36.65,Fee Schedule,,97.52,,,97.52,Other,110% of Medicare,53.08,,,53.08,Fee Schedule,,15,,,15,Other,186% of Medicaid,62.51,,,62.51,Fee Schedule,,122.14,,,122.14,Fee Schedule,,35.39,,,35.39,Fee Schedule,,62.51,,,62.51,Fee Schedule,,122.14,,,122.14,Fee Schedule,,66.56,,,66.56,Fee Schedule,,137.9,70,,137.9,percent of total billed charges,All Other,79.85,,,79.85,Fee Schedule,,67.68,,,67.68,Fee Schedule,,25.28,,,25.28,Fee Schedule,,25.28,,,25.28,Fee Schedule,,25.28,,,25.28,Fee Schedule,,25.28,,,25.28,Fee Schedule,,8.11,,,8.11,Other,100% of Medicaid,8.11,,,8.11,Other,100% of Medicaid,8.11,,,8.11,Other,100% of Medicaid,8.11,,,8.11,Other,100% of Medicaid,18.25,,,18.25,Other,225% of Medicaid,12.41,,,12.41,Other,153% of Medicaid,18.25,,,18.25,Other,225% of Medicaid,11.35,,,11.35,Other,140% of Medicaid,18.25,,,18.25,Other,225% of Medicaid,21.09,,,21.09,Other,260% of Medicaid,26.28,,,26.28,Other,324% of Medicaid,17.44,,,17.44,Other,215% of Medicaid,17.44,,,17.44,Other,215% of Medicaid,10.14,,,10.14,Other,125% of Medicaid,8.11,145.78,
ENCEPHALITIS ANTIBODY,86651,CPT,,78086651,CDM,302,RC,,,both,,,83,61.42,,,61.42,Other,150% of Medicare + 9.63% HCRA Surcharge,37.35,45,,37.35,percent of total billed charges,Critical Access Hospital RCC factor,39.7,,,39.7,Fee Schedule,,35.74,,,35.74,Fee Schedule,,43.11,,,43.11,Fee Schedule,,38.77,,,38.77,Fee Schedule,,36.65,,,36.65,Fee Schedule,,41.09,,,41.09,Other,110% of Medicare,41.55,,,41.55,Fee Schedule,,15,,,15,Other,186% of Medicaid,48.93,,,48.93,Fee Schedule,,51.46,,,51.46,Fee Schedule,,27.7,,,27.7,Fee Schedule,,48.93,,,48.93,Fee Schedule,,51.46,,,51.46,Fee Schedule,,52.1,,,52.1,Fee Schedule,,58.1,70,,58.1,percent of total billed charges,All Other,62.51,,,62.51,Fee Schedule,,52.98,,,52.98,Fee Schedule,,19.79,,,19.79,Fee Schedule,,19.79,,,19.79,Fee Schedule,,19.79,,,19.79,Fee Schedule,,19.79,,,19.79,Fee Schedule,,8.11,,,8.11,Other,100% of Medicaid,8.11,,,8.11,Other,100% of Medicaid,8.11,,,8.11,Other,100% of Medicaid,8.11,,,8.11,Other,100% of Medicaid,18.25,,,18.25,Other,225% of Medicaid,12.41,,,12.41,Other,153% of Medicaid,18.25,,,18.25,Other,225% of Medicaid,11.35,,,11.35,Other,140% of Medicaid,18.25,,,18.25,Other,225% of Medicaid,21.09,,,21.09,Other,260% of Medicaid,26.28,,,26.28,Other,324% of Medicaid,17.44,,,17.44,Other,215% of Medicaid,17.44,,,17.44,Other,215% of Medicaid,10.14,,,10.14,Other,125% of Medicaid,8.11,62.51,
ENCEPHALITIS ANTIBODY,86653,CPT,,78086653,CDM,302,RC,,,both,,,83,61.42,,,61.42,Other,150% of Medicare + 9.63% HCRA Surcharge,37.35,45,,37.35,percent of total billed charges,Critical Access Hospital RCC factor,39.7,,,39.7,Fee Schedule,,35.74,,,35.74,Fee Schedule,,43.11,,,43.11,Fee Schedule,,38.77,,,38.77,Fee Schedule,,36.65,,,36.65,Fee Schedule,,41.09,,,41.09,Other,110% of Medicare,41.55,,,41.55,Fee Schedule,,15,,,15,Other,186% of Medicaid,48.93,,,48.93,Fee Schedule,,51.46,,,51.46,Fee Schedule,,27.7,,,27.7,Fee Schedule,,48.93,,,48.93,Fee Schedule,,51.46,,,51.46,Fee Schedule,,52.1,,,52.1,Fee Schedule,,58.1,70,,58.1,percent of total billed charges,All Other,62.51,,,62.51,Fee Schedule,,52.98,,,52.98,Fee Schedule,,19.79,,,19.79,Fee Schedule,,19.79,,,19.79,Fee Schedule,,19.79,,,19.79,Fee Schedule,,19.79,,,19.79,Fee Schedule,,8.11,,,8.11,Other,100% of Medicaid,8.11,,,8.11,Other,100% of Medicaid,8.11,,,8.11,Other,100% of Medicaid,8.11,,,8.11,Other,100% of Medicaid,18.25,,,18.25,Other,225% of Medicaid,12.41,,,12.41,Other,153% of Medicaid,18.25,,,18.25,Other,225% of Medicaid,11.35,,,11.35,Other,140% of Medicaid,18.25,,,18.25,Other,225% of Medicaid,21.09,,,21.09,Other,260% of Medicaid,26.28,,,26.28,Other,324% of Medicaid,17.44,,,17.44,Other,215% of Medicaid,17.44,,,17.44,Other,215% of Medicaid,10.14,,,10.14,Other,125% of Medicaid,8.11,62.51,
AB; ENCEPHALITIS W EQUINE,86654,CPT,,78086654,CDM,302,RC,,,both,,,37,27.38,,,27.38,Other,150% of Medicare + 9.63% HCRA Surcharge,16.65,45,,16.65,percent of total billed charges,Critical Access Hospital RCC factor,39.7,,,39.7,Fee Schedule,,35.74,,,35.74,Fee Schedule,,43.11,,,43.11,Fee Schedule,,38.77,,,38.77,Fee Schedule,,36.65,,,36.65,Fee Schedule,,18.32,,,18.32,Other,110% of Medicare,41.55,,,41.55,Fee Schedule,,15,,,15,Other,186% of Medicaid,48.93,,,48.93,Fee Schedule,,22.94,,,22.94,Fee Schedule,,27.7,,,27.7,Fee Schedule,,48.93,,,48.93,Fee Schedule,,22.94,,,22.94,Fee Schedule,,52.1,,,52.1,Fee Schedule,,25.9,70,,25.9,percent of total billed charges,All Other,62.51,,,62.51,Fee Schedule,,52.98,,,52.98,Fee Schedule,,19.79,,,19.79,Fee Schedule,,19.79,,,19.79,Fee Schedule,,19.79,,,19.79,Fee Schedule,,19.79,,,19.79,Fee Schedule,,8.11,,,8.11,Other,100% of Medicaid,8.11,,,8.11,Other,100% of Medicaid,8.11,,,8.11,Other,100% of Medicaid,8.11,,,8.11,Other,100% of Medicaid,18.25,,,18.25,Other,225% of Medicaid,12.41,,,12.41,Other,153% of Medicaid,18.25,,,18.25,Other,225% of Medicaid,11.35,,,11.35,Other,140% of Medicaid,18.25,,,18.25,Other,225% of Medicaid,21.09,,,21.09,Other,260% of Medicaid,26.28,,,26.28,Other,324% of Medicaid,17.44,,,17.44,Other,215% of Medicaid,17.44,,,17.44,Other,215% of Medicaid,10.14,,,10.14,Other,125% of Medicaid,8.11,62.51,
ENTEROVIRUS ANTIBODY,86658,CPT,,78086658,CDM,302,RC,,,both,,,83,61.42,,,61.42,Other,150% of Medicare + 9.63% HCRA Surcharge,37.35,45,,37.35,percent of total billed charges,Critical Access Hospital RCC factor,39.22,,,39.22,Fee Schedule,,35.31,,,35.31,Fee Schedule,,43.11,,,43.11,Fee Schedule,,38.77,,,38.77,Fee Schedule,,36.65,,,36.65,Fee Schedule,,41.09,,,41.09,Other,110% of Medicare,41.04,,,41.04,Fee Schedule,,15,,,15,Other,186% of Medicaid,48.34,,,48.34,Fee Schedule,,51.46,,,51.46,Fee Schedule,,27.36,,,27.36,Fee Schedule,,48.34,,,48.34,Fee Schedule,,51.46,,,51.46,Fee Schedule,,51.47,,,51.47,Fee Schedule,,58.1,70,,58.1,percent of total billed charges,All Other,61.75,,,61.75,Fee Schedule,,52.34,,,52.34,Fee Schedule,,19.55,,,19.55,Fee Schedule,,19.55,,,19.55,Fee Schedule,,19.55,,,19.55,Fee Schedule,,19.55,,,19.55,Fee Schedule,,8.11,,,8.11,Other,100% of Medicaid,8.11,,,8.11,Other,100% of Medicaid,8.11,,,8.11,Other,100% of Medicaid,8.11,,,8.11,Other,100% of Medicaid,18.25,,,18.25,Other,225% of Medicaid,12.41,,,12.41,Other,153% of Medicaid,18.25,,,18.25,Other,225% of Medicaid,11.35,,,11.35,Other,140% of Medicaid,18.25,,,18.25,Other,225% of Medicaid,21.09,,,21.09,Other,260% of Medicaid,26.28,,,26.28,Other,324% of Medicaid,17.44,,,17.44,Other,215% of Medicaid,17.44,,,17.44,Other,215% of Medicaid,10.14,,,10.14,Other,125% of Medicaid,8.11,61.75,
EPSTEIN-BARR ANTIBODY,86663,CPT,,78086663,CDM,302,RC,,,both,,,86,63.64,,,63.64,Other,150% of Medicare + 9.63% HCRA Surcharge,38.7,45,,38.7,percent of total billed charges,Critical Access Hospital RCC factor,39.49,,,39.49,Fee Schedule,,35.56,,,35.56,Fee Schedule,,97.28,,,97.28,Fee Schedule,,87.5,,,87.5,Fee Schedule,,82.7,,,82.7,Fee Schedule,,42.57,,,42.57,Other,110% of Medicare,41.33,,,41.33,Fee Schedule,,24,,,24,Other,186% of Medicaid,48.68,,,48.68,Fee Schedule,,53.32,,,53.32,Fee Schedule,,27.55,,,27.55,Fee Schedule,,48.68,,,48.68,Fee Schedule,,53.32,,,53.32,Fee Schedule,,51.82,,,51.82,Fee Schedule,,60.2,70,,60.2,percent of total billed charges,All Other,62.18,,,62.18,Fee Schedule,,52.7,,,52.7,Fee Schedule,,19.68,,,19.68,Fee Schedule,,19.68,,,19.68,Fee Schedule,,19.68,,,19.68,Fee Schedule,,19.68,,,19.68,Fee Schedule,,13.12,,,13.12,Other,100% of Medicaid,13.12,,,13.12,Other,100% of Medicaid,13.12,,,13.12,Other,100% of Medicaid,13.12,,,13.12,Other,100% of Medicaid,29.52,,,29.52,Other,225% of Medicaid,20.07,,,20.07,Other,153% of Medicaid,29.52,,,29.52,Other,225% of Medicaid,18.37,,,18.37,Other,140% of Medicaid,29.52,,,29.52,Other,225% of Medicaid,34.11,,,34.11,Other,260% of Medicaid,42.51,,,42.51,Other,324% of Medicaid,28.21,,,28.21,Other,215% of Medicaid,28.21,,,28.21,Other,215% of Medicaid,16.4,,,16.4,Other,125% of Medicaid,13.12,97.28,
EPSTEIN-BARR ANTIBODY,86664,CPT,,78086664,CDM,302,RC,,,both,,,99,73.26,,,73.26,Other,150% of Medicare + 9.63% HCRA Surcharge,44.55,45,,44.55,percent of total billed charges,Critical Access Hospital RCC factor,46.02,,,46.02,Fee Schedule,,41.44,,,41.44,Fee Schedule,,113.46,,,113.46,Fee Schedule,,102.05,,,102.05,Fee Schedule,,96.45,,,96.45,Fee Schedule,,49.01,,,49.01,Other,110% of Medicare,48.16,,,48.16,Fee Schedule,,28,,,28,Other,186% of Medicaid,56.73,,,56.73,Fee Schedule,,61.38,,,61.38,Fee Schedule,,32.11,,,32.11,Fee Schedule,,56.73,,,56.73,Fee Schedule,,61.38,,,61.38,Fee Schedule,,60.4,,,60.4,Fee Schedule,,69.3,70,,69.3,percent of total billed charges,All Other,72.46,,,72.46,Fee Schedule,,61.41,,,61.41,Fee Schedule,,22.94,,,22.94,Fee Schedule,,22.94,,,22.94,Fee Schedule,,22.94,,,22.94,Fee Schedule,,22.94,,,22.94,Fee Schedule,,15.29,,,15.29,Other,100% of Medicaid,15.29,,,15.29,Other,100% of Medicaid,15.29,,,15.29,Other,100% of Medicaid,15.29,,,15.29,Other,100% of Medicaid,34.4,,,34.4,Other,225% of Medicaid,23.39,,,23.39,Other,153% of Medicaid,34.4,,,34.4,Other,225% of Medicaid,21.41,,,21.41,Other,140% of Medicaid,34.4,,,34.4,Other,225% of Medicaid,39.75,,,39.75,Other,260% of Medicaid,49.54,,,49.54,Other,324% of Medicaid,32.87,,,32.87,Other,215% of Medicaid,32.87,,,32.87,Other,215% of Medicaid,19.11,,,19.11,Other,125% of Medicaid,15.29,113.46,
EPSTEIN-BARR ANTIBODY,86665,CPT,,78086665,CDM,302,RC,,,both,,,117,86.58,,,86.58,Other,150% of Medicare + 9.63% HCRA Surcharge,52.65,45,,52.65,percent of total billed charges,Critical Access Hospital RCC factor,54.6,,,54.6,Fee Schedule,,49.16,,,49.16,Fee Schedule,,134.54,,,134.54,Fee Schedule,,121.01,,,121.01,Fee Schedule,,114.37,,,114.37,Fee Schedule,,57.92,,,57.92,Other,110% of Medicare,57.14,,,57.14,Fee Schedule,,34,,,34,Other,186% of Medicaid,67.3,,,67.3,Fee Schedule,,72.54,,,72.54,Fee Schedule,,38.09,,,38.09,Fee Schedule,,67.3,,,67.3,Fee Schedule,,72.54,,,72.54,Fee Schedule,,71.65,,,71.65,Fee Schedule,,81.9,70,,81.9,percent of total billed charges,All Other,85.97,,,85.97,Fee Schedule,,72.86,,,72.86,Fee Schedule,,27.21,,,27.21,Fee Schedule,,27.21,,,27.21,Fee Schedule,,27.21,,,27.21,Fee Schedule,,27.21,,,27.21,Fee Schedule,,18.14,,,18.14,Other,100% of Medicaid,18.14,,,18.14,Other,100% of Medicaid,18.14,,,18.14,Other,100% of Medicaid,18.14,,,18.14,Other,100% of Medicaid,40.82,,,40.82,Other,225% of Medicaid,27.75,,,27.75,Other,153% of Medicaid,40.82,,,40.82,Other,225% of Medicaid,25.4,,,25.4,Other,140% of Medicaid,40.82,,,40.82,Other,225% of Medicaid,47.16,,,47.16,Other,260% of Medicaid,58.77,,,58.77,Other,324% of Medicaid,39,,,39,Other,215% of Medicaid,39,,,39,Other,215% of Medicaid,22.68,,,22.68,Other,125% of Medicaid,18.14,134.54,
FRANCISELLA TULARENSIS,86668,CPT,,78086668,CDM,302,RC,,,both,,,109,80.66,,,80.66,Other,150% of Medicare + 9.63% HCRA Surcharge,49.05,45,,49.05,percent of total billed charges,Critical Access Hospital RCC factor,42.62,,,42.62,Fee Schedule,,38.37,,,38.37,Fee Schedule,,77.15,,,77.15,Fee Schedule,,69.39,,,69.39,Fee Schedule,,65.59,,,65.59,Fee Schedule,,53.96,,,53.96,Other,110% of Medicare,44.6,,,44.6,Fee Schedule,,22,,,22,Other,186% of Medicaid,52.53,,,52.53,Fee Schedule,,67.58,,,67.58,Fee Schedule,,29.74,,,29.74,Fee Schedule,,52.53,,,52.53,Fee Schedule,,67.58,,,67.58,Fee Schedule,,55.93,,,55.93,Fee Schedule,,76.3,70,,76.3,percent of total billed charges,All Other,67.1,,,67.1,Fee Schedule,,56.88,,,56.88,Fee Schedule,,21.24,,,21.24,Fee Schedule,,21.24,,,21.24,Fee Schedule,,21.24,,,21.24,Fee Schedule,,21.24,,,21.24,Fee Schedule,,11.62,,,11.62,Other,100% of Medicaid,11.62,,,11.62,Other,100% of Medicaid,11.62,,,11.62,Other,100% of Medicaid,11.62,,,11.62,Other,100% of Medicaid,26.13,,,26.13,Other,225% of Medicaid,17.77,,,17.77,Other,153% of Medicaid,26.13,,,26.13,Other,225% of Medicaid,16.26,,,16.26,Other,140% of Medicaid,26.13,,,26.13,Other,225% of Medicaid,30.2,,,30.2,Other,260% of Medicaid,37.63,,,37.63,Other,324% of Medicaid,24.97,,,24.97,Other,215% of Medicaid,24.97,,,24.97,Other,215% of Medicaid,14.52,,,14.52,Other,125% of Medicaid,11.62,80.66,
FUNGUS ANTIBODY,86671,CPT,,78086671,CDM,302,RC,,,both,,,132,97.68,,,97.68,Other,150% of Medicare + 9.63% HCRA Surcharge,59.4,45,,59.4,percent of total billed charges,Critical Access Hospital RCC factor,36.87,,,36.87,Fee Schedule,,33.2,,,33.2,Fee Schedule,,37.68,,,37.68,Fee Schedule,,33.89,,,33.89,Fee Schedule,,32.03,,,32.03,Fee Schedule,,65.34,,,65.34,Other,110% of Medicare,38.59,,,38.59,Fee Schedule,,0.01,,,0.01,Other,186% of Medicaid,45.45,,,45.45,Fee Schedule,,81.84,,,81.84,Fee Schedule,,25.73,,,25.73,Fee Schedule,,45.45,,,45.45,Fee Schedule,,81.84,,,81.84,Fee Schedule,,48.39,,,48.39,Fee Schedule,,92.4,70,,92.4,percent of total billed charges,All Other,58.05,,,58.05,Fee Schedule,,49.2,,,49.2,Fee Schedule,,18.38,,,18.38,Fee Schedule,,18.38,,,18.38,Fee Schedule,,18.38,,,18.38,Fee Schedule,,18.38,,,18.38,Fee Schedule,,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,97.68,
GIARDIA LAMBLIA ANTIBODY,86674,CPT,,78086674,CDM,302,RC,,,both,,,271,200.54,,,200.54,Other,150% of Medicare + 9.63% HCRA Surcharge,121.95,45,,121.95,percent of total billed charges,Critical Access Hospital RCC factor,44.31,,,44.31,Fee Schedule,,39.89,,,39.89,Fee Schedule,,109.19,,,109.19,Fee Schedule,,98.21,,,98.21,Fee Schedule,,92.83,,,92.83,Fee Schedule,,134.15,,,134.15,Other,110% of Medicare,46.37,,,46.37,Fee Schedule,,27,,,27,Other,186% of Medicaid,54.61,,,54.61,Fee Schedule,,168.02,,,168.02,Fee Schedule,,30.91,,,30.91,Fee Schedule,,54.61,,,54.61,Fee Schedule,,168.02,,,168.02,Fee Schedule,,58.14,,,58.14,Fee Schedule,,189.7,70,,189.7,percent of total billed charges,All Other,69.76,,,69.76,Fee Schedule,,59.12,,,59.12,Fee Schedule,,22.08,,,22.08,Fee Schedule,,22.08,,,22.08,Fee Schedule,,22.08,,,22.08,Fee Schedule,,22.08,,,22.08,Fee Schedule,,14.72,,,14.72,Other,100% of Medicaid,14.72,,,14.72,Other,100% of Medicaid,14.72,,,14.72,Other,100% of Medicaid,14.72,,,14.72,Other,100% of Medicaid,33.12,,,33.12,Other,225% of Medicaid,22.52,,,22.52,Other,153% of Medicaid,33.12,,,33.12,Other,225% of Medicaid,20.61,,,20.61,Other,140% of Medicaid,33.12,,,33.12,Other,225% of Medicaid,38.27,,,38.27,Other,260% of Medicaid,47.69,,,47.69,Other,324% of Medicaid,31.65,,,31.65,Other,215% of Medicaid,31.65,,,31.65,Other,215% of Medicaid,18.4,,,18.4,Other,125% of Medicaid,14.72,200.54,
HELMINTH ANTIBODY,86682,CPT,,78086682,CDM,302,RC,,,both,,,312,230.88,,,230.88,Other,150% of Medicare + 9.63% HCRA Surcharge,140.4,45,,140.4,percent of total billed charges,Critical Access Hospital RCC factor,39.16,,,39.16,Fee Schedule,,35.26,,,35.26,Fee Schedule,,43.11,,,43.11,Fee Schedule,,38.77,,,38.77,Fee Schedule,,36.65,,,36.65,Fee Schedule,,154.44,,,154.44,Other,110% of Medicare,40.98,,,40.98,Fee Schedule,,0.01,,,0.01,Other,186% of Medicaid,48.27,,,48.27,Fee Schedule,,193.44,,,193.44,Fee Schedule,,27.32,,,27.32,Fee Schedule,,48.27,,,48.27,Fee Schedule,,193.44,,,193.44,Fee Schedule,,51.39,,,51.39,Fee Schedule,,218.4,70,,218.4,percent of total billed charges,All Other,61.65,,,61.65,Fee Schedule,,52.26,,,52.26,Fee Schedule,,19.52,,,19.52,Fee Schedule,,19.52,,,19.52,Fee Schedule,,19.52,,,19.52,Fee Schedule,,19.52,,,19.52,Fee Schedule,,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,230.88,
HEMOPHILUS INFLUENZA ANTIBDY,86684,CPT,,78086684,CDM,302,RC,,,both,,,51,37.74,,,37.74,Other,150% of Medicare + 9.63% HCRA Surcharge,22.95,45,,22.95,percent of total billed charges,Critical Access Hospital RCC factor,47.68,,,47.68,Fee Schedule,,42.93,,,42.93,Fee Schedule,,117.52,,,117.52,Fee Schedule,,105.7,,,105.7,Fee Schedule,,99.9,,,99.9,Fee Schedule,,25.25,,,25.25,Other,110% of Medicare,49.9,,,49.9,Fee Schedule,,29,,,29,Other,186% of Medicaid,58.77,,,58.77,Fee Schedule,,31.62,,,31.62,Fee Schedule,,33.26,,,33.26,Fee Schedule,,58.77,,,58.77,Fee Schedule,,31.62,,,31.62,Fee Schedule,,62.57,,,62.57,Fee Schedule,,35.7,70,,35.7,percent of total billed charges,All Other,75.07,,,75.07,Fee Schedule,,63.62,,,63.62,Fee Schedule,,23.76,,,23.76,Fee Schedule,,23.76,,,23.76,Fee Schedule,,23.76,,,23.76,Fee Schedule,,23.76,,,23.76,Fee Schedule,,15.84,,,15.84,Other,100% of Medicaid,15.84,,,15.84,Other,100% of Medicaid,15.84,,,15.84,Other,100% of Medicaid,15.84,,,15.84,Other,100% of Medicaid,35.64,,,35.64,Other,225% of Medicaid,24.24,,,24.24,Other,153% of Medicaid,35.64,,,35.64,Other,225% of Medicaid,22.18,,,22.18,Other,140% of Medicaid,35.64,,,35.64,Other,225% of Medicaid,41.18,,,41.18,Other,260% of Medicaid,51.32,,,51.32,Other,324% of Medicaid,34.06,,,34.06,Other,215% of Medicaid,34.06,,,34.06,Other,215% of Medicaid,19.8,,,19.8,Other,125% of Medicaid,15.84,117.52,
HTLV-I ANTIBODY,86687,CPT,,78086687,CDM,302,RC,,,both,,,126,93.24,,,93.24,Other,150% of Medicare + 9.63% HCRA Surcharge,56.7,45,,56.7,percent of total billed charges,Critical Access Hospital RCC factor,27.36,,,27.36,Fee Schedule,,24.63,,,24.63,Fee Schedule,,62.24,,,62.24,Fee Schedule,,55.98,,,55.98,Fee Schedule,,52.91,,,52.91,Fee Schedule,,62.37,,,62.37,Other,110% of Medicare,28.63,,,28.63,Fee Schedule,,17,,,17,Other,186% of Medicaid,33.72,,,33.72,Fee Schedule,,78.12,,,78.12,Fee Schedule,,19.09,,,19.09,Fee Schedule,,33.72,,,33.72,Fee Schedule,,78.12,,,78.12,Fee Schedule,,35.91,,,35.91,Fee Schedule,,88.2,70,,88.2,percent of total billed charges,All Other,43.08,,,43.08,Fee Schedule,,36.51,,,36.51,Fee Schedule,,13.64,,,13.64,Fee Schedule,,13.64,,,13.64,Fee Schedule,,13.64,,,13.64,Fee Schedule,,13.64,,,13.64,Fee Schedule,,9.09,,,9.09,Other,100% of Medicaid,9.09,,,9.09,Other,100% of Medicaid,9.09,,,9.09,Other,100% of Medicaid,9.09,,,9.09,Other,100% of Medicaid,20.45,,,20.45,Other,225% of Medicaid,13.91,,,13.91,Other,153% of Medicaid,20.45,,,20.45,Other,225% of Medicaid,12.73,,,12.73,Other,140% of Medicaid,20.45,,,20.45,Other,225% of Medicaid,23.63,,,23.63,Other,260% of Medicaid,29.45,,,29.45,Other,324% of Medicaid,19.54,,,19.54,Other,215% of Medicaid,19.54,,,19.54,Other,215% of Medicaid,11.36,,,11.36,Other,125% of Medicaid,9.09,93.24,
HTLV OR HIV ANTIBODY WB,86689,CPT,,78086689,CDM,302,RC,,,both,,,116,85.84,,,85.84,Other,150% of Medicare + 9.63% HCRA Surcharge,52.2,45,,52.2,percent of total billed charges,Critical Access Hospital RCC factor,58.24,,,58.24,Fee Schedule,,52.44,,,52.44,Fee Schedule,,143.5,,,143.5,Fee Schedule,,129.07,,,129.07,Fee Schedule,,121.99,,,121.99,Fee Schedule,,57.42,,,57.42,Other,110% of Medicare,60.95,,,60.95,Fee Schedule,,36,,,36,Other,186% of Medicaid,71.79,,,71.79,Fee Schedule,,71.92,,,71.92,Fee Schedule,,40.64,,,40.64,Fee Schedule,,71.79,,,71.79,Fee Schedule,,71.92,,,71.92,Fee Schedule,,76.43,,,76.43,Fee Schedule,,81.2,70,,81.2,percent of total billed charges,All Other,91.7,,,91.7,Fee Schedule,,77.72,,,77.72,Fee Schedule,,29.03,,,29.03,Fee Schedule,,29.03,,,29.03,Fee Schedule,,29.03,,,29.03,Fee Schedule,,29.03,,,29.03,Fee Schedule,,19.35,,,19.35,Other,100% of Medicaid,19.35,,,19.35,Other,100% of Medicaid,19.35,,,19.35,Other,100% of Medicaid,19.35,,,19.35,Other,100% of Medicaid,43.54,,,43.54,Other,225% of Medicaid,29.61,,,29.61,Other,153% of Medicaid,43.54,,,43.54,Other,225% of Medicaid,27.09,,,27.09,Other,140% of Medicaid,43.54,,,43.54,Other,225% of Medicaid,50.31,,,50.31,Other,260% of Medicaid,62.69,,,62.69,Other,324% of Medicaid,41.6,,,41.6,Other,215% of Medicaid,41.6,,,41.6,Other,215% of Medicaid,24.19,,,24.19,Other,125% of Medicaid,19.35,143.5,
HEPATITIS DELTA AGENT,86692,CPT,,78086692,CDM,302,RC,,,both,,,166,122.84,,,122.84,Other,150% of Medicare + 9.63% HCRA Surcharge,74.7,45,,74.7,percent of total billed charges,Critical Access Hospital RCC factor,51.65,,,51.65,Fee Schedule,,46.5,,,46.5,Fee Schedule,,127.27,,,127.27,Fee Schedule,,114.47,,,114.47,Fee Schedule,,108.19,,,108.19,Fee Schedule,,82.17,,,82.17,Other,110% of Medicare,54.05,,,54.05,Fee Schedule,,32,,,32,Other,186% of Medicaid,63.66,,,63.66,Fee Schedule,,102.92,,,102.92,Fee Schedule,,36.04,,,36.04,Fee Schedule,,63.66,,,63.66,Fee Schedule,,102.92,,,102.92,Fee Schedule,,67.78,,,67.78,Fee Schedule,,116.2,70,,116.2,percent of total billed charges,All Other,81.32,,,81.32,Fee Schedule,,68.93,,,68.93,Fee Schedule,,25.74,,,25.74,Fee Schedule,,25.74,,,25.74,Fee Schedule,,25.74,,,25.74,Fee Schedule,,25.74,,,25.74,Fee Schedule,,17.16,,,17.16,Other,100% of Medicaid,17.16,,,17.16,Other,100% of Medicaid,17.16,,,17.16,Other,100% of Medicaid,17.16,,,17.16,Other,100% of Medicaid,38.61,,,38.61,Other,225% of Medicaid,26.25,,,26.25,Other,153% of Medicaid,38.61,,,38.61,Other,225% of Medicaid,24.02,,,24.02,Other,140% of Medicaid,38.61,,,38.61,Other,225% of Medicaid,44.62,,,44.62,Other,260% of Medicaid,55.6,,,55.6,Other,324% of Medicaid,36.89,,,36.89,Other,215% of Medicaid,36.89,,,36.89,Other,215% of Medicaid,21.45,,,21.45,Other,125% of Medicaid,17.16,127.27,
HERPES SIMPLEX TEST,86694,CPT,,78086694,CDM,302,RC,,,both,,,271,200.54,,,200.54,Other,150% of Medicare + 9.63% HCRA Surcharge,121.95,45,,121.95,percent of total billed charges,Critical Access Hospital RCC factor,43.31,,,43.31,Fee Schedule,,39,,,39,Fee Schedule,,106.72,,,106.72,Fee Schedule,,95.99,,,95.99,Fee Schedule,,90.72,,,90.72,Fee Schedule,,134.15,,,134.15,Other,110% of Medicare,45.33,,,45.33,Fee Schedule,,18,,,18,Other,186% of Medicaid,53.39,,,53.39,Fee Schedule,,168.02,,,168.02,Fee Schedule,,30.22,,,30.22,Fee Schedule,,53.39,,,53.39,Fee Schedule,,168.02,,,168.02,Fee Schedule,,56.84,,,56.84,Fee Schedule,,189.7,70,,189.7,percent of total billed charges,All Other,68.19,,,68.19,Fee Schedule,,57.8,,,57.8,Fee Schedule,,21.59,,,21.59,Fee Schedule,,21.59,,,21.59,Fee Schedule,,21.59,,,21.59,Fee Schedule,,21.59,,,21.59,Fee Schedule,,9.88,,,9.88,Other,100% of Medicaid,9.88,,,9.88,Other,100% of Medicaid,9.88,,,9.88,Other,100% of Medicaid,9.88,,,9.88,Other,100% of Medicaid,22.23,,,22.23,Other,225% of Medicaid,15.11,,,15.11,Other,153% of Medicaid,22.23,,,22.23,Other,225% of Medicaid,13.83,,,13.83,Other,140% of Medicaid,22.23,,,22.23,Other,225% of Medicaid,25.68,,,25.68,Other,260% of Medicaid,32.01,,,32.01,Other,324% of Medicaid,21.24,,,21.24,Other,215% of Medicaid,21.24,,,21.24,Other,215% of Medicaid,12.35,,,12.35,Other,125% of Medicaid,9.88,200.54,
HISTOPLASMA,86698,CPT,,78086698,CDM,302,RC,,,both,,,266,196.84,,,196.84,Other,150% of Medicare + 9.63% HCRA Surcharge,119.7,45,,119.7,percent of total billed charges,Critical Access Hospital RCC factor,41.51,,,41.51,Fee Schedule,,37.37,,,37.37,Fee Schedule,,83.27,,,83.27,Fee Schedule,,74.89,,,74.89,Fee Schedule,,70.78,,,70.78,Fee Schedule,,131.67,,,131.67,Other,110% of Medicare,43.44,,,43.44,Fee Schedule,,23,,,23,Other,186% of Medicaid,51.16,,,51.16,Fee Schedule,,164.92,,,164.92,Fee Schedule,,28.96,,,28.96,Fee Schedule,,51.16,,,51.16,Fee Schedule,,164.92,,,164.92,Fee Schedule,,54.47,,,54.47,Fee Schedule,,186.2,70,,186.2,percent of total billed charges,All Other,65.35,,,65.35,Fee Schedule,,55.39,,,55.39,Fee Schedule,,20.69,,,20.69,Fee Schedule,,20.69,,,20.69,Fee Schedule,,20.69,,,20.69,Fee Schedule,,20.69,,,20.69,Fee Schedule,,12.53,,,12.53,Other,100% of Medicaid,12.53,,,12.53,Other,100% of Medicaid,12.53,,,12.53,Other,100% of Medicaid,12.53,,,12.53,Other,100% of Medicaid,28.2,,,28.2,Other,225% of Medicaid,19.18,,,19.18,Other,153% of Medicaid,28.2,,,28.2,Other,225% of Medicaid,17.55,,,17.55,Other,140% of Medicaid,28.2,,,28.2,Other,225% of Medicaid,32.59,,,32.59,Other,260% of Medicaid,40.61,,,40.61,Other,324% of Medicaid,26.95,,,26.95,Other,215% of Medicaid,26.95,,,26.95,Other,215% of Medicaid,15.67,,,15.67,Other,125% of Medicaid,12.53,196.84,
AB; HIV-2,86702,CPT,,78086702,CDM,302,RC,,,both,,,88,65.12,,,65.12,Other,150% of Medicare + 9.63% HCRA Surcharge,39.6,45,,39.6,percent of total billed charges,Critical Access Hospital RCC factor,40.7,,,40.7,Fee Schedule,,36.64,,,36.64,Fee Schedule,,100.29,,,100.29,Fee Schedule,,90.2,,,90.2,Fee Schedule,,85.25,,,85.25,Fee Schedule,,43.56,,,43.56,Other,110% of Medicare,42.59,,,42.59,Fee Schedule,,25,,,25,Other,186% of Medicaid,50.16,,,50.16,Fee Schedule,,54.56,,,54.56,Fee Schedule,,28.39,,,28.39,Fee Schedule,,50.16,,,50.16,Fee Schedule,,54.56,,,54.56,Fee Schedule,,53.4,,,53.4,Fee Schedule,,61.6,70,,61.6,percent of total billed charges,All Other,64.07,,,64.07,Fee Schedule,,54.3,,,54.3,Fee Schedule,,20.28,,,20.28,Fee Schedule,,20.28,,,20.28,Fee Schedule,,20.28,,,20.28,Fee Schedule,,20.28,,,20.28,Fee Schedule,,13.52,,,13.52,Other,100% of Medicaid,13.52,,,13.52,Other,100% of Medicaid,13.52,,,13.52,Other,100% of Medicaid,13.52,,,13.52,Other,100% of Medicaid,30.42,,,30.42,Other,225% of Medicaid,20.69,,,20.69,Other,153% of Medicaid,30.42,,,30.42,Other,225% of Medicaid,18.93,,,18.93,Other,140% of Medicaid,30.42,,,30.42,Other,225% of Medicaid,35.15,,,35.15,Other,260% of Medicaid,43.8,,,43.8,Other,324% of Medicaid,29.07,,,29.07,Other,215% of Medicaid,29.07,,,29.07,Other,215% of Medicaid,16.9,,,16.9,Other,125% of Medicaid,13.52,100.29,
HIV-1/HIV-2 SINGLE ASSAY,86703,CPT,,78086703,CDM,302,RC,,,both,,,89,65.86,,,65.86,Other,150% of Medicare + 9.63% HCRA Surcharge,40.05,45,,40.05,percent of total billed charges,Critical Access Hospital RCC factor,41.27,,,41.27,Fee Schedule,,37.15,,,37.15,Fee Schedule,,101.71,,,101.71,Fee Schedule,,91.48,,,91.48,Fee Schedule,,86.46,,,86.46,Fee Schedule,,44.06,,,44.06,Other,110% of Medicare,43.19,,,43.19,Fee Schedule,,26,,,26,Other,186% of Medicaid,50.86,,,50.86,Fee Schedule,,55.18,,,55.18,Fee Schedule,,28.79,,,28.79,Fee Schedule,,50.86,,,50.86,Fee Schedule,,55.18,,,55.18,Fee Schedule,,54.15,,,54.15,Fee Schedule,,62.3,70,,62.3,percent of total billed charges,All Other,64.97,,,64.97,Fee Schedule,,55.07,,,55.07,Fee Schedule,,20.57,,,20.57,Fee Schedule,,20.57,,,20.57,Fee Schedule,,20.57,,,20.57,Fee Schedule,,20.57,,,20.57,Fee Schedule,,13.71,,,13.71,Other,100% of Medicaid,13.71,,,13.71,Other,100% of Medicaid,13.71,,,13.71,Other,100% of Medicaid,13.71,,,13.71,Other,100% of Medicaid,30.85,,,30.85,Other,225% of Medicaid,20.98,,,20.98,Other,153% of Medicaid,30.85,,,30.85,Other,225% of Medicaid,19.19,,,19.19,Other,140% of Medicaid,30.85,,,30.85,Other,225% of Medicaid,35.65,,,35.65,Other,260% of Medicaid,44.42,,,44.42,Other,324% of Medicaid,29.48,,,29.48,Other,215% of Medicaid,29.48,,,29.48,Other,215% of Medicaid,17.14,,,17.14,Other,125% of Medicaid,13.71,101.71,
HEP B CORE ANTIBODY TOTAL,86704,CPT,,78086704,CDM,302,RC,,,both,,,186,137.64,,,137.64,Other,150% of Medicare + 9.63% HCRA Surcharge,83.7,45,,83.7,percent of total billed charges,Critical Access Hospital RCC factor,36.27,,,36.27,Fee Schedule,,32.66,,,32.66,Fee Schedule,,89.38,,,89.38,Fee Schedule,,80.39,,,80.39,Fee Schedule,,75.98,,,75.98,Fee Schedule,,92.07,,,92.07,Other,110% of Medicare,37.96,,,37.96,Fee Schedule,,19,,,19,Other,186% of Medicaid,44.71,,,44.71,Fee Schedule,,115.32,,,115.32,Fee Schedule,,25.31,,,25.31,Fee Schedule,,44.71,,,44.71,Fee Schedule,,115.32,,,115.32,Fee Schedule,,47.6,,,47.6,Fee Schedule,,130.2,70,,130.2,percent of total billed charges,All Other,57.11,,,57.11,Fee Schedule,,48.4,,,48.4,Fee Schedule,,18.08,,,18.08,Fee Schedule,,18.08,,,18.08,Fee Schedule,,18.08,,,18.08,Fee Schedule,,18.08,,,18.08,Fee Schedule,,10.2,,,10.2,Other,100% of Medicaid,10.2,,,10.2,Other,100% of Medicaid,10.2,,,10.2,Other,100% of Medicaid,10.2,,,10.2,Other,100% of Medicaid,22.95,,,22.95,Other,225% of Medicaid,15.61,,,15.61,Other,153% of Medicaid,22.95,,,22.95,Other,225% of Medicaid,14.28,,,14.28,Other,140% of Medicaid,22.95,,,22.95,Other,225% of Medicaid,26.52,,,26.52,Other,260% of Medicaid,33.05,,,33.05,Other,324% of Medicaid,21.93,,,21.93,Other,215% of Medicaid,21.93,,,21.93,Other,215% of Medicaid,12.75,,,12.75,Other,125% of Medicaid,10.2,137.64,
HEP B CORE ANTIBODY IGM,86705,CPT,,78086705,CDM,302,RC,,,both,,,206,152.44,,,152.44,Other,150% of Medicare + 9.63% HCRA Surcharge,92.7,45,,92.7,percent of total billed charges,Critical Access Hospital RCC factor,35.43,,,35.43,Fee Schedule,,31.9,,,31.9,Fee Schedule,,87.27,,,87.27,Fee Schedule,,78.49,,,78.49,Fee Schedule,,74.19,,,74.19,Fee Schedule,,101.97,,,101.97,Other,110% of Medicare,37.08,,,37.08,Fee Schedule,,19,,,19,Other,186% of Medicaid,43.67,,,43.67,Fee Schedule,,127.72,,,127.72,Fee Schedule,,24.72,,,24.72,Fee Schedule,,43.67,,,43.67,Fee Schedule,,127.72,,,127.72,Fee Schedule,,46.49,,,46.49,Fee Schedule,,144.2,70,,144.2,percent of total billed charges,All Other,55.78,,,55.78,Fee Schedule,,47.28,,,47.28,Fee Schedule,,17.66,,,17.66,Fee Schedule,,17.66,,,17.66,Fee Schedule,,17.66,,,17.66,Fee Schedule,,17.66,,,17.66,Fee Schedule,,10.2,,,10.2,Other,100% of Medicaid,10.2,,,10.2,Other,100% of Medicaid,10.2,,,10.2,Other,100% of Medicaid,10.2,,,10.2,Other,100% of Medicaid,22.95,,,22.95,Other,225% of Medicaid,15.61,,,15.61,Other,153% of Medicaid,22.95,,,22.95,Other,225% of Medicaid,14.28,,,14.28,Other,140% of Medicaid,22.95,,,22.95,Other,225% of Medicaid,26.52,,,26.52,Other,260% of Medicaid,33.05,,,33.05,Other,324% of Medicaid,21.93,,,21.93,Other,215% of Medicaid,21.93,,,21.93,Other,215% of Medicaid,12.75,,,12.75,Other,125% of Medicaid,10.2,152.44,
HEP B SURFACE ANTIBODY,86706,CPT,,78086706,CDM,302,RC,,,both,,,182,134.68,,,134.68,Other,150% of Medicare + 9.63% HCRA Surcharge,81.9,45,,81.9,percent of total billed charges,Critical Access Hospital RCC factor,32.33,,,32.33,Fee Schedule,,29.11,,,29.11,Fee Schedule,,79.68,,,79.68,Fee Schedule,,71.67,,,71.67,Fee Schedule,,67.74,,,67.74,Fee Schedule,,90.09,,,90.09,Other,110% of Medicare,33.83,,,33.83,Fee Schedule,,19,,,19,Other,186% of Medicaid,39.85,,,39.85,Fee Schedule,,112.84,,,112.84,Fee Schedule,,22.55,,,22.55,Fee Schedule,,39.85,,,39.85,Fee Schedule,,112.84,,,112.84,Fee Schedule,,42.42,,,42.42,Fee Schedule,,127.4,70,,127.4,percent of total billed charges,All Other,50.9,,,50.9,Fee Schedule,,43.14,,,43.14,Fee Schedule,,16.11,,,16.11,Fee Schedule,,16.11,,,16.11,Fee Schedule,,16.11,,,16.11,Fee Schedule,,16.11,,,16.11,Fee Schedule,,10.2,,,10.2,Other,100% of Medicaid,10.2,,,10.2,Other,100% of Medicaid,10.2,,,10.2,Other,100% of Medicaid,10.2,,,10.2,Other,100% of Medicaid,22.95,,,22.95,Other,225% of Medicaid,15.61,,,15.61,Other,153% of Medicaid,22.95,,,22.95,Other,225% of Medicaid,14.28,,,14.28,Other,140% of Medicaid,22.95,,,22.95,Other,225% of Medicaid,26.52,,,26.52,Other,260% of Medicaid,33.05,,,33.05,Other,324% of Medicaid,21.93,,,21.93,Other,215% of Medicaid,21.93,,,21.93,Other,215% of Medicaid,12.75,,,12.75,Other,125% of Medicaid,10.2,134.68,
HEP BE ANTIBODY,86707,CPT,,78086707,CDM,302,RC,,,both,,,174,128.76,,,128.76,Other,150% of Medicare + 9.63% HCRA Surcharge,78.3,45,,78.3,percent of total billed charges,Critical Access Hospital RCC factor,34.83,,,34.83,Fee Schedule,,31.35,,,31.35,Fee Schedule,,85.8,,,85.8,Fee Schedule,,77.17,,,77.17,Fee Schedule,,72.93,,,72.93,Fee Schedule,,86.13,,,86.13,Other,110% of Medicare,36.45,,,36.45,Fee Schedule,,19,,,19,Other,186% of Medicaid,42.92,,,42.92,Fee Schedule,,107.88,,,107.88,Fee Schedule,,24.3,,,24.3,Fee Schedule,,42.92,,,42.92,Fee Schedule,,107.88,,,107.88,Fee Schedule,,45.7,,,45.7,Fee Schedule,,121.8,70,,121.8,percent of total billed charges,All Other,54.83,,,54.83,Fee Schedule,,46.47,,,46.47,Fee Schedule,,17.36,,,17.36,Fee Schedule,,17.36,,,17.36,Fee Schedule,,17.36,,,17.36,Fee Schedule,,17.36,,,17.36,Fee Schedule,,10.2,,,10.2,Other,100% of Medicaid,10.2,,,10.2,Other,100% of Medicaid,10.2,,,10.2,Other,100% of Medicaid,10.2,,,10.2,Other,100% of Medicaid,22.95,,,22.95,Other,225% of Medicaid,15.61,,,15.61,Other,153% of Medicaid,22.95,,,22.95,Other,225% of Medicaid,14.28,,,14.28,Other,140% of Medicaid,22.95,,,22.95,Other,225% of Medicaid,26.52,,,26.52,Other,260% of Medicaid,33.05,,,33.05,Other,324% of Medicaid,21.93,,,21.93,Other,215% of Medicaid,21.93,,,21.93,Other,215% of Medicaid,12.75,,,12.75,Other,125% of Medicaid,10.2,128.76,
HEP A ANTIBODY TOTAL,86708,CPT,,78086708,CDM,302,RC,,,both,,,168,124.32,,,124.32,Other,150% of Medicare + 9.63% HCRA Surcharge,75.6,45,,75.6,percent of total billed charges,Critical Access Hospital RCC factor,37.29,,,37.29,Fee Schedule,,33.58,,,33.58,Fee Schedule,,91.86,,,91.86,Fee Schedule,,82.62,,,82.62,Fee Schedule,,78.09,,,78.09,Fee Schedule,,83.16,,,83.16,Other,110% of Medicare,39.03,,,39.03,Fee Schedule,,19,,,19,Other,186% of Medicaid,45.97,,,45.97,Fee Schedule,,104.16,,,104.16,Fee Schedule,,26.02,,,26.02,Fee Schedule,,45.97,,,45.97,Fee Schedule,,104.16,,,104.16,Fee Schedule,,48.94,,,48.94,Fee Schedule,,117.6,70,,117.6,percent of total billed charges,All Other,58.72,,,58.72,Fee Schedule,,49.77,,,49.77,Fee Schedule,,18.59,,,18.59,Fee Schedule,,18.59,,,18.59,Fee Schedule,,18.59,,,18.59,Fee Schedule,,18.59,,,18.59,Fee Schedule,,10.1,,,10.1,Other,100% of Medicaid,10.1,,,10.1,Other,100% of Medicaid,10.1,,,10.1,Other,100% of Medicaid,10.1,,,10.1,Other,100% of Medicaid,22.73,,,22.73,Other,225% of Medicaid,15.45,,,15.45,Other,153% of Medicaid,22.73,,,22.73,Other,225% of Medicaid,14.14,,,14.14,Other,140% of Medicaid,22.73,,,22.73,Other,225% of Medicaid,26.26,,,26.26,Other,260% of Medicaid,32.72,,,32.72,Other,324% of Medicaid,21.72,,,21.72,Other,215% of Medicaid,21.72,,,21.72,Other,215% of Medicaid,12.63,,,12.63,Other,125% of Medicaid,10.1,124.32,
HEP A ANTIBODY IGM,86709,CPT,,78086709,CDM,302,RC,,,both,,,185,136.9,,,136.9,Other,150% of Medicare + 9.63% HCRA Surcharge,83.25,45,,83.25,percent of total billed charges,Critical Access Hospital RCC factor,33.89,,,33.89,Fee Schedule,,30.51,,,30.51,Fee Schedule,,83.48,,,83.48,Fee Schedule,,75.08,,,75.08,Fee Schedule,,70.96,,,70.96,Fee Schedule,,91.58,,,91.58,Other,110% of Medicare,35.47,,,35.47,Fee Schedule,,19,,,19,Other,186% of Medicaid,41.77,,,41.77,Fee Schedule,,114.7,,,114.7,Fee Schedule,,23.65,,,23.65,Fee Schedule,,41.77,,,41.77,Fee Schedule,,114.7,,,114.7,Fee Schedule,,44.48,,,44.48,Fee Schedule,,129.5,70,,129.5,percent of total billed charges,All Other,53.36,,,53.36,Fee Schedule,,45.23,,,45.23,Fee Schedule,,16.89,,,16.89,Fee Schedule,,16.89,,,16.89,Fee Schedule,,16.89,,,16.89,Fee Schedule,,16.89,,,16.89,Fee Schedule,,10.1,,,10.1,Other,100% of Medicaid,10.1,,,10.1,Other,100% of Medicaid,10.1,,,10.1,Other,100% of Medicaid,10.1,,,10.1,Other,100% of Medicaid,22.73,,,22.73,Other,225% of Medicaid,15.45,,,15.45,Other,153% of Medicaid,22.73,,,22.73,Other,225% of Medicaid,14.14,,,14.14,Other,140% of Medicaid,22.73,,,22.73,Other,225% of Medicaid,26.26,,,26.26,Other,260% of Medicaid,32.72,,,32.72,Other,324% of Medicaid,21.72,,,21.72,Other,215% of Medicaid,21.72,,,21.72,Other,215% of Medicaid,12.63,,,12.63,Other,125% of Medicaid,10.1,136.9,
INFLUENZA VIRUS ANTIBODY,86710,CPT,,78086710,CDM,302,RC,,,both,,,254,187.96,,,187.96,Other,150% of Medicare + 9.63% HCRA Surcharge,114.3,45,,114.3,percent of total billed charges,Critical Access Hospital RCC factor,40.79,,,40.79,Fee Schedule,,36.72,,,36.72,Fee Schedule,,100.55,,,100.55,Fee Schedule,,90.44,,,90.44,Fee Schedule,,85.48,,,85.48,Fee Schedule,,125.73,,,125.73,Other,110% of Medicare,42.68,,,42.68,Fee Schedule,,25,,,25,Other,186% of Medicaid,50.27,,,50.27,Fee Schedule,,157.48,,,157.48,Fee Schedule,,28.46,,,28.46,Fee Schedule,,50.27,,,50.27,Fee Schedule,,157.48,,,157.48,Fee Schedule,,53.52,,,53.52,Fee Schedule,,177.8,70,,177.8,percent of total billed charges,All Other,64.21,,,64.21,Fee Schedule,,54.43,,,54.43,Fee Schedule,,20.33,,,20.33,Fee Schedule,,20.33,,,20.33,Fee Schedule,,20.33,,,20.33,Fee Schedule,,20.33,,,20.33,Fee Schedule,,13.55,,,13.55,Other,100% of Medicaid,13.55,,,13.55,Other,100% of Medicaid,13.55,,,13.55,Other,100% of Medicaid,13.55,,,13.55,Other,100% of Medicaid,30.49,,,30.49,Other,225% of Medicaid,20.73,,,20.73,Other,153% of Medicaid,30.49,,,30.49,Other,225% of Medicaid,18.97,,,18.97,Other,140% of Medicaid,30.49,,,30.49,Other,225% of Medicaid,35.23,,,35.23,Other,260% of Medicaid,43.9,,,43.9,Other,324% of Medicaid,29.13,,,29.13,Other,215% of Medicaid,29.13,,,29.13,Other,215% of Medicaid,16.94,,,16.94,Other,125% of Medicaid,13.55,187.96,
JOHN CUNNINGHAM ANTIBODY,86711,CPT,,78086711,CDM,302,RC,,,both,,,54,39.96,,,39.96,Other,150% of Medicare + 9.63% HCRA Surcharge,24.3,45,,24.3,percent of total billed charges,Critical Access Hospital RCC factor,50.84,,,50.84,Fee Schedule,,45.77,,,45.77,Fee Schedule,,7.92,,,7.92,Fee Schedule,,7.92,,,7.92,Fee Schedule,,7.92,,,7.92,Fee Schedule,,26.73,,,26.73,Other,110% of Medicare,53.2,,,53.2,Fee Schedule,,18,,,18,Other,186% of Medicaid,62.66,,,62.66,Fee Schedule,,33.48,,,33.48,Fee Schedule,,35.47,,,35.47,Fee Schedule,,62.66,,,62.66,Fee Schedule,,33.48,,,33.48,Fee Schedule,,66.72,,,66.72,Fee Schedule,,37.8,70,,37.8,percent of total billed charges,All Other,80.04,,,80.04,Fee Schedule,,67.84,,,67.84,Fee Schedule,,25.34,,,25.34,Fee Schedule,,25.34,,,25.34,Fee Schedule,,25.34,,,25.34,Fee Schedule,,25.34,,,25.34,Fee Schedule,,9.88,,,9.88,Other,100% of Medicaid,9.88,,,9.88,Other,100% of Medicaid,9.88,,,9.88,Other,100% of Medicaid,9.88,,,9.88,Other,100% of Medicaid,22.23,,,22.23,Other,225% of Medicaid,15.11,,,15.11,Other,153% of Medicaid,22.23,,,22.23,Other,225% of Medicaid,13.83,,,13.83,Other,140% of Medicaid,22.23,,,22.23,Other,225% of Medicaid,25.68,,,25.68,Other,260% of Medicaid,32.01,,,32.01,Other,324% of Medicaid,21.24,,,21.24,Other,215% of Medicaid,21.24,,,21.24,Other,215% of Medicaid,12.35,,,12.35,Other,125% of Medicaid,7.92,80.04,
LEGIONELLA ANTIBODY,86713,CPT,,78086713,CDM,302,RC,,,both,,,275,203.5,,,203.5,Other,150% of Medicare + 9.63% HCRA Surcharge,123.75,45,,123.75,percent of total billed charges,Critical Access Hospital RCC factor,46.05,,,46.05,Fee Schedule,,41.46,,,41.46,Fee Schedule,,113.46,,,113.46,Fee Schedule,,102.05,,,102.05,Fee Schedule,,96.45,,,96.45,Fee Schedule,,136.13,,,136.13,Other,110% of Medicare,48.2,,,48.2,Fee Schedule,,28,,,28,Other,186% of Medicaid,56.76,,,56.76,Fee Schedule,,170.5,,,170.5,Fee Schedule,,32.13,,,32.13,Fee Schedule,,56.76,,,56.76,Fee Schedule,,170.5,,,170.5,Fee Schedule,,60.44,,,60.44,Fee Schedule,,192.5,70,,192.5,percent of total billed charges,All Other,72.51,,,72.51,Fee Schedule,,61.45,,,61.45,Fee Schedule,,22.95,,,22.95,Fee Schedule,,22.95,,,22.95,Fee Schedule,,22.95,,,22.95,Fee Schedule,,22.95,,,22.95,Fee Schedule,,15.3,,,15.3,Other,100% of Medicaid,15.3,,,15.3,Other,100% of Medicaid,15.3,,,15.3,Other,100% of Medicaid,15.3,,,15.3,Other,100% of Medicaid,34.43,,,34.43,Other,225% of Medicaid,23.41,,,23.41,Other,153% of Medicaid,34.43,,,34.43,Other,225% of Medicaid,21.42,,,21.42,Other,140% of Medicaid,34.43,,,34.43,Other,225% of Medicaid,39.78,,,39.78,Other,260% of Medicaid,49.57,,,49.57,Other,324% of Medicaid,32.9,,,32.9,Other,215% of Medicaid,32.9,,,32.9,Other,215% of Medicaid,19.13,,,19.13,Other,125% of Medicaid,15.3,203.5,
LEPTOSPIRA ANTIBODY,86720,CPT,,78086720,CDM,302,RC,,,both,,,252,186.48,,,186.48,Other,150% of Medicare + 9.63% HCRA Surcharge,113.4,45,,113.4,percent of total billed charges,Critical Access Hospital RCC factor,48.76,,,48.76,Fee Schedule,,43.9,,,43.9,Fee Schedule,,43.11,,,43.11,Fee Schedule,,38.77,,,38.77,Fee Schedule,,36.65,,,36.65,Fee Schedule,,124.74,,,124.74,Other,110% of Medicare,51.03,,,51.03,Fee Schedule,,15,,,15,Other,186% of Medicaid,60.1,,,60.1,Fee Schedule,,156.24,,,156.24,Fee Schedule,,34.02,,,34.02,Fee Schedule,,60.1,,,60.1,Fee Schedule,,156.24,,,156.24,Fee Schedule,,63.99,,,63.99,Fee Schedule,,176.4,70,,176.4,percent of total billed charges,All Other,76.77,,,76.77,Fee Schedule,,65.07,,,65.07,Fee Schedule,,24.3,,,24.3,Fee Schedule,,24.3,,,24.3,Fee Schedule,,24.3,,,24.3,Fee Schedule,,24.3,,,24.3,Fee Schedule,,8.11,,,8.11,Other,100% of Medicaid,8.11,,,8.11,Other,100% of Medicaid,8.11,,,8.11,Other,100% of Medicaid,8.11,,,8.11,Other,100% of Medicaid,18.25,,,18.25,Other,225% of Medicaid,12.41,,,12.41,Other,153% of Medicaid,18.25,,,18.25,Other,225% of Medicaid,11.35,,,11.35,Other,140% of Medicaid,18.25,,,18.25,Other,225% of Medicaid,21.09,,,21.09,Other,260% of Medicaid,26.28,,,26.28,Other,324% of Medicaid,17.44,,,17.44,Other,215% of Medicaid,17.44,,,17.44,Other,215% of Medicaid,10.14,,,10.14,Other,125% of Medicaid,8.11,186.48,
AB LCM,86727,CPT,,78086727,CDM,302,RC,,,both,,,42,31.08,,,31.08,Other,150% of Medicare + 9.63% HCRA Surcharge,18.9,45,,18.9,percent of total billed charges,Critical Access Hospital RCC factor,38.74,,,38.74,Fee Schedule,,34.88,,,34.88,Fee Schedule,,43.11,,,43.11,Fee Schedule,,38.77,,,38.77,Fee Schedule,,36.65,,,36.65,Fee Schedule,,20.79,,,20.79,Other,110% of Medicare,40.54,,,40.54,Fee Schedule,,15,,,15,Other,186% of Medicaid,47.75,,,47.75,Fee Schedule,,26.04,,,26.04,Fee Schedule,,27.03,,,27.03,Fee Schedule,,47.75,,,47.75,Fee Schedule,,26.04,,,26.04,Fee Schedule,,50.84,,,50.84,Fee Schedule,,29.4,70,,29.4,percent of total billed charges,All Other,60.99,,,60.99,Fee Schedule,,51.69,,,51.69,Fee Schedule,,19.31,,,19.31,Fee Schedule,,19.31,,,19.31,Fee Schedule,,19.31,,,19.31,Fee Schedule,,19.31,,,19.31,Fee Schedule,,8.11,,,8.11,Other,100% of Medicaid,8.11,,,8.11,Other,100% of Medicaid,8.11,,,8.11,Other,100% of Medicaid,8.11,,,8.11,Other,100% of Medicaid,18.25,,,18.25,Other,225% of Medicaid,12.41,,,12.41,Other,153% of Medicaid,18.25,,,18.25,Other,225% of Medicaid,11.35,,,11.35,Other,140% of Medicaid,18.25,,,18.25,Other,225% of Medicaid,21.09,,,21.09,Other,260% of Medicaid,26.28,,,26.28,Other,324% of Medicaid,17.44,,,17.44,Other,215% of Medicaid,17.44,,,17.44,Other,215% of Medicaid,10.14,,,10.14,Other,125% of Medicaid,8.11,60.99,
MYCOPLASMA ANTIBODY,86738,CPT,,78086738,CDM,302,RC,,,both,,,204,150.96,,,150.96,Other,150% of Medicare + 9.63% HCRA Surcharge,91.8,45,,91.8,percent of total billed charges,Critical Access Hospital RCC factor,39.85,,,39.85,Fee Schedule,,35.88,,,35.88,Fee Schedule,,98.23,,,98.23,Fee Schedule,,88.35,,,88.35,Fee Schedule,,83.51,,,83.51,Fee Schedule,,100.98,,,100.98,Other,110% of Medicare,41.71,,,41.71,Fee Schedule,,25,,,25,Other,186% of Medicaid,49.12,,,49.12,Fee Schedule,,126.48,,,126.48,Fee Schedule,,27.8,,,27.8,Fee Schedule,,49.12,,,49.12,Fee Schedule,,126.48,,,126.48,Fee Schedule,,52.3,,,52.3,Fee Schedule,,142.8,70,,142.8,percent of total billed charges,All Other,62.74,,,62.74,Fee Schedule,,53.18,,,53.18,Fee Schedule,,19.86,,,19.86,Fee Schedule,,19.86,,,19.86,Fee Schedule,,19.86,,,19.86,Fee Schedule,,19.86,,,19.86,Fee Schedule,,13.24,,,13.24,Other,100% of Medicaid,13.24,,,13.24,Other,100% of Medicaid,13.24,,,13.24,Other,100% of Medicaid,13.24,,,13.24,Other,100% of Medicaid,29.79,,,29.79,Other,225% of Medicaid,20.26,,,20.26,Other,153% of Medicaid,29.79,,,29.79,Other,225% of Medicaid,18.54,,,18.54,Other,140% of Medicaid,29.79,,,29.79,Other,225% of Medicaid,34.42,,,34.42,Other,260% of Medicaid,42.9,,,42.9,Other,324% of Medicaid,28.47,,,28.47,Other,215% of Medicaid,28.47,,,28.47,Other,215% of Medicaid,16.55,,,16.55,Other,125% of Medicaid,13.24,150.96,
PARVOVIRUS ANTIBODY,86747,CPT,,78086747,CDM,302,RC,,,both,,,170,125.8,,,125.8,Other,150% of Medicare + 9.63% HCRA Surcharge,76.5,45,,76.5,percent of total billed charges,Critical Access Hospital RCC factor,45.24,,,45.24,Fee Schedule,,40.73,,,40.73,Fee Schedule,,111.51,,,111.51,Fee Schedule,,100.3,,,100.3,Fee Schedule,,94.8,,,94.8,Fee Schedule,,84.15,,,84.15,Other,110% of Medicare,47.34,,,47.34,Fee Schedule,,28,,,28,Other,186% of Medicaid,55.76,,,55.76,Fee Schedule,,105.4,,,105.4,Fee Schedule,,31.56,,,31.56,Fee Schedule,,55.76,,,55.76,Fee Schedule,,105.4,,,105.4,Fee Schedule,,59.37,,,59.37,Fee Schedule,,119,70,,119,percent of total billed charges,All Other,71.23,,,71.23,Fee Schedule,,60.37,,,60.37,Fee Schedule,,22.55,,,22.55,Fee Schedule,,22.55,,,22.55,Fee Schedule,,22.55,,,22.55,Fee Schedule,,22.55,,,22.55,Fee Schedule,,15.03,,,15.03,Other,100% of Medicaid,15.03,,,15.03,Other,100% of Medicaid,15.03,,,15.03,Other,100% of Medicaid,15.03,,,15.03,Other,100% of Medicaid,33.82,,,33.82,Other,225% of Medicaid,23,,,23,Other,153% of Medicaid,33.82,,,33.82,Other,225% of Medicaid,21.04,,,21.04,Other,140% of Medicaid,33.82,,,33.82,Other,225% of Medicaid,39.08,,,39.08,Other,260% of Medicaid,48.7,,,48.7,Other,324% of Medicaid,32.31,,,32.31,Other,215% of Medicaid,32.31,,,32.31,Other,215% of Medicaid,18.79,,,18.79,Other,125% of Medicaid,15.03,125.8,
RESPIRATORY VIRUS ANTIBODY,86756,CPT,,78086756,CDM,302,RC,,,both,,,173,128.02,,,128.02,Other,150% of Medicare + 9.63% HCRA Surcharge,77.85,45,,77.85,percent of total billed charges,Critical Access Hospital RCC factor,47.83,,,47.83,Fee Schedule,,43.06,,,43.06,Fee Schedule,,43.11,,,43.11,Fee Schedule,,38.77,,,38.77,Fee Schedule,,36.65,,,36.65,Fee Schedule,,85.64,,,85.64,Other,110% of Medicare,50.05,,,50.05,Fee Schedule,,15,,,15,Other,186% of Medicaid,58.95,,,58.95,Fee Schedule,,107.26,,,107.26,Fee Schedule,,33.37,,,33.37,Fee Schedule,,58.95,,,58.95,Fee Schedule,,107.26,,,107.26,Fee Schedule,,62.77,,,62.77,Fee Schedule,,121.1,70,,121.1,percent of total billed charges,All Other,75.3,,,75.3,Fee Schedule,,63.82,,,63.82,Fee Schedule,,23.84,,,23.84,Fee Schedule,,23.84,,,23.84,Fee Schedule,,23.84,,,23.84,Fee Schedule,,23.84,,,23.84,Fee Schedule,,8.11,,,8.11,Other,100% of Medicaid,8.11,,,8.11,Other,100% of Medicaid,8.11,,,8.11,Other,100% of Medicaid,8.11,,,8.11,Other,100% of Medicaid,18.25,,,18.25,Other,225% of Medicaid,12.41,,,12.41,Other,153% of Medicaid,18.25,,,18.25,Other,225% of Medicaid,11.35,,,11.35,Other,140% of Medicaid,18.25,,,18.25,Other,225% of Medicaid,21.09,,,21.09,Other,260% of Medicaid,26.28,,,26.28,Other,324% of Medicaid,17.44,,,17.44,Other,215% of Medicaid,17.44,,,17.44,Other,215% of Medicaid,10.14,,,10.14,Other,125% of Medicaid,8.11,128.02,
RICKETTSIA ANTIBODY,86757,CPT,,78086757,CDM,302,RC,,,both,,,272,201.28,,,201.28,Other,150% of Medicare + 9.63% HCRA Surcharge,122.4,45,,122.4,percent of total billed charges,Critical Access Hospital RCC factor,58.24,,,58.24,Fee Schedule,,52.44,,,52.44,Fee Schedule,,143.5,,,143.5,Fee Schedule,,129.07,,,129.07,Fee Schedule,,121.99,,,121.99,Fee Schedule,,134.64,,,134.64,Other,110% of Medicare,60.95,,,60.95,Fee Schedule,,36,,,36,Other,186% of Medicaid,71.79,,,71.79,Fee Schedule,,168.64,,,168.64,Fee Schedule,,40.64,,,40.64,Fee Schedule,,71.79,,,71.79,Fee Schedule,,168.64,,,168.64,Fee Schedule,,76.43,,,76.43,Fee Schedule,,190.4,70,,190.4,percent of total billed charges,All Other,91.7,,,91.7,Fee Schedule,,77.72,,,77.72,Fee Schedule,,29.03,,,29.03,Fee Schedule,,29.03,,,29.03,Fee Schedule,,29.03,,,29.03,Fee Schedule,,29.03,,,29.03,Fee Schedule,,19.35,,,19.35,Other,100% of Medicaid,19.35,,,19.35,Other,100% of Medicaid,19.35,,,19.35,Other,100% of Medicaid,19.35,,,19.35,Other,100% of Medicaid,43.54,,,43.54,Other,225% of Medicaid,29.61,,,29.61,Other,153% of Medicaid,43.54,,,43.54,Other,225% of Medicaid,27.09,,,27.09,Other,140% of Medicaid,43.54,,,43.54,Other,225% of Medicaid,50.31,,,50.31,Other,260% of Medicaid,62.69,,,62.69,Other,324% of Medicaid,41.6,,,41.6,Other,215% of Medicaid,41.6,,,41.6,Other,215% of Medicaid,24.19,,,24.19,Other,125% of Medicaid,19.35,201.28,
ROTAVIRUS ANTIBODY,86759,CPT,,78086759,CDM,302,RC,,,both,,,219,162.06,,,162.06,Other,150% of Medicare + 9.63% HCRA Surcharge,98.55,45,,98.55,percent of total billed charges,Critical Access Hospital RCC factor,54.87,,,54.87,Fee Schedule,,49.4,,,49.4,Fee Schedule,,97.81,,,97.81,Fee Schedule,,87.97,,,87.97,Fee Schedule,,83.15,,,83.15,Fee Schedule,,108.41,,,108.41,Other,110% of Medicare,57.42,,,57.42,Fee Schedule,,27,,,27,Other,186% of Medicaid,67.63,,,67.63,Fee Schedule,,135.78,,,135.78,Fee Schedule,,38.28,,,38.28,Fee Schedule,,67.63,,,67.63,Fee Schedule,,135.78,,,135.78,Fee Schedule,,72.01,,,72.01,Fee Schedule,,153.3,70,,153.3,percent of total billed charges,All Other,86.39,,,86.39,Fee Schedule,,73.22,,,73.22,Fee Schedule,,27.35,,,27.35,Fee Schedule,,27.35,,,27.35,Fee Schedule,,27.35,,,27.35,Fee Schedule,,27.35,,,27.35,Fee Schedule,,14.73,,,14.73,Other,100% of Medicaid,14.73,,,14.73,Other,100% of Medicaid,14.73,,,14.73,Other,100% of Medicaid,14.73,,,14.73,Other,100% of Medicaid,33.13,,,33.13,Other,225% of Medicaid,22.53,,,22.53,Other,153% of Medicaid,33.13,,,33.13,Other,225% of Medicaid,20.62,,,20.62,Other,140% of Medicaid,33.13,,,33.13,Other,225% of Medicaid,38.29,,,38.29,Other,260% of Medicaid,47.71,,,47.71,Other,324% of Medicaid,31.66,,,31.66,Other,215% of Medicaid,31.66,,,31.66,Other,215% of Medicaid,18.41,,,18.41,Other,125% of Medicaid,14.73,162.06,
RUBELLA ANTIBODY,86762,CPT,,78086762,CDM,302,RC,,,both,,,132,97.68,,,97.68,Other,150% of Medicare + 9.63% HCRA Surcharge,59.4,45,,59.4,percent of total billed charges,Critical Access Hospital RCC factor,43.31,,,43.31,Fee Schedule,,39,,,39,Fee Schedule,,106.72,,,106.72,Fee Schedule,,95.99,,,95.99,Fee Schedule,,90.72,,,90.72,Fee Schedule,,65.34,,,65.34,Other,110% of Medicare,45.33,,,45.33,Fee Schedule,,27,,,27,Other,186% of Medicaid,53.39,,,53.39,Fee Schedule,,81.84,,,81.84,Fee Schedule,,30.22,,,30.22,Fee Schedule,,53.39,,,53.39,Fee Schedule,,81.84,,,81.84,Fee Schedule,,56.84,,,56.84,Fee Schedule,,92.4,70,,92.4,percent of total billed charges,All Other,68.19,,,68.19,Fee Schedule,,57.8,,,57.8,Fee Schedule,,21.59,,,21.59,Fee Schedule,,21.59,,,21.59,Fee Schedule,,21.59,,,21.59,Fee Schedule,,21.59,,,21.59,Fee Schedule,,14.39,,,14.39,Other,100% of Medicaid,14.39,,,14.39,Other,100% of Medicaid,14.39,,,14.39,Other,100% of Medicaid,14.39,,,14.39,Other,100% of Medicaid,32.38,,,32.38,Other,225% of Medicaid,22.02,,,22.02,Other,153% of Medicaid,32.38,,,32.38,Other,225% of Medicaid,20.15,,,20.15,Other,140% of Medicaid,32.38,,,32.38,Other,225% of Medicaid,37.41,,,37.41,Other,260% of Medicaid,46.62,,,46.62,Other,324% of Medicaid,30.94,,,30.94,Other,215% of Medicaid,30.94,,,30.94,Other,215% of Medicaid,17.99,,,17.99,Other,125% of Medicaid,14.39,106.72,
RUBEOLA ANTIBODY,86765,CPT,,78086765,CDM,302,RC,,,both,,,132,97.68,,,97.68,Other,150% of Medicare + 9.63% HCRA Surcharge,59.4,45,,59.4,percent of total billed charges,Critical Access Hospital RCC factor,38.77,,,38.77,Fee Schedule,,34.9,,,34.9,Fee Schedule,,95.55,,,95.55,Fee Schedule,,85.94,,,85.94,Fee Schedule,,81.22,,,81.22,Fee Schedule,,65.34,,,65.34,Other,110% of Medicare,40.57,,,40.57,Fee Schedule,,24,,,24,Other,186% of Medicaid,47.78,,,47.78,Fee Schedule,,81.84,,,81.84,Fee Schedule,,27.05,,,27.05,Fee Schedule,,47.78,,,47.78,Fee Schedule,,81.84,,,81.84,Fee Schedule,,50.88,,,50.88,Fee Schedule,,92.4,70,,92.4,percent of total billed charges,All Other,61.04,,,61.04,Fee Schedule,,51.73,,,51.73,Fee Schedule,,19.32,,,19.32,Fee Schedule,,19.32,,,19.32,Fee Schedule,,19.32,,,19.32,Fee Schedule,,19.32,,,19.32,Fee Schedule,,12.88,,,12.88,Other,100% of Medicaid,12.88,,,12.88,Other,100% of Medicaid,12.88,,,12.88,Other,100% of Medicaid,12.88,,,12.88,Other,100% of Medicaid,28.98,,,28.98,Other,225% of Medicaid,19.71,,,19.71,Other,153% of Medicaid,28.98,,,28.98,Other,225% of Medicaid,18.03,,,18.03,Other,140% of Medicaid,28.98,,,28.98,Other,225% of Medicaid,33.49,,,33.49,Other,260% of Medicaid,41.73,,,41.73,Other,324% of Medicaid,27.69,,,27.69,Other,215% of Medicaid,27.69,,,27.69,Other,215% of Medicaid,16.1,,,16.1,Other,125% of Medicaid,12.88,97.68,
SALMONELLA ANTIBODY,86768,CPT,,78086768,CDM,302,RC,,,both,,,42,31.08,,,31.08,Other,150% of Medicare + 9.63% HCRA Surcharge,18.9,45,,18.9,percent of total billed charges,Critical Access Hospital RCC factor,39.7,,,39.7,Fee Schedule,,35.74,,,35.74,Fee Schedule,,60.66,,,60.66,Fee Schedule,,54.56,,,54.56,Fee Schedule,,51.56,,,51.56,Fee Schedule,,20.79,,,20.79,Other,110% of Medicare,41.55,,,41.55,Fee Schedule,,17,,,17,Other,186% of Medicaid,48.93,,,48.93,Fee Schedule,,26.04,,,26.04,Fee Schedule,,27.7,,,27.7,Fee Schedule,,48.93,,,48.93,Fee Schedule,,26.04,,,26.04,Fee Schedule,,52.1,,,52.1,Fee Schedule,,29.4,70,,29.4,percent of total billed charges,All Other,62.51,,,62.51,Fee Schedule,,52.98,,,52.98,Fee Schedule,,19.79,,,19.79,Fee Schedule,,19.79,,,19.79,Fee Schedule,,19.79,,,19.79,Fee Schedule,,19.79,,,19.79,Fee Schedule,,9.14,,,9.14,Other,100% of Medicaid,9.14,,,9.14,Other,100% of Medicaid,9.14,,,9.14,Other,100% of Medicaid,9.14,,,9.14,Other,100% of Medicaid,20.57,,,20.57,Other,225% of Medicaid,13.98,,,13.98,Other,153% of Medicaid,20.57,,,20.57,Other,225% of Medicaid,12.8,,,12.8,Other,140% of Medicaid,20.57,,,20.57,Other,225% of Medicaid,23.77,,,23.77,Other,260% of Medicaid,29.62,,,29.62,Other,324% of Medicaid,19.65,,,19.65,Other,215% of Medicaid,19.65,,,19.65,Other,215% of Medicaid,11.43,,,11.43,Other,125% of Medicaid,9.14,62.51,
SARS-COV-2 COVID-19 ANTIBODY,86769,CPT,,78086769,CDM,302,RC,,,both,,,170,125.8,,,125.8,Other,150% of Medicare + 9.63% HCRA Surcharge,76.5,45,,76.5,percent of total billed charges,Critical Access Hospital RCC factor,126.81,,,126.81,Fee Schedule,,114.17,,,114.17,Fee Schedule,,19.38,,,19.38,Fee Schedule,,19.38,,,19.38,Fee Schedule,,19.38,,,19.38,Fee Schedule,,84.15,,,84.15,Other,110% of Medicare,132.71,,,132.71,Fee Schedule,,47,,,47,Other,186% of Medicaid,156.3,,,156.3,Fee Schedule,,105.4,,,105.4,Fee Schedule,,88.47,,,88.47,Fee Schedule,,156.3,,,156.3,Fee Schedule,,105.4,,,105.4,Fee Schedule,,166.41,,,166.41,Fee Schedule,,119,70,,119,percent of total billed charges,All Other,199.66,,,199.66,Fee Schedule,,169.22,,,169.22,Fee Schedule,,63.2,,,63.2,Fee Schedule,,63.2,,,63.2,Fee Schedule,,63.2,,,63.2,Fee Schedule,,63.2,,,63.2,Fee Schedule,,25.28,,,25.28,Other,100% of Medicaid,25.28,,,25.28,Other,100% of Medicaid,25.28,,,25.28,Other,100% of Medicaid,25.28,,,25.28,Other,100% of Medicaid,56.88,,,56.88,Other,225% of Medicaid,38.68,,,38.68,Other,153% of Medicaid,56.88,,,56.88,Other,225% of Medicaid,35.39,,,35.39,Other,140% of Medicaid,56.88,,,56.88,Other,225% of Medicaid,65.73,,,65.73,Other,260% of Medicaid,81.91,,,81.91,Other,324% of Medicaid,54.35,,,54.35,Other,215% of Medicaid,54.35,,,54.35,Other,215% of Medicaid,31.6,,,31.6,Other,125% of Medicaid,19.38,199.66,
TETANUS ANTIBODY,86774,CPT,,78086774,CDM,302,RC,,,both,,,247,182.78,,,182.78,Other,150% of Medicare + 9.63% HCRA Surcharge,111.15,45,,111.15,percent of total billed charges,Critical Access Hospital RCC factor,44.55,,,44.55,Fee Schedule,,40.11,,,40.11,Fee Schedule,,109.72,,,109.72,Fee Schedule,,98.69,,,98.69,Fee Schedule,,93.27,,,93.27,Fee Schedule,,122.27,,,122.27,Other,110% of Medicare,46.62,,,46.62,Fee Schedule,,18,,,18,Other,186% of Medicaid,54.91,,,54.91,Fee Schedule,,153.14,,,153.14,Fee Schedule,,31.08,,,31.08,Fee Schedule,,54.91,,,54.91,Fee Schedule,,153.14,,,153.14,Fee Schedule,,58.46,,,58.46,Fee Schedule,,172.9,70,,172.9,percent of total billed charges,All Other,70.14,,,70.14,Fee Schedule,,59.45,,,59.45,Fee Schedule,,22.2,,,22.2,Fee Schedule,,22.2,,,22.2,Fee Schedule,,22.2,,,22.2,Fee Schedule,,22.2,,,22.2,Fee Schedule,,9.88,,,9.88,Other,100% of Medicaid,9.88,,,9.88,Other,100% of Medicaid,9.88,,,9.88,Other,100% of Medicaid,9.88,,,9.88,Other,100% of Medicaid,22.23,,,22.23,Other,225% of Medicaid,15.11,,,15.11,Other,153% of Medicaid,22.23,,,22.23,Other,225% of Medicaid,13.83,,,13.83,Other,140% of Medicaid,22.23,,,22.23,Other,225% of Medicaid,25.68,,,25.68,Other,260% of Medicaid,32.01,,,32.01,Other,324% of Medicaid,21.24,,,21.24,Other,215% of Medicaid,21.24,,,21.24,Other,215% of Medicaid,12.35,,,12.35,Other,125% of Medicaid,9.88,182.78,
TOXOPLASMA ANTIBODY IGM,86778,CPT,,78086778,CDM,302,RC,,,both,,,324,239.76,,,239.76,Other,150% of Medicare + 9.63% HCRA Surcharge,145.8,45,,145.8,percent of total billed charges,Critical Access Hospital RCC factor,43.37,,,43.37,Fee Schedule,,39.05,,,39.05,Fee Schedule,,94.7,,,94.7,Fee Schedule,,85.18,,,85.18,Fee Schedule,,80.51,,,80.51,Fee Schedule,,160.38,,,160.38,Other,110% of Medicare,45.39,,,45.39,Fee Schedule,,27,,,27,Other,186% of Medicaid,53.46,,,53.46,Fee Schedule,,200.88,,,200.88,Fee Schedule,,30.26,,,30.26,Fee Schedule,,53.46,,,53.46,Fee Schedule,,200.88,,,200.88,Fee Schedule,,56.92,,,56.92,Fee Schedule,,226.8,70,,226.8,percent of total billed charges,All Other,68.29,,,68.29,Fee Schedule,,57.88,,,57.88,Fee Schedule,,21.62,,,21.62,Fee Schedule,,21.62,,,21.62,Fee Schedule,,21.62,,,21.62,Fee Schedule,,21.62,,,21.62,Fee Schedule,,14.26,,,14.26,Other,100% of Medicaid,14.26,,,14.26,Other,100% of Medicaid,14.26,,,14.26,Other,100% of Medicaid,14.26,,,14.26,Other,100% of Medicaid,32.09,,,32.09,Other,225% of Medicaid,21.82,,,21.82,Other,153% of Medicaid,32.09,,,32.09,Other,225% of Medicaid,19.97,,,19.97,Other,140% of Medicaid,32.09,,,32.09,Other,225% of Medicaid,37.08,,,37.08,Other,260% of Medicaid,46.21,,,46.21,Other,324% of Medicaid,30.66,,,30.66,Other,215% of Medicaid,30.66,,,30.66,Other,215% of Medicaid,17.83,,,17.83,Other,125% of Medicaid,14.26,239.76,
TREPONEMA PALLIDUM,86780,CPT,,78086780,CDM,302,RC,,,both,,,218,161.32,,,161.32,Other,150% of Medicare + 9.63% HCRA Surcharge,98.1,45,,98.1,percent of total billed charges,Critical Access Hospital RCC factor,39.85,,,39.85,Fee Schedule,,35.88,,,35.88,Fee Schedule,,98.18,,,98.18,Fee Schedule,,88.31,,,88.31,Fee Schedule,,83.46,,,83.46,Fee Schedule,,107.91,,,107.91,Other,110% of Medicare,41.71,,,41.71,Fee Schedule,,24,,,24,Other,186% of Medicaid,49.12,,,49.12,Fee Schedule,,135.16,,,135.16,Fee Schedule,,27.8,,,27.8,Fee Schedule,,49.12,,,49.12,Fee Schedule,,135.16,,,135.16,Fee Schedule,,52.3,,,52.3,Fee Schedule,,152.6,70,,152.6,percent of total billed charges,All Other,62.74,,,62.74,Fee Schedule,,53.18,,,53.18,Fee Schedule,,19.86,,,19.86,Fee Schedule,,19.86,,,19.86,Fee Schedule,,19.86,,,19.86,Fee Schedule,,19.86,,,19.86,Fee Schedule,,12.76,,,12.76,Other,100% of Medicaid,12.76,,,12.76,Other,100% of Medicaid,12.76,,,12.76,Other,100% of Medicaid,12.76,,,12.76,Other,100% of Medicaid,28.7,,,28.7,Other,225% of Medicaid,19.52,,,19.52,Other,153% of Medicaid,28.7,,,28.7,Other,225% of Medicaid,17.86,,,17.86,Other,140% of Medicaid,28.7,,,28.7,Other,225% of Medicaid,33.17,,,33.17,Other,260% of Medicaid,41.33,,,41.33,Other,324% of Medicaid,27.43,,,27.43,Other,215% of Medicaid,27.43,,,27.43,Other,215% of Medicaid,15.95,,,15.95,Other,125% of Medicaid,12.76,161.32,
VARICELLA-ZOSTER ANTIBODY,86787,CPT,,78086787,CDM,302,RC,,,both,,,224,165.76,,,165.76,Other,150% of Medicare + 9.63% HCRA Surcharge,100.8,45,,100.8,percent of total billed charges,Critical Access Hospital RCC factor,38.77,,,38.77,Fee Schedule,,34.9,,,34.9,Fee Schedule,,43.11,,,43.11,Fee Schedule,,38.77,,,38.77,Fee Schedule,,36.65,,,36.65,Fee Schedule,,110.88,,,110.88,Other,110% of Medicare,40.57,,,40.57,Fee Schedule,,15,,,15,Other,186% of Medicaid,47.78,,,47.78,Fee Schedule,,138.88,,,138.88,Fee Schedule,,27.05,,,27.05,Fee Schedule,,47.78,,,47.78,Fee Schedule,,138.88,,,138.88,Fee Schedule,,50.88,,,50.88,Fee Schedule,,156.8,70,,156.8,percent of total billed charges,All Other,61.04,,,61.04,Fee Schedule,,51.73,,,51.73,Fee Schedule,,19.32,,,19.32,Fee Schedule,,19.32,,,19.32,Fee Schedule,,19.32,,,19.32,Fee Schedule,,19.32,,,19.32,Fee Schedule,,8.11,,,8.11,Other,100% of Medicaid,8.11,,,8.11,Other,100% of Medicaid,8.11,,,8.11,Other,100% of Medicaid,8.11,,,8.11,Other,100% of Medicaid,18.25,,,18.25,Other,225% of Medicaid,12.41,,,12.41,Other,153% of Medicaid,18.25,,,18.25,Other,225% of Medicaid,11.35,,,11.35,Other,140% of Medicaid,18.25,,,18.25,Other,225% of Medicaid,21.09,,,21.09,Other,260% of Medicaid,26.28,,,26.28,Other,324% of Medicaid,17.44,,,17.44,Other,215% of Medicaid,17.44,,,17.44,Other,215% of Medicaid,10.14,,,10.14,Other,125% of Medicaid,8.11,165.76,
WEST NILE VIRUS AB IGM,86788,CPT,,78086788,CDM,302,RC,,,both,,,41,30.34,,,30.34,Other,150% of Medicare + 9.63% HCRA Surcharge,18.45,45,,18.45,percent of total billed charges,Critical Access Hospital RCC factor,50.72,,,50.72,Fee Schedule,,45.66,,,45.66,Fee Schedule,,43.11,,,43.11,Fee Schedule,,38.77,,,38.77,Fee Schedule,,36.65,,,36.65,Fee Schedule,,20.3,,,20.3,Other,110% of Medicare,53.08,,,53.08,Fee Schedule,,15,,,15,Other,186% of Medicaid,62.51,,,62.51,Fee Schedule,,25.42,,,25.42,Fee Schedule,,35.39,,,35.39,Fee Schedule,,62.51,,,62.51,Fee Schedule,,25.42,,,25.42,Fee Schedule,,66.56,,,66.56,Fee Schedule,,28.7,70,,28.7,percent of total billed charges,All Other,79.85,,,79.85,Fee Schedule,,67.68,,,67.68,Fee Schedule,,25.28,,,25.28,Fee Schedule,,25.28,,,25.28,Fee Schedule,,25.28,,,25.28,Fee Schedule,,25.28,,,25.28,Fee Schedule,,8.11,,,8.11,Other,100% of Medicaid,8.11,,,8.11,Other,100% of Medicaid,8.11,,,8.11,Other,100% of Medicaid,8.11,,,8.11,Other,100% of Medicaid,18.25,,,18.25,Other,225% of Medicaid,12.41,,,12.41,Other,153% of Medicaid,18.25,,,18.25,Other,225% of Medicaid,11.35,,,11.35,Other,140% of Medicaid,18.25,,,18.25,Other,225% of Medicaid,21.09,,,21.09,Other,260% of Medicaid,26.28,,,26.28,Other,324% of Medicaid,17.44,,,17.44,Other,215% of Medicaid,17.44,,,17.44,Other,215% of Medicaid,10.14,,,10.14,Other,125% of Medicaid,8.11,79.85,
WEST NILE VIRUS ANTIBODY,86789,CPT,,78086789,CDM,302,RC,,,both,,,107,79.18,,,79.18,Other,150% of Medicare + 9.63% HCRA Surcharge,48.15,45,,48.15,percent of total billed charges,Critical Access Hospital RCC factor,43.31,,,43.31,Fee Schedule,,39,,,39,Fee Schedule,,106.72,,,106.72,Fee Schedule,,95.99,,,95.99,Fee Schedule,,90.72,,,90.72,Fee Schedule,,52.97,,,52.97,Other,110% of Medicare,45.33,,,45.33,Fee Schedule,,27,,,27,Other,186% of Medicaid,53.39,,,53.39,Fee Schedule,,66.34,,,66.34,Fee Schedule,,30.22,,,30.22,Fee Schedule,,53.39,,,53.39,Fee Schedule,,66.34,,,66.34,Fee Schedule,,56.84,,,56.84,Fee Schedule,,74.9,70,,74.9,percent of total billed charges,All Other,68.19,,,68.19,Fee Schedule,,57.8,,,57.8,Fee Schedule,,21.59,,,21.59,Fee Schedule,,21.59,,,21.59,Fee Schedule,,21.59,,,21.59,Fee Schedule,,21.59,,,21.59,Fee Schedule,,14.39,,,14.39,Other,100% of Medicaid,14.39,,,14.39,Other,100% of Medicaid,14.39,,,14.39,Other,100% of Medicaid,14.39,,,14.39,Other,100% of Medicaid,32.38,,,32.38,Other,225% of Medicaid,22.02,,,22.02,Other,153% of Medicaid,32.38,,,32.38,Other,225% of Medicaid,20.15,,,20.15,Other,140% of Medicaid,32.38,,,32.38,Other,225% of Medicaid,37.41,,,37.41,Other,260% of Medicaid,46.62,,,46.62,Other,324% of Medicaid,30.94,,,30.94,Other,215% of Medicaid,30.94,,,30.94,Other,215% of Medicaid,17.99,,,17.99,Other,125% of Medicaid,14.39,106.72,
VIRUS ANTIBODY NOS,86790,CPT,,78086790,CDM,302,RC,,,both,,,168,124.32,,,124.32,Other,150% of Medicare + 9.63% HCRA Surcharge,75.6,45,,75.6,percent of total billed charges,Critical Access Hospital RCC factor,38.77,,,38.77,Fee Schedule,,34.9,,,34.9,Fee Schedule,,43.11,,,43.11,Fee Schedule,,38.77,,,38.77,Fee Schedule,,36.65,,,36.65,Fee Schedule,,83.16,,,83.16,Other,110% of Medicare,40.57,,,40.57,Fee Schedule,,0.01,,,0.01,Other,186% of Medicaid,47.78,,,47.78,Fee Schedule,,104.16,,,104.16,Fee Schedule,,27.05,,,27.05,Fee Schedule,,47.78,,,47.78,Fee Schedule,,104.16,,,104.16,Fee Schedule,,50.88,,,50.88,Fee Schedule,,117.6,70,,117.6,percent of total billed charges,All Other,61.04,,,61.04,Fee Schedule,,51.73,,,51.73,Fee Schedule,,19.32,,,19.32,Fee Schedule,,19.32,,,19.32,Fee Schedule,,19.32,,,19.32,Fee Schedule,,19.32,,,19.32,Fee Schedule,,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,124.32,
THYROGLOBULIN ANTIBODY,86800,CPT,,78086800,CDM,302,RC,,,both,,,268,198.32,,,198.32,Other,150% of Medicare + 9.63% HCRA Surcharge,120.6,45,,120.6,percent of total billed charges,Critical Access Hospital RCC factor,47.89,,,47.89,Fee Schedule,,43.12,,,43.12,Fee Schedule,,117.94,,,117.94,Fee Schedule,,106.08,,,106.08,Fee Schedule,,100.26,,,100.26,Fee Schedule,,132.66,,,132.66,Other,110% of Medicare,50.12,,,50.12,Fee Schedule,,25,,,25,Other,186% of Medicaid,59.03,,,59.03,Fee Schedule,,166.16,,,166.16,Fee Schedule,,33.41,,,33.41,Fee Schedule,,59.03,,,59.03,Fee Schedule,,166.16,,,166.16,Fee Schedule,,62.84,,,62.84,Fee Schedule,,187.6,70,,187.6,percent of total billed charges,All Other,75.4,,,75.4,Fee Schedule,,63.9,,,63.9,Fee Schedule,,23.87,,,23.87,Fee Schedule,,23.87,,,23.87,Fee Schedule,,23.87,,,23.87,Fee Schedule,,23.87,,,23.87,Fee Schedule,,13.48,,,13.48,Other,100% of Medicaid,13.48,,,13.48,Other,100% of Medicaid,13.48,,,13.48,Other,100% of Medicaid,13.48,,,13.48,Other,100% of Medicaid,30.34,,,30.34,Other,225% of Medicaid,20.63,,,20.63,Other,153% of Medicaid,30.34,,,30.34,Other,225% of Medicaid,18.88,,,18.88,Other,140% of Medicaid,30.34,,,30.34,Other,225% of Medicaid,35.06,,,35.06,Other,260% of Medicaid,43.69,,,43.69,Other,324% of Medicaid,28.99,,,28.99,Other,215% of Medicaid,28.99,,,28.99,Other,215% of Medicaid,16.85,,,16.85,Other,125% of Medicaid,13.48,198.32,
HEPATITIS C AB TEST,86803,CPT,,78086803,CDM,302,RC,,,both,,,284,210.16,,,210.16,Other,150% of Medicare + 9.63% HCRA Surcharge,127.8,45,,127.8,percent of total billed charges,Critical Access Hospital RCC factor,42.95,,,42.95,Fee Schedule,,38.67,,,38.67,Fee Schedule,,105.82,,,105.82,Fee Schedule,,95.18,,,95.18,Fee Schedule,,89.96,,,89.96,Fee Schedule,,140.58,,,140.58,Other,110% of Medicare,44.95,,,44.95,Fee Schedule,,19,,,19,Other,186% of Medicaid,52.94,,,52.94,Fee Schedule,,176.08,,,176.08,Fee Schedule,,29.97,,,29.97,Fee Schedule,,52.94,,,52.94,Fee Schedule,,176.08,,,176.08,Fee Schedule,,56.37,,,56.37,Fee Schedule,,198.8,70,,198.8,percent of total billed charges,All Other,67.63,,,67.63,Fee Schedule,,57.32,,,57.32,Fee Schedule,,21.41,,,21.41,Fee Schedule,,21.41,,,21.41,Fee Schedule,,21.41,,,21.41,Fee Schedule,,21.41,,,21.41,Fee Schedule,,10.1,,,10.1,Other,100% of Medicaid,10.1,,,10.1,Other,100% of Medicaid,10.1,,,10.1,Other,100% of Medicaid,10.1,,,10.1,Other,100% of Medicaid,22.73,,,22.73,Other,225% of Medicaid,15.45,,,15.45,Other,153% of Medicaid,22.73,,,22.73,Other,225% of Medicaid,14.14,,,14.14,Other,140% of Medicaid,22.73,,,22.73,Other,225% of Medicaid,26.26,,,26.26,Other,260% of Medicaid,32.72,,,32.72,Other,324% of Medicaid,21.72,,,21.72,Other,215% of Medicaid,21.72,,,21.72,Other,215% of Medicaid,12.63,,,12.63,Other,125% of Medicaid,10.1,210.16,
HEP C AB TEST CONFIRM,86804,CPT,,78086804,CDM,302,RC,,,both,,,312,230.88,,,230.88,Other,150% of Medicare + 9.63% HCRA Surcharge,140.4,45,,140.4,percent of total billed charges,Critical Access Hospital RCC factor,46.62,,,46.62,Fee Schedule,,41.98,,,41.98,Fee Schedule,,114.89,,,114.89,Fee Schedule,,103.33,,,103.33,Fee Schedule,,97.66,,,97.66,Fee Schedule,,154.44,,,154.44,Other,110% of Medicare,48.79,,,48.79,Fee Schedule,,29,,,29,Other,186% of Medicaid,57.47,,,57.47,Fee Schedule,,193.44,,,193.44,Fee Schedule,,32.53,,,32.53,Fee Schedule,,57.47,,,57.47,Fee Schedule,,193.44,,,193.44,Fee Schedule,,61.19,,,61.19,Fee Schedule,,218.4,70,,218.4,percent of total billed charges,All Other,73.41,,,73.41,Fee Schedule,,62.22,,,62.22,Fee Schedule,,23.24,,,23.24,Fee Schedule,,23.24,,,23.24,Fee Schedule,,23.24,,,23.24,Fee Schedule,,23.24,,,23.24,Fee Schedule,,15.49,,,15.49,Other,100% of Medicaid,15.49,,,15.49,Other,100% of Medicaid,15.49,,,15.49,Other,100% of Medicaid,15.49,,,15.49,Other,100% of Medicaid,34.85,,,34.85,Other,225% of Medicaid,23.7,,,23.7,Other,153% of Medicaid,34.85,,,34.85,Other,225% of Medicaid,21.69,,,21.69,Other,140% of Medicaid,34.85,,,34.85,Other,225% of Medicaid,40.27,,,40.27,Other,260% of Medicaid,50.19,,,50.19,Other,324% of Medicaid,33.3,,,33.3,Other,215% of Medicaid,33.3,,,33.3,Other,215% of Medicaid,19.36,,,19.36,Other,125% of Medicaid,15.49,230.88,
HLA TYPING A B PR C,86812,CPT,,78086812,CDM,302,RC,,,both,,,293,216.82,,,216.82,Other,150% of Medicare + 9.63% HCRA Surcharge,131.85,45,,131.85,percent of total billed charges,Critical Access Hospital RCC factor,77.69,,,77.69,Fee Schedule,,69.95,,,69.95,Fee Schedule,,191.41,,,191.41,Fee Schedule,,172.16,,,172.16,Fee Schedule,,162.71,,,162.71,Fee Schedule,,145.04,,,145.04,Other,110% of Medicare,81.3,,,81.3,Fee Schedule,,72,,,72,Other,186% of Medicaid,95.76,,,95.76,Fee Schedule,,181.66,,,181.66,Fee Schedule,,54.2,,,54.2,Fee Schedule,,95.76,,,95.76,Fee Schedule,,181.66,,,181.66,Fee Schedule,,101.95,,,101.95,Fee Schedule,,205.1,70,,205.1,percent of total billed charges,All Other,122.31,,,122.31,Fee Schedule,,103.67,,,103.67,Fee Schedule,,38.72,,,38.72,Fee Schedule,,38.72,,,38.72,Fee Schedule,,38.72,,,38.72,Fee Schedule,,38.72,,,38.72,Fee Schedule,,38.81,,,38.81,Other,100% of Medicaid,38.81,,,38.81,Other,100% of Medicaid,38.81,,,38.81,Other,100% of Medicaid,38.81,,,38.81,Other,100% of Medicaid,87.32,,,87.32,Other,225% of Medicaid,59.37,,,59.37,Other,153% of Medicaid,87.32,,,87.32,Other,225% of Medicaid,54.33,,,54.33,Other,140% of Medicaid,87.32,,,87.32,Other,225% of Medicaid,100.9,,,100.9,Other,260% of Medicaid,125.73,,,125.73,Other,324% of Medicaid,83.43,,,83.43,Other,215% of Medicaid,83.43,,,83.43,Other,215% of Medicaid,48.51,,,48.51,Other,125% of Medicaid,38.72,216.82,
HLA TYPING A B OR C,86813,CPT,,78086813,CDM,302,RC,,,both,,,343,253.82,,,253.82,Other,150% of Medicare + 9.63% HCRA Surcharge,154.35,45,,154.35,percent of total billed charges,Critical Access Hospital RCC factor,174.58,,,174.58,Fee Schedule,,157.18,,,157.18,Fee Schedule,,430.08,,,430.08,Fee Schedule,,386.83,,,386.83,Fee Schedule,,365.61,,,365.61,Fee Schedule,,169.79,,,169.79,Other,110% of Medicare,182.7,,,182.7,Fee Schedule,,72,,,72,Other,186% of Medicaid,215.18,,,215.18,Fee Schedule,,212.66,,,212.66,Fee Schedule,,121.8,,,121.8,Fee Schedule,,215.18,,,215.18,Fee Schedule,,212.66,,,212.66,Fee Schedule,,229.1,,,229.1,Fee Schedule,,240.1,70,,240.1,percent of total billed charges,All Other,274.86,,,274.86,Fee Schedule,,232.96,,,232.96,Fee Schedule,,87,,,87,Fee Schedule,,87,,,87,Fee Schedule,,87,,,87,Fee Schedule,,87,,,87,Fee Schedule,,38.81,,,38.81,Other,100% of Medicaid,38.81,,,38.81,Other,100% of Medicaid,38.81,,,38.81,Other,100% of Medicaid,38.81,,,38.81,Other,100% of Medicaid,87.32,,,87.32,Other,225% of Medicaid,59.37,,,59.37,Other,153% of Medicaid,87.32,,,87.32,Other,225% of Medicaid,54.33,,,54.33,Other,140% of Medicaid,87.32,,,87.32,Other,225% of Medicaid,100.9,,,100.9,Other,260% of Medicaid,125.73,,,125.73,Other,324% of Medicaid,83.43,,,83.43,Other,215% of Medicaid,83.43,,,83.43,Other,215% of Medicaid,48.51,,,48.51,Other,125% of Medicaid,38.81,430.08,
HLA TYPING DR/DQ,86817,CPT,,78086817,CDM,302,RC,,,both,,,382,282.68,,,282.68,Other,150% of Medicare + 9.63% HCRA Surcharge,171.9,45,,171.9,percent of total billed charges,Critical Access Hospital RCC factor,319.48,,,319.48,Fee Schedule,,287.64,,,287.64,Fee Schedule,,477.51,,,477.51,Fee Schedule,,429.49,,,429.49,Fee Schedule,,405.93,,,405.93,Fee Schedule,,189.09,,,189.09,Other,110% of Medicare,334.34,,,334.34,Fee Schedule,,72,,,72,Other,186% of Medicaid,393.78,,,393.78,Fee Schedule,,236.84,,,236.84,Fee Schedule,,222.89,,,222.89,Fee Schedule,,393.78,,,393.78,Fee Schedule,,236.84,,,236.84,Fee Schedule,,419.25,,,419.25,Fee Schedule,,267.4,70,,267.4,percent of total billed charges,All Other,503,,,503,Fee Schedule,,426.32,,,426.32,Fee Schedule,,159.21,,,159.21,Fee Schedule,,159.21,,,159.21,Fee Schedule,,159.21,,,159.21,Fee Schedule,,159.21,,,159.21,Fee Schedule,,38.81,,,38.81,Other,100% of Medicaid,38.81,,,38.81,Other,100% of Medicaid,38.81,,,38.81,Other,100% of Medicaid,38.81,,,38.81,Other,100% of Medicaid,87.32,,,87.32,Other,225% of Medicaid,59.37,,,59.37,Other,153% of Medicaid,87.32,,,87.32,Other,225% of Medicaid,54.33,,,54.33,Other,140% of Medicaid,87.32,,,87.32,Other,225% of Medicaid,100.9,,,100.9,Other,260% of Medicaid,125.73,,,125.73,Other,324% of Medicaid,83.43,,,83.43,Other,215% of Medicaid,83.43,,,83.43,Other,215% of Medicaid,48.51,,,48.51,Other,125% of Medicaid,38.81,503,
HLA X-MATH NON-CYTOTOXIC,86825,CPT,,78086825,CDM,302,RC,,,both,,,346,256.04,,,256.04,Other,150% of Medicare + 9.63% HCRA Surcharge,155.7,45,,155.7,percent of total billed charges,Critical Access Hospital RCC factor,329.56,,,329.56,Fee Schedule,,296.72,,,296.72,Fee Schedule,,595.67,,,595.67,Fee Schedule,,535.76,,,535.76,Fee Schedule,,506.37,,,506.37,Fee Schedule,,171.27,,,171.27,Other,110% of Medicare,344.89,,,344.89,Fee Schedule,,72,,,72,Other,186% of Medicaid,406.21,,,406.21,Fee Schedule,,214.52,,,214.52,Fee Schedule,,229.93,,,229.93,Fee Schedule,,406.21,,,406.21,Fee Schedule,,214.52,,,214.52,Fee Schedule,,432.49,,,432.49,Fee Schedule,,242.2,70,,242.2,percent of total billed charges,All Other,518.88,,,518.88,Fee Schedule,,439.78,,,439.78,Fee Schedule,,164.24,,,164.24,Fee Schedule,,164.24,,,164.24,Fee Schedule,,164.24,,,164.24,Fee Schedule,,164.24,,,164.24,Fee Schedule,,38.81,,,38.81,Other,100% of Medicaid,38.81,,,38.81,Other,100% of Medicaid,38.81,,,38.81,Other,100% of Medicaid,38.81,,,38.81,Other,100% of Medicaid,87.32,,,87.32,Other,225% of Medicaid,59.37,,,59.37,Other,153% of Medicaid,87.32,,,87.32,Other,225% of Medicaid,54.33,,,54.33,Other,140% of Medicaid,87.32,,,87.32,Other,225% of Medicaid,100.9,,,100.9,Other,260% of Medicaid,125.73,,,125.73,Other,324% of Medicaid,83.43,,,83.43,Other,215% of Medicaid,83.43,,,83.43,Other,215% of Medicaid,48.51,,,48.51,Other,125% of Medicaid,38.81,595.67,
HLA X-MATH NONCYTOTOXIC ADDL,86826,CPT,,78086826,CDM,302,RC,,,both,,,116,85.84,,,85.84,Other,150% of Medicare + 9.63% HCRA Surcharge,52.2,45,,52.2,percent of total billed charges,Critical Access Hospital RCC factor,109.96,,,109.96,Fee Schedule,,99,,,99,Fee Schedule,,198.52,,,198.52,Fee Schedule,,178.56,,,178.56,Fee Schedule,,168.76,,,168.76,Fee Schedule,,57.42,,,57.42,Other,110% of Medicare,115.07,,,115.07,Fee Schedule,,72,,,72,Other,186% of Medicaid,135.53,,,135.53,Fee Schedule,,71.92,,,71.92,Fee Schedule,,76.71,,,76.71,Fee Schedule,,135.53,,,135.53,Fee Schedule,,71.92,,,71.92,Fee Schedule,,144.29,,,144.29,Fee Schedule,,81.2,70,,81.2,percent of total billed charges,All Other,173.12,,,173.12,Fee Schedule,,146.73,,,146.73,Fee Schedule,,54.8,,,54.8,Fee Schedule,,54.8,,,54.8,Fee Schedule,,54.8,,,54.8,Fee Schedule,,54.8,,,54.8,Fee Schedule,,38.81,,,38.81,Other,100% of Medicaid,38.81,,,38.81,Other,100% of Medicaid,38.81,,,38.81,Other,100% of Medicaid,38.81,,,38.81,Other,100% of Medicaid,87.32,,,87.32,Other,225% of Medicaid,59.37,,,59.37,Other,153% of Medicaid,87.32,,,87.32,Other,225% of Medicaid,54.33,,,54.33,Other,140% of Medicaid,87.32,,,87.32,Other,225% of Medicaid,100.9,,,100.9,Other,260% of Medicaid,125.73,,,125.73,Other,324% of Medicaid,83.43,,,83.43,Other,215% of Medicaid,83.43,,,83.43,Other,215% of Medicaid,48.51,,,48.51,Other,125% of Medicaid,38.81,198.52,
HLA CLASS I&II ANTIBODY QUAL,86828,CPT,,78086828,CDM,302,RC,,,both,,,203,150.22,,,150.22,Other,150% of Medicare + 9.63% HCRA Surcharge,91.35,45,,91.35,percent of total billed charges,Critical Access Hospital RCC factor,193.21,,,193.21,Fee Schedule,,173.95,,,173.95,Fee Schedule,,21.76,,,21.76,Fee Schedule,,21.76,,,21.76,Fee Schedule,,21.76,,,21.76,Fee Schedule,,100.49,,,100.49,Other,110% of Medicare,202.2,,,202.2,Fee Schedule,,72,,,72,Other,186% of Medicaid,238.14,,,238.14,Fee Schedule,,125.86,,,125.86,Fee Schedule,,134.8,,,134.8,Fee Schedule,,238.14,,,238.14,Fee Schedule,,125.86,,,125.86,Fee Schedule,,253.55,,,253.55,Fee Schedule,,142.1,70,,142.1,percent of total billed charges,All Other,304.2,,,304.2,Fee Schedule,,257.83,,,257.83,Fee Schedule,,96.29,,,96.29,Fee Schedule,,96.29,,,96.29,Fee Schedule,,96.29,,,96.29,Fee Schedule,,96.29,,,96.29,Fee Schedule,,38.81,,,38.81,Other,100% of Medicaid,38.81,,,38.81,Other,100% of Medicaid,38.81,,,38.81,Other,100% of Medicaid,38.81,,,38.81,Other,100% of Medicaid,87.32,,,87.32,Other,225% of Medicaid,59.37,,,59.37,Other,153% of Medicaid,87.32,,,87.32,Other,225% of Medicaid,54.33,,,54.33,Other,140% of Medicaid,87.32,,,87.32,Other,225% of Medicaid,100.9,,,100.9,Other,260% of Medicaid,125.73,,,125.73,Other,324% of Medicaid,83.43,,,83.43,Other,215% of Medicaid,83.43,,,83.43,Other,215% of Medicaid,48.51,,,48.51,Other,125% of Medicaid,21.76,304.2,
HLA CLASS I HIGH DEFIN QUAL,86832,CPT,,78086832,CDM,302,RC,,,both,,,1021,755.54,,,755.54,Other,150% of Medicare + 9.63% HCRA Surcharge,459.45,45,,459.45,percent of total billed charges,Critical Access Hospital RCC factor,974.49,,,974.49,Fee Schedule,,877.36,,,877.36,Fee Schedule,,69.76,,,69.76,Fee Schedule,,69.76,,,69.76,Fee Schedule,,69.76,,,69.76,Fee Schedule,,505.4,,,505.4,Other,110% of Medicare,1019.81,,,1019.81,Fee Schedule,,72,,,72,Other,186% of Medicaid,1201.11,,,1201.11,Fee Schedule,,633.02,,,633.02,Fee Schedule,,679.88,,,679.88,Fee Schedule,,1201.11,,,1201.11,Fee Schedule,,633.02,,,633.02,Fee Schedule,,1278.81,,,1278.81,Fee Schedule,,714.7,70,,714.7,percent of total billed charges,All Other,1534.26,,,1534.26,Fee Schedule,,1300.38,,,1300.38,Fee Schedule,,485.63,,,485.63,Fee Schedule,,485.63,,,485.63,Fee Schedule,,485.63,,,485.63,Fee Schedule,,485.63,,,485.63,Fee Schedule,,38.8,,,38.8,Other,100% of Medicaid,38.8,,,38.8,Other,100% of Medicaid,38.8,,,38.8,Other,100% of Medicaid,38.8,,,38.8,Other,100% of Medicaid,87.31,,,87.31,Other,225% of Medicaid,59.37,,,59.37,Other,153% of Medicaid,87.31,,,87.31,Other,225% of Medicaid,54.32,,,54.32,Other,140% of Medicaid,87.31,,,87.31,Other,225% of Medicaid,100.89,,,100.89,Other,260% of Medicaid,125.72,,,125.72,Other,324% of Medicaid,83.43,,,83.43,Other,215% of Medicaid,83.43,,,83.43,Other,215% of Medicaid,48.5,,,48.5,Other,125% of Medicaid,38.8,1534.26,
HLA CLASS II HIGH DEFIN QUAL,86833,CPT,,78086833,CDM,302,RC,,,both,,,1027,759.98,,,759.98,Other,150% of Medicare + 9.63% HCRA Surcharge,462.15,45,,462.15,percent of total billed charges,Critical Access Hospital RCC factor,980.66,,,980.66,Fee Schedule,,882.92,,,882.92,Fee Schedule,,63.42,,,63.42,Fee Schedule,,63.42,,,63.42,Fee Schedule,,63.42,,,63.42,Fee Schedule,,508.37,,,508.37,Other,110% of Medicare,1026.27,,,1026.27,Fee Schedule,,72,,,72,Other,186% of Medicaid,1208.72,,,1208.72,Fee Schedule,,636.74,,,636.74,Fee Schedule,,684.18,,,684.18,Fee Schedule,,1208.72,,,1208.72,Fee Schedule,,636.74,,,636.74,Fee Schedule,,1286.91,,,1286.91,Fee Schedule,,718.9,70,,718.9,percent of total billed charges,All Other,1543.98,,,1543.98,Fee Schedule,,1308.62,,,1308.62,Fee Schedule,,488.7,,,488.7,Fee Schedule,,488.7,,,488.7,Fee Schedule,,488.7,,,488.7,Fee Schedule,,488.7,,,488.7,Fee Schedule,,38.8,,,38.8,Other,100% of Medicaid,38.8,,,38.8,Other,100% of Medicaid,38.8,,,38.8,Other,100% of Medicaid,38.8,,,38.8,Other,100% of Medicaid,87.31,,,87.31,Other,225% of Medicaid,59.37,,,59.37,Other,153% of Medicaid,87.31,,,87.31,Other,225% of Medicaid,54.32,,,54.32,Other,140% of Medicaid,87.31,,,87.31,Other,225% of Medicaid,100.89,,,100.89,Other,260% of Medicaid,125.72,,,125.72,Other,324% of Medicaid,83.43,,,83.43,Other,215% of Medicaid,83.43,,,83.43,Other,215% of Medicaid,48.5,,,48.5,Other,125% of Medicaid,38.8,1543.98,
PROTHROMBIN ABS,86849,CPT,,78086849,CDM,302,RC,,,both,,,609,450.66,,,450.66,Other,150% of Medicare + 9.63% HCRA Surcharge,274.05,45,,274.05,percent of total billed charges,Critical Access Hospital RCC factor,395.85,65,,395.85,percent of total billed charges,All Other,359.31,65,,359.31,percent of total billed charges,All Other,7.5,,,7.5,Fee Schedule,,7.5,,,7.5,Fee Schedule,,7.5,,,7.5,Fee Schedule,,301.46,,,301.46,Other,110% of Medicare,414.12,68,,414.12,percent of total billed charges,All Other,0.01,,,0.01,Other,186% of Medicaid,505.47,83,,505.47,percent of total billed charges,All Other,377.58,62,,377.58,percent of total billed charges,Lab and Radiology,334.95,55,,334.95,percent of total billed charges,Default if not on Fee Schedule,487.2,80,,487.2,percent of total billed charges,All Other,377.58,62,,377.58,percent of total billed charges,Lab and Radiology,487.2,80,,487.2,percent of total billed charges,All Other,426.3,70,,426.3,percent of total billed charges,All Other,395.85,65,,395.85,percent of total billed charges,Default if not in Fee Schedule,395.85,65,,395.85,percent of total billed charges,Default if not in Fee Schedule,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,505.47,
RBC ANTIBODY ELUTION,86860,CPT,,78086860,CDM,302,RC,,,both,,,355,262.7,,,262.7,Other,150% of Medicare + 9.63% HCRA Surcharge,159.75,45,,159.75,percent of total billed charges,Critical Access Hospital RCC factor,230.75,65,,230.75,percent of total billed charges,All Other,209.45,65,,209.45,percent of total billed charges,All Other,8.44,,,8.44,Fee Schedule,,8.44,,,8.44,Fee Schedule,,8.44,,,8.44,Fee Schedule,,175.73,,,175.73,Other,110% of Medicare,241.4,68,,241.4,percent of total billed charges,All Other,22,,,22,Other,186% of Medicaid,294.65,83,,294.65,percent of total billed charges,All Other,220.1,62,,220.1,percent of total billed charges,Lab and Radiology,195.25,55,,195.25,percent of total billed charges,Default if not on Fee Schedule,284,80,,284,percent of total billed charges,All Other,220.1,62,,220.1,percent of total billed charges,Lab and Radiology,284,80,,284,percent of total billed charges,All Other,248.5,70,,248.5,percent of total billed charges,All Other,230.75,65,,230.75,percent of total billed charges,Default if not in Fee Schedule,230.75,65,,230.75,percent of total billed charges,Default if not in Fee Schedule,215.25,,,215.25,Fee Schedule,,215.25,,,215.25,Fee Schedule,,215.25,,,215.25,Fee Schedule,,215.25,,,215.25,Fee Schedule,,11.82,,,11.82,Other,100% of Medicaid,11.82,,,11.82,Other,100% of Medicaid,11.82,,,11.82,Other,100% of Medicaid,11.82,,,11.82,Other,100% of Medicaid,26.59,,,26.59,Other,225% of Medicaid,18.08,,,18.08,Other,153% of Medicaid,26.59,,,26.59,Other,225% of Medicaid,16.54,,,16.54,Other,140% of Medicaid,26.59,,,26.59,Other,225% of Medicaid,30.72,,,30.72,Other,260% of Medicaid,38.29,,,38.29,Other,324% of Medicaid,25.41,,,25.41,Other,215% of Medicaid,25.41,,,25.41,Other,215% of Medicaid,14.77,,,14.77,Other,125% of Medicaid,8.44,294.65,
RBC ANTIBODY IDENTIFICATION,86870,CPT,,78086870,CDM,302,RC,,,both,,,731,540.94,,,540.94,Other,150% of Medicare + 9.63% HCRA Surcharge,328.95,45,,328.95,percent of total billed charges,Critical Access Hospital RCC factor,475.15,65,,475.15,percent of total billed charges,All Other,431.29,65,,431.29,percent of total billed charges,All Other,11.57,,,11.57,Fee Schedule,,11.57,,,11.57,Fee Schedule,,11.57,,,11.57,Fee Schedule,,361.85,,,361.85,Other,110% of Medicare,497.08,68,,497.08,percent of total billed charges,All Other,26,,,26,Other,186% of Medicaid,606.73,83,,606.73,percent of total billed charges,All Other,453.22,62,,453.22,percent of total billed charges,Lab and Radiology,402.05,55,,402.05,percent of total billed charges,Default if not on Fee Schedule,584.8,80,,584.8,percent of total billed charges,All Other,453.22,62,,453.22,percent of total billed charges,Lab and Radiology,584.8,80,,584.8,percent of total billed charges,All Other,511.7,70,,511.7,percent of total billed charges,All Other,475.15,65,,475.15,percent of total billed charges,Default if not in Fee Schedule,475.15,65,,475.15,percent of total billed charges,Default if not in Fee Schedule,425.12,,,425.12,Fee Schedule,,425.12,,,425.12,Fee Schedule,,425.12,,,425.12,Fee Schedule,,425.12,,,425.12,Fee Schedule,,14.24,,,14.24,Other,100% of Medicaid,14.24,,,14.24,Other,100% of Medicaid,14.24,,,14.24,Other,100% of Medicaid,14.24,,,14.24,Other,100% of Medicaid,32.04,,,32.04,Other,225% of Medicaid,21.79,,,21.79,Other,153% of Medicaid,32.04,,,32.04,Other,225% of Medicaid,19.94,,,19.94,Other,140% of Medicaid,32.04,,,32.04,Other,225% of Medicaid,37.03,,,37.03,Other,260% of Medicaid,46.14,,,46.14,Other,324% of Medicaid,30.62,,,30.62,Other,215% of Medicaid,30.62,,,30.62,Other,215% of Medicaid,17.8,,,17.8,Other,125% of Medicaid,11.57,606.73,
COOMBS TEST DIRECT,86880,CPT,,78086880,CDM,302,RC,,,both,,,131,96.94,,,96.94,Other,150% of Medicare + 9.63% HCRA Surcharge,58.95,45,,58.95,percent of total billed charges,Critical Access Hospital RCC factor,16.22,,,16.22,Fee Schedule,,14.61,,,14.61,Fee Schedule,,39.84,,,39.84,Fee Schedule,,35.83,,,35.83,Fee Schedule,,33.87,,,33.87,Fee Schedule,,64.85,,,64.85,Other,110% of Medicare,16.98,,,16.98,Fee Schedule,,9,,,9,Other,186% of Medicaid,20,,,20,Fee Schedule,,81.22,,,81.22,Fee Schedule,,11.32,,,11.32,Fee Schedule,,20,,,20,Fee Schedule,,81.22,,,81.22,Fee Schedule,,21.29,,,21.29,Fee Schedule,,91.7,70,,91.7,percent of total billed charges,All Other,25.54,,,25.54,Fee Schedule,,21.65,,,21.65,Fee Schedule,,8.09,,,8.09,Fee Schedule,,8.09,,,8.09,Fee Schedule,,8.09,,,8.09,Fee Schedule,,8.09,,,8.09,Fee Schedule,,4.74,,,4.74,Other,100% of Medicaid,4.74,,,4.74,Other,100% of Medicaid,4.74,,,4.74,Other,100% of Medicaid,4.74,,,4.74,Other,100% of Medicaid,10.66,,,10.66,Other,225% of Medicaid,7.25,,,7.25,Other,153% of Medicaid,10.66,,,10.66,Other,225% of Medicaid,6.63,,,6.63,Other,140% of Medicaid,10.66,,,10.66,Other,225% of Medicaid,12.32,,,12.32,Other,260% of Medicaid,15.35,,,15.35,Other,324% of Medicaid,10.18,,,10.18,Other,215% of Medicaid,10.18,,,10.18,Other,215% of Medicaid,5.92,,,5.92,Other,125% of Medicaid,4.74,96.94,
COOMBS TEST INDIRECT QUAL,86885,CPT,,78086885,CDM,302,RC,,,both,,,355,262.7,,,262.7,Other,150% of Medicare + 9.63% HCRA Surcharge,159.75,45,,159.75,percent of total billed charges,Critical Access Hospital RCC factor,17.22,,,17.22,Fee Schedule,,15.5,,,15.5,Fee Schedule,,42.48,,,42.48,Fee Schedule,,38.2,,,38.2,Fee Schedule,,36.11,,,36.11,Fee Schedule,,175.73,,,175.73,Other,110% of Medicare,18.02,,,18.02,Fee Schedule,,72,,,72,Other,186% of Medicaid,21.22,,,21.22,Fee Schedule,,220.1,,,220.1,Fee Schedule,,12.01,,,12.01,Fee Schedule,,21.22,,,21.22,Fee Schedule,,220.1,,,220.1,Fee Schedule,,22.59,,,22.59,Fee Schedule,,248.5,70,,248.5,percent of total billed charges,All Other,27.11,,,27.11,Fee Schedule,,22.98,,,22.98,Fee Schedule,,8.58,,,8.58,Fee Schedule,,8.58,,,8.58,Fee Schedule,,8.58,,,8.58,Fee Schedule,,8.58,,,8.58,Fee Schedule,,38.81,,,38.81,Other,100% of Medicaid,38.81,,,38.81,Other,100% of Medicaid,38.81,,,38.81,Other,100% of Medicaid,38.81,,,38.81,Other,100% of Medicaid,87.32,,,87.32,Other,225% of Medicaid,59.37,,,59.37,Other,153% of Medicaid,87.32,,,87.32,Other,225% of Medicaid,54.33,,,54.33,Other,140% of Medicaid,87.32,,,87.32,Other,225% of Medicaid,100.9,,,100.9,Other,260% of Medicaid,125.73,,,125.73,Other,324% of Medicaid,83.43,,,83.43,Other,215% of Medicaid,83.43,,,83.43,Other,215% of Medicaid,48.51,,,48.51,Other,125% of Medicaid,8.58,262.7,
BLOOD TYPE ANTIGEN DONOR EA,86902,CPT,,78086902,CDM,302,RC,,,both,,,731,540.94,,,540.94,Other,150% of Medicare + 9.63% HCRA Surcharge,328.95,45,,328.95,percent of total billed charges,Critical Access Hospital RCC factor,19.11,,,19.11,Fee Schedule,,17.21,,,17.21,Fee Schedule,,28.35,,,28.35,Fee Schedule,,25.5,,,25.5,Fee Schedule,,24.1,,,24.1,Fee Schedule,,361.85,,,361.85,Other,110% of Medicare,20,,,20,Fee Schedule,,72,,,72,Other,186% of Medicaid,23.56,,,23.56,Fee Schedule,,453.22,,,453.22,Fee Schedule,,13.34,,,13.34,Fee Schedule,,23.56,,,23.56,Fee Schedule,,453.22,,,453.22,Fee Schedule,,25.08,,,25.08,Fee Schedule,,511.7,70,,511.7,percent of total billed charges,All Other,30.09,,,30.09,Fee Schedule,,25.51,,,25.51,Fee Schedule,,9.53,,,9.53,Fee Schedule,,9.53,,,9.53,Fee Schedule,,9.53,,,9.53,Fee Schedule,,9.53,,,9.53,Fee Schedule,,38.81,,,38.81,Other,100% of Medicaid,38.81,,,38.81,Other,100% of Medicaid,38.81,,,38.81,Other,100% of Medicaid,38.81,,,38.81,Other,100% of Medicaid,87.32,,,87.32,Other,225% of Medicaid,59.37,,,59.37,Other,153% of Medicaid,87.32,,,87.32,Other,225% of Medicaid,54.33,,,54.33,Other,140% of Medicaid,87.32,,,87.32,Other,225% of Medicaid,100.9,,,100.9,Other,260% of Medicaid,125.73,,,125.73,Other,324% of Medicaid,83.43,,,83.43,Other,215% of Medicaid,83.43,,,83.43,Other,215% of Medicaid,48.51,,,48.51,Other,125% of Medicaid,9.53,540.94,
BLOOD TYPING RBC ANTIGENS,86905,CPT,,78086905,CDM,302,RC,,,both,,,731,540.94,,,540.94,Other,150% of Medicare + 9.63% HCRA Surcharge,328.95,45,,328.95,percent of total billed charges,Critical Access Hospital RCC factor,11.53,,,11.53,Fee Schedule,,10.38,,,10.38,Fee Schedule,,28.35,,,28.35,Fee Schedule,,25.5,,,25.5,Fee Schedule,,24.1,,,24.1,Fee Schedule,,361.85,,,361.85,Other,110% of Medicare,12.06,,,12.06,Fee Schedule,,7,,,7,Other,186% of Medicaid,14.21,,,14.21,Fee Schedule,,453.22,,,453.22,Fee Schedule,,8.04,,,8.04,Fee Schedule,,14.21,,,14.21,Fee Schedule,,453.22,,,453.22,Fee Schedule,,15.13,,,15.13,Fee Schedule,,511.7,70,,511.7,percent of total billed charges,All Other,18.15,,,18.15,Fee Schedule,,15.38,,,15.38,Fee Schedule,,5.75,,,5.75,Fee Schedule,,5.75,,,5.75,Fee Schedule,,5.75,,,5.75,Fee Schedule,,5.75,,,5.75,Fee Schedule,,3.83,,,3.83,Other,100% of Medicaid,3.83,,,3.83,Other,100% of Medicaid,3.83,,,3.83,Other,100% of Medicaid,3.83,,,3.83,Other,100% of Medicaid,8.62,,,8.62,Other,225% of Medicaid,5.86,,,5.86,Other,153% of Medicaid,8.62,,,8.62,Other,225% of Medicaid,5.36,,,5.36,Other,140% of Medicaid,8.62,,,8.62,Other,225% of Medicaid,9.96,,,9.96,Other,260% of Medicaid,12.41,,,12.41,Other,324% of Medicaid,8.23,,,8.23,Other,215% of Medicaid,8.23,,,8.23,Other,215% of Medicaid,4.79,,,4.79,Other,125% of Medicaid,3.83,540.94,
BLD TYPING SEROLOGIC RH PHNT,86906,CPT,,78086906,CDM,302,RC,,,both,,,133,98.42,,,98.42,Other,150% of Medicare + 9.63% HCRA Surcharge,59.85,45,,59.85,percent of total billed charges,Critical Access Hospital RCC factor,23.33,,,23.33,Fee Schedule,,21,,,21,Fee Schedule,,57.5,,,57.5,Fee Schedule,,51.71,,,51.71,Fee Schedule,,48.88,,,48.88,Fee Schedule,,65.84,,,65.84,Other,110% of Medicare,24.41,,,24.41,Fee Schedule,,72,,,72,Other,186% of Medicaid,28.75,,,28.75,Fee Schedule,,82.46,,,82.46,Fee Schedule,,16.28,,,16.28,Fee Schedule,,28.75,,,28.75,Fee Schedule,,82.46,,,82.46,Fee Schedule,,30.61,,,30.61,Fee Schedule,,93.1,70,,93.1,percent of total billed charges,All Other,36.73,,,36.73,Fee Schedule,,31.13,,,31.13,Fee Schedule,,11.63,,,11.63,Fee Schedule,,11.63,,,11.63,Fee Schedule,,11.63,,,11.63,Fee Schedule,,11.63,,,11.63,Fee Schedule,,38.81,,,38.81,Other,100% of Medicaid,38.81,,,38.81,Other,100% of Medicaid,38.81,,,38.81,Other,100% of Medicaid,38.81,,,38.81,Other,100% of Medicaid,87.32,,,87.32,Other,225% of Medicaid,59.37,,,59.37,Other,153% of Medicaid,87.32,,,87.32,Other,225% of Medicaid,54.33,,,54.33,Other,140% of Medicaid,87.32,,,87.32,Other,225% of Medicaid,100.9,,,100.9,Other,260% of Medicaid,125.73,,,125.73,Other,324% of Medicaid,83.43,,,83.43,Other,215% of Medicaid,83.43,,,83.43,Other,215% of Medicaid,48.51,,,48.51,Other,125% of Medicaid,11.63,125.73,
COMPATIBILITY TEST ANTIGLOB,86922,CPT,,78086922,CDM,302,RC,,,both,,,355,262.7,,,262.7,Other,150% of Medicare + 9.63% HCRA Surcharge,159.75,45,,159.75,percent of total billed charges,Critical Access Hospital RCC factor,230.75,65,,230.75,percent of total billed charges,All Other,209.45,65,,209.45,percent of total billed charges,All Other,10.08,,,10.08,Fee Schedule,,10.08,,,10.08,Fee Schedule,,10.08,,,10.08,Fee Schedule,,175.73,,,175.73,Other,110% of Medicare,241.4,68,,241.4,percent of total billed charges,All Other,72,,,72,Other,186% of Medicaid,294.65,83,,294.65,percent of total billed charges,All Other,220.1,62,,220.1,percent of total billed charges,Lab and Radiology,195.25,55,,195.25,percent of total billed charges,Default if not on Fee Schedule,284,80,,284,percent of total billed charges,All Other,220.1,62,,220.1,percent of total billed charges,Lab and Radiology,284,80,,284,percent of total billed charges,All Other,248.5,70,,248.5,percent of total billed charges,All Other,230.75,65,,230.75,percent of total billed charges,Default if not in Fee Schedule,230.75,65,,230.75,percent of total billed charges,Default if not in Fee Schedule,215.25,,,215.25,Fee Schedule,,215.25,,,215.25,Fee Schedule,,215.25,,,215.25,Fee Schedule,,215.25,,,215.25,Fee Schedule,,38.8,,,38.8,Other,100% of Medicaid,38.8,,,38.8,Other,100% of Medicaid,38.8,,,38.8,Other,100% of Medicaid,38.8,,,38.8,Other,100% of Medicaid,87.31,,,87.31,Other,225% of Medicaid,59.37,,,59.37,Other,153% of Medicaid,87.31,,,87.31,Other,225% of Medicaid,54.32,,,54.32,Other,140% of Medicaid,87.31,,,87.31,Other,225% of Medicaid,100.89,,,100.89,Other,260% of Medicaid,125.72,,,125.72,Other,324% of Medicaid,83.43,,,83.43,Other,215% of Medicaid,83.43,,,83.43,Other,215% of Medicaid,48.5,,,48.5,Other,125% of Medicaid,10.08,294.65,
BLOOD PRODUCT/IRRADIATION,86945,CPT,,78086945,CDM,302,RC,,,both,,,78,57.72,,,57.72,Other,150% of Medicare + 9.63% HCRA Surcharge,35.1,45,,35.1,percent of total billed charges,Critical Access Hospital RCC factor,50.7,65,,50.7,percent of total billed charges,All Other,46.02,65,,46.02,percent of total billed charges,All Other,7.9,,,7.9,Fee Schedule,,7.9,,,7.9,Fee Schedule,,7.9,,,7.9,Fee Schedule,,38.61,,,38.61,Other,110% of Medicare,53.04,68,,53.04,percent of total billed charges,All Other,71,,,71,Other,186% of Medicaid,64.74,83,,64.74,percent of total billed charges,All Other,48.36,62,,48.36,percent of total billed charges,Lab and Radiology,42.9,55,,42.9,percent of total billed charges,Default if not on Fee Schedule,62.4,80,,62.4,percent of total billed charges,All Other,48.36,62,,48.36,percent of total billed charges,Lab and Radiology,62.4,80,,62.4,percent of total billed charges,All Other,54.6,70,,54.6,percent of total billed charges,All Other,50.7,65,,50.7,percent of total billed charges,Default if not in Fee Schedule,50.7,65,,50.7,percent of total billed charges,Default if not in Fee Schedule,50.15,,,50.15,Fee Schedule,,50.15,,,50.15,Fee Schedule,,50.15,,,50.15,Fee Schedule,,50.15,,,50.15,Fee Schedule,,38.29,,,38.29,Other,100% of Medicaid,38.29,,,38.29,Other,100% of Medicaid,38.29,,,38.29,Other,100% of Medicaid,38.29,,,38.29,Other,100% of Medicaid,86.15,,,86.15,Other,225% of Medicaid,58.58,,,58.58,Other,153% of Medicaid,86.15,,,86.15,Other,225% of Medicaid,53.6,,,53.6,Other,140% of Medicaid,86.15,,,86.15,Other,225% of Medicaid,99.55,,,99.55,Other,260% of Medicaid,124.06,,,124.06,Other,324% of Medicaid,82.32,,,82.32,Other,215% of Medicaid,82.32,,,82.32,Other,215% of Medicaid,47.86,,,47.86,Other,125% of Medicaid,7.9,124.06,
RBC PRETX INCUBATJ W/CHEMICL,86970,CPT,,78086970,CDM,302,RC,,,both,,,133,98.42,,,98.42,Other,150% of Medicare + 9.63% HCRA Surcharge,59.85,45,,59.85,percent of total billed charges,Critical Access Hospital RCC factor,86.45,65,,86.45,percent of total billed charges,All Other,78.47,65,,78.47,percent of total billed charges,All Other,101.75,76.5,,101.75,percent of total billed charges,All Other,94.43,69,,94.43,percent of total billed charges,All Other,91.77,65,,91.77,percent of total billed charges,All Other,65.84,,,65.84,Other,110% of Medicare,90.44,68,,90.44,percent of total billed charges,All Other,71,,,71,Other,186% of Medicaid,110.39,83,,110.39,percent of total billed charges,All Other,82.46,62,,82.46,percent of total billed charges,Lab and Radiology,73.15,55,,73.15,percent of total billed charges,Default if not on Fee Schedule,106.4,80,,106.4,percent of total billed charges,All Other,82.46,62,,82.46,percent of total billed charges,Lab and Radiology,106.4,80,,106.4,percent of total billed charges,All Other,93.1,70,,93.1,percent of total billed charges,All Other,86.45,65,,86.45,percent of total billed charges,Default if not in Fee Schedule,86.45,65,,86.45,percent of total billed charges,Default if not in Fee Schedule,50.15,,,50.15,Fee Schedule,,50.15,,,50.15,Fee Schedule,,50.15,,,50.15,Fee Schedule,,50.15,,,50.15,Fee Schedule,,38.29,,,38.29,Other,100% of Medicaid,38.29,,,38.29,Other,100% of Medicaid,38.29,,,38.29,Other,100% of Medicaid,38.29,,,38.29,Other,100% of Medicaid,86.15,,,86.15,Other,225% of Medicaid,58.58,,,58.58,Other,153% of Medicaid,86.15,,,86.15,Other,225% of Medicaid,53.6,,,53.6,Other,140% of Medicaid,86.15,,,86.15,Other,225% of Medicaid,99.55,,,99.55,Other,260% of Medicaid,124.06,,,124.06,Other,324% of Medicaid,82.32,,,82.32,Other,215% of Medicaid,82.32,,,82.32,Other,215% of Medicaid,47.86,,,47.86,Other,125% of Medicaid,38.29,124.06,
RBC PRETREATMENT,86971,CPT,,78086971,CDM,302,RC,,,both,,,731,540.94,,,540.94,Other,150% of Medicare + 9.63% HCRA Surcharge,328.95,45,,328.95,percent of total billed charges,Critical Access Hospital RCC factor,475.15,65,,475.15,percent of total billed charges,All Other,431.29,65,,431.29,percent of total billed charges,All Other,559.22,76.5,,559.22,percent of total billed charges,All Other,519.01,69,,519.01,percent of total billed charges,All Other,504.39,65,,504.39,percent of total billed charges,All Other,361.85,,,361.85,Other,110% of Medicare,497.08,68,,497.08,percent of total billed charges,All Other,71,,,71,Other,186% of Medicaid,606.73,83,,606.73,percent of total billed charges,All Other,453.22,62,,453.22,percent of total billed charges,Lab and Radiology,402.05,55,,402.05,percent of total billed charges,Default if not on Fee Schedule,584.8,80,,584.8,percent of total billed charges,All Other,453.22,62,,453.22,percent of total billed charges,Lab and Radiology,584.8,80,,584.8,percent of total billed charges,All Other,511.7,70,,511.7,percent of total billed charges,All Other,475.15,65,,475.15,percent of total billed charges,Default if not in Fee Schedule,475.15,65,,475.15,percent of total billed charges,Default if not in Fee Schedule,425.12,,,425.12,Fee Schedule,,425.12,,,425.12,Fee Schedule,,425.12,,,425.12,Fee Schedule,,425.12,,,425.12,Fee Schedule,,38.29,,,38.29,Other,100% of Medicaid,38.29,,,38.29,Other,100% of Medicaid,38.29,,,38.29,Other,100% of Medicaid,38.29,,,38.29,Other,100% of Medicaid,86.15,,,86.15,Other,225% of Medicaid,58.58,,,58.58,Other,153% of Medicaid,86.15,,,86.15,Other,225% of Medicaid,53.6,,,53.6,Other,140% of Medicaid,86.15,,,86.15,Other,225% of Medicaid,99.55,,,99.55,Other,260% of Medicaid,124.06,,,124.06,Other,324% of Medicaid,82.32,,,82.32,Other,215% of Medicaid,82.32,,,82.32,Other,215% of Medicaid,47.86,,,47.86,Other,125% of Medicaid,38.29,606.73,
RBC SERUM PRETX INCUBJ DRUGS,86975,CPT,,78086975,CDM,302,RC,,,both,,,1054,779.96,,,779.96,Other,150% of Medicare + 9.63% HCRA Surcharge,474.3,45,,474.3,percent of total billed charges,Critical Access Hospital RCC factor,685.1,65,,685.1,percent of total billed charges,All Other,621.86,65,,621.86,percent of total billed charges,All Other,806.31,76.5,,806.31,percent of total billed charges,All Other,748.34,69,,748.34,percent of total billed charges,All Other,727.26,65,,727.26,percent of total billed charges,All Other,521.73,,,521.73,Other,110% of Medicare,716.72,68,,716.72,percent of total billed charges,All Other,71,,,71,Other,186% of Medicaid,874.82,83,,874.82,percent of total billed charges,All Other,653.48,62,,653.48,percent of total billed charges,Lab and Radiology,579.7,55,,579.7,percent of total billed charges,Default if not on Fee Schedule,843.2,80,,843.2,percent of total billed charges,All Other,653.48,62,,653.48,percent of total billed charges,Lab and Radiology,843.2,80,,843.2,percent of total billed charges,All Other,737.8,70,,737.8,percent of total billed charges,All Other,685.1,65,,685.1,percent of total billed charges,Default if not in Fee Schedule,685.1,65,,685.1,percent of total billed charges,Default if not in Fee Schedule,163.55,,,163.55,Fee Schedule,,163.55,,,163.55,Fee Schedule,,163.55,,,163.55,Fee Schedule,,163.55,,,163.55,Fee Schedule,,38.29,,,38.29,Other,100% of Medicaid,38.29,,,38.29,Other,100% of Medicaid,38.29,,,38.29,Other,100% of Medicaid,38.29,,,38.29,Other,100% of Medicaid,86.15,,,86.15,Other,225% of Medicaid,58.58,,,58.58,Other,153% of Medicaid,86.15,,,86.15,Other,225% of Medicaid,53.6,,,53.6,Other,140% of Medicaid,86.15,,,86.15,Other,225% of Medicaid,99.55,,,99.55,Other,260% of Medicaid,124.06,,,124.06,Other,324% of Medicaid,82.32,,,82.32,Other,215% of Medicaid,82.32,,,82.32,Other,215% of Medicaid,47.86,,,47.86,Other,125% of Medicaid,38.29,874.82,
RBC SERUM PRETX INCUBJ/INHIB,86977,CPT,,78086977,CDM,302,RC,,,both,,,579,428.46,,,428.46,Other,150% of Medicare + 9.63% HCRA Surcharge,260.55,45,,260.55,percent of total billed charges,Critical Access Hospital RCC factor,376.35,65,,376.35,percent of total billed charges,All Other,341.61,65,,341.61,percent of total billed charges,All Other,442.94,76.5,,442.94,percent of total billed charges,All Other,411.09,69,,411.09,percent of total billed charges,All Other,399.51,65,,399.51,percent of total billed charges,All Other,286.61,,,286.61,Other,110% of Medicare,393.72,68,,393.72,percent of total billed charges,All Other,71,,,71,Other,186% of Medicaid,480.57,83,,480.57,percent of total billed charges,All Other,358.98,62,,358.98,percent of total billed charges,Lab and Radiology,318.45,55,,318.45,percent of total billed charges,Default if not on Fee Schedule,463.2,80,,463.2,percent of total billed charges,All Other,358.98,62,,358.98,percent of total billed charges,Lab and Radiology,463.2,80,,463.2,percent of total billed charges,All Other,405.3,70,,405.3,percent of total billed charges,All Other,376.35,65,,376.35,percent of total billed charges,Default if not in Fee Schedule,376.35,65,,376.35,percent of total billed charges,Default if not in Fee Schedule,215.25,,,215.25,Fee Schedule,,215.25,,,215.25,Fee Schedule,,215.25,,,215.25,Fee Schedule,,215.25,,,215.25,Fee Schedule,,38.29,,,38.29,Other,100% of Medicaid,38.29,,,38.29,Other,100% of Medicaid,38.29,,,38.29,Other,100% of Medicaid,38.29,,,38.29,Other,100% of Medicaid,86.15,,,86.15,Other,225% of Medicaid,58.58,,,58.58,Other,153% of Medicaid,86.15,,,86.15,Other,225% of Medicaid,53.6,,,53.6,Other,140% of Medicaid,86.15,,,86.15,Other,225% of Medicaid,99.55,,,99.55,Other,260% of Medicaid,124.06,,,124.06,Other,324% of Medicaid,82.32,,,82.32,Other,215% of Medicaid,82.32,,,82.32,Other,215% of Medicaid,47.86,,,47.86,Other,125% of Medicaid,38.29,480.57,
TRANSFUSION PROCEDURE,86999,CPT,,78086999,CDM,302,RC,,,both,,,86,63.64,,,63.64,Other,150% of Medicare + 9.63% HCRA Surcharge,38.7,45,,38.7,percent of total billed charges,Critical Access Hospital RCC factor,55.9,65,,55.9,percent of total billed charges,All Other,50.74,65,,50.74,percent of total billed charges,All Other,65.79,76.5,,65.79,percent of total billed charges,All Other,61.06,69,,61.06,percent of total billed charges,All Other,59.34,65,,59.34,percent of total billed charges,All Other,42.57,,,42.57,Other,110% of Medicare,58.48,68,,58.48,percent of total billed charges,All Other,72,,,72,Other,186% of Medicaid,71.38,83,,71.38,percent of total billed charges,All Other,53.32,62,,53.32,percent of total billed charges,Lab and Radiology,47.3,55,,47.3,percent of total billed charges,Default if not on Fee Schedule,68.8,80,,68.8,percent of total billed charges,All Other,53.32,62,,53.32,percent of total billed charges,Lab and Radiology,68.8,80,,68.8,percent of total billed charges,All Other,60.2,70,,60.2,percent of total billed charges,All Other,55.9,65,,55.9,percent of total billed charges,Default if not in Fee Schedule,55.9,65,,55.9,percent of total billed charges,Default if not in Fee Schedule,34.49,,,34.49,Fee Schedule,,34.49,,,34.49,Fee Schedule,,34.49,,,34.49,Fee Schedule,,34.49,,,34.49,Fee Schedule,,38.81,,,38.81,Other,100% of Medicaid,38.81,,,38.81,Other,100% of Medicaid,38.81,,,38.81,Other,100% of Medicaid,38.81,,,38.81,Other,100% of Medicaid,87.32,,,87.32,Other,225% of Medicaid,59.37,,,59.37,Other,153% of Medicaid,87.32,,,87.32,Other,225% of Medicaid,54.33,,,54.33,Other,140% of Medicaid,87.32,,,87.32,Other,225% of Medicaid,100.9,,,100.9,Other,260% of Medicaid,125.73,,,125.73,Other,324% of Medicaid,83.43,,,83.43,Other,215% of Medicaid,83.43,,,83.43,Other,215% of Medicaid,48.51,,,48.51,Other,125% of Medicaid,34.49,125.73,
ALLERG SP IGE; QUAN OR SEMIQUAN,86003,CPT,TC,85086003,CDM,302,RC,,,both,,,45,33.3,,,33.3,Other,150% of Medicare + 9.63% HCRA Surcharge,20.25,45,,20.25,percent of total billed charges,Critical Access Hospital RCC factor,15.71,,,15.71,Fee Schedule,,14.15,,,14.15,Fee Schedule,,37,,,37,Fee Schedule,,33.27,,,33.27,Fee Schedule,,31.45,,,31.45,Fee Schedule,,22.28,,,22.28,Other,110% of Medicare,16.44,,,16.44,Fee Schedule,,7,,,7,Other,186% of Medicaid,19.37,,,19.37,Fee Schedule,,27.9,,,27.9,Fee Schedule,,10.96,,,10.96,Fee Schedule,,19.37,,,19.37,Fee Schedule,,27.9,,,27.9,Fee Schedule,,20.62,,,20.62,Fee Schedule,,31.5,70,,31.5,percent of total billed charges,All Other,24.74,,,24.74,Fee Schedule,,20.97,,,20.97,Fee Schedule,,7.83,,,7.83,Fee Schedule,,7.83,,,7.83,Fee Schedule,,7.83,,,7.83,Fee Schedule,,7.83,,,7.83,Fee Schedule,,3.69,,,3.69,Other,100% of Medicaid,3.69,,,3.69,Other,100% of Medicaid,3.69,,,3.69,Other,100% of Medicaid,3.69,,,3.69,Other,100% of Medicaid,8.29,,,8.29,Other,225% of Medicaid,5.64,,,5.64,Other,153% of Medicaid,8.29,,,8.29,Other,225% of Medicaid,5.16,,,5.16,Other,140% of Medicaid,8.29,,,8.29,Other,225% of Medicaid,9.58,,,9.58,Other,260% of Medicaid,11.94,,,11.94,Other,324% of Medicaid,7.93,,,7.93,Other,215% of Medicaid,7.93,,,7.93,Other,215% of Medicaid,4.61,,,4.61,Other,125% of Medicaid,3.69,37,
PROTHROMBIN TIME,85610,CPT,,30085610,CDM,305,RC,,,both,,,41,30.34,,,30.34,Other,150% of Medicare + 9.63% HCRA Surcharge,18.45,45,,18.45,percent of total billed charges,Critical Access Hospital RCC factor,12.91,,,12.91,Fee Schedule,,11.63,,,11.63,Fee Schedule,,29.14,,,29.14,Fee Schedule,,26.21,,,26.21,Fee Schedule,,24.77,,,24.77,Fee Schedule,,20.3,,,20.3,Other,110% of Medicare,13.51,,,13.51,Fee Schedule,,7,,,7,Other,186% of Medicaid,15.92,,,15.92,Fee Schedule,,25.42,,,25.42,Fee Schedule,,9.01,,,9.01,Fee Schedule,,15.92,,,15.92,Fee Schedule,,25.42,,,25.42,Fee Schedule,,16.95,,,16.95,Fee Schedule,,28.7,70,,28.7,percent of total billed charges,All Other,20.33,,,20.33,Fee Schedule,,17.23,,,17.23,Fee Schedule,,6.44,,,6.44,Fee Schedule,,6.44,,,6.44,Fee Schedule,,6.44,,,6.44,Fee Schedule,,6.44,,,6.44,Fee Schedule,,3.95,,,3.95,Other,100% of Medicaid,3.95,,,3.95,Other,100% of Medicaid,3.95,,,3.95,Other,100% of Medicaid,3.95,,,3.95,Other,100% of Medicaid,8.89,,,8.89,Other,225% of Medicaid,6.04,,,6.04,Other,153% of Medicaid,8.89,,,8.89,Other,225% of Medicaid,5.53,,,5.53,Other,140% of Medicaid,8.89,,,8.89,Other,225% of Medicaid,10.27,,,10.27,Other,260% of Medicaid,12.8,,,12.8,Other,324% of Medicaid,8.49,,,8.49,Other,215% of Medicaid,8.49,,,8.49,Other,215% of Medicaid,4.94,,,4.94,Other,125% of Medicaid,3.95,30.34,
HEMOGLOBIN FETAL,85461,CPT,,77085461,CDM,305,RC,,,both,,,93,68.82,,,68.82,Other,150% of Medicare + 9.63% HCRA Surcharge,41.85,45,,41.85,percent of total billed charges,Critical Access Hospital RCC factor,28.17,,,28.17,Fee Schedule,,25.37,,,25.37,Fee Schedule,,49.22,,,49.22,Fee Schedule,,44.27,,,44.27,Fee Schedule,,41.84,,,41.84,Fee Schedule,,46.04,,,46.04,Other,110% of Medicare,29.48,,,29.48,Fee Schedule,,17,,,17,Other,186% of Medicaid,34.73,,,34.73,Fee Schedule,,57.66,,,57.66,Fee Schedule,,19.66,,,19.66,Fee Schedule,,34.73,,,34.73,Fee Schedule,,57.66,,,57.66,Fee Schedule,,36.97,,,36.97,Fee Schedule,,65.1,70,,65.1,percent of total billed charges,All Other,44.36,,,44.36,Fee Schedule,,37.6,,,37.6,Fee Schedule,,14.04,,,14.04,Fee Schedule,,14.04,,,14.04,Fee Schedule,,14.04,,,14.04,Fee Schedule,,14.04,,,14.04,Fee Schedule,,9.36,,,9.36,Other,100% of Medicaid,9.36,,,9.36,Other,100% of Medicaid,9.36,,,9.36,Other,100% of Medicaid,9.36,,,9.36,Other,100% of Medicaid,21.06,,,21.06,Other,225% of Medicaid,14.32,,,14.32,Other,153% of Medicaid,21.06,,,21.06,Other,225% of Medicaid,13.1,,,13.1,Other,140% of Medicaid,21.06,,,21.06,Other,225% of Medicaid,24.34,,,24.34,Other,260% of Medicaid,30.33,,,30.33,Other,324% of Medicaid,20.12,,,20.12,Other,215% of Medicaid,20.12,,,20.12,Other,215% of Medicaid,11.7,,,11.7,Other,125% of Medicaid,9.36,68.82,
BLEEDING TIME TEST,85002,CPT,,78085002,CDM,305,RC,,,both,,,47,34.78,,,34.78,Other,150% of Medicare + 9.63% HCRA Surcharge,21.15,45,,21.15,percent of total billed charges,Critical Access Hospital RCC factor,14.51,,,14.51,Fee Schedule,,13.06,,,13.06,Fee Schedule,,33.36,,,33.36,Fee Schedule,,30,,,30,Fee Schedule,,28.36,,,28.36,Fee Schedule,,23.27,,,23.27,Other,110% of Medicare,15.18,,,15.18,Fee Schedule,,6,,,6,Other,186% of Medicaid,17.88,,,17.88,Fee Schedule,,29.14,,,29.14,Fee Schedule,,10.12,,,10.12,Fee Schedule,,17.88,,,17.88,Fee Schedule,,29.14,,,29.14,Fee Schedule,,19.04,,,19.04,Fee Schedule,,32.9,70,,32.9,percent of total billed charges,All Other,22.84,,,22.84,Fee Schedule,,19.36,,,19.36,Fee Schedule,,7.23,,,7.23,Fee Schedule,,7.23,,,7.23,Fee Schedule,,7.23,,,7.23,Fee Schedule,,7.23,,,7.23,Fee Schedule,,3.03,,,3.03,Other,100% of Medicaid,3.03,,,3.03,Other,100% of Medicaid,3.03,,,3.03,Other,100% of Medicaid,3.03,,,3.03,Other,100% of Medicaid,6.82,,,6.82,Other,225% of Medicaid,4.64,,,4.64,Other,153% of Medicaid,6.82,,,6.82,Other,225% of Medicaid,4.24,,,4.24,Other,140% of Medicaid,6.82,,,6.82,Other,225% of Medicaid,7.88,,,7.88,Other,260% of Medicaid,9.82,,,9.82,Other,324% of Medicaid,6.51,,,6.51,Other,215% of Medicaid,6.51,,,6.51,Other,215% of Medicaid,3.79,,,3.79,Other,125% of Medicaid,3.03,34.78,
AUTOMATED DIFF WBC COUNT,85004,CPT,,78085004,CDM,305,RC,,,both,,,33,24.42,,,24.42,Other,150% of Medicare + 9.63% HCRA Surcharge,14.85,45,,14.85,percent of total billed charges,Critical Access Hospital RCC factor,19.47,,,19.47,Fee Schedule,,17.53,,,17.53,Fee Schedule,,43.11,,,43.11,Fee Schedule,,38.77,,,38.77,Fee Schedule,,36.65,,,36.65,Fee Schedule,,16.34,,,16.34,Other,110% of Medicare,20.38,,,20.38,Fee Schedule,,6,,,6,Other,186% of Medicaid,24,,,24,Fee Schedule,,20.46,,,20.46,Fee Schedule,,13.59,,,13.59,Fee Schedule,,24,,,24,Fee Schedule,,20.46,,,20.46,Fee Schedule,,25.56,,,25.56,Fee Schedule,,23.1,70,,23.1,percent of total billed charges,All Other,30.66,,,30.66,Fee Schedule,,25.99,,,25.99,Fee Schedule,,9.71,,,9.71,Fee Schedule,,9.71,,,9.71,Fee Schedule,,9.71,,,9.71,Fee Schedule,,9.71,,,9.71,Fee Schedule,,3.2,,,3.2,Other,100% of Medicaid,3.2,,,3.2,Other,100% of Medicaid,3.2,,,3.2,Other,100% of Medicaid,3.2,,,3.2,Other,100% of Medicaid,7.2,,,7.2,Other,225% of Medicaid,4.9,,,4.9,Other,153% of Medicaid,7.2,,,7.2,Other,225% of Medicaid,4.48,,,4.48,Other,140% of Medicaid,7.2,,,7.2,Other,225% of Medicaid,8.32,,,8.32,Other,260% of Medicaid,10.37,,,10.37,Other,324% of Medicaid,6.88,,,6.88,Other,215% of Medicaid,6.88,,,6.88,Other,215% of Medicaid,4,,,4,Other,125% of Medicaid,3.2,43.11,
BL SMEAR W/DIFF WBC COUNT,85007,CPT,,78085007,CDM,305,RC,,,both,,,40,29.6,,,29.6,Other,150% of Medicare + 9.63% HCRA Surcharge,18,45,,18,percent of total billed charges,Critical Access Hospital RCC factor,11.44,,,11.44,Fee Schedule,,10.3,,,10.3,Fee Schedule,,25.51,,,25.51,Fee Schedule,,22.94,,,22.94,Fee Schedule,,21.68,,,21.68,Fee Schedule,,19.8,,,19.8,Other,110% of Medicare,11.97,,,11.97,Fee Schedule,,3,,,3,Other,186% of Medicaid,14.1,,,14.1,Fee Schedule,,24.8,,,24.8,Fee Schedule,,7.98,,,7.98,Fee Schedule,,14.1,,,14.1,Fee Schedule,,24.8,,,24.8,Fee Schedule,,15.01,,,15.01,Fee Schedule,,28,70,,28,percent of total billed charges,All Other,18.01,,,18.01,Fee Schedule,,15.26,,,15.26,Fee Schedule,,5.7,,,5.7,Fee Schedule,,5.7,,,5.7,Fee Schedule,,5.7,,,5.7,Fee Schedule,,5.7,,,5.7,Fee Schedule,,1.44,,,1.44,Other,100% of Medicaid,1.44,,,1.44,Other,100% of Medicaid,1.44,,,1.44,Other,100% of Medicaid,1.44,,,1.44,Other,100% of Medicaid,3.25,,,3.25,Other,225% of Medicaid,2.21,,,2.21,Other,153% of Medicaid,3.25,,,3.25,Other,225% of Medicaid,2.02,,,2.02,Other,140% of Medicaid,3.25,,,3.25,Other,225% of Medicaid,3.76,,,3.76,Other,260% of Medicaid,4.68,,,4.68,Other,324% of Medicaid,3.11,,,3.11,Other,215% of Medicaid,3.11,,,3.11,Other,215% of Medicaid,1.81,,,1.81,Other,125% of Medicaid,1.44,29.6,
BL SMEAR W/O DIFF WBC COUNT,85008,CPT,,78085008,CDM,305,RC,,,both,,,38,28.12,,,28.12,Other,150% of Medicare + 9.63% HCRA Surcharge,17.1,45,,17.1,percent of total billed charges,Critical Access Hospital RCC factor,10.32,,,10.32,Fee Schedule,,9.3,,,9.3,Fee Schedule,,25.51,,,25.51,Fee Schedule,,22.94,,,22.94,Fee Schedule,,21.68,,,21.68,Fee Schedule,,18.81,,,18.81,Other,110% of Medicare,10.8,,,10.8,Fee Schedule,,19,,,19,Other,186% of Medicaid,12.73,,,12.73,Fee Schedule,,23.56,,,23.56,Fee Schedule,,7.2,,,7.2,Fee Schedule,,12.73,,,12.73,Fee Schedule,,23.56,,,23.56,Fee Schedule,,13.55,,,13.55,Fee Schedule,,26.6,70,,26.6,percent of total billed charges,All Other,16.25,,,16.25,Fee Schedule,,13.78,,,13.78,Fee Schedule,,5.15,,,5.15,Fee Schedule,,5.15,,,5.15,Fee Schedule,,5.15,,,5.15,Fee Schedule,,5.15,,,5.15,Fee Schedule,,10.45,,,10.45,Other,100% of Medicaid,10.45,,,10.45,Other,100% of Medicaid,10.45,,,10.45,Other,100% of Medicaid,10.45,,,10.45,Other,100% of Medicaid,23.51,,,23.51,Other,225% of Medicaid,15.99,,,15.99,Other,153% of Medicaid,23.51,,,23.51,Other,225% of Medicaid,14.63,,,14.63,Other,140% of Medicaid,23.51,,,23.51,Other,225% of Medicaid,27.16,,,27.16,Other,260% of Medicaid,33.85,,,33.85,Other,324% of Medicaid,22.46,,,22.46,Other,215% of Medicaid,22.46,,,22.46,Other,215% of Medicaid,13.06,,,13.06,Other,125% of Medicaid,5.15,33.85,
HEMOGLOBIN,85018,CPT,,78085018,CDM,305,RC,,,both,,,83,61.42,,,61.42,Other,150% of Medicare + 9.63% HCRA Surcharge,37.35,45,,37.35,percent of total billed charges,Critical Access Hospital RCC factor,7.13,,,7.13,Fee Schedule,,6.42,,,6.42,Fee Schedule,,17.55,,,17.55,Fee Schedule,,15.78,,,15.78,Fee Schedule,,14.92,,,14.92,Fee Schedule,,41.09,,,41.09,Other,110% of Medicare,7.47,,,7.47,Fee Schedule,,4,,,4,Other,186% of Medicaid,8.79,,,8.79,Fee Schedule,,51.46,,,51.46,Fee Schedule,,4.98,,,4.98,Fee Schedule,,8.79,,,8.79,Fee Schedule,,51.46,,,51.46,Fee Schedule,,9.36,,,9.36,Fee Schedule,,58.1,70,,58.1,percent of total billed charges,All Other,11.23,,,11.23,Fee Schedule,,9.52,,,9.52,Fee Schedule,,3.56,,,3.56,Fee Schedule,,3.56,,,3.56,Fee Schedule,,3.56,,,3.56,Fee Schedule,,3.56,,,3.56,Fee Schedule,,2.02,,,2.02,Other,100% of Medicaid,2.02,,,2.02,Other,100% of Medicaid,2.02,,,2.02,Other,100% of Medicaid,2.02,,,2.02,Other,100% of Medicaid,4.55,,,4.55,Other,225% of Medicaid,3.09,,,3.09,Other,153% of Medicaid,4.55,,,4.55,Other,225% of Medicaid,2.83,,,2.83,Other,140% of Medicaid,4.55,,,4.55,Other,225% of Medicaid,5.25,,,5.25,Other,260% of Medicaid,6.54,,,6.54,Other,324% of Medicaid,4.34,,,4.34,Other,215% of Medicaid,4.34,,,4.34,Other,215% of Medicaid,2.53,,,2.53,Other,125% of Medicaid,2.02,61.42,
COMPLETE CBC W/AUTO DIFF WBC,85025,CPT,,78085025,CDM,305,RC,,,both,,,124,91.76,,,91.76,Other,150% of Medicare + 9.63% HCRA Surcharge,55.8,45,,55.8,percent of total billed charges,Critical Access Hospital RCC factor,23.39,,,23.39,Fee Schedule,,21.06,,,21.06,Fee Schedule,,57.65,,,57.65,Fee Schedule,,51.86,,,51.86,Fee Schedule,,49.01,,,49.01,Fee Schedule,,61.38,,,61.38,Other,110% of Medicare,24.48,,,24.48,Fee Schedule,,6,,,6,Other,186% of Medicaid,28.83,,,28.83,Fee Schedule,,76.88,,,76.88,Fee Schedule,,16.32,,,16.32,Fee Schedule,,28.83,,,28.83,Fee Schedule,,76.88,,,76.88,Fee Schedule,,30.69,,,30.69,Fee Schedule,,86.8,70,,86.8,percent of total billed charges,All Other,36.82,,,36.82,Fee Schedule,,31.21,,,31.21,Fee Schedule,,11.66,,,11.66,Fee Schedule,,11.66,,,11.66,Fee Schedule,,11.66,,,11.66,Fee Schedule,,11.66,,,11.66,Fee Schedule,,3.2,,,3.2,Other,100% of Medicaid,3.2,,,3.2,Other,100% of Medicaid,3.2,,,3.2,Other,100% of Medicaid,3.2,,,3.2,Other,100% of Medicaid,7.2,,,7.2,Other,225% of Medicaid,4.9,,,4.9,Other,153% of Medicaid,7.2,,,7.2,Other,225% of Medicaid,4.48,,,4.48,Other,140% of Medicaid,7.2,,,7.2,Other,225% of Medicaid,8.32,,,8.32,Other,260% of Medicaid,10.37,,,10.37,Other,324% of Medicaid,6.88,,,6.88,Other,215% of Medicaid,6.88,,,6.88,Other,215% of Medicaid,4,,,4,Other,125% of Medicaid,3.2,91.76,
COMPLETE CBC AUTOMATED,85027,CPT,,78085027,CDM,305,RC,,,both,,,100,74,,,74,Other,150% of Medicare + 9.63% HCRA Surcharge,45,45,,45,percent of total billed charges,Critical Access Hospital RCC factor,19.47,,,19.47,Fee Schedule,,17.53,,,17.53,Fee Schedule,,43.11,,,43.11,Fee Schedule,,38.77,,,38.77,Fee Schedule,,36.65,,,36.65,Fee Schedule,,49.5,,,49.5,Other,110% of Medicare,20.38,,,20.38,Fee Schedule,,6,,,6,Other,186% of Medicaid,24,,,24,Fee Schedule,,62,,,62,Fee Schedule,,13.59,,,13.59,Fee Schedule,,24,,,24,Fee Schedule,,62,,,62,Fee Schedule,,25.56,,,25.56,Fee Schedule,,70,70,,70,percent of total billed charges,All Other,30.66,,,30.66,Fee Schedule,,25.99,,,25.99,Fee Schedule,,9.71,,,9.71,Fee Schedule,,9.71,,,9.71,Fee Schedule,,9.71,,,9.71,Fee Schedule,,9.71,,,9.71,Fee Schedule,,3.2,,,3.2,Other,100% of Medicaid,3.2,,,3.2,Other,100% of Medicaid,3.2,,,3.2,Other,100% of Medicaid,3.2,,,3.2,Other,100% of Medicaid,7.2,,,7.2,Other,225% of Medicaid,4.9,,,4.9,Other,153% of Medicaid,7.2,,,7.2,Other,225% of Medicaid,4.48,,,4.48,Other,140% of Medicaid,7.2,,,7.2,Other,225% of Medicaid,8.32,,,8.32,Other,260% of Medicaid,10.37,,,10.37,Other,324% of Medicaid,6.88,,,6.88,Other,215% of Medicaid,6.88,,,6.88,Other,215% of Medicaid,4,,,4,Other,125% of Medicaid,3.2,74,
MANUAL CELL COUNT EACH,85032,CPT,,78085032,CDM,305,RC,,,both,,,38,28.12,,,28.12,Other,150% of Medicare + 9.63% HCRA Surcharge,17.1,45,,17.1,percent of total billed charges,Critical Access Hospital RCC factor,12.97,,,12.97,Fee Schedule,,11.68,,,11.68,Fee Schedule,,31.88,,,31.88,Fee Schedule,,28.68,,,28.68,Fee Schedule,,27.1,,,27.1,Fee Schedule,,18.81,,,18.81,Other,110% of Medicare,13.58,,,13.58,Fee Schedule,,4,,,4,Other,186% of Medicaid,15.99,,,15.99,Fee Schedule,,23.56,,,23.56,Fee Schedule,,9.05,,,9.05,Fee Schedule,,15.99,,,15.99,Fee Schedule,,23.56,,,23.56,Fee Schedule,,17.02,,,17.02,Fee Schedule,,26.6,70,,26.6,percent of total billed charges,All Other,20.43,,,20.43,Fee Schedule,,17.31,,,17.31,Fee Schedule,,6.47,,,6.47,Fee Schedule,,6.47,,,6.47,Fee Schedule,,6.47,,,6.47,Fee Schedule,,6.47,,,6.47,Fee Schedule,,2.02,,,2.02,Other,100% of Medicaid,2.02,,,2.02,Other,100% of Medicaid,2.02,,,2.02,Other,100% of Medicaid,2.02,,,2.02,Other,100% of Medicaid,4.55,,,4.55,Other,225% of Medicaid,3.09,,,3.09,Other,153% of Medicaid,4.55,,,4.55,Other,225% of Medicaid,2.83,,,2.83,Other,140% of Medicaid,4.55,,,4.55,Other,225% of Medicaid,5.25,,,5.25,Other,260% of Medicaid,6.54,,,6.54,Other,324% of Medicaid,4.34,,,4.34,Other,215% of Medicaid,4.34,,,4.34,Other,215% of Medicaid,2.53,,,2.53,Other,125% of Medicaid,2.02,31.88,
AUTOMATED RBC COUNT,85041,CPT,,78085041,CDM,305,RC,,,both,,,41,30.34,,,30.34,Other,150% of Medicare + 9.63% HCRA Surcharge,18.45,45,,18.45,percent of total billed charges,Critical Access Hospital RCC factor,9.09,,,9.09,Fee Schedule,,8.18,,,8.18,Fee Schedule,,22.34,,,22.34,Fee Schedule,,20.1,,,20.1,Fee Schedule,,19,,,19,Fee Schedule,,20.3,,,20.3,Other,110% of Medicare,9.51,,,9.51,Fee Schedule,,6,,,6,Other,186% of Medicaid,11.2,,,11.2,Fee Schedule,,25.42,,,25.42,Fee Schedule,,6.34,,,6.34,Fee Schedule,,11.2,,,11.2,Fee Schedule,,25.42,,,25.42,Fee Schedule,,11.93,,,11.93,Fee Schedule,,28.7,70,,28.7,percent of total billed charges,All Other,14.31,,,14.31,Fee Schedule,,12.13,,,12.13,Fee Schedule,,4.53,,,4.53,Fee Schedule,,4.53,,,4.53,Fee Schedule,,4.53,,,4.53,Fee Schedule,,4.53,,,4.53,Fee Schedule,,3.02,,,3.02,Other,100% of Medicaid,3.02,,,3.02,Other,100% of Medicaid,3.02,,,3.02,Other,100% of Medicaid,3.02,,,3.02,Other,100% of Medicaid,6.8,,,6.8,Other,225% of Medicaid,4.62,,,4.62,Other,153% of Medicaid,6.8,,,6.8,Other,225% of Medicaid,4.23,,,4.23,Other,140% of Medicaid,6.8,,,6.8,Other,225% of Medicaid,7.85,,,7.85,Other,260% of Medicaid,9.78,,,9.78,Other,324% of Medicaid,6.49,,,6.49,Other,215% of Medicaid,6.49,,,6.49,Other,215% of Medicaid,3.78,,,3.78,Other,125% of Medicaid,3.02,30.34,
MANUAL RETICULOCYTE COUNT,85044,CPT,,78085044,CDM,305,RC,,,both,,,77,56.98,,,56.98,Other,150% of Medicare + 9.63% HCRA Surcharge,34.65,45,,34.65,percent of total billed charges,Critical Access Hospital RCC factor,12.97,,,12.97,Fee Schedule,,11.68,,,11.68,Fee Schedule,,31.88,,,31.88,Fee Schedule,,28.68,,,28.68,Fee Schedule,,27.1,,,27.1,Fee Schedule,,38.12,,,38.12,Other,110% of Medicare,13.58,,,13.58,Fee Schedule,,3,,,3,Other,186% of Medicaid,15.99,,,15.99,Fee Schedule,,47.74,,,47.74,Fee Schedule,,9.05,,,9.05,Fee Schedule,,15.99,,,15.99,Fee Schedule,,47.74,,,47.74,Fee Schedule,,17.02,,,17.02,Fee Schedule,,53.9,70,,53.9,percent of total billed charges,All Other,20.43,,,20.43,Fee Schedule,,17.31,,,17.31,Fee Schedule,,6.47,,,6.47,Fee Schedule,,6.47,,,6.47,Fee Schedule,,6.47,,,6.47,Fee Schedule,,6.47,,,6.47,Fee Schedule,,1.44,,,1.44,Other,100% of Medicaid,1.44,,,1.44,Other,100% of Medicaid,1.44,,,1.44,Other,100% of Medicaid,1.44,,,1.44,Other,100% of Medicaid,3.25,,,3.25,Other,225% of Medicaid,2.21,,,2.21,Other,153% of Medicaid,3.25,,,3.25,Other,225% of Medicaid,2.02,,,2.02,Other,140% of Medicaid,3.25,,,3.25,Other,225% of Medicaid,3.76,,,3.76,Other,260% of Medicaid,4.68,,,4.68,Other,324% of Medicaid,3.11,,,3.11,Other,215% of Medicaid,3.11,,,3.11,Other,215% of Medicaid,1.81,,,1.81,Other,125% of Medicaid,1.44,56.98,
AUTOMATED RETICULOCYTE COUNT,85045,CPT,,78085045,CDM,305,RC,,,both,,,55,40.7,,,40.7,Other,150% of Medicare + 9.63% HCRA Surcharge,24.75,45,,24.75,percent of total billed charges,Critical Access Hospital RCC factor,12.01,,,12.01,Fee Schedule,,10.81,,,10.81,Fee Schedule,,29.67,,,29.67,Fee Schedule,,26.69,,,26.69,Fee Schedule,,25.22,,,25.22,Fee Schedule,,27.23,,,27.23,Other,110% of Medicare,12.57,,,12.57,Fee Schedule,,6,,,6,Other,186% of Medicaid,14.8,,,14.8,Fee Schedule,,34.1,,,34.1,Fee Schedule,,8.38,,,8.38,Fee Schedule,,14.8,,,14.8,Fee Schedule,,34.1,,,34.1,Fee Schedule,,15.76,,,15.76,Fee Schedule,,38.5,70,,38.5,percent of total billed charges,All Other,18.91,,,18.91,Fee Schedule,,16.03,,,16.03,Fee Schedule,,5.99,,,5.99,Fee Schedule,,5.99,,,5.99,Fee Schedule,,5.99,,,5.99,Fee Schedule,,5.99,,,5.99,Fee Schedule,,3.2,,,3.2,Other,100% of Medicaid,3.2,,,3.2,Other,100% of Medicaid,3.2,,,3.2,Other,100% of Medicaid,3.2,,,3.2,Other,100% of Medicaid,7.2,,,7.2,Other,225% of Medicaid,4.9,,,4.9,Other,153% of Medicaid,7.2,,,7.2,Other,225% of Medicaid,4.48,,,4.48,Other,140% of Medicaid,7.2,,,7.2,Other,225% of Medicaid,8.32,,,8.32,Other,260% of Medicaid,10.37,,,10.37,Other,324% of Medicaid,6.88,,,6.88,Other,215% of Medicaid,6.88,,,6.88,Other,215% of Medicaid,4,,,4,Other,125% of Medicaid,3.2,40.7,
AUTOMATED LEUKOCYTE COUNT,85048,CPT,,78085048,CDM,305,RC,,,both,,,57,42.18,,,42.18,Other,150% of Medicare + 9.63% HCRA Surcharge,25.65,45,,25.65,percent of total billed charges,Critical Access Hospital RCC factor,7.65,,,7.65,Fee Schedule,,6.88,,,6.88,Fee Schedule,,18.81,,,18.81,Fee Schedule,,16.92,,,16.92,Fee Schedule,,15.99,,,15.99,Fee Schedule,,28.22,,,28.22,Other,110% of Medicare,8,,,8,Fee Schedule,,5,,,5,Other,186% of Medicaid,9.42,,,9.42,Fee Schedule,,35.34,,,35.34,Fee Schedule,,5.33,,,5.33,Fee Schedule,,9.42,,,9.42,Fee Schedule,,35.34,,,35.34,Fee Schedule,,10.03,,,10.03,Fee Schedule,,39.9,70,,39.9,percent of total billed charges,All Other,12.04,,,12.04,Fee Schedule,,10.2,,,10.2,Fee Schedule,,3.81,,,3.81,Fee Schedule,,3.81,,,3.81,Fee Schedule,,3.81,,,3.81,Fee Schedule,,3.81,,,3.81,Fee Schedule,,2.54,,,2.54,Other,100% of Medicaid,2.54,,,2.54,Other,100% of Medicaid,2.54,,,2.54,Other,100% of Medicaid,2.54,,,2.54,Other,100% of Medicaid,5.72,,,5.72,Other,225% of Medicaid,3.89,,,3.89,Other,153% of Medicaid,5.72,,,5.72,Other,225% of Medicaid,3.56,,,3.56,Other,140% of Medicaid,5.72,,,5.72,Other,225% of Medicaid,6.6,,,6.6,Other,260% of Medicaid,8.23,,,8.23,Other,324% of Medicaid,5.46,,,5.46,Other,215% of Medicaid,5.46,,,5.46,Other,215% of Medicaid,3.18,,,3.18,Other,125% of Medicaid,2.54,42.18,
RETICULATED PLATELET ASSAY,85055,CPT,,78085055,CDM,305,RC,,,both,,,114,84.36,,,84.36,Other,150% of Medicare + 9.63% HCRA Surcharge,51.3,45,,51.3,percent of total billed charges,Critical Access Hospital RCC factor,107.58,,,107.58,Fee Schedule,,96.86,,,96.86,Fee Schedule,,198.52,,,198.52,Fee Schedule,,178.56,,,178.56,Fee Schedule,,168.76,,,168.76,Fee Schedule,,56.43,,,56.43,Other,110% of Medicare,112.58,,,112.58,Fee Schedule,,44,,,44,Other,186% of Medicaid,132.6,,,132.6,Fee Schedule,,70.68,,,70.68,Fee Schedule,,75.05,,,75.05,Fee Schedule,,132.6,,,132.6,Fee Schedule,,70.68,,,70.68,Fee Schedule,,141.17,,,141.17,Fee Schedule,,79.8,70,,79.8,percent of total billed charges,All Other,169.37,,,169.37,Fee Schedule,,143.55,,,143.55,Fee Schedule,,53.61,,,53.61,Fee Schedule,,53.61,,,53.61,Fee Schedule,,53.61,,,53.61,Fee Schedule,,53.61,,,53.61,Fee Schedule,,23.4,,,23.4,Other,100% of Medicaid,23.4,,,23.4,Other,100% of Medicaid,23.4,,,23.4,Other,100% of Medicaid,23.4,,,23.4,Other,100% of Medicaid,52.65,,,52.65,Other,225% of Medicaid,35.8,,,35.8,Other,153% of Medicaid,52.65,,,52.65,Other,225% of Medicaid,32.76,,,32.76,Other,140% of Medicaid,52.65,,,52.65,Other,225% of Medicaid,60.84,,,60.84,Other,260% of Medicaid,75.82,,,75.82,Other,324% of Medicaid,50.31,,,50.31,Other,215% of Medicaid,50.31,,,50.31,Other,215% of Medicaid,29.25,,,29.25,Other,125% of Medicaid,23.4,198.52,
CHROMOGENIC SUBSTRATE ASSAY,85130,CPT,,78085130,CDM,305,RC,,,both,,,44,32.56,,,32.56,Other,150% of Medicare + 9.63% HCRA Surcharge,19.8,45,,19.8,percent of total billed charges,Critical Access Hospital RCC factor,35.79,,,35.79,Fee Schedule,,32.22,,,32.22,Fee Schedule,,56.71,,,56.71,Fee Schedule,,51,,,51,Fee Schedule,,48.2,,,48.2,Fee Schedule,,21.78,,,21.78,Other,110% of Medicare,37.45,,,37.45,Fee Schedule,,19,,,19,Other,186% of Medicaid,44.11,,,44.11,Fee Schedule,,27.28,,,27.28,Fee Schedule,,24.97,,,24.97,Fee Schedule,,44.11,,,44.11,Fee Schedule,,27.28,,,27.28,Fee Schedule,,46.97,,,46.97,Fee Schedule,,30.8,70,,30.8,percent of total billed charges,All Other,56.35,,,56.35,Fee Schedule,,47.76,,,47.76,Fee Schedule,,17.84,,,17.84,Fee Schedule,,17.84,,,17.84,Fee Schedule,,17.84,,,17.84,Fee Schedule,,17.84,,,17.84,Fee Schedule,,10.45,,,10.45,Other,100% of Medicaid,10.45,,,10.45,Other,100% of Medicaid,10.45,,,10.45,Other,100% of Medicaid,10.45,,,10.45,Other,100% of Medicaid,23.51,,,23.51,Other,225% of Medicaid,15.99,,,15.99,Other,153% of Medicaid,23.51,,,23.51,Other,225% of Medicaid,14.63,,,14.63,Other,140% of Medicaid,23.51,,,23.51,Other,225% of Medicaid,27.16,,,27.16,Other,260% of Medicaid,33.85,,,33.85,Other,324% of Medicaid,22.46,,,22.46,Other,215% of Medicaid,22.46,,,22.46,Other,215% of Medicaid,13.06,,,13.06,Other,125% of Medicaid,10.45,56.71,
BLOOD CLOT RETRACTION,85170,CPT,,78085170,CDM,305,RC,,,both,,,34,25.16,,,25.16,Other,150% of Medicare + 9.63% HCRA Surcharge,15.3,45,,15.3,percent of total billed charges,Critical Access Hospital RCC factor,49.06,,,49.06,Fee Schedule,,44.17,,,44.17,Fee Schedule,,26.82,,,26.82,Fee Schedule,,24.13,,,24.13,Fee Schedule,,22.8,,,22.8,Fee Schedule,,16.83,,,16.83,Other,110% of Medicare,51.35,,,51.35,Fee Schedule,,23,,,23,Other,186% of Medicaid,60.47,,,60.47,Fee Schedule,,21.08,,,21.08,Fee Schedule,,34.23,,,34.23,Fee Schedule,,60.47,,,60.47,Fee Schedule,,21.08,,,21.08,Fee Schedule,,64.39,,,64.39,Fee Schedule,,23.8,70,,23.8,percent of total billed charges,All Other,77.25,,,77.25,Fee Schedule,,65.47,,,65.47,Fee Schedule,,24.45,,,24.45,Fee Schedule,,24.45,,,24.45,Fee Schedule,,24.45,,,24.45,Fee Schedule,,24.45,,,24.45,Fee Schedule,,12.56,,,12.56,Other,100% of Medicaid,12.56,,,12.56,Other,100% of Medicaid,12.56,,,12.56,Other,100% of Medicaid,12.56,,,12.56,Other,100% of Medicaid,28.27,,,28.27,Other,225% of Medicaid,19.22,,,19.22,Other,153% of Medicaid,28.27,,,28.27,Other,225% of Medicaid,17.59,,,17.59,Other,140% of Medicaid,28.27,,,28.27,Other,225% of Medicaid,32.67,,,32.67,Other,260% of Medicaid,40.71,,,40.71,Other,324% of Medicaid,27.01,,,27.01,Other,215% of Medicaid,27.01,,,27.01,Other,215% of Medicaid,15.7,,,15.7,Other,125% of Medicaid,12.56,77.25,
BLOOD CLOT FACTOR II TEST,85210,CPT,,78085210,CDM,305,RC,,,both,,,150,111,,,111,Other,150% of Medicare + 9.63% HCRA Surcharge,67.5,45,,67.5,percent of total billed charges,Critical Access Hospital RCC factor,39.07,,,39.07,Fee Schedule,,35.18,,,35.18,Fee Schedule,,96.28,,,96.28,Fee Schedule,,86.6,,,86.6,Fee Schedule,,81.85,,,81.85,Fee Schedule,,74.25,,,74.25,Other,110% of Medicare,40.89,,,40.89,Fee Schedule,,24,,,24,Other,186% of Medicaid,48.16,,,48.16,Fee Schedule,,93,,,93,Fee Schedule,,27.26,,,27.26,Fee Schedule,,48.16,,,48.16,Fee Schedule,,93,,,93,Fee Schedule,,51.27,,,51.27,Fee Schedule,,105,70,,105,percent of total billed charges,All Other,61.51,,,61.51,Fee Schedule,,52.14,,,52.14,Fee Schedule,,19.47,,,19.47,Fee Schedule,,19.47,,,19.47,Fee Schedule,,19.47,,,19.47,Fee Schedule,,19.47,,,19.47,Fee Schedule,,12.98,,,12.98,Other,100% of Medicaid,12.98,,,12.98,Other,100% of Medicaid,12.98,,,12.98,Other,100% of Medicaid,12.98,,,12.98,Other,100% of Medicaid,29.21,,,29.21,Other,225% of Medicaid,19.86,,,19.86,Other,153% of Medicaid,29.21,,,29.21,Other,225% of Medicaid,18.17,,,18.17,Other,140% of Medicaid,29.21,,,29.21,Other,225% of Medicaid,33.75,,,33.75,Other,260% of Medicaid,42.06,,,42.06,Other,324% of Medicaid,27.91,,,27.91,Other,215% of Medicaid,27.91,,,27.91,Other,215% of Medicaid,16.23,,,16.23,Other,125% of Medicaid,12.98,111,
BLOOD CLOT FACTOR V TEST,85220,CPT,,78085220,CDM,305,RC,,,both,,,558,412.92,,,412.92,Other,150% of Medicare + 9.63% HCRA Surcharge,251.1,45,,251.1,percent of total billed charges,Critical Access Hospital RCC factor,53.13,,,53.13,Fee Schedule,,47.83,,,47.83,Fee Schedule,,130.85,,,130.85,Fee Schedule,,117.69,,,117.69,Fee Schedule,,111.24,,,111.24,Fee Schedule,,276.21,,,276.21,Other,110% of Medicare,55.6,,,55.6,Fee Schedule,,33,,,33,Other,186% of Medicaid,65.48,,,65.48,Fee Schedule,,345.96,,,345.96,Fee Schedule,,37.07,,,37.07,Fee Schedule,,65.48,,,65.48,Fee Schedule,,345.96,,,345.96,Fee Schedule,,69.72,,,69.72,Fee Schedule,,390.6,70,,390.6,percent of total billed charges,All Other,83.64,,,83.64,Fee Schedule,,70.89,,,70.89,Fee Schedule,,26.48,,,26.48,Fee Schedule,,26.48,,,26.48,Fee Schedule,,26.48,,,26.48,Fee Schedule,,26.48,,,26.48,Fee Schedule,,17.65,,,17.65,Other,100% of Medicaid,17.65,,,17.65,Other,100% of Medicaid,17.65,,,17.65,Other,100% of Medicaid,17.65,,,17.65,Other,100% of Medicaid,39.71,,,39.71,Other,225% of Medicaid,27,,,27,Other,153% of Medicaid,39.71,,,39.71,Other,225% of Medicaid,24.71,,,24.71,Other,140% of Medicaid,39.71,,,39.71,Other,225% of Medicaid,45.89,,,45.89,Other,260% of Medicaid,57.19,,,57.19,Other,324% of Medicaid,37.95,,,37.95,Other,215% of Medicaid,37.95,,,37.95,Other,215% of Medicaid,22.06,,,22.06,Other,125% of Medicaid,17.65,412.92,
BLOOD CLOT FACTOR VII TEST,85230,CPT,,78085230,CDM,305,RC,,,both,,,521,385.54,,,385.54,Other,150% of Medicare + 9.63% HCRA Surcharge,234.45,45,,234.45,percent of total billed charges,Critical Access Hospital RCC factor,53.88,,,53.88,Fee Schedule,,48.51,,,48.51,Fee Schedule,,132.8,,,132.8,Fee Schedule,,119.45,,,119.45,Fee Schedule,,112.9,,,112.9,Fee Schedule,,257.9,,,257.9,Other,110% of Medicare,56.39,,,56.39,Fee Schedule,,33,,,33,Other,186% of Medicaid,66.41,,,66.41,Fee Schedule,,323.02,,,323.02,Fee Schedule,,37.59,,,37.59,Fee Schedule,,66.41,,,66.41,Fee Schedule,,323.02,,,323.02,Fee Schedule,,70.71,,,70.71,Fee Schedule,,364.7,70,,364.7,percent of total billed charges,All Other,84.83,,,84.83,Fee Schedule,,71.9,,,71.9,Fee Schedule,,26.85,,,26.85,Fee Schedule,,26.85,,,26.85,Fee Schedule,,26.85,,,26.85,Fee Schedule,,26.85,,,26.85,Fee Schedule,,17.9,,,17.9,Other,100% of Medicaid,17.9,,,17.9,Other,100% of Medicaid,17.9,,,17.9,Other,100% of Medicaid,17.9,,,17.9,Other,100% of Medicaid,40.28,,,40.28,Other,225% of Medicaid,27.39,,,27.39,Other,153% of Medicaid,40.28,,,40.28,Other,225% of Medicaid,25.06,,,25.06,Other,140% of Medicaid,40.28,,,40.28,Other,225% of Medicaid,46.54,,,46.54,Other,260% of Medicaid,58,,,58,Other,324% of Medicaid,38.49,,,38.49,Other,215% of Medicaid,38.49,,,38.49,Other,215% of Medicaid,22.38,,,22.38,Other,125% of Medicaid,17.9,385.54,
BLOOD CLOT FACTOR VIII TEST,85240,CPT,,78085240,CDM,305,RC,,,both,,,762,563.88,,,563.88,Other,150% of Medicare + 9.63% HCRA Surcharge,342.9,45,,342.9,percent of total billed charges,Critical Access Hospital RCC factor,53.88,,,53.88,Fee Schedule,,48.51,,,48.51,Fee Schedule,,64.87,,,64.87,Fee Schedule,,58.35,,,58.35,Fee Schedule,,55.15,,,55.15,Fee Schedule,,377.19,,,377.19,Other,110% of Medicare,56.39,,,56.39,Fee Schedule,,18,,,18,Other,186% of Medicaid,66.41,,,66.41,Fee Schedule,,472.44,,,472.44,Fee Schedule,,37.59,,,37.59,Fee Schedule,,66.41,,,66.41,Fee Schedule,,472.44,,,472.44,Fee Schedule,,70.71,,,70.71,Fee Schedule,,533.4,70,,533.4,percent of total billed charges,All Other,84.83,,,84.83,Fee Schedule,,71.9,,,71.9,Fee Schedule,,26.85,,,26.85,Fee Schedule,,26.85,,,26.85,Fee Schedule,,26.85,,,26.85,Fee Schedule,,26.85,,,26.85,Fee Schedule,,9.49,,,9.49,Other,100% of Medicaid,9.49,,,9.49,Other,100% of Medicaid,9.49,,,9.49,Other,100% of Medicaid,9.49,,,9.49,Other,100% of Medicaid,21.36,,,21.36,Other,225% of Medicaid,14.53,,,14.53,Other,153% of Medicaid,21.36,,,21.36,Other,225% of Medicaid,13.29,,,13.29,Other,140% of Medicaid,21.36,,,21.36,Other,225% of Medicaid,24.68,,,24.68,Other,260% of Medicaid,30.76,,,30.76,Other,324% of Medicaid,20.41,,,20.41,Other,215% of Medicaid,20.41,,,20.41,Other,215% of Medicaid,11.87,,,11.87,Other,125% of Medicaid,9.49,563.88,
BLOOD CLOT FACTOR VIII TEST,85244,CPT,,78085244,CDM,305,RC,,,both,,,653,483.22,,,483.22,Other,150% of Medicare + 9.63% HCRA Surcharge,293.85,45,,293.85,percent of total billed charges,Critical Access Hospital RCC factor,61.46,,,61.46,Fee Schedule,,55.34,,,55.34,Fee Schedule,,64.87,,,64.87,Fee Schedule,,58.35,,,58.35,Fee Schedule,,55.15,,,55.15,Fee Schedule,,323.24,,,323.24,Other,110% of Medicare,64.32,,,64.32,Fee Schedule,,18,,,18,Other,186% of Medicaid,75.76,,,75.76,Fee Schedule,,404.86,,,404.86,Fee Schedule,,42.88,,,42.88,Fee Schedule,,75.76,,,75.76,Fee Schedule,,404.86,,,404.86,Fee Schedule,,80.66,,,80.66,Fee Schedule,,457.1,70,,457.1,percent of total billed charges,All Other,96.77,,,96.77,Fee Schedule,,82.02,,,82.02,Fee Schedule,,30.63,,,30.63,Fee Schedule,,30.63,,,30.63,Fee Schedule,,30.63,,,30.63,Fee Schedule,,30.63,,,30.63,Fee Schedule,,9.49,,,9.49,Other,100% of Medicaid,9.49,,,9.49,Other,100% of Medicaid,9.49,,,9.49,Other,100% of Medicaid,9.49,,,9.49,Other,100% of Medicaid,21.36,,,21.36,Other,225% of Medicaid,14.53,,,14.53,Other,153% of Medicaid,21.36,,,21.36,Other,225% of Medicaid,13.29,,,13.29,Other,140% of Medicaid,21.36,,,21.36,Other,225% of Medicaid,24.68,,,24.68,Other,260% of Medicaid,30.76,,,30.76,Other,324% of Medicaid,20.41,,,20.41,Other,215% of Medicaid,20.41,,,20.41,Other,215% of Medicaid,11.87,,,11.87,Other,125% of Medicaid,9.49,483.22,
CLOTTING FACTOR VIII RISTOCETI,85245,CPT,,78085245,CDM,305,RC,,,both,,,140,103.6,,,103.6,Other,150% of Medicare + 9.63% HCRA Surcharge,63,45,,63,percent of total billed charges,Critical Access Hospital RCC factor,69.05,,,69.05,Fee Schedule,,62.17,,,62.17,Fee Schedule,,64.87,,,64.87,Fee Schedule,,58.35,,,58.35,Fee Schedule,,55.15,,,55.15,Fee Schedule,,69.3,,,69.3,Other,110% of Medicare,72.26,,,72.26,Fee Schedule,,18,,,18,Other,186% of Medicaid,85.11,,,85.11,Fee Schedule,,86.8,,,86.8,Fee Schedule,,48.17,,,48.17,Fee Schedule,,85.11,,,85.11,Fee Schedule,,86.8,,,86.8,Fee Schedule,,90.61,,,90.61,Fee Schedule,,98,70,,98,percent of total billed charges,All Other,108.71,,,108.71,Fee Schedule,,92.14,,,92.14,Fee Schedule,,34.41,,,34.41,Fee Schedule,,34.41,,,34.41,Fee Schedule,,34.41,,,34.41,Fee Schedule,,34.41,,,34.41,Fee Schedule,,9.49,,,9.49,Other,100% of Medicaid,9.49,,,9.49,Other,100% of Medicaid,9.49,,,9.49,Other,100% of Medicaid,9.49,,,9.49,Other,100% of Medicaid,21.36,,,21.36,Other,225% of Medicaid,14.53,,,14.53,Other,153% of Medicaid,21.36,,,21.36,Other,225% of Medicaid,13.29,,,13.29,Other,140% of Medicaid,21.36,,,21.36,Other,225% of Medicaid,24.68,,,24.68,Other,260% of Medicaid,30.76,,,30.76,Other,324% of Medicaid,20.41,,,20.41,Other,215% of Medicaid,20.41,,,20.41,Other,215% of Medicaid,11.87,,,11.87,Other,125% of Medicaid,9.49,108.71,
BLOOD CLOT FACTOR VIII TEST,85246,CPT,,78085246,CDM,305,RC,,,both,,,762,563.88,,,563.88,Other,150% of Medicare + 9.63% HCRA Surcharge,342.9,45,,342.9,percent of total billed charges,Critical Access Hospital RCC factor,69.05,,,69.05,Fee Schedule,,62.17,,,62.17,Fee Schedule,,64.87,,,64.87,Fee Schedule,,58.35,,,58.35,Fee Schedule,,55.15,,,55.15,Fee Schedule,,377.19,,,377.19,Other,110% of Medicare,72.26,,,72.26,Fee Schedule,,18,,,18,Other,186% of Medicaid,85.11,,,85.11,Fee Schedule,,472.44,,,472.44,Fee Schedule,,48.17,,,48.17,Fee Schedule,,85.11,,,85.11,Fee Schedule,,472.44,,,472.44,Fee Schedule,,90.61,,,90.61,Fee Schedule,,533.4,70,,533.4,percent of total billed charges,All Other,108.71,,,108.71,Fee Schedule,,92.14,,,92.14,Fee Schedule,,34.41,,,34.41,Fee Schedule,,34.41,,,34.41,Fee Schedule,,34.41,,,34.41,Fee Schedule,,34.41,,,34.41,Fee Schedule,,9.49,,,9.49,Other,100% of Medicaid,9.49,,,9.49,Other,100% of Medicaid,9.49,,,9.49,Other,100% of Medicaid,9.49,,,9.49,Other,100% of Medicaid,21.36,,,21.36,Other,225% of Medicaid,14.53,,,14.53,Other,153% of Medicaid,21.36,,,21.36,Other,225% of Medicaid,13.29,,,13.29,Other,140% of Medicaid,21.36,,,21.36,Other,225% of Medicaid,24.68,,,24.68,Other,260% of Medicaid,30.76,,,30.76,Other,324% of Medicaid,20.41,,,20.41,Other,215% of Medicaid,20.41,,,20.41,Other,215% of Medicaid,11.87,,,11.87,Other,125% of Medicaid,9.49,563.88,
BLOOD CLOT FACTOR VIII TEST,85247,CPT,,78085247,CDM,305,RC,,,both,,,653,483.22,,,483.22,Other,150% of Medicare + 9.63% HCRA Surcharge,293.85,45,,293.85,percent of total billed charges,Critical Access Hospital RCC factor,69.05,,,69.05,Fee Schedule,,62.17,,,62.17,Fee Schedule,,64.87,,,64.87,Fee Schedule,,58.35,,,58.35,Fee Schedule,,55.15,,,55.15,Fee Schedule,,323.24,,,323.24,Other,110% of Medicare,72.26,,,72.26,Fee Schedule,,22,,,22,Other,186% of Medicaid,85.11,,,85.11,Fee Schedule,,404.86,,,404.86,Fee Schedule,,48.17,,,48.17,Fee Schedule,,85.11,,,85.11,Fee Schedule,,404.86,,,404.86,Fee Schedule,,90.61,,,90.61,Fee Schedule,,457.1,70,,457.1,percent of total billed charges,All Other,108.71,,,108.71,Fee Schedule,,92.14,,,92.14,Fee Schedule,,34.41,,,34.41,Fee Schedule,,34.41,,,34.41,Fee Schedule,,34.41,,,34.41,Fee Schedule,,34.41,,,34.41,Fee Schedule,,11.89,,,11.89,Other,100% of Medicaid,11.89,,,11.89,Other,100% of Medicaid,11.89,,,11.89,Other,100% of Medicaid,11.89,,,11.89,Other,100% of Medicaid,26.75,,,26.75,Other,225% of Medicaid,18.19,,,18.19,Other,153% of Medicaid,26.75,,,26.75,Other,225% of Medicaid,16.64,,,16.64,Other,140% of Medicaid,26.75,,,26.75,Other,225% of Medicaid,30.91,,,30.91,Other,260% of Medicaid,38.52,,,38.52,Other,324% of Medicaid,25.56,,,25.56,Other,215% of Medicaid,25.56,,,25.56,Other,215% of Medicaid,14.86,,,14.86,Other,125% of Medicaid,11.89,483.22,
BLOOD CLOT FACTOR IX TEST,85250,CPT,,78085250,CDM,305,RC,,,both,,,435,321.9,,,321.9,Other,150% of Medicare + 9.63% HCRA Surcharge,195.75,45,,195.75,percent of total billed charges,Critical Access Hospital RCC factor,57.31,,,57.31,Fee Schedule,,51.6,,,51.6,Fee Schedule,,137.39,,,137.39,Fee Schedule,,123.57,,,123.57,Fee Schedule,,116.79,,,116.79,Fee Schedule,,215.33,,,215.33,Other,110% of Medicare,59.98,,,59.98,Fee Schedule,,35,,,35,Other,186% of Medicaid,70.64,,,70.64,Fee Schedule,,269.7,,,269.7,Fee Schedule,,39.98,,,39.98,Fee Schedule,,70.64,,,70.64,Fee Schedule,,269.7,,,269.7,Fee Schedule,,75.21,,,75.21,Fee Schedule,,304.5,70,,304.5,percent of total billed charges,All Other,90.23,,,90.23,Fee Schedule,,76.48,,,76.48,Fee Schedule,,28.56,,,28.56,Fee Schedule,,28.56,,,28.56,Fee Schedule,,28.56,,,28.56,Fee Schedule,,28.56,,,28.56,Fee Schedule,,19.04,,,19.04,Other,100% of Medicaid,19.04,,,19.04,Other,100% of Medicaid,19.04,,,19.04,Other,100% of Medicaid,19.04,,,19.04,Other,100% of Medicaid,42.84,,,42.84,Other,225% of Medicaid,29.13,,,29.13,Other,153% of Medicaid,42.84,,,42.84,Other,225% of Medicaid,26.66,,,26.66,Other,140% of Medicaid,42.84,,,42.84,Other,225% of Medicaid,49.5,,,49.5,Other,260% of Medicaid,61.69,,,61.69,Other,324% of Medicaid,40.94,,,40.94,Other,215% of Medicaid,40.94,,,40.94,Other,215% of Medicaid,23.8,,,23.8,Other,125% of Medicaid,19.04,321.9,
BLOOD CLOT FACTOR X TEST,85260,CPT,,78085260,CDM,305,RC,,,both,,,446,330.04,,,330.04,Other,150% of Medicare + 9.63% HCRA Surcharge,200.7,45,,200.7,percent of total billed charges,Critical Access Hospital RCC factor,53.88,,,53.88,Fee Schedule,,48.51,,,48.51,Fee Schedule,,132.8,,,132.8,Fee Schedule,,119.45,,,119.45,Fee Schedule,,112.9,,,112.9,Fee Schedule,,220.77,,,220.77,Other,110% of Medicare,56.39,,,56.39,Fee Schedule,,33,,,33,Other,186% of Medicaid,66.41,,,66.41,Fee Schedule,,276.52,,,276.52,Fee Schedule,,37.59,,,37.59,Fee Schedule,,66.41,,,66.41,Fee Schedule,,276.52,,,276.52,Fee Schedule,,70.71,,,70.71,Fee Schedule,,312.2,70,,312.2,percent of total billed charges,All Other,84.83,,,84.83,Fee Schedule,,71.9,,,71.9,Fee Schedule,,26.85,,,26.85,Fee Schedule,,26.85,,,26.85,Fee Schedule,,26.85,,,26.85,Fee Schedule,,26.85,,,26.85,Fee Schedule,,17.9,,,17.9,Other,100% of Medicaid,17.9,,,17.9,Other,100% of Medicaid,17.9,,,17.9,Other,100% of Medicaid,17.9,,,17.9,Other,100% of Medicaid,40.28,,,40.28,Other,225% of Medicaid,27.39,,,27.39,Other,153% of Medicaid,40.28,,,40.28,Other,225% of Medicaid,25.06,,,25.06,Other,140% of Medicaid,40.28,,,40.28,Other,225% of Medicaid,46.54,,,46.54,Other,260% of Medicaid,58,,,58,Other,324% of Medicaid,38.49,,,38.49,Other,215% of Medicaid,38.49,,,38.49,Other,215% of Medicaid,22.38,,,22.38,Other,125% of Medicaid,17.9,330.04,
BLOOD CLOT FACTOR XI TEST,85270,CPT,,78085270,CDM,305,RC,,,both,,,454,335.96,,,335.96,Other,150% of Medicare + 9.63% HCRA Surcharge,204.3,45,,204.3,percent of total billed charges,Critical Access Hospital RCC factor,53.88,,,53.88,Fee Schedule,,48.51,,,48.51,Fee Schedule,,132.8,,,132.8,Fee Schedule,,119.45,,,119.45,Fee Schedule,,112.9,,,112.9,Fee Schedule,,224.73,,,224.73,Other,110% of Medicare,56.39,,,56.39,Fee Schedule,,33,,,33,Other,186% of Medicaid,66.41,,,66.41,Fee Schedule,,281.48,,,281.48,Fee Schedule,,37.59,,,37.59,Fee Schedule,,66.41,,,66.41,Fee Schedule,,281.48,,,281.48,Fee Schedule,,70.71,,,70.71,Fee Schedule,,317.8,70,,317.8,percent of total billed charges,All Other,84.83,,,84.83,Fee Schedule,,71.9,,,71.9,Fee Schedule,,26.85,,,26.85,Fee Schedule,,26.85,,,26.85,Fee Schedule,,26.85,,,26.85,Fee Schedule,,26.85,,,26.85,Fee Schedule,,17.9,,,17.9,Other,100% of Medicaid,17.9,,,17.9,Other,100% of Medicaid,17.9,,,17.9,Other,100% of Medicaid,17.9,,,17.9,Other,100% of Medicaid,40.28,,,40.28,Other,225% of Medicaid,27.39,,,27.39,Other,153% of Medicaid,40.28,,,40.28,Other,225% of Medicaid,25.06,,,25.06,Other,140% of Medicaid,40.28,,,40.28,Other,225% of Medicaid,46.54,,,46.54,Other,260% of Medicaid,58,,,58,Other,324% of Medicaid,38.49,,,38.49,Other,215% of Medicaid,38.49,,,38.49,Other,215% of Medicaid,22.38,,,22.38,Other,125% of Medicaid,17.9,335.96,
BLOOD CLOT FACTOR XII TEST,85280,CPT,,78085280,CDM,305,RC,,,both,,,416,307.84,,,307.84,Other,150% of Medicare + 9.63% HCRA Surcharge,187.2,45,,187.2,percent of total billed charges,Critical Access Hospital RCC factor,58.24,,,58.24,Fee Schedule,,52.44,,,52.44,Fee Schedule,,137.39,,,137.39,Fee Schedule,,123.57,,,123.57,Fee Schedule,,116.79,,,116.79,Fee Schedule,,205.92,,,205.92,Other,110% of Medicare,60.95,,,60.95,Fee Schedule,,36,,,36,Other,186% of Medicaid,71.79,,,71.79,Fee Schedule,,257.92,,,257.92,Fee Schedule,,40.64,,,40.64,Fee Schedule,,71.79,,,71.79,Fee Schedule,,257.92,,,257.92,Fee Schedule,,76.43,,,76.43,Fee Schedule,,291.2,70,,291.2,percent of total billed charges,All Other,91.7,,,91.7,Fee Schedule,,77.72,,,77.72,Fee Schedule,,29.03,,,29.03,Fee Schedule,,29.03,,,29.03,Fee Schedule,,29.03,,,29.03,Fee Schedule,,29.03,,,29.03,Fee Schedule,,19.35,,,19.35,Other,100% of Medicaid,19.35,,,19.35,Other,100% of Medicaid,19.35,,,19.35,Other,100% of Medicaid,19.35,,,19.35,Other,100% of Medicaid,43.54,,,43.54,Other,225% of Medicaid,29.61,,,29.61,Other,153% of Medicaid,43.54,,,43.54,Other,225% of Medicaid,27.09,,,27.09,Other,140% of Medicaid,43.54,,,43.54,Other,225% of Medicaid,50.31,,,50.31,Other,260% of Medicaid,62.69,,,62.69,Other,324% of Medicaid,41.6,,,41.6,Other,215% of Medicaid,41.6,,,41.6,Other,215% of Medicaid,24.19,,,24.19,Other,125% of Medicaid,19.35,307.84,
BLOOD CLOT FACTOR XIII TEST,85290,CPT,,78085290,CDM,305,RC,,,both,,,416,307.84,,,307.84,Other,150% of Medicare + 9.63% HCRA Surcharge,187.2,45,,187.2,percent of total billed charges,Critical Access Hospital RCC factor,49.18,,,49.18,Fee Schedule,,44.28,,,44.28,Fee Schedule,,54.6,,,54.6,Fee Schedule,,49.11,,,49.11,Fee Schedule,,46.41,,,46.41,Fee Schedule,,205.92,,,205.92,Other,110% of Medicare,51.47,,,51.47,Fee Schedule,,15,,,15,Other,186% of Medicaid,60.62,,,60.62,Fee Schedule,,257.92,,,257.92,Fee Schedule,,34.31,,,34.31,Fee Schedule,,60.62,,,60.62,Fee Schedule,,257.92,,,257.92,Fee Schedule,,64.54,,,64.54,Fee Schedule,,291.2,70,,291.2,percent of total billed charges,All Other,77.44,,,77.44,Fee Schedule,,65.63,,,65.63,Fee Schedule,,24.51,,,24.51,Fee Schedule,,24.51,,,24.51,Fee Schedule,,24.51,,,24.51,Fee Schedule,,24.51,,,24.51,Fee Schedule,,8.01,,,8.01,Other,100% of Medicaid,8.01,,,8.01,Other,100% of Medicaid,8.01,,,8.01,Other,100% of Medicaid,8.01,,,8.01,Other,100% of Medicaid,18.02,,,18.02,Other,225% of Medicaid,12.25,,,12.25,Other,153% of Medicaid,18.02,,,18.02,Other,225% of Medicaid,11.21,,,11.21,Other,140% of Medicaid,18.02,,,18.02,Other,225% of Medicaid,20.82,,,20.82,Other,260% of Medicaid,25.95,,,25.95,Other,324% of Medicaid,17.22,,,17.22,Other,215% of Medicaid,17.22,,,17.22,Other,215% of Medicaid,10.01,,,10.01,Other,125% of Medicaid,8.01,307.84,
CLOTTING; FACTOR XIII SCREEN SOLUBLE,85291,CPT,,78085291,CDM,305,RC,,,both,,,416,307.84,,,307.84,Other,150% of Medicare + 9.63% HCRA Surcharge,187.2,45,,187.2,percent of total billed charges,Critical Access Hospital RCC factor,27.42,,,27.42,Fee Schedule,,24.69,,,24.69,Fee Schedule,,54.6,,,54.6,Fee Schedule,,49.11,,,49.11,Fee Schedule,,46.41,,,46.41,Fee Schedule,,205.92,,,205.92,Other,110% of Medicare,28.7,,,28.7,Fee Schedule,,13,,,13,Other,186% of Medicaid,33.8,,,33.8,Fee Schedule,,257.92,,,257.92,Fee Schedule,,19.13,,,19.13,Fee Schedule,,33.8,,,33.8,Fee Schedule,,257.92,,,257.92,Fee Schedule,,35.98,,,35.98,Fee Schedule,,291.2,70,,291.2,percent of total billed charges,All Other,43.17,,,43.17,Fee Schedule,,36.59,,,36.59,Fee Schedule,,13.67,,,13.67,Fee Schedule,,13.67,,,13.67,Fee Schedule,,13.67,,,13.67,Fee Schedule,,13.67,,,13.67,Fee Schedule,,7.17,,,7.17,Other,100% of Medicaid,7.17,,,7.17,Other,100% of Medicaid,7.17,,,7.17,Other,100% of Medicaid,7.17,,,7.17,Other,100% of Medicaid,16.13,,,16.13,Other,225% of Medicaid,10.97,,,10.97,Other,153% of Medicaid,16.13,,,16.13,Other,225% of Medicaid,10.04,,,10.04,Other,140% of Medicaid,16.13,,,16.13,Other,225% of Medicaid,18.64,,,18.64,Other,260% of Medicaid,23.23,,,23.23,Other,324% of Medicaid,15.42,,,15.42,Other,215% of Medicaid,15.42,,,15.42,Other,215% of Medicaid,8.96,,,8.96,Other,125% of Medicaid,7.17,307.84,
ANTITHROMBIN III TEST,85300,CPT,,78085300,CDM,305,RC,,,both,,,409,302.66,,,302.66,Other,150% of Medicare + 9.63% HCRA Surcharge,184.05,45,,184.05,percent of total billed charges,Critical Access Hospital RCC factor,35.67,,,35.67,Fee Schedule,,32.11,,,32.11,Fee Schedule,,64.87,,,64.87,Fee Schedule,,58.35,,,58.35,Fee Schedule,,55.15,,,55.15,Fee Schedule,,202.46,,,202.46,Other,110% of Medicare,37.33,,,37.33,Fee Schedule,,18,,,18,Other,186% of Medicaid,43.96,,,43.96,Fee Schedule,,253.58,,,253.58,Fee Schedule,,24.89,,,24.89,Fee Schedule,,43.96,,,43.96,Fee Schedule,,253.58,,,253.58,Fee Schedule,,46.81,,,46.81,Fee Schedule,,286.3,70,,286.3,percent of total billed charges,All Other,56.16,,,56.16,Fee Schedule,,47.6,,,47.6,Fee Schedule,,17.78,,,17.78,Fee Schedule,,17.78,,,17.78,Fee Schedule,,17.78,,,17.78,Fee Schedule,,17.78,,,17.78,Fee Schedule,,9.52,,,9.52,Other,100% of Medicaid,9.52,,,9.52,Other,100% of Medicaid,9.52,,,9.52,Other,100% of Medicaid,9.52,,,9.52,Other,100% of Medicaid,21.43,,,21.43,Other,225% of Medicaid,14.57,,,14.57,Other,153% of Medicaid,21.43,,,21.43,Other,225% of Medicaid,13.33,,,13.33,Other,140% of Medicaid,21.43,,,21.43,Other,225% of Medicaid,24.76,,,24.76,Other,260% of Medicaid,30.86,,,30.86,Other,324% of Medicaid,20.48,,,20.48,Other,215% of Medicaid,20.48,,,20.48,Other,215% of Medicaid,11.91,,,11.91,Other,125% of Medicaid,9.52,302.66,
ANTITHROMBIN III TEST,85301,CPT,,78085301,CDM,305,RC,,,both,,,409,302.66,,,302.66,Other,150% of Medicare + 9.63% HCRA Surcharge,184.05,45,,184.05,percent of total billed charges,Critical Access Hospital RCC factor,32.54,,,32.54,Fee Schedule,,29.3,,,29.3,Fee Schedule,,80.16,,,80.16,Fee Schedule,,72.1,,,72.1,Fee Schedule,,68.14,,,68.14,Fee Schedule,,202.46,,,202.46,Other,110% of Medicare,34.05,,,34.05,Fee Schedule,,20,,,20,Other,186% of Medicaid,40.11,,,40.11,Fee Schedule,,253.58,,,253.58,Fee Schedule,,22.7,,,22.7,Fee Schedule,,40.11,,,40.11,Fee Schedule,,253.58,,,253.58,Fee Schedule,,42.7,,,42.7,Fee Schedule,,286.3,70,,286.3,percent of total billed charges,All Other,51.23,,,51.23,Fee Schedule,,43.42,,,43.42,Fee Schedule,,16.22,,,16.22,Fee Schedule,,16.22,,,16.22,Fee Schedule,,16.22,,,16.22,Fee Schedule,,16.22,,,16.22,Fee Schedule,,10.81,,,10.81,Other,100% of Medicaid,10.81,,,10.81,Other,100% of Medicaid,10.81,,,10.81,Other,100% of Medicaid,10.81,,,10.81,Other,100% of Medicaid,24.32,,,24.32,Other,225% of Medicaid,16.54,,,16.54,Other,153% of Medicaid,24.32,,,24.32,Other,225% of Medicaid,15.13,,,15.13,Other,140% of Medicaid,24.32,,,24.32,Other,225% of Medicaid,28.11,,,28.11,Other,260% of Medicaid,35.02,,,35.02,Other,324% of Medicaid,23.24,,,23.24,Other,215% of Medicaid,23.24,,,23.24,Other,215% of Medicaid,13.51,,,13.51,Other,125% of Medicaid,10.81,302.66,
BLOOD CLOT INHIBITOR ANTIGEN,85302,CPT,,78085302,CDM,305,RC,,,both,,,454,335.96,,,335.96,Other,150% of Medicare + 9.63% HCRA Surcharge,204.3,45,,204.3,percent of total billed charges,Critical Access Hospital RCC factor,36.15,,,36.15,Fee Schedule,,32.55,,,32.55,Fee Schedule,,89.17,,,89.17,Fee Schedule,,80.2,,,80.2,Fee Schedule,,75.8,,,75.8,Fee Schedule,,224.73,,,224.73,Other,110% of Medicare,37.83,,,37.83,Fee Schedule,,22,,,22,Other,186% of Medicaid,44.56,,,44.56,Fee Schedule,,281.48,,,281.48,Fee Schedule,,25.22,,,25.22,Fee Schedule,,44.56,,,44.56,Fee Schedule,,281.48,,,281.48,Fee Schedule,,47.44,,,47.44,Fee Schedule,,317.8,70,,317.8,percent of total billed charges,All Other,56.92,,,56.92,Fee Schedule,,48.24,,,48.24,Fee Schedule,,18.02,,,18.02,Fee Schedule,,18.02,,,18.02,Fee Schedule,,18.02,,,18.02,Fee Schedule,,18.02,,,18.02,Fee Schedule,,12.01,,,12.01,Other,100% of Medicaid,12.01,,,12.01,Other,100% of Medicaid,12.01,,,12.01,Other,100% of Medicaid,12.01,,,12.01,Other,100% of Medicaid,27.02,,,27.02,Other,225% of Medicaid,18.38,,,18.38,Other,153% of Medicaid,27.02,,,27.02,Other,225% of Medicaid,16.81,,,16.81,Other,140% of Medicaid,27.02,,,27.02,Other,225% of Medicaid,31.23,,,31.23,Other,260% of Medicaid,38.91,,,38.91,Other,324% of Medicaid,25.82,,,25.82,Other,215% of Medicaid,25.82,,,25.82,Other,215% of Medicaid,15.01,,,15.01,Other,125% of Medicaid,12.01,335.96,
BLOOD CLOT INHIBITOR TEST,85303,CPT,,78085303,CDM,305,RC,,,both,,,301,222.74,,,222.74,Other,150% of Medicare + 9.63% HCRA Surcharge,135.45,45,,135.45,percent of total billed charges,Critical Access Hospital RCC factor,41.66,,,41.66,Fee Schedule,,37.51,,,37.51,Fee Schedule,,102.55,,,102.55,Fee Schedule,,92.24,,,92.24,Fee Schedule,,87.18,,,87.18,Fee Schedule,,149,,,149,Other,110% of Medicare,43.6,,,43.6,Fee Schedule,,26,,,26,Other,186% of Medicaid,51.35,,,51.35,Fee Schedule,,186.62,,,186.62,Fee Schedule,,29.06,,,29.06,Fee Schedule,,51.35,,,51.35,Fee Schedule,,186.62,,,186.62,Fee Schedule,,54.67,,,54.67,Fee Schedule,,210.7,70,,210.7,percent of total billed charges,All Other,65.59,,,65.59,Fee Schedule,,55.59,,,55.59,Fee Schedule,,20.76,,,20.76,Fee Schedule,,20.76,,,20.76,Fee Schedule,,20.76,,,20.76,Fee Schedule,,20.76,,,20.76,Fee Schedule,,13.84,,,13.84,Other,100% of Medicaid,13.84,,,13.84,Other,100% of Medicaid,13.84,,,13.84,Other,100% of Medicaid,13.84,,,13.84,Other,100% of Medicaid,31.14,,,31.14,Other,225% of Medicaid,21.18,,,21.18,Other,153% of Medicaid,31.14,,,31.14,Other,225% of Medicaid,19.38,,,19.38,Other,140% of Medicaid,31.14,,,31.14,Other,225% of Medicaid,35.98,,,35.98,Other,260% of Medicaid,44.84,,,44.84,Other,324% of Medicaid,29.76,,,29.76,Other,215% of Medicaid,29.76,,,29.76,Other,215% of Medicaid,17.3,,,17.3,Other,125% of Medicaid,13.84,222.74,
CLOTTING INHIBITOR; PROTEIN S TOTAL,85305,CPT,,78085305,CDM,305,RC,,,both,,,454,335.96,,,335.96,Other,150% of Medicare + 9.63% HCRA Surcharge,204.3,45,,204.3,percent of total billed charges,Critical Access Hospital RCC factor,34.95,,,34.95,Fee Schedule,,31.46,,,31.46,Fee Schedule,,86.01,,,86.01,Fee Schedule,,77.36,,,77.36,Fee Schedule,,73.11,,,73.11,Fee Schedule,,224.73,,,224.73,Other,110% of Medicare,36.57,,,36.57,Fee Schedule,,22,,,22,Other,186% of Medicaid,43.07,,,43.07,Fee Schedule,,281.48,,,281.48,Fee Schedule,,24.38,,,24.38,Fee Schedule,,43.07,,,43.07,Fee Schedule,,281.48,,,281.48,Fee Schedule,,45.86,,,45.86,Fee Schedule,,317.8,70,,317.8,percent of total billed charges,All Other,55.02,,,55.02,Fee Schedule,,46.63,,,46.63,Fee Schedule,,17.42,,,17.42,Fee Schedule,,17.42,,,17.42,Fee Schedule,,17.42,,,17.42,Fee Schedule,,17.42,,,17.42,Fee Schedule,,11.61,,,11.61,Other,100% of Medicaid,11.61,,,11.61,Other,100% of Medicaid,11.61,,,11.61,Other,100% of Medicaid,11.61,,,11.61,Other,100% of Medicaid,26.12,,,26.12,Other,225% of Medicaid,17.76,,,17.76,Other,153% of Medicaid,26.12,,,26.12,Other,225% of Medicaid,16.25,,,16.25,Other,140% of Medicaid,26.12,,,26.12,Other,225% of Medicaid,30.19,,,30.19,Other,260% of Medicaid,37.62,,,37.62,Other,324% of Medicaid,24.96,,,24.96,Other,215% of Medicaid,24.96,,,24.96,Other,215% of Medicaid,14.51,,,14.51,Other,125% of Medicaid,11.61,335.96,
BLOOD CLOT INHIBITOR TEST,85306,CPT,,78085306,CDM,305,RC,,,both,,,301,222.74,,,222.74,Other,150% of Medicare + 9.63% HCRA Surcharge,135.45,45,,135.45,percent of total billed charges,Critical Access Hospital RCC factor,46.11,,,46.11,Fee Schedule,,41.52,,,41.52,Fee Schedule,,105.98,,,105.98,Fee Schedule,,95.32,,,95.32,Fee Schedule,,90.09,,,90.09,Fee Schedule,,149,,,149,Other,110% of Medicare,48.26,,,48.26,Fee Schedule,,28,,,28,Other,186% of Medicaid,56.84,,,56.84,Fee Schedule,,186.62,,,186.62,Fee Schedule,,32.17,,,32.17,Fee Schedule,,56.84,,,56.84,Fee Schedule,,186.62,,,186.62,Fee Schedule,,60.51,,,60.51,Fee Schedule,,210.7,70,,210.7,percent of total billed charges,All Other,72.6,,,72.6,Fee Schedule,,61.53,,,61.53,Fee Schedule,,22.98,,,22.98,Fee Schedule,,22.98,,,22.98,Fee Schedule,,22.98,,,22.98,Fee Schedule,,22.98,,,22.98,Fee Schedule,,15.32,,,15.32,Other,100% of Medicaid,15.32,,,15.32,Other,100% of Medicaid,15.32,,,15.32,Other,100% of Medicaid,15.32,,,15.32,Other,100% of Medicaid,34.47,,,34.47,Other,225% of Medicaid,23.44,,,23.44,Other,153% of Medicaid,34.47,,,34.47,Other,225% of Medicaid,21.45,,,21.45,Other,140% of Medicaid,34.47,,,34.47,Other,225% of Medicaid,39.83,,,39.83,Other,260% of Medicaid,49.64,,,49.64,Other,324% of Medicaid,32.94,,,32.94,Other,215% of Medicaid,32.94,,,32.94,Other,215% of Medicaid,19.15,,,19.15,Other,125% of Medicaid,15.32,222.74,
ASSAY ACTIVATED PROTEIN C,85307,CPT,,78085307,CDM,305,RC,,,both,,,86,63.64,,,63.64,Other,150% of Medicare + 9.63% HCRA Surcharge,38.7,45,,38.7,percent of total billed charges,Critical Access Hospital RCC factor,46.11,,,46.11,Fee Schedule,,41.52,,,41.52,Fee Schedule,,105.98,,,105.98,Fee Schedule,,95.32,,,95.32,Fee Schedule,,90.09,,,90.09,Fee Schedule,,42.57,,,42.57,Other,110% of Medicare,48.26,,,48.26,Fee Schedule,,28,,,28,Other,186% of Medicaid,56.84,,,56.84,Fee Schedule,,53.32,,,53.32,Fee Schedule,,32.17,,,32.17,Fee Schedule,,56.84,,,56.84,Fee Schedule,,53.32,,,53.32,Fee Schedule,,60.51,,,60.51,Fee Schedule,,60.2,70,,60.2,percent of total billed charges,All Other,72.6,,,72.6,Fee Schedule,,61.53,,,61.53,Fee Schedule,,22.98,,,22.98,Fee Schedule,,22.98,,,22.98,Fee Schedule,,22.98,,,22.98,Fee Schedule,,22.98,,,22.98,Fee Schedule,,14.88,,,14.88,Other,100% of Medicaid,14.88,,,14.88,Other,100% of Medicaid,14.88,,,14.88,Other,100% of Medicaid,14.88,,,14.88,Other,100% of Medicaid,33.47,,,33.47,Other,225% of Medicaid,22.76,,,22.76,Other,153% of Medicaid,33.47,,,33.47,Other,225% of Medicaid,20.83,,,20.83,Other,140% of Medicaid,33.47,,,33.47,Other,225% of Medicaid,38.68,,,38.68,Other,260% of Medicaid,48.2,,,48.2,Other,324% of Medicaid,31.99,,,31.99,Other,215% of Medicaid,31.99,,,31.99,Other,215% of Medicaid,18.6,,,18.6,Other,125% of Medicaid,14.88,105.98,
FACTOR INHIBITOR TEST,85335,CPT,,78085335,CDM,305,RC,,,both,,,486,359.64,,,359.64,Other,150% of Medicare + 9.63% HCRA Surcharge,218.7,45,,218.7,percent of total billed charges,Critical Access Hospital RCC factor,38.74,,,38.74,Fee Schedule,,34.88,,,34.88,Fee Schedule,,82.05,,,82.05,Fee Schedule,,73.8,,,73.8,Fee Schedule,,69.75,,,69.75,Fee Schedule,,240.57,,,240.57,Other,110% of Medicare,40.54,,,40.54,Fee Schedule,,24,,,24,Other,186% of Medicaid,47.75,,,47.75,Fee Schedule,,301.32,,,301.32,Fee Schedule,,27.03,,,27.03,Fee Schedule,,47.75,,,47.75,Fee Schedule,,301.32,,,301.32,Fee Schedule,,50.84,,,50.84,Fee Schedule,,340.2,70,,340.2,percent of total billed charges,All Other,60.99,,,60.99,Fee Schedule,,51.69,,,51.69,Fee Schedule,,19.31,,,19.31,Fee Schedule,,19.31,,,19.31,Fee Schedule,,19.31,,,19.31,Fee Schedule,,19.31,,,19.31,Fee Schedule,,12.87,,,12.87,Other,100% of Medicaid,12.87,,,12.87,Other,100% of Medicaid,12.87,,,12.87,Other,100% of Medicaid,12.87,,,12.87,Other,100% of Medicaid,28.96,,,28.96,Other,225% of Medicaid,19.69,,,19.69,Other,153% of Medicaid,28.96,,,28.96,Other,225% of Medicaid,18.02,,,18.02,Other,140% of Medicaid,28.96,,,28.96,Other,225% of Medicaid,33.46,,,33.46,Other,260% of Medicaid,41.7,,,41.7,Other,324% of Medicaid,27.67,,,27.67,Other,215% of Medicaid,27.67,,,27.67,Other,215% of Medicaid,16.09,,,16.09,Other,125% of Medicaid,12.87,359.64,
THROMBOMODULIN,85337,CPT,,78085337,CDM,305,RC,,,both,,,248,183.52,,,183.52,Other,150% of Medicare + 9.63% HCRA Surcharge,111.6,45,,111.6,percent of total billed charges,Critical Access Hospital RCC factor,51.98,,,51.98,Fee Schedule,,46.8,,,46.8,Fee Schedule,,77.31,,,77.31,Fee Schedule,,69.54,,,69.54,Fee Schedule,,65.72,,,65.72,Fee Schedule,,122.76,,,122.76,Other,110% of Medicare,54.4,,,54.4,Fee Schedule,,26,,,26,Other,186% of Medicaid,64.07,,,64.07,Fee Schedule,,153.76,,,153.76,Fee Schedule,,36.27,,,36.27,Fee Schedule,,64.07,,,64.07,Fee Schedule,,153.76,,,153.76,Fee Schedule,,68.22,,,68.22,Fee Schedule,,173.6,70,,173.6,percent of total billed charges,All Other,81.84,,,81.84,Fee Schedule,,69.37,,,69.37,Fee Schedule,,25.91,,,25.91,Fee Schedule,,25.91,,,25.91,Fee Schedule,,25.91,,,25.91,Fee Schedule,,25.91,,,25.91,Fee Schedule,,13.82,,,13.82,Other,100% of Medicaid,13.82,,,13.82,Other,100% of Medicaid,13.82,,,13.82,Other,100% of Medicaid,13.82,,,13.82,Other,100% of Medicaid,31.09,,,31.09,Other,225% of Medicaid,21.14,,,21.14,Other,153% of Medicaid,31.09,,,31.09,Other,225% of Medicaid,19.34,,,19.34,Other,140% of Medicaid,31.09,,,31.09,Other,225% of Medicaid,35.92,,,35.92,Other,260% of Medicaid,44.77,,,44.77,Other,324% of Medicaid,29.71,,,29.71,Other,215% of Medicaid,29.71,,,29.71,Other,215% of Medicaid,17.27,,,17.27,Other,125% of Medicaid,13.82,183.52,
COAGULATION TIME,85345,CPT,,78085345,CDM,305,RC,,,both,,,61,45.14,,,45.14,Other,150% of Medicare + 9.63% HCRA Surcharge,27.45,45,,27.45,percent of total billed charges,Critical Access Hospital RCC factor,14.12,,,14.12,Fee Schedule,,12.71,,,12.71,Fee Schedule,,31.88,,,31.88,Fee Schedule,,28.68,,,28.68,Fee Schedule,,27.1,,,27.1,Fee Schedule,,30.2,,,30.2,Other,110% of Medicare,14.77,,,14.77,Fee Schedule,,23,,,23,Other,186% of Medicaid,17.4,,,17.4,Fee Schedule,,37.82,,,37.82,Fee Schedule,,9.85,,,9.85,Fee Schedule,,17.4,,,17.4,Fee Schedule,,37.82,,,37.82,Fee Schedule,,18.53,,,18.53,Fee Schedule,,42.7,70,,42.7,percent of total billed charges,All Other,22.23,,,22.23,Fee Schedule,,18.84,,,18.84,Fee Schedule,,7.04,,,7.04,Fee Schedule,,7.04,,,7.04,Fee Schedule,,7.04,,,7.04,Fee Schedule,,7.04,,,7.04,Fee Schedule,,12.56,,,12.56,Other,100% of Medicaid,12.56,,,12.56,Other,100% of Medicaid,12.56,,,12.56,Other,100% of Medicaid,12.56,,,12.56,Other,100% of Medicaid,28.27,,,28.27,Other,225% of Medicaid,19.22,,,19.22,Other,153% of Medicaid,28.27,,,28.27,Other,225% of Medicaid,17.59,,,17.59,Other,140% of Medicaid,28.27,,,28.27,Other,225% of Medicaid,32.67,,,32.67,Other,260% of Medicaid,40.71,,,40.71,Other,324% of Medicaid,27.01,,,27.01,Other,215% of Medicaid,27.01,,,27.01,Other,215% of Medicaid,15.7,,,15.7,Other,125% of Medicaid,7.04,45.14,
COAGULATION TIME ACTIVATED,85347,CPT,,78085347,CDM,305,RC,,,both,,,24,17.76,,,17.76,Other,150% of Medicare + 9.63% HCRA Surcharge,10.8,45,,10.8,percent of total billed charges,Critical Access Hospital RCC factor,12.88,,,12.88,Fee Schedule,,11.6,,,11.6,Fee Schedule,,31.57,,,31.57,Fee Schedule,,28.39,,,28.39,Fee Schedule,,26.84,,,26.84,Fee Schedule,,11.88,,,11.88,Other,110% of Medicare,13.48,,,13.48,Fee Schedule,,8,,,8,Other,186% of Medicaid,15.88,,,15.88,Fee Schedule,,14.88,,,14.88,Fee Schedule,,8.99,,,8.99,Fee Schedule,,15.88,,,15.88,Fee Schedule,,14.88,,,14.88,Fee Schedule,,16.91,,,16.91,Fee Schedule,,16.8,70,,16.8,percent of total billed charges,All Other,20.28,,,20.28,Fee Schedule,,17.19,,,17.19,Fee Schedule,,6.42,,,6.42,Fee Schedule,,6.42,,,6.42,Fee Schedule,,6.42,,,6.42,Fee Schedule,,6.42,,,6.42,Fee Schedule,,4.28,,,4.28,Other,100% of Medicaid,4.28,,,4.28,Other,100% of Medicaid,4.28,,,4.28,Other,100% of Medicaid,4.28,,,4.28,Other,100% of Medicaid,9.63,,,9.63,Other,225% of Medicaid,6.55,,,6.55,Other,153% of Medicaid,9.63,,,9.63,Other,225% of Medicaid,5.99,,,5.99,Other,140% of Medicaid,9.63,,,9.63,Other,225% of Medicaid,11.13,,,11.13,Other,260% of Medicaid,13.87,,,13.87,Other,324% of Medicaid,9.2,,,9.2,Other,215% of Medicaid,9.2,,,9.2,Other,215% of Medicaid,5.35,,,5.35,Other,125% of Medicaid,4.28,31.57,
EUGLOBULIN LYSIS,85360,CPT,,78085360,CDM,305,RC,,,both,,,50,37,,,37,Other,150% of Medicare + 9.63% HCRA Surcharge,22.5,45,,22.5,percent of total billed charges,Critical Access Hospital RCC factor,25.31,,,25.31,Fee Schedule,,22.79,,,22.79,Fee Schedule,,45.59,,,45.59,Fee Schedule,,41,,,41,Fee Schedule,,38.75,,,38.75,Fee Schedule,,24.75,,,24.75,Other,110% of Medicare,26.49,,,26.49,Fee Schedule,,12,,,12,Other,186% of Medicaid,31.2,,,31.2,Fee Schedule,,31,,,31,Fee Schedule,,17.66,,,17.66,Fee Schedule,,31.2,,,31.2,Fee Schedule,,31,,,31,Fee Schedule,,33.22,,,33.22,Fee Schedule,,35,70,,35,percent of total billed charges,All Other,39.86,,,39.86,Fee Schedule,,33.78,,,33.78,Fee Schedule,,12.62,,,12.62,Fee Schedule,,12.62,,,12.62,Fee Schedule,,12.62,,,12.62,Fee Schedule,,12.62,,,12.62,Fee Schedule,,6.67,,,6.67,Other,100% of Medicaid,6.67,,,6.67,Other,100% of Medicaid,6.67,,,6.67,Other,100% of Medicaid,6.67,,,6.67,Other,100% of Medicaid,15,,,15,Other,225% of Medicaid,10.2,,,10.2,Other,153% of Medicaid,15,,,15,Other,225% of Medicaid,9.33,,,9.33,Other,140% of Medicaid,15,,,15,Other,225% of Medicaid,17.33,,,17.33,Other,260% of Medicaid,21.6,,,21.6,Other,324% of Medicaid,14.33,,,14.33,Other,215% of Medicaid,14.33,,,14.33,Other,215% of Medicaid,8.33,,,8.33,Other,125% of Medicaid,6.67,45.59,
FIBRIN DEGRADATION PRODUCTS,85362,CPT,,78085362,CDM,305,RC,,,both,,,155,114.7,,,114.7,Other,150% of Medicare + 9.63% HCRA Surcharge,69.75,45,,69.75,percent of total billed charges,Critical Access Hospital RCC factor,20.74,,,20.74,Fee Schedule,,18.67,,,18.67,Fee Schedule,,51.07,,,51.07,Fee Schedule,,45.93,,,45.93,Fee Schedule,,43.41,,,43.41,Fee Schedule,,76.73,,,76.73,Other,110% of Medicare,21.7,,,21.7,Fee Schedule,,13,,,13,Other,186% of Medicaid,25.56,,,25.56,Fee Schedule,,96.1,,,96.1,Fee Schedule,,14.47,,,14.47,Fee Schedule,,25.56,,,25.56,Fee Schedule,,96.1,,,96.1,Fee Schedule,,27.22,,,27.22,Fee Schedule,,108.5,70,,108.5,percent of total billed charges,All Other,32.65,,,32.65,Fee Schedule,,27.67,,,27.67,Fee Schedule,,10.34,,,10.34,Fee Schedule,,10.34,,,10.34,Fee Schedule,,10.34,,,10.34,Fee Schedule,,10.34,,,10.34,Fee Schedule,,6.89,,,6.89,Other,100% of Medicaid,6.89,,,6.89,Other,100% of Medicaid,6.89,,,6.89,Other,100% of Medicaid,6.89,,,6.89,Other,100% of Medicaid,15.5,,,15.5,Other,225% of Medicaid,10.54,,,10.54,Other,153% of Medicaid,15.5,,,15.5,Other,225% of Medicaid,9.65,,,9.65,Other,140% of Medicaid,15.5,,,15.5,Other,225% of Medicaid,17.91,,,17.91,Other,260% of Medicaid,22.32,,,22.32,Other,324% of Medicaid,14.81,,,14.81,Other,215% of Medicaid,14.81,,,14.81,Other,215% of Medicaid,8.61,,,8.61,Other,125% of Medicaid,6.89,114.7,
FIBRIN DEGRADE SEMIQUANT,85378,CPT,,78085378,CDM,305,RC,,,both,,,155,114.7,,,114.7,Other,150% of Medicare + 9.63% HCRA Surcharge,69.75,45,,69.75,percent of total billed charges,Critical Access Hospital RCC factor,29.26,,,29.26,Fee Schedule,,26.34,,,26.34,Fee Schedule,,52.86,,,52.86,Fee Schedule,,47.54,,,47.54,Fee Schedule,,44.93,,,44.93,Fee Schedule,,76.73,,,76.73,Other,110% of Medicare,30.62,,,30.62,Fee Schedule,,18,,,18,Other,186% of Medicaid,36.06,,,36.06,Fee Schedule,,96.1,,,96.1,Fee Schedule,,20.41,,,20.41,Fee Schedule,,36.06,,,36.06,Fee Schedule,,96.1,,,96.1,Fee Schedule,,38.39,,,38.39,Fee Schedule,,108.5,70,,108.5,percent of total billed charges,All Other,46.06,,,46.06,Fee Schedule,,39.04,,,39.04,Fee Schedule,,14.58,,,14.58,Fee Schedule,,14.58,,,14.58,Fee Schedule,,14.58,,,14.58,Fee Schedule,,14.58,,,14.58,Fee Schedule,,9.72,,,9.72,Other,100% of Medicaid,9.72,,,9.72,Other,100% of Medicaid,9.72,,,9.72,Other,100% of Medicaid,9.72,,,9.72,Other,100% of Medicaid,21.87,,,21.87,Other,225% of Medicaid,14.87,,,14.87,Other,153% of Medicaid,21.87,,,21.87,Other,225% of Medicaid,13.61,,,13.61,Other,140% of Medicaid,21.87,,,21.87,Other,225% of Medicaid,25.27,,,25.27,Other,260% of Medicaid,31.49,,,31.49,Other,324% of Medicaid,20.9,,,20.9,Other,215% of Medicaid,20.9,,,20.9,Other,215% of Medicaid,12.15,,,12.15,Other,125% of Medicaid,9.72,114.7,
FIBRIN DEGRADATION QUANT,85379,CPT,,78085379,CDM,305,RC,,,both,,,182,134.68,,,134.68,Other,150% of Medicare + 9.63% HCRA Surcharge,81.9,45,,81.9,percent of total billed charges,Critical Access Hospital RCC factor,30.64,,,30.64,Fee Schedule,,27.59,,,27.59,Fee Schedule,,60.13,,,60.13,Fee Schedule,,54.08,,,54.08,Fee Schedule,,51.12,,,51.12,Fee Schedule,,90.09,,,90.09,Other,110% of Medicare,32.07,,,32.07,Fee Schedule,,19,,,19,Other,186% of Medicaid,37.77,,,37.77,Fee Schedule,,112.84,,,112.84,Fee Schedule,,21.38,,,21.38,Fee Schedule,,37.77,,,37.77,Fee Schedule,,112.84,,,112.84,Fee Schedule,,40.21,,,40.21,Fee Schedule,,127.4,70,,127.4,percent of total billed charges,All Other,48.24,,,48.24,Fee Schedule,,40.89,,,40.89,Fee Schedule,,15.27,,,15.27,Fee Schedule,,15.27,,,15.27,Fee Schedule,,15.27,,,15.27,Fee Schedule,,15.27,,,15.27,Fee Schedule,,10.18,,,10.18,Other,100% of Medicaid,10.18,,,10.18,Other,100% of Medicaid,10.18,,,10.18,Other,100% of Medicaid,10.18,,,10.18,Other,100% of Medicaid,22.91,,,22.91,Other,225% of Medicaid,15.58,,,15.58,Other,153% of Medicaid,22.91,,,22.91,Other,225% of Medicaid,14.25,,,14.25,Other,140% of Medicaid,22.91,,,22.91,Other,225% of Medicaid,26.47,,,26.47,Other,260% of Medicaid,32.98,,,32.98,Other,324% of Medicaid,21.89,,,21.89,Other,215% of Medicaid,21.89,,,21.89,Other,215% of Medicaid,12.73,,,12.73,Other,125% of Medicaid,10.18,134.68,
FIBRINOGEN,85384,CPT,,78085384,CDM,305,RC,,,both,,,118,87.32,,,87.32,Other,150% of Medicare + 9.63% HCRA Surcharge,53.1,45,,53.1,percent of total billed charges,Critical Access Hospital RCC factor,29.26,,,29.26,Fee Schedule,,26.34,,,26.34,Fee Schedule,,62.98,,,62.98,Fee Schedule,,56.64,,,56.64,Fee Schedule,,53.54,,,53.54,Fee Schedule,,58.41,,,58.41,Other,110% of Medicare,30.62,,,30.62,Fee Schedule,,13,,,13,Other,186% of Medicaid,36.06,,,36.06,Fee Schedule,,73.16,,,73.16,Fee Schedule,,20.41,,,20.41,Fee Schedule,,36.06,,,36.06,Fee Schedule,,73.16,,,73.16,Fee Schedule,,38.39,,,38.39,Fee Schedule,,82.6,70,,82.6,percent of total billed charges,All Other,46.06,,,46.06,Fee Schedule,,39.04,,,39.04,Fee Schedule,,14.58,,,14.58,Fee Schedule,,14.58,,,14.58,Fee Schedule,,14.58,,,14.58,Fee Schedule,,14.58,,,14.58,Fee Schedule,,6.97,,,6.97,Other,100% of Medicaid,6.97,,,6.97,Other,100% of Medicaid,6.97,,,6.97,Other,100% of Medicaid,6.97,,,6.97,Other,100% of Medicaid,15.68,,,15.68,Other,225% of Medicaid,10.66,,,10.66,Other,153% of Medicaid,15.68,,,15.68,Other,225% of Medicaid,9.76,,,9.76,Other,140% of Medicaid,15.68,,,15.68,Other,225% of Medicaid,18.12,,,18.12,Other,260% of Medicaid,22.58,,,22.58,Other,324% of Medicaid,14.98,,,14.98,Other,215% of Medicaid,14.98,,,14.98,Other,215% of Medicaid,8.71,,,8.71,Other,125% of Medicaid,6.97,87.32,
FIBRINOGEN,85385,CPT,,78085385,CDM,305,RC,,,both,,,110,81.4,,,81.4,Other,150% of Medicare + 9.63% HCRA Surcharge,49.5,45,,49.5,percent of total billed charges,Critical Access Hospital RCC factor,43.52,,,43.52,Fee Schedule,,39.19,,,39.19,Fee Schedule,,62.98,,,62.98,Fee Schedule,,56.64,,,56.64,Fee Schedule,,53.54,,,53.54,Fee Schedule,,54.45,,,54.45,Other,110% of Medicare,45.55,,,45.55,Fee Schedule,,13,,,13,Other,186% of Medicaid,53.65,,,53.65,Fee Schedule,,68.2,,,68.2,Fee Schedule,,30.37,,,30.37,Fee Schedule,,53.65,,,53.65,Fee Schedule,,68.2,,,68.2,Fee Schedule,,57.12,,,57.12,Fee Schedule,,77,70,,77,percent of total billed charges,All Other,68.53,,,68.53,Fee Schedule,,58.08,,,58.08,Fee Schedule,,21.69,,,21.69,Fee Schedule,,21.69,,,21.69,Fee Schedule,,21.69,,,21.69,Fee Schedule,,21.69,,,21.69,Fee Schedule,,6.97,,,6.97,Other,100% of Medicaid,6.97,,,6.97,Other,100% of Medicaid,6.97,,,6.97,Other,100% of Medicaid,6.97,,,6.97,Other,100% of Medicaid,15.68,,,15.68,Other,225% of Medicaid,10.66,,,10.66,Other,153% of Medicaid,15.68,,,15.68,Other,225% of Medicaid,9.76,,,9.76,Other,140% of Medicaid,15.68,,,15.68,Other,225% of Medicaid,18.12,,,18.12,Other,260% of Medicaid,22.58,,,22.58,Other,324% of Medicaid,14.98,,,14.98,Other,215% of Medicaid,14.98,,,14.98,Other,215% of Medicaid,8.71,,,8.71,Other,125% of Medicaid,6.97,81.4,
FIBRINOLYSINS SCREEN,85390,CPT,,78085390,CDM,305,RC,,,both,,,33,24.42,,,24.42,Other,150% of Medicare + 9.63% HCRA Surcharge,14.85,45,,14.85,percent of total billed charges,Critical Access Hospital RCC factor,46.59,,,46.59,Fee Schedule,,41.95,,,41.95,Fee Schedule,,38.31,,,38.31,Fee Schedule,,34.46,,,34.46,Fee Schedule,,32.57,,,32.57,Fee Schedule,,16.34,,,16.34,Other,110% of Medicare,48.76,,,48.76,Fee Schedule,,23,,,23,Other,186% of Medicaid,57.43,,,57.43,Fee Schedule,,20.46,,,20.46,Fee Schedule,,32.51,,,32.51,Fee Schedule,,57.43,,,57.43,Fee Schedule,,20.46,,,20.46,Fee Schedule,,61.15,,,61.15,Fee Schedule,,23.1,70,,23.1,percent of total billed charges,All Other,73.36,,,73.36,Fee Schedule,,62.18,,,62.18,Fee Schedule,,23.22,,,23.22,Fee Schedule,,23.22,,,23.22,Fee Schedule,,23.22,,,23.22,Fee Schedule,,23.22,,,23.22,Fee Schedule,,12.56,,,12.56,Other,100% of Medicaid,12.56,,,12.56,Other,100% of Medicaid,12.56,,,12.56,Other,100% of Medicaid,12.56,,,12.56,Other,100% of Medicaid,28.27,,,28.27,Other,225% of Medicaid,19.22,,,19.22,Other,153% of Medicaid,28.27,,,28.27,Other,225% of Medicaid,17.59,,,17.59,Other,140% of Medicaid,28.27,,,28.27,Other,225% of Medicaid,32.67,,,32.67,Other,260% of Medicaid,40.71,,,40.71,Other,324% of Medicaid,27.01,,,27.01,Other,215% of Medicaid,27.01,,,27.01,Other,215% of Medicaid,15.7,,,15.7,Other,125% of Medicaid,12.56,73.36,
CLOTTING ASSAY WHOLE BLOOD,85396,CPT,,78085396,CDM,305,RC,,,both,,,29,21.46,,,21.46,Other,150% of Medicare + 9.63% HCRA Surcharge,13.05,45,,13.05,percent of total billed charges,Critical Access Hospital RCC factor,60.26,,,60.26,Fee Schedule,,54.25,,,54.25,Fee Schedule,,113.36,,,113.36,Fee Schedule,,101.96,,,101.96,Fee Schedule,,96.36,,,96.36,Fee Schedule,,14.36,,,14.36,Other,110% of Medicare,63.06,,,63.06,Fee Schedule,,70,,,70,Other,186% of Medicaid,74.27,,,74.27,Fee Schedule,,17.98,,,17.98,Fee Schedule,,42.04,,,42.04,Fee Schedule,,74.27,,,74.27,Fee Schedule,,17.98,,,17.98,Fee Schedule,,79.08,,,79.08,Fee Schedule,,20.3,70,,20.3,percent of total billed charges,All Other,93.48,,,93.48,Fee Schedule,,79.23,,,79.23,Fee Schedule,,31.4,,,31.4,Fee Schedule,,31.4,,,31.4,Fee Schedule,,31.4,,,31.4,Fee Schedule,,31.4,,,31.4,Fee Schedule,,37.66,,,37.66,Other,100% of Medicaid,37.66,,,37.66,Other,100% of Medicaid,37.66,,,37.66,Other,100% of Medicaid,37.66,,,37.66,Other,100% of Medicaid,84.74,,,84.74,Other,225% of Medicaid,57.62,,,57.62,Other,153% of Medicaid,84.74,,,84.74,Other,225% of Medicaid,52.73,,,52.73,Other,140% of Medicaid,84.74,,,84.74,Other,225% of Medicaid,97.92,,,97.92,Other,260% of Medicaid,122.02,,,122.02,Other,324% of Medicaid,80.97,,,80.97,Other,215% of Medicaid,80.97,,,80.97,Other,215% of Medicaid,47.08,,,47.08,Other,125% of Medicaid,13.05,122.02,
CLOTTING FUNCT ACTIVITY,85397,CPT,,78085397,CDM,305,RC,,,both,,,120,88.8,,,88.8,Other,150% of Medicare + 9.63% HCRA Surcharge,54,45,,54,percent of total billed charges,Critical Access Hospital RCC factor,92.89,,,92.89,Fee Schedule,,83.63,,,83.63,Fee Schedule,,64.87,,,64.87,Fee Schedule,,58.35,,,58.35,Fee Schedule,,55.15,,,55.15,Fee Schedule,,59.4,,,59.4,Other,110% of Medicare,97.21,,,97.21,Fee Schedule,,18,,,18,Other,186% of Medicaid,114.49,,,114.49,Fee Schedule,,74.4,,,74.4,Fee Schedule,,64.81,,,64.81,Fee Schedule,,114.49,,,114.49,Fee Schedule,,74.4,,,74.4,Fee Schedule,,121.9,,,121.9,Fee Schedule,,84,70,,84,percent of total billed charges,All Other,146.25,,,146.25,Fee Schedule,,123.95,,,123.95,Fee Schedule,,46.29,,,46.29,Fee Schedule,,46.29,,,46.29,Fee Schedule,,46.29,,,46.29,Fee Schedule,,46.29,,,46.29,Fee Schedule,,9.49,,,9.49,Other,100% of Medicaid,9.49,,,9.49,Other,100% of Medicaid,9.49,,,9.49,Other,100% of Medicaid,9.49,,,9.49,Other,100% of Medicaid,21.36,,,21.36,Other,225% of Medicaid,14.53,,,14.53,Other,153% of Medicaid,21.36,,,21.36,Other,225% of Medicaid,13.29,,,13.29,Other,140% of Medicaid,21.36,,,21.36,Other,225% of Medicaid,24.68,,,24.68,Other,260% of Medicaid,30.76,,,30.76,Other,324% of Medicaid,20.41,,,20.41,Other,215% of Medicaid,20.41,,,20.41,Other,215% of Medicaid,11.87,,,11.87,Other,125% of Medicaid,9.49,146.25,
FIBRINOLYTIC ANTIPLASMIN,85410,CPT,,78085410,CDM,305,RC,,,both,,,45,33.3,,,33.3,Other,150% of Medicare + 9.63% HCRA Surcharge,20.25,45,,20.25,percent of total billed charges,Critical Access Hospital RCC factor,23.21,,,23.21,Fee Schedule,,20.89,,,20.89,Fee Schedule,,57.23,,,57.23,Fee Schedule,,51.48,,,51.48,Fee Schedule,,48.65,,,48.65,Fee Schedule,,22.28,,,22.28,Other,110% of Medicare,24.29,,,24.29,Fee Schedule,,23,,,23,Other,186% of Medicaid,28.6,,,28.6,Fee Schedule,,27.9,,,27.9,Fee Schedule,,16.19,,,16.19,Fee Schedule,,28.6,,,28.6,Fee Schedule,,27.9,,,27.9,Fee Schedule,,30.45,,,30.45,Fee Schedule,,31.5,70,,31.5,percent of total billed charges,All Other,36.54,,,36.54,Fee Schedule,,30.97,,,30.97,Fee Schedule,,11.57,,,11.57,Fee Schedule,,11.57,,,11.57,Fee Schedule,,11.57,,,11.57,Fee Schedule,,11.57,,,11.57,Fee Schedule,,12.56,,,12.56,Other,100% of Medicaid,12.56,,,12.56,Other,100% of Medicaid,12.56,,,12.56,Other,100% of Medicaid,12.56,,,12.56,Other,100% of Medicaid,28.27,,,28.27,Other,225% of Medicaid,19.22,,,19.22,Other,153% of Medicaid,28.27,,,28.27,Other,225% of Medicaid,17.59,,,17.59,Other,140% of Medicaid,28.27,,,28.27,Other,225% of Medicaid,32.67,,,32.67,Other,260% of Medicaid,40.71,,,40.71,Other,324% of Medicaid,27.01,,,27.01,Other,215% of Medicaid,27.01,,,27.01,Other,215% of Medicaid,15.7,,,15.7,Other,125% of Medicaid,11.57,57.23,
FIBRINOLYTIC PLASMINOGEN,85415,CPT,,78085415,CDM,305,RC,,,both,,,55,40.7,,,40.7,Other,150% of Medicare + 9.63% HCRA Surcharge,24.75,45,,24.75,percent of total billed charges,Critical Access Hospital RCC factor,51.74,,,51.74,Fee Schedule,,46.58,,,46.58,Fee Schedule,,62.19,,,62.19,Fee Schedule,,55.93,,,55.93,Fee Schedule,,52.86,,,52.86,Fee Schedule,,27.23,,,27.23,Other,110% of Medicare,54.15,,,54.15,Fee Schedule,,23,,,23,Other,186% of Medicaid,63.77,,,63.77,Fee Schedule,,34.1,,,34.1,Fee Schedule,,36.1,,,36.1,Fee Schedule,,63.77,,,63.77,Fee Schedule,,34.1,,,34.1,Fee Schedule,,67.9,,,67.9,Fee Schedule,,38.5,70,,38.5,percent of total billed charges,All Other,81.46,,,81.46,Fee Schedule,,69.05,,,69.05,Fee Schedule,,25.79,,,25.79,Fee Schedule,,25.79,,,25.79,Fee Schedule,,25.79,,,25.79,Fee Schedule,,25.79,,,25.79,Fee Schedule,,12.56,,,12.56,Other,100% of Medicaid,12.56,,,12.56,Other,100% of Medicaid,12.56,,,12.56,Other,100% of Medicaid,12.56,,,12.56,Other,100% of Medicaid,28.27,,,28.27,Other,225% of Medicaid,19.22,,,19.22,Other,153% of Medicaid,28.27,,,28.27,Other,225% of Medicaid,17.59,,,17.59,Other,140% of Medicaid,28.27,,,28.27,Other,225% of Medicaid,32.67,,,32.67,Other,260% of Medicaid,40.71,,,40.71,Other,324% of Medicaid,27.01,,,27.01,Other,215% of Medicaid,27.01,,,27.01,Other,215% of Medicaid,15.7,,,15.7,Other,125% of Medicaid,12.56,81.46,
FIBRINOLYTIC PLASMINOGEN,85420,CPT,,78085420,CDM,305,RC,,,both,,,152,112.48,,,112.48,Other,150% of Medicare + 9.63% HCRA Surcharge,68.4,45,,68.4,percent of total billed charges,Critical Access Hospital RCC factor,19.66,,,19.66,Fee Schedule,,17.7,,,17.7,Fee Schedule,,46.17,,,46.17,Fee Schedule,,41.52,,,41.52,Fee Schedule,,39.24,,,39.24,Fee Schedule,,75.24,,,75.24,Other,110% of Medicare,20.57,,,20.57,Fee Schedule,,23,,,23,Other,186% of Medicaid,24.23,,,24.23,Fee Schedule,,94.24,,,94.24,Fee Schedule,,13.71,,,13.71,Fee Schedule,,24.23,,,24.23,Fee Schedule,,94.24,,,94.24,Fee Schedule,,25.79,,,25.79,Fee Schedule,,106.4,70,,106.4,percent of total billed charges,All Other,30.95,,,30.95,Fee Schedule,,26.23,,,26.23,Fee Schedule,,9.8,,,9.8,Fee Schedule,,9.8,,,9.8,Fee Schedule,,9.8,,,9.8,Fee Schedule,,9.8,,,9.8,Fee Schedule,,12.56,,,12.56,Other,100% of Medicaid,12.56,,,12.56,Other,100% of Medicaid,12.56,,,12.56,Other,100% of Medicaid,12.56,,,12.56,Other,100% of Medicaid,28.27,,,28.27,Other,225% of Medicaid,19.22,,,19.22,Other,153% of Medicaid,28.27,,,28.27,Other,225% of Medicaid,17.59,,,17.59,Other,140% of Medicaid,28.27,,,28.27,Other,225% of Medicaid,32.67,,,32.67,Other,260% of Medicaid,40.71,,,40.71,Other,324% of Medicaid,27.01,,,27.01,Other,215% of Medicaid,27.01,,,27.01,Other,215% of Medicaid,15.7,,,15.7,Other,125% of Medicaid,9.8,112.48,
HEMOGLOBIN FETAL,85460,CPT,,78085460,CDM,305,RC,,,both,,,26,19.24,,,19.24,Other,150% of Medicare + 9.63% HCRA Surcharge,11.7,45,,11.7,percent of total billed charges,Critical Access Hospital RCC factor,23.27,,,23.27,Fee Schedule,,20.95,,,20.95,Fee Schedule,,57.39,,,57.39,Fee Schedule,,51.62,,,51.62,Fee Schedule,,48.79,,,48.79,Fee Schedule,,12.87,,,12.87,Other,110% of Medicare,24.35,,,24.35,Fee Schedule,,14,,,14,Other,186% of Medicaid,28.68,,,28.68,Fee Schedule,,16.12,,,16.12,Fee Schedule,,16.23,,,16.23,Fee Schedule,,28.68,,,28.68,Fee Schedule,,16.12,,,16.12,Fee Schedule,,30.53,,,30.53,Fee Schedule,,18.2,70,,18.2,percent of total billed charges,All Other,36.63,,,36.63,Fee Schedule,,31.05,,,31.05,Fee Schedule,,11.6,,,11.6,Fee Schedule,,11.6,,,11.6,Fee Schedule,,11.6,,,11.6,Fee Schedule,,11.6,,,11.6,Fee Schedule,,7.73,,,7.73,Other,100% of Medicaid,7.73,,,7.73,Other,100% of Medicaid,7.73,,,7.73,Other,100% of Medicaid,7.73,,,7.73,Other,100% of Medicaid,17.39,,,17.39,Other,225% of Medicaid,11.83,,,11.83,Other,153% of Medicaid,17.39,,,17.39,Other,225% of Medicaid,10.82,,,10.82,Other,140% of Medicaid,17.39,,,17.39,Other,225% of Medicaid,20.1,,,20.1,Other,260% of Medicaid,25.05,,,25.05,Other,324% of Medicaid,16.62,,,16.62,Other,215% of Medicaid,16.62,,,16.62,Other,215% of Medicaid,9.66,,,9.66,Other,125% of Medicaid,7.73,57.39,
HEMOGLOBIN FETAL,85461,CPT,,78085461,CDM,305,RC,,,both,,,93,68.82,,,68.82,Other,150% of Medicare + 9.63% HCRA Surcharge,41.85,45,,41.85,percent of total billed charges,Critical Access Hospital RCC factor,28.17,,,28.17,Fee Schedule,,25.37,,,25.37,Fee Schedule,,49.22,,,49.22,Fee Schedule,,44.27,,,44.27,Fee Schedule,,41.84,,,41.84,Fee Schedule,,46.04,,,46.04,Other,110% of Medicare,29.48,,,29.48,Fee Schedule,,17,,,17,Other,186% of Medicaid,34.73,,,34.73,Fee Schedule,,57.66,,,57.66,Fee Schedule,,19.66,,,19.66,Fee Schedule,,34.73,,,34.73,Fee Schedule,,57.66,,,57.66,Fee Schedule,,36.97,,,36.97,Fee Schedule,,65.1,70,,65.1,percent of total billed charges,All Other,44.36,,,44.36,Fee Schedule,,37.6,,,37.6,Fee Schedule,,14.04,,,14.04,Fee Schedule,,14.04,,,14.04,Fee Schedule,,14.04,,,14.04,Fee Schedule,,14.04,,,14.04,Fee Schedule,,9.36,,,9.36,Other,100% of Medicaid,9.36,,,9.36,Other,100% of Medicaid,9.36,,,9.36,Other,100% of Medicaid,9.36,,,9.36,Other,100% of Medicaid,21.06,,,21.06,Other,225% of Medicaid,14.32,,,14.32,Other,153% of Medicaid,21.06,,,21.06,Other,225% of Medicaid,13.1,,,13.1,Other,140% of Medicaid,21.06,,,21.06,Other,225% of Medicaid,24.34,,,24.34,Other,260% of Medicaid,30.33,,,30.33,Other,324% of Medicaid,20.12,,,20.12,Other,215% of Medicaid,20.12,,,20.12,Other,215% of Medicaid,11.7,,,11.7,Other,125% of Medicaid,9.36,68.82,
HEMOLYSIN,85475,CPT,,78085475,CDM,305,RC,,,both,,,52,38.48,,,38.48,Other,150% of Medicare + 9.63% HCRA Surcharge,23.4,45,,23.4,percent of total billed charges,Critical Access Hospital RCC factor,26.7,,,26.7,Fee Schedule,,24.04,,,24.04,Fee Schedule,,65.77,,,65.77,Fee Schedule,,59.16,,,59.16,Fee Schedule,,55.91,,,55.91,Fee Schedule,,25.74,,,25.74,Other,110% of Medicare,27.94,,,27.94,Fee Schedule,,16,,,16,Other,186% of Medicaid,32.91,,,32.91,Fee Schedule,,32.24,,,32.24,Fee Schedule,,18.63,,,18.63,Fee Schedule,,32.91,,,32.91,Fee Schedule,,32.24,,,32.24,Fee Schedule,,35.04,,,35.04,Fee Schedule,,36.4,70,,36.4,percent of total billed charges,All Other,42.04,,,42.04,Fee Schedule,,35.63,,,35.63,Fee Schedule,,13.31,,,13.31,Fee Schedule,,13.31,,,13.31,Fee Schedule,,13.31,,,13.31,Fee Schedule,,13.31,,,13.31,Fee Schedule,,8.87,,,8.87,Other,100% of Medicaid,8.87,,,8.87,Other,100% of Medicaid,8.87,,,8.87,Other,100% of Medicaid,8.87,,,8.87,Other,100% of Medicaid,19.96,,,19.96,Other,225% of Medicaid,13.57,,,13.57,Other,153% of Medicaid,19.96,,,19.96,Other,225% of Medicaid,12.42,,,12.42,Other,140% of Medicaid,19.96,,,19.96,Other,225% of Medicaid,23.06,,,23.06,Other,260% of Medicaid,28.74,,,28.74,Other,324% of Medicaid,19.07,,,19.07,Other,215% of Medicaid,19.07,,,19.07,Other,215% of Medicaid,11.09,,,11.09,Other,125% of Medicaid,8.87,65.77,
HEPARIN ASSAY,85520,CPT,,78085520,CDM,305,RC,,,both,,,255,188.7,,,188.7,Other,150% of Medicare + 9.63% HCRA Surcharge,114.75,45,,114.75,percent of total billed charges,Critical Access Hospital RCC factor,39.4,,,39.4,Fee Schedule,,35.47,,,35.47,Fee Schedule,,97.13,,,97.13,Fee Schedule,,87.36,,,87.36,Fee Schedule,,82.57,,,82.57,Fee Schedule,,126.23,,,126.23,Other,110% of Medicare,41.23,,,41.23,Fee Schedule,,24,,,24,Other,186% of Medicaid,48.56,,,48.56,Fee Schedule,,158.1,,,158.1,Fee Schedule,,27.49,,,27.49,Fee Schedule,,48.56,,,48.56,Fee Schedule,,158.1,,,158.1,Fee Schedule,,51.71,,,51.71,Fee Schedule,,178.5,70,,178.5,percent of total billed charges,All Other,62.03,,,62.03,Fee Schedule,,52.58,,,52.58,Fee Schedule,,19.64,,,19.64,Fee Schedule,,19.64,,,19.64,Fee Schedule,,19.64,,,19.64,Fee Schedule,,19.64,,,19.64,Fee Schedule,,13.09,,,13.09,Other,100% of Medicaid,13.09,,,13.09,Other,100% of Medicaid,13.09,,,13.09,Other,100% of Medicaid,13.09,,,13.09,Other,100% of Medicaid,29.45,,,29.45,Other,225% of Medicaid,20.03,,,20.03,Other,153% of Medicaid,29.45,,,29.45,Other,225% of Medicaid,18.33,,,18.33,Other,140% of Medicaid,29.45,,,29.45,Other,225% of Medicaid,34.03,,,34.03,Other,260% of Medicaid,42.41,,,42.41,Other,324% of Medicaid,28.14,,,28.14,Other,215% of Medicaid,28.14,,,28.14,Other,215% of Medicaid,16.36,,,16.36,Other,125% of Medicaid,13.09,188.7,
WBC ALKALINE PHOSPHATASE,85540,CPT,,78085540,CDM,305,RC,,,both,,,129,95.46,,,95.46,Other,150% of Medicare + 9.63% HCRA Surcharge,58.05,45,,58.05,percent of total billed charges,Critical Access Hospital RCC factor,25.89,,,25.89,Fee Schedule,,23.31,,,23.31,Fee Schedule,,63.82,,,63.82,Fee Schedule,,57.4,,,57.4,Fee Schedule,,54.25,,,54.25,Fee Schedule,,63.86,,,63.86,Other,110% of Medicare,27.09,,,27.09,Fee Schedule,,16,,,16,Other,186% of Medicaid,31.91,,,31.91,Fee Schedule,,79.98,,,79.98,Fee Schedule,,18.06,,,18.06,Fee Schedule,,31.91,,,31.91,Fee Schedule,,79.98,,,79.98,Fee Schedule,,33.97,,,33.97,Fee Schedule,,90.3,70,,90.3,percent of total billed charges,All Other,40.76,,,40.76,Fee Schedule,,34.54,,,34.54,Fee Schedule,,12.9,,,12.9,Fee Schedule,,12.9,,,12.9,Fee Schedule,,12.9,,,12.9,Fee Schedule,,12.9,,,12.9,Fee Schedule,,8.6,,,8.6,Other,100% of Medicaid,8.6,,,8.6,Other,100% of Medicaid,8.6,,,8.6,Other,100% of Medicaid,8.6,,,8.6,Other,100% of Medicaid,19.35,,,19.35,Other,225% of Medicaid,13.16,,,13.16,Other,153% of Medicaid,19.35,,,19.35,Other,225% of Medicaid,12.04,,,12.04,Other,140% of Medicaid,19.35,,,19.35,Other,225% of Medicaid,22.36,,,22.36,Other,260% of Medicaid,27.86,,,27.86,Other,324% of Medicaid,18.49,,,18.49,Other,215% of Medicaid,18.49,,,18.49,Other,215% of Medicaid,10.75,,,10.75,Other,125% of Medicaid,8.6,95.46,
MURAMIDASE,85549,CPT,,78085549,CDM,305,RC,,,both,,,292,216.08,,,216.08,Other,150% of Medicare + 9.63% HCRA Surcharge,131.4,45,,131.4,percent of total billed charges,Critical Access Hospital RCC factor,56.44,,,56.44,Fee Schedule,,50.81,,,50.81,Fee Schedule,,139.13,,,139.13,Fee Schedule,,125.14,,,125.14,Fee Schedule,,118.27,,,118.27,Fee Schedule,,144.54,,,144.54,Other,110% of Medicare,59.06,,,59.06,Fee Schedule,,35,,,35,Other,186% of Medicaid,69.56,,,69.56,Fee Schedule,,181.04,,,181.04,Fee Schedule,,39.38,,,39.38,Fee Schedule,,69.56,,,69.56,Fee Schedule,,181.04,,,181.04,Fee Schedule,,74.06,,,74.06,Fee Schedule,,204.4,70,,204.4,percent of total billed charges,All Other,88.86,,,88.86,Fee Schedule,,75.31,,,75.31,Fee Schedule,,28.13,,,28.13,Fee Schedule,,28.13,,,28.13,Fee Schedule,,28.13,,,28.13,Fee Schedule,,28.13,,,28.13,Fee Schedule,,18.75,,,18.75,Other,100% of Medicaid,18.75,,,18.75,Other,100% of Medicaid,18.75,,,18.75,Other,100% of Medicaid,18.75,,,18.75,Other,100% of Medicaid,42.19,,,42.19,Other,225% of Medicaid,28.69,,,28.69,Other,153% of Medicaid,42.19,,,42.19,Other,225% of Medicaid,26.25,,,26.25,Other,140% of Medicaid,42.19,,,42.19,Other,225% of Medicaid,48.75,,,48.75,Other,260% of Medicaid,60.75,,,60.75,Other,324% of Medicaid,40.31,,,40.31,Other,215% of Medicaid,40.31,,,40.31,Other,215% of Medicaid,23.44,,,23.44,Other,125% of Medicaid,18.75,216.08,
RBC OSMOTIC FRAGILITY,85555,CPT,,78085555,CDM,305,RC,,,both,,,50,37,,,37,Other,150% of Medicare + 9.63% HCRA Surcharge,22.5,45,,22.5,percent of total billed charges,Critical Access Hospital RCC factor,22.48,,,22.48,Fee Schedule,,20.24,,,20.24,Fee Schedule,,49.59,,,49.59,Fee Schedule,,44.6,,,44.6,Fee Schedule,,42.16,,,42.16,Fee Schedule,,24.75,,,24.75,Other,110% of Medicare,23.53,,,23.53,Fee Schedule,,14,,,14,Other,186% of Medicaid,27.71,,,27.71,Fee Schedule,,31,,,31,Fee Schedule,,15.69,,,15.69,Fee Schedule,,27.71,,,27.71,Fee Schedule,,31,,,31,Fee Schedule,,29.51,,,29.51,Fee Schedule,,35,70,,35,percent of total billed charges,All Other,35.4,,,35.4,Fee Schedule,,30,,,30,Fee Schedule,,11.21,,,11.21,Fee Schedule,,11.21,,,11.21,Fee Schedule,,11.21,,,11.21,Fee Schedule,,11.21,,,11.21,Fee Schedule,,7.47,,,7.47,Other,100% of Medicaid,7.47,,,7.47,Other,100% of Medicaid,7.47,,,7.47,Other,100% of Medicaid,7.47,,,7.47,Other,100% of Medicaid,16.81,,,16.81,Other,225% of Medicaid,11.43,,,11.43,Other,153% of Medicaid,16.81,,,16.81,Other,225% of Medicaid,10.46,,,10.46,Other,140% of Medicaid,16.81,,,16.81,Other,225% of Medicaid,19.42,,,19.42,Other,260% of Medicaid,24.2,,,24.2,Other,324% of Medicaid,16.06,,,16.06,Other,215% of Medicaid,16.06,,,16.06,Other,215% of Medicaid,9.34,,,9.34,Other,125% of Medicaid,7.47,49.59,
RBC OSMOTIC FRAGILITY,85557,CPT,,78085557,CDM,305,RC,,,both,,,82,60.68,,,60.68,Other,150% of Medicare + 9.63% HCRA Surcharge,36.9,45,,36.9,percent of total billed charges,Critical Access Hospital RCC factor,40.21,,,40.21,Fee Schedule,,36.21,,,36.21,Fee Schedule,,64.87,,,64.87,Fee Schedule,,58.35,,,58.35,Fee Schedule,,55.15,,,55.15,Fee Schedule,,40.59,,,40.59,Other,110% of Medicare,42.08,,,42.08,Fee Schedule,,18,,,18,Other,186% of Medicaid,49.57,,,49.57,Fee Schedule,,50.84,,,50.84,Fee Schedule,,28.06,,,28.06,Fee Schedule,,49.57,,,49.57,Fee Schedule,,50.84,,,50.84,Fee Schedule,,52.77,,,52.77,Fee Schedule,,57.4,70,,57.4,percent of total billed charges,All Other,63.31,,,63.31,Fee Schedule,,53.66,,,53.66,Fee Schedule,,20.04,,,20.04,Fee Schedule,,20.04,,,20.04,Fee Schedule,,20.04,,,20.04,Fee Schedule,,20.04,,,20.04,Fee Schedule,,9.52,,,9.52,Other,100% of Medicaid,9.52,,,9.52,Other,100% of Medicaid,9.52,,,9.52,Other,100% of Medicaid,9.52,,,9.52,Other,100% of Medicaid,21.43,,,21.43,Other,225% of Medicaid,14.57,,,14.57,Other,153% of Medicaid,21.43,,,21.43,Other,225% of Medicaid,13.33,,,13.33,Other,140% of Medicaid,21.43,,,21.43,Other,225% of Medicaid,24.76,,,24.76,Other,260% of Medicaid,30.86,,,30.86,Other,324% of Medicaid,20.48,,,20.48,Other,215% of Medicaid,20.48,,,20.48,Other,215% of Medicaid,11.91,,,11.91,Other,125% of Medicaid,9.52,64.87,
BLOOD PLATELET AGGREGATION,85576,CPT,,78085576,CDM,305,RC,,,both,,,129,95.46,,,95.46,Other,150% of Medicare + 9.63% HCRA Surcharge,58.05,45,,58.05,percent of total billed charges,Critical Access Hospital RCC factor,74.98,,,74.98,Fee Schedule,,67.51,,,67.51,Fee Schedule,,159.31,,,159.31,Fee Schedule,,143.29,,,143.29,Fee Schedule,,135.43,,,135.43,Fee Schedule,,63.86,,,63.86,Other,110% of Medicare,78.47,,,78.47,Fee Schedule,,20,,,20,Other,186% of Medicaid,92.42,,,92.42,Fee Schedule,,79.98,,,79.98,Fee Schedule,,52.31,,,52.31,Fee Schedule,,92.42,,,92.42,Fee Schedule,,79.98,,,79.98,Fee Schedule,,98.39,,,98.39,Fee Schedule,,90.3,70,,90.3,percent of total billed charges,All Other,118.05,,,118.05,Fee Schedule,,100.05,,,100.05,Fee Schedule,,37.37,,,37.37,Fee Schedule,,37.37,,,37.37,Fee Schedule,,37.37,,,37.37,Fee Schedule,,37.37,,,37.37,Fee Schedule,,10.82,,,10.82,Other,100% of Medicaid,10.82,,,10.82,Other,100% of Medicaid,10.82,,,10.82,Other,100% of Medicaid,10.82,,,10.82,Other,100% of Medicaid,24.34,,,24.34,Other,225% of Medicaid,16.55,,,16.55,Other,153% of Medicaid,24.34,,,24.34,Other,225% of Medicaid,15.14,,,15.14,Other,140% of Medicaid,24.34,,,24.34,Other,225% of Medicaid,28.12,,,28.12,Other,260% of Medicaid,35.05,,,35.05,Other,324% of Medicaid,23.26,,,23.26,Other,215% of Medicaid,23.26,,,23.26,Other,215% of Medicaid,13.52,,,13.52,Other,125% of Medicaid,10.82,159.31,
HEXAGNAL PHOSPH PLTLT NEUTRL,85598,CPT,,78085598,CDM,305,RC,,,both,,,88,65.12,,,65.12,Other,150% of Medicare + 9.63% HCRA Surcharge,39.6,45,,39.6,percent of total billed charges,Critical Access Hospital RCC factor,54.12,,,54.12,Fee Schedule,,48.73,,,48.73,Fee Schedule,,100.13,,,100.13,Fee Schedule,,90.06,,,90.06,Fee Schedule,,85.12,,,85.12,Fee Schedule,,43.56,,,43.56,Other,110% of Medicare,56.64,,,56.64,Fee Schedule,,23,,,23,Other,186% of Medicaid,66.71,,,66.71,Fee Schedule,,54.56,,,54.56,Fee Schedule,,37.76,,,37.76,Fee Schedule,,66.71,,,66.71,Fee Schedule,,54.56,,,54.56,Fee Schedule,,71.02,,,71.02,Fee Schedule,,61.6,70,,61.6,percent of total billed charges,All Other,85.21,,,85.21,Fee Schedule,,72.22,,,72.22,Fee Schedule,,26.97,,,26.97,Fee Schedule,,26.97,,,26.97,Fee Schedule,,26.97,,,26.97,Fee Schedule,,26.97,,,26.97,Fee Schedule,,12.56,,,12.56,Other,100% of Medicaid,12.56,,,12.56,Other,100% of Medicaid,12.56,,,12.56,Other,100% of Medicaid,12.56,,,12.56,Other,100% of Medicaid,28.27,,,28.27,Other,225% of Medicaid,19.22,,,19.22,Other,153% of Medicaid,28.27,,,28.27,Other,225% of Medicaid,17.59,,,17.59,Other,140% of Medicaid,28.27,,,28.27,Other,225% of Medicaid,32.67,,,32.67,Other,260% of Medicaid,40.71,,,40.71,Other,324% of Medicaid,27.01,,,27.01,Other,215% of Medicaid,27.01,,,27.01,Other,215% of Medicaid,15.7,,,15.7,Other,125% of Medicaid,12.56,100.13,
PROTHROMBIN TIME,85610,CPT,,78085610,CDM,305,RC,,,both,,,41,30.34,,,30.34,Other,150% of Medicare + 9.63% HCRA Surcharge,18.45,45,,18.45,percent of total billed charges,Critical Access Hospital RCC factor,12.91,,,12.91,Fee Schedule,,11.63,,,11.63,Fee Schedule,,29.14,,,29.14,Fee Schedule,,26.21,,,26.21,Fee Schedule,,24.77,,,24.77,Fee Schedule,,20.3,,,20.3,Other,110% of Medicare,13.51,,,13.51,Fee Schedule,,7,,,7,Other,186% of Medicaid,15.92,,,15.92,Fee Schedule,,25.42,,,25.42,Fee Schedule,,9.01,,,9.01,Fee Schedule,,15.92,,,15.92,Fee Schedule,,25.42,,,25.42,Fee Schedule,,16.95,,,16.95,Fee Schedule,,28.7,70,,28.7,percent of total billed charges,All Other,20.33,,,20.33,Fee Schedule,,17.23,,,17.23,Fee Schedule,,6.44,,,6.44,Fee Schedule,,6.44,,,6.44,Fee Schedule,,6.44,,,6.44,Fee Schedule,,6.44,,,6.44,Fee Schedule,,3.95,,,3.95,Other,100% of Medicaid,3.95,,,3.95,Other,100% of Medicaid,3.95,,,3.95,Other,100% of Medicaid,3.95,,,3.95,Other,100% of Medicaid,8.89,,,8.89,Other,225% of Medicaid,6.04,,,6.04,Other,153% of Medicaid,8.89,,,8.89,Other,225% of Medicaid,5.53,,,5.53,Other,140% of Medicaid,8.89,,,8.89,Other,225% of Medicaid,10.27,,,10.27,Other,260% of Medicaid,12.8,,,12.8,Other,324% of Medicaid,8.49,,,8.49,Other,215% of Medicaid,8.49,,,8.49,Other,215% of Medicaid,4.94,,,4.94,Other,125% of Medicaid,3.95,30.34,
RUSSELL VIPER VENOM DILUTED,85613,CPT,,78085613,CDM,305,RC,,,both,,,224,165.76,,,165.76,Other,150% of Medicare + 9.63% HCRA Surcharge,100.8,45,,100.8,percent of total billed charges,Critical Access Hospital RCC factor,28.84,,,28.84,Fee Schedule,,25.96,,,25.96,Fee Schedule,,43.11,,,43.11,Fee Schedule,,38.77,,,38.77,Fee Schedule,,36.65,,,36.65,Fee Schedule,,110.88,,,110.88,Other,110% of Medicare,30.18,,,30.18,Fee Schedule,,15,,,15,Other,186% of Medicaid,35.54,,,35.54,Fee Schedule,,138.88,,,138.88,Fee Schedule,,20.12,,,20.12,Fee Schedule,,35.54,,,35.54,Fee Schedule,,138.88,,,138.88,Fee Schedule,,37.84,,,37.84,Fee Schedule,,156.8,70,,156.8,percent of total billed charges,All Other,45.4,,,45.4,Fee Schedule,,38.48,,,38.48,Fee Schedule,,14.37,,,14.37,Fee Schedule,,14.37,,,14.37,Fee Schedule,,14.37,,,14.37,Fee Schedule,,14.37,,,14.37,Fee Schedule,,7.9,,,7.9,Other,100% of Medicaid,7.9,,,7.9,Other,100% of Medicaid,7.9,,,7.9,Other,100% of Medicaid,7.9,,,7.9,Other,100% of Medicaid,17.77,,,17.77,Other,225% of Medicaid,12.08,,,12.08,Other,153% of Medicaid,17.77,,,17.77,Other,225% of Medicaid,11.06,,,11.06,Other,140% of Medicaid,17.77,,,17.77,Other,225% of Medicaid,20.54,,,20.54,Other,260% of Medicaid,25.59,,,25.59,Other,324% of Medicaid,16.98,,,16.98,Other,215% of Medicaid,16.98,,,16.98,Other,215% of Medicaid,9.87,,,9.87,Other,125% of Medicaid,7.9,165.76,
REPTILASE TEST,85635,CPT,,78085635,CDM,305,RC,,,both,,,32,23.68,,,23.68,Other,150% of Medicare + 9.63% HCRA Surcharge,14.4,45,,14.4,percent of total billed charges,Critical Access Hospital RCC factor,29.65,,,29.65,Fee Schedule,,26.69,,,26.69,Fee Schedule,,73.04,,,73.04,Fee Schedule,,65.7,,,65.7,Fee Schedule,,62.09,,,62.09,Fee Schedule,,15.84,,,15.84,Other,110% of Medicare,31.03,,,31.03,Fee Schedule,,16,,,16,Other,186% of Medicaid,36.54,,,36.54,Fee Schedule,,19.84,,,19.84,Fee Schedule,,20.69,,,20.69,Fee Schedule,,36.54,,,36.54,Fee Schedule,,19.84,,,19.84,Fee Schedule,,38.91,,,38.91,Fee Schedule,,22.4,70,,22.4,percent of total billed charges,All Other,46.68,,,46.68,Fee Schedule,,39.56,,,39.56,Fee Schedule,,14.78,,,14.78,Fee Schedule,,14.78,,,14.78,Fee Schedule,,14.78,,,14.78,Fee Schedule,,14.78,,,14.78,Fee Schedule,,8.56,,,8.56,Other,100% of Medicaid,8.56,,,8.56,Other,100% of Medicaid,8.56,,,8.56,Other,100% of Medicaid,8.56,,,8.56,Other,100% of Medicaid,19.27,,,19.27,Other,225% of Medicaid,13.1,,,13.1,Other,153% of Medicaid,19.27,,,19.27,Other,225% of Medicaid,11.99,,,11.99,Other,140% of Medicaid,19.27,,,19.27,Other,225% of Medicaid,22.27,,,22.27,Other,260% of Medicaid,27.75,,,27.75,Other,324% of Medicaid,18.41,,,18.41,Other,215% of Medicaid,18.41,,,18.41,Other,215% of Medicaid,10.71,,,10.71,Other,125% of Medicaid,8.56,73.04,
RBC SED RATE NONAUTOMATED,85651,CPT,,78085651,CDM,305,RC,,,both,,,70,51.8,,,51.8,Other,150% of Medicare + 9.63% HCRA Surcharge,31.5,45,,31.5,percent of total billed charges,Critical Access Hospital RCC factor,12.85,,,12.85,Fee Schedule,,11.57,,,11.57,Fee Schedule,,26.35,,,26.35,Fee Schedule,,23.7,,,23.7,Fee Schedule,,22.4,,,22.4,Fee Schedule,,34.65,,,34.65,Other,110% of Medicare,13.45,,,13.45,Fee Schedule,,4,,,4,Other,186% of Medicaid,15.84,,,15.84,Fee Schedule,,43.4,,,43.4,Fee Schedule,,8.97,,,8.97,Fee Schedule,,15.84,,,15.84,Fee Schedule,,43.4,,,43.4,Fee Schedule,,16.87,,,16.87,Fee Schedule,,49,70,,49,percent of total billed charges,All Other,20.24,,,20.24,Fee Schedule,,17.15,,,17.15,Fee Schedule,,6.41,,,6.41,Fee Schedule,,6.41,,,6.41,Fee Schedule,,6.41,,,6.41,Fee Schedule,,6.41,,,6.41,Fee Schedule,,2.02,,,2.02,Other,100% of Medicaid,2.02,,,2.02,Other,100% of Medicaid,2.02,,,2.02,Other,100% of Medicaid,2.02,,,2.02,Other,100% of Medicaid,4.55,,,4.55,Other,225% of Medicaid,3.09,,,3.09,Other,153% of Medicaid,4.55,,,4.55,Other,225% of Medicaid,2.83,,,2.83,Other,140% of Medicaid,4.55,,,4.55,Other,225% of Medicaid,5.25,,,5.25,Other,260% of Medicaid,6.54,,,6.54,Other,324% of Medicaid,4.34,,,4.34,Other,215% of Medicaid,4.34,,,4.34,Other,215% of Medicaid,2.53,,,2.53,Other,125% of Medicaid,2.02,51.8,
AUTOM ERYTHROCYTE SED RATE,85652,CPT,,78085652,CDM,305,RC,,,both,,,16,11.84,,,11.84,Other,150% of Medicare + 9.63% HCRA Surcharge,7.2,45,,7.2,percent of total billed charges,Critical Access Hospital RCC factor,8.13,,,8.13,Fee Schedule,,7.32,,,7.32,Fee Schedule,,20.03,,,20.03,Fee Schedule,,18.01,,,18.01,Fee Schedule,,17.02,,,17.02,Fee Schedule,,7.92,,,7.92,Other,110% of Medicare,8.51,,,8.51,Fee Schedule,,4,,,4,Other,186% of Medicaid,10.02,,,10.02,Fee Schedule,,9.92,,,9.92,Fee Schedule,,5.67,,,5.67,Fee Schedule,,10.02,,,10.02,Fee Schedule,,9.92,,,9.92,Fee Schedule,,10.67,,,10.67,Fee Schedule,,11.2,70,,11.2,percent of total billed charges,All Other,12.8,,,12.8,Fee Schedule,,10.84,,,10.84,Fee Schedule,,4.05,,,4.05,Fee Schedule,,4.05,,,4.05,Fee Schedule,,4.05,,,4.05,Fee Schedule,,4.05,,,4.05,Fee Schedule,,2.02,,,2.02,Other,100% of Medicaid,2.02,,,2.02,Other,100% of Medicaid,2.02,,,2.02,Other,100% of Medicaid,2.02,,,2.02,Other,100% of Medicaid,4.55,,,4.55,Other,225% of Medicaid,3.09,,,3.09,Other,153% of Medicaid,4.55,,,4.55,Other,225% of Medicaid,2.83,,,2.83,Other,140% of Medicaid,4.55,,,4.55,Other,225% of Medicaid,5.25,,,5.25,Other,260% of Medicaid,6.54,,,6.54,Other,324% of Medicaid,4.34,,,4.34,Other,215% of Medicaid,4.34,,,4.34,Other,215% of Medicaid,2.53,,,2.53,Other,125% of Medicaid,2.02,20.03,
RBC SICKLE CELL TEST,85660,CPT,,78085660,CDM,305,RC,,,both,,,80,59.2,,,59.2,Other,150% of Medicare + 9.63% HCRA Surcharge,36,45,,36,percent of total billed charges,Critical Access Hospital RCC factor,16.59,,,16.59,Fee Schedule,,14.93,,,14.93,Fee Schedule,,30.3,,,30.3,Fee Schedule,,27.26,,,27.26,Fee Schedule,,25.76,,,25.76,Fee Schedule,,39.6,,,39.6,Other,110% of Medicare,17.36,,,17.36,Fee Schedule,,19,,,19,Other,186% of Medicaid,20.44,,,20.44,Fee Schedule,,49.6,,,49.6,Fee Schedule,,11.57,,,11.57,Fee Schedule,,20.44,,,20.44,Fee Schedule,,49.6,,,49.6,Fee Schedule,,21.76,,,21.76,Fee Schedule,,56,70,,56,percent of total billed charges,All Other,26.11,,,26.11,Fee Schedule,,22.13,,,22.13,Fee Schedule,,8.27,,,8.27,Fee Schedule,,8.27,,,8.27,Fee Schedule,,8.27,,,8.27,Fee Schedule,,8.27,,,8.27,Fee Schedule,,10.45,,,10.45,Other,100% of Medicaid,10.45,,,10.45,Other,100% of Medicaid,10.45,,,10.45,Other,100% of Medicaid,10.45,,,10.45,Other,100% of Medicaid,23.51,,,23.51,Other,225% of Medicaid,15.99,,,15.99,Other,153% of Medicaid,23.51,,,23.51,Other,225% of Medicaid,14.63,,,14.63,Other,140% of Medicaid,23.51,,,23.51,Other,225% of Medicaid,27.16,,,27.16,Other,260% of Medicaid,33.85,,,33.85,Other,324% of Medicaid,22.46,,,22.46,Other,215% of Medicaid,22.46,,,22.46,Other,215% of Medicaid,13.06,,,13.06,Other,125% of Medicaid,8.27,59.2,
THROMBIN TIME PLASMA,85670,CPT,,78085670,CDM,305,RC,,,both,,,108,79.92,,,79.92,Other,150% of Medicare + 9.63% HCRA Surcharge,48.6,45,,48.6,percent of total billed charges,Critical Access Hospital RCC factor,17.37,,,17.37,Fee Schedule,,15.64,,,15.64,Fee Schedule,,42.85,,,42.85,Fee Schedule,,38.54,,,38.54,Fee Schedule,,36.42,,,36.42,Fee Schedule,,53.46,,,53.46,Other,110% of Medicare,18.18,,,18.18,Fee Schedule,,10,,,10,Other,186% of Medicaid,21.41,,,21.41,Fee Schedule,,66.96,,,66.96,Fee Schedule,,12.12,,,12.12,Fee Schedule,,21.41,,,21.41,Fee Schedule,,66.96,,,66.96,Fee Schedule,,22.79,,,22.79,Fee Schedule,,75.6,70,,75.6,percent of total billed charges,All Other,27.34,,,27.34,Fee Schedule,,23.18,,,23.18,Fee Schedule,,8.66,,,8.66,Fee Schedule,,8.66,,,8.66,Fee Schedule,,8.66,,,8.66,Fee Schedule,,8.66,,,8.66,Fee Schedule,,5.35,,,5.35,Other,100% of Medicaid,5.35,,,5.35,Other,100% of Medicaid,5.35,,,5.35,Other,100% of Medicaid,5.35,,,5.35,Other,100% of Medicaid,12.04,,,12.04,Other,225% of Medicaid,8.19,,,8.19,Other,153% of Medicaid,12.04,,,12.04,Other,225% of Medicaid,7.49,,,7.49,Other,140% of Medicaid,12.04,,,12.04,Other,225% of Medicaid,13.92,,,13.92,Other,260% of Medicaid,17.34,,,17.34,Other,324% of Medicaid,11.51,,,11.51,Other,215% of Medicaid,11.51,,,11.51,Other,215% of Medicaid,6.69,,,6.69,Other,125% of Medicaid,5.35,79.92,
THROMBOPLASTIN INHIBITION,85705,CPT,,78085705,CDM,305,RC,,,both,,,270,199.8,,,199.8,Other,150% of Medicare + 9.63% HCRA Surcharge,121.5,45,,121.5,percent of total billed charges,Critical Access Hospital RCC factor,28.99,,,28.99,Fee Schedule,,26.1,,,26.1,Fee Schedule,,43.11,,,43.11,Fee Schedule,,38.77,,,38.77,Fee Schedule,,36.65,,,36.65,Fee Schedule,,133.65,,,133.65,Other,110% of Medicare,30.33,,,30.33,Fee Schedule,,14,,,14,Other,186% of Medicaid,35.73,,,35.73,Fee Schedule,,167.4,,,167.4,Fee Schedule,,20.22,,,20.22,Fee Schedule,,35.73,,,35.73,Fee Schedule,,167.4,,,167.4,Fee Schedule,,38.04,,,38.04,Fee Schedule,,189,70,,189,percent of total billed charges,All Other,45.64,,,45.64,Fee Schedule,,38.68,,,38.68,Fee Schedule,,14.45,,,14.45,Fee Schedule,,14.45,,,14.45,Fee Schedule,,14.45,,,14.45,Fee Schedule,,14.45,,,14.45,Fee Schedule,,7.69,,,7.69,Other,100% of Medicaid,7.69,,,7.69,Other,100% of Medicaid,7.69,,,7.69,Other,100% of Medicaid,7.69,,,7.69,Other,100% of Medicaid,17.29,,,17.29,Other,225% of Medicaid,11.76,,,11.76,Other,153% of Medicaid,17.29,,,17.29,Other,225% of Medicaid,10.76,,,10.76,Other,140% of Medicaid,17.29,,,17.29,Other,225% of Medicaid,19.98,,,19.98,Other,260% of Medicaid,24.9,,,24.9,Other,324% of Medicaid,16.53,,,16.53,Other,215% of Medicaid,16.53,,,16.53,Other,215% of Medicaid,9.61,,,9.61,Other,125% of Medicaid,7.69,199.8,
BLOOD VISCOSITY EXAMINATION,85810,CPT,,78085810,CDM,305,RC,,,both,,,186,137.64,,,137.64,Other,150% of Medicare + 9.63% HCRA Surcharge,83.7,45,,83.7,percent of total billed charges,Critical Access Hospital RCC factor,35.13,,,35.13,Fee Schedule,,31.63,,,31.63,Fee Schedule,,86.59,,,86.59,Fee Schedule,,77.88,,,77.88,Fee Schedule,,73.61,,,73.61,Fee Schedule,,92.07,,,92.07,Other,110% of Medicare,36.76,,,36.76,Fee Schedule,,22,,,22,Other,186% of Medicaid,43.3,,,43.3,Fee Schedule,,115.32,,,115.32,Fee Schedule,,24.51,,,24.51,Fee Schedule,,43.3,,,43.3,Fee Schedule,,115.32,,,115.32,Fee Schedule,,46.1,,,46.1,Fee Schedule,,130.2,70,,130.2,percent of total billed charges,All Other,55.3,,,55.3,Fee Schedule,,46.87,,,46.87,Fee Schedule,,17.51,,,17.51,Fee Schedule,,17.51,,,17.51,Fee Schedule,,17.51,,,17.51,Fee Schedule,,17.51,,,17.51,Fee Schedule,,11.67,,,11.67,Other,100% of Medicaid,11.67,,,11.67,Other,100% of Medicaid,11.67,,,11.67,Other,100% of Medicaid,11.67,,,11.67,Other,100% of Medicaid,26.26,,,26.26,Other,225% of Medicaid,17.86,,,17.86,Other,153% of Medicaid,26.26,,,26.26,Other,225% of Medicaid,16.34,,,16.34,Other,140% of Medicaid,26.26,,,26.26,Other,225% of Medicaid,30.34,,,30.34,Other,260% of Medicaid,37.81,,,37.81,Other,324% of Medicaid,25.09,,,25.09,Other,215% of Medicaid,25.09,,,25.09,Other,215% of Medicaid,14.59,,,14.59,Other,125% of Medicaid,11.67,137.64,
PERIPHERAL BLD SMEAR,85060,CPT,TC,85085060,CDM,305,RC,,,both,,,119,88.06,,,88.06,Other,150% of Medicare + 9.63% HCRA Surcharge,53.55,45,,53.55,percent of total billed charges,Critical Access Hospital RCC factor,74.14,,,74.14,Fee Schedule,,66.75,,,66.75,Fee Schedule,,137.55,,,137.55,Fee Schedule,,123.71,,,123.71,Fee Schedule,,116.93,,,116.93,Fee Schedule,,58.91,,,58.91,Other,110% of Medicare,77.58,,,77.58,Fee Schedule,,38,,,38,Other,186% of Medicaid,91.38,,,91.38,Fee Schedule,,73.78,,,73.78,Fee Schedule,,51.72,,,51.72,Fee Schedule,,91.38,,,91.38,Fee Schedule,,73.78,,,73.78,Fee Schedule,,97.29,,,97.29,Fee Schedule,,83.3,70,,83.3,percent of total billed charges,All Other,116.44,,,116.44,Fee Schedule,,98.69,,,98.69,Fee Schedule,,37.89,,,37.89,Fee Schedule,,37.89,,,37.89,Fee Schedule,,37.89,,,37.89,Fee Schedule,,37.89,,,37.89,Fee Schedule,,20.42,,,20.42,Other,100% of Medicaid,20.42,,,20.42,Other,100% of Medicaid,20.42,,,20.42,Other,100% of Medicaid,20.42,,,20.42,Other,100% of Medicaid,45.95,,,45.95,Other,225% of Medicaid,31.25,,,31.25,Other,153% of Medicaid,45.95,,,45.95,Other,225% of Medicaid,28.59,,,28.59,Other,140% of Medicaid,45.95,,,45.95,Other,225% of Medicaid,53.1,,,53.1,Other,260% of Medicaid,66.17,,,66.17,Other,324% of Medicaid,43.91,,,43.91,Other,215% of Medicaid,43.91,,,43.91,Other,215% of Medicaid,25.53,,,25.53,Other,125% of Medicaid,20.42,137.55,
BM SMR INTERP,85097,CPT,TC,85085097,CDM,305,RC,,,both,,,1749,1294.26,,,1294.26,Other,150% of Medicare + 9.63% HCRA Surcharge,787.05,45,,787.05,percent of total billed charges,Critical Access Hospital RCC factor,148.93,,,148.93,Fee Schedule,,134.09,,,134.09,Fee Schedule,,538.8,,,538.8,Fee Schedule,,484.62,,,484.62,Fee Schedule,,458.04,,,458.04,Fee Schedule,,865.76,,,865.76,Other,110% of Medicare,155.86,,,155.86,Fee Schedule,,38,,,38,Other,186% of Medicaid,183.57,,,183.57,Fee Schedule,,1084.38,,,1084.38,Fee Schedule,,103.91,,,103.91,Fee Schedule,,183.57,,,183.57,Fee Schedule,,1084.38,,,1084.38,Fee Schedule,,195.45,,,195.45,Fee Schedule,,1224.3,70,,1224.3,percent of total billed charges,All Other,229.6,,,229.6,Fee Schedule,,194.6,,,194.6,Fee Schedule,,942.3,,,942.3,Fee Schedule,,942.3,,,942.3,Fee Schedule,,942.3,,,942.3,Fee Schedule,,942.3,,,942.3,Fee Schedule,,20.42,,,20.42,Other,100% of Medicaid,20.42,,,20.42,Other,100% of Medicaid,20.42,,,20.42,Other,100% of Medicaid,20.42,,,20.42,Other,100% of Medicaid,45.95,,,45.95,Other,225% of Medicaid,31.25,,,31.25,Other,153% of Medicaid,45.95,,,45.95,Other,225% of Medicaid,28.59,,,28.59,Other,140% of Medicaid,45.95,,,45.95,Other,225% of Medicaid,53.1,,,53.1,Other,260% of Medicaid,66.17,,,66.17,Other,324% of Medicaid,43.91,,,43.91,Other,215% of Medicaid,43.91,,,43.91,Other,215% of Medicaid,25.53,,,25.53,Other,125% of Medicaid,20.42,1294.26,
PLT AGGREGATION (IN VITRO) EA AGENT,85576,CPT,TC,85085576,CDM,305,RC,,,both,,,129,95.46,,,95.46,Other,150% of Medicare + 9.63% HCRA Surcharge,58.05,45,,58.05,percent of total billed charges,Critical Access Hospital RCC factor,74.98,,,74.98,Fee Schedule,,67.51,,,67.51,Fee Schedule,,159.31,,,159.31,Fee Schedule,,143.29,,,143.29,Fee Schedule,,135.43,,,135.43,Fee Schedule,,63.86,,,63.86,Other,110% of Medicare,78.47,,,78.47,Fee Schedule,,20,,,20,Other,186% of Medicaid,92.42,,,92.42,Fee Schedule,,79.98,,,79.98,Fee Schedule,,52.31,,,52.31,Fee Schedule,,92.42,,,92.42,Fee Schedule,,79.98,,,79.98,Fee Schedule,,98.39,,,98.39,Fee Schedule,,90.3,70,,90.3,percent of total billed charges,All Other,118.05,,,118.05,Fee Schedule,,100.05,,,100.05,Fee Schedule,,37.37,,,37.37,Fee Schedule,,37.37,,,37.37,Fee Schedule,,37.37,,,37.37,Fee Schedule,,37.37,,,37.37,Fee Schedule,,10.82,,,10.82,Other,100% of Medicaid,10.82,,,10.82,Other,100% of Medicaid,10.82,,,10.82,Other,100% of Medicaid,10.82,,,10.82,Other,100% of Medicaid,24.34,,,24.34,Other,225% of Medicaid,16.55,,,16.55,Other,153% of Medicaid,24.34,,,24.34,Other,225% of Medicaid,15.14,,,15.14,Other,140% of Medicaid,24.34,,,24.34,Other,225% of Medicaid,28.12,,,28.12,Other,260% of Medicaid,35.05,,,35.05,Other,324% of Medicaid,23.26,,,23.26,Other,215% of Medicaid,23.26,,,23.26,Other,215% of Medicaid,13.52,,,13.52,Other,125% of Medicaid,10.82,159.31,
COVID-19 LAB TEST NON-CDC,U0002,HCPCS,,78000014,CDM,306,RC,,,both,,,158,116.92,,,116.92,Other,150% of Medicare + 9.63% HCRA Surcharge,71.1,45,,71.1,percent of total billed charges,Critical Access Hospital RCC factor,154.44,,,154.44,Fee Schedule,,139.05,,,139.05,Fee Schedule,,61.57,,,61.57,Fee Schedule,,61.57,,,61.57,Fee Schedule,,61.57,,,61.57,Fee Schedule,,78.21,,,78.21,Other,110% of Medicare,161.63,,,161.63,Fee Schedule,,57,,,57,Other,186% of Medicaid,190.36,,,190.36,Fee Schedule,,97.96,,,97.96,Fee Schedule,,107.75,,,107.75,Fee Schedule,,190.36,,,190.36,Fee Schedule,,97.96,,,97.96,Fee Schedule,,202.67,,,202.67,Fee Schedule,,110.6,70,,110.6,percent of total billed charges,All Other,243.16,,,243.16,Fee Schedule,,206.09,,,206.09,Fee Schedule,,76.97,,,76.97,Fee Schedule,,76.97,,,76.97,Fee Schedule,,76.97,,,76.97,Fee Schedule,,76.97,,,76.97,Fee Schedule,,30.79,,,30.79,Other,100% of Medicaid,30.79,,,30.79,Other,100% of Medicaid,30.79,,,30.79,Other,100% of Medicaid,30.79,,,30.79,Other,100% of Medicaid,69.28,,,69.28,Other,225% of Medicaid,47.11,,,47.11,Other,153% of Medicaid,69.28,,,69.28,Other,225% of Medicaid,43.11,,,43.11,Other,140% of Medicaid,69.28,,,69.28,Other,225% of Medicaid,80.05,,,80.05,Other,260% of Medicaid,99.76,,,99.76,Other,324% of Medicaid,66.2,,,66.2,Other,215% of Medicaid,66.2,,,66.2,Other,215% of Medicaid,38.49,,,38.49,Other,125% of Medicaid,30.79,243.16,
CDC 2019 COVID DIAGNOSTIC PANEL,U0001,HCPCS,,78000015,CDM,306,RC,,,both,,,158,116.92,,,116.92,Other,150% of Medicare + 9.63% HCRA Surcharge,71.1,45,,71.1,percent of total billed charges,Critical Access Hospital RCC factor,108.12,,,108.12,Fee Schedule,,97.34,,,97.34,Fee Schedule,,17.33,,,17.33,Fee Schedule,,17.33,,,17.33,Fee Schedule,,17.33,,,17.33,Fee Schedule,,78.21,,,78.21,Other,110% of Medicare,113.15,,,113.15,Fee Schedule,,17,,,17,Other,186% of Medicaid,133.26,,,133.26,Fee Schedule,,97.96,,,97.96,Fee Schedule,,75.43,,,75.43,Fee Schedule,,133.26,,,133.26,Fee Schedule,,97.96,,,97.96,Fee Schedule,,141.88,,,141.88,Fee Schedule,,110.6,70,,110.6,percent of total billed charges,All Other,170.23,,,170.23,Fee Schedule,,144.28,,,144.28,Fee Schedule,,53.88,,,53.88,Fee Schedule,,53.88,,,53.88,Fee Schedule,,53.88,,,53.88,Fee Schedule,,53.88,,,53.88,Fee Schedule,,9.14,,,9.14,Other,100% of Medicaid,9.14,,,9.14,Other,100% of Medicaid,9.14,,,9.14,Other,100% of Medicaid,9.14,,,9.14,Other,100% of Medicaid,20.56,,,20.56,Other,225% of Medicaid,13.98,,,13.98,Other,153% of Medicaid,20.56,,,20.56,Other,225% of Medicaid,12.79,,,12.79,Other,140% of Medicaid,20.56,,,20.56,Other,225% of Medicaid,23.76,,,23.76,Other,260% of Medicaid,29.6,,,29.6,Other,324% of Medicaid,19.64,,,19.64,Other,215% of Medicaid,19.64,,,19.64,Other,215% of Medicaid,11.42,,,11.42,Other,125% of Medicaid,9.14,170.23,
SARS-COV-2-COVID-19 AMP PRB HIGH TECH,U0003,HCPCS,,78000016,CDM,306,RC,,,both,,,161,119.14,,,119.14,Other,150% of Medicare + 9.63% HCRA Surcharge,72.45,45,,72.45,percent of total billed charges,Critical Access Hospital RCC factor,104.65,65,,104.65,percent of total billed charges,All Other,94.99,65,,94.99,percent of total billed charges,All Other,100,,,100,Fee Schedule,,100,,,100,Fee Schedule,,100,,,100,Fee Schedule,,79.7,,,79.7,Other,110% of Medicare,109.48,68,,109.48,percent of total billed charges,All Other,67,,,67,Other,186% of Medicaid,133.63,83,,133.63,percent of total billed charges,All Other,99.82,62,,99.82,percent of total billed charges,Lab and Radiology,88.55,55,,88.55,percent of total billed charges,Default if not on Fee Schedule,128.8,80,,128.8,percent of total billed charges,All Other,99.82,62,,99.82,percent of total billed charges,Lab and Radiology,128.8,80,,128.8,percent of total billed charges,All Other,112.7,70,,112.7,percent of total billed charges,All Other,355.43,,,355.43,Fee Schedule,,301.25,,,301.25,Fee Schedule,,80.5,,,80.5,Fee Schedule,,80.5,,,80.5,Fee Schedule,,80.5,,,80.5,Fee Schedule,,80.5,,,80.5,Fee Schedule,,36.17,,,36.17,Other,100% of Medicaid,36.17,,,36.17,Other,100% of Medicaid,36.17,,,36.17,Other,100% of Medicaid,36.17,,,36.17,Other,100% of Medicaid,81.38,,,81.38,Other,225% of Medicaid,55.34,,,55.34,Other,153% of Medicaid,81.38,,,81.38,Other,225% of Medicaid,50.64,,,50.64,Other,140% of Medicaid,81.38,,,81.38,Other,225% of Medicaid,94.04,,,94.04,Other,260% of Medicaid,117.19,,,117.19,Other,324% of Medicaid,77.77,,,77.77,Other,215% of Medicaid,77.77,,,77.77,Other,215% of Medicaid,45.21,,,45.21,Other,125% of Medicaid,36.17,355.43,
COV-19 AMP PRB HGH THRUPUT WITHIN 2 DAYS,U0005,HCPCS,,78000017,CDM,306,RC,,,both,,,75,55.5,,,55.5,Other,150% of Medicare + 9.63% HCRA Surcharge,33.75,45,,33.75,percent of total billed charges,Critical Access Hospital RCC factor,48.75,65,,48.75,percent of total billed charges,All Other,44.25,65,,44.25,percent of total billed charges,All Other,25,,,25,Fee Schedule,,25,,,25,Fee Schedule,,25,,,25,Fee Schedule,,37.13,,,37.13,Other,110% of Medicare,51,68,,51,percent of total billed charges,All Other,17,,,17,Other,186% of Medicaid,62.25,83,,62.25,percent of total billed charges,All Other,46.5,62,,46.5,percent of total billed charges,Lab and Radiology,41.25,55,,41.25,percent of total billed charges,Default if not on Fee Schedule,60,80,,60,percent of total billed charges,All Other,46.5,62,,46.5,percent of total billed charges,Lab and Radiology,60,80,,60,percent of total billed charges,All Other,52.5,70,,52.5,percent of total billed charges,All Other,118.48,,,118.48,Fee Schedule,,100.42,,,100.42,Fee Schedule,,37.5,,,37.5,Fee Schedule,,37.5,,,37.5,Fee Schedule,,37.5,,,37.5,Fee Schedule,,37.5,,,37.5,Fee Schedule,,9.14,,,9.14,Other,100% of Medicaid,9.14,,,9.14,Other,100% of Medicaid,9.14,,,9.14,Other,100% of Medicaid,9.14,,,9.14,Other,100% of Medicaid,20.56,,,20.56,Other,225% of Medicaid,13.98,,,13.98,Other,153% of Medicaid,20.56,,,20.56,Other,225% of Medicaid,12.79,,,12.79,Other,140% of Medicaid,20.56,,,20.56,Other,225% of Medicaid,23.76,,,23.76,Other,260% of Medicaid,29.6,,,29.6,Other,324% of Medicaid,19.64,,,19.64,Other,215% of Medicaid,19.64,,,19.64,Other,215% of Medicaid,11.42,,,11.42,Other,125% of Medicaid,9.14,118.48,
COV-19 TEST NON-CDC HGH THRU,U0004,HCPCS,,78000018,CDM,306,RC,,,both,,,161,119.14,,,119.14,Other,150% of Medicare + 9.63% HCRA Surcharge,72.45,45,,72.45,percent of total billed charges,Critical Access Hospital RCC factor,104.65,65,,104.65,percent of total billed charges,All Other,94.99,65,,94.99,percent of total billed charges,All Other,100,,,100,Fee Schedule,,100,,,100,Fee Schedule,,100,,,100,Fee Schedule,,79.7,,,79.7,Other,110% of Medicare,109.48,68,,109.48,percent of total billed charges,All Other,67,,,67,Other,186% of Medicaid,133.63,83,,133.63,percent of total billed charges,All Other,99.82,62,,99.82,percent of total billed charges,Lab and Radiology,88.55,55,,88.55,percent of total billed charges,Default if not on Fee Schedule,128.8,80,,128.8,percent of total billed charges,All Other,99.82,62,,99.82,percent of total billed charges,Lab and Radiology,128.8,80,,128.8,percent of total billed charges,All Other,112.7,70,,112.7,percent of total billed charges,All Other,355.43,,,355.43,Fee Schedule,,301.25,,,301.25,Fee Schedule,,80.5,,,80.5,Fee Schedule,,80.5,,,80.5,Fee Schedule,,80.5,,,80.5,Fee Schedule,,80.5,,,80.5,Fee Schedule,,36.17,,,36.17,Other,100% of Medicaid,36.17,,,36.17,Other,100% of Medicaid,36.17,,,36.17,Other,100% of Medicaid,36.17,,,36.17,Other,100% of Medicaid,81.38,,,81.38,Other,225% of Medicaid,55.34,,,55.34,Other,153% of Medicaid,81.38,,,81.38,Other,225% of Medicaid,50.64,,,50.64,Other,140% of Medicaid,81.38,,,81.38,Other,225% of Medicaid,94.04,,,94.04,Other,260% of Medicaid,117.19,,,117.19,Other,324% of Medicaid,77.77,,,77.77,Other,215% of Medicaid,77.77,,,77.77,Other,215% of Medicaid,45.21,,,45.21,Other,125% of Medicaid,36.17,355.43,
SPLECIMEN CONCENTRATION,87015,CPT,,78087015,CDM,306,RC,,,both,,,227,167.98,,,167.98,Other,150% of Medicare + 9.63% HCRA Surcharge,102.15,45,,102.15,percent of total billed charges,Critical Access Hospital RCC factor,20.11,,,20.11,Fee Schedule,,18.1,,,18.1,Fee Schedule,,49.54,,,49.54,Fee Schedule,,44.56,,,44.56,Fee Schedule,,42.11,,,42.11,Fee Schedule,,112.37,,,112.37,Other,110% of Medicare,21.04,,,21.04,Fee Schedule,,6,,,6,Other,186% of Medicaid,24.78,,,24.78,Fee Schedule,,140.74,,,140.74,Fee Schedule,,14.03,,,14.03,Fee Schedule,,24.78,,,24.78,Fee Schedule,,140.74,,,140.74,Fee Schedule,,26.39,,,26.39,Fee Schedule,,158.9,70,,158.9,percent of total billed charges,All Other,31.66,,,31.66,Fee Schedule,,26.83,,,26.83,Fee Schedule,,10.02,,,10.02,Fee Schedule,,10.02,,,10.02,Fee Schedule,,10.02,,,10.02,Fee Schedule,,10.02,,,10.02,Fee Schedule,,3.28,,,3.28,Other,100% of Medicaid,3.28,,,3.28,Other,100% of Medicaid,3.28,,,3.28,Other,100% of Medicaid,3.28,,,3.28,Other,100% of Medicaid,7.39,,,7.39,Other,225% of Medicaid,5.02,,,5.02,Other,153% of Medicaid,7.39,,,7.39,Other,225% of Medicaid,4.6,,,4.6,Other,140% of Medicaid,7.39,,,7.39,Other,225% of Medicaid,8.53,,,8.53,Other,260% of Medicaid,10.64,,,10.64,Other,324% of Medicaid,7.06,,,7.06,Other,215% of Medicaid,7.06,,,7.06,Other,215% of Medicaid,4.1,,,4.1,Other,125% of Medicaid,3.28,167.98,
BLOOD CULTURE FOR BACTERIA,87040,CPT,,78087040,CDM,306,RC,,,both,,,166,122.84,,,122.84,Other,150% of Medicare + 9.63% HCRA Surcharge,74.7,45,,74.7,percent of total billed charges,Critical Access Hospital RCC factor,31.06,,,31.06,Fee Schedule,,27.97,,,27.97,Fee Schedule,,64.87,,,64.87,Fee Schedule,,58.35,,,58.35,Fee Schedule,,55.15,,,55.15,Fee Schedule,,82.17,,,82.17,Other,110% of Medicare,32.51,,,32.51,Fee Schedule,,15,,,15,Other,186% of Medicaid,38.29,,,38.29,Fee Schedule,,102.92,,,102.92,Fee Schedule,,21.67,,,21.67,Fee Schedule,,38.29,,,38.29,Fee Schedule,,102.92,,,102.92,Fee Schedule,,40.76,,,40.76,Fee Schedule,,116.2,70,,116.2,percent of total billed charges,All Other,48.91,,,48.91,Fee Schedule,,41.45,,,41.45,Fee Schedule,,15.48,,,15.48,Fee Schedule,,15.48,,,15.48,Fee Schedule,,15.48,,,15.48,Fee Schedule,,15.48,,,15.48,Fee Schedule,,8.23,,,8.23,Other,100% of Medicaid,8.23,,,8.23,Other,100% of Medicaid,8.23,,,8.23,Other,100% of Medicaid,8.23,,,8.23,Other,100% of Medicaid,18.52,,,18.52,Other,225% of Medicaid,12.59,,,12.59,Other,153% of Medicaid,18.52,,,18.52,Other,225% of Medicaid,11.52,,,11.52,Other,140% of Medicaid,18.52,,,18.52,Other,225% of Medicaid,21.4,,,21.4,Other,260% of Medicaid,26.67,,,26.67,Other,324% of Medicaid,17.7,,,17.7,Other,215% of Medicaid,17.7,,,17.7,Other,215% of Medicaid,10.29,,,10.29,Other,125% of Medicaid,8.23,122.84,
FECES CULTURE BACTERIA,87045,CPT,,78087045,CDM,306,RC,,,both,,,193,142.82,,,142.82,Other,150% of Medicare + 9.63% HCRA Surcharge,86.85,45,,86.85,percent of total billed charges,Critical Access Hospital RCC factor,28.41,,,28.41,Fee Schedule,,25.58,,,25.58,Fee Schedule,,69.99,,,69.99,Fee Schedule,,62.95,,,62.95,Fee Schedule,,59.49,,,59.49,Fee Schedule,,95.54,,,95.54,Other,110% of Medicare,29.74,,,29.74,Fee Schedule,,15,,,15,Other,186% of Medicaid,35.02,,,35.02,Fee Schedule,,119.66,,,119.66,Fee Schedule,,19.82,,,19.82,Fee Schedule,,35.02,,,35.02,Fee Schedule,,119.66,,,119.66,Fee Schedule,,37.29,,,37.29,Fee Schedule,,135.1,70,,135.1,percent of total billed charges,All Other,44.74,,,44.74,Fee Schedule,,37.92,,,37.92,Fee Schedule,,14.16,,,14.16,Fee Schedule,,14.16,,,14.16,Fee Schedule,,14.16,,,14.16,Fee Schedule,,14.16,,,14.16,Fee Schedule,,8.23,,,8.23,Other,100% of Medicaid,8.23,,,8.23,Other,100% of Medicaid,8.23,,,8.23,Other,100% of Medicaid,8.23,,,8.23,Other,100% of Medicaid,18.52,,,18.52,Other,225% of Medicaid,12.59,,,12.59,Other,153% of Medicaid,18.52,,,18.52,Other,225% of Medicaid,11.52,,,11.52,Other,140% of Medicaid,18.52,,,18.52,Other,225% of Medicaid,21.4,,,21.4,Other,260% of Medicaid,26.67,,,26.67,Other,324% of Medicaid,17.7,,,17.7,Other,215% of Medicaid,17.7,,,17.7,Other,215% of Medicaid,10.29,,,10.29,Other,125% of Medicaid,8.23,142.82,
STOOL CULTR BACTERIA EACH,87046,CPT,,78087046,CDM,306,RC,,,both,,,68,50.32,,,50.32,Other,150% of Medicare + 9.63% HCRA Surcharge,30.6,45,,30.6,percent of total billed charges,Critical Access Hospital RCC factor,28.41,,,28.41,Fee Schedule,,25.58,,,25.58,Fee Schedule,,69.99,,,69.99,Fee Schedule,,62.95,,,62.95,Fee Schedule,,59.49,,,59.49,Fee Schedule,,33.66,,,33.66,Other,110% of Medicare,29.74,,,29.74,Fee Schedule,,6,,,6,Other,186% of Medicaid,35.02,,,35.02,Fee Schedule,,42.16,,,42.16,Fee Schedule,,19.82,,,19.82,Fee Schedule,,35.02,,,35.02,Fee Schedule,,42.16,,,42.16,Fee Schedule,,37.29,,,37.29,Fee Schedule,,47.6,70,,47.6,percent of total billed charges,All Other,44.74,,,44.74,Fee Schedule,,37.92,,,37.92,Fee Schedule,,14.16,,,14.16,Fee Schedule,,14.16,,,14.16,Fee Schedule,,14.16,,,14.16,Fee Schedule,,14.16,,,14.16,Fee Schedule,,2.98,,,2.98,Other,100% of Medicaid,2.98,,,2.98,Other,100% of Medicaid,2.98,,,2.98,Other,100% of Medicaid,2.98,,,2.98,Other,100% of Medicaid,6.7,,,6.7,Other,225% of Medicaid,4.56,,,4.56,Other,153% of Medicaid,6.7,,,6.7,Other,225% of Medicaid,4.17,,,4.17,Other,140% of Medicaid,6.7,,,6.7,Other,225% of Medicaid,7.75,,,7.75,Other,260% of Medicaid,9.65,,,9.65,Other,324% of Medicaid,6.41,,,6.41,Other,215% of Medicaid,6.41,,,6.41,Other,215% of Medicaid,3.72,,,3.72,Other,125% of Medicaid,2.98,69.99,
CULTURE BACTERIA OTHER,87070,CPT,,78087070,CDM,306,RC,,,both,,,216,159.84,,,159.84,Other,150% of Medicare + 9.63% HCRA Surcharge,97.2,45,,97.2,percent of total billed charges,Critical Access Hospital RCC factor,25.95,,,25.95,Fee Schedule,,23.36,,,23.36,Fee Schedule,,63.87,,,63.87,Fee Schedule,,57.45,,,57.45,Fee Schedule,,54.3,,,54.3,Fee Schedule,,106.92,,,106.92,Other,110% of Medicare,27.15,,,27.15,Fee Schedule,,15,,,15,Other,186% of Medicaid,31.98,,,31.98,Fee Schedule,,133.92,,,133.92,Fee Schedule,,18.1,,,18.1,Fee Schedule,,31.98,,,31.98,Fee Schedule,,133.92,,,133.92,Fee Schedule,,34.05,,,34.05,Fee Schedule,,151.2,70,,151.2,percent of total billed charges,All Other,40.85,,,40.85,Fee Schedule,,34.62,,,34.62,Fee Schedule,,12.93,,,12.93,Fee Schedule,,12.93,,,12.93,Fee Schedule,,12.93,,,12.93,Fee Schedule,,12.93,,,12.93,Fee Schedule,,8.23,,,8.23,Other,100% of Medicaid,8.23,,,8.23,Other,100% of Medicaid,8.23,,,8.23,Other,100% of Medicaid,8.23,,,8.23,Other,100% of Medicaid,18.52,,,18.52,Other,225% of Medicaid,12.59,,,12.59,Other,153% of Medicaid,18.52,,,18.52,Other,225% of Medicaid,11.52,,,11.52,Other,140% of Medicaid,18.52,,,18.52,Other,225% of Medicaid,21.4,,,21.4,Other,260% of Medicaid,26.67,,,26.67,Other,324% of Medicaid,17.7,,,17.7,Other,215% of Medicaid,17.7,,,17.7,Other,215% of Medicaid,10.29,,,10.29,Other,125% of Medicaid,8.23,159.84,
CULTURE AEROBIC QUANT OTHER,87071,CPT,,78087071,CDM,306,RC,,,both,,,32,23.68,,,23.68,Other,150% of Medicare + 9.63% HCRA Surcharge,14.4,45,,14.4,percent of total billed charges,Critical Access Hospital RCC factor,29.77,,,29.77,Fee Schedule,,26.8,,,26.8,Fee Schedule,,69.99,,,69.99,Fee Schedule,,62.95,,,62.95,Fee Schedule,,59.49,,,59.49,Fee Schedule,,15.84,,,15.84,Other,110% of Medicare,31.15,,,31.15,Fee Schedule,,17,,,17,Other,186% of Medicaid,36.69,,,36.69,Fee Schedule,,19.84,,,19.84,Fee Schedule,,20.77,,,20.77,Fee Schedule,,36.69,,,36.69,Fee Schedule,,19.84,,,19.84,Fee Schedule,,39.07,,,39.07,Fee Schedule,,22.4,70,,22.4,percent of total billed charges,All Other,46.87,,,46.87,Fee Schedule,,39.72,,,39.72,Fee Schedule,,14.84,,,14.84,Fee Schedule,,14.84,,,14.84,Fee Schedule,,14.84,,,14.84,Fee Schedule,,14.84,,,14.84,Fee Schedule,,9.14,,,9.14,Other,100% of Medicaid,9.14,,,9.14,Other,100% of Medicaid,9.14,,,9.14,Other,100% of Medicaid,9.14,,,9.14,Other,100% of Medicaid,20.56,,,20.56,Other,225% of Medicaid,13.98,,,13.98,Other,153% of Medicaid,20.56,,,20.56,Other,225% of Medicaid,12.79,,,12.79,Other,140% of Medicaid,20.56,,,20.56,Other,225% of Medicaid,23.76,,,23.76,Other,260% of Medicaid,29.6,,,29.6,Other,324% of Medicaid,19.64,,,19.64,Other,215% of Medicaid,19.64,,,19.64,Other,215% of Medicaid,11.42,,,11.42,Other,125% of Medicaid,9.14,69.99,
CULTR BACTERIA EXCEPT BLOOD,87075,CPT,,78087075,CDM,306,RC,,,both,,,210,155.4,,,155.4,Other,150% of Medicare + 9.63% HCRA Surcharge,94.5,45,,94.5,percent of total billed charges,Critical Access Hospital RCC factor,28.5,,,28.5,Fee Schedule,,25.66,,,25.66,Fee Schedule,,70.14,,,70.14,Fee Schedule,,63.09,,,63.09,Fee Schedule,,59.63,,,59.63,Fee Schedule,,103.95,,,103.95,Other,110% of Medicare,29.83,,,29.83,Fee Schedule,,18,,,18,Other,186% of Medicaid,35.13,,,35.13,Fee Schedule,,130.2,,,130.2,Fee Schedule,,19.89,,,19.89,Fee Schedule,,35.13,,,35.13,Fee Schedule,,130.2,,,130.2,Fee Schedule,,37.41,,,37.41,Fee Schedule,,147,70,,147,percent of total billed charges,All Other,44.88,,,44.88,Fee Schedule,,38.04,,,38.04,Fee Schedule,,14.21,,,14.21,Fee Schedule,,14.21,,,14.21,Fee Schedule,,14.21,,,14.21,Fee Schedule,,14.21,,,14.21,Fee Schedule,,9.47,,,9.47,Other,100% of Medicaid,9.47,,,9.47,Other,100% of Medicaid,9.47,,,9.47,Other,100% of Medicaid,9.47,,,9.47,Other,100% of Medicaid,21.31,,,21.31,Other,225% of Medicaid,14.49,,,14.49,Other,153% of Medicaid,21.31,,,21.31,Other,225% of Medicaid,13.26,,,13.26,Other,140% of Medicaid,21.31,,,21.31,Other,225% of Medicaid,24.62,,,24.62,Other,260% of Medicaid,30.68,,,30.68,Other,324% of Medicaid,20.36,,,20.36,Other,215% of Medicaid,20.36,,,20.36,Other,215% of Medicaid,11.84,,,11.84,Other,125% of Medicaid,9.47,155.4,
CULTURE ANAEROBE IDENT EACH,87076,CPT,,78087076,CDM,306,RC,,,both,,,65,48.1,,,48.1,Other,150% of Medicare + 9.63% HCRA Surcharge,29.25,45,,29.25,percent of total billed charges,Critical Access Hospital RCC factor,24.32,,,24.32,Fee Schedule,,21.9,,,21.9,Fee Schedule,,59.92,,,59.92,Fee Schedule,,53.89,,,53.89,Fee Schedule,,50.94,,,50.94,Fee Schedule,,32.18,,,32.18,Other,110% of Medicare,25.45,,,25.45,Fee Schedule,,15,,,15,Other,186% of Medicaid,29.98,,,29.98,Fee Schedule,,40.3,,,40.3,Fee Schedule,,16.97,,,16.97,Fee Schedule,,29.98,,,29.98,Fee Schedule,,40.3,,,40.3,Fee Schedule,,31.92,,,31.92,Fee Schedule,,45.5,70,,45.5,percent of total billed charges,All Other,38.29,,,38.29,Fee Schedule,,32.45,,,32.45,Fee Schedule,,12.12,,,12.12,Fee Schedule,,12.12,,,12.12,Fee Schedule,,12.12,,,12.12,Fee Schedule,,12.12,,,12.12,Fee Schedule,,8.08,,,8.08,Other,100% of Medicaid,8.08,,,8.08,Other,100% of Medicaid,8.08,,,8.08,Other,100% of Medicaid,8.08,,,8.08,Other,100% of Medicaid,18.18,,,18.18,Other,225% of Medicaid,12.36,,,12.36,Other,153% of Medicaid,18.18,,,18.18,Other,225% of Medicaid,11.31,,,11.31,Other,140% of Medicaid,18.18,,,18.18,Other,225% of Medicaid,21.01,,,21.01,Other,260% of Medicaid,26.18,,,26.18,Other,324% of Medicaid,17.37,,,17.37,Other,215% of Medicaid,17.37,,,17.37,Other,215% of Medicaid,10.1,,,10.1,Other,125% of Medicaid,8.08,59.92,
CULTURE SCREEN ONLY,87081,CPT,,78087081,CDM,306,RC,,,both,,,171,126.54,,,126.54,Other,150% of Medicare + 9.63% HCRA Surcharge,76.95,45,,76.95,percent of total billed charges,Critical Access Hospital RCC factor,19.96,,,19.96,Fee Schedule,,17.97,,,17.97,Fee Schedule,,49.17,,,49.17,Fee Schedule,,44.22,,,44.22,Fee Schedule,,41.8,,,41.8,Fee Schedule,,84.65,,,84.65,Other,110% of Medicare,20.88,,,20.88,Fee Schedule,,10,,,10,Other,186% of Medicaid,24.6,,,24.6,Fee Schedule,,106.02,,,106.02,Fee Schedule,,13.92,,,13.92,Fee Schedule,,24.6,,,24.6,Fee Schedule,,106.02,,,106.02,Fee Schedule,,26.19,,,26.19,Fee Schedule,,119.7,70,,119.7,percent of total billed charges,All Other,31.42,,,31.42,Fee Schedule,,26.63,,,26.63,Fee Schedule,,9.95,,,9.95,Fee Schedule,,9.95,,,9.95,Fee Schedule,,9.95,,,9.95,Fee Schedule,,9.95,,,9.95,Fee Schedule,,5.25,,,5.25,Other,100% of Medicaid,5.25,,,5.25,Other,100% of Medicaid,5.25,,,5.25,Other,100% of Medicaid,5.25,,,5.25,Other,100% of Medicaid,11.82,,,11.82,Other,225% of Medicaid,8.04,,,8.04,Other,153% of Medicaid,11.82,,,11.82,Other,225% of Medicaid,7.35,,,7.35,Other,140% of Medicaid,11.82,,,11.82,Other,225% of Medicaid,13.66,,,13.66,Other,260% of Medicaid,17.02,,,17.02,Other,324% of Medicaid,11.29,,,11.29,Other,215% of Medicaid,11.29,,,11.29,Other,215% of Medicaid,6.57,,,6.57,Other,125% of Medicaid,5.25,126.54,
URINE CULTURE/COLONY COUNT,87086,CPT,,78087086,CDM,306,RC,,,both,,,128,94.72,,,94.72,Other,150% of Medicare + 9.63% HCRA Surcharge,57.6,45,,57.6,percent of total billed charges,Critical Access Hospital RCC factor,24.29,,,24.29,Fee Schedule,,21.87,,,21.87,Fee Schedule,,59.87,,,59.87,Fee Schedule,,53.85,,,53.85,Fee Schedule,,50.89,,,50.89,Fee Schedule,,63.36,,,63.36,Other,110% of Medicare,25.42,,,25.42,Fee Schedule,,15,,,15,Other,186% of Medicaid,29.94,,,29.94,Fee Schedule,,79.36,,,79.36,Fee Schedule,,16.95,,,16.95,Fee Schedule,,29.94,,,29.94,Fee Schedule,,79.36,,,79.36,Fee Schedule,,31.88,,,31.88,Fee Schedule,,89.6,70,,89.6,percent of total billed charges,All Other,38.24,,,38.24,Fee Schedule,,32.41,,,32.41,Fee Schedule,,12.11,,,12.11,Fee Schedule,,12.11,,,12.11,Fee Schedule,,12.11,,,12.11,Fee Schedule,,12.11,,,12.11,Fee Schedule,,8.07,,,8.07,Other,100% of Medicaid,8.07,,,8.07,Other,100% of Medicaid,8.07,,,8.07,Other,100% of Medicaid,8.07,,,8.07,Other,100% of Medicaid,18.16,,,18.16,Other,225% of Medicaid,12.35,,,12.35,Other,153% of Medicaid,18.16,,,18.16,Other,225% of Medicaid,11.3,,,11.3,Other,140% of Medicaid,18.16,,,18.16,Other,225% of Medicaid,20.98,,,20.98,Other,260% of Medicaid,26.15,,,26.15,Other,324% of Medicaid,17.35,,,17.35,Other,215% of Medicaid,17.35,,,17.35,Other,215% of Medicaid,10.09,,,10.09,Other,125% of Medicaid,8.07,94.72,
URINE BACTERIA CULTURE,87088,CPT,,78087088,CDM,306,RC,,,both,,,166,122.84,,,122.84,Other,150% of Medicare + 9.63% HCRA Surcharge,74.7,45,,74.7,percent of total billed charges,Critical Access Hospital RCC factor,24.35,,,24.35,Fee Schedule,,21.92,,,21.92,Fee Schedule,,60.08,,,60.08,Fee Schedule,,54.04,,,54.04,Fee Schedule,,51.07,,,51.07,Fee Schedule,,82.17,,,82.17,Other,110% of Medicare,25.48,,,25.48,Fee Schedule,,15,,,15,Other,186% of Medicaid,30.01,,,30.01,Fee Schedule,,102.92,,,102.92,Fee Schedule,,16.99,,,16.99,Fee Schedule,,30.01,,,30.01,Fee Schedule,,102.92,,,102.92,Fee Schedule,,31.96,,,31.96,Fee Schedule,,116.2,70,,116.2,percent of total billed charges,All Other,38.34,,,38.34,Fee Schedule,,32.49,,,32.49,Fee Schedule,,12.14,,,12.14,Fee Schedule,,12.14,,,12.14,Fee Schedule,,12.14,,,12.14,Fee Schedule,,12.14,,,12.14,Fee Schedule,,8.09,,,8.09,Other,100% of Medicaid,8.09,,,8.09,Other,100% of Medicaid,8.09,,,8.09,Other,100% of Medicaid,8.09,,,8.09,Other,100% of Medicaid,18.2,,,18.2,Other,225% of Medicaid,12.38,,,12.38,Other,153% of Medicaid,18.2,,,18.2,Other,225% of Medicaid,11.33,,,11.33,Other,140% of Medicaid,18.2,,,18.2,Other,225% of Medicaid,21.03,,,21.03,Other,260% of Medicaid,26.21,,,26.21,Other,324% of Medicaid,17.39,,,17.39,Other,215% of Medicaid,17.39,,,17.39,Other,215% of Medicaid,10.11,,,10.11,Other,125% of Medicaid,8.09,122.84,
SKIN FUNGI CULTURE,87101,CPT,,78087101,CDM,306,RC,,,both,,,138,102.12,,,102.12,Other,150% of Medicare + 9.63% HCRA Surcharge,62.1,45,,62.1,percent of total billed charges,Critical Access Hospital RCC factor,23.21,,,23.21,Fee Schedule,,20.89,,,20.89,Fee Schedule,,57.23,,,57.23,Fee Schedule,,51.48,,,51.48,Fee Schedule,,48.65,,,48.65,Fee Schedule,,68.31,,,68.31,Other,110% of Medicare,24.29,,,24.29,Fee Schedule,,14,,,14,Other,186% of Medicaid,28.6,,,28.6,Fee Schedule,,85.56,,,85.56,Fee Schedule,,16.19,,,16.19,Fee Schedule,,28.6,,,28.6,Fee Schedule,,85.56,,,85.56,Fee Schedule,,30.45,,,30.45,Fee Schedule,,96.6,70,,96.6,percent of total billed charges,All Other,36.54,,,36.54,Fee Schedule,,30.97,,,30.97,Fee Schedule,,11.57,,,11.57,Fee Schedule,,11.57,,,11.57,Fee Schedule,,11.57,,,11.57,Fee Schedule,,11.57,,,11.57,Fee Schedule,,7.71,,,7.71,Other,100% of Medicaid,7.71,,,7.71,Other,100% of Medicaid,7.71,,,7.71,Other,100% of Medicaid,7.71,,,7.71,Other,100% of Medicaid,17.35,,,17.35,Other,225% of Medicaid,11.8,,,11.8,Other,153% of Medicaid,17.35,,,17.35,Other,225% of Medicaid,10.79,,,10.79,Other,140% of Medicaid,17.35,,,17.35,Other,225% of Medicaid,20.05,,,20.05,Other,260% of Medicaid,24.98,,,24.98,Other,324% of Medicaid,16.58,,,16.58,Other,215% of Medicaid,16.58,,,16.58,Other,215% of Medicaid,9.64,,,9.64,Other,125% of Medicaid,7.71,102.12,
FUNGUS ISOLATION CULTURE,87102,CPT,,78087102,CDM,306,RC,,,both,,,105,77.7,,,77.7,Other,150% of Medicare + 9.63% HCRA Surcharge,47.25,45,,47.25,percent of total billed charges,Critical Access Hospital RCC factor,25.31,,,25.31,Fee Schedule,,22.79,,,22.79,Fee Schedule,,62.34,,,62.34,Fee Schedule,,56.07,,,56.07,Fee Schedule,,53,,,53,Fee Schedule,,51.98,,,51.98,Other,110% of Medicare,26.49,,,26.49,Fee Schedule,,16,,,16,Other,186% of Medicaid,31.2,,,31.2,Fee Schedule,,65.1,,,65.1,Fee Schedule,,17.66,,,17.66,Fee Schedule,,31.2,,,31.2,Fee Schedule,,65.1,,,65.1,Fee Schedule,,33.22,,,33.22,Fee Schedule,,73.5,70,,73.5,percent of total billed charges,All Other,39.86,,,39.86,Fee Schedule,,33.78,,,33.78,Fee Schedule,,12.62,,,12.62,Fee Schedule,,12.62,,,12.62,Fee Schedule,,12.62,,,12.62,Fee Schedule,,12.62,,,12.62,Fee Schedule,,8.41,,,8.41,Other,100% of Medicaid,8.41,,,8.41,Other,100% of Medicaid,8.41,,,8.41,Other,100% of Medicaid,8.41,,,8.41,Other,100% of Medicaid,18.92,,,18.92,Other,225% of Medicaid,12.87,,,12.87,Other,153% of Medicaid,18.92,,,18.92,Other,225% of Medicaid,11.77,,,11.77,Other,140% of Medicaid,18.92,,,18.92,Other,225% of Medicaid,21.87,,,21.87,Other,260% of Medicaid,27.25,,,27.25,Other,324% of Medicaid,18.08,,,18.08,Other,215% of Medicaid,18.08,,,18.08,Other,215% of Medicaid,10.51,,,10.51,Other,125% of Medicaid,8.41,77.7,
BLOOD FUNGUS CULTURE,87103,CPT,,78087103,CDM,306,RC,,,both,,,66,48.84,,,48.84,Other,150% of Medicare + 9.63% HCRA Surcharge,29.7,45,,29.7,percent of total billed charges,Critical Access Hospital RCC factor,61.58,,,61.58,Fee Schedule,,55.45,,,55.45,Fee Schedule,,66.88,,,66.88,Fee Schedule,,60.15,,,60.15,Fee Schedule,,56.85,,,56.85,Fee Schedule,,32.67,,,32.67,Other,110% of Medicare,64.45,,,64.45,Fee Schedule,,21,,,21,Other,186% of Medicaid,75.91,,,75.91,Fee Schedule,,40.92,,,40.92,Fee Schedule,,42.97,,,42.97,Fee Schedule,,75.91,,,75.91,Fee Schedule,,40.92,,,40.92,Fee Schedule,,80.82,,,80.82,Fee Schedule,,46.2,70,,46.2,percent of total billed charges,All Other,96.96,,,96.96,Fee Schedule,,82.18,,,82.18,Fee Schedule,,30.69,,,30.69,Fee Schedule,,30.69,,,30.69,Fee Schedule,,30.69,,,30.69,Fee Schedule,,30.69,,,30.69,Fee Schedule,,11.48,,,11.48,Other,100% of Medicaid,11.48,,,11.48,Other,100% of Medicaid,11.48,,,11.48,Other,100% of Medicaid,11.48,,,11.48,Other,100% of Medicaid,25.84,,,25.84,Other,225% of Medicaid,17.57,,,17.57,Other,153% of Medicaid,25.84,,,25.84,Other,225% of Medicaid,16.08,,,16.08,Other,140% of Medicaid,25.84,,,25.84,Other,225% of Medicaid,29.86,,,29.86,Other,260% of Medicaid,37.21,,,37.21,Other,324% of Medicaid,24.69,,,24.69,Other,215% of Medicaid,24.69,,,24.69,Other,215% of Medicaid,14.35,,,14.35,Other,125% of Medicaid,11.48,96.96,
FUNGI IDENTIFICATION YEAST,87106,CPT,,78087106,CDM,306,RC,,,both,,,137,101.38,,,101.38,Other,150% of Medicare + 9.63% HCRA Surcharge,61.65,45,,61.65,percent of total billed charges,Critical Access Hospital RCC factor,31.06,,,31.06,Fee Schedule,,27.97,,,27.97,Fee Schedule,,76.57,,,76.57,Fee Schedule,,68.87,,,68.87,Fee Schedule,,65.09,,,65.09,Fee Schedule,,67.82,,,67.82,Other,110% of Medicare,32.51,,,32.51,Fee Schedule,,18,,,18,Other,186% of Medicaid,38.29,,,38.29,Fee Schedule,,84.94,,,84.94,Fee Schedule,,21.67,,,21.67,Fee Schedule,,38.29,,,38.29,Fee Schedule,,84.94,,,84.94,Fee Schedule,,40.76,,,40.76,Fee Schedule,,95.9,70,,95.9,percent of total billed charges,All Other,48.91,,,48.91,Fee Schedule,,41.45,,,41.45,Fee Schedule,,15.48,,,15.48,Fee Schedule,,15.48,,,15.48,Fee Schedule,,15.48,,,15.48,Fee Schedule,,15.48,,,15.48,Fee Schedule,,9.8,,,9.8,Other,100% of Medicaid,9.8,,,9.8,Other,100% of Medicaid,9.8,,,9.8,Other,100% of Medicaid,9.8,,,9.8,Other,100% of Medicaid,22.04,,,22.04,Other,225% of Medicaid,14.99,,,14.99,Other,153% of Medicaid,22.04,,,22.04,Other,225% of Medicaid,13.72,,,13.72,Other,140% of Medicaid,22.04,,,22.04,Other,225% of Medicaid,25.47,,,25.47,Other,260% of Medicaid,31.74,,,31.74,Other,324% of Medicaid,21.06,,,21.06,Other,215% of Medicaid,21.06,,,21.06,Other,215% of Medicaid,12.25,,,12.25,Other,125% of Medicaid,9.8,101.38,
FUNGI IDENTIFICATION MOLD,87107,CPT,,78087107,CDM,306,RC,,,both,,,213,157.62,,,157.62,Other,150% of Medicare + 9.63% HCRA Surcharge,95.85,45,,95.85,percent of total billed charges,Critical Access Hospital RCC factor,31.06,,,31.06,Fee Schedule,,27.97,,,27.97,Fee Schedule,,76.57,,,76.57,Fee Schedule,,68.87,,,68.87,Fee Schedule,,65.09,,,65.09,Fee Schedule,,105.44,,,105.44,Other,110% of Medicare,32.51,,,32.51,Fee Schedule,,18,,,18,Other,186% of Medicaid,38.29,,,38.29,Fee Schedule,,132.06,,,132.06,Fee Schedule,,21.67,,,21.67,Fee Schedule,,38.29,,,38.29,Fee Schedule,,132.06,,,132.06,Fee Schedule,,40.76,,,40.76,Fee Schedule,,149.1,70,,149.1,percent of total billed charges,All Other,48.91,,,48.91,Fee Schedule,,41.45,,,41.45,Fee Schedule,,15.48,,,15.48,Fee Schedule,,15.48,,,15.48,Fee Schedule,,15.48,,,15.48,Fee Schedule,,15.48,,,15.48,Fee Schedule,,9.8,,,9.8,Other,100% of Medicaid,9.8,,,9.8,Other,100% of Medicaid,9.8,,,9.8,Other,100% of Medicaid,9.8,,,9.8,Other,100% of Medicaid,22.04,,,22.04,Other,225% of Medicaid,14.99,,,14.99,Other,153% of Medicaid,22.04,,,22.04,Other,225% of Medicaid,13.72,,,13.72,Other,140% of Medicaid,22.04,,,22.04,Other,225% of Medicaid,25.47,,,25.47,Other,260% of Medicaid,31.74,,,31.74,Other,324% of Medicaid,21.06,,,21.06,Other,215% of Medicaid,21.06,,,21.06,Other,215% of Medicaid,12.25,,,12.25,Other,125% of Medicaid,9.8,157.62,
CHLAMYHDIA CULTURE,87110,CPT,,78087110,CDM,306,RC,,,both,,,281,207.94,,,207.94,Other,150% of Medicare + 9.63% HCRA Surcharge,126.45,45,,126.45,percent of total billed charges,Critical Access Hospital RCC factor,59,,,59,Fee Schedule,,53.12,,,53.12,Fee Schedule,,64.87,,,64.87,Fee Schedule,,58.35,,,58.35,Fee Schedule,,55.15,,,55.15,Fee Schedule,,139.1,,,139.1,Other,110% of Medicare,61.74,,,61.74,Fee Schedule,,15,,,15,Other,186% of Medicaid,72.72,,,72.72,Fee Schedule,,174.22,,,174.22,Fee Schedule,,41.16,,,41.16,Fee Schedule,,72.72,,,72.72,Fee Schedule,,174.22,,,174.22,Fee Schedule,,77.42,,,77.42,Fee Schedule,,196.7,70,,196.7,percent of total billed charges,All Other,92.89,,,92.89,Fee Schedule,,78.73,,,78.73,Fee Schedule,,29.4,,,29.4,Fee Schedule,,29.4,,,29.4,Fee Schedule,,29.4,,,29.4,Fee Schedule,,29.4,,,29.4,Fee Schedule,,8.23,,,8.23,Other,100% of Medicaid,8.23,,,8.23,Other,100% of Medicaid,8.23,,,8.23,Other,100% of Medicaid,8.23,,,8.23,Other,100% of Medicaid,18.52,,,18.52,Other,225% of Medicaid,12.59,,,12.59,Other,153% of Medicaid,18.52,,,18.52,Other,225% of Medicaid,11.52,,,11.52,Other,140% of Medicaid,18.52,,,18.52,Other,225% of Medicaid,21.4,,,21.4,Other,260% of Medicaid,26.67,,,26.67,Other,324% of Medicaid,17.7,,,17.7,Other,215% of Medicaid,17.7,,,17.7,Other,215% of Medicaid,10.29,,,10.29,Other,125% of Medicaid,8.23,207.94,
MYCOBACTERIA CULTURE,87116,CPT,,78087116,CDM,306,RC,,,both,,,164,121.36,,,121.36,Other,150% of Medicare + 9.63% HCRA Surcharge,73.8,45,,73.8,percent of total billed charges,Critical Access Hospital RCC factor,32.51,,,32.51,Fee Schedule,,29.27,,,29.27,Fee Schedule,,80.16,,,80.16,Fee Schedule,,72.1,,,72.1,Fee Schedule,,68.14,,,68.14,Fee Schedule,,81.18,,,81.18,Other,110% of Medicare,34.02,,,34.02,Fee Schedule,,20,,,20,Other,186% of Medicaid,40.07,,,40.07,Fee Schedule,,101.68,,,101.68,Fee Schedule,,22.68,,,22.68,Fee Schedule,,40.07,,,40.07,Fee Schedule,,101.68,,,101.68,Fee Schedule,,42.66,,,42.66,Fee Schedule,,114.8,70,,114.8,percent of total billed charges,All Other,51.18,,,51.18,Fee Schedule,,43.38,,,43.38,Fee Schedule,,16.2,,,16.2,Fee Schedule,,16.2,,,16.2,Fee Schedule,,16.2,,,16.2,Fee Schedule,,16.2,,,16.2,Fee Schedule,,10.8,,,10.8,Other,100% of Medicaid,10.8,,,10.8,Other,100% of Medicaid,10.8,,,10.8,Other,100% of Medicaid,10.8,,,10.8,Other,100% of Medicaid,24.3,,,24.3,Other,225% of Medicaid,16.52,,,16.52,Other,153% of Medicaid,24.3,,,24.3,Other,225% of Medicaid,15.12,,,15.12,Other,140% of Medicaid,24.3,,,24.3,Other,225% of Medicaid,28.08,,,28.08,Other,260% of Medicaid,34.99,,,34.99,Other,324% of Medicaid,23.22,,,23.22,Other,215% of Medicaid,23.22,,,23.22,Other,215% of Medicaid,13.5,,,13.5,Other,125% of Medicaid,10.8,121.36,
MYCOBACTERIC IDENTIFICATION,87118,CPT,,78087118,CDM,306,RC,,,both,,,71,52.54,,,52.54,Other,150% of Medicare + 9.63% HCRA Surcharge,31.95,45,,31.95,percent of total billed charges,Critical Access Hospital RCC factor,43.98,,,43.98,Fee Schedule,,39.59,,,39.59,Fee Schedule,,81.16,,,81.16,Fee Schedule,,73,,,73,Fee Schedule,,68.99,,,68.99,Fee Schedule,,35.15,,,35.15,Other,110% of Medicare,46.02,,,46.02,Fee Schedule,,27,,,27,Other,186% of Medicaid,54.2,,,54.2,Fee Schedule,,44.02,,,44.02,Fee Schedule,,30.68,,,30.68,Fee Schedule,,54.2,,,54.2,Fee Schedule,,44.02,,,44.02,Fee Schedule,,57.71,,,57.71,Fee Schedule,,49.7,70,,49.7,percent of total billed charges,All Other,69.24,,,69.24,Fee Schedule,,58.68,,,58.68,Fee Schedule,,21.92,,,21.92,Fee Schedule,,21.92,,,21.92,Fee Schedule,,21.92,,,21.92,Fee Schedule,,21.92,,,21.92,Fee Schedule,,14.61,,,14.61,Other,100% of Medicaid,14.61,,,14.61,Other,100% of Medicaid,14.61,,,14.61,Other,100% of Medicaid,14.61,,,14.61,Other,100% of Medicaid,32.87,,,32.87,Other,225% of Medicaid,22.35,,,22.35,Other,153% of Medicaid,32.87,,,32.87,Other,225% of Medicaid,20.45,,,20.45,Other,140% of Medicaid,32.87,,,32.87,Other,225% of Medicaid,37.99,,,37.99,Other,260% of Medicaid,47.34,,,47.34,Other,324% of Medicaid,31.41,,,31.41,Other,215% of Medicaid,31.41,,,31.41,Other,215% of Medicaid,18.26,,,18.26,Other,125% of Medicaid,14.61,81.16,
CULTURE IMMUNOFLUORESC,87140,CPT,,78087140,CDM,306,RC,,,both,,,44,32.56,,,32.56,Other,150% of Medicare + 9.63% HCRA Surcharge,19.8,45,,19.8,percent of total billed charges,Critical Access Hospital RCC factor,16.77,,,16.77,Fee Schedule,,15.09,,,15.09,Fee Schedule,,41.32,,,41.32,Fee Schedule,,37.16,,,37.16,Fee Schedule,,35.12,,,35.12,Fee Schedule,,21.78,,,21.78,Other,110% of Medicare,17.55,,,17.55,Fee Schedule,,17,,,17,Other,186% of Medicaid,20.66,,,20.66,Fee Schedule,,27.28,,,27.28,Fee Schedule,,11.7,,,11.7,Fee Schedule,,20.66,,,20.66,Fee Schedule,,27.28,,,27.28,Fee Schedule,,22,,,22,Fee Schedule,,30.8,70,,30.8,percent of total billed charges,All Other,26.4,,,26.4,Fee Schedule,,22.37,,,22.37,Fee Schedule,,8.36,,,8.36,Fee Schedule,,8.36,,,8.36,Fee Schedule,,8.36,,,8.36,Fee Schedule,,8.36,,,8.36,Fee Schedule,,9.14,,,9.14,Other,100% of Medicaid,9.14,,,9.14,Other,100% of Medicaid,9.14,,,9.14,Other,100% of Medicaid,9.14,,,9.14,Other,100% of Medicaid,20.56,,,20.56,Other,225% of Medicaid,13.98,,,13.98,Other,153% of Medicaid,20.56,,,20.56,Other,225% of Medicaid,12.79,,,12.79,Other,140% of Medicaid,20.56,,,20.56,Other,225% of Medicaid,23.76,,,23.76,Other,260% of Medicaid,29.6,,,29.6,Other,324% of Medicaid,19.64,,,19.64,Other,215% of Medicaid,19.64,,,19.64,Other,215% of Medicaid,11.42,,,11.42,Other,125% of Medicaid,8.36,41.32,
CULTURE TYPLE IMMUNOLOGIC,87147,CPT,,78087147,CDM,306,RC,,,both,,,66,48.84,,,48.84,Other,150% of Medicare + 9.63% HCRA Surcharge,29.7,45,,29.7,percent of total billed charges,Critical Access Hospital RCC factor,15.59,,,15.59,Fee Schedule,,14.04,,,14.04,Fee Schedule,,38.37,,,38.37,Fee Schedule,,34.51,,,34.51,Fee Schedule,,32.61,,,32.61,Fee Schedule,,32.67,,,32.67,Other,110% of Medicare,16.32,,,16.32,Fee Schedule,,17,,,17,Other,186% of Medicaid,19.22,,,19.22,Fee Schedule,,40.92,,,40.92,Fee Schedule,,10.88,,,10.88,Fee Schedule,,19.22,,,19.22,Fee Schedule,,40.92,,,40.92,Fee Schedule,,20.46,,,20.46,Fee Schedule,,46.2,70,,46.2,percent of total billed charges,All Other,24.55,,,24.55,Fee Schedule,,20.81,,,20.81,Fee Schedule,,7.77,,,7.77,Fee Schedule,,7.77,,,7.77,Fee Schedule,,7.77,,,7.77,Fee Schedule,,7.77,,,7.77,Fee Schedule,,9.14,,,9.14,Other,100% of Medicaid,9.14,,,9.14,Other,100% of Medicaid,9.14,,,9.14,Other,100% of Medicaid,9.14,,,9.14,Other,100% of Medicaid,20.56,,,20.56,Other,225% of Medicaid,13.98,,,13.98,Other,153% of Medicaid,20.56,,,20.56,Other,225% of Medicaid,12.79,,,12.79,Other,140% of Medicaid,20.56,,,20.56,Other,225% of Medicaid,23.76,,,23.76,Other,260% of Medicaid,29.6,,,29.6,Other,324% of Medicaid,19.64,,,19.64,Other,215% of Medicaid,19.64,,,19.64,Other,215% of Medicaid,11.42,,,11.42,Other,125% of Medicaid,7.77,48.84,
DNA.RNA DIRECT PROBE,87149,CPT,,78087149,CDM,306,RC,,,both,,,129,95.46,,,95.46,Other,150% of Medicare + 9.63% HCRA Surcharge,58.05,45,,58.05,percent of total billed charges,Critical Access Hospital RCC factor,60.35,,,60.35,Fee Schedule,,54.34,,,54.34,Fee Schedule,,148.72,,,148.72,Fee Schedule,,133.76,,,133.76,Fee Schedule,,126.43,,,126.43,Fee Schedule,,63.86,,,63.86,Other,110% of Medicare,63.16,,,63.16,Fee Schedule,,17,,,17,Other,186% of Medicaid,74.39,,,74.39,Fee Schedule,,79.98,,,79.98,Fee Schedule,,42.11,,,42.11,Fee Schedule,,74.39,,,74.39,Fee Schedule,,79.98,,,79.98,Fee Schedule,,79.2,,,79.2,Fee Schedule,,90.3,70,,90.3,percent of total billed charges,All Other,95.02,,,95.02,Fee Schedule,,80.53,,,80.53,Fee Schedule,,30.08,,,30.08,Fee Schedule,,30.08,,,30.08,Fee Schedule,,30.08,,,30.08,Fee Schedule,,30.08,,,30.08,Fee Schedule,,9.14,,,9.14,Other,100% of Medicaid,9.14,,,9.14,Other,100% of Medicaid,9.14,,,9.14,Other,100% of Medicaid,9.14,,,9.14,Other,100% of Medicaid,20.56,,,20.56,Other,225% of Medicaid,13.98,,,13.98,Other,153% of Medicaid,20.56,,,20.56,Other,225% of Medicaid,12.79,,,12.79,Other,140% of Medicaid,20.56,,,20.56,Other,225% of Medicaid,23.76,,,23.76,Other,260% of Medicaid,29.6,,,29.6,Other,324% of Medicaid,19.64,,,19.64,Other,215% of Medicaid,19.64,,,19.64,Other,215% of Medicaid,11.42,,,11.42,Other,125% of Medicaid,9.14,148.72,
DNA/RNA SEQUENCING,87153,CPT,,78087153,CDM,306,RC,,,both,,,876,648.24,,,648.24,Other,150% of Medicare + 9.63% HCRA Surcharge,394.2,45,,394.2,percent of total billed charges,Critical Access Hospital RCC factor,347.23,,,347.23,Fee Schedule,,312.63,,,312.63,Fee Schedule,,855.48,,,855.48,Fee Schedule,,769.44,,,769.44,Fee Schedule,,727.24,,,727.24,Fee Schedule,,433.62,,,433.62,Other,110% of Medicare,363.38,,,363.38,Fee Schedule,,94,,,94,Other,186% of Medicaid,427.99,,,427.99,Fee Schedule,,543.12,,,543.12,Fee Schedule,,242.26,,,242.26,Fee Schedule,,427.99,,,427.99,Fee Schedule,,543.12,,,543.12,Fee Schedule,,455.67,,,455.67,Fee Schedule,,613.2,70,,613.2,percent of total billed charges,All Other,546.7,,,546.7,Fee Schedule,,463.36,,,463.36,Fee Schedule,,173.04,,,173.04,Fee Schedule,,173.04,,,173.04,Fee Schedule,,173.04,,,173.04,Fee Schedule,,173.04,,,173.04,Fee Schedule,,50.37,,,50.37,Other,100% of Medicaid,50.37,,,50.37,Other,100% of Medicaid,50.37,,,50.37,Other,100% of Medicaid,50.37,,,50.37,Other,100% of Medicaid,113.32,,,113.32,Other,225% of Medicaid,77.06,,,77.06,Other,153% of Medicaid,113.32,,,113.32,Other,225% of Medicaid,70.51,,,70.51,Other,140% of Medicaid,113.32,,,113.32,Other,225% of Medicaid,130.95,,,130.95,Other,260% of Medicaid,163.19,,,163.19,Other,324% of Medicaid,108.29,,,108.29,Other,215% of Medicaid,108.29,,,108.29,Other,215% of Medicaid,62.96,,,62.96,Other,125% of Medicaid,50.37,855.48,
CULTURE TYPING ADDED METHOD,87158,CPT,,78087158,CDM,306,RC,,,both,,,33,24.42,,,24.42,Other,150% of Medicare + 9.63% HCRA Surcharge,14.85,45,,14.85,percent of total billed charges,Critical Access Hospital RCC factor,23.3,,,23.3,Fee Schedule,,20.98,,,20.98,Fee Schedule,,38.79,,,38.79,Fee Schedule,,34.89,,,34.89,Fee Schedule,,32.97,,,32.97,Fee Schedule,,16.34,,,16.34,Other,110% of Medicare,24.38,,,24.38,Fee Schedule,,17,,,17,Other,186% of Medicaid,28.72,,,28.72,Fee Schedule,,20.46,,,20.46,Fee Schedule,,16.25,,,16.25,Fee Schedule,,28.72,,,28.72,Fee Schedule,,20.46,,,20.46,Fee Schedule,,30.57,,,30.57,Fee Schedule,,23.1,70,,23.1,percent of total billed charges,All Other,36.68,,,36.68,Fee Schedule,,31.09,,,31.09,Fee Schedule,,11.61,,,11.61,Fee Schedule,,11.61,,,11.61,Fee Schedule,,11.61,,,11.61,Fee Schedule,,11.61,,,11.61,Fee Schedule,,9.14,,,9.14,Other,100% of Medicaid,9.14,,,9.14,Other,100% of Medicaid,9.14,,,9.14,Other,100% of Medicaid,9.14,,,9.14,Other,100% of Medicaid,20.56,,,20.56,Other,225% of Medicaid,13.98,,,13.98,Other,153% of Medicaid,20.56,,,20.56,Other,225% of Medicaid,12.79,,,12.79,Other,140% of Medicaid,20.56,,,20.56,Other,225% of Medicaid,23.76,,,23.76,Other,260% of Medicaid,29.6,,,29.6,Other,324% of Medicaid,19.64,,,19.64,Other,215% of Medicaid,19.64,,,19.64,Other,215% of Medicaid,11.42,,,11.42,Other,125% of Medicaid,9.14,38.79,
DARK FIELD EXAMINATION,87164,CPT,,78087164,CDM,306,RC,,,both,,,71,52.54,,,52.54,Other,150% of Medicare + 9.63% HCRA Surcharge,31.95,45,,31.95,percent of total billed charges,Critical Access Hospital RCC factor,32.33,,,32.33,Fee Schedule,,29.11,,,29.11,Fee Schedule,,79.68,,,79.68,Fee Schedule,,71.67,,,71.67,Fee Schedule,,67.74,,,67.74,Fee Schedule,,35.15,,,35.15,Other,110% of Medicare,33.83,,,33.83,Fee Schedule,,15,,,15,Other,186% of Medicaid,39.85,,,39.85,Fee Schedule,,44.02,,,44.02,Fee Schedule,,22.55,,,22.55,Fee Schedule,,39.85,,,39.85,Fee Schedule,,44.02,,,44.02,Fee Schedule,,42.42,,,42.42,Fee Schedule,,49.7,70,,49.7,percent of total billed charges,All Other,50.9,,,50.9,Fee Schedule,,43.14,,,43.14,Fee Schedule,,16.11,,,16.11,Fee Schedule,,16.11,,,16.11,Fee Schedule,,16.11,,,16.11,Fee Schedule,,16.11,,,16.11,Fee Schedule,,8.08,,,8.08,Other,100% of Medicaid,8.08,,,8.08,Other,100% of Medicaid,8.08,,,8.08,Other,100% of Medicaid,8.08,,,8.08,Other,100% of Medicaid,18.18,,,18.18,Other,225% of Medicaid,12.36,,,12.36,Other,153% of Medicaid,18.18,,,18.18,Other,225% of Medicaid,11.31,,,11.31,Other,140% of Medicaid,18.18,,,18.18,Other,225% of Medicaid,21.01,,,21.01,Other,260% of Medicaid,26.18,,,26.18,Other,324% of Medicaid,17.37,,,17.37,Other,215% of Medicaid,17.37,,,17.37,Other,215% of Medicaid,10.1,,,10.1,Other,125% of Medicaid,8.08,79.68,
MACROSCOPIC EXAM ARTHROPOD,87168,CPT,,78087168,CDM,306,RC,,,both,,,109,80.66,,,80.66,Other,150% of Medicare + 9.63% HCRA Surcharge,49.05,45,,49.05,percent of total billed charges,Critical Access Hospital RCC factor,12.85,,,12.85,Fee Schedule,,11.57,,,11.57,Fee Schedule,,31.67,,,31.67,Fee Schedule,,28.49,,,28.49,Fee Schedule,,26.92,,,26.92,Fee Schedule,,53.96,,,53.96,Other,110% of Medicare,13.45,,,13.45,Fee Schedule,,17,,,17,Other,186% of Medicaid,15.84,,,15.84,Fee Schedule,,67.58,,,67.58,Fee Schedule,,8.97,,,8.97,Fee Schedule,,15.84,,,15.84,Fee Schedule,,67.58,,,67.58,Fee Schedule,,16.87,,,16.87,Fee Schedule,,76.3,70,,76.3,percent of total billed charges,All Other,20.24,,,20.24,Fee Schedule,,17.15,,,17.15,Fee Schedule,,6.41,,,6.41,Fee Schedule,,6.41,,,6.41,Fee Schedule,,6.41,,,6.41,Fee Schedule,,6.41,,,6.41,Fee Schedule,,9.14,,,9.14,Other,100% of Medicaid,9.14,,,9.14,Other,100% of Medicaid,9.14,,,9.14,Other,100% of Medicaid,9.14,,,9.14,Other,100% of Medicaid,20.56,,,20.56,Other,225% of Medicaid,13.98,,,13.98,Other,153% of Medicaid,20.56,,,20.56,Other,225% of Medicaid,12.79,,,12.79,Other,140% of Medicaid,20.56,,,20.56,Other,225% of Medicaid,23.76,,,23.76,Other,260% of Medicaid,29.6,,,29.6,Other,324% of Medicaid,19.64,,,19.64,Other,215% of Medicaid,19.64,,,19.64,Other,215% of Medicaid,11.42,,,11.42,Other,125% of Medicaid,6.41,80.66,
MACROSCOPIC EXAM PARASITE,87169,CPT,,78087169,CDM,306,RC,,,both,,,196,145.04,,,145.04,Other,150% of Medicare + 9.63% HCRA Surcharge,88.2,45,,88.2,percent of total billed charges,Critical Access Hospital RCC factor,12.97,,,12.97,Fee Schedule,,11.68,,,11.68,Fee Schedule,,31.67,,,31.67,Fee Schedule,,28.49,,,28.49,Fee Schedule,,26.92,,,26.92,Fee Schedule,,97.02,,,97.02,Other,110% of Medicare,13.58,,,13.58,Fee Schedule,,4,,,4,Other,186% of Medicaid,15.99,,,15.99,Fee Schedule,,121.52,,,121.52,Fee Schedule,,9.05,,,9.05,Fee Schedule,,15.99,,,15.99,Fee Schedule,,121.52,,,121.52,Fee Schedule,,17.02,,,17.02,Fee Schedule,,137.2,70,,137.2,percent of total billed charges,All Other,20.43,,,20.43,Fee Schedule,,17.31,,,17.31,Fee Schedule,,6.47,,,6.47,Fee Schedule,,6.47,,,6.47,Fee Schedule,,6.47,,,6.47,Fee Schedule,,6.47,,,6.47,Fee Schedule,,2.02,,,2.02,Other,100% of Medicaid,2.02,,,2.02,Other,100% of Medicaid,2.02,,,2.02,Other,100% of Medicaid,2.02,,,2.02,Other,100% of Medicaid,4.55,,,4.55,Other,225% of Medicaid,3.09,,,3.09,Other,153% of Medicaid,4.55,,,4.55,Other,225% of Medicaid,2.83,,,2.83,Other,140% of Medicaid,4.55,,,4.55,Other,225% of Medicaid,5.25,,,5.25,Other,260% of Medicaid,6.54,,,6.54,Other,324% of Medicaid,4.34,,,4.34,Other,215% of Medicaid,4.34,,,4.34,Other,215% of Medicaid,2.53,,,2.53,Other,125% of Medicaid,2.02,145.04,
PINWORM EXAM,87172,CPT,,78087172,CDM,306,RC,,,both,,,70,51.8,,,51.8,Other,150% of Medicare + 9.63% HCRA Surcharge,31.5,45,,31.5,percent of total billed charges,Critical Access Hospital RCC factor,12.85,,,12.85,Fee Schedule,,11.57,,,11.57,Fee Schedule,,31.67,,,31.67,Fee Schedule,,28.49,,,28.49,Fee Schedule,,26.92,,,26.92,Fee Schedule,,34.65,,,34.65,Other,110% of Medicare,13.45,,,13.45,Fee Schedule,,4,,,4,Other,186% of Medicaid,15.84,,,15.84,Fee Schedule,,43.4,,,43.4,Fee Schedule,,8.97,,,8.97,Fee Schedule,,15.84,,,15.84,Fee Schedule,,43.4,,,43.4,Fee Schedule,,16.87,,,16.87,Fee Schedule,,49,70,,49,percent of total billed charges,All Other,20.24,,,20.24,Fee Schedule,,17.15,,,17.15,Fee Schedule,,6.41,,,6.41,Fee Schedule,,6.41,,,6.41,Fee Schedule,,6.41,,,6.41,Fee Schedule,,6.41,,,6.41,Fee Schedule,,2.02,,,2.02,Other,100% of Medicaid,2.02,,,2.02,Other,100% of Medicaid,2.02,,,2.02,Other,100% of Medicaid,2.02,,,2.02,Other,100% of Medicaid,4.55,,,4.55,Other,225% of Medicaid,3.09,,,3.09,Other,153% of Medicaid,4.55,,,4.55,Other,225% of Medicaid,2.83,,,2.83,Other,140% of Medicaid,4.55,,,4.55,Other,225% of Medicaid,5.25,,,5.25,Other,260% of Medicaid,6.54,,,6.54,Other,324% of Medicaid,4.34,,,4.34,Other,215% of Medicaid,4.34,,,4.34,Other,215% of Medicaid,2.53,,,2.53,Other,125% of Medicaid,2.02,51.8,
TISSUE HOMOGENIZATION CULTR,87176,CPT,,78087176,CDM,306,RC,,,both,,,26,19.24,,,19.24,Other,150% of Medicare + 9.63% HCRA Surcharge,11.7,45,,11.7,percent of total billed charges,Critical Access Hospital RCC factor,17.7,,,17.7,Fee Schedule,,15.93,,,15.93,Fee Schedule,,43.64,,,43.64,Fee Schedule,,39.25,,,39.25,Fee Schedule,,37.09,,,37.09,Fee Schedule,,12.87,,,12.87,Other,110% of Medicare,18.52,,,18.52,Fee Schedule,,17,,,17,Other,186% of Medicaid,21.81,,,21.81,Fee Schedule,,16.12,,,16.12,Fee Schedule,,12.35,,,12.35,Fee Schedule,,21.81,,,21.81,Fee Schedule,,16.12,,,16.12,Fee Schedule,,23.23,,,23.23,Fee Schedule,,18.2,70,,18.2,percent of total billed charges,All Other,27.87,,,27.87,Fee Schedule,,23.62,,,23.62,Fee Schedule,,8.82,,,8.82,Fee Schedule,,8.82,,,8.82,Fee Schedule,,8.82,,,8.82,Fee Schedule,,8.82,,,8.82,Fee Schedule,,9.14,,,9.14,Other,100% of Medicaid,9.14,,,9.14,Other,100% of Medicaid,9.14,,,9.14,Other,100% of Medicaid,9.14,,,9.14,Other,100% of Medicaid,20.56,,,20.56,Other,225% of Medicaid,13.98,,,13.98,Other,153% of Medicaid,20.56,,,20.56,Other,225% of Medicaid,12.79,,,12.79,Other,140% of Medicaid,20.56,,,20.56,Other,225% of Medicaid,23.76,,,23.76,Other,260% of Medicaid,29.6,,,29.6,Other,324% of Medicaid,19.64,,,19.64,Other,215% of Medicaid,19.64,,,19.64,Other,215% of Medicaid,11.42,,,11.42,Other,125% of Medicaid,8.82,43.64,
MICROBE SUSCEPTIBLE DIFUSE,87181,CPT,,78087181,CDM,306,RC,,,both,,,30,22.2,,,22.2,Other,150% of Medicare + 9.63% HCRA Surcharge,13.5,45,,13.5,percent of total billed charges,Critical Access Hospital RCC factor,14.3,,,14.3,Fee Schedule,,12.87,,,12.87,Fee Schedule,,35.2,,,35.2,Fee Schedule,,31.66,,,31.66,Fee Schedule,,29.93,,,29.93,Fee Schedule,,14.85,,,14.85,Other,110% of Medicare,14.96,,,14.96,Fee Schedule,,8,,,8,Other,186% of Medicaid,17.62,,,17.62,Fee Schedule,,18.6,,,18.6,Fee Schedule,,9.98,,,9.98,Fee Schedule,,17.62,,,17.62,Fee Schedule,,18.6,,,18.6,Fee Schedule,,18.76,,,18.76,Fee Schedule,,21,70,,21,percent of total billed charges,All Other,22.51,,,22.51,Fee Schedule,,19.08,,,19.08,Fee Schedule,,7.13,,,7.13,Fee Schedule,,7.13,,,7.13,Fee Schedule,,7.13,,,7.13,Fee Schedule,,7.13,,,7.13,Fee Schedule,,4.55,,,4.55,Other,100% of Medicaid,4.55,,,4.55,Other,100% of Medicaid,4.55,,,4.55,Other,100% of Medicaid,4.55,,,4.55,Other,100% of Medicaid,10.23,,,10.23,Other,225% of Medicaid,6.95,,,6.95,Other,153% of Medicaid,10.23,,,10.23,Other,225% of Medicaid,6.36,,,6.36,Other,140% of Medicaid,10.23,,,10.23,Other,225% of Medicaid,11.82,,,11.82,Other,260% of Medicaid,14.73,,,14.73,Other,324% of Medicaid,9.77,,,9.77,Other,215% of Medicaid,9.77,,,9.77,Other,215% of Medicaid,5.68,,,5.68,Other,125% of Medicaid,4.55,35.2,
MICROBE SUSCEPLTIBLE DISK,87184,CPT,,78087184,CDM,306,RC,,,both,,,60,44.4,,,44.4,Other,150% of Medicare + 9.63% HCRA Surcharge,27,45,,27,percent of total billed charges,Critical Access Hospital RCC factor,22.51,,,22.51,Fee Schedule,,20.27,,,20.27,Fee Schedule,,43.11,,,43.11,Fee Schedule,,38.77,,,38.77,Fee Schedule,,36.65,,,36.65,Fee Schedule,,29.7,,,29.7,Other,110% of Medicare,23.56,,,23.56,Fee Schedule,,12,,,12,Other,186% of Medicaid,27.75,,,27.75,Fee Schedule,,37.2,,,37.2,Fee Schedule,,15.71,,,15.71,Fee Schedule,,27.75,,,27.75,Fee Schedule,,37.2,,,37.2,Fee Schedule,,29.55,,,29.55,Fee Schedule,,42,70,,42,percent of total billed charges,All Other,35.45,,,35.45,Fee Schedule,,30.04,,,30.04,Fee Schedule,,11.22,,,11.22,Fee Schedule,,11.22,,,11.22,Fee Schedule,,11.22,,,11.22,Fee Schedule,,11.22,,,11.22,Fee Schedule,,6.66,,,6.66,Other,100% of Medicaid,6.66,,,6.66,Other,100% of Medicaid,6.66,,,6.66,Other,100% of Medicaid,6.66,,,6.66,Other,100% of Medicaid,14.98,,,14.98,Other,225% of Medicaid,10.18,,,10.18,Other,153% of Medicaid,14.98,,,14.98,Other,225% of Medicaid,9.32,,,9.32,Other,140% of Medicaid,14.98,,,14.98,Other,225% of Medicaid,17.31,,,17.31,Other,260% of Medicaid,21.57,,,21.57,Other,324% of Medicaid,14.31,,,14.31,Other,215% of Medicaid,14.31,,,14.31,Other,215% of Medicaid,8.32,,,8.32,Other,125% of Medicaid,6.66,44.4,
MICROBE SUSCEPTIBLE ENZYME,87185,CPT,,78087185,CDM,306,RC,,,both,,,30,22.2,,,22.2,Other,150% of Medicare + 9.63% HCRA Surcharge,13.5,45,,13.5,percent of total billed charges,Critical Access Hospital RCC factor,14.3,,,14.3,Fee Schedule,,12.87,,,12.87,Fee Schedule,,35.2,,,35.2,Fee Schedule,,31.66,,,31.66,Fee Schedule,,29.93,,,29.93,Fee Schedule,,14.85,,,14.85,Other,110% of Medicare,14.96,,,14.96,Fee Schedule,,8,,,8,Other,186% of Medicaid,17.62,,,17.62,Fee Schedule,,18.6,,,18.6,Fee Schedule,,9.98,,,9.98,Fee Schedule,,17.62,,,17.62,Fee Schedule,,18.6,,,18.6,Fee Schedule,,18.76,,,18.76,Fee Schedule,,21,70,,21,percent of total billed charges,All Other,22.51,,,22.51,Fee Schedule,,19.08,,,19.08,Fee Schedule,,7.13,,,7.13,Fee Schedule,,7.13,,,7.13,Fee Schedule,,7.13,,,7.13,Fee Schedule,,7.13,,,7.13,Fee Schedule,,4.55,,,4.55,Other,100% of Medicaid,4.55,,,4.55,Other,100% of Medicaid,4.55,,,4.55,Other,100% of Medicaid,4.55,,,4.55,Other,100% of Medicaid,10.23,,,10.23,Other,225% of Medicaid,6.95,,,6.95,Other,153% of Medicaid,10.23,,,10.23,Other,225% of Medicaid,6.36,,,6.36,Other,140% of Medicaid,10.23,,,10.23,Other,225% of Medicaid,11.82,,,11.82,Other,260% of Medicaid,14.73,,,14.73,Other,324% of Medicaid,9.77,,,9.77,Other,215% of Medicaid,9.77,,,9.77,Other,215% of Medicaid,5.68,,,5.68,Other,125% of Medicaid,4.55,35.2,
MICROBE SUSCEPTIBLE,87186,CPT,,78087186,CDM,306,RC,,,both,,,166,122.84,,,122.84,Other,150% of Medicare + 9.63% HCRA Surcharge,74.7,45,,74.7,percent of total billed charges,Critical Access Hospital RCC factor,26.04,,,26.04,Fee Schedule,,23.44,,,23.44,Fee Schedule,,43.11,,,43.11,Fee Schedule,,38.77,,,38.77,Fee Schedule,,36.65,,,36.65,Fee Schedule,,82.17,,,82.17,Other,110% of Medicare,27.25,,,27.25,Fee Schedule,,12,,,12,Other,186% of Medicaid,32.09,,,32.09,Fee Schedule,,102.92,,,102.92,Fee Schedule,,18.17,,,18.17,Fee Schedule,,32.09,,,32.09,Fee Schedule,,102.92,,,102.92,Fee Schedule,,34.17,,,34.17,Fee Schedule,,116.2,70,,116.2,percent of total billed charges,All Other,40.99,,,40.99,Fee Schedule,,34.74,,,34.74,Fee Schedule,,12.98,,,12.98,Fee Schedule,,12.98,,,12.98,Fee Schedule,,12.98,,,12.98,Fee Schedule,,12.98,,,12.98,Fee Schedule,,6.66,,,6.66,Other,100% of Medicaid,6.66,,,6.66,Other,100% of Medicaid,6.66,,,6.66,Other,100% of Medicaid,6.66,,,6.66,Other,100% of Medicaid,14.98,,,14.98,Other,225% of Medicaid,10.18,,,10.18,Other,153% of Medicaid,14.98,,,14.98,Other,225% of Medicaid,9.32,,,9.32,Other,140% of Medicaid,14.98,,,14.98,Other,225% of Medicaid,17.31,,,17.31,Other,260% of Medicaid,21.57,,,21.57,Other,324% of Medicaid,14.31,,,14.31,Other,215% of Medicaid,14.31,,,14.31,Other,215% of Medicaid,8.32,,,8.32,Other,125% of Medicaid,6.66,122.84,
SMEAR GRAM STAIN,87205,CPT,,78087205,CDM,306,RC,,,both,,,72,53.28,,,53.28,Other,150% of Medicare + 9.63% HCRA Surcharge,32.4,45,,32.4,percent of total billed charges,Critical Access Hospital RCC factor,12.85,,,12.85,Fee Schedule,,11.57,,,11.57,Fee Schedule,,31.67,,,31.67,Fee Schedule,,28.49,,,28.49,Fee Schedule,,26.92,,,26.92,Fee Schedule,,35.64,,,35.64,Other,110% of Medicare,13.45,,,13.45,Fee Schedule,,6,,,6,Other,186% of Medicaid,15.84,,,15.84,Fee Schedule,,44.64,,,44.64,Fee Schedule,,8.97,,,8.97,Fee Schedule,,15.84,,,15.84,Fee Schedule,,44.64,,,44.64,Fee Schedule,,16.87,,,16.87,Fee Schedule,,50.4,70,,50.4,percent of total billed charges,All Other,20.24,,,20.24,Fee Schedule,,17.15,,,17.15,Fee Schedule,,6.41,,,6.41,Fee Schedule,,6.41,,,6.41,Fee Schedule,,6.41,,,6.41,Fee Schedule,,6.41,,,6.41,Fee Schedule,,3.43,,,3.43,Other,100% of Medicaid,3.43,,,3.43,Other,100% of Medicaid,3.43,,,3.43,Other,100% of Medicaid,3.43,,,3.43,Other,100% of Medicaid,7.73,,,7.73,Other,225% of Medicaid,5.25,,,5.25,Other,153% of Medicaid,7.73,,,7.73,Other,225% of Medicaid,4.81,,,4.81,Other,140% of Medicaid,7.73,,,7.73,Other,225% of Medicaid,8.93,,,8.93,Other,260% of Medicaid,11.13,,,11.13,Other,324% of Medicaid,7.38,,,7.38,Other,215% of Medicaid,7.38,,,7.38,Other,215% of Medicaid,4.29,,,4.29,Other,125% of Medicaid,3.43,53.28,
SMEAR FLUJORESCENT/ACID STAI,87206,CPT,,78087206,CDM,306,RC,,,both,,,92,68.08,,,68.08,Other,150% of Medicare + 9.63% HCRA Surcharge,41.4,45,,41.4,percent of total billed charges,Critical Access Hospital RCC factor,16.22,,,16.22,Fee Schedule,,14.61,,,14.61,Fee Schedule,,39.84,,,39.84,Fee Schedule,,35.83,,,35.83,Fee Schedule,,33.87,,,33.87,Fee Schedule,,45.54,,,45.54,Other,110% of Medicare,16.98,,,16.98,Fee Schedule,,10,,,10,Other,186% of Medicaid,20,,,20,Fee Schedule,,57.04,,,57.04,Fee Schedule,,11.32,,,11.32,Fee Schedule,,20,,,20,Fee Schedule,,57.04,,,57.04,Fee Schedule,,21.29,,,21.29,Fee Schedule,,64.4,70,,64.4,percent of total billed charges,All Other,25.54,,,25.54,Fee Schedule,,21.65,,,21.65,Fee Schedule,,8.09,,,8.09,Fee Schedule,,8.09,,,8.09,Fee Schedule,,8.09,,,8.09,Fee Schedule,,8.09,,,8.09,Fee Schedule,,5.39,,,5.39,Other,100% of Medicaid,5.39,,,5.39,Other,100% of Medicaid,5.39,,,5.39,Other,100% of Medicaid,5.39,,,5.39,Other,100% of Medicaid,12.13,,,12.13,Other,225% of Medicaid,8.25,,,8.25,Other,153% of Medicaid,12.13,,,12.13,Other,225% of Medicaid,7.55,,,7.55,Other,140% of Medicaid,12.13,,,12.13,Other,225% of Medicaid,14.01,,,14.01,Other,260% of Medicaid,17.46,,,17.46,Other,324% of Medicaid,11.59,,,11.59,Other,215% of Medicaid,11.59,,,11.59,Other,215% of Medicaid,6.74,,,6.74,Other,125% of Medicaid,5.39,68.08,
SMEAR SPECIAL STAIN,87207,CPT,,78087207,CDM,306,RC,,,both,,,107,79.18,,,79.18,Other,150% of Medicare + 9.63% HCRA Surcharge,48.15,45,,48.15,percent of total billed charges,Critical Access Hospital RCC factor,18.03,,,18.03,Fee Schedule,,16.23,,,16.23,Fee Schedule,,44.48,,,44.48,Fee Schedule,,40.01,,,40.01,Fee Schedule,,37.81,,,37.81,Fee Schedule,,52.97,,,52.97,Other,110% of Medicare,18.87,,,18.87,Fee Schedule,,11,,,11,Other,186% of Medicaid,22.22,,,22.22,Fee Schedule,,66.34,,,66.34,Fee Schedule,,12.58,,,12.58,Fee Schedule,,22.22,,,22.22,Fee Schedule,,66.34,,,66.34,Fee Schedule,,23.66,,,23.66,Fee Schedule,,74.9,70,,74.9,percent of total billed charges,All Other,28.39,,,28.39,Fee Schedule,,24.06,,,24.06,Fee Schedule,,8.99,,,8.99,Fee Schedule,,8.99,,,8.99,Fee Schedule,,8.99,,,8.99,Fee Schedule,,8.99,,,8.99,Fee Schedule,,5.99,,,5.99,Other,100% of Medicaid,5.99,,,5.99,Other,100% of Medicaid,5.99,,,5.99,Other,100% of Medicaid,5.99,,,5.99,Other,100% of Medicaid,13.48,,,13.48,Other,225% of Medicaid,9.16,,,9.16,Other,153% of Medicaid,13.48,,,13.48,Other,225% of Medicaid,8.39,,,8.39,Other,140% of Medicaid,13.48,,,13.48,Other,225% of Medicaid,15.57,,,15.57,Other,260% of Medicaid,19.41,,,19.41,Other,324% of Medicaid,12.88,,,12.88,Other,215% of Medicaid,12.88,,,12.88,Other,215% of Medicaid,7.49,,,7.49,Other,125% of Medicaid,5.99,79.18,
SMEAR COMPLEX STAIN,87209,CPT,,78087209,CDM,306,RC,,,both,,,116,85.84,,,85.84,Other,150% of Medicare + 9.63% HCRA Surcharge,52.2,45,,52.2,percent of total billed charges,Critical Access Hospital RCC factor,54.12,,,54.12,Fee Schedule,,48.73,,,48.73,Fee Schedule,,133.28,,,133.28,Fee Schedule,,119.87,,,119.87,Fee Schedule,,113.3,,,113.3,Fee Schedule,,57.42,,,57.42,Other,110% of Medicare,56.64,,,56.64,Fee Schedule,,11,,,11,Other,186% of Medicaid,66.71,,,66.71,Fee Schedule,,71.92,,,71.92,Fee Schedule,,37.76,,,37.76,Fee Schedule,,66.71,,,66.71,Fee Schedule,,71.92,,,71.92,Fee Schedule,,71.02,,,71.02,Fee Schedule,,81.2,70,,81.2,percent of total billed charges,All Other,85.21,,,85.21,Fee Schedule,,72.22,,,72.22,Fee Schedule,,26.97,,,26.97,Fee Schedule,,26.97,,,26.97,Fee Schedule,,26.97,,,26.97,Fee Schedule,,26.97,,,26.97,Fee Schedule,,5.91,,,5.91,Other,100% of Medicaid,5.91,,,5.91,Other,100% of Medicaid,5.91,,,5.91,Other,100% of Medicaid,5.91,,,5.91,Other,100% of Medicaid,13.29,,,13.29,Other,225% of Medicaid,9.04,,,9.04,Other,153% of Medicaid,13.29,,,13.29,Other,225% of Medicaid,8.27,,,8.27,Other,140% of Medicaid,13.29,,,13.29,Other,225% of Medicaid,15.36,,,15.36,Other,260% of Medicaid,19.14,,,19.14,Other,324% of Medicaid,12.7,,,12.7,Other,215% of Medicaid,12.7,,,12.7,Other,215% of Medicaid,7.39,,,7.39,Other,125% of Medicaid,5.91,133.28,
SMEAR WET MOUNT SALINE/INK,87210,CPT,,78087210,CDM,306,RC,,,both,,,142,105.08,,,105.08,Other,150% of Medicare + 9.63% HCRA Surcharge,63.9,45,,63.9,percent of total billed charges,Critical Access Hospital RCC factor,17.52,,,17.52,Fee Schedule,,15.77,,,15.77,Fee Schedule,,31.67,,,31.67,Fee Schedule,,28.49,,,28.49,Fee Schedule,,26.92,,,26.92,Fee Schedule,,70.29,,,70.29,Other,110% of Medicare,18.33,,,18.33,Fee Schedule,,6,,,6,Other,186% of Medicaid,21.59,,,21.59,Fee Schedule,,88.04,,,88.04,Fee Schedule,,12.22,,,12.22,Fee Schedule,,21.59,,,21.59,Fee Schedule,,88.04,,,88.04,Fee Schedule,,22.99,,,22.99,Fee Schedule,,99.4,70,,99.4,percent of total billed charges,All Other,27.58,,,27.58,Fee Schedule,,23.38,,,23.38,Fee Schedule,,8.73,,,8.73,Fee Schedule,,8.73,,,8.73,Fee Schedule,,8.73,,,8.73,Fee Schedule,,8.73,,,8.73,Fee Schedule,,3.43,,,3.43,Other,100% of Medicaid,3.43,,,3.43,Other,100% of Medicaid,3.43,,,3.43,Other,100% of Medicaid,3.43,,,3.43,Other,100% of Medicaid,7.73,,,7.73,Other,225% of Medicaid,5.25,,,5.25,Other,153% of Medicaid,7.73,,,7.73,Other,225% of Medicaid,4.81,,,4.81,Other,140% of Medicaid,7.73,,,7.73,Other,225% of Medicaid,8.93,,,8.93,Other,260% of Medicaid,11.13,,,11.13,Other,324% of Medicaid,7.38,,,7.38,Other,215% of Medicaid,7.38,,,7.38,Other,215% of Medicaid,4.29,,,4.29,Other,125% of Medicaid,3.43,105.08,
TISSUE EXAM FOR FUNGI,87220,CPT,,78087220,CDM,306,RC,,,both,,,144,106.56,,,106.56,Other,150% of Medicare + 9.63% HCRA Surcharge,64.8,45,,64.8,percent of total billed charges,Critical Access Hospital RCC factor,12.85,,,12.85,Fee Schedule,,11.57,,,11.57,Fee Schedule,,31.67,,,31.67,Fee Schedule,,28.49,,,28.49,Fee Schedule,,26.92,,,26.92,Fee Schedule,,71.28,,,71.28,Other,110% of Medicare,13.45,,,13.45,Fee Schedule,,17,,,17,Other,186% of Medicaid,15.84,,,15.84,Fee Schedule,,89.28,,,89.28,Fee Schedule,,8.97,,,8.97,Fee Schedule,,15.84,,,15.84,Fee Schedule,,89.28,,,89.28,Fee Schedule,,16.87,,,16.87,Fee Schedule,,100.8,70,,100.8,percent of total billed charges,All Other,20.24,,,20.24,Fee Schedule,,17.15,,,17.15,Fee Schedule,,6.41,,,6.41,Fee Schedule,,6.41,,,6.41,Fee Schedule,,6.41,,,6.41,Fee Schedule,,6.41,,,6.41,Fee Schedule,,9.14,,,9.14,Other,100% of Medicaid,9.14,,,9.14,Other,100% of Medicaid,9.14,,,9.14,Other,100% of Medicaid,9.14,,,9.14,Other,100% of Medicaid,20.56,,,20.56,Other,225% of Medicaid,13.98,,,13.98,Other,153% of Medicaid,20.56,,,20.56,Other,225% of Medicaid,12.79,,,12.79,Other,140% of Medicaid,20.56,,,20.56,Other,225% of Medicaid,23.76,,,23.76,Other,260% of Medicaid,29.6,,,29.6,Other,324% of Medicaid,19.64,,,19.64,Other,215% of Medicaid,19.64,,,19.64,Other,215% of Medicaid,11.42,,,11.42,Other,125% of Medicaid,6.41,106.56,
ASSAY TOXIN OR ANTITOXIN,87230,CPT,,78087230,CDM,306,RC,,,both,,,89,65.86,,,65.86,Other,150% of Medicare + 9.63% HCRA Surcharge,40.05,45,,40.05,percent of total billed charges,Critical Access Hospital RCC factor,59.42,,,59.42,Fee Schedule,,53.5,,,53.5,Fee Schedule,,64.87,,,64.87,Fee Schedule,,58.35,,,58.35,Fee Schedule,,55.15,,,55.15,Fee Schedule,,44.06,,,44.06,Other,110% of Medicare,62.18,,,62.18,Fee Schedule,,18,,,18,Other,186% of Medicaid,73.24,,,73.24,Fee Schedule,,55.18,,,55.18,Fee Schedule,,41.45,,,41.45,Fee Schedule,,73.24,,,73.24,Fee Schedule,,55.18,,,55.18,Fee Schedule,,77.97,,,77.97,Fee Schedule,,62.3,70,,62.3,percent of total billed charges,All Other,93.55,,,93.55,Fee Schedule,,79.29,,,79.29,Fee Schedule,,29.61,,,29.61,Fee Schedule,,29.61,,,29.61,Fee Schedule,,29.61,,,29.61,Fee Schedule,,29.61,,,29.61,Fee Schedule,,9.49,,,9.49,Other,100% of Medicaid,9.49,,,9.49,Other,100% of Medicaid,9.49,,,9.49,Other,100% of Medicaid,9.49,,,9.49,Other,100% of Medicaid,21.36,,,21.36,Other,225% of Medicaid,14.53,,,14.53,Other,153% of Medicaid,21.36,,,21.36,Other,225% of Medicaid,13.29,,,13.29,Other,140% of Medicaid,21.36,,,21.36,Other,225% of Medicaid,24.68,,,24.68,Other,260% of Medicaid,30.76,,,30.76,Other,324% of Medicaid,20.41,,,20.41,Other,215% of Medicaid,20.41,,,20.41,Other,215% of Medicaid,11.87,,,11.87,Other,125% of Medicaid,9.49,93.55,
VIRUS INOCULATION TISSUE,87250,CPT,,78087250,CDM,306,RC,,,both,,,236,174.64,,,174.64,Other,150% of Medicare + 9.63% HCRA Surcharge,106.2,45,,106.2,percent of total billed charges,Critical Access Hospital RCC factor,58.88,,,58.88,Fee Schedule,,53.01,,,53.01,Fee Schedule,,145.03,,,145.03,Fee Schedule,,130.44,,,130.44,Fee Schedule,,123.29,,,123.29,Fee Schedule,,116.82,,,116.82,Other,110% of Medicare,61.61,,,61.61,Fee Schedule,,36,,,36,Other,186% of Medicaid,72.57,,,72.57,Fee Schedule,,146.32,,,146.32,Fee Schedule,,41.08,,,41.08,Fee Schedule,,72.57,,,72.57,Fee Schedule,,146.32,,,146.32,Fee Schedule,,77.26,,,77.26,Fee Schedule,,165.2,70,,165.2,percent of total billed charges,All Other,92.7,,,92.7,Fee Schedule,,78.57,,,78.57,Fee Schedule,,29.34,,,29.34,Fee Schedule,,29.34,,,29.34,Fee Schedule,,29.34,,,29.34,Fee Schedule,,29.34,,,29.34,Fee Schedule,,19.56,,,19.56,Other,100% of Medicaid,19.56,,,19.56,Other,100% of Medicaid,19.56,,,19.56,Other,100% of Medicaid,19.56,,,19.56,Other,100% of Medicaid,44.01,,,44.01,Other,225% of Medicaid,29.93,,,29.93,Other,153% of Medicaid,44.01,,,44.01,Other,225% of Medicaid,27.38,,,27.38,Other,140% of Medicaid,44.01,,,44.01,Other,225% of Medicaid,50.86,,,50.86,Other,260% of Medicaid,63.37,,,63.37,Other,324% of Medicaid,42.05,,,42.05,Other,215% of Medicaid,42.05,,,42.05,Other,215% of Medicaid,24.45,,,24.45,Other,125% of Medicaid,19.56,174.64,
VIRUS ISOLATE; TISSUE CULT INOC,87252,CPT,,78087252,CDM,306,RC,,,both,,,275,203.5,,,203.5,Other,150% of Medicare + 9.63% HCRA Surcharge,123.75,45,,123.75,percent of total billed charges,Critical Access Hospital RCC factor,78.47,,,78.47,Fee Schedule,,70.65,,,70.65,Fee Schedule,,193.3,,,193.3,Fee Schedule,,173.86,,,173.86,Fee Schedule,,164.33,,,164.33,Fee Schedule,,136.13,,,136.13,Other,110% of Medicare,82.12,,,82.12,Fee Schedule,,48,,,48,Other,186% of Medicaid,96.72,,,96.72,Fee Schedule,,170.5,,,170.5,Fee Schedule,,54.75,,,54.75,Fee Schedule,,96.72,,,96.72,Fee Schedule,,170.5,,,170.5,Fee Schedule,,102.98,,,102.98,Fee Schedule,,192.5,70,,192.5,percent of total billed charges,All Other,123.55,,,123.55,Fee Schedule,,104.71,,,104.71,Fee Schedule,,39.11,,,39.11,Fee Schedule,,39.11,,,39.11,Fee Schedule,,39.11,,,39.11,Fee Schedule,,39.11,,,39.11,Fee Schedule,,26.07,,,26.07,Other,100% of Medicaid,26.07,,,26.07,Other,100% of Medicaid,26.07,,,26.07,Other,100% of Medicaid,26.07,,,26.07,Other,100% of Medicaid,58.66,,,58.66,Other,225% of Medicaid,39.89,,,39.89,Other,153% of Medicaid,58.66,,,58.66,Other,225% of Medicaid,36.5,,,36.5,Other,140% of Medicaid,58.66,,,58.66,Other,225% of Medicaid,67.78,,,67.78,Other,260% of Medicaid,84.47,,,84.47,Other,324% of Medicaid,56.05,,,56.05,Other,215% of Medicaid,56.05,,,56.05,Other,215% of Medicaid,32.59,,,32.59,Other,125% of Medicaid,26.07,203.5,
VIRUS INOCULATE TISSUE ADDL,87253,CPT,,78087253,CDM,306,RC,,,both,,,157,116.18,,,116.18,Other,150% of Medicare + 9.63% HCRA Surcharge,70.65,45,,70.65,percent of total billed charges,Critical Access Hospital RCC factor,60.8,,,60.8,Fee Schedule,,54.74,,,54.74,Fee Schedule,,149.77,,,149.77,Fee Schedule,,134.71,,,134.71,Fee Schedule,,127.32,,,127.32,Fee Schedule,,77.72,,,77.72,Other,110% of Medicare,63.63,,,63.63,Fee Schedule,,38,,,38,Other,186% of Medicaid,74.94,,,74.94,Fee Schedule,,97.34,,,97.34,Fee Schedule,,42.42,,,42.42,Fee Schedule,,74.94,,,74.94,Fee Schedule,,97.34,,,97.34,Fee Schedule,,79.79,,,79.79,Fee Schedule,,109.9,70,,109.9,percent of total billed charges,All Other,95.73,,,95.73,Fee Schedule,,81.14,,,81.14,Fee Schedule,,30.3,,,30.3,Fee Schedule,,30.3,,,30.3,Fee Schedule,,30.3,,,30.3,Fee Schedule,,30.3,,,30.3,Fee Schedule,,20.2,,,20.2,Other,100% of Medicaid,20.2,,,20.2,Other,100% of Medicaid,20.2,,,20.2,Other,100% of Medicaid,20.2,,,20.2,Other,100% of Medicaid,45.45,,,45.45,Other,225% of Medicaid,30.91,,,30.91,Other,153% of Medicaid,45.45,,,45.45,Other,225% of Medicaid,28.28,,,28.28,Other,140% of Medicaid,45.45,,,45.45,Other,225% of Medicaid,52.52,,,52.52,Other,260% of Medicaid,65.45,,,65.45,Other,324% of Medicaid,43.43,,,43.43,Other,215% of Medicaid,43.43,,,43.43,Other,215% of Medicaid,25.25,,,25.25,Other,125% of Medicaid,20.2,149.77,
GENET VIRUS ISOLATE HSV,87255,CPT,,78087255,CDM,306,RC,,,both,,,217,160.58,,,160.58,Other,150% of Medicare + 9.63% HCRA Surcharge,97.65,45,,97.65,percent of total billed charges,Critical Access Hospital RCC factor,101.92,,,101.92,Fee Schedule,,91.76,,,91.76,Fee Schedule,,251.17,,,251.17,Fee Schedule,,225.91,,,225.91,Fee Schedule,,213.52,,,213.52,Fee Schedule,,107.42,,,107.42,Other,110% of Medicare,106.66,,,106.66,Fee Schedule,,13,,,13,Other,186% of Medicaid,125.62,,,125.62,Fee Schedule,,134.54,,,134.54,Fee Schedule,,71.11,,,71.11,Fee Schedule,,125.62,,,125.62,Fee Schedule,,134.54,,,134.54,Fee Schedule,,133.75,,,133.75,Fee Schedule,,151.9,70,,151.9,percent of total billed charges,All Other,160.46,,,160.46,Fee Schedule,,136,,,136,Fee Schedule,,50.79,,,50.79,Fee Schedule,,50.79,,,50.79,Fee Schedule,,50.79,,,50.79,Fee Schedule,,50.79,,,50.79,Fee Schedule,,6.83,,,6.83,Other,100% of Medicaid,6.83,,,6.83,Other,100% of Medicaid,6.83,,,6.83,Other,100% of Medicaid,6.83,,,6.83,Other,100% of Medicaid,15.36,,,15.36,Other,225% of Medicaid,10.45,,,10.45,Other,153% of Medicaid,15.36,,,15.36,Other,225% of Medicaid,9.56,,,9.56,Other,140% of Medicaid,15.36,,,15.36,Other,225% of Medicaid,17.75,,,17.75,Other,260% of Medicaid,22.12,,,22.12,Other,324% of Medicaid,14.68,,,14.68,Other,215% of Medicaid,14.68,,,14.68,Other,215% of Medicaid,8.53,,,8.53,Other,125% of Medicaid,6.83,251.17,
ADENOVIRUS AG BY IF,87260,CPT,,78087260,CDM,306,RC,,,both,,,48,35.52,,,35.52,Other,150% of Medicare + 9.63% HCRA Surcharge,21.6,45,,21.6,percent of total billed charges,Critical Access Hospital RCC factor,43.43,,,43.43,Fee Schedule,,39.11,,,39.11,Fee Schedule,,64.87,,,64.87,Fee Schedule,,58.35,,,58.35,Fee Schedule,,55.15,,,55.15,Fee Schedule,,23.76,,,23.76,Other,110% of Medicare,45.45,,,45.45,Fee Schedule,,15,,,15,Other,186% of Medicaid,53.54,,,53.54,Fee Schedule,,29.76,,,29.76,Fee Schedule,,30.3,,,30.3,Fee Schedule,,53.54,,,53.54,Fee Schedule,,29.76,,,29.76,Fee Schedule,,57,,,57,Fee Schedule,,33.6,70,,33.6,percent of total billed charges,All Other,68.38,,,68.38,Fee Schedule,,57.96,,,57.96,Fee Schedule,,21.65,,,21.65,Fee Schedule,,21.65,,,21.65,Fee Schedule,,21.65,,,21.65,Fee Schedule,,21.65,,,21.65,Fee Schedule,,8.11,,,8.11,Other,100% of Medicaid,8.11,,,8.11,Other,100% of Medicaid,8.11,,,8.11,Other,100% of Medicaid,8.11,,,8.11,Other,100% of Medicaid,18.25,,,18.25,Other,225% of Medicaid,12.41,,,12.41,Other,153% of Medicaid,18.25,,,18.25,Other,225% of Medicaid,11.35,,,11.35,Other,140% of Medicaid,18.25,,,18.25,Other,225% of Medicaid,21.09,,,21.09,Other,260% of Medicaid,26.28,,,26.28,Other,324% of Medicaid,17.44,,,17.44,Other,215% of Medicaid,17.44,,,17.44,Other,215% of Medicaid,10.14,,,10.14,Other,125% of Medicaid,8.11,68.38,
PERTUSSIS AG IF,87265,CPT,,78087265,CDM,306,RC,,,both,,,411,304.14,,,304.14,Other,150% of Medicare + 9.63% HCRA Surcharge,184.95,45,,184.95,percent of total billed charges,Critical Access Hospital RCC factor,36.06,,,36.06,Fee Schedule,,32.47,,,32.47,Fee Schedule,,64.87,,,64.87,Fee Schedule,,58.35,,,58.35,Fee Schedule,,55.15,,,55.15,Fee Schedule,,203.45,,,203.45,Other,110% of Medicare,37.74,,,37.74,Fee Schedule,,15,,,15,Other,186% of Medicaid,44.45,,,44.45,Fee Schedule,,254.82,,,254.82,Fee Schedule,,25.16,,,25.16,Fee Schedule,,44.45,,,44.45,Fee Schedule,,254.82,,,254.82,Fee Schedule,,47.32,,,47.32,Fee Schedule,,287.7,70,,287.7,percent of total billed charges,All Other,56.77,,,56.77,Fee Schedule,,48.12,,,48.12,Fee Schedule,,17.97,,,17.97,Fee Schedule,,17.97,,,17.97,Fee Schedule,,17.97,,,17.97,Fee Schedule,,17.97,,,17.97,Fee Schedule,,8.11,,,8.11,Other,100% of Medicaid,8.11,,,8.11,Other,100% of Medicaid,8.11,,,8.11,Other,100% of Medicaid,8.11,,,8.11,Other,100% of Medicaid,18.25,,,18.25,Other,225% of Medicaid,12.41,,,12.41,Other,153% of Medicaid,18.25,,,18.25,Other,225% of Medicaid,11.35,,,11.35,Other,140% of Medicaid,18.25,,,18.25,Other,225% of Medicaid,21.09,,,21.09,Other,260% of Medicaid,26.28,,,26.28,Other,324% of Medicaid,17.44,,,17.44,Other,215% of Medicaid,17.44,,,17.44,Other,215% of Medicaid,10.14,,,10.14,Other,125% of Medicaid,8.11,304.14,
CHLAMYDIA T AG BY DFA,87270,CPT,,78087270,CDM,306,RC,,,both,,,62,45.88,,,45.88,Other,150% of Medicare + 9.63% HCRA Surcharge,27.9,45,,27.9,percent of total billed charges,Critical Access Hospital RCC factor,36.06,,,36.06,Fee Schedule,,32.47,,,32.47,Fee Schedule,,64.87,,,64.87,Fee Schedule,,58.35,,,58.35,Fee Schedule,,55.15,,,55.15,Fee Schedule,,30.69,,,30.69,Other,110% of Medicare,37.74,,,37.74,Fee Schedule,,15,,,15,Other,186% of Medicaid,44.45,,,44.45,Fee Schedule,,38.44,,,38.44,Fee Schedule,,25.16,,,25.16,Fee Schedule,,44.45,,,44.45,Fee Schedule,,38.44,,,38.44,Fee Schedule,,47.32,,,47.32,Fee Schedule,,43.4,70,,43.4,percent of total billed charges,All Other,56.77,,,56.77,Fee Schedule,,48.12,,,48.12,Fee Schedule,,17.97,,,17.97,Fee Schedule,,17.97,,,17.97,Fee Schedule,,17.97,,,17.97,Fee Schedule,,17.97,,,17.97,Fee Schedule,,8.11,,,8.11,Other,100% of Medicaid,8.11,,,8.11,Other,100% of Medicaid,8.11,,,8.11,Other,100% of Medicaid,8.11,,,8.11,Other,100% of Medicaid,18.25,,,18.25,Other,225% of Medicaid,12.41,,,12.41,Other,153% of Medicaid,18.25,,,18.25,Other,225% of Medicaid,11.35,,,11.35,Other,140% of Medicaid,18.25,,,18.25,Other,225% of Medicaid,21.09,,,21.09,Other,260% of Medicaid,26.28,,,26.28,Other,324% of Medicaid,17.44,,,17.44,Other,215% of Medicaid,17.44,,,17.44,Other,215% of Medicaid,10.14,,,10.14,Other,125% of Medicaid,8.11,64.87,
INFLUENZA B AG BY IF,87275,CPT,,78087275,CDM,306,RC,,,both,,,67,49.58,,,49.58,Other,150% of Medicare + 9.63% HCRA Surcharge,30.15,45,,30.15,percent of total billed charges,Critical Access Hospital RCC factor,36.87,,,36.87,Fee Schedule,,33.2,,,33.2,Fee Schedule,,64.87,,,64.87,Fee Schedule,,58.35,,,58.35,Fee Schedule,,55.15,,,55.15,Fee Schedule,,33.17,,,33.17,Other,110% of Medicare,38.59,,,38.59,Fee Schedule,,23,,,23,Other,186% of Medicaid,45.45,,,45.45,Fee Schedule,,41.54,,,41.54,Fee Schedule,,25.73,,,25.73,Fee Schedule,,45.45,,,45.45,Fee Schedule,,41.54,,,41.54,Fee Schedule,,48.39,,,48.39,Fee Schedule,,46.9,70,,46.9,percent of total billed charges,All Other,58.05,,,58.05,Fee Schedule,,49.2,,,49.2,Fee Schedule,,18.38,,,18.38,Fee Schedule,,18.38,,,18.38,Fee Schedule,,18.38,,,18.38,Fee Schedule,,18.38,,,18.38,Fee Schedule,,12.25,,,12.25,Other,100% of Medicaid,12.25,,,12.25,Other,100% of Medicaid,12.25,,,12.25,Other,100% of Medicaid,12.25,,,12.25,Other,100% of Medicaid,27.56,,,27.56,Other,225% of Medicaid,18.74,,,18.74,Other,153% of Medicaid,27.56,,,27.56,Other,225% of Medicaid,17.15,,,17.15,Other,140% of Medicaid,27.56,,,27.56,Other,225% of Medicaid,31.85,,,31.85,Other,260% of Medicaid,39.69,,,39.69,Other,324% of Medicaid,26.34,,,26.34,Other,215% of Medicaid,26.34,,,26.34,Other,215% of Medicaid,15.31,,,15.31,Other,125% of Medicaid,12.25,64.87,
INFLUENZA A AG BY DFA,87276,CPT,,78087276,CDM,306,RC,,,both,,,67,49.58,,,49.58,Other,150% of Medicare + 9.63% HCRA Surcharge,30.15,45,,30.15,percent of total billed charges,Critical Access Hospital RCC factor,48.37,,,48.37,Fee Schedule,,43.55,,,43.55,Fee Schedule,,64.87,,,64.87,Fee Schedule,,58.35,,,58.35,Fee Schedule,,55.15,,,55.15,Fee Schedule,,33.17,,,33.17,Other,110% of Medicare,50.62,,,50.62,Fee Schedule,,27,,,27,Other,186% of Medicaid,59.62,,,59.62,Fee Schedule,,41.54,,,41.54,Fee Schedule,,33.75,,,33.75,Fee Schedule,,59.62,,,59.62,Fee Schedule,,41.54,,,41.54,Fee Schedule,,63.48,,,63.48,Fee Schedule,,46.9,70,,46.9,percent of total billed charges,All Other,76.16,,,76.16,Fee Schedule,,64.55,,,64.55,Fee Schedule,,24.11,,,24.11,Fee Schedule,,24.11,,,24.11,Fee Schedule,,24.11,,,24.11,Fee Schedule,,24.11,,,24.11,Fee Schedule,,14.65,,,14.65,Other,100% of Medicaid,14.65,,,14.65,Other,100% of Medicaid,14.65,,,14.65,Other,100% of Medicaid,14.65,,,14.65,Other,100% of Medicaid,32.95,,,32.95,Other,225% of Medicaid,22.41,,,22.41,Other,153% of Medicaid,32.95,,,32.95,Other,225% of Medicaid,20.5,,,20.5,Other,140% of Medicaid,32.95,,,32.95,Other,225% of Medicaid,38.08,,,38.08,Other,260% of Medicaid,47.45,,,47.45,Other,324% of Medicaid,31.49,,,31.49,Other,215% of Medicaid,31.49,,,31.49,Other,215% of Medicaid,18.31,,,18.31,Other,125% of Medicaid,14.65,76.16,
PARAINFLUENZA AG BY DFA,87279,CPT,,78087279,CDM,306,RC,,,both,,,56,41.44,,,41.44,Other,150% of Medicare + 9.63% HCRA Surcharge,25.2,45,,25.2,percent of total billed charges,Critical Access Hospital RCC factor,49.45,,,49.45,Fee Schedule,,44.53,,,44.53,Fee Schedule,,64.87,,,64.87,Fee Schedule,,58.35,,,58.35,Fee Schedule,,55.15,,,55.15,Fee Schedule,,27.72,,,27.72,Other,110% of Medicare,51.75,,,51.75,Fee Schedule,,15,,,15,Other,186% of Medicaid,60.96,,,60.96,Fee Schedule,,34.72,,,34.72,Fee Schedule,,34.5,,,34.5,Fee Schedule,,60.96,,,60.96,Fee Schedule,,34.72,,,34.72,Fee Schedule,,64.9,,,64.9,Fee Schedule,,39.2,70,,39.2,percent of total billed charges,All Other,77.86,,,77.86,Fee Schedule,,65.99,,,65.99,Fee Schedule,,24.65,,,24.65,Fee Schedule,,24.65,,,24.65,Fee Schedule,,24.65,,,24.65,Fee Schedule,,24.65,,,24.65,Fee Schedule,,8.11,,,8.11,Other,100% of Medicaid,8.11,,,8.11,Other,100% of Medicaid,8.11,,,8.11,Other,100% of Medicaid,8.11,,,8.11,Other,100% of Medicaid,18.25,,,18.25,Other,225% of Medicaid,12.41,,,12.41,Other,153% of Medicaid,18.25,,,18.25,Other,225% of Medicaid,11.35,,,11.35,Other,140% of Medicaid,18.25,,,18.25,Other,225% of Medicaid,21.09,,,21.09,Other,260% of Medicaid,26.28,,,26.28,Other,324% of Medicaid,17.44,,,17.44,Other,215% of Medicaid,17.44,,,17.44,Other,215% of Medicaid,10.14,,,10.14,Other,125% of Medicaid,8.11,77.86,
RSV AG BY IF,87280,CPT,,78087280,CDM,306,RC,,,both,,,55,40.7,,,40.7,Other,150% of Medicare + 9.63% HCRA Surcharge,24.75,45,,24.75,percent of total billed charges,Critical Access Hospital RCC factor,40.39,,,40.39,Fee Schedule,,36.37,,,36.37,Fee Schedule,,64.87,,,64.87,Fee Schedule,,58.35,,,58.35,Fee Schedule,,55.15,,,55.15,Fee Schedule,,27.23,,,27.23,Other,110% of Medicare,42.27,,,42.27,Fee Schedule,,15,,,15,Other,186% of Medicaid,49.79,,,49.79,Fee Schedule,,34.1,,,34.1,Fee Schedule,,28.18,,,28.18,Fee Schedule,,49.79,,,49.79,Fee Schedule,,34.1,,,34.1,Fee Schedule,,53.01,,,53.01,Fee Schedule,,38.5,70,,38.5,percent of total billed charges,All Other,63.6,,,63.6,Fee Schedule,,53.9,,,53.9,Fee Schedule,,20.13,,,20.13,Fee Schedule,,20.13,,,20.13,Fee Schedule,,20.13,,,20.13,Fee Schedule,,20.13,,,20.13,Fee Schedule,,8.11,,,8.11,Other,100% of Medicaid,8.11,,,8.11,Other,100% of Medicaid,8.11,,,8.11,Other,100% of Medicaid,8.11,,,8.11,Other,100% of Medicaid,18.25,,,18.25,Other,225% of Medicaid,12.41,,,12.41,Other,153% of Medicaid,18.25,,,18.25,Other,225% of Medicaid,11.35,,,11.35,Other,140% of Medicaid,18.25,,,18.25,Other,225% of Medicaid,21.09,,,21.09,Other,260% of Medicaid,26.28,,,26.28,Other,324% of Medicaid,17.44,,,17.44,Other,215% of Medicaid,17.44,,,17.44,Other,215% of Medicaid,10.14,,,10.14,Other,125% of Medicaid,8.11,64.87,
PNEUMOCYSTIS CARINII AG IF,87281,CPT,,78087281,CDM,306,RC,,,both,,,430,318.2,,,318.2,Other,150% of Medicare + 9.63% HCRA Surcharge,193.5,45,,193.5,percent of total billed charges,Critical Access Hospital RCC factor,36.06,,,36.06,Fee Schedule,,32.47,,,32.47,Fee Schedule,,64.87,,,64.87,Fee Schedule,,58.35,,,58.35,Fee Schedule,,55.15,,,55.15,Fee Schedule,,212.85,,,212.85,Other,110% of Medicare,37.74,,,37.74,Fee Schedule,,15,,,15,Other,186% of Medicaid,44.45,,,44.45,Fee Schedule,,266.6,,,266.6,Fee Schedule,,25.16,,,25.16,Fee Schedule,,44.45,,,44.45,Fee Schedule,,266.6,,,266.6,Fee Schedule,,47.32,,,47.32,Fee Schedule,,301,70,,301,percent of total billed charges,All Other,56.77,,,56.77,Fee Schedule,,48.12,,,48.12,Fee Schedule,,17.97,,,17.97,Fee Schedule,,17.97,,,17.97,Fee Schedule,,17.97,,,17.97,Fee Schedule,,17.97,,,17.97,Fee Schedule,,8.11,,,8.11,Other,100% of Medicaid,8.11,,,8.11,Other,100% of Medicaid,8.11,,,8.11,Other,100% of Medicaid,8.11,,,8.11,Other,100% of Medicaid,18.25,,,18.25,Other,225% of Medicaid,12.41,,,12.41,Other,153% of Medicaid,18.25,,,18.25,Other,225% of Medicaid,11.35,,,11.35,Other,140% of Medicaid,18.25,,,18.25,Other,225% of Medicaid,21.09,,,21.09,Other,260% of Medicaid,26.28,,,26.28,Other,324% of Medicaid,17.44,,,17.44,Other,215% of Medicaid,17.44,,,17.44,Other,215% of Medicaid,10.14,,,10.14,Other,125% of Medicaid,8.11,318.2,
VARICELLA ZOSTER AG IF,87290,CPT,,78087290,CDM,306,RC,,,both,,,44,32.56,,,32.56,Other,150% of Medicare + 9.63% HCRA Surcharge,19.8,45,,19.8,percent of total billed charges,Critical Access Hospital RCC factor,40.39,,,40.39,Fee Schedule,,36.37,,,36.37,Fee Schedule,,64.87,,,64.87,Fee Schedule,,58.35,,,58.35,Fee Schedule,,55.15,,,55.15,Fee Schedule,,21.78,,,21.78,Other,110% of Medicare,42.27,,,42.27,Fee Schedule,,15,,,15,Other,186% of Medicaid,49.79,,,49.79,Fee Schedule,,27.28,,,27.28,Fee Schedule,,28.18,,,28.18,Fee Schedule,,49.79,,,49.79,Fee Schedule,,27.28,,,27.28,Fee Schedule,,53.01,,,53.01,Fee Schedule,,30.8,70,,30.8,percent of total billed charges,All Other,63.6,,,63.6,Fee Schedule,,53.9,,,53.9,Fee Schedule,,20.13,,,20.13,Fee Schedule,,20.13,,,20.13,Fee Schedule,,20.13,,,20.13,Fee Schedule,,20.13,,,20.13,Fee Schedule,,8.11,,,8.11,Other,100% of Medicaid,8.11,,,8.11,Other,100% of Medicaid,8.11,,,8.11,Other,100% of Medicaid,8.11,,,8.11,Other,100% of Medicaid,18.25,,,18.25,Other,225% of Medicaid,12.41,,,12.41,Other,153% of Medicaid,18.25,,,18.25,Other,225% of Medicaid,11.35,,,11.35,Other,140% of Medicaid,18.25,,,18.25,Other,225% of Medicaid,21.09,,,21.09,Other,260% of Medicaid,26.28,,,26.28,Other,324% of Medicaid,17.44,,,17.44,Other,215% of Medicaid,17.44,,,17.44,Other,215% of Medicaid,10.14,,,10.14,Other,125% of Medicaid,8.11,64.87,
INFECTIOUS AGENT ANTIGEN DETEC,87299,CPT,,78087299,CDM,306,RC,,,both,,,74,54.76,,,54.76,Other,150% of Medicare + 9.63% HCRA Surcharge,33.3,45,,33.3,percent of total billed charges,Critical Access Hospital RCC factor,48.46,,,48.46,Fee Schedule,,43.63,,,43.63,Fee Schedule,,64.87,,,64.87,Fee Schedule,,58.35,,,58.35,Fee Schedule,,55.15,,,55.15,Fee Schedule,,36.63,,,36.63,Other,110% of Medicare,50.72,,,50.72,Fee Schedule,,30,,,30,Other,186% of Medicaid,59.73,,,59.73,Fee Schedule,,45.88,,,45.88,Fee Schedule,,33.81,,,33.81,Fee Schedule,,59.73,,,59.73,Fee Schedule,,45.88,,,45.88,Fee Schedule,,63.6,,,63.6,Fee Schedule,,51.8,70,,51.8,percent of total billed charges,All Other,76.3,,,76.3,Fee Schedule,,64.67,,,64.67,Fee Schedule,,24.15,,,24.15,Fee Schedule,,24.15,,,24.15,Fee Schedule,,24.15,,,24.15,Fee Schedule,,24.15,,,24.15,Fee Schedule,,16.1,,,16.1,Other,100% of Medicaid,16.1,,,16.1,Other,100% of Medicaid,16.1,,,16.1,Other,100% of Medicaid,16.1,,,16.1,Other,100% of Medicaid,36.23,,,36.23,Other,225% of Medicaid,24.63,,,24.63,Other,153% of Medicaid,36.23,,,36.23,Other,225% of Medicaid,22.54,,,22.54,Other,140% of Medicaid,36.23,,,36.23,Other,225% of Medicaid,41.86,,,41.86,Other,260% of Medicaid,52.16,,,52.16,Other,324% of Medicaid,34.62,,,34.62,Other,215% of Medicaid,34.62,,,34.62,Other,215% of Medicaid,20.13,,,20.13,Other,125% of Medicaid,16.1,76.3,
CLOSTRIDIUM AG EIA,87324,CPT,,78087324,CDM,306,RC,,,both,,,302,223.48,,,223.48,Other,150% of Medicare + 9.63% HCRA Surcharge,135.9,45,,135.9,percent of total billed charges,Critical Access Hospital RCC factor,36.06,,,36.06,Fee Schedule,,32.47,,,32.47,Fee Schedule,,64.87,,,64.87,Fee Schedule,,58.35,,,58.35,Fee Schedule,,55.15,,,55.15,Fee Schedule,,149.49,,,149.49,Other,110% of Medicare,37.74,,,37.74,Fee Schedule,,18,,,18,Other,186% of Medicaid,44.45,,,44.45,Fee Schedule,,187.24,,,187.24,Fee Schedule,,25.16,,,25.16,Fee Schedule,,44.45,,,44.45,Fee Schedule,,187.24,,,187.24,Fee Schedule,,47.32,,,47.32,Fee Schedule,,211.4,70,,211.4,percent of total billed charges,All Other,56.77,,,56.77,Fee Schedule,,48.12,,,48.12,Fee Schedule,,17.97,,,17.97,Fee Schedule,,17.97,,,17.97,Fee Schedule,,17.97,,,17.97,Fee Schedule,,17.97,,,17.97,Fee Schedule,,9.49,,,9.49,Other,100% of Medicaid,9.49,,,9.49,Other,100% of Medicaid,9.49,,,9.49,Other,100% of Medicaid,9.49,,,9.49,Other,100% of Medicaid,21.36,,,21.36,Other,225% of Medicaid,14.53,,,14.53,Other,153% of Medicaid,21.36,,,21.36,Other,225% of Medicaid,13.29,,,13.29,Other,140% of Medicaid,21.36,,,21.36,Other,225% of Medicaid,24.68,,,24.68,Other,260% of Medicaid,30.76,,,30.76,Other,324% of Medicaid,20.41,,,20.41,Other,215% of Medicaid,20.41,,,20.41,Other,215% of Medicaid,11.87,,,11.87,Other,125% of Medicaid,9.49,223.48,
CRYPTOCOCCUS NEOFORM AG EIA,87327,CPT,,78087327,CDM,306,RC,,,both,,,78,57.72,,,57.72,Other,150% of Medicare + 9.63% HCRA Surcharge,35.1,45,,35.1,percent of total billed charges,Critical Access Hospital RCC factor,40.39,,,40.39,Fee Schedule,,36.37,,,36.37,Fee Schedule,,64.87,,,64.87,Fee Schedule,,58.35,,,58.35,Fee Schedule,,55.15,,,55.15,Fee Schedule,,38.61,,,38.61,Other,110% of Medicare,42.27,,,42.27,Fee Schedule,,15,,,15,Other,186% of Medicaid,49.79,,,49.79,Fee Schedule,,48.36,,,48.36,Fee Schedule,,28.18,,,28.18,Fee Schedule,,49.79,,,49.79,Fee Schedule,,48.36,,,48.36,Fee Schedule,,53.01,,,53.01,Fee Schedule,,54.6,70,,54.6,percent of total billed charges,All Other,63.6,,,63.6,Fee Schedule,,53.9,,,53.9,Fee Schedule,,20.13,,,20.13,Fee Schedule,,20.13,,,20.13,Fee Schedule,,20.13,,,20.13,Fee Schedule,,20.13,,,20.13,Fee Schedule,,8.11,,,8.11,Other,100% of Medicaid,8.11,,,8.11,Other,100% of Medicaid,8.11,,,8.11,Other,100% of Medicaid,8.11,,,8.11,Other,100% of Medicaid,18.25,,,18.25,Other,225% of Medicaid,12.41,,,12.41,Other,153% of Medicaid,18.25,,,18.25,Other,225% of Medicaid,11.35,,,11.35,Other,140% of Medicaid,18.25,,,18.25,Other,225% of Medicaid,21.09,,,21.09,Other,260% of Medicaid,26.28,,,26.28,Other,324% of Medicaid,17.44,,,17.44,Other,215% of Medicaid,17.44,,,17.44,Other,215% of Medicaid,10.14,,,10.14,Other,125% of Medicaid,8.11,64.87,
CRYPTOSPORIDIUM AG EIA,87328,CPT,,78087328,CDM,306,RC,,,both,,,69,51.06,,,51.06,Other,150% of Medicare + 9.63% HCRA Surcharge,31.05,45,,31.05,percent of total billed charges,Critical Access Hospital RCC factor,41.6,,,41.6,Fee Schedule,,37.45,,,37.45,Fee Schedule,,64.87,,,64.87,Fee Schedule,,58.35,,,58.35,Fee Schedule,,55.15,,,55.15,Fee Schedule,,34.16,,,34.16,Other,110% of Medicare,43.53,,,43.53,Fee Schedule,,26,,,26,Other,186% of Medicaid,51.27,,,51.27,Fee Schedule,,42.78,,,42.78,Fee Schedule,,29.02,,,29.02,Fee Schedule,,51.27,,,51.27,Fee Schedule,,42.78,,,42.78,Fee Schedule,,54.59,,,54.59,Fee Schedule,,48.3,70,,48.3,percent of total billed charges,All Other,65.49,,,65.49,Fee Schedule,,55.51,,,55.51,Fee Schedule,,20.73,,,20.73,Fee Schedule,,20.73,,,20.73,Fee Schedule,,20.73,,,20.73,Fee Schedule,,20.73,,,20.73,Fee Schedule,,13.82,,,13.82,Other,100% of Medicaid,13.82,,,13.82,Other,100% of Medicaid,13.82,,,13.82,Other,100% of Medicaid,13.82,,,13.82,Other,100% of Medicaid,31.1,,,31.1,Other,225% of Medicaid,21.14,,,21.14,Other,153% of Medicaid,31.1,,,31.1,Other,225% of Medicaid,19.35,,,19.35,Other,140% of Medicaid,31.1,,,31.1,Other,225% of Medicaid,35.93,,,35.93,Other,260% of Medicaid,44.78,,,44.78,Other,324% of Medicaid,29.71,,,29.71,Other,215% of Medicaid,29.71,,,29.71,Other,215% of Medicaid,17.28,,,17.28,Other,125% of Medicaid,13.82,65.49,
ENTAMOEB HIST GROUP AG EIA,87337,CPT,,78087337,CDM,306,RC,,,both,,,60,44.4,,,44.4,Other,150% of Medicare + 9.63% HCRA Surcharge,27,45,,27,percent of total billed charges,Critical Access Hospital RCC factor,36.06,,,36.06,Fee Schedule,,32.47,,,32.47,Fee Schedule,,64.87,,,64.87,Fee Schedule,,58.35,,,58.35,Fee Schedule,,55.15,,,55.15,Fee Schedule,,29.7,,,29.7,Other,110% of Medicare,37.74,,,37.74,Fee Schedule,,15,,,15,Other,186% of Medicaid,44.45,,,44.45,Fee Schedule,,37.2,,,37.2,Fee Schedule,,25.16,,,25.16,Fee Schedule,,44.45,,,44.45,Fee Schedule,,37.2,,,37.2,Fee Schedule,,47.32,,,47.32,Fee Schedule,,42,70,,42,percent of total billed charges,All Other,56.77,,,56.77,Fee Schedule,,48.12,,,48.12,Fee Schedule,,17.97,,,17.97,Fee Schedule,,17.97,,,17.97,Fee Schedule,,17.97,,,17.97,Fee Schedule,,17.97,,,17.97,Fee Schedule,,8.11,,,8.11,Other,100% of Medicaid,8.11,,,8.11,Other,100% of Medicaid,8.11,,,8.11,Other,100% of Medicaid,8.11,,,8.11,Other,100% of Medicaid,18.25,,,18.25,Other,225% of Medicaid,12.41,,,12.41,Other,153% of Medicaid,18.25,,,18.25,Other,225% of Medicaid,11.35,,,11.35,Other,140% of Medicaid,18.25,,,18.25,Other,225% of Medicaid,21.09,,,21.09,Other,260% of Medicaid,26.28,,,26.28,Other,324% of Medicaid,17.44,,,17.44,Other,215% of Medicaid,17.44,,,17.44,Other,215% of Medicaid,10.14,,,10.14,Other,125% of Medicaid,8.11,64.87,
HPYLORI STOOL EIA,87338,CPT,,78087338,CDM,306,RC,,,both,,,93,68.82,,,68.82,Other,150% of Medicare + 9.63% HCRA Surcharge,41.85,45,,41.85,percent of total billed charges,Critical Access Hospital RCC factor,43.28,,,43.28,Fee Schedule,,38.97,,,38.97,Fee Schedule,,106.66,,,106.66,Fee Schedule,,95.94,,,95.94,Fee Schedule,,90.68,,,90.68,Fee Schedule,,46.04,,,46.04,Other,110% of Medicare,45.3,,,45.3,Fee Schedule,,15,,,15,Other,186% of Medicaid,53.35,,,53.35,Fee Schedule,,57.66,,,57.66,Fee Schedule,,30.2,,,30.2,Fee Schedule,,53.35,,,53.35,Fee Schedule,,57.66,,,57.66,Fee Schedule,,56.8,,,56.8,Fee Schedule,,65.1,70,,65.1,percent of total billed charges,All Other,68.15,,,68.15,Fee Schedule,,57.76,,,57.76,Fee Schedule,,21.57,,,21.57,Fee Schedule,,21.57,,,21.57,Fee Schedule,,21.57,,,21.57,Fee Schedule,,21.57,,,21.57,Fee Schedule,,8.11,,,8.11,Other,100% of Medicaid,8.11,,,8.11,Other,100% of Medicaid,8.11,,,8.11,Other,100% of Medicaid,8.11,,,8.11,Other,100% of Medicaid,18.25,,,18.25,Other,225% of Medicaid,12.41,,,12.41,Other,153% of Medicaid,18.25,,,18.25,Other,225% of Medicaid,11.35,,,11.35,Other,140% of Medicaid,18.25,,,18.25,Other,225% of Medicaid,21.09,,,21.09,Other,260% of Medicaid,26.28,,,26.28,Other,324% of Medicaid,17.44,,,17.44,Other,215% of Medicaid,17.44,,,17.44,Other,215% of Medicaid,10.14,,,10.14,Other,125% of Medicaid,8.11,106.66,
HEPATITIS B SURFACE AG EIA,87340,CPT,,78087340,CDM,306,RC,,,both,,,139,102.86,,,102.86,Other,150% of Medicare + 9.63% HCRA Surcharge,62.55,45,,62.55,percent of total billed charges,Critical Access Hospital RCC factor,31.09,,,31.09,Fee Schedule,,27.99,,,27.99,Fee Schedule,,76.57,,,76.57,Fee Schedule,,68.87,,,68.87,Fee Schedule,,65.09,,,65.09,Fee Schedule,,68.81,,,68.81,Other,110% of Medicare,32.54,,,32.54,Fee Schedule,,19,,,19,Other,186% of Medicaid,38.32,,,38.32,Fee Schedule,,86.18,,,86.18,Fee Schedule,,21.69,,,21.69,Fee Schedule,,38.32,,,38.32,Fee Schedule,,86.18,,,86.18,Fee Schedule,,40.8,,,40.8,Fee Schedule,,97.3,70,,97.3,percent of total billed charges,All Other,48.95,,,48.95,Fee Schedule,,41.49,,,41.49,Fee Schedule,,15.5,,,15.5,Fee Schedule,,15.5,,,15.5,Fee Schedule,,15.5,,,15.5,Fee Schedule,,15.5,,,15.5,Fee Schedule,,10.33,,,10.33,Other,100% of Medicaid,10.33,,,10.33,Other,100% of Medicaid,10.33,,,10.33,Other,100% of Medicaid,10.33,,,10.33,Other,100% of Medicaid,23.24,,,23.24,Other,225% of Medicaid,15.8,,,15.8,Other,153% of Medicaid,23.24,,,23.24,Other,225% of Medicaid,14.46,,,14.46,Other,140% of Medicaid,23.24,,,23.24,Other,225% of Medicaid,26.86,,,26.86,Other,260% of Medicaid,33.47,,,33.47,Other,324% of Medicaid,22.21,,,22.21,Other,215% of Medicaid,22.21,,,22.21,Other,215% of Medicaid,12.91,,,12.91,Other,125% of Medicaid,10.33,102.86,
HEPATITIS B SURFACE AG IA,87341,CPT,,78087341,CDM,306,RC,,,both,,,33,24.42,,,24.42,Other,150% of Medicare + 9.63% HCRA Surcharge,14.85,45,,14.85,percent of total billed charges,Critical Access Hospital RCC factor,31.09,,,31.09,Fee Schedule,,27.99,,,27.99,Fee Schedule,,76.57,,,76.57,Fee Schedule,,68.87,,,68.87,Fee Schedule,,65.09,,,65.09,Fee Schedule,,16.34,,,16.34,Other,110% of Medicare,32.54,,,32.54,Fee Schedule,,19,,,19,Other,186% of Medicaid,38.32,,,38.32,Fee Schedule,,20.46,,,20.46,Fee Schedule,,21.69,,,21.69,Fee Schedule,,38.32,,,38.32,Fee Schedule,,20.46,,,20.46,Fee Schedule,,40.8,,,40.8,Fee Schedule,,23.1,70,,23.1,percent of total billed charges,All Other,48.95,,,48.95,Fee Schedule,,41.49,,,41.49,Fee Schedule,,15.5,,,15.5,Fee Schedule,,15.5,,,15.5,Fee Schedule,,15.5,,,15.5,Fee Schedule,,15.5,,,15.5,Fee Schedule,,10.33,,,10.33,Other,100% of Medicaid,10.33,,,10.33,Other,100% of Medicaid,10.33,,,10.33,Other,100% of Medicaid,10.33,,,10.33,Other,100% of Medicaid,23.24,,,23.24,Other,225% of Medicaid,15.8,,,15.8,Other,153% of Medicaid,23.24,,,23.24,Other,225% of Medicaid,14.46,,,14.46,Other,140% of Medicaid,23.24,,,23.24,Other,225% of Medicaid,26.86,,,26.86,Other,260% of Medicaid,33.47,,,33.47,Other,324% of Medicaid,22.21,,,22.21,Other,215% of Medicaid,22.21,,,22.21,Other,215% of Medicaid,12.91,,,12.91,Other,125% of Medicaid,10.33,76.57,
HEPATITIS BE AG EIA,87350,CPT,,78087350,CDM,306,RC,,,both,,,168,124.32,,,124.32,Other,150% of Medicare + 9.63% HCRA Surcharge,75.6,45,,75.6,percent of total billed charges,Critical Access Hospital RCC factor,34.71,,,34.71,Fee Schedule,,31.25,,,31.25,Fee Schedule,,85.48,,,85.48,Fee Schedule,,76.88,,,76.88,Fee Schedule,,72.67,,,72.67,Fee Schedule,,83.16,,,83.16,Other,110% of Medicare,36.32,,,36.32,Fee Schedule,,19,,,19,Other,186% of Medicaid,42.78,,,42.78,Fee Schedule,,104.16,,,104.16,Fee Schedule,,24.21,,,24.21,Fee Schedule,,42.78,,,42.78,Fee Schedule,,104.16,,,104.16,Fee Schedule,,45.54,,,45.54,Fee Schedule,,117.6,70,,117.6,percent of total billed charges,All Other,54.64,,,54.64,Fee Schedule,,46.31,,,46.31,Fee Schedule,,17.3,,,17.3,Fee Schedule,,17.3,,,17.3,Fee Schedule,,17.3,,,17.3,Fee Schedule,,17.3,,,17.3,Fee Schedule,,10.2,,,10.2,Other,100% of Medicaid,10.2,,,10.2,Other,100% of Medicaid,10.2,,,10.2,Other,100% of Medicaid,10.2,,,10.2,Other,100% of Medicaid,22.95,,,22.95,Other,225% of Medicaid,15.61,,,15.61,Other,153% of Medicaid,22.95,,,22.95,Other,225% of Medicaid,14.28,,,14.28,Other,140% of Medicaid,22.95,,,22.95,Other,225% of Medicaid,26.52,,,26.52,Other,260% of Medicaid,33.05,,,33.05,Other,324% of Medicaid,21.93,,,21.93,Other,215% of Medicaid,21.93,,,21.93,Other,215% of Medicaid,12.75,,,12.75,Other,125% of Medicaid,10.2,124.32,
HISTOPLASMA CAPSUL AG EIA,87385,CPT,,78087385,CDM,306,RC,,,both,,,70,51.8,,,51.8,Other,150% of Medicare + 9.63% HCRA Surcharge,31.5,45,,31.5,percent of total billed charges,Critical Access Hospital RCC factor,39.88,,,39.88,Fee Schedule,,35.91,,,35.91,Fee Schedule,,64.87,,,64.87,Fee Schedule,,58.35,,,58.35,Fee Schedule,,55.15,,,55.15,Fee Schedule,,34.65,,,34.65,Other,110% of Medicare,41.74,,,41.74,Fee Schedule,,23,,,23,Other,186% of Medicaid,49.16,,,49.16,Fee Schedule,,43.4,,,43.4,Fee Schedule,,27.83,,,27.83,Fee Schedule,,49.16,,,49.16,Fee Schedule,,43.4,,,43.4,Fee Schedule,,52.34,,,52.34,Fee Schedule,,49,70,,49,percent of total billed charges,All Other,62.79,,,62.79,Fee Schedule,,53.22,,,53.22,Fee Schedule,,19.88,,,19.88,Fee Schedule,,19.88,,,19.88,Fee Schedule,,19.88,,,19.88,Fee Schedule,,19.88,,,19.88,Fee Schedule,,12.53,,,12.53,Other,100% of Medicaid,12.53,,,12.53,Other,100% of Medicaid,12.53,,,12.53,Other,100% of Medicaid,12.53,,,12.53,Other,100% of Medicaid,28.2,,,28.2,Other,225% of Medicaid,19.18,,,19.18,Other,153% of Medicaid,28.2,,,28.2,Other,225% of Medicaid,17.55,,,17.55,Other,140% of Medicaid,28.2,,,28.2,Other,225% of Medicaid,32.59,,,32.59,Other,260% of Medicaid,40.61,,,40.61,Other,324% of Medicaid,26.95,,,26.95,Other,215% of Medicaid,26.95,,,26.95,Other,215% of Medicaid,15.67,,,15.67,Other,125% of Medicaid,12.53,64.87,
HIV-1 AG W/HIV-1 & HIV-2 AB,87389,CPT,,78087389,CDM,306,RC,,,both,,,136,100.64,,,100.64,Other,150% of Medicare + 9.63% HCRA Surcharge,61.2,45,,61.2,percent of total billed charges,Critical Access Hospital RCC factor,72.48,,,72.48,Fee Schedule,,65.26,,,65.26,Fee Schedule,,13.65,,,13.65,Fee Schedule,,13.65,,,13.65,Fee Schedule,,13.65,,,13.65,Fee Schedule,,67.32,,,67.32,Other,110% of Medicare,75.85,,,75.85,Fee Schedule,,35,,,35,Other,186% of Medicaid,89.34,,,89.34,Fee Schedule,,84.32,,,84.32,Fee Schedule,,50.57,,,50.57,Fee Schedule,,89.34,,,89.34,Fee Schedule,,84.32,,,84.32,Fee Schedule,,95.12,,,95.12,Fee Schedule,,95.2,70,,95.2,percent of total billed charges,All Other,114.12,,,114.12,Fee Schedule,,96.72,,,96.72,Fee Schedule,,36.12,,,36.12,Fee Schedule,,36.12,,,36.12,Fee Schedule,,36.12,,,36.12,Fee Schedule,,36.12,,,36.12,Fee Schedule,,18.67,,,18.67,Other,100% of Medicaid,18.67,,,18.67,Other,100% of Medicaid,18.67,,,18.67,Other,100% of Medicaid,18.67,,,18.67,Other,100% of Medicaid,42.02,,,42.02,Other,225% of Medicaid,28.57,,,28.57,Other,153% of Medicaid,42.02,,,42.02,Other,225% of Medicaid,26.14,,,26.14,Other,140% of Medicaid,42.02,,,42.02,Other,225% of Medicaid,48.55,,,48.55,Other,260% of Medicaid,60.51,,,60.51,Other,324% of Medicaid,40.15,,,40.15,Other,215% of Medicaid,40.15,,,40.15,Other,215% of Medicaid,23.34,,,23.34,Other,125% of Medicaid,13.65,114.12,
INFLUENZA A/B AG EIA,87400,CPT,,78087400,CDM,306,RC,,,both,,,167,123.58,,,123.58,Other,150% of Medicare + 9.63% HCRA Surcharge,75.15,45,,75.15,percent of total billed charges,Critical Access Hospital RCC factor,42.53,,,42.53,Fee Schedule,,38.29,,,38.29,Fee Schedule,,64.87,,,64.87,Fee Schedule,,58.35,,,58.35,Fee Schedule,,55.15,,,55.15,Fee Schedule,,82.67,,,82.67,Other,110% of Medicare,44.51,,,44.51,Fee Schedule,,17,,,17,Other,186% of Medicaid,52.42,,,52.42,Fee Schedule,,103.54,,,103.54,Fee Schedule,,29.67,,,29.67,Fee Schedule,,52.42,,,52.42,Fee Schedule,,103.54,,,103.54,Fee Schedule,,55.81,,,55.81,Fee Schedule,,116.9,70,,116.9,percent of total billed charges,All Other,66.96,,,66.96,Fee Schedule,,56.75,,,56.75,Fee Schedule,,21.2,,,21.2,Fee Schedule,,21.2,,,21.2,Fee Schedule,,21.2,,,21.2,Fee Schedule,,21.2,,,21.2,Fee Schedule,,9.14,,,9.14,Other,100% of Medicaid,9.14,,,9.14,Other,100% of Medicaid,9.14,,,9.14,Other,100% of Medicaid,9.14,,,9.14,Other,100% of Medicaid,20.56,,,20.56,Other,225% of Medicaid,13.98,,,13.98,Other,153% of Medicaid,20.56,,,20.56,Other,225% of Medicaid,12.79,,,12.79,Other,140% of Medicaid,20.56,,,20.56,Other,225% of Medicaid,23.76,,,23.76,Other,260% of Medicaid,29.6,,,29.6,Other,324% of Medicaid,19.64,,,19.64,Other,215% of Medicaid,19.64,,,19.64,Other,215% of Medicaid,11.42,,,11.42,Other,125% of Medicaid,9.14,123.58,
RESP SYNCYTIAL VIRUS AG IA,87420,CPT,,78087420,CDM,306,RC,,,both,,,45,33.3,,,33.3,Other,150% of Medicare + 9.63% HCRA Surcharge,20.25,45,,20.25,percent of total billed charges,Critical Access Hospital RCC factor,41.87,,,41.87,Fee Schedule,,37.7,,,37.7,Fee Schedule,,64.87,,,64.87,Fee Schedule,,58.35,,,58.35,Fee Schedule,,55.15,,,55.15,Fee Schedule,,22.28,,,22.28,Other,110% of Medicare,43.82,,,43.82,Fee Schedule,,15,,,15,Other,186% of Medicaid,51.61,,,51.61,Fee Schedule,,27.9,,,27.9,Fee Schedule,,29.21,,,29.21,Fee Schedule,,51.61,,,51.61,Fee Schedule,,27.9,,,27.9,Fee Schedule,,54.94,,,54.94,Fee Schedule,,31.5,70,,31.5,percent of total billed charges,All Other,65.92,,,65.92,Fee Schedule,,55.87,,,55.87,Fee Schedule,,20.87,,,20.87,Fee Schedule,,20.87,,,20.87,Fee Schedule,,20.87,,,20.87,Fee Schedule,,20.87,,,20.87,Fee Schedule,,8.11,,,8.11,Other,100% of Medicaid,8.11,,,8.11,Other,100% of Medicaid,8.11,,,8.11,Other,100% of Medicaid,8.11,,,8.11,Other,100% of Medicaid,18.25,,,18.25,Other,225% of Medicaid,12.41,,,12.41,Other,153% of Medicaid,18.25,,,18.25,Other,225% of Medicaid,11.35,,,11.35,Other,140% of Medicaid,18.25,,,18.25,Other,225% of Medicaid,21.09,,,21.09,Other,260% of Medicaid,26.28,,,26.28,Other,324% of Medicaid,17.44,,,17.44,Other,215% of Medicaid,17.44,,,17.44,Other,215% of Medicaid,10.14,,,10.14,Other,125% of Medicaid,8.11,65.92,
SHIGA-LIKE TOXIN AG EIA,87427,CPT,,78087427,CDM,306,RC,,,both,,,70,51.8,,,51.8,Other,150% of Medicare + 9.63% HCRA Surcharge,31.5,45,,31.5,percent of total billed charges,Critical Access Hospital RCC factor,36.06,,,36.06,Fee Schedule,,32.47,,,32.47,Fee Schedule,,64.87,,,64.87,Fee Schedule,,58.35,,,58.35,Fee Schedule,,55.15,,,55.15,Fee Schedule,,34.65,,,34.65,Other,110% of Medicare,37.74,,,37.74,Fee Schedule,,22,,,22,Other,186% of Medicaid,44.45,,,44.45,Fee Schedule,,43.4,,,43.4,Fee Schedule,,25.16,,,25.16,Fee Schedule,,44.45,,,44.45,Fee Schedule,,43.4,,,43.4,Fee Schedule,,47.32,,,47.32,Fee Schedule,,49,70,,49,percent of total billed charges,All Other,56.77,,,56.77,Fee Schedule,,48.12,,,48.12,Fee Schedule,,17.97,,,17.97,Fee Schedule,,17.97,,,17.97,Fee Schedule,,17.97,,,17.97,Fee Schedule,,17.97,,,17.97,Fee Schedule,,11.98,,,11.98,Other,100% of Medicaid,11.98,,,11.98,Other,100% of Medicaid,11.98,,,11.98,Other,100% of Medicaid,11.98,,,11.98,Other,100% of Medicaid,26.96,,,26.96,Other,225% of Medicaid,18.33,,,18.33,Other,153% of Medicaid,26.96,,,26.96,Other,225% of Medicaid,16.77,,,16.77,Other,140% of Medicaid,26.96,,,26.96,Other,225% of Medicaid,31.15,,,31.15,Other,260% of Medicaid,38.82,,,38.82,Other,324% of Medicaid,25.76,,,25.76,Other,215% of Medicaid,25.76,,,25.76,Other,215% of Medicaid,14.98,,,14.98,Other,125% of Medicaid,11.98,64.87,
AG DETECT NOS EIA MULT,87449,CPT,,78087449,CDM,306,RC,,,both,,,367,271.58,,,271.58,Other,150% of Medicare + 9.63% HCRA Surcharge,165.15,45,,165.15,percent of total billed charges,Critical Access Hospital RCC factor,36.06,,,36.06,Fee Schedule,,32.47,,,32.47,Fee Schedule,,64.87,,,64.87,Fee Schedule,,58.35,,,58.35,Fee Schedule,,55.15,,,55.15,Fee Schedule,,181.67,,,181.67,Other,110% of Medicare,37.74,,,37.74,Fee Schedule,,10,,,10,Other,186% of Medicaid,44.45,,,44.45,Fee Schedule,,227.54,,,227.54,Fee Schedule,,25.16,,,25.16,Fee Schedule,,44.45,,,44.45,Fee Schedule,,227.54,,,227.54,Fee Schedule,,47.32,,,47.32,Fee Schedule,,256.9,70,,256.9,percent of total billed charges,All Other,56.77,,,56.77,Fee Schedule,,48.12,,,48.12,Fee Schedule,,17.97,,,17.97,Fee Schedule,,17.97,,,17.97,Fee Schedule,,17.97,,,17.97,Fee Schedule,,17.97,,,17.97,Fee Schedule,,5.25,,,5.25,Other,100% of Medicaid,5.25,,,5.25,Other,100% of Medicaid,5.25,,,5.25,Other,100% of Medicaid,5.25,,,5.25,Other,100% of Medicaid,11.82,,,11.82,Other,225% of Medicaid,8.04,,,8.04,Other,153% of Medicaid,11.82,,,11.82,Other,225% of Medicaid,7.35,,,7.35,Other,140% of Medicaid,11.82,,,11.82,Other,225% of Medicaid,13.66,,,13.66,Other,260% of Medicaid,17.02,,,17.02,Other,324% of Medicaid,11.29,,,11.29,Other,215% of Medicaid,11.29,,,11.29,Other,215% of Medicaid,6.57,,,6.57,Other,125% of Medicaid,5.25,271.58,
ANAPLSMA PHGCYTOPHLM AMP PRB,87468,CPT,,78087468,CDM,306,RC,,,both,,,74,54.76,,,54.76,Other,150% of Medicare + 9.63% HCRA Surcharge,33.3,45,,33.3,percent of total billed charges,Critical Access Hospital RCC factor,105.62,,,105.62,Fee Schedule,,95.09,,,95.09,Fee Schedule,,56.61,76.5,,56.61,percent of total billed charges,All Other,52.54,69,,52.54,percent of total billed charges,All Other,51.06,65,,51.06,percent of total billed charges,All Other,36.63,,,36.63,Other,110% of Medicare,110.53,,,110.53,Fee Schedule,,40,,,40,Other,186% of Medicaid,130.18,,,130.18,Fee Schedule,,45.88,,,45.88,Fee Schedule,,73.69,,,73.69,Fee Schedule,,130.18,,,130.18,Fee Schedule,,45.88,,,45.88,Fee Schedule,,138.61,,,138.61,Fee Schedule,,51.8,70,,51.8,percent of total billed charges,All Other,48.1,65,,48.1,percent of total billed charges,Default if not in Fee Schedule,48.1,65,,48.1,percent of total billed charges,Default if not in Fee Schedule,52.64,,,52.64,Fee Schedule,,52.64,,,52.64,Fee Schedule,,52.64,,,52.64,Fee Schedule,,52.64,,,52.64,Fee Schedule,,21.64,,,21.64,Other,100% of Medicaid,21.64,,,21.64,Other,100% of Medicaid,21.64,,,21.64,Other,100% of Medicaid,21.64,,,21.64,Other,100% of Medicaid,48.69,,,48.69,Other,225% of Medicaid,33.11,,,33.11,Other,153% of Medicaid,48.69,,,48.69,Other,225% of Medicaid,30.3,,,30.3,Other,140% of Medicaid,48.69,,,48.69,Other,225% of Medicaid,56.26,,,56.26,Other,260% of Medicaid,70.11,,,70.11,Other,324% of Medicaid,46.53,,,46.53,Other,215% of Medicaid,46.53,,,46.53,Other,215% of Medicaid,27.05,,,27.05,Other,125% of Medicaid,21.64,138.61,
CANDIDA DNA DIR PROBE,87480,CPT,,78087480,CDM,306,RC,,,both,,,65,48.1,,,48.1,Other,150% of Medicare + 9.63% HCRA Surcharge,29.25,45,,29.25,percent of total billed charges,Critical Access Hospital RCC factor,60.35,,,60.35,Fee Schedule,,54.34,,,54.34,Fee Schedule,,148.72,,,148.72,Fee Schedule,,133.76,,,133.76,Fee Schedule,,126.43,,,126.43,Fee Schedule,,32.18,,,32.18,Other,110% of Medicare,63.16,,,63.16,Fee Schedule,,26,,,26,Other,186% of Medicaid,74.39,,,74.39,Fee Schedule,,40.3,,,40.3,Fee Schedule,,42.11,,,42.11,Fee Schedule,,74.39,,,74.39,Fee Schedule,,40.3,,,40.3,Fee Schedule,,79.2,,,79.2,Fee Schedule,,45.5,70,,45.5,percent of total billed charges,All Other,95.02,,,95.02,Fee Schedule,,80.53,,,80.53,Fee Schedule,,30.08,,,30.08,Fee Schedule,,30.08,,,30.08,Fee Schedule,,30.08,,,30.08,Fee Schedule,,30.08,,,30.08,Fee Schedule,,14.09,,,14.09,Other,100% of Medicaid,14.09,,,14.09,Other,100% of Medicaid,14.09,,,14.09,Other,100% of Medicaid,14.09,,,14.09,Other,100% of Medicaid,31.7,,,31.7,Other,225% of Medicaid,21.56,,,21.56,Other,153% of Medicaid,31.7,,,31.7,Other,225% of Medicaid,19.73,,,19.73,Other,140% of Medicaid,31.7,,,31.7,Other,225% of Medicaid,36.63,,,36.63,Other,260% of Medicaid,45.65,,,45.65,Other,324% of Medicaid,30.29,,,30.29,Other,215% of Medicaid,30.29,,,30.29,Other,215% of Medicaid,17.61,,,17.61,Other,125% of Medicaid,14.09,148.72,
CANDIDA DNA AMP PROBE,87481,CPT,,78087481,CDM,306,RC,,,both,,,112,82.88,,,82.88,Other,150% of Medicare + 9.63% HCRA Surcharge,50.4,45,,50.4,percent of total billed charges,Critical Access Hospital RCC factor,105.62,,,105.62,Fee Schedule,,95.09,,,95.09,Fee Schedule,,260.29,,,260.29,Fee Schedule,,234.11,,,234.11,Fee Schedule,,221.27,,,221.27,Fee Schedule,,55.44,,,55.44,Other,110% of Medicare,110.53,,,110.53,Fee Schedule,,39,,,39,Other,186% of Medicaid,130.18,,,130.18,Fee Schedule,,69.44,,,69.44,Fee Schedule,,73.69,,,73.69,Fee Schedule,,130.18,,,130.18,Fee Schedule,,69.44,,,69.44,Fee Schedule,,138.61,,,138.61,Fee Schedule,,78.4,70,,78.4,percent of total billed charges,All Other,166.29,,,166.29,Fee Schedule,,140.94,,,140.94,Fee Schedule,,52.64,,,52.64,Fee Schedule,,52.64,,,52.64,Fee Schedule,,52.64,,,52.64,Fee Schedule,,52.64,,,52.64,Fee Schedule,,21.05,,,21.05,Other,100% of Medicaid,21.05,,,21.05,Other,100% of Medicaid,21.05,,,21.05,Other,100% of Medicaid,21.05,,,21.05,Other,100% of Medicaid,47.36,,,47.36,Other,225% of Medicaid,32.21,,,32.21,Other,153% of Medicaid,47.36,,,47.36,Other,225% of Medicaid,29.47,,,29.47,Other,140% of Medicaid,47.36,,,47.36,Other,225% of Medicaid,54.73,,,54.73,Other,260% of Medicaid,68.2,,,68.2,Other,324% of Medicaid,45.26,,,45.26,Other,215% of Medicaid,45.26,,,45.26,Other,215% of Medicaid,26.31,,,26.31,Other,125% of Medicaid,21.05,260.29,
CNS DNA AMP PROBE TYPE 12-25,87483,CPT,,78087483,CDM,306,RC,,,both,,,1314,972.36,,,972.36,Other,150% of Medicare + 9.63% HCRA Surcharge,591.3,45,,591.3,percent of total billed charges,Critical Access Hospital RCC factor,1254.51,,,1254.51,Fee Schedule,,1129.47,,,1129.47,Fee Schedule,,228.69,,,228.69,Fee Schedule,,228.69,,,228.69,Fee Schedule,,228.69,,,228.69,Fee Schedule,,650.43,,,650.43,Other,110% of Medicare,1312.86,,,1312.86,Fee Schedule,,94,,,94,Other,186% of Medicaid,1546.25,,,1546.25,Fee Schedule,,814.68,,,814.68,Fee Schedule,,875.24,,,875.24,Fee Schedule,,1546.25,,,1546.25,Fee Schedule,,814.68,,,814.68,Fee Schedule,,1646.28,,,1646.28,Fee Schedule,,919.8,70,,919.8,percent of total billed charges,All Other,1975.14,,,1975.14,Fee Schedule,,1674.05,,,1674.05,Fee Schedule,,625.17,,,625.17,Fee Schedule,,625.17,,,625.17,Fee Schedule,,625.17,,,625.17,Fee Schedule,,625.17,,,625.17,Fee Schedule,,50.37,,,50.37,Other,100% of Medicaid,50.37,,,50.37,Other,100% of Medicaid,50.37,,,50.37,Other,100% of Medicaid,50.37,,,50.37,Other,100% of Medicaid,113.32,,,113.32,Other,225% of Medicaid,77.06,,,77.06,Other,153% of Medicaid,113.32,,,113.32,Other,225% of Medicaid,70.51,,,70.51,Other,140% of Medicaid,113.32,,,113.32,Other,225% of Medicaid,130.95,,,130.95,Other,260% of Medicaid,163.19,,,163.19,Other,324% of Medicaid,108.29,,,108.29,Other,215% of Medicaid,108.29,,,108.29,Other,215% of Medicaid,62.96,,,62.96,Other,125% of Medicaid,50.37,1975.14,
EHRLICHA CHAFFEENSIS AMP PRB,87484,CPT,,78087484,CDM,306,RC,,,both,,,74,54.76,,,54.76,Other,150% of Medicare + 9.63% HCRA Surcharge,33.3,45,,33.3,percent of total billed charges,Critical Access Hospital RCC factor,105.62,,,105.62,Fee Schedule,,95.09,,,95.09,Fee Schedule,,56.61,76.5,,56.61,percent of total billed charges,All Other,52.54,69,,52.54,percent of total billed charges,All Other,51.06,65,,51.06,percent of total billed charges,All Other,36.63,,,36.63,Other,110% of Medicare,110.53,,,110.53,Fee Schedule,,40,,,40,Other,186% of Medicaid,130.18,,,130.18,Fee Schedule,,45.88,,,45.88,Fee Schedule,,73.69,,,73.69,Fee Schedule,,130.18,,,130.18,Fee Schedule,,45.88,,,45.88,Fee Schedule,,138.61,,,138.61,Fee Schedule,,51.8,70,,51.8,percent of total billed charges,All Other,48.1,65,,48.1,percent of total billed charges,Default if not in Fee Schedule,48.1,65,,48.1,percent of total billed charges,Default if not in Fee Schedule,52.64,,,52.64,Fee Schedule,,52.64,,,52.64,Fee Schedule,,52.64,,,52.64,Fee Schedule,,52.64,,,52.64,Fee Schedule,,21.64,,,21.64,Other,100% of Medicaid,21.64,,,21.64,Other,100% of Medicaid,21.64,,,21.64,Other,100% of Medicaid,21.64,,,21.64,Other,100% of Medicaid,48.69,,,48.69,Other,225% of Medicaid,33.11,,,33.11,Other,153% of Medicaid,48.69,,,48.69,Other,225% of Medicaid,30.3,,,30.3,Other,140% of Medicaid,48.69,,,48.69,Other,225% of Medicaid,56.26,,,56.26,Other,260% of Medicaid,70.11,,,70.11,Other,324% of Medicaid,46.53,,,46.53,Other,215% of Medicaid,46.53,,,46.53,Other,215% of Medicaid,27.05,,,27.05,Other,125% of Medicaid,21.64,138.61,
CHYLMD PNEUM DNA AMP PROBE,87486,CPT,,78087486,CDM,306,RC,,,both,,,223,165.02,,,165.02,Other,150% of Medicare + 9.63% HCRA Surcharge,100.35,45,,100.35,percent of total billed charges,Critical Access Hospital RCC factor,105.62,,,105.62,Fee Schedule,,95.09,,,95.09,Fee Schedule,,260.29,,,260.29,Fee Schedule,,234.11,,,234.11,Fee Schedule,,221.27,,,221.27,Fee Schedule,,110.39,,,110.39,Other,110% of Medicare,110.53,,,110.53,Fee Schedule,,40,,,40,Other,186% of Medicaid,130.18,,,130.18,Fee Schedule,,138.26,,,138.26,Fee Schedule,,73.69,,,73.69,Fee Schedule,,130.18,,,130.18,Fee Schedule,,138.26,,,138.26,Fee Schedule,,138.61,,,138.61,Fee Schedule,,156.1,70,,156.1,percent of total billed charges,All Other,166.29,,,166.29,Fee Schedule,,140.94,,,140.94,Fee Schedule,,52.64,,,52.64,Fee Schedule,,52.64,,,52.64,Fee Schedule,,52.64,,,52.64,Fee Schedule,,52.64,,,52.64,Fee Schedule,,21.64,,,21.64,Other,100% of Medicaid,21.64,,,21.64,Other,100% of Medicaid,21.64,,,21.64,Other,100% of Medicaid,21.64,,,21.64,Other,100% of Medicaid,48.7,,,48.7,Other,225% of Medicaid,33.12,,,33.12,Other,153% of Medicaid,48.7,,,48.7,Other,225% of Medicaid,30.3,,,30.3,Other,140% of Medicaid,48.7,,,48.7,Other,225% of Medicaid,56.28,,,56.28,Other,260% of Medicaid,70.13,,,70.13,Other,324% of Medicaid,46.54,,,46.54,Other,215% of Medicaid,46.54,,,46.54,Other,215% of Medicaid,27.06,,,27.06,Other,125% of Medicaid,21.64,260.29,
CHYLMD TRACH DNA DIR PROBE,87490,CPT,,78087490,CDM,306,RC,,,both,,,223,165.02,,,165.02,Other,150% of Medicare + 9.63% HCRA Surcharge,100.35,45,,100.35,percent of total billed charges,Critical Access Hospital RCC factor,68.48,,,68.48,Fee Schedule,,61.65,,,61.65,Fee Schedule,,148.72,,,148.72,Fee Schedule,,133.76,,,133.76,Fee Schedule,,126.43,,,126.43,Fee Schedule,,110.39,,,110.39,Other,110% of Medicare,71.66,,,71.66,Fee Schedule,,15,,,15,Other,186% of Medicaid,84.4,,,84.4,Fee Schedule,,138.26,,,138.26,Fee Schedule,,47.78,,,47.78,Fee Schedule,,84.4,,,84.4,Fee Schedule,,138.26,,,138.26,Fee Schedule,,89.86,,,89.86,Fee Schedule,,156.1,70,,156.1,percent of total billed charges,All Other,107.81,,,107.81,Fee Schedule,,91.38,,,91.38,Fee Schedule,,34.13,,,34.13,Fee Schedule,,34.13,,,34.13,Fee Schedule,,34.13,,,34.13,Fee Schedule,,34.13,,,34.13,Fee Schedule,,8.11,,,8.11,Other,100% of Medicaid,8.11,,,8.11,Other,100% of Medicaid,8.11,,,8.11,Other,100% of Medicaid,8.11,,,8.11,Other,100% of Medicaid,18.25,,,18.25,Other,225% of Medicaid,12.41,,,12.41,Other,153% of Medicaid,18.25,,,18.25,Other,225% of Medicaid,11.35,,,11.35,Other,140% of Medicaid,18.25,,,18.25,Other,225% of Medicaid,21.09,,,21.09,Other,260% of Medicaid,26.28,,,26.28,Other,324% of Medicaid,17.44,,,17.44,Other,215% of Medicaid,17.44,,,17.44,Other,215% of Medicaid,10.14,,,10.14,Other,125% of Medicaid,8.11,165.02,
CHYLMD TRACH DNA AMP PROBE,87491,CPT,,78087491,CDM,306,RC,,,both,,,260,192.4,,,192.4,Other,150% of Medicare + 9.63% HCRA Surcharge,117,45,,117,percent of total billed charges,Critical Access Hospital RCC factor,105.62,,,105.62,Fee Schedule,,95.09,,,95.09,Fee Schedule,,260.29,,,260.29,Fee Schedule,,234.11,,,234.11,Fee Schedule,,221.27,,,221.27,Fee Schedule,,128.7,,,128.7,Other,110% of Medicare,110.53,,,110.53,Fee Schedule,,40,,,40,Other,186% of Medicaid,130.18,,,130.18,Fee Schedule,,161.2,,,161.2,Fee Schedule,,73.69,,,73.69,Fee Schedule,,130.18,,,130.18,Fee Schedule,,161.2,,,161.2,Fee Schedule,,138.61,,,138.61,Fee Schedule,,182,70,,182,percent of total billed charges,All Other,166.29,,,166.29,Fee Schedule,,140.94,,,140.94,Fee Schedule,,52.64,,,52.64,Fee Schedule,,52.64,,,52.64,Fee Schedule,,52.64,,,52.64,Fee Schedule,,52.64,,,52.64,Fee Schedule,,21.64,,,21.64,Other,100% of Medicaid,21.64,,,21.64,Other,100% of Medicaid,21.64,,,21.64,Other,100% of Medicaid,21.64,,,21.64,Other,100% of Medicaid,48.7,,,48.7,Other,225% of Medicaid,33.12,,,33.12,Other,153% of Medicaid,48.7,,,48.7,Other,225% of Medicaid,30.3,,,30.3,Other,140% of Medicaid,48.7,,,48.7,Other,225% of Medicaid,56.28,,,56.28,Other,260% of Medicaid,70.13,,,70.13,Other,324% of Medicaid,46.54,,,46.54,Other,215% of Medicaid,46.54,,,46.54,Other,215% of Medicaid,27.06,,,27.06,Other,125% of Medicaid,21.64,260.29,
C DIFF AMPLIFIED PROBE,87493,CPT,,78087493,CDM,306,RC,,,both,,,223,165.02,,,165.02,Other,150% of Medicare + 9.63% HCRA Surcharge,100.35,45,,100.35,percent of total billed charges,Critical Access Hospital RCC factor,112.18,,,112.18,Fee Schedule,,101,,,101,Fee Schedule,,260.29,,,260.29,Fee Schedule,,234.11,,,234.11,Fee Schedule,,221.27,,,221.27,Fee Schedule,,110.39,,,110.39,Other,110% of Medicare,117.4,,,117.4,Fee Schedule,,67,,,67,Other,186% of Medicaid,138.27,,,138.27,Fee Schedule,,138.26,,,138.26,Fee Schedule,,78.27,,,78.27,Fee Schedule,,138.27,,,138.27,Fee Schedule,,138.26,,,138.26,Fee Schedule,,147.22,,,147.22,Fee Schedule,,156.1,70,,156.1,percent of total billed charges,All Other,176.62,,,176.62,Fee Schedule,,149.7,,,149.7,Fee Schedule,,55.91,,,55.91,Fee Schedule,,55.91,,,55.91,Fee Schedule,,55.91,,,55.91,Fee Schedule,,55.91,,,55.91,Fee Schedule,,36.17,,,36.17,Other,100% of Medicaid,36.17,,,36.17,Other,100% of Medicaid,36.17,,,36.17,Other,100% of Medicaid,36.17,,,36.17,Other,100% of Medicaid,81.38,,,81.38,Other,225% of Medicaid,55.34,,,55.34,Other,153% of Medicaid,81.38,,,81.38,Other,225% of Medicaid,50.64,,,50.64,Other,140% of Medicaid,81.38,,,81.38,Other,225% of Medicaid,94.04,,,94.04,Other,260% of Medicaid,117.19,,,117.19,Other,324% of Medicaid,77.77,,,77.77,Other,215% of Medicaid,77.77,,,77.77,Other,215% of Medicaid,45.21,,,45.21,Other,125% of Medicaid,36.17,260.29,
CYTOMEG DNA AMP PROBE,87496,CPT,,78087496,CDM,306,RC,,,both,,,957,708.18,,,708.18,Other,150% of Medicare + 9.63% HCRA Surcharge,430.65,45,,430.65,percent of total billed charges,Critical Access Hospital RCC factor,105.62,,,105.62,Fee Schedule,,95.09,,,95.09,Fee Schedule,,260.29,,,260.29,Fee Schedule,,234.11,,,234.11,Fee Schedule,,221.27,,,221.27,Fee Schedule,,473.72,,,473.72,Other,110% of Medicare,110.53,,,110.53,Fee Schedule,,44,,,44,Other,186% of Medicaid,130.18,,,130.18,Fee Schedule,,593.34,,,593.34,Fee Schedule,,73.69,,,73.69,Fee Schedule,,130.18,,,130.18,Fee Schedule,,593.34,,,593.34,Fee Schedule,,138.61,,,138.61,Fee Schedule,,669.9,70,,669.9,percent of total billed charges,All Other,166.29,,,166.29,Fee Schedule,,140.94,,,140.94,Fee Schedule,,52.64,,,52.64,Fee Schedule,,52.64,,,52.64,Fee Schedule,,52.64,,,52.64,Fee Schedule,,52.64,,,52.64,Fee Schedule,,23.62,,,23.62,Other,100% of Medicaid,23.62,,,23.62,Other,100% of Medicaid,23.62,,,23.62,Other,100% of Medicaid,23.62,,,23.62,Other,100% of Medicaid,53.15,,,53.15,Other,225% of Medicaid,36.14,,,36.14,Other,153% of Medicaid,53.15,,,53.15,Other,225% of Medicaid,33.07,,,33.07,Other,140% of Medicaid,53.15,,,53.15,Other,225% of Medicaid,61.42,,,61.42,Other,260% of Medicaid,76.54,,,76.54,Other,324% of Medicaid,50.79,,,50.79,Other,215% of Medicaid,50.79,,,50.79,Other,215% of Medicaid,29.53,,,29.53,Other,125% of Medicaid,23.62,708.18,
ENTEROVIRUS DNA AMP PROBE,87498,CPT,,78087498,CDM,306,RC,,,both,,,208,153.92,,,153.92,Other,150% of Medicare + 9.63% HCRA Surcharge,93.6,45,,93.6,percent of total billed charges,Critical Access Hospital RCC factor,105.62,,,105.62,Fee Schedule,,95.09,,,95.09,Fee Schedule,,260.29,,,260.29,Fee Schedule,,234.11,,,234.11,Fee Schedule,,221.27,,,221.27,Fee Schedule,,102.96,,,102.96,Other,110% of Medicare,110.53,,,110.53,Fee Schedule,,40,,,40,Other,186% of Medicaid,130.18,,,130.18,Fee Schedule,,128.96,,,128.96,Fee Schedule,,73.69,,,73.69,Fee Schedule,,130.18,,,130.18,Fee Schedule,,128.96,,,128.96,Fee Schedule,,138.61,,,138.61,Fee Schedule,,145.6,70,,145.6,percent of total billed charges,All Other,166.29,,,166.29,Fee Schedule,,140.94,,,140.94,Fee Schedule,,52.64,,,52.64,Fee Schedule,,52.64,,,52.64,Fee Schedule,,52.64,,,52.64,Fee Schedule,,52.64,,,52.64,Fee Schedule,,21.64,,,21.64,Other,100% of Medicaid,21.64,,,21.64,Other,100% of Medicaid,21.64,,,21.64,Other,100% of Medicaid,21.64,,,21.64,Other,100% of Medicaid,48.7,,,48.7,Other,225% of Medicaid,33.12,,,33.12,Other,153% of Medicaid,48.7,,,48.7,Other,225% of Medicaid,30.3,,,30.3,Other,140% of Medicaid,48.7,,,48.7,Other,225% of Medicaid,56.28,,,56.28,Other,260% of Medicaid,70.13,,,70.13,Other,324% of Medicaid,46.54,,,46.54,Other,215% of Medicaid,46.54,,,46.54,Other,215% of Medicaid,27.06,,,27.06,Other,125% of Medicaid,21.64,260.29,
INFLUENZA DNA AMP PROB 1+,87501,CPT,,78087501,CDM,306,RC,,,both,,,304,224.96,,,224.96,Other,150% of Medicare + 9.63% HCRA Surcharge,136.8,45,,136.8,percent of total billed charges,Critical Access Hospital RCC factor,154.44,,,154.44,Fee Schedule,,139.05,,,139.05,Fee Schedule,,380.6,,,380.6,Fee Schedule,,342.32,,,342.32,Fee Schedule,,323.55,,,323.55,Fee Schedule,,150.48,,,150.48,Other,110% of Medicare,161.63,,,161.63,Fee Schedule,,95,,,95,Other,186% of Medicaid,190.36,,,190.36,Fee Schedule,,188.48,,,188.48,Fee Schedule,,107.75,,,107.75,Fee Schedule,,190.36,,,190.36,Fee Schedule,,188.48,,,188.48,Fee Schedule,,202.67,,,202.67,Fee Schedule,,212.8,70,,212.8,percent of total billed charges,All Other,243.16,,,243.16,Fee Schedule,,206.09,,,206.09,Fee Schedule,,76.97,,,76.97,Fee Schedule,,76.97,,,76.97,Fee Schedule,,76.97,,,76.97,Fee Schedule,,76.97,,,76.97,Fee Schedule,,51.31,,,51.31,Other,100% of Medicaid,51.31,,,51.31,Other,100% of Medicaid,51.31,,,51.31,Other,100% of Medicaid,51.31,,,51.31,Other,100% of Medicaid,115.45,,,115.45,Other,225% of Medicaid,78.5,,,78.5,Other,153% of Medicaid,115.45,,,115.45,Other,225% of Medicaid,71.83,,,71.83,Other,140% of Medicaid,115.45,,,115.45,Other,225% of Medicaid,133.41,,,133.41,Other,260% of Medicaid,166.24,,,166.24,Other,324% of Medicaid,110.32,,,110.32,Other,215% of Medicaid,110.32,,,110.32,Other,215% of Medicaid,64.14,,,64.14,Other,125% of Medicaid,51.31,380.6,
INFLUENZA DNA AMP PROBE,87502,CPT,,78087502,CDM,306,RC,,,both,,,658,486.92,,,486.92,Other,150% of Medicare + 9.63% HCRA Surcharge,296.1,45,,296.1,percent of total billed charges,Critical Access Hospital RCC factor,288.36,,,288.36,Fee Schedule,,259.62,,,259.62,Fee Schedule,,631.08,,,631.08,Fee Schedule,,567.62,,,567.62,Fee Schedule,,536.48,,,536.48,Fee Schedule,,325.71,,,325.71,Other,110% of Medicare,301.77,,,301.77,Fee Schedule,,100,,,100,Other,186% of Medicaid,355.42,,,355.42,Fee Schedule,,407.96,,,407.96,Fee Schedule,,201.18,,,201.18,Fee Schedule,,355.42,,,355.42,Fee Schedule,,407.96,,,407.96,Fee Schedule,,378.41,,,378.41,Fee Schedule,,460.6,70,,460.6,percent of total billed charges,All Other,454,,,454,Fee Schedule,,384.79,,,384.79,Fee Schedule,,143.7,,,143.7,Fee Schedule,,143.7,,,143.7,Fee Schedule,,143.7,,,143.7,Fee Schedule,,143.7,,,143.7,Fee Schedule,,53.98,,,53.98,Other,100% of Medicaid,53.98,,,53.98,Other,100% of Medicaid,53.98,,,53.98,Other,100% of Medicaid,53.98,,,53.98,Other,100% of Medicaid,121.47,,,121.47,Other,225% of Medicaid,82.6,,,82.6,Other,153% of Medicaid,121.47,,,121.47,Other,225% of Medicaid,75.58,,,75.58,Other,140% of Medicaid,121.47,,,121.47,Other,225% of Medicaid,140.36,,,140.36,Other,260% of Medicaid,174.91,,,174.91,Other,324% of Medicaid,116.07,,,116.07,Other,215% of Medicaid,116.07,,,116.07,Other,215% of Medicaid,67.48,,,67.48,Other,125% of Medicaid,53.98,631.08,
INFLUENZA DNA AMP PROB >2 TYPES,87503,CPT,,78087503,CDM,306,RC,,,both,,,124,91.76,,,91.76,Other,150% of Medicare + 9.63% HCRA Surcharge,55.8,45,,55.8,percent of total billed charges,Critical Access Hospital RCC factor,87.95,,,87.95,Fee Schedule,,79.19,,,79.19,Fee Schedule,,153.99,,,153.99,Fee Schedule,,138.5,,,138.5,Fee Schedule,,130.91,,,130.91,Fee Schedule,,61.38,,,61.38,Other,110% of Medicare,92.04,,,92.04,Fee Schedule,,40,,,40,Other,186% of Medicaid,108.41,,,108.41,Fee Schedule,,76.88,,,76.88,Fee Schedule,,61.36,,,61.36,Fee Schedule,,108.41,,,108.41,Fee Schedule,,76.88,,,76.88,Fee Schedule,,115.42,,,115.42,Fee Schedule,,86.8,70,,86.8,percent of total billed charges,All Other,138.47,,,138.47,Fee Schedule,,117.37,,,117.37,Fee Schedule,,43.83,,,43.83,Fee Schedule,,43.83,,,43.83,Fee Schedule,,43.83,,,43.83,Fee Schedule,,43.83,,,43.83,Fee Schedule,,21.64,,,21.64,Other,100% of Medicaid,21.64,,,21.64,Other,100% of Medicaid,21.64,,,21.64,Other,100% of Medicaid,21.64,,,21.64,Other,100% of Medicaid,48.7,,,48.7,Other,225% of Medicaid,33.12,,,33.12,Other,153% of Medicaid,48.7,,,48.7,Other,225% of Medicaid,30.3,,,30.3,Other,140% of Medicaid,48.7,,,48.7,Other,225% of Medicaid,56.28,,,56.28,Other,260% of Medicaid,70.13,,,70.13,Other,324% of Medicaid,46.54,,,46.54,Other,215% of Medicaid,46.54,,,46.54,Other,215% of Medicaid,27.06,,,27.06,Other,125% of Medicaid,21.64,153.99,
IADNA-DNA/RNA PROBE TQ 12-25,87507,CPT,,78087507,CDM,306,RC,,,both,,,3862,2857.89,,,2857.89,Other,150% of Medicare + 9.63% HCRA Surcharge,1737.9,45,,1737.9,percent of total billed charges,Critical Access Hospital RCC factor,1254.51,,,1254.51,Fee Schedule,,1129.47,,,1129.47,Fee Schedule,,226.87,,,226.87,Fee Schedule,,226.87,,,226.87,Fee Schedule,,226.87,,,226.87,Fee Schedule,,1911.69,,,1911.69,Other,110% of Medicare,1312.86,,,1312.86,Fee Schedule,,94,,,94,Other,186% of Medicaid,1546.25,,,1546.25,Fee Schedule,,2394.44,,,2394.44,Fee Schedule,,875.24,,,875.24,Fee Schedule,,1546.25,,,1546.25,Fee Schedule,,2394.44,,,2394.44,Fee Schedule,,1646.28,,,1646.28,Fee Schedule,,2703.4,70,,2703.4,percent of total billed charges,All Other,1975.14,,,1975.14,Fee Schedule,,1674.05,,,1674.05,Fee Schedule,,625.17,,,625.17,Fee Schedule,,625.17,,,625.17,Fee Schedule,,625.17,,,625.17,Fee Schedule,,625.17,,,625.17,Fee Schedule,,50.37,,,50.37,Other,100% of Medicaid,50.37,,,50.37,Other,100% of Medicaid,50.37,,,50.37,Other,100% of Medicaid,50.37,,,50.37,Other,100% of Medicaid,113.32,,,113.32,Other,225% of Medicaid,77.06,,,77.06,Other,153% of Medicaid,113.32,,,113.32,Other,225% of Medicaid,70.51,,,70.51,Other,140% of Medicaid,113.32,,,113.32,Other,225% of Medicaid,130.95,,,130.95,Other,260% of Medicaid,163.19,,,163.19,Other,324% of Medicaid,108.29,,,108.29,Other,215% of Medicaid,108.29,,,108.29,Other,215% of Medicaid,62.96,,,62.96,Other,125% of Medicaid,50.37,2857.89,
GARDNER VAG DNA DIR PROBE,87510,CPT,,78087510,CDM,306,RC,,,both,,,65,48.1,,,48.1,Other,150% of Medicare + 9.63% HCRA Surcharge,29.25,45,,29.25,percent of total billed charges,Critical Access Hospital RCC factor,60.35,,,60.35,Fee Schedule,,54.34,,,54.34,Fee Schedule,,148.72,,,148.72,Fee Schedule,,133.76,,,133.76,Fee Schedule,,126.43,,,126.43,Fee Schedule,,32.18,,,32.18,Other,110% of Medicare,63.16,,,63.16,Fee Schedule,,26,,,26,Other,186% of Medicaid,74.39,,,74.39,Fee Schedule,,40.3,,,40.3,Fee Schedule,,42.11,,,42.11,Fee Schedule,,74.39,,,74.39,Fee Schedule,,40.3,,,40.3,Fee Schedule,,79.2,,,79.2,Fee Schedule,,45.5,70,,45.5,percent of total billed charges,All Other,95.02,,,95.02,Fee Schedule,,80.53,,,80.53,Fee Schedule,,30.08,,,30.08,Fee Schedule,,30.08,,,30.08,Fee Schedule,,30.08,,,30.08,Fee Schedule,,30.08,,,30.08,Fee Schedule,,14.09,,,14.09,Other,100% of Medicaid,14.09,,,14.09,Other,100% of Medicaid,14.09,,,14.09,Other,100% of Medicaid,14.09,,,14.09,Other,100% of Medicaid,31.7,,,31.7,Other,225% of Medicaid,21.56,,,21.56,Other,153% of Medicaid,31.7,,,31.7,Other,225% of Medicaid,19.73,,,19.73,Other,140% of Medicaid,31.7,,,31.7,Other,225% of Medicaid,36.63,,,36.63,Other,260% of Medicaid,45.65,,,45.65,Other,324% of Medicaid,30.29,,,30.29,Other,215% of Medicaid,30.29,,,30.29,Other,215% of Medicaid,17.61,,,17.61,Other,125% of Medicaid,14.09,148.72,
GARDNER VAG DNA QUANT,87512,CPT,,78087512,CDM,306,RC,,,both,,,133,98.42,,,98.42,Other,150% of Medicare + 9.63% HCRA Surcharge,59.85,45,,59.85,percent of total billed charges,Critical Access Hospital RCC factor,125.7,,,125.7,Fee Schedule,,113.17,,,113.17,Fee Schedule,,309.61,,,309.61,Fee Schedule,,278.48,,,278.48,Fee Schedule,,263.2,,,263.2,Fee Schedule,,65.84,,,65.84,Other,110% of Medicare,131.54,,,131.54,Fee Schedule,,67,,,67,Other,186% of Medicaid,154.93,,,154.93,Fee Schedule,,82.46,,,82.46,Fee Schedule,,87.7,,,87.7,Fee Schedule,,154.93,,,154.93,Fee Schedule,,82.46,,,82.46,Fee Schedule,,164.95,,,164.95,Fee Schedule,,93.1,70,,93.1,percent of total billed charges,All Other,197.9,,,197.9,Fee Schedule,,167.73,,,167.73,Fee Schedule,,62.64,,,62.64,Fee Schedule,,62.64,,,62.64,Fee Schedule,,62.64,,,62.64,Fee Schedule,,62.64,,,62.64,Fee Schedule,,36.17,,,36.17,Other,100% of Medicaid,36.17,,,36.17,Other,100% of Medicaid,36.17,,,36.17,Other,100% of Medicaid,36.17,,,36.17,Other,100% of Medicaid,81.38,,,81.38,Other,225% of Medicaid,55.34,,,55.34,Other,153% of Medicaid,81.38,,,81.38,Other,225% of Medicaid,50.64,,,50.64,Other,140% of Medicaid,81.38,,,81.38,Other,225% of Medicaid,94.04,,,94.04,Other,260% of Medicaid,117.19,,,117.19,Other,324% of Medicaid,77.77,,,77.77,Other,215% of Medicaid,77.77,,,77.77,Other,215% of Medicaid,45.21,,,45.21,Other,125% of Medicaid,36.17,309.61,
HEPATITIS B DNA DIR PROBE,87515,CPT,,78087515,CDM,306,RC,,,both,,,356,263.44,,,263.44,Other,150% of Medicare + 9.63% HCRA Surcharge,160.2,45,,160.2,percent of total billed charges,Critical Access Hospital RCC factor,231.4,65,,231.4,percent of total billed charges,All Other,210.04,65,,210.04,percent of total billed charges,All Other,9.57,,,9.57,Fee Schedule,,9.57,,,9.57,Fee Schedule,,9.57,,,9.57,Fee Schedule,,176.22,,,176.22,Other,110% of Medicare,242.08,68,,242.08,percent of total billed charges,All Other,67,,,67,Other,186% of Medicaid,295.48,83,,295.48,percent of total billed charges,All Other,220.72,62,,220.72,percent of total billed charges,Lab and Radiology,195.8,55,,195.8,percent of total billed charges,Default if not on Fee Schedule,284.8,80,,284.8,percent of total billed charges,All Other,220.72,62,,220.72,percent of total billed charges,Lab and Radiology,284.8,80,,284.8,percent of total billed charges,All Other,249.2,70,,249.2,percent of total billed charges,All Other,231.4,65,,231.4,percent of total billed charges,Default if not in Fee Schedule,231.4,65,,231.4,percent of total billed charges,Default if not in Fee Schedule,178,,,178,Fee Schedule,,178,,,178,Fee Schedule,,178,,,178,Fee Schedule,,178,,,178,Fee Schedule,,36.17,,,36.17,Other,100% of Medicaid,36.17,,,36.17,Other,100% of Medicaid,36.17,,,36.17,Other,100% of Medicaid,36.17,,,36.17,Other,100% of Medicaid,81.38,,,81.38,Other,225% of Medicaid,55.34,,,55.34,Other,153% of Medicaid,81.38,,,81.38,Other,225% of Medicaid,50.64,,,50.64,Other,140% of Medicaid,81.38,,,81.38,Other,225% of Medicaid,94.04,,,94.04,Other,260% of Medicaid,117.19,,,117.19,Other,324% of Medicaid,77.77,,,77.77,Other,215% of Medicaid,77.77,,,77.77,Other,215% of Medicaid,45.21,,,45.21,Other,125% of Medicaid,9.57,295.48,
HEPATITIS B DNA AMP PROBE,87516,CPT,,78087516,CDM,306,RC,,,both,,,228,168.72,,,168.72,Other,150% of Medicare + 9.63% HCRA Surcharge,102.6,45,,102.6,percent of total billed charges,Critical Access Hospital RCC factor,105.62,,,105.62,Fee Schedule,,95.09,,,95.09,Fee Schedule,,260.29,,,260.29,Fee Schedule,,234.11,,,234.11,Fee Schedule,,221.27,,,221.27,Fee Schedule,,112.86,,,112.86,Other,110% of Medicare,110.53,,,110.53,Fee Schedule,,40,,,40,Other,186% of Medicaid,130.18,,,130.18,Fee Schedule,,141.36,,,141.36,Fee Schedule,,73.69,,,73.69,Fee Schedule,,130.18,,,130.18,Fee Schedule,,141.36,,,141.36,Fee Schedule,,138.61,,,138.61,Fee Schedule,,159.6,70,,159.6,percent of total billed charges,All Other,166.29,,,166.29,Fee Schedule,,140.94,,,140.94,Fee Schedule,,52.64,,,52.64,Fee Schedule,,52.64,,,52.64,Fee Schedule,,52.64,,,52.64,Fee Schedule,,52.64,,,52.64,Fee Schedule,,21.64,,,21.64,Other,100% of Medicaid,21.64,,,21.64,Other,100% of Medicaid,21.64,,,21.64,Other,100% of Medicaid,21.64,,,21.64,Other,100% of Medicaid,48.7,,,48.7,Other,225% of Medicaid,33.12,,,33.12,Other,153% of Medicaid,48.7,,,48.7,Other,225% of Medicaid,30.3,,,30.3,Other,140% of Medicaid,48.7,,,48.7,Other,225% of Medicaid,56.28,,,56.28,Other,260% of Medicaid,70.13,,,70.13,Other,324% of Medicaid,46.54,,,46.54,Other,215% of Medicaid,46.54,,,46.54,Other,215% of Medicaid,27.06,,,27.06,Other,125% of Medicaid,21.64,260.29,
HEPATITIS B DNA QUANT,87517,CPT,,78087517,CDM,306,RC,,,both,,,403,298.22,,,298.22,Other,150% of Medicare + 9.63% HCRA Surcharge,181.35,45,,181.35,percent of total billed charges,Critical Access Hospital RCC factor,128.95,,,128.95,Fee Schedule,,116.1,,,116.1,Fee Schedule,,317.68,,,317.68,Fee Schedule,,285.73,,,285.73,Fee Schedule,,270.05,,,270.05,Fee Schedule,,199.49,,,199.49,Other,110% of Medicare,134.95,,,134.95,Fee Schedule,,67,,,67,Other,186% of Medicaid,158.94,,,158.94,Fee Schedule,,249.86,,,249.86,Fee Schedule,,89.96,,,89.96,Fee Schedule,,158.94,,,158.94,Fee Schedule,,249.86,,,249.86,Fee Schedule,,169.22,,,169.22,Fee Schedule,,282.1,70,,282.1,percent of total billed charges,All Other,203.02,,,203.02,Fee Schedule,,172.07,,,172.07,Fee Schedule,,64.26,,,64.26,Fee Schedule,,64.26,,,64.26,Fee Schedule,,64.26,,,64.26,Fee Schedule,,64.26,,,64.26,Fee Schedule,,36.17,,,36.17,Other,100% of Medicaid,36.17,,,36.17,Other,100% of Medicaid,36.17,,,36.17,Other,100% of Medicaid,36.17,,,36.17,Other,100% of Medicaid,81.38,,,81.38,Other,225% of Medicaid,55.34,,,55.34,Other,153% of Medicaid,81.38,,,81.38,Other,225% of Medicaid,50.64,,,50.64,Other,140% of Medicaid,81.38,,,81.38,Other,225% of Medicaid,94.04,,,94.04,Other,260% of Medicaid,117.19,,,117.19,Other,324% of Medicaid,77.77,,,77.77,Other,215% of Medicaid,77.77,,,77.77,Other,215% of Medicaid,45.21,,,45.21,Other,125% of Medicaid,36.17,317.68,
HSV DNA AMP PROBE,87529,CPT,,78087529,CDM,306,RC,,,both,,,249,184.26,,,184.26,Other,150% of Medicare + 9.63% HCRA Surcharge,112.05,45,,112.05,percent of total billed charges,Critical Access Hospital RCC factor,105.62,,,105.62,Fee Schedule,,95.09,,,95.09,Fee Schedule,,260.29,,,260.29,Fee Schedule,,234.11,,,234.11,Fee Schedule,,221.27,,,221.27,Fee Schedule,,123.26,,,123.26,Other,110% of Medicare,110.53,,,110.53,Fee Schedule,,60,,,60,Other,186% of Medicaid,130.18,,,130.18,Fee Schedule,,154.38,,,154.38,Fee Schedule,,73.69,,,73.69,Fee Schedule,,130.18,,,130.18,Fee Schedule,,154.38,,,154.38,Fee Schedule,,138.61,,,138.61,Fee Schedule,,174.3,70,,174.3,percent of total billed charges,All Other,166.29,,,166.29,Fee Schedule,,140.94,,,140.94,Fee Schedule,,52.64,,,52.64,Fee Schedule,,52.64,,,52.64,Fee Schedule,,52.64,,,52.64,Fee Schedule,,52.64,,,52.64,Fee Schedule,,32.47,,,32.47,Other,100% of Medicaid,32.47,,,32.47,Other,100% of Medicaid,32.47,,,32.47,Other,100% of Medicaid,32.47,,,32.47,Other,100% of Medicaid,73.06,,,73.06,Other,225% of Medicaid,49.68,,,49.68,Other,153% of Medicaid,73.06,,,73.06,Other,225% of Medicaid,45.46,,,45.46,Other,140% of Medicaid,73.06,,,73.06,Other,225% of Medicaid,84.43,,,84.43,Other,260% of Medicaid,105.21,,,105.21,Other,324% of Medicaid,69.81,,,69.81,Other,215% of Medicaid,69.81,,,69.81,Other,215% of Medicaid,40.59,,,40.59,Other,125% of Medicaid,32.47,260.29,
HSV DNA QUANT,87530,CPT,,78087530,CDM,306,RC,,,both,,,136,100.64,,,100.64,Other,150% of Medicare + 9.63% HCRA Surcharge,61.2,45,,61.2,percent of total billed charges,Critical Access Hospital RCC factor,128.95,,,128.95,Fee Schedule,,116.1,,,116.1,Fee Schedule,,317.68,,,317.68,Fee Schedule,,285.73,,,285.73,Fee Schedule,,270.05,,,270.05,Fee Schedule,,67.32,,,67.32,Other,110% of Medicare,134.95,,,134.95,Fee Schedule,,67,,,67,Other,186% of Medicaid,158.94,,,158.94,Fee Schedule,,84.32,,,84.32,Fee Schedule,,89.96,,,89.96,Fee Schedule,,158.94,,,158.94,Fee Schedule,,84.32,,,84.32,Fee Schedule,,169.22,,,169.22,Fee Schedule,,95.2,70,,95.2,percent of total billed charges,All Other,203.02,,,203.02,Fee Schedule,,172.07,,,172.07,Fee Schedule,,64.26,,,64.26,Fee Schedule,,64.26,,,64.26,Fee Schedule,,64.26,,,64.26,Fee Schedule,,64.26,,,64.26,Fee Schedule,,36.17,,,36.17,Other,100% of Medicaid,36.17,,,36.17,Other,100% of Medicaid,36.17,,,36.17,Other,100% of Medicaid,36.17,,,36.17,Other,100% of Medicaid,81.38,,,81.38,Other,225% of Medicaid,55.34,,,55.34,Other,153% of Medicaid,81.38,,,81.38,Other,225% of Medicaid,50.64,,,50.64,Other,140% of Medicaid,81.38,,,81.38,Other,225% of Medicaid,94.04,,,94.04,Other,260% of Medicaid,117.19,,,117.19,Other,324% of Medicaid,77.77,,,77.77,Other,215% of Medicaid,77.77,,,77.77,Other,215% of Medicaid,45.21,,,45.21,Other,125% of Medicaid,36.17,317.68,
HHV-6 DNA AMP PROBE,87532,CPT,,78087532,CDM,306,RC,,,both,,,223,165.02,,,165.02,Other,150% of Medicare + 9.63% HCRA Surcharge,100.35,45,,100.35,percent of total billed charges,Critical Access Hospital RCC factor,105.62,,,105.62,Fee Schedule,,95.09,,,95.09,Fee Schedule,,260.29,,,260.29,Fee Schedule,,234.11,,,234.11,Fee Schedule,,221.27,,,221.27,Fee Schedule,,110.39,,,110.39,Other,110% of Medicare,110.53,,,110.53,Fee Schedule,,67,,,67,Other,186% of Medicaid,130.18,,,130.18,Fee Schedule,,138.26,,,138.26,Fee Schedule,,73.69,,,73.69,Fee Schedule,,130.18,,,130.18,Fee Schedule,,138.26,,,138.26,Fee Schedule,,138.61,,,138.61,Fee Schedule,,156.1,70,,156.1,percent of total billed charges,All Other,166.29,,,166.29,Fee Schedule,,140.94,,,140.94,Fee Schedule,,52.64,,,52.64,Fee Schedule,,52.64,,,52.64,Fee Schedule,,52.64,,,52.64,Fee Schedule,,52.64,,,52.64,Fee Schedule,,36.17,,,36.17,Other,100% of Medicaid,36.17,,,36.17,Other,100% of Medicaid,36.17,,,36.17,Other,100% of Medicaid,36.17,,,36.17,Other,100% of Medicaid,81.38,,,81.38,Other,225% of Medicaid,55.34,,,55.34,Other,153% of Medicaid,81.38,,,81.38,Other,225% of Medicaid,50.64,,,50.64,Other,140% of Medicaid,81.38,,,81.38,Other,225% of Medicaid,94.04,,,94.04,Other,260% of Medicaid,117.19,,,117.19,Other,324% of Medicaid,77.77,,,77.77,Other,215% of Medicaid,77.77,,,77.77,Other,215% of Medicaid,45.21,,,45.21,Other,125% of Medicaid,36.17,260.29,
HHV-6 DNA QUANT,87533,CPT,,78087533,CDM,306,RC,,,both,,,133,98.42,,,98.42,Other,150% of Medicare + 9.63% HCRA Surcharge,59.85,45,,59.85,percent of total billed charges,Critical Access Hospital RCC factor,125.7,,,125.7,Fee Schedule,,113.17,,,113.17,Fee Schedule,,309.61,,,309.61,Fee Schedule,,278.48,,,278.48,Fee Schedule,,263.2,,,263.2,Fee Schedule,,65.84,,,65.84,Other,110% of Medicare,131.54,,,131.54,Fee Schedule,,67,,,67,Other,186% of Medicaid,154.93,,,154.93,Fee Schedule,,82.46,,,82.46,Fee Schedule,,87.7,,,87.7,Fee Schedule,,154.93,,,154.93,Fee Schedule,,82.46,,,82.46,Fee Schedule,,164.95,,,164.95,Fee Schedule,,93.1,70,,93.1,percent of total billed charges,All Other,197.9,,,197.9,Fee Schedule,,167.73,,,167.73,Fee Schedule,,62.64,,,62.64,Fee Schedule,,62.64,,,62.64,Fee Schedule,,62.64,,,62.64,Fee Schedule,,62.64,,,62.64,Fee Schedule,,36.17,,,36.17,Other,100% of Medicaid,36.17,,,36.17,Other,100% of Medicaid,36.17,,,36.17,Other,100% of Medicaid,36.17,,,36.17,Other,100% of Medicaid,81.38,,,81.38,Other,225% of Medicaid,55.34,,,55.34,Other,153% of Medicaid,81.38,,,81.38,Other,225% of Medicaid,50.64,,,50.64,Other,140% of Medicaid,81.38,,,81.38,Other,225% of Medicaid,94.04,,,94.04,Other,260% of Medicaid,117.19,,,117.19,Other,324% of Medicaid,77.77,,,77.77,Other,215% of Medicaid,77.77,,,77.77,Other,215% of Medicaid,45.21,,,45.21,Other,125% of Medicaid,36.17,309.61,
HIV-L DNA AMP PROBE,87535,CPT,,78087535,CDM,306,RC,,,both,,,223,165.02,,,165.02,Other,150% of Medicare + 9.63% HCRA Surcharge,100.35,45,,100.35,percent of total billed charges,Critical Access Hospital RCC factor,105.62,,,105.62,Fee Schedule,,95.09,,,95.09,Fee Schedule,,260.29,,,260.29,Fee Schedule,,234.11,,,234.11,Fee Schedule,,221.27,,,221.27,Fee Schedule,,110.39,,,110.39,Other,110% of Medicare,110.53,,,110.53,Fee Schedule,,40,,,40,Other,186% of Medicaid,130.18,,,130.18,Fee Schedule,,138.26,,,138.26,Fee Schedule,,73.69,,,73.69,Fee Schedule,,130.18,,,130.18,Fee Schedule,,138.26,,,138.26,Fee Schedule,,138.61,,,138.61,Fee Schedule,,156.1,70,,156.1,percent of total billed charges,All Other,166.29,,,166.29,Fee Schedule,,140.94,,,140.94,Fee Schedule,,52.64,,,52.64,Fee Schedule,,52.64,,,52.64,Fee Schedule,,52.64,,,52.64,Fee Schedule,,52.64,,,52.64,Fee Schedule,,21.64,,,21.64,Other,100% of Medicaid,21.64,,,21.64,Other,100% of Medicaid,21.64,,,21.64,Other,100% of Medicaid,21.64,,,21.64,Other,100% of Medicaid,48.7,,,48.7,Other,225% of Medicaid,33.12,,,33.12,Other,153% of Medicaid,48.7,,,48.7,Other,225% of Medicaid,30.3,,,30.3,Other,140% of Medicaid,48.7,,,48.7,Other,225% of Medicaid,56.28,,,56.28,Other,260% of Medicaid,70.13,,,70.13,Other,324% of Medicaid,46.54,,,46.54,Other,215% of Medicaid,46.54,,,46.54,Other,215% of Medicaid,27.06,,,27.06,Other,125% of Medicaid,21.64,260.29,
LEGION PNEUMO DNA AMP PROB,87541,CPT,,78087541,CDM,306,RC,,,both,,,112,82.88,,,82.88,Other,150% of Medicare + 9.63% HCRA Surcharge,50.4,45,,50.4,percent of total billed charges,Critical Access Hospital RCC factor,105.62,,,105.62,Fee Schedule,,95.09,,,95.09,Fee Schedule,,260.29,,,260.29,Fee Schedule,,234.11,,,234.11,Fee Schedule,,221.27,,,221.27,Fee Schedule,,55.44,,,55.44,Other,110% of Medicare,110.53,,,110.53,Fee Schedule,,67,,,67,Other,186% of Medicaid,130.18,,,130.18,Fee Schedule,,69.44,,,69.44,Fee Schedule,,73.69,,,73.69,Fee Schedule,,130.18,,,130.18,Fee Schedule,,69.44,,,69.44,Fee Schedule,,138.61,,,138.61,Fee Schedule,,78.4,70,,78.4,percent of total billed charges,All Other,166.29,,,166.29,Fee Schedule,,140.94,,,140.94,Fee Schedule,,52.64,,,52.64,Fee Schedule,,52.64,,,52.64,Fee Schedule,,52.64,,,52.64,Fee Schedule,,52.64,,,52.64,Fee Schedule,,36.17,,,36.17,Other,100% of Medicaid,36.17,,,36.17,Other,100% of Medicaid,36.17,,,36.17,Other,100% of Medicaid,36.17,,,36.17,Other,100% of Medicaid,81.38,,,81.38,Other,225% of Medicaid,55.34,,,55.34,Other,153% of Medicaid,81.38,,,81.38,Other,225% of Medicaid,50.64,,,50.64,Other,140% of Medicaid,81.38,,,81.38,Other,225% of Medicaid,94.04,,,94.04,Other,260% of Medicaid,117.19,,,117.19,Other,324% of Medicaid,77.77,,,77.77,Other,215% of Medicaid,77.77,,,77.77,Other,215% of Medicaid,45.21,,,45.21,Other,125% of Medicaid,36.17,260.29,
M. TUBERCULO DNA AMP PROBE,87556,CPT,,78087556,CDM,306,RC,,,both,,,223,165.02,,,165.02,Other,150% of Medicare + 9.63% HCRA Surcharge,100.35,45,,100.35,percent of total billed charges,Critical Access Hospital RCC factor,125.46,,,125.46,Fee Schedule,,112.95,,,112.95,Fee Schedule,,260.29,,,260.29,Fee Schedule,,234.11,,,234.11,Fee Schedule,,221.27,,,221.27,Fee Schedule,,110.39,,,110.39,Other,110% of Medicare,131.29,,,131.29,Fee Schedule,,78,,,78,Other,186% of Medicaid,154.63,,,154.63,Fee Schedule,,138.26,,,138.26,Fee Schedule,,87.53,,,87.53,Fee Schedule,,154.63,,,154.63,Fee Schedule,,138.26,,,138.26,Fee Schedule,,164.64,,,164.64,Fee Schedule,,156.1,70,,156.1,percent of total billed charges,All Other,197.52,,,197.52,Fee Schedule,,167.41,,,167.41,Fee Schedule,,62.52,,,62.52,Fee Schedule,,62.52,,,62.52,Fee Schedule,,62.52,,,62.52,Fee Schedule,,62.52,,,62.52,Fee Schedule,,41.68,,,41.68,Other,100% of Medicaid,41.68,,,41.68,Other,100% of Medicaid,41.68,,,41.68,Other,100% of Medicaid,41.68,,,41.68,Other,100% of Medicaid,93.78,,,93.78,Other,225% of Medicaid,63.77,,,63.77,Other,153% of Medicaid,93.78,,,93.78,Other,225% of Medicaid,58.35,,,58.35,Other,140% of Medicaid,93.78,,,93.78,Other,225% of Medicaid,108.37,,,108.37,Other,260% of Medicaid,135.04,,,135.04,Other,324% of Medicaid,89.61,,,89.61,Other,215% of Medicaid,89.61,,,89.61,Other,215% of Medicaid,52.1,,,52.1,Other,125% of Medicaid,41.68,260.29,
MYCOPLASMA AMPLIF NA PROBE,87581,CPT,,78087581,CDM,306,RC,,,both,,,170,125.8,,,125.8,Other,150% of Medicare + 9.63% HCRA Surcharge,76.5,45,,76.5,percent of total billed charges,Critical Access Hospital RCC factor,105.62,,,105.62,Fee Schedule,,95.09,,,95.09,Fee Schedule,,260.29,,,260.29,Fee Schedule,,234.11,,,234.11,Fee Schedule,,221.27,,,221.27,Fee Schedule,,84.15,,,84.15,Other,110% of Medicare,110.53,,,110.53,Fee Schedule,,40,,,40,Other,186% of Medicaid,130.18,,,130.18,Fee Schedule,,105.4,,,105.4,Fee Schedule,,73.69,,,73.69,Fee Schedule,,130.18,,,130.18,Fee Schedule,,105.4,,,105.4,Fee Schedule,,138.61,,,138.61,Fee Schedule,,119,70,,119,percent of total billed charges,All Other,166.29,,,166.29,Fee Schedule,,140.94,,,140.94,Fee Schedule,,52.64,,,52.64,Fee Schedule,,52.64,,,52.64,Fee Schedule,,52.64,,,52.64,Fee Schedule,,52.64,,,52.64,Fee Schedule,,21.64,,,21.64,Other,100% of Medicaid,21.64,,,21.64,Other,100% of Medicaid,21.64,,,21.64,Other,100% of Medicaid,21.64,,,21.64,Other,100% of Medicaid,48.7,,,48.7,Other,225% of Medicaid,33.12,,,33.12,Other,153% of Medicaid,48.7,,,48.7,Other,225% of Medicaid,30.3,,,30.3,Other,140% of Medicaid,48.7,,,48.7,Other,225% of Medicaid,56.28,,,56.28,Other,260% of Medicaid,70.13,,,70.13,Other,324% of Medicaid,46.54,,,46.54,Other,215% of Medicaid,46.54,,,46.54,Other,215% of Medicaid,27.06,,,27.06,Other,125% of Medicaid,21.64,260.29,
N.GONORRHOEAE DNA DIR PROB,87590,CPT,,78087590,CDM,306,RC,,,both,,,217,160.58,,,160.58,Other,150% of Medicare + 9.63% HCRA Surcharge,97.65,45,,97.65,percent of total billed charges,Critical Access Hospital RCC factor,80.91,,,80.91,Fee Schedule,,72.84,,,72.84,Fee Schedule,,148.72,,,148.72,Fee Schedule,,133.76,,,133.76,Fee Schedule,,126.43,,,126.43,Fee Schedule,,107.42,,,107.42,Other,110% of Medicare,84.67,,,84.67,Fee Schedule,,15,,,15,Other,186% of Medicaid,99.72,,,99.72,Fee Schedule,,134.54,,,134.54,Fee Schedule,,56.45,,,56.45,Fee Schedule,,99.72,,,99.72,Fee Schedule,,134.54,,,134.54,Fee Schedule,,106.18,,,106.18,Fee Schedule,,151.9,70,,151.9,percent of total billed charges,All Other,127.39,,,127.39,Fee Schedule,,107.97,,,107.97,Fee Schedule,,40.32,,,40.32,Fee Schedule,,40.32,,,40.32,Fee Schedule,,40.32,,,40.32,Fee Schedule,,40.32,,,40.32,Fee Schedule,,8.11,,,8.11,Other,100% of Medicaid,8.11,,,8.11,Other,100% of Medicaid,8.11,,,8.11,Other,100% of Medicaid,8.11,,,8.11,Other,100% of Medicaid,18.25,,,18.25,Other,225% of Medicaid,12.41,,,12.41,Other,153% of Medicaid,18.25,,,18.25,Other,225% of Medicaid,11.35,,,11.35,Other,140% of Medicaid,18.25,,,18.25,Other,225% of Medicaid,21.09,,,21.09,Other,260% of Medicaid,26.28,,,26.28,Other,324% of Medicaid,17.44,,,17.44,Other,215% of Medicaid,17.44,,,17.44,Other,215% of Medicaid,10.14,,,10.14,Other,125% of Medicaid,8.11,160.58,
N.GONORRHOEAE DNA AMP PROB,87591,CPT,,78087591,CDM,306,RC,,,both,,,223,165.02,,,165.02,Other,150% of Medicare + 9.63% HCRA Surcharge,100.35,45,,100.35,percent of total billed charges,Critical Access Hospital RCC factor,105.62,,,105.62,Fee Schedule,,95.09,,,95.09,Fee Schedule,,260.29,,,260.29,Fee Schedule,,234.11,,,234.11,Fee Schedule,,221.27,,,221.27,Fee Schedule,,110.39,,,110.39,Other,110% of Medicare,110.53,,,110.53,Fee Schedule,,40,,,40,Other,186% of Medicaid,130.18,,,130.18,Fee Schedule,,138.26,,,138.26,Fee Schedule,,73.69,,,73.69,Fee Schedule,,130.18,,,130.18,Fee Schedule,,138.26,,,138.26,Fee Schedule,,138.61,,,138.61,Fee Schedule,,156.1,70,,156.1,percent of total billed charges,All Other,166.29,,,166.29,Fee Schedule,,140.94,,,140.94,Fee Schedule,,52.64,,,52.64,Fee Schedule,,52.64,,,52.64,Fee Schedule,,52.64,,,52.64,Fee Schedule,,52.64,,,52.64,Fee Schedule,,21.64,,,21.64,Other,100% of Medicaid,21.64,,,21.64,Other,100% of Medicaid,21.64,,,21.64,Other,100% of Medicaid,21.64,,,21.64,Other,100% of Medicaid,48.7,,,48.7,Other,225% of Medicaid,33.12,,,33.12,Other,153% of Medicaid,48.7,,,48.7,Other,225% of Medicaid,30.3,,,30.3,Other,140% of Medicaid,48.7,,,48.7,Other,225% of Medicaid,56.28,,,56.28,Other,260% of Medicaid,70.13,,,70.13,Other,324% of Medicaid,46.54,,,46.54,Other,215% of Medicaid,46.54,,,46.54,Other,215% of Medicaid,27.06,,,27.06,Other,125% of Medicaid,21.64,260.29,
ORTHOPOXVIRUS AMP PRB,87593,CPT,,78087593,CDM,306,RC,,,both,,,170,125.8,,,125.8,Other,150% of Medicare + 9.63% HCRA Surcharge,76.5,45,,76.5,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,130.05,76.5,,130.05,percent of total billed charges,All Other,120.7,69,,120.7,percent of total billed charges,All Other,117.3,65,,117.3,percent of total billed charges,All Other,84.15,,,84.15,Other,110% of Medicare,0.01,,,0.01,Fee Schedule,,96,,,96,Other,186% of Medicaid,0.01,,,0.01,Fee Schedule,,105.4,,,105.4,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,105.4,,,105.4,Fee Schedule,,0.01,,,0.01,Fee Schedule,,119,70,,119,percent of total billed charges,All Other,110.5,65,,110.5,percent of total billed charges,Default if not in Fee Schedule,110.5,65,,110.5,percent of total billed charges,Default if not in Fee Schedule,76.76,,,76.76,Fee Schedule,,76.76,,,76.76,Fee Schedule,,76.76,,,76.76,Fee Schedule,,76.76,,,76.76,Fee Schedule,,51.82,,,51.82,Other,100% of Medicaid,51.82,,,51.82,Other,100% of Medicaid,51.82,,,51.82,Other,100% of Medicaid,51.82,,,51.82,Other,100% of Medicaid,116.6,,,116.6,Other,225% of Medicaid,79.29,,,79.29,Other,153% of Medicaid,116.6,,,116.6,Other,225% of Medicaid,72.55,,,72.55,Other,140% of Medicaid,116.6,,,116.6,Other,225% of Medicaid,134.74,,,134.74,Other,260% of Medicaid,167.91,,,167.91,Other,324% of Medicaid,111.42,,,111.42,Other,215% of Medicaid,111.42,,,111.42,Other,215% of Medicaid,64.78,,,64.78,Other,125% of Medicaid,0.01,167.91,
HPV HIGH-RISK TYPES,87624,CPT,,78087624,CDM,306,RC,,,both,,,167,123.58,,,123.58,Other,150% of Medicare + 9.63% HCRA Surcharge,75.15,45,,75.15,percent of total billed charges,Critical Access Hospital RCC factor,105.62,,,105.62,Fee Schedule,,95.09,,,95.09,Fee Schedule,,19.1,,,19.1,Fee Schedule,,19.1,,,19.1,Fee Schedule,,19.1,,,19.1,Fee Schedule,,82.67,,,82.67,Other,110% of Medicare,110.53,,,110.53,Fee Schedule,,52,,,52,Other,186% of Medicaid,130.18,,,130.18,Fee Schedule,,103.54,,,103.54,Fee Schedule,,73.69,,,73.69,Fee Schedule,,130.18,,,130.18,Fee Schedule,,103.54,,,103.54,Fee Schedule,,138.61,,,138.61,Fee Schedule,,116.9,70,,116.9,percent of total billed charges,All Other,166.29,,,166.29,Fee Schedule,,140.94,,,140.94,Fee Schedule,,52.64,,,52.64,Fee Schedule,,52.64,,,52.64,Fee Schedule,,52.64,,,52.64,Fee Schedule,,52.64,,,52.64,Fee Schedule,,28.13,,,28.13,Other,100% of Medicaid,28.13,,,28.13,Other,100% of Medicaid,28.13,,,28.13,Other,100% of Medicaid,28.13,,,28.13,Other,100% of Medicaid,63.29,,,63.29,Other,225% of Medicaid,43.04,,,43.04,Other,153% of Medicaid,63.29,,,63.29,Other,225% of Medicaid,39.38,,,39.38,Other,140% of Medicaid,63.29,,,63.29,Other,225% of Medicaid,73.13,,,73.13,Other,260% of Medicaid,91.14,,,91.14,Other,324% of Medicaid,60.48,,,60.48,Other,215% of Medicaid,60.48,,,60.48,Other,215% of Medicaid,35.16,,,35.16,Other,125% of Medicaid,19.1,166.29,
HPV TYPES 16&18 ONLY,87625,CPT,,78087625,CDM,306,RC,,,both,,,129,95.46,,,95.46,Other,150% of Medicare + 9.63% HCRA Surcharge,58.05,45,,58.05,percent of total billed charges,Critical Access Hospital RCC factor,122.06,,,122.06,Fee Schedule,,109.89,,,109.89,Fee Schedule,,19.1,,,19.1,Fee Schedule,,19.1,,,19.1,Fee Schedule,,19.1,,,19.1,Fee Schedule,,63.86,,,63.86,Other,110% of Medicare,127.73,,,127.73,Fee Schedule,,52,,,52,Other,186% of Medicaid,150.44,,,150.44,Fee Schedule,,79.98,,,79.98,Fee Schedule,,85.16,,,85.16,Fee Schedule,,150.44,,,150.44,Fee Schedule,,79.98,,,79.98,Fee Schedule,,160.17,,,160.17,Fee Schedule,,90.3,70,,90.3,percent of total billed charges,All Other,192.17,,,192.17,Fee Schedule,,162.87,,,162.87,Fee Schedule,,60.83,,,60.83,Fee Schedule,,60.83,,,60.83,Fee Schedule,,60.83,,,60.83,Fee Schedule,,60.83,,,60.83,Fee Schedule,,28.13,,,28.13,Other,100% of Medicaid,28.13,,,28.13,Other,100% of Medicaid,28.13,,,28.13,Other,100% of Medicaid,28.13,,,28.13,Other,100% of Medicaid,63.29,,,63.29,Other,225% of Medicaid,43.04,,,43.04,Other,153% of Medicaid,63.29,,,63.29,Other,225% of Medicaid,39.38,,,39.38,Other,140% of Medicaid,63.29,,,63.29,Other,225% of Medicaid,73.13,,,73.13,Other,260% of Medicaid,91.14,,,91.14,Other,324% of Medicaid,60.48,,,60.48,Other,215% of Medicaid,60.48,,,60.48,Other,215% of Medicaid,35.16,,,35.16,Other,125% of Medicaid,19.1,192.17,
RESP VIRUS 12-25 TARGETS,87633,CPT,,78087633,CDM,306,RC,,,both,,,835,617.9,,,617.9,Other,150% of Medicare + 9.63% HCRA Surcharge,375.75,45,,375.75,percent of total billed charges,Critical Access Hospital RCC factor,1254.51,,,1254.51,Fee Schedule,,1129.47,,,1129.47,Fee Schedule,,229.16,,,229.16,Fee Schedule,,229.16,,,229.16,Fee Schedule,,229.16,,,229.16,Fee Schedule,,413.33,,,413.33,Other,110% of Medicare,1312.86,,,1312.86,Fee Schedule,,94,,,94,Other,186% of Medicaid,1546.25,,,1546.25,Fee Schedule,,517.7,,,517.7,Fee Schedule,,875.24,,,875.24,Fee Schedule,,1546.25,,,1546.25,Fee Schedule,,517.7,,,517.7,Fee Schedule,,1646.28,,,1646.28,Fee Schedule,,584.5,70,,584.5,percent of total billed charges,All Other,1975.14,,,1975.14,Fee Schedule,,1674.05,,,1674.05,Fee Schedule,,625.17,,,625.17,Fee Schedule,,625.17,,,625.17,Fee Schedule,,625.17,,,625.17,Fee Schedule,,625.17,,,625.17,Fee Schedule,,50.37,,,50.37,Other,100% of Medicaid,50.37,,,50.37,Other,100% of Medicaid,50.37,,,50.37,Other,100% of Medicaid,50.37,,,50.37,Other,100% of Medicaid,113.32,,,113.32,Other,225% of Medicaid,77.06,,,77.06,Other,153% of Medicaid,113.32,,,113.32,Other,225% of Medicaid,70.51,,,70.51,Other,140% of Medicaid,113.32,,,113.32,Other,225% of Medicaid,130.95,,,130.95,Other,260% of Medicaid,163.19,,,163.19,Other,324% of Medicaid,108.29,,,108.29,Other,215% of Medicaid,108.29,,,108.29,Other,215% of Medicaid,62.96,,,62.96,Other,125% of Medicaid,50.37,1975.14,
SARS-COV-2 COVID-19 AMP PRB,87635,CPT,,78087635,CDM,306,RC,,,both,,,170,125.8,,,125.8,Other,150% of Medicare + 9.63% HCRA Surcharge,76.5,45,,76.5,percent of total billed charges,Critical Access Hospital RCC factor,154.44,,,154.44,Fee Schedule,,139.05,,,139.05,Fee Schedule,,61.57,,,61.57,Fee Schedule,,61.57,,,61.57,Fee Schedule,,61.57,,,61.57,Fee Schedule,,84.15,,,84.15,Other,110% of Medicare,161.63,,,161.63,Fee Schedule,,57,,,57,Other,186% of Medicaid,190.36,,,190.36,Fee Schedule,,105.4,,,105.4,Fee Schedule,,107.75,,,107.75,Fee Schedule,,190.36,,,190.36,Fee Schedule,,105.4,,,105.4,Fee Schedule,,202.67,,,202.67,Fee Schedule,,119,70,,119,percent of total billed charges,All Other,243.16,,,243.16,Fee Schedule,,206.09,,,206.09,Fee Schedule,,76.97,,,76.97,Fee Schedule,,76.97,,,76.97,Fee Schedule,,76.97,,,76.97,Fee Schedule,,76.97,,,76.97,Fee Schedule,,30.79,,,30.79,Other,100% of Medicaid,30.79,,,30.79,Other,100% of Medicaid,30.79,,,30.79,Other,100% of Medicaid,30.79,,,30.79,Other,100% of Medicaid,69.28,,,69.28,Other,225% of Medicaid,47.11,,,47.11,Other,153% of Medicaid,69.28,,,69.28,Other,225% of Medicaid,43.11,,,43.11,Other,140% of Medicaid,69.28,,,69.28,Other,225% of Medicaid,80.05,,,80.05,Other,260% of Medicaid,99.76,,,99.76,Other,324% of Medicaid,66.2,,,66.2,Other,215% of Medicaid,66.2,,,66.2,Other,215% of Medicaid,38.49,,,38.49,Other,125% of Medicaid,30.79,243.16,
SARSCOV2 & INF A&B AMP PRB,87636,CPT,,78087636,CDM,306,RC,,,both,,,287,212.38,,,212.38,Other,150% of Medicare + 9.63% HCRA Surcharge,129.15,45,,129.15,percent of total billed charges,Critical Access Hospital RCC factor,142.63,,,142.63,Fee Schedule,,142.63,,,142.63,Fee Schedule,,142.63,,,142.63,Fee Schedule,,142.63,,,142.63,Fee Schedule,,142.63,,,142.63,Fee Schedule,,142.07,,,142.07,Other,110% of Medicare,449.28,,,449.28,Fee Schedule,,159,,,159,Other,186% of Medicaid,529.16,,,529.16,Fee Schedule,,177.94,,,177.94,Fee Schedule,,299.52,,,299.52,Fee Schedule,,529.16,,,529.16,Fee Schedule,,177.94,,,177.94,Fee Schedule,,563.39,,,563.39,Fee Schedule,,200.9,70,,200.9,percent of total billed charges,All Other,675.93,,,675.93,Fee Schedule,,572.89,,,572.89,Fee Schedule,,213.9,,,213.9,Fee Schedule,,213.9,,,213.9,Fee Schedule,,213.9,,,213.9,Fee Schedule,,213.9,,,213.9,Fee Schedule,,85.59,,,85.59,Other,100% of Medicaid,85.59,,,85.59,Other,100% of Medicaid,85.59,,,85.59,Other,100% of Medicaid,85.59,,,85.59,Other,100% of Medicaid,192.58,,,192.58,Other,225% of Medicaid,130.95,,,130.95,Other,153% of Medicaid,192.58,,,192.58,Other,225% of Medicaid,119.83,,,119.83,Other,140% of Medicaid,192.58,,,192.58,Other,225% of Medicaid,222.53,,,222.53,Other,260% of Medicaid,277.31,,,277.31,Other,324% of Medicaid,184.02,,,184.02,Other,215% of Medicaid,184.02,,,184.02,Other,215% of Medicaid,106.99,,,106.99,Other,125% of Medicaid,85.59,675.93,
SARSCOV2&INF A&B&RSV AMP PRB,87637,CPT,,78087637,CDM,306,RC,,,both,,,287,212.38,,,212.38,Other,150% of Medicare + 9.63% HCRA Surcharge,129.15,45,,129.15,percent of total billed charges,Critical Access Hospital RCC factor,429.32,,,429.32,Fee Schedule,,386.53,,,386.53,Fee Schedule,,142.63,,,142.63,Fee Schedule,,142.63,,,142.63,Fee Schedule,,142.63,,,142.63,Fee Schedule,,142.07,,,142.07,Other,110% of Medicare,449.28,,,449.28,Fee Schedule,,159,,,159,Other,186% of Medicaid,529.16,,,529.16,Fee Schedule,,177.94,,,177.94,Fee Schedule,,299.52,,,299.52,Fee Schedule,,529.16,,,529.16,Fee Schedule,,177.94,,,177.94,Fee Schedule,,563.39,,,563.39,Fee Schedule,,200.9,70,,200.9,percent of total billed charges,All Other,675.93,,,675.93,Fee Schedule,,572.89,,,572.89,Fee Schedule,,213.9,,,213.9,Fee Schedule,,213.9,,,213.9,Fee Schedule,,213.9,,,213.9,Fee Schedule,,213.9,,,213.9,Fee Schedule,,85.59,,,85.59,Other,100% of Medicaid,85.59,,,85.59,Other,100% of Medicaid,85.59,,,85.59,Other,100% of Medicaid,85.59,,,85.59,Other,100% of Medicaid,192.58,,,192.58,Other,225% of Medicaid,130.95,,,130.95,Other,153% of Medicaid,192.58,,,192.58,Other,225% of Medicaid,119.83,,,119.83,Other,140% of Medicaid,192.58,,,192.58,Other,225% of Medicaid,222.53,,,222.53,Other,260% of Medicaid,277.31,,,277.31,Other,324% of Medicaid,184.02,,,184.02,Other,215% of Medicaid,184.02,,,184.02,Other,215% of Medicaid,106.99,,,106.99,Other,125% of Medicaid,85.59,675.93,
STREP B DNA AMP PROBE,87653,CPT,,78087653,CDM,306,RC,,,both,,,94,69.56,,,69.56,Other,150% of Medicare + 9.63% HCRA Surcharge,42.3,45,,42.3,percent of total billed charges,Critical Access Hospital RCC factor,105.62,,,105.62,Fee Schedule,,95.09,,,95.09,Fee Schedule,,260.29,,,260.29,Fee Schedule,,234.11,,,234.11,Fee Schedule,,221.27,,,221.27,Fee Schedule,,46.53,,,46.53,Other,110% of Medicare,110.53,,,110.53,Fee Schedule,,40,,,40,Other,186% of Medicaid,130.18,,,130.18,Fee Schedule,,58.28,,,58.28,Fee Schedule,,73.69,,,73.69,Fee Schedule,,130.18,,,130.18,Fee Schedule,,58.28,,,58.28,Fee Schedule,,138.61,,,138.61,Fee Schedule,,65.8,70,,65.8,percent of total billed charges,All Other,166.29,,,166.29,Fee Schedule,,140.94,,,140.94,Fee Schedule,,52.64,,,52.64,Fee Schedule,,52.64,,,52.64,Fee Schedule,,52.64,,,52.64,Fee Schedule,,52.64,,,52.64,Fee Schedule,,21.64,,,21.64,Other,100% of Medicaid,21.64,,,21.64,Other,100% of Medicaid,21.64,,,21.64,Other,100% of Medicaid,21.64,,,21.64,Other,100% of Medicaid,48.7,,,48.7,Other,225% of Medicaid,33.12,,,33.12,Other,153% of Medicaid,48.7,,,48.7,Other,225% of Medicaid,30.3,,,30.3,Other,140% of Medicaid,48.7,,,48.7,Other,225% of Medicaid,56.28,,,56.28,Other,260% of Medicaid,70.13,,,70.13,Other,324% of Medicaid,46.54,,,46.54,Other,215% of Medicaid,46.54,,,46.54,Other,215% of Medicaid,27.06,,,27.06,Other,125% of Medicaid,21.64,260.29,
TRICHOMONAS VAGIN DIR PROBE,87660,CPT,,78087660,CDM,306,RC,,,both,,,65,48.1,,,48.1,Other,150% of Medicare + 9.63% HCRA Surcharge,29.25,45,,29.25,percent of total billed charges,Critical Access Hospital RCC factor,60.35,,,60.35,Fee Schedule,,54.34,,,54.34,Fee Schedule,,148.72,,,148.72,Fee Schedule,,133.76,,,133.76,Fee Schedule,,126.43,,,126.43,Fee Schedule,,32.18,,,32.18,Other,110% of Medicare,63.16,,,63.16,Fee Schedule,,26,,,26,Other,186% of Medicaid,74.39,,,74.39,Fee Schedule,,40.3,,,40.3,Fee Schedule,,42.11,,,42.11,Fee Schedule,,74.39,,,74.39,Fee Schedule,,40.3,,,40.3,Fee Schedule,,79.2,,,79.2,Fee Schedule,,45.5,70,,45.5,percent of total billed charges,All Other,95.02,,,95.02,Fee Schedule,,80.53,,,80.53,Fee Schedule,,30.08,,,30.08,Fee Schedule,,30.08,,,30.08,Fee Schedule,,30.08,,,30.08,Fee Schedule,,30.08,,,30.08,Fee Schedule,,14.09,,,14.09,Other,100% of Medicaid,14.09,,,14.09,Other,100% of Medicaid,14.09,,,14.09,Other,100% of Medicaid,14.09,,,14.09,Other,100% of Medicaid,31.7,,,31.7,Other,225% of Medicaid,21.56,,,21.56,Other,153% of Medicaid,31.7,,,31.7,Other,225% of Medicaid,19.73,,,19.73,Other,140% of Medicaid,31.7,,,31.7,Other,225% of Medicaid,36.63,,,36.63,Other,260% of Medicaid,45.65,,,45.65,Other,324% of Medicaid,30.29,,,30.29,Other,215% of Medicaid,30.29,,,30.29,Other,215% of Medicaid,17.61,,,17.61,Other,125% of Medicaid,14.09,148.72,
TRICHOMONAS VAGINALIS AMPLIF,87661,CPT,,78087661,CDM,306,RC,,,both,,,79,58.46,,,58.46,Other,150% of Medicare + 9.63% HCRA Surcharge,35.55,45,,35.55,percent of total billed charges,Critical Access Hospital RCC factor,105.62,,,105.62,Fee Schedule,,95.09,,,95.09,Fee Schedule,,19.15,,,19.15,Fee Schedule,,19.15,,,19.15,Fee Schedule,,19.15,,,19.15,Fee Schedule,,39.11,,,39.11,Other,110% of Medicare,110.53,,,110.53,Fee Schedule,,40,,,40,Other,186% of Medicaid,130.18,,,130.18,Fee Schedule,,48.98,,,48.98,Fee Schedule,,73.69,,,73.69,Fee Schedule,,130.18,,,130.18,Fee Schedule,,48.98,,,48.98,Fee Schedule,,138.61,,,138.61,Fee Schedule,,55.3,70,,55.3,percent of total billed charges,All Other,166.29,,,166.29,Fee Schedule,,140.94,,,140.94,Fee Schedule,,52.64,,,52.64,Fee Schedule,,52.64,,,52.64,Fee Schedule,,52.64,,,52.64,Fee Schedule,,52.64,,,52.64,Fee Schedule,,21.64,,,21.64,Other,100% of Medicaid,21.64,,,21.64,Other,100% of Medicaid,21.64,,,21.64,Other,100% of Medicaid,21.64,,,21.64,Other,100% of Medicaid,48.7,,,48.7,Other,225% of Medicaid,33.12,,,33.12,Other,153% of Medicaid,48.7,,,48.7,Other,225% of Medicaid,30.3,,,30.3,Other,140% of Medicaid,48.7,,,48.7,Other,225% of Medicaid,56.28,,,56.28,Other,260% of Medicaid,70.13,,,70.13,Other,324% of Medicaid,46.54,,,46.54,Other,215% of Medicaid,46.54,,,46.54,Other,215% of Medicaid,27.06,,,27.06,Other,125% of Medicaid,19.15,166.29,
DETECT AGENT NOS DNA DIR,87797,CPT,,78087797,CDM,306,RC,,,both,,,160,118.4,,,118.4,Other,150% of Medicare + 9.63% HCRA Surcharge,72,45,,72,percent of total billed charges,Critical Access Hospital RCC factor,90.39,,,90.39,Fee Schedule,,81.38,,,81.38,Fee Schedule,,148.72,,,148.72,Fee Schedule,,133.76,,,133.76,Fee Schedule,,126.43,,,126.43,Fee Schedule,,79.2,,,79.2,Other,110% of Medicare,94.59,,,94.59,Fee Schedule,,0.01,,,0.01,Other,186% of Medicaid,111.41,,,111.41,Fee Schedule,,99.2,,,99.2,Fee Schedule,,63.06,,,63.06,Fee Schedule,,111.41,,,111.41,Fee Schedule,,99.2,,,99.2,Fee Schedule,,118.62,,,118.62,Fee Schedule,,112,70,,112,percent of total billed charges,All Other,142.31,,,142.31,Fee Schedule,,120.62,,,120.62,Fee Schedule,,45.05,,,45.05,Fee Schedule,,45.05,,,45.05,Fee Schedule,,45.05,,,45.05,Fee Schedule,,45.05,,,45.05,Fee Schedule,,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,148.72,
DETECT AGENT NOS DNA QUANT,87799,CPT,,78087799,CDM,306,RC,,,both,,,430,318.2,,,318.2,Other,150% of Medicare + 9.63% HCRA Surcharge,193.5,45,,193.5,percent of total billed charges,Critical Access Hospital RCC factor,128.95,,,128.95,Fee Schedule,,116.1,,,116.1,Fee Schedule,,317.68,,,317.68,Fee Schedule,,285.73,,,285.73,Fee Schedule,,270.05,,,270.05,Fee Schedule,,212.85,,,212.85,Other,110% of Medicare,134.95,,,134.95,Fee Schedule,,67,,,67,Other,186% of Medicaid,158.94,,,158.94,Fee Schedule,,266.6,,,266.6,Fee Schedule,,89.96,,,89.96,Fee Schedule,,158.94,,,158.94,Fee Schedule,,266.6,,,266.6,Fee Schedule,,169.22,,,169.22,Fee Schedule,,301,70,,301,percent of total billed charges,All Other,203.02,,,203.02,Fee Schedule,,172.07,,,172.07,Fee Schedule,,64.26,,,64.26,Fee Schedule,,64.26,,,64.26,Fee Schedule,,64.26,,,64.26,Fee Schedule,,64.26,,,64.26,Fee Schedule,,36.17,,,36.17,Other,100% of Medicaid,36.17,,,36.17,Other,100% of Medicaid,36.17,,,36.17,Other,100% of Medicaid,36.17,,,36.17,Other,100% of Medicaid,81.38,,,81.38,Other,225% of Medicaid,55.34,,,55.34,Other,153% of Medicaid,81.38,,,81.38,Other,225% of Medicaid,50.64,,,50.64,Other,140% of Medicaid,81.38,,,81.38,Other,225% of Medicaid,94.04,,,94.04,Other,260% of Medicaid,117.19,,,117.19,Other,324% of Medicaid,77.77,,,77.77,Other,215% of Medicaid,77.77,,,77.77,Other,215% of Medicaid,45.21,,,45.21,Other,125% of Medicaid,36.17,318.2,
DIR NA PROBE MULTI ORGANISMS,87800,CPT,,78087800,CDM,306,RC,,,both,,,238,176.12,,,176.12,Other,150% of Medicare + 9.63% HCRA Surcharge,107.1,45,,107.1,percent of total billed charges,Critical Access Hospital RCC factor,131.45,,,131.45,Fee Schedule,,118.35,,,118.35,Fee Schedule,,297.44,,,297.44,Fee Schedule,,267.53,,,267.53,Fee Schedule,,252.85,,,252.85,Fee Schedule,,117.81,,,117.81,Other,110% of Medicare,137.56,,,137.56,Fee Schedule,,52,,,52,Other,186% of Medicaid,162.02,,,162.02,Fee Schedule,,147.56,,,147.56,Fee Schedule,,91.71,,,91.71,Fee Schedule,,162.02,,,162.02,Fee Schedule,,147.56,,,147.56,Fee Schedule,,172.5,,,172.5,Fee Schedule,,166.6,70,,166.6,percent of total billed charges,All Other,206.95,,,206.95,Fee Schedule,,175.41,,,175.41,Fee Schedule,,65.51,,,65.51,Fee Schedule,,65.51,,,65.51,Fee Schedule,,65.51,,,65.51,Fee Schedule,,65.51,,,65.51,Fee Schedule,,28.19,,,28.19,Other,100% of Medicaid,28.19,,,28.19,Other,100% of Medicaid,28.19,,,28.19,Other,100% of Medicaid,28.19,,,28.19,Other,100% of Medicaid,63.43,,,63.43,Other,225% of Medicaid,43.13,,,43.13,Other,153% of Medicaid,63.43,,,63.43,Other,225% of Medicaid,39.46,,,39.46,Other,140% of Medicaid,63.43,,,63.43,Other,225% of Medicaid,73.29,,,73.29,Other,260% of Medicaid,91.33,,,91.33,Other,324% of Medicaid,60.61,,,60.61,Other,215% of Medicaid,60.61,,,60.61,Other,215% of Medicaid,35.24,,,35.24,Other,125% of Medicaid,28.19,297.44,
DETECT AGNT MULT DNA AMPLI,87801,CPT,,78087801,CDM,306,RC,,,both,,,414,306.36,,,306.36,Other,150% of Medicare + 9.63% HCRA Surcharge,186.3,45,,186.3,percent of total billed charges,Critical Access Hospital RCC factor,211.3,,,211.3,Fee Schedule,,190.24,,,190.24,Fee Schedule,,520.57,,,520.57,Fee Schedule,,468.22,,,468.22,Fee Schedule,,442.53,,,442.53,Fee Schedule,,204.93,,,204.93,Other,110% of Medicare,221.13,,,221.13,Fee Schedule,,75,,,75,Other,186% of Medicaid,260.44,,,260.44,Fee Schedule,,256.68,,,256.68,Fee Schedule,,147.42,,,147.42,Fee Schedule,,260.44,,,260.44,Fee Schedule,,256.68,,,256.68,Fee Schedule,,277.29,,,277.29,Fee Schedule,,289.8,70,,289.8,percent of total billed charges,All Other,332.68,,,332.68,Fee Schedule,,281.97,,,281.97,Fee Schedule,,105.3,,,105.3,Fee Schedule,,105.3,,,105.3,Fee Schedule,,105.3,,,105.3,Fee Schedule,,105.3,,,105.3,Fee Schedule,,40.4,,,40.4,Other,100% of Medicaid,40.4,,,40.4,Other,100% of Medicaid,40.4,,,40.4,Other,100% of Medicaid,40.4,,,40.4,Other,100% of Medicaid,90.9,,,90.9,Other,225% of Medicaid,61.81,,,61.81,Other,153% of Medicaid,90.9,,,90.9,Other,225% of Medicaid,56.56,,,56.56,Other,140% of Medicaid,90.9,,,90.9,Other,225% of Medicaid,105.04,,,105.04,Other,260% of Medicaid,130.9,,,130.9,Other,324% of Medicaid,86.86,,,86.86,Other,215% of Medicaid,86.86,,,86.86,Other,215% of Medicaid,50.5,,,50.5,Other,125% of Medicaid,40.4,520.57,
STREP B IA W DO,87802,CPT,,78087802,CDM,306,RC,,,both,,,69,51.06,,,51.06,Other,150% of Medicare + 9.63% HCRA Surcharge,31.05,45,,31.05,percent of total billed charges,Critical Access Hospital RCC factor,38.32,,,38.32,Fee Schedule,,34.5,,,34.5,Fee Schedule,,64.87,,,64.87,Fee Schedule,,58.35,,,58.35,Fee Schedule,,55.15,,,55.15,Fee Schedule,,34.16,,,34.16,Other,110% of Medicare,40.1,,,40.1,Fee Schedule,,17,,,17,Other,186% of Medicaid,47.23,,,47.23,Fee Schedule,,42.78,,,42.78,Fee Schedule,,26.73,,,26.73,Fee Schedule,,47.23,,,47.23,Fee Schedule,,42.78,,,42.78,Fee Schedule,,50.28,,,50.28,Fee Schedule,,48.3,70,,48.3,percent of total billed charges,All Other,60.33,,,60.33,Fee Schedule,,51.13,,,51.13,Fee Schedule,,19.1,,,19.1,Fee Schedule,,19.1,,,19.1,Fee Schedule,,19.1,,,19.1,Fee Schedule,,19.1,,,19.1,Fee Schedule,,9.14,,,9.14,Other,100% of Medicaid,9.14,,,9.14,Other,100% of Medicaid,9.14,,,9.14,Other,100% of Medicaid,9.14,,,9.14,Other,100% of Medicaid,20.56,,,20.56,Other,225% of Medicaid,13.98,,,13.98,Other,153% of Medicaid,20.56,,,20.56,Other,225% of Medicaid,12.79,,,12.79,Other,140% of Medicaid,20.56,,,20.56,Other,225% of Medicaid,23.76,,,23.76,Other,260% of Medicaid,29.6,,,29.6,Other,324% of Medicaid,19.64,,,19.64,Other,215% of Medicaid,19.64,,,19.64,Other,215% of Medicaid,11.42,,,11.42,Other,125% of Medicaid,9.14,64.87,
INFLUENZA ASSAY W/OPTIC,87804,CPT,,78087804,CDM,306,RC,,,both,,,233,172.42,,,172.42,Other,150% of Medicare + 9.63% HCRA Surcharge,104.85,45,,104.85,percent of total billed charges,Critical Access Hospital RCC factor,49.82,,,49.82,Fee Schedule,,44.85,,,44.85,Fee Schedule,,64.87,,,64.87,Fee Schedule,,58.35,,,58.35,Fee Schedule,,55.15,,,55.15,Fee Schedule,,115.34,,,115.34,Other,110% of Medicare,52.13,,,52.13,Fee Schedule,,27,,,27,Other,186% of Medicaid,61.4,,,61.4,Fee Schedule,,144.46,,,144.46,Fee Schedule,,34.76,,,34.76,Fee Schedule,,61.4,,,61.4,Fee Schedule,,144.46,,,144.46,Fee Schedule,,65.37,,,65.37,Fee Schedule,,163.1,70,,163.1,percent of total billed charges,All Other,78.43,,,78.43,Fee Schedule,,66.48,,,66.48,Fee Schedule,,24.83,,,24.83,Fee Schedule,,24.83,,,24.83,Fee Schedule,,24.83,,,24.83,Fee Schedule,,24.83,,,24.83,Fee Schedule,,14.65,,,14.65,Other,100% of Medicaid,14.65,,,14.65,Other,100% of Medicaid,14.65,,,14.65,Other,100% of Medicaid,14.65,,,14.65,Other,100% of Medicaid,32.95,,,32.95,Other,225% of Medicaid,22.41,,,22.41,Other,153% of Medicaid,32.95,,,32.95,Other,225% of Medicaid,20.5,,,20.5,Other,140% of Medicaid,32.95,,,32.95,Other,225% of Medicaid,38.08,,,38.08,Other,260% of Medicaid,47.45,,,47.45,Other,324% of Medicaid,31.49,,,31.49,Other,215% of Medicaid,31.49,,,31.49,Other,215% of Medicaid,18.31,,,18.31,Other,125% of Medicaid,14.65,172.42,
STREP A ASSAY W/OPTIC,87880,CPT,,78087880,CDM,306,RC,,,both,,,74,54.76,,,54.76,Other,150% of Medicare + 9.63% HCRA Surcharge,33.3,45,,33.3,percent of total billed charges,Critical Access Hospital RCC factor,49.76,,,49.76,Fee Schedule,,44.8,,,44.8,Fee Schedule,,64.87,,,64.87,Fee Schedule,,58.35,,,58.35,Fee Schedule,,55.15,,,55.15,Fee Schedule,,36.63,,,36.63,Other,110% of Medicare,52.07,,,52.07,Fee Schedule,,7,,,7,Other,186% of Medicaid,61.33,,,61.33,Fee Schedule,,45.88,,,45.88,Fee Schedule,,34.71,,,34.71,Fee Schedule,,61.33,,,61.33,Fee Schedule,,45.88,,,45.88,Fee Schedule,,65.29,,,65.29,Fee Schedule,,51.8,70,,51.8,percent of total billed charges,All Other,78.34,,,78.34,Fee Schedule,,66.39,,,66.39,Fee Schedule,,24.8,,,24.8,Fee Schedule,,24.8,,,24.8,Fee Schedule,,24.8,,,24.8,Fee Schedule,,24.8,,,24.8,Fee Schedule,,3.79,,,3.79,Other,100% of Medicaid,3.79,,,3.79,Other,100% of Medicaid,3.79,,,3.79,Other,100% of Medicaid,3.79,,,3.79,Other,100% of Medicaid,8.52,,,8.52,Other,225% of Medicaid,5.79,,,5.79,Other,153% of Medicaid,8.52,,,8.52,Other,225% of Medicaid,5.3,,,5.3,Other,140% of Medicaid,8.52,,,8.52,Other,225% of Medicaid,9.85,,,9.85,Other,260% of Medicaid,12.27,,,12.27,Other,324% of Medicaid,8.14,,,8.14,Other,215% of Medicaid,8.14,,,8.14,Other,215% of Medicaid,4.73,,,4.73,Other,125% of Medicaid,3.79,78.34,
PHENOTYPE INFECT AGENT DRUG,87900,CPT,,78087900,CDM,306,RC,,,both,,,924,683.76,,,683.76,Other,150% of Medicare + 9.63% HCRA Surcharge,415.8,45,,415.8,percent of total billed charges,Critical Access Hospital RCC factor,392.35,,,392.35,Fee Schedule,,353.25,,,353.25,Fee Schedule,,966.62,,,966.62,Fee Schedule,,869.41,,,869.41,Fee Schedule,,821.72,,,821.72,Fee Schedule,,457.38,,,457.38,Other,110% of Medicare,410.6,,,410.6,Fee Schedule,,150,,,150,Other,186% of Medicaid,483.6,,,483.6,Fee Schedule,,572.88,,,572.88,Fee Schedule,,273.74,,,273.74,Fee Schedule,,483.6,,,483.6,Fee Schedule,,572.88,,,572.88,Fee Schedule,,514.88,,,514.88,Fee Schedule,,646.8,70,,646.8,percent of total billed charges,All Other,617.73,,,617.73,Fee Schedule,,523.57,,,523.57,Fee Schedule,,195.53,,,195.53,Fee Schedule,,195.53,,,195.53,Fee Schedule,,195.53,,,195.53,Fee Schedule,,195.53,,,195.53,Fee Schedule,,80.8,,,80.8,Other,100% of Medicaid,80.8,,,80.8,Other,100% of Medicaid,80.8,,,80.8,Other,100% of Medicaid,80.8,,,80.8,Other,100% of Medicaid,181.8,,,181.8,Other,225% of Medicaid,123.62,,,123.62,Other,153% of Medicaid,181.8,,,181.8,Other,225% of Medicaid,113.12,,,113.12,Other,140% of Medicaid,181.8,,,181.8,Other,225% of Medicaid,210.08,,,210.08,Other,260% of Medicaid,261.79,,,261.79,Other,324% of Medicaid,173.72,,,173.72,Other,215% of Medicaid,173.72,,,173.72,Other,215% of Medicaid,101,,,101,Other,125% of Medicaid,80.8,966.62,
GENOTYPE DNA/RNA HIV,87906,CPT,,78087906,CDM,306,RC,,,both,,,407,301.18,,,301.18,Other,150% of Medicare + 9.63% HCRA Surcharge,183.15,45,,183.15,percent of total billed charges,Critical Access Hospital RCC factor,387.48,,,387.48,Fee Schedule,,348.86,,,348.86,Fee Schedule,,954.61,,,954.61,Fee Schedule,,858.6,,,858.6,Fee Schedule,,811.51,,,811.51,Fee Schedule,,201.47,,,201.47,Other,110% of Medicare,405.5,,,405.5,Fee Schedule,,239,,,239,Other,186% of Medicaid,477.59,,,477.59,Fee Schedule,,252.34,,,252.34,Fee Schedule,,270.33,,,270.33,Fee Schedule,,477.59,,,477.59,Fee Schedule,,252.34,,,252.34,Fee Schedule,,508.48,,,508.48,Fee Schedule,,284.9,70,,284.9,percent of total billed charges,All Other,610.06,,,610.06,Fee Schedule,,517.06,,,517.06,Fee Schedule,,193.1,,,193.1,Fee Schedule,,193.1,,,193.1,Fee Schedule,,193.1,,,193.1,Fee Schedule,,193.1,,,193.1,Fee Schedule,,128.73,,,128.73,Other,100% of Medicaid,128.73,,,128.73,Other,100% of Medicaid,128.73,,,128.73,Other,100% of Medicaid,128.73,,,128.73,Other,100% of Medicaid,289.64,,,289.64,Other,225% of Medicaid,196.96,,,196.96,Other,153% of Medicaid,289.64,,,289.64,Other,225% of Medicaid,180.22,,,180.22,Other,140% of Medicaid,289.64,,,289.64,Other,225% of Medicaid,334.7,,,334.7,Other,260% of Medicaid,417.09,,,417.09,Other,324% of Medicaid,276.77,,,276.77,Other,215% of Medicaid,276.77,,,276.77,Other,215% of Medicaid,160.91,,,160.91,Other,125% of Medicaid,128.73,954.61,
GENOTYPE CYTOMEGALOVIRUS,87910,CPT,,78087910,CDM,306,RC,,,both,,,812,600.88,,,600.88,Other,150% of Medicare + 9.63% HCRA Surcharge,365.4,45,,365.4,percent of total billed charges,Critical Access Hospital RCC factor,774.92,,,774.92,Fee Schedule,,697.69,,,697.69,Fee Schedule,,141.55,,,141.55,Fee Schedule,,141.55,,,141.55,Fee Schedule,,141.55,,,141.55,Fee Schedule,,401.94,,,401.94,Other,110% of Medicare,810.97,,,810.97,Fee Schedule,,94,,,94,Other,186% of Medicaid,955.14,,,955.14,Fee Schedule,,503.44,,,503.44,Fee Schedule,,540.65,,,540.65,Fee Schedule,,955.14,,,955.14,Fee Schedule,,503.44,,,503.44,Fee Schedule,,1016.93,,,1016.93,Fee Schedule,,568.4,70,,568.4,percent of total billed charges,All Other,1220.06,,,1220.06,Fee Schedule,,1034.08,,,1034.08,Fee Schedule,,386.18,,,386.18,Fee Schedule,,386.18,,,386.18,Fee Schedule,,386.18,,,386.18,Fee Schedule,,386.18,,,386.18,Fee Schedule,,50.37,,,50.37,Other,100% of Medicaid,50.37,,,50.37,Other,100% of Medicaid,50.37,,,50.37,Other,100% of Medicaid,50.37,,,50.37,Other,100% of Medicaid,113.32,,,113.32,Other,225% of Medicaid,77.06,,,77.06,Other,153% of Medicaid,113.32,,,113.32,Other,225% of Medicaid,70.51,,,70.51,Other,140% of Medicaid,113.32,,,113.32,Other,225% of Medicaid,130.95,,,130.95,Other,260% of Medicaid,163.19,,,163.19,Other,324% of Medicaid,108.29,,,108.29,Other,215% of Medicaid,108.29,,,108.29,Other,215% of Medicaid,62.96,,,62.96,Other,125% of Medicaid,50.37,1220.06,
GENOTYPE DNA HEPATITIS B,87912,CPT,,78087912,CDM,306,RC,,,both,,,812,600.88,,,600.88,Other,150% of Medicare + 9.63% HCRA Surcharge,365.4,45,,365.4,percent of total billed charges,Critical Access Hospital RCC factor,774.92,,,774.92,Fee Schedule,,697.69,,,697.69,Fee Schedule,,141.55,,,141.55,Fee Schedule,,141.55,,,141.55,Fee Schedule,,141.55,,,141.55,Fee Schedule,,401.94,,,401.94,Other,110% of Medicare,810.97,,,810.97,Fee Schedule,,94,,,94,Other,186% of Medicaid,955.14,,,955.14,Fee Schedule,,503.44,,,503.44,Fee Schedule,,540.65,,,540.65,Fee Schedule,,955.14,,,955.14,Fee Schedule,,503.44,,,503.44,Fee Schedule,,1016.93,,,1016.93,Fee Schedule,,568.4,70,,568.4,percent of total billed charges,All Other,1220.06,,,1220.06,Fee Schedule,,1034.08,,,1034.08,Fee Schedule,,386.18,,,386.18,Fee Schedule,,386.18,,,386.18,Fee Schedule,,386.18,,,386.18,Fee Schedule,,386.18,,,386.18,Fee Schedule,,50.37,,,50.37,Other,100% of Medicaid,50.37,,,50.37,Other,100% of Medicaid,50.37,,,50.37,Other,100% of Medicaid,50.37,,,50.37,Other,100% of Medicaid,113.32,,,113.32,Other,225% of Medicaid,77.06,,,77.06,Other,153% of Medicaid,113.32,,,113.32,Other,225% of Medicaid,70.51,,,70.51,Other,140% of Medicaid,113.32,,,113.32,Other,225% of Medicaid,130.95,,,130.95,Other,260% of Medicaid,163.19,,,163.19,Other,324% of Medicaid,108.29,,,108.29,Other,215% of Medicaid,108.29,,,108.29,Other,215% of Medicaid,62.96,,,62.96,Other,125% of Medicaid,50.37,1220.06,
TROFILE(R),87999,CPT,,78087999,CDM,306,RC,,,both,,,9740,7207.62,,,7207.62,Other,150% of Medicare + 9.63% HCRA Surcharge,4383,45,,4383,percent of total billed charges,Critical Access Hospital RCC factor,6331,65,,6331,percent of total billed charges,All Other,5746.6,65,,5746.6,percent of total billed charges,All Other,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,4821.3,,,4821.3,Other,110% of Medicare,6623.2,68,,6623.2,percent of total billed charges,All Other,17,,,17,Other,186% of Medicaid,8084.2,83,,8084.2,percent of total billed charges,All Other,6038.8,62,,6038.8,percent of total billed charges,Lab and Radiology,5357,55,,5357,percent of total billed charges,Default if not on Fee Schedule,7792,80,,7792,percent of total billed charges,All Other,6038.8,62,,6038.8,percent of total billed charges,Lab and Radiology,7792,80,,7792,percent of total billed charges,All Other,6818,70,,6818,percent of total billed charges,All Other,6331,65,,6331,percent of total billed charges,Default if not in Fee Schedule,6331,65,,6331,percent of total billed charges,Default if not in Fee Schedule,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,9.14,,,9.14,Other,100% of Medicaid,9.14,,,9.14,Other,100% of Medicaid,9.14,,,9.14,Other,100% of Medicaid,9.14,,,9.14,Other,100% of Medicaid,20.56,,,20.56,Other,225% of Medicaid,13.98,,,13.98,Other,153% of Medicaid,20.56,,,20.56,Other,225% of Medicaid,12.79,,,12.79,Other,140% of Medicaid,20.56,,,20.56,Other,225% of Medicaid,23.76,,,23.76,Other,260% of Medicaid,29.6,,,29.6,Other,324% of Medicaid,19.64,,,19.64,Other,215% of Medicaid,19.64,,,19.64,Other,215% of Medicaid,11.42,,,11.42,Other,125% of Medicaid,0.01,8084.2,
HPV HIGH-RISK TYPES,87624,CPT,,78187624,CDM,306,RC,,,both,,,167,123.58,,,123.58,Other,150% of Medicare + 9.63% HCRA Surcharge,75.15,45,,75.15,percent of total billed charges,Critical Access Hospital RCC factor,105.62,,,105.62,Fee Schedule,,95.09,,,95.09,Fee Schedule,,19.1,,,19.1,Fee Schedule,,19.1,,,19.1,Fee Schedule,,19.1,,,19.1,Fee Schedule,,82.67,,,82.67,Other,110% of Medicare,110.53,,,110.53,Fee Schedule,,52,,,52,Other,186% of Medicaid,130.18,,,130.18,Fee Schedule,,103.54,,,103.54,Fee Schedule,,73.69,,,73.69,Fee Schedule,,130.18,,,130.18,Fee Schedule,,103.54,,,103.54,Fee Schedule,,138.61,,,138.61,Fee Schedule,,116.9,70,,116.9,percent of total billed charges,All Other,166.29,,,166.29,Fee Schedule,,140.94,,,140.94,Fee Schedule,,52.64,,,52.64,Fee Schedule,,52.64,,,52.64,Fee Schedule,,52.64,,,52.64,Fee Schedule,,52.64,,,52.64,Fee Schedule,,28.13,,,28.13,Other,100% of Medicaid,28.13,,,28.13,Other,100% of Medicaid,28.13,,,28.13,Other,100% of Medicaid,28.13,,,28.13,Other,100% of Medicaid,63.29,,,63.29,Other,225% of Medicaid,43.04,,,43.04,Other,153% of Medicaid,63.29,,,63.29,Other,225% of Medicaid,39.38,,,39.38,Other,140% of Medicaid,63.29,,,63.29,Other,225% of Medicaid,73.13,,,73.13,Other,260% of Medicaid,91.14,,,91.14,Other,324% of Medicaid,60.48,,,60.48,Other,215% of Medicaid,60.48,,,60.48,Other,215% of Medicaid,35.16,,,35.16,Other,125% of Medicaid,19.1,166.29,
SENSITIVITY - MACROBROTH EA AGNT,87188,CPT,,79087188,CDM,306,RC,,,both,,,34,25.16,,,25.16,Other,150% of Medicare + 9.63% HCRA Surcharge,15.3,45,,15.3,percent of total billed charges,Critical Access Hospital RCC factor,19.99,,,19.99,Fee Schedule,,17.99,,,17.99,Fee Schedule,,43.11,,,43.11,Fee Schedule,,38.77,,,38.77,Fee Schedule,,36.65,,,36.65,Fee Schedule,,16.83,,,16.83,Other,110% of Medicare,20.92,,,20.92,Fee Schedule,,8,,,8,Other,186% of Medicaid,24.63,,,24.63,Fee Schedule,,21.08,,,21.08,Fee Schedule,,13.94,,,13.94,Fee Schedule,,24.63,,,24.63,Fee Schedule,,21.08,,,21.08,Fee Schedule,,26.23,,,26.23,Fee Schedule,,23.8,70,,23.8,percent of total billed charges,All Other,31.47,,,31.47,Fee Schedule,,26.67,,,26.67,Fee Schedule,,9.96,,,9.96,Fee Schedule,,9.96,,,9.96,Fee Schedule,,9.96,,,9.96,Fee Schedule,,9.96,,,9.96,Fee Schedule,,4.55,,,4.55,Other,100% of Medicaid,4.55,,,4.55,Other,100% of Medicaid,4.55,,,4.55,Other,100% of Medicaid,4.55,,,4.55,Other,100% of Medicaid,10.23,,,10.23,Other,225% of Medicaid,6.95,,,6.95,Other,153% of Medicaid,10.23,,,10.23,Other,225% of Medicaid,6.36,,,6.36,Other,140% of Medicaid,10.23,,,10.23,Other,225% of Medicaid,11.82,,,11.82,Other,260% of Medicaid,14.73,,,14.73,Other,324% of Medicaid,9.77,,,9.77,Other,215% of Medicaid,9.77,,,9.77,Other,215% of Medicaid,5.68,,,5.68,Other,125% of Medicaid,4.55,43.11,
URINALYSIS NONAUTO W/O SCOPE,81002,CPT,,30081002,CDM,307,RC,,,both,,,35,25.9,,,25.9,Other,150% of Medicare + 9.63% HCRA Surcharge,15.75,45,,15.75,percent of total billed charges,Critical Access Hospital RCC factor,10.47,,,10.47,Fee Schedule,,9.43,,,9.43,Fee Schedule,,18.97,,,18.97,Fee Schedule,,17.06,,,17.06,Fee Schedule,,16.13,,,16.13,Fee Schedule,,17.33,,,17.33,Other,110% of Medicare,10.96,,,10.96,Fee Schedule,,4,,,4,Other,186% of Medicaid,12.91,,,12.91,Fee Schedule,,21.7,,,21.7,Fee Schedule,,7.31,,,7.31,Fee Schedule,,12.91,,,12.91,Fee Schedule,,21.7,,,21.7,Fee Schedule,,13.75,,,13.75,Fee Schedule,,24.5,70,,24.5,percent of total billed charges,All Other,16.49,,,16.49,Fee Schedule,,13.98,,,13.98,Fee Schedule,,5.22,,,5.22,Fee Schedule,,5.22,,,5.22,Fee Schedule,,5.22,,,5.22,Fee Schedule,,5.22,,,5.22,Fee Schedule,,2.02,,,2.02,Other,100% of Medicaid,2.02,,,2.02,Other,100% of Medicaid,2.02,,,2.02,Other,100% of Medicaid,2.02,,,2.02,Other,100% of Medicaid,4.55,,,4.55,Other,225% of Medicaid,3.09,,,3.09,Other,153% of Medicaid,4.55,,,4.55,Other,225% of Medicaid,2.83,,,2.83,Other,140% of Medicaid,4.55,,,4.55,Other,225% of Medicaid,5.25,,,5.25,Other,260% of Medicaid,6.54,,,6.54,Other,324% of Medicaid,4.34,,,4.34,Other,215% of Medicaid,4.34,,,4.34,Other,215% of Medicaid,2.53,,,2.53,Other,125% of Medicaid,2.02,25.9,
URINALYSIS AUTO W/O SCOPE,81003,CPT,,30081003,CDM,307,RC,,,both,,,41,30.34,,,30.34,Other,150% of Medicare + 9.63% HCRA Surcharge,18.45,45,,18.45,percent of total billed charges,Critical Access Hospital RCC factor,6.77,,,6.77,Fee Schedule,,6.1,,,6.1,Fee Schedule,,16.65,,,16.65,Fee Schedule,,14.98,,,14.98,Fee Schedule,,14.16,,,14.16,Fee Schedule,,20.3,,,20.3,Other,110% of Medicare,7.09,,,7.09,Fee Schedule,,4,,,4,Other,186% of Medicaid,8.35,,,8.35,Fee Schedule,,25.42,,,25.42,Fee Schedule,,4.73,,,4.73,Fee Schedule,,8.35,,,8.35,Fee Schedule,,25.42,,,25.42,Fee Schedule,,8.89,,,8.89,Fee Schedule,,28.7,70,,28.7,percent of total billed charges,All Other,10.66,,,10.66,Fee Schedule,,9.04,,,9.04,Fee Schedule,,3.38,,,3.38,Fee Schedule,,3.38,,,3.38,Fee Schedule,,3.38,,,3.38,Fee Schedule,,3.38,,,3.38,Fee Schedule,,2.02,,,2.02,Other,100% of Medicaid,2.02,,,2.02,Other,100% of Medicaid,2.02,,,2.02,Other,100% of Medicaid,2.02,,,2.02,Other,100% of Medicaid,4.55,,,4.55,Other,225% of Medicaid,3.09,,,3.09,Other,153% of Medicaid,4.55,,,4.55,Other,225% of Medicaid,2.83,,,2.83,Other,140% of Medicaid,4.55,,,4.55,Other,225% of Medicaid,5.25,,,5.25,Other,260% of Medicaid,6.54,,,6.54,Other,324% of Medicaid,4.34,,,4.34,Other,215% of Medicaid,4.34,,,4.34,Other,215% of Medicaid,2.53,,,2.53,Other,125% of Medicaid,2.02,30.34,
URINE PREGNANCY TEST,81025,CPT,,30081025,CDM,307,RC,,,both,,,57,42.18,,,42.18,Other,150% of Medicare + 9.63% HCRA Surcharge,25.65,45,,25.65,percent of total billed charges,Critical Access Hospital RCC factor,25.92,,,25.92,Fee Schedule,,23.33,,,23.33,Fee Schedule,,46.9,,,46.9,Fee Schedule,,42.19,,,42.19,Fee Schedule,,39.87,,,39.87,Fee Schedule,,28.22,,,28.22,Other,110% of Medicare,27.12,,,27.12,Fee Schedule,,4,,,4,Other,186% of Medicaid,31.94,,,31.94,Fee Schedule,,35.34,,,35.34,Fee Schedule,,18.08,,,18.08,Fee Schedule,,31.94,,,31.94,Fee Schedule,,35.34,,,35.34,Fee Schedule,,34.01,,,34.01,Fee Schedule,,39.9,70,,39.9,percent of total billed charges,All Other,40.8,,,40.8,Fee Schedule,,34.58,,,34.58,Fee Schedule,,12.92,,,12.92,Fee Schedule,,12.92,,,12.92,Fee Schedule,,12.92,,,12.92,Fee Schedule,,12.92,,,12.92,Fee Schedule,,2.02,,,2.02,Other,100% of Medicaid,2.02,,,2.02,Other,100% of Medicaid,2.02,,,2.02,Other,100% of Medicaid,2.02,,,2.02,Other,100% of Medicaid,4.55,,,4.55,Other,225% of Medicaid,3.09,,,3.09,Other,153% of Medicaid,4.55,,,4.55,Other,225% of Medicaid,2.83,,,2.83,Other,140% of Medicaid,4.55,,,4.55,Other,225% of Medicaid,5.25,,,5.25,Other,260% of Medicaid,6.54,,,6.54,Other,324% of Medicaid,4.34,,,4.34,Other,215% of Medicaid,4.34,,,4.34,Other,215% of Medicaid,2.53,,,2.53,Other,125% of Medicaid,2.02,46.9,
URINE PREGNANCY VISUAL COLOR,81025,CPT,,34081025,CDM,307,RC,,,both,,,57,42.18,,,42.18,Other,150% of Medicare + 9.63% HCRA Surcharge,25.65,45,,25.65,percent of total billed charges,Critical Access Hospital RCC factor,25.92,,,25.92,Fee Schedule,,23.33,,,23.33,Fee Schedule,,46.9,,,46.9,Fee Schedule,,42.19,,,42.19,Fee Schedule,,39.87,,,39.87,Fee Schedule,,28.22,,,28.22,Other,110% of Medicare,27.12,,,27.12,Fee Schedule,,4,,,4,Other,186% of Medicaid,31.94,,,31.94,Fee Schedule,,35.34,,,35.34,Fee Schedule,,18.08,,,18.08,Fee Schedule,,31.94,,,31.94,Fee Schedule,,35.34,,,35.34,Fee Schedule,,34.01,,,34.01,Fee Schedule,,39.9,70,,39.9,percent of total billed charges,All Other,40.8,,,40.8,Fee Schedule,,34.58,,,34.58,Fee Schedule,,12.92,,,12.92,Fee Schedule,,12.92,,,12.92,Fee Schedule,,12.92,,,12.92,Fee Schedule,,12.92,,,12.92,Fee Schedule,,2.02,,,2.02,Other,100% of Medicaid,2.02,,,2.02,Other,100% of Medicaid,2.02,,,2.02,Other,100% of Medicaid,2.02,,,2.02,Other,100% of Medicaid,4.55,,,4.55,Other,225% of Medicaid,3.09,,,3.09,Other,153% of Medicaid,4.55,,,4.55,Other,225% of Medicaid,2.83,,,2.83,Other,140% of Medicaid,4.55,,,4.55,Other,225% of Medicaid,5.25,,,5.25,Other,260% of Medicaid,6.54,,,6.54,Other,324% of Medicaid,4.34,,,4.34,Other,215% of Medicaid,4.34,,,4.34,Other,215% of Medicaid,2.53,,,2.53,Other,125% of Medicaid,2.02,46.9,
URINALYSIS NONAUTO W/SCOPE,81000,CPT,,78081000,CDM,307,RC,,,both,,,29,21.46,,,21.46,Other,150% of Medicare + 9.63% HCRA Surcharge,13.05,45,,13.05,percent of total billed charges,Critical Access Hospital RCC factor,12.1,,,12.1,Fee Schedule,,10.89,,,10.89,Fee Schedule,,23.45,,,23.45,Fee Schedule,,21.09,,,21.09,Fee Schedule,,19.94,,,19.94,Fee Schedule,,14.36,,,14.36,Other,110% of Medicare,12.66,,,12.66,Fee Schedule,,7,,,7,Other,186% of Medicaid,14.91,,,14.91,Fee Schedule,,17.98,,,17.98,Fee Schedule,,8.44,,,8.44,Fee Schedule,,14.91,,,14.91,Fee Schedule,,17.98,,,17.98,Fee Schedule,,15.88,,,15.88,Fee Schedule,,20.3,70,,20.3,percent of total billed charges,All Other,19.05,,,19.05,Fee Schedule,,16.15,,,16.15,Fee Schedule,,6.03,,,6.03,Fee Schedule,,6.03,,,6.03,Fee Schedule,,6.03,,,6.03,Fee Schedule,,6.03,,,6.03,Fee Schedule,,4,,,4,Other,100% of Medicaid,4,,,4,Other,100% of Medicaid,4,,,4,Other,100% of Medicaid,4,,,4,Other,100% of Medicaid,9,,,9,Other,225% of Medicaid,6.12,,,6.12,Other,153% of Medicaid,9,,,9,Other,225% of Medicaid,5.6,,,5.6,Other,140% of Medicaid,9,,,9,Other,225% of Medicaid,10.4,,,10.4,Other,260% of Medicaid,12.96,,,12.96,Other,324% of Medicaid,8.6,,,8.6,Other,215% of Medicaid,8.6,,,8.6,Other,215% of Medicaid,5,,,5,Other,125% of Medicaid,4,23.45,
URINALYSIS AUTO W/SCOPE,81001,CPT,,78081001,CDM,307,RC,,,both,,,74,54.76,,,54.76,Other,150% of Medicare + 9.63% HCRA Surcharge,33.3,45,,33.3,percent of total billed charges,Critical Access Hospital RCC factor,9.54,,,9.54,Fee Schedule,,8.59,,,8.59,Fee Schedule,,23.45,,,23.45,Fee Schedule,,21.09,,,21.09,Fee Schedule,,19.94,,,19.94,Fee Schedule,,36.63,,,36.63,Other,110% of Medicare,9.99,,,9.99,Fee Schedule,,6,,,6,Other,186% of Medicaid,11.76,,,11.76,Fee Schedule,,45.88,,,45.88,Fee Schedule,,6.66,,,6.66,Fee Schedule,,11.76,,,11.76,Fee Schedule,,45.88,,,45.88,Fee Schedule,,12.52,,,12.52,Fee Schedule,,51.8,70,,51.8,percent of total billed charges,All Other,15.02,,,15.02,Fee Schedule,,12.73,,,12.73,Fee Schedule,,4.76,,,4.76,Fee Schedule,,4.76,,,4.76,Fee Schedule,,4.76,,,4.76,Fee Schedule,,4.76,,,4.76,Fee Schedule,,3.17,,,3.17,Other,100% of Medicaid,3.17,,,3.17,Other,100% of Medicaid,3.17,,,3.17,Other,100% of Medicaid,3.17,,,3.17,Other,100% of Medicaid,7.13,,,7.13,Other,225% of Medicaid,4.85,,,4.85,Other,153% of Medicaid,7.13,,,7.13,Other,225% of Medicaid,4.44,,,4.44,Other,140% of Medicaid,7.13,,,7.13,Other,225% of Medicaid,8.24,,,8.24,Other,260% of Medicaid,10.27,,,10.27,Other,324% of Medicaid,6.82,,,6.82,Other,215% of Medicaid,6.82,,,6.82,Other,215% of Medicaid,3.96,,,3.96,Other,125% of Medicaid,3.17,54.76,
URINALYSIS NONAUTO W/O SCOPE,81002,CPT,,78081002,CDM,307,RC,,,both,,,35,25.9,,,25.9,Other,150% of Medicare + 9.63% HCRA Surcharge,15.75,45,,15.75,percent of total billed charges,Critical Access Hospital RCC factor,10.47,,,10.47,Fee Schedule,,9.43,,,9.43,Fee Schedule,,18.97,,,18.97,Fee Schedule,,17.06,,,17.06,Fee Schedule,,16.13,,,16.13,Fee Schedule,,17.33,,,17.33,Other,110% of Medicare,10.96,,,10.96,Fee Schedule,,4,,,4,Other,186% of Medicaid,12.91,,,12.91,Fee Schedule,,21.7,,,21.7,Fee Schedule,,7.31,,,7.31,Fee Schedule,,12.91,,,12.91,Fee Schedule,,21.7,,,21.7,Fee Schedule,,13.75,,,13.75,Fee Schedule,,24.5,70,,24.5,percent of total billed charges,All Other,16.49,,,16.49,Fee Schedule,,13.98,,,13.98,Fee Schedule,,5.22,,,5.22,Fee Schedule,,5.22,,,5.22,Fee Schedule,,5.22,,,5.22,Fee Schedule,,5.22,,,5.22,Fee Schedule,,2.02,,,2.02,Other,100% of Medicaid,2.02,,,2.02,Other,100% of Medicaid,2.02,,,2.02,Other,100% of Medicaid,2.02,,,2.02,Other,100% of Medicaid,4.55,,,4.55,Other,225% of Medicaid,3.09,,,3.09,Other,153% of Medicaid,4.55,,,4.55,Other,225% of Medicaid,2.83,,,2.83,Other,140% of Medicaid,4.55,,,4.55,Other,225% of Medicaid,5.25,,,5.25,Other,260% of Medicaid,6.54,,,6.54,Other,324% of Medicaid,4.34,,,4.34,Other,215% of Medicaid,4.34,,,4.34,Other,215% of Medicaid,2.53,,,2.53,Other,125% of Medicaid,2.02,25.9,
URINALYSIS,81005,CPT,,78081005,CDM,307,RC,,,both,,,32,23.68,,,23.68,Other,150% of Medicare + 9.63% HCRA Surcharge,14.4,45,,14.4,percent of total billed charges,Critical Access Hospital RCC factor,6.53,,,6.53,Fee Schedule,,5.88,,,5.88,Fee Schedule,,16.07,,,16.07,Fee Schedule,,14.46,,,14.46,Fee Schedule,,13.66,,,13.66,Fee Schedule,,15.84,,,15.84,Other,110% of Medicare,6.84,,,6.84,Fee Schedule,,19,,,19,Other,186% of Medicaid,8.05,,,8.05,Fee Schedule,,19.84,,,19.84,Fee Schedule,,4.56,,,4.56,Fee Schedule,,8.05,,,8.05,Fee Schedule,,19.84,,,19.84,Fee Schedule,,8.57,,,8.57,Fee Schedule,,22.4,70,,22.4,percent of total billed charges,All Other,10.28,,,10.28,Fee Schedule,,8.72,,,8.72,Fee Schedule,,3.26,,,3.26,Fee Schedule,,3.26,,,3.26,Fee Schedule,,3.26,,,3.26,Fee Schedule,,3.26,,,3.26,Fee Schedule,,9.96,,,9.96,Other,100% of Medicaid,9.96,,,9.96,Other,100% of Medicaid,9.96,,,9.96,Other,100% of Medicaid,9.96,,,9.96,Other,100% of Medicaid,22.4,,,22.4,Other,225% of Medicaid,15.23,,,15.23,Other,153% of Medicaid,22.4,,,22.4,Other,225% of Medicaid,13.94,,,13.94,Other,140% of Medicaid,22.4,,,22.4,Other,225% of Medicaid,25.88,,,25.88,Other,260% of Medicaid,32.25,,,32.25,Other,324% of Medicaid,21.4,,,21.4,Other,215% of Medicaid,21.4,,,21.4,Other,215% of Medicaid,12.44,,,12.44,Other,125% of Medicaid,3.26,32.25,
MICROSCOPIC EXAM OF URINE,81015,CPT,,78081015,CDM,307,RC,,,both,,,68,50.32,,,50.32,Other,150% of Medicare + 9.63% HCRA Surcharge,30.6,45,,30.6,percent of total billed charges,Critical Access Hospital RCC factor,9.18,,,9.18,Fee Schedule,,8.27,,,8.27,Fee Schedule,,22.56,,,22.56,Fee Schedule,,20.29,,,20.29,Fee Schedule,,19.17,,,19.17,Fee Schedule,,33.66,,,33.66,Other,110% of Medicare,9.61,,,9.61,Fee Schedule,,4,,,4,Other,186% of Medicaid,11.32,,,11.32,Fee Schedule,,42.16,,,42.16,Fee Schedule,,6.41,,,6.41,Fee Schedule,,11.32,,,11.32,Fee Schedule,,42.16,,,42.16,Fee Schedule,,12.05,,,12.05,Fee Schedule,,47.6,70,,47.6,percent of total billed charges,All Other,14.45,,,14.45,Fee Schedule,,12.25,,,12.25,Fee Schedule,,4.58,,,4.58,Fee Schedule,,4.58,,,4.58,Fee Schedule,,4.58,,,4.58,Fee Schedule,,4.58,,,4.58,Fee Schedule,,2.02,,,2.02,Other,100% of Medicaid,2.02,,,2.02,Other,100% of Medicaid,2.02,,,2.02,Other,100% of Medicaid,2.02,,,2.02,Other,100% of Medicaid,4.55,,,4.55,Other,225% of Medicaid,3.09,,,3.09,Other,153% of Medicaid,4.55,,,4.55,Other,225% of Medicaid,2.83,,,2.83,Other,140% of Medicaid,4.55,,,4.55,Other,225% of Medicaid,5.25,,,5.25,Other,260% of Medicaid,6.54,,,6.54,Other,324% of Medicaid,4.34,,,4.34,Other,215% of Medicaid,4.34,,,4.34,Other,215% of Medicaid,2.53,,,2.53,Other,125% of Medicaid,2.02,50.32,
URINALYSIS VOLUME MEASURE,81050,CPT,,78081050,CDM,307,RC,,,both,,,12,8.88,,,8.88,Other,150% of Medicare + 9.63% HCRA Surcharge,5.4,45,,5.4,percent of total billed charges,Critical Access Hospital RCC factor,10.96,,,10.96,Fee Schedule,,9.86,,,9.86,Fee Schedule,,22.24,,,22.24,Fee Schedule,,20,,,20,Fee Schedule,,18.91,,,18.91,Fee Schedule,,5.94,,,5.94,Other,110% of Medicare,11.47,,,11.47,Fee Schedule,,19,,,19,Other,186% of Medicaid,13.5,,,13.5,Fee Schedule,,7.44,,,7.44,Fee Schedule,,7.64,,,7.64,Fee Schedule,,13.5,,,13.5,Fee Schedule,,7.44,,,7.44,Fee Schedule,,14.38,,,14.38,Fee Schedule,,8.4,70,,8.4,percent of total billed charges,All Other,17.25,,,17.25,Fee Schedule,,14.62,,,14.62,Fee Schedule,,5.46,,,5.46,Fee Schedule,,5.46,,,5.46,Fee Schedule,,5.46,,,5.46,Fee Schedule,,5.46,,,5.46,Fee Schedule,,9.96,,,9.96,Other,100% of Medicaid,9.96,,,9.96,Other,100% of Medicaid,9.96,,,9.96,Other,100% of Medicaid,9.96,,,9.96,Other,100% of Medicaid,22.4,,,22.4,Other,225% of Medicaid,15.23,,,15.23,Other,153% of Medicaid,22.4,,,22.4,Other,225% of Medicaid,13.94,,,13.94,Other,140% of Medicaid,22.4,,,22.4,Other,225% of Medicaid,25.88,,,25.88,Other,260% of Medicaid,32.25,,,32.25,Other,324% of Medicaid,21.4,,,21.4,Other,215% of Medicaid,21.4,,,21.4,Other,215% of Medicaid,12.44,,,12.44,Other,125% of Medicaid,5.4,32.25,
URINALYSIS NONAUTO W/O SCOPE,81002,CPT,,82081002,CDM,307,RC,,,both,,,35,25.9,,,25.9,Other,150% of Medicare + 9.63% HCRA Surcharge,15.75,45,,15.75,percent of total billed charges,Critical Access Hospital RCC factor,10.47,,,10.47,Fee Schedule,,9.43,,,9.43,Fee Schedule,,18.97,,,18.97,Fee Schedule,,17.06,,,17.06,Fee Schedule,,16.13,,,16.13,Fee Schedule,,17.33,,,17.33,Other,110% of Medicare,10.96,,,10.96,Fee Schedule,,4,,,4,Other,186% of Medicaid,12.91,,,12.91,Fee Schedule,,21.7,,,21.7,Fee Schedule,,7.31,,,7.31,Fee Schedule,,12.91,,,12.91,Fee Schedule,,21.7,,,21.7,Fee Schedule,,13.75,,,13.75,Fee Schedule,,24.5,70,,24.5,percent of total billed charges,All Other,16.49,,,16.49,Fee Schedule,,13.98,,,13.98,Fee Schedule,,5.22,,,5.22,Fee Schedule,,5.22,,,5.22,Fee Schedule,,5.22,,,5.22,Fee Schedule,,5.22,,,5.22,Fee Schedule,,2.02,,,2.02,Other,100% of Medicaid,2.02,,,2.02,Other,100% of Medicaid,2.02,,,2.02,Other,100% of Medicaid,2.02,,,2.02,Other,100% of Medicaid,4.55,,,4.55,Other,225% of Medicaid,3.09,,,3.09,Other,153% of Medicaid,4.55,,,4.55,Other,225% of Medicaid,2.83,,,2.83,Other,140% of Medicaid,4.55,,,4.55,Other,225% of Medicaid,5.25,,,5.25,Other,260% of Medicaid,6.54,,,6.54,Other,324% of Medicaid,4.34,,,4.34,Other,215% of Medicaid,4.34,,,4.34,Other,215% of Medicaid,2.53,,,2.53,Other,125% of Medicaid,2.02,25.9,
URINALYSIS AUTO W/O SCOPE,81003,CPT,,82081003,CDM,307,RC,,,both,,,41,30.34,,,30.34,Other,150% of Medicare + 9.63% HCRA Surcharge,18.45,45,,18.45,percent of total billed charges,Critical Access Hospital RCC factor,6.77,,,6.77,Fee Schedule,,6.1,,,6.1,Fee Schedule,,16.65,,,16.65,Fee Schedule,,14.98,,,14.98,Fee Schedule,,14.16,,,14.16,Fee Schedule,,20.3,,,20.3,Other,110% of Medicare,7.09,,,7.09,Fee Schedule,,4,,,4,Other,186% of Medicaid,8.35,,,8.35,Fee Schedule,,25.42,,,25.42,Fee Schedule,,4.73,,,4.73,Fee Schedule,,8.35,,,8.35,Fee Schedule,,25.42,,,25.42,Fee Schedule,,8.89,,,8.89,Fee Schedule,,28.7,70,,28.7,percent of total billed charges,All Other,10.66,,,10.66,Fee Schedule,,9.04,,,9.04,Fee Schedule,,3.38,,,3.38,Fee Schedule,,3.38,,,3.38,Fee Schedule,,3.38,,,3.38,Fee Schedule,,3.38,,,3.38,Fee Schedule,,2.02,,,2.02,Other,100% of Medicaid,2.02,,,2.02,Other,100% of Medicaid,2.02,,,2.02,Other,100% of Medicaid,2.02,,,2.02,Other,100% of Medicaid,4.55,,,4.55,Other,225% of Medicaid,3.09,,,3.09,Other,153% of Medicaid,4.55,,,4.55,Other,225% of Medicaid,2.83,,,2.83,Other,140% of Medicaid,4.55,,,4.55,Other,225% of Medicaid,5.25,,,5.25,Other,260% of Medicaid,6.54,,,6.54,Other,324% of Medicaid,4.34,,,4.34,Other,215% of Medicaid,4.34,,,4.34,Other,215% of Medicaid,2.53,,,2.53,Other,125% of Medicaid,2.02,30.34,
URINE PREGNANCY TEST,81025,CPT,,82081025,CDM,307,RC,,,both,,,57,42.18,,,42.18,Other,150% of Medicare + 9.63% HCRA Surcharge,25.65,45,,25.65,percent of total billed charges,Critical Access Hospital RCC factor,25.92,,,25.92,Fee Schedule,,23.33,,,23.33,Fee Schedule,,46.9,,,46.9,Fee Schedule,,42.19,,,42.19,Fee Schedule,,39.87,,,39.87,Fee Schedule,,28.22,,,28.22,Other,110% of Medicare,27.12,,,27.12,Fee Schedule,,4,,,4,Other,186% of Medicaid,31.94,,,31.94,Fee Schedule,,35.34,,,35.34,Fee Schedule,,18.08,,,18.08,Fee Schedule,,31.94,,,31.94,Fee Schedule,,35.34,,,35.34,Fee Schedule,,34.01,,,34.01,Fee Schedule,,39.9,70,,39.9,percent of total billed charges,All Other,40.8,,,40.8,Fee Schedule,,34.58,,,34.58,Fee Schedule,,12.92,,,12.92,Fee Schedule,,12.92,,,12.92,Fee Schedule,,12.92,,,12.92,Fee Schedule,,12.92,,,12.92,Fee Schedule,,2.02,,,2.02,Other,100% of Medicaid,2.02,,,2.02,Other,100% of Medicaid,2.02,,,2.02,Other,100% of Medicaid,2.02,,,2.02,Other,100% of Medicaid,4.55,,,4.55,Other,225% of Medicaid,3.09,,,3.09,Other,153% of Medicaid,4.55,,,4.55,Other,225% of Medicaid,2.83,,,2.83,Other,140% of Medicaid,4.55,,,4.55,Other,225% of Medicaid,5.25,,,5.25,Other,260% of Medicaid,6.54,,,6.54,Other,324% of Medicaid,4.34,,,4.34,Other,215% of Medicaid,4.34,,,4.34,Other,215% of Medicaid,2.53,,,2.53,Other,125% of Medicaid,2.02,46.9,
ROUTINE VENIPUNCTURE,36415,CPT,,26036415,CDM,309,RC,,,both,,,21,15.54,,,15.54,Other,150% of Medicare + 9.63% HCRA Surcharge,9.45,45,,9.45,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,15.81,,,15.81,Fee Schedule,,14.22,,,14.22,Fee Schedule,,13.44,,,13.44,Fee Schedule,,10.4,,,10.4,Other,110% of Medicare,27.81,,,27.81,Fee Schedule,,61,,,61,Other,186% of Medicaid,32.76,,,32.76,Fee Schedule,,13.02,,,13.02,Fee Schedule,,18.54,,,18.54,Fee Schedule,,32.76,,,32.76,Fee Schedule,,13.02,,,13.02,Fee Schedule,,34.88,,,34.88,Fee Schedule,,14.7,70,,14.7,percent of total billed charges,All Other,14.22,,,14.22,Fee Schedule,,12.05,,,12.05,Fee Schedule,,4.5,,,4.5,Fee Schedule,,4.5,,,4.5,Fee Schedule,,4.5,,,4.5,Fee Schedule,,4.5,,,4.5,Fee Schedule,,32.83,,,32.83,Other,100% of Medicaid,32.83,,,32.83,Other,100% of Medicaid,32.83,,,32.83,Other,100% of Medicaid,32.83,,,32.83,Other,100% of Medicaid,73.87,,,73.87,Other,225% of Medicaid,50.23,,,50.23,Other,153% of Medicaid,73.87,,,73.87,Other,225% of Medicaid,45.96,,,45.96,Other,140% of Medicaid,73.87,,,73.87,Other,225% of Medicaid,85.36,,,85.36,Other,260% of Medicaid,106.38,,,106.38,Other,324% of Medicaid,70.59,,,70.59,Other,215% of Medicaid,70.59,,,70.59,Other,215% of Medicaid,41.04,,,41.04,Other,125% of Medicaid,0.01,106.38,
TRAVL 1 WAY NEC LAB SPEC TRIP,P9604,HCPCS,,78000009,CDM,309,RC,,,both,,,47,34.78,,,34.78,Other,150% of Medicare + 9.63% HCRA Surcharge,21.15,45,,21.15,percent of total billed charges,Critical Access Hospital RCC factor,30.55,65,,30.55,percent of total billed charges,All Other,27.73,65,,27.73,percent of total billed charges,All Other,3,,,3,Fee Schedule,,3,,,3,Fee Schedule,,3,,,3,Fee Schedule,,23.27,,,23.27,Other,110% of Medicare,31.96,68,,31.96,percent of total billed charges,All Other,18,,,18,Other,186% of Medicaid,39.01,83,,39.01,percent of total billed charges,All Other,29.14,62,,29.14,percent of total billed charges,Lab and Radiology,25.85,55,,25.85,percent of total billed charges,Default if not on Fee Schedule,37.6,80,,37.6,percent of total billed charges,All Other,29.14,62,,29.14,percent of total billed charges,Lab and Radiology,37.6,80,,37.6,percent of total billed charges,All Other,32.9,70,,32.9,percent of total billed charges,All Other,30.55,65,,30.55,percent of total billed charges,Default if not in Fee Schedule,30.55,65,,30.55,percent of total billed charges,Default if not in Fee Schedule,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,9.44,,,9.44,Other,100% of Medicaid,9.44,,,9.44,Other,100% of Medicaid,9.44,,,9.44,Other,100% of Medicaid,9.44,,,9.44,Other,100% of Medicaid,21.25,,,21.25,Other,225% of Medicaid,14.45,,,14.45,Other,153% of Medicaid,21.25,,,21.25,Other,225% of Medicaid,13.22,,,13.22,Other,140% of Medicaid,21.25,,,21.25,Other,225% of Medicaid,24.55,,,24.55,Other,260% of Medicaid,30.6,,,30.6,Other,324% of Medicaid,20.3,,,20.3,Other,215% of Medicaid,20.3,,,20.3,Other,215% of Medicaid,11.8,,,11.8,Other,125% of Medicaid,0.01,39.01,
DRUG ASSAY VEDOLIZUMAB,80280,CPT,,78080280,CDM,309,RC,,,both,,,260,192.4,,,192.4,Other,150% of Medicare + 9.63% HCRA Surcharge,117,45,,117,percent of total billed charges,Critical Access Hospital RCC factor,116.1,,,116.1,Fee Schedule,,104.52,,,104.52,Fee Schedule,,30.86,,,30.86,Fee Schedule,,30.86,,,30.86,Fee Schedule,,30.86,,,30.86,Fee Schedule,,128.7,,,128.7,Other,110% of Medicare,121.5,,,121.5,Fee Schedule,,20,,,20,Other,186% of Medicaid,143.09,,,143.09,Fee Schedule,,161.2,,,161.2,Fee Schedule,,81,,,81,Fee Schedule,,143.09,,,143.09,Fee Schedule,,161.2,,,161.2,Fee Schedule,,152.35,,,152.35,Fee Schedule,,182,70,,182,percent of total billed charges,All Other,182.78,,,182.78,Fee Schedule,,154.92,,,154.92,Fee Schedule,,57.86,,,57.86,Fee Schedule,,57.86,,,57.86,Fee Schedule,,57.86,,,57.86,Fee Schedule,,57.86,,,57.86,Fee Schedule,,10.61,,,10.61,Other,100% of Medicaid,10.61,,,10.61,Other,100% of Medicaid,10.61,,,10.61,Other,100% of Medicaid,10.61,,,10.61,Other,100% of Medicaid,23.86,,,23.86,Other,225% of Medicaid,16.23,,,16.23,Other,153% of Medicaid,23.86,,,23.86,Other,225% of Medicaid,14.85,,,14.85,Other,140% of Medicaid,23.86,,,23.86,Other,225% of Medicaid,27.57,,,27.57,Other,260% of Medicaid,34.36,,,34.36,Other,324% of Medicaid,22.8,,,22.8,Other,215% of Medicaid,22.8,,,22.8,Other,215% of Medicaid,13.26,,,13.26,Other,125% of Medicaid,10.61,192.4,
ASSAY OF CATHEPSIN-D,82387,CPT,,78082387,CDM,309,RC,,,both,,,1042,771.08,,,771.08,Other,150% of Medicare + 9.63% HCRA Surcharge,468.9,45,,468.9,percent of total billed charges,Critical Access Hospital RCC factor,54.36,,,54.36,Fee Schedule,,48.94,,,48.94,Fee Schedule,,127.01,,,127.01,Fee Schedule,,114.23,,,114.23,Fee Schedule,,107.97,,,107.97,Fee Schedule,,515.79,,,515.79,Other,110% of Medicare,56.89,,,56.89,Fee Schedule,,19,,,19,Other,186% of Medicaid,67,,,67,Fee Schedule,,646.04,,,646.04,Fee Schedule,,37.93,,,37.93,Fee Schedule,,67,,,67,Fee Schedule,,646.04,,,646.04,Fee Schedule,,71.34,,,71.34,Fee Schedule,,729.4,70,,729.4,percent of total billed charges,All Other,85.59,,,85.59,Fee Schedule,,72.54,,,72.54,Fee Schedule,,27.09,,,27.09,Fee Schedule,,27.09,,,27.09,Fee Schedule,,27.09,,,27.09,Fee Schedule,,27.09,,,27.09,Fee Schedule,,10.16,,,10.16,Other,100% of Medicaid,10.16,,,10.16,Other,100% of Medicaid,10.16,,,10.16,Other,100% of Medicaid,10.16,,,10.16,Other,100% of Medicaid,22.85,,,22.85,Other,225% of Medicaid,15.54,,,15.54,Other,153% of Medicaid,22.85,,,22.85,Other,225% of Medicaid,14.22,,,14.22,Other,140% of Medicaid,22.85,,,22.85,Other,225% of Medicaid,26.4,,,26.4,Other,260% of Medicaid,32.9,,,32.9,Other,324% of Medicaid,21.83,,,21.83,Other,215% of Medicaid,21.83,,,21.83,Other,215% of Medicaid,12.69,,,12.69,Other,125% of Medicaid,10.16,771.08,
CHEMILUMINESCENT ASSAY,82397,CPT,,78082397,CDM,309,RC,,,both,,,260,192.4,,,192.4,Other,150% of Medicare + 9.63% HCRA Surcharge,117,45,,117,percent of total billed charges,Critical Access Hospital RCC factor,42.5,,,42.5,Fee Schedule,,38.27,,,38.27,Fee Schedule,,79.26,,,79.26,Fee Schedule,,71.29,,,71.29,Fee Schedule,,67.38,,,67.38,Fee Schedule,,128.7,,,128.7,Other,110% of Medicare,44.48,,,44.48,Fee Schedule,,19,,,19,Other,186% of Medicaid,52.39,,,52.39,Fee Schedule,,161.2,,,161.2,Fee Schedule,,29.65,,,29.65,Fee Schedule,,52.39,,,52.39,Fee Schedule,,161.2,,,161.2,Fee Schedule,,55.77,,,55.77,Fee Schedule,,182,70,,182,percent of total billed charges,All Other,66.92,,,66.92,Fee Schedule,,56.71,,,56.71,Fee Schedule,,21.18,,,21.18,Fee Schedule,,21.18,,,21.18,Fee Schedule,,21.18,,,21.18,Fee Schedule,,21.18,,,21.18,Fee Schedule,,10.16,,,10.16,Other,100% of Medicaid,10.16,,,10.16,Other,100% of Medicaid,10.16,,,10.16,Other,100% of Medicaid,10.16,,,10.16,Other,100% of Medicaid,22.85,,,22.85,Other,225% of Medicaid,15.54,,,15.54,Other,153% of Medicaid,22.85,,,22.85,Other,225% of Medicaid,14.22,,,14.22,Other,140% of Medicaid,22.85,,,22.85,Other,225% of Medicaid,26.4,,,26.4,Other,260% of Medicaid,32.9,,,32.9,Other,324% of Medicaid,21.83,,,21.83,Other,215% of Medicaid,21.83,,,21.83,Other,215% of Medicaid,12.69,,,12.69,Other,125% of Medicaid,10.16,192.4,
ASSAY OF IGE,82785,CPT,,78082785,CDM,309,RC,,,both,,,237,175.38,,,175.38,Other,150% of Medicare + 9.63% HCRA Surcharge,106.65,45,,106.65,percent of total billed charges,Critical Access Hospital RCC factor,49.54,,,49.54,Fee Schedule,,44.61,,,44.61,Fee Schedule,,122.16,,,122.16,Fee Schedule,,109.87,,,109.87,Fee Schedule,,103.85,,,103.85,Fee Schedule,,117.32,,,117.32,Other,110% of Medicare,51.85,,,51.85,Fee Schedule,,23,,,23,Other,186% of Medicaid,61.07,,,61.07,Fee Schedule,,146.94,,,146.94,Fee Schedule,,34.57,,,34.57,Fee Schedule,,61.07,,,61.07,Fee Schedule,,146.94,,,146.94,Fee Schedule,,65.02,,,65.02,Fee Schedule,,165.9,70,,165.9,percent of total billed charges,All Other,78,,,78,Fee Schedule,,66.11,,,66.11,Fee Schedule,,24.69,,,24.69,Fee Schedule,,24.69,,,24.69,Fee Schedule,,24.69,,,24.69,Fee Schedule,,24.69,,,24.69,Fee Schedule,,12.63,,,12.63,Other,100% of Medicaid,12.63,,,12.63,Other,100% of Medicaid,12.63,,,12.63,Other,100% of Medicaid,12.63,,,12.63,Other,100% of Medicaid,28.41,,,28.41,Other,225% of Medicaid,19.32,,,19.32,Other,153% of Medicaid,28.41,,,28.41,Other,225% of Medicaid,17.68,,,17.68,Other,140% of Medicaid,28.41,,,28.41,Other,225% of Medicaid,32.83,,,32.83,Other,260% of Medicaid,40.91,,,40.91,Other,324% of Medicaid,27.14,,,27.14,Other,215% of Medicaid,27.14,,,27.14,Other,215% of Medicaid,15.78,,,15.78,Other,125% of Medicaid,12.63,175.38,
ASSAY OF HOMOCYSTINE,83090,CPT,,78083090,CDM,309,RC,,,both,,,1113,823.62,,,823.62,Other,150% of Medicare + 9.63% HCRA Surcharge,500.85,45,,500.85,percent of total billed charges,Critical Access Hospital RCC factor,53.94,,,53.94,Fee Schedule,,48.56,,,48.56,Fee Schedule,,125.11,,,125.11,Fee Schedule,,112.53,,,112.53,Fee Schedule,,106.36,,,106.36,Fee Schedule,,550.94,,,550.94,Other,110% of Medicare,56.45,,,56.45,Fee Schedule,,33,,,33,Other,186% of Medicaid,66.48,,,66.48,Fee Schedule,,690.06,,,690.06,Fee Schedule,,37.63,,,37.63,Fee Schedule,,66.48,,,66.48,Fee Schedule,,690.06,,,690.06,Fee Schedule,,70.78,,,70.78,Fee Schedule,,779.1,70,,779.1,percent of total billed charges,All Other,84.92,,,84.92,Fee Schedule,,71.98,,,71.98,Fee Schedule,,26.88,,,26.88,Fee Schedule,,26.88,,,26.88,Fee Schedule,,26.88,,,26.88,Fee Schedule,,26.88,,,26.88,Fee Schedule,,17.92,,,17.92,Other,100% of Medicaid,17.92,,,17.92,Other,100% of Medicaid,17.92,,,17.92,Other,100% of Medicaid,17.92,,,17.92,Other,100% of Medicaid,40.32,,,40.32,Other,225% of Medicaid,27.42,,,27.42,Other,153% of Medicaid,40.32,,,40.32,Other,225% of Medicaid,25.09,,,25.09,Other,140% of Medicaid,40.32,,,40.32,Other,225% of Medicaid,46.59,,,46.59,Other,260% of Medicaid,58.06,,,58.06,Other,324% of Medicaid,38.53,,,38.53,Other,215% of Medicaid,38.53,,,38.53,Other,215% of Medicaid,22.4,,,22.4,Other,125% of Medicaid,17.92,823.62,
COMPLEMENT FIXATION EACH,86171,CPT,,78086171,CDM,309,RC,,,both,,,350,259,,,259,Other,150% of Medicare + 9.63% HCRA Surcharge,157.5,45,,157.5,percent of total billed charges,Critical Access Hospital RCC factor,30.13,,,30.13,Fee Schedule,,27.13,,,27.13,Fee Schedule,,74.31,,,74.31,Fee Schedule,,66.83,,,66.83,Fee Schedule,,63.17,,,63.17,Fee Schedule,,173.25,,,173.25,Other,110% of Medicare,31.53,,,31.53,Fee Schedule,,18,,,18,Other,186% of Medicaid,37.14,,,37.14,Fee Schedule,,217,,,217,Fee Schedule,,21.02,,,21.02,Fee Schedule,,37.14,,,37.14,Fee Schedule,,217,,,217,Fee Schedule,,39.54,,,39.54,Fee Schedule,,245,70,,245,percent of total billed charges,All Other,47.44,,,47.44,Fee Schedule,,40.21,,,40.21,Fee Schedule,,15.02,,,15.02,Fee Schedule,,15.02,,,15.02,Fee Schedule,,15.02,,,15.02,Fee Schedule,,15.02,,,15.02,Fee Schedule,,9.88,,,9.88,Other,100% of Medicaid,9.88,,,9.88,Other,100% of Medicaid,9.88,,,9.88,Other,100% of Medicaid,9.88,,,9.88,Other,100% of Medicaid,22.23,,,22.23,Other,225% of Medicaid,15.11,,,15.11,Other,153% of Medicaid,22.23,,,22.23,Other,225% of Medicaid,13.83,,,13.83,Other,140% of Medicaid,22.23,,,22.23,Other,225% of Medicaid,25.68,,,25.68,Other,260% of Medicaid,32.01,,,32.01,Other,324% of Medicaid,21.24,,,21.24,Other,215% of Medicaid,21.24,,,21.24,Other,215% of Medicaid,12.35,,,12.35,Other,125% of Medicaid,9.88,259,
IMMUNOASSAY TUMOR QUAL,86294,CPT,,78086294,CDM,309,RC,,,both,,,166,122.84,,,122.84,Other,150% of Medicare + 9.63% HCRA Surcharge,74.7,45,,74.7,percent of total billed charges,Critical Access Hospital RCC factor,76.97,,,76.97,Fee Schedule,,69.29,,,69.29,Fee Schedule,,121.21,,,121.21,Fee Schedule,,109.02,,,109.02,Fee Schedule,,103.04,,,103.04,Fee Schedule,,82.17,,,82.17,Other,110% of Medicare,80.55,,,80.55,Fee Schedule,,15,,,15,Other,186% of Medicaid,94.86,,,94.86,Fee Schedule,,102.92,,,102.92,Fee Schedule,,53.7,,,53.7,Fee Schedule,,94.86,,,94.86,Fee Schedule,,102.92,,,102.92,Fee Schedule,,101,,,101,Fee Schedule,,116.2,70,,116.2,percent of total billed charges,All Other,121.18,,,121.18,Fee Schedule,,102.71,,,102.71,Fee Schedule,,38.36,,,38.36,Fee Schedule,,38.36,,,38.36,Fee Schedule,,38.36,,,38.36,Fee Schedule,,38.36,,,38.36,Fee Schedule,,8.11,,,8.11,Other,100% of Medicaid,8.11,,,8.11,Other,100% of Medicaid,8.11,,,8.11,Other,100% of Medicaid,8.11,,,8.11,Other,100% of Medicaid,18.25,,,18.25,Other,225% of Medicaid,12.41,,,12.41,Other,153% of Medicaid,18.25,,,18.25,Other,225% of Medicaid,11.35,,,11.35,Other,140% of Medicaid,18.25,,,18.25,Other,225% of Medicaid,21.09,,,21.09,Other,260% of Medicaid,26.28,,,26.28,Other,324% of Medicaid,17.44,,,17.44,Other,215% of Medicaid,17.44,,,17.44,Other,215% of Medicaid,10.14,,,10.14,Other,125% of Medicaid,8.11,122.84,
OTHER IMMUNOELECTROPHORESIS,86325,CPT,,78086325,CDM,309,RC,,,both,,,327,241.98,,,241.98,Other,150% of Medicare + 9.63% HCRA Surcharge,147.15,45,,147.15,percent of total billed charges,Critical Access Hospital RCC factor,69.62,,,69.62,Fee Schedule,,62.68,,,62.68,Fee Schedule,,165.79,,,165.79,Fee Schedule,,149.12,,,149.12,Fee Schedule,,140.94,,,140.94,Fee Schedule,,161.87,,,161.87,Other,110% of Medicare,72.86,,,72.86,Fee Schedule,,43,,,43,Other,186% of Medicaid,85.81,,,85.81,Fee Schedule,,202.74,,,202.74,Fee Schedule,,48.57,,,48.57,Fee Schedule,,85.81,,,85.81,Fee Schedule,,202.74,,,202.74,Fee Schedule,,91.36,,,91.36,Fee Schedule,,228.9,70,,228.9,percent of total billed charges,All Other,109.61,,,109.61,Fee Schedule,,92.9,,,92.9,Fee Schedule,,34.7,,,34.7,Fee Schedule,,34.7,,,34.7,Fee Schedule,,34.7,,,34.7,Fee Schedule,,34.7,,,34.7,Fee Schedule,,23.13,,,23.13,Other,100% of Medicaid,23.13,,,23.13,Other,100% of Medicaid,23.13,,,23.13,Other,100% of Medicaid,23.13,,,23.13,Other,100% of Medicaid,52.04,,,52.04,Other,225% of Medicaid,35.39,,,35.39,Other,153% of Medicaid,52.04,,,52.04,Other,225% of Medicaid,32.38,,,32.38,Other,140% of Medicaid,52.04,,,52.04,Other,225% of Medicaid,60.14,,,60.14,Other,260% of Medicaid,74.94,,,74.94,Other,324% of Medicaid,49.73,,,49.73,Other,215% of Medicaid,49.73,,,49.73,Other,215% of Medicaid,28.91,,,28.91,Other,125% of Medicaid,23.13,241.98,
TRICHINELLA ANTIBODY,86784,CPT,,78086784,CDM,309,RC,,,both,,,284,210.16,,,210.16,Other,150% of Medicare + 9.63% HCRA Surcharge,127.8,45,,127.8,percent of total billed charges,Critical Access Hospital RCC factor,37.81,,,37.81,Fee Schedule,,34.04,,,34.04,Fee Schedule,,43.11,,,43.11,Fee Schedule,,38.77,,,38.77,Fee Schedule,,36.65,,,36.65,Fee Schedule,,140.58,,,140.58,Other,110% of Medicare,39.56,,,39.56,Fee Schedule,,15,,,15,Other,186% of Medicaid,46.6,,,46.6,Fee Schedule,,176.08,,,176.08,Fee Schedule,,26.38,,,26.38,Fee Schedule,,46.6,,,46.6,Fee Schedule,,176.08,,,176.08,Fee Schedule,,49.61,,,49.61,Fee Schedule,,198.8,70,,198.8,percent of total billed charges,All Other,59.52,,,59.52,Fee Schedule,,50.45,,,50.45,Fee Schedule,,18.84,,,18.84,Fee Schedule,,18.84,,,18.84,Fee Schedule,,18.84,,,18.84,Fee Schedule,,18.84,,,18.84,Fee Schedule,,8.11,,,8.11,Other,100% of Medicaid,8.11,,,8.11,Other,100% of Medicaid,8.11,,,8.11,Other,100% of Medicaid,8.11,,,8.11,Other,100% of Medicaid,18.25,,,18.25,Other,225% of Medicaid,12.41,,,12.41,Other,153% of Medicaid,18.25,,,18.25,Other,225% of Medicaid,11.35,,,11.35,Other,140% of Medicaid,18.25,,,18.25,Other,225% of Medicaid,21.09,,,21.09,Other,260% of Medicaid,26.28,,,26.28,Other,324% of Medicaid,17.44,,,17.44,Other,215% of Medicaid,17.44,,,17.44,Other,215% of Medicaid,10.14,,,10.14,Other,125% of Medicaid,8.11,210.16,
COOMBS TEST INDIRECT TITER,86886,CPT,,78086886,CDM,309,RC,,,both,,,355,262.7,,,262.7,Other,150% of Medicare + 9.63% HCRA Surcharge,159.75,45,,159.75,percent of total billed charges,Critical Access Hospital RCC factor,15.59,,,15.59,Fee Schedule,,14.04,,,14.04,Fee Schedule,,38.37,,,38.37,Fee Schedule,,34.51,,,34.51,Fee Schedule,,32.61,,,32.61,Fee Schedule,,175.73,,,175.73,Other,110% of Medicare,16.32,,,16.32,Fee Schedule,,72,,,72,Other,186% of Medicaid,19.22,,,19.22,Fee Schedule,,220.1,,,220.1,Fee Schedule,,10.88,,,10.88,Fee Schedule,,19.22,,,19.22,Fee Schedule,,220.1,,,220.1,Fee Schedule,,20.46,,,20.46,Fee Schedule,,248.5,70,,248.5,percent of total billed charges,All Other,24.55,,,24.55,Fee Schedule,,20.81,,,20.81,Fee Schedule,,7.77,,,7.77,Fee Schedule,,7.77,,,7.77,Fee Schedule,,7.77,,,7.77,Fee Schedule,,7.77,,,7.77,Fee Schedule,,38.81,,,38.81,Other,100% of Medicaid,38.81,,,38.81,Other,100% of Medicaid,38.81,,,38.81,Other,100% of Medicaid,38.81,,,38.81,Other,100% of Medicaid,87.32,,,87.32,Other,225% of Medicaid,59.37,,,59.37,Other,153% of Medicaid,87.32,,,87.32,Other,225% of Medicaid,54.33,,,54.33,Other,140% of Medicaid,87.32,,,87.32,Other,225% of Medicaid,100.9,,,100.9,Other,260% of Medicaid,125.73,,,125.73,Other,324% of Medicaid,83.43,,,83.43,Other,215% of Medicaid,83.43,,,83.43,Other,215% of Medicaid,48.51,,,48.51,Other,125% of Medicaid,7.77,262.7,
BLOOD TYPING ABO,86900,CPT,,78086900,CDM,309,RC,,,both,,,263,194.62,,,194.62,Other,150% of Medicare + 9.63% HCRA Surcharge,118.35,45,,118.35,percent of total billed charges,Critical Access Hospital RCC factor,9,,,9,Fee Schedule,,8.1,,,8.1,Fee Schedule,,22.13,,,22.13,Fee Schedule,,19.91,,,19.91,Fee Schedule,,18.82,,,18.82,Fee Schedule,,130.19,,,130.19,Other,110% of Medicare,9.42,,,9.42,Fee Schedule,,6,,,6,Other,186% of Medicaid,11.09,,,11.09,Fee Schedule,,163.06,,,163.06,Fee Schedule,,6.28,,,6.28,Fee Schedule,,11.09,,,11.09,Fee Schedule,,163.06,,,163.06,Fee Schedule,,11.81,,,11.81,Fee Schedule,,184.1,70,,184.1,percent of total billed charges,All Other,14.17,,,14.17,Fee Schedule,,12.01,,,12.01,Fee Schedule,,4.49,,,4.49,Fee Schedule,,4.49,,,4.49,Fee Schedule,,4.49,,,4.49,Fee Schedule,,4.49,,,4.49,Fee Schedule,,2.99,,,2.99,Other,100% of Medicaid,2.99,,,2.99,Other,100% of Medicaid,2.99,,,2.99,Other,100% of Medicaid,2.99,,,2.99,Other,100% of Medicaid,6.73,,,6.73,Other,225% of Medicaid,4.57,,,4.57,Other,153% of Medicaid,6.73,,,6.73,Other,225% of Medicaid,4.19,,,4.19,Other,140% of Medicaid,6.73,,,6.73,Other,225% of Medicaid,7.77,,,7.77,Other,260% of Medicaid,9.69,,,9.69,Other,324% of Medicaid,6.43,,,6.43,Other,215% of Medicaid,6.43,,,6.43,Other,215% of Medicaid,3.74,,,3.74,Other,125% of Medicaid,2.99,194.62,
COMPATIBILITY TEST ELECTRIC,86923,CPT,,78086923,CDM,309,RC,,,both,,,579,428.46,,,428.46,Other,150% of Medicare + 9.63% HCRA Surcharge,260.55,45,,260.55,percent of total billed charges,Critical Access Hospital RCC factor,376.35,65,,376.35,percent of total billed charges,All Other,341.61,65,,341.61,percent of total billed charges,All Other,7.49,,,7.49,Fee Schedule,,7.49,,,7.49,Fee Schedule,,7.49,,,7.49,Fee Schedule,,286.61,,,286.61,Other,110% of Medicare,393.72,68,,393.72,percent of total billed charges,All Other,72,,,72,Other,186% of Medicaid,480.57,83,,480.57,percent of total billed charges,All Other,358.98,62,,358.98,percent of total billed charges,Lab and Radiology,318.45,55,,318.45,percent of total billed charges,Default if not on Fee Schedule,463.2,80,,463.2,percent of total billed charges,All Other,358.98,62,,358.98,percent of total billed charges,Lab and Radiology,463.2,80,,463.2,percent of total billed charges,All Other,405.3,70,,405.3,percent of total billed charges,All Other,376.35,65,,376.35,percent of total billed charges,Default if not in Fee Schedule,376.35,65,,376.35,percent of total billed charges,Default if not in Fee Schedule,215.25,,,215.25,Fee Schedule,,215.25,,,215.25,Fee Schedule,,215.25,,,215.25,Fee Schedule,,215.25,,,215.25,Fee Schedule,,38.8,,,38.8,Other,100% of Medicaid,38.8,,,38.8,Other,100% of Medicaid,38.8,,,38.8,Other,100% of Medicaid,38.8,,,38.8,Other,100% of Medicaid,87.31,,,87.31,Other,225% of Medicaid,59.37,,,59.37,Other,153% of Medicaid,87.31,,,87.31,Other,225% of Medicaid,54.32,,,54.32,Other,140% of Medicaid,87.31,,,87.31,Other,225% of Medicaid,100.89,,,100.89,Other,260% of Medicaid,125.72,,,125.72,Other,324% of Medicaid,83.43,,,83.43,Other,215% of Medicaid,83.43,,,83.43,Other,215% of Medicaid,48.5,,,48.5,Other,125% of Medicaid,7.49,480.57,
HEMOLYSINS/AGGLUTININS AUTO,86940,CPT,,78086940,CDM,309,RC,,,both,,,63,46.62,,,46.62,Other,150% of Medicare + 9.63% HCRA Surcharge,28.35,45,,28.35,percent of total billed charges,Critical Access Hospital RCC factor,26.4,,,26.4,Fee Schedule,,23.77,,,23.77,Fee Schedule,,60.82,,,60.82,Fee Schedule,,54.7,,,54.7,Fee Schedule,,51.7,,,51.7,Fee Schedule,,31.19,,,31.19,Other,110% of Medicare,27.63,,,27.63,Fee Schedule,,13,,,13,Other,186% of Medicaid,32.54,,,32.54,Fee Schedule,,39.06,,,39.06,Fee Schedule,,18.42,,,18.42,Fee Schedule,,32.54,,,32.54,Fee Schedule,,39.06,,,39.06,Fee Schedule,,34.64,,,34.64,Fee Schedule,,44.1,70,,44.1,percent of total billed charges,All Other,41.56,,,41.56,Fee Schedule,,35.23,,,35.23,Fee Schedule,,13.16,,,13.16,Fee Schedule,,13.16,,,13.16,Fee Schedule,,13.16,,,13.16,Fee Schedule,,13.16,,,13.16,Fee Schedule,,7.21,,,7.21,Other,100% of Medicaid,7.21,,,7.21,Other,100% of Medicaid,7.21,,,7.21,Other,100% of Medicaid,7.21,,,7.21,Other,100% of Medicaid,16.23,,,16.23,Other,225% of Medicaid,11.03,,,11.03,Other,153% of Medicaid,16.23,,,16.23,Other,225% of Medicaid,10.1,,,10.1,Other,140% of Medicaid,16.23,,,16.23,Other,225% of Medicaid,18.75,,,18.75,Other,260% of Medicaid,23.36,,,23.36,Other,324% of Medicaid,15.5,,,15.5,Other,215% of Medicaid,15.5,,,15.5,Other,215% of Medicaid,9.01,,,9.01,Other,125% of Medicaid,7.21,60.82,
GIARDIA AG EIA,87329,CPT,,78087329,CDM,309,RC,,,both,,,173,128.02,,,128.02,Other,150% of Medicare + 9.63% HCRA Surcharge,77.85,45,,77.85,percent of total billed charges,Critical Access Hospital RCC factor,36.06,,,36.06,Fee Schedule,,32.47,,,32.47,Fee Schedule,,64.87,,,64.87,Fee Schedule,,58.35,,,58.35,Fee Schedule,,55.15,,,55.15,Fee Schedule,,85.64,,,85.64,Other,110% of Medicare,37.74,,,37.74,Fee Schedule,,22,,,22,Other,186% of Medicaid,44.45,,,44.45,Fee Schedule,,107.26,,,107.26,Fee Schedule,,25.16,,,25.16,Fee Schedule,,44.45,,,44.45,Fee Schedule,,107.26,,,107.26,Fee Schedule,,47.32,,,47.32,Fee Schedule,,121.1,70,,121.1,percent of total billed charges,All Other,56.77,,,56.77,Fee Schedule,,48.12,,,48.12,Fee Schedule,,17.97,,,17.97,Fee Schedule,,17.97,,,17.97,Fee Schedule,,17.97,,,17.97,Fee Schedule,,17.97,,,17.97,Fee Schedule,,11.98,,,11.98,Other,100% of Medicaid,11.98,,,11.98,Other,100% of Medicaid,11.98,,,11.98,Other,100% of Medicaid,11.98,,,11.98,Other,100% of Medicaid,26.96,,,26.96,Other,225% of Medicaid,18.33,,,18.33,Other,153% of Medicaid,26.96,,,26.96,Other,225% of Medicaid,16.77,,,16.77,Other,140% of Medicaid,26.96,,,26.96,Other,225% of Medicaid,31.15,,,31.15,Other,260% of Medicaid,38.82,,,38.82,Other,324% of Medicaid,25.76,,,25.76,Other,215% of Medicaid,25.76,,,25.76,Other,215% of Medicaid,14.98,,,14.98,Other,125% of Medicaid,11.98,128.02,
ROTAVIRUS AG EIA,87425,CPT,,78087425,CDM,309,RC,,,both,,,83,61.42,,,61.42,Other,150% of Medicare + 9.63% HCRA Surcharge,37.35,45,,37.35,percent of total billed charges,Critical Access Hospital RCC factor,36.06,,,36.06,Fee Schedule,,32.47,,,32.47,Fee Schedule,,64.87,,,64.87,Fee Schedule,,58.35,,,58.35,Fee Schedule,,55.15,,,55.15,Fee Schedule,,41.09,,,41.09,Other,110% of Medicare,37.74,,,37.74,Fee Schedule,,22,,,22,Other,186% of Medicaid,44.45,,,44.45,Fee Schedule,,51.46,,,51.46,Fee Schedule,,25.16,,,25.16,Fee Schedule,,44.45,,,44.45,Fee Schedule,,51.46,,,51.46,Fee Schedule,,47.32,,,47.32,Fee Schedule,,58.1,70,,58.1,percent of total billed charges,All Other,56.77,,,56.77,Fee Schedule,,48.12,,,48.12,Fee Schedule,,17.97,,,17.97,Fee Schedule,,17.97,,,17.97,Fee Schedule,,17.97,,,17.97,Fee Schedule,,17.97,,,17.97,Fee Schedule,,11.98,,,11.98,Other,100% of Medicaid,11.98,,,11.98,Other,100% of Medicaid,11.98,,,11.98,Other,100% of Medicaid,11.98,,,11.98,Other,100% of Medicaid,26.96,,,26.96,Other,225% of Medicaid,18.33,,,18.33,Other,153% of Medicaid,26.96,,,26.96,Other,225% of Medicaid,16.77,,,16.77,Other,140% of Medicaid,26.96,,,26.96,Other,225% of Medicaid,31.15,,,31.15,Other,260% of Medicaid,38.82,,,38.82,Other,324% of Medicaid,25.76,,,25.76,Other,215% of Medicaid,25.76,,,25.76,Other,215% of Medicaid,14.98,,,14.98,Other,125% of Medicaid,11.98,64.87,
LYME DIS DNA AMP PROBE,87476,CPT,,78087476,CDM,309,RC,,,both,,,961,711.14,,,711.14,Other,150% of Medicare + 9.63% HCRA Surcharge,432.45,45,,432.45,percent of total billed charges,Critical Access Hospital RCC factor,105.62,,,105.62,Fee Schedule,,95.09,,,95.09,Fee Schedule,,260.29,,,260.29,Fee Schedule,,234.11,,,234.11,Fee Schedule,,221.27,,,221.27,Fee Schedule,,475.7,,,475.7,Other,110% of Medicare,110.53,,,110.53,Fee Schedule,,40,,,40,Other,186% of Medicaid,130.18,,,130.18,Fee Schedule,,595.82,,,595.82,Fee Schedule,,73.69,,,73.69,Fee Schedule,,130.18,,,130.18,Fee Schedule,,595.82,,,595.82,Fee Schedule,,138.61,,,138.61,Fee Schedule,,672.7,70,,672.7,percent of total billed charges,All Other,166.29,,,166.29,Fee Schedule,,140.94,,,140.94,Fee Schedule,,52.64,,,52.64,Fee Schedule,,52.64,,,52.64,Fee Schedule,,52.64,,,52.64,Fee Schedule,,52.64,,,52.64,Fee Schedule,,21.64,,,21.64,Other,100% of Medicaid,21.64,,,21.64,Other,100% of Medicaid,21.64,,,21.64,Other,100% of Medicaid,21.64,,,21.64,Other,100% of Medicaid,48.7,,,48.7,Other,225% of Medicaid,33.12,,,33.12,Other,153% of Medicaid,48.7,,,48.7,Other,225% of Medicaid,30.3,,,30.3,Other,140% of Medicaid,48.7,,,48.7,Other,225% of Medicaid,56.28,,,56.28,Other,260% of Medicaid,70.13,,,70.13,Other,324% of Medicaid,46.54,,,46.54,Other,215% of Medicaid,46.54,,,46.54,Other,215% of Medicaid,27.06,,,27.06,Other,125% of Medicaid,21.64,711.14,
HEPATITIS C RNA QUANT,87522,CPT,,78087522,CDM,309,RC,,,both,,,529,391.46,,,391.46,Other,150% of Medicare + 9.63% HCRA Surcharge,238.05,45,,238.05,percent of total billed charges,Critical Access Hospital RCC factor,128.95,,,128.95,Fee Schedule,,116.1,,,116.1,Fee Schedule,,317.68,,,317.68,Fee Schedule,,285.73,,,285.73,Fee Schedule,,270.05,,,270.05,Fee Schedule,,261.86,,,261.86,Other,110% of Medicare,134.95,,,134.95,Fee Schedule,,80,,,80,Other,186% of Medicaid,158.94,,,158.94,Fee Schedule,,327.98,,,327.98,Fee Schedule,,89.96,,,89.96,Fee Schedule,,158.94,,,158.94,Fee Schedule,,327.98,,,327.98,Fee Schedule,,169.22,,,169.22,Fee Schedule,,370.3,70,,370.3,percent of total billed charges,All Other,203.02,,,203.02,Fee Schedule,,172.07,,,172.07,Fee Schedule,,64.26,,,64.26,Fee Schedule,,64.26,,,64.26,Fee Schedule,,64.26,,,64.26,Fee Schedule,,64.26,,,64.26,Fee Schedule,,42.84,,,42.84,Other,100% of Medicaid,42.84,,,42.84,Other,100% of Medicaid,42.84,,,42.84,Other,100% of Medicaid,42.84,,,42.84,Other,100% of Medicaid,96.39,,,96.39,Other,225% of Medicaid,65.55,,,65.55,Other,153% of Medicaid,96.39,,,96.39,Other,225% of Medicaid,59.98,,,59.98,Other,140% of Medicaid,96.39,,,96.39,Other,225% of Medicaid,111.38,,,111.38,Other,260% of Medicaid,138.8,,,138.8,Other,324% of Medicaid,92.11,,,92.11,Other,215% of Medicaid,92.11,,,92.11,Other,215% of Medicaid,53.55,,,53.55,Other,125% of Medicaid,42.84,391.46,
AGENT NOS ASSAY W/OPTIC,87899,CPT,,78087899,CDM,309,RC,,,both,,,108,79.92,,,79.92,Other,150% of Medicare + 9.63% HCRA Surcharge,48.6,45,,48.6,percent of total billed charges,Critical Access Hospital RCC factor,48.37,,,48.37,Fee Schedule,,43.55,,,43.55,Fee Schedule,,64.87,,,64.87,Fee Schedule,,58.35,,,58.35,Fee Schedule,,55.15,,,55.15,Fee Schedule,,53.46,,,53.46,Other,110% of Medicare,50.62,,,50.62,Fee Schedule,,15,,,15,Other,186% of Medicaid,59.62,,,59.62,Fee Schedule,,66.96,,,66.96,Fee Schedule,,33.75,,,33.75,Fee Schedule,,59.62,,,59.62,Fee Schedule,,66.96,,,66.96,Fee Schedule,,63.48,,,63.48,Fee Schedule,,75.6,70,,75.6,percent of total billed charges,All Other,76.16,,,76.16,Fee Schedule,,64.55,,,64.55,Fee Schedule,,24.11,,,24.11,Fee Schedule,,24.11,,,24.11,Fee Schedule,,24.11,,,24.11,Fee Schedule,,24.11,,,24.11,Fee Schedule,,8.11,,,8.11,Other,100% of Medicaid,8.11,,,8.11,Other,100% of Medicaid,8.11,,,8.11,Other,100% of Medicaid,8.11,,,8.11,Other,100% of Medicaid,18.25,,,18.25,Other,225% of Medicaid,12.41,,,12.41,Other,153% of Medicaid,18.25,,,18.25,Other,225% of Medicaid,11.35,,,11.35,Other,140% of Medicaid,18.25,,,18.25,Other,225% of Medicaid,21.09,,,21.09,Other,260% of Medicaid,26.28,,,26.28,Other,324% of Medicaid,17.44,,,17.44,Other,215% of Medicaid,17.44,,,17.44,Other,215% of Medicaid,10.14,,,10.14,Other,125% of Medicaid,8.11,79.92,
BODY FLUID CELL COUNT,89051,CPT,,78089051,CDM,309,RC,,,both,,,74,54.76,,,54.76,Other,150% of Medicare + 9.63% HCRA Surcharge,33.3,45,,33.3,percent of total billed charges,Critical Access Hospital RCC factor,16.86,,,16.86,Fee Schedule,,15.18,,,15.18,Fee Schedule,,31.83,,,31.83,Fee Schedule,,28.63,,,28.63,Fee Schedule,,27.06,,,27.06,Fee Schedule,,36.63,,,36.63,Other,110% of Medicare,17.64,,,17.64,Fee Schedule,,5,,,5,Other,186% of Medicaid,20.78,,,20.78,Fee Schedule,,45.88,,,45.88,Fee Schedule,,11.76,,,11.76,Fee Schedule,,20.78,,,20.78,Fee Schedule,,45.88,,,45.88,Fee Schedule,,22.12,,,22.12,Fee Schedule,,51.8,70,,51.8,percent of total billed charges,All Other,26.54,,,26.54,Fee Schedule,,22.49,,,22.49,Fee Schedule,,8.4,,,8.4,Fee Schedule,,8.4,,,8.4,Fee Schedule,,8.4,,,8.4,Fee Schedule,,8.4,,,8.4,Fee Schedule,,2.83,,,2.83,Other,100% of Medicaid,2.83,,,2.83,Other,100% of Medicaid,2.83,,,2.83,Other,100% of Medicaid,2.83,,,2.83,Other,100% of Medicaid,6.36,,,6.36,Other,225% of Medicaid,4.33,,,4.33,Other,153% of Medicaid,6.36,,,6.36,Other,225% of Medicaid,3.96,,,3.96,Other,140% of Medicaid,6.36,,,6.36,Other,225% of Medicaid,7.35,,,7.35,Other,260% of Medicaid,9.16,,,9.16,Other,324% of Medicaid,6.08,,,6.08,Other,215% of Medicaid,6.08,,,6.08,Other,215% of Medicaid,3.54,,,3.54,Other,125% of Medicaid,2.83,54.76,
EXAM SYNOVIAL FLUID CRYSTALS,89060,CPT,,78089060,CDM,309,RC,,,both,,,80,59.2,,,59.2,Other,150% of Medicare + 9.63% HCRA Surcharge,36,45,,36,percent of total billed charges,Critical Access Hospital RCC factor,22.06,,,22.06,Fee Schedule,,19.86,,,19.86,Fee Schedule,,53.02,,,53.02,Fee Schedule,,47.68,,,47.68,Fee Schedule,,45.07,,,45.07,Fee Schedule,,39.6,,,39.6,Other,110% of Medicare,23.09,,,23.09,Fee Schedule,,11,,,11,Other,186% of Medicaid,27.19,,,27.19,Fee Schedule,,49.6,,,49.6,Fee Schedule,,15.39,,,15.39,Fee Schedule,,27.19,,,27.19,Fee Schedule,,49.6,,,49.6,Fee Schedule,,28.95,,,28.95,Fee Schedule,,56,70,,56,percent of total billed charges,All Other,34.74,,,34.74,Fee Schedule,,29.44,,,29.44,Fee Schedule,,11,,,11,Fee Schedule,,11,,,11,Fee Schedule,,11,,,11,Fee Schedule,,11,,,11,Fee Schedule,,6.06,,,6.06,Other,100% of Medicaid,6.06,,,6.06,Other,100% of Medicaid,6.06,,,6.06,Other,100% of Medicaid,6.06,,,6.06,Other,100% of Medicaid,13.64,,,13.64,Other,225% of Medicaid,9.27,,,9.27,Other,153% of Medicaid,13.64,,,13.64,Other,225% of Medicaid,8.48,,,8.48,Other,140% of Medicaid,13.64,,,13.64,Other,225% of Medicaid,15.76,,,15.76,Other,260% of Medicaid,19.63,,,19.63,Other,324% of Medicaid,13.03,,,13.03,Other,215% of Medicaid,13.03,,,13.03,Other,215% of Medicaid,7.58,,,7.58,Other,125% of Medicaid,6.06,59.2,
SPECIMEN FAT STAIN,89125,CPT,,78089125,CDM,309,RC,,,both,,,31,22.94,,,22.94,Other,150% of Medicare + 9.63% HCRA Surcharge,13.95,45,,13.95,percent of total billed charges,Critical Access Hospital RCC factor,17.7,,,17.7,Fee Schedule,,15.93,,,15.93,Fee Schedule,,32.04,,,32.04,Fee Schedule,,28.82,,,28.82,Fee Schedule,,27.24,,,27.24,Fee Schedule,,15.35,,,15.35,Other,110% of Medicare,18.52,,,18.52,Fee Schedule,,65,,,65,Other,186% of Medicaid,21.81,,,21.81,Fee Schedule,,19.22,,,19.22,Fee Schedule,,12.35,,,12.35,Fee Schedule,,21.81,,,21.81,Fee Schedule,,19.22,,,19.22,Fee Schedule,,23.23,,,23.23,Fee Schedule,,21.7,70,,21.7,percent of total billed charges,All Other,27.87,,,27.87,Fee Schedule,,23.62,,,23.62,Fee Schedule,,8.82,,,8.82,Fee Schedule,,8.82,,,8.82,Fee Schedule,,8.82,,,8.82,Fee Schedule,,8.82,,,8.82,Fee Schedule,,35.14,,,35.14,Other,100% of Medicaid,35.14,,,35.14,Other,100% of Medicaid,35.14,,,35.14,Other,100% of Medicaid,35.14,,,35.14,Other,100% of Medicaid,79.05,,,79.05,Other,225% of Medicaid,53.76,,,53.76,Other,153% of Medicaid,79.05,,,79.05,Other,225% of Medicaid,49.19,,,49.19,Other,140% of Medicaid,79.05,,,79.05,Other,225% of Medicaid,91.35,,,91.35,Other,260% of Medicaid,113.84,,,113.84,Other,324% of Medicaid,75.54,,,75.54,Other,215% of Medicaid,75.54,,,75.54,Other,215% of Medicaid,43.92,,,43.92,Other,125% of Medicaid,8.82,113.84,
NASAL SMEAR FOR EOSINOPHILS,89190,CPT,,78089190,CDM,309,RC,,,both,,,61,45.14,,,45.14,Other,150% of Medicare + 9.63% HCRA Surcharge,27.45,45,,27.45,percent of total billed charges,Critical Access Hospital RCC factor,17.43,,,17.43,Fee Schedule,,15.69,,,15.69,Fee Schedule,,35.2,,,35.2,Fee Schedule,,31.66,,,31.66,Fee Schedule,,29.93,,,29.93,Fee Schedule,,30.2,,,30.2,Other,110% of Medicare,18.24,,,18.24,Fee Schedule,,9,,,9,Other,186% of Medicaid,21.48,,,21.48,Fee Schedule,,37.82,,,37.82,Fee Schedule,,12.16,,,12.16,Fee Schedule,,21.48,,,21.48,Fee Schedule,,37.82,,,37.82,Fee Schedule,,22.87,,,22.87,Fee Schedule,,42.7,70,,42.7,percent of total billed charges,All Other,27.44,,,27.44,Fee Schedule,,23.26,,,23.26,Fee Schedule,,8.69,,,8.69,Fee Schedule,,8.69,,,8.69,Fee Schedule,,8.69,,,8.69,Fee Schedule,,8.69,,,8.69,Fee Schedule,,4.75,,,4.75,Other,100% of Medicaid,4.75,,,4.75,Other,100% of Medicaid,4.75,,,4.75,Other,100% of Medicaid,4.75,,,4.75,Other,100% of Medicaid,10.68,,,10.68,Other,225% of Medicaid,7.26,,,7.26,Other,153% of Medicaid,10.68,,,10.68,Other,225% of Medicaid,6.65,,,6.65,Other,140% of Medicaid,10.68,,,10.68,Other,225% of Medicaid,12.34,,,12.34,Other,260% of Medicaid,15.38,,,15.38,Other,324% of Medicaid,10.21,,,10.21,Other,215% of Medicaid,10.21,,,10.21,Other,215% of Medicaid,5.93,,,5.93,Other,125% of Medicaid,4.75,45.14,
COLLECT SWEAT FOR TEST,89230,CPT,,78089230,CDM,309,RC,,,both,,,161,119.14,,,119.14,Other,150% of Medicare + 9.63% HCRA Surcharge,72.45,45,,72.45,percent of total billed charges,Critical Access Hospital RCC factor,9.96,,,9.96,Fee Schedule,,8.97,,,8.97,Fee Schedule,,20.71,,,20.71,Fee Schedule,,18.63,,,18.63,Fee Schedule,,17.61,,,17.61,Fee Schedule,,79.7,,,79.7,Other,110% of Medicare,10.43,,,10.43,Fee Schedule,,12,,,12,Other,186% of Medicaid,12.28,,,12.28,Fee Schedule,,99.82,,,99.82,Fee Schedule,,6.95,,,6.95,Fee Schedule,,12.28,,,12.28,Fee Schedule,,99.82,,,99.82,Fee Schedule,,13.07,,,13.07,Fee Schedule,,112.7,70,,112.7,percent of total billed charges,All Other,11.48,,,11.48,Fee Schedule,,9.73,,,9.73,Fee Schedule,,74.21,,,74.21,Fee Schedule,,74.21,,,74.21,Fee Schedule,,74.21,,,74.21,Fee Schedule,,74.21,,,74.21,Fee Schedule,,6.44,,,6.44,Other,100% of Medicaid,6.44,,,6.44,Other,100% of Medicaid,6.44,,,6.44,Other,100% of Medicaid,6.44,,,6.44,Other,100% of Medicaid,14.5,,,14.5,Other,225% of Medicaid,9.86,,,9.86,Other,153% of Medicaid,14.5,,,14.5,Other,225% of Medicaid,9.02,,,9.02,Other,140% of Medicaid,14.5,,,14.5,Other,225% of Medicaid,16.75,,,16.75,Other,260% of Medicaid,20.88,,,20.88,Other,324% of Medicaid,13.85,,,13.85,Other,215% of Medicaid,13.85,,,13.85,Other,215% of Medicaid,8.05,,,8.05,Other,125% of Medicaid,6.44,119.14,
SEMEN; PRESENCE & MOTILITY,89300,CPT,,78089300,CDM,309,RC,,,both,,,174,128.76,,,128.76,Other,150% of Medicare + 9.63% HCRA Surcharge,78.3,45,,78.3,percent of total billed charges,Critical Access Hospital RCC factor,29.62,,,29.62,Fee Schedule,,26.67,,,26.67,Fee Schedule,,66.14,,,66.14,Fee Schedule,,59.49,,,59.49,Fee Schedule,,56.22,,,56.22,Fee Schedule,,86.13,,,86.13,Other,110% of Medicare,31,,,31,Fee Schedule,,65,,,65,Other,186% of Medicaid,36.51,,,36.51,Fee Schedule,,107.88,,,107.88,Fee Schedule,,20.66,,,20.66,Fee Schedule,,36.51,,,36.51,Fee Schedule,,107.88,,,107.88,Fee Schedule,,38.87,,,38.87,Fee Schedule,,121.8,70,,121.8,percent of total billed charges,All Other,46.63,,,46.63,Fee Schedule,,39.52,,,39.52,Fee Schedule,,14.76,,,14.76,Fee Schedule,,14.76,,,14.76,Fee Schedule,,14.76,,,14.76,Fee Schedule,,14.76,,,14.76,Fee Schedule,,35.14,,,35.14,Other,100% of Medicaid,35.14,,,35.14,Other,100% of Medicaid,35.14,,,35.14,Other,100% of Medicaid,35.14,,,35.14,Other,100% of Medicaid,79.05,,,79.05,Other,225% of Medicaid,53.76,,,53.76,Other,153% of Medicaid,79.05,,,79.05,Other,225% of Medicaid,49.19,,,49.19,Other,140% of Medicaid,79.05,,,79.05,Other,225% of Medicaid,91.35,,,91.35,Other,260% of Medicaid,113.84,,,113.84,Other,324% of Medicaid,75.54,,,75.54,Other,215% of Medicaid,75.54,,,75.54,Other,215% of Medicaid,43.92,,,43.92,Other,125% of Medicaid,14.76,128.76,
SEMEN; MOTILITY & COUNT,89310,CPT,,78089310,CDM,309,RC,,,both,,,123,91.02,,,91.02,Other,150% of Medicare + 9.63% HCRA Surcharge,55.35,45,,55.35,percent of total billed charges,Critical Access Hospital RCC factor,25.92,,,25.92,Fee Schedule,,23.33,,,23.33,Fee Schedule,,63.82,,,63.82,Fee Schedule,,57.4,,,57.4,Fee Schedule,,54.25,,,54.25,Fee Schedule,,60.89,,,60.89,Other,110% of Medicare,27.12,,,27.12,Fee Schedule,,65,,,65,Other,186% of Medicaid,31.94,,,31.94,Fee Schedule,,76.26,,,76.26,Fee Schedule,,18.08,,,18.08,Fee Schedule,,31.94,,,31.94,Fee Schedule,,76.26,,,76.26,Fee Schedule,,34.01,,,34.01,Fee Schedule,,86.1,70,,86.1,percent of total billed charges,All Other,40.8,,,40.8,Fee Schedule,,34.58,,,34.58,Fee Schedule,,12.92,,,12.92,Fee Schedule,,12.92,,,12.92,Fee Schedule,,12.92,,,12.92,Fee Schedule,,12.92,,,12.92,Fee Schedule,,35.14,,,35.14,Other,100% of Medicaid,35.14,,,35.14,Other,100% of Medicaid,35.14,,,35.14,Other,100% of Medicaid,35.14,,,35.14,Other,100% of Medicaid,79.05,,,79.05,Other,225% of Medicaid,53.76,,,53.76,Other,153% of Medicaid,79.05,,,79.05,Other,225% of Medicaid,49.19,,,49.19,Other,140% of Medicaid,79.05,,,79.05,Other,225% of Medicaid,91.35,,,91.35,Other,260% of Medicaid,113.84,,,113.84,Other,324% of Medicaid,75.54,,,75.54,Other,215% of Medicaid,75.54,,,75.54,Other,215% of Medicaid,43.92,,,43.92,Other,125% of Medicaid,12.92,113.84,
SEMEN ANALYSIS VOL/COUNT/MOT,89320,CPT,,78089320,CDM,309,RC,,,both,,,225,166.5,,,166.5,Other,150% of Medicare + 9.63% HCRA Surcharge,101.25,45,,101.25,percent of total billed charges,Critical Access Hospital RCC factor,37.05,,,37.05,Fee Schedule,,33.36,,,33.36,Fee Schedule,,89.38,,,89.38,Fee Schedule,,80.39,,,80.39,Fee Schedule,,75.98,,,75.98,Fee Schedule,,111.38,,,111.38,Other,110% of Medicare,38.78,,,38.78,Fee Schedule,,65,,,65,Other,186% of Medicaid,45.67,,,45.67,Fee Schedule,,139.5,,,139.5,Fee Schedule,,25.85,,,25.85,Fee Schedule,,45.67,,,45.67,Fee Schedule,,139.5,,,139.5,Fee Schedule,,48.62,,,48.62,Fee Schedule,,157.5,70,,157.5,percent of total billed charges,All Other,58.34,,,58.34,Fee Schedule,,49.44,,,49.44,Fee Schedule,,18.47,,,18.47,Fee Schedule,,18.47,,,18.47,Fee Schedule,,18.47,,,18.47,Fee Schedule,,18.47,,,18.47,Fee Schedule,,35.14,,,35.14,Other,100% of Medicaid,35.14,,,35.14,Other,100% of Medicaid,35.14,,,35.14,Other,100% of Medicaid,35.14,,,35.14,Other,100% of Medicaid,79.05,,,79.05,Other,225% of Medicaid,53.76,,,53.76,Other,153% of Medicaid,79.05,,,79.05,Other,225% of Medicaid,49.19,,,49.19,Other,140% of Medicaid,79.05,,,79.05,Other,225% of Medicaid,91.35,,,91.35,Other,260% of Medicaid,113.84,,,113.84,Other,324% of Medicaid,75.54,,,75.54,Other,215% of Medicaid,75.54,,,75.54,Other,215% of Medicaid,43.92,,,43.92,Other,125% of Medicaid,18.47,166.5,
SPECIMEN HANDLING PT-LAB,99001,CPT,,78099001,CDM,309,RC,,,both,,,57,42.18,,,42.18,Other,150% of Medicare + 9.63% HCRA Surcharge,25.65,45,,25.65,percent of total billed charges,Critical Access Hospital RCC factor,37.05,65,,37.05,percent of total billed charges,All Other,33.63,65,,33.63,percent of total billed charges,All Other,5.68,,,5.68,Fee Schedule,,5.68,,,5.68,Fee Schedule,,5.68,,,5.68,Fee Schedule,,28.22,,,28.22,Other,110% of Medicare,38.76,68,,38.76,percent of total billed charges,All Other,61,,,61,Other,186% of Medicaid,47.31,83,,47.31,percent of total billed charges,All Other,35.34,62,,35.34,percent of total billed charges,Lab and Radiology,31.35,55,,31.35,percent of total billed charges,Default if not on Fee Schedule,45.6,80,,45.6,percent of total billed charges,All Other,35.34,62,,35.34,percent of total billed charges,Lab and Radiology,45.6,80,,45.6,percent of total billed charges,All Other,39.9,70,,39.9,percent of total billed charges,All Other,37.05,65,,37.05,percent of total billed charges,Default if not in Fee Schedule,37.05,65,,37.05,percent of total billed charges,Default if not in Fee Schedule,9.21,,,9.21,Fee Schedule,,9.21,,,9.21,Fee Schedule,,9.21,,,9.21,Fee Schedule,,9.21,,,9.21,Fee Schedule,,32.83,,,32.83,Other,100% of Medicaid,32.83,,,32.83,Other,100% of Medicaid,32.83,,,32.83,Other,100% of Medicaid,32.83,,,32.83,Other,100% of Medicaid,73.87,,,73.87,Other,225% of Medicaid,50.23,,,50.23,Other,153% of Medicaid,73.87,,,73.87,Other,225% of Medicaid,45.96,,,45.96,Other,140% of Medicaid,73.87,,,73.87,Other,225% of Medicaid,85.36,,,85.36,Other,260% of Medicaid,106.38,,,106.38,Other,324% of Medicaid,70.59,,,70.59,Other,215% of Medicaid,70.59,,,70.59,Other,215% of Medicaid,41.04,,,41.04,Other,125% of Medicaid,5.68,106.38,
PATH CLIN CONSLT SF 5-20,80503,CPT,,78080503,CDM,310,RC,,,both,,,194,143.56,,,143.56,Other,150% of Medicare + 9.63% HCRA Surcharge,87.3,45,,87.3,percent of total billed charges,Critical Access Hospital RCC factor,68.63,,,68.63,Fee Schedule,,61.79,,,61.79,Fee Schedule,,24.78,,,24.78,Fee Schedule,,24.78,,,24.78,Fee Schedule,,24.78,,,24.78,Fee Schedule,,96.03,,,96.03,Other,110% of Medicare,71.82,,,71.82,Fee Schedule,,30,,,30,Other,186% of Medicaid,84.59,,,84.59,Fee Schedule,,120.28,,,120.28,Fee Schedule,,47.88,,,47.88,Fee Schedule,,84.59,,,84.59,Fee Schedule,,120.28,,,120.28,Fee Schedule,,90.06,,,90.06,Fee Schedule,,135.8,70,,135.8,percent of total billed charges,All Other,106.6,,,106.6,Fee Schedule,,90.35,,,90.35,Fee Schedule,,76.13,,,76.13,Fee Schedule,,76.13,,,76.13,Fee Schedule,,76.13,,,76.13,Fee Schedule,,76.13,,,76.13,Fee Schedule,,16.15,,,16.15,Other,100% of Medicaid,16.15,,,16.15,Other,100% of Medicaid,16.15,,,16.15,Other,100% of Medicaid,16.15,,,16.15,Other,100% of Medicaid,36.34,,,36.34,Other,225% of Medicaid,24.71,,,24.71,Other,153% of Medicaid,36.34,,,36.34,Other,225% of Medicaid,22.61,,,22.61,Other,140% of Medicaid,36.34,,,36.34,Other,225% of Medicaid,41.99,,,41.99,Other,260% of Medicaid,52.33,,,52.33,Other,324% of Medicaid,34.72,,,34.72,Other,215% of Medicaid,34.72,,,34.72,Other,215% of Medicaid,20.19,,,20.19,Other,125% of Medicaid,16.15,143.56,
MOPATH PROCEDURE LEVEL 8,81407,CPT,,78081407,CDM,310,RC,,,both,,,2666,1972.85,,,1972.85,Other,150% of Medicare + 9.63% HCRA Surcharge,1199.7,45,,1199.7,percent of total billed charges,Critical Access Hospital RCC factor,2547.27,,,2547.27,Fee Schedule,,2293.39,,,2293.39,Fee Schedule,,846.27,,,846.27,Fee Schedule,,846.27,,,846.27,Fee Schedule,,846.27,,,846.27,Fee Schedule,,1319.67,,,1319.67,Other,110% of Medicare,2665.75,,,2665.75,Fee Schedule,,0.01,,,0.01,Other,186% of Medicaid,3139.66,,,3139.66,Fee Schedule,,1652.92,,,1652.92,Fee Schedule,,1777.17,,,1777.17,Fee Schedule,,3139.66,,,3139.66,Fee Schedule,,1652.92,,,1652.92,Fee Schedule,,3342.77,,,3342.77,Fee Schedule,,1866.2,70,,1866.2,percent of total billed charges,All Other,4010.5,,,4010.5,Fee Schedule,,3399.15,,,3399.15,Fee Schedule,,1269.41,,,1269.41,Fee Schedule,,1269.41,,,1269.41,Fee Schedule,,1269.41,,,1269.41,Fee Schedule,,1269.41,,,1269.41,Fee Schedule,,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4010.5,
FETAL CHRMOML ANEUPLOIDY,81420,CPT,,78081420,CDM,310,RC,,,both,,,2392,1770.09,,,1770.09,Other,150% of Medicare + 9.63% HCRA Surcharge,1076.4,45,,1076.4,percent of total billed charges,Critical Access Hospital RCC factor,2284.74,,,2284.74,Fee Schedule,,2057.03,,,2057.03,Fee Schedule,,700,,,700,Fee Schedule,,700,,,700,Fee Schedule,,700,,,700,Fee Schedule,,1184.04,,,1184.04,Other,110% of Medicare,2391.01,,,2391.01,Fee Schedule,,0.01,,,0.01,Other,186% of Medicaid,2816.08,,,2816.08,Fee Schedule,,1483.04,,,1483.04,Fee Schedule,,1594.01,,,1594.01,Fee Schedule,,2816.08,,,2816.08,Fee Schedule,,1483.04,,,1483.04,Fee Schedule,,2998.25,,,2998.25,Fee Schedule,,1674.4,70,,1674.4,percent of total billed charges,All Other,3597.16,,,3597.16,Fee Schedule,,3048.82,,,3048.82,Fee Schedule,,1138.58,,,1138.58,Fee Schedule,,1138.58,,,1138.58,Fee Schedule,,1138.58,,,1138.58,Fee Schedule,,1138.58,,,1138.58,Fee Schedule,,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3597.16,
NOONAN SPECTRUM DISORDERS,81442,CPT,,78081442,CDM,310,RC,,,both,,,4818,3565.33,,,3565.33,Other,150% of Medicare + 9.63% HCRA Surcharge,2168.1,45,,2168.1,percent of total billed charges,Critical Access Hospital RCC factor,6452.24,,,6452.24,Fee Schedule,,5809.16,,,5809.16,Fee Schedule,,1071.8,,,1071.8,Fee Schedule,,1071.8,,,1071.8,Fee Schedule,,1071.8,,,1071.8,Fee Schedule,,2384.91,,,2384.91,Other,110% of Medicare,6752.34,,,6752.34,Fee Schedule,,0.01,,,0.01,Other,186% of Medicaid,7952.76,,,7952.76,Fee Schedule,,2987.16,,,2987.16,Fee Schedule,,4501.56,,,4501.56,Fee Schedule,,7952.76,,,7952.76,Fee Schedule,,2987.16,,,2987.16,Fee Schedule,,8467.22,,,8467.22,Fee Schedule,,3372.6,70,,3372.6,percent of total billed charges,All Other,10158.6,,,10158.6,Fee Schedule,,8610.03,,,8610.03,Fee Schedule,,3215.4,,,3215.4,Fee Schedule,,3215.4,,,3215.4,Fee Schedule,,3215.4,,,3215.4,Fee Schedule,,3215.4,,,3215.4,Fee Schedule,,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,10158.6,
ONC BRST MRNA 70 CNT 31 GENE,81523,CPT,,78081523,CDM,310,RC,,,both,,,12200,9028.03,,,9028.03,Other,150% of Medicare + 9.63% HCRA Surcharge,5490,45,,5490,percent of total billed charges,Critical Access Hospital RCC factor,11657.73,,,11657.73,Fee Schedule,,10495.83,,,10495.83,Fee Schedule,,3873,,,3873,Fee Schedule,,3873,,,3873,Fee Schedule,,3873,,,3873,Fee Schedule,,6039,,,6039,Other,110% of Medicare,12199.95,,,12199.95,Fee Schedule,,0.01,,,0.01,Other,186% of Medicaid,14368.83,,,14368.83,Fee Schedule,,7564,,,7564,Fee Schedule,,8133.3,,,8133.3,Fee Schedule,,14368.83,,,14368.83,Fee Schedule,,7564,,,7564,Fee Schedule,,15298.35,,,15298.35,Fee Schedule,,8540,70,,8540,percent of total billed charges,All Other,18354.28,,,18354.28,Fee Schedule,,15556.37,,,15556.37,Fee Schedule,,5809.5,,,5809.5,Fee Schedule,,5809.5,,,5809.5,Fee Schedule,,5809.5,,,5809.5,Fee Schedule,,5809.5,,,5809.5,Fee Schedule,,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,18354.28,
NFCT DS CHRNC HCV 6 ASSAYS,81596,CPT,,78081596,CDM,310,RC,,,both,,,228,168.72,,,168.72,Other,150% of Medicare + 9.63% HCRA Surcharge,102.6,45,,102.6,percent of total billed charges,Critical Access Hospital RCC factor,217.29,,,217.29,Fee Schedule,,195.63,,,195.63,Fee Schedule,,72.19,,,72.19,Fee Schedule,,72.19,,,72.19,Fee Schedule,,72.19,,,72.19,Fee Schedule,,112.86,,,112.86,Other,110% of Medicare,227.4,,,227.4,Fee Schedule,,108,,,108,Other,186% of Medicaid,267.82,,,267.82,Fee Schedule,,141.36,,,141.36,Fee Schedule,,151.6,,,151.6,Fee Schedule,,267.82,,,267.82,Fee Schedule,,141.36,,,141.36,Fee Schedule,,285.15,,,285.15,Fee Schedule,,159.6,70,,159.6,percent of total billed charges,All Other,342.11,,,342.11,Fee Schedule,,289.96,,,289.96,Fee Schedule,,108.29,,,108.29,Fee Schedule,,108.29,,,108.29,Fee Schedule,,108.29,,,108.29,Fee Schedule,,108.29,,,108.29,Fee Schedule,,58.33,,,58.33,Other,100% of Medicaid,58.33,,,58.33,Other,100% of Medicaid,58.33,,,58.33,Other,100% of Medicaid,58.33,,,58.33,Other,100% of Medicaid,131.24,,,131.24,Other,225% of Medicaid,89.24,,,89.24,Other,153% of Medicaid,131.24,,,131.24,Other,225% of Medicaid,81.66,,,81.66,Other,140% of Medicaid,131.24,,,131.24,Other,225% of Medicaid,151.65,,,151.65,Other,260% of Medicaid,188.98,,,188.98,Other,324% of Medicaid,125.4,,,125.4,Other,215% of Medicaid,125.4,,,125.4,Other,215% of Medicaid,72.91,,,72.91,Other,125% of Medicaid,58.33,342.11,
BONE MARROW INTERPRETATION,85097,CPT,,78085097,CDM,310,RC,,,both,,,1749,1294.26,,,1294.26,Other,150% of Medicare + 9.63% HCRA Surcharge,787.05,45,,787.05,percent of total billed charges,Critical Access Hospital RCC factor,148.93,,,148.93,Fee Schedule,,134.09,,,134.09,Fee Schedule,,538.8,,,538.8,Fee Schedule,,484.62,,,484.62,Fee Schedule,,458.04,,,458.04,Fee Schedule,,865.76,,,865.76,Other,110% of Medicare,155.86,,,155.86,Fee Schedule,,38,,,38,Other,186% of Medicaid,183.57,,,183.57,Fee Schedule,,1084.38,,,1084.38,Fee Schedule,,103.91,,,103.91,Fee Schedule,,183.57,,,183.57,Fee Schedule,,1084.38,,,1084.38,Fee Schedule,,195.45,,,195.45,Fee Schedule,,1224.3,70,,1224.3,percent of total billed charges,All Other,229.6,,,229.6,Fee Schedule,,194.6,,,194.6,Fee Schedule,,942.3,,,942.3,Fee Schedule,,942.3,,,942.3,Fee Schedule,,942.3,,,942.3,Fee Schedule,,942.3,,,942.3,Fee Schedule,,20.42,,,20.42,Other,100% of Medicaid,20.42,,,20.42,Other,100% of Medicaid,20.42,,,20.42,Other,100% of Medicaid,20.42,,,20.42,Other,100% of Medicaid,45.95,,,45.95,Other,225% of Medicaid,31.25,,,31.25,Other,153% of Medicaid,45.95,,,45.95,Other,225% of Medicaid,28.59,,,28.59,Other,140% of Medicaid,45.95,,,45.95,Other,225% of Medicaid,53.1,,,53.1,Other,260% of Medicaid,66.17,,,66.17,Other,324% of Medicaid,43.91,,,43.91,Other,215% of Medicaid,43.91,,,43.91,Other,215% of Medicaid,25.53,,,25.53,Other,125% of Medicaid,20.42,1294.26,
CYTP URNE 3-5 PROBES EA SPEC,88120,CPT,,78088120,CDM,310,RC,,,both,,,2695,1994.31,,,1994.31,Other,150% of Medicare + 9.63% HCRA Surcharge,1212.75,45,,1212.75,percent of total billed charges,Critical Access Hospital RCC factor,1712.99,,,1712.99,Fee Schedule,,1542.26,,,1542.26,Fee Schedule,,2721.11,,,2721.11,Fee Schedule,,2447.45,,,2447.45,Fee Schedule,,2313.2,,,2313.2,Fee Schedule,,1334.03,,,1334.03,Other,110% of Medicare,1792.67,,,1792.67,Fee Schedule,,334,,,334,Other,186% of Medicaid,2111.36,,,2111.36,Fee Schedule,,1670.9,,,1670.9,Fee Schedule,,1195.11,,,1195.11,Fee Schedule,,2111.36,,,2111.36,Fee Schedule,,1670.9,,,1670.9,Fee Schedule,,2247.95,,,2247.95,Fee Schedule,,1886.5,70,,1886.5,percent of total billed charges,All Other,2712.56,,,2712.56,Fee Schedule,,2299.06,,,2299.06,Fee Schedule,,215.25,,,215.25,Fee Schedule,,215.25,,,215.25,Fee Schedule,,215.25,,,215.25,Fee Schedule,,215.25,,,215.25,Fee Schedule,,179.38,,,179.38,Other,100% of Medicaid,179.38,,,179.38,Other,100% of Medicaid,179.38,,,179.38,Other,100% of Medicaid,179.38,,,179.38,Other,100% of Medicaid,403.6,,,403.6,Other,225% of Medicaid,274.45,,,274.45,Other,153% of Medicaid,403.6,,,403.6,Other,225% of Medicaid,251.13,,,251.13,Other,140% of Medicaid,403.6,,,403.6,Other,225% of Medicaid,466.38,,,466.38,Other,260% of Medicaid,581.18,,,581.18,Other,324% of Medicaid,385.66,,,385.66,Other,215% of Medicaid,385.66,,,385.66,Other,215% of Medicaid,224.22,,,224.22,Other,125% of Medicaid,179.38,2721.11,
CYTOPATH C/V AUTO FLUID REDO,88175,CPT,,78088175,CDM,310,RC,,,both,,,159,117.66,,,117.66,Other,150% of Medicare + 9.63% HCRA Surcharge,71.55,45,,71.55,percent of total billed charges,Critical Access Hospital RCC factor,80.1,,,80.1,Fee Schedule,,72.11,,,72.11,Fee Schedule,,184.77,,,184.77,Fee Schedule,,166.18,,,166.18,Fee Schedule,,157.07,,,157.07,Fee Schedule,,78.71,,,78.71,Other,110% of Medicare,83.82,,,83.82,Fee Schedule,,49,,,49,Other,186% of Medicaid,98.72,,,98.72,Fee Schedule,,98.58,,,98.58,Fee Schedule,,55.88,,,55.88,Fee Schedule,,98.72,,,98.72,Fee Schedule,,98.58,,,98.58,Fee Schedule,,105.11,,,105.11,Fee Schedule,,111.3,70,,111.3,percent of total billed charges,All Other,126.11,,,126.11,Fee Schedule,,106.88,,,106.88,Fee Schedule,,39.92,,,39.92,Fee Schedule,,39.92,,,39.92,Fee Schedule,,39.92,,,39.92,Fee Schedule,,39.92,,,39.92,Fee Schedule,,26.61,,,26.61,Other,100% of Medicaid,26.61,,,26.61,Other,100% of Medicaid,26.61,,,26.61,Other,100% of Medicaid,26.61,,,26.61,Other,100% of Medicaid,59.87,,,59.87,Other,225% of Medicaid,40.71,,,40.71,Other,153% of Medicaid,59.87,,,59.87,Other,225% of Medicaid,37.25,,,37.25,Other,140% of Medicaid,59.87,,,59.87,Other,225% of Medicaid,69.19,,,69.19,Other,260% of Medicaid,86.22,,,86.22,Other,324% of Medicaid,57.21,,,57.21,Other,215% of Medicaid,57.21,,,57.21,Other,215% of Medicaid,33.26,,,33.26,Other,125% of Medicaid,26.61,184.77,
TISSUE CULTURE PLACENTA,88235,CPT,,78088235,CDM,310,RC,,,both,,,961,711.14,,,711.14,Other,150% of Medicare + 9.63% HCRA Surcharge,432.45,45,,432.45,percent of total billed charges,Critical Access Hospital RCC factor,452.4,,,452.4,Fee Schedule,,407.31,,,407.31,Fee Schedule,,190.72,,,190.72,Fee Schedule,,171.54,,,171.54,Fee Schedule,,162.13,,,162.13,Fee Schedule,,475.7,,,475.7,Other,110% of Medicare,473.45,,,473.45,Fee Schedule,,248,,,248,Other,186% of Medicaid,557.61,,,557.61,Fee Schedule,,595.82,,,595.82,Fee Schedule,,315.63,,,315.63,Fee Schedule,,557.61,,,557.61,Fee Schedule,,595.82,,,595.82,Fee Schedule,,593.69,,,593.69,Fee Schedule,,672.7,70,,672.7,percent of total billed charges,All Other,712.28,,,712.28,Fee Schedule,,603.7,,,603.7,Fee Schedule,,225.45,,,225.45,Fee Schedule,,225.45,,,225.45,Fee Schedule,,225.45,,,225.45,Fee Schedule,,225.45,,,225.45,Fee Schedule,,133.23,,,133.23,Other,100% of Medicaid,133.23,,,133.23,Other,100% of Medicaid,133.23,,,133.23,Other,100% of Medicaid,133.23,,,133.23,Other,100% of Medicaid,299.77,,,299.77,Other,225% of Medicaid,203.84,,,203.84,Other,153% of Medicaid,299.77,,,299.77,Other,225% of Medicaid,186.52,,,186.52,Other,140% of Medicaid,299.77,,,299.77,Other,225% of Medicaid,346.4,,,346.4,Other,260% of Medicaid,431.66,,,431.66,Other,324% of Medicaid,286.44,,,286.44,Other,215% of Medicaid,286.44,,,286.44,Other,215% of Medicaid,166.54,,,166.54,Other,125% of Medicaid,133.23,712.28,
CHROMOSOME ANALYSIS 20-25,88264,CPT,,78088264,CDM,310,RC,,,both,,,1316,973.84,,,973.84,Other,150% of Medicare + 9.63% HCRA Surcharge,592.2,45,,592.2,percent of total billed charges,Critical Access Hospital RCC factor,435.28,,,435.28,Fee Schedule,,391.89,,,391.89,Fee Schedule,,924.36,,,924.36,Fee Schedule,,831.4,,,831.4,Fee Schedule,,785.79,,,785.79,Fee Schedule,,651.42,,,651.42,Other,110% of Medicare,455.52,,,455.52,Fee Schedule,,0.01,,,0.01,Other,186% of Medicaid,536.5,,,536.5,Fee Schedule,,815.92,,,815.92,Fee Schedule,,303.68,,,303.68,Fee Schedule,,536.5,,,536.5,Fee Schedule,,815.92,,,815.92,Fee Schedule,,571.21,,,571.21,Fee Schedule,,921.2,70,,921.2,percent of total billed charges,All Other,685.31,,,685.31,Fee Schedule,,580.84,,,580.84,Fee Schedule,,216.92,,,216.92,Fee Schedule,,216.92,,,216.92,Fee Schedule,,216.92,,,216.92,Fee Schedule,,216.92,,,216.92,Fee Schedule,,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,973.84,
CHROMOSOME ANALYS PLACENTA,88267,CPT,,78088267,CDM,310,RC,,,both,,,1316,973.84,,,973.84,Other,150% of Medicare + 9.63% HCRA Surcharge,592.2,45,,592.2,percent of total billed charges,Critical Access Hospital RCC factor,567.6,,,567.6,Fee Schedule,,511.02,,,511.02,Fee Schedule,,1333.2,,,1333.2,Fee Schedule,,1199.13,,,1199.13,Fee Schedule,,1133.35,,,1133.35,Fee Schedule,,651.42,,,651.42,Other,110% of Medicare,594,,,594,Fee Schedule,,169,,,169,Other,186% of Medicaid,699.59,,,699.59,Fee Schedule,,815.92,,,815.92,Fee Schedule,,396,,,396,Fee Schedule,,699.59,,,699.59,Fee Schedule,,815.92,,,815.92,Fee Schedule,,744.85,,,744.85,Fee Schedule,,921.2,70,,921.2,percent of total billed charges,All Other,893.64,,,893.64,Fee Schedule,,757.41,,,757.41,Fee Schedule,,282.86,,,282.86,Fee Schedule,,282.86,,,282.86,Fee Schedule,,282.86,,,282.86,Fee Schedule,,282.86,,,282.86,Fee Schedule,,90.9,,,90.9,Other,100% of Medicaid,90.9,,,90.9,Other,100% of Medicaid,90.9,,,90.9,Other,100% of Medicaid,90.9,,,90.9,Other,100% of Medicaid,204.53,,,204.53,Other,225% of Medicaid,139.08,,,139.08,Other,153% of Medicaid,204.53,,,204.53,Other,225% of Medicaid,127.26,,,127.26,Other,140% of Medicaid,204.53,,,204.53,Other,225% of Medicaid,236.34,,,236.34,Other,260% of Medicaid,294.52,,,294.52,Other,324% of Medicaid,195.44,,,195.44,Other,215% of Medicaid,195.44,,,195.44,Other,215% of Medicaid,113.63,,,113.63,Other,125% of Medicaid,90.9,1333.2,
CHROMOSOME KARYOTYPE STUDY,88280,CPT,,78088280,CDM,310,RC,,,both,,,206,152.44,,,152.44,Other,150% of Medicare + 9.63% HCRA Surcharge,92.7,45,,92.7,percent of total billed charges,Critical Access Hospital RCC factor,100.74,,,100.74,Fee Schedule,,90.7,,,90.7,Fee Schedule,,186.14,,,186.14,Fee Schedule,,167.42,,,167.42,Fee Schedule,,158.23,,,158.23,Fee Schedule,,101.97,,,101.97,Other,110% of Medicare,105.43,,,105.43,Fee Schedule,,19,,,19,Other,186% of Medicaid,124.17,,,124.17,Fee Schedule,,127.72,,,127.72,Fee Schedule,,70.29,,,70.29,Fee Schedule,,124.17,,,124.17,Fee Schedule,,127.72,,,127.72,Fee Schedule,,132.21,,,132.21,Fee Schedule,,144.2,70,,144.2,percent of total billed charges,All Other,158.62,,,158.62,Fee Schedule,,134.44,,,134.44,Fee Schedule,,50.21,,,50.21,Fee Schedule,,50.21,,,50.21,Fee Schedule,,50.21,,,50.21,Fee Schedule,,50.21,,,50.21,Fee Schedule,,10.1,,,10.1,Other,100% of Medicaid,10.1,,,10.1,Other,100% of Medicaid,10.1,,,10.1,Other,100% of Medicaid,10.1,,,10.1,Other,100% of Medicaid,22.73,,,22.73,Other,225% of Medicaid,15.45,,,15.45,Other,153% of Medicaid,22.73,,,22.73,Other,225% of Medicaid,14.14,,,14.14,Other,140% of Medicaid,22.73,,,22.73,Other,225% of Medicaid,26.26,,,26.26,Other,260% of Medicaid,32.72,,,32.72,Other,324% of Medicaid,21.72,,,21.72,Other,215% of Medicaid,21.72,,,21.72,Other,215% of Medicaid,12.63,,,12.63,Other,125% of Medicaid,10.1,186.14,
COMPREHENSIVE REVIEW OF DATA,88325,CPT,,78088325,CDM,310,RC,,,both,,,579,428.46,,,428.46,Other,150% of Medicare + 9.63% HCRA Surcharge,260.55,45,,260.55,percent of total billed charges,Critical Access Hospital RCC factor,412.37,,,412.37,Fee Schedule,,371.27,,,371.27,Fee Schedule,,1242.4,,,1242.4,Fee Schedule,,1117.46,,,1117.46,Fee Schedule,,1056.16,,,1056.16,Fee Schedule,,286.61,,,286.61,Other,110% of Medicare,431.55,,,431.55,Fee Schedule,,103,,,103,Other,186% of Medicaid,508.27,,,508.27,Fee Schedule,,358.98,,,358.98,Fee Schedule,,287.7,,,287.7,Fee Schedule,,508.27,,,508.27,Fee Schedule,,358.98,,,358.98,Fee Schedule,,541.15,,,541.15,Fee Schedule,,405.3,70,,405.3,percent of total billed charges,All Other,642.88,,,642.88,Fee Schedule,,544.88,,,544.88,Fee Schedule,,74.21,,,74.21,Fee Schedule,,74.21,,,74.21,Fee Schedule,,74.21,,,74.21,Fee Schedule,,74.21,,,74.21,Fee Schedule,,55.61,,,55.61,Other,100% of Medicaid,55.61,,,55.61,Other,100% of Medicaid,55.61,,,55.61,Other,100% of Medicaid,55.61,,,55.61,Other,100% of Medicaid,125.13,,,125.13,Other,225% of Medicaid,85.09,,,85.09,Other,153% of Medicaid,125.13,,,125.13,Other,225% of Medicaid,77.86,,,77.86,Other,140% of Medicaid,125.13,,,125.13,Other,225% of Medicaid,144.59,,,144.59,Other,260% of Medicaid,180.18,,,180.18,Other,324% of Medicaid,119.57,,,119.57,Other,215% of Medicaid,119.57,,,119.57,Other,215% of Medicaid,69.51,,,69.51,Other,125% of Medicaid,55.61,1242.4,
IMMUNOHISTO ANTIBODY SLIDE,88341,CPT,,78088341,CDM,310,RC,,,both,,,357,264.18,,,264.18,Other,150% of Medicare + 9.63% HCRA Surcharge,160.65,45,,160.65,percent of total billed charges,Critical Access Hospital RCC factor,208.2,,,208.2,Fee Schedule,,187.45,,,187.45,Fee Schedule,,18.31,,,18.31,Fee Schedule,,18.31,,,18.31,Fee Schedule,,18.31,,,18.31,Fee Schedule,,176.72,,,176.72,Other,110% of Medicare,217.89,,,217.89,Fee Schedule,,48,,,48,Other,186% of Medicaid,256.62,,,256.62,Fee Schedule,,221.34,,,221.34,Fee Schedule,,145.26,,,145.26,Fee Schedule,,256.62,,,256.62,Fee Schedule,,221.34,,,221.34,Fee Schedule,,273.22,,,273.22,Fee Schedule,,249.9,70,,249.9,percent of total billed charges,All Other,291.92,,,291.92,Fee Schedule,,247.42,,,247.42,Fee Schedule,,96.9,,,96.9,Fee Schedule,,96.9,,,96.9,Fee Schedule,,96.9,,,96.9,Fee Schedule,,96.9,,,96.9,Fee Schedule,,25.62,,,25.62,Other,100% of Medicaid,25.62,,,25.62,Other,100% of Medicaid,25.62,,,25.62,Other,100% of Medicaid,25.62,,,25.62,Other,100% of Medicaid,57.65,,,57.65,Other,225% of Medicaid,39.2,,,39.2,Other,153% of Medicaid,57.65,,,57.65,Other,225% of Medicaid,35.87,,,35.87,Other,140% of Medicaid,57.65,,,57.65,Other,225% of Medicaid,66.62,,,66.62,Other,260% of Medicaid,83.02,,,83.02,Other,324% of Medicaid,55.09,,,55.09,Other,215% of Medicaid,55.09,,,55.09,Other,215% of Medicaid,32.03,,,32.03,Other,125% of Medicaid,18.31,291.92,
IMMUNOHISTO ANTIBODY SLIDE,88344,CPT,,78088344,CDM,310,RC,,,both,,,731,540.94,,,540.94,Other,150% of Medicare + 9.63% HCRA Surcharge,328.95,45,,328.95,percent of total billed charges,Critical Access Hospital RCC factor,444.91,,,444.91,Fee Schedule,,400.57,,,400.57,Fee Schedule,,30.75,,,30.75,Fee Schedule,,30.75,,,30.75,Fee Schedule,,30.75,,,30.75,Fee Schedule,,361.85,,,361.85,Other,110% of Medicare,465.6,,,465.6,Fee Schedule,,48,,,48,Other,186% of Medicaid,548.38,,,548.38,Fee Schedule,,453.22,,,453.22,Fee Schedule,,310.4,,,310.4,Fee Schedule,,548.38,,,548.38,Fee Schedule,,453.22,,,453.22,Fee Schedule,,583.85,,,583.85,Fee Schedule,,511.7,70,,511.7,percent of total billed charges,All Other,639.6,,,639.6,Fee Schedule,,542.1,,,542.1,Fee Schedule,,425.12,,,425.12,Fee Schedule,,425.12,,,425.12,Fee Schedule,,425.12,,,425.12,Fee Schedule,,425.12,,,425.12,Fee Schedule,,25.62,,,25.62,Other,100% of Medicaid,25.62,,,25.62,Other,100% of Medicaid,25.62,,,25.62,Other,100% of Medicaid,25.62,,,25.62,Other,100% of Medicaid,57.65,,,57.65,Other,225% of Medicaid,39.2,,,39.2,Other,153% of Medicaid,57.65,,,57.65,Other,225% of Medicaid,35.87,,,35.87,Other,140% of Medicaid,57.65,,,57.65,Other,225% of Medicaid,66.62,,,66.62,Other,260% of Medicaid,83.02,,,83.02,Other,324% of Medicaid,55.09,,,55.09,Other,215% of Medicaid,55.09,,,55.09,Other,215% of Medicaid,32.03,,,32.03,Other,125% of Medicaid,25.62,639.6,
IMMUNOFLUORESCENT STUDY,88346,CPT,,78088346,CDM,310,RC,,,both,,,731,540.94,,,540.94,Other,150% of Medicare + 9.63% HCRA Surcharge,328.95,45,,328.95,percent of total billed charges,Critical Access Hospital RCC factor,377.48,,,377.48,Fee Schedule,,339.86,,,339.86,Fee Schedule,,409.69,,,409.69,Fee Schedule,,368.49,,,368.49,Fee Schedule,,348.28,,,348.28,Fee Schedule,,361.85,,,361.85,Other,110% of Medicare,395.04,,,395.04,Fee Schedule,,36,,,36,Other,186% of Medicaid,465.27,,,465.27,Fee Schedule,,453.22,,,453.22,Fee Schedule,,263.36,,,263.36,Fee Schedule,,465.27,,,465.27,Fee Schedule,,453.22,,,453.22,Fee Schedule,,495.37,,,495.37,Fee Schedule,,511.7,70,,511.7,percent of total billed charges,All Other,567.44,,,567.44,Fee Schedule,,480.94,,,480.94,Fee Schedule,,425.12,,,425.12,Fee Schedule,,425.12,,,425.12,Fee Schedule,,425.12,,,425.12,Fee Schedule,,425.12,,,425.12,Fee Schedule,,19.44,,,19.44,Other,100% of Medicaid,19.44,,,19.44,Other,100% of Medicaid,19.44,,,19.44,Other,100% of Medicaid,19.44,,,19.44,Other,100% of Medicaid,43.75,,,43.75,Other,225% of Medicaid,29.75,,,29.75,Other,153% of Medicaid,43.75,,,43.75,Other,225% of Medicaid,27.22,,,27.22,Other,140% of Medicaid,43.75,,,43.75,Other,225% of Medicaid,50.55,,,50.55,Other,260% of Medicaid,62.99,,,62.99,Other,324% of Medicaid,41.8,,,41.8,Other,215% of Medicaid,41.8,,,41.8,Other,215% of Medicaid,24.3,,,24.3,Other,125% of Medicaid,19.44,567.44,
ELECTRON MICROSCOPY,88348,CPT,,78088348,CDM,310,RC,,,both,,,2218,1641.33,,,1641.33,Other,150% of Medicare + 9.63% HCRA Surcharge,998.1,45,,998.1,percent of total billed charges,Critical Access Hospital RCC factor,1342.25,,,1342.25,Fee Schedule,,1208.47,,,1208.47,Fee Schedule,,4094.63,,,4094.63,Fee Schedule,,3682.84,,,3682.84,Fee Schedule,,3480.83,,,3480.83,Fee Schedule,,1097.91,,,1097.91,Other,110% of Medicare,1404.68,,,1404.68,Fee Schedule,,123,,,123,Other,186% of Medicaid,1654.4,,,1654.4,Fee Schedule,,1375.16,,,1375.16,Fee Schedule,,936.45,,,936.45,Fee Schedule,,1654.4,,,1654.4,Fee Schedule,,1375.16,,,1375.16,Fee Schedule,,1761.42,,,1761.42,Fee Schedule,,1552.6,70,,1552.6,percent of total billed charges,All Other,1828.6,,,1828.6,Fee Schedule,,1549.85,,,1549.85,Fee Schedule,,942.3,,,942.3,Fee Schedule,,942.3,,,942.3,Fee Schedule,,942.3,,,942.3,Fee Schedule,,942.3,,,942.3,Fee Schedule,,65.91,,,65.91,Other,100% of Medicaid,65.91,,,65.91,Other,100% of Medicaid,65.91,,,65.91,Other,100% of Medicaid,65.91,,,65.91,Other,100% of Medicaid,148.29,,,148.29,Other,225% of Medicaid,100.84,,,100.84,Other,153% of Medicaid,148.29,,,148.29,Other,225% of Medicaid,92.27,,,92.27,Other,140% of Medicaid,148.29,,,148.29,Other,225% of Medicaid,171.35,,,171.35,Other,260% of Medicaid,213.53,,,213.53,Other,324% of Medicaid,141.7,,,141.7,Other,215% of Medicaid,141.7,,,141.7,Other,215% of Medicaid,82.38,,,82.38,Other,125% of Medicaid,65.91,4094.63,
IMMUNOFLUOR ANTB ADDL STAIN,88350,CPT,,78088350,CDM,310,RC,,,both,,,240,177.6,,,177.6,Other,150% of Medicare + 9.63% HCRA Surcharge,108,45,,108,percent of total billed charges,Critical Access Hospital RCC factor,281.4,,,281.4,Fee Schedule,,253.36,,,253.36,Fee Schedule,,40.4,,,40.4,Fee Schedule,,40.4,,,40.4,Fee Schedule,,40.4,,,40.4,Fee Schedule,,118.8,,,118.8,Other,110% of Medicare,294.49,,,294.49,Fee Schedule,,31,,,31,Other,186% of Medicaid,346.85,,,346.85,Fee Schedule,,148.8,,,148.8,Fee Schedule,,196.33,,,196.33,Fee Schedule,,346.85,,,346.85,Fee Schedule,,148.8,,,148.8,Fee Schedule,,369.29,,,369.29,Fee Schedule,,168,70,,168,percent of total billed charges,All Other,431.32,,,431.32,Fee Schedule,,365.57,,,365.57,Fee Schedule,,95.82,,,95.82,Fee Schedule,,95.82,,,95.82,Fee Schedule,,95.82,,,95.82,Fee Schedule,,95.82,,,95.82,Fee Schedule,,16.41,,,16.41,Other,100% of Medicaid,16.41,,,16.41,Other,100% of Medicaid,16.41,,,16.41,Other,100% of Medicaid,16.41,,,16.41,Other,100% of Medicaid,36.93,,,36.93,Other,225% of Medicaid,25.11,,,25.11,Other,153% of Medicaid,36.93,,,36.93,Other,225% of Medicaid,22.98,,,22.98,Other,140% of Medicaid,36.93,,,36.93,Other,225% of Medicaid,42.67,,,42.67,Other,260% of Medicaid,53.18,,,53.18,Other,324% of Medicaid,35.29,,,35.29,Other,215% of Medicaid,35.29,,,35.29,Other,215% of Medicaid,20.52,,,20.52,Other,125% of Medicaid,16.41,431.32,
TUMOR IMMUNOHISTOCHEM/MANUAL,88360,CPT,,78088360,CDM,310,RC,,,both,,,682,504.68,,,504.68,Other,150% of Medicare + 9.63% HCRA Surcharge,306.9,45,,306.9,percent of total billed charges,Critical Access Hospital RCC factor,262.86,,,262.86,Fee Schedule,,236.66,,,236.66,Fee Schedule,,478.36,,,478.36,Fee Schedule,,430.25,,,430.25,Fee Schedule,,406.65,,,406.65,Fee Schedule,,337.59,,,337.59,Other,110% of Medicare,275.09,,,275.09,Fee Schedule,,48,,,48,Other,186% of Medicaid,323.99,,,323.99,Fee Schedule,,422.84,,,422.84,Fee Schedule,,183.39,,,183.39,Fee Schedule,,323.99,,,323.99,Fee Schedule,,422.84,,,422.84,Fee Schedule,,344.95,,,344.95,Fee Schedule,,477.4,70,,477.4,percent of total billed charges,All Other,383.76,,,383.76,Fee Schedule,,325.26,,,325.26,Fee Schedule,,215.25,,,215.25,Fee Schedule,,215.25,,,215.25,Fee Schedule,,215.25,,,215.25,Fee Schedule,,215.25,,,215.25,Fee Schedule,,25.62,,,25.62,Other,100% of Medicaid,25.62,,,25.62,Other,100% of Medicaid,25.62,,,25.62,Other,100% of Medicaid,25.62,,,25.62,Other,100% of Medicaid,57.65,,,57.65,Other,225% of Medicaid,39.2,,,39.2,Other,153% of Medicaid,57.65,,,57.65,Other,225% of Medicaid,35.87,,,35.87,Other,140% of Medicaid,57.65,,,57.65,Other,225% of Medicaid,66.62,,,66.62,Other,260% of Medicaid,83.02,,,83.02,Other,324% of Medicaid,55.09,,,55.09,Other,215% of Medicaid,55.09,,,55.09,Other,215% of Medicaid,32.03,,,32.03,Other,125% of Medicaid,25.62,504.68,
TUMOR IMMUNOHISTOCHEM/COMPUT,88361,CPT,,78088361,CDM,310,RC,,,both,,,731,540.94,,,540.94,Other,150% of Medicare + 9.63% HCRA Surcharge,328.95,45,,328.95,percent of total billed charges,Critical Access Hospital RCC factor,253.05,,,253.05,Fee Schedule,,227.83,,,227.83,Fee Schedule,,645.42,,,645.42,Fee Schedule,,580.51,,,580.51,Fee Schedule,,548.67,,,548.67,Fee Schedule,,361.85,,,361.85,Other,110% of Medicare,264.82,,,264.82,Fee Schedule,,48,,,48,Other,186% of Medicaid,311.9,,,311.9,Fee Schedule,,453.22,,,453.22,Fee Schedule,,176.55,,,176.55,Fee Schedule,,311.9,,,311.9,Fee Schedule,,453.22,,,453.22,Fee Schedule,,332.08,,,332.08,Fee Schedule,,511.7,70,,511.7,percent of total billed charges,All Other,372.28,,,372.28,Fee Schedule,,315.53,,,315.53,Fee Schedule,,425.12,,,425.12,Fee Schedule,,425.12,,,425.12,Fee Schedule,,425.12,,,425.12,Fee Schedule,,425.12,,,425.12,Fee Schedule,,25.62,,,25.62,Other,100% of Medicaid,25.62,,,25.62,Other,100% of Medicaid,25.62,,,25.62,Other,100% of Medicaid,25.62,,,25.62,Other,100% of Medicaid,57.65,,,57.65,Other,225% of Medicaid,39.2,,,39.2,Other,153% of Medicaid,57.65,,,57.65,Other,225% of Medicaid,35.87,,,35.87,Other,140% of Medicaid,57.65,,,57.65,Other,225% of Medicaid,66.62,,,66.62,Other,260% of Medicaid,83.02,,,83.02,Other,324% of Medicaid,55.09,,,55.09,Other,215% of Medicaid,55.09,,,55.09,Other,215% of Medicaid,32.03,,,32.03,Other,125% of Medicaid,25.62,645.42,
INSITU HYBRIDIZATION (FISH),88365,CPT,,78088365,CDM,310,RC,,,both,,,666,492.84,,,492.84,Other,150% of Medicare + 9.63% HCRA Surcharge,299.7,45,,299.7,percent of total billed charges,Critical Access Hospital RCC factor,445.06,,,445.06,Fee Schedule,,400.7,,,400.7,Fee Schedule,,730.11,,,730.11,Fee Schedule,,656.68,,,656.68,Fee Schedule,,620.66,,,620.66,Fee Schedule,,329.67,,,329.67,Other,110% of Medicare,465.76,,,465.76,Fee Schedule,,334,,,334,Other,186% of Medicaid,548.56,,,548.56,Fee Schedule,,412.92,,,412.92,Fee Schedule,,310.51,,,310.51,Fee Schedule,,548.56,,,548.56,Fee Schedule,,412.92,,,412.92,Fee Schedule,,584.05,,,584.05,Fee Schedule,,466.2,70,,466.2,percent of total billed charges,All Other,659.28,,,659.28,Fee Schedule,,558.78,,,558.78,Fee Schedule,,215.25,,,215.25,Fee Schedule,,215.25,,,215.25,Fee Schedule,,215.25,,,215.25,Fee Schedule,,215.25,,,215.25,Fee Schedule,,179.38,,,179.38,Other,100% of Medicaid,179.38,,,179.38,Other,100% of Medicaid,179.38,,,179.38,Other,100% of Medicaid,179.38,,,179.38,Other,100% of Medicaid,403.61,,,403.61,Other,225% of Medicaid,274.45,,,274.45,Other,153% of Medicaid,403.61,,,403.61,Other,225% of Medicaid,251.13,,,251.13,Other,140% of Medicaid,403.61,,,403.61,Other,225% of Medicaid,466.39,,,466.39,Other,260% of Medicaid,581.19,,,581.19,Other,324% of Medicaid,385.67,,,385.67,Other,215% of Medicaid,385.67,,,385.67,Other,215% of Medicaid,224.23,,,224.23,Other,125% of Medicaid,179.38,730.11,
INSITU HYBRIDIZATION AUTO,88367,CPT,,78088367,CDM,310,RC,,,both,,,731,540.94,,,540.94,Other,150% of Medicare + 9.63% HCRA Surcharge,328.95,45,,328.95,percent of total billed charges,Critical Access Hospital RCC factor,260.7,,,260.7,Fee Schedule,,234.71,,,234.71,Fee Schedule,,1315.87,,,1315.87,Fee Schedule,,1183.53,,,1183.53,Fee Schedule,,1118.61,,,1118.61,Fee Schedule,,361.85,,,361.85,Other,110% of Medicare,272.82,,,272.82,Fee Schedule,,334,,,334,Other,186% of Medicaid,321.32,,,321.32,Fee Schedule,,453.22,,,453.22,Fee Schedule,,181.88,,,181.88,Fee Schedule,,321.32,,,321.32,Fee Schedule,,453.22,,,453.22,Fee Schedule,,342.11,,,342.11,Fee Schedule,,511.7,70,,511.7,percent of total billed charges,All Other,385.4,,,385.4,Fee Schedule,,326.65,,,326.65,Fee Schedule,,425.12,,,425.12,Fee Schedule,,425.12,,,425.12,Fee Schedule,,425.12,,,425.12,Fee Schedule,,425.12,,,425.12,Fee Schedule,,179.38,,,179.38,Other,100% of Medicaid,179.38,,,179.38,Other,100% of Medicaid,179.38,,,179.38,Other,100% of Medicaid,179.38,,,179.38,Other,100% of Medicaid,403.61,,,403.61,Other,225% of Medicaid,274.45,,,274.45,Other,153% of Medicaid,403.61,,,403.61,Other,225% of Medicaid,251.13,,,251.13,Other,140% of Medicaid,403.61,,,403.61,Other,225% of Medicaid,466.39,,,466.39,Other,260% of Medicaid,581.19,,,581.19,Other,324% of Medicaid,385.67,,,385.67,Other,215% of Medicaid,385.67,,,385.67,Other,215% of Medicaid,224.23,,,224.23,Other,125% of Medicaid,179.38,1315.87,
PROTEIN ANALYSIS W/PROBE,88372,CPT,,78088372,CDM,310,RC,,,both,,,145,107.3,,,107.3,Other,150% of Medicare + 9.63% HCRA Surcharge,65.25,45,,65.25,percent of total billed charges,Critical Access Hospital RCC factor,78.92,,,78.92,Fee Schedule,,71.06,,,71.06,Fee Schedule,,168.69,,,168.69,Fee Schedule,,151.73,,,151.73,Fee Schedule,,143.4,,,143.4,Fee Schedule,,71.78,,,71.78,Other,110% of Medicare,82.59,,,82.59,Fee Schedule,,122,,,122,Other,186% of Medicaid,97.28,,,97.28,Fee Schedule,,89.9,,,89.9,Fee Schedule,,55.06,,,55.06,Fee Schedule,,97.28,,,97.28,Fee Schedule,,89.9,,,89.9,Fee Schedule,,103.57,,,103.57,Fee Schedule,,101.5,70,,101.5,percent of total billed charges,All Other,124.26,,,124.26,Fee Schedule,,105.32,,,105.32,Fee Schedule,,39.33,,,39.33,Fee Schedule,,39.33,,,39.33,Fee Schedule,,39.33,,,39.33,Fee Schedule,,39.33,,,39.33,Fee Schedule,,65.37,,,65.37,Other,100% of Medicaid,65.37,,,65.37,Other,100% of Medicaid,65.37,,,65.37,Other,100% of Medicaid,65.37,,,65.37,Other,100% of Medicaid,147.09,,,147.09,Other,225% of Medicaid,100.02,,,100.02,Other,153% of Medicaid,147.09,,,147.09,Other,225% of Medicaid,91.52,,,91.52,Other,140% of Medicaid,147.09,,,147.09,Other,225% of Medicaid,169.97,,,169.97,Other,260% of Medicaid,211.81,,,211.81,Other,324% of Medicaid,140.55,,,140.55,Other,215% of Medicaid,140.55,,,140.55,Other,215% of Medicaid,81.72,,,81.72,Other,125% of Medicaid,39.33,211.81,
M/PHMTRC ALYS ISHQUANT/SEMIQ CPTR EACH,88374,CPT,,78088374,CDM,310,RC,,,both,,,579,428.46,,,428.46,Other,150% of Medicare + 9.63% HCRA Surcharge,260.55,45,,260.55,percent of total billed charges,Critical Access Hospital RCC factor,807.91,,,807.91,Fee Schedule,,727.39,,,727.39,Fee Schedule,,63.79,,,63.79,Fee Schedule,,63.79,,,63.79,Fee Schedule,,63.79,,,63.79,Fee Schedule,,286.61,,,286.61,Other,110% of Medicare,845.49,,,845.49,Fee Schedule,,334,,,334,Other,186% of Medicaid,995.8,,,995.8,Fee Schedule,,358.98,,,358.98,Fee Schedule,,563.66,,,563.66,Fee Schedule,,995.8,,,995.8,Fee Schedule,,358.98,,,358.98,Fee Schedule,,1060.22,,,1060.22,Fee Schedule,,405.3,70,,405.3,percent of total billed charges,All Other,1367.76,,,1367.76,Fee Schedule,,1159.26,,,1159.26,Fee Schedule,,215.25,,,215.25,Fee Schedule,,215.25,,,215.25,Fee Schedule,,215.25,,,215.25,Fee Schedule,,215.25,,,215.25,Fee Schedule,,179.38,,,179.38,Other,100% of Medicaid,179.38,,,179.38,Other,100% of Medicaid,179.38,,,179.38,Other,100% of Medicaid,179.38,,,179.38,Other,100% of Medicaid,403.61,,,403.61,Other,225% of Medicaid,274.45,,,274.45,Other,153% of Medicaid,403.61,,,403.61,Other,225% of Medicaid,251.13,,,251.13,Other,140% of Medicaid,403.61,,,403.61,Other,225% of Medicaid,466.39,,,466.39,Other,260% of Medicaid,581.19,,,581.19,Other,324% of Medicaid,385.67,,,385.67,Other,215% of Medicaid,385.67,,,385.67,Other,215% of Medicaid,224.23,,,224.23,Other,125% of Medicaid,63.79,1367.76,
M/PHMTRC ALYS ISHQUANT/SEMIQ,88377,CPT,,78088377,CDM,310,RC,,,both,,,1621,1199.54,,,1199.54,Other,150% of Medicare + 9.63% HCRA Surcharge,729.45,45,,729.45,percent of total billed charges,Critical Access Hospital RCC factor,1091.64,,,1091.64,Fee Schedule,,982.84,,,982.84,Fee Schedule,,59.35,,,59.35,Fee Schedule,,59.35,,,59.35,Fee Schedule,,59.35,,,59.35,Fee Schedule,,802.4,,,802.4,Other,110% of Medicare,1142.41,,,1142.41,Fee Schedule,,334,,,334,Other,186% of Medicaid,1345.51,,,1345.51,Fee Schedule,,1005.02,,,1005.02,Fee Schedule,,761.61,,,761.61,Fee Schedule,,1345.51,,,1345.51,Fee Schedule,,1005.02,,,1005.02,Fee Schedule,,1432.55,,,1432.55,Fee Schedule,,1134.7,70,,1134.7,percent of total billed charges,All Other,1649.84,,,1649.84,Fee Schedule,,1398.34,,,1398.34,Fee Schedule,,215.25,,,215.25,Fee Schedule,,215.25,,,215.25,Fee Schedule,,215.25,,,215.25,Fee Schedule,,215.25,,,215.25,Fee Schedule,,179.38,,,179.38,Other,100% of Medicaid,179.38,,,179.38,Other,100% of Medicaid,179.38,,,179.38,Other,100% of Medicaid,179.38,,,179.38,Other,100% of Medicaid,403.61,,,403.61,Other,225% of Medicaid,274.45,,,274.45,Other,153% of Medicaid,403.61,,,403.61,Other,225% of Medicaid,251.13,,,251.13,Other,140% of Medicaid,403.61,,,403.61,Other,225% of Medicaid,466.39,,,466.39,Other,260% of Medicaid,581.19,,,581.19,Other,324% of Medicaid,385.67,,,385.67,Other,215% of Medicaid,385.67,,,385.67,Other,215% of Medicaid,224.23,,,224.23,Other,125% of Medicaid,59.35,1649.84,
MICRODISSECTION LASER,88380,CPT,,78088380,CDM,310,RC,,,both,,,663,490.62,,,490.62,Other,150% of Medicare + 9.63% HCRA Surcharge,298.35,45,,298.35,percent of total billed charges,Critical Access Hospital RCC factor,241.4,,,241.4,Fee Schedule,,217.34,,,217.34,Fee Schedule,,691.16,,,691.16,Fee Schedule,,621.65,,,621.65,Fee Schedule,,587.55,,,587.55,Fee Schedule,,328.19,,,328.19,Other,110% of Medicare,252.63,,,252.63,Fee Schedule,,123,,,123,Other,186% of Medicaid,297.54,,,297.54,Fee Schedule,,411.06,,,411.06,Fee Schedule,,168.42,,,168.42,Fee Schedule,,297.54,,,297.54,Fee Schedule,,411.06,,,411.06,Fee Schedule,,316.79,,,316.79,Fee Schedule,,464.1,70,,464.1,percent of total billed charges,All Other,354.24,,,354.24,Fee Schedule,,300.24,,,300.24,Fee Schedule,,120.18,,,120.18,Fee Schedule,,120.18,,,120.18,Fee Schedule,,120.18,,,120.18,Fee Schedule,,120.18,,,120.18,Fee Schedule,,65.91,,,65.91,Other,100% of Medicaid,65.91,,,65.91,Other,100% of Medicaid,65.91,,,65.91,Other,100% of Medicaid,65.91,,,65.91,Other,100% of Medicaid,148.29,,,148.29,Other,225% of Medicaid,100.84,,,100.84,Other,153% of Medicaid,148.29,,,148.29,Other,225% of Medicaid,92.27,,,92.27,Other,140% of Medicaid,148.29,,,148.29,Other,225% of Medicaid,171.35,,,171.35,Other,260% of Medicaid,213.53,,,213.53,Other,324% of Medicaid,141.7,,,141.7,Other,215% of Medicaid,141.7,,,141.7,Other,215% of Medicaid,82.38,,,82.38,Other,125% of Medicaid,65.91,691.16,
MICRODISSECTION MANUAL,88381,CPT,,78088381,CDM,310,RC,,,both,,,72,53.28,,,53.28,Other,150% of Medicare + 9.63% HCRA Surcharge,32.4,45,,32.4,percent of total billed charges,Critical Access Hospital RCC factor,584.93,,,584.93,Fee Schedule,,526.63,,,526.63,Fee Schedule,,881.09,,,881.09,Fee Schedule,,792.48,,,792.48,Fee Schedule,,749.01,,,749.01,Fee Schedule,,35.64,,,35.64,Other,110% of Medicare,612.14,,,612.14,Fee Schedule,,87,,,87,Other,186% of Medicaid,720.96,,,720.96,Fee Schedule,,44.64,,,44.64,Fee Schedule,,408.09,,,408.09,Fee Schedule,,720.96,,,720.96,Fee Schedule,,44.64,,,44.64,Fee Schedule,,767.6,,,767.6,Fee Schedule,,50.4,70,,50.4,percent of total billed charges,All Other,900.36,,,900.36,Fee Schedule,,763.11,,,763.11,Fee Schedule,,235.49,,,235.49,Fee Schedule,,235.49,,,235.49,Fee Schedule,,235.49,,,235.49,Fee Schedule,,235.49,,,235.49,Fee Schedule,,46.77,,,46.77,Other,100% of Medicaid,46.77,,,46.77,Other,100% of Medicaid,46.77,,,46.77,Other,100% of Medicaid,46.77,,,46.77,Other,100% of Medicaid,105.23,,,105.23,Other,225% of Medicaid,71.56,,,71.56,Other,153% of Medicaid,105.23,,,105.23,Other,225% of Medicaid,65.48,,,65.48,Other,140% of Medicaid,105.23,,,105.23,Other,225% of Medicaid,121.6,,,121.6,Other,260% of Medicaid,151.53,,,151.53,Other,324% of Medicaid,100.55,,,100.55,Other,215% of Medicaid,100.55,,,100.55,Other,215% of Medicaid,58.46,,,58.46,Other,125% of Medicaid,32.4,900.36,
"PROSTATE BIOPSY, ANY MTHD",G0416,HCPCS,TC,85000001,CDM,310,RC,,,both,,,2649,1960.27,,,1960.27,Other,150% of Medicare + 9.63% HCRA Surcharge,1192.05,45,,1192.05,percent of total billed charges,Critical Access Hospital RCC factor,665.12,,,665.12,Fee Schedule,,598.4,,,598.4,Fee Schedule,,2780.4,,,2780.4,Fee Schedule,,2500.78,,,2500.78,Fee Schedule,,2363.6,,,2363.6,Fee Schedule,,1311.26,,,1311.26,Other,110% of Medicare,790.22,,,790.22,Fee Schedule,,123,,,123,Other,186% of Medicaid,929.91,,,929.91,Fee Schedule,,1642.38,,,1642.38,Fee Schedule,,437.85,,,437.85,Fee Schedule,,929.91,,,929.91,Fee Schedule,,1642.38,,,1642.38,Fee Schedule,,823.58,,,823.58,Fee Schedule,,1854.3,70,,1854.3,percent of total billed charges,All Other,857.72,,,857.72,Fee Schedule,,726.97,,,726.97,Fee Schedule,,425.12,,,425.12,Fee Schedule,,425.12,,,425.12,Fee Schedule,,425.12,,,425.12,Fee Schedule,,425.12,,,425.12,Fee Schedule,,65.91,,,65.91,Other,100% of Medicaid,65.91,,,65.91,Other,100% of Medicaid,65.91,,,65.91,Other,100% of Medicaid,65.91,,,65.91,Other,100% of Medicaid,148.29,,,148.29,Other,225% of Medicaid,100.84,,,100.84,Other,153% of Medicaid,148.29,,,148.29,Other,225% of Medicaid,92.27,,,92.27,Other,140% of Medicaid,148.29,,,148.29,Other,225% of Medicaid,171.35,,,171.35,Other,260% of Medicaid,213.53,,,213.53,Other,324% of Medicaid,141.7,,,141.7,Other,215% of Medicaid,141.7,,,141.7,Other,215% of Medicaid,82.38,,,82.38,Other,125% of Medicaid,65.91,2780.4,
SURG PATH LEVEL-I GROSS ONLY,88300,CPT,TC,85088300,CDM,310,RC,,,both,,,123,91.02,,,91.02,Other,150% of Medicare + 9.63% HCRA Surcharge,55.35,45,,55.35,percent of total billed charges,Critical Access Hospital RCC factor,39.4,,,39.4,Fee Schedule,,35.47,,,35.47,Fee Schedule,,151.14,,,151.14,Fee Schedule,,135.94,,,135.94,Fee Schedule,,128.49,,,128.49,Fee Schedule,,60.89,,,60.89,Other,110% of Medicare,41.23,,,41.23,Fee Schedule,,87,,,87,Other,186% of Medicaid,48.56,,,48.56,Fee Schedule,,76.26,,,76.26,Fee Schedule,,27.49,,,27.49,Fee Schedule,,48.56,,,48.56,Fee Schedule,,76.26,,,76.26,Fee Schedule,,51.71,,,51.71,Fee Schedule,,86.1,70,,86.1,percent of total billed charges,All Other,52.48,,,52.48,Fee Schedule,,44.48,,,44.48,Fee Schedule,,34.49,,,34.49,Fee Schedule,,34.49,,,34.49,Fee Schedule,,34.49,,,34.49,Fee Schedule,,34.49,,,34.49,Fee Schedule,,46.77,,,46.77,Other,100% of Medicaid,46.77,,,46.77,Other,100% of Medicaid,46.77,,,46.77,Other,100% of Medicaid,46.77,,,46.77,Other,100% of Medicaid,105.23,,,105.23,Other,225% of Medicaid,71.56,,,71.56,Other,153% of Medicaid,105.23,,,105.23,Other,225% of Medicaid,65.48,,,65.48,Other,140% of Medicaid,105.23,,,105.23,Other,225% of Medicaid,121.6,,,121.6,Other,260% of Medicaid,151.53,,,151.53,Other,324% of Medicaid,100.55,,,100.55,Other,215% of Medicaid,100.55,,,100.55,Other,215% of Medicaid,58.46,,,58.46,Other,125% of Medicaid,27.49,151.53,
SURG PATH LVL 2,88302,CPT,TC,85088302,CDM,310,RC,,,both,,,478,353.72,,,353.72,Other,150% of Medicare + 9.63% HCRA Surcharge,215.1,45,,215.1,percent of total billed charges,Critical Access Hospital RCC factor,87.38,,,87.38,Fee Schedule,,78.67,,,78.67,Fee Schedule,,315.88,,,315.88,Fee Schedule,,284.12,,,284.12,Fee Schedule,,268.53,,,268.53,Fee Schedule,,236.61,,,236.61,Other,110% of Medicare,91.44,,,91.44,Fee Schedule,,36,,,36,Other,186% of Medicaid,107.7,,,107.7,Fee Schedule,,296.36,,,296.36,Fee Schedule,,60.96,,,60.96,Fee Schedule,,107.7,,,107.7,Fee Schedule,,296.36,,,296.36,Fee Schedule,,114.67,,,114.67,Fee Schedule,,334.6,70,,334.6,percent of total billed charges,All Other,119.72,,,119.72,Fee Schedule,,101.47,,,101.47,Fee Schedule,,34.49,,,34.49,Fee Schedule,,34.49,,,34.49,Fee Schedule,,34.49,,,34.49,Fee Schedule,,34.49,,,34.49,Fee Schedule,,19.5,,,19.5,Other,100% of Medicaid,19.5,,,19.5,Other,100% of Medicaid,19.5,,,19.5,Other,100% of Medicaid,19.5,,,19.5,Other,100% of Medicaid,43.88,,,43.88,Other,225% of Medicaid,29.84,,,29.84,Other,153% of Medicaid,43.88,,,43.88,Other,225% of Medicaid,27.3,,,27.3,Other,140% of Medicaid,43.88,,,43.88,Other,225% of Medicaid,50.71,,,50.71,Other,260% of Medicaid,63.19,,,63.19,Other,324% of Medicaid,41.93,,,41.93,Other,215% of Medicaid,41.93,,,41.93,Other,215% of Medicaid,24.38,,,24.38,Other,125% of Medicaid,19.5,353.72,
TISSUE EXAM BY PATHOLOGIST LVL 3,88304,CPT,TC,85088304,CDM,310,RC,,,both,,,478,353.72,,,353.72,Other,150% of Medicare + 9.63% HCRA Surcharge,215.1,45,,215.1,percent of total billed charges,Critical Access Hospital RCC factor,104.81,,,104.81,Fee Schedule,,94.36,,,94.36,Fee Schedule,,347.93,,,347.93,Fee Schedule,,312.93,,,312.93,Fee Schedule,,295.77,,,295.77,Fee Schedule,,236.61,,,236.61,Other,110% of Medicare,109.68,,,109.68,Fee Schedule,,48,,,48,Other,186% of Medicaid,129.18,,,129.18,Fee Schedule,,296.36,,,296.36,Fee Schedule,,73.12,,,73.12,Fee Schedule,,129.18,,,129.18,Fee Schedule,,296.36,,,296.36,Fee Schedule,,137.54,,,137.54,Fee Schedule,,334.6,70,,334.6,percent of total billed charges,All Other,145.96,,,145.96,Fee Schedule,,123.71,,,123.71,Fee Schedule,,74.21,,,74.21,Fee Schedule,,74.21,,,74.21,Fee Schedule,,74.21,,,74.21,Fee Schedule,,74.21,,,74.21,Fee Schedule,,25.58,,,25.58,Other,100% of Medicaid,25.58,,,25.58,Other,100% of Medicaid,25.58,,,25.58,Other,100% of Medicaid,25.58,,,25.58,Other,100% of Medicaid,57.56,,,57.56,Other,225% of Medicaid,39.14,,,39.14,Other,153% of Medicaid,57.56,,,57.56,Other,225% of Medicaid,35.82,,,35.82,Other,140% of Medicaid,57.56,,,57.56,Other,225% of Medicaid,66.52,,,66.52,Other,260% of Medicaid,82.89,,,82.89,Other,324% of Medicaid,55,,,55,Other,215% of Medicaid,55,,,55,Other,215% of Medicaid,31.98,,,31.98,Other,125% of Medicaid,25.58,353.72,
TISSUE EXAM BY PATHOLOGIST LVL 4,88305,CPT,TC,85088305,CDM,310,RC,,,both,,,478,353.72,,,353.72,Other,150% of Medicare + 9.63% HCRA Surcharge,215.1,45,,215.1,percent of total billed charges,Critical Access Hospital RCC factor,116.79,,,116.79,Fee Schedule,,105.15,,,105.15,Fee Schedule,,469.19,,,469.19,Fee Schedule,,422,,,422,Fee Schedule,,398.85,,,398.85,Fee Schedule,,236.61,,,236.61,Other,110% of Medicare,122.22,,,122.22,Fee Schedule,,81,,,81,Other,186% of Medicaid,143.95,,,143.95,Fee Schedule,,296.36,,,296.36,Fee Schedule,,81.48,,,81.48,Fee Schedule,,143.95,,,143.95,Fee Schedule,,296.36,,,296.36,Fee Schedule,,153.26,,,153.26,Fee Schedule,,334.6,70,,334.6,percent of total billed charges,All Other,164,,,164,Fee Schedule,,139,,,139,Fee Schedule,,74.21,,,74.21,Fee Schedule,,74.21,,,74.21,Fee Schedule,,74.21,,,74.21,Fee Schedule,,74.21,,,74.21,Fee Schedule,,43.62,,,43.62,Other,100% of Medicaid,43.62,,,43.62,Other,100% of Medicaid,43.62,,,43.62,Other,100% of Medicaid,43.62,,,43.62,Other,100% of Medicaid,98.15,,,98.15,Other,225% of Medicaid,66.74,,,66.74,Other,153% of Medicaid,98.15,,,98.15,Other,225% of Medicaid,61.07,,,61.07,Other,140% of Medicaid,98.15,,,98.15,Other,225% of Medicaid,113.42,,,113.42,Other,260% of Medicaid,141.33,,,141.33,Other,324% of Medicaid,93.79,,,93.79,Other,215% of Medicaid,93.79,,,93.79,Other,215% of Medicaid,54.53,,,54.53,Other,125% of Medicaid,43.62,469.19,
TISSUE EXAM BY PATHOLOGIST LVL 5,88307,CPT,TC,85088307,CDM,310,RC,,,both,,,1051,777.74,,,777.74,Other,150% of Medicare + 9.63% HCRA Surcharge,472.95,45,,472.95,percent of total billed charges,Critical Access Hospital RCC factor,684.11,,,684.11,Fee Schedule,,615.93,,,615.93,Fee Schedule,,988.65,,,988.65,Fee Schedule,,889.22,,,889.22,Fee Schedule,,840.45,,,840.45,Fee Schedule,,520.25,,,520.25,Other,110% of Medicare,715.93,,,715.93,Fee Schedule,,328,,,328,Other,186% of Medicaid,843.21,,,843.21,Fee Schedule,,651.62,,,651.62,Fee Schedule,,477.29,,,477.29,Fee Schedule,,843.21,,,843.21,Fee Schedule,,651.62,,,651.62,Fee Schedule,,897.76,,,897.76,Fee Schedule,,735.7,70,,735.7,percent of total billed charges,All Other,987.28,,,987.28,Fee Schedule,,836.78,,,836.78,Fee Schedule,,425.12,,,425.12,Fee Schedule,,425.12,,,425.12,Fee Schedule,,425.12,,,425.12,Fee Schedule,,425.12,,,425.12,Fee Schedule,,176.15,,,176.15,Other,100% of Medicaid,176.15,,,176.15,Other,100% of Medicaid,176.15,,,176.15,Other,100% of Medicaid,176.15,,,176.15,Other,100% of Medicaid,396.35,,,396.35,Other,225% of Medicaid,269.52,,,269.52,Other,153% of Medicaid,396.35,,,396.35,Other,225% of Medicaid,246.62,,,246.62,Other,140% of Medicaid,396.35,,,396.35,Other,225% of Medicaid,458,,,458,Other,260% of Medicaid,570.74,,,570.74,Other,324% of Medicaid,378.73,,,378.73,Other,215% of Medicaid,378.73,,,378.73,Other,215% of Medicaid,220.19,,,220.19,Other,125% of Medicaid,176.15,988.65,
TISSUE EXAM BY PATHOLOGIST LVL 6,88309,CPT,TC,85088309,CDM,310,RC,,,both,,,1859,1375.66,,,1375.66,Other,150% of Medicare + 9.63% HCRA Surcharge,836.55,45,,836.55,percent of total billed charges,Critical Access Hospital RCC factor,959.92,,,959.92,Fee Schedule,,864.25,,,864.25,Fee Schedule,,1373.31,,,1373.31,Fee Schedule,,1235.2,,,1235.2,Fee Schedule,,1167.44,,,1167.44,Fee Schedule,,920.21,,,920.21,Other,110% of Medicare,1004.57,,,1004.57,Fee Schedule,,498,,,498,Other,186% of Medicaid,1183.16,,,1183.16,Fee Schedule,,1152.58,,,1152.58,Fee Schedule,,669.71,,,669.71,Fee Schedule,,1183.16,,,1183.16,Fee Schedule,,1152.58,,,1152.58,Fee Schedule,,1259.69,,,1259.69,Fee Schedule,,1301.3,70,,1301.3,percent of total billed charges,All Other,1407.12,,,1407.12,Fee Schedule,,1192.62,,,1192.62,Fee Schedule,,942.3,,,942.3,Fee Schedule,,942.3,,,942.3,Fee Schedule,,942.3,,,942.3,Fee Schedule,,942.3,,,942.3,Fee Schedule,,267.64,,,267.64,Other,100% of Medicaid,267.64,,,267.64,Other,100% of Medicaid,267.64,,,267.64,Other,100% of Medicaid,267.64,,,267.64,Other,100% of Medicaid,602.19,,,602.19,Other,225% of Medicaid,409.49,,,409.49,Other,153% of Medicaid,602.19,,,602.19,Other,225% of Medicaid,374.7,,,374.7,Other,140% of Medicaid,602.19,,,602.19,Other,225% of Medicaid,695.86,,,695.86,Other,260% of Medicaid,867.15,,,867.15,Other,324% of Medicaid,575.43,,,575.43,Other,215% of Medicaid,575.43,,,575.43,Other,215% of Medicaid,334.55,,,334.55,Other,125% of Medicaid,267.64,1407.12,
DECALCIFICATION,88311,CPT,TC,85088311,CDM,310,RC,,,both,,,171,126.54,,,126.54,Other,150% of Medicare + 9.63% HCRA Surcharge,76.95,45,,76.95,percent of total billed charges,Critical Access Hospital RCC factor,28.5,,,28.5,Fee Schedule,,25.66,,,25.66,Fee Schedule,,45.85,,,45.85,Fee Schedule,,41.24,,,41.24,Fee Schedule,,38.98,,,38.98,Fee Schedule,,84.65,,,84.65,Other,110% of Medicare,29.83,,,29.83,Fee Schedule,,87,,,87,Other,186% of Medicaid,35.13,,,35.13,Fee Schedule,,106.02,,,106.02,Fee Schedule,,19.89,,,19.89,Fee Schedule,,35.13,,,35.13,Fee Schedule,,106.02,,,106.02,Fee Schedule,,37.41,,,37.41,Fee Schedule,,119.7,70,,119.7,percent of total billed charges,All Other,41,,,41,Fee Schedule,,34.75,,,34.75,Fee Schedule,,13.53,,,13.53,Fee Schedule,,13.53,,,13.53,Fee Schedule,,13.53,,,13.53,Fee Schedule,,13.53,,,13.53,Fee Schedule,,46.77,,,46.77,Other,100% of Medicaid,46.77,,,46.77,Other,100% of Medicaid,46.77,,,46.77,Other,100% of Medicaid,46.77,,,46.77,Other,100% of Medicaid,105.23,,,105.23,Other,225% of Medicaid,71.56,,,71.56,Other,153% of Medicaid,105.23,,,105.23,Other,225% of Medicaid,65.48,,,65.48,Other,140% of Medicaid,105.23,,,105.23,Other,225% of Medicaid,121.6,,,121.6,Other,260% of Medicaid,151.53,,,151.53,Other,324% of Medicaid,100.55,,,100.55,Other,215% of Medicaid,100.55,,,100.55,Other,215% of Medicaid,58.46,,,58.46,Other,125% of Medicaid,13.53,151.53,
SPECIAL STAINS GROUP 1,88312,CPT,TC,85088312,CDM,310,RC,,,both,,,435,321.9,,,321.9,Other,150% of Medicare + 9.63% HCRA Surcharge,195.75,45,,195.75,percent of total billed charges,Critical Access Hospital RCC factor,284.66,,,284.66,Fee Schedule,,256.28,,,256.28,Fee Schedule,,542.44,,,542.44,Fee Schedule,,487.89,,,487.89,Fee Schedule,,461.13,,,461.13,Fee Schedule,,215.33,,,215.33,Other,110% of Medicare,297.9,,,297.9,Fee Schedule,,25,,,25,Other,186% of Medicaid,350.85,,,350.85,Fee Schedule,,269.7,,,269.7,Fee Schedule,,198.6,,,198.6,Fee Schedule,,350.85,,,350.85,Fee Schedule,,269.7,,,269.7,Fee Schedule,,373.55,,,373.55,Fee Schedule,,304.5,70,,304.5,percent of total billed charges,All Other,418.2,,,418.2,Fee Schedule,,354.45,,,354.45,Fee Schedule,,74.21,,,74.21,Fee Schedule,,74.21,,,74.21,Fee Schedule,,74.21,,,74.21,Fee Schedule,,74.21,,,74.21,Fee Schedule,,13.31,,,13.31,Other,100% of Medicaid,13.31,,,13.31,Other,100% of Medicaid,13.31,,,13.31,Other,100% of Medicaid,13.31,,,13.31,Other,100% of Medicaid,29.95,,,29.95,Other,225% of Medicaid,20.37,,,20.37,Other,153% of Medicaid,29.95,,,29.95,Other,225% of Medicaid,18.64,,,18.64,Other,140% of Medicaid,29.95,,,29.95,Other,225% of Medicaid,34.61,,,34.61,Other,260% of Medicaid,43.13,,,43.13,Other,324% of Medicaid,28.62,,,28.62,Other,215% of Medicaid,28.62,,,28.62,Other,215% of Medicaid,16.64,,,16.64,Other,125% of Medicaid,13.31,542.44,
SPECIAL STAINS GROUP 2,88313,CPT,TC,85088313,CDM,310,RC,,,both,,,361,267.14,,,267.14,Other,150% of Medicare + 9.63% HCRA Surcharge,162.45,45,,162.45,percent of total billed charges,Critical Access Hospital RCC factor,233.43,,,233.43,Fee Schedule,,210.16,,,210.16,Fee Schedule,,446.32,,,446.32,Fee Schedule,,401.43,,,401.43,Fee Schedule,,379.41,,,379.41,Fee Schedule,,178.7,,,178.7,Other,110% of Medicare,244.28,,,244.28,Fee Schedule,,19,,,19,Other,186% of Medicaid,287.71,,,287.71,Fee Schedule,,223.82,,,223.82,Fee Schedule,,162.86,,,162.86,Fee Schedule,,287.71,,,287.71,Fee Schedule,,223.82,,,223.82,Fee Schedule,,306.32,,,306.32,Fee Schedule,,252.7,70,,252.7,percent of total billed charges,All Other,332.92,,,332.92,Fee Schedule,,282.17,,,282.17,Fee Schedule,,50.15,,,50.15,Fee Schedule,,50.15,,,50.15,Fee Schedule,,50.15,,,50.15,Fee Schedule,,50.15,,,50.15,Fee Schedule,,9.98,,,9.98,Other,100% of Medicaid,9.98,,,9.98,Other,100% of Medicaid,9.98,,,9.98,Other,100% of Medicaid,9.98,,,9.98,Other,100% of Medicaid,22.45,,,22.45,Other,225% of Medicaid,15.27,,,15.27,Other,153% of Medicaid,22.45,,,22.45,Other,225% of Medicaid,13.97,,,13.97,Other,140% of Medicaid,22.45,,,22.45,Other,225% of Medicaid,25.94,,,25.94,Other,260% of Medicaid,32.33,,,32.33,Other,324% of Medicaid,21.45,,,21.45,Other,215% of Medicaid,21.45,,,21.45,Other,215% of Medicaid,12.47,,,12.47,Other,125% of Medicaid,9.98,446.32,
REF CONSULT PREP ELSEWHERE,88321,CPT,TC,85088321,CDM,310,RC,,,both,,,210,155.4,,,155.4,Other,150% of Medicare + 9.63% HCRA Surcharge,94.5,45,,94.5,percent of total billed charges,Critical Access Hospital RCC factor,257.63,,,257.63,Fee Schedule,,231.95,,,231.95,Fee Schedule,,545.45,,,545.45,Fee Schedule,,490.59,,,490.59,Fee Schedule,,463.68,,,463.68,Fee Schedule,,103.95,,,103.95,Other,110% of Medicare,269.61,,,269.61,Fee Schedule,,103,,,103,Other,186% of Medicaid,317.54,,,317.54,Fee Schedule,,130.2,,,130.2,Fee Schedule,,179.74,,,179.74,Fee Schedule,,317.54,,,317.54,Fee Schedule,,130.2,,,130.2,Fee Schedule,,338.08,,,338.08,Fee Schedule,,147,70,,147,percent of total billed charges,All Other,398.52,,,398.52,Fee Schedule,,337.77,,,337.77,Fee Schedule,,50.15,,,50.15,Fee Schedule,,50.15,,,50.15,Fee Schedule,,50.15,,,50.15,Fee Schedule,,50.15,,,50.15,Fee Schedule,,55.61,,,55.61,Other,100% of Medicaid,55.61,,,55.61,Other,100% of Medicaid,55.61,,,55.61,Other,100% of Medicaid,55.61,,,55.61,Other,100% of Medicaid,125.13,,,125.13,Other,225% of Medicaid,85.09,,,85.09,Other,153% of Medicaid,125.13,,,125.13,Other,225% of Medicaid,77.86,,,77.86,Other,140% of Medicaid,125.13,,,125.13,Other,225% of Medicaid,144.59,,,144.59,Other,260% of Medicaid,180.18,,,180.18,Other,324% of Medicaid,119.57,,,119.57,Other,215% of Medicaid,119.57,,,119.57,Other,215% of Medicaid,69.51,,,69.51,Other,125% of Medicaid,50.15,545.45,
REF CONSULT W SLIDE PREP,88323,CPT,TC,85088323,CDM,310,RC,,,both,,,386,285.64,,,285.64,Other,150% of Medicare + 9.63% HCRA Surcharge,173.7,45,,173.7,percent of total billed charges,Critical Access Hospital RCC factor,97.16,,,97.16,Fee Schedule,,87.48,,,87.48,Fee Schedule,,395.99,,,395.99,Fee Schedule,,356.16,,,356.16,Fee Schedule,,336.63,,,336.63,Fee Schedule,,191.07,,,191.07,Other,110% of Medicare,101.68,,,101.68,Fee Schedule,,103,,,103,Other,186% of Medicaid,119.76,,,119.76,Fee Schedule,,239.32,,,239.32,Fee Schedule,,67.79,,,67.79,Fee Schedule,,119.76,,,119.76,Fee Schedule,,239.32,,,239.32,Fee Schedule,,127.51,,,127.51,Fee Schedule,,270.2,70,,270.2,percent of total billed charges,All Other,129.56,,,129.56,Fee Schedule,,109.81,,,109.81,Fee Schedule,,74.21,,,74.21,Fee Schedule,,74.21,,,74.21,Fee Schedule,,74.21,,,74.21,Fee Schedule,,74.21,,,74.21,Fee Schedule,,55.61,,,55.61,Other,100% of Medicaid,55.61,,,55.61,Other,100% of Medicaid,55.61,,,55.61,Other,100% of Medicaid,55.61,,,55.61,Other,100% of Medicaid,125.13,,,125.13,Other,225% of Medicaid,85.09,,,85.09,Other,153% of Medicaid,125.13,,,125.13,Other,225% of Medicaid,77.86,,,77.86,Other,140% of Medicaid,125.13,,,125.13,Other,225% of Medicaid,144.59,,,144.59,Other,260% of Medicaid,180.18,,,180.18,Other,324% of Medicaid,119.57,,,119.57,Other,215% of Medicaid,119.57,,,119.57,Other,215% of Medicaid,69.51,,,69.51,Other,125% of Medicaid,55.61,395.99,
PATH CONSULT DURING SURGERY,88329,CPT,,85088329,CDM,310,RC,,,both,,,411,304.14,,,304.14,Other,150% of Medicare + 9.63% HCRA Surcharge,184.95,45,,184.95,percent of total billed charges,Critical Access Hospital RCC factor,108.96,,,108.96,Fee Schedule,,98.1,,,98.1,Fee Schedule,,323.16,,,323.16,Fee Schedule,,290.66,,,290.66,Fee Schedule,,274.71,,,274.71,Fee Schedule,,203.45,,,203.45,Other,110% of Medicare,114.03,,,114.03,Fee Schedule,,103,,,103,Other,186% of Medicaid,134.3,,,134.3,Fee Schedule,,254.82,,,254.82,Fee Schedule,,76.02,,,76.02,Fee Schedule,,134.3,,,134.3,Fee Schedule,,254.82,,,254.82,Fee Schedule,,142.99,,,142.99,Fee Schedule,,287.7,70,,287.7,percent of total billed charges,All Other,168.92,,,168.92,Fee Schedule,,143.17,,,143.17,Fee Schedule,,50.15,,,50.15,Fee Schedule,,50.15,,,50.15,Fee Schedule,,50.15,,,50.15,Fee Schedule,,50.15,,,50.15,Fee Schedule,,55.61,,,55.61,Other,100% of Medicaid,55.61,,,55.61,Other,100% of Medicaid,55.61,,,55.61,Other,100% of Medicaid,55.61,,,55.61,Other,100% of Medicaid,125.13,,,125.13,Other,225% of Medicaid,85.09,,,85.09,Other,153% of Medicaid,125.13,,,125.13,Other,225% of Medicaid,77.86,,,77.86,Other,140% of Medicaid,125.13,,,125.13,Other,225% of Medicaid,144.59,,,144.59,Other,260% of Medicaid,180.18,,,180.18,Other,324% of Medicaid,119.57,,,119.57,Other,215% of Medicaid,119.57,,,119.57,Other,215% of Medicaid,69.51,,,69.51,Other,125% of Medicaid,50.15,323.16,
SP CONSULT; 1ST TB W FS SGL SP,88331,CPT,TC,85088331,CDM,310,RC,,,both,,,581,429.94,,,429.94,Other,150% of Medicare + 9.63% HCRA Surcharge,261.45,45,,261.45,percent of total billed charges,Critical Access Hospital RCC factor,135.33,,,135.33,Fee Schedule,,121.84,,,121.84,Fee Schedule,,215.23,,,215.23,Fee Schedule,,193.58,,,193.58,Fee Schedule,,182.96,,,182.96,Fee Schedule,,287.6,,,287.6,Other,110% of Medicare,141.62,,,141.62,Fee Schedule,,103,,,103,Other,186% of Medicaid,166.8,,,166.8,Fee Schedule,,360.22,,,360.22,Fee Schedule,,94.42,,,94.42,Fee Schedule,,166.8,,,166.8,Fee Schedule,,360.22,,,360.22,Fee Schedule,,177.59,,,177.59,Fee Schedule,,406.7,70,,406.7,percent of total billed charges,All Other,196.8,,,196.8,Fee Schedule,,166.8,,,166.8,Fee Schedule,,215.25,,,215.25,Fee Schedule,,215.25,,,215.25,Fee Schedule,,215.25,,,215.25,Fee Schedule,,215.25,,,215.25,Fee Schedule,,55.61,,,55.61,Other,100% of Medicaid,55.61,,,55.61,Other,100% of Medicaid,55.61,,,55.61,Other,100% of Medicaid,55.61,,,55.61,Other,100% of Medicaid,125.13,,,125.13,Other,225% of Medicaid,85.09,,,85.09,Other,153% of Medicaid,125.13,,,125.13,Other,225% of Medicaid,77.86,,,77.86,Other,140% of Medicaid,125.13,,,125.13,Other,225% of Medicaid,144.59,,,144.59,Other,260% of Medicaid,180.18,,,180.18,Other,324% of Medicaid,119.57,,,119.57,Other,215% of Medicaid,119.57,,,119.57,Other,215% of Medicaid,69.51,,,69.51,Other,125% of Medicaid,55.61,429.94,
PATH CONSULT INTRAOP ADDL,88332,CPT,TC,85088332,CDM,310,RC,,,both,,,158,116.92,,,116.92,Other,150% of Medicare + 9.63% HCRA Surcharge,71.1,45,,71.1,percent of total billed charges,Critical Access Hospital RCC factor,81.9,,,81.9,Fee Schedule,,73.74,,,73.74,Fee Schedule,,75.62,,,75.62,Fee Schedule,,68.02,,,68.02,Fee Schedule,,64.29,,,64.29,Fee Schedule,,78.21,,,78.21,Other,110% of Medicare,85.71,,,85.71,Fee Schedule,,103,,,103,Other,186% of Medicaid,100.95,,,100.95,Fee Schedule,,97.96,,,97.96,Fee Schedule,,57.14,,,57.14,Fee Schedule,,100.95,,,100.95,Fee Schedule,,97.96,,,97.96,Fee Schedule,,107.48,,,107.48,Fee Schedule,,110.6,70,,110.6,percent of total billed charges,All Other,116.44,,,116.44,Fee Schedule,,98.69,,,98.69,Fee Schedule,,34.65,,,34.65,Fee Schedule,,34.65,,,34.65,Fee Schedule,,34.65,,,34.65,Fee Schedule,,34.65,,,34.65,Fee Schedule,,55.61,,,55.61,Other,100% of Medicaid,55.61,,,55.61,Other,100% of Medicaid,55.61,,,55.61,Other,100% of Medicaid,55.61,,,55.61,Other,100% of Medicaid,125.13,,,125.13,Other,225% of Medicaid,85.09,,,85.09,Other,153% of Medicaid,125.13,,,125.13,Other,225% of Medicaid,77.86,,,77.86,Other,140% of Medicaid,125.13,,,125.13,Other,225% of Medicaid,144.59,,,144.59,Other,260% of Medicaid,180.18,,,180.18,Other,324% of Medicaid,119.57,,,119.57,Other,215% of Medicaid,119.57,,,119.57,Other,215% of Medicaid,69.51,,,69.51,Other,125% of Medicaid,34.65,180.18,
INTRAOP CYTO PATH CONSULT 1,88333,CPT,TC,85088333,CDM,310,RC,,,both,,,1834,1357.16,,,1357.16,Other,150% of Medicare + 9.63% HCRA Surcharge,825.3,45,,825.3,percent of total billed charges,Critical Access Hospital RCC factor,104.81,,,104.81,Fee Schedule,,94.36,,,94.36,Fee Schedule,,235.78,,,235.78,Fee Schedule,,212.07,,,212.07,Fee Schedule,,200.44,,,200.44,Fee Schedule,,907.83,,,907.83,Other,110% of Medicare,109.68,,,109.68,Fee Schedule,,103,,,103,Other,186% of Medicaid,129.18,,,129.18,Fee Schedule,,1137.08,,,1137.08,Fee Schedule,,73.12,,,73.12,Fee Schedule,,129.18,,,129.18,Fee Schedule,,1137.08,,,1137.08,Fee Schedule,,137.54,,,137.54,Fee Schedule,,1283.8,70,,1283.8,percent of total billed charges,All Other,155.8,,,155.8,Fee Schedule,,132.05,,,132.05,Fee Schedule,,942.3,,,942.3,Fee Schedule,,942.3,,,942.3,Fee Schedule,,942.3,,,942.3,Fee Schedule,,942.3,,,942.3,Fee Schedule,,55.61,,,55.61,Other,100% of Medicaid,55.61,,,55.61,Other,100% of Medicaid,55.61,,,55.61,Other,100% of Medicaid,55.61,,,55.61,Other,100% of Medicaid,125.13,,,125.13,Other,225% of Medicaid,85.09,,,85.09,Other,153% of Medicaid,125.13,,,125.13,Other,225% of Medicaid,77.86,,,77.86,Other,140% of Medicaid,125.13,,,125.13,Other,225% of Medicaid,144.59,,,144.59,Other,260% of Medicaid,180.18,,,180.18,Other,324% of Medicaid,119.57,,,119.57,Other,215% of Medicaid,119.57,,,119.57,Other,215% of Medicaid,69.51,,,69.51,Other,125% of Medicaid,55.61,1357.16,
INTRAOP CYTO PATH CONSULT 2,88334,CPT,TC,85088334,CDM,310,RC,,,both,,,184,136.16,,,136.16,Other,150% of Medicare + 9.63% HCRA Surcharge,82.8,45,,82.8,percent of total billed charges,Critical Access Hospital RCC factor,63.21,,,63.21,Fee Schedule,,56.91,,,56.91,Fee Schedule,,148.82,,,148.82,Fee Schedule,,133.86,,,133.86,Fee Schedule,,126.52,,,126.52,Fee Schedule,,91.08,,,91.08,Other,110% of Medicare,66.15,,,66.15,Fee Schedule,,103,,,103,Other,186% of Medicaid,77.91,,,77.91,Fee Schedule,,114.08,,,114.08,Fee Schedule,,44.1,,,44.1,Fee Schedule,,77.91,,,77.91,Fee Schedule,,114.08,,,114.08,Fee Schedule,,82.95,,,82.95,Fee Schedule,,128.8,70,,128.8,percent of total billed charges,All Other,91.84,,,91.84,Fee Schedule,,77.84,,,77.84,Fee Schedule,,27.06,,,27.06,Fee Schedule,,27.06,,,27.06,Fee Schedule,,27.06,,,27.06,Fee Schedule,,27.06,,,27.06,Fee Schedule,,55.61,,,55.61,Other,100% of Medicaid,55.61,,,55.61,Other,100% of Medicaid,55.61,,,55.61,Other,100% of Medicaid,55.61,,,55.61,Other,100% of Medicaid,125.13,,,125.13,Other,225% of Medicaid,85.09,,,85.09,Other,153% of Medicaid,125.13,,,125.13,Other,225% of Medicaid,77.86,,,77.86,Other,140% of Medicaid,125.13,,,125.13,Other,225% of Medicaid,144.59,,,144.59,Other,260% of Medicaid,180.18,,,180.18,Other,324% of Medicaid,119.57,,,119.57,Other,215% of Medicaid,119.57,,,119.57,Other,215% of Medicaid,69.51,,,69.51,Other,125% of Medicaid,27.06,180.18,
IMMUNOHISTO ANTIBODY SLIDE,88341,CPT,TC,85088341,CDM,310,RC,,,both,,,357,264.18,,,264.18,Other,150% of Medicare + 9.63% HCRA Surcharge,160.65,45,,160.65,percent of total billed charges,Critical Access Hospital RCC factor,208.2,,,208.2,Fee Schedule,,187.45,,,187.45,Fee Schedule,,18.31,,,18.31,Fee Schedule,,18.31,,,18.31,Fee Schedule,,18.31,,,18.31,Fee Schedule,,176.72,,,176.72,Other,110% of Medicare,217.89,,,217.89,Fee Schedule,,48,,,48,Other,186% of Medicaid,256.62,,,256.62,Fee Schedule,,221.34,,,221.34,Fee Schedule,,145.26,,,145.26,Fee Schedule,,256.62,,,256.62,Fee Schedule,,221.34,,,221.34,Fee Schedule,,273.22,,,273.22,Fee Schedule,,249.9,70,,249.9,percent of total billed charges,All Other,291.92,,,291.92,Fee Schedule,,247.42,,,247.42,Fee Schedule,,96.9,,,96.9,Fee Schedule,,96.9,,,96.9,Fee Schedule,,96.9,,,96.9,Fee Schedule,,96.9,,,96.9,Fee Schedule,,25.62,,,25.62,Other,100% of Medicaid,25.62,,,25.62,Other,100% of Medicaid,25.62,,,25.62,Other,100% of Medicaid,25.62,,,25.62,Other,100% of Medicaid,57.65,,,57.65,Other,225% of Medicaid,39.2,,,39.2,Other,153% of Medicaid,57.65,,,57.65,Other,225% of Medicaid,35.87,,,35.87,Other,140% of Medicaid,57.65,,,57.65,Other,225% of Medicaid,66.62,,,66.62,Other,260% of Medicaid,83.02,,,83.02,Other,324% of Medicaid,55.09,,,55.09,Other,215% of Medicaid,55.09,,,55.09,Other,215% of Medicaid,32.03,,,32.03,Other,125% of Medicaid,18.31,291.92,
IMMUNOHISTO ANTIBODY SLIDE,88342,CPT,TC,85088342,CDM,310,RC,,,both,,,747,552.78,,,552.78,Other,150% of Medicare + 9.63% HCRA Surcharge,336.15,45,,336.15,percent of total billed charges,Critical Access Hospital RCC factor,236.71,,,236.71,Fee Schedule,,213.11,,,213.11,Fee Schedule,,423.44,,,423.44,Fee Schedule,,380.86,,,380.86,Fee Schedule,,359.97,,,359.97,Fee Schedule,,369.77,,,369.77,Other,110% of Medicare,247.72,,,247.72,Fee Schedule,,48,,,48,Other,186% of Medicaid,291.75,,,291.75,Fee Schedule,,463.14,,,463.14,Fee Schedule,,165.14,,,165.14,Fee Schedule,,291.75,,,291.75,Fee Schedule,,463.14,,,463.14,Fee Schedule,,310.63,,,310.63,Fee Schedule,,522.9,70,,522.9,percent of total billed charges,All Other,321.44,,,321.44,Fee Schedule,,272.44,,,272.44,Fee Schedule,,215.25,,,215.25,Fee Schedule,,215.25,,,215.25,Fee Schedule,,215.25,,,215.25,Fee Schedule,,215.25,,,215.25,Fee Schedule,,25.62,,,25.62,Other,100% of Medicaid,25.62,,,25.62,Other,100% of Medicaid,25.62,,,25.62,Other,100% of Medicaid,25.62,,,25.62,Other,100% of Medicaid,57.65,,,57.65,Other,225% of Medicaid,39.2,,,39.2,Other,153% of Medicaid,57.65,,,57.65,Other,225% of Medicaid,35.87,,,35.87,Other,140% of Medicaid,57.65,,,57.65,Other,225% of Medicaid,66.62,,,66.62,Other,260% of Medicaid,83.02,,,83.02,Other,324% of Medicaid,55.09,,,55.09,Other,215% of Medicaid,55.09,,,55.09,Other,215% of Medicaid,32.03,,,32.03,Other,125% of Medicaid,25.62,552.78,
IMMUNOHISTO ANTIBODY SLIDE,88344,CPT,TC,85088344,CDM,310,RC,,,both,,,731,540.94,,,540.94,Other,150% of Medicare + 9.63% HCRA Surcharge,328.95,45,,328.95,percent of total billed charges,Critical Access Hospital RCC factor,444.91,,,444.91,Fee Schedule,,400.57,,,400.57,Fee Schedule,,30.75,,,30.75,Fee Schedule,,30.75,,,30.75,Fee Schedule,,30.75,,,30.75,Fee Schedule,,361.85,,,361.85,Other,110% of Medicare,465.6,,,465.6,Fee Schedule,,48,,,48,Other,186% of Medicaid,548.38,,,548.38,Fee Schedule,,453.22,,,453.22,Fee Schedule,,310.4,,,310.4,Fee Schedule,,548.38,,,548.38,Fee Schedule,,453.22,,,453.22,Fee Schedule,,583.85,,,583.85,Fee Schedule,,511.7,70,,511.7,percent of total billed charges,All Other,639.6,,,639.6,Fee Schedule,,542.1,,,542.1,Fee Schedule,,425.12,,,425.12,Fee Schedule,,425.12,,,425.12,Fee Schedule,,425.12,,,425.12,Fee Schedule,,425.12,,,425.12,Fee Schedule,,25.62,,,25.62,Other,100% of Medicaid,25.62,,,25.62,Other,100% of Medicaid,25.62,,,25.62,Other,100% of Medicaid,25.62,,,25.62,Other,100% of Medicaid,57.65,,,57.65,Other,225% of Medicaid,39.2,,,39.2,Other,153% of Medicaid,57.65,,,57.65,Other,225% of Medicaid,35.87,,,35.87,Other,140% of Medicaid,57.65,,,57.65,Other,225% of Medicaid,66.62,,,66.62,Other,260% of Medicaid,83.02,,,83.02,Other,324% of Medicaid,55.09,,,55.09,Other,215% of Medicaid,55.09,,,55.09,Other,215% of Medicaid,32.03,,,32.03,Other,125% of Medicaid,25.62,639.6,
IMMUNOFLUOR ANTB 1ST STAIN,88346,CPT,TC,85088346,CDM,310,RC,,,both,,,731,540.94,,,540.94,Other,150% of Medicare + 9.63% HCRA Surcharge,328.95,45,,328.95,percent of total billed charges,Critical Access Hospital RCC factor,377.48,,,377.48,Fee Schedule,,339.86,,,339.86,Fee Schedule,,409.69,,,409.69,Fee Schedule,,368.49,,,368.49,Fee Schedule,,348.28,,,348.28,Fee Schedule,,361.85,,,361.85,Other,110% of Medicare,395.04,,,395.04,Fee Schedule,,36,,,36,Other,186% of Medicaid,465.27,,,465.27,Fee Schedule,,453.22,,,453.22,Fee Schedule,,263.36,,,263.36,Fee Schedule,,465.27,,,465.27,Fee Schedule,,453.22,,,453.22,Fee Schedule,,495.37,,,495.37,Fee Schedule,,511.7,70,,511.7,percent of total billed charges,All Other,567.44,,,567.44,Fee Schedule,,480.94,,,480.94,Fee Schedule,,425.12,,,425.12,Fee Schedule,,425.12,,,425.12,Fee Schedule,,425.12,,,425.12,Fee Schedule,,425.12,,,425.12,Fee Schedule,,19.44,,,19.44,Other,100% of Medicaid,19.44,,,19.44,Other,100% of Medicaid,19.44,,,19.44,Other,100% of Medicaid,19.44,,,19.44,Other,100% of Medicaid,43.75,,,43.75,Other,225% of Medicaid,29.75,,,29.75,Other,153% of Medicaid,43.75,,,43.75,Other,225% of Medicaid,27.22,,,27.22,Other,140% of Medicaid,43.75,,,43.75,Other,225% of Medicaid,50.55,,,50.55,Other,260% of Medicaid,62.99,,,62.99,Other,324% of Medicaid,41.8,,,41.8,Other,215% of Medicaid,41.8,,,41.8,Other,215% of Medicaid,24.3,,,24.3,Other,125% of Medicaid,19.44,567.44,
ELECTRON MICROSCOPY,88348,CPT,TC,85088348,CDM,310,RC,,,both,,,2218,1641.33,,,1641.33,Other,150% of Medicare + 9.63% HCRA Surcharge,998.1,45,,998.1,percent of total billed charges,Critical Access Hospital RCC factor,1342.25,,,1342.25,Fee Schedule,,1208.47,,,1208.47,Fee Schedule,,4094.63,,,4094.63,Fee Schedule,,3682.84,,,3682.84,Fee Schedule,,3480.83,,,3480.83,Fee Schedule,,1097.91,,,1097.91,Other,110% of Medicare,1404.68,,,1404.68,Fee Schedule,,123,,,123,Other,186% of Medicaid,1654.4,,,1654.4,Fee Schedule,,1375.16,,,1375.16,Fee Schedule,,936.45,,,936.45,Fee Schedule,,1654.4,,,1654.4,Fee Schedule,,1375.16,,,1375.16,Fee Schedule,,1761.42,,,1761.42,Fee Schedule,,1552.6,70,,1552.6,percent of total billed charges,All Other,1828.6,,,1828.6,Fee Schedule,,1549.85,,,1549.85,Fee Schedule,,942.3,,,942.3,Fee Schedule,,942.3,,,942.3,Fee Schedule,,942.3,,,942.3,Fee Schedule,,942.3,,,942.3,Fee Schedule,,65.91,,,65.91,Other,100% of Medicaid,65.91,,,65.91,Other,100% of Medicaid,65.91,,,65.91,Other,100% of Medicaid,65.91,,,65.91,Other,100% of Medicaid,148.29,,,148.29,Other,225% of Medicaid,100.84,,,100.84,Other,153% of Medicaid,148.29,,,148.29,Other,225% of Medicaid,92.27,,,92.27,Other,140% of Medicaid,148.29,,,148.29,Other,225% of Medicaid,171.35,,,171.35,Other,260% of Medicaid,213.53,,,213.53,Other,324% of Medicaid,141.7,,,141.7,Other,215% of Medicaid,141.7,,,141.7,Other,215% of Medicaid,82.38,,,82.38,Other,125% of Medicaid,65.91,4094.63,
IMMUNOFLUOR ANTB ADDL STAIN,88350,CPT,TC,85088350,CDM,310,RC,,,both,,,240,177.6,,,177.6,Other,150% of Medicare + 9.63% HCRA Surcharge,108,45,,108,percent of total billed charges,Critical Access Hospital RCC factor,281.4,,,281.4,Fee Schedule,,253.36,,,253.36,Fee Schedule,,40.4,,,40.4,Fee Schedule,,40.4,,,40.4,Fee Schedule,,40.4,,,40.4,Fee Schedule,,118.8,,,118.8,Other,110% of Medicare,294.49,,,294.49,Fee Schedule,,31,,,31,Other,186% of Medicaid,346.85,,,346.85,Fee Schedule,,148.8,,,148.8,Fee Schedule,,196.33,,,196.33,Fee Schedule,,346.85,,,346.85,Fee Schedule,,148.8,,,148.8,Fee Schedule,,369.29,,,369.29,Fee Schedule,,168,70,,168,percent of total billed charges,All Other,431.32,,,431.32,Fee Schedule,,365.57,,,365.57,Fee Schedule,,95.82,,,95.82,Fee Schedule,,95.82,,,95.82,Fee Schedule,,95.82,,,95.82,Fee Schedule,,95.82,,,95.82,Fee Schedule,,16.41,,,16.41,Other,100% of Medicaid,16.41,,,16.41,Other,100% of Medicaid,16.41,,,16.41,Other,100% of Medicaid,16.41,,,16.41,Other,100% of Medicaid,36.93,,,36.93,Other,225% of Medicaid,25.11,,,25.11,Other,153% of Medicaid,36.93,,,36.93,Other,225% of Medicaid,22.98,,,22.98,Other,140% of Medicaid,36.93,,,36.93,Other,225% of Medicaid,42.67,,,42.67,Other,260% of Medicaid,53.18,,,53.18,Other,324% of Medicaid,35.29,,,35.29,Other,215% of Medicaid,35.29,,,35.29,Other,215% of Medicaid,20.52,,,20.52,Other,125% of Medicaid,16.41,431.32,
TUMOR IMMUNOHISTOCHEM/MANUAL,88360,CPT,TC,85088360,CDM,310,RC,,,both,,,682,504.68,,,504.68,Other,150% of Medicare + 9.63% HCRA Surcharge,306.9,45,,306.9,percent of total billed charges,Critical Access Hospital RCC factor,262.86,,,262.86,Fee Schedule,,236.66,,,236.66,Fee Schedule,,478.36,,,478.36,Fee Schedule,,430.25,,,430.25,Fee Schedule,,406.65,,,406.65,Fee Schedule,,337.59,,,337.59,Other,110% of Medicare,275.09,,,275.09,Fee Schedule,,48,,,48,Other,186% of Medicaid,323.99,,,323.99,Fee Schedule,,422.84,,,422.84,Fee Schedule,,183.39,,,183.39,Fee Schedule,,323.99,,,323.99,Fee Schedule,,422.84,,,422.84,Fee Schedule,,344.95,,,344.95,Fee Schedule,,477.4,70,,477.4,percent of total billed charges,All Other,383.76,,,383.76,Fee Schedule,,325.26,,,325.26,Fee Schedule,,215.25,,,215.25,Fee Schedule,,215.25,,,215.25,Fee Schedule,,215.25,,,215.25,Fee Schedule,,215.25,,,215.25,Fee Schedule,,25.62,,,25.62,Other,100% of Medicaid,25.62,,,25.62,Other,100% of Medicaid,25.62,,,25.62,Other,100% of Medicaid,25.62,,,25.62,Other,100% of Medicaid,57.65,,,57.65,Other,225% of Medicaid,39.2,,,39.2,Other,153% of Medicaid,57.65,,,57.65,Other,225% of Medicaid,35.87,,,35.87,Other,140% of Medicaid,57.65,,,57.65,Other,225% of Medicaid,66.62,,,66.62,Other,260% of Medicaid,83.02,,,83.02,Other,324% of Medicaid,55.09,,,55.09,Other,215% of Medicaid,55.09,,,55.09,Other,215% of Medicaid,32.03,,,32.03,Other,125% of Medicaid,25.62,504.68,
TUMOR IMMUNOHISTOCHEM/COMPUT,88361,CPT,TC,85088361,CDM,310,RC,,,both,,,731,540.94,,,540.94,Other,150% of Medicare + 9.63% HCRA Surcharge,328.95,45,,328.95,percent of total billed charges,Critical Access Hospital RCC factor,253.05,,,253.05,Fee Schedule,,227.83,,,227.83,Fee Schedule,,645.42,,,645.42,Fee Schedule,,580.51,,,580.51,Fee Schedule,,548.67,,,548.67,Fee Schedule,,361.85,,,361.85,Other,110% of Medicare,264.82,,,264.82,Fee Schedule,,48,,,48,Other,186% of Medicaid,311.9,,,311.9,Fee Schedule,,453.22,,,453.22,Fee Schedule,,176.55,,,176.55,Fee Schedule,,311.9,,,311.9,Fee Schedule,,453.22,,,453.22,Fee Schedule,,332.08,,,332.08,Fee Schedule,,511.7,70,,511.7,percent of total billed charges,All Other,372.28,,,372.28,Fee Schedule,,315.53,,,315.53,Fee Schedule,,425.12,,,425.12,Fee Schedule,,425.12,,,425.12,Fee Schedule,,425.12,,,425.12,Fee Schedule,,425.12,,,425.12,Fee Schedule,,25.62,,,25.62,Other,100% of Medicaid,25.62,,,25.62,Other,100% of Medicaid,25.62,,,25.62,Other,100% of Medicaid,25.62,,,25.62,Other,100% of Medicaid,57.65,,,57.65,Other,225% of Medicaid,39.2,,,39.2,Other,153% of Medicaid,57.65,,,57.65,Other,225% of Medicaid,35.87,,,35.87,Other,140% of Medicaid,57.65,,,57.65,Other,225% of Medicaid,66.62,,,66.62,Other,260% of Medicaid,83.02,,,83.02,Other,324% of Medicaid,55.09,,,55.09,Other,215% of Medicaid,55.09,,,55.09,Other,215% of Medicaid,32.03,,,32.03,Other,125% of Medicaid,25.62,645.42,
INSITU HYBRIDIZATION (FISH),88364,CPT,TC,85088364,CDM,310,RC,,,both,,,1683,1245.42,,,1245.42,Other,150% of Medicare + 9.63% HCRA Surcharge,757.35,45,,757.35,percent of total billed charges,Critical Access Hospital RCC factor,329.35,,,329.35,Fee Schedule,,296.53,,,296.53,Fee Schedule,,28.03,,,28.03,Fee Schedule,,28.03,,,28.03,Fee Schedule,,28.03,,,28.03,Fee Schedule,,833.09,,,833.09,Other,110% of Medicare,344.67,,,344.67,Fee Schedule,,334,,,334,Other,186% of Medicaid,405.95,,,405.95,Fee Schedule,,1043.46,,,1043.46,Fee Schedule,,229.78,,,229.78,Fee Schedule,,405.95,,,405.95,Fee Schedule,,1043.46,,,1043.46,Fee Schedule,,432.21,,,432.21,Fee Schedule,,1178.1,70,,1178.1,percent of total billed charges,All Other,501.84,,,501.84,Fee Schedule,,425.34,,,425.34,Fee Schedule,,156.45,,,156.45,Fee Schedule,,156.45,,,156.45,Fee Schedule,,156.45,,,156.45,Fee Schedule,,156.45,,,156.45,Fee Schedule,,179.38,,,179.38,Other,100% of Medicaid,179.38,,,179.38,Other,100% of Medicaid,179.38,,,179.38,Other,100% of Medicaid,179.38,,,179.38,Other,100% of Medicaid,403.61,,,403.61,Other,225% of Medicaid,274.45,,,274.45,Other,153% of Medicaid,403.61,,,403.61,Other,225% of Medicaid,251.13,,,251.13,Other,140% of Medicaid,403.61,,,403.61,Other,225% of Medicaid,466.39,,,466.39,Other,260% of Medicaid,581.19,,,581.19,Other,324% of Medicaid,385.67,,,385.67,Other,215% of Medicaid,385.67,,,385.67,Other,215% of Medicaid,224.23,,,224.23,Other,125% of Medicaid,28.03,1245.42,
INSITU HYBRIDIZATION (FISH),88365,CPT,TC,85088365,CDM,310,RC,,,both,,,666,492.84,,,492.84,Other,150% of Medicare + 9.63% HCRA Surcharge,299.7,45,,299.7,percent of total billed charges,Critical Access Hospital RCC factor,445.06,,,445.06,Fee Schedule,,400.7,,,400.7,Fee Schedule,,730.11,,,730.11,Fee Schedule,,656.68,,,656.68,Fee Schedule,,620.66,,,620.66,Fee Schedule,,329.67,,,329.67,Other,110% of Medicare,465.76,,,465.76,Fee Schedule,,334,,,334,Other,186% of Medicaid,548.56,,,548.56,Fee Schedule,,412.92,,,412.92,Fee Schedule,,310.51,,,310.51,Fee Schedule,,548.56,,,548.56,Fee Schedule,,412.92,,,412.92,Fee Schedule,,584.05,,,584.05,Fee Schedule,,466.2,70,,466.2,percent of total billed charges,All Other,659.28,,,659.28,Fee Schedule,,558.78,,,558.78,Fee Schedule,,215.25,,,215.25,Fee Schedule,,215.25,,,215.25,Fee Schedule,,215.25,,,215.25,Fee Schedule,,215.25,,,215.25,Fee Schedule,,179.38,,,179.38,Other,100% of Medicaid,179.38,,,179.38,Other,100% of Medicaid,179.38,,,179.38,Other,100% of Medicaid,179.38,,,179.38,Other,100% of Medicaid,403.61,,,403.61,Other,225% of Medicaid,274.45,,,274.45,Other,153% of Medicaid,403.61,,,403.61,Other,225% of Medicaid,251.13,,,251.13,Other,140% of Medicaid,403.61,,,403.61,Other,225% of Medicaid,466.39,,,466.39,Other,260% of Medicaid,581.19,,,581.19,Other,324% of Medicaid,385.67,,,385.67,Other,215% of Medicaid,385.67,,,385.67,Other,215% of Medicaid,224.23,,,224.23,Other,125% of Medicaid,179.38,730.11,
INSITU HYBRIDIZATION MANUAL,88368,CPT,TC,85088368,CDM,310,RC,,,both,,,1015,751.1,,,751.1,Other,150% of Medicare + 9.63% HCRA Surcharge,456.75,45,,456.75,percent of total billed charges,Critical Access Hospital RCC factor,351.33,,,351.33,Fee Schedule,,316.31,,,316.31,Fee Schedule,,1061.91,,,1061.91,Fee Schedule,,955.11,,,955.11,Fee Schedule,,902.72,,,902.72,Fee Schedule,,502.43,,,502.43,Other,110% of Medicare,367.67,,,367.67,Fee Schedule,,334,,,334,Other,186% of Medicaid,433.03,,,433.03,Fee Schedule,,629.3,,,629.3,Fee Schedule,,245.11,,,245.11,Fee Schedule,,433.03,,,433.03,Fee Schedule,,629.3,,,629.3,Fee Schedule,,461.04,,,461.04,Fee Schedule,,710.5,70,,710.5,percent of total billed charges,All Other,459.2,,,459.2,Fee Schedule,,389.2,,,389.2,Fee Schedule,,425.12,,,425.12,Fee Schedule,,425.12,,,425.12,Fee Schedule,,425.12,,,425.12,Fee Schedule,,425.12,,,425.12,Fee Schedule,,179.38,,,179.38,Other,100% of Medicaid,179.38,,,179.38,Other,100% of Medicaid,179.38,,,179.38,Other,100% of Medicaid,179.38,,,179.38,Other,100% of Medicaid,403.61,,,403.61,Other,225% of Medicaid,274.45,,,274.45,Other,153% of Medicaid,403.61,,,403.61,Other,225% of Medicaid,251.13,,,251.13,Other,140% of Medicaid,403.61,,,403.61,Other,225% of Medicaid,466.39,,,466.39,Other,260% of Medicaid,581.19,,,581.19,Other,324% of Medicaid,385.67,,,385.67,Other,215% of Medicaid,385.67,,,385.67,Other,215% of Medicaid,224.23,,,224.23,Other,125% of Medicaid,179.38,1061.91,
M/PHMTRC ALYS ISHQUANT/SEMIQ,88377,CPT,TC,85088377,CDM,310,RC,,,both,,,1621,1199.54,,,1199.54,Other,150% of Medicare + 9.63% HCRA Surcharge,729.45,45,,729.45,percent of total billed charges,Critical Access Hospital RCC factor,1091.64,,,1091.64,Fee Schedule,,982.84,,,982.84,Fee Schedule,,59.35,,,59.35,Fee Schedule,,59.35,,,59.35,Fee Schedule,,59.35,,,59.35,Fee Schedule,,802.4,,,802.4,Other,110% of Medicare,1142.41,,,1142.41,Fee Schedule,,334,,,334,Other,186% of Medicaid,1345.51,,,1345.51,Fee Schedule,,1005.02,,,1005.02,Fee Schedule,,761.61,,,761.61,Fee Schedule,,1345.51,,,1345.51,Fee Schedule,,1005.02,,,1005.02,Fee Schedule,,1432.55,,,1432.55,Fee Schedule,,1134.7,70,,1134.7,percent of total billed charges,All Other,1649.84,,,1649.84,Fee Schedule,,1398.34,,,1398.34,Fee Schedule,,215.25,,,215.25,Fee Schedule,,215.25,,,215.25,Fee Schedule,,215.25,,,215.25,Fee Schedule,,215.25,,,215.25,Fee Schedule,,179.38,,,179.38,Other,100% of Medicaid,179.38,,,179.38,Other,100% of Medicaid,179.38,,,179.38,Other,100% of Medicaid,179.38,,,179.38,Other,100% of Medicaid,403.61,,,403.61,Other,225% of Medicaid,274.45,,,274.45,Other,153% of Medicaid,403.61,,,403.61,Other,225% of Medicaid,251.13,,,251.13,Other,140% of Medicaid,403.61,,,403.61,Other,225% of Medicaid,466.39,,,466.39,Other,260% of Medicaid,581.19,,,581.19,Other,324% of Medicaid,385.67,,,385.67,Other,215% of Medicaid,385.67,,,385.67,Other,215% of Medicaid,224.23,,,224.23,Other,125% of Medicaid,59.35,1649.84,
TARGETED GENOMIC SEQ ANALYS,81450,CPT,TC,85181450,CDM,310,RC,,,both,,,1596,1181.04,,,1181.04,Other,150% of Medicare + 9.63% HCRA Surcharge,718.2,45,,718.2,percent of total billed charges,Critical Access Hospital RCC factor,2286.19,,,2286.19,Fee Schedule,,2058.33,,,2058.33,Fee Schedule,,846.27,,,846.27,Fee Schedule,,846.27,,,846.27,Fee Schedule,,846.27,,,846.27,Fee Schedule,,790.02,,,790.02,Other,110% of Medicare,2392.52,,,2392.52,Fee Schedule,,0.01,,,0.01,Other,186% of Medicaid,2817.86,,,2817.86,Fee Schedule,,989.52,,,989.52,Fee Schedule,,1595.01,,,1595.01,Fee Schedule,,2817.86,,,2817.86,Fee Schedule,,989.52,,,989.52,Fee Schedule,,3000.14,,,3000.14,Fee Schedule,,1117.2,70,,1117.2,percent of total billed charges,All Other,3599.44,,,3599.44,Fee Schedule,,3050.74,,,3050.74,Fee Schedule,,1139.3,,,1139.3,Fee Schedule,,1139.3,,,1139.3,Fee Schedule,,1139.3,,,1139.3,Fee Schedule,,1139.3,,,1139.3,Fee Schedule,,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3599.44,
CYTOPATH FL NONGYN SMEARS,88104,CPT,,78088104,CDM,311,RC,,,both,,,270,199.8,,,199.8,Other,150% of Medicare + 9.63% HCRA Surcharge,121.5,45,,121.5,percent of total billed charges,Critical Access Hospital RCC factor,160.55,,,160.55,Fee Schedule,,144.55,,,144.55,Fee Schedule,,254.12,,,254.12,Fee Schedule,,228.56,,,228.56,Fee Schedule,,216.03,,,216.03,Fee Schedule,,133.65,,,133.65,Other,110% of Medicare,168.02,,,168.02,Fee Schedule,,36,,,36,Other,186% of Medicaid,197.89,,,197.89,Fee Schedule,,167.4,,,167.4,Fee Schedule,,112.01,,,112.01,Fee Schedule,,197.89,,,197.89,Fee Schedule,,167.4,,,167.4,Fee Schedule,,210.69,,,210.69,Fee Schedule,,189,70,,189,percent of total billed charges,All Other,193.52,,,193.52,Fee Schedule,,164.02,,,164.02,Fee Schedule,,50.15,,,50.15,Fee Schedule,,50.15,,,50.15,Fee Schedule,,50.15,,,50.15,Fee Schedule,,50.15,,,50.15,Fee Schedule,,19.31,,,19.31,Other,100% of Medicaid,19.31,,,19.31,Other,100% of Medicaid,19.31,,,19.31,Other,100% of Medicaid,19.31,,,19.31,Other,100% of Medicaid,43.45,,,43.45,Other,225% of Medicaid,29.55,,,29.55,Other,153% of Medicaid,43.45,,,43.45,Other,225% of Medicaid,27.04,,,27.04,Other,140% of Medicaid,43.45,,,43.45,Other,225% of Medicaid,50.21,,,50.21,Other,260% of Medicaid,62.57,,,62.57,Other,324% of Medicaid,41.52,,,41.52,Other,215% of Medicaid,41.52,,,41.52,Other,215% of Medicaid,24.14,,,24.14,Other,125% of Medicaid,19.31,254.12,
CYTOPATH FL NONGYN FILTER,88106,CPT,,78088106,CDM,311,RC,,,both,,,284,210.16,,,210.16,Other,150% of Medicare + 9.63% HCRA Surcharge,127.8,45,,127.8,percent of total billed charges,Critical Access Hospital RCC factor,173.65,,,173.65,Fee Schedule,,156.34,,,156.34,Fee Schedule,,354.78,,,354.78,Fee Schedule,,319.1,,,319.1,Fee Schedule,,301.59,,,301.59,Fee Schedule,,140.58,,,140.58,Other,110% of Medicare,181.72,,,181.72,Fee Schedule,,36,,,36,Other,186% of Medicaid,214.03,,,214.03,Fee Schedule,,176.08,,,176.08,Fee Schedule,,121.15,,,121.15,Fee Schedule,,214.03,,,214.03,Fee Schedule,,176.08,,,176.08,Fee Schedule,,227.88,,,227.88,Fee Schedule,,198.8,70,,198.8,percent of total billed charges,All Other,232.88,,,232.88,Fee Schedule,,197.38,,,197.38,Fee Schedule,,34.49,,,34.49,Fee Schedule,,34.49,,,34.49,Fee Schedule,,34.49,,,34.49,Fee Schedule,,34.49,,,34.49,Fee Schedule,,19.31,,,19.31,Other,100% of Medicaid,19.31,,,19.31,Other,100% of Medicaid,19.31,,,19.31,Other,100% of Medicaid,19.31,,,19.31,Other,100% of Medicaid,43.45,,,43.45,Other,225% of Medicaid,29.55,,,29.55,Other,153% of Medicaid,43.45,,,43.45,Other,225% of Medicaid,27.04,,,27.04,Other,140% of Medicaid,43.45,,,43.45,Other,225% of Medicaid,50.21,,,50.21,Other,260% of Medicaid,62.57,,,62.57,Other,324% of Medicaid,41.52,,,41.52,Other,215% of Medicaid,41.52,,,41.52,Other,215% of Medicaid,24.14,,,24.14,Other,125% of Medicaid,19.31,354.78,
CYHTOPATH CONCENTRATE TECH,88108,CPT,,78088108,CDM,311,RC,,,both,,,300,222,,,222,Other,150% of Medicare + 9.63% HCRA Surcharge,135,45,,135,percent of total billed charges,Critical Access Hospital RCC factor,153.87,,,153.87,Fee Schedule,,138.54,,,138.54,Fee Schedule,,325.05,,,325.05,Fee Schedule,,292.36,,,292.36,Fee Schedule,,276.33,,,276.33,Fee Schedule,,148.5,,,148.5,Other,110% of Medicare,161.03,,,161.03,Fee Schedule,,36,,,36,Other,186% of Medicaid,189.66,,,189.66,Fee Schedule,,186,,,186,Fee Schedule,,107.35,,,107.35,Fee Schedule,,189.66,,,189.66,Fee Schedule,,186,,,186,Fee Schedule,,201.92,,,201.92,Fee Schedule,,210,70,,210,percent of total billed charges,All Other,203.36,,,203.36,Fee Schedule,,172.36,,,172.36,Fee Schedule,,50.15,,,50.15,Fee Schedule,,50.15,,,50.15,Fee Schedule,,50.15,,,50.15,Fee Schedule,,50.15,,,50.15,Fee Schedule,,19.31,,,19.31,Other,100% of Medicaid,19.31,,,19.31,Other,100% of Medicaid,19.31,,,19.31,Other,100% of Medicaid,19.31,,,19.31,Other,100% of Medicaid,43.45,,,43.45,Other,225% of Medicaid,29.55,,,29.55,Other,153% of Medicaid,43.45,,,43.45,Other,225% of Medicaid,27.04,,,27.04,Other,140% of Medicaid,43.45,,,43.45,Other,225% of Medicaid,50.21,,,50.21,Other,260% of Medicaid,62.57,,,62.57,Other,324% of Medicaid,41.52,,,41.52,Other,215% of Medicaid,41.52,,,41.52,Other,215% of Medicaid,24.14,,,24.14,Other,125% of Medicaid,19.31,325.05,
CYTOPATH CELL ENHANCE TECH,88112,CPT,,78088112,CDM,311,RC,,,both,,,250,185,,,185,Other,150% of Medicare + 9.63% HCRA Surcharge,112.5,45,,112.5,percent of total billed charges,Critical Access Hospital RCC factor,135.33,,,135.33,Fee Schedule,,121.84,,,121.84,Fee Schedule,,311.3,,,311.3,Fee Schedule,,279.99,,,279.99,Fee Schedule,,264.63,,,264.63,Fee Schedule,,123.75,,,123.75,Other,110% of Medicare,141.62,,,141.62,Fee Schedule,,54,,,54,Other,186% of Medicaid,166.8,,,166.8,Fee Schedule,,155,,,155,Fee Schedule,,94.42,,,94.42,Fee Schedule,,166.8,,,166.8,Fee Schedule,,155,,,155,Fee Schedule,,177.59,,,177.59,Fee Schedule,,175,70,,175,percent of total billed charges,All Other,188.6,,,188.6,Fee Schedule,,159.85,,,159.85,Fee Schedule,,74.21,,,74.21,Fee Schedule,,74.21,,,74.21,Fee Schedule,,74.21,,,74.21,Fee Schedule,,74.21,,,74.21,Fee Schedule,,29.11,,,29.11,Other,100% of Medicaid,29.11,,,29.11,Other,100% of Medicaid,29.11,,,29.11,Other,100% of Medicaid,29.11,,,29.11,Other,100% of Medicaid,65.49,,,65.49,Other,225% of Medicaid,44.54,,,44.54,Other,153% of Medicaid,65.49,,,65.49,Other,225% of Medicaid,40.75,,,40.75,Other,140% of Medicaid,65.49,,,65.49,Other,225% of Medicaid,75.68,,,75.68,Other,260% of Medicaid,94.31,,,94.31,Other,324% of Medicaid,62.58,,,62.58,Other,215% of Medicaid,62.58,,,62.58,Other,215% of Medicaid,36.39,,,36.39,Other,125% of Medicaid,29.11,311.3,
SEX CHROMATIN IDENTIFICATION,88130,CPT,,78088130,CDM,311,RC,,,both,,,91,67.34,,,67.34,Other,150% of Medicare + 9.63% HCRA Surcharge,40.95,45,,40.95,percent of total billed charges,Critical Access Hospital RCC factor,54.12,,,54.12,Fee Schedule,,48.73,,,48.73,Fee Schedule,,111.62,,,111.62,Fee Schedule,,100.39,,,100.39,Fee Schedule,,94.89,,,94.89,Fee Schedule,,45.05,,,45.05,Other,110% of Medicare,56.64,,,56.64,Fee Schedule,,65,,,65,Other,186% of Medicaid,66.71,,,66.71,Fee Schedule,,56.42,,,56.42,Fee Schedule,,37.76,,,37.76,Fee Schedule,,66.71,,,66.71,Fee Schedule,,56.42,,,56.42,Fee Schedule,,71.02,,,71.02,Fee Schedule,,63.7,70,,63.7,percent of total billed charges,All Other,85.21,,,85.21,Fee Schedule,,72.22,,,72.22,Fee Schedule,,26.97,,,26.97,Fee Schedule,,26.97,,,26.97,Fee Schedule,,26.97,,,26.97,Fee Schedule,,26.97,,,26.97,Fee Schedule,,35.14,,,35.14,Other,100% of Medicaid,35.14,,,35.14,Other,100% of Medicaid,35.14,,,35.14,Other,100% of Medicaid,35.14,,,35.14,Other,100% of Medicaid,79.05,,,79.05,Other,225% of Medicaid,53.76,,,53.76,Other,153% of Medicaid,79.05,,,79.05,Other,225% of Medicaid,49.19,,,49.19,Other,140% of Medicaid,79.05,,,79.05,Other,225% of Medicaid,91.35,,,91.35,Other,260% of Medicaid,113.84,,,113.84,Other,324% of Medicaid,75.54,,,75.54,Other,215% of Medicaid,75.54,,,75.54,Other,215% of Medicaid,43.92,,,43.92,Other,125% of Medicaid,26.97,113.84,
CYTOPATH C/V INTERPRET,88141,CPT,,78088141,CDM,311,RC,,,both,,,143,105.82,,,105.82,Other,150% of Medicare + 9.63% HCRA Surcharge,64.35,45,,64.35,percent of total billed charges,Critical Access Hospital RCC factor,77.12,,,77.12,Fee Schedule,,69.43,,,69.43,Fee Schedule,,177.65,,,177.65,Fee Schedule,,159.79,,,159.79,Fee Schedule,,151.02,,,151.02,Fee Schedule,,70.79,,,70.79,Other,110% of Medicare,80.7,,,80.7,Fee Schedule,,16,,,16,Other,186% of Medicaid,95.05,,,95.05,Fee Schedule,,88.66,,,88.66,Fee Schedule,,53.8,,,53.8,Fee Schedule,,95.05,,,95.05,Fee Schedule,,88.66,,,88.66,Fee Schedule,,101.2,,,101.2,Fee Schedule,,100.1,70,,100.1,percent of total billed charges,All Other,106.6,,,106.6,Fee Schedule,,90.35,,,90.35,Fee Schedule,,39.53,,,39.53,Fee Schedule,,39.53,,,39.53,Fee Schedule,,39.53,,,39.53,Fee Schedule,,39.53,,,39.53,Fee Schedule,,8.38,,,8.38,Other,100% of Medicaid,8.38,,,8.38,Other,100% of Medicaid,8.38,,,8.38,Other,100% of Medicaid,8.38,,,8.38,Other,100% of Medicaid,18.86,,,18.86,Other,225% of Medicaid,12.83,,,12.83,Other,153% of Medicaid,18.86,,,18.86,Other,225% of Medicaid,11.74,,,11.74,Other,140% of Medicaid,18.86,,,18.86,Other,225% of Medicaid,21.8,,,21.8,Other,260% of Medicaid,27.16,,,27.16,Other,324% of Medicaid,18.02,,,18.02,Other,215% of Medicaid,18.02,,,18.02,Other,215% of Medicaid,10.48,,,10.48,Other,125% of Medicaid,8.38,177.65,
CYTOPATH C/V THIN LAYER,88142,CPT,,78088142,CDM,311,RC,,,both,,,141,104.34,,,104.34,Other,150% of Medicare + 9.63% HCRA Surcharge,63.45,45,,63.45,percent of total billed charges,Critical Access Hospital RCC factor,60.98,,,60.98,Fee Schedule,,54.9,,,54.9,Fee Schedule,,150.25,,,150.25,Fee Schedule,,135.14,,,135.14,Fee Schedule,,127.72,,,127.72,Fee Schedule,,69.8,,,69.8,Other,110% of Medicare,63.82,,,63.82,Fee Schedule,,38,,,38,Other,186% of Medicaid,75.16,,,75.16,Fee Schedule,,87.42,,,87.42,Fee Schedule,,42.55,,,42.55,Fee Schedule,,75.16,,,75.16,Fee Schedule,,87.42,,,87.42,Fee Schedule,,80.03,,,80.03,Fee Schedule,,98.7,70,,98.7,percent of total billed charges,All Other,96.01,,,96.01,Fee Schedule,,81.38,,,81.38,Fee Schedule,,30.39,,,30.39,Fee Schedule,,30.39,,,30.39,Fee Schedule,,30.39,,,30.39,Fee Schedule,,30.39,,,30.39,Fee Schedule,,20.26,,,20.26,Other,100% of Medicaid,20.26,,,20.26,Other,100% of Medicaid,20.26,,,20.26,Other,100% of Medicaid,20.26,,,20.26,Other,100% of Medicaid,45.59,,,45.59,Other,225% of Medicaid,31,,,31,Other,153% of Medicaid,45.59,,,45.59,Other,225% of Medicaid,28.36,,,28.36,Other,140% of Medicaid,45.59,,,45.59,Other,225% of Medicaid,52.68,,,52.68,Other,260% of Medicaid,65.64,,,65.64,Other,324% of Medicaid,43.56,,,43.56,Other,215% of Medicaid,43.56,,,43.56,Other,215% of Medicaid,25.33,,,25.33,Other,125% of Medicaid,20.26,150.25,
CYTOPATH C/V REDO,88153,CPT,,78088153,CDM,311,RC,,,both,,,66,48.84,,,48.84,Other,150% of Medicare + 9.63% HCRA Surcharge,29.7,45,,29.7,percent of total billed charges,Critical Access Hospital RCC factor,72.33,,,72.33,Fee Schedule,,65.12,,,65.12,Fee Schedule,,78.36,,,78.36,Fee Schedule,,70.48,,,70.48,Fee Schedule,,66.62,,,66.62,Fee Schedule,,32.67,,,32.67,Other,110% of Medicare,75.69,,,75.69,Fee Schedule,,29,,,29,Other,186% of Medicaid,89.15,,,89.15,Fee Schedule,,40.92,,,40.92,Fee Schedule,,50.46,,,50.46,Fee Schedule,,89.15,,,89.15,Fee Schedule,,40.92,,,40.92,Fee Schedule,,94.92,,,94.92,Fee Schedule,,46.2,70,,46.2,percent of total billed charges,All Other,113.88,,,113.88,Fee Schedule,,96.52,,,96.52,Fee Schedule,,36.05,,,36.05,Fee Schedule,,36.05,,,36.05,Fee Schedule,,36.05,,,36.05,Fee Schedule,,36.05,,,36.05,Fee Schedule,,15.57,,,15.57,Other,100% of Medicaid,15.57,,,15.57,Other,100% of Medicaid,15.57,,,15.57,Other,100% of Medicaid,15.57,,,15.57,Other,100% of Medicaid,35.04,,,35.04,Other,225% of Medicaid,23.83,,,23.83,Other,153% of Medicaid,35.04,,,35.04,Other,225% of Medicaid,21.8,,,21.8,Other,140% of Medicaid,35.04,,,35.04,Other,225% of Medicaid,40.49,,,40.49,Other,260% of Medicaid,50.46,,,50.46,Other,324% of Medicaid,33.48,,,33.48,Other,215% of Medicaid,33.48,,,33.48,Other,215% of Medicaid,19.47,,,19.47,Other,125% of Medicaid,15.57,113.88,
CYTOPATH C/V INDEX ADD-ON,88155,CPT,,78088155,CDM,311,RC,,,both,,,80,59.2,,,59.2,Other,150% of Medicare + 9.63% HCRA Surcharge,36,45,,36,percent of total billed charges,Critical Access Hospital RCC factor,44.1,,,44.1,Fee Schedule,,39.7,,,39.7,Fee Schedule,,44.48,,,44.48,Fee Schedule,,40.01,,,40.01,Fee Schedule,,37.81,,,37.81,Fee Schedule,,39.6,,,39.6,Other,110% of Medicare,46.15,,,46.15,Fee Schedule,,51,,,51,Other,186% of Medicaid,54.35,,,54.35,Fee Schedule,,49.6,,,49.6,Fee Schedule,,30.77,,,30.77,Fee Schedule,,54.35,,,54.35,Fee Schedule,,49.6,,,49.6,Fee Schedule,,57.87,,,57.87,Fee Schedule,,56,70,,56,percent of total billed charges,All Other,69.43,,,69.43,Fee Schedule,,58.84,,,58.84,Fee Schedule,,21.98,,,21.98,Fee Schedule,,21.98,,,21.98,Fee Schedule,,21.98,,,21.98,Fee Schedule,,21.98,,,21.98,Fee Schedule,,27.32,,,27.32,Other,100% of Medicaid,27.32,,,27.32,Other,100% of Medicaid,27.32,,,27.32,Other,100% of Medicaid,27.32,,,27.32,Other,100% of Medicaid,61.48,,,61.48,Other,225% of Medicaid,41.8,,,41.8,Other,153% of Medicaid,61.48,,,61.48,Other,225% of Medicaid,38.25,,,38.25,Other,140% of Medicaid,61.48,,,61.48,Other,225% of Medicaid,71.04,,,71.04,Other,260% of Medicaid,88.53,,,88.53,Other,324% of Medicaid,58.74,,,58.74,Other,215% of Medicaid,58.74,,,58.74,Other,215% of Medicaid,34.15,,,34.15,Other,125% of Medicaid,21.98,88.53,
CYTOPATH SMEAR OTHER SOURCE,88161,CPT,,78088161,CDM,311,RC,,,both,,,258,190.92,,,190.92,Other,150% of Medicare + 9.63% HCRA Surcharge,116.1,45,,116.1,percent of total billed charges,Critical Access Hospital RCC factor,186.71,,,186.71,Fee Schedule,,168.1,,,168.1,Fee Schedule,,206.06,,,206.06,Fee Schedule,,185.33,,,185.33,Fee Schedule,,175.17,,,175.17,Fee Schedule,,127.71,,,127.71,Other,110% of Medicare,195.39,,,195.39,Fee Schedule,,36,,,36,Other,186% of Medicaid,230.13,,,230.13,Fee Schedule,,159.96,,,159.96,Fee Schedule,,130.26,,,130.26,Fee Schedule,,230.13,,,230.13,Fee Schedule,,159.96,,,159.96,Fee Schedule,,245.02,,,245.02,Fee Schedule,,180.6,70,,180.6,percent of total billed charges,All Other,234.52,,,234.52,Fee Schedule,,198.77,,,198.77,Fee Schedule,,34.49,,,34.49,Fee Schedule,,34.49,,,34.49,Fee Schedule,,34.49,,,34.49,Fee Schedule,,34.49,,,34.49,Fee Schedule,,19.31,,,19.31,Other,100% of Medicaid,19.31,,,19.31,Other,100% of Medicaid,19.31,,,19.31,Other,100% of Medicaid,19.31,,,19.31,Other,100% of Medicaid,43.45,,,43.45,Other,225% of Medicaid,29.55,,,29.55,Other,153% of Medicaid,43.45,,,43.45,Other,225% of Medicaid,27.04,,,27.04,Other,140% of Medicaid,43.45,,,43.45,Other,225% of Medicaid,50.21,,,50.21,Other,260% of Medicaid,62.57,,,62.57,Other,324% of Medicaid,41.52,,,41.52,Other,215% of Medicaid,41.52,,,41.52,Other,215% of Medicaid,24.14,,,24.14,Other,125% of Medicaid,19.31,245.02,
CYTOPATH TBS C/V MANUAL,88164,CPT,,78088164,CDM,311,RC,,,both,,,76,56.24,,,56.24,Other,150% of Medicare + 9.63% HCRA Surcharge,34.2,45,,34.2,percent of total billed charges,Critical Access Hospital RCC factor,53.46,,,53.46,Fee Schedule,,48.13,,,48.13,Fee Schedule,,78.36,,,78.36,Fee Schedule,,70.48,,,70.48,Fee Schedule,,66.62,,,66.62,Fee Schedule,,37.62,,,37.62,Other,110% of Medicare,55.94,,,55.94,Fee Schedule,,28,,,28,Other,186% of Medicaid,65.89,,,65.89,Fee Schedule,,47.12,,,47.12,Fee Schedule,,37.3,,,37.3,Fee Schedule,,65.89,,,65.89,Fee Schedule,,47.12,,,47.12,Fee Schedule,,70.15,,,70.15,Fee Schedule,,53.2,70,,53.2,percent of total billed charges,All Other,75.45,,,75.45,Fee Schedule,,63.94,,,63.94,Fee Schedule,,22.68,,,22.68,Fee Schedule,,22.68,,,22.68,Fee Schedule,,22.68,,,22.68,Fee Schedule,,22.68,,,22.68,Fee Schedule,,14.8,,,14.8,Other,100% of Medicaid,14.8,,,14.8,Other,100% of Medicaid,14.8,,,14.8,Other,100% of Medicaid,14.8,,,14.8,Other,100% of Medicaid,33.29,,,33.29,Other,225% of Medicaid,22.64,,,22.64,Other,153% of Medicaid,33.29,,,33.29,Other,225% of Medicaid,20.72,,,20.72,Other,140% of Medicaid,33.29,,,33.29,Other,225% of Medicaid,38.47,,,38.47,Other,260% of Medicaid,47.94,,,47.94,Other,324% of Medicaid,31.81,,,31.81,Other,215% of Medicaid,31.81,,,31.81,Other,215% of Medicaid,18.5,,,18.5,Other,125% of Medicaid,14.8,78.36,
CYTP DX EVAL FNA LST EA SITE,88172,CPT,,78088172,CDM,311,RC,,,both,,,682,504.68,,,504.68,Other,150% of Medicare + 9.63% HCRA Surcharge,306.9,45,,306.9,percent of total billed charges,Critical Access Hospital RCC factor,71.01,,,71.01,Fee Schedule,,63.93,,,63.93,Fee Schedule,,139.71,,,139.71,Fee Schedule,,125.66,,,125.66,Fee Schedule,,118.76,,,118.76,Fee Schedule,,337.59,,,337.59,Other,110% of Medicare,74.31,,,74.31,Fee Schedule,,131,,,131,Other,186% of Medicaid,87.52,,,87.52,Fee Schedule,,422.84,,,422.84,Fee Schedule,,49.54,,,49.54,Fee Schedule,,87.52,,,87.52,Fee Schedule,,422.84,,,422.84,Fee Schedule,,93.18,,,93.18,Fee Schedule,,477.4,70,,477.4,percent of total billed charges,All Other,93.48,,,93.48,Fee Schedule,,79.23,,,79.23,Fee Schedule,,215.25,,,215.25,Fee Schedule,,215.25,,,215.25,Fee Schedule,,215.25,,,215.25,Fee Schedule,,215.25,,,215.25,Fee Schedule,,70.35,,,70.35,Other,100% of Medicaid,70.35,,,70.35,Other,100% of Medicaid,70.35,,,70.35,Other,100% of Medicaid,70.35,,,70.35,Other,100% of Medicaid,158.29,,,158.29,Other,225% of Medicaid,107.64,,,107.64,Other,153% of Medicaid,158.29,,,158.29,Other,225% of Medicaid,98.49,,,98.49,Other,140% of Medicaid,158.29,,,158.29,Other,225% of Medicaid,182.91,,,182.91,Other,260% of Medicaid,227.93,,,227.93,Other,324% of Medicaid,151.25,,,151.25,Other,215% of Medicaid,151.25,,,151.25,Other,215% of Medicaid,87.94,,,87.94,Other,125% of Medicaid,49.54,504.68,
CYTOPATH EVAL FNA REPORT,88173,CPT,,78088173,CDM,311,RC,,,both,,,540,399.6,,,399.6,Other,150% of Medicare + 9.63% HCRA Surcharge,243,45,,243,percent of total billed charges,Critical Access Hospital RCC factor,327.52,,,327.52,Fee Schedule,,294.88,,,294.88,Fee Schedule,,466.92,,,466.92,Fee Schedule,,419.96,,,419.96,Fee Schedule,,396.93,,,396.93,Fee Schedule,,267.3,,,267.3,Other,110% of Medicare,342.75,,,342.75,Fee Schedule,,36,,,36,Other,186% of Medicaid,403.69,,,403.69,Fee Schedule,,334.8,,,334.8,Fee Schedule,,228.5,,,228.5,Fee Schedule,,403.69,,,403.69,Fee Schedule,,334.8,,,334.8,Fee Schedule,,429.8,,,429.8,Fee Schedule,,378,70,,378,percent of total billed charges,All Other,423.12,,,423.12,Fee Schedule,,358.62,,,358.62,Fee Schedule,,74.21,,,74.21,Fee Schedule,,74.21,,,74.21,Fee Schedule,,74.21,,,74.21,Fee Schedule,,74.21,,,74.21,Fee Schedule,,19.31,,,19.31,Other,100% of Medicaid,19.31,,,19.31,Other,100% of Medicaid,19.31,,,19.31,Other,100% of Medicaid,19.31,,,19.31,Other,100% of Medicaid,43.45,,,43.45,Other,225% of Medicaid,29.55,,,29.55,Other,153% of Medicaid,43.45,,,43.45,Other,225% of Medicaid,27.04,,,27.04,Other,140% of Medicaid,43.45,,,43.45,Other,225% of Medicaid,50.21,,,50.21,Other,260% of Medicaid,62.57,,,62.57,Other,324% of Medicaid,41.52,,,41.52,Other,215% of Medicaid,41.52,,,41.52,Other,215% of Medicaid,24.14,,,24.14,Other,125% of Medicaid,19.31,466.92,
CYTP FNA EVAL EA ADDL,88177,CPT,,78088177,CDM,311,RC,,,both,,,91,67.34,,,67.34,Other,150% of Medicare + 9.63% HCRA Surcharge,40.95,45,,40.95,percent of total billed charges,Critical Access Hospital RCC factor,27.24,,,27.24,Fee Schedule,,24.53,,,24.53,Fee Schedule,,43.58,,,43.58,Fee Schedule,,39.2,,,39.2,Fee Schedule,,37.05,,,37.05,Fee Schedule,,45.05,,,45.05,Other,110% of Medicare,28.51,,,28.51,Fee Schedule,,122,,,122,Other,186% of Medicaid,33.58,,,33.58,Fee Schedule,,56.42,,,56.42,Fee Schedule,,19.01,,,19.01,Fee Schedule,,33.58,,,33.58,Fee Schedule,,56.42,,,56.42,Fee Schedule,,35.75,,,35.75,Fee Schedule,,63.7,70,,63.7,percent of total billed charges,All Other,34.44,,,34.44,Fee Schedule,,29.19,,,29.19,Fee Schedule,,10.83,,,10.83,Fee Schedule,,10.83,,,10.83,Fee Schedule,,10.83,,,10.83,Fee Schedule,,10.83,,,10.83,Fee Schedule,,65.37,,,65.37,Other,100% of Medicaid,65.37,,,65.37,Other,100% of Medicaid,65.37,,,65.37,Other,100% of Medicaid,65.37,,,65.37,Other,100% of Medicaid,147.09,,,147.09,Other,225% of Medicaid,100.02,,,100.02,Other,153% of Medicaid,147.09,,,147.09,Other,225% of Medicaid,91.52,,,91.52,Other,140% of Medicaid,147.09,,,147.09,Other,225% of Medicaid,169.97,,,169.97,Other,260% of Medicaid,211.81,,,211.81,Other,324% of Medicaid,140.55,,,140.55,Other,215% of Medicaid,140.55,,,140.55,Other,215% of Medicaid,81.72,,,81.72,Other,125% of Medicaid,10.83,211.81,
CELL MARKER STUDY,88182,CPT,,78088182,CDM,311,RC,,,both,,,481,355.94,,,355.94,Other,150% of Medicare + 9.63% HCRA Surcharge,216.45,45,,216.45,percent of total billed charges,Critical Access Hospital RCC factor,425.95,,,425.95,Fee Schedule,,383.49,,,383.49,Fee Schedule,,467.13,,,467.13,Fee Schedule,,420.15,,,420.15,Fee Schedule,,397.11,,,397.11,Fee Schedule,,238.1,,,238.1,Other,110% of Medicare,445.76,,,445.76,Fee Schedule,,122,,,122,Other,186% of Medicaid,525,,,525,Fee Schedule,,298.22,,,298.22,Fee Schedule,,297.17,,,297.17,Fee Schedule,,525,,,525,Fee Schedule,,298.22,,,298.22,Fee Schedule,,558.96,,,558.96,Fee Schedule,,336.7,70,,336.7,percent of total billed charges,All Other,524.8,,,524.8,Fee Schedule,,444.8,,,444.8,Fee Schedule,,74.21,,,74.21,Fee Schedule,,74.21,,,74.21,Fee Schedule,,74.21,,,74.21,Fee Schedule,,74.21,,,74.21,Fee Schedule,,65.37,,,65.37,Other,100% of Medicaid,65.37,,,65.37,Other,100% of Medicaid,65.37,,,65.37,Other,100% of Medicaid,65.37,,,65.37,Other,100% of Medicaid,147.09,,,147.09,Other,225% of Medicaid,100.02,,,100.02,Other,153% of Medicaid,147.09,,,147.09,Other,225% of Medicaid,91.52,,,91.52,Other,140% of Medicaid,147.09,,,147.09,Other,225% of Medicaid,169.97,,,169.97,Other,260% of Medicaid,211.81,,,211.81,Other,324% of Medicaid,140.55,,,140.55,Other,215% of Medicaid,140.55,,,140.55,Other,215% of Medicaid,81.72,,,81.72,Other,125% of Medicaid,65.37,558.96,
FLOWCYTOMETRY/ TC 1 MARKER,88184,CPT,,78088184,CDM,311,RC,,,both,,,731,540.94,,,540.94,Other,150% of Medicare + 9.63% HCRA Surcharge,328.95,45,,328.95,percent of total billed charges,Critical Access Hospital RCC factor,255.4,,,255.4,Fee Schedule,,229.94,,,229.94,Fee Schedule,,565.31,,,565.31,Fee Schedule,,508.46,,,508.46,Fee Schedule,,480.57,,,480.57,Fee Schedule,,361.85,,,361.85,Other,110% of Medicare,267.28,,,267.28,Fee Schedule,,44,,,44,Other,186% of Medicaid,314.79,,,314.79,Fee Schedule,,453.22,,,453.22,Fee Schedule,,178.19,,,178.19,Fee Schedule,,314.79,,,314.79,Fee Schedule,,453.22,,,453.22,Fee Schedule,,335.16,,,335.16,Fee Schedule,,511.7,70,,511.7,percent of total billed charges,All Other,328,,,328,Fee Schedule,,278,,,278,Fee Schedule,,425.12,,,425.12,Fee Schedule,,425.12,,,425.12,Fee Schedule,,425.12,,,425.12,Fee Schedule,,425.12,,,425.12,Fee Schedule,,23.4,,,23.4,Other,100% of Medicaid,23.4,,,23.4,Other,100% of Medicaid,23.4,,,23.4,Other,100% of Medicaid,23.4,,,23.4,Other,100% of Medicaid,52.65,,,52.65,Other,225% of Medicaid,35.8,,,35.8,Other,153% of Medicaid,52.65,,,52.65,Other,225% of Medicaid,32.76,,,32.76,Other,140% of Medicaid,52.65,,,52.65,Other,225% of Medicaid,60.84,,,60.84,Other,260% of Medicaid,75.82,,,75.82,Other,324% of Medicaid,50.31,,,50.31,Other,215% of Medicaid,50.31,,,50.31,Other,215% of Medicaid,29.25,,,29.25,Other,125% of Medicaid,23.4,565.31,
FLOWCYTOMETRY/TC ADD-ON,88185,CPT,,78088185,CDM,311,RC,,,both,,,270,199.8,,,199.8,Other,150% of Medicare + 9.63% HCRA Surcharge,121.5,45,,121.5,percent of total billed charges,Critical Access Hospital RCC factor,77.39,,,77.39,Fee Schedule,,69.67,,,69.67,Fee Schedule,,338.76,,,338.76,Fee Schedule,,304.69,,,304.69,Fee Schedule,,287.97,,,287.97,Fee Schedule,,133.65,,,133.65,Other,110% of Medicare,80.99,,,80.99,Fee Schedule,,29,,,29,Other,186% of Medicaid,95.38,,,95.38,Fee Schedule,,167.4,,,167.4,Fee Schedule,,53.99,,,53.99,Fee Schedule,,95.38,,,95.38,Fee Schedule,,167.4,,,167.4,Fee Schedule,,101.55,,,101.55,Fee Schedule,,189,70,,189,percent of total billed charges,All Other,104.96,,,104.96,Fee Schedule,,88.96,,,88.96,Fee Schedule,,33.57,,,33.57,Fee Schedule,,33.57,,,33.57,Fee Schedule,,33.57,,,33.57,Fee Schedule,,33.57,,,33.57,Fee Schedule,,15.6,,,15.6,Other,100% of Medicaid,15.6,,,15.6,Other,100% of Medicaid,15.6,,,15.6,Other,100% of Medicaid,15.6,,,15.6,Other,100% of Medicaid,35.11,,,35.11,Other,225% of Medicaid,23.87,,,23.87,Other,153% of Medicaid,35.11,,,35.11,Other,225% of Medicaid,21.85,,,21.85,Other,140% of Medicaid,35.11,,,35.11,Other,225% of Medicaid,40.57,,,40.57,Other,260% of Medicaid,50.56,,,50.56,Other,324% of Medicaid,33.55,,,33.55,Other,215% of Medicaid,33.55,,,33.55,Other,215% of Medicaid,19.51,,,19.51,Other,125% of Medicaid,15.6,338.76,
FLOWCYTOMETRY/READ 2-8,88187,CPT,,78088187,CDM,311,RC,,,both,,,338,250.12,,,250.12,Other,150% of Medicare + 9.63% HCRA Surcharge,152.1,45,,152.1,percent of total billed charges,Critical Access Hospital RCC factor,110.56,,,110.56,Fee Schedule,,99.54,,,99.54,Fee Schedule,,400.68,,,400.68,Fee Schedule,,360.38,,,360.38,Fee Schedule,,340.61,,,340.61,Fee Schedule,,167.31,,,167.31,Other,110% of Medicare,115.7,,,115.7,Fee Schedule,,38,,,38,Other,186% of Medicaid,136.27,,,136.27,Fee Schedule,,209.56,,,209.56,Fee Schedule,,77.13,,,77.13,Fee Schedule,,136.27,,,136.27,Fee Schedule,,209.56,,,209.56,Fee Schedule,,145.08,,,145.08,Fee Schedule,,236.6,70,,236.6,percent of total billed charges,All Other,170.56,,,170.56,Fee Schedule,,144.56,,,144.56,Fee Schedule,,59.01,,,59.01,Fee Schedule,,59.01,,,59.01,Fee Schedule,,59.01,,,59.01,Fee Schedule,,59.01,,,59.01,Fee Schedule,,20.2,,,20.2,Other,100% of Medicaid,20.2,,,20.2,Other,100% of Medicaid,20.2,,,20.2,Other,100% of Medicaid,20.2,,,20.2,Other,100% of Medicaid,45.45,,,45.45,Other,225% of Medicaid,30.91,,,30.91,Other,153% of Medicaid,45.45,,,45.45,Other,225% of Medicaid,28.28,,,28.28,Other,140% of Medicaid,45.45,,,45.45,Other,225% of Medicaid,52.52,,,52.52,Other,260% of Medicaid,65.45,,,65.45,Other,324% of Medicaid,43.43,,,43.43,Other,215% of Medicaid,43.43,,,43.43,Other,215% of Medicaid,25.25,,,25.25,Other,125% of Medicaid,20.2,400.68,
FLOWCYTOMETRY/READ 9-15,88188,CPT,,78088188,CDM,311,RC,,,both,,,417,308.58,,,308.58,Other,150% of Medicare + 9.63% HCRA Surcharge,187.65,45,,187.65,percent of total billed charges,Critical Access Hospital RCC factor,191.17,,,191.17,Fee Schedule,,172.11,,,172.11,Fee Schedule,,497.22,,,497.22,Fee Schedule,,447.22,,,447.22,Fee Schedule,,422.69,,,422.69,Fee Schedule,,206.42,,,206.42,Other,110% of Medicare,200.06,,,200.06,Fee Schedule,,47,,,47,Other,186% of Medicaid,235.62,,,235.62,Fee Schedule,,258.54,,,258.54,Fee Schedule,,133.37,,,133.37,Fee Schedule,,235.62,,,235.62,Fee Schedule,,258.54,,,258.54,Fee Schedule,,250.86,,,250.86,Fee Schedule,,291.9,70,,291.9,percent of total billed charges,All Other,298.48,,,298.48,Fee Schedule,,252.98,,,252.98,Fee Schedule,,99.06,,,99.06,Fee Schedule,,99.06,,,99.06,Fee Schedule,,99.06,,,99.06,Fee Schedule,,99.06,,,99.06,Fee Schedule,,25.25,,,25.25,Other,100% of Medicaid,25.25,,,25.25,Other,100% of Medicaid,25.25,,,25.25,Other,100% of Medicaid,25.25,,,25.25,Other,100% of Medicaid,56.81,,,56.81,Other,225% of Medicaid,38.63,,,38.63,Other,153% of Medicaid,56.81,,,56.81,Other,225% of Medicaid,35.35,,,35.35,Other,140% of Medicaid,56.81,,,56.81,Other,225% of Medicaid,65.65,,,65.65,Other,260% of Medicaid,81.81,,,81.81,Other,324% of Medicaid,54.29,,,54.29,Other,215% of Medicaid,54.29,,,54.29,Other,215% of Medicaid,31.56,,,31.56,Other,125% of Medicaid,25.25,497.22,
FLOW CYTOMETRY INTERP 16&> MAR,88189,CPT,,78088189,CDM,311,RC,,,both,,,189,139.86,,,139.86,Other,150% of Medicare + 9.63% HCRA Surcharge,85.05,45,,85.05,percent of total billed charges,Critical Access Hospital RCC factor,258.29,,,258.29,Fee Schedule,,232.55,,,232.55,Fee Schedule,,605.84,,,605.84,Fee Schedule,,544.91,,,544.91,Fee Schedule,,515.02,,,515.02,Fee Schedule,,93.56,,,93.56,Other,110% of Medicare,270.3,,,270.3,Fee Schedule,,56,,,56,Other,186% of Medicaid,318.36,,,318.36,Fee Schedule,,117.18,,,117.18,Fee Schedule,,180.2,,,180.2,Fee Schedule,,318.36,,,318.36,Fee Schedule,,117.18,,,117.18,Fee Schedule,,338.95,,,338.95,Fee Schedule,,132.3,70,,132.3,percent of total billed charges,All Other,400.16,,,400.16,Fee Schedule,,339.16,,,339.16,Fee Schedule,,133.17,,,133.17,Fee Schedule,,133.17,,,133.17,Fee Schedule,,133.17,,,133.17,Fee Schedule,,133.17,,,133.17,Fee Schedule,,30.3,,,30.3,Other,100% of Medicaid,30.3,,,30.3,Other,100% of Medicaid,30.3,,,30.3,Other,100% of Medicaid,30.3,,,30.3,Other,100% of Medicaid,68.18,,,68.18,Other,225% of Medicaid,46.36,,,46.36,Other,153% of Medicaid,68.18,,,68.18,Other,225% of Medicaid,42.42,,,42.42,Other,140% of Medicaid,68.18,,,68.18,Other,225% of Medicaid,78.78,,,78.78,Other,260% of Medicaid,98.17,,,98.17,Other,324% of Medicaid,65.15,,,65.15,Other,215% of Medicaid,65.15,,,65.15,Other,215% of Medicaid,37.88,,,37.88,Other,125% of Medicaid,30.3,605.84,
TISSUE CULTURE LYMPHOCYTE,88230,CPT,,78088230,CDM,311,RC,,,both,,,601,444.74,,,444.74,Other,150% of Medicare + 9.63% HCRA Surcharge,270.45,45,,270.45,percent of total billed charges,Critical Access Hospital RCC factor,350.63,,,350.63,Fee Schedule,,315.69,,,315.69,Fee Schedule,,152.36,,,152.36,Fee Schedule,,137.03,,,137.03,Fee Schedule,,129.52,,,129.52,Fee Schedule,,297.5,,,297.5,Other,110% of Medicare,366.94,,,366.94,Fee Schedule,,75,,,75,Other,186% of Medicaid,432.18,,,432.18,Fee Schedule,,372.62,,,372.62,Fee Schedule,,244.63,,,244.63,Fee Schedule,,432.18,,,432.18,Fee Schedule,,372.62,,,372.62,Fee Schedule,,460.14,,,460.14,Fee Schedule,,420.7,70,,420.7,percent of total billed charges,All Other,552.05,,,552.05,Fee Schedule,,467.9,,,467.9,Fee Schedule,,174.74,,,174.74,Fee Schedule,,174.74,,,174.74,Fee Schedule,,174.74,,,174.74,Fee Schedule,,174.74,,,174.74,Fee Schedule,,40.4,,,40.4,Other,100% of Medicaid,40.4,,,40.4,Other,100% of Medicaid,40.4,,,40.4,Other,100% of Medicaid,40.4,,,40.4,Other,100% of Medicaid,90.9,,,90.9,Other,225% of Medicaid,61.81,,,61.81,Other,153% of Medicaid,90.9,,,90.9,Other,225% of Medicaid,56.56,,,56.56,Other,140% of Medicaid,90.9,,,90.9,Other,225% of Medicaid,105.04,,,105.04,Other,260% of Medicaid,130.9,,,130.9,Other,324% of Medicaid,86.86,,,86.86,Other,215% of Medicaid,86.86,,,86.86,Other,215% of Medicaid,50.5,,,50.5,Other,125% of Medicaid,40.4,552.05,
TISSUE CULTURE SKIN/BIOPSY,88233,CPT,,78088233,CDM,311,RC,,,both,,,865,640.1,,,640.1,Other,150% of Medicare + 9.63% HCRA Surcharge,389.25,45,,389.25,percent of total billed charges,Critical Access Hospital RCC factor,423.6,,,423.6,Fee Schedule,,381.38,,,381.38,Fee Schedule,,190.72,,,190.72,Fee Schedule,,171.54,,,171.54,Fee Schedule,,162.13,,,162.13,Fee Schedule,,428.18,,,428.18,Other,110% of Medicare,443.3,,,443.3,Fee Schedule,,248,,,248,Other,186% of Medicaid,522.11,,,522.11,Fee Schedule,,536.3,,,536.3,Fee Schedule,,295.53,,,295.53,Fee Schedule,,522.11,,,522.11,Fee Schedule,,536.3,,,536.3,Fee Schedule,,555.88,,,555.88,Fee Schedule,,605.5,70,,605.5,percent of total billed charges,All Other,666.92,,,666.92,Fee Schedule,,565.26,,,565.26,Fee Schedule,,211.1,,,211.1,Fee Schedule,,211.1,,,211.1,Fee Schedule,,211.1,,,211.1,Fee Schedule,,211.1,,,211.1,Fee Schedule,,133.23,,,133.23,Other,100% of Medicaid,133.23,,,133.23,Other,100% of Medicaid,133.23,,,133.23,Other,100% of Medicaid,133.23,,,133.23,Other,100% of Medicaid,299.77,,,299.77,Other,225% of Medicaid,203.84,,,203.84,Other,153% of Medicaid,299.77,,,299.77,Other,225% of Medicaid,186.52,,,186.52,Other,140% of Medicaid,299.77,,,299.77,Other,225% of Medicaid,346.4,,,346.4,Other,260% of Medicaid,431.66,,,431.66,Other,324% of Medicaid,286.44,,,286.44,Other,215% of Medicaid,286.44,,,286.44,Other,215% of Medicaid,166.54,,,166.54,Other,125% of Medicaid,133.23,666.92,
TISSSUE CULTURE BONE MARROW,88237,CPT,,78088237,CDM,311,RC,,,both,,,798,590.52,,,590.52,Other,150% of Medicare + 9.63% HCRA Surcharge,359.1,45,,359.1,percent of total billed charges,Critical Access Hospital RCC factor,432.69,,,432.69,Fee Schedule,,389.56,,,389.56,Fee Schedule,,190.72,,,190.72,Fee Schedule,,171.54,,,171.54,Fee Schedule,,162.13,,,162.13,Fee Schedule,,395.01,,,395.01,Other,110% of Medicare,452.81,,,452.81,Fee Schedule,,188,,,188,Other,186% of Medicaid,533.31,,,533.31,Fee Schedule,,494.76,,,494.76,Fee Schedule,,301.88,,,301.88,Fee Schedule,,533.31,,,533.31,Fee Schedule,,494.76,,,494.76,Fee Schedule,,567.81,,,567.81,Fee Schedule,,558.6,70,,558.6,percent of total billed charges,All Other,681.24,,,681.24,Fee Schedule,,577.39,,,577.39,Fee Schedule,,215.63,,,215.63,Fee Schedule,,215.63,,,215.63,Fee Schedule,,215.63,,,215.63,Fee Schedule,,215.63,,,215.63,Fee Schedule,,101.03,,,101.03,Other,100% of Medicaid,101.03,,,101.03,Other,100% of Medicaid,101.03,,,101.03,Other,100% of Medicaid,101.03,,,101.03,Other,100% of Medicaid,227.32,,,227.32,Other,225% of Medicaid,154.58,,,154.58,Other,153% of Medicaid,227.32,,,227.32,Other,225% of Medicaid,141.44,,,141.44,Other,140% of Medicaid,227.32,,,227.32,Other,225% of Medicaid,262.68,,,262.68,Other,260% of Medicaid,327.34,,,327.34,Other,324% of Medicaid,217.22,,,217.22,Other,215% of Medicaid,217.22,,,217.22,Other,215% of Medicaid,126.29,,,126.29,Other,125% of Medicaid,101.03,681.24,
TISSUE CULTURE TUMOR,88239,CPT,,78088239,CDM,311,RC,,,both,,,762,563.88,,,563.88,Other,150% of Medicare + 9.63% HCRA Surcharge,342.9,45,,342.9,percent of total billed charges,Critical Access Hospital RCC factor,444.04,,,444.04,Fee Schedule,,399.78,,,399.78,Fee Schedule,,152.36,,,152.36,Fee Schedule,,137.03,,,137.03,Fee Schedule,,129.52,,,129.52,Fee Schedule,,377.19,,,377.19,Other,110% of Medicare,464.69,,,464.69,Fee Schedule,,248,,,248,Other,186% of Medicaid,547.3,,,547.3,Fee Schedule,,472.44,,,472.44,Fee Schedule,,309.79,,,309.79,Fee Schedule,,547.3,,,547.3,Fee Schedule,,472.44,,,472.44,Fee Schedule,,582.7,,,582.7,Fee Schedule,,533.4,70,,533.4,percent of total billed charges,All Other,699.1,,,699.1,Fee Schedule,,592.53,,,592.53,Fee Schedule,,221.28,,,221.28,Fee Schedule,,221.28,,,221.28,Fee Schedule,,221.28,,,221.28,Fee Schedule,,221.28,,,221.28,Fee Schedule,,133.23,,,133.23,Other,100% of Medicaid,133.23,,,133.23,Other,100% of Medicaid,133.23,,,133.23,Other,100% of Medicaid,133.23,,,133.23,Other,100% of Medicaid,299.77,,,299.77,Other,225% of Medicaid,203.84,,,203.84,Other,153% of Medicaid,299.77,,,299.77,Other,225% of Medicaid,186.52,,,186.52,Other,140% of Medicaid,299.77,,,299.77,Other,225% of Medicaid,346.4,,,346.4,Other,260% of Medicaid,431.66,,,431.66,Other,324% of Medicaid,286.44,,,286.44,Other,215% of Medicaid,286.44,,,286.44,Other,215% of Medicaid,166.54,,,166.54,Other,125% of Medicaid,129.52,699.1,
CHROMOSOME ANALYSIS 45,88263,CPT,,78088263,CDM,311,RC,,,both,,,474,350.76,,,350.76,Other,150% of Medicare + 9.63% HCRA Surcharge,213.3,45,,213.3,percent of total billed charges,Critical Access Hospital RCC factor,452.37,,,452.37,Fee Schedule,,407.29,,,407.29,Fee Schedule,,1114.5,,,1114.5,Fee Schedule,,1002.42,,,1002.42,Fee Schedule,,947.43,,,947.43,Fee Schedule,,234.63,,,234.63,Other,110% of Medicare,473.41,,,473.41,Fee Schedule,,188,,,188,Other,186% of Medicaid,557.58,,,557.58,Fee Schedule,,293.88,,,293.88,Fee Schedule,,315.61,,,315.61,Fee Schedule,,557.58,,,557.58,Fee Schedule,,293.88,,,293.88,Fee Schedule,,593.65,,,593.65,Fee Schedule,,331.8,70,,331.8,percent of total billed charges,All Other,712.23,,,712.23,Fee Schedule,,603.66,,,603.66,Fee Schedule,,225.44,,,225.44,Fee Schedule,,225.44,,,225.44,Fee Schedule,,225.44,,,225.44,Fee Schedule,,225.44,,,225.44,Fee Schedule,,101,,,101,Other,100% of Medicaid,101,,,101,Other,100% of Medicaid,101,,,101,Other,100% of Medicaid,101,,,101,Other,100% of Medicaid,227.25,,,227.25,Other,225% of Medicaid,154.53,,,154.53,Other,153% of Medicaid,227.25,,,227.25,Other,225% of Medicaid,141.4,,,141.4,Other,140% of Medicaid,227.25,,,227.25,Other,225% of Medicaid,262.6,,,262.6,Other,260% of Medicaid,327.24,,,327.24,Other,324% of Medicaid,217.15,,,217.15,Other,215% of Medicaid,217.15,,,217.15,Other,215% of Medicaid,126.25,,,126.25,Other,125% of Medicaid,101,1114.5,
CHROM ANALY SITU AF CELLS FROM,88269,CPT,,78088269,CDM,311,RC,,,both,,,856,633.44,,,633.44,Other,150% of Medicare + 9.63% HCRA Surcharge,385.2,45,,385.2,percent of total billed charges,Critical Access Hospital RCC factor,522.72,,,522.72,Fee Schedule,,470.62,,,470.62,Fee Schedule,,898.85,,,898.85,Fee Schedule,,808.45,,,808.45,Fee Schedule,,764.11,,,764.11,Fee Schedule,,423.72,,,423.72,Other,110% of Medicare,547.03,,,547.03,Fee Schedule,,141,,,141,Other,186% of Medicaid,644.28,,,644.28,Fee Schedule,,530.72,,,530.72,Fee Schedule,,364.69,,,364.69,Fee Schedule,,644.28,,,644.28,Fee Schedule,,530.72,,,530.72,Fee Schedule,,685.96,,,685.96,Fee Schedule,,599.2,70,,599.2,percent of total billed charges,All Other,822.98,,,822.98,Fee Schedule,,697.53,,,697.53,Fee Schedule,,260.49,,,260.49,Fee Schedule,,260.49,,,260.49,Fee Schedule,,260.49,,,260.49,Fee Schedule,,260.49,,,260.49,Fee Schedule,,75.75,,,75.75,Other,100% of Medicaid,75.75,,,75.75,Other,100% of Medicaid,75.75,,,75.75,Other,100% of Medicaid,75.75,,,75.75,Other,100% of Medicaid,170.44,,,170.44,Other,225% of Medicaid,115.9,,,115.9,Other,153% of Medicaid,170.44,,,170.44,Other,225% of Medicaid,106.05,,,106.05,Other,140% of Medicaid,170.44,,,170.44,Other,225% of Medicaid,196.95,,,196.95,Other,260% of Medicaid,245.43,,,245.43,Other,324% of Medicaid,162.86,,,162.86,Other,215% of Medicaid,162.86,,,162.86,Other,215% of Medicaid,94.69,,,94.69,Other,125% of Medicaid,75.75,898.85,
CYTOGENETICS DNA PROBE,88271,CPT,,78088271,CDM,311,RC,,,both,,,1019,754.06,,,754.06,Other,150% of Medicare + 9.63% HCRA Surcharge,458.55,45,,458.55,percent of total billed charges,Critical Access Hospital RCC factor,64.47,,,64.47,Fee Schedule,,58.05,,,58.05,Fee Schedule,,134.23,,,134.23,Fee Schedule,,120.73,,,120.73,Fee Schedule,,114.11,,,114.11,Fee Schedule,,504.41,,,504.41,Other,110% of Medicare,67.47,,,67.47,Fee Schedule,,40,,,40,Other,186% of Medicaid,79.47,,,79.47,Fee Schedule,,631.78,,,631.78,Fee Schedule,,44.98,,,44.98,Fee Schedule,,79.47,,,79.47,Fee Schedule,,631.78,,,631.78,Fee Schedule,,84.61,,,84.61,Fee Schedule,,713.3,70,,713.3,percent of total billed charges,All Other,101.51,,,101.51,Fee Schedule,,86.04,,,86.04,Fee Schedule,,32.13,,,32.13,Fee Schedule,,32.13,,,32.13,Fee Schedule,,32.13,,,32.13,Fee Schedule,,32.13,,,32.13,Fee Schedule,,21.42,,,21.42,Other,100% of Medicaid,21.42,,,21.42,Other,100% of Medicaid,21.42,,,21.42,Other,100% of Medicaid,21.42,,,21.42,Other,100% of Medicaid,48.2,,,48.2,Other,225% of Medicaid,32.77,,,32.77,Other,153% of Medicaid,48.2,,,48.2,Other,225% of Medicaid,29.99,,,29.99,Other,140% of Medicaid,48.2,,,48.2,Other,225% of Medicaid,55.69,,,55.69,Other,260% of Medicaid,69.4,,,69.4,Other,324% of Medicaid,46.05,,,46.05,Other,215% of Medicaid,46.05,,,46.05,Other,215% of Medicaid,26.78,,,26.78,Other,125% of Medicaid,21.42,754.06,
CYTOGENETICS 10-30,88273,CPT,,78088273,CDM,311,RC,,,both,,,170,125.8,,,125.8,Other,150% of Medicare + 9.63% HCRA Surcharge,76.5,45,,76.5,percent of total billed charges,Critical Access Hospital RCC factor,104.78,,,104.78,Fee Schedule,,94.34,,,94.34,Fee Schedule,,214.65,,,214.65,Fee Schedule,,193.06,,,193.06,Fee Schedule,,182.47,,,182.47,Fee Schedule,,84.15,,,84.15,Other,110% of Medicare,109.65,,,109.65,Fee Schedule,,65,,,65,Other,186% of Medicaid,129.15,,,129.15,Fee Schedule,,105.4,,,105.4,Fee Schedule,,73.1,,,73.1,Fee Schedule,,129.15,,,129.15,Fee Schedule,,105.4,,,105.4,Fee Schedule,,137.5,,,137.5,Fee Schedule,,119,70,,119,percent of total billed charges,All Other,164.97,,,164.97,Fee Schedule,,139.82,,,139.82,Fee Schedule,,52.22,,,52.22,Fee Schedule,,52.22,,,52.22,Fee Schedule,,52.22,,,52.22,Fee Schedule,,52.22,,,52.22,Fee Schedule,,34.81,,,34.81,Other,100% of Medicaid,34.81,,,34.81,Other,100% of Medicaid,34.81,,,34.81,Other,100% of Medicaid,34.81,,,34.81,Other,100% of Medicaid,78.32,,,78.32,Other,225% of Medicaid,53.26,,,53.26,Other,153% of Medicaid,78.32,,,78.32,Other,225% of Medicaid,48.73,,,48.73,Other,140% of Medicaid,78.32,,,78.32,Other,225% of Medicaid,90.51,,,90.51,Other,260% of Medicaid,112.78,,,112.78,Other,324% of Medicaid,74.84,,,74.84,Other,215% of Medicaid,74.84,,,74.84,Other,215% of Medicaid,43.51,,,43.51,Other,125% of Medicaid,34.81,214.65,
CYTOGENETICS 100-300,88275,CPT,,78088275,CDM,311,RC,,,both,,,239,176.86,,,176.86,Other,150% of Medicare + 9.63% HCRA Surcharge,107.55,45,,107.55,percent of total billed charges,Critical Access Hospital RCC factor,154.08,,,154.08,Fee Schedule,,138.72,,,138.72,Fee Schedule,,297.81,,,297.81,Fee Schedule,,267.86,,,267.86,Fee Schedule,,253.16,,,253.16,Fee Schedule,,118.31,,,118.31,Other,110% of Medicare,161.25,,,161.25,Fee Schedule,,95,,,95,Other,186% of Medicaid,189.91,,,189.91,Fee Schedule,,148.18,,,148.18,Fee Schedule,,107.5,,,107.5,Fee Schedule,,189.91,,,189.91,Fee Schedule,,148.18,,,148.18,Fee Schedule,,202.2,,,202.2,Fee Schedule,,167.3,70,,167.3,percent of total billed charges,All Other,242.59,,,242.59,Fee Schedule,,205.61,,,205.61,Fee Schedule,,76.79,,,76.79,Fee Schedule,,76.79,,,76.79,Fee Schedule,,76.79,,,76.79,Fee Schedule,,76.79,,,76.79,Fee Schedule,,51.19,,,51.19,Other,100% of Medicaid,51.19,,,51.19,Other,100% of Medicaid,51.19,,,51.19,Other,100% of Medicaid,51.19,,,51.19,Other,100% of Medicaid,115.18,,,115.18,Other,225% of Medicaid,78.32,,,78.32,Other,153% of Medicaid,115.18,,,115.18,Other,225% of Medicaid,71.67,,,71.67,Other,140% of Medicaid,115.18,,,115.18,Other,225% of Medicaid,133.09,,,133.09,Other,260% of Medicaid,165.86,,,165.86,Other,324% of Medicaid,110.06,,,110.06,Other,215% of Medicaid,110.06,,,110.06,Other,215% of Medicaid,63.99,,,63.99,Other,125% of Medicaid,51.19,297.81,
CHROMOSOME BANDING STUD,88283,CPT,,78088283,CDM,311,RC,,,both,,,217,160.58,,,160.58,Other,150% of Medicare + 9.63% HCRA Surcharge,97.65,45,,97.65,percent of total billed charges,Critical Access Hospital RCC factor,206.49,,,206.49,Fee Schedule,,185.91,,,185.91,Fee Schedule,,387.82,,,387.82,Fee Schedule,,348.82,,,348.82,Fee Schedule,,329.68,,,329.68,Fee Schedule,,107.42,,,107.42,Other,110% of Medicare,216.09,,,216.09,Fee Schedule,,0.01,,,0.01,Other,186% of Medicaid,254.51,,,254.51,Fee Schedule,,134.54,,,134.54,Fee Schedule,,144.06,,,144.06,Fee Schedule,,254.51,,,254.51,Fee Schedule,,134.54,,,134.54,Fee Schedule,,270.97,,,270.97,Fee Schedule,,151.9,70,,151.9,percent of total billed charges,All Other,325.1,,,325.1,Fee Schedule,,275.54,,,275.54,Fee Schedule,,102.9,,,102.9,Fee Schedule,,102.9,,,102.9,Fee Schedule,,102.9,,,102.9,Fee Schedule,,102.9,,,102.9,Fee Schedule,,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,387.82,
CHROM ANALY ADDTL CELL COUNTS,88285,CPT,,78088285,CDM,311,RC,,,both,,,114,84.36,,,84.36,Other,150% of Medicare + 9.63% HCRA Surcharge,51.3,45,,51.3,percent of total billed charges,Critical Access Hospital RCC factor,81,,,81,Fee Schedule,,72.93,,,72.93,Fee Schedule,,140.92,,,140.92,Fee Schedule,,126.75,,,126.75,Fee Schedule,,119.8,,,119.8,Fee Schedule,,56.43,,,56.43,Other,110% of Medicare,84.77,,,84.77,Fee Schedule,,9,,,9,Other,186% of Medicaid,99.84,,,99.84,Fee Schedule,,70.68,,,70.68,Fee Schedule,,56.51,,,56.51,Fee Schedule,,99.84,,,99.84,Fee Schedule,,70.68,,,70.68,Fee Schedule,,106.29,,,106.29,Fee Schedule,,79.8,70,,79.8,percent of total billed charges,All Other,127.53,,,127.53,Fee Schedule,,108.09,,,108.09,Fee Schedule,,40.37,,,40.37,Fee Schedule,,40.37,,,40.37,Fee Schedule,,40.37,,,40.37,Fee Schedule,,40.37,,,40.37,Fee Schedule,,5.05,,,5.05,Other,100% of Medicaid,5.05,,,5.05,Other,100% of Medicaid,5.05,,,5.05,Other,100% of Medicaid,5.05,,,5.05,Other,100% of Medicaid,11.36,,,11.36,Other,225% of Medicaid,7.73,,,7.73,Other,153% of Medicaid,11.36,,,11.36,Other,225% of Medicaid,7.07,,,7.07,Other,140% of Medicaid,11.36,,,11.36,Other,225% of Medicaid,13.13,,,13.13,Other,260% of Medicaid,16.36,,,16.36,Other,324% of Medicaid,10.86,,,10.86,Other,215% of Medicaid,10.86,,,10.86,Other,215% of Medicaid,6.31,,,6.31,Other,125% of Medicaid,5.05,140.92,
CHROMOSOME ANALY ADDTL HI RES,88289,CPT,,78088289,CDM,311,RC,,,both,,,205,151.7,,,151.7,Other,150% of Medicare + 9.63% HCRA Surcharge,92.25,45,,92.25,percent of total billed charges,Critical Access Hospital RCC factor,103.63,,,103.63,Fee Schedule,,93.31,,,93.31,Fee Schedule,,255.38,,,255.38,Fee Schedule,,229.7,,,229.7,Fee Schedule,,217.1,,,217.1,Fee Schedule,,101.48,,,101.48,Other,110% of Medicare,108.45,,,108.45,Fee Schedule,,0.01,,,0.01,Other,186% of Medicaid,127.74,,,127.74,Fee Schedule,,127.1,,,127.1,Fee Schedule,,72.3,,,72.3,Fee Schedule,,127.74,,,127.74,Fee Schedule,,127.1,,,127.1,Fee Schedule,,136,,,136,Fee Schedule,,143.5,70,,143.5,percent of total billed charges,All Other,163.16,,,163.16,Fee Schedule,,138.29,,,138.29,Fee Schedule,,51.65,,,51.65,Fee Schedule,,51.65,,,51.65,Fee Schedule,,51.65,,,51.65,Fee Schedule,,51.65,,,51.65,Fee Schedule,,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,255.38,
CYTOPATH FL NONGYN SMEARS,88104,CPT,TC,85088104,CDM,311,RC,,,both,,,270,199.8,,,199.8,Other,150% of Medicare + 9.63% HCRA Surcharge,121.5,45,,121.5,percent of total billed charges,Critical Access Hospital RCC factor,160.55,,,160.55,Fee Schedule,,144.55,,,144.55,Fee Schedule,,254.12,,,254.12,Fee Schedule,,228.56,,,228.56,Fee Schedule,,216.03,,,216.03,Fee Schedule,,133.65,,,133.65,Other,110% of Medicare,168.02,,,168.02,Fee Schedule,,36,,,36,Other,186% of Medicaid,197.89,,,197.89,Fee Schedule,,167.4,,,167.4,Fee Schedule,,112.01,,,112.01,Fee Schedule,,197.89,,,197.89,Fee Schedule,,167.4,,,167.4,Fee Schedule,,210.69,,,210.69,Fee Schedule,,189,70,,189,percent of total billed charges,All Other,193.52,,,193.52,Fee Schedule,,164.02,,,164.02,Fee Schedule,,50.15,,,50.15,Fee Schedule,,50.15,,,50.15,Fee Schedule,,50.15,,,50.15,Fee Schedule,,50.15,,,50.15,Fee Schedule,,19.31,,,19.31,Other,100% of Medicaid,19.31,,,19.31,Other,100% of Medicaid,19.31,,,19.31,Other,100% of Medicaid,19.31,,,19.31,Other,100% of Medicaid,43.45,,,43.45,Other,225% of Medicaid,29.55,,,29.55,Other,153% of Medicaid,43.45,,,43.45,Other,225% of Medicaid,27.04,,,27.04,Other,140% of Medicaid,43.45,,,43.45,Other,225% of Medicaid,50.21,,,50.21,Other,260% of Medicaid,62.57,,,62.57,Other,324% of Medicaid,41.52,,,41.52,Other,215% of Medicaid,41.52,,,41.52,Other,215% of Medicaid,24.14,,,24.14,Other,125% of Medicaid,19.31,254.12,
CP CONCENTR TECH SMEAR,88108,CPT,TC,85088108,CDM,311,RC,,,both,,,300,222,,,222,Other,150% of Medicare + 9.63% HCRA Surcharge,135,45,,135,percent of total billed charges,Critical Access Hospital RCC factor,153.87,,,153.87,Fee Schedule,,138.54,,,138.54,Fee Schedule,,325.05,,,325.05,Fee Schedule,,292.36,,,292.36,Fee Schedule,,276.33,,,276.33,Fee Schedule,,148.5,,,148.5,Other,110% of Medicare,161.03,,,161.03,Fee Schedule,,36,,,36,Other,186% of Medicaid,189.66,,,189.66,Fee Schedule,,186,,,186,Fee Schedule,,107.35,,,107.35,Fee Schedule,,189.66,,,189.66,Fee Schedule,,186,,,186,Fee Schedule,,201.92,,,201.92,Fee Schedule,,210,70,,210,percent of total billed charges,All Other,203.36,,,203.36,Fee Schedule,,172.36,,,172.36,Fee Schedule,,50.15,,,50.15,Fee Schedule,,50.15,,,50.15,Fee Schedule,,50.15,,,50.15,Fee Schedule,,50.15,,,50.15,Fee Schedule,,19.31,,,19.31,Other,100% of Medicaid,19.31,,,19.31,Other,100% of Medicaid,19.31,,,19.31,Other,100% of Medicaid,19.31,,,19.31,Other,100% of Medicaid,43.45,,,43.45,Other,225% of Medicaid,29.55,,,29.55,Other,153% of Medicaid,43.45,,,43.45,Other,225% of Medicaid,27.04,,,27.04,Other,140% of Medicaid,43.45,,,43.45,Other,225% of Medicaid,50.21,,,50.21,Other,260% of Medicaid,62.57,,,62.57,Other,324% of Medicaid,41.52,,,41.52,Other,215% of Medicaid,41.52,,,41.52,Other,215% of Medicaid,24.14,,,24.14,Other,125% of Medicaid,19.31,325.05,
CYTOPATH CELL ENHANCE TECH,88112,CPT,TC,85088112,CDM,311,RC,,,both,,,250,185,,,185,Other,150% of Medicare + 9.63% HCRA Surcharge,112.5,45,,112.5,percent of total billed charges,Critical Access Hospital RCC factor,135.33,,,135.33,Fee Schedule,,121.84,,,121.84,Fee Schedule,,311.3,,,311.3,Fee Schedule,,279.99,,,279.99,Fee Schedule,,264.63,,,264.63,Fee Schedule,,123.75,,,123.75,Other,110% of Medicare,141.62,,,141.62,Fee Schedule,,54,,,54,Other,186% of Medicaid,166.8,,,166.8,Fee Schedule,,155,,,155,Fee Schedule,,94.42,,,94.42,Fee Schedule,,166.8,,,166.8,Fee Schedule,,155,,,155,Fee Schedule,,177.59,,,177.59,Fee Schedule,,175,70,,175,percent of total billed charges,All Other,188.6,,,188.6,Fee Schedule,,159.85,,,159.85,Fee Schedule,,74.21,,,74.21,Fee Schedule,,74.21,,,74.21,Fee Schedule,,74.21,,,74.21,Fee Schedule,,74.21,,,74.21,Fee Schedule,,29.11,,,29.11,Other,100% of Medicaid,29.11,,,29.11,Other,100% of Medicaid,29.11,,,29.11,Other,100% of Medicaid,29.11,,,29.11,Other,100% of Medicaid,65.49,,,65.49,Other,225% of Medicaid,44.54,,,44.54,Other,153% of Medicaid,65.49,,,65.49,Other,225% of Medicaid,40.75,,,40.75,Other,140% of Medicaid,65.49,,,65.49,Other,225% of Medicaid,75.68,,,75.68,Other,260% of Medicaid,94.31,,,94.31,Other,324% of Medicaid,62.58,,,62.58,Other,215% of Medicaid,62.58,,,62.58,Other,215% of Medicaid,36.39,,,36.39,Other,125% of Medicaid,29.11,311.3,
CP SMR OTHR; SCRN & INT,88160,CPT,TC,85088160,CDM,311,RC,,,both,,,258,190.92,,,190.92,Other,150% of Medicare + 9.63% HCRA Surcharge,116.1,45,,116.1,percent of total billed charges,Critical Access Hospital RCC factor,180.18,,,180.18,Fee Schedule,,162.22,,,162.22,Fee Schedule,,201.47,,,201.47,Fee Schedule,,181.21,,,181.21,Fee Schedule,,171.27,,,171.27,Fee Schedule,,127.71,,,127.71,Other,110% of Medicare,188.56,,,188.56,Fee Schedule,,36,,,36,Other,186% of Medicaid,222.08,,,222.08,Fee Schedule,,159.96,,,159.96,Fee Schedule,,125.71,,,125.71,Fee Schedule,,222.08,,,222.08,Fee Schedule,,159.96,,,159.96,Fee Schedule,,236.45,,,236.45,Fee Schedule,,180.6,70,,180.6,percent of total billed charges,All Other,223.04,,,223.04,Fee Schedule,,189.04,,,189.04,Fee Schedule,,34.49,,,34.49,Fee Schedule,,34.49,,,34.49,Fee Schedule,,34.49,,,34.49,Fee Schedule,,34.49,,,34.49,Fee Schedule,,19.31,,,19.31,Other,100% of Medicaid,19.31,,,19.31,Other,100% of Medicaid,19.31,,,19.31,Other,100% of Medicaid,19.31,,,19.31,Other,100% of Medicaid,43.45,,,43.45,Other,225% of Medicaid,29.55,,,29.55,Other,153% of Medicaid,43.45,,,43.45,Other,225% of Medicaid,27.04,,,27.04,Other,140% of Medicaid,43.45,,,43.45,Other,225% of Medicaid,50.21,,,50.21,Other,260% of Medicaid,62.57,,,62.57,Other,324% of Medicaid,41.52,,,41.52,Other,215% of Medicaid,41.52,,,41.52,Other,215% of Medicaid,24.14,,,24.14,Other,125% of Medicaid,19.31,236.45,
CYTOPATH SMEAR OTHER SOURCE,88161,CPT,TC,85088161,CDM,311,RC,,,both,,,258,190.92,,,190.92,Other,150% of Medicare + 9.63% HCRA Surcharge,116.1,45,,116.1,percent of total billed charges,Critical Access Hospital RCC factor,186.71,,,186.71,Fee Schedule,,168.1,,,168.1,Fee Schedule,,206.06,,,206.06,Fee Schedule,,185.33,,,185.33,Fee Schedule,,175.17,,,175.17,Fee Schedule,,127.71,,,127.71,Other,110% of Medicare,195.39,,,195.39,Fee Schedule,,36,,,36,Other,186% of Medicaid,230.13,,,230.13,Fee Schedule,,159.96,,,159.96,Fee Schedule,,130.26,,,130.26,Fee Schedule,,230.13,,,230.13,Fee Schedule,,159.96,,,159.96,Fee Schedule,,245.02,,,245.02,Fee Schedule,,180.6,70,,180.6,percent of total billed charges,All Other,234.52,,,234.52,Fee Schedule,,198.77,,,198.77,Fee Schedule,,34.49,,,34.49,Fee Schedule,,34.49,,,34.49,Fee Schedule,,34.49,,,34.49,Fee Schedule,,34.49,,,34.49,Fee Schedule,,19.31,,,19.31,Other,100% of Medicaid,19.31,,,19.31,Other,100% of Medicaid,19.31,,,19.31,Other,100% of Medicaid,19.31,,,19.31,Other,100% of Medicaid,43.45,,,43.45,Other,225% of Medicaid,29.55,,,29.55,Other,153% of Medicaid,43.45,,,43.45,Other,225% of Medicaid,27.04,,,27.04,Other,140% of Medicaid,43.45,,,43.45,Other,225% of Medicaid,50.21,,,50.21,Other,260% of Medicaid,62.57,,,62.57,Other,324% of Medicaid,41.52,,,41.52,Other,215% of Medicaid,41.52,,,41.52,Other,215% of Medicaid,24.14,,,24.14,Other,125% of Medicaid,19.31,245.02,
CP SMR OTHR; > 5 SLIDES,88162,CPT,TC,85088162,CDM,311,RC,,,both,,,329,243.46,,,243.46,Other,150% of Medicare + 9.63% HCRA Surcharge,148.05,45,,148.05,percent of total billed charges,Critical Access Hospital RCC factor,297,,,297,Fee Schedule,,267.4,,,267.4,Fee Schedule,,276.99,,,276.99,Fee Schedule,,249.13,,,249.13,Fee Schedule,,235.47,,,235.47,Fee Schedule,,162.86,,,162.86,Other,110% of Medicare,310.81,,,310.81,Fee Schedule,,36,,,36,Other,186% of Medicaid,366.07,,,366.07,Fee Schedule,,203.98,,,203.98,Fee Schedule,,207.21,,,207.21,Fee Schedule,,366.07,,,366.07,Fee Schedule,,203.98,,,203.98,Fee Schedule,,389.75,,,389.75,Fee Schedule,,230.3,70,,230.3,percent of total billed charges,All Other,360.8,,,360.8,Fee Schedule,,305.8,,,305.8,Fee Schedule,,74.21,,,74.21,Fee Schedule,,74.21,,,74.21,Fee Schedule,,74.21,,,74.21,Fee Schedule,,74.21,,,74.21,Fee Schedule,,19.31,,,19.31,Other,100% of Medicaid,19.31,,,19.31,Other,100% of Medicaid,19.31,,,19.31,Other,100% of Medicaid,19.31,,,19.31,Other,100% of Medicaid,43.45,,,43.45,Other,225% of Medicaid,29.55,,,29.55,Other,153% of Medicaid,43.45,,,43.45,Other,225% of Medicaid,27.04,,,27.04,Other,140% of Medicaid,43.45,,,43.45,Other,225% of Medicaid,50.21,,,50.21,Other,260% of Medicaid,62.57,,,62.57,Other,324% of Medicaid,41.52,,,41.52,Other,215% of Medicaid,41.52,,,41.52,Other,215% of Medicaid,24.14,,,24.14,Other,125% of Medicaid,19.31,389.75,
CYTP DX EVAL FNA 1ST EA SITE,88172,CPT,TC,85088172,CDM,311,RC,,,both,,,682,504.68,,,504.68,Other,150% of Medicare + 9.63% HCRA Surcharge,306.9,45,,306.9,percent of total billed charges,Critical Access Hospital RCC factor,71.01,,,71.01,Fee Schedule,,63.93,,,63.93,Fee Schedule,,139.71,,,139.71,Fee Schedule,,125.66,,,125.66,Fee Schedule,,118.76,,,118.76,Fee Schedule,,337.59,,,337.59,Other,110% of Medicare,74.31,,,74.31,Fee Schedule,,131,,,131,Other,186% of Medicaid,87.52,,,87.52,Fee Schedule,,422.84,,,422.84,Fee Schedule,,49.54,,,49.54,Fee Schedule,,87.52,,,87.52,Fee Schedule,,422.84,,,422.84,Fee Schedule,,93.18,,,93.18,Fee Schedule,,477.4,70,,477.4,percent of total billed charges,All Other,93.48,,,93.48,Fee Schedule,,79.23,,,79.23,Fee Schedule,,215.25,,,215.25,Fee Schedule,,215.25,,,215.25,Fee Schedule,,215.25,,,215.25,Fee Schedule,,215.25,,,215.25,Fee Schedule,,70.35,,,70.35,Other,100% of Medicaid,70.35,,,70.35,Other,100% of Medicaid,70.35,,,70.35,Other,100% of Medicaid,70.35,,,70.35,Other,100% of Medicaid,158.29,,,158.29,Other,225% of Medicaid,107.64,,,107.64,Other,153% of Medicaid,158.29,,,158.29,Other,225% of Medicaid,98.49,,,98.49,Other,140% of Medicaid,158.29,,,158.29,Other,225% of Medicaid,182.91,,,182.91,Other,260% of Medicaid,227.93,,,227.93,Other,324% of Medicaid,151.25,,,151.25,Other,215% of Medicaid,151.25,,,151.25,Other,215% of Medicaid,87.94,,,87.94,Other,125% of Medicaid,49.54,504.68,
EVAL OF FNA; INT & REP,88173,CPT,TC,85088173,CDM,311,RC,,,both,,,540,399.6,,,399.6,Other,150% of Medicare + 9.63% HCRA Surcharge,243,45,,243,percent of total billed charges,Critical Access Hospital RCC factor,327.52,,,327.52,Fee Schedule,,294.88,,,294.88,Fee Schedule,,466.92,,,466.92,Fee Schedule,,419.96,,,419.96,Fee Schedule,,396.93,,,396.93,Fee Schedule,,267.3,,,267.3,Other,110% of Medicare,342.75,,,342.75,Fee Schedule,,36,,,36,Other,186% of Medicaid,403.69,,,403.69,Fee Schedule,,334.8,,,334.8,Fee Schedule,,228.5,,,228.5,Fee Schedule,,403.69,,,403.69,Fee Schedule,,334.8,,,334.8,Fee Schedule,,429.8,,,429.8,Fee Schedule,,378,70,,378,percent of total billed charges,All Other,423.12,,,423.12,Fee Schedule,,358.62,,,358.62,Fee Schedule,,74.21,,,74.21,Fee Schedule,,74.21,,,74.21,Fee Schedule,,74.21,,,74.21,Fee Schedule,,74.21,,,74.21,Fee Schedule,,19.31,,,19.31,Other,100% of Medicaid,19.31,,,19.31,Other,100% of Medicaid,19.31,,,19.31,Other,100% of Medicaid,19.31,,,19.31,Other,100% of Medicaid,43.45,,,43.45,Other,225% of Medicaid,29.55,,,29.55,Other,153% of Medicaid,43.45,,,43.45,Other,225% of Medicaid,27.04,,,27.04,Other,140% of Medicaid,43.45,,,43.45,Other,225% of Medicaid,50.21,,,50.21,Other,260% of Medicaid,62.57,,,62.57,Other,324% of Medicaid,41.52,,,41.52,Other,215% of Medicaid,41.52,,,41.52,Other,215% of Medicaid,24.14,,,24.14,Other,125% of Medicaid,19.31,466.92,
CYTP FNA EVAL EA ADDL,88177,CPT,TC,85088177,CDM,311,RC,,,both,,,91,67.34,,,67.34,Other,150% of Medicare + 9.63% HCRA Surcharge,40.95,45,,40.95,percent of total billed charges,Critical Access Hospital RCC factor,27.24,,,27.24,Fee Schedule,,24.53,,,24.53,Fee Schedule,,43.58,,,43.58,Fee Schedule,,39.2,,,39.2,Fee Schedule,,37.05,,,37.05,Fee Schedule,,45.05,,,45.05,Other,110% of Medicare,28.51,,,28.51,Fee Schedule,,122,,,122,Other,186% of Medicaid,33.58,,,33.58,Fee Schedule,,56.42,,,56.42,Fee Schedule,,19.01,,,19.01,Fee Schedule,,33.58,,,33.58,Fee Schedule,,56.42,,,56.42,Fee Schedule,,35.75,,,35.75,Fee Schedule,,63.7,70,,63.7,percent of total billed charges,All Other,34.44,,,34.44,Fee Schedule,,29.19,,,29.19,Fee Schedule,,10.83,,,10.83,Fee Schedule,,10.83,,,10.83,Fee Schedule,,10.83,,,10.83,Fee Schedule,,10.83,,,10.83,Fee Schedule,,65.37,,,65.37,Other,100% of Medicaid,65.37,,,65.37,Other,100% of Medicaid,65.37,,,65.37,Other,100% of Medicaid,65.37,,,65.37,Other,100% of Medicaid,147.09,,,147.09,Other,225% of Medicaid,100.02,,,100.02,Other,153% of Medicaid,147.09,,,147.09,Other,225% of Medicaid,91.52,,,91.52,Other,140% of Medicaid,147.09,,,147.09,Other,225% of Medicaid,169.97,,,169.97,Other,260% of Medicaid,211.81,,,211.81,Other,324% of Medicaid,140.55,,,140.55,Other,215% of Medicaid,140.55,,,140.55,Other,215% of Medicaid,81.72,,,81.72,Other,125% of Medicaid,10.83,211.81,
FLOW CYTOMETRY TC 1ST MARKER,88184,CPT,TC,85088184,CDM,311,RC,,,both,,,731,540.94,,,540.94,Other,150% of Medicare + 9.63% HCRA Surcharge,328.95,45,,328.95,percent of total billed charges,Critical Access Hospital RCC factor,255.4,,,255.4,Fee Schedule,,229.94,,,229.94,Fee Schedule,,565.31,,,565.31,Fee Schedule,,508.46,,,508.46,Fee Schedule,,480.57,,,480.57,Fee Schedule,,361.85,,,361.85,Other,110% of Medicare,267.28,,,267.28,Fee Schedule,,44,,,44,Other,186% of Medicaid,314.79,,,314.79,Fee Schedule,,453.22,,,453.22,Fee Schedule,,178.19,,,178.19,Fee Schedule,,314.79,,,314.79,Fee Schedule,,453.22,,,453.22,Fee Schedule,,335.16,,,335.16,Fee Schedule,,511.7,70,,511.7,percent of total billed charges,All Other,328,,,328,Fee Schedule,,278,,,278,Fee Schedule,,425.12,,,425.12,Fee Schedule,,425.12,,,425.12,Fee Schedule,,425.12,,,425.12,Fee Schedule,,425.12,,,425.12,Fee Schedule,,23.4,,,23.4,Other,100% of Medicaid,23.4,,,23.4,Other,100% of Medicaid,23.4,,,23.4,Other,100% of Medicaid,23.4,,,23.4,Other,100% of Medicaid,52.65,,,52.65,Other,225% of Medicaid,35.8,,,35.8,Other,153% of Medicaid,52.65,,,52.65,Other,225% of Medicaid,32.76,,,32.76,Other,140% of Medicaid,52.65,,,52.65,Other,225% of Medicaid,60.84,,,60.84,Other,260% of Medicaid,75.82,,,75.82,Other,324% of Medicaid,50.31,,,50.31,Other,215% of Medicaid,50.31,,,50.31,Other,215% of Medicaid,29.25,,,29.25,Other,125% of Medicaid,23.4,565.31,
FLOW CYTOMETRY EA ADDTL MARKER,88185,CPT,TC,85088185,CDM,311,RC,,,both,,,270,199.8,,,199.8,Other,150% of Medicare + 9.63% HCRA Surcharge,121.5,45,,121.5,percent of total billed charges,Critical Access Hospital RCC factor,77.39,,,77.39,Fee Schedule,,69.67,,,69.67,Fee Schedule,,338.76,,,338.76,Fee Schedule,,304.69,,,304.69,Fee Schedule,,287.97,,,287.97,Fee Schedule,,133.65,,,133.65,Other,110% of Medicare,80.99,,,80.99,Fee Schedule,,29,,,29,Other,186% of Medicaid,95.38,,,95.38,Fee Schedule,,167.4,,,167.4,Fee Schedule,,53.99,,,53.99,Fee Schedule,,95.38,,,95.38,Fee Schedule,,167.4,,,167.4,Fee Schedule,,101.55,,,101.55,Fee Schedule,,189,70,,189,percent of total billed charges,All Other,104.96,,,104.96,Fee Schedule,,88.96,,,88.96,Fee Schedule,,33.57,,,33.57,Fee Schedule,,33.57,,,33.57,Fee Schedule,,33.57,,,33.57,Fee Schedule,,33.57,,,33.57,Fee Schedule,,15.6,,,15.6,Other,100% of Medicaid,15.6,,,15.6,Other,100% of Medicaid,15.6,,,15.6,Other,100% of Medicaid,15.6,,,15.6,Other,100% of Medicaid,35.11,,,35.11,Other,225% of Medicaid,23.87,,,23.87,Other,153% of Medicaid,35.11,,,35.11,Other,225% of Medicaid,21.85,,,21.85,Other,140% of Medicaid,35.11,,,35.11,Other,225% of Medicaid,40.57,,,40.57,Other,260% of Medicaid,50.56,,,50.56,Other,324% of Medicaid,33.55,,,33.55,Other,215% of Medicaid,33.55,,,33.55,Other,215% of Medicaid,19.51,,,19.51,Other,125% of Medicaid,15.6,338.76,
FLOW CYTOMETRY INTERP 2-8 MARKERS,88187,CPT,TC,85088187,CDM,311,RC,,,both,,,338,250.12,,,250.12,Other,150% of Medicare + 9.63% HCRA Surcharge,152.1,45,,152.1,percent of total billed charges,Critical Access Hospital RCC factor,110.56,,,110.56,Fee Schedule,,99.54,,,99.54,Fee Schedule,,400.68,,,400.68,Fee Schedule,,360.38,,,360.38,Fee Schedule,,340.61,,,340.61,Fee Schedule,,167.31,,,167.31,Other,110% of Medicare,115.7,,,115.7,Fee Schedule,,38,,,38,Other,186% of Medicaid,136.27,,,136.27,Fee Schedule,,209.56,,,209.56,Fee Schedule,,77.13,,,77.13,Fee Schedule,,136.27,,,136.27,Fee Schedule,,209.56,,,209.56,Fee Schedule,,145.08,,,145.08,Fee Schedule,,236.6,70,,236.6,percent of total billed charges,All Other,170.56,,,170.56,Fee Schedule,,144.56,,,144.56,Fee Schedule,,59.01,,,59.01,Fee Schedule,,59.01,,,59.01,Fee Schedule,,59.01,,,59.01,Fee Schedule,,59.01,,,59.01,Fee Schedule,,20.2,,,20.2,Other,100% of Medicaid,20.2,,,20.2,Other,100% of Medicaid,20.2,,,20.2,Other,100% of Medicaid,20.2,,,20.2,Other,100% of Medicaid,45.45,,,45.45,Other,225% of Medicaid,30.91,,,30.91,Other,153% of Medicaid,45.45,,,45.45,Other,225% of Medicaid,28.28,,,28.28,Other,140% of Medicaid,45.45,,,45.45,Other,225% of Medicaid,52.52,,,52.52,Other,260% of Medicaid,65.45,,,65.45,Other,324% of Medicaid,43.43,,,43.43,Other,215% of Medicaid,43.43,,,43.43,Other,215% of Medicaid,25.25,,,25.25,Other,125% of Medicaid,20.2,400.68,
TISSUE CULTURE; BM BLD CELLS,88237,CPT,TC,85088237,CDM,311,RC,,,both,,,798,590.52,,,590.52,Other,150% of Medicare + 9.63% HCRA Surcharge,359.1,45,,359.1,percent of total billed charges,Critical Access Hospital RCC factor,432.69,,,432.69,Fee Schedule,,389.56,,,389.56,Fee Schedule,,190.72,,,190.72,Fee Schedule,,171.54,,,171.54,Fee Schedule,,162.13,,,162.13,Fee Schedule,,395.01,,,395.01,Other,110% of Medicare,452.81,,,452.81,Fee Schedule,,188,,,188,Other,186% of Medicaid,533.31,,,533.31,Fee Schedule,,494.76,,,494.76,Fee Schedule,,301.88,,,301.88,Fee Schedule,,533.31,,,533.31,Fee Schedule,,494.76,,,494.76,Fee Schedule,,567.81,,,567.81,Fee Schedule,,558.6,70,,558.6,percent of total billed charges,All Other,681.24,,,681.24,Fee Schedule,,577.39,,,577.39,Fee Schedule,,215.63,,,215.63,Fee Schedule,,215.63,,,215.63,Fee Schedule,,215.63,,,215.63,Fee Schedule,,215.63,,,215.63,Fee Schedule,,101.03,,,101.03,Other,100% of Medicaid,101.03,,,101.03,Other,100% of Medicaid,101.03,,,101.03,Other,100% of Medicaid,101.03,,,101.03,Other,100% of Medicaid,227.32,,,227.32,Other,225% of Medicaid,154.58,,,154.58,Other,153% of Medicaid,227.32,,,227.32,Other,225% of Medicaid,141.44,,,141.44,Other,140% of Medicaid,227.32,,,227.32,Other,225% of Medicaid,262.68,,,262.68,Other,260% of Medicaid,327.34,,,327.34,Other,324% of Medicaid,217.22,,,217.22,Other,215% of Medicaid,217.22,,,217.22,Other,215% of Medicaid,126.29,,,126.29,Other,125% of Medicaid,101.03,681.24,
CHROM ANALY; 20-25 CELLS,88264,CPT,TC,85088264,CDM,311,RC,,,both,,,1316,973.84,,,973.84,Other,150% of Medicare + 9.63% HCRA Surcharge,592.2,45,,592.2,percent of total billed charges,Critical Access Hospital RCC factor,435.28,,,435.28,Fee Schedule,,391.89,,,391.89,Fee Schedule,,924.36,,,924.36,Fee Schedule,,831.4,,,831.4,Fee Schedule,,785.79,,,785.79,Fee Schedule,,651.42,,,651.42,Other,110% of Medicare,455.52,,,455.52,Fee Schedule,,0.01,,,0.01,Other,186% of Medicaid,536.5,,,536.5,Fee Schedule,,815.92,,,815.92,Fee Schedule,,303.68,,,303.68,Fee Schedule,,536.5,,,536.5,Fee Schedule,,815.92,,,815.92,Fee Schedule,,571.21,,,571.21,Fee Schedule,,921.2,70,,921.2,percent of total billed charges,All Other,685.31,,,685.31,Fee Schedule,,580.84,,,580.84,Fee Schedule,,216.92,,,216.92,Fee Schedule,,216.92,,,216.92,Fee Schedule,,216.92,,,216.92,Fee Schedule,,216.92,,,216.92,Fee Schedule,,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,973.84,
CHROM ANALY; ADDTL KARYOT EA STUDY,88280,CPT,TC,85088280,CDM,311,RC,,,both,,,206,152.44,,,152.44,Other,150% of Medicare + 9.63% HCRA Surcharge,92.7,45,,92.7,percent of total billed charges,Critical Access Hospital RCC factor,100.74,,,100.74,Fee Schedule,,90.7,,,90.7,Fee Schedule,,186.14,,,186.14,Fee Schedule,,167.42,,,167.42,Fee Schedule,,158.23,,,158.23,Fee Schedule,,101.97,,,101.97,Other,110% of Medicare,105.43,,,105.43,Fee Schedule,,19,,,19,Other,186% of Medicaid,124.17,,,124.17,Fee Schedule,,127.72,,,127.72,Fee Schedule,,70.29,,,70.29,Fee Schedule,,124.17,,,124.17,Fee Schedule,,127.72,,,127.72,Fee Schedule,,132.21,,,132.21,Fee Schedule,,144.2,70,,144.2,percent of total billed charges,All Other,158.62,,,158.62,Fee Schedule,,134.44,,,134.44,Fee Schedule,,50.21,,,50.21,Fee Schedule,,50.21,,,50.21,Fee Schedule,,50.21,,,50.21,Fee Schedule,,50.21,,,50.21,Fee Schedule,,10.1,,,10.1,Other,100% of Medicaid,10.1,,,10.1,Other,100% of Medicaid,10.1,,,10.1,Other,100% of Medicaid,10.1,,,10.1,Other,100% of Medicaid,22.73,,,22.73,Other,225% of Medicaid,15.45,,,15.45,Other,153% of Medicaid,22.73,,,22.73,Other,225% of Medicaid,14.14,,,14.14,Other,140% of Medicaid,22.73,,,22.73,Other,225% of Medicaid,26.26,,,26.26,Other,260% of Medicaid,32.72,,,32.72,Other,324% of Medicaid,21.72,,,21.72,Other,215% of Medicaid,21.72,,,21.72,Other,215% of Medicaid,12.63,,,12.63,Other,125% of Medicaid,10.1,186.14,
TISSUE EXAM BY PATHOLOGIST,88305,CPT,,78088305,CDM,312,RC,,,both,,,478,353.72,,,353.72,Other,150% of Medicare + 9.63% HCRA Surcharge,215.1,45,,215.1,percent of total billed charges,Critical Access Hospital RCC factor,116.79,,,116.79,Fee Schedule,,105.15,,,105.15,Fee Schedule,,469.19,,,469.19,Fee Schedule,,422,,,422,Fee Schedule,,398.85,,,398.85,Fee Schedule,,236.61,,,236.61,Other,110% of Medicare,122.22,,,122.22,Fee Schedule,,81,,,81,Other,186% of Medicaid,143.95,,,143.95,Fee Schedule,,296.36,,,296.36,Fee Schedule,,81.48,,,81.48,Fee Schedule,,143.95,,,143.95,Fee Schedule,,296.36,,,296.36,Fee Schedule,,153.26,,,153.26,Fee Schedule,,334.6,70,,334.6,percent of total billed charges,All Other,164,,,164,Fee Schedule,,139,,,139,Fee Schedule,,74.21,,,74.21,Fee Schedule,,74.21,,,74.21,Fee Schedule,,74.21,,,74.21,Fee Schedule,,74.21,,,74.21,Fee Schedule,,43.62,,,43.62,Other,100% of Medicaid,43.62,,,43.62,Other,100% of Medicaid,43.62,,,43.62,Other,100% of Medicaid,43.62,,,43.62,Other,100% of Medicaid,98.15,,,98.15,Other,225% of Medicaid,66.74,,,66.74,Other,153% of Medicaid,98.15,,,98.15,Other,225% of Medicaid,61.07,,,61.07,Other,140% of Medicaid,98.15,,,98.15,Other,225% of Medicaid,113.42,,,113.42,Other,260% of Medicaid,141.33,,,141.33,Other,324% of Medicaid,93.79,,,93.79,Other,215% of Medicaid,93.79,,,93.79,Other,215% of Medicaid,54.53,,,54.53,Other,125% of Medicaid,43.62,469.19,
DECALCIFY TISSUE,88311,CPT,,78088311,CDM,312,RC,,,both,,,171,126.54,,,126.54,Other,150% of Medicare + 9.63% HCRA Surcharge,76.95,45,,76.95,percent of total billed charges,Critical Access Hospital RCC factor,28.5,,,28.5,Fee Schedule,,25.66,,,25.66,Fee Schedule,,45.85,,,45.85,Fee Schedule,,41.24,,,41.24,Fee Schedule,,38.98,,,38.98,Fee Schedule,,84.65,,,84.65,Other,110% of Medicare,29.83,,,29.83,Fee Schedule,,87,,,87,Other,186% of Medicaid,35.13,,,35.13,Fee Schedule,,106.02,,,106.02,Fee Schedule,,19.89,,,19.89,Fee Schedule,,35.13,,,35.13,Fee Schedule,,106.02,,,106.02,Fee Schedule,,37.41,,,37.41,Fee Schedule,,119.7,70,,119.7,percent of total billed charges,All Other,41,,,41,Fee Schedule,,34.75,,,34.75,Fee Schedule,,13.53,,,13.53,Fee Schedule,,13.53,,,13.53,Fee Schedule,,13.53,,,13.53,Fee Schedule,,13.53,,,13.53,Fee Schedule,,46.77,,,46.77,Other,100% of Medicaid,46.77,,,46.77,Other,100% of Medicaid,46.77,,,46.77,Other,100% of Medicaid,46.77,,,46.77,Other,100% of Medicaid,105.23,,,105.23,Other,225% of Medicaid,71.56,,,71.56,Other,153% of Medicaid,105.23,,,105.23,Other,225% of Medicaid,65.48,,,65.48,Other,140% of Medicaid,105.23,,,105.23,Other,225% of Medicaid,121.6,,,121.6,Other,260% of Medicaid,151.53,,,151.53,Other,324% of Medicaid,100.55,,,100.55,Other,215% of Medicaid,100.55,,,100.55,Other,215% of Medicaid,58.46,,,58.46,Other,125% of Medicaid,13.53,151.53,
SPECIAL STAINS GROUP 2,88313,CPT,,78088313,CDM,312,RC,,,both,,,361,267.14,,,267.14,Other,150% of Medicare + 9.63% HCRA Surcharge,162.45,45,,162.45,percent of total billed charges,Critical Access Hospital RCC factor,233.43,,,233.43,Fee Schedule,,210.16,,,210.16,Fee Schedule,,446.32,,,446.32,Fee Schedule,,401.43,,,401.43,Fee Schedule,,379.41,,,379.41,Fee Schedule,,178.7,,,178.7,Other,110% of Medicare,244.28,,,244.28,Fee Schedule,,19,,,19,Other,186% of Medicaid,287.71,,,287.71,Fee Schedule,,223.82,,,223.82,Fee Schedule,,162.86,,,162.86,Fee Schedule,,287.71,,,287.71,Fee Schedule,,223.82,,,223.82,Fee Schedule,,306.32,,,306.32,Fee Schedule,,252.7,70,,252.7,percent of total billed charges,All Other,332.92,,,332.92,Fee Schedule,,282.17,,,282.17,Fee Schedule,,50.15,,,50.15,Fee Schedule,,50.15,,,50.15,Fee Schedule,,50.15,,,50.15,Fee Schedule,,50.15,,,50.15,Fee Schedule,,9.98,,,9.98,Other,100% of Medicaid,9.98,,,9.98,Other,100% of Medicaid,9.98,,,9.98,Other,100% of Medicaid,9.98,,,9.98,Other,100% of Medicaid,22.45,,,22.45,Other,225% of Medicaid,15.27,,,15.27,Other,153% of Medicaid,22.45,,,22.45,Other,225% of Medicaid,13.97,,,13.97,Other,140% of Medicaid,22.45,,,22.45,Other,225% of Medicaid,25.94,,,25.94,Other,260% of Medicaid,32.33,,,32.33,Other,324% of Medicaid,21.45,,,21.45,Other,215% of Medicaid,21.45,,,21.45,Other,215% of Medicaid,12.47,,,12.47,Other,125% of Medicaid,9.98,446.32,
PATH CONSULT INTROP,88329,CPT,,78088329,CDM,312,RC,,,both,,,411,304.14,,,304.14,Other,150% of Medicare + 9.63% HCRA Surcharge,184.95,45,,184.95,percent of total billed charges,Critical Access Hospital RCC factor,108.96,,,108.96,Fee Schedule,,98.1,,,98.1,Fee Schedule,,323.16,,,323.16,Fee Schedule,,290.66,,,290.66,Fee Schedule,,274.71,,,274.71,Fee Schedule,,203.45,,,203.45,Other,110% of Medicare,114.03,,,114.03,Fee Schedule,,103,,,103,Other,186% of Medicaid,134.3,,,134.3,Fee Schedule,,254.82,,,254.82,Fee Schedule,,76.02,,,76.02,Fee Schedule,,134.3,,,134.3,Fee Schedule,,254.82,,,254.82,Fee Schedule,,142.99,,,142.99,Fee Schedule,,287.7,70,,287.7,percent of total billed charges,All Other,168.92,,,168.92,Fee Schedule,,143.17,,,143.17,Fee Schedule,,50.15,,,50.15,Fee Schedule,,50.15,,,50.15,Fee Schedule,,50.15,,,50.15,Fee Schedule,,50.15,,,50.15,Fee Schedule,,55.61,,,55.61,Other,100% of Medicaid,55.61,,,55.61,Other,100% of Medicaid,55.61,,,55.61,Other,100% of Medicaid,55.61,,,55.61,Other,100% of Medicaid,125.13,,,125.13,Other,225% of Medicaid,85.09,,,85.09,Other,153% of Medicaid,125.13,,,125.13,Other,225% of Medicaid,77.86,,,77.86,Other,140% of Medicaid,125.13,,,125.13,Other,225% of Medicaid,144.59,,,144.59,Other,260% of Medicaid,180.18,,,180.18,Other,324% of Medicaid,119.57,,,119.57,Other,215% of Medicaid,119.57,,,119.57,Other,215% of Medicaid,69.51,,,69.51,Other,125% of Medicaid,50.15,323.16,
PATH CONSULT INTRAOP ADDL,88332,CPT,,78088332,CDM,312,RC,,,both,,,158,116.92,,,116.92,Other,150% of Medicare + 9.63% HCRA Surcharge,71.1,45,,71.1,percent of total billed charges,Critical Access Hospital RCC factor,81.9,,,81.9,Fee Schedule,,73.74,,,73.74,Fee Schedule,,75.62,,,75.62,Fee Schedule,,68.02,,,68.02,Fee Schedule,,64.29,,,64.29,Fee Schedule,,78.21,,,78.21,Other,110% of Medicare,85.71,,,85.71,Fee Schedule,,103,,,103,Other,186% of Medicaid,100.95,,,100.95,Fee Schedule,,97.96,,,97.96,Fee Schedule,,57.14,,,57.14,Fee Schedule,,100.95,,,100.95,Fee Schedule,,97.96,,,97.96,Fee Schedule,,107.48,,,107.48,Fee Schedule,,110.6,70,,110.6,percent of total billed charges,All Other,116.44,,,116.44,Fee Schedule,,98.69,,,98.69,Fee Schedule,,34.65,,,34.65,Fee Schedule,,34.65,,,34.65,Fee Schedule,,34.65,,,34.65,Fee Schedule,,34.65,,,34.65,Fee Schedule,,55.61,,,55.61,Other,100% of Medicaid,55.61,,,55.61,Other,100% of Medicaid,55.61,,,55.61,Other,100% of Medicaid,55.61,,,55.61,Other,100% of Medicaid,125.13,,,125.13,Other,225% of Medicaid,85.09,,,85.09,Other,153% of Medicaid,125.13,,,125.13,Other,225% of Medicaid,77.86,,,77.86,Other,140% of Medicaid,125.13,,,125.13,Other,225% of Medicaid,144.59,,,144.59,Other,260% of Medicaid,180.18,,,180.18,Other,324% of Medicaid,119.57,,,119.57,Other,215% of Medicaid,119.57,,,119.57,Other,215% of Medicaid,69.51,,,69.51,Other,125% of Medicaid,34.65,180.18,
IMMUNOHISTOCHEMISTRY,88342,CPT,,78088342,CDM,312,RC,,,both,,,747,552.78,,,552.78,Other,150% of Medicare + 9.63% HCRA Surcharge,336.15,45,,336.15,percent of total billed charges,Critical Access Hospital RCC factor,236.71,,,236.71,Fee Schedule,,213.11,,,213.11,Fee Schedule,,423.44,,,423.44,Fee Schedule,,380.86,,,380.86,Fee Schedule,,359.97,,,359.97,Fee Schedule,,369.77,,,369.77,Other,110% of Medicare,247.72,,,247.72,Fee Schedule,,48,,,48,Other,186% of Medicaid,291.75,,,291.75,Fee Schedule,,463.14,,,463.14,Fee Schedule,,165.14,,,165.14,Fee Schedule,,291.75,,,291.75,Fee Schedule,,463.14,,,463.14,Fee Schedule,,310.63,,,310.63,Fee Schedule,,522.9,70,,522.9,percent of total billed charges,All Other,321.44,,,321.44,Fee Schedule,,272.44,,,272.44,Fee Schedule,,215.25,,,215.25,Fee Schedule,,215.25,,,215.25,Fee Schedule,,215.25,,,215.25,Fee Schedule,,215.25,,,215.25,Fee Schedule,,25.62,,,25.62,Other,100% of Medicaid,25.62,,,25.62,Other,100% of Medicaid,25.62,,,25.62,Other,100% of Medicaid,25.62,,,25.62,Other,100% of Medicaid,57.65,,,57.65,Other,225% of Medicaid,39.2,,,39.2,Other,153% of Medicaid,57.65,,,57.65,Other,225% of Medicaid,35.87,,,35.87,Other,140% of Medicaid,57.65,,,57.65,Other,225% of Medicaid,66.62,,,66.62,Other,260% of Medicaid,83.02,,,83.02,Other,324% of Medicaid,55.09,,,55.09,Other,215% of Medicaid,55.09,,,55.09,Other,215% of Medicaid,32.03,,,32.03,Other,125% of Medicaid,25.62,552.78,
CYTOPATH SMEAR OTHER SOURCE,88160,CPT,,78088160,CDM,319,RC,,,both,,,258,190.92,,,190.92,Other,150% of Medicare + 9.63% HCRA Surcharge,116.1,45,,116.1,percent of total billed charges,Critical Access Hospital RCC factor,180.18,,,180.18,Fee Schedule,,162.22,,,162.22,Fee Schedule,,201.47,,,201.47,Fee Schedule,,181.21,,,181.21,Fee Schedule,,171.27,,,171.27,Fee Schedule,,127.71,,,127.71,Other,110% of Medicare,188.56,,,188.56,Fee Schedule,,36,,,36,Other,186% of Medicaid,222.08,,,222.08,Fee Schedule,,159.96,,,159.96,Fee Schedule,,125.71,,,125.71,Fee Schedule,,222.08,,,222.08,Fee Schedule,,159.96,,,159.96,Fee Schedule,,236.45,,,236.45,Fee Schedule,,180.6,70,,180.6,percent of total billed charges,All Other,223.04,,,223.04,Fee Schedule,,189.04,,,189.04,Fee Schedule,,34.49,,,34.49,Fee Schedule,,34.49,,,34.49,Fee Schedule,,34.49,,,34.49,Fee Schedule,,34.49,,,34.49,Fee Schedule,,19.31,,,19.31,Other,100% of Medicaid,19.31,,,19.31,Other,100% of Medicaid,19.31,,,19.31,Other,100% of Medicaid,19.31,,,19.31,Other,100% of Medicaid,43.45,,,43.45,Other,225% of Medicaid,29.55,,,29.55,Other,153% of Medicaid,43.45,,,43.45,Other,225% of Medicaid,27.04,,,27.04,Other,140% of Medicaid,43.45,,,43.45,Other,225% of Medicaid,50.21,,,50.21,Other,260% of Medicaid,62.57,,,62.57,Other,324% of Medicaid,41.52,,,41.52,Other,215% of Medicaid,41.52,,,41.52,Other,215% of Medicaid,24.14,,,24.14,Other,125% of Medicaid,19.31,236.45,
CHROMOSOME ANALYSIS 20-25,88245,CPT,,78088245,CDM,319,RC,,,both,,,1316,973.84,,,973.84,Other,150% of Medicare + 9.63% HCRA Surcharge,592.2,45,,592.2,percent of total billed charges,Critical Access Hospital RCC factor,521.24,,,521.24,Fee Schedule,,469.29,,,469.29,Fee Schedule,,577.86,,,577.86,Fee Schedule,,519.74,,,519.74,Fee Schedule,,491.23,,,491.23,Fee Schedule,,651.42,,,651.42,Other,110% of Medicare,545.49,,,545.49,Fee Schedule,,169,,,169,Other,186% of Medicaid,642.46,,,642.46,Fee Schedule,,815.92,,,815.92,Fee Schedule,,363.66,,,363.66,Fee Schedule,,642.46,,,642.46,Fee Schedule,,815.92,,,815.92,Fee Schedule,,684.02,,,684.02,Fee Schedule,,921.2,70,,921.2,percent of total billed charges,All Other,820.66,,,820.66,Fee Schedule,,695.56,,,695.56,Fee Schedule,,259.76,,,259.76,Fee Schedule,,259.76,,,259.76,Fee Schedule,,259.76,,,259.76,Fee Schedule,,259.76,,,259.76,Fee Schedule,,90.9,,,90.9,Other,100% of Medicaid,90.9,,,90.9,Other,100% of Medicaid,90.9,,,90.9,Other,100% of Medicaid,90.9,,,90.9,Other,100% of Medicaid,204.53,,,204.53,Other,225% of Medicaid,139.08,,,139.08,Other,153% of Medicaid,204.53,,,204.53,Other,225% of Medicaid,127.26,,,127.26,Other,140% of Medicaid,204.53,,,204.53,Other,225% of Medicaid,236.34,,,236.34,Other,260% of Medicaid,294.52,,,294.52,Other,324% of Medicaid,195.44,,,195.44,Other,215% of Medicaid,195.44,,,195.44,Other,215% of Medicaid,113.63,,,113.63,Other,125% of Medicaid,90.9,973.84,
CHROMOSOME ANALYSIS 50-100,88248,CPT,,78088248,CDM,319,RC,,,both,,,1316,973.84,,,973.84,Other,150% of Medicare + 9.63% HCRA Surcharge,592.2,45,,592.2,percent of total billed charges,Critical Access Hospital RCC factor,521.24,,,521.24,Fee Schedule,,469.29,,,469.29,Fee Schedule,,1284.3,,,1284.3,Fee Schedule,,1155.14,,,1155.14,Fee Schedule,,1091.78,,,1091.78,Fee Schedule,,651.42,,,651.42,Other,110% of Medicare,545.49,,,545.49,Fee Schedule,,188,,,188,Other,186% of Medicaid,642.46,,,642.46,Fee Schedule,,815.92,,,815.92,Fee Schedule,,363.66,,,363.66,Fee Schedule,,642.46,,,642.46,Fee Schedule,,815.92,,,815.92,Fee Schedule,,684.02,,,684.02,Fee Schedule,,921.2,70,,921.2,percent of total billed charges,All Other,820.66,,,820.66,Fee Schedule,,695.56,,,695.56,Fee Schedule,,259.76,,,259.76,Fee Schedule,,259.76,,,259.76,Fee Schedule,,259.76,,,259.76,Fee Schedule,,259.76,,,259.76,Fee Schedule,,101,,,101,Other,100% of Medicaid,101,,,101,Other,100% of Medicaid,101,,,101,Other,100% of Medicaid,101,,,101,Other,100% of Medicaid,227.25,,,227.25,Other,225% of Medicaid,154.53,,,154.53,Other,153% of Medicaid,227.25,,,227.25,Other,225% of Medicaid,141.4,,,141.4,Other,140% of Medicaid,227.25,,,227.25,Other,225% of Medicaid,262.6,,,262.6,Other,260% of Medicaid,327.24,,,327.24,Other,324% of Medicaid,217.15,,,217.15,Other,215% of Medicaid,217.15,,,217.15,Other,215% of Medicaid,126.25,,,126.25,Other,125% of Medicaid,101,1284.3,
CHROMOSOME ANALYSIS 15-20,88262,CPT,,78088262,CDM,319,RC,,,both,,,1316,973.84,,,973.84,Other,150% of Medicare + 9.63% HCRA Surcharge,592.2,45,,592.2,percent of total billed charges,Critical Access Hospital RCC factor,377.72,,,377.72,Fee Schedule,,340.08,,,340.08,Fee Schedule,,924.36,,,924.36,Fee Schedule,,831.4,,,831.4,Fee Schedule,,785.79,,,785.79,Fee Schedule,,651.42,,,651.42,Other,110% of Medicare,395.29,,,395.29,Fee Schedule,,188,,,188,Other,186% of Medicaid,465.57,,,465.57,Fee Schedule,,815.92,,,815.92,Fee Schedule,,263.53,,,263.53,Fee Schedule,,465.57,,,465.57,Fee Schedule,,815.92,,,815.92,Fee Schedule,,495.69,,,495.69,Fee Schedule,,921.2,70,,921.2,percent of total billed charges,All Other,594.7,,,594.7,Fee Schedule,,504.05,,,504.05,Fee Schedule,,188.24,,,188.24,Fee Schedule,,188.24,,,188.24,Fee Schedule,,188.24,,,188.24,Fee Schedule,,188.24,,,188.24,Fee Schedule,,101,,,101,Other,100% of Medicaid,101,,,101,Other,100% of Medicaid,101,,,101,Other,100% of Medicaid,101,,,101,Other,100% of Medicaid,227.25,,,227.25,Other,225% of Medicaid,154.53,,,154.53,Other,153% of Medicaid,227.25,,,227.25,Other,225% of Medicaid,141.4,,,141.4,Other,140% of Medicaid,227.25,,,227.25,Other,225% of Medicaid,262.6,,,262.6,Other,260% of Medicaid,327.24,,,327.24,Other,324% of Medicaid,217.15,,,217.15,Other,215% of Medicaid,217.15,,,217.15,Other,215% of Medicaid,126.25,,,126.25,Other,125% of Medicaid,101,973.84,
SURGICAL PATH GROSS,88300,CPT,,78088300,CDM,319,RC,,,both,,,123,91.02,,,91.02,Other,150% of Medicare + 9.63% HCRA Surcharge,55.35,45,,55.35,percent of total billed charges,Critical Access Hospital RCC factor,39.4,,,39.4,Fee Schedule,,35.47,,,35.47,Fee Schedule,,151.14,,,151.14,Fee Schedule,,135.94,,,135.94,Fee Schedule,,128.49,,,128.49,Fee Schedule,,60.89,,,60.89,Other,110% of Medicare,41.23,,,41.23,Fee Schedule,,87,,,87,Other,186% of Medicaid,48.56,,,48.56,Fee Schedule,,76.26,,,76.26,Fee Schedule,,27.49,,,27.49,Fee Schedule,,48.56,,,48.56,Fee Schedule,,76.26,,,76.26,Fee Schedule,,51.71,,,51.71,Fee Schedule,,86.1,70,,86.1,percent of total billed charges,All Other,52.48,,,52.48,Fee Schedule,,44.48,,,44.48,Fee Schedule,,34.49,,,34.49,Fee Schedule,,34.49,,,34.49,Fee Schedule,,34.49,,,34.49,Fee Schedule,,34.49,,,34.49,Fee Schedule,,46.77,,,46.77,Other,100% of Medicaid,46.77,,,46.77,Other,100% of Medicaid,46.77,,,46.77,Other,100% of Medicaid,46.77,,,46.77,Other,100% of Medicaid,105.23,,,105.23,Other,225% of Medicaid,71.56,,,71.56,Other,153% of Medicaid,105.23,,,105.23,Other,225% of Medicaid,65.48,,,65.48,Other,140% of Medicaid,105.23,,,105.23,Other,225% of Medicaid,121.6,,,121.6,Other,260% of Medicaid,151.53,,,151.53,Other,324% of Medicaid,100.55,,,100.55,Other,215% of Medicaid,100.55,,,100.55,Other,215% of Medicaid,58.46,,,58.46,Other,125% of Medicaid,27.49,151.53,
TISSUE EXAM BY PATHOLOGIST,88302,CPT,,78088302,CDM,319,RC,,,both,,,478,353.72,,,353.72,Other,150% of Medicare + 9.63% HCRA Surcharge,215.1,45,,215.1,percent of total billed charges,Critical Access Hospital RCC factor,87.38,,,87.38,Fee Schedule,,78.67,,,78.67,Fee Schedule,,315.88,,,315.88,Fee Schedule,,284.12,,,284.12,Fee Schedule,,268.53,,,268.53,Fee Schedule,,236.61,,,236.61,Other,110% of Medicare,91.44,,,91.44,Fee Schedule,,36,,,36,Other,186% of Medicaid,107.7,,,107.7,Fee Schedule,,296.36,,,296.36,Fee Schedule,,60.96,,,60.96,Fee Schedule,,107.7,,,107.7,Fee Schedule,,296.36,,,296.36,Fee Schedule,,114.67,,,114.67,Fee Schedule,,334.6,70,,334.6,percent of total billed charges,All Other,119.72,,,119.72,Fee Schedule,,101.47,,,101.47,Fee Schedule,,34.49,,,34.49,Fee Schedule,,34.49,,,34.49,Fee Schedule,,34.49,,,34.49,Fee Schedule,,34.49,,,34.49,Fee Schedule,,19.5,,,19.5,Other,100% of Medicaid,19.5,,,19.5,Other,100% of Medicaid,19.5,,,19.5,Other,100% of Medicaid,19.5,,,19.5,Other,100% of Medicaid,43.88,,,43.88,Other,225% of Medicaid,29.84,,,29.84,Other,153% of Medicaid,43.88,,,43.88,Other,225% of Medicaid,27.3,,,27.3,Other,140% of Medicaid,43.88,,,43.88,Other,225% of Medicaid,50.71,,,50.71,Other,260% of Medicaid,63.19,,,63.19,Other,324% of Medicaid,41.93,,,41.93,Other,215% of Medicaid,41.93,,,41.93,Other,215% of Medicaid,24.38,,,24.38,Other,125% of Medicaid,19.5,353.72,
TISSUE EXAM BY PATHOLOGIST,88304,CPT,,78088304,CDM,319,RC,,,both,,,478,353.72,,,353.72,Other,150% of Medicare + 9.63% HCRA Surcharge,215.1,45,,215.1,percent of total billed charges,Critical Access Hospital RCC factor,104.81,,,104.81,Fee Schedule,,94.36,,,94.36,Fee Schedule,,347.93,,,347.93,Fee Schedule,,312.93,,,312.93,Fee Schedule,,295.77,,,295.77,Fee Schedule,,236.61,,,236.61,Other,110% of Medicare,109.68,,,109.68,Fee Schedule,,48,,,48,Other,186% of Medicaid,129.18,,,129.18,Fee Schedule,,296.36,,,296.36,Fee Schedule,,73.12,,,73.12,Fee Schedule,,129.18,,,129.18,Fee Schedule,,296.36,,,296.36,Fee Schedule,,137.54,,,137.54,Fee Schedule,,334.6,70,,334.6,percent of total billed charges,All Other,145.96,,,145.96,Fee Schedule,,123.71,,,123.71,Fee Schedule,,74.21,,,74.21,Fee Schedule,,74.21,,,74.21,Fee Schedule,,74.21,,,74.21,Fee Schedule,,74.21,,,74.21,Fee Schedule,,25.58,,,25.58,Other,100% of Medicaid,25.58,,,25.58,Other,100% of Medicaid,25.58,,,25.58,Other,100% of Medicaid,25.58,,,25.58,Other,100% of Medicaid,57.56,,,57.56,Other,225% of Medicaid,39.14,,,39.14,Other,153% of Medicaid,57.56,,,57.56,Other,225% of Medicaid,35.82,,,35.82,Other,140% of Medicaid,57.56,,,57.56,Other,225% of Medicaid,66.52,,,66.52,Other,260% of Medicaid,82.89,,,82.89,Other,324% of Medicaid,55,,,55,Other,215% of Medicaid,55,,,55,Other,215% of Medicaid,31.98,,,31.98,Other,125% of Medicaid,25.58,353.72,
TISSUE EXAM BY PATHOLOGIST,88307,CPT,,78088307,CDM,319,RC,,,both,,,1051,777.74,,,777.74,Other,150% of Medicare + 9.63% HCRA Surcharge,472.95,45,,472.95,percent of total billed charges,Critical Access Hospital RCC factor,684.11,,,684.11,Fee Schedule,,615.93,,,615.93,Fee Schedule,,988.65,,,988.65,Fee Schedule,,889.22,,,889.22,Fee Schedule,,840.45,,,840.45,Fee Schedule,,520.25,,,520.25,Other,110% of Medicare,715.93,,,715.93,Fee Schedule,,328,,,328,Other,186% of Medicaid,843.21,,,843.21,Fee Schedule,,651.62,,,651.62,Fee Schedule,,477.29,,,477.29,Fee Schedule,,843.21,,,843.21,Fee Schedule,,651.62,,,651.62,Fee Schedule,,897.76,,,897.76,Fee Schedule,,735.7,70,,735.7,percent of total billed charges,All Other,987.28,,,987.28,Fee Schedule,,836.78,,,836.78,Fee Schedule,,425.12,,,425.12,Fee Schedule,,425.12,,,425.12,Fee Schedule,,425.12,,,425.12,Fee Schedule,,425.12,,,425.12,Fee Schedule,,176.15,,,176.15,Other,100% of Medicaid,176.15,,,176.15,Other,100% of Medicaid,176.15,,,176.15,Other,100% of Medicaid,176.15,,,176.15,Other,100% of Medicaid,396.35,,,396.35,Other,225% of Medicaid,269.52,,,269.52,Other,153% of Medicaid,396.35,,,396.35,Other,225% of Medicaid,246.62,,,246.62,Other,140% of Medicaid,396.35,,,396.35,Other,225% of Medicaid,458,,,458,Other,260% of Medicaid,570.74,,,570.74,Other,324% of Medicaid,378.73,,,378.73,Other,215% of Medicaid,378.73,,,378.73,Other,215% of Medicaid,220.19,,,220.19,Other,125% of Medicaid,176.15,988.65,
TISSUE EXAM BY PATHOLOGIST,88309,CPT,,78088309,CDM,319,RC,,,both,,,1859,1375.66,,,1375.66,Other,150% of Medicare + 9.63% HCRA Surcharge,836.55,45,,836.55,percent of total billed charges,Critical Access Hospital RCC factor,959.92,,,959.92,Fee Schedule,,864.25,,,864.25,Fee Schedule,,1373.31,,,1373.31,Fee Schedule,,1235.2,,,1235.2,Fee Schedule,,1167.44,,,1167.44,Fee Schedule,,920.21,,,920.21,Other,110% of Medicare,1004.57,,,1004.57,Fee Schedule,,498,,,498,Other,186% of Medicaid,1183.16,,,1183.16,Fee Schedule,,1152.58,,,1152.58,Fee Schedule,,669.71,,,669.71,Fee Schedule,,1183.16,,,1183.16,Fee Schedule,,1152.58,,,1152.58,Fee Schedule,,1259.69,,,1259.69,Fee Schedule,,1301.3,70,,1301.3,percent of total billed charges,All Other,1407.12,,,1407.12,Fee Schedule,,1192.62,,,1192.62,Fee Schedule,,942.3,,,942.3,Fee Schedule,,942.3,,,942.3,Fee Schedule,,942.3,,,942.3,Fee Schedule,,942.3,,,942.3,Fee Schedule,,267.64,,,267.64,Other,100% of Medicaid,267.64,,,267.64,Other,100% of Medicaid,267.64,,,267.64,Other,100% of Medicaid,267.64,,,267.64,Other,100% of Medicaid,602.19,,,602.19,Other,225% of Medicaid,409.49,,,409.49,Other,153% of Medicaid,602.19,,,602.19,Other,225% of Medicaid,374.7,,,374.7,Other,140% of Medicaid,602.19,,,602.19,Other,225% of Medicaid,695.86,,,695.86,Other,260% of Medicaid,867.15,,,867.15,Other,324% of Medicaid,575.43,,,575.43,Other,215% of Medicaid,575.43,,,575.43,Other,215% of Medicaid,334.55,,,334.55,Other,125% of Medicaid,267.64,1407.12,
SPECIAL STAINS GROUP 1,88312,CPT,,78088312,CDM,319,RC,,,both,,,435,321.9,,,321.9,Other,150% of Medicare + 9.63% HCRA Surcharge,195.75,45,,195.75,percent of total billed charges,Critical Access Hospital RCC factor,284.66,,,284.66,Fee Schedule,,256.28,,,256.28,Fee Schedule,,542.44,,,542.44,Fee Schedule,,487.89,,,487.89,Fee Schedule,,461.13,,,461.13,Fee Schedule,,215.33,,,215.33,Other,110% of Medicare,297.9,,,297.9,Fee Schedule,,25,,,25,Other,186% of Medicaid,350.85,,,350.85,Fee Schedule,,269.7,,,269.7,Fee Schedule,,198.6,,,198.6,Fee Schedule,,350.85,,,350.85,Fee Schedule,,269.7,,,269.7,Fee Schedule,,373.55,,,373.55,Fee Schedule,,304.5,70,,304.5,percent of total billed charges,All Other,418.2,,,418.2,Fee Schedule,,354.45,,,354.45,Fee Schedule,,74.21,,,74.21,Fee Schedule,,74.21,,,74.21,Fee Schedule,,74.21,,,74.21,Fee Schedule,,74.21,,,74.21,Fee Schedule,,13.31,,,13.31,Other,100% of Medicaid,13.31,,,13.31,Other,100% of Medicaid,13.31,,,13.31,Other,100% of Medicaid,13.31,,,13.31,Other,100% of Medicaid,29.95,,,29.95,Other,225% of Medicaid,20.37,,,20.37,Other,153% of Medicaid,29.95,,,29.95,Other,225% of Medicaid,18.64,,,18.64,Other,140% of Medicaid,29.95,,,29.95,Other,225% of Medicaid,34.61,,,34.61,Other,260% of Medicaid,43.13,,,43.13,Other,324% of Medicaid,28.62,,,28.62,Other,215% of Medicaid,28.62,,,28.62,Other,215% of Medicaid,16.64,,,16.64,Other,125% of Medicaid,13.31,542.44,
ENZYME HISTOCHEMISTRY,88319,CPT,,78088319,CDM,319,RC,,,both,,,1749,1294.26,,,1294.26,Other,150% of Medicare + 9.63% HCRA Surcharge,787.05,45,,787.05,percent of total billed charges,Critical Access Hospital RCC factor,362.22,,,362.22,Fee Schedule,,326.12,,,326.12,Fee Schedule,,807.89,,,807.89,Fee Schedule,,726.64,,,726.64,Fee Schedule,,686.78,,,686.78,Fee Schedule,,865.76,,,865.76,Other,110% of Medicare,379.07,,,379.07,Fee Schedule,,66,,,66,Other,186% of Medicaid,446.46,,,446.46,Fee Schedule,,1084.38,,,1084.38,Fee Schedule,,252.71,,,252.71,Fee Schedule,,446.46,,,446.46,Fee Schedule,,1084.38,,,1084.38,Fee Schedule,,475.34,,,475.34,Fee Schedule,,1224.3,70,,1224.3,percent of total billed charges,All Other,546.12,,,546.12,Fee Schedule,,462.87,,,462.87,Fee Schedule,,942.3,,,942.3,Fee Schedule,,942.3,,,942.3,Fee Schedule,,942.3,,,942.3,Fee Schedule,,942.3,,,942.3,Fee Schedule,,35.54,,,35.54,Other,100% of Medicaid,35.54,,,35.54,Other,100% of Medicaid,35.54,,,35.54,Other,100% of Medicaid,35.54,,,35.54,Other,100% of Medicaid,79.97,,,79.97,Other,225% of Medicaid,54.38,,,54.38,Other,153% of Medicaid,79.97,,,79.97,Other,225% of Medicaid,49.76,,,49.76,Other,140% of Medicaid,79.97,,,79.97,Other,225% of Medicaid,92.41,,,92.41,Other,260% of Medicaid,115.16,,,115.16,Other,324% of Medicaid,76.42,,,76.42,Other,215% of Medicaid,76.42,,,76.42,Other,215% of Medicaid,44.43,,,44.43,Other,125% of Medicaid,35.54,1294.26,
MICROSLIDE CONSULTATION,88321,CPT,,78088321,CDM,319,RC,,,both,,,210,155.4,,,155.4,Other,150% of Medicare + 9.63% HCRA Surcharge,94.5,45,,94.5,percent of total billed charges,Critical Access Hospital RCC factor,257.63,,,257.63,Fee Schedule,,231.95,,,231.95,Fee Schedule,,545.45,,,545.45,Fee Schedule,,490.59,,,490.59,Fee Schedule,,463.68,,,463.68,Fee Schedule,,103.95,,,103.95,Other,110% of Medicare,269.61,,,269.61,Fee Schedule,,103,,,103,Other,186% of Medicaid,317.54,,,317.54,Fee Schedule,,130.2,,,130.2,Fee Schedule,,179.74,,,179.74,Fee Schedule,,317.54,,,317.54,Fee Schedule,,130.2,,,130.2,Fee Schedule,,338.08,,,338.08,Fee Schedule,,147,70,,147,percent of total billed charges,All Other,398.52,,,398.52,Fee Schedule,,337.77,,,337.77,Fee Schedule,,50.15,,,50.15,Fee Schedule,,50.15,,,50.15,Fee Schedule,,50.15,,,50.15,Fee Schedule,,50.15,,,50.15,Fee Schedule,,55.61,,,55.61,Other,100% of Medicaid,55.61,,,55.61,Other,100% of Medicaid,55.61,,,55.61,Other,100% of Medicaid,55.61,,,55.61,Other,100% of Medicaid,125.13,,,125.13,Other,225% of Medicaid,85.09,,,85.09,Other,153% of Medicaid,125.13,,,125.13,Other,225% of Medicaid,77.86,,,77.86,Other,140% of Medicaid,125.13,,,125.13,Other,225% of Medicaid,144.59,,,144.59,Other,260% of Medicaid,180.18,,,180.18,Other,324% of Medicaid,119.57,,,119.57,Other,215% of Medicaid,119.57,,,119.57,Other,215% of Medicaid,69.51,,,69.51,Other,125% of Medicaid,50.15,545.45,
MICROSLIDE CONSULTATION,88323,CPT,,78088323,CDM,319,RC,,,both,,,386,285.64,,,285.64,Other,150% of Medicare + 9.63% HCRA Surcharge,173.7,45,,173.7,percent of total billed charges,Critical Access Hospital RCC factor,97.16,,,97.16,Fee Schedule,,87.48,,,87.48,Fee Schedule,,395.99,,,395.99,Fee Schedule,,356.16,,,356.16,Fee Schedule,,336.63,,,336.63,Fee Schedule,,191.07,,,191.07,Other,110% of Medicare,101.68,,,101.68,Fee Schedule,,103,,,103,Other,186% of Medicaid,119.76,,,119.76,Fee Schedule,,239.32,,,239.32,Fee Schedule,,67.79,,,67.79,Fee Schedule,,119.76,,,119.76,Fee Schedule,,239.32,,,239.32,Fee Schedule,,127.51,,,127.51,Fee Schedule,,270.2,70,,270.2,percent of total billed charges,All Other,129.56,,,129.56,Fee Schedule,,109.81,,,109.81,Fee Schedule,,74.21,,,74.21,Fee Schedule,,74.21,,,74.21,Fee Schedule,,74.21,,,74.21,Fee Schedule,,74.21,,,74.21,Fee Schedule,,55.61,,,55.61,Other,100% of Medicaid,55.61,,,55.61,Other,100% of Medicaid,55.61,,,55.61,Other,100% of Medicaid,55.61,,,55.61,Other,100% of Medicaid,125.13,,,125.13,Other,225% of Medicaid,85.09,,,85.09,Other,153% of Medicaid,125.13,,,125.13,Other,225% of Medicaid,77.86,,,77.86,Other,140% of Medicaid,125.13,,,125.13,Other,225% of Medicaid,144.59,,,144.59,Other,260% of Medicaid,180.18,,,180.18,Other,324% of Medicaid,119.57,,,119.57,Other,215% of Medicaid,119.57,,,119.57,Other,215% of Medicaid,69.51,,,69.51,Other,125% of Medicaid,55.61,395.99,
PATH CONSULT INTRAOP 1 BLOC,88331,CPT,,78088331,CDM,319,RC,,,both,,,581,429.94,,,429.94,Other,150% of Medicare + 9.63% HCRA Surcharge,261.45,45,,261.45,percent of total billed charges,Critical Access Hospital RCC factor,135.33,,,135.33,Fee Schedule,,121.84,,,121.84,Fee Schedule,,215.23,,,215.23,Fee Schedule,,193.58,,,193.58,Fee Schedule,,182.96,,,182.96,Fee Schedule,,287.6,,,287.6,Other,110% of Medicare,141.62,,,141.62,Fee Schedule,,103,,,103,Other,186% of Medicaid,166.8,,,166.8,Fee Schedule,,360.22,,,360.22,Fee Schedule,,94.42,,,94.42,Fee Schedule,,166.8,,,166.8,Fee Schedule,,360.22,,,360.22,Fee Schedule,,177.59,,,177.59,Fee Schedule,,406.7,70,,406.7,percent of total billed charges,All Other,196.8,,,196.8,Fee Schedule,,166.8,,,166.8,Fee Schedule,,215.25,,,215.25,Fee Schedule,,215.25,,,215.25,Fee Schedule,,215.25,,,215.25,Fee Schedule,,215.25,,,215.25,Fee Schedule,,55.61,,,55.61,Other,100% of Medicaid,55.61,,,55.61,Other,100% of Medicaid,55.61,,,55.61,Other,100% of Medicaid,55.61,,,55.61,Other,100% of Medicaid,125.13,,,125.13,Other,225% of Medicaid,85.09,,,85.09,Other,153% of Medicaid,125.13,,,125.13,Other,225% of Medicaid,77.86,,,77.86,Other,140% of Medicaid,125.13,,,125.13,Other,225% of Medicaid,144.59,,,144.59,Other,260% of Medicaid,180.18,,,180.18,Other,324% of Medicaid,119.57,,,119.57,Other,215% of Medicaid,119.57,,,119.57,Other,215% of Medicaid,69.51,,,69.51,Other,125% of Medicaid,55.61,429.94,
INTRAOP CYTO PATH CONSULT 1,88333,CPT,,78088333,CDM,319,RC,,,both,,,1834,1357.16,,,1357.16,Other,150% of Medicare + 9.63% HCRA Surcharge,825.3,45,,825.3,percent of total billed charges,Critical Access Hospital RCC factor,104.81,,,104.81,Fee Schedule,,94.36,,,94.36,Fee Schedule,,235.78,,,235.78,Fee Schedule,,212.07,,,212.07,Fee Schedule,,200.44,,,200.44,Fee Schedule,,907.83,,,907.83,Other,110% of Medicare,109.68,,,109.68,Fee Schedule,,103,,,103,Other,186% of Medicaid,129.18,,,129.18,Fee Schedule,,1137.08,,,1137.08,Fee Schedule,,73.12,,,73.12,Fee Schedule,,129.18,,,129.18,Fee Schedule,,1137.08,,,1137.08,Fee Schedule,,137.54,,,137.54,Fee Schedule,,1283.8,70,,1283.8,percent of total billed charges,All Other,155.8,,,155.8,Fee Schedule,,132.05,,,132.05,Fee Schedule,,942.3,,,942.3,Fee Schedule,,942.3,,,942.3,Fee Schedule,,942.3,,,942.3,Fee Schedule,,942.3,,,942.3,Fee Schedule,,55.61,,,55.61,Other,100% of Medicaid,55.61,,,55.61,Other,100% of Medicaid,55.61,,,55.61,Other,100% of Medicaid,55.61,,,55.61,Other,100% of Medicaid,125.13,,,125.13,Other,225% of Medicaid,85.09,,,85.09,Other,153% of Medicaid,125.13,,,125.13,Other,225% of Medicaid,77.86,,,77.86,Other,140% of Medicaid,125.13,,,125.13,Other,225% of Medicaid,144.59,,,144.59,Other,260% of Medicaid,180.18,,,180.18,Other,324% of Medicaid,119.57,,,119.57,Other,215% of Medicaid,119.57,,,119.57,Other,215% of Medicaid,69.51,,,69.51,Other,125% of Medicaid,55.61,1357.16,
INTRAOP CYTO PATH CONSULT 2,88334,CPT,,78088334,CDM,319,RC,,,both,,,184,136.16,,,136.16,Other,150% of Medicare + 9.63% HCRA Surcharge,82.8,45,,82.8,percent of total billed charges,Critical Access Hospital RCC factor,63.21,,,63.21,Fee Schedule,,56.91,,,56.91,Fee Schedule,,148.82,,,148.82,Fee Schedule,,133.86,,,133.86,Fee Schedule,,126.52,,,126.52,Fee Schedule,,91.08,,,91.08,Other,110% of Medicare,66.15,,,66.15,Fee Schedule,,103,,,103,Other,186% of Medicaid,77.91,,,77.91,Fee Schedule,,114.08,,,114.08,Fee Schedule,,44.1,,,44.1,Fee Schedule,,77.91,,,77.91,Fee Schedule,,114.08,,,114.08,Fee Schedule,,82.95,,,82.95,Fee Schedule,,128.8,70,,128.8,percent of total billed charges,All Other,91.84,,,91.84,Fee Schedule,,77.84,,,77.84,Fee Schedule,,27.06,,,27.06,Fee Schedule,,27.06,,,27.06,Fee Schedule,,27.06,,,27.06,Fee Schedule,,27.06,,,27.06,Fee Schedule,,55.61,,,55.61,Other,100% of Medicaid,55.61,,,55.61,Other,100% of Medicaid,55.61,,,55.61,Other,100% of Medicaid,55.61,,,55.61,Other,100% of Medicaid,125.13,,,125.13,Other,225% of Medicaid,85.09,,,85.09,Other,153% of Medicaid,125.13,,,125.13,Other,225% of Medicaid,77.86,,,77.86,Other,140% of Medicaid,125.13,,,125.13,Other,225% of Medicaid,144.59,,,144.59,Other,260% of Medicaid,180.18,,,180.18,Other,324% of Medicaid,119.57,,,119.57,Other,215% of Medicaid,119.57,,,119.57,Other,215% of Medicaid,69.51,,,69.51,Other,125% of Medicaid,27.06,180.18,
XR EXAM OF JAW <4 VIEWS,70100,CPT,TC,42070100,CDM,320,RC,,,both,,,231,170.94,,,170.94,Other,150% of Medicare + 9.63% HCRA Surcharge,103.95,45,,103.95,percent of total billed charges,Critical Access Hospital RCC factor,105.3,,,105.3,Fee Schedule,,94.74,,,94.74,Fee Schedule,,162.58,,,162.58,Fee Schedule,,146.23,,,146.23,Fee Schedule,,138.21,,,138.21,Fee Schedule,,114.35,,,114.35,Other,110% of Medicare,125.11,,,125.11,Fee Schedule,,53,,,53,Other,186% of Medicaid,147.22,,,147.22,Fee Schedule,,143.22,,,143.22,Fee Schedule,,69.32,,,69.32,Fee Schedule,,147.22,,,147.22,Fee Schedule,,143.22,,,143.22,Fee Schedule,,130.39,,,130.39,Fee Schedule,,161.7,70,,161.7,percent of total billed charges,All Other,145.96,,,145.96,Fee Schedule,,123.71,,,123.71,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,170.94,
XR MANDIBLE BI 4 VIEWS MINU,70110,CPT,TC,42070110,CDM,320,RC,,,both,,,510,377.4,,,377.4,Other,150% of Medicare + 9.63% HCRA Surcharge,229.5,45,,229.5,percent of total billed charges,Critical Access Hospital RCC factor,111.08,,,111.08,Fee Schedule,,99.93,,,99.93,Fee Schedule,,185.45,,,185.45,Fee Schedule,,166.8,,,166.8,Fee Schedule,,157.65,,,157.65,Fee Schedule,,252.45,,,252.45,Other,110% of Medicare,131.97,,,131.97,Fee Schedule,,53,,,53,Other,186% of Medicaid,155.3,,,155.3,Fee Schedule,,316.2,,,316.2,Fee Schedule,,73.12,,,73.12,Fee Schedule,,155.3,,,155.3,Fee Schedule,,316.2,,,316.2,Fee Schedule,,137.54,,,137.54,Fee Schedule,,357,70,,357,percent of total billed charges,All Other,157.44,,,157.44,Fee Schedule,,133.44,,,133.44,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,377.4,
XR EXAM OF MASTOIDS 3+ VIEW,70130,CPT,TC,42070130,CDM,320,RC,,,both,,,653,483.22,,,483.22,Other,150% of Medicare + 9.63% HCRA Surcharge,293.85,45,,293.85,percent of total billed charges,Critical Access Hospital RCC factor,159.6,,,159.6,Fee Schedule,,143.59,,,143.59,Fee Schedule,,267.82,,,267.82,Fee Schedule,,240.89,,,240.89,Fee Schedule,,227.67,,,227.67,Fee Schedule,,323.24,,,323.24,Other,110% of Medicare,189.61,,,189.61,Fee Schedule,,53,,,53,Other,186% of Medicaid,223.13,,,223.13,Fee Schedule,,404.86,,,404.86,Fee Schedule,,105.06,,,105.06,Fee Schedule,,223.13,,,223.13,Fee Schedule,,404.86,,,404.86,Fee Schedule,,197.62,,,197.62,Fee Schedule,,457.1,70,,457.1,percent of total billed charges,All Other,227.96,,,227.96,Fee Schedule,,193.21,,,193.21,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,483.22,
XR  OF FACIAL BONES <3 VIEW,70140,CPT,TC,42070140,CDM,320,RC,,,both,,,198,146.52,,,146.52,Other,150% of Medicare + 9.63% HCRA Surcharge,89.1,45,,89.1,percent of total billed charges,Critical Access Hospital RCC factor,78.73,,,78.73,Fee Schedule,,70.83,,,70.83,Fee Schedule,,139.71,,,139.71,Fee Schedule,,125.66,,,125.66,Fee Schedule,,118.76,,,118.76,Fee Schedule,,98.01,,,98.01,Other,110% of Medicare,93.54,,,93.54,Fee Schedule,,53,,,53,Other,186% of Medicaid,110.07,,,110.07,Fee Schedule,,122.76,,,122.76,Fee Schedule,,51.83,,,51.83,Fee Schedule,,110.07,,,110.07,Fee Schedule,,122.76,,,122.76,Fee Schedule,,97.49,,,97.49,Fee Schedule,,138.6,70,,138.6,percent of total billed charges,All Other,109.88,,,109.88,Fee Schedule,,93.13,,,93.13,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,146.52,
XR EXAM OF FACIAL BONES 3+ VIEWS,70150,CPT,TC,42070150,CDM,320,RC,,,both,,,248,183.52,,,183.52,Other,150% of Medicare + 9.63% HCRA Surcharge,111.6,45,,111.6,percent of total billed charges,Critical Access Hospital RCC factor,121.48,,,121.48,Fee Schedule,,109.29,,,109.29,Fee Schedule,,203.74,,,203.74,Fee Schedule,,183.25,,,183.25,Fee Schedule,,173.2,,,173.2,Fee Schedule,,122.76,,,122.76,Other,110% of Medicare,144.32,,,144.32,Fee Schedule,,53,,,53,Other,186% of Medicaid,169.84,,,169.84,Fee Schedule,,153.76,,,153.76,Fee Schedule,,79.97,,,79.97,Fee Schedule,,169.84,,,169.84,Fee Schedule,,153.76,,,153.76,Fee Schedule,,150.42,,,150.42,Fee Schedule,,173.6,70,,173.6,percent of total billed charges,All Other,172.2,,,172.2,Fee Schedule,,145.95,,,145.95,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,203.74,
XR NASAL BONES 3 VIEWS,70160,CPT,TC,42070160,CDM,320,RC,,,both,,,470,347.8,,,347.8,Other,150% of Medicare + 9.63% HCRA Surcharge,211.5,45,,211.5,percent of total billed charges,Critical Access Hospital RCC factor,102.97,,,102.97,Fee Schedule,,92.64,,,92.64,Fee Schedule,,167.16,,,167.16,Fee Schedule,,150.35,,,150.35,Fee Schedule,,142.11,,,142.11,Fee Schedule,,232.65,,,232.65,Other,110% of Medicare,122.34,,,122.34,Fee Schedule,,53,,,53,Other,186% of Medicaid,143.97,,,143.97,Fee Schedule,,291.4,,,291.4,Fee Schedule,,67.79,,,67.79,Fee Schedule,,143.97,,,143.97,Fee Schedule,,291.4,,,291.4,Fee Schedule,,127.51,,,127.51,Fee Schedule,,329,70,,329,percent of total billed charges,All Other,145.96,,,145.96,Fee Schedule,,123.71,,,123.71,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,347.8,
XR EYE SOCKETS 4+ VIEWS,70200,CPT,TC,42070200,CDM,320,RC,,,both,,,248,183.52,,,183.52,Other,150% of Medicare + 9.63% HCRA Surcharge,111.6,45,,111.6,percent of total billed charges,Critical Access Hospital RCC factor,120.33,,,120.33,Fee Schedule,,108.26,,,108.26,Fee Schedule,,206.06,,,206.06,Fee Schedule,,185.33,,,185.33,Fee Schedule,,175.17,,,175.17,Fee Schedule,,122.76,,,122.76,Other,110% of Medicare,142.96,,,142.96,Fee Schedule,,53,,,53,Other,186% of Medicaid,168.23,,,168.23,Fee Schedule,,153.76,,,153.76,Fee Schedule,,79.21,,,79.21,Fee Schedule,,168.23,,,168.23,Fee Schedule,,153.76,,,153.76,Fee Schedule,,148.99,,,148.99,Fee Schedule,,173.6,70,,173.6,percent of total billed charges,All Other,172.2,,,172.2,Fee Schedule,,145.95,,,145.95,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,206.06,
XR EXAM OF SINUSES <3 VIEWS,70210,CPT,TC,42070210,CDM,320,RC,,,both,,,282,208.68,,,208.68,Other,150% of Medicare + 9.63% HCRA Surcharge,126.9,45,,126.9,percent of total billed charges,Critical Access Hospital RCC factor,83.35,,,83.35,Fee Schedule,,74.99,,,74.99,Fee Schedule,,151.14,,,151.14,Fee Schedule,,135.94,,,135.94,Fee Schedule,,128.49,,,128.49,Fee Schedule,,139.59,,,139.59,Other,110% of Medicare,99.03,,,99.03,Fee Schedule,,53,,,53,Other,186% of Medicaid,116.54,,,116.54,Fee Schedule,,174.84,,,174.84,Fee Schedule,,54.87,,,54.87,Fee Schedule,,116.54,,,116.54,Fee Schedule,,174.84,,,174.84,Fee Schedule,,103.21,,,103.21,Fee Schedule,,197.4,70,,197.4,percent of total billed charges,All Other,118.08,,,118.08,Fee Schedule,,100.08,,,100.08,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,208.68,
XR PARANASAL SINUSES 3 VIEW,70220,CPT,TC,42070220,CDM,320,RC,,,both,,,601,444.74,,,444.74,Other,150% of Medicare + 9.63% HCRA Surcharge,270.45,45,,270.45,percent of total billed charges,Critical Access Hospital RCC factor,94.9,,,94.9,Fee Schedule,,85.38,,,85.38,Fee Schedule,,180.87,,,180.87,Fee Schedule,,162.68,,,162.68,Fee Schedule,,153.75,,,153.75,Fee Schedule,,297.5,,,297.5,Other,110% of Medicare,112.75,,,112.75,Fee Schedule,,53,,,53,Other,186% of Medicaid,132.69,,,132.69,Fee Schedule,,372.62,,,372.62,Fee Schedule,,62.48,,,62.48,Fee Schedule,,132.69,,,132.69,Fee Schedule,,372.62,,,372.62,Fee Schedule,,117.51,,,117.51,Fee Schedule,,420.7,70,,420.7,percent of total billed charges,All Other,134.48,,,134.48,Fee Schedule,,113.98,,,113.98,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,444.74,
XR SELLA TURCICA,70240,CPT,TC,42070240,CDM,320,RC,,,both,,,472,349.28,,,349.28,Other,150% of Medicare + 9.63% HCRA Surcharge,212.4,45,,212.4,percent of total billed charges,Critical Access Hospital RCC factor,83.35,,,83.35,Fee Schedule,,74.99,,,74.99,Fee Schedule,,137.39,,,137.39,Fee Schedule,,123.57,,,123.57,Fee Schedule,,116.79,,,116.79,Fee Schedule,,233.64,,,233.64,Other,110% of Medicare,99.03,,,99.03,Fee Schedule,,53,,,53,Other,186% of Medicaid,116.54,,,116.54,Fee Schedule,,292.64,,,292.64,Fee Schedule,,54.87,,,54.87,Fee Schedule,,116.54,,,116.54,Fee Schedule,,292.64,,,292.64,Fee Schedule,,103.21,,,103.21,Fee Schedule,,330.4,70,,330.4,percent of total billed charges,All Other,118.08,,,118.08,Fee Schedule,,100.08,,,100.08,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,349.28,
XR SKULL COMPLETE,70250,CPT,TC,42070250,CDM,320,RC,,,both,,,242,179.08,,,179.08,Other,150% of Medicare + 9.63% HCRA Surcharge,108.9,45,,108.9,percent of total billed charges,Critical Access Hospital RCC factor,96.05,,,96.05,Fee Schedule,,86.42,,,86.42,Fee Schedule,,169.43,,,169.43,Fee Schedule,,152.39,,,152.39,Fee Schedule,,144.03,,,144.03,Fee Schedule,,119.79,,,119.79,Other,110% of Medicare,114.12,,,114.12,Fee Schedule,,53,,,53,Other,186% of Medicaid,134.29,,,134.29,Fee Schedule,,150.04,,,150.04,Fee Schedule,,63.23,,,63.23,Fee Schedule,,134.29,,,134.29,Fee Schedule,,150.04,,,150.04,Fee Schedule,,118.93,,,118.93,Fee Schedule,,169.4,70,,169.4,percent of total billed charges,All Other,132.84,,,132.84,Fee Schedule,,112.59,,,112.59,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,179.33,
XR SKULL COMPLETE MIN 4 VIE,70260,CPT,TC,42070260,CDM,320,RC,,,both,,,330,244.2,,,244.2,Other,150% of Medicare + 9.63% HCRA Surcharge,148.5,45,,148.5,percent of total billed charges,Critical Access Hospital RCC factor,108.78,,,108.78,Fee Schedule,,97.87,,,97.87,Fee Schedule,,208.32,,,208.32,Fee Schedule,,187.37,,,187.37,Fee Schedule,,177.09,,,177.09,Fee Schedule,,163.35,,,163.35,Other,110% of Medicare,129.24,,,129.24,Fee Schedule,,53,,,53,Other,186% of Medicaid,152.09,,,152.09,Fee Schedule,,204.6,,,204.6,Fee Schedule,,71.61,,,71.61,Fee Schedule,,152.09,,,152.09,Fee Schedule,,204.6,,,204.6,Fee Schedule,,134.7,,,134.7,Fee Schedule,,231,70,,231,percent of total billed charges,All Other,154.16,,,154.16,Fee Schedule,,130.66,,,130.66,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,244.2,
TMJ JOINT - UNILATERAL,70328,CPT,TC,42070328,CDM,320,RC,,,both,,,649,480.26,,,480.26,Other,150% of Medicare + 9.63% HCRA Surcharge,292.05,45,,292.05,percent of total billed charges,Critical Access Hospital RCC factor,90.28,,,90.28,Fee Schedule,,81.22,,,81.22,Fee Schedule,,148.82,,,148.82,Fee Schedule,,133.86,,,133.86,Fee Schedule,,126.52,,,126.52,Fee Schedule,,321.26,,,321.26,Other,110% of Medicare,107.26,,,107.26,Fee Schedule,,53,,,53,Other,186% of Medicaid,126.22,,,126.22,Fee Schedule,,402.38,,,402.38,Fee Schedule,,59.43,,,59.43,Fee Schedule,,126.22,,,126.22,Fee Schedule,,402.38,,,402.38,Fee Schedule,,111.79,,,111.79,Fee Schedule,,454.3,70,,454.3,percent of total billed charges,All Other,127.92,,,127.92,Fee Schedule,,108.42,,,108.42,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,480.26,
XR TM JOINT BILATERAL,70330,CPT,TC,42070330,CDM,320,RC,,,both,,,288,213.12,,,213.12,Other,150% of Medicare + 9.63% HCRA Surcharge,129.6,45,,129.6,percent of total billed charges,Critical Access Hospital RCC factor,144.57,,,144.57,Fee Schedule,,130.07,,,130.07,Fee Schedule,,244.95,,,244.95,Fee Schedule,,220.32,,,220.32,Fee Schedule,,208.23,,,208.23,Fee Schedule,,142.56,,,142.56,Other,110% of Medicare,171.76,,,171.76,Fee Schedule,,53,,,53,Other,186% of Medicaid,202.13,,,202.13,Fee Schedule,,178.56,,,178.56,Fee Schedule,,95.17,,,95.17,Fee Schedule,,202.13,,,202.13,Fee Schedule,,178.56,,,178.56,Fee Schedule,,179.01,,,179.01,Fee Schedule,,201.6,70,,201.6,percent of total billed charges,All Other,206.64,,,206.64,Fee Schedule,,175.14,,,175.14,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,244.95,
XR NECK SOFT TISSUES,70360,CPT,TC,42070360,CDM,320,RC,,,both,,,231,170.94,,,170.94,Other,150% of Medicare + 9.63% HCRA Surcharge,103.95,45,,103.95,percent of total billed charges,Critical Access Hospital RCC factor,78.73,,,78.73,Fee Schedule,,70.83,,,70.83,Fee Schedule,,130.54,,,130.54,Fee Schedule,,117.41,,,117.41,Fee Schedule,,110.97,,,110.97,Fee Schedule,,114.35,,,114.35,Other,110% of Medicare,93.54,,,93.54,Fee Schedule,,53,,,53,Other,186% of Medicaid,110.07,,,110.07,Fee Schedule,,143.22,,,143.22,Fee Schedule,,51.83,,,51.83,Fee Schedule,,110.07,,,110.07,Fee Schedule,,143.22,,,143.22,Fee Schedule,,97.49,,,97.49,Fee Schedule,,161.7,70,,161.7,percent of total billed charges,All Other,111.52,,,111.52,Fee Schedule,,94.52,,,94.52,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,170.94,
SALIVARY GLAND CALCULUS,70380,CPT,TC,42070380,CDM,320,RC,,,both,,,624,461.76,,,461.76,Other,150% of Medicare + 9.63% HCRA Surcharge,280.8,45,,280.8,percent of total billed charges,Critical Access Hospital RCC factor,102.97,,,102.97,Fee Schedule,,92.64,,,92.64,Fee Schedule,,206.06,,,206.06,Fee Schedule,,185.33,,,185.33,Fee Schedule,,175.17,,,175.17,Fee Schedule,,308.88,,,308.88,Other,110% of Medicare,122.34,,,122.34,Fee Schedule,,53,,,53,Other,186% of Medicaid,143.97,,,143.97,Fee Schedule,,386.88,,,386.88,Fee Schedule,,67.79,,,67.79,Fee Schedule,,143.97,,,143.97,Fee Schedule,,386.88,,,386.88,Fee Schedule,,127.51,,,127.51,Fee Schedule,,436.8,70,,436.8,percent of total billed charges,All Other,145.96,,,145.96,Fee Schedule,,123.71,,,123.71,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,461.76,
SIALOGRAM,70390,CPT,TC,42070390,CDM,320,RC,,,both,,,894,661.56,,,661.56,Other,150% of Medicare + 9.63% HCRA Surcharge,402.3,45,,402.3,percent of total billed charges,Critical Access Hospital RCC factor,339.83,,,339.83,Fee Schedule,,305.74,,,305.74,Fee Schedule,,558.46,,,558.46,Fee Schedule,,502.3,,,502.3,Fee Schedule,,474.75,,,474.75,Fee Schedule,,442.53,,,442.53,Other,110% of Medicare,403.75,,,403.75,Fee Schedule,,392,,,392,Other,186% of Medicaid,475.12,,,475.12,Fee Schedule,,554.28,,,554.28,Fee Schedule,,223.71,,,223.71,Fee Schedule,,475.12,,,475.12,Fee Schedule,,554.28,,,554.28,Fee Schedule,,420.79,,,420.79,Fee Schedule,,625.8,70,,625.8,percent of total billed charges,All Other,503.48,,,503.48,Fee Schedule,,426.73,,,426.73,Fee Schedule,,372.86,,,372.86,Fee Schedule,,372.86,,,372.86,Fee Schedule,,372.86,,,372.86,Fee Schedule,,372.86,,,372.86,Fee Schedule,,210.57,,,210.57,Other,100% of Medicaid,210.57,,,210.57,Other,100% of Medicaid,210.57,,,210.57,Other,100% of Medicaid,210.57,,,210.57,Other,100% of Medicaid,473.77,,,473.77,Other,225% of Medicaid,322.17,,,322.17,Other,153% of Medicaid,473.77,,,473.77,Other,225% of Medicaid,294.79,,,294.79,Other,140% of Medicaid,473.77,,,473.77,Other,225% of Medicaid,547.47,,,547.47,Other,260% of Medicaid,682.23,,,682.23,Other,324% of Medicaid,452.72,,,452.72,Other,215% of Medicaid,452.72,,,452.72,Other,215% of Medicaid,263.21,,,263.21,Other,125% of Medicaid,210.57,682.23,
XR RIBS BILATERAL,71110,CPT,TC,42071110,CDM,320,RC,,,both,,,513,379.62,,,379.62,Other,150% of Medicare + 9.63% HCRA Surcharge,230.85,45,,230.85,percent of total billed charges,Critical Access Hospital RCC factor,105.3,,,105.3,Fee Schedule,,94.74,,,94.74,Fee Schedule,,187.77,,,187.77,Fee Schedule,,168.89,,,168.89,Fee Schedule,,159.62,,,159.62,Fee Schedule,,253.94,,,253.94,Other,110% of Medicare,125.11,,,125.11,Fee Schedule,,53,,,53,Other,186% of Medicaid,147.22,,,147.22,Fee Schedule,,318.06,,,318.06,Fee Schedule,,69.32,,,69.32,Fee Schedule,,147.22,,,147.22,Fee Schedule,,318.06,,,318.06,Fee Schedule,,130.39,,,130.39,Fee Schedule,,359.1,70,,359.1,percent of total billed charges,All Other,147.6,,,147.6,Fee Schedule,,125.1,,,125.1,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,379.62,
XR RIBS BILATERAL 4 VIEWS A,71111,CPT,TC,42071111,CDM,320,RC,,,both,,,548,405.52,,,405.52,Other,150% of Medicare + 9.63% HCRA Surcharge,246.6,45,,246.6,percent of total billed charges,Critical Access Hospital RCC factor,129.55,,,129.55,Fee Schedule,,116.55,,,116.55,Fee Schedule,,251.8,,,251.8,Fee Schedule,,226.48,,,226.48,Fee Schedule,,214.05,,,214.05,Fee Schedule,,271.26,,,271.26,Other,110% of Medicare,153.91,,,153.91,Fee Schedule,,53,,,53,Other,186% of Medicaid,181.12,,,181.12,Fee Schedule,,339.76,,,339.76,Fee Schedule,,85.28,,,85.28,Fee Schedule,,181.12,,,181.12,Fee Schedule,,339.76,,,339.76,Fee Schedule,,160.41,,,160.41,Fee Schedule,,383.6,70,,383.6,percent of total billed charges,All Other,183.68,,,183.68,Fee Schedule,,155.68,,,155.68,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,405.52,
XR OF STERNUM 2 VIEWS,71120,CPT,TC,42071120,CDM,320,RC,,,both,,,548,405.52,,,405.52,Other,150% of Medicare + 9.63% HCRA Surcharge,246.6,45,,246.6,percent of total billed charges,Critical Access Hospital RCC factor,84.5,,,84.5,Fee Schedule,,76.03,,,76.03,Fee Schedule,,151.14,,,151.14,Fee Schedule,,135.94,,,135.94,Fee Schedule,,128.49,,,128.49,Fee Schedule,,271.26,,,271.26,Other,110% of Medicare,100.4,,,100.4,Fee Schedule,,53,,,53,Other,186% of Medicaid,118.15,,,118.15,Fee Schedule,,339.76,,,339.76,Fee Schedule,,55.63,,,55.63,Fee Schedule,,118.15,,,118.15,Fee Schedule,,339.76,,,339.76,Fee Schedule,,104.64,,,104.64,Fee Schedule,,383.6,70,,383.6,percent of total billed charges,All Other,119.72,,,119.72,Fee Schedule,,101.47,,,101.47,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,405.52,
XR SPINE 1 VIEW,72020,CPT,TC,42072020,CDM,320,RC,,,both,,,433,320.42,,,320.42,Other,150% of Medicare + 9.63% HCRA Surcharge,194.85,45,,194.85,percent of total billed charges,Critical Access Hospital RCC factor,57.93,,,57.93,Fee Schedule,,52.12,,,52.12,Fee Schedule,,109.93,,,109.93,Fee Schedule,,98.88,,,98.88,Fee Schedule,,93.45,,,93.45,Fee Schedule,,214.34,,,214.34,Other,110% of Medicare,68.83,,,68.83,Fee Schedule,,53,,,53,Other,186% of Medicaid,80.99,,,80.99,Fee Schedule,,268.46,,,268.46,Fee Schedule,,38.14,,,38.14,Fee Schedule,,80.99,,,80.99,Fee Schedule,,268.46,,,268.46,Fee Schedule,,71.73,,,71.73,Fee Schedule,,303.1,70,,303.1,percent of total billed charges,All Other,82,,,82,Fee Schedule,,69.5,,,69.5,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,320.42,
XR CERVICAL SPINE 2-3 VIEWS,72040,CPT,TC,42072040,CDM,320,RC,,,both,,,481,355.94,,,355.94,Other,150% of Medicare + 9.63% HCRA Surcharge,216.45,45,,216.45,percent of total billed charges,Critical Access Hospital RCC factor,100.68,,,100.68,Fee Schedule,,90.58,,,90.58,Fee Schedule,,185.45,,,185.45,Fee Schedule,,166.8,,,166.8,Fee Schedule,,157.65,,,157.65,Fee Schedule,,238.1,,,238.1,Other,110% of Medicare,119.61,,,119.61,Fee Schedule,,53,,,53,Other,186% of Medicaid,140.76,,,140.76,Fee Schedule,,298.22,,,298.22,Fee Schedule,,66.28,,,66.28,Fee Schedule,,140.76,,,140.76,Fee Schedule,,298.22,,,298.22,Fee Schedule,,124.66,,,124.66,Fee Schedule,,336.7,70,,336.7,percent of total billed charges,All Other,141.04,,,141.04,Fee Schedule,,119.54,,,119.54,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,355.94,
XR CERVICAL SPINE 4 VIEWS,72050,CPT,TC,42072050,CDM,320,RC,,,both,,,525,388.5,,,388.5,Other,150% of Medicare + 9.63% HCRA Surcharge,236.25,45,,236.25,percent of total billed charges,Critical Access Hospital RCC factor,142.27,,,142.27,Fee Schedule,,128,,,128,Fee Schedule,,251.8,,,251.8,Fee Schedule,,226.48,,,226.48,Fee Schedule,,214.05,,,214.05,Fee Schedule,,259.88,,,259.88,Other,110% of Medicare,169.03,,,169.03,Fee Schedule,,53,,,53,Other,186% of Medicaid,198.92,,,198.92,Fee Schedule,,325.5,,,325.5,Fee Schedule,,93.66,,,93.66,Fee Schedule,,198.92,,,198.92,Fee Schedule,,325.5,,,325.5,Fee Schedule,,176.17,,,176.17,Fee Schedule,,367.5,70,,367.5,percent of total billed charges,All Other,196.8,,,196.8,Fee Schedule,,166.8,,,166.8,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,388.5,
XR CERVICAL SPINE COMP,72052,CPT,TC,42072052,CDM,320,RC,,,both,,,624,461.76,,,461.76,Other,150% of Medicare + 9.63% HCRA Surcharge,280.8,45,,280.8,percent of total billed charges,Critical Access Hospital RCC factor,167.7,,,167.7,Fee Schedule,,150.88,,,150.88,Fee Schedule,,331.9,,,331.9,Fee Schedule,,298.53,,,298.53,Fee Schedule,,282.15,,,282.15,Fee Schedule,,308.88,,,308.88,Other,110% of Medicare,199.24,,,199.24,Fee Schedule,,53,,,53,Other,186% of Medicaid,234.46,,,234.46,Fee Schedule,,386.88,,,386.88,Fee Schedule,,110.4,,,110.4,Fee Schedule,,234.46,,,234.46,Fee Schedule,,386.88,,,386.88,Fee Schedule,,207.65,,,207.65,Fee Schedule,,436.8,70,,436.8,percent of total billed charges,All Other,234.52,,,234.52,Fee Schedule,,198.77,,,198.77,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,461.76,
XR THORACIC SPINE 2 VIEWS,72070,CPT,TC,42072070,CDM,320,RC,,,both,,,587,434.38,,,434.38,Other,150% of Medicare + 9.63% HCRA Surcharge,264.15,45,,264.15,percent of total billed charges,Critical Access Hospital RCC factor,81.03,,,81.03,Fee Schedule,,72.9,,,72.9,Fee Schedule,,155.73,,,155.73,Fee Schedule,,140.07,,,140.07,Fee Schedule,,132.38,,,132.38,Fee Schedule,,290.57,,,290.57,Other,110% of Medicare,96.27,,,96.27,Fee Schedule,,53,,,53,Other,186% of Medicaid,113.28,,,113.28,Fee Schedule,,363.94,,,363.94,Fee Schedule,,53.34,,,53.34,Fee Schedule,,113.28,,,113.28,Fee Schedule,,363.94,,,363.94,Fee Schedule,,100.33,,,100.33,Fee Schedule,,410.9,70,,410.9,percent of total billed charges,All Other,113.16,,,113.16,Fee Schedule,,95.91,,,95.91,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,434.38,
XR THORACIC SPINE 3 VIEWS,72072,CPT,TC,42072072,CDM,320,RC,,,both,,,550,407,,,407,Other,150% of Medicare + 9.63% HCRA Surcharge,247.5,45,,247.5,percent of total billed charges,Critical Access Hospital RCC factor,100.68,,,100.68,Fee Schedule,,90.58,,,90.58,Fee Schedule,,183.19,,,183.19,Fee Schedule,,164.76,,,164.76,Fee Schedule,,155.72,,,155.72,Fee Schedule,,272.25,,,272.25,Other,110% of Medicare,119.61,,,119.61,Fee Schedule,,53,,,53,Other,186% of Medicaid,140.76,,,140.76,Fee Schedule,,341,,,341,Fee Schedule,,66.28,,,66.28,Fee Schedule,,140.76,,,140.76,Fee Schedule,,341,,,341,Fee Schedule,,124.66,,,124.66,Fee Schedule,,385,70,,385,percent of total billed charges,All Other,139.4,,,139.4,Fee Schedule,,118.15,,,118.15,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,407,
XR EXAM OF THORACIC SPINE 4+ VIEWS,72074,CPT,TC,42072074,CDM,320,RC,,,both,,,242,179.08,,,179.08,Other,150% of Medicare + 9.63% HCRA Surcharge,108.9,45,,108.9,percent of total billed charges,Critical Access Hospital RCC factor,114.55,,,114.55,Fee Schedule,,103.06,,,103.06,Fee Schedule,,228.93,,,228.93,Fee Schedule,,205.91,,,205.91,Fee Schedule,,194.61,,,194.61,Fee Schedule,,119.79,,,119.79,Other,110% of Medicare,136.1,,,136.1,Fee Schedule,,53,,,53,Other,186% of Medicaid,160.16,,,160.16,Fee Schedule,,150.04,,,150.04,Fee Schedule,,75.41,,,75.41,Fee Schedule,,160.16,,,160.16,Fee Schedule,,150.04,,,150.04,Fee Schedule,,141.84,,,141.84,Fee Schedule,,169.4,70,,169.4,percent of total billed charges,All Other,160.72,,,160.72,Fee Schedule,,136.22,,,136.22,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,228.93,
XR THORACOLUMBAR 2 VIEWS,72080,CPT,TC,42072080,CDM,320,RC,,,both,,,362,267.88,,,267.88,Other,150% of Medicare + 9.63% HCRA Surcharge,162.9,45,,162.9,percent of total billed charges,Critical Access Hospital RCC factor,85.65,,,85.65,Fee Schedule,,77.06,,,77.06,Fee Schedule,,169.43,,,169.43,Fee Schedule,,152.39,,,152.39,Fee Schedule,,144.03,,,144.03,Fee Schedule,,179.19,,,179.19,Other,110% of Medicare,101.76,,,101.76,Fee Schedule,,53,,,53,Other,186% of Medicaid,119.75,,,119.75,Fee Schedule,,224.44,,,224.44,Fee Schedule,,56.39,,,56.39,Fee Schedule,,119.75,,,119.75,Fee Schedule,,224.44,,,224.44,Fee Schedule,,106.06,,,106.06,Fee Schedule,,253.4,70,,253.4,percent of total billed charges,All Other,121.36,,,121.36,Fee Schedule,,102.86,,,102.86,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,267.88,
X-RAY EXAM ENTIRE SPI 1 VW,72081,CPT,TC,42072081,CDM,320,RC,,,both,,,204,150.96,,,150.96,Other,150% of Medicare + 9.63% HCRA Surcharge,91.8,45,,91.8,percent of total billed charges,Critical Access Hospital RCC factor,105.3,,,105.3,Fee Schedule,,94.74,,,94.74,Fee Schedule,,24.57,,,24.57,Fee Schedule,,24.57,,,24.57,Fee Schedule,,24.57,,,24.57,Fee Schedule,,100.98,,,100.98,Other,110% of Medicare,125.11,,,125.11,Fee Schedule,,53,,,53,Other,186% of Medicaid,147.22,,,147.22,Fee Schedule,,126.48,,,126.48,Fee Schedule,,69.32,,,69.32,Fee Schedule,,147.22,,,147.22,Fee Schedule,,126.48,,,126.48,Fee Schedule,,130.39,,,130.39,Fee Schedule,,142.8,70,,142.8,percent of total billed charges,All Other,147.6,,,147.6,Fee Schedule,,125.1,,,125.1,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,24.57,150.96,
X-RAY EXAM ENTIRE SPI 2/3 VW,72082,CPT,TC,42072082,CDM,320,RC,,,both,,,351,259.74,,,259.74,Other,150% of Medicare + 9.63% HCRA Surcharge,157.95,45,,157.95,percent of total billed charges,Critical Access Hospital RCC factor,191.94,,,191.94,Fee Schedule,,172.69,,,172.69,Fee Schedule,,44.99,,,44.99,Fee Schedule,,44.99,,,44.99,Fee Schedule,,44.99,,,44.99,Fee Schedule,,173.75,,,173.75,Other,110% of Medicare,228.04,,,228.04,Fee Schedule,,53,,,53,Other,186% of Medicaid,268.36,,,268.36,Fee Schedule,,217.62,,,217.62,Fee Schedule,,126.36,,,126.36,Fee Schedule,,268.36,,,268.36,Fee Schedule,,217.62,,,217.62,Fee Schedule,,237.67,,,237.67,Fee Schedule,,245.7,70,,245.7,percent of total billed charges,All Other,270.6,,,270.6,Fee Schedule,,229.35,,,229.35,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,270.6,
X-RAY EXAM ENTIRE SPI 4/5 VW,72083,CPT,TC,42072083,CDM,320,RC,,,both,,,638,472.12,,,472.12,Other,150% of Medicare + 9.63% HCRA Surcharge,287.1,45,,287.1,percent of total billed charges,Critical Access Hospital RCC factor,217.37,,,217.37,Fee Schedule,,195.56,,,195.56,Fee Schedule,,55.38,,,55.38,Fee Schedule,,55.38,,,55.38,Fee Schedule,,55.38,,,55.38,Fee Schedule,,315.81,,,315.81,Other,110% of Medicare,258.25,,,258.25,Fee Schedule,,53,,,53,Other,186% of Medicaid,303.9,,,303.9,Fee Schedule,,395.56,,,395.56,Fee Schedule,,143.09,,,143.09,Fee Schedule,,303.9,,,303.9,Fee Schedule,,395.56,,,395.56,Fee Schedule,,269.15,,,269.15,Fee Schedule,,446.6,70,,446.6,percent of total billed charges,All Other,301.76,,,301.76,Fee Schedule,,255.76,,,255.76,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,472.12,
X-RAY EXAM ENTIRE SPI 6/> VW,72084,CPT,TC,42072084,CDM,320,RC,,,both,,,638,472.12,,,472.12,Other,150% of Medicare + 9.63% HCRA Surcharge,287.1,45,,287.1,percent of total billed charges,Critical Access Hospital RCC factor,274.15,,,274.15,Fee Schedule,,246.65,,,246.65,Fee Schedule,,64.37,,,64.37,Fee Schedule,,64.37,,,64.37,Fee Schedule,,64.37,,,64.37,Fee Schedule,,315.81,,,315.81,Other,110% of Medicare,325.71,,,325.71,Fee Schedule,,53,,,53,Other,186% of Medicaid,383.29,,,383.29,Fee Schedule,,395.56,,,395.56,Fee Schedule,,180.47,,,180.47,Fee Schedule,,383.29,,,383.29,Fee Schedule,,395.56,,,395.56,Fee Schedule,,339.46,,,339.46,Fee Schedule,,446.6,70,,446.6,percent of total billed charges,All Other,385.4,,,385.4,Fee Schedule,,326.65,,,326.65,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,472.12,
XRLUMBAR SPINE 2 VIEWS,72100,CPT,TC,42072100,CDM,320,RC,,,both,,,494,365.56,,,365.56,Other,150% of Medicare + 9.63% HCRA Surcharge,222.3,45,,222.3,percent of total billed charges,Critical Access Hospital RCC factor,101.82,,,101.82,Fee Schedule,,91.61,,,91.61,Fee Schedule,,196.89,,,196.89,Fee Schedule,,177.09,,,177.09,Fee Schedule,,167.37,,,167.37,Fee Schedule,,244.53,,,244.53,Other,110% of Medicare,120.98,,,120.98,Fee Schedule,,53,,,53,Other,186% of Medicaid,142.36,,,142.36,Fee Schedule,,306.28,,,306.28,Fee Schedule,,67.03,,,67.03,Fee Schedule,,142.36,,,142.36,Fee Schedule,,306.28,,,306.28,Fee Schedule,,126.08,,,126.08,Fee Schedule,,345.8,70,,345.8,percent of total billed charges,All Other,142.68,,,142.68,Fee Schedule,,120.93,,,120.93,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,365.56,
XR LUMBAR SPINE COMPLETE,72110,CPT,TC,42072110,CDM,320,RC,,,both,,,695,514.3,,,514.3,Other,150% of Medicare + 9.63% HCRA Surcharge,312.75,45,,312.75,percent of total billed charges,Critical Access Hospital RCC factor,137.65,,,137.65,Fee Schedule,,123.84,,,123.84,Fee Schedule,,270.14,,,270.14,Fee Schedule,,242.97,,,242.97,Fee Schedule,,229.64,,,229.64,Fee Schedule,,344.03,,,344.03,Other,110% of Medicare,163.54,,,163.54,Fee Schedule,,53,,,53,Other,186% of Medicaid,192.45,,,192.45,Fee Schedule,,430.9,,,430.9,Fee Schedule,,90.62,,,90.62,Fee Schedule,,192.45,,,192.45,Fee Schedule,,430.9,,,430.9,Fee Schedule,,170.44,,,170.44,Fee Schedule,,486.5,70,,486.5,percent of total billed charges,All Other,190.24,,,190.24,Fee Schedule,,161.24,,,161.24,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,514.3,
XR LUMBAR SPINE COMP W FLEX,72114,CPT,TC,42072114,CDM,320,RC,,,both,,,867,641.58,,,641.58,Other,150% of Medicare + 9.63% HCRA Surcharge,390.15,45,,390.15,percent of total billed charges,Critical Access Hospital RCC factor,163.07,,,163.07,Fee Schedule,,146.71,,,146.71,Fee Schedule,,377.7,,,377.7,Fee Schedule,,339.72,,,339.72,Fee Schedule,,321.08,,,321.08,Fee Schedule,,429.17,,,429.17,Other,110% of Medicare,193.74,,,193.74,Fee Schedule,,53,,,53,Other,186% of Medicaid,228,,,228,Fee Schedule,,537.54,,,537.54,Fee Schedule,,107.35,,,107.35,Fee Schedule,,228,,,228,Fee Schedule,,537.54,,,537.54,Fee Schedule,,201.92,,,201.92,Fee Schedule,,606.9,70,,606.9,percent of total billed charges,All Other,232.88,,,232.88,Fee Schedule,,197.38,,,197.38,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,641.58,
XR EXAM OF LOWER SPINE,72120,CPT,TC,42072120,CDM,320,RC,,,both,,,706,522.44,,,522.44,Other,150% of Medicare + 9.63% HCRA Surcharge,317.7,45,,317.7,percent of total billed charges,Critical Access Hospital RCC factor,104.15,,,104.15,Fee Schedule,,93.71,,,93.71,Fee Schedule,,270.14,,,270.14,Fee Schedule,,242.97,,,242.97,Fee Schedule,,229.64,,,229.64,Fee Schedule,,349.47,,,349.47,Other,110% of Medicare,123.74,,,123.74,Fee Schedule,,53,,,53,Other,186% of Medicaid,145.62,,,145.62,Fee Schedule,,437.72,,,437.72,Fee Schedule,,68.57,,,68.57,Fee Schedule,,145.62,,,145.62,Fee Schedule,,437.72,,,437.72,Fee Schedule,,128.97,,,128.97,Fee Schedule,,494.2,70,,494.2,percent of total billed charges,All Other,147.6,,,147.6,Fee Schedule,,125.1,,,125.1,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,522.44,
XR PELVIS 1 VIEW,72170,CPT,TC,42072170,CDM,320,RC,,,both,,,392,290.08,,,290.08,Other,150% of Medicare + 9.63% HCRA Surcharge,176.4,45,,176.4,percent of total billed charges,Critical Access Hospital RCC factor,68.33,,,68.33,Fee Schedule,,61.48,,,61.48,Fee Schedule,,121.37,,,121.37,Fee Schedule,,109.16,,,109.16,Fee Schedule,,103.17,,,103.17,Fee Schedule,,194.04,,,194.04,Other,110% of Medicare,81.18,,,81.18,Fee Schedule,,53,,,53,Other,186% of Medicaid,95.53,,,95.53,Fee Schedule,,243.04,,,243.04,Fee Schedule,,44.98,,,44.98,Fee Schedule,,95.53,,,95.53,Fee Schedule,,243.04,,,243.04,Fee Schedule,,84.61,,,84.61,Fee Schedule,,274.4,70,,274.4,percent of total billed charges,All Other,95.12,,,95.12,Fee Schedule,,80.62,,,80.62,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,290.08,
XR EXAM OF PELVIS 3+ VIEWS,72190,CPT,TC,42072190,CDM,320,RC,,,both,,,605,447.7,,,447.7,Other,150% of Medicare + 9.63% HCRA Surcharge,272.25,45,,272.25,percent of total billed charges,Critical Access Hospital RCC factor,105.3,,,105.3,Fee Schedule,,94.74,,,94.74,Fee Schedule,,208.32,,,208.32,Fee Schedule,,187.37,,,187.37,Fee Schedule,,177.09,,,177.09,Fee Schedule,,299.48,,,299.48,Other,110% of Medicare,125.11,,,125.11,Fee Schedule,,53,,,53,Other,186% of Medicaid,147.22,,,147.22,Fee Schedule,,375.1,,,375.1,Fee Schedule,,69.32,,,69.32,Fee Schedule,,147.22,,,147.22,Fee Schedule,,375.1,,,375.1,Fee Schedule,,130.39,,,130.39,Fee Schedule,,423.5,70,,423.5,percent of total billed charges,All Other,147.6,,,147.6,Fee Schedule,,125.1,,,125.1,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,447.7,
XR SACROILIAC JTS 1 OR 2 VI,72200,CPT,TC,42072200,CDM,320,RC,,,both,,,242,179.08,,,179.08,Other,150% of Medicare + 9.63% HCRA Surcharge,108.9,45,,108.9,percent of total billed charges,Critical Access Hospital RCC factor,87.98,,,87.98,Fee Schedule,,79.15,,,79.15,Fee Schedule,,144.29,,,144.29,Fee Schedule,,129.78,,,129.78,Fee Schedule,,122.66,,,122.66,Fee Schedule,,119.79,,,119.79,Other,110% of Medicare,104.53,,,104.53,Fee Schedule,,53,,,53,Other,186% of Medicaid,123.01,,,123.01,Fee Schedule,,150.04,,,150.04,Fee Schedule,,57.92,,,57.92,Fee Schedule,,123.01,,,123.01,Fee Schedule,,150.04,,,150.04,Fee Schedule,,108.94,,,108.94,Fee Schedule,,169.4,70,,169.4,percent of total billed charges,All Other,121.36,,,121.36,Fee Schedule,,102.86,,,102.86,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,179.33,
XR SACROILIAC JOINTS 3 VIEW,72202,CPT,TC,42072202,CDM,320,RC,,,both,,,242,179.08,,,179.08,Other,150% of Medicare + 9.63% HCRA Surcharge,108.9,45,,108.9,percent of total billed charges,Critical Access Hospital RCC factor,99.53,,,99.53,Fee Schedule,,89.54,,,89.54,Fee Schedule,,171.75,,,171.75,Fee Schedule,,154.48,,,154.48,Fee Schedule,,146,,,146,Fee Schedule,,119.79,,,119.79,Other,110% of Medicare,118.25,,,118.25,Fee Schedule,,53,,,53,Other,186% of Medicaid,139.15,,,139.15,Fee Schedule,,150.04,,,150.04,Fee Schedule,,65.52,,,65.52,Fee Schedule,,139.15,,,139.15,Fee Schedule,,150.04,,,150.04,Fee Schedule,,123.24,,,123.24,Fee Schedule,,169.4,70,,169.4,percent of total billed charges,All Other,139.4,,,139.4,Fee Schedule,,118.15,,,118.15,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,179.33,
XR SACRUM & COCCYX 2 VIEWS,72220,CPT,TC,42072220,CDM,320,RC,,,both,,,437,323.38,,,323.38,Other,150% of Medicare + 9.63% HCRA Surcharge,196.65,45,,196.65,percent of total billed charges,Critical Access Hospital RCC factor,84.5,,,84.5,Fee Schedule,,76.03,,,76.03,Fee Schedule,,141.97,,,141.97,Fee Schedule,,127.7,,,127.7,Fee Schedule,,120.69,,,120.69,Fee Schedule,,216.32,,,216.32,Other,110% of Medicare,100.4,,,100.4,Fee Schedule,,53,,,53,Other,186% of Medicaid,118.15,,,118.15,Fee Schedule,,270.94,,,270.94,Fee Schedule,,55.63,,,55.63,Fee Schedule,,118.15,,,118.15,Fee Schedule,,270.94,,,270.94,Fee Schedule,,104.64,,,104.64,Fee Schedule,,305.9,70,,305.9,percent of total billed charges,All Other,118.08,,,118.08,Fee Schedule,,100.08,,,100.08,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,323.38,
MYELOGRAM CERVICAL,72240,CPT,TC,42072240,CDM,320,RC,,,both,,,1939,1434.86,,,1434.86,Other,150% of Medicare + 9.63% HCRA Surcharge,872.55,45,,872.55,percent of total billed charges,Critical Access Hospital RCC factor,239.31,,,239.31,Fee Schedule,,215.31,,,215.31,Fee Schedule,,672.87,,,672.87,Fee Schedule,,605.2,,,605.2,Fee Schedule,,572.01,,,572.01,Fee Schedule,,959.81,,,959.81,Other,110% of Medicare,284.33,,,284.33,Fee Schedule,,914,,,914,Other,186% of Medicaid,334.59,,,334.59,Fee Schedule,,1202.18,,,1202.18,Fee Schedule,,157.54,,,157.54,Fee Schedule,,334.59,,,334.59,Fee Schedule,,1202.18,,,1202.18,Fee Schedule,,296.33,,,296.33,Fee Schedule,,1357.3,70,,1357.3,percent of total billed charges,All Other,354.24,,,354.24,Fee Schedule,,300.24,,,300.24,Fee Schedule,,1089.31,,,1089.31,Fee Schedule,,1089.31,,,1089.31,Fee Schedule,,1089.31,,,1089.31,Fee Schedule,,1089.31,,,1089.31,Fee Schedule,,491.65,,,491.65,Other,100% of Medicaid,491.65,,,491.65,Other,100% of Medicaid,491.65,,,491.65,Other,100% of Medicaid,491.65,,,491.65,Other,100% of Medicaid,1106.21,,,1106.21,Other,225% of Medicaid,752.22,,,752.22,Other,153% of Medicaid,1106.21,,,1106.21,Other,225% of Medicaid,688.31,,,688.31,Other,140% of Medicaid,1106.21,,,1106.21,Other,225% of Medicaid,1278.28,,,1278.28,Other,260% of Medicaid,1592.94,,,1592.94,Other,324% of Medicaid,1057.04,,,1057.04,Other,215% of Medicaid,1057.04,,,1057.04,Other,215% of Medicaid,614.56,,,614.56,Other,125% of Medicaid,157.54,1592.94,
MYELOGRAM THORACIC,72255,CPT,TC,42072255,CDM,320,RC,,,both,,,1939,1434.86,,,1434.86,Other,150% of Medicare + 9.63% HCRA Surcharge,872.55,45,,872.55,percent of total billed charges,Critical Access Hospital RCC factor,225.44,,,225.44,Fee Schedule,,202.82,,,202.82,Fee Schedule,,617.96,,,617.96,Fee Schedule,,555.81,,,555.81,Fee Schedule,,525.32,,,525.32,Fee Schedule,,959.81,,,959.81,Other,110% of Medicare,267.84,,,267.84,Fee Schedule,,914,,,914,Other,186% of Medicaid,315.19,,,315.19,Fee Schedule,,1202.18,,,1202.18,Fee Schedule,,148.41,,,148.41,Fee Schedule,,315.19,,,315.19,Fee Schedule,,1202.18,,,1202.18,Fee Schedule,,279.15,,,279.15,Fee Schedule,,1357.3,70,,1357.3,percent of total billed charges,All Other,360.8,,,360.8,Fee Schedule,,305.8,,,305.8,Fee Schedule,,1089.31,,,1089.31,Fee Schedule,,1089.31,,,1089.31,Fee Schedule,,1089.31,,,1089.31,Fee Schedule,,1089.31,,,1089.31,Fee Schedule,,491.65,,,491.65,Other,100% of Medicaid,491.65,,,491.65,Other,100% of Medicaid,491.65,,,491.65,Other,100% of Medicaid,491.65,,,491.65,Other,100% of Medicaid,1106.21,,,1106.21,Other,225% of Medicaid,752.22,,,752.22,Other,153% of Medicaid,1106.21,,,1106.21,Other,225% of Medicaid,688.31,,,688.31,Other,140% of Medicaid,1106.21,,,1106.21,Other,225% of Medicaid,1278.28,,,1278.28,Other,260% of Medicaid,1592.94,,,1592.94,Other,324% of Medicaid,1057.04,,,1057.04,Other,215% of Medicaid,1057.04,,,1057.04,Other,215% of Medicaid,614.56,,,614.56,Other,125% of Medicaid,148.41,1592.94,
MYELOGRAM LUMBOSACRAL,72265,CPT,TC,42072265,CDM,320,RC,,,both,,,2536,1876.65,,,1876.65,Other,150% of Medicare + 9.63% HCRA Surcharge,1141.2,45,,1141.2,percent of total billed charges,Critical Access Hospital RCC factor,241.61,,,241.61,Fee Schedule,,217.37,,,217.37,Fee Schedule,,654.59,,,654.59,Fee Schedule,,588.76,,,588.76,Fee Schedule,,556.46,,,556.46,Fee Schedule,,1255.32,,,1255.32,Other,110% of Medicare,287.05,,,287.05,Fee Schedule,,914,,,914,Other,186% of Medicaid,337.8,,,337.8,Fee Schedule,,1572.32,,,1572.32,Fee Schedule,,159.05,,,159.05,Fee Schedule,,337.8,,,337.8,Fee Schedule,,1572.32,,,1572.32,Fee Schedule,,299.17,,,299.17,Fee Schedule,,1775.2,70,,1775.2,percent of total billed charges,All Other,346.04,,,346.04,Fee Schedule,,293.29,,,293.29,Fee Schedule,,1089.31,,,1089.31,Fee Schedule,,1089.31,,,1089.31,Fee Schedule,,1089.31,,,1089.31,Fee Schedule,,1089.31,,,1089.31,Fee Schedule,,491.65,,,491.65,Other,100% of Medicaid,491.65,,,491.65,Other,100% of Medicaid,491.65,,,491.65,Other,100% of Medicaid,491.65,,,491.65,Other,100% of Medicaid,1106.21,,,1106.21,Other,225% of Medicaid,752.22,,,752.22,Other,153% of Medicaid,1106.21,,,1106.21,Other,225% of Medicaid,688.31,,,688.31,Other,140% of Medicaid,1106.21,,,1106.21,Other,225% of Medicaid,1278.28,,,1278.28,Other,260% of Medicaid,1592.94,,,1592.94,Other,324% of Medicaid,1057.04,,,1057.04,Other,215% of Medicaid,1057.04,,,1057.04,Other,215% of Medicaid,614.56,,,614.56,Other,125% of Medicaid,159.05,1876.65,
X-RAY C/T SPINE DISK,72285,CPT,TC,42072285,CDM,320,RC,,,both,,,4047,2994.79,,,2994.79,Other,150% of Medicare + 9.63% HCRA Surcharge,1821.15,45,,1821.15,percent of total billed charges,Critical Access Hospital RCC factor,267.03,,,267.03,Fee Schedule,,240.25,,,240.25,Fee Schedule,,604.21,,,604.21,Fee Schedule,,543.44,,,543.44,Fee Schedule,,513.63,,,513.63,Fee Schedule,,2003.27,,,2003.27,Other,110% of Medicare,317.26,,,317.26,Fee Schedule,,914,,,914,Other,186% of Medicaid,373.35,,,373.35,Fee Schedule,,2509.14,,,2509.14,Fee Schedule,,175.79,,,175.79,Fee Schedule,,373.35,,,373.35,Fee Schedule,,2509.14,,,2509.14,Fee Schedule,,330.65,,,330.65,Fee Schedule,,2832.9,70,,2832.9,percent of total billed charges,All Other,350.96,,,350.96,Fee Schedule,,297.46,,,297.46,Fee Schedule,,2750.96,,,2750.96,Fee Schedule,,2750.96,,,2750.96,Fee Schedule,,2750.96,,,2750.96,Fee Schedule,,2750.96,,,2750.96,Fee Schedule,,491.65,,,491.65,Other,100% of Medicaid,491.65,,,491.65,Other,100% of Medicaid,491.65,,,491.65,Other,100% of Medicaid,491.65,,,491.65,Other,100% of Medicaid,1106.21,,,1106.21,Other,225% of Medicaid,752.22,,,752.22,Other,153% of Medicaid,1106.21,,,1106.21,Other,225% of Medicaid,688.31,,,688.31,Other,140% of Medicaid,1106.21,,,1106.21,Other,225% of Medicaid,1278.28,,,1278.28,Other,260% of Medicaid,1592.94,,,1592.94,Other,324% of Medicaid,1057.04,,,1057.04,Other,215% of Medicaid,1057.04,,,1057.04,Other,215% of Medicaid,614.56,,,614.56,Other,125% of Medicaid,175.79,2994.79,
XR OF LOWER SPINE DISK,72295,CPT,TC,42072295,CDM,320,RC,,,both,,,6489,4801.88,,,4801.88,Other,150% of Medicare + 9.63% HCRA Surcharge,2920.05,45,,2920.05,percent of total billed charges,Critical Access Hospital RCC factor,250.86,,,250.86,Fee Schedule,,225.7,,,225.7,Fee Schedule,,595.09,,,595.09,Fee Schedule,,535.24,,,535.24,Fee Schedule,,505.88,,,505.88,Fee Schedule,,3212.06,,,3212.06,Other,110% of Medicare,298.05,,,298.05,Fee Schedule,,914,,,914,Other,186% of Medicaid,350.73,,,350.73,Fee Schedule,,4023.18,,,4023.18,Fee Schedule,,165.14,,,165.14,Fee Schedule,,350.73,,,350.73,Fee Schedule,,4023.18,,,4023.18,Fee Schedule,,310.63,,,310.63,Fee Schedule,,4542.3,70,,4542.3,percent of total billed charges,All Other,355.88,,,355.88,Fee Schedule,,301.63,,,301.63,Fee Schedule,,2750.96,,,2750.96,Fee Schedule,,2750.96,,,2750.96,Fee Schedule,,2750.96,,,2750.96,Fee Schedule,,2750.96,,,2750.96,Fee Schedule,,491.65,,,491.65,Other,100% of Medicaid,491.65,,,491.65,Other,100% of Medicaid,491.65,,,491.65,Other,100% of Medicaid,491.65,,,491.65,Other,100% of Medicaid,1106.21,,,1106.21,Other,225% of Medicaid,752.22,,,752.22,Other,153% of Medicaid,1106.21,,,1106.21,Other,225% of Medicaid,688.31,,,688.31,Other,140% of Medicaid,1106.21,,,1106.21,Other,225% of Medicaid,1278.28,,,1278.28,Other,260% of Medicaid,1592.94,,,1592.94,Other,324% of Medicaid,1057.04,,,1057.04,Other,215% of Medicaid,1057.04,,,1057.04,Other,215% of Medicaid,614.56,,,614.56,Other,125% of Medicaid,165.14,4801.88,
XR EXAM OF SHOULDER 1 VIEW,73020,CPT,TC,42073020,CDM,320,RC,,,both,,,231,170.94,,,170.94,Other,150% of Medicare + 9.63% HCRA Surcharge,103.95,45,,103.95,percent of total billed charges,Critical Access Hospital RCC factor,49.86,,,49.86,Fee Schedule,,44.86,,,44.86,Fee Schedule,,109.93,,,109.93,Fee Schedule,,98.88,,,98.88,Fee Schedule,,93.45,,,93.45,Fee Schedule,,114.35,,,114.35,Other,110% of Medicare,59.24,,,59.24,Fee Schedule,,53,,,53,Other,186% of Medicaid,69.71,,,69.71,Fee Schedule,,143.22,,,143.22,Fee Schedule,,32.82,,,32.82,Fee Schedule,,69.71,,,69.71,Fee Schedule,,143.22,,,143.22,Fee Schedule,,61.74,,,61.74,Fee Schedule,,161.7,70,,161.7,percent of total billed charges,All Other,68.88,,,68.88,Fee Schedule,,58.38,,,58.38,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,170.94,
ACJ BILATERAL W/WO WEIGHTS,73050,CPT,TC,42073050,CDM,320,RC,,,both,,,606,448.44,,,448.44,Other,150% of Medicare + 9.63% HCRA Surcharge,272.7,45,,272.7,percent of total billed charges,Critical Access Hospital RCC factor,69.48,,,69.48,Fee Schedule,,62.51,,,62.51,Fee Schedule,,185.45,,,185.45,Fee Schedule,,166.8,,,166.8,Fee Schedule,,157.65,,,157.65,Fee Schedule,,299.97,,,299.97,Other,110% of Medicare,82.55,,,82.55,Fee Schedule,,53,,,53,Other,186% of Medicaid,97.14,,,97.14,Fee Schedule,,375.72,,,375.72,Fee Schedule,,45.74,,,45.74,Fee Schedule,,97.14,,,97.14,Fee Schedule,,375.72,,,375.72,Fee Schedule,,86.03,,,86.03,Fee Schedule,,424.2,70,,424.2,percent of total billed charges,All Other,95.12,,,95.12,Fee Schedule,,80.62,,,80.62,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,448.44,
XR EXAM OF ELBOW 2 VIEWS,73070,CPT,TC,42073070,CDM,320,RC,,,both,,,231,170.94,,,170.94,Other,150% of Medicare + 9.63% HCRA Surcharge,103.95,45,,103.95,percent of total billed charges,Critical Access Hospital RCC factor,74.1,,,74.1,Fee Schedule,,66.67,,,66.67,Fee Schedule,,139.71,,,139.71,Fee Schedule,,125.66,,,125.66,Fee Schedule,,118.76,,,118.76,Fee Schedule,,114.35,,,114.35,Other,110% of Medicare,88.04,,,88.04,Fee Schedule,,53,,,53,Other,186% of Medicaid,103.61,,,103.61,Fee Schedule,,143.22,,,143.22,Fee Schedule,,48.78,,,48.78,Fee Schedule,,103.61,,,103.61,Fee Schedule,,143.22,,,143.22,Fee Schedule,,91.76,,,91.76,Fee Schedule,,161.7,70,,161.7,percent of total billed charges,All Other,103.32,,,103.32,Fee Schedule,,87.57,,,87.57,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,170.94,
XR EXAM OF WRIST 2 VIEWS,73100,CPT,TC,42073100,CDM,320,RC,,,both,,,231,170.94,,,170.94,Other,150% of Medicare + 9.63% HCRA Surcharge,103.95,45,,103.95,percent of total billed charges,Critical Access Hospital RCC factor,90.28,,,90.28,Fee Schedule,,81.22,,,81.22,Fee Schedule,,148.82,,,148.82,Fee Schedule,,133.86,,,133.86,Fee Schedule,,126.52,,,126.52,Fee Schedule,,114.35,,,114.35,Other,110% of Medicare,107.26,,,107.26,Fee Schedule,,53,,,53,Other,186% of Medicaid,126.22,,,126.22,Fee Schedule,,143.22,,,143.22,Fee Schedule,,59.43,,,59.43,Fee Schedule,,126.22,,,126.22,Fee Schedule,,143.22,,,143.22,Fee Schedule,,111.79,,,111.79,Fee Schedule,,161.7,70,,161.7,percent of total billed charges,All Other,126.28,,,126.28,Fee Schedule,,107.03,,,107.03,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,170.94,
X-RAY EXAM HIPS BI 2 VIEWS,73521,CPT,TC,42073521,CDM,320,RC,,,both,,,392,290.08,,,290.08,Other,150% of Medicare + 9.63% HCRA Surcharge,176.4,45,,176.4,percent of total billed charges,Critical Access Hospital RCC factor,106.45,,,106.45,Fee Schedule,,95.77,,,95.77,Fee Schedule,,25.61,,,25.61,Fee Schedule,,25.61,,,25.61,Fee Schedule,,25.61,,,25.61,Fee Schedule,,194.04,,,194.04,Other,110% of Medicare,126.47,,,126.47,Fee Schedule,,53,,,53,Other,186% of Medicaid,148.83,,,148.83,Fee Schedule,,243.04,,,243.04,Fee Schedule,,70.08,,,70.08,Fee Schedule,,148.83,,,148.83,Fee Schedule,,243.04,,,243.04,Fee Schedule,,131.81,,,131.81,Fee Schedule,,274.4,70,,274.4,percent of total billed charges,All Other,149.24,,,149.24,Fee Schedule,,126.49,,,126.49,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,25.61,290.08,
X-RAY EXAM HIPS BI 3-4 VIEWS,73522,CPT,TC,42073522,CDM,320,RC,,,both,,,336,248.64,,,248.64,Other,150% of Medicare + 9.63% HCRA Surcharge,151.2,45,,151.2,percent of total billed charges,Critical Access Hospital RCC factor,138.8,,,138.8,Fee Schedule,,124.87,,,124.87,Fee Schedule,,32.88,,,32.88,Fee Schedule,,32.88,,,32.88,Fee Schedule,,32.88,,,32.88,Fee Schedule,,166.32,,,166.32,Other,110% of Medicare,164.9,,,164.9,Fee Schedule,,53,,,53,Other,186% of Medicaid,194.05,,,194.05,Fee Schedule,,208.32,,,208.32,Fee Schedule,,91.37,,,91.37,Fee Schedule,,194.05,,,194.05,Fee Schedule,,208.32,,,208.32,Fee Schedule,,171.86,,,171.86,Fee Schedule,,235.2,70,,235.2,percent of total billed charges,All Other,193.52,,,193.52,Fee Schedule,,164.02,,,164.02,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,248.64,
X-RAY EXAM HIPS BI 5/> VIEWS,73523,CPT,TC,42073523,CDM,320,RC,,,both,,,638,472.12,,,472.12,Other,150% of Medicare + 9.63% HCRA Surcharge,287.1,45,,287.1,percent of total billed charges,Critical Access Hospital RCC factor,163.07,,,163.07,Fee Schedule,,146.71,,,146.71,Fee Schedule,,39.46,,,39.46,Fee Schedule,,39.46,,,39.46,Fee Schedule,,39.46,,,39.46,Fee Schedule,,315.81,,,315.81,Other,110% of Medicare,193.74,,,193.74,Fee Schedule,,53,,,53,Other,186% of Medicaid,228,,,228,Fee Schedule,,395.56,,,395.56,Fee Schedule,,107.35,,,107.35,Fee Schedule,,228,,,228,Fee Schedule,,395.56,,,395.56,Fee Schedule,,201.92,,,201.92,Fee Schedule,,446.6,70,,446.6,percent of total billed charges,All Other,227.96,,,227.96,Fee Schedule,,193.21,,,193.21,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,472.12,
XR EXAM OF KNEE 1 OR 2 VIEW,73560,CPT,TC,42073560,CDM,320,RC,,,both,,,407,301.18,,,301.18,Other,150% of Medicare + 9.63% HCRA Surcharge,183.15,45,,183.15,percent of total billed charges,Critical Access Hospital RCC factor,91.43,,,91.43,Fee Schedule,,82.25,,,82.25,Fee Schedule,,144.29,,,144.29,Fee Schedule,,129.78,,,129.78,Fee Schedule,,122.66,,,122.66,Fee Schedule,,201.47,,,201.47,Other,110% of Medicare,108.62,,,108.62,Fee Schedule,,53,,,53,Other,186% of Medicaid,127.82,,,127.82,Fee Schedule,,252.34,,,252.34,Fee Schedule,,60.19,,,60.19,Fee Schedule,,127.82,,,127.82,Fee Schedule,,252.34,,,252.34,Fee Schedule,,113.21,,,113.21,Fee Schedule,,284.9,70,,284.9,percent of total billed charges,All Other,127.92,,,127.92,Fee Schedule,,108.42,,,108.42,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,301.18,
XR BOTH KNEES STANDING AP,73565,CPT,TC,42073565,CDM,320,RC,,,both,,,566,418.84,,,418.84,Other,150% of Medicare + 9.63% HCRA Surcharge,254.7,45,,254.7,percent of total billed charges,Critical Access Hospital RCC factor,111.08,,,111.08,Fee Schedule,,99.93,,,99.93,Fee Schedule,,164.85,,,164.85,Fee Schedule,,148.27,,,148.27,Fee Schedule,,140.13,,,140.13,Fee Schedule,,280.17,,,280.17,Other,110% of Medicare,131.97,,,131.97,Fee Schedule,,53,,,53,Other,186% of Medicaid,155.3,,,155.3,Fee Schedule,,350.92,,,350.92,Fee Schedule,,73.12,,,73.12,Fee Schedule,,155.3,,,155.3,Fee Schedule,,350.92,,,350.92,Fee Schedule,,137.54,,,137.54,Fee Schedule,,396.2,70,,396.2,percent of total billed charges,All Other,157.44,,,157.44,Fee Schedule,,133.44,,,133.44,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,418.84,
XR EXAM OF LOWER LEG 2 VIEW,73590,CPT,TC,42073590,CDM,320,RC,,,both,,,373,276.02,,,276.02,Other,150% of Medicare + 9.63% HCRA Surcharge,167.85,45,,167.85,percent of total billed charges,Critical Access Hospital RCC factor,83.35,,,83.35,Fee Schedule,,74.99,,,74.99,Fee Schedule,,130.54,,,130.54,Fee Schedule,,117.41,,,117.41,Fee Schedule,,110.97,,,110.97,Fee Schedule,,184.64,,,184.64,Other,110% of Medicare,99.03,,,99.03,Fee Schedule,,53,,,53,Other,186% of Medicaid,116.54,,,116.54,Fee Schedule,,231.26,,,231.26,Fee Schedule,,54.87,,,54.87,Fee Schedule,,116.54,,,116.54,Fee Schedule,,231.26,,,231.26,Fee Schedule,,103.21,,,103.21,Fee Schedule,,261.1,70,,261.1,percent of total billed charges,All Other,116.44,,,116.44,Fee Schedule,,98.69,,,98.69,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,276.02,
XR EXAM OF LEG INFANT 2 VIE,73592,CPT,TC,42073592,CDM,320,RC,,,both,,,231,170.94,,,170.94,Other,150% of Medicare + 9.63% HCRA Surcharge,103.95,45,,103.95,percent of total billed charges,Critical Access Hospital RCC factor,83.35,,,83.35,Fee Schedule,,74.99,,,74.99,Fee Schedule,,155.73,,,155.73,Fee Schedule,,140.07,,,140.07,Fee Schedule,,132.38,,,132.38,Fee Schedule,,114.35,,,114.35,Other,110% of Medicare,99.03,,,99.03,Fee Schedule,,53,,,53,Other,186% of Medicaid,116.54,,,116.54,Fee Schedule,,143.22,,,143.22,Fee Schedule,,54.87,,,54.87,Fee Schedule,,116.54,,,116.54,Fee Schedule,,143.22,,,143.22,Fee Schedule,,103.21,,,103.21,Fee Schedule,,161.7,70,,161.7,percent of total billed charges,All Other,118.08,,,118.08,Fee Schedule,,100.08,,,100.08,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,170.94,
XR EXAM OF ANKLE 2 VIEWS,73600,CPT,TC,42073600,CDM,320,RC,,,both,,,231,170.94,,,170.94,Other,150% of Medicare + 9.63% HCRA Surcharge,103.95,45,,103.95,percent of total billed charges,Critical Access Hospital RCC factor,85.65,,,85.65,Fee Schedule,,77.06,,,77.06,Fee Schedule,,137.39,,,137.39,Fee Schedule,,123.57,,,123.57,Fee Schedule,,116.79,,,116.79,Fee Schedule,,114.35,,,114.35,Other,110% of Medicare,101.76,,,101.76,Fee Schedule,,53,,,53,Other,186% of Medicaid,119.75,,,119.75,Fee Schedule,,143.22,,,143.22,Fee Schedule,,56.39,,,56.39,Fee Schedule,,119.75,,,119.75,Fee Schedule,,143.22,,,143.22,Fee Schedule,,106.06,,,106.06,Fee Schedule,,161.7,70,,161.7,percent of total billed charges,All Other,119.72,,,119.72,Fee Schedule,,101.47,,,101.47,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,170.94,
XR EXAM OF FOOT; 2 VIEWS,73620,CPT,TC,42073620,CDM,320,RC,,,both,,,231,170.94,,,170.94,Other,150% of Medicare + 9.63% HCRA Surcharge,103.95,45,,103.95,percent of total billed charges,Critical Access Hospital RCC factor,74.1,,,74.1,Fee Schedule,,66.67,,,66.67,Fee Schedule,,132.8,,,132.8,Fee Schedule,,119.45,,,119.45,Fee Schedule,,112.9,,,112.9,Fee Schedule,,114.35,,,114.35,Other,110% of Medicare,88.04,,,88.04,Fee Schedule,,53,,,53,Other,186% of Medicaid,103.61,,,103.61,Fee Schedule,,143.22,,,143.22,Fee Schedule,,48.78,,,48.78,Fee Schedule,,103.61,,,103.61,Fee Schedule,,143.22,,,143.22,Fee Schedule,,91.76,,,91.76,Fee Schedule,,161.7,70,,161.7,percent of total billed charges,All Other,101.68,,,101.68,Fee Schedule,,86.18,,,86.18,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,170.94,
XR EXAM OF FOOT; 3+ VIEWS,73630,CPT,TC,42073630,CDM,320,RC,,,both,,,373,276.02,,,276.02,Other,150% of Medicare + 9.63% HCRA Surcharge,167.85,45,,167.85,percent of total billed charges,Critical Access Hospital RCC factor,91.43,,,91.43,Fee Schedule,,82.25,,,82.25,Fee Schedule,,157.99,,,157.99,Fee Schedule,,142.11,,,142.11,Fee Schedule,,134.31,,,134.31,Fee Schedule,,184.64,,,184.64,Other,110% of Medicare,108.62,,,108.62,Fee Schedule,,53,,,53,Other,186% of Medicaid,127.82,,,127.82,Fee Schedule,,231.26,,,231.26,Fee Schedule,,60.19,,,60.19,Fee Schedule,,127.82,,,127.82,Fee Schedule,,231.26,,,231.26,Fee Schedule,,113.21,,,113.21,Fee Schedule,,261.1,70,,261.1,percent of total billed charges,All Other,129.56,,,129.56,Fee Schedule,,109.81,,,109.81,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,276.02,
X-RAY EXAM ABDOMEN 1 VIEW,74018,CPT,TC,42074018,CDM,320,RC,,,both,,,437,323.38,,,323.38,Other,150% of Medicare + 9.63% HCRA Surcharge,196.65,45,,196.65,percent of total billed charges,Critical Access Hospital RCC factor,75.25,,,75.25,Fee Schedule,,67.7,,,67.7,Fee Schedule,,17.12,,,17.12,Fee Schedule,,17.12,,,17.12,Fee Schedule,,17.12,,,17.12,Fee Schedule,,216.32,,,216.32,Other,110% of Medicare,89.41,,,89.41,Fee Schedule,,53,,,53,Other,186% of Medicaid,105.21,,,105.21,Fee Schedule,,270.94,,,270.94,Fee Schedule,,49.54,,,49.54,Fee Schedule,,105.21,,,105.21,Fee Schedule,,270.94,,,270.94,Fee Schedule,,93.18,,,93.18,Fee Schedule,,305.9,70,,305.9,percent of total billed charges,All Other,104.96,,,104.96,Fee Schedule,,88.96,,,88.96,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,17.12,323.38,
X-RAY EXAM ABDOMEN 2 VIEWS,74019,CPT,TC,42074019,CDM,320,RC,,,both,,,242,179.08,,,179.08,Other,150% of Medicare + 9.63% HCRA Surcharge,108.9,45,,108.9,percent of total billed charges,Critical Access Hospital RCC factor,90.28,,,90.28,Fee Schedule,,81.22,,,81.22,Fee Schedule,,20.47,,,20.47,Fee Schedule,,20.47,,,20.47,Fee Schedule,,20.47,,,20.47,Fee Schedule,,119.79,,,119.79,Other,110% of Medicare,107.26,,,107.26,Fee Schedule,,53,,,53,Other,186% of Medicaid,126.22,,,126.22,Fee Schedule,,150.04,,,150.04,Fee Schedule,,59.43,,,59.43,Fee Schedule,,126.22,,,126.22,Fee Schedule,,150.04,,,150.04,Fee Schedule,,111.79,,,111.79,Fee Schedule,,169.4,70,,169.4,percent of total billed charges,All Other,126.28,,,126.28,Fee Schedule,,107.03,,,107.03,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,20.47,179.33,
X-RAY ABDOMEN 3+ VIEWS,74021,CPT,,42074021,CDM,320,RC,,,both,,,408,301.92,,,301.92,Other,150% of Medicare + 9.63% HCRA Surcharge,183.6,45,,183.6,percent of total billed charges,Critical Access Hospital RCC factor,105.3,,,105.3,Fee Schedule,,94.74,,,94.74,Fee Schedule,,23.83,,,23.83,Fee Schedule,,23.83,,,23.83,Fee Schedule,,23.83,,,23.83,Fee Schedule,,201.96,,,201.96,Other,110% of Medicare,125.11,,,125.11,Fee Schedule,,53,,,53,Other,186% of Medicaid,147.22,,,147.22,Fee Schedule,,252.96,,,252.96,Fee Schedule,,69.32,,,69.32,Fee Schedule,,147.22,,,147.22,Fee Schedule,,252.96,,,252.96,Fee Schedule,,130.39,,,130.39,Fee Schedule,,285.6,70,,285.6,percent of total billed charges,All Other,149.24,,,149.24,Fee Schedule,,126.49,,,126.49,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,23.83,301.92,
XR PHARYNX/CERVICAL ESOPH,74210,CPT,TC,42074210,CDM,320,RC,,,both,,,494,365.56,,,365.56,Other,150% of Medicare + 9.63% HCRA Surcharge,222.3,45,,222.3,percent of total billed charges,Critical Access Hospital RCC factor,233.54,,,233.54,Fee Schedule,,210.11,,,210.11,Fee Schedule,,412.01,,,412.01,Fee Schedule,,370.57,,,370.57,Fee Schedule,,350.25,,,350.25,Fee Schedule,,244.53,,,244.53,Other,110% of Medicare,277.47,,,277.47,Fee Schedule,,53,,,53,Other,186% of Medicaid,326.52,,,326.52,Fee Schedule,,306.28,,,306.28,Fee Schedule,,153.74,,,153.74,Fee Schedule,,326.52,,,326.52,Fee Schedule,,306.28,,,306.28,Fee Schedule,,289.18,,,289.18,Fee Schedule,,345.8,70,,345.8,percent of total billed charges,All Other,350.96,,,350.96,Fee Schedule,,297.46,,,297.46,Fee Schedule,,291.55,,,291.55,Fee Schedule,,291.55,,,291.55,Fee Schedule,,291.55,,,291.55,Fee Schedule,,291.55,,,291.55,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,412.01,
XR ESOPHAGUS,74220,CPT,TC,42074220,CDM,320,RC,,,both,,,864,639.36,,,639.36,Other,150% of Medicare + 9.63% HCRA Surcharge,388.8,45,,388.8,percent of total billed charges,Critical Access Hospital RCC factor,240.46,,,240.46,Fee Schedule,,216.34,,,216.34,Fee Schedule,,455.49,,,455.49,Fee Schedule,,409.68,,,409.68,Fee Schedule,,387.21,,,387.21,Fee Schedule,,427.68,,,427.68,Other,110% of Medicare,285.69,,,285.69,Fee Schedule,,53,,,53,Other,186% of Medicaid,336.19,,,336.19,Fee Schedule,,535.68,,,535.68,Fee Schedule,,158.3,,,158.3,Fee Schedule,,336.19,,,336.19,Fee Schedule,,535.68,,,535.68,Fee Schedule,,297.75,,,297.75,Fee Schedule,,604.8,70,,604.8,percent of total billed charges,All Other,354.24,,,354.24,Fee Schedule,,300.24,,,300.24,Fee Schedule,,291.55,,,291.55,Fee Schedule,,291.55,,,291.55,Fee Schedule,,291.55,,,291.55,Fee Schedule,,291.55,,,291.55,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,639.36,
X-RAY XM ESOPHAGUS 2CNTRST,74221,CPT,,42074221,CDM,320,RC,,,both,,,626,463.24,,,463.24,Other,150% of Medicare + 9.63% HCRA Surcharge,281.7,45,,281.7,percent of total billed charges,Critical Access Hospital RCC factor,267.03,,,267.03,Fee Schedule,,240.25,,,240.25,Fee Schedule,,72.9,,,72.9,Fee Schedule,,72.9,,,72.9,Fee Schedule,,72.9,,,72.9,Fee Schedule,,309.87,,,309.87,Other,110% of Medicare,317.26,,,317.26,Fee Schedule,,392,,,392,Other,186% of Medicaid,373.35,,,373.35,Fee Schedule,,388.12,,,388.12,Fee Schedule,,175.79,,,175.79,Fee Schedule,,373.35,,,373.35,Fee Schedule,,388.12,,,388.12,Fee Schedule,,330.65,,,330.65,Fee Schedule,,438.2,70,,438.2,percent of total billed charges,All Other,393.6,,,393.6,Fee Schedule,,333.6,,,333.6,Fee Schedule,,291.55,,,291.55,Fee Schedule,,291.55,,,291.55,Fee Schedule,,291.55,,,291.55,Fee Schedule,,291.55,,,291.55,Fee Schedule,,210.57,,,210.57,Other,100% of Medicaid,210.57,,,210.57,Other,100% of Medicaid,210.57,,,210.57,Other,100% of Medicaid,210.57,,,210.57,Other,100% of Medicaid,473.77,,,473.77,Other,225% of Medicaid,322.17,,,322.17,Other,153% of Medicaid,473.77,,,473.77,Other,225% of Medicaid,294.79,,,294.79,Other,140% of Medicaid,473.77,,,473.77,Other,225% of Medicaid,547.47,,,547.47,Other,260% of Medicaid,682.23,,,682.23,Other,324% of Medicaid,452.72,,,452.72,Other,215% of Medicaid,452.72,,,452.72,Other,215% of Medicaid,263.21,,,263.21,Other,125% of Medicaid,72.9,682.23,
SWALLOWING FUNCTION W/CINE -VI,74230,CPT,TC,42074230,CDM,320,RC,,,both,,,953,705.22,,,705.22,Other,150% of Medicare + 9.63% HCRA Surcharge,428.85,45,,428.85,percent of total billed charges,Critical Access Hospital RCC factor,345.6,,,345.6,Fee Schedule,,310.94,,,310.94,Fee Schedule,,441.73,,,441.73,Fee Schedule,,397.31,,,397.31,Fee Schedule,,375.51,,,375.51,Fee Schedule,,471.74,,,471.74,Other,110% of Medicare,410.61,,,410.61,Fee Schedule,,392,,,392,Other,186% of Medicaid,483.2,,,483.2,Fee Schedule,,590.86,,,590.86,Fee Schedule,,227.51,,,227.51,Fee Schedule,,483.2,,,483.2,Fee Schedule,,590.86,,,590.86,Fee Schedule,,427.94,,,427.94,Fee Schedule,,667.1,70,,667.1,percent of total billed charges,All Other,514.96,,,514.96,Fee Schedule,,436.46,,,436.46,Fee Schedule,,291.55,,,291.55,Fee Schedule,,291.55,,,291.55,Fee Schedule,,291.55,,,291.55,Fee Schedule,,291.55,,,291.55,Fee Schedule,,210.57,,,210.57,Other,100% of Medicaid,210.57,,,210.57,Other,100% of Medicaid,210.57,,,210.57,Other,100% of Medicaid,210.57,,,210.57,Other,100% of Medicaid,473.77,,,473.77,Other,225% of Medicaid,322.17,,,322.17,Other,153% of Medicaid,473.77,,,473.77,Other,225% of Medicaid,294.79,,,294.79,Other,140% of Medicaid,473.77,,,473.77,Other,225% of Medicaid,547.47,,,547.47,Other,260% of Medicaid,682.23,,,682.23,Other,324% of Medicaid,452.72,,,452.72,Other,215% of Medicaid,452.72,,,452.72,Other,215% of Medicaid,263.21,,,263.21,Other,125% of Medicaid,210.57,705.22,
XR UPPER GI TRACT WO KUB,74240,CPT,TC,42074240,CDM,320,RC,,,both,,,915,677.1,,,677.1,Other,150% of Medicare + 9.63% HCRA Surcharge,411.75,45,,411.75,percent of total billed charges,Critical Access Hospital RCC factor,294.76,,,294.76,Fee Schedule,,265.19,,,265.19,Fee Schedule,,524.15,,,524.15,Fee Schedule,,471.44,,,471.44,Fee Schedule,,445.58,,,445.58,Fee Schedule,,452.93,,,452.93,Other,110% of Medicare,350.2,,,350.2,Fee Schedule,,392,,,392,Other,186% of Medicaid,412.1,,,412.1,Fee Schedule,,567.3,,,567.3,Fee Schedule,,194.04,,,194.04,Fee Schedule,,412.1,,,412.1,Fee Schedule,,567.3,,,567.3,Fee Schedule,,364.98,,,364.98,Fee Schedule,,640.5,70,,640.5,percent of total billed charges,All Other,432.96,,,432.96,Fee Schedule,,366.96,,,366.96,Fee Schedule,,291.55,,,291.55,Fee Schedule,,291.55,,,291.55,Fee Schedule,,291.55,,,291.55,Fee Schedule,,291.55,,,291.55,Fee Schedule,,210.57,,,210.57,Other,100% of Medicaid,210.57,,,210.57,Other,100% of Medicaid,210.57,,,210.57,Other,100% of Medicaid,210.57,,,210.57,Other,100% of Medicaid,473.77,,,473.77,Other,225% of Medicaid,322.17,,,322.17,Other,153% of Medicaid,473.77,,,473.77,Other,225% of Medicaid,294.79,,,294.79,Other,140% of Medicaid,473.77,,,473.77,Other,225% of Medicaid,547.47,,,547.47,Other,260% of Medicaid,682.23,,,682.23,Other,324% of Medicaid,452.72,,,452.72,Other,215% of Medicaid,452.72,,,452.72,Other,215% of Medicaid,263.21,,,263.21,Other,125% of Medicaid,194.04,682.23,
XR UPPER GI W/AIR WO KUB,74246,CPT,TC,42074246,CDM,320,RC,,,both,,,763,564.62,,,564.62,Other,150% of Medicare + 9.63% HCRA Surcharge,343.35,45,,343.35,percent of total billed charges,Critical Access Hospital RCC factor,336.35,,,336.35,Fee Schedule,,302.61,,,302.61,Fee Schedule,,583.65,,,583.65,Fee Schedule,,524.96,,,524.96,Fee Schedule,,496.16,,,496.16,Fee Schedule,,377.69,,,377.69,Other,110% of Medicare,399.62,,,399.62,Fee Schedule,,392,,,392,Other,186% of Medicaid,470.26,,,470.26,Fee Schedule,,473.06,,,473.06,Fee Schedule,,221.42,,,221.42,Fee Schedule,,470.26,,,470.26,Fee Schedule,,473.06,,,473.06,Fee Schedule,,416.49,,,416.49,Fee Schedule,,534.1,70,,534.1,percent of total billed charges,All Other,498.56,,,498.56,Fee Schedule,,422.56,,,422.56,Fee Schedule,,291.55,,,291.55,Fee Schedule,,291.55,,,291.55,Fee Schedule,,291.55,,,291.55,Fee Schedule,,291.55,,,291.55,Fee Schedule,,210.57,,,210.57,Other,100% of Medicaid,210.57,,,210.57,Other,100% of Medicaid,210.57,,,210.57,Other,100% of Medicaid,210.57,,,210.57,Other,100% of Medicaid,473.77,,,473.77,Other,225% of Medicaid,322.17,,,322.17,Other,153% of Medicaid,473.77,,,473.77,Other,225% of Medicaid,294.79,,,294.79,Other,140% of Medicaid,473.77,,,473.77,Other,225% of Medicaid,547.47,,,547.47,Other,260% of Medicaid,682.23,,,682.23,Other,324% of Medicaid,452.72,,,452.72,Other,215% of Medicaid,452.72,,,452.72,Other,215% of Medicaid,263.21,,,263.21,Other,125% of Medicaid,210.57,682.23,
X-RAY SM INT F-THRU STD,74248,CPT,,42074248,CDM,320,RC,,,both,,,135,99.9,,,99.9,Other,150% of Medicare + 9.63% HCRA Surcharge,60.75,45,,60.75,percent of total billed charges,Critical Access Hospital RCC factor,172.29,,,172.29,Fee Schedule,,155.01,,,155.01,Fee Schedule,,46.62,,,46.62,Fee Schedule,,46.62,,,46.62,Fee Schedule,,46.62,,,46.62,Fee Schedule,,66.83,,,66.83,Other,110% of Medicare,204.7,,,204.7,Fee Schedule,,392,,,392,Other,186% of Medicaid,240.88,,,240.88,Fee Schedule,,83.7,,,83.7,Fee Schedule,,113.42,,,113.42,Fee Schedule,,240.88,,,240.88,Fee Schedule,,83.7,,,83.7,Fee Schedule,,213.34,,,213.34,Fee Schedule,,94.5,70,,94.5,percent of total billed charges,All Other,254.2,,,254.2,Fee Schedule,,215.45,,,215.45,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,210.57,,,210.57,Other,100% of Medicaid,210.57,,,210.57,Other,100% of Medicaid,210.57,,,210.57,Other,100% of Medicaid,210.57,,,210.57,Other,100% of Medicaid,473.77,,,473.77,Other,225% of Medicaid,322.17,,,322.17,Other,153% of Medicaid,473.77,,,473.77,Other,225% of Medicaid,294.79,,,294.79,Other,140% of Medicaid,473.77,,,473.77,Other,225% of Medicaid,547.47,,,547.47,Other,260% of Medicaid,682.23,,,682.23,Other,324% of Medicaid,452.72,,,452.72,Other,215% of Medicaid,452.72,,,452.72,Other,215% of Medicaid,263.21,,,263.21,Other,125% of Medicaid,0.01,682.23,
XR SMALL BOWEL,74250,CPT,TC,42074250,CDM,320,RC,,,both,,,792,586.08,,,586.08,Other,150% of Medicare + 9.63% HCRA Surcharge,356.4,45,,356.4,percent of total billed charges,Critical Access Hospital RCC factor,291.31,,,291.31,Fee Schedule,,262.09,,,262.09,Fee Schedule,,563.05,,,563.05,Fee Schedule,,506.42,,,506.42,Fee Schedule,,478.64,,,478.64,Fee Schedule,,392.04,,,392.04,Other,110% of Medicare,346.1,,,346.1,Fee Schedule,,392,,,392,Other,186% of Medicaid,407.29,,,407.29,Fee Schedule,,491.04,,,491.04,Fee Schedule,,191.77,,,191.77,Fee Schedule,,407.29,,,407.29,Fee Schedule,,491.04,,,491.04,Fee Schedule,,360.71,,,360.71,Fee Schedule,,554.4,70,,554.4,percent of total billed charges,All Other,429.68,,,429.68,Fee Schedule,,364.18,,,364.18,Fee Schedule,,291.55,,,291.55,Fee Schedule,,291.55,,,291.55,Fee Schedule,,291.55,,,291.55,Fee Schedule,,291.55,,,291.55,Fee Schedule,,210.57,,,210.57,Other,100% of Medicaid,210.57,,,210.57,Other,100% of Medicaid,210.57,,,210.57,Other,100% of Medicaid,210.57,,,210.57,Other,100% of Medicaid,473.77,,,473.77,Other,225% of Medicaid,322.17,,,322.17,Other,153% of Medicaid,473.77,,,473.77,Other,225% of Medicaid,294.79,,,294.79,Other,140% of Medicaid,473.77,,,473.77,Other,225% of Medicaid,547.47,,,547.47,Other,260% of Medicaid,682.23,,,682.23,Other,324% of Medicaid,452.72,,,452.72,Other,215% of Medicaid,452.72,,,452.72,Other,215% of Medicaid,263.21,,,263.21,Other,125% of Medicaid,191.77,682.23,
XR SML BOWEL VIA ENTEROCLYS,74251,CPT,TC,42074251,CDM,320,RC,,,both,,,3420,2530.81,,,2530.81,Other,150% of Medicare + 9.63% HCRA Surcharge,1539,45,,1539,percent of total billed charges,Critical Access Hospital RCC factor,618.22,,,618.22,Fee Schedule,,556.21,,,556.21,Fee Schedule,,954.24,,,954.24,Fee Schedule,,858.27,,,858.27,Fee Schedule,,811.19,,,811.19,Fee Schedule,,1692.9,,,1692.9,Other,110% of Medicare,734.5,,,734.5,Fee Schedule,,392,,,392,Other,186% of Medicaid,864.35,,,864.35,Fee Schedule,,2120.4,,,2120.4,Fee Schedule,,406.98,,,406.98,Fee Schedule,,864.35,,,864.35,Fee Schedule,,2120.4,,,2120.4,Fee Schedule,,765.51,,,765.51,Fee Schedule,,2394,70,,2394,percent of total billed charges,All Other,1618.68,,,1618.68,Fee Schedule,,1371.93,,,1371.93,Fee Schedule,,291.55,,,291.55,Fee Schedule,,291.55,,,291.55,Fee Schedule,,291.55,,,291.55,Fee Schedule,,291.55,,,291.55,Fee Schedule,,210.57,,,210.57,Other,100% of Medicaid,210.57,,,210.57,Other,100% of Medicaid,210.57,,,210.57,Other,100% of Medicaid,210.57,,,210.57,Other,100% of Medicaid,473.77,,,473.77,Other,225% of Medicaid,322.17,,,322.17,Other,153% of Medicaid,473.77,,,473.77,Other,225% of Medicaid,294.79,,,294.79,Other,140% of Medicaid,473.77,,,473.77,Other,225% of Medicaid,547.47,,,547.47,Other,260% of Medicaid,682.23,,,682.23,Other,324% of Medicaid,452.72,,,452.72,Other,215% of Medicaid,452.72,,,452.72,Other,215% of Medicaid,263.21,,,263.21,Other,125% of Medicaid,210.57,2530.81,
XR COLON W CONTRAST,74270,CPT,TC,42074270,CDM,320,RC,,,both,,,1022,756.28,,,756.28,Other,150% of Medicare + 9.63% HCRA Surcharge,459.9,45,,459.9,percent of total billed charges,Critical Access Hospital RCC factor,364.07,,,364.07,Fee Schedule,,327.55,,,327.55,Fee Schedule,,585.92,,,585.92,Fee Schedule,,526.99,,,526.99,Fee Schedule,,498.09,,,498.09,Fee Schedule,,505.89,,,505.89,Other,110% of Medicare,432.55,,,432.55,Fee Schedule,,392,,,392,Other,186% of Medicaid,509.02,,,509.02,Fee Schedule,,633.64,,,633.64,Fee Schedule,,239.67,,,239.67,Fee Schedule,,509.02,,,509.02,Fee Schedule,,633.64,,,633.64,Fee Schedule,,450.81,,,450.81,Fee Schedule,,715.4,70,,715.4,percent of total billed charges,All Other,536.28,,,536.28,Fee Schedule,,454.53,,,454.53,Fee Schedule,,291.55,,,291.55,Fee Schedule,,291.55,,,291.55,Fee Schedule,,291.55,,,291.55,Fee Schedule,,291.55,,,291.55,Fee Schedule,,210.57,,,210.57,Other,100% of Medicaid,210.57,,,210.57,Other,100% of Medicaid,210.57,,,210.57,Other,100% of Medicaid,210.57,,,210.57,Other,100% of Medicaid,473.77,,,473.77,Other,225% of Medicaid,322.17,,,322.17,Other,153% of Medicaid,473.77,,,473.77,Other,225% of Medicaid,294.79,,,294.79,Other,140% of Medicaid,473.77,,,473.77,Other,225% of Medicaid,547.47,,,547.47,Other,260% of Medicaid,682.23,,,682.23,Other,324% of Medicaid,452.72,,,452.72,Other,215% of Medicaid,452.72,,,452.72,Other,215% of Medicaid,263.21,,,263.21,Other,125% of Medicaid,210.57,756.28,
THERAP BE/AIR FOR OBSTRUCT,74283,CPT,TC,42074283,CDM,320,RC,,,both,,,934,691.16,,,691.16,Other,150% of Medicare + 9.63% HCRA Surcharge,420.3,45,,420.3,percent of total billed charges,Critical Access Hospital RCC factor,541.98,,,541.98,Fee Schedule,,487.61,,,487.61,Fee Schedule,,583.65,,,583.65,Fee Schedule,,524.96,,,524.96,Fee Schedule,,496.16,,,496.16,Fee Schedule,,462.33,,,462.33,Other,110% of Medicare,643.92,,,643.92,Fee Schedule,,392,,,392,Other,186% of Medicaid,757.75,,,757.75,Fee Schedule,,579.08,,,579.08,Fee Schedule,,356.79,,,356.79,Fee Schedule,,757.75,,,757.75,Fee Schedule,,579.08,,,579.08,Fee Schedule,,671.11,,,671.11,Fee Schedule,,653.8,70,,653.8,percent of total billed charges,All Other,795.4,,,795.4,Fee Schedule,,674.15,,,674.15,Fee Schedule,,291.55,,,291.55,Fee Schedule,,291.55,,,291.55,Fee Schedule,,291.55,,,291.55,Fee Schedule,,291.55,,,291.55,Fee Schedule,,210.57,,,210.57,Other,100% of Medicaid,210.57,,,210.57,Other,100% of Medicaid,210.57,,,210.57,Other,100% of Medicaid,210.57,,,210.57,Other,100% of Medicaid,473.77,,,473.77,Other,225% of Medicaid,322.17,,,322.17,Other,153% of Medicaid,473.77,,,473.77,Other,225% of Medicaid,294.79,,,294.79,Other,140% of Medicaid,473.77,,,473.77,Other,225% of Medicaid,547.47,,,547.47,Other,260% of Medicaid,682.23,,,682.23,Other,324% of Medicaid,452.72,,,452.72,Other,215% of Medicaid,452.72,,,452.72,Other,215% of Medicaid,263.21,,,263.21,Other,125% of Medicaid,210.57,795.4,
ORAL GALLBLADDER STUDY,74290,CPT,TC,42074290,CDM,320,RC,,,both,,,615,455.1,,,455.1,Other,150% of Medicare + 9.63% HCRA Surcharge,276.75,45,,276.75,percent of total billed charges,Critical Access Hospital RCC factor,242.79,,,242.79,Fee Schedule,,218.44,,,218.44,Fee Schedule,,357.1,,,357.1,Fee Schedule,,321.18,,,321.18,Fee Schedule,,303.56,,,303.56,Fee Schedule,,304.43,,,304.43,Other,110% of Medicare,288.46,,,288.46,Fee Schedule,,392,,,392,Other,186% of Medicaid,339.45,,,339.45,Fee Schedule,,381.3,,,381.3,Fee Schedule,,159.83,,,159.83,Fee Schedule,,339.45,,,339.45,Fee Schedule,,381.3,,,381.3,Fee Schedule,,300.63,,,300.63,Fee Schedule,,430.5,70,,430.5,percent of total billed charges,All Other,360.8,,,360.8,Fee Schedule,,305.8,,,305.8,Fee Schedule,,291.55,,,291.55,Fee Schedule,,291.55,,,291.55,Fee Schedule,,291.55,,,291.55,Fee Schedule,,291.55,,,291.55,Fee Schedule,,210.57,,,210.57,Other,100% of Medicaid,210.57,,,210.57,Other,100% of Medicaid,210.57,,,210.57,Other,100% of Medicaid,210.57,,,210.57,Other,100% of Medicaid,473.77,,,473.77,Other,225% of Medicaid,322.17,,,322.17,Other,153% of Medicaid,473.77,,,473.77,Other,225% of Medicaid,294.79,,,294.79,Other,140% of Medicaid,473.77,,,473.77,Other,225% of Medicaid,547.47,,,547.47,Other,260% of Medicaid,682.23,,,682.23,Other,324% of Medicaid,452.72,,,452.72,Other,215% of Medicaid,452.72,,,452.72,Other,215% of Medicaid,263.21,,,263.21,Other,125% of Medicaid,159.83,682.23,
CHOLANGIOGRAM INTRAOP,74300,CPT,TC,42074300,CDM,320,RC,,,both,,,1428,1056.72,,,1056.72,Other,150% of Medicare + 9.63% HCRA Surcharge,642.6,45,,642.6,percent of total billed charges,Critical Access Hospital RCC factor,928.2,65,,928.2,percent of total billed charges,All Other,842.52,65,,842.52,percent of total billed charges,All Other,33.47,,,33.47,Fee Schedule,,33.47,,,33.47,Fee Schedule,,33.47,,,33.47,Fee Schedule,,706.86,,,706.86,Other,110% of Medicare,971.04,68,,971.04,percent of total billed charges,All Other,544,,,544,Other,186% of Medicaid,1142.4,80,,1142.4,percent of total billed charges,All Other,1185.24,83,,1185.24,percent of total billed charges,All Other,785.4,55,,785.4,percent of total billed charges,Default if not on Fee Schedule,1142.4,80,,1142.4,percent of total billed charges,All Other,1185.24,83,,1185.24,percent of total billed charges,All Other,1142.4,80,,1142.4,percent of total billed charges,All Other,999.6,70,,999.6,percent of total billed charges,All Other,928.2,65,,928.2,percent of total billed charges,Default if not in Fee Schedule,928.2,65,,928.2,percent of total billed charges,Default if not in Fee Schedule,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,292.43,,,292.43,Other,100% of Medicaid,292.43,,,292.43,Other,100% of Medicaid,292.43,,,292.43,Other,100% of Medicaid,292.43,,,292.43,Other,100% of Medicaid,657.97,,,657.97,Other,225% of Medicaid,447.42,,,447.42,Other,153% of Medicaid,657.97,,,657.97,Other,225% of Medicaid,409.4,,,409.4,Other,140% of Medicaid,657.97,,,657.97,Other,225% of Medicaid,760.32,,,760.32,Other,260% of Medicaid,947.48,,,947.48,Other,324% of Medicaid,628.73,,,628.73,Other,215% of Medicaid,628.73,,,628.73,Other,215% of Medicaid,365.54,,,365.54,Other,125% of Medicaid,0.01,1185.24,
ENDO CATH - BILE DUCTS,74328,CPT,TC,42074328,CDM,320,RC,,,both,,,638,472.12,,,472.12,Other,150% of Medicare + 9.63% HCRA Surcharge,287.1,45,,287.1,percent of total billed charges,Critical Access Hospital RCC factor,414.7,65,,414.7,percent of total billed charges,All Other,376.42,65,,376.42,percent of total billed charges,All Other,81.44,,,81.44,Fee Schedule,,81.44,,,81.44,Fee Schedule,,81.44,,,81.44,Fee Schedule,,315.81,,,315.81,Other,110% of Medicare,433.84,68,,433.84,percent of total billed charges,All Other,544,,,544,Other,186% of Medicaid,510.4,80,,510.4,percent of total billed charges,All Other,529.54,83,,529.54,percent of total billed charges,All Other,350.9,55,,350.9,percent of total billed charges,Default if not on Fee Schedule,510.4,80,,510.4,percent of total billed charges,All Other,529.54,83,,529.54,percent of total billed charges,All Other,510.4,80,,510.4,percent of total billed charges,All Other,446.6,70,,446.6,percent of total billed charges,All Other,414.7,65,,414.7,percent of total billed charges,Default if not in Fee Schedule,414.7,65,,414.7,percent of total billed charges,Default if not in Fee Schedule,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,292.43,,,292.43,Other,100% of Medicaid,292.43,,,292.43,Other,100% of Medicaid,292.43,,,292.43,Other,100% of Medicaid,292.43,,,292.43,Other,100% of Medicaid,657.97,,,657.97,Other,225% of Medicaid,447.42,,,447.42,Other,153% of Medicaid,657.97,,,657.97,Other,225% of Medicaid,409.4,,,409.4,Other,140% of Medicaid,657.97,,,657.97,Other,225% of Medicaid,760.32,,,760.32,Other,260% of Medicaid,947.48,,,947.48,Other,324% of Medicaid,628.73,,,628.73,Other,215% of Medicaid,628.73,,,628.73,Other,215% of Medicaid,365.54,,,365.54,Other,125% of Medicaid,0.01,947.48,
ENDO CATH - PANCR DUCT,74329,CPT,TC,42074329,CDM,320,RC,,,both,,,749,554.26,,,554.26,Other,150% of Medicare + 9.63% HCRA Surcharge,337.05,45,,337.05,percent of total billed charges,Critical Access Hospital RCC factor,486.85,65,,486.85,percent of total billed charges,All Other,441.91,65,,441.91,percent of total billed charges,All Other,65.22,,,65.22,Fee Schedule,,65.22,,,65.22,Fee Schedule,,65.22,,,65.22,Fee Schedule,,370.76,,,370.76,Other,110% of Medicare,509.32,68,,509.32,percent of total billed charges,All Other,544,,,544,Other,186% of Medicaid,599.2,80,,599.2,percent of total billed charges,All Other,621.67,83,,621.67,percent of total billed charges,All Other,411.95,55,,411.95,percent of total billed charges,Default if not on Fee Schedule,599.2,80,,599.2,percent of total billed charges,All Other,621.67,83,,621.67,percent of total billed charges,All Other,599.2,80,,599.2,percent of total billed charges,All Other,524.3,70,,524.3,percent of total billed charges,All Other,486.85,65,,486.85,percent of total billed charges,Default if not in Fee Schedule,486.85,65,,486.85,percent of total billed charges,Default if not in Fee Schedule,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,292.43,,,292.43,Other,100% of Medicaid,292.43,,,292.43,Other,100% of Medicaid,292.43,,,292.43,Other,100% of Medicaid,292.43,,,292.43,Other,100% of Medicaid,657.97,,,657.97,Other,225% of Medicaid,447.42,,,447.42,Other,153% of Medicaid,657.97,,,657.97,Other,225% of Medicaid,409.4,,,409.4,Other,140% of Medicaid,657.97,,,657.97,Other,225% of Medicaid,760.32,,,760.32,Other,260% of Medicaid,947.48,,,947.48,Other,324% of Medicaid,628.73,,,628.73,Other,215% of Medicaid,628.73,,,628.73,Other,215% of Medicaid,365.54,,,365.54,Other,125% of Medicaid,0.01,947.48,
ENDO CATH BIL & PANCR - ERCP,74330,CPT,TC,42074330,CDM,320,RC,,,both,,,2170,1605.81,,,1605.81,Other,150% of Medicare + 9.63% HCRA Surcharge,976.5,45,,976.5,percent of total billed charges,Critical Access Hospital RCC factor,1410.5,65,,1410.5,percent of total billed charges,All Other,1280.3,65,,1280.3,percent of total billed charges,All Other,121.13,,,121.13,Fee Schedule,,121.13,,,121.13,Fee Schedule,,121.13,,,121.13,Fee Schedule,,1074.15,,,1074.15,Other,110% of Medicare,1475.6,68,,1475.6,percent of total billed charges,All Other,544,,,544,Other,186% of Medicaid,1736,80,,1736,percent of total billed charges,All Other,1801.1,83,,1801.1,percent of total billed charges,All Other,1193.5,55,,1193.5,percent of total billed charges,Default if not on Fee Schedule,1736,80,,1736,percent of total billed charges,All Other,1801.1,83,,1801.1,percent of total billed charges,All Other,1736,80,,1736,percent of total billed charges,All Other,1519,70,,1519,percent of total billed charges,All Other,1410.5,65,,1410.5,percent of total billed charges,Default if not in Fee Schedule,1410.5,65,,1410.5,percent of total billed charges,Default if not in Fee Schedule,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,292.43,,,292.43,Other,100% of Medicaid,292.43,,,292.43,Other,100% of Medicaid,292.43,,,292.43,Other,100% of Medicaid,292.43,,,292.43,Other,100% of Medicaid,657.97,,,657.97,Other,225% of Medicaid,447.42,,,447.42,Other,153% of Medicaid,657.97,,,657.97,Other,225% of Medicaid,409.4,,,409.4,Other,140% of Medicaid,657.97,,,657.97,Other,225% of Medicaid,760.32,,,760.32,Other,260% of Medicaid,947.48,,,947.48,Other,324% of Medicaid,628.73,,,628.73,Other,215% of Medicaid,628.73,,,628.73,Other,215% of Medicaid,365.54,,,365.54,Other,125% of Medicaid,0.01,1801.1,
DILATE FOR STRICTURE/OBSTR,74360,CPT,TC,42074360,CDM,320,RC,,,both,,,816,603.84,,,603.84,Other,150% of Medicare + 9.63% HCRA Surcharge,367.2,45,,367.2,percent of total billed charges,Critical Access Hospital RCC factor,530.4,65,,530.4,percent of total billed charges,All Other,481.44,65,,481.44,percent of total billed charges,All Other,87.31,,,87.31,Fee Schedule,,87.31,,,87.31,Fee Schedule,,87.31,,,87.31,Fee Schedule,,403.92,,,403.92,Other,110% of Medicare,554.88,68,,554.88,percent of total billed charges,All Other,544,,,544,Other,186% of Medicaid,652.8,80,,652.8,percent of total billed charges,All Other,505.92,62,,505.92,percent of total billed charges,Lab and Radiology,448.8,55,,448.8,percent of total billed charges,Default if not on Fee Schedule,652.8,80,,652.8,percent of total billed charges,All Other,505.92,62,,505.92,percent of total billed charges,Lab and Radiology,652.8,80,,652.8,percent of total billed charges,All Other,571.2,70,,571.2,percent of total billed charges,All Other,530.4,65,,530.4,percent of total billed charges,Default if not in Fee Schedule,530.4,65,,530.4,percent of total billed charges,Default if not in Fee Schedule,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,292.43,,,292.43,Other,100% of Medicaid,292.43,,,292.43,Other,100% of Medicaid,292.43,,,292.43,Other,100% of Medicaid,292.43,,,292.43,Other,100% of Medicaid,657.97,,,657.97,Other,225% of Medicaid,447.42,,,447.42,Other,153% of Medicaid,657.97,,,657.97,Other,225% of Medicaid,409.4,,,409.4,Other,140% of Medicaid,657.97,,,657.97,Other,225% of Medicaid,760.32,,,760.32,Other,260% of Medicaid,947.48,,,947.48,Other,324% of Medicaid,628.73,,,628.73,Other,215% of Medicaid,628.73,,,628.73,Other,215% of Medicaid,365.54,,,365.54,Other,125% of Medicaid,0.01,947.48,
IVP W/WO TOMOGRAPHY/KUB,74400,CPT,TC,42074400,CDM,320,RC,,,both,,,997,737.78,,,737.78,Other,150% of Medicare + 9.63% HCRA Surcharge,448.65,45,,448.65,percent of total billed charges,Critical Access Hospital RCC factor,388.51,,,388.51,Fee Schedule,,349.54,,,349.54,Fee Schedule,,592.77,,,592.77,Fee Schedule,,533.16,,,533.16,Fee Schedule,,503.91,,,503.91,Fee Schedule,,493.52,,,493.52,Other,110% of Medicare,461.58,,,461.58,Fee Schedule,,392,,,392,Other,186% of Medicaid,543.18,,,543.18,Fee Schedule,,618.14,,,618.14,Fee Schedule,,255.76,,,255.76,Fee Schedule,,543.18,,,543.18,Fee Schedule,,618.14,,,618.14,Fee Schedule,,481.07,,,481.07,Fee Schedule,,697.9,70,,697.9,percent of total billed charges,All Other,565.8,,,565.8,Fee Schedule,,479.55,,,479.55,Fee Schedule,,291.55,,,291.55,Fee Schedule,,291.55,,,291.55,Fee Schedule,,291.55,,,291.55,Fee Schedule,,291.55,,,291.55,Fee Schedule,,210.57,,,210.57,Other,100% of Medicaid,210.57,,,210.57,Other,100% of Medicaid,210.57,,,210.57,Other,100% of Medicaid,210.57,,,210.57,Other,100% of Medicaid,473.77,,,473.77,Other,225% of Medicaid,322.17,,,322.17,Other,153% of Medicaid,473.77,,,473.77,Other,225% of Medicaid,294.79,,,294.79,Other,140% of Medicaid,473.77,,,473.77,Other,225% of Medicaid,547.47,,,547.47,Other,260% of Medicaid,682.23,,,682.23,Other,324% of Medicaid,452.72,,,452.72,Other,215% of Medicaid,452.72,,,452.72,Other,215% of Medicaid,263.21,,,263.21,Other,125% of Medicaid,210.57,737.78,
IVP W TOMOGRAPHY,74415,CPT,TC,42074415,CDM,320,RC,,,both,,,1023,757.02,,,757.02,Other,150% of Medicare + 9.63% HCRA Surcharge,460.35,45,,460.35,percent of total billed charges,Critical Access Hospital RCC factor,445.1,,,445.1,Fee Schedule,,400.45,,,400.45,Fee Schedule,,757.56,,,757.56,Fee Schedule,,681.38,,,681.38,Fee Schedule,,644,,,644,Fee Schedule,,506.39,,,506.39,Other,110% of Medicare,528.82,,,528.82,Fee Schedule,,392,,,392,Other,186% of Medicaid,622.3,,,622.3,Fee Schedule,,634.26,,,634.26,Fee Schedule,,293.01,,,293.01,Fee Schedule,,622.3,,,622.3,Fee Schedule,,634.26,,,634.26,Fee Schedule,,551.14,,,551.14,Fee Schedule,,716.1,70,,716.1,percent of total billed charges,All Other,662.56,,,662.56,Fee Schedule,,561.56,,,561.56,Fee Schedule,,291.55,,,291.55,Fee Schedule,,291.55,,,291.55,Fee Schedule,,291.55,,,291.55,Fee Schedule,,291.55,,,291.55,Fee Schedule,,210.57,,,210.57,Other,100% of Medicaid,210.57,,,210.57,Other,100% of Medicaid,210.57,,,210.57,Other,100% of Medicaid,210.57,,,210.57,Other,100% of Medicaid,473.77,,,473.77,Other,225% of Medicaid,322.17,,,322.17,Other,153% of Medicaid,473.77,,,473.77,Other,225% of Medicaid,294.79,,,294.79,Other,140% of Medicaid,473.77,,,473.77,Other,225% of Medicaid,547.47,,,547.47,Other,260% of Medicaid,682.23,,,682.23,Other,324% of Medicaid,452.72,,,452.72,Other,215% of Medicaid,452.72,,,452.72,Other,215% of Medicaid,263.21,,,263.21,Other,125% of Medicaid,210.57,757.56,
RETROGRADE PYELOGRAM,74420,CPT,TC,42074420,CDM,320,RC,,,both,,,1142,845.08,,,845.08,Other,150% of Medicare + 9.63% HCRA Surcharge,513.9,45,,513.9,percent of total billed charges,Critical Access Hospital RCC factor,187.32,,,187.32,Fee Schedule,,168.53,,,168.53,Fee Schedule,,1185.43,,,1185.43,Fee Schedule,,1066.22,,,1066.22,Fee Schedule,,1007.73,,,1007.73,Fee Schedule,,565.29,,,565.29,Other,110% of Medicare,222.55,,,222.55,Fee Schedule,,392,,,392,Other,186% of Medicaid,261.89,,,261.89,Fee Schedule,,708.04,,,708.04,Fee Schedule,,123.31,,,123.31,Fee Schedule,,261.89,,,261.89,Fee Schedule,,708.04,,,708.04,Fee Schedule,,231.94,,,231.94,Fee Schedule,,799.4,70,,799.4,percent of total billed charges,All Other,257.48,,,257.48,Fee Schedule,,218.23,,,218.23,Fee Schedule,,610.96,,,610.96,Fee Schedule,,610.96,,,610.96,Fee Schedule,,610.96,,,610.96,Fee Schedule,,610.96,,,610.96,Fee Schedule,,210.57,,,210.57,Other,100% of Medicaid,210.57,,,210.57,Other,100% of Medicaid,210.57,,,210.57,Other,100% of Medicaid,210.57,,,210.57,Other,100% of Medicaid,473.77,,,473.77,Other,225% of Medicaid,322.17,,,322.17,Other,153% of Medicaid,473.77,,,473.77,Other,225% of Medicaid,294.79,,,294.79,Other,140% of Medicaid,473.77,,,473.77,Other,225% of Medicaid,547.47,,,547.47,Other,260% of Medicaid,682.23,,,682.23,Other,324% of Medicaid,452.72,,,452.72,Other,215% of Medicaid,452.72,,,452.72,Other,215% of Medicaid,263.21,,,263.21,Other,125% of Medicaid,123.31,1185.43,
XR URINARY TRACT W CONTRAST,74425,CPT,TC,42074425,CDM,320,RC,,,both,,,1137,841.38,,,841.38,Other,150% of Medicare + 9.63% HCRA Surcharge,511.65,45,,511.65,percent of total billed charges,Critical Access Hospital RCC factor,389.5,,,389.5,Fee Schedule,,350.43,,,350.43,Fee Schedule,,1185.43,,,1185.43,Fee Schedule,,1066.22,,,1066.22,Fee Schedule,,1007.73,,,1007.73,Fee Schedule,,562.82,,,562.82,Other,110% of Medicare,462.76,,,462.76,Fee Schedule,,392,,,392,Other,186% of Medicaid,544.57,,,544.57,Fee Schedule,,704.94,,,704.94,Fee Schedule,,256.41,,,256.41,Fee Schedule,,544.57,,,544.57,Fee Schedule,,704.94,,,704.94,Fee Schedule,,482.3,,,482.3,Fee Schedule,,795.9,70,,795.9,percent of total billed charges,All Other,567.44,,,567.44,Fee Schedule,,480.94,,,480.94,Fee Schedule,,610.96,,,610.96,Fee Schedule,,610.96,,,610.96,Fee Schedule,,610.96,,,610.96,Fee Schedule,,610.96,,,610.96,Fee Schedule,,210.57,,,210.57,Other,100% of Medicaid,210.57,,,210.57,Other,100% of Medicaid,210.57,,,210.57,Other,100% of Medicaid,210.57,,,210.57,Other,100% of Medicaid,473.77,,,473.77,Other,225% of Medicaid,322.17,,,322.17,Other,153% of Medicaid,473.77,,,473.77,Other,225% of Medicaid,294.79,,,294.79,Other,140% of Medicaid,473.77,,,473.77,Other,225% of Medicaid,547.47,,,547.47,Other,260% of Medicaid,682.23,,,682.23,Other,324% of Medicaid,452.72,,,452.72,Other,215% of Medicaid,452.72,,,452.72,Other,215% of Medicaid,263.21,,,263.21,Other,125% of Medicaid,210.57,1185.43,
XR BLADDER 3+ VIEWS W CONTR,74430,CPT,TC,42074430,CDM,320,RC,,,both,,,838,620.12,,,620.12,Other,150% of Medicare + 9.63% HCRA Surcharge,377.1,45,,377.1,percent of total billed charges,Critical Access Hospital RCC factor,91.43,,,91.43,Fee Schedule,,82.25,,,82.25,Fee Schedule,,306.71,,,306.71,Fee Schedule,,275.87,,,275.87,Fee Schedule,,260.74,,,260.74,Fee Schedule,,414.81,,,414.81,Other,110% of Medicare,108.62,,,108.62,Fee Schedule,,392,,,392,Other,186% of Medicaid,127.82,,,127.82,Fee Schedule,,519.56,,,519.56,Fee Schedule,,60.19,,,60.19,Fee Schedule,,127.82,,,127.82,Fee Schedule,,519.56,,,519.56,Fee Schedule,,113.21,,,113.21,Fee Schedule,,586.6,70,,586.6,percent of total billed charges,All Other,126.28,,,126.28,Fee Schedule,,107.03,,,107.03,Fee Schedule,,610.96,,,610.96,Fee Schedule,,610.96,,,610.96,Fee Schedule,,610.96,,,610.96,Fee Schedule,,610.96,,,610.96,Fee Schedule,,210.57,,,210.57,Other,100% of Medicaid,210.57,,,210.57,Other,100% of Medicaid,210.57,,,210.57,Other,100% of Medicaid,210.57,,,210.57,Other,100% of Medicaid,473.77,,,473.77,Other,225% of Medicaid,322.17,,,322.17,Other,153% of Medicaid,473.77,,,473.77,Other,225% of Medicaid,294.79,,,294.79,Other,140% of Medicaid,473.77,,,473.77,Other,225% of Medicaid,547.47,,,547.47,Other,260% of Medicaid,682.23,,,682.23,Other,324% of Medicaid,452.72,,,452.72,Other,215% of Medicaid,452.72,,,452.72,Other,215% of Medicaid,263.21,,,263.21,Other,125% of Medicaid,60.19,682.23,
URETHROGRAM RETROGRADE,74450,CPT,TC,42074450,CDM,320,RC,,,both,,,1235,913.9,,,913.9,Other,150% of Medicare + 9.63% HCRA Surcharge,555.75,45,,555.75,percent of total billed charges,Critical Access Hospital RCC factor,802.75,65,,802.75,percent of total billed charges,All Other,728.65,65,,728.65,percent of total billed charges,All Other,1185.43,,,1185.43,Fee Schedule,,1066.22,,,1066.22,Fee Schedule,,1007.73,,,1007.73,Fee Schedule,,611.33,,,611.33,Other,110% of Medicare,839.8,68,,839.8,percent of total billed charges,All Other,392,,,392,Other,186% of Medicaid,988,80,,988,percent of total billed charges,All Other,1025.05,83,,1025.05,percent of total billed charges,All Other,1025.05,83,,1025.05,percent of total billed charges,All Other,988,80,,988,percent of total billed charges,All Other,1025.05,83,,1025.05,percent of total billed charges,All Other,988,80,,988,percent of total billed charges,All Other,864.5,70,,864.5,percent of total billed charges,All Other,802.75,65,,802.75,percent of total billed charges,Default if not in Fee Schedule,802.75,65,,802.75,percent of total billed charges,Default if not in Fee Schedule,372.86,,,372.86,Fee Schedule,,372.86,,,372.86,Fee Schedule,,372.86,,,372.86,Fee Schedule,,372.86,,,372.86,Fee Schedule,,210.57,,,210.57,Other,100% of Medicaid,210.57,,,210.57,Other,100% of Medicaid,210.57,,,210.57,Other,100% of Medicaid,210.57,,,210.57,Other,100% of Medicaid,473.77,,,473.77,Other,225% of Medicaid,322.17,,,322.17,Other,153% of Medicaid,473.77,,,473.77,Other,225% of Medicaid,294.79,,,294.79,Other,140% of Medicaid,473.77,,,473.77,Other,225% of Medicaid,547.47,,,547.47,Other,260% of Medicaid,682.23,,,682.23,Other,324% of Medicaid,452.72,,,452.72,Other,215% of Medicaid,452.72,,,452.72,Other,215% of Medicaid,263.21,,,263.21,Other,125% of Medicaid,210.57,1185.43,
DILATION URETERS/URETHRA/NEPHR,74485,CPT,TC,42074485,CDM,320,RC,,,both,,,5267,3897.59,,,3897.59,Other,150% of Medicare + 9.63% HCRA Surcharge,2370.15,45,,2370.15,percent of total billed charges,Critical Access Hospital RCC factor,280.91,,,280.91,Fee Schedule,,252.73,,,252.73,Fee Schedule,,565.31,,,565.31,Fee Schedule,,508.46,,,508.46,Fee Schedule,,480.57,,,480.57,Fee Schedule,,2607.17,,,2607.17,Other,110% of Medicare,333.75,,,333.75,Fee Schedule,,544,,,544,Other,186% of Medicaid,392.75,,,392.75,Fee Schedule,,3265.54,,,3265.54,Fee Schedule,,184.93,,,184.93,Fee Schedule,,392.75,,,392.75,Fee Schedule,,3265.54,,,3265.54,Fee Schedule,,347.84,,,347.84,Fee Schedule,,3686.9,70,,3686.9,percent of total billed charges,All Other,401.8,,,401.8,Fee Schedule,,340.55,,,340.55,Fee Schedule,,2834.48,,,2834.48,Fee Schedule,,2834.48,,,2834.48,Fee Schedule,,2834.48,,,2834.48,Fee Schedule,,2834.48,,,2834.48,Fee Schedule,,292.43,,,292.43,Other,100% of Medicaid,292.43,,,292.43,Other,100% of Medicaid,292.43,,,292.43,Other,100% of Medicaid,292.43,,,292.43,Other,100% of Medicaid,657.97,,,657.97,Other,225% of Medicaid,447.42,,,447.42,Other,153% of Medicaid,657.97,,,657.97,Other,225% of Medicaid,409.4,,,409.4,Other,140% of Medicaid,657.97,,,657.97,Other,225% of Medicaid,760.32,,,760.32,Other,260% of Medicaid,947.48,,,947.48,Other,324% of Medicaid,628.73,,,628.73,Other,215% of Medicaid,628.73,,,628.73,Other,215% of Medicaid,365.54,,,365.54,Other,125% of Medicaid,184.93,3897.59,
HYSTEROSALPINGOGRAM,74740,CPT,TC,42074740,CDM,320,RC,,,both,,,1169,865.06,,,865.06,Other,150% of Medicare + 9.63% HCRA Surcharge,526.05,45,,526.05,percent of total billed charges,Critical Access Hospital RCC factor,262.41,,,262.41,Fee Schedule,,236.09,,,236.09,Fee Schedule,,409.69,,,409.69,Fee Schedule,,368.49,,,368.49,Fee Schedule,,348.28,,,348.28,Fee Schedule,,578.66,,,578.66,Other,110% of Medicare,311.77,,,311.77,Fee Schedule,,392,,,392,Other,186% of Medicaid,366.88,,,366.88,Fee Schedule,,724.78,,,724.78,Fee Schedule,,172.75,,,172.75,Fee Schedule,,366.88,,,366.88,Fee Schedule,,724.78,,,724.78,Fee Schedule,,324.93,,,324.93,Fee Schedule,,818.3,70,,818.3,percent of total billed charges,All Other,393.6,,,393.6,Fee Schedule,,333.6,,,333.6,Fee Schedule,,372.86,,,372.86,Fee Schedule,,372.86,,,372.86,Fee Schedule,,372.86,,,372.86,Fee Schedule,,372.86,,,372.86,Fee Schedule,,210.57,,,210.57,Other,100% of Medicaid,210.57,,,210.57,Other,100% of Medicaid,210.57,,,210.57,Other,100% of Medicaid,210.57,,,210.57,Other,100% of Medicaid,473.77,,,473.77,Other,225% of Medicaid,322.17,,,322.17,Other,153% of Medicaid,473.77,,,473.77,Other,225% of Medicaid,294.79,,,294.79,Other,140% of Medicaid,473.77,,,473.77,Other,225% of Medicaid,547.47,,,547.47,Other,260% of Medicaid,682.23,,,682.23,Other,324% of Medicaid,452.72,,,452.72,Other,215% of Medicaid,452.72,,,452.72,Other,215% of Medicaid,263.21,,,263.21,Other,125% of Medicaid,172.75,865.06,
SHUNTOGRAM,75809,CPT,TC,42075809,CDM,320,RC,,,both,,,667,493.58,,,493.58,Other,150% of Medicare + 9.63% HCRA Surcharge,300.15,45,,300.15,percent of total billed charges,Critical Access Hospital RCC factor,205.82,,,205.82,Fee Schedule,,185.17,,,185.17,Fee Schedule,,501.23,,,501.23,Fee Schedule,,450.82,,,450.82,Fee Schedule,,426.09,,,426.09,Fee Schedule,,330.17,,,330.17,Other,110% of Medicare,244.53,,,244.53,Fee Schedule,,392,,,392,Other,186% of Medicaid,287.76,,,287.76,Fee Schedule,,413.54,,,413.54,Fee Schedule,,135.49,,,135.49,Fee Schedule,,287.76,,,287.76,Fee Schedule,,413.54,,,413.54,Fee Schedule,,254.85,,,254.85,Fee Schedule,,466.9,70,,466.9,percent of total billed charges,All Other,291.92,,,291.92,Fee Schedule,,247.42,,,247.42,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,210.57,,,210.57,Other,100% of Medicaid,210.57,,,210.57,Other,100% of Medicaid,210.57,,,210.57,Other,100% of Medicaid,210.57,,,210.57,Other,100% of Medicaid,473.77,,,473.77,Other,225% of Medicaid,322.17,,,322.17,Other,153% of Medicaid,473.77,,,473.77,Other,225% of Medicaid,294.79,,,294.79,Other,140% of Medicaid,473.77,,,473.77,Other,225% of Medicaid,547.47,,,547.47,Other,260% of Medicaid,682.23,,,682.23,Other,324% of Medicaid,452.72,,,452.72,Other,215% of Medicaid,452.72,,,452.72,Other,215% of Medicaid,263.21,,,263.21,Other,125% of Medicaid,135.49,682.23,
VENOGRAM EXTREMITY UNIL,75820,CPT,TC,42075820,CDM,320,RC,,,both,,,3649,2700.27,,,2700.27,Other,150% of Medicare + 9.63% HCRA Surcharge,1642.05,45,,1642.05,percent of total billed charges,Critical Access Hospital RCC factor,205.82,,,205.82,Fee Schedule,,185.17,,,185.17,Fee Schedule,,611.11,,,611.11,Fee Schedule,,549.65,,,549.65,Fee Schedule,,519.5,,,519.5,Fee Schedule,,1806.26,,,1806.26,Other,110% of Medicare,244.53,,,244.53,Fee Schedule,,490,,,490,Other,186% of Medicaid,287.76,,,287.76,Fee Schedule,,2262.38,,,2262.38,Fee Schedule,,135.49,,,135.49,Fee Schedule,,287.76,,,287.76,Fee Schedule,,2262.38,,,2262.38,Fee Schedule,,254.85,,,254.85,Fee Schedule,,2554.3,70,,2554.3,percent of total billed charges,All Other,300.12,,,300.12,Fee Schedule,,254.37,,,254.37,Fee Schedule,,1008.82,,,1008.82,Fee Schedule,,1008.82,,,1008.82,Fee Schedule,,1008.82,,,1008.82,Fee Schedule,,1008.82,,,1008.82,Fee Schedule,,263.19,,,263.19,Other,100% of Medicaid,263.19,,,263.19,Other,100% of Medicaid,263.19,,,263.19,Other,100% of Medicaid,263.19,,,263.19,Other,100% of Medicaid,592.18,,,592.18,Other,225% of Medicaid,402.68,,,402.68,Other,153% of Medicaid,592.18,,,592.18,Other,225% of Medicaid,368.47,,,368.47,Other,140% of Medicaid,592.18,,,592.18,Other,225% of Medicaid,684.3,,,684.3,Other,260% of Medicaid,852.74,,,852.74,Other,324% of Medicaid,565.86,,,565.86,Other,215% of Medicaid,565.86,,,565.86,Other,215% of Medicaid,328.99,,,328.99,Other,125% of Medicaid,135.49,2700.27,
VENOGRAPHY EXTREMITY; BILATERAL,75822,CPT,TC,42075822,CDM,320,RC,,,both,,,3350,2479.01,,,2479.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1507.5,45,,1507.5,percent of total billed charges,Critical Access Hospital RCC factor,227.77,,,227.77,Fee Schedule,,204.92,,,204.92,Fee Schedule,,684.31,,,684.31,Fee Schedule,,615.49,,,615.49,Fee Schedule,,581.73,,,581.73,Fee Schedule,,1658.25,,,1658.25,Other,110% of Medicare,270.61,,,270.61,Fee Schedule,,490,,,490,Other,186% of Medicaid,318.44,,,318.44,Fee Schedule,,2077,,,2077,Fee Schedule,,149.94,,,149.94,Fee Schedule,,318.44,,,318.44,Fee Schedule,,2077,,,2077,Fee Schedule,,282.03,,,282.03,Fee Schedule,,2345,70,,2345,percent of total billed charges,All Other,323.08,,,323.08,Fee Schedule,,273.83,,,273.83,Fee Schedule,,2609.81,,,2609.81,Fee Schedule,,2609.81,,,2609.81,Fee Schedule,,2609.81,,,2609.81,Fee Schedule,,2609.81,,,2609.81,Fee Schedule,,263.19,,,263.19,Other,100% of Medicaid,263.19,,,263.19,Other,100% of Medicaid,263.19,,,263.19,Other,100% of Medicaid,263.19,,,263.19,Other,100% of Medicaid,592.18,,,592.18,Other,225% of Medicaid,402.68,,,402.68,Other,153% of Medicaid,592.18,,,592.18,Other,225% of Medicaid,368.47,,,368.47,Other,140% of Medicaid,592.18,,,592.18,Other,225% of Medicaid,684.3,,,684.3,Other,260% of Medicaid,852.74,,,852.74,Other,324% of Medicaid,565.86,,,565.86,Other,215% of Medicaid,565.86,,,565.86,Other,215% of Medicaid,328.99,,,328.99,Other,125% of Medicaid,149.94,2609.81,
VENOGRAPHY W SERIALOGRAPHY,75827,CPT,TC,42075827,CDM,320,RC,,,both,,,3350,2479.01,,,2479.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1507.5,45,,1507.5,percent of total billed charges,Critical Access Hospital RCC factor,228.91,,,228.91,Fee Schedule,,205.95,,,205.95,Fee Schedule,,1032.13,,,1032.13,Fee Schedule,,928.33,,,928.33,Fee Schedule,,877.41,,,877.41,Fee Schedule,,1658.25,,,1658.25,Other,110% of Medicare,271.97,,,271.97,Fee Schedule,,490,,,490,Other,186% of Medicaid,320.05,,,320.05,Fee Schedule,,2077,,,2077,Fee Schedule,,150.7,,,150.7,Fee Schedule,,320.05,,,320.05,Fee Schedule,,2077,,,2077,Fee Schedule,,283.45,,,283.45,Fee Schedule,,2345,70,,2345,percent of total billed charges,All Other,329.64,,,329.64,Fee Schedule,,279.39,,,279.39,Fee Schedule,,1008.82,,,1008.82,Fee Schedule,,1008.82,,,1008.82,Fee Schedule,,1008.82,,,1008.82,Fee Schedule,,1008.82,,,1008.82,Fee Schedule,,263.19,,,263.19,Other,100% of Medicaid,263.19,,,263.19,Other,100% of Medicaid,263.19,,,263.19,Other,100% of Medicaid,263.19,,,263.19,Other,100% of Medicaid,592.18,,,592.18,Other,225% of Medicaid,402.68,,,402.68,Other,153% of Medicaid,592.18,,,592.18,Other,225% of Medicaid,368.47,,,368.47,Other,140% of Medicaid,592.18,,,592.18,Other,225% of Medicaid,684.3,,,684.3,Other,260% of Medicaid,852.74,,,852.74,Other,324% of Medicaid,565.86,,,565.86,Other,215% of Medicaid,565.86,,,565.86,Other,215% of Medicaid,328.99,,,328.99,Other,125% of Medicaid,150.7,2479.01,
REMOVE CVD LUMEN OBSTRUCT,75902,CPT,TC,42075902,CDM,320,RC,,,both,,,406,300.44,,,300.44,Other,150% of Medicare + 9.63% HCRA Surcharge,182.7,45,,182.7,percent of total billed charges,Critical Access Hospital RCC factor,242.79,,,242.79,Fee Schedule,,218.44,,,218.44,Fee Schedule,,389.14,,,389.14,Fee Schedule,,350,,,350,Fee Schedule,,330.8,,,330.8,Fee Schedule,,200.97,,,200.97,Other,110% of Medicare,288.46,,,288.46,Fee Schedule,,544,,,544,Other,186% of Medicaid,339.45,,,339.45,Fee Schedule,,251.72,,,251.72,Fee Schedule,,159.83,,,159.83,Fee Schedule,,339.45,,,339.45,Fee Schedule,,251.72,,,251.72,Fee Schedule,,300.63,,,300.63,Fee Schedule,,284.2,70,,284.2,percent of total billed charges,All Other,370.64,,,370.64,Fee Schedule,,314.14,,,314.14,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,292.43,,,292.43,Other,100% of Medicaid,292.43,,,292.43,Other,100% of Medicaid,292.43,,,292.43,Other,100% of Medicaid,292.43,,,292.43,Other,100% of Medicaid,657.97,,,657.97,Other,225% of Medicaid,447.42,,,447.42,Other,153% of Medicaid,657.97,,,657.97,Other,225% of Medicaid,409.4,,,409.4,Other,140% of Medicaid,657.97,,,657.97,Other,225% of Medicaid,760.32,,,760.32,Other,260% of Medicaid,947.48,,,947.48,Other,324% of Medicaid,628.73,,,628.73,Other,215% of Medicaid,628.73,,,628.73,Other,215% of Medicaid,365.54,,,365.54,Other,125% of Medicaid,0.01,947.48,
XR CONTROL CATHETER CHANGE,75984,CPT,TC,42075984,CDM,320,RC,,,both,,,590,436.6,,,436.6,Other,150% of Medicare + 9.63% HCRA Surcharge,265.5,45,,265.5,percent of total billed charges,Critical Access Hospital RCC factor,201.19,,,201.19,Fee Schedule,,181.01,,,181.01,Fee Schedule,,535.59,,,535.59,Fee Schedule,,481.73,,,481.73,Fee Schedule,,455.3,,,455.3,Fee Schedule,,292.05,,,292.05,Other,110% of Medicare,239.04,,,239.04,Fee Schedule,,544,,,544,Other,186% of Medicaid,281.29,,,281.29,Fee Schedule,,365.8,,,365.8,Fee Schedule,,132.45,,,132.45,Fee Schedule,,281.29,,,281.29,Fee Schedule,,365.8,,,365.8,Fee Schedule,,249.13,,,249.13,Fee Schedule,,413,70,,413,percent of total billed charges,All Other,295.2,,,295.2,Fee Schedule,,250.2,,,250.2,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,292.43,,,292.43,Other,100% of Medicaid,292.43,,,292.43,Other,100% of Medicaid,292.43,,,292.43,Other,100% of Medicaid,292.43,,,292.43,Other,100% of Medicaid,657.97,,,657.97,Other,225% of Medicaid,447.42,,,447.42,Other,153% of Medicaid,657.97,,,657.97,Other,225% of Medicaid,409.4,,,409.4,Other,140% of Medicaid,657.97,,,657.97,Other,225% of Medicaid,760.32,,,760.32,Other,260% of Medicaid,947.48,,,947.48,Other,324% of Medicaid,628.73,,,628.73,Other,215% of Medicaid,628.73,,,628.73,Other,215% of Medicaid,365.54,,,365.54,Other,125% of Medicaid,0.01,947.48,
FLUOROSCOPE EXAM =< 1 HR,76000,CPT,TC,42076000,CDM,320,RC,,,both,,,527,389.98,,,389.98,Other,150% of Medicare + 9.63% HCRA Surcharge,237.15,45,,237.15,percent of total billed charges,Critical Access Hospital RCC factor,97.2,,,97.2,Fee Schedule,,87.45,,,87.45,Fee Schedule,,466.92,,,466.92,Fee Schedule,,419.96,,,419.96,Fee Schedule,,396.93,,,396.93,Fee Schedule,,260.87,,,260.87,Other,110% of Medicare,115.48,,,115.48,Fee Schedule,,392,,,392,Other,186% of Medicaid,135.9,,,135.9,Fee Schedule,,326.74,,,326.74,Fee Schedule,,63.99,,,63.99,Fee Schedule,,135.9,,,135.9,Fee Schedule,,326.74,,,326.74,Fee Schedule,,120.36,,,120.36,Fee Schedule,,368.9,70,,368.9,percent of total billed charges,All Other,136.12,,,136.12,Fee Schedule,,115.37,,,115.37,Fee Schedule,,372.86,,,372.86,Fee Schedule,,372.86,,,372.86,Fee Schedule,,372.86,,,372.86,Fee Schedule,,372.86,,,372.86,Fee Schedule,,210.57,,,210.57,Other,100% of Medicaid,210.57,,,210.57,Other,100% of Medicaid,210.57,,,210.57,Other,100% of Medicaid,210.57,,,210.57,Other,100% of Medicaid,473.77,,,473.77,Other,225% of Medicaid,322.17,,,322.17,Other,153% of Medicaid,473.77,,,473.77,Other,225% of Medicaid,294.79,,,294.79,Other,140% of Medicaid,473.77,,,473.77,Other,225% of Medicaid,547.47,,,547.47,Other,260% of Medicaid,682.23,,,682.23,Other,324% of Medicaid,452.72,,,452.72,Other,215% of Medicaid,452.72,,,452.72,Other,215% of Medicaid,263.21,,,263.21,Other,125% of Medicaid,63.99,682.23,
NOSE TO RECTUM FOR FB CHILD,76010,CPT,TC,42076010,CDM,320,RC,,,both,,,231,170.94,,,170.94,Other,150% of Medicare + 9.63% HCRA Surcharge,103.95,45,,103.95,percent of total billed charges,Critical Access Hospital RCC factor,72.96,,,72.96,Fee Schedule,,65.64,,,65.64,Fee Schedule,,125.95,,,125.95,Fee Schedule,,113.29,,,113.29,Fee Schedule,,107.07,,,107.07,Fee Schedule,,114.35,,,114.35,Other,110% of Medicare,86.68,,,86.68,Fee Schedule,,53,,,53,Other,186% of Medicaid,102,,,102,Fee Schedule,,143.22,,,143.22,Fee Schedule,,48.03,,,48.03,Fee Schedule,,102,,,102,Fee Schedule,,143.22,,,143.22,Fee Schedule,,90.34,,,90.34,Fee Schedule,,161.7,70,,161.7,percent of total billed charges,All Other,103.32,,,103.32,Fee Schedule,,87.57,,,87.57,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,170.94,
ABSCESS FISTULA/SINUS TRACT ST,76080,CPT,TC,42076080,CDM,320,RC,,,both,,,1134,839.16,,,839.16,Other,150% of Medicare + 9.63% HCRA Surcharge,510.3,45,,510.3,percent of total billed charges,Critical Access Hospital RCC factor,122.62,,,122.62,Fee Schedule,,110.32,,,110.32,Fee Schedule,,240.36,,,240.36,Fee Schedule,,216.19,,,216.19,Fee Schedule,,204.33,,,204.33,Fee Schedule,,561.33,,,561.33,Other,110% of Medicare,145.69,,,145.69,Fee Schedule,,392,,,392,Other,186% of Medicaid,171.44,,,171.44,Fee Schedule,,703.08,,,703.08,Fee Schedule,,80.72,,,80.72,Fee Schedule,,171.44,,,171.44,Fee Schedule,,703.08,,,703.08,Fee Schedule,,151.84,,,151.84,Fee Schedule,,793.8,70,,793.8,percent of total billed charges,All Other,175.48,,,175.48,Fee Schedule,,148.73,,,148.73,Fee Schedule,,770.53,,,770.53,Fee Schedule,,770.53,,,770.53,Fee Schedule,,770.53,,,770.53,Fee Schedule,,770.53,,,770.53,Fee Schedule,,210.57,,,210.57,Other,100% of Medicaid,210.57,,,210.57,Other,100% of Medicaid,210.57,,,210.57,Other,100% of Medicaid,210.57,,,210.57,Other,100% of Medicaid,473.77,,,473.77,Other,225% of Medicaid,322.17,,,322.17,Other,153% of Medicaid,473.77,,,473.77,Other,225% of Medicaid,294.79,,,294.79,Other,140% of Medicaid,473.77,,,473.77,Other,225% of Medicaid,547.47,,,547.47,Other,260% of Medicaid,682.23,,,682.23,Other,324% of Medicaid,452.72,,,452.72,Other,215% of Medicaid,452.72,,,452.72,Other,215% of Medicaid,263.21,,,263.21,Other,125% of Medicaid,80.72,839.16,
TOMOGRAM,76100,CPT,TC,42076100,CDM,320,RC,,,both,,,816,603.84,,,603.84,Other,150% of Medicare + 9.63% HCRA Surcharge,367.2,45,,367.2,percent of total billed charges,Critical Access Hospital RCC factor,215.04,,,215.04,Fee Schedule,,193.47,,,193.47,Fee Schedule,,510.4,,,510.4,Fee Schedule,,459.07,,,459.07,Fee Schedule,,433.89,,,433.89,Fee Schedule,,403.92,,,403.92,Other,110% of Medicare,255.48,,,255.48,Fee Schedule,,53,,,53,Other,186% of Medicaid,300.65,,,300.65,Fee Schedule,,505.92,,,505.92,Fee Schedule,,141.56,,,141.56,Fee Schedule,,300.65,,,300.65,Fee Schedule,,505.92,,,505.92,Fee Schedule,,266.27,,,266.27,Fee Schedule,,571.2,70,,571.2,percent of total billed charges,All Other,305.04,,,305.04,Fee Schedule,,258.54,,,258.54,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,603.84,
CINE/VIDEO X-RAYS,76120,CPT,,42076120,CDM,320,RC,,,both,,,399,295.26,,,295.26,Other,150% of Medicare + 9.63% HCRA Surcharge,179.55,45,,179.55,percent of total billed charges,Critical Access Hospital RCC factor,343.28,,,343.28,Fee Schedule,,308.84,,,308.84,Fee Schedule,,391.4,,,391.4,Fee Schedule,,352.04,,,352.04,Fee Schedule,,332.73,,,332.73,Fee Schedule,,197.51,,,197.51,Other,110% of Medicare,407.84,,,407.84,Fee Schedule,,53,,,53,Other,186% of Medicaid,479.94,,,479.94,Fee Schedule,,247.38,,,247.38,Fee Schedule,,225.98,,,225.98,Fee Schedule,,479.94,,,479.94,Fee Schedule,,247.38,,,247.38,Fee Schedule,,425.06,,,425.06,Fee Schedule,,279.3,70,,279.3,percent of total billed charges,All Other,477.24,,,477.24,Fee Schedule,,404.49,,,404.49,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,479.94,
FLUOROSCOPIC GUIDANCE FOR CV,77001,CPT,TC,42077001,CDM,320,RC,,,both,,,581,429.94,,,429.94,Other,150% of Medicare + 9.63% HCRA Surcharge,261.45,45,,261.45,percent of total billed charges,Critical Access Hospital RCC factor,280.91,,,280.91,Fee Schedule,,252.73,,,252.73,Fee Schedule,,643.1,,,643.1,Fee Schedule,,578.42,,,578.42,Fee Schedule,,546.69,,,546.69,Fee Schedule,,287.6,,,287.6,Other,110% of Medicare,333.75,,,333.75,Fee Schedule,,544,,,544,Other,186% of Medicaid,392.75,,,392.75,Fee Schedule,,360.22,,,360.22,Fee Schedule,,184.93,,,184.93,Fee Schedule,,392.75,,,392.75,Fee Schedule,,360.22,,,360.22,Fee Schedule,,347.84,,,347.84,Fee Schedule,,406.7,70,,406.7,percent of total billed charges,All Other,416.56,,,416.56,Fee Schedule,,353.06,,,353.06,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,292.43,,,292.43,Other,100% of Medicaid,292.43,,,292.43,Other,100% of Medicaid,292.43,,,292.43,Other,100% of Medicaid,292.43,,,292.43,Other,100% of Medicaid,657.97,,,657.97,Other,225% of Medicaid,447.42,,,447.42,Other,153% of Medicaid,657.97,,,657.97,Other,225% of Medicaid,409.4,,,409.4,Other,140% of Medicaid,657.97,,,657.97,Other,225% of Medicaid,760.32,,,760.32,Other,260% of Medicaid,947.48,,,947.48,Other,324% of Medicaid,628.73,,,628.73,Other,215% of Medicaid,628.73,,,628.73,Other,215% of Medicaid,365.54,,,365.54,Other,125% of Medicaid,0.01,947.48,
NEEDLE LOCALIZATION BY XR,77002,CPT,TC,42077002,CDM,320,RC,,,both,,,577,426.98,,,426.98,Other,150% of Medicare + 9.63% HCRA Surcharge,259.65,45,,259.65,percent of total billed charges,Critical Access Hospital RCC factor,310.93,,,310.93,Fee Schedule,,279.74,,,279.74,Fee Schedule,,325.05,,,325.05,Fee Schedule,,292.36,,,292.36,Fee Schedule,,276.33,,,276.33,Fee Schedule,,285.62,,,285.62,Other,110% of Medicare,369.41,,,369.41,Fee Schedule,,544,,,544,Other,186% of Medicaid,434.72,,,434.72,Fee Schedule,,357.74,,,357.74,Fee Schedule,,204.69,,,204.69,Fee Schedule,,434.72,,,434.72,Fee Schedule,,357.74,,,357.74,Fee Schedule,,385.01,,,385.01,Fee Schedule,,403.9,70,,403.9,percent of total billed charges,All Other,441.16,,,441.16,Fee Schedule,,373.91,,,373.91,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,292.43,,,292.43,Other,100% of Medicaid,292.43,,,292.43,Other,100% of Medicaid,292.43,,,292.43,Other,100% of Medicaid,292.43,,,292.43,Other,100% of Medicaid,657.97,,,657.97,Other,225% of Medicaid,447.42,,,447.42,Other,153% of Medicaid,657.97,,,657.97,Other,225% of Medicaid,409.4,,,409.4,Other,140% of Medicaid,657.97,,,657.97,Other,225% of Medicaid,760.32,,,760.32,Other,260% of Medicaid,947.48,,,947.48,Other,324% of Medicaid,628.73,,,628.73,Other,215% of Medicaid,628.73,,,628.73,Other,215% of Medicaid,365.54,,,365.54,Other,125% of Medicaid,0.01,947.48,
FLUOROGUIDE FOR SPINE INJECT,77003,CPT,TC,42077003,CDM,320,RC,,,both,,,618,457.32,,,457.32,Other,150% of Medicare + 9.63% HCRA Surcharge,278.1,45,,278.1,percent of total billed charges,Critical Access Hospital RCC factor,267.03,,,267.03,Fee Schedule,,240.25,,,240.25,Fee Schedule,,222.08,,,222.08,Fee Schedule,,199.74,,,199.74,Fee Schedule,,188.79,,,188.79,Fee Schedule,,305.91,,,305.91,Other,110% of Medicare,317.26,,,317.26,Fee Schedule,,544,,,544,Other,186% of Medicaid,373.35,,,373.35,Fee Schedule,,383.16,,,383.16,Fee Schedule,,175.79,,,175.79,Fee Schedule,,373.35,,,373.35,Fee Schedule,,383.16,,,383.16,Fee Schedule,,330.65,,,330.65,Fee Schedule,,432.6,70,,432.6,percent of total billed charges,All Other,378.84,,,378.84,Fee Schedule,,321.09,,,321.09,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,292.43,,,292.43,Other,100% of Medicaid,292.43,,,292.43,Other,100% of Medicaid,292.43,,,292.43,Other,100% of Medicaid,292.43,,,292.43,Other,100% of Medicaid,657.97,,,657.97,Other,225% of Medicaid,447.42,,,447.42,Other,153% of Medicaid,657.97,,,657.97,Other,225% of Medicaid,409.4,,,409.4,Other,140% of Medicaid,657.97,,,657.97,Other,225% of Medicaid,760.32,,,760.32,Other,260% of Medicaid,947.48,,,947.48,Other,324% of Medicaid,628.73,,,628.73,Other,215% of Medicaid,628.73,,,628.73,Other,215% of Medicaid,365.54,,,365.54,Other,125% of Medicaid,0.01,947.48,
XR FOR BONE AGE,77072,CPT,TC,42077072,CDM,320,RC,,,both,,,242,179.08,,,179.08,Other,150% of Medicare + 9.63% HCRA Surcharge,108.9,45,,108.9,percent of total billed charges,Critical Access Hospital RCC factor,59.08,,,59.08,Fee Schedule,,53.15,,,53.15,Fee Schedule,,96.23,,,96.23,Fee Schedule,,86.55,,,86.55,Fee Schedule,,81.8,,,81.8,Fee Schedule,,119.79,,,119.79,Other,110% of Medicare,70.19,,,70.19,Fee Schedule,,53,,,53,Other,186% of Medicaid,82.6,,,82.6,Fee Schedule,,150.04,,,150.04,Fee Schedule,,38.89,,,38.89,Fee Schedule,,82.6,,,82.6,Fee Schedule,,150.04,,,150.04,Fee Schedule,,73.15,,,73.15,Fee Schedule,,169.4,70,,169.4,percent of total billed charges,All Other,83.64,,,83.64,Fee Schedule,,70.89,,,70.89,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,179.33,
XR BONE SURVEY LIMITED,77074,CPT,TC,42077074,CDM,320,RC,,,both,,,331,244.94,,,244.94,Other,150% of Medicare + 9.63% HCRA Surcharge,148.95,45,,148.95,percent of total billed charges,Critical Access Hospital RCC factor,154.97,,,154.97,Fee Schedule,,139.42,,,139.42,Fee Schedule,,320.47,,,320.47,Fee Schedule,,288.24,,,288.24,Fee Schedule,,272.43,,,272.43,Fee Schedule,,163.85,,,163.85,Other,110% of Medicare,184.12,,,184.12,Fee Schedule,,53,,,53,Other,186% of Medicaid,216.67,,,216.67,Fee Schedule,,205.22,,,205.22,Fee Schedule,,102.02,,,102.02,Fee Schedule,,216.67,,,216.67,Fee Schedule,,205.22,,,205.22,Fee Schedule,,191.89,,,191.89,Fee Schedule,,231.7,70,,231.7,percent of total billed charges,All Other,218.12,,,218.12,Fee Schedule,,184.87,,,184.87,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,320.47,
XR BONE SURVEY COMPLETE,77075,CPT,TC,42077075,CDM,320,RC,,,both,,,534,395.16,,,395.16,Other,150% of Medicare + 9.63% HCRA Surcharge,240.3,45,,240.3,percent of total billed charges,Critical Access Hospital RCC factor,255.65,,,255.65,Fee Schedule,,230,,,230,Fee Schedule,,510.4,,,510.4,Fee Schedule,,459.07,,,459.07,Fee Schedule,,433.89,,,433.89,Fee Schedule,,264.33,,,264.33,Other,110% of Medicare,303.73,,,303.73,Fee Schedule,,392,,,392,Other,186% of Medicaid,357.42,,,357.42,Fee Schedule,,331.08,,,331.08,Fee Schedule,,168.29,,,168.29,Fee Schedule,,357.42,,,357.42,Fee Schedule,,331.08,,,331.08,Fee Schedule,,316.55,,,316.55,Fee Schedule,,373.8,70,,373.8,percent of total billed charges,All Other,359.16,,,359.16,Fee Schedule,,304.41,,,304.41,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,210.57,,,210.57,Other,100% of Medicaid,210.57,,,210.57,Other,100% of Medicaid,210.57,,,210.57,Other,100% of Medicaid,210.57,,,210.57,Other,100% of Medicaid,473.77,,,473.77,Other,225% of Medicaid,322.17,,,322.17,Other,153% of Medicaid,473.77,,,473.77,Other,225% of Medicaid,294.79,,,294.79,Other,140% of Medicaid,473.77,,,473.77,Other,225% of Medicaid,547.47,,,547.47,Other,260% of Medicaid,682.23,,,682.23,Other,324% of Medicaid,452.72,,,452.72,Other,215% of Medicaid,452.72,,,452.72,Other,215% of Medicaid,263.21,,,263.21,Other,125% of Medicaid,168.29,682.23,
XR BONE SURVEY INFANT,77076,CPT,TC,42077076,CDM,320,RC,,,both,,,510,377.4,,,377.4,Other,150% of Medicare + 9.63% HCRA Surcharge,229.5,45,,229.5,percent of total billed charges,Critical Access Hospital RCC factor,257.98,,,257.98,Fee Schedule,,232.1,,,232.1,Fee Schedule,,448.64,,,448.64,Fee Schedule,,403.52,,,403.52,Fee Schedule,,381.38,,,381.38,Fee Schedule,,252.45,,,252.45,Other,110% of Medicare,306.5,,,306.5,Fee Schedule,,53,,,53,Other,186% of Medicaid,360.68,,,360.68,Fee Schedule,,316.2,,,316.2,Fee Schedule,,169.83,,,169.83,Fee Schedule,,360.68,,,360.68,Fee Schedule,,316.2,,,316.2,Fee Schedule,,319.44,,,319.44,Fee Schedule,,357,70,,357,percent of total billed charges,All Other,362.44,,,362.44,Fee Schedule,,307.19,,,307.19,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,448.64,
XR EYE DETECT FOREIGN BODY,70030,CPT,TCLT,42170030,CDM,320,RC,,,both,,,241,178.34,,,178.34,Other,150% of Medicare + 9.63% HCRA Surcharge,108.45,45,,108.45,percent of total billed charges,Critical Access Hospital RCC factor,84.5,,,84.5,Fee Schedule,,76.03,,,76.03,Fee Schedule,,137.39,,,137.39,Fee Schedule,,123.57,,,123.57,Fee Schedule,,116.79,,,116.79,Fee Schedule,,119.3,,,119.3,Other,110% of Medicare,100.4,,,100.4,Fee Schedule,,53,,,53,Other,186% of Medicaid,118.15,,,118.15,Fee Schedule,,149.42,,,149.42,Fee Schedule,,55.63,,,55.63,Fee Schedule,,118.15,,,118.15,Fee Schedule,,149.42,,,149.42,Fee Schedule,,104.64,,,104.64,Fee Schedule,,168.7,70,,168.7,percent of total billed charges,All Other,116.44,,,116.44,Fee Schedule,,98.69,,,98.69,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,178.34,
XR RIBS 2 VIEWS LEFT,71100,CPT,TCLT,42171100,CDM,320,RC,,,both,,,437,323.38,,,323.38,Other,150% of Medicare + 9.63% HCRA Surcharge,196.65,45,,196.65,percent of total billed charges,Critical Access Hospital RCC factor,91.43,,,91.43,Fee Schedule,,82.25,,,82.25,Fee Schedule,,146.56,,,146.56,Fee Schedule,,131.82,,,131.82,Fee Schedule,,124.59,,,124.59,Fee Schedule,,216.32,,,216.32,Other,110% of Medicare,108.62,,,108.62,Fee Schedule,,53,,,53,Other,186% of Medicaid,127.82,,,127.82,Fee Schedule,,270.94,,,270.94,Fee Schedule,,60.19,,,60.19,Fee Schedule,,127.82,,,127.82,Fee Schedule,,270.94,,,270.94,Fee Schedule,,113.21,,,113.21,Fee Schedule,,305.9,70,,305.9,percent of total billed charges,All Other,127.92,,,127.92,Fee Schedule,,108.42,,,108.42,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,323.38,
XR RIBS 3 VIEWS + CXR LT,71101,CPT,TCLT,42171101,CDM,320,RC,,,both,,,437,323.38,,,323.38,Other,150% of Medicare + 9.63% HCRA Surcharge,196.65,45,,196.65,percent of total billed charges,Critical Access Hospital RCC factor,102.97,,,102.97,Fee Schedule,,92.64,,,92.64,Fee Schedule,,178.6,,,178.6,Fee Schedule,,160.64,,,160.64,Fee Schedule,,151.83,,,151.83,Fee Schedule,,216.32,,,216.32,Other,110% of Medicare,122.34,,,122.34,Fee Schedule,,53,,,53,Other,186% of Medicaid,143.97,,,143.97,Fee Schedule,,270.94,,,270.94,Fee Schedule,,67.79,,,67.79,Fee Schedule,,143.97,,,143.97,Fee Schedule,,270.94,,,270.94,Fee Schedule,,127.51,,,127.51,Fee Schedule,,305.9,70,,305.9,percent of total billed charges,All Other,144.32,,,144.32,Fee Schedule,,122.32,,,122.32,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,323.38,
XR CLAVICLE LEFT,73000,CPT,TCLT,42173000,CDM,320,RC,,,both,,,373,276.02,,,276.02,Other,150% of Medicare + 9.63% HCRA Surcharge,167.85,45,,167.85,percent of total billed charges,Critical Access Hospital RCC factor,85.65,,,85.65,Fee Schedule,,77.06,,,77.06,Fee Schedule,,139.71,,,139.71,Fee Schedule,,125.66,,,125.66,Fee Schedule,,118.76,,,118.76,Fee Schedule,,184.64,,,184.64,Other,110% of Medicare,101.76,,,101.76,Fee Schedule,,53,,,53,Other,186% of Medicaid,119.75,,,119.75,Fee Schedule,,231.26,,,231.26,Fee Schedule,,56.39,,,56.39,Fee Schedule,,119.75,,,119.75,Fee Schedule,,231.26,,,231.26,Fee Schedule,,106.06,,,106.06,Fee Schedule,,261.1,70,,261.1,percent of total billed charges,All Other,118.08,,,118.08,Fee Schedule,,100.08,,,100.08,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,276.02,
XR SCAPULA LEFT,73010,CPT,TCLT,42173010,CDM,320,RC,,,both,,,242,179.08,,,179.08,Other,150% of Medicare + 9.63% HCRA Surcharge,108.9,45,,108.9,percent of total billed charges,Critical Access Hospital RCC factor,53.3,,,53.3,Fee Schedule,,47.96,,,47.96,Fee Schedule,,144.29,,,144.29,Fee Schedule,,129.78,,,129.78,Fee Schedule,,122.66,,,122.66,Fee Schedule,,119.79,,,119.79,Other,110% of Medicare,63.33,,,63.33,Fee Schedule,,53,,,53,Other,186% of Medicaid,74.53,,,74.53,Fee Schedule,,150.04,,,150.04,Fee Schedule,,35.09,,,35.09,Fee Schedule,,74.53,,,74.53,Fee Schedule,,150.04,,,150.04,Fee Schedule,,66,,,66,Fee Schedule,,169.4,70,,169.4,percent of total billed charges,All Other,73.8,,,73.8,Fee Schedule,,62.55,,,62.55,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,179.33,
XR SHOULDER 1 V LT,73020,CPT,TCLT,42173020,CDM,320,RC,,,both,,,231,170.94,,,170.94,Other,150% of Medicare + 9.63% HCRA Surcharge,103.95,45,,103.95,percent of total billed charges,Critical Access Hospital RCC factor,49.86,,,49.86,Fee Schedule,,44.86,,,44.86,Fee Schedule,,109.93,,,109.93,Fee Schedule,,98.88,,,98.88,Fee Schedule,,93.45,,,93.45,Fee Schedule,,114.35,,,114.35,Other,110% of Medicare,59.24,,,59.24,Fee Schedule,,53,,,53,Other,186% of Medicaid,69.71,,,69.71,Fee Schedule,,143.22,,,143.22,Fee Schedule,,32.82,,,32.82,Fee Schedule,,69.71,,,69.71,Fee Schedule,,143.22,,,143.22,Fee Schedule,,61.74,,,61.74,Fee Schedule,,161.7,70,,161.7,percent of total billed charges,All Other,68.88,,,68.88,Fee Schedule,,58.38,,,58.38,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,170.94,
XR SHOULDER 2 VIEWS OR MO LT,73030,CPT,TCLT,42173030,CDM,320,RC,,,both,,,407,301.18,,,301.18,Other,150% of Medicare + 9.63% HCRA Surcharge,183.15,45,,183.15,percent of total billed charges,Critical Access Hospital RCC factor,90.28,,,90.28,Fee Schedule,,81.22,,,81.22,Fee Schedule,,141.97,,,141.97,Fee Schedule,,127.7,,,127.7,Fee Schedule,,120.69,,,120.69,Fee Schedule,,201.47,,,201.47,Other,110% of Medicare,107.26,,,107.26,Fee Schedule,,53,,,53,Other,186% of Medicaid,126.22,,,126.22,Fee Schedule,,252.34,,,252.34,Fee Schedule,,59.43,,,59.43,Fee Schedule,,126.22,,,126.22,Fee Schedule,,252.34,,,252.34,Fee Schedule,,111.79,,,111.79,Fee Schedule,,284.9,70,,284.9,percent of total billed charges,All Other,124.64,,,124.64,Fee Schedule,,105.64,,,105.64,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,301.18,
XR HUMERUS LEFT,73060,CPT,TCLT,42173060,CDM,320,RC,,,both,,,373,276.02,,,276.02,Other,150% of Medicare + 9.63% HCRA Surcharge,167.85,45,,167.85,percent of total billed charges,Critical Access Hospital RCC factor,84.5,,,84.5,Fee Schedule,,76.03,,,76.03,Fee Schedule,,139.71,,,139.71,Fee Schedule,,125.66,,,125.66,Fee Schedule,,118.76,,,118.76,Fee Schedule,,184.64,,,184.64,Other,110% of Medicare,100.4,,,100.4,Fee Schedule,,53,,,53,Other,186% of Medicaid,118.15,,,118.15,Fee Schedule,,231.26,,,231.26,Fee Schedule,,55.63,,,55.63,Fee Schedule,,118.15,,,118.15,Fee Schedule,,231.26,,,231.26,Fee Schedule,,104.64,,,104.64,Fee Schedule,,261.1,70,,261.1,percent of total billed charges,All Other,118.08,,,118.08,Fee Schedule,,100.08,,,100.08,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,276.02,
XR ELBOW 2 VIEW LEFT,73070,CPT,TCLT,42173070,CDM,320,RC,,,both,,,231,170.94,,,170.94,Other,150% of Medicare + 9.63% HCRA Surcharge,103.95,45,,103.95,percent of total billed charges,Critical Access Hospital RCC factor,74.1,,,74.1,Fee Schedule,,66.67,,,66.67,Fee Schedule,,139.71,,,139.71,Fee Schedule,,125.66,,,125.66,Fee Schedule,,118.76,,,118.76,Fee Schedule,,114.35,,,114.35,Other,110% of Medicare,88.04,,,88.04,Fee Schedule,,53,,,53,Other,186% of Medicaid,103.61,,,103.61,Fee Schedule,,143.22,,,143.22,Fee Schedule,,48.78,,,48.78,Fee Schedule,,103.61,,,103.61,Fee Schedule,,143.22,,,143.22,Fee Schedule,,91.76,,,91.76,Fee Schedule,,161.7,70,,161.7,percent of total billed charges,All Other,103.32,,,103.32,Fee Schedule,,87.57,,,87.57,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,170.94,
XR ELBOW 3 VIEWS LT,73080,CPT,TCLT,42173080,CDM,320,RC,,,both,,,392,290.08,,,290.08,Other,150% of Medicare + 9.63% HCRA Surcharge,176.4,45,,176.4,percent of total billed charges,Critical Access Hospital RCC factor,85.65,,,85.65,Fee Schedule,,77.06,,,77.06,Fee Schedule,,174.02,,,174.02,Fee Schedule,,156.51,,,156.51,Fee Schedule,,147.93,,,147.93,Fee Schedule,,194.04,,,194.04,Other,110% of Medicare,101.76,,,101.76,Fee Schedule,,53,,,53,Other,186% of Medicaid,119.75,,,119.75,Fee Schedule,,243.04,,,243.04,Fee Schedule,,56.39,,,56.39,Fee Schedule,,119.75,,,119.75,Fee Schedule,,243.04,,,243.04,Fee Schedule,,106.06,,,106.06,Fee Schedule,,274.4,70,,274.4,percent of total billed charges,All Other,118.08,,,118.08,Fee Schedule,,100.08,,,100.08,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,290.08,
XR ARTHROGRAM ELBOW LT,73085,CPT,TCLT,42173085,CDM,320,RC,,,both,,,1199,887.26,,,887.26,Other,150% of Medicare + 9.63% HCRA Surcharge,539.55,45,,539.55,percent of total billed charges,Critical Access Hospital RCC factor,258.96,,,258.96,Fee Schedule,,232.99,,,232.99,Fee Schedule,,476.09,,,476.09,Fee Schedule,,428.21,,,428.21,Fee Schedule,,404.72,,,404.72,Fee Schedule,,593.51,,,593.51,Other,110% of Medicare,307.67,,,307.67,Fee Schedule,,392,,,392,Other,186% of Medicaid,362.06,,,362.06,Fee Schedule,,743.38,,,743.38,Fee Schedule,,170.48,,,170.48,Fee Schedule,,362.06,,,362.06,Fee Schedule,,743.38,,,743.38,Fee Schedule,,320.66,,,320.66,Fee Schedule,,839.3,70,,839.3,percent of total billed charges,All Other,424.76,,,424.76,Fee Schedule,,360.01,,,360.01,Fee Schedule,,610.96,,,610.96,Fee Schedule,,610.96,,,610.96,Fee Schedule,,610.96,,,610.96,Fee Schedule,,610.96,,,610.96,Fee Schedule,,210.57,,,210.57,Other,100% of Medicaid,210.57,,,210.57,Other,100% of Medicaid,210.57,,,210.57,Other,100% of Medicaid,210.57,,,210.57,Other,100% of Medicaid,473.77,,,473.77,Other,225% of Medicaid,322.17,,,322.17,Other,153% of Medicaid,473.77,,,473.77,Other,225% of Medicaid,294.79,,,294.79,Other,140% of Medicaid,473.77,,,473.77,Other,225% of Medicaid,547.47,,,547.47,Other,260% of Medicaid,682.23,,,682.23,Other,324% of Medicaid,452.72,,,452.72,Other,215% of Medicaid,452.72,,,452.72,Other,215% of Medicaid,263.21,,,263.21,Other,125% of Medicaid,170.48,887.26,
XR FOREARM LT,73090,CPT,TCLT,42173090,CDM,320,RC,,,both,,,334,247.16,,,247.16,Other,150% of Medicare + 9.63% HCRA Surcharge,150.3,45,,150.3,percent of total billed charges,Critical Access Hospital RCC factor,75.25,,,75.25,Fee Schedule,,67.7,,,67.7,Fee Schedule,,135.12,,,135.12,Fee Schedule,,121.53,,,121.53,Fee Schedule,,114.87,,,114.87,Fee Schedule,,165.33,,,165.33,Other,110% of Medicare,89.41,,,89.41,Fee Schedule,,53,,,53,Other,186% of Medicaid,105.21,,,105.21,Fee Schedule,,207.08,,,207.08,Fee Schedule,,49.54,,,49.54,Fee Schedule,,105.21,,,105.21,Fee Schedule,,207.08,,,207.08,Fee Schedule,,93.18,,,93.18,Fee Schedule,,233.8,70,,233.8,percent of total billed charges,All Other,104.96,,,104.96,Fee Schedule,,88.96,,,88.96,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,247.16,
XR UPPER EXT CHILD 2 V LT,73092,CPT,TCLT,42173092,CDM,320,RC,,,both,,,242,179.08,,,179.08,Other,150% of Medicare + 9.63% HCRA Surcharge,108.9,45,,108.9,percent of total billed charges,Critical Access Hospital RCC factor,83.35,,,83.35,Fee Schedule,,74.99,,,74.99,Fee Schedule,,153.41,,,153.41,Fee Schedule,,137.98,,,137.98,Fee Schedule,,130.41,,,130.41,Fee Schedule,,119.79,,,119.79,Other,110% of Medicare,99.03,,,99.03,Fee Schedule,,53,,,53,Other,186% of Medicaid,116.54,,,116.54,Fee Schedule,,150.04,,,150.04,Fee Schedule,,54.87,,,54.87,Fee Schedule,,116.54,,,116.54,Fee Schedule,,150.04,,,150.04,Fee Schedule,,103.21,,,103.21,Fee Schedule,,169.4,70,,169.4,percent of total billed charges,All Other,118.08,,,118.08,Fee Schedule,,100.08,,,100.08,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,179.33,
XR WRIST 2 VIEWS LT,73100,CPT,TCLT,42173100,CDM,320,RC,,,both,,,231,170.94,,,170.94,Other,150% of Medicare + 9.63% HCRA Surcharge,103.95,45,,103.95,percent of total billed charges,Critical Access Hospital RCC factor,90.28,,,90.28,Fee Schedule,,81.22,,,81.22,Fee Schedule,,148.82,,,148.82,Fee Schedule,,133.86,,,133.86,Fee Schedule,,126.52,,,126.52,Fee Schedule,,114.35,,,114.35,Other,110% of Medicare,107.26,,,107.26,Fee Schedule,,53,,,53,Other,186% of Medicaid,126.22,,,126.22,Fee Schedule,,143.22,,,143.22,Fee Schedule,,59.43,,,59.43,Fee Schedule,,126.22,,,126.22,Fee Schedule,,143.22,,,143.22,Fee Schedule,,111.79,,,111.79,Fee Schedule,,161.7,70,,161.7,percent of total billed charges,All Other,126.28,,,126.28,Fee Schedule,,107.03,,,107.03,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,170.94,
XR WRIST 3+ VIEWS LT,73110,CPT,TCLT,42173110,CDM,320,RC,,,both,,,330,244.2,,,244.2,Other,150% of Medicare + 9.63% HCRA Surcharge,148.5,45,,148.5,percent of total billed charges,Critical Access Hospital RCC factor,114.55,,,114.55,Fee Schedule,,103.06,,,103.06,Fee Schedule,,187.77,,,187.77,Fee Schedule,,168.89,,,168.89,Fee Schedule,,159.62,,,159.62,Fee Schedule,,163.35,,,163.35,Other,110% of Medicare,136.1,,,136.1,Fee Schedule,,53,,,53,Other,186% of Medicaid,160.16,,,160.16,Fee Schedule,,204.6,,,204.6,Fee Schedule,,75.41,,,75.41,Fee Schedule,,160.16,,,160.16,Fee Schedule,,204.6,,,204.6,Fee Schedule,,141.84,,,141.84,Fee Schedule,,231,70,,231,percent of total billed charges,All Other,159.08,,,159.08,Fee Schedule,,134.83,,,134.83,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,244.2,
XR HAND 2 VIEWS LT,73120,CPT,TCLT,42173120,CDM,320,RC,,,both,,,242,179.08,,,179.08,Other,150% of Medicare + 9.63% HCRA Surcharge,108.9,45,,108.9,percent of total billed charges,Critical Access Hospital RCC factor,82.21,,,82.21,Fee Schedule,,73.96,,,73.96,Fee Schedule,,132.8,,,132.8,Fee Schedule,,119.45,,,119.45,Fee Schedule,,112.9,,,112.9,Fee Schedule,,119.79,,,119.79,Other,110% of Medicare,97.67,,,97.67,Fee Schedule,,53,,,53,Other,186% of Medicaid,114.93,,,114.93,Fee Schedule,,150.04,,,150.04,Fee Schedule,,54.12,,,54.12,Fee Schedule,,114.93,,,114.93,Fee Schedule,,150.04,,,150.04,Fee Schedule,,101.79,,,101.79,Fee Schedule,,169.4,70,,169.4,percent of total billed charges,All Other,113.16,,,113.16,Fee Schedule,,95.91,,,95.91,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,179.33,
XR HAND 3+ VIEWS LT,73130,CPT,TCLT,42173130,CDM,320,RC,,,both,,,352,260.48,,,260.48,Other,150% of Medicare + 9.63% HCRA Surcharge,158.4,45,,158.4,percent of total billed charges,Critical Access Hospital RCC factor,100.68,,,100.68,Fee Schedule,,90.58,,,90.58,Fee Schedule,,160.26,,,160.26,Fee Schedule,,144.14,,,144.14,Fee Schedule,,136.24,,,136.24,Fee Schedule,,174.24,,,174.24,Other,110% of Medicare,119.61,,,119.61,Fee Schedule,,53,,,53,Other,186% of Medicaid,140.76,,,140.76,Fee Schedule,,218.24,,,218.24,Fee Schedule,,66.28,,,66.28,Fee Schedule,,140.76,,,140.76,Fee Schedule,,218.24,,,218.24,Fee Schedule,,124.66,,,124.66,Fee Schedule,,246.4,70,,246.4,percent of total billed charges,All Other,137.76,,,137.76,Fee Schedule,,116.76,,,116.76,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,260.48,
XR FINGER 2+ VIEWS LT,73140,CPT,TCLT,42173140,CDM,320,RC,,,both,,,231,170.94,,,170.94,Other,150% of Medicare + 9.63% HCRA Surcharge,103.95,45,,103.95,percent of total billed charges,Critical Access Hospital RCC factor,109.93,,,109.93,Fee Schedule,,98.9,,,98.9,Fee Schedule,,167.16,,,167.16,Fee Schedule,,150.35,,,150.35,Fee Schedule,,142.11,,,142.11,Fee Schedule,,114.35,,,114.35,Other,110% of Medicare,130.6,,,130.6,Fee Schedule,,53,,,53,Other,186% of Medicaid,153.69,,,153.69,Fee Schedule,,143.22,,,143.22,Fee Schedule,,72.37,,,72.37,Fee Schedule,,153.69,,,153.69,Fee Schedule,,143.22,,,143.22,Fee Schedule,,136.12,,,136.12,Fee Schedule,,161.7,70,,161.7,percent of total billed charges,All Other,150.88,,,150.88,Fee Schedule,,127.88,,,127.88,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,170.94,
X-RAY EXAM HIP UNI 1 VIEW LT,73501,CPT,TCLT,42173501,CDM,320,RC,,,both,,,237,175.38,,,175.38,Other,150% of Medicare + 9.63% HCRA Surcharge,106.65,45,,106.65,percent of total billed charges,Critical Access Hospital RCC factor,83.35,,,83.35,Fee Schedule,,74.99,,,74.99,Fee Schedule,,20.07,,,20.07,Fee Schedule,,20.07,,,20.07,Fee Schedule,,20.07,,,20.07,Fee Schedule,,117.32,,,117.32,Other,110% of Medicare,99.03,,,99.03,Fee Schedule,,53,,,53,Other,186% of Medicaid,116.54,,,116.54,Fee Schedule,,146.94,,,146.94,Fee Schedule,,54.87,,,54.87,Fee Schedule,,116.54,,,116.54,Fee Schedule,,146.94,,,146.94,Fee Schedule,,103.21,,,103.21,Fee Schedule,,165.9,70,,165.9,percent of total billed charges,All Other,114.8,,,114.8,Fee Schedule,,97.3,,,97.3,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,20.07,175.38,
X-RAY EXAM HIP UNI 2-3 VIEWS LT,73502,CPT,TCLT,42173502,CDM,320,RC,,,both,,,268,198.32,,,198.32,Other,150% of Medicare + 9.63% HCRA Surcharge,120.6,45,,120.6,percent of total billed charges,Critical Access Hospital RCC factor,128.4,,,128.4,Fee Schedule,,115.52,,,115.52,Fee Schedule,,29.42,,,29.42,Fee Schedule,,29.42,,,29.42,Fee Schedule,,29.42,,,29.42,Fee Schedule,,132.66,,,132.66,Other,110% of Medicare,152.55,,,152.55,Fee Schedule,,53,,,53,Other,186% of Medicaid,179.52,,,179.52,Fee Schedule,,166.16,,,166.16,Fee Schedule,,84.53,,,84.53,Fee Schedule,,179.52,,,179.52,Fee Schedule,,166.16,,,166.16,Fee Schedule,,158.99,,,158.99,Fee Schedule,,187.6,70,,187.6,percent of total billed charges,All Other,177.12,,,177.12,Fee Schedule,,150.12,,,150.12,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,198.32,
X-RAY EXAM HIP UNI 4/> VIEWS LT,73503,CPT,TCLT,42173503,CDM,320,RC,,,both,,,336,248.64,,,248.64,Other,150% of Medicare + 9.63% HCRA Surcharge,151.2,45,,151.2,percent of total billed charges,Critical Access Hospital RCC factor,163.07,,,163.07,Fee Schedule,,146.71,,,146.71,Fee Schedule,,36.34,,,36.34,Fee Schedule,,36.34,,,36.34,Fee Schedule,,36.34,,,36.34,Fee Schedule,,166.32,,,166.32,Other,110% of Medicare,193.74,,,193.74,Fee Schedule,,53,,,53,Other,186% of Medicaid,228,,,228,Fee Schedule,,208.32,,,208.32,Fee Schedule,,107.35,,,107.35,Fee Schedule,,228,,,228,Fee Schedule,,208.32,,,208.32,Fee Schedule,,201.92,,,201.92,Fee Schedule,,235.2,70,,235.2,percent of total billed charges,All Other,224.68,,,224.68,Fee Schedule,,190.43,,,190.43,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,248.64,
X-RAY EXAM OF FEMUR 1 LT,73551,CPT,TCLT,42173551,CDM,320,RC,,,both,,,237,175.38,,,175.38,Other,150% of Medicare + 9.63% HCRA Surcharge,106.65,45,,106.65,percent of total billed charges,Critical Access Hospital RCC factor,74.1,,,74.1,Fee Schedule,,66.67,,,66.67,Fee Schedule,,19.04,,,19.04,Fee Schedule,,19.04,,,19.04,Fee Schedule,,19.04,,,19.04,Fee Schedule,,117.32,,,117.32,Other,110% of Medicare,88.04,,,88.04,Fee Schedule,,53,,,53,Other,186% of Medicaid,103.61,,,103.61,Fee Schedule,,146.94,,,146.94,Fee Schedule,,48.78,,,48.78,Fee Schedule,,103.61,,,103.61,Fee Schedule,,146.94,,,146.94,Fee Schedule,,91.76,,,91.76,Fee Schedule,,165.9,70,,165.9,percent of total billed charges,All Other,103.32,,,103.32,Fee Schedule,,87.57,,,87.57,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,19.04,175.38,
X-RAY EXAM OF FEMUR 2/> LT,73552,CPT,TCLT,42173552,CDM,320,RC,,,both,,,237,175.38,,,175.38,Other,150% of Medicare + 9.63% HCRA Surcharge,106.65,45,,106.65,percent of total billed charges,Critical Access Hospital RCC factor,93.75,,,93.75,Fee Schedule,,84.35,,,84.35,Fee Schedule,,22.84,,,22.84,Fee Schedule,,22.84,,,22.84,Fee Schedule,,22.84,,,22.84,Fee Schedule,,117.32,,,117.32,Other,110% of Medicare,111.39,,,111.39,Fee Schedule,,53,,,53,Other,186% of Medicaid,131.08,,,131.08,Fee Schedule,,146.94,,,146.94,Fee Schedule,,61.72,,,61.72,Fee Schedule,,131.08,,,131.08,Fee Schedule,,146.94,,,146.94,Fee Schedule,,116.09,,,116.09,Fee Schedule,,165.9,70,,165.9,percent of total billed charges,All Other,129.56,,,129.56,Fee Schedule,,109.81,,,109.81,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,22.84,175.38,
XR KNEE 1 OR 2 VIEWS LT,73560,CPT,TCLT,42173560,CDM,320,RC,,,both,,,407,301.18,,,301.18,Other,150% of Medicare + 9.63% HCRA Surcharge,183.15,45,,183.15,percent of total billed charges,Critical Access Hospital RCC factor,91.43,,,91.43,Fee Schedule,,82.25,,,82.25,Fee Schedule,,144.29,,,144.29,Fee Schedule,,129.78,,,129.78,Fee Schedule,,122.66,,,122.66,Fee Schedule,,201.47,,,201.47,Other,110% of Medicare,108.62,,,108.62,Fee Schedule,,53,,,53,Other,186% of Medicaid,127.82,,,127.82,Fee Schedule,,252.34,,,252.34,Fee Schedule,,60.19,,,60.19,Fee Schedule,,127.82,,,127.82,Fee Schedule,,252.34,,,252.34,Fee Schedule,,113.21,,,113.21,Fee Schedule,,284.9,70,,284.9,percent of total billed charges,All Other,127.92,,,127.92,Fee Schedule,,108.42,,,108.42,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,301.18,
XR KNEE 3 VIEWS LT,73562,CPT,TCLT,42173562,CDM,320,RC,,,both,,,445,329.3,,,329.3,Other,150% of Medicare + 9.63% HCRA Surcharge,200.25,45,,200.25,percent of total billed charges,Critical Access Hospital RCC factor,111.08,,,111.08,Fee Schedule,,99.93,,,99.93,Fee Schedule,,180.87,,,180.87,Fee Schedule,,162.68,,,162.68,Fee Schedule,,153.75,,,153.75,Fee Schedule,,220.28,,,220.28,Other,110% of Medicare,131.97,,,131.97,Fee Schedule,,53,,,53,Other,186% of Medicaid,155.3,,,155.3,Fee Schedule,,275.9,,,275.9,Fee Schedule,,73.12,,,73.12,Fee Schedule,,155.3,,,155.3,Fee Schedule,,275.9,,,275.9,Fee Schedule,,137.54,,,137.54,Fee Schedule,,311.5,70,,311.5,percent of total billed charges,All Other,155.8,,,155.8,Fee Schedule,,132.05,,,132.05,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,329.3,
XR KNEE 4+ VIEWS LT,73564,CPT,TCLT,42173564,CDM,320,RC,,,both,,,445,329.3,,,329.3,Other,150% of Medicare + 9.63% HCRA Surcharge,200.25,45,,200.25,percent of total billed charges,Critical Access Hospital RCC factor,126.1,,,126.1,Fee Schedule,,113.45,,,113.45,Fee Schedule,,206.06,,,206.06,Fee Schedule,,185.33,,,185.33,Fee Schedule,,175.17,,,175.17,Fee Schedule,,220.28,,,220.28,Other,110% of Medicare,149.82,,,149.82,Fee Schedule,,53,,,53,Other,186% of Medicaid,176.3,,,176.3,Fee Schedule,,275.9,,,275.9,Fee Schedule,,83.01,,,83.01,Fee Schedule,,176.3,,,176.3,Fee Schedule,,275.9,,,275.9,Fee Schedule,,156.14,,,156.14,Fee Schedule,,311.5,70,,311.5,percent of total billed charges,All Other,173.84,,,173.84,Fee Schedule,,147.34,,,147.34,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,329.3,
XR TIBIA/FIBULA 2 VIEWS LT,73590,CPT,TCLT,42173590,CDM,320,RC,,,both,,,373,276.02,,,276.02,Other,150% of Medicare + 9.63% HCRA Surcharge,167.85,45,,167.85,percent of total billed charges,Critical Access Hospital RCC factor,83.35,,,83.35,Fee Schedule,,74.99,,,74.99,Fee Schedule,,130.54,,,130.54,Fee Schedule,,117.41,,,117.41,Fee Schedule,,110.97,,,110.97,Fee Schedule,,184.64,,,184.64,Other,110% of Medicare,99.03,,,99.03,Fee Schedule,,53,,,53,Other,186% of Medicaid,116.54,,,116.54,Fee Schedule,,231.26,,,231.26,Fee Schedule,,54.87,,,54.87,Fee Schedule,,116.54,,,116.54,Fee Schedule,,231.26,,,231.26,Fee Schedule,,103.21,,,103.21,Fee Schedule,,261.1,70,,261.1,percent of total billed charges,All Other,116.44,,,116.44,Fee Schedule,,98.69,,,98.69,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,276.02,
XR LEG INFANT 2 VIEWS LT,73592,CPT,TCLT,42173592,CDM,320,RC,,,both,,,231,170.94,,,170.94,Other,150% of Medicare + 9.63% HCRA Surcharge,103.95,45,,103.95,percent of total billed charges,Critical Access Hospital RCC factor,83.35,,,83.35,Fee Schedule,,74.99,,,74.99,Fee Schedule,,155.73,,,155.73,Fee Schedule,,140.07,,,140.07,Fee Schedule,,132.38,,,132.38,Fee Schedule,,114.35,,,114.35,Other,110% of Medicare,99.03,,,99.03,Fee Schedule,,53,,,53,Other,186% of Medicaid,116.54,,,116.54,Fee Schedule,,143.22,,,143.22,Fee Schedule,,54.87,,,54.87,Fee Schedule,,116.54,,,116.54,Fee Schedule,,143.22,,,143.22,Fee Schedule,,103.21,,,103.21,Fee Schedule,,161.7,70,,161.7,percent of total billed charges,All Other,118.08,,,118.08,Fee Schedule,,100.08,,,100.08,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,170.94,
XR ANKLE 2 VIEWS LT,73600,CPT,TCLT,42173600,CDM,320,RC,,,both,,,231,170.94,,,170.94,Other,150% of Medicare + 9.63% HCRA Surcharge,103.95,45,,103.95,percent of total billed charges,Critical Access Hospital RCC factor,85.65,,,85.65,Fee Schedule,,77.06,,,77.06,Fee Schedule,,137.39,,,137.39,Fee Schedule,,123.57,,,123.57,Fee Schedule,,116.79,,,116.79,Fee Schedule,,114.35,,,114.35,Other,110% of Medicare,101.76,,,101.76,Fee Schedule,,53,,,53,Other,186% of Medicaid,119.75,,,119.75,Fee Schedule,,143.22,,,143.22,Fee Schedule,,56.39,,,56.39,Fee Schedule,,119.75,,,119.75,Fee Schedule,,143.22,,,143.22,Fee Schedule,,106.06,,,106.06,Fee Schedule,,161.7,70,,161.7,percent of total billed charges,All Other,119.72,,,119.72,Fee Schedule,,101.47,,,101.47,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,170.94,
XR ANKLE 3+ VIEWS LT,73610,CPT,TCLT,42173610,CDM,320,RC,,,both,,,348,257.52,,,257.52,Other,150% of Medicare + 9.63% HCRA Surcharge,156.6,45,,156.6,percent of total billed charges,Critical Access Hospital RCC factor,98.38,,,98.38,Fee Schedule,,88.51,,,88.51,Fee Schedule,,162.58,,,162.58,Fee Schedule,,146.23,,,146.23,Fee Schedule,,138.21,,,138.21,Fee Schedule,,172.26,,,172.26,Other,110% of Medicare,116.88,,,116.88,Fee Schedule,,53,,,53,Other,186% of Medicaid,137.55,,,137.55,Fee Schedule,,215.76,,,215.76,Fee Schedule,,64.76,,,64.76,Fee Schedule,,137.55,,,137.55,Fee Schedule,,215.76,,,215.76,Fee Schedule,,121.82,,,121.82,Fee Schedule,,243.6,70,,243.6,percent of total billed charges,All Other,139.4,,,139.4,Fee Schedule,,118.15,,,118.15,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,257.52,
XR FOOT 2 VIEWS LT,73620,CPT,TCLT,42173620,CDM,320,RC,,,both,,,231,170.94,,,170.94,Other,150% of Medicare + 9.63% HCRA Surcharge,103.95,45,,103.95,percent of total billed charges,Critical Access Hospital RCC factor,74.1,,,74.1,Fee Schedule,,66.67,,,66.67,Fee Schedule,,132.8,,,132.8,Fee Schedule,,119.45,,,119.45,Fee Schedule,,112.9,,,112.9,Fee Schedule,,114.35,,,114.35,Other,110% of Medicare,88.04,,,88.04,Fee Schedule,,53,,,53,Other,186% of Medicaid,103.61,,,103.61,Fee Schedule,,143.22,,,143.22,Fee Schedule,,48.78,,,48.78,Fee Schedule,,103.61,,,103.61,Fee Schedule,,143.22,,,143.22,Fee Schedule,,91.76,,,91.76,Fee Schedule,,161.7,70,,161.7,percent of total billed charges,All Other,101.68,,,101.68,Fee Schedule,,86.18,,,86.18,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,170.94,
XR FOOT 3+ VIEWS LT,73630,CPT,TCLT,42173630,CDM,320,RC,,,both,,,373,276.02,,,276.02,Other,150% of Medicare + 9.63% HCRA Surcharge,167.85,45,,167.85,percent of total billed charges,Critical Access Hospital RCC factor,91.43,,,91.43,Fee Schedule,,82.25,,,82.25,Fee Schedule,,157.99,,,157.99,Fee Schedule,,142.11,,,142.11,Fee Schedule,,134.31,,,134.31,Fee Schedule,,184.64,,,184.64,Other,110% of Medicare,108.62,,,108.62,Fee Schedule,,53,,,53,Other,186% of Medicaid,127.82,,,127.82,Fee Schedule,,231.26,,,231.26,Fee Schedule,,60.19,,,60.19,Fee Schedule,,127.82,,,127.82,Fee Schedule,,231.26,,,231.26,Fee Schedule,,113.21,,,113.21,Fee Schedule,,261.1,70,,261.1,percent of total billed charges,All Other,129.56,,,129.56,Fee Schedule,,109.81,,,109.81,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,276.02,
XR HEEL 2+ VIEWS LT,73650,CPT,TCLT,42173650,CDM,320,RC,,,both,,,231,170.94,,,170.94,Other,150% of Medicare + 9.63% HCRA Surcharge,103.95,45,,103.95,percent of total billed charges,Critical Access Hospital RCC factor,72.96,,,72.96,Fee Schedule,,65.64,,,65.64,Fee Schedule,,135.12,,,135.12,Fee Schedule,,121.53,,,121.53,Fee Schedule,,114.87,,,114.87,Fee Schedule,,114.35,,,114.35,Other,110% of Medicare,86.68,,,86.68,Fee Schedule,,53,,,53,Other,186% of Medicaid,102,,,102,Fee Schedule,,143.22,,,143.22,Fee Schedule,,48.03,,,48.03,Fee Schedule,,102,,,102,Fee Schedule,,143.22,,,143.22,Fee Schedule,,90.34,,,90.34,Fee Schedule,,161.7,70,,161.7,percent of total billed charges,All Other,103.32,,,103.32,Fee Schedule,,87.57,,,87.57,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,170.94,
XR TOE(S) 2+ VIEWS LT,73660,CPT,TCLT,42173660,CDM,320,RC,,,both,,,231,170.94,,,170.94,Other,150% of Medicare + 9.63% HCRA Surcharge,103.95,45,,103.95,percent of total billed charges,Critical Access Hospital RCC factor,79.88,,,79.88,Fee Schedule,,71.86,,,71.86,Fee Schedule,,155.73,,,155.73,Fee Schedule,,140.07,,,140.07,Fee Schedule,,132.38,,,132.38,Fee Schedule,,114.35,,,114.35,Other,110% of Medicare,94.9,,,94.9,Fee Schedule,,53,,,53,Other,186% of Medicaid,111.68,,,111.68,Fee Schedule,,143.22,,,143.22,Fee Schedule,,52.58,,,52.58,Fee Schedule,,111.68,,,111.68,Fee Schedule,,143.22,,,143.22,Fee Schedule,,98.91,,,98.91,Fee Schedule,,161.7,70,,161.7,percent of total billed charges,All Other,111.52,,,111.52,Fee Schedule,,94.52,,,94.52,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,170.94,
XR SURGICAL SPECIMEN RT,76098,CPT,RT,42176098,CDM,320,RC,,,both,,,1844,1364.56,,,1364.56,Other,150% of Medicare + 9.63% HCRA Surcharge,829.8,45,,829.8,percent of total billed charges,Critical Access Hospital RCC factor,96.05,,,96.05,Fee Schedule,,86.42,,,86.42,Fee Schedule,,75.62,,,75.62,Fee Schedule,,68.02,,,68.02,Fee Schedule,,64.29,,,64.29,Fee Schedule,,912.78,,,912.78,Other,110% of Medicare,114.12,,,114.12,Fee Schedule,,392,,,392,Other,186% of Medicaid,134.29,,,134.29,Fee Schedule,,1143.28,,,1143.28,Fee Schedule,,63.23,,,63.23,Fee Schedule,,134.29,,,134.29,Fee Schedule,,1143.28,,,1143.28,Fee Schedule,,118.93,,,118.93,Fee Schedule,,1290.8,70,,1290.8,percent of total billed charges,All Other,124.64,,,124.64,Fee Schedule,,105.64,,,105.64,Fee Schedule,,770.53,,,770.53,Fee Schedule,,770.53,,,770.53,Fee Schedule,,770.53,,,770.53,Fee Schedule,,770.53,,,770.53,Fee Schedule,,210.57,,,210.57,Other,100% of Medicaid,210.57,,,210.57,Other,100% of Medicaid,210.57,,,210.57,Other,100% of Medicaid,210.57,,,210.57,Other,100% of Medicaid,473.77,,,473.77,Other,225% of Medicaid,322.17,,,322.17,Other,153% of Medicaid,473.77,,,473.77,Other,225% of Medicaid,294.79,,,294.79,Other,140% of Medicaid,473.77,,,473.77,Other,225% of Medicaid,547.47,,,547.47,Other,260% of Medicaid,682.23,,,682.23,Other,324% of Medicaid,452.72,,,452.72,Other,215% of Medicaid,452.72,,,452.72,Other,215% of Medicaid,263.21,,,263.21,Other,125% of Medicaid,63.23,1364.56,
XR EYE DETECT FOREIGN BODY,70030,CPT,TCRT,42270030,CDM,320,RC,,,both,,,241,178.34,,,178.34,Other,150% of Medicare + 9.63% HCRA Surcharge,108.45,45,,108.45,percent of total billed charges,Critical Access Hospital RCC factor,84.5,,,84.5,Fee Schedule,,76.03,,,76.03,Fee Schedule,,137.39,,,137.39,Fee Schedule,,123.57,,,123.57,Fee Schedule,,116.79,,,116.79,Fee Schedule,,119.3,,,119.3,Other,110% of Medicare,100.4,,,100.4,Fee Schedule,,53,,,53,Other,186% of Medicaid,118.15,,,118.15,Fee Schedule,,149.42,,,149.42,Fee Schedule,,55.63,,,55.63,Fee Schedule,,118.15,,,118.15,Fee Schedule,,149.42,,,149.42,Fee Schedule,,104.64,,,104.64,Fee Schedule,,168.7,70,,168.7,percent of total billed charges,All Other,116.44,,,116.44,Fee Schedule,,98.69,,,98.69,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,178.34,
XR RIBS 2 VIEWS RIGHT,71100,CPT,TCRT,42271100,CDM,320,RC,,,both,,,437,323.38,,,323.38,Other,150% of Medicare + 9.63% HCRA Surcharge,196.65,45,,196.65,percent of total billed charges,Critical Access Hospital RCC factor,91.43,,,91.43,Fee Schedule,,82.25,,,82.25,Fee Schedule,,146.56,,,146.56,Fee Schedule,,131.82,,,131.82,Fee Schedule,,124.59,,,124.59,Fee Schedule,,216.32,,,216.32,Other,110% of Medicare,108.62,,,108.62,Fee Schedule,,53,,,53,Other,186% of Medicaid,127.82,,,127.82,Fee Schedule,,270.94,,,270.94,Fee Schedule,,60.19,,,60.19,Fee Schedule,,127.82,,,127.82,Fee Schedule,,270.94,,,270.94,Fee Schedule,,113.21,,,113.21,Fee Schedule,,305.9,70,,305.9,percent of total billed charges,All Other,127.92,,,127.92,Fee Schedule,,108.42,,,108.42,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,323.38,
XR RIBS 3 VIEWS + CXR RT,71101,CPT,TCRT,42271101,CDM,320,RC,,,both,,,437,323.38,,,323.38,Other,150% of Medicare + 9.63% HCRA Surcharge,196.65,45,,196.65,percent of total billed charges,Critical Access Hospital RCC factor,102.97,,,102.97,Fee Schedule,,92.64,,,92.64,Fee Schedule,,178.6,,,178.6,Fee Schedule,,160.64,,,160.64,Fee Schedule,,151.83,,,151.83,Fee Schedule,,216.32,,,216.32,Other,110% of Medicare,122.34,,,122.34,Fee Schedule,,53,,,53,Other,186% of Medicaid,143.97,,,143.97,Fee Schedule,,270.94,,,270.94,Fee Schedule,,67.79,,,67.79,Fee Schedule,,143.97,,,143.97,Fee Schedule,,270.94,,,270.94,Fee Schedule,,127.51,,,127.51,Fee Schedule,,305.9,70,,305.9,percent of total billed charges,All Other,144.32,,,144.32,Fee Schedule,,122.32,,,122.32,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,323.38,
XR CLAVICLE RIGHT,73000,CPT,TCRT,42273000,CDM,320,RC,,,both,,,373,276.02,,,276.02,Other,150% of Medicare + 9.63% HCRA Surcharge,167.85,45,,167.85,percent of total billed charges,Critical Access Hospital RCC factor,85.65,,,85.65,Fee Schedule,,77.06,,,77.06,Fee Schedule,,139.71,,,139.71,Fee Schedule,,125.66,,,125.66,Fee Schedule,,118.76,,,118.76,Fee Schedule,,184.64,,,184.64,Other,110% of Medicare,101.76,,,101.76,Fee Schedule,,53,,,53,Other,186% of Medicaid,119.75,,,119.75,Fee Schedule,,231.26,,,231.26,Fee Schedule,,56.39,,,56.39,Fee Schedule,,119.75,,,119.75,Fee Schedule,,231.26,,,231.26,Fee Schedule,,106.06,,,106.06,Fee Schedule,,261.1,70,,261.1,percent of total billed charges,All Other,118.08,,,118.08,Fee Schedule,,100.08,,,100.08,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,276.02,
XR SCAPULA RIGHT,73010,CPT,TCRT,42273010,CDM,320,RC,,,both,,,242,179.08,,,179.08,Other,150% of Medicare + 9.63% HCRA Surcharge,108.9,45,,108.9,percent of total billed charges,Critical Access Hospital RCC factor,53.3,,,53.3,Fee Schedule,,47.96,,,47.96,Fee Schedule,,144.29,,,144.29,Fee Schedule,,129.78,,,129.78,Fee Schedule,,122.66,,,122.66,Fee Schedule,,119.79,,,119.79,Other,110% of Medicare,63.33,,,63.33,Fee Schedule,,53,,,53,Other,186% of Medicaid,74.53,,,74.53,Fee Schedule,,150.04,,,150.04,Fee Schedule,,35.09,,,35.09,Fee Schedule,,74.53,,,74.53,Fee Schedule,,150.04,,,150.04,Fee Schedule,,66,,,66,Fee Schedule,,169.4,70,,169.4,percent of total billed charges,All Other,73.8,,,73.8,Fee Schedule,,62.55,,,62.55,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,179.33,
XR SHOULDER 1 V RT,73020,CPT,TCRT,42273020,CDM,320,RC,,,both,,,231,170.94,,,170.94,Other,150% of Medicare + 9.63% HCRA Surcharge,103.95,45,,103.95,percent of total billed charges,Critical Access Hospital RCC factor,49.86,,,49.86,Fee Schedule,,44.86,,,44.86,Fee Schedule,,109.93,,,109.93,Fee Schedule,,98.88,,,98.88,Fee Schedule,,93.45,,,93.45,Fee Schedule,,114.35,,,114.35,Other,110% of Medicare,59.24,,,59.24,Fee Schedule,,53,,,53,Other,186% of Medicaid,69.71,,,69.71,Fee Schedule,,143.22,,,143.22,Fee Schedule,,32.82,,,32.82,Fee Schedule,,69.71,,,69.71,Fee Schedule,,143.22,,,143.22,Fee Schedule,,61.74,,,61.74,Fee Schedule,,161.7,70,,161.7,percent of total billed charges,All Other,68.88,,,68.88,Fee Schedule,,58.38,,,58.38,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,170.94,
XR SHOULDER 2 VIEWS OR MO RT,73030,CPT,TCRT,42273030,CDM,320,RC,,,both,,,407,301.18,,,301.18,Other,150% of Medicare + 9.63% HCRA Surcharge,183.15,45,,183.15,percent of total billed charges,Critical Access Hospital RCC factor,90.28,,,90.28,Fee Schedule,,81.22,,,81.22,Fee Schedule,,141.97,,,141.97,Fee Schedule,,127.7,,,127.7,Fee Schedule,,120.69,,,120.69,Fee Schedule,,201.47,,,201.47,Other,110% of Medicare,107.26,,,107.26,Fee Schedule,,53,,,53,Other,186% of Medicaid,126.22,,,126.22,Fee Schedule,,252.34,,,252.34,Fee Schedule,,59.43,,,59.43,Fee Schedule,,126.22,,,126.22,Fee Schedule,,252.34,,,252.34,Fee Schedule,,111.79,,,111.79,Fee Schedule,,284.9,70,,284.9,percent of total billed charges,All Other,124.64,,,124.64,Fee Schedule,,105.64,,,105.64,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,301.18,
XR HUMERUS RIGHT,73060,CPT,TCRT,42273060,CDM,320,RC,,,both,,,373,276.02,,,276.02,Other,150% of Medicare + 9.63% HCRA Surcharge,167.85,45,,167.85,percent of total billed charges,Critical Access Hospital RCC factor,84.5,,,84.5,Fee Schedule,,76.03,,,76.03,Fee Schedule,,139.71,,,139.71,Fee Schedule,,125.66,,,125.66,Fee Schedule,,118.76,,,118.76,Fee Schedule,,184.64,,,184.64,Other,110% of Medicare,100.4,,,100.4,Fee Schedule,,53,,,53,Other,186% of Medicaid,118.15,,,118.15,Fee Schedule,,231.26,,,231.26,Fee Schedule,,55.63,,,55.63,Fee Schedule,,118.15,,,118.15,Fee Schedule,,231.26,,,231.26,Fee Schedule,,104.64,,,104.64,Fee Schedule,,261.1,70,,261.1,percent of total billed charges,All Other,118.08,,,118.08,Fee Schedule,,100.08,,,100.08,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,276.02,
XR ELBOW 2 VIEW RIGHT,73070,CPT,TCRT,42273070,CDM,320,RC,,,both,,,231,170.94,,,170.94,Other,150% of Medicare + 9.63% HCRA Surcharge,103.95,45,,103.95,percent of total billed charges,Critical Access Hospital RCC factor,74.1,,,74.1,Fee Schedule,,66.67,,,66.67,Fee Schedule,,139.71,,,139.71,Fee Schedule,,125.66,,,125.66,Fee Schedule,,118.76,,,118.76,Fee Schedule,,114.35,,,114.35,Other,110% of Medicare,88.04,,,88.04,Fee Schedule,,53,,,53,Other,186% of Medicaid,103.61,,,103.61,Fee Schedule,,143.22,,,143.22,Fee Schedule,,48.78,,,48.78,Fee Schedule,,103.61,,,103.61,Fee Schedule,,143.22,,,143.22,Fee Schedule,,91.76,,,91.76,Fee Schedule,,161.7,70,,161.7,percent of total billed charges,All Other,103.32,,,103.32,Fee Schedule,,87.57,,,87.57,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,170.94,
XR ELBOW 3 VIEWS RT,73080,CPT,TCRT,42273080,CDM,320,RC,,,both,,,392,290.08,,,290.08,Other,150% of Medicare + 9.63% HCRA Surcharge,176.4,45,,176.4,percent of total billed charges,Critical Access Hospital RCC factor,85.65,,,85.65,Fee Schedule,,77.06,,,77.06,Fee Schedule,,174.02,,,174.02,Fee Schedule,,156.51,,,156.51,Fee Schedule,,147.93,,,147.93,Fee Schedule,,194.04,,,194.04,Other,110% of Medicare,101.76,,,101.76,Fee Schedule,,53,,,53,Other,186% of Medicaid,119.75,,,119.75,Fee Schedule,,243.04,,,243.04,Fee Schedule,,56.39,,,56.39,Fee Schedule,,119.75,,,119.75,Fee Schedule,,243.04,,,243.04,Fee Schedule,,106.06,,,106.06,Fee Schedule,,274.4,70,,274.4,percent of total billed charges,All Other,118.08,,,118.08,Fee Schedule,,100.08,,,100.08,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,290.08,
XR ARTHROGRAM ELBOW RT,73085,CPT,TCRT,42273085,CDM,320,RC,,,both,,,1199,887.26,,,887.26,Other,150% of Medicare + 9.63% HCRA Surcharge,539.55,45,,539.55,percent of total billed charges,Critical Access Hospital RCC factor,258.96,,,258.96,Fee Schedule,,232.99,,,232.99,Fee Schedule,,476.09,,,476.09,Fee Schedule,,428.21,,,428.21,Fee Schedule,,404.72,,,404.72,Fee Schedule,,593.51,,,593.51,Other,110% of Medicare,307.67,,,307.67,Fee Schedule,,392,,,392,Other,186% of Medicaid,362.06,,,362.06,Fee Schedule,,743.38,,,743.38,Fee Schedule,,170.48,,,170.48,Fee Schedule,,362.06,,,362.06,Fee Schedule,,743.38,,,743.38,Fee Schedule,,320.66,,,320.66,Fee Schedule,,839.3,70,,839.3,percent of total billed charges,All Other,424.76,,,424.76,Fee Schedule,,360.01,,,360.01,Fee Schedule,,610.96,,,610.96,Fee Schedule,,610.96,,,610.96,Fee Schedule,,610.96,,,610.96,Fee Schedule,,610.96,,,610.96,Fee Schedule,,210.57,,,210.57,Other,100% of Medicaid,210.57,,,210.57,Other,100% of Medicaid,210.57,,,210.57,Other,100% of Medicaid,210.57,,,210.57,Other,100% of Medicaid,473.77,,,473.77,Other,225% of Medicaid,322.17,,,322.17,Other,153% of Medicaid,473.77,,,473.77,Other,225% of Medicaid,294.79,,,294.79,Other,140% of Medicaid,473.77,,,473.77,Other,225% of Medicaid,547.47,,,547.47,Other,260% of Medicaid,682.23,,,682.23,Other,324% of Medicaid,452.72,,,452.72,Other,215% of Medicaid,452.72,,,452.72,Other,215% of Medicaid,263.21,,,263.21,Other,125% of Medicaid,170.48,887.26,
XR FOREARM RT,73090,CPT,TCRT,42273090,CDM,320,RC,,,both,,,334,247.16,,,247.16,Other,150% of Medicare + 9.63% HCRA Surcharge,150.3,45,,150.3,percent of total billed charges,Critical Access Hospital RCC factor,75.25,,,75.25,Fee Schedule,,67.7,,,67.7,Fee Schedule,,135.12,,,135.12,Fee Schedule,,121.53,,,121.53,Fee Schedule,,114.87,,,114.87,Fee Schedule,,165.33,,,165.33,Other,110% of Medicare,89.41,,,89.41,Fee Schedule,,53,,,53,Other,186% of Medicaid,105.21,,,105.21,Fee Schedule,,207.08,,,207.08,Fee Schedule,,49.54,,,49.54,Fee Schedule,,105.21,,,105.21,Fee Schedule,,207.08,,,207.08,Fee Schedule,,93.18,,,93.18,Fee Schedule,,233.8,70,,233.8,percent of total billed charges,All Other,104.96,,,104.96,Fee Schedule,,88.96,,,88.96,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,247.16,
XR UPPER EXT CHILD 2 V RT,73092,CPT,TCRT,42273092,CDM,320,RC,,,both,,,242,179.08,,,179.08,Other,150% of Medicare + 9.63% HCRA Surcharge,108.9,45,,108.9,percent of total billed charges,Critical Access Hospital RCC factor,83.35,,,83.35,Fee Schedule,,74.99,,,74.99,Fee Schedule,,153.41,,,153.41,Fee Schedule,,137.98,,,137.98,Fee Schedule,,130.41,,,130.41,Fee Schedule,,119.79,,,119.79,Other,110% of Medicare,99.03,,,99.03,Fee Schedule,,53,,,53,Other,186% of Medicaid,116.54,,,116.54,Fee Schedule,,150.04,,,150.04,Fee Schedule,,54.87,,,54.87,Fee Schedule,,116.54,,,116.54,Fee Schedule,,150.04,,,150.04,Fee Schedule,,103.21,,,103.21,Fee Schedule,,169.4,70,,169.4,percent of total billed charges,All Other,118.08,,,118.08,Fee Schedule,,100.08,,,100.08,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,179.33,
XR WRIST 2 VIEWS RT,73100,CPT,TCRT,42273100,CDM,320,RC,,,both,,,231,170.94,,,170.94,Other,150% of Medicare + 9.63% HCRA Surcharge,103.95,45,,103.95,percent of total billed charges,Critical Access Hospital RCC factor,90.28,,,90.28,Fee Schedule,,81.22,,,81.22,Fee Schedule,,148.82,,,148.82,Fee Schedule,,133.86,,,133.86,Fee Schedule,,126.52,,,126.52,Fee Schedule,,114.35,,,114.35,Other,110% of Medicare,107.26,,,107.26,Fee Schedule,,53,,,53,Other,186% of Medicaid,126.22,,,126.22,Fee Schedule,,143.22,,,143.22,Fee Schedule,,59.43,,,59.43,Fee Schedule,,126.22,,,126.22,Fee Schedule,,143.22,,,143.22,Fee Schedule,,111.79,,,111.79,Fee Schedule,,161.7,70,,161.7,percent of total billed charges,All Other,126.28,,,126.28,Fee Schedule,,107.03,,,107.03,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,170.94,
XR WRIST 3+ VIEWS RT,73110,CPT,TCRT,42273110,CDM,320,RC,,,both,,,330,244.2,,,244.2,Other,150% of Medicare + 9.63% HCRA Surcharge,148.5,45,,148.5,percent of total billed charges,Critical Access Hospital RCC factor,114.55,,,114.55,Fee Schedule,,103.06,,,103.06,Fee Schedule,,187.77,,,187.77,Fee Schedule,,168.89,,,168.89,Fee Schedule,,159.62,,,159.62,Fee Schedule,,163.35,,,163.35,Other,110% of Medicare,136.1,,,136.1,Fee Schedule,,53,,,53,Other,186% of Medicaid,160.16,,,160.16,Fee Schedule,,204.6,,,204.6,Fee Schedule,,75.41,,,75.41,Fee Schedule,,160.16,,,160.16,Fee Schedule,,204.6,,,204.6,Fee Schedule,,141.84,,,141.84,Fee Schedule,,231,70,,231,percent of total billed charges,All Other,159.08,,,159.08,Fee Schedule,,134.83,,,134.83,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,244.2,
XR HAND 2 VIEWS RT,73120,CPT,TCRT,42273120,CDM,320,RC,,,both,,,242,179.08,,,179.08,Other,150% of Medicare + 9.63% HCRA Surcharge,108.9,45,,108.9,percent of total billed charges,Critical Access Hospital RCC factor,82.21,,,82.21,Fee Schedule,,73.96,,,73.96,Fee Schedule,,132.8,,,132.8,Fee Schedule,,119.45,,,119.45,Fee Schedule,,112.9,,,112.9,Fee Schedule,,119.79,,,119.79,Other,110% of Medicare,97.67,,,97.67,Fee Schedule,,53,,,53,Other,186% of Medicaid,114.93,,,114.93,Fee Schedule,,150.04,,,150.04,Fee Schedule,,54.12,,,54.12,Fee Schedule,,114.93,,,114.93,Fee Schedule,,150.04,,,150.04,Fee Schedule,,101.79,,,101.79,Fee Schedule,,169.4,70,,169.4,percent of total billed charges,All Other,113.16,,,113.16,Fee Schedule,,95.91,,,95.91,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,179.33,
XR HAND 3+ VIEWS RT,73130,CPT,TCRT,42273130,CDM,320,RC,,,both,,,352,260.48,,,260.48,Other,150% of Medicare + 9.63% HCRA Surcharge,158.4,45,,158.4,percent of total billed charges,Critical Access Hospital RCC factor,100.68,,,100.68,Fee Schedule,,90.58,,,90.58,Fee Schedule,,160.26,,,160.26,Fee Schedule,,144.14,,,144.14,Fee Schedule,,136.24,,,136.24,Fee Schedule,,174.24,,,174.24,Other,110% of Medicare,119.61,,,119.61,Fee Schedule,,53,,,53,Other,186% of Medicaid,140.76,,,140.76,Fee Schedule,,218.24,,,218.24,Fee Schedule,,66.28,,,66.28,Fee Schedule,,140.76,,,140.76,Fee Schedule,,218.24,,,218.24,Fee Schedule,,124.66,,,124.66,Fee Schedule,,246.4,70,,246.4,percent of total billed charges,All Other,137.76,,,137.76,Fee Schedule,,116.76,,,116.76,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,260.48,
XR FINGER 2+ VIEWS RT,73140,CPT,TCRT,42273140,CDM,320,RC,,,both,,,231,170.94,,,170.94,Other,150% of Medicare + 9.63% HCRA Surcharge,103.95,45,,103.95,percent of total billed charges,Critical Access Hospital RCC factor,109.93,,,109.93,Fee Schedule,,98.9,,,98.9,Fee Schedule,,167.16,,,167.16,Fee Schedule,,150.35,,,150.35,Fee Schedule,,142.11,,,142.11,Fee Schedule,,114.35,,,114.35,Other,110% of Medicare,130.6,,,130.6,Fee Schedule,,53,,,53,Other,186% of Medicaid,153.69,,,153.69,Fee Schedule,,143.22,,,143.22,Fee Schedule,,72.37,,,72.37,Fee Schedule,,153.69,,,153.69,Fee Schedule,,143.22,,,143.22,Fee Schedule,,136.12,,,136.12,Fee Schedule,,161.7,70,,161.7,percent of total billed charges,All Other,150.88,,,150.88,Fee Schedule,,127.88,,,127.88,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,170.94,
X-RAY EXAM HIP UNI 1 VIEW RT,73501,CPT,TCRT,42273501,CDM,320,RC,,,both,,,237,175.38,,,175.38,Other,150% of Medicare + 9.63% HCRA Surcharge,106.65,45,,106.65,percent of total billed charges,Critical Access Hospital RCC factor,83.35,,,83.35,Fee Schedule,,74.99,,,74.99,Fee Schedule,,20.07,,,20.07,Fee Schedule,,20.07,,,20.07,Fee Schedule,,20.07,,,20.07,Fee Schedule,,117.32,,,117.32,Other,110% of Medicare,99.03,,,99.03,Fee Schedule,,53,,,53,Other,186% of Medicaid,116.54,,,116.54,Fee Schedule,,146.94,,,146.94,Fee Schedule,,54.87,,,54.87,Fee Schedule,,116.54,,,116.54,Fee Schedule,,146.94,,,146.94,Fee Schedule,,103.21,,,103.21,Fee Schedule,,165.9,70,,165.9,percent of total billed charges,All Other,114.8,,,114.8,Fee Schedule,,97.3,,,97.3,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,20.07,175.38,
X-RAY EXAM HIP UNI 2-3 VIEWS RT,73502,CPT,TCRT,42273502,CDM,320,RC,,,both,,,268,198.32,,,198.32,Other,150% of Medicare + 9.63% HCRA Surcharge,120.6,45,,120.6,percent of total billed charges,Critical Access Hospital RCC factor,128.4,,,128.4,Fee Schedule,,115.52,,,115.52,Fee Schedule,,29.42,,,29.42,Fee Schedule,,29.42,,,29.42,Fee Schedule,,29.42,,,29.42,Fee Schedule,,132.66,,,132.66,Other,110% of Medicare,152.55,,,152.55,Fee Schedule,,53,,,53,Other,186% of Medicaid,179.52,,,179.52,Fee Schedule,,166.16,,,166.16,Fee Schedule,,84.53,,,84.53,Fee Schedule,,179.52,,,179.52,Fee Schedule,,166.16,,,166.16,Fee Schedule,,158.99,,,158.99,Fee Schedule,,187.6,70,,187.6,percent of total billed charges,All Other,177.12,,,177.12,Fee Schedule,,150.12,,,150.12,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,198.32,
X-RAY EXAM HIP UNI 4/> VIEWS RT,73503,CPT,TCRT,42273503,CDM,320,RC,,,both,,,336,248.64,,,248.64,Other,150% of Medicare + 9.63% HCRA Surcharge,151.2,45,,151.2,percent of total billed charges,Critical Access Hospital RCC factor,163.07,,,163.07,Fee Schedule,,146.71,,,146.71,Fee Schedule,,36.34,,,36.34,Fee Schedule,,36.34,,,36.34,Fee Schedule,,36.34,,,36.34,Fee Schedule,,166.32,,,166.32,Other,110% of Medicare,193.74,,,193.74,Fee Schedule,,53,,,53,Other,186% of Medicaid,228,,,228,Fee Schedule,,208.32,,,208.32,Fee Schedule,,107.35,,,107.35,Fee Schedule,,228,,,228,Fee Schedule,,208.32,,,208.32,Fee Schedule,,201.92,,,201.92,Fee Schedule,,235.2,70,,235.2,percent of total billed charges,All Other,224.68,,,224.68,Fee Schedule,,190.43,,,190.43,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,248.64,
X-RAY EXAM OF FEMUR 1 RT,73551,CPT,TCRT,42273551,CDM,320,RC,,,both,,,237,175.38,,,175.38,Other,150% of Medicare + 9.63% HCRA Surcharge,106.65,45,,106.65,percent of total billed charges,Critical Access Hospital RCC factor,74.1,,,74.1,Fee Schedule,,66.67,,,66.67,Fee Schedule,,19.04,,,19.04,Fee Schedule,,19.04,,,19.04,Fee Schedule,,19.04,,,19.04,Fee Schedule,,117.32,,,117.32,Other,110% of Medicare,88.04,,,88.04,Fee Schedule,,53,,,53,Other,186% of Medicaid,103.61,,,103.61,Fee Schedule,,146.94,,,146.94,Fee Schedule,,48.78,,,48.78,Fee Schedule,,103.61,,,103.61,Fee Schedule,,146.94,,,146.94,Fee Schedule,,91.76,,,91.76,Fee Schedule,,165.9,70,,165.9,percent of total billed charges,All Other,103.32,,,103.32,Fee Schedule,,87.57,,,87.57,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,19.04,175.38,
X-RAY EXAM OF FEMUR 2/> RT,73552,CPT,TCRT,42273552,CDM,320,RC,,,both,,,237,175.38,,,175.38,Other,150% of Medicare + 9.63% HCRA Surcharge,106.65,45,,106.65,percent of total billed charges,Critical Access Hospital RCC factor,93.75,,,93.75,Fee Schedule,,84.35,,,84.35,Fee Schedule,,22.84,,,22.84,Fee Schedule,,22.84,,,22.84,Fee Schedule,,22.84,,,22.84,Fee Schedule,,117.32,,,117.32,Other,110% of Medicare,111.39,,,111.39,Fee Schedule,,53,,,53,Other,186% of Medicaid,131.08,,,131.08,Fee Schedule,,146.94,,,146.94,Fee Schedule,,61.72,,,61.72,Fee Schedule,,131.08,,,131.08,Fee Schedule,,146.94,,,146.94,Fee Schedule,,116.09,,,116.09,Fee Schedule,,165.9,70,,165.9,percent of total billed charges,All Other,129.56,,,129.56,Fee Schedule,,109.81,,,109.81,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,22.84,175.38,
XR KNEE 1 OR 2 VIEWS RT,73560,CPT,TCRT,42273560,CDM,320,RC,,,both,,,407,301.18,,,301.18,Other,150% of Medicare + 9.63% HCRA Surcharge,183.15,45,,183.15,percent of total billed charges,Critical Access Hospital RCC factor,91.43,,,91.43,Fee Schedule,,82.25,,,82.25,Fee Schedule,,144.29,,,144.29,Fee Schedule,,129.78,,,129.78,Fee Schedule,,122.66,,,122.66,Fee Schedule,,201.47,,,201.47,Other,110% of Medicare,108.62,,,108.62,Fee Schedule,,53,,,53,Other,186% of Medicaid,127.82,,,127.82,Fee Schedule,,252.34,,,252.34,Fee Schedule,,60.19,,,60.19,Fee Schedule,,127.82,,,127.82,Fee Schedule,,252.34,,,252.34,Fee Schedule,,113.21,,,113.21,Fee Schedule,,284.9,70,,284.9,percent of total billed charges,All Other,127.92,,,127.92,Fee Schedule,,108.42,,,108.42,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,301.18,
XR KNEE 3 VIEWS RT,73562,CPT,TCRT,42273562,CDM,320,RC,,,both,,,445,329.3,,,329.3,Other,150% of Medicare + 9.63% HCRA Surcharge,200.25,45,,200.25,percent of total billed charges,Critical Access Hospital RCC factor,111.08,,,111.08,Fee Schedule,,99.93,,,99.93,Fee Schedule,,180.87,,,180.87,Fee Schedule,,162.68,,,162.68,Fee Schedule,,153.75,,,153.75,Fee Schedule,,220.28,,,220.28,Other,110% of Medicare,131.97,,,131.97,Fee Schedule,,53,,,53,Other,186% of Medicaid,155.3,,,155.3,Fee Schedule,,275.9,,,275.9,Fee Schedule,,73.12,,,73.12,Fee Schedule,,155.3,,,155.3,Fee Schedule,,275.9,,,275.9,Fee Schedule,,137.54,,,137.54,Fee Schedule,,311.5,70,,311.5,percent of total billed charges,All Other,155.8,,,155.8,Fee Schedule,,132.05,,,132.05,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,329.3,
XR KNEE 4+ VIEWS RT,73564,CPT,TCRT,42273564,CDM,320,RC,,,both,,,445,329.3,,,329.3,Other,150% of Medicare + 9.63% HCRA Surcharge,200.25,45,,200.25,percent of total billed charges,Critical Access Hospital RCC factor,126.1,,,126.1,Fee Schedule,,113.45,,,113.45,Fee Schedule,,206.06,,,206.06,Fee Schedule,,185.33,,,185.33,Fee Schedule,,175.17,,,175.17,Fee Schedule,,220.28,,,220.28,Other,110% of Medicare,149.82,,,149.82,Fee Schedule,,53,,,53,Other,186% of Medicaid,176.3,,,176.3,Fee Schedule,,275.9,,,275.9,Fee Schedule,,83.01,,,83.01,Fee Schedule,,176.3,,,176.3,Fee Schedule,,275.9,,,275.9,Fee Schedule,,156.14,,,156.14,Fee Schedule,,311.5,70,,311.5,percent of total billed charges,All Other,173.84,,,173.84,Fee Schedule,,147.34,,,147.34,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,329.3,
XR TIBIA/FIBULA 2 VIEWS RT,73590,CPT,TCRT,42273590,CDM,320,RC,,,both,,,373,276.02,,,276.02,Other,150% of Medicare + 9.63% HCRA Surcharge,167.85,45,,167.85,percent of total billed charges,Critical Access Hospital RCC factor,83.35,,,83.35,Fee Schedule,,74.99,,,74.99,Fee Schedule,,130.54,,,130.54,Fee Schedule,,117.41,,,117.41,Fee Schedule,,110.97,,,110.97,Fee Schedule,,184.64,,,184.64,Other,110% of Medicare,99.03,,,99.03,Fee Schedule,,53,,,53,Other,186% of Medicaid,116.54,,,116.54,Fee Schedule,,231.26,,,231.26,Fee Schedule,,54.87,,,54.87,Fee Schedule,,116.54,,,116.54,Fee Schedule,,231.26,,,231.26,Fee Schedule,,103.21,,,103.21,Fee Schedule,,261.1,70,,261.1,percent of total billed charges,All Other,116.44,,,116.44,Fee Schedule,,98.69,,,98.69,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,276.02,
XR LEG INFANT 2 VIEWS RT,73592,CPT,TCRT,42273592,CDM,320,RC,,,both,,,231,170.94,,,170.94,Other,150% of Medicare + 9.63% HCRA Surcharge,103.95,45,,103.95,percent of total billed charges,Critical Access Hospital RCC factor,83.35,,,83.35,Fee Schedule,,74.99,,,74.99,Fee Schedule,,155.73,,,155.73,Fee Schedule,,140.07,,,140.07,Fee Schedule,,132.38,,,132.38,Fee Schedule,,114.35,,,114.35,Other,110% of Medicare,99.03,,,99.03,Fee Schedule,,53,,,53,Other,186% of Medicaid,116.54,,,116.54,Fee Schedule,,143.22,,,143.22,Fee Schedule,,54.87,,,54.87,Fee Schedule,,116.54,,,116.54,Fee Schedule,,143.22,,,143.22,Fee Schedule,,103.21,,,103.21,Fee Schedule,,161.7,70,,161.7,percent of total billed charges,All Other,118.08,,,118.08,Fee Schedule,,100.08,,,100.08,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,170.94,
XR ANKLE 2 VIEWS RT,73600,CPT,TCRT,42273600,CDM,320,RC,,,both,,,231,170.94,,,170.94,Other,150% of Medicare + 9.63% HCRA Surcharge,103.95,45,,103.95,percent of total billed charges,Critical Access Hospital RCC factor,85.65,,,85.65,Fee Schedule,,77.06,,,77.06,Fee Schedule,,137.39,,,137.39,Fee Schedule,,123.57,,,123.57,Fee Schedule,,116.79,,,116.79,Fee Schedule,,114.35,,,114.35,Other,110% of Medicare,101.76,,,101.76,Fee Schedule,,53,,,53,Other,186% of Medicaid,119.75,,,119.75,Fee Schedule,,143.22,,,143.22,Fee Schedule,,56.39,,,56.39,Fee Schedule,,119.75,,,119.75,Fee Schedule,,143.22,,,143.22,Fee Schedule,,106.06,,,106.06,Fee Schedule,,161.7,70,,161.7,percent of total billed charges,All Other,119.72,,,119.72,Fee Schedule,,101.47,,,101.47,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,170.94,
XR ANKLE 3+ VIEWS RT,73610,CPT,TCRT,42273610,CDM,320,RC,,,both,,,348,257.52,,,257.52,Other,150% of Medicare + 9.63% HCRA Surcharge,156.6,45,,156.6,percent of total billed charges,Critical Access Hospital RCC factor,98.38,,,98.38,Fee Schedule,,88.51,,,88.51,Fee Schedule,,162.58,,,162.58,Fee Schedule,,146.23,,,146.23,Fee Schedule,,138.21,,,138.21,Fee Schedule,,172.26,,,172.26,Other,110% of Medicare,116.88,,,116.88,Fee Schedule,,53,,,53,Other,186% of Medicaid,137.55,,,137.55,Fee Schedule,,215.76,,,215.76,Fee Schedule,,64.76,,,64.76,Fee Schedule,,137.55,,,137.55,Fee Schedule,,215.76,,,215.76,Fee Schedule,,121.82,,,121.82,Fee Schedule,,243.6,70,,243.6,percent of total billed charges,All Other,139.4,,,139.4,Fee Schedule,,118.15,,,118.15,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,257.52,
XR FOOT 2 VIEWS RT,73620,CPT,TCRT,42273620,CDM,320,RC,,,both,,,231,170.94,,,170.94,Other,150% of Medicare + 9.63% HCRA Surcharge,103.95,45,,103.95,percent of total billed charges,Critical Access Hospital RCC factor,74.1,,,74.1,Fee Schedule,,66.67,,,66.67,Fee Schedule,,132.8,,,132.8,Fee Schedule,,119.45,,,119.45,Fee Schedule,,112.9,,,112.9,Fee Schedule,,114.35,,,114.35,Other,110% of Medicare,88.04,,,88.04,Fee Schedule,,53,,,53,Other,186% of Medicaid,103.61,,,103.61,Fee Schedule,,143.22,,,143.22,Fee Schedule,,48.78,,,48.78,Fee Schedule,,103.61,,,103.61,Fee Schedule,,143.22,,,143.22,Fee Schedule,,91.76,,,91.76,Fee Schedule,,161.7,70,,161.7,percent of total billed charges,All Other,101.68,,,101.68,Fee Schedule,,86.18,,,86.18,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,170.94,
XR FOOT 3+ VIEWS RT,73630,CPT,TCRT,42273630,CDM,320,RC,,,both,,,373,276.02,,,276.02,Other,150% of Medicare + 9.63% HCRA Surcharge,167.85,45,,167.85,percent of total billed charges,Critical Access Hospital RCC factor,91.43,,,91.43,Fee Schedule,,82.25,,,82.25,Fee Schedule,,157.99,,,157.99,Fee Schedule,,142.11,,,142.11,Fee Schedule,,134.31,,,134.31,Fee Schedule,,184.64,,,184.64,Other,110% of Medicare,108.62,,,108.62,Fee Schedule,,53,,,53,Other,186% of Medicaid,127.82,,,127.82,Fee Schedule,,231.26,,,231.26,Fee Schedule,,60.19,,,60.19,Fee Schedule,,127.82,,,127.82,Fee Schedule,,231.26,,,231.26,Fee Schedule,,113.21,,,113.21,Fee Schedule,,261.1,70,,261.1,percent of total billed charges,All Other,129.56,,,129.56,Fee Schedule,,109.81,,,109.81,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,276.02,
XR HEEL 2+ VIEWS RT,73650,CPT,TCRT,42273650,CDM,320,RC,,,both,,,231,170.94,,,170.94,Other,150% of Medicare + 9.63% HCRA Surcharge,103.95,45,,103.95,percent of total billed charges,Critical Access Hospital RCC factor,72.96,,,72.96,Fee Schedule,,65.64,,,65.64,Fee Schedule,,135.12,,,135.12,Fee Schedule,,121.53,,,121.53,Fee Schedule,,114.87,,,114.87,Fee Schedule,,114.35,,,114.35,Other,110% of Medicare,86.68,,,86.68,Fee Schedule,,53,,,53,Other,186% of Medicaid,102,,,102,Fee Schedule,,143.22,,,143.22,Fee Schedule,,48.03,,,48.03,Fee Schedule,,102,,,102,Fee Schedule,,143.22,,,143.22,Fee Schedule,,90.34,,,90.34,Fee Schedule,,161.7,70,,161.7,percent of total billed charges,All Other,103.32,,,103.32,Fee Schedule,,87.57,,,87.57,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,170.94,
XR TOE(S) 2+ VIEWS RT,73660,CPT,TCRT,42273660,CDM,320,RC,,,both,,,231,170.94,,,170.94,Other,150% of Medicare + 9.63% HCRA Surcharge,103.95,45,,103.95,percent of total billed charges,Critical Access Hospital RCC factor,79.88,,,79.88,Fee Schedule,,71.86,,,71.86,Fee Schedule,,155.73,,,155.73,Fee Schedule,,140.07,,,140.07,Fee Schedule,,132.38,,,132.38,Fee Schedule,,114.35,,,114.35,Other,110% of Medicare,94.9,,,94.9,Fee Schedule,,53,,,53,Other,186% of Medicaid,111.68,,,111.68,Fee Schedule,,143.22,,,143.22,Fee Schedule,,52.58,,,52.58,Fee Schedule,,111.68,,,111.68,Fee Schedule,,143.22,,,143.22,Fee Schedule,,98.91,,,98.91,Fee Schedule,,161.7,70,,161.7,percent of total billed charges,All Other,111.52,,,111.52,Fee Schedule,,94.52,,,94.52,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,170.94,
XR SURGICAL SPECIMEN LT,76098,CPT,,42276098,CDM,320,RC,,,both,,,1844,1364.56,,,1364.56,Other,150% of Medicare + 9.63% HCRA Surcharge,829.8,45,,829.8,percent of total billed charges,Critical Access Hospital RCC factor,96.05,,,96.05,Fee Schedule,,86.42,,,86.42,Fee Schedule,,75.62,,,75.62,Fee Schedule,,68.02,,,68.02,Fee Schedule,,64.29,,,64.29,Fee Schedule,,912.78,,,912.78,Other,110% of Medicare,114.12,,,114.12,Fee Schedule,,392,,,392,Other,186% of Medicaid,134.29,,,134.29,Fee Schedule,,1143.28,,,1143.28,Fee Schedule,,63.23,,,63.23,Fee Schedule,,134.29,,,134.29,Fee Schedule,,1143.28,,,1143.28,Fee Schedule,,118.93,,,118.93,Fee Schedule,,1290.8,70,,1290.8,percent of total billed charges,All Other,124.64,,,124.64,Fee Schedule,,105.64,,,105.64,Fee Schedule,,770.53,,,770.53,Fee Schedule,,770.53,,,770.53,Fee Schedule,,770.53,,,770.53,Fee Schedule,,770.53,,,770.53,Fee Schedule,,210.57,,,210.57,Other,100% of Medicaid,210.57,,,210.57,Other,100% of Medicaid,210.57,,,210.57,Other,100% of Medicaid,210.57,,,210.57,Other,100% of Medicaid,473.77,,,473.77,Other,225% of Medicaid,322.17,,,322.17,Other,153% of Medicaid,473.77,,,473.77,Other,225% of Medicaid,294.79,,,294.79,Other,140% of Medicaid,473.77,,,473.77,Other,225% of Medicaid,547.47,,,547.47,Other,260% of Medicaid,682.23,,,682.23,Other,324% of Medicaid,452.72,,,452.72,Other,215% of Medicaid,452.72,,,452.72,Other,215% of Medicaid,263.21,,,263.21,Other,125% of Medicaid,63.23,1364.56,
XR EYE DETECT FOREIGN BODY BILAT,70030,CPT,TC50,42370030,CDM,320,RC,,,both,,,362,267.88,,,267.88,Other,150% of Medicare + 9.63% HCRA Surcharge,162.9,45,,162.9,percent of total billed charges,Critical Access Hospital RCC factor,84.5,,,84.5,Fee Schedule,,76.03,,,76.03,Fee Schedule,,137.39,,,137.39,Fee Schedule,,123.57,,,123.57,Fee Schedule,,116.79,,,116.79,Fee Schedule,,179.19,,,179.19,Other,110% of Medicare,100.4,,,100.4,Fee Schedule,,53,,,53,Other,186% of Medicaid,118.15,,,118.15,Fee Schedule,,224.44,,,224.44,Fee Schedule,,55.63,,,55.63,Fee Schedule,,118.15,,,118.15,Fee Schedule,,224.44,,,224.44,Fee Schedule,,104.64,,,104.64,Fee Schedule,,253.4,70,,253.4,percent of total billed charges,All Other,116.44,,,116.44,Fee Schedule,,98.69,,,98.69,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,267.88,
XR CLAVICLE BILAT,73000,CPT,TC50,42373000,CDM,320,RC,,,both,,,560,414.4,,,414.4,Other,150% of Medicare + 9.63% HCRA Surcharge,252,45,,252,percent of total billed charges,Critical Access Hospital RCC factor,85.65,,,85.65,Fee Schedule,,77.06,,,77.06,Fee Schedule,,139.71,,,139.71,Fee Schedule,,125.66,,,125.66,Fee Schedule,,118.76,,,118.76,Fee Schedule,,277.2,,,277.2,Other,110% of Medicare,101.76,,,101.76,Fee Schedule,,53,,,53,Other,186% of Medicaid,119.75,,,119.75,Fee Schedule,,347.2,,,347.2,Fee Schedule,,56.39,,,56.39,Fee Schedule,,119.75,,,119.75,Fee Schedule,,347.2,,,347.2,Fee Schedule,,106.06,,,106.06,Fee Schedule,,392,70,,392,percent of total billed charges,All Other,118.08,,,118.08,Fee Schedule,,100.08,,,100.08,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,414.4,
XR OF SCAPULA BILAT,73010,CPT,TC50,42373010,CDM,320,RC,,,both,,,363,268.62,,,268.62,Other,150% of Medicare + 9.63% HCRA Surcharge,163.35,45,,163.35,percent of total billed charges,Critical Access Hospital RCC factor,53.3,,,53.3,Fee Schedule,,47.96,,,47.96,Fee Schedule,,144.29,,,144.29,Fee Schedule,,129.78,,,129.78,Fee Schedule,,122.66,,,122.66,Fee Schedule,,179.69,,,179.69,Other,110% of Medicare,63.33,,,63.33,Fee Schedule,,53,,,53,Other,186% of Medicaid,74.53,,,74.53,Fee Schedule,,225.06,,,225.06,Fee Schedule,,35.09,,,35.09,Fee Schedule,,74.53,,,74.53,Fee Schedule,,225.06,,,225.06,Fee Schedule,,66,,,66,Fee Schedule,,254.1,70,,254.1,percent of total billed charges,All Other,73.8,,,73.8,Fee Schedule,,62.55,,,62.55,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,268.62,
XR SHOULDER 1 VBILAT,73020,CPT,TC50,42373020,CDM,320,RC,,,both,,,347,256.78,,,256.78,Other,150% of Medicare + 9.63% HCRA Surcharge,156.15,45,,156.15,percent of total billed charges,Critical Access Hospital RCC factor,49.86,,,49.86,Fee Schedule,,44.86,,,44.86,Fee Schedule,,109.93,,,109.93,Fee Schedule,,98.88,,,98.88,Fee Schedule,,93.45,,,93.45,Fee Schedule,,171.77,,,171.77,Other,110% of Medicare,59.24,,,59.24,Fee Schedule,,53,,,53,Other,186% of Medicaid,69.71,,,69.71,Fee Schedule,,215.14,,,215.14,Fee Schedule,,32.82,,,32.82,Fee Schedule,,69.71,,,69.71,Fee Schedule,,215.14,,,215.14,Fee Schedule,,61.74,,,61.74,Fee Schedule,,242.9,70,,242.9,percent of total billed charges,All Other,68.88,,,68.88,Fee Schedule,,58.38,,,58.38,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,256.78,
XR SHOULDER 2 VIEWS BILAT,73030,CPT,TC50,42373030,CDM,320,RC,,,both,,,611,452.14,,,452.14,Other,150% of Medicare + 9.63% HCRA Surcharge,274.95,45,,274.95,percent of total billed charges,Critical Access Hospital RCC factor,90.28,,,90.28,Fee Schedule,,81.22,,,81.22,Fee Schedule,,141.97,,,141.97,Fee Schedule,,127.7,,,127.7,Fee Schedule,,120.69,,,120.69,Fee Schedule,,302.45,,,302.45,Other,110% of Medicare,107.26,,,107.26,Fee Schedule,,53,,,53,Other,186% of Medicaid,126.22,,,126.22,Fee Schedule,,378.82,,,378.82,Fee Schedule,,59.43,,,59.43,Fee Schedule,,126.22,,,126.22,Fee Schedule,,378.82,,,378.82,Fee Schedule,,111.79,,,111.79,Fee Schedule,,427.7,70,,427.7,percent of total billed charges,All Other,124.64,,,124.64,Fee Schedule,,105.64,,,105.64,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,452.14,
XR HUMERUS 2 VIEW BILAT,73060,CPT,TC50,42373060,CDM,320,RC,,,both,,,560,414.4,,,414.4,Other,150% of Medicare + 9.63% HCRA Surcharge,252,45,,252,percent of total billed charges,Critical Access Hospital RCC factor,84.5,,,84.5,Fee Schedule,,76.03,,,76.03,Fee Schedule,,139.71,,,139.71,Fee Schedule,,125.66,,,125.66,Fee Schedule,,118.76,,,118.76,Fee Schedule,,277.2,,,277.2,Other,110% of Medicare,100.4,,,100.4,Fee Schedule,,53,,,53,Other,186% of Medicaid,118.15,,,118.15,Fee Schedule,,347.2,,,347.2,Fee Schedule,,55.63,,,55.63,Fee Schedule,,118.15,,,118.15,Fee Schedule,,347.2,,,347.2,Fee Schedule,,104.64,,,104.64,Fee Schedule,,392,70,,392,percent of total billed charges,All Other,118.08,,,118.08,Fee Schedule,,100.08,,,100.08,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,414.4,
XR ELBOW 2 V BILAT,73070,CPT,TC50,42373070,CDM,320,RC,,,both,,,347,256.78,,,256.78,Other,150% of Medicare + 9.63% HCRA Surcharge,156.15,45,,156.15,percent of total billed charges,Critical Access Hospital RCC factor,74.1,,,74.1,Fee Schedule,,66.67,,,66.67,Fee Schedule,,139.71,,,139.71,Fee Schedule,,125.66,,,125.66,Fee Schedule,,118.76,,,118.76,Fee Schedule,,171.77,,,171.77,Other,110% of Medicare,88.04,,,88.04,Fee Schedule,,53,,,53,Other,186% of Medicaid,103.61,,,103.61,Fee Schedule,,215.14,,,215.14,Fee Schedule,,48.78,,,48.78,Fee Schedule,,103.61,,,103.61,Fee Schedule,,215.14,,,215.14,Fee Schedule,,91.76,,,91.76,Fee Schedule,,242.9,70,,242.9,percent of total billed charges,All Other,103.32,,,103.32,Fee Schedule,,87.57,,,87.57,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,256.78,
XR ELBOW 3 VIEWS  BILAT,73080,CPT,TC50,42373080,CDM,320,RC,,,both,,,588,435.12,,,435.12,Other,150% of Medicare + 9.63% HCRA Surcharge,264.6,45,,264.6,percent of total billed charges,Critical Access Hospital RCC factor,85.65,,,85.65,Fee Schedule,,77.06,,,77.06,Fee Schedule,,174.02,,,174.02,Fee Schedule,,156.51,,,156.51,Fee Schedule,,147.93,,,147.93,Fee Schedule,,291.06,,,291.06,Other,110% of Medicare,101.76,,,101.76,Fee Schedule,,53,,,53,Other,186% of Medicaid,119.75,,,119.75,Fee Schedule,,364.56,,,364.56,Fee Schedule,,56.39,,,56.39,Fee Schedule,,119.75,,,119.75,Fee Schedule,,364.56,,,364.56,Fee Schedule,,106.06,,,106.06,Fee Schedule,,411.6,70,,411.6,percent of total billed charges,All Other,118.08,,,118.08,Fee Schedule,,100.08,,,100.08,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,435.12,
XR ARTHROGRAM ELBOW BILAT,73085,CPT,TC50,42373085,CDM,320,RC,,,both,,,1799,1331.26,,,1331.26,Other,150% of Medicare + 9.63% HCRA Surcharge,809.55,45,,809.55,percent of total billed charges,Critical Access Hospital RCC factor,258.96,,,258.96,Fee Schedule,,232.99,,,232.99,Fee Schedule,,476.09,,,476.09,Fee Schedule,,428.21,,,428.21,Fee Schedule,,404.72,,,404.72,Fee Schedule,,890.51,,,890.51,Other,110% of Medicare,307.67,,,307.67,Fee Schedule,,392,,,392,Other,186% of Medicaid,362.06,,,362.06,Fee Schedule,,1115.38,,,1115.38,Fee Schedule,,170.48,,,170.48,Fee Schedule,,362.06,,,362.06,Fee Schedule,,1115.38,,,1115.38,Fee Schedule,,320.66,,,320.66,Fee Schedule,,1259.3,70,,1259.3,percent of total billed charges,All Other,424.76,,,424.76,Fee Schedule,,360.01,,,360.01,Fee Schedule,,610.96,,,610.96,Fee Schedule,,610.96,,,610.96,Fee Schedule,,610.96,,,610.96,Fee Schedule,,610.96,,,610.96,Fee Schedule,,210.57,,,210.57,Other,100% of Medicaid,210.57,,,210.57,Other,100% of Medicaid,210.57,,,210.57,Other,100% of Medicaid,210.57,,,210.57,Other,100% of Medicaid,473.77,,,473.77,Other,225% of Medicaid,322.17,,,322.17,Other,153% of Medicaid,473.77,,,473.77,Other,225% of Medicaid,294.79,,,294.79,Other,140% of Medicaid,473.77,,,473.77,Other,225% of Medicaid,547.47,,,547.47,Other,260% of Medicaid,682.23,,,682.23,Other,324% of Medicaid,452.72,,,452.72,Other,215% of Medicaid,452.72,,,452.72,Other,215% of Medicaid,263.21,,,263.21,Other,125% of Medicaid,170.48,1331.26,
XR FOREARM BILAT,73090,CPT,TC50,42373090,CDM,320,RC,,,both,,,501,370.74,,,370.74,Other,150% of Medicare + 9.63% HCRA Surcharge,225.45,45,,225.45,percent of total billed charges,Critical Access Hospital RCC factor,75.25,,,75.25,Fee Schedule,,67.7,,,67.7,Fee Schedule,,135.12,,,135.12,Fee Schedule,,121.53,,,121.53,Fee Schedule,,114.87,,,114.87,Fee Schedule,,248,,,248,Other,110% of Medicare,89.41,,,89.41,Fee Schedule,,53,,,53,Other,186% of Medicaid,105.21,,,105.21,Fee Schedule,,310.62,,,310.62,Fee Schedule,,49.54,,,49.54,Fee Schedule,,105.21,,,105.21,Fee Schedule,,310.62,,,310.62,Fee Schedule,,93.18,,,93.18,Fee Schedule,,350.7,70,,350.7,percent of total billed charges,All Other,104.96,,,104.96,Fee Schedule,,88.96,,,88.96,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,370.74,
XR UPPER EXT CHILD BILAT,73092,CPT,TC50,42373092,CDM,320,RC,,,both,,,363,268.62,,,268.62,Other,150% of Medicare + 9.63% HCRA Surcharge,163.35,45,,163.35,percent of total billed charges,Critical Access Hospital RCC factor,83.35,,,83.35,Fee Schedule,,74.99,,,74.99,Fee Schedule,,153.41,,,153.41,Fee Schedule,,137.98,,,137.98,Fee Schedule,,130.41,,,130.41,Fee Schedule,,179.69,,,179.69,Other,110% of Medicare,99.03,,,99.03,Fee Schedule,,53,,,53,Other,186% of Medicaid,116.54,,,116.54,Fee Schedule,,225.06,,,225.06,Fee Schedule,,54.87,,,54.87,Fee Schedule,,116.54,,,116.54,Fee Schedule,,225.06,,,225.06,Fee Schedule,,103.21,,,103.21,Fee Schedule,,254.1,70,,254.1,percent of total billed charges,All Other,118.08,,,118.08,Fee Schedule,,100.08,,,100.08,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,268.62,
XR WRIST 2 VIEWS BILAT,73100,CPT,TC50,42373100,CDM,320,RC,,,both,,,347,256.78,,,256.78,Other,150% of Medicare + 9.63% HCRA Surcharge,156.15,45,,156.15,percent of total billed charges,Critical Access Hospital RCC factor,90.28,,,90.28,Fee Schedule,,81.22,,,81.22,Fee Schedule,,148.82,,,148.82,Fee Schedule,,133.86,,,133.86,Fee Schedule,,126.52,,,126.52,Fee Schedule,,171.77,,,171.77,Other,110% of Medicare,107.26,,,107.26,Fee Schedule,,53,,,53,Other,186% of Medicaid,126.22,,,126.22,Fee Schedule,,215.14,,,215.14,Fee Schedule,,59.43,,,59.43,Fee Schedule,,126.22,,,126.22,Fee Schedule,,215.14,,,215.14,Fee Schedule,,111.79,,,111.79,Fee Schedule,,242.9,70,,242.9,percent of total billed charges,All Other,126.28,,,126.28,Fee Schedule,,107.03,,,107.03,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,256.78,
XR WRIST 3+ V BILAT,73110,CPT,TC50,42373110,CDM,320,RC,,,both,,,495,366.3,,,366.3,Other,150% of Medicare + 9.63% HCRA Surcharge,222.75,45,,222.75,percent of total billed charges,Critical Access Hospital RCC factor,114.55,,,114.55,Fee Schedule,,103.06,,,103.06,Fee Schedule,,187.77,,,187.77,Fee Schedule,,168.89,,,168.89,Fee Schedule,,159.62,,,159.62,Fee Schedule,,245.03,,,245.03,Other,110% of Medicare,136.1,,,136.1,Fee Schedule,,53,,,53,Other,186% of Medicaid,160.16,,,160.16,Fee Schedule,,306.9,,,306.9,Fee Schedule,,75.41,,,75.41,Fee Schedule,,160.16,,,160.16,Fee Schedule,,306.9,,,306.9,Fee Schedule,,141.84,,,141.84,Fee Schedule,,346.5,70,,346.5,percent of total billed charges,All Other,159.08,,,159.08,Fee Schedule,,134.83,,,134.83,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,366.3,
XR HAND 2 VIEWS BILAT,73120,CPT,TC50,42373120,CDM,320,RC,,,both,,,363,268.62,,,268.62,Other,150% of Medicare + 9.63% HCRA Surcharge,163.35,45,,163.35,percent of total billed charges,Critical Access Hospital RCC factor,82.21,,,82.21,Fee Schedule,,73.96,,,73.96,Fee Schedule,,132.8,,,132.8,Fee Schedule,,119.45,,,119.45,Fee Schedule,,112.9,,,112.9,Fee Schedule,,179.69,,,179.69,Other,110% of Medicare,97.67,,,97.67,Fee Schedule,,53,,,53,Other,186% of Medicaid,114.93,,,114.93,Fee Schedule,,225.06,,,225.06,Fee Schedule,,54.12,,,54.12,Fee Schedule,,114.93,,,114.93,Fee Schedule,,225.06,,,225.06,Fee Schedule,,101.79,,,101.79,Fee Schedule,,254.1,70,,254.1,percent of total billed charges,All Other,113.16,,,113.16,Fee Schedule,,95.91,,,95.91,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,268.62,
XR HAND 3+ VIEWS BILAT,73130,CPT,TC50,42373130,CDM,320,RC,,,both,,,528,390.72,,,390.72,Other,150% of Medicare + 9.63% HCRA Surcharge,237.6,45,,237.6,percent of total billed charges,Critical Access Hospital RCC factor,100.68,,,100.68,Fee Schedule,,90.58,,,90.58,Fee Schedule,,160.26,,,160.26,Fee Schedule,,144.14,,,144.14,Fee Schedule,,136.24,,,136.24,Fee Schedule,,261.36,,,261.36,Other,110% of Medicare,119.61,,,119.61,Fee Schedule,,53,,,53,Other,186% of Medicaid,140.76,,,140.76,Fee Schedule,,327.36,,,327.36,Fee Schedule,,66.28,,,66.28,Fee Schedule,,140.76,,,140.76,Fee Schedule,,327.36,,,327.36,Fee Schedule,,124.66,,,124.66,Fee Schedule,,369.6,70,,369.6,percent of total billed charges,All Other,137.76,,,137.76,Fee Schedule,,116.76,,,116.76,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,390.72,
XR FINGER 2+ VIEWS BILAT,73140,CPT,TC50,42373140,CDM,320,RC,,,both,,,347,256.78,,,256.78,Other,150% of Medicare + 9.63% HCRA Surcharge,156.15,45,,156.15,percent of total billed charges,Critical Access Hospital RCC factor,109.93,,,109.93,Fee Schedule,,98.9,,,98.9,Fee Schedule,,167.16,,,167.16,Fee Schedule,,150.35,,,150.35,Fee Schedule,,142.11,,,142.11,Fee Schedule,,171.77,,,171.77,Other,110% of Medicare,130.6,,,130.6,Fee Schedule,,53,,,53,Other,186% of Medicaid,153.69,,,153.69,Fee Schedule,,215.14,,,215.14,Fee Schedule,,72.37,,,72.37,Fee Schedule,,153.69,,,153.69,Fee Schedule,,215.14,,,215.14,Fee Schedule,,136.12,,,136.12,Fee Schedule,,242.9,70,,242.9,percent of total billed charges,All Other,150.88,,,150.88,Fee Schedule,,127.88,,,127.88,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,256.78,
X-RAY EXAM OF FEMUR 1 BILATERAL,73551,CPT,TC50,42373551,CDM,320,RC,,,both,,,356,263.44,,,263.44,Other,150% of Medicare + 9.63% HCRA Surcharge,160.2,45,,160.2,percent of total billed charges,Critical Access Hospital RCC factor,74.1,,,74.1,Fee Schedule,,66.67,,,66.67,Fee Schedule,,19.04,,,19.04,Fee Schedule,,19.04,,,19.04,Fee Schedule,,19.04,,,19.04,Fee Schedule,,176.22,,,176.22,Other,110% of Medicare,88.04,,,88.04,Fee Schedule,,53,,,53,Other,186% of Medicaid,103.61,,,103.61,Fee Schedule,,220.72,,,220.72,Fee Schedule,,48.78,,,48.78,Fee Schedule,,103.61,,,103.61,Fee Schedule,,220.72,,,220.72,Fee Schedule,,91.76,,,91.76,Fee Schedule,,249.2,70,,249.2,percent of total billed charges,All Other,103.32,,,103.32,Fee Schedule,,87.57,,,87.57,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,19.04,263.44,
X-RAY EXAM OF FEMUR 2/> BILAT,73552,CPT,TC50,42373552,CDM,320,RC,,,both,,,356,263.44,,,263.44,Other,150% of Medicare + 9.63% HCRA Surcharge,160.2,45,,160.2,percent of total billed charges,Critical Access Hospital RCC factor,93.75,,,93.75,Fee Schedule,,84.35,,,84.35,Fee Schedule,,22.84,,,22.84,Fee Schedule,,22.84,,,22.84,Fee Schedule,,22.84,,,22.84,Fee Schedule,,176.22,,,176.22,Other,110% of Medicare,111.39,,,111.39,Fee Schedule,,53,,,53,Other,186% of Medicaid,131.08,,,131.08,Fee Schedule,,220.72,,,220.72,Fee Schedule,,61.72,,,61.72,Fee Schedule,,131.08,,,131.08,Fee Schedule,,220.72,,,220.72,Fee Schedule,,116.09,,,116.09,Fee Schedule,,249.2,70,,249.2,percent of total billed charges,All Other,129.56,,,129.56,Fee Schedule,,109.81,,,109.81,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,22.84,263.44,
XR KNEE 1 OR 2 VIEWS BILAT,73560,CPT,TC50,42373560,CDM,320,RC,,,both,,,611,452.14,,,452.14,Other,150% of Medicare + 9.63% HCRA Surcharge,274.95,45,,274.95,percent of total billed charges,Critical Access Hospital RCC factor,91.43,,,91.43,Fee Schedule,,82.25,,,82.25,Fee Schedule,,144.29,,,144.29,Fee Schedule,,129.78,,,129.78,Fee Schedule,,122.66,,,122.66,Fee Schedule,,302.45,,,302.45,Other,110% of Medicare,108.62,,,108.62,Fee Schedule,,53,,,53,Other,186% of Medicaid,127.82,,,127.82,Fee Schedule,,378.82,,,378.82,Fee Schedule,,60.19,,,60.19,Fee Schedule,,127.82,,,127.82,Fee Schedule,,378.82,,,378.82,Fee Schedule,,113.21,,,113.21,Fee Schedule,,427.7,70,,427.7,percent of total billed charges,All Other,127.92,,,127.92,Fee Schedule,,108.42,,,108.42,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,452.14,
XR KNEE 3 VIEWS BILAT,73562,CPT,TC50,42373562,CDM,320,RC,,,both,,,668,494.32,,,494.32,Other,150% of Medicare + 9.63% HCRA Surcharge,300.6,45,,300.6,percent of total billed charges,Critical Access Hospital RCC factor,111.08,,,111.08,Fee Schedule,,99.93,,,99.93,Fee Schedule,,180.87,,,180.87,Fee Schedule,,162.68,,,162.68,Fee Schedule,,153.75,,,153.75,Fee Schedule,,330.66,,,330.66,Other,110% of Medicare,131.97,,,131.97,Fee Schedule,,53,,,53,Other,186% of Medicaid,155.3,,,155.3,Fee Schedule,,414.16,,,414.16,Fee Schedule,,73.12,,,73.12,Fee Schedule,,155.3,,,155.3,Fee Schedule,,414.16,,,414.16,Fee Schedule,,137.54,,,137.54,Fee Schedule,,467.6,70,,467.6,percent of total billed charges,All Other,155.8,,,155.8,Fee Schedule,,132.05,,,132.05,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,494.32,
XR KNEE 4+ VIEWS BILAT,73564,CPT,TC50,42373564,CDM,320,RC,,,both,,,668,494.32,,,494.32,Other,150% of Medicare + 9.63% HCRA Surcharge,300.6,45,,300.6,percent of total billed charges,Critical Access Hospital RCC factor,126.1,,,126.1,Fee Schedule,,113.45,,,113.45,Fee Schedule,,206.06,,,206.06,Fee Schedule,,185.33,,,185.33,Fee Schedule,,175.17,,,175.17,Fee Schedule,,330.66,,,330.66,Other,110% of Medicare,149.82,,,149.82,Fee Schedule,,53,,,53,Other,186% of Medicaid,176.3,,,176.3,Fee Schedule,,414.16,,,414.16,Fee Schedule,,83.01,,,83.01,Fee Schedule,,176.3,,,176.3,Fee Schedule,,414.16,,,414.16,Fee Schedule,,156.14,,,156.14,Fee Schedule,,467.6,70,,467.6,percent of total billed charges,All Other,173.84,,,173.84,Fee Schedule,,147.34,,,147.34,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,494.32,
XR TIBIA/FIBULA 2 VIEWS BIL,73590,CPT,TC50,42373590,CDM,320,RC,,,both,,,560,414.4,,,414.4,Other,150% of Medicare + 9.63% HCRA Surcharge,252,45,,252,percent of total billed charges,Critical Access Hospital RCC factor,83.35,,,83.35,Fee Schedule,,74.99,,,74.99,Fee Schedule,,130.54,,,130.54,Fee Schedule,,117.41,,,117.41,Fee Schedule,,110.97,,,110.97,Fee Schedule,,277.2,,,277.2,Other,110% of Medicare,99.03,,,99.03,Fee Schedule,,53,,,53,Other,186% of Medicaid,116.54,,,116.54,Fee Schedule,,347.2,,,347.2,Fee Schedule,,54.87,,,54.87,Fee Schedule,,116.54,,,116.54,Fee Schedule,,347.2,,,347.2,Fee Schedule,,103.21,,,103.21,Fee Schedule,,392,70,,392,percent of total billed charges,All Other,116.44,,,116.44,Fee Schedule,,98.69,,,98.69,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,414.4,
XR LEG INFANT 2 VIEWS BILAT,73592,CPT,TC50,42373592,CDM,320,RC,,,both,,,347,256.78,,,256.78,Other,150% of Medicare + 9.63% HCRA Surcharge,156.15,45,,156.15,percent of total billed charges,Critical Access Hospital RCC factor,83.35,,,83.35,Fee Schedule,,74.99,,,74.99,Fee Schedule,,155.73,,,155.73,Fee Schedule,,140.07,,,140.07,Fee Schedule,,132.38,,,132.38,Fee Schedule,,171.77,,,171.77,Other,110% of Medicare,99.03,,,99.03,Fee Schedule,,53,,,53,Other,186% of Medicaid,116.54,,,116.54,Fee Schedule,,215.14,,,215.14,Fee Schedule,,54.87,,,54.87,Fee Schedule,,116.54,,,116.54,Fee Schedule,,215.14,,,215.14,Fee Schedule,,103.21,,,103.21,Fee Schedule,,242.9,70,,242.9,percent of total billed charges,All Other,118.08,,,118.08,Fee Schedule,,100.08,,,100.08,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,256.78,
XR ANKLE 2 V BILAT,73600,CPT,TC50,42373600,CDM,320,RC,,,both,,,347,256.78,,,256.78,Other,150% of Medicare + 9.63% HCRA Surcharge,156.15,45,,156.15,percent of total billed charges,Critical Access Hospital RCC factor,85.65,,,85.65,Fee Schedule,,77.06,,,77.06,Fee Schedule,,137.39,,,137.39,Fee Schedule,,123.57,,,123.57,Fee Schedule,,116.79,,,116.79,Fee Schedule,,171.77,,,171.77,Other,110% of Medicare,101.76,,,101.76,Fee Schedule,,53,,,53,Other,186% of Medicaid,119.75,,,119.75,Fee Schedule,,215.14,,,215.14,Fee Schedule,,56.39,,,56.39,Fee Schedule,,119.75,,,119.75,Fee Schedule,,215.14,,,215.14,Fee Schedule,,106.06,,,106.06,Fee Schedule,,242.9,70,,242.9,percent of total billed charges,All Other,119.72,,,119.72,Fee Schedule,,101.47,,,101.47,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,256.78,
XR ANKLE 3+ VIEWS BILAT,73610,CPT,TC50,42373610,CDM,320,RC,,,both,,,522,386.28,,,386.28,Other,150% of Medicare + 9.63% HCRA Surcharge,234.9,45,,234.9,percent of total billed charges,Critical Access Hospital RCC factor,98.38,,,98.38,Fee Schedule,,88.51,,,88.51,Fee Schedule,,162.58,,,162.58,Fee Schedule,,146.23,,,146.23,Fee Schedule,,138.21,,,138.21,Fee Schedule,,258.39,,,258.39,Other,110% of Medicare,116.88,,,116.88,Fee Schedule,,53,,,53,Other,186% of Medicaid,137.55,,,137.55,Fee Schedule,,323.64,,,323.64,Fee Schedule,,64.76,,,64.76,Fee Schedule,,137.55,,,137.55,Fee Schedule,,323.64,,,323.64,Fee Schedule,,121.82,,,121.82,Fee Schedule,,365.4,70,,365.4,percent of total billed charges,All Other,139.4,,,139.4,Fee Schedule,,118.15,,,118.15,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,386.28,
XR FOOT 2 V BILAT,73620,CPT,TC50,42373620,CDM,320,RC,,,both,,,347,256.78,,,256.78,Other,150% of Medicare + 9.63% HCRA Surcharge,156.15,45,,156.15,percent of total billed charges,Critical Access Hospital RCC factor,74.1,,,74.1,Fee Schedule,,66.67,,,66.67,Fee Schedule,,132.8,,,132.8,Fee Schedule,,119.45,,,119.45,Fee Schedule,,112.9,,,112.9,Fee Schedule,,171.77,,,171.77,Other,110% of Medicare,88.04,,,88.04,Fee Schedule,,53,,,53,Other,186% of Medicaid,103.61,,,103.61,Fee Schedule,,215.14,,,215.14,Fee Schedule,,48.78,,,48.78,Fee Schedule,,103.61,,,103.61,Fee Schedule,,215.14,,,215.14,Fee Schedule,,91.76,,,91.76,Fee Schedule,,242.9,70,,242.9,percent of total billed charges,All Other,101.68,,,101.68,Fee Schedule,,86.18,,,86.18,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,256.78,
XR FOOT 3+ VIEWS BILAT,73630,CPT,TC50,42373630,CDM,320,RC,,,both,,,560,414.4,,,414.4,Other,150% of Medicare + 9.63% HCRA Surcharge,252,45,,252,percent of total billed charges,Critical Access Hospital RCC factor,91.43,,,91.43,Fee Schedule,,82.25,,,82.25,Fee Schedule,,157.99,,,157.99,Fee Schedule,,142.11,,,142.11,Fee Schedule,,134.31,,,134.31,Fee Schedule,,277.2,,,277.2,Other,110% of Medicare,108.62,,,108.62,Fee Schedule,,53,,,53,Other,186% of Medicaid,127.82,,,127.82,Fee Schedule,,347.2,,,347.2,Fee Schedule,,60.19,,,60.19,Fee Schedule,,127.82,,,127.82,Fee Schedule,,347.2,,,347.2,Fee Schedule,,113.21,,,113.21,Fee Schedule,,392,70,,392,percent of total billed charges,All Other,129.56,,,129.56,Fee Schedule,,109.81,,,109.81,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,414.4,
XR HEEL 2+ VIEWS BILAT,73650,CPT,TC50,42373650,CDM,320,RC,,,both,,,347,256.78,,,256.78,Other,150% of Medicare + 9.63% HCRA Surcharge,156.15,45,,156.15,percent of total billed charges,Critical Access Hospital RCC factor,72.96,,,72.96,Fee Schedule,,65.64,,,65.64,Fee Schedule,,135.12,,,135.12,Fee Schedule,,121.53,,,121.53,Fee Schedule,,114.87,,,114.87,Fee Schedule,,171.77,,,171.77,Other,110% of Medicare,86.68,,,86.68,Fee Schedule,,53,,,53,Other,186% of Medicaid,102,,,102,Fee Schedule,,215.14,,,215.14,Fee Schedule,,48.03,,,48.03,Fee Schedule,,102,,,102,Fee Schedule,,215.14,,,215.14,Fee Schedule,,90.34,,,90.34,Fee Schedule,,242.9,70,,242.9,percent of total billed charges,All Other,103.32,,,103.32,Fee Schedule,,87.57,,,87.57,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,256.78,
XR TOE(S) 2+ VIEWS  BILAT,73660,CPT,TC50,42373660,CDM,320,RC,,,both,,,347,256.78,,,256.78,Other,150% of Medicare + 9.63% HCRA Surcharge,156.15,45,,156.15,percent of total billed charges,Critical Access Hospital RCC factor,79.88,,,79.88,Fee Schedule,,71.86,,,71.86,Fee Schedule,,155.73,,,155.73,Fee Schedule,,140.07,,,140.07,Fee Schedule,,132.38,,,132.38,Fee Schedule,,171.77,,,171.77,Other,110% of Medicare,94.9,,,94.9,Fee Schedule,,53,,,53,Other,186% of Medicaid,111.68,,,111.68,Fee Schedule,,215.14,,,215.14,Fee Schedule,,52.58,,,52.58,Fee Schedule,,111.68,,,111.68,Fee Schedule,,215.14,,,215.14,Fee Schedule,,98.91,,,98.91,Fee Schedule,,242.9,70,,242.9,percent of total billed charges,All Other,111.52,,,111.52,Fee Schedule,,94.52,,,94.52,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,256.78,
XR EXAM OF JAW <4 VIEWS W/ FY MOD,70100,CPT,FY,42670100,CDM,320,RC,,,both,,,231,170.94,,,170.94,Other,150% of Medicare + 9.63% HCRA Surcharge,103.95,45,,103.95,percent of total billed charges,Critical Access Hospital RCC factor,105.3,,,105.3,Fee Schedule,,94.74,,,94.74,Fee Schedule,,162.58,,,162.58,Fee Schedule,,146.23,,,146.23,Fee Schedule,,138.21,,,138.21,Fee Schedule,,114.35,,,114.35,Other,110% of Medicare,125.11,,,125.11,Fee Schedule,,53,,,53,Other,186% of Medicaid,147.22,,,147.22,Fee Schedule,,143.22,,,143.22,Fee Schedule,,69.32,,,69.32,Fee Schedule,,147.22,,,147.22,Fee Schedule,,143.22,,,143.22,Fee Schedule,,130.39,,,130.39,Fee Schedule,,161.7,70,,161.7,percent of total billed charges,All Other,145.96,,,145.96,Fee Schedule,,123.71,,,123.71,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,170.94,
XR MANDIBLE BI 4 VIEWS MINU W/ FY MOD,70110,CPT,FY,42670110,CDM,320,RC,,,both,,,510,377.4,,,377.4,Other,150% of Medicare + 9.63% HCRA Surcharge,229.5,45,,229.5,percent of total billed charges,Critical Access Hospital RCC factor,111.08,,,111.08,Fee Schedule,,99.93,,,99.93,Fee Schedule,,185.45,,,185.45,Fee Schedule,,166.8,,,166.8,Fee Schedule,,157.65,,,157.65,Fee Schedule,,252.45,,,252.45,Other,110% of Medicare,131.97,,,131.97,Fee Schedule,,53,,,53,Other,186% of Medicaid,155.3,,,155.3,Fee Schedule,,316.2,,,316.2,Fee Schedule,,73.12,,,73.12,Fee Schedule,,155.3,,,155.3,Fee Schedule,,316.2,,,316.2,Fee Schedule,,137.54,,,137.54,Fee Schedule,,357,70,,357,percent of total billed charges,All Other,157.44,,,157.44,Fee Schedule,,133.44,,,133.44,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,377.4,
XR EXAM OF MASTOIDS 3+ VIEW W/ FY MOD,70130,CPT,FY,42670130,CDM,320,RC,,,both,,,653,483.22,,,483.22,Other,150% of Medicare + 9.63% HCRA Surcharge,293.85,45,,293.85,percent of total billed charges,Critical Access Hospital RCC factor,159.6,,,159.6,Fee Schedule,,143.59,,,143.59,Fee Schedule,,267.82,,,267.82,Fee Schedule,,240.89,,,240.89,Fee Schedule,,227.67,,,227.67,Fee Schedule,,323.24,,,323.24,Other,110% of Medicare,189.61,,,189.61,Fee Schedule,,53,,,53,Other,186% of Medicaid,223.13,,,223.13,Fee Schedule,,404.86,,,404.86,Fee Schedule,,105.06,,,105.06,Fee Schedule,,223.13,,,223.13,Fee Schedule,,404.86,,,404.86,Fee Schedule,,197.62,,,197.62,Fee Schedule,,457.1,70,,457.1,percent of total billed charges,All Other,227.96,,,227.96,Fee Schedule,,193.21,,,193.21,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,483.22,
XR  OF FACIAL BONES <3 VIEW W/ FY MOD,70140,CPT,FY,42670140,CDM,320,RC,,,both,,,198,146.52,,,146.52,Other,150% of Medicare + 9.63% HCRA Surcharge,89.1,45,,89.1,percent of total billed charges,Critical Access Hospital RCC factor,78.73,,,78.73,Fee Schedule,,70.83,,,70.83,Fee Schedule,,139.71,,,139.71,Fee Schedule,,125.66,,,125.66,Fee Schedule,,118.76,,,118.76,Fee Schedule,,98.01,,,98.01,Other,110% of Medicare,93.54,,,93.54,Fee Schedule,,53,,,53,Other,186% of Medicaid,110.07,,,110.07,Fee Schedule,,122.76,,,122.76,Fee Schedule,,51.83,,,51.83,Fee Schedule,,110.07,,,110.07,Fee Schedule,,122.76,,,122.76,Fee Schedule,,97.49,,,97.49,Fee Schedule,,138.6,70,,138.6,percent of total billed charges,All Other,109.88,,,109.88,Fee Schedule,,93.13,,,93.13,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,146.52,
XR EXAM OF FACIAL BONES 3+ VIEWS W/ FY,70150,CPT,FY,42670150,CDM,320,RC,,,both,,,248,183.52,,,183.52,Other,150% of Medicare + 9.63% HCRA Surcharge,111.6,45,,111.6,percent of total billed charges,Critical Access Hospital RCC factor,121.48,,,121.48,Fee Schedule,,109.29,,,109.29,Fee Schedule,,203.74,,,203.74,Fee Schedule,,183.25,,,183.25,Fee Schedule,,173.2,,,173.2,Fee Schedule,,122.76,,,122.76,Other,110% of Medicare,144.32,,,144.32,Fee Schedule,,53,,,53,Other,186% of Medicaid,169.84,,,169.84,Fee Schedule,,153.76,,,153.76,Fee Schedule,,79.97,,,79.97,Fee Schedule,,169.84,,,169.84,Fee Schedule,,153.76,,,153.76,Fee Schedule,,150.42,,,150.42,Fee Schedule,,173.6,70,,173.6,percent of total billed charges,All Other,172.2,,,172.2,Fee Schedule,,145.95,,,145.95,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,203.74,
XR NASAL BONES 3 VIEWS W/ FY MOD,70160,CPT,FY,42670160,CDM,320,RC,,,both,,,470,347.8,,,347.8,Other,150% of Medicare + 9.63% HCRA Surcharge,211.5,45,,211.5,percent of total billed charges,Critical Access Hospital RCC factor,102.97,,,102.97,Fee Schedule,,92.64,,,92.64,Fee Schedule,,167.16,,,167.16,Fee Schedule,,150.35,,,150.35,Fee Schedule,,142.11,,,142.11,Fee Schedule,,232.65,,,232.65,Other,110% of Medicare,122.34,,,122.34,Fee Schedule,,53,,,53,Other,186% of Medicaid,143.97,,,143.97,Fee Schedule,,291.4,,,291.4,Fee Schedule,,67.79,,,67.79,Fee Schedule,,143.97,,,143.97,Fee Schedule,,291.4,,,291.4,Fee Schedule,,127.51,,,127.51,Fee Schedule,,329,70,,329,percent of total billed charges,All Other,145.96,,,145.96,Fee Schedule,,123.71,,,123.71,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,347.8,
XR EYE SOCKETS 4+ VIEWS W/ FY MOD,70200,CPT,FY,42670200,CDM,320,RC,,,both,,,248,183.52,,,183.52,Other,150% of Medicare + 9.63% HCRA Surcharge,111.6,45,,111.6,percent of total billed charges,Critical Access Hospital RCC factor,120.33,,,120.33,Fee Schedule,,108.26,,,108.26,Fee Schedule,,206.06,,,206.06,Fee Schedule,,185.33,,,185.33,Fee Schedule,,175.17,,,175.17,Fee Schedule,,122.76,,,122.76,Other,110% of Medicare,142.96,,,142.96,Fee Schedule,,53,,,53,Other,186% of Medicaid,168.23,,,168.23,Fee Schedule,,153.76,,,153.76,Fee Schedule,,79.21,,,79.21,Fee Schedule,,168.23,,,168.23,Fee Schedule,,153.76,,,153.76,Fee Schedule,,148.99,,,148.99,Fee Schedule,,173.6,70,,173.6,percent of total billed charges,All Other,172.2,,,172.2,Fee Schedule,,145.95,,,145.95,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,206.06,
XR EXAM OF SINUSES <3 VIEWS W/ FY MOD,70210,CPT,FY,42670210,CDM,320,RC,,,both,,,282,208.68,,,208.68,Other,150% of Medicare + 9.63% HCRA Surcharge,126.9,45,,126.9,percent of total billed charges,Critical Access Hospital RCC factor,83.35,,,83.35,Fee Schedule,,74.99,,,74.99,Fee Schedule,,151.14,,,151.14,Fee Schedule,,135.94,,,135.94,Fee Schedule,,128.49,,,128.49,Fee Schedule,,139.59,,,139.59,Other,110% of Medicare,99.03,,,99.03,Fee Schedule,,53,,,53,Other,186% of Medicaid,116.54,,,116.54,Fee Schedule,,174.84,,,174.84,Fee Schedule,,54.87,,,54.87,Fee Schedule,,116.54,,,116.54,Fee Schedule,,174.84,,,174.84,Fee Schedule,,103.21,,,103.21,Fee Schedule,,197.4,70,,197.4,percent of total billed charges,All Other,118.08,,,118.08,Fee Schedule,,100.08,,,100.08,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,208.68,
XR PARANASAL SINUSES 3 VIEW W/ FY MOD,70220,CPT,FY,42670220,CDM,320,RC,,,both,,,601,444.74,,,444.74,Other,150% of Medicare + 9.63% HCRA Surcharge,270.45,45,,270.45,percent of total billed charges,Critical Access Hospital RCC factor,94.9,,,94.9,Fee Schedule,,85.38,,,85.38,Fee Schedule,,180.87,,,180.87,Fee Schedule,,162.68,,,162.68,Fee Schedule,,153.75,,,153.75,Fee Schedule,,297.5,,,297.5,Other,110% of Medicare,112.75,,,112.75,Fee Schedule,,53,,,53,Other,186% of Medicaid,132.69,,,132.69,Fee Schedule,,372.62,,,372.62,Fee Schedule,,62.48,,,62.48,Fee Schedule,,132.69,,,132.69,Fee Schedule,,372.62,,,372.62,Fee Schedule,,117.51,,,117.51,Fee Schedule,,420.7,70,,420.7,percent of total billed charges,All Other,134.48,,,134.48,Fee Schedule,,113.98,,,113.98,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,444.74,
XR SELLA TURCICA W/ FY MOD,70240,CPT,FY,42670240,CDM,320,RC,,,both,,,472,349.28,,,349.28,Other,150% of Medicare + 9.63% HCRA Surcharge,212.4,45,,212.4,percent of total billed charges,Critical Access Hospital RCC factor,83.35,,,83.35,Fee Schedule,,74.99,,,74.99,Fee Schedule,,137.39,,,137.39,Fee Schedule,,123.57,,,123.57,Fee Schedule,,116.79,,,116.79,Fee Schedule,,233.64,,,233.64,Other,110% of Medicare,99.03,,,99.03,Fee Schedule,,53,,,53,Other,186% of Medicaid,116.54,,,116.54,Fee Schedule,,292.64,,,292.64,Fee Schedule,,54.87,,,54.87,Fee Schedule,,116.54,,,116.54,Fee Schedule,,292.64,,,292.64,Fee Schedule,,103.21,,,103.21,Fee Schedule,,330.4,70,,330.4,percent of total billed charges,All Other,118.08,,,118.08,Fee Schedule,,100.08,,,100.08,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,349.28,
XR SKULL COMPLETE W/ FY MOD,70250,CPT,FY,42670250,CDM,320,RC,,,both,,,242,179.08,,,179.08,Other,150% of Medicare + 9.63% HCRA Surcharge,108.9,45,,108.9,percent of total billed charges,Critical Access Hospital RCC factor,96.05,,,96.05,Fee Schedule,,86.42,,,86.42,Fee Schedule,,169.43,,,169.43,Fee Schedule,,152.39,,,152.39,Fee Schedule,,144.03,,,144.03,Fee Schedule,,119.79,,,119.79,Other,110% of Medicare,114.12,,,114.12,Fee Schedule,,53,,,53,Other,186% of Medicaid,134.29,,,134.29,Fee Schedule,,150.04,,,150.04,Fee Schedule,,63.23,,,63.23,Fee Schedule,,134.29,,,134.29,Fee Schedule,,150.04,,,150.04,Fee Schedule,,118.93,,,118.93,Fee Schedule,,169.4,70,,169.4,percent of total billed charges,All Other,132.84,,,132.84,Fee Schedule,,112.59,,,112.59,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,179.33,
XR SKULL COMPLETE MIN 4 VIE W/ FY MOD,70260,CPT,FY,42670260,CDM,320,RC,,,both,,,330,244.2,,,244.2,Other,150% of Medicare + 9.63% HCRA Surcharge,148.5,45,,148.5,percent of total billed charges,Critical Access Hospital RCC factor,108.78,,,108.78,Fee Schedule,,97.87,,,97.87,Fee Schedule,,208.32,,,208.32,Fee Schedule,,187.37,,,187.37,Fee Schedule,,177.09,,,177.09,Fee Schedule,,163.35,,,163.35,Other,110% of Medicare,129.24,,,129.24,Fee Schedule,,53,,,53,Other,186% of Medicaid,152.09,,,152.09,Fee Schedule,,204.6,,,204.6,Fee Schedule,,71.61,,,71.61,Fee Schedule,,152.09,,,152.09,Fee Schedule,,204.6,,,204.6,Fee Schedule,,134.7,,,134.7,Fee Schedule,,231,70,,231,percent of total billed charges,All Other,154.16,,,154.16,Fee Schedule,,130.66,,,130.66,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,244.2,
TMJ JOINT - UNILATERAL W/ FY MOD,70328,CPT,FY,42670328,CDM,320,RC,,,both,,,649,480.26,,,480.26,Other,150% of Medicare + 9.63% HCRA Surcharge,292.05,45,,292.05,percent of total billed charges,Critical Access Hospital RCC factor,90.28,,,90.28,Fee Schedule,,81.22,,,81.22,Fee Schedule,,148.82,,,148.82,Fee Schedule,,133.86,,,133.86,Fee Schedule,,126.52,,,126.52,Fee Schedule,,321.26,,,321.26,Other,110% of Medicare,107.26,,,107.26,Fee Schedule,,53,,,53,Other,186% of Medicaid,126.22,,,126.22,Fee Schedule,,402.38,,,402.38,Fee Schedule,,59.43,,,59.43,Fee Schedule,,126.22,,,126.22,Fee Schedule,,402.38,,,402.38,Fee Schedule,,111.79,,,111.79,Fee Schedule,,454.3,70,,454.3,percent of total billed charges,All Other,127.92,,,127.92,Fee Schedule,,108.42,,,108.42,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,480.26,
XR TM JOINT BILATERAL W/ FY MOD,70330,CPT,FY,42670330,CDM,320,RC,,,both,,,288,213.12,,,213.12,Other,150% of Medicare + 9.63% HCRA Surcharge,129.6,45,,129.6,percent of total billed charges,Critical Access Hospital RCC factor,144.57,,,144.57,Fee Schedule,,130.07,,,130.07,Fee Schedule,,244.95,,,244.95,Fee Schedule,,220.32,,,220.32,Fee Schedule,,208.23,,,208.23,Fee Schedule,,142.56,,,142.56,Other,110% of Medicare,171.76,,,171.76,Fee Schedule,,53,,,53,Other,186% of Medicaid,202.13,,,202.13,Fee Schedule,,178.56,,,178.56,Fee Schedule,,95.17,,,95.17,Fee Schedule,,202.13,,,202.13,Fee Schedule,,178.56,,,178.56,Fee Schedule,,179.01,,,179.01,Fee Schedule,,201.6,70,,201.6,percent of total billed charges,All Other,206.64,,,206.64,Fee Schedule,,175.14,,,175.14,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,244.95,
XR NECK SOFT TISSUES W/ FY MOD,70360,CPT,FY,42670360,CDM,320,RC,,,both,,,231,170.94,,,170.94,Other,150% of Medicare + 9.63% HCRA Surcharge,103.95,45,,103.95,percent of total billed charges,Critical Access Hospital RCC factor,78.73,,,78.73,Fee Schedule,,70.83,,,70.83,Fee Schedule,,130.54,,,130.54,Fee Schedule,,117.41,,,117.41,Fee Schedule,,110.97,,,110.97,Fee Schedule,,114.35,,,114.35,Other,110% of Medicare,93.54,,,93.54,Fee Schedule,,53,,,53,Other,186% of Medicaid,110.07,,,110.07,Fee Schedule,,143.22,,,143.22,Fee Schedule,,51.83,,,51.83,Fee Schedule,,110.07,,,110.07,Fee Schedule,,143.22,,,143.22,Fee Schedule,,97.49,,,97.49,Fee Schedule,,161.7,70,,161.7,percent of total billed charges,All Other,111.52,,,111.52,Fee Schedule,,94.52,,,94.52,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,170.94,
SALIVARY GLAND CALCULUS W/ FY MOD,70380,CPT,FY,42670380,CDM,320,RC,,,both,,,624,461.76,,,461.76,Other,150% of Medicare + 9.63% HCRA Surcharge,280.8,45,,280.8,percent of total billed charges,Critical Access Hospital RCC factor,102.97,,,102.97,Fee Schedule,,92.64,,,92.64,Fee Schedule,,206.06,,,206.06,Fee Schedule,,185.33,,,185.33,Fee Schedule,,175.17,,,175.17,Fee Schedule,,308.88,,,308.88,Other,110% of Medicare,122.34,,,122.34,Fee Schedule,,53,,,53,Other,186% of Medicaid,143.97,,,143.97,Fee Schedule,,386.88,,,386.88,Fee Schedule,,67.79,,,67.79,Fee Schedule,,143.97,,,143.97,Fee Schedule,,386.88,,,386.88,Fee Schedule,,127.51,,,127.51,Fee Schedule,,436.8,70,,436.8,percent of total billed charges,All Other,145.96,,,145.96,Fee Schedule,,123.71,,,123.71,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,461.76,
SIALOGRAM W/ FY MOD,70390,CPT,FY,42670390,CDM,320,RC,,,both,,,894,661.56,,,661.56,Other,150% of Medicare + 9.63% HCRA Surcharge,402.3,45,,402.3,percent of total billed charges,Critical Access Hospital RCC factor,339.83,,,339.83,Fee Schedule,,305.74,,,305.74,Fee Schedule,,558.46,,,558.46,Fee Schedule,,502.3,,,502.3,Fee Schedule,,474.75,,,474.75,Fee Schedule,,442.53,,,442.53,Other,110% of Medicare,403.75,,,403.75,Fee Schedule,,392,,,392,Other,186% of Medicaid,475.12,,,475.12,Fee Schedule,,554.28,,,554.28,Fee Schedule,,223.71,,,223.71,Fee Schedule,,475.12,,,475.12,Fee Schedule,,554.28,,,554.28,Fee Schedule,,420.79,,,420.79,Fee Schedule,,625.8,70,,625.8,percent of total billed charges,All Other,503.48,,,503.48,Fee Schedule,,426.73,,,426.73,Fee Schedule,,372.86,,,372.86,Fee Schedule,,372.86,,,372.86,Fee Schedule,,372.86,,,372.86,Fee Schedule,,372.86,,,372.86,Fee Schedule,,210.57,,,210.57,Other,100% of Medicaid,210.57,,,210.57,Other,100% of Medicaid,210.57,,,210.57,Other,100% of Medicaid,210.57,,,210.57,Other,100% of Medicaid,473.77,,,473.77,Other,225% of Medicaid,322.17,,,322.17,Other,153% of Medicaid,473.77,,,473.77,Other,225% of Medicaid,294.79,,,294.79,Other,140% of Medicaid,473.77,,,473.77,Other,225% of Medicaid,547.47,,,547.47,Other,260% of Medicaid,682.23,,,682.23,Other,324% of Medicaid,452.72,,,452.72,Other,215% of Medicaid,452.72,,,452.72,Other,215% of Medicaid,263.21,,,263.21,Other,125% of Medicaid,210.57,682.23,
XR RIBS BILATERAL W/ FY MOD,71110,CPT,FY,42671110,CDM,320,RC,,,both,,,513,379.62,,,379.62,Other,150% of Medicare + 9.63% HCRA Surcharge,230.85,45,,230.85,percent of total billed charges,Critical Access Hospital RCC factor,105.3,,,105.3,Fee Schedule,,94.74,,,94.74,Fee Schedule,,187.77,,,187.77,Fee Schedule,,168.89,,,168.89,Fee Schedule,,159.62,,,159.62,Fee Schedule,,253.94,,,253.94,Other,110% of Medicare,125.11,,,125.11,Fee Schedule,,53,,,53,Other,186% of Medicaid,147.22,,,147.22,Fee Schedule,,318.06,,,318.06,Fee Schedule,,69.32,,,69.32,Fee Schedule,,147.22,,,147.22,Fee Schedule,,318.06,,,318.06,Fee Schedule,,130.39,,,130.39,Fee Schedule,,359.1,70,,359.1,percent of total billed charges,All Other,147.6,,,147.6,Fee Schedule,,125.1,,,125.1,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,379.62,
XR RIBS BILATERAL 4 VIEWS A W/ FY MOD,71111,CPT,FY,42671111,CDM,320,RC,,,both,,,548,405.52,,,405.52,Other,150% of Medicare + 9.63% HCRA Surcharge,246.6,45,,246.6,percent of total billed charges,Critical Access Hospital RCC factor,129.55,,,129.55,Fee Schedule,,116.55,,,116.55,Fee Schedule,,251.8,,,251.8,Fee Schedule,,226.48,,,226.48,Fee Schedule,,214.05,,,214.05,Fee Schedule,,271.26,,,271.26,Other,110% of Medicare,153.91,,,153.91,Fee Schedule,,53,,,53,Other,186% of Medicaid,181.12,,,181.12,Fee Schedule,,339.76,,,339.76,Fee Schedule,,85.28,,,85.28,Fee Schedule,,181.12,,,181.12,Fee Schedule,,339.76,,,339.76,Fee Schedule,,160.41,,,160.41,Fee Schedule,,383.6,70,,383.6,percent of total billed charges,All Other,183.68,,,183.68,Fee Schedule,,155.68,,,155.68,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,405.52,
XR OF STERNUM 2 VIEWS W/ FY MOD,71120,CPT,FY,42671120,CDM,320,RC,,,both,,,548,405.52,,,405.52,Other,150% of Medicare + 9.63% HCRA Surcharge,246.6,45,,246.6,percent of total billed charges,Critical Access Hospital RCC factor,84.5,,,84.5,Fee Schedule,,76.03,,,76.03,Fee Schedule,,151.14,,,151.14,Fee Schedule,,135.94,,,135.94,Fee Schedule,,128.49,,,128.49,Fee Schedule,,271.26,,,271.26,Other,110% of Medicare,100.4,,,100.4,Fee Schedule,,53,,,53,Other,186% of Medicaid,118.15,,,118.15,Fee Schedule,,339.76,,,339.76,Fee Schedule,,55.63,,,55.63,Fee Schedule,,118.15,,,118.15,Fee Schedule,,339.76,,,339.76,Fee Schedule,,104.64,,,104.64,Fee Schedule,,383.6,70,,383.6,percent of total billed charges,All Other,119.72,,,119.72,Fee Schedule,,101.47,,,101.47,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,405.52,
XR SPINE 1 VIEW W/ FY MOD,72020,CPT,FY,42672020,CDM,320,RC,,,both,,,433,320.42,,,320.42,Other,150% of Medicare + 9.63% HCRA Surcharge,194.85,45,,194.85,percent of total billed charges,Critical Access Hospital RCC factor,57.93,,,57.93,Fee Schedule,,52.12,,,52.12,Fee Schedule,,109.93,,,109.93,Fee Schedule,,98.88,,,98.88,Fee Schedule,,93.45,,,93.45,Fee Schedule,,214.34,,,214.34,Other,110% of Medicare,68.83,,,68.83,Fee Schedule,,53,,,53,Other,186% of Medicaid,80.99,,,80.99,Fee Schedule,,268.46,,,268.46,Fee Schedule,,38.14,,,38.14,Fee Schedule,,80.99,,,80.99,Fee Schedule,,268.46,,,268.46,Fee Schedule,,71.73,,,71.73,Fee Schedule,,303.1,70,,303.1,percent of total billed charges,All Other,82,,,82,Fee Schedule,,69.5,,,69.5,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,320.42,
XR CERVICAL SPINE 2-3 VIEWS W/ FY MOD,72040,CPT,FY,42672040,CDM,320,RC,,,both,,,481,355.94,,,355.94,Other,150% of Medicare + 9.63% HCRA Surcharge,216.45,45,,216.45,percent of total billed charges,Critical Access Hospital RCC factor,100.68,,,100.68,Fee Schedule,,90.58,,,90.58,Fee Schedule,,185.45,,,185.45,Fee Schedule,,166.8,,,166.8,Fee Schedule,,157.65,,,157.65,Fee Schedule,,238.1,,,238.1,Other,110% of Medicare,119.61,,,119.61,Fee Schedule,,53,,,53,Other,186% of Medicaid,140.76,,,140.76,Fee Schedule,,298.22,,,298.22,Fee Schedule,,66.28,,,66.28,Fee Schedule,,140.76,,,140.76,Fee Schedule,,298.22,,,298.22,Fee Schedule,,124.66,,,124.66,Fee Schedule,,336.7,70,,336.7,percent of total billed charges,All Other,141.04,,,141.04,Fee Schedule,,119.54,,,119.54,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,355.94,
XR CERVICAL SPINE 4 VIEWS W/ FY MOD,72050,CPT,FY,42672050,CDM,320,RC,,,both,,,525,388.5,,,388.5,Other,150% of Medicare + 9.63% HCRA Surcharge,236.25,45,,236.25,percent of total billed charges,Critical Access Hospital RCC factor,142.27,,,142.27,Fee Schedule,,128,,,128,Fee Schedule,,251.8,,,251.8,Fee Schedule,,226.48,,,226.48,Fee Schedule,,214.05,,,214.05,Fee Schedule,,259.88,,,259.88,Other,110% of Medicare,169.03,,,169.03,Fee Schedule,,53,,,53,Other,186% of Medicaid,198.92,,,198.92,Fee Schedule,,325.5,,,325.5,Fee Schedule,,93.66,,,93.66,Fee Schedule,,198.92,,,198.92,Fee Schedule,,325.5,,,325.5,Fee Schedule,,176.17,,,176.17,Fee Schedule,,367.5,70,,367.5,percent of total billed charges,All Other,196.8,,,196.8,Fee Schedule,,166.8,,,166.8,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,388.5,
XR CERVICAL SPINE COMP W/ FY MOD,72052,CPT,FY,42672052,CDM,320,RC,,,both,,,624,461.76,,,461.76,Other,150% of Medicare + 9.63% HCRA Surcharge,280.8,45,,280.8,percent of total billed charges,Critical Access Hospital RCC factor,167.7,,,167.7,Fee Schedule,,150.88,,,150.88,Fee Schedule,,331.9,,,331.9,Fee Schedule,,298.53,,,298.53,Fee Schedule,,282.15,,,282.15,Fee Schedule,,308.88,,,308.88,Other,110% of Medicare,199.24,,,199.24,Fee Schedule,,53,,,53,Other,186% of Medicaid,234.46,,,234.46,Fee Schedule,,386.88,,,386.88,Fee Schedule,,110.4,,,110.4,Fee Schedule,,234.46,,,234.46,Fee Schedule,,386.88,,,386.88,Fee Schedule,,207.65,,,207.65,Fee Schedule,,436.8,70,,436.8,percent of total billed charges,All Other,234.52,,,234.52,Fee Schedule,,198.77,,,198.77,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,461.76,
XR THORACIC SPINE 2 VIEWS W/ FY MOD,72070,CPT,FY,42672070,CDM,320,RC,,,both,,,587,434.38,,,434.38,Other,150% of Medicare + 9.63% HCRA Surcharge,264.15,45,,264.15,percent of total billed charges,Critical Access Hospital RCC factor,81.03,,,81.03,Fee Schedule,,72.9,,,72.9,Fee Schedule,,155.73,,,155.73,Fee Schedule,,140.07,,,140.07,Fee Schedule,,132.38,,,132.38,Fee Schedule,,290.57,,,290.57,Other,110% of Medicare,96.27,,,96.27,Fee Schedule,,53,,,53,Other,186% of Medicaid,113.28,,,113.28,Fee Schedule,,363.94,,,363.94,Fee Schedule,,53.34,,,53.34,Fee Schedule,,113.28,,,113.28,Fee Schedule,,363.94,,,363.94,Fee Schedule,,100.33,,,100.33,Fee Schedule,,410.9,70,,410.9,percent of total billed charges,All Other,113.16,,,113.16,Fee Schedule,,95.91,,,95.91,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,434.38,
XR THORACIC SPINE 3 VIEWS W/ FY MOD,72072,CPT,FY,42672072,CDM,320,RC,,,both,,,550,407,,,407,Other,150% of Medicare + 9.63% HCRA Surcharge,247.5,45,,247.5,percent of total billed charges,Critical Access Hospital RCC factor,100.68,,,100.68,Fee Schedule,,90.58,,,90.58,Fee Schedule,,183.19,,,183.19,Fee Schedule,,164.76,,,164.76,Fee Schedule,,155.72,,,155.72,Fee Schedule,,272.25,,,272.25,Other,110% of Medicare,119.61,,,119.61,Fee Schedule,,53,,,53,Other,186% of Medicaid,140.76,,,140.76,Fee Schedule,,341,,,341,Fee Schedule,,66.28,,,66.28,Fee Schedule,,140.76,,,140.76,Fee Schedule,,341,,,341,Fee Schedule,,124.66,,,124.66,Fee Schedule,,385,70,,385,percent of total billed charges,All Other,139.4,,,139.4,Fee Schedule,,118.15,,,118.15,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,407,
XR EXAM OF THORACIC SPINE 4+ VIEWS W/ FY,72074,CPT,FY,42672074,CDM,320,RC,,,both,,,242,179.08,,,179.08,Other,150% of Medicare + 9.63% HCRA Surcharge,108.9,45,,108.9,percent of total billed charges,Critical Access Hospital RCC factor,114.55,,,114.55,Fee Schedule,,103.06,,,103.06,Fee Schedule,,228.93,,,228.93,Fee Schedule,,205.91,,,205.91,Fee Schedule,,194.61,,,194.61,Fee Schedule,,119.79,,,119.79,Other,110% of Medicare,136.1,,,136.1,Fee Schedule,,53,,,53,Other,186% of Medicaid,160.16,,,160.16,Fee Schedule,,150.04,,,150.04,Fee Schedule,,75.41,,,75.41,Fee Schedule,,160.16,,,160.16,Fee Schedule,,150.04,,,150.04,Fee Schedule,,141.84,,,141.84,Fee Schedule,,169.4,70,,169.4,percent of total billed charges,All Other,160.72,,,160.72,Fee Schedule,,136.22,,,136.22,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,228.93,
XR THORACOLUMBAR 2 VIEWS W/ FY MOD,72080,CPT,FY,42672080,CDM,320,RC,,,both,,,362,267.88,,,267.88,Other,150% of Medicare + 9.63% HCRA Surcharge,162.9,45,,162.9,percent of total billed charges,Critical Access Hospital RCC factor,85.65,,,85.65,Fee Schedule,,77.06,,,77.06,Fee Schedule,,169.43,,,169.43,Fee Schedule,,152.39,,,152.39,Fee Schedule,,144.03,,,144.03,Fee Schedule,,179.19,,,179.19,Other,110% of Medicare,101.76,,,101.76,Fee Schedule,,53,,,53,Other,186% of Medicaid,119.75,,,119.75,Fee Schedule,,224.44,,,224.44,Fee Schedule,,56.39,,,56.39,Fee Schedule,,119.75,,,119.75,Fee Schedule,,224.44,,,224.44,Fee Schedule,,106.06,,,106.06,Fee Schedule,,253.4,70,,253.4,percent of total billed charges,All Other,121.36,,,121.36,Fee Schedule,,102.86,,,102.86,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,267.88,
X-RAY EXAM ENTIRE SPI 1 VW W/ FY MOD,72081,CPT,FY,42672081,CDM,320,RC,,,both,,,204,150.96,,,150.96,Other,150% of Medicare + 9.63% HCRA Surcharge,91.8,45,,91.8,percent of total billed charges,Critical Access Hospital RCC factor,105.3,,,105.3,Fee Schedule,,94.74,,,94.74,Fee Schedule,,24.57,,,24.57,Fee Schedule,,24.57,,,24.57,Fee Schedule,,24.57,,,24.57,Fee Schedule,,100.98,,,100.98,Other,110% of Medicare,125.11,,,125.11,Fee Schedule,,53,,,53,Other,186% of Medicaid,147.22,,,147.22,Fee Schedule,,126.48,,,126.48,Fee Schedule,,69.32,,,69.32,Fee Schedule,,147.22,,,147.22,Fee Schedule,,126.48,,,126.48,Fee Schedule,,130.39,,,130.39,Fee Schedule,,142.8,70,,142.8,percent of total billed charges,All Other,147.6,,,147.6,Fee Schedule,,125.1,,,125.1,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,24.57,150.96,
X-RAY EXAM ENTIRE SPI 2/3 VW W/ FY MOD,72082,CPT,FY,42672082,CDM,320,RC,,,both,,,351,259.74,,,259.74,Other,150% of Medicare + 9.63% HCRA Surcharge,157.95,45,,157.95,percent of total billed charges,Critical Access Hospital RCC factor,191.94,,,191.94,Fee Schedule,,172.69,,,172.69,Fee Schedule,,44.99,,,44.99,Fee Schedule,,44.99,,,44.99,Fee Schedule,,44.99,,,44.99,Fee Schedule,,173.75,,,173.75,Other,110% of Medicare,228.04,,,228.04,Fee Schedule,,53,,,53,Other,186% of Medicaid,268.36,,,268.36,Fee Schedule,,217.62,,,217.62,Fee Schedule,,126.36,,,126.36,Fee Schedule,,268.36,,,268.36,Fee Schedule,,217.62,,,217.62,Fee Schedule,,237.67,,,237.67,Fee Schedule,,245.7,70,,245.7,percent of total billed charges,All Other,270.6,,,270.6,Fee Schedule,,229.35,,,229.35,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,270.6,
X-RAY EXAM ENTIRE SPI 4/5 VW W/ FY MOD,72083,CPT,FY,42672083,CDM,320,RC,,,both,,,638,472.12,,,472.12,Other,150% of Medicare + 9.63% HCRA Surcharge,287.1,45,,287.1,percent of total billed charges,Critical Access Hospital RCC factor,217.37,,,217.37,Fee Schedule,,195.56,,,195.56,Fee Schedule,,55.38,,,55.38,Fee Schedule,,55.38,,,55.38,Fee Schedule,,55.38,,,55.38,Fee Schedule,,315.81,,,315.81,Other,110% of Medicare,258.25,,,258.25,Fee Schedule,,53,,,53,Other,186% of Medicaid,303.9,,,303.9,Fee Schedule,,395.56,,,395.56,Fee Schedule,,143.09,,,143.09,Fee Schedule,,303.9,,,303.9,Fee Schedule,,395.56,,,395.56,Fee Schedule,,269.15,,,269.15,Fee Schedule,,446.6,70,,446.6,percent of total billed charges,All Other,301.76,,,301.76,Fee Schedule,,255.76,,,255.76,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,472.12,
X-RAY EXAM ENTIRE SPI 6/> VW W/ FY MOD,72084,CPT,FY,42672084,CDM,320,RC,,,both,,,638,472.12,,,472.12,Other,150% of Medicare + 9.63% HCRA Surcharge,287.1,45,,287.1,percent of total billed charges,Critical Access Hospital RCC factor,274.15,,,274.15,Fee Schedule,,246.65,,,246.65,Fee Schedule,,64.37,,,64.37,Fee Schedule,,64.37,,,64.37,Fee Schedule,,64.37,,,64.37,Fee Schedule,,315.81,,,315.81,Other,110% of Medicare,325.71,,,325.71,Fee Schedule,,53,,,53,Other,186% of Medicaid,383.29,,,383.29,Fee Schedule,,395.56,,,395.56,Fee Schedule,,180.47,,,180.47,Fee Schedule,,383.29,,,383.29,Fee Schedule,,395.56,,,395.56,Fee Schedule,,339.46,,,339.46,Fee Schedule,,446.6,70,,446.6,percent of total billed charges,All Other,385.4,,,385.4,Fee Schedule,,326.65,,,326.65,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,472.12,
XRLUMBAR SPINE 2 VIEWS W/ FY MOD,72100,CPT,FY,42672100,CDM,320,RC,,,both,,,494,365.56,,,365.56,Other,150% of Medicare + 9.63% HCRA Surcharge,222.3,45,,222.3,percent of total billed charges,Critical Access Hospital RCC factor,101.82,,,101.82,Fee Schedule,,91.61,,,91.61,Fee Schedule,,196.89,,,196.89,Fee Schedule,,177.09,,,177.09,Fee Schedule,,167.37,,,167.37,Fee Schedule,,244.53,,,244.53,Other,110% of Medicare,120.98,,,120.98,Fee Schedule,,53,,,53,Other,186% of Medicaid,142.36,,,142.36,Fee Schedule,,306.28,,,306.28,Fee Schedule,,67.03,,,67.03,Fee Schedule,,142.36,,,142.36,Fee Schedule,,306.28,,,306.28,Fee Schedule,,126.08,,,126.08,Fee Schedule,,345.8,70,,345.8,percent of total billed charges,All Other,142.68,,,142.68,Fee Schedule,,120.93,,,120.93,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,365.56,
XR LUMBAR SPINE COMPLETE W/FY MOD,72110,CPT,FY,42672110,CDM,320,RC,,,both,,,695,514.3,,,514.3,Other,150% of Medicare + 9.63% HCRA Surcharge,312.75,45,,312.75,percent of total billed charges,Critical Access Hospital RCC factor,137.65,,,137.65,Fee Schedule,,123.84,,,123.84,Fee Schedule,,270.14,,,270.14,Fee Schedule,,242.97,,,242.97,Fee Schedule,,229.64,,,229.64,Fee Schedule,,344.03,,,344.03,Other,110% of Medicare,163.54,,,163.54,Fee Schedule,,53,,,53,Other,186% of Medicaid,192.45,,,192.45,Fee Schedule,,430.9,,,430.9,Fee Schedule,,90.62,,,90.62,Fee Schedule,,192.45,,,192.45,Fee Schedule,,430.9,,,430.9,Fee Schedule,,170.44,,,170.44,Fee Schedule,,486.5,70,,486.5,percent of total billed charges,All Other,190.24,,,190.24,Fee Schedule,,161.24,,,161.24,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,514.3,
XR LUMBAR SPINE COMP W FLEX W/ FY MOD,72114,CPT,FY,42672114,CDM,320,RC,,,both,,,867,641.58,,,641.58,Other,150% of Medicare + 9.63% HCRA Surcharge,390.15,45,,390.15,percent of total billed charges,Critical Access Hospital RCC factor,163.07,,,163.07,Fee Schedule,,146.71,,,146.71,Fee Schedule,,377.7,,,377.7,Fee Schedule,,339.72,,,339.72,Fee Schedule,,321.08,,,321.08,Fee Schedule,,429.17,,,429.17,Other,110% of Medicare,193.74,,,193.74,Fee Schedule,,53,,,53,Other,186% of Medicaid,228,,,228,Fee Schedule,,537.54,,,537.54,Fee Schedule,,107.35,,,107.35,Fee Schedule,,228,,,228,Fee Schedule,,537.54,,,537.54,Fee Schedule,,201.92,,,201.92,Fee Schedule,,606.9,70,,606.9,percent of total billed charges,All Other,232.88,,,232.88,Fee Schedule,,197.38,,,197.38,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,641.58,
XR EXAM OF LOWER SPINE W/ FY MOD,72120,CPT,FY,42672120,CDM,320,RC,,,both,,,706,522.44,,,522.44,Other,150% of Medicare + 9.63% HCRA Surcharge,317.7,45,,317.7,percent of total billed charges,Critical Access Hospital RCC factor,104.15,,,104.15,Fee Schedule,,93.71,,,93.71,Fee Schedule,,270.14,,,270.14,Fee Schedule,,242.97,,,242.97,Fee Schedule,,229.64,,,229.64,Fee Schedule,,349.47,,,349.47,Other,110% of Medicare,123.74,,,123.74,Fee Schedule,,53,,,53,Other,186% of Medicaid,145.62,,,145.62,Fee Schedule,,437.72,,,437.72,Fee Schedule,,68.57,,,68.57,Fee Schedule,,145.62,,,145.62,Fee Schedule,,437.72,,,437.72,Fee Schedule,,128.97,,,128.97,Fee Schedule,,494.2,70,,494.2,percent of total billed charges,All Other,147.6,,,147.6,Fee Schedule,,125.1,,,125.1,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,522.44,
XR PELVIS 1 VIEW W/ FY MOD,72170,CPT,FY,42672170,CDM,320,RC,,,both,,,392,290.08,,,290.08,Other,150% of Medicare + 9.63% HCRA Surcharge,176.4,45,,176.4,percent of total billed charges,Critical Access Hospital RCC factor,68.33,,,68.33,Fee Schedule,,61.48,,,61.48,Fee Schedule,,121.37,,,121.37,Fee Schedule,,109.16,,,109.16,Fee Schedule,,103.17,,,103.17,Fee Schedule,,194.04,,,194.04,Other,110% of Medicare,81.18,,,81.18,Fee Schedule,,53,,,53,Other,186% of Medicaid,95.53,,,95.53,Fee Schedule,,243.04,,,243.04,Fee Schedule,,44.98,,,44.98,Fee Schedule,,95.53,,,95.53,Fee Schedule,,243.04,,,243.04,Fee Schedule,,84.61,,,84.61,Fee Schedule,,274.4,70,,274.4,percent of total billed charges,All Other,95.12,,,95.12,Fee Schedule,,80.62,,,80.62,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,290.08,
XR EXAM OF PELVIS 3+ VIEWS W/ FY MOD,72190,CPT,FY,42672190,CDM,320,RC,,,both,,,605,447.7,,,447.7,Other,150% of Medicare + 9.63% HCRA Surcharge,272.25,45,,272.25,percent of total billed charges,Critical Access Hospital RCC factor,105.3,,,105.3,Fee Schedule,,94.74,,,94.74,Fee Schedule,,208.32,,,208.32,Fee Schedule,,187.37,,,187.37,Fee Schedule,,177.09,,,177.09,Fee Schedule,,299.48,,,299.48,Other,110% of Medicare,125.11,,,125.11,Fee Schedule,,53,,,53,Other,186% of Medicaid,147.22,,,147.22,Fee Schedule,,375.1,,,375.1,Fee Schedule,,69.32,,,69.32,Fee Schedule,,147.22,,,147.22,Fee Schedule,,375.1,,,375.1,Fee Schedule,,130.39,,,130.39,Fee Schedule,,423.5,70,,423.5,percent of total billed charges,All Other,147.6,,,147.6,Fee Schedule,,125.1,,,125.1,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,447.7,
XR SACROILIAC JTS 1 OR 2 VI W/ FY MOD,72200,CPT,FY,42672200,CDM,320,RC,,,both,,,242,179.08,,,179.08,Other,150% of Medicare + 9.63% HCRA Surcharge,108.9,45,,108.9,percent of total billed charges,Critical Access Hospital RCC factor,87.98,,,87.98,Fee Schedule,,79.15,,,79.15,Fee Schedule,,144.29,,,144.29,Fee Schedule,,129.78,,,129.78,Fee Schedule,,122.66,,,122.66,Fee Schedule,,119.79,,,119.79,Other,110% of Medicare,104.53,,,104.53,Fee Schedule,,53,,,53,Other,186% of Medicaid,123.01,,,123.01,Fee Schedule,,150.04,,,150.04,Fee Schedule,,57.92,,,57.92,Fee Schedule,,123.01,,,123.01,Fee Schedule,,150.04,,,150.04,Fee Schedule,,108.94,,,108.94,Fee Schedule,,169.4,70,,169.4,percent of total billed charges,All Other,121.36,,,121.36,Fee Schedule,,102.86,,,102.86,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,179.33,
XR SACROILIAC JOINTS 3 VIEW W/ FY MOD,72202,CPT,FY,42672202,CDM,320,RC,,,both,,,242,179.08,,,179.08,Other,150% of Medicare + 9.63% HCRA Surcharge,108.9,45,,108.9,percent of total billed charges,Critical Access Hospital RCC factor,99.53,,,99.53,Fee Schedule,,89.54,,,89.54,Fee Schedule,,171.75,,,171.75,Fee Schedule,,154.48,,,154.48,Fee Schedule,,146,,,146,Fee Schedule,,119.79,,,119.79,Other,110% of Medicare,118.25,,,118.25,Fee Schedule,,53,,,53,Other,186% of Medicaid,139.15,,,139.15,Fee Schedule,,150.04,,,150.04,Fee Schedule,,65.52,,,65.52,Fee Schedule,,139.15,,,139.15,Fee Schedule,,150.04,,,150.04,Fee Schedule,,123.24,,,123.24,Fee Schedule,,169.4,70,,169.4,percent of total billed charges,All Other,139.4,,,139.4,Fee Schedule,,118.15,,,118.15,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,179.33,
XR SACRUM & COCCYX 2 VIEWS W/ FY MOD,72220,CPT,FY,42672220,CDM,320,RC,,,both,,,437,323.38,,,323.38,Other,150% of Medicare + 9.63% HCRA Surcharge,196.65,45,,196.65,percent of total billed charges,Critical Access Hospital RCC factor,84.5,,,84.5,Fee Schedule,,76.03,,,76.03,Fee Schedule,,141.97,,,141.97,Fee Schedule,,127.7,,,127.7,Fee Schedule,,120.69,,,120.69,Fee Schedule,,216.32,,,216.32,Other,110% of Medicare,100.4,,,100.4,Fee Schedule,,53,,,53,Other,186% of Medicaid,118.15,,,118.15,Fee Schedule,,270.94,,,270.94,Fee Schedule,,55.63,,,55.63,Fee Schedule,,118.15,,,118.15,Fee Schedule,,270.94,,,270.94,Fee Schedule,,104.64,,,104.64,Fee Schedule,,305.9,70,,305.9,percent of total billed charges,All Other,118.08,,,118.08,Fee Schedule,,100.08,,,100.08,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,323.38,
MYELOGRAM CERVICAL W/ FY MOD,72240,CPT,FY,42672240,CDM,320,RC,,,both,,,1939,1434.86,,,1434.86,Other,150% of Medicare + 9.63% HCRA Surcharge,872.55,45,,872.55,percent of total billed charges,Critical Access Hospital RCC factor,239.31,,,239.31,Fee Schedule,,215.31,,,215.31,Fee Schedule,,672.87,,,672.87,Fee Schedule,,605.2,,,605.2,Fee Schedule,,572.01,,,572.01,Fee Schedule,,959.81,,,959.81,Other,110% of Medicare,284.33,,,284.33,Fee Schedule,,914,,,914,Other,186% of Medicaid,334.59,,,334.59,Fee Schedule,,1202.18,,,1202.18,Fee Schedule,,157.54,,,157.54,Fee Schedule,,334.59,,,334.59,Fee Schedule,,1202.18,,,1202.18,Fee Schedule,,296.33,,,296.33,Fee Schedule,,1357.3,70,,1357.3,percent of total billed charges,All Other,354.24,,,354.24,Fee Schedule,,300.24,,,300.24,Fee Schedule,,1089.31,,,1089.31,Fee Schedule,,1089.31,,,1089.31,Fee Schedule,,1089.31,,,1089.31,Fee Schedule,,1089.31,,,1089.31,Fee Schedule,,491.65,,,491.65,Other,100% of Medicaid,491.65,,,491.65,Other,100% of Medicaid,491.65,,,491.65,Other,100% of Medicaid,491.65,,,491.65,Other,100% of Medicaid,1106.21,,,1106.21,Other,225% of Medicaid,752.22,,,752.22,Other,153% of Medicaid,1106.21,,,1106.21,Other,225% of Medicaid,688.31,,,688.31,Other,140% of Medicaid,1106.21,,,1106.21,Other,225% of Medicaid,1278.28,,,1278.28,Other,260% of Medicaid,1592.94,,,1592.94,Other,324% of Medicaid,1057.04,,,1057.04,Other,215% of Medicaid,1057.04,,,1057.04,Other,215% of Medicaid,614.56,,,614.56,Other,125% of Medicaid,157.54,1592.94,
MYELOGRAM THORACIC W/ FY MOD,72255,CPT,FY,42672255,CDM,320,RC,,,both,,,1939,1434.86,,,1434.86,Other,150% of Medicare + 9.63% HCRA Surcharge,872.55,45,,872.55,percent of total billed charges,Critical Access Hospital RCC factor,225.44,,,225.44,Fee Schedule,,202.82,,,202.82,Fee Schedule,,617.96,,,617.96,Fee Schedule,,555.81,,,555.81,Fee Schedule,,525.32,,,525.32,Fee Schedule,,959.81,,,959.81,Other,110% of Medicare,267.84,,,267.84,Fee Schedule,,914,,,914,Other,186% of Medicaid,315.19,,,315.19,Fee Schedule,,1202.18,,,1202.18,Fee Schedule,,148.41,,,148.41,Fee Schedule,,315.19,,,315.19,Fee Schedule,,1202.18,,,1202.18,Fee Schedule,,279.15,,,279.15,Fee Schedule,,1357.3,70,,1357.3,percent of total billed charges,All Other,360.8,,,360.8,Fee Schedule,,305.8,,,305.8,Fee Schedule,,1089.31,,,1089.31,Fee Schedule,,1089.31,,,1089.31,Fee Schedule,,1089.31,,,1089.31,Fee Schedule,,1089.31,,,1089.31,Fee Schedule,,491.65,,,491.65,Other,100% of Medicaid,491.65,,,491.65,Other,100% of Medicaid,491.65,,,491.65,Other,100% of Medicaid,491.65,,,491.65,Other,100% of Medicaid,1106.21,,,1106.21,Other,225% of Medicaid,752.22,,,752.22,Other,153% of Medicaid,1106.21,,,1106.21,Other,225% of Medicaid,688.31,,,688.31,Other,140% of Medicaid,1106.21,,,1106.21,Other,225% of Medicaid,1278.28,,,1278.28,Other,260% of Medicaid,1592.94,,,1592.94,Other,324% of Medicaid,1057.04,,,1057.04,Other,215% of Medicaid,1057.04,,,1057.04,Other,215% of Medicaid,614.56,,,614.56,Other,125% of Medicaid,148.41,1592.94,
MYELOGRAM LUMBOSACRAL W/ FY MOD,72265,CPT,FY,42672265,CDM,320,RC,,,both,,,2536,1876.65,,,1876.65,Other,150% of Medicare + 9.63% HCRA Surcharge,1141.2,45,,1141.2,percent of total billed charges,Critical Access Hospital RCC factor,241.61,,,241.61,Fee Schedule,,217.37,,,217.37,Fee Schedule,,654.59,,,654.59,Fee Schedule,,588.76,,,588.76,Fee Schedule,,556.46,,,556.46,Fee Schedule,,1255.32,,,1255.32,Other,110% of Medicare,287.05,,,287.05,Fee Schedule,,914,,,914,Other,186% of Medicaid,337.8,,,337.8,Fee Schedule,,1572.32,,,1572.32,Fee Schedule,,159.05,,,159.05,Fee Schedule,,337.8,,,337.8,Fee Schedule,,1572.32,,,1572.32,Fee Schedule,,299.17,,,299.17,Fee Schedule,,1775.2,70,,1775.2,percent of total billed charges,All Other,346.04,,,346.04,Fee Schedule,,293.29,,,293.29,Fee Schedule,,1089.31,,,1089.31,Fee Schedule,,1089.31,,,1089.31,Fee Schedule,,1089.31,,,1089.31,Fee Schedule,,1089.31,,,1089.31,Fee Schedule,,491.65,,,491.65,Other,100% of Medicaid,491.65,,,491.65,Other,100% of Medicaid,491.65,,,491.65,Other,100% of Medicaid,491.65,,,491.65,Other,100% of Medicaid,1106.21,,,1106.21,Other,225% of Medicaid,752.22,,,752.22,Other,153% of Medicaid,1106.21,,,1106.21,Other,225% of Medicaid,688.31,,,688.31,Other,140% of Medicaid,1106.21,,,1106.21,Other,225% of Medicaid,1278.28,,,1278.28,Other,260% of Medicaid,1592.94,,,1592.94,Other,324% of Medicaid,1057.04,,,1057.04,Other,215% of Medicaid,1057.04,,,1057.04,Other,215% of Medicaid,614.56,,,614.56,Other,125% of Medicaid,159.05,1876.65,
X-RAY C/T SPINE DISK W/ FY MOD,72285,CPT,FY,42672285,CDM,320,RC,,,both,,,4047,2994.79,,,2994.79,Other,150% of Medicare + 9.63% HCRA Surcharge,1821.15,45,,1821.15,percent of total billed charges,Critical Access Hospital RCC factor,267.03,,,267.03,Fee Schedule,,240.25,,,240.25,Fee Schedule,,604.21,,,604.21,Fee Schedule,,543.44,,,543.44,Fee Schedule,,513.63,,,513.63,Fee Schedule,,2003.27,,,2003.27,Other,110% of Medicare,317.26,,,317.26,Fee Schedule,,914,,,914,Other,186% of Medicaid,373.35,,,373.35,Fee Schedule,,2509.14,,,2509.14,Fee Schedule,,175.79,,,175.79,Fee Schedule,,373.35,,,373.35,Fee Schedule,,2509.14,,,2509.14,Fee Schedule,,330.65,,,330.65,Fee Schedule,,2832.9,70,,2832.9,percent of total billed charges,All Other,350.96,,,350.96,Fee Schedule,,297.46,,,297.46,Fee Schedule,,2750.96,,,2750.96,Fee Schedule,,2750.96,,,2750.96,Fee Schedule,,2750.96,,,2750.96,Fee Schedule,,2750.96,,,2750.96,Fee Schedule,,491.65,,,491.65,Other,100% of Medicaid,491.65,,,491.65,Other,100% of Medicaid,491.65,,,491.65,Other,100% of Medicaid,491.65,,,491.65,Other,100% of Medicaid,1106.21,,,1106.21,Other,225% of Medicaid,752.22,,,752.22,Other,153% of Medicaid,1106.21,,,1106.21,Other,225% of Medicaid,688.31,,,688.31,Other,140% of Medicaid,1106.21,,,1106.21,Other,225% of Medicaid,1278.28,,,1278.28,Other,260% of Medicaid,1592.94,,,1592.94,Other,324% of Medicaid,1057.04,,,1057.04,Other,215% of Medicaid,1057.04,,,1057.04,Other,215% of Medicaid,614.56,,,614.56,Other,125% of Medicaid,175.79,2994.79,
XR OF LOWER SPINE DISK W/ FY MOD,72295,CPT,FY,42672295,CDM,320,RC,,,both,,,6489,4801.88,,,4801.88,Other,150% of Medicare + 9.63% HCRA Surcharge,2920.05,45,,2920.05,percent of total billed charges,Critical Access Hospital RCC factor,250.86,,,250.86,Fee Schedule,,225.7,,,225.7,Fee Schedule,,595.09,,,595.09,Fee Schedule,,535.24,,,535.24,Fee Schedule,,505.88,,,505.88,Fee Schedule,,3212.06,,,3212.06,Other,110% of Medicare,298.05,,,298.05,Fee Schedule,,914,,,914,Other,186% of Medicaid,350.73,,,350.73,Fee Schedule,,4023.18,,,4023.18,Fee Schedule,,165.14,,,165.14,Fee Schedule,,350.73,,,350.73,Fee Schedule,,4023.18,,,4023.18,Fee Schedule,,310.63,,,310.63,Fee Schedule,,4542.3,70,,4542.3,percent of total billed charges,All Other,355.88,,,355.88,Fee Schedule,,301.63,,,301.63,Fee Schedule,,2750.96,,,2750.96,Fee Schedule,,2750.96,,,2750.96,Fee Schedule,,2750.96,,,2750.96,Fee Schedule,,2750.96,,,2750.96,Fee Schedule,,491.65,,,491.65,Other,100% of Medicaid,491.65,,,491.65,Other,100% of Medicaid,491.65,,,491.65,Other,100% of Medicaid,491.65,,,491.65,Other,100% of Medicaid,1106.21,,,1106.21,Other,225% of Medicaid,752.22,,,752.22,Other,153% of Medicaid,1106.21,,,1106.21,Other,225% of Medicaid,688.31,,,688.31,Other,140% of Medicaid,1106.21,,,1106.21,Other,225% of Medicaid,1278.28,,,1278.28,Other,260% of Medicaid,1592.94,,,1592.94,Other,324% of Medicaid,1057.04,,,1057.04,Other,215% of Medicaid,1057.04,,,1057.04,Other,215% of Medicaid,614.56,,,614.56,Other,125% of Medicaid,165.14,4801.88,
XR EXAM OF SHOULDER 1 VIEW W/ FY MOD,73020,CPT,FY,42673020,CDM,320,RC,,,both,,,231,170.94,,,170.94,Other,150% of Medicare + 9.63% HCRA Surcharge,103.95,45,,103.95,percent of total billed charges,Critical Access Hospital RCC factor,49.86,,,49.86,Fee Schedule,,44.86,,,44.86,Fee Schedule,,109.93,,,109.93,Fee Schedule,,98.88,,,98.88,Fee Schedule,,93.45,,,93.45,Fee Schedule,,114.35,,,114.35,Other,110% of Medicare,59.24,,,59.24,Fee Schedule,,53,,,53,Other,186% of Medicaid,69.71,,,69.71,Fee Schedule,,143.22,,,143.22,Fee Schedule,,32.82,,,32.82,Fee Schedule,,69.71,,,69.71,Fee Schedule,,143.22,,,143.22,Fee Schedule,,61.74,,,61.74,Fee Schedule,,161.7,70,,161.7,percent of total billed charges,All Other,68.88,,,68.88,Fee Schedule,,58.38,,,58.38,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,170.94,
ACJ BILATERAL W/WO WEIGHTS W/ FY MOD,73050,CPT,FY,42673050,CDM,320,RC,,,both,,,606,448.44,,,448.44,Other,150% of Medicare + 9.63% HCRA Surcharge,272.7,45,,272.7,percent of total billed charges,Critical Access Hospital RCC factor,69.48,,,69.48,Fee Schedule,,62.51,,,62.51,Fee Schedule,,185.45,,,185.45,Fee Schedule,,166.8,,,166.8,Fee Schedule,,157.65,,,157.65,Fee Schedule,,299.97,,,299.97,Other,110% of Medicare,82.55,,,82.55,Fee Schedule,,53,,,53,Other,186% of Medicaid,97.14,,,97.14,Fee Schedule,,375.72,,,375.72,Fee Schedule,,45.74,,,45.74,Fee Schedule,,97.14,,,97.14,Fee Schedule,,375.72,,,375.72,Fee Schedule,,86.03,,,86.03,Fee Schedule,,424.2,70,,424.2,percent of total billed charges,All Other,95.12,,,95.12,Fee Schedule,,80.62,,,80.62,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,448.44,
XR EXAM OF ELBOW 2 VIEWS W/ FY MOD,73070,CPT,FY,42673070,CDM,320,RC,,,both,,,231,170.94,,,170.94,Other,150% of Medicare + 9.63% HCRA Surcharge,103.95,45,,103.95,percent of total billed charges,Critical Access Hospital RCC factor,74.1,,,74.1,Fee Schedule,,66.67,,,66.67,Fee Schedule,,139.71,,,139.71,Fee Schedule,,125.66,,,125.66,Fee Schedule,,118.76,,,118.76,Fee Schedule,,114.35,,,114.35,Other,110% of Medicare,88.04,,,88.04,Fee Schedule,,53,,,53,Other,186% of Medicaid,103.61,,,103.61,Fee Schedule,,143.22,,,143.22,Fee Schedule,,48.78,,,48.78,Fee Schedule,,103.61,,,103.61,Fee Schedule,,143.22,,,143.22,Fee Schedule,,91.76,,,91.76,Fee Schedule,,161.7,70,,161.7,percent of total billed charges,All Other,103.32,,,103.32,Fee Schedule,,87.57,,,87.57,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,170.94,
XR EXAM OF WRIST 2 VIEWS W/ FY MOD,73100,CPT,FY,42673100,CDM,320,RC,,,both,,,231,170.94,,,170.94,Other,150% of Medicare + 9.63% HCRA Surcharge,103.95,45,,103.95,percent of total billed charges,Critical Access Hospital RCC factor,90.28,,,90.28,Fee Schedule,,81.22,,,81.22,Fee Schedule,,148.82,,,148.82,Fee Schedule,,133.86,,,133.86,Fee Schedule,,126.52,,,126.52,Fee Schedule,,114.35,,,114.35,Other,110% of Medicare,107.26,,,107.26,Fee Schedule,,53,,,53,Other,186% of Medicaid,126.22,,,126.22,Fee Schedule,,143.22,,,143.22,Fee Schedule,,59.43,,,59.43,Fee Schedule,,126.22,,,126.22,Fee Schedule,,143.22,,,143.22,Fee Schedule,,111.79,,,111.79,Fee Schedule,,161.7,70,,161.7,percent of total billed charges,All Other,126.28,,,126.28,Fee Schedule,,107.03,,,107.03,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,170.94,
X-RAY EXAM HIPS BI 2 VIEWS W/ FY MOD,73521,CPT,FY,42673521,CDM,320,RC,,,both,,,392,290.08,,,290.08,Other,150% of Medicare + 9.63% HCRA Surcharge,176.4,45,,176.4,percent of total billed charges,Critical Access Hospital RCC factor,106.45,,,106.45,Fee Schedule,,95.77,,,95.77,Fee Schedule,,25.61,,,25.61,Fee Schedule,,25.61,,,25.61,Fee Schedule,,25.61,,,25.61,Fee Schedule,,194.04,,,194.04,Other,110% of Medicare,126.47,,,126.47,Fee Schedule,,53,,,53,Other,186% of Medicaid,148.83,,,148.83,Fee Schedule,,243.04,,,243.04,Fee Schedule,,70.08,,,70.08,Fee Schedule,,148.83,,,148.83,Fee Schedule,,243.04,,,243.04,Fee Schedule,,131.81,,,131.81,Fee Schedule,,274.4,70,,274.4,percent of total billed charges,All Other,149.24,,,149.24,Fee Schedule,,126.49,,,126.49,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,25.61,290.08,
X-RAY EXAM HIPS BI 3-4 VIEWS W/ FY MOD,73522,CPT,FY,42673522,CDM,320,RC,,,both,,,336,248.64,,,248.64,Other,150% of Medicare + 9.63% HCRA Surcharge,151.2,45,,151.2,percent of total billed charges,Critical Access Hospital RCC factor,138.8,,,138.8,Fee Schedule,,124.87,,,124.87,Fee Schedule,,32.88,,,32.88,Fee Schedule,,32.88,,,32.88,Fee Schedule,,32.88,,,32.88,Fee Schedule,,166.32,,,166.32,Other,110% of Medicare,164.9,,,164.9,Fee Schedule,,53,,,53,Other,186% of Medicaid,194.05,,,194.05,Fee Schedule,,208.32,,,208.32,Fee Schedule,,91.37,,,91.37,Fee Schedule,,194.05,,,194.05,Fee Schedule,,208.32,,,208.32,Fee Schedule,,171.86,,,171.86,Fee Schedule,,235.2,70,,235.2,percent of total billed charges,All Other,193.52,,,193.52,Fee Schedule,,164.02,,,164.02,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,248.64,
X-RAY EXAM HIPS BI 5/> VIEWS W/ FY MOD,73523,CPT,FY,42673523,CDM,320,RC,,,both,,,638,472.12,,,472.12,Other,150% of Medicare + 9.63% HCRA Surcharge,287.1,45,,287.1,percent of total billed charges,Critical Access Hospital RCC factor,163.07,,,163.07,Fee Schedule,,146.71,,,146.71,Fee Schedule,,39.46,,,39.46,Fee Schedule,,39.46,,,39.46,Fee Schedule,,39.46,,,39.46,Fee Schedule,,315.81,,,315.81,Other,110% of Medicare,193.74,,,193.74,Fee Schedule,,53,,,53,Other,186% of Medicaid,228,,,228,Fee Schedule,,395.56,,,395.56,Fee Schedule,,107.35,,,107.35,Fee Schedule,,228,,,228,Fee Schedule,,395.56,,,395.56,Fee Schedule,,201.92,,,201.92,Fee Schedule,,446.6,70,,446.6,percent of total billed charges,All Other,227.96,,,227.96,Fee Schedule,,193.21,,,193.21,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,472.12,
XR EXAM OF KNEE 1 OR 2 VIEW W/ FY MOD,73560,CPT,FY,42673560,CDM,320,RC,,,both,,,407,301.18,,,301.18,Other,150% of Medicare + 9.63% HCRA Surcharge,183.15,45,,183.15,percent of total billed charges,Critical Access Hospital RCC factor,91.43,,,91.43,Fee Schedule,,82.25,,,82.25,Fee Schedule,,144.29,,,144.29,Fee Schedule,,129.78,,,129.78,Fee Schedule,,122.66,,,122.66,Fee Schedule,,201.47,,,201.47,Other,110% of Medicare,108.62,,,108.62,Fee Schedule,,53,,,53,Other,186% of Medicaid,127.82,,,127.82,Fee Schedule,,252.34,,,252.34,Fee Schedule,,60.19,,,60.19,Fee Schedule,,127.82,,,127.82,Fee Schedule,,252.34,,,252.34,Fee Schedule,,113.21,,,113.21,Fee Schedule,,284.9,70,,284.9,percent of total billed charges,All Other,127.92,,,127.92,Fee Schedule,,108.42,,,108.42,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,301.18,
XR BOTH KNEES STANDING AP W/ FY MOD,73565,CPT,FY,42673565,CDM,320,RC,,,both,,,566,418.84,,,418.84,Other,150% of Medicare + 9.63% HCRA Surcharge,254.7,45,,254.7,percent of total billed charges,Critical Access Hospital RCC factor,111.08,,,111.08,Fee Schedule,,99.93,,,99.93,Fee Schedule,,164.85,,,164.85,Fee Schedule,,148.27,,,148.27,Fee Schedule,,140.13,,,140.13,Fee Schedule,,280.17,,,280.17,Other,110% of Medicare,131.97,,,131.97,Fee Schedule,,53,,,53,Other,186% of Medicaid,155.3,,,155.3,Fee Schedule,,350.92,,,350.92,Fee Schedule,,73.12,,,73.12,Fee Schedule,,155.3,,,155.3,Fee Schedule,,350.92,,,350.92,Fee Schedule,,137.54,,,137.54,Fee Schedule,,396.2,70,,396.2,percent of total billed charges,All Other,157.44,,,157.44,Fee Schedule,,133.44,,,133.44,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,418.84,
XR EXAM OF LOWER LEG 2 VIEW W/ FY MOD,73590,CPT,FY,42673590,CDM,320,RC,,,both,,,373,276.02,,,276.02,Other,150% of Medicare + 9.63% HCRA Surcharge,167.85,45,,167.85,percent of total billed charges,Critical Access Hospital RCC factor,83.35,,,83.35,Fee Schedule,,74.99,,,74.99,Fee Schedule,,130.54,,,130.54,Fee Schedule,,117.41,,,117.41,Fee Schedule,,110.97,,,110.97,Fee Schedule,,184.64,,,184.64,Other,110% of Medicare,99.03,,,99.03,Fee Schedule,,53,,,53,Other,186% of Medicaid,116.54,,,116.54,Fee Schedule,,231.26,,,231.26,Fee Schedule,,54.87,,,54.87,Fee Schedule,,116.54,,,116.54,Fee Schedule,,231.26,,,231.26,Fee Schedule,,103.21,,,103.21,Fee Schedule,,261.1,70,,261.1,percent of total billed charges,All Other,116.44,,,116.44,Fee Schedule,,98.69,,,98.69,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,276.02,
XR EXAM OF LEG INFANT 2 VIE W/ FY MOD,73592,CPT,FY,42673592,CDM,320,RC,,,both,,,231,170.94,,,170.94,Other,150% of Medicare + 9.63% HCRA Surcharge,103.95,45,,103.95,percent of total billed charges,Critical Access Hospital RCC factor,83.35,,,83.35,Fee Schedule,,74.99,,,74.99,Fee Schedule,,155.73,,,155.73,Fee Schedule,,140.07,,,140.07,Fee Schedule,,132.38,,,132.38,Fee Schedule,,114.35,,,114.35,Other,110% of Medicare,99.03,,,99.03,Fee Schedule,,53,,,53,Other,186% of Medicaid,116.54,,,116.54,Fee Schedule,,143.22,,,143.22,Fee Schedule,,54.87,,,54.87,Fee Schedule,,116.54,,,116.54,Fee Schedule,,143.22,,,143.22,Fee Schedule,,103.21,,,103.21,Fee Schedule,,161.7,70,,161.7,percent of total billed charges,All Other,118.08,,,118.08,Fee Schedule,,100.08,,,100.08,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,170.94,
XR EXAM OF ANKLE 2 VIEWS W/ FY MOD,73600,CPT,FY,42673600,CDM,320,RC,,,both,,,231,170.94,,,170.94,Other,150% of Medicare + 9.63% HCRA Surcharge,103.95,45,,103.95,percent of total billed charges,Critical Access Hospital RCC factor,85.65,,,85.65,Fee Schedule,,77.06,,,77.06,Fee Schedule,,137.39,,,137.39,Fee Schedule,,123.57,,,123.57,Fee Schedule,,116.79,,,116.79,Fee Schedule,,114.35,,,114.35,Other,110% of Medicare,101.76,,,101.76,Fee Schedule,,53,,,53,Other,186% of Medicaid,119.75,,,119.75,Fee Schedule,,143.22,,,143.22,Fee Schedule,,56.39,,,56.39,Fee Schedule,,119.75,,,119.75,Fee Schedule,,143.22,,,143.22,Fee Schedule,,106.06,,,106.06,Fee Schedule,,161.7,70,,161.7,percent of total billed charges,All Other,119.72,,,119.72,Fee Schedule,,101.47,,,101.47,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,170.94,
XR EXAM OF FOOT 2 VIEWS W/ FY MOD,73620,CPT,FY,42673620,CDM,320,RC,,,both,,,231,170.94,,,170.94,Other,150% of Medicare + 9.63% HCRA Surcharge,103.95,45,,103.95,percent of total billed charges,Critical Access Hospital RCC factor,74.1,,,74.1,Fee Schedule,,66.67,,,66.67,Fee Schedule,,132.8,,,132.8,Fee Schedule,,119.45,,,119.45,Fee Schedule,,112.9,,,112.9,Fee Schedule,,114.35,,,114.35,Other,110% of Medicare,88.04,,,88.04,Fee Schedule,,53,,,53,Other,186% of Medicaid,103.61,,,103.61,Fee Schedule,,143.22,,,143.22,Fee Schedule,,48.78,,,48.78,Fee Schedule,,103.61,,,103.61,Fee Schedule,,143.22,,,143.22,Fee Schedule,,91.76,,,91.76,Fee Schedule,,161.7,70,,161.7,percent of total billed charges,All Other,101.68,,,101.68,Fee Schedule,,86.18,,,86.18,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,170.94,
XR EXAM OF FOOT 3+ VIEWS W/ FY MOD,73630,CPT,FY,42673630,CDM,320,RC,,,both,,,373,276.02,,,276.02,Other,150% of Medicare + 9.63% HCRA Surcharge,167.85,45,,167.85,percent of total billed charges,Critical Access Hospital RCC factor,91.43,,,91.43,Fee Schedule,,82.25,,,82.25,Fee Schedule,,157.99,,,157.99,Fee Schedule,,142.11,,,142.11,Fee Schedule,,134.31,,,134.31,Fee Schedule,,184.64,,,184.64,Other,110% of Medicare,108.62,,,108.62,Fee Schedule,,53,,,53,Other,186% of Medicaid,127.82,,,127.82,Fee Schedule,,231.26,,,231.26,Fee Schedule,,60.19,,,60.19,Fee Schedule,,127.82,,,127.82,Fee Schedule,,231.26,,,231.26,Fee Schedule,,113.21,,,113.21,Fee Schedule,,261.1,70,,261.1,percent of total billed charges,All Other,129.56,,,129.56,Fee Schedule,,109.81,,,109.81,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,276.02,
X-RAY EXAM ABDOMEN 1 VIEW W/ FY MOD,74018,CPT,FY,42674018,CDM,320,RC,,,both,,,437,323.38,,,323.38,Other,150% of Medicare + 9.63% HCRA Surcharge,196.65,45,,196.65,percent of total billed charges,Critical Access Hospital RCC factor,75.25,,,75.25,Fee Schedule,,67.7,,,67.7,Fee Schedule,,17.12,,,17.12,Fee Schedule,,17.12,,,17.12,Fee Schedule,,17.12,,,17.12,Fee Schedule,,216.32,,,216.32,Other,110% of Medicare,89.41,,,89.41,Fee Schedule,,53,,,53,Other,186% of Medicaid,105.21,,,105.21,Fee Schedule,,270.94,,,270.94,Fee Schedule,,49.54,,,49.54,Fee Schedule,,105.21,,,105.21,Fee Schedule,,270.94,,,270.94,Fee Schedule,,93.18,,,93.18,Fee Schedule,,305.9,70,,305.9,percent of total billed charges,All Other,104.96,,,104.96,Fee Schedule,,88.96,,,88.96,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,17.12,323.38,
X-RAY EXAM ABDOMEN 2 VIEWS W/ FY MOD,74019,CPT,FY,42674019,CDM,320,RC,,,both,,,242,179.08,,,179.08,Other,150% of Medicare + 9.63% HCRA Surcharge,108.9,45,,108.9,percent of total billed charges,Critical Access Hospital RCC factor,90.28,,,90.28,Fee Schedule,,81.22,,,81.22,Fee Schedule,,20.47,,,20.47,Fee Schedule,,20.47,,,20.47,Fee Schedule,,20.47,,,20.47,Fee Schedule,,119.79,,,119.79,Other,110% of Medicare,107.26,,,107.26,Fee Schedule,,53,,,53,Other,186% of Medicaid,126.22,,,126.22,Fee Schedule,,150.04,,,150.04,Fee Schedule,,59.43,,,59.43,Fee Schedule,,126.22,,,126.22,Fee Schedule,,150.04,,,150.04,Fee Schedule,,111.79,,,111.79,Fee Schedule,,169.4,70,,169.4,percent of total billed charges,All Other,126.28,,,126.28,Fee Schedule,,107.03,,,107.03,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,20.47,179.33,
X-RAY ABDOMEN 3+ VIEWS W FY MOD,74021,CPT,FY,42674021,CDM,320,RC,,,both,,,408,301.92,,,301.92,Other,150% of Medicare + 9.63% HCRA Surcharge,183.6,45,,183.6,percent of total billed charges,Critical Access Hospital RCC factor,105.3,,,105.3,Fee Schedule,,94.74,,,94.74,Fee Schedule,,23.83,,,23.83,Fee Schedule,,23.83,,,23.83,Fee Schedule,,23.83,,,23.83,Fee Schedule,,201.96,,,201.96,Other,110% of Medicare,125.11,,,125.11,Fee Schedule,,53,,,53,Other,186% of Medicaid,147.22,,,147.22,Fee Schedule,,252.96,,,252.96,Fee Schedule,,69.32,,,69.32,Fee Schedule,,147.22,,,147.22,Fee Schedule,,252.96,,,252.96,Fee Schedule,,130.39,,,130.39,Fee Schedule,,285.6,70,,285.6,percent of total billed charges,All Other,149.24,,,149.24,Fee Schedule,,126.49,,,126.49,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,23.83,301.92,
XR PHARYNX/CERVICAL ESOPH W/ FY MOD,74210,CPT,FY,42674210,CDM,320,RC,,,both,,,494,365.56,,,365.56,Other,150% of Medicare + 9.63% HCRA Surcharge,222.3,45,,222.3,percent of total billed charges,Critical Access Hospital RCC factor,233.54,,,233.54,Fee Schedule,,210.11,,,210.11,Fee Schedule,,412.01,,,412.01,Fee Schedule,,370.57,,,370.57,Fee Schedule,,350.25,,,350.25,Fee Schedule,,244.53,,,244.53,Other,110% of Medicare,277.47,,,277.47,Fee Schedule,,53,,,53,Other,186% of Medicaid,326.52,,,326.52,Fee Schedule,,306.28,,,306.28,Fee Schedule,,153.74,,,153.74,Fee Schedule,,326.52,,,326.52,Fee Schedule,,306.28,,,306.28,Fee Schedule,,289.18,,,289.18,Fee Schedule,,345.8,70,,345.8,percent of total billed charges,All Other,350.96,,,350.96,Fee Schedule,,297.46,,,297.46,Fee Schedule,,291.55,,,291.55,Fee Schedule,,291.55,,,291.55,Fee Schedule,,291.55,,,291.55,Fee Schedule,,291.55,,,291.55,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,412.01,
XR ESOPHAGUS W/ FY MOD,74220,CPT,FY,42674220,CDM,320,RC,,,both,,,864,639.36,,,639.36,Other,150% of Medicare + 9.63% HCRA Surcharge,388.8,45,,388.8,percent of total billed charges,Critical Access Hospital RCC factor,240.46,,,240.46,Fee Schedule,,216.34,,,216.34,Fee Schedule,,455.49,,,455.49,Fee Schedule,,409.68,,,409.68,Fee Schedule,,387.21,,,387.21,Fee Schedule,,427.68,,,427.68,Other,110% of Medicare,285.69,,,285.69,Fee Schedule,,53,,,53,Other,186% of Medicaid,336.19,,,336.19,Fee Schedule,,535.68,,,535.68,Fee Schedule,,158.3,,,158.3,Fee Schedule,,336.19,,,336.19,Fee Schedule,,535.68,,,535.68,Fee Schedule,,297.75,,,297.75,Fee Schedule,,604.8,70,,604.8,percent of total billed charges,All Other,354.24,,,354.24,Fee Schedule,,300.24,,,300.24,Fee Schedule,,291.55,,,291.55,Fee Schedule,,291.55,,,291.55,Fee Schedule,,291.55,,,291.55,Fee Schedule,,291.55,,,291.55,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,639.36,
SWALLOWING FUNCTION W/CINE -VI W/ FY MOD,74230,CPT,FY,42674230,CDM,320,RC,,,both,,,953,705.22,,,705.22,Other,150% of Medicare + 9.63% HCRA Surcharge,428.85,45,,428.85,percent of total billed charges,Critical Access Hospital RCC factor,345.6,,,345.6,Fee Schedule,,310.94,,,310.94,Fee Schedule,,441.73,,,441.73,Fee Schedule,,397.31,,,397.31,Fee Schedule,,375.51,,,375.51,Fee Schedule,,471.74,,,471.74,Other,110% of Medicare,410.61,,,410.61,Fee Schedule,,392,,,392,Other,186% of Medicaid,483.2,,,483.2,Fee Schedule,,590.86,,,590.86,Fee Schedule,,227.51,,,227.51,Fee Schedule,,483.2,,,483.2,Fee Schedule,,590.86,,,590.86,Fee Schedule,,427.94,,,427.94,Fee Schedule,,667.1,70,,667.1,percent of total billed charges,All Other,514.96,,,514.96,Fee Schedule,,436.46,,,436.46,Fee Schedule,,291.55,,,291.55,Fee Schedule,,291.55,,,291.55,Fee Schedule,,291.55,,,291.55,Fee Schedule,,291.55,,,291.55,Fee Schedule,,210.57,,,210.57,Other,100% of Medicaid,210.57,,,210.57,Other,100% of Medicaid,210.57,,,210.57,Other,100% of Medicaid,210.57,,,210.57,Other,100% of Medicaid,473.77,,,473.77,Other,225% of Medicaid,322.17,,,322.17,Other,153% of Medicaid,473.77,,,473.77,Other,225% of Medicaid,294.79,,,294.79,Other,140% of Medicaid,473.77,,,473.77,Other,225% of Medicaid,547.47,,,547.47,Other,260% of Medicaid,682.23,,,682.23,Other,324% of Medicaid,452.72,,,452.72,Other,215% of Medicaid,452.72,,,452.72,Other,215% of Medicaid,263.21,,,263.21,Other,125% of Medicaid,210.57,705.22,
XR UPPER GI TRACT WO KUB W/ FY MOD,74240,CPT,FY,42674240,CDM,320,RC,,,both,,,915,677.1,,,677.1,Other,150% of Medicare + 9.63% HCRA Surcharge,411.75,45,,411.75,percent of total billed charges,Critical Access Hospital RCC factor,294.76,,,294.76,Fee Schedule,,265.19,,,265.19,Fee Schedule,,524.15,,,524.15,Fee Schedule,,471.44,,,471.44,Fee Schedule,,445.58,,,445.58,Fee Schedule,,452.93,,,452.93,Other,110% of Medicare,350.2,,,350.2,Fee Schedule,,392,,,392,Other,186% of Medicaid,412.1,,,412.1,Fee Schedule,,567.3,,,567.3,Fee Schedule,,194.04,,,194.04,Fee Schedule,,412.1,,,412.1,Fee Schedule,,567.3,,,567.3,Fee Schedule,,364.98,,,364.98,Fee Schedule,,640.5,70,,640.5,percent of total billed charges,All Other,432.96,,,432.96,Fee Schedule,,366.96,,,366.96,Fee Schedule,,291.55,,,291.55,Fee Schedule,,291.55,,,291.55,Fee Schedule,,291.55,,,291.55,Fee Schedule,,291.55,,,291.55,Fee Schedule,,210.57,,,210.57,Other,100% of Medicaid,210.57,,,210.57,Other,100% of Medicaid,210.57,,,210.57,Other,100% of Medicaid,210.57,,,210.57,Other,100% of Medicaid,473.77,,,473.77,Other,225% of Medicaid,322.17,,,322.17,Other,153% of Medicaid,473.77,,,473.77,Other,225% of Medicaid,294.79,,,294.79,Other,140% of Medicaid,473.77,,,473.77,Other,225% of Medicaid,547.47,,,547.47,Other,260% of Medicaid,682.23,,,682.23,Other,324% of Medicaid,452.72,,,452.72,Other,215% of Medicaid,452.72,,,452.72,Other,215% of Medicaid,263.21,,,263.21,Other,125% of Medicaid,194.04,682.23,
XR UPPER GI W/AIR WO KUB W/ FY MOD,74246,CPT,FY,42674246,CDM,320,RC,,,both,,,763,564.62,,,564.62,Other,150% of Medicare + 9.63% HCRA Surcharge,343.35,45,,343.35,percent of total billed charges,Critical Access Hospital RCC factor,336.35,,,336.35,Fee Schedule,,302.61,,,302.61,Fee Schedule,,583.65,,,583.65,Fee Schedule,,524.96,,,524.96,Fee Schedule,,496.16,,,496.16,Fee Schedule,,377.69,,,377.69,Other,110% of Medicare,399.62,,,399.62,Fee Schedule,,392,,,392,Other,186% of Medicaid,470.26,,,470.26,Fee Schedule,,473.06,,,473.06,Fee Schedule,,221.42,,,221.42,Fee Schedule,,470.26,,,470.26,Fee Schedule,,473.06,,,473.06,Fee Schedule,,416.49,,,416.49,Fee Schedule,,534.1,70,,534.1,percent of total billed charges,All Other,498.56,,,498.56,Fee Schedule,,422.56,,,422.56,Fee Schedule,,291.55,,,291.55,Fee Schedule,,291.55,,,291.55,Fee Schedule,,291.55,,,291.55,Fee Schedule,,291.55,,,291.55,Fee Schedule,,210.57,,,210.57,Other,100% of Medicaid,210.57,,,210.57,Other,100% of Medicaid,210.57,,,210.57,Other,100% of Medicaid,210.57,,,210.57,Other,100% of Medicaid,473.77,,,473.77,Other,225% of Medicaid,322.17,,,322.17,Other,153% of Medicaid,473.77,,,473.77,Other,225% of Medicaid,294.79,,,294.79,Other,140% of Medicaid,473.77,,,473.77,Other,225% of Medicaid,547.47,,,547.47,Other,260% of Medicaid,682.23,,,682.23,Other,324% of Medicaid,452.72,,,452.72,Other,215% of Medicaid,452.72,,,452.72,Other,215% of Medicaid,263.21,,,263.21,Other,125% of Medicaid,210.57,682.23,
XR SMALL BOWEL W/ FY MOD,74250,CPT,FY,42674250,CDM,320,RC,,,both,,,792,586.08,,,586.08,Other,150% of Medicare + 9.63% HCRA Surcharge,356.4,45,,356.4,percent of total billed charges,Critical Access Hospital RCC factor,291.31,,,291.31,Fee Schedule,,262.09,,,262.09,Fee Schedule,,563.05,,,563.05,Fee Schedule,,506.42,,,506.42,Fee Schedule,,478.64,,,478.64,Fee Schedule,,392.04,,,392.04,Other,110% of Medicare,346.1,,,346.1,Fee Schedule,,392,,,392,Other,186% of Medicaid,407.29,,,407.29,Fee Schedule,,491.04,,,491.04,Fee Schedule,,191.77,,,191.77,Fee Schedule,,407.29,,,407.29,Fee Schedule,,491.04,,,491.04,Fee Schedule,,360.71,,,360.71,Fee Schedule,,554.4,70,,554.4,percent of total billed charges,All Other,429.68,,,429.68,Fee Schedule,,364.18,,,364.18,Fee Schedule,,291.55,,,291.55,Fee Schedule,,291.55,,,291.55,Fee Schedule,,291.55,,,291.55,Fee Schedule,,291.55,,,291.55,Fee Schedule,,210.57,,,210.57,Other,100% of Medicaid,210.57,,,210.57,Other,100% of Medicaid,210.57,,,210.57,Other,100% of Medicaid,210.57,,,210.57,Other,100% of Medicaid,473.77,,,473.77,Other,225% of Medicaid,322.17,,,322.17,Other,153% of Medicaid,473.77,,,473.77,Other,225% of Medicaid,294.79,,,294.79,Other,140% of Medicaid,473.77,,,473.77,Other,225% of Medicaid,547.47,,,547.47,Other,260% of Medicaid,682.23,,,682.23,Other,324% of Medicaid,452.72,,,452.72,Other,215% of Medicaid,452.72,,,452.72,Other,215% of Medicaid,263.21,,,263.21,Other,125% of Medicaid,191.77,682.23,
XR SML BOWEL VIA ENTEROCLYS W/ FY MOD,74251,CPT,FY,42674251,CDM,320,RC,,,both,,,3420,2530.81,,,2530.81,Other,150% of Medicare + 9.63% HCRA Surcharge,1539,45,,1539,percent of total billed charges,Critical Access Hospital RCC factor,618.22,,,618.22,Fee Schedule,,556.21,,,556.21,Fee Schedule,,954.24,,,954.24,Fee Schedule,,858.27,,,858.27,Fee Schedule,,811.19,,,811.19,Fee Schedule,,1692.9,,,1692.9,Other,110% of Medicare,734.5,,,734.5,Fee Schedule,,392,,,392,Other,186% of Medicaid,864.35,,,864.35,Fee Schedule,,2120.4,,,2120.4,Fee Schedule,,406.98,,,406.98,Fee Schedule,,864.35,,,864.35,Fee Schedule,,2120.4,,,2120.4,Fee Schedule,,765.51,,,765.51,Fee Schedule,,2394,70,,2394,percent of total billed charges,All Other,1618.68,,,1618.68,Fee Schedule,,1371.93,,,1371.93,Fee Schedule,,291.55,,,291.55,Fee Schedule,,291.55,,,291.55,Fee Schedule,,291.55,,,291.55,Fee Schedule,,291.55,,,291.55,Fee Schedule,,210.57,,,210.57,Other,100% of Medicaid,210.57,,,210.57,Other,100% of Medicaid,210.57,,,210.57,Other,100% of Medicaid,210.57,,,210.57,Other,100% of Medicaid,473.77,,,473.77,Other,225% of Medicaid,322.17,,,322.17,Other,153% of Medicaid,473.77,,,473.77,Other,225% of Medicaid,294.79,,,294.79,Other,140% of Medicaid,473.77,,,473.77,Other,225% of Medicaid,547.47,,,547.47,Other,260% of Medicaid,682.23,,,682.23,Other,324% of Medicaid,452.72,,,452.72,Other,215% of Medicaid,452.72,,,452.72,Other,215% of Medicaid,263.21,,,263.21,Other,125% of Medicaid,210.57,2530.81,
XR COLON W CONTRAST W/ FY MOD,74270,CPT,FY,42674270,CDM,320,RC,,,both,,,1022,756.28,,,756.28,Other,150% of Medicare + 9.63% HCRA Surcharge,459.9,45,,459.9,percent of total billed charges,Critical Access Hospital RCC factor,364.07,,,364.07,Fee Schedule,,327.55,,,327.55,Fee Schedule,,585.92,,,585.92,Fee Schedule,,526.99,,,526.99,Fee Schedule,,498.09,,,498.09,Fee Schedule,,505.89,,,505.89,Other,110% of Medicare,432.55,,,432.55,Fee Schedule,,392,,,392,Other,186% of Medicaid,509.02,,,509.02,Fee Schedule,,633.64,,,633.64,Fee Schedule,,239.67,,,239.67,Fee Schedule,,509.02,,,509.02,Fee Schedule,,633.64,,,633.64,Fee Schedule,,450.81,,,450.81,Fee Schedule,,715.4,70,,715.4,percent of total billed charges,All Other,536.28,,,536.28,Fee Schedule,,454.53,,,454.53,Fee Schedule,,291.55,,,291.55,Fee Schedule,,291.55,,,291.55,Fee Schedule,,291.55,,,291.55,Fee Schedule,,291.55,,,291.55,Fee Schedule,,210.57,,,210.57,Other,100% of Medicaid,210.57,,,210.57,Other,100% of Medicaid,210.57,,,210.57,Other,100% of Medicaid,210.57,,,210.57,Other,100% of Medicaid,473.77,,,473.77,Other,225% of Medicaid,322.17,,,322.17,Other,153% of Medicaid,473.77,,,473.77,Other,225% of Medicaid,294.79,,,294.79,Other,140% of Medicaid,473.77,,,473.77,Other,225% of Medicaid,547.47,,,547.47,Other,260% of Medicaid,682.23,,,682.23,Other,324% of Medicaid,452.72,,,452.72,Other,215% of Medicaid,452.72,,,452.72,Other,215% of Medicaid,263.21,,,263.21,Other,125% of Medicaid,210.57,756.28,
THERAP BE/AIR FOR OBSTRUCT W/ FY MOD,74283,CPT,FY,42674283,CDM,320,RC,,,both,,,934,691.16,,,691.16,Other,150% of Medicare + 9.63% HCRA Surcharge,420.3,45,,420.3,percent of total billed charges,Critical Access Hospital RCC factor,541.98,,,541.98,Fee Schedule,,487.61,,,487.61,Fee Schedule,,583.65,,,583.65,Fee Schedule,,524.96,,,524.96,Fee Schedule,,496.16,,,496.16,Fee Schedule,,462.33,,,462.33,Other,110% of Medicare,643.92,,,643.92,Fee Schedule,,392,,,392,Other,186% of Medicaid,757.75,,,757.75,Fee Schedule,,579.08,,,579.08,Fee Schedule,,356.79,,,356.79,Fee Schedule,,757.75,,,757.75,Fee Schedule,,579.08,,,579.08,Fee Schedule,,671.11,,,671.11,Fee Schedule,,653.8,70,,653.8,percent of total billed charges,All Other,795.4,,,795.4,Fee Schedule,,674.15,,,674.15,Fee Schedule,,291.55,,,291.55,Fee Schedule,,291.55,,,291.55,Fee Schedule,,291.55,,,291.55,Fee Schedule,,291.55,,,291.55,Fee Schedule,,210.57,,,210.57,Other,100% of Medicaid,210.57,,,210.57,Other,100% of Medicaid,210.57,,,210.57,Other,100% of Medicaid,210.57,,,210.57,Other,100% of Medicaid,473.77,,,473.77,Other,225% of Medicaid,322.17,,,322.17,Other,153% of Medicaid,473.77,,,473.77,Other,225% of Medicaid,294.79,,,294.79,Other,140% of Medicaid,473.77,,,473.77,Other,225% of Medicaid,547.47,,,547.47,Other,260% of Medicaid,682.23,,,682.23,Other,324% of Medicaid,452.72,,,452.72,Other,215% of Medicaid,452.72,,,452.72,Other,215% of Medicaid,263.21,,,263.21,Other,125% of Medicaid,210.57,795.4,
ORAL GALLBLADDER STUDY W/ FY MOD,74290,CPT,FY,42674290,CDM,320,RC,,,both,,,615,455.1,,,455.1,Other,150% of Medicare + 9.63% HCRA Surcharge,276.75,45,,276.75,percent of total billed charges,Critical Access Hospital RCC factor,242.79,,,242.79,Fee Schedule,,218.44,,,218.44,Fee Schedule,,357.1,,,357.1,Fee Schedule,,321.18,,,321.18,Fee Schedule,,303.56,,,303.56,Fee Schedule,,304.43,,,304.43,Other,110% of Medicare,288.46,,,288.46,Fee Schedule,,392,,,392,Other,186% of Medicaid,339.45,,,339.45,Fee Schedule,,381.3,,,381.3,Fee Schedule,,159.83,,,159.83,Fee Schedule,,339.45,,,339.45,Fee Schedule,,381.3,,,381.3,Fee Schedule,,300.63,,,300.63,Fee Schedule,,430.5,70,,430.5,percent of total billed charges,All Other,360.8,,,360.8,Fee Schedule,,305.8,,,305.8,Fee Schedule,,291.55,,,291.55,Fee Schedule,,291.55,,,291.55,Fee Schedule,,291.55,,,291.55,Fee Schedule,,291.55,,,291.55,Fee Schedule,,210.57,,,210.57,Other,100% of Medicaid,210.57,,,210.57,Other,100% of Medicaid,210.57,,,210.57,Other,100% of Medicaid,210.57,,,210.57,Other,100% of Medicaid,473.77,,,473.77,Other,225% of Medicaid,322.17,,,322.17,Other,153% of Medicaid,473.77,,,473.77,Other,225% of Medicaid,294.79,,,294.79,Other,140% of Medicaid,473.77,,,473.77,Other,225% of Medicaid,547.47,,,547.47,Other,260% of Medicaid,682.23,,,682.23,Other,324% of Medicaid,452.72,,,452.72,Other,215% of Medicaid,452.72,,,452.72,Other,215% of Medicaid,263.21,,,263.21,Other,125% of Medicaid,159.83,682.23,
CHOLANGIOGRAM INTRAOP W/ FY MOD,74300,CPT,FY,42674300,CDM,320,RC,,,both,,,1428,1056.72,,,1056.72,Other,150% of Medicare + 9.63% HCRA Surcharge,642.6,45,,642.6,percent of total billed charges,Critical Access Hospital RCC factor,928.2,65,,928.2,percent of total billed charges,All Other,842.52,65,,842.52,percent of total billed charges,All Other,33.47,,,33.47,Fee Schedule,,33.47,,,33.47,Fee Schedule,,33.47,,,33.47,Fee Schedule,,706.86,,,706.86,Other,110% of Medicare,971.04,68,,971.04,percent of total billed charges,All Other,544,,,544,Other,186% of Medicaid,1142.4,80,,1142.4,percent of total billed charges,All Other,1185.24,83,,1185.24,percent of total billed charges,All Other,1185.24,83,,1185.24,percent of total billed charges,All Other,1142.4,80,,1142.4,percent of total billed charges,All Other,1185.24,83,,1185.24,percent of total billed charges,All Other,1142.4,80,,1142.4,percent of total billed charges,All Other,999.6,70,,999.6,percent of total billed charges,All Other,928.2,65,,928.2,percent of total billed charges,Default if not in Fee Schedule,928.2,65,,928.2,percent of total billed charges,Default if not in Fee Schedule,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,292.43,,,292.43,Other,100% of Medicaid,292.43,,,292.43,Other,100% of Medicaid,292.43,,,292.43,Other,100% of Medicaid,292.43,,,292.43,Other,100% of Medicaid,657.97,,,657.97,Other,225% of Medicaid,447.42,,,447.42,Other,153% of Medicaid,657.97,,,657.97,Other,225% of Medicaid,409.4,,,409.4,Other,140% of Medicaid,657.97,,,657.97,Other,225% of Medicaid,760.32,,,760.32,Other,260% of Medicaid,947.48,,,947.48,Other,324% of Medicaid,628.73,,,628.73,Other,215% of Medicaid,628.73,,,628.73,Other,215% of Medicaid,365.54,,,365.54,Other,125% of Medicaid,0.01,1185.24,
ENDO CATH - BILE DUCTS W/ FY MOD,74328,CPT,FY,42674328,CDM,320,RC,,,both,,,638,472.12,,,472.12,Other,150% of Medicare + 9.63% HCRA Surcharge,287.1,45,,287.1,percent of total billed charges,Critical Access Hospital RCC factor,414.7,65,,414.7,percent of total billed charges,All Other,376.42,65,,376.42,percent of total billed charges,All Other,81.44,,,81.44,Fee Schedule,,81.44,,,81.44,Fee Schedule,,81.44,,,81.44,Fee Schedule,,315.81,,,315.81,Other,110% of Medicare,433.84,68,,433.84,percent of total billed charges,All Other,544,,,544,Other,186% of Medicaid,510.4,80,,510.4,percent of total billed charges,All Other,529.54,83,,529.54,percent of total billed charges,All Other,529.54,83,,529.54,percent of total billed charges,All Other,510.4,80,,510.4,percent of total billed charges,All Other,529.54,83,,529.54,percent of total billed charges,All Other,510.4,80,,510.4,percent of total billed charges,All Other,446.6,70,,446.6,percent of total billed charges,All Other,414.7,65,,414.7,percent of total billed charges,Default if not in Fee Schedule,414.7,65,,414.7,percent of total billed charges,Default if not in Fee Schedule,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,292.43,,,292.43,Other,100% of Medicaid,292.43,,,292.43,Other,100% of Medicaid,292.43,,,292.43,Other,100% of Medicaid,292.43,,,292.43,Other,100% of Medicaid,657.97,,,657.97,Other,225% of Medicaid,447.42,,,447.42,Other,153% of Medicaid,657.97,,,657.97,Other,225% of Medicaid,409.4,,,409.4,Other,140% of Medicaid,657.97,,,657.97,Other,225% of Medicaid,760.32,,,760.32,Other,260% of Medicaid,947.48,,,947.48,Other,324% of Medicaid,628.73,,,628.73,Other,215% of Medicaid,628.73,,,628.73,Other,215% of Medicaid,365.54,,,365.54,Other,125% of Medicaid,0.01,947.48,
ENDO CATH - PANCR DUCT W/ FY MOD,74329,CPT,FY,42674329,CDM,320,RC,,,both,,,749,554.26,,,554.26,Other,150% of Medicare + 9.63% HCRA Surcharge,337.05,45,,337.05,percent of total billed charges,Critical Access Hospital RCC factor,486.85,65,,486.85,percent of total billed charges,All Other,441.91,65,,441.91,percent of total billed charges,All Other,65.22,,,65.22,Fee Schedule,,65.22,,,65.22,Fee Schedule,,65.22,,,65.22,Fee Schedule,,370.76,,,370.76,Other,110% of Medicare,509.32,68,,509.32,percent of total billed charges,All Other,544,,,544,Other,186% of Medicaid,599.2,80,,599.2,percent of total billed charges,All Other,621.67,83,,621.67,percent of total billed charges,All Other,621.67,83,,621.67,percent of total billed charges,All Other,599.2,80,,599.2,percent of total billed charges,All Other,621.67,83,,621.67,percent of total billed charges,All Other,599.2,80,,599.2,percent of total billed charges,All Other,524.3,70,,524.3,percent of total billed charges,All Other,486.85,65,,486.85,percent of total billed charges,Default if not in Fee Schedule,486.85,65,,486.85,percent of total billed charges,Default if not in Fee Schedule,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,292.43,,,292.43,Other,100% of Medicaid,292.43,,,292.43,Other,100% of Medicaid,292.43,,,292.43,Other,100% of Medicaid,292.43,,,292.43,Other,100% of Medicaid,657.97,,,657.97,Other,225% of Medicaid,447.42,,,447.42,Other,153% of Medicaid,657.97,,,657.97,Other,225% of Medicaid,409.4,,,409.4,Other,140% of Medicaid,657.97,,,657.97,Other,225% of Medicaid,760.32,,,760.32,Other,260% of Medicaid,947.48,,,947.48,Other,324% of Medicaid,628.73,,,628.73,Other,215% of Medicaid,628.73,,,628.73,Other,215% of Medicaid,365.54,,,365.54,Other,125% of Medicaid,0.01,947.48,
ENDO CATH BIL & PANCR - ERCP W/ FY MOD,74330,CPT,FY,42674330,CDM,320,RC,,,both,,,2170,1605.81,,,1605.81,Other,150% of Medicare + 9.63% HCRA Surcharge,976.5,45,,976.5,percent of total billed charges,Critical Access Hospital RCC factor,1410.5,65,,1410.5,percent of total billed charges,All Other,1280.3,65,,1280.3,percent of total billed charges,All Other,121.13,,,121.13,Fee Schedule,,121.13,,,121.13,Fee Schedule,,121.13,,,121.13,Fee Schedule,,1074.15,,,1074.15,Other,110% of Medicare,1475.6,68,,1475.6,percent of total billed charges,All Other,544,,,544,Other,186% of Medicaid,1736,80,,1736,percent of total billed charges,All Other,1801.1,83,,1801.1,percent of total billed charges,All Other,1801.1,83,,1801.1,percent of total billed charges,All Other,1736,80,,1736,percent of total billed charges,All Other,1801.1,83,,1801.1,percent of total billed charges,All Other,1736,80,,1736,percent of total billed charges,All Other,1519,70,,1519,percent of total billed charges,All Other,1410.5,65,,1410.5,percent of total billed charges,Default if not in Fee Schedule,1410.5,65,,1410.5,percent of total billed charges,Default if not in Fee Schedule,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,292.43,,,292.43,Other,100% of Medicaid,292.43,,,292.43,Other,100% of Medicaid,292.43,,,292.43,Other,100% of Medicaid,292.43,,,292.43,Other,100% of Medicaid,657.97,,,657.97,Other,225% of Medicaid,447.42,,,447.42,Other,153% of Medicaid,657.97,,,657.97,Other,225% of Medicaid,409.4,,,409.4,Other,140% of Medicaid,657.97,,,657.97,Other,225% of Medicaid,760.32,,,760.32,Other,260% of Medicaid,947.48,,,947.48,Other,324% of Medicaid,628.73,,,628.73,Other,215% of Medicaid,628.73,,,628.73,Other,215% of Medicaid,365.54,,,365.54,Other,125% of Medicaid,0.01,1801.1,
DILATE FOR STRICTURE/OBSTR W/ FY MOD,74360,CPT,FY,42674360,CDM,320,RC,,,both,,,816,603.84,,,603.84,Other,150% of Medicare + 9.63% HCRA Surcharge,367.2,45,,367.2,percent of total billed charges,Critical Access Hospital RCC factor,530.4,65,,530.4,percent of total billed charges,All Other,481.44,65,,481.44,percent of total billed charges,All Other,87.31,,,87.31,Fee Schedule,,87.31,,,87.31,Fee Schedule,,87.31,,,87.31,Fee Schedule,,403.92,,,403.92,Other,110% of Medicare,554.88,68,,554.88,percent of total billed charges,All Other,544,,,544,Other,186% of Medicaid,652.8,80,,652.8,percent of total billed charges,All Other,505.92,62,,505.92,percent of total billed charges,Lab and Radiology,448.8,83,,448.8,percent of total billed charges,All Other,652.8,80,,652.8,percent of total billed charges,All Other,505.92,62,,505.92,percent of total billed charges,Lab and Radiology,652.8,80,,652.8,percent of total billed charges,All Other,571.2,70,,571.2,percent of total billed charges,All Other,530.4,65,,530.4,percent of total billed charges,Default if not in Fee Schedule,530.4,65,,530.4,percent of total billed charges,Default if not in Fee Schedule,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,292.43,,,292.43,Other,100% of Medicaid,292.43,,,292.43,Other,100% of Medicaid,292.43,,,292.43,Other,100% of Medicaid,292.43,,,292.43,Other,100% of Medicaid,657.97,,,657.97,Other,225% of Medicaid,447.42,,,447.42,Other,153% of Medicaid,657.97,,,657.97,Other,225% of Medicaid,409.4,,,409.4,Other,140% of Medicaid,657.97,,,657.97,Other,225% of Medicaid,760.32,,,760.32,Other,260% of Medicaid,947.48,,,947.48,Other,324% of Medicaid,628.73,,,628.73,Other,215% of Medicaid,628.73,,,628.73,Other,215% of Medicaid,365.54,,,365.54,Other,125% of Medicaid,0.01,947.48,
IVP W/WO TOMOGRAPHY/KUB W/ FY MOD,74400,CPT,FY,42674400,CDM,320,RC,,,both,,,997,737.78,,,737.78,Other,150% of Medicare + 9.63% HCRA Surcharge,448.65,45,,448.65,percent of total billed charges,Critical Access Hospital RCC factor,388.51,,,388.51,Fee Schedule,,349.54,,,349.54,Fee Schedule,,592.77,,,592.77,Fee Schedule,,533.16,,,533.16,Fee Schedule,,503.91,,,503.91,Fee Schedule,,493.52,,,493.52,Other,110% of Medicare,461.58,,,461.58,Fee Schedule,,392,,,392,Other,186% of Medicaid,543.18,,,543.18,Fee Schedule,,618.14,,,618.14,Fee Schedule,,255.76,,,255.76,Fee Schedule,,543.18,,,543.18,Fee Schedule,,618.14,,,618.14,Fee Schedule,,481.07,,,481.07,Fee Schedule,,697.9,70,,697.9,percent of total billed charges,All Other,565.8,,,565.8,Fee Schedule,,479.55,,,479.55,Fee Schedule,,291.55,,,291.55,Fee Schedule,,291.55,,,291.55,Fee Schedule,,291.55,,,291.55,Fee Schedule,,291.55,,,291.55,Fee Schedule,,210.57,,,210.57,Other,100% of Medicaid,210.57,,,210.57,Other,100% of Medicaid,210.57,,,210.57,Other,100% of Medicaid,210.57,,,210.57,Other,100% of Medicaid,473.77,,,473.77,Other,225% of Medicaid,322.17,,,322.17,Other,153% of Medicaid,473.77,,,473.77,Other,225% of Medicaid,294.79,,,294.79,Other,140% of Medicaid,473.77,,,473.77,Other,225% of Medicaid,547.47,,,547.47,Other,260% of Medicaid,682.23,,,682.23,Other,324% of Medicaid,452.72,,,452.72,Other,215% of Medicaid,452.72,,,452.72,Other,215% of Medicaid,263.21,,,263.21,Other,125% of Medicaid,210.57,737.78,
IVP W TOMOGRAPHY W/ FY MOD,74415,CPT,FY,42674415,CDM,320,RC,,,both,,,1023,757.02,,,757.02,Other,150% of Medicare + 9.63% HCRA Surcharge,460.35,45,,460.35,percent of total billed charges,Critical Access Hospital RCC factor,445.1,,,445.1,Fee Schedule,,400.45,,,400.45,Fee Schedule,,757.56,,,757.56,Fee Schedule,,681.38,,,681.38,Fee Schedule,,644,,,644,Fee Schedule,,506.39,,,506.39,Other,110% of Medicare,528.82,,,528.82,Fee Schedule,,392,,,392,Other,186% of Medicaid,622.3,,,622.3,Fee Schedule,,634.26,,,634.26,Fee Schedule,,293.01,,,293.01,Fee Schedule,,622.3,,,622.3,Fee Schedule,,634.26,,,634.26,Fee Schedule,,551.14,,,551.14,Fee Schedule,,716.1,70,,716.1,percent of total billed charges,All Other,662.56,,,662.56,Fee Schedule,,561.56,,,561.56,Fee Schedule,,291.55,,,291.55,Fee Schedule,,291.55,,,291.55,Fee Schedule,,291.55,,,291.55,Fee Schedule,,291.55,,,291.55,Fee Schedule,,210.57,,,210.57,Other,100% of Medicaid,210.57,,,210.57,Other,100% of Medicaid,210.57,,,210.57,Other,100% of Medicaid,210.57,,,210.57,Other,100% of Medicaid,473.77,,,473.77,Other,225% of Medicaid,322.17,,,322.17,Other,153% of Medicaid,473.77,,,473.77,Other,225% of Medicaid,294.79,,,294.79,Other,140% of Medicaid,473.77,,,473.77,Other,225% of Medicaid,547.47,,,547.47,Other,260% of Medicaid,682.23,,,682.23,Other,324% of Medicaid,452.72,,,452.72,Other,215% of Medicaid,452.72,,,452.72,Other,215% of Medicaid,263.21,,,263.21,Other,125% of Medicaid,210.57,757.56,
RETROGRADE PYELOGRAM W/ FY MOD,74420,CPT,FY,42674420,CDM,320,RC,,,both,,,1142,845.08,,,845.08,Other,150% of Medicare + 9.63% HCRA Surcharge,513.9,45,,513.9,percent of total billed charges,Critical Access Hospital RCC factor,187.32,,,187.32,Fee Schedule,,168.53,,,168.53,Fee Schedule,,1185.43,,,1185.43,Fee Schedule,,1066.22,,,1066.22,Fee Schedule,,1007.73,,,1007.73,Fee Schedule,,565.29,,,565.29,Other,110% of Medicare,222.55,,,222.55,Fee Schedule,,392,,,392,Other,186% of Medicaid,261.89,,,261.89,Fee Schedule,,708.04,,,708.04,Fee Schedule,,123.31,,,123.31,Fee Schedule,,261.89,,,261.89,Fee Schedule,,708.04,,,708.04,Fee Schedule,,231.94,,,231.94,Fee Schedule,,799.4,70,,799.4,percent of total billed charges,All Other,257.48,,,257.48,Fee Schedule,,218.23,,,218.23,Fee Schedule,,610.96,,,610.96,Fee Schedule,,610.96,,,610.96,Fee Schedule,,610.96,,,610.96,Fee Schedule,,610.96,,,610.96,Fee Schedule,,210.57,,,210.57,Other,100% of Medicaid,210.57,,,210.57,Other,100% of Medicaid,210.57,,,210.57,Other,100% of Medicaid,210.57,,,210.57,Other,100% of Medicaid,473.77,,,473.77,Other,225% of Medicaid,322.17,,,322.17,Other,153% of Medicaid,473.77,,,473.77,Other,225% of Medicaid,294.79,,,294.79,Other,140% of Medicaid,473.77,,,473.77,Other,225% of Medicaid,547.47,,,547.47,Other,260% of Medicaid,682.23,,,682.23,Other,324% of Medicaid,452.72,,,452.72,Other,215% of Medicaid,452.72,,,452.72,Other,215% of Medicaid,263.21,,,263.21,Other,125% of Medicaid,123.31,1185.43,
XR URINARY TRACT W CONTRAST W/ FY MOD,74425,CPT,FY,42674425,CDM,320,RC,,,both,,,1062,785.88,,,785.88,Other,150% of Medicare + 9.63% HCRA Surcharge,477.9,45,,477.9,percent of total billed charges,Critical Access Hospital RCC factor,389.5,,,389.5,Fee Schedule,,350.43,,,350.43,Fee Schedule,,1185.43,,,1185.43,Fee Schedule,,1066.22,,,1066.22,Fee Schedule,,1007.73,,,1007.73,Fee Schedule,,525.69,,,525.69,Other,110% of Medicare,462.76,,,462.76,Fee Schedule,,392,,,392,Other,186% of Medicaid,544.57,,,544.57,Fee Schedule,,658.44,,,658.44,Fee Schedule,,256.41,,,256.41,Fee Schedule,,544.57,,,544.57,Fee Schedule,,658.44,,,658.44,Fee Schedule,,482.3,,,482.3,Fee Schedule,,743.4,70,,743.4,percent of total billed charges,All Other,567.44,,,567.44,Fee Schedule,,480.94,,,480.94,Fee Schedule,,610.96,,,610.96,Fee Schedule,,610.96,,,610.96,Fee Schedule,,610.96,,,610.96,Fee Schedule,,610.96,,,610.96,Fee Schedule,,210.57,,,210.57,Other,100% of Medicaid,210.57,,,210.57,Other,100% of Medicaid,210.57,,,210.57,Other,100% of Medicaid,210.57,,,210.57,Other,100% of Medicaid,473.77,,,473.77,Other,225% of Medicaid,322.17,,,322.17,Other,153% of Medicaid,473.77,,,473.77,Other,225% of Medicaid,294.79,,,294.79,Other,140% of Medicaid,473.77,,,473.77,Other,225% of Medicaid,547.47,,,547.47,Other,260% of Medicaid,682.23,,,682.23,Other,324% of Medicaid,452.72,,,452.72,Other,215% of Medicaid,452.72,,,452.72,Other,215% of Medicaid,263.21,,,263.21,Other,125% of Medicaid,210.57,1185.43,
XR BLADDER 3+ VIEWS W CONTR W/ FY MOD,74430,CPT,FY,42674430,CDM,320,RC,,,both,,,838,620.12,,,620.12,Other,150% of Medicare + 9.63% HCRA Surcharge,377.1,45,,377.1,percent of total billed charges,Critical Access Hospital RCC factor,91.43,,,91.43,Fee Schedule,,82.25,,,82.25,Fee Schedule,,306.71,,,306.71,Fee Schedule,,275.87,,,275.87,Fee Schedule,,260.74,,,260.74,Fee Schedule,,414.81,,,414.81,Other,110% of Medicare,108.62,,,108.62,Fee Schedule,,392,,,392,Other,186% of Medicaid,127.82,,,127.82,Fee Schedule,,519.56,,,519.56,Fee Schedule,,60.19,,,60.19,Fee Schedule,,127.82,,,127.82,Fee Schedule,,519.56,,,519.56,Fee Schedule,,113.21,,,113.21,Fee Schedule,,586.6,70,,586.6,percent of total billed charges,All Other,126.28,,,126.28,Fee Schedule,,107.03,,,107.03,Fee Schedule,,610.96,,,610.96,Fee Schedule,,610.96,,,610.96,Fee Schedule,,610.96,,,610.96,Fee Schedule,,610.96,,,610.96,Fee Schedule,,210.57,,,210.57,Other,100% of Medicaid,210.57,,,210.57,Other,100% of Medicaid,210.57,,,210.57,Other,100% of Medicaid,210.57,,,210.57,Other,100% of Medicaid,473.77,,,473.77,Other,225% of Medicaid,322.17,,,322.17,Other,153% of Medicaid,473.77,,,473.77,Other,225% of Medicaid,294.79,,,294.79,Other,140% of Medicaid,473.77,,,473.77,Other,225% of Medicaid,547.47,,,547.47,Other,260% of Medicaid,682.23,,,682.23,Other,324% of Medicaid,452.72,,,452.72,Other,215% of Medicaid,452.72,,,452.72,Other,215% of Medicaid,263.21,,,263.21,Other,125% of Medicaid,60.19,682.23,
URETHROGRAM RETROGRADE W/ FY MOD,74450,CPT,FY,42674450,CDM,320,RC,,,both,,,1235,913.9,,,913.9,Other,150% of Medicare + 9.63% HCRA Surcharge,555.75,45,,555.75,percent of total billed charges,Critical Access Hospital RCC factor,802.75,65,,802.75,percent of total billed charges,All Other,728.65,65,,728.65,percent of total billed charges,All Other,1185.43,,,1185.43,Fee Schedule,,1066.22,,,1066.22,Fee Schedule,,1007.73,,,1007.73,Fee Schedule,,611.33,,,611.33,Other,110% of Medicare,839.8,68,,839.8,percent of total billed charges,All Other,392,,,392,Other,186% of Medicaid,988,80,,988,percent of total billed charges,All Other,1025.05,83,,1025.05,percent of total billed charges,All Other,1025.05,83,,1025.05,percent of total billed charges,All Other,988,80,,988,percent of total billed charges,All Other,1025.05,83,,1025.05,percent of total billed charges,All Other,988,80,,988,percent of total billed charges,All Other,864.5,70,,864.5,percent of total billed charges,All Other,802.75,65,,802.75,percent of total billed charges,Default if not in Fee Schedule,802.75,65,,802.75,percent of total billed charges,Default if not in Fee Schedule,372.86,,,372.86,Fee Schedule,,372.86,,,372.86,Fee Schedule,,372.86,,,372.86,Fee Schedule,,372.86,,,372.86,Fee Schedule,,210.57,,,210.57,Other,100% of Medicaid,210.57,,,210.57,Other,100% of Medicaid,210.57,,,210.57,Other,100% of Medicaid,210.57,,,210.57,Other,100% of Medicaid,473.77,,,473.77,Other,225% of Medicaid,322.17,,,322.17,Other,153% of Medicaid,473.77,,,473.77,Other,225% of Medicaid,294.79,,,294.79,Other,140% of Medicaid,473.77,,,473.77,Other,225% of Medicaid,547.47,,,547.47,Other,260% of Medicaid,682.23,,,682.23,Other,324% of Medicaid,452.72,,,452.72,Other,215% of Medicaid,452.72,,,452.72,Other,215% of Medicaid,263.21,,,263.21,Other,125% of Medicaid,210.57,1185.43,
DILATION URETERS/URETHRA/NEPHR W/ FY MOD,74485,CPT,FY,42674485,CDM,320,RC,,,both,,,5267,3897.59,,,3897.59,Other,150% of Medicare + 9.63% HCRA Surcharge,2370.15,45,,2370.15,percent of total billed charges,Critical Access Hospital RCC factor,280.91,,,280.91,Fee Schedule,,252.73,,,252.73,Fee Schedule,,565.31,,,565.31,Fee Schedule,,508.46,,,508.46,Fee Schedule,,480.57,,,480.57,Fee Schedule,,2607.17,,,2607.17,Other,110% of Medicare,333.75,,,333.75,Fee Schedule,,544,,,544,Other,186% of Medicaid,392.75,,,392.75,Fee Schedule,,3265.54,,,3265.54,Fee Schedule,,184.93,,,184.93,Fee Schedule,,392.75,,,392.75,Fee Schedule,,3265.54,,,3265.54,Fee Schedule,,347.84,,,347.84,Fee Schedule,,3686.9,70,,3686.9,percent of total billed charges,All Other,401.8,,,401.8,Fee Schedule,,340.55,,,340.55,Fee Schedule,,2834.48,,,2834.48,Fee Schedule,,2834.48,,,2834.48,Fee Schedule,,2834.48,,,2834.48,Fee Schedule,,2834.48,,,2834.48,Fee Schedule,,292.43,,,292.43,Other,100% of Medicaid,292.43,,,292.43,Other,100% of Medicaid,292.43,,,292.43,Other,100% of Medicaid,292.43,,,292.43,Other,100% of Medicaid,657.97,,,657.97,Other,225% of Medicaid,447.42,,,447.42,Other,153% of Medicaid,657.97,,,657.97,Other,225% of Medicaid,409.4,,,409.4,Other,140% of Medicaid,657.97,,,657.97,Other,225% of Medicaid,760.32,,,760.32,Other,260% of Medicaid,947.48,,,947.48,Other,324% of Medicaid,628.73,,,628.73,Other,215% of Medicaid,628.73,,,628.73,Other,215% of Medicaid,365.54,,,365.54,Other,125% of Medicaid,184.93,3897.59,
HYSTEROSALPINGOGRAM W/ FY MOD,74740,CPT,FY,42674740,CDM,320,RC,,,both,,,1169,865.06,,,865.06,Other,150% of Medicare + 9.63% HCRA Surcharge,526.05,45,,526.05,percent of total billed charges,Critical Access Hospital RCC factor,262.41,,,262.41,Fee Schedule,,236.09,,,236.09,Fee Schedule,,409.69,,,409.69,Fee Schedule,,368.49,,,368.49,Fee Schedule,,348.28,,,348.28,Fee Schedule,,578.66,,,578.66,Other,110% of Medicare,311.77,,,311.77,Fee Schedule,,392,,,392,Other,186% of Medicaid,366.88,,,366.88,Fee Schedule,,724.78,,,724.78,Fee Schedule,,172.75,,,172.75,Fee Schedule,,366.88,,,366.88,Fee Schedule,,724.78,,,724.78,Fee Schedule,,324.93,,,324.93,Fee Schedule,,818.3,70,,818.3,percent of total billed charges,All Other,393.6,,,393.6,Fee Schedule,,333.6,,,333.6,Fee Schedule,,372.86,,,372.86,Fee Schedule,,372.86,,,372.86,Fee Schedule,,372.86,,,372.86,Fee Schedule,,372.86,,,372.86,Fee Schedule,,210.57,,,210.57,Other,100% of Medicaid,210.57,,,210.57,Other,100% of Medicaid,210.57,,,210.57,Other,100% of Medicaid,210.57,,,210.57,Other,100% of Medicaid,473.77,,,473.77,Other,225% of Medicaid,322.17,,,322.17,Other,153% of Medicaid,473.77,,,473.77,Other,225% of Medicaid,294.79,,,294.79,Other,140% of Medicaid,473.77,,,473.77,Other,225% of Medicaid,547.47,,,547.47,Other,260% of Medicaid,682.23,,,682.23,Other,324% of Medicaid,452.72,,,452.72,Other,215% of Medicaid,452.72,,,452.72,Other,215% of Medicaid,263.21,,,263.21,Other,125% of Medicaid,172.75,865.06,
SHUNTOGRAM W/ FY MOD,75809,CPT,FY,42675809,CDM,320,RC,,,both,,,667,493.58,,,493.58,Other,150% of Medicare + 9.63% HCRA Surcharge,300.15,45,,300.15,percent of total billed charges,Critical Access Hospital RCC factor,205.82,,,205.82,Fee Schedule,,185.17,,,185.17,Fee Schedule,,501.23,,,501.23,Fee Schedule,,450.82,,,450.82,Fee Schedule,,426.09,,,426.09,Fee Schedule,,330.17,,,330.17,Other,110% of Medicare,244.53,,,244.53,Fee Schedule,,392,,,392,Other,186% of Medicaid,287.76,,,287.76,Fee Schedule,,413.54,,,413.54,Fee Schedule,,135.49,,,135.49,Fee Schedule,,287.76,,,287.76,Fee Schedule,,413.54,,,413.54,Fee Schedule,,254.85,,,254.85,Fee Schedule,,466.9,70,,466.9,percent of total billed charges,All Other,291.92,,,291.92,Fee Schedule,,247.42,,,247.42,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,210.57,,,210.57,Other,100% of Medicaid,210.57,,,210.57,Other,100% of Medicaid,210.57,,,210.57,Other,100% of Medicaid,210.57,,,210.57,Other,100% of Medicaid,473.77,,,473.77,Other,225% of Medicaid,322.17,,,322.17,Other,153% of Medicaid,473.77,,,473.77,Other,225% of Medicaid,294.79,,,294.79,Other,140% of Medicaid,473.77,,,473.77,Other,225% of Medicaid,547.47,,,547.47,Other,260% of Medicaid,682.23,,,682.23,Other,324% of Medicaid,452.72,,,452.72,Other,215% of Medicaid,452.72,,,452.72,Other,215% of Medicaid,263.21,,,263.21,Other,125% of Medicaid,135.49,682.23,
VENOGRAM EXTREMITY UNIL W/ FY MOD,75820,CPT,FY,42675820,CDM,320,RC,,,both,,,3649,2700.27,,,2700.27,Other,150% of Medicare + 9.63% HCRA Surcharge,1642.05,45,,1642.05,percent of total billed charges,Critical Access Hospital RCC factor,205.82,,,205.82,Fee Schedule,,185.17,,,185.17,Fee Schedule,,611.11,,,611.11,Fee Schedule,,549.65,,,549.65,Fee Schedule,,519.5,,,519.5,Fee Schedule,,1806.26,,,1806.26,Other,110% of Medicare,244.53,,,244.53,Fee Schedule,,490,,,490,Other,186% of Medicaid,287.76,,,287.76,Fee Schedule,,2262.38,,,2262.38,Fee Schedule,,135.49,,,135.49,Fee Schedule,,287.76,,,287.76,Fee Schedule,,2262.38,,,2262.38,Fee Schedule,,254.85,,,254.85,Fee Schedule,,2554.3,70,,2554.3,percent of total billed charges,All Other,300.12,,,300.12,Fee Schedule,,254.37,,,254.37,Fee Schedule,,1008.82,,,1008.82,Fee Schedule,,1008.82,,,1008.82,Fee Schedule,,1008.82,,,1008.82,Fee Schedule,,1008.82,,,1008.82,Fee Schedule,,263.19,,,263.19,Other,100% of Medicaid,263.19,,,263.19,Other,100% of Medicaid,263.19,,,263.19,Other,100% of Medicaid,263.19,,,263.19,Other,100% of Medicaid,592.18,,,592.18,Other,225% of Medicaid,402.68,,,402.68,Other,153% of Medicaid,592.18,,,592.18,Other,225% of Medicaid,368.47,,,368.47,Other,140% of Medicaid,592.18,,,592.18,Other,225% of Medicaid,684.3,,,684.3,Other,260% of Medicaid,852.74,,,852.74,Other,324% of Medicaid,565.86,,,565.86,Other,215% of Medicaid,565.86,,,565.86,Other,215% of Medicaid,328.99,,,328.99,Other,125% of Medicaid,135.49,2700.27,
VENOGRAPHY EXTREMITY BILATERAL FY MOD,75822,CPT,FY,42675822,CDM,320,RC,,,both,,,3350,2479.01,,,2479.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1507.5,45,,1507.5,percent of total billed charges,Critical Access Hospital RCC factor,227.77,,,227.77,Fee Schedule,,204.92,,,204.92,Fee Schedule,,684.31,,,684.31,Fee Schedule,,615.49,,,615.49,Fee Schedule,,581.73,,,581.73,Fee Schedule,,1658.25,,,1658.25,Other,110% of Medicare,270.61,,,270.61,Fee Schedule,,490,,,490,Other,186% of Medicaid,318.44,,,318.44,Fee Schedule,,2077,,,2077,Fee Schedule,,149.94,,,149.94,Fee Schedule,,318.44,,,318.44,Fee Schedule,,2077,,,2077,Fee Schedule,,282.03,,,282.03,Fee Schedule,,2345,70,,2345,percent of total billed charges,All Other,323.08,,,323.08,Fee Schedule,,273.83,,,273.83,Fee Schedule,,2609.81,,,2609.81,Fee Schedule,,2609.81,,,2609.81,Fee Schedule,,2609.81,,,2609.81,Fee Schedule,,2609.81,,,2609.81,Fee Schedule,,263.19,,,263.19,Other,100% of Medicaid,263.19,,,263.19,Other,100% of Medicaid,263.19,,,263.19,Other,100% of Medicaid,263.19,,,263.19,Other,100% of Medicaid,592.18,,,592.18,Other,225% of Medicaid,402.68,,,402.68,Other,153% of Medicaid,592.18,,,592.18,Other,225% of Medicaid,368.47,,,368.47,Other,140% of Medicaid,592.18,,,592.18,Other,225% of Medicaid,684.3,,,684.3,Other,260% of Medicaid,852.74,,,852.74,Other,324% of Medicaid,565.86,,,565.86,Other,215% of Medicaid,565.86,,,565.86,Other,215% of Medicaid,328.99,,,328.99,Other,125% of Medicaid,149.94,2609.81,
VENOGRAPHY W SERIALOGRAPHY FY MOD,75827,CPT,FY,42675827,CDM,320,RC,,,both,,,3350,2479.01,,,2479.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1507.5,45,,1507.5,percent of total billed charges,Critical Access Hospital RCC factor,228.91,,,228.91,Fee Schedule,,205.95,,,205.95,Fee Schedule,,1032.13,,,1032.13,Fee Schedule,,928.33,,,928.33,Fee Schedule,,877.41,,,877.41,Fee Schedule,,1658.25,,,1658.25,Other,110% of Medicare,271.97,,,271.97,Fee Schedule,,490,,,490,Other,186% of Medicaid,320.05,,,320.05,Fee Schedule,,2077,,,2077,Fee Schedule,,150.7,,,150.7,Fee Schedule,,320.05,,,320.05,Fee Schedule,,2077,,,2077,Fee Schedule,,283.45,,,283.45,Fee Schedule,,2345,70,,2345,percent of total billed charges,All Other,329.64,,,329.64,Fee Schedule,,279.39,,,279.39,Fee Schedule,,1008.82,,,1008.82,Fee Schedule,,1008.82,,,1008.82,Fee Schedule,,1008.82,,,1008.82,Fee Schedule,,1008.82,,,1008.82,Fee Schedule,,263.19,,,263.19,Other,100% of Medicaid,263.19,,,263.19,Other,100% of Medicaid,263.19,,,263.19,Other,100% of Medicaid,263.19,,,263.19,Other,100% of Medicaid,592.18,,,592.18,Other,225% of Medicaid,402.68,,,402.68,Other,153% of Medicaid,592.18,,,592.18,Other,225% of Medicaid,368.47,,,368.47,Other,140% of Medicaid,592.18,,,592.18,Other,225% of Medicaid,684.3,,,684.3,Other,260% of Medicaid,852.74,,,852.74,Other,324% of Medicaid,565.86,,,565.86,Other,215% of Medicaid,565.86,,,565.86,Other,215% of Medicaid,328.99,,,328.99,Other,125% of Medicaid,150.7,2479.01,
REMOVE CVD LUMEN OBSTRUCT FY MOD,75902,CPT,FY,42675902,CDM,320,RC,,,both,,,406,300.44,,,300.44,Other,150% of Medicare + 9.63% HCRA Surcharge,182.7,45,,182.7,percent of total billed charges,Critical Access Hospital RCC factor,242.79,,,242.79,Fee Schedule,,218.44,,,218.44,Fee Schedule,,389.14,,,389.14,Fee Schedule,,350,,,350,Fee Schedule,,330.8,,,330.8,Fee Schedule,,200.97,,,200.97,Other,110% of Medicare,288.46,,,288.46,Fee Schedule,,544,,,544,Other,186% of Medicaid,339.45,,,339.45,Fee Schedule,,251.72,,,251.72,Fee Schedule,,159.83,,,159.83,Fee Schedule,,339.45,,,339.45,Fee Schedule,,251.72,,,251.72,Fee Schedule,,300.63,,,300.63,Fee Schedule,,284.2,70,,284.2,percent of total billed charges,All Other,370.64,,,370.64,Fee Schedule,,314.14,,,314.14,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,292.43,,,292.43,Other,100% of Medicaid,292.43,,,292.43,Other,100% of Medicaid,292.43,,,292.43,Other,100% of Medicaid,292.43,,,292.43,Other,100% of Medicaid,657.97,,,657.97,Other,225% of Medicaid,447.42,,,447.42,Other,153% of Medicaid,657.97,,,657.97,Other,225% of Medicaid,409.4,,,409.4,Other,140% of Medicaid,657.97,,,657.97,Other,225% of Medicaid,760.32,,,760.32,Other,260% of Medicaid,947.48,,,947.48,Other,324% of Medicaid,628.73,,,628.73,Other,215% of Medicaid,628.73,,,628.73,Other,215% of Medicaid,365.54,,,365.54,Other,125% of Medicaid,0.01,947.48,
XR CONTROL CATHETER CHANGE FY MOD,75984,CPT,FY,42675984,CDM,320,RC,,,both,,,590,436.6,,,436.6,Other,150% of Medicare + 9.63% HCRA Surcharge,265.5,45,,265.5,percent of total billed charges,Critical Access Hospital RCC factor,201.19,,,201.19,Fee Schedule,,181.01,,,181.01,Fee Schedule,,535.59,,,535.59,Fee Schedule,,481.73,,,481.73,Fee Schedule,,455.3,,,455.3,Fee Schedule,,292.05,,,292.05,Other,110% of Medicare,239.04,,,239.04,Fee Schedule,,544,,,544,Other,186% of Medicaid,281.29,,,281.29,Fee Schedule,,365.8,,,365.8,Fee Schedule,,132.45,,,132.45,Fee Schedule,,281.29,,,281.29,Fee Schedule,,365.8,,,365.8,Fee Schedule,,249.13,,,249.13,Fee Schedule,,413,70,,413,percent of total billed charges,All Other,295.2,,,295.2,Fee Schedule,,250.2,,,250.2,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,292.43,,,292.43,Other,100% of Medicaid,292.43,,,292.43,Other,100% of Medicaid,292.43,,,292.43,Other,100% of Medicaid,292.43,,,292.43,Other,100% of Medicaid,657.97,,,657.97,Other,225% of Medicaid,447.42,,,447.42,Other,153% of Medicaid,657.97,,,657.97,Other,225% of Medicaid,409.4,,,409.4,Other,140% of Medicaid,657.97,,,657.97,Other,225% of Medicaid,760.32,,,760.32,Other,260% of Medicaid,947.48,,,947.48,Other,324% of Medicaid,628.73,,,628.73,Other,215% of Medicaid,628.73,,,628.73,Other,215% of Medicaid,365.54,,,365.54,Other,125% of Medicaid,0.01,947.48,
FLUOROSCOPE EXAM =< 1 HR FY MOD,76000,CPT,FY,42676000,CDM,320,RC,,,both,,,527,389.98,,,389.98,Other,150% of Medicare + 9.63% HCRA Surcharge,237.15,45,,237.15,percent of total billed charges,Critical Access Hospital RCC factor,97.2,,,97.2,Fee Schedule,,87.45,,,87.45,Fee Schedule,,466.92,,,466.92,Fee Schedule,,419.96,,,419.96,Fee Schedule,,396.93,,,396.93,Fee Schedule,,260.87,,,260.87,Other,110% of Medicare,115.48,,,115.48,Fee Schedule,,392,,,392,Other,186% of Medicaid,135.9,,,135.9,Fee Schedule,,326.74,,,326.74,Fee Schedule,,63.99,,,63.99,Fee Schedule,,135.9,,,135.9,Fee Schedule,,326.74,,,326.74,Fee Schedule,,120.36,,,120.36,Fee Schedule,,368.9,70,,368.9,percent of total billed charges,All Other,136.12,,,136.12,Fee Schedule,,115.37,,,115.37,Fee Schedule,,372.86,,,372.86,Fee Schedule,,372.86,,,372.86,Fee Schedule,,372.86,,,372.86,Fee Schedule,,372.86,,,372.86,Fee Schedule,,210.57,,,210.57,Other,100% of Medicaid,210.57,,,210.57,Other,100% of Medicaid,210.57,,,210.57,Other,100% of Medicaid,210.57,,,210.57,Other,100% of Medicaid,473.77,,,473.77,Other,225% of Medicaid,322.17,,,322.17,Other,153% of Medicaid,473.77,,,473.77,Other,225% of Medicaid,294.79,,,294.79,Other,140% of Medicaid,473.77,,,473.77,Other,225% of Medicaid,547.47,,,547.47,Other,260% of Medicaid,682.23,,,682.23,Other,324% of Medicaid,452.72,,,452.72,Other,215% of Medicaid,452.72,,,452.72,Other,215% of Medicaid,263.21,,,263.21,Other,125% of Medicaid,63.99,682.23,
FLUOROSCOPE EXAM EXTENSIVE 1+ FY MOD,76001,CPT,FY,42676001,CDM,320,RC,,,both,,,825,610.5,,,610.5,Other,150% of Medicare + 9.63% HCRA Surcharge,371.25,45,,371.25,percent of total billed charges,Critical Access Hospital RCC factor,536.25,65,,536.25,percent of total billed charges,All Other,486.75,65,,486.75,percent of total billed charges,All Other,97.09,,,97.09,Fee Schedule,,97.09,,,97.09,Fee Schedule,,97.09,,,97.09,Fee Schedule,,408.38,,,408.38,Other,110% of Medicare,561,68,,561,percent of total billed charges,All Other,392,,,392,Other,186% of Medicaid,660,80,,660,percent of total billed charges,All Other,511.5,62,,511.5,percent of total billed charges,Lab and Radiology,453.75,83,,453.75,percent of total billed charges,All Other,660,80,,660,percent of total billed charges,All Other,511.5,62,,511.5,percent of total billed charges,Lab and Radiology,660,80,,660,percent of total billed charges,All Other,577.5,70,,577.5,percent of total billed charges,All Other,536.25,65,,536.25,percent of total billed charges,Default if not in Fee Schedule,536.25,65,,536.25,percent of total billed charges,Default if not in Fee Schedule,412.5,,,412.5,Fee Schedule,,412.5,,,412.5,Fee Schedule,,412.5,,,412.5,Fee Schedule,,412.5,,,412.5,Fee Schedule,,210.57,,,210.57,Other,100% of Medicaid,210.57,,,210.57,Other,100% of Medicaid,210.57,,,210.57,Other,100% of Medicaid,210.57,,,210.57,Other,100% of Medicaid,473.77,,,473.77,Other,225% of Medicaid,322.17,,,322.17,Other,153% of Medicaid,473.77,,,473.77,Other,225% of Medicaid,294.79,,,294.79,Other,140% of Medicaid,473.77,,,473.77,Other,225% of Medicaid,547.47,,,547.47,Other,260% of Medicaid,682.23,,,682.23,Other,324% of Medicaid,452.72,,,452.72,Other,215% of Medicaid,452.72,,,452.72,Other,215% of Medicaid,263.21,,,263.21,Other,125% of Medicaid,97.09,682.23,
NOSE TO RECTUM FOR FB CHILD FY MOD,76010,CPT,FY,42676010,CDM,320,RC,,,both,,,231,170.94,,,170.94,Other,150% of Medicare + 9.63% HCRA Surcharge,103.95,45,,103.95,percent of total billed charges,Critical Access Hospital RCC factor,72.96,,,72.96,Fee Schedule,,65.64,,,65.64,Fee Schedule,,125.95,,,125.95,Fee Schedule,,113.29,,,113.29,Fee Schedule,,107.07,,,107.07,Fee Schedule,,114.35,,,114.35,Other,110% of Medicare,86.68,,,86.68,Fee Schedule,,53,,,53,Other,186% of Medicaid,102,,,102,Fee Schedule,,143.22,,,143.22,Fee Schedule,,48.03,,,48.03,Fee Schedule,,102,,,102,Fee Schedule,,143.22,,,143.22,Fee Schedule,,90.34,,,90.34,Fee Schedule,,161.7,70,,161.7,percent of total billed charges,All Other,103.32,,,103.32,Fee Schedule,,87.57,,,87.57,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,170.94,
ABSCESS FISTULA/SINUS TRACT ST FY MOD,76080,CPT,FY,42676080,CDM,320,RC,,,both,,,1134,839.16,,,839.16,Other,150% of Medicare + 9.63% HCRA Surcharge,510.3,45,,510.3,percent of total billed charges,Critical Access Hospital RCC factor,122.62,,,122.62,Fee Schedule,,110.32,,,110.32,Fee Schedule,,240.36,,,240.36,Fee Schedule,,216.19,,,216.19,Fee Schedule,,204.33,,,204.33,Fee Schedule,,561.33,,,561.33,Other,110% of Medicare,145.69,,,145.69,Fee Schedule,,392,,,392,Other,186% of Medicaid,171.44,,,171.44,Fee Schedule,,703.08,,,703.08,Fee Schedule,,80.72,,,80.72,Fee Schedule,,171.44,,,171.44,Fee Schedule,,703.08,,,703.08,Fee Schedule,,151.84,,,151.84,Fee Schedule,,793.8,70,,793.8,percent of total billed charges,All Other,175.48,,,175.48,Fee Schedule,,148.73,,,148.73,Fee Schedule,,770.53,,,770.53,Fee Schedule,,770.53,,,770.53,Fee Schedule,,770.53,,,770.53,Fee Schedule,,770.53,,,770.53,Fee Schedule,,210.57,,,210.57,Other,100% of Medicaid,210.57,,,210.57,Other,100% of Medicaid,210.57,,,210.57,Other,100% of Medicaid,210.57,,,210.57,Other,100% of Medicaid,473.77,,,473.77,Other,225% of Medicaid,322.17,,,322.17,Other,153% of Medicaid,473.77,,,473.77,Other,225% of Medicaid,294.79,,,294.79,Other,140% of Medicaid,473.77,,,473.77,Other,225% of Medicaid,547.47,,,547.47,Other,260% of Medicaid,682.23,,,682.23,Other,324% of Medicaid,452.72,,,452.72,Other,215% of Medicaid,452.72,,,452.72,Other,215% of Medicaid,263.21,,,263.21,Other,125% of Medicaid,80.72,839.16,
TOMOGRAM FY MOD,76100,CPT,FY,42676100,CDM,320,RC,,,both,,,816,603.84,,,603.84,Other,150% of Medicare + 9.63% HCRA Surcharge,367.2,45,,367.2,percent of total billed charges,Critical Access Hospital RCC factor,215.04,,,215.04,Fee Schedule,,193.47,,,193.47,Fee Schedule,,510.4,,,510.4,Fee Schedule,,459.07,,,459.07,Fee Schedule,,433.89,,,433.89,Fee Schedule,,403.92,,,403.92,Other,110% of Medicare,255.48,,,255.48,Fee Schedule,,53,,,53,Other,186% of Medicaid,300.65,,,300.65,Fee Schedule,,505.92,,,505.92,Fee Schedule,,141.56,,,141.56,Fee Schedule,,300.65,,,300.65,Fee Schedule,,505.92,,,505.92,Fee Schedule,,266.27,,,266.27,Fee Schedule,,571.2,70,,571.2,percent of total billed charges,All Other,305.04,,,305.04,Fee Schedule,,258.54,,,258.54,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,603.84,
FLUOROSCOPIC GUIDANCE FOR CV FY MOD,77001,CPT,FY,42677001,CDM,320,RC,,,both,,,581,429.94,,,429.94,Other,150% of Medicare + 9.63% HCRA Surcharge,261.45,45,,261.45,percent of total billed charges,Critical Access Hospital RCC factor,280.91,,,280.91,Fee Schedule,,252.73,,,252.73,Fee Schedule,,643.1,,,643.1,Fee Schedule,,578.42,,,578.42,Fee Schedule,,546.69,,,546.69,Fee Schedule,,287.6,,,287.6,Other,110% of Medicare,333.75,,,333.75,Fee Schedule,,544,,,544,Other,186% of Medicaid,392.75,,,392.75,Fee Schedule,,360.22,,,360.22,Fee Schedule,,184.93,,,184.93,Fee Schedule,,392.75,,,392.75,Fee Schedule,,360.22,,,360.22,Fee Schedule,,347.84,,,347.84,Fee Schedule,,406.7,70,,406.7,percent of total billed charges,All Other,416.56,,,416.56,Fee Schedule,,353.06,,,353.06,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,292.43,,,292.43,Other,100% of Medicaid,292.43,,,292.43,Other,100% of Medicaid,292.43,,,292.43,Other,100% of Medicaid,292.43,,,292.43,Other,100% of Medicaid,657.97,,,657.97,Other,225% of Medicaid,447.42,,,447.42,Other,153% of Medicaid,657.97,,,657.97,Other,225% of Medicaid,409.4,,,409.4,Other,140% of Medicaid,657.97,,,657.97,Other,225% of Medicaid,760.32,,,760.32,Other,260% of Medicaid,947.48,,,947.48,Other,324% of Medicaid,628.73,,,628.73,Other,215% of Medicaid,628.73,,,628.73,Other,215% of Medicaid,365.54,,,365.54,Other,125% of Medicaid,0.01,947.48,
NEEDLE LOCALIZATION BY XR FY MOD,77002,CPT,FY,42677002,CDM,320,RC,,,both,,,577,426.98,,,426.98,Other,150% of Medicare + 9.63% HCRA Surcharge,259.65,45,,259.65,percent of total billed charges,Critical Access Hospital RCC factor,310.93,,,310.93,Fee Schedule,,279.74,,,279.74,Fee Schedule,,325.05,,,325.05,Fee Schedule,,292.36,,,292.36,Fee Schedule,,276.33,,,276.33,Fee Schedule,,285.62,,,285.62,Other,110% of Medicare,369.41,,,369.41,Fee Schedule,,544,,,544,Other,186% of Medicaid,434.72,,,434.72,Fee Schedule,,357.74,,,357.74,Fee Schedule,,204.69,,,204.69,Fee Schedule,,434.72,,,434.72,Fee Schedule,,357.74,,,357.74,Fee Schedule,,385.01,,,385.01,Fee Schedule,,403.9,70,,403.9,percent of total billed charges,All Other,441.16,,,441.16,Fee Schedule,,373.91,,,373.91,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,292.43,,,292.43,Other,100% of Medicaid,292.43,,,292.43,Other,100% of Medicaid,292.43,,,292.43,Other,100% of Medicaid,292.43,,,292.43,Other,100% of Medicaid,657.97,,,657.97,Other,225% of Medicaid,447.42,,,447.42,Other,153% of Medicaid,657.97,,,657.97,Other,225% of Medicaid,409.4,,,409.4,Other,140% of Medicaid,657.97,,,657.97,Other,225% of Medicaid,760.32,,,760.32,Other,260% of Medicaid,947.48,,,947.48,Other,324% of Medicaid,628.73,,,628.73,Other,215% of Medicaid,628.73,,,628.73,Other,215% of Medicaid,365.54,,,365.54,Other,125% of Medicaid,0.01,947.48,
FLUOROGUIDE FOR SPINE INJECT FY MOD,77003,CPT,FY,42677003,CDM,320,RC,,,both,,,618,457.32,,,457.32,Other,150% of Medicare + 9.63% HCRA Surcharge,278.1,45,,278.1,percent of total billed charges,Critical Access Hospital RCC factor,267.03,,,267.03,Fee Schedule,,240.25,,,240.25,Fee Schedule,,222.08,,,222.08,Fee Schedule,,199.74,,,199.74,Fee Schedule,,188.79,,,188.79,Fee Schedule,,305.91,,,305.91,Other,110% of Medicare,317.26,,,317.26,Fee Schedule,,544,,,544,Other,186% of Medicaid,373.35,,,373.35,Fee Schedule,,383.16,,,383.16,Fee Schedule,,175.79,,,175.79,Fee Schedule,,373.35,,,373.35,Fee Schedule,,383.16,,,383.16,Fee Schedule,,330.65,,,330.65,Fee Schedule,,432.6,70,,432.6,percent of total billed charges,All Other,378.84,,,378.84,Fee Schedule,,321.09,,,321.09,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,292.43,,,292.43,Other,100% of Medicaid,292.43,,,292.43,Other,100% of Medicaid,292.43,,,292.43,Other,100% of Medicaid,292.43,,,292.43,Other,100% of Medicaid,657.97,,,657.97,Other,225% of Medicaid,447.42,,,447.42,Other,153% of Medicaid,657.97,,,657.97,Other,225% of Medicaid,409.4,,,409.4,Other,140% of Medicaid,657.97,,,657.97,Other,225% of Medicaid,760.32,,,760.32,Other,260% of Medicaid,947.48,,,947.48,Other,324% of Medicaid,628.73,,,628.73,Other,215% of Medicaid,628.73,,,628.73,Other,215% of Medicaid,365.54,,,365.54,Other,125% of Medicaid,0.01,947.48,
XR FOR BONE AGE FY MOD,77072,CPT,FY,42677072,CDM,320,RC,,,both,,,242,179.08,,,179.08,Other,150% of Medicare + 9.63% HCRA Surcharge,108.9,45,,108.9,percent of total billed charges,Critical Access Hospital RCC factor,59.08,,,59.08,Fee Schedule,,53.15,,,53.15,Fee Schedule,,96.23,,,96.23,Fee Schedule,,86.55,,,86.55,Fee Schedule,,81.8,,,81.8,Fee Schedule,,119.79,,,119.79,Other,110% of Medicare,70.19,,,70.19,Fee Schedule,,53,,,53,Other,186% of Medicaid,82.6,,,82.6,Fee Schedule,,150.04,,,150.04,Fee Schedule,,38.89,,,38.89,Fee Schedule,,82.6,,,82.6,Fee Schedule,,150.04,,,150.04,Fee Schedule,,73.15,,,73.15,Fee Schedule,,169.4,70,,169.4,percent of total billed charges,All Other,83.64,,,83.64,Fee Schedule,,70.89,,,70.89,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,179.33,
XR BONE SURVEY LIMITED FY MOD,77074,CPT,FY,42677074,CDM,320,RC,,,both,,,331,244.94,,,244.94,Other,150% of Medicare + 9.63% HCRA Surcharge,148.95,45,,148.95,percent of total billed charges,Critical Access Hospital RCC factor,154.97,,,154.97,Fee Schedule,,139.42,,,139.42,Fee Schedule,,320.47,,,320.47,Fee Schedule,,288.24,,,288.24,Fee Schedule,,272.43,,,272.43,Fee Schedule,,163.85,,,163.85,Other,110% of Medicare,184.12,,,184.12,Fee Schedule,,53,,,53,Other,186% of Medicaid,216.67,,,216.67,Fee Schedule,,205.22,,,205.22,Fee Schedule,,102.02,,,102.02,Fee Schedule,,216.67,,,216.67,Fee Schedule,,205.22,,,205.22,Fee Schedule,,191.89,,,191.89,Fee Schedule,,231.7,70,,231.7,percent of total billed charges,All Other,218.12,,,218.12,Fee Schedule,,184.87,,,184.87,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,320.47,
XR BONE SURVEY COMPLETE FY MOD,77075,CPT,FY,42677075,CDM,320,RC,,,both,,,534,395.16,,,395.16,Other,150% of Medicare + 9.63% HCRA Surcharge,240.3,45,,240.3,percent of total billed charges,Critical Access Hospital RCC factor,255.65,,,255.65,Fee Schedule,,230,,,230,Fee Schedule,,510.4,,,510.4,Fee Schedule,,459.07,,,459.07,Fee Schedule,,433.89,,,433.89,Fee Schedule,,264.33,,,264.33,Other,110% of Medicare,303.73,,,303.73,Fee Schedule,,392,,,392,Other,186% of Medicaid,357.42,,,357.42,Fee Schedule,,331.08,,,331.08,Fee Schedule,,168.29,,,168.29,Fee Schedule,,357.42,,,357.42,Fee Schedule,,331.08,,,331.08,Fee Schedule,,316.55,,,316.55,Fee Schedule,,373.8,70,,373.8,percent of total billed charges,All Other,359.16,,,359.16,Fee Schedule,,304.41,,,304.41,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,210.57,,,210.57,Other,100% of Medicaid,210.57,,,210.57,Other,100% of Medicaid,210.57,,,210.57,Other,100% of Medicaid,210.57,,,210.57,Other,100% of Medicaid,473.77,,,473.77,Other,225% of Medicaid,322.17,,,322.17,Other,153% of Medicaid,473.77,,,473.77,Other,225% of Medicaid,294.79,,,294.79,Other,140% of Medicaid,473.77,,,473.77,Other,225% of Medicaid,547.47,,,547.47,Other,260% of Medicaid,682.23,,,682.23,Other,324% of Medicaid,452.72,,,452.72,Other,215% of Medicaid,452.72,,,452.72,Other,215% of Medicaid,263.21,,,263.21,Other,125% of Medicaid,168.29,682.23,
XR BONE SURVEY INFANT FY MOD,77076,CPT,FY,42677076,CDM,320,RC,,,both,,,510,377.4,,,377.4,Other,150% of Medicare + 9.63% HCRA Surcharge,229.5,45,,229.5,percent of total billed charges,Critical Access Hospital RCC factor,257.98,,,257.98,Fee Schedule,,232.1,,,232.1,Fee Schedule,,448.64,,,448.64,Fee Schedule,,403.52,,,403.52,Fee Schedule,,381.38,,,381.38,Fee Schedule,,252.45,,,252.45,Other,110% of Medicare,306.5,,,306.5,Fee Schedule,,53,,,53,Other,186% of Medicaid,360.68,,,360.68,Fee Schedule,,316.2,,,316.2,Fee Schedule,,169.83,,,169.83,Fee Schedule,,360.68,,,360.68,Fee Schedule,,316.2,,,316.2,Fee Schedule,,319.44,,,319.44,Fee Schedule,,357,70,,357,percent of total billed charges,All Other,362.44,,,362.44,Fee Schedule,,307.19,,,307.19,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,448.64,
XR EYE DETECT FOREIGN BODY FY MOD,70030,CPT,FYLT,42770030,CDM,320,RC,,,both,,,241,178.34,,,178.34,Other,150% of Medicare + 9.63% HCRA Surcharge,108.45,45,,108.45,percent of total billed charges,Critical Access Hospital RCC factor,84.5,,,84.5,Fee Schedule,,76.03,,,76.03,Fee Schedule,,137.39,,,137.39,Fee Schedule,,123.57,,,123.57,Fee Schedule,,116.79,,,116.79,Fee Schedule,,119.3,,,119.3,Other,110% of Medicare,100.4,,,100.4,Fee Schedule,,53,,,53,Other,186% of Medicaid,118.15,,,118.15,Fee Schedule,,149.42,,,149.42,Fee Schedule,,55.63,,,55.63,Fee Schedule,,118.15,,,118.15,Fee Schedule,,149.42,,,149.42,Fee Schedule,,104.64,,,104.64,Fee Schedule,,168.7,70,,168.7,percent of total billed charges,All Other,116.44,,,116.44,Fee Schedule,,98.69,,,98.69,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,178.34,
XR RIBS 2 VIEWS LEFT FY MOD,71100,CPT,FYLT,42771100,CDM,320,RC,,,both,,,437,323.38,,,323.38,Other,150% of Medicare + 9.63% HCRA Surcharge,196.65,45,,196.65,percent of total billed charges,Critical Access Hospital RCC factor,91.43,,,91.43,Fee Schedule,,82.25,,,82.25,Fee Schedule,,146.56,,,146.56,Fee Schedule,,131.82,,,131.82,Fee Schedule,,124.59,,,124.59,Fee Schedule,,216.32,,,216.32,Other,110% of Medicare,108.62,,,108.62,Fee Schedule,,53,,,53,Other,186% of Medicaid,127.82,,,127.82,Fee Schedule,,270.94,,,270.94,Fee Schedule,,60.19,,,60.19,Fee Schedule,,127.82,,,127.82,Fee Schedule,,270.94,,,270.94,Fee Schedule,,113.21,,,113.21,Fee Schedule,,305.9,70,,305.9,percent of total billed charges,All Other,127.92,,,127.92,Fee Schedule,,108.42,,,108.42,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,323.38,
XR RIBS 3 VIEWS + CXR LT FY MOD,71101,CPT,FYLT,42771101,CDM,320,RC,,,both,,,437,323.38,,,323.38,Other,150% of Medicare + 9.63% HCRA Surcharge,196.65,45,,196.65,percent of total billed charges,Critical Access Hospital RCC factor,102.97,,,102.97,Fee Schedule,,92.64,,,92.64,Fee Schedule,,178.6,,,178.6,Fee Schedule,,160.64,,,160.64,Fee Schedule,,151.83,,,151.83,Fee Schedule,,216.32,,,216.32,Other,110% of Medicare,122.34,,,122.34,Fee Schedule,,53,,,53,Other,186% of Medicaid,143.97,,,143.97,Fee Schedule,,270.94,,,270.94,Fee Schedule,,67.79,,,67.79,Fee Schedule,,143.97,,,143.97,Fee Schedule,,270.94,,,270.94,Fee Schedule,,127.51,,,127.51,Fee Schedule,,305.9,70,,305.9,percent of total billed charges,All Other,144.32,,,144.32,Fee Schedule,,122.32,,,122.32,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,323.38,
XR CLAVICLE LEFT FY MOD,73000,CPT,FYLT,42773000,CDM,320,RC,,,both,,,373,276.02,,,276.02,Other,150% of Medicare + 9.63% HCRA Surcharge,167.85,45,,167.85,percent of total billed charges,Critical Access Hospital RCC factor,85.65,,,85.65,Fee Schedule,,77.06,,,77.06,Fee Schedule,,139.71,,,139.71,Fee Schedule,,125.66,,,125.66,Fee Schedule,,118.76,,,118.76,Fee Schedule,,184.64,,,184.64,Other,110% of Medicare,101.76,,,101.76,Fee Schedule,,53,,,53,Other,186% of Medicaid,119.75,,,119.75,Fee Schedule,,231.26,,,231.26,Fee Schedule,,56.39,,,56.39,Fee Schedule,,119.75,,,119.75,Fee Schedule,,231.26,,,231.26,Fee Schedule,,106.06,,,106.06,Fee Schedule,,261.1,70,,261.1,percent of total billed charges,All Other,118.08,,,118.08,Fee Schedule,,100.08,,,100.08,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,276.02,
XR SCAPULA LEFT FY MOD,73010,CPT,FYLT,42773010,CDM,320,RC,,,both,,,242,179.08,,,179.08,Other,150% of Medicare + 9.63% HCRA Surcharge,108.9,45,,108.9,percent of total billed charges,Critical Access Hospital RCC factor,53.3,,,53.3,Fee Schedule,,47.96,,,47.96,Fee Schedule,,144.29,,,144.29,Fee Schedule,,129.78,,,129.78,Fee Schedule,,122.66,,,122.66,Fee Schedule,,119.79,,,119.79,Other,110% of Medicare,63.33,,,63.33,Fee Schedule,,53,,,53,Other,186% of Medicaid,74.53,,,74.53,Fee Schedule,,150.04,,,150.04,Fee Schedule,,35.09,,,35.09,Fee Schedule,,74.53,,,74.53,Fee Schedule,,150.04,,,150.04,Fee Schedule,,66,,,66,Fee Schedule,,169.4,70,,169.4,percent of total billed charges,All Other,73.8,,,73.8,Fee Schedule,,62.55,,,62.55,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,179.33,
XR SHOULDER 1 V LT FY MOD,73020,CPT,FYLT,42773020,CDM,320,RC,,,both,,,231,170.94,,,170.94,Other,150% of Medicare + 9.63% HCRA Surcharge,103.95,45,,103.95,percent of total billed charges,Critical Access Hospital RCC factor,49.86,,,49.86,Fee Schedule,,44.86,,,44.86,Fee Schedule,,109.93,,,109.93,Fee Schedule,,98.88,,,98.88,Fee Schedule,,93.45,,,93.45,Fee Schedule,,114.35,,,114.35,Other,110% of Medicare,59.24,,,59.24,Fee Schedule,,53,,,53,Other,186% of Medicaid,69.71,,,69.71,Fee Schedule,,143.22,,,143.22,Fee Schedule,,32.82,,,32.82,Fee Schedule,,69.71,,,69.71,Fee Schedule,,143.22,,,143.22,Fee Schedule,,61.74,,,61.74,Fee Schedule,,161.7,70,,161.7,percent of total billed charges,All Other,68.88,,,68.88,Fee Schedule,,58.38,,,58.38,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,170.94,
XR SHOULDER 2 VIEWS OR MO LT FY MOD,73030,CPT,FYLT,42773030,CDM,320,RC,,,both,,,407,301.18,,,301.18,Other,150% of Medicare + 9.63% HCRA Surcharge,183.15,45,,183.15,percent of total billed charges,Critical Access Hospital RCC factor,90.28,,,90.28,Fee Schedule,,81.22,,,81.22,Fee Schedule,,141.97,,,141.97,Fee Schedule,,127.7,,,127.7,Fee Schedule,,120.69,,,120.69,Fee Schedule,,201.47,,,201.47,Other,110% of Medicare,107.26,,,107.26,Fee Schedule,,53,,,53,Other,186% of Medicaid,126.22,,,126.22,Fee Schedule,,252.34,,,252.34,Fee Schedule,,59.43,,,59.43,Fee Schedule,,126.22,,,126.22,Fee Schedule,,252.34,,,252.34,Fee Schedule,,111.79,,,111.79,Fee Schedule,,284.9,70,,284.9,percent of total billed charges,All Other,124.64,,,124.64,Fee Schedule,,105.64,,,105.64,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,301.18,
XR HUMERUS LEFT FY MOD,73060,CPT,FYLT,42773060,CDM,320,RC,,,both,,,373,276.02,,,276.02,Other,150% of Medicare + 9.63% HCRA Surcharge,167.85,45,,167.85,percent of total billed charges,Critical Access Hospital RCC factor,84.5,,,84.5,Fee Schedule,,76.03,,,76.03,Fee Schedule,,139.71,,,139.71,Fee Schedule,,125.66,,,125.66,Fee Schedule,,118.76,,,118.76,Fee Schedule,,184.64,,,184.64,Other,110% of Medicare,100.4,,,100.4,Fee Schedule,,53,,,53,Other,186% of Medicaid,118.15,,,118.15,Fee Schedule,,231.26,,,231.26,Fee Schedule,,55.63,,,55.63,Fee Schedule,,118.15,,,118.15,Fee Schedule,,231.26,,,231.26,Fee Schedule,,104.64,,,104.64,Fee Schedule,,261.1,70,,261.1,percent of total billed charges,All Other,118.08,,,118.08,Fee Schedule,,100.08,,,100.08,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,276.02,
XR ELBOW 2 VIEW LEFT FY MOD,73070,CPT,FYLT,42773070,CDM,320,RC,,,both,,,231,170.94,,,170.94,Other,150% of Medicare + 9.63% HCRA Surcharge,103.95,45,,103.95,percent of total billed charges,Critical Access Hospital RCC factor,74.1,,,74.1,Fee Schedule,,66.67,,,66.67,Fee Schedule,,139.71,,,139.71,Fee Schedule,,125.66,,,125.66,Fee Schedule,,118.76,,,118.76,Fee Schedule,,114.35,,,114.35,Other,110% of Medicare,88.04,,,88.04,Fee Schedule,,53,,,53,Other,186% of Medicaid,103.61,,,103.61,Fee Schedule,,143.22,,,143.22,Fee Schedule,,48.78,,,48.78,Fee Schedule,,103.61,,,103.61,Fee Schedule,,143.22,,,143.22,Fee Schedule,,91.76,,,91.76,Fee Schedule,,161.7,70,,161.7,percent of total billed charges,All Other,103.32,,,103.32,Fee Schedule,,87.57,,,87.57,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,170.94,
XR ELBOW 3 VIEWS LT FY MOD,73080,CPT,FYLT,42773080,CDM,320,RC,,,both,,,392,290.08,,,290.08,Other,150% of Medicare + 9.63% HCRA Surcharge,176.4,45,,176.4,percent of total billed charges,Critical Access Hospital RCC factor,85.65,,,85.65,Fee Schedule,,77.06,,,77.06,Fee Schedule,,174.02,,,174.02,Fee Schedule,,156.51,,,156.51,Fee Schedule,,147.93,,,147.93,Fee Schedule,,194.04,,,194.04,Other,110% of Medicare,101.76,,,101.76,Fee Schedule,,53,,,53,Other,186% of Medicaid,119.75,,,119.75,Fee Schedule,,243.04,,,243.04,Fee Schedule,,56.39,,,56.39,Fee Schedule,,119.75,,,119.75,Fee Schedule,,243.04,,,243.04,Fee Schedule,,106.06,,,106.06,Fee Schedule,,274.4,70,,274.4,percent of total billed charges,All Other,118.08,,,118.08,Fee Schedule,,100.08,,,100.08,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,290.08,
XR ARTHROGRAM ELBOW LT FY MOD,73085,CPT,FYLT,42773085,CDM,320,RC,,,both,,,1199,887.26,,,887.26,Other,150% of Medicare + 9.63% HCRA Surcharge,539.55,45,,539.55,percent of total billed charges,Critical Access Hospital RCC factor,258.96,,,258.96,Fee Schedule,,232.99,,,232.99,Fee Schedule,,476.09,,,476.09,Fee Schedule,,428.21,,,428.21,Fee Schedule,,404.72,,,404.72,Fee Schedule,,593.51,,,593.51,Other,110% of Medicare,307.67,,,307.67,Fee Schedule,,392,,,392,Other,186% of Medicaid,362.06,,,362.06,Fee Schedule,,743.38,,,743.38,Fee Schedule,,170.48,,,170.48,Fee Schedule,,362.06,,,362.06,Fee Schedule,,743.38,,,743.38,Fee Schedule,,320.66,,,320.66,Fee Schedule,,839.3,70,,839.3,percent of total billed charges,All Other,424.76,,,424.76,Fee Schedule,,360.01,,,360.01,Fee Schedule,,610.96,,,610.96,Fee Schedule,,610.96,,,610.96,Fee Schedule,,610.96,,,610.96,Fee Schedule,,610.96,,,610.96,Fee Schedule,,210.57,,,210.57,Other,100% of Medicaid,210.57,,,210.57,Other,100% of Medicaid,210.57,,,210.57,Other,100% of Medicaid,210.57,,,210.57,Other,100% of Medicaid,473.77,,,473.77,Other,225% of Medicaid,322.17,,,322.17,Other,153% of Medicaid,473.77,,,473.77,Other,225% of Medicaid,294.79,,,294.79,Other,140% of Medicaid,473.77,,,473.77,Other,225% of Medicaid,547.47,,,547.47,Other,260% of Medicaid,682.23,,,682.23,Other,324% of Medicaid,452.72,,,452.72,Other,215% of Medicaid,452.72,,,452.72,Other,215% of Medicaid,263.21,,,263.21,Other,125% of Medicaid,170.48,887.26,
XR FOREARM LT FY MOD,73090,CPT,FYLT,42773090,CDM,320,RC,,,both,,,334,247.16,,,247.16,Other,150% of Medicare + 9.63% HCRA Surcharge,150.3,45,,150.3,percent of total billed charges,Critical Access Hospital RCC factor,75.25,,,75.25,Fee Schedule,,67.7,,,67.7,Fee Schedule,,135.12,,,135.12,Fee Schedule,,121.53,,,121.53,Fee Schedule,,114.87,,,114.87,Fee Schedule,,165.33,,,165.33,Other,110% of Medicare,89.41,,,89.41,Fee Schedule,,53,,,53,Other,186% of Medicaid,105.21,,,105.21,Fee Schedule,,207.08,,,207.08,Fee Schedule,,49.54,,,49.54,Fee Schedule,,105.21,,,105.21,Fee Schedule,,207.08,,,207.08,Fee Schedule,,93.18,,,93.18,Fee Schedule,,233.8,70,,233.8,percent of total billed charges,All Other,104.96,,,104.96,Fee Schedule,,88.96,,,88.96,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,247.16,
XR UPPER EXT CHILD 2 V LT FY MOD,73092,CPT,FYLT,42773092,CDM,320,RC,,,both,,,242,179.08,,,179.08,Other,150% of Medicare + 9.63% HCRA Surcharge,108.9,45,,108.9,percent of total billed charges,Critical Access Hospital RCC factor,83.35,,,83.35,Fee Schedule,,74.99,,,74.99,Fee Schedule,,153.41,,,153.41,Fee Schedule,,137.98,,,137.98,Fee Schedule,,130.41,,,130.41,Fee Schedule,,119.79,,,119.79,Other,110% of Medicare,99.03,,,99.03,Fee Schedule,,53,,,53,Other,186% of Medicaid,116.54,,,116.54,Fee Schedule,,150.04,,,150.04,Fee Schedule,,54.87,,,54.87,Fee Schedule,,116.54,,,116.54,Fee Schedule,,150.04,,,150.04,Fee Schedule,,103.21,,,103.21,Fee Schedule,,169.4,70,,169.4,percent of total billed charges,All Other,118.08,,,118.08,Fee Schedule,,100.08,,,100.08,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,179.33,
XR WRIST 2 VIEWS LT FYMOD,73100,CPT,FYLT,42773100,CDM,320,RC,,,both,,,231,170.94,,,170.94,Other,150% of Medicare + 9.63% HCRA Surcharge,103.95,45,,103.95,percent of total billed charges,Critical Access Hospital RCC factor,90.28,,,90.28,Fee Schedule,,81.22,,,81.22,Fee Schedule,,148.82,,,148.82,Fee Schedule,,133.86,,,133.86,Fee Schedule,,126.52,,,126.52,Fee Schedule,,114.35,,,114.35,Other,110% of Medicare,107.26,,,107.26,Fee Schedule,,53,,,53,Other,186% of Medicaid,126.22,,,126.22,Fee Schedule,,143.22,,,143.22,Fee Schedule,,59.43,,,59.43,Fee Schedule,,126.22,,,126.22,Fee Schedule,,143.22,,,143.22,Fee Schedule,,111.79,,,111.79,Fee Schedule,,161.7,70,,161.7,percent of total billed charges,All Other,126.28,,,126.28,Fee Schedule,,107.03,,,107.03,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,170.94,
XR WRIST 3+ VIEWS LT FY MOD,73110,CPT,FYLT,42773110,CDM,320,RC,,,both,,,330,244.2,,,244.2,Other,150% of Medicare + 9.63% HCRA Surcharge,148.5,45,,148.5,percent of total billed charges,Critical Access Hospital RCC factor,114.55,,,114.55,Fee Schedule,,103.06,,,103.06,Fee Schedule,,187.77,,,187.77,Fee Schedule,,168.89,,,168.89,Fee Schedule,,159.62,,,159.62,Fee Schedule,,163.35,,,163.35,Other,110% of Medicare,136.1,,,136.1,Fee Schedule,,53,,,53,Other,186% of Medicaid,160.16,,,160.16,Fee Schedule,,204.6,,,204.6,Fee Schedule,,75.41,,,75.41,Fee Schedule,,160.16,,,160.16,Fee Schedule,,204.6,,,204.6,Fee Schedule,,141.84,,,141.84,Fee Schedule,,231,70,,231,percent of total billed charges,All Other,159.08,,,159.08,Fee Schedule,,134.83,,,134.83,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,244.2,
XR HAND 2 VIEWS LT FY MOD,73120,CPT,FYLT,42773120,CDM,320,RC,,,both,,,242,179.08,,,179.08,Other,150% of Medicare + 9.63% HCRA Surcharge,108.9,45,,108.9,percent of total billed charges,Critical Access Hospital RCC factor,82.21,,,82.21,Fee Schedule,,73.96,,,73.96,Fee Schedule,,132.8,,,132.8,Fee Schedule,,119.45,,,119.45,Fee Schedule,,112.9,,,112.9,Fee Schedule,,119.79,,,119.79,Other,110% of Medicare,97.67,,,97.67,Fee Schedule,,53,,,53,Other,186% of Medicaid,114.93,,,114.93,Fee Schedule,,150.04,,,150.04,Fee Schedule,,54.12,,,54.12,Fee Schedule,,114.93,,,114.93,Fee Schedule,,150.04,,,150.04,Fee Schedule,,101.79,,,101.79,Fee Schedule,,169.4,70,,169.4,percent of total billed charges,All Other,113.16,,,113.16,Fee Schedule,,95.91,,,95.91,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,179.33,
XR HAND 3+ VIEWS LT FY MOD,73130,CPT,FYLT,42773130,CDM,320,RC,,,both,,,352,260.48,,,260.48,Other,150% of Medicare + 9.63% HCRA Surcharge,158.4,45,,158.4,percent of total billed charges,Critical Access Hospital RCC factor,100.68,,,100.68,Fee Schedule,,90.58,,,90.58,Fee Schedule,,160.26,,,160.26,Fee Schedule,,144.14,,,144.14,Fee Schedule,,136.24,,,136.24,Fee Schedule,,174.24,,,174.24,Other,110% of Medicare,119.61,,,119.61,Fee Schedule,,53,,,53,Other,186% of Medicaid,140.76,,,140.76,Fee Schedule,,218.24,,,218.24,Fee Schedule,,66.28,,,66.28,Fee Schedule,,140.76,,,140.76,Fee Schedule,,218.24,,,218.24,Fee Schedule,,124.66,,,124.66,Fee Schedule,,246.4,70,,246.4,percent of total billed charges,All Other,137.76,,,137.76,Fee Schedule,,116.76,,,116.76,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,260.48,
XR FINGER 2+ VIEWS LT FY MOD,73140,CPT,FYLT,42773140,CDM,320,RC,,,both,,,231,170.94,,,170.94,Other,150% of Medicare + 9.63% HCRA Surcharge,103.95,45,,103.95,percent of total billed charges,Critical Access Hospital RCC factor,109.93,,,109.93,Fee Schedule,,98.9,,,98.9,Fee Schedule,,167.16,,,167.16,Fee Schedule,,150.35,,,150.35,Fee Schedule,,142.11,,,142.11,Fee Schedule,,114.35,,,114.35,Other,110% of Medicare,130.6,,,130.6,Fee Schedule,,53,,,53,Other,186% of Medicaid,153.69,,,153.69,Fee Schedule,,143.22,,,143.22,Fee Schedule,,72.37,,,72.37,Fee Schedule,,153.69,,,153.69,Fee Schedule,,143.22,,,143.22,Fee Schedule,,136.12,,,136.12,Fee Schedule,,161.7,70,,161.7,percent of total billed charges,All Other,150.88,,,150.88,Fee Schedule,,127.88,,,127.88,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,170.94,
X-RAY EXAM HIP UNI 1 VIEW LT FY MOD,73501,CPT,FYLT,42773501,CDM,320,RC,,,both,,,237,175.38,,,175.38,Other,150% of Medicare + 9.63% HCRA Surcharge,106.65,45,,106.65,percent of total billed charges,Critical Access Hospital RCC factor,83.35,,,83.35,Fee Schedule,,74.99,,,74.99,Fee Schedule,,20.07,,,20.07,Fee Schedule,,20.07,,,20.07,Fee Schedule,,20.07,,,20.07,Fee Schedule,,117.32,,,117.32,Other,110% of Medicare,99.03,,,99.03,Fee Schedule,,53,,,53,Other,186% of Medicaid,116.54,,,116.54,Fee Schedule,,146.94,,,146.94,Fee Schedule,,54.87,,,54.87,Fee Schedule,,116.54,,,116.54,Fee Schedule,,146.94,,,146.94,Fee Schedule,,103.21,,,103.21,Fee Schedule,,165.9,70,,165.9,percent of total billed charges,All Other,114.8,,,114.8,Fee Schedule,,97.3,,,97.3,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,20.07,175.38,
X-RAY EXAM HIP UNI 2-3 VIEWS LT FY MOD,73502,CPT,FYLT,42773502,CDM,320,RC,,,both,,,268,198.32,,,198.32,Other,150% of Medicare + 9.63% HCRA Surcharge,120.6,45,,120.6,percent of total billed charges,Critical Access Hospital RCC factor,128.4,,,128.4,Fee Schedule,,115.52,,,115.52,Fee Schedule,,29.42,,,29.42,Fee Schedule,,29.42,,,29.42,Fee Schedule,,29.42,,,29.42,Fee Schedule,,132.66,,,132.66,Other,110% of Medicare,152.55,,,152.55,Fee Schedule,,53,,,53,Other,186% of Medicaid,179.52,,,179.52,Fee Schedule,,166.16,,,166.16,Fee Schedule,,84.53,,,84.53,Fee Schedule,,179.52,,,179.52,Fee Schedule,,166.16,,,166.16,Fee Schedule,,158.99,,,158.99,Fee Schedule,,187.6,70,,187.6,percent of total billed charges,All Other,177.12,,,177.12,Fee Schedule,,150.12,,,150.12,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,198.32,
X-RAY EXAM HIP UNI 4/> VIEWS LT FY MOD,73503,CPT,FYLT,42773503,CDM,320,RC,,,both,,,336,248.64,,,248.64,Other,150% of Medicare + 9.63% HCRA Surcharge,151.2,45,,151.2,percent of total billed charges,Critical Access Hospital RCC factor,163.07,,,163.07,Fee Schedule,,146.71,,,146.71,Fee Schedule,,36.34,,,36.34,Fee Schedule,,36.34,,,36.34,Fee Schedule,,36.34,,,36.34,Fee Schedule,,166.32,,,166.32,Other,110% of Medicare,193.74,,,193.74,Fee Schedule,,53,,,53,Other,186% of Medicaid,228,,,228,Fee Schedule,,208.32,,,208.32,Fee Schedule,,107.35,,,107.35,Fee Schedule,,228,,,228,Fee Schedule,,208.32,,,208.32,Fee Schedule,,201.92,,,201.92,Fee Schedule,,235.2,70,,235.2,percent of total billed charges,All Other,224.68,,,224.68,Fee Schedule,,190.43,,,190.43,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,248.64,
X-RAY EXAM OF FEMUR 1 LT FY MOD,73551,CPT,FYLT,42773551,CDM,320,RC,,,both,,,237,175.38,,,175.38,Other,150% of Medicare + 9.63% HCRA Surcharge,106.65,45,,106.65,percent of total billed charges,Critical Access Hospital RCC factor,74.1,,,74.1,Fee Schedule,,66.67,,,66.67,Fee Schedule,,19.04,,,19.04,Fee Schedule,,19.04,,,19.04,Fee Schedule,,19.04,,,19.04,Fee Schedule,,117.32,,,117.32,Other,110% of Medicare,88.04,,,88.04,Fee Schedule,,53,,,53,Other,186% of Medicaid,103.61,,,103.61,Fee Schedule,,146.94,,,146.94,Fee Schedule,,48.78,,,48.78,Fee Schedule,,103.61,,,103.61,Fee Schedule,,146.94,,,146.94,Fee Schedule,,91.76,,,91.76,Fee Schedule,,165.9,70,,165.9,percent of total billed charges,All Other,103.32,,,103.32,Fee Schedule,,87.57,,,87.57,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,19.04,175.38,
X-RAY EXAM OF FEMUR 2/> LT FY MOD,73552,CPT,FYLT,42773552,CDM,320,RC,,,both,,,237,175.38,,,175.38,Other,150% of Medicare + 9.63% HCRA Surcharge,106.65,45,,106.65,percent of total billed charges,Critical Access Hospital RCC factor,93.75,,,93.75,Fee Schedule,,84.35,,,84.35,Fee Schedule,,22.84,,,22.84,Fee Schedule,,22.84,,,22.84,Fee Schedule,,22.84,,,22.84,Fee Schedule,,117.32,,,117.32,Other,110% of Medicare,111.39,,,111.39,Fee Schedule,,53,,,53,Other,186% of Medicaid,131.08,,,131.08,Fee Schedule,,146.94,,,146.94,Fee Schedule,,61.72,,,61.72,Fee Schedule,,131.08,,,131.08,Fee Schedule,,146.94,,,146.94,Fee Schedule,,116.09,,,116.09,Fee Schedule,,165.9,70,,165.9,percent of total billed charges,All Other,129.56,,,129.56,Fee Schedule,,109.81,,,109.81,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,22.84,175.38,
XR KNEE 1 OR 2 VIEWS LT FY MOD,73560,CPT,FYLT,42773560,CDM,320,RC,,,both,,,407,301.18,,,301.18,Other,150% of Medicare + 9.63% HCRA Surcharge,183.15,45,,183.15,percent of total billed charges,Critical Access Hospital RCC factor,91.43,,,91.43,Fee Schedule,,82.25,,,82.25,Fee Schedule,,144.29,,,144.29,Fee Schedule,,129.78,,,129.78,Fee Schedule,,122.66,,,122.66,Fee Schedule,,201.47,,,201.47,Other,110% of Medicare,108.62,,,108.62,Fee Schedule,,53,,,53,Other,186% of Medicaid,127.82,,,127.82,Fee Schedule,,252.34,,,252.34,Fee Schedule,,60.19,,,60.19,Fee Schedule,,127.82,,,127.82,Fee Schedule,,252.34,,,252.34,Fee Schedule,,113.21,,,113.21,Fee Schedule,,284.9,70,,284.9,percent of total billed charges,All Other,127.92,,,127.92,Fee Schedule,,108.42,,,108.42,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,301.18,
XR KNEE 3 VIEWS LT FY MOD,73562,CPT,FYLT,42773562,CDM,320,RC,,,both,,,445,329.3,,,329.3,Other,150% of Medicare + 9.63% HCRA Surcharge,200.25,45,,200.25,percent of total billed charges,Critical Access Hospital RCC factor,111.08,,,111.08,Fee Schedule,,99.93,,,99.93,Fee Schedule,,180.87,,,180.87,Fee Schedule,,162.68,,,162.68,Fee Schedule,,153.75,,,153.75,Fee Schedule,,220.28,,,220.28,Other,110% of Medicare,131.97,,,131.97,Fee Schedule,,53,,,53,Other,186% of Medicaid,155.3,,,155.3,Fee Schedule,,275.9,,,275.9,Fee Schedule,,73.12,,,73.12,Fee Schedule,,155.3,,,155.3,Fee Schedule,,275.9,,,275.9,Fee Schedule,,137.54,,,137.54,Fee Schedule,,311.5,70,,311.5,percent of total billed charges,All Other,155.8,,,155.8,Fee Schedule,,132.05,,,132.05,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,329.3,
XR KNEE 4+ VIEWS LT FY MOD,73564,CPT,FYLT,42773564,CDM,320,RC,,,both,,,445,329.3,,,329.3,Other,150% of Medicare + 9.63% HCRA Surcharge,200.25,45,,200.25,percent of total billed charges,Critical Access Hospital RCC factor,126.1,,,126.1,Fee Schedule,,113.45,,,113.45,Fee Schedule,,206.06,,,206.06,Fee Schedule,,185.33,,,185.33,Fee Schedule,,175.17,,,175.17,Fee Schedule,,220.28,,,220.28,Other,110% of Medicare,149.82,,,149.82,Fee Schedule,,53,,,53,Other,186% of Medicaid,176.3,,,176.3,Fee Schedule,,275.9,,,275.9,Fee Schedule,,83.01,,,83.01,Fee Schedule,,176.3,,,176.3,Fee Schedule,,275.9,,,275.9,Fee Schedule,,156.14,,,156.14,Fee Schedule,,311.5,70,,311.5,percent of total billed charges,All Other,173.84,,,173.84,Fee Schedule,,147.34,,,147.34,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,329.3,
XR TIBIA/FIBULA 2 VIEWS LT FY MOD,73590,CPT,FYLT,42773590,CDM,320,RC,,,both,,,373,276.02,,,276.02,Other,150% of Medicare + 9.63% HCRA Surcharge,167.85,45,,167.85,percent of total billed charges,Critical Access Hospital RCC factor,83.35,,,83.35,Fee Schedule,,74.99,,,74.99,Fee Schedule,,130.54,,,130.54,Fee Schedule,,117.41,,,117.41,Fee Schedule,,110.97,,,110.97,Fee Schedule,,184.64,,,184.64,Other,110% of Medicare,99.03,,,99.03,Fee Schedule,,53,,,53,Other,186% of Medicaid,116.54,,,116.54,Fee Schedule,,231.26,,,231.26,Fee Schedule,,54.87,,,54.87,Fee Schedule,,116.54,,,116.54,Fee Schedule,,231.26,,,231.26,Fee Schedule,,103.21,,,103.21,Fee Schedule,,261.1,70,,261.1,percent of total billed charges,All Other,116.44,,,116.44,Fee Schedule,,98.69,,,98.69,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,276.02,
XR LEG INFANT 2 VIEWS LT FY MOD,73592,CPT,FYLT,42773592,CDM,320,RC,,,both,,,231,170.94,,,170.94,Other,150% of Medicare + 9.63% HCRA Surcharge,103.95,45,,103.95,percent of total billed charges,Critical Access Hospital RCC factor,83.35,,,83.35,Fee Schedule,,74.99,,,74.99,Fee Schedule,,155.73,,,155.73,Fee Schedule,,140.07,,,140.07,Fee Schedule,,132.38,,,132.38,Fee Schedule,,114.35,,,114.35,Other,110% of Medicare,99.03,,,99.03,Fee Schedule,,53,,,53,Other,186% of Medicaid,116.54,,,116.54,Fee Schedule,,143.22,,,143.22,Fee Schedule,,54.87,,,54.87,Fee Schedule,,116.54,,,116.54,Fee Schedule,,143.22,,,143.22,Fee Schedule,,103.21,,,103.21,Fee Schedule,,161.7,70,,161.7,percent of total billed charges,All Other,118.08,,,118.08,Fee Schedule,,100.08,,,100.08,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,170.94,
XR ANKLE 2 VIEWS LT FY MOD,73600,CPT,FYLT,42773600,CDM,320,RC,,,both,,,231,170.94,,,170.94,Other,150% of Medicare + 9.63% HCRA Surcharge,103.95,45,,103.95,percent of total billed charges,Critical Access Hospital RCC factor,85.65,,,85.65,Fee Schedule,,77.06,,,77.06,Fee Schedule,,137.39,,,137.39,Fee Schedule,,123.57,,,123.57,Fee Schedule,,116.79,,,116.79,Fee Schedule,,114.35,,,114.35,Other,110% of Medicare,101.76,,,101.76,Fee Schedule,,53,,,53,Other,186% of Medicaid,119.75,,,119.75,Fee Schedule,,143.22,,,143.22,Fee Schedule,,56.39,,,56.39,Fee Schedule,,119.75,,,119.75,Fee Schedule,,143.22,,,143.22,Fee Schedule,,106.06,,,106.06,Fee Schedule,,161.7,70,,161.7,percent of total billed charges,All Other,119.72,,,119.72,Fee Schedule,,101.47,,,101.47,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,170.94,
XR ANKLE 3+ VIEWS LT FY MOD,73610,CPT,FYLT,42773610,CDM,320,RC,,,both,,,348,257.52,,,257.52,Other,150% of Medicare + 9.63% HCRA Surcharge,156.6,45,,156.6,percent of total billed charges,Critical Access Hospital RCC factor,98.38,,,98.38,Fee Schedule,,88.51,,,88.51,Fee Schedule,,162.58,,,162.58,Fee Schedule,,146.23,,,146.23,Fee Schedule,,138.21,,,138.21,Fee Schedule,,172.26,,,172.26,Other,110% of Medicare,116.88,,,116.88,Fee Schedule,,53,,,53,Other,186% of Medicaid,137.55,,,137.55,Fee Schedule,,215.76,,,215.76,Fee Schedule,,64.76,,,64.76,Fee Schedule,,137.55,,,137.55,Fee Schedule,,215.76,,,215.76,Fee Schedule,,121.82,,,121.82,Fee Schedule,,243.6,70,,243.6,percent of total billed charges,All Other,139.4,,,139.4,Fee Schedule,,118.15,,,118.15,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,257.52,
XR FOOT 2 VIEWS LT FY MOD,73620,CPT,FYLT,42773620,CDM,320,RC,,,both,,,231,170.94,,,170.94,Other,150% of Medicare + 9.63% HCRA Surcharge,103.95,45,,103.95,percent of total billed charges,Critical Access Hospital RCC factor,74.1,,,74.1,Fee Schedule,,66.67,,,66.67,Fee Schedule,,132.8,,,132.8,Fee Schedule,,119.45,,,119.45,Fee Schedule,,112.9,,,112.9,Fee Schedule,,114.35,,,114.35,Other,110% of Medicare,88.04,,,88.04,Fee Schedule,,53,,,53,Other,186% of Medicaid,103.61,,,103.61,Fee Schedule,,143.22,,,143.22,Fee Schedule,,48.78,,,48.78,Fee Schedule,,103.61,,,103.61,Fee Schedule,,143.22,,,143.22,Fee Schedule,,91.76,,,91.76,Fee Schedule,,161.7,70,,161.7,percent of total billed charges,All Other,101.68,,,101.68,Fee Schedule,,86.18,,,86.18,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,170.94,
XR FOOT 3+ VIEWS LT FY MOD,73630,CPT,FYLT,42773630,CDM,320,RC,,,both,,,373,276.02,,,276.02,Other,150% of Medicare + 9.63% HCRA Surcharge,167.85,45,,167.85,percent of total billed charges,Critical Access Hospital RCC factor,91.43,,,91.43,Fee Schedule,,82.25,,,82.25,Fee Schedule,,157.99,,,157.99,Fee Schedule,,142.11,,,142.11,Fee Schedule,,134.31,,,134.31,Fee Schedule,,184.64,,,184.64,Other,110% of Medicare,108.62,,,108.62,Fee Schedule,,53,,,53,Other,186% of Medicaid,127.82,,,127.82,Fee Schedule,,231.26,,,231.26,Fee Schedule,,60.19,,,60.19,Fee Schedule,,127.82,,,127.82,Fee Schedule,,231.26,,,231.26,Fee Schedule,,113.21,,,113.21,Fee Schedule,,261.1,70,,261.1,percent of total billed charges,All Other,129.56,,,129.56,Fee Schedule,,109.81,,,109.81,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,276.02,
XR HEEL 2+ VIEWS LT FY MOD,73650,CPT,FYLT,42773650,CDM,320,RC,,,both,,,231,170.94,,,170.94,Other,150% of Medicare + 9.63% HCRA Surcharge,103.95,45,,103.95,percent of total billed charges,Critical Access Hospital RCC factor,72.96,,,72.96,Fee Schedule,,65.64,,,65.64,Fee Schedule,,135.12,,,135.12,Fee Schedule,,121.53,,,121.53,Fee Schedule,,114.87,,,114.87,Fee Schedule,,114.35,,,114.35,Other,110% of Medicare,86.68,,,86.68,Fee Schedule,,53,,,53,Other,186% of Medicaid,102,,,102,Fee Schedule,,143.22,,,143.22,Fee Schedule,,48.03,,,48.03,Fee Schedule,,102,,,102,Fee Schedule,,143.22,,,143.22,Fee Schedule,,90.34,,,90.34,Fee Schedule,,161.7,70,,161.7,percent of total billed charges,All Other,103.32,,,103.32,Fee Schedule,,87.57,,,87.57,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,170.94,
XR TOE(S) 2+ VIEWS LT FY MOD,73660,CPT,FYLT,42773660,CDM,320,RC,,,both,,,231,170.94,,,170.94,Other,150% of Medicare + 9.63% HCRA Surcharge,103.95,45,,103.95,percent of total billed charges,Critical Access Hospital RCC factor,79.88,,,79.88,Fee Schedule,,71.86,,,71.86,Fee Schedule,,155.73,,,155.73,Fee Schedule,,140.07,,,140.07,Fee Schedule,,132.38,,,132.38,Fee Schedule,,114.35,,,114.35,Other,110% of Medicare,94.9,,,94.9,Fee Schedule,,53,,,53,Other,186% of Medicaid,111.68,,,111.68,Fee Schedule,,143.22,,,143.22,Fee Schedule,,52.58,,,52.58,Fee Schedule,,111.68,,,111.68,Fee Schedule,,143.22,,,143.22,Fee Schedule,,98.91,,,98.91,Fee Schedule,,161.7,70,,161.7,percent of total billed charges,All Other,111.52,,,111.52,Fee Schedule,,94.52,,,94.52,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,170.94,
XR EYE DETECT FOREIGN BODY FY MOD,70030,CPT,FYRT,42870030,CDM,320,RC,,,both,,,241,178.34,,,178.34,Other,150% of Medicare + 9.63% HCRA Surcharge,108.45,45,,108.45,percent of total billed charges,Critical Access Hospital RCC factor,84.5,,,84.5,Fee Schedule,,76.03,,,76.03,Fee Schedule,,137.39,,,137.39,Fee Schedule,,123.57,,,123.57,Fee Schedule,,116.79,,,116.79,Fee Schedule,,119.3,,,119.3,Other,110% of Medicare,100.4,,,100.4,Fee Schedule,,53,,,53,Other,186% of Medicaid,118.15,,,118.15,Fee Schedule,,149.42,,,149.42,Fee Schedule,,55.63,,,55.63,Fee Schedule,,118.15,,,118.15,Fee Schedule,,149.42,,,149.42,Fee Schedule,,104.64,,,104.64,Fee Schedule,,168.7,70,,168.7,percent of total billed charges,All Other,116.44,,,116.44,Fee Schedule,,98.69,,,98.69,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,178.34,
XR RIBS 2 VIEWS RIGHT FY MOD,71100,CPT,FYRT,42871100,CDM,320,RC,,,both,,,437,323.38,,,323.38,Other,150% of Medicare + 9.63% HCRA Surcharge,196.65,45,,196.65,percent of total billed charges,Critical Access Hospital RCC factor,91.43,,,91.43,Fee Schedule,,82.25,,,82.25,Fee Schedule,,146.56,,,146.56,Fee Schedule,,131.82,,,131.82,Fee Schedule,,124.59,,,124.59,Fee Schedule,,216.32,,,216.32,Other,110% of Medicare,108.62,,,108.62,Fee Schedule,,53,,,53,Other,186% of Medicaid,127.82,,,127.82,Fee Schedule,,270.94,,,270.94,Fee Schedule,,60.19,,,60.19,Fee Schedule,,127.82,,,127.82,Fee Schedule,,270.94,,,270.94,Fee Schedule,,113.21,,,113.21,Fee Schedule,,305.9,70,,305.9,percent of total billed charges,All Other,127.92,,,127.92,Fee Schedule,,108.42,,,108.42,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,323.38,
XR RIBS 3 VIEWS + CXR RT FY MOD,71101,CPT,FYRT,42871101,CDM,320,RC,,,both,,,437,323.38,,,323.38,Other,150% of Medicare + 9.63% HCRA Surcharge,196.65,45,,196.65,percent of total billed charges,Critical Access Hospital RCC factor,102.97,,,102.97,Fee Schedule,,92.64,,,92.64,Fee Schedule,,178.6,,,178.6,Fee Schedule,,160.64,,,160.64,Fee Schedule,,151.83,,,151.83,Fee Schedule,,216.32,,,216.32,Other,110% of Medicare,122.34,,,122.34,Fee Schedule,,53,,,53,Other,186% of Medicaid,143.97,,,143.97,Fee Schedule,,270.94,,,270.94,Fee Schedule,,67.79,,,67.79,Fee Schedule,,143.97,,,143.97,Fee Schedule,,270.94,,,270.94,Fee Schedule,,127.51,,,127.51,Fee Schedule,,305.9,70,,305.9,percent of total billed charges,All Other,144.32,,,144.32,Fee Schedule,,122.32,,,122.32,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,323.38,
XR CLAVICLE RIGHT FY MOD,73000,CPT,FYRT,42873000,CDM,320,RC,,,both,,,373,276.02,,,276.02,Other,150% of Medicare + 9.63% HCRA Surcharge,167.85,45,,167.85,percent of total billed charges,Critical Access Hospital RCC factor,85.65,,,85.65,Fee Schedule,,77.06,,,77.06,Fee Schedule,,139.71,,,139.71,Fee Schedule,,125.66,,,125.66,Fee Schedule,,118.76,,,118.76,Fee Schedule,,184.64,,,184.64,Other,110% of Medicare,101.76,,,101.76,Fee Schedule,,53,,,53,Other,186% of Medicaid,119.75,,,119.75,Fee Schedule,,231.26,,,231.26,Fee Schedule,,56.39,,,56.39,Fee Schedule,,119.75,,,119.75,Fee Schedule,,231.26,,,231.26,Fee Schedule,,106.06,,,106.06,Fee Schedule,,261.1,70,,261.1,percent of total billed charges,All Other,118.08,,,118.08,Fee Schedule,,100.08,,,100.08,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,276.02,
XR SCAPULA RIGHT FY MOD,73010,CPT,FYRT,42873010,CDM,320,RC,,,both,,,242,179.08,,,179.08,Other,150% of Medicare + 9.63% HCRA Surcharge,108.9,45,,108.9,percent of total billed charges,Critical Access Hospital RCC factor,53.3,,,53.3,Fee Schedule,,47.96,,,47.96,Fee Schedule,,144.29,,,144.29,Fee Schedule,,129.78,,,129.78,Fee Schedule,,122.66,,,122.66,Fee Schedule,,119.79,,,119.79,Other,110% of Medicare,63.33,,,63.33,Fee Schedule,,53,,,53,Other,186% of Medicaid,74.53,,,74.53,Fee Schedule,,150.04,,,150.04,Fee Schedule,,35.09,,,35.09,Fee Schedule,,74.53,,,74.53,Fee Schedule,,150.04,,,150.04,Fee Schedule,,66,,,66,Fee Schedule,,169.4,70,,169.4,percent of total billed charges,All Other,73.8,,,73.8,Fee Schedule,,62.55,,,62.55,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,179.33,
XR SHOULDER 1 V RT FY MOD,73020,CPT,FYRT,42873020,CDM,320,RC,,,both,,,231,170.94,,,170.94,Other,150% of Medicare + 9.63% HCRA Surcharge,103.95,45,,103.95,percent of total billed charges,Critical Access Hospital RCC factor,49.86,,,49.86,Fee Schedule,,44.86,,,44.86,Fee Schedule,,109.93,,,109.93,Fee Schedule,,98.88,,,98.88,Fee Schedule,,93.45,,,93.45,Fee Schedule,,114.35,,,114.35,Other,110% of Medicare,59.24,,,59.24,Fee Schedule,,53,,,53,Other,186% of Medicaid,69.71,,,69.71,Fee Schedule,,143.22,,,143.22,Fee Schedule,,32.82,,,32.82,Fee Schedule,,69.71,,,69.71,Fee Schedule,,143.22,,,143.22,Fee Schedule,,61.74,,,61.74,Fee Schedule,,161.7,70,,161.7,percent of total billed charges,All Other,68.88,,,68.88,Fee Schedule,,58.38,,,58.38,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,170.94,
XR SHOULDER 2 VIEWS OR MO RT FY MOD,73030,CPT,FYRT,42873030,CDM,320,RC,,,both,,,407,301.18,,,301.18,Other,150% of Medicare + 9.63% HCRA Surcharge,183.15,45,,183.15,percent of total billed charges,Critical Access Hospital RCC factor,90.28,,,90.28,Fee Schedule,,81.22,,,81.22,Fee Schedule,,141.97,,,141.97,Fee Schedule,,127.7,,,127.7,Fee Schedule,,120.69,,,120.69,Fee Schedule,,201.47,,,201.47,Other,110% of Medicare,107.26,,,107.26,Fee Schedule,,53,,,53,Other,186% of Medicaid,126.22,,,126.22,Fee Schedule,,252.34,,,252.34,Fee Schedule,,59.43,,,59.43,Fee Schedule,,126.22,,,126.22,Fee Schedule,,252.34,,,252.34,Fee Schedule,,111.79,,,111.79,Fee Schedule,,284.9,70,,284.9,percent of total billed charges,All Other,124.64,,,124.64,Fee Schedule,,105.64,,,105.64,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,301.18,
XR HUMERUS RIGHT FY MOD,73060,CPT,FYRT,42873060,CDM,320,RC,,,both,,,373,276.02,,,276.02,Other,150% of Medicare + 9.63% HCRA Surcharge,167.85,45,,167.85,percent of total billed charges,Critical Access Hospital RCC factor,84.5,,,84.5,Fee Schedule,,76.03,,,76.03,Fee Schedule,,139.71,,,139.71,Fee Schedule,,125.66,,,125.66,Fee Schedule,,118.76,,,118.76,Fee Schedule,,184.64,,,184.64,Other,110% of Medicare,100.4,,,100.4,Fee Schedule,,53,,,53,Other,186% of Medicaid,118.15,,,118.15,Fee Schedule,,231.26,,,231.26,Fee Schedule,,55.63,,,55.63,Fee Schedule,,118.15,,,118.15,Fee Schedule,,231.26,,,231.26,Fee Schedule,,104.64,,,104.64,Fee Schedule,,261.1,70,,261.1,percent of total billed charges,All Other,118.08,,,118.08,Fee Schedule,,100.08,,,100.08,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,276.02,
XR ELBOW 2 VIEW RIGHT FY MOD,73070,CPT,FYRT,42873070,CDM,320,RC,,,both,,,231,170.94,,,170.94,Other,150% of Medicare + 9.63% HCRA Surcharge,103.95,45,,103.95,percent of total billed charges,Critical Access Hospital RCC factor,74.1,,,74.1,Fee Schedule,,66.67,,,66.67,Fee Schedule,,139.71,,,139.71,Fee Schedule,,125.66,,,125.66,Fee Schedule,,118.76,,,118.76,Fee Schedule,,114.35,,,114.35,Other,110% of Medicare,88.04,,,88.04,Fee Schedule,,53,,,53,Other,186% of Medicaid,103.61,,,103.61,Fee Schedule,,143.22,,,143.22,Fee Schedule,,48.78,,,48.78,Fee Schedule,,103.61,,,103.61,Fee Schedule,,143.22,,,143.22,Fee Schedule,,91.76,,,91.76,Fee Schedule,,161.7,70,,161.7,percent of total billed charges,All Other,103.32,,,103.32,Fee Schedule,,87.57,,,87.57,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,170.94,
XR ELBOW 3 VIEWS RT FY MOD,73080,CPT,FYRT,42873080,CDM,320,RC,,,both,,,392,290.08,,,290.08,Other,150% of Medicare + 9.63% HCRA Surcharge,176.4,45,,176.4,percent of total billed charges,Critical Access Hospital RCC factor,85.65,,,85.65,Fee Schedule,,77.06,,,77.06,Fee Schedule,,174.02,,,174.02,Fee Schedule,,156.51,,,156.51,Fee Schedule,,147.93,,,147.93,Fee Schedule,,194.04,,,194.04,Other,110% of Medicare,101.76,,,101.76,Fee Schedule,,53,,,53,Other,186% of Medicaid,119.75,,,119.75,Fee Schedule,,243.04,,,243.04,Fee Schedule,,56.39,,,56.39,Fee Schedule,,119.75,,,119.75,Fee Schedule,,243.04,,,243.04,Fee Schedule,,106.06,,,106.06,Fee Schedule,,274.4,70,,274.4,percent of total billed charges,All Other,118.08,,,118.08,Fee Schedule,,100.08,,,100.08,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,290.08,
XR ARTHROGRAM ELBOW RT FY MOD,73085,CPT,FYRT,42873085,CDM,320,RC,,,both,,,1199,887.26,,,887.26,Other,150% of Medicare + 9.63% HCRA Surcharge,539.55,45,,539.55,percent of total billed charges,Critical Access Hospital RCC factor,258.96,,,258.96,Fee Schedule,,232.99,,,232.99,Fee Schedule,,476.09,,,476.09,Fee Schedule,,428.21,,,428.21,Fee Schedule,,404.72,,,404.72,Fee Schedule,,593.51,,,593.51,Other,110% of Medicare,307.67,,,307.67,Fee Schedule,,392,,,392,Other,186% of Medicaid,362.06,,,362.06,Fee Schedule,,743.38,,,743.38,Fee Schedule,,170.48,,,170.48,Fee Schedule,,362.06,,,362.06,Fee Schedule,,743.38,,,743.38,Fee Schedule,,320.66,,,320.66,Fee Schedule,,839.3,70,,839.3,percent of total billed charges,All Other,424.76,,,424.76,Fee Schedule,,360.01,,,360.01,Fee Schedule,,610.96,,,610.96,Fee Schedule,,610.96,,,610.96,Fee Schedule,,610.96,,,610.96,Fee Schedule,,610.96,,,610.96,Fee Schedule,,210.57,,,210.57,Other,100% of Medicaid,210.57,,,210.57,Other,100% of Medicaid,210.57,,,210.57,Other,100% of Medicaid,210.57,,,210.57,Other,100% of Medicaid,473.77,,,473.77,Other,225% of Medicaid,322.17,,,322.17,Other,153% of Medicaid,473.77,,,473.77,Other,225% of Medicaid,294.79,,,294.79,Other,140% of Medicaid,473.77,,,473.77,Other,225% of Medicaid,547.47,,,547.47,Other,260% of Medicaid,682.23,,,682.23,Other,324% of Medicaid,452.72,,,452.72,Other,215% of Medicaid,452.72,,,452.72,Other,215% of Medicaid,263.21,,,263.21,Other,125% of Medicaid,170.48,887.26,
XR FOREARM RT FY MOD,73090,CPT,FYRT,42873090,CDM,320,RC,,,both,,,334,247.16,,,247.16,Other,150% of Medicare + 9.63% HCRA Surcharge,150.3,45,,150.3,percent of total billed charges,Critical Access Hospital RCC factor,75.25,,,75.25,Fee Schedule,,67.7,,,67.7,Fee Schedule,,135.12,,,135.12,Fee Schedule,,121.53,,,121.53,Fee Schedule,,114.87,,,114.87,Fee Schedule,,165.33,,,165.33,Other,110% of Medicare,89.41,,,89.41,Fee Schedule,,53,,,53,Other,186% of Medicaid,105.21,,,105.21,Fee Schedule,,207.08,,,207.08,Fee Schedule,,49.54,,,49.54,Fee Schedule,,105.21,,,105.21,Fee Schedule,,207.08,,,207.08,Fee Schedule,,93.18,,,93.18,Fee Schedule,,233.8,70,,233.8,percent of total billed charges,All Other,104.96,,,104.96,Fee Schedule,,88.96,,,88.96,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,247.16,
XR UPPER EXT CHILD 2 V RT FY MOD,73092,CPT,FYRT,42873092,CDM,320,RC,,,both,,,242,179.08,,,179.08,Other,150% of Medicare + 9.63% HCRA Surcharge,108.9,45,,108.9,percent of total billed charges,Critical Access Hospital RCC factor,83.35,,,83.35,Fee Schedule,,74.99,,,74.99,Fee Schedule,,153.41,,,153.41,Fee Schedule,,137.98,,,137.98,Fee Schedule,,130.41,,,130.41,Fee Schedule,,119.79,,,119.79,Other,110% of Medicare,99.03,,,99.03,Fee Schedule,,53,,,53,Other,186% of Medicaid,116.54,,,116.54,Fee Schedule,,150.04,,,150.04,Fee Schedule,,54.87,,,54.87,Fee Schedule,,116.54,,,116.54,Fee Schedule,,150.04,,,150.04,Fee Schedule,,103.21,,,103.21,Fee Schedule,,169.4,70,,169.4,percent of total billed charges,All Other,118.08,,,118.08,Fee Schedule,,100.08,,,100.08,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,179.33,
XR WRIST 2 VIEWS RT FY MOD,73100,CPT,FYRT,42873100,CDM,320,RC,,,both,,,231,170.94,,,170.94,Other,150% of Medicare + 9.63% HCRA Surcharge,103.95,45,,103.95,percent of total billed charges,Critical Access Hospital RCC factor,90.28,,,90.28,Fee Schedule,,81.22,,,81.22,Fee Schedule,,148.82,,,148.82,Fee Schedule,,133.86,,,133.86,Fee Schedule,,126.52,,,126.52,Fee Schedule,,114.35,,,114.35,Other,110% of Medicare,107.26,,,107.26,Fee Schedule,,53,,,53,Other,186% of Medicaid,126.22,,,126.22,Fee Schedule,,143.22,,,143.22,Fee Schedule,,59.43,,,59.43,Fee Schedule,,126.22,,,126.22,Fee Schedule,,143.22,,,143.22,Fee Schedule,,111.79,,,111.79,Fee Schedule,,161.7,70,,161.7,percent of total billed charges,All Other,126.28,,,126.28,Fee Schedule,,107.03,,,107.03,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,170.94,
XR WRIST 3+ VIEWS RT FY MOD,73110,CPT,FYRT,42873110,CDM,320,RC,,,both,,,330,244.2,,,244.2,Other,150% of Medicare + 9.63% HCRA Surcharge,148.5,45,,148.5,percent of total billed charges,Critical Access Hospital RCC factor,114.55,,,114.55,Fee Schedule,,103.06,,,103.06,Fee Schedule,,187.77,,,187.77,Fee Schedule,,168.89,,,168.89,Fee Schedule,,159.62,,,159.62,Fee Schedule,,163.35,,,163.35,Other,110% of Medicare,136.1,,,136.1,Fee Schedule,,53,,,53,Other,186% of Medicaid,160.16,,,160.16,Fee Schedule,,204.6,,,204.6,Fee Schedule,,75.41,,,75.41,Fee Schedule,,160.16,,,160.16,Fee Schedule,,204.6,,,204.6,Fee Schedule,,141.84,,,141.84,Fee Schedule,,231,70,,231,percent of total billed charges,All Other,159.08,,,159.08,Fee Schedule,,134.83,,,134.83,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,244.2,
XR HAND 2 VIEWS RT FY MOD,73120,CPT,FYRT,42873120,CDM,320,RC,,,both,,,242,179.08,,,179.08,Other,150% of Medicare + 9.63% HCRA Surcharge,108.9,45,,108.9,percent of total billed charges,Critical Access Hospital RCC factor,82.21,,,82.21,Fee Schedule,,73.96,,,73.96,Fee Schedule,,132.8,,,132.8,Fee Schedule,,119.45,,,119.45,Fee Schedule,,112.9,,,112.9,Fee Schedule,,119.79,,,119.79,Other,110% of Medicare,97.67,,,97.67,Fee Schedule,,53,,,53,Other,186% of Medicaid,114.93,,,114.93,Fee Schedule,,150.04,,,150.04,Fee Schedule,,54.12,,,54.12,Fee Schedule,,114.93,,,114.93,Fee Schedule,,150.04,,,150.04,Fee Schedule,,101.79,,,101.79,Fee Schedule,,169.4,70,,169.4,percent of total billed charges,All Other,113.16,,,113.16,Fee Schedule,,95.91,,,95.91,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,179.33,
XR HAND 3+ VIEWS RT FY MOD,73130,CPT,FYRT,42873130,CDM,320,RC,,,both,,,352,260.48,,,260.48,Other,150% of Medicare + 9.63% HCRA Surcharge,158.4,45,,158.4,percent of total billed charges,Critical Access Hospital RCC factor,100.68,,,100.68,Fee Schedule,,90.58,,,90.58,Fee Schedule,,160.26,,,160.26,Fee Schedule,,144.14,,,144.14,Fee Schedule,,136.24,,,136.24,Fee Schedule,,174.24,,,174.24,Other,110% of Medicare,119.61,,,119.61,Fee Schedule,,53,,,53,Other,186% of Medicaid,140.76,,,140.76,Fee Schedule,,218.24,,,218.24,Fee Schedule,,66.28,,,66.28,Fee Schedule,,140.76,,,140.76,Fee Schedule,,218.24,,,218.24,Fee Schedule,,124.66,,,124.66,Fee Schedule,,246.4,70,,246.4,percent of total billed charges,All Other,137.76,,,137.76,Fee Schedule,,116.76,,,116.76,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,260.48,
XR FINGER 2+ VIEWS RT FY MOD,73140,CPT,FYRT,42873140,CDM,320,RC,,,both,,,231,170.94,,,170.94,Other,150% of Medicare + 9.63% HCRA Surcharge,103.95,45,,103.95,percent of total billed charges,Critical Access Hospital RCC factor,109.93,,,109.93,Fee Schedule,,98.9,,,98.9,Fee Schedule,,167.16,,,167.16,Fee Schedule,,150.35,,,150.35,Fee Schedule,,142.11,,,142.11,Fee Schedule,,114.35,,,114.35,Other,110% of Medicare,130.6,,,130.6,Fee Schedule,,53,,,53,Other,186% of Medicaid,153.69,,,153.69,Fee Schedule,,143.22,,,143.22,Fee Schedule,,72.37,,,72.37,Fee Schedule,,153.69,,,153.69,Fee Schedule,,143.22,,,143.22,Fee Schedule,,136.12,,,136.12,Fee Schedule,,161.7,70,,161.7,percent of total billed charges,All Other,150.88,,,150.88,Fee Schedule,,127.88,,,127.88,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,170.94,
X-RAY EXAM HIP UNI 1 VIEW RT FY MOD,73501,CPT,FYRT,42873501,CDM,320,RC,,,both,,,237,175.38,,,175.38,Other,150% of Medicare + 9.63% HCRA Surcharge,106.65,45,,106.65,percent of total billed charges,Critical Access Hospital RCC factor,83.35,,,83.35,Fee Schedule,,74.99,,,74.99,Fee Schedule,,20.07,,,20.07,Fee Schedule,,20.07,,,20.07,Fee Schedule,,20.07,,,20.07,Fee Schedule,,117.32,,,117.32,Other,110% of Medicare,99.03,,,99.03,Fee Schedule,,53,,,53,Other,186% of Medicaid,116.54,,,116.54,Fee Schedule,,146.94,,,146.94,Fee Schedule,,54.87,,,54.87,Fee Schedule,,116.54,,,116.54,Fee Schedule,,146.94,,,146.94,Fee Schedule,,103.21,,,103.21,Fee Schedule,,165.9,70,,165.9,percent of total billed charges,All Other,114.8,,,114.8,Fee Schedule,,97.3,,,97.3,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,20.07,175.38,
X-RAY EXAM HIP UNI 2-3 VIEWS RT FY MOD,73502,CPT,FYRT,42873502,CDM,320,RC,,,both,,,268,198.32,,,198.32,Other,150% of Medicare + 9.63% HCRA Surcharge,120.6,45,,120.6,percent of total billed charges,Critical Access Hospital RCC factor,128.4,,,128.4,Fee Schedule,,115.52,,,115.52,Fee Schedule,,29.42,,,29.42,Fee Schedule,,29.42,,,29.42,Fee Schedule,,29.42,,,29.42,Fee Schedule,,132.66,,,132.66,Other,110% of Medicare,152.55,,,152.55,Fee Schedule,,53,,,53,Other,186% of Medicaid,179.52,,,179.52,Fee Schedule,,166.16,,,166.16,Fee Schedule,,84.53,,,84.53,Fee Schedule,,179.52,,,179.52,Fee Schedule,,166.16,,,166.16,Fee Schedule,,158.99,,,158.99,Fee Schedule,,187.6,70,,187.6,percent of total billed charges,All Other,177.12,,,177.12,Fee Schedule,,150.12,,,150.12,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,198.32,
X-RAY EXAM HIP UNI 4/> VIEWS RT FY MOD,73503,CPT,FYRT,42873503,CDM,320,RC,,,both,,,336,248.64,,,248.64,Other,150% of Medicare + 9.63% HCRA Surcharge,151.2,45,,151.2,percent of total billed charges,Critical Access Hospital RCC factor,163.07,,,163.07,Fee Schedule,,146.71,,,146.71,Fee Schedule,,36.34,,,36.34,Fee Schedule,,36.34,,,36.34,Fee Schedule,,36.34,,,36.34,Fee Schedule,,166.32,,,166.32,Other,110% of Medicare,193.74,,,193.74,Fee Schedule,,53,,,53,Other,186% of Medicaid,228,,,228,Fee Schedule,,208.32,,,208.32,Fee Schedule,,107.35,,,107.35,Fee Schedule,,228,,,228,Fee Schedule,,208.32,,,208.32,Fee Schedule,,201.92,,,201.92,Fee Schedule,,235.2,70,,235.2,percent of total billed charges,All Other,224.68,,,224.68,Fee Schedule,,190.43,,,190.43,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,248.64,
X-RAY EXAM OF FEMUR 1 RT FY MOD,73551,CPT,FYRT,42873551,CDM,320,RC,,,both,,,237,175.38,,,175.38,Other,150% of Medicare + 9.63% HCRA Surcharge,106.65,45,,106.65,percent of total billed charges,Critical Access Hospital RCC factor,74.1,,,74.1,Fee Schedule,,66.67,,,66.67,Fee Schedule,,19.04,,,19.04,Fee Schedule,,19.04,,,19.04,Fee Schedule,,19.04,,,19.04,Fee Schedule,,117.32,,,117.32,Other,110% of Medicare,88.04,,,88.04,Fee Schedule,,53,,,53,Other,186% of Medicaid,103.61,,,103.61,Fee Schedule,,146.94,,,146.94,Fee Schedule,,48.78,,,48.78,Fee Schedule,,103.61,,,103.61,Fee Schedule,,146.94,,,146.94,Fee Schedule,,91.76,,,91.76,Fee Schedule,,165.9,70,,165.9,percent of total billed charges,All Other,103.32,,,103.32,Fee Schedule,,87.57,,,87.57,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,19.04,175.38,
X-RAY EXAM OF FEMUR 2/> RT FY MOD,73552,CPT,FYRT,42873552,CDM,320,RC,,,both,,,237,175.38,,,175.38,Other,150% of Medicare + 9.63% HCRA Surcharge,106.65,45,,106.65,percent of total billed charges,Critical Access Hospital RCC factor,93.75,,,93.75,Fee Schedule,,84.35,,,84.35,Fee Schedule,,22.84,,,22.84,Fee Schedule,,22.84,,,22.84,Fee Schedule,,22.84,,,22.84,Fee Schedule,,117.32,,,117.32,Other,110% of Medicare,111.39,,,111.39,Fee Schedule,,53,,,53,Other,186% of Medicaid,131.08,,,131.08,Fee Schedule,,146.94,,,146.94,Fee Schedule,,61.72,,,61.72,Fee Schedule,,131.08,,,131.08,Fee Schedule,,146.94,,,146.94,Fee Schedule,,116.09,,,116.09,Fee Schedule,,165.9,70,,165.9,percent of total billed charges,All Other,129.56,,,129.56,Fee Schedule,,109.81,,,109.81,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,22.84,175.38,
XR KNEE 1 OR 2 VIEWS RT FY MOD,73560,CPT,FYRT,42873560,CDM,320,RC,,,both,,,407,301.18,,,301.18,Other,150% of Medicare + 9.63% HCRA Surcharge,183.15,45,,183.15,percent of total billed charges,Critical Access Hospital RCC factor,91.43,,,91.43,Fee Schedule,,82.25,,,82.25,Fee Schedule,,144.29,,,144.29,Fee Schedule,,129.78,,,129.78,Fee Schedule,,122.66,,,122.66,Fee Schedule,,201.47,,,201.47,Other,110% of Medicare,108.62,,,108.62,Fee Schedule,,53,,,53,Other,186% of Medicaid,127.82,,,127.82,Fee Schedule,,252.34,,,252.34,Fee Schedule,,60.19,,,60.19,Fee Schedule,,127.82,,,127.82,Fee Schedule,,252.34,,,252.34,Fee Schedule,,113.21,,,113.21,Fee Schedule,,284.9,70,,284.9,percent of total billed charges,All Other,127.92,,,127.92,Fee Schedule,,108.42,,,108.42,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,301.18,
XR KNEE 3 VIEWS RT FY MOD,73562,CPT,FYRT,42873562,CDM,320,RC,,,both,,,445,329.3,,,329.3,Other,150% of Medicare + 9.63% HCRA Surcharge,200.25,45,,200.25,percent of total billed charges,Critical Access Hospital RCC factor,111.08,,,111.08,Fee Schedule,,99.93,,,99.93,Fee Schedule,,180.87,,,180.87,Fee Schedule,,162.68,,,162.68,Fee Schedule,,153.75,,,153.75,Fee Schedule,,220.28,,,220.28,Other,110% of Medicare,131.97,,,131.97,Fee Schedule,,53,,,53,Other,186% of Medicaid,155.3,,,155.3,Fee Schedule,,275.9,,,275.9,Fee Schedule,,73.12,,,73.12,Fee Schedule,,155.3,,,155.3,Fee Schedule,,275.9,,,275.9,Fee Schedule,,137.54,,,137.54,Fee Schedule,,311.5,70,,311.5,percent of total billed charges,All Other,155.8,,,155.8,Fee Schedule,,132.05,,,132.05,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,329.3,
XR KNEE 4+ VIEWS RT FY MOD,73564,CPT,FYRT,42873564,CDM,320,RC,,,both,,,445,329.3,,,329.3,Other,150% of Medicare + 9.63% HCRA Surcharge,200.25,45,,200.25,percent of total billed charges,Critical Access Hospital RCC factor,126.1,,,126.1,Fee Schedule,,113.45,,,113.45,Fee Schedule,,206.06,,,206.06,Fee Schedule,,185.33,,,185.33,Fee Schedule,,175.17,,,175.17,Fee Schedule,,220.28,,,220.28,Other,110% of Medicare,149.82,,,149.82,Fee Schedule,,53,,,53,Other,186% of Medicaid,176.3,,,176.3,Fee Schedule,,275.9,,,275.9,Fee Schedule,,83.01,,,83.01,Fee Schedule,,176.3,,,176.3,Fee Schedule,,275.9,,,275.9,Fee Schedule,,156.14,,,156.14,Fee Schedule,,311.5,70,,311.5,percent of total billed charges,All Other,173.84,,,173.84,Fee Schedule,,147.34,,,147.34,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,329.3,
XR TIBIA/FIBULA 2 VIEWS RT FY MOD,73590,CPT,FYRT,42873590,CDM,320,RC,,,both,,,373,276.02,,,276.02,Other,150% of Medicare + 9.63% HCRA Surcharge,167.85,45,,167.85,percent of total billed charges,Critical Access Hospital RCC factor,83.35,,,83.35,Fee Schedule,,74.99,,,74.99,Fee Schedule,,130.54,,,130.54,Fee Schedule,,117.41,,,117.41,Fee Schedule,,110.97,,,110.97,Fee Schedule,,184.64,,,184.64,Other,110% of Medicare,99.03,,,99.03,Fee Schedule,,53,,,53,Other,186% of Medicaid,116.54,,,116.54,Fee Schedule,,231.26,,,231.26,Fee Schedule,,54.87,,,54.87,Fee Schedule,,116.54,,,116.54,Fee Schedule,,231.26,,,231.26,Fee Schedule,,103.21,,,103.21,Fee Schedule,,261.1,70,,261.1,percent of total billed charges,All Other,116.44,,,116.44,Fee Schedule,,98.69,,,98.69,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,276.02,
XR LEG INFANT 2 VIEWS RT FY MOD,73592,CPT,FYRT,42873592,CDM,320,RC,,,both,,,231,170.94,,,170.94,Other,150% of Medicare + 9.63% HCRA Surcharge,103.95,45,,103.95,percent of total billed charges,Critical Access Hospital RCC factor,83.35,,,83.35,Fee Schedule,,74.99,,,74.99,Fee Schedule,,155.73,,,155.73,Fee Schedule,,140.07,,,140.07,Fee Schedule,,132.38,,,132.38,Fee Schedule,,114.35,,,114.35,Other,110% of Medicare,99.03,,,99.03,Fee Schedule,,53,,,53,Other,186% of Medicaid,116.54,,,116.54,Fee Schedule,,143.22,,,143.22,Fee Schedule,,54.87,,,54.87,Fee Schedule,,116.54,,,116.54,Fee Schedule,,143.22,,,143.22,Fee Schedule,,103.21,,,103.21,Fee Schedule,,161.7,70,,161.7,percent of total billed charges,All Other,118.08,,,118.08,Fee Schedule,,100.08,,,100.08,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,170.94,
XR ANKLE 2 VIEWS RT FY MOD,73600,CPT,FYRT,42873600,CDM,320,RC,,,both,,,231,170.94,,,170.94,Other,150% of Medicare + 9.63% HCRA Surcharge,103.95,45,,103.95,percent of total billed charges,Critical Access Hospital RCC factor,85.65,,,85.65,Fee Schedule,,77.06,,,77.06,Fee Schedule,,137.39,,,137.39,Fee Schedule,,123.57,,,123.57,Fee Schedule,,116.79,,,116.79,Fee Schedule,,114.35,,,114.35,Other,110% of Medicare,101.76,,,101.76,Fee Schedule,,53,,,53,Other,186% of Medicaid,119.75,,,119.75,Fee Schedule,,143.22,,,143.22,Fee Schedule,,56.39,,,56.39,Fee Schedule,,119.75,,,119.75,Fee Schedule,,143.22,,,143.22,Fee Schedule,,106.06,,,106.06,Fee Schedule,,161.7,70,,161.7,percent of total billed charges,All Other,119.72,,,119.72,Fee Schedule,,101.47,,,101.47,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,170.94,
XR ANKLE 3+ VIEWS RT FY MOD,73610,CPT,FYRT,42873610,CDM,320,RC,,,both,,,348,257.52,,,257.52,Other,150% of Medicare + 9.63% HCRA Surcharge,156.6,45,,156.6,percent of total billed charges,Critical Access Hospital RCC factor,98.38,,,98.38,Fee Schedule,,88.51,,,88.51,Fee Schedule,,162.58,,,162.58,Fee Schedule,,146.23,,,146.23,Fee Schedule,,138.21,,,138.21,Fee Schedule,,172.26,,,172.26,Other,110% of Medicare,116.88,,,116.88,Fee Schedule,,53,,,53,Other,186% of Medicaid,137.55,,,137.55,Fee Schedule,,215.76,,,215.76,Fee Schedule,,64.76,,,64.76,Fee Schedule,,137.55,,,137.55,Fee Schedule,,215.76,,,215.76,Fee Schedule,,121.82,,,121.82,Fee Schedule,,243.6,70,,243.6,percent of total billed charges,All Other,139.4,,,139.4,Fee Schedule,,118.15,,,118.15,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,257.52,
XR FOOT 2 VIEWS RT FY MOD,73620,CPT,FYRT,42873620,CDM,320,RC,,,both,,,231,170.94,,,170.94,Other,150% of Medicare + 9.63% HCRA Surcharge,103.95,45,,103.95,percent of total billed charges,Critical Access Hospital RCC factor,74.1,,,74.1,Fee Schedule,,66.67,,,66.67,Fee Schedule,,132.8,,,132.8,Fee Schedule,,119.45,,,119.45,Fee Schedule,,112.9,,,112.9,Fee Schedule,,114.35,,,114.35,Other,110% of Medicare,88.04,,,88.04,Fee Schedule,,53,,,53,Other,186% of Medicaid,103.61,,,103.61,Fee Schedule,,143.22,,,143.22,Fee Schedule,,48.78,,,48.78,Fee Schedule,,103.61,,,103.61,Fee Schedule,,143.22,,,143.22,Fee Schedule,,91.76,,,91.76,Fee Schedule,,161.7,70,,161.7,percent of total billed charges,All Other,101.68,,,101.68,Fee Schedule,,86.18,,,86.18,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,170.94,
XR FOOT 3+ VIEWS RT FY MOD,73630,CPT,FYRT,42873630,CDM,320,RC,,,both,,,373,276.02,,,276.02,Other,150% of Medicare + 9.63% HCRA Surcharge,167.85,45,,167.85,percent of total billed charges,Critical Access Hospital RCC factor,91.43,,,91.43,Fee Schedule,,82.25,,,82.25,Fee Schedule,,157.99,,,157.99,Fee Schedule,,142.11,,,142.11,Fee Schedule,,134.31,,,134.31,Fee Schedule,,184.64,,,184.64,Other,110% of Medicare,108.62,,,108.62,Fee Schedule,,53,,,53,Other,186% of Medicaid,127.82,,,127.82,Fee Schedule,,231.26,,,231.26,Fee Schedule,,60.19,,,60.19,Fee Schedule,,127.82,,,127.82,Fee Schedule,,231.26,,,231.26,Fee Schedule,,113.21,,,113.21,Fee Schedule,,261.1,70,,261.1,percent of total billed charges,All Other,129.56,,,129.56,Fee Schedule,,109.81,,,109.81,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,276.02,
XR HEEL 2+ VIEWS RT FY MOD,73650,CPT,FYRT,42873650,CDM,320,RC,,,both,,,231,170.94,,,170.94,Other,150% of Medicare + 9.63% HCRA Surcharge,103.95,45,,103.95,percent of total billed charges,Critical Access Hospital RCC factor,72.96,,,72.96,Fee Schedule,,65.64,,,65.64,Fee Schedule,,135.12,,,135.12,Fee Schedule,,121.53,,,121.53,Fee Schedule,,114.87,,,114.87,Fee Schedule,,114.35,,,114.35,Other,110% of Medicare,86.68,,,86.68,Fee Schedule,,53,,,53,Other,186% of Medicaid,102,,,102,Fee Schedule,,143.22,,,143.22,Fee Schedule,,48.03,,,48.03,Fee Schedule,,102,,,102,Fee Schedule,,143.22,,,143.22,Fee Schedule,,90.34,,,90.34,Fee Schedule,,161.7,70,,161.7,percent of total billed charges,All Other,103.32,,,103.32,Fee Schedule,,87.57,,,87.57,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,170.94,
XR TOE(S) 2+ VIEWS RT FY MOD,73660,CPT,FYRT,42873660,CDM,320,RC,,,both,,,231,170.94,,,170.94,Other,150% of Medicare + 9.63% HCRA Surcharge,103.95,45,,103.95,percent of total billed charges,Critical Access Hospital RCC factor,79.88,,,79.88,Fee Schedule,,71.86,,,71.86,Fee Schedule,,155.73,,,155.73,Fee Schedule,,140.07,,,140.07,Fee Schedule,,132.38,,,132.38,Fee Schedule,,114.35,,,114.35,Other,110% of Medicare,94.9,,,94.9,Fee Schedule,,53,,,53,Other,186% of Medicaid,111.68,,,111.68,Fee Schedule,,143.22,,,143.22,Fee Schedule,,52.58,,,52.58,Fee Schedule,,111.68,,,111.68,Fee Schedule,,143.22,,,143.22,Fee Schedule,,98.91,,,98.91,Fee Schedule,,161.7,70,,161.7,percent of total billed charges,All Other,111.52,,,111.52,Fee Schedule,,94.52,,,94.52,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,170.94,
XR EYE DETECT FOREIGN BODY BILAT FY MOD,70030,CPT,FY50,42970030,CDM,320,RC,,,both,,,362,267.88,,,267.88,Other,150% of Medicare + 9.63% HCRA Surcharge,162.9,45,,162.9,percent of total billed charges,Critical Access Hospital RCC factor,84.5,,,84.5,Fee Schedule,,76.03,,,76.03,Fee Schedule,,137.39,,,137.39,Fee Schedule,,123.57,,,123.57,Fee Schedule,,116.79,,,116.79,Fee Schedule,,179.19,,,179.19,Other,110% of Medicare,100.4,,,100.4,Fee Schedule,,53,,,53,Other,186% of Medicaid,118.15,,,118.15,Fee Schedule,,224.44,,,224.44,Fee Schedule,,55.63,,,55.63,Fee Schedule,,118.15,,,118.15,Fee Schedule,,224.44,,,224.44,Fee Schedule,,104.64,,,104.64,Fee Schedule,,253.4,70,,253.4,percent of total billed charges,All Other,116.44,,,116.44,Fee Schedule,,98.69,,,98.69,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,267.88,
XR CLAVICLE BILAT FY MOD,73000,CPT,FY50,42973000,CDM,320,RC,,,both,,,560,414.4,,,414.4,Other,150% of Medicare + 9.63% HCRA Surcharge,252,45,,252,percent of total billed charges,Critical Access Hospital RCC factor,85.65,,,85.65,Fee Schedule,,77.06,,,77.06,Fee Schedule,,139.71,,,139.71,Fee Schedule,,125.66,,,125.66,Fee Schedule,,118.76,,,118.76,Fee Schedule,,277.2,,,277.2,Other,110% of Medicare,101.76,,,101.76,Fee Schedule,,53,,,53,Other,186% of Medicaid,119.75,,,119.75,Fee Schedule,,347.2,,,347.2,Fee Schedule,,56.39,,,56.39,Fee Schedule,,119.75,,,119.75,Fee Schedule,,347.2,,,347.2,Fee Schedule,,106.06,,,106.06,Fee Schedule,,392,70,,392,percent of total billed charges,All Other,118.08,,,118.08,Fee Schedule,,100.08,,,100.08,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,414.4,
XR OF SCAPULA BILAT FY MOD,73010,CPT,FY50,42973010,CDM,320,RC,,,both,,,363,268.62,,,268.62,Other,150% of Medicare + 9.63% HCRA Surcharge,163.35,45,,163.35,percent of total billed charges,Critical Access Hospital RCC factor,53.3,,,53.3,Fee Schedule,,47.96,,,47.96,Fee Schedule,,144.29,,,144.29,Fee Schedule,,129.78,,,129.78,Fee Schedule,,122.66,,,122.66,Fee Schedule,,179.69,,,179.69,Other,110% of Medicare,63.33,,,63.33,Fee Schedule,,53,,,53,Other,186% of Medicaid,74.53,,,74.53,Fee Schedule,,225.06,,,225.06,Fee Schedule,,35.09,,,35.09,Fee Schedule,,74.53,,,74.53,Fee Schedule,,225.06,,,225.06,Fee Schedule,,66,,,66,Fee Schedule,,254.1,70,,254.1,percent of total billed charges,All Other,73.8,,,73.8,Fee Schedule,,62.55,,,62.55,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,268.62,
XR SHOULDER 1 VBILAT FY MOD,73020,CPT,FY50,42973020,CDM,320,RC,,,both,,,347,256.78,,,256.78,Other,150% of Medicare + 9.63% HCRA Surcharge,156.15,45,,156.15,percent of total billed charges,Critical Access Hospital RCC factor,49.86,,,49.86,Fee Schedule,,44.86,,,44.86,Fee Schedule,,109.93,,,109.93,Fee Schedule,,98.88,,,98.88,Fee Schedule,,93.45,,,93.45,Fee Schedule,,171.77,,,171.77,Other,110% of Medicare,59.24,,,59.24,Fee Schedule,,53,,,53,Other,186% of Medicaid,69.71,,,69.71,Fee Schedule,,215.14,,,215.14,Fee Schedule,,32.82,,,32.82,Fee Schedule,,69.71,,,69.71,Fee Schedule,,215.14,,,215.14,Fee Schedule,,61.74,,,61.74,Fee Schedule,,242.9,70,,242.9,percent of total billed charges,All Other,68.88,,,68.88,Fee Schedule,,58.38,,,58.38,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,256.78,
XR SHOULDER 2 VIEWS BILAT FY MOD,73030,CPT,FY50,42973030,CDM,320,RC,,,both,,,611,452.14,,,452.14,Other,150% of Medicare + 9.63% HCRA Surcharge,274.95,45,,274.95,percent of total billed charges,Critical Access Hospital RCC factor,90.28,,,90.28,Fee Schedule,,81.22,,,81.22,Fee Schedule,,141.97,,,141.97,Fee Schedule,,127.7,,,127.7,Fee Schedule,,120.69,,,120.69,Fee Schedule,,302.45,,,302.45,Other,110% of Medicare,107.26,,,107.26,Fee Schedule,,53,,,53,Other,186% of Medicaid,126.22,,,126.22,Fee Schedule,,378.82,,,378.82,Fee Schedule,,59.43,,,59.43,Fee Schedule,,126.22,,,126.22,Fee Schedule,,378.82,,,378.82,Fee Schedule,,111.79,,,111.79,Fee Schedule,,427.7,70,,427.7,percent of total billed charges,All Other,124.64,,,124.64,Fee Schedule,,105.64,,,105.64,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,452.14,
XR HUMERUS 2 VIEW BILAT FY MOD,73060,CPT,FY50,42973060,CDM,320,RC,,,both,,,560,414.4,,,414.4,Other,150% of Medicare + 9.63% HCRA Surcharge,252,45,,252,percent of total billed charges,Critical Access Hospital RCC factor,84.5,,,84.5,Fee Schedule,,76.03,,,76.03,Fee Schedule,,139.71,,,139.71,Fee Schedule,,125.66,,,125.66,Fee Schedule,,118.76,,,118.76,Fee Schedule,,277.2,,,277.2,Other,110% of Medicare,100.4,,,100.4,Fee Schedule,,53,,,53,Other,186% of Medicaid,118.15,,,118.15,Fee Schedule,,347.2,,,347.2,Fee Schedule,,55.63,,,55.63,Fee Schedule,,118.15,,,118.15,Fee Schedule,,347.2,,,347.2,Fee Schedule,,104.64,,,104.64,Fee Schedule,,392,70,,392,percent of total billed charges,All Other,118.08,,,118.08,Fee Schedule,,100.08,,,100.08,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,414.4,
XR ELBOW 2 V BILAT FY MOD,73070,CPT,FY50,42973070,CDM,320,RC,,,both,,,347,256.78,,,256.78,Other,150% of Medicare + 9.63% HCRA Surcharge,156.15,45,,156.15,percent of total billed charges,Critical Access Hospital RCC factor,74.1,,,74.1,Fee Schedule,,66.67,,,66.67,Fee Schedule,,139.71,,,139.71,Fee Schedule,,125.66,,,125.66,Fee Schedule,,118.76,,,118.76,Fee Schedule,,171.77,,,171.77,Other,110% of Medicare,88.04,,,88.04,Fee Schedule,,53,,,53,Other,186% of Medicaid,103.61,,,103.61,Fee Schedule,,215.14,,,215.14,Fee Schedule,,48.78,,,48.78,Fee Schedule,,103.61,,,103.61,Fee Schedule,,215.14,,,215.14,Fee Schedule,,91.76,,,91.76,Fee Schedule,,242.9,70,,242.9,percent of total billed charges,All Other,103.32,,,103.32,Fee Schedule,,87.57,,,87.57,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,256.78,
XR ELBOW 3 VIEWS  BILAT FY MOD,73080,CPT,FY50,42973080,CDM,320,RC,,,both,,,588,435.12,,,435.12,Other,150% of Medicare + 9.63% HCRA Surcharge,264.6,45,,264.6,percent of total billed charges,Critical Access Hospital RCC factor,85.65,,,85.65,Fee Schedule,,77.06,,,77.06,Fee Schedule,,174.02,,,174.02,Fee Schedule,,156.51,,,156.51,Fee Schedule,,147.93,,,147.93,Fee Schedule,,291.06,,,291.06,Other,110% of Medicare,101.76,,,101.76,Fee Schedule,,53,,,53,Other,186% of Medicaid,119.75,,,119.75,Fee Schedule,,364.56,,,364.56,Fee Schedule,,56.39,,,56.39,Fee Schedule,,119.75,,,119.75,Fee Schedule,,364.56,,,364.56,Fee Schedule,,106.06,,,106.06,Fee Schedule,,411.6,70,,411.6,percent of total billed charges,All Other,118.08,,,118.08,Fee Schedule,,100.08,,,100.08,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,435.12,
XR ARTHROGRAM ELBOW BILAT FY MOD,73085,CPT,FY50,42973085,CDM,320,RC,,,both,,,1799,1331.26,,,1331.26,Other,150% of Medicare + 9.63% HCRA Surcharge,809.55,45,,809.55,percent of total billed charges,Critical Access Hospital RCC factor,258.96,,,258.96,Fee Schedule,,232.99,,,232.99,Fee Schedule,,476.09,,,476.09,Fee Schedule,,428.21,,,428.21,Fee Schedule,,404.72,,,404.72,Fee Schedule,,890.51,,,890.51,Other,110% of Medicare,307.67,,,307.67,Fee Schedule,,392,,,392,Other,186% of Medicaid,362.06,,,362.06,Fee Schedule,,1115.38,,,1115.38,Fee Schedule,,170.48,,,170.48,Fee Schedule,,362.06,,,362.06,Fee Schedule,,1115.38,,,1115.38,Fee Schedule,,320.66,,,320.66,Fee Schedule,,1259.3,70,,1259.3,percent of total billed charges,All Other,424.76,,,424.76,Fee Schedule,,360.01,,,360.01,Fee Schedule,,610.96,,,610.96,Fee Schedule,,610.96,,,610.96,Fee Schedule,,610.96,,,610.96,Fee Schedule,,610.96,,,610.96,Fee Schedule,,210.57,,,210.57,Other,100% of Medicaid,210.57,,,210.57,Other,100% of Medicaid,210.57,,,210.57,Other,100% of Medicaid,210.57,,,210.57,Other,100% of Medicaid,473.77,,,473.77,Other,225% of Medicaid,322.17,,,322.17,Other,153% of Medicaid,473.77,,,473.77,Other,225% of Medicaid,294.79,,,294.79,Other,140% of Medicaid,473.77,,,473.77,Other,225% of Medicaid,547.47,,,547.47,Other,260% of Medicaid,682.23,,,682.23,Other,324% of Medicaid,452.72,,,452.72,Other,215% of Medicaid,452.72,,,452.72,Other,215% of Medicaid,263.21,,,263.21,Other,125% of Medicaid,170.48,1331.26,
XR FOREARM BILAT FY MOD,73090,CPT,FY50,42973090,CDM,320,RC,,,both,,,501,370.74,,,370.74,Other,150% of Medicare + 9.63% HCRA Surcharge,225.45,45,,225.45,percent of total billed charges,Critical Access Hospital RCC factor,75.25,,,75.25,Fee Schedule,,67.7,,,67.7,Fee Schedule,,135.12,,,135.12,Fee Schedule,,121.53,,,121.53,Fee Schedule,,114.87,,,114.87,Fee Schedule,,248,,,248,Other,110% of Medicare,89.41,,,89.41,Fee Schedule,,53,,,53,Other,186% of Medicaid,105.21,,,105.21,Fee Schedule,,310.62,,,310.62,Fee Schedule,,49.54,,,49.54,Fee Schedule,,105.21,,,105.21,Fee Schedule,,310.62,,,310.62,Fee Schedule,,93.18,,,93.18,Fee Schedule,,350.7,70,,350.7,percent of total billed charges,All Other,104.96,,,104.96,Fee Schedule,,88.96,,,88.96,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,370.74,
XR UPPER EXT CHILD BILAT FY MOD,73092,CPT,FY50,42973092,CDM,320,RC,,,both,,,363,268.62,,,268.62,Other,150% of Medicare + 9.63% HCRA Surcharge,163.35,45,,163.35,percent of total billed charges,Critical Access Hospital RCC factor,83.35,,,83.35,Fee Schedule,,74.99,,,74.99,Fee Schedule,,153.41,,,153.41,Fee Schedule,,137.98,,,137.98,Fee Schedule,,130.41,,,130.41,Fee Schedule,,179.69,,,179.69,Other,110% of Medicare,99.03,,,99.03,Fee Schedule,,53,,,53,Other,186% of Medicaid,116.54,,,116.54,Fee Schedule,,225.06,,,225.06,Fee Schedule,,54.87,,,54.87,Fee Schedule,,116.54,,,116.54,Fee Schedule,,225.06,,,225.06,Fee Schedule,,103.21,,,103.21,Fee Schedule,,254.1,70,,254.1,percent of total billed charges,All Other,118.08,,,118.08,Fee Schedule,,100.08,,,100.08,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,268.62,
XR WRIST 2 VIEWS BILAT FY MOD,73100,CPT,FY50,42973100,CDM,320,RC,,,both,,,347,256.78,,,256.78,Other,150% of Medicare + 9.63% HCRA Surcharge,156.15,45,,156.15,percent of total billed charges,Critical Access Hospital RCC factor,90.28,,,90.28,Fee Schedule,,81.22,,,81.22,Fee Schedule,,148.82,,,148.82,Fee Schedule,,133.86,,,133.86,Fee Schedule,,126.52,,,126.52,Fee Schedule,,171.77,,,171.77,Other,110% of Medicare,107.26,,,107.26,Fee Schedule,,53,,,53,Other,186% of Medicaid,126.22,,,126.22,Fee Schedule,,215.14,,,215.14,Fee Schedule,,59.43,,,59.43,Fee Schedule,,126.22,,,126.22,Fee Schedule,,215.14,,,215.14,Fee Schedule,,111.79,,,111.79,Fee Schedule,,242.9,70,,242.9,percent of total billed charges,All Other,126.28,,,126.28,Fee Schedule,,107.03,,,107.03,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,256.78,
XR WRIST 3+ V BILAT FY MOD,73110,CPT,FY50,42973110,CDM,320,RC,,,both,,,495,366.3,,,366.3,Other,150% of Medicare + 9.63% HCRA Surcharge,222.75,45,,222.75,percent of total billed charges,Critical Access Hospital RCC factor,114.55,,,114.55,Fee Schedule,,103.06,,,103.06,Fee Schedule,,187.77,,,187.77,Fee Schedule,,168.89,,,168.89,Fee Schedule,,159.62,,,159.62,Fee Schedule,,245.03,,,245.03,Other,110% of Medicare,136.1,,,136.1,Fee Schedule,,53,,,53,Other,186% of Medicaid,160.16,,,160.16,Fee Schedule,,306.9,,,306.9,Fee Schedule,,75.41,,,75.41,Fee Schedule,,160.16,,,160.16,Fee Schedule,,306.9,,,306.9,Fee Schedule,,141.84,,,141.84,Fee Schedule,,346.5,70,,346.5,percent of total billed charges,All Other,159.08,,,159.08,Fee Schedule,,134.83,,,134.83,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,366.3,
XR HAND 2 VIEWS BILAT FY MOD,73120,CPT,FY50,42973120,CDM,320,RC,,,both,,,363,268.62,,,268.62,Other,150% of Medicare + 9.63% HCRA Surcharge,163.35,45,,163.35,percent of total billed charges,Critical Access Hospital RCC factor,82.21,,,82.21,Fee Schedule,,73.96,,,73.96,Fee Schedule,,132.8,,,132.8,Fee Schedule,,119.45,,,119.45,Fee Schedule,,112.9,,,112.9,Fee Schedule,,179.69,,,179.69,Other,110% of Medicare,97.67,,,97.67,Fee Schedule,,53,,,53,Other,186% of Medicaid,114.93,,,114.93,Fee Schedule,,225.06,,,225.06,Fee Schedule,,54.12,,,54.12,Fee Schedule,,114.93,,,114.93,Fee Schedule,,225.06,,,225.06,Fee Schedule,,101.79,,,101.79,Fee Schedule,,254.1,70,,254.1,percent of total billed charges,All Other,113.16,,,113.16,Fee Schedule,,95.91,,,95.91,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,268.62,
XR HAND 3+ VIEWS BILAT FY MOD,73130,CPT,FY50,42973130,CDM,320,RC,,,both,,,528,390.72,,,390.72,Other,150% of Medicare + 9.63% HCRA Surcharge,237.6,45,,237.6,percent of total billed charges,Critical Access Hospital RCC factor,100.68,,,100.68,Fee Schedule,,90.58,,,90.58,Fee Schedule,,160.26,,,160.26,Fee Schedule,,144.14,,,144.14,Fee Schedule,,136.24,,,136.24,Fee Schedule,,261.36,,,261.36,Other,110% of Medicare,119.61,,,119.61,Fee Schedule,,53,,,53,Other,186% of Medicaid,140.76,,,140.76,Fee Schedule,,327.36,,,327.36,Fee Schedule,,66.28,,,66.28,Fee Schedule,,140.76,,,140.76,Fee Schedule,,327.36,,,327.36,Fee Schedule,,124.66,,,124.66,Fee Schedule,,369.6,70,,369.6,percent of total billed charges,All Other,137.76,,,137.76,Fee Schedule,,116.76,,,116.76,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,390.72,
XR FINGER 2+ VIEWS BILAT FY MOD,73140,CPT,FY50,42973140,CDM,320,RC,,,both,,,347,256.78,,,256.78,Other,150% of Medicare + 9.63% HCRA Surcharge,156.15,45,,156.15,percent of total billed charges,Critical Access Hospital RCC factor,109.93,,,109.93,Fee Schedule,,98.9,,,98.9,Fee Schedule,,167.16,,,167.16,Fee Schedule,,150.35,,,150.35,Fee Schedule,,142.11,,,142.11,Fee Schedule,,171.77,,,171.77,Other,110% of Medicare,130.6,,,130.6,Fee Schedule,,53,,,53,Other,186% of Medicaid,153.69,,,153.69,Fee Schedule,,215.14,,,215.14,Fee Schedule,,72.37,,,72.37,Fee Schedule,,153.69,,,153.69,Fee Schedule,,215.14,,,215.14,Fee Schedule,,136.12,,,136.12,Fee Schedule,,242.9,70,,242.9,percent of total billed charges,All Other,150.88,,,150.88,Fee Schedule,,127.88,,,127.88,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,256.78,
X-RAY EXAM OF FEMUR 1 BILATERAL FY MOD,73551,CPT,FY50,42973551,CDM,320,RC,,,both,,,356,263.44,,,263.44,Other,150% of Medicare + 9.63% HCRA Surcharge,160.2,45,,160.2,percent of total billed charges,Critical Access Hospital RCC factor,74.1,,,74.1,Fee Schedule,,66.67,,,66.67,Fee Schedule,,19.04,,,19.04,Fee Schedule,,19.04,,,19.04,Fee Schedule,,19.04,,,19.04,Fee Schedule,,176.22,,,176.22,Other,110% of Medicare,88.04,,,88.04,Fee Schedule,,53,,,53,Other,186% of Medicaid,103.61,,,103.61,Fee Schedule,,220.72,,,220.72,Fee Schedule,,48.78,,,48.78,Fee Schedule,,103.61,,,103.61,Fee Schedule,,220.72,,,220.72,Fee Schedule,,91.76,,,91.76,Fee Schedule,,249.2,70,,249.2,percent of total billed charges,All Other,103.32,,,103.32,Fee Schedule,,87.57,,,87.57,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,19.04,263.44,
X-RAY EXAM OF FEMUR 2/> BILAT FY MOD,73552,CPT,FY50,42973552,CDM,320,RC,,,both,,,356,263.44,,,263.44,Other,150% of Medicare + 9.63% HCRA Surcharge,160.2,45,,160.2,percent of total billed charges,Critical Access Hospital RCC factor,93.75,,,93.75,Fee Schedule,,84.35,,,84.35,Fee Schedule,,22.84,,,22.84,Fee Schedule,,22.84,,,22.84,Fee Schedule,,22.84,,,22.84,Fee Schedule,,176.22,,,176.22,Other,110% of Medicare,111.39,,,111.39,Fee Schedule,,53,,,53,Other,186% of Medicaid,131.08,,,131.08,Fee Schedule,,220.72,,,220.72,Fee Schedule,,61.72,,,61.72,Fee Schedule,,131.08,,,131.08,Fee Schedule,,220.72,,,220.72,Fee Schedule,,116.09,,,116.09,Fee Schedule,,249.2,70,,249.2,percent of total billed charges,All Other,129.56,,,129.56,Fee Schedule,,109.81,,,109.81,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,22.84,263.44,
XR KNEE 1 OR 2 VIEWS BILAT FY MOD,73560,CPT,FY50,42973560,CDM,320,RC,,,both,,,611,452.14,,,452.14,Other,150% of Medicare + 9.63% HCRA Surcharge,274.95,45,,274.95,percent of total billed charges,Critical Access Hospital RCC factor,91.43,,,91.43,Fee Schedule,,82.25,,,82.25,Fee Schedule,,144.29,,,144.29,Fee Schedule,,129.78,,,129.78,Fee Schedule,,122.66,,,122.66,Fee Schedule,,302.45,,,302.45,Other,110% of Medicare,108.62,,,108.62,Fee Schedule,,53,,,53,Other,186% of Medicaid,127.82,,,127.82,Fee Schedule,,378.82,,,378.82,Fee Schedule,,60.19,,,60.19,Fee Schedule,,127.82,,,127.82,Fee Schedule,,378.82,,,378.82,Fee Schedule,,113.21,,,113.21,Fee Schedule,,427.7,70,,427.7,percent of total billed charges,All Other,127.92,,,127.92,Fee Schedule,,108.42,,,108.42,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,452.14,
XR KNEE 3 VIEWS BILAT FY MOD,73562,CPT,FY50,42973562,CDM,320,RC,,,both,,,668,494.32,,,494.32,Other,150% of Medicare + 9.63% HCRA Surcharge,300.6,45,,300.6,percent of total billed charges,Critical Access Hospital RCC factor,111.08,,,111.08,Fee Schedule,,99.93,,,99.93,Fee Schedule,,180.87,,,180.87,Fee Schedule,,162.68,,,162.68,Fee Schedule,,153.75,,,153.75,Fee Schedule,,330.66,,,330.66,Other,110% of Medicare,131.97,,,131.97,Fee Schedule,,53,,,53,Other,186% of Medicaid,155.3,,,155.3,Fee Schedule,,414.16,,,414.16,Fee Schedule,,73.12,,,73.12,Fee Schedule,,155.3,,,155.3,Fee Schedule,,414.16,,,414.16,Fee Schedule,,137.54,,,137.54,Fee Schedule,,467.6,70,,467.6,percent of total billed charges,All Other,155.8,,,155.8,Fee Schedule,,132.05,,,132.05,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,494.32,
XR KNEE 4+ VIEWS BILAT FY MOD,73564,CPT,FY50,42973564,CDM,320,RC,,,both,,,668,494.32,,,494.32,Other,150% of Medicare + 9.63% HCRA Surcharge,300.6,45,,300.6,percent of total billed charges,Critical Access Hospital RCC factor,126.1,,,126.1,Fee Schedule,,113.45,,,113.45,Fee Schedule,,206.06,,,206.06,Fee Schedule,,185.33,,,185.33,Fee Schedule,,175.17,,,175.17,Fee Schedule,,330.66,,,330.66,Other,110% of Medicare,149.82,,,149.82,Fee Schedule,,53,,,53,Other,186% of Medicaid,176.3,,,176.3,Fee Schedule,,414.16,,,414.16,Fee Schedule,,83.01,,,83.01,Fee Schedule,,176.3,,,176.3,Fee Schedule,,414.16,,,414.16,Fee Schedule,,156.14,,,156.14,Fee Schedule,,467.6,70,,467.6,percent of total billed charges,All Other,173.84,,,173.84,Fee Schedule,,147.34,,,147.34,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,494.32,
XR TIBIA/FIBULA 2 VIEWS BIL FY MOD,73590,CPT,FY50,42973590,CDM,320,RC,,,both,,,560,414.4,,,414.4,Other,150% of Medicare + 9.63% HCRA Surcharge,252,45,,252,percent of total billed charges,Critical Access Hospital RCC factor,83.35,,,83.35,Fee Schedule,,74.99,,,74.99,Fee Schedule,,130.54,,,130.54,Fee Schedule,,117.41,,,117.41,Fee Schedule,,110.97,,,110.97,Fee Schedule,,277.2,,,277.2,Other,110% of Medicare,99.03,,,99.03,Fee Schedule,,53,,,53,Other,186% of Medicaid,116.54,,,116.54,Fee Schedule,,347.2,,,347.2,Fee Schedule,,54.87,,,54.87,Fee Schedule,,116.54,,,116.54,Fee Schedule,,347.2,,,347.2,Fee Schedule,,103.21,,,103.21,Fee Schedule,,392,70,,392,percent of total billed charges,All Other,116.44,,,116.44,Fee Schedule,,98.69,,,98.69,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,414.4,
XR LEG INFANT 2 VIEWS BILAT FY MOD,73592,CPT,FY50,42973592,CDM,320,RC,,,both,,,347,256.78,,,256.78,Other,150% of Medicare + 9.63% HCRA Surcharge,156.15,45,,156.15,percent of total billed charges,Critical Access Hospital RCC factor,83.35,,,83.35,Fee Schedule,,74.99,,,74.99,Fee Schedule,,155.73,,,155.73,Fee Schedule,,140.07,,,140.07,Fee Schedule,,132.38,,,132.38,Fee Schedule,,171.77,,,171.77,Other,110% of Medicare,99.03,,,99.03,Fee Schedule,,53,,,53,Other,186% of Medicaid,116.54,,,116.54,Fee Schedule,,215.14,,,215.14,Fee Schedule,,54.87,,,54.87,Fee Schedule,,116.54,,,116.54,Fee Schedule,,215.14,,,215.14,Fee Schedule,,103.21,,,103.21,Fee Schedule,,242.9,70,,242.9,percent of total billed charges,All Other,118.08,,,118.08,Fee Schedule,,100.08,,,100.08,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,256.78,
XR ANKLE 2 V BILAT FY MOD,73600,CPT,FY50,42973600,CDM,320,RC,,,both,,,347,256.78,,,256.78,Other,150% of Medicare + 9.63% HCRA Surcharge,156.15,45,,156.15,percent of total billed charges,Critical Access Hospital RCC factor,85.65,,,85.65,Fee Schedule,,77.06,,,77.06,Fee Schedule,,137.39,,,137.39,Fee Schedule,,123.57,,,123.57,Fee Schedule,,116.79,,,116.79,Fee Schedule,,171.77,,,171.77,Other,110% of Medicare,101.76,,,101.76,Fee Schedule,,53,,,53,Other,186% of Medicaid,119.75,,,119.75,Fee Schedule,,215.14,,,215.14,Fee Schedule,,56.39,,,56.39,Fee Schedule,,119.75,,,119.75,Fee Schedule,,215.14,,,215.14,Fee Schedule,,106.06,,,106.06,Fee Schedule,,242.9,70,,242.9,percent of total billed charges,All Other,119.72,,,119.72,Fee Schedule,,101.47,,,101.47,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,256.78,
XR ANKLE 3+ VIEWS BILAT FY MOD,73610,CPT,FY50,42973610,CDM,320,RC,,,both,,,522,386.28,,,386.28,Other,150% of Medicare + 9.63% HCRA Surcharge,234.9,45,,234.9,percent of total billed charges,Critical Access Hospital RCC factor,98.38,,,98.38,Fee Schedule,,88.51,,,88.51,Fee Schedule,,162.58,,,162.58,Fee Schedule,,146.23,,,146.23,Fee Schedule,,138.21,,,138.21,Fee Schedule,,258.39,,,258.39,Other,110% of Medicare,116.88,,,116.88,Fee Schedule,,53,,,53,Other,186% of Medicaid,137.55,,,137.55,Fee Schedule,,323.64,,,323.64,Fee Schedule,,64.76,,,64.76,Fee Schedule,,137.55,,,137.55,Fee Schedule,,323.64,,,323.64,Fee Schedule,,121.82,,,121.82,Fee Schedule,,365.4,70,,365.4,percent of total billed charges,All Other,139.4,,,139.4,Fee Schedule,,118.15,,,118.15,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,386.28,
XR FOOT 2 V BILAT FY MOD,73620,CPT,FY50,42973620,CDM,320,RC,,,both,,,347,256.78,,,256.78,Other,150% of Medicare + 9.63% HCRA Surcharge,156.15,45,,156.15,percent of total billed charges,Critical Access Hospital RCC factor,74.1,,,74.1,Fee Schedule,,66.67,,,66.67,Fee Schedule,,132.8,,,132.8,Fee Schedule,,119.45,,,119.45,Fee Schedule,,112.9,,,112.9,Fee Schedule,,171.77,,,171.77,Other,110% of Medicare,88.04,,,88.04,Fee Schedule,,53,,,53,Other,186% of Medicaid,103.61,,,103.61,Fee Schedule,,215.14,,,215.14,Fee Schedule,,48.78,,,48.78,Fee Schedule,,103.61,,,103.61,Fee Schedule,,215.14,,,215.14,Fee Schedule,,91.76,,,91.76,Fee Schedule,,242.9,70,,242.9,percent of total billed charges,All Other,101.68,,,101.68,Fee Schedule,,86.18,,,86.18,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,256.78,
XR FOOT 3+ VIEWS BILAT FY MOD,73630,CPT,FY50,42973630,CDM,320,RC,,,both,,,560,414.4,,,414.4,Other,150% of Medicare + 9.63% HCRA Surcharge,252,45,,252,percent of total billed charges,Critical Access Hospital RCC factor,91.43,,,91.43,Fee Schedule,,82.25,,,82.25,Fee Schedule,,157.99,,,157.99,Fee Schedule,,142.11,,,142.11,Fee Schedule,,134.31,,,134.31,Fee Schedule,,277.2,,,277.2,Other,110% of Medicare,108.62,,,108.62,Fee Schedule,,53,,,53,Other,186% of Medicaid,127.82,,,127.82,Fee Schedule,,347.2,,,347.2,Fee Schedule,,60.19,,,60.19,Fee Schedule,,127.82,,,127.82,Fee Schedule,,347.2,,,347.2,Fee Schedule,,113.21,,,113.21,Fee Schedule,,392,70,,392,percent of total billed charges,All Other,129.56,,,129.56,Fee Schedule,,109.81,,,109.81,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,414.4,
XR HEEL 2+ VIEWS BILAT FY MOD,73650,CPT,FY50,42973650,CDM,320,RC,,,both,,,347,256.78,,,256.78,Other,150% of Medicare + 9.63% HCRA Surcharge,156.15,45,,156.15,percent of total billed charges,Critical Access Hospital RCC factor,72.96,,,72.96,Fee Schedule,,65.64,,,65.64,Fee Schedule,,135.12,,,135.12,Fee Schedule,,121.53,,,121.53,Fee Schedule,,114.87,,,114.87,Fee Schedule,,171.77,,,171.77,Other,110% of Medicare,86.68,,,86.68,Fee Schedule,,53,,,53,Other,186% of Medicaid,102,,,102,Fee Schedule,,215.14,,,215.14,Fee Schedule,,48.03,,,48.03,Fee Schedule,,102,,,102,Fee Schedule,,215.14,,,215.14,Fee Schedule,,90.34,,,90.34,Fee Schedule,,242.9,70,,242.9,percent of total billed charges,All Other,103.32,,,103.32,Fee Schedule,,87.57,,,87.57,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,256.78,
XR TOE(S) 2+ VIEWS  BILAT FY MOD,73660,CPT,FY50,42973660,CDM,320,RC,,,both,,,347,256.78,,,256.78,Other,150% of Medicare + 9.63% HCRA Surcharge,156.15,45,,156.15,percent of total billed charges,Critical Access Hospital RCC factor,79.88,,,79.88,Fee Schedule,,71.86,,,71.86,Fee Schedule,,155.73,,,155.73,Fee Schedule,,140.07,,,140.07,Fee Schedule,,132.38,,,132.38,Fee Schedule,,171.77,,,171.77,Other,110% of Medicare,94.9,,,94.9,Fee Schedule,,53,,,53,Other,186% of Medicaid,111.68,,,111.68,Fee Schedule,,215.14,,,215.14,Fee Schedule,,52.58,,,52.58,Fee Schedule,,111.68,,,111.68,Fee Schedule,,215.14,,,215.14,Fee Schedule,,98.91,,,98.91,Fee Schedule,,242.9,70,,242.9,percent of total billed charges,All Other,111.52,,,111.52,Fee Schedule,,94.52,,,94.52,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,256.78,
XR EXAM OF JAW 4+ VIEWS W/ FY MOD,70110,CPT,FY,43070110,CDM,320,RC,,,both,,,510,377.4,,,377.4,Other,150% of Medicare + 9.63% HCRA Surcharge,229.5,45,,229.5,percent of total billed charges,Critical Access Hospital RCC factor,111.08,,,111.08,Fee Schedule,,99.93,,,99.93,Fee Schedule,,185.45,,,185.45,Fee Schedule,,166.8,,,166.8,Fee Schedule,,157.65,,,157.65,Fee Schedule,,252.45,,,252.45,Other,110% of Medicare,131.97,,,131.97,Fee Schedule,,53,,,53,Other,186% of Medicaid,155.3,,,155.3,Fee Schedule,,316.2,,,316.2,Fee Schedule,,73.12,,,73.12,Fee Schedule,,155.3,,,155.3,Fee Schedule,,316.2,,,316.2,Fee Schedule,,137.54,,,137.54,Fee Schedule,,357,70,,357,percent of total billed charges,All Other,157.44,,,157.44,Fee Schedule,,133.44,,,133.44,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,377.4,
XR EXAM OF MASTOIDS 3+ VIEW W/ FY MOD,70130,CPT,FY,43070130,CDM,320,RC,,,both,,,653,483.22,,,483.22,Other,150% of Medicare + 9.63% HCRA Surcharge,293.85,45,,293.85,percent of total billed charges,Critical Access Hospital RCC factor,159.6,,,159.6,Fee Schedule,,143.59,,,143.59,Fee Schedule,,267.82,,,267.82,Fee Schedule,,240.89,,,240.89,Fee Schedule,,227.67,,,227.67,Fee Schedule,,323.24,,,323.24,Other,110% of Medicare,189.61,,,189.61,Fee Schedule,,53,,,53,Other,186% of Medicaid,223.13,,,223.13,Fee Schedule,,404.86,,,404.86,Fee Schedule,,105.06,,,105.06,Fee Schedule,,223.13,,,223.13,Fee Schedule,,404.86,,,404.86,Fee Schedule,,197.62,,,197.62,Fee Schedule,,457.1,70,,457.1,percent of total billed charges,All Other,227.96,,,227.96,Fee Schedule,,193.21,,,193.21,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,483.22,
XR  OF FACIAL BONES < 3 VIEWS W/ FY MOD,70140,CPT,FY,43070140,CDM,320,RC,,,both,,,198,146.52,,,146.52,Other,150% of Medicare + 9.63% HCRA Surcharge,89.1,45,,89.1,percent of total billed charges,Critical Access Hospital RCC factor,78.73,,,78.73,Fee Schedule,,70.83,,,70.83,Fee Schedule,,139.71,,,139.71,Fee Schedule,,125.66,,,125.66,Fee Schedule,,118.76,,,118.76,Fee Schedule,,98.01,,,98.01,Other,110% of Medicare,93.54,,,93.54,Fee Schedule,,53,,,53,Other,186% of Medicaid,110.07,,,110.07,Fee Schedule,,122.76,,,122.76,Fee Schedule,,51.83,,,51.83,Fee Schedule,,110.07,,,110.07,Fee Schedule,,122.76,,,122.76,Fee Schedule,,97.49,,,97.49,Fee Schedule,,138.6,70,,138.6,percent of total billed charges,All Other,109.88,,,109.88,Fee Schedule,,93.13,,,93.13,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,146.52,
XR EXAM OF FACIAL BONES 3+ VIEWS W/ FY,70150,CPT,FY,43070150,CDM,320,RC,,,both,,,248,183.52,,,183.52,Other,150% of Medicare + 9.63% HCRA Surcharge,111.6,45,,111.6,percent of total billed charges,Critical Access Hospital RCC factor,121.48,,,121.48,Fee Schedule,,109.29,,,109.29,Fee Schedule,,203.74,,,203.74,Fee Schedule,,183.25,,,183.25,Fee Schedule,,173.2,,,173.2,Fee Schedule,,122.76,,,122.76,Other,110% of Medicare,144.32,,,144.32,Fee Schedule,,53,,,53,Other,186% of Medicaid,169.84,,,169.84,Fee Schedule,,153.76,,,153.76,Fee Schedule,,79.97,,,79.97,Fee Schedule,,169.84,,,169.84,Fee Schedule,,153.76,,,153.76,Fee Schedule,,150.42,,,150.42,Fee Schedule,,173.6,70,,173.6,percent of total billed charges,All Other,172.2,,,172.2,Fee Schedule,,145.95,,,145.95,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,203.74,
XR NASAL BONES 3 VIEWS W/ FY MOD,70160,CPT,FY,43070160,CDM,320,RC,,,both,,,470,347.8,,,347.8,Other,150% of Medicare + 9.63% HCRA Surcharge,211.5,45,,211.5,percent of total billed charges,Critical Access Hospital RCC factor,102.97,,,102.97,Fee Schedule,,92.64,,,92.64,Fee Schedule,,167.16,,,167.16,Fee Schedule,,150.35,,,150.35,Fee Schedule,,142.11,,,142.11,Fee Schedule,,232.65,,,232.65,Other,110% of Medicare,122.34,,,122.34,Fee Schedule,,53,,,53,Other,186% of Medicaid,143.97,,,143.97,Fee Schedule,,291.4,,,291.4,Fee Schedule,,67.79,,,67.79,Fee Schedule,,143.97,,,143.97,Fee Schedule,,291.4,,,291.4,Fee Schedule,,127.51,,,127.51,Fee Schedule,,329,70,,329,percent of total billed charges,All Other,145.96,,,145.96,Fee Schedule,,123.71,,,123.71,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,347.8,
XR EYE SOCKETS 4+ VIEWS W/ FY MOD,70200,CPT,FY,43070200,CDM,320,RC,,,both,,,248,183.52,,,183.52,Other,150% of Medicare + 9.63% HCRA Surcharge,111.6,45,,111.6,percent of total billed charges,Critical Access Hospital RCC factor,120.33,,,120.33,Fee Schedule,,108.26,,,108.26,Fee Schedule,,206.06,,,206.06,Fee Schedule,,185.33,,,185.33,Fee Schedule,,175.17,,,175.17,Fee Schedule,,122.76,,,122.76,Other,110% of Medicare,142.96,,,142.96,Fee Schedule,,53,,,53,Other,186% of Medicaid,168.23,,,168.23,Fee Schedule,,153.76,,,153.76,Fee Schedule,,79.21,,,79.21,Fee Schedule,,168.23,,,168.23,Fee Schedule,,153.76,,,153.76,Fee Schedule,,148.99,,,148.99,Fee Schedule,,173.6,70,,173.6,percent of total billed charges,All Other,172.2,,,172.2,Fee Schedule,,145.95,,,145.95,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,206.06,
XR EXAM OF SINUSES <3 VIEWS W/ FY MOD,70210,CPT,FY,43070210,CDM,320,RC,,,both,,,282,208.68,,,208.68,Other,150% of Medicare + 9.63% HCRA Surcharge,126.9,45,,126.9,percent of total billed charges,Critical Access Hospital RCC factor,83.35,,,83.35,Fee Schedule,,74.99,,,74.99,Fee Schedule,,151.14,,,151.14,Fee Schedule,,135.94,,,135.94,Fee Schedule,,128.49,,,128.49,Fee Schedule,,139.59,,,139.59,Other,110% of Medicare,99.03,,,99.03,Fee Schedule,,53,,,53,Other,186% of Medicaid,116.54,,,116.54,Fee Schedule,,174.84,,,174.84,Fee Schedule,,54.87,,,54.87,Fee Schedule,,116.54,,,116.54,Fee Schedule,,174.84,,,174.84,Fee Schedule,,103.21,,,103.21,Fee Schedule,,197.4,70,,197.4,percent of total billed charges,All Other,118.08,,,118.08,Fee Schedule,,100.08,,,100.08,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,208.68,
XR EXAM OF SINUSES 3+ VIEWS W/ FY MOD,70220,CPT,FY,43070220,CDM,320,RC,,,both,,,601,444.74,,,444.74,Other,150% of Medicare + 9.63% HCRA Surcharge,270.45,45,,270.45,percent of total billed charges,Critical Access Hospital RCC factor,94.9,,,94.9,Fee Schedule,,85.38,,,85.38,Fee Schedule,,180.87,,,180.87,Fee Schedule,,162.68,,,162.68,Fee Schedule,,153.75,,,153.75,Fee Schedule,,297.5,,,297.5,Other,110% of Medicare,112.75,,,112.75,Fee Schedule,,53,,,53,Other,186% of Medicaid,132.69,,,132.69,Fee Schedule,,372.62,,,372.62,Fee Schedule,,62.48,,,62.48,Fee Schedule,,132.69,,,132.69,Fee Schedule,,372.62,,,372.62,Fee Schedule,,117.51,,,117.51,Fee Schedule,,420.7,70,,420.7,percent of total billed charges,All Other,134.48,,,134.48,Fee Schedule,,113.98,,,113.98,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,444.74,
XR SELLA TURCICA W/ FY MOD,70240,CPT,FY,43070240,CDM,320,RC,,,both,,,472,349.28,,,349.28,Other,150% of Medicare + 9.63% HCRA Surcharge,212.4,45,,212.4,percent of total billed charges,Critical Access Hospital RCC factor,83.35,,,83.35,Fee Schedule,,74.99,,,74.99,Fee Schedule,,137.39,,,137.39,Fee Schedule,,123.57,,,123.57,Fee Schedule,,116.79,,,116.79,Fee Schedule,,233.64,,,233.64,Other,110% of Medicare,99.03,,,99.03,Fee Schedule,,53,,,53,Other,186% of Medicaid,116.54,,,116.54,Fee Schedule,,292.64,,,292.64,Fee Schedule,,54.87,,,54.87,Fee Schedule,,116.54,,,116.54,Fee Schedule,,292.64,,,292.64,Fee Schedule,,103.21,,,103.21,Fee Schedule,,330.4,70,,330.4,percent of total billed charges,All Other,118.08,,,118.08,Fee Schedule,,100.08,,,100.08,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,349.28,
XR SKULL COMPLETE W/ FY MOD,70250,CPT,FY,43070250,CDM,320,RC,,,both,,,242,179.08,,,179.08,Other,150% of Medicare + 9.63% HCRA Surcharge,108.9,45,,108.9,percent of total billed charges,Critical Access Hospital RCC factor,96.05,,,96.05,Fee Schedule,,86.42,,,86.42,Fee Schedule,,169.43,,,169.43,Fee Schedule,,152.39,,,152.39,Fee Schedule,,144.03,,,144.03,Fee Schedule,,119.79,,,119.79,Other,110% of Medicare,114.12,,,114.12,Fee Schedule,,53,,,53,Other,186% of Medicaid,134.29,,,134.29,Fee Schedule,,150.04,,,150.04,Fee Schedule,,63.23,,,63.23,Fee Schedule,,134.29,,,134.29,Fee Schedule,,150.04,,,150.04,Fee Schedule,,118.93,,,118.93,Fee Schedule,,169.4,70,,169.4,percent of total billed charges,All Other,132.84,,,132.84,Fee Schedule,,112.59,,,112.59,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,179.33,
XR SKULL COMPLETE MIN 4 VIE W/ FY MOD,70260,CPT,FY,43070260,CDM,320,RC,,,both,,,330,244.2,,,244.2,Other,150% of Medicare + 9.63% HCRA Surcharge,148.5,45,,148.5,percent of total billed charges,Critical Access Hospital RCC factor,108.78,,,108.78,Fee Schedule,,97.87,,,97.87,Fee Schedule,,208.32,,,208.32,Fee Schedule,,187.37,,,187.37,Fee Schedule,,177.09,,,177.09,Fee Schedule,,163.35,,,163.35,Other,110% of Medicare,129.24,,,129.24,Fee Schedule,,53,,,53,Other,186% of Medicaid,152.09,,,152.09,Fee Schedule,,204.6,,,204.6,Fee Schedule,,71.61,,,71.61,Fee Schedule,,152.09,,,152.09,Fee Schedule,,204.6,,,204.6,Fee Schedule,,134.7,,,134.7,Fee Schedule,,231,70,,231,percent of total billed charges,All Other,154.16,,,154.16,Fee Schedule,,130.66,,,130.66,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,244.2,
TMJ JOINT - UNILATERAL W/ FY MOD,70328,CPT,FY,43070328,CDM,320,RC,,,both,,,649,480.26,,,480.26,Other,150% of Medicare + 9.63% HCRA Surcharge,292.05,45,,292.05,percent of total billed charges,Critical Access Hospital RCC factor,90.28,,,90.28,Fee Schedule,,81.22,,,81.22,Fee Schedule,,148.82,,,148.82,Fee Schedule,,133.86,,,133.86,Fee Schedule,,126.52,,,126.52,Fee Schedule,,321.26,,,321.26,Other,110% of Medicare,107.26,,,107.26,Fee Schedule,,53,,,53,Other,186% of Medicaid,126.22,,,126.22,Fee Schedule,,402.38,,,402.38,Fee Schedule,,59.43,,,59.43,Fee Schedule,,126.22,,,126.22,Fee Schedule,,402.38,,,402.38,Fee Schedule,,111.79,,,111.79,Fee Schedule,,454.3,70,,454.3,percent of total billed charges,All Other,127.92,,,127.92,Fee Schedule,,108.42,,,108.42,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,480.26,
XR TM JOINT BILATERAL W/ FY MOD,70360,CPT,FY,43070360,CDM,320,RC,,,both,,,231,170.94,,,170.94,Other,150% of Medicare + 9.63% HCRA Surcharge,103.95,45,,103.95,percent of total billed charges,Critical Access Hospital RCC factor,78.73,,,78.73,Fee Schedule,,70.83,,,70.83,Fee Schedule,,130.54,,,130.54,Fee Schedule,,117.41,,,117.41,Fee Schedule,,110.97,,,110.97,Fee Schedule,,114.35,,,114.35,Other,110% of Medicare,93.54,,,93.54,Fee Schedule,,53,,,53,Other,186% of Medicaid,110.07,,,110.07,Fee Schedule,,143.22,,,143.22,Fee Schedule,,51.83,,,51.83,Fee Schedule,,110.07,,,110.07,Fee Schedule,,143.22,,,143.22,Fee Schedule,,97.49,,,97.49,Fee Schedule,,161.7,70,,161.7,percent of total billed charges,All Other,111.52,,,111.52,Fee Schedule,,94.52,,,94.52,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,170.94,
SALIVARY GLAND CALCULUS W/ FY MOD,70380,CPT,FY,43070380,CDM,320,RC,,,both,,,624,461.76,,,461.76,Other,150% of Medicare + 9.63% HCRA Surcharge,280.8,45,,280.8,percent of total billed charges,Critical Access Hospital RCC factor,102.97,,,102.97,Fee Schedule,,92.64,,,92.64,Fee Schedule,,206.06,,,206.06,Fee Schedule,,185.33,,,185.33,Fee Schedule,,175.17,,,175.17,Fee Schedule,,308.88,,,308.88,Other,110% of Medicare,122.34,,,122.34,Fee Schedule,,53,,,53,Other,186% of Medicaid,143.97,,,143.97,Fee Schedule,,386.88,,,386.88,Fee Schedule,,67.79,,,67.79,Fee Schedule,,143.97,,,143.97,Fee Schedule,,386.88,,,386.88,Fee Schedule,,127.51,,,127.51,Fee Schedule,,436.8,70,,436.8,percent of total billed charges,All Other,145.96,,,145.96,Fee Schedule,,123.71,,,123.71,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,461.76,
XR RIBS BILATERAL W/ FY MOD,71110,CPT,FY,43071110,CDM,320,RC,,,both,,,513,379.62,,,379.62,Other,150% of Medicare + 9.63% HCRA Surcharge,230.85,45,,230.85,percent of total billed charges,Critical Access Hospital RCC factor,105.3,,,105.3,Fee Schedule,,94.74,,,94.74,Fee Schedule,,187.77,,,187.77,Fee Schedule,,168.89,,,168.89,Fee Schedule,,159.62,,,159.62,Fee Schedule,,253.94,,,253.94,Other,110% of Medicare,125.11,,,125.11,Fee Schedule,,53,,,53,Other,186% of Medicaid,147.22,,,147.22,Fee Schedule,,318.06,,,318.06,Fee Schedule,,69.32,,,69.32,Fee Schedule,,147.22,,,147.22,Fee Schedule,,318.06,,,318.06,Fee Schedule,,130.39,,,130.39,Fee Schedule,,359.1,70,,359.1,percent of total billed charges,All Other,147.6,,,147.6,Fee Schedule,,125.1,,,125.1,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,379.62,
XR RIBS BILATERAL 4 VIEWS A W/FY MOD,71111,CPT,FY,43071111,CDM,320,RC,,,both,,,548,405.52,,,405.52,Other,150% of Medicare + 9.63% HCRA Surcharge,246.6,45,,246.6,percent of total billed charges,Critical Access Hospital RCC factor,129.55,,,129.55,Fee Schedule,,116.55,,,116.55,Fee Schedule,,251.8,,,251.8,Fee Schedule,,226.48,,,226.48,Fee Schedule,,214.05,,,214.05,Fee Schedule,,271.26,,,271.26,Other,110% of Medicare,153.91,,,153.91,Fee Schedule,,53,,,53,Other,186% of Medicaid,181.12,,,181.12,Fee Schedule,,339.76,,,339.76,Fee Schedule,,85.28,,,85.28,Fee Schedule,,181.12,,,181.12,Fee Schedule,,339.76,,,339.76,Fee Schedule,,160.41,,,160.41,Fee Schedule,,383.6,70,,383.6,percent of total billed charges,All Other,183.68,,,183.68,Fee Schedule,,155.68,,,155.68,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,405.52,
XR OF STERNUM 2 VIEWS W/ FY MOD,71120,CPT,FY,43071120,CDM,320,RC,,,both,,,548,405.52,,,405.52,Other,150% of Medicare + 9.63% HCRA Surcharge,246.6,45,,246.6,percent of total billed charges,Critical Access Hospital RCC factor,84.5,,,84.5,Fee Schedule,,76.03,,,76.03,Fee Schedule,,151.14,,,151.14,Fee Schedule,,135.94,,,135.94,Fee Schedule,,128.49,,,128.49,Fee Schedule,,271.26,,,271.26,Other,110% of Medicare,100.4,,,100.4,Fee Schedule,,53,,,53,Other,186% of Medicaid,118.15,,,118.15,Fee Schedule,,339.76,,,339.76,Fee Schedule,,55.63,,,55.63,Fee Schedule,,118.15,,,118.15,Fee Schedule,,339.76,,,339.76,Fee Schedule,,104.64,,,104.64,Fee Schedule,,383.6,70,,383.6,percent of total billed charges,All Other,119.72,,,119.72,Fee Schedule,,101.47,,,101.47,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,405.52,
XR EXAM OF BREASTBONE 3+ VI W/ FY MOD,71130,CPT,FY,43071130,CDM,320,RC,,,both,,,520,384.8,,,384.8,Other,150% of Medicare + 9.63% HCRA Surcharge,234,45,,234,percent of total billed charges,Critical Access Hospital RCC factor,107.6,,,107.6,Fee Schedule,,96.81,,,96.81,Fee Schedule,,180.87,,,180.87,Fee Schedule,,162.68,,,162.68,Fee Schedule,,153.75,,,153.75,Fee Schedule,,257.4,,,257.4,Other,110% of Medicare,127.84,,,127.84,Fee Schedule,,53,,,53,Other,186% of Medicaid,150.44,,,150.44,Fee Schedule,,322.4,,,322.4,Fee Schedule,,70.83,,,70.83,Fee Schedule,,150.44,,,150.44,Fee Schedule,,322.4,,,322.4,Fee Schedule,,133.23,,,133.23,Fee Schedule,,364,70,,364,percent of total billed charges,All Other,152.52,,,152.52,Fee Schedule,,129.27,,,129.27,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,384.8,
XR SPINE 1 VIEW W/ FY MOD,72020,CPT,FY,43072020,CDM,320,RC,,,both,,,433,320.42,,,320.42,Other,150% of Medicare + 9.63% HCRA Surcharge,194.85,45,,194.85,percent of total billed charges,Critical Access Hospital RCC factor,57.93,,,57.93,Fee Schedule,,52.12,,,52.12,Fee Schedule,,109.93,,,109.93,Fee Schedule,,98.88,,,98.88,Fee Schedule,,93.45,,,93.45,Fee Schedule,,214.34,,,214.34,Other,110% of Medicare,68.83,,,68.83,Fee Schedule,,53,,,53,Other,186% of Medicaid,80.99,,,80.99,Fee Schedule,,268.46,,,268.46,Fee Schedule,,38.14,,,38.14,Fee Schedule,,80.99,,,80.99,Fee Schedule,,268.46,,,268.46,Fee Schedule,,71.73,,,71.73,Fee Schedule,,303.1,70,,303.1,percent of total billed charges,All Other,82,,,82,Fee Schedule,,69.5,,,69.5,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,320.42,
XR CERVICAL SPINE 2-3 VIEWS W/ FY MOD,72040,CPT,FY,43072040,CDM,320,RC,,,both,,,481,355.94,,,355.94,Other,150% of Medicare + 9.63% HCRA Surcharge,216.45,45,,216.45,percent of total billed charges,Critical Access Hospital RCC factor,100.68,,,100.68,Fee Schedule,,90.58,,,90.58,Fee Schedule,,185.45,,,185.45,Fee Schedule,,166.8,,,166.8,Fee Schedule,,157.65,,,157.65,Fee Schedule,,238.1,,,238.1,Other,110% of Medicare,119.61,,,119.61,Fee Schedule,,53,,,53,Other,186% of Medicaid,140.76,,,140.76,Fee Schedule,,298.22,,,298.22,Fee Schedule,,66.28,,,66.28,Fee Schedule,,140.76,,,140.76,Fee Schedule,,298.22,,,298.22,Fee Schedule,,124.66,,,124.66,Fee Schedule,,336.7,70,,336.7,percent of total billed charges,All Other,141.04,,,141.04,Fee Schedule,,119.54,,,119.54,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,355.94,
XR CERVICAL SPINE 4 VIEWS W/ FY MOD,72050,CPT,FY,43072050,CDM,320,RC,,,both,,,525,388.5,,,388.5,Other,150% of Medicare + 9.63% HCRA Surcharge,236.25,45,,236.25,percent of total billed charges,Critical Access Hospital RCC factor,142.27,,,142.27,Fee Schedule,,128,,,128,Fee Schedule,,251.8,,,251.8,Fee Schedule,,226.48,,,226.48,Fee Schedule,,214.05,,,214.05,Fee Schedule,,259.88,,,259.88,Other,110% of Medicare,169.03,,,169.03,Fee Schedule,,53,,,53,Other,186% of Medicaid,198.92,,,198.92,Fee Schedule,,325.5,,,325.5,Fee Schedule,,93.66,,,93.66,Fee Schedule,,198.92,,,198.92,Fee Schedule,,325.5,,,325.5,Fee Schedule,,176.17,,,176.17,Fee Schedule,,367.5,70,,367.5,percent of total billed charges,All Other,196.8,,,196.8,Fee Schedule,,166.8,,,166.8,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,388.5,
XR CERVICAL SPINE COMP W/ FY MOD,72052,CPT,FY,43072052,CDM,320,RC,,,both,,,624,461.76,,,461.76,Other,150% of Medicare + 9.63% HCRA Surcharge,280.8,45,,280.8,percent of total billed charges,Critical Access Hospital RCC factor,167.7,,,167.7,Fee Schedule,,150.88,,,150.88,Fee Schedule,,331.9,,,331.9,Fee Schedule,,298.53,,,298.53,Fee Schedule,,282.15,,,282.15,Fee Schedule,,308.88,,,308.88,Other,110% of Medicare,199.24,,,199.24,Fee Schedule,,53,,,53,Other,186% of Medicaid,234.46,,,234.46,Fee Schedule,,386.88,,,386.88,Fee Schedule,,110.4,,,110.4,Fee Schedule,,234.46,,,234.46,Fee Schedule,,386.88,,,386.88,Fee Schedule,,207.65,,,207.65,Fee Schedule,,436.8,70,,436.8,percent of total billed charges,All Other,234.52,,,234.52,Fee Schedule,,198.77,,,198.77,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,461.76,
XR THORACIC SPINE 2 VIEWS W/ FY MOD,72070,CPT,FY,43072070,CDM,320,RC,,,both,,,587,434.38,,,434.38,Other,150% of Medicare + 9.63% HCRA Surcharge,264.15,45,,264.15,percent of total billed charges,Critical Access Hospital RCC factor,81.03,,,81.03,Fee Schedule,,72.9,,,72.9,Fee Schedule,,155.73,,,155.73,Fee Schedule,,140.07,,,140.07,Fee Schedule,,132.38,,,132.38,Fee Schedule,,290.57,,,290.57,Other,110% of Medicare,96.27,,,96.27,Fee Schedule,,53,,,53,Other,186% of Medicaid,113.28,,,113.28,Fee Schedule,,363.94,,,363.94,Fee Schedule,,53.34,,,53.34,Fee Schedule,,113.28,,,113.28,Fee Schedule,,363.94,,,363.94,Fee Schedule,,100.33,,,100.33,Fee Schedule,,410.9,70,,410.9,percent of total billed charges,All Other,113.16,,,113.16,Fee Schedule,,95.91,,,95.91,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,434.38,
XR THORACIC SPINE 3 VIEWS W/ FY MOD,72072,CPT,FY,43072072,CDM,320,RC,,,both,,,550,407,,,407,Other,150% of Medicare + 9.63% HCRA Surcharge,247.5,45,,247.5,percent of total billed charges,Critical Access Hospital RCC factor,100.68,,,100.68,Fee Schedule,,90.58,,,90.58,Fee Schedule,,183.19,,,183.19,Fee Schedule,,164.76,,,164.76,Fee Schedule,,155.72,,,155.72,Fee Schedule,,272.25,,,272.25,Other,110% of Medicare,119.61,,,119.61,Fee Schedule,,53,,,53,Other,186% of Medicaid,140.76,,,140.76,Fee Schedule,,341,,,341,Fee Schedule,,66.28,,,66.28,Fee Schedule,,140.76,,,140.76,Fee Schedule,,341,,,341,Fee Schedule,,124.66,,,124.66,Fee Schedule,,385,70,,385,percent of total billed charges,All Other,139.4,,,139.4,Fee Schedule,,118.15,,,118.15,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,407,
XR EXAM OF THORACIC SPINE 4+ VIEWS W/ FY,72074,CPT,FY,43072074,CDM,320,RC,,,both,,,242,179.08,,,179.08,Other,150% of Medicare + 9.63% HCRA Surcharge,108.9,45,,108.9,percent of total billed charges,Critical Access Hospital RCC factor,114.55,,,114.55,Fee Schedule,,103.06,,,103.06,Fee Schedule,,228.93,,,228.93,Fee Schedule,,205.91,,,205.91,Fee Schedule,,194.61,,,194.61,Fee Schedule,,119.79,,,119.79,Other,110% of Medicare,136.1,,,136.1,Fee Schedule,,53,,,53,Other,186% of Medicaid,160.16,,,160.16,Fee Schedule,,150.04,,,150.04,Fee Schedule,,75.41,,,75.41,Fee Schedule,,160.16,,,160.16,Fee Schedule,,150.04,,,150.04,Fee Schedule,,141.84,,,141.84,Fee Schedule,,169.4,70,,169.4,percent of total billed charges,All Other,160.72,,,160.72,Fee Schedule,,136.22,,,136.22,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,228.93,
XR THORACOLUMBAR 2 VIEWS W/ FY MOD,72080,CPT,FY,43072080,CDM,320,RC,,,both,,,362,267.88,,,267.88,Other,150% of Medicare + 9.63% HCRA Surcharge,162.9,45,,162.9,percent of total billed charges,Critical Access Hospital RCC factor,85.65,,,85.65,Fee Schedule,,77.06,,,77.06,Fee Schedule,,169.43,,,169.43,Fee Schedule,,152.39,,,152.39,Fee Schedule,,144.03,,,144.03,Fee Schedule,,179.19,,,179.19,Other,110% of Medicare,101.76,,,101.76,Fee Schedule,,53,,,53,Other,186% of Medicaid,119.75,,,119.75,Fee Schedule,,224.44,,,224.44,Fee Schedule,,56.39,,,56.39,Fee Schedule,,119.75,,,119.75,Fee Schedule,,224.44,,,224.44,Fee Schedule,,106.06,,,106.06,Fee Schedule,,253.4,70,,253.4,percent of total billed charges,All Other,121.36,,,121.36,Fee Schedule,,102.86,,,102.86,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,267.88,
X-RAY EXAM ENTIRE SPI 1 VW W/ FY MOD,72081,CPT,FY,43072081,CDM,320,RC,,,both,,,204,150.96,,,150.96,Other,150% of Medicare + 9.63% HCRA Surcharge,91.8,45,,91.8,percent of total billed charges,Critical Access Hospital RCC factor,105.3,,,105.3,Fee Schedule,,94.74,,,94.74,Fee Schedule,,24.57,,,24.57,Fee Schedule,,24.57,,,24.57,Fee Schedule,,24.57,,,24.57,Fee Schedule,,100.98,,,100.98,Other,110% of Medicare,125.11,,,125.11,Fee Schedule,,53,,,53,Other,186% of Medicaid,147.22,,,147.22,Fee Schedule,,126.48,,,126.48,Fee Schedule,,69.32,,,69.32,Fee Schedule,,147.22,,,147.22,Fee Schedule,,126.48,,,126.48,Fee Schedule,,130.39,,,130.39,Fee Schedule,,142.8,70,,142.8,percent of total billed charges,All Other,147.6,,,147.6,Fee Schedule,,125.1,,,125.1,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,24.57,150.96,
X-RAY EXAM ENTIRE SPI 2/3 VW W/ FY MOD,72082,CPT,FY,43072082,CDM,320,RC,,,both,,,351,259.74,,,259.74,Other,150% of Medicare + 9.63% HCRA Surcharge,157.95,45,,157.95,percent of total billed charges,Critical Access Hospital RCC factor,191.94,,,191.94,Fee Schedule,,172.69,,,172.69,Fee Schedule,,44.99,,,44.99,Fee Schedule,,44.99,,,44.99,Fee Schedule,,44.99,,,44.99,Fee Schedule,,173.75,,,173.75,Other,110% of Medicare,228.04,,,228.04,Fee Schedule,,53,,,53,Other,186% of Medicaid,268.36,,,268.36,Fee Schedule,,217.62,,,217.62,Fee Schedule,,126.36,,,126.36,Fee Schedule,,268.36,,,268.36,Fee Schedule,,217.62,,,217.62,Fee Schedule,,237.67,,,237.67,Fee Schedule,,245.7,70,,245.7,percent of total billed charges,All Other,270.6,,,270.6,Fee Schedule,,229.35,,,229.35,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,270.6,
X-RAY EXAM ENTIRE SPI 4/5 VW W/ FY MOD,72083,CPT,FY,43072083,CDM,320,RC,,,both,,,638,472.12,,,472.12,Other,150% of Medicare + 9.63% HCRA Surcharge,287.1,45,,287.1,percent of total billed charges,Critical Access Hospital RCC factor,217.37,,,217.37,Fee Schedule,,195.56,,,195.56,Fee Schedule,,55.38,,,55.38,Fee Schedule,,55.38,,,55.38,Fee Schedule,,55.38,,,55.38,Fee Schedule,,315.81,,,315.81,Other,110% of Medicare,258.25,,,258.25,Fee Schedule,,53,,,53,Other,186% of Medicaid,303.9,,,303.9,Fee Schedule,,395.56,,,395.56,Fee Schedule,,143.09,,,143.09,Fee Schedule,,303.9,,,303.9,Fee Schedule,,395.56,,,395.56,Fee Schedule,,269.15,,,269.15,Fee Schedule,,446.6,70,,446.6,percent of total billed charges,All Other,301.76,,,301.76,Fee Schedule,,255.76,,,255.76,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,472.12,
X-RAY EXAM ENTIRE SPI 6/> VW W/ FY MOD,72084,CPT,FY,43072084,CDM,320,RC,,,both,,,638,472.12,,,472.12,Other,150% of Medicare + 9.63% HCRA Surcharge,287.1,45,,287.1,percent of total billed charges,Critical Access Hospital RCC factor,274.15,,,274.15,Fee Schedule,,246.65,,,246.65,Fee Schedule,,64.37,,,64.37,Fee Schedule,,64.37,,,64.37,Fee Schedule,,64.37,,,64.37,Fee Schedule,,315.81,,,315.81,Other,110% of Medicare,325.71,,,325.71,Fee Schedule,,53,,,53,Other,186% of Medicaid,383.29,,,383.29,Fee Schedule,,395.56,,,395.56,Fee Schedule,,180.47,,,180.47,Fee Schedule,,383.29,,,383.29,Fee Schedule,,395.56,,,395.56,Fee Schedule,,339.46,,,339.46,Fee Schedule,,446.6,70,,446.6,percent of total billed charges,All Other,385.4,,,385.4,Fee Schedule,,326.65,,,326.65,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,472.12,
XR LUMBAR SPINE 2 VIEWS W/ FY MOD,72100,CPT,FY,43072100,CDM,320,RC,,,both,,,494,365.56,,,365.56,Other,150% of Medicare + 9.63% HCRA Surcharge,222.3,45,,222.3,percent of total billed charges,Critical Access Hospital RCC factor,101.82,,,101.82,Fee Schedule,,91.61,,,91.61,Fee Schedule,,196.89,,,196.89,Fee Schedule,,177.09,,,177.09,Fee Schedule,,167.37,,,167.37,Fee Schedule,,244.53,,,244.53,Other,110% of Medicare,120.98,,,120.98,Fee Schedule,,53,,,53,Other,186% of Medicaid,142.36,,,142.36,Fee Schedule,,306.28,,,306.28,Fee Schedule,,67.03,,,67.03,Fee Schedule,,142.36,,,142.36,Fee Schedule,,306.28,,,306.28,Fee Schedule,,126.08,,,126.08,Fee Schedule,,345.8,70,,345.8,percent of total billed charges,All Other,142.68,,,142.68,Fee Schedule,,120.93,,,120.93,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,365.56,
XR LUMBAR SPINE COMPLETE W/ FY MOD,72110,CPT,FY,43072110,CDM,320,RC,,,both,,,695,514.3,,,514.3,Other,150% of Medicare + 9.63% HCRA Surcharge,312.75,45,,312.75,percent of total billed charges,Critical Access Hospital RCC factor,137.65,,,137.65,Fee Schedule,,123.84,,,123.84,Fee Schedule,,270.14,,,270.14,Fee Schedule,,242.97,,,242.97,Fee Schedule,,229.64,,,229.64,Fee Schedule,,344.03,,,344.03,Other,110% of Medicare,163.54,,,163.54,Fee Schedule,,53,,,53,Other,186% of Medicaid,192.45,,,192.45,Fee Schedule,,430.9,,,430.9,Fee Schedule,,90.62,,,90.62,Fee Schedule,,192.45,,,192.45,Fee Schedule,,430.9,,,430.9,Fee Schedule,,170.44,,,170.44,Fee Schedule,,486.5,70,,486.5,percent of total billed charges,All Other,190.24,,,190.24,Fee Schedule,,161.24,,,161.24,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,514.3,
XR LUMBAR SPINE COMP W FLEX W/ FY MOD,72114,CPT,FY,43072114,CDM,320,RC,,,both,,,867,641.58,,,641.58,Other,150% of Medicare + 9.63% HCRA Surcharge,390.15,45,,390.15,percent of total billed charges,Critical Access Hospital RCC factor,163.07,,,163.07,Fee Schedule,,146.71,,,146.71,Fee Schedule,,377.7,,,377.7,Fee Schedule,,339.72,,,339.72,Fee Schedule,,321.08,,,321.08,Fee Schedule,,429.17,,,429.17,Other,110% of Medicare,193.74,,,193.74,Fee Schedule,,53,,,53,Other,186% of Medicaid,228,,,228,Fee Schedule,,537.54,,,537.54,Fee Schedule,,107.35,,,107.35,Fee Schedule,,228,,,228,Fee Schedule,,537.54,,,537.54,Fee Schedule,,201.92,,,201.92,Fee Schedule,,606.9,70,,606.9,percent of total billed charges,All Other,232.88,,,232.88,Fee Schedule,,197.38,,,197.38,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,641.58,
XR EXAM OF LOWER SPINE W/ FY MOD,72120,CPT,FY,43072120,CDM,320,RC,,,both,,,706,522.44,,,522.44,Other,150% of Medicare + 9.63% HCRA Surcharge,317.7,45,,317.7,percent of total billed charges,Critical Access Hospital RCC factor,104.15,,,104.15,Fee Schedule,,93.71,,,93.71,Fee Schedule,,270.14,,,270.14,Fee Schedule,,242.97,,,242.97,Fee Schedule,,229.64,,,229.64,Fee Schedule,,349.47,,,349.47,Other,110% of Medicare,123.74,,,123.74,Fee Schedule,,53,,,53,Other,186% of Medicaid,145.62,,,145.62,Fee Schedule,,437.72,,,437.72,Fee Schedule,,68.57,,,68.57,Fee Schedule,,145.62,,,145.62,Fee Schedule,,437.72,,,437.72,Fee Schedule,,128.97,,,128.97,Fee Schedule,,494.2,70,,494.2,percent of total billed charges,All Other,147.6,,,147.6,Fee Schedule,,125.1,,,125.1,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,522.44,
XR PELVIS 1 VIEW W/ FY MOD,72170,CPT,FY,43072170,CDM,320,RC,,,both,,,392,290.08,,,290.08,Other,150% of Medicare + 9.63% HCRA Surcharge,176.4,45,,176.4,percent of total billed charges,Critical Access Hospital RCC factor,68.33,,,68.33,Fee Schedule,,61.48,,,61.48,Fee Schedule,,121.37,,,121.37,Fee Schedule,,109.16,,,109.16,Fee Schedule,,103.17,,,103.17,Fee Schedule,,194.04,,,194.04,Other,110% of Medicare,81.18,,,81.18,Fee Schedule,,53,,,53,Other,186% of Medicaid,95.53,,,95.53,Fee Schedule,,243.04,,,243.04,Fee Schedule,,44.98,,,44.98,Fee Schedule,,95.53,,,95.53,Fee Schedule,,243.04,,,243.04,Fee Schedule,,84.61,,,84.61,Fee Schedule,,274.4,70,,274.4,percent of total billed charges,All Other,95.12,,,95.12,Fee Schedule,,80.62,,,80.62,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,290.08,
XR EXAM OF PELVIS 3+ VIEWS W/ FY MOD,72190,CPT,FY,43072190,CDM,320,RC,,,both,,,605,447.7,,,447.7,Other,150% of Medicare + 9.63% HCRA Surcharge,272.25,45,,272.25,percent of total billed charges,Critical Access Hospital RCC factor,105.3,,,105.3,Fee Schedule,,94.74,,,94.74,Fee Schedule,,208.32,,,208.32,Fee Schedule,,187.37,,,187.37,Fee Schedule,,177.09,,,177.09,Fee Schedule,,299.48,,,299.48,Other,110% of Medicare,125.11,,,125.11,Fee Schedule,,53,,,53,Other,186% of Medicaid,147.22,,,147.22,Fee Schedule,,375.1,,,375.1,Fee Schedule,,69.32,,,69.32,Fee Schedule,,147.22,,,147.22,Fee Schedule,,375.1,,,375.1,Fee Schedule,,130.39,,,130.39,Fee Schedule,,423.5,70,,423.5,percent of total billed charges,All Other,147.6,,,147.6,Fee Schedule,,125.1,,,125.1,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,447.7,
XR SACROILIAC JTS 1 OR 2 VI W/ FY MOD,72200,CPT,FY,43072200,CDM,320,RC,,,both,,,242,179.08,,,179.08,Other,150% of Medicare + 9.63% HCRA Surcharge,108.9,45,,108.9,percent of total billed charges,Critical Access Hospital RCC factor,87.98,,,87.98,Fee Schedule,,79.15,,,79.15,Fee Schedule,,144.29,,,144.29,Fee Schedule,,129.78,,,129.78,Fee Schedule,,122.66,,,122.66,Fee Schedule,,119.79,,,119.79,Other,110% of Medicare,104.53,,,104.53,Fee Schedule,,53,,,53,Other,186% of Medicaid,123.01,,,123.01,Fee Schedule,,150.04,,,150.04,Fee Schedule,,57.92,,,57.92,Fee Schedule,,123.01,,,123.01,Fee Schedule,,150.04,,,150.04,Fee Schedule,,108.94,,,108.94,Fee Schedule,,169.4,70,,169.4,percent of total billed charges,All Other,121.36,,,121.36,Fee Schedule,,102.86,,,102.86,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,179.33,
XR SACROILIAC JOINTS 3 VIEW W/ FY MOD,72202,CPT,FY,43072202,CDM,320,RC,,,both,,,242,179.08,,,179.08,Other,150% of Medicare + 9.63% HCRA Surcharge,108.9,45,,108.9,percent of total billed charges,Critical Access Hospital RCC factor,99.53,,,99.53,Fee Schedule,,89.54,,,89.54,Fee Schedule,,171.75,,,171.75,Fee Schedule,,154.48,,,154.48,Fee Schedule,,146,,,146,Fee Schedule,,119.79,,,119.79,Other,110% of Medicare,118.25,,,118.25,Fee Schedule,,53,,,53,Other,186% of Medicaid,139.15,,,139.15,Fee Schedule,,150.04,,,150.04,Fee Schedule,,65.52,,,65.52,Fee Schedule,,139.15,,,139.15,Fee Schedule,,150.04,,,150.04,Fee Schedule,,123.24,,,123.24,Fee Schedule,,169.4,70,,169.4,percent of total billed charges,All Other,139.4,,,139.4,Fee Schedule,,118.15,,,118.15,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,179.33,
XR SACRUM & COCCYX 2 VIEWS W/ FY MOD,72220,CPT,FY,43072220,CDM,320,RC,,,both,,,437,323.38,,,323.38,Other,150% of Medicare + 9.63% HCRA Surcharge,196.65,45,,196.65,percent of total billed charges,Critical Access Hospital RCC factor,84.5,,,84.5,Fee Schedule,,76.03,,,76.03,Fee Schedule,,141.97,,,141.97,Fee Schedule,,127.7,,,127.7,Fee Schedule,,120.69,,,120.69,Fee Schedule,,216.32,,,216.32,Other,110% of Medicare,100.4,,,100.4,Fee Schedule,,53,,,53,Other,186% of Medicaid,118.15,,,118.15,Fee Schedule,,270.94,,,270.94,Fee Schedule,,55.63,,,55.63,Fee Schedule,,118.15,,,118.15,Fee Schedule,,270.94,,,270.94,Fee Schedule,,104.64,,,104.64,Fee Schedule,,305.9,70,,305.9,percent of total billed charges,All Other,118.08,,,118.08,Fee Schedule,,100.08,,,100.08,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,323.38,
MYELOGRAM THORACIC W/ FY MOD,72255,CPT,FY,43072255,CDM,320,RC,,,both,,,1939,1434.86,,,1434.86,Other,150% of Medicare + 9.63% HCRA Surcharge,872.55,45,,872.55,percent of total billed charges,Critical Access Hospital RCC factor,225.44,,,225.44,Fee Schedule,,202.82,,,202.82,Fee Schedule,,617.96,,,617.96,Fee Schedule,,555.81,,,555.81,Fee Schedule,,525.32,,,525.32,Fee Schedule,,959.81,,,959.81,Other,110% of Medicare,267.84,,,267.84,Fee Schedule,,914,,,914,Other,186% of Medicaid,315.19,,,315.19,Fee Schedule,,1202.18,,,1202.18,Fee Schedule,,148.41,,,148.41,Fee Schedule,,315.19,,,315.19,Fee Schedule,,1202.18,,,1202.18,Fee Schedule,,279.15,,,279.15,Fee Schedule,,1357.3,70,,1357.3,percent of total billed charges,All Other,360.8,,,360.8,Fee Schedule,,305.8,,,305.8,Fee Schedule,,1089.31,,,1089.31,Fee Schedule,,1089.31,,,1089.31,Fee Schedule,,1089.31,,,1089.31,Fee Schedule,,1089.31,,,1089.31,Fee Schedule,,491.65,,,491.65,Other,100% of Medicaid,491.65,,,491.65,Other,100% of Medicaid,491.65,,,491.65,Other,100% of Medicaid,491.65,,,491.65,Other,100% of Medicaid,1106.21,,,1106.21,Other,225% of Medicaid,752.22,,,752.22,Other,153% of Medicaid,1106.21,,,1106.21,Other,225% of Medicaid,688.31,,,688.31,Other,140% of Medicaid,1106.21,,,1106.21,Other,225% of Medicaid,1278.28,,,1278.28,Other,260% of Medicaid,1592.94,,,1592.94,Other,324% of Medicaid,1057.04,,,1057.04,Other,215% of Medicaid,1057.04,,,1057.04,Other,215% of Medicaid,614.56,,,614.56,Other,125% of Medicaid,148.41,1592.94,
X-RAY C/T SPINE DISK W/ FY MOD,72285,CPT,FY,43072285,CDM,320,RC,,,both,,,4047,2994.79,,,2994.79,Other,150% of Medicare + 9.63% HCRA Surcharge,1821.15,45,,1821.15,percent of total billed charges,Critical Access Hospital RCC factor,267.03,,,267.03,Fee Schedule,,240.25,,,240.25,Fee Schedule,,604.21,,,604.21,Fee Schedule,,543.44,,,543.44,Fee Schedule,,513.63,,,513.63,Fee Schedule,,2003.27,,,2003.27,Other,110% of Medicare,317.26,,,317.26,Fee Schedule,,914,,,914,Other,186% of Medicaid,373.35,,,373.35,Fee Schedule,,2509.14,,,2509.14,Fee Schedule,,175.79,,,175.79,Fee Schedule,,373.35,,,373.35,Fee Schedule,,2509.14,,,2509.14,Fee Schedule,,330.65,,,330.65,Fee Schedule,,2832.9,70,,2832.9,percent of total billed charges,All Other,350.96,,,350.96,Fee Schedule,,297.46,,,297.46,Fee Schedule,,2750.96,,,2750.96,Fee Schedule,,2750.96,,,2750.96,Fee Schedule,,2750.96,,,2750.96,Fee Schedule,,2750.96,,,2750.96,Fee Schedule,,491.65,,,491.65,Other,100% of Medicaid,491.65,,,491.65,Other,100% of Medicaid,491.65,,,491.65,Other,100% of Medicaid,491.65,,,491.65,Other,100% of Medicaid,1106.21,,,1106.21,Other,225% of Medicaid,752.22,,,752.22,Other,153% of Medicaid,1106.21,,,1106.21,Other,225% of Medicaid,688.31,,,688.31,Other,140% of Medicaid,1106.21,,,1106.21,Other,225% of Medicaid,1278.28,,,1278.28,Other,260% of Medicaid,1592.94,,,1592.94,Other,324% of Medicaid,1057.04,,,1057.04,Other,215% of Medicaid,1057.04,,,1057.04,Other,215% of Medicaid,614.56,,,614.56,Other,125% of Medicaid,175.79,2994.79,
ACJ BILATERAL W/WO WEIGHTS W/ FY MOD,73050,CPT,FY,43073050,CDM,320,RC,,,both,,,606,448.44,,,448.44,Other,150% of Medicare + 9.63% HCRA Surcharge,272.7,45,,272.7,percent of total billed charges,Critical Access Hospital RCC factor,69.48,,,69.48,Fee Schedule,,62.51,,,62.51,Fee Schedule,,185.45,,,185.45,Fee Schedule,,166.8,,,166.8,Fee Schedule,,157.65,,,157.65,Fee Schedule,,299.97,,,299.97,Other,110% of Medicare,82.55,,,82.55,Fee Schedule,,53,,,53,Other,186% of Medicaid,97.14,,,97.14,Fee Schedule,,375.72,,,375.72,Fee Schedule,,45.74,,,45.74,Fee Schedule,,97.14,,,97.14,Fee Schedule,,375.72,,,375.72,Fee Schedule,,86.03,,,86.03,Fee Schedule,,424.2,70,,424.2,percent of total billed charges,All Other,95.12,,,95.12,Fee Schedule,,80.62,,,80.62,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,448.44,
XR EXAM OF WRIST 2 VIEWS W/ FY MOD,73100,CPT,FY,43073100,CDM,320,RC,,,both,,,231,170.94,,,170.94,Other,150% of Medicare + 9.63% HCRA Surcharge,103.95,45,,103.95,percent of total billed charges,Critical Access Hospital RCC factor,90.28,,,90.28,Fee Schedule,,81.22,,,81.22,Fee Schedule,,148.82,,,148.82,Fee Schedule,,133.86,,,133.86,Fee Schedule,,126.52,,,126.52,Fee Schedule,,114.35,,,114.35,Other,110% of Medicare,107.26,,,107.26,Fee Schedule,,53,,,53,Other,186% of Medicaid,126.22,,,126.22,Fee Schedule,,143.22,,,143.22,Fee Schedule,,59.43,,,59.43,Fee Schedule,,126.22,,,126.22,Fee Schedule,,143.22,,,143.22,Fee Schedule,,111.79,,,111.79,Fee Schedule,,161.7,70,,161.7,percent of total billed charges,All Other,126.28,,,126.28,Fee Schedule,,107.03,,,107.03,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,170.94,
X-RAY EXAM HIPS BI 2 VIEWS W/ FY MOD,73521,CPT,FY,43073521,CDM,320,RC,,,both,,,392,290.08,,,290.08,Other,150% of Medicare + 9.63% HCRA Surcharge,176.4,45,,176.4,percent of total billed charges,Critical Access Hospital RCC factor,106.45,,,106.45,Fee Schedule,,95.77,,,95.77,Fee Schedule,,25.61,,,25.61,Fee Schedule,,25.61,,,25.61,Fee Schedule,,25.61,,,25.61,Fee Schedule,,194.04,,,194.04,Other,110% of Medicare,126.47,,,126.47,Fee Schedule,,53,,,53,Other,186% of Medicaid,148.83,,,148.83,Fee Schedule,,243.04,,,243.04,Fee Schedule,,70.08,,,70.08,Fee Schedule,,148.83,,,148.83,Fee Schedule,,243.04,,,243.04,Fee Schedule,,131.81,,,131.81,Fee Schedule,,274.4,70,,274.4,percent of total billed charges,All Other,149.24,,,149.24,Fee Schedule,,126.49,,,126.49,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,25.61,290.08,
X-RAY EXAM HIPS BI 3-4 VIEWS W/ FY MOD,73522,CPT,FY,43073522,CDM,320,RC,,,both,,,336,248.64,,,248.64,Other,150% of Medicare + 9.63% HCRA Surcharge,151.2,45,,151.2,percent of total billed charges,Critical Access Hospital RCC factor,138.8,,,138.8,Fee Schedule,,124.87,,,124.87,Fee Schedule,,32.88,,,32.88,Fee Schedule,,32.88,,,32.88,Fee Schedule,,32.88,,,32.88,Fee Schedule,,166.32,,,166.32,Other,110% of Medicare,164.9,,,164.9,Fee Schedule,,53,,,53,Other,186% of Medicaid,194.05,,,194.05,Fee Schedule,,208.32,,,208.32,Fee Schedule,,91.37,,,91.37,Fee Schedule,,194.05,,,194.05,Fee Schedule,,208.32,,,208.32,Fee Schedule,,171.86,,,171.86,Fee Schedule,,235.2,70,,235.2,percent of total billed charges,All Other,193.52,,,193.52,Fee Schedule,,164.02,,,164.02,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,248.64,
X-RAY EXAM HIPS BI 5/> VIEWS W/ FY MOD,73523,CPT,FY,43073523,CDM,320,RC,,,both,,,638,472.12,,,472.12,Other,150% of Medicare + 9.63% HCRA Surcharge,287.1,45,,287.1,percent of total billed charges,Critical Access Hospital RCC factor,163.07,,,163.07,Fee Schedule,,146.71,,,146.71,Fee Schedule,,39.46,,,39.46,Fee Schedule,,39.46,,,39.46,Fee Schedule,,39.46,,,39.46,Fee Schedule,,315.81,,,315.81,Other,110% of Medicare,193.74,,,193.74,Fee Schedule,,53,,,53,Other,186% of Medicaid,228,,,228,Fee Schedule,,395.56,,,395.56,Fee Schedule,,107.35,,,107.35,Fee Schedule,,228,,,228,Fee Schedule,,395.56,,,395.56,Fee Schedule,,201.92,,,201.92,Fee Schedule,,446.6,70,,446.6,percent of total billed charges,All Other,227.96,,,227.96,Fee Schedule,,193.21,,,193.21,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,472.12,
XR KNEE 1 OR 2 VIEW W/ FY MOD,73560,CPT,FY,43073560,CDM,320,RC,,,both,,,407,301.18,,,301.18,Other,150% of Medicare + 9.63% HCRA Surcharge,183.15,45,,183.15,percent of total billed charges,Critical Access Hospital RCC factor,91.43,,,91.43,Fee Schedule,,82.25,,,82.25,Fee Schedule,,144.29,,,144.29,Fee Schedule,,129.78,,,129.78,Fee Schedule,,122.66,,,122.66,Fee Schedule,,201.47,,,201.47,Other,110% of Medicare,108.62,,,108.62,Fee Schedule,,53,,,53,Other,186% of Medicaid,127.82,,,127.82,Fee Schedule,,252.34,,,252.34,Fee Schedule,,60.19,,,60.19,Fee Schedule,,127.82,,,127.82,Fee Schedule,,252.34,,,252.34,Fee Schedule,,113.21,,,113.21,Fee Schedule,,284.9,70,,284.9,percent of total billed charges,All Other,127.92,,,127.92,Fee Schedule,,108.42,,,108.42,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,301.18,
XR BOTH KNEES STANDING AP W/ FY MOD,73565,CPT,FY,43073565,CDM,320,RC,,,both,,,566,418.84,,,418.84,Other,150% of Medicare + 9.63% HCRA Surcharge,254.7,45,,254.7,percent of total billed charges,Critical Access Hospital RCC factor,111.08,,,111.08,Fee Schedule,,99.93,,,99.93,Fee Schedule,,164.85,,,164.85,Fee Schedule,,148.27,,,148.27,Fee Schedule,,140.13,,,140.13,Fee Schedule,,280.17,,,280.17,Other,110% of Medicare,131.97,,,131.97,Fee Schedule,,53,,,53,Other,186% of Medicaid,155.3,,,155.3,Fee Schedule,,350.92,,,350.92,Fee Schedule,,73.12,,,73.12,Fee Schedule,,155.3,,,155.3,Fee Schedule,,350.92,,,350.92,Fee Schedule,,137.54,,,137.54,Fee Schedule,,396.2,70,,396.2,percent of total billed charges,All Other,157.44,,,157.44,Fee Schedule,,133.44,,,133.44,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,418.84,
XR EXAM OF LEG INFANT 2 VIEWS W/ FY MOD,73592,CPT,FY,43073592,CDM,320,RC,,,both,,,231,170.94,,,170.94,Other,150% of Medicare + 9.63% HCRA Surcharge,103.95,45,,103.95,percent of total billed charges,Critical Access Hospital RCC factor,83.35,,,83.35,Fee Schedule,,74.99,,,74.99,Fee Schedule,,155.73,,,155.73,Fee Schedule,,140.07,,,140.07,Fee Schedule,,132.38,,,132.38,Fee Schedule,,114.35,,,114.35,Other,110% of Medicare,99.03,,,99.03,Fee Schedule,,53,,,53,Other,186% of Medicaid,116.54,,,116.54,Fee Schedule,,143.22,,,143.22,Fee Schedule,,54.87,,,54.87,Fee Schedule,,116.54,,,116.54,Fee Schedule,,143.22,,,143.22,Fee Schedule,,103.21,,,103.21,Fee Schedule,,161.7,70,,161.7,percent of total billed charges,All Other,118.08,,,118.08,Fee Schedule,,100.08,,,100.08,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,170.94,
X-RAY EXAM ABDOMEN 1 VIEW W/ FY MOD,74018,CPT,FY,43074018,CDM,320,RC,,,both,,,437,323.38,,,323.38,Other,150% of Medicare + 9.63% HCRA Surcharge,196.65,45,,196.65,percent of total billed charges,Critical Access Hospital RCC factor,75.25,,,75.25,Fee Schedule,,67.7,,,67.7,Fee Schedule,,17.12,,,17.12,Fee Schedule,,17.12,,,17.12,Fee Schedule,,17.12,,,17.12,Fee Schedule,,216.32,,,216.32,Other,110% of Medicare,89.41,,,89.41,Fee Schedule,,53,,,53,Other,186% of Medicaid,105.21,,,105.21,Fee Schedule,,270.94,,,270.94,Fee Schedule,,49.54,,,49.54,Fee Schedule,,105.21,,,105.21,Fee Schedule,,270.94,,,270.94,Fee Schedule,,93.18,,,93.18,Fee Schedule,,305.9,70,,305.9,percent of total billed charges,All Other,104.96,,,104.96,Fee Schedule,,88.96,,,88.96,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,17.12,323.38,
X-RAY EXAM ABDOMEN 2 VIEWS W/ FY MOD,74019,CPT,FY,43074019,CDM,320,RC,,,both,,,242,179.08,,,179.08,Other,150% of Medicare + 9.63% HCRA Surcharge,108.9,45,,108.9,percent of total billed charges,Critical Access Hospital RCC factor,90.28,,,90.28,Fee Schedule,,81.22,,,81.22,Fee Schedule,,20.47,,,20.47,Fee Schedule,,20.47,,,20.47,Fee Schedule,,20.47,,,20.47,Fee Schedule,,119.79,,,119.79,Other,110% of Medicare,107.26,,,107.26,Fee Schedule,,53,,,53,Other,186% of Medicaid,126.22,,,126.22,Fee Schedule,,150.04,,,150.04,Fee Schedule,,59.43,,,59.43,Fee Schedule,,126.22,,,126.22,Fee Schedule,,150.04,,,150.04,Fee Schedule,,111.79,,,111.79,Fee Schedule,,169.4,70,,169.4,percent of total billed charges,All Other,126.28,,,126.28,Fee Schedule,,107.03,,,107.03,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,20.47,179.33,
X-RAY ABDOMEN 3+ VIEWS W/ FY MOD,74021,CPT,FY,43074021,CDM,320,RC,,,both,,,408,301.92,,,301.92,Other,150% of Medicare + 9.63% HCRA Surcharge,183.6,45,,183.6,percent of total billed charges,Critical Access Hospital RCC factor,105.3,,,105.3,Fee Schedule,,94.74,,,94.74,Fee Schedule,,23.83,,,23.83,Fee Schedule,,23.83,,,23.83,Fee Schedule,,23.83,,,23.83,Fee Schedule,,201.96,,,201.96,Other,110% of Medicare,125.11,,,125.11,Fee Schedule,,53,,,53,Other,186% of Medicaid,147.22,,,147.22,Fee Schedule,,252.96,,,252.96,Fee Schedule,,69.32,,,69.32,Fee Schedule,,147.22,,,147.22,Fee Schedule,,252.96,,,252.96,Fee Schedule,,130.39,,,130.39,Fee Schedule,,285.6,70,,285.6,percent of total billed charges,All Other,149.24,,,149.24,Fee Schedule,,126.49,,,126.49,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,23.83,301.92,
THERAP BE/AIR FOR OBSTRUCT W/ FY MOD,74283,CPT,FY,43074283,CDM,320,RC,,,both,,,934,691.16,,,691.16,Other,150% of Medicare + 9.63% HCRA Surcharge,420.3,45,,420.3,percent of total billed charges,Critical Access Hospital RCC factor,541.98,,,541.98,Fee Schedule,,487.61,,,487.61,Fee Schedule,,583.65,,,583.65,Fee Schedule,,524.96,,,524.96,Fee Schedule,,496.16,,,496.16,Fee Schedule,,462.33,,,462.33,Other,110% of Medicare,643.92,,,643.92,Fee Schedule,,392,,,392,Other,186% of Medicaid,757.75,,,757.75,Fee Schedule,,579.08,,,579.08,Fee Schedule,,356.79,,,356.79,Fee Schedule,,757.75,,,757.75,Fee Schedule,,579.08,,,579.08,Fee Schedule,,671.11,,,671.11,Fee Schedule,,653.8,70,,653.8,percent of total billed charges,All Other,795.4,,,795.4,Fee Schedule,,674.15,,,674.15,Fee Schedule,,291.55,,,291.55,Fee Schedule,,291.55,,,291.55,Fee Schedule,,291.55,,,291.55,Fee Schedule,,291.55,,,291.55,Fee Schedule,,210.57,,,210.57,Other,100% of Medicaid,210.57,,,210.57,Other,100% of Medicaid,210.57,,,210.57,Other,100% of Medicaid,210.57,,,210.57,Other,100% of Medicaid,473.77,,,473.77,Other,225% of Medicaid,322.17,,,322.17,Other,153% of Medicaid,473.77,,,473.77,Other,225% of Medicaid,294.79,,,294.79,Other,140% of Medicaid,473.77,,,473.77,Other,225% of Medicaid,547.47,,,547.47,Other,260% of Medicaid,682.23,,,682.23,Other,324% of Medicaid,452.72,,,452.72,Other,215% of Medicaid,452.72,,,452.72,Other,215% of Medicaid,263.21,,,263.21,Other,125% of Medicaid,210.57,795.4,
ENDO CATH - BILE DUCTS W/ FY MOD,74328,CPT,FY,43074328,CDM,320,RC,,,both,,,638,472.12,,,472.12,Other,150% of Medicare + 9.63% HCRA Surcharge,287.1,45,,287.1,percent of total billed charges,Critical Access Hospital RCC factor,414.7,65,,414.7,percent of total billed charges,All Other,376.42,65,,376.42,percent of total billed charges,All Other,81.44,,,81.44,Fee Schedule,,81.44,,,81.44,Fee Schedule,,81.44,,,81.44,Fee Schedule,,315.81,,,315.81,Other,110% of Medicare,433.84,68,,433.84,percent of total billed charges,All Other,544,,,544,Other,186% of Medicaid,510.4,80,,510.4,percent of total billed charges,All Other,529.54,83,,529.54,percent of total billed charges,All Other,529.54,83,,529.54,percent of total billed charges,All Other,510.4,80,,510.4,percent of total billed charges,All Other,529.54,83,,529.54,percent of total billed charges,All Other,510.4,80,,510.4,percent of total billed charges,All Other,446.6,70,,446.6,percent of total billed charges,All Other,414.7,65,,414.7,percent of total billed charges,Default if not in Fee Schedule,414.7,65,,414.7,percent of total billed charges,Default if not in Fee Schedule,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,292.43,,,292.43,Other,100% of Medicaid,292.43,,,292.43,Other,100% of Medicaid,292.43,,,292.43,Other,100% of Medicaid,292.43,,,292.43,Other,100% of Medicaid,657.97,,,657.97,Other,225% of Medicaid,447.42,,,447.42,Other,153% of Medicaid,657.97,,,657.97,Other,225% of Medicaid,409.4,,,409.4,Other,140% of Medicaid,657.97,,,657.97,Other,225% of Medicaid,760.32,,,760.32,Other,260% of Medicaid,947.48,,,947.48,Other,324% of Medicaid,628.73,,,628.73,Other,215% of Medicaid,628.73,,,628.73,Other,215% of Medicaid,365.54,,,365.54,Other,125% of Medicaid,0.01,947.48,
ENDO CATH - PANCR DUCT W/ FY MOD,74329,CPT,FY,43074329,CDM,320,RC,,,both,,,749,554.26,,,554.26,Other,150% of Medicare + 9.63% HCRA Surcharge,337.05,45,,337.05,percent of total billed charges,Critical Access Hospital RCC factor,486.85,65,,486.85,percent of total billed charges,All Other,441.91,65,,441.91,percent of total billed charges,All Other,65.22,,,65.22,Fee Schedule,,65.22,,,65.22,Fee Schedule,,65.22,,,65.22,Fee Schedule,,370.76,,,370.76,Other,110% of Medicare,509.32,68,,509.32,percent of total billed charges,All Other,544,,,544,Other,186% of Medicaid,599.2,80,,599.2,percent of total billed charges,All Other,621.67,83,,621.67,percent of total billed charges,All Other,621.67,83,,621.67,percent of total billed charges,All Other,599.2,80,,599.2,percent of total billed charges,All Other,621.67,83,,621.67,percent of total billed charges,All Other,599.2,80,,599.2,percent of total billed charges,All Other,524.3,70,,524.3,percent of total billed charges,All Other,486.85,65,,486.85,percent of total billed charges,Default if not in Fee Schedule,486.85,65,,486.85,percent of total billed charges,Default if not in Fee Schedule,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,292.43,,,292.43,Other,100% of Medicaid,292.43,,,292.43,Other,100% of Medicaid,292.43,,,292.43,Other,100% of Medicaid,292.43,,,292.43,Other,100% of Medicaid,657.97,,,657.97,Other,225% of Medicaid,447.42,,,447.42,Other,153% of Medicaid,657.97,,,657.97,Other,225% of Medicaid,409.4,,,409.4,Other,140% of Medicaid,657.97,,,657.97,Other,225% of Medicaid,760.32,,,760.32,Other,260% of Medicaid,947.48,,,947.48,Other,324% of Medicaid,628.73,,,628.73,Other,215% of Medicaid,628.73,,,628.73,Other,215% of Medicaid,365.54,,,365.54,Other,125% of Medicaid,0.01,947.48,
ENDO CATH BIL & PANCR - ERCP W/ FY MOD,74330,CPT,FY,43074330,CDM,320,RC,,,both,,,2170,1605.81,,,1605.81,Other,150% of Medicare + 9.63% HCRA Surcharge,976.5,45,,976.5,percent of total billed charges,Critical Access Hospital RCC factor,1410.5,65,,1410.5,percent of total billed charges,All Other,1280.3,65,,1280.3,percent of total billed charges,All Other,121.13,,,121.13,Fee Schedule,,121.13,,,121.13,Fee Schedule,,121.13,,,121.13,Fee Schedule,,1074.15,,,1074.15,Other,110% of Medicare,1475.6,68,,1475.6,percent of total billed charges,All Other,544,,,544,Other,186% of Medicaid,1736,80,,1736,percent of total billed charges,All Other,1801.1,83,,1801.1,percent of total billed charges,All Other,1801.1,83,,1801.1,percent of total billed charges,All Other,1736,80,,1736,percent of total billed charges,All Other,1801.1,83,,1801.1,percent of total billed charges,All Other,1736,80,,1736,percent of total billed charges,All Other,1519,70,,1519,percent of total billed charges,All Other,1410.5,65,,1410.5,percent of total billed charges,Default if not in Fee Schedule,1410.5,65,,1410.5,percent of total billed charges,Default if not in Fee Schedule,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,292.43,,,292.43,Other,100% of Medicaid,292.43,,,292.43,Other,100% of Medicaid,292.43,,,292.43,Other,100% of Medicaid,292.43,,,292.43,Other,100% of Medicaid,657.97,,,657.97,Other,225% of Medicaid,447.42,,,447.42,Other,153% of Medicaid,657.97,,,657.97,Other,225% of Medicaid,409.4,,,409.4,Other,140% of Medicaid,657.97,,,657.97,Other,225% of Medicaid,760.32,,,760.32,Other,260% of Medicaid,947.48,,,947.48,Other,324% of Medicaid,628.73,,,628.73,Other,215% of Medicaid,628.73,,,628.73,Other,215% of Medicaid,365.54,,,365.54,Other,125% of Medicaid,0.01,1801.1,
SHUNTOGRAM W/ FY MOD,75809,CPT,FY,43075809,CDM,320,RC,,,both,,,667,493.58,,,493.58,Other,150% of Medicare + 9.63% HCRA Surcharge,300.15,45,,300.15,percent of total billed charges,Critical Access Hospital RCC factor,205.82,,,205.82,Fee Schedule,,185.17,,,185.17,Fee Schedule,,501.23,,,501.23,Fee Schedule,,450.82,,,450.82,Fee Schedule,,426.09,,,426.09,Fee Schedule,,330.17,,,330.17,Other,110% of Medicare,244.53,,,244.53,Fee Schedule,,392,,,392,Other,186% of Medicaid,287.76,,,287.76,Fee Schedule,,413.54,,,413.54,Fee Schedule,,135.49,,,135.49,Fee Schedule,,287.76,,,287.76,Fee Schedule,,413.54,,,413.54,Fee Schedule,,254.85,,,254.85,Fee Schedule,,466.9,70,,466.9,percent of total billed charges,All Other,291.92,,,291.92,Fee Schedule,,247.42,,,247.42,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,210.57,,,210.57,Other,100% of Medicaid,210.57,,,210.57,Other,100% of Medicaid,210.57,,,210.57,Other,100% of Medicaid,210.57,,,210.57,Other,100% of Medicaid,473.77,,,473.77,Other,225% of Medicaid,322.17,,,322.17,Other,153% of Medicaid,473.77,,,473.77,Other,225% of Medicaid,294.79,,,294.79,Other,140% of Medicaid,473.77,,,473.77,Other,225% of Medicaid,547.47,,,547.47,Other,260% of Medicaid,682.23,,,682.23,Other,324% of Medicaid,452.72,,,452.72,Other,215% of Medicaid,452.72,,,452.72,Other,215% of Medicaid,263.21,,,263.21,Other,125% of Medicaid,135.49,682.23,
VENOGRAPHY EXTREMITY BIL W/ FY MOD,75822,CPT,FY,43075822,CDM,320,RC,,,both,,,3350,2479.01,,,2479.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1507.5,45,,1507.5,percent of total billed charges,Critical Access Hospital RCC factor,227.77,,,227.77,Fee Schedule,,204.92,,,204.92,Fee Schedule,,684.31,,,684.31,Fee Schedule,,615.49,,,615.49,Fee Schedule,,581.73,,,581.73,Fee Schedule,,1658.25,,,1658.25,Other,110% of Medicare,270.61,,,270.61,Fee Schedule,,490,,,490,Other,186% of Medicaid,318.44,,,318.44,Fee Schedule,,2077,,,2077,Fee Schedule,,149.94,,,149.94,Fee Schedule,,318.44,,,318.44,Fee Schedule,,2077,,,2077,Fee Schedule,,282.03,,,282.03,Fee Schedule,,2345,70,,2345,percent of total billed charges,All Other,323.08,,,323.08,Fee Schedule,,273.83,,,273.83,Fee Schedule,,2609.81,,,2609.81,Fee Schedule,,2609.81,,,2609.81,Fee Schedule,,2609.81,,,2609.81,Fee Schedule,,2609.81,,,2609.81,Fee Schedule,,263.19,,,263.19,Other,100% of Medicaid,263.19,,,263.19,Other,100% of Medicaid,263.19,,,263.19,Other,100% of Medicaid,263.19,,,263.19,Other,100% of Medicaid,592.18,,,592.18,Other,225% of Medicaid,402.68,,,402.68,Other,153% of Medicaid,592.18,,,592.18,Other,225% of Medicaid,368.47,,,368.47,Other,140% of Medicaid,592.18,,,592.18,Other,225% of Medicaid,684.3,,,684.3,Other,260% of Medicaid,852.74,,,852.74,Other,324% of Medicaid,565.86,,,565.86,Other,215% of Medicaid,565.86,,,565.86,Other,215% of Medicaid,328.99,,,328.99,Other,125% of Medicaid,149.94,2609.81,
FLUOROSCOPE EXAM =< 1 HR W/ FY MOD,76000,CPT,FY,43076000,CDM,320,RC,,,both,,,527,389.98,,,389.98,Other,150% of Medicare + 9.63% HCRA Surcharge,237.15,45,,237.15,percent of total billed charges,Critical Access Hospital RCC factor,97.2,,,97.2,Fee Schedule,,87.45,,,87.45,Fee Schedule,,466.92,,,466.92,Fee Schedule,,419.96,,,419.96,Fee Schedule,,396.93,,,396.93,Fee Schedule,,260.87,,,260.87,Other,110% of Medicare,115.48,,,115.48,Fee Schedule,,392,,,392,Other,186% of Medicaid,135.9,,,135.9,Fee Schedule,,326.74,,,326.74,Fee Schedule,,63.99,,,63.99,Fee Schedule,,135.9,,,135.9,Fee Schedule,,326.74,,,326.74,Fee Schedule,,120.36,,,120.36,Fee Schedule,,368.9,70,,368.9,percent of total billed charges,All Other,136.12,,,136.12,Fee Schedule,,115.37,,,115.37,Fee Schedule,,372.86,,,372.86,Fee Schedule,,372.86,,,372.86,Fee Schedule,,372.86,,,372.86,Fee Schedule,,372.86,,,372.86,Fee Schedule,,210.57,,,210.57,Other,100% of Medicaid,210.57,,,210.57,Other,100% of Medicaid,210.57,,,210.57,Other,100% of Medicaid,210.57,,,210.57,Other,100% of Medicaid,473.77,,,473.77,Other,225% of Medicaid,322.17,,,322.17,Other,153% of Medicaid,473.77,,,473.77,Other,225% of Medicaid,294.79,,,294.79,Other,140% of Medicaid,473.77,,,473.77,Other,225% of Medicaid,547.47,,,547.47,Other,260% of Medicaid,682.23,,,682.23,Other,324% of Medicaid,452.72,,,452.72,Other,215% of Medicaid,452.72,,,452.72,Other,215% of Medicaid,263.21,,,263.21,Other,125% of Medicaid,63.99,682.23,
NOSE TO RECTUM FOR FB CHILD W/ FY MOD,76010,CPT,FY,43076010,CDM,320,RC,,,both,,,231,170.94,,,170.94,Other,150% of Medicare + 9.63% HCRA Surcharge,103.95,45,,103.95,percent of total billed charges,Critical Access Hospital RCC factor,72.96,,,72.96,Fee Schedule,,65.64,,,65.64,Fee Schedule,,125.95,,,125.95,Fee Schedule,,113.29,,,113.29,Fee Schedule,,107.07,,,107.07,Fee Schedule,,114.35,,,114.35,Other,110% of Medicare,86.68,,,86.68,Fee Schedule,,53,,,53,Other,186% of Medicaid,102,,,102,Fee Schedule,,143.22,,,143.22,Fee Schedule,,48.03,,,48.03,Fee Schedule,,102,,,102,Fee Schedule,,143.22,,,143.22,Fee Schedule,,90.34,,,90.34,Fee Schedule,,161.7,70,,161.7,percent of total billed charges,All Other,103.32,,,103.32,Fee Schedule,,87.57,,,87.57,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,170.94,
FLUOROSCOPIC GUIDANCE FOR CV W/ FY MOD,77001,CPT,FY,43077001,CDM,320,RC,,,both,,,581,429.94,,,429.94,Other,150% of Medicare + 9.63% HCRA Surcharge,261.45,45,,261.45,percent of total billed charges,Critical Access Hospital RCC factor,280.91,,,280.91,Fee Schedule,,252.73,,,252.73,Fee Schedule,,643.1,,,643.1,Fee Schedule,,578.42,,,578.42,Fee Schedule,,546.69,,,546.69,Fee Schedule,,287.6,,,287.6,Other,110% of Medicare,333.75,,,333.75,Fee Schedule,,544,,,544,Other,186% of Medicaid,392.75,,,392.75,Fee Schedule,,360.22,,,360.22,Fee Schedule,,184.93,,,184.93,Fee Schedule,,392.75,,,392.75,Fee Schedule,,360.22,,,360.22,Fee Schedule,,347.84,,,347.84,Fee Schedule,,406.7,70,,406.7,percent of total billed charges,All Other,416.56,,,416.56,Fee Schedule,,353.06,,,353.06,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,292.43,,,292.43,Other,100% of Medicaid,292.43,,,292.43,Other,100% of Medicaid,292.43,,,292.43,Other,100% of Medicaid,292.43,,,292.43,Other,100% of Medicaid,657.97,,,657.97,Other,225% of Medicaid,447.42,,,447.42,Other,153% of Medicaid,657.97,,,657.97,Other,225% of Medicaid,409.4,,,409.4,Other,140% of Medicaid,657.97,,,657.97,Other,225% of Medicaid,760.32,,,760.32,Other,260% of Medicaid,947.48,,,947.48,Other,324% of Medicaid,628.73,,,628.73,Other,215% of Medicaid,628.73,,,628.73,Other,215% of Medicaid,365.54,,,365.54,Other,125% of Medicaid,0.01,947.48,
NEEDLE LOCALIZATION BY XR W/ FY MOD,77002,CPT,FY,43077002,CDM,320,RC,,,both,,,577,426.98,,,426.98,Other,150% of Medicare + 9.63% HCRA Surcharge,259.65,45,,259.65,percent of total billed charges,Critical Access Hospital RCC factor,310.93,,,310.93,Fee Schedule,,279.74,,,279.74,Fee Schedule,,325.05,,,325.05,Fee Schedule,,292.36,,,292.36,Fee Schedule,,276.33,,,276.33,Fee Schedule,,285.62,,,285.62,Other,110% of Medicare,369.41,,,369.41,Fee Schedule,,544,,,544,Other,186% of Medicaid,434.72,,,434.72,Fee Schedule,,357.74,,,357.74,Fee Schedule,,204.69,,,204.69,Fee Schedule,,434.72,,,434.72,Fee Schedule,,357.74,,,357.74,Fee Schedule,,385.01,,,385.01,Fee Schedule,,403.9,70,,403.9,percent of total billed charges,All Other,441.16,,,441.16,Fee Schedule,,373.91,,,373.91,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,292.43,,,292.43,Other,100% of Medicaid,292.43,,,292.43,Other,100% of Medicaid,292.43,,,292.43,Other,100% of Medicaid,292.43,,,292.43,Other,100% of Medicaid,657.97,,,657.97,Other,225% of Medicaid,447.42,,,447.42,Other,153% of Medicaid,657.97,,,657.97,Other,225% of Medicaid,409.4,,,409.4,Other,140% of Medicaid,657.97,,,657.97,Other,225% of Medicaid,760.32,,,760.32,Other,260% of Medicaid,947.48,,,947.48,Other,324% of Medicaid,628.73,,,628.73,Other,215% of Medicaid,628.73,,,628.73,Other,215% of Medicaid,365.54,,,365.54,Other,125% of Medicaid,0.01,947.48,
XR FOR BONE AGE W/ FY MOD,77072,CPT,FY,43077072,CDM,320,RC,,,both,,,242,179.08,,,179.08,Other,150% of Medicare + 9.63% HCRA Surcharge,108.9,45,,108.9,percent of total billed charges,Critical Access Hospital RCC factor,59.08,,,59.08,Fee Schedule,,53.15,,,53.15,Fee Schedule,,96.23,,,96.23,Fee Schedule,,86.55,,,86.55,Fee Schedule,,81.8,,,81.8,Fee Schedule,,119.79,,,119.79,Other,110% of Medicare,70.19,,,70.19,Fee Schedule,,53,,,53,Other,186% of Medicaid,82.6,,,82.6,Fee Schedule,,150.04,,,150.04,Fee Schedule,,38.89,,,38.89,Fee Schedule,,82.6,,,82.6,Fee Schedule,,150.04,,,150.04,Fee Schedule,,73.15,,,73.15,Fee Schedule,,169.4,70,,169.4,percent of total billed charges,All Other,83.64,,,83.64,Fee Schedule,,70.89,,,70.89,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,179.33,
XR BONE SURVEY LIMITED W/ FY MOD,77074,CPT,FY,43077074,CDM,320,RC,,,both,,,331,244.94,,,244.94,Other,150% of Medicare + 9.63% HCRA Surcharge,148.95,45,,148.95,percent of total billed charges,Critical Access Hospital RCC factor,154.97,,,154.97,Fee Schedule,,139.42,,,139.42,Fee Schedule,,320.47,,,320.47,Fee Schedule,,288.24,,,288.24,Fee Schedule,,272.43,,,272.43,Fee Schedule,,163.85,,,163.85,Other,110% of Medicare,184.12,,,184.12,Fee Schedule,,53,,,53,Other,186% of Medicaid,216.67,,,216.67,Fee Schedule,,205.22,,,205.22,Fee Schedule,,102.02,,,102.02,Fee Schedule,,216.67,,,216.67,Fee Schedule,,205.22,,,205.22,Fee Schedule,,191.89,,,191.89,Fee Schedule,,231.7,70,,231.7,percent of total billed charges,All Other,218.12,,,218.12,Fee Schedule,,184.87,,,184.87,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,320.47,
XR BONE SURVEY COMPLETE W/ FY MOD,77075,CPT,FY,43077075,CDM,320,RC,,,both,,,534,395.16,,,395.16,Other,150% of Medicare + 9.63% HCRA Surcharge,240.3,45,,240.3,percent of total billed charges,Critical Access Hospital RCC factor,255.65,,,255.65,Fee Schedule,,230,,,230,Fee Schedule,,510.4,,,510.4,Fee Schedule,,459.07,,,459.07,Fee Schedule,,433.89,,,433.89,Fee Schedule,,264.33,,,264.33,Other,110% of Medicare,303.73,,,303.73,Fee Schedule,,392,,,392,Other,186% of Medicaid,357.42,,,357.42,Fee Schedule,,331.08,,,331.08,Fee Schedule,,168.29,,,168.29,Fee Schedule,,357.42,,,357.42,Fee Schedule,,331.08,,,331.08,Fee Schedule,,316.55,,,316.55,Fee Schedule,,373.8,70,,373.8,percent of total billed charges,All Other,359.16,,,359.16,Fee Schedule,,304.41,,,304.41,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,210.57,,,210.57,Other,100% of Medicaid,210.57,,,210.57,Other,100% of Medicaid,210.57,,,210.57,Other,100% of Medicaid,210.57,,,210.57,Other,100% of Medicaid,473.77,,,473.77,Other,225% of Medicaid,322.17,,,322.17,Other,153% of Medicaid,473.77,,,473.77,Other,225% of Medicaid,294.79,,,294.79,Other,140% of Medicaid,473.77,,,473.77,Other,225% of Medicaid,547.47,,,547.47,Other,260% of Medicaid,682.23,,,682.23,Other,324% of Medicaid,452.72,,,452.72,Other,215% of Medicaid,452.72,,,452.72,Other,215% of Medicaid,263.21,,,263.21,Other,125% of Medicaid,168.29,682.23,
XR BONE SURVEY INFANT W/ FY MOD,77076,CPT,FY,43077076,CDM,320,RC,,,both,,,510,377.4,,,377.4,Other,150% of Medicare + 9.63% HCRA Surcharge,229.5,45,,229.5,percent of total billed charges,Critical Access Hospital RCC factor,257.98,,,257.98,Fee Schedule,,232.1,,,232.1,Fee Schedule,,448.64,,,448.64,Fee Schedule,,403.52,,,403.52,Fee Schedule,,381.38,,,381.38,Fee Schedule,,252.45,,,252.45,Other,110% of Medicare,306.5,,,306.5,Fee Schedule,,53,,,53,Other,186% of Medicaid,360.68,,,360.68,Fee Schedule,,316.2,,,316.2,Fee Schedule,,169.83,,,169.83,Fee Schedule,,360.68,,,360.68,Fee Schedule,,316.2,,,316.2,Fee Schedule,,319.44,,,319.44,Fee Schedule,,357,70,,357,percent of total billed charges,All Other,362.44,,,362.44,Fee Schedule,,307.19,,,307.19,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,448.64,
BONE DENSITY STUDY DEXA W/ FY MOD,77080,CPT,FY,43077080,CDM,320,RC,,,both,,,683,505.42,,,505.42,Other,150% of Medicare + 9.63% HCRA Surcharge,307.35,45,,307.35,percent of total billed charges,Critical Access Hospital RCC factor,102.97,,,102.97,Fee Schedule,,92.64,,,92.64,Fee Schedule,,584.86,,,584.86,Fee Schedule,,526.05,,,526.05,Fee Schedule,,497.19,,,497.19,Fee Schedule,,338.09,,,338.09,Other,110% of Medicare,122.34,,,122.34,Fee Schedule,,253,,,253,Other,186% of Medicaid,143.97,,,143.97,Fee Schedule,,423.46,,,423.46,Fee Schedule,,67.79,,,67.79,Fee Schedule,,143.97,,,143.97,Fee Schedule,,423.46,,,423.46,Fee Schedule,,127.51,,,127.51,Fee Schedule,,478.1,70,,478.1,percent of total billed charges,All Other,134.48,,,134.48,Fee Schedule,,113.98,,,113.98,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,135.83,,,135.83,Other,100% of Medicaid,135.83,,,135.83,Other,100% of Medicaid,135.83,,,135.83,Other,100% of Medicaid,135.83,,,135.83,Other,100% of Medicaid,305.62,,,305.62,Other,225% of Medicaid,207.82,,,207.82,Other,153% of Medicaid,305.62,,,305.62,Other,225% of Medicaid,190.17,,,190.17,Other,140% of Medicaid,305.62,,,305.62,Other,225% of Medicaid,353.16,,,353.16,Other,260% of Medicaid,440.1,,,440.1,Other,324% of Medicaid,292.04,,,292.04,Other,215% of Medicaid,292.04,,,292.04,Other,215% of Medicaid,169.79,,,169.79,Other,125% of Medicaid,67.79,584.86,
XR EYE DETECT FOREIGN BODY LT W/ FY MOD,70030,CPT,FYLT,43170030,CDM,320,RC,,,both,,,241,178.34,,,178.34,Other,150% of Medicare + 9.63% HCRA Surcharge,108.45,45,,108.45,percent of total billed charges,Critical Access Hospital RCC factor,84.5,,,84.5,Fee Schedule,,76.03,,,76.03,Fee Schedule,,137.39,,,137.39,Fee Schedule,,123.57,,,123.57,Fee Schedule,,116.79,,,116.79,Fee Schedule,,119.3,,,119.3,Other,110% of Medicare,100.4,,,100.4,Fee Schedule,,53,,,53,Other,186% of Medicaid,118.15,,,118.15,Fee Schedule,,149.42,,,149.42,Fee Schedule,,55.63,,,55.63,Fee Schedule,,118.15,,,118.15,Fee Schedule,,149.42,,,149.42,Fee Schedule,,104.64,,,104.64,Fee Schedule,,168.7,70,,168.7,percent of total billed charges,All Other,116.44,,,116.44,Fee Schedule,,98.69,,,98.69,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,178.34,
XR RIBS 2 VIEWS LEFT W/ FY MOD,71100,CPT,FYLT,43171100,CDM,320,RC,,,both,,,437,323.38,,,323.38,Other,150% of Medicare + 9.63% HCRA Surcharge,196.65,45,,196.65,percent of total billed charges,Critical Access Hospital RCC factor,91.43,,,91.43,Fee Schedule,,82.25,,,82.25,Fee Schedule,,146.56,,,146.56,Fee Schedule,,131.82,,,131.82,Fee Schedule,,124.59,,,124.59,Fee Schedule,,216.32,,,216.32,Other,110% of Medicare,108.62,,,108.62,Fee Schedule,,53,,,53,Other,186% of Medicaid,127.82,,,127.82,Fee Schedule,,270.94,,,270.94,Fee Schedule,,60.19,,,60.19,Fee Schedule,,127.82,,,127.82,Fee Schedule,,270.94,,,270.94,Fee Schedule,,113.21,,,113.21,Fee Schedule,,305.9,70,,305.9,percent of total billed charges,All Other,127.92,,,127.92,Fee Schedule,,108.42,,,108.42,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,323.38,
XR RIBS 3 VIEWS + CXR LT W/ FY MOD,71101,CPT,FYLT,43171101,CDM,320,RC,,,both,,,437,323.38,,,323.38,Other,150% of Medicare + 9.63% HCRA Surcharge,196.65,45,,196.65,percent of total billed charges,Critical Access Hospital RCC factor,102.97,,,102.97,Fee Schedule,,92.64,,,92.64,Fee Schedule,,178.6,,,178.6,Fee Schedule,,160.64,,,160.64,Fee Schedule,,151.83,,,151.83,Fee Schedule,,216.32,,,216.32,Other,110% of Medicare,122.34,,,122.34,Fee Schedule,,53,,,53,Other,186% of Medicaid,143.97,,,143.97,Fee Schedule,,270.94,,,270.94,Fee Schedule,,67.79,,,67.79,Fee Schedule,,143.97,,,143.97,Fee Schedule,,270.94,,,270.94,Fee Schedule,,127.51,,,127.51,Fee Schedule,,305.9,70,,305.9,percent of total billed charges,All Other,144.32,,,144.32,Fee Schedule,,122.32,,,122.32,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,323.38,
XR CLAVICLE LEFT W/ FY MOD,73000,CPT,FYLT,43173000,CDM,320,RC,,,both,,,373,276.02,,,276.02,Other,150% of Medicare + 9.63% HCRA Surcharge,167.85,45,,167.85,percent of total billed charges,Critical Access Hospital RCC factor,85.65,,,85.65,Fee Schedule,,77.06,,,77.06,Fee Schedule,,139.71,,,139.71,Fee Schedule,,125.66,,,125.66,Fee Schedule,,118.76,,,118.76,Fee Schedule,,184.64,,,184.64,Other,110% of Medicare,101.76,,,101.76,Fee Schedule,,53,,,53,Other,186% of Medicaid,119.75,,,119.75,Fee Schedule,,231.26,,,231.26,Fee Schedule,,56.39,,,56.39,Fee Schedule,,119.75,,,119.75,Fee Schedule,,231.26,,,231.26,Fee Schedule,,106.06,,,106.06,Fee Schedule,,261.1,70,,261.1,percent of total billed charges,All Other,118.08,,,118.08,Fee Schedule,,100.08,,,100.08,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,276.02,
XR SCAPULA LEFT W/ FY MOD,73010,CPT,FYLT,43173010,CDM,320,RC,,,both,,,242,179.08,,,179.08,Other,150% of Medicare + 9.63% HCRA Surcharge,108.9,45,,108.9,percent of total billed charges,Critical Access Hospital RCC factor,53.3,,,53.3,Fee Schedule,,47.96,,,47.96,Fee Schedule,,144.29,,,144.29,Fee Schedule,,129.78,,,129.78,Fee Schedule,,122.66,,,122.66,Fee Schedule,,119.79,,,119.79,Other,110% of Medicare,63.33,,,63.33,Fee Schedule,,53,,,53,Other,186% of Medicaid,74.53,,,74.53,Fee Schedule,,150.04,,,150.04,Fee Schedule,,35.09,,,35.09,Fee Schedule,,74.53,,,74.53,Fee Schedule,,150.04,,,150.04,Fee Schedule,,66,,,66,Fee Schedule,,169.4,70,,169.4,percent of total billed charges,All Other,73.8,,,73.8,Fee Schedule,,62.55,,,62.55,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,179.33,
XR SHOULDER 1 V LT W/ FY MOD,73020,CPT,FYLT,43173020,CDM,320,RC,,,both,,,231,170.94,,,170.94,Other,150% of Medicare + 9.63% HCRA Surcharge,103.95,45,,103.95,percent of total billed charges,Critical Access Hospital RCC factor,49.86,,,49.86,Fee Schedule,,44.86,,,44.86,Fee Schedule,,109.93,,,109.93,Fee Schedule,,98.88,,,98.88,Fee Schedule,,93.45,,,93.45,Fee Schedule,,114.35,,,114.35,Other,110% of Medicare,59.24,,,59.24,Fee Schedule,,53,,,53,Other,186% of Medicaid,69.71,,,69.71,Fee Schedule,,143.22,,,143.22,Fee Schedule,,32.82,,,32.82,Fee Schedule,,69.71,,,69.71,Fee Schedule,,143.22,,,143.22,Fee Schedule,,61.74,,,61.74,Fee Schedule,,161.7,70,,161.7,percent of total billed charges,All Other,68.88,,,68.88,Fee Schedule,,58.38,,,58.38,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,170.94,
XR SHOULDER 2+ VIEWS LT W/ FY MOD,73030,CPT,FYLT,43173030,CDM,320,RC,,,both,,,407,301.18,,,301.18,Other,150% of Medicare + 9.63% HCRA Surcharge,183.15,45,,183.15,percent of total billed charges,Critical Access Hospital RCC factor,90.28,,,90.28,Fee Schedule,,81.22,,,81.22,Fee Schedule,,141.97,,,141.97,Fee Schedule,,127.7,,,127.7,Fee Schedule,,120.69,,,120.69,Fee Schedule,,201.47,,,201.47,Other,110% of Medicare,107.26,,,107.26,Fee Schedule,,53,,,53,Other,186% of Medicaid,126.22,,,126.22,Fee Schedule,,252.34,,,252.34,Fee Schedule,,59.43,,,59.43,Fee Schedule,,126.22,,,126.22,Fee Schedule,,252.34,,,252.34,Fee Schedule,,111.79,,,111.79,Fee Schedule,,284.9,70,,284.9,percent of total billed charges,All Other,124.64,,,124.64,Fee Schedule,,105.64,,,105.64,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,301.18,
XR HUMERUS LEFT W/ FY MOD,73060,CPT,FYLT,43173060,CDM,320,RC,,,both,,,373,276.02,,,276.02,Other,150% of Medicare + 9.63% HCRA Surcharge,167.85,45,,167.85,percent of total billed charges,Critical Access Hospital RCC factor,84.5,,,84.5,Fee Schedule,,76.03,,,76.03,Fee Schedule,,139.71,,,139.71,Fee Schedule,,125.66,,,125.66,Fee Schedule,,118.76,,,118.76,Fee Schedule,,184.64,,,184.64,Other,110% of Medicare,100.4,,,100.4,Fee Schedule,,53,,,53,Other,186% of Medicaid,118.15,,,118.15,Fee Schedule,,231.26,,,231.26,Fee Schedule,,55.63,,,55.63,Fee Schedule,,118.15,,,118.15,Fee Schedule,,231.26,,,231.26,Fee Schedule,,104.64,,,104.64,Fee Schedule,,261.1,70,,261.1,percent of total billed charges,All Other,118.08,,,118.08,Fee Schedule,,100.08,,,100.08,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,276.02,
XR ELBOW 2 VIEW LEFT W/ FY MOD,73070,CPT,FYLT,43173070,CDM,320,RC,,,both,,,231,170.94,,,170.94,Other,150% of Medicare + 9.63% HCRA Surcharge,103.95,45,,103.95,percent of total billed charges,Critical Access Hospital RCC factor,74.1,,,74.1,Fee Schedule,,66.67,,,66.67,Fee Schedule,,139.71,,,139.71,Fee Schedule,,125.66,,,125.66,Fee Schedule,,118.76,,,118.76,Fee Schedule,,114.35,,,114.35,Other,110% of Medicare,88.04,,,88.04,Fee Schedule,,53,,,53,Other,186% of Medicaid,103.61,,,103.61,Fee Schedule,,143.22,,,143.22,Fee Schedule,,48.78,,,48.78,Fee Schedule,,103.61,,,103.61,Fee Schedule,,143.22,,,143.22,Fee Schedule,,91.76,,,91.76,Fee Schedule,,161.7,70,,161.7,percent of total billed charges,All Other,103.32,,,103.32,Fee Schedule,,87.57,,,87.57,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,170.94,
XR ELBOW 3 VIEWS LT W/ FY MOD,73080,CPT,FYLT,43173080,CDM,320,RC,,,both,,,392,290.08,,,290.08,Other,150% of Medicare + 9.63% HCRA Surcharge,176.4,45,,176.4,percent of total billed charges,Critical Access Hospital RCC factor,85.65,,,85.65,Fee Schedule,,77.06,,,77.06,Fee Schedule,,174.02,,,174.02,Fee Schedule,,156.51,,,156.51,Fee Schedule,,147.93,,,147.93,Fee Schedule,,194.04,,,194.04,Other,110% of Medicare,101.76,,,101.76,Fee Schedule,,53,,,53,Other,186% of Medicaid,119.75,,,119.75,Fee Schedule,,243.04,,,243.04,Fee Schedule,,56.39,,,56.39,Fee Schedule,,119.75,,,119.75,Fee Schedule,,243.04,,,243.04,Fee Schedule,,106.06,,,106.06,Fee Schedule,,274.4,70,,274.4,percent of total billed charges,All Other,118.08,,,118.08,Fee Schedule,,100.08,,,100.08,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,290.08,
XR FOREARM LT W/ FY MOD,73090,CPT,FYLT,43173090,CDM,320,RC,,,both,,,334,247.16,,,247.16,Other,150% of Medicare + 9.63% HCRA Surcharge,150.3,45,,150.3,percent of total billed charges,Critical Access Hospital RCC factor,75.25,,,75.25,Fee Schedule,,67.7,,,67.7,Fee Schedule,,135.12,,,135.12,Fee Schedule,,121.53,,,121.53,Fee Schedule,,114.87,,,114.87,Fee Schedule,,165.33,,,165.33,Other,110% of Medicare,89.41,,,89.41,Fee Schedule,,53,,,53,Other,186% of Medicaid,105.21,,,105.21,Fee Schedule,,207.08,,,207.08,Fee Schedule,,49.54,,,49.54,Fee Schedule,,105.21,,,105.21,Fee Schedule,,207.08,,,207.08,Fee Schedule,,93.18,,,93.18,Fee Schedule,,233.8,70,,233.8,percent of total billed charges,All Other,104.96,,,104.96,Fee Schedule,,88.96,,,88.96,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,247.16,
XR UPPER EXT CHILD 2 V LT W/ FY MOD,73092,CPT,FYLT,43173092,CDM,320,RC,,,both,,,242,179.08,,,179.08,Other,150% of Medicare + 9.63% HCRA Surcharge,108.9,45,,108.9,percent of total billed charges,Critical Access Hospital RCC factor,83.35,,,83.35,Fee Schedule,,74.99,,,74.99,Fee Schedule,,153.41,,,153.41,Fee Schedule,,137.98,,,137.98,Fee Schedule,,130.41,,,130.41,Fee Schedule,,119.79,,,119.79,Other,110% of Medicare,99.03,,,99.03,Fee Schedule,,53,,,53,Other,186% of Medicaid,116.54,,,116.54,Fee Schedule,,150.04,,,150.04,Fee Schedule,,54.87,,,54.87,Fee Schedule,,116.54,,,116.54,Fee Schedule,,150.04,,,150.04,Fee Schedule,,103.21,,,103.21,Fee Schedule,,169.4,70,,169.4,percent of total billed charges,All Other,118.08,,,118.08,Fee Schedule,,100.08,,,100.08,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,179.33,
XR WRIST 2 VIEWS LT W/ FY MOD,73100,CPT,FYLT,43173100,CDM,320,RC,,,both,,,231,170.94,,,170.94,Other,150% of Medicare + 9.63% HCRA Surcharge,103.95,45,,103.95,percent of total billed charges,Critical Access Hospital RCC factor,90.28,,,90.28,Fee Schedule,,81.22,,,81.22,Fee Schedule,,148.82,,,148.82,Fee Schedule,,133.86,,,133.86,Fee Schedule,,126.52,,,126.52,Fee Schedule,,114.35,,,114.35,Other,110% of Medicare,107.26,,,107.26,Fee Schedule,,53,,,53,Other,186% of Medicaid,126.22,,,126.22,Fee Schedule,,143.22,,,143.22,Fee Schedule,,59.43,,,59.43,Fee Schedule,,126.22,,,126.22,Fee Schedule,,143.22,,,143.22,Fee Schedule,,111.79,,,111.79,Fee Schedule,,161.7,70,,161.7,percent of total billed charges,All Other,126.28,,,126.28,Fee Schedule,,107.03,,,107.03,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,170.94,
XR WRIST 3+ VIEWS LT W/ FY MOD,73110,CPT,FYLT,43173110,CDM,320,RC,,,both,,,330,244.2,,,244.2,Other,150% of Medicare + 9.63% HCRA Surcharge,148.5,45,,148.5,percent of total billed charges,Critical Access Hospital RCC factor,114.55,,,114.55,Fee Schedule,,103.06,,,103.06,Fee Schedule,,187.77,,,187.77,Fee Schedule,,168.89,,,168.89,Fee Schedule,,159.62,,,159.62,Fee Schedule,,163.35,,,163.35,Other,110% of Medicare,136.1,,,136.1,Fee Schedule,,53,,,53,Other,186% of Medicaid,160.16,,,160.16,Fee Schedule,,204.6,,,204.6,Fee Schedule,,75.41,,,75.41,Fee Schedule,,160.16,,,160.16,Fee Schedule,,204.6,,,204.6,Fee Schedule,,141.84,,,141.84,Fee Schedule,,231,70,,231,percent of total billed charges,All Other,159.08,,,159.08,Fee Schedule,,134.83,,,134.83,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,244.2,
XR HAND 2 VIEWS LT W/ FY MOD,73120,CPT,FYLT,43173120,CDM,320,RC,,,both,,,242,179.08,,,179.08,Other,150% of Medicare + 9.63% HCRA Surcharge,108.9,45,,108.9,percent of total billed charges,Critical Access Hospital RCC factor,82.21,,,82.21,Fee Schedule,,73.96,,,73.96,Fee Schedule,,132.8,,,132.8,Fee Schedule,,119.45,,,119.45,Fee Schedule,,112.9,,,112.9,Fee Schedule,,119.79,,,119.79,Other,110% of Medicare,97.67,,,97.67,Fee Schedule,,53,,,53,Other,186% of Medicaid,114.93,,,114.93,Fee Schedule,,150.04,,,150.04,Fee Schedule,,54.12,,,54.12,Fee Schedule,,114.93,,,114.93,Fee Schedule,,150.04,,,150.04,Fee Schedule,,101.79,,,101.79,Fee Schedule,,169.4,70,,169.4,percent of total billed charges,All Other,113.16,,,113.16,Fee Schedule,,95.91,,,95.91,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,179.33,
XR HAND 3+ VIEWS LT W/ FY MOD,73130,CPT,FYLT,43173130,CDM,320,RC,,,both,,,352,260.48,,,260.48,Other,150% of Medicare + 9.63% HCRA Surcharge,158.4,45,,158.4,percent of total billed charges,Critical Access Hospital RCC factor,100.68,,,100.68,Fee Schedule,,90.58,,,90.58,Fee Schedule,,160.26,,,160.26,Fee Schedule,,144.14,,,144.14,Fee Schedule,,136.24,,,136.24,Fee Schedule,,174.24,,,174.24,Other,110% of Medicare,119.61,,,119.61,Fee Schedule,,53,,,53,Other,186% of Medicaid,140.76,,,140.76,Fee Schedule,,218.24,,,218.24,Fee Schedule,,66.28,,,66.28,Fee Schedule,,140.76,,,140.76,Fee Schedule,,218.24,,,218.24,Fee Schedule,,124.66,,,124.66,Fee Schedule,,246.4,70,,246.4,percent of total billed charges,All Other,137.76,,,137.76,Fee Schedule,,116.76,,,116.76,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,260.48,
XR FINGER 2+ VIEWS LT W/ FY MOD,73140,CPT,FYLT,43173140,CDM,320,RC,,,both,,,231,170.94,,,170.94,Other,150% of Medicare + 9.63% HCRA Surcharge,103.95,45,,103.95,percent of total billed charges,Critical Access Hospital RCC factor,109.93,,,109.93,Fee Schedule,,98.9,,,98.9,Fee Schedule,,167.16,,,167.16,Fee Schedule,,150.35,,,150.35,Fee Schedule,,142.11,,,142.11,Fee Schedule,,114.35,,,114.35,Other,110% of Medicare,130.6,,,130.6,Fee Schedule,,53,,,53,Other,186% of Medicaid,153.69,,,153.69,Fee Schedule,,143.22,,,143.22,Fee Schedule,,72.37,,,72.37,Fee Schedule,,153.69,,,153.69,Fee Schedule,,143.22,,,143.22,Fee Schedule,,136.12,,,136.12,Fee Schedule,,161.7,70,,161.7,percent of total billed charges,All Other,150.88,,,150.88,Fee Schedule,,127.88,,,127.88,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,170.94,
X-RAY EXAM HIP UNI 1 VIEW LT W/ FY MOD,73501,CPT,FYLT,43173501,CDM,320,RC,,,both,,,237,175.38,,,175.38,Other,150% of Medicare + 9.63% HCRA Surcharge,106.65,45,,106.65,percent of total billed charges,Critical Access Hospital RCC factor,83.35,,,83.35,Fee Schedule,,74.99,,,74.99,Fee Schedule,,20.07,,,20.07,Fee Schedule,,20.07,,,20.07,Fee Schedule,,20.07,,,20.07,Fee Schedule,,117.32,,,117.32,Other,110% of Medicare,99.03,,,99.03,Fee Schedule,,53,,,53,Other,186% of Medicaid,116.54,,,116.54,Fee Schedule,,146.94,,,146.94,Fee Schedule,,54.87,,,54.87,Fee Schedule,,116.54,,,116.54,Fee Schedule,,146.94,,,146.94,Fee Schedule,,103.21,,,103.21,Fee Schedule,,165.9,70,,165.9,percent of total billed charges,All Other,114.8,,,114.8,Fee Schedule,,97.3,,,97.3,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,20.07,175.38,
X-RAY EXAM HIP UNI 2-3 VIEWS LT W/ FY,73502,CPT,FYLT,43173502,CDM,320,RC,,,both,,,250,185,,,185,Other,150% of Medicare + 9.63% HCRA Surcharge,112.5,45,,112.5,percent of total billed charges,Critical Access Hospital RCC factor,128.4,,,128.4,Fee Schedule,,115.52,,,115.52,Fee Schedule,,29.42,,,29.42,Fee Schedule,,29.42,,,29.42,Fee Schedule,,29.42,,,29.42,Fee Schedule,,123.75,,,123.75,Other,110% of Medicare,152.55,,,152.55,Fee Schedule,,53,,,53,Other,186% of Medicaid,179.52,,,179.52,Fee Schedule,,155,,,155,Fee Schedule,,84.53,,,84.53,Fee Schedule,,179.52,,,179.52,Fee Schedule,,155,,,155,Fee Schedule,,158.99,,,158.99,Fee Schedule,,175,70,,175,percent of total billed charges,All Other,177.12,,,177.12,Fee Schedule,,150.12,,,150.12,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,185,
X-RAY EXAM HIP UNI 4/> VIEWS LT W/ FY,73503,CPT,FYLT,43173503,CDM,320,RC,,,both,,,336,248.64,,,248.64,Other,150% of Medicare + 9.63% HCRA Surcharge,151.2,45,,151.2,percent of total billed charges,Critical Access Hospital RCC factor,163.07,,,163.07,Fee Schedule,,146.71,,,146.71,Fee Schedule,,36.34,,,36.34,Fee Schedule,,36.34,,,36.34,Fee Schedule,,36.34,,,36.34,Fee Schedule,,166.32,,,166.32,Other,110% of Medicare,193.74,,,193.74,Fee Schedule,,53,,,53,Other,186% of Medicaid,228,,,228,Fee Schedule,,208.32,,,208.32,Fee Schedule,,107.35,,,107.35,Fee Schedule,,228,,,228,Fee Schedule,,208.32,,,208.32,Fee Schedule,,201.92,,,201.92,Fee Schedule,,235.2,70,,235.2,percent of total billed charges,All Other,224.68,,,224.68,Fee Schedule,,190.43,,,190.43,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,248.64,
X-RAY EXAM OF FEMUR 1 LT W/ FY MOD,73551,CPT,FYLT,43173551,CDM,320,RC,,,both,,,237,175.38,,,175.38,Other,150% of Medicare + 9.63% HCRA Surcharge,106.65,45,,106.65,percent of total billed charges,Critical Access Hospital RCC factor,74.1,,,74.1,Fee Schedule,,66.67,,,66.67,Fee Schedule,,19.04,,,19.04,Fee Schedule,,19.04,,,19.04,Fee Schedule,,19.04,,,19.04,Fee Schedule,,117.32,,,117.32,Other,110% of Medicare,88.04,,,88.04,Fee Schedule,,53,,,53,Other,186% of Medicaid,103.61,,,103.61,Fee Schedule,,146.94,,,146.94,Fee Schedule,,48.78,,,48.78,Fee Schedule,,103.61,,,103.61,Fee Schedule,,146.94,,,146.94,Fee Schedule,,91.76,,,91.76,Fee Schedule,,165.9,70,,165.9,percent of total billed charges,All Other,103.32,,,103.32,Fee Schedule,,87.57,,,87.57,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,19.04,175.38,
X-RAY EXAM OF FEMUR 2/> LT W/ FY MOD,73552,CPT,FYLT,43173552,CDM,320,RC,,,both,,,237,175.38,,,175.38,Other,150% of Medicare + 9.63% HCRA Surcharge,106.65,45,,106.65,percent of total billed charges,Critical Access Hospital RCC factor,93.75,,,93.75,Fee Schedule,,84.35,,,84.35,Fee Schedule,,22.84,,,22.84,Fee Schedule,,22.84,,,22.84,Fee Schedule,,22.84,,,22.84,Fee Schedule,,117.32,,,117.32,Other,110% of Medicare,111.39,,,111.39,Fee Schedule,,53,,,53,Other,186% of Medicaid,131.08,,,131.08,Fee Schedule,,146.94,,,146.94,Fee Schedule,,61.72,,,61.72,Fee Schedule,,131.08,,,131.08,Fee Schedule,,146.94,,,146.94,Fee Schedule,,116.09,,,116.09,Fee Schedule,,165.9,70,,165.9,percent of total billed charges,All Other,129.56,,,129.56,Fee Schedule,,109.81,,,109.81,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,22.84,175.38,
XR KNEE 1 OR 2 VIEWS LT W/ FY MOD,73560,CPT,FYLT,43173560,CDM,320,RC,,,both,,,407,301.18,,,301.18,Other,150% of Medicare + 9.63% HCRA Surcharge,183.15,45,,183.15,percent of total billed charges,Critical Access Hospital RCC factor,91.43,,,91.43,Fee Schedule,,82.25,,,82.25,Fee Schedule,,144.29,,,144.29,Fee Schedule,,129.78,,,129.78,Fee Schedule,,122.66,,,122.66,Fee Schedule,,201.47,,,201.47,Other,110% of Medicare,108.62,,,108.62,Fee Schedule,,53,,,53,Other,186% of Medicaid,127.82,,,127.82,Fee Schedule,,252.34,,,252.34,Fee Schedule,,60.19,,,60.19,Fee Schedule,,127.82,,,127.82,Fee Schedule,,252.34,,,252.34,Fee Schedule,,113.21,,,113.21,Fee Schedule,,284.9,70,,284.9,percent of total billed charges,All Other,127.92,,,127.92,Fee Schedule,,108.42,,,108.42,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,301.18,
XR KNEE 3 VIEWS LT W/ FY MOD,73562,CPT,FYLT,43173562,CDM,320,RC,,,both,,,445,329.3,,,329.3,Other,150% of Medicare + 9.63% HCRA Surcharge,200.25,45,,200.25,percent of total billed charges,Critical Access Hospital RCC factor,111.08,,,111.08,Fee Schedule,,99.93,,,99.93,Fee Schedule,,180.87,,,180.87,Fee Schedule,,162.68,,,162.68,Fee Schedule,,153.75,,,153.75,Fee Schedule,,220.28,,,220.28,Other,110% of Medicare,131.97,,,131.97,Fee Schedule,,53,,,53,Other,186% of Medicaid,155.3,,,155.3,Fee Schedule,,275.9,,,275.9,Fee Schedule,,73.12,,,73.12,Fee Schedule,,155.3,,,155.3,Fee Schedule,,275.9,,,275.9,Fee Schedule,,137.54,,,137.54,Fee Schedule,,311.5,70,,311.5,percent of total billed charges,All Other,155.8,,,155.8,Fee Schedule,,132.05,,,132.05,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,329.3,
XR KNEE 4+ VIEWS LT W/ FY MOD,73564,CPT,FYLT,43173564,CDM,320,RC,,,both,,,445,329.3,,,329.3,Other,150% of Medicare + 9.63% HCRA Surcharge,200.25,45,,200.25,percent of total billed charges,Critical Access Hospital RCC factor,126.1,,,126.1,Fee Schedule,,113.45,,,113.45,Fee Schedule,,206.06,,,206.06,Fee Schedule,,185.33,,,185.33,Fee Schedule,,175.17,,,175.17,Fee Schedule,,220.28,,,220.28,Other,110% of Medicare,149.82,,,149.82,Fee Schedule,,53,,,53,Other,186% of Medicaid,176.3,,,176.3,Fee Schedule,,275.9,,,275.9,Fee Schedule,,83.01,,,83.01,Fee Schedule,,176.3,,,176.3,Fee Schedule,,275.9,,,275.9,Fee Schedule,,156.14,,,156.14,Fee Schedule,,311.5,70,,311.5,percent of total billed charges,All Other,173.84,,,173.84,Fee Schedule,,147.34,,,147.34,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,329.3,
XR TIBIA/FIBULA 2 VIEWS LT W/ FY MOD,73590,CPT,FYLT,43173590,CDM,320,RC,,,both,,,373,276.02,,,276.02,Other,150% of Medicare + 9.63% HCRA Surcharge,167.85,45,,167.85,percent of total billed charges,Critical Access Hospital RCC factor,83.35,,,83.35,Fee Schedule,,74.99,,,74.99,Fee Schedule,,130.54,,,130.54,Fee Schedule,,117.41,,,117.41,Fee Schedule,,110.97,,,110.97,Fee Schedule,,184.64,,,184.64,Other,110% of Medicare,99.03,,,99.03,Fee Schedule,,53,,,53,Other,186% of Medicaid,116.54,,,116.54,Fee Schedule,,231.26,,,231.26,Fee Schedule,,54.87,,,54.87,Fee Schedule,,116.54,,,116.54,Fee Schedule,,231.26,,,231.26,Fee Schedule,,103.21,,,103.21,Fee Schedule,,261.1,70,,261.1,percent of total billed charges,All Other,116.44,,,116.44,Fee Schedule,,98.69,,,98.69,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,276.02,
XR ANKLE 2 VIEWS LT W/ FY MOD,73600,CPT,FYLT,43173600,CDM,320,RC,,,both,,,231,170.94,,,170.94,Other,150% of Medicare + 9.63% HCRA Surcharge,103.95,45,,103.95,percent of total billed charges,Critical Access Hospital RCC factor,85.65,,,85.65,Fee Schedule,,77.06,,,77.06,Fee Schedule,,137.39,,,137.39,Fee Schedule,,123.57,,,123.57,Fee Schedule,,116.79,,,116.79,Fee Schedule,,114.35,,,114.35,Other,110% of Medicare,101.76,,,101.76,Fee Schedule,,53,,,53,Other,186% of Medicaid,119.75,,,119.75,Fee Schedule,,143.22,,,143.22,Fee Schedule,,56.39,,,56.39,Fee Schedule,,119.75,,,119.75,Fee Schedule,,143.22,,,143.22,Fee Schedule,,106.06,,,106.06,Fee Schedule,,161.7,70,,161.7,percent of total billed charges,All Other,119.72,,,119.72,Fee Schedule,,101.47,,,101.47,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,170.94,
XR ANKLE 3+ VIEWS LT W/ FY MOD,73610,CPT,FYLT,43173610,CDM,320,RC,,,both,,,348,257.52,,,257.52,Other,150% of Medicare + 9.63% HCRA Surcharge,156.6,45,,156.6,percent of total billed charges,Critical Access Hospital RCC factor,98.38,,,98.38,Fee Schedule,,88.51,,,88.51,Fee Schedule,,162.58,,,162.58,Fee Schedule,,146.23,,,146.23,Fee Schedule,,138.21,,,138.21,Fee Schedule,,172.26,,,172.26,Other,110% of Medicare,116.88,,,116.88,Fee Schedule,,53,,,53,Other,186% of Medicaid,137.55,,,137.55,Fee Schedule,,215.76,,,215.76,Fee Schedule,,64.76,,,64.76,Fee Schedule,,137.55,,,137.55,Fee Schedule,,215.76,,,215.76,Fee Schedule,,121.82,,,121.82,Fee Schedule,,243.6,70,,243.6,percent of total billed charges,All Other,139.4,,,139.4,Fee Schedule,,118.15,,,118.15,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,257.52,
XR FOOT 2 VIEWS LT W/ FY MOD,73620,CPT,FYLT,43173620,CDM,320,RC,,,both,,,231,170.94,,,170.94,Other,150% of Medicare + 9.63% HCRA Surcharge,103.95,45,,103.95,percent of total billed charges,Critical Access Hospital RCC factor,74.1,,,74.1,Fee Schedule,,66.67,,,66.67,Fee Schedule,,132.8,,,132.8,Fee Schedule,,119.45,,,119.45,Fee Schedule,,112.9,,,112.9,Fee Schedule,,114.35,,,114.35,Other,110% of Medicare,88.04,,,88.04,Fee Schedule,,53,,,53,Other,186% of Medicaid,103.61,,,103.61,Fee Schedule,,143.22,,,143.22,Fee Schedule,,48.78,,,48.78,Fee Schedule,,103.61,,,103.61,Fee Schedule,,143.22,,,143.22,Fee Schedule,,91.76,,,91.76,Fee Schedule,,161.7,70,,161.7,percent of total billed charges,All Other,101.68,,,101.68,Fee Schedule,,86.18,,,86.18,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,170.94,
XR FOOT 3+ VIEWS LT W/ FY MOD,73630,CPT,FYLT,43173630,CDM,320,RC,,,both,,,373,276.02,,,276.02,Other,150% of Medicare + 9.63% HCRA Surcharge,167.85,45,,167.85,percent of total billed charges,Critical Access Hospital RCC factor,91.43,,,91.43,Fee Schedule,,82.25,,,82.25,Fee Schedule,,157.99,,,157.99,Fee Schedule,,142.11,,,142.11,Fee Schedule,,134.31,,,134.31,Fee Schedule,,184.64,,,184.64,Other,110% of Medicare,108.62,,,108.62,Fee Schedule,,53,,,53,Other,186% of Medicaid,127.82,,,127.82,Fee Schedule,,231.26,,,231.26,Fee Schedule,,60.19,,,60.19,Fee Schedule,,127.82,,,127.82,Fee Schedule,,231.26,,,231.26,Fee Schedule,,113.21,,,113.21,Fee Schedule,,261.1,70,,261.1,percent of total billed charges,All Other,129.56,,,129.56,Fee Schedule,,109.81,,,109.81,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,276.02,
XR HEEL 2+ VIEWS LT W/ FY MOD,73650,CPT,FYLT,43173650,CDM,320,RC,,,both,,,231,170.94,,,170.94,Other,150% of Medicare + 9.63% HCRA Surcharge,103.95,45,,103.95,percent of total billed charges,Critical Access Hospital RCC factor,72.96,,,72.96,Fee Schedule,,65.64,,,65.64,Fee Schedule,,135.12,,,135.12,Fee Schedule,,121.53,,,121.53,Fee Schedule,,114.87,,,114.87,Fee Schedule,,114.35,,,114.35,Other,110% of Medicare,86.68,,,86.68,Fee Schedule,,53,,,53,Other,186% of Medicaid,102,,,102,Fee Schedule,,143.22,,,143.22,Fee Schedule,,48.03,,,48.03,Fee Schedule,,102,,,102,Fee Schedule,,143.22,,,143.22,Fee Schedule,,90.34,,,90.34,Fee Schedule,,161.7,70,,161.7,percent of total billed charges,All Other,103.32,,,103.32,Fee Schedule,,87.57,,,87.57,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,170.94,
XR TOE(S) 2+ VIEWS LT W/ FY MOD,73660,CPT,FYLT,43173660,CDM,320,RC,,,both,,,231,170.94,,,170.94,Other,150% of Medicare + 9.63% HCRA Surcharge,103.95,45,,103.95,percent of total billed charges,Critical Access Hospital RCC factor,79.88,,,79.88,Fee Schedule,,71.86,,,71.86,Fee Schedule,,155.73,,,155.73,Fee Schedule,,140.07,,,140.07,Fee Schedule,,132.38,,,132.38,Fee Schedule,,114.35,,,114.35,Other,110% of Medicare,94.9,,,94.9,Fee Schedule,,53,,,53,Other,186% of Medicaid,111.68,,,111.68,Fee Schedule,,143.22,,,143.22,Fee Schedule,,52.58,,,52.58,Fee Schedule,,111.68,,,111.68,Fee Schedule,,143.22,,,143.22,Fee Schedule,,98.91,,,98.91,Fee Schedule,,161.7,70,,161.7,percent of total billed charges,All Other,111.52,,,111.52,Fee Schedule,,94.52,,,94.52,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,170.94,
XR EYE DETECT FOREIGN BODY RT W/ FY MOD,70030,CPT,FYRT,43270030,CDM,320,RC,,,both,,,241,178.34,,,178.34,Other,150% of Medicare + 9.63% HCRA Surcharge,108.45,45,,108.45,percent of total billed charges,Critical Access Hospital RCC factor,84.5,,,84.5,Fee Schedule,,76.03,,,76.03,Fee Schedule,,137.39,,,137.39,Fee Schedule,,123.57,,,123.57,Fee Schedule,,116.79,,,116.79,Fee Schedule,,119.3,,,119.3,Other,110% of Medicare,100.4,,,100.4,Fee Schedule,,53,,,53,Other,186% of Medicaid,118.15,,,118.15,Fee Schedule,,149.42,,,149.42,Fee Schedule,,55.63,,,55.63,Fee Schedule,,118.15,,,118.15,Fee Schedule,,149.42,,,149.42,Fee Schedule,,104.64,,,104.64,Fee Schedule,,168.7,70,,168.7,percent of total billed charges,All Other,116.44,,,116.44,Fee Schedule,,98.69,,,98.69,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,178.34,
XR RIBS 2 VIEWS RIGHT W/ FY MOD,71100,CPT,FYRT,43271100,CDM,320,RC,,,both,,,437,323.38,,,323.38,Other,150% of Medicare + 9.63% HCRA Surcharge,196.65,45,,196.65,percent of total billed charges,Critical Access Hospital RCC factor,91.43,,,91.43,Fee Schedule,,82.25,,,82.25,Fee Schedule,,146.56,,,146.56,Fee Schedule,,131.82,,,131.82,Fee Schedule,,124.59,,,124.59,Fee Schedule,,216.32,,,216.32,Other,110% of Medicare,108.62,,,108.62,Fee Schedule,,53,,,53,Other,186% of Medicaid,127.82,,,127.82,Fee Schedule,,270.94,,,270.94,Fee Schedule,,60.19,,,60.19,Fee Schedule,,127.82,,,127.82,Fee Schedule,,270.94,,,270.94,Fee Schedule,,113.21,,,113.21,Fee Schedule,,305.9,70,,305.9,percent of total billed charges,All Other,127.92,,,127.92,Fee Schedule,,108.42,,,108.42,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,323.38,
XR RIBS 3 VIEWS + CXR RT W/ FY MOD,71101,CPT,FYRT,43271101,CDM,320,RC,,,both,,,437,323.38,,,323.38,Other,150% of Medicare + 9.63% HCRA Surcharge,196.65,45,,196.65,percent of total billed charges,Critical Access Hospital RCC factor,102.97,,,102.97,Fee Schedule,,92.64,,,92.64,Fee Schedule,,178.6,,,178.6,Fee Schedule,,160.64,,,160.64,Fee Schedule,,151.83,,,151.83,Fee Schedule,,216.32,,,216.32,Other,110% of Medicare,122.34,,,122.34,Fee Schedule,,53,,,53,Other,186% of Medicaid,143.97,,,143.97,Fee Schedule,,270.94,,,270.94,Fee Schedule,,67.79,,,67.79,Fee Schedule,,143.97,,,143.97,Fee Schedule,,270.94,,,270.94,Fee Schedule,,127.51,,,127.51,Fee Schedule,,305.9,70,,305.9,percent of total billed charges,All Other,144.32,,,144.32,Fee Schedule,,122.32,,,122.32,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,323.38,
XR CLAVICLE RIGHT W/ FY MOD,73000,CPT,FYRT,43273000,CDM,320,RC,,,both,,,373,276.02,,,276.02,Other,150% of Medicare + 9.63% HCRA Surcharge,167.85,45,,167.85,percent of total billed charges,Critical Access Hospital RCC factor,85.65,,,85.65,Fee Schedule,,77.06,,,77.06,Fee Schedule,,139.71,,,139.71,Fee Schedule,,125.66,,,125.66,Fee Schedule,,118.76,,,118.76,Fee Schedule,,184.64,,,184.64,Other,110% of Medicare,101.76,,,101.76,Fee Schedule,,53,,,53,Other,186% of Medicaid,119.75,,,119.75,Fee Schedule,,231.26,,,231.26,Fee Schedule,,56.39,,,56.39,Fee Schedule,,119.75,,,119.75,Fee Schedule,,231.26,,,231.26,Fee Schedule,,106.06,,,106.06,Fee Schedule,,261.1,70,,261.1,percent of total billed charges,All Other,118.08,,,118.08,Fee Schedule,,100.08,,,100.08,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,276.02,
XR SCAPULA RIGHT W/ FY MOD,73010,CPT,FYRT,43273010,CDM,320,RC,,,both,,,242,179.08,,,179.08,Other,150% of Medicare + 9.63% HCRA Surcharge,108.9,45,,108.9,percent of total billed charges,Critical Access Hospital RCC factor,53.3,,,53.3,Fee Schedule,,47.96,,,47.96,Fee Schedule,,144.29,,,144.29,Fee Schedule,,129.78,,,129.78,Fee Schedule,,122.66,,,122.66,Fee Schedule,,119.79,,,119.79,Other,110% of Medicare,63.33,,,63.33,Fee Schedule,,53,,,53,Other,186% of Medicaid,74.53,,,74.53,Fee Schedule,,150.04,,,150.04,Fee Schedule,,35.09,,,35.09,Fee Schedule,,74.53,,,74.53,Fee Schedule,,150.04,,,150.04,Fee Schedule,,66,,,66,Fee Schedule,,169.4,70,,169.4,percent of total billed charges,All Other,73.8,,,73.8,Fee Schedule,,62.55,,,62.55,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,179.33,
XR SHOULDER 1 V RT W/ FY MOD,73020,CPT,FYRT,43273020,CDM,320,RC,,,both,,,231,170.94,,,170.94,Other,150% of Medicare + 9.63% HCRA Surcharge,103.95,45,,103.95,percent of total billed charges,Critical Access Hospital RCC factor,49.86,,,49.86,Fee Schedule,,44.86,,,44.86,Fee Schedule,,109.93,,,109.93,Fee Schedule,,98.88,,,98.88,Fee Schedule,,93.45,,,93.45,Fee Schedule,,114.35,,,114.35,Other,110% of Medicare,59.24,,,59.24,Fee Schedule,,53,,,53,Other,186% of Medicaid,69.71,,,69.71,Fee Schedule,,143.22,,,143.22,Fee Schedule,,32.82,,,32.82,Fee Schedule,,69.71,,,69.71,Fee Schedule,,143.22,,,143.22,Fee Schedule,,61.74,,,61.74,Fee Schedule,,161.7,70,,161.7,percent of total billed charges,All Other,68.88,,,68.88,Fee Schedule,,58.38,,,58.38,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,170.94,
XR SHOULDER 2+ VIEWS RT W/ FY MOD,73030,CPT,FYRT,43273030,CDM,320,RC,,,both,,,407,301.18,,,301.18,Other,150% of Medicare + 9.63% HCRA Surcharge,183.15,45,,183.15,percent of total billed charges,Critical Access Hospital RCC factor,90.28,,,90.28,Fee Schedule,,81.22,,,81.22,Fee Schedule,,141.97,,,141.97,Fee Schedule,,127.7,,,127.7,Fee Schedule,,120.69,,,120.69,Fee Schedule,,201.47,,,201.47,Other,110% of Medicare,107.26,,,107.26,Fee Schedule,,53,,,53,Other,186% of Medicaid,126.22,,,126.22,Fee Schedule,,252.34,,,252.34,Fee Schedule,,59.43,,,59.43,Fee Schedule,,126.22,,,126.22,Fee Schedule,,252.34,,,252.34,Fee Schedule,,111.79,,,111.79,Fee Schedule,,284.9,70,,284.9,percent of total billed charges,All Other,124.64,,,124.64,Fee Schedule,,105.64,,,105.64,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,301.18,
XR HUMERUS RIGHT W/ FY MOD,73060,CPT,FYRT,43273060,CDM,320,RC,,,both,,,373,276.02,,,276.02,Other,150% of Medicare + 9.63% HCRA Surcharge,167.85,45,,167.85,percent of total billed charges,Critical Access Hospital RCC factor,84.5,,,84.5,Fee Schedule,,76.03,,,76.03,Fee Schedule,,139.71,,,139.71,Fee Schedule,,125.66,,,125.66,Fee Schedule,,118.76,,,118.76,Fee Schedule,,184.64,,,184.64,Other,110% of Medicare,100.4,,,100.4,Fee Schedule,,53,,,53,Other,186% of Medicaid,118.15,,,118.15,Fee Schedule,,231.26,,,231.26,Fee Schedule,,55.63,,,55.63,Fee Schedule,,118.15,,,118.15,Fee Schedule,,231.26,,,231.26,Fee Schedule,,104.64,,,104.64,Fee Schedule,,261.1,70,,261.1,percent of total billed charges,All Other,118.08,,,118.08,Fee Schedule,,100.08,,,100.08,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,276.02,
XR ELBOW 2 VIEW RIGHT W/ FY MOD,73070,CPT,FYRT,43273070,CDM,320,RC,,,both,,,231,170.94,,,170.94,Other,150% of Medicare + 9.63% HCRA Surcharge,103.95,45,,103.95,percent of total billed charges,Critical Access Hospital RCC factor,74.1,,,74.1,Fee Schedule,,66.67,,,66.67,Fee Schedule,,139.71,,,139.71,Fee Schedule,,125.66,,,125.66,Fee Schedule,,118.76,,,118.76,Fee Schedule,,114.35,,,114.35,Other,110% of Medicare,88.04,,,88.04,Fee Schedule,,53,,,53,Other,186% of Medicaid,103.61,,,103.61,Fee Schedule,,143.22,,,143.22,Fee Schedule,,48.78,,,48.78,Fee Schedule,,103.61,,,103.61,Fee Schedule,,143.22,,,143.22,Fee Schedule,,91.76,,,91.76,Fee Schedule,,161.7,70,,161.7,percent of total billed charges,All Other,103.32,,,103.32,Fee Schedule,,87.57,,,87.57,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,170.94,
XR ELBOW 3 VIEWS RT W/ FY MOD,73080,CPT,FYRT,43273080,CDM,320,RC,,,both,,,392,290.08,,,290.08,Other,150% of Medicare + 9.63% HCRA Surcharge,176.4,45,,176.4,percent of total billed charges,Critical Access Hospital RCC factor,85.65,,,85.65,Fee Schedule,,77.06,,,77.06,Fee Schedule,,174.02,,,174.02,Fee Schedule,,156.51,,,156.51,Fee Schedule,,147.93,,,147.93,Fee Schedule,,194.04,,,194.04,Other,110% of Medicare,101.76,,,101.76,Fee Schedule,,53,,,53,Other,186% of Medicaid,119.75,,,119.75,Fee Schedule,,243.04,,,243.04,Fee Schedule,,56.39,,,56.39,Fee Schedule,,119.75,,,119.75,Fee Schedule,,243.04,,,243.04,Fee Schedule,,106.06,,,106.06,Fee Schedule,,274.4,70,,274.4,percent of total billed charges,All Other,118.08,,,118.08,Fee Schedule,,100.08,,,100.08,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,290.08,
XR FOREARM RT W/ FY MOD,73090,CPT,FYRT,43273090,CDM,320,RC,,,both,,,334,247.16,,,247.16,Other,150% of Medicare + 9.63% HCRA Surcharge,150.3,45,,150.3,percent of total billed charges,Critical Access Hospital RCC factor,75.25,,,75.25,Fee Schedule,,67.7,,,67.7,Fee Schedule,,135.12,,,135.12,Fee Schedule,,121.53,,,121.53,Fee Schedule,,114.87,,,114.87,Fee Schedule,,165.33,,,165.33,Other,110% of Medicare,89.41,,,89.41,Fee Schedule,,53,,,53,Other,186% of Medicaid,105.21,,,105.21,Fee Schedule,,207.08,,,207.08,Fee Schedule,,49.54,,,49.54,Fee Schedule,,105.21,,,105.21,Fee Schedule,,207.08,,,207.08,Fee Schedule,,93.18,,,93.18,Fee Schedule,,233.8,70,,233.8,percent of total billed charges,All Other,104.96,,,104.96,Fee Schedule,,88.96,,,88.96,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,247.16,
XR UPPER EXT CHILD 2 V RT W/ FY MOD,73092,CPT,FYRT,43273092,CDM,320,RC,,,both,,,242,179.08,,,179.08,Other,150% of Medicare + 9.63% HCRA Surcharge,108.9,45,,108.9,percent of total billed charges,Critical Access Hospital RCC factor,83.35,,,83.35,Fee Schedule,,74.99,,,74.99,Fee Schedule,,153.41,,,153.41,Fee Schedule,,137.98,,,137.98,Fee Schedule,,130.41,,,130.41,Fee Schedule,,119.79,,,119.79,Other,110% of Medicare,99.03,,,99.03,Fee Schedule,,53,,,53,Other,186% of Medicaid,116.54,,,116.54,Fee Schedule,,150.04,,,150.04,Fee Schedule,,54.87,,,54.87,Fee Schedule,,116.54,,,116.54,Fee Schedule,,150.04,,,150.04,Fee Schedule,,103.21,,,103.21,Fee Schedule,,169.4,70,,169.4,percent of total billed charges,All Other,118.08,,,118.08,Fee Schedule,,100.08,,,100.08,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,179.33,
XR WRIST 2 VIEWS RT W/ FY MOD,73100,CPT,FYRT,43273100,CDM,320,RC,,,both,,,231,170.94,,,170.94,Other,150% of Medicare + 9.63% HCRA Surcharge,103.95,45,,103.95,percent of total billed charges,Critical Access Hospital RCC factor,90.28,,,90.28,Fee Schedule,,81.22,,,81.22,Fee Schedule,,148.82,,,148.82,Fee Schedule,,133.86,,,133.86,Fee Schedule,,126.52,,,126.52,Fee Schedule,,114.35,,,114.35,Other,110% of Medicare,107.26,,,107.26,Fee Schedule,,53,,,53,Other,186% of Medicaid,126.22,,,126.22,Fee Schedule,,143.22,,,143.22,Fee Schedule,,59.43,,,59.43,Fee Schedule,,126.22,,,126.22,Fee Schedule,,143.22,,,143.22,Fee Schedule,,111.79,,,111.79,Fee Schedule,,161.7,70,,161.7,percent of total billed charges,All Other,126.28,,,126.28,Fee Schedule,,107.03,,,107.03,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,170.94,
XR WRIST 3+ VIEWS RT W/ FY MOD,73110,CPT,FYRT,43273110,CDM,320,RC,,,both,,,330,244.2,,,244.2,Other,150% of Medicare + 9.63% HCRA Surcharge,148.5,45,,148.5,percent of total billed charges,Critical Access Hospital RCC factor,114.55,,,114.55,Fee Schedule,,103.06,,,103.06,Fee Schedule,,187.77,,,187.77,Fee Schedule,,168.89,,,168.89,Fee Schedule,,159.62,,,159.62,Fee Schedule,,163.35,,,163.35,Other,110% of Medicare,136.1,,,136.1,Fee Schedule,,53,,,53,Other,186% of Medicaid,160.16,,,160.16,Fee Schedule,,204.6,,,204.6,Fee Schedule,,75.41,,,75.41,Fee Schedule,,160.16,,,160.16,Fee Schedule,,204.6,,,204.6,Fee Schedule,,141.84,,,141.84,Fee Schedule,,231,70,,231,percent of total billed charges,All Other,159.08,,,159.08,Fee Schedule,,134.83,,,134.83,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,244.2,
XR HAND 2 VIEWS RT W/ FY MOD,73120,CPT,FYRT,43273120,CDM,320,RC,,,both,,,242,179.08,,,179.08,Other,150% of Medicare + 9.63% HCRA Surcharge,108.9,45,,108.9,percent of total billed charges,Critical Access Hospital RCC factor,82.21,,,82.21,Fee Schedule,,73.96,,,73.96,Fee Schedule,,132.8,,,132.8,Fee Schedule,,119.45,,,119.45,Fee Schedule,,112.9,,,112.9,Fee Schedule,,119.79,,,119.79,Other,110% of Medicare,97.67,,,97.67,Fee Schedule,,53,,,53,Other,186% of Medicaid,114.93,,,114.93,Fee Schedule,,150.04,,,150.04,Fee Schedule,,54.12,,,54.12,Fee Schedule,,114.93,,,114.93,Fee Schedule,,150.04,,,150.04,Fee Schedule,,101.79,,,101.79,Fee Schedule,,169.4,70,,169.4,percent of total billed charges,All Other,113.16,,,113.16,Fee Schedule,,95.91,,,95.91,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,179.33,
XR HAND 3+ VIEWS RT W/ FY MOD,73130,CPT,FYRT,43273130,CDM,320,RC,,,both,,,352,260.48,,,260.48,Other,150% of Medicare + 9.63% HCRA Surcharge,158.4,45,,158.4,percent of total billed charges,Critical Access Hospital RCC factor,100.68,,,100.68,Fee Schedule,,90.58,,,90.58,Fee Schedule,,160.26,,,160.26,Fee Schedule,,144.14,,,144.14,Fee Schedule,,136.24,,,136.24,Fee Schedule,,174.24,,,174.24,Other,110% of Medicare,119.61,,,119.61,Fee Schedule,,53,,,53,Other,186% of Medicaid,140.76,,,140.76,Fee Schedule,,218.24,,,218.24,Fee Schedule,,66.28,,,66.28,Fee Schedule,,140.76,,,140.76,Fee Schedule,,218.24,,,218.24,Fee Schedule,,124.66,,,124.66,Fee Schedule,,246.4,70,,246.4,percent of total billed charges,All Other,137.76,,,137.76,Fee Schedule,,116.76,,,116.76,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,260.48,
X-RAY EXAM HIP UNI 1 VIEW RT W/ FY MOD,73501,CPT,FYRT,43273501,CDM,320,RC,,,both,,,237,175.38,,,175.38,Other,150% of Medicare + 9.63% HCRA Surcharge,106.65,45,,106.65,percent of total billed charges,Critical Access Hospital RCC factor,83.35,,,83.35,Fee Schedule,,74.99,,,74.99,Fee Schedule,,20.07,,,20.07,Fee Schedule,,20.07,,,20.07,Fee Schedule,,20.07,,,20.07,Fee Schedule,,117.32,,,117.32,Other,110% of Medicare,99.03,,,99.03,Fee Schedule,,53,,,53,Other,186% of Medicaid,116.54,,,116.54,Fee Schedule,,146.94,,,146.94,Fee Schedule,,54.87,,,54.87,Fee Schedule,,116.54,,,116.54,Fee Schedule,,146.94,,,146.94,Fee Schedule,,103.21,,,103.21,Fee Schedule,,165.9,70,,165.9,percent of total billed charges,All Other,114.8,,,114.8,Fee Schedule,,97.3,,,97.3,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,20.07,175.38,
X-RAY EXAM HIP UNI 2-3 VIEWS RT W/ FY,73502,CPT,FYRT,43273502,CDM,320,RC,,,both,,,250,185,,,185,Other,150% of Medicare + 9.63% HCRA Surcharge,112.5,45,,112.5,percent of total billed charges,Critical Access Hospital RCC factor,128.4,,,128.4,Fee Schedule,,115.52,,,115.52,Fee Schedule,,29.42,,,29.42,Fee Schedule,,29.42,,,29.42,Fee Schedule,,29.42,,,29.42,Fee Schedule,,123.75,,,123.75,Other,110% of Medicare,152.55,,,152.55,Fee Schedule,,53,,,53,Other,186% of Medicaid,179.52,,,179.52,Fee Schedule,,155,,,155,Fee Schedule,,84.53,,,84.53,Fee Schedule,,179.52,,,179.52,Fee Schedule,,155,,,155,Fee Schedule,,158.99,,,158.99,Fee Schedule,,175,70,,175,percent of total billed charges,All Other,177.12,,,177.12,Fee Schedule,,150.12,,,150.12,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,185,
X-RAY EXAM HIP UNI 4/> VIEWS RT W/ FY,73503,CPT,FYRT,43273503,CDM,320,RC,,,both,,,336,248.64,,,248.64,Other,150% of Medicare + 9.63% HCRA Surcharge,151.2,45,,151.2,percent of total billed charges,Critical Access Hospital RCC factor,163.07,,,163.07,Fee Schedule,,146.71,,,146.71,Fee Schedule,,36.34,,,36.34,Fee Schedule,,36.34,,,36.34,Fee Schedule,,36.34,,,36.34,Fee Schedule,,166.32,,,166.32,Other,110% of Medicare,193.74,,,193.74,Fee Schedule,,53,,,53,Other,186% of Medicaid,228,,,228,Fee Schedule,,208.32,,,208.32,Fee Schedule,,107.35,,,107.35,Fee Schedule,,228,,,228,Fee Schedule,,208.32,,,208.32,Fee Schedule,,201.92,,,201.92,Fee Schedule,,235.2,70,,235.2,percent of total billed charges,All Other,224.68,,,224.68,Fee Schedule,,190.43,,,190.43,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,248.64,
X-RAY EXAM OF FEMUR 1 RT W/ FY MOD,73551,CPT,FYRT,43273551,CDM,320,RC,,,both,,,237,175.38,,,175.38,Other,150% of Medicare + 9.63% HCRA Surcharge,106.65,45,,106.65,percent of total billed charges,Critical Access Hospital RCC factor,74.1,,,74.1,Fee Schedule,,66.67,,,66.67,Fee Schedule,,19.04,,,19.04,Fee Schedule,,19.04,,,19.04,Fee Schedule,,19.04,,,19.04,Fee Schedule,,117.32,,,117.32,Other,110% of Medicare,88.04,,,88.04,Fee Schedule,,53,,,53,Other,186% of Medicaid,103.61,,,103.61,Fee Schedule,,146.94,,,146.94,Fee Schedule,,48.78,,,48.78,Fee Schedule,,103.61,,,103.61,Fee Schedule,,146.94,,,146.94,Fee Schedule,,91.76,,,91.76,Fee Schedule,,165.9,70,,165.9,percent of total billed charges,All Other,103.32,,,103.32,Fee Schedule,,87.57,,,87.57,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,19.04,175.38,
X-RAY EXAM OF FEMUR 2/> RT W/ FY MOD,73552,CPT,FYRT,43273552,CDM,320,RC,,,both,,,237,175.38,,,175.38,Other,150% of Medicare + 9.63% HCRA Surcharge,106.65,45,,106.65,percent of total billed charges,Critical Access Hospital RCC factor,93.75,,,93.75,Fee Schedule,,84.35,,,84.35,Fee Schedule,,22.84,,,22.84,Fee Schedule,,22.84,,,22.84,Fee Schedule,,22.84,,,22.84,Fee Schedule,,117.32,,,117.32,Other,110% of Medicare,111.39,,,111.39,Fee Schedule,,53,,,53,Other,186% of Medicaid,131.08,,,131.08,Fee Schedule,,146.94,,,146.94,Fee Schedule,,61.72,,,61.72,Fee Schedule,,131.08,,,131.08,Fee Schedule,,146.94,,,146.94,Fee Schedule,,116.09,,,116.09,Fee Schedule,,165.9,70,,165.9,percent of total billed charges,All Other,129.56,,,129.56,Fee Schedule,,109.81,,,109.81,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,22.84,175.38,
XR KNEE 1 OR 2 VIEWS RT W/ FY MOD,73560,CPT,FYRT,43273560,CDM,320,RC,,,both,,,407,301.18,,,301.18,Other,150% of Medicare + 9.63% HCRA Surcharge,183.15,45,,183.15,percent of total billed charges,Critical Access Hospital RCC factor,91.43,,,91.43,Fee Schedule,,82.25,,,82.25,Fee Schedule,,144.29,,,144.29,Fee Schedule,,129.78,,,129.78,Fee Schedule,,122.66,,,122.66,Fee Schedule,,201.47,,,201.47,Other,110% of Medicare,108.62,,,108.62,Fee Schedule,,53,,,53,Other,186% of Medicaid,127.82,,,127.82,Fee Schedule,,252.34,,,252.34,Fee Schedule,,60.19,,,60.19,Fee Schedule,,127.82,,,127.82,Fee Schedule,,252.34,,,252.34,Fee Schedule,,113.21,,,113.21,Fee Schedule,,284.9,70,,284.9,percent of total billed charges,All Other,127.92,,,127.92,Fee Schedule,,108.42,,,108.42,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,301.18,
XR KNEE 3 VIEWS RT W/ FY MOD,73562,CPT,FYRT,43273562,CDM,320,RC,,,both,,,445,329.3,,,329.3,Other,150% of Medicare + 9.63% HCRA Surcharge,200.25,45,,200.25,percent of total billed charges,Critical Access Hospital RCC factor,111.08,,,111.08,Fee Schedule,,99.93,,,99.93,Fee Schedule,,180.87,,,180.87,Fee Schedule,,162.68,,,162.68,Fee Schedule,,153.75,,,153.75,Fee Schedule,,220.28,,,220.28,Other,110% of Medicare,131.97,,,131.97,Fee Schedule,,53,,,53,Other,186% of Medicaid,155.3,,,155.3,Fee Schedule,,275.9,,,275.9,Fee Schedule,,73.12,,,73.12,Fee Schedule,,155.3,,,155.3,Fee Schedule,,275.9,,,275.9,Fee Schedule,,137.54,,,137.54,Fee Schedule,,311.5,70,,311.5,percent of total billed charges,All Other,155.8,,,155.8,Fee Schedule,,132.05,,,132.05,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,329.3,
XR KNEE 4+ VIEWS RT W/FY MOD,73564,CPT,FYRT,43273564,CDM,320,RC,,,both,,,445,329.3,,,329.3,Other,150% of Medicare + 9.63% HCRA Surcharge,200.25,45,,200.25,percent of total billed charges,Critical Access Hospital RCC factor,126.1,,,126.1,Fee Schedule,,113.45,,,113.45,Fee Schedule,,206.06,,,206.06,Fee Schedule,,185.33,,,185.33,Fee Schedule,,175.17,,,175.17,Fee Schedule,,220.28,,,220.28,Other,110% of Medicare,149.82,,,149.82,Fee Schedule,,53,,,53,Other,186% of Medicaid,176.3,,,176.3,Fee Schedule,,275.9,,,275.9,Fee Schedule,,83.01,,,83.01,Fee Schedule,,176.3,,,176.3,Fee Schedule,,275.9,,,275.9,Fee Schedule,,156.14,,,156.14,Fee Schedule,,311.5,70,,311.5,percent of total billed charges,All Other,173.84,,,173.84,Fee Schedule,,147.34,,,147.34,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,329.3,
XR TIBIA/FIBULA 2 VIEWS RT W/ FY MOD,73590,CPT,FYRT,43273590,CDM,320,RC,,,both,,,373,276.02,,,276.02,Other,150% of Medicare + 9.63% HCRA Surcharge,167.85,45,,167.85,percent of total billed charges,Critical Access Hospital RCC factor,83.35,,,83.35,Fee Schedule,,74.99,,,74.99,Fee Schedule,,130.54,,,130.54,Fee Schedule,,117.41,,,117.41,Fee Schedule,,110.97,,,110.97,Fee Schedule,,184.64,,,184.64,Other,110% of Medicare,99.03,,,99.03,Fee Schedule,,53,,,53,Other,186% of Medicaid,116.54,,,116.54,Fee Schedule,,231.26,,,231.26,Fee Schedule,,54.87,,,54.87,Fee Schedule,,116.54,,,116.54,Fee Schedule,,231.26,,,231.26,Fee Schedule,,103.21,,,103.21,Fee Schedule,,261.1,70,,261.1,percent of total billed charges,All Other,116.44,,,116.44,Fee Schedule,,98.69,,,98.69,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,276.02,
XR ANKLE 2 VIEWS RT W/ FY MOD,73600,CPT,FYRT,43273600,CDM,320,RC,,,both,,,231,170.94,,,170.94,Other,150% of Medicare + 9.63% HCRA Surcharge,103.95,45,,103.95,percent of total billed charges,Critical Access Hospital RCC factor,85.65,,,85.65,Fee Schedule,,77.06,,,77.06,Fee Schedule,,137.39,,,137.39,Fee Schedule,,123.57,,,123.57,Fee Schedule,,116.79,,,116.79,Fee Schedule,,114.35,,,114.35,Other,110% of Medicare,101.76,,,101.76,Fee Schedule,,53,,,53,Other,186% of Medicaid,119.75,,,119.75,Fee Schedule,,143.22,,,143.22,Fee Schedule,,56.39,,,56.39,Fee Schedule,,119.75,,,119.75,Fee Schedule,,143.22,,,143.22,Fee Schedule,,106.06,,,106.06,Fee Schedule,,161.7,70,,161.7,percent of total billed charges,All Other,119.72,,,119.72,Fee Schedule,,101.47,,,101.47,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,170.94,
XR ANKLE 3+ VIEWS RT W/ FY MOD,73610,CPT,FYRT,43273610,CDM,320,RC,,,both,,,348,257.52,,,257.52,Other,150% of Medicare + 9.63% HCRA Surcharge,156.6,45,,156.6,percent of total billed charges,Critical Access Hospital RCC factor,98.38,,,98.38,Fee Schedule,,88.51,,,88.51,Fee Schedule,,162.58,,,162.58,Fee Schedule,,146.23,,,146.23,Fee Schedule,,138.21,,,138.21,Fee Schedule,,172.26,,,172.26,Other,110% of Medicare,116.88,,,116.88,Fee Schedule,,53,,,53,Other,186% of Medicaid,137.55,,,137.55,Fee Schedule,,215.76,,,215.76,Fee Schedule,,64.76,,,64.76,Fee Schedule,,137.55,,,137.55,Fee Schedule,,215.76,,,215.76,Fee Schedule,,121.82,,,121.82,Fee Schedule,,243.6,70,,243.6,percent of total billed charges,All Other,139.4,,,139.4,Fee Schedule,,118.15,,,118.15,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,257.52,
XR FOOT 2 VIEWS RT W/ FY MOD,73620,CPT,FYRT,43273620,CDM,320,RC,,,both,,,231,170.94,,,170.94,Other,150% of Medicare + 9.63% HCRA Surcharge,103.95,45,,103.95,percent of total billed charges,Critical Access Hospital RCC factor,74.1,,,74.1,Fee Schedule,,66.67,,,66.67,Fee Schedule,,132.8,,,132.8,Fee Schedule,,119.45,,,119.45,Fee Schedule,,112.9,,,112.9,Fee Schedule,,114.35,,,114.35,Other,110% of Medicare,88.04,,,88.04,Fee Schedule,,53,,,53,Other,186% of Medicaid,103.61,,,103.61,Fee Schedule,,143.22,,,143.22,Fee Schedule,,48.78,,,48.78,Fee Schedule,,103.61,,,103.61,Fee Schedule,,143.22,,,143.22,Fee Schedule,,91.76,,,91.76,Fee Schedule,,161.7,70,,161.7,percent of total billed charges,All Other,101.68,,,101.68,Fee Schedule,,86.18,,,86.18,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,170.94,
XR FOOT 3+ VIEWS RT W/ FY MOD,73630,CPT,FYRT,43273630,CDM,320,RC,,,both,,,373,276.02,,,276.02,Other,150% of Medicare + 9.63% HCRA Surcharge,167.85,45,,167.85,percent of total billed charges,Critical Access Hospital RCC factor,91.43,,,91.43,Fee Schedule,,82.25,,,82.25,Fee Schedule,,157.99,,,157.99,Fee Schedule,,142.11,,,142.11,Fee Schedule,,134.31,,,134.31,Fee Schedule,,184.64,,,184.64,Other,110% of Medicare,108.62,,,108.62,Fee Schedule,,53,,,53,Other,186% of Medicaid,127.82,,,127.82,Fee Schedule,,231.26,,,231.26,Fee Schedule,,60.19,,,60.19,Fee Schedule,,127.82,,,127.82,Fee Schedule,,231.26,,,231.26,Fee Schedule,,113.21,,,113.21,Fee Schedule,,261.1,70,,261.1,percent of total billed charges,All Other,129.56,,,129.56,Fee Schedule,,109.81,,,109.81,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,276.02,
XR HEEL 2+ VIEWS RT W/ FY MOD,73650,CPT,FYRT,43273650,CDM,320,RC,,,both,,,231,170.94,,,170.94,Other,150% of Medicare + 9.63% HCRA Surcharge,103.95,45,,103.95,percent of total billed charges,Critical Access Hospital RCC factor,72.96,,,72.96,Fee Schedule,,65.64,,,65.64,Fee Schedule,,135.12,,,135.12,Fee Schedule,,121.53,,,121.53,Fee Schedule,,114.87,,,114.87,Fee Schedule,,114.35,,,114.35,Other,110% of Medicare,86.68,,,86.68,Fee Schedule,,53,,,53,Other,186% of Medicaid,102,,,102,Fee Schedule,,143.22,,,143.22,Fee Schedule,,48.03,,,48.03,Fee Schedule,,102,,,102,Fee Schedule,,143.22,,,143.22,Fee Schedule,,90.34,,,90.34,Fee Schedule,,161.7,70,,161.7,percent of total billed charges,All Other,103.32,,,103.32,Fee Schedule,,87.57,,,87.57,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,170.94,
XR TOE(S) 2+ VIEWS RT W/ FY MOD,73660,CPT,FYRT,43273660,CDM,320,RC,,,both,,,231,170.94,,,170.94,Other,150% of Medicare + 9.63% HCRA Surcharge,103.95,45,,103.95,percent of total billed charges,Critical Access Hospital RCC factor,79.88,,,79.88,Fee Schedule,,71.86,,,71.86,Fee Schedule,,155.73,,,155.73,Fee Schedule,,140.07,,,140.07,Fee Schedule,,132.38,,,132.38,Fee Schedule,,114.35,,,114.35,Other,110% of Medicare,94.9,,,94.9,Fee Schedule,,53,,,53,Other,186% of Medicaid,111.68,,,111.68,Fee Schedule,,143.22,,,143.22,Fee Schedule,,52.58,,,52.58,Fee Schedule,,111.68,,,111.68,Fee Schedule,,143.22,,,143.22,Fee Schedule,,98.91,,,98.91,Fee Schedule,,161.7,70,,161.7,percent of total billed charges,All Other,111.52,,,111.52,Fee Schedule,,94.52,,,94.52,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,170.94,
XR EYE DETECT FOREIGN BODY BILAT W/ FY,70030,CPT,FY50,43370030,CDM,320,RC,,,both,,,362,267.88,,,267.88,Other,150% of Medicare + 9.63% HCRA Surcharge,162.9,45,,162.9,percent of total billed charges,Critical Access Hospital RCC factor,84.5,,,84.5,Fee Schedule,,76.03,,,76.03,Fee Schedule,,137.39,,,137.39,Fee Schedule,,123.57,,,123.57,Fee Schedule,,116.79,,,116.79,Fee Schedule,,179.19,,,179.19,Other,110% of Medicare,100.4,,,100.4,Fee Schedule,,53,,,53,Other,186% of Medicaid,118.15,,,118.15,Fee Schedule,,224.44,,,224.44,Fee Schedule,,55.63,,,55.63,Fee Schedule,,118.15,,,118.15,Fee Schedule,,224.44,,,224.44,Fee Schedule,,104.64,,,104.64,Fee Schedule,,253.4,70,,253.4,percent of total billed charges,All Other,116.44,,,116.44,Fee Schedule,,98.69,,,98.69,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,267.88,
XR CLAVICLE BILAT W/ FY MOD,73000,CPT,FY50,43373000,CDM,320,RC,,,both,,,560,414.4,,,414.4,Other,150% of Medicare + 9.63% HCRA Surcharge,252,45,,252,percent of total billed charges,Critical Access Hospital RCC factor,85.65,,,85.65,Fee Schedule,,77.06,,,77.06,Fee Schedule,,139.71,,,139.71,Fee Schedule,,125.66,,,125.66,Fee Schedule,,118.76,,,118.76,Fee Schedule,,277.2,,,277.2,Other,110% of Medicare,101.76,,,101.76,Fee Schedule,,53,,,53,Other,186% of Medicaid,119.75,,,119.75,Fee Schedule,,347.2,,,347.2,Fee Schedule,,56.39,,,56.39,Fee Schedule,,119.75,,,119.75,Fee Schedule,,347.2,,,347.2,Fee Schedule,,106.06,,,106.06,Fee Schedule,,392,70,,392,percent of total billed charges,All Other,118.08,,,118.08,Fee Schedule,,100.08,,,100.08,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,414.4,
XR OF SCAPULA BILAT W/ FY MOD,73010,CPT,FY50,43373010,CDM,320,RC,,,both,,,363,268.62,,,268.62,Other,150% of Medicare + 9.63% HCRA Surcharge,163.35,45,,163.35,percent of total billed charges,Critical Access Hospital RCC factor,53.3,,,53.3,Fee Schedule,,47.96,,,47.96,Fee Schedule,,144.29,,,144.29,Fee Schedule,,129.78,,,129.78,Fee Schedule,,122.66,,,122.66,Fee Schedule,,179.69,,,179.69,Other,110% of Medicare,63.33,,,63.33,Fee Schedule,,53,,,53,Other,186% of Medicaid,74.53,,,74.53,Fee Schedule,,225.06,,,225.06,Fee Schedule,,35.09,,,35.09,Fee Schedule,,74.53,,,74.53,Fee Schedule,,225.06,,,225.06,Fee Schedule,,66,,,66,Fee Schedule,,254.1,70,,254.1,percent of total billed charges,All Other,73.8,,,73.8,Fee Schedule,,62.55,,,62.55,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,268.62,
XR SHOULDER 2+ VIEWS BILAT W/ FY MOD,73030,CPT,FY50,43373030,CDM,320,RC,,,both,,,611,452.14,,,452.14,Other,150% of Medicare + 9.63% HCRA Surcharge,274.95,45,,274.95,percent of total billed charges,Critical Access Hospital RCC factor,90.28,,,90.28,Fee Schedule,,81.22,,,81.22,Fee Schedule,,141.97,,,141.97,Fee Schedule,,127.7,,,127.7,Fee Schedule,,120.69,,,120.69,Fee Schedule,,302.45,,,302.45,Other,110% of Medicare,107.26,,,107.26,Fee Schedule,,53,,,53,Other,186% of Medicaid,126.22,,,126.22,Fee Schedule,,378.82,,,378.82,Fee Schedule,,59.43,,,59.43,Fee Schedule,,126.22,,,126.22,Fee Schedule,,378.82,,,378.82,Fee Schedule,,111.79,,,111.79,Fee Schedule,,427.7,70,,427.7,percent of total billed charges,All Other,124.64,,,124.64,Fee Schedule,,105.64,,,105.64,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,452.14,
XR HUMERUS 2 VIEW BILAT W/ FY MOD,73060,CPT,FY50,43373060,CDM,320,RC,,,both,,,560,414.4,,,414.4,Other,150% of Medicare + 9.63% HCRA Surcharge,252,45,,252,percent of total billed charges,Critical Access Hospital RCC factor,84.5,,,84.5,Fee Schedule,,76.03,,,76.03,Fee Schedule,,139.71,,,139.71,Fee Schedule,,125.66,,,125.66,Fee Schedule,,118.76,,,118.76,Fee Schedule,,277.2,,,277.2,Other,110% of Medicare,100.4,,,100.4,Fee Schedule,,53,,,53,Other,186% of Medicaid,118.15,,,118.15,Fee Schedule,,347.2,,,347.2,Fee Schedule,,55.63,,,55.63,Fee Schedule,,118.15,,,118.15,Fee Schedule,,347.2,,,347.2,Fee Schedule,,104.64,,,104.64,Fee Schedule,,392,70,,392,percent of total billed charges,All Other,118.08,,,118.08,Fee Schedule,,100.08,,,100.08,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,414.4,
XR ELBOW 3 VIEWS  BILAT W/ FY MOD,73080,CPT,FY50,43373080,CDM,320,RC,,,both,,,588,435.12,,,435.12,Other,150% of Medicare + 9.63% HCRA Surcharge,264.6,45,,264.6,percent of total billed charges,Critical Access Hospital RCC factor,85.65,,,85.65,Fee Schedule,,77.06,,,77.06,Fee Schedule,,174.02,,,174.02,Fee Schedule,,156.51,,,156.51,Fee Schedule,,147.93,,,147.93,Fee Schedule,,291.06,,,291.06,Other,110% of Medicare,101.76,,,101.76,Fee Schedule,,53,,,53,Other,186% of Medicaid,119.75,,,119.75,Fee Schedule,,364.56,,,364.56,Fee Schedule,,56.39,,,56.39,Fee Schedule,,119.75,,,119.75,Fee Schedule,,364.56,,,364.56,Fee Schedule,,106.06,,,106.06,Fee Schedule,,411.6,70,,411.6,percent of total billed charges,All Other,118.08,,,118.08,Fee Schedule,,100.08,,,100.08,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,435.12,
XR FOREARM BILAT W/ FY MOD,73090,CPT,FY50,43373090,CDM,320,RC,,,both,,,501,370.74,,,370.74,Other,150% of Medicare + 9.63% HCRA Surcharge,225.45,45,,225.45,percent of total billed charges,Critical Access Hospital RCC factor,75.25,,,75.25,Fee Schedule,,67.7,,,67.7,Fee Schedule,,135.12,,,135.12,Fee Schedule,,121.53,,,121.53,Fee Schedule,,114.87,,,114.87,Fee Schedule,,248,,,248,Other,110% of Medicare,89.41,,,89.41,Fee Schedule,,53,,,53,Other,186% of Medicaid,105.21,,,105.21,Fee Schedule,,310.62,,,310.62,Fee Schedule,,49.54,,,49.54,Fee Schedule,,105.21,,,105.21,Fee Schedule,,310.62,,,310.62,Fee Schedule,,93.18,,,93.18,Fee Schedule,,350.7,70,,350.7,percent of total billed charges,All Other,104.96,,,104.96,Fee Schedule,,88.96,,,88.96,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,370.74,
XR UPPER EXT CHILD BILAT W/ FY MOD,73092,CPT,FY50,43373092,CDM,320,RC,,,both,,,363,268.62,,,268.62,Other,150% of Medicare + 9.63% HCRA Surcharge,163.35,45,,163.35,percent of total billed charges,Critical Access Hospital RCC factor,83.35,,,83.35,Fee Schedule,,74.99,,,74.99,Fee Schedule,,153.41,,,153.41,Fee Schedule,,137.98,,,137.98,Fee Schedule,,130.41,,,130.41,Fee Schedule,,179.69,,,179.69,Other,110% of Medicare,99.03,,,99.03,Fee Schedule,,53,,,53,Other,186% of Medicaid,116.54,,,116.54,Fee Schedule,,225.06,,,225.06,Fee Schedule,,54.87,,,54.87,Fee Schedule,,116.54,,,116.54,Fee Schedule,,225.06,,,225.06,Fee Schedule,,103.21,,,103.21,Fee Schedule,,254.1,70,,254.1,percent of total billed charges,All Other,118.08,,,118.08,Fee Schedule,,100.08,,,100.08,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,268.62,
XR WRIST 2 VIEWS BILAT W/ FY MOD,73100,CPT,FY50,43373100,CDM,320,RC,,,both,,,347,256.78,,,256.78,Other,150% of Medicare + 9.63% HCRA Surcharge,156.15,45,,156.15,percent of total billed charges,Critical Access Hospital RCC factor,90.28,,,90.28,Fee Schedule,,81.22,,,81.22,Fee Schedule,,148.82,,,148.82,Fee Schedule,,133.86,,,133.86,Fee Schedule,,126.52,,,126.52,Fee Schedule,,171.77,,,171.77,Other,110% of Medicare,107.26,,,107.26,Fee Schedule,,53,,,53,Other,186% of Medicaid,126.22,,,126.22,Fee Schedule,,215.14,,,215.14,Fee Schedule,,59.43,,,59.43,Fee Schedule,,126.22,,,126.22,Fee Schedule,,215.14,,,215.14,Fee Schedule,,111.79,,,111.79,Fee Schedule,,242.9,70,,242.9,percent of total billed charges,All Other,126.28,,,126.28,Fee Schedule,,107.03,,,107.03,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,256.78,
XR WRIST 3+ V BILAT W/ FY MOD,73110,CPT,FY50,43373110,CDM,320,RC,,,both,,,495,366.3,,,366.3,Other,150% of Medicare + 9.63% HCRA Surcharge,222.75,45,,222.75,percent of total billed charges,Critical Access Hospital RCC factor,114.55,,,114.55,Fee Schedule,,103.06,,,103.06,Fee Schedule,,187.77,,,187.77,Fee Schedule,,168.89,,,168.89,Fee Schedule,,159.62,,,159.62,Fee Schedule,,245.03,,,245.03,Other,110% of Medicare,136.1,,,136.1,Fee Schedule,,53,,,53,Other,186% of Medicaid,160.16,,,160.16,Fee Schedule,,306.9,,,306.9,Fee Schedule,,75.41,,,75.41,Fee Schedule,,160.16,,,160.16,Fee Schedule,,306.9,,,306.9,Fee Schedule,,141.84,,,141.84,Fee Schedule,,346.5,70,,346.5,percent of total billed charges,All Other,159.08,,,159.08,Fee Schedule,,134.83,,,134.83,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,366.3,
XR HAND 2 VIEWS BILAT W/ FY MOD,73120,CPT,FY50,43373120,CDM,320,RC,,,both,,,363,268.62,,,268.62,Other,150% of Medicare + 9.63% HCRA Surcharge,163.35,45,,163.35,percent of total billed charges,Critical Access Hospital RCC factor,82.21,,,82.21,Fee Schedule,,73.96,,,73.96,Fee Schedule,,132.8,,,132.8,Fee Schedule,,119.45,,,119.45,Fee Schedule,,112.9,,,112.9,Fee Schedule,,179.69,,,179.69,Other,110% of Medicare,97.67,,,97.67,Fee Schedule,,53,,,53,Other,186% of Medicaid,114.93,,,114.93,Fee Schedule,,225.06,,,225.06,Fee Schedule,,54.12,,,54.12,Fee Schedule,,114.93,,,114.93,Fee Schedule,,225.06,,,225.06,Fee Schedule,,101.79,,,101.79,Fee Schedule,,254.1,70,,254.1,percent of total billed charges,All Other,113.16,,,113.16,Fee Schedule,,95.91,,,95.91,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,268.62,
XR HAND 3+ VIEWS BILAT W/ FY MOD,73130,CPT,FY50,43373130,CDM,320,RC,,,both,,,528,390.72,,,390.72,Other,150% of Medicare + 9.63% HCRA Surcharge,237.6,45,,237.6,percent of total billed charges,Critical Access Hospital RCC factor,100.68,,,100.68,Fee Schedule,,90.58,,,90.58,Fee Schedule,,160.26,,,160.26,Fee Schedule,,144.14,,,144.14,Fee Schedule,,136.24,,,136.24,Fee Schedule,,261.36,,,261.36,Other,110% of Medicare,119.61,,,119.61,Fee Schedule,,53,,,53,Other,186% of Medicaid,140.76,,,140.76,Fee Schedule,,327.36,,,327.36,Fee Schedule,,66.28,,,66.28,Fee Schedule,,140.76,,,140.76,Fee Schedule,,327.36,,,327.36,Fee Schedule,,124.66,,,124.66,Fee Schedule,,369.6,70,,369.6,percent of total billed charges,All Other,137.76,,,137.76,Fee Schedule,,116.76,,,116.76,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,390.72,
XR KNEE 1 OR 2 VIEWS BILAT W/ FY MOD,73560,CPT,FY50,43373560,CDM,320,RC,,,both,,,611,452.14,,,452.14,Other,150% of Medicare + 9.63% HCRA Surcharge,274.95,45,,274.95,percent of total billed charges,Critical Access Hospital RCC factor,91.43,,,91.43,Fee Schedule,,82.25,,,82.25,Fee Schedule,,144.29,,,144.29,Fee Schedule,,129.78,,,129.78,Fee Schedule,,122.66,,,122.66,Fee Schedule,,302.45,,,302.45,Other,110% of Medicare,108.62,,,108.62,Fee Schedule,,53,,,53,Other,186% of Medicaid,127.82,,,127.82,Fee Schedule,,378.82,,,378.82,Fee Schedule,,60.19,,,60.19,Fee Schedule,,127.82,,,127.82,Fee Schedule,,378.82,,,378.82,Fee Schedule,,113.21,,,113.21,Fee Schedule,,427.7,70,,427.7,percent of total billed charges,All Other,127.92,,,127.92,Fee Schedule,,108.42,,,108.42,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,452.14,
XR KNEE 3 VIEWS BILAT W/ FY MOD,73562,CPT,FY50,43373562,CDM,320,RC,,,both,,,668,494.32,,,494.32,Other,150% of Medicare + 9.63% HCRA Surcharge,300.6,45,,300.6,percent of total billed charges,Critical Access Hospital RCC factor,111.08,,,111.08,Fee Schedule,,99.93,,,99.93,Fee Schedule,,180.87,,,180.87,Fee Schedule,,162.68,,,162.68,Fee Schedule,,153.75,,,153.75,Fee Schedule,,330.66,,,330.66,Other,110% of Medicare,131.97,,,131.97,Fee Schedule,,53,,,53,Other,186% of Medicaid,155.3,,,155.3,Fee Schedule,,414.16,,,414.16,Fee Schedule,,73.12,,,73.12,Fee Schedule,,155.3,,,155.3,Fee Schedule,,414.16,,,414.16,Fee Schedule,,137.54,,,137.54,Fee Schedule,,467.6,70,,467.6,percent of total billed charges,All Other,155.8,,,155.8,Fee Schedule,,132.05,,,132.05,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,494.32,
XR KNEE 4+ VIEWS BILAT W/ FY MOD,73564,CPT,FY50,43373564,CDM,320,RC,,,both,,,668,494.32,,,494.32,Other,150% of Medicare + 9.63% HCRA Surcharge,300.6,45,,300.6,percent of total billed charges,Critical Access Hospital RCC factor,126.1,,,126.1,Fee Schedule,,113.45,,,113.45,Fee Schedule,,206.06,,,206.06,Fee Schedule,,185.33,,,185.33,Fee Schedule,,175.17,,,175.17,Fee Schedule,,330.66,,,330.66,Other,110% of Medicare,149.82,,,149.82,Fee Schedule,,53,,,53,Other,186% of Medicaid,176.3,,,176.3,Fee Schedule,,414.16,,,414.16,Fee Schedule,,83.01,,,83.01,Fee Schedule,,176.3,,,176.3,Fee Schedule,,414.16,,,414.16,Fee Schedule,,156.14,,,156.14,Fee Schedule,,467.6,70,,467.6,percent of total billed charges,All Other,173.84,,,173.84,Fee Schedule,,147.34,,,147.34,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,494.32,
XR TIBIA/FIBULA 2 VIEWS BIL W/ FY MOD,73590,CPT,FY50,43373590,CDM,320,RC,,,both,,,560,414.4,,,414.4,Other,150% of Medicare + 9.63% HCRA Surcharge,252,45,,252,percent of total billed charges,Critical Access Hospital RCC factor,83.35,,,83.35,Fee Schedule,,74.99,,,74.99,Fee Schedule,,130.54,,,130.54,Fee Schedule,,117.41,,,117.41,Fee Schedule,,110.97,,,110.97,Fee Schedule,,277.2,,,277.2,Other,110% of Medicare,99.03,,,99.03,Fee Schedule,,53,,,53,Other,186% of Medicaid,116.54,,,116.54,Fee Schedule,,347.2,,,347.2,Fee Schedule,,54.87,,,54.87,Fee Schedule,,116.54,,,116.54,Fee Schedule,,347.2,,,347.2,Fee Schedule,,103.21,,,103.21,Fee Schedule,,392,70,,392,percent of total billed charges,All Other,116.44,,,116.44,Fee Schedule,,98.69,,,98.69,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,414.4,
XR ANKLE 2 V BILAT W/ FY MOD,73600,CPT,FY50,43373600,CDM,320,RC,,,both,,,347,256.78,,,256.78,Other,150% of Medicare + 9.63% HCRA Surcharge,156.15,45,,156.15,percent of total billed charges,Critical Access Hospital RCC factor,85.65,,,85.65,Fee Schedule,,77.06,,,77.06,Fee Schedule,,137.39,,,137.39,Fee Schedule,,123.57,,,123.57,Fee Schedule,,116.79,,,116.79,Fee Schedule,,171.77,,,171.77,Other,110% of Medicare,101.76,,,101.76,Fee Schedule,,53,,,53,Other,186% of Medicaid,119.75,,,119.75,Fee Schedule,,215.14,,,215.14,Fee Schedule,,56.39,,,56.39,Fee Schedule,,119.75,,,119.75,Fee Schedule,,215.14,,,215.14,Fee Schedule,,106.06,,,106.06,Fee Schedule,,242.9,70,,242.9,percent of total billed charges,All Other,119.72,,,119.72,Fee Schedule,,101.47,,,101.47,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,256.78,
XR ANKLE 3+ VIEWS BILAT W/ FY MOD,73610,CPT,FY50,43373610,CDM,320,RC,,,both,,,522,386.28,,,386.28,Other,150% of Medicare + 9.63% HCRA Surcharge,234.9,45,,234.9,percent of total billed charges,Critical Access Hospital RCC factor,98.38,,,98.38,Fee Schedule,,88.51,,,88.51,Fee Schedule,,162.58,,,162.58,Fee Schedule,,146.23,,,146.23,Fee Schedule,,138.21,,,138.21,Fee Schedule,,258.39,,,258.39,Other,110% of Medicare,116.88,,,116.88,Fee Schedule,,53,,,53,Other,186% of Medicaid,137.55,,,137.55,Fee Schedule,,323.64,,,323.64,Fee Schedule,,64.76,,,64.76,Fee Schedule,,137.55,,,137.55,Fee Schedule,,323.64,,,323.64,Fee Schedule,,121.82,,,121.82,Fee Schedule,,365.4,70,,365.4,percent of total billed charges,All Other,139.4,,,139.4,Fee Schedule,,118.15,,,118.15,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,386.28,
XR FOOT 2 V BILAT W/ FY MOD,73620,CPT,FY50,43373620,CDM,320,RC,,,both,,,347,256.78,,,256.78,Other,150% of Medicare + 9.63% HCRA Surcharge,156.15,45,,156.15,percent of total billed charges,Critical Access Hospital RCC factor,74.1,,,74.1,Fee Schedule,,66.67,,,66.67,Fee Schedule,,132.8,,,132.8,Fee Schedule,,119.45,,,119.45,Fee Schedule,,112.9,,,112.9,Fee Schedule,,171.77,,,171.77,Other,110% of Medicare,88.04,,,88.04,Fee Schedule,,53,,,53,Other,186% of Medicaid,103.61,,,103.61,Fee Schedule,,215.14,,,215.14,Fee Schedule,,48.78,,,48.78,Fee Schedule,,103.61,,,103.61,Fee Schedule,,215.14,,,215.14,Fee Schedule,,91.76,,,91.76,Fee Schedule,,242.9,70,,242.9,percent of total billed charges,All Other,101.68,,,101.68,Fee Schedule,,86.18,,,86.18,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,256.78,
XR FOOT 3+ VIEWS BILAT W/ FY MOD,73630,CPT,FY50,43373630,CDM,320,RC,,,both,,,560,414.4,,,414.4,Other,150% of Medicare + 9.63% HCRA Surcharge,252,45,,252,percent of total billed charges,Critical Access Hospital RCC factor,91.43,,,91.43,Fee Schedule,,82.25,,,82.25,Fee Schedule,,157.99,,,157.99,Fee Schedule,,142.11,,,142.11,Fee Schedule,,134.31,,,134.31,Fee Schedule,,277.2,,,277.2,Other,110% of Medicare,108.62,,,108.62,Fee Schedule,,53,,,53,Other,186% of Medicaid,127.82,,,127.82,Fee Schedule,,347.2,,,347.2,Fee Schedule,,60.19,,,60.19,Fee Schedule,,127.82,,,127.82,Fee Schedule,,347.2,,,347.2,Fee Schedule,,113.21,,,113.21,Fee Schedule,,392,70,,392,percent of total billed charges,All Other,129.56,,,129.56,Fee Schedule,,109.81,,,109.81,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,414.4,
XR HEEL 2+ VIEWS BILAT W/ FY MOD,73650,CPT,FY50,43373650,CDM,320,RC,,,both,,,347,256.78,,,256.78,Other,150% of Medicare + 9.63% HCRA Surcharge,156.15,45,,156.15,percent of total billed charges,Critical Access Hospital RCC factor,72.96,,,72.96,Fee Schedule,,65.64,,,65.64,Fee Schedule,,135.12,,,135.12,Fee Schedule,,121.53,,,121.53,Fee Schedule,,114.87,,,114.87,Fee Schedule,,171.77,,,171.77,Other,110% of Medicare,86.68,,,86.68,Fee Schedule,,53,,,53,Other,186% of Medicaid,102,,,102,Fee Schedule,,215.14,,,215.14,Fee Schedule,,48.03,,,48.03,Fee Schedule,,102,,,102,Fee Schedule,,215.14,,,215.14,Fee Schedule,,90.34,,,90.34,Fee Schedule,,242.9,70,,242.9,percent of total billed charges,All Other,103.32,,,103.32,Fee Schedule,,87.57,,,87.57,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,256.78,
XR TOE(S) 2+ VIEWS  BILAT W/ FY MOD,73660,CPT,FY50,43373660,CDM,320,RC,,,both,,,347,256.78,,,256.78,Other,150% of Medicare + 9.63% HCRA Surcharge,156.15,45,,156.15,percent of total billed charges,Critical Access Hospital RCC factor,79.88,,,79.88,Fee Schedule,,71.86,,,71.86,Fee Schedule,,155.73,,,155.73,Fee Schedule,,140.07,,,140.07,Fee Schedule,,132.38,,,132.38,Fee Schedule,,171.77,,,171.77,Other,110% of Medicare,94.9,,,94.9,Fee Schedule,,53,,,53,Other,186% of Medicaid,111.68,,,111.68,Fee Schedule,,215.14,,,215.14,Fee Schedule,,52.58,,,52.58,Fee Schedule,,111.68,,,111.68,Fee Schedule,,215.14,,,215.14,Fee Schedule,,98.91,,,98.91,Fee Schedule,,242.9,70,,242.9,percent of total billed charges,All Other,111.52,,,111.52,Fee Schedule,,94.52,,,94.52,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,256.78,
SUPERIOR SAGITTAL SINUS VENOGRAM,75870,CPT,TC,45075870,CDM,320,RC,,,both,,,6707,4963.2,,,4963.2,Other,150% of Medicare + 9.63% HCRA Surcharge,3018.15,45,,3018.15,percent of total billed charges,Critical Access Hospital RCC factor,339.99,,,339.99,Fee Schedule,,305.88,,,305.88,Fee Schedule,,1036.71,,,1036.71,Fee Schedule,,932.45,,,932.45,Fee Schedule,,881.31,,,881.31,Fee Schedule,,3319.97,,,3319.97,Other,110% of Medicare,403.94,,,403.94,Fee Schedule,,490,,,490,Other,186% of Medicaid,475.35,,,475.35,Fee Schedule,,4158.34,,,4158.34,Fee Schedule,,223.82,,,223.82,Fee Schedule,,475.35,,,475.35,Fee Schedule,,4158.34,,,4158.34,Fee Schedule,,420.99,,,420.99,Fee Schedule,,4694.9,70,,4694.9,percent of total billed charges,All Other,503.48,,,503.48,Fee Schedule,,426.73,,,426.73,Fee Schedule,,2609.81,,,2609.81,Fee Schedule,,2609.81,,,2609.81,Fee Schedule,,2609.81,,,2609.81,Fee Schedule,,2609.81,,,2609.81,Fee Schedule,,263.19,,,263.19,Other,100% of Medicaid,263.19,,,263.19,Other,100% of Medicaid,263.19,,,263.19,Other,100% of Medicaid,263.19,,,263.19,Other,100% of Medicaid,592.18,,,592.18,Other,225% of Medicaid,402.68,,,402.68,Other,153% of Medicaid,592.18,,,592.18,Other,225% of Medicaid,368.47,,,368.47,Other,140% of Medicaid,592.18,,,592.18,Other,225% of Medicaid,684.3,,,684.3,Other,260% of Medicaid,852.74,,,852.74,Other,324% of Medicaid,565.86,,,565.86,Other,215% of Medicaid,565.86,,,565.86,Other,215% of Medicaid,328.99,,,328.99,Other,125% of Medicaid,223.82,4963.2,
SINUS TRACT INJ; DX,20501,CPT,,46020501,CDM,320,RC,,,both,,,146,108.04,,,108.04,Other,150% of Medicare + 9.63% HCRA Surcharge,65.7,45,,65.7,percent of total billed charges,Critical Access Hospital RCC factor,120.04,,,120.04,Fee Schedule,,108,,,108,Fee Schedule,,111.69,76.5,,111.69,percent of total billed charges,All Other,103.66,69,,103.66,percent of total billed charges,All Other,100.74,65,,100.74,percent of total billed charges,All Other,72.27,,,72.27,Other,110% of Medicare,142.62,,,142.62,Fee Schedule,,967,,,967,Other,186% of Medicaid,167.83,,,167.83,Fee Schedule,,90.52,,,90.52,Fee Schedule,,79.02,,,79.02,Fee Schedule,,167.83,,,167.83,Fee Schedule,,90.52,,,90.52,Fee Schedule,,148.64,,,148.64,Fee Schedule,,102.2,70,,102.2,percent of total billed charges,All Other,178.76,,,178.76,Fee Schedule,,151.51,,,151.51,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,519.86,,,519.86,Other,100% of Medicaid,519.86,,,519.86,Other,100% of Medicaid,519.86,,,519.86,Other,100% of Medicaid,519.86,,,519.86,Other,100% of Medicaid,1169.68,,,1169.68,Other,225% of Medicaid,795.38,,,795.38,Other,153% of Medicaid,1169.68,,,1169.68,Other,225% of Medicaid,727.8,,,727.8,Other,140% of Medicaid,1169.68,,,1169.68,Other,225% of Medicaid,1351.62,,,1351.62,Other,260% of Medicaid,1684.33,,,1684.33,Other,324% of Medicaid,1117.69,,,1117.69,Other,215% of Medicaid,1117.69,,,1117.69,Other,215% of Medicaid,649.82,,,649.82,Other,125% of Medicaid,0.01,1684.33,
XRAY CONTROL CATHETER CHANGE,75984,CPT,TC,46075984,CDM,320,RC,,,both,,,590,436.6,,,436.6,Other,150% of Medicare + 9.63% HCRA Surcharge,265.5,45,,265.5,percent of total billed charges,Critical Access Hospital RCC factor,201.19,,,201.19,Fee Schedule,,181.01,,,181.01,Fee Schedule,,535.59,,,535.59,Fee Schedule,,481.73,,,481.73,Fee Schedule,,455.3,,,455.3,Fee Schedule,,292.05,,,292.05,Other,110% of Medicare,239.04,,,239.04,Fee Schedule,,544,,,544,Other,186% of Medicaid,281.29,,,281.29,Fee Schedule,,365.8,,,365.8,Fee Schedule,,132.45,,,132.45,Fee Schedule,,281.29,,,281.29,Fee Schedule,,365.8,,,365.8,Fee Schedule,,249.13,,,249.13,Fee Schedule,,413,70,,413,percent of total billed charges,All Other,295.2,,,295.2,Fee Schedule,,250.2,,,250.2,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,292.43,,,292.43,Other,100% of Medicaid,292.43,,,292.43,Other,100% of Medicaid,292.43,,,292.43,Other,100% of Medicaid,292.43,,,292.43,Other,100% of Medicaid,657.97,,,657.97,Other,225% of Medicaid,447.42,,,447.42,Other,153% of Medicaid,657.97,,,657.97,Other,225% of Medicaid,409.4,,,409.4,Other,140% of Medicaid,657.97,,,657.97,Other,225% of Medicaid,760.32,,,760.32,Other,260% of Medicaid,947.48,,,947.48,Other,324% of Medicaid,628.73,,,628.73,Other,215% of Medicaid,628.73,,,628.73,Other,215% of Medicaid,365.54,,,365.54,Other,125% of Medicaid,0.01,947.48,
ABSCESS FISTULA/SINUS TRACT ST,76080,CPT,TC,46076080,CDM,320,RC,,,both,,,1134,839.16,,,839.16,Other,150% of Medicare + 9.63% HCRA Surcharge,510.3,45,,510.3,percent of total billed charges,Critical Access Hospital RCC factor,122.62,,,122.62,Fee Schedule,,110.32,,,110.32,Fee Schedule,,240.36,,,240.36,Fee Schedule,,216.19,,,216.19,Fee Schedule,,204.33,,,204.33,Fee Schedule,,561.33,,,561.33,Other,110% of Medicare,145.69,,,145.69,Fee Schedule,,392,,,392,Other,186% of Medicaid,171.44,,,171.44,Fee Schedule,,703.08,,,703.08,Fee Schedule,,80.72,,,80.72,Fee Schedule,,171.44,,,171.44,Fee Schedule,,703.08,,,703.08,Fee Schedule,,151.84,,,151.84,Fee Schedule,,793.8,70,,793.8,percent of total billed charges,All Other,175.48,,,175.48,Fee Schedule,,148.73,,,148.73,Fee Schedule,,770.53,,,770.53,Fee Schedule,,770.53,,,770.53,Fee Schedule,,770.53,,,770.53,Fee Schedule,,770.53,,,770.53,Fee Schedule,,210.57,,,210.57,Other,100% of Medicaid,210.57,,,210.57,Other,100% of Medicaid,210.57,,,210.57,Other,100% of Medicaid,210.57,,,210.57,Other,100% of Medicaid,473.77,,,473.77,Other,225% of Medicaid,322.17,,,322.17,Other,153% of Medicaid,473.77,,,473.77,Other,225% of Medicaid,294.79,,,294.79,Other,140% of Medicaid,473.77,,,473.77,Other,225% of Medicaid,547.47,,,547.47,Other,260% of Medicaid,682.23,,,682.23,Other,324% of Medicaid,452.72,,,452.72,Other,215% of Medicaid,452.72,,,452.72,Other,215% of Medicaid,263.21,,,263.21,Other,125% of Medicaid,80.72,839.16,
X-RAYS BONE LENGTH STUDIES,77073,CPT,TC,46077073,CDM,320,RC,,,both,,,242,179.08,,,179.08,Other,150% of Medicare + 9.63% HCRA Surcharge,108.9,45,,108.9,percent of total billed charges,Critical Access Hospital RCC factor,112.22,,,112.22,Fee Schedule,,100.97,,,100.97,Fee Schedule,,164.85,,,164.85,Fee Schedule,,148.27,,,148.27,Fee Schedule,,140.13,,,140.13,Fee Schedule,,119.79,,,119.79,Other,110% of Medicare,133.33,,,133.33,Fee Schedule,,53,,,53,Other,186% of Medicaid,156.9,,,156.9,Fee Schedule,,150.04,,,150.04,Fee Schedule,,73.88,,,73.88,Fee Schedule,,156.9,,,156.9,Fee Schedule,,150.04,,,150.04,Fee Schedule,,138.96,,,138.96,Fee Schedule,,169.4,70,,169.4,percent of total billed charges,All Other,157.44,,,157.44,Fee Schedule,,133.44,,,133.44,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,179.33,
SINUS TRACT INJ; DX,20501,CPT,,47020501,CDM,320,RC,,,both,,,146,108.04,,,108.04,Other,150% of Medicare + 9.63% HCRA Surcharge,65.7,45,,65.7,percent of total billed charges,Critical Access Hospital RCC factor,120.04,,,120.04,Fee Schedule,,108,,,108,Fee Schedule,,111.69,76.5,,111.69,percent of total billed charges,All Other,103.66,69,,103.66,percent of total billed charges,All Other,100.74,65,,100.74,percent of total billed charges,All Other,72.27,,,72.27,Other,110% of Medicare,142.62,,,142.62,Fee Schedule,,967,,,967,Other,186% of Medicaid,167.83,,,167.83,Fee Schedule,,90.52,,,90.52,Fee Schedule,,79.02,,,79.02,Fee Schedule,,167.83,,,167.83,Fee Schedule,,90.52,,,90.52,Fee Schedule,,148.64,,,148.64,Fee Schedule,,102.2,70,,102.2,percent of total billed charges,All Other,178.76,,,178.76,Fee Schedule,,151.51,,,151.51,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,519.86,,,519.86,Other,100% of Medicaid,519.86,,,519.86,Other,100% of Medicaid,519.86,,,519.86,Other,100% of Medicaid,519.86,,,519.86,Other,100% of Medicaid,1169.68,,,1169.68,Other,225% of Medicaid,795.38,,,795.38,Other,153% of Medicaid,1169.68,,,1169.68,Other,225% of Medicaid,727.8,,,727.8,Other,140% of Medicaid,1169.68,,,1169.68,Other,225% of Medicaid,1351.62,,,1351.62,Other,260% of Medicaid,1684.33,,,1684.33,Other,324% of Medicaid,1117.69,,,1117.69,Other,215% of Medicaid,1117.69,,,1117.69,Other,215% of Medicaid,649.82,,,649.82,Other,125% of Medicaid,0.01,1684.33,
INSERT PLEURAL CATH,32550,CPT,,47032550,CDM,320,RC,,,both,,,11690,8650.63,,,8650.63,Other,150% of Medicare + 9.63% HCRA Surcharge,5260.5,45,,5260.5,percent of total billed charges,Critical Access Hospital RCC factor,677.78,,,677.78,Fee Schedule,,609.79,,,609.79,Fee Schedule,,8942.85,76.5,,8942.85,percent of total billed charges,All Other,8299.9,69,,8299.9,percent of total billed charges,All Other,8066.1,65,,8066.1,percent of total billed charges,All Other,5786.55,,,5786.55,Other,110% of Medicare,805.26,,,805.26,Fee Schedule,,1197,,,1197,Other,186% of Medicaid,947.62,,,947.62,Fee Schedule,,7247.8,,,7247.8,Fee Schedule,,446.19,,,446.19,Fee Schedule,,947.62,,,947.62,Fee Schedule,,7247.8,,,7247.8,Fee Schedule,,839.26,,,839.26,Fee Schedule,,8183,70,,8183,percent of total billed charges,All Other,982.36,,,982.36,Fee Schedule,,832.61,,,832.61,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,643.35,,,643.35,Other,100% of Medicaid,643.35,,,643.35,Other,100% of Medicaid,643.35,,,643.35,Other,100% of Medicaid,643.35,,,643.35,Other,100% of Medicaid,1447.55,,,1447.55,Other,225% of Medicaid,984.33,,,984.33,Other,153% of Medicaid,1447.55,,,1447.55,Other,225% of Medicaid,900.7,,,900.7,Other,140% of Medicaid,1447.55,,,1447.55,Other,225% of Medicaid,1672.72,,,1672.72,Other,260% of Medicaid,2084.47,,,2084.47,Other,324% of Medicaid,1383.21,,,1383.21,Other,215% of Medicaid,1383.21,,,1383.21,Other,215% of Medicaid,804.19,,,804.19,Other,125% of Medicaid,0.01,8942.85,
SIALOGRAM,70390,CPT,TC,47070390,CDM,320,RC,,,both,,,894,661.56,,,661.56,Other,150% of Medicare + 9.63% HCRA Surcharge,402.3,45,,402.3,percent of total billed charges,Critical Access Hospital RCC factor,339.83,,,339.83,Fee Schedule,,305.74,,,305.74,Fee Schedule,,558.46,,,558.46,Fee Schedule,,502.3,,,502.3,Fee Schedule,,474.75,,,474.75,Fee Schedule,,442.53,,,442.53,Other,110% of Medicare,403.75,,,403.75,Fee Schedule,,392,,,392,Other,186% of Medicaid,475.12,,,475.12,Fee Schedule,,554.28,,,554.28,Fee Schedule,,223.71,,,223.71,Fee Schedule,,475.12,,,475.12,Fee Schedule,,554.28,,,554.28,Fee Schedule,,420.79,,,420.79,Fee Schedule,,625.8,70,,625.8,percent of total billed charges,All Other,503.48,,,503.48,Fee Schedule,,426.73,,,426.73,Fee Schedule,,372.86,,,372.86,Fee Schedule,,372.86,,,372.86,Fee Schedule,,372.86,,,372.86,Fee Schedule,,372.86,,,372.86,Fee Schedule,,210.57,,,210.57,Other,100% of Medicaid,210.57,,,210.57,Other,100% of Medicaid,210.57,,,210.57,Other,100% of Medicaid,210.57,,,210.57,Other,100% of Medicaid,473.77,,,473.77,Other,225% of Medicaid,322.17,,,322.17,Other,153% of Medicaid,473.77,,,473.77,Other,225% of Medicaid,294.79,,,294.79,Other,140% of Medicaid,473.77,,,473.77,Other,225% of Medicaid,547.47,,,547.47,Other,260% of Medicaid,682.23,,,682.23,Other,324% of Medicaid,452.72,,,452.72,Other,215% of Medicaid,452.72,,,452.72,Other,215% of Medicaid,263.21,,,263.21,Other,125% of Medicaid,210.57,682.23,
MYELOGRAM CERVICAL,72240,CPT,TC,47072240,CDM,320,RC,,,both,,,1939,1434.86,,,1434.86,Other,150% of Medicare + 9.63% HCRA Surcharge,872.55,45,,872.55,percent of total billed charges,Critical Access Hospital RCC factor,239.31,,,239.31,Fee Schedule,,215.31,,,215.31,Fee Schedule,,672.87,,,672.87,Fee Schedule,,605.2,,,605.2,Fee Schedule,,572.01,,,572.01,Fee Schedule,,959.81,,,959.81,Other,110% of Medicare,284.33,,,284.33,Fee Schedule,,914,,,914,Other,186% of Medicaid,334.59,,,334.59,Fee Schedule,,1202.18,,,1202.18,Fee Schedule,,157.54,,,157.54,Fee Schedule,,334.59,,,334.59,Fee Schedule,,1202.18,,,1202.18,Fee Schedule,,296.33,,,296.33,Fee Schedule,,1357.3,70,,1357.3,percent of total billed charges,All Other,354.24,,,354.24,Fee Schedule,,300.24,,,300.24,Fee Schedule,,1089.31,,,1089.31,Fee Schedule,,1089.31,,,1089.31,Fee Schedule,,1089.31,,,1089.31,Fee Schedule,,1089.31,,,1089.31,Fee Schedule,,491.65,,,491.65,Other,100% of Medicaid,491.65,,,491.65,Other,100% of Medicaid,491.65,,,491.65,Other,100% of Medicaid,491.65,,,491.65,Other,100% of Medicaid,1106.21,,,1106.21,Other,225% of Medicaid,752.22,,,752.22,Other,153% of Medicaid,1106.21,,,1106.21,Other,225% of Medicaid,688.31,,,688.31,Other,140% of Medicaid,1106.21,,,1106.21,Other,225% of Medicaid,1278.28,,,1278.28,Other,260% of Medicaid,1592.94,,,1592.94,Other,324% of Medicaid,1057.04,,,1057.04,Other,215% of Medicaid,1057.04,,,1057.04,Other,215% of Medicaid,614.56,,,614.56,Other,125% of Medicaid,157.54,1592.94,
MYELOGRAM THORACIC,72255,CPT,TC,47072255,CDM,320,RC,,,both,,,1939,1434.86,,,1434.86,Other,150% of Medicare + 9.63% HCRA Surcharge,872.55,45,,872.55,percent of total billed charges,Critical Access Hospital RCC factor,225.44,,,225.44,Fee Schedule,,202.82,,,202.82,Fee Schedule,,617.96,,,617.96,Fee Schedule,,555.81,,,555.81,Fee Schedule,,525.32,,,525.32,Fee Schedule,,959.81,,,959.81,Other,110% of Medicare,267.84,,,267.84,Fee Schedule,,914,,,914,Other,186% of Medicaid,315.19,,,315.19,Fee Schedule,,1202.18,,,1202.18,Fee Schedule,,148.41,,,148.41,Fee Schedule,,315.19,,,315.19,Fee Schedule,,1202.18,,,1202.18,Fee Schedule,,279.15,,,279.15,Fee Schedule,,1357.3,70,,1357.3,percent of total billed charges,All Other,360.8,,,360.8,Fee Schedule,,305.8,,,305.8,Fee Schedule,,1089.31,,,1089.31,Fee Schedule,,1089.31,,,1089.31,Fee Schedule,,1089.31,,,1089.31,Fee Schedule,,1089.31,,,1089.31,Fee Schedule,,491.65,,,491.65,Other,100% of Medicaid,491.65,,,491.65,Other,100% of Medicaid,491.65,,,491.65,Other,100% of Medicaid,491.65,,,491.65,Other,100% of Medicaid,1106.21,,,1106.21,Other,225% of Medicaid,752.22,,,752.22,Other,153% of Medicaid,1106.21,,,1106.21,Other,225% of Medicaid,688.31,,,688.31,Other,140% of Medicaid,1106.21,,,1106.21,Other,225% of Medicaid,1278.28,,,1278.28,Other,260% of Medicaid,1592.94,,,1592.94,Other,324% of Medicaid,1057.04,,,1057.04,Other,215% of Medicaid,1057.04,,,1057.04,Other,215% of Medicaid,614.56,,,614.56,Other,125% of Medicaid,148.41,1592.94,
MYELOGRAM LUMBOSACRAL,72265,CPT,,47072265,CDM,320,RC,,,both,,,2536,1876.65,,,1876.65,Other,150% of Medicare + 9.63% HCRA Surcharge,1141.2,45,,1141.2,percent of total billed charges,Critical Access Hospital RCC factor,241.61,,,241.61,Fee Schedule,,217.37,,,217.37,Fee Schedule,,654.59,,,654.59,Fee Schedule,,588.76,,,588.76,Fee Schedule,,556.46,,,556.46,Fee Schedule,,1255.32,,,1255.32,Other,110% of Medicare,287.05,,,287.05,Fee Schedule,,914,,,914,Other,186% of Medicaid,337.8,,,337.8,Fee Schedule,,1572.32,,,1572.32,Fee Schedule,,159.05,,,159.05,Fee Schedule,,337.8,,,337.8,Fee Schedule,,1572.32,,,1572.32,Fee Schedule,,299.17,,,299.17,Fee Schedule,,1775.2,70,,1775.2,percent of total billed charges,All Other,346.04,,,346.04,Fee Schedule,,293.29,,,293.29,Fee Schedule,,1089.31,,,1089.31,Fee Schedule,,1089.31,,,1089.31,Fee Schedule,,1089.31,,,1089.31,Fee Schedule,,1089.31,,,1089.31,Fee Schedule,,491.65,,,491.65,Other,100% of Medicaid,491.65,,,491.65,Other,100% of Medicaid,491.65,,,491.65,Other,100% of Medicaid,491.65,,,491.65,Other,100% of Medicaid,1106.21,,,1106.21,Other,225% of Medicaid,752.22,,,752.22,Other,153% of Medicaid,1106.21,,,1106.21,Other,225% of Medicaid,688.31,,,688.31,Other,140% of Medicaid,1106.21,,,1106.21,Other,225% of Medicaid,1278.28,,,1278.28,Other,260% of Medicaid,1592.94,,,1592.94,Other,324% of Medicaid,1057.04,,,1057.04,Other,215% of Medicaid,1057.04,,,1057.04,Other,215% of Medicaid,614.56,,,614.56,Other,125% of Medicaid,159.05,1876.65,
CONTRAST X-RAY SPINE 2+ REGIONS,72270,CPT,,47072270,CDM,320,RC,,,both,,,1840,1361.6,,,1361.6,Other,150% of Medicare + 9.63% HCRA Surcharge,828,45,,828,percent of total billed charges,Critical Access Hospital RCC factor,306.3,,,306.3,Fee Schedule,,275.58,,,275.58,Fee Schedule,,1006.99,,,1006.99,Fee Schedule,,905.72,,,905.72,Fee Schedule,,856.04,,,856.04,Fee Schedule,,910.8,,,910.8,Other,110% of Medicare,363.92,,,363.92,Fee Schedule,,914,,,914,Other,186% of Medicaid,428.25,,,428.25,Fee Schedule,,1140.8,,,1140.8,Fee Schedule,,201.64,,,201.64,Fee Schedule,,428.25,,,428.25,Fee Schedule,,1140.8,,,1140.8,Fee Schedule,,379.28,,,379.28,Fee Schedule,,1288,70,,1288,percent of total billed charges,All Other,498.56,,,498.56,Fee Schedule,,422.56,,,422.56,Fee Schedule,,1089.31,,,1089.31,Fee Schedule,,1089.31,,,1089.31,Fee Schedule,,1089.31,,,1089.31,Fee Schedule,,1089.31,,,1089.31,Fee Schedule,,491.65,,,491.65,Other,100% of Medicaid,491.65,,,491.65,Other,100% of Medicaid,491.65,,,491.65,Other,100% of Medicaid,491.65,,,491.65,Other,100% of Medicaid,1106.21,,,1106.21,Other,225% of Medicaid,752.22,,,752.22,Other,153% of Medicaid,1106.21,,,1106.21,Other,225% of Medicaid,688.31,,,688.31,Other,140% of Medicaid,1106.21,,,1106.21,Other,225% of Medicaid,1278.28,,,1278.28,Other,260% of Medicaid,1592.94,,,1592.94,Other,324% of Medicaid,1057.04,,,1057.04,Other,215% of Medicaid,1057.04,,,1057.04,Other,215% of Medicaid,614.56,,,614.56,Other,125% of Medicaid,201.64,1592.94,
X-RAY C/T SPINE DISK,72285,CPT,,47072285,CDM,320,RC,,,both,,,4047,2994.79,,,2994.79,Other,150% of Medicare + 9.63% HCRA Surcharge,1821.15,45,,1821.15,percent of total billed charges,Critical Access Hospital RCC factor,267.03,,,267.03,Fee Schedule,,240.25,,,240.25,Fee Schedule,,604.21,,,604.21,Fee Schedule,,543.44,,,543.44,Fee Schedule,,513.63,,,513.63,Fee Schedule,,2003.27,,,2003.27,Other,110% of Medicare,317.26,,,317.26,Fee Schedule,,914,,,914,Other,186% of Medicaid,373.35,,,373.35,Fee Schedule,,2509.14,,,2509.14,Fee Schedule,,175.79,,,175.79,Fee Schedule,,373.35,,,373.35,Fee Schedule,,2509.14,,,2509.14,Fee Schedule,,330.65,,,330.65,Fee Schedule,,2832.9,70,,2832.9,percent of total billed charges,All Other,350.96,,,350.96,Fee Schedule,,297.46,,,297.46,Fee Schedule,,2750.96,,,2750.96,Fee Schedule,,2750.96,,,2750.96,Fee Schedule,,2750.96,,,2750.96,Fee Schedule,,2750.96,,,2750.96,Fee Schedule,,491.65,,,491.65,Other,100% of Medicaid,491.65,,,491.65,Other,100% of Medicaid,491.65,,,491.65,Other,100% of Medicaid,491.65,,,491.65,Other,100% of Medicaid,1106.21,,,1106.21,Other,225% of Medicaid,752.22,,,752.22,Other,153% of Medicaid,1106.21,,,1106.21,Other,225% of Medicaid,688.31,,,688.31,Other,140% of Medicaid,1106.21,,,1106.21,Other,225% of Medicaid,1278.28,,,1278.28,Other,260% of Medicaid,1592.94,,,1592.94,Other,324% of Medicaid,1057.04,,,1057.04,Other,215% of Medicaid,1057.04,,,1057.04,Other,215% of Medicaid,614.56,,,614.56,Other,125% of Medicaid,175.79,2994.79,
X-RAY OF LOWER SPINE DISK,72295,CPT,,47072295,CDM,320,RC,,,both,,,6489,4801.88,,,4801.88,Other,150% of Medicare + 9.63% HCRA Surcharge,2920.05,45,,2920.05,percent of total billed charges,Critical Access Hospital RCC factor,250.86,,,250.86,Fee Schedule,,225.7,,,225.7,Fee Schedule,,595.09,,,595.09,Fee Schedule,,535.24,,,535.24,Fee Schedule,,505.88,,,505.88,Fee Schedule,,3212.06,,,3212.06,Other,110% of Medicare,298.05,,,298.05,Fee Schedule,,914,,,914,Other,186% of Medicaid,350.73,,,350.73,Fee Schedule,,4023.18,,,4023.18,Fee Schedule,,165.14,,,165.14,Fee Schedule,,350.73,,,350.73,Fee Schedule,,4023.18,,,4023.18,Fee Schedule,,310.63,,,310.63,Fee Schedule,,4542.3,70,,4542.3,percent of total billed charges,All Other,355.88,,,355.88,Fee Schedule,,301.63,,,301.63,Fee Schedule,,2750.96,,,2750.96,Fee Schedule,,2750.96,,,2750.96,Fee Schedule,,2750.96,,,2750.96,Fee Schedule,,2750.96,,,2750.96,Fee Schedule,,491.65,,,491.65,Other,100% of Medicaid,491.65,,,491.65,Other,100% of Medicaid,491.65,,,491.65,Other,100% of Medicaid,491.65,,,491.65,Other,100% of Medicaid,1106.21,,,1106.21,Other,225% of Medicaid,752.22,,,752.22,Other,153% of Medicaid,1106.21,,,1106.21,Other,225% of Medicaid,688.31,,,688.31,Other,140% of Medicaid,1106.21,,,1106.21,Other,225% of Medicaid,1278.28,,,1278.28,Other,260% of Medicaid,1592.94,,,1592.94,Other,324% of Medicaid,1057.04,,,1057.04,Other,215% of Medicaid,1057.04,,,1057.04,Other,215% of Medicaid,614.56,,,614.56,Other,125% of Medicaid,165.14,4801.88,
CHOLANGIOGRAM INTRAOP,74300,CPT,TC,47074300,CDM,320,RC,,,both,,,1428,1056.72,,,1056.72,Other,150% of Medicare + 9.63% HCRA Surcharge,642.6,45,,642.6,percent of total billed charges,Critical Access Hospital RCC factor,928.2,65,,928.2,percent of total billed charges,All Other,842.52,65,,842.52,percent of total billed charges,All Other,33.47,,,33.47,Fee Schedule,,33.47,,,33.47,Fee Schedule,,33.47,,,33.47,Fee Schedule,,706.86,,,706.86,Other,110% of Medicare,971.04,68,,971.04,percent of total billed charges,All Other,544,,,544,Other,186% of Medicaid,1142.4,80,,1142.4,percent of total billed charges,All Other,1185.24,83,,1185.24,percent of total billed charges,All Other,1185.24,83,,1185.24,percent of total billed charges,All Other,1142.4,80,,1142.4,percent of total billed charges,All Other,1185.24,83,,1185.24,percent of total billed charges,All Other,1142.4,80,,1142.4,percent of total billed charges,All Other,999.6,70,,999.6,percent of total billed charges,All Other,928.2,65,,928.2,percent of total billed charges,Default if not in Fee Schedule,928.2,65,,928.2,percent of total billed charges,Default if not in Fee Schedule,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,292.43,,,292.43,Other,100% of Medicaid,292.43,,,292.43,Other,100% of Medicaid,292.43,,,292.43,Other,100% of Medicaid,292.43,,,292.43,Other,100% of Medicaid,657.97,,,657.97,Other,225% of Medicaid,447.42,,,447.42,Other,153% of Medicaid,657.97,,,657.97,Other,225% of Medicaid,409.4,,,409.4,Other,140% of Medicaid,657.97,,,657.97,Other,225% of Medicaid,760.32,,,760.32,Other,260% of Medicaid,947.48,,,947.48,Other,324% of Medicaid,628.73,,,628.73,Other,215% of Medicaid,628.73,,,628.73,Other,215% of Medicaid,365.54,,,365.54,Other,125% of Medicaid,0.01,1185.24,
PTHD BILE DUCT STRICTURE,74363,CPT,TC,47074363,CDM,320,RC,,,both,,,194,143.56,,,143.56,Other,150% of Medicare + 9.63% HCRA Surcharge,87.3,45,,87.3,percent of total billed charges,Critical Access Hospital RCC factor,126.1,65,,126.1,percent of total billed charges,All Other,114.46,65,,114.46,percent of total billed charges,All Other,77.65,,,77.65,Fee Schedule,,77.65,,,77.65,Fee Schedule,,77.65,,,77.65,Fee Schedule,,96.03,,,96.03,Other,110% of Medicare,131.92,68,,131.92,percent of total billed charges,All Other,544,,,544,Other,186% of Medicaid,155.2,80,,155.2,percent of total billed charges,All Other,161.02,83,,161.02,percent of total billed charges,All Other,161.02,83,,161.02,percent of total billed charges,All Other,155.2,80,,155.2,percent of total billed charges,All Other,161.02,83,,161.02,percent of total billed charges,All Other,155.2,80,,155.2,percent of total billed charges,All Other,135.8,70,,135.8,percent of total billed charges,All Other,126.1,65,,126.1,percent of total billed charges,Default if not in Fee Schedule,126.1,65,,126.1,percent of total billed charges,Default if not in Fee Schedule,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,292.43,,,292.43,Other,100% of Medicaid,292.43,,,292.43,Other,100% of Medicaid,292.43,,,292.43,Other,100% of Medicaid,292.43,,,292.43,Other,100% of Medicaid,657.97,,,657.97,Other,225% of Medicaid,447.42,,,447.42,Other,153% of Medicaid,657.97,,,657.97,Other,225% of Medicaid,409.4,,,409.4,Other,140% of Medicaid,657.97,,,657.97,Other,225% of Medicaid,760.32,,,760.32,Other,260% of Medicaid,947.48,,,947.48,Other,324% of Medicaid,628.73,,,628.73,Other,215% of Medicaid,628.73,,,628.73,Other,215% of Medicaid,365.54,,,365.54,Other,125% of Medicaid,0.01,947.48,
CONTRST X-RAY URINARY TRACT,74425,CPT,TC,47074425,CDM,320,RC,,,both,,,1137,841.38,,,841.38,Other,150% of Medicare + 9.63% HCRA Surcharge,511.65,45,,511.65,percent of total billed charges,Critical Access Hospital RCC factor,389.5,,,389.5,Fee Schedule,,350.43,,,350.43,Fee Schedule,,1185.43,,,1185.43,Fee Schedule,,1066.22,,,1066.22,Fee Schedule,,1007.73,,,1007.73,Fee Schedule,,562.82,,,562.82,Other,110% of Medicare,462.76,,,462.76,Fee Schedule,,392,,,392,Other,186% of Medicaid,544.57,,,544.57,Fee Schedule,,704.94,,,704.94,Fee Schedule,,256.41,,,256.41,Fee Schedule,,544.57,,,544.57,Fee Schedule,,704.94,,,704.94,Fee Schedule,,482.3,,,482.3,Fee Schedule,,795.9,70,,795.9,percent of total billed charges,All Other,567.44,,,567.44,Fee Schedule,,480.94,,,480.94,Fee Schedule,,610.96,,,610.96,Fee Schedule,,610.96,,,610.96,Fee Schedule,,610.96,,,610.96,Fee Schedule,,610.96,,,610.96,Fee Schedule,,210.57,,,210.57,Other,100% of Medicaid,210.57,,,210.57,Other,100% of Medicaid,210.57,,,210.57,Other,100% of Medicaid,210.57,,,210.57,Other,100% of Medicaid,473.77,,,473.77,Other,225% of Medicaid,322.17,,,322.17,Other,153% of Medicaid,473.77,,,473.77,Other,225% of Medicaid,294.79,,,294.79,Other,140% of Medicaid,473.77,,,473.77,Other,225% of Medicaid,547.47,,,547.47,Other,260% of Medicaid,682.23,,,682.23,Other,324% of Medicaid,452.72,,,452.72,Other,215% of Medicaid,452.72,,,452.72,Other,215% of Medicaid,263.21,,,263.21,Other,125% of Medicaid,210.57,1185.43,
DILATE URETERS/URETHRA/NEPHROSTOMY,74485,CPT,,47074485,CDM,320,RC,,,both,,,5267,3897.59,,,3897.59,Other,150% of Medicare + 9.63% HCRA Surcharge,2370.15,45,,2370.15,percent of total billed charges,Critical Access Hospital RCC factor,280.91,,,280.91,Fee Schedule,,252.73,,,252.73,Fee Schedule,,565.31,,,565.31,Fee Schedule,,508.46,,,508.46,Fee Schedule,,480.57,,,480.57,Fee Schedule,,2607.17,,,2607.17,Other,110% of Medicare,333.75,,,333.75,Fee Schedule,,544,,,544,Other,186% of Medicaid,392.75,,,392.75,Fee Schedule,,3265.54,,,3265.54,Fee Schedule,,184.93,,,184.93,Fee Schedule,,392.75,,,392.75,Fee Schedule,,3265.54,,,3265.54,Fee Schedule,,347.84,,,347.84,Fee Schedule,,3686.9,70,,3686.9,percent of total billed charges,All Other,401.8,,,401.8,Fee Schedule,,340.55,,,340.55,Fee Schedule,,2834.48,,,2834.48,Fee Schedule,,2834.48,,,2834.48,Fee Schedule,,2834.48,,,2834.48,Fee Schedule,,2834.48,,,2834.48,Fee Schedule,,292.43,,,292.43,Other,100% of Medicaid,292.43,,,292.43,Other,100% of Medicaid,292.43,,,292.43,Other,100% of Medicaid,292.43,,,292.43,Other,100% of Medicaid,657.97,,,657.97,Other,225% of Medicaid,447.42,,,447.42,Other,153% of Medicaid,657.97,,,657.97,Other,225% of Medicaid,409.4,,,409.4,Other,140% of Medicaid,657.97,,,657.97,Other,225% of Medicaid,760.32,,,760.32,Other,260% of Medicaid,947.48,,,947.48,Other,324% of Medicaid,628.73,,,628.73,Other,215% of Medicaid,628.73,,,628.73,Other,215% of Medicaid,365.54,,,365.54,Other,125% of Medicaid,184.93,3897.59,
ANGIOGRAPHY PELVIC,75736,CPT,TC,47075736,CDM,320,RC,,,both,,,11570,8561.83,,,8561.83,Other,150% of Medicare + 9.63% HCRA Surcharge,5206.5,45,,5206.5,percent of total billed charges,Critical Access Hospital RCC factor,320.53,,,320.53,Fee Schedule,,288.38,,,288.38,Fee Schedule,,1176.32,,,1176.32,Fee Schedule,,1058.02,,,1058.02,Fee Schedule,,999.98,,,999.98,Fee Schedule,,5727.15,,,5727.15,Other,110% of Medicare,380.82,,,380.82,Fee Schedule,,1421,,,1421,Other,186% of Medicaid,448.14,,,448.14,Fee Schedule,,7173.4,,,7173.4,Fee Schedule,,211.01,,,211.01,Fee Schedule,,448.14,,,448.14,Fee Schedule,,7173.4,,,7173.4,Fee Schedule,,396.9,,,396.9,Fee Schedule,,8099,70,,8099,percent of total billed charges,All Other,436.24,,,436.24,Fee Schedule,,369.74,,,369.74,Fee Schedule,,7353.9,,,7353.9,Fee Schedule,,7353.9,,,7353.9,Fee Schedule,,7353.9,,,7353.9,Fee Schedule,,7353.9,,,7353.9,Fee Schedule,,763.74,,,763.74,Other,100% of Medicaid,763.74,,,763.74,Other,100% of Medicaid,763.74,,,763.74,Other,100% of Medicaid,763.74,,,763.74,Other,100% of Medicaid,1718.42,,,1718.42,Other,225% of Medicaid,1168.52,,,1168.52,Other,153% of Medicaid,1718.42,,,1718.42,Other,225% of Medicaid,1069.24,,,1069.24,Other,140% of Medicaid,1718.42,,,1718.42,Other,225% of Medicaid,1985.73,,,1985.73,Other,260% of Medicaid,2474.52,,,2474.52,Other,324% of Medicaid,1642.04,,,1642.04,Other,215% of Medicaid,1642.04,,,1642.04,Other,215% of Medicaid,954.68,,,954.68,Other,125% of Medicaid,211.01,8561.83,
ANGIOGRAPHY EACH ADD VESSEL,75774,CPT,TC,47075774,CDM,320,RC,,,both,,,3889,2877.87,,,2877.87,Other,150% of Medicare + 9.63% HCRA Surcharge,1750.05,45,,1750.05,percent of total billed charges,Critical Access Hospital RCC factor,176.92,,,176.92,Fee Schedule,,159.17,,,159.17,Fee Schedule,,952.03,,,952.03,Fee Schedule,,856.28,,,856.28,Fee Schedule,,809.31,,,809.31,Fee Schedule,,1925.06,,,1925.06,Other,110% of Medicare,210.19,,,210.19,Fee Schedule,,1421,,,1421,Other,186% of Medicaid,247.35,,,247.35,Fee Schedule,,2411.18,,,2411.18,Fee Schedule,,116.47,,,116.47,Fee Schedule,,247.35,,,247.35,Fee Schedule,,2411.18,,,2411.18,Fee Schedule,,219.07,,,219.07,Fee Schedule,,2722.3,70,,2722.3,percent of total billed charges,All Other,252.56,,,252.56,Fee Schedule,,214.06,,,214.06,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,763.74,,,763.74,Other,100% of Medicaid,763.74,,,763.74,Other,100% of Medicaid,763.74,,,763.74,Other,100% of Medicaid,763.74,,,763.74,Other,100% of Medicaid,1718.42,,,1718.42,Other,225% of Medicaid,1168.52,,,1168.52,Other,153% of Medicaid,1718.42,,,1718.42,Other,225% of Medicaid,1069.24,,,1069.24,Other,140% of Medicaid,1718.42,,,1718.42,Other,225% of Medicaid,1985.73,,,1985.73,Other,260% of Medicaid,2474.52,,,2474.52,Other,324% of Medicaid,1642.04,,,1642.04,Other,215% of Medicaid,1642.04,,,1642.04,Other,215% of Medicaid,954.68,,,954.68,Other,125% of Medicaid,0.01,2877.87,
SHUNTOGRAM,75809,CPT,TC,47075809,CDM,320,RC,,,both,,,667,493.58,,,493.58,Other,150% of Medicare + 9.63% HCRA Surcharge,300.15,45,,300.15,percent of total billed charges,Critical Access Hospital RCC factor,205.82,,,205.82,Fee Schedule,,185.17,,,185.17,Fee Schedule,,501.23,,,501.23,Fee Schedule,,450.82,,,450.82,Fee Schedule,,426.09,,,426.09,Fee Schedule,,330.17,,,330.17,Other,110% of Medicare,244.53,,,244.53,Fee Schedule,,392,,,392,Other,186% of Medicaid,287.76,,,287.76,Fee Schedule,,413.54,,,413.54,Fee Schedule,,135.49,,,135.49,Fee Schedule,,287.76,,,287.76,Fee Schedule,,413.54,,,413.54,Fee Schedule,,254.85,,,254.85,Fee Schedule,,466.9,70,,466.9,percent of total billed charges,All Other,291.92,,,291.92,Fee Schedule,,247.42,,,247.42,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,210.57,,,210.57,Other,100% of Medicaid,210.57,,,210.57,Other,100% of Medicaid,210.57,,,210.57,Other,100% of Medicaid,210.57,,,210.57,Other,100% of Medicaid,473.77,,,473.77,Other,225% of Medicaid,322.17,,,322.17,Other,153% of Medicaid,473.77,,,473.77,Other,225% of Medicaid,294.79,,,294.79,Other,140% of Medicaid,473.77,,,473.77,Other,225% of Medicaid,547.47,,,547.47,Other,260% of Medicaid,682.23,,,682.23,Other,324% of Medicaid,452.72,,,452.72,Other,215% of Medicaid,452.72,,,452.72,Other,215% of Medicaid,263.21,,,263.21,Other,125% of Medicaid,135.49,682.23,
UNILATERAL VENOGRAM,75820,CPT,TC,47075820,CDM,320,RC,,,both,,,3649,2700.27,,,2700.27,Other,150% of Medicare + 9.63% HCRA Surcharge,1642.05,45,,1642.05,percent of total billed charges,Critical Access Hospital RCC factor,205.82,,,205.82,Fee Schedule,,185.17,,,185.17,Fee Schedule,,611.11,,,611.11,Fee Schedule,,549.65,,,549.65,Fee Schedule,,519.5,,,519.5,Fee Schedule,,1806.26,,,1806.26,Other,110% of Medicare,244.53,,,244.53,Fee Schedule,,490,,,490,Other,186% of Medicaid,287.76,,,287.76,Fee Schedule,,2262.38,,,2262.38,Fee Schedule,,135.49,,,135.49,Fee Schedule,,287.76,,,287.76,Fee Schedule,,2262.38,,,2262.38,Fee Schedule,,254.85,,,254.85,Fee Schedule,,2554.3,70,,2554.3,percent of total billed charges,All Other,300.12,,,300.12,Fee Schedule,,254.37,,,254.37,Fee Schedule,,1008.82,,,1008.82,Fee Schedule,,1008.82,,,1008.82,Fee Schedule,,1008.82,,,1008.82,Fee Schedule,,1008.82,,,1008.82,Fee Schedule,,263.19,,,263.19,Other,100% of Medicaid,263.19,,,263.19,Other,100% of Medicaid,263.19,,,263.19,Other,100% of Medicaid,263.19,,,263.19,Other,100% of Medicaid,592.18,,,592.18,Other,225% of Medicaid,402.68,,,402.68,Other,153% of Medicaid,592.18,,,592.18,Other,225% of Medicaid,368.47,,,368.47,Other,140% of Medicaid,592.18,,,592.18,Other,225% of Medicaid,684.3,,,684.3,Other,260% of Medicaid,852.74,,,852.74,Other,324% of Medicaid,565.86,,,565.86,Other,215% of Medicaid,565.86,,,565.86,Other,215% of Medicaid,328.99,,,328.99,Other,125% of Medicaid,135.49,2700.27,
VENOGRAPHY EXTREMITY; BILATERA,75822,CPT,TC,47075822,CDM,320,RC,,,both,,,3350,2479.01,,,2479.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1507.5,45,,1507.5,percent of total billed charges,Critical Access Hospital RCC factor,227.77,,,227.77,Fee Schedule,,204.92,,,204.92,Fee Schedule,,684.31,,,684.31,Fee Schedule,,615.49,,,615.49,Fee Schedule,,581.73,,,581.73,Fee Schedule,,1658.25,,,1658.25,Other,110% of Medicare,270.61,,,270.61,Fee Schedule,,490,,,490,Other,186% of Medicaid,318.44,,,318.44,Fee Schedule,,2077,,,2077,Fee Schedule,,149.94,,,149.94,Fee Schedule,,318.44,,,318.44,Fee Schedule,,2077,,,2077,Fee Schedule,,282.03,,,282.03,Fee Schedule,,2345,70,,2345,percent of total billed charges,All Other,323.08,,,323.08,Fee Schedule,,273.83,,,273.83,Fee Schedule,,2609.81,,,2609.81,Fee Schedule,,2609.81,,,2609.81,Fee Schedule,,2609.81,,,2609.81,Fee Schedule,,2609.81,,,2609.81,Fee Schedule,,263.19,,,263.19,Other,100% of Medicaid,263.19,,,263.19,Other,100% of Medicaid,263.19,,,263.19,Other,100% of Medicaid,263.19,,,263.19,Other,100% of Medicaid,592.18,,,592.18,Other,225% of Medicaid,402.68,,,402.68,Other,153% of Medicaid,592.18,,,592.18,Other,225% of Medicaid,368.47,,,368.47,Other,140% of Medicaid,592.18,,,592.18,Other,225% of Medicaid,684.3,,,684.3,Other,260% of Medicaid,852.74,,,852.74,Other,324% of Medicaid,565.86,,,565.86,Other,215% of Medicaid,565.86,,,565.86,Other,215% of Medicaid,328.99,,,328.99,Other,125% of Medicaid,149.94,2609.81,
SUPERIOR VENA CAVAGRAM,75827,CPT,TC,47075827,CDM,320,RC,,,both,,,3350,2479.01,,,2479.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1507.5,45,,1507.5,percent of total billed charges,Critical Access Hospital RCC factor,228.91,,,228.91,Fee Schedule,,205.95,,,205.95,Fee Schedule,,1032.13,,,1032.13,Fee Schedule,,928.33,,,928.33,Fee Schedule,,877.41,,,877.41,Fee Schedule,,1658.25,,,1658.25,Other,110% of Medicare,271.97,,,271.97,Fee Schedule,,490,,,490,Other,186% of Medicaid,320.05,,,320.05,Fee Schedule,,2077,,,2077,Fee Schedule,,150.7,,,150.7,Fee Schedule,,320.05,,,320.05,Fee Schedule,,2077,,,2077,Fee Schedule,,283.45,,,283.45,Fee Schedule,,2345,70,,2345,percent of total billed charges,All Other,329.64,,,329.64,Fee Schedule,,279.39,,,279.39,Fee Schedule,,1008.82,,,1008.82,Fee Schedule,,1008.82,,,1008.82,Fee Schedule,,1008.82,,,1008.82,Fee Schedule,,1008.82,,,1008.82,Fee Schedule,,263.19,,,263.19,Other,100% of Medicaid,263.19,,,263.19,Other,100% of Medicaid,263.19,,,263.19,Other,100% of Medicaid,263.19,,,263.19,Other,100% of Medicaid,592.18,,,592.18,Other,225% of Medicaid,402.68,,,402.68,Other,153% of Medicaid,592.18,,,592.18,Other,225% of Medicaid,368.47,,,368.47,Other,140% of Medicaid,592.18,,,592.18,Other,225% of Medicaid,684.3,,,684.3,Other,260% of Medicaid,852.74,,,852.74,Other,324% of Medicaid,565.86,,,565.86,Other,215% of Medicaid,565.86,,,565.86,Other,215% of Medicaid,328.99,,,328.99,Other,125% of Medicaid,150.7,2479.01,
UNIL SELCTV RENAL VENOGRAM,75831,CPT,,47075831,CDM,320,RC,,,both,,,8040,5949.62,,,5949.62,Other,150% of Medicare + 9.63% HCRA Surcharge,3618,45,,3618,percent of total billed charges,Critical Access Hospital RCC factor,238.32,,,238.32,Fee Schedule,,214.42,,,214.42,Fee Schedule,,1034.45,,,1034.45,Fee Schedule,,930.41,,,930.41,Fee Schedule,,879.38,,,879.38,Fee Schedule,,3979.8,,,3979.8,Other,110% of Medicare,283.15,,,283.15,Fee Schedule,,544,,,544,Other,186% of Medicaid,333.21,,,333.21,Fee Schedule,,4984.8,,,4984.8,Fee Schedule,,156.89,,,156.89,Fee Schedule,,333.21,,,333.21,Fee Schedule,,4984.8,,,4984.8,Fee Schedule,,295.1,,,295.1,Fee Schedule,,5628,70,,5628,percent of total billed charges,All Other,334.56,,,334.56,Fee Schedule,,283.56,,,283.56,Fee Schedule,,4434.05,,,4434.05,Fee Schedule,,4434.05,,,4434.05,Fee Schedule,,4434.05,,,4434.05,Fee Schedule,,4434.05,,,4434.05,Fee Schedule,,292.43,,,292.43,Other,100% of Medicaid,292.43,,,292.43,Other,100% of Medicaid,292.43,,,292.43,Other,100% of Medicaid,292.43,,,292.43,Other,100% of Medicaid,657.98,,,657.98,Other,225% of Medicaid,447.42,,,447.42,Other,153% of Medicaid,657.98,,,657.98,Other,225% of Medicaid,409.41,,,409.41,Other,140% of Medicaid,657.98,,,657.98,Other,225% of Medicaid,760.33,,,760.33,Other,260% of Medicaid,947.49,,,947.49,Other,324% of Medicaid,628.73,,,628.73,Other,215% of Medicaid,628.73,,,628.73,Other,215% of Medicaid,365.54,,,365.54,Other,125% of Medicaid,156.89,5949.62,
UNIL SELCTV ADRENAL VENOGRAM,75840,CPT,TC,47075840,CDM,320,RC,,,both,,,7864,5819.38,,,5819.38,Other,150% of Medicare + 9.63% HCRA Surcharge,3538.8,45,,3538.8,percent of total billed charges,Critical Access Hospital RCC factor,260.27,,,260.27,Fee Schedule,,234.16,,,234.16,Fee Schedule,,1013.84,,,1013.84,Fee Schedule,,911.88,,,911.88,Fee Schedule,,861.86,,,861.86,Fee Schedule,,3892.68,,,3892.68,Other,110% of Medicare,309.23,,,309.23,Fee Schedule,,544,,,544,Other,186% of Medicaid,363.89,,,363.89,Fee Schedule,,4875.68,,,4875.68,Fee Schedule,,171.34,,,171.34,Fee Schedule,,363.89,,,363.89,Fee Schedule,,4875.68,,,4875.68,Fee Schedule,,322.28,,,322.28,Fee Schedule,,5504.8,70,,5504.8,percent of total billed charges,All Other,367.36,,,367.36,Fee Schedule,,311.36,,,311.36,Fee Schedule,,4434.05,,,4434.05,Fee Schedule,,4434.05,,,4434.05,Fee Schedule,,4434.05,,,4434.05,Fee Schedule,,4434.05,,,4434.05,Fee Schedule,,292.43,,,292.43,Other,100% of Medicaid,292.43,,,292.43,Other,100% of Medicaid,292.43,,,292.43,Other,100% of Medicaid,292.43,,,292.43,Other,100% of Medicaid,657.98,,,657.98,Other,225% of Medicaid,447.42,,,447.42,Other,153% of Medicaid,657.98,,,657.98,Other,225% of Medicaid,409.41,,,409.41,Other,140% of Medicaid,657.98,,,657.98,Other,225% of Medicaid,760.33,,,760.33,Other,260% of Medicaid,947.49,,,947.49,Other,324% of Medicaid,628.73,,,628.73,Other,215% of Medicaid,628.73,,,628.73,Other,215% of Medicaid,365.54,,,365.54,Other,125% of Medicaid,171.34,5819.38,
BILAT SELCTV ADRENAL VENOGRAM,75842,CPT,TC,47075842,CDM,320,RC,,,both,,,11570,8561.83,,,8561.83,Other,150% of Medicare + 9.63% HCRA Surcharge,5206.5,45,,5206.5,percent of total billed charges,Critical Access Hospital RCC factor,307.64,,,307.64,Fee Schedule,,276.78,,,276.78,Fee Schedule,,1137.42,,,1137.42,Fee Schedule,,1023.03,,,1023.03,Fee Schedule,,966.92,,,966.92,Fee Schedule,,5727.15,,,5727.15,Other,110% of Medicare,365.51,,,365.51,Fee Schedule,,1421,,,1421,Other,186% of Medicaid,430.12,,,430.12,Fee Schedule,,7173.4,,,7173.4,Fee Schedule,,202.52,,,202.52,Fee Schedule,,430.12,,,430.12,Fee Schedule,,7173.4,,,7173.4,Fee Schedule,,380.94,,,380.94,Fee Schedule,,8099,70,,8099,percent of total billed charges,All Other,428.04,,,428.04,Fee Schedule,,362.79,,,362.79,Fee Schedule,,7353.9,,,7353.9,Fee Schedule,,7353.9,,,7353.9,Fee Schedule,,7353.9,,,7353.9,Fee Schedule,,7353.9,,,7353.9,Fee Schedule,,763.74,,,763.74,Other,100% of Medicaid,763.74,,,763.74,Other,100% of Medicaid,763.74,,,763.74,Other,100% of Medicaid,763.74,,,763.74,Other,100% of Medicaid,1718.42,,,1718.42,Other,225% of Medicaid,1168.52,,,1168.52,Other,153% of Medicaid,1718.42,,,1718.42,Other,225% of Medicaid,1069.24,,,1069.24,Other,140% of Medicaid,1718.42,,,1718.42,Other,225% of Medicaid,1985.73,,,1985.73,Other,260% of Medicaid,2474.52,,,2474.52,Other,324% of Medicaid,1642.04,,,1642.04,Other,215% of Medicaid,1642.04,,,1642.04,Other,215% of Medicaid,954.68,,,954.68,Other,125% of Medicaid,202.52,8561.83,
SINUS OR JUGL CATH VENOGRAM,75860,CPT,,47075860,CDM,320,RC,,,both,,,6707,4963.2,,,4963.2,Other,150% of Medicare + 9.63% HCRA Surcharge,3018.15,45,,3018.15,percent of total billed charges,Critical Access Hospital RCC factor,253.35,,,253.35,Fee Schedule,,227.94,,,227.94,Fee Schedule,,1045.88,,,1045.88,Fee Schedule,,940.7,,,940.7,Fee Schedule,,889.1,,,889.1,Fee Schedule,,3319.97,,,3319.97,Other,110% of Medicare,301,,,301,Fee Schedule,,544,,,544,Other,186% of Medicaid,354.21,,,354.21,Fee Schedule,,4158.34,,,4158.34,Fee Schedule,,166.78,,,166.78,Fee Schedule,,354.21,,,354.21,Fee Schedule,,4158.34,,,4158.34,Fee Schedule,,313.71,,,313.71,Fee Schedule,,4694.9,70,,4694.9,percent of total billed charges,All Other,357.52,,,357.52,Fee Schedule,,303.02,,,303.02,Fee Schedule,,4434.05,,,4434.05,Fee Schedule,,4434.05,,,4434.05,Fee Schedule,,4434.05,,,4434.05,Fee Schedule,,4434.05,,,4434.05,Fee Schedule,,292.43,,,292.43,Other,100% of Medicaid,292.43,,,292.43,Other,100% of Medicaid,292.43,,,292.43,Other,100% of Medicaid,292.43,,,292.43,Other,100% of Medicaid,657.98,,,657.98,Other,225% of Medicaid,447.42,,,447.42,Other,153% of Medicaid,657.98,,,657.98,Other,225% of Medicaid,409.41,,,409.41,Other,140% of Medicaid,657.98,,,657.98,Other,225% of Medicaid,760.33,,,760.33,Other,260% of Medicaid,947.49,,,947.49,Other,324% of Medicaid,628.73,,,628.73,Other,215% of Medicaid,628.73,,,628.73,Other,215% of Medicaid,365.54,,,365.54,Other,125% of Medicaid,166.78,4963.2,
VENUS SAMPLING,75893,CPT,TC,47075893,CDM,320,RC,,,both,,,11570,8561.83,,,8561.83,Other,150% of Medicare + 9.63% HCRA Surcharge,5206.5,45,,5206.5,percent of total billed charges,Critical Access Hospital RCC factor,277.59,,,277.59,Fee Schedule,,249.75,,,249.75,Fee Schedule,,1027.54,,,1027.54,Fee Schedule,,924.21,,,924.21,Fee Schedule,,873.51,,,873.51,Fee Schedule,,5727.15,,,5727.15,Other,110% of Medicare,329.81,,,329.81,Fee Schedule,,1421,,,1421,Other,186% of Medicaid,388.11,,,388.11,Fee Schedule,,7173.4,,,7173.4,Fee Schedule,,182.74,,,182.74,Fee Schedule,,388.11,,,388.11,Fee Schedule,,7173.4,,,7173.4,Fee Schedule,,343.73,,,343.73,Fee Schedule,,8099,70,,8099,percent of total billed charges,All Other,383.76,,,383.76,Fee Schedule,,325.26,,,325.26,Fee Schedule,,7353.9,,,7353.9,Fee Schedule,,7353.9,,,7353.9,Fee Schedule,,7353.9,,,7353.9,Fee Schedule,,7353.9,,,7353.9,Fee Schedule,,763.74,,,763.74,Other,100% of Medicaid,763.74,,,763.74,Other,100% of Medicaid,763.74,,,763.74,Other,100% of Medicaid,763.74,,,763.74,Other,100% of Medicaid,1718.42,,,1718.42,Other,225% of Medicaid,1168.52,,,1168.52,Other,153% of Medicaid,1718.42,,,1718.42,Other,225% of Medicaid,1069.24,,,1069.24,Other,140% of Medicaid,1718.42,,,1718.42,Other,225% of Medicaid,1985.73,,,1985.73,Other,260% of Medicaid,2474.52,,,2474.52,Other,324% of Medicaid,1642.04,,,1642.04,Other,215% of Medicaid,1642.04,,,1642.04,Other,215% of Medicaid,954.68,,,954.68,Other,125% of Medicaid,182.74,8561.83,
TRANSCATH THERAPY FOLLOW UP,75898,CPT,TC,47075898,CDM,320,RC,,,both,,,6707,4963.2,,,4963.2,Other,150% of Medicare + 9.63% HCRA Surcharge,3018.15,45,,3018.15,percent of total billed charges,Critical Access Hospital RCC factor,4359.55,65,,4359.55,percent of total billed charges,All Other,3957.13,65,,3957.13,percent of total billed charges,All Other,510.4,,,510.4,Fee Schedule,,459.07,,,459.07,Fee Schedule,,433.89,,,433.89,Fee Schedule,,3319.97,,,3319.97,Other,110% of Medicare,4560.76,68,,4560.76,percent of total billed charges,All Other,490,,,490,Other,186% of Medicaid,5365.6,80,,5365.6,percent of total billed charges,All Other,5566.81,83,,5566.81,percent of total billed charges,All Other,5566.81,83,,5566.81,percent of total billed charges,All Other,5365.6,80,,5365.6,percent of total billed charges,All Other,5566.81,83,,5566.81,percent of total billed charges,All Other,5365.6,80,,5365.6,percent of total billed charges,All Other,4694.9,70,,4694.9,percent of total billed charges,All Other,4359.55,65,,4359.55,percent of total billed charges,Default if not in Fee Schedule,4359.55,65,,4359.55,percent of total billed charges,Default if not in Fee Schedule,2609.81,,,2609.81,Fee Schedule,,2609.81,,,2609.81,Fee Schedule,,2609.81,,,2609.81,Fee Schedule,,2609.81,,,2609.81,Fee Schedule,,263.19,,,263.19,Other,100% of Medicaid,263.19,,,263.19,Other,100% of Medicaid,263.19,,,263.19,Other,100% of Medicaid,263.19,,,263.19,Other,100% of Medicaid,592.18,,,592.18,Other,225% of Medicaid,402.68,,,402.68,Other,153% of Medicaid,592.18,,,592.18,Other,225% of Medicaid,368.47,,,368.47,Other,140% of Medicaid,592.18,,,592.18,Other,225% of Medicaid,684.3,,,684.3,Other,260% of Medicaid,852.74,,,852.74,Other,324% of Medicaid,565.86,,,565.86,Other,215% of Medicaid,565.86,,,565.86,Other,215% of Medicaid,328.99,,,328.99,Other,125% of Medicaid,263.19,5566.81,
REM OBSTRUCTN FROM CVD,75901,CPT,TC,47075901,CDM,320,RC,,,both,,,1171,866.54,,,866.54,Other,150% of Medicare + 9.63% HCRA Surcharge,526.95,45,,526.95,percent of total billed charges,Critical Access Hospital RCC factor,711.98,,,711.98,Fee Schedule,,640.56,,,640.56,Fee Schedule,,965.78,,,965.78,Fee Schedule,,868.65,,,868.65,Fee Schedule,,821,,,821,Fee Schedule,,579.65,,,579.65,Other,110% of Medicare,845.89,,,845.89,Fee Schedule,,544,,,544,Other,186% of Medicaid,995.43,,,995.43,Fee Schedule,,726.02,,,726.02,Fee Schedule,,468.7,,,468.7,Fee Schedule,,995.43,,,995.43,Fee Schedule,,726.02,,,726.02,Fee Schedule,,881.6,,,881.6,Fee Schedule,,819.7,70,,819.7,percent of total billed charges,All Other,1066,,,1066,Fee Schedule,,903.5,,,903.5,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,292.43,,,292.43,Other,100% of Medicaid,292.43,,,292.43,Other,100% of Medicaid,292.43,,,292.43,Other,100% of Medicaid,292.43,,,292.43,Other,100% of Medicaid,657.97,,,657.97,Other,225% of Medicaid,447.42,,,447.42,Other,153% of Medicaid,657.97,,,657.97,Other,225% of Medicaid,409.4,,,409.4,Other,140% of Medicaid,657.97,,,657.97,Other,225% of Medicaid,760.32,,,760.32,Other,260% of Medicaid,947.48,,,947.48,Other,324% of Medicaid,628.73,,,628.73,Other,215% of Medicaid,628.73,,,628.73,Other,215% of Medicaid,365.54,,,365.54,Other,125% of Medicaid,0.01,1066,
REM CVD LUMEN OBSTR,75902,CPT,,47075902,CDM,320,RC,,,both,,,406,300.44,,,300.44,Other,150% of Medicare + 9.63% HCRA Surcharge,182.7,45,,182.7,percent of total billed charges,Critical Access Hospital RCC factor,242.79,,,242.79,Fee Schedule,,218.44,,,218.44,Fee Schedule,,389.14,,,389.14,Fee Schedule,,350,,,350,Fee Schedule,,330.8,,,330.8,Fee Schedule,,200.97,,,200.97,Other,110% of Medicare,288.46,,,288.46,Fee Schedule,,544,,,544,Other,186% of Medicaid,339.45,,,339.45,Fee Schedule,,251.72,,,251.72,Fee Schedule,,159.83,,,159.83,Fee Schedule,,339.45,,,339.45,Fee Schedule,,251.72,,,251.72,Fee Schedule,,300.63,,,300.63,Fee Schedule,,284.2,70,,284.2,percent of total billed charges,All Other,370.64,,,370.64,Fee Schedule,,314.14,,,314.14,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,292.43,,,292.43,Other,100% of Medicaid,292.43,,,292.43,Other,100% of Medicaid,292.43,,,292.43,Other,100% of Medicaid,292.43,,,292.43,Other,100% of Medicaid,657.97,,,657.97,Other,225% of Medicaid,447.42,,,447.42,Other,153% of Medicaid,657.97,,,657.97,Other,225% of Medicaid,409.4,,,409.4,Other,140% of Medicaid,657.97,,,657.97,Other,225% of Medicaid,760.32,,,760.32,Other,260% of Medicaid,947.48,,,947.48,Other,324% of Medicaid,628.73,,,628.73,Other,215% of Medicaid,628.73,,,628.73,Other,215% of Medicaid,365.54,,,365.54,Other,125% of Medicaid,0.01,947.48,
XRAY CONTROL CATHETER CHANGE,75984,CPT,TC,47075984,CDM,320,RC,,,both,,,590,436.6,,,436.6,Other,150% of Medicare + 9.63% HCRA Surcharge,265.5,45,,265.5,percent of total billed charges,Critical Access Hospital RCC factor,201.19,,,201.19,Fee Schedule,,181.01,,,181.01,Fee Schedule,,535.59,,,535.59,Fee Schedule,,481.73,,,481.73,Fee Schedule,,455.3,,,455.3,Fee Schedule,,292.05,,,292.05,Other,110% of Medicare,239.04,,,239.04,Fee Schedule,,544,,,544,Other,186% of Medicaid,281.29,,,281.29,Fee Schedule,,365.8,,,365.8,Fee Schedule,,132.45,,,132.45,Fee Schedule,,281.29,,,281.29,Fee Schedule,,365.8,,,365.8,Fee Schedule,,249.13,,,249.13,Fee Schedule,,413,70,,413,percent of total billed charges,All Other,295.2,,,295.2,Fee Schedule,,250.2,,,250.2,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,292.43,,,292.43,Other,100% of Medicaid,292.43,,,292.43,Other,100% of Medicaid,292.43,,,292.43,Other,100% of Medicaid,292.43,,,292.43,Other,100% of Medicaid,657.97,,,657.97,Other,225% of Medicaid,447.42,,,447.42,Other,153% of Medicaid,657.97,,,657.97,Other,225% of Medicaid,409.4,,,409.4,Other,140% of Medicaid,657.97,,,657.97,Other,225% of Medicaid,760.32,,,760.32,Other,260% of Medicaid,947.48,,,947.48,Other,324% of Medicaid,628.73,,,628.73,Other,215% of Medicaid,628.73,,,628.73,Other,215% of Medicaid,365.54,,,365.54,Other,125% of Medicaid,0.01,947.48,
DRAINAGE CATH UNDER XR,75989,CPT,TC,47075989,CDM,320,RC,,,both,,,2125,1572.51,,,1572.51,Other,150% of Medicare + 9.63% HCRA Surcharge,956.25,45,,956.25,percent of total billed charges,Critical Access Hospital RCC factor,197.72,,,197.72,Fee Schedule,,177.88,,,177.88,Fee Schedule,,521.84,,,521.84,Fee Schedule,,469.35,,,469.35,Fee Schedule,,443.61,,,443.61,Fee Schedule,,1051.88,,,1051.88,Other,110% of Medicare,234.9,,,234.9,Fee Schedule,,544,,,544,Other,186% of Medicaid,276.43,,,276.43,Fee Schedule,,1317.5,,,1317.5,Fee Schedule,,130.16,,,130.16,Fee Schedule,,276.43,,,276.43,Fee Schedule,,1317.5,,,1317.5,Fee Schedule,,244.82,,,244.82,Fee Schedule,,1487.5,70,,1487.5,percent of total billed charges,All Other,291.92,,,291.92,Fee Schedule,,247.42,,,247.42,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,292.43,,,292.43,Other,100% of Medicaid,292.43,,,292.43,Other,100% of Medicaid,292.43,,,292.43,Other,100% of Medicaid,292.43,,,292.43,Other,100% of Medicaid,657.97,,,657.97,Other,225% of Medicaid,447.42,,,447.42,Other,153% of Medicaid,657.97,,,657.97,Other,225% of Medicaid,409.4,,,409.4,Other,140% of Medicaid,657.97,,,657.97,Other,225% of Medicaid,760.32,,,760.32,Other,260% of Medicaid,947.48,,,947.48,Other,324% of Medicaid,628.73,,,628.73,Other,215% of Medicaid,628.73,,,628.73,Other,215% of Medicaid,365.54,,,365.54,Other,125% of Medicaid,0.01,1572.51,
FLUOROSCOPE EXAM =< 1 HR,76000,CPT,,47076000,CDM,320,RC,,,both,,,527,389.98,,,389.98,Other,150% of Medicare + 9.63% HCRA Surcharge,237.15,45,,237.15,percent of total billed charges,Critical Access Hospital RCC factor,97.2,,,97.2,Fee Schedule,,87.45,,,87.45,Fee Schedule,,466.92,,,466.92,Fee Schedule,,419.96,,,419.96,Fee Schedule,,396.93,,,396.93,Fee Schedule,,260.87,,,260.87,Other,110% of Medicare,115.48,,,115.48,Fee Schedule,,392,,,392,Other,186% of Medicaid,135.9,,,135.9,Fee Schedule,,326.74,,,326.74,Fee Schedule,,63.99,,,63.99,Fee Schedule,,135.9,,,135.9,Fee Schedule,,326.74,,,326.74,Fee Schedule,,120.36,,,120.36,Fee Schedule,,368.9,70,,368.9,percent of total billed charges,All Other,136.12,,,136.12,Fee Schedule,,115.37,,,115.37,Fee Schedule,,372.86,,,372.86,Fee Schedule,,372.86,,,372.86,Fee Schedule,,372.86,,,372.86,Fee Schedule,,372.86,,,372.86,Fee Schedule,,210.57,,,210.57,Other,100% of Medicaid,210.57,,,210.57,Other,100% of Medicaid,210.57,,,210.57,Other,100% of Medicaid,210.57,,,210.57,Other,100% of Medicaid,473.77,,,473.77,Other,225% of Medicaid,322.17,,,322.17,Other,153% of Medicaid,473.77,,,473.77,Other,225% of Medicaid,294.79,,,294.79,Other,140% of Medicaid,473.77,,,473.77,Other,225% of Medicaid,547.47,,,547.47,Other,260% of Medicaid,682.23,,,682.23,Other,324% of Medicaid,452.72,,,452.72,Other,215% of Medicaid,452.72,,,452.72,Other,215% of Medicaid,263.21,,,263.21,Other,125% of Medicaid,63.99,682.23,
FLUOROGUIDE FOR VEIN DEVICE,77001,CPT,,47077001,CDM,320,RC,,,both,,,581,429.94,,,429.94,Other,150% of Medicare + 9.63% HCRA Surcharge,261.45,45,,261.45,percent of total billed charges,Critical Access Hospital RCC factor,280.91,,,280.91,Fee Schedule,,252.73,,,252.73,Fee Schedule,,643.1,,,643.1,Fee Schedule,,578.42,,,578.42,Fee Schedule,,546.69,,,546.69,Fee Schedule,,287.6,,,287.6,Other,110% of Medicare,333.75,,,333.75,Fee Schedule,,544,,,544,Other,186% of Medicaid,392.75,,,392.75,Fee Schedule,,360.22,,,360.22,Fee Schedule,,184.93,,,184.93,Fee Schedule,,392.75,,,392.75,Fee Schedule,,360.22,,,360.22,Fee Schedule,,347.84,,,347.84,Fee Schedule,,406.7,70,,406.7,percent of total billed charges,All Other,416.56,,,416.56,Fee Schedule,,353.06,,,353.06,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,292.43,,,292.43,Other,100% of Medicaid,292.43,,,292.43,Other,100% of Medicaid,292.43,,,292.43,Other,100% of Medicaid,292.43,,,292.43,Other,100% of Medicaid,657.97,,,657.97,Other,225% of Medicaid,447.42,,,447.42,Other,153% of Medicaid,657.97,,,657.97,Other,225% of Medicaid,409.4,,,409.4,Other,140% of Medicaid,657.97,,,657.97,Other,225% of Medicaid,760.32,,,760.32,Other,260% of Medicaid,947.48,,,947.48,Other,324% of Medicaid,628.73,,,628.73,Other,215% of Medicaid,628.73,,,628.73,Other,215% of Medicaid,365.54,,,365.54,Other,125% of Medicaid,0.01,947.48,
NEEDLE LOCALIZATION BY XRAY,77002,CPT,,47077002,CDM,320,RC,,,both,,,577,426.98,,,426.98,Other,150% of Medicare + 9.63% HCRA Surcharge,259.65,45,,259.65,percent of total billed charges,Critical Access Hospital RCC factor,310.93,,,310.93,Fee Schedule,,279.74,,,279.74,Fee Schedule,,325.05,,,325.05,Fee Schedule,,292.36,,,292.36,Fee Schedule,,276.33,,,276.33,Fee Schedule,,285.62,,,285.62,Other,110% of Medicare,369.41,,,369.41,Fee Schedule,,544,,,544,Other,186% of Medicaid,434.72,,,434.72,Fee Schedule,,357.74,,,357.74,Fee Schedule,,204.69,,,204.69,Fee Schedule,,434.72,,,434.72,Fee Schedule,,357.74,,,357.74,Fee Schedule,,385.01,,,385.01,Fee Schedule,,403.9,70,,403.9,percent of total billed charges,All Other,441.16,,,441.16,Fee Schedule,,373.91,,,373.91,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,292.43,,,292.43,Other,100% of Medicaid,292.43,,,292.43,Other,100% of Medicaid,292.43,,,292.43,Other,100% of Medicaid,292.43,,,292.43,Other,100% of Medicaid,657.97,,,657.97,Other,225% of Medicaid,447.42,,,447.42,Other,153% of Medicaid,657.97,,,657.97,Other,225% of Medicaid,409.4,,,409.4,Other,140% of Medicaid,657.97,,,657.97,Other,225% of Medicaid,760.32,,,760.32,Other,260% of Medicaid,947.48,,,947.48,Other,324% of Medicaid,628.73,,,628.73,Other,215% of Medicaid,628.73,,,628.73,Other,215% of Medicaid,365.54,,,365.54,Other,125% of Medicaid,0.01,947.48,
FLUOROGUIDE FOR SPINE INJECT,77003,CPT,,47077003,CDM,320,RC,,,both,,,618,457.32,,,457.32,Other,150% of Medicare + 9.63% HCRA Surcharge,278.1,45,,278.1,percent of total billed charges,Critical Access Hospital RCC factor,267.03,,,267.03,Fee Schedule,,240.25,,,240.25,Fee Schedule,,222.08,,,222.08,Fee Schedule,,199.74,,,199.74,Fee Schedule,,188.79,,,188.79,Fee Schedule,,305.91,,,305.91,Other,110% of Medicare,317.26,,,317.26,Fee Schedule,,544,,,544,Other,186% of Medicaid,373.35,,,373.35,Fee Schedule,,383.16,,,383.16,Fee Schedule,,175.79,,,175.79,Fee Schedule,,373.35,,,373.35,Fee Schedule,,383.16,,,383.16,Fee Schedule,,330.65,,,330.65,Fee Schedule,,432.6,70,,432.6,percent of total billed charges,All Other,378.84,,,378.84,Fee Schedule,,321.09,,,321.09,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,292.43,,,292.43,Other,100% of Medicaid,292.43,,,292.43,Other,100% of Medicaid,292.43,,,292.43,Other,100% of Medicaid,292.43,,,292.43,Other,100% of Medicaid,657.97,,,657.97,Other,225% of Medicaid,447.42,,,447.42,Other,153% of Medicaid,657.97,,,657.97,Other,225% of Medicaid,409.4,,,409.4,Other,140% of Medicaid,657.97,,,657.97,Other,225% of Medicaid,760.32,,,760.32,Other,260% of Medicaid,947.48,,,947.48,Other,324% of Medicaid,628.73,,,628.73,Other,215% of Medicaid,628.73,,,628.73,Other,215% of Medicaid,365.54,,,365.54,Other,125% of Medicaid,0.01,947.48,
INTRVASC US NONCORONARY 1ST,37252,CPT,,47437230,CDM,320,RC,,,both,,,1082,800.68,,,800.68,Other,150% of Medicare + 9.63% HCRA Surcharge,486.9,45,,486.9,percent of total billed charges,Critical Access Hospital RCC factor,293.89,,,293.89,Fee Schedule,,264.41,,,264.41,Fee Schedule,,827.73,76.5,,827.73,percent of total billed charges,All Other,768.22,69,,768.22,percent of total billed charges,All Other,746.58,65,,746.58,percent of total billed charges,All Other,535.59,,,535.59,Other,110% of Medicare,349.17,,,349.17,Fee Schedule,,3003,,,3003,Other,186% of Medicaid,410.9,,,410.9,Fee Schedule,,670.84,,,670.84,Fee Schedule,,193.47,,,193.47,Fee Schedule,,410.9,,,410.9,Fee Schedule,,670.84,,,670.84,Fee Schedule,,363.91,,,363.91,Fee Schedule,,757.4,70,,757.4,percent of total billed charges,All Other,424.76,,,424.76,Fee Schedule,,360.01,,,360.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,1614.25,,,1614.25,Other,100% of Medicaid,1614.25,,,1614.25,Other,100% of Medicaid,1614.25,,,1614.25,Other,100% of Medicaid,1614.25,,,1614.25,Other,100% of Medicaid,3632.06,,,3632.06,Other,225% of Medicaid,2469.8,,,2469.8,Other,153% of Medicaid,3632.06,,,3632.06,Other,225% of Medicaid,2259.95,,,2259.95,Other,140% of Medicaid,3632.06,,,3632.06,Other,225% of Medicaid,4197.05,,,4197.05,Other,260% of Medicaid,5230.17,,,5230.17,Other,324% of Medicaid,3470.64,,,3470.64,Other,215% of Medicaid,3470.64,,,3470.64,Other,215% of Medicaid,2017.81,,,2017.81,Other,125% of Medicaid,0.01,5230.17,
INTRVASC US NONCORONARY ADDL,37253,CPT,,47437231,CDM,320,RC,,,both,,,993,734.82,,,734.82,Other,150% of Medicare + 9.63% HCRA Surcharge,446.85,45,,446.85,percent of total billed charges,Critical Access Hospital RCC factor,233.57,,,233.57,Fee Schedule,,210.14,,,210.14,Fee Schedule,,759.65,76.5,,759.65,percent of total billed charges,All Other,705.03,69,,705.03,percent of total billed charges,All Other,685.17,65,,685.17,percent of total billed charges,All Other,491.54,,,491.54,Other,110% of Medicare,277.5,,,277.5,Fee Schedule,,3003,,,3003,Other,186% of Medicaid,326.56,,,326.56,Fee Schedule,,615.66,,,615.66,Fee Schedule,,153.76,,,153.76,Fee Schedule,,326.56,,,326.56,Fee Schedule,,615.66,,,615.66,Fee Schedule,,289.22,,,289.22,Fee Schedule,,695.1,70,,695.1,percent of total billed charges,All Other,336.2,,,336.2,Fee Schedule,,284.95,,,284.95,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,1614.25,,,1614.25,Other,100% of Medicaid,1614.25,,,1614.25,Other,100% of Medicaid,1614.25,,,1614.25,Other,100% of Medicaid,1614.25,,,1614.25,Other,100% of Medicaid,3632.06,,,3632.06,Other,225% of Medicaid,2469.8,,,2469.8,Other,153% of Medicaid,3632.06,,,3632.06,Other,225% of Medicaid,2259.95,,,2259.95,Other,140% of Medicaid,3632.06,,,3632.06,Other,225% of Medicaid,4197.05,,,4197.05,Other,260% of Medicaid,5230.17,,,5230.17,Other,324% of Medicaid,3470.64,,,3470.64,Other,215% of Medicaid,3470.64,,,3470.64,Other,215% of Medicaid,2017.81,,,2017.81,Other,125% of Medicaid,0.01,5230.17,
UNILATERAL VENOGRAM,75820,CPT,TC,49075820,CDM,320,RC,,,both,,,3649,2700.27,,,2700.27,Other,150% of Medicare + 9.63% HCRA Surcharge,1642.05,45,,1642.05,percent of total billed charges,Critical Access Hospital RCC factor,205.82,,,205.82,Fee Schedule,,185.17,,,185.17,Fee Schedule,,611.11,,,611.11,Fee Schedule,,549.65,,,549.65,Fee Schedule,,519.5,,,519.5,Fee Schedule,,1806.26,,,1806.26,Other,110% of Medicare,244.53,,,244.53,Fee Schedule,,490,,,490,Other,186% of Medicaid,287.76,,,287.76,Fee Schedule,,2262.38,,,2262.38,Fee Schedule,,135.49,,,135.49,Fee Schedule,,287.76,,,287.76,Fee Schedule,,2262.38,,,2262.38,Fee Schedule,,254.85,,,254.85,Fee Schedule,,2554.3,70,,2554.3,percent of total billed charges,All Other,300.12,,,300.12,Fee Schedule,,254.37,,,254.37,Fee Schedule,,1008.82,,,1008.82,Fee Schedule,,1008.82,,,1008.82,Fee Schedule,,1008.82,,,1008.82,Fee Schedule,,1008.82,,,1008.82,Fee Schedule,,263.19,,,263.19,Other,100% of Medicaid,263.19,,,263.19,Other,100% of Medicaid,263.19,,,263.19,Other,100% of Medicaid,263.19,,,263.19,Other,100% of Medicaid,592.18,,,592.18,Other,225% of Medicaid,402.68,,,402.68,Other,153% of Medicaid,592.18,,,592.18,Other,225% of Medicaid,368.47,,,368.47,Other,140% of Medicaid,592.18,,,592.18,Other,225% of Medicaid,684.3,,,684.3,Other,260% of Medicaid,852.74,,,852.74,Other,324% of Medicaid,565.86,,,565.86,Other,215% of Medicaid,565.86,,,565.86,Other,215% of Medicaid,328.99,,,328.99,Other,125% of Medicaid,135.49,2700.27,
SINUS OR JUGL CATH VENOGRAM,75860,CPT,,49075860,CDM,320,RC,,,both,,,6707,4963.2,,,4963.2,Other,150% of Medicare + 9.63% HCRA Surcharge,3018.15,45,,3018.15,percent of total billed charges,Critical Access Hospital RCC factor,253.35,,,253.35,Fee Schedule,,227.94,,,227.94,Fee Schedule,,1045.88,,,1045.88,Fee Schedule,,940.7,,,940.7,Fee Schedule,,889.1,,,889.1,Fee Schedule,,3319.97,,,3319.97,Other,110% of Medicare,301,,,301,Fee Schedule,,544,,,544,Other,186% of Medicaid,354.21,,,354.21,Fee Schedule,,4158.34,,,4158.34,Fee Schedule,,166.78,,,166.78,Fee Schedule,,354.21,,,354.21,Fee Schedule,,4158.34,,,4158.34,Fee Schedule,,313.71,,,313.71,Fee Schedule,,4694.9,70,,4694.9,percent of total billed charges,All Other,357.52,,,357.52,Fee Schedule,,303.02,,,303.02,Fee Schedule,,4434.05,,,4434.05,Fee Schedule,,4434.05,,,4434.05,Fee Schedule,,4434.05,,,4434.05,Fee Schedule,,4434.05,,,4434.05,Fee Schedule,,292.43,,,292.43,Other,100% of Medicaid,292.43,,,292.43,Other,100% of Medicaid,292.43,,,292.43,Other,100% of Medicaid,292.43,,,292.43,Other,100% of Medicaid,657.98,,,657.98,Other,225% of Medicaid,447.42,,,447.42,Other,153% of Medicaid,657.98,,,657.98,Other,225% of Medicaid,409.41,,,409.41,Other,140% of Medicaid,657.98,,,657.98,Other,225% of Medicaid,760.33,,,760.33,Other,260% of Medicaid,947.49,,,947.49,Other,324% of Medicaid,628.73,,,628.73,Other,215% of Medicaid,628.73,,,628.73,Other,215% of Medicaid,365.54,,,365.54,Other,125% of Medicaid,166.78,4963.2,
CINE/VIDEO X-RAYS,76120,CPT,,49176120,CDM,320,RC,,,both,,,399,295.26,,,295.26,Other,150% of Medicare + 9.63% HCRA Surcharge,179.55,45,,179.55,percent of total billed charges,Critical Access Hospital RCC factor,343.28,,,343.28,Fee Schedule,,308.84,,,308.84,Fee Schedule,,391.4,,,391.4,Fee Schedule,,352.04,,,352.04,Fee Schedule,,332.73,,,332.73,Fee Schedule,,197.51,,,197.51,Other,110% of Medicare,407.84,,,407.84,Fee Schedule,,53,,,53,Other,186% of Medicaid,479.94,,,479.94,Fee Schedule,,247.38,,,247.38,Fee Schedule,,225.98,,,225.98,Fee Schedule,,479.94,,,479.94,Fee Schedule,,247.38,,,247.38,Fee Schedule,,425.06,,,425.06,Fee Schedule,,279.3,70,,279.3,percent of total billed charges,All Other,477.24,,,477.24,Fee Schedule,,404.49,,,404.49,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,479.94,
X-RAY BREAST SPECIMEN,76098,CPT,TC,54076098,CDM,320,RC,,,both,,,1844,1364.56,,,1364.56,Other,150% of Medicare + 9.63% HCRA Surcharge,829.8,45,,829.8,percent of total billed charges,Critical Access Hospital RCC factor,96.05,,,96.05,Fee Schedule,,86.42,,,86.42,Fee Schedule,,75.62,,,75.62,Fee Schedule,,68.02,,,68.02,Fee Schedule,,64.29,,,64.29,Fee Schedule,,912.78,,,912.78,Other,110% of Medicare,114.12,,,114.12,Fee Schedule,,392,,,392,Other,186% of Medicaid,134.29,,,134.29,Fee Schedule,,1143.28,,,1143.28,Fee Schedule,,63.23,,,63.23,Fee Schedule,,134.29,,,134.29,Fee Schedule,,1143.28,,,1143.28,Fee Schedule,,118.93,,,118.93,Fee Schedule,,1290.8,70,,1290.8,percent of total billed charges,All Other,124.64,,,124.64,Fee Schedule,,105.64,,,105.64,Fee Schedule,,770.53,,,770.53,Fee Schedule,,770.53,,,770.53,Fee Schedule,,770.53,,,770.53,Fee Schedule,,770.53,,,770.53,Fee Schedule,,210.57,,,210.57,Other,100% of Medicaid,210.57,,,210.57,Other,100% of Medicaid,210.57,,,210.57,Other,100% of Medicaid,210.57,,,210.57,Other,100% of Medicaid,473.77,,,473.77,Other,225% of Medicaid,322.17,,,322.17,Other,153% of Medicaid,473.77,,,473.77,Other,225% of Medicaid,294.79,,,294.79,Other,140% of Medicaid,473.77,,,473.77,Other,225% of Medicaid,547.47,,,547.47,Other,260% of Medicaid,682.23,,,682.23,Other,324% of Medicaid,452.72,,,452.72,Other,215% of Medicaid,452.72,,,452.72,Other,215% of Medicaid,263.21,,,263.21,Other,125% of Medicaid,63.23,1364.56,
X-RAY OF MAMMARY DUCT,77053,CPT,TC,54077053,CDM,320,RC,,,both,,,894,661.56,,,661.56,Other,150% of Medicare + 9.63% HCRA Surcharge,402.3,45,,402.3,percent of total billed charges,Critical Access Hospital RCC factor,128.4,,,128.4,Fee Schedule,,115.52,,,115.52,Fee Schedule,,338.76,,,338.76,Fee Schedule,,304.69,,,304.69,Fee Schedule,,287.97,,,287.97,Fee Schedule,,442.53,,,442.53,Other,110% of Medicare,152.55,,,152.55,Fee Schedule,,392,,,392,Other,186% of Medicaid,179.52,,,179.52,Fee Schedule,,554.28,,,554.28,Fee Schedule,,84.53,,,84.53,Fee Schedule,,179.52,,,179.52,Fee Schedule,,554.28,,,554.28,Fee Schedule,,158.99,,,158.99,Fee Schedule,,625.8,70,,625.8,percent of total billed charges,All Other,177.12,,,177.12,Fee Schedule,,150.12,,,150.12,Fee Schedule,,372.86,,,372.86,Fee Schedule,,372.86,,,372.86,Fee Schedule,,372.86,,,372.86,Fee Schedule,,372.86,,,372.86,Fee Schedule,,210.57,,,210.57,Other,100% of Medicaid,210.57,,,210.57,Other,100% of Medicaid,210.57,,,210.57,Other,100% of Medicaid,210.57,,,210.57,Other,100% of Medicaid,473.77,,,473.77,Other,225% of Medicaid,322.17,,,322.17,Other,153% of Medicaid,473.77,,,473.77,Other,225% of Medicaid,294.79,,,294.79,Other,140% of Medicaid,473.77,,,473.77,Other,225% of Medicaid,547.47,,,547.47,Other,260% of Medicaid,682.23,,,682.23,Other,324% of Medicaid,452.72,,,452.72,Other,215% of Medicaid,452.72,,,452.72,Other,215% of Medicaid,263.21,,,263.21,Other,125% of Medicaid,84.53,682.23,
X-RAY OF MAMMARY DUCTS,77054,CPT,TC,54077054,CDM,320,RC,,,both,,,1120,828.8,,,828.8,Other,150% of Medicare + 9.63% HCRA Surcharge,504,45,,504,percent of total billed charges,Critical Access Hospital RCC factor,167.7,,,167.7,Fee Schedule,,150.88,,,150.88,Fee Schedule,,466.92,,,466.92,Fee Schedule,,419.96,,,419.96,Fee Schedule,,396.93,,,396.93,Fee Schedule,,554.4,,,554.4,Other,110% of Medicare,199.24,,,199.24,Fee Schedule,,392,,,392,Other,186% of Medicaid,234.46,,,234.46,Fee Schedule,,694.4,,,694.4,Fee Schedule,,110.4,,,110.4,Fee Schedule,,234.46,,,234.46,Fee Schedule,,694.4,,,694.4,Fee Schedule,,207.65,,,207.65,Fee Schedule,,784,70,,784,percent of total billed charges,All Other,232.88,,,232.88,Fee Schedule,,197.38,,,197.38,Fee Schedule,,372.86,,,372.86,Fee Schedule,,372.86,,,372.86,Fee Schedule,,372.86,,,372.86,Fee Schedule,,372.86,,,372.86,Fee Schedule,,210.57,,,210.57,Other,100% of Medicaid,210.57,,,210.57,Other,100% of Medicaid,210.57,,,210.57,Other,100% of Medicaid,210.57,,,210.57,Other,100% of Medicaid,473.77,,,473.77,Other,225% of Medicaid,322.17,,,322.17,Other,153% of Medicaid,473.77,,,473.77,Other,225% of Medicaid,294.79,,,294.79,Other,140% of Medicaid,473.77,,,473.77,Other,225% of Medicaid,547.47,,,547.47,Other,260% of Medicaid,682.23,,,682.23,Other,324% of Medicaid,452.72,,,452.72,Other,215% of Medicaid,452.72,,,452.72,Other,215% of Medicaid,263.21,,,263.21,Other,125% of Medicaid,110.4,828.8,
BONE DENSITY STUDY DEXA,77080,CPT,TC,54077080,CDM,320,RC,,,both,,,683,505.42,,,505.42,Other,150% of Medicare + 9.63% HCRA Surcharge,307.35,45,,307.35,percent of total billed charges,Critical Access Hospital RCC factor,102.97,,,102.97,Fee Schedule,,92.64,,,92.64,Fee Schedule,,584.86,,,584.86,Fee Schedule,,526.05,,,526.05,Fee Schedule,,497.19,,,497.19,Fee Schedule,,338.09,,,338.09,Other,110% of Medicare,122.34,,,122.34,Fee Schedule,,253,,,253,Other,186% of Medicaid,143.97,,,143.97,Fee Schedule,,423.46,,,423.46,Fee Schedule,,67.79,,,67.79,Fee Schedule,,143.97,,,143.97,Fee Schedule,,423.46,,,423.46,Fee Schedule,,127.51,,,127.51,Fee Schedule,,478.1,70,,478.1,percent of total billed charges,All Other,134.48,,,134.48,Fee Schedule,,113.98,,,113.98,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,135.83,,,135.83,Other,100% of Medicaid,135.83,,,135.83,Other,100% of Medicaid,135.83,,,135.83,Other,100% of Medicaid,135.83,,,135.83,Other,100% of Medicaid,305.62,,,305.62,Other,225% of Medicaid,207.82,,,207.82,Other,153% of Medicaid,305.62,,,305.62,Other,225% of Medicaid,190.17,,,190.17,Other,140% of Medicaid,305.62,,,305.62,Other,225% of Medicaid,353.16,,,353.16,Other,260% of Medicaid,440.1,,,440.1,Other,324% of Medicaid,292.04,,,292.04,Other,215% of Medicaid,292.04,,,292.04,Other,215% of Medicaid,169.79,,,169.79,Other,125% of Medicaid,67.79,584.86,
BONE DENSITY PERIPHERAL,77081,CPT,TC,54077081,CDM,320,RC,,,both,,,1041,770.34,,,770.34,Other,150% of Medicare + 9.63% HCRA Surcharge,468.45,45,,468.45,percent of total billed charges,Critical Access Hospital RCC factor,77.58,,,77.58,Fee Schedule,,69.8,,,69.8,Fee Schedule,,128.27,,,128.27,Fee Schedule,,115.37,,,115.37,Fee Schedule,,109.04,,,109.04,Fee Schedule,,515.3,,,515.3,Other,110% of Medicare,92.17,,,92.17,Fee Schedule,,253,,,253,Other,186% of Medicaid,108.47,,,108.47,Fee Schedule,,645.42,,,645.42,Fee Schedule,,51.07,,,51.07,Fee Schedule,,108.47,,,108.47,Fee Schedule,,645.42,,,645.42,Fee Schedule,,96.06,,,96.06,Fee Schedule,,728.7,70,,728.7,percent of total billed charges,All Other,103.32,,,103.32,Fee Schedule,,87.57,,,87.57,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,135.83,,,135.83,Other,100% of Medicaid,135.83,,,135.83,Other,100% of Medicaid,135.83,,,135.83,Other,100% of Medicaid,135.83,,,135.83,Other,100% of Medicaid,305.62,,,305.62,Other,225% of Medicaid,207.82,,,207.82,Other,153% of Medicaid,305.62,,,305.62,Other,225% of Medicaid,190.17,,,190.17,Other,140% of Medicaid,305.62,,,305.62,Other,225% of Medicaid,353.16,,,353.16,Other,260% of Medicaid,440.1,,,440.1,Other,324% of Medicaid,292.04,,,292.04,Other,215% of Medicaid,292.04,,,292.04,Other,215% of Medicaid,169.79,,,169.79,Other,125% of Medicaid,51.07,770.34,
XR SURGICAL SPECIMEN LT,76098,CPT,TCLT,54176098,CDM,320,RC,,,both,,,1844,1364.56,,,1364.56,Other,150% of Medicare + 9.63% HCRA Surcharge,829.8,45,,829.8,percent of total billed charges,Critical Access Hospital RCC factor,96.05,,,96.05,Fee Schedule,,86.42,,,86.42,Fee Schedule,,75.62,,,75.62,Fee Schedule,,68.02,,,68.02,Fee Schedule,,64.29,,,64.29,Fee Schedule,,912.78,,,912.78,Other,110% of Medicare,114.12,,,114.12,Fee Schedule,,392,,,392,Other,186% of Medicaid,134.29,,,134.29,Fee Schedule,,1143.28,,,1143.28,Fee Schedule,,63.23,,,63.23,Fee Schedule,,134.29,,,134.29,Fee Schedule,,1143.28,,,1143.28,Fee Schedule,,118.93,,,118.93,Fee Schedule,,1290.8,70,,1290.8,percent of total billed charges,All Other,124.64,,,124.64,Fee Schedule,,105.64,,,105.64,Fee Schedule,,770.53,,,770.53,Fee Schedule,,770.53,,,770.53,Fee Schedule,,770.53,,,770.53,Fee Schedule,,770.53,,,770.53,Fee Schedule,,210.57,,,210.57,Other,100% of Medicaid,210.57,,,210.57,Other,100% of Medicaid,210.57,,,210.57,Other,100% of Medicaid,210.57,,,210.57,Other,100% of Medicaid,473.77,,,473.77,Other,225% of Medicaid,322.17,,,322.17,Other,153% of Medicaid,473.77,,,473.77,Other,225% of Medicaid,294.79,,,294.79,Other,140% of Medicaid,473.77,,,473.77,Other,225% of Medicaid,547.47,,,547.47,Other,260% of Medicaid,682.23,,,682.23,Other,324% of Medicaid,452.72,,,452.72,Other,215% of Medicaid,452.72,,,452.72,Other,215% of Medicaid,263.21,,,263.21,Other,125% of Medicaid,63.23,1364.56,
XR SURGICAL SPECIMEN RT,76098,CPT,TCRT,54276098,CDM,320,RC,,,both,,,1844,1364.56,,,1364.56,Other,150% of Medicare + 9.63% HCRA Surcharge,829.8,45,,829.8,percent of total billed charges,Critical Access Hospital RCC factor,96.05,,,96.05,Fee Schedule,,86.42,,,86.42,Fee Schedule,,75.62,,,75.62,Fee Schedule,,68.02,,,68.02,Fee Schedule,,64.29,,,64.29,Fee Schedule,,912.78,,,912.78,Other,110% of Medicare,114.12,,,114.12,Fee Schedule,,392,,,392,Other,186% of Medicaid,134.29,,,134.29,Fee Schedule,,1143.28,,,1143.28,Fee Schedule,,63.23,,,63.23,Fee Schedule,,134.29,,,134.29,Fee Schedule,,1143.28,,,1143.28,Fee Schedule,,118.93,,,118.93,Fee Schedule,,1290.8,70,,1290.8,percent of total billed charges,All Other,124.64,,,124.64,Fee Schedule,,105.64,,,105.64,Fee Schedule,,770.53,,,770.53,Fee Schedule,,770.53,,,770.53,Fee Schedule,,770.53,,,770.53,Fee Schedule,,770.53,,,770.53,Fee Schedule,,210.57,,,210.57,Other,100% of Medicaid,210.57,,,210.57,Other,100% of Medicaid,210.57,,,210.57,Other,100% of Medicaid,210.57,,,210.57,Other,100% of Medicaid,473.77,,,473.77,Other,225% of Medicaid,322.17,,,322.17,Other,153% of Medicaid,473.77,,,473.77,Other,225% of Medicaid,294.79,,,294.79,Other,140% of Medicaid,473.77,,,473.77,Other,225% of Medicaid,547.47,,,547.47,Other,260% of Medicaid,682.23,,,682.23,Other,324% of Medicaid,452.72,,,452.72,Other,215% of Medicaid,452.72,,,452.72,Other,215% of Medicaid,263.21,,,263.21,Other,125% of Medicaid,63.23,1364.56,
TMJ JOINT ARTHROGRAPHY,70332,CPT,TC,42070332,CDM,322,RC,,,both,,,527,389.98,,,389.98,Other,150% of Medicare + 9.63% HCRA Surcharge,237.15,45,,237.15,percent of total billed charges,Critical Access Hospital RCC factor,198.86,,,198.86,Fee Schedule,,178.92,,,178.92,Fee Schedule,,386.82,,,386.82,Fee Schedule,,347.92,,,347.92,Fee Schedule,,328.83,,,328.83,Fee Schedule,,260.87,,,260.87,Other,110% of Medicare,236.27,,,236.27,Fee Schedule,,392,,,392,Other,186% of Medicaid,278.04,,,278.04,Fee Schedule,,326.74,,,326.74,Fee Schedule,,130.91,,,130.91,Fee Schedule,,278.04,,,278.04,Fee Schedule,,326.74,,,326.74,Fee Schedule,,246.24,,,246.24,Fee Schedule,,368.9,70,,368.9,percent of total billed charges,All Other,295.2,,,295.2,Fee Schedule,,250.2,,,250.2,Fee Schedule,,372.86,,,372.86,Fee Schedule,,372.86,,,372.86,Fee Schedule,,372.86,,,372.86,Fee Schedule,,372.86,,,372.86,Fee Schedule,,210.57,,,210.57,Other,100% of Medicaid,210.57,,,210.57,Other,100% of Medicaid,210.57,,,210.57,Other,100% of Medicaid,210.57,,,210.57,Other,100% of Medicaid,473.77,,,473.77,Other,225% of Medicaid,322.17,,,322.17,Other,153% of Medicaid,473.77,,,473.77,Other,225% of Medicaid,294.79,,,294.79,Other,140% of Medicaid,473.77,,,473.77,Other,225% of Medicaid,547.47,,,547.47,Other,260% of Medicaid,682.23,,,682.23,Other,324% of Medicaid,452.72,,,452.72,Other,215% of Medicaid,452.72,,,452.72,Other,215% of Medicaid,263.21,,,263.21,Other,125% of Medicaid,130.91,682.23,
XR SHOULDER ARTHROGRAM LT,73040,CPT,TCLT,42173040,CDM,322,RC,,,both,,,1307,967.18,,,967.18,Other,150% of Medicare + 9.63% HCRA Surcharge,588.15,45,,588.15,percent of total billed charges,Critical Access Hospital RCC factor,365.22,,,365.22,Fee Schedule,,328.59,,,328.59,Fee Schedule,,544.71,,,544.71,Fee Schedule,,489.93,,,489.93,Fee Schedule,,463.05,,,463.05,Fee Schedule,,646.97,,,646.97,Other,110% of Medicare,433.92,,,433.92,Fee Schedule,,392,,,392,Other,186% of Medicaid,510.63,,,510.63,Fee Schedule,,810.34,,,810.34,Fee Schedule,,240.43,,,240.43,Fee Schedule,,510.63,,,510.63,Fee Schedule,,810.34,,,810.34,Fee Schedule,,452.24,,,452.24,Fee Schedule,,914.9,70,,914.9,percent of total billed charges,All Other,521.52,,,521.52,Fee Schedule,,442.02,,,442.02,Fee Schedule,,610.96,,,610.96,Fee Schedule,,610.96,,,610.96,Fee Schedule,,610.96,,,610.96,Fee Schedule,,610.96,,,610.96,Fee Schedule,,210.57,,,210.57,Other,100% of Medicaid,210.57,,,210.57,Other,100% of Medicaid,210.57,,,210.57,Other,100% of Medicaid,210.57,,,210.57,Other,100% of Medicaid,473.77,,,473.77,Other,225% of Medicaid,322.17,,,322.17,Other,153% of Medicaid,473.77,,,473.77,Other,225% of Medicaid,294.79,,,294.79,Other,140% of Medicaid,473.77,,,473.77,Other,225% of Medicaid,547.47,,,547.47,Other,260% of Medicaid,682.23,,,682.23,Other,324% of Medicaid,452.72,,,452.72,Other,215% of Medicaid,452.72,,,452.72,Other,215% of Medicaid,263.21,,,263.21,Other,125% of Medicaid,210.57,967.18,
XR ARTHROGRAM WRIST LT,73115,CPT,TCLT,42173115,CDM,322,RC,,,both,,,1199,887.26,,,887.26,Other,150% of Medicare + 9.63% HCRA Surcharge,539.55,45,,539.55,percent of total billed charges,Critical Access Hospital RCC factor,375.62,,,375.62,Fee Schedule,,337.94,,,337.94,Fee Schedule,,549.29,,,549.29,Fee Schedule,,494.05,,,494.05,Fee Schedule,,466.95,,,466.95,Fee Schedule,,593.51,,,593.51,Other,110% of Medicare,446.27,,,446.27,Fee Schedule,,392,,,392,Other,186% of Medicaid,525.17,,,525.17,Fee Schedule,,743.38,,,743.38,Fee Schedule,,247.28,,,247.28,Fee Schedule,,525.17,,,525.17,Fee Schedule,,743.38,,,743.38,Fee Schedule,,465.11,,,465.11,Fee Schedule,,839.3,70,,839.3,percent of total billed charges,All Other,544.48,,,544.48,Fee Schedule,,461.48,,,461.48,Fee Schedule,,610.96,,,610.96,Fee Schedule,,610.96,,,610.96,Fee Schedule,,610.96,,,610.96,Fee Schedule,,610.96,,,610.96,Fee Schedule,,210.57,,,210.57,Other,100% of Medicaid,210.57,,,210.57,Other,100% of Medicaid,210.57,,,210.57,Other,100% of Medicaid,210.57,,,210.57,Other,100% of Medicaid,473.77,,,473.77,Other,225% of Medicaid,322.17,,,322.17,Other,153% of Medicaid,473.77,,,473.77,Other,225% of Medicaid,294.79,,,294.79,Other,140% of Medicaid,473.77,,,473.77,Other,225% of Medicaid,547.47,,,547.47,Other,260% of Medicaid,682.23,,,682.23,Other,324% of Medicaid,452.72,,,452.72,Other,215% of Medicaid,452.72,,,452.72,Other,215% of Medicaid,263.21,,,263.21,Other,125% of Medicaid,210.57,887.26,
XR ARTHROGRAM HIP LT,73525,CPT,TCLT,42173525,CDM,322,RC,,,both,,,1199,887.26,,,887.26,Other,150% of Medicare + 9.63% HCRA Surcharge,539.55,45,,539.55,percent of total billed charges,Critical Access Hospital RCC factor,350.23,,,350.23,Fee Schedule,,315.1,,,315.1,Fee Schedule,,489.79,,,489.79,Fee Schedule,,440.54,,,440.54,Fee Schedule,,416.37,,,416.37,Fee Schedule,,593.51,,,593.51,Other,110% of Medicare,416.1,,,416.1,Fee Schedule,,392,,,392,Other,186% of Medicaid,489.66,,,489.66,Fee Schedule,,743.38,,,743.38,Fee Schedule,,230.56,,,230.56,Fee Schedule,,489.66,,,489.66,Fee Schedule,,743.38,,,743.38,Fee Schedule,,433.67,,,433.67,Fee Schedule,,839.3,70,,839.3,percent of total billed charges,All Other,526.44,,,526.44,Fee Schedule,,446.19,,,446.19,Fee Schedule,,610.96,,,610.96,Fee Schedule,,610.96,,,610.96,Fee Schedule,,610.96,,,610.96,Fee Schedule,,610.96,,,610.96,Fee Schedule,,210.57,,,210.57,Other,100% of Medicaid,210.57,,,210.57,Other,100% of Medicaid,210.57,,,210.57,Other,100% of Medicaid,210.57,,,210.57,Other,100% of Medicaid,473.77,,,473.77,Other,225% of Medicaid,322.17,,,322.17,Other,153% of Medicaid,473.77,,,473.77,Other,225% of Medicaid,294.79,,,294.79,Other,140% of Medicaid,473.77,,,473.77,Other,225% of Medicaid,547.47,,,547.47,Other,260% of Medicaid,682.23,,,682.23,Other,324% of Medicaid,452.72,,,452.72,Other,215% of Medicaid,452.72,,,452.72,Other,215% of Medicaid,263.21,,,263.21,Other,125% of Medicaid,210.57,887.26,
ARTHROGRAM KNEE LT,73580,CPT,TCLT,42173580,CDM,322,RC,,,both,,,1199,887.26,,,887.26,Other,150% of Medicare + 9.63% HCRA Surcharge,539.55,45,,539.55,percent of total billed charges,Critical Access Hospital RCC factor,278.58,,,278.58,Fee Schedule,,250.64,,,250.64,Fee Schedule,,695.75,,,695.75,Fee Schedule,,625.77,,,625.77,Fee Schedule,,591.45,,,591.45,Fee Schedule,,593.51,,,593.51,Other,110% of Medicare,330.98,,,330.98,Fee Schedule,,392,,,392,Other,186% of Medicaid,389.49,,,389.49,Fee Schedule,,743.38,,,743.38,Fee Schedule,,183.39,,,183.39,Fee Schedule,,389.49,,,389.49,Fee Schedule,,743.38,,,743.38,Fee Schedule,,344.95,,,344.95,Fee Schedule,,839.3,70,,839.3,percent of total billed charges,All Other,595.32,,,595.32,Fee Schedule,,504.57,,,504.57,Fee Schedule,,610.96,,,610.96,Fee Schedule,,610.96,,,610.96,Fee Schedule,,610.96,,,610.96,Fee Schedule,,610.96,,,610.96,Fee Schedule,,210.57,,,210.57,Other,100% of Medicaid,210.57,,,210.57,Other,100% of Medicaid,210.57,,,210.57,Other,100% of Medicaid,210.57,,,210.57,Other,100% of Medicaid,473.77,,,473.77,Other,225% of Medicaid,322.17,,,322.17,Other,153% of Medicaid,473.77,,,473.77,Other,225% of Medicaid,294.79,,,294.79,Other,140% of Medicaid,473.77,,,473.77,Other,225% of Medicaid,547.47,,,547.47,Other,260% of Medicaid,682.23,,,682.23,Other,324% of Medicaid,452.72,,,452.72,Other,215% of Medicaid,452.72,,,452.72,Other,215% of Medicaid,263.21,,,263.21,Other,125% of Medicaid,183.39,887.26,
XR SHOULDER ARTHROGRAM RT,73040,CPT,TCRT,42273040,CDM,322,RC,,,both,,,1307,967.18,,,967.18,Other,150% of Medicare + 9.63% HCRA Surcharge,588.15,45,,588.15,percent of total billed charges,Critical Access Hospital RCC factor,365.22,,,365.22,Fee Schedule,,328.59,,,328.59,Fee Schedule,,544.71,,,544.71,Fee Schedule,,489.93,,,489.93,Fee Schedule,,463.05,,,463.05,Fee Schedule,,646.97,,,646.97,Other,110% of Medicare,433.92,,,433.92,Fee Schedule,,392,,,392,Other,186% of Medicaid,510.63,,,510.63,Fee Schedule,,810.34,,,810.34,Fee Schedule,,240.43,,,240.43,Fee Schedule,,510.63,,,510.63,Fee Schedule,,810.34,,,810.34,Fee Schedule,,452.24,,,452.24,Fee Schedule,,914.9,70,,914.9,percent of total billed charges,All Other,521.52,,,521.52,Fee Schedule,,442.02,,,442.02,Fee Schedule,,610.96,,,610.96,Fee Schedule,,610.96,,,610.96,Fee Schedule,,610.96,,,610.96,Fee Schedule,,610.96,,,610.96,Fee Schedule,,210.57,,,210.57,Other,100% of Medicaid,210.57,,,210.57,Other,100% of Medicaid,210.57,,,210.57,Other,100% of Medicaid,210.57,,,210.57,Other,100% of Medicaid,473.77,,,473.77,Other,225% of Medicaid,322.17,,,322.17,Other,153% of Medicaid,473.77,,,473.77,Other,225% of Medicaid,294.79,,,294.79,Other,140% of Medicaid,473.77,,,473.77,Other,225% of Medicaid,547.47,,,547.47,Other,260% of Medicaid,682.23,,,682.23,Other,324% of Medicaid,452.72,,,452.72,Other,215% of Medicaid,452.72,,,452.72,Other,215% of Medicaid,263.21,,,263.21,Other,125% of Medicaid,210.57,967.18,
XR ARTHROGRAM WRIST RT,73115,CPT,TCRT,42273115,CDM,322,RC,,,both,,,1199,887.26,,,887.26,Other,150% of Medicare + 9.63% HCRA Surcharge,539.55,45,,539.55,percent of total billed charges,Critical Access Hospital RCC factor,375.62,,,375.62,Fee Schedule,,337.94,,,337.94,Fee Schedule,,549.29,,,549.29,Fee Schedule,,494.05,,,494.05,Fee Schedule,,466.95,,,466.95,Fee Schedule,,593.51,,,593.51,Other,110% of Medicare,446.27,,,446.27,Fee Schedule,,392,,,392,Other,186% of Medicaid,525.17,,,525.17,Fee Schedule,,743.38,,,743.38,Fee Schedule,,247.28,,,247.28,Fee Schedule,,525.17,,,525.17,Fee Schedule,,743.38,,,743.38,Fee Schedule,,465.11,,,465.11,Fee Schedule,,839.3,70,,839.3,percent of total billed charges,All Other,544.48,,,544.48,Fee Schedule,,461.48,,,461.48,Fee Schedule,,610.96,,,610.96,Fee Schedule,,610.96,,,610.96,Fee Schedule,,610.96,,,610.96,Fee Schedule,,610.96,,,610.96,Fee Schedule,,210.57,,,210.57,Other,100% of Medicaid,210.57,,,210.57,Other,100% of Medicaid,210.57,,,210.57,Other,100% of Medicaid,210.57,,,210.57,Other,100% of Medicaid,473.77,,,473.77,Other,225% of Medicaid,322.17,,,322.17,Other,153% of Medicaid,473.77,,,473.77,Other,225% of Medicaid,294.79,,,294.79,Other,140% of Medicaid,473.77,,,473.77,Other,225% of Medicaid,547.47,,,547.47,Other,260% of Medicaid,682.23,,,682.23,Other,324% of Medicaid,452.72,,,452.72,Other,215% of Medicaid,452.72,,,452.72,Other,215% of Medicaid,263.21,,,263.21,Other,125% of Medicaid,210.57,887.26,
XR ARTHROGRAM HIP RT,73525,CPT,TCRT,42273525,CDM,322,RC,,,both,,,1199,887.26,,,887.26,Other,150% of Medicare + 9.63% HCRA Surcharge,539.55,45,,539.55,percent of total billed charges,Critical Access Hospital RCC factor,350.23,,,350.23,Fee Schedule,,315.1,,,315.1,Fee Schedule,,489.79,,,489.79,Fee Schedule,,440.54,,,440.54,Fee Schedule,,416.37,,,416.37,Fee Schedule,,593.51,,,593.51,Other,110% of Medicare,416.1,,,416.1,Fee Schedule,,392,,,392,Other,186% of Medicaid,489.66,,,489.66,Fee Schedule,,743.38,,,743.38,Fee Schedule,,230.56,,,230.56,Fee Schedule,,489.66,,,489.66,Fee Schedule,,743.38,,,743.38,Fee Schedule,,433.67,,,433.67,Fee Schedule,,839.3,70,,839.3,percent of total billed charges,All Other,526.44,,,526.44,Fee Schedule,,446.19,,,446.19,Fee Schedule,,610.96,,,610.96,Fee Schedule,,610.96,,,610.96,Fee Schedule,,610.96,,,610.96,Fee Schedule,,610.96,,,610.96,Fee Schedule,,210.57,,,210.57,Other,100% of Medicaid,210.57,,,210.57,Other,100% of Medicaid,210.57,,,210.57,Other,100% of Medicaid,210.57,,,210.57,Other,100% of Medicaid,473.77,,,473.77,Other,225% of Medicaid,322.17,,,322.17,Other,153% of Medicaid,473.77,,,473.77,Other,225% of Medicaid,294.79,,,294.79,Other,140% of Medicaid,473.77,,,473.77,Other,225% of Medicaid,547.47,,,547.47,Other,260% of Medicaid,682.23,,,682.23,Other,324% of Medicaid,452.72,,,452.72,Other,215% of Medicaid,452.72,,,452.72,Other,215% of Medicaid,263.21,,,263.21,Other,125% of Medicaid,210.57,887.26,
ARTHROGRAM KNEE RT,73580,CPT,TCRT,42273580,CDM,322,RC,,,both,,,1199,887.26,,,887.26,Other,150% of Medicare + 9.63% HCRA Surcharge,539.55,45,,539.55,percent of total billed charges,Critical Access Hospital RCC factor,278.58,,,278.58,Fee Schedule,,250.64,,,250.64,Fee Schedule,,695.75,,,695.75,Fee Schedule,,625.77,,,625.77,Fee Schedule,,591.45,,,591.45,Fee Schedule,,593.51,,,593.51,Other,110% of Medicare,330.98,,,330.98,Fee Schedule,,392,,,392,Other,186% of Medicaid,389.49,,,389.49,Fee Schedule,,743.38,,,743.38,Fee Schedule,,183.39,,,183.39,Fee Schedule,,389.49,,,389.49,Fee Schedule,,743.38,,,743.38,Fee Schedule,,344.95,,,344.95,Fee Schedule,,839.3,70,,839.3,percent of total billed charges,All Other,595.32,,,595.32,Fee Schedule,,504.57,,,504.57,Fee Schedule,,610.96,,,610.96,Fee Schedule,,610.96,,,610.96,Fee Schedule,,610.96,,,610.96,Fee Schedule,,610.96,,,610.96,Fee Schedule,,210.57,,,210.57,Other,100% of Medicaid,210.57,,,210.57,Other,100% of Medicaid,210.57,,,210.57,Other,100% of Medicaid,210.57,,,210.57,Other,100% of Medicaid,473.77,,,473.77,Other,225% of Medicaid,322.17,,,322.17,Other,153% of Medicaid,473.77,,,473.77,Other,225% of Medicaid,294.79,,,294.79,Other,140% of Medicaid,473.77,,,473.77,Other,225% of Medicaid,547.47,,,547.47,Other,260% of Medicaid,682.23,,,682.23,Other,324% of Medicaid,452.72,,,452.72,Other,215% of Medicaid,452.72,,,452.72,Other,215% of Medicaid,263.21,,,263.21,Other,125% of Medicaid,183.39,887.26,
XR SHOULDER ARTHROGRAM BILAT,73040,CPT,TC50,42373040,CDM,322,RC,,,both,,,1961,1451.14,,,1451.14,Other,150% of Medicare + 9.63% HCRA Surcharge,882.45,45,,882.45,percent of total billed charges,Critical Access Hospital RCC factor,365.22,,,365.22,Fee Schedule,,328.59,,,328.59,Fee Schedule,,544.71,,,544.71,Fee Schedule,,489.93,,,489.93,Fee Schedule,,463.05,,,463.05,Fee Schedule,,970.7,,,970.7,Other,110% of Medicare,433.92,,,433.92,Fee Schedule,,392,,,392,Other,186% of Medicaid,510.63,,,510.63,Fee Schedule,,1215.82,,,1215.82,Fee Schedule,,240.43,,,240.43,Fee Schedule,,510.63,,,510.63,Fee Schedule,,1215.82,,,1215.82,Fee Schedule,,452.24,,,452.24,Fee Schedule,,1372.7,70,,1372.7,percent of total billed charges,All Other,521.52,,,521.52,Fee Schedule,,442.02,,,442.02,Fee Schedule,,610.96,,,610.96,Fee Schedule,,610.96,,,610.96,Fee Schedule,,610.96,,,610.96,Fee Schedule,,610.96,,,610.96,Fee Schedule,,210.57,,,210.57,Other,100% of Medicaid,210.57,,,210.57,Other,100% of Medicaid,210.57,,,210.57,Other,100% of Medicaid,210.57,,,210.57,Other,100% of Medicaid,473.77,,,473.77,Other,225% of Medicaid,322.17,,,322.17,Other,153% of Medicaid,473.77,,,473.77,Other,225% of Medicaid,294.79,,,294.79,Other,140% of Medicaid,473.77,,,473.77,Other,225% of Medicaid,547.47,,,547.47,Other,260% of Medicaid,682.23,,,682.23,Other,324% of Medicaid,452.72,,,452.72,Other,215% of Medicaid,452.72,,,452.72,Other,215% of Medicaid,263.21,,,263.21,Other,125% of Medicaid,210.57,1451.14,
XR ARTHROGRAM WRIST BILAT,73115,CPT,TC50,42373115,CDM,322,RC,,,both,,,1799,1331.26,,,1331.26,Other,150% of Medicare + 9.63% HCRA Surcharge,809.55,45,,809.55,percent of total billed charges,Critical Access Hospital RCC factor,375.62,,,375.62,Fee Schedule,,337.94,,,337.94,Fee Schedule,,549.29,,,549.29,Fee Schedule,,494.05,,,494.05,Fee Schedule,,466.95,,,466.95,Fee Schedule,,890.51,,,890.51,Other,110% of Medicare,446.27,,,446.27,Fee Schedule,,392,,,392,Other,186% of Medicaid,525.17,,,525.17,Fee Schedule,,1115.38,,,1115.38,Fee Schedule,,247.28,,,247.28,Fee Schedule,,525.17,,,525.17,Fee Schedule,,1115.38,,,1115.38,Fee Schedule,,465.11,,,465.11,Fee Schedule,,1259.3,70,,1259.3,percent of total billed charges,All Other,544.48,,,544.48,Fee Schedule,,461.48,,,461.48,Fee Schedule,,610.96,,,610.96,Fee Schedule,,610.96,,,610.96,Fee Schedule,,610.96,,,610.96,Fee Schedule,,610.96,,,610.96,Fee Schedule,,210.57,,,210.57,Other,100% of Medicaid,210.57,,,210.57,Other,100% of Medicaid,210.57,,,210.57,Other,100% of Medicaid,210.57,,,210.57,Other,100% of Medicaid,473.77,,,473.77,Other,225% of Medicaid,322.17,,,322.17,Other,153% of Medicaid,473.77,,,473.77,Other,225% of Medicaid,294.79,,,294.79,Other,140% of Medicaid,473.77,,,473.77,Other,225% of Medicaid,547.47,,,547.47,Other,260% of Medicaid,682.23,,,682.23,Other,324% of Medicaid,452.72,,,452.72,Other,215% of Medicaid,452.72,,,452.72,Other,215% of Medicaid,263.21,,,263.21,Other,125% of Medicaid,210.57,1331.26,
XR ARTHROGRAM HIP BILAT,73525,CPT,TC50,42373525,CDM,322,RC,,,both,,,1799,1331.26,,,1331.26,Other,150% of Medicare + 9.63% HCRA Surcharge,809.55,45,,809.55,percent of total billed charges,Critical Access Hospital RCC factor,350.23,,,350.23,Fee Schedule,,315.1,,,315.1,Fee Schedule,,489.79,,,489.79,Fee Schedule,,440.54,,,440.54,Fee Schedule,,416.37,,,416.37,Fee Schedule,,890.51,,,890.51,Other,110% of Medicare,416.1,,,416.1,Fee Schedule,,392,,,392,Other,186% of Medicaid,489.66,,,489.66,Fee Schedule,,1115.38,,,1115.38,Fee Schedule,,230.56,,,230.56,Fee Schedule,,489.66,,,489.66,Fee Schedule,,1115.38,,,1115.38,Fee Schedule,,433.67,,,433.67,Fee Schedule,,1259.3,70,,1259.3,percent of total billed charges,All Other,526.44,,,526.44,Fee Schedule,,446.19,,,446.19,Fee Schedule,,610.96,,,610.96,Fee Schedule,,610.96,,,610.96,Fee Schedule,,610.96,,,610.96,Fee Schedule,,610.96,,,610.96,Fee Schedule,,210.57,,,210.57,Other,100% of Medicaid,210.57,,,210.57,Other,100% of Medicaid,210.57,,,210.57,Other,100% of Medicaid,210.57,,,210.57,Other,100% of Medicaid,473.77,,,473.77,Other,225% of Medicaid,322.17,,,322.17,Other,153% of Medicaid,473.77,,,473.77,Other,225% of Medicaid,294.79,,,294.79,Other,140% of Medicaid,473.77,,,473.77,Other,225% of Medicaid,547.47,,,547.47,Other,260% of Medicaid,682.23,,,682.23,Other,324% of Medicaid,452.72,,,452.72,Other,215% of Medicaid,452.72,,,452.72,Other,215% of Medicaid,263.21,,,263.21,Other,125% of Medicaid,210.57,1331.26,
ARTHROGRAM KNEE BILAT,73580,CPT,TC50,42373580,CDM,322,RC,,,both,,,1799,1331.26,,,1331.26,Other,150% of Medicare + 9.63% HCRA Surcharge,809.55,45,,809.55,percent of total billed charges,Critical Access Hospital RCC factor,278.58,,,278.58,Fee Schedule,,250.64,,,250.64,Fee Schedule,,695.75,,,695.75,Fee Schedule,,625.77,,,625.77,Fee Schedule,,591.45,,,591.45,Fee Schedule,,890.51,,,890.51,Other,110% of Medicare,330.98,,,330.98,Fee Schedule,,392,,,392,Other,186% of Medicaid,389.49,,,389.49,Fee Schedule,,1115.38,,,1115.38,Fee Schedule,,183.39,,,183.39,Fee Schedule,,389.49,,,389.49,Fee Schedule,,1115.38,,,1115.38,Fee Schedule,,344.95,,,344.95,Fee Schedule,,1259.3,70,,1259.3,percent of total billed charges,All Other,595.32,,,595.32,Fee Schedule,,504.57,,,504.57,Fee Schedule,,610.96,,,610.96,Fee Schedule,,610.96,,,610.96,Fee Schedule,,610.96,,,610.96,Fee Schedule,,610.96,,,610.96,Fee Schedule,,210.57,,,210.57,Other,100% of Medicaid,210.57,,,210.57,Other,100% of Medicaid,210.57,,,210.57,Other,100% of Medicaid,210.57,,,210.57,Other,100% of Medicaid,473.77,,,473.77,Other,225% of Medicaid,322.17,,,322.17,Other,153% of Medicaid,473.77,,,473.77,Other,225% of Medicaid,294.79,,,294.79,Other,140% of Medicaid,473.77,,,473.77,Other,225% of Medicaid,547.47,,,547.47,Other,260% of Medicaid,682.23,,,682.23,Other,324% of Medicaid,452.72,,,452.72,Other,215% of Medicaid,452.72,,,452.72,Other,215% of Medicaid,263.21,,,263.21,Other,125% of Medicaid,183.39,1331.26,
TMJ JOINT ARTHROGRAPHY W/ FY MOD,70332,CPT,FY,42670332,CDM,322,RC,,,both,,,527,389.98,,,389.98,Other,150% of Medicare + 9.63% HCRA Surcharge,237.15,45,,237.15,percent of total billed charges,Critical Access Hospital RCC factor,198.86,,,198.86,Fee Schedule,,178.92,,,178.92,Fee Schedule,,386.82,,,386.82,Fee Schedule,,347.92,,,347.92,Fee Schedule,,328.83,,,328.83,Fee Schedule,,260.87,,,260.87,Other,110% of Medicare,236.27,,,236.27,Fee Schedule,,392,,,392,Other,186% of Medicaid,278.04,,,278.04,Fee Schedule,,326.74,,,326.74,Fee Schedule,,130.91,,,130.91,Fee Schedule,,278.04,,,278.04,Fee Schedule,,326.74,,,326.74,Fee Schedule,,246.24,,,246.24,Fee Schedule,,368.9,70,,368.9,percent of total billed charges,All Other,295.2,,,295.2,Fee Schedule,,250.2,,,250.2,Fee Schedule,,372.86,,,372.86,Fee Schedule,,372.86,,,372.86,Fee Schedule,,372.86,,,372.86,Fee Schedule,,372.86,,,372.86,Fee Schedule,,210.57,,,210.57,Other,100% of Medicaid,210.57,,,210.57,Other,100% of Medicaid,210.57,,,210.57,Other,100% of Medicaid,210.57,,,210.57,Other,100% of Medicaid,473.77,,,473.77,Other,225% of Medicaid,322.17,,,322.17,Other,153% of Medicaid,473.77,,,473.77,Other,225% of Medicaid,294.79,,,294.79,Other,140% of Medicaid,473.77,,,473.77,Other,225% of Medicaid,547.47,,,547.47,Other,260% of Medicaid,682.23,,,682.23,Other,324% of Medicaid,452.72,,,452.72,Other,215% of Medicaid,452.72,,,452.72,Other,215% of Medicaid,263.21,,,263.21,Other,125% of Medicaid,130.91,682.23,
XR SHOULDER ARTHROGRAM LT FY MOD,73040,CPT,FYLT,42773040,CDM,322,RC,,,both,,,1307,967.18,,,967.18,Other,150% of Medicare + 9.63% HCRA Surcharge,588.15,45,,588.15,percent of total billed charges,Critical Access Hospital RCC factor,365.22,,,365.22,Fee Schedule,,328.59,,,328.59,Fee Schedule,,544.71,,,544.71,Fee Schedule,,489.93,,,489.93,Fee Schedule,,463.05,,,463.05,Fee Schedule,,646.97,,,646.97,Other,110% of Medicare,433.92,,,433.92,Fee Schedule,,392,,,392,Other,186% of Medicaid,510.63,,,510.63,Fee Schedule,,810.34,,,810.34,Fee Schedule,,240.43,,,240.43,Fee Schedule,,510.63,,,510.63,Fee Schedule,,810.34,,,810.34,Fee Schedule,,452.24,,,452.24,Fee Schedule,,914.9,70,,914.9,percent of total billed charges,All Other,521.52,,,521.52,Fee Schedule,,442.02,,,442.02,Fee Schedule,,610.96,,,610.96,Fee Schedule,,610.96,,,610.96,Fee Schedule,,610.96,,,610.96,Fee Schedule,,610.96,,,610.96,Fee Schedule,,210.57,,,210.57,Other,100% of Medicaid,210.57,,,210.57,Other,100% of Medicaid,210.57,,,210.57,Other,100% of Medicaid,210.57,,,210.57,Other,100% of Medicaid,473.77,,,473.77,Other,225% of Medicaid,322.17,,,322.17,Other,153% of Medicaid,473.77,,,473.77,Other,225% of Medicaid,294.79,,,294.79,Other,140% of Medicaid,473.77,,,473.77,Other,225% of Medicaid,547.47,,,547.47,Other,260% of Medicaid,682.23,,,682.23,Other,324% of Medicaid,452.72,,,452.72,Other,215% of Medicaid,452.72,,,452.72,Other,215% of Medicaid,263.21,,,263.21,Other,125% of Medicaid,210.57,967.18,
XR ARTHROGRAM WRIST LT FY MOD,73115,CPT,FYLT,42773115,CDM,322,RC,,,both,,,1199,887.26,,,887.26,Other,150% of Medicare + 9.63% HCRA Surcharge,539.55,45,,539.55,percent of total billed charges,Critical Access Hospital RCC factor,375.62,,,375.62,Fee Schedule,,337.94,,,337.94,Fee Schedule,,549.29,,,549.29,Fee Schedule,,494.05,,,494.05,Fee Schedule,,466.95,,,466.95,Fee Schedule,,593.51,,,593.51,Other,110% of Medicare,446.27,,,446.27,Fee Schedule,,392,,,392,Other,186% of Medicaid,525.17,,,525.17,Fee Schedule,,743.38,,,743.38,Fee Schedule,,247.28,,,247.28,Fee Schedule,,525.17,,,525.17,Fee Schedule,,743.38,,,743.38,Fee Schedule,,465.11,,,465.11,Fee Schedule,,839.3,70,,839.3,percent of total billed charges,All Other,544.48,,,544.48,Fee Schedule,,461.48,,,461.48,Fee Schedule,,610.96,,,610.96,Fee Schedule,,610.96,,,610.96,Fee Schedule,,610.96,,,610.96,Fee Schedule,,610.96,,,610.96,Fee Schedule,,210.57,,,210.57,Other,100% of Medicaid,210.57,,,210.57,Other,100% of Medicaid,210.57,,,210.57,Other,100% of Medicaid,210.57,,,210.57,Other,100% of Medicaid,473.77,,,473.77,Other,225% of Medicaid,322.17,,,322.17,Other,153% of Medicaid,473.77,,,473.77,Other,225% of Medicaid,294.79,,,294.79,Other,140% of Medicaid,473.77,,,473.77,Other,225% of Medicaid,547.47,,,547.47,Other,260% of Medicaid,682.23,,,682.23,Other,324% of Medicaid,452.72,,,452.72,Other,215% of Medicaid,452.72,,,452.72,Other,215% of Medicaid,263.21,,,263.21,Other,125% of Medicaid,210.57,887.26,
XR ARTHROGRAM HIP LT FY MOD,73525,CPT,FYLT,42773525,CDM,322,RC,,,both,,,1199,887.26,,,887.26,Other,150% of Medicare + 9.63% HCRA Surcharge,539.55,45,,539.55,percent of total billed charges,Critical Access Hospital RCC factor,350.23,,,350.23,Fee Schedule,,315.1,,,315.1,Fee Schedule,,489.79,,,489.79,Fee Schedule,,440.54,,,440.54,Fee Schedule,,416.37,,,416.37,Fee Schedule,,593.51,,,593.51,Other,110% of Medicare,416.1,,,416.1,Fee Schedule,,392,,,392,Other,186% of Medicaid,489.66,,,489.66,Fee Schedule,,743.38,,,743.38,Fee Schedule,,230.56,,,230.56,Fee Schedule,,489.66,,,489.66,Fee Schedule,,743.38,,,743.38,Fee Schedule,,433.67,,,433.67,Fee Schedule,,839.3,70,,839.3,percent of total billed charges,All Other,526.44,,,526.44,Fee Schedule,,446.19,,,446.19,Fee Schedule,,610.96,,,610.96,Fee Schedule,,610.96,,,610.96,Fee Schedule,,610.96,,,610.96,Fee Schedule,,610.96,,,610.96,Fee Schedule,,210.57,,,210.57,Other,100% of Medicaid,210.57,,,210.57,Other,100% of Medicaid,210.57,,,210.57,Other,100% of Medicaid,210.57,,,210.57,Other,100% of Medicaid,473.77,,,473.77,Other,225% of Medicaid,322.17,,,322.17,Other,153% of Medicaid,473.77,,,473.77,Other,225% of Medicaid,294.79,,,294.79,Other,140% of Medicaid,473.77,,,473.77,Other,225% of Medicaid,547.47,,,547.47,Other,260% of Medicaid,682.23,,,682.23,Other,324% of Medicaid,452.72,,,452.72,Other,215% of Medicaid,452.72,,,452.72,Other,215% of Medicaid,263.21,,,263.21,Other,125% of Medicaid,210.57,887.26,
ARTHROGRAM KNEE LT FY MOD,73580,CPT,FYLT,42773580,CDM,322,RC,,,both,,,1199,887.26,,,887.26,Other,150% of Medicare + 9.63% HCRA Surcharge,539.55,45,,539.55,percent of total billed charges,Critical Access Hospital RCC factor,278.58,,,278.58,Fee Schedule,,250.64,,,250.64,Fee Schedule,,695.75,,,695.75,Fee Schedule,,625.77,,,625.77,Fee Schedule,,591.45,,,591.45,Fee Schedule,,593.51,,,593.51,Other,110% of Medicare,330.98,,,330.98,Fee Schedule,,392,,,392,Other,186% of Medicaid,389.49,,,389.49,Fee Schedule,,743.38,,,743.38,Fee Schedule,,183.39,,,183.39,Fee Schedule,,389.49,,,389.49,Fee Schedule,,743.38,,,743.38,Fee Schedule,,344.95,,,344.95,Fee Schedule,,839.3,70,,839.3,percent of total billed charges,All Other,595.32,,,595.32,Fee Schedule,,504.57,,,504.57,Fee Schedule,,610.96,,,610.96,Fee Schedule,,610.96,,,610.96,Fee Schedule,,610.96,,,610.96,Fee Schedule,,610.96,,,610.96,Fee Schedule,,210.57,,,210.57,Other,100% of Medicaid,210.57,,,210.57,Other,100% of Medicaid,210.57,,,210.57,Other,100% of Medicaid,210.57,,,210.57,Other,100% of Medicaid,473.77,,,473.77,Other,225% of Medicaid,322.17,,,322.17,Other,153% of Medicaid,473.77,,,473.77,Other,225% of Medicaid,294.79,,,294.79,Other,140% of Medicaid,473.77,,,473.77,Other,225% of Medicaid,547.47,,,547.47,Other,260% of Medicaid,682.23,,,682.23,Other,324% of Medicaid,452.72,,,452.72,Other,215% of Medicaid,452.72,,,452.72,Other,215% of Medicaid,263.21,,,263.21,Other,125% of Medicaid,183.39,887.26,
XR SHOULDER ARTHROGRAM RT FY MOD,73040,CPT,FYRT,42873040,CDM,322,RC,,,both,,,1307,967.18,,,967.18,Other,150% of Medicare + 9.63% HCRA Surcharge,588.15,45,,588.15,percent of total billed charges,Critical Access Hospital RCC factor,365.22,,,365.22,Fee Schedule,,328.59,,,328.59,Fee Schedule,,544.71,,,544.71,Fee Schedule,,489.93,,,489.93,Fee Schedule,,463.05,,,463.05,Fee Schedule,,646.97,,,646.97,Other,110% of Medicare,433.92,,,433.92,Fee Schedule,,392,,,392,Other,186% of Medicaid,510.63,,,510.63,Fee Schedule,,810.34,,,810.34,Fee Schedule,,240.43,,,240.43,Fee Schedule,,510.63,,,510.63,Fee Schedule,,810.34,,,810.34,Fee Schedule,,452.24,,,452.24,Fee Schedule,,914.9,70,,914.9,percent of total billed charges,All Other,521.52,,,521.52,Fee Schedule,,442.02,,,442.02,Fee Schedule,,610.96,,,610.96,Fee Schedule,,610.96,,,610.96,Fee Schedule,,610.96,,,610.96,Fee Schedule,,610.96,,,610.96,Fee Schedule,,210.57,,,210.57,Other,100% of Medicaid,210.57,,,210.57,Other,100% of Medicaid,210.57,,,210.57,Other,100% of Medicaid,210.57,,,210.57,Other,100% of Medicaid,473.77,,,473.77,Other,225% of Medicaid,322.17,,,322.17,Other,153% of Medicaid,473.77,,,473.77,Other,225% of Medicaid,294.79,,,294.79,Other,140% of Medicaid,473.77,,,473.77,Other,225% of Medicaid,547.47,,,547.47,Other,260% of Medicaid,682.23,,,682.23,Other,324% of Medicaid,452.72,,,452.72,Other,215% of Medicaid,452.72,,,452.72,Other,215% of Medicaid,263.21,,,263.21,Other,125% of Medicaid,210.57,967.18,
XR ARTHROGRAM WRIST RT FY MOD,73115,CPT,FYRT,42873115,CDM,322,RC,,,both,,,1199,887.26,,,887.26,Other,150% of Medicare + 9.63% HCRA Surcharge,539.55,45,,539.55,percent of total billed charges,Critical Access Hospital RCC factor,375.62,,,375.62,Fee Schedule,,337.94,,,337.94,Fee Schedule,,549.29,,,549.29,Fee Schedule,,494.05,,,494.05,Fee Schedule,,466.95,,,466.95,Fee Schedule,,593.51,,,593.51,Other,110% of Medicare,446.27,,,446.27,Fee Schedule,,392,,,392,Other,186% of Medicaid,525.17,,,525.17,Fee Schedule,,743.38,,,743.38,Fee Schedule,,247.28,,,247.28,Fee Schedule,,525.17,,,525.17,Fee Schedule,,743.38,,,743.38,Fee Schedule,,465.11,,,465.11,Fee Schedule,,839.3,70,,839.3,percent of total billed charges,All Other,544.48,,,544.48,Fee Schedule,,461.48,,,461.48,Fee Schedule,,610.96,,,610.96,Fee Schedule,,610.96,,,610.96,Fee Schedule,,610.96,,,610.96,Fee Schedule,,610.96,,,610.96,Fee Schedule,,210.57,,,210.57,Other,100% of Medicaid,210.57,,,210.57,Other,100% of Medicaid,210.57,,,210.57,Other,100% of Medicaid,210.57,,,210.57,Other,100% of Medicaid,473.77,,,473.77,Other,225% of Medicaid,322.17,,,322.17,Other,153% of Medicaid,473.77,,,473.77,Other,225% of Medicaid,294.79,,,294.79,Other,140% of Medicaid,473.77,,,473.77,Other,225% of Medicaid,547.47,,,547.47,Other,260% of Medicaid,682.23,,,682.23,Other,324% of Medicaid,452.72,,,452.72,Other,215% of Medicaid,452.72,,,452.72,Other,215% of Medicaid,263.21,,,263.21,Other,125% of Medicaid,210.57,887.26,
XR ARTHROGRAM HIP RT FY MOD,73525,CPT,FYRT,42873525,CDM,322,RC,,,both,,,1199,887.26,,,887.26,Other,150% of Medicare + 9.63% HCRA Surcharge,539.55,45,,539.55,percent of total billed charges,Critical Access Hospital RCC factor,350.23,,,350.23,Fee Schedule,,315.1,,,315.1,Fee Schedule,,489.79,,,489.79,Fee Schedule,,440.54,,,440.54,Fee Schedule,,416.37,,,416.37,Fee Schedule,,593.51,,,593.51,Other,110% of Medicare,416.1,,,416.1,Fee Schedule,,392,,,392,Other,186% of Medicaid,489.66,,,489.66,Fee Schedule,,743.38,,,743.38,Fee Schedule,,230.56,,,230.56,Fee Schedule,,489.66,,,489.66,Fee Schedule,,743.38,,,743.38,Fee Schedule,,433.67,,,433.67,Fee Schedule,,839.3,70,,839.3,percent of total billed charges,All Other,526.44,,,526.44,Fee Schedule,,446.19,,,446.19,Fee Schedule,,610.96,,,610.96,Fee Schedule,,610.96,,,610.96,Fee Schedule,,610.96,,,610.96,Fee Schedule,,610.96,,,610.96,Fee Schedule,,210.57,,,210.57,Other,100% of Medicaid,210.57,,,210.57,Other,100% of Medicaid,210.57,,,210.57,Other,100% of Medicaid,210.57,,,210.57,Other,100% of Medicaid,473.77,,,473.77,Other,225% of Medicaid,322.17,,,322.17,Other,153% of Medicaid,473.77,,,473.77,Other,225% of Medicaid,294.79,,,294.79,Other,140% of Medicaid,473.77,,,473.77,Other,225% of Medicaid,547.47,,,547.47,Other,260% of Medicaid,682.23,,,682.23,Other,324% of Medicaid,452.72,,,452.72,Other,215% of Medicaid,452.72,,,452.72,Other,215% of Medicaid,263.21,,,263.21,Other,125% of Medicaid,210.57,887.26,
ARTHROGRAM KNEE RT FY MOD,73580,CPT,FYRT,42873580,CDM,322,RC,,,both,,,1199,887.26,,,887.26,Other,150% of Medicare + 9.63% HCRA Surcharge,539.55,45,,539.55,percent of total billed charges,Critical Access Hospital RCC factor,278.58,,,278.58,Fee Schedule,,250.64,,,250.64,Fee Schedule,,695.75,,,695.75,Fee Schedule,,625.77,,,625.77,Fee Schedule,,591.45,,,591.45,Fee Schedule,,593.51,,,593.51,Other,110% of Medicare,330.98,,,330.98,Fee Schedule,,392,,,392,Other,186% of Medicaid,389.49,,,389.49,Fee Schedule,,743.38,,,743.38,Fee Schedule,,183.39,,,183.39,Fee Schedule,,389.49,,,389.49,Fee Schedule,,743.38,,,743.38,Fee Schedule,,344.95,,,344.95,Fee Schedule,,839.3,70,,839.3,percent of total billed charges,All Other,595.32,,,595.32,Fee Schedule,,504.57,,,504.57,Fee Schedule,,610.96,,,610.96,Fee Schedule,,610.96,,,610.96,Fee Schedule,,610.96,,,610.96,Fee Schedule,,610.96,,,610.96,Fee Schedule,,210.57,,,210.57,Other,100% of Medicaid,210.57,,,210.57,Other,100% of Medicaid,210.57,,,210.57,Other,100% of Medicaid,210.57,,,210.57,Other,100% of Medicaid,473.77,,,473.77,Other,225% of Medicaid,322.17,,,322.17,Other,153% of Medicaid,473.77,,,473.77,Other,225% of Medicaid,294.79,,,294.79,Other,140% of Medicaid,473.77,,,473.77,Other,225% of Medicaid,547.47,,,547.47,Other,260% of Medicaid,682.23,,,682.23,Other,324% of Medicaid,452.72,,,452.72,Other,215% of Medicaid,452.72,,,452.72,Other,215% of Medicaid,263.21,,,263.21,Other,125% of Medicaid,183.39,887.26,
XR SHOULDER ARTHROGRAM BILAT FY MOD,73040,CPT,FY50,42973040,CDM,322,RC,,,both,,,1961,1451.14,,,1451.14,Other,150% of Medicare + 9.63% HCRA Surcharge,882.45,45,,882.45,percent of total billed charges,Critical Access Hospital RCC factor,365.22,,,365.22,Fee Schedule,,328.59,,,328.59,Fee Schedule,,544.71,,,544.71,Fee Schedule,,489.93,,,489.93,Fee Schedule,,463.05,,,463.05,Fee Schedule,,970.7,,,970.7,Other,110% of Medicare,433.92,,,433.92,Fee Schedule,,392,,,392,Other,186% of Medicaid,510.63,,,510.63,Fee Schedule,,1215.82,,,1215.82,Fee Schedule,,240.43,,,240.43,Fee Schedule,,510.63,,,510.63,Fee Schedule,,1215.82,,,1215.82,Fee Schedule,,452.24,,,452.24,Fee Schedule,,1372.7,70,,1372.7,percent of total billed charges,All Other,521.52,,,521.52,Fee Schedule,,442.02,,,442.02,Fee Schedule,,610.96,,,610.96,Fee Schedule,,610.96,,,610.96,Fee Schedule,,610.96,,,610.96,Fee Schedule,,610.96,,,610.96,Fee Schedule,,210.57,,,210.57,Other,100% of Medicaid,210.57,,,210.57,Other,100% of Medicaid,210.57,,,210.57,Other,100% of Medicaid,210.57,,,210.57,Other,100% of Medicaid,473.77,,,473.77,Other,225% of Medicaid,322.17,,,322.17,Other,153% of Medicaid,473.77,,,473.77,Other,225% of Medicaid,294.79,,,294.79,Other,140% of Medicaid,473.77,,,473.77,Other,225% of Medicaid,547.47,,,547.47,Other,260% of Medicaid,682.23,,,682.23,Other,324% of Medicaid,452.72,,,452.72,Other,215% of Medicaid,452.72,,,452.72,Other,215% of Medicaid,263.21,,,263.21,Other,125% of Medicaid,210.57,1451.14,
XR ARTHROGRAM WRIST BILAT FY MOD,73115,CPT,FY50,42973115,CDM,322,RC,,,both,,,1799,1331.26,,,1331.26,Other,150% of Medicare + 9.63% HCRA Surcharge,809.55,45,,809.55,percent of total billed charges,Critical Access Hospital RCC factor,375.62,,,375.62,Fee Schedule,,337.94,,,337.94,Fee Schedule,,549.29,,,549.29,Fee Schedule,,494.05,,,494.05,Fee Schedule,,466.95,,,466.95,Fee Schedule,,890.51,,,890.51,Other,110% of Medicare,446.27,,,446.27,Fee Schedule,,392,,,392,Other,186% of Medicaid,525.17,,,525.17,Fee Schedule,,1115.38,,,1115.38,Fee Schedule,,247.28,,,247.28,Fee Schedule,,525.17,,,525.17,Fee Schedule,,1115.38,,,1115.38,Fee Schedule,,465.11,,,465.11,Fee Schedule,,1259.3,70,,1259.3,percent of total billed charges,All Other,544.48,,,544.48,Fee Schedule,,461.48,,,461.48,Fee Schedule,,610.96,,,610.96,Fee Schedule,,610.96,,,610.96,Fee Schedule,,610.96,,,610.96,Fee Schedule,,610.96,,,610.96,Fee Schedule,,210.57,,,210.57,Other,100% of Medicaid,210.57,,,210.57,Other,100% of Medicaid,210.57,,,210.57,Other,100% of Medicaid,210.57,,,210.57,Other,100% of Medicaid,473.77,,,473.77,Other,225% of Medicaid,322.17,,,322.17,Other,153% of Medicaid,473.77,,,473.77,Other,225% of Medicaid,294.79,,,294.79,Other,140% of Medicaid,473.77,,,473.77,Other,225% of Medicaid,547.47,,,547.47,Other,260% of Medicaid,682.23,,,682.23,Other,324% of Medicaid,452.72,,,452.72,Other,215% of Medicaid,452.72,,,452.72,Other,215% of Medicaid,263.21,,,263.21,Other,125% of Medicaid,210.57,1331.26,
XR ARTHROGRAM HIP BILAT FY MOD,73525,CPT,FY50,42973525,CDM,322,RC,,,both,,,1799,1331.26,,,1331.26,Other,150% of Medicare + 9.63% HCRA Surcharge,809.55,45,,809.55,percent of total billed charges,Critical Access Hospital RCC factor,350.23,,,350.23,Fee Schedule,,315.1,,,315.1,Fee Schedule,,489.79,,,489.79,Fee Schedule,,440.54,,,440.54,Fee Schedule,,416.37,,,416.37,Fee Schedule,,890.51,,,890.51,Other,110% of Medicare,416.1,,,416.1,Fee Schedule,,392,,,392,Other,186% of Medicaid,489.66,,,489.66,Fee Schedule,,1115.38,,,1115.38,Fee Schedule,,230.56,,,230.56,Fee Schedule,,489.66,,,489.66,Fee Schedule,,1115.38,,,1115.38,Fee Schedule,,433.67,,,433.67,Fee Schedule,,1259.3,70,,1259.3,percent of total billed charges,All Other,526.44,,,526.44,Fee Schedule,,446.19,,,446.19,Fee Schedule,,610.96,,,610.96,Fee Schedule,,610.96,,,610.96,Fee Schedule,,610.96,,,610.96,Fee Schedule,,610.96,,,610.96,Fee Schedule,,210.57,,,210.57,Other,100% of Medicaid,210.57,,,210.57,Other,100% of Medicaid,210.57,,,210.57,Other,100% of Medicaid,210.57,,,210.57,Other,100% of Medicaid,473.77,,,473.77,Other,225% of Medicaid,322.17,,,322.17,Other,153% of Medicaid,473.77,,,473.77,Other,225% of Medicaid,294.79,,,294.79,Other,140% of Medicaid,473.77,,,473.77,Other,225% of Medicaid,547.47,,,547.47,Other,260% of Medicaid,682.23,,,682.23,Other,324% of Medicaid,452.72,,,452.72,Other,215% of Medicaid,452.72,,,452.72,Other,215% of Medicaid,263.21,,,263.21,Other,125% of Medicaid,210.57,1331.26,
ARTHROGRAM KNEE BILAT FY MOD,73580,CPT,FY50,42973580,CDM,322,RC,,,both,,,1799,1331.26,,,1331.26,Other,150% of Medicare + 9.63% HCRA Surcharge,809.55,45,,809.55,percent of total billed charges,Critical Access Hospital RCC factor,278.58,,,278.58,Fee Schedule,,250.64,,,250.64,Fee Schedule,,695.75,,,695.75,Fee Schedule,,625.77,,,625.77,Fee Schedule,,591.45,,,591.45,Fee Schedule,,890.51,,,890.51,Other,110% of Medicare,330.98,,,330.98,Fee Schedule,,392,,,392,Other,186% of Medicaid,389.49,,,389.49,Fee Schedule,,1115.38,,,1115.38,Fee Schedule,,183.39,,,183.39,Fee Schedule,,389.49,,,389.49,Fee Schedule,,1115.38,,,1115.38,Fee Schedule,,344.95,,,344.95,Fee Schedule,,1259.3,70,,1259.3,percent of total billed charges,All Other,595.32,,,595.32,Fee Schedule,,504.57,,,504.57,Fee Schedule,,610.96,,,610.96,Fee Schedule,,610.96,,,610.96,Fee Schedule,,610.96,,,610.96,Fee Schedule,,610.96,,,610.96,Fee Schedule,,210.57,,,210.57,Other,100% of Medicaid,210.57,,,210.57,Other,100% of Medicaid,210.57,,,210.57,Other,100% of Medicaid,210.57,,,210.57,Other,100% of Medicaid,473.77,,,473.77,Other,225% of Medicaid,322.17,,,322.17,Other,153% of Medicaid,473.77,,,473.77,Other,225% of Medicaid,294.79,,,294.79,Other,140% of Medicaid,473.77,,,473.77,Other,225% of Medicaid,547.47,,,547.47,Other,260% of Medicaid,682.23,,,682.23,Other,324% of Medicaid,452.72,,,452.72,Other,215% of Medicaid,452.72,,,452.72,Other,215% of Medicaid,263.21,,,263.21,Other,125% of Medicaid,183.39,1331.26,
TMJ JOINT ARTHROGRAPHY W/ FY MOD,70332,CPT,FY,43070332,CDM,322,RC,,,both,,,527,389.98,,,389.98,Other,150% of Medicare + 9.63% HCRA Surcharge,237.15,45,,237.15,percent of total billed charges,Critical Access Hospital RCC factor,198.86,,,198.86,Fee Schedule,,178.92,,,178.92,Fee Schedule,,386.82,,,386.82,Fee Schedule,,347.92,,,347.92,Fee Schedule,,328.83,,,328.83,Fee Schedule,,260.87,,,260.87,Other,110% of Medicare,236.27,,,236.27,Fee Schedule,,392,,,392,Other,186% of Medicaid,278.04,,,278.04,Fee Schedule,,326.74,,,326.74,Fee Schedule,,130.91,,,130.91,Fee Schedule,,278.04,,,278.04,Fee Schedule,,326.74,,,326.74,Fee Schedule,,246.24,,,246.24,Fee Schedule,,368.9,70,,368.9,percent of total billed charges,All Other,295.2,,,295.2,Fee Schedule,,250.2,,,250.2,Fee Schedule,,372.86,,,372.86,Fee Schedule,,372.86,,,372.86,Fee Schedule,,372.86,,,372.86,Fee Schedule,,372.86,,,372.86,Fee Schedule,,210.57,,,210.57,Other,100% of Medicaid,210.57,,,210.57,Other,100% of Medicaid,210.57,,,210.57,Other,100% of Medicaid,210.57,,,210.57,Other,100% of Medicaid,473.77,,,473.77,Other,225% of Medicaid,322.17,,,322.17,Other,153% of Medicaid,473.77,,,473.77,Other,225% of Medicaid,294.79,,,294.79,Other,140% of Medicaid,473.77,,,473.77,Other,225% of Medicaid,547.47,,,547.47,Other,260% of Medicaid,682.23,,,682.23,Other,324% of Medicaid,452.72,,,452.72,Other,215% of Medicaid,452.72,,,452.72,Other,215% of Medicaid,263.21,,,263.21,Other,125% of Medicaid,130.91,682.23,
EXTREMITY ANGIO - UNIL,75710,CPT,TC,42075710,CDM,323,RC,,,both,,,9172,6787.3,,,6787.3,Other,150% of Medicare + 9.63% HCRA Surcharge,4127.4,45,,4127.4,percent of total billed charges,Critical Access Hospital RCC factor,239.47,,,239.47,Fee Schedule,,215.45,,,215.45,Fee Schedule,,1196.92,,,1196.92,Fee Schedule,,1076.55,,,1076.55,Fee Schedule,,1017.5,,,1017.5,Fee Schedule,,4540.14,,,4540.14,Other,110% of Medicare,284.52,,,284.52,Fee Schedule,,544,,,544,Other,186% of Medicaid,334.81,,,334.81,Fee Schedule,,5686.64,,,5686.64,Fee Schedule,,157.65,,,157.65,Fee Schedule,,334.81,,,334.81,Fee Schedule,,5686.64,,,5686.64,Fee Schedule,,296.53,,,296.53,Fee Schedule,,6420.4,70,,6420.4,percent of total billed charges,All Other,341.12,,,341.12,Fee Schedule,,289.12,,,289.12,Fee Schedule,,4434.05,,,4434.05,Fee Schedule,,4434.05,,,4434.05,Fee Schedule,,4434.05,,,4434.05,Fee Schedule,,4434.05,,,4434.05,Fee Schedule,,292.43,,,292.43,Other,100% of Medicaid,292.43,,,292.43,Other,100% of Medicaid,292.43,,,292.43,Other,100% of Medicaid,292.43,,,292.43,Other,100% of Medicaid,657.98,,,657.98,Other,225% of Medicaid,447.42,,,447.42,Other,153% of Medicaid,657.98,,,657.98,Other,225% of Medicaid,409.41,,,409.41,Other,140% of Medicaid,657.98,,,657.98,Other,225% of Medicaid,760.33,,,760.33,Other,260% of Medicaid,947.49,,,947.49,Other,324% of Medicaid,628.73,,,628.73,Other,215% of Medicaid,628.73,,,628.73,Other,215% of Medicaid,365.54,,,365.54,Other,125% of Medicaid,157.65,6787.3,
EXTREMITY ANGIO - UNIL W/ FY MOD,75710,CPT,FY,42675710,CDM,323,RC,,,both,,,9172,6787.3,,,6787.3,Other,150% of Medicare + 9.63% HCRA Surcharge,4127.4,45,,4127.4,percent of total billed charges,Critical Access Hospital RCC factor,239.47,,,239.47,Fee Schedule,,215.45,,,215.45,Fee Schedule,,1196.92,,,1196.92,Fee Schedule,,1076.55,,,1076.55,Fee Schedule,,1017.5,,,1017.5,Fee Schedule,,4540.14,,,4540.14,Other,110% of Medicare,284.52,,,284.52,Fee Schedule,,544,,,544,Other,186% of Medicaid,334.81,,,334.81,Fee Schedule,,5686.64,,,5686.64,Fee Schedule,,157.65,,,157.65,Fee Schedule,,334.81,,,334.81,Fee Schedule,,5686.64,,,5686.64,Fee Schedule,,296.53,,,296.53,Fee Schedule,,6420.4,70,,6420.4,percent of total billed charges,All Other,341.12,,,341.12,Fee Schedule,,289.12,,,289.12,Fee Schedule,,4434.05,,,4434.05,Fee Schedule,,4434.05,,,4434.05,Fee Schedule,,4434.05,,,4434.05,Fee Schedule,,4434.05,,,4434.05,Fee Schedule,,292.43,,,292.43,Other,100% of Medicaid,292.43,,,292.43,Other,100% of Medicaid,292.43,,,292.43,Other,100% of Medicaid,292.43,,,292.43,Other,100% of Medicaid,657.98,,,657.98,Other,225% of Medicaid,447.42,,,447.42,Other,153% of Medicaid,657.98,,,657.98,Other,225% of Medicaid,409.41,,,409.41,Other,140% of Medicaid,657.98,,,657.98,Other,225% of Medicaid,760.33,,,760.33,Other,260% of Medicaid,947.49,,,947.49,Other,324% of Medicaid,628.73,,,628.73,Other,215% of Medicaid,628.73,,,628.73,Other,215% of Medicaid,365.54,,,365.54,Other,125% of Medicaid,157.65,6787.3,
THORACIC AORTOGRAM W SERIALOGR,75605,CPT,TC,47075605,CDM,323,RC,,,both,,,11570,8561.83,,,8561.83,Other,150% of Medicare + 9.63% HCRA Surcharge,5206.5,45,,5206.5,percent of total billed charges,Critical Access Hospital RCC factor,237.18,,,237.18,Fee Schedule,,213.38,,,213.38,Fee Schedule,,1061.91,,,1061.91,Fee Schedule,,955.11,,,955.11,Fee Schedule,,902.72,,,902.72,Fee Schedule,,5727.15,,,5727.15,Other,110% of Medicare,281.79,,,281.79,Fee Schedule,,1421,,,1421,Other,186% of Medicaid,331.6,,,331.6,Fee Schedule,,7173.4,,,7173.4,Fee Schedule,,156.14,,,156.14,Fee Schedule,,331.6,,,331.6,Fee Schedule,,7173.4,,,7173.4,Fee Schedule,,293.68,,,293.68,Fee Schedule,,8099,70,,8099,percent of total billed charges,All Other,334.56,,,334.56,Fee Schedule,,283.56,,,283.56,Fee Schedule,,7353.9,,,7353.9,Fee Schedule,,7353.9,,,7353.9,Fee Schedule,,7353.9,,,7353.9,Fee Schedule,,7353.9,,,7353.9,Fee Schedule,,763.74,,,763.74,Other,100% of Medicaid,763.74,,,763.74,Other,100% of Medicaid,763.74,,,763.74,Other,100% of Medicaid,763.74,,,763.74,Other,100% of Medicaid,1718.42,,,1718.42,Other,225% of Medicaid,1168.52,,,1168.52,Other,153% of Medicaid,1718.42,,,1718.42,Other,225% of Medicaid,1069.24,,,1069.24,Other,140% of Medicaid,1718.42,,,1718.42,Other,225% of Medicaid,1985.73,,,1985.73,Other,260% of Medicaid,2474.52,,,2474.52,Other,324% of Medicaid,1642.04,,,1642.04,Other,215% of Medicaid,1642.04,,,1642.04,Other,215% of Medicaid,954.68,,,954.68,Other,125% of Medicaid,156.14,8561.83,
ABDOMINAL ARTERIOGRAPHY,75625,CPT,TC,47075625,CDM,323,RC,,,both,,,6707,4963.2,,,4963.2,Other,150% of Medicare + 9.63% HCRA Surcharge,3018.15,45,,3018.15,percent of total billed charges,Critical Access Hospital RCC factor,208.12,,,208.12,Fee Schedule,,187.24,,,187.24,Fee Schedule,,1064.17,,,1064.17,Fee Schedule,,957.15,,,957.15,Fee Schedule,,904.65,,,904.65,Fee Schedule,,3319.97,,,3319.97,Other,110% of Medicare,247.26,,,247.26,Fee Schedule,,544,,,544,Other,186% of Medicaid,290.97,,,290.97,Fee Schedule,,4158.34,,,4158.34,Fee Schedule,,137,,,137,Fee Schedule,,290.97,,,290.97,Fee Schedule,,4158.34,,,4158.34,Fee Schedule,,257.7,,,257.7,Fee Schedule,,4694.9,70,,4694.9,percent of total billed charges,All Other,298.48,,,298.48,Fee Schedule,,252.98,,,252.98,Fee Schedule,,4434.05,,,4434.05,Fee Schedule,,4434.05,,,4434.05,Fee Schedule,,4434.05,,,4434.05,Fee Schedule,,4434.05,,,4434.05,Fee Schedule,,292.43,,,292.43,Other,100% of Medicaid,292.43,,,292.43,Other,100% of Medicaid,292.43,,,292.43,Other,100% of Medicaid,292.43,,,292.43,Other,100% of Medicaid,657.98,,,657.98,Other,225% of Medicaid,447.42,,,447.42,Other,153% of Medicaid,657.98,,,657.98,Other,225% of Medicaid,409.41,,,409.41,Other,140% of Medicaid,657.98,,,657.98,Other,225% of Medicaid,760.33,,,760.33,Other,260% of Medicaid,947.49,,,947.49,Other,324% of Medicaid,628.73,,,628.73,Other,215% of Medicaid,628.73,,,628.73,Other,215% of Medicaid,365.54,,,365.54,Other,125% of Medicaid,137,4963.2,
ABDOMINAL AORTOGRAM W RUN,75630,CPT,TC,47075630,CDM,323,RC,,,both,,,9613,7113.64,,,7113.64,Other,150% of Medicare + 9.63% HCRA Surcharge,4325.85,45,,4325.85,percent of total billed charges,Critical Access Hospital RCC factor,224.45,,,224.45,Fee Schedule,,201.93,,,201.93,Fee Schedule,,1089.36,,,1089.36,Fee Schedule,,979.81,,,979.81,Fee Schedule,,926.06,,,926.06,Fee Schedule,,4758.44,,,4758.44,Other,110% of Medicare,266.66,,,266.66,Fee Schedule,,544,,,544,Other,186% of Medicaid,313.81,,,313.81,Fee Schedule,,5960.06,,,5960.06,Fee Schedule,,147.76,,,147.76,Fee Schedule,,313.81,,,313.81,Fee Schedule,,5960.06,,,5960.06,Fee Schedule,,277.92,,,277.92,Fee Schedule,,6729.1,70,,6729.1,percent of total billed charges,All Other,319.8,,,319.8,Fee Schedule,,271.05,,,271.05,Fee Schedule,,4434.05,,,4434.05,Fee Schedule,,4434.05,,,4434.05,Fee Schedule,,4434.05,,,4434.05,Fee Schedule,,4434.05,,,4434.05,Fee Schedule,,292.43,,,292.43,Other,100% of Medicaid,292.43,,,292.43,Other,100% of Medicaid,292.43,,,292.43,Other,100% of Medicaid,292.43,,,292.43,Other,100% of Medicaid,657.98,,,657.98,Other,225% of Medicaid,447.42,,,447.42,Other,153% of Medicaid,657.98,,,657.98,Other,225% of Medicaid,409.41,,,409.41,Other,140% of Medicaid,657.98,,,657.98,Other,225% of Medicaid,760.33,,,760.33,Other,260% of Medicaid,947.49,,,947.49,Other,324% of Medicaid,628.73,,,628.73,Other,215% of Medicaid,628.73,,,628.73,Other,215% of Medicaid,365.54,,,365.54,Other,125% of Medicaid,147.76,7113.64,
EXTREMITY ANGIO UNI,75710,CPT,TC,47075710,CDM,323,RC,,,both,,,9172,6787.3,,,6787.3,Other,150% of Medicare + 9.63% HCRA Surcharge,4127.4,45,,4127.4,percent of total billed charges,Critical Access Hospital RCC factor,239.47,,,239.47,Fee Schedule,,215.45,,,215.45,Fee Schedule,,1196.92,,,1196.92,Fee Schedule,,1076.55,,,1076.55,Fee Schedule,,1017.5,,,1017.5,Fee Schedule,,4540.14,,,4540.14,Other,110% of Medicare,284.52,,,284.52,Fee Schedule,,544,,,544,Other,186% of Medicaid,334.81,,,334.81,Fee Schedule,,5686.64,,,5686.64,Fee Schedule,,157.65,,,157.65,Fee Schedule,,334.81,,,334.81,Fee Schedule,,5686.64,,,5686.64,Fee Schedule,,296.53,,,296.53,Fee Schedule,,6420.4,70,,6420.4,percent of total billed charges,All Other,341.12,,,341.12,Fee Schedule,,289.12,,,289.12,Fee Schedule,,4434.05,,,4434.05,Fee Schedule,,4434.05,,,4434.05,Fee Schedule,,4434.05,,,4434.05,Fee Schedule,,4434.05,,,4434.05,Fee Schedule,,292.43,,,292.43,Other,100% of Medicaid,292.43,,,292.43,Other,100% of Medicaid,292.43,,,292.43,Other,100% of Medicaid,292.43,,,292.43,Other,100% of Medicaid,657.98,,,657.98,Other,225% of Medicaid,447.42,,,447.42,Other,153% of Medicaid,657.98,,,657.98,Other,225% of Medicaid,409.41,,,409.41,Other,140% of Medicaid,657.98,,,657.98,Other,225% of Medicaid,760.33,,,760.33,Other,260% of Medicaid,947.49,,,947.49,Other,324% of Medicaid,628.73,,,628.73,Other,215% of Medicaid,628.73,,,628.73,Other,215% of Medicaid,365.54,,,365.54,Other,125% of Medicaid,157.65,6787.3,
EXTREMITY ANGIO BILAT,75716,CPT,TC,47075716,CDM,323,RC,,,both,,,10286,7611.67,,,7611.67,Other,150% of Medicare + 9.63% HCRA Surcharge,4628.7,45,,4628.7,percent of total billed charges,Critical Access Hospital RCC factor,249.87,,,249.87,Fee Schedule,,224.81,,,224.81,Fee Schedule,,1377.89,,,1377.89,Fee Schedule,,1239.32,,,1239.32,Fee Schedule,,1171.34,,,1171.34,Fee Schedule,,5091.57,,,5091.57,Other,110% of Medicare,296.87,,,296.87,Fee Schedule,,544,,,544,Other,186% of Medicaid,349.35,,,349.35,Fee Schedule,,6377.32,,,6377.32,Fee Schedule,,164.49,,,164.49,Fee Schedule,,349.35,,,349.35,Fee Schedule,,6377.32,,,6377.32,Fee Schedule,,309.4,,,309.4,Fee Schedule,,7200.2,70,,7200.2,percent of total billed charges,All Other,352.6,,,352.6,Fee Schedule,,298.85,,,298.85,Fee Schedule,,4434.05,,,4434.05,Fee Schedule,,4434.05,,,4434.05,Fee Schedule,,4434.05,,,4434.05,Fee Schedule,,4434.05,,,4434.05,Fee Schedule,,292.43,,,292.43,Other,100% of Medicaid,292.43,,,292.43,Other,100% of Medicaid,292.43,,,292.43,Other,100% of Medicaid,292.43,,,292.43,Other,100% of Medicaid,657.98,,,657.98,Other,225% of Medicaid,447.42,,,447.42,Other,153% of Medicaid,657.98,,,657.98,Other,225% of Medicaid,409.41,,,409.41,Other,140% of Medicaid,657.98,,,657.98,Other,225% of Medicaid,760.33,,,760.33,Other,260% of Medicaid,947.49,,,947.49,Other,324% of Medicaid,628.73,,,628.73,Other,215% of Medicaid,628.73,,,628.73,Other,215% of Medicaid,365.54,,,365.54,Other,125% of Medicaid,164.49,7611.67,
VISCERAL ANGIOGRAPHY,75726,CPT,TC,47075726,CDM,323,RC,,,both,,,11570,8561.83,,,8561.83,Other,150% of Medicare + 9.63% HCRA Surcharge,5206.5,45,,5206.5,percent of total billed charges,Critical Access Hospital RCC factor,269.52,,,269.52,Fee Schedule,,242.49,,,242.49,Fee Schedule,,1178.58,,,1178.58,Fee Schedule,,1060.05,,,1060.05,Fee Schedule,,1001.91,,,1001.91,Fee Schedule,,5727.15,,,5727.15,Other,110% of Medicare,320.22,,,320.22,Fee Schedule,,1421,,,1421,Other,186% of Medicaid,376.83,,,376.83,Fee Schedule,,7173.4,,,7173.4,Fee Schedule,,177.43,,,177.43,Fee Schedule,,376.83,,,376.83,Fee Schedule,,7173.4,,,7173.4,Fee Schedule,,333.74,,,333.74,Fee Schedule,,8099,70,,8099,percent of total billed charges,All Other,380.48,,,380.48,Fee Schedule,,322.48,,,322.48,Fee Schedule,,7353.9,,,7353.9,Fee Schedule,,7353.9,,,7353.9,Fee Schedule,,7353.9,,,7353.9,Fee Schedule,,7353.9,,,7353.9,Fee Schedule,,763.74,,,763.74,Other,100% of Medicaid,763.74,,,763.74,Other,100% of Medicaid,763.74,,,763.74,Other,100% of Medicaid,763.74,,,763.74,Other,100% of Medicaid,1718.42,,,1718.42,Other,225% of Medicaid,1168.52,,,1168.52,Other,153% of Medicaid,1718.42,,,1718.42,Other,225% of Medicaid,1069.24,,,1069.24,Other,140% of Medicaid,1718.42,,,1718.42,Other,225% of Medicaid,1985.73,,,1985.73,Other,260% of Medicaid,2474.52,,,2474.52,Other,324% of Medicaid,1642.04,,,1642.04,Other,215% of Medicaid,1642.04,,,1642.04,Other,215% of Medicaid,954.68,,,954.68,Other,125% of Medicaid,177.43,8561.83,
ADRENAL ANGIOGR UNIL,75731,CPT,TC,47075731,CDM,323,RC,,,both,,,8073,5974.04,,,5974.04,Other,150% of Medicare + 9.63% HCRA Surcharge,3632.85,45,,3632.85,percent of total billed charges,Critical Access Hospital RCC factor,347.1,,,347.1,Fee Schedule,,312.28,,,312.28,Fee Schedule,,1196.92,,,1196.92,Fee Schedule,,1076.55,,,1076.55,Fee Schedule,,1017.5,,,1017.5,Fee Schedule,,3996.14,,,3996.14,Other,110% of Medicare,412.39,,,412.39,Fee Schedule,,544,,,544,Other,186% of Medicaid,485.29,,,485.29,Fee Schedule,,5005.26,,,5005.26,Fee Schedule,,228.5,,,228.5,Fee Schedule,,485.29,,,485.29,Fee Schedule,,5005.26,,,5005.26,Fee Schedule,,429.8,,,429.8,Fee Schedule,,5651.1,70,,5651.1,percent of total billed charges,All Other,475.6,,,475.6,Fee Schedule,,403.1,,,403.1,Fee Schedule,,2609.81,,,2609.81,Fee Schedule,,2609.81,,,2609.81,Fee Schedule,,2609.81,,,2609.81,Fee Schedule,,2609.81,,,2609.81,Fee Schedule,,292.43,,,292.43,Other,100% of Medicaid,292.43,,,292.43,Other,100% of Medicaid,292.43,,,292.43,Other,100% of Medicaid,292.43,,,292.43,Other,100% of Medicaid,657.98,,,657.98,Other,225% of Medicaid,447.42,,,447.42,Other,153% of Medicaid,657.98,,,657.98,Other,225% of Medicaid,409.41,,,409.41,Other,140% of Medicaid,657.98,,,657.98,Other,225% of Medicaid,760.33,,,760.33,Other,260% of Medicaid,947.49,,,947.49,Other,324% of Medicaid,628.73,,,628.73,Other,215% of Medicaid,628.73,,,628.73,Other,215% of Medicaid,365.54,,,365.54,Other,125% of Medicaid,228.5,5974.04,
ADRENAL ANGIOGR BILAT,75733,CPT,TC,47075733,CDM,323,RC,,,both,,,7864,5819.38,,,5819.38,Other,150% of Medicare + 9.63% HCRA Surcharge,3538.8,45,,3538.8,percent of total billed charges,Critical Access Hospital RCC factor,390.01,,,390.01,Fee Schedule,,350.89,,,350.89,Fee Schedule,,1373.31,,,1373.31,Fee Schedule,,1235.2,,,1235.2,Fee Schedule,,1167.44,,,1167.44,Fee Schedule,,3892.68,,,3892.68,Other,110% of Medicare,463.37,,,463.37,Fee Schedule,,544,,,544,Other,186% of Medicaid,545.28,,,545.28,Fee Schedule,,4875.68,,,4875.68,Fee Schedule,,256.75,,,256.75,Fee Schedule,,545.28,,,545.28,Fee Schedule,,4875.68,,,4875.68,Fee Schedule,,482.93,,,482.93,Fee Schedule,,5504.8,70,,5504.8,percent of total billed charges,All Other,524.8,,,524.8,Fee Schedule,,444.8,,,444.8,Fee Schedule,,4434.05,,,4434.05,Fee Schedule,,4434.05,,,4434.05,Fee Schedule,,4434.05,,,4434.05,Fee Schedule,,4434.05,,,4434.05,Fee Schedule,,292.43,,,292.43,Other,100% of Medicaid,292.43,,,292.43,Other,100% of Medicaid,292.43,,,292.43,Other,100% of Medicaid,292.43,,,292.43,Other,100% of Medicaid,657.98,,,657.98,Other,225% of Medicaid,447.42,,,447.42,Other,153% of Medicaid,657.98,,,657.98,Other,225% of Medicaid,409.41,,,409.41,Other,140% of Medicaid,657.98,,,657.98,Other,225% of Medicaid,760.33,,,760.33,Other,260% of Medicaid,947.49,,,947.49,Other,324% of Medicaid,628.73,,,628.73,Other,215% of Medicaid,628.73,,,628.73,Other,215% of Medicaid,365.54,,,365.54,Other,125% of Medicaid,256.75,5819.38,
PULMONARY UNI SELECTIVE ANGI,75741,CPT,TC,47075741,CDM,323,RC,,,both,,,7864,5819.38,,,5819.38,Other,150% of Medicare + 9.63% HCRA Surcharge,3538.8,45,,3538.8,percent of total billed charges,Critical Access Hospital RCC factor,245.25,,,245.25,Fee Schedule,,220.65,,,220.65,Fee Schedule,,1036.71,,,1036.71,Fee Schedule,,932.45,,,932.45,Fee Schedule,,881.31,,,881.31,Fee Schedule,,3892.68,,,3892.68,Other,110% of Medicare,291.38,,,291.38,Fee Schedule,,544,,,544,Other,186% of Medicaid,342.88,,,342.88,Fee Schedule,,4875.68,,,4875.68,Fee Schedule,,161.45,,,161.45,Fee Schedule,,342.88,,,342.88,Fee Schedule,,4875.68,,,4875.68,Fee Schedule,,303.68,,,303.68,Fee Schedule,,5504.8,70,,5504.8,percent of total billed charges,All Other,347.68,,,347.68,Fee Schedule,,294.68,,,294.68,Fee Schedule,,4434.05,,,4434.05,Fee Schedule,,4434.05,,,4434.05,Fee Schedule,,4434.05,,,4434.05,Fee Schedule,,4434.05,,,4434.05,Fee Schedule,,292.43,,,292.43,Other,100% of Medicaid,292.43,,,292.43,Other,100% of Medicaid,292.43,,,292.43,Other,100% of Medicaid,292.43,,,292.43,Other,100% of Medicaid,657.98,,,657.98,Other,225% of Medicaid,447.42,,,447.42,Other,153% of Medicaid,657.98,,,657.98,Other,225% of Medicaid,409.41,,,409.41,Other,140% of Medicaid,657.98,,,657.98,Other,225% of Medicaid,760.33,,,760.33,Other,260% of Medicaid,947.49,,,947.49,Other,324% of Medicaid,628.73,,,628.73,Other,215% of Medicaid,628.73,,,628.73,Other,215% of Medicaid,365.54,,,365.54,Other,125% of Medicaid,161.45,5819.38,
PULMONARY BILAT SELECTIVE ANGI,75743,CPT,TC,47075743,CDM,323,RC,,,both,,,7864,5819.38,,,5819.38,Other,150% of Medicare + 9.63% HCRA Surcharge,3538.8,45,,3538.8,percent of total billed charges,Critical Access Hospital RCC factor,249.87,,,249.87,Fee Schedule,,224.81,,,224.81,Fee Schedule,,1093.95,,,1093.95,Fee Schedule,,983.93,,,983.93,Fee Schedule,,929.96,,,929.96,Fee Schedule,,3892.68,,,3892.68,Other,110% of Medicare,296.87,,,296.87,Fee Schedule,,544,,,544,Other,186% of Medicaid,349.35,,,349.35,Fee Schedule,,4875.68,,,4875.68,Fee Schedule,,164.49,,,164.49,Fee Schedule,,349.35,,,349.35,Fee Schedule,,4875.68,,,4875.68,Fee Schedule,,309.4,,,309.4,Fee Schedule,,5504.8,70,,5504.8,percent of total billed charges,All Other,354.24,,,354.24,Fee Schedule,,300.24,,,300.24,Fee Schedule,,4434.05,,,4434.05,Fee Schedule,,4434.05,,,4434.05,Fee Schedule,,4434.05,,,4434.05,Fee Schedule,,4434.05,,,4434.05,Fee Schedule,,292.43,,,292.43,Other,100% of Medicaid,292.43,,,292.43,Other,100% of Medicaid,292.43,,,292.43,Other,100% of Medicaid,292.43,,,292.43,Other,100% of Medicaid,657.98,,,657.98,Other,225% of Medicaid,447.42,,,447.42,Other,153% of Medicaid,657.98,,,657.98,Other,225% of Medicaid,409.41,,,409.41,Other,140% of Medicaid,657.98,,,657.98,Other,225% of Medicaid,760.33,,,760.33,Other,260% of Medicaid,947.49,,,947.49,Other,324% of Medicaid,628.73,,,628.73,Other,215% of Medicaid,628.73,,,628.73,Other,215% of Medicaid,365.54,,,365.54,Other,125% of Medicaid,164.49,5819.38,
EXTREMITY ANGIO UNI LT,75710,CPT,TCLT,47175710,CDM,323,RC,,,both,,,9172,6787.3,,,6787.3,Other,150% of Medicare + 9.63% HCRA Surcharge,4127.4,45,,4127.4,percent of total billed charges,Critical Access Hospital RCC factor,239.47,,,239.47,Fee Schedule,,215.45,,,215.45,Fee Schedule,,1196.92,,,1196.92,Fee Schedule,,1076.55,,,1076.55,Fee Schedule,,1017.5,,,1017.5,Fee Schedule,,4540.14,,,4540.14,Other,110% of Medicare,284.52,,,284.52,Fee Schedule,,544,,,544,Other,186% of Medicaid,334.81,,,334.81,Fee Schedule,,5686.64,,,5686.64,Fee Schedule,,157.65,,,157.65,Fee Schedule,,334.81,,,334.81,Fee Schedule,,5686.64,,,5686.64,Fee Schedule,,296.53,,,296.53,Fee Schedule,,6420.4,70,,6420.4,percent of total billed charges,All Other,341.12,,,341.12,Fee Schedule,,289.12,,,289.12,Fee Schedule,,4434.05,,,4434.05,Fee Schedule,,4434.05,,,4434.05,Fee Schedule,,4434.05,,,4434.05,Fee Schedule,,4434.05,,,4434.05,Fee Schedule,,292.43,,,292.43,Other,100% of Medicaid,292.43,,,292.43,Other,100% of Medicaid,292.43,,,292.43,Other,100% of Medicaid,292.43,,,292.43,Other,100% of Medicaid,657.98,,,657.98,Other,225% of Medicaid,447.42,,,447.42,Other,153% of Medicaid,657.98,,,657.98,Other,225% of Medicaid,409.41,,,409.41,Other,140% of Medicaid,657.98,,,657.98,Other,225% of Medicaid,760.33,,,760.33,Other,260% of Medicaid,947.49,,,947.49,Other,324% of Medicaid,628.73,,,628.73,Other,215% of Medicaid,628.73,,,628.73,Other,215% of Medicaid,365.54,,,365.54,Other,125% of Medicaid,157.65,6787.3,
EXTREMITY ANGIO BILAT 59 MOD,75716,CPT,TC59,47175716,CDM,323,RC,,,both,,,10286,7611.67,,,7611.67,Other,150% of Medicare + 9.63% HCRA Surcharge,4628.7,45,,4628.7,percent of total billed charges,Critical Access Hospital RCC factor,249.87,,,249.87,Fee Schedule,,224.81,,,224.81,Fee Schedule,,1377.89,,,1377.89,Fee Schedule,,1239.32,,,1239.32,Fee Schedule,,1171.34,,,1171.34,Fee Schedule,,5091.57,,,5091.57,Other,110% of Medicare,296.87,,,296.87,Fee Schedule,,544,,,544,Other,186% of Medicaid,349.35,,,349.35,Fee Schedule,,6377.32,,,6377.32,Fee Schedule,,164.49,,,164.49,Fee Schedule,,349.35,,,349.35,Fee Schedule,,6377.32,,,6377.32,Fee Schedule,,309.4,,,309.4,Fee Schedule,,7200.2,70,,7200.2,percent of total billed charges,All Other,352.6,,,352.6,Fee Schedule,,298.85,,,298.85,Fee Schedule,,4434.05,,,4434.05,Fee Schedule,,4434.05,,,4434.05,Fee Schedule,,4434.05,,,4434.05,Fee Schedule,,4434.05,,,4434.05,Fee Schedule,,292.43,,,292.43,Other,100% of Medicaid,292.43,,,292.43,Other,100% of Medicaid,292.43,,,292.43,Other,100% of Medicaid,292.43,,,292.43,Other,100% of Medicaid,657.98,,,657.98,Other,225% of Medicaid,447.42,,,447.42,Other,153% of Medicaid,657.98,,,657.98,Other,225% of Medicaid,409.41,,,409.41,Other,140% of Medicaid,657.98,,,657.98,Other,225% of Medicaid,760.33,,,760.33,Other,260% of Medicaid,947.49,,,947.49,Other,324% of Medicaid,628.73,,,628.73,Other,215% of Medicaid,628.73,,,628.73,Other,215% of Medicaid,365.54,,,365.54,Other,125% of Medicaid,164.49,7611.67,
EXTREMITY ANGIO UNI RT,75710,CPT,TCRT,47275710,CDM,323,RC,,,both,,,9172,6787.3,,,6787.3,Other,150% of Medicare + 9.63% HCRA Surcharge,4127.4,45,,4127.4,percent of total billed charges,Critical Access Hospital RCC factor,239.47,,,239.47,Fee Schedule,,215.45,,,215.45,Fee Schedule,,1196.92,,,1196.92,Fee Schedule,,1076.55,,,1076.55,Fee Schedule,,1017.5,,,1017.5,Fee Schedule,,4540.14,,,4540.14,Other,110% of Medicare,284.52,,,284.52,Fee Schedule,,544,,,544,Other,186% of Medicaid,334.81,,,334.81,Fee Schedule,,5686.64,,,5686.64,Fee Schedule,,157.65,,,157.65,Fee Schedule,,334.81,,,334.81,Fee Schedule,,5686.64,,,5686.64,Fee Schedule,,296.53,,,296.53,Fee Schedule,,6420.4,70,,6420.4,percent of total billed charges,All Other,341.12,,,341.12,Fee Schedule,,289.12,,,289.12,Fee Schedule,,4434.05,,,4434.05,Fee Schedule,,4434.05,,,4434.05,Fee Schedule,,4434.05,,,4434.05,Fee Schedule,,4434.05,,,4434.05,Fee Schedule,,292.43,,,292.43,Other,100% of Medicaid,292.43,,,292.43,Other,100% of Medicaid,292.43,,,292.43,Other,100% of Medicaid,292.43,,,292.43,Other,100% of Medicaid,657.98,,,657.98,Other,225% of Medicaid,447.42,,,447.42,Other,153% of Medicaid,657.98,,,657.98,Other,225% of Medicaid,409.41,,,409.41,Other,140% of Medicaid,657.98,,,657.98,Other,225% of Medicaid,760.33,,,760.33,Other,260% of Medicaid,947.49,,,947.49,Other,324% of Medicaid,628.73,,,628.73,Other,215% of Medicaid,628.73,,,628.73,Other,215% of Medicaid,365.54,,,365.54,Other,125% of Medicaid,157.65,6787.3,
EXTREMITY ANGIO UNI LT 59 MOD,75710,CPT,TC59,47475710,CDM,323,RC,,,both,,,9172,6787.3,,,6787.3,Other,150% of Medicare + 9.63% HCRA Surcharge,4127.4,45,,4127.4,percent of total billed charges,Critical Access Hospital RCC factor,239.47,,,239.47,Fee Schedule,,215.45,,,215.45,Fee Schedule,,1196.92,,,1196.92,Fee Schedule,,1076.55,,,1076.55,Fee Schedule,,1017.5,,,1017.5,Fee Schedule,,4540.14,,,4540.14,Other,110% of Medicare,284.52,,,284.52,Fee Schedule,,544,,,544,Other,186% of Medicaid,334.81,,,334.81,Fee Schedule,,5686.64,,,5686.64,Fee Schedule,,157.65,,,157.65,Fee Schedule,,334.81,,,334.81,Fee Schedule,,5686.64,,,5686.64,Fee Schedule,,296.53,,,296.53,Fee Schedule,,6420.4,70,,6420.4,percent of total billed charges,All Other,341.12,,,341.12,Fee Schedule,,289.12,,,289.12,Fee Schedule,,4434.05,,,4434.05,Fee Schedule,,4434.05,,,4434.05,Fee Schedule,,4434.05,,,4434.05,Fee Schedule,,4434.05,,,4434.05,Fee Schedule,,292.43,,,292.43,Other,100% of Medicaid,292.43,,,292.43,Other,100% of Medicaid,292.43,,,292.43,Other,100% of Medicaid,292.43,,,292.43,Other,100% of Medicaid,657.98,,,657.98,Other,225% of Medicaid,447.42,,,447.42,Other,153% of Medicaid,657.98,,,657.98,Other,225% of Medicaid,409.41,,,409.41,Other,140% of Medicaid,657.98,,,657.98,Other,225% of Medicaid,760.33,,,760.33,Other,260% of Medicaid,947.49,,,947.49,Other,324% of Medicaid,628.73,,,628.73,Other,215% of Medicaid,628.73,,,628.73,Other,215% of Medicaid,365.54,,,365.54,Other,125% of Medicaid,157.65,6787.3,
EXTREMITY ANGIO UNI RT 59 MOD,75710,CPT,TC59,47575710,CDM,323,RC,,,both,,,9172,6787.3,,,6787.3,Other,150% of Medicare + 9.63% HCRA Surcharge,4127.4,45,,4127.4,percent of total billed charges,Critical Access Hospital RCC factor,239.47,,,239.47,Fee Schedule,,215.45,,,215.45,Fee Schedule,,1196.92,,,1196.92,Fee Schedule,,1076.55,,,1076.55,Fee Schedule,,1017.5,,,1017.5,Fee Schedule,,4540.14,,,4540.14,Other,110% of Medicare,284.52,,,284.52,Fee Schedule,,544,,,544,Other,186% of Medicaid,334.81,,,334.81,Fee Schedule,,5686.64,,,5686.64,Fee Schedule,,157.65,,,157.65,Fee Schedule,,334.81,,,334.81,Fee Schedule,,5686.64,,,5686.64,Fee Schedule,,296.53,,,296.53,Fee Schedule,,6420.4,70,,6420.4,percent of total billed charges,All Other,341.12,,,341.12,Fee Schedule,,289.12,,,289.12,Fee Schedule,,4434.05,,,4434.05,Fee Schedule,,4434.05,,,4434.05,Fee Schedule,,4434.05,,,4434.05,Fee Schedule,,4434.05,,,4434.05,Fee Schedule,,292.43,,,292.43,Other,100% of Medicaid,292.43,,,292.43,Other,100% of Medicaid,292.43,,,292.43,Other,100% of Medicaid,292.43,,,292.43,Other,100% of Medicaid,657.98,,,657.98,Other,225% of Medicaid,447.42,,,447.42,Other,153% of Medicaid,657.98,,,657.98,Other,225% of Medicaid,409.41,,,409.41,Other,140% of Medicaid,657.98,,,657.98,Other,225% of Medicaid,760.33,,,760.33,Other,260% of Medicaid,947.49,,,947.49,Other,324% of Medicaid,628.73,,,628.73,Other,215% of Medicaid,628.73,,,628.73,Other,215% of Medicaid,365.54,,,365.54,Other,125% of Medicaid,157.65,6787.3,
ABDOMINAL ARTERIOGRAPHY,75625,CPT,TC,49075625,CDM,323,RC,,,both,,,6707,4963.2,,,4963.2,Other,150% of Medicare + 9.63% HCRA Surcharge,3018.15,45,,3018.15,percent of total billed charges,Critical Access Hospital RCC factor,208.12,,,208.12,Fee Schedule,,187.24,,,187.24,Fee Schedule,,1064.17,,,1064.17,Fee Schedule,,957.15,,,957.15,Fee Schedule,,904.65,,,904.65,Fee Schedule,,3319.97,,,3319.97,Other,110% of Medicare,247.26,,,247.26,Fee Schedule,,544,,,544,Other,186% of Medicaid,290.97,,,290.97,Fee Schedule,,4158.34,,,4158.34,Fee Schedule,,137,,,137,Fee Schedule,,290.97,,,290.97,Fee Schedule,,4158.34,,,4158.34,Fee Schedule,,257.7,,,257.7,Fee Schedule,,4694.9,70,,4694.9,percent of total billed charges,All Other,298.48,,,298.48,Fee Schedule,,252.98,,,252.98,Fee Schedule,,4434.05,,,4434.05,Fee Schedule,,4434.05,,,4434.05,Fee Schedule,,4434.05,,,4434.05,Fee Schedule,,4434.05,,,4434.05,Fee Schedule,,292.43,,,292.43,Other,100% of Medicaid,292.43,,,292.43,Other,100% of Medicaid,292.43,,,292.43,Other,100% of Medicaid,292.43,,,292.43,Other,100% of Medicaid,657.98,,,657.98,Other,225% of Medicaid,447.42,,,447.42,Other,153% of Medicaid,657.98,,,657.98,Other,225% of Medicaid,409.41,,,409.41,Other,140% of Medicaid,657.98,,,657.98,Other,225% of Medicaid,760.33,,,760.33,Other,260% of Medicaid,947.49,,,947.49,Other,324% of Medicaid,628.73,,,628.73,Other,215% of Medicaid,628.73,,,628.73,Other,215% of Medicaid,365.54,,,365.54,Other,125% of Medicaid,137,4963.2,
EXTREMITY ANGIO BILAT,75716,CPT,TC,49075716,CDM,323,RC,,,both,,,10286,7611.67,,,7611.67,Other,150% of Medicare + 9.63% HCRA Surcharge,4628.7,45,,4628.7,percent of total billed charges,Critical Access Hospital RCC factor,249.87,,,249.87,Fee Schedule,,224.81,,,224.81,Fee Schedule,,1377.89,,,1377.89,Fee Schedule,,1239.32,,,1239.32,Fee Schedule,,1171.34,,,1171.34,Fee Schedule,,5091.57,,,5091.57,Other,110% of Medicare,296.87,,,296.87,Fee Schedule,,544,,,544,Other,186% of Medicaid,349.35,,,349.35,Fee Schedule,,6377.32,,,6377.32,Fee Schedule,,164.49,,,164.49,Fee Schedule,,349.35,,,349.35,Fee Schedule,,6377.32,,,6377.32,Fee Schedule,,309.4,,,309.4,Fee Schedule,,7200.2,70,,7200.2,percent of total billed charges,All Other,352.6,,,352.6,Fee Schedule,,298.85,,,298.85,Fee Schedule,,4434.05,,,4434.05,Fee Schedule,,4434.05,,,4434.05,Fee Schedule,,4434.05,,,4434.05,Fee Schedule,,4434.05,,,4434.05,Fee Schedule,,292.43,,,292.43,Other,100% of Medicaid,292.43,,,292.43,Other,100% of Medicaid,292.43,,,292.43,Other,100% of Medicaid,292.43,,,292.43,Other,100% of Medicaid,657.98,,,657.98,Other,225% of Medicaid,447.42,,,447.42,Other,153% of Medicaid,657.98,,,657.98,Other,225% of Medicaid,409.41,,,409.41,Other,140% of Medicaid,657.98,,,657.98,Other,225% of Medicaid,760.33,,,760.33,Other,260% of Medicaid,947.49,,,947.49,Other,324% of Medicaid,628.73,,,628.73,Other,215% of Medicaid,628.73,,,628.73,Other,215% of Medicaid,365.54,,,365.54,Other,125% of Medicaid,164.49,7611.67,
X-RAY EXAM CHEST 1 VIEW,71045,CPT,TC,42071045,CDM,324,RC,,,both,,,310,229.4,,,229.4,Other,150% of Medicare + 9.63% HCRA Surcharge,139.5,45,,139.5,percent of total billed charges,Critical Access Hospital RCC factor,60.26,,,60.26,Fee Schedule,,54.21,,,54.21,Fee Schedule,,10.16,,,10.16,Fee Schedule,,10.16,,,10.16,Fee Schedule,,10.16,,,10.16,Fee Schedule,,153.45,,,153.45,Other,110% of Medicare,71.59,,,71.59,Fee Schedule,,53,,,53,Other,186% of Medicaid,84.25,,,84.25,Fee Schedule,,192.2,,,192.2,Fee Schedule,,39.67,,,39.67,Fee Schedule,,84.25,,,84.25,Fee Schedule,,192.2,,,192.2,Fee Schedule,,74.62,,,74.62,Fee Schedule,,217,70,,217,percent of total billed charges,All Other,83.64,,,83.64,Fee Schedule,,70.89,,,70.89,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,10.16,229.4,
X-RAY EXAM CHEST 2 VIEWS,71046,CPT,TC,42071046,CDM,324,RC,,,both,,,369,273.06,,,273.06,Other,150% of Medicare + 9.63% HCRA Surcharge,166.05,45,,166.05,percent of total billed charges,Critical Access Hospital RCC factor,81.03,,,81.03,Fee Schedule,,72.9,,,72.9,Fee Schedule,,18.62,,,18.62,Fee Schedule,,18.62,,,18.62,Fee Schedule,,18.62,,,18.62,Fee Schedule,,182.66,,,182.66,Other,110% of Medicare,96.27,,,96.27,Fee Schedule,,53,,,53,Other,186% of Medicaid,113.28,,,113.28,Fee Schedule,,228.78,,,228.78,Fee Schedule,,53.34,,,53.34,Fee Schedule,,113.28,,,113.28,Fee Schedule,,228.78,,,228.78,Fee Schedule,,100.33,,,100.33,Fee Schedule,,258.3,70,,258.3,percent of total billed charges,All Other,113.16,,,113.16,Fee Schedule,,95.91,,,95.91,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,18.62,273.06,
X-RAY EXAM CHEST 3 VIEWS,71047,CPT,TC,42071047,CDM,324,RC,,,both,,,338,250.12,,,250.12,Other,150% of Medicare + 9.63% HCRA Surcharge,152.1,45,,152.1,percent of total billed charges,Critical Access Hospital RCC factor,101.82,,,101.82,Fee Schedule,,91.61,,,91.61,Fee Schedule,,23.7,,,23.7,Fee Schedule,,23.7,,,23.7,Fee Schedule,,23.7,,,23.7,Fee Schedule,,167.31,,,167.31,Other,110% of Medicare,120.98,,,120.98,Fee Schedule,,53,,,53,Other,186% of Medicaid,142.36,,,142.36,Fee Schedule,,209.56,,,209.56,Fee Schedule,,67.03,,,67.03,Fee Schedule,,142.36,,,142.36,Fee Schedule,,209.56,,,209.56,Fee Schedule,,126.08,,,126.08,Fee Schedule,,236.6,70,,236.6,percent of total billed charges,All Other,144.32,,,144.32,Fee Schedule,,122.32,,,122.32,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,23.7,250.12,
X-RAY EXAM CHEST 4+ VIEWS,71048,CPT,TC,42071048,CDM,324,RC,,,both,,,460,340.4,,,340.4,Other,150% of Medicare + 9.63% HCRA Surcharge,207,45,,207,percent of total billed charges,Critical Access Hospital RCC factor,108.78,,,108.78,Fee Schedule,,97.87,,,97.87,Fee Schedule,,24.38,,,24.38,Fee Schedule,,24.38,,,24.38,Fee Schedule,,24.38,,,24.38,Fee Schedule,,227.7,,,227.7,Other,110% of Medicare,129.24,,,129.24,Fee Schedule,,53,,,53,Other,186% of Medicaid,152.09,,,152.09,Fee Schedule,,285.2,,,285.2,Fee Schedule,,71.61,,,71.61,Fee Schedule,,152.09,,,152.09,Fee Schedule,,285.2,,,285.2,Fee Schedule,,134.7,,,134.7,Fee Schedule,,322,70,,322,percent of total billed charges,All Other,154.16,,,154.16,Fee Schedule,,130.66,,,130.66,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,24.38,340.4,
XR EXAM OF BREASTBONE 3+ VI,71130,CPT,TC,42071130,CDM,324,RC,,,both,,,520,384.8,,,384.8,Other,150% of Medicare + 9.63% HCRA Surcharge,234,45,,234,percent of total billed charges,Critical Access Hospital RCC factor,107.6,,,107.6,Fee Schedule,,96.81,,,96.81,Fee Schedule,,180.87,,,180.87,Fee Schedule,,162.68,,,162.68,Fee Schedule,,153.75,,,153.75,Fee Schedule,,257.4,,,257.4,Other,110% of Medicare,127.84,,,127.84,Fee Schedule,,53,,,53,Other,186% of Medicaid,150.44,,,150.44,Fee Schedule,,322.4,,,322.4,Fee Schedule,,70.83,,,70.83,Fee Schedule,,150.44,,,150.44,Fee Schedule,,322.4,,,322.4,Fee Schedule,,133.23,,,133.23,Fee Schedule,,364,70,,364,percent of total billed charges,All Other,152.52,,,152.52,Fee Schedule,,129.27,,,129.27,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,384.8,
X-RAY EXAM CHEST 1 VIEW W/ FY MOD,71045,CPT,FY,42671045,CDM,324,RC,,,both,,,310,229.4,,,229.4,Other,150% of Medicare + 9.63% HCRA Surcharge,139.5,45,,139.5,percent of total billed charges,Critical Access Hospital RCC factor,60.26,,,60.26,Fee Schedule,,54.21,,,54.21,Fee Schedule,,10.16,,,10.16,Fee Schedule,,10.16,,,10.16,Fee Schedule,,10.16,,,10.16,Fee Schedule,,153.45,,,153.45,Other,110% of Medicare,71.59,,,71.59,Fee Schedule,,53,,,53,Other,186% of Medicaid,84.25,,,84.25,Fee Schedule,,192.2,,,192.2,Fee Schedule,,39.67,,,39.67,Fee Schedule,,84.25,,,84.25,Fee Schedule,,192.2,,,192.2,Fee Schedule,,74.62,,,74.62,Fee Schedule,,217,70,,217,percent of total billed charges,All Other,83.64,,,83.64,Fee Schedule,,70.89,,,70.89,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,10.16,229.4,
X-RAY EXAM CHEST 2 VIEWS W/ FY MOD,71046,CPT,FY,42671046,CDM,324,RC,,,both,,,369,273.06,,,273.06,Other,150% of Medicare + 9.63% HCRA Surcharge,166.05,45,,166.05,percent of total billed charges,Critical Access Hospital RCC factor,81.03,,,81.03,Fee Schedule,,72.9,,,72.9,Fee Schedule,,18.62,,,18.62,Fee Schedule,,18.62,,,18.62,Fee Schedule,,18.62,,,18.62,Fee Schedule,,182.66,,,182.66,Other,110% of Medicare,96.27,,,96.27,Fee Schedule,,53,,,53,Other,186% of Medicaid,113.28,,,113.28,Fee Schedule,,228.78,,,228.78,Fee Schedule,,53.34,,,53.34,Fee Schedule,,113.28,,,113.28,Fee Schedule,,228.78,,,228.78,Fee Schedule,,100.33,,,100.33,Fee Schedule,,258.3,70,,258.3,percent of total billed charges,All Other,113.16,,,113.16,Fee Schedule,,95.91,,,95.91,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,18.62,273.06,
X-RAY EXAM CHEST 3 VIEWS W/ FY MOD,71047,CPT,FY,42671047,CDM,324,RC,,,both,,,338,250.12,,,250.12,Other,150% of Medicare + 9.63% HCRA Surcharge,152.1,45,,152.1,percent of total billed charges,Critical Access Hospital RCC factor,101.82,,,101.82,Fee Schedule,,91.61,,,91.61,Fee Schedule,,23.7,,,23.7,Fee Schedule,,23.7,,,23.7,Fee Schedule,,23.7,,,23.7,Fee Schedule,,167.31,,,167.31,Other,110% of Medicare,120.98,,,120.98,Fee Schedule,,53,,,53,Other,186% of Medicaid,142.36,,,142.36,Fee Schedule,,209.56,,,209.56,Fee Schedule,,67.03,,,67.03,Fee Schedule,,142.36,,,142.36,Fee Schedule,,209.56,,,209.56,Fee Schedule,,126.08,,,126.08,Fee Schedule,,236.6,70,,236.6,percent of total billed charges,All Other,144.32,,,144.32,Fee Schedule,,122.32,,,122.32,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,23.7,250.12,
X-RAY EXAM CHEST 4+ VIEWS W/ FY MOD,71048,CPT,FY,42671048,CDM,324,RC,,,both,,,460,340.4,,,340.4,Other,150% of Medicare + 9.63% HCRA Surcharge,207,45,,207,percent of total billed charges,Critical Access Hospital RCC factor,108.78,,,108.78,Fee Schedule,,97.87,,,97.87,Fee Schedule,,24.38,,,24.38,Fee Schedule,,24.38,,,24.38,Fee Schedule,,24.38,,,24.38,Fee Schedule,,227.7,,,227.7,Other,110% of Medicare,129.24,,,129.24,Fee Schedule,,53,,,53,Other,186% of Medicaid,152.09,,,152.09,Fee Schedule,,285.2,,,285.2,Fee Schedule,,71.61,,,71.61,Fee Schedule,,152.09,,,152.09,Fee Schedule,,285.2,,,285.2,Fee Schedule,,134.7,,,134.7,Fee Schedule,,322,70,,322,percent of total billed charges,All Other,154.16,,,154.16,Fee Schedule,,130.66,,,130.66,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,24.38,340.4,
XR EXAM OF BREASTBONE 3+ VI W/ FY MOD,71130,CPT,FY,42671130,CDM,324,RC,,,both,,,520,384.8,,,384.8,Other,150% of Medicare + 9.63% HCRA Surcharge,234,45,,234,percent of total billed charges,Critical Access Hospital RCC factor,107.6,,,107.6,Fee Schedule,,96.81,,,96.81,Fee Schedule,,180.87,,,180.87,Fee Schedule,,162.68,,,162.68,Fee Schedule,,153.75,,,153.75,Fee Schedule,,257.4,,,257.4,Other,110% of Medicare,127.84,,,127.84,Fee Schedule,,53,,,53,Other,186% of Medicaid,150.44,,,150.44,Fee Schedule,,322.4,,,322.4,Fee Schedule,,70.83,,,70.83,Fee Schedule,,150.44,,,150.44,Fee Schedule,,322.4,,,322.4,Fee Schedule,,133.23,,,133.23,Fee Schedule,,364,70,,364,percent of total billed charges,All Other,152.52,,,152.52,Fee Schedule,,129.27,,,129.27,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,384.8,
X-RAY EXAM CHEST 2 VIEWS W/ FY MOD,71046,CPT,FY,43071046,CDM,324,RC,,,both,,,369,273.06,,,273.06,Other,150% of Medicare + 9.63% HCRA Surcharge,166.05,45,,166.05,percent of total billed charges,Critical Access Hospital RCC factor,81.03,,,81.03,Fee Schedule,,72.9,,,72.9,Fee Schedule,,18.62,,,18.62,Fee Schedule,,18.62,,,18.62,Fee Schedule,,18.62,,,18.62,Fee Schedule,,182.66,,,182.66,Other,110% of Medicare,96.27,,,96.27,Fee Schedule,,53,,,53,Other,186% of Medicaid,113.28,,,113.28,Fee Schedule,,228.78,,,228.78,Fee Schedule,,53.34,,,53.34,Fee Schedule,,113.28,,,113.28,Fee Schedule,,228.78,,,228.78,Fee Schedule,,100.33,,,100.33,Fee Schedule,,258.3,70,,258.3,percent of total billed charges,All Other,113.16,,,113.16,Fee Schedule,,95.91,,,95.91,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,18.62,273.06,
X-RAY EXAM CHEST 2 VIEWS W/ FY MOD,71046,CPT,FY,43071046FY,CDM,324,RC,,,both,,,369,273.06,,,273.06,Other,150% of Medicare + 9.63% HCRA Surcharge,166.05,45,,166.05,percent of total billed charges,Critical Access Hospital RCC factor,81.03,,,81.03,Fee Schedule,,72.9,,,72.9,Fee Schedule,,18.62,,,18.62,Fee Schedule,,18.62,,,18.62,Fee Schedule,,18.62,,,18.62,Fee Schedule,,182.66,,,182.66,Other,110% of Medicare,96.27,,,96.27,Fee Schedule,,53,,,53,Other,186% of Medicaid,113.28,,,113.28,Fee Schedule,,228.78,,,228.78,Fee Schedule,,53.34,,,53.34,Fee Schedule,,113.28,,,113.28,Fee Schedule,,228.78,,,228.78,Fee Schedule,,100.33,,,100.33,Fee Schedule,,258.3,70,,258.3,percent of total billed charges,All Other,113.16,,,113.16,Fee Schedule,,95.91,,,95.91,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,18.62,273.06,
XR COLON W AIR & BARIUM,74280,CPT,TC,42074280,CDM,329,RC,,,both,,,1452,1074.48,,,1074.48,Other,150% of Medicare + 9.63% HCRA Surcharge,653.4,45,,653.4,percent of total billed charges,Critical Access Hospital RCC factor,557.17,,,557.17,Fee Schedule,,501.27,,,501.27,Fee Schedule,,956.61,,,956.61,Fee Schedule,,860.4,,,860.4,Fee Schedule,,813.21,,,813.21,Fee Schedule,,718.74,,,718.74,Other,110% of Medicare,661.96,,,661.96,Fee Schedule,,392,,,392,Other,186% of Medicaid,778.98,,,778.98,Fee Schedule,,900.24,,,900.24,Fee Schedule,,366.79,,,366.79,Fee Schedule,,778.98,,,778.98,Fee Schedule,,900.24,,,900.24,Fee Schedule,,689.91,,,689.91,Fee Schedule,,1016.4,70,,1016.4,percent of total billed charges,All Other,826.56,,,826.56,Fee Schedule,,700.56,,,700.56,Fee Schedule,,291.55,,,291.55,Fee Schedule,,291.55,,,291.55,Fee Schedule,,291.55,,,291.55,Fee Schedule,,291.55,,,291.55,Fee Schedule,,210.57,,,210.57,Other,100% of Medicaid,210.57,,,210.57,Other,100% of Medicaid,210.57,,,210.57,Other,100% of Medicaid,210.57,,,210.57,Other,100% of Medicaid,473.77,,,473.77,Other,225% of Medicaid,322.17,,,322.17,Other,153% of Medicaid,473.77,,,473.77,Other,225% of Medicaid,294.79,,,294.79,Other,140% of Medicaid,473.77,,,473.77,Other,225% of Medicaid,547.47,,,547.47,Other,260% of Medicaid,682.23,,,682.23,Other,324% of Medicaid,452.72,,,452.72,Other,215% of Medicaid,452.72,,,452.72,Other,215% of Medicaid,263.21,,,263.21,Other,125% of Medicaid,210.57,1074.48,
XR COLON W AIR & BARIUM W/ FY MOD,74280,CPT,FY,42674280,CDM,329,RC,,,both,,,1452,1074.48,,,1074.48,Other,150% of Medicare + 9.63% HCRA Surcharge,653.4,45,,653.4,percent of total billed charges,Critical Access Hospital RCC factor,557.17,,,557.17,Fee Schedule,,501.27,,,501.27,Fee Schedule,,956.61,,,956.61,Fee Schedule,,860.4,,,860.4,Fee Schedule,,813.21,,,813.21,Fee Schedule,,718.74,,,718.74,Other,110% of Medicare,661.96,,,661.96,Fee Schedule,,392,,,392,Other,186% of Medicaid,778.98,,,778.98,Fee Schedule,,900.24,,,900.24,Fee Schedule,,366.79,,,366.79,Fee Schedule,,778.98,,,778.98,Fee Schedule,,900.24,,,900.24,Fee Schedule,,689.91,,,689.91,Fee Schedule,,1016.4,70,,1016.4,percent of total billed charges,All Other,826.56,,,826.56,Fee Schedule,,700.56,,,700.56,Fee Schedule,,291.55,,,291.55,Fee Schedule,,291.55,,,291.55,Fee Schedule,,291.55,,,291.55,Fee Schedule,,291.55,,,291.55,Fee Schedule,,210.57,,,210.57,Other,100% of Medicaid,210.57,,,210.57,Other,100% of Medicaid,210.57,,,210.57,Other,100% of Medicaid,210.57,,,210.57,Other,100% of Medicaid,473.77,,,473.77,Other,225% of Medicaid,322.17,,,322.17,Other,153% of Medicaid,473.77,,,473.77,Other,225% of Medicaid,294.79,,,294.79,Other,140% of Medicaid,473.77,,,473.77,Other,225% of Medicaid,547.47,,,547.47,Other,260% of Medicaid,682.23,,,682.23,Other,324% of Medicaid,452.72,,,452.72,Other,215% of Medicaid,452.72,,,452.72,Other,215% of Medicaid,263.21,,,263.21,Other,125% of Medicaid,210.57,1074.48,
XR FINGER 2+ VIEWS RT W/ FY MOD,73140,CPT,FYRT,43273140,CDM,329,RC,,,both,,,231,170.94,,,170.94,Other,150% of Medicare + 9.63% HCRA Surcharge,103.95,45,,103.95,percent of total billed charges,Critical Access Hospital RCC factor,109.93,,,109.93,Fee Schedule,,98.9,,,98.9,Fee Schedule,,167.16,,,167.16,Fee Schedule,,150.35,,,150.35,Fee Schedule,,142.11,,,142.11,Fee Schedule,,114.35,,,114.35,Other,110% of Medicare,130.6,,,130.6,Fee Schedule,,53,,,53,Other,186% of Medicaid,153.69,,,153.69,Fee Schedule,,143.22,,,143.22,Fee Schedule,,72.37,,,72.37,Fee Schedule,,153.69,,,153.69,Fee Schedule,,143.22,,,143.22,Fee Schedule,,136.12,,,136.12,Fee Schedule,,161.7,70,,161.7,percent of total billed charges,All Other,150.88,,,150.88,Fee Schedule,,127.88,,,127.88,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,28.67,,,28.67,Other,100% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,43.86,,,43.86,Other,153% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,40.13,,,40.13,Other,140% of Medicaid,64.5,,,64.5,Other,225% of Medicaid,74.54,,,74.54,Other,260% of Medicaid,92.88,,,92.88,Other,324% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,61.63,,,61.63,Other,215% of Medicaid,35.83,,,35.83,Other,125% of Medicaid,28.67,170.94,
CAVOGRAM INFERIOR,75825,CPT,TC,47075825,CDM,329,RC,,,both,,,6707,4963.2,,,4963.2,Other,150% of Medicare + 9.63% HCRA Surcharge,3018.15,45,,3018.15,percent of total billed charges,Critical Access Hospital RCC factor,213.89,,,213.89,Fee Schedule,,192.43,,,192.43,Fee Schedule,,1011.52,,,1011.52,Fee Schedule,,909.8,,,909.8,Fee Schedule,,859.89,,,859.89,Fee Schedule,,3319.97,,,3319.97,Other,110% of Medicare,254.12,,,254.12,Fee Schedule,,544,,,544,Other,186% of Medicaid,299.04,,,299.04,Fee Schedule,,4158.34,,,4158.34,Fee Schedule,,140.81,,,140.81,Fee Schedule,,299.04,,,299.04,Fee Schedule,,4158.34,,,4158.34,Fee Schedule,,264.85,,,264.85,Fee Schedule,,4694.9,70,,4694.9,percent of total billed charges,All Other,303.4,,,303.4,Fee Schedule,,257.15,,,257.15,Fee Schedule,,4434.05,,,4434.05,Fee Schedule,,4434.05,,,4434.05,Fee Schedule,,4434.05,,,4434.05,Fee Schedule,,4434.05,,,4434.05,Fee Schedule,,292.43,,,292.43,Other,100% of Medicaid,292.43,,,292.43,Other,100% of Medicaid,292.43,,,292.43,Other,100% of Medicaid,292.43,,,292.43,Other,100% of Medicaid,657.98,,,657.98,Other,225% of Medicaid,447.42,,,447.42,Other,153% of Medicaid,657.98,,,657.98,Other,225% of Medicaid,409.41,,,409.41,Other,140% of Medicaid,657.98,,,657.98,Other,225% of Medicaid,760.33,,,760.33,Other,260% of Medicaid,947.49,,,947.49,Other,324% of Medicaid,628.73,,,628.73,Other,215% of Medicaid,628.73,,,628.73,Other,215% of Medicaid,365.54,,,365.54,Other,125% of Medicaid,140.81,4963.2,
ARTERIAL EMBOLIZATION,75894,CPT,TC,47075894,CDM,329,RC,,,both,,,2144,1586.57,,,1586.57,Other,150% of Medicare + 9.63% HCRA Surcharge,964.8,45,,964.8,percent of total billed charges,Critical Access Hospital RCC factor,1393.6,65,,1393.6,percent of total billed charges,All Other,1264.96,65,,1264.96,percent of total billed charges,All Other,914.17,,,914.17,Fee Schedule,,914.17,,,914.17,Fee Schedule,,914.17,,,914.17,Fee Schedule,,1061.28,,,1061.28,Other,110% of Medicare,1457.92,68,,1457.92,percent of total billed charges,All Other,544,,,544,Other,186% of Medicaid,1715.2,80,,1715.2,percent of total billed charges,All Other,1779.52,83,,1779.52,percent of total billed charges,All Other,1779.52,83,,1779.52,percent of total billed charges,All Other,1715.2,80,,1715.2,percent of total billed charges,All Other,1779.52,83,,1779.52,percent of total billed charges,All Other,1715.2,80,,1715.2,percent of total billed charges,All Other,1500.8,70,,1500.8,percent of total billed charges,All Other,1393.6,65,,1393.6,percent of total billed charges,Default if not in Fee Schedule,1393.6,65,,1393.6,percent of total billed charges,Default if not in Fee Schedule,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,292.43,,,292.43,Other,100% of Medicaid,292.43,,,292.43,Other,100% of Medicaid,292.43,,,292.43,Other,100% of Medicaid,292.43,,,292.43,Other,100% of Medicaid,657.97,,,657.97,Other,225% of Medicaid,447.42,,,447.42,Other,153% of Medicaid,657.97,,,657.97,Other,225% of Medicaid,409.4,,,409.4,Other,140% of Medicaid,657.97,,,657.97,Other,225% of Medicaid,760.32,,,760.32,Other,260% of Medicaid,947.48,,,947.48,Other,324% of Medicaid,628.73,,,628.73,Other,215% of Medicaid,628.73,,,628.73,Other,215% of Medicaid,365.54,,,365.54,Other,125% of Medicaid,0.01,1779.52,
CHEMO ADMIN NON HORMONAL SC/IM,96401,CPT,,34096401,CDM,331,RC,,,both,,,201,148.74,,,148.74,Other,150% of Medicare + 9.63% HCRA Surcharge,90.45,45,,90.45,percent of total billed charges,Critical Access Hospital RCC factor,598,,,598,Case Rate,Chemotherapy Per Visit,538,,,538,Case Rate,Chemotherapy Per Visit,1061,,,1061,Case Rate,Chemotherapy Per Visit,955,,,955,Case Rate,Chemotherapy Per Visit,902,,,902,Case Rate,Chemotherapy Per Visit,99.5,,,99.5,Other,110% of Medicare,136.68,68,,136.68,percent of total billed charges,All Other,58,,,58,Other,186% of Medicaid,160.8,80,,160.8,percent of total billed charges,All Other,166.83,83,,166.83,percent of total billed charges,All Other,166.83,83,,166.83,percent of total billed charges,All Other,160.8,80,,160.8,percent of total billed charges,All Other,166.83,83,,166.83,percent of total billed charges,All Other,160.8,80,,160.8,percent of total billed charges,All Other,140.7,70,,140.7,percent of total billed charges,All Other,369,,,369,Fee Schedule,,312.75,,,312.75,Fee Schedule,,953,,,953,Case Rate,Chemotherapy Per Visit,858,,,858,Case Rate,Chemotherapy Per Visit,953,,,953,Case Rate,Chemotherapy Per Visit,810,,,810,Case Rate,Chemotherapy Per Visit,31.2,,,31.2,Other,100% of Medicaid,31.2,,,31.2,Other,100% of Medicaid,31.2,,,31.2,Other,100% of Medicaid,31.2,,,31.2,Other,100% of Medicaid,70.2,,,70.2,Other,225% of Medicaid,47.74,,,47.74,Other,153% of Medicaid,70.2,,,70.2,Other,225% of Medicaid,43.68,,,43.68,Other,140% of Medicaid,70.2,,,70.2,Other,225% of Medicaid,81.12,,,81.12,Other,260% of Medicaid,101.09,,,101.09,Other,324% of Medicaid,67.08,,,67.08,Other,215% of Medicaid,67.08,,,67.08,Other,215% of Medicaid,39,,,39,Other,125% of Medicaid,31.2,1061,
CHEMO SUBQ/IM HORMONAL,96402,CPT,,34096402,CDM,331,RC,,,both,,,187,138.38,,,138.38,Other,150% of Medicare + 9.63% HCRA Surcharge,84.15,45,,84.15,percent of total billed charges,Critical Access Hospital RCC factor,598,,,598,Case Rate,Chemotherapy Per Visit,538,,,538,Case Rate,Chemotherapy Per Visit,1061,,,1061,Case Rate,Chemotherapy Per Visit,955,,,955,Case Rate,Chemotherapy Per Visit,902,,,902,Case Rate,Chemotherapy Per Visit,92.57,,,92.57,Other,110% of Medicare,127.16,68,,127.16,percent of total billed charges,All Other,58,,,58,Other,186% of Medicaid,149.6,80,,149.6,percent of total billed charges,All Other,155.21,83,,155.21,percent of total billed charges,All Other,155.21,83,,155.21,percent of total billed charges,All Other,149.6,80,,149.6,percent of total billed charges,All Other,155.21,83,,155.21,percent of total billed charges,All Other,149.6,80,,149.6,percent of total billed charges,All Other,130.9,70,,130.9,percent of total billed charges,All Other,160.72,,,160.72,Fee Schedule,,136.22,,,136.22,Fee Schedule,,953,,,953,Case Rate,Chemotherapy Per Visit,858,,,858,Case Rate,Chemotherapy Per Visit,953,,,953,Case Rate,Chemotherapy Per Visit,810,,,810,Case Rate,Chemotherapy Per Visit,31.2,,,31.2,Other,100% of Medicaid,31.2,,,31.2,Other,100% of Medicaid,31.2,,,31.2,Other,100% of Medicaid,31.2,,,31.2,Other,100% of Medicaid,70.2,,,70.2,Other,225% of Medicaid,47.74,,,47.74,Other,153% of Medicaid,70.2,,,70.2,Other,225% of Medicaid,43.68,,,43.68,Other,140% of Medicaid,70.2,,,70.2,Other,225% of Medicaid,81.12,,,81.12,Other,260% of Medicaid,101.09,,,101.09,Other,324% of Medicaid,67.08,,,67.08,Other,215% of Medicaid,67.08,,,67.08,Other,215% of Medicaid,39,,,39,Other,125% of Medicaid,31.2,1061,
CHEMO IV PUSH SNGL DRUG INITIA,96409,CPT,,34096409,CDM,331,RC,,,both,,,1106,818.44,,,818.44,Other,150% of Medicare + 9.63% HCRA Surcharge,497.7,45,,497.7,percent of total billed charges,Critical Access Hospital RCC factor,598,,,598,Case Rate,Chemotherapy Per Visit,538,,,538,Case Rate,Chemotherapy Per Visit,1061,,,1061,Case Rate,Chemotherapy Per Visit,955,,,955,Case Rate,Chemotherapy Per Visit,902,,,902,Case Rate,Chemotherapy Per Visit,547.47,,,547.47,Other,110% of Medicare,752.08,68,,752.08,percent of total billed charges,All Other,58,,,58,Other,186% of Medicaid,884.8,80,,884.8,percent of total billed charges,All Other,917.98,83,,917.98,percent of total billed charges,All Other,917.98,83,,917.98,percent of total billed charges,All Other,884.8,80,,884.8,percent of total billed charges,All Other,917.98,83,,917.98,percent of total billed charges,All Other,884.8,80,,884.8,percent of total billed charges,All Other,774.2,70,,774.2,percent of total billed charges,All Other,511.68,,,511.68,Fee Schedule,,433.68,,,433.68,Fee Schedule,,953,,,953,Case Rate,Chemotherapy Per Visit,858,,,858,Case Rate,Chemotherapy Per Visit,953,,,953,Case Rate,Chemotherapy Per Visit,810,,,810,Case Rate,Chemotherapy Per Visit,31.2,,,31.2,Other,100% of Medicaid,31.2,,,31.2,Other,100% of Medicaid,31.2,,,31.2,Other,100% of Medicaid,31.2,,,31.2,Other,100% of Medicaid,70.2,,,70.2,Other,225% of Medicaid,47.74,,,47.74,Other,153% of Medicaid,70.2,,,70.2,Other,225% of Medicaid,43.68,,,43.68,Other,140% of Medicaid,70.2,,,70.2,Other,225% of Medicaid,81.12,,,81.12,Other,260% of Medicaid,101.09,,,101.09,Other,324% of Medicaid,67.08,,,67.08,Other,215% of Medicaid,67.08,,,67.08,Other,215% of Medicaid,39,,,39,Other,125% of Medicaid,31.2,1061,
CHEMO IV PUSH TECHNIQUE EA ADL,96411,CPT,,34096411,CDM,331,RC,,,both,,,1352,1000.48,,,1000.48,Other,150% of Medicare + 9.63% HCRA Surcharge,608.4,45,,608.4,percent of total billed charges,Critical Access Hospital RCC factor,598,,,598,Case Rate,Chemotherapy Per Visit,538,,,538,Case Rate,Chemotherapy Per Visit,1061,,,1061,Case Rate,Chemotherapy Per Visit,955,,,955,Case Rate,Chemotherapy Per Visit,902,,,902,Case Rate,Chemotherapy Per Visit,669.24,,,669.24,Other,110% of Medicare,919.36,68,,919.36,percent of total billed charges,All Other,58,,,58,Other,186% of Medicaid,1081.6,80,,1081.6,percent of total billed charges,All Other,1122.16,83,,1122.16,percent of total billed charges,All Other,1122.16,83,,1122.16,percent of total billed charges,All Other,1081.6,80,,1081.6,percent of total billed charges,All Other,1122.16,83,,1122.16,percent of total billed charges,All Other,1081.6,80,,1081.6,percent of total billed charges,All Other,946.4,70,,946.4,percent of total billed charges,All Other,278.8,,,278.8,Fee Schedule,,236.3,,,236.3,Fee Schedule,,953,,,953,Case Rate,Chemotherapy Per Visit,858,,,858,Case Rate,Chemotherapy Per Visit,953,,,953,Case Rate,Chemotherapy Per Visit,810,,,810,Case Rate,Chemotherapy Per Visit,31.2,,,31.2,Other,100% of Medicaid,31.2,,,31.2,Other,100% of Medicaid,31.2,,,31.2,Other,100% of Medicaid,31.2,,,31.2,Other,100% of Medicaid,70.2,,,70.2,Other,225% of Medicaid,47.74,,,47.74,Other,153% of Medicaid,70.2,,,70.2,Other,225% of Medicaid,43.68,,,43.68,Other,140% of Medicaid,70.2,,,70.2,Other,225% of Medicaid,81.12,,,81.12,Other,260% of Medicaid,101.09,,,101.09,Other,324% of Medicaid,67.08,,,67.08,Other,215% of Medicaid,67.08,,,67.08,Other,215% of Medicaid,39,,,39,Other,125% of Medicaid,31.2,1122.16,
CHEMO CNS (INTRATHECAL) W LP,96450,CPT,,42096450,CDM,331,RC,,,both,,,932,689.68,,,689.68,Other,150% of Medicare + 9.63% HCRA Surcharge,419.4,45,,419.4,percent of total billed charges,Critical Access Hospital RCC factor,598,,,598,Case Rate,Chemotherapy Per Visit,538,,,538,Case Rate,Chemotherapy Per Visit,1061,,,1061,Case Rate,Chemotherapy Per Visit,955,,,955,Case Rate,Chemotherapy Per Visit,902,,,902,Case Rate,Chemotherapy Per Visit,461.34,,,461.34,Other,110% of Medicare,633.76,68,,633.76,percent of total billed charges,All Other,1098,,,1098,Other,186% of Medicaid,745.6,80,,745.6,percent of total billed charges,All Other,773.56,83,,773.56,percent of total billed charges,All Other,773.56,83,,773.56,percent of total billed charges,All Other,745.6,80,,745.6,percent of total billed charges,All Other,773.56,83,,773.56,percent of total billed charges,All Other,745.6,80,,745.6,percent of total billed charges,All Other,652.4,70,,652.4,percent of total billed charges,All Other,367.36,,,367.36,Fee Schedule,,311.36,,,311.36,Fee Schedule,,953,,,953,Case Rate,Chemotherapy Per Visit,858,,,858,Case Rate,Chemotherapy Per Visit,953,,,953,Case Rate,Chemotherapy Per Visit,810,,,810,Case Rate,Chemotherapy Per Visit,590.24,,,590.24,Other,100% of Medicaid,590.24,,,590.24,Other,100% of Medicaid,590.24,,,590.24,Other,100% of Medicaid,590.24,,,590.24,Other,100% of Medicaid,1328.05,,,1328.05,Other,225% of Medicaid,903.07,,,903.07,Other,153% of Medicaid,1328.05,,,1328.05,Other,225% of Medicaid,826.34,,,826.34,Other,140% of Medicaid,1328.05,,,1328.05,Other,225% of Medicaid,1534.64,,,1534.64,Other,260% of Medicaid,1912.39,,,1912.39,Other,324% of Medicaid,1269.03,,,1269.03,Other,215% of Medicaid,1269.03,,,1269.03,Other,215% of Medicaid,737.81,,,737.81,Other,125% of Medicaid,311.36,1912.39,
CHEMO CNS (INTRATHECAL) W LP FY MOD,96450,CPT,,42696450,CDM,331,RC,,,both,,,932,689.68,,,689.68,Other,150% of Medicare + 9.63% HCRA Surcharge,419.4,45,,419.4,percent of total billed charges,Critical Access Hospital RCC factor,598,,,598,Case Rate,Chemotherapy Per Visit,538,,,538,Case Rate,Chemotherapy Per Visit,1061,,,1061,Case Rate,Chemotherapy Per Visit,955,,,955,Case Rate,Chemotherapy Per Visit,902,,,902,Case Rate,Chemotherapy Per Visit,461.34,,,461.34,Other,110% of Medicare,633.76,68,,633.76,percent of total billed charges,All Other,1098,,,1098,Other,186% of Medicaid,745.6,80,,745.6,percent of total billed charges,All Other,773.56,83,,773.56,percent of total billed charges,All Other,773.56,83,,773.56,percent of total billed charges,All Other,745.6,80,,745.6,percent of total billed charges,All Other,773.56,83,,773.56,percent of total billed charges,All Other,745.6,80,,745.6,percent of total billed charges,All Other,652.4,70,,652.4,percent of total billed charges,All Other,367.36,,,367.36,Fee Schedule,,311.36,,,311.36,Fee Schedule,,953,,,953,Case Rate,Chemotherapy Per Visit,858,,,858,Case Rate,Chemotherapy Per Visit,953,,,953,Case Rate,Chemotherapy Per Visit,810,,,810,Case Rate,Chemotherapy Per Visit,590.24,,,590.24,Other,100% of Medicaid,590.24,,,590.24,Other,100% of Medicaid,590.24,,,590.24,Other,100% of Medicaid,590.24,,,590.24,Other,100% of Medicaid,1328.05,,,1328.05,Other,225% of Medicaid,903.07,,,903.07,Other,153% of Medicaid,1328.05,,,1328.05,Other,225% of Medicaid,826.34,,,826.34,Other,140% of Medicaid,1328.05,,,1328.05,Other,225% of Medicaid,1534.64,,,1534.64,Other,260% of Medicaid,1912.39,,,1912.39,Other,324% of Medicaid,1269.03,,,1269.03,Other,215% of Medicaid,1269.03,,,1269.03,Other,215% of Medicaid,737.81,,,737.81,Other,125% of Medicaid,311.36,1912.39,
CHEMO ADMIN NON HORMONAL SC/IM,96401,CPT,,75096401,CDM,331,RC,,,both,,,201,148.74,,,148.74,Other,150% of Medicare + 9.63% HCRA Surcharge,90.45,45,,90.45,percent of total billed charges,Critical Access Hospital RCC factor,598,,,598,Case Rate,Chemotherapy Per Visit,538,,,538,Case Rate,Chemotherapy Per Visit,1061,,,1061,Case Rate,Chemotherapy Per Visit,955,,,955,Case Rate,Chemotherapy Per Visit,902,,,902,Case Rate,Chemotherapy Per Visit,99.5,,,99.5,Other,110% of Medicare,136.68,68,,136.68,percent of total billed charges,All Other,58,,,58,Other,186% of Medicaid,160.8,80,,160.8,percent of total billed charges,All Other,166.83,83,,166.83,percent of total billed charges,All Other,166.83,83,,166.83,percent of total billed charges,All Other,160.8,80,,160.8,percent of total billed charges,All Other,166.83,83,,166.83,percent of total billed charges,All Other,160.8,80,,160.8,percent of total billed charges,All Other,140.7,70,,140.7,percent of total billed charges,All Other,369,,,369,Fee Schedule,,312.75,,,312.75,Fee Schedule,,953,,,953,Case Rate,Chemotherapy Per Visit,858,,,858,Case Rate,Chemotherapy Per Visit,953,,,953,Case Rate,Chemotherapy Per Visit,810,,,810,Case Rate,Chemotherapy Per Visit,31.2,,,31.2,Other,100% of Medicaid,31.2,,,31.2,Other,100% of Medicaid,31.2,,,31.2,Other,100% of Medicaid,31.2,,,31.2,Other,100% of Medicaid,70.2,,,70.2,Other,225% of Medicaid,47.74,,,47.74,Other,153% of Medicaid,70.2,,,70.2,Other,225% of Medicaid,43.68,,,43.68,Other,140% of Medicaid,70.2,,,70.2,Other,225% of Medicaid,81.12,,,81.12,Other,260% of Medicaid,101.09,,,101.09,Other,324% of Medicaid,67.08,,,67.08,Other,215% of Medicaid,67.08,,,67.08,Other,215% of Medicaid,39,,,39,Other,125% of Medicaid,31.2,1061,
CHEMO SUBQ/IM HORMONAL,96402,CPT,,75096402,CDM,331,RC,,,both,,,187,138.38,,,138.38,Other,150% of Medicare + 9.63% HCRA Surcharge,84.15,45,,84.15,percent of total billed charges,Critical Access Hospital RCC factor,598,,,598,Case Rate,Chemotherapy Per Visit,538,,,538,Case Rate,Chemotherapy Per Visit,1061,,,1061,Case Rate,Chemotherapy Per Visit,955,,,955,Case Rate,Chemotherapy Per Visit,902,,,902,Case Rate,Chemotherapy Per Visit,92.57,,,92.57,Other,110% of Medicare,127.16,68,,127.16,percent of total billed charges,All Other,58,,,58,Other,186% of Medicaid,149.6,80,,149.6,percent of total billed charges,All Other,155.21,83,,155.21,percent of total billed charges,All Other,155.21,83,,155.21,percent of total billed charges,All Other,149.6,80,,149.6,percent of total billed charges,All Other,155.21,83,,155.21,percent of total billed charges,All Other,149.6,80,,149.6,percent of total billed charges,All Other,130.9,70,,130.9,percent of total billed charges,All Other,160.72,,,160.72,Fee Schedule,,136.22,,,136.22,Fee Schedule,,953,,,953,Case Rate,Chemotherapy Per Visit,858,,,858,Case Rate,Chemotherapy Per Visit,953,,,953,Case Rate,Chemotherapy Per Visit,810,,,810,Case Rate,Chemotherapy Per Visit,31.2,,,31.2,Other,100% of Medicaid,31.2,,,31.2,Other,100% of Medicaid,31.2,,,31.2,Other,100% of Medicaid,31.2,,,31.2,Other,100% of Medicaid,70.2,,,70.2,Other,225% of Medicaid,47.74,,,47.74,Other,153% of Medicaid,70.2,,,70.2,Other,225% of Medicaid,43.68,,,43.68,Other,140% of Medicaid,70.2,,,70.2,Other,225% of Medicaid,81.12,,,81.12,Other,260% of Medicaid,101.09,,,101.09,Other,324% of Medicaid,67.08,,,67.08,Other,215% of Medicaid,67.08,,,67.08,Other,215% of Medicaid,39,,,39,Other,125% of Medicaid,31.2,1061,
CHEMO IV PUSH SNGL DRUG INITIA,96409,CPT,,75096409,CDM,331,RC,,,both,,,1106,818.44,,,818.44,Other,150% of Medicare + 9.63% HCRA Surcharge,497.7,45,,497.7,percent of total billed charges,Critical Access Hospital RCC factor,598,,,598,Case Rate,Chemotherapy Per Visit,538,,,538,Case Rate,Chemotherapy Per Visit,1061,,,1061,Case Rate,Chemotherapy Per Visit,955,,,955,Case Rate,Chemotherapy Per Visit,902,,,902,Case Rate,Chemotherapy Per Visit,547.47,,,547.47,Other,110% of Medicare,752.08,68,,752.08,percent of total billed charges,All Other,58,,,58,Other,186% of Medicaid,884.8,80,,884.8,percent of total billed charges,All Other,917.98,83,,917.98,percent of total billed charges,All Other,917.98,83,,917.98,percent of total billed charges,All Other,884.8,80,,884.8,percent of total billed charges,All Other,917.98,83,,917.98,percent of total billed charges,All Other,884.8,80,,884.8,percent of total billed charges,All Other,774.2,70,,774.2,percent of total billed charges,All Other,511.68,,,511.68,Fee Schedule,,433.68,,,433.68,Fee Schedule,,953,,,953,Case Rate,Chemotherapy Per Visit,858,,,858,Case Rate,Chemotherapy Per Visit,953,,,953,Case Rate,Chemotherapy Per Visit,810,,,810,Case Rate,Chemotherapy Per Visit,31.2,,,31.2,Other,100% of Medicaid,31.2,,,31.2,Other,100% of Medicaid,31.2,,,31.2,Other,100% of Medicaid,31.2,,,31.2,Other,100% of Medicaid,70.2,,,70.2,Other,225% of Medicaid,47.74,,,47.74,Other,153% of Medicaid,70.2,,,70.2,Other,225% of Medicaid,43.68,,,43.68,Other,140% of Medicaid,70.2,,,70.2,Other,225% of Medicaid,81.12,,,81.12,Other,260% of Medicaid,101.09,,,101.09,Other,324% of Medicaid,67.08,,,67.08,Other,215% of Medicaid,67.08,,,67.08,Other,215% of Medicaid,39,,,39,Other,125% of Medicaid,31.2,1061,
CHEMO IV PUSH TECHNIQUE EA ADL,96411,CPT,,75096411,CDM,331,RC,,,both,,,1352,1000.48,,,1000.48,Other,150% of Medicare + 9.63% HCRA Surcharge,608.4,45,,608.4,percent of total billed charges,Critical Access Hospital RCC factor,598,,,598,Case Rate,Chemotherapy Per Visit,538,,,538,Case Rate,Chemotherapy Per Visit,1061,,,1061,Case Rate,Chemotherapy Per Visit,955,,,955,Case Rate,Chemotherapy Per Visit,902,,,902,Case Rate,Chemotherapy Per Visit,669.24,,,669.24,Other,110% of Medicare,919.36,68,,919.36,percent of total billed charges,All Other,58,,,58,Other,186% of Medicaid,1081.6,80,,1081.6,percent of total billed charges,All Other,1122.16,83,,1122.16,percent of total billed charges,All Other,1122.16,83,,1122.16,percent of total billed charges,All Other,1081.6,80,,1081.6,percent of total billed charges,All Other,1122.16,83,,1122.16,percent of total billed charges,All Other,1081.6,80,,1081.6,percent of total billed charges,All Other,946.4,70,,946.4,percent of total billed charges,All Other,278.8,,,278.8,Fee Schedule,,236.3,,,236.3,Fee Schedule,,953,,,953,Case Rate,Chemotherapy Per Visit,858,,,858,Case Rate,Chemotherapy Per Visit,953,,,953,Case Rate,Chemotherapy Per Visit,810,,,810,Case Rate,Chemotherapy Per Visit,31.2,,,31.2,Other,100% of Medicaid,31.2,,,31.2,Other,100% of Medicaid,31.2,,,31.2,Other,100% of Medicaid,31.2,,,31.2,Other,100% of Medicaid,70.2,,,70.2,Other,225% of Medicaid,47.74,,,47.74,Other,153% of Medicaid,70.2,,,70.2,Other,225% of Medicaid,43.68,,,43.68,Other,140% of Medicaid,70.2,,,70.2,Other,225% of Medicaid,81.12,,,81.12,Other,260% of Medicaid,101.09,,,101.09,Other,324% of Medicaid,67.08,,,67.08,Other,215% of Medicaid,67.08,,,67.08,Other,215% of Medicaid,39,,,39,Other,125% of Medicaid,31.2,1122.16,
CHEMO ANTI-NEOPL SQ/IM,96401,CPT,,82096401,CDM,331,RC,,,both,,,201,148.74,,,148.74,Other,150% of Medicare + 9.63% HCRA Surcharge,90.45,45,,90.45,percent of total billed charges,Critical Access Hospital RCC factor,598,,,598,Case Rate,Chemotherapy Per Visit,538,,,538,Case Rate,Chemotherapy Per Visit,1061,,,1061,Case Rate,Chemotherapy Per Visit,955,,,955,Case Rate,Chemotherapy Per Visit,902,,,902,Case Rate,Chemotherapy Per Visit,99.5,,,99.5,Other,110% of Medicare,136.68,68,,136.68,percent of total billed charges,All Other,58,,,58,Other,186% of Medicaid,160.8,80,,160.8,percent of total billed charges,All Other,166.83,83,,166.83,percent of total billed charges,All Other,166.83,83,,166.83,percent of total billed charges,All Other,160.8,80,,160.8,percent of total billed charges,All Other,166.83,83,,166.83,percent of total billed charges,All Other,160.8,80,,160.8,percent of total billed charges,All Other,140.7,70,,140.7,percent of total billed charges,All Other,369,,,369,Fee Schedule,,312.75,,,312.75,Fee Schedule,,953,,,953,Case Rate,Chemotherapy Per Visit,858,,,858,Case Rate,Chemotherapy Per Visit,953,,,953,Case Rate,Chemotherapy Per Visit,810,,,810,Case Rate,Chemotherapy Per Visit,31.2,,,31.2,Other,100% of Medicaid,31.2,,,31.2,Other,100% of Medicaid,31.2,,,31.2,Other,100% of Medicaid,31.2,,,31.2,Other,100% of Medicaid,70.2,,,70.2,Other,225% of Medicaid,47.74,,,47.74,Other,153% of Medicaid,70.2,,,70.2,Other,225% of Medicaid,43.68,,,43.68,Other,140% of Medicaid,70.2,,,70.2,Other,225% of Medicaid,81.12,,,81.12,Other,260% of Medicaid,101.09,,,101.09,Other,324% of Medicaid,67.08,,,67.08,Other,215% of Medicaid,67.08,,,67.08,Other,215% of Medicaid,39,,,39,Other,125% of Medicaid,31.2,1061,
CHEMO HORMON ANTINEOPL SQ/IM,96402,CPT,,82096402,CDM,331,RC,,,both,,,187,138.38,,,138.38,Other,150% of Medicare + 9.63% HCRA Surcharge,84.15,45,,84.15,percent of total billed charges,Critical Access Hospital RCC factor,598,,,598,Case Rate,Chemotherapy Per Visit,538,,,538,Case Rate,Chemotherapy Per Visit,1061,,,1061,Case Rate,Chemotherapy Per Visit,955,,,955,Case Rate,Chemotherapy Per Visit,902,,,902,Case Rate,Chemotherapy Per Visit,92.57,,,92.57,Other,110% of Medicare,127.16,68,,127.16,percent of total billed charges,All Other,58,,,58,Other,186% of Medicaid,149.6,80,,149.6,percent of total billed charges,All Other,155.21,83,,155.21,percent of total billed charges,All Other,155.21,83,,155.21,percent of total billed charges,All Other,149.6,80,,149.6,percent of total billed charges,All Other,155.21,83,,155.21,percent of total billed charges,All Other,149.6,80,,149.6,percent of total billed charges,All Other,130.9,70,,130.9,percent of total billed charges,All Other,160.72,,,160.72,Fee Schedule,,136.22,,,136.22,Fee Schedule,,953,,,953,Case Rate,Chemotherapy Per Visit,858,,,858,Case Rate,Chemotherapy Per Visit,953,,,953,Case Rate,Chemotherapy Per Visit,810,,,810,Case Rate,Chemotherapy Per Visit,31.2,,,31.2,Other,100% of Medicaid,31.2,,,31.2,Other,100% of Medicaid,31.2,,,31.2,Other,100% of Medicaid,31.2,,,31.2,Other,100% of Medicaid,70.2,,,70.2,Other,225% of Medicaid,47.74,,,47.74,Other,153% of Medicaid,70.2,,,70.2,Other,225% of Medicaid,43.68,,,43.68,Other,140% of Medicaid,70.2,,,70.2,Other,225% of Medicaid,81.12,,,81.12,Other,260% of Medicaid,101.09,,,101.09,Other,324% of Medicaid,67.08,,,67.08,Other,215% of Medicaid,67.08,,,67.08,Other,215% of Medicaid,39,,,39,Other,125% of Medicaid,31.2,1061,
CHEMO IV PUSH SNGL DRUG,96409,CPT,,82096409,CDM,331,RC,,,both,,,1106,818.44,,,818.44,Other,150% of Medicare + 9.63% HCRA Surcharge,497.7,45,,497.7,percent of total billed charges,Critical Access Hospital RCC factor,598,,,598,Case Rate,Chemotherapy Per Visit,538,,,538,Case Rate,Chemotherapy Per Visit,1061,,,1061,Case Rate,Chemotherapy Per Visit,955,,,955,Case Rate,Chemotherapy Per Visit,902,,,902,Case Rate,Chemotherapy Per Visit,547.47,,,547.47,Other,110% of Medicare,752.08,68,,752.08,percent of total billed charges,All Other,58,,,58,Other,186% of Medicaid,884.8,80,,884.8,percent of total billed charges,All Other,917.98,83,,917.98,percent of total billed charges,All Other,917.98,83,,917.98,percent of total billed charges,All Other,884.8,80,,884.8,percent of total billed charges,All Other,917.98,83,,917.98,percent of total billed charges,All Other,884.8,80,,884.8,percent of total billed charges,All Other,774.2,70,,774.2,percent of total billed charges,All Other,511.68,,,511.68,Fee Schedule,,433.68,,,433.68,Fee Schedule,,953,,,953,Case Rate,Chemotherapy Per Visit,858,,,858,Case Rate,Chemotherapy Per Visit,953,,,953,Case Rate,Chemotherapy Per Visit,810,,,810,Case Rate,Chemotherapy Per Visit,31.2,,,31.2,Other,100% of Medicaid,31.2,,,31.2,Other,100% of Medicaid,31.2,,,31.2,Other,100% of Medicaid,31.2,,,31.2,Other,100% of Medicaid,70.2,,,70.2,Other,225% of Medicaid,47.74,,,47.74,Other,153% of Medicaid,70.2,,,70.2,Other,225% of Medicaid,43.68,,,43.68,Other,140% of Medicaid,70.2,,,70.2,Other,225% of Medicaid,81.12,,,81.12,Other,260% of Medicaid,101.09,,,101.09,Other,324% of Medicaid,67.08,,,67.08,Other,215% of Medicaid,67.08,,,67.08,Other,215% of Medicaid,39,,,39,Other,125% of Medicaid,31.2,1061,
CHEMO IV PUSH ADDL DRUG,96411,CPT,,82096411,CDM,331,RC,,,both,,,1352,1000.48,,,1000.48,Other,150% of Medicare + 9.63% HCRA Surcharge,608.4,45,,608.4,percent of total billed charges,Critical Access Hospital RCC factor,598,,,598,Case Rate,Chemotherapy Per Visit,538,,,538,Case Rate,Chemotherapy Per Visit,1061,,,1061,Case Rate,Chemotherapy Per Visit,955,,,955,Case Rate,Chemotherapy Per Visit,902,,,902,Case Rate,Chemotherapy Per Visit,669.24,,,669.24,Other,110% of Medicare,919.36,68,,919.36,percent of total billed charges,All Other,58,,,58,Other,186% of Medicaid,1081.6,80,,1081.6,percent of total billed charges,All Other,1122.16,83,,1122.16,percent of total billed charges,All Other,1122.16,83,,1122.16,percent of total billed charges,All Other,1081.6,80,,1081.6,percent of total billed charges,All Other,1122.16,83,,1122.16,percent of total billed charges,All Other,1081.6,80,,1081.6,percent of total billed charges,All Other,946.4,70,,946.4,percent of total billed charges,All Other,278.8,,,278.8,Fee Schedule,,236.3,,,236.3,Fee Schedule,,953,,,953,Case Rate,Chemotherapy Per Visit,858,,,858,Case Rate,Chemotherapy Per Visit,953,,,953,Case Rate,Chemotherapy Per Visit,810,,,810,Case Rate,Chemotherapy Per Visit,31.2,,,31.2,Other,100% of Medicaid,31.2,,,31.2,Other,100% of Medicaid,31.2,,,31.2,Other,100% of Medicaid,31.2,,,31.2,Other,100% of Medicaid,70.2,,,70.2,Other,225% of Medicaid,47.74,,,47.74,Other,153% of Medicaid,70.2,,,70.2,Other,225% of Medicaid,43.68,,,43.68,Other,140% of Medicaid,70.2,,,70.2,Other,225% of Medicaid,81.12,,,81.12,Other,260% of Medicaid,101.09,,,101.09,Other,324% of Medicaid,67.08,,,67.08,Other,215% of Medicaid,67.08,,,67.08,Other,215% of Medicaid,39,,,39,Other,125% of Medicaid,31.2,1122.16,
CHEMO IV INFUSION UP TO 1 HR,96413,CPT,,34096413,CDM,335,RC,,,both,,,1118,827.32,,,827.32,Other,150% of Medicare + 9.63% HCRA Surcharge,503.1,45,,503.1,percent of total billed charges,Critical Access Hospital RCC factor,598,,,598,Case Rate,Chemotherapy Per Visit,538,,,538,Case Rate,Chemotherapy Per Visit,1061,,,1061,Case Rate,Chemotherapy Per Visit,955,,,955,Case Rate,Chemotherapy Per Visit,902,,,902,Case Rate,Chemotherapy Per Visit,553.41,,,553.41,Other,110% of Medicare,760.24,68,,760.24,percent of total billed charges,All Other,411,,,411,Other,186% of Medicaid,894.4,80,,894.4,percent of total billed charges,All Other,927.94,83,,927.94,percent of total billed charges,All Other,927.94,83,,927.94,percent of total billed charges,All Other,894.4,80,,894.4,percent of total billed charges,All Other,927.94,83,,927.94,percent of total billed charges,All Other,894.4,80,,894.4,percent of total billed charges,All Other,782.6,70,,782.6,percent of total billed charges,All Other,664.2,,,664.2,Fee Schedule,,562.95,,,562.95,Fee Schedule,,953,,,953,Case Rate,Chemotherapy Per Visit,858,,,858,Case Rate,Chemotherapy Per Visit,953,,,953,Case Rate,Chemotherapy Per Visit,810,,,810,Case Rate,Chemotherapy Per Visit,221.06,,,221.06,Other,100% of Medicaid,221.06,,,221.06,Other,100% of Medicaid,221.06,,,221.06,Other,100% of Medicaid,221.06,,,221.06,Other,100% of Medicaid,497.39,,,497.39,Other,225% of Medicaid,338.22,,,338.22,Other,153% of Medicaid,497.39,,,497.39,Other,225% of Medicaid,309.49,,,309.49,Other,140% of Medicaid,497.39,,,497.39,Other,225% of Medicaid,574.76,,,574.76,Other,260% of Medicaid,716.24,,,716.24,Other,324% of Medicaid,475.28,,,475.28,Other,215% of Medicaid,475.28,,,475.28,Other,215% of Medicaid,276.33,,,276.33,Other,125% of Medicaid,221.06,1061,
CHEMO ADMIN INF EA ADDL HR,96415,CPT,,34096415,CDM,335,RC,,,both,,,1106,818.44,,,818.44,Other,150% of Medicare + 9.63% HCRA Surcharge,497.7,45,,497.7,percent of total billed charges,Critical Access Hospital RCC factor,598,,,598,Case Rate,Chemotherapy Per Visit,538,,,538,Case Rate,Chemotherapy Per Visit,1061,,,1061,Case Rate,Chemotherapy Per Visit,955,,,955,Case Rate,Chemotherapy Per Visit,902,,,902,Case Rate,Chemotherapy Per Visit,547.47,,,547.47,Other,110% of Medicare,752.08,68,,752.08,percent of total billed charges,All Other,1098,,,1098,Other,186% of Medicaid,884.8,80,,884.8,percent of total billed charges,All Other,917.98,83,,917.98,percent of total billed charges,All Other,917.98,83,,917.98,percent of total billed charges,All Other,884.8,80,,884.8,percent of total billed charges,All Other,917.98,83,,917.98,percent of total billed charges,All Other,884.8,80,,884.8,percent of total billed charges,All Other,774.2,70,,774.2,percent of total billed charges,All Other,141.04,,,141.04,Fee Schedule,,119.54,,,119.54,Fee Schedule,,953,,,953,Case Rate,Chemotherapy Per Visit,858,,,858,Case Rate,Chemotherapy Per Visit,953,,,953,Case Rate,Chemotherapy Per Visit,810,,,810,Case Rate,Chemotherapy Per Visit,590.24,,,590.24,Other,100% of Medicaid,590.24,,,590.24,Other,100% of Medicaid,590.24,,,590.24,Other,100% of Medicaid,590.24,,,590.24,Other,100% of Medicaid,1328.05,,,1328.05,Other,225% of Medicaid,903.07,,,903.07,Other,153% of Medicaid,1328.05,,,1328.05,Other,225% of Medicaid,826.34,,,826.34,Other,140% of Medicaid,1328.05,,,1328.05,Other,225% of Medicaid,1534.64,,,1534.64,Other,260% of Medicaid,1912.39,,,1912.39,Other,324% of Medicaid,1269.03,,,1269.03,Other,215% of Medicaid,1269.03,,,1269.03,Other,215% of Medicaid,737.81,,,737.81,Other,125% of Medicaid,119.54,1912.39,
CHEMO INITIATION IV PROLONGPMP,96416,CPT,,34096416,CDM,335,RC,,,both,,,1027,759.98,,,759.98,Other,150% of Medicare + 9.63% HCRA Surcharge,462.15,45,,462.15,percent of total billed charges,Critical Access Hospital RCC factor,598,,,598,Case Rate,Chemotherapy Per Visit,538,,,538,Case Rate,Chemotherapy Per Visit,1061,,,1061,Case Rate,Chemotherapy Per Visit,955,,,955,Case Rate,Chemotherapy Per Visit,902,,,902,Case Rate,Chemotherapy Per Visit,508.37,,,508.37,Other,110% of Medicare,698.36,68,,698.36,percent of total billed charges,All Other,1098,,,1098,Other,186% of Medicaid,821.6,80,,821.6,percent of total billed charges,All Other,852.41,83,,852.41,percent of total billed charges,All Other,852.41,83,,852.41,percent of total billed charges,All Other,821.6,80,,821.6,percent of total billed charges,All Other,852.41,83,,852.41,percent of total billed charges,All Other,821.6,80,,821.6,percent of total billed charges,All Other,718.9,70,,718.9,percent of total billed charges,All Other,651.08,,,651.08,Fee Schedule,,551.83,,,551.83,Fee Schedule,,953,,,953,Case Rate,Chemotherapy Per Visit,858,,,858,Case Rate,Chemotherapy Per Visit,953,,,953,Case Rate,Chemotherapy Per Visit,810,,,810,Case Rate,Chemotherapy Per Visit,590.24,,,590.24,Other,100% of Medicaid,590.24,,,590.24,Other,100% of Medicaid,590.24,,,590.24,Other,100% of Medicaid,590.24,,,590.24,Other,100% of Medicaid,1328.05,,,1328.05,Other,225% of Medicaid,903.07,,,903.07,Other,153% of Medicaid,1328.05,,,1328.05,Other,225% of Medicaid,826.34,,,826.34,Other,140% of Medicaid,1328.05,,,1328.05,Other,225% of Medicaid,1534.64,,,1534.64,Other,260% of Medicaid,1912.39,,,1912.39,Other,324% of Medicaid,1269.03,,,1269.03,Other,215% of Medicaid,1269.03,,,1269.03,Other,215% of Medicaid,737.81,,,737.81,Other,125% of Medicaid,462.15,1912.39,
CHEMO IVPB SEQUENTIAL UP TO 1,96417,CPT,,34096417,CDM,335,RC,,,both,,,1106,818.44,,,818.44,Other,150% of Medicare + 9.63% HCRA Surcharge,497.7,45,,497.7,percent of total billed charges,Critical Access Hospital RCC factor,598,,,598,Case Rate,Chemotherapy Per Visit,538,,,538,Case Rate,Chemotherapy Per Visit,1061,,,1061,Case Rate,Chemotherapy Per Visit,955,,,955,Case Rate,Chemotherapy Per Visit,902,,,902,Case Rate,Chemotherapy Per Visit,547.47,,,547.47,Other,110% of Medicare,752.08,68,,752.08,percent of total billed charges,All Other,411,,,411,Other,186% of Medicaid,884.8,80,,884.8,percent of total billed charges,All Other,917.98,83,,917.98,percent of total billed charges,All Other,917.98,83,,917.98,percent of total billed charges,All Other,884.8,80,,884.8,percent of total billed charges,All Other,917.98,83,,917.98,percent of total billed charges,All Other,884.8,80,,884.8,percent of total billed charges,All Other,774.2,70,,774.2,percent of total billed charges,All Other,323.08,,,323.08,Fee Schedule,,273.83,,,273.83,Fee Schedule,,953,,,953,Case Rate,Chemotherapy Per Visit,858,,,858,Case Rate,Chemotherapy Per Visit,953,,,953,Case Rate,Chemotherapy Per Visit,810,,,810,Case Rate,Chemotherapy Per Visit,221.06,,,221.06,Other,100% of Medicaid,221.06,,,221.06,Other,100% of Medicaid,221.06,,,221.06,Other,100% of Medicaid,221.06,,,221.06,Other,100% of Medicaid,497.39,,,497.39,Other,225% of Medicaid,338.22,,,338.22,Other,153% of Medicaid,497.39,,,497.39,Other,225% of Medicaid,309.49,,,309.49,Other,140% of Medicaid,497.39,,,497.39,Other,225% of Medicaid,574.76,,,574.76,Other,260% of Medicaid,716.24,,,716.24,Other,324% of Medicaid,475.28,,,475.28,Other,215% of Medicaid,475.28,,,475.28,Other,215% of Medicaid,276.33,,,276.33,Other,125% of Medicaid,221.06,1061,
CHEMO IV INFUSION UP TO 1 HR,96413,CPT,,75096413,CDM,335,RC,,,both,,,1118,827.32,,,827.32,Other,150% of Medicare + 9.63% HCRA Surcharge,503.1,45,,503.1,percent of total billed charges,Critical Access Hospital RCC factor,598,,,598,Case Rate,Chemotherapy Per Visit,538,,,538,Case Rate,Chemotherapy Per Visit,1061,,,1061,Case Rate,Chemotherapy Per Visit,955,,,955,Case Rate,Chemotherapy Per Visit,902,,,902,Case Rate,Chemotherapy Per Visit,553.41,,,553.41,Other,110% of Medicare,760.24,68,,760.24,percent of total billed charges,All Other,411,,,411,Other,186% of Medicaid,894.4,80,,894.4,percent of total billed charges,All Other,927.94,83,,927.94,percent of total billed charges,All Other,927.94,83,,927.94,percent of total billed charges,All Other,894.4,80,,894.4,percent of total billed charges,All Other,927.94,83,,927.94,percent of total billed charges,All Other,894.4,80,,894.4,percent of total billed charges,All Other,782.6,70,,782.6,percent of total billed charges,All Other,664.2,,,664.2,Fee Schedule,,562.95,,,562.95,Fee Schedule,,953,,,953,Case Rate,Chemotherapy Per Visit,858,,,858,Case Rate,Chemotherapy Per Visit,953,,,953,Case Rate,Chemotherapy Per Visit,810,,,810,Case Rate,Chemotherapy Per Visit,221.06,,,221.06,Other,100% of Medicaid,221.06,,,221.06,Other,100% of Medicaid,221.06,,,221.06,Other,100% of Medicaid,221.06,,,221.06,Other,100% of Medicaid,497.39,,,497.39,Other,225% of Medicaid,338.22,,,338.22,Other,153% of Medicaid,497.39,,,497.39,Other,225% of Medicaid,309.49,,,309.49,Other,140% of Medicaid,497.39,,,497.39,Other,225% of Medicaid,574.76,,,574.76,Other,260% of Medicaid,716.24,,,716.24,Other,324% of Medicaid,475.28,,,475.28,Other,215% of Medicaid,475.28,,,475.28,Other,215% of Medicaid,276.33,,,276.33,Other,125% of Medicaid,221.06,1061,
CHEMO ADMIN INF EA ADDL HR,96415,CPT,,75096415,CDM,335,RC,,,both,,,1106,818.44,,,818.44,Other,150% of Medicare + 9.63% HCRA Surcharge,497.7,45,,497.7,percent of total billed charges,Critical Access Hospital RCC factor,598,,,598,Case Rate,Chemotherapy Per Visit,538,,,538,Case Rate,Chemotherapy Per Visit,1061,,,1061,Case Rate,Chemotherapy Per Visit,955,,,955,Case Rate,Chemotherapy Per Visit,902,,,902,Case Rate,Chemotherapy Per Visit,547.47,,,547.47,Other,110% of Medicare,752.08,68,,752.08,percent of total billed charges,All Other,1098,,,1098,Other,186% of Medicaid,884.8,80,,884.8,percent of total billed charges,All Other,917.98,83,,917.98,percent of total billed charges,All Other,917.98,83,,917.98,percent of total billed charges,All Other,884.8,80,,884.8,percent of total billed charges,All Other,917.98,83,,917.98,percent of total billed charges,All Other,884.8,80,,884.8,percent of total billed charges,All Other,774.2,70,,774.2,percent of total billed charges,All Other,141.04,,,141.04,Fee Schedule,,119.54,,,119.54,Fee Schedule,,953,,,953,Case Rate,Chemotherapy Per Visit,858,,,858,Case Rate,Chemotherapy Per Visit,953,,,953,Case Rate,Chemotherapy Per Visit,810,,,810,Case Rate,Chemotherapy Per Visit,590.24,,,590.24,Other,100% of Medicaid,590.24,,,590.24,Other,100% of Medicaid,590.24,,,590.24,Other,100% of Medicaid,590.24,,,590.24,Other,100% of Medicaid,1328.05,,,1328.05,Other,225% of Medicaid,903.07,,,903.07,Other,153% of Medicaid,1328.05,,,1328.05,Other,225% of Medicaid,826.34,,,826.34,Other,140% of Medicaid,1328.05,,,1328.05,Other,225% of Medicaid,1534.64,,,1534.64,Other,260% of Medicaid,1912.39,,,1912.39,Other,324% of Medicaid,1269.03,,,1269.03,Other,215% of Medicaid,1269.03,,,1269.03,Other,215% of Medicaid,737.81,,,737.81,Other,125% of Medicaid,119.54,1912.39,
CHEMO INITIATION IV PROLONGPMP,96416,CPT,,75096416,CDM,335,RC,,,both,,,1027,759.98,,,759.98,Other,150% of Medicare + 9.63% HCRA Surcharge,462.15,45,,462.15,percent of total billed charges,Critical Access Hospital RCC factor,598,,,598,Case Rate,Chemotherapy Per Visit,538,,,538,Case Rate,Chemotherapy Per Visit,1061,,,1061,Case Rate,Chemotherapy Per Visit,955,,,955,Case Rate,Chemotherapy Per Visit,902,,,902,Case Rate,Chemotherapy Per Visit,508.37,,,508.37,Other,110% of Medicare,698.36,68,,698.36,percent of total billed charges,All Other,1098,,,1098,Other,186% of Medicaid,821.6,80,,821.6,percent of total billed charges,All Other,852.41,83,,852.41,percent of total billed charges,All Other,852.41,83,,852.41,percent of total billed charges,All Other,821.6,80,,821.6,percent of total billed charges,All Other,852.41,83,,852.41,percent of total billed charges,All Other,821.6,80,,821.6,percent of total billed charges,All Other,718.9,70,,718.9,percent of total billed charges,All Other,651.08,,,651.08,Fee Schedule,,551.83,,,551.83,Fee Schedule,,953,,,953,Case Rate,Chemotherapy Per Visit,858,,,858,Case Rate,Chemotherapy Per Visit,953,,,953,Case Rate,Chemotherapy Per Visit,810,,,810,Case Rate,Chemotherapy Per Visit,590.24,,,590.24,Other,100% of Medicaid,590.24,,,590.24,Other,100% of Medicaid,590.24,,,590.24,Other,100% of Medicaid,590.24,,,590.24,Other,100% of Medicaid,1328.05,,,1328.05,Other,225% of Medicaid,903.07,,,903.07,Other,153% of Medicaid,1328.05,,,1328.05,Other,225% of Medicaid,826.34,,,826.34,Other,140% of Medicaid,1328.05,,,1328.05,Other,225% of Medicaid,1534.64,,,1534.64,Other,260% of Medicaid,1912.39,,,1912.39,Other,324% of Medicaid,1269.03,,,1269.03,Other,215% of Medicaid,1269.03,,,1269.03,Other,215% of Medicaid,737.81,,,737.81,Other,125% of Medicaid,462.15,1912.39,
CHEMO IVPB SEQUENTIAL UP TO 1,96417,CPT,,75096417,CDM,335,RC,,,both,,,1106,818.44,,,818.44,Other,150% of Medicare + 9.63% HCRA Surcharge,497.7,45,,497.7,percent of total billed charges,Critical Access Hospital RCC factor,598,,,598,Case Rate,Chemotherapy Per Visit,538,,,538,Case Rate,Chemotherapy Per Visit,1061,,,1061,Case Rate,Chemotherapy Per Visit,955,,,955,Case Rate,Chemotherapy Per Visit,902,,,902,Case Rate,Chemotherapy Per Visit,547.47,,,547.47,Other,110% of Medicare,752.08,68,,752.08,percent of total billed charges,All Other,411,,,411,Other,186% of Medicaid,884.8,80,,884.8,percent of total billed charges,All Other,917.98,83,,917.98,percent of total billed charges,All Other,917.98,83,,917.98,percent of total billed charges,All Other,884.8,80,,884.8,percent of total billed charges,All Other,917.98,83,,917.98,percent of total billed charges,All Other,884.8,80,,884.8,percent of total billed charges,All Other,774.2,70,,774.2,percent of total billed charges,All Other,323.08,,,323.08,Fee Schedule,,273.83,,,273.83,Fee Schedule,,953,,,953,Case Rate,Chemotherapy Per Visit,858,,,858,Case Rate,Chemotherapy Per Visit,953,,,953,Case Rate,Chemotherapy Per Visit,810,,,810,Case Rate,Chemotherapy Per Visit,221.06,,,221.06,Other,100% of Medicaid,221.06,,,221.06,Other,100% of Medicaid,221.06,,,221.06,Other,100% of Medicaid,221.06,,,221.06,Other,100% of Medicaid,497.39,,,497.39,Other,225% of Medicaid,338.22,,,338.22,Other,153% of Medicaid,497.39,,,497.39,Other,225% of Medicaid,309.49,,,309.49,Other,140% of Medicaid,497.39,,,497.39,Other,225% of Medicaid,574.76,,,574.76,Other,260% of Medicaid,716.24,,,716.24,Other,324% of Medicaid,475.28,,,475.28,Other,215% of Medicaid,475.28,,,475.28,Other,215% of Medicaid,276.33,,,276.33,Other,125% of Medicaid,221.06,1061,
CHEMO IA; INFUSION; > 8 HRS,96425,CPT,,75096425,CDM,335,RC,,,both,,,878,649.72,,,649.72,Other,150% of Medicare + 9.63% HCRA Surcharge,395.1,45,,395.1,percent of total billed charges,Critical Access Hospital RCC factor,598,,,598,Case Rate,Chemotherapy Per Visit,538,,,538,Case Rate,Chemotherapy Per Visit,1061,,,1061,Case Rate,Chemotherapy Per Visit,955,,,955,Case Rate,Chemotherapy Per Visit,902,,,902,Case Rate,Chemotherapy Per Visit,434.61,,,434.61,Other,110% of Medicare,597.04,68,,597.04,percent of total billed charges,All Other,1098,,,1098,Other,186% of Medicaid,702.4,80,,702.4,percent of total billed charges,All Other,728.74,83,,728.74,percent of total billed charges,All Other,728.74,83,,728.74,percent of total billed charges,All Other,702.4,80,,702.4,percent of total billed charges,All Other,728.74,83,,728.74,percent of total billed charges,All Other,702.4,80,,702.4,percent of total billed charges,All Other,614.6,70,,614.6,percent of total billed charges,All Other,859.36,,,859.36,Fee Schedule,,728.36,,,728.36,Fee Schedule,,953,,,953,Case Rate,Chemotherapy Per Visit,858,,,858,Case Rate,Chemotherapy Per Visit,953,,,953,Case Rate,Chemotherapy Per Visit,810,,,810,Case Rate,Chemotherapy Per Visit,590.24,,,590.24,Other,100% of Medicaid,590.24,,,590.24,Other,100% of Medicaid,590.24,,,590.24,Other,100% of Medicaid,590.24,,,590.24,Other,100% of Medicaid,1328.05,,,1328.05,Other,225% of Medicaid,903.07,,,903.07,Other,153% of Medicaid,1328.05,,,1328.05,Other,225% of Medicaid,826.34,,,826.34,Other,140% of Medicaid,1328.05,,,1328.05,Other,225% of Medicaid,1534.64,,,1534.64,Other,260% of Medicaid,1912.39,,,1912.39,Other,324% of Medicaid,1269.03,,,1269.03,Other,215% of Medicaid,1269.03,,,1269.03,Other,215% of Medicaid,737.81,,,737.81,Other,125% of Medicaid,395.1,1912.39,
CHEMO IV INFUSION UP TO 1 HOUR,96413,CPT,,82096413,CDM,335,RC,,,both,,,1118,827.32,,,827.32,Other,150% of Medicare + 9.63% HCRA Surcharge,503.1,45,,503.1,percent of total billed charges,Critical Access Hospital RCC factor,598,,,598,Case Rate,Chemotherapy Per Visit,538,,,538,Case Rate,Chemotherapy Per Visit,1061,,,1061,Case Rate,Chemotherapy Per Visit,955,,,955,Case Rate,Chemotherapy Per Visit,902,,,902,Case Rate,Chemotherapy Per Visit,553.41,,,553.41,Other,110% of Medicare,760.24,68,,760.24,percent of total billed charges,All Other,411,,,411,Other,186% of Medicaid,894.4,80,,894.4,percent of total billed charges,All Other,927.94,83,,927.94,percent of total billed charges,All Other,927.94,83,,927.94,percent of total billed charges,All Other,894.4,80,,894.4,percent of total billed charges,All Other,927.94,83,,927.94,percent of total billed charges,All Other,894.4,80,,894.4,percent of total billed charges,All Other,782.6,70,,782.6,percent of total billed charges,All Other,664.2,,,664.2,Fee Schedule,,562.95,,,562.95,Fee Schedule,,953,,,953,Case Rate,Chemotherapy Per Visit,858,,,858,Case Rate,Chemotherapy Per Visit,953,,,953,Case Rate,Chemotherapy Per Visit,810,,,810,Case Rate,Chemotherapy Per Visit,221.06,,,221.06,Other,100% of Medicaid,221.06,,,221.06,Other,100% of Medicaid,221.06,,,221.06,Other,100% of Medicaid,221.06,,,221.06,Other,100% of Medicaid,497.39,,,497.39,Other,225% of Medicaid,338.22,,,338.22,Other,153% of Medicaid,497.39,,,497.39,Other,225% of Medicaid,309.49,,,309.49,Other,140% of Medicaid,497.39,,,497.39,Other,225% of Medicaid,574.76,,,574.76,Other,260% of Medicaid,716.24,,,716.24,Other,324% of Medicaid,475.28,,,475.28,Other,215% of Medicaid,475.28,,,475.28,Other,215% of Medicaid,276.33,,,276.33,Other,125% of Medicaid,221.06,1061,
CHEMO ADMIN INF EA ADDL HR,96415,CPT,,82096415,CDM,335,RC,,,both,,,1106,818.44,,,818.44,Other,150% of Medicare + 9.63% HCRA Surcharge,497.7,45,,497.7,percent of total billed charges,Critical Access Hospital RCC factor,598,,,598,Case Rate,Chemotherapy Per Visit,538,,,538,Case Rate,Chemotherapy Per Visit,1061,,,1061,Case Rate,Chemotherapy Per Visit,955,,,955,Case Rate,Chemotherapy Per Visit,902,,,902,Case Rate,Chemotherapy Per Visit,547.47,,,547.47,Other,110% of Medicare,752.08,68,,752.08,percent of total billed charges,All Other,1098,,,1098,Other,186% of Medicaid,884.8,80,,884.8,percent of total billed charges,All Other,917.98,83,,917.98,percent of total billed charges,All Other,917.98,83,,917.98,percent of total billed charges,All Other,884.8,80,,884.8,percent of total billed charges,All Other,917.98,83,,917.98,percent of total billed charges,All Other,884.8,80,,884.8,percent of total billed charges,All Other,774.2,70,,774.2,percent of total billed charges,All Other,141.04,,,141.04,Fee Schedule,,119.54,,,119.54,Fee Schedule,,953,,,953,Case Rate,Chemotherapy Per Visit,858,,,858,Case Rate,Chemotherapy Per Visit,953,,,953,Case Rate,Chemotherapy Per Visit,810,,,810,Case Rate,Chemotherapy Per Visit,590.24,,,590.24,Other,100% of Medicaid,590.24,,,590.24,Other,100% of Medicaid,590.24,,,590.24,Other,100% of Medicaid,590.24,,,590.24,Other,100% of Medicaid,1328.05,,,1328.05,Other,225% of Medicaid,903.07,,,903.07,Other,153% of Medicaid,1328.05,,,1328.05,Other,225% of Medicaid,826.34,,,826.34,Other,140% of Medicaid,1328.05,,,1328.05,Other,225% of Medicaid,1534.64,,,1534.64,Other,260% of Medicaid,1912.39,,,1912.39,Other,324% of Medicaid,1269.03,,,1269.03,Other,215% of Medicaid,1269.03,,,1269.03,Other,215% of Medicaid,737.81,,,737.81,Other,125% of Medicaid,119.54,1912.39,
CHEMO PROLONG 8+HRS INFUSE W/PUMP,96416,CPT,,82096416,CDM,335,RC,,,both,,,1027,759.98,,,759.98,Other,150% of Medicare + 9.63% HCRA Surcharge,462.15,45,,462.15,percent of total billed charges,Critical Access Hospital RCC factor,598,,,598,Case Rate,Chemotherapy Per Visit,538,,,538,Case Rate,Chemotherapy Per Visit,1061,,,1061,Case Rate,Chemotherapy Per Visit,955,,,955,Case Rate,Chemotherapy Per Visit,902,,,902,Case Rate,Chemotherapy Per Visit,508.37,,,508.37,Other,110% of Medicare,698.36,68,,698.36,percent of total billed charges,All Other,1098,,,1098,Other,186% of Medicaid,821.6,80,,821.6,percent of total billed charges,All Other,852.41,83,,852.41,percent of total billed charges,All Other,852.41,83,,852.41,percent of total billed charges,All Other,821.6,80,,821.6,percent of total billed charges,All Other,852.41,83,,852.41,percent of total billed charges,All Other,821.6,80,,821.6,percent of total billed charges,All Other,718.9,70,,718.9,percent of total billed charges,All Other,651.08,,,651.08,Fee Schedule,,551.83,,,551.83,Fee Schedule,,953,,,953,Case Rate,Chemotherapy Per Visit,858,,,858,Case Rate,Chemotherapy Per Visit,953,,,953,Case Rate,Chemotherapy Per Visit,810,,,810,Case Rate,Chemotherapy Per Visit,590.24,,,590.24,Other,100% of Medicaid,590.24,,,590.24,Other,100% of Medicaid,590.24,,,590.24,Other,100% of Medicaid,590.24,,,590.24,Other,100% of Medicaid,1328.05,,,1328.05,Other,225% of Medicaid,903.07,,,903.07,Other,153% of Medicaid,1328.05,,,1328.05,Other,225% of Medicaid,826.34,,,826.34,Other,140% of Medicaid,1328.05,,,1328.05,Other,225% of Medicaid,1534.64,,,1534.64,Other,260% of Medicaid,1912.39,,,1912.39,Other,324% of Medicaid,1269.03,,,1269.03,Other,215% of Medicaid,1269.03,,,1269.03,Other,215% of Medicaid,737.81,,,737.81,Other,125% of Medicaid,462.15,1912.39,
CHEMO IV INFUS EACH ADDL SEQ =<1 HR,96417,CPT,,82096417,CDM,335,RC,,,both,,,1106,818.44,,,818.44,Other,150% of Medicare + 9.63% HCRA Surcharge,497.7,45,,497.7,percent of total billed charges,Critical Access Hospital RCC factor,598,,,598,Case Rate,Chemotherapy Per Visit,538,,,538,Case Rate,Chemotherapy Per Visit,1061,,,1061,Case Rate,Chemotherapy Per Visit,955,,,955,Case Rate,Chemotherapy Per Visit,902,,,902,Case Rate,Chemotherapy Per Visit,547.47,,,547.47,Other,110% of Medicare,752.08,68,,752.08,percent of total billed charges,All Other,411,,,411,Other,186% of Medicaid,884.8,80,,884.8,percent of total billed charges,All Other,917.98,83,,917.98,percent of total billed charges,All Other,917.98,83,,917.98,percent of total billed charges,All Other,884.8,80,,884.8,percent of total billed charges,All Other,917.98,83,,917.98,percent of total billed charges,All Other,884.8,80,,884.8,percent of total billed charges,All Other,774.2,70,,774.2,percent of total billed charges,All Other,323.08,,,323.08,Fee Schedule,,273.83,,,273.83,Fee Schedule,,953,,,953,Case Rate,Chemotherapy Per Visit,858,,,858,Case Rate,Chemotherapy Per Visit,953,,,953,Case Rate,Chemotherapy Per Visit,810,,,810,Case Rate,Chemotherapy Per Visit,221.06,,,221.06,Other,100% of Medicaid,221.06,,,221.06,Other,100% of Medicaid,221.06,,,221.06,Other,100% of Medicaid,221.06,,,221.06,Other,100% of Medicaid,497.39,,,497.39,Other,225% of Medicaid,338.22,,,338.22,Other,153% of Medicaid,497.39,,,497.39,Other,225% of Medicaid,309.49,,,309.49,Other,140% of Medicaid,497.39,,,497.39,Other,225% of Medicaid,574.76,,,574.76,Other,260% of Medicaid,716.24,,,716.24,Other,324% of Medicaid,475.28,,,475.28,Other,215% of Medicaid,475.28,,,475.28,Other,215% of Medicaid,276.33,,,276.33,Other,125% of Medicaid,221.06,1061,
THYROID UPTAKE MEASUREMENT,78012,CPT,TC,50078012,CDM,341,RC,,,both,,,876,648.24,,,648.24,Other,150% of Medicare + 9.63% HCRA Surcharge,394.2,45,,394.2,percent of total billed charges,Critical Access Hospital RCC factor,251.21,,,251.21,Fee Schedule,,226.01,,,226.01,Fee Schedule,,72.2,,,72.2,Fee Schedule,,72.2,,,72.2,Fee Schedule,,72.2,,,72.2,Fee Schedule,,433.62,,,433.62,Other,110% of Medicare,298.46,,,298.46,Fee Schedule,,524,,,524,Other,186% of Medicaid,351.23,,,351.23,Fee Schedule,,543.12,,,543.12,Fee Schedule,,165.38,,,165.38,Fee Schedule,,351.23,,,351.23,Fee Schedule,,543.12,,,543.12,Fee Schedule,,311.06,,,311.06,Fee Schedule,,613.2,70,,613.2,percent of total billed charges,All Other,349.32,,,349.32,Fee Schedule,,296.07,,,296.07,Fee Schedule,,589.01,,,589.01,Fee Schedule,,589.01,,,589.01,Fee Schedule,,589.01,,,589.01,Fee Schedule,,589.01,,,589.01,Fee Schedule,,281.88,,,281.88,Other,100% of Medicaid,281.88,,,281.88,Other,100% of Medicaid,281.88,,,281.88,Other,100% of Medicaid,281.88,,,281.88,Other,100% of Medicaid,634.23,,,634.23,Other,225% of Medicaid,431.28,,,431.28,Other,153% of Medicaid,634.23,,,634.23,Other,225% of Medicaid,394.63,,,394.63,Other,140% of Medicaid,634.23,,,634.23,Other,225% of Medicaid,732.89,,,732.89,Other,260% of Medicaid,913.29,,,913.29,Other,324% of Medicaid,606.04,,,606.04,Other,215% of Medicaid,606.04,,,606.04,Other,215% of Medicaid,352.35,,,352.35,Other,125% of Medicaid,72.2,913.29,
THYROID IMAGING W/BLOOD FLOW ONLY,78013,CPT,TC,50078013,CDM,341,RC,,,both,,,1365,1010.1,,,1010.1,Other,150% of Medicare + 9.63% HCRA Surcharge,614.25,45,,614.25,percent of total billed charges,Critical Access Hospital RCC factor,535.57,,,535.57,Fee Schedule,,481.84,,,481.84,Fee Schedule,,175.68,,,175.68,Fee Schedule,,175.68,,,175.68,Fee Schedule,,175.68,,,175.68,Fee Schedule,,675.68,,,675.68,Other,110% of Medicare,636.3,,,636.3,Fee Schedule,,524,,,524,Other,186% of Medicaid,748.79,,,748.79,Fee Schedule,,846.3,,,846.3,Fee Schedule,,352.57,,,352.57,Fee Schedule,,748.79,,,748.79,Fee Schedule,,846.3,,,846.3,Fee Schedule,,663.17,,,663.17,Fee Schedule,,955.5,70,,955.5,percent of total billed charges,All Other,818.36,,,818.36,Fee Schedule,,693.61,,,693.61,Fee Schedule,,589.01,,,589.01,Fee Schedule,,589.01,,,589.01,Fee Schedule,,589.01,,,589.01,Fee Schedule,,589.01,,,589.01,Fee Schedule,,281.88,,,281.88,Other,100% of Medicaid,281.88,,,281.88,Other,100% of Medicaid,281.88,,,281.88,Other,100% of Medicaid,281.88,,,281.88,Other,100% of Medicaid,634.23,,,634.23,Other,225% of Medicaid,431.28,,,431.28,Other,153% of Medicaid,634.23,,,634.23,Other,225% of Medicaid,394.63,,,394.63,Other,140% of Medicaid,634.23,,,634.23,Other,225% of Medicaid,732.89,,,732.89,Other,260% of Medicaid,913.29,,,913.29,Other,324% of Medicaid,606.04,,,606.04,Other,215% of Medicaid,606.04,,,606.04,Other,215% of Medicaid,352.35,,,352.35,Other,125% of Medicaid,175.68,1010.1,
THYROID IMAGING W/BLOOD FLOW AND UPTAKE,78014,CPT,TC,50078014,CDM,341,RC,,,both,,,2000,1480.01,,,1480.01,Other,150% of Medicare + 9.63% HCRA Surcharge,900,45,,900,percent of total billed charges,Critical Access Hospital RCC factor,676.5,,,676.5,Fee Schedule,,608.64,,,608.64,Fee Schedule,,219.34,,,219.34,Fee Schedule,,219.34,,,219.34,Fee Schedule,,219.34,,,219.34,Fee Schedule,,990,,,990,Other,110% of Medicare,803.75,,,803.75,Fee Schedule,,524,,,524,Other,186% of Medicaid,945.83,,,945.83,Fee Schedule,,1240,,,1240,Fee Schedule,,445.35,,,445.35,Fee Schedule,,945.83,,,945.83,Fee Schedule,,1240,,,1240,Fee Schedule,,837.68,,,837.68,Fee Schedule,,1400,70,,1400,percent of total billed charges,All Other,993.84,,,993.84,Fee Schedule,,842.34,,,842.34,Fee Schedule,,589.01,,,589.01,Fee Schedule,,589.01,,,589.01,Fee Schedule,,589.01,,,589.01,Fee Schedule,,589.01,,,589.01,Fee Schedule,,281.88,,,281.88,Other,100% of Medicaid,281.88,,,281.88,Other,100% of Medicaid,281.88,,,281.88,Other,100% of Medicaid,281.88,,,281.88,Other,100% of Medicaid,634.23,,,634.23,Other,225% of Medicaid,431.28,,,431.28,Other,153% of Medicaid,634.23,,,634.23,Other,225% of Medicaid,394.63,,,394.63,Other,140% of Medicaid,634.23,,,634.23,Other,225% of Medicaid,732.89,,,732.89,Other,260% of Medicaid,913.29,,,913.29,Other,324% of Medicaid,606.04,,,606.04,Other,215% of Medicaid,606.04,,,606.04,Other,215% of Medicaid,352.35,,,352.35,Other,125% of Medicaid,219.34,1480.01,
THYROID METS; WHOLE BODY,78018,CPT,TC,50078018,CDM,341,RC,,,both,,,2150,1591.01,,,1591.01,Other,150% of Medicare + 9.63% HCRA Surcharge,967.5,45,,967.5,percent of total billed charges,Critical Access Hospital RCC factor,853.42,,,853.42,Fee Schedule,,767.81,,,767.81,Fee Schedule,,1865.32,,,1865.32,Fee Schedule,,1677.72,,,1677.72,Fee Schedule,,1585.7,,,1585.7,Fee Schedule,,1064.25,,,1064.25,Other,110% of Medicare,1013.94,,,1013.94,Fee Schedule,,524,,,524,Other,186% of Medicaid,1193.18,,,1193.18,Fee Schedule,,1333,,,1333,Fee Schedule,,561.81,,,561.81,Fee Schedule,,1193.18,,,1193.18,Fee Schedule,,1333,,,1333,Fee Schedule,,1056.74,,,1056.74,Fee Schedule,,1505,70,,1505,percent of total billed charges,All Other,1264.44,,,1264.44,Fee Schedule,,1071.69,,,1071.69,Fee Schedule,,755.17,,,755.17,Fee Schedule,,755.17,,,755.17,Fee Schedule,,755.17,,,755.17,Fee Schedule,,755.17,,,755.17,Fee Schedule,,281.88,,,281.88,Other,100% of Medicaid,281.88,,,281.88,Other,100% of Medicaid,281.88,,,281.88,Other,100% of Medicaid,281.88,,,281.88,Other,100% of Medicaid,634.23,,,634.23,Other,225% of Medicaid,431.28,,,431.28,Other,153% of Medicaid,634.23,,,634.23,Other,225% of Medicaid,394.63,,,394.63,Other,140% of Medicaid,634.23,,,634.23,Other,225% of Medicaid,732.89,,,732.89,Other,260% of Medicaid,913.29,,,913.29,Other,324% of Medicaid,606.04,,,606.04,Other,215% of Medicaid,606.04,,,606.04,Other,215% of Medicaid,352.35,,,352.35,Other,125% of Medicaid,281.88,1865.32,
PARATHYROID NUCLEAR IMAGING,78070,CPT,TC,50078070,CDM,341,RC,,,both,,,2412,1784.89,,,1784.89,Other,150% of Medicare + 9.63% HCRA Surcharge,1085.4,45,,1085.4,percent of total billed charges,Critical Access Hospital RCC factor,806.08,,,806.08,Fee Schedule,,725.22,,,725.22,Fee Schedule,,844.68,,,844.68,Fee Schedule,,759.73,,,759.73,Fee Schedule,,718.05,,,718.05,Fee Schedule,,1193.94,,,1193.94,Other,110% of Medicare,957.7,,,957.7,Fee Schedule,,1144,,,1144,Other,186% of Medicaid,1127,,,1127,Fee Schedule,,1495.44,,,1495.44,Fee Schedule,,530.65,,,530.65,Fee Schedule,,1127,,,1127,Fee Schedule,,1495.44,,,1495.44,Fee Schedule,,998.13,,,998.13,Fee Schedule,,1688.4,70,,1688.4,percent of total billed charges,All Other,1179.16,,,1179.16,Fee Schedule,,999.41,,,999.41,Fee Schedule,,589.01,,,589.01,Fee Schedule,,589.01,,,589.01,Fee Schedule,,589.01,,,589.01,Fee Schedule,,589.01,,,589.01,Fee Schedule,,615.17,,,615.17,Other,100% of Medicaid,615.17,,,615.17,Other,100% of Medicaid,615.17,,,615.17,Other,100% of Medicaid,615.17,,,615.17,Other,100% of Medicaid,1384.13,,,1384.13,Other,225% of Medicaid,941.21,,,941.21,Other,153% of Medicaid,1384.13,,,1384.13,Other,225% of Medicaid,861.24,,,861.24,Other,140% of Medicaid,1384.13,,,1384.13,Other,225% of Medicaid,1599.44,,,1599.44,Other,260% of Medicaid,1993.15,,,1993.15,Other,324% of Medicaid,1322.62,,,1322.62,Other,215% of Medicaid,1322.62,,,1322.62,Other,215% of Medicaid,768.96,,,768.96,Other,125% of Medicaid,530.65,1993.15,
PARATHYRD PLANAR W/WO SUBTRJ,78071,CPT,TC,50078071,CDM,341,RC,,,both,,,2578,1907.73,,,1907.73,Other,150% of Medicare + 9.63% HCRA Surcharge,1160.1,45,,1160.1,percent of total billed charges,Critical Access Hospital RCC factor,920.44,,,920.44,Fee Schedule,,828.11,,,828.11,Fee Schedule,,295.66,,,295.66,Fee Schedule,,295.66,,,295.66,Fee Schedule,,295.66,,,295.66,Fee Schedule,,1276.11,,,1276.11,Other,110% of Medicare,1093.57,,,1093.57,Fee Schedule,,524,,,524,Other,186% of Medicaid,1286.89,,,1286.89,Fee Schedule,,1598.36,,,1598.36,Fee Schedule,,605.93,,,605.93,Fee Schedule,,1286.89,,,1286.89,Fee Schedule,,1598.36,,,1598.36,Fee Schedule,,1139.73,,,1139.73,Fee Schedule,,1804.6,70,,1804.6,percent of total billed charges,All Other,1354.64,,,1354.64,Fee Schedule,,1148.14,,,1148.14,Fee Schedule,,589.01,,,589.01,Fee Schedule,,589.01,,,589.01,Fee Schedule,,589.01,,,589.01,Fee Schedule,,589.01,,,589.01,Fee Schedule,,281.88,,,281.88,Other,100% of Medicaid,281.88,,,281.88,Other,100% of Medicaid,281.88,,,281.88,Other,100% of Medicaid,281.88,,,281.88,Other,100% of Medicaid,634.23,,,634.23,Other,225% of Medicaid,431.28,,,431.28,Other,153% of Medicaid,634.23,,,634.23,Other,225% of Medicaid,394.63,,,394.63,Other,140% of Medicaid,634.23,,,634.23,Other,225% of Medicaid,732.89,,,732.89,Other,260% of Medicaid,913.29,,,913.29,Other,324% of Medicaid,606.04,,,606.04,Other,215% of Medicaid,606.04,,,606.04,Other,215% of Medicaid,352.35,,,352.35,Other,125% of Medicaid,281.88,1907.73,
BONE MARROW IMAGING LIMITED,78102,CPT,TC,50078102,CDM,341,RC,,,both,,,1238,916.12,,,916.12,Other,150% of Medicare + 9.63% HCRA Surcharge,557.1,45,,557.1,percent of total billed charges,Critical Access Hospital RCC factor,472.02,,,472.02,Fee Schedule,,424.67,,,424.67,Fee Schedule,,940.8,,,940.8,Fee Schedule,,846.18,,,846.18,Fee Schedule,,799.77,,,799.77,Fee Schedule,,612.81,,,612.81,Other,110% of Medicare,560.81,,,560.81,Fee Schedule,,524,,,524,Other,186% of Medicaid,659.95,,,659.95,Fee Schedule,,767.56,,,767.56,Fee Schedule,,310.74,,,310.74,Fee Schedule,,659.95,,,659.95,Fee Schedule,,767.56,,,767.56,Fee Schedule,,584.48,,,584.48,Fee Schedule,,866.6,70,,866.6,percent of total billed charges,All Other,680.6,,,680.6,Fee Schedule,,576.85,,,576.85,Fee Schedule,,589.01,,,589.01,Fee Schedule,,589.01,,,589.01,Fee Schedule,,589.01,,,589.01,Fee Schedule,,589.01,,,589.01,Fee Schedule,,281.88,,,281.88,Other,100% of Medicaid,281.88,,,281.88,Other,100% of Medicaid,281.88,,,281.88,Other,100% of Medicaid,281.88,,,281.88,Other,100% of Medicaid,634.23,,,634.23,Other,225% of Medicaid,431.28,,,431.28,Other,153% of Medicaid,634.23,,,634.23,Other,225% of Medicaid,394.63,,,394.63,Other,140% of Medicaid,634.23,,,634.23,Other,225% of Medicaid,732.89,,,732.89,Other,260% of Medicaid,913.29,,,913.29,Other,324% of Medicaid,606.04,,,606.04,Other,215% of Medicaid,606.04,,,606.04,Other,215% of Medicaid,352.35,,,352.35,Other,125% of Medicaid,281.88,940.8,
BM IMAGING; MULTIPLE AREAS,78103,CPT,TC,50078103,CDM,341,RC,,,both,,,1458,1078.92,,,1078.92,Other,150% of Medicare + 9.63% HCRA Surcharge,656.1,45,,656.1,percent of total billed charges,Critical Access Hospital RCC factor,491.67,,,491.67,Fee Schedule,,442.35,,,442.35,Fee Schedule,,1233.71,,,1233.71,Fee Schedule,,1109.63,,,1109.63,Fee Schedule,,1048.77,,,1048.77,Fee Schedule,,721.71,,,721.71,Other,110% of Medicare,584.15,,,584.15,Fee Schedule,,524,,,524,Other,186% of Medicaid,687.42,,,687.42,Fee Schedule,,903.96,,,903.96,Fee Schedule,,323.67,,,323.67,Fee Schedule,,687.42,,,687.42,Fee Schedule,,903.96,,,903.96,Fee Schedule,,608.81,,,608.81,Fee Schedule,,1020.6,70,,1020.6,percent of total billed charges,All Other,736.36,,,736.36,Fee Schedule,,624.11,,,624.11,Fee Schedule,,589.01,,,589.01,Fee Schedule,,589.01,,,589.01,Fee Schedule,,589.01,,,589.01,Fee Schedule,,589.01,,,589.01,Fee Schedule,,281.88,,,281.88,Other,100% of Medicaid,281.88,,,281.88,Other,100% of Medicaid,281.88,,,281.88,Other,100% of Medicaid,281.88,,,281.88,Other,100% of Medicaid,634.23,,,634.23,Other,225% of Medicaid,431.28,,,431.28,Other,153% of Medicaid,634.23,,,634.23,Other,225% of Medicaid,394.63,,,394.63,Other,140% of Medicaid,634.23,,,634.23,Other,225% of Medicaid,732.89,,,732.89,Other,260% of Medicaid,913.29,,,913.29,Other,324% of Medicaid,606.04,,,606.04,Other,215% of Medicaid,606.04,,,606.04,Other,215% of Medicaid,352.35,,,352.35,Other,125% of Medicaid,281.88,1233.71,
RED CELL SEQUESTRATION,78140,CPT,TC,50078140,CDM,341,RC,,,both,,,1739,1286.86,,,1286.86,Other,150% of Medicare + 9.63% HCRA Surcharge,782.55,45,,782.55,percent of total billed charges,Critical Access Hospital RCC factor,296.61,,,296.61,Fee Schedule,,266.85,,,266.85,Fee Schedule,,732.58,,,732.58,Fee Schedule,,658.91,,,658.91,Fee Schedule,,622.76,,,622.76,Fee Schedule,,860.81,,,860.81,Other,110% of Medicare,352.39,,,352.39,Fee Schedule,,524,,,524,Other,186% of Medicaid,414.69,,,414.69,Fee Schedule,,1078.18,,,1078.18,Fee Schedule,,195.26,,,195.26,Fee Schedule,,414.69,,,414.69,Fee Schedule,,1078.18,,,1078.18,Fee Schedule,,367.27,,,367.27,Fee Schedule,,1217.3,70,,1217.3,percent of total billed charges,All Other,419.84,,,419.84,Fee Schedule,,355.84,,,355.84,Fee Schedule,,589.01,,,589.01,Fee Schedule,,589.01,,,589.01,Fee Schedule,,589.01,,,589.01,Fee Schedule,,589.01,,,589.01,Fee Schedule,,281.88,,,281.88,Other,100% of Medicaid,281.88,,,281.88,Other,100% of Medicaid,281.88,,,281.88,Other,100% of Medicaid,281.88,,,281.88,Other,100% of Medicaid,634.23,,,634.23,Other,225% of Medicaid,431.28,,,431.28,Other,153% of Medicaid,634.23,,,634.23,Other,225% of Medicaid,394.63,,,394.63,Other,140% of Medicaid,634.23,,,634.23,Other,225% of Medicaid,732.89,,,732.89,Other,260% of Medicaid,913.29,,,913.29,Other,324% of Medicaid,606.04,,,606.04,Other,215% of Medicaid,606.04,,,606.04,Other,215% of Medicaid,352.35,,,352.35,Other,125% of Medicaid,195.26,1286.86,
LYMPH NODE IMAGING,78195,CPT,TC,50078195,CDM,341,RC,,,both,,,2568,1900.33,,,1900.33,Other,150% of Medicare + 9.63% HCRA Surcharge,1155.6,45,,1155.6,percent of total billed charges,Critical Access Hospital RCC factor,933.33,,,933.33,Fee Schedule,,839.7,,,839.7,Fee Schedule,,1732.57,,,1732.57,Fee Schedule,,1558.32,,,1558.32,Fee Schedule,,1472.84,,,1472.84,Fee Schedule,,1271.16,,,1271.16,Other,110% of Medicare,1108.88,,,1108.88,Fee Schedule,,1144,,,1144,Other,186% of Medicaid,1304.91,,,1304.91,Fee Schedule,,1592.16,,,1592.16,Fee Schedule,,614.42,,,614.42,Fee Schedule,,1304.91,,,1304.91,Fee Schedule,,1592.16,,,1592.16,Fee Schedule,,1155.69,,,1155.69,Fee Schedule,,1797.6,70,,1797.6,percent of total billed charges,All Other,1374.32,,,1374.32,Fee Schedule,,1164.82,,,1164.82,Fee Schedule,,755.17,,,755.17,Fee Schedule,,755.17,,,755.17,Fee Schedule,,755.17,,,755.17,Fee Schedule,,755.17,,,755.17,Fee Schedule,,615.17,,,615.17,Other,100% of Medicaid,615.17,,,615.17,Other,100% of Medicaid,615.17,,,615.17,Other,100% of Medicaid,615.17,,,615.17,Other,100% of Medicaid,1384.13,,,1384.13,Other,225% of Medicaid,941.21,,,941.21,Other,153% of Medicaid,1384.13,,,1384.13,Other,225% of Medicaid,861.24,,,861.24,Other,140% of Medicaid,1384.13,,,1384.13,Other,225% of Medicaid,1599.44,,,1599.44,Other,260% of Medicaid,1993.15,,,1993.15,Other,324% of Medicaid,1322.62,,,1322.62,Other,215% of Medicaid,1322.62,,,1322.62,Other,215% of Medicaid,768.96,,,768.96,Other,125% of Medicaid,614.42,1993.15,
LIVER & SPLEEN STATIC ONLY,78215,CPT,TC,50078215,CDM,341,RC,,,both,,,1343,993.82,,,993.82,Other,150% of Medicare + 9.63% HCRA Surcharge,604.35,45,,604.35,percent of total billed charges,Critical Access Hospital RCC factor,554.04,,,554.04,Fee Schedule,,498.46,,,498.46,Fee Schedule,,1130.73,,,1130.73,Fee Schedule,,1017.01,,,1017.01,Fee Schedule,,961.23,,,961.23,Fee Schedule,,664.79,,,664.79,Other,110% of Medicare,658.25,,,658.25,Fee Schedule,,1144,,,1144,Other,186% of Medicaid,774.61,,,774.61,Fee Schedule,,832.66,,,832.66,Fee Schedule,,364.73,,,364.73,Fee Schedule,,774.61,,,774.61,Fee Schedule,,832.66,,,832.66,Fee Schedule,,686.04,,,686.04,Fee Schedule,,940.1,70,,940.1,percent of total billed charges,All Other,801.96,,,801.96,Fee Schedule,,679.71,,,679.71,Fee Schedule,,589.01,,,589.01,Fee Schedule,,589.01,,,589.01,Fee Schedule,,589.01,,,589.01,Fee Schedule,,589.01,,,589.01,Fee Schedule,,615.17,,,615.17,Other,100% of Medicaid,615.17,,,615.17,Other,100% of Medicaid,615.17,,,615.17,Other,100% of Medicaid,615.17,,,615.17,Other,100% of Medicaid,1384.13,,,1384.13,Other,225% of Medicaid,941.21,,,941.21,Other,153% of Medicaid,1384.13,,,1384.13,Other,225% of Medicaid,861.24,,,861.24,Other,140% of Medicaid,1384.13,,,1384.13,Other,225% of Medicaid,1599.44,,,1599.44,Other,260% of Medicaid,1993.15,,,1993.15,Other,324% of Medicaid,1322.62,,,1322.62,Other,215% of Medicaid,1322.62,,,1322.62,Other,215% of Medicaid,768.96,,,768.96,Other,125% of Medicaid,364.73,1993.15,
HEPATOBILIARY SYSTEM IMAGING,78226,CPT,TC,50078226,CDM,341,RC,,,both,,,2718,2011.33,,,2011.33,Other,150% of Medicare + 9.63% HCRA Surcharge,1223.1,45,,1223.1,percent of total billed charges,Critical Access Hospital RCC factor,910.04,,,910.04,Fee Schedule,,818.75,,,818.75,Fee Schedule,,282.47,,,282.47,Fee Schedule,,282.47,,,282.47,Fee Schedule,,282.47,,,282.47,Fee Schedule,,1345.41,,,1345.41,Other,110% of Medicare,1081.21,,,1081.21,Fee Schedule,,524,,,524,Other,186% of Medicaid,1272.35,,,1272.35,Fee Schedule,,1685.16,,,1685.16,Fee Schedule,,599.09,,,599.09,Fee Schedule,,1272.35,,,1272.35,Fee Schedule,,1685.16,,,1685.16,Fee Schedule,,1126.86,,,1126.86,Fee Schedule,,1902.6,70,,1902.6,percent of total billed charges,All Other,1341.52,,,1341.52,Fee Schedule,,1137.02,,,1137.02,Fee Schedule,,589.01,,,589.01,Fee Schedule,,589.01,,,589.01,Fee Schedule,,589.01,,,589.01,Fee Schedule,,589.01,,,589.01,Fee Schedule,,281.88,,,281.88,Other,100% of Medicaid,281.88,,,281.88,Other,100% of Medicaid,281.88,,,281.88,Other,100% of Medicaid,281.88,,,281.88,Other,100% of Medicaid,634.23,,,634.23,Other,225% of Medicaid,431.28,,,431.28,Other,153% of Medicaid,634.23,,,634.23,Other,225% of Medicaid,394.63,,,394.63,Other,140% of Medicaid,634.23,,,634.23,Other,225% of Medicaid,732.89,,,732.89,Other,260% of Medicaid,913.29,,,913.29,Other,324% of Medicaid,606.04,,,606.04,Other,215% of Medicaid,606.04,,,606.04,Other,215% of Medicaid,352.35,,,352.35,Other,125% of Medicaid,281.88,2011.33,
HEPATOBIL SYST IMAGE W/DRUG,78227,CPT,TC,50078227,CDM,341,RC,,,both,,,3731,2760.95,,,2760.95,Other,150% of Medicare + 9.63% HCRA Surcharge,1678.95,45,,1678.95,percent of total billed charges,Critical Access Hospital RCC factor,1237.34,,,1237.34,Fee Schedule,,1113.22,,,1113.22,Fee Schedule,,387.38,,,387.38,Fee Schedule,,387.38,,,387.38,Fee Schedule,,387.38,,,387.38,Fee Schedule,,1846.85,,,1846.85,Other,110% of Medicare,1470.07,,,1470.07,Fee Schedule,,524,,,524,Other,186% of Medicaid,1729.94,,,1729.94,Fee Schedule,,2313.22,,,2313.22,Fee Schedule,,814.55,,,814.55,Fee Schedule,,1729.94,,,1729.94,Fee Schedule,,2313.22,,,2313.22,Fee Schedule,,1532.13,,,1532.13,Fee Schedule,,2611.7,70,,2611.7,percent of total billed charges,All Other,1826.96,,,1826.96,Fee Schedule,,1548.46,,,1548.46,Fee Schedule,,755.17,,,755.17,Fee Schedule,,755.17,,,755.17,Fee Schedule,,755.17,,,755.17,Fee Schedule,,755.17,,,755.17,Fee Schedule,,281.88,,,281.88,Other,100% of Medicaid,281.88,,,281.88,Other,100% of Medicaid,281.88,,,281.88,Other,100% of Medicaid,281.88,,,281.88,Other,100% of Medicaid,634.23,,,634.23,Other,225% of Medicaid,431.28,,,431.28,Other,153% of Medicaid,634.23,,,634.23,Other,225% of Medicaid,394.63,,,394.63,Other,140% of Medicaid,634.23,,,634.23,Other,225% of Medicaid,732.89,,,732.89,Other,260% of Medicaid,913.29,,,913.29,Other,324% of Medicaid,606.04,,,606.04,Other,215% of Medicaid,606.04,,,606.04,Other,215% of Medicaid,352.35,,,352.35,Other,125% of Medicaid,281.88,2760.95,
GASTRIC REFLUX SCAN,78262,CPT,TC,50078262,CDM,341,RC,,,both,,,1658,1226.92,,,1226.92,Other,150% of Medicare + 9.63% HCRA Surcharge,746.1,45,,746.1,percent of total billed charges,Critical Access Hospital RCC factor,675.51,,,675.51,Fee Schedule,,607.75,,,607.75,Fee Schedule,,1430.49,,,1430.49,Fee Schedule,,1286.63,,,1286.63,Fee Schedule,,1216.05,,,1216.05,Fee Schedule,,820.71,,,820.71,Other,110% of Medicare,802.57,,,802.57,Fee Schedule,,524,,,524,Other,186% of Medicaid,944.45,,,944.45,Fee Schedule,,1027.96,,,1027.96,Fee Schedule,,444.7,,,444.7,Fee Schedule,,944.45,,,944.45,Fee Schedule,,1027.96,,,1027.96,Fee Schedule,,836.45,,,836.45,Fee Schedule,,1160.6,70,,1160.6,percent of total billed charges,All Other,982.36,,,982.36,Fee Schedule,,832.61,,,832.61,Fee Schedule,,589.01,,,589.01,Fee Schedule,,589.01,,,589.01,Fee Schedule,,589.01,,,589.01,Fee Schedule,,589.01,,,589.01,Fee Schedule,,281.88,,,281.88,Other,100% of Medicaid,281.88,,,281.88,Other,100% of Medicaid,281.88,,,281.88,Other,100% of Medicaid,281.88,,,281.88,Other,100% of Medicaid,634.23,,,634.23,Other,225% of Medicaid,431.28,,,431.28,Other,153% of Medicaid,634.23,,,634.23,Other,225% of Medicaid,394.63,,,394.63,Other,140% of Medicaid,634.23,,,634.23,Other,225% of Medicaid,732.89,,,732.89,Other,260% of Medicaid,913.29,,,913.29,Other,324% of Medicaid,606.04,,,606.04,Other,215% of Medicaid,606.04,,,606.04,Other,215% of Medicaid,352.35,,,352.35,Other,125% of Medicaid,281.88,1430.49,
GASTRIC EMPTYING STUDY,78264,CPT,TC,50078264,CDM,341,RC,,,both,,,2746,2032.05,,,2032.05,Other,150% of Medicare + 9.63% HCRA Surcharge,1235.7,45,,1235.7,percent of total billed charges,Critical Access Hospital RCC factor,921.75,,,921.75,Fee Schedule,,829.29,,,829.29,Fee Schedule,,1611.3,,,1611.3,Fee Schedule,,1449.26,,,1449.26,Fee Schedule,,1369.76,,,1369.76,Fee Schedule,,1359.27,,,1359.27,Other,110% of Medicare,1095.12,,,1095.12,Fee Schedule,,524,,,524,Other,186% of Medicaid,1288.72,,,1288.72,Fee Schedule,,1702.52,,,1702.52,Fee Schedule,,606.8,,,606.8,Fee Schedule,,1288.72,,,1288.72,Fee Schedule,,1702.52,,,1702.52,Fee Schedule,,1141.35,,,1141.35,Fee Schedule,,1922.2,70,,1922.2,percent of total billed charges,All Other,1354.64,,,1354.64,Fee Schedule,,1148.14,,,1148.14,Fee Schedule,,589.01,,,589.01,Fee Schedule,,589.01,,,589.01,Fee Schedule,,589.01,,,589.01,Fee Schedule,,589.01,,,589.01,Fee Schedule,,281.88,,,281.88,Other,100% of Medicaid,281.88,,,281.88,Other,100% of Medicaid,281.88,,,281.88,Other,100% of Medicaid,281.88,,,281.88,Other,100% of Medicaid,634.23,,,634.23,Other,225% of Medicaid,431.28,,,431.28,Other,153% of Medicaid,634.23,,,634.23,Other,225% of Medicaid,394.63,,,394.63,Other,140% of Medicaid,634.23,,,634.23,Other,225% of Medicaid,732.89,,,732.89,Other,260% of Medicaid,913.29,,,913.29,Other,324% of Medicaid,606.04,,,606.04,Other,215% of Medicaid,606.04,,,606.04,Other,215% of Medicaid,352.35,,,352.35,Other,125% of Medicaid,281.88,2032.05,
ACUTE GI BLOOD LOSS IMAGING,78278,CPT,TC,50078278,CDM,341,RC,,,both,,,2767,2047.59,,,2047.59,Other,150% of Medicare + 9.63% HCRA Surcharge,1245.15,45,,1245.15,percent of total billed charges,Critical Access Hospital RCC factor,947.17,,,947.17,Fee Schedule,,852.16,,,852.16,Fee Schedule,,1611.2,,,1611.2,Fee Schedule,,1449.16,,,1449.16,Fee Schedule,,1369.67,,,1369.67,Fee Schedule,,1369.67,,,1369.67,Other,110% of Medicare,1125.33,,,1125.33,Fee Schedule,,1144,,,1144,Other,186% of Medicaid,1324.26,,,1324.26,Fee Schedule,,1715.54,,,1715.54,Fee Schedule,,623.53,,,623.53,Fee Schedule,,1324.26,,,1324.26,Fee Schedule,,1715.54,,,1715.54,Fee Schedule,,1172.83,,,1172.83,Fee Schedule,,1936.9,70,,1936.9,percent of total billed charges,All Other,1392.36,,,1392.36,Fee Schedule,,1180.11,,,1180.11,Fee Schedule,,589.01,,,589.01,Fee Schedule,,589.01,,,589.01,Fee Schedule,,589.01,,,589.01,Fee Schedule,,589.01,,,589.01,Fee Schedule,,615.17,,,615.17,Other,100% of Medicaid,615.17,,,615.17,Other,100% of Medicaid,615.17,,,615.17,Other,100% of Medicaid,615.17,,,615.17,Other,100% of Medicaid,1384.13,,,1384.13,Other,225% of Medicaid,941.21,,,941.21,Other,153% of Medicaid,1384.13,,,1384.13,Other,225% of Medicaid,861.24,,,861.24,Other,140% of Medicaid,1384.13,,,1384.13,Other,225% of Medicaid,1599.44,,,1599.44,Other,260% of Medicaid,1993.15,,,1993.15,Other,324% of Medicaid,1322.62,,,1322.62,Other,215% of Medicaid,1322.62,,,1322.62,Other,215% of Medicaid,768.96,,,768.96,Other,125% of Medicaid,589.01,2047.59,
MECKELS DIVERTICULUM,78290,CPT,TC,50078290,CDM,341,RC,,,both,,,2524,1867.77,,,1867.77,Other,150% of Medicare + 9.63% HCRA Surcharge,1135.8,45,,1135.8,percent of total billed charges,Critical Access Hospital RCC factor,934.48,,,934.48,Fee Schedule,,840.74,,,840.74,Fee Schedule,,1613.57,,,1613.57,Fee Schedule,,1451.29,,,1451.29,Fee Schedule,,1371.69,,,1371.69,Fee Schedule,,1249.38,,,1249.38,Other,110% of Medicare,1110.24,,,1110.24,Fee Schedule,,524,,,524,Other,186% of Medicaid,1306.51,,,1306.51,Fee Schedule,,1564.88,,,1564.88,Fee Schedule,,615.17,,,615.17,Fee Schedule,,1306.51,,,1306.51,Fee Schedule,,1564.88,,,1564.88,Fee Schedule,,1157.11,,,1157.11,Fee Schedule,,1766.8,70,,1766.8,percent of total billed charges,All Other,1375.96,,,1375.96,Fee Schedule,,1166.21,,,1166.21,Fee Schedule,,589.01,,,589.01,Fee Schedule,,589.01,,,589.01,Fee Schedule,,589.01,,,589.01,Fee Schedule,,589.01,,,589.01,Fee Schedule,,281.88,,,281.88,Other,100% of Medicaid,281.88,,,281.88,Other,100% of Medicaid,281.88,,,281.88,Other,100% of Medicaid,281.88,,,281.88,Other,100% of Medicaid,634.23,,,634.23,Other,225% of Medicaid,431.28,,,431.28,Other,153% of Medicaid,634.23,,,634.23,Other,225% of Medicaid,394.63,,,394.63,Other,140% of Medicaid,634.23,,,634.23,Other,225% of Medicaid,732.89,,,732.89,Other,260% of Medicaid,913.29,,,913.29,Other,324% of Medicaid,606.04,,,606.04,Other,215% of Medicaid,606.04,,,606.04,Other,215% of Medicaid,352.35,,,352.35,Other,125% of Medicaid,281.88,1867.77,
PERITON-VENOUS SHUNT PATENCY,78291,CPT,,50078291,CDM,341,RC,,,both,,,1758,1300.92,,,1300.92,Other,150% of Medicare + 9.63% HCRA Surcharge,791.1,45,,791.1,percent of total billed charges,Critical Access Hospital RCC factor,697.46,,,697.46,Fee Schedule,,627.5,,,627.5,Fee Schedule,,1409.94,,,1409.94,Fee Schedule,,1268.14,,,1268.14,Fee Schedule,,1198.58,,,1198.58,Fee Schedule,,870.21,,,870.21,Other,110% of Medicare,828.65,,,828.65,Fee Schedule,,524,,,524,Other,186% of Medicaid,975.13,,,975.13,Fee Schedule,,1089.96,,,1089.96,Fee Schedule,,459.14,,,459.14,Fee Schedule,,975.13,,,975.13,Fee Schedule,,1089.96,,,1089.96,Fee Schedule,,863.63,,,863.63,Fee Schedule,,1230.6,70,,1230.6,percent of total billed charges,All Other,1015.16,,,1015.16,Fee Schedule,,860.41,,,860.41,Fee Schedule,,589.01,,,589.01,Fee Schedule,,589.01,,,589.01,Fee Schedule,,589.01,,,589.01,Fee Schedule,,589.01,,,589.01,Fee Schedule,,281.88,,,281.88,Other,100% of Medicaid,281.88,,,281.88,Other,100% of Medicaid,281.88,,,281.88,Other,100% of Medicaid,281.88,,,281.88,Other,100% of Medicaid,634.23,,,634.23,Other,225% of Medicaid,431.28,,,431.28,Other,153% of Medicaid,634.23,,,634.23,Other,225% of Medicaid,394.63,,,394.63,Other,140% of Medicaid,634.23,,,634.23,Other,225% of Medicaid,732.89,,,732.89,Other,260% of Medicaid,913.29,,,913.29,Other,324% of Medicaid,606.04,,,606.04,Other,215% of Medicaid,606.04,,,606.04,Other,215% of Medicaid,352.35,,,352.35,Other,125% of Medicaid,281.88,1409.94,
BONE AND OR JT IMAGING LIMITED,78300,CPT,TC,50078300,CDM,341,RC,,,both,,,1304,964.96,,,964.96,Other,150% of Medicare + 9.63% HCRA Surcharge,586.8,45,,586.8,percent of total billed charges,Critical Access Hospital RCC factor,617.42,,,617.42,Fee Schedule,,555.49,,,555.49,Fee Schedule,,979.69,,,979.69,Fee Schedule,,881.17,,,881.17,Fee Schedule,,832.83,,,832.83,Fee Schedule,,645.48,,,645.48,Other,110% of Medicare,733.55,,,733.55,Fee Schedule,,524,,,524,Other,186% of Medicaid,863.23,,,863.23,Fee Schedule,,808.48,,,808.48,Fee Schedule,,406.46,,,406.46,Fee Schedule,,863.23,,,863.23,Fee Schedule,,808.48,,,808.48,Fee Schedule,,764.52,,,764.52,Fee Schedule,,912.8,70,,912.8,percent of total billed charges,All Other,916.76,,,916.76,Fee Schedule,,777.01,,,777.01,Fee Schedule,,589.01,,,589.01,Fee Schedule,,589.01,,,589.01,Fee Schedule,,589.01,,,589.01,Fee Schedule,,589.01,,,589.01,Fee Schedule,,281.88,,,281.88,Other,100% of Medicaid,281.88,,,281.88,Other,100% of Medicaid,281.88,,,281.88,Other,100% of Medicaid,281.88,,,281.88,Other,100% of Medicaid,634.23,,,634.23,Other,225% of Medicaid,431.28,,,431.28,Other,153% of Medicaid,634.23,,,634.23,Other,225% of Medicaid,394.63,,,394.63,Other,140% of Medicaid,634.23,,,634.23,Other,225% of Medicaid,732.89,,,732.89,Other,260% of Medicaid,913.29,,,913.29,Other,324% of Medicaid,606.04,,,606.04,Other,215% of Medicaid,606.04,,,606.04,Other,215% of Medicaid,352.35,,,352.35,Other,125% of Medicaid,281.88,979.69,
BONE/JOINT MULTI AREAS,78305,CPT,TC,50078305,CDM,341,RC,,,both,,,1509,1116.66,,,1116.66,Other,150% of Medicare + 9.63% HCRA Surcharge,679.05,45,,679.05,percent of total billed charges,Critical Access Hospital RCC factor,733.13,,,733.13,Fee Schedule,,659.58,,,659.58,Fee Schedule,,1293.21,,,1293.21,Fee Schedule,,1163.15,,,1163.15,Fee Schedule,,1099.35,,,1099.35,Fee Schedule,,746.96,,,746.96,Other,110% of Medicare,871.02,,,871.02,Fee Schedule,,524,,,524,Other,186% of Medicaid,1025,,,1025,Fee Schedule,,935.58,,,935.58,Fee Schedule,,482.62,,,482.62,Fee Schedule,,1025,,,1025,Fee Schedule,,935.58,,,935.58,Fee Schedule,,907.79,,,907.79,Fee Schedule,,1056.3,70,,1056.3,percent of total billed charges,All Other,1090.6,,,1090.6,Fee Schedule,,924.35,,,924.35,Fee Schedule,,589.01,,,589.01,Fee Schedule,,589.01,,,589.01,Fee Schedule,,589.01,,,589.01,Fee Schedule,,589.01,,,589.01,Fee Schedule,,281.88,,,281.88,Other,100% of Medicaid,281.88,,,281.88,Other,100% of Medicaid,281.88,,,281.88,Other,100% of Medicaid,281.88,,,281.88,Other,100% of Medicaid,634.23,,,634.23,Other,225% of Medicaid,431.28,,,431.28,Other,153% of Medicaid,634.23,,,634.23,Other,225% of Medicaid,394.63,,,394.63,Other,140% of Medicaid,634.23,,,634.23,Other,225% of Medicaid,732.89,,,732.89,Other,260% of Medicaid,913.29,,,913.29,Other,324% of Medicaid,606.04,,,606.04,Other,215% of Medicaid,606.04,,,606.04,Other,215% of Medicaid,352.35,,,352.35,Other,125% of Medicaid,281.88,1293.21,
BONE SCAN WHOLE BODY,78306,CPT,TC,50078306,CDM,341,RC,,,both,,,1934,1431.16,,,1431.16,Other,150% of Medicare + 9.63% HCRA Surcharge,870.3,45,,870.3,percent of total billed charges,Critical Access Hospital RCC factor,797.82,,,797.82,Fee Schedule,,717.79,,,717.79,Fee Schedule,,1421.37,,,1421.37,Fee Schedule,,1278.43,,,1278.43,Fee Schedule,,1208.3,,,1208.3,Fee Schedule,,957.33,,,957.33,Other,110% of Medicare,947.88,,,947.88,Fee Schedule,,524,,,524,Other,186% of Medicaid,1115.45,,,1115.45,Fee Schedule,,1199.08,,,1199.08,Fee Schedule,,525.21,,,525.21,Fee Schedule,,1115.45,,,1115.45,Fee Schedule,,1199.08,,,1199.08,Fee Schedule,,987.9,,,987.9,Fee Schedule,,1353.8,70,,1353.8,percent of total billed charges,All Other,1182.44,,,1182.44,Fee Schedule,,1002.19,,,1002.19,Fee Schedule,,589.01,,,589.01,Fee Schedule,,589.01,,,589.01,Fee Schedule,,589.01,,,589.01,Fee Schedule,,589.01,,,589.01,Fee Schedule,,281.88,,,281.88,Other,100% of Medicaid,281.88,,,281.88,Other,100% of Medicaid,281.88,,,281.88,Other,100% of Medicaid,281.88,,,281.88,Other,100% of Medicaid,634.23,,,634.23,Other,225% of Medicaid,431.28,,,431.28,Other,153% of Medicaid,634.23,,,634.23,Other,225% of Medicaid,394.63,,,394.63,Other,140% of Medicaid,634.23,,,634.23,Other,225% of Medicaid,732.89,,,732.89,Other,260% of Medicaid,913.29,,,913.29,Other,324% of Medicaid,606.04,,,606.04,Other,215% of Medicaid,606.04,,,606.04,Other,215% of Medicaid,352.35,,,352.35,Other,125% of Medicaid,281.88,1431.16,
THREE PHASE BONE SCAN,78315,CPT,TC,50078315,CDM,341,RC,,,both,,,2733,2022.43,,,2022.43,Other,150% of Medicare + 9.63% HCRA Surcharge,1229.85,45,,1229.85,percent of total billed charges,Critical Access Hospital RCC factor,935.63,,,935.63,Fee Schedule,,841.77,,,841.77,Fee Schedule,,1647.82,,,1647.82,Fee Schedule,,1482.1,,,1482.1,Fee Schedule,,1400.81,,,1400.81,Fee Schedule,,1352.84,,,1352.84,Other,110% of Medicare,1111.61,,,1111.61,Fee Schedule,,524,,,524,Other,186% of Medicaid,1308.12,,,1308.12,Fee Schedule,,1694.46,,,1694.46,Fee Schedule,,615.93,,,615.93,Fee Schedule,,1308.12,,,1308.12,Fee Schedule,,1694.46,,,1694.46,Fee Schedule,,1158.54,,,1158.54,Fee Schedule,,1913.1,70,,1913.1,percent of total billed charges,All Other,1375.96,,,1375.96,Fee Schedule,,1166.21,,,1166.21,Fee Schedule,,589.01,,,589.01,Fee Schedule,,589.01,,,589.01,Fee Schedule,,589.01,,,589.01,Fee Schedule,,589.01,,,589.01,Fee Schedule,,281.88,,,281.88,Other,100% of Medicaid,281.88,,,281.88,Other,100% of Medicaid,281.88,,,281.88,Other,100% of Medicaid,281.88,,,281.88,Other,100% of Medicaid,634.23,,,634.23,Other,225% of Medicaid,431.28,,,431.28,Other,153% of Medicaid,634.23,,,634.23,Other,225% of Medicaid,394.63,,,394.63,Other,140% of Medicaid,634.23,,,634.23,Other,225% of Medicaid,732.89,,,732.89,Other,260% of Medicaid,913.29,,,913.29,Other,324% of Medicaid,606.04,,,606.04,Other,215% of Medicaid,606.04,,,606.04,Other,215% of Medicaid,352.35,,,352.35,Other,125% of Medicaid,281.88,2022.43,
HT MUSCLE IMAGE SPECT SING,78451,CPT,TC,50078451,CDM,341,RC,,,both,,,3860,2856.41,,,2856.41,Other,150% of Medicare + 9.63% HCRA Surcharge,1737,45,,1737,percent of total billed charges,Critical Access Hospital RCC factor,867.3,,,867.3,Fee Schedule,,780.3,,,780.3,Fee Schedule,,1853.83,,,1853.83,Fee Schedule,,1667.39,,,1667.39,Fee Schedule,,1575.93,,,1575.93,Fee Schedule,,1910.7,,,1910.7,Other,110% of Medicare,1030.43,,,1030.43,Fee Schedule,,1144,,,1144,Other,186% of Medicaid,1212.58,,,1212.58,Fee Schedule,,2393.2,,,2393.2,Fee Schedule,,570.95,,,570.95,Fee Schedule,,1212.58,,,1212.58,Fee Schedule,,2393.2,,,2393.2,Fee Schedule,,1073.93,,,1073.93,Fee Schedule,,2702,70,,2702,percent of total billed charges,All Other,1267.72,,,1267.72,Fee Schedule,,1074.47,,,1074.47,Fee Schedule,,2035.5,,,2035.5,Fee Schedule,,2035.5,,,2035.5,Fee Schedule,,2035.5,,,2035.5,Fee Schedule,,2035.5,,,2035.5,Fee Schedule,,615.17,,,615.17,Other,100% of Medicaid,615.17,,,615.17,Other,100% of Medicaid,615.17,,,615.17,Other,100% of Medicaid,615.17,,,615.17,Other,100% of Medicaid,1384.13,,,1384.13,Other,225% of Medicaid,941.21,,,941.21,Other,153% of Medicaid,1384.13,,,1384.13,Other,225% of Medicaid,861.24,,,861.24,Other,140% of Medicaid,1384.13,,,1384.13,Other,225% of Medicaid,1599.44,,,1599.44,Other,260% of Medicaid,1993.15,,,1993.15,Other,324% of Medicaid,1322.62,,,1322.62,Other,215% of Medicaid,1322.62,,,1322.62,Other,215% of Medicaid,768.96,,,768.96,Other,125% of Medicaid,570.95,2856.41,
HT MUSCLE IMAGE SPECT MULT,78452,CPT,TC,50078452,CDM,341,RC,,,both,,,4216,3119.85,,,3119.85,Other,150% of Medicare + 9.63% HCRA Surcharge,1897.2,45,,1897.2,percent of total billed charges,Critical Access Hospital RCC factor,1245.57,,,1245.57,Fee Schedule,,1120.62,,,1120.62,Fee Schedule,,2693.76,,,2693.76,Fee Schedule,,2422.85,,,2422.85,Fee Schedule,,2289.95,,,2289.95,Fee Schedule,,2086.92,,,2086.92,Other,110% of Medicare,1479.84,,,1479.84,Fee Schedule,,1144,,,1144,Other,186% of Medicaid,1741.45,,,1741.45,Fee Schedule,,2613.92,,,2613.92,Fee Schedule,,819.97,,,819.97,Fee Schedule,,1741.45,,,1741.45,Fee Schedule,,2613.92,,,2613.92,Fee Schedule,,1542.32,,,1542.32,Fee Schedule,,2951.2,70,,2951.2,percent of total billed charges,All Other,1831.88,,,1831.88,Fee Schedule,,1552.63,,,1552.63,Fee Schedule,,2035.5,,,2035.5,Fee Schedule,,2035.5,,,2035.5,Fee Schedule,,2035.5,,,2035.5,Fee Schedule,,2035.5,,,2035.5,Fee Schedule,,615.17,,,615.17,Other,100% of Medicaid,615.17,,,615.17,Other,100% of Medicaid,615.17,,,615.17,Other,100% of Medicaid,615.17,,,615.17,Other,100% of Medicaid,1384.13,,,1384.13,Other,225% of Medicaid,941.21,,,941.21,Other,153% of Medicaid,1384.13,,,1384.13,Other,225% of Medicaid,861.24,,,861.24,Other,140% of Medicaid,1384.13,,,1384.13,Other,225% of Medicaid,1599.44,,,1599.44,Other,260% of Medicaid,1993.15,,,1993.15,Other,324% of Medicaid,1322.62,,,1322.62,Other,215% of Medicaid,1322.62,,,1322.62,Other,215% of Medicaid,768.96,,,768.96,Other,125% of Medicaid,615.17,3119.85,
HT MUSCLE IMAGE PLANAR SING,78453,CPT,TC,50078453,CDM,341,RC,,,both,,,3310,2449.41,,,2449.41,Other,150% of Medicare + 9.63% HCRA Surcharge,1489.5,45,,1489.5,percent of total billed charges,Critical Access Hospital RCC factor,770.26,,,770.26,Fee Schedule,,692.99,,,692.99,Fee Schedule,,1650.2,,,1650.2,Fee Schedule,,1484.24,,,1484.24,Fee Schedule,,1402.82,,,1402.82,Fee Schedule,,1638.45,,,1638.45,Other,110% of Medicare,915.13,,,915.13,Fee Schedule,,1144,,,1144,Other,186% of Medicaid,1076.91,,,1076.91,Fee Schedule,,2052.2,,,2052.2,Fee Schedule,,507.07,,,507.07,Fee Schedule,,1076.91,,,1076.91,Fee Schedule,,2052.2,,,2052.2,Fee Schedule,,953.77,,,953.77,Fee Schedule,,2317,70,,2317,percent of total billed charges,All Other,1144.72,,,1144.72,Fee Schedule,,970.22,,,970.22,Fee Schedule,,2035.5,,,2035.5,Fee Schedule,,2035.5,,,2035.5,Fee Schedule,,2035.5,,,2035.5,Fee Schedule,,2035.5,,,2035.5,Fee Schedule,,615.17,,,615.17,Other,100% of Medicaid,615.17,,,615.17,Other,100% of Medicaid,615.17,,,615.17,Other,100% of Medicaid,615.17,,,615.17,Other,100% of Medicaid,1384.13,,,1384.13,Other,225% of Medicaid,941.21,,,941.21,Other,153% of Medicaid,1384.13,,,1384.13,Other,225% of Medicaid,861.24,,,861.24,Other,140% of Medicaid,1384.13,,,1384.13,Other,225% of Medicaid,1599.44,,,1599.44,Other,260% of Medicaid,1993.15,,,1993.15,Other,324% of Medicaid,1322.62,,,1322.62,Other,215% of Medicaid,1322.62,,,1322.62,Other,215% of Medicaid,768.96,,,768.96,Other,125% of Medicaid,507.07,2449.41,
HT MUSC IMAGE PLANAR MULT,78454,CPT,TC,50078454,CDM,341,RC,,,both,,,2989,2211.87,,,2211.87,Other,150% of Medicare + 9.63% HCRA Surcharge,1345.05,45,,1345.05,percent of total billed charges,Critical Access Hospital RCC factor,1165.69,,,1165.69,Fee Schedule,,1048.76,,,1048.76,Fee Schedule,,2419.19,,,2419.19,Fee Schedule,,2175.9,,,2175.9,Fee Schedule,,2056.54,,,2056.54,Fee Schedule,,1479.56,,,1479.56,Other,110% of Medicare,1384.94,,,1384.94,Fee Schedule,,1144,,,1144,Other,186% of Medicaid,1629.77,,,1629.77,Fee Schedule,,1853.18,,,1853.18,Fee Schedule,,767.38,,,767.38,Fee Schedule,,1629.77,,,1629.77,Fee Schedule,,1853.18,,,1853.18,Fee Schedule,,1443.41,,,1443.41,Fee Schedule,,2092.3,70,,2092.3,percent of total billed charges,All Other,1707.24,,,1707.24,Fee Schedule,,1446.99,,,1446.99,Fee Schedule,,2035.5,,,2035.5,Fee Schedule,,2035.5,,,2035.5,Fee Schedule,,2035.5,,,2035.5,Fee Schedule,,2035.5,,,2035.5,Fee Schedule,,615.17,,,615.17,Other,100% of Medicaid,615.17,,,615.17,Other,100% of Medicaid,615.17,,,615.17,Other,100% of Medicaid,615.17,,,615.17,Other,100% of Medicaid,1384.13,,,1384.13,Other,225% of Medicaid,941.21,,,941.21,Other,153% of Medicaid,1384.13,,,1384.13,Other,225% of Medicaid,861.24,,,861.24,Other,140% of Medicaid,1384.13,,,1384.13,Other,225% of Medicaid,1599.44,,,1599.44,Other,260% of Medicaid,1993.15,,,1993.15,Other,324% of Medicaid,1322.62,,,1322.62,Other,215% of Medicaid,1322.62,,,1322.62,Other,215% of Medicaid,768.96,,,768.96,Other,125% of Medicaid,615.17,2419.19,
MI PLANAR QUAL/QUAN,78466,CPT,TC,50078466,CDM,341,RC,,,both,,,1268,938.32,,,938.32,Other,150% of Medicare + 9.63% HCRA Surcharge,570.6,45,,570.6,percent of total billed charges,Critical Access Hospital RCC factor,469.73,,,469.73,Fee Schedule,,422.61,,,422.61,Fee Schedule,,982.01,,,982.01,Fee Schedule,,883.25,,,883.25,Fee Schedule,,834.8,,,834.8,Fee Schedule,,627.66,,,627.66,Other,110% of Medicare,558.08,,,558.08,Fee Schedule,,524,,,524,Other,186% of Medicaid,656.74,,,656.74,Fee Schedule,,786.16,,,786.16,Fee Schedule,,309.23,,,309.23,Fee Schedule,,656.74,,,656.74,Fee Schedule,,786.16,,,786.16,Fee Schedule,,581.64,,,581.64,Fee Schedule,,887.6,70,,887.6,percent of total billed charges,All Other,742.92,,,742.92,Fee Schedule,,629.67,,,629.67,Fee Schedule,,589.01,,,589.01,Fee Schedule,,589.01,,,589.01,Fee Schedule,,589.01,,,589.01,Fee Schedule,,589.01,,,589.01,Fee Schedule,,281.88,,,281.88,Other,100% of Medicaid,281.88,,,281.88,Other,100% of Medicaid,281.88,,,281.88,Other,100% of Medicaid,281.88,,,281.88,Other,100% of Medicaid,634.23,,,634.23,Other,225% of Medicaid,431.28,,,431.28,Other,153% of Medicaid,634.23,,,634.23,Other,225% of Medicaid,394.63,,,394.63,Other,140% of Medicaid,634.23,,,634.23,Other,225% of Medicaid,732.89,,,732.89,Other,260% of Medicaid,913.29,,,913.29,Other,324% of Medicaid,606.04,,,606.04,Other,215% of Medicaid,606.04,,,606.04,Other,215% of Medicaid,352.35,,,352.35,Other,125% of Medicaid,281.88,982.01,
MUGA SGL W WM AND EF,78472,CPT,TC,50078472,CDM,341,RC,,,both,,,1669,1235.06,,,1235.06,Other,150% of Medicare + 9.63% HCRA Surcharge,751.05,45,,751.05,percent of total billed charges,Critical Access Hospital RCC factor,573.69,,,573.69,Fee Schedule,,516.14,,,516.14,Fee Schedule,,1366.46,,,1366.46,Fee Schedule,,1229.03,,,1229.03,Fee Schedule,,1161.62,,,1161.62,Fee Schedule,,826.16,,,826.16,Other,110% of Medicare,681.59,,,681.59,Fee Schedule,,524,,,524,Other,186% of Medicaid,802.09,,,802.09,Fee Schedule,,1034.78,,,1034.78,Fee Schedule,,377.66,,,377.66,Fee Schedule,,802.09,,,802.09,Fee Schedule,,1034.78,,,1034.78,Fee Schedule,,710.37,,,710.37,Fee Schedule,,1168.3,70,,1168.3,percent of total billed charges,All Other,839.68,,,839.68,Fee Schedule,,711.68,,,711.68,Fee Schedule,,589.01,,,589.01,Fee Schedule,,589.01,,,589.01,Fee Schedule,,589.01,,,589.01,Fee Schedule,,589.01,,,589.01,Fee Schedule,,281.88,,,281.88,Other,100% of Medicaid,281.88,,,281.88,Other,100% of Medicaid,281.88,,,281.88,Other,100% of Medicaid,281.88,,,281.88,Other,100% of Medicaid,634.23,,,634.23,Other,225% of Medicaid,431.28,,,431.28,Other,153% of Medicaid,634.23,,,634.23,Other,225% of Medicaid,394.63,,,394.63,Other,140% of Medicaid,634.23,,,634.23,Other,225% of Medicaid,732.89,,,732.89,Other,260% of Medicaid,913.29,,,913.29,Other,324% of Medicaid,606.04,,,606.04,Other,215% of Medicaid,606.04,,,606.04,Other,215% of Medicaid,352.35,,,352.35,Other,125% of Medicaid,281.88,1366.46,
MUGA; MULTI W WM & EF,78473,CPT,TC,50078473,CDM,341,RC,,,both,,,1724,1275.76,,,1275.76,Other,150% of Medicare + 9.63% HCRA Surcharge,775.8,45,,775.8,percent of total billed charges,Critical Access Hospital RCC factor,697.46,,,697.46,Fee Schedule,,627.5,,,627.5,Fee Schedule,,1741.74,,,1741.74,Fee Schedule,,1566.57,,,1566.57,Fee Schedule,,1480.64,,,1480.64,Fee Schedule,,853.38,,,853.38,Other,110% of Medicare,828.65,,,828.65,Fee Schedule,,524,,,524,Other,186% of Medicaid,975.13,,,975.13,Fee Schedule,,1068.88,,,1068.88,Fee Schedule,,459.14,,,459.14,Fee Schedule,,975.13,,,975.13,Fee Schedule,,1068.88,,,1068.88,Fee Schedule,,863.63,,,863.63,Fee Schedule,,1206.8,70,,1206.8,percent of total billed charges,All Other,1016.8,,,1016.8,Fee Schedule,,861.8,,,861.8,Fee Schedule,,589.01,,,589.01,Fee Schedule,,589.01,,,589.01,Fee Schedule,,589.01,,,589.01,Fee Schedule,,589.01,,,589.01,Fee Schedule,,281.88,,,281.88,Other,100% of Medicaid,281.88,,,281.88,Other,100% of Medicaid,281.88,,,281.88,Other,100% of Medicaid,281.88,,,281.88,Other,100% of Medicaid,634.23,,,634.23,Other,225% of Medicaid,431.28,,,431.28,Other,153% of Medicaid,634.23,,,634.23,Other,225% of Medicaid,394.63,,,394.63,Other,140% of Medicaid,634.23,,,634.23,Other,225% of Medicaid,732.89,,,732.89,Other,260% of Medicaid,913.29,,,913.29,Other,324% of Medicaid,606.04,,,606.04,Other,215% of Medicaid,606.04,,,606.04,Other,215% of Medicaid,352.35,,,352.35,Other,125% of Medicaid,281.88,1741.74,
LUNG VENTILATION IMAGING,78579,CPT,TC,50078579,CDM,341,RC,,,both,,,1285,950.9,,,950.9,Other,150% of Medicare + 9.63% HCRA Surcharge,578.25,45,,578.25,percent of total billed charges,Critical Access Hospital RCC factor,520.38,,,520.38,Fee Schedule,,468.18,,,468.18,Fee Schedule,,156.38,,,156.38,Fee Schedule,,156.38,,,156.38,Fee Schedule,,156.38,,,156.38,Fee Schedule,,636.08,,,636.08,Other,110% of Medicare,618.26,,,618.26,Fee Schedule,,1144,,,1144,Other,186% of Medicaid,727.56,,,727.56,Fee Schedule,,796.7,,,796.7,Fee Schedule,,342.57,,,342.57,Fee Schedule,,727.56,,,727.56,Fee Schedule,,796.7,,,796.7,Fee Schedule,,644.36,,,644.36,Fee Schedule,,899.5,70,,899.5,percent of total billed charges,All Other,759.32,,,759.32,Fee Schedule,,643.57,,,643.57,Fee Schedule,,589.01,,,589.01,Fee Schedule,,589.01,,,589.01,Fee Schedule,,589.01,,,589.01,Fee Schedule,,589.01,,,589.01,Fee Schedule,,615.17,,,615.17,Other,100% of Medicaid,615.17,,,615.17,Other,100% of Medicaid,615.17,,,615.17,Other,100% of Medicaid,615.17,,,615.17,Other,100% of Medicaid,1384.13,,,1384.13,Other,225% of Medicaid,941.21,,,941.21,Other,153% of Medicaid,1384.13,,,1384.13,Other,225% of Medicaid,861.24,,,861.24,Other,140% of Medicaid,1384.13,,,1384.13,Other,225% of Medicaid,1599.44,,,1599.44,Other,260% of Medicaid,1993.15,,,1993.15,Other,324% of Medicaid,1322.62,,,1322.62,Other,215% of Medicaid,1322.62,,,1322.62,Other,215% of Medicaid,768.96,,,768.96,Other,125% of Medicaid,156.38,1993.15,
PULMONARY PERFUSION IMAGING,78580,CPT,TC,50078580,CDM,341,RC,,,both,,,1872,1385.28,,,1385.28,Other,150% of Medicare + 9.63% HCRA Surcharge,842.4,45,,842.4,percent of total billed charges,Critical Access Hospital RCC factor,633.76,,,633.76,Fee Schedule,,570.18,,,570.18,Fee Schedule,,1187.96,,,1187.96,Fee Schedule,,1068.49,,,1068.49,Fee Schedule,,1009.88,,,1009.88,Fee Schedule,,926.64,,,926.64,Other,110% of Medicare,752.96,,,752.96,Fee Schedule,,1144,,,1144,Other,186% of Medicaid,886.07,,,886.07,Fee Schedule,,1160.64,,,1160.64,Fee Schedule,,417.21,,,417.21,Fee Schedule,,886.07,,,886.07,Fee Schedule,,1160.64,,,1160.64,Fee Schedule,,784.75,,,784.75,Fee Schedule,,1310.4,70,,1310.4,percent of total billed charges,All Other,929.88,,,929.88,Fee Schedule,,788.13,,,788.13,Fee Schedule,,589.01,,,589.01,Fee Schedule,,589.01,,,589.01,Fee Schedule,,589.01,,,589.01,Fee Schedule,,589.01,,,589.01,Fee Schedule,,615.17,,,615.17,Other,100% of Medicaid,615.17,,,615.17,Other,100% of Medicaid,615.17,,,615.17,Other,100% of Medicaid,615.17,,,615.17,Other,100% of Medicaid,1384.13,,,1384.13,Other,225% of Medicaid,941.21,,,941.21,Other,153% of Medicaid,1384.13,,,1384.13,Other,225% of Medicaid,861.24,,,861.24,Other,140% of Medicaid,1384.13,,,1384.13,Other,225% of Medicaid,1599.44,,,1599.44,Other,260% of Medicaid,1993.15,,,1993.15,Other,324% of Medicaid,1322.62,,,1322.62,Other,215% of Medicaid,1322.62,,,1322.62,Other,215% of Medicaid,768.96,,,768.96,Other,125% of Medicaid,417.21,1993.15,
LUNG VENTILAT&PERFUS IMAGING,78582,CPT,TC,50078582,CDM,341,RC,,,both,,,2603,1926.23,,,1926.23,Other,150% of Medicare + 9.63% HCRA Surcharge,1171.35,45,,1171.35,percent of total billed charges,Critical Access Hospital RCC factor,882.32,,,882.32,Fee Schedule,,793.81,,,793.81,Fee Schedule,,270.41,,,270.41,Fee Schedule,,270.41,,,270.41,Fee Schedule,,270.41,,,270.41,Fee Schedule,,1288.49,,,1288.49,Other,110% of Medicare,1048.28,,,1048.28,Fee Schedule,,1144,,,1144,Other,186% of Medicaid,1233.59,,,1233.59,Fee Schedule,,1613.86,,,1613.86,Fee Schedule,,580.84,,,580.84,Fee Schedule,,1233.59,,,1233.59,Fee Schedule,,1613.86,,,1613.86,Fee Schedule,,1092.53,,,1092.53,Fee Schedule,,1822.1,70,,1822.1,percent of total billed charges,All Other,1302.16,,,1302.16,Fee Schedule,,1103.66,,,1103.66,Fee Schedule,,755.17,,,755.17,Fee Schedule,,755.17,,,755.17,Fee Schedule,,755.17,,,755.17,Fee Schedule,,755.17,,,755.17,Fee Schedule,,615.17,,,615.17,Other,100% of Medicaid,615.17,,,615.17,Other,100% of Medicaid,615.17,,,615.17,Other,100% of Medicaid,615.17,,,615.17,Other,100% of Medicaid,1384.13,,,1384.13,Other,225% of Medicaid,941.21,,,941.21,Other,153% of Medicaid,1384.13,,,1384.13,Other,225% of Medicaid,861.24,,,861.24,Other,140% of Medicaid,1384.13,,,1384.13,Other,225% of Medicaid,1599.44,,,1599.44,Other,260% of Medicaid,1993.15,,,1993.15,Other,324% of Medicaid,1322.62,,,1322.62,Other,215% of Medicaid,1322.62,,,1322.62,Other,215% of Medicaid,768.96,,,768.96,Other,125% of Medicaid,270.41,1993.15,
LUNG PERFUSION DIFFERENTIAL,78597,CPT,,50078597,CDM,341,RC,,,both,,,1412,1044.88,,,1044.88,Other,150% of Medicare + 9.63% HCRA Surcharge,635.4,45,,635.4,percent of total billed charges,Critical Access Hospital RCC factor,522.68,,,522.68,Fee Schedule,,470.25,,,470.25,Fee Schedule,,160.95,,,160.95,Fee Schedule,,160.95,,,160.95,Fee Schedule,,160.95,,,160.95,Fee Schedule,,698.94,,,698.94,Other,110% of Medicare,620.99,,,620.99,Fee Schedule,,1144,,,1144,Other,186% of Medicaid,730.77,,,730.77,Fee Schedule,,875.44,,,875.44,Fee Schedule,,344.09,,,344.09,Fee Schedule,,730.77,,,730.77,Fee Schedule,,875.44,,,875.44,Fee Schedule,,647.21,,,647.21,Fee Schedule,,988.4,70,,988.4,percent of total billed charges,All Other,774.08,,,774.08,Fee Schedule,,656.08,,,656.08,Fee Schedule,,589.01,,,589.01,Fee Schedule,,589.01,,,589.01,Fee Schedule,,589.01,,,589.01,Fee Schedule,,589.01,,,589.01,Fee Schedule,,615.17,,,615.17,Other,100% of Medicaid,615.17,,,615.17,Other,100% of Medicaid,615.17,,,615.17,Other,100% of Medicaid,615.17,,,615.17,Other,100% of Medicaid,1384.13,,,1384.13,Other,225% of Medicaid,941.21,,,941.21,Other,153% of Medicaid,1384.13,,,1384.13,Other,225% of Medicaid,861.24,,,861.24,Other,140% of Medicaid,1384.13,,,1384.13,Other,225% of Medicaid,1599.44,,,1599.44,Other,260% of Medicaid,1993.15,,,1993.15,Other,324% of Medicaid,1322.62,,,1322.62,Other,215% of Medicaid,1322.62,,,1322.62,Other,215% of Medicaid,768.96,,,768.96,Other,125% of Medicaid,160.95,1993.15,
LUNG PERF&VENTILAT DIFERENTL QUANT,78598,CPT,TC,50078598,CDM,341,RC,,,both,,,2093,1548.83,,,1548.83,Other,150% of Medicare + 9.63% HCRA Surcharge,941.85,45,,941.85,percent of total billed charges,Critical Access Hospital RCC factor,823.4,,,823.4,Fee Schedule,,740.8,,,740.8,Fee Schedule,,253.15,,,253.15,Fee Schedule,,253.15,,,253.15,Fee Schedule,,253.15,,,253.15,Fee Schedule,,1036.04,,,1036.04,Other,110% of Medicare,978.27,,,978.27,Fee Schedule,,1144,,,1144,Other,186% of Medicaid,1151.22,,,1151.22,Fee Schedule,,1297.66,,,1297.66,Fee Schedule,,542.05,,,542.05,Fee Schedule,,1151.22,,,1151.22,Fee Schedule,,1297.66,,,1297.66,Fee Schedule,,1019.57,,,1019.57,Fee Schedule,,1465.1,70,,1465.1,percent of total billed charges,All Other,1220.16,,,1220.16,Fee Schedule,,1034.16,,,1034.16,Fee Schedule,,755.17,,,755.17,Fee Schedule,,755.17,,,755.17,Fee Schedule,,755.17,,,755.17,Fee Schedule,,755.17,,,755.17,Fee Schedule,,615.17,,,615.17,Other,100% of Medicaid,615.17,,,615.17,Other,100% of Medicaid,615.17,,,615.17,Other,100% of Medicaid,615.17,,,615.17,Other,100% of Medicaid,1384.13,,,1384.13,Other,225% of Medicaid,941.21,,,941.21,Other,153% of Medicaid,1384.13,,,1384.13,Other,225% of Medicaid,861.24,,,861.24,Other,140% of Medicaid,1384.13,,,1384.13,Other,225% of Medicaid,1599.44,,,1599.44,Other,260% of Medicaid,1993.15,,,1993.15,Other,324% of Medicaid,1322.62,,,1322.62,Other,215% of Medicaid,1322.62,,,1322.62,Other,215% of Medicaid,768.96,,,768.96,Other,125% of Medicaid,253.15,1993.15,
CISTERNOGRAPHY,78630,CPT,TC,50078630,CDM,341,RC,,,both,,,2806,2076.45,,,2076.45,Other,150% of Medicare + 9.63% HCRA Surcharge,1262.7,45,,1262.7,percent of total billed charges,Critical Access Hospital RCC factor,959.9,,,959.9,Fee Schedule,,863.61,,,863.61,Fee Schedule,,2039.23,,,2039.23,Fee Schedule,,1834.14,,,1834.14,Fee Schedule,,1733.54,,,1733.54,Fee Schedule,,1388.97,,,1388.97,Other,110% of Medicare,1140.45,,,1140.45,Fee Schedule,,1144,,,1144,Other,186% of Medicaid,1342.06,,,1342.06,Fee Schedule,,1739.72,,,1739.72,Fee Schedule,,631.91,,,631.91,Fee Schedule,,1342.06,,,1342.06,Fee Schedule,,1739.72,,,1739.72,Fee Schedule,,1188.59,,,1188.59,Fee Schedule,,1964.2,70,,1964.2,percent of total billed charges,All Other,1413.68,,,1413.68,Fee Schedule,,1198.18,,,1198.18,Fee Schedule,,755.17,,,755.17,Fee Schedule,,755.17,,,755.17,Fee Schedule,,755.17,,,755.17,Fee Schedule,,755.17,,,755.17,Fee Schedule,,615.17,,,615.17,Other,100% of Medicaid,615.17,,,615.17,Other,100% of Medicaid,615.17,,,615.17,Other,100% of Medicaid,615.17,,,615.17,Other,100% of Medicaid,1384.13,,,1384.13,Other,225% of Medicaid,941.21,,,941.21,Other,153% of Medicaid,1384.13,,,1384.13,Other,225% of Medicaid,861.24,,,861.24,Other,140% of Medicaid,1384.13,,,1384.13,Other,225% of Medicaid,1599.44,,,1599.44,Other,260% of Medicaid,1993.15,,,1993.15,Other,324% of Medicaid,1322.62,,,1322.62,Other,215% of Medicaid,1322.62,,,1322.62,Other,215% of Medicaid,768.96,,,768.96,Other,125% of Medicaid,615.17,2076.45,
CSF SHUNT EVALUATION,78645,CPT,TC,50078645,CDM,341,RC,,,both,,,2346,1736.05,,,1736.05,Other,150% of Medicare + 9.63% HCRA Surcharge,1055.7,45,,1055.7,percent of total billed charges,Critical Access Hospital RCC factor,934.48,,,934.48,Fee Schedule,,840.74,,,840.74,Fee Schedule,,1620.42,,,1620.42,Fee Schedule,,1457.46,,,1457.46,Fee Schedule,,1377.51,,,1377.51,Fee Schedule,,1161.27,,,1161.27,Other,110% of Medicare,1110.24,,,1110.24,Fee Schedule,,1144,,,1144,Other,186% of Medicaid,1306.51,,,1306.51,Fee Schedule,,1454.52,,,1454.52,Fee Schedule,,615.17,,,615.17,Fee Schedule,,1306.51,,,1306.51,Fee Schedule,,1454.52,,,1454.52,Fee Schedule,,1157.11,,,1157.11,Fee Schedule,,1642.2,70,,1642.2,percent of total billed charges,All Other,1372.68,,,1372.68,Fee Schedule,,1163.43,,,1163.43,Fee Schedule,,755.17,,,755.17,Fee Schedule,,755.17,,,755.17,Fee Schedule,,755.17,,,755.17,Fee Schedule,,755.17,,,755.17,Fee Schedule,,615.17,,,615.17,Other,100% of Medicaid,615.17,,,615.17,Other,100% of Medicaid,615.17,,,615.17,Other,100% of Medicaid,615.17,,,615.17,Other,100% of Medicaid,1384.13,,,1384.13,Other,225% of Medicaid,941.21,,,941.21,Other,153% of Medicaid,1384.13,,,1384.13,Other,225% of Medicaid,861.24,,,861.24,Other,140% of Medicaid,1384.13,,,1384.13,Other,225% of Medicaid,1599.44,,,1599.44,Other,260% of Medicaid,1993.15,,,1993.15,Other,324% of Medicaid,1322.62,,,1322.62,Other,215% of Medicaid,1322.62,,,1322.62,Other,215% of Medicaid,768.96,,,768.96,Other,125% of Medicaid,615.17,1993.15,
CSF LEAKAGE IMAGING,78650,CPT,TC,50078650,CDM,341,RC,,,both,,,2989,2211.87,,,2211.87,Other,150% of Medicare + 9.63% HCRA Surcharge,1345.05,45,,1345.05,percent of total billed charges,Critical Access Hospital RCC factor,776.19,,,776.19,Fee Schedule,,698.33,,,698.33,Fee Schedule,,2016.3,,,2016.3,Fee Schedule,,1813.52,,,1813.52,Fee Schedule,,1714.05,,,1714.05,Fee Schedule,,1479.56,,,1479.56,Other,110% of Medicare,922.18,,,922.18,Fee Schedule,,1144,,,1144,Other,186% of Medicaid,1085.21,,,1085.21,Fee Schedule,,1853.18,,,1853.18,Fee Schedule,,510.97,,,510.97,Fee Schedule,,1085.21,,,1085.21,Fee Schedule,,1853.18,,,1853.18,Fee Schedule,,961.11,,,961.11,Fee Schedule,,2092.3,70,,2092.3,percent of total billed charges,All Other,1169.32,,,1169.32,Fee Schedule,,991.07,,,991.07,Fee Schedule,,2035.5,,,2035.5,Fee Schedule,,2035.5,,,2035.5,Fee Schedule,,2035.5,,,2035.5,Fee Schedule,,2035.5,,,2035.5,Fee Schedule,,615.17,,,615.17,Other,100% of Medicaid,615.17,,,615.17,Other,100% of Medicaid,615.17,,,615.17,Other,100% of Medicaid,615.17,,,615.17,Other,100% of Medicaid,1384.13,,,1384.13,Other,225% of Medicaid,941.21,,,941.21,Other,153% of Medicaid,1384.13,,,1384.13,Other,225% of Medicaid,861.24,,,861.24,Other,140% of Medicaid,1384.13,,,1384.13,Other,225% of Medicaid,1599.44,,,1599.44,Other,260% of Medicaid,1993.15,,,1993.15,Other,324% of Medicaid,1322.62,,,1322.62,Other,215% of Medicaid,1322.62,,,1322.62,Other,215% of Medicaid,768.96,,,768.96,Other,125% of Medicaid,510.97,2211.87,
KIDNEY FLOW AND FUNCTION IMAGE,78707,CPT,TC,50078707,CDM,341,RC,,,both,,,1578,1167.72,,,1167.72,Other,150% of Medicare + 9.63% HCRA Surcharge,710.1,45,,710.1,percent of total billed charges,Critical Access Hospital RCC factor,595.64,,,595.64,Fee Schedule,,535.89,,,535.89,Fee Schedule,,1286.35,,,1286.35,Fee Schedule,,1156.99,,,1156.99,Fee Schedule,,1093.52,,,1093.52,Fee Schedule,,781.11,,,781.11,Other,110% of Medicare,707.67,,,707.67,Fee Schedule,,524,,,524,Other,186% of Medicaid,832.77,,,832.77,Fee Schedule,,978.36,,,978.36,Fee Schedule,,392.11,,,392.11,Fee Schedule,,832.77,,,832.77,Fee Schedule,,978.36,,,978.36,Fee Schedule,,737.54,,,737.54,Fee Schedule,,1104.6,70,,1104.6,percent of total billed charges,All Other,865.92,,,865.92,Fee Schedule,,733.92,,,733.92,Fee Schedule,,755.17,,,755.17,Fee Schedule,,755.17,,,755.17,Fee Schedule,,755.17,,,755.17,Fee Schedule,,755.17,,,755.17,Fee Schedule,,281.88,,,281.88,Other,100% of Medicaid,281.88,,,281.88,Other,100% of Medicaid,281.88,,,281.88,Other,100% of Medicaid,281.88,,,281.88,Other,100% of Medicaid,634.23,,,634.23,Other,225% of Medicaid,431.28,,,431.28,Other,153% of Medicaid,634.23,,,634.23,Other,225% of Medicaid,394.63,,,394.63,Other,140% of Medicaid,634.23,,,634.23,Other,225% of Medicaid,732.89,,,732.89,Other,260% of Medicaid,913.29,,,913.29,Other,324% of Medicaid,606.04,,,606.04,Other,215% of Medicaid,606.04,,,606.04,Other,215% of Medicaid,352.35,,,352.35,Other,125% of Medicaid,281.88,1286.35,
RENAL FLOW SINGLE W PHARM INT,78708,CPT,TC,50078708,CDM,341,RC,,,both,,,2068,1530.33,,,1530.33,Other,150% of Medicare + 9.63% HCRA Surcharge,930.6,45,,930.6,percent of total billed charges,Critical Access Hospital RCC factor,416.74,,,416.74,Fee Schedule,,374.94,,,374.94,Fee Schedule,,817.22,,,817.22,Fee Schedule,,735.03,,,735.03,Fee Schedule,,694.71,,,694.71,Fee Schedule,,1023.66,,,1023.66,Other,110% of Medicare,495.13,,,495.13,Fee Schedule,,524,,,524,Other,186% of Medicaid,582.65,,,582.65,Fee Schedule,,1282.16,,,1282.16,Fee Schedule,,274.34,,,274.34,Fee Schedule,,582.65,,,582.65,Fee Schedule,,1282.16,,,1282.16,Fee Schedule,,516.03,,,516.03,Fee Schedule,,1447.6,70,,1447.6,percent of total billed charges,All Other,577.28,,,577.28,Fee Schedule,,489.28,,,489.28,Fee Schedule,,755.17,,,755.17,Fee Schedule,,755.17,,,755.17,Fee Schedule,,755.17,,,755.17,Fee Schedule,,755.17,,,755.17,Fee Schedule,,281.88,,,281.88,Other,100% of Medicaid,281.88,,,281.88,Other,100% of Medicaid,281.88,,,281.88,Other,100% of Medicaid,281.88,,,281.88,Other,100% of Medicaid,634.23,,,634.23,Other,225% of Medicaid,431.28,,,431.28,Other,153% of Medicaid,634.23,,,634.23,Other,225% of Medicaid,394.63,,,394.63,Other,140% of Medicaid,634.23,,,634.23,Other,225% of Medicaid,732.89,,,732.89,Other,260% of Medicaid,913.29,,,913.29,Other,324% of Medicaid,606.04,,,606.04,Other,215% of Medicaid,606.04,,,606.04,Other,215% of Medicaid,352.35,,,352.35,Other,125% of Medicaid,274.34,1530.33,
RENAL FLOW MULT W PHARM INTER,78709,CPT,TC,50078709,CDM,341,RC,,,both,,,2348,1737.53,,,1737.53,Other,150% of Medicare + 9.63% HCRA Surcharge,1056.6,45,,1056.6,percent of total billed charges,Critical Access Hospital RCC factor,949.5,,,949.5,Fee Schedule,,854.26,,,854.26,Fee Schedule,,2002.6,,,2002.6,Fee Schedule,,1801.2,,,1801.2,Fee Schedule,,1702.4,,,1702.4,Fee Schedule,,1162.26,,,1162.26,Other,110% of Medicare,1128.09,,,1128.09,Fee Schedule,,524,,,524,Other,186% of Medicaid,1327.52,,,1327.52,Fee Schedule,,1455.76,,,1455.76,Fee Schedule,,625.07,,,625.07,Fee Schedule,,1327.52,,,1327.52,Fee Schedule,,1455.76,,,1455.76,Fee Schedule,,1175.72,,,1175.72,Fee Schedule,,1643.6,70,,1643.6,percent of total billed charges,All Other,1398.92,,,1398.92,Fee Schedule,,1185.67,,,1185.67,Fee Schedule,,755.17,,,755.17,Fee Schedule,,755.17,,,755.17,Fee Schedule,,755.17,,,755.17,Fee Schedule,,755.17,,,755.17,Fee Schedule,,281.88,,,281.88,Other,100% of Medicaid,281.88,,,281.88,Other,100% of Medicaid,281.88,,,281.88,Other,100% of Medicaid,281.88,,,281.88,Other,100% of Medicaid,634.23,,,634.23,Other,225% of Medicaid,431.28,,,431.28,Other,153% of Medicaid,634.23,,,634.23,Other,225% of Medicaid,394.63,,,394.63,Other,140% of Medicaid,634.23,,,634.23,Other,225% of Medicaid,732.89,,,732.89,Other,260% of Medicaid,913.29,,,913.29,Other,324% of Medicaid,606.04,,,606.04,Other,215% of Medicaid,606.04,,,606.04,Other,215% of Medicaid,352.35,,,352.35,Other,125% of Medicaid,281.88,2002.6,
TESTICULAR IMAGING W/FLOW,78761,CPT,TC,50078761,CDM,341,RC,,,both,,,1406,1040.44,,,1040.44,Other,150% of Medicare + 9.63% HCRA Surcharge,632.7,45,,632.7,percent of total billed charges,Critical Access Hospital RCC factor,567.92,,,567.92,Fee Schedule,,510.95,,,510.95,Fee Schedule,,1192.55,,,1192.55,Fee Schedule,,1072.61,,,1072.61,Fee Schedule,,1013.78,,,1013.78,Fee Schedule,,695.97,,,695.97,Other,110% of Medicare,674.73,,,674.73,Fee Schedule,,524,,,524,Other,186% of Medicaid,794.01,,,794.01,Fee Schedule,,871.72,,,871.72,Fee Schedule,,373.86,,,373.86,Fee Schedule,,794.01,,,794.01,Fee Schedule,,871.72,,,871.72,Fee Schedule,,703.22,,,703.22,Fee Schedule,,984.2,70,,984.2,percent of total billed charges,All Other,823.28,,,823.28,Fee Schedule,,697.78,,,697.78,Fee Schedule,,589.01,,,589.01,Fee Schedule,,589.01,,,589.01,Fee Schedule,,589.01,,,589.01,Fee Schedule,,589.01,,,589.01,Fee Schedule,,281.88,,,281.88,Other,100% of Medicaid,281.88,,,281.88,Other,100% of Medicaid,281.88,,,281.88,Other,100% of Medicaid,281.88,,,281.88,Other,100% of Medicaid,634.23,,,634.23,Other,225% of Medicaid,431.28,,,431.28,Other,153% of Medicaid,634.23,,,634.23,Other,225% of Medicaid,394.63,,,394.63,Other,140% of Medicaid,634.23,,,634.23,Other,225% of Medicaid,732.89,,,732.89,Other,260% of Medicaid,913.29,,,913.29,Other,324% of Medicaid,606.04,,,606.04,Other,215% of Medicaid,606.04,,,606.04,Other,215% of Medicaid,352.35,,,352.35,Other,125% of Medicaid,281.88,1192.55,
LIMITED TUMOR LOCALIZ/RP DISTR,78800,CPT,TC,50078800,CDM,341,RC,,,both,,,2180,1613.21,,,1613.21,Other,150% of Medicare + 9.63% HCRA Surcharge,981,45,,981,percent of total billed charges,Critical Access Hospital RCC factor,700.78,,,700.78,Fee Schedule,,630.48,,,630.48,Fee Schedule,,1041.51,,,1041.51,Fee Schedule,,936.77,,,936.77,Fee Schedule,,885.38,,,885.38,Fee Schedule,,1079.1,,,1079.1,Other,110% of Medicare,832.59,,,832.59,Fee Schedule,,1144,,,1144,Other,186% of Medicaid,979.77,,,979.77,Fee Schedule,,1351.6,,,1351.6,Fee Schedule,,461.33,,,461.33,Fee Schedule,,979.77,,,979.77,Fee Schedule,,1351.6,,,1351.6,Fee Schedule,,867.74,,,867.74,Fee Schedule,,1526,70,,1526,percent of total billed charges,All Other,1029.92,,,1029.92,Fee Schedule,,872.92,,,872.92,Fee Schedule,,589.01,,,589.01,Fee Schedule,,589.01,,,589.01,Fee Schedule,,589.01,,,589.01,Fee Schedule,,589.01,,,589.01,Fee Schedule,,615.17,,,615.17,Other,100% of Medicaid,615.17,,,615.17,Other,100% of Medicaid,615.17,,,615.17,Other,100% of Medicaid,615.17,,,615.17,Other,100% of Medicaid,1384.13,,,1384.13,Other,225% of Medicaid,941.21,,,941.21,Other,153% of Medicaid,1384.13,,,1384.13,Other,225% of Medicaid,861.24,,,861.24,Other,140% of Medicaid,1384.13,,,1384.13,Other,225% of Medicaid,1599.44,,,1599.44,Other,260% of Medicaid,1993.15,,,1993.15,Other,324% of Medicaid,1322.62,,,1322.62,Other,215% of Medicaid,1322.62,,,1322.62,Other,215% of Medicaid,768.96,,,768.96,Other,125% of Medicaid,461.33,1993.15,
TUMOR LOCALIZ; MULTI AREAS,78801,CPT,TC,50078801,CDM,341,RC,,,both,,,1972,1459.28,,,1459.28,Other,150% of Medicare + 9.63% HCRA Surcharge,887.4,45,,887.4,percent of total billed charges,Critical Access Hospital RCC factor,748.15,,,748.15,Fee Schedule,,673.1,,,673.1,Fee Schedule,,1439.66,,,1439.66,Fee Schedule,,1294.87,,,1294.87,Fee Schedule,,1223.85,,,1223.85,Fee Schedule,,976.14,,,976.14,Other,110% of Medicare,888.87,,,888.87,Fee Schedule,,1144,,,1144,Other,186% of Medicaid,1046,,,1046,Fee Schedule,,1222.64,,,1222.64,Fee Schedule,,492.51,,,492.51,Fee Schedule,,1046,,,1046,Fee Schedule,,1222.64,,,1222.64,Fee Schedule,,926.39,,,926.39,Fee Schedule,,1380.4,70,,1380.4,percent of total billed charges,All Other,1115.2,,,1115.2,Fee Schedule,,945.2,,,945.2,Fee Schedule,,589.01,,,589.01,Fee Schedule,,589.01,,,589.01,Fee Schedule,,589.01,,,589.01,Fee Schedule,,589.01,,,589.01,Fee Schedule,,615.17,,,615.17,Other,100% of Medicaid,615.17,,,615.17,Other,100% of Medicaid,615.17,,,615.17,Other,100% of Medicaid,615.17,,,615.17,Other,100% of Medicaid,1384.13,,,1384.13,Other,225% of Medicaid,941.21,,,941.21,Other,153% of Medicaid,1384.13,,,1384.13,Other,225% of Medicaid,861.24,,,861.24,Other,140% of Medicaid,1384.13,,,1384.13,Other,225% of Medicaid,1599.44,,,1599.44,Other,260% of Medicaid,1993.15,,,1993.15,Other,324% of Medicaid,1322.62,,,1322.62,Other,215% of Medicaid,1322.62,,,1322.62,Other,215% of Medicaid,768.96,,,768.96,Other,125% of Medicaid,492.51,1993.15,
TUMOR IMAGING WB SGL DAY,78802,CPT,TC,50078802,CDM,341,RC,,,both,,,2989,2211.87,,,2211.87,Other,150% of Medicare + 9.63% HCRA Surcharge,1345.05,45,,1345.05,percent of total billed charges,Critical Access Hospital RCC factor,849.78,,,849.78,Fee Schedule,,764.54,,,764.54,Fee Schedule,,1917.91,,,1917.91,Fee Schedule,,1725.03,,,1725.03,Fee Schedule,,1630.41,,,1630.41,Fee Schedule,,1479.56,,,1479.56,Other,110% of Medicare,1009.62,,,1009.62,Fee Schedule,,1144,,,1144,Other,186% of Medicaid,1188.1,,,1188.1,Fee Schedule,,1853.18,,,1853.18,Fee Schedule,,559.42,,,559.42,Fee Schedule,,1188.1,,,1188.1,Fee Schedule,,1853.18,,,1853.18,Fee Schedule,,1052.24,,,1052.24,Fee Schedule,,2092.3,70,,2092.3,percent of total billed charges,All Other,1261.16,,,1261.16,Fee Schedule,,1068.91,,,1068.91,Fee Schedule,,2035.5,,,2035.5,Fee Schedule,,2035.5,,,2035.5,Fee Schedule,,2035.5,,,2035.5,Fee Schedule,,2035.5,,,2035.5,Fee Schedule,,615.17,,,615.17,Other,100% of Medicaid,615.17,,,615.17,Other,100% of Medicaid,615.17,,,615.17,Other,100% of Medicaid,615.17,,,615.17,Other,100% of Medicaid,1384.13,,,1384.13,Other,225% of Medicaid,941.21,,,941.21,Other,153% of Medicaid,1384.13,,,1384.13,Other,225% of Medicaid,861.24,,,861.24,Other,140% of Medicaid,1384.13,,,1384.13,Other,225% of Medicaid,1599.44,,,1599.44,Other,260% of Medicaid,1993.15,,,1993.15,Other,324% of Medicaid,1322.62,,,1322.62,Other,215% of Medicaid,1322.62,,,1322.62,Other,215% of Medicaid,768.96,,,768.96,Other,125% of Medicaid,559.42,2211.87,
TUMOR LOCALIZ; SPECT (3D),78803,CPT,TC,50078803,CDM,341,RC,,,both,,,2989,2211.87,,,2211.87,Other,150% of Medicare + 9.63% HCRA Surcharge,1345.05,45,,1345.05,percent of total billed charges,Critical Access Hospital RCC factor,1033.66,,,1033.66,Fee Schedule,,929.97,,,929.97,Fee Schedule,,2009.45,,,2009.45,Fee Schedule,,1807.36,,,1807.36,Fee Schedule,,1708.22,,,1708.22,Fee Schedule,,1479.56,,,1479.56,Other,110% of Medicare,1228.07,,,1228.07,Fee Schedule,,1144,,,1144,Other,186% of Medicaid,1445.17,,,1445.17,Fee Schedule,,1853.18,,,1853.18,Fee Schedule,,680.46,,,680.46,Fee Schedule,,1445.17,,,1445.17,Fee Schedule,,1853.18,,,1853.18,Fee Schedule,,1279.92,,,1279.92,Fee Schedule,,2092.3,70,,2092.3,percent of total billed charges,All Other,1539.96,,,1539.96,Fee Schedule,,1305.21,,,1305.21,Fee Schedule,,2035.5,,,2035.5,Fee Schedule,,2035.5,,,2035.5,Fee Schedule,,2035.5,,,2035.5,Fee Schedule,,2035.5,,,2035.5,Fee Schedule,,615.17,,,615.17,Other,100% of Medicaid,615.17,,,615.17,Other,100% of Medicaid,615.17,,,615.17,Other,100% of Medicaid,615.17,,,615.17,Other,100% of Medicaid,1384.13,,,1384.13,Other,225% of Medicaid,941.21,,,941.21,Other,153% of Medicaid,1384.13,,,1384.13,Other,225% of Medicaid,861.24,,,861.24,Other,140% of Medicaid,1384.13,,,1384.13,Other,225% of Medicaid,1599.44,,,1599.44,Other,260% of Medicaid,1993.15,,,1993.15,Other,324% of Medicaid,1322.62,,,1322.62,Other,215% of Medicaid,1322.62,,,1322.62,Other,215% of Medicaid,768.96,,,768.96,Other,125% of Medicaid,615.17,2211.87,
TUMOR IMAGING WB 2+ DAYS,78804,CPT,TC,50078804,CDM,341,RC,,,both,,,4429,3277.47,,,3277.47,Other,150% of Medicare + 9.63% HCRA Surcharge,1993.05,45,,1993.05,percent of total billed charges,Critical Access Hospital RCC factor,1873.04,,,1873.04,Fee Schedule,,1685.15,,,1685.15,Fee Schedule,,3558.88,,,3558.88,Fee Schedule,,3200.97,,,3200.97,Fee Schedule,,3025.39,,,3025.39,Fee Schedule,,2192.36,,,2192.36,Other,110% of Medicare,2225.34,,,2225.34,Fee Schedule,,1144,,,1144,Other,186% of Medicaid,2618.73,,,2618.73,Fee Schedule,,2745.98,,,2745.98,Fee Schedule,,1233.04,,,1233.04,Fee Schedule,,2618.73,,,2618.73,Fee Schedule,,2745.98,,,2745.98,Fee Schedule,,2319.28,,,2319.28,Fee Schedule,,3100.3,70,,3100.3,percent of total billed charges,All Other,2806.04,,,2806.04,Fee Schedule,,2378.29,,,2378.29,Fee Schedule,,2035.5,,,2035.5,Fee Schedule,,2035.5,,,2035.5,Fee Schedule,,2035.5,,,2035.5,Fee Schedule,,2035.5,,,2035.5,Fee Schedule,,615.17,,,615.17,Other,100% of Medicaid,615.17,,,615.17,Other,100% of Medicaid,615.17,,,615.17,Other,100% of Medicaid,615.17,,,615.17,Other,100% of Medicaid,1384.13,,,1384.13,Other,225% of Medicaid,941.21,,,941.21,Other,153% of Medicaid,1384.13,,,1384.13,Other,225% of Medicaid,861.24,,,861.24,Other,140% of Medicaid,1384.13,,,1384.13,Other,225% of Medicaid,1599.44,,,1599.44,Other,260% of Medicaid,1993.15,,,1993.15,Other,324% of Medicaid,1322.62,,,1322.62,Other,215% of Medicaid,1322.62,,,1322.62,Other,215% of Medicaid,768.96,,,768.96,Other,125% of Medicaid,615.17,3558.88,
TUMOR LOCALIZ; MULTI AREAS,78801,CPT,TC,54078801,CDM,341,RC,,,both,,,1972,1459.28,,,1459.28,Other,150% of Medicare + 9.63% HCRA Surcharge,887.4,45,,887.4,percent of total billed charges,Critical Access Hospital RCC factor,748.15,,,748.15,Fee Schedule,,673.1,,,673.1,Fee Schedule,,1439.66,,,1439.66,Fee Schedule,,1294.87,,,1294.87,Fee Schedule,,1223.85,,,1223.85,Fee Schedule,,976.14,,,976.14,Other,110% of Medicare,888.87,,,888.87,Fee Schedule,,1144,,,1144,Other,186% of Medicaid,1046,,,1046,Fee Schedule,,1222.64,,,1222.64,Fee Schedule,,492.51,,,492.51,Fee Schedule,,1046,,,1046,Fee Schedule,,1222.64,,,1222.64,Fee Schedule,,926.39,,,926.39,Fee Schedule,,1380.4,70,,1380.4,percent of total billed charges,All Other,1115.2,,,1115.2,Fee Schedule,,945.2,,,945.2,Fee Schedule,,589.01,,,589.01,Fee Schedule,,589.01,,,589.01,Fee Schedule,,589.01,,,589.01,Fee Schedule,,589.01,,,589.01,Fee Schedule,,615.17,,,615.17,Other,100% of Medicaid,615.17,,,615.17,Other,100% of Medicaid,615.17,,,615.17,Other,100% of Medicaid,615.17,,,615.17,Other,100% of Medicaid,1384.13,,,1384.13,Other,225% of Medicaid,941.21,,,941.21,Other,153% of Medicaid,1384.13,,,1384.13,Other,225% of Medicaid,861.24,,,861.24,Other,140% of Medicaid,1384.13,,,1384.13,Other,225% of Medicaid,1599.44,,,1599.44,Other,260% of Medicaid,1993.15,,,1993.15,Other,324% of Medicaid,1322.62,,,1322.62,Other,215% of Medicaid,1322.62,,,1322.62,Other,215% of Medicaid,768.96,,,768.96,Other,125% of Medicaid,492.51,1993.15,
THYROID RADIATION THERAPY,79005,CPT,TC,50079005,CDM,342,RC,,,both,,,1657,1226.18,,,1226.18,Other,150% of Medicare + 9.63% HCRA Surcharge,745.65,45,,745.65,percent of total billed charges,Critical Access Hospital RCC factor,178.26,,,178.26,Fee Schedule,,160.38,,,160.38,Fee Schedule,,368.53,,,368.53,Fee Schedule,,331.47,,,331.47,Fee Schedule,,313.29,,,313.29,Fee Schedule,,820.22,,,820.22,Other,110% of Medicare,211.79,,,211.79,Fee Schedule,,597,,,597,Other,186% of Medicaid,249.22,,,249.22,Fee Schedule,,1027.34,,,1027.34,Fee Schedule,,117.35,,,117.35,Fee Schedule,,249.22,,,249.22,Fee Schedule,,1027.34,,,1027.34,Fee Schedule,,220.73,,,220.73,Fee Schedule,,1159.9,70,,1159.9,percent of total billed charges,All Other,247.64,,,247.64,Fee Schedule,,209.89,,,209.89,Fee Schedule,,379.84,,,379.84,Fee Schedule,,379.84,,,379.84,Fee Schedule,,379.84,,,379.84,Fee Schedule,,379.84,,,379.84,Fee Schedule,,320.9,,,320.9,Other,100% of Medicaid,320.9,,,320.9,Other,100% of Medicaid,320.9,,,320.9,Other,100% of Medicaid,320.9,,,320.9,Other,100% of Medicaid,722.03,,,722.03,Other,225% of Medicaid,490.98,,,490.98,Other,153% of Medicaid,722.03,,,722.03,Other,225% of Medicaid,449.26,,,449.26,Other,140% of Medicaid,722.03,,,722.03,Other,225% of Medicaid,834.35,,,834.35,Other,260% of Medicaid,1039.72,,,1039.72,Other,324% of Medicaid,689.94,,,689.94,Other,215% of Medicaid,689.94,,,689.94,Other,215% of Medicaid,401.13,,,401.13,Other,125% of Medicaid,117.35,1226.18,
RADIOPH RX BY IV ADMIN,79101,CPT,TC,50079101,CDM,342,RC,,,both,,,5012,3708.89,,,3708.89,Other,150% of Medicare + 9.63% HCRA Surcharge,2255.4,45,,2255.4,percent of total billed charges,Critical Access Hospital RCC factor,186.33,,,186.33,Fee Schedule,,167.64,,,167.64,Fee Schedule,,400.57,,,400.57,Fee Schedule,,360.29,,,360.29,Fee Schedule,,340.52,,,340.52,Fee Schedule,,2480.94,,,2480.94,Other,110% of Medicare,221.37,,,221.37,Fee Schedule,,597,,,597,Other,186% of Medicaid,260.51,,,260.51,Fee Schedule,,3107.44,,,3107.44,Fee Schedule,,122.66,,,122.66,Fee Schedule,,260.51,,,260.51,Fee Schedule,,3107.44,,,3107.44,Fee Schedule,,230.72,,,230.72,Fee Schedule,,3508.4,70,,3508.4,percent of total billed charges,All Other,257.48,,,257.48,Fee Schedule,,218.23,,,218.23,Fee Schedule,,379.84,,,379.84,Fee Schedule,,379.84,,,379.84,Fee Schedule,,379.84,,,379.84,Fee Schedule,,379.84,,,379.84,Fee Schedule,,320.9,,,320.9,Other,100% of Medicaid,320.9,,,320.9,Other,100% of Medicaid,320.9,,,320.9,Other,100% of Medicaid,320.9,,,320.9,Other,100% of Medicaid,722.03,,,722.03,Other,225% of Medicaid,490.98,,,490.98,Other,153% of Medicaid,722.03,,,722.03,Other,225% of Medicaid,449.26,,,449.26,Other,140% of Medicaid,722.03,,,722.03,Other,225% of Medicaid,834.35,,,834.35,Other,260% of Medicaid,1039.72,,,1039.72,Other,324% of Medicaid,689.94,,,689.94,Other,215% of Medicaid,689.94,,,689.94,Other,215% of Medicaid,401.13,,,401.13,Other,125% of Medicaid,122.66,3708.89,
RPHARM MONOCLONAL AB THERAPY,79403,CPT,TC,50079403,CDM,342,RC,,,both,,,1425,1054.5,,,1054.5,Other,150% of Medicare + 9.63% HCRA Surcharge,641.25,45,,641.25,percent of total billed charges,Critical Access Hospital RCC factor,350.74,,,350.74,Fee Schedule,,315.56,,,315.56,Fee Schedule,,620.44,,,620.44,Fee Schedule,,558.04,,,558.04,Fee Schedule,,527.43,,,527.43,Fee Schedule,,705.38,,,705.38,Other,110% of Medicare,416.71,,,416.71,Fee Schedule,,597,,,597,Other,186% of Medicaid,490.38,,,490.38,Fee Schedule,,883.5,,,883.5,Fee Schedule,,230.9,,,230.9,Fee Schedule,,490.38,,,490.38,Fee Schedule,,883.5,,,883.5,Fee Schedule,,434.3,,,434.3,Fee Schedule,,997.5,70,,997.5,percent of total billed charges,All Other,332.92,,,332.92,Fee Schedule,,282.17,,,282.17,Fee Schedule,,379.84,,,379.84,Fee Schedule,,379.84,,,379.84,Fee Schedule,,379.84,,,379.84,Fee Schedule,,379.84,,,379.84,Fee Schedule,,320.9,,,320.9,Other,100% of Medicaid,320.9,,,320.9,Other,100% of Medicaid,320.9,,,320.9,Other,100% of Medicaid,320.9,,,320.9,Other,100% of Medicaid,722.03,,,722.03,Other,225% of Medicaid,490.98,,,490.98,Other,153% of Medicaid,722.03,,,722.03,Other,225% of Medicaid,449.26,,,449.26,Other,140% of Medicaid,722.03,,,722.03,Other,225% of Medicaid,834.35,,,834.35,Other,260% of Medicaid,1039.72,,,1039.72,Other,324% of Medicaid,689.94,,,689.94,Other,215% of Medicaid,689.94,,,689.94,Other,215% of Medicaid,401.13,,,401.13,Other,125% of Medicaid,230.9,1054.5,
RADIOPHARMACEUTICAL DIAGNOSTIC,A4641,HCPCS,,50000001,CDM,343,RC,,,both,,,0.01,0.01,,,0.01,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,45,,0.01,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,250,,,250,Fee Schedule,,250,,,250,Fee Schedule,,250,,,250,Fee Schedule,,0.01,,,0.01,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,70,,0.01,percent of total billed charges,All Other,0.01,36,,0.01,percent of total billed charges,Radiopharmaceutical,0.01,36,,0.01,percent of total billed charges,Radiopharmaceutical,0.01,35,,0.01,percent of total billed charges,Radiopharmaceutical,0.01,35,,0.01,percent of total billed charges,Radiopharmaceutical,0.01,35,,0.01,percent of total billed charges,Radiopharmaceutical,0.01,35,,0.01,percent of total billed charges,Radiopharmaceutical,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,250,
TC99M SESTAMIBI PER DOSE,A9500,HCPCS,,50000002,CDM,343,RC,,,both,,,108,79.92,,,79.92,Other,150% of Medicare + 9.63% HCRA Surcharge,48.6,45,,48.6,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,36.72,34,,36.72,percent of total billed charges,Radiopharmaceutical,36.72,34,,36.72,percent of total billed charges,Radiopharmaceutical,36.72,34,,36.72,percent of total billed charges,Radiopharmaceutical,53.46,,,53.46,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,75.6,70,,75.6,percent of total billed charges,All Other,38.88,36,,38.88,percent of total billed charges,Radiopharmaceutical,38.88,36,,38.88,percent of total billed charges,Radiopharmaceutical,37.8,35,,37.8,percent of total billed charges,Radiopharmaceutical,37.8,35,,37.8,percent of total billed charges,Radiopharmaceutical,37.8,35,,37.8,percent of total billed charges,Radiopharmaceutical,37.8,35,,37.8,percent of total billed charges,Radiopharmaceutical,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,79.92,
TC99M TETROFOSMIN,A9502,HCPCS,,50000003,CDM,343,RC,,,both,,,216,159.84,,,159.84,Other,150% of Medicare + 9.63% HCRA Surcharge,97.2,45,,97.2,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,73.44,34,,73.44,percent of total billed charges,Radiopharmaceutical,73.44,34,,73.44,percent of total billed charges,Radiopharmaceutical,73.44,34,,73.44,percent of total billed charges,Radiopharmaceutical,106.92,,,106.92,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,151.2,70,,151.2,percent of total billed charges,All Other,77.76,36,,77.76,percent of total billed charges,Radiopharmaceutical,77.76,36,,77.76,percent of total billed charges,Radiopharmaceutical,75.6,35,,75.6,percent of total billed charges,Radiopharmaceutical,75.6,35,,75.6,percent of total billed charges,Radiopharmaceutical,75.6,35,,75.6,percent of total billed charges,Radiopharmaceutical,75.6,35,,75.6,percent of total billed charges,Radiopharmaceutical,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,159.84,
TC99M MEDRONATE UP TO 30 MCI,A9503,HCPCS,,50000004,CDM,343,RC,,,both,,,45.78,33.88,,,33.88,Other,150% of Medicare + 9.63% HCRA Surcharge,20.6,45,,20.6,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,15.57,34,,15.57,percent of total billed charges,Radiopharmaceutical,15.57,34,,15.57,percent of total billed charges,Radiopharmaceutical,15.57,34,,15.57,percent of total billed charges,Radiopharmaceutical,22.66,,,22.66,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,32.05,70,,32.05,percent of total billed charges,All Other,16.48,36,,16.48,percent of total billed charges,Radiopharmaceutical,16.48,36,,16.48,percent of total billed charges,Radiopharmaceutical,16.02,35,,16.02,percent of total billed charges,Radiopharmaceutical,16.02,35,,16.02,percent of total billed charges,Radiopharmaceutical,16.02,35,,16.02,percent of total billed charges,Radiopharmaceutical,16.02,35,,16.02,percent of total billed charges,Radiopharmaceutical,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,33.88,
TL201 THALLIUM PER 1 MCI,A9505,HCPCS,,50000005,CDM,343,RC,,,both,,,45.78,33.88,,,33.88,Other,150% of Medicare + 9.63% HCRA Surcharge,20.6,45,,20.6,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,15.57,34,,15.57,percent of total billed charges,Radiopharmaceutical,15.57,34,,15.57,percent of total billed charges,Radiopharmaceutical,15.57,34,,15.57,percent of total billed charges,Radiopharmaceutical,22.66,,,22.66,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,32.05,70,,32.05,percent of total billed charges,All Other,16.48,36,,16.48,percent of total billed charges,Radiopharmaceutical,16.48,36,,16.48,percent of total billed charges,Radiopharmaceutical,16.02,35,,16.02,percent of total billed charges,Radiopharmaceutical,16.02,35,,16.02,percent of total billed charges,Radiopharmaceutical,16.02,35,,16.02,percent of total billed charges,Radiopharmaceutical,16.02,35,,16.02,percent of total billed charges,Radiopharmaceutical,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,33.88,
IN111 CAPROMAB =< 10 MCI,A9507,HCPCS,,50000006,CDM,343,RC,,,both,,,0.01,0.01,,,0.01,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,45,,0.01,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,3193.12,,,3193.12,Fee Schedule,,3193.12,,,3193.12,Fee Schedule,,3193.12,,,3193.12,Fee Schedule,,0.01,,,0.01,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,70,,0.01,percent of total billed charges,All Other,0.01,36,,0.01,percent of total billed charges,Radiopharmaceutical,0.01,36,,0.01,percent of total billed charges,Radiopharmaceutical,0.01,35,,0.01,percent of total billed charges,Radiopharmaceutical,0.01,35,,0.01,percent of total billed charges,Radiopharmaceutical,0.01,35,,0.01,percent of total billed charges,Radiopharmaceutical,0.01,35,,0.01,percent of total billed charges,Radiopharmaceutical,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3193.12,
TC99M DISOFENIN =< 15MCI,A9510,HCPCS,,50000007,CDM,343,RC,,,both,,,109,80.66,,,80.66,Other,150% of Medicare + 9.63% HCRA Surcharge,49.05,45,,49.05,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,42.84,,,42.84,Fee Schedule,,42.84,,,42.84,Fee Schedule,,42.84,,,42.84,Fee Schedule,,53.96,,,53.96,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,76.3,70,,76.3,percent of total billed charges,All Other,70.85,36,,70.85,percent of total billed charges,Radiopharmaceutical,70.85,36,,70.85,percent of total billed charges,Radiopharmaceutical,38.15,35,,38.15,percent of total billed charges,Radiopharmaceutical,38.15,35,,38.15,percent of total billed charges,Radiopharmaceutical,38.15,35,,38.15,percent of total billed charges,Radiopharmaceutical,38.15,35,,38.15,percent of total billed charges,Radiopharmaceutical,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,80.66,
TC99M PERTECHNETATE PER 1 MCI,A9512,HCPCS,,50000008,CDM,343,RC,,,both,,,1.09,0.81,,,0.81,Other,150% of Medicare + 9.63% HCRA Surcharge,0.49,45,,0.49,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.37,34,,0.37,percent of total billed charges,Radiopharmaceutical,0.37,34,,0.37,percent of total billed charges,Radiopharmaceutical,0.37,34,,0.37,percent of total billed charges,Radiopharmaceutical,0.54,,,0.54,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.76,70,,0.76,percent of total billed charges,All Other,0.39,36,,0.39,percent of total billed charges,Radiopharmaceutical,0.39,36,,0.39,percent of total billed charges,Radiopharmaceutical,0.38,35,,0.38,percent of total billed charges,Radiopharmaceutical,0.38,35,,0.38,percent of total billed charges,Radiopharmaceutical,0.38,35,,0.38,percent of total billed charges,Radiopharmaceutical,0.38,35,,0.38,percent of total billed charges,Radiopharmaceutical,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,0.81,
IODINE I-123 SOD IODIDE PER 100 MCI,A9516,HCPCS,,50000009,CDM,343,RC,,,both,,,78,57.72,,,57.72,Other,150% of Medicare + 9.63% HCRA Surcharge,35.1,45,,35.1,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,26.52,34,,26.52,percent of total billed charges,Radiopharmaceutical,26.52,34,,26.52,percent of total billed charges,Radiopharmaceutical,26.52,34,,26.52,percent of total billed charges,Radiopharmaceutical,38.61,,,38.61,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,54.6,70,,54.6,percent of total billed charges,All Other,28.08,36,,28.08,percent of total billed charges,Radiopharmaceutical,28.08,36,,28.08,percent of total billed charges,Radiopharmaceutical,27.3,35,,27.3,percent of total billed charges,Radiopharmaceutical,27.3,35,,27.3,percent of total billed charges,Radiopharmaceutical,27.3,35,,27.3,percent of total billed charges,Radiopharmaceutical,27.3,35,,27.3,percent of total billed charges,Radiopharmaceutical,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,57.72,
TC99M EXAMETAZIME UP TO 25 MCI,A9521,HCPCS,,50000011,CDM,343,RC,,,both,,,4210,3115.41,,,3115.41,Other,150% of Medicare + 9.63% HCRA Surcharge,1894.5,45,,1894.5,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1431.4,34,,1431.4,percent of total billed charges,Radiopharmaceutical,1431.4,34,,1431.4,percent of total billed charges,Radiopharmaceutical,1431.4,34,,1431.4,percent of total billed charges,Radiopharmaceutical,2083.95,,,2083.95,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2947,70,,2947,percent of total billed charges,All Other,1515.6,36,,1515.6,percent of total billed charges,Radiopharmaceutical,1515.6,36,,1515.6,percent of total billed charges,Radiopharmaceutical,1473.5,35,,1473.5,percent of total billed charges,Radiopharmaceutical,1473.5,35,,1473.5,percent of total billed charges,Radiopharmaceutical,1473.5,35,,1473.5,percent of total billed charges,Radiopharmaceutical,1473.5,35,,1473.5,percent of total billed charges,Radiopharmaceutical,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3115.41,
TC99M MEBROFENIN UP TO 15 MCI,A9537,HCPCS,,50000012,CDM,343,RC,,,both,,,109,80.66,,,80.66,Other,150% of Medicare + 9.63% HCRA Surcharge,49.05,45,,49.05,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,37.06,34,,37.06,percent of total billed charges,Radiopharmaceutical,37.06,34,,37.06,percent of total billed charges,Radiopharmaceutical,37.06,34,,37.06,percent of total billed charges,Radiopharmaceutical,53.96,,,53.96,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,76.3,70,,76.3,percent of total billed charges,All Other,39.24,36,,39.24,percent of total billed charges,Radiopharmaceutical,39.24,36,,39.24,percent of total billed charges,Radiopharmaceutical,38.15,35,,38.15,percent of total billed charges,Radiopharmaceutical,38.15,35,,38.15,percent of total billed charges,Radiopharmaceutical,38.15,35,,38.15,percent of total billed charges,Radiopharmaceutical,38.15,35,,38.15,percent of total billed charges,Radiopharmaceutical,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,80.66,
TC99M PYROPHOSPHATE UP TO 25 M,A9538,HCPCS,,50000013,CDM,343,RC,,,both,,,65,48.1,,,48.1,Other,150% of Medicare + 9.63% HCRA Surcharge,29.25,45,,29.25,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,22.1,34,,22.1,percent of total billed charges,Radiopharmaceutical,22.1,34,,22.1,percent of total billed charges,Radiopharmaceutical,22.1,34,,22.1,percent of total billed charges,Radiopharmaceutical,32.18,,,32.18,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,45.5,70,,45.5,percent of total billed charges,All Other,23.4,36,,23.4,percent of total billed charges,Radiopharmaceutical,23.4,36,,23.4,percent of total billed charges,Radiopharmaceutical,22.75,35,,22.75,percent of total billed charges,Radiopharmaceutical,22.75,35,,22.75,percent of total billed charges,Radiopharmaceutical,22.75,35,,22.75,percent of total billed charges,Radiopharmaceutical,22.75,35,,22.75,percent of total billed charges,Radiopharmaceutical,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,48.1,
TC99M PENTETATE UP TO 25 MCI,A9539,HCPCS,,50000014,CDM,343,RC,,,both,,,249,184.26,,,184.26,Other,150% of Medicare + 9.63% HCRA Surcharge,112.05,45,,112.05,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,84.66,34,,84.66,percent of total billed charges,Radiopharmaceutical,84.66,34,,84.66,percent of total billed charges,Radiopharmaceutical,84.66,34,,84.66,percent of total billed charges,Radiopharmaceutical,123.26,,,123.26,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,174.3,70,,174.3,percent of total billed charges,All Other,89.64,36,,89.64,percent of total billed charges,Radiopharmaceutical,89.64,36,,89.64,percent of total billed charges,Radiopharmaceutical,87.15,35,,87.15,percent of total billed charges,Radiopharmaceutical,87.15,35,,87.15,percent of total billed charges,Radiopharmaceutical,87.15,35,,87.15,percent of total billed charges,Radiopharmaceutical,87.15,35,,87.15,percent of total billed charges,Radiopharmaceutical,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,184.26,
TC99M MAA UP TO 10 MCI,A9540,HCPCS,,50000015,CDM,343,RC,,,both,,,313,231.62,,,231.62,Other,150% of Medicare + 9.63% HCRA Surcharge,140.85,45,,140.85,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,106.42,34,,106.42,percent of total billed charges,Radiopharmaceutical,106.42,34,,106.42,percent of total billed charges,Radiopharmaceutical,106.42,34,,106.42,percent of total billed charges,Radiopharmaceutical,154.94,,,154.94,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,219.1,70,,219.1,percent of total billed charges,All Other,112.68,36,,112.68,percent of total billed charges,Radiopharmaceutical,112.68,36,,112.68,percent of total billed charges,Radiopharmaceutical,109.55,35,,109.55,percent of total billed charges,Radiopharmaceutical,109.55,35,,109.55,percent of total billed charges,Radiopharmaceutical,109.55,35,,109.55,percent of total billed charges,Radiopharmaceutical,109.55,35,,109.55,percent of total billed charges,Radiopharmaceutical,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,231.62,
TC99M SULFUR COLLOID UP TO 20,A9541,HCPCS,,50000016,CDM,343,RC,,,both,,,215,159.1,,,159.1,Other,150% of Medicare + 9.63% HCRA Surcharge,96.75,45,,96.75,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,73.1,34,,73.1,percent of total billed charges,Radiopharmaceutical,73.1,34,,73.1,percent of total billed charges,Radiopharmaceutical,73.1,34,,73.1,percent of total billed charges,Radiopharmaceutical,106.43,,,106.43,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,150.5,70,,150.5,percent of total billed charges,All Other,77.4,36,,77.4,percent of total billed charges,Radiopharmaceutical,77.4,36,,77.4,percent of total billed charges,Radiopharmaceutical,75.25,35,,75.25,percent of total billed charges,Radiopharmaceutical,75.25,35,,75.25,percent of total billed charges,Radiopharmaceutical,75.25,35,,75.25,percent of total billed charges,Radiopharmaceutical,75.25,35,,75.25,percent of total billed charges,Radiopharmaceutical,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,159.1,
IN111 OXYQUINOLINE PER 0.5 MCI,A9547,HCPCS,,50000017,CDM,343,RC,,,both,,,4039,2988.87,,,2988.87,Other,150% of Medicare + 9.63% HCRA Surcharge,1817.55,45,,1817.55,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1373.26,34,,1373.26,percent of total billed charges,Radiopharmaceutical,1373.26,34,,1373.26,percent of total billed charges,Radiopharmaceutical,1373.26,34,,1373.26,percent of total billed charges,Radiopharmaceutical,1999.31,,,1999.31,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2827.3,70,,2827.3,percent of total billed charges,All Other,1454.04,36,,1454.04,percent of total billed charges,Radiopharmaceutical,1454.04,36,,1454.04,percent of total billed charges,Radiopharmaceutical,1413.65,35,,1413.65,percent of total billed charges,Radiopharmaceutical,1413.65,35,,1413.65,percent of total billed charges,Radiopharmaceutical,1413.65,35,,1413.65,percent of total billed charges,Radiopharmaceutical,1413.65,35,,1413.65,percent of total billed charges,Radiopharmaceutical,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2988.87,
IN111 PENTETATE PER 0.5 MCI,A9548,HCPCS,,50000018,CDM,343,RC,,,both,,,3935,2911.91,,,2911.91,Other,150% of Medicare + 9.63% HCRA Surcharge,1770.75,45,,1770.75,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1337.9,34,,1337.9,percent of total billed charges,Radiopharmaceutical,1337.9,34,,1337.9,percent of total billed charges,Radiopharmaceutical,1337.9,34,,1337.9,percent of total billed charges,Radiopharmaceutical,1947.83,,,1947.83,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2754.5,70,,2754.5,percent of total billed charges,All Other,1416.6,36,,1416.6,percent of total billed charges,Radiopharmaceutical,1416.6,36,,1416.6,percent of total billed charges,Radiopharmaceutical,1377.25,35,,1377.25,percent of total billed charges,Radiopharmaceutical,1377.25,35,,1377.25,percent of total billed charges,Radiopharmaceutical,1377.25,35,,1377.25,percent of total billed charges,Radiopharmaceutical,1377.25,35,,1377.25,percent of total billed charges,Radiopharmaceutical,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2911.91,
GA67 GALLIUM PER 1 MCI,A9556,HCPCS,,50000019,CDM,343,RC,,,both,,,115,85.1,,,85.1,Other,150% of Medicare + 9.63% HCRA Surcharge,51.75,45,,51.75,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,39.1,34,,39.1,percent of total billed charges,Radiopharmaceutical,39.1,34,,39.1,percent of total billed charges,Radiopharmaceutical,39.1,34,,39.1,percent of total billed charges,Radiopharmaceutical,56.93,,,56.93,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,80.5,70,,80.5,percent of total billed charges,All Other,41.4,36,,41.4,percent of total billed charges,Radiopharmaceutical,41.4,36,,41.4,percent of total billed charges,Radiopharmaceutical,40.25,35,,40.25,percent of total billed charges,Radiopharmaceutical,40.25,35,,40.25,percent of total billed charges,Radiopharmaceutical,40.25,35,,40.25,percent of total billed charges,Radiopharmaceutical,40.25,35,,40.25,percent of total billed charges,Radiopharmaceutical,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,85.1,
TC99M BICISATE UP TO 25 MCI,A9557,HCPCS,,50000020,CDM,343,RC,,,both,,,3262,2413.89,,,2413.89,Other,150% of Medicare + 9.63% HCRA Surcharge,1467.9,45,,1467.9,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,379.53,,,379.53,Fee Schedule,,379.53,,,379.53,Fee Schedule,,379.53,,,379.53,Fee Schedule,,1614.69,,,1614.69,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2283.4,70,,2283.4,percent of total billed charges,All Other,2120.3,36,,2120.3,percent of total billed charges,Radiopharmaceutical,2120.3,36,,2120.3,percent of total billed charges,Radiopharmaceutical,1141.7,35,,1141.7,percent of total billed charges,Radiopharmaceutical,1141.7,35,,1141.7,percent of total billed charges,Radiopharmaceutical,1141.7,35,,1141.7,percent of total billed charges,Radiopharmaceutical,1141.7,35,,1141.7,percent of total billed charges,Radiopharmaceutical,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2413.89,
TC99M LABELED RBC UP TO 30 MCI,A9560,HCPCS,,50000021,CDM,343,RC,,,both,,,273,202.02,,,202.02,Other,150% of Medicare + 9.63% HCRA Surcharge,122.85,45,,122.85,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,92.82,34,,92.82,percent of total billed charges,Radiopharmaceutical,92.82,34,,92.82,percent of total billed charges,Radiopharmaceutical,92.82,34,,92.82,percent of total billed charges,Radiopharmaceutical,135.14,,,135.14,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,191.1,70,,191.1,percent of total billed charges,All Other,98.28,36,,98.28,percent of total billed charges,Radiopharmaceutical,98.28,36,,98.28,percent of total billed charges,Radiopharmaceutical,95.55,35,,95.55,percent of total billed charges,Radiopharmaceutical,95.55,35,,95.55,percent of total billed charges,Radiopharmaceutical,95.55,35,,95.55,percent of total billed charges,Radiopharmaceutical,95.55,35,,95.55,percent of total billed charges,Radiopharmaceutical,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,202.02,
TC99M MERTIATIDE UP TO 15 MCI,A9562,HCPCS,,50000022,CDM,343,RC,,,both,,,803,594.22,,,594.22,Other,150% of Medicare + 9.63% HCRA Surcharge,361.35,45,,361.35,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,273.02,34,,273.02,percent of total billed charges,Radiopharmaceutical,273.02,34,,273.02,percent of total billed charges,Radiopharmaceutical,273.02,34,,273.02,percent of total billed charges,Radiopharmaceutical,397.49,,,397.49,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,562.1,70,,562.1,percent of total billed charges,All Other,289.08,36,,289.08,percent of total billed charges,Radiopharmaceutical,289.08,36,,289.08,percent of total billed charges,Radiopharmaceutical,281.05,35,,281.05,percent of total billed charges,Radiopharmaceutical,281.05,35,,281.05,percent of total billed charges,Radiopharmaceutical,281.05,35,,281.05,percent of total billed charges,Radiopharmaceutical,281.05,35,,281.05,percent of total billed charges,Radiopharmaceutical,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,594.22,
INDIUM IN-111 AUTO WBC,A9570,HCPCS,,50000023,CDM,343,RC,,,both,,,4141,3064.35,,,3064.35,Other,150% of Medicare + 9.63% HCRA Surcharge,1863.45,45,,1863.45,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1407.94,34,,1407.94,percent of total billed charges,Radiopharmaceutical,1407.94,34,,1407.94,percent of total billed charges,Radiopharmaceutical,1407.94,34,,1407.94,percent of total billed charges,Radiopharmaceutical,2049.8,,,2049.8,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2898.7,70,,2898.7,percent of total billed charges,All Other,1490.76,36,,1490.76,percent of total billed charges,Radiopharmaceutical,1490.76,36,,1490.76,percent of total billed charges,Radiopharmaceutical,1449.35,35,,1449.35,percent of total billed charges,Radiopharmaceutical,1449.35,35,,1449.35,percent of total billed charges,Radiopharmaceutical,1449.35,35,,1449.35,percent of total billed charges,Radiopharmaceutical,1449.35,35,,1449.35,percent of total billed charges,Radiopharmaceutical,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3064.35,
INDIUM IN-111 PENTETREOTIDE UP,A9572,HCPCS,,50000024,CDM,343,RC,,,both,,,7693,5692.84,,,5692.84,Other,150% of Medicare + 9.63% HCRA Surcharge,3461.85,45,,3461.85,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2615.62,34,,2615.62,percent of total billed charges,Radiopharmaceutical,2615.62,34,,2615.62,percent of total billed charges,Radiopharmaceutical,2615.62,34,,2615.62,percent of total billed charges,Radiopharmaceutical,3808.04,,,3808.04,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,5385.1,70,,5385.1,percent of total billed charges,All Other,2769.48,36,,2769.48,percent of total billed charges,Radiopharmaceutical,2769.48,36,,2769.48,percent of total billed charges,Radiopharmaceutical,2692.55,35,,2692.55,percent of total billed charges,Radiopharmaceutical,2692.55,35,,2692.55,percent of total billed charges,Radiopharmaceutical,2692.55,35,,2692.55,percent of total billed charges,Radiopharmaceutical,2692.55,35,,2692.55,percent of total billed charges,Radiopharmaceutical,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5692.84,
TECHNETIUM TC-99M AEROSOL,A9567,HCPCS,,50000026,CDM,343,RC,,,both,,,249,184.26,,,184.26,Other,150% of Medicare + 9.63% HCRA Surcharge,112.05,45,,112.05,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,84.66,34,,84.66,percent of total billed charges,Radiopharmaceutical,84.66,34,,84.66,percent of total billed charges,Radiopharmaceutical,84.66,34,,84.66,percent of total billed charges,Radiopharmaceutical,123.26,,,123.26,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,174.3,70,,174.3,percent of total billed charges,All Other,89.64,36,,89.64,percent of total billed charges,Radiopharmaceutical,89.64,36,,89.64,percent of total billed charges,Radiopharmaceutical,87.15,35,,87.15,percent of total billed charges,Radiopharmaceutical,87.15,35,,87.15,percent of total billed charges,Radiopharmaceutical,87.15,35,,87.15,percent of total billed charges,Radiopharmaceutical,87.15,35,,87.15,percent of total billed charges,Radiopharmaceutical,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,184.26,
I131 IODIDE CAP RX PER 1 MCI,A9517,HCPCS,,50000010,CDM,344,RC,,,both,,,231,170.94,,,170.94,Other,150% of Medicare + 9.63% HCRA Surcharge,103.95,45,,103.95,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,78.54,34,,78.54,percent of total billed charges,Radiopharmaceutical,78.54,34,,78.54,percent of total billed charges,Radiopharmaceutical,78.54,34,,78.54,percent of total billed charges,Radiopharmaceutical,114.35,,,114.35,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,613,,,613,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,161.7,70,,161.7,percent of total billed charges,All Other,83.16,36,,83.16,percent of total billed charges,Radiopharmaceutical,83.16,36,,83.16,percent of total billed charges,Radiopharmaceutical,80.85,35,,80.85,percent of total billed charges,Radiopharmaceutical,80.85,35,,80.85,percent of total billed charges,Radiopharmaceutical,80.85,35,,80.85,percent of total billed charges,Radiopharmaceutical,80.85,35,,80.85,percent of total billed charges,Radiopharmaceutical,329.5,,,329.5,Other,100% of Medicaid,329.5,,,329.5,Other,100% of Medicaid,329.5,,,329.5,Other,100% of Medicaid,329.5,,,329.5,Other,100% of Medicaid,741.37,,,741.37,Other,225% of Medicaid,504.13,,,504.13,Other,153% of Medicaid,741.37,,,741.37,Other,225% of Medicaid,461.3,,,461.3,Other,140% of Medicaid,741.37,,,741.37,Other,225% of Medicaid,856.7,,,856.7,Other,260% of Medicaid,1067.58,,,1067.58,Other,324% of Medicaid,708.42,,,708.42,Other,215% of Medicaid,708.42,,,708.42,Other,215% of Medicaid,411.87,,,411.87,Other,125% of Medicaid,0.01,1067.58,
CT SOFT TISSUE NECK WO CONTRAST,70490,CPT,TC,46070490,CDM,350,RC,,,both,,,2134,1579.17,,,1579.17,Other,150% of Medicare + 9.63% HCRA Surcharge,960.3,45,,960.3,percent of total billed charges,Critical Access Hospital RCC factor,324.81,,,324.81,Fee Schedule,,292.22,,,292.22,Fee Schedule,,1306.75,,,1306.75,Fee Schedule,,1175.33,,,1175.33,Fee Schedule,,1110.86,,,1110.86,Fee Schedule,,1056.33,,,1056.33,Other,110% of Medicare,385.9,,,385.9,Fee Schedule,,458,,,458,Other,186% of Medicaid,454.12,,,454.12,Fee Schedule,,1323.08,,,1323.08,Fee Schedule,,213.82,,,213.82,Fee Schedule,,454.12,,,454.12,Fee Schedule,,1323.08,,,1323.08,Fee Schedule,,402.19,,,402.19,Fee Schedule,,1493.8,70,,1493.8,percent of total billed charges,All Other,467.4,,,467.4,Fee Schedule,,396.15,,,396.15,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,246,,,246,Other,100% of Medicaid,246,,,246,Other,100% of Medicaid,246,,,246,Other,100% of Medicaid,246,,,246,Other,100% of Medicaid,553.49,,,553.49,Other,225% of Medicaid,376.37,,,376.37,Other,153% of Medicaid,553.49,,,553.49,Other,225% of Medicaid,344.39,,,344.39,Other,140% of Medicaid,553.49,,,553.49,Other,225% of Medicaid,639.59,,,639.59,Other,260% of Medicaid,797.03,,,797.03,Other,324% of Medicaid,528.89,,,528.89,Other,215% of Medicaid,528.89,,,528.89,Other,215% of Medicaid,307.5,,,307.5,Other,125% of Medicaid,179.33,1579.17,
CT ANGIOGRAPHY HEAD,70496,CPT,TC,46070496,CDM,350,RC,,,both,,,2326,1721.25,,,1721.25,Other,150% of Medicare + 9.63% HCRA Surcharge,1046.7,45,,1046.7,percent of total billed charges,Critical Access Hospital RCC factor,618.57,,,618.57,Fee Schedule,,556.52,,,556.52,Fee Schedule,,2281.59,,,2281.59,Fee Schedule,,2052.14,,,2052.14,Fee Schedule,,1939.57,,,1939.57,Fee Schedule,,1151.37,,,1151.37,Other,110% of Medicare,734.92,,,734.92,Fee Schedule,,580,,,580,Other,186% of Medicaid,864.84,,,864.84,Fee Schedule,,1442.12,,,1442.12,Fee Schedule,,407.21,,,407.21,Fee Schedule,,864.84,,,864.84,Fee Schedule,,1442.12,,,1442.12,Fee Schedule,,765.94,,,765.94,Fee Schedule,,1628.2,70,,1628.2,percent of total billed charges,All Other,1003.68,,,1003.68,Fee Schedule,,850.68,,,850.68,Fee Schedule,,291.55,,,291.55,Fee Schedule,,291.55,,,291.55,Fee Schedule,,291.55,,,291.55,Fee Schedule,,291.55,,,291.55,Fee Schedule,,311.93,,,311.93,Other,100% of Medicaid,311.93,,,311.93,Other,100% of Medicaid,311.93,,,311.93,Other,100% of Medicaid,311.93,,,311.93,Other,100% of Medicaid,701.85,,,701.85,Other,225% of Medicaid,477.26,,,477.26,Other,153% of Medicaid,701.85,,,701.85,Other,225% of Medicaid,436.71,,,436.71,Other,140% of Medicaid,701.85,,,701.85,Other,225% of Medicaid,811.02,,,811.02,Other,260% of Medicaid,1010.66,,,1010.66,Other,324% of Medicaid,670.66,,,670.66,Other,215% of Medicaid,670.66,,,670.66,Other,215% of Medicaid,389.92,,,389.92,Other,125% of Medicaid,291.55,2281.59,
CT ANGIOGRAPHY NECK,70498,CPT,TC,46070498,CDM,350,RC,,,both,,,2326,1721.25,,,1721.25,Other,150% of Medicare + 9.63% HCRA Surcharge,1046.7,45,,1046.7,percent of total billed charges,Critical Access Hospital RCC factor,618.57,,,618.57,Fee Schedule,,556.52,,,556.52,Fee Schedule,,2281.59,,,2281.59,Fee Schedule,,2052.14,,,2052.14,Fee Schedule,,1939.57,,,1939.57,Fee Schedule,,1151.37,,,1151.37,Other,110% of Medicare,734.92,,,734.92,Fee Schedule,,580,,,580,Other,186% of Medicaid,864.84,,,864.84,Fee Schedule,,1442.12,,,1442.12,Fee Schedule,,407.21,,,407.21,Fee Schedule,,864.84,,,864.84,Fee Schedule,,1442.12,,,1442.12,Fee Schedule,,765.94,,,765.94,Fee Schedule,,1628.2,70,,1628.2,percent of total billed charges,All Other,1002.04,,,1002.04,Fee Schedule,,849.29,,,849.29,Fee Schedule,,291.55,,,291.55,Fee Schedule,,291.55,,,291.55,Fee Schedule,,291.55,,,291.55,Fee Schedule,,291.55,,,291.55,Fee Schedule,,311.93,,,311.93,Other,100% of Medicaid,311.93,,,311.93,Other,100% of Medicaid,311.93,,,311.93,Other,100% of Medicaid,311.93,,,311.93,Other,100% of Medicaid,701.85,,,701.85,Other,225% of Medicaid,477.26,,,477.26,Other,153% of Medicaid,701.85,,,701.85,Other,225% of Medicaid,436.71,,,436.71,Other,140% of Medicaid,701.85,,,701.85,Other,225% of Medicaid,811.02,,,811.02,Other,260% of Medicaid,1010.66,,,1010.66,Other,324% of Medicaid,670.66,,,670.66,Other,215% of Medicaid,670.66,,,670.66,Other,215% of Medicaid,389.92,,,389.92,Other,125% of Medicaid,291.55,2281.59,
CT ANGIO CHEST W CONTRAST,71275,CPT,TC,46071275,CDM,350,RC,,,both,,,3156,2335.45,,,2335.45,Other,150% of Medicare + 9.63% HCRA Surcharge,1420.2,45,,1420.2,percent of total billed charges,Critical Access Hospital RCC factor,618.57,,,618.57,Fee Schedule,,556.52,,,556.52,Fee Schedule,,2279.28,,,2279.28,Fee Schedule,,2050.05,,,2050.05,Fee Schedule,,1937.6,,,1937.6,Fee Schedule,,1562.22,,,1562.22,Other,110% of Medicare,734.92,,,734.92,Fee Schedule,,580,,,580,Other,186% of Medicaid,864.84,,,864.84,Fee Schedule,,1956.72,,,1956.72,Fee Schedule,,407.21,,,407.21,Fee Schedule,,864.84,,,864.84,Fee Schedule,,1956.72,,,1956.72,Fee Schedule,,765.94,,,765.94,Fee Schedule,,2209.2,70,,2209.2,percent of total billed charges,All Other,1016.8,,,1016.8,Fee Schedule,,861.8,,,861.8,Fee Schedule,,291.55,,,291.55,Fee Schedule,,291.55,,,291.55,Fee Schedule,,291.55,,,291.55,Fee Schedule,,291.55,,,291.55,Fee Schedule,,311.93,,,311.93,Other,100% of Medicaid,311.93,,,311.93,Other,100% of Medicaid,311.93,,,311.93,Other,100% of Medicaid,311.93,,,311.93,Other,100% of Medicaid,701.85,,,701.85,Other,225% of Medicaid,477.26,,,477.26,Other,153% of Medicaid,701.85,,,701.85,Other,225% of Medicaid,436.71,,,436.71,Other,140% of Medicaid,701.85,,,701.85,Other,225% of Medicaid,811.02,,,811.02,Other,260% of Medicaid,1010.66,,,1010.66,Other,324% of Medicaid,670.66,,,670.66,Other,215% of Medicaid,670.66,,,670.66,Other,215% of Medicaid,389.92,,,389.92,Other,125% of Medicaid,291.55,2335.45,
CT ANGIO PELVIS W CONTRAST,72191,CPT,TC,46072191,CDM,350,RC,,,both,,,2895,2142.31,,,2142.31,Other,150% of Medicare + 9.63% HCRA Surcharge,1302.75,45,,1302.75,percent of total billed charges,Critical Access Hospital RCC factor,617.27,,,617.27,Fee Schedule,,555.35,,,555.35,Fee Schedule,,2279.28,,,2279.28,Fee Schedule,,2050.05,,,2050.05,Fee Schedule,,1937.6,,,1937.6,Fee Schedule,,1433.03,,,1433.03,Other,110% of Medicare,733.37,,,733.37,Fee Schedule,,580,,,580,Other,186% of Medicaid,863.01,,,863.01,Fee Schedule,,1794.9,,,1794.9,Fee Schedule,,406.35,,,406.35,Fee Schedule,,863.01,,,863.01,Fee Schedule,,1794.9,,,1794.9,Fee Schedule,,764.33,,,764.33,Fee Schedule,,2026.5,70,,2026.5,percent of total billed charges,All Other,1156.2,,,1156.2,Fee Schedule,,979.95,,,979.95,Fee Schedule,,291.55,,,291.55,Fee Schedule,,291.55,,,291.55,Fee Schedule,,291.55,,,291.55,Fee Schedule,,291.55,,,291.55,Fee Schedule,,311.93,,,311.93,Other,100% of Medicaid,311.93,,,311.93,Other,100% of Medicaid,311.93,,,311.93,Other,100% of Medicaid,311.93,,,311.93,Other,100% of Medicaid,701.85,,,701.85,Other,225% of Medicaid,477.26,,,477.26,Other,153% of Medicaid,701.85,,,701.85,Other,225% of Medicaid,436.71,,,436.71,Other,140% of Medicaid,701.85,,,701.85,Other,225% of Medicaid,811.02,,,811.02,Other,260% of Medicaid,1010.66,,,1010.66,Other,324% of Medicaid,670.66,,,670.66,Other,215% of Medicaid,670.66,,,670.66,Other,215% of Medicaid,389.92,,,389.92,Other,125% of Medicaid,291.55,2279.28,
CT L EXT W AND WO CONTRAST,73702,CPT,TC,46073702,CDM,350,RC,,,both,,,3156,2335.45,,,2335.45,Other,150% of Medicare + 9.63% HCRA Surcharge,1420.2,45,,1420.2,percent of total billed charges,Critical Access Hospital RCC factor,498.25,,,498.25,Fee Schedule,,448.27,,,448.27,Fee Schedule,,2192.32,,,2192.32,Fee Schedule,,1971.84,,,1971.84,Fee Schedule,,1863.68,,,1863.68,Fee Schedule,,1562.22,,,1562.22,Other,110% of Medicare,591.96,,,591.96,Fee Schedule,,547,,,547,Other,186% of Medicaid,696.61,,,696.61,Fee Schedule,,1956.72,,,1956.72,Fee Schedule,,328,,,328,Fee Schedule,,696.61,,,696.61,Fee Schedule,,1956.72,,,1956.72,Fee Schedule,,616.95,,,616.95,Fee Schedule,,2209.2,70,,2209.2,percent of total billed charges,All Other,715.04,,,715.04,Fee Schedule,,606.04,,,606.04,Fee Schedule,,291.55,,,291.55,Fee Schedule,,291.55,,,291.55,Fee Schedule,,291.55,,,291.55,Fee Schedule,,291.55,,,291.55,Fee Schedule,,293.99,,,293.99,Other,100% of Medicaid,293.99,,,293.99,Other,100% of Medicaid,293.99,,,293.99,Other,100% of Medicaid,293.99,,,293.99,Other,100% of Medicaid,661.49,,,661.49,Other,225% of Medicaid,449.81,,,449.81,Other,153% of Medicaid,661.49,,,661.49,Other,225% of Medicaid,411.59,,,411.59,Other,140% of Medicaid,661.49,,,661.49,Other,225% of Medicaid,764.39,,,764.39,Other,260% of Medicaid,952.54,,,952.54,Other,324% of Medicaid,632.09,,,632.09,Other,215% of Medicaid,632.09,,,632.09,Other,215% of Medicaid,367.49,,,367.49,Other,125% of Medicaid,291.55,2335.45,
CT ANGIOGRAPHY L EXT W AND WO CONTRAST,73706,CPT,TC,46073706,CDM,350,RC,,,both,,,2309,1708.67,,,1708.67,Other,150% of Medicare + 9.63% HCRA Surcharge,1039.05,45,,1039.05,percent of total billed charges,Critical Access Hospital RCC factor,618.57,,,618.57,Fee Schedule,,556.52,,,556.52,Fee Schedule,,2279.28,,,2279.28,Fee Schedule,,2050.05,,,2050.05,Fee Schedule,,1937.6,,,1937.6,Fee Schedule,,1142.96,,,1142.96,Other,110% of Medicare,734.92,,,734.92,Fee Schedule,,580,,,580,Other,186% of Medicaid,864.84,,,864.84,Fee Schedule,,1431.58,,,1431.58,Fee Schedule,,407.21,,,407.21,Fee Schedule,,864.84,,,864.84,Fee Schedule,,1431.58,,,1431.58,Fee Schedule,,765.94,,,765.94,Fee Schedule,,1616.3,70,,1616.3,percent of total billed charges,All Other,1226.72,,,1226.72,Fee Schedule,,1039.72,,,1039.72,Fee Schedule,,291.55,,,291.55,Fee Schedule,,291.55,,,291.55,Fee Schedule,,291.55,,,291.55,Fee Schedule,,291.55,,,291.55,Fee Schedule,,311.93,,,311.93,Other,100% of Medicaid,311.93,,,311.93,Other,100% of Medicaid,311.93,,,311.93,Other,100% of Medicaid,311.93,,,311.93,Other,100% of Medicaid,701.85,,,701.85,Other,225% of Medicaid,477.26,,,477.26,Other,153% of Medicaid,701.85,,,701.85,Other,225% of Medicaid,436.71,,,436.71,Other,140% of Medicaid,701.85,,,701.85,Other,225% of Medicaid,811.02,,,811.02,Other,260% of Medicaid,1010.66,,,1010.66,Other,324% of Medicaid,670.66,,,670.66,Other,215% of Medicaid,670.66,,,670.66,Other,215% of Medicaid,389.92,,,389.92,Other,125% of Medicaid,291.55,2279.28,
CT ABDOMEN W AND WO CONTRAST,74170,CPT,TC,46074170,CDM,350,RC,,,both,,,3156,2335.45,,,2335.45,Other,150% of Medicare + 9.63% HCRA Surcharge,1420.2,45,,1420.2,percent of total billed charges,Critical Access Hospital RCC factor,618.41,,,618.41,Fee Schedule,,556.38,,,556.38,Fee Schedule,,2251.82,,,2251.82,Fee Schedule,,2025.35,,,2025.35,Fee Schedule,,1914.26,,,1914.26,Fee Schedule,,1562.22,,,1562.22,Other,110% of Medicare,734.73,,,734.73,Fee Schedule,,547,,,547,Other,186% of Medicaid,864.62,,,864.62,Fee Schedule,,1956.72,,,1956.72,Fee Schedule,,407.11,,,407.11,Fee Schedule,,864.62,,,864.62,Fee Schedule,,1956.72,,,1956.72,Fee Schedule,,765.75,,,765.75,Fee Schedule,,2209.2,70,,2209.2,percent of total billed charges,All Other,1038.12,,,1038.12,Fee Schedule,,879.87,,,879.87,Fee Schedule,,291.55,,,291.55,Fee Schedule,,291.55,,,291.55,Fee Schedule,,291.55,,,291.55,Fee Schedule,,291.55,,,291.55,Fee Schedule,,293.99,,,293.99,Other,100% of Medicaid,293.99,,,293.99,Other,100% of Medicaid,293.99,,,293.99,Other,100% of Medicaid,293.99,,,293.99,Other,100% of Medicaid,661.49,,,661.49,Other,225% of Medicaid,449.81,,,449.81,Other,153% of Medicaid,661.49,,,661.49,Other,225% of Medicaid,411.59,,,411.59,Other,140% of Medicaid,661.49,,,661.49,Other,225% of Medicaid,764.39,,,764.39,Other,260% of Medicaid,952.54,,,952.54,Other,324% of Medicaid,632.09,,,632.09,Other,215% of Medicaid,632.09,,,632.09,Other,215% of Medicaid,367.49,,,367.49,Other,125% of Medicaid,291.55,2335.45,
CT CALCIUM SCORING,75571,CPT,TC,46075571,CDM,350,RC,,,both,,,608,449.92,,,449.92,Other,150% of Medicare + 9.63% HCRA Surcharge,273.6,45,,273.6,percent of total billed charges,Critical Access Hospital RCC factor,261.42,,,261.42,Fee Schedule,,235.2,,,235.2,Fee Schedule,,313.62,,,313.62,Fee Schedule,,282.08,,,282.08,Fee Schedule,,266.6,,,266.6,Fee Schedule,,300.96,,,300.96,Other,110% of Medicare,310.59,,,310.59,Fee Schedule,,458,,,458,Other,186% of Medicaid,365.5,,,365.5,Fee Schedule,,376.96,,,376.96,Fee Schedule,,172.1,,,172.1,Fee Schedule,,365.5,,,365.5,Fee Schedule,,376.96,,,376.96,Fee Schedule,,323.7,,,323.7,Fee Schedule,,425.6,70,,425.6,percent of total billed charges,All Other,367.36,,,367.36,Fee Schedule,,311.36,,,311.36,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,246,,,246,Other,100% of Medicaid,246,,,246,Other,100% of Medicaid,246,,,246,Other,100% of Medicaid,246,,,246,Other,100% of Medicaid,553.49,,,553.49,Other,225% of Medicaid,376.37,,,376.37,Other,153% of Medicaid,553.49,,,553.49,Other,225% of Medicaid,344.39,,,344.39,Other,140% of Medicaid,553.49,,,553.49,Other,225% of Medicaid,639.59,,,639.59,Other,260% of Medicaid,797.03,,,797.03,Other,324% of Medicaid,528.89,,,528.89,Other,215% of Medicaid,528.89,,,528.89,Other,215% of Medicaid,307.5,,,307.5,Other,125% of Medicaid,127.7,797.03,
CT HRT W 3D IMAGE,75572,CPT,TC,46075572,CDM,350,RC,,,both,,,1601,1184.74,,,1184.74,Other,150% of Medicare + 9.63% HCRA Surcharge,720.45,45,,720.45,percent of total billed charges,Critical Access Hospital RCC factor,528.46,,,528.46,Fee Schedule,,475.44,,,475.44,Fee Schedule,,1409.73,,,1409.73,Fee Schedule,,1267.95,,,1267.95,Fee Schedule,,1198.4,,,1198.4,Fee Schedule,,792.5,,,792.5,Other,110% of Medicare,627.85,,,627.85,Fee Schedule,,547,,,547,Other,186% of Medicaid,738.84,,,738.84,Fee Schedule,,992.62,,,992.62,Fee Schedule,,347.89,,,347.89,Fee Schedule,,738.84,,,738.84,Fee Schedule,,992.62,,,992.62,Fee Schedule,,654.36,,,654.36,Fee Schedule,,1120.7,70,,1120.7,percent of total billed charges,All Other,752.76,,,752.76,Fee Schedule,,638.01,,,638.01,Fee Schedule,,291.55,,,291.55,Fee Schedule,,291.55,,,291.55,Fee Schedule,,291.55,,,291.55,Fee Schedule,,291.55,,,291.55,Fee Schedule,,293.99,,,293.99,Other,100% of Medicaid,293.99,,,293.99,Other,100% of Medicaid,293.99,,,293.99,Other,100% of Medicaid,293.99,,,293.99,Other,100% of Medicaid,661.49,,,661.49,Other,225% of Medicaid,449.81,,,449.81,Other,153% of Medicaid,661.49,,,661.49,Other,225% of Medicaid,411.59,,,411.59,Other,140% of Medicaid,661.49,,,661.49,Other,225% of Medicaid,764.39,,,764.39,Other,260% of Medicaid,952.54,,,952.54,Other,324% of Medicaid,632.09,,,632.09,Other,215% of Medicaid,632.09,,,632.09,Other,215% of Medicaid,367.49,,,367.49,Other,125% of Medicaid,291.55,1409.73,
CT HRT W 3D IMAGE CONGEN,75573,CPT,TC,46075573,CDM,350,RC,,,both,,,2007,1485.19,,,1485.19,Other,150% of Medicare + 9.63% HCRA Surcharge,903.15,45,,903.15,percent of total billed charges,Critical Access Hospital RCC factor,618.73,,,618.73,Fee Schedule,,556.67,,,556.67,Fee Schedule,,1730.09,,,1730.09,Fee Schedule,,1556.09,,,1556.09,Fee Schedule,,1470.74,,,1470.74,Fee Schedule,,993.47,,,993.47,Other,110% of Medicare,735.11,,,735.11,Fee Schedule,,547,,,547,Other,186% of Medicaid,865.06,,,865.06,Fee Schedule,,1244.34,,,1244.34,Fee Schedule,,407.32,,,407.32,Fee Schedule,,865.06,,,865.06,Fee Schedule,,1244.34,,,1244.34,Fee Schedule,,766.14,,,766.14,Fee Schedule,,1404.9,70,,1404.9,percent of total billed charges,All Other,964.32,,,964.32,Fee Schedule,,817.32,,,817.32,Fee Schedule,,291.55,,,291.55,Fee Schedule,,291.55,,,291.55,Fee Schedule,,291.55,,,291.55,Fee Schedule,,291.55,,,291.55,Fee Schedule,,293.99,,,293.99,Other,100% of Medicaid,293.99,,,293.99,Other,100% of Medicaid,293.99,,,293.99,Other,100% of Medicaid,293.99,,,293.99,Other,100% of Medicaid,661.49,,,661.49,Other,225% of Medicaid,449.81,,,449.81,Other,153% of Medicaid,661.49,,,661.49,Other,225% of Medicaid,411.59,,,411.59,Other,140% of Medicaid,661.49,,,661.49,Other,225% of Medicaid,764.39,,,764.39,Other,260% of Medicaid,952.54,,,952.54,Other,324% of Medicaid,632.09,,,632.09,Other,215% of Medicaid,632.09,,,632.09,Other,215% of Medicaid,367.49,,,367.49,Other,125% of Medicaid,291.55,1730.09,
CT ANGIO HRT W 3D IMAGE,75574,CPT,TC,46075574,CDM,350,RC,,,both,,,2679,1982.47,,,1982.47,Other,150% of Medicare + 9.63% HCRA Surcharge,1205.55,45,,1205.55,percent of total billed charges,Critical Access Hospital RCC factor,617.42,,,617.42,Fee Schedule,,555.49,,,555.49,Fee Schedule,,1730.09,,,1730.09,Fee Schedule,,1556.09,,,1556.09,Fee Schedule,,1470.74,,,1470.74,Fee Schedule,,1326.11,,,1326.11,Other,110% of Medicare,733.55,,,733.55,Fee Schedule,,580,,,580,Other,186% of Medicaid,863.23,,,863.23,Fee Schedule,,1660.98,,,1660.98,Fee Schedule,,406.46,,,406.46,Fee Schedule,,863.23,,,863.23,Fee Schedule,,1660.98,,,1660.98,Fee Schedule,,764.52,,,764.52,Fee Schedule,,1875.3,70,,1875.3,percent of total billed charges,All Other,1100.44,,,1100.44,Fee Schedule,,932.69,,,932.69,Fee Schedule,,291.55,,,291.55,Fee Schedule,,291.55,,,291.55,Fee Schedule,,291.55,,,291.55,Fee Schedule,,291.55,,,291.55,Fee Schedule,,311.93,,,311.93,Other,100% of Medicaid,311.93,,,311.93,Other,100% of Medicaid,311.93,,,311.93,Other,100% of Medicaid,311.93,,,311.93,Other,100% of Medicaid,701.85,,,701.85,Other,225% of Medicaid,477.26,,,477.26,Other,153% of Medicaid,701.85,,,701.85,Other,225% of Medicaid,436.71,,,436.71,Other,140% of Medicaid,701.85,,,701.85,Other,225% of Medicaid,811.02,,,811.02,Other,260% of Medicaid,1010.66,,,1010.66,Other,324% of Medicaid,670.66,,,670.66,Other,215% of Medicaid,670.66,,,670.66,Other,215% of Medicaid,389.92,,,389.92,Other,125% of Medicaid,291.55,1982.47,
CT ANGIO AORTA W CONTRAST,75635,CPT,TC,46075635,CDM,350,RC,,,both,,,3156,2335.45,,,2335.45,Other,150% of Medicare + 9.63% HCRA Surcharge,1420.2,45,,1420.2,percent of total billed charges,Critical Access Hospital RCC factor,618.57,,,618.57,Fee Schedule,,556.52,,,556.52,Fee Schedule,,2279.38,,,2279.38,Fee Schedule,,2050.14,,,2050.14,Fee Schedule,,1937.69,,,1937.69,Fee Schedule,,1562.22,,,1562.22,Other,110% of Medicare,734.92,,,734.92,Fee Schedule,,580,,,580,Other,186% of Medicaid,864.84,,,864.84,Fee Schedule,,1956.72,,,1956.72,Fee Schedule,,407.21,,,407.21,Fee Schedule,,864.84,,,864.84,Fee Schedule,,1956.72,,,1956.72,Fee Schedule,,765.94,,,765.94,Fee Schedule,,2209.2,70,,2209.2,percent of total billed charges,All Other,1546.52,,,1546.52,Fee Schedule,,1310.77,,,1310.77,Fee Schedule,,291.55,,,291.55,Fee Schedule,,291.55,,,291.55,Fee Schedule,,291.55,,,291.55,Fee Schedule,,291.55,,,291.55,Fee Schedule,,311.93,,,311.93,Other,100% of Medicaid,311.93,,,311.93,Other,100% of Medicaid,311.93,,,311.93,Other,100% of Medicaid,311.93,,,311.93,Other,100% of Medicaid,701.85,,,701.85,Other,225% of Medicaid,477.26,,,477.26,Other,153% of Medicaid,701.85,,,701.85,Other,225% of Medicaid,436.71,,,436.71,Other,140% of Medicaid,701.85,,,701.85,Other,225% of Medicaid,811.02,,,811.02,Other,260% of Medicaid,1010.66,,,1010.66,Other,324% of Medicaid,670.66,,,670.66,Other,215% of Medicaid,670.66,,,670.66,Other,215% of Medicaid,389.92,,,389.92,Other,125% of Medicaid,291.55,2335.45,
RADIOLOGIC GUIDANCE FOR PROCED,75989,CPT,TC,46075989,CDM,350,RC,,,both,,,2125,1572.51,,,1572.51,Other,150% of Medicare + 9.63% HCRA Surcharge,956.25,45,,956.25,percent of total billed charges,Critical Access Hospital RCC factor,197.72,,,197.72,Fee Schedule,,177.88,,,177.88,Fee Schedule,,521.84,,,521.84,Fee Schedule,,469.35,,,469.35,Fee Schedule,,443.61,,,443.61,Fee Schedule,,1051.88,,,1051.88,Other,110% of Medicare,234.9,,,234.9,Fee Schedule,,544,,,544,Other,186% of Medicaid,276.43,,,276.43,Fee Schedule,,1317.5,,,1317.5,Fee Schedule,,130.16,,,130.16,Fee Schedule,,276.43,,,276.43,Fee Schedule,,1317.5,,,1317.5,Fee Schedule,,244.82,,,244.82,Fee Schedule,,1487.5,70,,1487.5,percent of total billed charges,All Other,291.92,,,291.92,Fee Schedule,,247.42,,,247.42,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,292.43,,,292.43,Other,100% of Medicaid,292.43,,,292.43,Other,100% of Medicaid,292.43,,,292.43,Other,100% of Medicaid,292.43,,,292.43,Other,100% of Medicaid,657.97,,,657.97,Other,225% of Medicaid,447.42,,,447.42,Other,153% of Medicaid,657.97,,,657.97,Other,225% of Medicaid,409.4,,,409.4,Other,140% of Medicaid,657.97,,,657.97,Other,225% of Medicaid,760.32,,,760.32,Other,260% of Medicaid,947.48,,,947.48,Other,324% of Medicaid,628.73,,,628.73,Other,215% of Medicaid,628.73,,,628.73,Other,215% of Medicaid,365.54,,,365.54,Other,125% of Medicaid,0.01,1572.51,
CT LIMITED OR FOLLOW-UP STUDY,76380,CPT,,46076380,CDM,350,RC,,,both,,,270,199.8,,,199.8,Other,150% of Medicare + 9.63% HCRA Surcharge,121.5,45,,121.5,percent of total billed charges,Critical Access Hospital RCC factor,305.16,,,305.16,Fee Schedule,,274.54,,,274.54,Fee Schedule,,764.41,,,764.41,Fee Schedule,,687.54,,,687.54,Fee Schedule,,649.82,,,649.82,Fee Schedule,,133.65,,,133.65,Other,110% of Medicare,362.55,,,362.55,Fee Schedule,,458,,,458,Other,186% of Medicaid,426.64,,,426.64,Fee Schedule,,167.4,,,167.4,Fee Schedule,,200.89,,,200.89,Fee Schedule,,426.64,,,426.64,Fee Schedule,,167.4,,,167.4,Fee Schedule,,377.86,,,377.86,Fee Schedule,,189,70,,189,percent of total billed charges,All Other,451,,,451,Fee Schedule,,382.25,,,382.25,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,246,,,246,Other,100% of Medicaid,246,,,246,Other,100% of Medicaid,246,,,246,Other,100% of Medicaid,246,,,246,Other,100% of Medicaid,553.49,,,553.49,Other,225% of Medicaid,376.37,,,376.37,Other,153% of Medicaid,553.49,,,553.49,Other,225% of Medicaid,344.39,,,344.39,Other,140% of Medicaid,553.49,,,553.49,Other,225% of Medicaid,639.59,,,639.59,Other,260% of Medicaid,797.03,,,797.03,Other,324% of Medicaid,528.89,,,528.89,Other,215% of Medicaid,528.89,,,528.89,Other,215% of Medicaid,307.5,,,307.5,Other,125% of Medicaid,121.5,797.03,
CT GUIDED STEREOTACTIC,77011,CPT,TC,46077011,CDM,350,RC,,,both,,,2262,1673.89,,,1673.89,Other,150% of Medicare + 9.63% HCRA Surcharge,1017.9,45,,1017.9,percent of total billed charges,Critical Access Hospital RCC factor,557.01,,,557.01,Fee Schedule,,501.13,,,501.13,Fee Schedule,,2849.07,,,2849.07,Fee Schedule,,2562.54,,,2562.54,Fee Schedule,,2421.98,,,2421.98,Fee Schedule,,1119.69,,,1119.69,Other,110% of Medicare,661.77,,,661.77,Fee Schedule,,299,,,299,Other,186% of Medicaid,778.76,,,778.76,Fee Schedule,,1402.44,,,1402.44,Fee Schedule,,366.68,,,366.68,Fee Schedule,,778.76,,,778.76,Fee Schedule,,1402.44,,,1402.44,Fee Schedule,,689.71,,,689.71,Fee Schedule,,1583.4,70,,1583.4,percent of total billed charges,All Other,811.8,,,811.8,Fee Schedule,,688.05,,,688.05,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,160.85,,,160.85,Other,100% of Medicaid,160.85,,,160.85,Other,100% of Medicaid,160.85,,,160.85,Other,100% of Medicaid,160.85,,,160.85,Other,100% of Medicaid,361.92,,,361.92,Other,225% of Medicaid,246.11,,,246.11,Other,153% of Medicaid,361.92,,,361.92,Other,225% of Medicaid,225.2,,,225.2,Other,140% of Medicaid,361.92,,,361.92,Other,225% of Medicaid,418.22,,,418.22,Other,260% of Medicaid,521.17,,,521.17,Other,324% of Medicaid,345.84,,,345.84,Other,215% of Medicaid,345.84,,,345.84,Other,215% of Medicaid,201.07,,,201.07,Other,125% of Medicaid,0.01,2849.07,
CT GUIDANCE FOR NEEDLE PLACEME,77012,CPT,TC,46077012,CDM,350,RC,,,both,,,2477,1832.99,,,1832.99,Other,150% of Medicare + 9.63% HCRA Surcharge,1114.65,45,,1114.65,percent of total billed charges,Critical Access Hospital RCC factor,245.09,,,245.09,Fee Schedule,,220.5,,,220.5,Fee Schedule,,718.62,,,718.62,Fee Schedule,,646.35,,,646.35,Fee Schedule,,610.89,,,610.89,Fee Schedule,,1226.12,,,1226.12,Other,110% of Medicare,291.19,,,291.19,Fee Schedule,,299,,,299,Other,186% of Medicaid,342.66,,,342.66,Fee Schedule,,1535.74,,,1535.74,Fee Schedule,,161.34,,,161.34,Fee Schedule,,342.66,,,342.66,Fee Schedule,,1535.74,,,1535.74,Fee Schedule,,303.48,,,303.48,Fee Schedule,,1733.9,70,,1733.9,percent of total billed charges,All Other,357.52,,,357.52,Fee Schedule,,303.02,,,303.02,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,160.85,,,160.85,Other,100% of Medicaid,160.85,,,160.85,Other,100% of Medicaid,160.85,,,160.85,Other,100% of Medicaid,160.85,,,160.85,Other,100% of Medicaid,361.92,,,361.92,Other,225% of Medicaid,246.11,,,246.11,Other,153% of Medicaid,361.92,,,361.92,Other,225% of Medicaid,225.2,,,225.2,Other,140% of Medicaid,361.92,,,361.92,Other,225% of Medicaid,418.22,,,418.22,Other,260% of Medicaid,521.17,,,521.17,Other,324% of Medicaid,345.84,,,345.84,Other,215% of Medicaid,345.84,,,345.84,Other,215% of Medicaid,201.07,,,201.07,Other,125% of Medicaid,0.01,1832.99,
CT GUIDANCE FOR ABLATION,77013,CPT,TC,46077013,CDM,350,RC,,,both,,,2125,1572.51,,,1572.51,Other,150% of Medicare + 9.63% HCRA Surcharge,956.25,45,,956.25,percent of total billed charges,Critical Access Hospital RCC factor,1381.25,65,,1381.25,percent of total billed charges,All Other,1253.75,65,,1253.75,percent of total billed charges,All Other,342.07,,,342.07,Fee Schedule,,342.07,,,342.07,Fee Schedule,,342.07,,,342.07,Fee Schedule,,1051.88,,,1051.88,Other,110% of Medicare,1445,,,1445,Fee Schedule,,299,,,299,Other,186% of Medicaid,1700,,,1700,percent of total billed charges,All Other,1763.75,83,,1763.75,percent of total billed charges,All Other,1763.75,83,,1763.75,percent of total billed charges,All Other,1700,80,,1700,percent of total billed charges,All Other,1763.75,83,,1763.75,percent of total billed charges,All Other,1700,80,,1700,percent of total billed charges,All Other,1487.5,70,,1487.5,percent of total billed charges,All Other,1381.25,65,,1381.25,percent of total billed charges,Default if not in Fee Schedule,1381.25,65,,1381.25,percent of total billed charges,Default if not in Fee Schedule,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,160.85,,,160.85,Other,100% of Medicaid,160.85,,,160.85,Other,100% of Medicaid,160.85,,,160.85,Other,100% of Medicaid,160.85,,,160.85,Other,100% of Medicaid,361.92,,,361.92,Other,225% of Medicaid,246.11,,,246.11,Other,153% of Medicaid,361.92,,,361.92,Other,225% of Medicaid,225.2,,,225.2,Other,140% of Medicaid,361.92,,,361.92,Other,225% of Medicaid,418.22,,,418.22,Other,260% of Medicaid,521.17,,,521.17,Other,324% of Medicaid,345.84,,,345.84,Other,215% of Medicaid,345.84,,,345.84,Other,215% of Medicaid,201.07,,,201.07,Other,125% of Medicaid,0.01,1763.75,
CT SCAN FOR THERAPY GUIDE,77014,CPT,TC,46077014,CDM,350,RC,,,both,,,1239,916.86,,,916.86,Other,150% of Medicare + 9.63% HCRA Surcharge,557.55,45,,557.55,percent of total billed charges,Critical Access Hospital RCC factor,261.26,,,261.26,Fee Schedule,,235.05,,,235.05,Fee Schedule,,1006.99,,,1006.99,Fee Schedule,,905.72,,,905.72,Fee Schedule,,856.04,,,856.04,Fee Schedule,,613.31,,,613.31,Other,110% of Medicare,310.4,,,310.4,Fee Schedule,,299,,,299,Other,186% of Medicaid,365.27,,,365.27,Fee Schedule,,768.18,,,768.18,Fee Schedule,,171.99,,,171.99,Fee Schedule,,365.27,,,365.27,Fee Schedule,,768.18,,,768.18,Fee Schedule,,323.51,,,323.51,Fee Schedule,,867.3,70,,867.3,percent of total billed charges,All Other,372.28,,,372.28,Fee Schedule,,315.53,,,315.53,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,160.85,,,160.85,Other,100% of Medicaid,160.85,,,160.85,Other,100% of Medicaid,160.85,,,160.85,Other,100% of Medicaid,160.85,,,160.85,Other,100% of Medicaid,361.92,,,361.92,Other,225% of Medicaid,246.11,,,246.11,Other,153% of Medicaid,361.92,,,361.92,Other,225% of Medicaid,225.2,,,225.2,Other,140% of Medicaid,361.92,,,361.92,Other,225% of Medicaid,418.22,,,418.22,Other,260% of Medicaid,521.17,,,521.17,Other,324% of Medicaid,345.84,,,345.84,Other,215% of Medicaid,345.84,,,345.84,Other,215% of Medicaid,201.07,,,201.07,Other,125% of Medicaid,0.01,1006.99,
CT ANGIO L EXT W AND WO CONTRAST LT,73706,CPT,TCLT,46173706,CDM,350,RC,,,both,,,2309,1708.67,,,1708.67,Other,150% of Medicare + 9.63% HCRA Surcharge,1039.05,45,,1039.05,percent of total billed charges,Critical Access Hospital RCC factor,618.57,,,618.57,Fee Schedule,,556.52,,,556.52,Fee Schedule,,2279.28,,,2279.28,Fee Schedule,,2050.05,,,2050.05,Fee Schedule,,1937.6,,,1937.6,Fee Schedule,,1142.96,,,1142.96,Other,110% of Medicare,734.92,,,734.92,Fee Schedule,,580,,,580,Other,186% of Medicaid,864.84,,,864.84,Fee Schedule,,1431.58,,,1431.58,Fee Schedule,,407.21,,,407.21,Fee Schedule,,864.84,,,864.84,Fee Schedule,,1431.58,,,1431.58,Fee Schedule,,765.94,,,765.94,Fee Schedule,,1616.3,70,,1616.3,percent of total billed charges,All Other,1226.72,,,1226.72,Fee Schedule,,1039.72,,,1039.72,Fee Schedule,,291.55,,,291.55,Fee Schedule,,291.55,,,291.55,Fee Schedule,,291.55,,,291.55,Fee Schedule,,291.55,,,291.55,Fee Schedule,,311.93,,,311.93,Other,100% of Medicaid,311.93,,,311.93,Other,100% of Medicaid,311.93,,,311.93,Other,100% of Medicaid,311.93,,,311.93,Other,100% of Medicaid,701.85,,,701.85,Other,225% of Medicaid,477.26,,,477.26,Other,153% of Medicaid,701.85,,,701.85,Other,225% of Medicaid,436.71,,,436.71,Other,140% of Medicaid,701.85,,,701.85,Other,225% of Medicaid,811.02,,,811.02,Other,260% of Medicaid,1010.66,,,1010.66,Other,324% of Medicaid,670.66,,,670.66,Other,215% of Medicaid,670.66,,,670.66,Other,215% of Medicaid,389.92,,,389.92,Other,125% of Medicaid,291.55,2279.28,
CT SCAN FOR NEEDLE BIOPSY LT,77012,CPT,TCLT,46177012,CDM,350,RC,,,both,,,2477,1832.99,,,1832.99,Other,150% of Medicare + 9.63% HCRA Surcharge,1114.65,45,,1114.65,percent of total billed charges,Critical Access Hospital RCC factor,245.09,,,245.09,Fee Schedule,,220.5,,,220.5,Fee Schedule,,718.62,,,718.62,Fee Schedule,,646.35,,,646.35,Fee Schedule,,610.89,,,610.89,Fee Schedule,,1226.12,,,1226.12,Other,110% of Medicare,291.19,,,291.19,Fee Schedule,,299,,,299,Other,186% of Medicaid,342.66,,,342.66,Fee Schedule,,1535.74,,,1535.74,Fee Schedule,,161.34,,,161.34,Fee Schedule,,342.66,,,342.66,Fee Schedule,,1535.74,,,1535.74,Fee Schedule,,303.48,,,303.48,Fee Schedule,,1733.9,70,,1733.9,percent of total billed charges,All Other,357.52,,,357.52,Fee Schedule,,303.02,,,303.02,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,160.85,,,160.85,Other,100% of Medicaid,160.85,,,160.85,Other,100% of Medicaid,160.85,,,160.85,Other,100% of Medicaid,160.85,,,160.85,Other,100% of Medicaid,361.92,,,361.92,Other,225% of Medicaid,246.11,,,246.11,Other,153% of Medicaid,361.92,,,361.92,Other,225% of Medicaid,225.2,,,225.2,Other,140% of Medicaid,361.92,,,361.92,Other,225% of Medicaid,418.22,,,418.22,Other,260% of Medicaid,521.17,,,521.17,Other,324% of Medicaid,345.84,,,345.84,Other,215% of Medicaid,345.84,,,345.84,Other,215% of Medicaid,201.07,,,201.07,Other,125% of Medicaid,0.01,1832.99,
CT ANGIO L EXT W AND WO CONTRAST RT,73706,CPT,TCRT,46273706,CDM,350,RC,,,both,,,2309,1708.67,,,1708.67,Other,150% of Medicare + 9.63% HCRA Surcharge,1039.05,45,,1039.05,percent of total billed charges,Critical Access Hospital RCC factor,618.57,,,618.57,Fee Schedule,,556.52,,,556.52,Fee Schedule,,2279.28,,,2279.28,Fee Schedule,,2050.05,,,2050.05,Fee Schedule,,1937.6,,,1937.6,Fee Schedule,,1142.96,,,1142.96,Other,110% of Medicare,734.92,,,734.92,Fee Schedule,,580,,,580,Other,186% of Medicaid,864.84,,,864.84,Fee Schedule,,1431.58,,,1431.58,Fee Schedule,,407.21,,,407.21,Fee Schedule,,864.84,,,864.84,Fee Schedule,,1431.58,,,1431.58,Fee Schedule,,765.94,,,765.94,Fee Schedule,,1616.3,70,,1616.3,percent of total billed charges,All Other,1226.72,,,1226.72,Fee Schedule,,1039.72,,,1039.72,Fee Schedule,,291.55,,,291.55,Fee Schedule,,291.55,,,291.55,Fee Schedule,,291.55,,,291.55,Fee Schedule,,291.55,,,291.55,Fee Schedule,,311.93,,,311.93,Other,100% of Medicaid,311.93,,,311.93,Other,100% of Medicaid,311.93,,,311.93,Other,100% of Medicaid,311.93,,,311.93,Other,100% of Medicaid,701.85,,,701.85,Other,225% of Medicaid,477.26,,,477.26,Other,153% of Medicaid,701.85,,,701.85,Other,225% of Medicaid,436.71,,,436.71,Other,140% of Medicaid,701.85,,,701.85,Other,225% of Medicaid,811.02,,,811.02,Other,260% of Medicaid,1010.66,,,1010.66,Other,324% of Medicaid,670.66,,,670.66,Other,215% of Medicaid,670.66,,,670.66,Other,215% of Medicaid,389.92,,,389.92,Other,125% of Medicaid,291.55,2279.28,
CT SCAN FOR NEEDLE BIOPSY RT,77012,CPT,TCRT,46277012,CDM,350,RC,,,both,,,2477,1832.99,,,1832.99,Other,150% of Medicare + 9.63% HCRA Surcharge,1114.65,45,,1114.65,percent of total billed charges,Critical Access Hospital RCC factor,245.09,,,245.09,Fee Schedule,,220.5,,,220.5,Fee Schedule,,718.62,,,718.62,Fee Schedule,,646.35,,,646.35,Fee Schedule,,610.89,,,610.89,Fee Schedule,,1226.12,,,1226.12,Other,110% of Medicare,291.19,,,291.19,Fee Schedule,,299,,,299,Other,186% of Medicaid,342.66,,,342.66,Fee Schedule,,1535.74,,,1535.74,Fee Schedule,,161.34,,,161.34,Fee Schedule,,342.66,,,342.66,Fee Schedule,,1535.74,,,1535.74,Fee Schedule,,303.48,,,303.48,Fee Schedule,,1733.9,70,,1733.9,percent of total billed charges,All Other,357.52,,,357.52,Fee Schedule,,303.02,,,303.02,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,160.85,,,160.85,Other,100% of Medicaid,160.85,,,160.85,Other,100% of Medicaid,160.85,,,160.85,Other,100% of Medicaid,160.85,,,160.85,Other,100% of Medicaid,361.92,,,361.92,Other,225% of Medicaid,246.11,,,246.11,Other,153% of Medicaid,361.92,,,361.92,Other,225% of Medicaid,225.2,,,225.2,Other,140% of Medicaid,361.92,,,361.92,Other,225% of Medicaid,418.22,,,418.22,Other,260% of Medicaid,521.17,,,521.17,Other,324% of Medicaid,345.84,,,345.84,Other,215% of Medicaid,345.84,,,345.84,Other,215% of Medicaid,201.07,,,201.07,Other,125% of Medicaid,0.01,1832.99,
CT ANGIO L EXT W AND WO CONTRAST BILAT,73706,CPT,TC50,46373706,CDM,350,RC,,,both,,,3464,2563.37,,,2563.37,Other,150% of Medicare + 9.63% HCRA Surcharge,1558.8,45,,1558.8,percent of total billed charges,Critical Access Hospital RCC factor,618.57,,,618.57,Fee Schedule,,556.52,,,556.52,Fee Schedule,,2279.28,,,2279.28,Fee Schedule,,2050.05,,,2050.05,Fee Schedule,,1937.6,,,1937.6,Fee Schedule,,1714.68,,,1714.68,Other,110% of Medicare,734.92,,,734.92,Fee Schedule,,580,,,580,Other,186% of Medicaid,864.84,,,864.84,Fee Schedule,,2147.68,,,2147.68,Fee Schedule,,407.21,,,407.21,Fee Schedule,,864.84,,,864.84,Fee Schedule,,2147.68,,,2147.68,Fee Schedule,,765.94,,,765.94,Fee Schedule,,2424.8,70,,2424.8,percent of total billed charges,All Other,1226.72,,,1226.72,Fee Schedule,,1039.72,,,1039.72,Fee Schedule,,291.55,,,291.55,Fee Schedule,,291.55,,,291.55,Fee Schedule,,291.55,,,291.55,Fee Schedule,,291.55,,,291.55,Fee Schedule,,311.93,,,311.93,Other,100% of Medicaid,311.93,,,311.93,Other,100% of Medicaid,311.93,,,311.93,Other,100% of Medicaid,311.93,,,311.93,Other,100% of Medicaid,701.85,,,701.85,Other,225% of Medicaid,477.26,,,477.26,Other,153% of Medicaid,701.85,,,701.85,Other,225% of Medicaid,436.71,,,436.71,Other,140% of Medicaid,701.85,,,701.85,Other,225% of Medicaid,811.02,,,811.02,Other,260% of Medicaid,1010.66,,,1010.66,Other,324% of Medicaid,670.66,,,670.66,Other,215% of Medicaid,670.66,,,670.66,Other,215% of Medicaid,389.92,,,389.92,Other,125% of Medicaid,291.55,2563.37,
3D RENDERING W/INTRP POSTPROCESS,76377,CPT,,47076377,CDM,350,RC,,,both,,,315,233.1,,,233.1,Other,150% of Medicare + 9.63% HCRA Surcharge,141.75,45,,141.75,percent of total billed charges,Critical Access Hospital RCC factor,141.29,,,141.29,Fee Schedule,,127.11,,,127.11,Fee Schedule,,366.21,,,366.21,Fee Schedule,,329.38,,,329.38,Fee Schedule,,311.32,,,311.32,Fee Schedule,,155.93,,,155.93,Other,110% of Medicare,167.86,,,167.86,Fee Schedule,,0.01,,,0.01,Other,186% of Medicaid,197.53,,,197.53,Fee Schedule,,195.3,,,195.3,Fee Schedule,,93.01,,,93.01,Fee Schedule,,197.53,,,197.53,Fee Schedule,,195.3,,,195.3,Fee Schedule,,174.95,,,174.95,Fee Schedule,,220.5,70,,220.5,percent of total billed charges,All Other,167.28,,,167.28,Fee Schedule,,141.78,,,141.78,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,366.21,
3D RENDER W/INTRP POSTPROCES,76376,CPT,,48076376,CDM,350,RC,,,both,,,67,49.58,,,49.58,Other,150% of Medicare + 9.63% HCRA Surcharge,30.15,45,,30.15,percent of total billed charges,Critical Access Hospital RCC factor,54.45,,,54.45,Fee Schedule,,48.99,,,48.99,Fee Schedule,,416.59,,,416.59,Fee Schedule,,374.7,,,374.7,Fee Schedule,,354.14,,,354.14,Fee Schedule,,33.17,,,33.17,Other,110% of Medicare,64.7,,,64.7,Fee Schedule,,0.01,,,0.01,Other,186% of Medicaid,76.13,,,76.13,Fee Schedule,,41.54,,,41.54,Fee Schedule,,35.85,,,35.85,Fee Schedule,,76.13,,,76.13,Fee Schedule,,41.54,,,41.54,Fee Schedule,,67.43,,,67.43,Fee Schedule,,46.9,70,,46.9,percent of total billed charges,All Other,65.6,,,65.6,Fee Schedule,,55.6,,,55.6,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,416.59,
3D RENDERING W/INTRP POSTPROCESS,76377,CPT,,48076377,CDM,350,RC,,,both,,,315,233.1,,,233.1,Other,150% of Medicare + 9.63% HCRA Surcharge,141.75,45,,141.75,percent of total billed charges,Critical Access Hospital RCC factor,141.29,,,141.29,Fee Schedule,,127.11,,,127.11,Fee Schedule,,366.21,,,366.21,Fee Schedule,,329.38,,,329.38,Fee Schedule,,311.32,,,311.32,Fee Schedule,,155.93,,,155.93,Other,110% of Medicare,167.86,,,167.86,Fee Schedule,,0.01,,,0.01,Other,186% of Medicaid,197.53,,,197.53,Fee Schedule,,195.3,,,195.3,Fee Schedule,,93.01,,,93.01,Fee Schedule,,197.53,,,197.53,Fee Schedule,,195.3,,,195.3,Fee Schedule,,174.95,,,174.95,Fee Schedule,,220.5,70,,220.5,percent of total billed charges,All Other,167.28,,,167.28,Fee Schedule,,141.78,,,141.78,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,366.21,
CT HEAD BRAIN WO CONTRAST,70450,CPT,TC,46070450,CDM,351,RC,,,both,,,2134,1579.17,,,1579.17,Other,150% of Medicare + 9.63% HCRA Surcharge,960.3,45,,960.3,percent of total billed charges,Critical Access Hospital RCC factor,239.31,,,239.31,Fee Schedule,,215.31,,,215.31,Fee Schedule,,1045.88,,,1045.88,Fee Schedule,,940.7,,,940.7,Fee Schedule,,889.1,,,889.1,Fee Schedule,,1056.33,,,1056.33,Other,110% of Medicare,284.33,,,284.33,Fee Schedule,,547,,,547,Other,186% of Medicaid,334.59,,,334.59,Fee Schedule,,1323.08,,,1323.08,Fee Schedule,,157.54,,,157.54,Fee Schedule,,334.59,,,334.59,Fee Schedule,,1323.08,,,1323.08,Fee Schedule,,296.33,,,296.33,Fee Schedule,,1493.8,70,,1493.8,percent of total billed charges,All Other,341.12,,,341.12,Fee Schedule,,289.12,,,289.12,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,293.99,,,293.99,Other,100% of Medicaid,293.99,,,293.99,Other,100% of Medicaid,293.99,,,293.99,Other,100% of Medicaid,293.99,,,293.99,Other,100% of Medicaid,661.49,,,661.49,Other,225% of Medicaid,449.81,,,449.81,Other,153% of Medicaid,661.49,,,661.49,Other,225% of Medicaid,411.59,,,411.59,Other,140% of Medicaid,661.49,,,661.49,Other,225% of Medicaid,764.39,,,764.39,Other,260% of Medicaid,952.54,,,952.54,Other,324% of Medicaid,632.09,,,632.09,Other,215% of Medicaid,632.09,,,632.09,Other,215% of Medicaid,367.49,,,367.49,Other,125% of Medicaid,157.54,1579.17,
CT HEAD BRAIN W CONTRAST,70460,CPT,TC,46070460,CDM,351,RC,,,both,,,2559,1893.67,,,1893.67,Other,150% of Medicare + 9.63% HCRA Surcharge,1151.55,45,,1151.55,percent of total billed charges,Critical Access Hospital RCC factor,343.28,,,343.28,Fee Schedule,,308.84,,,308.84,Fee Schedule,,1354.81,,,1354.81,Fee Schedule,,1218.56,,,1218.56,Fee Schedule,,1151.72,,,1151.72,Fee Schedule,,1266.71,,,1266.71,Other,110% of Medicare,407.84,,,407.84,Fee Schedule,,547,,,547,Other,186% of Medicaid,479.94,,,479.94,Fee Schedule,,1586.58,,,1586.58,Fee Schedule,,225.98,,,225.98,Fee Schedule,,479.94,,,479.94,Fee Schedule,,1586.58,,,1586.58,Fee Schedule,,425.06,,,425.06,Fee Schedule,,1791.3,70,,1791.3,percent of total billed charges,All Other,493.64,,,493.64,Fee Schedule,,418.39,,,418.39,Fee Schedule,,291.55,,,291.55,Fee Schedule,,291.55,,,291.55,Fee Schedule,,291.55,,,291.55,Fee Schedule,,291.55,,,291.55,Fee Schedule,,293.99,,,293.99,Other,100% of Medicaid,293.99,,,293.99,Other,100% of Medicaid,293.99,,,293.99,Other,100% of Medicaid,293.99,,,293.99,Other,100% of Medicaid,661.49,,,661.49,Other,225% of Medicaid,449.81,,,449.81,Other,153% of Medicaid,661.49,,,661.49,Other,225% of Medicaid,411.59,,,411.59,Other,140% of Medicaid,661.49,,,661.49,Other,225% of Medicaid,764.39,,,764.39,Other,260% of Medicaid,952.54,,,952.54,Other,324% of Medicaid,632.09,,,632.09,Other,215% of Medicaid,632.09,,,632.09,Other,215% of Medicaid,367.49,,,367.49,Other,125% of Medicaid,225.98,1893.67,
CT HEAD BRAIN W AND WO CONTRAST,70470,CPT,TC,46070470,CDM,351,RC,,,both,,,3156,2335.45,,,2335.45,Other,150% of Medicare + 9.63% HCRA Surcharge,1420.2,45,,1420.2,percent of total billed charges,Critical Access Hospital RCC factor,410.46,,,410.46,Fee Schedule,,369.28,,,369.28,Fee Schedule,,1668.27,,,1668.27,Fee Schedule,,1500.49,,,1500.49,Fee Schedule,,1418.19,,,1418.19,Fee Schedule,,1562.22,,,1562.22,Other,110% of Medicare,487.66,,,487.66,Fee Schedule,,547,,,547,Other,186% of Medicaid,573.87,,,573.87,Fee Schedule,,1956.72,,,1956.72,Fee Schedule,,270.21,,,270.21,Fee Schedule,,573.87,,,573.87,Fee Schedule,,1956.72,,,1956.72,Fee Schedule,,508.25,,,508.25,Fee Schedule,,2209.2,70,,2209.2,percent of total billed charges,All Other,592.04,,,592.04,Fee Schedule,,501.79,,,501.79,Fee Schedule,,291.55,,,291.55,Fee Schedule,,291.55,,,291.55,Fee Schedule,,291.55,,,291.55,Fee Schedule,,291.55,,,291.55,Fee Schedule,,293.99,,,293.99,Other,100% of Medicaid,293.99,,,293.99,Other,100% of Medicaid,293.99,,,293.99,Other,100% of Medicaid,293.99,,,293.99,Other,100% of Medicaid,661.49,,,661.49,Other,225% of Medicaid,449.81,,,449.81,Other,153% of Medicaid,661.49,,,661.49,Other,225% of Medicaid,411.59,,,411.59,Other,140% of Medicaid,661.49,,,661.49,Other,225% of Medicaid,764.39,,,764.39,Other,260% of Medicaid,952.54,,,952.54,Other,324% of Medicaid,632.09,,,632.09,Other,215% of Medicaid,632.09,,,632.09,Other,215% of Medicaid,367.49,,,367.49,Other,125% of Medicaid,270.21,2335.45,
CT ORBITS WO CONTRAST,70480,CPT,TC,46070480,CDM,351,RC,,,both,,,2134,1579.17,,,1579.17,Other,150% of Medicare + 9.63% HCRA Surcharge,960.3,45,,960.3,percent of total billed charges,Critical Access Hospital RCC factor,356.16,,,356.16,Fee Schedule,,320.44,,,320.44,Fee Schedule,,1306.75,,,1306.75,Fee Schedule,,1175.33,,,1175.33,Fee Schedule,,1110.86,,,1110.86,Fee Schedule,,1056.33,,,1056.33,Other,110% of Medicare,423.15,,,423.15,Fee Schedule,,458,,,458,Other,186% of Medicaid,497.96,,,497.96,Fee Schedule,,1323.08,,,1323.08,Fee Schedule,,234.47,,,234.47,Fee Schedule,,497.96,,,497.96,Fee Schedule,,1323.08,,,1323.08,Fee Schedule,,441.02,,,441.02,Fee Schedule,,1493.8,70,,1493.8,percent of total billed charges,All Other,510.04,,,510.04,Fee Schedule,,432.29,,,432.29,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,246,,,246,Other,100% of Medicaid,246,,,246,Other,100% of Medicaid,246,,,246,Other,100% of Medicaid,246,,,246,Other,100% of Medicaid,553.49,,,553.49,Other,225% of Medicaid,376.37,,,376.37,Other,153% of Medicaid,553.49,,,553.49,Other,225% of Medicaid,344.39,,,344.39,Other,140% of Medicaid,553.49,,,553.49,Other,225% of Medicaid,639.59,,,639.59,Other,260% of Medicaid,797.03,,,797.03,Other,324% of Medicaid,528.89,,,528.89,Other,215% of Medicaid,528.89,,,528.89,Other,215% of Medicaid,307.5,,,307.5,Other,125% of Medicaid,179.33,1579.17,
CT ORBITS W CONTRAST,70481,CPT,TC,46070481,CDM,351,RC,,,both,,,2559,1893.67,,,1893.67,Other,150% of Medicare + 9.63% HCRA Surcharge,1151.55,45,,1151.55,percent of total billed charges,Critical Access Hospital RCC factor,458.98,,,458.98,Fee Schedule,,412.94,,,412.94,Fee Schedule,,2006.97,,,2006.97,Fee Schedule,,1805.13,,,1805.13,Fee Schedule,,1706.12,,,1706.12,Fee Schedule,,1266.71,,,1266.71,Other,110% of Medicare,545.31,,,545.31,Fee Schedule,,547,,,547,Other,186% of Medicaid,641.7,,,641.7,Fee Schedule,,1586.58,,,1586.58,Fee Schedule,,302.15,,,302.15,Fee Schedule,,641.7,,,641.7,Fee Schedule,,1586.58,,,1586.58,Fee Schedule,,568.33,,,568.33,Fee Schedule,,1791.3,70,,1791.3,percent of total billed charges,All Other,662.56,,,662.56,Fee Schedule,,561.56,,,561.56,Fee Schedule,,291.55,,,291.55,Fee Schedule,,291.55,,,291.55,Fee Schedule,,291.55,,,291.55,Fee Schedule,,291.55,,,291.55,Fee Schedule,,293.99,,,293.99,Other,100% of Medicaid,293.99,,,293.99,Other,100% of Medicaid,293.99,,,293.99,Other,100% of Medicaid,293.99,,,293.99,Other,100% of Medicaid,661.49,,,661.49,Other,225% of Medicaid,449.81,,,449.81,Other,153% of Medicaid,661.49,,,661.49,Other,225% of Medicaid,411.59,,,411.59,Other,140% of Medicaid,661.49,,,661.49,Other,225% of Medicaid,764.39,,,764.39,Other,260% of Medicaid,952.54,,,952.54,Other,324% of Medicaid,632.09,,,632.09,Other,215% of Medicaid,632.09,,,632.09,Other,215% of Medicaid,367.49,,,367.49,Other,125% of Medicaid,291.55,2006.97,
CT ORBITS W AND WO CONTRAST,70482,CPT,TC,46070482,CDM,351,RC,,,both,,,2084,1542.17,,,1542.17,Other,150% of Medicare + 9.63% HCRA Surcharge,937.8,45,,937.8,percent of total billed charges,Critical Access Hospital RCC factor,544.47,,,544.47,Fee Schedule,,489.85,,,489.85,Fee Schedule,,2251.82,,,2251.82,Fee Schedule,,2025.35,,,2025.35,Fee Schedule,,1914.26,,,1914.26,Fee Schedule,,1031.58,,,1031.58,Other,110% of Medicare,646.88,,,646.88,Fee Schedule,,547,,,547,Other,186% of Medicaid,761.23,,,761.23,Fee Schedule,,1292.08,,,1292.08,Fee Schedule,,358.43,,,358.43,Fee Schedule,,761.23,,,761.23,Fee Schedule,,1292.08,,,1292.08,Fee Schedule,,674.19,,,674.19,Fee Schedule,,1458.8,70,,1458.8,percent of total billed charges,All Other,790.48,,,790.48,Fee Schedule,,669.98,,,669.98,Fee Schedule,,291.55,,,291.55,Fee Schedule,,291.55,,,291.55,Fee Schedule,,291.55,,,291.55,Fee Schedule,,291.55,,,291.55,Fee Schedule,,293.99,,,293.99,Other,100% of Medicaid,293.99,,,293.99,Other,100% of Medicaid,293.99,,,293.99,Other,100% of Medicaid,293.99,,,293.99,Other,100% of Medicaid,661.49,,,661.49,Other,225% of Medicaid,449.81,,,449.81,Other,153% of Medicaid,661.49,,,661.49,Other,225% of Medicaid,411.59,,,411.59,Other,140% of Medicaid,661.49,,,661.49,Other,225% of Medicaid,764.39,,,764.39,Other,260% of Medicaid,952.54,,,952.54,Other,324% of Medicaid,632.09,,,632.09,Other,215% of Medicaid,632.09,,,632.09,Other,215% of Medicaid,367.49,,,367.49,Other,125% of Medicaid,291.55,2251.82,
CT MAXILLOFACIAL WO CONTRAST,70486,CPT,TC,46070486,CDM,351,RC,,,both,,,2134,1579.17,,,1579.17,Other,150% of Medicare + 9.63% HCRA Surcharge,960.3,45,,960.3,percent of total billed charges,Critical Access Hospital RCC factor,316.7,,,316.7,Fee Schedule,,284.93,,,284.93,Fee Schedule,,1306.75,,,1306.75,Fee Schedule,,1175.33,,,1175.33,Fee Schedule,,1110.86,,,1110.86,Fee Schedule,,1056.33,,,1056.33,Other,110% of Medicare,376.27,,,376.27,Fee Schedule,,458,,,458,Other,186% of Medicaid,442.79,,,442.79,Fee Schedule,,1323.08,,,1323.08,Fee Schedule,,208.49,,,208.49,Fee Schedule,,442.79,,,442.79,Fee Schedule,,1323.08,,,1323.08,Fee Schedule,,392.16,,,392.16,Fee Schedule,,1493.8,70,,1493.8,percent of total billed charges,All Other,452.64,,,452.64,Fee Schedule,,383.64,,,383.64,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,246,,,246,Other,100% of Medicaid,246,,,246,Other,100% of Medicaid,246,,,246,Other,100% of Medicaid,246,,,246,Other,100% of Medicaid,553.49,,,553.49,Other,225% of Medicaid,376.37,,,376.37,Other,153% of Medicaid,553.49,,,553.49,Other,225% of Medicaid,344.39,,,344.39,Other,140% of Medicaid,553.49,,,553.49,Other,225% of Medicaid,639.59,,,639.59,Other,260% of Medicaid,797.03,,,797.03,Other,324% of Medicaid,528.89,,,528.89,Other,215% of Medicaid,528.89,,,528.89,Other,215% of Medicaid,307.5,,,307.5,Other,125% of Medicaid,179.33,1579.17,
CT MAXILLOFACIAL W CONTRAST,70487,CPT,TC,46070487,CDM,351,RC,,,both,,,2559,1893.67,,,1893.67,Other,150% of Medicare + 9.63% HCRA Surcharge,1151.55,45,,1151.55,percent of total billed charges,Critical Access Hospital RCC factor,358.46,,,358.46,Fee Schedule,,322.5,,,322.5,Fee Schedule,,1700.31,,,1700.31,Fee Schedule,,1529.31,,,1529.31,Fee Schedule,,1445.43,,,1445.43,Fee Schedule,,1266.71,,,1266.71,Other,110% of Medicare,425.88,,,425.88,Fee Schedule,,547,,,547,Other,186% of Medicaid,501.17,,,501.17,Fee Schedule,,1586.58,,,1586.58,Fee Schedule,,235.98,,,235.98,Fee Schedule,,501.17,,,501.17,Fee Schedule,,1586.58,,,1586.58,Fee Schedule,,443.86,,,443.86,Fee Schedule,,1791.3,70,,1791.3,percent of total billed charges,All Other,514.96,,,514.96,Fee Schedule,,436.46,,,436.46,Fee Schedule,,291.55,,,291.55,Fee Schedule,,291.55,,,291.55,Fee Schedule,,291.55,,,291.55,Fee Schedule,,291.55,,,291.55,Fee Schedule,,293.99,,,293.99,Other,100% of Medicaid,293.99,,,293.99,Other,100% of Medicaid,293.99,,,293.99,Other,100% of Medicaid,293.99,,,293.99,Other,100% of Medicaid,661.49,,,661.49,Other,225% of Medicaid,449.81,,,449.81,Other,153% of Medicaid,661.49,,,661.49,Other,225% of Medicaid,411.59,,,411.59,Other,140% of Medicaid,661.49,,,661.49,Other,225% of Medicaid,764.39,,,764.39,Other,260% of Medicaid,952.54,,,952.54,Other,324% of Medicaid,632.09,,,632.09,Other,215% of Medicaid,632.09,,,632.09,Other,215% of Medicaid,367.49,,,367.49,Other,125% of Medicaid,235.98,1893.67,
CT MAXILLOFACIAL W AND WO CONTRAST,70488,CPT,TC,46070488,CDM,351,RC,,,both,,,2163,1600.63,,,1600.63,Other,150% of Medicare + 9.63% HCRA Surcharge,973.35,45,,973.35,percent of total billed charges,Critical Access Hospital RCC factor,449.73,,,449.73,Fee Schedule,,404.61,,,404.61,Fee Schedule,,2121.39,,,2121.39,Fee Schedule,,1908.04,,,1908.04,Fee Schedule,,1803.38,,,1803.38,Fee Schedule,,1070.69,,,1070.69,Other,110% of Medicare,534.31,,,534.31,Fee Schedule,,547,,,547,Other,186% of Medicaid,628.77,,,628.77,Fee Schedule,,1341.06,,,1341.06,Fee Schedule,,296.06,,,296.06,Fee Schedule,,628.77,,,628.77,Fee Schedule,,1341.06,,,1341.06,Fee Schedule,,556.87,,,556.87,Fee Schedule,,1514.1,70,,1514.1,percent of total billed charges,All Other,652.72,,,652.72,Fee Schedule,,553.22,,,553.22,Fee Schedule,,291.55,,,291.55,Fee Schedule,,291.55,,,291.55,Fee Schedule,,291.55,,,291.55,Fee Schedule,,291.55,,,291.55,Fee Schedule,,293.99,,,293.99,Other,100% of Medicaid,293.99,,,293.99,Other,100% of Medicaid,293.99,,,293.99,Other,100% of Medicaid,293.99,,,293.99,Other,100% of Medicaid,661.49,,,661.49,Other,225% of Medicaid,449.81,,,449.81,Other,153% of Medicaid,661.49,,,661.49,Other,225% of Medicaid,411.59,,,411.59,Other,140% of Medicaid,661.49,,,661.49,Other,225% of Medicaid,764.39,,,764.39,Other,260% of Medicaid,952.54,,,952.54,Other,324% of Medicaid,632.09,,,632.09,Other,215% of Medicaid,632.09,,,632.09,Other,215% of Medicaid,367.49,,,367.49,Other,125% of Medicaid,291.55,2121.39,
CT NECK SOFT TISSUE W CONTRAST,70491,CPT,TC,46070491,CDM,351,RC,,,both,,,2559,1893.67,,,1893.67,Other,150% of Medicare + 9.63% HCRA Surcharge,1151.55,45,,1151.55,percent of total billed charges,Critical Access Hospital RCC factor,431.26,,,431.26,Fee Schedule,,388,,,388,Fee Schedule,,1631.7,,,1631.7,Fee Schedule,,1467.6,,,1467.6,Fee Schedule,,1387.1,,,1387.1,Fee Schedule,,1266.71,,,1266.71,Other,110% of Medicare,512.37,,,512.37,Fee Schedule,,547,,,547,Other,186% of Medicaid,602.95,,,602.95,Fee Schedule,,1586.58,,,1586.58,Fee Schedule,,283.9,,,283.9,Fee Schedule,,602.95,,,602.95,Fee Schedule,,1586.58,,,1586.58,Fee Schedule,,534,,,534,Fee Schedule,,1791.3,70,,1791.3,percent of total billed charges,All Other,623.2,,,623.2,Fee Schedule,,528.2,,,528.2,Fee Schedule,,291.55,,,291.55,Fee Schedule,,291.55,,,291.55,Fee Schedule,,291.55,,,291.55,Fee Schedule,,291.55,,,291.55,Fee Schedule,,293.99,,,293.99,Other,100% of Medicaid,293.99,,,293.99,Other,100% of Medicaid,293.99,,,293.99,Other,100% of Medicaid,293.99,,,293.99,Other,100% of Medicaid,661.49,,,661.49,Other,225% of Medicaid,449.81,,,449.81,Other,153% of Medicaid,661.49,,,661.49,Other,225% of Medicaid,411.59,,,411.59,Other,140% of Medicaid,661.49,,,661.49,Other,225% of Medicaid,764.39,,,764.39,Other,260% of Medicaid,952.54,,,952.54,Other,324% of Medicaid,632.09,,,632.09,Other,215% of Medicaid,632.09,,,632.09,Other,215% of Medicaid,367.49,,,367.49,Other,125% of Medicaid,283.9,1893.67,
CT NECK SOFT TISSUE W AND WO CONTRAST,70492,CPT,TC,46070492,CDM,351,RC,,,both,,,2085,1542.91,,,1542.91,Other,150% of Medicare + 9.63% HCRA Surcharge,938.25,45,,938.25,percent of total billed charges,Critical Access Hospital RCC factor,524.82,,,524.82,Fee Schedule,,472.17,,,472.17,Fee Schedule,,2043.6,,,2043.6,Fee Schedule,,1838.08,,,1838.08,Fee Schedule,,1737.25,,,1737.25,Fee Schedule,,1032.08,,,1032.08,Other,110% of Medicare,623.53,,,623.53,Fee Schedule,,547,,,547,Other,186% of Medicaid,733.76,,,733.76,Fee Schedule,,1292.7,,,1292.7,Fee Schedule,,345.49,,,345.49,Fee Schedule,,733.76,,,733.76,Fee Schedule,,1292.7,,,1292.7,Fee Schedule,,649.85,,,649.85,Fee Schedule,,1459.5,70,,1459.5,percent of total billed charges,All Other,760.96,,,760.96,Fee Schedule,,644.96,,,644.96,Fee Schedule,,291.55,,,291.55,Fee Schedule,,291.55,,,291.55,Fee Schedule,,291.55,,,291.55,Fee Schedule,,291.55,,,291.55,Fee Schedule,,293.99,,,293.99,Other,100% of Medicaid,293.99,,,293.99,Other,100% of Medicaid,293.99,,,293.99,Other,100% of Medicaid,293.99,,,293.99,Other,100% of Medicaid,661.49,,,661.49,Other,225% of Medicaid,449.81,,,449.81,Other,153% of Medicaid,661.49,,,661.49,Other,225% of Medicaid,411.59,,,411.59,Other,140% of Medicaid,661.49,,,661.49,Other,225% of Medicaid,764.39,,,764.39,Other,260% of Medicaid,952.54,,,952.54,Other,324% of Medicaid,632.09,,,632.09,Other,215% of Medicaid,632.09,,,632.09,Other,215% of Medicaid,367.49,,,367.49,Other,125% of Medicaid,291.55,2043.6,
CT ORBITS W CONTRAST W 59 MOD,70481,CPT,59,46170481,CDM,351,RC,,,both,,,2559,1893.67,,,1893.67,Other,150% of Medicare + 9.63% HCRA Surcharge,1151.55,45,,1151.55,percent of total billed charges,Critical Access Hospital RCC factor,458.98,,,458.98,Fee Schedule,,412.94,,,412.94,Fee Schedule,,2006.97,,,2006.97,Fee Schedule,,1805.13,,,1805.13,Fee Schedule,,1706.12,,,1706.12,Fee Schedule,,1266.71,,,1266.71,Other,110% of Medicare,545.31,,,545.31,Fee Schedule,,547,,,547,Other,186% of Medicaid,641.7,,,641.7,Fee Schedule,,1586.58,,,1586.58,Fee Schedule,,302.15,,,302.15,Fee Schedule,,641.7,,,641.7,Fee Schedule,,1586.58,,,1586.58,Fee Schedule,,568.33,,,568.33,Fee Schedule,,1791.3,70,,1791.3,percent of total billed charges,All Other,662.56,,,662.56,Fee Schedule,,561.56,,,561.56,Fee Schedule,,291.55,,,291.55,Fee Schedule,,291.55,,,291.55,Fee Schedule,,291.55,,,291.55,Fee Schedule,,291.55,,,291.55,Fee Schedule,,293.99,,,293.99,Other,100% of Medicaid,293.99,,,293.99,Other,100% of Medicaid,293.99,,,293.99,Other,100% of Medicaid,293.99,,,293.99,Other,100% of Medicaid,661.49,,,661.49,Other,225% of Medicaid,449.81,,,449.81,Other,153% of Medicaid,661.49,,,661.49,Other,225% of Medicaid,411.59,,,411.59,Other,140% of Medicaid,661.49,,,661.49,Other,225% of Medicaid,764.39,,,764.39,Other,260% of Medicaid,952.54,,,952.54,Other,324% of Medicaid,632.09,,,632.09,Other,215% of Medicaid,632.09,,,632.09,Other,215% of Medicaid,367.49,,,367.49,Other,125% of Medicaid,291.55,2006.97,
CT CHEST WO CONTRAST,71250,CPT,TC,46071250,CDM,352,RC,,,both,,,2134,1579.17,,,1579.17,Other,150% of Medicare + 9.63% HCRA Surcharge,960.3,45,,960.3,percent of total billed charges,Critical Access Hospital RCC factor,297.08,,,297.08,Fee Schedule,,267.28,,,267.28,Fee Schedule,,1306.75,,,1306.75,Fee Schedule,,1175.33,,,1175.33,Fee Schedule,,1110.86,,,1110.86,Fee Schedule,,1056.33,,,1056.33,Other,110% of Medicare,352.96,,,352.96,Fee Schedule,,458,,,458,Other,186% of Medicaid,415.36,,,415.36,Fee Schedule,,1323.08,,,1323.08,Fee Schedule,,195.57,,,195.57,Fee Schedule,,415.36,,,415.36,Fee Schedule,,1323.08,,,1323.08,Fee Schedule,,367.86,,,367.86,Fee Schedule,,1493.8,70,,1493.8,percent of total billed charges,All Other,424.76,,,424.76,Fee Schedule,,360.01,,,360.01,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,246,,,246,Other,100% of Medicaid,246,,,246,Other,100% of Medicaid,246,,,246,Other,100% of Medicaid,246,,,246,Other,100% of Medicaid,553.49,,,553.49,Other,225% of Medicaid,376.37,,,376.37,Other,153% of Medicaid,553.49,,,553.49,Other,225% of Medicaid,344.39,,,344.39,Other,140% of Medicaid,553.49,,,553.49,Other,225% of Medicaid,639.59,,,639.59,Other,260% of Medicaid,797.03,,,797.03,Other,324% of Medicaid,528.89,,,528.89,Other,215% of Medicaid,528.89,,,528.89,Other,215% of Medicaid,307.5,,,307.5,Other,125% of Medicaid,179.33,1579.17,
CT CHEST W CONTRAST,71260,CPT,TC,46071260,CDM,352,RC,,,both,,,2134,1579.17,,,1579.17,Other,150% of Medicare + 9.63% HCRA Surcharge,960.3,45,,960.3,percent of total billed charges,Critical Access Hospital RCC factor,404.68,,,404.68,Fee Schedule,,364.09,,,364.09,Fee Schedule,,1684.29,,,1684.29,Fee Schedule,,1514.9,,,1514.9,Fee Schedule,,1431.81,,,1431.81,Fee Schedule,,1056.33,,,1056.33,Other,110% of Medicare,480.8,,,480.8,Fee Schedule,,547,,,547,Other,186% of Medicaid,565.8,,,565.8,Fee Schedule,,1323.08,,,1323.08,Fee Schedule,,266.41,,,266.41,Fee Schedule,,565.8,,,565.8,Fee Schedule,,1323.08,,,1323.08,Fee Schedule,,501.1,,,501.1,Fee Schedule,,1493.8,70,,1493.8,percent of total billed charges,All Other,580.56,,,580.56,Fee Schedule,,492.06,,,492.06,Fee Schedule,,291.55,,,291.55,Fee Schedule,,291.55,,,291.55,Fee Schedule,,291.55,,,291.55,Fee Schedule,,291.55,,,291.55,Fee Schedule,,293.99,,,293.99,Other,100% of Medicaid,293.99,,,293.99,Other,100% of Medicaid,293.99,,,293.99,Other,100% of Medicaid,293.99,,,293.99,Other,100% of Medicaid,661.49,,,661.49,Other,225% of Medicaid,449.81,,,449.81,Other,153% of Medicaid,661.49,,,661.49,Other,225% of Medicaid,411.59,,,411.59,Other,140% of Medicaid,661.49,,,661.49,Other,225% of Medicaid,764.39,,,764.39,Other,260% of Medicaid,952.54,,,952.54,Other,324% of Medicaid,632.09,,,632.09,Other,215% of Medicaid,632.09,,,632.09,Other,215% of Medicaid,367.49,,,367.49,Other,125% of Medicaid,266.41,1684.29,
CT CHEST W AND WO CONTRAST,71270,CPT,TC,46071270,CDM,352,RC,,,both,,,3156,2335.45,,,2335.45,Other,150% of Medicare + 9.63% HCRA Surcharge,1420.2,45,,1420.2,percent of total billed charges,Critical Access Hospital RCC factor,495.95,,,495.95,Fee Schedule,,446.2,,,446.2,Fee Schedule,,2119.12,,,2119.12,Fee Schedule,,1906,,,1906,Fee Schedule,,1801.45,,,1801.45,Fee Schedule,,1562.22,,,1562.22,Other,110% of Medicare,589.23,,,589.23,Fee Schedule,,547,,,547,Other,186% of Medicaid,693.4,,,693.4,Fee Schedule,,1956.72,,,1956.72,Fee Schedule,,326.49,,,326.49,Fee Schedule,,693.4,,,693.4,Fee Schedule,,1956.72,,,1956.72,Fee Schedule,,614.11,,,614.11,Fee Schedule,,2209.2,70,,2209.2,percent of total billed charges,All Other,718.32,,,718.32,Fee Schedule,,608.82,,,608.82,Fee Schedule,,291.55,,,291.55,Fee Schedule,,291.55,,,291.55,Fee Schedule,,291.55,,,291.55,Fee Schedule,,291.55,,,291.55,Fee Schedule,,293.99,,,293.99,Other,100% of Medicaid,293.99,,,293.99,Other,100% of Medicaid,293.99,,,293.99,Other,100% of Medicaid,293.99,,,293.99,Other,100% of Medicaid,661.49,,,661.49,Other,225% of Medicaid,449.81,,,449.81,Other,153% of Medicaid,661.49,,,661.49,Other,225% of Medicaid,411.59,,,411.59,Other,140% of Medicaid,661.49,,,661.49,Other,225% of Medicaid,764.39,,,764.39,Other,260% of Medicaid,952.54,,,952.54,Other,324% of Medicaid,632.09,,,632.09,Other,215% of Medicaid,632.09,,,632.09,Other,215% of Medicaid,367.49,,,367.49,Other,125% of Medicaid,291.55,2335.45,
CT THORAX LUNG CANCER SCR C-,71271,CPT,,46071271,CDM,352,RC,,,both,,,1329,983.46,,,983.46,Other,150% of Medicare + 9.63% HCRA Surcharge,598.05,45,,598.05,percent of total billed charges,Critical Access Hospital RCC factor,313.42,,,313.42,Fee Schedule,,281.98,,,281.98,Fee Schedule,,96,,,96,Fee Schedule,,96,,,96,Fee Schedule,,96,,,96,Fee Schedule,,657.86,,,657.86,Other,110% of Medicare,372.37,,,372.37,Fee Schedule,,458,,,458,Other,186% of Medicaid,438.2,,,438.2,Fee Schedule,,823.98,,,823.98,Fee Schedule,,206.33,,,206.33,Fee Schedule,,438.2,,,438.2,Fee Schedule,,823.98,,,823.98,Fee Schedule,,388.09,,,388.09,Fee Schedule,,930.3,70,,930.3,percent of total billed charges,All Other,447.72,,,447.72,Fee Schedule,,379.47,,,379.47,Fee Schedule,,129.44,,,129.44,Fee Schedule,,129.44,,,129.44,Fee Schedule,,129.44,,,129.44,Fee Schedule,,129.44,,,129.44,Fee Schedule,,246,,,246,Other,100% of Medicaid,246,,,246,Other,100% of Medicaid,246,,,246,Other,100% of Medicaid,246,,,246,Other,100% of Medicaid,553.49,,,553.49,Other,225% of Medicaid,376.37,,,376.37,Other,153% of Medicaid,553.49,,,553.49,Other,225% of Medicaid,344.39,,,344.39,Other,140% of Medicaid,553.49,,,553.49,Other,225% of Medicaid,639.59,,,639.59,Other,260% of Medicaid,797.03,,,797.03,Other,324% of Medicaid,528.89,,,528.89,Other,215% of Medicaid,528.89,,,528.89,Other,215% of Medicaid,307.5,,,307.5,Other,125% of Medicaid,96,983.46,
CT CERV SPINE WO CONTRAST,72125,CPT,TC,46072125,CDM,352,RC,,,both,,,2134,1579.17,,,1579.17,Other,150% of Medicare + 9.63% HCRA Surcharge,960.3,45,,960.3,percent of total billed charges,Critical Access Hospital RCC factor,300.53,,,300.53,Fee Schedule,,270.38,,,270.38,Fee Schedule,,1306.75,,,1306.75,Fee Schedule,,1175.33,,,1175.33,Fee Schedule,,1110.86,,,1110.86,Fee Schedule,,1056.33,,,1056.33,Other,110% of Medicare,357.06,,,357.06,Fee Schedule,,458,,,458,Other,186% of Medicaid,420.18,,,420.18,Fee Schedule,,1323.08,,,1323.08,Fee Schedule,,197.84,,,197.84,Fee Schedule,,420.18,,,420.18,Fee Schedule,,1323.08,,,1323.08,Fee Schedule,,372.13,,,372.13,Fee Schedule,,1493.8,70,,1493.8,percent of total billed charges,All Other,429.68,,,429.68,Fee Schedule,,364.18,,,364.18,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,246,,,246,Other,100% of Medicaid,246,,,246,Other,100% of Medicaid,246,,,246,Other,100% of Medicaid,246,,,246,Other,100% of Medicaid,553.49,,,553.49,Other,225% of Medicaid,376.37,,,376.37,Other,153% of Medicaid,553.49,,,553.49,Other,225% of Medicaid,344.39,,,344.39,Other,140% of Medicaid,553.49,,,553.49,Other,225% of Medicaid,639.59,,,639.59,Other,260% of Medicaid,797.03,,,797.03,Other,324% of Medicaid,528.89,,,528.89,Other,215% of Medicaid,528.89,,,528.89,Other,215% of Medicaid,307.5,,,307.5,Other,125% of Medicaid,179.33,1579.17,
CT CERV SPINE W CONTRAST,72126,CPT,TC,46072126,CDM,352,RC,,,both,,,2559,1893.67,,,1893.67,Other,150% of Medicare + 9.63% HCRA Surcharge,1151.55,45,,1151.55,percent of total billed charges,Critical Access Hospital RCC factor,402.39,,,402.39,Fee Schedule,,362.02,,,362.02,Fee Schedule,,1688.88,,,1688.88,Fee Schedule,,1519.03,,,1519.03,Fee Schedule,,1435.71,,,1435.71,Fee Schedule,,1266.71,,,1266.71,Other,110% of Medicare,478.07,,,478.07,Fee Schedule,,547,,,547,Other,186% of Medicaid,562.58,,,562.58,Fee Schedule,,1586.58,,,1586.58,Fee Schedule,,264.89,,,264.89,Fee Schedule,,562.58,,,562.58,Fee Schedule,,1586.58,,,1586.58,Fee Schedule,,498.25,,,498.25,Fee Schedule,,1791.3,70,,1791.3,percent of total billed charges,All Other,578.92,,,578.92,Fee Schedule,,490.67,,,490.67,Fee Schedule,,610.96,,,610.96,Fee Schedule,,610.96,,,610.96,Fee Schedule,,610.96,,,610.96,Fee Schedule,,610.96,,,610.96,Fee Schedule,,293.99,,,293.99,Other,100% of Medicaid,293.99,,,293.99,Other,100% of Medicaid,293.99,,,293.99,Other,100% of Medicaid,293.99,,,293.99,Other,100% of Medicaid,661.49,,,661.49,Other,225% of Medicaid,449.81,,,449.81,Other,153% of Medicaid,661.49,,,661.49,Other,225% of Medicaid,411.59,,,411.59,Other,140% of Medicaid,661.49,,,661.49,Other,225% of Medicaid,764.39,,,764.39,Other,260% of Medicaid,952.54,,,952.54,Other,324% of Medicaid,632.09,,,632.09,Other,215% of Medicaid,632.09,,,632.09,Other,215% of Medicaid,367.49,,,367.49,Other,125% of Medicaid,264.89,1893.67,
CT CERV SPINE W AND WO CONTRAST,72127,CPT,TC,46072127,CDM,352,RC,,,both,,,2895,2142.31,,,2142.31,Other,150% of Medicare + 9.63% HCRA Surcharge,1302.75,45,,1302.75,percent of total billed charges,Critical Access Hospital RCC factor,497.1,,,497.1,Fee Schedule,,447.23,,,447.23,Fee Schedule,,2116.8,,,2116.8,Fee Schedule,,1903.92,,,1903.92,Fee Schedule,,1799.48,,,1799.48,Fee Schedule,,1433.03,,,1433.03,Other,110% of Medicare,590.6,,,590.6,Fee Schedule,,547,,,547,Other,186% of Medicaid,695,,,695,Fee Schedule,,1794.9,,,1794.9,Fee Schedule,,327.24,,,327.24,Fee Schedule,,695,,,695,Fee Schedule,,1794.9,,,1794.9,Fee Schedule,,615.53,,,615.53,Fee Schedule,,2026.5,70,,2026.5,percent of total billed charges,All Other,718.32,,,718.32,Fee Schedule,,608.82,,,608.82,Fee Schedule,,291.55,,,291.55,Fee Schedule,,291.55,,,291.55,Fee Schedule,,291.55,,,291.55,Fee Schedule,,291.55,,,291.55,Fee Schedule,,293.99,,,293.99,Other,100% of Medicaid,293.99,,,293.99,Other,100% of Medicaid,293.99,,,293.99,Other,100% of Medicaid,293.99,,,293.99,Other,100% of Medicaid,661.49,,,661.49,Other,225% of Medicaid,449.81,,,449.81,Other,153% of Medicaid,661.49,,,661.49,Other,225% of Medicaid,411.59,,,411.59,Other,140% of Medicaid,661.49,,,661.49,Other,225% of Medicaid,764.39,,,764.39,Other,260% of Medicaid,952.54,,,952.54,Other,324% of Medicaid,632.09,,,632.09,Other,215% of Medicaid,632.09,,,632.09,Other,215% of Medicaid,367.49,,,367.49,Other,125% of Medicaid,291.55,2142.31,
CT T SPINE WO CONTRAST,72128,CPT,TC,46072128,CDM,352,RC,,,both,,,2134,1579.17,,,1579.17,Other,150% of Medicare + 9.63% HCRA Surcharge,960.3,45,,960.3,percent of total billed charges,Critical Access Hospital RCC factor,299.38,,,299.38,Fee Schedule,,269.35,,,269.35,Fee Schedule,,1306.75,,,1306.75,Fee Schedule,,1175.33,,,1175.33,Fee Schedule,,1110.86,,,1110.86,Fee Schedule,,1056.33,,,1056.33,Other,110% of Medicare,355.69,,,355.69,Fee Schedule,,458,,,458,Other,186% of Medicaid,418.57,,,418.57,Fee Schedule,,1323.08,,,1323.08,Fee Schedule,,197.09,,,197.09,Fee Schedule,,418.57,,,418.57,Fee Schedule,,1323.08,,,1323.08,Fee Schedule,,370.71,,,370.71,Fee Schedule,,1493.8,70,,1493.8,percent of total billed charges,All Other,428.04,,,428.04,Fee Schedule,,362.79,,,362.79,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,246,,,246,Other,100% of Medicaid,246,,,246,Other,100% of Medicaid,246,,,246,Other,100% of Medicaid,246,,,246,Other,100% of Medicaid,553.49,,,553.49,Other,225% of Medicaid,376.37,,,376.37,Other,153% of Medicaid,553.49,,,553.49,Other,225% of Medicaid,344.39,,,344.39,Other,140% of Medicaid,553.49,,,553.49,Other,225% of Medicaid,639.59,,,639.59,Other,260% of Medicaid,797.03,,,797.03,Other,324% of Medicaid,528.89,,,528.89,Other,215% of Medicaid,528.89,,,528.89,Other,215% of Medicaid,307.5,,,307.5,Other,125% of Medicaid,179.33,1579.17,
CT T SPINE W CONTRAST,72129,CPT,TC,46072129,CDM,352,RC,,,both,,,2559,1893.67,,,1893.67,Other,150% of Medicare + 9.63% HCRA Surcharge,1151.55,45,,1151.55,percent of total billed charges,Critical Access Hospital RCC factor,405.83,,,405.83,Fee Schedule,,365.12,,,365.12,Fee Schedule,,1691.2,,,1691.2,Fee Schedule,,1521.11,,,1521.11,Fee Schedule,,1437.68,,,1437.68,Fee Schedule,,1266.71,,,1266.71,Other,110% of Medicare,482.16,,,482.16,Fee Schedule,,547,,,547,Other,186% of Medicaid,567.4,,,567.4,Fee Schedule,,1586.58,,,1586.58,Fee Schedule,,267.16,,,267.16,Fee Schedule,,567.4,,,567.4,Fee Schedule,,1586.58,,,1586.58,Fee Schedule,,502.52,,,502.52,Fee Schedule,,1791.3,70,,1791.3,percent of total billed charges,All Other,583.84,,,583.84,Fee Schedule,,494.84,,,494.84,Fee Schedule,,291.55,,,291.55,Fee Schedule,,291.55,,,291.55,Fee Schedule,,291.55,,,291.55,Fee Schedule,,291.55,,,291.55,Fee Schedule,,293.99,,,293.99,Other,100% of Medicaid,293.99,,,293.99,Other,100% of Medicaid,293.99,,,293.99,Other,100% of Medicaid,293.99,,,293.99,Other,100% of Medicaid,661.49,,,661.49,Other,225% of Medicaid,449.81,,,449.81,Other,153% of Medicaid,661.49,,,661.49,Other,225% of Medicaid,411.59,,,411.59,Other,140% of Medicaid,661.49,,,661.49,Other,225% of Medicaid,764.39,,,764.39,Other,260% of Medicaid,952.54,,,952.54,Other,324% of Medicaid,632.09,,,632.09,Other,215% of Medicaid,632.09,,,632.09,Other,215% of Medicaid,367.49,,,367.49,Other,125% of Medicaid,267.16,1893.67,
CT T SPINE W AND WO CONTRAST,72130,CPT,TC,46072130,CDM,352,RC,,,both,,,2895,2142.31,,,2142.31,Other,150% of Medicare + 9.63% HCRA Surcharge,1302.75,45,,1302.75,percent of total billed charges,Critical Access Hospital RCC factor,500.57,,,500.57,Fee Schedule,,450.36,,,450.36,Fee Schedule,,2119.12,,,2119.12,Fee Schedule,,1906,,,1906,Fee Schedule,,1801.45,,,1801.45,Fee Schedule,,1433.03,,,1433.03,Other,110% of Medicare,594.73,,,594.73,Fee Schedule,,547,,,547,Other,186% of Medicaid,699.86,,,699.86,Fee Schedule,,1794.9,,,1794.9,Fee Schedule,,329.53,,,329.53,Fee Schedule,,699.86,,,699.86,Fee Schedule,,1794.9,,,1794.9,Fee Schedule,,619.83,,,619.83,Fee Schedule,,2026.5,70,,2026.5,percent of total billed charges,All Other,723.24,,,723.24,Fee Schedule,,612.99,,,612.99,Fee Schedule,,291.55,,,291.55,Fee Schedule,,291.55,,,291.55,Fee Schedule,,291.55,,,291.55,Fee Schedule,,291.55,,,291.55,Fee Schedule,,293.99,,,293.99,Other,100% of Medicaid,293.99,,,293.99,Other,100% of Medicaid,293.99,,,293.99,Other,100% of Medicaid,293.99,,,293.99,Other,100% of Medicaid,661.49,,,661.49,Other,225% of Medicaid,449.81,,,449.81,Other,153% of Medicaid,661.49,,,661.49,Other,225% of Medicaid,411.59,,,411.59,Other,140% of Medicaid,661.49,,,661.49,Other,225% of Medicaid,764.39,,,764.39,Other,260% of Medicaid,952.54,,,952.54,Other,324% of Medicaid,632.09,,,632.09,Other,215% of Medicaid,632.09,,,632.09,Other,215% of Medicaid,367.49,,,367.49,Other,125% of Medicaid,291.55,2142.31,
CT L SPINE WO CONTRAST,72131,CPT,TC,46072131,CDM,352,RC,,,both,,,2134,1579.17,,,1579.17,Other,150% of Medicare + 9.63% HCRA Surcharge,960.3,45,,960.3,percent of total billed charges,Critical Access Hospital RCC factor,297.08,,,297.08,Fee Schedule,,267.28,,,267.28,Fee Schedule,,1306.75,,,1306.75,Fee Schedule,,1175.33,,,1175.33,Fee Schedule,,1110.86,,,1110.86,Fee Schedule,,1056.33,,,1056.33,Other,110% of Medicare,352.96,,,352.96,Fee Schedule,,458,,,458,Other,186% of Medicaid,415.36,,,415.36,Fee Schedule,,1323.08,,,1323.08,Fee Schedule,,195.57,,,195.57,Fee Schedule,,415.36,,,415.36,Fee Schedule,,1323.08,,,1323.08,Fee Schedule,,367.86,,,367.86,Fee Schedule,,1493.8,70,,1493.8,percent of total billed charges,All Other,426.4,,,426.4,Fee Schedule,,361.4,,,361.4,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,246,,,246,Other,100% of Medicaid,246,,,246,Other,100% of Medicaid,246,,,246,Other,100% of Medicaid,246,,,246,Other,100% of Medicaid,553.49,,,553.49,Other,225% of Medicaid,376.37,,,376.37,Other,153% of Medicaid,553.49,,,553.49,Other,225% of Medicaid,344.39,,,344.39,Other,140% of Medicaid,553.49,,,553.49,Other,225% of Medicaid,639.59,,,639.59,Other,260% of Medicaid,797.03,,,797.03,Other,324% of Medicaid,528.89,,,528.89,Other,215% of Medicaid,528.89,,,528.89,Other,215% of Medicaid,307.5,,,307.5,Other,125% of Medicaid,179.33,1579.17,
CT L SPINE W CONTRAST,72132,CPT,TC,46072132,CDM,352,RC,,,both,,,2559,1893.67,,,1893.67,Other,150% of Medicare + 9.63% HCRA Surcharge,1151.55,45,,1151.55,percent of total billed charges,Critical Access Hospital RCC factor,403.54,,,403.54,Fee Schedule,,363.06,,,363.06,Fee Schedule,,1686.61,,,1686.61,Fee Schedule,,1516.99,,,1516.99,Fee Schedule,,1433.78,,,1433.78,Fee Schedule,,1266.71,,,1266.71,Other,110% of Medicare,479.44,,,479.44,Fee Schedule,,547,,,547,Other,186% of Medicaid,564.19,,,564.19,Fee Schedule,,1586.58,,,1586.58,Fee Schedule,,265.65,,,265.65,Fee Schedule,,564.19,,,564.19,Fee Schedule,,1586.58,,,1586.58,Fee Schedule,,499.68,,,499.68,Fee Schedule,,1791.3,70,,1791.3,percent of total billed charges,All Other,578.92,,,578.92,Fee Schedule,,490.67,,,490.67,Fee Schedule,,610.96,,,610.96,Fee Schedule,,610.96,,,610.96,Fee Schedule,,610.96,,,610.96,Fee Schedule,,610.96,,,610.96,Fee Schedule,,293.99,,,293.99,Other,100% of Medicaid,293.99,,,293.99,Other,100% of Medicaid,293.99,,,293.99,Other,100% of Medicaid,293.99,,,293.99,Other,100% of Medicaid,661.49,,,661.49,Other,225% of Medicaid,449.81,,,449.81,Other,153% of Medicaid,661.49,,,661.49,Other,225% of Medicaid,411.59,,,411.59,Other,140% of Medicaid,661.49,,,661.49,Other,225% of Medicaid,764.39,,,764.39,Other,260% of Medicaid,952.54,,,952.54,Other,324% of Medicaid,632.09,,,632.09,Other,215% of Medicaid,632.09,,,632.09,Other,215% of Medicaid,367.49,,,367.49,Other,125% of Medicaid,265.65,1893.67,
CT L SPINE W AND WO CONTRAST,72133,CPT,TC,46072133,CDM,352,RC,,,both,,,2895,2142.31,,,2142.31,Other,150% of Medicare + 9.63% HCRA Surcharge,1302.75,45,,1302.75,percent of total billed charges,Critical Access Hospital RCC factor,498.25,,,498.25,Fee Schedule,,448.27,,,448.27,Fee Schedule,,2116.8,,,2116.8,Fee Schedule,,1903.92,,,1903.92,Fee Schedule,,1799.48,,,1799.48,Fee Schedule,,1433.03,,,1433.03,Other,110% of Medicare,591.96,,,591.96,Fee Schedule,,547,,,547,Other,186% of Medicaid,696.61,,,696.61,Fee Schedule,,1794.9,,,1794.9,Fee Schedule,,328,,,328,Fee Schedule,,696.61,,,696.61,Fee Schedule,,1794.9,,,1794.9,Fee Schedule,,616.95,,,616.95,Fee Schedule,,2026.5,70,,2026.5,percent of total billed charges,All Other,716.68,,,716.68,Fee Schedule,,607.43,,,607.43,Fee Schedule,,291.55,,,291.55,Fee Schedule,,291.55,,,291.55,Fee Schedule,,291.55,,,291.55,Fee Schedule,,291.55,,,291.55,Fee Schedule,,293.99,,,293.99,Other,100% of Medicaid,293.99,,,293.99,Other,100% of Medicaid,293.99,,,293.99,Other,100% of Medicaid,293.99,,,293.99,Other,100% of Medicaid,661.49,,,661.49,Other,225% of Medicaid,449.81,,,449.81,Other,153% of Medicaid,661.49,,,661.49,Other,225% of Medicaid,411.59,,,411.59,Other,140% of Medicaid,661.49,,,661.49,Other,225% of Medicaid,764.39,,,764.39,Other,260% of Medicaid,952.54,,,952.54,Other,324% of Medicaid,632.09,,,632.09,Other,215% of Medicaid,632.09,,,632.09,Other,215% of Medicaid,367.49,,,367.49,Other,125% of Medicaid,291.55,2142.31,
CT PELVIS WO CONTRAST,72192,CPT,TC,46072192,CDM,352,RC,,,both,,,2134,1579.17,,,1579.17,Other,150% of Medicare + 9.63% HCRA Surcharge,960.3,45,,960.3,percent of total billed charges,Critical Access Hospital RCC factor,295.9,,,295.9,Fee Schedule,,266.22,,,266.22,Fee Schedule,,1279.29,,,1279.29,Fee Schedule,,1150.64,,,1150.64,Fee Schedule,,1087.52,,,1087.52,Fee Schedule,,1056.33,,,1056.33,Other,110% of Medicare,351.56,,,351.56,Fee Schedule,,458,,,458,Other,186% of Medicaid,413.71,,,413.71,Fee Schedule,,1323.08,,,1323.08,Fee Schedule,,194.8,,,194.8,Fee Schedule,,413.71,,,413.71,Fee Schedule,,1323.08,,,1323.08,Fee Schedule,,366.4,,,366.4,Fee Schedule,,1493.8,70,,1493.8,percent of total billed charges,All Other,424.76,,,424.76,Fee Schedule,,360.01,,,360.01,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,246,,,246,Other,100% of Medicaid,246,,,246,Other,100% of Medicaid,246,,,246,Other,100% of Medicaid,246,,,246,Other,100% of Medicaid,553.49,,,553.49,Other,225% of Medicaid,376.37,,,376.37,Other,153% of Medicaid,553.49,,,553.49,Other,225% of Medicaid,344.39,,,344.39,Other,140% of Medicaid,553.49,,,553.49,Other,225% of Medicaid,639.59,,,639.59,Other,260% of Medicaid,797.03,,,797.03,Other,324% of Medicaid,528.89,,,528.89,Other,215% of Medicaid,528.89,,,528.89,Other,215% of Medicaid,307.5,,,307.5,Other,125% of Medicaid,179.33,1579.17,
CT PELVIS W CONTRAST,72193,CPT,TC,46072193,CDM,352,RC,,,both,,,2559,1893.67,,,1893.67,Other,150% of Medicare + 9.63% HCRA Surcharge,1151.55,45,,1151.55,percent of total billed charges,Critical Access Hospital RCC factor,618.41,,,618.41,Fee Schedule,,556.38,,,556.38,Fee Schedule,,1599.66,,,1599.66,Fee Schedule,,1438.78,,,1438.78,Fee Schedule,,1359.86,,,1359.86,Fee Schedule,,1266.71,,,1266.71,Other,110% of Medicare,734.73,,,734.73,Fee Schedule,,547,,,547,Other,186% of Medicaid,864.62,,,864.62,Fee Schedule,,1586.58,,,1586.58,Fee Schedule,,407.11,,,407.11,Fee Schedule,,864.62,,,864.62,Fee Schedule,,1586.58,,,1586.58,Fee Schedule,,765.75,,,765.75,Fee Schedule,,1791.3,70,,1791.3,percent of total billed charges,All Other,924.96,,,924.96,Fee Schedule,,783.96,,,783.96,Fee Schedule,,291.55,,,291.55,Fee Schedule,,291.55,,,291.55,Fee Schedule,,291.55,,,291.55,Fee Schedule,,291.55,,,291.55,Fee Schedule,,293.99,,,293.99,Other,100% of Medicaid,293.99,,,293.99,Other,100% of Medicaid,293.99,,,293.99,Other,100% of Medicaid,293.99,,,293.99,Other,100% of Medicaid,661.49,,,661.49,Other,225% of Medicaid,449.81,,,449.81,Other,153% of Medicaid,661.49,,,661.49,Other,225% of Medicaid,411.59,,,411.59,Other,140% of Medicaid,661.49,,,661.49,Other,225% of Medicaid,764.39,,,764.39,Other,260% of Medicaid,952.54,,,952.54,Other,324% of Medicaid,632.09,,,632.09,Other,215% of Medicaid,632.09,,,632.09,Other,215% of Medicaid,367.49,,,367.49,Other,125% of Medicaid,291.55,1893.67,
CT PELVIS W AND WO CONTRAST,72194,CPT,TC,46072194,CDM,352,RC,,,both,,,3156,2335.45,,,2335.45,Other,150% of Medicare + 9.63% HCRA Surcharge,1420.2,45,,1420.2,percent of total billed charges,Critical Access Hospital RCC factor,618.41,,,618.41,Fee Schedule,,556.38,,,556.38,Fee Schedule,,2139.67,,,2139.67,Fee Schedule,,1924.49,,,1924.49,Fee Schedule,,1818.92,,,1818.92,Fee Schedule,,1562.22,,,1562.22,Other,110% of Medicare,734.73,,,734.73,Fee Schedule,,547,,,547,Other,186% of Medicaid,864.62,,,864.62,Fee Schedule,,1956.72,,,1956.72,Fee Schedule,,407.11,,,407.11,Fee Schedule,,864.62,,,864.62,Fee Schedule,,1956.72,,,1956.72,Fee Schedule,,765.75,,,765.75,Fee Schedule,,2209.2,70,,2209.2,percent of total billed charges,All Other,1033.2,,,1033.2,Fee Schedule,,875.7,,,875.7,Fee Schedule,,291.55,,,291.55,Fee Schedule,,291.55,,,291.55,Fee Schedule,,291.55,,,291.55,Fee Schedule,,291.55,,,291.55,Fee Schedule,,293.99,,,293.99,Other,100% of Medicaid,293.99,,,293.99,Other,100% of Medicaid,293.99,,,293.99,Other,100% of Medicaid,293.99,,,293.99,Other,100% of Medicaid,661.49,,,661.49,Other,225% of Medicaid,449.81,,,449.81,Other,153% of Medicaid,661.49,,,661.49,Other,225% of Medicaid,411.59,,,411.59,Other,140% of Medicaid,661.49,,,661.49,Other,225% of Medicaid,764.39,,,764.39,Other,260% of Medicaid,952.54,,,952.54,Other,324% of Medicaid,632.09,,,632.09,Other,215% of Medicaid,632.09,,,632.09,Other,215% of Medicaid,367.49,,,367.49,Other,125% of Medicaid,291.55,2335.45,
CT ANGIO U EXT W AND WO CONTRAST,73206,CPT,TC,46073206,CDM,352,RC,,,both,,,3301,2442.75,,,2442.75,Other,150% of Medicare + 9.63% HCRA Surcharge,1485.45,45,,1485.45,percent of total billed charges,Critical Access Hospital RCC factor,617.27,,,617.27,Fee Schedule,,555.35,,,555.35,Fee Schedule,,2279.28,,,2279.28,Fee Schedule,,2050.05,,,2050.05,Fee Schedule,,1937.6,,,1937.6,Fee Schedule,,1634,,,1634,Other,110% of Medicare,733.37,,,733.37,Fee Schedule,,580,,,580,Other,186% of Medicaid,863.01,,,863.01,Fee Schedule,,2046.62,,,2046.62,Fee Schedule,,406.35,,,406.35,Fee Schedule,,863.01,,,863.01,Fee Schedule,,2046.62,,,2046.62,Fee Schedule,,764.33,,,764.33,Fee Schedule,,2310.7,70,,2310.7,percent of total billed charges,All Other,1116.84,,,1116.84,Fee Schedule,,946.59,,,946.59,Fee Schedule,,291.55,,,291.55,Fee Schedule,,291.55,,,291.55,Fee Schedule,,291.55,,,291.55,Fee Schedule,,291.55,,,291.55,Fee Schedule,,311.93,,,311.93,Other,100% of Medicaid,311.93,,,311.93,Other,100% of Medicaid,311.93,,,311.93,Other,100% of Medicaid,311.93,,,311.93,Other,100% of Medicaid,701.85,,,701.85,Other,225% of Medicaid,477.26,,,477.26,Other,153% of Medicaid,701.85,,,701.85,Other,225% of Medicaid,436.71,,,436.71,Other,140% of Medicaid,701.85,,,701.85,Other,225% of Medicaid,811.02,,,811.02,Other,260% of Medicaid,1010.66,,,1010.66,Other,324% of Medicaid,670.66,,,670.66,Other,215% of Medicaid,670.66,,,670.66,Other,215% of Medicaid,389.92,,,389.92,Other,125% of Medicaid,291.55,2442.75,
CT ABDOMEN WO CONTRAST,74150,CPT,TC,46074150,CDM,352,RC,,,both,,,2134,1579.17,,,1579.17,Other,150% of Medicare + 9.63% HCRA Surcharge,960.3,45,,960.3,percent of total billed charges,Critical Access Hospital RCC factor,292.46,,,292.46,Fee Schedule,,263.12,,,263.12,Fee Schedule,,1270.12,,,1270.12,Fee Schedule,,1142.39,,,1142.39,Fee Schedule,,1079.72,,,1079.72,Fee Schedule,,1056.33,,,1056.33,Other,110% of Medicare,347.47,,,347.47,Fee Schedule,,458,,,458,Other,186% of Medicaid,408.89,,,408.89,Fee Schedule,,1323.08,,,1323.08,Fee Schedule,,192.53,,,192.53,Fee Schedule,,408.89,,,408.89,Fee Schedule,,1323.08,,,1323.08,Fee Schedule,,362.14,,,362.14,Fee Schedule,,1493.8,70,,1493.8,percent of total billed charges,All Other,419.84,,,419.84,Fee Schedule,,355.84,,,355.84,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,246,,,246,Other,100% of Medicaid,246,,,246,Other,100% of Medicaid,246,,,246,Other,100% of Medicaid,246,,,246,Other,100% of Medicaid,553.49,,,553.49,Other,225% of Medicaid,376.37,,,376.37,Other,153% of Medicaid,553.49,,,553.49,Other,225% of Medicaid,344.39,,,344.39,Other,140% of Medicaid,553.49,,,553.49,Other,225% of Medicaid,639.59,,,639.59,Other,260% of Medicaid,797.03,,,797.03,Other,324% of Medicaid,528.89,,,528.89,Other,215% of Medicaid,528.89,,,528.89,Other,215% of Medicaid,307.5,,,307.5,Other,125% of Medicaid,179.33,1579.17,
CT ABDOMEN W CONTRAST,74160,CPT,TC,46074160,CDM,352,RC,,,both,,,2559,1893.67,,,1893.67,Other,150% of Medicare + 9.63% HCRA Surcharge,1151.55,45,,1151.55,percent of total billed charges,Critical Access Hospital RCC factor,618.41,,,618.41,Fee Schedule,,556.38,,,556.38,Fee Schedule,,1830.75,,,1830.75,Fee Schedule,,1646.63,,,1646.63,Fee Schedule,,1556.31,,,1556.31,Fee Schedule,,1266.71,,,1266.71,Other,110% of Medicare,734.73,,,734.73,Fee Schedule,,547,,,547,Other,186% of Medicaid,864.62,,,864.62,Fee Schedule,,1586.58,,,1586.58,Fee Schedule,,407.11,,,407.11,Fee Schedule,,864.62,,,864.62,Fee Schedule,,1586.58,,,1586.58,Fee Schedule,,765.75,,,765.75,Fee Schedule,,1791.3,70,,1791.3,percent of total billed charges,All Other,921.68,,,921.68,Fee Schedule,,781.18,,,781.18,Fee Schedule,,291.55,,,291.55,Fee Schedule,,291.55,,,291.55,Fee Schedule,,291.55,,,291.55,Fee Schedule,,291.55,,,291.55,Fee Schedule,,293.99,,,293.99,Other,100% of Medicaid,293.99,,,293.99,Other,100% of Medicaid,293.99,,,293.99,Other,100% of Medicaid,293.99,,,293.99,Other,100% of Medicaid,661.49,,,661.49,Other,225% of Medicaid,449.81,,,449.81,Other,153% of Medicaid,661.49,,,661.49,Other,225% of Medicaid,411.59,,,411.59,Other,140% of Medicaid,661.49,,,661.49,Other,225% of Medicaid,764.39,,,764.39,Other,260% of Medicaid,952.54,,,952.54,Other,324% of Medicaid,632.09,,,632.09,Other,215% of Medicaid,632.09,,,632.09,Other,215% of Medicaid,367.49,,,367.49,Other,125% of Medicaid,291.55,1893.67,
CT ANGIO ABD PELVIS W AND WO CONTRAST,74174,CPT,TC,46074174,CDM,352,RC,,,both,,,2623,1941.03,,,1941.03,Other,150% of Medicare + 9.63% HCRA Surcharge,1180.35,45,,1180.35,percent of total billed charges,Critical Access Hospital RCC factor,998.82,,,998.82,Fee Schedule,,898.63,,,898.63,Fee Schedule,,246.54,,,246.54,Fee Schedule,,246.54,,,246.54,Fee Schedule,,246.54,,,246.54,Fee Schedule,,1298.39,,,1298.39,Other,110% of Medicare,1186.69,,,1186.69,Fee Schedule,,580,,,580,Other,186% of Medicaid,1396.47,,,1396.47,Fee Schedule,,1626.26,,,1626.26,Fee Schedule,,657.53,,,657.53,Fee Schedule,,1396.47,,,1396.47,Fee Schedule,,1626.26,,,1626.26,Fee Schedule,,1236.78,,,1236.78,Fee Schedule,,1836.1,70,,1836.1,percent of total billed charges,All Other,1453.04,,,1453.04,Fee Schedule,,1231.54,,,1231.54,Fee Schedule,,610.96,,,610.96,Fee Schedule,,610.96,,,610.96,Fee Schedule,,610.96,,,610.96,Fee Schedule,,610.96,,,610.96,Fee Schedule,,311.93,,,311.93,Other,100% of Medicaid,311.93,,,311.93,Other,100% of Medicaid,311.93,,,311.93,Other,100% of Medicaid,311.93,,,311.93,Other,100% of Medicaid,701.85,,,701.85,Other,225% of Medicaid,477.26,,,477.26,Other,153% of Medicaid,701.85,,,701.85,Other,225% of Medicaid,436.71,,,436.71,Other,140% of Medicaid,701.85,,,701.85,Other,225% of Medicaid,811.02,,,811.02,Other,260% of Medicaid,1010.66,,,1010.66,Other,324% of Medicaid,670.66,,,670.66,Other,215% of Medicaid,670.66,,,670.66,Other,215% of Medicaid,389.92,,,389.92,Other,125% of Medicaid,246.54,1941.03,
CT ANGIO ABD W AND WO CONTRAST,74175,CPT,TC,46074175,CDM,352,RC,,,both,,,3156,2335.45,,,2335.45,Other,150% of Medicare + 9.63% HCRA Surcharge,1420.2,45,,1420.2,percent of total billed charges,Critical Access Hospital RCC factor,617.27,,,617.27,Fee Schedule,,555.35,,,555.35,Fee Schedule,,2281.59,,,2281.59,Fee Schedule,,2052.14,,,2052.14,Fee Schedule,,1939.57,,,1939.57,Fee Schedule,,1562.22,,,1562.22,Other,110% of Medicare,733.37,,,733.37,Fee Schedule,,580,,,580,Other,186% of Medicaid,863.01,,,863.01,Fee Schedule,,1956.72,,,1956.72,Fee Schedule,,406.35,,,406.35,Fee Schedule,,863.01,,,863.01,Fee Schedule,,1956.72,,,1956.72,Fee Schedule,,764.33,,,764.33,Fee Schedule,,2209.2,70,,2209.2,percent of total billed charges,All Other,1154.56,,,1154.56,Fee Schedule,,978.56,,,978.56,Fee Schedule,,291.55,,,291.55,Fee Schedule,,291.55,,,291.55,Fee Schedule,,291.55,,,291.55,Fee Schedule,,291.55,,,291.55,Fee Schedule,,311.93,,,311.93,Other,100% of Medicaid,311.93,,,311.93,Other,100% of Medicaid,311.93,,,311.93,Other,100% of Medicaid,311.93,,,311.93,Other,100% of Medicaid,701.85,,,701.85,Other,225% of Medicaid,477.26,,,477.26,Other,153% of Medicaid,701.85,,,701.85,Other,225% of Medicaid,436.71,,,436.71,Other,140% of Medicaid,701.85,,,701.85,Other,225% of Medicaid,811.02,,,811.02,Other,260% of Medicaid,1010.66,,,1010.66,Other,324% of Medicaid,670.66,,,670.66,Other,215% of Medicaid,670.66,,,670.66,Other,215% of Medicaid,389.92,,,389.92,Other,125% of Medicaid,291.55,2335.45,
CT ABDOMEN PELVIS WO CONTRAST,74176,CPT,TC,46074176,CDM,352,RC,,,both,,,2134,1579.17,,,1579.17,Other,150% of Medicare + 9.63% HCRA Surcharge,960.3,45,,960.3,percent of total billed charges,Critical Access Hospital RCC factor,368.86,,,368.86,Fee Schedule,,331.86,,,331.86,Fee Schedule,,888,,,888,Fee Schedule,,798.69,,,798.69,Fee Schedule,,754.88,,,754.88,Fee Schedule,,1056.33,,,1056.33,Other,110% of Medicare,438.24,,,438.24,Fee Schedule,,547,,,547,Other,186% of Medicaid,515.71,,,515.71,Fee Schedule,,1323.08,,,1323.08,Fee Schedule,,242.82,,,242.82,Fee Schedule,,515.71,,,515.71,Fee Schedule,,1323.08,,,1323.08,Fee Schedule,,456.74,,,456.74,Fee Schedule,,1493.8,70,,1493.8,percent of total billed charges,All Other,526.44,,,526.44,Fee Schedule,,446.19,,,446.19,Fee Schedule,,372.86,,,372.86,Fee Schedule,,372.86,,,372.86,Fee Schedule,,372.86,,,372.86,Fee Schedule,,372.86,,,372.86,Fee Schedule,,293.99,,,293.99,Other,100% of Medicaid,293.99,,,293.99,Other,100% of Medicaid,293.99,,,293.99,Other,100% of Medicaid,293.99,,,293.99,Other,100% of Medicaid,661.49,,,661.49,Other,225% of Medicaid,449.81,,,449.81,Other,153% of Medicaid,661.49,,,661.49,Other,225% of Medicaid,411.59,,,411.59,Other,140% of Medicaid,661.49,,,661.49,Other,225% of Medicaid,764.39,,,764.39,Other,260% of Medicaid,952.54,,,952.54,Other,324% of Medicaid,632.09,,,632.09,Other,215% of Medicaid,632.09,,,632.09,Other,215% of Medicaid,367.49,,,367.49,Other,125% of Medicaid,242.82,1579.17,
CT ABDOMEN PELVIS W CONTRAST,74177,CPT,TC,46074177,CDM,352,RC,,,both,,,2559,1893.67,,,1893.67,Other,150% of Medicare + 9.63% HCRA Surcharge,1151.55,45,,1151.55,percent of total billed charges,Critical Access Hospital RCC factor,784.77,,,784.77,Fee Schedule,,706.05,,,706.05,Fee Schedule,,1693.46,,,1693.46,Fee Schedule,,1523.15,,,1523.15,Fee Schedule,,1439.6,,,1439.6,Fee Schedule,,1266.71,,,1266.71,Other,110% of Medicare,932.38,,,932.38,Fee Schedule,,547,,,547,Other,186% of Medicaid,1097.2,,,1097.2,Fee Schedule,,1586.58,,,1586.58,Fee Schedule,,516.62,,,516.62,Fee Schedule,,1097.2,,,1097.2,Fee Schedule,,1586.58,,,1586.58,Fee Schedule,,971.74,,,971.74,Fee Schedule,,1791.3,70,,1791.3,percent of total billed charges,All Other,1157.84,,,1157.84,Fee Schedule,,981.34,,,981.34,Fee Schedule,,610.96,,,610.96,Fee Schedule,,610.96,,,610.96,Fee Schedule,,610.96,,,610.96,Fee Schedule,,610.96,,,610.96,Fee Schedule,,293.99,,,293.99,Other,100% of Medicaid,293.99,,,293.99,Other,100% of Medicaid,293.99,,,293.99,Other,100% of Medicaid,293.99,,,293.99,Other,100% of Medicaid,661.49,,,661.49,Other,225% of Medicaid,449.81,,,449.81,Other,153% of Medicaid,661.49,,,661.49,Other,225% of Medicaid,411.59,,,411.59,Other,140% of Medicaid,661.49,,,661.49,Other,225% of Medicaid,764.39,,,764.39,Other,260% of Medicaid,952.54,,,952.54,Other,324% of Medicaid,632.09,,,632.09,Other,215% of Medicaid,632.09,,,632.09,Other,215% of Medicaid,367.49,,,367.49,Other,125% of Medicaid,293.99,1893.67,
CT ABDOMEN PELVIS W AND WO CONTRAST,74178,CPT,TC,46074178,CDM,352,RC,,,both,,,3156,2335.45,,,2335.45,Other,150% of Medicare + 9.63% HCRA Surcharge,1420.2,45,,1420.2,percent of total billed charges,Critical Access Hospital RCC factor,886.6,,,886.6,Fee Schedule,,797.66,,,797.66,Fee Schedule,,2238.06,,,2238.06,Fee Schedule,,2012.98,,,2012.98,Fee Schedule,,1902.57,,,1902.57,Fee Schedule,,1562.22,,,1562.22,Other,110% of Medicare,1053.35,,,1053.35,Fee Schedule,,547,,,547,Other,186% of Medicaid,1239.57,,,1239.57,Fee Schedule,,1956.72,,,1956.72,Fee Schedule,,583.65,,,583.65,Fee Schedule,,1239.57,,,1239.57,Fee Schedule,,1956.72,,,1956.72,Fee Schedule,,1097.82,,,1097.82,Fee Schedule,,2209.2,70,,2209.2,percent of total billed charges,All Other,1305.44,,,1305.44,Fee Schedule,,1106.44,,,1106.44,Fee Schedule,,610.96,,,610.96,Fee Schedule,,610.96,,,610.96,Fee Schedule,,610.96,,,610.96,Fee Schedule,,610.96,,,610.96,Fee Schedule,,293.99,,,293.99,Other,100% of Medicaid,293.99,,,293.99,Other,100% of Medicaid,293.99,,,293.99,Other,100% of Medicaid,293.99,,,293.99,Other,100% of Medicaid,661.49,,,661.49,Other,225% of Medicaid,449.81,,,449.81,Other,153% of Medicaid,661.49,,,661.49,Other,225% of Medicaid,411.59,,,411.59,Other,140% of Medicaid,661.49,,,661.49,Other,225% of Medicaid,764.39,,,764.39,Other,260% of Medicaid,952.54,,,952.54,Other,324% of Medicaid,632.09,,,632.09,Other,215% of Medicaid,632.09,,,632.09,Other,215% of Medicaid,367.49,,,367.49,Other,125% of Medicaid,293.99,2335.45,
CT U EXT WO CONTRAST LT,73200,CPT,TCLT,46173200,CDM,352,RC,,,both,,,2134,1579.17,,,1579.17,Other,150% of Medicare + 9.63% HCRA Surcharge,960.3,45,,960.3,percent of total billed charges,Critical Access Hospital RCC factor,369.85,,,369.85,Fee Schedule,,332.75,,,332.75,Fee Schedule,,1306.75,,,1306.75,Fee Schedule,,1175.33,,,1175.33,Fee Schedule,,1110.86,,,1110.86,Fee Schedule,,1056.33,,,1056.33,Other,110% of Medicare,439.41,,,439.41,Fee Schedule,,458,,,458,Other,186% of Medicaid,517.09,,,517.09,Fee Schedule,,1323.08,,,1323.08,Fee Schedule,,243.47,,,243.47,Fee Schedule,,517.09,,,517.09,Fee Schedule,,1323.08,,,1323.08,Fee Schedule,,457.96,,,457.96,Fee Schedule,,1493.8,70,,1493.8,percent of total billed charges,All Other,601.88,,,601.88,Fee Schedule,,510.13,,,510.13,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,246,,,246,Other,100% of Medicaid,246,,,246,Other,100% of Medicaid,246,,,246,Other,100% of Medicaid,246,,,246,Other,100% of Medicaid,553.49,,,553.49,Other,225% of Medicaid,376.37,,,376.37,Other,153% of Medicaid,553.49,,,553.49,Other,225% of Medicaid,344.39,,,344.39,Other,140% of Medicaid,553.49,,,553.49,Other,225% of Medicaid,639.59,,,639.59,Other,260% of Medicaid,797.03,,,797.03,Other,324% of Medicaid,528.89,,,528.89,Other,215% of Medicaid,528.89,,,528.89,Other,215% of Medicaid,307.5,,,307.5,Other,125% of Medicaid,179.33,1579.17,
CT U EXT W CONTRAST LT,73201,CPT,TCLT,46173201,CDM,352,RC,,,both,,,2559,1893.67,,,1893.67,Other,150% of Medicare + 9.63% HCRA Surcharge,1151.55,45,,1151.55,percent of total billed charges,Critical Access Hospital RCC factor,526,,,526,Fee Schedule,,473.23,,,473.23,Fee Schedule,,1633.96,,,1633.96,Fee Schedule,,1469.64,,,1469.64,Fee Schedule,,1389.02,,,1389.02,Fee Schedule,,1266.71,,,1266.71,Other,110% of Medicare,624.93,,,624.93,Fee Schedule,,547,,,547,Other,186% of Medicaid,735.41,,,735.41,Fee Schedule,,1586.58,,,1586.58,Fee Schedule,,346.27,,,346.27,Fee Schedule,,735.41,,,735.41,Fee Schedule,,1586.58,,,1586.58,Fee Schedule,,651.32,,,651.32,Fee Schedule,,1791.3,70,,1791.3,percent of total billed charges,All Other,765.88,,,765.88,Fee Schedule,,649.13,,,649.13,Fee Schedule,,610.96,,,610.96,Fee Schedule,,610.96,,,610.96,Fee Schedule,,610.96,,,610.96,Fee Schedule,,610.96,,,610.96,Fee Schedule,,293.99,,,293.99,Other,100% of Medicaid,293.99,,,293.99,Other,100% of Medicaid,293.99,,,293.99,Other,100% of Medicaid,293.99,,,293.99,Other,100% of Medicaid,661.49,,,661.49,Other,225% of Medicaid,449.81,,,449.81,Other,153% of Medicaid,661.49,,,661.49,Other,225% of Medicaid,411.59,,,411.59,Other,140% of Medicaid,661.49,,,661.49,Other,225% of Medicaid,764.39,,,764.39,Other,260% of Medicaid,952.54,,,952.54,Other,324% of Medicaid,632.09,,,632.09,Other,215% of Medicaid,632.09,,,632.09,Other,215% of Medicaid,367.49,,,367.49,Other,125% of Medicaid,293.99,1893.67,
CT U EXT W AND WO CONTRAST LT,73202,CPT,TCLT,46173202,CDM,352,RC,,,both,,,3156,2335.45,,,2335.45,Other,150% of Medicare + 9.63% HCRA Surcharge,1420.2,45,,1420.2,percent of total billed charges,Critical Access Hospital RCC factor,618.41,,,618.41,Fee Schedule,,556.38,,,556.38,Fee Schedule,,2180.88,,,2180.88,Fee Schedule,,1961.55,,,1961.55,Fee Schedule,,1853.96,,,1853.96,Fee Schedule,,1562.22,,,1562.22,Other,110% of Medicare,734.73,,,734.73,Fee Schedule,,547,,,547,Other,186% of Medicaid,864.62,,,864.62,Fee Schedule,,1956.72,,,1956.72,Fee Schedule,,407.11,,,407.11,Fee Schedule,,864.62,,,864.62,Fee Schedule,,1956.72,,,1956.72,Fee Schedule,,765.75,,,765.75,Fee Schedule,,2209.2,70,,2209.2,percent of total billed charges,All Other,1011.88,,,1011.88,Fee Schedule,,857.63,,,857.63,Fee Schedule,,291.55,,,291.55,Fee Schedule,,291.55,,,291.55,Fee Schedule,,291.55,,,291.55,Fee Schedule,,291.55,,,291.55,Fee Schedule,,293.99,,,293.99,Other,100% of Medicaid,293.99,,,293.99,Other,100% of Medicaid,293.99,,,293.99,Other,100% of Medicaid,293.99,,,293.99,Other,100% of Medicaid,661.49,,,661.49,Other,225% of Medicaid,449.81,,,449.81,Other,153% of Medicaid,661.49,,,661.49,Other,225% of Medicaid,411.59,,,411.59,Other,140% of Medicaid,661.49,,,661.49,Other,225% of Medicaid,764.39,,,764.39,Other,260% of Medicaid,952.54,,,952.54,Other,324% of Medicaid,632.09,,,632.09,Other,215% of Medicaid,632.09,,,632.09,Other,215% of Medicaid,367.49,,,367.49,Other,125% of Medicaid,291.55,2335.45,
CT ANGIO U EXT W AND WO CONTRAST LT,73206,CPT,TCLT,46173206,CDM,352,RC,,,both,,,3301,2442.75,,,2442.75,Other,150% of Medicare + 9.63% HCRA Surcharge,1485.45,45,,1485.45,percent of total billed charges,Critical Access Hospital RCC factor,617.27,,,617.27,Fee Schedule,,555.35,,,555.35,Fee Schedule,,2279.28,,,2279.28,Fee Schedule,,2050.05,,,2050.05,Fee Schedule,,1937.6,,,1937.6,Fee Schedule,,1634,,,1634,Other,110% of Medicare,733.37,,,733.37,Fee Schedule,,580,,,580,Other,186% of Medicaid,863.01,,,863.01,Fee Schedule,,2046.62,,,2046.62,Fee Schedule,,406.35,,,406.35,Fee Schedule,,863.01,,,863.01,Fee Schedule,,2046.62,,,2046.62,Fee Schedule,,764.33,,,764.33,Fee Schedule,,2310.7,70,,2310.7,percent of total billed charges,All Other,1116.84,,,1116.84,Fee Schedule,,946.59,,,946.59,Fee Schedule,,291.55,,,291.55,Fee Schedule,,291.55,,,291.55,Fee Schedule,,291.55,,,291.55,Fee Schedule,,291.55,,,291.55,Fee Schedule,,311.93,,,311.93,Other,100% of Medicaid,311.93,,,311.93,Other,100% of Medicaid,311.93,,,311.93,Other,100% of Medicaid,311.93,,,311.93,Other,100% of Medicaid,701.85,,,701.85,Other,225% of Medicaid,477.26,,,477.26,Other,153% of Medicaid,701.85,,,701.85,Other,225% of Medicaid,436.71,,,436.71,Other,140% of Medicaid,701.85,,,701.85,Other,225% of Medicaid,811.02,,,811.02,Other,260% of Medicaid,1010.66,,,1010.66,Other,324% of Medicaid,670.66,,,670.66,Other,215% of Medicaid,670.66,,,670.66,Other,215% of Medicaid,389.92,,,389.92,Other,125% of Medicaid,291.55,2442.75,
CT L EXT WO CONTRAST LT,73700,CPT,TCLT,46173700,CDM,352,RC,,,both,,,2134,1579.17,,,1579.17,Other,150% of Medicare + 9.63% HCRA Surcharge,960.3,45,,960.3,percent of total billed charges,Critical Access Hospital RCC factor,298.23,,,298.23,Fee Schedule,,268.32,,,268.32,Fee Schedule,,1306.75,,,1306.75,Fee Schedule,,1175.33,,,1175.33,Fee Schedule,,1110.86,,,1110.86,Fee Schedule,,1056.33,,,1056.33,Other,110% of Medicare,354.33,,,354.33,Fee Schedule,,458,,,458,Other,186% of Medicaid,416.97,,,416.97,Fee Schedule,,1323.08,,,1323.08,Fee Schedule,,196.33,,,196.33,Fee Schedule,,416.97,,,416.97,Fee Schedule,,1323.08,,,1323.08,Fee Schedule,,369.29,,,369.29,Fee Schedule,,1493.8,70,,1493.8,percent of total billed charges,All Other,426.4,,,426.4,Fee Schedule,,361.4,,,361.4,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,246,,,246,Other,100% of Medicaid,246,,,246,Other,100% of Medicaid,246,,,246,Other,100% of Medicaid,246,,,246,Other,100% of Medicaid,553.49,,,553.49,Other,225% of Medicaid,376.37,,,376.37,Other,153% of Medicaid,553.49,,,553.49,Other,225% of Medicaid,344.39,,,344.39,Other,140% of Medicaid,553.49,,,553.49,Other,225% of Medicaid,639.59,,,639.59,Other,260% of Medicaid,797.03,,,797.03,Other,324% of Medicaid,528.89,,,528.89,Other,215% of Medicaid,528.89,,,528.89,Other,215% of Medicaid,307.5,,,307.5,Other,125% of Medicaid,179.33,1579.17,
CT L EXT W CONTRAST LT,73701,CPT,TCLT,46173701,CDM,352,RC,,,both,,,2559,1893.67,,,1893.67,Other,150% of Medicare + 9.63% HCRA Surcharge,1151.55,45,,1151.55,percent of total billed charges,Critical Access Hospital RCC factor,404.68,,,404.68,Fee Schedule,,364.09,,,364.09,Fee Schedule,,1652.3,,,1652.3,Fee Schedule,,1486.13,,,1486.13,Fee Schedule,,1404.61,,,1404.61,Fee Schedule,,1266.71,,,1266.71,Other,110% of Medicare,480.8,,,480.8,Fee Schedule,,547,,,547,Other,186% of Medicaid,565.8,,,565.8,Fee Schedule,,1586.58,,,1586.58,Fee Schedule,,266.41,,,266.41,Fee Schedule,,565.8,,,565.8,Fee Schedule,,1586.58,,,1586.58,Fee Schedule,,501.1,,,501.1,Fee Schedule,,1791.3,70,,1791.3,percent of total billed charges,All Other,582.2,,,582.2,Fee Schedule,,493.45,,,493.45,Fee Schedule,,291.55,,,291.55,Fee Schedule,,291.55,,,291.55,Fee Schedule,,291.55,,,291.55,Fee Schedule,,291.55,,,291.55,Fee Schedule,,293.99,,,293.99,Other,100% of Medicaid,293.99,,,293.99,Other,100% of Medicaid,293.99,,,293.99,Other,100% of Medicaid,293.99,,,293.99,Other,100% of Medicaid,661.49,,,661.49,Other,225% of Medicaid,449.81,,,449.81,Other,153% of Medicaid,661.49,,,661.49,Other,225% of Medicaid,411.59,,,411.59,Other,140% of Medicaid,661.49,,,661.49,Other,225% of Medicaid,764.39,,,764.39,Other,260% of Medicaid,952.54,,,952.54,Other,324% of Medicaid,632.09,,,632.09,Other,215% of Medicaid,632.09,,,632.09,Other,215% of Medicaid,367.49,,,367.49,Other,125% of Medicaid,266.41,1893.67,
CT L EXT W AND WO CONTRAST LT,73702,CPT,TCLT,46173702,CDM,352,RC,,,both,,,3156,2335.45,,,2335.45,Other,150% of Medicare + 9.63% HCRA Surcharge,1420.2,45,,1420.2,percent of total billed charges,Critical Access Hospital RCC factor,498.25,,,498.25,Fee Schedule,,448.27,,,448.27,Fee Schedule,,2192.32,,,2192.32,Fee Schedule,,1971.84,,,1971.84,Fee Schedule,,1863.68,,,1863.68,Fee Schedule,,1562.22,,,1562.22,Other,110% of Medicare,591.96,,,591.96,Fee Schedule,,547,,,547,Other,186% of Medicaid,696.61,,,696.61,Fee Schedule,,1956.72,,,1956.72,Fee Schedule,,328,,,328,Fee Schedule,,696.61,,,696.61,Fee Schedule,,1956.72,,,1956.72,Fee Schedule,,616.95,,,616.95,Fee Schedule,,2209.2,70,,2209.2,percent of total billed charges,All Other,715.04,,,715.04,Fee Schedule,,606.04,,,606.04,Fee Schedule,,291.55,,,291.55,Fee Schedule,,291.55,,,291.55,Fee Schedule,,291.55,,,291.55,Fee Schedule,,291.55,,,291.55,Fee Schedule,,293.99,,,293.99,Other,100% of Medicaid,293.99,,,293.99,Other,100% of Medicaid,293.99,,,293.99,Other,100% of Medicaid,293.99,,,293.99,Other,100% of Medicaid,661.49,,,661.49,Other,225% of Medicaid,449.81,,,449.81,Other,153% of Medicaid,661.49,,,661.49,Other,225% of Medicaid,411.59,,,411.59,Other,140% of Medicaid,661.49,,,661.49,Other,225% of Medicaid,764.39,,,764.39,Other,260% of Medicaid,952.54,,,952.54,Other,324% of Medicaid,632.09,,,632.09,Other,215% of Medicaid,632.09,,,632.09,Other,215% of Medicaid,367.49,,,367.49,Other,125% of Medicaid,291.55,2335.45,
CT U EXT WO CONTRAST RT,73200,CPT,TCRT,46273200,CDM,352,RC,,,both,,,2134,1579.17,,,1579.17,Other,150% of Medicare + 9.63% HCRA Surcharge,960.3,45,,960.3,percent of total billed charges,Critical Access Hospital RCC factor,369.85,,,369.85,Fee Schedule,,332.75,,,332.75,Fee Schedule,,1306.75,,,1306.75,Fee Schedule,,1175.33,,,1175.33,Fee Schedule,,1110.86,,,1110.86,Fee Schedule,,1056.33,,,1056.33,Other,110% of Medicare,439.41,,,439.41,Fee Schedule,,458,,,458,Other,186% of Medicaid,517.09,,,517.09,Fee Schedule,,1323.08,,,1323.08,Fee Schedule,,243.47,,,243.47,Fee Schedule,,517.09,,,517.09,Fee Schedule,,1323.08,,,1323.08,Fee Schedule,,457.96,,,457.96,Fee Schedule,,1493.8,70,,1493.8,percent of total billed charges,All Other,601.88,,,601.88,Fee Schedule,,510.13,,,510.13,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,246,,,246,Other,100% of Medicaid,246,,,246,Other,100% of Medicaid,246,,,246,Other,100% of Medicaid,246,,,246,Other,100% of Medicaid,553.49,,,553.49,Other,225% of Medicaid,376.37,,,376.37,Other,153% of Medicaid,553.49,,,553.49,Other,225% of Medicaid,344.39,,,344.39,Other,140% of Medicaid,553.49,,,553.49,Other,225% of Medicaid,639.59,,,639.59,Other,260% of Medicaid,797.03,,,797.03,Other,324% of Medicaid,528.89,,,528.89,Other,215% of Medicaid,528.89,,,528.89,Other,215% of Medicaid,307.5,,,307.5,Other,125% of Medicaid,179.33,1579.17,
CT U EXT W CONTRAST RT,73201,CPT,TCRT,46273201,CDM,352,RC,,,both,,,2559,1893.67,,,1893.67,Other,150% of Medicare + 9.63% HCRA Surcharge,1151.55,45,,1151.55,percent of total billed charges,Critical Access Hospital RCC factor,526,,,526,Fee Schedule,,473.23,,,473.23,Fee Schedule,,1633.96,,,1633.96,Fee Schedule,,1469.64,,,1469.64,Fee Schedule,,1389.02,,,1389.02,Fee Schedule,,1266.71,,,1266.71,Other,110% of Medicare,624.93,,,624.93,Fee Schedule,,547,,,547,Other,186% of Medicaid,735.41,,,735.41,Fee Schedule,,1586.58,,,1586.58,Fee Schedule,,346.27,,,346.27,Fee Schedule,,735.41,,,735.41,Fee Schedule,,1586.58,,,1586.58,Fee Schedule,,651.32,,,651.32,Fee Schedule,,1791.3,70,,1791.3,percent of total billed charges,All Other,765.88,,,765.88,Fee Schedule,,649.13,,,649.13,Fee Schedule,,610.96,,,610.96,Fee Schedule,,610.96,,,610.96,Fee Schedule,,610.96,,,610.96,Fee Schedule,,610.96,,,610.96,Fee Schedule,,293.99,,,293.99,Other,100% of Medicaid,293.99,,,293.99,Other,100% of Medicaid,293.99,,,293.99,Other,100% of Medicaid,293.99,,,293.99,Other,100% of Medicaid,661.49,,,661.49,Other,225% of Medicaid,449.81,,,449.81,Other,153% of Medicaid,661.49,,,661.49,Other,225% of Medicaid,411.59,,,411.59,Other,140% of Medicaid,661.49,,,661.49,Other,225% of Medicaid,764.39,,,764.39,Other,260% of Medicaid,952.54,,,952.54,Other,324% of Medicaid,632.09,,,632.09,Other,215% of Medicaid,632.09,,,632.09,Other,215% of Medicaid,367.49,,,367.49,Other,125% of Medicaid,293.99,1893.67,
CT U EXT W AND WO CONTRAST RT,73202,CPT,TCRT,46273202,CDM,352,RC,,,both,,,3156,2335.45,,,2335.45,Other,150% of Medicare + 9.63% HCRA Surcharge,1420.2,45,,1420.2,percent of total billed charges,Critical Access Hospital RCC factor,618.41,,,618.41,Fee Schedule,,556.38,,,556.38,Fee Schedule,,2180.88,,,2180.88,Fee Schedule,,1961.55,,,1961.55,Fee Schedule,,1853.96,,,1853.96,Fee Schedule,,1562.22,,,1562.22,Other,110% of Medicare,734.73,,,734.73,Fee Schedule,,547,,,547,Other,186% of Medicaid,864.62,,,864.62,Fee Schedule,,1956.72,,,1956.72,Fee Schedule,,407.11,,,407.11,Fee Schedule,,864.62,,,864.62,Fee Schedule,,1956.72,,,1956.72,Fee Schedule,,765.75,,,765.75,Fee Schedule,,2209.2,70,,2209.2,percent of total billed charges,All Other,1011.88,,,1011.88,Fee Schedule,,857.63,,,857.63,Fee Schedule,,291.55,,,291.55,Fee Schedule,,291.55,,,291.55,Fee Schedule,,291.55,,,291.55,Fee Schedule,,291.55,,,291.55,Fee Schedule,,293.99,,,293.99,Other,100% of Medicaid,293.99,,,293.99,Other,100% of Medicaid,293.99,,,293.99,Other,100% of Medicaid,293.99,,,293.99,Other,100% of Medicaid,661.49,,,661.49,Other,225% of Medicaid,449.81,,,449.81,Other,153% of Medicaid,661.49,,,661.49,Other,225% of Medicaid,411.59,,,411.59,Other,140% of Medicaid,661.49,,,661.49,Other,225% of Medicaid,764.39,,,764.39,Other,260% of Medicaid,952.54,,,952.54,Other,324% of Medicaid,632.09,,,632.09,Other,215% of Medicaid,632.09,,,632.09,Other,215% of Medicaid,367.49,,,367.49,Other,125% of Medicaid,291.55,2335.45,
CT ANGIO U EXT W AND WO CONTRAST RT,73206,CPT,TCRT,46273206,CDM,352,RC,,,both,,,3301,2442.75,,,2442.75,Other,150% of Medicare + 9.63% HCRA Surcharge,1485.45,45,,1485.45,percent of total billed charges,Critical Access Hospital RCC factor,617.27,,,617.27,Fee Schedule,,555.35,,,555.35,Fee Schedule,,2279.28,,,2279.28,Fee Schedule,,2050.05,,,2050.05,Fee Schedule,,1937.6,,,1937.6,Fee Schedule,,1634,,,1634,Other,110% of Medicare,733.37,,,733.37,Fee Schedule,,580,,,580,Other,186% of Medicaid,863.01,,,863.01,Fee Schedule,,2046.62,,,2046.62,Fee Schedule,,406.35,,,406.35,Fee Schedule,,863.01,,,863.01,Fee Schedule,,2046.62,,,2046.62,Fee Schedule,,764.33,,,764.33,Fee Schedule,,2310.7,70,,2310.7,percent of total billed charges,All Other,1116.84,,,1116.84,Fee Schedule,,946.59,,,946.59,Fee Schedule,,291.55,,,291.55,Fee Schedule,,291.55,,,291.55,Fee Schedule,,291.55,,,291.55,Fee Schedule,,291.55,,,291.55,Fee Schedule,,311.93,,,311.93,Other,100% of Medicaid,311.93,,,311.93,Other,100% of Medicaid,311.93,,,311.93,Other,100% of Medicaid,311.93,,,311.93,Other,100% of Medicaid,701.85,,,701.85,Other,225% of Medicaid,477.26,,,477.26,Other,153% of Medicaid,701.85,,,701.85,Other,225% of Medicaid,436.71,,,436.71,Other,140% of Medicaid,701.85,,,701.85,Other,225% of Medicaid,811.02,,,811.02,Other,260% of Medicaid,1010.66,,,1010.66,Other,324% of Medicaid,670.66,,,670.66,Other,215% of Medicaid,670.66,,,670.66,Other,215% of Medicaid,389.92,,,389.92,Other,125% of Medicaid,291.55,2442.75,
CT L EXT WO CONTRAST RT,73700,CPT,TCRT,46273700,CDM,352,RC,,,both,,,2134,1579.17,,,1579.17,Other,150% of Medicare + 9.63% HCRA Surcharge,960.3,45,,960.3,percent of total billed charges,Critical Access Hospital RCC factor,298.23,,,298.23,Fee Schedule,,268.32,,,268.32,Fee Schedule,,1306.75,,,1306.75,Fee Schedule,,1175.33,,,1175.33,Fee Schedule,,1110.86,,,1110.86,Fee Schedule,,1056.33,,,1056.33,Other,110% of Medicare,354.33,,,354.33,Fee Schedule,,458,,,458,Other,186% of Medicaid,416.97,,,416.97,Fee Schedule,,1323.08,,,1323.08,Fee Schedule,,196.33,,,196.33,Fee Schedule,,416.97,,,416.97,Fee Schedule,,1323.08,,,1323.08,Fee Schedule,,369.29,,,369.29,Fee Schedule,,1493.8,70,,1493.8,percent of total billed charges,All Other,426.4,,,426.4,Fee Schedule,,361.4,,,361.4,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,246,,,246,Other,100% of Medicaid,246,,,246,Other,100% of Medicaid,246,,,246,Other,100% of Medicaid,246,,,246,Other,100% of Medicaid,553.49,,,553.49,Other,225% of Medicaid,376.37,,,376.37,Other,153% of Medicaid,553.49,,,553.49,Other,225% of Medicaid,344.39,,,344.39,Other,140% of Medicaid,553.49,,,553.49,Other,225% of Medicaid,639.59,,,639.59,Other,260% of Medicaid,797.03,,,797.03,Other,324% of Medicaid,528.89,,,528.89,Other,215% of Medicaid,528.89,,,528.89,Other,215% of Medicaid,307.5,,,307.5,Other,125% of Medicaid,179.33,1579.17,
CT L EXT W CONTRAST RT,73701,CPT,TCRT,46273701,CDM,352,RC,,,both,,,2559,1893.67,,,1893.67,Other,150% of Medicare + 9.63% HCRA Surcharge,1151.55,45,,1151.55,percent of total billed charges,Critical Access Hospital RCC factor,404.68,,,404.68,Fee Schedule,,364.09,,,364.09,Fee Schedule,,1652.3,,,1652.3,Fee Schedule,,1486.13,,,1486.13,Fee Schedule,,1404.61,,,1404.61,Fee Schedule,,1266.71,,,1266.71,Other,110% of Medicare,480.8,,,480.8,Fee Schedule,,547,,,547,Other,186% of Medicaid,565.8,,,565.8,Fee Schedule,,1586.58,,,1586.58,Fee Schedule,,266.41,,,266.41,Fee Schedule,,565.8,,,565.8,Fee Schedule,,1586.58,,,1586.58,Fee Schedule,,501.1,,,501.1,Fee Schedule,,1791.3,70,,1791.3,percent of total billed charges,All Other,582.2,,,582.2,Fee Schedule,,493.45,,,493.45,Fee Schedule,,291.55,,,291.55,Fee Schedule,,291.55,,,291.55,Fee Schedule,,291.55,,,291.55,Fee Schedule,,291.55,,,291.55,Fee Schedule,,293.99,,,293.99,Other,100% of Medicaid,293.99,,,293.99,Other,100% of Medicaid,293.99,,,293.99,Other,100% of Medicaid,293.99,,,293.99,Other,100% of Medicaid,661.49,,,661.49,Other,225% of Medicaid,449.81,,,449.81,Other,153% of Medicaid,661.49,,,661.49,Other,225% of Medicaid,411.59,,,411.59,Other,140% of Medicaid,661.49,,,661.49,Other,225% of Medicaid,764.39,,,764.39,Other,260% of Medicaid,952.54,,,952.54,Other,324% of Medicaid,632.09,,,632.09,Other,215% of Medicaid,632.09,,,632.09,Other,215% of Medicaid,367.49,,,367.49,Other,125% of Medicaid,266.41,1893.67,
CT L EXT W AND WO CONTRAST RT,73702,CPT,TCRT,46273702,CDM,352,RC,,,both,,,3156,2335.45,,,2335.45,Other,150% of Medicare + 9.63% HCRA Surcharge,1420.2,45,,1420.2,percent of total billed charges,Critical Access Hospital RCC factor,498.25,,,498.25,Fee Schedule,,448.27,,,448.27,Fee Schedule,,2192.32,,,2192.32,Fee Schedule,,1971.84,,,1971.84,Fee Schedule,,1863.68,,,1863.68,Fee Schedule,,1562.22,,,1562.22,Other,110% of Medicare,591.96,,,591.96,Fee Schedule,,547,,,547,Other,186% of Medicaid,696.61,,,696.61,Fee Schedule,,1956.72,,,1956.72,Fee Schedule,,328,,,328,Fee Schedule,,696.61,,,696.61,Fee Schedule,,1956.72,,,1956.72,Fee Schedule,,616.95,,,616.95,Fee Schedule,,2209.2,70,,2209.2,percent of total billed charges,All Other,715.04,,,715.04,Fee Schedule,,606.04,,,606.04,Fee Schedule,,291.55,,,291.55,Fee Schedule,,291.55,,,291.55,Fee Schedule,,291.55,,,291.55,Fee Schedule,,291.55,,,291.55,Fee Schedule,,293.99,,,293.99,Other,100% of Medicaid,293.99,,,293.99,Other,100% of Medicaid,293.99,,,293.99,Other,100% of Medicaid,293.99,,,293.99,Other,100% of Medicaid,661.49,,,661.49,Other,225% of Medicaid,449.81,,,449.81,Other,153% of Medicaid,661.49,,,661.49,Other,225% of Medicaid,411.59,,,411.59,Other,140% of Medicaid,661.49,,,661.49,Other,225% of Medicaid,764.39,,,764.39,Other,260% of Medicaid,952.54,,,952.54,Other,324% of Medicaid,632.09,,,632.09,Other,215% of Medicaid,632.09,,,632.09,Other,215% of Medicaid,367.49,,,367.49,Other,125% of Medicaid,291.55,2335.45,
CT ANGIO U EXT W AND WO CONTRAST BILAT,73206,CPT,TC50,46373206,CDM,352,RC,,,both,,,4952,3664.49,,,3664.49,Other,150% of Medicare + 9.63% HCRA Surcharge,2228.4,45,,2228.4,percent of total billed charges,Critical Access Hospital RCC factor,617.27,,,617.27,Fee Schedule,,555.35,,,555.35,Fee Schedule,,2279.28,,,2279.28,Fee Schedule,,2050.05,,,2050.05,Fee Schedule,,1937.6,,,1937.6,Fee Schedule,,2451.24,,,2451.24,Other,110% of Medicare,733.37,,,733.37,Fee Schedule,,580,,,580,Other,186% of Medicaid,863.01,,,863.01,Fee Schedule,,3070.24,,,3070.24,Fee Schedule,,406.35,,,406.35,Fee Schedule,,863.01,,,863.01,Fee Schedule,,3070.24,,,3070.24,Fee Schedule,,764.33,,,764.33,Fee Schedule,,3466.4,70,,3466.4,percent of total billed charges,All Other,1116.84,,,1116.84,Fee Schedule,,946.59,,,946.59,Fee Schedule,,291.55,,,291.55,Fee Schedule,,291.55,,,291.55,Fee Schedule,,291.55,,,291.55,Fee Schedule,,291.55,,,291.55,Fee Schedule,,311.93,,,311.93,Other,100% of Medicaid,311.93,,,311.93,Other,100% of Medicaid,311.93,,,311.93,Other,100% of Medicaid,311.93,,,311.93,Other,100% of Medicaid,701.85,,,701.85,Other,225% of Medicaid,477.26,,,477.26,Other,153% of Medicaid,701.85,,,701.85,Other,225% of Medicaid,436.71,,,436.71,Other,140% of Medicaid,701.85,,,701.85,Other,225% of Medicaid,811.02,,,811.02,Other,260% of Medicaid,1010.66,,,1010.66,Other,324% of Medicaid,670.66,,,670.66,Other,215% of Medicaid,670.66,,,670.66,Other,215% of Medicaid,389.92,,,389.92,Other,125% of Medicaid,291.55,3664.49,
INSERT DRUG IMPLANT,11981,CPT,,26011981,CDM,360,RC,,,both,,,727,537.98,,,537.98,Other,150% of Medicare + 9.63% HCRA Surcharge,327.15,45,,327.15,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",359.87,,,359.87,Other,110% of Medicare,494.36,,,494.36,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",733.11,,,733.11,Other,186% of Medicaid,581.6,,,581.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",581.6,,,581.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",581.6,,,581.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",508.9,70,,508.9,percent of total billed charges,All Other,306.68,,,306.68,Fee Schedule,,259.93,,,259.93,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",394.14,,,394.14,Other,100% of Medicaid,394.14,,,394.14,Other,100% of Medicaid,394.14,,,394.14,Other,100% of Medicaid,394.14,,,394.14,Other,100% of Medicaid,886.83,,,886.83,Other,225% of Medicaid,603.04,,,603.04,Other,153% of Medicaid,886.83,,,886.83,Other,225% of Medicaid,551.8,,,551.8,Other,140% of Medicaid,886.83,,,886.83,Other,225% of Medicaid,1024.78,,,1024.78,Other,260% of Medicaid,1277.03,,,1277.03,Other,324% of Medicaid,847.41,,,847.41,Other,215% of Medicaid,847.41,,,847.41,Other,215% of Medicaid,492.68,,,492.68,Other,125% of Medicaid,259.93,7216,
REMOVE W INS DRUG IMPLANT,11983,CPT,,26011983,CDM,360,RC,,,both,,,2379,1760.47,,,1760.47,Other,150% of Medicare + 9.63% HCRA Surcharge,1070.55,45,,1070.55,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",1177.61,,,1177.61,Other,110% of Medicare,1617.72,,,1617.72,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",733.11,,,733.11,Other,186% of Medicaid,1903.2,,,1903.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1903.2,,,1903.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1903.2,,,1903.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1665.3,70,,1665.3,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",394.14,,,394.14,Other,100% of Medicaid,394.14,,,394.14,Other,100% of Medicaid,394.14,,,394.14,Other,100% of Medicaid,394.14,,,394.14,Other,100% of Medicaid,886.83,,,886.83,Other,225% of Medicaid,603.04,,,603.04,Other,153% of Medicaid,886.83,,,886.83,Other,225% of Medicaid,551.8,,,551.8,Other,140% of Medicaid,886.83,,,886.83,Other,225% of Medicaid,1024.78,,,1024.78,Other,260% of Medicaid,1277.03,,,1277.03,Other,324% of Medicaid,847.41,,,847.41,Other,215% of Medicaid,847.41,,,847.41,Other,215% of Medicaid,492.68,,,492.68,Other,125% of Medicaid,394.14,7216,
INSERT IUD,58300,CPT,,26058300,CDM,360,RC,,,both,,,554,409.96,,,409.96,Other,150% of Medicare + 9.63% HCRA Surcharge,249.3,45,,249.3,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",274.23,,,274.23,Other,110% of Medicare,376.72,,,376.72,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",226.07,,,226.07,Other,186% of Medicaid,443.2,,,443.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",443.2,,,443.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",443.2,,,443.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",387.8,70,,387.8,percent of total billed charges,All Other,244.36,,,244.36,Fee Schedule,,207.11,,,207.11,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",121.54,,,121.54,Other,100% of Medicaid,121.54,,,121.54,Other,100% of Medicaid,121.54,,,121.54,Other,100% of Medicaid,121.54,,,121.54,Other,100% of Medicaid,273.47,,,273.47,Other,225% of Medicaid,185.96,,,185.96,Other,153% of Medicaid,273.47,,,273.47,Other,225% of Medicaid,170.16,,,170.16,Other,140% of Medicaid,273.47,,,273.47,Other,225% of Medicaid,316.01,,,316.01,Other,260% of Medicaid,393.8,,,393.8,Other,324% of Medicaid,261.32,,,261.32,Other,215% of Medicaid,261.32,,,261.32,Other,215% of Medicaid,151.93,,,151.93,Other,125% of Medicaid,121.54,7216,
EPISIOTOMY OR VAGINAL REPAIR,59300,CPT,,26059300,CDM,360,RC,,,both,,,6366,4710.86,,,4710.86,Other,150% of Medicare + 9.63% HCRA Surcharge,2864.7,45,,2864.7,percent of total billed charges,Critical Access Hospital RCC factor,2480,,,2480,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2232,,,2232,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3648,,,3648,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3283,,,3283,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3101,,,3101,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3151.17,,,3151.17,Other,110% of Medicare,4328.88,,,4328.88,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1902.33,,,1902.33,Other,186% of Medicaid,5092.8,,,5092.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",5092.8,,,5092.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",5092.8,,,5092.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",4456.2,70,,4456.2,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",4531,,,4531,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4079,,,4079,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4531,,,4531,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3852,,,3852,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",1022.76,,,1022.76,Other,100% of Medicaid,1022.76,,,1022.76,Other,100% of Medicaid,1022.76,,,1022.76,Other,100% of Medicaid,1022.76,,,1022.76,Other,100% of Medicaid,2301.2,,,2301.2,Other,225% of Medicaid,1564.82,,,1564.82,Other,153% of Medicaid,2301.2,,,2301.2,Other,225% of Medicaid,1431.86,,,1431.86,Other,140% of Medicaid,2301.2,,,2301.2,Other,225% of Medicaid,2659.17,,,2659.17,Other,260% of Medicaid,3313.73,,,3313.73,Other,324% of Medicaid,2198.93,,,2198.93,Other,215% of Medicaid,2198.93,,,2198.93,Other,215% of Medicaid,1278.45,,,1278.45,Other,125% of Medicaid,1022.76,7216,
EXT CEPHALIC VERSION,59412,CPT,,26059412,CDM,360,RC,,,both,,,6366,4710.86,,,4710.86,Other,150% of Medicare + 9.63% HCRA Surcharge,2864.7,45,,2864.7,percent of total billed charges,Critical Access Hospital RCC factor,4565,,,4565,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4565,,,4565,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3648,,,3648,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3283,,,3283,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3101,,,3101,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3151.17,,,3151.17,Other,110% of Medicare,4328.88,,,4328.88,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1453.49,,,1453.49,Other,186% of Medicaid,5092.8,,,5092.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",5092.8,,,5092.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",5092.8,,,5092.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",4456.2,70,,4456.2,percent of total billed charges,All Other,496.92,,,496.92,Fee Schedule,,421.17,,,421.17,Fee Schedule,,4531,,,4531,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4079,,,4079,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4531,,,4531,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3852,,,3852,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",781.45,,,781.45,Other,100% of Medicaid,781.45,,,781.45,Other,100% of Medicaid,781.45,,,781.45,Other,100% of Medicaid,781.45,,,781.45,Other,100% of Medicaid,1758.26,,,1758.26,Other,225% of Medicaid,1195.62,,,1195.62,Other,153% of Medicaid,1758.26,,,1758.26,Other,225% of Medicaid,1094.03,,,1094.03,Other,140% of Medicaid,1758.26,,,1758.26,Other,225% of Medicaid,2031.76,,,2031.76,Other,260% of Medicaid,2531.89,,,2531.89,Other,324% of Medicaid,1680.11,,,1680.11,Other,215% of Medicaid,1680.11,,,1680.11,Other,215% of Medicaid,976.81,,,976.81,Other,125% of Medicaid,421.17,7216,
SHAVE LES S/N/H/F/G; 0.5CM/<,11305,CPT,,30011305,CDM,360,RC,,,both,,,656,485.44,,,485.44,Other,150% of Medicare + 9.63% HCRA Surcharge,295.2,45,,295.2,percent of total billed charges,Critical Access Hospital RCC factor,4565,,,4565,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4109,,,4109,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",324.72,,,324.72,Other,110% of Medicare,446.08,,,446.08,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",733.11,,,733.11,Other,186% of Medicaid,524.8,,,524.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",524.8,,,524.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",524.8,,,524.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",459.2,70,,459.2,percent of total billed charges,All Other,183.68,,,183.68,Fee Schedule,,155.68,,,155.68,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",394.14,,,394.14,Other,100% of Medicaid,394.14,,,394.14,Other,100% of Medicaid,394.14,,,394.14,Other,100% of Medicaid,394.14,,,394.14,Other,100% of Medicaid,886.83,,,886.83,Other,225% of Medicaid,603.04,,,603.04,Other,153% of Medicaid,886.83,,,886.83,Other,225% of Medicaid,551.8,,,551.8,Other,140% of Medicaid,886.83,,,886.83,Other,225% of Medicaid,1024.78,,,1024.78,Other,260% of Medicaid,1277.03,,,1277.03,Other,324% of Medicaid,847.41,,,847.41,Other,215% of Medicaid,847.41,,,847.41,Other,215% of Medicaid,492.68,,,492.68,Other,125% of Medicaid,155.68,7216,
MUSCLE BIOPSY PERCUT,20206,CPT,,30020206,CDM,360,RC,,,both,,,3377,2498.99,,,2498.99,Other,150% of Medicare + 9.63% HCRA Surcharge,1519.65,45,,1519.65,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3648,,,3648,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3283,,,3283,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3101,,,3101,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",1671.62,,,1671.62,Other,110% of Medicare,2296.36,,,2296.36,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1037.55,,,1037.55,Other,186% of Medicaid,2701.6,,,2701.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2701.6,,,2701.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",3578,,,3578,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2363.9,70,,2363.9,percent of total billed charges,All Other,273.88,,,273.88,Fee Schedule,,232.13,,,232.13,Fee Schedule,,4055,,,4055,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3649,,,3649,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4055,,,4055,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3448,,,3448,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",557.82,,,557.82,Other,100% of Medicaid,557.82,,,557.82,Other,100% of Medicaid,557.82,,,557.82,Other,100% of Medicaid,557.82,,,557.82,Other,100% of Medicaid,1255.1,,,1255.1,Other,225% of Medicaid,853.47,,,853.47,Other,153% of Medicaid,1255.1,,,1255.1,Other,225% of Medicaid,780.95,,,780.95,Other,140% of Medicaid,1255.1,,,1255.1,Other,225% of Medicaid,1450.34,,,1450.34,Other,260% of Medicaid,1807.35,,,1807.35,Other,324% of Medicaid,1199.32,,,1199.32,Other,215% of Medicaid,1199.32,,,1199.32,Other,215% of Medicaid,697.28,,,697.28,Other,125% of Medicaid,232.13,7216,
EXPLORE REPAIR CHEST,32110,CPT,,30032110,CDM,360,RC,,,both,,,6852,5070.5,,,5070.5,Other,150% of Medicare + 9.63% HCRA Surcharge,3083.4,45,,3083.4,percent of total billed charges,Critical Access Hospital RCC factor,4565,,,4565,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4109,,,4109,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",6807,,,6807,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",6126,,,6126,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",5786,,,5786,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3391.74,,,3391.74,Other,110% of Medicare,4659.36,,,4659.36,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",3575.85,,,3575.85,Other,186% of Medicaid,5481.6,,,5481.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",5481.6,,,5481.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",5481.6,,,5481.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",4796.4,70,,4796.4,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",4531,,,4531,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4079,,,4079,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4531,,,4531,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3852,,,3852,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",1922.5,,,1922.5,Other,100% of Medicaid,1922.5,,,1922.5,Other,100% of Medicaid,1922.5,,,1922.5,Other,100% of Medicaid,1922.5,,,1922.5,Other,100% of Medicaid,4325.62,,,4325.62,Other,225% of Medicaid,2941.42,,,2941.42,Other,153% of Medicaid,4325.62,,,4325.62,Other,225% of Medicaid,2691.5,,,2691.5,Other,140% of Medicaid,4325.62,,,4325.62,Other,225% of Medicaid,4998.5,,,4998.5,Other,260% of Medicaid,6228.89,,,6228.89,Other,324% of Medicaid,4133.37,,,4133.37,Other,215% of Medicaid,4133.37,,,4133.37,Other,215% of Medicaid,2403.12,,,2403.12,Other,125% of Medicaid,1922.5,7216,
THORACOTOMY W CARD MASSAGE,32160,CPT,,30032160,CDM,360,RC,,,both,,,3056,2261.45,,,2261.45,Other,150% of Medicare + 9.63% HCRA Surcharge,1375.2,45,,1375.2,percent of total billed charges,Critical Access Hospital RCC factor,4565,,,4565,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4109,,,4109,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",6807,,,6807,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",6126,,,6126,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",5786,,,5786,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",1512.72,,,1512.72,Other,110% of Medicare,2078.08,,,2078.08,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",3575.85,,,3575.85,Other,186% of Medicaid,2444.8,,,2444.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2444.8,,,2444.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2444.8,,,2444.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2139.2,70,,2139.2,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",4531,,,4531,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4079,,,4079,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4531,,,4531,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3852,,,3852,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",1922.5,,,1922.5,Other,100% of Medicaid,1922.5,,,1922.5,Other,100% of Medicaid,1922.5,,,1922.5,Other,100% of Medicaid,1922.5,,,1922.5,Other,100% of Medicaid,4325.62,,,4325.62,Other,225% of Medicaid,2941.42,,,2941.42,Other,153% of Medicaid,4325.62,,,4325.62,Other,225% of Medicaid,2691.5,,,2691.5,Other,140% of Medicaid,4325.62,,,4325.62,Other,225% of Medicaid,4998.5,,,4998.5,Other,260% of Medicaid,6228.89,,,6228.89,Other,324% of Medicaid,4133.37,,,4133.37,Other,215% of Medicaid,4133.37,,,4133.37,Other,215% of Medicaid,2403.12,,,2403.12,Other,125% of Medicaid,1375.2,7216,
REM TUNNELED CVAD W PORT/PUMP,36590,CPT,,30036590,CDM,360,RC,,,both,,,4327,3201.99,,,3201.99,Other,150% of Medicare + 9.63% HCRA Surcharge,1947.15,45,,1947.15,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2141.87,,,2141.87,Other,110% of Medicare,2942.36,,,2942.36,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1556.72,,,1556.72,Other,186% of Medicaid,3461.6,,,3461.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",3461.6,,,3461.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",3578,,,3578,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",3028.9,70,,3028.9,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",4055,,,4055,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3649,,,3649,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4055,,,4055,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3448,,,3448,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",836.95,,,836.95,Other,100% of Medicaid,836.95,,,836.95,Other,100% of Medicaid,836.95,,,836.95,Other,100% of Medicaid,836.95,,,836.95,Other,100% of Medicaid,1883.13,,,1883.13,Other,225% of Medicaid,1280.53,,,1280.53,Other,153% of Medicaid,1883.13,,,1883.13,Other,225% of Medicaid,1171.73,,,1171.73,Other,140% of Medicaid,1883.13,,,1883.13,Other,225% of Medicaid,2176.07,,,2176.07,Other,260% of Medicaid,2711.71,,,2711.71,Other,324% of Medicaid,1799.44,,,1799.44,Other,215% of Medicaid,1799.44,,,1799.44,Other,215% of Medicaid,1046.19,,,1046.19,Other,125% of Medicaid,836.95,7216,
UGI W BX. SGL/MULTIPLE,43239,CPT,,30043239,CDM,360,RC,,,both,,,2490,1842.61,,,1842.61,Other,150% of Medicare + 9.63% HCRA Surcharge,1120.5,45,,1120.5,percent of total billed charges,Critical Access Hospital RCC factor,2480,,,2480,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2232,,,2232,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",1232.55,,,1232.55,Other,110% of Medicare,1693.2,,,1693.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1530.86,,,1530.86,Other,186% of Medicaid,1992,,,1992,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1992,,,1992,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",4252,,,4252,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1743,70,,1743,percent of total billed charges,All Other,3387,,,3387,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",2879,,,2879,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",4055,,,4055,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3649,,,3649,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4055,,,4055,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3448,,,3448,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",823.04,,,823.04,Other,100% of Medicaid,823.04,,,823.04,Other,100% of Medicaid,823.04,,,823.04,Other,100% of Medicaid,823.04,,,823.04,Other,100% of Medicaid,1851.85,,,1851.85,Other,225% of Medicaid,1259.26,,,1259.26,Other,153% of Medicaid,1851.85,,,1851.85,Other,225% of Medicaid,1152.26,,,1152.26,Other,140% of Medicaid,1851.85,,,1851.85,Other,225% of Medicaid,2139.92,,,2139.92,Other,260% of Medicaid,2666.66,,,2666.66,Other,324% of Medicaid,1769.55,,,1769.55,Other,215% of Medicaid,1769.55,,,1769.55,Other,215% of Medicaid,1028.81,,,1028.81,Other,125% of Medicaid,823.04,7216,
REPLACE G C TUBE PERC,49450,CPT,,30049450,CDM,360,RC,,,both,,,2408,1781.93,,,1781.93,Other,150% of Medicare + 9.63% HCRA Surcharge,1083.6,45,,1083.6,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",1191.96,,,1191.96,Other,110% of Medicare,1637.44,,,1637.44,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1030.37,,,1030.37,Other,186% of Medicaid,1926.4,,,1926.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1926.4,,,1926.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1926.4,,,1926.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1685.6,70,,1685.6,percent of total billed charges,All Other,309.96,,,309.96,Fee Schedule,,262.71,,,262.71,Fee Schedule,,4055,,,4055,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3649,,,3649,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4055,,,4055,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3448,,,3448,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",553.96,,,553.96,Other,100% of Medicaid,553.96,,,553.96,Other,100% of Medicaid,553.96,,,553.96,Other,100% of Medicaid,553.96,,,553.96,Other,100% of Medicaid,1246.41,,,1246.41,Other,225% of Medicaid,847.56,,,847.56,Other,153% of Medicaid,1246.41,,,1246.41,Other,225% of Medicaid,775.55,,,775.55,Other,140% of Medicaid,1246.41,,,1246.41,Other,225% of Medicaid,1440.3,,,1440.3,Other,260% of Medicaid,1794.83,,,1794.83,Other,324% of Medicaid,1191.02,,,1191.02,Other,215% of Medicaid,1191.02,,,1191.02,Other,215% of Medicaid,692.45,,,692.45,Other,125% of Medicaid,262.71,7216,
BURR HOLES,61154,CPT,,30061154,CDM,360,RC,,,both,,,5490,4062.61,,,4062.61,Other,150% of Medicare + 9.63% HCRA Surcharge,2470.5,45,,2470.5,percent of total billed charges,Critical Access Hospital RCC factor,4565,,,4565,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4109,,,4109,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4476,,,4476,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4028,,,4028,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3805,,,3805,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2717.55,,,2717.55,Other,110% of Medicare,3733.2,,,3733.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",4145.5,,,4145.5,Other,186% of Medicaid,4392,,,4392,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",4392,,,4392,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",4392,,,4392,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",3843,70,,3843,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",4531,,,4531,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4079,,,4079,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4531,,,4531,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3852,,,3852,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2228.76,,,2228.76,Other,100% of Medicaid,2228.76,,,2228.76,Other,100% of Medicaid,2228.76,,,2228.76,Other,100% of Medicaid,2228.76,,,2228.76,Other,100% of Medicaid,5014.72,,,5014.72,Other,225% of Medicaid,3410.01,,,3410.01,Other,153% of Medicaid,5014.72,,,5014.72,Other,225% of Medicaid,3120.27,,,3120.27,Other,140% of Medicaid,5014.72,,,5014.72,Other,225% of Medicaid,5794.79,,,5794.79,Other,260% of Medicaid,7221.19,,,7221.19,Other,324% of Medicaid,4791.84,,,4791.84,Other,215% of Medicaid,4791.84,,,4791.84,Other,215% of Medicaid,2785.95,,,2785.95,Other,125% of Medicaid,2228.76,7221.19,
INJ ANESTH GREATER OCCIPITAL NERVE,64405,CPT,,30064405,CDM,360,RC,,,both,,,1164,861.36,,,861.36,Other,150% of Medicare + 9.63% HCRA Surcharge,523.8,45,,523.8,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",576.18,,,576.18,Other,110% of Medicare,791.52,,,791.52,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",966.11,,,966.11,Other,186% of Medicaid,931.2,,,931.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",931.2,,,931.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",931.2,,,931.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",814.8,70,,814.8,percent of total billed charges,All Other,255.84,,,255.84,Fee Schedule,,216.84,,,216.84,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",519.42,,,519.42,Other,100% of Medicaid,519.42,,,519.42,Other,100% of Medicaid,519.42,,,519.42,Other,100% of Medicaid,519.42,,,519.42,Other,100% of Medicaid,1168.69,,,1168.69,Other,225% of Medicaid,794.71,,,794.71,Other,153% of Medicaid,1168.69,,,1168.69,Other,225% of Medicaid,727.18,,,727.18,Other,140% of Medicaid,1168.69,,,1168.69,Other,225% of Medicaid,1350.48,,,1350.48,Other,260% of Medicaid,1682.91,,,1682.91,Other,324% of Medicaid,1116.74,,,1116.74,Other,215% of Medicaid,1116.74,,,1116.74,Other,215% of Medicaid,649.27,,,649.27,Other,125% of Medicaid,216.84,7216,
THROMBOLYSIS CORONARY IV,92977,CPT,,30092977,CDM,360,RC,,,both,,,769,569.06,,,569.06,Other,150% of Medicare + 9.63% HCRA Surcharge,346.05,45,,346.05,percent of total billed charges,Critical Access Hospital RCC factor,4565,,,4565,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4109,,,4109,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",380.66,,,380.66,Other,110% of Medicare,522.92,,,522.92,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1097.85,,,1097.85,Other,186% of Medicaid,615.2,,,615.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",615.2,,,615.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",615.2,,,615.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",538.3,70,,538.3,percent of total billed charges,All Other,250.92,,,250.92,Fee Schedule,,212.67,,,212.67,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",590.24,,,590.24,Other,100% of Medicaid,590.24,,,590.24,Other,100% of Medicaid,590.24,,,590.24,Other,100% of Medicaid,590.24,,,590.24,Other,100% of Medicaid,1328.05,,,1328.05,Other,225% of Medicaid,903.07,,,903.07,Other,153% of Medicaid,1328.05,,,1328.05,Other,225% of Medicaid,826.34,,,826.34,Other,140% of Medicaid,1328.05,,,1328.05,Other,225% of Medicaid,1534.64,,,1534.64,Other,260% of Medicaid,1912.39,,,1912.39,Other,324% of Medicaid,1269.03,,,1269.03,Other,215% of Medicaid,1269.03,,,1269.03,Other,215% of Medicaid,737.81,,,737.81,Other,125% of Medicaid,212.67,7216,
RPLC GTUBE NO REVJ TRC,43762,CPT,,34043762,CDM,360,RC,,,both,,,1648,1219.52,,,1219.52,Other,150% of Medicare + 9.63% HCRA Surcharge,741.6,45,,741.6,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",815.76,,,815.76,Other,110% of Medicare,1120.64,,,1120.64,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1030.37,,,1030.37,Other,186% of Medicaid,1318.4,,,1318.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1318.4,,,1318.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1318.4,,,1318.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1153.6,70,,1153.6,percent of total billed charges,All Other,178.76,,,178.76,Fee Schedule,,151.51,,,151.51,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",553.96,,,553.96,Other,100% of Medicaid,553.96,,,553.96,Other,100% of Medicaid,553.96,,,553.96,Other,100% of Medicaid,553.96,,,553.96,Other,100% of Medicaid,1246.41,,,1246.41,Other,225% of Medicaid,847.56,,,847.56,Other,153% of Medicaid,1246.41,,,1246.41,Other,225% of Medicaid,775.55,,,775.55,Other,140% of Medicaid,1246.41,,,1246.41,Other,225% of Medicaid,1440.3,,,1440.3,Other,260% of Medicaid,1794.83,,,1794.83,Other,324% of Medicaid,1191.02,,,1191.02,Other,215% of Medicaid,1191.02,,,1191.02,Other,215% of Medicaid,692.45,,,692.45,Other,125% of Medicaid,151.51,7216,
RPLC GTUBE REVJ GSTRST TRC,43763,CPT,,34043763,CDM,360,RC,,,both,,,1592,1178.08,,,1178.08,Other,150% of Medicare + 9.63% HCRA Surcharge,716.4,45,,716.4,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",788.04,,,788.04,Other,110% of Medicare,1082.56,,,1082.56,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1030.37,,,1030.37,Other,186% of Medicaid,1273.6,,,1273.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1273.6,,,1273.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1273.6,,,1273.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1114.4,70,,1114.4,percent of total billed charges,All Other,410,,,410,Fee Schedule,,347.5,,,347.5,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",553.96,,,553.96,Other,100% of Medicaid,553.96,,,553.96,Other,100% of Medicaid,553.96,,,553.96,Other,100% of Medicaid,553.96,,,553.96,Other,100% of Medicaid,1246.41,,,1246.41,Other,225% of Medicaid,847.56,,,847.56,Other,153% of Medicaid,1246.41,,,1246.41,Other,225% of Medicaid,775.55,,,775.55,Other,140% of Medicaid,1246.41,,,1246.41,Other,225% of Medicaid,1440.3,,,1440.3,Other,260% of Medicaid,1794.83,,,1794.83,Other,324% of Medicaid,1191.02,,,1191.02,Other,215% of Medicaid,1191.02,,,1191.02,Other,215% of Medicaid,692.45,,,692.45,Other,125% of Medicaid,347.5,7216,
REPLACE G C TUBE PERC,49450,CPT,,34049450,CDM,360,RC,,,both,,,2408,1781.93,,,1781.93,Other,150% of Medicare + 9.63% HCRA Surcharge,1083.6,45,,1083.6,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",1191.96,,,1191.96,Other,110% of Medicare,1637.44,,,1637.44,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1030.37,,,1030.37,Other,186% of Medicaid,1926.4,,,1926.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1926.4,,,1926.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1926.4,,,1926.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1685.6,70,,1685.6,percent of total billed charges,All Other,309.96,,,309.96,Fee Schedule,,262.71,,,262.71,Fee Schedule,,4055,,,4055,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3649,,,3649,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4055,,,4055,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3448,,,3448,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",553.96,,,553.96,Other,100% of Medicaid,553.96,,,553.96,Other,100% of Medicaid,553.96,,,553.96,Other,100% of Medicaid,553.96,,,553.96,Other,100% of Medicaid,1246.41,,,1246.41,Other,225% of Medicaid,847.56,,,847.56,Other,153% of Medicaid,1246.41,,,1246.41,Other,225% of Medicaid,775.55,,,775.55,Other,140% of Medicaid,1246.41,,,1246.41,Other,225% of Medicaid,1440.3,,,1440.3,Other,260% of Medicaid,1794.83,,,1794.83,Other,324% of Medicaid,1191.02,,,1191.02,Other,215% of Medicaid,1191.02,,,1191.02,Other,215% of Medicaid,692.45,,,692.45,Other,125% of Medicaid,262.71,7216,
FNA W/O IMAGE,10021,CPT,,42010021,CDM,360,RC,,,both,,,841,622.34,,,622.34,Other,150% of Medicare + 9.63% HCRA Surcharge,378.45,45,,378.45,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",416.3,,,416.3,Other,110% of Medicare,571.88,,,571.88,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1037.55,,,1037.55,Other,186% of Medicaid,672.8,,,672.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",672.8,,,672.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",672.8,,,672.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",588.7,70,,588.7,percent of total billed charges,All Other,262.4,,,262.4,Fee Schedule,,222.4,,,222.4,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",557.82,,,557.82,Other,100% of Medicaid,557.82,,,557.82,Other,100% of Medicaid,557.82,,,557.82,Other,100% of Medicaid,557.82,,,557.82,Other,100% of Medicaid,1255.1,,,1255.1,Other,225% of Medicaid,853.47,,,853.47,Other,153% of Medicaid,1255.1,,,1255.1,Other,225% of Medicaid,780.95,,,780.95,Other,140% of Medicaid,1255.1,,,1255.1,Other,225% of Medicaid,1450.34,,,1450.34,Other,260% of Medicaid,1807.35,,,1807.35,Other,324% of Medicaid,1199.32,,,1199.32,Other,215% of Medicaid,1199.32,,,1199.32,Other,215% of Medicaid,697.28,,,697.28,Other,125% of Medicaid,222.4,7216,
KNEE ARTHROGRAPHY INJ,27369,CPT,,42027369,CDM,360,RC,,,both,,,213,157.62,,,157.62,Other,150% of Medicare + 9.63% HCRA Surcharge,95.85,45,,95.85,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",105.44,,,105.44,Other,110% of Medicare,144.84,,,144.84,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",966.93,,,966.93,Other,186% of Medicaid,170.4,,,170.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",170.4,,,170.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",170.4,,,170.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",149.1,70,,149.1,percent of total billed charges,All Other,191.88,,,191.88,Fee Schedule,,162.63,,,162.63,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",519.86,,,519.86,Other,100% of Medicaid,519.86,,,519.86,Other,100% of Medicaid,519.86,,,519.86,Other,100% of Medicaid,519.86,,,519.86,Other,100% of Medicaid,1169.68,,,1169.68,Other,225% of Medicaid,795.38,,,795.38,Other,153% of Medicaid,1169.68,,,1169.68,Other,225% of Medicaid,727.8,,,727.8,Other,140% of Medicaid,1169.68,,,1169.68,Other,225% of Medicaid,1351.62,,,1351.62,Other,260% of Medicaid,1684.33,,,1684.33,Other,324% of Medicaid,1117.69,,,1117.69,Other,215% of Medicaid,1117.69,,,1117.69,Other,215% of Medicaid,649.82,,,649.82,Other,125% of Medicaid,95.85,7216,
ASPIRATE PLEURA W IMAGING,32555,CPT,,42032555,CDM,360,RC,,,both,,,2118,1567.33,,,1567.33,Other,150% of Medicare + 9.63% HCRA Surcharge,953.1,45,,953.1,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",1048.41,,,1048.41,Other,110% of Medicare,1440.24,,,1440.24,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1196.64,,,1196.64,Other,186% of Medicaid,1694.4,,,1694.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1694.4,,,1694.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1694.4,,,1694.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1482.6,70,,1482.6,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",643.35,,,643.35,Other,100% of Medicaid,643.35,,,643.35,Other,100% of Medicaid,643.35,,,643.35,Other,100% of Medicaid,643.35,,,643.35,Other,100% of Medicaid,1447.55,,,1447.55,Other,225% of Medicaid,984.33,,,984.33,Other,153% of Medicaid,1447.55,,,1447.55,Other,225% of Medicaid,900.7,,,900.7,Other,140% of Medicaid,1447.55,,,1447.55,Other,225% of Medicaid,1672.72,,,1672.72,Other,260% of Medicaid,2084.47,,,2084.47,Other,324% of Medicaid,1383.21,,,1383.21,Other,215% of Medicaid,1383.21,,,1383.21,Other,215% of Medicaid,804.19,,,804.19,Other,125% of Medicaid,643.35,7216,
INS NON-TUNNEL CV CATH 5 YRS/>,36556,CPT,,42036556,CDM,360,RC,,,both,,,6707,4963.2,,,4963.2,Other,150% of Medicare + 9.63% HCRA Surcharge,3018.15,45,,3018.15,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3648,,,3648,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3283,,,3283,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3101,,,3101,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3319.97,,,3319.97,Other,110% of Medicare,4560.76,,,4560.76,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",586.68,,,586.68,Other,186% of Medicaid,5365.6,,,5365.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",5365.6,,,5365.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",3578,,,3578,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",4694.9,70,,4694.9,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",315.42,,,315.42,Other,100% of Medicaid,315.42,,,315.42,Other,100% of Medicaid,315.42,,,315.42,Other,100% of Medicaid,315.42,,,315.42,Other,100% of Medicaid,709.7,,,709.7,Other,225% of Medicaid,482.6,,,482.6,Other,153% of Medicaid,709.7,,,709.7,Other,225% of Medicaid,441.59,,,441.59,Other,140% of Medicaid,709.7,,,709.7,Other,225% of Medicaid,820.1,,,820.1,Other,260% of Medicaid,1021.97,,,1021.97,Other,324% of Medicaid,678.16,,,678.16,Other,215% of Medicaid,678.16,,,678.16,Other,215% of Medicaid,394.28,,,394.28,Other,125% of Medicaid,315.42,7216,
INS TUNNELED CV CATH W SQ PORT,36560,CPT,,42036560,CDM,360,RC,,,both,,,8952,6624.5,,,6624.5,Other,150% of Medicare + 9.63% HCRA Surcharge,4028.4,45,,4028.4,percent of total billed charges,Critical Access Hospital RCC factor,3473,,,3473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3126,,,3126,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4476,,,4476,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4028,,,4028,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3805,,,3805,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4431.24,,,4431.24,Other,110% of Medicare,6152,,,6152,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2490.15,,,2490.15,Other,186% of Medicaid,7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",5266,,,5266,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",6266.4,70,,6266.4,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",4913,,,4913,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4422,,,4422,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4913,,,4913,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4176,,,4176,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",1338.79,,,1338.79,Other,100% of Medicaid,1338.79,,,1338.79,Other,100% of Medicaid,1338.79,,,1338.79,Other,100% of Medicaid,1338.79,,,1338.79,Other,100% of Medicaid,3012.28,,,3012.28,Other,225% of Medicaid,2048.35,,,2048.35,Other,153% of Medicaid,3012.28,,,3012.28,Other,225% of Medicaid,1874.31,,,1874.31,Other,140% of Medicaid,3012.28,,,3012.28,Other,225% of Medicaid,3480.85,,,3480.85,Other,260% of Medicaid,4337.68,,,4337.68,Other,324% of Medicaid,2878.4,,,2878.4,Other,215% of Medicaid,2878.4,,,2878.4,Other,215% of Medicaid,1673.49,,,1673.49,Other,125% of Medicaid,1338.79,9473,
REPLACE PICC CATH,36584,CPT,,42036584,CDM,360,RC,,,both,,,3500,2590.01,,,2590.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1575,45,,1575,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3648,,,3648,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3283,,,3283,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3101,,,3101,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",1732.5,,,1732.5,Other,110% of Medicare,2380,,,2380,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",586.68,,,586.68,Other,186% of Medicaid,2800,,,2800,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2800,,,2800,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",3578,,,3578,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2450,70,,2450,percent of total billed charges,All Other,280.44,,,280.44,Fee Schedule,,237.69,,,237.69,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",315.42,,,315.42,Other,100% of Medicaid,315.42,,,315.42,Other,100% of Medicaid,315.42,,,315.42,Other,100% of Medicaid,315.42,,,315.42,Other,100% of Medicaid,709.7,,,709.7,Other,225% of Medicaid,482.6,,,482.6,Other,153% of Medicaid,709.7,,,709.7,Other,225% of Medicaid,441.59,,,441.59,Other,140% of Medicaid,709.7,,,709.7,Other,225% of Medicaid,820.1,,,820.1,Other,260% of Medicaid,1021.97,,,1021.97,Other,324% of Medicaid,678.16,,,678.16,Other,215% of Medicaid,678.16,,,678.16,Other,215% of Medicaid,394.28,,,394.28,Other,125% of Medicaid,237.69,7216,
INJ FOR SIALOGRAPHY,42550,CPT,,42042550,CDM,360,RC,,,both,,,246,182.04,,,182.04,Other,150% of Medicare + 9.63% HCRA Surcharge,110.7,45,,110.7,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",121.77,,,121.77,Other,110% of Medicare,167.28,,,167.28,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",966.93,,,966.93,Other,186% of Medicaid,196.8,,,196.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",196.8,,,196.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",196.8,,,196.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",172.2,70,,172.2,percent of total billed charges,All Other,295.2,,,295.2,Fee Schedule,,250.2,,,250.2,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",519.86,,,519.86,Other,100% of Medicaid,519.86,,,519.86,Other,100% of Medicaid,519.86,,,519.86,Other,100% of Medicaid,519.86,,,519.86,Other,100% of Medicaid,1169.68,,,1169.68,Other,225% of Medicaid,795.38,,,795.38,Other,153% of Medicaid,1169.68,,,1169.68,Other,225% of Medicaid,727.8,,,727.8,Other,140% of Medicaid,1169.68,,,1169.68,Other,225% of Medicaid,1351.62,,,1351.62,Other,260% of Medicaid,1684.33,,,1684.33,Other,324% of Medicaid,1117.69,,,1117.69,Other,215% of Medicaid,1117.69,,,1117.69,Other,215% of Medicaid,649.82,,,649.82,Other,125% of Medicaid,110.7,7216,
INJECTION FOR CHOLANGIOGRAM,47531,CPT,,42047531,CDM,360,RC,,,both,,,7974,5900.78,,,5900.78,Other,150% of Medicare + 9.63% HCRA Surcharge,3588.3,45,,3588.3,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4476,,,4476,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4028,,,4028,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3805,,,3805,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3947.13,,,3947.13,Other,110% of Medicare,5422.32,,,5422.32,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",786.95,,,786.95,Other,186% of Medicaid,6379.2,,,6379.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",6379.2,,,6379.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",6379.2,,,6379.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",5581.8,70,,5581.8,percent of total billed charges,All Other,332.92,,,332.92,Fee Schedule,,282.17,,,282.17,Fee Schedule,,4913,,,4913,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4422,,,4422,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4913,,,4913,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4176,,,4176,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",423.09,,,423.09,Other,100% of Medicaid,423.09,,,423.09,Other,100% of Medicaid,423.09,,,423.09,Other,100% of Medicaid,423.09,,,423.09,Other,100% of Medicaid,951.96,,,951.96,Other,225% of Medicaid,647.33,,,647.33,Other,153% of Medicaid,951.96,,,951.96,Other,225% of Medicaid,592.33,,,592.33,Other,140% of Medicaid,951.96,,,951.96,Other,225% of Medicaid,1100.04,,,1100.04,Other,260% of Medicaid,1370.82,,,1370.82,Other,324% of Medicaid,909.65,,,909.65,Other,215% of Medicaid,909.65,,,909.65,Other,215% of Medicaid,528.86,,,528.86,Other,125% of Medicaid,282.17,7216,
INJ TO EVAL PERITONEAL-VENOUS,49427,CPT,,42049427,CDM,360,RC,,,both,,,177,130.98,,,130.98,Other,150% of Medicare + 9.63% HCRA Surcharge,79.65,45,,79.65,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",87.62,,,87.62,Other,110% of Medicare,120.36,,,120.36,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",966.93,,,966.93,Other,186% of Medicaid,141.6,,,141.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",141.6,,,141.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",141.6,,,141.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",123.9,70,,123.9,percent of total billed charges,All Other,185.32,,,185.32,Fee Schedule,,157.07,,,157.07,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",519.86,,,519.86,Other,100% of Medicaid,519.86,,,519.86,Other,100% of Medicaid,519.86,,,519.86,Other,100% of Medicaid,519.86,,,519.86,Other,100% of Medicaid,1169.68,,,1169.68,Other,225% of Medicaid,795.38,,,795.38,Other,153% of Medicaid,1169.68,,,1169.68,Other,225% of Medicaid,727.8,,,727.8,Other,140% of Medicaid,1169.68,,,1169.68,Other,225% of Medicaid,1351.62,,,1351.62,Other,260% of Medicaid,1684.33,,,1684.33,Other,324% of Medicaid,1117.69,,,1117.69,Other,215% of Medicaid,1117.69,,,1117.69,Other,215% of Medicaid,649.82,,,649.82,Other,125% of Medicaid,79.65,7216,
FLUORO EXAM OF G/COLON TUBE,49465,CPT,,42049465,CDM,360,RC,,,both,,,701,518.74,,,518.74,Other,150% of Medicare + 9.63% HCRA Surcharge,315.45,45,,315.45,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",347,,,347,Other,110% of Medicare,476.68,,,476.68,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",623.23,,,623.23,Other,186% of Medicaid,560.8,,,560.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",560.8,,,560.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",560.8,,,560.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",490.7,70,,490.7,percent of total billed charges,All Other,144.32,,,144.32,Fee Schedule,,122.32,,,122.32,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",335.07,,,335.07,Other,100% of Medicaid,335.07,,,335.07,Other,100% of Medicaid,335.07,,,335.07,Other,100% of Medicaid,335.07,,,335.07,Other,100% of Medicaid,753.91,,,753.91,Other,225% of Medicaid,512.66,,,512.66,Other,153% of Medicaid,753.91,,,753.91,Other,225% of Medicaid,469.1,,,469.1,Other,140% of Medicaid,753.91,,,753.91,Other,225% of Medicaid,871.18,,,871.18,Other,260% of Medicaid,1085.63,,,1085.63,Other,324% of Medicaid,720.4,,,720.4,Other,215% of Medicaid,720.4,,,720.4,Other,215% of Medicaid,418.84,,,418.84,Other,125% of Medicaid,122.32,7216,
NJX PX NFROSGRM &/URTRGRM,50431,CPT,,42050431,CDM,360,RC,,,both,,,2318,1715.33,,,1715.33,Other,150% of Medicare + 9.63% HCRA Surcharge,1043.1,45,,1043.1,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",1147.41,,,1147.41,Other,110% of Medicare,1576.24,,,1576.24,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",903.43,,,903.43,Other,186% of Medicaid,1854.4,,,1854.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1854.4,,,1854.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1854.4,,,1854.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1622.6,70,,1622.6,percent of total billed charges,All Other,309.96,,,309.96,Fee Schedule,,262.71,,,262.71,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",485.72,,,485.72,Other,100% of Medicaid,485.72,,,485.72,Other,100% of Medicaid,485.72,,,485.72,Other,100% of Medicaid,485.72,,,485.72,Other,100% of Medicaid,1092.86,,,1092.86,Other,225% of Medicaid,743.14,,,743.14,Other,153% of Medicaid,1092.86,,,1092.86,Other,225% of Medicaid,680,,,680,Other,140% of Medicaid,1092.86,,,1092.86,Other,225% of Medicaid,1262.86,,,1262.86,Other,260% of Medicaid,1573.72,,,1573.72,Other,324% of Medicaid,1044.29,,,1044.29,Other,215% of Medicaid,1044.29,,,1044.29,Other,215% of Medicaid,607.14,,,607.14,Other,125% of Medicaid,262.71,7216,
CYSTO W DIL OF URETHRAL STRICT,52281,CPT,,42052281,CDM,360,RC,,,both,,,5732,4241.69,,,4241.69,Other,150% of Medicare + 9.63% HCRA Surcharge,2579.4,45,,2579.4,percent of total billed charges,Critical Access Hospital RCC factor,2480,,,2480,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2232,,,2232,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3648,,,3648,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3283,,,3283,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3101,,,3101,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2837.34,,,2837.34,Other,110% of Medicare,3897.76,,,3897.76,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2876.72,,,2876.72,Other,186% of Medicaid,4585.6,,,4585.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",4585.6,,,4585.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",4252,,,4252,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",4012.4,70,,4012.4,percent of total billed charges,All Other,3387,,,3387,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",2879,,,2879,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",4055,,,4055,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3649,,,3649,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4055,,,4055,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3448,,,3448,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",1546.62,,,1546.62,Other,100% of Medicaid,1546.62,,,1546.62,Other,100% of Medicaid,1546.62,,,1546.62,Other,100% of Medicaid,1546.62,,,1546.62,Other,100% of Medicaid,3479.91,,,3479.91,Other,225% of Medicaid,2366.34,,,2366.34,Other,153% of Medicaid,3479.91,,,3479.91,Other,225% of Medicaid,2165.27,,,2165.27,Other,140% of Medicaid,3479.91,,,3479.91,Other,225% of Medicaid,4021.22,,,4021.22,Other,260% of Medicaid,5011.06,,,5011.06,Other,324% of Medicaid,3325.24,,,3325.24,Other,215% of Medicaid,3325.24,,,3325.24,Other,215% of Medicaid,1933.28,,,1933.28,Other,125% of Medicaid,1546.62,7216,
INJECT FOR SPINE DISK XR LU,62290,CPT,,42062290,CDM,360,RC,,,both,,,652,482.48,,,482.48,Other,150% of Medicare + 9.63% HCRA Surcharge,293.4,45,,293.4,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",322.74,,,322.74,Other,110% of Medicare,443.36,,,443.36,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",966.93,,,966.93,Other,186% of Medicaid,521.6,,,521.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",521.6,,,521.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",521.6,,,521.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",456.4,70,,456.4,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",519.86,,,519.86,Other,100% of Medicaid,519.86,,,519.86,Other,100% of Medicaid,519.86,,,519.86,Other,100% of Medicaid,519.86,,,519.86,Other,100% of Medicaid,1169.68,,,1169.68,Other,225% of Medicaid,795.38,,,795.38,Other,153% of Medicaid,1169.68,,,1169.68,Other,225% of Medicaid,727.8,,,727.8,Other,140% of Medicaid,1169.68,,,1169.68,Other,225% of Medicaid,1351.62,,,1351.62,Other,260% of Medicaid,1684.33,,,1684.33,Other,324% of Medicaid,1117.69,,,1117.69,Other,215% of Medicaid,1117.69,,,1117.69,Other,215% of Medicaid,649.82,,,649.82,Other,125% of Medicaid,293.4,7216,
MYELOGRAPHY LUMBAR INJECTION,62302,CPT,,42062302,CDM,360,RC,,,both,,,2329,1723.47,,,1723.47,Other,150% of Medicare + 9.63% HCRA Surcharge,1048.05,45,,1048.05,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",1152.86,,,1152.86,Other,110% of Medicare,1583.72,,,1583.72,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1185.33,,,1185.33,Other,186% of Medicaid,1863.2,,,1863.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1863.2,,,1863.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1863.2,,,1863.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1630.3,70,,1630.3,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",637.28,,,637.28,Other,100% of Medicaid,637.28,,,637.28,Other,100% of Medicaid,637.28,,,637.28,Other,100% of Medicaid,637.28,,,637.28,Other,100% of Medicaid,1433.87,,,1433.87,Other,225% of Medicaid,975.03,,,975.03,Other,153% of Medicaid,1433.87,,,1433.87,Other,225% of Medicaid,892.19,,,892.19,Other,140% of Medicaid,1433.87,,,1433.87,Other,225% of Medicaid,1656.92,,,1656.92,Other,260% of Medicaid,2064.77,,,2064.77,Other,324% of Medicaid,1370.14,,,1370.14,Other,215% of Medicaid,1370.14,,,1370.14,Other,215% of Medicaid,796.59,,,796.59,Other,125% of Medicaid,637.28,7216,
MYELOGRAPHY LUMBAR INJECTION,62303,CPT,,42062303,CDM,360,RC,,,both,,,2329,1723.47,,,1723.47,Other,150% of Medicare + 9.63% HCRA Surcharge,1048.05,45,,1048.05,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",1152.86,,,1152.86,Other,110% of Medicare,1583.72,,,1583.72,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1185.33,,,1185.33,Other,186% of Medicaid,1863.2,,,1863.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1863.2,,,1863.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1863.2,,,1863.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1630.3,70,,1630.3,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",637.28,,,637.28,Other,100% of Medicaid,637.28,,,637.28,Other,100% of Medicaid,637.28,,,637.28,Other,100% of Medicaid,637.28,,,637.28,Other,100% of Medicaid,1433.87,,,1433.87,Other,225% of Medicaid,975.03,,,975.03,Other,153% of Medicaid,1433.87,,,1433.87,Other,225% of Medicaid,892.19,,,892.19,Other,140% of Medicaid,1433.87,,,1433.87,Other,225% of Medicaid,1656.92,,,1656.92,Other,260% of Medicaid,2064.77,,,2064.77,Other,324% of Medicaid,1370.14,,,1370.14,Other,215% of Medicaid,1370.14,,,1370.14,Other,215% of Medicaid,796.59,,,796.59,Other,125% of Medicaid,637.28,7216,
MYELOGRAPHY LUMBAR INJECTION,62304,CPT,,42062304,CDM,360,RC,,,both,,,2329,1723.47,,,1723.47,Other,150% of Medicare + 9.63% HCRA Surcharge,1048.05,45,,1048.05,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",1152.86,,,1152.86,Other,110% of Medicare,1583.72,,,1583.72,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1185.33,,,1185.33,Other,186% of Medicaid,1863.2,,,1863.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1863.2,,,1863.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1863.2,,,1863.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1630.3,70,,1630.3,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",637.28,,,637.28,Other,100% of Medicaid,637.28,,,637.28,Other,100% of Medicaid,637.28,,,637.28,Other,100% of Medicaid,637.28,,,637.28,Other,100% of Medicaid,1433.87,,,1433.87,Other,225% of Medicaid,975.03,,,975.03,Other,153% of Medicaid,1433.87,,,1433.87,Other,225% of Medicaid,892.19,,,892.19,Other,140% of Medicaid,1433.87,,,1433.87,Other,225% of Medicaid,1656.92,,,1656.92,Other,260% of Medicaid,2064.77,,,2064.77,Other,324% of Medicaid,1370.14,,,1370.14,Other,215% of Medicaid,1370.14,,,1370.14,Other,215% of Medicaid,796.59,,,796.59,Other,125% of Medicaid,637.28,7216,
MYELOGRAPHY LUMBAR INJECTION,62305,CPT,,42062305,CDM,360,RC,,,both,,,2329,1723.47,,,1723.47,Other,150% of Medicare + 9.63% HCRA Surcharge,1048.05,45,,1048.05,percent of total billed charges,Critical Access Hospital RCC factor,2480,,,2480,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2232,,,2232,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",1152.86,,,1152.86,Other,110% of Medicare,1583.72,,,1583.72,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1185.33,,,1185.33,Other,186% of Medicaid,1863.2,,,1863.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1863.2,,,1863.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1863.2,,,1863.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1630.3,70,,1630.3,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",637.28,,,637.28,Other,100% of Medicaid,637.28,,,637.28,Other,100% of Medicaid,637.28,,,637.28,Other,100% of Medicaid,637.28,,,637.28,Other,100% of Medicaid,1433.87,,,1433.87,Other,225% of Medicaid,975.03,,,975.03,Other,153% of Medicaid,1433.87,,,1433.87,Other,225% of Medicaid,892.19,,,892.19,Other,140% of Medicaid,1433.87,,,1433.87,Other,225% of Medicaid,1656.92,,,1656.92,Other,260% of Medicaid,2064.77,,,2064.77,Other,324% of Medicaid,1370.14,,,1370.14,Other,215% of Medicaid,1370.14,,,1370.14,Other,215% of Medicaid,796.59,,,796.59,Other,125% of Medicaid,637.28,7216,
INJ FACET JNT-LMBR/SACRL,64493,CPT,,42064493,CDM,360,RC,,,both,,,2477,1832.99,,,1832.99,Other,150% of Medicare + 9.63% HCRA Surcharge,1114.65,45,,1114.65,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",1226.12,,,1226.12,Other,110% of Medicare,1684.36,,,1684.36,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1116.35,,,1116.35,Other,186% of Medicaid,1981.6,,,1981.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1981.6,,,1981.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1981.6,,,1981.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1733.9,70,,1733.9,percent of total billed charges,All Other,431.32,,,431.32,Fee Schedule,,365.57,,,365.57,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",600.19,,,600.19,Other,100% of Medicaid,600.19,,,600.19,Other,100% of Medicaid,600.19,,,600.19,Other,100% of Medicaid,600.19,,,600.19,Other,100% of Medicaid,1350.43,,,1350.43,Other,225% of Medicaid,918.29,,,918.29,Other,153% of Medicaid,1350.43,,,1350.43,Other,225% of Medicaid,840.26,,,840.26,Other,140% of Medicaid,1350.43,,,1350.43,Other,225% of Medicaid,1560.49,,,1560.49,Other,260% of Medicaid,1944.61,,,1944.61,Other,324% of Medicaid,1290.41,,,1290.41,Other,215% of Medicaid,1290.41,,,1290.41,Other,215% of Medicaid,750.24,,,750.24,Other,125% of Medicaid,365.57,7216,
INJ ANES FACET JT L/S ADDL,64494,CPT,,42064494,CDM,360,RC,,,both,,,918,679.32,,,679.32,Other,150% of Medicare + 9.63% HCRA Surcharge,413.1,45,,413.1,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",454.41,,,454.41,Other,110% of Medicare,624.24,,,624.24,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1116.35,,,1116.35,Other,186% of Medicaid,734.4,,,734.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",734.4,,,734.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",734.4,,,734.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",642.6,70,,642.6,percent of total billed charges,All Other,246,,,246,Fee Schedule,,208.5,,,208.5,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",600.19,,,600.19,Other,100% of Medicaid,600.19,,,600.19,Other,100% of Medicaid,600.19,,,600.19,Other,100% of Medicaid,600.19,,,600.19,Other,100% of Medicaid,1350.43,,,1350.43,Other,225% of Medicaid,918.29,,,918.29,Other,153% of Medicaid,1350.43,,,1350.43,Other,225% of Medicaid,840.26,,,840.26,Other,140% of Medicaid,1350.43,,,1350.43,Other,225% of Medicaid,1560.49,,,1560.49,Other,260% of Medicaid,1944.61,,,1944.61,Other,324% of Medicaid,1290.41,,,1290.41,Other,215% of Medicaid,1290.41,,,1290.41,Other,215% of Medicaid,750.24,,,750.24,Other,125% of Medicaid,208.5,7216,
FNA W/O IMAGE W/ FY MOD,10021,CPT,,42610021,CDM,360,RC,,,both,,,841,622.34,,,622.34,Other,150% of Medicare + 9.63% HCRA Surcharge,378.45,45,,378.45,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",416.3,,,416.3,Other,110% of Medicare,571.88,,,571.88,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1037.55,,,1037.55,Other,186% of Medicaid,672.8,,,672.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",672.8,,,672.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",672.8,,,672.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",588.7,70,,588.7,percent of total billed charges,All Other,262.4,,,262.4,Fee Schedule,,222.4,,,222.4,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",557.82,,,557.82,Other,100% of Medicaid,557.82,,,557.82,Other,100% of Medicaid,557.82,,,557.82,Other,100% of Medicaid,557.82,,,557.82,Other,100% of Medicaid,1255.1,,,1255.1,Other,225% of Medicaid,853.47,,,853.47,Other,153% of Medicaid,1255.1,,,1255.1,Other,225% of Medicaid,780.95,,,780.95,Other,140% of Medicaid,1255.1,,,1255.1,Other,225% of Medicaid,1450.34,,,1450.34,Other,260% of Medicaid,1807.35,,,1807.35,Other,324% of Medicaid,1199.32,,,1199.32,Other,215% of Medicaid,1199.32,,,1199.32,Other,215% of Medicaid,697.28,,,697.28,Other,125% of Medicaid,222.4,7216,
KNEE ARTHROGRAPHY INJ W/ FY MOD,27369,CPT,,42627369,CDM,360,RC,,,both,,,213,157.62,,,157.62,Other,150% of Medicare + 9.63% HCRA Surcharge,95.85,45,,95.85,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",105.44,,,105.44,Other,110% of Medicare,144.84,,,144.84,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",966.93,,,966.93,Other,186% of Medicaid,170.4,,,170.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",170.4,,,170.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",170.4,,,170.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",149.1,70,,149.1,percent of total billed charges,All Other,191.88,,,191.88,Fee Schedule,,162.63,,,162.63,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",519.86,,,519.86,Other,100% of Medicaid,519.86,,,519.86,Other,100% of Medicaid,519.86,,,519.86,Other,100% of Medicaid,519.86,,,519.86,Other,100% of Medicaid,1169.68,,,1169.68,Other,225% of Medicaid,795.38,,,795.38,Other,153% of Medicaid,1169.68,,,1169.68,Other,225% of Medicaid,727.8,,,727.8,Other,140% of Medicaid,1169.68,,,1169.68,Other,225% of Medicaid,1351.62,,,1351.62,Other,260% of Medicaid,1684.33,,,1684.33,Other,324% of Medicaid,1117.69,,,1117.69,Other,215% of Medicaid,1117.69,,,1117.69,Other,215% of Medicaid,649.82,,,649.82,Other,125% of Medicaid,95.85,7216,
ASPIRATE PLEURA W IMAGING W/ FY MOD,32555,CPT,,42632555,CDM,360,RC,,,both,,,2118,1567.33,,,1567.33,Other,150% of Medicare + 9.63% HCRA Surcharge,953.1,45,,953.1,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",1048.41,,,1048.41,Other,110% of Medicare,1440.24,,,1440.24,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1196.64,,,1196.64,Other,186% of Medicaid,1694.4,,,1694.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1694.4,,,1694.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1694.4,,,1694.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1482.6,70,,1482.6,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",643.35,,,643.35,Other,100% of Medicaid,643.35,,,643.35,Other,100% of Medicaid,643.35,,,643.35,Other,100% of Medicaid,643.35,,,643.35,Other,100% of Medicaid,1447.55,,,1447.55,Other,225% of Medicaid,984.33,,,984.33,Other,153% of Medicaid,1447.55,,,1447.55,Other,225% of Medicaid,900.7,,,900.7,Other,140% of Medicaid,1447.55,,,1447.55,Other,225% of Medicaid,1672.72,,,1672.72,Other,260% of Medicaid,2084.47,,,2084.47,Other,324% of Medicaid,1383.21,,,1383.21,Other,215% of Medicaid,1383.21,,,1383.21,Other,215% of Medicaid,804.19,,,804.19,Other,125% of Medicaid,643.35,7216,
INS NON-TUNNEL CV CATH 5 YRS W/ FY MOD,36556,CPT,,42636556,CDM,360,RC,,,both,,,6707,4963.2,,,4963.2,Other,150% of Medicare + 9.63% HCRA Surcharge,3018.15,45,,3018.15,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3648,,,3648,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3283,,,3283,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3101,,,3101,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3319.97,,,3319.97,Other,110% of Medicare,4560.76,,,4560.76,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",586.68,,,586.68,Other,186% of Medicaid,5365.6,,,5365.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",5365.6,,,5365.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",3578,,,3578,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",4694.9,70,,4694.9,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",315.42,,,315.42,Other,100% of Medicaid,315.42,,,315.42,Other,100% of Medicaid,315.42,,,315.42,Other,100% of Medicaid,315.42,,,315.42,Other,100% of Medicaid,709.7,,,709.7,Other,225% of Medicaid,482.6,,,482.6,Other,153% of Medicaid,709.7,,,709.7,Other,225% of Medicaid,441.59,,,441.59,Other,140% of Medicaid,709.7,,,709.7,Other,225% of Medicaid,820.1,,,820.1,Other,260% of Medicaid,1021.97,,,1021.97,Other,324% of Medicaid,678.16,,,678.16,Other,215% of Medicaid,678.16,,,678.16,Other,215% of Medicaid,394.28,,,394.28,Other,125% of Medicaid,315.42,7216,
INS TUNNELED CV CATH W SQ PORT W/ FY MOD,36560,CPT,,42636560,CDM,360,RC,,,both,,,8952,6624.5,,,6624.5,Other,150% of Medicare + 9.63% HCRA Surcharge,4028.4,45,,4028.4,percent of total billed charges,Critical Access Hospital RCC factor,3473,,,3473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3126,,,3126,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4476,,,4476,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4028,,,4028,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3805,,,3805,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4431.24,,,4431.24,Other,110% of Medicare,6152,,,6152,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2490.15,,,2490.15,Other,186% of Medicaid,7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",5266,,,5266,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",6266.4,70,,6266.4,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",4913,,,4913,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4422,,,4422,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4913,,,4913,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4176,,,4176,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",1338.79,,,1338.79,Other,100% of Medicaid,1338.79,,,1338.79,Other,100% of Medicaid,1338.79,,,1338.79,Other,100% of Medicaid,1338.79,,,1338.79,Other,100% of Medicaid,3012.28,,,3012.28,Other,225% of Medicaid,2048.35,,,2048.35,Other,153% of Medicaid,3012.28,,,3012.28,Other,225% of Medicaid,1874.31,,,1874.31,Other,140% of Medicaid,3012.28,,,3012.28,Other,225% of Medicaid,3480.85,,,3480.85,Other,260% of Medicaid,4337.68,,,4337.68,Other,324% of Medicaid,2878.4,,,2878.4,Other,215% of Medicaid,2878.4,,,2878.4,Other,215% of Medicaid,1673.49,,,1673.49,Other,125% of Medicaid,1338.79,9473,
REPLACE PICC CATH W/ FY MOD,36584,CPT,,42636584,CDM,360,RC,,,both,,,3500,2590.01,,,2590.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1575,45,,1575,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3648,,,3648,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3283,,,3283,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3101,,,3101,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",1732.5,,,1732.5,Other,110% of Medicare,2380,,,2380,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",586.68,,,586.68,Other,186% of Medicaid,2800,,,2800,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2800,,,2800,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",3578,,,3578,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2450,70,,2450,percent of total billed charges,All Other,280.44,,,280.44,Fee Schedule,,237.69,,,237.69,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",315.42,,,315.42,Other,100% of Medicaid,315.42,,,315.42,Other,100% of Medicaid,315.42,,,315.42,Other,100% of Medicaid,315.42,,,315.42,Other,100% of Medicaid,709.7,,,709.7,Other,225% of Medicaid,482.6,,,482.6,Other,153% of Medicaid,709.7,,,709.7,Other,225% of Medicaid,441.59,,,441.59,Other,140% of Medicaid,709.7,,,709.7,Other,225% of Medicaid,820.1,,,820.1,Other,260% of Medicaid,1021.97,,,1021.97,Other,324% of Medicaid,678.16,,,678.16,Other,215% of Medicaid,678.16,,,678.16,Other,215% of Medicaid,394.28,,,394.28,Other,125% of Medicaid,237.69,7216,
INJ FOR SIALOGRAPHY W/ FY MOD,42550,CPT,,42642550,CDM,360,RC,,,both,,,246,182.04,,,182.04,Other,150% of Medicare + 9.63% HCRA Surcharge,110.7,45,,110.7,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",121.77,,,121.77,Other,110% of Medicare,167.28,,,167.28,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",966.93,,,966.93,Other,186% of Medicaid,196.8,,,196.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",196.8,,,196.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",196.8,,,196.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",172.2,70,,172.2,percent of total billed charges,All Other,295.2,,,295.2,Fee Schedule,,250.2,,,250.2,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",519.86,,,519.86,Other,100% of Medicaid,519.86,,,519.86,Other,100% of Medicaid,519.86,,,519.86,Other,100% of Medicaid,519.86,,,519.86,Other,100% of Medicaid,1169.68,,,1169.68,Other,225% of Medicaid,795.38,,,795.38,Other,153% of Medicaid,1169.68,,,1169.68,Other,225% of Medicaid,727.8,,,727.8,Other,140% of Medicaid,1169.68,,,1169.68,Other,225% of Medicaid,1351.62,,,1351.62,Other,260% of Medicaid,1684.33,,,1684.33,Other,324% of Medicaid,1117.69,,,1117.69,Other,215% of Medicaid,1117.69,,,1117.69,Other,215% of Medicaid,649.82,,,649.82,Other,125% of Medicaid,110.7,7216,
INJECTION FOR CHOLANGIOGRAM W/ FY MOD,47531,CPT,,42647531,CDM,360,RC,,,both,,,7974,5900.78,,,5900.78,Other,150% of Medicare + 9.63% HCRA Surcharge,3588.3,45,,3588.3,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4476,,,4476,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4028,,,4028,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3805,,,3805,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3947.13,,,3947.13,Other,110% of Medicare,5422.32,,,5422.32,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",786.95,,,786.95,Other,186% of Medicaid,6379.2,,,6379.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",6379.2,,,6379.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",6379.2,,,6379.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",5581.8,70,,5581.8,percent of total billed charges,All Other,332.92,,,332.92,Fee Schedule,,282.17,,,282.17,Fee Schedule,,4913,,,4913,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4422,,,4422,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4913,,,4913,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4176,,,4176,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",423.09,,,423.09,Other,100% of Medicaid,423.09,,,423.09,Other,100% of Medicaid,423.09,,,423.09,Other,100% of Medicaid,423.09,,,423.09,Other,100% of Medicaid,951.96,,,951.96,Other,225% of Medicaid,647.33,,,647.33,Other,153% of Medicaid,951.96,,,951.96,Other,225% of Medicaid,592.33,,,592.33,Other,140% of Medicaid,951.96,,,951.96,Other,225% of Medicaid,1100.04,,,1100.04,Other,260% of Medicaid,1370.82,,,1370.82,Other,324% of Medicaid,909.65,,,909.65,Other,215% of Medicaid,909.65,,,909.65,Other,215% of Medicaid,528.86,,,528.86,Other,125% of Medicaid,282.17,7216,
INJ TO EVAL PERITONEAL-VENOUS W/ FY MOD,49427,CPT,,42649427,CDM,360,RC,,,both,,,177,130.98,,,130.98,Other,150% of Medicare + 9.63% HCRA Surcharge,79.65,45,,79.65,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",87.62,,,87.62,Other,110% of Medicare,120.36,,,120.36,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",966.93,,,966.93,Other,186% of Medicaid,141.6,,,141.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",141.6,,,141.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",141.6,,,141.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",123.9,70,,123.9,percent of total billed charges,All Other,185.32,,,185.32,Fee Schedule,,157.07,,,157.07,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",519.86,,,519.86,Other,100% of Medicaid,519.86,,,519.86,Other,100% of Medicaid,519.86,,,519.86,Other,100% of Medicaid,519.86,,,519.86,Other,100% of Medicaid,1169.68,,,1169.68,Other,225% of Medicaid,795.38,,,795.38,Other,153% of Medicaid,1169.68,,,1169.68,Other,225% of Medicaid,727.8,,,727.8,Other,140% of Medicaid,1169.68,,,1169.68,Other,225% of Medicaid,1351.62,,,1351.62,Other,260% of Medicaid,1684.33,,,1684.33,Other,324% of Medicaid,1117.69,,,1117.69,Other,215% of Medicaid,1117.69,,,1117.69,Other,215% of Medicaid,649.82,,,649.82,Other,125% of Medicaid,79.65,7216,
FLUORO EXAM OF G/COLON TUBE W/ FY MOD,49465,CPT,,42649465,CDM,360,RC,,,both,,,655,484.7,,,484.7,Other,150% of Medicare + 9.63% HCRA Surcharge,294.75,45,,294.75,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",324.23,,,324.23,Other,110% of Medicare,445.4,,,445.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",623.23,,,623.23,Other,186% of Medicaid,524,,,524,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",524,,,524,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",524,,,524,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",458.5,70,,458.5,percent of total billed charges,All Other,144.32,,,144.32,Fee Schedule,,122.32,,,122.32,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",335.07,,,335.07,Other,100% of Medicaid,335.07,,,335.07,Other,100% of Medicaid,335.07,,,335.07,Other,100% of Medicaid,335.07,,,335.07,Other,100% of Medicaid,753.91,,,753.91,Other,225% of Medicaid,512.66,,,512.66,Other,153% of Medicaid,753.91,,,753.91,Other,225% of Medicaid,469.1,,,469.1,Other,140% of Medicaid,753.91,,,753.91,Other,225% of Medicaid,871.18,,,871.18,Other,260% of Medicaid,1085.63,,,1085.63,Other,324% of Medicaid,720.4,,,720.4,Other,215% of Medicaid,720.4,,,720.4,Other,215% of Medicaid,418.84,,,418.84,Other,125% of Medicaid,122.32,7216,
NJX PX NFROSGRM &/URTRGRM W/ FY MOD,50431,CPT,,42650431,CDM,360,RC,,,both,,,2318,1715.33,,,1715.33,Other,150% of Medicare + 9.63% HCRA Surcharge,1043.1,45,,1043.1,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",1147.41,,,1147.41,Other,110% of Medicare,1576.24,,,1576.24,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",903.43,,,903.43,Other,186% of Medicaid,1854.4,,,1854.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1854.4,,,1854.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1854.4,,,1854.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1622.6,70,,1622.6,percent of total billed charges,All Other,309.96,,,309.96,Fee Schedule,,262.71,,,262.71,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",485.72,,,485.72,Other,100% of Medicaid,485.72,,,485.72,Other,100% of Medicaid,485.72,,,485.72,Other,100% of Medicaid,485.72,,,485.72,Other,100% of Medicaid,1092.86,,,1092.86,Other,225% of Medicaid,743.14,,,743.14,Other,153% of Medicaid,1092.86,,,1092.86,Other,225% of Medicaid,680,,,680,Other,140% of Medicaid,1092.86,,,1092.86,Other,225% of Medicaid,1262.86,,,1262.86,Other,260% of Medicaid,1573.72,,,1573.72,Other,324% of Medicaid,1044.29,,,1044.29,Other,215% of Medicaid,1044.29,,,1044.29,Other,215% of Medicaid,607.14,,,607.14,Other,125% of Medicaid,262.71,7216,
CYSTO W DIL OF URETHRAL STRICT W/ FY MOD,52281,CPT,,42652281,CDM,360,RC,,,both,,,5732,4241.69,,,4241.69,Other,150% of Medicare + 9.63% HCRA Surcharge,2579.4,45,,2579.4,percent of total billed charges,Critical Access Hospital RCC factor,2480,,,2480,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2232,,,2232,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3648,,,3648,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3283,,,3283,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3101,,,3101,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2837.34,,,2837.34,Other,110% of Medicare,3897.76,,,3897.76,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2876.72,,,2876.72,Other,186% of Medicaid,4585.6,,,4585.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",4585.6,,,4585.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",4252,,,4252,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",4012.4,70,,4012.4,percent of total billed charges,All Other,3387,,,3387,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",2879,,,2879,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",4055,,,4055,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3649,,,3649,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4055,,,4055,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3448,,,3448,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",1546.62,,,1546.62,Other,100% of Medicaid,1546.62,,,1546.62,Other,100% of Medicaid,1546.62,,,1546.62,Other,100% of Medicaid,1546.62,,,1546.62,Other,100% of Medicaid,3479.91,,,3479.91,Other,225% of Medicaid,2366.34,,,2366.34,Other,153% of Medicaid,3479.91,,,3479.91,Other,225% of Medicaid,2165.27,,,2165.27,Other,140% of Medicaid,3479.91,,,3479.91,Other,225% of Medicaid,4021.22,,,4021.22,Other,260% of Medicaid,5011.06,,,5011.06,Other,324% of Medicaid,3325.24,,,3325.24,Other,215% of Medicaid,3325.24,,,3325.24,Other,215% of Medicaid,1933.28,,,1933.28,Other,125% of Medicaid,1546.62,7216,
INJECT FOR SPINE DISK XR LU W/ FY MOD,62290,CPT,,42662290,CDM,360,RC,,,both,,,652,482.48,,,482.48,Other,150% of Medicare + 9.63% HCRA Surcharge,293.4,45,,293.4,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",322.74,,,322.74,Other,110% of Medicare,443.36,,,443.36,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",966.93,,,966.93,Other,186% of Medicaid,521.6,,,521.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",521.6,,,521.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",521.6,,,521.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",456.4,70,,456.4,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",519.86,,,519.86,Other,100% of Medicaid,519.86,,,519.86,Other,100% of Medicaid,519.86,,,519.86,Other,100% of Medicaid,519.86,,,519.86,Other,100% of Medicaid,1169.68,,,1169.68,Other,225% of Medicaid,795.38,,,795.38,Other,153% of Medicaid,1169.68,,,1169.68,Other,225% of Medicaid,727.8,,,727.8,Other,140% of Medicaid,1169.68,,,1169.68,Other,225% of Medicaid,1351.62,,,1351.62,Other,260% of Medicaid,1684.33,,,1684.33,Other,324% of Medicaid,1117.69,,,1117.69,Other,215% of Medicaid,1117.69,,,1117.69,Other,215% of Medicaid,649.82,,,649.82,Other,125% of Medicaid,293.4,7216,
MYELOGRAPHY LUMBAR INJECTION W/ FY MOD,62302,CPT,,42662302,CDM,360,RC,,,both,,,2329,1723.47,,,1723.47,Other,150% of Medicare + 9.63% HCRA Surcharge,1048.05,45,,1048.05,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",1152.86,,,1152.86,Other,110% of Medicare,1583.72,,,1583.72,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1185.33,,,1185.33,Other,186% of Medicaid,1863.2,,,1863.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1863.2,,,1863.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1863.2,,,1863.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1630.3,70,,1630.3,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",637.28,,,637.28,Other,100% of Medicaid,637.28,,,637.28,Other,100% of Medicaid,637.28,,,637.28,Other,100% of Medicaid,637.28,,,637.28,Other,100% of Medicaid,1433.87,,,1433.87,Other,225% of Medicaid,975.03,,,975.03,Other,153% of Medicaid,1433.87,,,1433.87,Other,225% of Medicaid,892.19,,,892.19,Other,140% of Medicaid,1433.87,,,1433.87,Other,225% of Medicaid,1656.92,,,1656.92,Other,260% of Medicaid,2064.77,,,2064.77,Other,324% of Medicaid,1370.14,,,1370.14,Other,215% of Medicaid,1370.14,,,1370.14,Other,215% of Medicaid,796.59,,,796.59,Other,125% of Medicaid,637.28,7216,
MYELOGRAPHY LUMBAR INJECTION W/ FY MOD,62303,CPT,,42662303,CDM,360,RC,,,both,,,2329,1723.47,,,1723.47,Other,150% of Medicare + 9.63% HCRA Surcharge,1048.05,45,,1048.05,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",1152.86,,,1152.86,Other,110% of Medicare,1583.72,,,1583.72,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1185.33,,,1185.33,Other,186% of Medicaid,1863.2,,,1863.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1863.2,,,1863.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1863.2,,,1863.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1630.3,70,,1630.3,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",637.28,,,637.28,Other,100% of Medicaid,637.28,,,637.28,Other,100% of Medicaid,637.28,,,637.28,Other,100% of Medicaid,637.28,,,637.28,Other,100% of Medicaid,1433.87,,,1433.87,Other,225% of Medicaid,975.03,,,975.03,Other,153% of Medicaid,1433.87,,,1433.87,Other,225% of Medicaid,892.19,,,892.19,Other,140% of Medicaid,1433.87,,,1433.87,Other,225% of Medicaid,1656.92,,,1656.92,Other,260% of Medicaid,2064.77,,,2064.77,Other,324% of Medicaid,1370.14,,,1370.14,Other,215% of Medicaid,1370.14,,,1370.14,Other,215% of Medicaid,796.59,,,796.59,Other,125% of Medicaid,637.28,7216,
MYELOGRAPHY LUMBAR INJECTION W/ FY MOD,62304,CPT,,42662304,CDM,360,RC,,,both,,,2329,1723.47,,,1723.47,Other,150% of Medicare + 9.63% HCRA Surcharge,1048.05,45,,1048.05,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",1152.86,,,1152.86,Other,110% of Medicare,1583.72,,,1583.72,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1185.33,,,1185.33,Other,186% of Medicaid,1863.2,,,1863.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1863.2,,,1863.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1863.2,,,1863.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1630.3,70,,1630.3,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",637.28,,,637.28,Other,100% of Medicaid,637.28,,,637.28,Other,100% of Medicaid,637.28,,,637.28,Other,100% of Medicaid,637.28,,,637.28,Other,100% of Medicaid,1433.87,,,1433.87,Other,225% of Medicaid,975.03,,,975.03,Other,153% of Medicaid,1433.87,,,1433.87,Other,225% of Medicaid,892.19,,,892.19,Other,140% of Medicaid,1433.87,,,1433.87,Other,225% of Medicaid,1656.92,,,1656.92,Other,260% of Medicaid,2064.77,,,2064.77,Other,324% of Medicaid,1370.14,,,1370.14,Other,215% of Medicaid,1370.14,,,1370.14,Other,215% of Medicaid,796.59,,,796.59,Other,125% of Medicaid,637.28,7216,
MYELOGRAPHY LUMBAR INJECTION W/ FY MOD,62305,CPT,,42662305,CDM,360,RC,,,both,,,2329,1723.47,,,1723.47,Other,150% of Medicare + 9.63% HCRA Surcharge,1048.05,45,,1048.05,percent of total billed charges,Critical Access Hospital RCC factor,2480,,,2480,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2232,,,2232,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",1152.86,,,1152.86,Other,110% of Medicare,1583.72,,,1583.72,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1185.33,,,1185.33,Other,186% of Medicaid,1863.2,,,1863.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1863.2,,,1863.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1863.2,,,1863.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1630.3,70,,1630.3,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",637.28,,,637.28,Other,100% of Medicaid,637.28,,,637.28,Other,100% of Medicaid,637.28,,,637.28,Other,100% of Medicaid,637.28,,,637.28,Other,100% of Medicaid,1433.87,,,1433.87,Other,225% of Medicaid,975.03,,,975.03,Other,153% of Medicaid,1433.87,,,1433.87,Other,225% of Medicaid,892.19,,,892.19,Other,140% of Medicaid,1433.87,,,1433.87,Other,225% of Medicaid,1656.92,,,1656.92,Other,260% of Medicaid,2064.77,,,2064.77,Other,324% of Medicaid,1370.14,,,1370.14,Other,215% of Medicaid,1370.14,,,1370.14,Other,215% of Medicaid,796.59,,,796.59,Other,125% of Medicaid,637.28,7216,
INJ FACET JNT-LMBR/SACRL W/ FY MOD,64493,CPT,,42664493,CDM,360,RC,,,both,,,2477,1832.99,,,1832.99,Other,150% of Medicare + 9.63% HCRA Surcharge,1114.65,45,,1114.65,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",1226.12,,,1226.12,Other,110% of Medicare,1684.36,,,1684.36,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1116.35,,,1116.35,Other,186% of Medicaid,1981.6,,,1981.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1981.6,,,1981.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1981.6,,,1981.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1733.9,70,,1733.9,percent of total billed charges,All Other,431.32,,,431.32,Fee Schedule,,365.57,,,365.57,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",600.19,,,600.19,Other,100% of Medicaid,600.19,,,600.19,Other,100% of Medicaid,600.19,,,600.19,Other,100% of Medicaid,600.19,,,600.19,Other,100% of Medicaid,1350.43,,,1350.43,Other,225% of Medicaid,918.29,,,918.29,Other,153% of Medicaid,1350.43,,,1350.43,Other,225% of Medicaid,840.26,,,840.26,Other,140% of Medicaid,1350.43,,,1350.43,Other,225% of Medicaid,1560.49,,,1560.49,Other,260% of Medicaid,1944.61,,,1944.61,Other,324% of Medicaid,1290.41,,,1290.41,Other,215% of Medicaid,1290.41,,,1290.41,Other,215% of Medicaid,750.24,,,750.24,Other,125% of Medicaid,365.57,7216,
INJ ANES FACET JT L/S ADDL W/ FY MOD,64494,CPT,,42664494,CDM,360,RC,,,both,,,918,679.32,,,679.32,Other,150% of Medicare + 9.63% HCRA Surcharge,413.1,45,,413.1,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",454.41,,,454.41,Other,110% of Medicare,624.24,,,624.24,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1116.35,,,1116.35,Other,186% of Medicaid,734.4,,,734.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",734.4,,,734.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",734.4,,,734.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",642.6,70,,642.6,percent of total billed charges,All Other,246,,,246,Fee Schedule,,208.5,,,208.5,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",600.19,,,600.19,Other,100% of Medicaid,600.19,,,600.19,Other,100% of Medicaid,600.19,,,600.19,Other,100% of Medicaid,600.19,,,600.19,Other,100% of Medicaid,1350.43,,,1350.43,Other,225% of Medicaid,918.29,,,918.29,Other,153% of Medicaid,1350.43,,,1350.43,Other,225% of Medicaid,840.26,,,840.26,Other,140% of Medicaid,1350.43,,,1350.43,Other,225% of Medicaid,1560.49,,,1560.49,Other,260% of Medicaid,1944.61,,,1944.61,Other,324% of Medicaid,1290.41,,,1290.41,Other,215% of Medicaid,1290.41,,,1290.41,Other,215% of Medicaid,750.24,,,750.24,Other,125% of Medicaid,208.5,7216,
INJECTION FOR CHOLANGIOGRAM W/ FY MOD,47531,CPT,FY,43047531,CDM,360,RC,,,both,,,7974,5900.78,,,5900.78,Other,150% of Medicare + 9.63% HCRA Surcharge,3588.3,45,,3588.3,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4476,,,4476,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4028,,,4028,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3805,,,3805,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3947.13,,,3947.13,Other,110% of Medicare,5422.32,,,5422.32,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",786.95,,,786.95,Other,186% of Medicaid,6379.2,,,6379.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",6379.2,,,6379.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",6379.2,,,6379.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",5581.8,70,,5581.8,percent of total billed charges,All Other,332.92,,,332.92,Fee Schedule,,282.17,,,282.17,Fee Schedule,,4913,,,4913,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4422,,,4422,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4913,,,4913,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4176,,,4176,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",423.09,,,423.09,Other,100% of Medicaid,423.09,,,423.09,Other,100% of Medicaid,423.09,,,423.09,Other,100% of Medicaid,423.09,,,423.09,Other,100% of Medicaid,951.96,,,951.96,Other,225% of Medicaid,647.33,,,647.33,Other,153% of Medicaid,951.96,,,951.96,Other,225% of Medicaid,592.33,,,592.33,Other,140% of Medicaid,951.96,,,951.96,Other,225% of Medicaid,1100.04,,,1100.04,Other,260% of Medicaid,1370.82,,,1370.82,Other,324% of Medicaid,909.65,,,909.65,Other,215% of Medicaid,909.65,,,909.65,Other,215% of Medicaid,528.86,,,528.86,Other,125% of Medicaid,282.17,7216,
FLUORO EXAM OF G/COLON TUBE W/ FY MOD,49465,CPT,FY,43049465,CDM,360,RC,,,both,,,655,484.7,,,484.7,Other,150% of Medicare + 9.63% HCRA Surcharge,294.75,45,,294.75,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",324.23,,,324.23,Other,110% of Medicare,445.4,,,445.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",623.23,,,623.23,Other,186% of Medicaid,524,,,524,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",524,,,524,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",524,,,524,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",458.5,70,,458.5,percent of total billed charges,All Other,144.32,,,144.32,Fee Schedule,,122.32,,,122.32,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",335.07,,,335.07,Other,100% of Medicaid,335.07,,,335.07,Other,100% of Medicaid,335.07,,,335.07,Other,100% of Medicaid,335.07,,,335.07,Other,100% of Medicaid,753.91,,,753.91,Other,225% of Medicaid,512.66,,,512.66,Other,153% of Medicaid,753.91,,,753.91,Other,225% of Medicaid,469.1,,,469.1,Other,140% of Medicaid,753.91,,,753.91,Other,225% of Medicaid,871.18,,,871.18,Other,260% of Medicaid,1085.63,,,1085.63,Other,324% of Medicaid,720.4,,,720.4,Other,215% of Medicaid,720.4,,,720.4,Other,215% of Medicaid,418.84,,,418.84,Other,125% of Medicaid,122.32,7216,
INJ FACET JNT-LMBR/SACRL W/ FY MOD,64493,CPT,FY,43064493,CDM,360,RC,,,both,,,2477,1832.99,,,1832.99,Other,150% of Medicare + 9.63% HCRA Surcharge,1114.65,45,,1114.65,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",1226.12,,,1226.12,Other,110% of Medicare,1684.36,,,1684.36,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1116.35,,,1116.35,Other,186% of Medicaid,1981.6,,,1981.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1981.6,,,1981.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1981.6,,,1981.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1733.9,70,,1733.9,percent of total billed charges,All Other,431.32,,,431.32,Fee Schedule,,365.57,,,365.57,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",600.19,,,600.19,Other,100% of Medicaid,600.19,,,600.19,Other,100% of Medicaid,600.19,,,600.19,Other,100% of Medicaid,600.19,,,600.19,Other,100% of Medicaid,1350.43,,,1350.43,Other,225% of Medicaid,918.29,,,918.29,Other,153% of Medicaid,1350.43,,,1350.43,Other,225% of Medicaid,840.26,,,840.26,Other,140% of Medicaid,1350.43,,,1350.43,Other,225% of Medicaid,1560.49,,,1560.49,Other,260% of Medicaid,1944.61,,,1944.61,Other,324% of Medicaid,1290.41,,,1290.41,Other,215% of Medicaid,1290.41,,,1290.41,Other,215% of Medicaid,750.24,,,750.24,Other,125% of Medicaid,365.57,7216,
INJ ANES FACET JT L/S ADDL W/ FY MOD,64494,CPT,FY,43064494,CDM,360,RC,,,both,,,918,679.32,,,679.32,Other,150% of Medicare + 9.63% HCRA Surcharge,413.1,45,,413.1,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",454.41,,,454.41,Other,110% of Medicare,624.24,,,624.24,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1116.35,,,1116.35,Other,186% of Medicaid,734.4,,,734.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",734.4,,,734.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",734.4,,,734.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",642.6,70,,642.6,percent of total billed charges,All Other,246,,,246,Fee Schedule,,208.5,,,208.5,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",600.19,,,600.19,Other,100% of Medicaid,600.19,,,600.19,Other,100% of Medicaid,600.19,,,600.19,Other,100% of Medicaid,600.19,,,600.19,Other,100% of Medicaid,1350.43,,,1350.43,Other,225% of Medicaid,918.29,,,918.29,Other,153% of Medicaid,1350.43,,,1350.43,Other,225% of Medicaid,840.26,,,840.26,Other,140% of Medicaid,1350.43,,,1350.43,Other,225% of Medicaid,1560.49,,,1560.49,Other,260% of Medicaid,1944.61,,,1944.61,Other,324% of Medicaid,1290.41,,,1290.41,Other,215% of Medicaid,1290.41,,,1290.41,Other,215% of Medicaid,750.24,,,750.24,Other,125% of Medicaid,208.5,7216,
FNA BX W/US GDN 1ST LES,10005,CPT,,44010005,CDM,360,RC,,,both,,,2621,1939.55,,,1939.55,Other,150% of Medicare + 9.63% HCRA Surcharge,1179.45,45,,1179.45,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",1297.4,,,1297.4,Other,110% of Medicare,1782.28,,,1782.28,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1037.55,,,1037.55,Other,186% of Medicaid,2096.8,,,2096.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2096.8,,,2096.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2096.8,,,2096.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1834.7,70,,1834.7,percent of total billed charges,All Other,355.88,,,355.88,Fee Schedule,,301.63,,,301.63,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",557.82,,,557.82,Other,100% of Medicaid,557.82,,,557.82,Other,100% of Medicaid,557.82,,,557.82,Other,100% of Medicaid,557.82,,,557.82,Other,100% of Medicaid,1255.1,,,1255.1,Other,225% of Medicaid,853.47,,,853.47,Other,153% of Medicaid,1255.1,,,1255.1,Other,225% of Medicaid,780.95,,,780.95,Other,140% of Medicaid,1255.1,,,1255.1,Other,225% of Medicaid,1450.34,,,1450.34,Other,260% of Medicaid,1807.35,,,1807.35,Other,324% of Medicaid,1199.32,,,1199.32,Other,215% of Medicaid,1199.32,,,1199.32,Other,215% of Medicaid,697.28,,,697.28,Other,125% of Medicaid,301.63,7216,
FNA BX W/US GDN EA ADDL,10006,CPT,,44010006,CDM,360,RC,,,both,,,1310,969.4,,,969.4,Other,150% of Medicare + 9.63% HCRA Surcharge,589.5,45,,589.5,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",648.45,,,648.45,Other,110% of Medicare,890.8,,,890.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1037.55,,,1037.55,Other,186% of Medicaid,1048,,,1048,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1048,,,1048,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1048,,,1048,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",917,70,,917,percent of total billed charges,All Other,242.72,,,242.72,Fee Schedule,,205.72,,,205.72,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",557.82,,,557.82,Other,100% of Medicaid,557.82,,,557.82,Other,100% of Medicaid,557.82,,,557.82,Other,100% of Medicaid,557.82,,,557.82,Other,100% of Medicaid,1255.1,,,1255.1,Other,225% of Medicaid,853.47,,,853.47,Other,153% of Medicaid,1255.1,,,1255.1,Other,225% of Medicaid,780.95,,,780.95,Other,140% of Medicaid,1255.1,,,1255.1,Other,225% of Medicaid,1450.34,,,1450.34,Other,260% of Medicaid,1807.35,,,1807.35,Other,324% of Medicaid,1199.32,,,1199.32,Other,215% of Medicaid,1199.32,,,1199.32,Other,215% of Medicaid,697.28,,,697.28,Other,125% of Medicaid,205.72,7216,
FNA BX W/FLUOR GDN 1ST LES,10007,CPT,,44010007,CDM,360,RC,,,both,,,2449,1812.27,,,1812.27,Other,150% of Medicare + 9.63% HCRA Surcharge,1102.05,45,,1102.05,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",1212.26,,,1212.26,Other,110% of Medicare,1665.32,,,1665.32,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1037.55,,,1037.55,Other,186% of Medicaid,1959.2,,,1959.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1959.2,,,1959.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1959.2,,,1959.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1714.3,70,,1714.3,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",557.82,,,557.82,Other,100% of Medicaid,557.82,,,557.82,Other,100% of Medicaid,557.82,,,557.82,Other,100% of Medicaid,557.82,,,557.82,Other,100% of Medicaid,1255.1,,,1255.1,Other,225% of Medicaid,853.47,,,853.47,Other,153% of Medicaid,1255.1,,,1255.1,Other,225% of Medicaid,780.95,,,780.95,Other,140% of Medicaid,1255.1,,,1255.1,Other,225% of Medicaid,1450.34,,,1450.34,Other,260% of Medicaid,1807.35,,,1807.35,Other,324% of Medicaid,1199.32,,,1199.32,Other,215% of Medicaid,1199.32,,,1199.32,Other,215% of Medicaid,697.28,,,697.28,Other,125% of Medicaid,557.82,7216,
FNA BX W/FLUOR GDN EA ADDL,10008,CPT,,44010008,CDM,360,RC,,,both,,,1202,889.48,,,889.48,Other,150% of Medicare + 9.63% HCRA Surcharge,540.9,45,,540.9,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",594.99,,,594.99,Other,110% of Medicare,817.36,,,817.36,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1037.55,,,1037.55,Other,186% of Medicaid,961.6,,,961.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",961.6,,,961.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",961.6,,,961.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",841.4,70,,841.4,percent of total billed charges,All Other,275.52,,,275.52,Fee Schedule,,233.52,,,233.52,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",557.82,,,557.82,Other,100% of Medicaid,557.82,,,557.82,Other,100% of Medicaid,557.82,,,557.82,Other,100% of Medicaid,557.82,,,557.82,Other,100% of Medicaid,1255.1,,,1255.1,Other,225% of Medicaid,853.47,,,853.47,Other,153% of Medicaid,1255.1,,,1255.1,Other,225% of Medicaid,780.95,,,780.95,Other,140% of Medicaid,1255.1,,,1255.1,Other,225% of Medicaid,1450.34,,,1450.34,Other,260% of Medicaid,1807.35,,,1807.35,Other,324% of Medicaid,1199.32,,,1199.32,Other,215% of Medicaid,1199.32,,,1199.32,Other,215% of Medicaid,697.28,,,697.28,Other,125% of Medicaid,233.52,7216,
FNA BX W/CT GDN 1ST LES,10009,CPT,,44010009,CDM,360,RC,,,both,,,2449,1812.27,,,1812.27,Other,150% of Medicare + 9.63% HCRA Surcharge,1102.05,45,,1102.05,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",1212.26,,,1212.26,Other,110% of Medicare,1665.32,,,1665.32,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1037.55,,,1037.55,Other,186% of Medicaid,1959.2,,,1959.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1959.2,,,1959.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1959.2,,,1959.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1714.3,70,,1714.3,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",557.82,,,557.82,Other,100% of Medicaid,557.82,,,557.82,Other,100% of Medicaid,557.82,,,557.82,Other,100% of Medicaid,557.82,,,557.82,Other,100% of Medicaid,1255.1,,,1255.1,Other,225% of Medicaid,853.47,,,853.47,Other,153% of Medicaid,1255.1,,,1255.1,Other,225% of Medicaid,780.95,,,780.95,Other,140% of Medicaid,1255.1,,,1255.1,Other,225% of Medicaid,1450.34,,,1450.34,Other,260% of Medicaid,1807.35,,,1807.35,Other,324% of Medicaid,1199.32,,,1199.32,Other,215% of Medicaid,1199.32,,,1199.32,Other,215% of Medicaid,697.28,,,697.28,Other,125% of Medicaid,557.82,7216,
FNA BX W/CT GDN EA ADDL,10010,CPT,,44010010,CDM,360,RC,,,both,,,1224,905.76,,,905.76,Other,150% of Medicare + 9.63% HCRA Surcharge,550.8,45,,550.8,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",605.88,,,605.88,Other,110% of Medicare,832.32,,,832.32,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1037.55,,,1037.55,Other,186% of Medicaid,979.2,,,979.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",979.2,,,979.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",979.2,,,979.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",856.8,70,,856.8,percent of total billed charges,All Other,382.12,,,382.12,Fee Schedule,,323.87,,,323.87,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",557.82,,,557.82,Other,100% of Medicaid,557.82,,,557.82,Other,100% of Medicaid,557.82,,,557.82,Other,100% of Medicaid,557.82,,,557.82,Other,100% of Medicaid,1255.1,,,1255.1,Other,225% of Medicaid,853.47,,,853.47,Other,153% of Medicaid,1255.1,,,1255.1,Other,225% of Medicaid,780.95,,,780.95,Other,140% of Medicaid,1255.1,,,1255.1,Other,225% of Medicaid,1450.34,,,1450.34,Other,260% of Medicaid,1807.35,,,1807.35,Other,324% of Medicaid,1199.32,,,1199.32,Other,215% of Medicaid,1199.32,,,1199.32,Other,215% of Medicaid,697.28,,,697.28,Other,125% of Medicaid,323.87,7216,
PLACE PO BREAST CATH FOR RAD,19296,CPT,,44019296,CDM,360,RC,,,both,,,19821,14667.59,,,14667.59,Other,150% of Medicare + 9.63% HCRA Surcharge,8919.45,45,,8919.45,percent of total billed charges,Critical Access Hospital RCC factor,7938,,,7938,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",7144,,,7144,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",7978,,,7978,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",7180,,,7180,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",6781,,,6781,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",9811.4,,,9811.4,Other,110% of Medicare,6152,,,6152,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",3861.21,,,3861.21,Other,186% of Medicaid,7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9196,,,9196,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",13874.7,70,,13874.7,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",6331,,,6331,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",5698,,,5698,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",6331,,,6331,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",5381,,,5381,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2075.92,,,2075.92,Other,100% of Medicaid,2075.92,,,2075.92,Other,100% of Medicaid,2075.92,,,2075.92,Other,100% of Medicaid,2075.92,,,2075.92,Other,100% of Medicaid,4670.82,,,4670.82,Other,225% of Medicaid,3176.15,,,3176.15,Other,153% of Medicaid,4670.82,,,4670.82,Other,225% of Medicaid,2906.29,,,2906.29,Other,140% of Medicaid,4670.82,,,4670.82,Other,225% of Medicaid,5397.39,,,5397.39,Other,260% of Medicaid,6725.98,,,6725.98,Other,324% of Medicaid,4463.22,,,4463.22,Other,215% of Medicaid,4463.22,,,4463.22,Other,215% of Medicaid,2594.9,,,2594.9,Other,125% of Medicaid,2075.92,14667.59,
CORE NDL BX LNG/MED PERQ,32408,CPT,,44032408,CDM,360,RC,,,both,,,4606,3408.45,,,3408.45,Other,150% of Medicare + 9.63% HCRA Surcharge,2072.7,45,,2072.7,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3648,,,3648,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3283,,,3283,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3101,,,3101,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2279.97,,,2279.97,Other,110% of Medicare,3132.08,,,3132.08,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1196.64,,,1196.64,Other,186% of Medicaid,3684.8,,,3684.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",3684.8,,,3684.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",3684.8,,,3684.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",3224.2,70,,3224.2,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",4055,,,4055,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3649,,,3649,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4055,,,4055,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3448,,,3448,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",643.35,,,643.35,Other,100% of Medicaid,643.35,,,643.35,Other,100% of Medicaid,643.35,,,643.35,Other,100% of Medicaid,643.35,,,643.35,Other,100% of Medicaid,1447.55,,,1447.55,Other,225% of Medicaid,984.33,,,984.33,Other,153% of Medicaid,1447.55,,,1447.55,Other,225% of Medicaid,900.7,,,900.7,Other,140% of Medicaid,1447.55,,,1447.55,Other,225% of Medicaid,1672.72,,,1672.72,Other,260% of Medicaid,2084.47,,,2084.47,Other,324% of Medicaid,1383.21,,,1383.21,Other,215% of Medicaid,1383.21,,,1383.21,Other,215% of Medicaid,804.19,,,804.19,Other,125% of Medicaid,643.35,7216,
ASPIRATE PLEURA W IMAGING,32555,CPT,,44032555,CDM,360,RC,,,both,,,2118,1567.33,,,1567.33,Other,150% of Medicare + 9.63% HCRA Surcharge,953.1,45,,953.1,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",1048.41,,,1048.41,Other,110% of Medicare,1440.24,,,1440.24,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1196.64,,,1196.64,Other,186% of Medicaid,1694.4,,,1694.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1694.4,,,1694.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1694.4,,,1694.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1482.6,70,,1482.6,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",643.35,,,643.35,Other,100% of Medicaid,643.35,,,643.35,Other,100% of Medicaid,643.35,,,643.35,Other,100% of Medicaid,643.35,,,643.35,Other,100% of Medicaid,1447.55,,,1447.55,Other,225% of Medicaid,984.33,,,984.33,Other,153% of Medicaid,1447.55,,,1447.55,Other,225% of Medicaid,900.7,,,900.7,Other,140% of Medicaid,1447.55,,,1447.55,Other,225% of Medicaid,1672.72,,,1672.72,Other,260% of Medicaid,2084.47,,,2084.47,Other,324% of Medicaid,1383.21,,,1383.21,Other,215% of Medicaid,1383.21,,,1383.21,Other,215% of Medicaid,804.19,,,804.19,Other,125% of Medicaid,643.35,7216,
BIOPSY LYMPH NODE NEEDLE,38505,CPT,,44038505,CDM,360,RC,,,both,,,3377,2498.99,,,2498.99,Other,150% of Medicare + 9.63% HCRA Surcharge,1519.65,45,,1519.65,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3648,,,3648,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3283,,,3283,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3101,,,3101,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",1671.62,,,1671.62,Other,110% of Medicare,2296.36,,,2296.36,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2241.85,,,2241.85,Other,186% of Medicaid,2701.6,,,2701.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2701.6,,,2701.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",3578,,,3578,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2363.9,70,,2363.9,percent of total billed charges,All Other,410,,,410,Fee Schedule,,347.5,,,347.5,Fee Schedule,,4055,,,4055,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3649,,,3649,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4055,,,4055,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3448,,,3448,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",1205.3,,,1205.3,Other,100% of Medicaid,1205.3,,,1205.3,Other,100% of Medicaid,1205.3,,,1205.3,Other,100% of Medicaid,1205.3,,,1205.3,Other,100% of Medicaid,2711.92,,,2711.92,Other,225% of Medicaid,1844.1,,,1844.1,Other,153% of Medicaid,2711.92,,,2711.92,Other,225% of Medicaid,1687.41,,,1687.41,Other,140% of Medicaid,2711.92,,,2711.92,Other,225% of Medicaid,3133.77,,,3133.77,Other,260% of Medicaid,3905.16,,,3905.16,Other,324% of Medicaid,2591.39,,,2591.39,Other,215% of Medicaid,2591.39,,,2591.39,Other,215% of Medicaid,1506.62,,,1506.62,Other,125% of Medicaid,347.5,7216,
SENTINEL NODE INJECTION,38792,CPT,,44038792,CDM,360,RC,,,both,,,1401,1036.74,,,1036.74,Other,150% of Medicare + 9.63% HCRA Surcharge,630.45,45,,630.45,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",693.5,,,693.5,Other,110% of Medicare,952.68,,,952.68,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",765.84,,,765.84,Other,186% of Medicaid,1120.8,,,1120.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1120.8,,,1120.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1120.8,,,1120.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",980.7,70,,980.7,percent of total billed charges,All Other,159.08,,,159.08,Fee Schedule,,134.83,,,134.83,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",411.74,,,411.74,Other,100% of Medicaid,411.74,,,411.74,Other,100% of Medicaid,411.74,,,411.74,Other,100% of Medicaid,411.74,,,411.74,Other,100% of Medicaid,926.42,,,926.42,Other,225% of Medicaid,629.97,,,629.97,Other,153% of Medicaid,926.42,,,926.42,Other,225% of Medicaid,576.44,,,576.44,Other,140% of Medicaid,926.42,,,926.42,Other,225% of Medicaid,1070.53,,,1070.53,Other,260% of Medicaid,1334.05,,,1334.05,Other,324% of Medicaid,885.25,,,885.25,Other,215% of Medicaid,885.25,,,885.25,Other,215% of Medicaid,514.68,,,514.68,Other,125% of Medicaid,134.83,7216,
PERCUTANEOUS CHOLECYSTOSTOMY,47490,CPT,,44047490,CDM,360,RC,,,both,,,12073,8934.05,,,8934.05,Other,150% of Medicare + 9.63% HCRA Surcharge,5432.85,45,,5432.85,percent of total billed charges,Critical Access Hospital RCC factor,4565,,,4565,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4109,,,4109,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4476,,,4476,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4028,,,4028,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3805,,,3805,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",5976.14,,,5976.14,Other,110% of Medicare,8209.64,,,8209.64,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2588.91,,,2588.91,Other,186% of Medicaid,9658.4,,,9658.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9658.4,,,9658.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9658.4,,,9658.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",8451.1,70,,8451.1,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",4913,,,4913,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4422,,,4422,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4913,,,4913,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4176,,,4176,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",1391.89,,,1391.89,Other,100% of Medicaid,1391.89,,,1391.89,Other,100% of Medicaid,1391.89,,,1391.89,Other,100% of Medicaid,1391.89,,,1391.89,Other,100% of Medicaid,3131.75,,,3131.75,Other,225% of Medicaid,2129.59,,,2129.59,Other,153% of Medicaid,3131.75,,,3131.75,Other,225% of Medicaid,1948.64,,,1948.64,Other,140% of Medicaid,3131.75,,,3131.75,Other,225% of Medicaid,3618.91,,,3618.91,Other,260% of Medicaid,4509.72,,,4509.72,Other,324% of Medicaid,2992.56,,,2992.56,Other,215% of Medicaid,2992.56,,,2992.56,Other,215% of Medicaid,1739.86,,,1739.86,Other,125% of Medicaid,1391.89,9658.4,
ABD PARACENTESIS W/IMAGING,49083,CPT,,44049083,CDM,360,RC,,,both,,,1893,1400.82,,,1400.82,Other,150% of Medicare + 9.63% HCRA Surcharge,851.85,45,,851.85,percent of total billed charges,Critical Access Hospital RCC factor,2480,,,2480,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2232,,,2232,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",937.04,,,937.04,Other,110% of Medicare,1287.24,,,1287.24,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1196.64,,,1196.64,Other,186% of Medicaid,1514.4,,,1514.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1514.4,,,1514.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1514.4,,,1514.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1325.1,70,,1325.1,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",4055,,,4055,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3649,,,3649,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4055,,,4055,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3448,,,3448,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",643.35,,,643.35,Other,100% of Medicaid,643.35,,,643.35,Other,100% of Medicaid,643.35,,,643.35,Other,100% of Medicaid,643.35,,,643.35,Other,100% of Medicaid,1447.55,,,1447.55,Other,225% of Medicaid,984.33,,,984.33,Other,153% of Medicaid,1447.55,,,1447.55,Other,225% of Medicaid,900.7,,,900.7,Other,140% of Medicaid,1447.55,,,1447.55,Other,225% of Medicaid,1672.72,,,1672.72,Other,260% of Medicaid,2084.47,,,2084.47,Other,324% of Medicaid,1383.21,,,1383.21,Other,215% of Medicaid,1383.21,,,1383.21,Other,215% of Medicaid,804.19,,,804.19,Other,125% of Medicaid,643.35,7216,
BIOPSY ABDOMINAL RETROPERITONE,49180,CPT,,44049180,CDM,360,RC,,,both,,,3462,2561.89,,,2561.89,Other,150% of Medicare + 9.63% HCRA Surcharge,1557.9,45,,1557.9,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3648,,,3648,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3283,,,3283,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3101,,,3101,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",1713.69,,,1713.69,Other,110% of Medicare,2354.16,,,2354.16,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1196.64,,,1196.64,Other,186% of Medicaid,2769.6,,,2769.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2769.6,,,2769.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",3578,,,3578,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2423.4,70,,2423.4,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",4055,,,4055,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3649,,,3649,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4055,,,4055,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3448,,,3448,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",643.35,,,643.35,Other,100% of Medicaid,643.35,,,643.35,Other,100% of Medicaid,643.35,,,643.35,Other,100% of Medicaid,643.35,,,643.35,Other,100% of Medicaid,1447.55,,,1447.55,Other,225% of Medicaid,984.33,,,984.33,Other,153% of Medicaid,1447.55,,,1447.55,Other,225% of Medicaid,900.7,,,900.7,Other,140% of Medicaid,1447.55,,,1447.55,Other,225% of Medicaid,1672.72,,,1672.72,Other,260% of Medicaid,2084.47,,,2084.47,Other,324% of Medicaid,1383.21,,,1383.21,Other,215% of Medicaid,1383.21,,,1383.21,Other,215% of Medicaid,804.19,,,804.19,Other,125% of Medicaid,643.35,7216,
RENAL BIOPSY PERCUTANEOUS,50200,CPT,,44050200,CDM,360,RC,,,both,,,3462,2561.89,,,2561.89,Other,150% of Medicare + 9.63% HCRA Surcharge,1557.9,45,,1557.9,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3648,,,3648,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3283,,,3283,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3101,,,3101,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",1713.69,,,1713.69,Other,110% of Medicare,2354.16,,,2354.16,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2011.18,,,2011.18,Other,186% of Medicaid,2769.6,,,2769.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2769.6,,,2769.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",3578,,,3578,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2423.4,70,,2423.4,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",4055,,,4055,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3649,,,3649,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4055,,,4055,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3448,,,3448,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",1081.28,,,1081.28,Other,100% of Medicaid,1081.28,,,1081.28,Other,100% of Medicaid,1081.28,,,1081.28,Other,100% of Medicaid,1081.28,,,1081.28,Other,100% of Medicaid,2432.88,,,2432.88,Other,225% of Medicaid,1654.36,,,1654.36,Other,153% of Medicaid,2432.88,,,2432.88,Other,225% of Medicaid,1513.79,,,1513.79,Other,140% of Medicaid,2432.88,,,2432.88,Other,225% of Medicaid,2811.33,,,2811.33,Other,260% of Medicaid,3503.35,,,3503.35,Other,324% of Medicaid,2324.75,,,2324.75,Other,215% of Medicaid,2324.75,,,2324.75,Other,215% of Medicaid,1351.6,,,1351.6,Other,125% of Medicaid,1081.28,7216,
DRAINAGE OF OVARIAN CYST(S) AB,58805,CPT,,44058805,CDM,360,RC,,,both,,,10374,7676.79,,,7676.79,Other,150% of Medicare + 9.63% HCRA Surcharge,4668.3,45,,4668.3,percent of total billed charges,Critical Access Hospital RCC factor,3473,,,3473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3126,,,3126,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3648,,,3648,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3283,,,3283,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3101,,,3101,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",5135.13,,,5135.13,Other,110% of Medicare,6152,,,6152,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2506.06,,,2506.06,Other,186% of Medicaid,7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",8299.2,,,8299.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7261.8,70,,7261.8,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",4531,,,4531,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4079,,,4079,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4531,,,4531,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3852,,,3852,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",1347.34,,,1347.34,Other,100% of Medicaid,1347.34,,,1347.34,Other,100% of Medicaid,1347.34,,,1347.34,Other,100% of Medicaid,1347.34,,,1347.34,Other,100% of Medicaid,3031.52,,,3031.52,Other,225% of Medicaid,2061.43,,,2061.43,Other,153% of Medicaid,3031.52,,,3031.52,Other,225% of Medicaid,1886.28,,,1886.28,Other,140% of Medicaid,3031.52,,,3031.52,Other,225% of Medicaid,3503.09,,,3503.09,Other,260% of Medicaid,4365.39,,,4365.39,Other,324% of Medicaid,2896.79,,,2896.79,Other,215% of Medicaid,2896.79,,,2896.79,Other,215% of Medicaid,1684.18,,,1684.18,Other,125% of Medicaid,1347.34,9473,
ASPIR/INJ THYROID CYST,60300,CPT,,44060300,CDM,360,RC,,,both,,,1462,1081.88,,,1081.88,Other,150% of Medicare + 9.63% HCRA Surcharge,657.9,45,,657.9,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",723.69,,,723.69,Other,110% of Medicare,994.16,,,994.16,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1037.55,,,1037.55,Other,186% of Medicaid,1169.6,,,1169.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1169.6,,,1169.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1169.6,,,1169.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1023.4,70,,1023.4,percent of total billed charges,All Other,234.52,,,234.52,Fee Schedule,,198.77,,,198.77,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",557.82,,,557.82,Other,100% of Medicaid,557.82,,,557.82,Other,100% of Medicaid,557.82,,,557.82,Other,100% of Medicaid,557.82,,,557.82,Other,100% of Medicaid,1255.1,,,1255.1,Other,225% of Medicaid,853.47,,,853.47,Other,153% of Medicaid,1255.1,,,1255.1,Other,225% of Medicaid,780.95,,,780.95,Other,140% of Medicaid,1255.1,,,1255.1,Other,225% of Medicaid,1450.34,,,1450.34,Other,260% of Medicaid,1807.35,,,1807.35,Other,324% of Medicaid,1199.32,,,1199.32,Other,215% of Medicaid,1199.32,,,1199.32,Other,215% of Medicaid,697.28,,,697.28,Other,125% of Medicaid,198.77,7216,
FNA BX W/US GDN 1ST LES/ INCOMPLETE,10005,CPT,73,44410005,CDM,360,RC,,,both,,,1462,1081.88,,,1081.88,Other,150% of Medicare + 9.63% HCRA Surcharge,657.9,45,,657.9,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",723.69,,,723.69,Other,110% of Medicare,994.16,,,994.16,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1037.55,,,1037.55,Other,186% of Medicaid,1169.6,,,1169.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1169.6,,,1169.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1169.6,,,1169.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1023.4,70,,1023.4,percent of total billed charges,All Other,355.88,,,355.88,Fee Schedule,,301.63,,,301.63,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",557.82,,,557.82,Other,100% of Medicaid,557.82,,,557.82,Other,100% of Medicaid,557.82,,,557.82,Other,100% of Medicaid,557.82,,,557.82,Other,100% of Medicaid,1255.1,,,1255.1,Other,225% of Medicaid,853.47,,,853.47,Other,153% of Medicaid,1255.1,,,1255.1,Other,225% of Medicaid,780.95,,,780.95,Other,140% of Medicaid,1255.1,,,1255.1,Other,225% of Medicaid,1450.34,,,1450.34,Other,260% of Medicaid,1807.35,,,1807.35,Other,324% of Medicaid,1199.32,,,1199.32,Other,215% of Medicaid,1199.32,,,1199.32,Other,215% of Medicaid,697.28,,,697.28,Other,125% of Medicaid,301.63,7216,
INCOMPLETE THORACENTESIS,32555,CPT,73,44432555,CDM,360,RC,,,both,,,1695,1254.3,,,1254.3,Other,150% of Medicare + 9.63% HCRA Surcharge,762.75,45,,762.75,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",839.03,,,839.03,Other,110% of Medicare,1152.6,,,1152.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1196.64,,,1196.64,Other,186% of Medicaid,1356,,,1356,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1356,,,1356,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1356,,,1356,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1186.5,70,,1186.5,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",643.35,,,643.35,Other,100% of Medicaid,643.35,,,643.35,Other,100% of Medicaid,643.35,,,643.35,Other,100% of Medicaid,643.35,,,643.35,Other,100% of Medicaid,1447.55,,,1447.55,Other,225% of Medicaid,984.33,,,984.33,Other,153% of Medicaid,1447.55,,,1447.55,Other,225% of Medicaid,900.7,,,900.7,Other,140% of Medicaid,1447.55,,,1447.55,Other,225% of Medicaid,1672.72,,,1672.72,Other,260% of Medicaid,2084.47,,,2084.47,Other,324% of Medicaid,1383.21,,,1383.21,Other,215% of Medicaid,1383.21,,,1383.21,Other,215% of Medicaid,804.19,,,804.19,Other,125% of Medicaid,643.35,7216,
INCOMPLETE PARACENTESIS,49083,CPT,73,44449083,CDM,360,RC,,,both,,,1515,1121.1,,,1121.1,Other,150% of Medicare + 9.63% HCRA Surcharge,681.75,45,,681.75,percent of total billed charges,Critical Access Hospital RCC factor,2480,,,2480,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2232,,,2232,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",749.93,,,749.93,Other,110% of Medicare,1030.2,,,1030.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1196.64,,,1196.64,Other,186% of Medicaid,1212,,,1212,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1212,,,1212,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1212,,,1212,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1060.5,70,,1060.5,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",4055,,,4055,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3649,,,3649,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4055,,,4055,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3448,,,3448,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",643.35,,,643.35,Other,100% of Medicaid,643.35,,,643.35,Other,100% of Medicaid,643.35,,,643.35,Other,100% of Medicaid,643.35,,,643.35,Other,100% of Medicaid,1447.55,,,1447.55,Other,225% of Medicaid,984.33,,,984.33,Other,153% of Medicaid,1447.55,,,1447.55,Other,225% of Medicaid,900.7,,,900.7,Other,140% of Medicaid,1447.55,,,1447.55,Other,225% of Medicaid,1672.72,,,1672.72,Other,260% of Medicaid,2084.47,,,2084.47,Other,324% of Medicaid,1383.21,,,1383.21,Other,215% of Medicaid,1383.21,,,1383.21,Other,215% of Medicaid,804.19,,,804.19,Other,125% of Medicaid,643.35,7216,
PUNCTURE DRAINAGE OF LESION,10160,CPT,,46010160,CDM,360,RC,,,both,,,841,622.34,,,622.34,Other,150% of Medicare + 9.63% HCRA Surcharge,378.45,45,,378.45,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",416.3,,,416.3,Other,110% of Medicare,571.88,,,571.88,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",733.11,,,733.11,Other,186% of Medicaid,672.8,,,672.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",672.8,,,672.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",672.8,,,672.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",588.7,70,,588.7,percent of total billed charges,All Other,457.56,,,457.56,Fee Schedule,,387.81,,,387.81,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",394.14,,,394.14,Other,100% of Medicaid,394.14,,,394.14,Other,100% of Medicaid,394.14,,,394.14,Other,100% of Medicaid,394.14,,,394.14,Other,100% of Medicaid,886.83,,,886.83,Other,225% of Medicaid,603.04,,,603.04,Other,153% of Medicaid,886.83,,,886.83,Other,225% of Medicaid,551.8,,,551.8,Other,140% of Medicaid,886.83,,,886.83,Other,225% of Medicaid,1024.78,,,1024.78,Other,260% of Medicaid,1277.03,,,1277.03,Other,324% of Medicaid,847.41,,,847.41,Other,215% of Medicaid,847.41,,,847.41,Other,215% of Medicaid,492.68,,,492.68,Other,125% of Medicaid,378.45,7216,
MUSCLE BIOPSY PERCUT,20206,CPT,,46020206,CDM,360,RC,,,both,,,3377,2498.99,,,2498.99,Other,150% of Medicare + 9.63% HCRA Surcharge,1519.65,45,,1519.65,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3648,,,3648,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3283,,,3283,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3101,,,3101,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",1671.62,,,1671.62,Other,110% of Medicare,2296.36,,,2296.36,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1037.55,,,1037.55,Other,186% of Medicaid,2701.6,,,2701.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2701.6,,,2701.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",3578,,,3578,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2363.9,70,,2363.9,percent of total billed charges,All Other,273.88,,,273.88,Fee Schedule,,232.13,,,232.13,Fee Schedule,,4055,,,4055,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3649,,,3649,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4055,,,4055,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3448,,,3448,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",557.82,,,557.82,Other,100% of Medicaid,557.82,,,557.82,Other,100% of Medicaid,557.82,,,557.82,Other,100% of Medicaid,557.82,,,557.82,Other,100% of Medicaid,1255.1,,,1255.1,Other,225% of Medicaid,853.47,,,853.47,Other,153% of Medicaid,1255.1,,,1255.1,Other,225% of Medicaid,780.95,,,780.95,Other,140% of Medicaid,1255.1,,,1255.1,Other,225% of Medicaid,1450.34,,,1450.34,Other,260% of Medicaid,1807.35,,,1807.35,Other,324% of Medicaid,1199.32,,,1199.32,Other,215% of Medicaid,1199.32,,,1199.32,Other,215% of Medicaid,697.28,,,697.28,Other,125% of Medicaid,232.13,7216,
BIOPSY BONE TROCAR NDL SPRFCL,20220,CPT,,46020220,CDM,360,RC,,,both,,,3426,2535.25,,,2535.25,Other,150% of Medicare + 9.63% HCRA Surcharge,1541.7,45,,1541.7,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3648,,,3648,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3283,,,3283,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3101,,,3101,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",1695.87,,,1695.87,Other,110% of Medicare,2329.68,,,2329.68,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1037.55,,,1037.55,Other,186% of Medicaid,2740.8,,,2740.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2740.8,,,2740.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",3578,,,3578,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2398.2,70,,2398.2,percent of total billed charges,All Other,416.56,,,416.56,Fee Schedule,,353.06,,,353.06,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",557.82,,,557.82,Other,100% of Medicaid,557.82,,,557.82,Other,100% of Medicaid,557.82,,,557.82,Other,100% of Medicaid,557.82,,,557.82,Other,100% of Medicaid,1255.1,,,1255.1,Other,225% of Medicaid,853.47,,,853.47,Other,153% of Medicaid,1255.1,,,1255.1,Other,225% of Medicaid,780.95,,,780.95,Other,140% of Medicaid,1255.1,,,1255.1,Other,225% of Medicaid,1450.34,,,1450.34,Other,260% of Medicaid,1807.35,,,1807.35,Other,324% of Medicaid,1199.32,,,1199.32,Other,215% of Medicaid,1199.32,,,1199.32,Other,215% of Medicaid,697.28,,,697.28,Other,125% of Medicaid,353.06,7216,
BIOPSY BONE DEEP,20225,CPT,,46020225,CDM,360,RC,,,both,,,6428,4756.74,,,4756.74,Other,150% of Medicare + 9.63% HCRA Surcharge,2892.6,45,,2892.6,percent of total billed charges,Critical Access Hospital RCC factor,2480,,,2480,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2232,,,2232,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3648,,,3648,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3283,,,3283,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3101,,,3101,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3181.86,,,3181.86,Other,110% of Medicare,4371.04,,,4371.04,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1973.06,,,1973.06,Other,186% of Medicaid,5142.4,,,5142.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",5142.4,,,5142.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",4252,,,4252,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",4499.6,70,,4499.6,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",4055,,,4055,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3649,,,3649,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4055,,,4055,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3448,,,3448,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",1060.79,,,1060.79,Other,100% of Medicaid,1060.79,,,1060.79,Other,100% of Medicaid,1060.79,,,1060.79,Other,100% of Medicaid,1060.79,,,1060.79,Other,100% of Medicaid,2386.77,,,2386.77,Other,225% of Medicaid,1623,,,1623,Other,153% of Medicaid,2386.77,,,2386.77,Other,225% of Medicaid,1485.1,,,1485.1,Other,140% of Medicaid,2386.77,,,2386.77,Other,225% of Medicaid,2758.05,,,2758.05,Other,260% of Medicaid,3436.95,,,3436.95,Other,324% of Medicaid,2280.69,,,2280.69,Other,215% of Medicaid,2280.69,,,2280.69,Other,215% of Medicaid,1325.98,,,1325.98,Other,125% of Medicaid,1060.79,7216,
DRAIN/INJECT SM JNT/BURSA,20600,CPT,,46020600,CDM,360,RC,,,both,,,1017,752.58,,,752.58,Other,150% of Medicare + 9.63% HCRA Surcharge,457.65,45,,457.65,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",503.42,,,503.42,Other,110% of Medicare,691.56,,,691.56,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",685.67,,,685.67,Other,186% of Medicaid,813.6,,,813.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",813.6,,,813.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",813.6,,,813.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",711.9,70,,711.9,percent of total billed charges,All Other,172.2,,,172.2,Fee Schedule,,145.95,,,145.95,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",368.64,,,368.64,Other,100% of Medicaid,368.64,,,368.64,Other,100% of Medicaid,368.64,,,368.64,Other,100% of Medicaid,368.64,,,368.64,Other,100% of Medicaid,829.44,,,829.44,Other,225% of Medicaid,564.02,,,564.02,Other,153% of Medicaid,829.44,,,829.44,Other,225% of Medicaid,516.1,,,516.1,Other,140% of Medicaid,829.44,,,829.44,Other,225% of Medicaid,958.46,,,958.46,Other,260% of Medicaid,1194.39,,,1194.39,Other,324% of Medicaid,792.58,,,792.58,Other,215% of Medicaid,792.58,,,792.58,Other,215% of Medicaid,460.8,,,460.8,Other,125% of Medicaid,145.95,7216,
DRAIN/INJ INTERM JNT/BURSA,20605,CPT,,46020605,CDM,360,RC,,,both,,,1017,752.58,,,752.58,Other,150% of Medicare + 9.63% HCRA Surcharge,457.65,45,,457.65,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",503.42,,,503.42,Other,110% of Medicare,691.56,,,691.56,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",685.67,,,685.67,Other,186% of Medicaid,813.6,,,813.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",813.6,,,813.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",813.6,,,813.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",711.9,70,,711.9,percent of total billed charges,All Other,178.76,,,178.76,Fee Schedule,,151.51,,,151.51,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",368.64,,,368.64,Other,100% of Medicaid,368.64,,,368.64,Other,100% of Medicaid,368.64,,,368.64,Other,100% of Medicaid,368.64,,,368.64,Other,100% of Medicaid,829.44,,,829.44,Other,225% of Medicaid,564.02,,,564.02,Other,153% of Medicaid,829.44,,,829.44,Other,225% of Medicaid,516.1,,,516.1,Other,140% of Medicaid,829.44,,,829.44,Other,225% of Medicaid,958.46,,,958.46,Other,260% of Medicaid,1194.39,,,1194.39,Other,324% of Medicaid,792.58,,,792.58,Other,215% of Medicaid,792.58,,,792.58,Other,215% of Medicaid,460.8,,,460.8,Other,125% of Medicaid,151.51,7216,
ARTHROCENTESIS MAJOR JOINT,20610,CPT,,46020610,CDM,360,RC,,,both,,,1017,752.58,,,752.58,Other,150% of Medicare + 9.63% HCRA Surcharge,457.65,45,,457.65,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",503.42,,,503.42,Other,110% of Medicare,691.56,,,691.56,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",685.67,,,685.67,Other,186% of Medicaid,813.6,,,813.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",813.6,,,813.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",813.6,,,813.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",711.9,70,,711.9,percent of total billed charges,All Other,218.12,,,218.12,Fee Schedule,,184.87,,,184.87,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",368.64,,,368.64,Other,100% of Medicaid,368.64,,,368.64,Other,100% of Medicaid,368.64,,,368.64,Other,100% of Medicaid,368.64,,,368.64,Other,100% of Medicaid,829.44,,,829.44,Other,225% of Medicaid,564.02,,,564.02,Other,153% of Medicaid,829.44,,,829.44,Other,225% of Medicaid,516.1,,,516.1,Other,140% of Medicaid,829.44,,,829.44,Other,225% of Medicaid,958.46,,,958.46,Other,260% of Medicaid,1194.39,,,1194.39,Other,324% of Medicaid,792.58,,,792.58,Other,215% of Medicaid,792.58,,,792.58,Other,215% of Medicaid,460.8,,,460.8,Other,125% of Medicaid,184.87,7216,
BIOPSY SOFT TISSUE PELVIS,27040,CPT,,46027040,CDM,360,RC,,,both,,,3377,2498.99,,,2498.99,Other,150% of Medicare + 9.63% HCRA Surcharge,1519.65,45,,1519.65,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3648,,,3648,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3283,,,3283,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3101,,,3101,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",1671.62,,,1671.62,Other,110% of Medicare,2296.36,,,2296.36,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1973.06,,,1973.06,Other,186% of Medicaid,2701.6,,,2701.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2701.6,,,2701.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",3578,,,3578,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2363.9,70,,2363.9,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",1060.79,,,1060.79,Other,100% of Medicaid,1060.79,,,1060.79,Other,100% of Medicaid,1060.79,,,1060.79,Other,100% of Medicaid,1060.79,,,1060.79,Other,100% of Medicaid,2386.77,,,2386.77,Other,225% of Medicaid,1623,,,1623,Other,153% of Medicaid,2386.77,,,2386.77,Other,225% of Medicaid,1485.1,,,1485.1,Other,140% of Medicaid,2386.77,,,2386.77,Other,225% of Medicaid,2758.05,,,2758.05,Other,260% of Medicaid,3436.95,,,3436.95,Other,324% of Medicaid,2280.69,,,2280.69,Other,215% of Medicaid,2280.69,,,2280.69,Other,215% of Medicaid,1325.98,,,1325.98,Other,125% of Medicaid,1060.79,7216,
ST BX; HIP/PELVIS; DEEP,27041,CPT,,46027041,CDM,360,RC,,,both,,,3377,2498.99,,,2498.99,Other,150% of Medicare + 9.63% HCRA Surcharge,1519.65,45,,1519.65,percent of total billed charges,Critical Access Hospital RCC factor,2480,,,2480,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2232,,,2232,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3648,,,3648,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3283,,,3283,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3101,,,3101,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",1671.62,,,1671.62,Other,110% of Medicare,2296.36,,,2296.36,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1973.06,,,1973.06,Other,186% of Medicaid,2701.6,,,2701.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2701.6,,,2701.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",4252,,,4252,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2363.9,70,,2363.9,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",1060.79,,,1060.79,Other,100% of Medicaid,1060.79,,,1060.79,Other,100% of Medicaid,1060.79,,,1060.79,Other,100% of Medicaid,1060.79,,,1060.79,Other,100% of Medicaid,2386.77,,,2386.77,Other,225% of Medicaid,1623,,,1623,Other,153% of Medicaid,2386.77,,,2386.77,Other,225% of Medicaid,1485.1,,,1485.1,Other,140% of Medicaid,2386.77,,,2386.77,Other,225% of Medicaid,2758.05,,,2758.05,Other,260% of Medicaid,3436.95,,,3436.95,Other,324% of Medicaid,2280.69,,,2280.69,Other,215% of Medicaid,2280.69,,,2280.69,Other,215% of Medicaid,1325.98,,,1325.98,Other,125% of Medicaid,1060.79,7216,
CT GUIDED BIOPSY KNEE,27323,CPT,,46027323,CDM,360,RC,,,both,,,3377,2498.99,,,2498.99,Other,150% of Medicare + 9.63% HCRA Surcharge,1519.65,45,,1519.65,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3648,,,3648,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3283,,,3283,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3101,,,3101,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",1671.62,,,1671.62,Other,110% of Medicare,2296.36,,,2296.36,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1973.06,,,1973.06,Other,186% of Medicaid,2701.6,,,2701.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2701.6,,,2701.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",3578,,,3578,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2363.9,70,,2363.9,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",1060.79,,,1060.79,Other,100% of Medicaid,1060.79,,,1060.79,Other,100% of Medicaid,1060.79,,,1060.79,Other,100% of Medicaid,1060.79,,,1060.79,Other,100% of Medicaid,2386.77,,,2386.77,Other,225% of Medicaid,1623,,,1623,Other,153% of Medicaid,2386.77,,,2386.77,Other,225% of Medicaid,1485.1,,,1485.1,Other,140% of Medicaid,2386.77,,,2386.77,Other,225% of Medicaid,2758.05,,,2758.05,Other,260% of Medicaid,3436.95,,,3436.95,Other,324% of Medicaid,2280.69,,,2280.69,Other,215% of Medicaid,2280.69,,,2280.69,Other,215% of Medicaid,1325.98,,,1325.98,Other,125% of Medicaid,1060.79,7216,
KNEE ARTHROGRAPHY INJ,27369,CPT,,46027369,CDM,360,RC,,,both,,,213,157.62,,,157.62,Other,150% of Medicare + 9.63% HCRA Surcharge,95.85,45,,95.85,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",105.44,,,105.44,Other,110% of Medicare,144.84,,,144.84,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",966.93,,,966.93,Other,186% of Medicaid,170.4,,,170.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",170.4,,,170.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",170.4,,,170.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",149.1,70,,149.1,percent of total billed charges,All Other,191.88,,,191.88,Fee Schedule,,162.63,,,162.63,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",519.86,,,519.86,Other,100% of Medicaid,519.86,,,519.86,Other,100% of Medicaid,519.86,,,519.86,Other,100% of Medicaid,519.86,,,519.86,Other,100% of Medicaid,1169.68,,,1169.68,Other,225% of Medicaid,795.38,,,795.38,Other,153% of Medicaid,1169.68,,,1169.68,Other,225% of Medicaid,727.8,,,727.8,Other,140% of Medicaid,1169.68,,,1169.68,Other,225% of Medicaid,1351.62,,,1351.62,Other,260% of Medicaid,1684.33,,,1684.33,Other,324% of Medicaid,1117.69,,,1117.69,Other,215% of Medicaid,1117.69,,,1117.69,Other,215% of Medicaid,649.82,,,649.82,Other,125% of Medicaid,95.85,7216,
EXCISION OF LESION LEG,27618,CPT,,46027618,CDM,360,RC,,,both,,,5898,4364.53,,,4364.53,Other,150% of Medicare + 9.63% HCRA Surcharge,2654.1,45,,2654.1,percent of total billed charges,Critical Access Hospital RCC factor,2480,,,2480,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2232,,,2232,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3648,,,3648,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3283,,,3283,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3101,,,3101,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2919.51,,,2919.51,Other,110% of Medicare,4010.64,,,4010.64,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1973.06,,,1973.06,Other,186% of Medicaid,4718.4,,,4718.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",4718.4,,,4718.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",4252,,,4252,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",4128.6,70,,4128.6,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",4055,,,4055,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3649,,,3649,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4055,,,4055,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3448,,,3448,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",1060.79,,,1060.79,Other,100% of Medicaid,1060.79,,,1060.79,Other,100% of Medicaid,1060.79,,,1060.79,Other,100% of Medicaid,1060.79,,,1060.79,Other,100% of Medicaid,2386.77,,,2386.77,Other,225% of Medicaid,1623,,,1623,Other,153% of Medicaid,2386.77,,,2386.77,Other,225% of Medicaid,1485.1,,,1485.1,Other,140% of Medicaid,2386.77,,,2386.77,Other,225% of Medicaid,2758.05,,,2758.05,Other,260% of Medicaid,3436.95,,,3436.95,Other,324% of Medicaid,2280.69,,,2280.69,Other,215% of Medicaid,2280.69,,,2280.69,Other,215% of Medicaid,1325.98,,,1325.98,Other,125% of Medicaid,1060.79,7216,
BIOPSY PLEURA PERC NEEDLE,32400,CPT,,46032400,CDM,360,RC,,,both,,,3377,2498.99,,,2498.99,Other,150% of Medicare + 9.63% HCRA Surcharge,1519.65,45,,1519.65,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3648,,,3648,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3283,,,3283,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3101,,,3101,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",1671.62,,,1671.62,Other,110% of Medicare,2296.36,,,2296.36,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1196.64,,,1196.64,Other,186% of Medicaid,2701.6,,,2701.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2701.6,,,2701.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",3578,,,3578,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2363.9,70,,2363.9,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",4055,,,4055,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3649,,,3649,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4055,,,4055,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3448,,,3448,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",643.35,,,643.35,Other,100% of Medicaid,643.35,,,643.35,Other,100% of Medicaid,643.35,,,643.35,Other,100% of Medicaid,643.35,,,643.35,Other,100% of Medicaid,1447.55,,,1447.55,Other,225% of Medicaid,984.33,,,984.33,Other,153% of Medicaid,1447.55,,,1447.55,Other,225% of Medicaid,900.7,,,900.7,Other,140% of Medicaid,1447.55,,,1447.55,Other,225% of Medicaid,1672.72,,,1672.72,Other,260% of Medicaid,2084.47,,,2084.47,Other,324% of Medicaid,1383.21,,,1383.21,Other,215% of Medicaid,1383.21,,,1383.21,Other,215% of Medicaid,804.19,,,804.19,Other,125% of Medicaid,643.35,7216,
CORE NDL BX LNG/MED PERQ,32408,CPT,,46032408,CDM,360,RC,,,both,,,4606,3408.45,,,3408.45,Other,150% of Medicare + 9.63% HCRA Surcharge,2072.7,45,,2072.7,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3648,,,3648,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3283,,,3283,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3101,,,3101,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2279.97,,,2279.97,Other,110% of Medicare,3132.08,,,3132.08,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1196.64,,,1196.64,Other,186% of Medicaid,3684.8,,,3684.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",3684.8,,,3684.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",3684.8,,,3684.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",3224.2,70,,3224.2,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",4055,,,4055,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3649,,,3649,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4055,,,4055,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3448,,,3448,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",643.35,,,643.35,Other,100% of Medicaid,643.35,,,643.35,Other,100% of Medicaid,643.35,,,643.35,Other,100% of Medicaid,643.35,,,643.35,Other,100% of Medicaid,1447.55,,,1447.55,Other,225% of Medicaid,984.33,,,984.33,Other,153% of Medicaid,1447.55,,,1447.55,Other,225% of Medicaid,900.7,,,900.7,Other,140% of Medicaid,1447.55,,,1447.55,Other,225% of Medicaid,1672.72,,,1672.72,Other,260% of Medicaid,2084.47,,,2084.47,Other,324% of Medicaid,1383.21,,,1383.21,Other,215% of Medicaid,1383.21,,,1383.21,Other,215% of Medicaid,804.19,,,804.19,Other,125% of Medicaid,643.35,7216,
ASPIRATE PLEURA W IMAGING,32555,CPT,,46032555,CDM,360,RC,,,both,,,2118,1567.33,,,1567.33,Other,150% of Medicare + 9.63% HCRA Surcharge,953.1,45,,953.1,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",1048.41,,,1048.41,Other,110% of Medicare,1440.24,,,1440.24,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1196.64,,,1196.64,Other,186% of Medicaid,1694.4,,,1694.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1694.4,,,1694.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1694.4,,,1694.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1482.6,70,,1482.6,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",643.35,,,643.35,Other,100% of Medicaid,643.35,,,643.35,Other,100% of Medicaid,643.35,,,643.35,Other,100% of Medicaid,643.35,,,643.35,Other,100% of Medicaid,1447.55,,,1447.55,Other,225% of Medicaid,984.33,,,984.33,Other,153% of Medicaid,1447.55,,,1447.55,Other,225% of Medicaid,900.7,,,900.7,Other,140% of Medicaid,1447.55,,,1447.55,Other,225% of Medicaid,1672.72,,,1672.72,Other,260% of Medicaid,2084.47,,,2084.47,Other,324% of Medicaid,1383.21,,,1383.21,Other,215% of Medicaid,1383.21,,,1383.21,Other,215% of Medicaid,804.19,,,804.19,Other,125% of Medicaid,643.35,7216,
CHEMICAL PLEURODESIS,32560,CPT,,46032560,CDM,360,RC,,,both,,,1815,1343.1,,,1343.1,Other,150% of Medicare + 9.63% HCRA Surcharge,816.75,45,,816.75,percent of total billed charges,Critical Access Hospital RCC factor,2480,,,2480,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2232,,,2232,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",898.43,,,898.43,Other,110% of Medicare,1234.2,,,1234.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1196.64,,,1196.64,Other,186% of Medicaid,1452,,,1452,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1452,,,1452,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1452,,,1452,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1270.5,70,,1270.5,percent of total billed charges,All Other,370.64,,,370.64,Fee Schedule,,314.14,,,314.14,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",643.35,,,643.35,Other,100% of Medicaid,643.35,,,643.35,Other,100% of Medicaid,643.35,,,643.35,Other,100% of Medicaid,643.35,,,643.35,Other,100% of Medicaid,1447.55,,,1447.55,Other,225% of Medicaid,984.33,,,984.33,Other,153% of Medicaid,1447.55,,,1447.55,Other,225% of Medicaid,900.7,,,900.7,Other,140% of Medicaid,1447.55,,,1447.55,Other,225% of Medicaid,1672.72,,,1672.72,Other,260% of Medicaid,2084.47,,,2084.47,Other,324% of Medicaid,1383.21,,,1383.21,Other,215% of Medicaid,1383.21,,,1383.21,Other,215% of Medicaid,804.19,,,804.19,Other,125% of Medicaid,314.14,7216,
CT GUIDED PERC RF ABLATE PUL T,32998,CPT,,46032998,CDM,360,RC,,,both,,,18449,13652.31,,,13652.31,Other,150% of Medicare + 9.63% HCRA Surcharge,8302.05,45,,8302.05,percent of total billed charges,Critical Access Hospital RCC factor,3969,,,3969,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3572,,,3572,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",5738,,,5738,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",5164,,,5164,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4877,,,4877,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",9132.26,,,9132.26,Other,110% of Medicare,6152,,,6152,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",4046.72,,,4046.72,Other,186% of Medicaid,7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",14759.2,,,14759.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",12914.3,70,,12914.3,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",6331,,,6331,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",5698,,,5698,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",6331,,,6331,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",5381,,,5381,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2175.66,,,2175.66,Other,100% of Medicaid,2175.66,,,2175.66,Other,100% of Medicaid,2175.66,,,2175.66,Other,100% of Medicaid,2175.66,,,2175.66,Other,100% of Medicaid,4895.23,,,4895.23,Other,225% of Medicaid,3328.76,,,3328.76,Other,153% of Medicaid,4895.23,,,4895.23,Other,225% of Medicaid,3045.92,,,3045.92,Other,140% of Medicaid,4895.23,,,4895.23,Other,225% of Medicaid,5656.71,,,5656.71,Other,260% of Medicaid,7049.13,,,7049.13,Other,324% of Medicaid,4677.66,,,4677.66,Other,215% of Medicaid,4677.66,,,4677.66,Other,215% of Medicaid,2719.57,,,2719.57,Other,125% of Medicaid,2175.66,14759.2,
NONSELECT CATH - TRANSLUMBAR AORTA,36160,CPT,,46036160,CDM,360,RC,,,both,,,533,394.42,,,394.42,Other,150% of Medicare + 9.63% HCRA Surcharge,239.85,45,,239.85,percent of total billed charges,Critical Access Hospital RCC factor,2480,,,2480,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2232,,,2232,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3648,,,3648,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3283,,,3283,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3101,,,3101,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",263.84,,,263.84,Other,110% of Medicare,362.44,,,362.44,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",516.02,,,516.02,Other,186% of Medicaid,426.4,,,426.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",426.4,,,426.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",426.4,,,426.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",373.1,70,,373.1,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",277.43,,,277.43,Other,100% of Medicaid,277.43,,,277.43,Other,100% of Medicaid,277.43,,,277.43,Other,100% of Medicaid,277.43,,,277.43,Other,100% of Medicaid,624.21,,,624.21,Other,225% of Medicaid,424.47,,,424.47,Other,153% of Medicaid,624.21,,,624.21,Other,225% of Medicaid,388.4,,,388.4,Other,140% of Medicaid,624.21,,,624.21,Other,225% of Medicaid,721.31,,,721.31,Other,260% of Medicaid,898.87,,,898.87,Other,324% of Medicaid,596.47,,,596.47,Other,215% of Medicaid,596.47,,,596.47,Other,215% of Medicaid,346.79,,,346.79,Other,125% of Medicaid,239.85,7216,
BONE MARROW ASPIRATION,38220,CPT,,46038220,CDM,360,RC,,,both,,,3377,2498.99,,,2498.99,Other,150% of Medicare + 9.63% HCRA Surcharge,1519.65,45,,1519.65,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3648,,,3648,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3283,,,3283,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3101,,,3101,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",1671.62,,,1671.62,Other,110% of Medicare,2296.36,,,2296.36,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1037.55,,,1037.55,Other,186% of Medicaid,2701.6,,,2701.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2701.6,,,2701.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2701.6,,,2701.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2363.9,70,,2363.9,percent of total billed charges,All Other,326.36,,,326.36,Fee Schedule,,276.61,,,276.61,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",557.82,,,557.82,Other,100% of Medicaid,557.82,,,557.82,Other,100% of Medicaid,557.82,,,557.82,Other,100% of Medicaid,557.82,,,557.82,Other,100% of Medicaid,1255.1,,,1255.1,Other,225% of Medicaid,853.47,,,853.47,Other,153% of Medicaid,1255.1,,,1255.1,Other,225% of Medicaid,780.95,,,780.95,Other,140% of Medicaid,1255.1,,,1255.1,Other,225% of Medicaid,1450.33,,,1450.33,Other,260% of Medicaid,1807.34,,,1807.34,Other,324% of Medicaid,1199.31,,,1199.31,Other,215% of Medicaid,1199.31,,,1199.31,Other,215% of Medicaid,697.28,,,697.28,Other,125% of Medicaid,276.61,7216,
BONE MARROW BIOPSY,38221,CPT,,46038221,CDM,360,RC,,,both,,,3926,2905.25,,,2905.25,Other,150% of Medicare + 9.63% HCRA Surcharge,1766.7,45,,1766.7,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3648,,,3648,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3283,,,3283,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3101,,,3101,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",1943.37,,,1943.37,Other,110% of Medicare,2669.68,,,2669.68,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1037.55,,,1037.55,Other,186% of Medicaid,3140.8,,,3140.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",3140.8,,,3140.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",3140.8,,,3140.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2748.2,70,,2748.2,percent of total billed charges,All Other,339.48,,,339.48,Fee Schedule,,287.73,,,287.73,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",557.82,,,557.82,Other,100% of Medicaid,557.82,,,557.82,Other,100% of Medicaid,557.82,,,557.82,Other,100% of Medicaid,557.82,,,557.82,Other,100% of Medicaid,1255.1,,,1255.1,Other,225% of Medicaid,853.47,,,853.47,Other,153% of Medicaid,1255.1,,,1255.1,Other,225% of Medicaid,780.95,,,780.95,Other,140% of Medicaid,1255.1,,,1255.1,Other,225% of Medicaid,1450.33,,,1450.33,Other,260% of Medicaid,1807.34,,,1807.34,Other,324% of Medicaid,1199.31,,,1199.31,Other,215% of Medicaid,1199.31,,,1199.31,Other,215% of Medicaid,697.28,,,697.28,Other,125% of Medicaid,287.73,7216,
BIOPSY LYMPH NODE NEEDLE,38505,CPT,,46038505,CDM,360,RC,,,both,,,3377,2498.99,,,2498.99,Other,150% of Medicare + 9.63% HCRA Surcharge,1519.65,45,,1519.65,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3648,,,3648,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3283,,,3283,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3101,,,3101,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",1671.62,,,1671.62,Other,110% of Medicare,2296.36,,,2296.36,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2241.85,,,2241.85,Other,186% of Medicaid,2701.6,,,2701.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2701.6,,,2701.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",3578,,,3578,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2363.9,70,,2363.9,percent of total billed charges,All Other,410,,,410,Fee Schedule,,347.5,,,347.5,Fee Schedule,,4055,,,4055,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3649,,,3649,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4055,,,4055,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3448,,,3448,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",1205.3,,,1205.3,Other,100% of Medicaid,1205.3,,,1205.3,Other,100% of Medicaid,1205.3,,,1205.3,Other,100% of Medicaid,1205.3,,,1205.3,Other,100% of Medicaid,2711.92,,,2711.92,Other,225% of Medicaid,1844.1,,,1844.1,Other,153% of Medicaid,2711.92,,,2711.92,Other,225% of Medicaid,1687.41,,,1687.41,Other,140% of Medicaid,2711.92,,,2711.92,Other,225% of Medicaid,3133.77,,,3133.77,Other,260% of Medicaid,3905.16,,,3905.16,Other,324% of Medicaid,2591.39,,,2591.39,Other,215% of Medicaid,2591.39,,,2591.39,Other,215% of Medicaid,1506.62,,,1506.62,Other,125% of Medicaid,347.5,7216,
BIOPSY OF LIVER NEEDLE PERC,47000,CPT,,46047000,CDM,360,RC,,,both,,,3495,2586.31,,,2586.31,Other,150% of Medicare + 9.63% HCRA Surcharge,1572.75,45,,1572.75,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3648,,,3648,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3283,,,3283,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3101,,,3101,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",1730.03,,,1730.03,Other,110% of Medicare,2376.6,,,2376.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1196.64,,,1196.64,Other,186% of Medicaid,2796,,,2796,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2796,,,2796,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",3578,,,3578,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2446.5,70,,2446.5,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",4055,,,4055,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3649,,,3649,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4055,,,4055,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3448,,,3448,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",643.35,,,643.35,Other,100% of Medicaid,643.35,,,643.35,Other,100% of Medicaid,643.35,,,643.35,Other,100% of Medicaid,643.35,,,643.35,Other,100% of Medicaid,1447.55,,,1447.55,Other,225% of Medicaid,984.33,,,984.33,Other,153% of Medicaid,1447.55,,,1447.55,Other,225% of Medicaid,900.7,,,900.7,Other,140% of Medicaid,1447.55,,,1447.55,Other,225% of Medicaid,1672.72,,,1672.72,Other,260% of Medicaid,2084.47,,,2084.47,Other,324% of Medicaid,1383.21,,,1383.21,Other,215% of Medicaid,1383.21,,,1383.21,Other,215% of Medicaid,804.19,,,804.19,Other,125% of Medicaid,643.35,7216,
ABLATION LIVER TUMORS PERCUT R,47382,CPT,,46047382,CDM,360,RC,,,both,,,18449,13652.31,,,13652.31,Other,150% of Medicare + 9.63% HCRA Surcharge,8302.05,45,,8302.05,percent of total billed charges,Critical Access Hospital RCC factor,3969,,,3969,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3572,,,3572,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",5738,,,5738,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",5164,,,5164,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4877,,,4877,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",9132.26,,,9132.26,Other,110% of Medicare,6152,,,6152,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",3989.38,,,3989.38,Other,186% of Medicaid,7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",14759.2,,,14759.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",12914.3,70,,12914.3,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",6331,,,6331,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",5698,,,5698,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",6331,,,6331,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",5381,,,5381,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2144.83,,,2144.83,Other,100% of Medicaid,2144.83,,,2144.83,Other,100% of Medicaid,2144.83,,,2144.83,Other,100% of Medicaid,2144.83,,,2144.83,Other,100% of Medicaid,4825.86,,,4825.86,Other,225% of Medicaid,3281.59,,,3281.59,Other,153% of Medicaid,4825.86,,,4825.86,Other,225% of Medicaid,3002.76,,,3002.76,Other,140% of Medicaid,4825.86,,,4825.86,Other,225% of Medicaid,5576.55,,,5576.55,Other,260% of Medicaid,6949.24,,,6949.24,Other,324% of Medicaid,4611.38,,,4611.38,Other,215% of Medicaid,4611.38,,,4611.38,Other,215% of Medicaid,2681.04,,,2681.04,Other,125% of Medicaid,2144.83,14759.2,
PERCUTANEOUS CHOLECYSTOSTOMY,47490,CPT,,46047490,CDM,360,RC,,,both,,,12073,8934.05,,,8934.05,Other,150% of Medicare + 9.63% HCRA Surcharge,5432.85,45,,5432.85,percent of total billed charges,Critical Access Hospital RCC factor,4565,,,4565,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4109,,,4109,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4476,,,4476,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4028,,,4028,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3805,,,3805,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",5976.14,,,5976.14,Other,110% of Medicare,8209.64,,,8209.64,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2588.91,,,2588.91,Other,186% of Medicaid,9658.4,,,9658.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9658.4,,,9658.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9658.4,,,9658.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",8451.1,70,,8451.1,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",4913,,,4913,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4422,,,4422,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4913,,,4913,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4176,,,4176,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",1391.89,,,1391.89,Other,100% of Medicaid,1391.89,,,1391.89,Other,100% of Medicaid,1391.89,,,1391.89,Other,100% of Medicaid,1391.89,,,1391.89,Other,100% of Medicaid,3131.75,,,3131.75,Other,225% of Medicaid,2129.59,,,2129.59,Other,153% of Medicaid,3131.75,,,3131.75,Other,225% of Medicaid,1948.64,,,1948.64,Other,140% of Medicaid,3131.75,,,3131.75,Other,225% of Medicaid,3618.91,,,3618.91,Other,260% of Medicaid,4509.72,,,4509.72,Other,324% of Medicaid,2992.56,,,2992.56,Other,215% of Medicaid,2992.56,,,2992.56,Other,215% of Medicaid,1739.86,,,1739.86,Other,125% of Medicaid,1391.89,9658.4,
PLMT BILIARY DRAINAGE CATH,47533,CPT,,46047533,CDM,360,RC,,,both,,,8980,6645.22,,,6645.22,Other,150% of Medicare + 9.63% HCRA Surcharge,4041,45,,4041,percent of total billed charges,Critical Access Hospital RCC factor,2480,,,2480,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2232,,,2232,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4476,,,4476,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4028,,,4028,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3805,,,3805,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4445.1,,,4445.1,Other,110% of Medicare,6106.4,,,6106.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2588.91,,,2588.91,Other,186% of Medicaid,7184,,,7184,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7184,,,7184,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7184,,,7184,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",6286,70,,6286,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",4913,,,4913,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4422,,,4422,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4913,,,4913,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4176,,,4176,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",1391.89,,,1391.89,Other,100% of Medicaid,1391.89,,,1391.89,Other,100% of Medicaid,1391.89,,,1391.89,Other,100% of Medicaid,1391.89,,,1391.89,Other,100% of Medicaid,3131.75,,,3131.75,Other,225% of Medicaid,2129.59,,,2129.59,Other,153% of Medicaid,3131.75,,,3131.75,Other,225% of Medicaid,1948.64,,,1948.64,Other,140% of Medicaid,3131.75,,,3131.75,Other,225% of Medicaid,3618.91,,,3618.91,Other,260% of Medicaid,4509.72,,,4509.72,Other,324% of Medicaid,2992.56,,,2992.56,Other,215% of Medicaid,2992.56,,,2992.56,Other,215% of Medicaid,1739.86,,,1739.86,Other,125% of Medicaid,1391.89,7216,
BIOPSY OF PANCREAS PERCUT,48102,CPT,,46048102,CDM,360,RC,,,both,,,3377,2498.99,,,2498.99,Other,150% of Medicare + 9.63% HCRA Surcharge,1519.65,45,,1519.65,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3648,,,3648,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3283,,,3283,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3101,,,3101,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",1671.62,,,1671.62,Other,110% of Medicare,2296.36,,,2296.36,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1196.64,,,1196.64,Other,186% of Medicaid,2701.6,,,2701.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2701.6,,,2701.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",3578,,,3578,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2363.9,70,,2363.9,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",4055,,,4055,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3649,,,3649,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4055,,,4055,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3448,,,3448,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",643.35,,,643.35,Other,100% of Medicaid,643.35,,,643.35,Other,100% of Medicaid,643.35,,,643.35,Other,100% of Medicaid,643.35,,,643.35,Other,100% of Medicaid,1447.55,,,1447.55,Other,225% of Medicaid,984.33,,,984.33,Other,153% of Medicaid,1447.55,,,1447.55,Other,225% of Medicaid,900.7,,,900.7,Other,140% of Medicaid,1447.55,,,1447.55,Other,225% of Medicaid,1672.72,,,1672.72,Other,260% of Medicaid,2084.47,,,2084.47,Other,324% of Medicaid,1383.21,,,1383.21,Other,215% of Medicaid,1383.21,,,1383.21,Other,215% of Medicaid,804.19,,,804.19,Other,125% of Medicaid,643.35,7216,
ABD PARACENTESIS W/IMAGING,49083,CPT,,46049083,CDM,360,RC,,,both,,,1893,1400.82,,,1400.82,Other,150% of Medicare + 9.63% HCRA Surcharge,851.85,45,,851.85,percent of total billed charges,Critical Access Hospital RCC factor,2480,,,2480,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2232,,,2232,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",937.04,,,937.04,Other,110% of Medicare,1287.24,,,1287.24,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1196.64,,,1196.64,Other,186% of Medicaid,1514.4,,,1514.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1514.4,,,1514.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1514.4,,,1514.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1325.1,70,,1325.1,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",4055,,,4055,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3649,,,3649,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4055,,,4055,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3448,,,3448,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",643.35,,,643.35,Other,100% of Medicaid,643.35,,,643.35,Other,100% of Medicaid,643.35,,,643.35,Other,100% of Medicaid,643.35,,,643.35,Other,100% of Medicaid,1447.55,,,1447.55,Other,225% of Medicaid,984.33,,,984.33,Other,153% of Medicaid,1447.55,,,1447.55,Other,225% of Medicaid,900.7,,,900.7,Other,140% of Medicaid,1447.55,,,1447.55,Other,225% of Medicaid,1672.72,,,1672.72,Other,260% of Medicaid,2084.47,,,2084.47,Other,324% of Medicaid,1383.21,,,1383.21,Other,215% of Medicaid,1383.21,,,1383.21,Other,215% of Medicaid,804.19,,,804.19,Other,125% of Medicaid,643.35,7216,
BIOPSY ABDOMINAL RETROPERITONE,49180,CPT,,46049180,CDM,360,RC,,,both,,,3462,2561.89,,,2561.89,Other,150% of Medicare + 9.63% HCRA Surcharge,1557.9,45,,1557.9,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3648,,,3648,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3283,,,3283,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3101,,,3101,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",1713.69,,,1713.69,Other,110% of Medicare,2354.16,,,2354.16,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1196.64,,,1196.64,Other,186% of Medicaid,2769.6,,,2769.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2769.6,,,2769.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",3578,,,3578,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2423.4,70,,2423.4,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",4055,,,4055,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3649,,,3649,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4055,,,4055,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3448,,,3448,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",643.35,,,643.35,Other,100% of Medicaid,643.35,,,643.35,Other,100% of Medicaid,643.35,,,643.35,Other,100% of Medicaid,643.35,,,643.35,Other,100% of Medicaid,1447.55,,,1447.55,Other,225% of Medicaid,984.33,,,984.33,Other,153% of Medicaid,1447.55,,,1447.55,Other,225% of Medicaid,900.7,,,900.7,Other,140% of Medicaid,1447.55,,,1447.55,Other,225% of Medicaid,1672.72,,,1672.72,Other,260% of Medicaid,2084.47,,,2084.47,Other,324% of Medicaid,1383.21,,,1383.21,Other,215% of Medicaid,1383.21,,,1383.21,Other,215% of Medicaid,804.19,,,804.19,Other,125% of Medicaid,643.35,7216,
SCLEROTX FLUID COLLECTION,49185,CPT,,46049185,CDM,360,RC,,,both,,,3377,2498.99,,,2498.99,Other,150% of Medicare + 9.63% HCRA Surcharge,1519.65,45,,1519.65,percent of total billed charges,Critical Access Hospital RCC factor,2480,,,2480,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2232,,,2232,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",1671.62,,,1671.62,Other,110% of Medicare,2296.36,,,2296.36,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1196.64,,,1196.64,Other,186% of Medicaid,2701.6,,,2701.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2701.6,,,2701.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2701.6,,,2701.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2363.9,70,,2363.9,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",643.35,,,643.35,Other,100% of Medicaid,643.35,,,643.35,Other,100% of Medicaid,643.35,,,643.35,Other,100% of Medicaid,643.35,,,643.35,Other,100% of Medicaid,1447.55,,,1447.55,Other,225% of Medicaid,984.33,,,984.33,Other,153% of Medicaid,1447.55,,,1447.55,Other,225% of Medicaid,900.7,,,900.7,Other,140% of Medicaid,1447.55,,,1447.55,Other,225% of Medicaid,1672.72,,,1672.72,Other,260% of Medicaid,2084.47,,,2084.47,Other,324% of Medicaid,1383.21,,,1383.21,Other,215% of Medicaid,1383.21,,,1383.21,Other,215% of Medicaid,804.19,,,804.19,Other,125% of Medicaid,643.35,7216,
EXC ABD TUM 5 CM OR LESS,49203,CPT,,46049203,CDM,360,RC,,,both,,,4374,3236.77,,,3236.77,Other,150% of Medicare + 9.63% HCRA Surcharge,1968.3,45,,1968.3,percent of total billed charges,Critical Access Hospital RCC factor,4565,,,4565,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4109,,,4109,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4476,,,4476,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4028,,,4028,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3805,,,3805,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2165.13,,,2165.13,Other,110% of Medicare,2974.32,,,2974.32,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",3190.69,,,3190.69,Other,186% of Medicaid,3499.2,,,3499.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",3499.2,,,3499.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",3499.2,,,3499.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",3061.8,70,,3061.8,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",4531,,,4531,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4079,,,4079,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4531,,,4531,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3852,,,3852,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",1715.42,,,1715.42,Other,100% of Medicaid,1715.42,,,1715.42,Other,100% of Medicaid,1715.42,,,1715.42,Other,100% of Medicaid,1715.42,,,1715.42,Other,100% of Medicaid,3859.7,,,3859.7,Other,225% of Medicaid,2624.6,,,2624.6,Other,153% of Medicaid,3859.7,,,3859.7,Other,225% of Medicaid,2401.59,,,2401.59,Other,140% of Medicaid,3859.7,,,3859.7,Other,225% of Medicaid,4460.1,,,4460.1,Other,260% of Medicaid,5557.97,,,5557.97,Other,324% of Medicaid,3688.16,,,3688.16,Other,215% of Medicaid,3688.16,,,3688.16,Other,215% of Medicaid,2144.28,,,2144.28,Other,125% of Medicaid,1715.42,7216,
EXC ABD TUM OVER 5 CM,49204,CPT,,46049204,CDM,360,RC,,,both,,,5567,4119.59,,,4119.59,Other,150% of Medicare + 9.63% HCRA Surcharge,2505.15,45,,2505.15,percent of total billed charges,Critical Access Hospital RCC factor,4565,,,4565,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4109,,,4109,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4476,,,4476,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4028,,,4028,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3805,,,3805,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2755.67,,,2755.67,Other,110% of Medicare,3785.56,,,3785.56,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",3190.69,,,3190.69,Other,186% of Medicaid,4453.6,,,4453.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",4453.6,,,4453.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",4453.6,,,4453.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",3896.9,70,,3896.9,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",6331,,,6331,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",5698,,,5698,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",6331,,,6331,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",5381,,,5381,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",1715.42,,,1715.42,Other,100% of Medicaid,1715.42,,,1715.42,Other,100% of Medicaid,1715.42,,,1715.42,Other,100% of Medicaid,1715.42,,,1715.42,Other,100% of Medicaid,3859.7,,,3859.7,Other,225% of Medicaid,2624.6,,,2624.6,Other,153% of Medicaid,3859.7,,,3859.7,Other,225% of Medicaid,2401.59,,,2401.59,Other,140% of Medicaid,3859.7,,,3859.7,Other,225% of Medicaid,4460.1,,,4460.1,Other,260% of Medicaid,5557.97,,,5557.97,Other,324% of Medicaid,3688.16,,,3688.16,Other,215% of Medicaid,3688.16,,,3688.16,Other,215% of Medicaid,2144.28,,,2144.28,Other,125% of Medicaid,1715.42,7216,
EXC ABD TUM OVER 10 CM,49205,CPT,,46049205,CDM,360,RC,,,both,,,6377,4719,,,4719,Other,150% of Medicare + 9.63% HCRA Surcharge,2869.65,45,,2869.65,percent of total billed charges,Critical Access Hospital RCC factor,4565,,,4565,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4109,,,4109,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4476,,,4476,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4028,,,4028,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3805,,,3805,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3156.62,,,3156.62,Other,110% of Medicare,4336.36,,,4336.36,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",3190.69,,,3190.69,Other,186% of Medicaid,5101.6,,,5101.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",5101.6,,,5101.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",5101.6,,,5101.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",4463.9,70,,4463.9,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",6331,,,6331,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",5698,,,5698,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",6331,,,6331,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",5381,,,5381,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",1715.42,,,1715.42,Other,100% of Medicaid,1715.42,,,1715.42,Other,100% of Medicaid,1715.42,,,1715.42,Other,100% of Medicaid,1715.42,,,1715.42,Other,100% of Medicaid,3859.7,,,3859.7,Other,225% of Medicaid,2624.6,,,2624.6,Other,153% of Medicaid,3859.7,,,3859.7,Other,225% of Medicaid,2401.59,,,2401.59,Other,140% of Medicaid,3859.7,,,3859.7,Other,225% of Medicaid,4460.1,,,4460.1,Other,260% of Medicaid,5557.97,,,5557.97,Other,324% of Medicaid,3688.16,,,3688.16,Other,215% of Medicaid,3688.16,,,3688.16,Other,215% of Medicaid,2144.28,,,2144.28,Other,125% of Medicaid,1715.42,7216,
CT GUIDED CATHETER EXCHANGE,49423,CPT,,46049423,CDM,360,RC,,,both,,,5324,3939.77,,,3939.77,Other,150% of Medicare + 9.63% HCRA Surcharge,2395.8,45,,2395.8,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3648,,,3648,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3283,,,3283,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3101,,,3101,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2635.38,,,2635.38,Other,110% of Medicare,3620.32,,,3620.32,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1196.64,,,1196.64,Other,186% of Medicaid,4259.2,,,4259.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",4259.2,,,4259.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",4259.2,,,4259.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",3726.8,70,,3726.8,percent of total billed charges,All Other,332.92,,,332.92,Fee Schedule,,282.17,,,282.17,Fee Schedule,,4055,,,4055,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3649,,,3649,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4055,,,4055,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3448,,,3448,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",643.35,,,643.35,Other,100% of Medicaid,643.35,,,643.35,Other,100% of Medicaid,643.35,,,643.35,Other,100% of Medicaid,643.35,,,643.35,Other,100% of Medicaid,1447.55,,,1447.55,Other,225% of Medicaid,984.33,,,984.33,Other,153% of Medicaid,1447.55,,,1447.55,Other,225% of Medicaid,900.7,,,900.7,Other,140% of Medicaid,1447.55,,,1447.55,Other,225% of Medicaid,1672.72,,,1672.72,Other,260% of Medicaid,2084.47,,,2084.47,Other,324% of Medicaid,1383.21,,,1383.21,Other,215% of Medicaid,1383.21,,,1383.21,Other,215% of Medicaid,804.19,,,804.19,Other,125% of Medicaid,282.17,7216,
BIOPSY OF KIDNEY PERCUT,50200,CPT,,46050200,CDM,360,RC,,,both,,,3462,2561.89,,,2561.89,Other,150% of Medicare + 9.63% HCRA Surcharge,1557.9,45,,1557.9,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3648,,,3648,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3283,,,3283,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3101,,,3101,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",1713.69,,,1713.69,Other,110% of Medicare,2354.16,,,2354.16,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2011.18,,,2011.18,Other,186% of Medicaid,2769.6,,,2769.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2769.6,,,2769.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",3578,,,3578,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2423.4,70,,2423.4,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",4055,,,4055,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3649,,,3649,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4055,,,4055,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3448,,,3448,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",1081.28,,,1081.28,Other,100% of Medicaid,1081.28,,,1081.28,Other,100% of Medicaid,1081.28,,,1081.28,Other,100% of Medicaid,1081.28,,,1081.28,Other,100% of Medicaid,2432.88,,,2432.88,Other,225% of Medicaid,1654.36,,,1654.36,Other,153% of Medicaid,2432.88,,,2432.88,Other,225% of Medicaid,1513.79,,,1513.79,Other,140% of Medicaid,2432.88,,,2432.88,Other,225% of Medicaid,2811.33,,,2811.33,Other,260% of Medicaid,3503.35,,,3503.35,Other,324% of Medicaid,2324.75,,,2324.75,Other,215% of Medicaid,2324.75,,,2324.75,Other,215% of Medicaid,1351.6,,,1351.6,Other,125% of Medicaid,1081.28,7216,
ASP A/O INJ RENAL CYST PERCUT,50390,CPT,,46050390,CDM,360,RC,,,both,,,3462,2561.89,,,2561.89,Other,150% of Medicare + 9.63% HCRA Surcharge,1557.9,45,,1557.9,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",1713.69,,,1713.69,Other,110% of Medicare,2354.16,,,2354.16,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",903.43,,,903.43,Other,186% of Medicaid,2769.6,,,2769.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2769.6,,,2769.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",3578,,,3578,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2423.4,70,,2423.4,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",485.72,,,485.72,Other,100% of Medicaid,485.72,,,485.72,Other,100% of Medicaid,485.72,,,485.72,Other,100% of Medicaid,485.72,,,485.72,Other,100% of Medicaid,1092.86,,,1092.86,Other,225% of Medicaid,743.14,,,743.14,Other,153% of Medicaid,1092.86,,,1092.86,Other,225% of Medicaid,680,,,680,Other,140% of Medicaid,1092.86,,,1092.86,Other,225% of Medicaid,1262.86,,,1262.86,Other,260% of Medicaid,1573.72,,,1573.72,Other,324% of Medicaid,1044.29,,,1044.29,Other,215% of Medicaid,1044.29,,,1044.29,Other,215% of Medicaid,607.14,,,607.14,Other,125% of Medicaid,485.72,7216,
PLMT NEPHROSTOMY CATHETER,50432,CPT,,46050432,CDM,360,RC,,,both,,,6214,4598.38,,,4598.38,Other,150% of Medicare + 9.63% HCRA Surcharge,2796.3,45,,2796.3,percent of total billed charges,Critical Access Hospital RCC factor,2480,,,2480,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2232,,,2232,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3648,,,3648,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3283,,,3283,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3101,,,3101,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3075.93,,,3075.93,Other,110% of Medicare,4225.52,,,4225.52,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2011.18,,,2011.18,Other,186% of Medicaid,4971.2,,,4971.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",4971.2,,,4971.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",4971.2,,,4971.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",4349.8,70,,4349.8,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",4531,,,4531,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4079,,,4079,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4531,,,4531,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3852,,,3852,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",1081.28,,,1081.28,Other,100% of Medicaid,1081.28,,,1081.28,Other,100% of Medicaid,1081.28,,,1081.28,Other,100% of Medicaid,1081.28,,,1081.28,Other,100% of Medicaid,2432.88,,,2432.88,Other,225% of Medicaid,1654.36,,,1654.36,Other,153% of Medicaid,2432.88,,,2432.88,Other,225% of Medicaid,1513.79,,,1513.79,Other,140% of Medicaid,2432.88,,,2432.88,Other,225% of Medicaid,2811.33,,,2811.33,Other,260% of Medicaid,3503.35,,,3503.35,Other,324% of Medicaid,2324.75,,,2324.75,Other,215% of Medicaid,2324.75,,,2324.75,Other,215% of Medicaid,1351.6,,,1351.6,Other,125% of Medicaid,1081.28,7216,
PLMT NEPHROURETERAL CATHETER,50433,CPT,,46050433,CDM,360,RC,,,both,,,7216,5339.86,,,5339.86,Other,150% of Medicare + 9.63% HCRA Surcharge,3247.2,45,,3247.2,percent of total billed charges,Critical Access Hospital RCC factor,2480,,,2480,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2232,,,2232,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3648,,,3648,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3283,,,3283,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3101,,,3101,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3571.92,,,3571.92,Other,110% of Medicare,4906.88,,,4906.88,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2586.25,,,2586.25,Other,186% of Medicaid,5772.8,,,5772.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",5772.8,,,5772.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",5772.8,,,5772.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",5051.2,70,,5051.2,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",4531,,,4531,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4079,,,4079,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4531,,,4531,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3852,,,3852,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",1390.46,,,1390.46,Other,100% of Medicaid,1390.46,,,1390.46,Other,100% of Medicaid,1390.46,,,1390.46,Other,100% of Medicaid,1390.46,,,1390.46,Other,100% of Medicaid,3128.53,,,3128.53,Other,225% of Medicaid,2127.4,,,2127.4,Other,153% of Medicaid,3128.53,,,3128.53,Other,225% of Medicaid,1946.64,,,1946.64,Other,140% of Medicaid,3128.53,,,3128.53,Other,225% of Medicaid,3615.19,,,3615.19,Other,260% of Medicaid,4505.09,,,4505.09,Other,324% of Medicaid,2989.49,,,2989.49,Other,215% of Medicaid,2989.49,,,2989.49,Other,215% of Medicaid,1738.07,,,1738.07,Other,125% of Medicaid,1390.46,7216,
CONVERT NEPHROSTOMY CATHETER,50434,CPT,,46050434,CDM,360,RC,,,both,,,4176,3090.25,,,3090.25,Other,150% of Medicare + 9.63% HCRA Surcharge,1879.2,45,,1879.2,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3648,,,3648,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3283,,,3283,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3101,,,3101,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2067.12,,,2067.12,Other,110% of Medicare,2839.68,,,2839.68,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2011.18,,,2011.18,Other,186% of Medicaid,3340.8,,,3340.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",3340.8,,,3340.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",3340.8,,,3340.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2923.2,70,,2923.2,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",1081.28,,,1081.28,Other,100% of Medicaid,1081.28,,,1081.28,Other,100% of Medicaid,1081.28,,,1081.28,Other,100% of Medicaid,1081.28,,,1081.28,Other,100% of Medicaid,2432.88,,,2432.88,Other,225% of Medicaid,1654.36,,,1654.36,Other,153% of Medicaid,2432.88,,,2432.88,Other,225% of Medicaid,1513.79,,,1513.79,Other,140% of Medicaid,2432.88,,,2432.88,Other,225% of Medicaid,2811.33,,,2811.33,Other,260% of Medicaid,3503.35,,,3503.35,Other,324% of Medicaid,2324.75,,,2324.75,Other,215% of Medicaid,2324.75,,,2324.75,Other,215% of Medicaid,1351.6,,,1351.6,Other,125% of Medicaid,1081.28,7216,
EXCHANGE NEPHROSTOMY CATH,50435,CPT,,46050435,CDM,360,RC,,,both,,,4176,3090.25,,,3090.25,Other,150% of Medicare + 9.63% HCRA Surcharge,1879.2,45,,1879.2,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3648,,,3648,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3283,,,3283,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3101,,,3101,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2067.12,,,2067.12,Other,110% of Medicare,2839.68,,,2839.68,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2011.18,,,2011.18,Other,186% of Medicaid,3340.8,,,3340.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",3340.8,,,3340.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",3340.8,,,3340.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2923.2,70,,2923.2,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",1081.28,,,1081.28,Other,100% of Medicaid,1081.28,,,1081.28,Other,100% of Medicaid,1081.28,,,1081.28,Other,100% of Medicaid,1081.28,,,1081.28,Other,100% of Medicaid,2432.88,,,2432.88,Other,225% of Medicaid,1654.36,,,1654.36,Other,153% of Medicaid,2432.88,,,2432.88,Other,225% of Medicaid,1513.79,,,1513.79,Other,140% of Medicaid,2432.88,,,2432.88,Other,225% of Medicaid,2811.33,,,2811.33,Other,260% of Medicaid,3503.35,,,3503.35,Other,324% of Medicaid,2324.75,,,2324.75,Other,215% of Medicaid,2324.75,,,2324.75,Other,215% of Medicaid,1351.6,,,1351.6,Other,125% of Medicaid,1081.28,7216,
CREATE PASSAGE TO KIDNEY,50437,CPT,,46050437,CDM,360,RC,,,both,,,8589,6355.88,,,6355.88,Other,150% of Medicare + 9.63% HCRA Surcharge,3865.05,45,,3865.05,percent of total billed charges,Critical Access Hospital RCC factor,2480,,,2480,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2232,,,2232,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4476,,,4476,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4028,,,4028,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3805,,,3805,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4251.56,,,4251.56,Other,110% of Medicare,5840.52,,,5840.52,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2011.18,,,2011.18,Other,186% of Medicaid,6871.2,,,6871.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",6871.2,,,6871.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",6871.2,,,6871.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",6012.3,70,,6012.3,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",4913,,,4913,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4422,,,4422,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4913,,,4913,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4176,,,4176,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",1081.28,,,1081.28,Other,100% of Medicaid,1081.28,,,1081.28,Other,100% of Medicaid,1081.28,,,1081.28,Other,100% of Medicaid,1081.28,,,1081.28,Other,100% of Medicaid,2432.88,,,2432.88,Other,225% of Medicaid,1654.36,,,1654.36,Other,153% of Medicaid,2432.88,,,2432.88,Other,225% of Medicaid,1513.79,,,1513.79,Other,140% of Medicaid,2432.88,,,2432.88,Other,225% of Medicaid,2811.33,,,2811.33,Other,260% of Medicaid,3503.35,,,3503.35,Other,324% of Medicaid,2324.75,,,2324.75,Other,215% of Medicaid,2324.75,,,2324.75,Other,215% of Medicaid,1351.6,,,1351.6,Other,125% of Medicaid,1081.28,7216,
PERC RF ABLATE 1+ RENAL TUMOR,50592,CPT,,46050592,CDM,360,RC,,,both,,,15948,11801.56,,,11801.56,Other,150% of Medicare + 9.63% HCRA Surcharge,7176.6,45,,7176.6,percent of total billed charges,Critical Access Hospital RCC factor,3969,,,3969,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3572,,,3572,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",5738,,,5738,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",5164,,,5164,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4877,,,4877,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",7894.26,,,7894.26,Other,110% of Medicare,6152,,,6152,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2586.25,,,2586.25,Other,186% of Medicaid,7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",12758.4,,,12758.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",11163.6,70,,11163.6,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",6331,,,6331,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",5698,,,5698,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",6331,,,6331,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",5381,,,5381,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",1390.46,,,1390.46,Other,100% of Medicaid,1390.46,,,1390.46,Other,100% of Medicaid,1390.46,,,1390.46,Other,100% of Medicaid,1390.46,,,1390.46,Other,100% of Medicaid,3128.53,,,3128.53,Other,225% of Medicaid,2127.4,,,2127.4,Other,153% of Medicaid,3128.53,,,3128.53,Other,225% of Medicaid,1946.64,,,1946.64,Other,140% of Medicaid,3128.53,,,3128.53,Other,225% of Medicaid,3615.19,,,3615.19,Other,260% of Medicaid,4505.09,,,4505.09,Other,324% of Medicaid,2989.49,,,2989.49,Other,215% of Medicaid,2989.49,,,2989.49,Other,215% of Medicaid,1738.07,,,1738.07,Other,125% of Medicaid,1390.46,12758.4,
ENDOLUMINAL BX URTR RNL PLVS,50606,CPT,,46050606,CDM,360,RC,,,both,,,657,486.18,,,486.18,Other,150% of Medicare + 9.63% HCRA Surcharge,295.65,45,,295.65,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",325.22,,,325.22,Other,110% of Medicare,446.76,,,446.76,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",3435.71,,,3435.71,Other,186% of Medicaid,525.6,,,525.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",525.6,,,525.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",525.6,,,525.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",459.9,70,,459.9,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",1847.16,,,1847.16,Other,100% of Medicaid,1847.16,,,1847.16,Other,100% of Medicaid,1847.16,,,1847.16,Other,100% of Medicaid,1847.16,,,1847.16,Other,100% of Medicaid,4156.1,,,4156.1,Other,225% of Medicaid,2826.15,,,2826.15,Other,153% of Medicaid,4156.1,,,4156.1,Other,225% of Medicaid,2586.02,,,2586.02,Other,140% of Medicaid,4156.1,,,4156.1,Other,225% of Medicaid,4802.61,,,4802.61,Other,260% of Medicaid,5984.79,,,5984.79,Other,324% of Medicaid,3971.39,,,3971.39,Other,215% of Medicaid,3971.39,,,3971.39,Other,215% of Medicaid,2308.95,,,2308.95,Other,125% of Medicaid,295.65,7216,
PLMT URETERAL STENT PRQ,50693,CPT,,46050693,CDM,360,RC,,,both,,,9252,6846.5,,,6846.5,Other,150% of Medicare + 9.63% HCRA Surcharge,4163.4,45,,4163.4,percent of total billed charges,Critical Access Hospital RCC factor,3473,,,3473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3126,,,3126,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3648,,,3648,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3283,,,3283,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3101,,,3101,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4579.74,,,4579.74,Other,110% of Medicare,6152,,,6152,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2586.25,,,2586.25,Other,186% of Medicaid,7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7401.6,,,7401.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",6476.4,70,,6476.4,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",4913,,,4913,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4422,,,4422,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4913,,,4913,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4176,,,4176,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",1390.46,,,1390.46,Other,100% of Medicaid,1390.46,,,1390.46,Other,100% of Medicaid,1390.46,,,1390.46,Other,100% of Medicaid,1390.46,,,1390.46,Other,100% of Medicaid,3128.53,,,3128.53,Other,225% of Medicaid,2127.4,,,2127.4,Other,153% of Medicaid,3128.53,,,3128.53,Other,225% of Medicaid,1946.64,,,1946.64,Other,140% of Medicaid,3128.53,,,3128.53,Other,225% of Medicaid,3615.19,,,3615.19,Other,260% of Medicaid,4505.09,,,4505.09,Other,324% of Medicaid,2989.49,,,2989.49,Other,215% of Medicaid,2989.49,,,2989.49,Other,215% of Medicaid,1738.07,,,1738.07,Other,125% of Medicaid,1390.46,9473,
PLMT URETERAL STENT PRQ,50694,CPT,,46050694,CDM,360,RC,,,both,,,9252,6846.5,,,6846.5,Other,150% of Medicare + 9.63% HCRA Surcharge,4163.4,45,,4163.4,percent of total billed charges,Critical Access Hospital RCC factor,3473,,,3473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3126,,,3126,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4476,,,4476,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4028,,,4028,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3805,,,3805,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4579.74,,,4579.74,Other,110% of Medicare,6152,,,6152,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2586.25,,,2586.25,Other,186% of Medicaid,7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7401.6,,,7401.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",6476.4,70,,6476.4,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",4913,,,4913,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4422,,,4422,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4913,,,4913,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4176,,,4176,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",1390.46,,,1390.46,Other,100% of Medicaid,1390.46,,,1390.46,Other,100% of Medicaid,1390.46,,,1390.46,Other,100% of Medicaid,1390.46,,,1390.46,Other,100% of Medicaid,3128.53,,,3128.53,Other,225% of Medicaid,2127.4,,,2127.4,Other,153% of Medicaid,3128.53,,,3128.53,Other,225% of Medicaid,1946.64,,,1946.64,Other,140% of Medicaid,3128.53,,,3128.53,Other,225% of Medicaid,3615.19,,,3615.19,Other,260% of Medicaid,4505.09,,,4505.09,Other,324% of Medicaid,2989.49,,,2989.49,Other,215% of Medicaid,2989.49,,,2989.49,Other,215% of Medicaid,1738.07,,,1738.07,Other,125% of Medicaid,1390.46,9473,
PLMT URETERAL STENT PRQ,50695,CPT,,46050695,CDM,360,RC,,,both,,,8488,6281.14,,,6281.14,Other,150% of Medicare + 9.63% HCRA Surcharge,3819.6,45,,3819.6,percent of total billed charges,Critical Access Hospital RCC factor,3473,,,3473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3126,,,3126,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4476,,,4476,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4028,,,4028,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3805,,,3805,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4201.56,,,4201.56,Other,110% of Medicare,6152,,,6152,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2586.25,,,2586.25,Other,186% of Medicaid,7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",6790.4,,,6790.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",5941.6,70,,5941.6,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",4913,,,4913,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4422,,,4422,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4913,,,4913,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4176,,,4176,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",1390.46,,,1390.46,Other,100% of Medicaid,1390.46,,,1390.46,Other,100% of Medicaid,1390.46,,,1390.46,Other,100% of Medicaid,1390.46,,,1390.46,Other,100% of Medicaid,3128.53,,,3128.53,Other,225% of Medicaid,2127.4,,,2127.4,Other,153% of Medicaid,3128.53,,,3128.53,Other,225% of Medicaid,1946.64,,,1946.64,Other,140% of Medicaid,3128.53,,,3128.53,Other,225% of Medicaid,3615.19,,,3615.19,Other,260% of Medicaid,4505.09,,,4505.09,Other,324% of Medicaid,2989.49,,,2989.49,Other,215% of Medicaid,2989.49,,,2989.49,Other,215% of Medicaid,1738.07,,,1738.07,Other,125% of Medicaid,1390.46,9473,
BIOPSY THYROID PERC NEEDLE,60100,CPT,,46060100,CDM,360,RC,,,both,,,1601,1184.74,,,1184.74,Other,150% of Medicare + 9.63% HCRA Surcharge,720.45,45,,720.45,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",792.5,,,792.5,Other,110% of Medicare,1088.68,,,1088.68,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1037.55,,,1037.55,Other,186% of Medicaid,1280.8,,,1280.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1280.8,,,1280.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1280.8,,,1280.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1120.7,70,,1120.7,percent of total billed charges,All Other,367.36,,,367.36,Fee Schedule,,311.36,,,311.36,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",557.82,,,557.82,Other,100% of Medicaid,557.82,,,557.82,Other,100% of Medicaid,557.82,,,557.82,Other,100% of Medicaid,557.82,,,557.82,Other,100% of Medicaid,1255.1,,,1255.1,Other,225% of Medicaid,853.47,,,853.47,Other,153% of Medicaid,1255.1,,,1255.1,Other,225% of Medicaid,780.95,,,780.95,Other,140% of Medicaid,1255.1,,,1255.1,Other,225% of Medicaid,1450.34,,,1450.34,Other,260% of Medicaid,1807.35,,,1807.35,Other,324% of Medicaid,1199.32,,,1199.32,Other,215% of Medicaid,1199.32,,,1199.32,Other,215% of Medicaid,697.28,,,697.28,Other,125% of Medicaid,311.36,7216,
CT GUIDED DISK ASPIRATION,62287,CPT,,46062287,CDM,360,RC,,,both,,,12158,8996.95,,,8996.95,Other,150% of Medicare + 9.63% HCRA Surcharge,5471.1,45,,5471.1,percent of total billed charges,Critical Access Hospital RCC factor,4827,,,4827,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4344,,,4344,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4970,,,4970,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4473,,,4473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4225,,,4225,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",6018.21,,,6018.21,Other,110% of Medicare,6152,,,6152,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",5525.48,,,5525.48,Other,186% of Medicaid,7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9196,,,9196,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",8510.6,70,,8510.6,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",4913,,,4913,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4422,,,4422,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4913,,,4913,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4176,,,4176,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2970.69,,,2970.69,Other,100% of Medicaid,2970.69,,,2970.69,Other,100% of Medicaid,2970.69,,,2970.69,Other,100% of Medicaid,2970.69,,,2970.69,Other,100% of Medicaid,6684.05,,,6684.05,Other,225% of Medicaid,4545.16,,,4545.16,Other,153% of Medicaid,6684.05,,,6684.05,Other,225% of Medicaid,4158.97,,,4158.97,Other,140% of Medicaid,6684.05,,,6684.05,Other,225% of Medicaid,7723.79,,,7723.79,Other,260% of Medicaid,9625.03,,,9625.03,Other,324% of Medicaid,6386.98,,,6386.98,Other,215% of Medicaid,6386.98,,,6386.98,Other,215% of Medicaid,3713.36,,,3713.36,Other,125% of Medicaid,2970.69,9625.03,
ASPIRATE PLEURA W IMAGING LT,32555,CPT,LT,46132555,CDM,360,RC,,,both,,,2118,1567.33,,,1567.33,Other,150% of Medicare + 9.63% HCRA Surcharge,953.1,45,,953.1,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",1048.41,,,1048.41,Other,110% of Medicare,1440.24,,,1440.24,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1196.64,,,1196.64,Other,186% of Medicaid,1694.4,,,1694.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1694.4,,,1694.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1694.4,,,1694.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1482.6,70,,1482.6,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",643.35,,,643.35,Other,100% of Medicaid,643.35,,,643.35,Other,100% of Medicaid,643.35,,,643.35,Other,100% of Medicaid,643.35,,,643.35,Other,100% of Medicaid,1447.55,,,1447.55,Other,225% of Medicaid,984.33,,,984.33,Other,153% of Medicaid,1447.55,,,1447.55,Other,225% of Medicaid,900.7,,,900.7,Other,140% of Medicaid,1447.55,,,1447.55,Other,225% of Medicaid,1672.72,,,1672.72,Other,260% of Medicaid,2084.47,,,2084.47,Other,324% of Medicaid,1383.21,,,1383.21,Other,215% of Medicaid,1383.21,,,1383.21,Other,215% of Medicaid,804.19,,,804.19,Other,125% of Medicaid,643.35,7216,
ASPIRATE PLEURA W IMAGING RT,32555,CPT,RT,46232555,CDM,360,RC,,,both,,,2118,1567.33,,,1567.33,Other,150% of Medicare + 9.63% HCRA Surcharge,953.1,45,,953.1,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",1048.41,,,1048.41,Other,110% of Medicare,1440.24,,,1440.24,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1196.64,,,1196.64,Other,186% of Medicaid,1694.4,,,1694.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1694.4,,,1694.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1694.4,,,1694.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1482.6,70,,1482.6,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",643.35,,,643.35,Other,100% of Medicaid,643.35,,,643.35,Other,100% of Medicaid,643.35,,,643.35,Other,100% of Medicaid,643.35,,,643.35,Other,100% of Medicaid,1447.55,,,1447.55,Other,225% of Medicaid,984.33,,,984.33,Other,153% of Medicaid,1447.55,,,1447.55,Other,225% of Medicaid,900.7,,,900.7,Other,140% of Medicaid,1447.55,,,1447.55,Other,225% of Medicaid,1672.72,,,1672.72,Other,260% of Medicaid,2084.47,,,2084.47,Other,324% of Medicaid,1383.21,,,1383.21,Other,215% of Medicaid,1383.21,,,1383.21,Other,215% of Medicaid,804.19,,,804.19,Other,125% of Medicaid,643.35,7216,
ASPIRATE PLEURA W IMAGING BILAT,32555,CPT,50,46332555,CDM,360,RC,,,both,,,3177,2350.99,,,2350.99,Other,150% of Medicare + 9.63% HCRA Surcharge,1429.65,45,,1429.65,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",1572.62,,,1572.62,Other,110% of Medicare,2160.36,,,2160.36,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1196.64,,,1196.64,Other,186% of Medicaid,2541.6,,,2541.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2541.6,,,2541.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2541.6,,,2541.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2223.9,70,,2223.9,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",643.35,,,643.35,Other,100% of Medicaid,643.35,,,643.35,Other,100% of Medicaid,643.35,,,643.35,Other,100% of Medicaid,643.35,,,643.35,Other,100% of Medicaid,1447.55,,,1447.55,Other,225% of Medicaid,984.33,,,984.33,Other,153% of Medicaid,1447.55,,,1447.55,Other,225% of Medicaid,900.7,,,900.7,Other,140% of Medicaid,1447.55,,,1447.55,Other,225% of Medicaid,1672.72,,,1672.72,Other,260% of Medicaid,2084.47,,,2084.47,Other,324% of Medicaid,1383.21,,,1383.21,Other,215% of Medicaid,1383.21,,,1383.21,Other,215% of Medicaid,804.19,,,804.19,Other,125% of Medicaid,643.35,7216,
CREATE PASSAGE TO KIDNEY BILATERAL,50437,CPT,50,46350395,CDM,360,RC,,,both,,,12884,9534.19,,,9534.19,Other,150% of Medicare + 9.63% HCRA Surcharge,5797.8,45,,5797.8,percent of total billed charges,Critical Access Hospital RCC factor,2480,,,2480,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2232,,,2232,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4476,,,4476,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4028,,,4028,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3805,,,3805,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",6377.58,,,6377.58,Other,110% of Medicare,8761.12,,,8761.12,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2011.18,,,2011.18,Other,186% of Medicaid,10307.2,,,10307.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",10307.2,,,10307.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",10307.2,,,10307.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9018.8,70,,9018.8,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",4913,,,4913,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4422,,,4422,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4913,,,4913,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4176,,,4176,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",1081.28,,,1081.28,Other,100% of Medicaid,1081.28,,,1081.28,Other,100% of Medicaid,1081.28,,,1081.28,Other,100% of Medicaid,1081.28,,,1081.28,Other,100% of Medicaid,2432.88,,,2432.88,Other,225% of Medicaid,1654.36,,,1654.36,Other,153% of Medicaid,2432.88,,,2432.88,Other,225% of Medicaid,1513.79,,,1513.79,Other,140% of Medicaid,2432.88,,,2432.88,Other,225% of Medicaid,2811.33,,,2811.33,Other,260% of Medicaid,3503.35,,,3503.35,Other,324% of Medicaid,2324.75,,,2324.75,Other,215% of Medicaid,2324.75,,,2324.75,Other,215% of Medicaid,1351.6,,,1351.6,Other,125% of Medicaid,1081.28,10307.2,
PLMT NEPHROSTOMY CATHETER,50432,CPT,50,46350432,CDM,360,RC,,,both,,,9321,6897.56,,,6897.56,Other,150% of Medicare + 9.63% HCRA Surcharge,4194.45,45,,4194.45,percent of total billed charges,Critical Access Hospital RCC factor,2480,,,2480,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2232,,,2232,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3648,,,3648,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3283,,,3283,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3101,,,3101,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4613.9,,,4613.9,Other,110% of Medicare,6338.28,,,6338.28,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2011.18,,,2011.18,Other,186% of Medicaid,7456.8,,,7456.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7456.8,,,7456.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7456.8,,,7456.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",6524.7,70,,6524.7,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",4531,,,4531,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4079,,,4079,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4531,,,4531,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3852,,,3852,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",1081.28,,,1081.28,Other,100% of Medicaid,1081.28,,,1081.28,Other,100% of Medicaid,1081.28,,,1081.28,Other,100% of Medicaid,1081.28,,,1081.28,Other,100% of Medicaid,2432.88,,,2432.88,Other,225% of Medicaid,1654.36,,,1654.36,Other,153% of Medicaid,2432.88,,,2432.88,Other,225% of Medicaid,1513.79,,,1513.79,Other,140% of Medicaid,2432.88,,,2432.88,Other,225% of Medicaid,2811.33,,,2811.33,Other,260% of Medicaid,3503.35,,,3503.35,Other,324% of Medicaid,2324.75,,,2324.75,Other,215% of Medicaid,2324.75,,,2324.75,Other,215% of Medicaid,1351.6,,,1351.6,Other,125% of Medicaid,1081.28,7456.8,
PERCUT LAMOT/LAM LUMBAR (MILD),0275T,HCPCS,,47000001,CDM,360,RC,,,both,,,14928,11046.76,,,11046.76,Other,150% of Medicare + 9.63% HCRA Surcharge,6717.6,45,,6717.6,percent of total billed charges,Critical Access Hospital RCC factor,4565,,,4565,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4109,,,4109,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",7978,,,7978,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",7180,,,7180,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",6781,,,6781,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",7389.36,,,7389.36,Other,110% of Medicare,10151.04,,,10151.04,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",5525.48,,,5525.48,Other,186% of Medicaid,11942.4,,,11942.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",11942.4,,,11942.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",11942.4,,,11942.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",10449.6,70,,10449.6,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",6331,,,6331,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",5698,,,5698,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",6331,,,6331,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",5381,,,5381,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2970.69,,,2970.69,Other,100% of Medicaid,2970.69,,,2970.69,Other,100% of Medicaid,2970.69,,,2970.69,Other,100% of Medicaid,2970.69,,,2970.69,Other,100% of Medicaid,6684.05,,,6684.05,Other,225% of Medicaid,4545.16,,,4545.16,Other,153% of Medicaid,6684.05,,,6684.05,Other,225% of Medicaid,4158.97,,,4158.97,Other,140% of Medicaid,6684.05,,,6684.05,Other,225% of Medicaid,7723.79,,,7723.79,Other,260% of Medicaid,9625.03,,,9625.03,Other,324% of Medicaid,6386.98,,,6386.98,Other,215% of Medicaid,6386.98,,,6386.98,Other,215% of Medicaid,3713.36,,,3713.36,Other,125% of Medicaid,2970.69,11942.4,
OCCLUSIVE DEVICE PLACEMENT,G0269,HCPCS,,47000002,CDM,360,RC,,,both,,,232,171.68,,,171.68,Other,150% of Medicare + 9.63% HCRA Surcharge,104.4,45,,104.4,percent of total billed charges,Critical Access Hospital RCC factor,4565,,,4565,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4109,,,4109,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,114.84,,,114.84,Other,110% of Medicare,157.76,,,157.76,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",0.01,,,0.01,Other,186% of Medicaid,185.6,,,185.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",185.6,,,185.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",185.6,,,185.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",162.4,70,,162.4,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,7216,
TRLUML PERIP ATHRC ILIAC ART,0238T,HCPCS,,47000007,CDM,360,RC,,,both,,,38665,28612.2,,,28612.2,Other,150% of Medicare + 9.63% HCRA Surcharge,17399.25,45,,17399.25,percent of total billed charges,Critical Access Hospital RCC factor,4565,,,4565,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4109,,,4109,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",7978,,,7978,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",7180,,,7180,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",6781,,,6781,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",19139.18,,,19139.18,Other,110% of Medicare,26292.2,,,26292.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",4605.54,,,4605.54,Other,186% of Medicaid,30932,,,30932,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",30932,,,30932,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",30932,,,30932,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",27065.5,70,,27065.5,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",6956,,,6956,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",6261,,,6261,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",6956,,,6956,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",5913,,,5913,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2476.1,,,2476.1,Other,100% of Medicaid,2476.1,,,2476.1,Other,100% of Medicaid,2476.1,,,2476.1,Other,100% of Medicaid,2476.1,,,2476.1,Other,100% of Medicaid,5571.22,,,5571.22,Other,225% of Medicaid,3788.43,,,3788.43,Other,153% of Medicaid,5571.22,,,5571.22,Other,225% of Medicaid,3466.54,,,3466.54,Other,140% of Medicaid,5571.22,,,5571.22,Other,225% of Medicaid,6437.85,,,6437.85,Other,260% of Medicaid,8022.56,,,8022.56,Other,324% of Medicaid,5323.61,,,5323.61,Other,215% of Medicaid,5323.61,,,5323.61,Other,215% of Medicaid,3095.12,,,3095.12,Other,125% of Medicaid,2476.1,30932,
REVASC INTRAVASC LITHOTRIPSY,C9764,HCPCS,,47000012,CDM,360,RC,,,both,,,33365,24690.18,,,24690.18,Other,150% of Medicare + 9.63% HCRA Surcharge,15014.25,45,,15014.25,percent of total billed charges,Critical Access Hospital RCC factor,3969,,,3969,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3572,,,3572,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",6807,,,6807,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",6126,,,6126,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",5786,,,5786,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",16515.68,,,16515.68,Other,110% of Medicare,6152,,,6152,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",3853.44,,,3853.44,Other,186% of Medicaid,7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",26692,,,26692,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",23355.5,70,,23355.5,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",6331,,,6331,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",5698,,,5698,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",6331,,,6331,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",5381,,,5381,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2071.74,,,2071.74,Other,100% of Medicaid,2071.74,,,2071.74,Other,100% of Medicaid,2071.74,,,2071.74,Other,100% of Medicaid,2071.74,,,2071.74,Other,100% of Medicaid,4661.42,,,4661.42,Other,225% of Medicaid,3169.77,,,3169.77,Other,153% of Medicaid,4661.42,,,4661.42,Other,225% of Medicaid,2900.44,,,2900.44,Other,140% of Medicaid,4661.42,,,4661.42,Other,225% of Medicaid,5386.53,,,5386.53,Other,260% of Medicaid,6712.45,,,6712.45,Other,324% of Medicaid,4454.25,,,4454.25,Other,215% of Medicaid,4454.25,,,4454.25,Other,215% of Medicaid,2589.68,,,2589.68,Other,125% of Medicaid,2071.74,26692,
REVASC INTRA LITHOTRIP-STENT,C9765,HCPCS,,47000013,CDM,360,RC,,,both,,,53991,39953.47,,,39953.47,Other,150% of Medicare + 9.63% HCRA Surcharge,24295.95,45,,24295.95,percent of total billed charges,Critical Access Hospital RCC factor,3969,,,3969,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3572,,,3572,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",7978,,,7978,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",7180,,,7180,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",6781,,,6781,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",26725.55,,,26725.55,Other,110% of Medicare,6152,,,6152,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",4605.53,,,4605.53,Other,186% of Medicaid,7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",43192.8,,,43192.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",37793.7,70,,37793.7,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",6956,,,6956,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",6261,,,6261,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",6956,,,6956,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",5913,,,5913,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2476.09,,,2476.09,Other,100% of Medicaid,2476.09,,,2476.09,Other,100% of Medicaid,2476.09,,,2476.09,Other,100% of Medicaid,2476.09,,,2476.09,Other,100% of Medicaid,5571.21,,,5571.21,Other,225% of Medicaid,3788.42,,,3788.42,Other,153% of Medicaid,5571.21,,,5571.21,Other,225% of Medicaid,3466.53,,,3466.53,Other,140% of Medicaid,5571.21,,,5571.21,Other,225% of Medicaid,6437.84,,,6437.84,Other,260% of Medicaid,8022.54,,,8022.54,Other,324% of Medicaid,5323.6,,,5323.6,Other,215% of Medicaid,5323.6,,,5323.6,Other,215% of Medicaid,3095.12,,,3095.12,Other,125% of Medicaid,2476.09,43192.8,
REVASC INTRA LITHOTRIP-ATHER,C9766,HCPCS,,47000014,CDM,360,RC,,,both,,,53991,39953.47,,,39953.47,Other,150% of Medicare + 9.63% HCRA Surcharge,24295.95,45,,24295.95,percent of total billed charges,Critical Access Hospital RCC factor,4827,,,4827,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4344,,,4344,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",7978,,,7978,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",7180,,,7180,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",6781,,,6781,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",26725.55,,,26725.55,Other,110% of Medicare,6152,,,6152,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",4605.53,,,4605.53,Other,186% of Medicaid,7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",43192.8,,,43192.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",37793.7,70,,37793.7,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",6956,,,6956,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",6261,,,6261,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",6956,,,6956,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",5913,,,5913,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2476.09,,,2476.09,Other,100% of Medicaid,2476.09,,,2476.09,Other,100% of Medicaid,2476.09,,,2476.09,Other,100% of Medicaid,2476.09,,,2476.09,Other,100% of Medicaid,5571.21,,,5571.21,Other,225% of Medicaid,3788.42,,,3788.42,Other,153% of Medicaid,5571.21,,,5571.21,Other,225% of Medicaid,3466.53,,,3466.53,Other,140% of Medicaid,5571.21,,,5571.21,Other,225% of Medicaid,6437.84,,,6437.84,Other,260% of Medicaid,8022.54,,,8022.54,Other,324% of Medicaid,5323.6,,,5323.6,Other,215% of Medicaid,5323.6,,,5323.6,Other,215% of Medicaid,3095.12,,,3095.12,Other,125% of Medicaid,2476.09,43192.8,
REVASC LITHOTRIP-STENT-ATHER,C9767,HCPCS,,47000015,CDM,360,RC,,,both,,,53991,39953.47,,,39953.47,Other,150% of Medicare + 9.63% HCRA Surcharge,24295.95,45,,24295.95,percent of total billed charges,Critical Access Hospital RCC factor,4827,,,4827,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4344,,,4344,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",7978,,,7978,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",7180,,,7180,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",6781,,,6781,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",26725.55,,,26725.55,Other,110% of Medicare,6152,,,6152,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",4605.54,,,4605.54,Other,186% of Medicaid,7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",43192.8,,,43192.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",37793.7,70,,37793.7,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",6956,,,6956,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",6261,,,6261,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",6956,,,6956,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",5913,,,5913,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2476.1,,,2476.1,Other,100% of Medicaid,2476.1,,,2476.1,Other,100% of Medicaid,2476.1,,,2476.1,Other,100% of Medicaid,2476.1,,,2476.1,Other,100% of Medicaid,5571.22,,,5571.22,Other,225% of Medicaid,3788.43,,,3788.43,Other,153% of Medicaid,5571.22,,,5571.22,Other,225% of Medicaid,3466.54,,,3466.54,Other,140% of Medicaid,5571.22,,,5571.22,Other,225% of Medicaid,6437.85,,,6437.85,Other,260% of Medicaid,8022.56,,,8022.56,Other,324% of Medicaid,5323.61,,,5323.61,Other,215% of Medicaid,5323.61,,,5323.61,Other,215% of Medicaid,3095.12,,,3095.12,Other,125% of Medicaid,2476.1,43192.8,
REVASC LITHOTRIP TIBI/PERONE,C9772,HCPCS,,47000016,CDM,360,RC,,,both,,,33365,24690.18,,,24690.18,Other,150% of Medicare + 9.63% HCRA Surcharge,15014.25,45,,15014.25,percent of total billed charges,Critical Access Hospital RCC factor,3969,,,3969,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3572,,,3572,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",7978,,,7978,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",7180,,,7180,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",6781,,,6781,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",16515.68,,,16515.68,Other,110% of Medicare,6152,,,6152,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",4605.53,,,4605.53,Other,186% of Medicaid,7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",26692,,,26692,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",23355.5,70,,23355.5,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",6956,,,6956,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",6261,,,6261,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",6956,,,6956,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",5913,,,5913,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2476.09,,,2476.09,Other,100% of Medicaid,2476.09,,,2476.09,Other,100% of Medicaid,2476.09,,,2476.09,Other,100% of Medicaid,2476.09,,,2476.09,Other,100% of Medicaid,5571.21,,,5571.21,Other,225% of Medicaid,3788.42,,,3788.42,Other,153% of Medicaid,5571.21,,,5571.21,Other,225% of Medicaid,3466.53,,,3466.53,Other,140% of Medicaid,5571.21,,,5571.21,Other,225% of Medicaid,6437.84,,,6437.84,Other,260% of Medicaid,8022.54,,,8022.54,Other,324% of Medicaid,5323.6,,,5323.6,Other,215% of Medicaid,5323.6,,,5323.6,Other,215% of Medicaid,3095.12,,,3095.12,Other,125% of Medicaid,2476.09,26692,
REVASC LITHOTR-STENT TIB/PER,C9773,HCPCS,,47000017,CDM,360,RC,,,both,,,53991,39953.47,,,39953.47,Other,150% of Medicare + 9.63% HCRA Surcharge,24295.95,45,,24295.95,percent of total billed charges,Critical Access Hospital RCC factor,3969,,,3969,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3572,,,3572,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",7978,,,7978,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",7180,,,7180,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",6781,,,6781,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",26725.55,,,26725.55,Other,110% of Medicare,6152,,,6152,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",4605.54,,,4605.54,Other,186% of Medicaid,7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",43192.8,,,43192.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",37793.7,70,,37793.7,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",6956,,,6956,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",6261,,,6261,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",6956,,,6956,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",5913,,,5913,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2476.1,,,2476.1,Other,100% of Medicaid,2476.1,,,2476.1,Other,100% of Medicaid,2476.1,,,2476.1,Other,100% of Medicaid,2476.1,,,2476.1,Other,100% of Medicaid,5571.22,,,5571.22,Other,225% of Medicaid,3788.43,,,3788.43,Other,153% of Medicaid,5571.22,,,5571.22,Other,225% of Medicaid,3466.54,,,3466.54,Other,140% of Medicaid,5571.22,,,5571.22,Other,225% of Medicaid,6437.85,,,6437.85,Other,260% of Medicaid,8022.56,,,8022.56,Other,324% of Medicaid,5323.61,,,5323.61,Other,215% of Medicaid,5323.61,,,5323.61,Other,215% of Medicaid,3095.12,,,3095.12,Other,125% of Medicaid,2476.1,43192.8,
REVASC LITHOTR-ATHER TIB/PER,C9774,HCPCS,,47000018,CDM,360,RC,,,both,,,53991,39953.47,,,39953.47,Other,150% of Medicare + 9.63% HCRA Surcharge,24295.95,45,,24295.95,percent of total billed charges,Critical Access Hospital RCC factor,3969,,,3969,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3572,,,3572,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",7978,,,7978,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",7180,,,7180,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",6781,,,6781,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",26725.55,,,26725.55,Other,110% of Medicare,6152,,,6152,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",4605.54,,,4605.54,Other,186% of Medicaid,7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",43192.8,,,43192.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",37793.7,70,,37793.7,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",6956,,,6956,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",6261,,,6261,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",6956,,,6956,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",5913,,,5913,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2476.1,,,2476.1,Other,100% of Medicaid,2476.1,,,2476.1,Other,100% of Medicaid,2476.1,,,2476.1,Other,100% of Medicaid,2476.1,,,2476.1,Other,100% of Medicaid,5571.22,,,5571.22,Other,225% of Medicaid,3788.43,,,3788.43,Other,153% of Medicaid,5571.22,,,5571.22,Other,225% of Medicaid,3466.54,,,3466.54,Other,140% of Medicaid,5571.22,,,5571.22,Other,225% of Medicaid,6437.85,,,6437.85,Other,260% of Medicaid,8022.56,,,8022.56,Other,324% of Medicaid,5323.61,,,5323.61,Other,215% of Medicaid,5323.61,,,5323.61,Other,215% of Medicaid,3095.12,,,3095.12,Other,125% of Medicaid,2476.1,43192.8,
REVASC LITH-STEN-ATH TIB/PER,C9775,HCPCS,,47000019,CDM,360,RC,,,both,,,53991,39953.47,,,39953.47,Other,150% of Medicare + 9.63% HCRA Surcharge,24295.95,45,,24295.95,percent of total billed charges,Critical Access Hospital RCC factor,3969,,,3969,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3572,,,3572,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",7978,,,7978,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",7180,,,7180,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",6781,,,6781,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",26725.55,,,26725.55,Other,110% of Medicare,6152,,,6152,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",4605.54,,,4605.54,Other,186% of Medicaid,7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",43192.8,,,43192.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",37793.7,70,,37793.7,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",6956,,,6956,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",6261,,,6261,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",6956,,,6956,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",5913,,,5913,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2476.1,,,2476.1,Other,100% of Medicaid,2476.1,,,2476.1,Other,100% of Medicaid,2476.1,,,2476.1,Other,100% of Medicaid,2476.1,,,2476.1,Other,100% of Medicaid,5571.22,,,5571.22,Other,225% of Medicaid,3788.43,,,3788.43,Other,153% of Medicaid,5571.22,,,5571.22,Other,225% of Medicaid,3466.54,,,3466.54,Other,140% of Medicaid,5571.22,,,5571.22,Other,225% of Medicaid,6437.85,,,6437.85,Other,260% of Medicaid,8022.56,,,8022.56,Other,324% of Medicaid,5323.61,,,5323.61,Other,215% of Medicaid,5323.61,,,5323.61,Other,215% of Medicaid,3095.12,,,3095.12,Other,125% of Medicaid,2476.1,43192.8,
FNA W/O IMAGE,10021,CPT,,47010021,CDM,360,RC,,,both,,,841,622.34,,,622.34,Other,150% of Medicare + 9.63% HCRA Surcharge,378.45,45,,378.45,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",416.3,,,416.3,Other,110% of Medicare,571.88,,,571.88,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1037.55,,,1037.55,Other,186% of Medicaid,672.8,,,672.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",672.8,,,672.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",672.8,,,672.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",588.7,70,,588.7,percent of total billed charges,All Other,262.4,,,262.4,Fee Schedule,,222.4,,,222.4,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",557.82,,,557.82,Other,100% of Medicaid,557.82,,,557.82,Other,100% of Medicaid,557.82,,,557.82,Other,100% of Medicaid,557.82,,,557.82,Other,100% of Medicaid,1255.1,,,1255.1,Other,225% of Medicaid,853.47,,,853.47,Other,153% of Medicaid,1255.1,,,1255.1,Other,225% of Medicaid,780.95,,,780.95,Other,140% of Medicaid,1255.1,,,1255.1,Other,225% of Medicaid,1450.34,,,1450.34,Other,260% of Medicaid,1807.35,,,1807.35,Other,324% of Medicaid,1199.32,,,1199.32,Other,215% of Medicaid,1199.32,,,1199.32,Other,215% of Medicaid,697.28,,,697.28,Other,125% of Medicaid,222.4,7216,
PERQ VERTEBRAL AUGMENTATION,22513,CPT,,47022513,CDM,360,RC,,,both,,,23950,17723.06,,,17723.06,Other,150% of Medicare + 9.63% HCRA Surcharge,10777.5,45,,10777.5,percent of total billed charges,Critical Access Hospital RCC factor,4827,,,4827,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4344,,,4344,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",7978,,,7978,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",7180,,,7180,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",6781,,,6781,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",11855.25,,,11855.25,Other,110% of Medicare,6152,,,6152,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",5525.48,,,5525.48,Other,186% of Medicaid,7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",19160,,,19160,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",16765,70,,16765,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",6331,,,6331,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",5698,,,5698,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",6331,,,6331,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",5381,,,5381,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2970.69,,,2970.69,Other,100% of Medicaid,2970.69,,,2970.69,Other,100% of Medicaid,2970.69,,,2970.69,Other,100% of Medicaid,2970.69,,,2970.69,Other,100% of Medicaid,6684.05,,,6684.05,Other,225% of Medicaid,4545.16,,,4545.16,Other,153% of Medicaid,6684.05,,,6684.05,Other,225% of Medicaid,4158.97,,,4158.97,Other,140% of Medicaid,6684.05,,,6684.05,Other,225% of Medicaid,7723.79,,,7723.79,Other,260% of Medicaid,9625.03,,,9625.03,Other,324% of Medicaid,6386.98,,,6386.98,Other,215% of Medicaid,6386.98,,,6386.98,Other,215% of Medicaid,3713.36,,,3713.36,Other,125% of Medicaid,2970.69,19160,
PERQ VERTEBRAL AUGMENTATION,22514,CPT,,47022514,CDM,360,RC,,,both,,,23950,17723.06,,,17723.06,Other,150% of Medicare + 9.63% HCRA Surcharge,10777.5,45,,10777.5,percent of total billed charges,Critical Access Hospital RCC factor,4827,,,4827,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4344,,,4344,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",7978,,,7978,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",7180,,,7180,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",6781,,,6781,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",11855.25,,,11855.25,Other,110% of Medicare,6152,,,6152,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",5525.48,,,5525.48,Other,186% of Medicaid,7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",19160,,,19160,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",16765,70,,16765,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",6331,,,6331,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",5698,,,5698,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",6331,,,6331,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",5381,,,5381,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2970.69,,,2970.69,Other,100% of Medicaid,2970.69,,,2970.69,Other,100% of Medicaid,2970.69,,,2970.69,Other,100% of Medicaid,2970.69,,,2970.69,Other,100% of Medicaid,6684.05,,,6684.05,Other,225% of Medicaid,4545.16,,,4545.16,Other,153% of Medicaid,6684.05,,,6684.05,Other,225% of Medicaid,4158.97,,,4158.97,Other,140% of Medicaid,6684.05,,,6684.05,Other,225% of Medicaid,7723.79,,,7723.79,Other,260% of Medicaid,9625.03,,,9625.03,Other,324% of Medicaid,6386.98,,,6386.98,Other,215% of Medicaid,6386.98,,,6386.98,Other,215% of Medicaid,3713.36,,,3713.36,Other,125% of Medicaid,2970.69,19160,
PERQ VERTEBRAL AUGMENTATION,22515,CPT,,47022515,CDM,360,RC,,,both,,,864,639.36,,,639.36,Other,150% of Medicare + 9.63% HCRA Surcharge,388.8,45,,388.8,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4970,,,4970,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4473,,,4473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4225,,,4225,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",427.68,,,427.68,Other,110% of Medicare,587.52,,,587.52,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",5525.48,,,5525.48,Other,186% of Medicaid,691.2,,,691.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",691.2,,,691.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",691.2,,,691.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",604.8,70,,604.8,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2970.69,,,2970.69,Other,100% of Medicaid,2970.69,,,2970.69,Other,100% of Medicaid,2970.69,,,2970.69,Other,100% of Medicaid,2970.69,,,2970.69,Other,100% of Medicaid,6684.05,,,6684.05,Other,225% of Medicaid,4545.16,,,4545.16,Other,153% of Medicaid,6684.05,,,6684.05,Other,225% of Medicaid,4158.97,,,4158.97,Other,140% of Medicaid,6684.05,,,6684.05,Other,225% of Medicaid,7723.79,,,7723.79,Other,260% of Medicaid,9625.03,,,9625.03,Other,324% of Medicaid,6386.98,,,6386.98,Other,215% of Medicaid,6386.98,,,6386.98,Other,215% of Medicaid,3713.36,,,3713.36,Other,125% of Medicaid,388.8,9625.03,
MANIPULATE KNEE JNT UNDER ANESTH,27570,CPT,,47027570,CDM,360,RC,,,both,,,4340,3211.61,,,3211.61,Other,150% of Medicare + 9.63% HCRA Surcharge,1953,45,,1953,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3648,,,3648,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3283,,,3283,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3101,,,3101,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2148.3,,,2148.3,Other,110% of Medicare,2951.2,,,2951.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1730.38,,,1730.38,Other,186% of Medicaid,3472,,,3472,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",3472,,,3472,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",3578,,,3578,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",3038,70,,3038,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",4055,,,4055,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3649,,,3649,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4055,,,4055,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3448,,,3448,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",930.31,,,930.31,Other,100% of Medicaid,930.31,,,930.31,Other,100% of Medicaid,930.31,,,930.31,Other,100% of Medicaid,930.31,,,930.31,Other,100% of Medicaid,2093.21,,,2093.21,Other,225% of Medicaid,1423.38,,,1423.38,Other,153% of Medicaid,2093.21,,,2093.21,Other,225% of Medicaid,1302.44,,,1302.44,Other,140% of Medicaid,2093.21,,,2093.21,Other,225% of Medicaid,2418.82,,,2418.82,Other,260% of Medicaid,3014.22,,,3014.22,Other,324% of Medicaid,2000.18,,,2000.18,Other,215% of Medicaid,2000.18,,,2000.18,Other,215% of Medicaid,1162.89,,,1162.89,Other,125% of Medicaid,930.31,7216,
INSERTION OF CHEST TUBE,32551,CPT,,47032551,CDM,360,RC,,,both,,,3350,2479.01,,,2479.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1507.5,45,,1507.5,percent of total billed charges,Critical Access Hospital RCC factor,2480,,,2480,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2232,,,2232,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3648,,,3648,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3283,,,3283,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3101,,,3101,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",1658.25,,,1658.25,Other,110% of Medicare,2278,,,2278,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1196.64,,,1196.64,Other,186% of Medicaid,2680,,,2680,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2680,,,2680,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2680,,,2680,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2345,70,,2345,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",643.35,,,643.35,Other,100% of Medicaid,643.35,,,643.35,Other,100% of Medicaid,643.35,,,643.35,Other,100% of Medicaid,643.35,,,643.35,Other,100% of Medicaid,1447.55,,,1447.55,Other,225% of Medicaid,984.33,,,984.33,Other,153% of Medicaid,1447.55,,,1447.55,Other,225% of Medicaid,900.7,,,900.7,Other,140% of Medicaid,1447.55,,,1447.55,Other,225% of Medicaid,1672.72,,,1672.72,Other,260% of Medicaid,2084.47,,,2084.47,Other,324% of Medicaid,1383.21,,,1383.21,Other,215% of Medicaid,1383.21,,,1383.21,Other,215% of Medicaid,804.19,,,804.19,Other,125% of Medicaid,643.35,7216,
ASPIRATE PLEURA W IMAGING,32555,CPT,,47032555,CDM,360,RC,,,both,,,2118,1567.33,,,1567.33,Other,150% of Medicare + 9.63% HCRA Surcharge,953.1,45,,953.1,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",1048.41,,,1048.41,Other,110% of Medicare,1440.24,,,1440.24,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1196.64,,,1196.64,Other,186% of Medicaid,1694.4,,,1694.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1694.4,,,1694.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1694.4,,,1694.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1482.6,70,,1482.6,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",643.35,,,643.35,Other,100% of Medicaid,643.35,,,643.35,Other,100% of Medicaid,643.35,,,643.35,Other,100% of Medicaid,643.35,,,643.35,Other,100% of Medicaid,1447.55,,,1447.55,Other,225% of Medicaid,984.33,,,984.33,Other,153% of Medicaid,1447.55,,,1447.55,Other,225% of Medicaid,900.7,,,900.7,Other,140% of Medicaid,1447.55,,,1447.55,Other,225% of Medicaid,1672.72,,,1672.72,Other,260% of Medicaid,2084.47,,,2084.47,Other,324% of Medicaid,1383.21,,,1383.21,Other,215% of Medicaid,1383.21,,,1383.21,Other,215% of Medicaid,804.19,,,804.19,Other,125% of Medicaid,643.35,7216,
INSERT CATH PLEURA W/ IMAGE,32557,CPT,,47032557,CDM,360,RC,,,both,,,3350,2479.01,,,2479.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1507.5,45,,1507.5,percent of total billed charges,Critical Access Hospital RCC factor,2480,,,2480,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2232,,,2232,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3648,,,3648,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3283,,,3283,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3101,,,3101,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",1658.25,,,1658.25,Other,110% of Medicare,2278,,,2278,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1196.64,,,1196.64,Other,186% of Medicaid,2680,,,2680,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2680,,,2680,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2680,,,2680,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2345,70,,2345,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",643.35,,,643.35,Other,100% of Medicaid,643.35,,,643.35,Other,100% of Medicaid,643.35,,,643.35,Other,100% of Medicaid,643.35,,,643.35,Other,100% of Medicaid,1447.55,,,1447.55,Other,225% of Medicaid,984.33,,,984.33,Other,153% of Medicaid,1447.55,,,1447.55,Other,225% of Medicaid,900.7,,,900.7,Other,140% of Medicaid,1447.55,,,1447.55,Other,225% of Medicaid,1672.72,,,1672.72,Other,260% of Medicaid,2084.47,,,2084.47,Other,324% of Medicaid,1383.21,,,1383.21,Other,215% of Medicaid,1383.21,,,1383.21,Other,215% of Medicaid,804.19,,,804.19,Other,125% of Medicaid,643.35,7216,
INSERT HEART PM VENTRICULAR,33207,CPT,,47033207,CDM,360,RC,,,both,,,23249,17204.32,,,17204.32,Other,150% of Medicare + 9.63% HCRA Surcharge,10462.05,45,,10462.05,percent of total billed charges,Critical Access Hospital RCC factor,5954,,,5954,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",5359,,,5359,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",7978,,,7978,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",7180,,,7180,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",6781,,,6781,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",11508.26,,,11508.26,Other,110% of Medicare,6152,,,6152,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",10683.75,,,10683.75,Other,186% of Medicaid,7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",18599.2,,,18599.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",16274.3,70,,16274.3,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",6956,,,6956,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",6261,,,6261,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",6956,,,6956,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",5913,,,5913,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",5743.95,,,5743.95,Other,100% of Medicaid,5743.95,,,5743.95,Other,100% of Medicaid,5743.95,,,5743.95,Other,100% of Medicaid,5743.95,,,5743.95,Other,100% of Medicaid,12923.9,,,12923.9,Other,225% of Medicaid,8788.25,,,8788.25,Other,153% of Medicaid,12923.9,,,12923.9,Other,225% of Medicaid,8041.54,,,8041.54,Other,140% of Medicaid,12923.9,,,12923.9,Other,225% of Medicaid,14934.28,,,14934.28,Other,260% of Medicaid,18610.41,,,18610.41,Other,324% of Medicaid,12349.5,,,12349.5,Other,215% of Medicaid,12349.5,,,12349.5,Other,215% of Medicaid,7179.94,,,7179.94,Other,125% of Medicaid,3343,18610.41,
DDD PACER INSERTION,33208,CPT,,47033208,CDM,360,RC,,,both,,,26727,19778.05,,,19778.05,Other,150% of Medicare + 9.63% HCRA Surcharge,12027.15,45,,12027.15,percent of total billed charges,Critical Access Hospital RCC factor,5954,,,5954,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",5359,,,5359,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",7978,,,7978,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",7180,,,7180,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",6781,,,6781,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",13229.87,,,13229.87,Other,110% of Medicare,6152,,,6152,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",10683.75,,,10683.75,Other,186% of Medicaid,7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",21381.6,,,21381.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",18708.9,70,,18708.9,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",7364,,,7364,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",6628,,,6628,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",7364,,,7364,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",6260,,,6260,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",5743.95,,,5743.95,Other,100% of Medicaid,5743.95,,,5743.95,Other,100% of Medicaid,5743.95,,,5743.95,Other,100% of Medicaid,5743.95,,,5743.95,Other,100% of Medicaid,12923.9,,,12923.9,Other,225% of Medicaid,8788.25,,,8788.25,Other,153% of Medicaid,12923.9,,,12923.9,Other,225% of Medicaid,8041.54,,,8041.54,Other,140% of Medicaid,12923.9,,,12923.9,Other,225% of Medicaid,14934.28,,,14934.28,Other,260% of Medicaid,18610.41,,,18610.41,Other,324% of Medicaid,12349.5,,,12349.5,Other,215% of Medicaid,12349.5,,,12349.5,Other,215% of Medicaid,7179.94,,,7179.94,Other,125% of Medicaid,3343,21381.6,
INS/REPL PG ONLY; SGL CHAMBER,33212,CPT,,47033212,CDM,360,RC,,,both,,,18374,13596.81,,,13596.81,Other,150% of Medicare + 9.63% HCRA Surcharge,8268.3,45,,8268.3,percent of total billed charges,Critical Access Hospital RCC factor,3473,,,3473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3126,,,3126,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",7978,,,7978,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",7180,,,7180,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",6781,,,6781,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",9095.13,,,9095.13,Other,110% of Medicare,6152,,,6152,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",10683.75,,,10683.75,Other,186% of Medicaid,7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",5266,,,5266,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",12861.8,70,,12861.8,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",6956,,,6956,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",6261,,,6261,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",6956,,,6956,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",5913,,,5913,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",5743.95,,,5743.95,Other,100% of Medicaid,5743.95,,,5743.95,Other,100% of Medicaid,5743.95,,,5743.95,Other,100% of Medicaid,5743.95,,,5743.95,Other,100% of Medicaid,12923.9,,,12923.9,Other,225% of Medicaid,8788.25,,,8788.25,Other,153% of Medicaid,12923.9,,,12923.9,Other,225% of Medicaid,8041.54,,,8041.54,Other,140% of Medicaid,12923.9,,,12923.9,Other,225% of Medicaid,14934.28,,,14934.28,Other,260% of Medicaid,18610.41,,,18610.41,Other,324% of Medicaid,12349.5,,,12349.5,Other,215% of Medicaid,12349.5,,,12349.5,Other,215% of Medicaid,7179.94,,,7179.94,Other,125% of Medicaid,3126,18610.41,
INSERTION OR REPLC OF PACE DC,33213,CPT,,47033213,CDM,360,RC,,,both,,,23249,17204.32,,,17204.32,Other,150% of Medicare + 9.63% HCRA Surcharge,10462.05,45,,10462.05,percent of total billed charges,Critical Access Hospital RCC factor,3473,,,3473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3126,,,3126,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",7978,,,7978,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",7180,,,7180,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",6781,,,6781,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",11508.26,,,11508.26,Other,110% of Medicare,6152,,,6152,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",10683.75,,,10683.75,Other,186% of Medicaid,7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",5266,,,5266,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",16274.3,70,,16274.3,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",6956,,,6956,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",6261,,,6261,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",6956,,,6956,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",5913,,,5913,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",5743.95,,,5743.95,Other,100% of Medicaid,5743.95,,,5743.95,Other,100% of Medicaid,5743.95,,,5743.95,Other,100% of Medicaid,5743.95,,,5743.95,Other,100% of Medicaid,12923.9,,,12923.9,Other,225% of Medicaid,8788.25,,,8788.25,Other,153% of Medicaid,12923.9,,,12923.9,Other,225% of Medicaid,8041.54,,,8041.54,Other,140% of Medicaid,12923.9,,,12923.9,Other,225% of Medicaid,14934.28,,,14934.28,Other,260% of Medicaid,18610.41,,,18610.41,Other,324% of Medicaid,12349.5,,,12349.5,Other,215% of Medicaid,12349.5,,,12349.5,Other,215% of Medicaid,7179.94,,,7179.94,Other,125% of Medicaid,3126,18610.41,
INSERT 1 ELECTRODE PM-DEFIB,33216,CPT,,47033216,CDM,360,RC,,,both,,,18374,13596.81,,,13596.81,Other,150% of Medicare + 9.63% HCRA Surcharge,8268.3,45,,8268.3,percent of total billed charges,Critical Access Hospital RCC factor,3969,,,3969,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3572,,,3572,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",7978,,,7978,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",7180,,,7180,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",6781,,,6781,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",9095.13,,,9095.13,Other,110% of Medicare,6152,,,6152,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",4536.91,,,4536.91,Other,186% of Medicaid,7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",14699.2,,,14699.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",12861.8,70,,12861.8,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",6331,,,6331,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",5698,,,5698,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",6331,,,6331,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",5381,,,5381,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2439.2,,,2439.2,Other,100% of Medicaid,2439.2,,,2439.2,Other,100% of Medicaid,2439.2,,,2439.2,Other,100% of Medicaid,2439.2,,,2439.2,Other,100% of Medicaid,5488.2,,,5488.2,Other,225% of Medicaid,3731.98,,,3731.98,Other,153% of Medicaid,5488.2,,,5488.2,Other,225% of Medicaid,3414.88,,,3414.88,Other,140% of Medicaid,5488.2,,,5488.2,Other,225% of Medicaid,6341.92,,,6341.92,Other,260% of Medicaid,7903.01,,,7903.01,Other,324% of Medicaid,5244.28,,,5244.28,Other,215% of Medicaid,5244.28,,,5244.28,Other,215% of Medicaid,3049,,,3049,Other,125% of Medicaid,2439.2,14699.2,
REPAIR LEAD PACE-DEFIB ONE,33218,CPT,,47033218,CDM,360,RC,,,both,,,7544,5582.58,,,5582.58,Other,150% of Medicare + 9.63% HCRA Surcharge,3394.8,45,,3394.8,percent of total billed charges,Critical Access Hospital RCC factor,3969,,,3969,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3572,,,3572,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4476,,,4476,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4028,,,4028,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3805,,,3805,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3734.28,,,3734.28,Other,110% of Medicare,6152,,,6152,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",4536.91,,,4536.91,Other,186% of Medicaid,7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",6035.2,,,6035.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",5280.8,70,,5280.8,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",4913,,,4913,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4422,,,4422,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4913,,,4913,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4176,,,4176,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2439.2,,,2439.2,Other,100% of Medicaid,2439.2,,,2439.2,Other,100% of Medicaid,2439.2,,,2439.2,Other,100% of Medicaid,2439.2,,,2439.2,Other,100% of Medicaid,5488.2,,,5488.2,Other,225% of Medicaid,3731.98,,,3731.98,Other,153% of Medicaid,5488.2,,,5488.2,Other,225% of Medicaid,3414.88,,,3414.88,Other,140% of Medicaid,5488.2,,,5488.2,Other,225% of Medicaid,6341.92,,,6341.92,Other,260% of Medicaid,7903.01,,,7903.01,Other,324% of Medicaid,5244.28,,,5244.28,Other,215% of Medicaid,5244.28,,,5244.28,Other,215% of Medicaid,3049,,,3049,Other,125% of Medicaid,2439.2,9473,
REVISE POCKET FOR DEFIB,33223,CPT,,47033223,CDM,360,RC,,,both,,,5004,3702.97,,,3702.97,Other,150% of Medicare + 9.63% HCRA Surcharge,2251.8,45,,2251.8,percent of total billed charges,Critical Access Hospital RCC factor,2480,,,2480,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2232,,,2232,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3648,,,3648,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3283,,,3283,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3101,,,3101,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2476.98,,,2476.98,Other,110% of Medicare,3402.72,,,3402.72,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",4536.91,,,4536.91,Other,186% of Medicaid,4003.2,,,4003.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",4003.2,,,4003.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",4252,,,4252,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",3502.8,70,,3502.8,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",4055,,,4055,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3649,,,3649,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4055,,,4055,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3448,,,3448,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2439.2,,,2439.2,Other,100% of Medicaid,2439.2,,,2439.2,Other,100% of Medicaid,2439.2,,,2439.2,Other,100% of Medicaid,2439.2,,,2439.2,Other,100% of Medicaid,5488.2,,,5488.2,Other,225% of Medicaid,3731.98,,,3731.98,Other,153% of Medicaid,5488.2,,,5488.2,Other,225% of Medicaid,3414.88,,,3414.88,Other,140% of Medicaid,5488.2,,,5488.2,Other,225% of Medicaid,6341.92,,,6341.92,Other,260% of Medicaid,7903.01,,,7903.01,Other,324% of Medicaid,5244.28,,,5244.28,Other,215% of Medicaid,5244.28,,,5244.28,Other,215% of Medicaid,3049,,,3049,Other,125% of Medicaid,2232,7903.01,
LV PACING LEAD ADD-ON,33225,CPT,,47033225,CDM,360,RC,,,both,,,40754,30158.06,,,30158.06,Other,150% of Medicare + 9.63% HCRA Surcharge,18339.3,45,,18339.3,percent of total billed charges,Critical Access Hospital RCC factor,3969,,,3969,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3572,,,3572,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3648,,,3648,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3283,,,3283,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3101,,,3101,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",20173.23,,,20173.23,Other,110% of Medicare,6152,,,6152,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",10683.75,,,10683.75,Other,186% of Medicaid,7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",32603.2,,,32603.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",28527.8,70,,28527.8,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",7364,,,7364,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",6628,,,6628,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",7364,,,7364,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",6260,,,6260,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",5743.95,,,5743.95,Other,100% of Medicaid,5743.95,,,5743.95,Other,100% of Medicaid,5743.95,,,5743.95,Other,100% of Medicaid,5743.95,,,5743.95,Other,100% of Medicaid,12923.9,,,12923.9,Other,225% of Medicaid,8788.25,,,8788.25,Other,153% of Medicaid,12923.9,,,12923.9,Other,225% of Medicaid,8041.54,,,8041.54,Other,140% of Medicaid,12923.9,,,12923.9,Other,225% of Medicaid,14934.28,,,14934.28,Other,260% of Medicaid,18610.41,,,18610.41,Other,324% of Medicaid,12349.5,,,12349.5,Other,215% of Medicaid,12349.5,,,12349.5,Other,215% of Medicaid,7179.94,,,7179.94,Other,125% of Medicaid,3101,32603.2,
REMOVE&REPLACE PM GEN SINGL,33227,CPT,,47033227,CDM,360,RC,,,both,,,30257,22390.26,,,22390.26,Other,150% of Medicare + 9.63% HCRA Surcharge,13615.65,45,,13615.65,percent of total billed charges,Critical Access Hospital RCC factor,3473,,,3473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3126,,,3126,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",7978,,,7978,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",7180,,,7180,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",6781,,,6781,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",14977.22,,,14977.22,Other,110% of Medicare,6152,,,6152,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",10683.75,,,10683.75,Other,186% of Medicaid,7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",24205.6,,,24205.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",21179.9,70,,21179.9,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",6956,,,6956,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",6261,,,6261,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",6956,,,6956,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",5913,,,5913,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",5743.95,,,5743.95,Other,100% of Medicaid,5743.95,,,5743.95,Other,100% of Medicaid,5743.95,,,5743.95,Other,100% of Medicaid,5743.95,,,5743.95,Other,100% of Medicaid,12923.9,,,12923.9,Other,225% of Medicaid,8788.25,,,8788.25,Other,153% of Medicaid,12923.9,,,12923.9,Other,225% of Medicaid,8041.54,,,8041.54,Other,140% of Medicaid,12923.9,,,12923.9,Other,225% of Medicaid,14934.28,,,14934.28,Other,260% of Medicaid,18610.41,,,18610.41,Other,324% of Medicaid,12349.5,,,12349.5,Other,215% of Medicaid,12349.5,,,12349.5,Other,215% of Medicaid,7179.94,,,7179.94,Other,125% of Medicaid,3126,24205.6,
REMV&REPLC PM GEN DUAL LEAD,33228,CPT,,47033228,CDM,360,RC,,,both,,,33159,24537.74,,,24537.74,Other,150% of Medicare + 9.63% HCRA Surcharge,14921.55,45,,14921.55,percent of total billed charges,Critical Access Hospital RCC factor,3473,,,3473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3126,,,3126,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",7978,,,7978,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",7180,,,7180,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",6781,,,6781,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",16413.71,,,16413.71,Other,110% of Medicare,6152,,,6152,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",10683.75,,,10683.75,Other,186% of Medicaid,7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",26527.2,,,26527.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",23211.3,70,,23211.3,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",6956,,,6956,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",6261,,,6261,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",6956,,,6956,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",5913,,,5913,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",5743.95,,,5743.95,Other,100% of Medicaid,5743.95,,,5743.95,Other,100% of Medicaid,5743.95,,,5743.95,Other,100% of Medicaid,5743.95,,,5743.95,Other,100% of Medicaid,12923.9,,,12923.9,Other,225% of Medicaid,8788.25,,,8788.25,Other,153% of Medicaid,12923.9,,,12923.9,Other,225% of Medicaid,8041.54,,,8041.54,Other,140% of Medicaid,12923.9,,,12923.9,Other,225% of Medicaid,14934.28,,,14934.28,Other,260% of Medicaid,18610.41,,,18610.41,Other,324% of Medicaid,12349.5,,,12349.5,Other,215% of Medicaid,12349.5,,,12349.5,Other,215% of Medicaid,7179.94,,,7179.94,Other,125% of Medicaid,3126,26527.2,
REMOVAL OF PERM PACEMAKER GNRT,33233,CPT,,47033233,CDM,360,RC,,,both,,,21018,15553.37,,,15553.37,Other,150% of Medicare + 9.63% HCRA Surcharge,9458.1,45,,9458.1,percent of total billed charges,Critical Access Hospital RCC factor,2480,,,2480,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2232,,,2232,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",7978,,,7978,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",7180,,,7180,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",6781,,,6781,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",10403.91,,,10403.91,Other,110% of Medicare,14292.24,,,14292.24,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",3946.83,,,3946.83,Other,186% of Medicaid,16814.4,,,16814.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",16814.4,,,16814.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",4252,,,4252,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",14712.6,70,,14712.6,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",4913,,,4913,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4422,,,4422,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4913,,,4913,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4176,,,4176,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2121.95,,,2121.95,Other,100% of Medicaid,2121.95,,,2121.95,Other,100% of Medicaid,2121.95,,,2121.95,Other,100% of Medicaid,2121.95,,,2121.95,Other,100% of Medicaid,4774.4,,,4774.4,Other,225% of Medicaid,3246.59,,,3246.59,Other,153% of Medicaid,4774.4,,,4774.4,Other,225% of Medicaid,2970.74,,,2970.74,Other,140% of Medicaid,4774.4,,,4774.4,Other,225% of Medicaid,5517.08,,,5517.08,Other,260% of Medicaid,6875.13,,,6875.13,Other,324% of Medicaid,4562.2,,,4562.2,Other,215% of Medicaid,4562.2,,,4562.2,Other,215% of Medicaid,2652.44,,,2652.44,Other,125% of Medicaid,2121.95,16814.4,
INSRT PULSE GEN W/SINGL LEAD,33240,CPT,,47033240,CDM,360,RC,,,both,,,51361,38007.27,,,38007.27,Other,150% of Medicare + 9.63% HCRA Surcharge,23112.45,45,,23112.45,percent of total billed charges,Critical Access Hospital RCC factor,5954,,,5954,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",5359,,,5359,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",7978,,,7978,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",7180,,,7180,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",6781,,,6781,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",25423.7,,,25423.7,Other,110% of Medicare,6152,,,6152,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",25102.82,,,25102.82,Other,186% of Medicaid,7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",41088.8,,,41088.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",35952.7,70,,35952.7,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",15267,,,15267,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",13740,,,13740,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",15267,,,15267,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",12977,,,12977,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",13496.14,,,13496.14,Other,100% of Medicaid,13496.14,,,13496.14,Other,100% of Medicaid,13496.14,,,13496.14,Other,100% of Medicaid,13496.14,,,13496.14,Other,100% of Medicaid,30366.31,,,30366.31,Other,225% of Medicaid,20649.09,,,20649.09,Other,153% of Medicaid,30366.31,,,30366.31,Other,225% of Medicaid,18894.6,,,18894.6,Other,140% of Medicaid,30366.31,,,30366.31,Other,225% of Medicaid,35089.96,,,35089.96,Other,260% of Medicaid,43727.49,,,43727.49,Other,324% of Medicaid,29016.7,,,29016.7,Other,215% of Medicaid,29016.7,,,29016.7,Other,215% of Medicaid,16870.17,,,16870.17,Other,125% of Medicaid,3343,43727.49,
INJ PERC EXTR ANEURYSM,36002,CPT,,47036002,CDM,360,RC,,,both,,,1304,964.96,,,964.96,Other,150% of Medicare + 9.63% HCRA Surcharge,586.8,45,,586.8,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",645.48,,,645.48,Other,110% of Medicare,886.72,,,886.72,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",728.47,,,728.47,Other,186% of Medicaid,1043.2,,,1043.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1043.2,,,1043.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1043.2,,,1043.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",912.8,70,,912.8,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",391.65,,,391.65,Other,100% of Medicaid,391.65,,,391.65,Other,100% of Medicaid,391.65,,,391.65,Other,100% of Medicaid,391.65,,,391.65,Other,100% of Medicaid,881.21,,,881.21,Other,225% of Medicaid,599.22,,,599.22,Other,153% of Medicaid,881.21,,,881.21,Other,225% of Medicaid,548.31,,,548.31,Other,140% of Medicaid,881.21,,,881.21,Other,225% of Medicaid,1018.29,,,1018.29,Other,260% of Medicaid,1268.95,,,1268.95,Other,324% of Medicaid,842.05,,,842.05,Other,215% of Medicaid,842.05,,,842.05,Other,215% of Medicaid,489.56,,,489.56,Other,125% of Medicaid,391.65,7216,
EX VEIN NEEDLE/INTRACATH UNI,36005,CPT,,47036005,CDM,360,RC,,,both,,,2233,1652.43,,,1652.43,Other,150% of Medicare + 9.63% HCRA Surcharge,1004.85,45,,1004.85,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",1105.34,,,1105.34,Other,110% of Medicare,1518.44,,,1518.44,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",516.02,,,516.02,Other,186% of Medicaid,1786.4,,,1786.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1786.4,,,1786.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1786.4,,,1786.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1563.1,70,,1563.1,percent of total billed charges,All Other,227.96,,,227.96,Fee Schedule,,193.21,,,193.21,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",277.43,,,277.43,Other,100% of Medicaid,277.43,,,277.43,Other,100% of Medicaid,277.43,,,277.43,Other,100% of Medicaid,277.43,,,277.43,Other,100% of Medicaid,624.21,,,624.21,Other,225% of Medicaid,424.47,,,424.47,Other,153% of Medicaid,624.21,,,624.21,Other,225% of Medicaid,388.4,,,388.4,Other,140% of Medicaid,624.21,,,624.21,Other,225% of Medicaid,721.31,,,721.31,Other,260% of Medicaid,898.87,,,898.87,Other,324% of Medicaid,596.47,,,596.47,Other,215% of Medicaid,596.47,,,596.47,Other,215% of Medicaid,346.79,,,346.79,Other,125% of Medicaid,193.21,7216,
SUP OR INFER VENA CAVA CATH,36010,CPT,,47036010,CDM,360,RC,,,both,,,800,592,,,592,Other,150% of Medicare + 9.63% HCRA Surcharge,360,45,,360,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",396,,,396,Other,110% of Medicare,544,,,544,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",516.02,,,516.02,Other,186% of Medicaid,640,,,640,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",640,,,640,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",640,,,640,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",560,70,,560,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",277.43,,,277.43,Other,100% of Medicaid,277.43,,,277.43,Other,100% of Medicaid,277.43,,,277.43,Other,100% of Medicaid,277.43,,,277.43,Other,100% of Medicaid,624.21,,,624.21,Other,225% of Medicaid,424.47,,,424.47,Other,153% of Medicaid,624.21,,,624.21,Other,225% of Medicaid,388.4,,,388.4,Other,140% of Medicaid,624.21,,,624.21,Other,225% of Medicaid,721.31,,,721.31,Other,260% of Medicaid,898.87,,,898.87,Other,324% of Medicaid,596.47,,,596.47,Other,215% of Medicaid,596.47,,,596.47,Other,215% of Medicaid,346.79,,,346.79,Other,125% of Medicaid,277.43,7216,
CATH INTRO/1ST ORDER VEIN,36011,CPT,,47036011,CDM,360,RC,,,both,,,1020,754.8,,,754.8,Other,150% of Medicare + 9.63% HCRA Surcharge,459,45,,459,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4476,,,4476,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4028,,,4028,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3805,,,3805,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",504.9,,,504.9,Other,110% of Medicare,693.6,,,693.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",516.02,,,516.02,Other,186% of Medicaid,816,,,816,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",816,,,816,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",816,,,816,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",714,70,,714,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",277.43,,,277.43,Other,100% of Medicaid,277.43,,,277.43,Other,100% of Medicaid,277.43,,,277.43,Other,100% of Medicaid,277.43,,,277.43,Other,100% of Medicaid,624.21,,,624.21,Other,225% of Medicaid,424.47,,,424.47,Other,153% of Medicaid,624.21,,,624.21,Other,225% of Medicaid,388.4,,,388.4,Other,140% of Medicaid,624.21,,,624.21,Other,225% of Medicaid,721.31,,,721.31,Other,260% of Medicaid,898.87,,,898.87,Other,324% of Medicaid,596.47,,,596.47,Other,215% of Medicaid,596.47,,,596.47,Other,215% of Medicaid,346.79,,,346.79,Other,125% of Medicaid,277.43,7216,
SELECTIVE CATH VEIN; 2ND ORDER FAMILY,36012,CPT,,47036012,CDM,360,RC,,,both,,,696,515.04,,,515.04,Other,150% of Medicare + 9.63% HCRA Surcharge,313.2,45,,313.2,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4476,,,4476,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4028,,,4028,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3805,,,3805,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",344.52,,,344.52,Other,110% of Medicare,473.28,,,473.28,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",516.02,,,516.02,Other,186% of Medicaid,556.8,,,556.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",556.8,,,556.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",556.8,,,556.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",487.2,70,,487.2,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",277.43,,,277.43,Other,100% of Medicaid,277.43,,,277.43,Other,100% of Medicaid,277.43,,,277.43,Other,100% of Medicaid,277.43,,,277.43,Other,100% of Medicaid,624.21,,,624.21,Other,225% of Medicaid,424.47,,,424.47,Other,153% of Medicaid,624.21,,,624.21,Other,225% of Medicaid,388.4,,,388.4,Other,140% of Medicaid,624.21,,,624.21,Other,225% of Medicaid,721.31,,,721.31,Other,260% of Medicaid,898.87,,,898.87,Other,324% of Medicaid,596.47,,,596.47,Other,215% of Medicaid,596.47,,,596.47,Other,215% of Medicaid,346.79,,,346.79,Other,125% of Medicaid,277.43,7216,
NS CATH - RETROGR BRACHIAL ARTERY,36120,CPT,,47036120,CDM,360,RC,,,both,,,363,268.62,,,268.62,Other,150% of Medicare + 9.63% HCRA Surcharge,163.35,45,,163.35,percent of total billed charges,Critical Access Hospital RCC factor,4565,,,4565,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4109,,,4109,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",179.69,,,179.69,Other,110% of Medicare,246.84,,,246.84,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",291.93,,,291.93,Other,186% of Medicaid,290.4,,,290.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",290.4,,,290.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",290.4,,,290.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",254.1,70,,254.1,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",4531,,,4531,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4079,,,4079,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4531,,,4531,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3852,,,3852,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",156.95,,,156.95,Other,100% of Medicaid,156.95,,,156.95,Other,100% of Medicaid,156.95,,,156.95,Other,100% of Medicaid,156.95,,,156.95,Other,100% of Medicaid,353.14,,,353.14,Other,225% of Medicaid,240.14,,,240.14,Other,153% of Medicaid,353.14,,,353.14,Other,225% of Medicaid,219.73,,,219.73,Other,140% of Medicaid,353.14,,,353.14,Other,225% of Medicaid,408.08,,,408.08,Other,260% of Medicaid,508.53,,,508.53,Other,324% of Medicaid,337.45,,,337.45,Other,215% of Medicaid,337.45,,,337.45,Other,215% of Medicaid,196.19,,,196.19,Other,125% of Medicaid,156.95,7216,
EX ARTERY NEEDLE/INTRACATH UN,36140,CPT,,47036140,CDM,360,RC,,,both,,,769,569.06,,,569.06,Other,150% of Medicare + 9.63% HCRA Surcharge,346.05,45,,346.05,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",380.66,,,380.66,Other,110% of Medicare,522.92,,,522.92,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",516.02,,,516.02,Other,186% of Medicaid,615.2,,,615.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",615.2,,,615.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",615.2,,,615.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",538.3,70,,538.3,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",277.43,,,277.43,Other,100% of Medicaid,277.43,,,277.43,Other,100% of Medicaid,277.43,,,277.43,Other,100% of Medicaid,277.43,,,277.43,Other,100% of Medicaid,624.21,,,624.21,Other,225% of Medicaid,424.47,,,424.47,Other,153% of Medicaid,624.21,,,624.21,Other,225% of Medicaid,388.4,,,388.4,Other,140% of Medicaid,624.21,,,624.21,Other,225% of Medicaid,721.31,,,721.31,Other,260% of Medicaid,898.87,,,898.87,Other,324% of Medicaid,596.47,,,596.47,Other,215% of Medicaid,596.47,,,596.47,Other,215% of Medicaid,346.79,,,346.79,Other,125% of Medicaid,277.43,7216,
NONSELECT CATH - TRANSLUMBAR AORTA,36160,CPT,,47036160,CDM,360,RC,,,both,,,533,394.42,,,394.42,Other,150% of Medicare + 9.63% HCRA Surcharge,239.85,45,,239.85,percent of total billed charges,Critical Access Hospital RCC factor,2480,,,2480,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2232,,,2232,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3648,,,3648,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3283,,,3283,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3101,,,3101,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",263.84,,,263.84,Other,110% of Medicare,362.44,,,362.44,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",516.02,,,516.02,Other,186% of Medicaid,426.4,,,426.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",426.4,,,426.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",426.4,,,426.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",373.1,70,,373.1,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",277.43,,,277.43,Other,100% of Medicaid,277.43,,,277.43,Other,100% of Medicaid,277.43,,,277.43,Other,100% of Medicaid,277.43,,,277.43,Other,100% of Medicaid,624.21,,,624.21,Other,225% of Medicaid,424.47,,,424.47,Other,153% of Medicaid,624.21,,,624.21,Other,225% of Medicaid,388.4,,,388.4,Other,140% of Medicaid,624.21,,,624.21,Other,225% of Medicaid,721.31,,,721.31,Other,260% of Medicaid,898.87,,,898.87,Other,324% of Medicaid,596.47,,,596.47,Other,215% of Medicaid,596.47,,,596.47,Other,215% of Medicaid,346.79,,,346.79,Other,125% of Medicaid,239.85,7216,
AORTA CATHETER FEMBRACAX,36200,CPT,,47036200,CDM,360,RC,,,both,,,1146,848.04,,,848.04,Other,150% of Medicare + 9.63% HCRA Surcharge,515.7,45,,515.7,percent of total billed charges,Critical Access Hospital RCC factor,2480,,,2480,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2232,,,2232,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3648,,,3648,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3283,,,3283,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3101,,,3101,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",567.27,,,567.27,Other,110% of Medicare,779.28,,,779.28,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",516.02,,,516.02,Other,186% of Medicaid,916.8,,,916.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",916.8,,,916.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",916.8,,,916.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",802.2,70,,802.2,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",277.43,,,277.43,Other,100% of Medicaid,277.43,,,277.43,Other,100% of Medicaid,277.43,,,277.43,Other,100% of Medicaid,277.43,,,277.43,Other,100% of Medicaid,624.21,,,624.21,Other,225% of Medicaid,424.47,,,424.47,Other,153% of Medicaid,624.21,,,624.21,Other,225% of Medicaid,388.4,,,388.4,Other,140% of Medicaid,624.21,,,624.21,Other,225% of Medicaid,721.31,,,721.31,Other,260% of Medicaid,898.87,,,898.87,Other,324% of Medicaid,596.47,,,596.47,Other,215% of Medicaid,596.47,,,596.47,Other,215% of Medicaid,346.79,,,346.79,Other,125% of Medicaid,277.43,7216,
SELECT CATH ART - BRACH-CEPH; 1ST ORDER,36215,CPT,,47036215,CDM,360,RC,,,both,,,1698,1256.52,,,1256.52,Other,150% of Medicare + 9.63% HCRA Surcharge,764.1,45,,764.1,percent of total billed charges,Critical Access Hospital RCC factor,2480,,,2480,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2232,,,2232,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4476,,,4476,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4028,,,4028,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3805,,,3805,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",840.51,,,840.51,Other,110% of Medicare,1154.64,,,1154.64,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",516.02,,,516.02,Other,186% of Medicaid,1358.4,,,1358.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1358.4,,,1358.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1358.4,,,1358.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1188.6,70,,1188.6,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",277.43,,,277.43,Other,100% of Medicaid,277.43,,,277.43,Other,100% of Medicaid,277.43,,,277.43,Other,100% of Medicaid,277.43,,,277.43,Other,100% of Medicaid,624.21,,,624.21,Other,225% of Medicaid,424.47,,,424.47,Other,153% of Medicaid,624.21,,,624.21,Other,225% of Medicaid,388.4,,,388.4,Other,140% of Medicaid,624.21,,,624.21,Other,225% of Medicaid,721.31,,,721.31,Other,260% of Medicaid,898.87,,,898.87,Other,324% of Medicaid,596.47,,,596.47,Other,215% of Medicaid,596.47,,,596.47,Other,215% of Medicaid,346.79,,,346.79,Other,125% of Medicaid,277.43,7216,
SELECT CATH ART - BRACH-CEPH; 2ND ORDER,36216,CPT,,47036216,CDM,360,RC,,,both,,,1757,1300.18,,,1300.18,Other,150% of Medicare + 9.63% HCRA Surcharge,790.65,45,,790.65,percent of total billed charges,Critical Access Hospital RCC factor,2480,,,2480,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2232,,,2232,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4476,,,4476,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4028,,,4028,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3805,,,3805,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",869.72,,,869.72,Other,110% of Medicare,1194.76,,,1194.76,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",516.02,,,516.02,Other,186% of Medicaid,1405.6,,,1405.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1405.6,,,1405.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1405.6,,,1405.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1229.9,70,,1229.9,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",277.43,,,277.43,Other,100% of Medicaid,277.43,,,277.43,Other,100% of Medicaid,277.43,,,277.43,Other,100% of Medicaid,277.43,,,277.43,Other,100% of Medicaid,624.21,,,624.21,Other,225% of Medicaid,424.47,,,424.47,Other,153% of Medicaid,624.21,,,624.21,Other,225% of Medicaid,388.4,,,388.4,Other,140% of Medicaid,624.21,,,624.21,Other,225% of Medicaid,721.31,,,721.31,Other,260% of Medicaid,898.87,,,898.87,Other,324% of Medicaid,596.47,,,596.47,Other,215% of Medicaid,596.47,,,596.47,Other,215% of Medicaid,346.79,,,346.79,Other,125% of Medicaid,277.43,7216,
LEFT CAROTID 1ST 2ND & 3RD,36217,CPT,,47036217,CDM,360,RC,,,both,,,2114,1564.37,,,1564.37,Other,150% of Medicare + 9.63% HCRA Surcharge,951.3,45,,951.3,percent of total billed charges,Critical Access Hospital RCC factor,2480,,,2480,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2232,,,2232,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4476,,,4476,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4028,,,4028,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3805,,,3805,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",1046.43,,,1046.43,Other,110% of Medicare,1437.52,,,1437.52,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",516.02,,,516.02,Other,186% of Medicaid,1691.2,,,1691.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1691.2,,,1691.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1691.2,,,1691.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1479.8,70,,1479.8,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",277.43,,,277.43,Other,100% of Medicaid,277.43,,,277.43,Other,100% of Medicaid,277.43,,,277.43,Other,100% of Medicaid,277.43,,,277.43,Other,100% of Medicaid,624.21,,,624.21,Other,225% of Medicaid,424.47,,,424.47,Other,153% of Medicaid,624.21,,,624.21,Other,225% of Medicaid,388.4,,,388.4,Other,140% of Medicaid,624.21,,,624.21,Other,225% of Medicaid,721.31,,,721.31,Other,260% of Medicaid,898.87,,,898.87,Other,324% of Medicaid,596.47,,,596.47,Other,215% of Medicaid,596.47,,,596.47,Other,215% of Medicaid,346.79,,,346.79,Other,125% of Medicaid,277.43,7216,
SELECT CATH ART - BRACH-CEPH; EA ADDTL,36218,CPT,,47036218,CDM,360,RC,,,both,,,210,155.4,,,155.4,Other,150% of Medicare + 9.63% HCRA Surcharge,94.5,45,,94.5,percent of total billed charges,Critical Access Hospital RCC factor,2480,,,2480,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2232,,,2232,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4476,,,4476,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4028,,,4028,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3805,,,3805,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",103.95,,,103.95,Other,110% of Medicare,142.8,,,142.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",516.02,,,516.02,Other,186% of Medicaid,168,,,168,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",168,,,168,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",168,,,168,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",147,70,,147,percent of total billed charges,All Other,246,,,246,Fee Schedule,,208.5,,,208.5,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",277.43,,,277.43,Other,100% of Medicaid,277.43,,,277.43,Other,100% of Medicaid,277.43,,,277.43,Other,100% of Medicaid,277.43,,,277.43,Other,100% of Medicaid,624.21,,,624.21,Other,225% of Medicaid,424.47,,,424.47,Other,153% of Medicaid,624.21,,,624.21,Other,225% of Medicaid,388.4,,,388.4,Other,140% of Medicaid,624.21,,,624.21,Other,225% of Medicaid,721.31,,,721.31,Other,260% of Medicaid,898.87,,,898.87,Other,324% of Medicaid,596.47,,,596.47,Other,215% of Medicaid,596.47,,,596.47,Other,215% of Medicaid,346.79,,,346.79,Other,125% of Medicaid,94.5,7216,
PLACE CATH THORACIC AORTA,36221,CPT,,47036221,CDM,360,RC,,,both,,,9535,7055.92,,,7055.92,Other,150% of Medicare + 9.63% HCRA Surcharge,4290.75,45,,4290.75,percent of total billed charges,Critical Access Hospital RCC factor,2480,,,2480,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2232,,,2232,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4476,,,4476,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4028,,,4028,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3805,,,3805,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4719.83,,,4719.83,Other,110% of Medicare,6483.8,,,6483.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1729.46,,,1729.46,Other,186% of Medicaid,7628,,,7628,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7628,,,7628,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7628,,,7628,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",6674.5,70,,6674.5,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",4913,,,4913,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4422,,,4422,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4913,,,4913,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4176,,,4176,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",929.82,,,929.82,Other,100% of Medicaid,929.82,,,929.82,Other,100% of Medicaid,929.82,,,929.82,Other,100% of Medicaid,929.82,,,929.82,Other,100% of Medicaid,2092.09,,,2092.09,Other,225% of Medicaid,1422.62,,,1422.62,Other,153% of Medicaid,2092.09,,,2092.09,Other,225% of Medicaid,1301.75,,,1301.75,Other,140% of Medicaid,2092.09,,,2092.09,Other,225% of Medicaid,2417.53,,,2417.53,Other,260% of Medicaid,3012.61,,,3012.61,Other,324% of Medicaid,1999.11,,,1999.11,Other,215% of Medicaid,1999.11,,,1999.11,Other,215% of Medicaid,1162.27,,,1162.27,Other,125% of Medicaid,929.82,7628,
PLACE CATH CAROTID/INOM ART,36222,CPT,,47036222,CDM,360,RC,,,both,,,8748,6473.54,,,6473.54,Other,150% of Medicare + 9.63% HCRA Surcharge,3936.6,45,,3936.6,percent of total billed charges,Critical Access Hospital RCC factor,2480,,,2480,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2232,,,2232,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4476,,,4476,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4028,,,4028,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3805,,,3805,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4330.26,,,4330.26,Other,110% of Medicare,5948.64,,,5948.64,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1729.46,,,1729.46,Other,186% of Medicaid,6998.4,,,6998.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",6998.4,,,6998.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",6998.4,,,6998.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",6123.6,70,,6123.6,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",4913,,,4913,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4422,,,4422,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4913,,,4913,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4176,,,4176,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",929.82,,,929.82,Other,100% of Medicaid,929.82,,,929.82,Other,100% of Medicaid,929.82,,,929.82,Other,100% of Medicaid,929.82,,,929.82,Other,100% of Medicaid,2092.09,,,2092.09,Other,225% of Medicaid,1422.62,,,1422.62,Other,153% of Medicaid,2092.09,,,2092.09,Other,225% of Medicaid,1301.75,,,1301.75,Other,140% of Medicaid,2092.09,,,2092.09,Other,225% of Medicaid,2417.53,,,2417.53,Other,260% of Medicaid,3012.61,,,3012.61,Other,324% of Medicaid,1999.11,,,1999.11,Other,215% of Medicaid,1999.11,,,1999.11,Other,215% of Medicaid,1162.27,,,1162.27,Other,125% of Medicaid,929.82,7216,
PLACE CATH CAROTID/INOM ART,36223,CPT,,47036223,CDM,360,RC,,,both,,,11570,8561.83,,,8561.83,Other,150% of Medicare + 9.63% HCRA Surcharge,5206.5,45,,5206.5,percent of total billed charges,Critical Access Hospital RCC factor,2480,,,2480,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2232,,,2232,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4970,,,4970,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4473,,,4473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4225,,,4225,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",5727.15,,,5727.15,Other,110% of Medicare,7867.6,,,7867.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1729.46,,,1729.46,Other,186% of Medicaid,9256,,,9256,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9256,,,9256,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9256,,,9256,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",8099,70,,8099,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",6331,,,6331,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",5698,,,5698,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",6331,,,6331,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",5381,,,5381,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",929.82,,,929.82,Other,100% of Medicaid,929.82,,,929.82,Other,100% of Medicaid,929.82,,,929.82,Other,100% of Medicaid,929.82,,,929.82,Other,100% of Medicaid,2092.09,,,2092.09,Other,225% of Medicaid,1422.62,,,1422.62,Other,153% of Medicaid,2092.09,,,2092.09,Other,225% of Medicaid,1301.75,,,1301.75,Other,140% of Medicaid,2092.09,,,2092.09,Other,225% of Medicaid,2417.53,,,2417.53,Other,260% of Medicaid,3012.61,,,3012.61,Other,324% of Medicaid,1999.11,,,1999.11,Other,215% of Medicaid,1999.11,,,1999.11,Other,215% of Medicaid,1162.27,,,1162.27,Other,125% of Medicaid,929.82,9256,
PLACE CATH CAROTID ART,36224,CPT,,47036224,CDM,360,RC,,,both,,,14383,10643.46,,,10643.46,Other,150% of Medicare + 9.63% HCRA Surcharge,6472.35,45,,6472.35,percent of total billed charges,Critical Access Hospital RCC factor,3473,,,3473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3126,,,3126,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4970,,,4970,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4473,,,4473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4225,,,4225,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",7119.59,,,7119.59,Other,110% of Medicare,6152,,,6152,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1729.46,,,1729.46,Other,186% of Medicaid,7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",11506.4,,,11506.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",10068.1,70,,10068.1,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",6331,,,6331,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",5698,,,5698,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",6331,,,6331,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",5381,,,5381,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",929.82,,,929.82,Other,100% of Medicaid,929.82,,,929.82,Other,100% of Medicaid,929.82,,,929.82,Other,100% of Medicaid,929.82,,,929.82,Other,100% of Medicaid,2092.09,,,2092.09,Other,225% of Medicaid,1422.62,,,1422.62,Other,153% of Medicaid,2092.09,,,2092.09,Other,225% of Medicaid,1301.75,,,1301.75,Other,140% of Medicaid,2092.09,,,2092.09,Other,225% of Medicaid,2417.53,,,2417.53,Other,260% of Medicaid,3012.61,,,3012.61,Other,324% of Medicaid,1999.11,,,1999.11,Other,215% of Medicaid,1999.11,,,1999.11,Other,215% of Medicaid,1162.27,,,1162.27,Other,125% of Medicaid,929.82,11506.4,
PLACE CATH SUBCLAVIAN ART,36225,CPT,,47036225,CDM,360,RC,,,both,,,8748,6473.54,,,6473.54,Other,150% of Medicare + 9.63% HCRA Surcharge,3936.6,45,,3936.6,percent of total billed charges,Critical Access Hospital RCC factor,2480,,,2480,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2232,,,2232,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4476,,,4476,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4028,,,4028,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3805,,,3805,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4330.26,,,4330.26,Other,110% of Medicare,5948.64,,,5948.64,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1729.46,,,1729.46,Other,186% of Medicaid,6998.4,,,6998.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",6998.4,,,6998.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",6998.4,,,6998.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",6123.6,70,,6123.6,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",4913,,,4913,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4422,,,4422,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4913,,,4913,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4176,,,4176,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",929.82,,,929.82,Other,100% of Medicaid,929.82,,,929.82,Other,100% of Medicaid,929.82,,,929.82,Other,100% of Medicaid,929.82,,,929.82,Other,100% of Medicaid,2092.09,,,2092.09,Other,225% of Medicaid,1422.62,,,1422.62,Other,153% of Medicaid,2092.09,,,2092.09,Other,225% of Medicaid,1301.75,,,1301.75,Other,140% of Medicaid,2092.09,,,2092.09,Other,225% of Medicaid,2417.53,,,2417.53,Other,260% of Medicaid,3012.61,,,3012.61,Other,324% of Medicaid,1999.11,,,1999.11,Other,215% of Medicaid,1999.11,,,1999.11,Other,215% of Medicaid,1162.27,,,1162.27,Other,125% of Medicaid,929.82,7216,
PLACE CATH VERTEBRAL ART,36226,CPT,,47036226,CDM,360,RC,,,both,,,14383,10643.46,,,10643.46,Other,150% of Medicare + 9.63% HCRA Surcharge,6472.35,45,,6472.35,percent of total billed charges,Critical Access Hospital RCC factor,3473,,,3473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3126,,,3126,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4970,,,4970,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4473,,,4473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4225,,,4225,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",7119.59,,,7119.59,Other,110% of Medicare,6152,,,6152,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1729.46,,,1729.46,Other,186% of Medicaid,7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",11506.4,,,11506.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",10068.1,70,,10068.1,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",6331,,,6331,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",5698,,,5698,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",6331,,,6331,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",5381,,,5381,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",929.82,,,929.82,Other,100% of Medicaid,929.82,,,929.82,Other,100% of Medicaid,929.82,,,929.82,Other,100% of Medicaid,929.82,,,929.82,Other,100% of Medicaid,2092.09,,,2092.09,Other,225% of Medicaid,1422.62,,,1422.62,Other,153% of Medicaid,2092.09,,,2092.09,Other,225% of Medicaid,1301.75,,,1301.75,Other,140% of Medicaid,2092.09,,,2092.09,Other,225% of Medicaid,2417.53,,,2417.53,Other,260% of Medicaid,3012.61,,,3012.61,Other,324% of Medicaid,1999.11,,,1999.11,Other,215% of Medicaid,1999.11,,,1999.11,Other,215% of Medicaid,1162.27,,,1162.27,Other,125% of Medicaid,929.82,11506.4,
PLACE CATH XTRNL CAROTID,36227,CPT,,47036227,CDM,360,RC,,,both,,,430,318.2,,,318.2,Other,150% of Medicare + 9.63% HCRA Surcharge,193.5,45,,193.5,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4476,,,4476,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4028,,,4028,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3805,,,3805,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",212.85,,,212.85,Other,110% of Medicare,292.4,,,292.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1729.46,,,1729.46,Other,186% of Medicaid,344,,,344,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",344,,,344,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",344,,,344,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",301,70,,301,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",929.82,,,929.82,Other,100% of Medicaid,929.82,,,929.82,Other,100% of Medicaid,929.82,,,929.82,Other,100% of Medicaid,929.82,,,929.82,Other,100% of Medicaid,2092.09,,,2092.09,Other,225% of Medicaid,1422.62,,,1422.62,Other,153% of Medicaid,2092.09,,,2092.09,Other,225% of Medicaid,1301.75,,,1301.75,Other,140% of Medicaid,2092.09,,,2092.09,Other,225% of Medicaid,2417.53,,,2417.53,Other,260% of Medicaid,3012.61,,,3012.61,Other,324% of Medicaid,1999.11,,,1999.11,Other,215% of Medicaid,1999.11,,,1999.11,Other,215% of Medicaid,1162.27,,,1162.27,Other,125% of Medicaid,193.5,7216,
PLACE CATH INTRACRANIAL ART,36228,CPT,,47036228,CDM,360,RC,,,both,,,643,475.82,,,475.82,Other,150% of Medicare + 9.63% HCRA Surcharge,289.35,45,,289.35,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4476,,,4476,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4028,,,4028,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3805,,,3805,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",318.29,,,318.29,Other,110% of Medicare,437.24,,,437.24,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1729.46,,,1729.46,Other,186% of Medicaid,514.4,,,514.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",514.4,,,514.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",514.4,,,514.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",450.1,70,,450.1,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",929.82,,,929.82,Other,100% of Medicaid,929.82,,,929.82,Other,100% of Medicaid,929.82,,,929.82,Other,100% of Medicaid,929.82,,,929.82,Other,100% of Medicaid,2092.09,,,2092.09,Other,225% of Medicaid,1422.62,,,1422.62,Other,153% of Medicaid,2092.09,,,2092.09,Other,225% of Medicaid,1301.75,,,1301.75,Other,140% of Medicaid,2092.09,,,2092.09,Other,225% of Medicaid,2417.53,,,2417.53,Other,260% of Medicaid,3012.61,,,3012.61,Other,324% of Medicaid,1999.11,,,1999.11,Other,215% of Medicaid,1999.11,,,1999.11,Other,215% of Medicaid,1162.27,,,1162.27,Other,125% of Medicaid,289.35,7216,
OTHER ABD AORTA VASC FAM 1ST,36245,CPT,,47036245,CDM,360,RC,,,both,,,1489,1101.86,,,1101.86,Other,150% of Medicare + 9.63% HCRA Surcharge,670.05,45,,670.05,percent of total billed charges,Critical Access Hospital RCC factor,2480,,,2480,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2232,,,2232,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4970,,,4970,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4473,,,4473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4225,,,4225,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",737.06,,,737.06,Other,110% of Medicare,1012.52,,,1012.52,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",516.02,,,516.02,Other,186% of Medicaid,1191.2,,,1191.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1191.2,,,1191.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1191.2,,,1191.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1042.3,70,,1042.3,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",277.43,,,277.43,Other,100% of Medicaid,277.43,,,277.43,Other,100% of Medicaid,277.43,,,277.43,Other,100% of Medicaid,277.43,,,277.43,Other,100% of Medicaid,624.21,,,624.21,Other,225% of Medicaid,424.47,,,424.47,Other,153% of Medicaid,624.21,,,624.21,Other,225% of Medicaid,388.4,,,388.4,Other,140% of Medicaid,624.21,,,624.21,Other,225% of Medicaid,721.31,,,721.31,Other,260% of Medicaid,898.87,,,898.87,Other,324% of Medicaid,596.47,,,596.47,Other,215% of Medicaid,596.47,,,596.47,Other,215% of Medicaid,346.79,,,346.79,Other,125% of Medicaid,277.43,7216,
OAAV 1ST & 2ND,36246,CPT,,47036246,CDM,360,RC,,,both,,,2057,1522.19,,,1522.19,Other,150% of Medicare + 9.63% HCRA Surcharge,925.65,45,,925.65,percent of total billed charges,Critical Access Hospital RCC factor,2480,,,2480,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2232,,,2232,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4970,,,4970,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4473,,,4473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4225,,,4225,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",1018.22,,,1018.22,Other,110% of Medicare,1398.76,,,1398.76,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",516.02,,,516.02,Other,186% of Medicaid,1645.6,,,1645.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1645.6,,,1645.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1645.6,,,1645.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1439.9,70,,1439.9,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",277.43,,,277.43,Other,100% of Medicaid,277.43,,,277.43,Other,100% of Medicaid,277.43,,,277.43,Other,100% of Medicaid,277.43,,,277.43,Other,100% of Medicaid,624.21,,,624.21,Other,225% of Medicaid,424.47,,,424.47,Other,153% of Medicaid,624.21,,,624.21,Other,225% of Medicaid,388.4,,,388.4,Other,140% of Medicaid,624.21,,,624.21,Other,225% of Medicaid,721.31,,,721.31,Other,260% of Medicaid,898.87,,,898.87,Other,324% of Medicaid,596.47,,,596.47,Other,215% of Medicaid,596.47,,,596.47,Other,215% of Medicaid,346.79,,,346.79,Other,125% of Medicaid,277.43,7216,
COM FEM CONTRA 1ST 2ND & 3RD,36247,CPT,,47036247,CDM,360,RC,,,both,,,2250,1665.01,,,1665.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1012.5,45,,1012.5,percent of total billed charges,Critical Access Hospital RCC factor,2480,,,2480,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2232,,,2232,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4970,,,4970,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4473,,,4473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4225,,,4225,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",1113.75,,,1113.75,Other,110% of Medicare,1530,,,1530,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",516.02,,,516.02,Other,186% of Medicaid,1800,,,1800,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1800,,,1800,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1800,,,1800,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1575,70,,1575,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",277.43,,,277.43,Other,100% of Medicaid,277.43,,,277.43,Other,100% of Medicaid,277.43,,,277.43,Other,100% of Medicaid,277.43,,,277.43,Other,100% of Medicaid,624.21,,,624.21,Other,225% of Medicaid,424.47,,,424.47,Other,153% of Medicaid,624.21,,,624.21,Other,225% of Medicaid,388.4,,,388.4,Other,140% of Medicaid,624.21,,,624.21,Other,225% of Medicaid,721.31,,,721.31,Other,260% of Medicaid,898.87,,,898.87,Other,324% of Medicaid,596.47,,,596.47,Other,215% of Medicaid,596.47,,,596.47,Other,215% of Medicaid,346.79,,,346.79,Other,125% of Medicaid,277.43,7216,
SMA EA ADD 2ND & 3RD VESL,36248,CPT,,47036248,CDM,360,RC,,,both,,,1053,779.22,,,779.22,Other,150% of Medicare + 9.63% HCRA Surcharge,473.85,45,,473.85,percent of total billed charges,Critical Access Hospital RCC factor,2480,,,2480,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2232,,,2232,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4970,,,4970,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4473,,,4473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4225,,,4225,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",521.24,,,521.24,Other,110% of Medicare,716.04,,,716.04,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",516.02,,,516.02,Other,186% of Medicaid,842.4,,,842.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",842.4,,,842.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",842.4,,,842.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",737.1,70,,737.1,percent of total billed charges,All Other,229.6,,,229.6,Fee Schedule,,194.6,,,194.6,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",277.43,,,277.43,Other,100% of Medicaid,277.43,,,277.43,Other,100% of Medicaid,277.43,,,277.43,Other,100% of Medicaid,277.43,,,277.43,Other,100% of Medicaid,624.21,,,624.21,Other,225% of Medicaid,424.47,,,424.47,Other,153% of Medicaid,624.21,,,624.21,Other,225% of Medicaid,388.4,,,388.4,Other,140% of Medicaid,624.21,,,624.21,Other,225% of Medicaid,721.31,,,721.31,Other,260% of Medicaid,898.87,,,898.87,Other,324% of Medicaid,596.47,,,596.47,Other,215% of Medicaid,596.47,,,596.47,Other,215% of Medicaid,346.79,,,346.79,Other,125% of Medicaid,194.6,7216,
INS CATH REN ART 1ST UNILAT,36251,CPT,,47036251,CDM,360,RC,,,both,,,8781,6497.96,,,6497.96,Other,150% of Medicare + 9.63% HCRA Surcharge,3951.45,45,,3951.45,percent of total billed charges,Critical Access Hospital RCC factor,2480,,,2480,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2232,,,2232,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4476,,,4476,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4028,,,4028,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3805,,,3805,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4346.6,,,4346.6,Other,110% of Medicare,5971.08,,,5971.08,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1729.46,,,1729.46,Other,186% of Medicaid,7024.8,,,7024.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7024.8,,,7024.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7024.8,,,7024.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",6146.7,70,,6146.7,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",4913,,,4913,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4422,,,4422,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4913,,,4913,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4176,,,4176,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",929.82,,,929.82,Other,100% of Medicaid,929.82,,,929.82,Other,100% of Medicaid,929.82,,,929.82,Other,100% of Medicaid,929.82,,,929.82,Other,100% of Medicaid,2092.09,,,2092.09,Other,225% of Medicaid,1422.62,,,1422.62,Other,153% of Medicaid,2092.09,,,2092.09,Other,225% of Medicaid,1301.75,,,1301.75,Other,140% of Medicaid,2092.09,,,2092.09,Other,225% of Medicaid,2417.53,,,2417.53,Other,260% of Medicaid,3012.61,,,3012.61,Other,324% of Medicaid,1999.11,,,1999.11,Other,215% of Medicaid,1999.11,,,1999.11,Other,215% of Medicaid,1162.27,,,1162.27,Other,125% of Medicaid,929.82,7216,
INS CATH REN ART 1ST BILAT,36252,CPT,,47036252,CDM,360,RC,,,both,,,8781,6497.96,,,6497.96,Other,150% of Medicare + 9.63% HCRA Surcharge,3951.45,45,,3951.45,percent of total billed charges,Critical Access Hospital RCC factor,2480,,,2480,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2232,,,2232,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4476,,,4476,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4028,,,4028,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3805,,,3805,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4346.6,,,4346.6,Other,110% of Medicare,5971.08,,,5971.08,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1729.46,,,1729.46,Other,186% of Medicaid,7024.8,,,7024.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7024.8,,,7024.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7024.8,,,7024.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",6146.7,70,,6146.7,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",4913,,,4913,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4422,,,4422,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4913,,,4913,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4176,,,4176,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",929.82,,,929.82,Other,100% of Medicaid,929.82,,,929.82,Other,100% of Medicaid,929.82,,,929.82,Other,100% of Medicaid,929.82,,,929.82,Other,100% of Medicaid,2092.09,,,2092.09,Other,225% of Medicaid,1422.62,,,1422.62,Other,153% of Medicaid,2092.09,,,2092.09,Other,225% of Medicaid,1301.75,,,1301.75,Other,140% of Medicaid,2092.09,,,2092.09,Other,225% of Medicaid,2417.53,,,2417.53,Other,260% of Medicaid,3012.61,,,3012.61,Other,324% of Medicaid,1999.11,,,1999.11,Other,215% of Medicaid,1999.11,,,1999.11,Other,215% of Medicaid,1162.27,,,1162.27,Other,125% of Medicaid,929.82,7216,
VENOUS SELECTIVE ORGAN BLOOD SAMPLING,36500,CPT,,47036500,CDM,360,RC,,,both,,,706,522.44,,,522.44,Other,150% of Medicare + 9.63% HCRA Surcharge,317.7,45,,317.7,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",349.47,,,349.47,Other,110% of Medicare,480.08,,,480.08,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",516.02,,,516.02,Other,186% of Medicaid,564.8,,,564.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",564.8,,,564.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",564.8,,,564.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",494.2,70,,494.2,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",277.43,,,277.43,Other,100% of Medicaid,277.43,,,277.43,Other,100% of Medicaid,277.43,,,277.43,Other,100% of Medicaid,277.43,,,277.43,Other,100% of Medicaid,624.21,,,624.21,Other,225% of Medicaid,424.47,,,424.47,Other,153% of Medicaid,624.21,,,624.21,Other,225% of Medicaid,388.4,,,388.4,Other,140% of Medicaid,624.21,,,624.21,Other,225% of Medicaid,721.31,,,721.31,Other,260% of Medicaid,898.87,,,898.87,Other,324% of Medicaid,596.47,,,596.47,Other,215% of Medicaid,596.47,,,596.47,Other,215% of Medicaid,346.79,,,346.79,Other,125% of Medicaid,277.43,7216,
INS NON TUN CV CATH >5 YR,36556,CPT,,47036556,CDM,360,RC,,,both,,,6707,4963.2,,,4963.2,Other,150% of Medicare + 9.63% HCRA Surcharge,3018.15,45,,3018.15,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3648,,,3648,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3283,,,3283,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3101,,,3101,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3319.97,,,3319.97,Other,110% of Medicare,4560.76,,,4560.76,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",586.68,,,586.68,Other,186% of Medicaid,5365.6,,,5365.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",5365.6,,,5365.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",3578,,,3578,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",4694.9,70,,4694.9,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",315.42,,,315.42,Other,100% of Medicaid,315.42,,,315.42,Other,100% of Medicaid,315.42,,,315.42,Other,100% of Medicaid,315.42,,,315.42,Other,100% of Medicaid,709.7,,,709.7,Other,225% of Medicaid,482.6,,,482.6,Other,153% of Medicaid,709.7,,,709.7,Other,225% of Medicaid,441.59,,,441.59,Other,140% of Medicaid,709.7,,,709.7,Other,225% of Medicaid,820.1,,,820.1,Other,260% of Medicaid,1021.97,,,1021.97,Other,324% of Medicaid,678.16,,,678.16,Other,215% of Medicaid,678.16,,,678.16,Other,215% of Medicaid,394.28,,,394.28,Other,125% of Medicaid,315.42,7216,
INSERT TUNNELED CV CATH,36558,CPT,,47036558,CDM,360,RC,,,both,,,7234,5353.18,,,5353.18,Other,150% of Medicare + 9.63% HCRA Surcharge,3255.3,45,,3255.3,percent of total billed charges,Critical Access Hospital RCC factor,2480,,,2480,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2232,,,2232,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4476,,,4476,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4028,,,4028,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3805,,,3805,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3580.83,,,3580.83,Other,110% of Medicare,4919.12,,,4919.12,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2490.15,,,2490.15,Other,186% of Medicaid,5787.2,,,5787.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",5787.2,,,5787.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",4252,,,4252,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",5063.8,70,,5063.8,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",4913,,,4913,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4422,,,4422,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4913,,,4913,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4176,,,4176,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",1338.79,,,1338.79,Other,100% of Medicaid,1338.79,,,1338.79,Other,100% of Medicaid,1338.79,,,1338.79,Other,100% of Medicaid,1338.79,,,1338.79,Other,100% of Medicaid,3012.28,,,3012.28,Other,225% of Medicaid,2048.35,,,2048.35,Other,153% of Medicaid,3012.28,,,3012.28,Other,225% of Medicaid,1874.31,,,1874.31,Other,140% of Medicaid,3012.28,,,3012.28,Other,225% of Medicaid,3480.85,,,3480.85,Other,260% of Medicaid,4337.68,,,4337.68,Other,324% of Medicaid,2878.4,,,2878.4,Other,215% of Medicaid,2878.4,,,2878.4,Other,215% of Medicaid,1673.49,,,1673.49,Other,125% of Medicaid,1338.79,7216,
PORT PLACEMENT >5,36561,CPT,,47036561,CDM,360,RC,,,both,,,8873,6566.04,,,6566.04,Other,150% of Medicare + 9.63% HCRA Surcharge,3992.85,45,,3992.85,percent of total billed charges,Critical Access Hospital RCC factor,3473,,,3473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3126,,,3126,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4476,,,4476,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4028,,,4028,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3805,,,3805,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4392.14,,,4392.14,Other,110% of Medicare,6152,,,6152,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2490.15,,,2490.15,Other,186% of Medicaid,7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",5266,,,5266,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",6211.1,70,,6211.1,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",4913,,,4913,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4422,,,4422,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4913,,,4913,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4176,,,4176,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",1338.79,,,1338.79,Other,100% of Medicaid,1338.79,,,1338.79,Other,100% of Medicaid,1338.79,,,1338.79,Other,100% of Medicaid,1338.79,,,1338.79,Other,100% of Medicaid,3012.28,,,3012.28,Other,225% of Medicaid,2048.35,,,2048.35,Other,153% of Medicaid,3012.28,,,3012.28,Other,225% of Medicaid,1874.31,,,1874.31,Other,140% of Medicaid,3012.28,,,3012.28,Other,225% of Medicaid,3480.85,,,3480.85,Other,260% of Medicaid,4337.68,,,4337.68,Other,324% of Medicaid,2878.4,,,2878.4,Other,215% of Medicaid,2878.4,,,2878.4,Other,215% of Medicaid,1673.49,,,1673.49,Other,125% of Medicaid,1338.79,9473,
INSERT PICC CATH >5 YRS O,36569,CPT,,47036569,CDM,360,RC,,,both,,,4042,2991.09,,,2991.09,Other,150% of Medicare + 9.63% HCRA Surcharge,1818.9,45,,1818.9,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3648,,,3648,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3283,,,3283,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3101,,,3101,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2000.79,,,2000.79,Other,110% of Medicare,2748.56,,,2748.56,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",586.68,,,586.68,Other,186% of Medicaid,3233.6,,,3233.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",3233.6,,,3233.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",3578,,,3578,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2829.4,70,,2829.4,percent of total billed charges,All Other,449.36,,,449.36,Fee Schedule,,380.86,,,380.86,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",315.42,,,315.42,Other,100% of Medicaid,315.42,,,315.42,Other,100% of Medicaid,315.42,,,315.42,Other,100% of Medicaid,315.42,,,315.42,Other,100% of Medicaid,709.7,,,709.7,Other,225% of Medicaid,482.6,,,482.6,Other,153% of Medicaid,709.7,,,709.7,Other,225% of Medicaid,441.59,,,441.59,Other,140% of Medicaid,709.7,,,709.7,Other,225% of Medicaid,820.1,,,820.1,Other,260% of Medicaid,1021.97,,,1021.97,Other,324% of Medicaid,678.16,,,678.16,Other,215% of Medicaid,678.16,,,678.16,Other,215% of Medicaid,394.28,,,394.28,Other,125% of Medicaid,315.42,7216,
INSJ PICC RS&I 5 YR+,36573,CPT,,47036573,CDM,360,RC,,,both,,,7992,5914.1,,,5914.1,Other,150% of Medicare + 9.63% HCRA Surcharge,3596.4,45,,3596.4,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3648,,,3648,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3283,,,3283,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3101,,,3101,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3956.04,,,3956.04,Other,110% of Medicare,5434.56,,,5434.56,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",586.68,,,586.68,Other,186% of Medicaid,6393.6,,,6393.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",6393.6,,,6393.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",6393.6,,,6393.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",5594.4,70,,5594.4,percent of total billed charges,All Other,403.44,,,403.44,Fee Schedule,,341.94,,,341.94,Fee Schedule,,4055,,,4055,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3649,,,3649,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4055,,,4055,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3448,,,3448,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",315.42,,,315.42,Other,100% of Medicaid,315.42,,,315.42,Other,100% of Medicaid,315.42,,,315.42,Other,100% of Medicaid,315.42,,,315.42,Other,100% of Medicaid,709.7,,,709.7,Other,225% of Medicaid,482.6,,,482.6,Other,153% of Medicaid,709.7,,,709.7,Other,225% of Medicaid,441.59,,,441.59,Other,140% of Medicaid,709.7,,,709.7,Other,225% of Medicaid,820.1,,,820.1,Other,260% of Medicaid,1021.97,,,1021.97,Other,324% of Medicaid,678.16,,,678.16,Other,215% of Medicaid,678.16,,,678.16,Other,215% of Medicaid,394.28,,,394.28,Other,125% of Medicaid,315.42,7216,
REPAIR CVA CATHETER,36575,CPT,,47036575,CDM,360,RC,,,both,,,1989,1471.86,,,1471.86,Other,150% of Medicare + 9.63% HCRA Surcharge,895.05,45,,895.05,percent of total billed charges,Critical Access Hospital RCC factor,2480,,,2480,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2232,,,2232,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",984.56,,,984.56,Other,110% of Medicare,1352.52,,,1352.52,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1556.72,,,1556.72,Other,186% of Medicaid,1591.2,,,1591.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1591.2,,,1591.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",4252,,,4252,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1392.3,70,,1392.3,percent of total billed charges,All Other,162.36,,,162.36,Fee Schedule,,137.61,,,137.61,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",836.95,,,836.95,Other,100% of Medicaid,836.95,,,836.95,Other,100% of Medicaid,836.95,,,836.95,Other,100% of Medicaid,836.95,,,836.95,Other,100% of Medicaid,1883.13,,,1883.13,Other,225% of Medicaid,1280.53,,,1280.53,Other,153% of Medicaid,1883.13,,,1883.13,Other,225% of Medicaid,1171.73,,,1171.73,Other,140% of Medicaid,1883.13,,,1883.13,Other,225% of Medicaid,2176.07,,,2176.07,Other,260% of Medicaid,2711.71,,,2711.71,Other,324% of Medicaid,1799.44,,,1799.44,Other,215% of Medicaid,1799.44,,,1799.44,Other,215% of Medicaid,1046.19,,,1046.19,Other,125% of Medicaid,137.61,7216,
PORT REMOVAL,36578,CPT,,47036578,CDM,360,RC,,,both,,,6707,4963.2,,,4963.2,Other,150% of Medicare + 9.63% HCRA Surcharge,3018.15,45,,3018.15,percent of total billed charges,Critical Access Hospital RCC factor,2480,,,2480,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2232,,,2232,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4476,,,4476,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4028,,,4028,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3805,,,3805,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3319.97,,,3319.97,Other,110% of Medicare,4560.76,,,4560.76,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1556.72,,,1556.72,Other,186% of Medicaid,5365.6,,,5365.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",5365.6,,,5365.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",4252,,,4252,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",4694.9,70,,4694.9,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",4913,,,4913,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4422,,,4422,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4913,,,4913,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4176,,,4176,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",836.95,,,836.95,Other,100% of Medicaid,836.95,,,836.95,Other,100% of Medicaid,836.95,,,836.95,Other,100% of Medicaid,836.95,,,836.95,Other,100% of Medicaid,1883.13,,,1883.13,Other,225% of Medicaid,1280.53,,,1280.53,Other,153% of Medicaid,1883.13,,,1883.13,Other,225% of Medicaid,1171.73,,,1171.73,Other,140% of Medicaid,1883.13,,,1883.13,Other,225% of Medicaid,2176.07,,,2176.07,Other,260% of Medicaid,2711.71,,,2711.71,Other,324% of Medicaid,1799.44,,,1799.44,Other,215% of Medicaid,1799.44,,,1799.44,Other,215% of Medicaid,1046.19,,,1046.19,Other,125% of Medicaid,836.95,7216,
REPLACE TUNNELED CV CATH,36581,CPT,,47036581,CDM,360,RC,,,both,,,7234,5353.18,,,5353.18,Other,150% of Medicare + 9.63% HCRA Surcharge,3255.3,45,,3255.3,percent of total billed charges,Critical Access Hospital RCC factor,2480,,,2480,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2232,,,2232,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4476,,,4476,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4028,,,4028,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3805,,,3805,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3580.83,,,3580.83,Other,110% of Medicare,4919.12,,,4919.12,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2490.15,,,2490.15,Other,186% of Medicaid,5787.2,,,5787.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",5787.2,,,5787.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",4252,,,4252,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",5063.8,70,,5063.8,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",4913,,,4913,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4422,,,4422,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4913,,,4913,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4176,,,4176,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",1338.79,,,1338.79,Other,100% of Medicaid,1338.79,,,1338.79,Other,100% of Medicaid,1338.79,,,1338.79,Other,100% of Medicaid,1338.79,,,1338.79,Other,100% of Medicaid,3012.28,,,3012.28,Other,225% of Medicaid,2048.35,,,2048.35,Other,153% of Medicaid,3012.28,,,3012.28,Other,225% of Medicaid,1874.31,,,1874.31,Other,140% of Medicaid,3012.28,,,3012.28,Other,225% of Medicaid,3480.85,,,3480.85,Other,260% of Medicaid,4337.68,,,4337.68,Other,324% of Medicaid,2878.4,,,2878.4,Other,215% of Medicaid,2878.4,,,2878.4,Other,215% of Medicaid,1673.49,,,1673.49,Other,125% of Medicaid,1338.79,7216,
REPLACE PICC CATH,36584,CPT,,47036584,CDM,360,RC,,,both,,,3500,2590.01,,,2590.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1575,45,,1575,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3648,,,3648,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3283,,,3283,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3101,,,3101,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",1732.5,,,1732.5,Other,110% of Medicare,2380,,,2380,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",586.68,,,586.68,Other,186% of Medicaid,2800,,,2800,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2800,,,2800,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",3578,,,3578,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2450,70,,2450,percent of total billed charges,All Other,280.44,,,280.44,Fee Schedule,,237.69,,,237.69,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",315.42,,,315.42,Other,100% of Medicaid,315.42,,,315.42,Other,100% of Medicaid,315.42,,,315.42,Other,100% of Medicaid,315.42,,,315.42,Other,100% of Medicaid,709.7,,,709.7,Other,225% of Medicaid,482.6,,,482.6,Other,153% of Medicaid,709.7,,,709.7,Other,225% of Medicaid,441.59,,,441.59,Other,140% of Medicaid,709.7,,,709.7,Other,225% of Medicaid,820.1,,,820.1,Other,260% of Medicaid,1021.97,,,1021.97,Other,324% of Medicaid,678.16,,,678.16,Other,215% of Medicaid,678.16,,,678.16,Other,215% of Medicaid,394.28,,,394.28,Other,125% of Medicaid,237.69,7216,
REMOVAL TUNNELED CV CATH,36589,CPT,,47036589,CDM,360,RC,,,both,,,2408,1781.93,,,1781.93,Other,150% of Medicare + 9.63% HCRA Surcharge,1083.6,45,,1083.6,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",1191.96,,,1191.96,Other,110% of Medicare,1637.44,,,1637.44,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1556.72,,,1556.72,Other,186% of Medicaid,1926.4,,,1926.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1926.4,,,1926.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",3578,,,3578,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1685.6,70,,1685.6,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",836.95,,,836.95,Other,100% of Medicaid,836.95,,,836.95,Other,100% of Medicaid,836.95,,,836.95,Other,100% of Medicaid,836.95,,,836.95,Other,100% of Medicaid,1883.13,,,1883.13,Other,225% of Medicaid,1280.53,,,1280.53,Other,153% of Medicaid,1883.13,,,1883.13,Other,225% of Medicaid,1171.73,,,1171.73,Other,140% of Medicaid,1883.13,,,1883.13,Other,225% of Medicaid,2176.07,,,2176.07,Other,260% of Medicaid,2711.71,,,2711.71,Other,324% of Medicaid,1799.44,,,1799.44,Other,215% of Medicaid,1799.44,,,1799.44,Other,215% of Medicaid,1046.19,,,1046.19,Other,125% of Medicaid,836.95,7216,
REM TUNNELED CVAD W PORT/PUMP,36590,CPT,,47036590,CDM,360,RC,,,both,,,4327,3201.99,,,3201.99,Other,150% of Medicare + 9.63% HCRA Surcharge,1947.15,45,,1947.15,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2141.87,,,2141.87,Other,110% of Medicare,2942.36,,,2942.36,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1556.72,,,1556.72,Other,186% of Medicaid,3461.6,,,3461.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",3461.6,,,3461.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",3578,,,3578,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",3028.9,70,,3028.9,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",4055,,,4055,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3649,,,3649,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4055,,,4055,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3448,,,3448,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",836.95,,,836.95,Other,100% of Medicaid,836.95,,,836.95,Other,100% of Medicaid,836.95,,,836.95,Other,100% of Medicaid,836.95,,,836.95,Other,100% of Medicaid,1883.13,,,1883.13,Other,225% of Medicaid,1280.53,,,1280.53,Other,153% of Medicaid,1883.13,,,1883.13,Other,225% of Medicaid,1171.73,,,1171.73,Other,140% of Medicaid,1883.13,,,1883.13,Other,225% of Medicaid,2176.07,,,2176.07,Other,260% of Medicaid,2711.71,,,2711.71,Other,324% of Medicaid,1799.44,,,1799.44,Other,215% of Medicaid,1799.44,,,1799.44,Other,215% of Medicaid,1046.19,,,1046.19,Other,125% of Medicaid,836.95,7216,
DECLOT VASCULAR DEVICE,36593,CPT,,47036593,CDM,360,RC,,,both,,,896,663.04,,,663.04,Other,150% of Medicare + 9.63% HCRA Surcharge,403.2,45,,403.2,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",443.52,,,443.52,Other,110% of Medicare,609.28,,,609.28,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",644.22,,,644.22,Other,186% of Medicaid,716.8,,,716.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",716.8,,,716.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",716.8,,,716.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",627.2,70,,627.2,percent of total billed charges,All Other,159.08,,,159.08,Fee Schedule,,134.83,,,134.83,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",346.35,,,346.35,Other,100% of Medicaid,346.35,,,346.35,Other,100% of Medicaid,346.35,,,346.35,Other,100% of Medicaid,346.35,,,346.35,Other,100% of Medicaid,779.3,,,779.3,Other,225% of Medicaid,529.92,,,529.92,Other,153% of Medicaid,779.3,,,779.3,Other,225% of Medicaid,484.9,,,484.9,Other,140% of Medicaid,779.3,,,779.3,Other,225% of Medicaid,900.52,,,900.52,Other,260% of Medicaid,1122.19,,,1122.19,Other,324% of Medicaid,744.66,,,744.66,Other,215% of Medicaid,744.66,,,744.66,Other,215% of Medicaid,432.94,,,432.94,Other,125% of Medicaid,134.83,7216,
SA MECH REM OBSTR CVAD,36595,CPT,,47036595,CDM,360,RC,,,both,,,8098,5992.54,,,5992.54,Other,150% of Medicare + 9.63% HCRA Surcharge,3644.1,45,,3644.1,percent of total billed charges,Critical Access Hospital RCC factor,3969,,,3969,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3572,,,3572,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4476,,,4476,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4028,,,4028,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3805,,,3805,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4008.51,,,4008.51,Other,110% of Medicare,6152,,,6152,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1556.72,,,1556.72,Other,186% of Medicaid,7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",6478.4,,,6478.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",5668.6,70,,5668.6,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",4913,,,4913,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4422,,,4422,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4913,,,4913,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4176,,,4176,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",836.95,,,836.95,Other,100% of Medicaid,836.95,,,836.95,Other,100% of Medicaid,836.95,,,836.95,Other,100% of Medicaid,836.95,,,836.95,Other,100% of Medicaid,1883.13,,,1883.13,Other,225% of Medicaid,1280.53,,,1280.53,Other,153% of Medicaid,1883.13,,,1883.13,Other,225% of Medicaid,1171.73,,,1171.73,Other,140% of Medicaid,1883.13,,,1883.13,Other,225% of Medicaid,2176.07,,,2176.07,Other,260% of Medicaid,2711.71,,,2711.71,Other,324% of Medicaid,1799.44,,,1799.44,Other,215% of Medicaid,1799.44,,,1799.44,Other,215% of Medicaid,1046.19,,,1046.19,Other,125% of Medicaid,836.95,9473,
MECH REM OF CVA LUMEN OBSTRUCT,36596,CPT,,47036596,CDM,360,RC,,,both,,,3708,2743.93,,,2743.93,Other,150% of Medicare + 9.63% HCRA Surcharge,1668.6,45,,1668.6,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3648,,,3648,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3283,,,3283,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3101,,,3101,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",1835.46,,,1835.46,Other,110% of Medicare,2521.44,,,2521.44,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1556.72,,,1556.72,Other,186% of Medicaid,2966.4,,,2966.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2966.4,,,2966.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2966.4,,,2966.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2595.6,70,,2595.6,percent of total billed charges,All Other,211.56,,,211.56,Fee Schedule,,179.31,,,179.31,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",836.95,,,836.95,Other,100% of Medicaid,836.95,,,836.95,Other,100% of Medicaid,836.95,,,836.95,Other,100% of Medicaid,836.95,,,836.95,Other,100% of Medicaid,1883.13,,,1883.13,Other,225% of Medicaid,1280.53,,,1280.53,Other,153% of Medicaid,1883.13,,,1883.13,Other,225% of Medicaid,1171.73,,,1171.73,Other,140% of Medicaid,1883.13,,,1883.13,Other,225% of Medicaid,2176.07,,,2176.07,Other,260% of Medicaid,2711.71,,,2711.71,Other,324% of Medicaid,1799.44,,,1799.44,Other,215% of Medicaid,1799.44,,,1799.44,Other,215% of Medicaid,1046.19,,,1046.19,Other,125% of Medicaid,179.31,7216,
REPOSIT CVC W FLUORO,36597,CPT,,47036597,CDM,360,RC,,,both,,,3709,2744.67,,,2744.67,Other,150% of Medicare + 9.63% HCRA Surcharge,1669.05,45,,1669.05,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3648,,,3648,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3283,,,3283,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3101,,,3101,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",1835.96,,,1835.96,Other,110% of Medicare,2522.12,,,2522.12,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1556.72,,,1556.72,Other,186% of Medicaid,2967.2,,,2967.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2967.2,,,2967.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2967.2,,,2967.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2596.3,70,,2596.3,percent of total billed charges,All Other,285.36,,,285.36,Fee Schedule,,241.86,,,241.86,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",836.95,,,836.95,Other,100% of Medicaid,836.95,,,836.95,Other,100% of Medicaid,836.95,,,836.95,Other,100% of Medicaid,836.95,,,836.95,Other,100% of Medicaid,1883.13,,,1883.13,Other,225% of Medicaid,1280.53,,,1280.53,Other,153% of Medicaid,1883.13,,,1883.13,Other,225% of Medicaid,1171.73,,,1171.73,Other,140% of Medicaid,1883.13,,,1883.13,Other,225% of Medicaid,2176.07,,,2176.07,Other,260% of Medicaid,2711.71,,,2711.71,Other,324% of Medicaid,1799.44,,,1799.44,Other,215% of Medicaid,1799.44,,,1799.44,Other,215% of Medicaid,1046.19,,,1046.19,Other,125% of Medicaid,241.86,7216,
CVA CHECK W/CONT AND FLUORO,36598,CPT,,47036598,CDM,360,RC,,,both,,,794,587.56,,,587.56,Other,150% of Medicare + 9.63% HCRA Surcharge,357.3,45,,357.3,percent of total billed charges,Critical Access Hospital RCC factor,2480,,,2480,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2232,,,2232,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",393.03,,,393.03,Other,110% of Medicare,539.92,,,539.92,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",966.93,,,966.93,Other,186% of Medicaid,635.2,,,635.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",635.2,,,635.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",635.2,,,635.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",555.8,70,,555.8,percent of total billed charges,All Other,173.84,,,173.84,Fee Schedule,,147.34,,,147.34,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",519.86,,,519.86,Other,100% of Medicaid,519.86,,,519.86,Other,100% of Medicaid,519.86,,,519.86,Other,100% of Medicaid,519.86,,,519.86,Other,100% of Medicaid,1169.68,,,1169.68,Other,225% of Medicaid,795.38,,,795.38,Other,153% of Medicaid,1169.68,,,1169.68,Other,225% of Medicaid,727.8,,,727.8,Other,140% of Medicaid,1169.68,,,1169.68,Other,225% of Medicaid,1351.62,,,1351.62,Other,260% of Medicaid,1684.33,,,1684.33,Other,324% of Medicaid,1117.69,,,1117.69,Other,215% of Medicaid,1117.69,,,1117.69,Other,215% of Medicaid,649.82,,,649.82,Other,125% of Medicaid,147.34,7216,
ARTERIAL CATH - SAMPLE/MONITOR,36620,CPT,,47036620,CDM,360,RC,,,both,,,299,221.26,,,221.26,Other,150% of Medicare + 9.63% HCRA Surcharge,134.55,45,,134.55,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",148.01,,,148.01,Other,110% of Medicare,203.32,,,203.32,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",516.02,,,516.02,Other,186% of Medicaid,239.2,,,239.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",239.2,,,239.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",239.2,,,239.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",209.3,70,,209.3,percent of total billed charges,All Other,211.56,,,211.56,Fee Schedule,,179.31,,,179.31,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",277.43,,,277.43,Other,100% of Medicaid,277.43,,,277.43,Other,100% of Medicaid,277.43,,,277.43,Other,100% of Medicaid,277.43,,,277.43,Other,100% of Medicaid,624.21,,,624.21,Other,225% of Medicaid,424.47,,,424.47,Other,153% of Medicaid,624.21,,,624.21,Other,225% of Medicaid,388.4,,,388.4,Other,140% of Medicaid,624.21,,,624.21,Other,225% of Medicaid,721.31,,,721.31,Other,260% of Medicaid,898.87,,,898.87,Other,324% of Medicaid,596.47,,,596.47,Other,215% of Medicaid,596.47,,,596.47,Other,215% of Medicaid,346.79,,,346.79,Other,125% of Medicaid,134.55,7216,
REVISE AV FISTULA - GRAFT,36832,CPT,,47036832,CDM,360,RC,,,both,,,30403,22498.3,,,22498.3,Other,150% of Medicare + 9.63% HCRA Surcharge,13681.35,45,,13681.35,percent of total billed charges,Critical Access Hospital RCC factor,3969,,,3969,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3572,,,3572,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4970,,,4970,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4473,,,4473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4225,,,4225,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",15049.49,,,15049.49,Other,110% of Medicare,6152,,,6152,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",4389.52,,,4389.52,Other,186% of Medicaid,7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",5743,,,5743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",21282.1,70,,21282.1,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",6331,,,6331,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",5698,,,5698,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",6331,,,6331,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",5381,,,5381,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2359.96,,,2359.96,Other,100% of Medicaid,2359.96,,,2359.96,Other,100% of Medicaid,2359.96,,,2359.96,Other,100% of Medicaid,2359.96,,,2359.96,Other,100% of Medicaid,5309.9,,,5309.9,Other,225% of Medicaid,3610.73,,,3610.73,Other,153% of Medicaid,5309.9,,,5309.9,Other,225% of Medicaid,3303.94,,,3303.94,Other,140% of Medicaid,5309.9,,,5309.9,Other,225% of Medicaid,6135.89,,,6135.89,Other,260% of Medicaid,7646.26,,,7646.26,Other,324% of Medicaid,5073.9,,,5073.9,Other,215% of Medicaid,5073.9,,,5073.9,Other,215% of Medicaid,2949.94,,,2949.94,Other,125% of Medicaid,2359.96,22498.3,
INTRO CATH DIALYSIS CIRCUIT,36901,CPT,,47036901,CDM,360,RC,,,both,,,3721,2753.55,,,2753.55,Other,150% of Medicare + 9.63% HCRA Surcharge,1674.45,45,,1674.45,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3648,,,3648,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3283,,,3283,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3101,,,3101,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",1841.9,,,1841.9,Other,110% of Medicare,2530.28,,,2530.28,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",786.95,,,786.95,Other,186% of Medicaid,2976.8,,,2976.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2976.8,,,2976.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2976.8,,,2976.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2604.7,70,,2604.7,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",4055,,,4055,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3649,,,3649,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4055,,,4055,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3448,,,3448,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",423.09,,,423.09,Other,100% of Medicaid,423.09,,,423.09,Other,100% of Medicaid,423.09,,,423.09,Other,100% of Medicaid,423.09,,,423.09,Other,100% of Medicaid,951.96,,,951.96,Other,225% of Medicaid,647.33,,,647.33,Other,153% of Medicaid,951.96,,,951.96,Other,225% of Medicaid,592.33,,,592.33,Other,140% of Medicaid,951.96,,,951.96,Other,225% of Medicaid,1100.04,,,1100.04,Other,260% of Medicaid,1370.82,,,1370.82,Other,324% of Medicaid,909.65,,,909.65,Other,215% of Medicaid,909.65,,,909.65,Other,215% of Medicaid,528.86,,,528.86,Other,125% of Medicaid,423.09,7216,
INTRO CATH DIALYSIS CIRCUIT,36902,CPT,,47036902,CDM,360,RC,,,both,,,26229,19409.53,,,19409.53,Other,150% of Medicare + 9.63% HCRA Surcharge,11803.05,45,,11803.05,percent of total billed charges,Critical Access Hospital RCC factor,5954,,,5954,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",5359,,,5359,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",6807,,,6807,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",6126,,,6126,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",5786,,,5786,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",12983.36,,,12983.36,Other,110% of Medicare,6152,,,6152,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",3853.44,,,3853.44,Other,186% of Medicaid,7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",20983.2,,,20983.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",18360.3,70,,18360.3,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",6331,,,6331,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",5698,,,5698,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",6331,,,6331,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",5381,,,5381,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2071.74,,,2071.74,Other,100% of Medicaid,2071.74,,,2071.74,Other,100% of Medicaid,2071.74,,,2071.74,Other,100% of Medicaid,2071.74,,,2071.74,Other,100% of Medicaid,4661.42,,,4661.42,Other,225% of Medicaid,3169.77,,,3169.77,Other,153% of Medicaid,4661.42,,,4661.42,Other,225% of Medicaid,2900.44,,,2900.44,Other,140% of Medicaid,4661.42,,,4661.42,Other,225% of Medicaid,5386.53,,,5386.53,Other,260% of Medicaid,6712.45,,,6712.45,Other,324% of Medicaid,4454.25,,,4454.25,Other,215% of Medicaid,4454.25,,,4454.25,Other,215% of Medicaid,2589.68,,,2589.68,Other,125% of Medicaid,2071.74,20983.2,
INTRO CATH DIALYSIS CIRCUIT,36903,CPT,,47036903,CDM,360,RC,,,both,,,53013,39229.75,,,39229.75,Other,150% of Medicare + 9.63% HCRA Surcharge,23855.85,45,,23855.85,percent of total billed charges,Critical Access Hospital RCC factor,5954,,,5954,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",5359,,,5359,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",7978,,,7978,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",7180,,,7180,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",6781,,,6781,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",26241.44,,,26241.44,Other,110% of Medicare,6152,,,6152,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",4605.54,,,4605.54,Other,186% of Medicaid,7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",42410.4,,,42410.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",37109.1,70,,37109.1,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",6956,,,6956,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",6261,,,6261,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",6956,,,6956,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",5913,,,5913,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2476.1,,,2476.1,Other,100% of Medicaid,2476.1,,,2476.1,Other,100% of Medicaid,2476.1,,,2476.1,Other,100% of Medicaid,2476.1,,,2476.1,Other,100% of Medicaid,5571.22,,,5571.22,Other,225% of Medicaid,3788.43,,,3788.43,Other,153% of Medicaid,5571.22,,,5571.22,Other,225% of Medicaid,3466.54,,,3466.54,Other,140% of Medicaid,5571.22,,,5571.22,Other,225% of Medicaid,6437.85,,,6437.85,Other,260% of Medicaid,8022.56,,,8022.56,Other,324% of Medicaid,5323.61,,,5323.61,Other,215% of Medicaid,5323.61,,,5323.61,Other,215% of Medicaid,3095.12,,,3095.12,Other,125% of Medicaid,2476.1,42410.4,
THRMBC/NFS DIALYSIS CIRCUIT,36904,CPT,,47036904,CDM,360,RC,,,both,,,24513,18139.68,,,18139.68,Other,150% of Medicare + 9.63% HCRA Surcharge,11030.85,45,,11030.85,percent of total billed charges,Critical Access Hospital RCC factor,4827,,,4827,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4344,,,4344,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",6807,,,6807,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",6126,,,6126,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",5786,,,5786,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",12133.94,,,12133.94,Other,110% of Medicare,6152,,,6152,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",3853.44,,,3853.44,Other,186% of Medicaid,7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",19610.4,,,19610.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",17159.1,70,,17159.1,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",6331,,,6331,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",5698,,,5698,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",6331,,,6331,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",5381,,,5381,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2071.74,,,2071.74,Other,100% of Medicaid,2071.74,,,2071.74,Other,100% of Medicaid,2071.74,,,2071.74,Other,100% of Medicaid,2071.74,,,2071.74,Other,100% of Medicaid,4661.42,,,4661.42,Other,225% of Medicaid,3169.77,,,3169.77,Other,153% of Medicaid,4661.42,,,4661.42,Other,225% of Medicaid,2900.44,,,2900.44,Other,140% of Medicaid,4661.42,,,4661.42,Other,225% of Medicaid,5386.53,,,5386.53,Other,260% of Medicaid,6712.45,,,6712.45,Other,324% of Medicaid,4454.25,,,4454.25,Other,215% of Medicaid,4454.25,,,4454.25,Other,215% of Medicaid,2589.68,,,2589.68,Other,125% of Medicaid,2071.74,19610.4,
THRMBC/NFS DIALYSIS CIRCUIT,36905,CPT,,47036905,CDM,360,RC,,,both,,,48636,35990.76,,,35990.76,Other,150% of Medicare + 9.63% HCRA Surcharge,21886.2,45,,21886.2,percent of total billed charges,Critical Access Hospital RCC factor,5954,,,5954,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",5359,,,5359,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",7978,,,7978,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",7180,,,7180,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",6781,,,6781,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",24074.82,,,24074.82,Other,110% of Medicare,6152,,,6152,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",4605.53,,,4605.53,Other,186% of Medicaid,7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",38908.8,,,38908.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",34045.2,70,,34045.2,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",6956,,,6956,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",6261,,,6261,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",6956,,,6956,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",5913,,,5913,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2476.09,,,2476.09,Other,100% of Medicaid,2476.09,,,2476.09,Other,100% of Medicaid,2476.09,,,2476.09,Other,100% of Medicaid,2476.09,,,2476.09,Other,100% of Medicaid,5571.21,,,5571.21,Other,225% of Medicaid,3788.42,,,3788.42,Other,153% of Medicaid,5571.21,,,5571.21,Other,225% of Medicaid,3466.53,,,3466.53,Other,140% of Medicaid,5571.21,,,5571.21,Other,225% of Medicaid,6437.84,,,6437.84,Other,260% of Medicaid,8022.54,,,8022.54,Other,324% of Medicaid,5323.6,,,5323.6,Other,215% of Medicaid,5323.6,,,5323.6,Other,215% of Medicaid,3095.12,,,3095.12,Other,125% of Medicaid,2476.09,38908.8,
THRMBC/NFS DIALYSIS CIRCUIT,36906,CPT,,47036906,CDM,360,RC,,,both,,,80352,59460.68,,,59460.68,Other,150% of Medicare + 9.63% HCRA Surcharge,36158.4,45,,36158.4,percent of total billed charges,Critical Access Hospital RCC factor,5954,,,5954,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",5359,,,5359,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",7978,,,7978,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",7180,,,7180,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",6781,,,6781,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",39774.24,,,39774.24,Other,110% of Medicare,6152,,,6152,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",4605.54,,,4605.54,Other,186% of Medicaid,7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",64281.6,,,64281.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",56246.4,70,,56246.4,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",8589,,,8589,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",7730,,,7730,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",8589,,,8589,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",7301,,,7301,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2476.1,,,2476.1,Other,100% of Medicaid,2476.1,,,2476.1,Other,100% of Medicaid,2476.1,,,2476.1,Other,100% of Medicaid,2476.1,,,2476.1,Other,100% of Medicaid,5571.22,,,5571.22,Other,225% of Medicaid,3788.43,,,3788.43,Other,153% of Medicaid,5571.22,,,5571.22,Other,225% of Medicaid,3466.54,,,3466.54,Other,140% of Medicaid,5571.22,,,5571.22,Other,225% of Medicaid,6437.85,,,6437.85,Other,260% of Medicaid,8022.56,,,8022.56,Other,324% of Medicaid,5323.61,,,5323.61,Other,215% of Medicaid,5323.61,,,5323.61,Other,215% of Medicaid,3095.12,,,3095.12,Other,125% of Medicaid,2476.1,64281.6,
BALO ANGIOP CTR DIALYSIS SEG,36907,CPT,,47036907,CDM,360,RC,,,both,,,700,518,,,518,Other,150% of Medicare + 9.63% HCRA Surcharge,315,45,,315,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",5738,,,5738,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",5164,,,5164,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4877,,,4877,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",346.5,,,346.5,Other,110% of Medicare,476,,,476,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",4605.53,,,4605.53,Other,186% of Medicaid,560,,,560,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",560,,,560,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",560,,,560,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",490,70,,490,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2476.09,,,2476.09,Other,100% of Medicaid,2476.09,,,2476.09,Other,100% of Medicaid,2476.09,,,2476.09,Other,100% of Medicaid,2476.09,,,2476.09,Other,100% of Medicaid,5571.21,,,5571.21,Other,225% of Medicaid,3788.42,,,3788.42,Other,153% of Medicaid,5571.21,,,5571.21,Other,225% of Medicaid,3466.53,,,3466.53,Other,140% of Medicaid,5571.21,,,5571.21,Other,225% of Medicaid,6437.84,,,6437.84,Other,260% of Medicaid,8022.54,,,8022.54,Other,324% of Medicaid,5323.6,,,5323.6,Other,215% of Medicaid,5323.6,,,5323.6,Other,215% of Medicaid,3095.12,,,3095.12,Other,125% of Medicaid,315,8022.54,
STENT PLMT CTR DIALYSIS SEG,36908,CPT,,47036908,CDM,360,RC,,,both,,,900,666,,,666,Other,150% of Medicare + 9.63% HCRA Surcharge,405,45,,405,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4970,,,4970,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4473,,,4473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4225,,,4225,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",445.5,,,445.5,Other,110% of Medicare,612,,,612,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",4605.53,,,4605.53,Other,186% of Medicaid,720,,,720,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",720,,,720,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",720,,,720,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",630,70,,630,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2476.09,,,2476.09,Other,100% of Medicaid,2476.09,,,2476.09,Other,100% of Medicaid,2476.09,,,2476.09,Other,100% of Medicaid,2476.09,,,2476.09,Other,100% of Medicaid,5571.21,,,5571.21,Other,225% of Medicaid,3788.42,,,3788.42,Other,153% of Medicaid,5571.21,,,5571.21,Other,225% of Medicaid,3466.53,,,3466.53,Other,140% of Medicaid,5571.21,,,5571.21,Other,225% of Medicaid,6437.84,,,6437.84,Other,260% of Medicaid,8022.54,,,8022.54,Other,324% of Medicaid,5323.6,,,5323.6,Other,215% of Medicaid,5323.6,,,5323.6,Other,215% of Medicaid,3095.12,,,3095.12,Other,125% of Medicaid,405,8022.54,
DIALYSIS CIRCUIT EMBOLJ,36909,CPT,,47036909,CDM,360,RC,,,both,,,998,738.52,,,738.52,Other,150% of Medicare + 9.63% HCRA Surcharge,449.1,45,,449.1,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4476,,,4476,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4028,,,4028,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3805,,,3805,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",494.01,,,494.01,Other,110% of Medicare,678.64,,,678.64,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",4605.54,,,4605.54,Other,186% of Medicaid,798.4,,,798.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",798.4,,,798.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",798.4,,,798.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",698.6,70,,698.6,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2476.1,,,2476.1,Other,100% of Medicaid,2476.1,,,2476.1,Other,100% of Medicaid,2476.1,,,2476.1,Other,100% of Medicaid,2476.1,,,2476.1,Other,100% of Medicaid,5571.22,,,5571.22,Other,225% of Medicaid,3788.43,,,3788.43,Other,153% of Medicaid,5571.22,,,5571.22,Other,225% of Medicaid,3466.54,,,3466.54,Other,140% of Medicaid,5571.22,,,5571.22,Other,225% of Medicaid,6437.85,,,6437.85,Other,260% of Medicaid,8022.56,,,8022.56,Other,324% of Medicaid,5323.61,,,5323.61,Other,215% of Medicaid,5323.61,,,5323.61,Other,215% of Medicaid,3095.12,,,3095.12,Other,125% of Medicaid,449.1,8022.56,
PRIM ART MECH THROMBECTOMY,37184,CPT,,47037184,CDM,360,RC,,,both,,,23894,17681.62,,,17681.62,Other,150% of Medicare + 9.63% HCRA Surcharge,10752.3,45,,10752.3,percent of total billed charges,Critical Access Hospital RCC factor,7938,,,7938,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",7144,,,7144,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",6807,,,6807,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",6126,,,6126,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",5786,,,5786,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",11827.53,,,11827.53,Other,110% of Medicare,6152,,,6152,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",4605.53,,,4605.53,Other,186% of Medicaid,7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",19115.2,,,19115.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",16725.8,70,,16725.8,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",6331,,,6331,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",5698,,,5698,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",6331,,,6331,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",5381,,,5381,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2476.09,,,2476.09,Other,100% of Medicaid,2476.09,,,2476.09,Other,100% of Medicaid,2476.09,,,2476.09,Other,100% of Medicaid,2476.09,,,2476.09,Other,100% of Medicaid,5571.21,,,5571.21,Other,225% of Medicaid,3788.42,,,3788.42,Other,153% of Medicaid,5571.21,,,5571.21,Other,225% of Medicaid,3466.53,,,3466.53,Other,140% of Medicaid,5571.21,,,5571.21,Other,225% of Medicaid,6437.84,,,6437.84,Other,260% of Medicaid,8022.54,,,8022.54,Other,324% of Medicaid,5323.6,,,5323.6,Other,215% of Medicaid,5323.6,,,5323.6,Other,215% of Medicaid,3095.12,,,3095.12,Other,125% of Medicaid,2476.09,19115.2,
PRIM ART M-THROMBECT ADD-ON,37185,CPT,,47037185,CDM,360,RC,,,both,,,12221,9043.57,,,9043.57,Other,150% of Medicare + 9.63% HCRA Surcharge,5499.45,45,,5499.45,percent of total billed charges,Critical Access Hospital RCC factor,2480,,,2480,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2232,,,2232,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4476,,,4476,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4028,,,4028,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3805,,,3805,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",6049.4,,,6049.4,Other,110% of Medicare,8310.28,,,8310.28,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",4605.53,,,4605.53,Other,186% of Medicaid,9776.8,,,9776.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9776.8,,,9776.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9776.8,,,9776.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",8554.7,70,,8554.7,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2476.09,,,2476.09,Other,100% of Medicaid,2476.09,,,2476.09,Other,100% of Medicaid,2476.09,,,2476.09,Other,100% of Medicaid,2476.09,,,2476.09,Other,100% of Medicaid,5571.21,,,5571.21,Other,225% of Medicaid,3788.42,,,3788.42,Other,153% of Medicaid,5571.21,,,5571.21,Other,225% of Medicaid,3466.53,,,3466.53,Other,140% of Medicaid,5571.21,,,5571.21,Other,225% of Medicaid,6437.84,,,6437.84,Other,260% of Medicaid,8022.54,,,8022.54,Other,324% of Medicaid,5323.6,,,5323.6,Other,215% of Medicaid,5323.6,,,5323.6,Other,215% of Medicaid,3095.12,,,3095.12,Other,125% of Medicaid,2232,9776.8,
SEC ART M-THROMBECT ADD-ON,37186,CPT,,47037186,CDM,360,RC,,,both,,,12092,8948.11,,,8948.11,Other,150% of Medicare + 9.63% HCRA Surcharge,5441.4,45,,5441.4,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4476,,,4476,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4028,,,4028,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3805,,,3805,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",5985.54,,,5985.54,Other,110% of Medicare,8222.56,,,8222.56,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",4605.54,,,4605.54,Other,186% of Medicaid,9673.6,,,9673.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9673.6,,,9673.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9673.6,,,9673.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",8464.4,70,,8464.4,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2476.1,,,2476.1,Other,100% of Medicaid,2476.1,,,2476.1,Other,100% of Medicaid,2476.1,,,2476.1,Other,100% of Medicaid,2476.1,,,2476.1,Other,100% of Medicaid,5571.22,,,5571.22,Other,225% of Medicaid,3788.43,,,3788.43,Other,153% of Medicaid,5571.22,,,5571.22,Other,225% of Medicaid,3466.54,,,3466.54,Other,140% of Medicaid,5571.22,,,5571.22,Other,225% of Medicaid,6437.85,,,6437.85,Other,260% of Medicaid,8022.56,,,8022.56,Other,324% of Medicaid,5323.61,,,5323.61,Other,215% of Medicaid,5323.61,,,5323.61,Other,215% of Medicaid,3095.12,,,3095.12,Other,125% of Medicaid,2053,9673.6,
VENOUS MECH THROMBECTOMY,37187,CPT,,47037187,CDM,360,RC,,,both,,,23894,17681.62,,,17681.62,Other,150% of Medicare + 9.63% HCRA Surcharge,10752.3,45,,10752.3,percent of total billed charges,Critical Access Hospital RCC factor,7938,,,7938,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",7144,,,7144,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",6807,,,6807,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",6126,,,6126,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",5786,,,5786,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",11827.53,,,11827.53,Other,110% of Medicare,6152,,,6152,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",3853.44,,,3853.44,Other,186% of Medicaid,7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",19115.2,,,19115.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",16725.8,70,,16725.8,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",6331,,,6331,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",5698,,,5698,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",6331,,,6331,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",5381,,,5381,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2071.74,,,2071.74,Other,100% of Medicaid,2071.74,,,2071.74,Other,100% of Medicaid,2071.74,,,2071.74,Other,100% of Medicaid,2071.74,,,2071.74,Other,100% of Medicaid,4661.42,,,4661.42,Other,225% of Medicaid,3169.77,,,3169.77,Other,153% of Medicaid,4661.42,,,4661.42,Other,225% of Medicaid,2900.44,,,2900.44,Other,140% of Medicaid,4661.42,,,4661.42,Other,225% of Medicaid,5386.53,,,5386.53,Other,260% of Medicaid,6712.45,,,6712.45,Other,324% of Medicaid,4454.25,,,4454.25,Other,215% of Medicaid,4454.25,,,4454.25,Other,215% of Medicaid,2589.68,,,2589.68,Other,125% of Medicaid,2071.74,19115.2,
VENOUS M-THROMBECTOMY ADD-ON,37188,CPT,,47037188,CDM,360,RC,,,both,,,12221,9043.57,,,9043.57,Other,150% of Medicare + 9.63% HCRA Surcharge,5499.45,45,,5499.45,percent of total billed charges,Critical Access Hospital RCC factor,7938,,,7938,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",7144,,,7144,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4476,,,4476,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4028,,,4028,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3805,,,3805,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",6049.4,,,6049.4,Other,110% of Medicare,6152,,,6152,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",3853.44,,,3853.44,Other,186% of Medicaid,7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9776.8,,,9776.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",8554.7,70,,8554.7,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",4913,,,4913,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4422,,,4422,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4913,,,4913,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4176,,,4176,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2071.74,,,2071.74,Other,100% of Medicaid,2071.74,,,2071.74,Other,100% of Medicaid,2071.74,,,2071.74,Other,100% of Medicaid,2071.74,,,2071.74,Other,100% of Medicaid,4661.42,,,4661.42,Other,225% of Medicaid,3169.77,,,3169.77,Other,153% of Medicaid,4661.42,,,4661.42,Other,225% of Medicaid,2900.44,,,2900.44,Other,140% of Medicaid,4661.42,,,4661.42,Other,225% of Medicaid,5386.53,,,5386.53,Other,260% of Medicaid,6712.45,,,6712.45,Other,324% of Medicaid,4454.25,,,4454.25,Other,215% of Medicaid,4454.25,,,4454.25,Other,215% of Medicaid,2589.68,,,2589.68,Other,125% of Medicaid,2071.74,9776.8,
INS ENDOVAS VENA CAVA FILTR,37191,CPT,,47037191,CDM,360,RC,,,both,,,15182,11234.72,,,11234.72,Other,150% of Medicare + 9.63% HCRA Surcharge,6831.9,45,,6831.9,percent of total billed charges,Critical Access Hospital RCC factor,3473,,,3473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3126,,,3126,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4970,,,4970,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4473,,,4473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4225,,,4225,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",7515.09,,,7515.09,Other,110% of Medicare,6152,,,6152,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",3853.44,,,3853.44,Other,186% of Medicaid,7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",12145.6,,,12145.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",10627.4,70,,10627.4,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",6331,,,6331,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",5698,,,5698,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",6331,,,6331,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",5381,,,5381,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2071.74,,,2071.74,Other,100% of Medicaid,2071.74,,,2071.74,Other,100% of Medicaid,2071.74,,,2071.74,Other,100% of Medicaid,2071.74,,,2071.74,Other,100% of Medicaid,4661.42,,,4661.42,Other,225% of Medicaid,3169.77,,,3169.77,Other,153% of Medicaid,4661.42,,,4661.42,Other,225% of Medicaid,2900.44,,,2900.44,Other,140% of Medicaid,4661.42,,,4661.42,Other,225% of Medicaid,5386.53,,,5386.53,Other,260% of Medicaid,6712.45,,,6712.45,Other,324% of Medicaid,4454.25,,,4454.25,Other,215% of Medicaid,4454.25,,,4454.25,Other,215% of Medicaid,2589.68,,,2589.68,Other,125% of Medicaid,2071.74,12145.6,
REDO ENDOVAS VENA CAVA FILTR,37192,CPT,,47037192,CDM,360,RC,,,both,,,8937,6613.4,,,6613.4,Other,150% of Medicare + 9.63% HCRA Surcharge,4021.65,45,,4021.65,percent of total billed charges,Critical Access Hospital RCC factor,3473,,,3473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3126,,,3126,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4476,,,4476,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4028,,,4028,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3805,,,3805,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4423.82,,,4423.82,Other,110% of Medicare,6152,,,6152,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",3853.44,,,3853.44,Other,186% of Medicaid,7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7149.6,,,7149.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",6255.9,70,,6255.9,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",4913,,,4913,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4422,,,4422,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4913,,,4913,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4176,,,4176,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2071.74,,,2071.74,Other,100% of Medicaid,2071.74,,,2071.74,Other,100% of Medicaid,2071.74,,,2071.74,Other,100% of Medicaid,2071.74,,,2071.74,Other,100% of Medicaid,4661.42,,,4661.42,Other,225% of Medicaid,3169.77,,,3169.77,Other,153% of Medicaid,4661.42,,,4661.42,Other,225% of Medicaid,2900.44,,,2900.44,Other,140% of Medicaid,4661.42,,,4661.42,Other,225% of Medicaid,5386.53,,,5386.53,Other,260% of Medicaid,6712.45,,,6712.45,Other,324% of Medicaid,4454.25,,,4454.25,Other,215% of Medicaid,4454.25,,,4454.25,Other,215% of Medicaid,2589.68,,,2589.68,Other,125% of Medicaid,2071.74,9473,
REM ENDOVAS VENA CAVA FILTER,37193,CPT,,47037193,CDM,360,RC,,,both,,,9563,7076.64,,,7076.64,Other,150% of Medicare + 9.63% HCRA Surcharge,4303.35,45,,4303.35,percent of total billed charges,Critical Access Hospital RCC factor,3473,,,3473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3126,,,3126,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4476,,,4476,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4028,,,4028,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3805,,,3805,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4733.69,,,4733.69,Other,110% of Medicare,6152,,,6152,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",3853.44,,,3853.44,Other,186% of Medicaid,7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7650.4,,,7650.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",6694.1,70,,6694.1,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",4913,,,4913,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4422,,,4422,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4913,,,4913,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4176,,,4176,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2071.74,,,2071.74,Other,100% of Medicaid,2071.74,,,2071.74,Other,100% of Medicaid,2071.74,,,2071.74,Other,100% of Medicaid,2071.74,,,2071.74,Other,100% of Medicaid,4661.42,,,4661.42,Other,225% of Medicaid,3169.77,,,3169.77,Other,153% of Medicaid,4661.42,,,4661.42,Other,225% of Medicaid,2900.44,,,2900.44,Other,140% of Medicaid,4661.42,,,4661.42,Other,225% of Medicaid,5386.53,,,5386.53,Other,260% of Medicaid,6712.45,,,6712.45,Other,324% of Medicaid,4454.25,,,4454.25,Other,215% of Medicaid,4454.25,,,4454.25,Other,215% of Medicaid,2589.68,,,2589.68,Other,125% of Medicaid,2071.74,9473,
REMOVE INTRAVAS FOREIGN BODY,37197,CPT,,47037197,CDM,360,RC,,,both,,,10036,7426.67,,,7426.67,Other,150% of Medicare + 9.63% HCRA Surcharge,4516.2,45,,4516.2,percent of total billed charges,Critical Access Hospital RCC factor,3473,,,3473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3126,,,3126,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4476,,,4476,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4028,,,4028,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3805,,,3805,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4967.82,,,4967.82,Other,110% of Medicare,6152,,,6152,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",3853.44,,,3853.44,Other,186% of Medicaid,7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",8028.8,,,8028.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7025.2,70,,7025.2,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",4913,,,4913,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4422,,,4422,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4913,,,4913,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4176,,,4176,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2071.74,,,2071.74,Other,100% of Medicaid,2071.74,,,2071.74,Other,100% of Medicaid,2071.74,,,2071.74,Other,100% of Medicaid,2071.74,,,2071.74,Other,100% of Medicaid,4661.42,,,4661.42,Other,225% of Medicaid,3169.77,,,3169.77,Other,153% of Medicaid,4661.42,,,4661.42,Other,225% of Medicaid,2900.44,,,2900.44,Other,140% of Medicaid,4661.42,,,4661.42,Other,225% of Medicaid,5386.53,,,5386.53,Other,260% of Medicaid,6712.45,,,6712.45,Other,324% of Medicaid,4454.25,,,4454.25,Other,215% of Medicaid,4454.25,,,4454.25,Other,215% of Medicaid,2589.68,,,2589.68,Other,125% of Medicaid,2071.74,9473,
THROMBOLYTIC ART THERAPY,37211,CPT,,47037211,CDM,360,RC,,,both,,,11570,8561.83,,,8561.83,Other,150% of Medicare + 9.63% HCRA Surcharge,5206.5,45,,5206.5,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4970,,,4970,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4473,,,4473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4225,,,4225,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",5727.15,,,5727.15,Other,110% of Medicare,7867.6,,,7867.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",3853.44,,,3853.44,Other,186% of Medicaid,9256,,,9256,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9256,,,9256,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9256,,,9256,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",8099,70,,8099,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",6331,,,6331,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",5698,,,5698,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",6331,,,6331,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",5381,,,5381,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2071.74,,,2071.74,Other,100% of Medicaid,2071.74,,,2071.74,Other,100% of Medicaid,2071.74,,,2071.74,Other,100% of Medicaid,2071.74,,,2071.74,Other,100% of Medicaid,4661.42,,,4661.42,Other,225% of Medicaid,3169.77,,,3169.77,Other,153% of Medicaid,4661.42,,,4661.42,Other,225% of Medicaid,2900.44,,,2900.44,Other,140% of Medicaid,4661.42,,,4661.42,Other,225% of Medicaid,5386.53,,,5386.53,Other,260% of Medicaid,6712.45,,,6712.45,Other,324% of Medicaid,4454.25,,,4454.25,Other,215% of Medicaid,4454.25,,,4454.25,Other,215% of Medicaid,2589.68,,,2589.68,Other,125% of Medicaid,2053,9256,
THROMBOLYTIC VENOUS THERAPY,37212,CPT,,47037212,CDM,360,RC,,,both,,,6707,4963.2,,,4963.2,Other,150% of Medicare + 9.63% HCRA Surcharge,3018.15,45,,3018.15,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4476,,,4476,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4028,,,4028,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3805,,,3805,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3319.97,,,3319.97,Other,110% of Medicare,4560.76,,,4560.76,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",3853.44,,,3853.44,Other,186% of Medicaid,5365.6,,,5365.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",5365.6,,,5365.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",5365.6,,,5365.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",4694.9,70,,4694.9,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",4913,,,4913,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4422,,,4422,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4913,,,4913,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4176,,,4176,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2071.74,,,2071.74,Other,100% of Medicaid,2071.74,,,2071.74,Other,100% of Medicaid,2071.74,,,2071.74,Other,100% of Medicaid,2071.74,,,2071.74,Other,100% of Medicaid,4661.42,,,4661.42,Other,225% of Medicaid,3169.77,,,3169.77,Other,153% of Medicaid,4661.42,,,4661.42,Other,225% of Medicaid,2900.44,,,2900.44,Other,140% of Medicaid,4661.42,,,4661.42,Other,225% of Medicaid,5386.53,,,5386.53,Other,260% of Medicaid,6712.45,,,6712.45,Other,324% of Medicaid,4454.25,,,4454.25,Other,215% of Medicaid,4454.25,,,4454.25,Other,215% of Medicaid,2589.68,,,2589.68,Other,125% of Medicaid,2053,7216,
THROMBLYTIC ART/VEN THERAPY,37213,CPT,,47037213,CDM,360,RC,,,both,,,6913,5115.64,,,5115.64,Other,150% of Medicare + 9.63% HCRA Surcharge,3110.85,45,,3110.85,percent of total billed charges,Critical Access Hospital RCC factor,3473,,,3473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3126,,,3126,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3648,,,3648,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3283,,,3283,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3101,,,3101,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3421.94,,,3421.94,Other,110% of Medicare,6152,,,6152,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",3853.44,,,3853.44,Other,186% of Medicaid,7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",5530.4,,,5530.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",4839.1,70,,4839.1,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2071.74,,,2071.74,Other,100% of Medicaid,2071.74,,,2071.74,Other,100% of Medicaid,2071.74,,,2071.74,Other,100% of Medicaid,2071.74,,,2071.74,Other,100% of Medicaid,4661.42,,,4661.42,Other,225% of Medicaid,3169.77,,,3169.77,Other,153% of Medicaid,4661.42,,,4661.42,Other,225% of Medicaid,2900.44,,,2900.44,Other,140% of Medicaid,4661.42,,,4661.42,Other,225% of Medicaid,5386.53,,,5386.53,Other,260% of Medicaid,6712.45,,,6712.45,Other,324% of Medicaid,4454.25,,,4454.25,Other,215% of Medicaid,4454.25,,,4454.25,Other,215% of Medicaid,2589.68,,,2589.68,Other,125% of Medicaid,2071.74,9473,
CESSJ THERAPY CATH REMOVAL,37214,CPT,,47037214,CDM,360,RC,,,both,,,6913,5115.64,,,5115.64,Other,150% of Medicare + 9.63% HCRA Surcharge,3110.85,45,,3110.85,percent of total billed charges,Critical Access Hospital RCC factor,3473,,,3473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3126,,,3126,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3648,,,3648,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3283,,,3283,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3101,,,3101,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3421.94,,,3421.94,Other,110% of Medicare,6152,,,6152,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",3853.44,,,3853.44,Other,186% of Medicaid,7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",5530.4,,,5530.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",4839.1,70,,4839.1,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2071.74,,,2071.74,Other,100% of Medicaid,2071.74,,,2071.74,Other,100% of Medicaid,2071.74,,,2071.74,Other,100% of Medicaid,2071.74,,,2071.74,Other,100% of Medicaid,4661.42,,,4661.42,Other,225% of Medicaid,3169.77,,,3169.77,Other,153% of Medicaid,4661.42,,,4661.42,Other,225% of Medicaid,2900.44,,,2900.44,Other,140% of Medicaid,4661.42,,,4661.42,Other,225% of Medicaid,5386.53,,,5386.53,Other,260% of Medicaid,6712.45,,,6712.45,Other,324% of Medicaid,4454.25,,,4454.25,Other,215% of Medicaid,4454.25,,,4454.25,Other,215% of Medicaid,2589.68,,,2589.68,Other,125% of Medicaid,2071.74,9473,
ILIAC REVASC,37220,CPT,,47037220,CDM,360,RC,,,both,,,18493,13684.87,,,13684.87,Other,150% of Medicare + 9.63% HCRA Surcharge,8321.85,45,,8321.85,percent of total billed charges,Critical Access Hospital RCC factor,3969,,,3969,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3572,,,3572,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",6807,,,6807,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",6126,,,6126,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",5786,,,5786,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",9154.04,,,9154.04,Other,110% of Medicare,6152,,,6152,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",4605.53,,,4605.53,Other,186% of Medicaid,7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",14794.4,,,14794.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",12945.1,70,,12945.1,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",6331,,,6331,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",5698,,,5698,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",6331,,,6331,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",5381,,,5381,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2476.09,,,2476.09,Other,100% of Medicaid,2476.09,,,2476.09,Other,100% of Medicaid,2476.09,,,2476.09,Other,100% of Medicaid,2476.09,,,2476.09,Other,100% of Medicaid,5571.21,,,5571.21,Other,225% of Medicaid,3788.42,,,3788.42,Other,153% of Medicaid,5571.21,,,5571.21,Other,225% of Medicaid,3466.53,,,3466.53,Other,140% of Medicaid,5571.21,,,5571.21,Other,225% of Medicaid,6437.84,,,6437.84,Other,260% of Medicaid,8022.54,,,8022.54,Other,324% of Medicaid,5323.6,,,5323.6,Other,215% of Medicaid,5323.6,,,5323.6,Other,215% of Medicaid,3095.12,,,3095.12,Other,125% of Medicaid,2476.09,14794.4,
ILIAC REVASC STENT,37221,CPT,,47037221,CDM,360,RC,,,both,,,39788,29443.22,,,29443.22,Other,150% of Medicare + 9.63% HCRA Surcharge,17904.6,45,,17904.6,percent of total billed charges,Critical Access Hospital RCC factor,3969,,,3969,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3572,,,3572,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",7978,,,7978,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",7180,,,7180,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",6781,,,6781,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",19695.06,,,19695.06,Other,110% of Medicare,6152,,,6152,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",4605.54,,,4605.54,Other,186% of Medicaid,7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",31830.4,,,31830.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",27851.6,70,,27851.6,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",6956,,,6956,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",6261,,,6261,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",6956,,,6956,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",5913,,,5913,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2476.1,,,2476.1,Other,100% of Medicaid,2476.1,,,2476.1,Other,100% of Medicaid,2476.1,,,2476.1,Other,100% of Medicaid,2476.1,,,2476.1,Other,100% of Medicaid,5571.22,,,5571.22,Other,225% of Medicaid,3788.43,,,3788.43,Other,153% of Medicaid,5571.22,,,5571.22,Other,225% of Medicaid,3466.54,,,3466.54,Other,140% of Medicaid,5571.22,,,5571.22,Other,225% of Medicaid,6437.85,,,6437.85,Other,260% of Medicaid,8022.56,,,8022.56,Other,324% of Medicaid,5323.61,,,5323.61,Other,215% of Medicaid,5323.61,,,5323.61,Other,215% of Medicaid,3095.12,,,3095.12,Other,125% of Medicaid,2476.1,31830.4,
ILIAC REVASC ADD-ON,37222,CPT,,47037222,CDM,360,RC,,,both,,,17283,12789.46,,,12789.46,Other,150% of Medicare + 9.63% HCRA Surcharge,7777.35,45,,7777.35,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",7978,,,7978,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",7180,,,7180,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",6781,,,6781,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",8555.09,,,8555.09,Other,110% of Medicare,11752.44,,,11752.44,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",4605.54,,,4605.54,Other,186% of Medicaid,13826.4,,,13826.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",13826.4,,,13826.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",13826.4,,,13826.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",12098.1,70,,12098.1,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",6331,,,6331,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",5698,,,5698,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",6331,,,6331,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",5381,,,5381,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2476.1,,,2476.1,Other,100% of Medicaid,2476.1,,,2476.1,Other,100% of Medicaid,2476.1,,,2476.1,Other,100% of Medicaid,2476.1,,,2476.1,Other,100% of Medicaid,5571.22,,,5571.22,Other,225% of Medicaid,3788.43,,,3788.43,Other,153% of Medicaid,5571.22,,,5571.22,Other,225% of Medicaid,3466.54,,,3466.54,Other,140% of Medicaid,5571.22,,,5571.22,Other,225% of Medicaid,6437.85,,,6437.85,Other,260% of Medicaid,8022.56,,,8022.56,Other,324% of Medicaid,5323.61,,,5323.61,Other,215% of Medicaid,5323.61,,,5323.61,Other,215% of Medicaid,3095.12,,,3095.12,Other,125% of Medicaid,2053,13826.4,
ILIAC REVASC W/STENT ADD-ON,37223,CPT,,47037223,CDM,360,RC,,,both,,,18493,13684.87,,,13684.87,Other,150% of Medicare + 9.63% HCRA Surcharge,8321.85,45,,8321.85,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",7978,,,7978,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",7180,,,7180,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",6781,,,6781,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",9154.04,,,9154.04,Other,110% of Medicare,12575.24,,,12575.24,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",4605.54,,,4605.54,Other,186% of Medicaid,14794.4,,,14794.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",14794.4,,,14794.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",14794.4,,,14794.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",12945.1,70,,12945.1,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",6331,,,6331,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",5698,,,5698,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",6331,,,6331,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",5381,,,5381,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2476.1,,,2476.1,Other,100% of Medicaid,2476.1,,,2476.1,Other,100% of Medicaid,2476.1,,,2476.1,Other,100% of Medicaid,2476.1,,,2476.1,Other,100% of Medicaid,5571.22,,,5571.22,Other,225% of Medicaid,3788.43,,,3788.43,Other,153% of Medicaid,5571.22,,,5571.22,Other,225% of Medicaid,3466.54,,,3466.54,Other,140% of Medicaid,5571.22,,,5571.22,Other,225% of Medicaid,6437.85,,,6437.85,Other,260% of Medicaid,8022.56,,,8022.56,Other,324% of Medicaid,5323.61,,,5323.61,Other,215% of Medicaid,5323.61,,,5323.61,Other,215% of Medicaid,3095.12,,,3095.12,Other,125% of Medicaid,2053,14794.4,
PTA FEMORAL POP ART EA VESSEL,37224,CPT,,47037224,CDM,360,RC,,,both,,,18493,13684.87,,,13684.87,Other,150% of Medicare + 9.63% HCRA Surcharge,8321.85,45,,8321.85,percent of total billed charges,Critical Access Hospital RCC factor,3969,,,3969,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3572,,,3572,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",6807,,,6807,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",6126,,,6126,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",5786,,,5786,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",9154.04,,,9154.04,Other,110% of Medicare,6152,,,6152,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",4605.53,,,4605.53,Other,186% of Medicaid,7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",14794.4,,,14794.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",12945.1,70,,12945.1,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",6331,,,6331,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",5698,,,5698,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",6331,,,6331,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",5381,,,5381,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2476.09,,,2476.09,Other,100% of Medicaid,2476.09,,,2476.09,Other,100% of Medicaid,2476.09,,,2476.09,Other,100% of Medicaid,2476.09,,,2476.09,Other,100% of Medicaid,5571.21,,,5571.21,Other,225% of Medicaid,3788.42,,,3788.42,Other,153% of Medicaid,5571.21,,,5571.21,Other,225% of Medicaid,3466.53,,,3466.53,Other,140% of Medicaid,5571.21,,,5571.21,Other,225% of Medicaid,6437.84,,,6437.84,Other,260% of Medicaid,8022.54,,,8022.54,Other,324% of Medicaid,5323.6,,,5323.6,Other,215% of Medicaid,5323.6,,,5323.6,Other,215% of Medicaid,3095.12,,,3095.12,Other,125% of Medicaid,2476.09,14794.4,
FEM/POPL REVAS W/ATHER,37225,CPT,,47037225,CDM,360,RC,,,both,,,39788,29443.22,,,29443.22,Other,150% of Medicare + 9.63% HCRA Surcharge,17904.6,45,,17904.6,percent of total billed charges,Critical Access Hospital RCC factor,3969,,,3969,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3572,,,3572,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",7978,,,7978,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",7180,,,7180,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",6781,,,6781,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",19695.06,,,19695.06,Other,110% of Medicare,6152,,,6152,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",4605.54,,,4605.54,Other,186% of Medicaid,7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",31830.4,,,31830.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",27851.6,70,,27851.6,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",6956,,,6956,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",6261,,,6261,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",6956,,,6956,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",5913,,,5913,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2476.1,,,2476.1,Other,100% of Medicaid,2476.1,,,2476.1,Other,100% of Medicaid,2476.1,,,2476.1,Other,100% of Medicaid,2476.1,,,2476.1,Other,100% of Medicaid,5571.22,,,5571.22,Other,225% of Medicaid,3788.43,,,3788.43,Other,153% of Medicaid,5571.22,,,5571.22,Other,225% of Medicaid,3466.54,,,3466.54,Other,140% of Medicaid,5571.22,,,5571.22,Other,225% of Medicaid,6437.85,,,6437.85,Other,260% of Medicaid,8022.56,,,8022.56,Other,324% of Medicaid,5323.61,,,5323.61,Other,215% of Medicaid,5323.61,,,5323.61,Other,215% of Medicaid,3095.12,,,3095.12,Other,125% of Medicaid,2476.1,31830.4,
FEM/POPL REVASC W/STENT,37226,CPT,,47037226,CDM,360,RC,,,both,,,39788,29443.22,,,29443.22,Other,150% of Medicare + 9.63% HCRA Surcharge,17904.6,45,,17904.6,percent of total billed charges,Critical Access Hospital RCC factor,3969,,,3969,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3572,,,3572,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",7978,,,7978,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",7180,,,7180,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",6781,,,6781,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",19695.06,,,19695.06,Other,110% of Medicare,6152,,,6152,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",4605.54,,,4605.54,Other,186% of Medicaid,7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",31830.4,,,31830.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",27851.6,70,,27851.6,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",6956,,,6956,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",6261,,,6261,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",6956,,,6956,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",5913,,,5913,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2476.1,,,2476.1,Other,100% of Medicaid,2476.1,,,2476.1,Other,100% of Medicaid,2476.1,,,2476.1,Other,100% of Medicaid,2476.1,,,2476.1,Other,100% of Medicaid,5571.22,,,5571.22,Other,225% of Medicaid,3788.43,,,3788.43,Other,153% of Medicaid,5571.22,,,5571.22,Other,225% of Medicaid,3466.54,,,3466.54,Other,140% of Medicaid,5571.22,,,5571.22,Other,225% of Medicaid,6437.85,,,6437.85,Other,260% of Medicaid,8022.56,,,8022.56,Other,324% of Medicaid,5323.61,,,5323.61,Other,215% of Medicaid,5323.61,,,5323.61,Other,215% of Medicaid,3095.12,,,3095.12,Other,125% of Medicaid,2476.1,31830.4,
FEM/POPL REVASC STNT & ATHER,37227,CPT,,47037227,CDM,360,RC,,,both,,,67088,49645.29,,,49645.29,Other,150% of Medicare + 9.63% HCRA Surcharge,30189.6,45,,30189.6,percent of total billed charges,Critical Access Hospital RCC factor,3969,,,3969,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3572,,,3572,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",7978,,,7978,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",7180,,,7180,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",6781,,,6781,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",33208.56,,,33208.56,Other,110% of Medicare,6152,,,6152,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",4605.54,,,4605.54,Other,186% of Medicaid,7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",53670.4,,,53670.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",46961.6,70,,46961.6,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",8589,,,8589,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",7730,,,7730,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",8589,,,8589,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",7301,,,7301,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2476.1,,,2476.1,Other,100% of Medicaid,2476.1,,,2476.1,Other,100% of Medicaid,2476.1,,,2476.1,Other,100% of Medicaid,2476.1,,,2476.1,Other,100% of Medicaid,5571.22,,,5571.22,Other,225% of Medicaid,3788.43,,,3788.43,Other,153% of Medicaid,5571.22,,,5571.22,Other,225% of Medicaid,3466.54,,,3466.54,Other,140% of Medicaid,5571.22,,,5571.22,Other,225% of Medicaid,6437.85,,,6437.85,Other,260% of Medicaid,8022.56,,,8022.56,Other,324% of Medicaid,5323.61,,,5323.61,Other,215% of Medicaid,5323.61,,,5323.61,Other,215% of Medicaid,3095.12,,,3095.12,Other,125% of Medicaid,2476.1,53670.4,
TIB/PER REVASC W/TLA,37228,CPT,,47037228,CDM,360,RC,,,both,,,23894,17681.62,,,17681.62,Other,150% of Medicare + 9.63% HCRA Surcharge,10752.3,45,,10752.3,percent of total billed charges,Critical Access Hospital RCC factor,3969,,,3969,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3572,,,3572,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",7978,,,7978,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",7180,,,7180,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",6781,,,6781,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",11827.53,,,11827.53,Other,110% of Medicare,6152,,,6152,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",4605.53,,,4605.53,Other,186% of Medicaid,7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",19115.2,,,19115.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",16725.8,70,,16725.8,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",6331,,,6331,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",5698,,,5698,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",6331,,,6331,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",5381,,,5381,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2476.09,,,2476.09,Other,100% of Medicaid,2476.09,,,2476.09,Other,100% of Medicaid,2476.09,,,2476.09,Other,100% of Medicaid,2476.09,,,2476.09,Other,100% of Medicaid,5571.21,,,5571.21,Other,225% of Medicaid,3788.42,,,3788.42,Other,153% of Medicaid,5571.21,,,5571.21,Other,225% of Medicaid,3466.53,,,3466.53,Other,140% of Medicaid,5571.21,,,5571.21,Other,225% of Medicaid,6437.84,,,6437.84,Other,260% of Medicaid,8022.54,,,8022.54,Other,324% of Medicaid,5323.6,,,5323.6,Other,215% of Medicaid,5323.6,,,5323.6,Other,215% of Medicaid,3095.12,,,3095.12,Other,125% of Medicaid,2476.09,19115.2,
TIB/PER REVASC W/ATHER,37229,CPT,,47037229,CDM,360,RC,,,both,,,39788,29443.22,,,29443.22,Other,150% of Medicare + 9.63% HCRA Surcharge,17904.6,45,,17904.6,percent of total billed charges,Critical Access Hospital RCC factor,3969,,,3969,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3572,,,3572,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",7978,,,7978,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",7180,,,7180,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",6781,,,6781,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",19695.06,,,19695.06,Other,110% of Medicare,6152,,,6152,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",4605.54,,,4605.54,Other,186% of Medicaid,7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",31830.4,,,31830.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",27851.6,70,,27851.6,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",6956,,,6956,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",6261,,,6261,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",6956,,,6956,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",5913,,,5913,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2476.1,,,2476.1,Other,100% of Medicaid,2476.1,,,2476.1,Other,100% of Medicaid,2476.1,,,2476.1,Other,100% of Medicaid,2476.1,,,2476.1,Other,100% of Medicaid,5571.22,,,5571.22,Other,225% of Medicaid,3788.43,,,3788.43,Other,153% of Medicaid,5571.22,,,5571.22,Other,225% of Medicaid,3466.54,,,3466.54,Other,140% of Medicaid,5571.22,,,5571.22,Other,225% of Medicaid,6437.85,,,6437.85,Other,260% of Medicaid,8022.56,,,8022.56,Other,324% of Medicaid,5323.61,,,5323.61,Other,215% of Medicaid,5323.61,,,5323.61,Other,215% of Medicaid,3095.12,,,3095.12,Other,125% of Medicaid,2476.1,31830.4,
TIB/PER REVASC W/STENT,37230,CPT,,47037230,CDM,360,RC,,,both,,,38665,28612.2,,,28612.2,Other,150% of Medicare + 9.63% HCRA Surcharge,17399.25,45,,17399.25,percent of total billed charges,Critical Access Hospital RCC factor,3969,,,3969,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3572,,,3572,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",7978,,,7978,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",7180,,,7180,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",6781,,,6781,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",19139.18,,,19139.18,Other,110% of Medicare,6152,,,6152,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",4605.54,,,4605.54,Other,186% of Medicaid,7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",30932,,,30932,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",27065.5,70,,27065.5,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",6956,,,6956,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",6261,,,6261,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",6956,,,6956,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",5913,,,5913,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2476.1,,,2476.1,Other,100% of Medicaid,2476.1,,,2476.1,Other,100% of Medicaid,2476.1,,,2476.1,Other,100% of Medicaid,2476.1,,,2476.1,Other,100% of Medicaid,5571.22,,,5571.22,Other,225% of Medicaid,3788.43,,,3788.43,Other,153% of Medicaid,5571.22,,,5571.22,Other,225% of Medicaid,3466.54,,,3466.54,Other,140% of Medicaid,5571.22,,,5571.22,Other,225% of Medicaid,6437.85,,,6437.85,Other,260% of Medicaid,8022.56,,,8022.56,Other,324% of Medicaid,5323.61,,,5323.61,Other,215% of Medicaid,5323.61,,,5323.61,Other,215% of Medicaid,3095.12,,,3095.12,Other,125% of Medicaid,2476.1,30932,
TIB/PER REVASC STENT & ATHER,37231,CPT,,47037231,CDM,360,RC,,,both,,,57522,42566.42,,,42566.42,Other,150% of Medicare + 9.63% HCRA Surcharge,25884.9,45,,25884.9,percent of total billed charges,Critical Access Hospital RCC factor,3969,,,3969,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3572,,,3572,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",7978,,,7978,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",7180,,,7180,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",6781,,,6781,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",28473.39,,,28473.39,Other,110% of Medicare,6152,,,6152,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",4605.54,,,4605.54,Other,186% of Medicaid,7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",46017.6,,,46017.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",40265.4,70,,40265.4,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",8589,,,8589,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",7730,,,7730,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",8589,,,8589,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",7301,,,7301,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2476.1,,,2476.1,Other,100% of Medicaid,2476.1,,,2476.1,Other,100% of Medicaid,2476.1,,,2476.1,Other,100% of Medicaid,2476.1,,,2476.1,Other,100% of Medicaid,5571.22,,,5571.22,Other,225% of Medicaid,3788.43,,,3788.43,Other,153% of Medicaid,5571.22,,,5571.22,Other,225% of Medicaid,3466.54,,,3466.54,Other,140% of Medicaid,5571.22,,,5571.22,Other,225% of Medicaid,6437.85,,,6437.85,Other,260% of Medicaid,8022.56,,,8022.56,Other,324% of Medicaid,5323.61,,,5323.61,Other,215% of Medicaid,5323.61,,,5323.61,Other,215% of Medicaid,3095.12,,,3095.12,Other,125% of Medicaid,2476.1,46017.6,
TIB/PER REVASC ADD-ON,37232,CPT,,47037232,CDM,360,RC,,,both,,,18493,13684.87,,,13684.87,Other,150% of Medicare + 9.63% HCRA Surcharge,8321.85,45,,8321.85,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",5738,,,5738,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",5164,,,5164,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4877,,,4877,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",9154.04,,,9154.04,Other,110% of Medicare,12575.24,,,12575.24,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",4605.54,,,4605.54,Other,186% of Medicaid,14794.4,,,14794.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",14794.4,,,14794.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",14794.4,,,14794.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",12945.1,70,,12945.1,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",6331,,,6331,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",5698,,,5698,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",6331,,,6331,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",5381,,,5381,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2476.1,,,2476.1,Other,100% of Medicaid,2476.1,,,2476.1,Other,100% of Medicaid,2476.1,,,2476.1,Other,100% of Medicaid,2476.1,,,2476.1,Other,100% of Medicaid,5571.22,,,5571.22,Other,225% of Medicaid,3788.43,,,3788.43,Other,153% of Medicaid,5571.22,,,5571.22,Other,225% of Medicaid,3466.54,,,3466.54,Other,140% of Medicaid,5571.22,,,5571.22,Other,225% of Medicaid,6437.85,,,6437.85,Other,260% of Medicaid,8022.56,,,8022.56,Other,324% of Medicaid,5323.61,,,5323.61,Other,215% of Medicaid,5323.61,,,5323.61,Other,215% of Medicaid,3095.12,,,3095.12,Other,125% of Medicaid,2053,14794.4,
TIB/PER REVAS W/ATHER ADD ON,37233,CPT,,47037233,CDM,360,RC,,,both,,,37185,27516.99,,,27516.99,Other,150% of Medicare + 9.63% HCRA Surcharge,16733.25,45,,16733.25,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",5738,,,5738,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",5164,,,5164,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4877,,,4877,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",18406.58,,,18406.58,Other,110% of Medicare,25285.8,,,25285.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",4605.54,,,4605.54,Other,186% of Medicaid,29748,,,29748,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",29748,,,29748,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",29748,,,29748,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",26029.5,70,,26029.5,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",6956,,,6956,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",6261,,,6261,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",6956,,,6956,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",5913,,,5913,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2476.1,,,2476.1,Other,100% of Medicaid,2476.1,,,2476.1,Other,100% of Medicaid,2476.1,,,2476.1,Other,100% of Medicaid,2476.1,,,2476.1,Other,100% of Medicaid,5571.22,,,5571.22,Other,225% of Medicaid,3788.43,,,3788.43,Other,153% of Medicaid,5571.22,,,5571.22,Other,225% of Medicaid,3466.54,,,3466.54,Other,140% of Medicaid,5571.22,,,5571.22,Other,225% of Medicaid,6437.85,,,6437.85,Other,260% of Medicaid,8022.56,,,8022.56,Other,324% of Medicaid,5323.61,,,5323.61,Other,215% of Medicaid,5323.61,,,5323.61,Other,215% of Medicaid,3095.12,,,3095.12,Other,125% of Medicaid,2053,29748,
REVSC OPN/PRQ TIB/PERO STENT,37234,CPT,,47037234,CDM,360,RC,,,both,,,15857,11734.22,,,11734.22,Other,150% of Medicare + 9.63% HCRA Surcharge,7135.65,45,,7135.65,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",5738,,,5738,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",5164,,,5164,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4877,,,4877,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",7849.22,,,7849.22,Other,110% of Medicare,10782.76,,,10782.76,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",4605.54,,,4605.54,Other,186% of Medicaid,12685.6,,,12685.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",12685.6,,,12685.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",12685.6,,,12685.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",11099.9,70,,11099.9,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",6331,,,6331,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",5698,,,5698,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",6331,,,6331,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",5381,,,5381,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2476.1,,,2476.1,Other,100% of Medicaid,2476.1,,,2476.1,Other,100% of Medicaid,2476.1,,,2476.1,Other,100% of Medicaid,2476.1,,,2476.1,Other,100% of Medicaid,5571.22,,,5571.22,Other,225% of Medicaid,3788.43,,,3788.43,Other,153% of Medicaid,5571.22,,,5571.22,Other,225% of Medicaid,3466.54,,,3466.54,Other,140% of Medicaid,5571.22,,,5571.22,Other,225% of Medicaid,6437.85,,,6437.85,Other,260% of Medicaid,8022.56,,,8022.56,Other,324% of Medicaid,5323.61,,,5323.61,Other,215% of Medicaid,5323.61,,,5323.61,Other,215% of Medicaid,3095.12,,,3095.12,Other,125% of Medicaid,2053,12685.6,
TIB/PER REVSC STNT & ATHER ADD,37235,CPT,,47037235,CDM,360,RC,,,both,,,15857,11734.22,,,11734.22,Other,150% of Medicare + 9.63% HCRA Surcharge,7135.65,45,,7135.65,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",5738,,,5738,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",5164,,,5164,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4877,,,4877,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",7849.22,,,7849.22,Other,110% of Medicare,10782.76,,,10782.76,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",4605.54,,,4605.54,Other,186% of Medicaid,12685.6,,,12685.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",12685.6,,,12685.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",12685.6,,,12685.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",11099.9,70,,11099.9,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",6331,,,6331,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",5698,,,5698,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",6331,,,6331,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",5381,,,5381,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2476.1,,,2476.1,Other,100% of Medicaid,2476.1,,,2476.1,Other,100% of Medicaid,2476.1,,,2476.1,Other,100% of Medicaid,2476.1,,,2476.1,Other,100% of Medicaid,5571.22,,,5571.22,Other,225% of Medicaid,3788.43,,,3788.43,Other,153% of Medicaid,5571.22,,,5571.22,Other,225% of Medicaid,3466.54,,,3466.54,Other,140% of Medicaid,5571.22,,,5571.22,Other,225% of Medicaid,6437.85,,,6437.85,Other,260% of Medicaid,8022.56,,,8022.56,Other,324% of Medicaid,5323.61,,,5323.61,Other,215% of Medicaid,5323.61,,,5323.61,Other,215% of Medicaid,3095.12,,,3095.12,Other,125% of Medicaid,2053,12685.6,
OPEN/PERQ PLACE STENT 1ST,37236,CPT,,47037236,CDM,360,RC,,,both,,,37733,27922.51,,,27922.51,Other,150% of Medicare + 9.63% HCRA Surcharge,16979.85,45,,16979.85,percent of total billed charges,Critical Access Hospital RCC factor,3473,,,3473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3126,,,3126,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",7978,,,7978,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",7180,,,7180,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",6781,,,6781,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",18677.84,,,18677.84,Other,110% of Medicare,6152,,,6152,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",4605.54,,,4605.54,Other,186% of Medicaid,7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",30186.4,,,30186.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",26413.1,70,,26413.1,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",6956,,,6956,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",6261,,,6261,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",6956,,,6956,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",5913,,,5913,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2476.1,,,2476.1,Other,100% of Medicaid,2476.1,,,2476.1,Other,100% of Medicaid,2476.1,,,2476.1,Other,100% of Medicaid,2476.1,,,2476.1,Other,100% of Medicaid,5571.22,,,5571.22,Other,225% of Medicaid,3788.43,,,3788.43,Other,153% of Medicaid,5571.22,,,5571.22,Other,225% of Medicaid,3466.54,,,3466.54,Other,140% of Medicaid,5571.22,,,5571.22,Other,225% of Medicaid,6437.85,,,6437.85,Other,260% of Medicaid,8022.56,,,8022.56,Other,324% of Medicaid,5323.61,,,5323.61,Other,215% of Medicaid,5323.61,,,5323.61,Other,215% of Medicaid,3095.12,,,3095.12,Other,125% of Medicaid,2476.1,30186.4,
OPEN/PERQ PLACE STENT EA ADD,37237,CPT,,47037237,CDM,360,RC,,,both,,,16742,12389.12,,,12389.12,Other,150% of Medicare + 9.63% HCRA Surcharge,7533.9,45,,7533.9,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3648,,,3648,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3283,,,3283,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3101,,,3101,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",8287.29,,,8287.29,Other,110% of Medicare,11384.56,,,11384.56,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",4605.54,,,4605.54,Other,186% of Medicaid,13393.6,,,13393.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",13393.6,,,13393.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",13393.6,,,13393.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",11719.4,70,,11719.4,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",6331,,,6331,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",5698,,,5698,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",6331,,,6331,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",5381,,,5381,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2476.1,,,2476.1,Other,100% of Medicaid,2476.1,,,2476.1,Other,100% of Medicaid,2476.1,,,2476.1,Other,100% of Medicaid,2476.1,,,2476.1,Other,100% of Medicaid,5571.22,,,5571.22,Other,225% of Medicaid,3788.43,,,3788.43,Other,153% of Medicaid,5571.22,,,5571.22,Other,225% of Medicaid,3466.54,,,3466.54,Other,140% of Medicaid,5571.22,,,5571.22,Other,225% of Medicaid,6437.85,,,6437.85,Other,260% of Medicaid,8022.56,,,8022.56,Other,324% of Medicaid,5323.61,,,5323.61,Other,215% of Medicaid,5323.61,,,5323.61,Other,215% of Medicaid,3095.12,,,3095.12,Other,125% of Medicaid,2053,13393.6,
OPEN/PERQ PLACE STENT SAME,37238,CPT,,47037238,CDM,360,RC,,,both,,,34617,25616.67,,,25616.67,Other,150% of Medicare + 9.63% HCRA Surcharge,15577.65,45,,15577.65,percent of total billed charges,Critical Access Hospital RCC factor,3473,,,3473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3126,,,3126,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",7978,,,7978,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",7180,,,7180,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",6781,,,6781,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",17135.42,,,17135.42,Other,110% of Medicare,6152,,,6152,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",4605.54,,,4605.54,Other,186% of Medicaid,7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",27693.6,,,27693.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",24231.9,70,,24231.9,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",6956,,,6956,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",6261,,,6261,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",6956,,,6956,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",5913,,,5913,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2476.1,,,2476.1,Other,100% of Medicaid,2476.1,,,2476.1,Other,100% of Medicaid,2476.1,,,2476.1,Other,100% of Medicaid,2476.1,,,2476.1,Other,100% of Medicaid,5571.22,,,5571.22,Other,225% of Medicaid,3788.43,,,3788.43,Other,153% of Medicaid,5571.22,,,5571.22,Other,225% of Medicaid,3466.54,,,3466.54,Other,140% of Medicaid,5571.22,,,5571.22,Other,225% of Medicaid,6437.85,,,6437.85,Other,260% of Medicaid,8022.56,,,8022.56,Other,324% of Medicaid,5323.61,,,5323.61,Other,215% of Medicaid,5323.61,,,5323.61,Other,215% of Medicaid,3095.12,,,3095.12,Other,125% of Medicaid,2476.1,27693.6,
OPEN/PERQ PLACE STENT EA ADD,37239,CPT,,47037239,CDM,360,RC,,,both,,,16742,12389.12,,,12389.12,Other,150% of Medicare + 9.63% HCRA Surcharge,7533.9,45,,7533.9,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3648,,,3648,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3283,,,3283,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3101,,,3101,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",8287.29,,,8287.29,Other,110% of Medicare,11384.56,,,11384.56,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",4605.54,,,4605.54,Other,186% of Medicaid,13393.6,,,13393.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",13393.6,,,13393.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",13393.6,,,13393.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",11719.4,70,,11719.4,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",6331,,,6331,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",5698,,,5698,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",6331,,,6331,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",5381,,,5381,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2476.1,,,2476.1,Other,100% of Medicaid,2476.1,,,2476.1,Other,100% of Medicaid,2476.1,,,2476.1,Other,100% of Medicaid,2476.1,,,2476.1,Other,100% of Medicaid,5571.22,,,5571.22,Other,225% of Medicaid,3788.43,,,3788.43,Other,153% of Medicaid,5571.22,,,5571.22,Other,225% of Medicaid,3466.54,,,3466.54,Other,140% of Medicaid,5571.22,,,5571.22,Other,225% of Medicaid,6437.85,,,6437.85,Other,260% of Medicaid,8022.56,,,8022.56,Other,324% of Medicaid,5323.61,,,5323.61,Other,215% of Medicaid,5323.61,,,5323.61,Other,215% of Medicaid,3095.12,,,3095.12,Other,125% of Medicaid,2053,13393.6,
VASC EMBOLIZE/OCCLUDE VENOUS,37241,CPT,,47037241,CDM,360,RC,,,both,,,35914,26576.45,,,26576.45,Other,150% of Medicare + 9.63% HCRA Surcharge,16161.3,45,,16161.3,percent of total billed charges,Critical Access Hospital RCC factor,3473,,,3473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3126,,,3126,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",7978,,,7978,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",7180,,,7180,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",6781,,,6781,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",17777.43,,,17777.43,Other,110% of Medicare,6152,,,6152,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",4605.54,,,4605.54,Other,186% of Medicaid,7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",28731.2,,,28731.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",25139.8,70,,25139.8,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",6956,,,6956,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",6261,,,6261,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",6956,,,6956,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",5913,,,5913,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2476.1,,,2476.1,Other,100% of Medicaid,2476.1,,,2476.1,Other,100% of Medicaid,2476.1,,,2476.1,Other,100% of Medicaid,2476.1,,,2476.1,Other,100% of Medicaid,5571.22,,,5571.22,Other,225% of Medicaid,3788.43,,,3788.43,Other,153% of Medicaid,5571.22,,,5571.22,Other,225% of Medicaid,3466.54,,,3466.54,Other,140% of Medicaid,5571.22,,,5571.22,Other,225% of Medicaid,6437.85,,,6437.85,Other,260% of Medicaid,8022.56,,,8022.56,Other,324% of Medicaid,5323.61,,,5323.61,Other,215% of Medicaid,5323.61,,,5323.61,Other,215% of Medicaid,3095.12,,,3095.12,Other,125% of Medicaid,2476.1,28731.2,
VASC EMBOLIZE/OCCLUDE ARTERY,37242,CPT,,47037242,CDM,360,RC,,,both,,,36585,27072.99,,,27072.99,Other,150% of Medicare + 9.63% HCRA Surcharge,16463.25,45,,16463.25,percent of total billed charges,Critical Access Hospital RCC factor,3473,,,3473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3126,,,3126,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",7978,,,7978,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",7180,,,7180,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",6781,,,6781,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",18109.58,,,18109.58,Other,110% of Medicare,6152,,,6152,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",4605.54,,,4605.54,Other,186% of Medicaid,7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",29268,,,29268,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",25609.5,70,,25609.5,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",6956,,,6956,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",6261,,,6261,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",6956,,,6956,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",5913,,,5913,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2476.1,,,2476.1,Other,100% of Medicaid,2476.1,,,2476.1,Other,100% of Medicaid,2476.1,,,2476.1,Other,100% of Medicaid,2476.1,,,2476.1,Other,100% of Medicaid,5571.22,,,5571.22,Other,225% of Medicaid,3788.43,,,3788.43,Other,153% of Medicaid,5571.22,,,5571.22,Other,225% of Medicaid,3466.54,,,3466.54,Other,140% of Medicaid,5571.22,,,5571.22,Other,225% of Medicaid,6437.85,,,6437.85,Other,260% of Medicaid,8022.56,,,8022.56,Other,324% of Medicaid,5323.61,,,5323.61,Other,215% of Medicaid,5323.61,,,5323.61,Other,215% of Medicaid,3095.12,,,3095.12,Other,125% of Medicaid,2476.1,29268,
VASC EMBOLIZE/OCCLUDE ORGAN,37243,CPT,,47037243,CDM,360,RC,,,both,,,33564,24837.44,,,24837.44,Other,150% of Medicare + 9.63% HCRA Surcharge,15103.8,45,,15103.8,percent of total billed charges,Critical Access Hospital RCC factor,3473,,,3473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3126,,,3126,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",7978,,,7978,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",7180,,,7180,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",6781,,,6781,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",16614.18,,,16614.18,Other,110% of Medicare,6152,,,6152,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",4605.54,,,4605.54,Other,186% of Medicaid,7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",26851.2,,,26851.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",23494.8,70,,23494.8,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",6956,,,6956,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",6261,,,6261,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",6956,,,6956,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",5913,,,5913,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2476.1,,,2476.1,Other,100% of Medicaid,2476.1,,,2476.1,Other,100% of Medicaid,2476.1,,,2476.1,Other,100% of Medicaid,2476.1,,,2476.1,Other,100% of Medicaid,5571.22,,,5571.22,Other,225% of Medicaid,3788.43,,,3788.43,Other,153% of Medicaid,5571.22,,,5571.22,Other,225% of Medicaid,3466.54,,,3466.54,Other,140% of Medicaid,5571.22,,,5571.22,Other,225% of Medicaid,6437.85,,,6437.85,Other,260% of Medicaid,8022.56,,,8022.56,Other,324% of Medicaid,5323.61,,,5323.61,Other,215% of Medicaid,5323.61,,,5323.61,Other,215% of Medicaid,3095.12,,,3095.12,Other,125% of Medicaid,2476.1,26851.2,
VASC EMBOLIZE/OCCLUDE BLEED,37244,CPT,,47037244,CDM,360,RC,,,both,,,33564,24837.44,,,24837.44,Other,150% of Medicare + 9.63% HCRA Surcharge,15103.8,45,,15103.8,percent of total billed charges,Critical Access Hospital RCC factor,3473,,,3473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3126,,,3126,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",7978,,,7978,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",7180,,,7180,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",6781,,,6781,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",16614.18,,,16614.18,Other,110% of Medicare,6152,,,6152,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",4605.54,,,4605.54,Other,186% of Medicaid,7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",26851.2,,,26851.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",23494.8,70,,23494.8,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",6956,,,6956,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",6261,,,6261,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",6956,,,6956,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",5913,,,5913,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2476.1,,,2476.1,Other,100% of Medicaid,2476.1,,,2476.1,Other,100% of Medicaid,2476.1,,,2476.1,Other,100% of Medicaid,2476.1,,,2476.1,Other,100% of Medicaid,5571.22,,,5571.22,Other,225% of Medicaid,3788.43,,,3788.43,Other,153% of Medicaid,5571.22,,,5571.22,Other,225% of Medicaid,3466.54,,,3466.54,Other,140% of Medicaid,5571.22,,,5571.22,Other,225% of Medicaid,6437.85,,,6437.85,Other,260% of Medicaid,8022.56,,,8022.56,Other,324% of Medicaid,5323.61,,,5323.61,Other,215% of Medicaid,5323.61,,,5323.61,Other,215% of Medicaid,3095.12,,,3095.12,Other,125% of Medicaid,2476.1,26851.2,
TRLUML BALO ANGIOP 1ST ART,37246,CPT,,47037246,CDM,360,RC,,,both,,,22489,16641.92,,,16641.92,Other,150% of Medicare + 9.63% HCRA Surcharge,10120.05,45,,10120.05,percent of total billed charges,Critical Access Hospital RCC factor,5954,,,5954,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",5359,,,5359,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",6807,,,6807,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",6126,,,6126,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",5786,,,5786,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",11132.06,,,11132.06,Other,110% of Medicare,6152,,,6152,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",3853.44,,,3853.44,Other,186% of Medicaid,7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",17991.2,,,17991.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",15742.3,70,,15742.3,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",6331,,,6331,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",5698,,,5698,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",6331,,,6331,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",5381,,,5381,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2071.74,,,2071.74,Other,100% of Medicaid,2071.74,,,2071.74,Other,100% of Medicaid,2071.74,,,2071.74,Other,100% of Medicaid,2071.74,,,2071.74,Other,100% of Medicaid,4661.42,,,4661.42,Other,225% of Medicaid,3169.77,,,3169.77,Other,153% of Medicaid,4661.42,,,4661.42,Other,225% of Medicaid,2900.44,,,2900.44,Other,140% of Medicaid,4661.42,,,4661.42,Other,225% of Medicaid,5386.53,,,5386.53,Other,260% of Medicaid,6712.45,,,6712.45,Other,324% of Medicaid,4454.25,,,4454.25,Other,215% of Medicaid,4454.25,,,4454.25,Other,215% of Medicaid,2589.68,,,2589.68,Other,125% of Medicaid,2071.74,17991.2,
TRLUML BALO ANGIOP ADDL ART,37247,CPT,,47037247,CDM,360,RC,,,both,,,849,628.26,,,628.26,Other,150% of Medicare + 9.63% HCRA Surcharge,382.05,45,,382.05,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4970,,,4970,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4473,,,4473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4225,,,4225,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",420.26,,,420.26,Other,110% of Medicare,577.32,,,577.32,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",4605.53,,,4605.53,Other,186% of Medicaid,679.2,,,679.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",679.2,,,679.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",679.2,,,679.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",594.3,70,,594.3,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2476.09,,,2476.09,Other,100% of Medicaid,2476.09,,,2476.09,Other,100% of Medicaid,2476.09,,,2476.09,Other,100% of Medicaid,2476.09,,,2476.09,Other,100% of Medicaid,5571.21,,,5571.21,Other,225% of Medicaid,3788.42,,,3788.42,Other,153% of Medicaid,5571.21,,,5571.21,Other,225% of Medicaid,3466.53,,,3466.53,Other,140% of Medicaid,5571.21,,,5571.21,Other,225% of Medicaid,6437.84,,,6437.84,Other,260% of Medicaid,8022.54,,,8022.54,Other,324% of Medicaid,5323.6,,,5323.6,Other,215% of Medicaid,5323.6,,,5323.6,Other,215% of Medicaid,3095.12,,,3095.12,Other,125% of Medicaid,382.05,8022.54,
TRLUML BALO ANGIOP 1ST VEIN,37248,CPT,,47037248,CDM,360,RC,,,both,,,22489,16641.92,,,16641.92,Other,150% of Medicare + 9.63% HCRA Surcharge,10120.05,45,,10120.05,percent of total billed charges,Critical Access Hospital RCC factor,5954,,,5954,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",5359,,,5359,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",6807,,,6807,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",6126,,,6126,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",5786,,,5786,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",11132.06,,,11132.06,Other,110% of Medicare,6152,,,6152,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",3853.44,,,3853.44,Other,186% of Medicaid,7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",17991.2,,,17991.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",15742.3,70,,15742.3,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",6331,,,6331,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",5698,,,5698,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",6331,,,6331,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",5381,,,5381,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2071.74,,,2071.74,Other,100% of Medicaid,2071.74,,,2071.74,Other,100% of Medicaid,2071.74,,,2071.74,Other,100% of Medicaid,2071.74,,,2071.74,Other,100% of Medicaid,4661.42,,,4661.42,Other,225% of Medicaid,3169.77,,,3169.77,Other,153% of Medicaid,4661.42,,,4661.42,Other,225% of Medicaid,2900.44,,,2900.44,Other,140% of Medicaid,4661.42,,,4661.42,Other,225% of Medicaid,5386.53,,,5386.53,Other,260% of Medicaid,6712.45,,,6712.45,Other,324% of Medicaid,4454.25,,,4454.25,Other,215% of Medicaid,4454.25,,,4454.25,Other,215% of Medicaid,2589.68,,,2589.68,Other,125% of Medicaid,2071.74,17991.2,
TRLUML BALO ANGIOP ADDL VEIN,37249,CPT,,47037249,CDM,360,RC,,,both,,,723,535.02,,,535.02,Other,150% of Medicare + 9.63% HCRA Surcharge,325.35,45,,325.35,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4970,,,4970,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4473,,,4473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4225,,,4225,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",357.89,,,357.89,Other,110% of Medicare,491.64,,,491.64,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",4605.53,,,4605.53,Other,186% of Medicaid,578.4,,,578.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",578.4,,,578.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",578.4,,,578.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",506.1,70,,506.1,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2476.09,,,2476.09,Other,100% of Medicaid,2476.09,,,2476.09,Other,100% of Medicaid,2476.09,,,2476.09,Other,100% of Medicaid,2476.09,,,2476.09,Other,100% of Medicaid,5571.21,,,5571.21,Other,225% of Medicaid,3788.42,,,3788.42,Other,153% of Medicaid,5571.21,,,5571.21,Other,225% of Medicaid,3466.53,,,3466.53,Other,140% of Medicaid,5571.21,,,5571.21,Other,225% of Medicaid,6437.84,,,6437.84,Other,260% of Medicaid,8022.54,,,8022.54,Other,324% of Medicaid,5323.6,,,5323.6,Other,215% of Medicaid,5323.6,,,5323.6,Other,215% of Medicaid,3095.12,,,3095.12,Other,125% of Medicaid,325.35,8022.54,
LIGATION/BAND ANGIOACCESS AV FISTULA,37607,CPT,,47037607,CDM,360,RC,,,both,,,8728,6458.74,,,6458.74,Other,150% of Medicare + 9.63% HCRA Surcharge,3927.6,45,,3927.6,percent of total billed charges,Critical Access Hospital RCC factor,3473,,,3473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3126,,,3126,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4476,,,4476,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4028,,,4028,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3805,,,3805,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4320.36,,,4320.36,Other,110% of Medicare,6152,,,6152,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",4418.36,,,4418.36,Other,186% of Medicaid,7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",5266,,,5266,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",6109.6,70,,6109.6,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",4913,,,4913,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4422,,,4422,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4913,,,4913,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4176,,,4176,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2375.46,,,2375.46,Other,100% of Medicaid,2375.46,,,2375.46,Other,100% of Medicaid,2375.46,,,2375.46,Other,100% of Medicaid,2375.46,,,2375.46,Other,100% of Medicaid,5344.79,,,5344.79,Other,225% of Medicaid,3634.45,,,3634.45,Other,153% of Medicaid,5344.79,,,5344.79,Other,225% of Medicaid,3325.64,,,3325.64,Other,140% of Medicaid,5344.79,,,5344.79,Other,225% of Medicaid,6176.2,,,6176.2,Other,260% of Medicaid,7696.49,,,7696.49,Other,324% of Medicaid,5107.24,,,5107.24,Other,215% of Medicaid,5107.24,,,5107.24,Other,215% of Medicaid,2969.33,,,2969.33,Other,125% of Medicaid,2375.46,9473,
BIOPSY SALIVARY GLAND; NEEDLE,42400,CPT,,47042400,CDM,360,RC,,,both,,,2405,1779.71,,,1779.71,Other,150% of Medicare + 9.63% HCRA Surcharge,1082.25,45,,1082.25,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",1190.48,,,1190.48,Other,110% of Medicare,1635.4,,,1635.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",428.6,,,428.6,Other,186% of Medicaid,1924,,,1924,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1924,,,1924,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1924,,,1924,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1683.5,70,,1683.5,percent of total billed charges,All Other,254.2,,,254.2,Fee Schedule,,215.45,,,215.45,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",230.43,,,230.43,Other,100% of Medicaid,230.43,,,230.43,Other,100% of Medicaid,230.43,,,230.43,Other,100% of Medicaid,230.43,,,230.43,Other,100% of Medicaid,518.46,,,518.46,Other,225% of Medicaid,352.55,,,352.55,Other,153% of Medicaid,518.46,,,518.46,Other,225% of Medicaid,322.6,,,322.6,Other,140% of Medicaid,518.46,,,518.46,Other,225% of Medicaid,599.11,,,599.11,Other,260% of Medicaid,746.59,,,746.59,Other,324% of Medicaid,495.42,,,495.42,Other,215% of Medicaid,495.42,,,495.42,Other,215% of Medicaid,288.03,,,288.03,Other,125% of Medicaid,215.45,7216,
INJ FOR SIALOGRAPHY,42550,CPT,,47042550,CDM,360,RC,,,both,,,246,182.04,,,182.04,Other,150% of Medicare + 9.63% HCRA Surcharge,110.7,45,,110.7,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",121.77,,,121.77,Other,110% of Medicare,167.28,,,167.28,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",966.93,,,966.93,Other,186% of Medicaid,196.8,,,196.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",196.8,,,196.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",196.8,,,196.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",172.2,70,,172.2,percent of total billed charges,All Other,295.2,,,295.2,Fee Schedule,,250.2,,,250.2,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",519.86,,,519.86,Other,100% of Medicaid,519.86,,,519.86,Other,100% of Medicaid,519.86,,,519.86,Other,100% of Medicaid,519.86,,,519.86,Other,100% of Medicaid,1169.68,,,1169.68,Other,225% of Medicaid,795.38,,,795.38,Other,153% of Medicaid,1169.68,,,1169.68,Other,225% of Medicaid,727.8,,,727.8,Other,140% of Medicaid,1169.68,,,1169.68,Other,225% of Medicaid,1351.62,,,1351.62,Other,260% of Medicaid,1684.33,,,1684.33,Other,324% of Medicaid,1117.69,,,1117.69,Other,215% of Medicaid,1117.69,,,1117.69,Other,215% of Medicaid,649.82,,,649.82,Other,125% of Medicaid,110.7,7216,
INJECTION FOR CHOLANGIOGRAM,47531,CPT,,47047531,CDM,360,RC,,,both,,,7974,5900.78,,,5900.78,Other,150% of Medicare + 9.63% HCRA Surcharge,3588.3,45,,3588.3,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4476,,,4476,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4028,,,4028,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3805,,,3805,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3947.13,,,3947.13,Other,110% of Medicare,5422.32,,,5422.32,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",786.95,,,786.95,Other,186% of Medicaid,6379.2,,,6379.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",6379.2,,,6379.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",6379.2,,,6379.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",5581.8,70,,5581.8,percent of total billed charges,All Other,332.92,,,332.92,Fee Schedule,,282.17,,,282.17,Fee Schedule,,4913,,,4913,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4422,,,4422,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4913,,,4913,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4176,,,4176,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",423.09,,,423.09,Other,100% of Medicaid,423.09,,,423.09,Other,100% of Medicaid,423.09,,,423.09,Other,100% of Medicaid,423.09,,,423.09,Other,100% of Medicaid,951.96,,,951.96,Other,225% of Medicaid,647.33,,,647.33,Other,153% of Medicaid,951.96,,,951.96,Other,225% of Medicaid,592.33,,,592.33,Other,140% of Medicaid,951.96,,,951.96,Other,225% of Medicaid,1100.04,,,1100.04,Other,260% of Medicaid,1370.82,,,1370.82,Other,324% of Medicaid,909.65,,,909.65,Other,215% of Medicaid,909.65,,,909.65,Other,215% of Medicaid,528.86,,,528.86,Other,125% of Medicaid,282.17,7216,
INJECTION FOR CHOLANGIOGRAM,47532,CPT,,47047532,CDM,360,RC,,,both,,,8239,6096.88,,,6096.88,Other,150% of Medicare + 9.63% HCRA Surcharge,3707.55,45,,3707.55,percent of total billed charges,Critical Access Hospital RCC factor,2480,,,2480,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2232,,,2232,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4476,,,4476,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4028,,,4028,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3805,,,3805,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4078.31,,,4078.31,Other,110% of Medicare,5602.52,,,5602.52,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",786.95,,,786.95,Other,186% of Medicaid,6591.2,,,6591.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",6591.2,,,6591.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",6591.2,,,6591.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",5767.3,70,,5767.3,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",4913,,,4913,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4422,,,4422,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4913,,,4913,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4176,,,4176,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",423.09,,,423.09,Other,100% of Medicaid,423.09,,,423.09,Other,100% of Medicaid,423.09,,,423.09,Other,100% of Medicaid,423.09,,,423.09,Other,100% of Medicaid,951.96,,,951.96,Other,225% of Medicaid,647.33,,,647.33,Other,153% of Medicaid,951.96,,,951.96,Other,225% of Medicaid,592.33,,,592.33,Other,140% of Medicaid,951.96,,,951.96,Other,225% of Medicaid,1100.04,,,1100.04,Other,260% of Medicaid,1370.82,,,1370.82,Other,324% of Medicaid,909.65,,,909.65,Other,215% of Medicaid,909.65,,,909.65,Other,215% of Medicaid,528.86,,,528.86,Other,125% of Medicaid,423.09,7216,
PLMT BILIARY DRAINAGE CATH,47533,CPT,,47047533,CDM,360,RC,,,both,,,8980,6645.22,,,6645.22,Other,150% of Medicare + 9.63% HCRA Surcharge,4041,45,,4041,percent of total billed charges,Critical Access Hospital RCC factor,2480,,,2480,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2232,,,2232,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4476,,,4476,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4028,,,4028,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3805,,,3805,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4445.1,,,4445.1,Other,110% of Medicare,6106.4,,,6106.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2588.91,,,2588.91,Other,186% of Medicaid,7184,,,7184,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7184,,,7184,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7184,,,7184,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",6286,70,,6286,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",4913,,,4913,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4422,,,4422,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4913,,,4913,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4176,,,4176,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",1391.89,,,1391.89,Other,100% of Medicaid,1391.89,,,1391.89,Other,100% of Medicaid,1391.89,,,1391.89,Other,100% of Medicaid,1391.89,,,1391.89,Other,100% of Medicaid,3131.75,,,3131.75,Other,225% of Medicaid,2129.59,,,2129.59,Other,153% of Medicaid,3131.75,,,3131.75,Other,225% of Medicaid,1948.64,,,1948.64,Other,140% of Medicaid,3131.75,,,3131.75,Other,225% of Medicaid,3618.91,,,3618.91,Other,260% of Medicaid,4509.72,,,4509.72,Other,324% of Medicaid,2992.56,,,2992.56,Other,215% of Medicaid,2992.56,,,2992.56,Other,215% of Medicaid,1739.86,,,1739.86,Other,125% of Medicaid,1391.89,7216,
PLMT BILIARY DRAINAGE CATH,47534,CPT,,47047534,CDM,360,RC,,,both,,,8239,6096.88,,,6096.88,Other,150% of Medicare + 9.63% HCRA Surcharge,3707.55,45,,3707.55,percent of total billed charges,Critical Access Hospital RCC factor,2480,,,2480,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2232,,,2232,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4476,,,4476,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4028,,,4028,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3805,,,3805,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4078.31,,,4078.31,Other,110% of Medicare,5602.52,,,5602.52,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2588.91,,,2588.91,Other,186% of Medicaid,6591.2,,,6591.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",6591.2,,,6591.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",6591.2,,,6591.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",5767.3,70,,5767.3,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",4913,,,4913,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4422,,,4422,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4913,,,4913,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4176,,,4176,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",1391.89,,,1391.89,Other,100% of Medicaid,1391.89,,,1391.89,Other,100% of Medicaid,1391.89,,,1391.89,Other,100% of Medicaid,1391.89,,,1391.89,Other,100% of Medicaid,3131.75,,,3131.75,Other,225% of Medicaid,2129.59,,,2129.59,Other,153% of Medicaid,3131.75,,,3131.75,Other,225% of Medicaid,1948.64,,,1948.64,Other,140% of Medicaid,3131.75,,,3131.75,Other,225% of Medicaid,3618.91,,,3618.91,Other,260% of Medicaid,4509.72,,,4509.72,Other,324% of Medicaid,2992.56,,,2992.56,Other,215% of Medicaid,2992.56,,,2992.56,Other,215% of Medicaid,1739.86,,,1739.86,Other,125% of Medicaid,1391.89,7216,
CONVERSION EXT BIL DRG CATH,47535,CPT,,47047535,CDM,360,RC,,,both,,,8239,6096.88,,,6096.88,Other,150% of Medicare + 9.63% HCRA Surcharge,3707.55,45,,3707.55,percent of total billed charges,Critical Access Hospital RCC factor,2480,,,2480,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2232,,,2232,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4476,,,4476,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4028,,,4028,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3805,,,3805,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4078.31,,,4078.31,Other,110% of Medicare,5602.52,,,5602.52,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2588.91,,,2588.91,Other,186% of Medicaid,6591.2,,,6591.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",6591.2,,,6591.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",6591.2,,,6591.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",5767.3,70,,5767.3,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",4913,,,4913,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4422,,,4422,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4913,,,4913,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4176,,,4176,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",1391.89,,,1391.89,Other,100% of Medicaid,1391.89,,,1391.89,Other,100% of Medicaid,1391.89,,,1391.89,Other,100% of Medicaid,1391.89,,,1391.89,Other,100% of Medicaid,3131.75,,,3131.75,Other,225% of Medicaid,2129.59,,,2129.59,Other,153% of Medicaid,3131.75,,,3131.75,Other,225% of Medicaid,1948.64,,,1948.64,Other,140% of Medicaid,3131.75,,,3131.75,Other,225% of Medicaid,3618.91,,,3618.91,Other,260% of Medicaid,4509.72,,,4509.72,Other,324% of Medicaid,2992.56,,,2992.56,Other,215% of Medicaid,2992.56,,,2992.56,Other,215% of Medicaid,1739.86,,,1739.86,Other,125% of Medicaid,1391.89,7216,
EXCHANGE BILIARY DRG CATH,47536,CPT,,47047536,CDM,360,RC,,,both,,,8239,6096.88,,,6096.88,Other,150% of Medicare + 9.63% HCRA Surcharge,3707.55,45,,3707.55,percent of total billed charges,Critical Access Hospital RCC factor,2480,,,2480,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2232,,,2232,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4476,,,4476,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4028,,,4028,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3805,,,3805,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4078.31,,,4078.31,Other,110% of Medicare,5602.52,,,5602.52,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2588.91,,,2588.91,Other,186% of Medicaid,6591.2,,,6591.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",6591.2,,,6591.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",6591.2,,,6591.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",5767.3,70,,5767.3,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",4913,,,4913,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4422,,,4422,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4913,,,4913,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4176,,,4176,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",1391.89,,,1391.89,Other,100% of Medicaid,1391.89,,,1391.89,Other,100% of Medicaid,1391.89,,,1391.89,Other,100% of Medicaid,1391.89,,,1391.89,Other,100% of Medicaid,3131.75,,,3131.75,Other,225% of Medicaid,2129.59,,,2129.59,Other,153% of Medicaid,3131.75,,,3131.75,Other,225% of Medicaid,1948.64,,,1948.64,Other,140% of Medicaid,3131.75,,,3131.75,Other,225% of Medicaid,3618.91,,,3618.91,Other,260% of Medicaid,4509.72,,,4509.72,Other,324% of Medicaid,2992.56,,,2992.56,Other,215% of Medicaid,2992.56,,,2992.56,Other,215% of Medicaid,1739.86,,,1739.86,Other,125% of Medicaid,1391.89,7216,
REMOVAL BILIARY DRG CATH,47537,CPT,,47047537,CDM,360,RC,,,both,,,1921,1421.54,,,1421.54,Other,150% of Medicare + 9.63% HCRA Surcharge,864.45,45,,864.45,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",950.9,,,950.9,Other,110% of Medicare,1306.28,,,1306.28,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1030.37,,,1030.37,Other,186% of Medicaid,1536.8,,,1536.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1536.8,,,1536.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1536.8,,,1536.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1344.7,70,,1344.7,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",4055,,,4055,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3649,,,3649,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4055,,,4055,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3448,,,3448,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",553.96,,,553.96,Other,100% of Medicaid,553.96,,,553.96,Other,100% of Medicaid,553.96,,,553.96,Other,100% of Medicaid,553.96,,,553.96,Other,100% of Medicaid,1246.41,,,1246.41,Other,225% of Medicaid,847.56,,,847.56,Other,153% of Medicaid,1246.41,,,1246.41,Other,225% of Medicaid,775.55,,,775.55,Other,140% of Medicaid,1246.41,,,1246.41,Other,225% of Medicaid,1440.3,,,1440.3,Other,260% of Medicaid,1794.83,,,1794.83,Other,324% of Medicaid,1191.02,,,1191.02,Other,215% of Medicaid,1191.02,,,1191.02,Other,215% of Medicaid,692.45,,,692.45,Other,125% of Medicaid,553.96,7216,
PERQ PLMT BILE DUCT STENT,47538,CPT,,47047538,CDM,360,RC,,,both,,,15583,11531.46,,,11531.46,Other,150% of Medicare + 9.63% HCRA Surcharge,7012.35,45,,7012.35,percent of total billed charges,Critical Access Hospital RCC factor,3473,,,3473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3126,,,3126,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",5738,,,5738,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",5164,,,5164,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4877,,,4877,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",7713.59,,,7713.59,Other,110% of Medicare,6152,,,6152,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2588.91,,,2588.91,Other,186% of Medicaid,7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",12466.4,,,12466.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",10908.1,70,,10908.1,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",6331,,,6331,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",5698,,,5698,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",6331,,,6331,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",5381,,,5381,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",1391.89,,,1391.89,Other,100% of Medicaid,1391.89,,,1391.89,Other,100% of Medicaid,1391.89,,,1391.89,Other,100% of Medicaid,1391.89,,,1391.89,Other,100% of Medicaid,3131.75,,,3131.75,Other,225% of Medicaid,2129.59,,,2129.59,Other,153% of Medicaid,3131.75,,,3131.75,Other,225% of Medicaid,1948.64,,,1948.64,Other,140% of Medicaid,3131.75,,,3131.75,Other,225% of Medicaid,3618.91,,,3618.91,Other,260% of Medicaid,4509.72,,,4509.72,Other,324% of Medicaid,2992.56,,,2992.56,Other,215% of Medicaid,2992.56,,,2992.56,Other,215% of Medicaid,1739.86,,,1739.86,Other,125% of Medicaid,1391.89,12466.4,
PERQ PLMT BILE DUCT STENT,47539,CPT,,47047539,CDM,360,RC,,,both,,,15583,11531.46,,,11531.46,Other,150% of Medicare + 9.63% HCRA Surcharge,7012.35,45,,7012.35,percent of total billed charges,Critical Access Hospital RCC factor,3473,,,3473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3126,,,3126,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",5738,,,5738,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",5164,,,5164,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4877,,,4877,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",7713.59,,,7713.59,Other,110% of Medicare,6152,,,6152,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2588.91,,,2588.91,Other,186% of Medicaid,7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",12466.4,,,12466.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",10908.1,70,,10908.1,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",6331,,,6331,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",5698,,,5698,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",6331,,,6331,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",5381,,,5381,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",1391.89,,,1391.89,Other,100% of Medicaid,1391.89,,,1391.89,Other,100% of Medicaid,1391.89,,,1391.89,Other,100% of Medicaid,1391.89,,,1391.89,Other,100% of Medicaid,3131.75,,,3131.75,Other,225% of Medicaid,2129.59,,,2129.59,Other,153% of Medicaid,3131.75,,,3131.75,Other,225% of Medicaid,1948.64,,,1948.64,Other,140% of Medicaid,3131.75,,,3131.75,Other,225% of Medicaid,3618.91,,,3618.91,Other,260% of Medicaid,4509.72,,,4509.72,Other,324% of Medicaid,2992.56,,,2992.56,Other,215% of Medicaid,2992.56,,,2992.56,Other,215% of Medicaid,1739.86,,,1739.86,Other,125% of Medicaid,1391.89,12466.4,
PERQ PLMT BILE DUCT STENT,47540,CPT,,47047540,CDM,360,RC,,,both,,,15583,11531.46,,,11531.46,Other,150% of Medicare + 9.63% HCRA Surcharge,7012.35,45,,7012.35,percent of total billed charges,Critical Access Hospital RCC factor,3473,,,3473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3126,,,3126,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",5738,,,5738,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",5164,,,5164,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4877,,,4877,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",7713.59,,,7713.59,Other,110% of Medicare,6152,,,6152,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",3989.38,,,3989.38,Other,186% of Medicaid,7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",12466.4,,,12466.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",10908.1,70,,10908.1,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",6331,,,6331,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",5698,,,5698,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",6331,,,6331,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",5381,,,5381,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2144.83,,,2144.83,Other,100% of Medicaid,2144.83,,,2144.83,Other,100% of Medicaid,2144.83,,,2144.83,Other,100% of Medicaid,2144.83,,,2144.83,Other,100% of Medicaid,4825.86,,,4825.86,Other,225% of Medicaid,3281.59,,,3281.59,Other,153% of Medicaid,4825.86,,,4825.86,Other,225% of Medicaid,3002.76,,,3002.76,Other,140% of Medicaid,4825.86,,,4825.86,Other,225% of Medicaid,5576.55,,,5576.55,Other,260% of Medicaid,6949.24,,,6949.24,Other,324% of Medicaid,4611.38,,,4611.38,Other,215% of Medicaid,4611.38,,,4611.38,Other,215% of Medicaid,2681.04,,,2681.04,Other,125% of Medicaid,2144.83,12466.4,
REMOVAL DUCT GLBLDR CALCULI,47544,CPT,,47047544,CDM,360,RC,,,both,,,862,637.88,,,637.88,Other,150% of Medicare + 9.63% HCRA Surcharge,387.9,45,,387.9,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3648,,,3648,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3283,,,3283,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3101,,,3101,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",426.69,,,426.69,Other,110% of Medicare,586.16,,,586.16,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",3989.38,,,3989.38,Other,186% of Medicaid,689.6,,,689.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",689.6,,,689.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",689.6,,,689.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",603.4,70,,603.4,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2144.83,,,2144.83,Other,100% of Medicaid,2144.83,,,2144.83,Other,100% of Medicaid,2144.83,,,2144.83,Other,100% of Medicaid,2144.83,,,2144.83,Other,100% of Medicaid,4825.86,,,4825.86,Other,225% of Medicaid,3281.59,,,3281.59,Other,153% of Medicaid,4825.86,,,4825.86,Other,225% of Medicaid,3002.76,,,3002.76,Other,140% of Medicaid,4825.86,,,4825.86,Other,225% of Medicaid,5576.55,,,5576.55,Other,260% of Medicaid,6949.24,,,6949.24,Other,324% of Medicaid,4611.38,,,4611.38,Other,215% of Medicaid,4611.38,,,4611.38,Other,215% of Medicaid,2681.04,,,2681.04,Other,125% of Medicaid,387.9,7216,
PERC DIL BILIARY STRICTURE WO,47555,CPT,,47047555,CDM,360,RC,,,both,,,9229,6829.48,,,6829.48,Other,150% of Medicare + 9.63% HCRA Surcharge,4153.05,45,,4153.05,percent of total billed charges,Critical Access Hospital RCC factor,3473,,,3473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3126,,,3126,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4476,,,4476,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4028,,,4028,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3805,,,3805,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4568.36,,,4568.36,Other,110% of Medicare,6152,,,6152,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2563.88,,,2563.88,Other,186% of Medicaid,7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",5266,,,5266,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",6460.3,70,,6460.3,percent of total billed charges,All Other,3387,,,3387,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",2879,,,2879,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",4913,,,4913,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4422,,,4422,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4913,,,4913,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4176,,,4176,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",1378.43,,,1378.43,Other,100% of Medicaid,1378.43,,,1378.43,Other,100% of Medicaid,1378.43,,,1378.43,Other,100% of Medicaid,1378.43,,,1378.43,Other,100% of Medicaid,3101.47,,,3101.47,Other,225% of Medicaid,2109,,,2109,Other,153% of Medicaid,3101.47,,,3101.47,Other,225% of Medicaid,1929.81,,,1929.81,Other,140% of Medicaid,3101.47,,,3101.47,Other,225% of Medicaid,3583.92,,,3583.92,Other,260% of Medicaid,4466.12,,,4466.12,Other,324% of Medicaid,2963.63,,,2963.63,Other,215% of Medicaid,2963.63,,,2963.63,Other,215% of Medicaid,1723.04,,,1723.04,Other,125% of Medicaid,1378.43,9473,
PERC DIL BILIARY STRICTURE W S,47556,CPT,,47047556,CDM,360,RC,,,both,,,11733,8682.45,,,8682.45,Other,150% of Medicare + 9.63% HCRA Surcharge,5279.85,45,,5279.85,percent of total billed charges,Critical Access Hospital RCC factor,3473,,,3473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3126,,,3126,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",5738,,,5738,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",5164,,,5164,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4877,,,4877,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",5807.84,,,5807.84,Other,110% of Medicare,6152,,,6152,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2563.88,,,2563.88,Other,186% of Medicaid,7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9196,,,9196,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",8213.1,70,,8213.1,percent of total billed charges,All Other,3387,,,3387,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",2879,,,2879,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",6331,,,6331,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",5698,,,5698,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",6331,,,6331,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",5381,,,5381,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",1378.43,,,1378.43,Other,100% of Medicaid,1378.43,,,1378.43,Other,100% of Medicaid,1378.43,,,1378.43,Other,100% of Medicaid,1378.43,,,1378.43,Other,100% of Medicaid,3101.47,,,3101.47,Other,225% of Medicaid,2109,,,2109,Other,153% of Medicaid,3101.47,,,3101.47,Other,225% of Medicaid,1929.81,,,1929.81,Other,140% of Medicaid,3101.47,,,3101.47,Other,225% of Medicaid,3583.92,,,3583.92,Other,260% of Medicaid,4466.12,,,4466.12,Other,324% of Medicaid,2963.63,,,2963.63,Other,215% of Medicaid,2963.63,,,2963.63,Other,215% of Medicaid,1723.04,,,1723.04,Other,125% of Medicaid,1378.43,9473,
ABD PARACENTESIS W/IMAGING,49083,CPT,,47049083,CDM,360,RC,,,both,,,1893,1400.82,,,1400.82,Other,150% of Medicare + 9.63% HCRA Surcharge,851.85,45,,851.85,percent of total billed charges,Critical Access Hospital RCC factor,2480,,,2480,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2232,,,2232,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",937.04,,,937.04,Other,110% of Medicare,1287.24,,,1287.24,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1196.64,,,1196.64,Other,186% of Medicaid,1514.4,,,1514.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1514.4,,,1514.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1514.4,,,1514.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1325.1,70,,1325.1,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",4055,,,4055,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3649,,,3649,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4055,,,4055,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3448,,,3448,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",643.35,,,643.35,Other,100% of Medicaid,643.35,,,643.35,Other,100% of Medicaid,643.35,,,643.35,Other,100% of Medicaid,643.35,,,643.35,Other,100% of Medicaid,1447.55,,,1447.55,Other,225% of Medicaid,984.33,,,984.33,Other,153% of Medicaid,1447.55,,,1447.55,Other,225% of Medicaid,900.7,,,900.7,Other,140% of Medicaid,1447.55,,,1447.55,Other,225% of Medicaid,1672.72,,,1672.72,Other,260% of Medicaid,2084.47,,,2084.47,Other,324% of Medicaid,1383.21,,,1383.21,Other,215% of Medicaid,1383.21,,,1383.21,Other,215% of Medicaid,804.19,,,804.19,Other,125% of Medicaid,643.35,7216,
INJ AIR/CONTRAST INTO PERITONEAL CAVITY,49400,CPT,,47049400,CDM,360,RC,,,both,,,1234,913.16,,,913.16,Other,150% of Medicare + 9.63% HCRA Surcharge,555.3,45,,555.3,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",610.83,,,610.83,Other,110% of Medicare,839.12,,,839.12,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",966.93,,,966.93,Other,186% of Medicaid,987.2,,,987.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",987.2,,,987.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",987.2,,,987.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",863.8,70,,863.8,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",519.86,,,519.86,Other,100% of Medicaid,519.86,,,519.86,Other,100% of Medicaid,519.86,,,519.86,Other,100% of Medicaid,519.86,,,519.86,Other,100% of Medicaid,1169.68,,,1169.68,Other,225% of Medicaid,795.38,,,795.38,Other,153% of Medicaid,1169.68,,,1169.68,Other,225% of Medicaid,727.8,,,727.8,Other,140% of Medicaid,1169.68,,,1169.68,Other,225% of Medicaid,1351.62,,,1351.62,Other,260% of Medicaid,1684.33,,,1684.33,Other,324% of Medicaid,1117.69,,,1117.69,Other,215% of Medicaid,1117.69,,,1117.69,Other,215% of Medicaid,649.82,,,649.82,Other,125% of Medicaid,519.86,7216,
EXCHANGE PREVIOUS DRAINAGE CATH,49423,CPT,,47049423,CDM,360,RC,,,both,,,5324,3939.77,,,3939.77,Other,150% of Medicare + 9.63% HCRA Surcharge,2395.8,45,,2395.8,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3648,,,3648,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3283,,,3283,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3101,,,3101,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2635.38,,,2635.38,Other,110% of Medicare,3620.32,,,3620.32,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1196.64,,,1196.64,Other,186% of Medicaid,4259.2,,,4259.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",4259.2,,,4259.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",4259.2,,,4259.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",3726.8,70,,3726.8,percent of total billed charges,All Other,332.92,,,332.92,Fee Schedule,,282.17,,,282.17,Fee Schedule,,4055,,,4055,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3649,,,3649,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4055,,,4055,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3448,,,3448,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",643.35,,,643.35,Other,100% of Medicaid,643.35,,,643.35,Other,100% of Medicaid,643.35,,,643.35,Other,100% of Medicaid,643.35,,,643.35,Other,100% of Medicaid,1447.55,,,1447.55,Other,225% of Medicaid,984.33,,,984.33,Other,153% of Medicaid,1447.55,,,1447.55,Other,225% of Medicaid,900.7,,,900.7,Other,140% of Medicaid,1447.55,,,1447.55,Other,225% of Medicaid,1672.72,,,1672.72,Other,260% of Medicaid,2084.47,,,2084.47,Other,324% of Medicaid,1383.21,,,1383.21,Other,215% of Medicaid,1383.21,,,1383.21,Other,215% of Medicaid,804.19,,,804.19,Other,125% of Medicaid,282.17,7216,
PLACE GASTROSTOMY TUBE PERC,49440,CPT,,47049440,CDM,360,RC,,,both,,,3921,2901.55,,,2901.55,Other,150% of Medicare + 9.63% HCRA Surcharge,1764.45,45,,1764.45,percent of total billed charges,Critical Access Hospital RCC factor,2480,,,2480,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2232,,,2232,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3648,,,3648,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3283,,,3283,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3101,,,3101,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",1940.9,,,1940.9,Other,110% of Medicare,2666.28,,,2666.28,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1030.37,,,1030.37,Other,186% of Medicaid,3136.8,,,3136.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",3136.8,,,3136.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",3136.8,,,3136.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2744.7,70,,2744.7,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",4055,,,4055,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3649,,,3649,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4055,,,4055,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3448,,,3448,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",553.96,,,553.96,Other,100% of Medicaid,553.96,,,553.96,Other,100% of Medicaid,553.96,,,553.96,Other,100% of Medicaid,553.96,,,553.96,Other,100% of Medicaid,1246.41,,,1246.41,Other,225% of Medicaid,847.56,,,847.56,Other,153% of Medicaid,1246.41,,,1246.41,Other,225% of Medicaid,775.55,,,775.55,Other,140% of Medicaid,1246.41,,,1246.41,Other,225% of Medicaid,1440.3,,,1440.3,Other,260% of Medicaid,1794.83,,,1794.83,Other,324% of Medicaid,1191.02,,,1191.02,Other,215% of Medicaid,1191.02,,,1191.02,Other,215% of Medicaid,692.45,,,692.45,Other,125% of Medicaid,553.96,7216,
PLACE DUOD/JEJ TUBE PERC,49441,CPT,,47049441,CDM,360,RC,,,both,,,8731,6460.96,,,6460.96,Other,150% of Medicare + 9.63% HCRA Surcharge,3928.95,45,,3928.95,percent of total billed charges,Critical Access Hospital RCC factor,2480,,,2480,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2232,,,2232,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3648,,,3648,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3283,,,3283,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3101,,,3101,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4321.85,,,4321.85,Other,110% of Medicare,5937.08,,,5937.08,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1030.37,,,1030.37,Other,186% of Medicaid,6984.8,,,6984.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",6984.8,,,6984.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",6984.8,,,6984.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",6111.7,70,,6111.7,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",4055,,,4055,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3649,,,3649,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4055,,,4055,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3448,,,3448,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",553.96,,,553.96,Other,100% of Medicaid,553.96,,,553.96,Other,100% of Medicaid,553.96,,,553.96,Other,100% of Medicaid,553.96,,,553.96,Other,100% of Medicaid,1246.41,,,1246.41,Other,225% of Medicaid,847.56,,,847.56,Other,153% of Medicaid,1246.41,,,1246.41,Other,225% of Medicaid,775.55,,,775.55,Other,140% of Medicaid,1246.41,,,1246.41,Other,225% of Medicaid,1440.3,,,1440.3,Other,260% of Medicaid,1794.83,,,1794.83,Other,324% of Medicaid,1191.02,,,1191.02,Other,215% of Medicaid,1191.02,,,1191.02,Other,215% of Medicaid,692.45,,,692.45,Other,125% of Medicaid,553.96,7216,
CHANGE G-TUBE TO G-J PERC,49446,CPT,,47049446,CDM,360,RC,,,both,,,4275,3163.51,,,3163.51,Other,150% of Medicare + 9.63% HCRA Surcharge,1923.75,45,,1923.75,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3648,,,3648,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3283,,,3283,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3101,,,3101,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2116.13,,,2116.13,Other,110% of Medicare,2907,,,2907,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1030.37,,,1030.37,Other,186% of Medicaid,3420,,,3420,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",3420,,,3420,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",3420,,,3420,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2992.5,70,,2992.5,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",4055,,,4055,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3649,,,3649,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4055,,,4055,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3448,,,3448,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",553.96,,,553.96,Other,100% of Medicaid,553.96,,,553.96,Other,100% of Medicaid,553.96,,,553.96,Other,100% of Medicaid,553.96,,,553.96,Other,100% of Medicaid,1246.41,,,1246.41,Other,225% of Medicaid,847.56,,,847.56,Other,153% of Medicaid,1246.41,,,1246.41,Other,225% of Medicaid,775.55,,,775.55,Other,140% of Medicaid,1246.41,,,1246.41,Other,225% of Medicaid,1440.3,,,1440.3,Other,260% of Medicaid,1794.83,,,1794.83,Other,324% of Medicaid,1191.02,,,1191.02,Other,215% of Medicaid,1191.02,,,1191.02,Other,215% of Medicaid,692.45,,,692.45,Other,125% of Medicaid,553.96,7216,
REPLACE G C TUBE PERC,49450,CPT,,47049450,CDM,360,RC,,,both,,,2408,1781.93,,,1781.93,Other,150% of Medicare + 9.63% HCRA Surcharge,1083.6,45,,1083.6,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",1191.96,,,1191.96,Other,110% of Medicare,1637.44,,,1637.44,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1030.37,,,1030.37,Other,186% of Medicaid,1926.4,,,1926.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1926.4,,,1926.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1926.4,,,1926.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1685.6,70,,1685.6,percent of total billed charges,All Other,309.96,,,309.96,Fee Schedule,,262.71,,,262.71,Fee Schedule,,4055,,,4055,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3649,,,3649,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4055,,,4055,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3448,,,3448,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",553.96,,,553.96,Other,100% of Medicaid,553.96,,,553.96,Other,100% of Medicaid,553.96,,,553.96,Other,100% of Medicaid,553.96,,,553.96,Other,100% of Medicaid,1246.41,,,1246.41,Other,225% of Medicaid,847.56,,,847.56,Other,153% of Medicaid,1246.41,,,1246.41,Other,225% of Medicaid,775.55,,,775.55,Other,140% of Medicaid,1246.41,,,1246.41,Other,225% of Medicaid,1440.3,,,1440.3,Other,260% of Medicaid,1794.83,,,1794.83,Other,324% of Medicaid,1191.02,,,1191.02,Other,215% of Medicaid,1191.02,,,1191.02,Other,215% of Medicaid,692.45,,,692.45,Other,125% of Medicaid,262.71,7216,
REPLACE G-J TUBE PERC,49452,CPT,,47049452,CDM,360,RC,,,both,,,2720,2012.81,,,2012.81,Other,150% of Medicare + 9.63% HCRA Surcharge,1224,45,,1224,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",1346.4,,,1346.4,Other,110% of Medicare,1849.6,,,1849.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1030.37,,,1030.37,Other,186% of Medicaid,2176,,,2176,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2176,,,2176,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2176,,,2176,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1904,70,,1904,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",4055,,,4055,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3649,,,3649,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4055,,,4055,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3448,,,3448,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",553.96,,,553.96,Other,100% of Medicaid,553.96,,,553.96,Other,100% of Medicaid,553.96,,,553.96,Other,100% of Medicaid,553.96,,,553.96,Other,100% of Medicaid,1246.41,,,1246.41,Other,225% of Medicaid,847.56,,,847.56,Other,153% of Medicaid,1246.41,,,1246.41,Other,225% of Medicaid,775.55,,,775.55,Other,140% of Medicaid,1246.41,,,1246.41,Other,225% of Medicaid,1440.3,,,1440.3,Other,260% of Medicaid,1794.83,,,1794.83,Other,324% of Medicaid,1191.02,,,1191.02,Other,215% of Medicaid,1191.02,,,1191.02,Other,215% of Medicaid,692.45,,,692.45,Other,125% of Medicaid,553.96,7216,
FLUORO EXAM OF G/COLON TUBE,49465,CPT,,47049465,CDM,360,RC,,,both,,,655,484.7,,,484.7,Other,150% of Medicare + 9.63% HCRA Surcharge,294.75,45,,294.75,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",324.23,,,324.23,Other,110% of Medicare,445.4,,,445.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",623.23,,,623.23,Other,186% of Medicaid,524,,,524,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",524,,,524,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",524,,,524,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",458.5,70,,458.5,percent of total billed charges,All Other,144.32,,,144.32,Fee Schedule,,122.32,,,122.32,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",335.07,,,335.07,Other,100% of Medicaid,335.07,,,335.07,Other,100% of Medicaid,335.07,,,335.07,Other,100% of Medicaid,335.07,,,335.07,Other,100% of Medicaid,753.91,,,753.91,Other,225% of Medicaid,512.66,,,512.66,Other,153% of Medicaid,753.91,,,753.91,Other,225% of Medicaid,469.1,,,469.1,Other,140% of Medicaid,753.91,,,753.91,Other,225% of Medicaid,871.18,,,871.18,Other,260% of Medicaid,1085.63,,,1085.63,Other,324% of Medicaid,720.4,,,720.4,Other,215% of Medicaid,720.4,,,720.4,Other,215% of Medicaid,418.84,,,418.84,Other,125% of Medicaid,122.32,7216,
CHANGE URETER STENT PERCUT,50382,CPT,,47050382,CDM,360,RC,,,both,,,7524,5567.78,,,5567.78,Other,150% of Medicare + 9.63% HCRA Surcharge,3385.8,45,,3385.8,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3648,,,3648,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3283,,,3283,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3101,,,3101,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3724.38,,,3724.38,Other,110% of Medicare,5116.32,,,5116.32,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2011.18,,,2011.18,Other,186% of Medicaid,6019.2,,,6019.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",6019.2,,,6019.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",6019.2,,,6019.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",5266.8,70,,5266.8,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",4531,,,4531,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4079,,,4079,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4531,,,4531,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3852,,,3852,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",1081.28,,,1081.28,Other,100% of Medicaid,1081.28,,,1081.28,Other,100% of Medicaid,1081.28,,,1081.28,Other,100% of Medicaid,1081.28,,,1081.28,Other,100% of Medicaid,2432.88,,,2432.88,Other,225% of Medicaid,1654.36,,,1654.36,Other,153% of Medicaid,2432.88,,,2432.88,Other,225% of Medicaid,1513.79,,,1513.79,Other,140% of Medicaid,2432.88,,,2432.88,Other,225% of Medicaid,2811.33,,,2811.33,Other,260% of Medicaid,3503.35,,,3503.35,Other,324% of Medicaid,2324.75,,,2324.75,Other,215% of Medicaid,2324.75,,,2324.75,Other,215% of Medicaid,1351.6,,,1351.6,Other,125% of Medicaid,1081.28,7216,
REMOVE URETER STENT PERCUT,50384,CPT,,47050384,CDM,360,RC,,,both,,,4460,3300.41,,,3300.41,Other,150% of Medicare + 9.63% HCRA Surcharge,2007,45,,2007,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3648,,,3648,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3283,,,3283,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3101,,,3101,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2207.7,,,2207.7,Other,110% of Medicare,3032.8,,,3032.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2011.18,,,2011.18,Other,186% of Medicaid,3568,,,3568,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",3568,,,3568,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",3568,,,3568,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",3122,70,,3122,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",4531,,,4531,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4079,,,4079,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4531,,,4531,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3852,,,3852,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",1081.28,,,1081.28,Other,100% of Medicaid,1081.28,,,1081.28,Other,100% of Medicaid,1081.28,,,1081.28,Other,100% of Medicaid,1081.28,,,1081.28,Other,100% of Medicaid,2432.88,,,2432.88,Other,225% of Medicaid,1654.36,,,1654.36,Other,153% of Medicaid,2432.88,,,2432.88,Other,225% of Medicaid,1513.79,,,1513.79,Other,140% of Medicaid,2432.88,,,2432.88,Other,225% of Medicaid,2811.33,,,2811.33,Other,260% of Medicaid,3503.35,,,3503.35,Other,324% of Medicaid,2324.75,,,2324.75,Other,215% of Medicaid,2324.75,,,2324.75,Other,215% of Medicaid,1351.6,,,1351.6,Other,125% of Medicaid,1081.28,7216,
CHANGE EXT/INT URETER STENT,50387,CPT,,47050387,CDM,360,RC,,,both,,,4738,3506.13,,,3506.13,Other,150% of Medicare + 9.63% HCRA Surcharge,2132.1,45,,2132.1,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3648,,,3648,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3283,,,3283,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3101,,,3101,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2345.31,,,2345.31,Other,110% of Medicare,3221.84,,,3221.84,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2011.18,,,2011.18,Other,186% of Medicaid,3790.4,,,3790.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",3790.4,,,3790.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",3790.4,,,3790.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",3316.6,70,,3316.6,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",4055,,,4055,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3649,,,3649,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4055,,,4055,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3448,,,3448,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",1081.28,,,1081.28,Other,100% of Medicaid,1081.28,,,1081.28,Other,100% of Medicaid,1081.28,,,1081.28,Other,100% of Medicaid,1081.28,,,1081.28,Other,100% of Medicaid,2432.88,,,2432.88,Other,225% of Medicaid,1654.36,,,1654.36,Other,153% of Medicaid,2432.88,,,2432.88,Other,225% of Medicaid,1513.79,,,1513.79,Other,140% of Medicaid,2432.88,,,2432.88,Other,225% of Medicaid,2811.33,,,2811.33,Other,260% of Medicaid,3503.35,,,3503.35,Other,324% of Medicaid,2324.75,,,2324.75,Other,215% of Medicaid,2324.75,,,2324.75,Other,215% of Medicaid,1351.6,,,1351.6,Other,125% of Medicaid,1081.28,7216,
REMOVAL RENAL TUBE W/FLUORO,50389,CPT,,47050389,CDM,360,RC,,,both,,,2009,1486.67,,,1486.67,Other,150% of Medicare + 9.63% HCRA Surcharge,904.05,45,,904.05,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",994.46,,,994.46,Other,110% of Medicare,1366.12,,,1366.12,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",903.43,,,903.43,Other,186% of Medicaid,1607.2,,,1607.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1607.2,,,1607.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1607.2,,,1607.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1406.3,70,,1406.3,percent of total billed charges,All Other,252.56,,,252.56,Fee Schedule,,214.06,,,214.06,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",485.72,,,485.72,Other,100% of Medicaid,485.72,,,485.72,Other,100% of Medicaid,485.72,,,485.72,Other,100% of Medicaid,485.72,,,485.72,Other,100% of Medicaid,1092.86,,,1092.86,Other,225% of Medicaid,743.14,,,743.14,Other,153% of Medicaid,1092.86,,,1092.86,Other,225% of Medicaid,680,,,680,Other,140% of Medicaid,1092.86,,,1092.86,Other,225% of Medicaid,1262.86,,,1262.86,Other,260% of Medicaid,1573.72,,,1573.72,Other,324% of Medicaid,1044.29,,,1044.29,Other,215% of Medicaid,1044.29,,,1044.29,Other,215% of Medicaid,607.14,,,607.14,Other,125% of Medicaid,214.06,7216,
NJX PX NFROSGRM &/URTRGRM,50430,CPT,,47050430,CDM,360,RC,,,both,,,2166,1602.85,,,1602.85,Other,150% of Medicare + 9.63% HCRA Surcharge,974.7,45,,974.7,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",1072.17,,,1072.17,Other,110% of Medicare,1472.88,,,1472.88,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",903.43,,,903.43,Other,186% of Medicaid,1732.8,,,1732.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1732.8,,,1732.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1732.8,,,1732.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1516.2,70,,1516.2,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",485.72,,,485.72,Other,100% of Medicaid,485.72,,,485.72,Other,100% of Medicaid,485.72,,,485.72,Other,100% of Medicaid,485.72,,,485.72,Other,100% of Medicaid,1092.86,,,1092.86,Other,225% of Medicaid,743.14,,,743.14,Other,153% of Medicaid,1092.86,,,1092.86,Other,225% of Medicaid,680,,,680,Other,140% of Medicaid,1092.86,,,1092.86,Other,225% of Medicaid,1262.86,,,1262.86,Other,260% of Medicaid,1573.72,,,1573.72,Other,324% of Medicaid,1044.29,,,1044.29,Other,215% of Medicaid,1044.29,,,1044.29,Other,215% of Medicaid,607.14,,,607.14,Other,125% of Medicaid,485.72,7216,
NJX PX NFROSGRM &/URTRGRM,50431,CPT,,47050431,CDM,360,RC,,,both,,,2318,1715.33,,,1715.33,Other,150% of Medicare + 9.63% HCRA Surcharge,1043.1,45,,1043.1,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",1147.41,,,1147.41,Other,110% of Medicare,1576.24,,,1576.24,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",903.43,,,903.43,Other,186% of Medicaid,1854.4,,,1854.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1854.4,,,1854.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1854.4,,,1854.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1622.6,70,,1622.6,percent of total billed charges,All Other,309.96,,,309.96,Fee Schedule,,262.71,,,262.71,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",485.72,,,485.72,Other,100% of Medicaid,485.72,,,485.72,Other,100% of Medicaid,485.72,,,485.72,Other,100% of Medicaid,485.72,,,485.72,Other,100% of Medicaid,1092.86,,,1092.86,Other,225% of Medicaid,743.14,,,743.14,Other,153% of Medicaid,1092.86,,,1092.86,Other,225% of Medicaid,680,,,680,Other,140% of Medicaid,1092.86,,,1092.86,Other,225% of Medicaid,1262.86,,,1262.86,Other,260% of Medicaid,1573.72,,,1573.72,Other,324% of Medicaid,1044.29,,,1044.29,Other,215% of Medicaid,1044.29,,,1044.29,Other,215% of Medicaid,607.14,,,607.14,Other,125% of Medicaid,262.71,7216,
PLMT NEPHROSTOMY CATHETER,50432,CPT,,47050432,CDM,360,RC,,,both,,,6214,4598.38,,,4598.38,Other,150% of Medicare + 9.63% HCRA Surcharge,2796.3,45,,2796.3,percent of total billed charges,Critical Access Hospital RCC factor,2480,,,2480,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2232,,,2232,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3648,,,3648,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3283,,,3283,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3101,,,3101,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3075.93,,,3075.93,Other,110% of Medicare,4225.52,,,4225.52,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2011.18,,,2011.18,Other,186% of Medicaid,4971.2,,,4971.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",4971.2,,,4971.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",4971.2,,,4971.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",4349.8,70,,4349.8,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",4531,,,4531,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4079,,,4079,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4531,,,4531,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3852,,,3852,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",1081.28,,,1081.28,Other,100% of Medicaid,1081.28,,,1081.28,Other,100% of Medicaid,1081.28,,,1081.28,Other,100% of Medicaid,1081.28,,,1081.28,Other,100% of Medicaid,2432.88,,,2432.88,Other,225% of Medicaid,1654.36,,,1654.36,Other,153% of Medicaid,2432.88,,,2432.88,Other,225% of Medicaid,1513.79,,,1513.79,Other,140% of Medicaid,2432.88,,,2432.88,Other,225% of Medicaid,2811.33,,,2811.33,Other,260% of Medicaid,3503.35,,,3503.35,Other,324% of Medicaid,2324.75,,,2324.75,Other,215% of Medicaid,2324.75,,,2324.75,Other,215% of Medicaid,1351.6,,,1351.6,Other,125% of Medicaid,1081.28,7216,
PLMT NEPHROURETERAL CATHETER,50433,CPT,,47050433,CDM,360,RC,,,both,,,7216,5339.86,,,5339.86,Other,150% of Medicare + 9.63% HCRA Surcharge,3247.2,45,,3247.2,percent of total billed charges,Critical Access Hospital RCC factor,2480,,,2480,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2232,,,2232,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3648,,,3648,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3283,,,3283,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3101,,,3101,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3571.92,,,3571.92,Other,110% of Medicare,4906.88,,,4906.88,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2586.25,,,2586.25,Other,186% of Medicaid,5772.8,,,5772.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",5772.8,,,5772.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",5772.8,,,5772.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",5051.2,70,,5051.2,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",4531,,,4531,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4079,,,4079,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4531,,,4531,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3852,,,3852,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",1390.46,,,1390.46,Other,100% of Medicaid,1390.46,,,1390.46,Other,100% of Medicaid,1390.46,,,1390.46,Other,100% of Medicaid,1390.46,,,1390.46,Other,100% of Medicaid,3128.53,,,3128.53,Other,225% of Medicaid,2127.4,,,2127.4,Other,153% of Medicaid,3128.53,,,3128.53,Other,225% of Medicaid,1946.64,,,1946.64,Other,140% of Medicaid,3128.53,,,3128.53,Other,225% of Medicaid,3615.19,,,3615.19,Other,260% of Medicaid,4505.09,,,4505.09,Other,324% of Medicaid,2989.49,,,2989.49,Other,215% of Medicaid,2989.49,,,2989.49,Other,215% of Medicaid,1738.07,,,1738.07,Other,125% of Medicaid,1390.46,7216,
CONVERT NEPHROSTOMY CATHETER,50434,CPT,,47050434,CDM,360,RC,,,both,,,4176,3090.25,,,3090.25,Other,150% of Medicare + 9.63% HCRA Surcharge,1879.2,45,,1879.2,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3648,,,3648,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3283,,,3283,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3101,,,3101,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2067.12,,,2067.12,Other,110% of Medicare,2839.68,,,2839.68,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2011.18,,,2011.18,Other,186% of Medicaid,3340.8,,,3340.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",3340.8,,,3340.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",3340.8,,,3340.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2923.2,70,,2923.2,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",1081.28,,,1081.28,Other,100% of Medicaid,1081.28,,,1081.28,Other,100% of Medicaid,1081.28,,,1081.28,Other,100% of Medicaid,1081.28,,,1081.28,Other,100% of Medicaid,2432.88,,,2432.88,Other,225% of Medicaid,1654.36,,,1654.36,Other,153% of Medicaid,2432.88,,,2432.88,Other,225% of Medicaid,1513.79,,,1513.79,Other,140% of Medicaid,2432.88,,,2432.88,Other,225% of Medicaid,2811.33,,,2811.33,Other,260% of Medicaid,3503.35,,,3503.35,Other,324% of Medicaid,2324.75,,,2324.75,Other,215% of Medicaid,2324.75,,,2324.75,Other,215% of Medicaid,1351.6,,,1351.6,Other,125% of Medicaid,1081.28,7216,
EXCHANGE NEPHROSTOMY CATH,50435,CPT,,47050435,CDM,360,RC,,,both,,,4176,3090.25,,,3090.25,Other,150% of Medicare + 9.63% HCRA Surcharge,1879.2,45,,1879.2,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3648,,,3648,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3283,,,3283,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3101,,,3101,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2067.12,,,2067.12,Other,110% of Medicare,2839.68,,,2839.68,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2011.18,,,2011.18,Other,186% of Medicaid,3340.8,,,3340.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",3340.8,,,3340.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",3340.8,,,3340.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2923.2,70,,2923.2,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",1081.28,,,1081.28,Other,100% of Medicaid,1081.28,,,1081.28,Other,100% of Medicaid,1081.28,,,1081.28,Other,100% of Medicaid,1081.28,,,1081.28,Other,100% of Medicaid,2432.88,,,2432.88,Other,225% of Medicaid,1654.36,,,1654.36,Other,153% of Medicaid,2432.88,,,2432.88,Other,225% of Medicaid,1513.79,,,1513.79,Other,140% of Medicaid,2432.88,,,2432.88,Other,225% of Medicaid,2811.33,,,2811.33,Other,260% of Medicaid,3503.35,,,3503.35,Other,324% of Medicaid,2324.75,,,2324.75,Other,215% of Medicaid,2324.75,,,2324.75,Other,215% of Medicaid,1351.6,,,1351.6,Other,125% of Medicaid,1081.28,7216,
CREATE PASSAGE TO KIDNEY,50437,CPT,,47050437,CDM,360,RC,,,both,,,8589,6355.88,,,6355.88,Other,150% of Medicare + 9.63% HCRA Surcharge,3865.05,45,,3865.05,percent of total billed charges,Critical Access Hospital RCC factor,2480,,,2480,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2232,,,2232,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4476,,,4476,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4028,,,4028,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3805,,,3805,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4251.56,,,4251.56,Other,110% of Medicare,5840.52,,,5840.52,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2011.18,,,2011.18,Other,186% of Medicaid,6871.2,,,6871.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",6871.2,,,6871.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",6871.2,,,6871.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",6012.3,70,,6012.3,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",4913,,,4913,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4422,,,4422,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4913,,,4913,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4176,,,4176,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",1081.28,,,1081.28,Other,100% of Medicaid,1081.28,,,1081.28,Other,100% of Medicaid,1081.28,,,1081.28,Other,100% of Medicaid,1081.28,,,1081.28,Other,100% of Medicaid,2432.88,,,2432.88,Other,225% of Medicaid,1654.36,,,1654.36,Other,153% of Medicaid,2432.88,,,2432.88,Other,225% of Medicaid,1513.79,,,1513.79,Other,140% of Medicaid,2432.88,,,2432.88,Other,225% of Medicaid,2811.33,,,2811.33,Other,260% of Medicaid,3503.35,,,3503.35,Other,324% of Medicaid,2324.75,,,2324.75,Other,215% of Medicaid,2324.75,,,2324.75,Other,215% of Medicaid,1351.6,,,1351.6,Other,125% of Medicaid,1081.28,7216,
ENDOLUMINAL BX URTR RNL PLVS,50606,CPT,,47050606,CDM,360,RC,,,both,,,657,486.18,,,486.18,Other,150% of Medicare + 9.63% HCRA Surcharge,295.65,45,,295.65,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",325.22,,,325.22,Other,110% of Medicare,446.76,,,446.76,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",3435.71,,,3435.71,Other,186% of Medicaid,525.6,,,525.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",525.6,,,525.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",525.6,,,525.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",459.9,70,,459.9,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",1847.16,,,1847.16,Other,100% of Medicaid,1847.16,,,1847.16,Other,100% of Medicaid,1847.16,,,1847.16,Other,100% of Medicaid,1847.16,,,1847.16,Other,100% of Medicaid,4156.1,,,4156.1,Other,225% of Medicaid,2826.15,,,2826.15,Other,153% of Medicaid,4156.1,,,4156.1,Other,225% of Medicaid,2586.02,,,2586.02,Other,140% of Medicaid,4156.1,,,4156.1,Other,225% of Medicaid,4802.61,,,4802.61,Other,260% of Medicaid,5984.79,,,5984.79,Other,324% of Medicaid,3971.39,,,3971.39,Other,215% of Medicaid,3971.39,,,3971.39,Other,215% of Medicaid,2308.95,,,2308.95,Other,125% of Medicaid,295.65,7216,
INJ FOR URETEROGRAM THRU INDWELLING CATH,50684,CPT,,47050684,CDM,360,RC,,,both,,,198,146.52,,,146.52,Other,150% of Medicare + 9.63% HCRA Surcharge,89.1,45,,89.1,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",98.01,,,98.01,Other,110% of Medicare,134.64,,,134.64,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",966.93,,,966.93,Other,186% of Medicaid,158.4,,,158.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",158.4,,,158.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",158.4,,,158.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",138.6,70,,138.6,percent of total billed charges,All Other,239.44,,,239.44,Fee Schedule,,202.94,,,202.94,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",519.86,,,519.86,Other,100% of Medicaid,519.86,,,519.86,Other,100% of Medicaid,519.86,,,519.86,Other,100% of Medicaid,519.86,,,519.86,Other,100% of Medicaid,1169.68,,,1169.68,Other,225% of Medicaid,795.38,,,795.38,Other,153% of Medicaid,1169.68,,,1169.68,Other,225% of Medicaid,727.8,,,727.8,Other,140% of Medicaid,1169.68,,,1169.68,Other,225% of Medicaid,1351.62,,,1351.62,Other,260% of Medicaid,1684.33,,,1684.33,Other,324% of Medicaid,1117.69,,,1117.69,Other,215% of Medicaid,1117.69,,,1117.69,Other,215% of Medicaid,649.82,,,649.82,Other,125% of Medicaid,89.1,7216,
PLMT URETERAL STENT PRQ,50693,CPT,,47050693,CDM,360,RC,,,both,,,9252,6846.5,,,6846.5,Other,150% of Medicare + 9.63% HCRA Surcharge,4163.4,45,,4163.4,percent of total billed charges,Critical Access Hospital RCC factor,3473,,,3473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3126,,,3126,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3648,,,3648,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3283,,,3283,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3101,,,3101,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4579.74,,,4579.74,Other,110% of Medicare,6152,,,6152,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2586.25,,,2586.25,Other,186% of Medicaid,7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7401.6,,,7401.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",6476.4,70,,6476.4,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",4913,,,4913,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4422,,,4422,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4913,,,4913,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4176,,,4176,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",1390.46,,,1390.46,Other,100% of Medicaid,1390.46,,,1390.46,Other,100% of Medicaid,1390.46,,,1390.46,Other,100% of Medicaid,1390.46,,,1390.46,Other,100% of Medicaid,3128.53,,,3128.53,Other,225% of Medicaid,2127.4,,,2127.4,Other,153% of Medicaid,3128.53,,,3128.53,Other,225% of Medicaid,1946.64,,,1946.64,Other,140% of Medicaid,3128.53,,,3128.53,Other,225% of Medicaid,3615.19,,,3615.19,Other,260% of Medicaid,4505.09,,,4505.09,Other,324% of Medicaid,2989.49,,,2989.49,Other,215% of Medicaid,2989.49,,,2989.49,Other,215% of Medicaid,1738.07,,,1738.07,Other,125% of Medicaid,1390.46,9473,
PLMT URETERAL STENT PRQ,50694,CPT,,47050694,CDM,360,RC,,,both,,,9252,6846.5,,,6846.5,Other,150% of Medicare + 9.63% HCRA Surcharge,4163.4,45,,4163.4,percent of total billed charges,Critical Access Hospital RCC factor,3473,,,3473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3126,,,3126,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4476,,,4476,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4028,,,4028,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3805,,,3805,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4579.74,,,4579.74,Other,110% of Medicare,6152,,,6152,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2586.25,,,2586.25,Other,186% of Medicaid,7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7401.6,,,7401.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",6476.4,70,,6476.4,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",4913,,,4913,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4422,,,4422,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4913,,,4913,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4176,,,4176,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",1390.46,,,1390.46,Other,100% of Medicaid,1390.46,,,1390.46,Other,100% of Medicaid,1390.46,,,1390.46,Other,100% of Medicaid,1390.46,,,1390.46,Other,100% of Medicaid,3128.53,,,3128.53,Other,225% of Medicaid,2127.4,,,2127.4,Other,153% of Medicaid,3128.53,,,3128.53,Other,225% of Medicaid,1946.64,,,1946.64,Other,140% of Medicaid,3128.53,,,3128.53,Other,225% of Medicaid,3615.19,,,3615.19,Other,260% of Medicaid,4505.09,,,4505.09,Other,324% of Medicaid,2989.49,,,2989.49,Other,215% of Medicaid,2989.49,,,2989.49,Other,215% of Medicaid,1738.07,,,1738.07,Other,125% of Medicaid,1390.46,9473,
PLMT URETERAL STENT PRQ,50695,CPT,,47050695,CDM,360,RC,,,both,,,8488,6281.14,,,6281.14,Other,150% of Medicare + 9.63% HCRA Surcharge,3819.6,45,,3819.6,percent of total billed charges,Critical Access Hospital RCC factor,3473,,,3473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3126,,,3126,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4476,,,4476,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4028,,,4028,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3805,,,3805,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4201.56,,,4201.56,Other,110% of Medicare,6152,,,6152,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2586.25,,,2586.25,Other,186% of Medicaid,7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",6790.4,,,6790.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",5941.6,70,,5941.6,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",4913,,,4913,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4422,,,4422,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4913,,,4913,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4176,,,4176,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",1390.46,,,1390.46,Other,100% of Medicaid,1390.46,,,1390.46,Other,100% of Medicaid,1390.46,,,1390.46,Other,100% of Medicaid,1390.46,,,1390.46,Other,100% of Medicaid,3128.53,,,3128.53,Other,225% of Medicaid,2127.4,,,2127.4,Other,153% of Medicaid,3128.53,,,3128.53,Other,225% of Medicaid,1946.64,,,1946.64,Other,140% of Medicaid,3128.53,,,3128.53,Other,225% of Medicaid,3615.19,,,3615.19,Other,260% of Medicaid,4505.09,,,4505.09,Other,324% of Medicaid,2989.49,,,2989.49,Other,215% of Medicaid,2989.49,,,2989.49,Other,215% of Medicaid,1738.07,,,1738.07,Other,125% of Medicaid,1390.46,9473,
CYSTOSCOPY IMPLANT STENT,52282,CPT,,47052282,CDM,360,RC,,,both,,,10227,7568.01,,,7568.01,Other,150% of Medicare + 9.63% HCRA Surcharge,4602.15,45,,4602.15,percent of total billed charges,Critical Access Hospital RCC factor,3473,,,3473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3126,,,3126,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4476,,,4476,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4028,,,4028,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3805,,,3805,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",5062.37,,,5062.37,Other,110% of Medicare,6152,,,6152,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1857.5,,,1857.5,Other,186% of Medicaid,7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9196,,,9196,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7158.9,70,,7158.9,percent of total billed charges,All Other,3387,,,3387,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",2879,,,2879,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",4531,,,4531,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4079,,,4079,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4531,,,4531,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3852,,,3852,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",998.66,,,998.66,Other,100% of Medicaid,998.66,,,998.66,Other,100% of Medicaid,998.66,,,998.66,Other,100% of Medicaid,998.66,,,998.66,Other,100% of Medicaid,2246.97,,,2246.97,Other,225% of Medicaid,1527.94,,,1527.94,Other,153% of Medicaid,2246.97,,,2246.97,Other,225% of Medicaid,1398.12,,,1398.12,Other,140% of Medicaid,2246.97,,,2246.97,Other,225% of Medicaid,2596.5,,,2596.5,Other,260% of Medicaid,3235.64,,,3235.64,Other,324% of Medicaid,2147.11,,,2147.11,Other,215% of Medicaid,2147.11,,,2147.11,Other,215% of Medicaid,1248.32,,,1248.32,Other,125% of Medicaid,998.66,9473,
TC EMBOLIZ HEMOST TUMOR NOT CN,61626,CPT,,47061626,CDM,360,RC,,,both,,,30955,22906.78,,,22906.78,Other,150% of Medicare + 9.63% HCRA Surcharge,13929.75,45,,13929.75,percent of total billed charges,Critical Access Hospital RCC factor,5459,,,5459,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4913,,,4913,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",7978,,,7978,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",7180,,,7180,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",6781,,,6781,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",15322.73,,,15322.73,Other,110% of Medicare,6152,,,6152,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",4555.38,,,4555.38,Other,186% of Medicaid,7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",24764,,,24764,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",21668.5,70,,21668.5,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",6956,,,6956,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",6261,,,6261,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",6956,,,6956,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",5913,,,5913,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2449.13,,,2449.13,Other,100% of Medicaid,2449.13,,,2449.13,Other,100% of Medicaid,2449.13,,,2449.13,Other,100% of Medicaid,2449.13,,,2449.13,Other,100% of Medicaid,5510.54,,,5510.54,Other,225% of Medicaid,3747.17,,,3747.17,Other,153% of Medicaid,5510.54,,,5510.54,Other,225% of Medicaid,3428.78,,,3428.78,Other,140% of Medicaid,5510.54,,,5510.54,Other,225% of Medicaid,6367.74,,,6367.74,Other,260% of Medicaid,7935.18,,,7935.18,Other,324% of Medicaid,5265.63,,,5265.63,Other,215% of Medicaid,5265.63,,,5265.63,Other,215% of Medicaid,3061.41,,,3061.41,Other,125% of Medicaid,2449.13,24764,
EVASC PRLNG ADMN RX AGNT 1ST,61650,CPT,,47061650,CDM,360,RC,,,both,,,2293,1696.83,,,1696.83,Other,150% of Medicare + 9.63% HCRA Surcharge,1031.85,45,,1031.85,percent of total billed charges,Critical Access Hospital RCC factor,4565,,,4565,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4109,,,4109,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",6807,,,6807,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",6126,,,6126,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",5786,,,5786,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",1135.04,,,1135.04,Other,110% of Medicare,1559.24,,,1559.24,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",4048.95,,,4048.95,Other,186% of Medicaid,1834.4,,,1834.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1834.4,,,1834.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1834.4,,,1834.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1605.1,70,,1605.1,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",4531,,,4531,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4079,,,4079,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4531,,,4531,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3852,,,3852,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2176.86,,,2176.86,Other,100% of Medicaid,2176.86,,,2176.86,Other,100% of Medicaid,2176.86,,,2176.86,Other,100% of Medicaid,2176.86,,,2176.86,Other,100% of Medicaid,4897.92,,,4897.92,Other,225% of Medicaid,3330.59,,,3330.59,Other,153% of Medicaid,4897.92,,,4897.92,Other,225% of Medicaid,3047.6,,,3047.6,Other,140% of Medicaid,4897.92,,,4897.92,Other,225% of Medicaid,5659.82,,,5659.82,Other,260% of Medicaid,7053.01,,,7053.01,Other,324% of Medicaid,4680.24,,,4680.24,Other,215% of Medicaid,4680.24,,,4680.24,Other,215% of Medicaid,2721.07,,,2721.07,Other,125% of Medicaid,1031.85,7216,
EVASC PRLNG ADMN RX AGNT ADD,61651,CPT,,47061651,CDM,360,RC,,,both,,,978,723.72,,,723.72,Other,150% of Medicare + 9.63% HCRA Surcharge,440.1,45,,440.1,percent of total billed charges,Critical Access Hospital RCC factor,4565,,,4565,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4109,,,4109,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",6807,,,6807,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",6126,,,6126,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",5786,,,5786,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",484.11,,,484.11,Other,110% of Medicare,665.04,,,665.04,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",4048.95,,,4048.95,Other,186% of Medicaid,782.4,,,782.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",782.4,,,782.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",782.4,,,782.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",684.6,70,,684.6,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",4531,,,4531,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4079,,,4079,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4531,,,4531,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3852,,,3852,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2176.86,,,2176.86,Other,100% of Medicaid,2176.86,,,2176.86,Other,100% of Medicaid,2176.86,,,2176.86,Other,100% of Medicaid,2176.86,,,2176.86,Other,100% of Medicaid,4897.92,,,4897.92,Other,225% of Medicaid,3330.59,,,3330.59,Other,153% of Medicaid,4897.92,,,4897.92,Other,225% of Medicaid,3047.6,,,3047.6,Other,140% of Medicaid,4897.92,,,4897.92,Other,225% of Medicaid,5659.82,,,5659.82,Other,260% of Medicaid,7053.01,,,7053.01,Other,324% of Medicaid,4680.24,,,4680.24,Other,215% of Medicaid,4680.24,,,4680.24,Other,215% of Medicaid,2721.07,,,2721.07,Other,125% of Medicaid,440.1,7216,
LUMBAR PUNC MYELOGRAM,62284,CPT,,47062284,CDM,360,RC,,,both,,,844,624.56,,,624.56,Other,150% of Medicare + 9.63% HCRA Surcharge,379.8,45,,379.8,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",417.78,,,417.78,Other,110% of Medicare,573.92,,,573.92,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",966.93,,,966.93,Other,186% of Medicaid,675.2,,,675.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",675.2,,,675.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",675.2,,,675.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",590.8,70,,590.8,percent of total billed charges,All Other,406.72,,,406.72,Fee Schedule,,344.72,,,344.72,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",519.86,,,519.86,Other,100% of Medicaid,519.86,,,519.86,Other,100% of Medicaid,519.86,,,519.86,Other,100% of Medicaid,519.86,,,519.86,Other,100% of Medicaid,1169.68,,,1169.68,Other,225% of Medicaid,795.38,,,795.38,Other,153% of Medicaid,1169.68,,,1169.68,Other,225% of Medicaid,727.8,,,727.8,Other,140% of Medicaid,1169.68,,,1169.68,Other,225% of Medicaid,1351.62,,,1351.62,Other,260% of Medicaid,1684.33,,,1684.33,Other,324% of Medicaid,1117.69,,,1117.69,Other,215% of Medicaid,1117.69,,,1117.69,Other,215% of Medicaid,649.82,,,649.82,Other,125% of Medicaid,344.72,7216,
INJ ANESTH GREATER OCCIPITAL NERVE,64405,CPT,,47064405,CDM,360,RC,,,both,,,1164,861.36,,,861.36,Other,150% of Medicare + 9.63% HCRA Surcharge,523.8,45,,523.8,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",576.18,,,576.18,Other,110% of Medicare,791.52,,,791.52,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",966.11,,,966.11,Other,186% of Medicaid,931.2,,,931.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",931.2,,,931.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",931.2,,,931.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",814.8,70,,814.8,percent of total billed charges,All Other,255.84,,,255.84,Fee Schedule,,216.84,,,216.84,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",519.42,,,519.42,Other,100% of Medicaid,519.42,,,519.42,Other,100% of Medicaid,519.42,,,519.42,Other,100% of Medicaid,519.42,,,519.42,Other,100% of Medicaid,1168.69,,,1168.69,Other,225% of Medicaid,794.71,,,794.71,Other,153% of Medicaid,1168.69,,,1168.69,Other,225% of Medicaid,727.18,,,727.18,Other,140% of Medicaid,1168.69,,,1168.69,Other,225% of Medicaid,1350.48,,,1350.48,Other,260% of Medicaid,1682.91,,,1682.91,Other,324% of Medicaid,1116.74,,,1116.74,Other,215% of Medicaid,1116.74,,,1116.74,Other,215% of Medicaid,649.27,,,649.27,Other,125% of Medicaid,216.84,7216,
INJ FORAMEN EPIDURAL C/T,64479,CPT,,47064479,CDM,360,RC,,,both,,,2231,1650.95,,,1650.95,Other,150% of Medicare + 9.63% HCRA Surcharge,1003.95,45,,1003.95,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",1104.35,,,1104.35,Other,110% of Medicare,1517.08,,,1517.08,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1116.35,,,1116.35,Other,186% of Medicaid,1784.8,,,1784.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1784.8,,,1784.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",3578,,,3578,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1561.7,70,,1561.7,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",600.19,,,600.19,Other,100% of Medicaid,600.19,,,600.19,Other,100% of Medicaid,600.19,,,600.19,Other,100% of Medicaid,600.19,,,600.19,Other,100% of Medicaid,1350.43,,,1350.43,Other,225% of Medicaid,918.29,,,918.29,Other,153% of Medicaid,1350.43,,,1350.43,Other,225% of Medicaid,840.26,,,840.26,Other,140% of Medicaid,1350.43,,,1350.43,Other,225% of Medicaid,1560.49,,,1560.49,Other,260% of Medicaid,1944.61,,,1944.61,Other,324% of Medicaid,1290.41,,,1290.41,Other,215% of Medicaid,1290.41,,,1290.41,Other,215% of Medicaid,750.24,,,750.24,Other,125% of Medicaid,600.19,7216,
INJ FORAMEN EPIDURAL C/T ADD-ON,64480,CPT,,47064480,CDM,360,RC,,,both,,,1152,852.48,,,852.48,Other,150% of Medicare + 9.63% HCRA Surcharge,518.4,45,,518.4,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",570.24,,,570.24,Other,110% of Medicare,783.36,,,783.36,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1116.35,,,1116.35,Other,186% of Medicaid,921.6,,,921.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",921.6,,,921.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",3578,,,3578,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",806.4,70,,806.4,percent of total billed charges,All Other,293.56,,,293.56,Fee Schedule,,248.81,,,248.81,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",600.19,,,600.19,Other,100% of Medicaid,600.19,,,600.19,Other,100% of Medicaid,600.19,,,600.19,Other,100% of Medicaid,600.19,,,600.19,Other,100% of Medicaid,1350.43,,,1350.43,Other,225% of Medicaid,918.29,,,918.29,Other,153% of Medicaid,1350.43,,,1350.43,Other,225% of Medicaid,840.26,,,840.26,Other,140% of Medicaid,1350.43,,,1350.43,Other,225% of Medicaid,1560.49,,,1560.49,Other,260% of Medicaid,1944.61,,,1944.61,Other,324% of Medicaid,1290.41,,,1290.41,Other,215% of Medicaid,1290.41,,,1290.41,Other,215% of Medicaid,750.24,,,750.24,Other,125% of Medicaid,248.81,7216,
INJ ANES TRANS EPI LUM X 1,64483,CPT,,47064483,CDM,360,RC,,,both,,,2477,1832.99,,,1832.99,Other,150% of Medicare + 9.63% HCRA Surcharge,1114.65,45,,1114.65,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",1226.12,,,1226.12,Other,110% of Medicare,1684.36,,,1684.36,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1116.35,,,1116.35,Other,186% of Medicaid,1981.6,,,1981.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1981.6,,,1981.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",3578,,,3578,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1733.9,70,,1733.9,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",600.19,,,600.19,Other,100% of Medicaid,600.19,,,600.19,Other,100% of Medicaid,600.19,,,600.19,Other,100% of Medicaid,600.19,,,600.19,Other,100% of Medicaid,1350.43,,,1350.43,Other,225% of Medicaid,918.29,,,918.29,Other,153% of Medicaid,1350.43,,,1350.43,Other,225% of Medicaid,840.26,,,840.26,Other,140% of Medicaid,1350.43,,,1350.43,Other,225% of Medicaid,1560.49,,,1560.49,Other,260% of Medicaid,1944.61,,,1944.61,Other,324% of Medicaid,1290.41,,,1290.41,Other,215% of Medicaid,1290.41,,,1290.41,Other,215% of Medicaid,750.24,,,750.24,Other,125% of Medicaid,600.19,7216,
INJ FORAMEN EPIDURAL L/S ADD-ON,64484,CPT,,47064484,CDM,360,RC,,,both,,,1152,852.48,,,852.48,Other,150% of Medicare + 9.63% HCRA Surcharge,518.4,45,,518.4,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",570.24,,,570.24,Other,110% of Medicare,783.36,,,783.36,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1116.35,,,1116.35,Other,186% of Medicaid,921.6,,,921.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",921.6,,,921.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",3578,,,3578,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",806.4,70,,806.4,percent of total billed charges,All Other,247.64,,,247.64,Fee Schedule,,209.89,,,209.89,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",600.19,,,600.19,Other,100% of Medicaid,600.19,,,600.19,Other,100% of Medicaid,600.19,,,600.19,Other,100% of Medicaid,600.19,,,600.19,Other,100% of Medicaid,1350.43,,,1350.43,Other,225% of Medicaid,918.29,,,918.29,Other,153% of Medicaid,1350.43,,,1350.43,Other,225% of Medicaid,840.26,,,840.26,Other,140% of Medicaid,1350.43,,,1350.43,Other,225% of Medicaid,1560.49,,,1560.49,Other,260% of Medicaid,1944.61,,,1944.61,Other,324% of Medicaid,1290.41,,,1290.41,Other,215% of Medicaid,1290.41,,,1290.41,Other,215% of Medicaid,750.24,,,750.24,Other,125% of Medicaid,209.89,7216,
INJ ANES FACET JT C/T X1,64490,CPT,,47064490,CDM,360,RC,,,both,,,2477,1832.99,,,1832.99,Other,150% of Medicare + 9.63% HCRA Surcharge,1114.65,45,,1114.65,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",1226.12,,,1226.12,Other,110% of Medicare,1684.36,,,1684.36,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1116.35,,,1116.35,Other,186% of Medicaid,1981.6,,,1981.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1981.6,,,1981.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1981.6,,,1981.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1733.9,70,,1733.9,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",600.19,,,600.19,Other,100% of Medicaid,600.19,,,600.19,Other,100% of Medicaid,600.19,,,600.19,Other,100% of Medicaid,600.19,,,600.19,Other,100% of Medicaid,1350.43,,,1350.43,Other,225% of Medicaid,918.29,,,918.29,Other,153% of Medicaid,1350.43,,,1350.43,Other,225% of Medicaid,840.26,,,840.26,Other,140% of Medicaid,1350.43,,,1350.43,Other,225% of Medicaid,1560.49,,,1560.49,Other,260% of Medicaid,1944.61,,,1944.61,Other,324% of Medicaid,1290.41,,,1290.41,Other,215% of Medicaid,1290.41,,,1290.41,Other,215% of Medicaid,750.24,,,750.24,Other,125% of Medicaid,600.19,7216,
INJ ANES FACET JT C/T ADDL,64491,CPT,,47064491,CDM,360,RC,,,both,,,871,644.54,,,644.54,Other,150% of Medicare + 9.63% HCRA Surcharge,391.95,45,,391.95,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",431.15,,,431.15,Other,110% of Medicare,592.28,,,592.28,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1116.35,,,1116.35,Other,186% of Medicaid,696.8,,,696.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",696.8,,,696.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",696.8,,,696.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",609.7,70,,609.7,percent of total billed charges,All Other,285.36,,,285.36,Fee Schedule,,241.86,,,241.86,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",600.19,,,600.19,Other,100% of Medicaid,600.19,,,600.19,Other,100% of Medicaid,600.19,,,600.19,Other,100% of Medicaid,600.19,,,600.19,Other,100% of Medicaid,1350.43,,,1350.43,Other,225% of Medicaid,918.29,,,918.29,Other,153% of Medicaid,1350.43,,,1350.43,Other,225% of Medicaid,840.26,,,840.26,Other,140% of Medicaid,1350.43,,,1350.43,Other,225% of Medicaid,1560.49,,,1560.49,Other,260% of Medicaid,1944.61,,,1944.61,Other,324% of Medicaid,1290.41,,,1290.41,Other,215% of Medicaid,1290.41,,,1290.41,Other,215% of Medicaid,750.24,,,750.24,Other,125% of Medicaid,241.86,7216,
INJ PARAVERT F JNT C/T 3 LEV,64492,CPT,,47064492,CDM,360,RC,,,both,,,871,644.54,,,644.54,Other,150% of Medicare + 9.63% HCRA Surcharge,391.95,45,,391.95,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",431.15,,,431.15,Other,110% of Medicare,592.28,,,592.28,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1116.35,,,1116.35,Other,186% of Medicaid,696.8,,,696.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",696.8,,,696.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",696.8,,,696.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",609.7,70,,609.7,percent of total billed charges,All Other,288.64,,,288.64,Fee Schedule,,244.64,,,244.64,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",600.19,,,600.19,Other,100% of Medicaid,600.19,,,600.19,Other,100% of Medicaid,600.19,,,600.19,Other,100% of Medicaid,600.19,,,600.19,Other,100% of Medicaid,1350.43,,,1350.43,Other,225% of Medicaid,918.29,,,918.29,Other,153% of Medicaid,1350.43,,,1350.43,Other,225% of Medicaid,840.26,,,840.26,Other,140% of Medicaid,1350.43,,,1350.43,Other,225% of Medicaid,1560.49,,,1560.49,Other,260% of Medicaid,1944.61,,,1944.61,Other,324% of Medicaid,1290.41,,,1290.41,Other,215% of Medicaid,1290.41,,,1290.41,Other,215% of Medicaid,750.24,,,750.24,Other,125% of Medicaid,244.64,7216,
INJ FACET JNT-LMBR/SACRL,64493,CPT,,47064493,CDM,360,RC,,,both,,,2477,1832.99,,,1832.99,Other,150% of Medicare + 9.63% HCRA Surcharge,1114.65,45,,1114.65,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",1226.12,,,1226.12,Other,110% of Medicare,1684.36,,,1684.36,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1116.35,,,1116.35,Other,186% of Medicaid,1981.6,,,1981.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1981.6,,,1981.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1981.6,,,1981.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1733.9,70,,1733.9,percent of total billed charges,All Other,431.32,,,431.32,Fee Schedule,,365.57,,,365.57,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",600.19,,,600.19,Other,100% of Medicaid,600.19,,,600.19,Other,100% of Medicaid,600.19,,,600.19,Other,100% of Medicaid,600.19,,,600.19,Other,100% of Medicaid,1350.43,,,1350.43,Other,225% of Medicaid,918.29,,,918.29,Other,153% of Medicaid,1350.43,,,1350.43,Other,225% of Medicaid,840.26,,,840.26,Other,140% of Medicaid,1350.43,,,1350.43,Other,225% of Medicaid,1560.49,,,1560.49,Other,260% of Medicaid,1944.61,,,1944.61,Other,324% of Medicaid,1290.41,,,1290.41,Other,215% of Medicaid,1290.41,,,1290.41,Other,215% of Medicaid,750.24,,,750.24,Other,125% of Medicaid,365.57,7216,
INJ ANES FACET JT L/S ADDL,64494,CPT,,47064494,CDM,360,RC,,,both,,,918,679.32,,,679.32,Other,150% of Medicare + 9.63% HCRA Surcharge,413.1,45,,413.1,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",454.41,,,454.41,Other,110% of Medicare,624.24,,,624.24,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1116.35,,,1116.35,Other,186% of Medicaid,734.4,,,734.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",734.4,,,734.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",734.4,,,734.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",642.6,70,,642.6,percent of total billed charges,All Other,246,,,246,Fee Schedule,,208.5,,,208.5,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",600.19,,,600.19,Other,100% of Medicaid,600.19,,,600.19,Other,100% of Medicaid,600.19,,,600.19,Other,100% of Medicaid,600.19,,,600.19,Other,100% of Medicaid,1350.43,,,1350.43,Other,225% of Medicaid,918.29,,,918.29,Other,153% of Medicaid,1350.43,,,1350.43,Other,225% of Medicaid,840.26,,,840.26,Other,140% of Medicaid,1350.43,,,1350.43,Other,225% of Medicaid,1560.49,,,1560.49,Other,260% of Medicaid,1944.61,,,1944.61,Other,324% of Medicaid,1290.41,,,1290.41,Other,215% of Medicaid,1290.41,,,1290.41,Other,215% of Medicaid,750.24,,,750.24,Other,125% of Medicaid,208.5,7216,
XR LUMBOSACRAL FACET BLOC,64495,CPT,,47064495,CDM,360,RC,,,both,,,871,644.54,,,644.54,Other,150% of Medicare + 9.63% HCRA Surcharge,391.95,45,,391.95,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",431.15,,,431.15,Other,110% of Medicare,592.28,,,592.28,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1116.35,,,1116.35,Other,186% of Medicaid,696.8,,,696.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",696.8,,,696.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",696.8,,,696.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",609.7,70,,609.7,percent of total billed charges,All Other,249.28,,,249.28,Fee Schedule,,211.28,,,211.28,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",600.19,,,600.19,Other,100% of Medicaid,600.19,,,600.19,Other,100% of Medicaid,600.19,,,600.19,Other,100% of Medicaid,600.19,,,600.19,Other,100% of Medicaid,1350.43,,,1350.43,Other,225% of Medicaid,918.29,,,918.29,Other,153% of Medicaid,1350.43,,,1350.43,Other,225% of Medicaid,840.26,,,840.26,Other,140% of Medicaid,1350.43,,,1350.43,Other,225% of Medicaid,1560.49,,,1560.49,Other,260% of Medicaid,1944.61,,,1944.61,Other,324% of Medicaid,1290.41,,,1290.41,Other,215% of Medicaid,1290.41,,,1290.41,Other,215% of Medicaid,750.24,,,750.24,Other,125% of Medicaid,211.28,7216,
PERITONEOGRAM AFTER INJECTION,74190,CPT,,47074190,CDM,360,RC,,,both,,,2943,2177.83,,,2177.83,Other,150% of Medicare + 9.63% HCRA Surcharge,1324.35,45,,1324.35,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",0.01,,,0.01,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1456.79,,,1456.79,Other,110% of Medicare,2001.24,68,,2001.24,percent of total billed charges,All Other,392,,,392,Other,186% of Medicaid,2354.4,80,,2354.4,percent of total billed charges,All Other,2442.69,83,,2442.69,percent of total billed charges,All Other,2442.69,83,,2442.69,percent of total billed charges,All Other,2354.4,80,,2354.4,percent of total billed charges,All Other,2442.69,83,,2442.69,percent of total billed charges,All Other,2354.4,,,2354.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2060.1,70,,2060.1,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",210.57,,,210.57,Other,100% of Medicaid,210.57,,,210.57,Other,100% of Medicaid,210.57,,,210.57,Other,100% of Medicaid,210.57,,,210.57,Other,100% of Medicaid,473.77,,,473.77,Other,225% of Medicaid,322.17,,,322.17,Other,153% of Medicaid,473.77,,,473.77,Other,225% of Medicaid,294.79,,,294.79,Other,140% of Medicaid,473.77,,,473.77,Other,225% of Medicaid,547.47,,,547.47,Other,260% of Medicaid,682.23,,,682.23,Other,324% of Medicaid,452.72,,,452.72,Other,215% of Medicaid,452.72,,,452.72,Other,215% of Medicaid,263.21,,,263.21,Other,125% of Medicaid,0.01,3933,
PLACE CATH THORACIC AORTA LT,36221,CPT,LT,47136221,CDM,360,RC,,,both,,,9535,7055.92,,,7055.92,Other,150% of Medicare + 9.63% HCRA Surcharge,4290.75,45,,4290.75,percent of total billed charges,Critical Access Hospital RCC factor,2480,,,2480,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2232,,,2232,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4476,,,4476,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4028,,,4028,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3805,,,3805,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4719.83,,,4719.83,Other,110% of Medicare,6483.8,,,6483.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1729.46,,,1729.46,Other,186% of Medicaid,7628,,,7628,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7628,,,7628,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7628,,,7628,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",6674.5,70,,6674.5,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",4913,,,4913,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4422,,,4422,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4913,,,4913,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4176,,,4176,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",929.82,,,929.82,Other,100% of Medicaid,929.82,,,929.82,Other,100% of Medicaid,929.82,,,929.82,Other,100% of Medicaid,929.82,,,929.82,Other,100% of Medicaid,2092.09,,,2092.09,Other,225% of Medicaid,1422.62,,,1422.62,Other,153% of Medicaid,2092.09,,,2092.09,Other,225% of Medicaid,1301.75,,,1301.75,Other,140% of Medicaid,2092.09,,,2092.09,Other,225% of Medicaid,2417.53,,,2417.53,Other,260% of Medicaid,3012.61,,,3012.61,Other,324% of Medicaid,1999.11,,,1999.11,Other,215% of Medicaid,1999.11,,,1999.11,Other,215% of Medicaid,1162.27,,,1162.27,Other,125% of Medicaid,929.82,7628,
PLACE CATH CAROTID/INOM ART LT,36222,CPT,LT,47136222,CDM,360,RC,,,both,,,8748,6473.54,,,6473.54,Other,150% of Medicare + 9.63% HCRA Surcharge,3936.6,45,,3936.6,percent of total billed charges,Critical Access Hospital RCC factor,2480,,,2480,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2232,,,2232,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4476,,,4476,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4028,,,4028,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3805,,,3805,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4330.26,,,4330.26,Other,110% of Medicare,5948.64,,,5948.64,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1729.46,,,1729.46,Other,186% of Medicaid,6998.4,,,6998.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",6998.4,,,6998.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",6998.4,,,6998.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",6123.6,70,,6123.6,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",4913,,,4913,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4422,,,4422,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4913,,,4913,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4176,,,4176,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",929.82,,,929.82,Other,100% of Medicaid,929.82,,,929.82,Other,100% of Medicaid,929.82,,,929.82,Other,100% of Medicaid,929.82,,,929.82,Other,100% of Medicaid,2092.09,,,2092.09,Other,225% of Medicaid,1422.62,,,1422.62,Other,153% of Medicaid,2092.09,,,2092.09,Other,225% of Medicaid,1301.75,,,1301.75,Other,140% of Medicaid,2092.09,,,2092.09,Other,225% of Medicaid,2417.53,,,2417.53,Other,260% of Medicaid,3012.61,,,3012.61,Other,324% of Medicaid,1999.11,,,1999.11,Other,215% of Medicaid,1999.11,,,1999.11,Other,215% of Medicaid,1162.27,,,1162.27,Other,125% of Medicaid,929.82,7216,
PLACE CATH CAROTID/INOM ART LT,36223,CPT,LT,47136223,CDM,360,RC,,,both,,,11570,8561.83,,,8561.83,Other,150% of Medicare + 9.63% HCRA Surcharge,5206.5,45,,5206.5,percent of total billed charges,Critical Access Hospital RCC factor,2480,,,2480,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2232,,,2232,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4970,,,4970,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4473,,,4473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4225,,,4225,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",5727.15,,,5727.15,Other,110% of Medicare,7867.6,,,7867.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1729.46,,,1729.46,Other,186% of Medicaid,9256,,,9256,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9256,,,9256,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9256,,,9256,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",8099,70,,8099,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",6331,,,6331,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",5698,,,5698,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",6331,,,6331,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",5381,,,5381,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",929.82,,,929.82,Other,100% of Medicaid,929.82,,,929.82,Other,100% of Medicaid,929.82,,,929.82,Other,100% of Medicaid,929.82,,,929.82,Other,100% of Medicaid,2092.09,,,2092.09,Other,225% of Medicaid,1422.62,,,1422.62,Other,153% of Medicaid,2092.09,,,2092.09,Other,225% of Medicaid,1301.75,,,1301.75,Other,140% of Medicaid,2092.09,,,2092.09,Other,225% of Medicaid,2417.53,,,2417.53,Other,260% of Medicaid,3012.61,,,3012.61,Other,324% of Medicaid,1999.11,,,1999.11,Other,215% of Medicaid,1999.11,,,1999.11,Other,215% of Medicaid,1162.27,,,1162.27,Other,125% of Medicaid,929.82,9256,
PLACE CATH CAROTID ART LT,36224,CPT,LT,47136224,CDM,360,RC,,,both,,,14383,10643.46,,,10643.46,Other,150% of Medicare + 9.63% HCRA Surcharge,6472.35,45,,6472.35,percent of total billed charges,Critical Access Hospital RCC factor,3473,,,3473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3126,,,3126,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4970,,,4970,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4473,,,4473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4225,,,4225,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",7119.59,,,7119.59,Other,110% of Medicare,6152,,,6152,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1729.46,,,1729.46,Other,186% of Medicaid,7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",11506.4,,,11506.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",10068.1,70,,10068.1,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",6331,,,6331,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",5698,,,5698,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",6331,,,6331,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",5381,,,5381,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",929.82,,,929.82,Other,100% of Medicaid,929.82,,,929.82,Other,100% of Medicaid,929.82,,,929.82,Other,100% of Medicaid,929.82,,,929.82,Other,100% of Medicaid,2092.09,,,2092.09,Other,225% of Medicaid,1422.62,,,1422.62,Other,153% of Medicaid,2092.09,,,2092.09,Other,225% of Medicaid,1301.75,,,1301.75,Other,140% of Medicaid,2092.09,,,2092.09,Other,225% of Medicaid,2417.53,,,2417.53,Other,260% of Medicaid,3012.61,,,3012.61,Other,324% of Medicaid,1999.11,,,1999.11,Other,215% of Medicaid,1999.11,,,1999.11,Other,215% of Medicaid,1162.27,,,1162.27,Other,125% of Medicaid,929.82,11506.4,
PLACE CATH SUBCLAVIAN ART LT,36225,CPT,LT,47136225,CDM,360,RC,,,both,,,8748,6473.54,,,6473.54,Other,150% of Medicare + 9.63% HCRA Surcharge,3936.6,45,,3936.6,percent of total billed charges,Critical Access Hospital RCC factor,2480,,,2480,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2232,,,2232,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4476,,,4476,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4028,,,4028,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3805,,,3805,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4330.26,,,4330.26,Other,110% of Medicare,5948.64,,,5948.64,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1729.46,,,1729.46,Other,186% of Medicaid,6998.4,,,6998.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",6998.4,,,6998.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",6998.4,,,6998.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",6123.6,70,,6123.6,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",4913,,,4913,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4422,,,4422,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4913,,,4913,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4176,,,4176,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",929.82,,,929.82,Other,100% of Medicaid,929.82,,,929.82,Other,100% of Medicaid,929.82,,,929.82,Other,100% of Medicaid,929.82,,,929.82,Other,100% of Medicaid,2092.09,,,2092.09,Other,225% of Medicaid,1422.62,,,1422.62,Other,153% of Medicaid,2092.09,,,2092.09,Other,225% of Medicaid,1301.75,,,1301.75,Other,140% of Medicaid,2092.09,,,2092.09,Other,225% of Medicaid,2417.53,,,2417.53,Other,260% of Medicaid,3012.61,,,3012.61,Other,324% of Medicaid,1999.11,,,1999.11,Other,215% of Medicaid,1999.11,,,1999.11,Other,215% of Medicaid,1162.27,,,1162.27,Other,125% of Medicaid,929.82,7216,
PLACE CATH VERTEBRAL ART LT,36226,CPT,LT,47136226,CDM,360,RC,,,both,,,14383,10643.46,,,10643.46,Other,150% of Medicare + 9.63% HCRA Surcharge,6472.35,45,,6472.35,percent of total billed charges,Critical Access Hospital RCC factor,3473,,,3473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3126,,,3126,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4970,,,4970,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4473,,,4473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4225,,,4225,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",7119.59,,,7119.59,Other,110% of Medicare,6152,,,6152,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1729.46,,,1729.46,Other,186% of Medicaid,7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",11506.4,,,11506.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",10068.1,70,,10068.1,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",6331,,,6331,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",5698,,,5698,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",6331,,,6331,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",5381,,,5381,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",929.82,,,929.82,Other,100% of Medicaid,929.82,,,929.82,Other,100% of Medicaid,929.82,,,929.82,Other,100% of Medicaid,929.82,,,929.82,Other,100% of Medicaid,2092.09,,,2092.09,Other,225% of Medicaid,1422.62,,,1422.62,Other,153% of Medicaid,2092.09,,,2092.09,Other,225% of Medicaid,1301.75,,,1301.75,Other,140% of Medicaid,2092.09,,,2092.09,Other,225% of Medicaid,2417.53,,,2417.53,Other,260% of Medicaid,3012.61,,,3012.61,Other,324% of Medicaid,1999.11,,,1999.11,Other,215% of Medicaid,1999.11,,,1999.11,Other,215% of Medicaid,1162.27,,,1162.27,Other,125% of Medicaid,929.82,11506.4,
PLACE CATH XTRNL CAROTID LT,36227,CPT,LT,47136227,CDM,360,RC,,,both,,,430,318.2,,,318.2,Other,150% of Medicare + 9.63% HCRA Surcharge,193.5,45,,193.5,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4476,,,4476,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4028,,,4028,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3805,,,3805,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",212.85,,,212.85,Other,110% of Medicare,292.4,,,292.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1729.46,,,1729.46,Other,186% of Medicaid,344,,,344,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",344,,,344,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",344,,,344,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",301,70,,301,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",929.82,,,929.82,Other,100% of Medicaid,929.82,,,929.82,Other,100% of Medicaid,929.82,,,929.82,Other,100% of Medicaid,929.82,,,929.82,Other,100% of Medicaid,2092.09,,,2092.09,Other,225% of Medicaid,1422.62,,,1422.62,Other,153% of Medicaid,2092.09,,,2092.09,Other,225% of Medicaid,1301.75,,,1301.75,Other,140% of Medicaid,2092.09,,,2092.09,Other,225% of Medicaid,2417.53,,,2417.53,Other,260% of Medicaid,3012.61,,,3012.61,Other,324% of Medicaid,1999.11,,,1999.11,Other,215% of Medicaid,1999.11,,,1999.11,Other,215% of Medicaid,1162.27,,,1162.27,Other,125% of Medicaid,193.5,7216,
PLACE CATH INTRACRANIAL ART LT,36228,CPT,LT,47136228,CDM,360,RC,,,both,,,643,475.82,,,475.82,Other,150% of Medicare + 9.63% HCRA Surcharge,289.35,45,,289.35,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4476,,,4476,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4028,,,4028,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3805,,,3805,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",318.29,,,318.29,Other,110% of Medicare,437.24,,,437.24,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1729.46,,,1729.46,Other,186% of Medicaid,514.4,,,514.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",514.4,,,514.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",514.4,,,514.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",450.1,70,,450.1,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",929.82,,,929.82,Other,100% of Medicaid,929.82,,,929.82,Other,100% of Medicaid,929.82,,,929.82,Other,100% of Medicaid,929.82,,,929.82,Other,100% of Medicaid,2092.09,,,2092.09,Other,225% of Medicaid,1422.62,,,1422.62,Other,153% of Medicaid,2092.09,,,2092.09,Other,225% of Medicaid,1301.75,,,1301.75,Other,140% of Medicaid,2092.09,,,2092.09,Other,225% of Medicaid,2417.53,,,2417.53,Other,260% of Medicaid,3012.61,,,3012.61,Other,324% of Medicaid,1999.11,,,1999.11,Other,215% of Medicaid,1999.11,,,1999.11,Other,215% of Medicaid,1162.27,,,1162.27,Other,125% of Medicaid,289.35,7216,
PLACE CATH THORACIC AORTA RT,36221,CPT,RT,47236221,CDM,360,RC,,,both,,,9535,7055.92,,,7055.92,Other,150% of Medicare + 9.63% HCRA Surcharge,4290.75,45,,4290.75,percent of total billed charges,Critical Access Hospital RCC factor,2480,,,2480,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2232,,,2232,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4476,,,4476,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4028,,,4028,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3805,,,3805,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4719.83,,,4719.83,Other,110% of Medicare,6483.8,,,6483.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1729.46,,,1729.46,Other,186% of Medicaid,7628,,,7628,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7628,,,7628,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7628,,,7628,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",6674.5,70,,6674.5,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",4913,,,4913,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4422,,,4422,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4913,,,4913,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4176,,,4176,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",929.82,,,929.82,Other,100% of Medicaid,929.82,,,929.82,Other,100% of Medicaid,929.82,,,929.82,Other,100% of Medicaid,929.82,,,929.82,Other,100% of Medicaid,2092.09,,,2092.09,Other,225% of Medicaid,1422.62,,,1422.62,Other,153% of Medicaid,2092.09,,,2092.09,Other,225% of Medicaid,1301.75,,,1301.75,Other,140% of Medicaid,2092.09,,,2092.09,Other,225% of Medicaid,2417.53,,,2417.53,Other,260% of Medicaid,3012.61,,,3012.61,Other,324% of Medicaid,1999.11,,,1999.11,Other,215% of Medicaid,1999.11,,,1999.11,Other,215% of Medicaid,1162.27,,,1162.27,Other,125% of Medicaid,929.82,7628,
PLACE CATH CAROTID/INOM ART RT,36222,CPT,RT,47236222,CDM,360,RC,,,both,,,8748,6473.54,,,6473.54,Other,150% of Medicare + 9.63% HCRA Surcharge,3936.6,45,,3936.6,percent of total billed charges,Critical Access Hospital RCC factor,2480,,,2480,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2232,,,2232,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4476,,,4476,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4028,,,4028,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3805,,,3805,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4330.26,,,4330.26,Other,110% of Medicare,5948.64,,,5948.64,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1729.46,,,1729.46,Other,186% of Medicaid,6998.4,,,6998.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",6998.4,,,6998.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",6998.4,,,6998.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",6123.6,70,,6123.6,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",4913,,,4913,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4422,,,4422,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4913,,,4913,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4176,,,4176,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",929.82,,,929.82,Other,100% of Medicaid,929.82,,,929.82,Other,100% of Medicaid,929.82,,,929.82,Other,100% of Medicaid,929.82,,,929.82,Other,100% of Medicaid,2092.09,,,2092.09,Other,225% of Medicaid,1422.62,,,1422.62,Other,153% of Medicaid,2092.09,,,2092.09,Other,225% of Medicaid,1301.75,,,1301.75,Other,140% of Medicaid,2092.09,,,2092.09,Other,225% of Medicaid,2417.53,,,2417.53,Other,260% of Medicaid,3012.61,,,3012.61,Other,324% of Medicaid,1999.11,,,1999.11,Other,215% of Medicaid,1999.11,,,1999.11,Other,215% of Medicaid,1162.27,,,1162.27,Other,125% of Medicaid,929.82,7216,
PLACE CATH CAROTID/INOM ART RT,36223,CPT,RT,47236223,CDM,360,RC,,,both,,,11570,8561.83,,,8561.83,Other,150% of Medicare + 9.63% HCRA Surcharge,5206.5,45,,5206.5,percent of total billed charges,Critical Access Hospital RCC factor,2480,,,2480,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2232,,,2232,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4970,,,4970,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4473,,,4473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4225,,,4225,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",5727.15,,,5727.15,Other,110% of Medicare,7867.6,,,7867.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1729.46,,,1729.46,Other,186% of Medicaid,9256,,,9256,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9256,,,9256,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9256,,,9256,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",8099,70,,8099,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",6331,,,6331,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",5698,,,5698,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",6331,,,6331,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",5381,,,5381,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",929.82,,,929.82,Other,100% of Medicaid,929.82,,,929.82,Other,100% of Medicaid,929.82,,,929.82,Other,100% of Medicaid,929.82,,,929.82,Other,100% of Medicaid,2092.09,,,2092.09,Other,225% of Medicaid,1422.62,,,1422.62,Other,153% of Medicaid,2092.09,,,2092.09,Other,225% of Medicaid,1301.75,,,1301.75,Other,140% of Medicaid,2092.09,,,2092.09,Other,225% of Medicaid,2417.53,,,2417.53,Other,260% of Medicaid,3012.61,,,3012.61,Other,324% of Medicaid,1999.11,,,1999.11,Other,215% of Medicaid,1999.11,,,1999.11,Other,215% of Medicaid,1162.27,,,1162.27,Other,125% of Medicaid,929.82,9256,
PLACE CATH CAROTID ART RT,36224,CPT,RT,47236224,CDM,360,RC,,,both,,,14383,10643.46,,,10643.46,Other,150% of Medicare + 9.63% HCRA Surcharge,6472.35,45,,6472.35,percent of total billed charges,Critical Access Hospital RCC factor,3473,,,3473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3126,,,3126,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4970,,,4970,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4473,,,4473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4225,,,4225,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",7119.59,,,7119.59,Other,110% of Medicare,6152,,,6152,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1729.46,,,1729.46,Other,186% of Medicaid,7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",11506.4,,,11506.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",10068.1,70,,10068.1,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",6331,,,6331,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",5698,,,5698,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",6331,,,6331,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",5381,,,5381,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",929.82,,,929.82,Other,100% of Medicaid,929.82,,,929.82,Other,100% of Medicaid,929.82,,,929.82,Other,100% of Medicaid,929.82,,,929.82,Other,100% of Medicaid,2092.09,,,2092.09,Other,225% of Medicaid,1422.62,,,1422.62,Other,153% of Medicaid,2092.09,,,2092.09,Other,225% of Medicaid,1301.75,,,1301.75,Other,140% of Medicaid,2092.09,,,2092.09,Other,225% of Medicaid,2417.53,,,2417.53,Other,260% of Medicaid,3012.61,,,3012.61,Other,324% of Medicaid,1999.11,,,1999.11,Other,215% of Medicaid,1999.11,,,1999.11,Other,215% of Medicaid,1162.27,,,1162.27,Other,125% of Medicaid,929.82,11506.4,
PLACE CATH SUBCLAVIAN ART RT,36225,CPT,RT,47236225,CDM,360,RC,,,both,,,8748,6473.54,,,6473.54,Other,150% of Medicare + 9.63% HCRA Surcharge,3936.6,45,,3936.6,percent of total billed charges,Critical Access Hospital RCC factor,2480,,,2480,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2232,,,2232,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4476,,,4476,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4028,,,4028,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3805,,,3805,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4330.26,,,4330.26,Other,110% of Medicare,5948.64,,,5948.64,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1729.46,,,1729.46,Other,186% of Medicaid,6998.4,,,6998.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",6998.4,,,6998.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",6998.4,,,6998.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",6123.6,70,,6123.6,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",4913,,,4913,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4422,,,4422,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4913,,,4913,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4176,,,4176,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",929.82,,,929.82,Other,100% of Medicaid,929.82,,,929.82,Other,100% of Medicaid,929.82,,,929.82,Other,100% of Medicaid,929.82,,,929.82,Other,100% of Medicaid,2092.09,,,2092.09,Other,225% of Medicaid,1422.62,,,1422.62,Other,153% of Medicaid,2092.09,,,2092.09,Other,225% of Medicaid,1301.75,,,1301.75,Other,140% of Medicaid,2092.09,,,2092.09,Other,225% of Medicaid,2417.53,,,2417.53,Other,260% of Medicaid,3012.61,,,3012.61,Other,324% of Medicaid,1999.11,,,1999.11,Other,215% of Medicaid,1999.11,,,1999.11,Other,215% of Medicaid,1162.27,,,1162.27,Other,125% of Medicaid,929.82,7216,
PLACE CATH VERTEBRAL ART RT,36226,CPT,RT,47236226,CDM,360,RC,,,both,,,14383,10643.46,,,10643.46,Other,150% of Medicare + 9.63% HCRA Surcharge,6472.35,45,,6472.35,percent of total billed charges,Critical Access Hospital RCC factor,3473,,,3473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3126,,,3126,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4970,,,4970,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4473,,,4473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4225,,,4225,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",7119.59,,,7119.59,Other,110% of Medicare,6152,,,6152,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1729.46,,,1729.46,Other,186% of Medicaid,7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",11506.4,,,11506.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",10068.1,70,,10068.1,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",6331,,,6331,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",5698,,,5698,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",6331,,,6331,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",5381,,,5381,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",929.82,,,929.82,Other,100% of Medicaid,929.82,,,929.82,Other,100% of Medicaid,929.82,,,929.82,Other,100% of Medicaid,929.82,,,929.82,Other,100% of Medicaid,2092.09,,,2092.09,Other,225% of Medicaid,1422.62,,,1422.62,Other,153% of Medicaid,2092.09,,,2092.09,Other,225% of Medicaid,1301.75,,,1301.75,Other,140% of Medicaid,2092.09,,,2092.09,Other,225% of Medicaid,2417.53,,,2417.53,Other,260% of Medicaid,3012.61,,,3012.61,Other,324% of Medicaid,1999.11,,,1999.11,Other,215% of Medicaid,1999.11,,,1999.11,Other,215% of Medicaid,1162.27,,,1162.27,Other,125% of Medicaid,929.82,11506.4,
PLACE CATH XTRNL CAROTID RT,36227,CPT,RT,47236227,CDM,360,RC,,,both,,,430,318.2,,,318.2,Other,150% of Medicare + 9.63% HCRA Surcharge,193.5,45,,193.5,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4476,,,4476,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4028,,,4028,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3805,,,3805,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",212.85,,,212.85,Other,110% of Medicare,292.4,,,292.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1729.46,,,1729.46,Other,186% of Medicaid,344,,,344,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",344,,,344,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",344,,,344,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",301,70,,301,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",929.82,,,929.82,Other,100% of Medicaid,929.82,,,929.82,Other,100% of Medicaid,929.82,,,929.82,Other,100% of Medicaid,929.82,,,929.82,Other,100% of Medicaid,2092.09,,,2092.09,Other,225% of Medicaid,1422.62,,,1422.62,Other,153% of Medicaid,2092.09,,,2092.09,Other,225% of Medicaid,1301.75,,,1301.75,Other,140% of Medicaid,2092.09,,,2092.09,Other,225% of Medicaid,2417.53,,,2417.53,Other,260% of Medicaid,3012.61,,,3012.61,Other,324% of Medicaid,1999.11,,,1999.11,Other,215% of Medicaid,1999.11,,,1999.11,Other,215% of Medicaid,1162.27,,,1162.27,Other,125% of Medicaid,193.5,7216,
PLACE CATH INTRACRANIAL ART RT,36228,CPT,RT,47236228,CDM,360,RC,,,both,,,643,475.82,,,475.82,Other,150% of Medicare + 9.63% HCRA Surcharge,289.35,45,,289.35,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4476,,,4476,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4028,,,4028,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3805,,,3805,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",318.29,,,318.29,Other,110% of Medicare,437.24,,,437.24,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1729.46,,,1729.46,Other,186% of Medicaid,514.4,,,514.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",514.4,,,514.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",514.4,,,514.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",450.1,70,,450.1,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",929.82,,,929.82,Other,100% of Medicaid,929.82,,,929.82,Other,100% of Medicaid,929.82,,,929.82,Other,100% of Medicaid,929.82,,,929.82,Other,100% of Medicaid,2092.09,,,2092.09,Other,225% of Medicaid,1422.62,,,1422.62,Other,153% of Medicaid,2092.09,,,2092.09,Other,225% of Medicaid,1301.75,,,1301.75,Other,140% of Medicaid,2092.09,,,2092.09,Other,225% of Medicaid,2417.53,,,2417.53,Other,260% of Medicaid,3012.61,,,3012.61,Other,324% of Medicaid,1999.11,,,1999.11,Other,215% of Medicaid,1999.11,,,1999.11,Other,215% of Medicaid,1162.27,,,1162.27,Other,125% of Medicaid,289.35,7216,
PLACE CATH THORACIC AORTA BILAT,36221,CPT,50,47336221,CDM,360,RC,,,both,,,14303,10584.26,,,10584.26,Other,150% of Medicare + 9.63% HCRA Surcharge,6436.35,45,,6436.35,percent of total billed charges,Critical Access Hospital RCC factor,2480,,,2480,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2232,,,2232,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4476,,,4476,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4028,,,4028,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3805,,,3805,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",7079.99,,,7079.99,Other,110% of Medicare,9726.04,,,9726.04,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1729.46,,,1729.46,Other,186% of Medicaid,11442.4,,,11442.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",11442.4,,,11442.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",11442.4,,,11442.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",10012.1,70,,10012.1,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",4913,,,4913,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4422,,,4422,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4913,,,4913,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4176,,,4176,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",929.82,,,929.82,Other,100% of Medicaid,929.82,,,929.82,Other,100% of Medicaid,929.82,,,929.82,Other,100% of Medicaid,929.82,,,929.82,Other,100% of Medicaid,2092.09,,,2092.09,Other,225% of Medicaid,1422.62,,,1422.62,Other,153% of Medicaid,2092.09,,,2092.09,Other,225% of Medicaid,1301.75,,,1301.75,Other,140% of Medicaid,2092.09,,,2092.09,Other,225% of Medicaid,2417.53,,,2417.53,Other,260% of Medicaid,3012.61,,,3012.61,Other,324% of Medicaid,1999.11,,,1999.11,Other,215% of Medicaid,1999.11,,,1999.11,Other,215% of Medicaid,1162.27,,,1162.27,Other,125% of Medicaid,929.82,11442.4,
PLACE CATH CAROTID/INOM ART BILAT,36222,CPT,50,47336222,CDM,360,RC,,,both,,,13122,9710.31,,,9710.31,Other,150% of Medicare + 9.63% HCRA Surcharge,5904.9,45,,5904.9,percent of total billed charges,Critical Access Hospital RCC factor,2480,,,2480,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2232,,,2232,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4476,,,4476,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4028,,,4028,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3805,,,3805,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",6495.39,,,6495.39,Other,110% of Medicare,8922.96,,,8922.96,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1729.46,,,1729.46,Other,186% of Medicaid,10497.6,,,10497.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",10497.6,,,10497.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",10497.6,,,10497.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9185.4,70,,9185.4,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",4913,,,4913,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4422,,,4422,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4913,,,4913,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4176,,,4176,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",929.82,,,929.82,Other,100% of Medicaid,929.82,,,929.82,Other,100% of Medicaid,929.82,,,929.82,Other,100% of Medicaid,929.82,,,929.82,Other,100% of Medicaid,2092.09,,,2092.09,Other,225% of Medicaid,1422.62,,,1422.62,Other,153% of Medicaid,2092.09,,,2092.09,Other,225% of Medicaid,1301.75,,,1301.75,Other,140% of Medicaid,2092.09,,,2092.09,Other,225% of Medicaid,2417.53,,,2417.53,Other,260% of Medicaid,3012.61,,,3012.61,Other,324% of Medicaid,1999.11,,,1999.11,Other,215% of Medicaid,1999.11,,,1999.11,Other,215% of Medicaid,1162.27,,,1162.27,Other,125% of Medicaid,929.82,10497.6,
PLACE CATH CAROTID/INOM ART BILAT,36223,CPT,50,47336223,CDM,360,RC,,,both,,,17355,12842.74,,,12842.74,Other,150% of Medicare + 9.63% HCRA Surcharge,7809.75,45,,7809.75,percent of total billed charges,Critical Access Hospital RCC factor,2480,,,2480,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2232,,,2232,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4970,,,4970,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4473,,,4473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4225,,,4225,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",8590.73,,,8590.73,Other,110% of Medicare,11801.4,,,11801.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1729.46,,,1729.46,Other,186% of Medicaid,13884,,,13884,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",13884,,,13884,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",13884,,,13884,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",12148.5,70,,12148.5,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",6331,,,6331,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",5698,,,5698,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",6331,,,6331,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",5381,,,5381,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",929.82,,,929.82,Other,100% of Medicaid,929.82,,,929.82,Other,100% of Medicaid,929.82,,,929.82,Other,100% of Medicaid,929.82,,,929.82,Other,100% of Medicaid,2092.09,,,2092.09,Other,225% of Medicaid,1422.62,,,1422.62,Other,153% of Medicaid,2092.09,,,2092.09,Other,225% of Medicaid,1301.75,,,1301.75,Other,140% of Medicaid,2092.09,,,2092.09,Other,225% of Medicaid,2417.53,,,2417.53,Other,260% of Medicaid,3012.61,,,3012.61,Other,324% of Medicaid,1999.11,,,1999.11,Other,215% of Medicaid,1999.11,,,1999.11,Other,215% of Medicaid,1162.27,,,1162.27,Other,125% of Medicaid,929.82,13884,
PLACE CATH CAROTID ART BILAT,36224,CPT,50,47336224,CDM,360,RC,,,both,,,21575,15965.55,,,15965.55,Other,150% of Medicare + 9.63% HCRA Surcharge,9708.75,45,,9708.75,percent of total billed charges,Critical Access Hospital RCC factor,3473,,,3473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3126,,,3126,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4970,,,4970,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4473,,,4473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4225,,,4225,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",10679.63,,,10679.63,Other,110% of Medicare,6152,,,6152,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1729.46,,,1729.46,Other,186% of Medicaid,7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",17260,,,17260,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",15102.5,70,,15102.5,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",6331,,,6331,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",5698,,,5698,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",6331,,,6331,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",5381,,,5381,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",929.82,,,929.82,Other,100% of Medicaid,929.82,,,929.82,Other,100% of Medicaid,929.82,,,929.82,Other,100% of Medicaid,929.82,,,929.82,Other,100% of Medicaid,2092.09,,,2092.09,Other,225% of Medicaid,1422.62,,,1422.62,Other,153% of Medicaid,2092.09,,,2092.09,Other,225% of Medicaid,1301.75,,,1301.75,Other,140% of Medicaid,2092.09,,,2092.09,Other,225% of Medicaid,2417.53,,,2417.53,Other,260% of Medicaid,3012.61,,,3012.61,Other,324% of Medicaid,1999.11,,,1999.11,Other,215% of Medicaid,1999.11,,,1999.11,Other,215% of Medicaid,1162.27,,,1162.27,Other,125% of Medicaid,929.82,17260,
PLACE CATH SUBCLAVIAN ART BILAT,36225,CPT,50,47336225,CDM,360,RC,,,both,,,13122,9710.31,,,9710.31,Other,150% of Medicare + 9.63% HCRA Surcharge,5904.9,45,,5904.9,percent of total billed charges,Critical Access Hospital RCC factor,2480,,,2480,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2232,,,2232,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4476,,,4476,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4028,,,4028,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3805,,,3805,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",6495.39,,,6495.39,Other,110% of Medicare,8922.96,,,8922.96,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1729.46,,,1729.46,Other,186% of Medicaid,10497.6,,,10497.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",10497.6,,,10497.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",10497.6,,,10497.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9185.4,70,,9185.4,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",4913,,,4913,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4422,,,4422,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4913,,,4913,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4176,,,4176,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",929.82,,,929.82,Other,100% of Medicaid,929.82,,,929.82,Other,100% of Medicaid,929.82,,,929.82,Other,100% of Medicaid,929.82,,,929.82,Other,100% of Medicaid,2092.09,,,2092.09,Other,225% of Medicaid,1422.62,,,1422.62,Other,153% of Medicaid,2092.09,,,2092.09,Other,225% of Medicaid,1301.75,,,1301.75,Other,140% of Medicaid,2092.09,,,2092.09,Other,225% of Medicaid,2417.53,,,2417.53,Other,260% of Medicaid,3012.61,,,3012.61,Other,324% of Medicaid,1999.11,,,1999.11,Other,215% of Medicaid,1999.11,,,1999.11,Other,215% of Medicaid,1162.27,,,1162.27,Other,125% of Medicaid,929.82,10497.6,
PLACE CATH VERTEBRAL ART BILAT,36226,CPT,50,47336226,CDM,360,RC,,,both,,,21575,15965.55,,,15965.55,Other,150% of Medicare + 9.63% HCRA Surcharge,9708.75,45,,9708.75,percent of total billed charges,Critical Access Hospital RCC factor,3473,,,3473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3126,,,3126,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4970,,,4970,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4473,,,4473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4225,,,4225,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",10679.63,,,10679.63,Other,110% of Medicare,6152,,,6152,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1729.46,,,1729.46,Other,186% of Medicaid,7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",17260,,,17260,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",15102.5,70,,15102.5,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",6331,,,6331,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",5698,,,5698,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",6331,,,6331,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",5381,,,5381,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",929.82,,,929.82,Other,100% of Medicaid,929.82,,,929.82,Other,100% of Medicaid,929.82,,,929.82,Other,100% of Medicaid,929.82,,,929.82,Other,100% of Medicaid,2092.09,,,2092.09,Other,225% of Medicaid,1422.62,,,1422.62,Other,153% of Medicaid,2092.09,,,2092.09,Other,225% of Medicaid,1301.75,,,1301.75,Other,140% of Medicaid,2092.09,,,2092.09,Other,225% of Medicaid,2417.53,,,2417.53,Other,260% of Medicaid,3012.61,,,3012.61,Other,324% of Medicaid,1999.11,,,1999.11,Other,215% of Medicaid,1999.11,,,1999.11,Other,215% of Medicaid,1162.27,,,1162.27,Other,125% of Medicaid,929.82,17260,
PLACE CATH XTRNL CAROTID BILAT,36227,CPT,50,47336227,CDM,360,RC,,,both,,,645,477.3,,,477.3,Other,150% of Medicare + 9.63% HCRA Surcharge,290.25,45,,290.25,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4476,,,4476,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4028,,,4028,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3805,,,3805,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",319.28,,,319.28,Other,110% of Medicare,438.6,,,438.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1729.46,,,1729.46,Other,186% of Medicaid,516,,,516,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",516,,,516,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",516,,,516,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",451.5,70,,451.5,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",929.82,,,929.82,Other,100% of Medicaid,929.82,,,929.82,Other,100% of Medicaid,929.82,,,929.82,Other,100% of Medicaid,929.82,,,929.82,Other,100% of Medicaid,2092.09,,,2092.09,Other,225% of Medicaid,1422.62,,,1422.62,Other,153% of Medicaid,2092.09,,,2092.09,Other,225% of Medicaid,1301.75,,,1301.75,Other,140% of Medicaid,2092.09,,,2092.09,Other,225% of Medicaid,2417.53,,,2417.53,Other,260% of Medicaid,3012.61,,,3012.61,Other,324% of Medicaid,1999.11,,,1999.11,Other,215% of Medicaid,1999.11,,,1999.11,Other,215% of Medicaid,1162.27,,,1162.27,Other,125% of Medicaid,290.25,7216,
PLACE CATH INTRACRANIAL ART BILAT,36228,CPT,50,47336228,CDM,360,RC,,,both,,,965,714.1,,,714.1,Other,150% of Medicare + 9.63% HCRA Surcharge,434.25,45,,434.25,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4476,,,4476,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4028,,,4028,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3805,,,3805,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",477.68,,,477.68,Other,110% of Medicare,656.2,,,656.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1729.46,,,1729.46,Other,186% of Medicaid,772,,,772,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",772,,,772,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",772,,,772,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",675.5,70,,675.5,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",929.82,,,929.82,Other,100% of Medicaid,929.82,,,929.82,Other,100% of Medicaid,929.82,,,929.82,Other,100% of Medicaid,929.82,,,929.82,Other,100% of Medicaid,2092.09,,,2092.09,Other,225% of Medicaid,1422.62,,,1422.62,Other,153% of Medicaid,2092.09,,,2092.09,Other,225% of Medicaid,1301.75,,,1301.75,Other,140% of Medicaid,2092.09,,,2092.09,Other,225% of Medicaid,2417.53,,,2417.53,Other,260% of Medicaid,3012.61,,,3012.61,Other,324% of Medicaid,1999.11,,,1999.11,Other,215% of Medicaid,1999.11,,,1999.11,Other,215% of Medicaid,1162.27,,,1162.27,Other,125% of Medicaid,434.25,7216,
INSERT PICC UNSUCCESSFUL,36569,CPT,74,47336569,CDM,360,RC,,,both,,,3235,2393.91,,,2393.91,Other,150% of Medicare + 9.63% HCRA Surcharge,1455.75,45,,1455.75,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3648,,,3648,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3283,,,3283,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3101,,,3101,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",1601.33,,,1601.33,Other,110% of Medicare,2199.8,,,2199.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",586.68,,,586.68,Other,186% of Medicaid,2588,,,2588,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2588,,,2588,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",3578,,,3578,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2264.5,70,,2264.5,percent of total billed charges,All Other,449.36,,,449.36,Fee Schedule,,380.86,,,380.86,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",315.42,,,315.42,Other,100% of Medicaid,315.42,,,315.42,Other,100% of Medicaid,315.42,,,315.42,Other,100% of Medicaid,315.42,,,315.42,Other,100% of Medicaid,709.7,,,709.7,Other,225% of Medicaid,482.6,,,482.6,Other,153% of Medicaid,709.7,,,709.7,Other,225% of Medicaid,441.59,,,441.59,Other,140% of Medicaid,709.7,,,709.7,Other,225% of Medicaid,820.1,,,820.1,Other,260% of Medicaid,1021.97,,,1021.97,Other,324% of Medicaid,678.16,,,678.16,Other,215% of Medicaid,678.16,,,678.16,Other,215% of Medicaid,394.28,,,394.28,Other,125% of Medicaid,315.42,7216,
INSERT PICC UNSUCCESSFUL,36573,CPT,74,47336573,CDM,360,RC,,,both,,,6394,4731.58,,,4731.58,Other,150% of Medicare + 9.63% HCRA Surcharge,2877.3,45,,2877.3,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3648,,,3648,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3283,,,3283,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3101,,,3101,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3165.03,,,3165.03,Other,110% of Medicare,4347.92,,,4347.92,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",586.68,,,586.68,Other,186% of Medicaid,5115.2,,,5115.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",5115.2,,,5115.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",5115.2,,,5115.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",4475.8,70,,4475.8,percent of total billed charges,All Other,403.44,,,403.44,Fee Schedule,,341.94,,,341.94,Fee Schedule,,4055,,,4055,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3649,,,3649,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4055,,,4055,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3448,,,3448,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",315.42,,,315.42,Other,100% of Medicaid,315.42,,,315.42,Other,100% of Medicaid,315.42,,,315.42,Other,100% of Medicaid,315.42,,,315.42,Other,100% of Medicaid,709.7,,,709.7,Other,225% of Medicaid,482.6,,,482.6,Other,153% of Medicaid,709.7,,,709.7,Other,225% of Medicaid,441.59,,,441.59,Other,140% of Medicaid,709.7,,,709.7,Other,225% of Medicaid,820.1,,,820.1,Other,260% of Medicaid,1021.97,,,1021.97,Other,324% of Medicaid,678.16,,,678.16,Other,215% of Medicaid,678.16,,,678.16,Other,215% of Medicaid,394.28,,,394.28,Other,125% of Medicaid,315.42,7216,
ILIAC REVASC BILAT,37220,CPT,50,47337220,CDM,360,RC,,,both,,,27740,20527.67,,,20527.67,Other,150% of Medicare + 9.63% HCRA Surcharge,12483,45,,12483,percent of total billed charges,Critical Access Hospital RCC factor,3969,,,3969,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3572,,,3572,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",6807,,,6807,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",6126,,,6126,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",5786,,,5786,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",13731.3,,,13731.3,Other,110% of Medicare,6152,,,6152,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",4605.53,,,4605.53,Other,186% of Medicaid,7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",22192,,,22192,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",19418,70,,19418,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",6331,,,6331,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",5698,,,5698,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",6331,,,6331,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",5381,,,5381,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2476.09,,,2476.09,Other,100% of Medicaid,2476.09,,,2476.09,Other,100% of Medicaid,2476.09,,,2476.09,Other,100% of Medicaid,2476.09,,,2476.09,Other,100% of Medicaid,5571.21,,,5571.21,Other,225% of Medicaid,3788.42,,,3788.42,Other,153% of Medicaid,5571.21,,,5571.21,Other,225% of Medicaid,3466.53,,,3466.53,Other,140% of Medicaid,5571.21,,,5571.21,Other,225% of Medicaid,6437.84,,,6437.84,Other,260% of Medicaid,8022.54,,,8022.54,Other,324% of Medicaid,5323.6,,,5323.6,Other,215% of Medicaid,5323.6,,,5323.6,Other,215% of Medicaid,3095.12,,,3095.12,Other,125% of Medicaid,2476.09,22192,
ILIAC REVASC STENT BILAT,37221,CPT,50,47337221,CDM,360,RC,,,both,,,59682,44164.83,,,44164.83,Other,150% of Medicare + 9.63% HCRA Surcharge,26856.9,45,,26856.9,percent of total billed charges,Critical Access Hospital RCC factor,3969,,,3969,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3572,,,3572,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",7978,,,7978,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",7180,,,7180,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",6781,,,6781,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",29542.59,,,29542.59,Other,110% of Medicare,6152,,,6152,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",4605.54,,,4605.54,Other,186% of Medicaid,7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",47745.6,,,47745.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",41777.4,70,,41777.4,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",6956,,,6956,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",6261,,,6261,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",6956,,,6956,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",5913,,,5913,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2476.1,,,2476.1,Other,100% of Medicaid,2476.1,,,2476.1,Other,100% of Medicaid,2476.1,,,2476.1,Other,100% of Medicaid,2476.1,,,2476.1,Other,100% of Medicaid,5571.22,,,5571.22,Other,225% of Medicaid,3788.43,,,3788.43,Other,153% of Medicaid,5571.22,,,5571.22,Other,225% of Medicaid,3466.54,,,3466.54,Other,140% of Medicaid,5571.22,,,5571.22,Other,225% of Medicaid,6437.85,,,6437.85,Other,260% of Medicaid,8022.56,,,8022.56,Other,324% of Medicaid,5323.61,,,5323.61,Other,215% of Medicaid,5323.61,,,5323.61,Other,215% of Medicaid,3095.12,,,3095.12,Other,125% of Medicaid,2476.1,47745.6,
CHANGE EXT/INT URETER STENT BILATERAL,50387,CPT,50,47350387,CDM,360,RC,,,both,,,7107,5259.2,,,5259.2,Other,150% of Medicare + 9.63% HCRA Surcharge,3198.15,45,,3198.15,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3648,,,3648,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3283,,,3283,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3101,,,3101,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3517.97,,,3517.97,Other,110% of Medicare,4832.76,,,4832.76,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2011.18,,,2011.18,Other,186% of Medicaid,5685.6,,,5685.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",5685.6,,,5685.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",5685.6,,,5685.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",4974.9,70,,4974.9,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",4055,,,4055,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3649,,,3649,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4055,,,4055,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3448,,,3448,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",1081.28,,,1081.28,Other,100% of Medicaid,1081.28,,,1081.28,Other,100% of Medicaid,1081.28,,,1081.28,Other,100% of Medicaid,1081.28,,,1081.28,Other,100% of Medicaid,2432.88,,,2432.88,Other,225% of Medicaid,1654.36,,,1654.36,Other,153% of Medicaid,2432.88,,,2432.88,Other,225% of Medicaid,1513.79,,,1513.79,Other,140% of Medicaid,2432.88,,,2432.88,Other,225% of Medicaid,2811.33,,,2811.33,Other,260% of Medicaid,3503.35,,,3503.35,Other,324% of Medicaid,2324.75,,,2324.75,Other,215% of Medicaid,2324.75,,,2324.75,Other,215% of Medicaid,1351.6,,,1351.6,Other,125% of Medicaid,1081.28,7216,
PLMT NEPHROSTOMY CATHETER,50432,CPT,50,47350432,CDM,360,RC,,,both,,,9321,6897.56,,,6897.56,Other,150% of Medicare + 9.63% HCRA Surcharge,4194.45,45,,4194.45,percent of total billed charges,Critical Access Hospital RCC factor,2480,,,2480,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2232,,,2232,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3648,,,3648,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3283,,,3283,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3101,,,3101,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4613.9,,,4613.9,Other,110% of Medicare,6338.28,,,6338.28,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2011.18,,,2011.18,Other,186% of Medicaid,7456.8,,,7456.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7456.8,,,7456.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7456.8,,,7456.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",6524.7,70,,6524.7,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",4531,,,4531,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4079,,,4079,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4531,,,4531,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3852,,,3852,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",1081.28,,,1081.28,Other,100% of Medicaid,1081.28,,,1081.28,Other,100% of Medicaid,1081.28,,,1081.28,Other,100% of Medicaid,1081.28,,,1081.28,Other,100% of Medicaid,2432.88,,,2432.88,Other,225% of Medicaid,1654.36,,,1654.36,Other,153% of Medicaid,2432.88,,,2432.88,Other,225% of Medicaid,1513.79,,,1513.79,Other,140% of Medicaid,2432.88,,,2432.88,Other,225% of Medicaid,2811.33,,,2811.33,Other,260% of Medicaid,3503.35,,,3503.35,Other,324% of Medicaid,2324.75,,,2324.75,Other,215% of Medicaid,2324.75,,,2324.75,Other,215% of Medicaid,1351.6,,,1351.6,Other,125% of Medicaid,1081.28,7456.8,
EXCHANGE NEPHROSTOMY CATH BILATERAL,50435,CPT,50,47350435,CDM,360,RC,,,both,,,6264,4635.38,,,4635.38,Other,150% of Medicare + 9.63% HCRA Surcharge,2818.8,45,,2818.8,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3648,,,3648,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3283,,,3283,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3101,,,3101,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3100.68,,,3100.68,Other,110% of Medicare,4259.52,,,4259.52,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2011.18,,,2011.18,Other,186% of Medicaid,5011.2,,,5011.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",5011.2,,,5011.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",5011.2,,,5011.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",4384.8,70,,4384.8,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",1081.28,,,1081.28,Other,100% of Medicaid,1081.28,,,1081.28,Other,100% of Medicaid,1081.28,,,1081.28,Other,100% of Medicaid,1081.28,,,1081.28,Other,100% of Medicaid,2432.88,,,2432.88,Other,225% of Medicaid,1654.36,,,1654.36,Other,153% of Medicaid,2432.88,,,2432.88,Other,225% of Medicaid,1513.79,,,1513.79,Other,140% of Medicaid,2432.88,,,2432.88,Other,225% of Medicaid,2811.33,,,2811.33,Other,260% of Medicaid,3503.35,,,3503.35,Other,324% of Medicaid,2324.75,,,2324.75,Other,215% of Medicaid,2324.75,,,2324.75,Other,215% of Medicaid,1351.6,,,1351.6,Other,125% of Medicaid,1081.28,7216,
PERC DRUG-EL COR STENT SING,C9600,HCPCS,,49000009,CDM,360,RC,,,both,,,32135,23779.98,,,23779.98,Other,150% of Medicare + 9.63% HCRA Surcharge,14460.75,45,,14460.75,percent of total billed charges,Critical Access Hospital RCC factor,4565,,,4565,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4109,,,4109,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",7978,,,7978,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",7180,,,7180,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",6781,,,6781,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",15906.83,,,15906.83,Other,110% of Medicare,21851.8,,,21851.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",4605.54,,,4605.54,Other,186% of Medicaid,25708,,,25708,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",25708,,,25708,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",25708,,,25708,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",22494.5,70,,22494.5,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",6956,,,6956,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",6261,,,6261,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",6956,,,6956,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",5913,,,5913,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2476.1,,,2476.1,Other,100% of Medicaid,2476.1,,,2476.1,Other,100% of Medicaid,2476.1,,,2476.1,Other,100% of Medicaid,2476.1,,,2476.1,Other,100% of Medicaid,5571.22,,,5571.22,Other,225% of Medicaid,3788.43,,,3788.43,Other,153% of Medicaid,5571.22,,,5571.22,Other,225% of Medicaid,3466.54,,,3466.54,Other,140% of Medicaid,5571.22,,,5571.22,Other,225% of Medicaid,6437.85,,,6437.85,Other,260% of Medicaid,8022.56,,,8022.56,Other,324% of Medicaid,5323.61,,,5323.61,Other,215% of Medicaid,5323.61,,,5323.61,Other,215% of Medicaid,3095.12,,,3095.12,Other,125% of Medicaid,2476.1,25708,
PERC D-E COR STENT ATHER S,C9602,HCPCS,,49000010,CDM,360,RC,,,both,,,51696,38255.17,,,38255.17,Other,150% of Medicare + 9.63% HCRA Surcharge,23263.2,45,,23263.2,percent of total billed charges,Critical Access Hospital RCC factor,4565,,,4565,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4109,,,4109,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",7978,,,7978,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",7180,,,7180,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",6781,,,6781,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",25589.52,,,25589.52,Other,110% of Medicare,35153.28,,,35153.28,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",4605.54,,,4605.54,Other,186% of Medicaid,41356.8,,,41356.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",41356.8,,,41356.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",41356.8,,,41356.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",36187.2,70,,36187.2,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",6956,,,6956,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",6261,,,6261,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",6956,,,6956,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",5913,,,5913,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2476.1,,,2476.1,Other,100% of Medicaid,2476.1,,,2476.1,Other,100% of Medicaid,2476.1,,,2476.1,Other,100% of Medicaid,2476.1,,,2476.1,Other,100% of Medicaid,5571.22,,,5571.22,Other,225% of Medicaid,3788.43,,,3788.43,Other,153% of Medicaid,5571.22,,,5571.22,Other,225% of Medicaid,3466.54,,,3466.54,Other,140% of Medicaid,5571.22,,,5571.22,Other,225% of Medicaid,6437.85,,,6437.85,Other,260% of Medicaid,8022.56,,,8022.56,Other,324% of Medicaid,5323.61,,,5323.61,Other,215% of Medicaid,5323.61,,,5323.61,Other,215% of Medicaid,3095.12,,,3095.12,Other,125% of Medicaid,2476.1,41356.8,
PERC D-E COR REVASC T CABG S,C9604,HCPCS,,49000011,CDM,360,RC,,,both,,,32135,23779.98,,,23779.98,Other,150% of Medicare + 9.63% HCRA Surcharge,14460.75,45,,14460.75,percent of total billed charges,Critical Access Hospital RCC factor,4565,,,4565,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4109,,,4109,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",7978,,,7978,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",7180,,,7180,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",6781,,,6781,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",15906.83,,,15906.83,Other,110% of Medicare,21851.8,,,21851.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",4605.54,,,4605.54,Other,186% of Medicaid,25708,,,25708,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",25708,,,25708,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",25708,,,25708,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",22494.5,70,,22494.5,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",6956,,,6956,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",6261,,,6261,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",6956,,,6956,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",5913,,,5913,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2476.1,,,2476.1,Other,100% of Medicaid,2476.1,,,2476.1,Other,100% of Medicaid,2476.1,,,2476.1,Other,100% of Medicaid,2476.1,,,2476.1,Other,100% of Medicaid,5571.22,,,5571.22,Other,225% of Medicaid,3788.43,,,3788.43,Other,153% of Medicaid,5571.22,,,5571.22,Other,225% of Medicaid,3466.54,,,3466.54,Other,140% of Medicaid,5571.22,,,5571.22,Other,225% of Medicaid,6437.85,,,6437.85,Other,260% of Medicaid,8022.56,,,8022.56,Other,324% of Medicaid,5323.61,,,5323.61,Other,215% of Medicaid,5323.61,,,5323.61,Other,215% of Medicaid,3095.12,,,3095.12,Other,125% of Medicaid,2476.1,25708,
PERC D-E COR REVASC CHRO SIN,C9607,HCPCS,,49000012,CDM,360,RC,,,both,,,51696,38255.17,,,38255.17,Other,150% of Medicare + 9.63% HCRA Surcharge,23263.2,45,,23263.2,percent of total billed charges,Critical Access Hospital RCC factor,4565,,,4565,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4109,,,4109,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",7978,,,7978,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",7180,,,7180,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",6781,,,6781,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",25589.52,,,25589.52,Other,110% of Medicare,35153.28,,,35153.28,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",4605.54,,,4605.54,Other,186% of Medicaid,41356.8,,,41356.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",41356.8,,,41356.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",41356.8,,,41356.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",36187.2,70,,36187.2,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",6956,,,6956,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",6261,,,6261,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",6956,,,6956,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",5913,,,5913,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2476.1,,,2476.1,Other,100% of Medicaid,2476.1,,,2476.1,Other,100% of Medicaid,2476.1,,,2476.1,Other,100% of Medicaid,2476.1,,,2476.1,Other,100% of Medicaid,5571.22,,,5571.22,Other,225% of Medicaid,3788.43,,,3788.43,Other,153% of Medicaid,5571.22,,,5571.22,Other,225% of Medicaid,3466.54,,,3466.54,Other,140% of Medicaid,5571.22,,,5571.22,Other,225% of Medicaid,6437.85,,,6437.85,Other,260% of Medicaid,8022.56,,,8022.56,Other,324% of Medicaid,5323.61,,,5323.61,Other,215% of Medicaid,5323.61,,,5323.61,Other,215% of Medicaid,3095.12,,,3095.12,Other,125% of Medicaid,2476.1,41356.8,
INSJ/RPLCMT ICDS SS ELTRD,0571T,HCPCS,,49000013,CDM,360,RC,,,both,,,104697,77476.04,,,77476.04,Other,150% of Medicare + 9.63% HCRA Surcharge,47113.65,45,,47113.65,percent of total billed charges,Critical Access Hospital RCC factor,5954,,,5954,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",5359,,,5359,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4970,,,4970,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4473,,,4473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4225,,,4225,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",51825.02,,,51825.02,Other,110% of Medicare,6152,,,6152,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",23160.14,,,23160.14,Other,186% of Medicaid,7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",83757.6,,,83757.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",73287.9,70,,73287.9,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",15267,,,15267,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",13740,,,13740,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",15267,,,15267,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",12977,,,12977,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",12451.69,,,12451.69,Other,100% of Medicaid,12451.69,,,12451.69,Other,100% of Medicaid,12451.69,,,12451.69,Other,100% of Medicaid,12451.69,,,12451.69,Other,100% of Medicaid,28016.3,,,28016.3,Other,225% of Medicaid,19051.08,,,19051.08,Other,153% of Medicaid,28016.3,,,28016.3,Other,225% of Medicaid,17432.36,,,17432.36,Other,140% of Medicaid,28016.3,,,28016.3,Other,225% of Medicaid,32374.39,,,32374.39,Other,260% of Medicaid,40343.47,,,40343.47,Other,324% of Medicaid,26771.13,,,26771.13,Other,215% of Medicaid,26771.13,,,26771.13,Other,215% of Medicaid,15564.61,,,15564.61,Other,125% of Medicaid,3343,83757.6,
INSERTION SS DFB ELECTRODE,0572T,HCPCS,,49000014,CDM,360,RC,,,both,,,24784,18340.22,,,18340.22,Other,150% of Medicare + 9.63% HCRA Surcharge,11152.8,45,,11152.8,percent of total billed charges,Critical Access Hospital RCC factor,3473,,,3473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3126,,,3126,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4970,,,4970,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4473,,,4473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4225,,,4225,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",12268.08,,,12268.08,Other,110% of Medicare,6152,,,6152,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",4031.77,,,4031.77,Other,186% of Medicaid,7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",19827.2,,,19827.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",17348.8,70,,17348.8,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",6956,,,6956,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",6261,,,6261,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",6956,,,6956,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",5913,,,5913,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2167.62,,,2167.62,Other,100% of Medicaid,2167.62,,,2167.62,Other,100% of Medicaid,2167.62,,,2167.62,Other,100% of Medicaid,2167.62,,,2167.62,Other,100% of Medicaid,4877.14,,,4877.14,Other,225% of Medicaid,3316.46,,,3316.46,Other,153% of Medicaid,4877.14,,,4877.14,Other,225% of Medicaid,3034.67,,,3034.67,Other,140% of Medicaid,4877.14,,,4877.14,Other,225% of Medicaid,5635.81,,,5635.81,Other,260% of Medicaid,7023.09,,,7023.09,Other,324% of Medicaid,4660.38,,,4660.38,Other,215% of Medicaid,4660.38,,,4660.38,Other,215% of Medicaid,2709.52,,,2709.52,Other,125% of Medicaid,2167.62,19827.2,
REMOVAL SS DFB ELECTRODE,0573T,HCPCS,,49000015,CDM,360,RC,,,both,,,9678,7161.74,,,7161.74,Other,150% of Medicare + 9.63% HCRA Surcharge,4355.1,45,,4355.1,percent of total billed charges,Critical Access Hospital RCC factor,3473,,,3473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3126,,,3126,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",5738,,,5738,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",5164,,,5164,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4877,,,4877,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4790.61,,,4790.61,Other,110% of Medicare,6152,,,6152,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",4031.77,,,4031.77,Other,186% of Medicaid,7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7742.4,,,7742.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",6774.6,70,,6774.6,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",4913,,,4913,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4422,,,4422,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4913,,,4913,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4176,,,4176,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2167.62,,,2167.62,Other,100% of Medicaid,2167.62,,,2167.62,Other,100% of Medicaid,2167.62,,,2167.62,Other,100% of Medicaid,2167.62,,,2167.62,Other,100% of Medicaid,4877.14,,,4877.14,Other,225% of Medicaid,3316.46,,,3316.46,Other,153% of Medicaid,4877.14,,,4877.14,Other,225% of Medicaid,3034.67,,,3034.67,Other,140% of Medicaid,4877.14,,,4877.14,Other,225% of Medicaid,5635.81,,,5635.81,Other,260% of Medicaid,7023.09,,,7023.09,Other,324% of Medicaid,4660.38,,,4660.38,Other,215% of Medicaid,4660.38,,,4660.38,Other,215% of Medicaid,2709.52,,,2709.52,Other,125% of Medicaid,2167.62,9473,
REPOS PREV SS IMPL DFB ELTRD,0574T,HCPCS,,49000016,CDM,360,RC,,,both,,,9678,7161.74,,,7161.74,Other,150% of Medicare + 9.63% HCRA Surcharge,4355.1,45,,4355.1,percent of total billed charges,Critical Access Hospital RCC factor,3473,,,3473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3126,,,3126,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",5738,,,5738,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",5164,,,5164,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4877,,,4877,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4790.61,,,4790.61,Other,110% of Medicare,6152,,,6152,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",4031.77,,,4031.77,Other,186% of Medicaid,7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7742.4,,,7742.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",6774.6,70,,6774.6,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",4913,,,4913,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4422,,,4422,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4913,,,4913,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4176,,,4176,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2167.62,,,2167.62,Other,100% of Medicaid,2167.62,,,2167.62,Other,100% of Medicaid,2167.62,,,2167.62,Other,100% of Medicaid,2167.62,,,2167.62,Other,100% of Medicaid,4877.14,,,4877.14,Other,225% of Medicaid,3316.46,,,3316.46,Other,153% of Medicaid,4877.14,,,4877.14,Other,225% of Medicaid,3034.67,,,3034.67,Other,140% of Medicaid,4877.14,,,4877.14,Other,225% of Medicaid,5635.81,,,5635.81,Other,260% of Medicaid,7023.09,,,7023.09,Other,324% of Medicaid,4660.38,,,4660.38,Other,215% of Medicaid,4660.38,,,4660.38,Other,215% of Medicaid,2709.52,,,2709.52,Other,125% of Medicaid,2167.62,9473,
RMVL SS IMPL DFB PG ONLY,0580T,HCPCS,,49000021,CDM,360,RC,,,both,,,9678,7161.74,,,7161.74,Other,150% of Medicare + 9.63% HCRA Surcharge,4355.1,45,,4355.1,percent of total billed charges,Critical Access Hospital RCC factor,3473,,,3473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3126,,,3126,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3648,,,3648,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3283,,,3283,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3101,,,3101,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4790.61,,,4790.61,Other,110% of Medicare,6152,,,6152,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",4031.77,,,4031.77,Other,186% of Medicaid,7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7742.4,,,7742.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",6774.6,70,,6774.6,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",4913,,,4913,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4422,,,4422,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4913,,,4913,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4176,,,4176,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2167.62,,,2167.62,Other,100% of Medicaid,2167.62,,,2167.62,Other,100% of Medicaid,2167.62,,,2167.62,Other,100% of Medicaid,2167.62,,,2167.62,Other,100% of Medicaid,4877.14,,,4877.14,Other,225% of Medicaid,3316.46,,,3316.46,Other,153% of Medicaid,4877.14,,,4877.14,Other,225% of Medicaid,3034.67,,,3034.67,Other,140% of Medicaid,4877.14,,,4877.14,Other,225% of Medicaid,5635.81,,,5635.81,Other,260% of Medicaid,7023.09,,,7023.09,Other,324% of Medicaid,4660.38,,,4660.38,Other,215% of Medicaid,4660.38,,,4660.38,Other,215% of Medicaid,2709.52,,,2709.52,Other,125% of Medicaid,2167.62,9473,
PERC DRUG-EL COR STENT BRAN,C9601,HCPCS,,49000026,CDM,360,RC,,,both,,,16067,11889.62,,,11889.62,Other,150% of Medicare + 9.63% HCRA Surcharge,7230.15,45,,7230.15,percent of total billed charges,Critical Access Hospital RCC factor,4565,,,4565,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4109,,,4109,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3648,,,3648,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3283,,,3283,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3101,,,3101,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",7953.17,,,7953.17,Other,110% of Medicare,10925.56,,,10925.56,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",4095.6,,,4095.6,Other,186% of Medicaid,12853.6,,,12853.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",12853.6,,,12853.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",12853.6,,,12853.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",11246.9,70,,11246.9,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2201.94,,,2201.94,Other,100% of Medicaid,2201.94,,,2201.94,Other,100% of Medicaid,2201.94,,,2201.94,Other,100% of Medicaid,2201.94,,,2201.94,Other,100% of Medicaid,4954.36,,,4954.36,Other,225% of Medicaid,3368.96,,,3368.96,Other,153% of Medicaid,4954.36,,,4954.36,Other,225% of Medicaid,3082.71,,,3082.71,Other,140% of Medicaid,4954.36,,,4954.36,Other,225% of Medicaid,5725.04,,,5725.04,Other,260% of Medicaid,7134.28,,,7134.28,Other,324% of Medicaid,4734.17,,,4734.17,Other,215% of Medicaid,4734.17,,,4734.17,Other,215% of Medicaid,2752.42,,,2752.42,Other,125% of Medicaid,2201.94,12853.6,
PERC D-E COR STENT ATHER BR,C9603,HCPCS,,49000027,CDM,360,RC,,,both,,,25848,19127.58,,,19127.58,Other,150% of Medicare + 9.63% HCRA Surcharge,11631.6,45,,11631.6,percent of total billed charges,Critical Access Hospital RCC factor,4565,,,4565,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4109,,,4109,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3648,,,3648,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3283,,,3283,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3101,,,3101,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",12794.76,,,12794.76,Other,110% of Medicare,17576.64,,,17576.64,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",4095.6,,,4095.6,Other,186% of Medicaid,20678.4,,,20678.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",20678.4,,,20678.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",20678.4,,,20678.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",18093.6,70,,18093.6,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2201.94,,,2201.94,Other,100% of Medicaid,2201.94,,,2201.94,Other,100% of Medicaid,2201.94,,,2201.94,Other,100% of Medicaid,2201.94,,,2201.94,Other,100% of Medicaid,4954.36,,,4954.36,Other,225% of Medicaid,3368.96,,,3368.96,Other,153% of Medicaid,4954.36,,,4954.36,Other,225% of Medicaid,3082.71,,,3082.71,Other,140% of Medicaid,4954.36,,,4954.36,Other,225% of Medicaid,5725.04,,,5725.04,Other,260% of Medicaid,7134.28,,,7134.28,Other,324% of Medicaid,4734.17,,,4734.17,Other,215% of Medicaid,4734.17,,,4734.17,Other,215% of Medicaid,2752.42,,,2752.42,Other,125% of Medicaid,2201.94,20678.4,
PERC D-E COR REVASC T CABG B,C9605,HCPCS,,49000028,CDM,360,RC,,,both,,,16067,11889.62,,,11889.62,Other,150% of Medicare + 9.63% HCRA Surcharge,7230.15,45,,7230.15,percent of total billed charges,Critical Access Hospital RCC factor,4565,,,4565,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4109,,,4109,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3648,,,3648,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3283,,,3283,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3101,,,3101,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",7953.17,,,7953.17,Other,110% of Medicare,10925.56,,,10925.56,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",4095.6,,,4095.6,Other,186% of Medicaid,12853.6,,,12853.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",12853.6,,,12853.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",12853.6,,,12853.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",11246.9,70,,11246.9,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2201.94,,,2201.94,Other,100% of Medicaid,2201.94,,,2201.94,Other,100% of Medicaid,2201.94,,,2201.94,Other,100% of Medicaid,2201.94,,,2201.94,Other,100% of Medicaid,4954.36,,,4954.36,Other,225% of Medicaid,3368.96,,,3368.96,Other,153% of Medicaid,4954.36,,,4954.36,Other,225% of Medicaid,3082.71,,,3082.71,Other,140% of Medicaid,4954.36,,,4954.36,Other,225% of Medicaid,5725.04,,,5725.04,Other,260% of Medicaid,7134.28,,,7134.28,Other,324% of Medicaid,4734.17,,,4734.17,Other,215% of Medicaid,4734.17,,,4734.17,Other,215% of Medicaid,2752.42,,,2752.42,Other,125% of Medicaid,2201.94,12853.6,
PERC D-E COR REVASC W AMI S,C9606,HCPCS,,49000029,CDM,360,RC,,,both,,,16067,11889.62,,,11889.62,Other,150% of Medicare + 9.63% HCRA Surcharge,7230.15,45,,7230.15,percent of total billed charges,Critical Access Hospital RCC factor,4565,,,4565,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4109,,,4109,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",7978,,,7978,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",7180,,,7180,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",6781,,,6781,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",7953.17,,,7953.17,Other,110% of Medicare,10925.56,,,10925.56,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",4095.6,,,4095.6,Other,186% of Medicaid,12853.6,,,12853.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",12853.6,,,12853.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",12853.6,,,12853.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",11246.9,70,,11246.9,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",4531,,,4531,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4079,,,4079,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4531,,,4531,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3852,,,3852,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2201.94,,,2201.94,Other,100% of Medicaid,2201.94,,,2201.94,Other,100% of Medicaid,2201.94,,,2201.94,Other,100% of Medicaid,2201.94,,,2201.94,Other,100% of Medicaid,4954.36,,,4954.36,Other,225% of Medicaid,3368.96,,,3368.96,Other,153% of Medicaid,4954.36,,,4954.36,Other,225% of Medicaid,3082.71,,,3082.71,Other,140% of Medicaid,4954.36,,,4954.36,Other,225% of Medicaid,5725.04,,,5725.04,Other,260% of Medicaid,7134.28,,,7134.28,Other,324% of Medicaid,4734.17,,,4734.17,Other,215% of Medicaid,4734.17,,,4734.17,Other,215% of Medicaid,2752.42,,,2752.42,Other,125% of Medicaid,2201.94,12853.6,
PERC D-E COR REVASC CHRO ADD,C9608,HCPCS,,49000030,CDM,360,RC,,,both,,,25848,19127.58,,,19127.58,Other,150% of Medicare + 9.63% HCRA Surcharge,11631.6,45,,11631.6,percent of total billed charges,Critical Access Hospital RCC factor,4565,,,4565,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4109,,,4109,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3648,,,3648,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3283,,,3283,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3101,,,3101,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",12794.76,,,12794.76,Other,110% of Medicare,17576.64,,,17576.64,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",4095.6,,,4095.6,Other,186% of Medicaid,20678.4,,,20678.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",20678.4,,,20678.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",20678.4,,,20678.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",18093.6,70,,18093.6,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2201.94,,,2201.94,Other,100% of Medicaid,2201.94,,,2201.94,Other,100% of Medicaid,2201.94,,,2201.94,Other,100% of Medicaid,2201.94,,,2201.94,Other,100% of Medicaid,4954.36,,,4954.36,Other,225% of Medicaid,3368.96,,,3368.96,Other,153% of Medicaid,4954.36,,,4954.36,Other,225% of Medicaid,3082.71,,,3082.71,Other,140% of Medicaid,4954.36,,,4954.36,Other,225% of Medicaid,5725.04,,,5725.04,Other,260% of Medicaid,7134.28,,,7134.28,Other,324% of Medicaid,4734.17,,,4734.17,Other,215% of Medicaid,4734.17,,,4734.17,Other,215% of Medicaid,2752.42,,,2752.42,Other,125% of Medicaid,2201.94,20678.4,
INSERT HEART PM ATRIAL,33206,CPT,,49033206,CDM,360,RC,,,both,,,23249,17204.32,,,17204.32,Other,150% of Medicare + 9.63% HCRA Surcharge,10462.05,45,,10462.05,percent of total billed charges,Critical Access Hospital RCC factor,5954,,,5954,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",5359,,,5359,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",7978,,,7978,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",7180,,,7180,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",6781,,,6781,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",11508.26,,,11508.26,Other,110% of Medicare,6152,,,6152,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",10683.75,,,10683.75,Other,186% of Medicaid,7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",18599.2,,,18599.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",16274.3,70,,16274.3,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",6956,,,6956,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",6261,,,6261,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",6956,,,6956,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",5913,,,5913,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",5743.95,,,5743.95,Other,100% of Medicaid,5743.95,,,5743.95,Other,100% of Medicaid,5743.95,,,5743.95,Other,100% of Medicaid,5743.95,,,5743.95,Other,100% of Medicaid,12923.9,,,12923.9,Other,225% of Medicaid,8788.25,,,8788.25,Other,153% of Medicaid,12923.9,,,12923.9,Other,225% of Medicaid,8041.54,,,8041.54,Other,140% of Medicaid,12923.9,,,12923.9,Other,225% of Medicaid,14934.28,,,14934.28,Other,260% of Medicaid,18610.41,,,18610.41,Other,324% of Medicaid,12349.5,,,12349.5,Other,215% of Medicaid,12349.5,,,12349.5,Other,215% of Medicaid,7179.94,,,7179.94,Other,125% of Medicaid,3343,18610.41,
INSERT HEART PM VENTRICULAR,33207,CPT,,49033207,CDM,360,RC,,,both,,,23249,17204.32,,,17204.32,Other,150% of Medicare + 9.63% HCRA Surcharge,10462.05,45,,10462.05,percent of total billed charges,Critical Access Hospital RCC factor,5954,,,5954,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",5359,,,5359,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",7978,,,7978,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",7180,,,7180,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",6781,,,6781,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",11508.26,,,11508.26,Other,110% of Medicare,6152,,,6152,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",10683.75,,,10683.75,Other,186% of Medicaid,7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",18599.2,,,18599.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",16274.3,70,,16274.3,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",6956,,,6956,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",6261,,,6261,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",6956,,,6956,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",5913,,,5913,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",5743.95,,,5743.95,Other,100% of Medicaid,5743.95,,,5743.95,Other,100% of Medicaid,5743.95,,,5743.95,Other,100% of Medicaid,5743.95,,,5743.95,Other,100% of Medicaid,12923.9,,,12923.9,Other,225% of Medicaid,8788.25,,,8788.25,Other,153% of Medicaid,12923.9,,,12923.9,Other,225% of Medicaid,8041.54,,,8041.54,Other,140% of Medicaid,12923.9,,,12923.9,Other,225% of Medicaid,14934.28,,,14934.28,Other,260% of Medicaid,18610.41,,,18610.41,Other,324% of Medicaid,12349.5,,,12349.5,Other,215% of Medicaid,12349.5,,,12349.5,Other,215% of Medicaid,7179.94,,,7179.94,Other,125% of Medicaid,3343,18610.41,
INSRT HEART PM ATRIAL & VENT,33208,CPT,,49033208,CDM,360,RC,,,both,,,26727,19778.05,,,19778.05,Other,150% of Medicare + 9.63% HCRA Surcharge,12027.15,45,,12027.15,percent of total billed charges,Critical Access Hospital RCC factor,5954,,,5954,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",5359,,,5359,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",7978,,,7978,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",7180,,,7180,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",6781,,,6781,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",13229.87,,,13229.87,Other,110% of Medicare,6152,,,6152,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",10683.75,,,10683.75,Other,186% of Medicaid,7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",21381.6,,,21381.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",18708.9,70,,18708.9,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",7364,,,7364,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",6628,,,6628,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",7364,,,7364,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",6260,,,6260,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",5743.95,,,5743.95,Other,100% of Medicaid,5743.95,,,5743.95,Other,100% of Medicaid,5743.95,,,5743.95,Other,100% of Medicaid,5743.95,,,5743.95,Other,100% of Medicaid,12923.9,,,12923.9,Other,225% of Medicaid,8788.25,,,8788.25,Other,153% of Medicaid,12923.9,,,12923.9,Other,225% of Medicaid,8041.54,,,8041.54,Other,140% of Medicaid,12923.9,,,12923.9,Other,225% of Medicaid,14934.28,,,14934.28,Other,260% of Medicaid,18610.41,,,18610.41,Other,324% of Medicaid,12349.5,,,12349.5,Other,215% of Medicaid,12349.5,,,12349.5,Other,215% of Medicaid,7179.94,,,7179.94,Other,125% of Medicaid,3343,21381.6,
INSERT PULSE GEN SNGL LEAD,33212,CPT,,49033212,CDM,360,RC,,,both,,,18374,13596.81,,,13596.81,Other,150% of Medicare + 9.63% HCRA Surcharge,8268.3,45,,8268.3,percent of total billed charges,Critical Access Hospital RCC factor,3473,,,3473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3126,,,3126,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",7978,,,7978,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",7180,,,7180,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",6781,,,6781,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",9095.13,,,9095.13,Other,110% of Medicare,6152,,,6152,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",10683.75,,,10683.75,Other,186% of Medicaid,7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",5266,,,5266,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",12861.8,70,,12861.8,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",6956,,,6956,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",6261,,,6261,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",6956,,,6956,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",5913,,,5913,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",5743.95,,,5743.95,Other,100% of Medicaid,5743.95,,,5743.95,Other,100% of Medicaid,5743.95,,,5743.95,Other,100% of Medicaid,5743.95,,,5743.95,Other,100% of Medicaid,12923.9,,,12923.9,Other,225% of Medicaid,8788.25,,,8788.25,Other,153% of Medicaid,12923.9,,,12923.9,Other,225% of Medicaid,8041.54,,,8041.54,Other,140% of Medicaid,12923.9,,,12923.9,Other,225% of Medicaid,14934.28,,,14934.28,Other,260% of Medicaid,18610.41,,,18610.41,Other,324% of Medicaid,12349.5,,,12349.5,Other,215% of Medicaid,12349.5,,,12349.5,Other,215% of Medicaid,7179.94,,,7179.94,Other,125% of Medicaid,3126,18610.41,
INSERT PULSE GEN DUAL LEADS,33213,CPT,,49033213,CDM,360,RC,,,both,,,23249,17204.32,,,17204.32,Other,150% of Medicare + 9.63% HCRA Surcharge,10462.05,45,,10462.05,percent of total billed charges,Critical Access Hospital RCC factor,3473,,,3473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3126,,,3126,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",7978,,,7978,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",7180,,,7180,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",6781,,,6781,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",11508.26,,,11508.26,Other,110% of Medicare,6152,,,6152,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",10683.75,,,10683.75,Other,186% of Medicaid,7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",5266,,,5266,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",16274.3,70,,16274.3,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",6956,,,6956,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",6261,,,6261,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",6956,,,6956,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",5913,,,5913,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",5743.95,,,5743.95,Other,100% of Medicaid,5743.95,,,5743.95,Other,100% of Medicaid,5743.95,,,5743.95,Other,100% of Medicaid,5743.95,,,5743.95,Other,100% of Medicaid,12923.9,,,12923.9,Other,225% of Medicaid,8788.25,,,8788.25,Other,153% of Medicaid,12923.9,,,12923.9,Other,225% of Medicaid,8041.54,,,8041.54,Other,140% of Medicaid,12923.9,,,12923.9,Other,225% of Medicaid,14934.28,,,14934.28,Other,260% of Medicaid,18610.41,,,18610.41,Other,324% of Medicaid,12349.5,,,12349.5,Other,215% of Medicaid,12349.5,,,12349.5,Other,215% of Medicaid,7179.94,,,7179.94,Other,125% of Medicaid,3126,18610.41,
UPGRADE IMPL PACEMKR; SC TO DC,33214,CPT,,49033214,CDM,360,RC,,,both,,,24061,17805.2,,,17805.2,Other,150% of Medicare + 9.63% HCRA Surcharge,10827.45,45,,10827.45,percent of total billed charges,Critical Access Hospital RCC factor,5954,,,5954,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",5359,,,5359,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",7978,,,7978,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",7180,,,7180,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",6781,,,6781,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",11910.2,,,11910.2,Other,110% of Medicare,6152,,,6152,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",10683.75,,,10683.75,Other,186% of Medicaid,7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",19248.8,,,19248.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",16842.7,70,,16842.7,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",7364,,,7364,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",6628,,,6628,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",7364,,,7364,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",6260,,,6260,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",5743.95,,,5743.95,Other,100% of Medicaid,5743.95,,,5743.95,Other,100% of Medicaid,5743.95,,,5743.95,Other,100% of Medicaid,5743.95,,,5743.95,Other,100% of Medicaid,12923.9,,,12923.9,Other,225% of Medicaid,8788.25,,,8788.25,Other,153% of Medicaid,12923.9,,,12923.9,Other,225% of Medicaid,8041.54,,,8041.54,Other,140% of Medicaid,12923.9,,,12923.9,Other,225% of Medicaid,14934.28,,,14934.28,Other,260% of Medicaid,18610.41,,,18610.41,Other,324% of Medicaid,12349.5,,,12349.5,Other,215% of Medicaid,12349.5,,,12349.5,Other,215% of Medicaid,7179.94,,,7179.94,Other,125% of Medicaid,3343,19248.8,
REPOSITION PACING-DEFIB LEAD,33215,CPT,,49033215,CDM,360,RC,,,both,,,6712,4966.9,,,4966.9,Other,150% of Medicare + 9.63% HCRA Surcharge,3020.4,45,,3020.4,percent of total billed charges,Critical Access Hospital RCC factor,3473,,,3473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3126,,,3126,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4476,,,4476,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4028,,,4028,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3805,,,3805,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3322.44,,,3322.44,Other,110% of Medicare,6152,,,6152,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",4536.91,,,4536.91,Other,186% of Medicaid,7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",5369.6,,,5369.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",4698.4,70,,4698.4,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",4913,,,4913,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4422,,,4422,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4913,,,4913,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4176,,,4176,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2439.2,,,2439.2,Other,100% of Medicaid,2439.2,,,2439.2,Other,100% of Medicaid,2439.2,,,2439.2,Other,100% of Medicaid,2439.2,,,2439.2,Other,100% of Medicaid,5488.2,,,5488.2,Other,225% of Medicaid,3731.98,,,3731.98,Other,153% of Medicaid,5488.2,,,5488.2,Other,225% of Medicaid,3414.88,,,3414.88,Other,140% of Medicaid,5488.2,,,5488.2,Other,225% of Medicaid,6341.92,,,6341.92,Other,260% of Medicaid,7903.01,,,7903.01,Other,324% of Medicaid,5244.28,,,5244.28,Other,215% of Medicaid,5244.28,,,5244.28,Other,215% of Medicaid,3049,,,3049,Other,125% of Medicaid,2439.2,9473,
INSERT 1 ELECTRODE PM-DEFIB,33216,CPT,,49033216,CDM,360,RC,,,both,,,18374,13596.81,,,13596.81,Other,150% of Medicare + 9.63% HCRA Surcharge,8268.3,45,,8268.3,percent of total billed charges,Critical Access Hospital RCC factor,3969,,,3969,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3572,,,3572,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",7978,,,7978,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",7180,,,7180,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",6781,,,6781,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",9095.13,,,9095.13,Other,110% of Medicare,6152,,,6152,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",4536.91,,,4536.91,Other,186% of Medicaid,7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",14699.2,,,14699.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",12861.8,70,,12861.8,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",6331,,,6331,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",5698,,,5698,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",6331,,,6331,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",5381,,,5381,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2439.2,,,2439.2,Other,100% of Medicaid,2439.2,,,2439.2,Other,100% of Medicaid,2439.2,,,2439.2,Other,100% of Medicaid,2439.2,,,2439.2,Other,100% of Medicaid,5488.2,,,5488.2,Other,225% of Medicaid,3731.98,,,3731.98,Other,153% of Medicaid,5488.2,,,5488.2,Other,225% of Medicaid,3414.88,,,3414.88,Other,140% of Medicaid,5488.2,,,5488.2,Other,225% of Medicaid,6341.92,,,6341.92,Other,260% of Medicaid,7903.01,,,7903.01,Other,324% of Medicaid,5244.28,,,5244.28,Other,215% of Medicaid,5244.28,,,5244.28,Other,215% of Medicaid,3049,,,3049,Other,125% of Medicaid,2439.2,14699.2,
INSERT 2 ELECTRODE PM-DEFIB,33217,CPT,,49033217,CDM,360,RC,,,both,,,18374,13596.81,,,13596.81,Other,150% of Medicare + 9.63% HCRA Surcharge,8268.3,45,,8268.3,percent of total billed charges,Critical Access Hospital RCC factor,3969,,,3969,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3572,,,3572,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",7978,,,7978,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",7180,,,7180,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",6781,,,6781,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",9095.13,,,9095.13,Other,110% of Medicare,6152,,,6152,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",4536.91,,,4536.91,Other,186% of Medicaid,7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",14699.2,,,14699.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",12861.8,70,,12861.8,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",6331,,,6331,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",5698,,,5698,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",6331,,,6331,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",5381,,,5381,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2439.2,,,2439.2,Other,100% of Medicaid,2439.2,,,2439.2,Other,100% of Medicaid,2439.2,,,2439.2,Other,100% of Medicaid,2439.2,,,2439.2,Other,100% of Medicaid,5488.2,,,5488.2,Other,225% of Medicaid,3731.98,,,3731.98,Other,153% of Medicaid,5488.2,,,5488.2,Other,225% of Medicaid,3414.88,,,3414.88,Other,140% of Medicaid,5488.2,,,5488.2,Other,225% of Medicaid,6341.92,,,6341.92,Other,260% of Medicaid,7903.01,,,7903.01,Other,324% of Medicaid,5244.28,,,5244.28,Other,215% of Medicaid,5244.28,,,5244.28,Other,215% of Medicaid,3049,,,3049,Other,125% of Medicaid,2439.2,14699.2,
REPAIR LEAD PACE-DEFIB ONE,33218,CPT,,49033218,CDM,360,RC,,,both,,,7544,5582.58,,,5582.58,Other,150% of Medicare + 9.63% HCRA Surcharge,3394.8,45,,3394.8,percent of total billed charges,Critical Access Hospital RCC factor,3969,,,3969,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3572,,,3572,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4476,,,4476,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4028,,,4028,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3805,,,3805,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3734.28,,,3734.28,Other,110% of Medicare,6152,,,6152,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",4536.91,,,4536.91,Other,186% of Medicaid,7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",6035.2,,,6035.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",5280.8,70,,5280.8,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",4913,,,4913,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4422,,,4422,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4913,,,4913,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4176,,,4176,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2439.2,,,2439.2,Other,100% of Medicaid,2439.2,,,2439.2,Other,100% of Medicaid,2439.2,,,2439.2,Other,100% of Medicaid,2439.2,,,2439.2,Other,100% of Medicaid,5488.2,,,5488.2,Other,225% of Medicaid,3731.98,,,3731.98,Other,153% of Medicaid,5488.2,,,5488.2,Other,225% of Medicaid,3414.88,,,3414.88,Other,140% of Medicaid,5488.2,,,5488.2,Other,225% of Medicaid,6341.92,,,6341.92,Other,260% of Medicaid,7903.01,,,7903.01,Other,324% of Medicaid,5244.28,,,5244.28,Other,215% of Medicaid,5244.28,,,5244.28,Other,215% of Medicaid,3049,,,3049,Other,125% of Medicaid,2439.2,9473,
REPAIR LEAD PACE-DEFIB DUAL,33220,CPT,,49033220,CDM,360,RC,,,both,,,7544,5582.58,,,5582.58,Other,150% of Medicare + 9.63% HCRA Surcharge,3394.8,45,,3394.8,percent of total billed charges,Critical Access Hospital RCC factor,3969,,,3969,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3572,,,3572,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4476,,,4476,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4028,,,4028,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3805,,,3805,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3734.28,,,3734.28,Other,110% of Medicare,6152,,,6152,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",4536.91,,,4536.91,Other,186% of Medicaid,7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",6035.2,,,6035.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",5280.8,70,,5280.8,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",4913,,,4913,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4422,,,4422,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4913,,,4913,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4176,,,4176,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2439.2,,,2439.2,Other,100% of Medicaid,2439.2,,,2439.2,Other,100% of Medicaid,2439.2,,,2439.2,Other,100% of Medicaid,2439.2,,,2439.2,Other,100% of Medicaid,5488.2,,,5488.2,Other,225% of Medicaid,3731.98,,,3731.98,Other,153% of Medicaid,5488.2,,,5488.2,Other,225% of Medicaid,3414.88,,,3414.88,Other,140% of Medicaid,5488.2,,,5488.2,Other,225% of Medicaid,6341.92,,,6341.92,Other,260% of Medicaid,7903.01,,,7903.01,Other,324% of Medicaid,5244.28,,,5244.28,Other,215% of Medicaid,5244.28,,,5244.28,Other,215% of Medicaid,3049,,,3049,Other,125% of Medicaid,2439.2,9473,
INSERT PULSE GEN MULT LEADS,33221,CPT,,49033221,CDM,360,RC,,,both,,,58236,43094.79,,,43094.79,Other,150% of Medicare + 9.63% HCRA Surcharge,26206.2,45,,26206.2,percent of total billed charges,Critical Access Hospital RCC factor,3473,,,3473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3126,,,3126,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",7978,,,7978,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",7180,,,7180,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",6781,,,6781,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",28826.82,,,28826.82,Other,110% of Medicare,6152,,,6152,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",10683.75,,,10683.75,Other,186% of Medicaid,7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",46588.8,,,46588.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",40765.2,70,,40765.2,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",6956,,,6956,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",6261,,,6261,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",6956,,,6956,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",5913,,,5913,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",5743.95,,,5743.95,Other,100% of Medicaid,5743.95,,,5743.95,Other,100% of Medicaid,5743.95,,,5743.95,Other,100% of Medicaid,5743.95,,,5743.95,Other,100% of Medicaid,12923.9,,,12923.9,Other,225% of Medicaid,8788.25,,,8788.25,Other,153% of Medicaid,12923.9,,,12923.9,Other,225% of Medicaid,8041.54,,,8041.54,Other,140% of Medicaid,12923.9,,,12923.9,Other,225% of Medicaid,14934.28,,,14934.28,Other,260% of Medicaid,18610.41,,,18610.41,Other,324% of Medicaid,12349.5,,,12349.5,Other,215% of Medicaid,12349.5,,,12349.5,Other,215% of Medicaid,7179.94,,,7179.94,Other,125% of Medicaid,3126,46588.8,
PACER POCKET REVISION,33222,CPT,,49033222,CDM,360,RC,,,both,,,4696,3475.05,,,3475.05,Other,150% of Medicare + 9.63% HCRA Surcharge,2113.2,45,,2113.2,percent of total billed charges,Critical Access Hospital RCC factor,2480,,,2480,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2232,,,2232,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3648,,,3648,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3283,,,3283,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3101,,,3101,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2324.52,,,2324.52,Other,110% of Medicare,3193.28,,,3193.28,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",4536.91,,,4536.91,Other,186% of Medicaid,3756.8,,,3756.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",3756.8,,,3756.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",4252,,,4252,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",3287.2,70,,3287.2,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",4055,,,4055,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3649,,,3649,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4055,,,4055,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3448,,,3448,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2439.2,,,2439.2,Other,100% of Medicaid,2439.2,,,2439.2,Other,100% of Medicaid,2439.2,,,2439.2,Other,100% of Medicaid,2439.2,,,2439.2,Other,100% of Medicaid,5488.2,,,5488.2,Other,225% of Medicaid,3731.98,,,3731.98,Other,153% of Medicaid,5488.2,,,5488.2,Other,225% of Medicaid,3414.88,,,3414.88,Other,140% of Medicaid,5488.2,,,5488.2,Other,225% of Medicaid,6341.92,,,6341.92,Other,260% of Medicaid,7903.01,,,7903.01,Other,324% of Medicaid,5244.28,,,5244.28,Other,215% of Medicaid,5244.28,,,5244.28,Other,215% of Medicaid,3049,,,3049,Other,125% of Medicaid,2113.2,7903.01,
REVISE POCKET FOR DEFIB,33223,CPT,,49033223,CDM,360,RC,,,both,,,5004,3702.97,,,3702.97,Other,150% of Medicare + 9.63% HCRA Surcharge,2251.8,45,,2251.8,percent of total billed charges,Critical Access Hospital RCC factor,2480,,,2480,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2232,,,2232,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3648,,,3648,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3283,,,3283,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3101,,,3101,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2476.98,,,2476.98,Other,110% of Medicare,3402.72,,,3402.72,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",4536.91,,,4536.91,Other,186% of Medicaid,4003.2,,,4003.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",4003.2,,,4003.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",4252,,,4252,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",3502.8,70,,3502.8,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",4055,,,4055,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3649,,,3649,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4055,,,4055,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3448,,,3448,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2439.2,,,2439.2,Other,100% of Medicaid,2439.2,,,2439.2,Other,100% of Medicaid,2439.2,,,2439.2,Other,100% of Medicaid,2439.2,,,2439.2,Other,100% of Medicaid,5488.2,,,5488.2,Other,225% of Medicaid,3731.98,,,3731.98,Other,153% of Medicaid,5488.2,,,5488.2,Other,225% of Medicaid,3414.88,,,3414.88,Other,140% of Medicaid,5488.2,,,5488.2,Other,225% of Medicaid,6341.92,,,6341.92,Other,260% of Medicaid,7903.01,,,7903.01,Other,324% of Medicaid,5244.28,,,5244.28,Other,215% of Medicaid,5244.28,,,5244.28,Other,215% of Medicaid,3049,,,3049,Other,125% of Medicaid,2232,7903.01,
INSERT PACING LEAD & CONNECT,33224,CPT,,49033224,CDM,360,RC,,,both,,,38162,28239.98,,,28239.98,Other,150% of Medicare + 9.63% HCRA Surcharge,17172.9,45,,17172.9,percent of total billed charges,Critical Access Hospital RCC factor,3473,,,3473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3126,,,3126,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",7978,,,7978,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",7180,,,7180,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",6781,,,6781,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",18890.19,,,18890.19,Other,110% of Medicare,6152,,,6152,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",10683.75,,,10683.75,Other,186% of Medicaid,7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",30529.6,,,30529.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",26713.4,70,,26713.4,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",7364,,,7364,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",6628,,,6628,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",7364,,,7364,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",6260,,,6260,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",5743.95,,,5743.95,Other,100% of Medicaid,5743.95,,,5743.95,Other,100% of Medicaid,5743.95,,,5743.95,Other,100% of Medicaid,5743.95,,,5743.95,Other,100% of Medicaid,12923.9,,,12923.9,Other,225% of Medicaid,8788.25,,,8788.25,Other,153% of Medicaid,12923.9,,,12923.9,Other,225% of Medicaid,8041.54,,,8041.54,Other,140% of Medicaid,12923.9,,,12923.9,Other,225% of Medicaid,14934.28,,,14934.28,Other,260% of Medicaid,18610.41,,,18610.41,Other,324% of Medicaid,12349.5,,,12349.5,Other,215% of Medicaid,12349.5,,,12349.5,Other,215% of Medicaid,7179.94,,,7179.94,Other,125% of Medicaid,3126,30529.6,
L VENTRIC PACING LEAD ADD-ON,33225,CPT,,49033225,CDM,360,RC,,,both,,,40754,30158.06,,,30158.06,Other,150% of Medicare + 9.63% HCRA Surcharge,18339.3,45,,18339.3,percent of total billed charges,Critical Access Hospital RCC factor,3969,,,3969,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3572,,,3572,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3648,,,3648,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3283,,,3283,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3101,,,3101,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",20173.23,,,20173.23,Other,110% of Medicare,6152,,,6152,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",10683.75,,,10683.75,Other,186% of Medicaid,7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",32603.2,,,32603.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",28527.8,70,,28527.8,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",7364,,,7364,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",6628,,,6628,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",7364,,,7364,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",6260,,,6260,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",5743.95,,,5743.95,Other,100% of Medicaid,5743.95,,,5743.95,Other,100% of Medicaid,5743.95,,,5743.95,Other,100% of Medicaid,5743.95,,,5743.95,Other,100% of Medicaid,12923.9,,,12923.9,Other,225% of Medicaid,8788.25,,,8788.25,Other,153% of Medicaid,12923.9,,,12923.9,Other,225% of Medicaid,8041.54,,,8041.54,Other,140% of Medicaid,12923.9,,,12923.9,Other,225% of Medicaid,14934.28,,,14934.28,Other,260% of Medicaid,18610.41,,,18610.41,Other,324% of Medicaid,12349.5,,,12349.5,Other,215% of Medicaid,12349.5,,,12349.5,Other,215% of Medicaid,7179.94,,,7179.94,Other,125% of Medicaid,3101,32603.2,
REPOSITION L VENTRIC LEAD,33226,CPT,,49033226,CDM,360,RC,,,both,,,6712,4966.9,,,4966.9,Other,150% of Medicare + 9.63% HCRA Surcharge,3020.4,45,,3020.4,percent of total billed charges,Critical Access Hospital RCC factor,3473,,,3473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3126,,,3126,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4476,,,4476,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4028,,,4028,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3805,,,3805,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3322.44,,,3322.44,Other,110% of Medicare,6152,,,6152,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",3946.83,,,3946.83,Other,186% of Medicaid,7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",5369.6,,,5369.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",4698.4,70,,4698.4,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",4913,,,4913,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4422,,,4422,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4913,,,4913,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4176,,,4176,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2121.95,,,2121.95,Other,100% of Medicaid,2121.95,,,2121.95,Other,100% of Medicaid,2121.95,,,2121.95,Other,100% of Medicaid,2121.95,,,2121.95,Other,100% of Medicaid,4774.4,,,4774.4,Other,225% of Medicaid,3246.59,,,3246.59,Other,153% of Medicaid,4774.4,,,4774.4,Other,225% of Medicaid,2970.74,,,2970.74,Other,140% of Medicaid,4774.4,,,4774.4,Other,225% of Medicaid,5517.08,,,5517.08,Other,260% of Medicaid,6875.13,,,6875.13,Other,324% of Medicaid,4562.2,,,4562.2,Other,215% of Medicaid,4562.2,,,4562.2,Other,215% of Medicaid,2652.44,,,2652.44,Other,125% of Medicaid,2121.95,9473,
REMOVE&REPLACE PM GEN SINGL,33227,CPT,,49033227,CDM,360,RC,,,both,,,30257,22390.26,,,22390.26,Other,150% of Medicare + 9.63% HCRA Surcharge,13615.65,45,,13615.65,percent of total billed charges,Critical Access Hospital RCC factor,3473,,,3473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3126,,,3126,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",7978,,,7978,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",7180,,,7180,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",6781,,,6781,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",14977.22,,,14977.22,Other,110% of Medicare,6152,,,6152,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",10683.75,,,10683.75,Other,186% of Medicaid,7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",24205.6,,,24205.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",21179.9,70,,21179.9,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",6956,,,6956,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",6261,,,6261,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",6956,,,6956,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",5913,,,5913,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",5743.95,,,5743.95,Other,100% of Medicaid,5743.95,,,5743.95,Other,100% of Medicaid,5743.95,,,5743.95,Other,100% of Medicaid,5743.95,,,5743.95,Other,100% of Medicaid,12923.9,,,12923.9,Other,225% of Medicaid,8788.25,,,8788.25,Other,153% of Medicaid,12923.9,,,12923.9,Other,225% of Medicaid,8041.54,,,8041.54,Other,140% of Medicaid,12923.9,,,12923.9,Other,225% of Medicaid,14934.28,,,14934.28,Other,260% of Medicaid,18610.41,,,18610.41,Other,324% of Medicaid,12349.5,,,12349.5,Other,215% of Medicaid,12349.5,,,12349.5,Other,215% of Medicaid,7179.94,,,7179.94,Other,125% of Medicaid,3126,24205.6,
REMV&REPLC PM GEN DUAL LEAD,33228,CPT,,49033228,CDM,360,RC,,,both,,,33159,24537.74,,,24537.74,Other,150% of Medicare + 9.63% HCRA Surcharge,14921.55,45,,14921.55,percent of total billed charges,Critical Access Hospital RCC factor,3473,,,3473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3126,,,3126,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",7978,,,7978,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",7180,,,7180,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",6781,,,6781,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",16413.71,,,16413.71,Other,110% of Medicare,6152,,,6152,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",10683.75,,,10683.75,Other,186% of Medicaid,7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",26527.2,,,26527.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",23211.3,70,,23211.3,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",6956,,,6956,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",6261,,,6261,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",6956,,,6956,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",5913,,,5913,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",5743.95,,,5743.95,Other,100% of Medicaid,5743.95,,,5743.95,Other,100% of Medicaid,5743.95,,,5743.95,Other,100% of Medicaid,5743.95,,,5743.95,Other,100% of Medicaid,12923.9,,,12923.9,Other,225% of Medicaid,8788.25,,,8788.25,Other,153% of Medicaid,12923.9,,,12923.9,Other,225% of Medicaid,8041.54,,,8041.54,Other,140% of Medicaid,12923.9,,,12923.9,Other,225% of Medicaid,14934.28,,,14934.28,Other,260% of Medicaid,18610.41,,,18610.41,Other,324% of Medicaid,12349.5,,,12349.5,Other,215% of Medicaid,12349.5,,,12349.5,Other,215% of Medicaid,7179.94,,,7179.94,Other,125% of Medicaid,3126,26527.2,
INSRT PULSE GEN W/DUAL LEADS,33230,CPT,,49033230,CDM,360,RC,,,both,,,73662,54510.06,,,54510.06,Other,150% of Medicare + 9.63% HCRA Surcharge,33147.9,45,,33147.9,percent of total billed charges,Critical Access Hospital RCC factor,3473,,,3473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3126,,,3126,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",7978,,,7978,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",7180,,,7180,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",6781,,,6781,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",36462.69,,,36462.69,Other,110% of Medicare,6152,,,6152,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",25102.82,,,25102.82,Other,186% of Medicaid,7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",58929.6,,,58929.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",51563.4,70,,51563.4,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",15267,,,15267,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",13740,,,13740,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",15267,,,15267,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",12977,,,12977,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",13496.14,,,13496.14,Other,100% of Medicaid,13496.14,,,13496.14,Other,100% of Medicaid,13496.14,,,13496.14,Other,100% of Medicaid,13496.14,,,13496.14,Other,100% of Medicaid,30366.31,,,30366.31,Other,225% of Medicaid,20649.09,,,20649.09,Other,153% of Medicaid,30366.31,,,30366.31,Other,225% of Medicaid,18894.6,,,18894.6,Other,140% of Medicaid,30366.31,,,30366.31,Other,225% of Medicaid,35089.96,,,35089.96,Other,260% of Medicaid,43727.49,,,43727.49,Other,324% of Medicaid,29016.7,,,29016.7,Other,215% of Medicaid,29016.7,,,29016.7,Other,215% of Medicaid,16870.17,,,16870.17,Other,125% of Medicaid,3126,58929.6,
INSRT PULSE GEN W/MULT LEADS,33231,CPT,,49033231,CDM,360,RC,,,both,,,104697,77476.04,,,77476.04,Other,150% of Medicare + 9.63% HCRA Surcharge,47113.65,45,,47113.65,percent of total billed charges,Critical Access Hospital RCC factor,3473,,,3473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3126,,,3126,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",7978,,,7978,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",7180,,,7180,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",6781,,,6781,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",51825.02,,,51825.02,Other,110% of Medicare,6152,,,6152,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",25102.82,,,25102.82,Other,186% of Medicaid,7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",83757.6,,,83757.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",73287.9,70,,73287.9,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",15267,,,15267,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",13740,,,13740,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",15267,,,15267,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",12977,,,12977,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",13496.14,,,13496.14,Other,100% of Medicaid,13496.14,,,13496.14,Other,100% of Medicaid,13496.14,,,13496.14,Other,100% of Medicaid,13496.14,,,13496.14,Other,100% of Medicaid,30366.31,,,30366.31,Other,225% of Medicaid,20649.09,,,20649.09,Other,153% of Medicaid,30366.31,,,30366.31,Other,225% of Medicaid,18894.6,,,18894.6,Other,140% of Medicaid,30366.31,,,30366.31,Other,225% of Medicaid,35089.96,,,35089.96,Other,260% of Medicaid,43727.49,,,43727.49,Other,324% of Medicaid,29016.7,,,29016.7,Other,215% of Medicaid,29016.7,,,29016.7,Other,215% of Medicaid,16870.17,,,16870.17,Other,125% of Medicaid,3126,83757.6,
REMOVAL OF PM GENERATOR,33233,CPT,,49033233,CDM,360,RC,,,both,,,21018,15553.37,,,15553.37,Other,150% of Medicare + 9.63% HCRA Surcharge,9458.1,45,,9458.1,percent of total billed charges,Critical Access Hospital RCC factor,2480,,,2480,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2232,,,2232,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",7978,,,7978,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",7180,,,7180,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",6781,,,6781,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",10403.91,,,10403.91,Other,110% of Medicare,14292.24,,,14292.24,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",3946.83,,,3946.83,Other,186% of Medicaid,16814.4,,,16814.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",16814.4,,,16814.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",4252,,,4252,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",14712.6,70,,14712.6,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",4913,,,4913,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4422,,,4422,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4913,,,4913,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4176,,,4176,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2121.95,,,2121.95,Other,100% of Medicaid,2121.95,,,2121.95,Other,100% of Medicaid,2121.95,,,2121.95,Other,100% of Medicaid,2121.95,,,2121.95,Other,100% of Medicaid,4774.4,,,4774.4,Other,225% of Medicaid,3246.59,,,3246.59,Other,153% of Medicaid,4774.4,,,4774.4,Other,225% of Medicaid,2970.74,,,2970.74,Other,140% of Medicaid,4774.4,,,4774.4,Other,225% of Medicaid,5517.08,,,5517.08,Other,260% of Medicaid,6875.13,,,6875.13,Other,324% of Medicaid,4562.2,,,4562.2,Other,215% of Medicaid,4562.2,,,4562.2,Other,215% of Medicaid,2652.44,,,2652.44,Other,125% of Medicaid,2121.95,16814.4,
REMOVE 1-PACER LEAD ONLY,33234,CPT,,49033234,CDM,360,RC,,,both,,,7544,5582.58,,,5582.58,Other,150% of Medicare + 9.63% HCRA Surcharge,3394.8,45,,3394.8,percent of total billed charges,Critical Access Hospital RCC factor,3969,,,3969,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3572,,,3572,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4476,,,4476,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4028,,,4028,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3805,,,3805,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3734.28,,,3734.28,Other,110% of Medicare,6152,,,6152,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",4536.91,,,4536.91,Other,186% of Medicaid,7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",6035.2,,,6035.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",5280.8,70,,5280.8,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",4913,,,4913,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4422,,,4422,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4913,,,4913,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4176,,,4176,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2439.2,,,2439.2,Other,100% of Medicaid,2439.2,,,2439.2,Other,100% of Medicaid,2439.2,,,2439.2,Other,100% of Medicaid,2439.2,,,2439.2,Other,100% of Medicaid,5488.2,,,5488.2,Other,225% of Medicaid,3731.98,,,3731.98,Other,153% of Medicaid,5488.2,,,5488.2,Other,225% of Medicaid,3414.88,,,3414.88,Other,140% of Medicaid,5488.2,,,5488.2,Other,225% of Medicaid,6341.92,,,6341.92,Other,260% of Medicaid,7903.01,,,7903.01,Other,324% of Medicaid,5244.28,,,5244.28,Other,215% of Medicaid,5244.28,,,5244.28,Other,215% of Medicaid,3049,,,3049,Other,125% of Medicaid,2439.2,9473,
REMOVE 2-PACER LEAD ONLY,33235,CPT,,49033235,CDM,360,RC,,,both,,,7544,5582.58,,,5582.58,Other,150% of Medicare + 9.63% HCRA Surcharge,3394.8,45,,3394.8,percent of total billed charges,Critical Access Hospital RCC factor,3969,,,3969,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3572,,,3572,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4476,,,4476,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4028,,,4028,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3805,,,3805,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3734.28,,,3734.28,Other,110% of Medicare,6152,,,6152,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",4536.91,,,4536.91,Other,186% of Medicaid,7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",6035.2,,,6035.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",5280.8,70,,5280.8,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",4913,,,4913,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4422,,,4422,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4913,,,4913,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4176,,,4176,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2439.2,,,2439.2,Other,100% of Medicaid,2439.2,,,2439.2,Other,100% of Medicaid,2439.2,,,2439.2,Other,100% of Medicaid,2439.2,,,2439.2,Other,100% of Medicaid,5488.2,,,5488.2,Other,225% of Medicaid,3731.98,,,3731.98,Other,153% of Medicaid,5488.2,,,5488.2,Other,225% of Medicaid,3414.88,,,3414.88,Other,140% of Medicaid,5488.2,,,5488.2,Other,225% of Medicaid,6341.92,,,6341.92,Other,260% of Medicaid,7903.01,,,7903.01,Other,324% of Medicaid,5244.28,,,5244.28,Other,215% of Medicaid,5244.28,,,5244.28,Other,215% of Medicaid,3049,,,3049,Other,125% of Medicaid,2439.2,9473,
INSRT PULSE GEN W/SINGL LEAD,33240,CPT,,49033240,CDM,360,RC,,,both,,,51361,38007.27,,,38007.27,Other,150% of Medicare + 9.63% HCRA Surcharge,23112.45,45,,23112.45,percent of total billed charges,Critical Access Hospital RCC factor,5954,,,5954,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",5359,,,5359,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",7978,,,7978,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",7180,,,7180,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",6781,,,6781,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",25423.7,,,25423.7,Other,110% of Medicare,6152,,,6152,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",25102.82,,,25102.82,Other,186% of Medicaid,7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",41088.8,,,41088.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",35952.7,70,,35952.7,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",15267,,,15267,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",13740,,,13740,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",15267,,,15267,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",12977,,,12977,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",13496.14,,,13496.14,Other,100% of Medicaid,13496.14,,,13496.14,Other,100% of Medicaid,13496.14,,,13496.14,Other,100% of Medicaid,13496.14,,,13496.14,Other,100% of Medicaid,30366.31,,,30366.31,Other,225% of Medicaid,20649.09,,,20649.09,Other,153% of Medicaid,30366.31,,,30366.31,Other,225% of Medicaid,18894.6,,,18894.6,Other,140% of Medicaid,30366.31,,,30366.31,Other,225% of Medicaid,35089.96,,,35089.96,Other,260% of Medicaid,43727.49,,,43727.49,Other,324% of Medicaid,29016.7,,,29016.7,Other,215% of Medicaid,29016.7,,,29016.7,Other,215% of Medicaid,16870.17,,,16870.17,Other,125% of Medicaid,3343,43727.49,
REMOVE PULSE GENERATOR,33241,CPT,,49033241,CDM,360,RC,,,both,,,7544,5582.58,,,5582.58,Other,150% of Medicare + 9.63% HCRA Surcharge,3394.8,45,,3394.8,percent of total billed charges,Critical Access Hospital RCC factor,3969,,,3969,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3572,,,3572,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4476,,,4476,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4028,,,4028,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3805,,,3805,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3734.28,,,3734.28,Other,110% of Medicare,6152,,,6152,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",3946.83,,,3946.83,Other,186% of Medicaid,7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",6035.2,,,6035.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",5280.8,70,,5280.8,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",4913,,,4913,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4422,,,4422,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4913,,,4913,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4176,,,4176,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2121.95,,,2121.95,Other,100% of Medicaid,2121.95,,,2121.95,Other,100% of Medicaid,2121.95,,,2121.95,Other,100% of Medicaid,2121.95,,,2121.95,Other,100% of Medicaid,4774.4,,,4774.4,Other,225% of Medicaid,3246.59,,,3246.59,Other,153% of Medicaid,4774.4,,,4774.4,Other,225% of Medicaid,2970.74,,,2970.74,Other,140% of Medicaid,4774.4,,,4774.4,Other,225% of Medicaid,5517.08,,,5517.08,Other,260% of Medicaid,6875.13,,,6875.13,Other,324% of Medicaid,4562.2,,,4562.2,Other,215% of Medicaid,4562.2,,,4562.2,Other,215% of Medicaid,2652.44,,,2652.44,Other,125% of Medicaid,2121.95,9473,
REM SC/DC ICD LEAD; TV EXTRACT,33244,CPT,,49033244,CDM,360,RC,,,both,,,7544,5582.58,,,5582.58,Other,150% of Medicare + 9.63% HCRA Surcharge,3394.8,45,,3394.8,percent of total billed charges,Critical Access Hospital RCC factor,3969,,,3969,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3572,,,3572,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4476,,,4476,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4028,,,4028,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3805,,,3805,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3734.28,,,3734.28,Other,110% of Medicare,6152,,,6152,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",4536.91,,,4536.91,Other,186% of Medicaid,7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",6035.2,,,6035.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",5280.8,70,,5280.8,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",4913,,,4913,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4422,,,4422,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4913,,,4913,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4176,,,4176,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2439.2,,,2439.2,Other,100% of Medicaid,2439.2,,,2439.2,Other,100% of Medicaid,2439.2,,,2439.2,Other,100% of Medicaid,2439.2,,,2439.2,Other,100% of Medicaid,5488.2,,,5488.2,Other,225% of Medicaid,3731.98,,,3731.98,Other,153% of Medicaid,5488.2,,,5488.2,Other,225% of Medicaid,3414.88,,,3414.88,Other,140% of Medicaid,5488.2,,,5488.2,Other,225% of Medicaid,6341.92,,,6341.92,Other,260% of Medicaid,7903.01,,,7903.01,Other,324% of Medicaid,5244.28,,,5244.28,Other,215% of Medicaid,5244.28,,,5244.28,Other,215% of Medicaid,3049,,,3049,Other,125% of Medicaid,2439.2,9473,
NSERT PACE-DEFIB W/LEAD,33249,CPT,,49033249,CDM,360,RC,,,both,,,72199,53427.44,,,53427.44,Other,150% of Medicare + 9.63% HCRA Surcharge,32489.55,45,,32489.55,percent of total billed charges,Critical Access Hospital RCC factor,5954,,,5954,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",5359,,,5359,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",7978,,,7978,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",7180,,,7180,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",6781,,,6781,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",35738.51,,,35738.51,Other,110% of Medicare,6152,,,6152,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",25102.82,,,25102.82,Other,186% of Medicaid,7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",57759.2,,,57759.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",50539.3,70,,50539.3,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",15267,,,15267,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",13740,,,13740,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",15267,,,15267,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",12977,,,12977,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",13496.14,,,13496.14,Other,100% of Medicaid,13496.14,,,13496.14,Other,100% of Medicaid,13496.14,,,13496.14,Other,100% of Medicaid,13496.14,,,13496.14,Other,100% of Medicaid,30366.31,,,30366.31,Other,225% of Medicaid,20649.09,,,20649.09,Other,153% of Medicaid,30366.31,,,30366.31,Other,225% of Medicaid,18894.6,,,18894.6,Other,140% of Medicaid,30366.31,,,30366.31,Other,225% of Medicaid,35089.96,,,35089.96,Other,260% of Medicaid,43727.49,,,43727.49,Other,324% of Medicaid,29016.7,,,29016.7,Other,215% of Medicaid,29016.7,,,29016.7,Other,215% of Medicaid,16870.17,,,16870.17,Other,125% of Medicaid,3343,57759.2,
REMV&REPLC CVD GEN SING LEAD,33262,CPT,,49033262,CDM,360,RC,,,both,,,51361,38007.27,,,38007.27,Other,150% of Medicare + 9.63% HCRA Surcharge,23112.45,45,,23112.45,percent of total billed charges,Critical Access Hospital RCC factor,3473,,,3473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3126,,,3126,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",7978,,,7978,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",7180,,,7180,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",6781,,,6781,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",25423.7,,,25423.7,Other,110% of Medicare,6152,,,6152,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",25102.82,,,25102.82,Other,186% of Medicaid,7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",41088.8,,,41088.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",35952.7,70,,35952.7,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",15267,,,15267,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",13740,,,13740,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",15267,,,15267,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",12977,,,12977,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",13496.14,,,13496.14,Other,100% of Medicaid,13496.14,,,13496.14,Other,100% of Medicaid,13496.14,,,13496.14,Other,100% of Medicaid,13496.14,,,13496.14,Other,100% of Medicaid,30366.31,,,30366.31,Other,225% of Medicaid,20649.09,,,20649.09,Other,153% of Medicaid,30366.31,,,30366.31,Other,225% of Medicaid,18894.6,,,18894.6,Other,140% of Medicaid,30366.31,,,30366.31,Other,225% of Medicaid,35089.96,,,35089.96,Other,260% of Medicaid,43727.49,,,43727.49,Other,324% of Medicaid,29016.7,,,29016.7,Other,215% of Medicaid,29016.7,,,29016.7,Other,215% of Medicaid,16870.17,,,16870.17,Other,125% of Medicaid,3126,43727.49,
REMV&REPLC CVD GEN DUAL LEAD,33263,CPT,,49033263,CDM,360,RC,,,both,,,51361,38007.27,,,38007.27,Other,150% of Medicare + 9.63% HCRA Surcharge,23112.45,45,,23112.45,percent of total billed charges,Critical Access Hospital RCC factor,3473,,,3473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3126,,,3126,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",7978,,,7978,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",7180,,,7180,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",6781,,,6781,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",25423.7,,,25423.7,Other,110% of Medicare,6152,,,6152,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",25102.82,,,25102.82,Other,186% of Medicaid,7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",41088.8,,,41088.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",35952.7,70,,35952.7,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",15267,,,15267,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",13740,,,13740,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",15267,,,15267,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",12977,,,12977,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",13496.14,,,13496.14,Other,100% of Medicaid,13496.14,,,13496.14,Other,100% of Medicaid,13496.14,,,13496.14,Other,100% of Medicaid,13496.14,,,13496.14,Other,100% of Medicaid,30366.31,,,30366.31,Other,225% of Medicaid,20649.09,,,20649.09,Other,153% of Medicaid,30366.31,,,30366.31,Other,225% of Medicaid,18894.6,,,18894.6,Other,140% of Medicaid,30366.31,,,30366.31,Other,225% of Medicaid,35089.96,,,35089.96,Other,260% of Medicaid,43727.49,,,43727.49,Other,324% of Medicaid,29016.7,,,29016.7,Other,215% of Medicaid,29016.7,,,29016.7,Other,215% of Medicaid,16870.17,,,16870.17,Other,125% of Medicaid,3126,43727.49,
REMV&REPLC CVD GEN MULT LEAD,33264,CPT,,49033264,CDM,360,RC,,,both,,,72199,53427.44,,,53427.44,Other,150% of Medicare + 9.63% HCRA Surcharge,32489.55,45,,32489.55,percent of total billed charges,Critical Access Hospital RCC factor,3473,,,3473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3126,,,3126,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",7978,,,7978,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",7180,,,7180,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",6781,,,6781,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",35738.51,,,35738.51,Other,110% of Medicare,6152,,,6152,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",25102.82,,,25102.82,Other,186% of Medicaid,7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",57759.2,,,57759.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",50539.3,70,,50539.3,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",15267,,,15267,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",13740,,,13740,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",15267,,,15267,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",12977,,,12977,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",13496.14,,,13496.14,Other,100% of Medicaid,13496.14,,,13496.14,Other,100% of Medicaid,13496.14,,,13496.14,Other,100% of Medicaid,13496.14,,,13496.14,Other,100% of Medicaid,30366.31,,,30366.31,Other,225% of Medicaid,20649.09,,,20649.09,Other,153% of Medicaid,30366.31,,,30366.31,Other,225% of Medicaid,18894.6,,,18894.6,Other,140% of Medicaid,30366.31,,,30366.31,Other,225% of Medicaid,35089.96,,,35089.96,Other,260% of Medicaid,43727.49,,,43727.49,Other,324% of Medicaid,29016.7,,,29016.7,Other,215% of Medicaid,29016.7,,,29016.7,Other,215% of Medicaid,16870.17,,,16870.17,Other,125% of Medicaid,3126,57759.2,
INSJ SUBQ CAR RHYTHM MNTR,33285,CPT,,49033285,CDM,360,RC,,,both,,,18374,13596.81,,,13596.81,Other,150% of Medicare + 9.63% HCRA Surcharge,8268.3,45,,8268.3,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",7978,,,7978,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",7180,,,7180,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",6781,,,6781,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",9095.13,,,9095.13,Other,110% of Medicare,12494.32,,,12494.32,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",10683.75,,,10683.75,Other,186% of Medicaid,14699.2,,,14699.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",14699.2,,,14699.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",14699.2,,,14699.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",12861.8,70,,12861.8,percent of total billed charges,All Other,423.12,,,423.12,Fee Schedule,,358.62,,,358.62,Fee Schedule,,6956,,,6956,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",6261,,,6261,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",6956,,,6956,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",5913,,,5913,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",5743.95,,,5743.95,Other,100% of Medicaid,5743.95,,,5743.95,Other,100% of Medicaid,5743.95,,,5743.95,Other,100% of Medicaid,5743.95,,,5743.95,Other,100% of Medicaid,12923.9,,,12923.9,Other,225% of Medicaid,8788.25,,,8788.25,Other,153% of Medicaid,12923.9,,,12923.9,Other,225% of Medicaid,8041.54,,,8041.54,Other,140% of Medicaid,12923.9,,,12923.9,Other,225% of Medicaid,14934.28,,,14934.28,Other,260% of Medicaid,18610.41,,,18610.41,Other,324% of Medicaid,12349.5,,,12349.5,Other,215% of Medicaid,12349.5,,,12349.5,Other,215% of Medicaid,7179.94,,,7179.94,Other,125% of Medicaid,358.62,18610.41,
REMOVE ILR,33286,CPT,,49033286,CDM,360,RC,,,both,,,2885,2134.91,,,2134.91,Other,150% of Medicare + 9.63% HCRA Surcharge,1298.25,45,,1298.25,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",1428.08,,,1428.08,Other,110% of Medicare,1961.8,,,1961.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",4536.91,,,4536.91,Other,186% of Medicaid,2308,,,2308,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2308,,,2308,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2308,,,2308,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2019.5,70,,2019.5,percent of total billed charges,All Other,418.2,,,418.2,Fee Schedule,,354.45,,,354.45,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2439.2,,,2439.2,Other,100% of Medicaid,2439.2,,,2439.2,Other,100% of Medicaid,2439.2,,,2439.2,Other,100% of Medicaid,2439.2,,,2439.2,Other,100% of Medicaid,5488.2,,,5488.2,Other,225% of Medicaid,3731.98,,,3731.98,Other,153% of Medicaid,5488.2,,,5488.2,Other,225% of Medicaid,3414.88,,,3414.88,Other,140% of Medicaid,5488.2,,,5488.2,Other,225% of Medicaid,6341.92,,,6341.92,Other,260% of Medicaid,7903.01,,,7903.01,Other,324% of Medicaid,5244.28,,,5244.28,Other,215% of Medicaid,5244.28,,,5244.28,Other,215% of Medicaid,3049,,,3049,Other,125% of Medicaid,354.45,7903.01,
INS IAB ASSIST DEVICE THRU FEM ART OPEN,33970,CPT,,49033970,CDM,360,RC,,,both,,,1358,1004.92,,,1004.92,Other,150% of Medicare + 9.63% HCRA Surcharge,611.1,45,,611.1,percent of total billed charges,Critical Access Hospital RCC factor,4565,,,4565,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4109,,,4109,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4476,,,4476,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4028,,,4028,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3805,,,3805,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",672.21,,,672.21,Other,110% of Medicare,923.44,,,923.44,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",3921.5,,,3921.5,Other,186% of Medicaid,1086.4,,,1086.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1086.4,,,1086.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1086.4,,,1086.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",950.6,70,,950.6,percent of total billed charges,All Other,1702.32,,,1702.32,Fee Schedule,,1442.82,,,1442.82,Fee Schedule,,4531,,,4531,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4079,,,4079,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4531,,,4531,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3852,,,3852,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2108.33,,,2108.33,Other,100% of Medicaid,2108.33,,,2108.33,Other,100% of Medicaid,2108.33,,,2108.33,Other,100% of Medicaid,2108.33,,,2108.33,Other,100% of Medicaid,4743.75,,,4743.75,Other,225% of Medicaid,3225.75,,,3225.75,Other,153% of Medicaid,4743.75,,,4743.75,Other,225% of Medicaid,2951.67,,,2951.67,Other,140% of Medicaid,4743.75,,,4743.75,Other,225% of Medicaid,5481.67,,,5481.67,Other,260% of Medicaid,6831,,,6831,Other,324% of Medicaid,4532.92,,,4532.92,Other,215% of Medicaid,4532.92,,,4532.92,Other,215% of Medicaid,2635.42,,,2635.42,Other,125% of Medicaid,611.1,7216,
AORTIC CIRCULATION ASSIST,33971,CPT,,49033971,CDM,360,RC,,,both,,,2709,2004.67,,,2004.67,Other,150% of Medicare + 9.63% HCRA Surcharge,1219.05,45,,1219.05,percent of total billed charges,Critical Access Hospital RCC factor,4565,,,4565,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4109,,,4109,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4476,,,4476,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4028,,,4028,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3805,,,3805,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",1340.96,,,1340.96,Other,110% of Medicare,1842.12,,,1842.12,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",3921.5,,,3921.5,Other,186% of Medicaid,2167.2,,,2167.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2167.2,,,2167.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2167.2,,,2167.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1896.3,70,,1896.3,percent of total billed charges,All Other,3416.12,,,3416.12,Fee Schedule,,2895.37,,,2895.37,Fee Schedule,,4531,,,4531,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4079,,,4079,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4531,,,4531,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3852,,,3852,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2108.33,,,2108.33,Other,100% of Medicaid,2108.33,,,2108.33,Other,100% of Medicaid,2108.33,,,2108.33,Other,100% of Medicaid,2108.33,,,2108.33,Other,100% of Medicaid,4743.75,,,4743.75,Other,225% of Medicaid,3225.75,,,3225.75,Other,153% of Medicaid,4743.75,,,4743.75,Other,225% of Medicaid,2951.67,,,2951.67,Other,140% of Medicaid,4743.75,,,4743.75,Other,225% of Medicaid,5481.67,,,5481.67,Other,260% of Medicaid,6831,,,6831,Other,324% of Medicaid,4532.92,,,4532.92,Other,215% of Medicaid,4532.92,,,4532.92,Other,215% of Medicaid,2635.42,,,2635.42,Other,125% of Medicaid,1219.05,7216,
INSERT IAB ASSIST DEVICE THRU ASC AORTA,33973,CPT,,49033973,CDM,360,RC,,,both,,,1968,1456.32,,,1456.32,Other,150% of Medicare + 9.63% HCRA Surcharge,885.6,45,,885.6,percent of total billed charges,Critical Access Hospital RCC factor,4565,,,4565,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4109,,,4109,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4476,,,4476,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4028,,,4028,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3805,,,3805,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",974.16,,,974.16,Other,110% of Medicare,1338.24,,,1338.24,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",3921.5,,,3921.5,Other,186% of Medicaid,1574.4,,,1574.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1574.4,,,1574.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1574.4,,,1574.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1377.6,70,,1377.6,percent of total billed charges,All Other,2412.44,,,2412.44,Fee Schedule,,2044.69,,,2044.69,Fee Schedule,,4531,,,4531,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4079,,,4079,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4531,,,4531,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3852,,,3852,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2108.33,,,2108.33,Other,100% of Medicaid,2108.33,,,2108.33,Other,100% of Medicaid,2108.33,,,2108.33,Other,100% of Medicaid,2108.33,,,2108.33,Other,100% of Medicaid,4743.75,,,4743.75,Other,225% of Medicaid,3225.75,,,3225.75,Other,153% of Medicaid,4743.75,,,4743.75,Other,225% of Medicaid,2951.67,,,2951.67,Other,140% of Medicaid,4743.75,,,4743.75,Other,225% of Medicaid,5481.67,,,5481.67,Other,260% of Medicaid,6831,,,6831,Other,324% of Medicaid,4532.92,,,4532.92,Other,215% of Medicaid,4532.92,,,4532.92,Other,215% of Medicaid,2635.42,,,2635.42,Other,125% of Medicaid,885.6,7216,
UNLISTED CARDIAC SURGERY,33999,CPT,,49033999,CDM,360,RC,,,both,,,2045,1513.31,,,1513.31,Other,150% of Medicare + 9.63% HCRA Surcharge,920.25,45,,920.25,percent of total billed charges,Critical Access Hospital RCC factor,4565,,,4565,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4109,,,4109,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1012.28,,,1012.28,Other,110% of Medicare,1390.6,,,1390.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",3921.5,,,3921.5,Other,186% of Medicaid,1636,,,1636,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1636,,,1636,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1636,,,1636,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1431.5,70,,1431.5,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2108.33,,,2108.33,Other,100% of Medicaid,2108.33,,,2108.33,Other,100% of Medicaid,2108.33,,,2108.33,Other,100% of Medicaid,2108.33,,,2108.33,Other,100% of Medicaid,4743.75,,,4743.75,Other,225% of Medicaid,3225.75,,,3225.75,Other,153% of Medicaid,4743.75,,,4743.75,Other,225% of Medicaid,2951.67,,,2951.67,Other,140% of Medicaid,4743.75,,,4743.75,Other,225% of Medicaid,5481.67,,,5481.67,Other,260% of Medicaid,6831,,,6831,Other,324% of Medicaid,4532.92,,,4532.92,Other,215% of Medicaid,4532.92,,,4532.92,Other,215% of Medicaid,2635.42,,,2635.42,Other,125% of Medicaid,0.01,7216,
EX VEIN NEEDLE/INTRACATH UNI,36005,CPT,,49036005,CDM,360,RC,,,both,,,2233,1652.43,,,1652.43,Other,150% of Medicare + 9.63% HCRA Surcharge,1004.85,45,,1004.85,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",1105.34,,,1105.34,Other,110% of Medicare,1518.44,,,1518.44,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",516.02,,,516.02,Other,186% of Medicaid,1786.4,,,1786.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1786.4,,,1786.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1786.4,,,1786.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1563.1,70,,1563.1,percent of total billed charges,All Other,227.96,,,227.96,Fee Schedule,,193.21,,,193.21,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",277.43,,,277.43,Other,100% of Medicaid,277.43,,,277.43,Other,100% of Medicaid,277.43,,,277.43,Other,100% of Medicaid,277.43,,,277.43,Other,100% of Medicaid,624.21,,,624.21,Other,225% of Medicaid,424.47,,,424.47,Other,153% of Medicaid,624.21,,,624.21,Other,225% of Medicaid,388.4,,,388.4,Other,140% of Medicaid,624.21,,,624.21,Other,225% of Medicaid,721.31,,,721.31,Other,260% of Medicaid,898.87,,,898.87,Other,324% of Medicaid,596.47,,,596.47,Other,215% of Medicaid,596.47,,,596.47,Other,215% of Medicaid,346.79,,,346.79,Other,125% of Medicaid,193.21,7216,
EX ARTERY NEEDLE/INTRACATH UN,36140,CPT,,49036140,CDM,360,RC,,,both,,,769,569.06,,,569.06,Other,150% of Medicare + 9.63% HCRA Surcharge,346.05,45,,346.05,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",380.66,,,380.66,Other,110% of Medicare,522.92,,,522.92,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",516.02,,,516.02,Other,186% of Medicaid,615.2,,,615.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",615.2,,,615.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",615.2,,,615.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",538.3,70,,538.3,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",277.43,,,277.43,Other,100% of Medicaid,277.43,,,277.43,Other,100% of Medicaid,277.43,,,277.43,Other,100% of Medicaid,277.43,,,277.43,Other,100% of Medicaid,624.21,,,624.21,Other,225% of Medicaid,424.47,,,424.47,Other,153% of Medicaid,624.21,,,624.21,Other,225% of Medicaid,388.4,,,388.4,Other,140% of Medicaid,624.21,,,624.21,Other,225% of Medicaid,721.31,,,721.31,Other,260% of Medicaid,898.87,,,898.87,Other,324% of Medicaid,596.47,,,596.47,Other,215% of Medicaid,596.47,,,596.47,Other,215% of Medicaid,346.79,,,346.79,Other,125% of Medicaid,277.43,7216,
AORTA CATHETER FEMBRACAX,36200,CPT,,49036200,CDM,360,RC,,,both,,,1146,848.04,,,848.04,Other,150% of Medicare + 9.63% HCRA Surcharge,515.7,45,,515.7,percent of total billed charges,Critical Access Hospital RCC factor,2480,,,2480,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2232,,,2232,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3648,,,3648,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3283,,,3283,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3101,,,3101,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",567.27,,,567.27,Other,110% of Medicare,779.28,,,779.28,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",516.02,,,516.02,Other,186% of Medicaid,916.8,,,916.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",916.8,,,916.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",916.8,,,916.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",802.2,70,,802.2,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",277.43,,,277.43,Other,100% of Medicaid,277.43,,,277.43,Other,100% of Medicaid,277.43,,,277.43,Other,100% of Medicaid,277.43,,,277.43,Other,100% of Medicaid,624.21,,,624.21,Other,225% of Medicaid,424.47,,,424.47,Other,153% of Medicaid,624.21,,,624.21,Other,225% of Medicaid,388.4,,,388.4,Other,140% of Medicaid,624.21,,,624.21,Other,225% of Medicaid,721.31,,,721.31,Other,260% of Medicaid,898.87,,,898.87,Other,324% of Medicaid,596.47,,,596.47,Other,215% of Medicaid,596.47,,,596.47,Other,215% of Medicaid,346.79,,,346.79,Other,125% of Medicaid,277.43,7216,
OAAV 1ST & 2ND,36246,CPT,,49036246,CDM,360,RC,,,both,,,2057,1522.19,,,1522.19,Other,150% of Medicare + 9.63% HCRA Surcharge,925.65,45,,925.65,percent of total billed charges,Critical Access Hospital RCC factor,2480,,,2480,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2232,,,2232,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4970,,,4970,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4473,,,4473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4225,,,4225,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",1018.22,,,1018.22,Other,110% of Medicare,1398.76,,,1398.76,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",516.02,,,516.02,Other,186% of Medicaid,1645.6,,,1645.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1645.6,,,1645.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1645.6,,,1645.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1439.9,70,,1439.9,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",277.43,,,277.43,Other,100% of Medicaid,277.43,,,277.43,Other,100% of Medicaid,277.43,,,277.43,Other,100% of Medicaid,277.43,,,277.43,Other,100% of Medicaid,624.21,,,624.21,Other,225% of Medicaid,424.47,,,424.47,Other,153% of Medicaid,624.21,,,624.21,Other,225% of Medicaid,388.4,,,388.4,Other,140% of Medicaid,624.21,,,624.21,Other,225% of Medicaid,721.31,,,721.31,Other,260% of Medicaid,898.87,,,898.87,Other,324% of Medicaid,596.47,,,596.47,Other,215% of Medicaid,596.47,,,596.47,Other,215% of Medicaid,346.79,,,346.79,Other,125% of Medicaid,277.43,7216,
INS CATH REN ART 1ST BILAT,36252,CPT,,49036252,CDM,360,RC,,,both,,,8781,6497.96,,,6497.96,Other,150% of Medicare + 9.63% HCRA Surcharge,3951.45,45,,3951.45,percent of total billed charges,Critical Access Hospital RCC factor,2480,,,2480,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2232,,,2232,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4476,,,4476,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4028,,,4028,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3805,,,3805,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4346.6,,,4346.6,Other,110% of Medicare,5971.08,,,5971.08,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1729.46,,,1729.46,Other,186% of Medicaid,7024.8,,,7024.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7024.8,,,7024.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7024.8,,,7024.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",6146.7,70,,6146.7,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",4913,,,4913,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4422,,,4422,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4913,,,4913,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4176,,,4176,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",929.82,,,929.82,Other,100% of Medicaid,929.82,,,929.82,Other,100% of Medicaid,929.82,,,929.82,Other,100% of Medicaid,929.82,,,929.82,Other,100% of Medicaid,2092.09,,,2092.09,Other,225% of Medicaid,1422.62,,,1422.62,Other,153% of Medicaid,2092.09,,,2092.09,Other,225% of Medicaid,1301.75,,,1301.75,Other,140% of Medicaid,2092.09,,,2092.09,Other,225% of Medicaid,2417.53,,,2417.53,Other,260% of Medicaid,3012.61,,,3012.61,Other,324% of Medicaid,1999.11,,,1999.11,Other,215% of Medicaid,1999.11,,,1999.11,Other,215% of Medicaid,1162.27,,,1162.27,Other,125% of Medicaid,929.82,7216,
INS CATH REN ART 2ND+ BILAT,36254,CPT,,49036254,CDM,360,RC,,,both,,,8749,6474.28,,,6474.28,Other,150% of Medicare + 9.63% HCRA Surcharge,3937.05,45,,3937.05,percent of total billed charges,Critical Access Hospital RCC factor,2480,,,2480,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2232,,,2232,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4476,,,4476,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4028,,,4028,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3805,,,3805,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4330.76,,,4330.76,Other,110% of Medicare,5949.32,,,5949.32,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1729.46,,,1729.46,Other,186% of Medicaid,6999.2,,,6999.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",6999.2,,,6999.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",6999.2,,,6999.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",6124.3,70,,6124.3,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",4913,,,4913,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4422,,,4422,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4913,,,4913,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4176,,,4176,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",929.82,,,929.82,Other,100% of Medicaid,929.82,,,929.82,Other,100% of Medicaid,929.82,,,929.82,Other,100% of Medicaid,929.82,,,929.82,Other,100% of Medicaid,2092.09,,,2092.09,Other,225% of Medicaid,1422.62,,,1422.62,Other,153% of Medicaid,2092.09,,,2092.09,Other,225% of Medicaid,1301.75,,,1301.75,Other,140% of Medicaid,2092.09,,,2092.09,Other,225% of Medicaid,2417.53,,,2417.53,Other,260% of Medicaid,3012.61,,,3012.61,Other,324% of Medicaid,1999.11,,,1999.11,Other,215% of Medicaid,1999.11,,,1999.11,Other,215% of Medicaid,1162.27,,,1162.27,Other,125% of Medicaid,929.82,7216,
INJ ANESTH; LUMB/THOR (SYMPATHETIC),64520,CPT,,49064520,CDM,360,RC,,,both,,,3427,2535.99,,,2535.99,Other,150% of Medicare + 9.63% HCRA Surcharge,1542.15,45,,1542.15,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",1696.37,,,1696.37,Other,110% of Medicare,2330.36,,,2330.36,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1116.35,,,1116.35,Other,186% of Medicaid,2741.6,,,2741.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2741.6,,,2741.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",3578,,,3578,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2398.9,70,,2398.9,percent of total billed charges,All Other,405.08,,,405.08,Fee Schedule,,343.33,,,343.33,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",600.19,,,600.19,Other,100% of Medicaid,600.19,,,600.19,Other,100% of Medicaid,600.19,,,600.19,Other,100% of Medicaid,600.19,,,600.19,Other,100% of Medicaid,1350.43,,,1350.43,Other,225% of Medicaid,918.29,,,918.29,Other,153% of Medicaid,1350.43,,,1350.43,Other,225% of Medicaid,840.26,,,840.26,Other,140% of Medicaid,1350.43,,,1350.43,Other,225% of Medicaid,1560.49,,,1560.49,Other,260% of Medicaid,1944.61,,,1944.61,Other,324% of Medicaid,1290.41,,,1290.41,Other,215% of Medicaid,1290.41,,,1290.41,Other,215% of Medicaid,750.24,,,750.24,Other,125% of Medicaid,343.33,7216,
IDENTIFY SENTINEL NODE,38792,CPT,,50038792,CDM,360,RC,,,both,,,1401,1036.74,,,1036.74,Other,150% of Medicare + 9.63% HCRA Surcharge,630.45,45,,630.45,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",693.5,,,693.5,Other,110% of Medicare,952.68,,,952.68,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",765.84,,,765.84,Other,186% of Medicaid,1120.8,,,1120.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1120.8,,,1120.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1120.8,,,1120.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",980.7,70,,980.7,percent of total billed charges,All Other,159.08,,,159.08,Fee Schedule,,134.83,,,134.83,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",411.74,,,411.74,Other,100% of Medicaid,411.74,,,411.74,Other,100% of Medicaid,411.74,,,411.74,Other,100% of Medicaid,411.74,,,411.74,Other,100% of Medicaid,926.42,,,926.42,Other,225% of Medicaid,629.97,,,629.97,Other,153% of Medicaid,926.42,,,926.42,Other,225% of Medicaid,576.44,,,576.44,Other,140% of Medicaid,926.42,,,926.42,Other,225% of Medicaid,1070.53,,,1070.53,Other,260% of Medicaid,1334.05,,,1334.05,Other,324% of Medicaid,885.25,,,885.25,Other,215% of Medicaid,885.25,,,885.25,Other,215% of Medicaid,514.68,,,514.68,Other,125% of Medicaid,134.83,7216,
INJ TO EVAL PERITONEAL-VENOUS,49427,CPT,,50049427,CDM,360,RC,,,both,,,177,130.98,,,130.98,Other,150% of Medicare + 9.63% HCRA Surcharge,79.65,45,,79.65,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",87.62,,,87.62,Other,110% of Medicare,120.36,,,120.36,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",966.93,,,966.93,Other,186% of Medicaid,141.6,,,141.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",141.6,,,141.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",141.6,,,141.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",123.9,70,,123.9,percent of total billed charges,All Other,185.32,,,185.32,Fee Schedule,,157.07,,,157.07,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",519.86,,,519.86,Other,100% of Medicaid,519.86,,,519.86,Other,100% of Medicaid,519.86,,,519.86,Other,100% of Medicaid,519.86,,,519.86,Other,100% of Medicaid,1169.68,,,1169.68,Other,225% of Medicaid,795.38,,,795.38,Other,153% of Medicaid,1169.68,,,1169.68,Other,225% of Medicaid,727.8,,,727.8,Other,140% of Medicaid,1169.68,,,1169.68,Other,225% of Medicaid,1351.62,,,1351.62,Other,260% of Medicaid,1684.33,,,1684.33,Other,324% of Medicaid,1117.69,,,1117.69,Other,215% of Medicaid,1117.69,,,1117.69,Other,215% of Medicaid,649.82,,,649.82,Other,125% of Medicaid,79.65,7216,
IDENTIFY SENTINEL NODE,38792,CPT,,50138792,CDM,360,RC,,,both,,,1401,1036.74,,,1036.74,Other,150% of Medicare + 9.63% HCRA Surcharge,630.45,45,,630.45,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",693.5,,,693.5,Other,110% of Medicare,952.68,,,952.68,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",765.84,,,765.84,Other,186% of Medicaid,1120.8,,,1120.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1120.8,,,1120.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1120.8,,,1120.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",980.7,70,,980.7,percent of total billed charges,All Other,159.08,,,159.08,Fee Schedule,,134.83,,,134.83,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",411.74,,,411.74,Other,100% of Medicaid,411.74,,,411.74,Other,100% of Medicaid,411.74,,,411.74,Other,100% of Medicaid,411.74,,,411.74,Other,100% of Medicaid,926.42,,,926.42,Other,225% of Medicaid,629.97,,,629.97,Other,153% of Medicaid,926.42,,,926.42,Other,225% of Medicaid,576.44,,,576.44,Other,140% of Medicaid,926.42,,,926.42,Other,225% of Medicaid,1070.53,,,1070.53,Other,260% of Medicaid,1334.05,,,1334.05,Other,324% of Medicaid,885.25,,,885.25,Other,215% of Medicaid,885.25,,,885.25,Other,215% of Medicaid,514.68,,,514.68,Other,125% of Medicaid,134.83,7216,
MAMMARY DUCT INJ,19030,CPT,,54019030,CDM,360,RC,,,both,,,403,298.22,,,298.22,Other,150% of Medicare + 9.63% HCRA Surcharge,181.35,45,,181.35,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",199.49,,,199.49,Other,110% of Medicare,274.04,,,274.04,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",966.93,,,966.93,Other,186% of Medicaid,322.4,,,322.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",322.4,,,322.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",322.4,,,322.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",282.1,70,,282.1,percent of total billed charges,All Other,360.8,,,360.8,Fee Schedule,,305.8,,,305.8,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",519.86,,,519.86,Other,100% of Medicaid,519.86,,,519.86,Other,100% of Medicaid,519.86,,,519.86,Other,100% of Medicaid,519.86,,,519.86,Other,100% of Medicaid,1169.68,,,1169.68,Other,225% of Medicaid,795.38,,,795.38,Other,153% of Medicaid,1169.68,,,1169.68,Other,225% of Medicaid,727.8,,,727.8,Other,140% of Medicaid,1169.68,,,1169.68,Other,225% of Medicaid,1351.62,,,1351.62,Other,260% of Medicaid,1684.33,,,1684.33,Other,324% of Medicaid,1117.69,,,1117.69,Other,215% of Medicaid,1117.69,,,1117.69,Other,215% of Medicaid,649.82,,,649.82,Other,125% of Medicaid,181.35,7216,
TENOTOMY OP FLEXOR; TOE SINGLE,28232,CPT,,73028232,CDM,360,RC,,,both,,,4778,3535.73,,,3535.73,Other,150% of Medicare + 9.63% HCRA Surcharge,2150.1,45,,2150.1,percent of total billed charges,Critical Access Hospital RCC factor,2480,,,2480,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2232,,,2232,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3648,,,3648,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3283,,,3283,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3101,,,3101,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2365.11,,,2365.11,Other,110% of Medicare,3249.04,,,3249.04,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2891.15,,,2891.15,Other,186% of Medicaid,3822.4,,,3822.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",3822.4,,,3822.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",3822.4,,,3822.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",3344.6,70,,3344.6,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",4531,,,4531,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4079,,,4079,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4531,,,4531,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3852,,,3852,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",1554.38,,,1554.38,Other,100% of Medicaid,1554.38,,,1554.38,Other,100% of Medicaid,1554.38,,,1554.38,Other,100% of Medicaid,1554.38,,,1554.38,Other,100% of Medicaid,3497.36,,,3497.36,Other,225% of Medicaid,2378.21,,,2378.21,Other,153% of Medicaid,3497.36,,,3497.36,Other,225% of Medicaid,2176.14,,,2176.14,Other,140% of Medicaid,3497.36,,,3497.36,Other,225% of Medicaid,4041.4,,,4041.4,Other,260% of Medicaid,5036.2,,,5036.2,Other,324% of Medicaid,3341.93,,,3341.93,Other,215% of Medicaid,3341.93,,,3341.93,Other,215% of Medicaid,1942.98,,,1942.98,Other,125% of Medicaid,1554.38,7216,
"drainge abscess/hemat,nasal, inter appr",30000,CPT,,82030000,CDM,360,RC,,,both,,,1037,767.38,,,767.38,Other,150% of Medicare + 9.63% HCRA Surcharge,466.65,45,,466.65,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",513.32,,,513.32,Other,110% of Medicare,705.16,,,705.16,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",423.06,,,423.06,Other,186% of Medicaid,829.6,,,829.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",829.6,,,829.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",829.6,,,829.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",725.9,70,,725.9,percent of total billed charges,All Other,583.84,,,583.84,Fee Schedule,,494.84,,,494.84,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",227.45,,,227.45,Other,100% of Medicaid,227.45,,,227.45,Other,100% of Medicaid,227.45,,,227.45,Other,100% of Medicaid,227.45,,,227.45,Other,100% of Medicaid,511.76,,,511.76,Other,225% of Medicaid,348,,,348,Other,153% of Medicaid,511.76,,,511.76,Other,225% of Medicaid,318.43,,,318.43,Other,140% of Medicaid,511.76,,,511.76,Other,225% of Medicaid,591.37,,,591.37,Other,260% of Medicaid,736.94,,,736.94,Other,324% of Medicaid,489.02,,,489.02,Other,215% of Medicaid,489.02,,,489.02,Other,215% of Medicaid,284.31,,,284.31,Other,125% of Medicaid,227.45,7216,
INTUBATION ET EMERGENT,31500,CPT,,82031500,CDM,360,RC,,,both,,,903,668.22,,,668.22,Other,150% of Medicare + 9.63% HCRA Surcharge,406.35,45,,406.35,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",446.99,,,446.99,Other,110% of Medicare,614.04,,,614.04,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1147.86,,,1147.86,Other,186% of Medicaid,722.4,,,722.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",722.4,,,722.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",722.4,,,722.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",632.1,70,,632.1,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",617.13,,,617.13,Other,100% of Medicaid,617.13,,,617.13,Other,100% of Medicaid,617.13,,,617.13,Other,100% of Medicaid,617.13,,,617.13,Other,100% of Medicaid,1388.54,,,1388.54,Other,225% of Medicaid,944.21,,,944.21,Other,153% of Medicaid,1388.54,,,1388.54,Other,225% of Medicaid,863.98,,,863.98,Other,140% of Medicaid,1388.54,,,1388.54,Other,225% of Medicaid,1604.54,,,1604.54,Other,260% of Medicaid,1999.5,,,1999.5,Other,324% of Medicaid,1326.83,,,1326.83,Other,215% of Medicaid,1326.83,,,1326.83,Other,215% of Medicaid,771.41,,,771.41,Other,125% of Medicaid,406.35,7216,
ASPIRATE PLEURA W IMAGING,32555,CPT,,82032555,CDM,360,RC,,,both,,,2118,1567.33,,,1567.33,Other,150% of Medicare + 9.63% HCRA Surcharge,953.1,45,,953.1,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",1048.41,,,1048.41,Other,110% of Medicare,1440.24,,,1440.24,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1196.64,,,1196.64,Other,186% of Medicaid,1694.4,,,1694.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1694.4,,,1694.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1694.4,,,1694.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1482.6,70,,1482.6,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",643.35,,,643.35,Other,100% of Medicaid,643.35,,,643.35,Other,100% of Medicaid,643.35,,,643.35,Other,100% of Medicaid,643.35,,,643.35,Other,100% of Medicaid,1447.55,,,1447.55,Other,225% of Medicaid,984.33,,,984.33,Other,153% of Medicaid,1447.55,,,1447.55,Other,225% of Medicaid,900.7,,,900.7,Other,140% of Medicaid,1447.55,,,1447.55,Other,225% of Medicaid,1672.72,,,1672.72,Other,260% of Medicaid,2084.47,,,2084.47,Other,324% of Medicaid,1383.21,,,1383.21,Other,215% of Medicaid,1383.21,,,1383.21,Other,215% of Medicaid,804.19,,,804.19,Other,125% of Medicaid,643.35,7216,
INSJ SUBQ CAR RHYTHM MNTR,33285,CPT,,82033285,CDM,360,RC,,,both,,,18374,13596.81,,,13596.81,Other,150% of Medicare + 9.63% HCRA Surcharge,8268.3,45,,8268.3,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",7978,,,7978,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",7180,,,7180,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",6781,,,6781,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",9095.13,,,9095.13,Other,110% of Medicare,12494.32,,,12494.32,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",10683.75,,,10683.75,Other,186% of Medicaid,14699.2,,,14699.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",14699.2,,,14699.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",14699.2,,,14699.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",12861.8,70,,12861.8,percent of total billed charges,All Other,423.12,,,423.12,Fee Schedule,,358.62,,,358.62,Fee Schedule,,6956,,,6956,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",6261,,,6261,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",6956,,,6956,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",5913,,,5913,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",5743.95,,,5743.95,Other,100% of Medicaid,5743.95,,,5743.95,Other,100% of Medicaid,5743.95,,,5743.95,Other,100% of Medicaid,5743.95,,,5743.95,Other,100% of Medicaid,12923.9,,,12923.9,Other,225% of Medicaid,8788.25,,,8788.25,Other,153% of Medicaid,12923.9,,,12923.9,Other,225% of Medicaid,8041.54,,,8041.54,Other,140% of Medicaid,12923.9,,,12923.9,Other,225% of Medicaid,14934.28,,,14934.28,Other,260% of Medicaid,18610.41,,,18610.41,Other,324% of Medicaid,12349.5,,,12349.5,Other,215% of Medicaid,12349.5,,,12349.5,Other,215% of Medicaid,7179.94,,,7179.94,Other,125% of Medicaid,358.62,18610.41,
DECLOT VASCULAR DEVICE,36593,CPT,,82036593,CDM,360,RC,,,both,,,896,663.04,,,663.04,Other,150% of Medicare + 9.63% HCRA Surcharge,403.2,45,,403.2,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",443.52,,,443.52,Other,110% of Medicare,609.28,,,609.28,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",644.22,,,644.22,Other,186% of Medicaid,716.8,,,716.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",716.8,,,716.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",716.8,,,716.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",627.2,70,,627.2,percent of total billed charges,All Other,159.08,,,159.08,Fee Schedule,,134.83,,,134.83,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",346.35,,,346.35,Other,100% of Medicaid,346.35,,,346.35,Other,100% of Medicaid,346.35,,,346.35,Other,100% of Medicaid,346.35,,,346.35,Other,100% of Medicaid,779.3,,,779.3,Other,225% of Medicaid,529.92,,,529.92,Other,153% of Medicaid,779.3,,,779.3,Other,225% of Medicaid,484.9,,,484.9,Other,140% of Medicaid,779.3,,,779.3,Other,225% of Medicaid,900.52,,,900.52,Other,260% of Medicaid,1122.19,,,1122.19,Other,324% of Medicaid,744.66,,,744.66,Other,215% of Medicaid,744.66,,,744.66,Other,215% of Medicaid,432.94,,,432.94,Other,125% of Medicaid,134.83,7216,
RECONST NAIL BED W GRFT,11762,CPT,,30011762,CDM,361,RC,,,both,,,5004,3702.97,,,3702.97,Other,150% of Medicare + 9.63% HCRA Surcharge,2251.8,45,,2251.8,percent of total billed charges,Critical Access Hospital RCC factor,2480,,,2480,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2232,,,2232,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3648,,,3648,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3283,,,3283,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3101,,,3101,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2476.98,,,2476.98,Other,110% of Medicare,3402.72,,,3402.72,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2241.85,,,2241.85,Other,186% of Medicaid,4003.2,,,4003.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",4003.2,,,4003.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",4003.2,,,4003.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",3502.8,70,,3502.8,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",4055,,,4055,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3649,,,3649,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4055,,,4055,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3448,,,3448,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",1205.3,,,1205.3,Other,100% of Medicaid,1205.3,,,1205.3,Other,100% of Medicaid,1205.3,,,1205.3,Other,100% of Medicaid,1205.3,,,1205.3,Other,100% of Medicaid,2711.92,,,2711.92,Other,225% of Medicaid,1844.1,,,1844.1,Other,153% of Medicaid,2711.92,,,2711.92,Other,225% of Medicaid,1687.41,,,1687.41,Other,140% of Medicaid,2711.92,,,2711.92,Other,225% of Medicaid,3133.77,,,3133.77,Other,260% of Medicaid,3905.16,,,3905.16,Other,324% of Medicaid,2591.39,,,2591.39,Other,215% of Medicaid,2591.39,,,2591.39,Other,215% of Medicaid,1506.62,,,1506.62,Other,125% of Medicaid,1205.3,7216,
ASPIRATE PLEURA WO IMAGING,32554,CPT,,34032554,CDM,361,RC,,,both,,,1729,1279.46,,,1279.46,Other,150% of Medicare + 9.63% HCRA Surcharge,778.05,45,,778.05,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",855.86,,,855.86,Other,110% of Medicare,1175.72,,,1175.72,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1196.64,,,1196.64,Other,186% of Medicaid,1383.2,,,1383.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1383.2,,,1383.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1383.2,,,1383.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1210.3,70,,1210.3,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",643.35,,,643.35,Other,100% of Medicaid,643.35,,,643.35,Other,100% of Medicaid,643.35,,,643.35,Other,100% of Medicaid,643.35,,,643.35,Other,100% of Medicaid,1447.55,,,1447.55,Other,225% of Medicaid,984.33,,,984.33,Other,153% of Medicaid,1447.55,,,1447.55,Other,225% of Medicaid,900.7,,,900.7,Other,140% of Medicaid,1447.55,,,1447.55,Other,225% of Medicaid,1672.72,,,1672.72,Other,260% of Medicaid,2084.47,,,2084.47,Other,324% of Medicaid,1383.21,,,1383.21,Other,215% of Medicaid,1383.21,,,1383.21,Other,215% of Medicaid,804.19,,,804.19,Other,125% of Medicaid,643.35,7216,
INSERT PICC CATH >5 YRS O,36569,CPT,,34036569,CDM,361,RC,,,both,,,4042,2991.09,,,2991.09,Other,150% of Medicare + 9.63% HCRA Surcharge,1818.9,45,,1818.9,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3648,,,3648,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3283,,,3283,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3101,,,3101,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2000.79,,,2000.79,Other,110% of Medicare,2748.56,,,2748.56,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",586.68,,,586.68,Other,186% of Medicaid,3233.6,,,3233.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",3233.6,,,3233.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",3578,,,3578,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2829.4,70,,2829.4,percent of total billed charges,All Other,449.36,,,449.36,Fee Schedule,,380.86,,,380.86,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",315.42,,,315.42,Other,100% of Medicaid,315.42,,,315.42,Other,100% of Medicaid,315.42,,,315.42,Other,100% of Medicaid,315.42,,,315.42,Other,100% of Medicaid,709.7,,,709.7,Other,225% of Medicaid,482.6,,,482.6,Other,153% of Medicaid,709.7,,,709.7,Other,225% of Medicaid,441.59,,,441.59,Other,140% of Medicaid,709.7,,,709.7,Other,225% of Medicaid,820.1,,,820.1,Other,260% of Medicaid,1021.97,,,1021.97,Other,324% of Medicaid,678.16,,,678.16,Other,215% of Medicaid,678.16,,,678.16,Other,215% of Medicaid,394.28,,,394.28,Other,125% of Medicaid,315.42,7216,
LUMBAR PUNCTURE,62270,CPT,,34062270,CDM,361,RC,,,both,,,1479,1094.46,,,1094.46,Other,150% of Medicare + 9.63% HCRA Surcharge,665.55,45,,665.55,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",732.11,,,732.11,Other,110% of Medicare,1005.72,,,1005.72,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1116.35,,,1116.35,Other,186% of Medicaid,1183.2,,,1183.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1183.2,,,1183.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",3578,,,3578,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1035.3,70,,1035.3,percent of total billed charges,All Other,298.48,,,298.48,Fee Schedule,,252.98,,,252.98,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",600.19,,,600.19,Other,100% of Medicaid,600.19,,,600.19,Other,100% of Medicaid,600.19,,,600.19,Other,100% of Medicaid,600.19,,,600.19,Other,100% of Medicaid,1350.43,,,1350.43,Other,225% of Medicaid,918.29,,,918.29,Other,153% of Medicaid,1350.43,,,1350.43,Other,225% of Medicaid,840.26,,,840.26,Other,140% of Medicaid,1350.43,,,1350.43,Other,225% of Medicaid,1560.49,,,1560.49,Other,260% of Medicaid,1944.61,,,1944.61,Other,324% of Medicaid,1290.41,,,1290.41,Other,215% of Medicaid,1290.41,,,1290.41,Other,215% of Medicaid,750.24,,,750.24,Other,125% of Medicaid,252.98,7216,
INJ EPIDURAL BLOOD OR CLOT PATCH,62273,CPT,,34062273,CDM,361,RC,,,both,,,2701,1998.75,,,1998.75,Other,150% of Medicare + 9.63% HCRA Surcharge,1215.45,45,,1215.45,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",1337,,,1337,Other,110% of Medicare,1836.68,,,1836.68,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1116.35,,,1116.35,Other,186% of Medicaid,2160.8,,,2160.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2160.8,,,2160.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",3578,,,3578,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1890.7,70,,1890.7,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",600.19,,,600.19,Other,100% of Medicaid,600.19,,,600.19,Other,100% of Medicaid,600.19,,,600.19,Other,100% of Medicaid,600.19,,,600.19,Other,100% of Medicaid,1350.43,,,1350.43,Other,225% of Medicaid,918.29,,,918.29,Other,153% of Medicaid,1350.43,,,1350.43,Other,225% of Medicaid,840.26,,,840.26,Other,140% of Medicaid,1350.43,,,1350.43,Other,225% of Medicaid,1560.49,,,1560.49,Other,260% of Medicaid,1944.61,,,1944.61,Other,324% of Medicaid,1290.41,,,1290.41,Other,215% of Medicaid,1290.41,,,1290.41,Other,215% of Medicaid,750.24,,,750.24,Other,125% of Medicaid,600.19,7216,
LUMBAR PUNCTURE INCOMPLETE AFTER ANES,62270,CPT,74,34162270,CDM,361,RC,,,both,,,1184,876.16,,,876.16,Other,150% of Medicare + 9.63% HCRA Surcharge,532.8,45,,532.8,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",586.08,,,586.08,Other,110% of Medicare,805.12,,,805.12,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1116.35,,,1116.35,Other,186% of Medicaid,947.2,,,947.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",947.2,,,947.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",3578,,,3578,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",828.8,70,,828.8,percent of total billed charges,All Other,298.48,,,298.48,Fee Schedule,,252.98,,,252.98,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",600.19,,,600.19,Other,100% of Medicaid,600.19,,,600.19,Other,100% of Medicaid,600.19,,,600.19,Other,100% of Medicaid,600.19,,,600.19,Other,100% of Medicaid,1350.43,,,1350.43,Other,225% of Medicaid,918.29,,,918.29,Other,153% of Medicaid,1350.43,,,1350.43,Other,225% of Medicaid,840.26,,,840.26,Other,140% of Medicaid,1350.43,,,1350.43,Other,225% of Medicaid,1560.49,,,1560.49,Other,260% of Medicaid,1944.61,,,1944.61,Other,324% of Medicaid,1290.41,,,1290.41,Other,215% of Medicaid,1290.41,,,1290.41,Other,215% of Medicaid,750.24,,,750.24,Other,125% of Medicaid,252.98,7216,
LUMBAR PUNCTURE INCOMPLETE BEFORE ANES,62270,CPT,73,34262270,CDM,361,RC,,,both,,,1184,876.16,,,876.16,Other,150% of Medicare + 9.63% HCRA Surcharge,532.8,45,,532.8,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",586.08,,,586.08,Other,110% of Medicare,805.12,,,805.12,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1116.35,,,1116.35,Other,186% of Medicaid,947.2,,,947.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",947.2,,,947.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",3578,,,3578,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",828.8,70,,828.8,percent of total billed charges,All Other,298.48,,,298.48,Fee Schedule,,252.98,,,252.98,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",600.19,,,600.19,Other,100% of Medicaid,600.19,,,600.19,Other,100% of Medicaid,600.19,,,600.19,Other,100% of Medicaid,600.19,,,600.19,Other,100% of Medicaid,1350.43,,,1350.43,Other,225% of Medicaid,918.29,,,918.29,Other,153% of Medicaid,1350.43,,,1350.43,Other,225% of Medicaid,840.26,,,840.26,Other,140% of Medicaid,1350.43,,,1350.43,Other,225% of Medicaid,1560.49,,,1560.49,Other,260% of Medicaid,1944.61,,,1944.61,Other,324% of Medicaid,1290.41,,,1290.41,Other,215% of Medicaid,1290.41,,,1290.41,Other,215% of Medicaid,750.24,,,750.24,Other,125% of Medicaid,252.98,7216,
DRAIN BREAST LESION ADD-ON,19001,CPT,,42019001,CDM,361,RC,,,both,,,514,380.36,,,380.36,Other,150% of Medicare + 9.63% HCRA Surcharge,231.3,45,,231.3,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",254.43,,,254.43,Other,110% of Medicare,349.52,,,349.52,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1037.55,,,1037.55,Other,186% of Medicaid,411.2,,,411.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",411.2,,,411.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",411.2,,,411.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",359.8,70,,359.8,percent of total billed charges,All Other,101.68,,,101.68,Fee Schedule,,86.18,,,86.18,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",557.82,,,557.82,Other,100% of Medicaid,557.82,,,557.82,Other,100% of Medicaid,557.82,,,557.82,Other,100% of Medicaid,557.82,,,557.82,Other,100% of Medicaid,1255.1,,,1255.1,Other,225% of Medicaid,853.47,,,853.47,Other,153% of Medicaid,1255.1,,,1255.1,Other,225% of Medicaid,780.95,,,780.95,Other,140% of Medicaid,1255.1,,,1255.1,Other,225% of Medicaid,1450.34,,,1450.34,Other,260% of Medicaid,1807.35,,,1807.35,Other,324% of Medicaid,1199.32,,,1199.32,Other,215% of Medicaid,1199.32,,,1199.32,Other,215% of Medicaid,697.28,,,697.28,Other,125% of Medicaid,86.18,7216,
ASPIRATE/INJECT MAJOR JOINT,20610,CPT,,42020610,CDM,361,RC,,,both,,,1017,752.58,,,752.58,Other,150% of Medicare + 9.63% HCRA Surcharge,457.65,45,,457.65,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",503.42,,,503.42,Other,110% of Medicare,691.56,,,691.56,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",685.67,,,685.67,Other,186% of Medicaid,813.6,,,813.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",813.6,,,813.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",813.6,,,813.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",711.9,70,,711.9,percent of total billed charges,All Other,218.12,,,218.12,Fee Schedule,,184.87,,,184.87,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",368.64,,,368.64,Other,100% of Medicaid,368.64,,,368.64,Other,100% of Medicaid,368.64,,,368.64,Other,100% of Medicaid,368.64,,,368.64,Other,100% of Medicaid,829.44,,,829.44,Other,225% of Medicaid,564.02,,,564.02,Other,153% of Medicaid,829.44,,,829.44,Other,225% of Medicaid,516.1,,,516.1,Other,140% of Medicaid,829.44,,,829.44,Other,225% of Medicaid,958.46,,,958.46,Other,260% of Medicaid,1194.39,,,1194.39,Other,324% of Medicaid,792.58,,,792.58,Other,215% of Medicaid,792.58,,,792.58,Other,215% of Medicaid,460.8,,,460.8,Other,125% of Medicaid,184.87,7216,
INJECTION FOR SHOULDER XR,23350,CPT,,42023350,CDM,361,RC,,,both,,,371,274.54,,,274.54,Other,150% of Medicare + 9.63% HCRA Surcharge,166.95,45,,166.95,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",183.65,,,183.65,Other,110% of Medicare,252.28,,,252.28,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",966.93,,,966.93,Other,186% of Medicaid,296.8,,,296.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",296.8,,,296.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",296.8,,,296.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",259.7,70,,259.7,percent of total billed charges,All Other,239.44,,,239.44,Fee Schedule,,202.94,,,202.94,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",519.86,,,519.86,Other,100% of Medicaid,519.86,,,519.86,Other,100% of Medicaid,519.86,,,519.86,Other,100% of Medicaid,519.86,,,519.86,Other,100% of Medicaid,1169.68,,,1169.68,Other,225% of Medicaid,795.38,,,795.38,Other,153% of Medicaid,1169.68,,,1169.68,Other,225% of Medicaid,727.8,,,727.8,Other,140% of Medicaid,1169.68,,,1169.68,Other,225% of Medicaid,1351.62,,,1351.62,Other,260% of Medicaid,1684.33,,,1684.33,Other,324% of Medicaid,1117.69,,,1117.69,Other,215% of Medicaid,1117.69,,,1117.69,Other,215% of Medicaid,649.82,,,649.82,Other,125% of Medicaid,166.95,7216,
INJECTION FOR ELBOW XR,24220,CPT,,42024220,CDM,361,RC,,,both,,,351,259.74,,,259.74,Other,150% of Medicare + 9.63% HCRA Surcharge,157.95,45,,157.95,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",173.75,,,173.75,Other,110% of Medicare,238.68,,,238.68,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",966.93,,,966.93,Other,186% of Medicaid,280.8,,,280.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",280.8,,,280.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",280.8,,,280.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",245.7,70,,245.7,percent of total billed charges,All Other,318.16,,,318.16,Fee Schedule,,269.66,,,269.66,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",519.86,,,519.86,Other,100% of Medicaid,519.86,,,519.86,Other,100% of Medicaid,519.86,,,519.86,Other,100% of Medicaid,519.86,,,519.86,Other,100% of Medicaid,1169.68,,,1169.68,Other,225% of Medicaid,795.38,,,795.38,Other,153% of Medicaid,1169.68,,,1169.68,Other,225% of Medicaid,727.8,,,727.8,Other,140% of Medicaid,1169.68,,,1169.68,Other,225% of Medicaid,1351.62,,,1351.62,Other,260% of Medicaid,1684.33,,,1684.33,Other,324% of Medicaid,1117.69,,,1117.69,Other,215% of Medicaid,1117.69,,,1117.69,Other,215% of Medicaid,649.82,,,649.82,Other,125% of Medicaid,157.95,7216,
INJECTION FOR WRIST XR,25246,CPT,,42025246,CDM,361,RC,,,both,,,386,285.64,,,285.64,Other,150% of Medicare + 9.63% HCRA Surcharge,173.7,45,,173.7,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",191.07,,,191.07,Other,110% of Medicare,262.48,,,262.48,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",966.93,,,966.93,Other,186% of Medicaid,308.8,,,308.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",308.8,,,308.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",308.8,,,308.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",270.2,70,,270.2,percent of total billed charges,All Other,349.32,,,349.32,Fee Schedule,,296.07,,,296.07,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",519.86,,,519.86,Other,100% of Medicaid,519.86,,,519.86,Other,100% of Medicaid,519.86,,,519.86,Other,100% of Medicaid,519.86,,,519.86,Other,100% of Medicaid,1169.68,,,1169.68,Other,225% of Medicaid,795.38,,,795.38,Other,153% of Medicaid,1169.68,,,1169.68,Other,225% of Medicaid,727.8,,,727.8,Other,140% of Medicaid,1169.68,,,1169.68,Other,225% of Medicaid,1351.62,,,1351.62,Other,260% of Medicaid,1684.33,,,1684.33,Other,324% of Medicaid,1117.69,,,1117.69,Other,215% of Medicaid,1117.69,,,1117.69,Other,215% of Medicaid,649.82,,,649.82,Other,125% of Medicaid,173.7,7216,
INJECTION FOR HIP XR,27093,CPT,,42027093,CDM,361,RC,,,both,,,389,287.86,,,287.86,Other,150% of Medicare + 9.63% HCRA Surcharge,175.05,45,,175.05,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",192.56,,,192.56,Other,110% of Medicare,264.52,,,264.52,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",966.93,,,966.93,Other,186% of Medicaid,311.2,,,311.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",311.2,,,311.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",311.2,,,311.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",272.3,70,,272.3,percent of total billed charges,All Other,324.72,,,324.72,Fee Schedule,,275.22,,,275.22,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",519.86,,,519.86,Other,100% of Medicaid,519.86,,,519.86,Other,100% of Medicaid,519.86,,,519.86,Other,100% of Medicaid,519.86,,,519.86,Other,100% of Medicaid,1169.68,,,1169.68,Other,225% of Medicaid,795.38,,,795.38,Other,153% of Medicaid,1169.68,,,1169.68,Other,225% of Medicaid,727.8,,,727.8,Other,140% of Medicaid,1169.68,,,1169.68,Other,225% of Medicaid,1351.62,,,1351.62,Other,260% of Medicaid,1684.33,,,1684.33,Other,324% of Medicaid,1117.69,,,1117.69,Other,215% of Medicaid,1117.69,,,1117.69,Other,215% of Medicaid,649.82,,,649.82,Other,125% of Medicaid,175.05,7216,
INS TUNNELED CV/2 CATH W/O P,36565,CPT,,42036565,CDM,361,RC,,,both,,,10036,7426.67,,,7426.67,Other,150% of Medicare + 9.63% HCRA Surcharge,4516.2,45,,4516.2,percent of total billed charges,Critical Access Hospital RCC factor,3473,,,3473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3126,,,3126,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4476,,,4476,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4028,,,4028,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3805,,,3805,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4967.82,,,4967.82,Other,110% of Medicare,6152,,,6152,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2490.15,,,2490.15,Other,186% of Medicaid,7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",5266,,,5266,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7025.2,70,,7025.2,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",4913,,,4913,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4422,,,4422,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4913,,,4913,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4176,,,4176,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",1338.79,,,1338.79,Other,100% of Medicaid,1338.79,,,1338.79,Other,100% of Medicaid,1338.79,,,1338.79,Other,100% of Medicaid,1338.79,,,1338.79,Other,100% of Medicaid,3012.28,,,3012.28,Other,225% of Medicaid,2048.35,,,2048.35,Other,153% of Medicaid,3012.28,,,3012.28,Other,225% of Medicaid,1874.31,,,1874.31,Other,140% of Medicaid,3012.28,,,3012.28,Other,225% of Medicaid,3480.85,,,3480.85,Other,260% of Medicaid,4337.68,,,4337.68,Other,324% of Medicaid,2878.4,,,2878.4,Other,215% of Medicaid,2878.4,,,2878.4,Other,215% of Medicaid,1673.49,,,1673.49,Other,125% of Medicaid,1338.79,9473,
INS PERIPH CV/PORT >5 YRS,36571,CPT,,42036571,CDM,361,RC,,,both,,,8373,6196.04,,,6196.04,Other,150% of Medicare + 9.63% HCRA Surcharge,3767.85,45,,3767.85,percent of total billed charges,Critical Access Hospital RCC factor,3473,,,3473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3126,,,3126,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4476,,,4476,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4028,,,4028,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3805,,,3805,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4144.64,,,4144.64,Other,110% of Medicare,6152,,,6152,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",586.68,,,586.68,Other,186% of Medicaid,7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",5266,,,5266,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",5861.1,70,,5861.1,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",4913,,,4913,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4422,,,4422,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4913,,,4913,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4176,,,4176,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",315.42,,,315.42,Other,100% of Medicaid,315.42,,,315.42,Other,100% of Medicaid,315.42,,,315.42,Other,100% of Medicaid,315.42,,,315.42,Other,100% of Medicaid,709.7,,,709.7,Other,225% of Medicaid,482.6,,,482.6,Other,153% of Medicaid,709.7,,,709.7,Other,225% of Medicaid,441.59,,,441.59,Other,140% of Medicaid,709.7,,,709.7,Other,225% of Medicaid,820.1,,,820.1,Other,260% of Medicaid,1021.97,,,1021.97,Other,324% of Medicaid,678.16,,,678.16,Other,215% of Medicaid,678.16,,,678.16,Other,215% of Medicaid,394.28,,,394.28,Other,125% of Medicaid,315.42,9473,
REPOSITION CV CATHETER,36597,CPT,,42036597,CDM,361,RC,,,both,,,3709,2744.67,,,2744.67,Other,150% of Medicare + 9.63% HCRA Surcharge,1669.05,45,,1669.05,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3648,,,3648,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3283,,,3283,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3101,,,3101,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",1835.96,,,1835.96,Other,110% of Medicare,2522.12,,,2522.12,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1556.72,,,1556.72,Other,186% of Medicaid,2967.2,,,2967.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2967.2,,,2967.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2967.2,,,2967.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2596.3,70,,2596.3,percent of total billed charges,All Other,285.36,,,285.36,Fee Schedule,,241.86,,,241.86,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",836.95,,,836.95,Other,100% of Medicaid,836.95,,,836.95,Other,100% of Medicaid,836.95,,,836.95,Other,100% of Medicaid,836.95,,,836.95,Other,100% of Medicaid,1883.13,,,1883.13,Other,225% of Medicaid,1280.53,,,1280.53,Other,153% of Medicaid,1883.13,,,1883.13,Other,225% of Medicaid,1171.73,,,1171.73,Other,140% of Medicaid,1883.13,,,1883.13,Other,225% of Medicaid,2176.07,,,2176.07,Other,260% of Medicaid,2711.71,,,2711.71,Other,324% of Medicaid,1799.44,,,1799.44,Other,215% of Medicaid,1799.44,,,1799.44,Other,215% of Medicaid,1046.19,,,1046.19,Other,125% of Medicaid,241.86,7216,
NEEDLE BIOPSY OF LIVER,47000,CPT,,42047000,CDM,361,RC,,,both,,,3495,2586.31,,,2586.31,Other,150% of Medicare + 9.63% HCRA Surcharge,1572.75,45,,1572.75,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3648,,,3648,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3283,,,3283,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3101,,,3101,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",1730.03,,,1730.03,Other,110% of Medicare,2376.6,,,2376.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1196.64,,,1196.64,Other,186% of Medicaid,2796,,,2796,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2796,,,2796,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",3578,,,3578,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2446.5,70,,2446.5,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",4055,,,4055,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3649,,,3649,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4055,,,4055,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3448,,,3448,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",643.35,,,643.35,Other,100% of Medicaid,643.35,,,643.35,Other,100% of Medicaid,643.35,,,643.35,Other,100% of Medicaid,643.35,,,643.35,Other,100% of Medicaid,1447.55,,,1447.55,Other,225% of Medicaid,984.33,,,984.33,Other,153% of Medicaid,1447.55,,,1447.55,Other,225% of Medicaid,900.7,,,900.7,Other,140% of Medicaid,1447.55,,,1447.55,Other,225% of Medicaid,1672.72,,,1672.72,Other,260% of Medicaid,2084.47,,,2084.47,Other,324% of Medicaid,1383.21,,,1383.21,Other,215% of Medicaid,1383.21,,,1383.21,Other,215% of Medicaid,804.19,,,804.19,Other,125% of Medicaid,643.35,7216,
IMAGE CATH FLUID PERI/RETRO,49406,CPT,,42049406,CDM,361,RC,,,both,,,5417,4008.59,,,4008.59,Other,150% of Medicare + 9.63% HCRA Surcharge,2437.65,45,,2437.65,percent of total billed charges,Critical Access Hospital RCC factor,2480,,,2480,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2232,,,2232,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3648,,,3648,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3283,,,3283,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3101,,,3101,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2681.42,,,2681.42,Other,110% of Medicare,3683.56,,,3683.56,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1196.64,,,1196.64,Other,186% of Medicaid,4333.6,,,4333.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",4333.6,,,4333.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",4333.6,,,4333.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",3791.9,70,,3791.9,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",4055,,,4055,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3649,,,3649,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4055,,,4055,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3448,,,3448,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",643.35,,,643.35,Other,100% of Medicaid,643.35,,,643.35,Other,100% of Medicaid,643.35,,,643.35,Other,100% of Medicaid,643.35,,,643.35,Other,100% of Medicaid,1447.55,,,1447.55,Other,225% of Medicaid,984.33,,,984.33,Other,153% of Medicaid,1447.55,,,1447.55,Other,225% of Medicaid,900.7,,,900.7,Other,140% of Medicaid,1447.55,,,1447.55,Other,225% of Medicaid,1672.72,,,1672.72,Other,260% of Medicaid,2084.47,,,2084.47,Other,324% of Medicaid,1383.21,,,1383.21,Other,215% of Medicaid,1383.21,,,1383.21,Other,215% of Medicaid,804.19,,,804.19,Other,125% of Medicaid,643.35,7216,
ASSESS CYST CONTRAST INJECT,49424,CPT,,42049424,CDM,361,RC,,,both,,,241,178.34,,,178.34,Other,150% of Medicare + 9.63% HCRA Surcharge,108.45,45,,108.45,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",119.3,,,119.3,Other,110% of Medicare,163.88,,,163.88,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",966.93,,,966.93,Other,186% of Medicaid,192.8,,,192.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",192.8,,,192.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",192.8,,,192.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",168.7,70,,168.7,percent of total billed charges,All Other,180.4,,,180.4,Fee Schedule,,152.9,,,152.9,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",519.86,,,519.86,Other,100% of Medicaid,519.86,,,519.86,Other,100% of Medicaid,519.86,,,519.86,Other,100% of Medicaid,519.86,,,519.86,Other,100% of Medicaid,1169.68,,,1169.68,Other,225% of Medicaid,795.38,,,795.38,Other,153% of Medicaid,1169.68,,,1169.68,Other,225% of Medicaid,727.8,,,727.8,Other,140% of Medicaid,1169.68,,,1169.68,Other,225% of Medicaid,1351.62,,,1351.62,Other,260% of Medicaid,1684.33,,,1684.33,Other,324% of Medicaid,1117.69,,,1117.69,Other,215% of Medicaid,1117.69,,,1117.69,Other,215% of Medicaid,649.82,,,649.82,Other,125% of Medicaid,108.45,7216,
INJECTION FOR URETER XR,50690,CPT,,42050690,CDM,361,RC,,,both,,,41,30.34,,,30.34,Other,150% of Medicare + 9.63% HCRA Surcharge,18.45,45,,18.45,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",20.3,,,20.3,Other,110% of Medicare,27.88,,,27.88,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",966.93,,,966.93,Other,186% of Medicaid,32.8,,,32.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",32.8,,,32.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",32.8,,,32.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",28.7,70,,28.7,percent of total billed charges,All Other,331.28,,,331.28,Fee Schedule,,280.78,,,280.78,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",519.86,,,519.86,Other,100% of Medicaid,519.86,,,519.86,Other,100% of Medicaid,519.86,,,519.86,Other,100% of Medicaid,519.86,,,519.86,Other,100% of Medicaid,1169.68,,,1169.68,Other,225% of Medicaid,795.38,,,795.38,Other,153% of Medicaid,1169.68,,,1169.68,Other,225% of Medicaid,727.8,,,727.8,Other,140% of Medicaid,1169.68,,,1169.68,Other,225% of Medicaid,1351.62,,,1351.62,Other,260% of Medicaid,1684.33,,,1684.33,Other,324% of Medicaid,1117.69,,,1117.69,Other,215% of Medicaid,1117.69,,,1117.69,Other,215% of Medicaid,649.82,,,649.82,Other,125% of Medicaid,18.45,7216,
INJECTION FOR BLADDER XR,51600,CPT,,42051600,CDM,361,RC,,,both,,,254,187.96,,,187.96,Other,150% of Medicare + 9.63% HCRA Surcharge,114.3,45,,114.3,percent of total billed charges,Critical Access Hospital RCC factor,4565,,,4565,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4109,,,4109,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",125.73,,,125.73,Other,110% of Medicare,172.72,,,172.72,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",966.93,,,966.93,Other,186% of Medicaid,203.2,,,203.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",203.2,,,203.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",203.2,,,203.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",177.8,70,,177.8,percent of total billed charges,All Other,209.92,,,209.92,Fee Schedule,,177.92,,,177.92,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",519.86,,,519.86,Other,100% of Medicaid,519.86,,,519.86,Other,100% of Medicaid,519.86,,,519.86,Other,100% of Medicaid,519.86,,,519.86,Other,100% of Medicaid,1169.68,,,1169.68,Other,225% of Medicaid,795.38,,,795.38,Other,153% of Medicaid,1169.68,,,1169.68,Other,225% of Medicaid,727.8,,,727.8,Other,140% of Medicaid,1169.68,,,1169.68,Other,225% of Medicaid,1351.62,,,1351.62,Other,260% of Medicaid,1684.33,,,1684.33,Other,324% of Medicaid,1117.69,,,1117.69,Other,215% of Medicaid,1117.69,,,1117.69,Other,215% of Medicaid,649.82,,,649.82,Other,125% of Medicaid,114.3,7216,
CHANGE OF BLADDER TUBE,51705,CPT,,42051705,CDM,361,RC,,,both,,,776,574.24,,,574.24,Other,150% of Medicare + 9.63% HCRA Surcharge,349.2,45,,349.2,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",384.12,,,384.12,Other,110% of Medicare,527.68,,,527.68,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",847.8,,,847.8,Other,186% of Medicaid,620.8,,,620.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",620.8,,,620.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",620.8,,,620.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",543.2,70,,543.2,percent of total billed charges,All Other,246,,,246,Fee Schedule,,208.5,,,208.5,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",455.81,,,455.81,Other,100% of Medicaid,455.81,,,455.81,Other,100% of Medicaid,455.81,,,455.81,Other,100% of Medicaid,455.81,,,455.81,Other,100% of Medicaid,1025.56,,,1025.56,Other,225% of Medicaid,697.38,,,697.38,Other,153% of Medicaid,1025.56,,,1025.56,Other,225% of Medicaid,638.13,,,638.13,Other,140% of Medicaid,1025.56,,,1025.56,Other,225% of Medicaid,1185.1,,,1185.1,Other,260% of Medicaid,1476.81,,,1476.81,Other,324% of Medicaid,979.98,,,979.98,Other,215% of Medicaid,979.98,,,979.98,Other,215% of Medicaid,569.76,,,569.76,Other,125% of Medicaid,208.5,7216,
HYSTEROSON INJECTION,58340,CPT,,42058340,CDM,361,RC,,,both,,,346,256.04,,,256.04,Other,150% of Medicare + 9.63% HCRA Surcharge,155.7,45,,155.7,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",171.27,,,171.27,Other,110% of Medicare,235.28,,,235.28,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",966.93,,,966.93,Other,186% of Medicaid,276.8,,,276.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",276.8,,,276.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",276.8,,,276.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",242.2,70,,242.2,percent of total billed charges,All Other,272.24,,,272.24,Fee Schedule,,230.74,,,230.74,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",519.86,,,519.86,Other,100% of Medicaid,519.86,,,519.86,Other,100% of Medicaid,519.86,,,519.86,Other,100% of Medicaid,519.86,,,519.86,Other,100% of Medicaid,1169.68,,,1169.68,Other,225% of Medicaid,795.38,,,795.38,Other,153% of Medicaid,1169.68,,,1169.68,Other,225% of Medicaid,727.8,,,727.8,Other,140% of Medicaid,1169.68,,,1169.68,Other,225% of Medicaid,1351.62,,,1351.62,Other,260% of Medicaid,1684.33,,,1684.33,Other,324% of Medicaid,1117.69,,,1117.69,Other,215% of Medicaid,1117.69,,,1117.69,Other,215% of Medicaid,649.82,,,649.82,Other,125% of Medicaid,155.7,7216,
BIOPSY THYROID PERC CORE NEEDL,60100,CPT,,42060100,CDM,361,RC,,,both,,,1601,1184.74,,,1184.74,Other,150% of Medicare + 9.63% HCRA Surcharge,720.45,45,,720.45,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",792.5,,,792.5,Other,110% of Medicare,1088.68,,,1088.68,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1037.55,,,1037.55,Other,186% of Medicaid,1280.8,,,1280.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1280.8,,,1280.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1280.8,,,1280.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1120.7,70,,1120.7,percent of total billed charges,All Other,367.36,,,367.36,Fee Schedule,,311.36,,,311.36,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",557.82,,,557.82,Other,100% of Medicaid,557.82,,,557.82,Other,100% of Medicaid,557.82,,,557.82,Other,100% of Medicaid,557.82,,,557.82,Other,100% of Medicaid,1255.1,,,1255.1,Other,225% of Medicaid,853.47,,,853.47,Other,153% of Medicaid,1255.1,,,1255.1,Other,225% of Medicaid,780.95,,,780.95,Other,140% of Medicaid,1255.1,,,1255.1,Other,225% of Medicaid,1450.34,,,1450.34,Other,260% of Medicaid,1807.35,,,1807.35,Other,324% of Medicaid,1199.32,,,1199.32,Other,215% of Medicaid,1199.32,,,1199.32,Other,215% of Medicaid,697.28,,,697.28,Other,125% of Medicaid,311.36,7216,
LUMBAR PUNCTURE,62270,CPT,,42062270,CDM,361,RC,,,both,,,1479,1094.46,,,1094.46,Other,150% of Medicare + 9.63% HCRA Surcharge,665.55,45,,665.55,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",732.11,,,732.11,Other,110% of Medicare,1005.72,,,1005.72,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1116.35,,,1116.35,Other,186% of Medicaid,1183.2,,,1183.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1183.2,,,1183.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",3578,,,3578,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1035.3,70,,1035.3,percent of total billed charges,All Other,298.48,,,298.48,Fee Schedule,,252.98,,,252.98,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",600.19,,,600.19,Other,100% of Medicaid,600.19,,,600.19,Other,100% of Medicaid,600.19,,,600.19,Other,100% of Medicaid,600.19,,,600.19,Other,100% of Medicaid,1350.43,,,1350.43,Other,225% of Medicaid,918.29,,,918.29,Other,153% of Medicaid,1350.43,,,1350.43,Other,225% of Medicaid,840.26,,,840.26,Other,140% of Medicaid,1350.43,,,1350.43,Other,225% of Medicaid,1560.49,,,1560.49,Other,260% of Medicaid,1944.61,,,1944.61,Other,324% of Medicaid,1290.41,,,1290.41,Other,215% of Medicaid,1290.41,,,1290.41,Other,215% of Medicaid,750.24,,,750.24,Other,125% of Medicaid,252.98,7216,
DRAIN CEREBRO SPINAL FLUID,62272,CPT,,42062272,CDM,361,RC,,,both,,,1452,1074.48,,,1074.48,Other,150% of Medicare + 9.63% HCRA Surcharge,653.4,45,,653.4,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",718.74,,,718.74,Other,110% of Medicare,987.36,,,987.36,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1116.35,,,1116.35,Other,186% of Medicaid,1161.6,,,1161.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1161.6,,,1161.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",3578,,,3578,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1016.4,70,,1016.4,percent of total billed charges,All Other,431.32,,,431.32,Fee Schedule,,365.57,,,365.57,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",600.19,,,600.19,Other,100% of Medicaid,600.19,,,600.19,Other,100% of Medicaid,600.19,,,600.19,Other,100% of Medicaid,600.19,,,600.19,Other,100% of Medicaid,1350.43,,,1350.43,Other,225% of Medicaid,918.29,,,918.29,Other,153% of Medicaid,1350.43,,,1350.43,Other,225% of Medicaid,840.26,,,840.26,Other,140% of Medicaid,1350.43,,,1350.43,Other,225% of Medicaid,1560.49,,,1560.49,Other,260% of Medicaid,1944.61,,,1944.61,Other,324% of Medicaid,1290.41,,,1290.41,Other,215% of Medicaid,1290.41,,,1290.41,Other,215% of Medicaid,750.24,,,750.24,Other,125% of Medicaid,365.57,7216,
LAMINOTOMY SINGLE CERVICAL,63040,CPT,,42063040,CDM,361,RC,,,both,,,15553,11509.26,,,11509.26,Other,150% of Medicare + 9.63% HCRA Surcharge,6998.85,45,,6998.85,percent of total billed charges,Critical Access Hospital RCC factor,4827,,,4827,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4344,,,4344,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",7978,,,7978,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",7180,,,7180,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",6781,,,6781,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",7698.74,,,7698.74,Other,110% of Medicare,6152,,,6152,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",5525.48,,,5525.48,Other,186% of Medicaid,7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",12442.4,,,12442.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",10887.1,70,,10887.1,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",6331,,,6331,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",5698,,,5698,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",6331,,,6331,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",5381,,,5381,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2970.69,,,2970.69,Other,100% of Medicaid,2970.69,,,2970.69,Other,100% of Medicaid,2970.69,,,2970.69,Other,100% of Medicaid,2970.69,,,2970.69,Other,100% of Medicaid,6684.05,,,6684.05,Other,225% of Medicaid,4545.16,,,4545.16,Other,153% of Medicaid,6684.05,,,6684.05,Other,225% of Medicaid,4158.97,,,4158.97,Other,140% of Medicaid,6684.05,,,6684.05,Other,225% of Medicaid,7723.79,,,7723.79,Other,260% of Medicaid,9625.03,,,9625.03,Other,324% of Medicaid,6386.98,,,6386.98,Other,215% of Medicaid,6386.98,,,6386.98,Other,215% of Medicaid,3713.36,,,3713.36,Other,125% of Medicaid,2970.69,12442.4,
LAMINOTOMY SINGLE LUMBAR,63042,CPT,,42063042,CDM,361,RC,,,both,,,15553,11509.26,,,11509.26,Other,150% of Medicare + 9.63% HCRA Surcharge,6998.85,45,,6998.85,percent of total billed charges,Critical Access Hospital RCC factor,4827,,,4827,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4344,,,4344,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",7978,,,7978,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",7180,,,7180,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",6781,,,6781,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",7698.74,,,7698.74,Other,110% of Medicare,6152,,,6152,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",5525.48,,,5525.48,Other,186% of Medicaid,7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",12442.4,,,12442.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",10887.1,70,,10887.1,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",6331,,,6331,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",5698,,,5698,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",6331,,,6331,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",5381,,,5381,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2970.69,,,2970.69,Other,100% of Medicaid,2970.69,,,2970.69,Other,100% of Medicaid,2970.69,,,2970.69,Other,100% of Medicaid,2970.69,,,2970.69,Other,100% of Medicaid,6684.05,,,6684.05,Other,225% of Medicaid,4545.16,,,4545.16,Other,153% of Medicaid,6684.05,,,6684.05,Other,225% of Medicaid,4158.97,,,4158.97,Other,140% of Medicaid,6684.05,,,6684.05,Other,225% of Medicaid,7723.79,,,7723.79,Other,260% of Medicaid,9625.03,,,9625.03,Other,324% of Medicaid,6386.98,,,6386.98,Other,215% of Medicaid,6386.98,,,6386.98,Other,215% of Medicaid,3713.36,,,3713.36,Other,125% of Medicaid,2970.69,12442.4,
UNLISTED PROCEDURE NERVOUS,64999,CPT,,42064999,CDM,361,RC,,,both,,,873,646.02,,,646.02,Other,150% of Medicare + 9.63% HCRA Surcharge,392.85,45,,392.85,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,432.14,,,432.14,Other,110% of Medicare,593.64,,,593.64,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",710.57,,,710.57,Other,186% of Medicaid,698.4,,,698.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",698.4,,,698.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",698.4,,,698.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",611.1,70,,611.1,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",382.03,,,382.03,Other,100% of Medicaid,382.03,,,382.03,Other,100% of Medicaid,382.03,,,382.03,Other,100% of Medicaid,382.03,,,382.03,Other,100% of Medicaid,859.56,,,859.56,Other,225% of Medicaid,584.5,,,584.5,Other,153% of Medicaid,859.56,,,859.56,Other,225% of Medicaid,534.84,,,534.84,Other,140% of Medicaid,859.56,,,859.56,Other,225% of Medicaid,993.27,,,993.27,Other,260% of Medicaid,1237.76,,,1237.76,Other,324% of Medicaid,821.35,,,821.35,Other,215% of Medicaid,821.35,,,821.35,Other,215% of Medicaid,477.53,,,477.53,Other,125% of Medicaid,0.01,7216,
HYSTEROSON INJECTION,58340,CPT,52,42158340,CDM,361,RC,,,both,,,277,204.98,,,204.98,Other,150% of Medicare + 9.63% HCRA Surcharge,124.65,45,,124.65,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",137.12,,,137.12,Other,110% of Medicare,188.36,,,188.36,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",966.93,,,966.93,Other,186% of Medicaid,221.6,,,221.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",221.6,,,221.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",221.6,,,221.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",193.9,70,,193.9,percent of total billed charges,All Other,272.24,,,272.24,Fee Schedule,,230.74,,,230.74,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",519.86,,,519.86,Other,100% of Medicaid,519.86,,,519.86,Other,100% of Medicaid,519.86,,,519.86,Other,100% of Medicaid,519.86,,,519.86,Other,100% of Medicaid,1169.68,,,1169.68,Other,225% of Medicaid,795.38,,,795.38,Other,153% of Medicaid,1169.68,,,1169.68,Other,225% of Medicaid,727.8,,,727.8,Other,140% of Medicaid,1169.68,,,1169.68,Other,225% of Medicaid,1351.62,,,1351.62,Other,260% of Medicaid,1684.33,,,1684.33,Other,324% of Medicaid,1117.69,,,1117.69,Other,215% of Medicaid,1117.69,,,1117.69,Other,215% of Medicaid,649.82,,,649.82,Other,125% of Medicaid,124.65,7216,
DRAIN BREAST LESION ADD-ON W/ FY MOD,19001,CPT,,42619001,CDM,361,RC,,,both,,,514,380.36,,,380.36,Other,150% of Medicare + 9.63% HCRA Surcharge,231.3,45,,231.3,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",254.43,,,254.43,Other,110% of Medicare,349.52,,,349.52,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1037.55,,,1037.55,Other,186% of Medicaid,411.2,,,411.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",411.2,,,411.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",411.2,,,411.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",359.8,70,,359.8,percent of total billed charges,All Other,101.68,,,101.68,Fee Schedule,,86.18,,,86.18,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",557.82,,,557.82,Other,100% of Medicaid,557.82,,,557.82,Other,100% of Medicaid,557.82,,,557.82,Other,100% of Medicaid,557.82,,,557.82,Other,100% of Medicaid,1255.1,,,1255.1,Other,225% of Medicaid,853.47,,,853.47,Other,153% of Medicaid,1255.1,,,1255.1,Other,225% of Medicaid,780.95,,,780.95,Other,140% of Medicaid,1255.1,,,1255.1,Other,225% of Medicaid,1450.34,,,1450.34,Other,260% of Medicaid,1807.35,,,1807.35,Other,324% of Medicaid,1199.32,,,1199.32,Other,215% of Medicaid,1199.32,,,1199.32,Other,215% of Medicaid,697.28,,,697.28,Other,125% of Medicaid,86.18,7216,
ASPIRATE/INJECT MAJOR JOINT W/ FY MOD,20610,CPT,,42620610,CDM,361,RC,,,both,,,1017,752.58,,,752.58,Other,150% of Medicare + 9.63% HCRA Surcharge,457.65,45,,457.65,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",503.42,,,503.42,Other,110% of Medicare,691.56,,,691.56,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",685.67,,,685.67,Other,186% of Medicaid,813.6,,,813.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",813.6,,,813.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",813.6,,,813.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",711.9,70,,711.9,percent of total billed charges,All Other,218.12,,,218.12,Fee Schedule,,184.87,,,184.87,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",368.64,,,368.64,Other,100% of Medicaid,368.64,,,368.64,Other,100% of Medicaid,368.64,,,368.64,Other,100% of Medicaid,368.64,,,368.64,Other,100% of Medicaid,829.44,,,829.44,Other,225% of Medicaid,564.02,,,564.02,Other,153% of Medicaid,829.44,,,829.44,Other,225% of Medicaid,516.1,,,516.1,Other,140% of Medicaid,829.44,,,829.44,Other,225% of Medicaid,958.46,,,958.46,Other,260% of Medicaid,1194.39,,,1194.39,Other,324% of Medicaid,792.58,,,792.58,Other,215% of Medicaid,792.58,,,792.58,Other,215% of Medicaid,460.8,,,460.8,Other,125% of Medicaid,184.87,7216,
INJECTION FOR SHOULDER XR W/ FY MOD,23350,CPT,,42623350,CDM,361,RC,,,both,,,371,274.54,,,274.54,Other,150% of Medicare + 9.63% HCRA Surcharge,166.95,45,,166.95,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",183.65,,,183.65,Other,110% of Medicare,252.28,,,252.28,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",966.93,,,966.93,Other,186% of Medicaid,296.8,,,296.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",296.8,,,296.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",296.8,,,296.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",259.7,70,,259.7,percent of total billed charges,All Other,239.44,,,239.44,Fee Schedule,,202.94,,,202.94,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",519.86,,,519.86,Other,100% of Medicaid,519.86,,,519.86,Other,100% of Medicaid,519.86,,,519.86,Other,100% of Medicaid,519.86,,,519.86,Other,100% of Medicaid,1169.68,,,1169.68,Other,225% of Medicaid,795.38,,,795.38,Other,153% of Medicaid,1169.68,,,1169.68,Other,225% of Medicaid,727.8,,,727.8,Other,140% of Medicaid,1169.68,,,1169.68,Other,225% of Medicaid,1351.62,,,1351.62,Other,260% of Medicaid,1684.33,,,1684.33,Other,324% of Medicaid,1117.69,,,1117.69,Other,215% of Medicaid,1117.69,,,1117.69,Other,215% of Medicaid,649.82,,,649.82,Other,125% of Medicaid,166.95,7216,
INJECTION FOR ELBOW XR W/ FY MOD,24220,CPT,,42624220,CDM,361,RC,,,both,,,351,259.74,,,259.74,Other,150% of Medicare + 9.63% HCRA Surcharge,157.95,45,,157.95,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",173.75,,,173.75,Other,110% of Medicare,238.68,,,238.68,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",966.93,,,966.93,Other,186% of Medicaid,280.8,,,280.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",280.8,,,280.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",280.8,,,280.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",245.7,70,,245.7,percent of total billed charges,All Other,318.16,,,318.16,Fee Schedule,,269.66,,,269.66,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",519.86,,,519.86,Other,100% of Medicaid,519.86,,,519.86,Other,100% of Medicaid,519.86,,,519.86,Other,100% of Medicaid,519.86,,,519.86,Other,100% of Medicaid,1169.68,,,1169.68,Other,225% of Medicaid,795.38,,,795.38,Other,153% of Medicaid,1169.68,,,1169.68,Other,225% of Medicaid,727.8,,,727.8,Other,140% of Medicaid,1169.68,,,1169.68,Other,225% of Medicaid,1351.62,,,1351.62,Other,260% of Medicaid,1684.33,,,1684.33,Other,324% of Medicaid,1117.69,,,1117.69,Other,215% of Medicaid,1117.69,,,1117.69,Other,215% of Medicaid,649.82,,,649.82,Other,125% of Medicaid,157.95,7216,
INJECTION FOR WRIST XR W/ FY MOD,25246,CPT,,42625246,CDM,361,RC,,,both,,,386,285.64,,,285.64,Other,150% of Medicare + 9.63% HCRA Surcharge,173.7,45,,173.7,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",191.07,,,191.07,Other,110% of Medicare,262.48,,,262.48,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",966.93,,,966.93,Other,186% of Medicaid,308.8,,,308.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",308.8,,,308.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",308.8,,,308.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",270.2,70,,270.2,percent of total billed charges,All Other,349.32,,,349.32,Fee Schedule,,296.07,,,296.07,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",519.86,,,519.86,Other,100% of Medicaid,519.86,,,519.86,Other,100% of Medicaid,519.86,,,519.86,Other,100% of Medicaid,519.86,,,519.86,Other,100% of Medicaid,1169.68,,,1169.68,Other,225% of Medicaid,795.38,,,795.38,Other,153% of Medicaid,1169.68,,,1169.68,Other,225% of Medicaid,727.8,,,727.8,Other,140% of Medicaid,1169.68,,,1169.68,Other,225% of Medicaid,1351.62,,,1351.62,Other,260% of Medicaid,1684.33,,,1684.33,Other,324% of Medicaid,1117.69,,,1117.69,Other,215% of Medicaid,1117.69,,,1117.69,Other,215% of Medicaid,649.82,,,649.82,Other,125% of Medicaid,173.7,7216,
INJECTION FOR HIP XR W/ FY MOD,27093,CPT,,42627093,CDM,361,RC,,,both,,,389,287.86,,,287.86,Other,150% of Medicare + 9.63% HCRA Surcharge,175.05,45,,175.05,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",192.56,,,192.56,Other,110% of Medicare,264.52,,,264.52,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",966.93,,,966.93,Other,186% of Medicaid,311.2,,,311.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",311.2,,,311.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",311.2,,,311.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",272.3,70,,272.3,percent of total billed charges,All Other,324.72,,,324.72,Fee Schedule,,275.22,,,275.22,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",519.86,,,519.86,Other,100% of Medicaid,519.86,,,519.86,Other,100% of Medicaid,519.86,,,519.86,Other,100% of Medicaid,519.86,,,519.86,Other,100% of Medicaid,1169.68,,,1169.68,Other,225% of Medicaid,795.38,,,795.38,Other,153% of Medicaid,1169.68,,,1169.68,Other,225% of Medicaid,727.8,,,727.8,Other,140% of Medicaid,1169.68,,,1169.68,Other,225% of Medicaid,1351.62,,,1351.62,Other,260% of Medicaid,1684.33,,,1684.33,Other,324% of Medicaid,1117.69,,,1117.69,Other,215% of Medicaid,1117.69,,,1117.69,Other,215% of Medicaid,649.82,,,649.82,Other,125% of Medicaid,175.05,7216,
INS TUNNELED CV/2 CATH W/O P W/ FY MOD,36565,CPT,,42636565,CDM,361,RC,,,both,,,10036,7426.67,,,7426.67,Other,150% of Medicare + 9.63% HCRA Surcharge,4516.2,45,,4516.2,percent of total billed charges,Critical Access Hospital RCC factor,3473,,,3473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3126,,,3126,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4476,,,4476,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4028,,,4028,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3805,,,3805,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4967.82,,,4967.82,Other,110% of Medicare,6152,,,6152,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2490.15,,,2490.15,Other,186% of Medicaid,7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",5266,,,5266,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7025.2,70,,7025.2,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",4913,,,4913,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4422,,,4422,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4913,,,4913,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4176,,,4176,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",1338.79,,,1338.79,Other,100% of Medicaid,1338.79,,,1338.79,Other,100% of Medicaid,1338.79,,,1338.79,Other,100% of Medicaid,1338.79,,,1338.79,Other,100% of Medicaid,3012.28,,,3012.28,Other,225% of Medicaid,2048.35,,,2048.35,Other,153% of Medicaid,3012.28,,,3012.28,Other,225% of Medicaid,1874.31,,,1874.31,Other,140% of Medicaid,3012.28,,,3012.28,Other,225% of Medicaid,3480.85,,,3480.85,Other,260% of Medicaid,4337.68,,,4337.68,Other,324% of Medicaid,2878.4,,,2878.4,Other,215% of Medicaid,2878.4,,,2878.4,Other,215% of Medicaid,1673.49,,,1673.49,Other,125% of Medicaid,1338.79,9473,
INS PERIPH CV/PORT >5 YRS W/ FY MOD,36571,CPT,,42636571,CDM,361,RC,,,both,,,8373,6196.04,,,6196.04,Other,150% of Medicare + 9.63% HCRA Surcharge,3767.85,45,,3767.85,percent of total billed charges,Critical Access Hospital RCC factor,3473,,,3473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3126,,,3126,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4476,,,4476,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4028,,,4028,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3805,,,3805,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4144.64,,,4144.64,Other,110% of Medicare,6152,,,6152,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",586.68,,,586.68,Other,186% of Medicaid,7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",5266,,,5266,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",5861.1,70,,5861.1,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",4913,,,4913,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4422,,,4422,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4913,,,4913,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4176,,,4176,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",315.42,,,315.42,Other,100% of Medicaid,315.42,,,315.42,Other,100% of Medicaid,315.42,,,315.42,Other,100% of Medicaid,315.42,,,315.42,Other,100% of Medicaid,709.7,,,709.7,Other,225% of Medicaid,482.6,,,482.6,Other,153% of Medicaid,709.7,,,709.7,Other,225% of Medicaid,441.59,,,441.59,Other,140% of Medicaid,709.7,,,709.7,Other,225% of Medicaid,820.1,,,820.1,Other,260% of Medicaid,1021.97,,,1021.97,Other,324% of Medicaid,678.16,,,678.16,Other,215% of Medicaid,678.16,,,678.16,Other,215% of Medicaid,394.28,,,394.28,Other,125% of Medicaid,315.42,9473,
REPOSITION CV CATHETER W/ FY MOD,36597,CPT,,42636597,CDM,361,RC,,,both,,,3709,2744.67,,,2744.67,Other,150% of Medicare + 9.63% HCRA Surcharge,1669.05,45,,1669.05,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3648,,,3648,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3283,,,3283,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3101,,,3101,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",1835.96,,,1835.96,Other,110% of Medicare,2522.12,,,2522.12,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1556.72,,,1556.72,Other,186% of Medicaid,2967.2,,,2967.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2967.2,,,2967.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2967.2,,,2967.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2596.3,70,,2596.3,percent of total billed charges,All Other,285.36,,,285.36,Fee Schedule,,241.86,,,241.86,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",836.95,,,836.95,Other,100% of Medicaid,836.95,,,836.95,Other,100% of Medicaid,836.95,,,836.95,Other,100% of Medicaid,836.95,,,836.95,Other,100% of Medicaid,1883.13,,,1883.13,Other,225% of Medicaid,1280.53,,,1280.53,Other,153% of Medicaid,1883.13,,,1883.13,Other,225% of Medicaid,1171.73,,,1171.73,Other,140% of Medicaid,1883.13,,,1883.13,Other,225% of Medicaid,2176.07,,,2176.07,Other,260% of Medicaid,2711.71,,,2711.71,Other,324% of Medicaid,1799.44,,,1799.44,Other,215% of Medicaid,1799.44,,,1799.44,Other,215% of Medicaid,1046.19,,,1046.19,Other,125% of Medicaid,241.86,7216,
INJ W/FLUOR EVAL CV DEVICE W/ FY MOD,36598,CPT,,42636598,CDM,361,RC,,,both,,,794,587.56,,,587.56,Other,150% of Medicare + 9.63% HCRA Surcharge,357.3,45,,357.3,percent of total billed charges,Critical Access Hospital RCC factor,2480,,,2480,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2232,,,2232,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",393.03,,,393.03,Other,110% of Medicare,539.92,,,539.92,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",966.93,,,966.93,Other,186% of Medicaid,635.2,,,635.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",635.2,,,635.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",635.2,,,635.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",555.8,70,,555.8,percent of total billed charges,All Other,173.84,,,173.84,Fee Schedule,,147.34,,,147.34,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",519.86,,,519.86,Other,100% of Medicaid,519.86,,,519.86,Other,100% of Medicaid,519.86,,,519.86,Other,100% of Medicaid,519.86,,,519.86,Other,100% of Medicaid,1169.68,,,1169.68,Other,225% of Medicaid,795.38,,,795.38,Other,153% of Medicaid,1169.68,,,1169.68,Other,225% of Medicaid,727.8,,,727.8,Other,140% of Medicaid,1169.68,,,1169.68,Other,225% of Medicaid,1351.62,,,1351.62,Other,260% of Medicaid,1684.33,,,1684.33,Other,324% of Medicaid,1117.69,,,1117.69,Other,215% of Medicaid,1117.69,,,1117.69,Other,215% of Medicaid,649.82,,,649.82,Other,125% of Medicaid,147.34,7216,
NEEDLE BIOPSY OF LIVER W/ FY MOD,47000,CPT,,42647000,CDM,361,RC,,,both,,,3495,2586.31,,,2586.31,Other,150% of Medicare + 9.63% HCRA Surcharge,1572.75,45,,1572.75,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3648,,,3648,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3283,,,3283,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3101,,,3101,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",1730.03,,,1730.03,Other,110% of Medicare,2376.6,,,2376.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1196.64,,,1196.64,Other,186% of Medicaid,2796,,,2796,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2796,,,2796,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",3578,,,3578,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2446.5,70,,2446.5,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",4055,,,4055,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3649,,,3649,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4055,,,4055,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3448,,,3448,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",643.35,,,643.35,Other,100% of Medicaid,643.35,,,643.35,Other,100% of Medicaid,643.35,,,643.35,Other,100% of Medicaid,643.35,,,643.35,Other,100% of Medicaid,1447.55,,,1447.55,Other,225% of Medicaid,984.33,,,984.33,Other,153% of Medicaid,1447.55,,,1447.55,Other,225% of Medicaid,900.7,,,900.7,Other,140% of Medicaid,1447.55,,,1447.55,Other,225% of Medicaid,1672.72,,,1672.72,Other,260% of Medicaid,2084.47,,,2084.47,Other,324% of Medicaid,1383.21,,,1383.21,Other,215% of Medicaid,1383.21,,,1383.21,Other,215% of Medicaid,804.19,,,804.19,Other,125% of Medicaid,643.35,7216,
IMAGE CATH FLUID PERI/RETRO W/ FY MOD,49406,CPT,,42649406,CDM,361,RC,,,both,,,5417,4008.59,,,4008.59,Other,150% of Medicare + 9.63% HCRA Surcharge,2437.65,45,,2437.65,percent of total billed charges,Critical Access Hospital RCC factor,2480,,,2480,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2232,,,2232,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3648,,,3648,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3283,,,3283,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3101,,,3101,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2681.42,,,2681.42,Other,110% of Medicare,3683.56,,,3683.56,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1196.64,,,1196.64,Other,186% of Medicaid,4333.6,,,4333.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",4333.6,,,4333.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",4333.6,,,4333.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",3791.9,70,,3791.9,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",4055,,,4055,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3649,,,3649,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4055,,,4055,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3448,,,3448,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",643.35,,,643.35,Other,100% of Medicaid,643.35,,,643.35,Other,100% of Medicaid,643.35,,,643.35,Other,100% of Medicaid,643.35,,,643.35,Other,100% of Medicaid,1447.55,,,1447.55,Other,225% of Medicaid,984.33,,,984.33,Other,153% of Medicaid,1447.55,,,1447.55,Other,225% of Medicaid,900.7,,,900.7,Other,140% of Medicaid,1447.55,,,1447.55,Other,225% of Medicaid,1672.72,,,1672.72,Other,260% of Medicaid,2084.47,,,2084.47,Other,324% of Medicaid,1383.21,,,1383.21,Other,215% of Medicaid,1383.21,,,1383.21,Other,215% of Medicaid,804.19,,,804.19,Other,125% of Medicaid,643.35,7216,
ASSESS CYST CONTRAST INJECT W/ FY MOD,49424,CPT,,42649424,CDM,361,RC,,,both,,,241,178.34,,,178.34,Other,150% of Medicare + 9.63% HCRA Surcharge,108.45,45,,108.45,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",119.3,,,119.3,Other,110% of Medicare,163.88,,,163.88,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",966.93,,,966.93,Other,186% of Medicaid,192.8,,,192.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",192.8,,,192.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",192.8,,,192.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",168.7,70,,168.7,percent of total billed charges,All Other,180.4,,,180.4,Fee Schedule,,152.9,,,152.9,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",519.86,,,519.86,Other,100% of Medicaid,519.86,,,519.86,Other,100% of Medicaid,519.86,,,519.86,Other,100% of Medicaid,519.86,,,519.86,Other,100% of Medicaid,1169.68,,,1169.68,Other,225% of Medicaid,795.38,,,795.38,Other,153% of Medicaid,1169.68,,,1169.68,Other,225% of Medicaid,727.8,,,727.8,Other,140% of Medicaid,1169.68,,,1169.68,Other,225% of Medicaid,1351.62,,,1351.62,Other,260% of Medicaid,1684.33,,,1684.33,Other,324% of Medicaid,1117.69,,,1117.69,Other,215% of Medicaid,1117.69,,,1117.69,Other,215% of Medicaid,649.82,,,649.82,Other,125% of Medicaid,108.45,7216,
INJECTION FOR URETER XR W/ FY MOD,50690,CPT,,42650690,CDM,361,RC,,,both,,,41,30.34,,,30.34,Other,150% of Medicare + 9.63% HCRA Surcharge,18.45,45,,18.45,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",20.3,,,20.3,Other,110% of Medicare,27.88,,,27.88,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",966.93,,,966.93,Other,186% of Medicaid,32.8,,,32.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",32.8,,,32.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",32.8,,,32.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",28.7,70,,28.7,percent of total billed charges,All Other,331.28,,,331.28,Fee Schedule,,280.78,,,280.78,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",519.86,,,519.86,Other,100% of Medicaid,519.86,,,519.86,Other,100% of Medicaid,519.86,,,519.86,Other,100% of Medicaid,519.86,,,519.86,Other,100% of Medicaid,1169.68,,,1169.68,Other,225% of Medicaid,795.38,,,795.38,Other,153% of Medicaid,1169.68,,,1169.68,Other,225% of Medicaid,727.8,,,727.8,Other,140% of Medicaid,1169.68,,,1169.68,Other,225% of Medicaid,1351.62,,,1351.62,Other,260% of Medicaid,1684.33,,,1684.33,Other,324% of Medicaid,1117.69,,,1117.69,Other,215% of Medicaid,1117.69,,,1117.69,Other,215% of Medicaid,649.82,,,649.82,Other,125% of Medicaid,18.45,7216,
INJECTION FOR BLADDER XR W/ FY MOD,51600,CPT,,42651600,CDM,361,RC,,,both,,,254,187.96,,,187.96,Other,150% of Medicare + 9.63% HCRA Surcharge,114.3,45,,114.3,percent of total billed charges,Critical Access Hospital RCC factor,4565,,,4565,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4109,,,4109,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",125.73,,,125.73,Other,110% of Medicare,172.72,,,172.72,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",966.93,,,966.93,Other,186% of Medicaid,203.2,,,203.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",203.2,,,203.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",203.2,,,203.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",177.8,70,,177.8,percent of total billed charges,All Other,209.92,,,209.92,Fee Schedule,,177.92,,,177.92,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",519.86,,,519.86,Other,100% of Medicaid,519.86,,,519.86,Other,100% of Medicaid,519.86,,,519.86,Other,100% of Medicaid,519.86,,,519.86,Other,100% of Medicaid,1169.68,,,1169.68,Other,225% of Medicaid,795.38,,,795.38,Other,153% of Medicaid,1169.68,,,1169.68,Other,225% of Medicaid,727.8,,,727.8,Other,140% of Medicaid,1169.68,,,1169.68,Other,225% of Medicaid,1351.62,,,1351.62,Other,260% of Medicaid,1684.33,,,1684.33,Other,324% of Medicaid,1117.69,,,1117.69,Other,215% of Medicaid,1117.69,,,1117.69,Other,215% of Medicaid,649.82,,,649.82,Other,125% of Medicaid,114.3,7216,
CHANGE OF BLADDER TUBE W/ FY MOD,51705,CPT,,42651705,CDM,361,RC,,,both,,,776,574.24,,,574.24,Other,150% of Medicare + 9.63% HCRA Surcharge,349.2,45,,349.2,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",384.12,,,384.12,Other,110% of Medicare,527.68,,,527.68,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",847.8,,,847.8,Other,186% of Medicaid,620.8,,,620.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",620.8,,,620.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",620.8,,,620.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",543.2,70,,543.2,percent of total billed charges,All Other,246,,,246,Fee Schedule,,208.5,,,208.5,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",455.81,,,455.81,Other,100% of Medicaid,455.81,,,455.81,Other,100% of Medicaid,455.81,,,455.81,Other,100% of Medicaid,455.81,,,455.81,Other,100% of Medicaid,1025.56,,,1025.56,Other,225% of Medicaid,697.38,,,697.38,Other,153% of Medicaid,1025.56,,,1025.56,Other,225% of Medicaid,638.13,,,638.13,Other,140% of Medicaid,1025.56,,,1025.56,Other,225% of Medicaid,1185.1,,,1185.1,Other,260% of Medicaid,1476.81,,,1476.81,Other,324% of Medicaid,979.98,,,979.98,Other,215% of Medicaid,979.98,,,979.98,Other,215% of Medicaid,569.76,,,569.76,Other,125% of Medicaid,208.5,7216,
HYSTEROSON INJECTION W/ FY MOD,58340,CPT,,42658340,CDM,361,RC,,,both,,,346,256.04,,,256.04,Other,150% of Medicare + 9.63% HCRA Surcharge,155.7,45,,155.7,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",171.27,,,171.27,Other,110% of Medicare,235.28,,,235.28,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",966.93,,,966.93,Other,186% of Medicaid,276.8,,,276.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",276.8,,,276.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",276.8,,,276.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",242.2,70,,242.2,percent of total billed charges,All Other,272.24,,,272.24,Fee Schedule,,230.74,,,230.74,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",519.86,,,519.86,Other,100% of Medicaid,519.86,,,519.86,Other,100% of Medicaid,519.86,,,519.86,Other,100% of Medicaid,519.86,,,519.86,Other,100% of Medicaid,1169.68,,,1169.68,Other,225% of Medicaid,795.38,,,795.38,Other,153% of Medicaid,1169.68,,,1169.68,Other,225% of Medicaid,727.8,,,727.8,Other,140% of Medicaid,1169.68,,,1169.68,Other,225% of Medicaid,1351.62,,,1351.62,Other,260% of Medicaid,1684.33,,,1684.33,Other,324% of Medicaid,1117.69,,,1117.69,Other,215% of Medicaid,1117.69,,,1117.69,Other,215% of Medicaid,649.82,,,649.82,Other,125% of Medicaid,155.7,7216,
BIOPSY THYROID PERC CORE NEEDL W/ FY MOD,60100,CPT,,42660100,CDM,361,RC,,,both,,,1601,1184.74,,,1184.74,Other,150% of Medicare + 9.63% HCRA Surcharge,720.45,45,,720.45,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",792.5,,,792.5,Other,110% of Medicare,1088.68,,,1088.68,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1037.55,,,1037.55,Other,186% of Medicaid,1280.8,,,1280.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1280.8,,,1280.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1280.8,,,1280.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1120.7,70,,1120.7,percent of total billed charges,All Other,367.36,,,367.36,Fee Schedule,,311.36,,,311.36,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",557.82,,,557.82,Other,100% of Medicaid,557.82,,,557.82,Other,100% of Medicaid,557.82,,,557.82,Other,100% of Medicaid,557.82,,,557.82,Other,100% of Medicaid,1255.1,,,1255.1,Other,225% of Medicaid,853.47,,,853.47,Other,153% of Medicaid,1255.1,,,1255.1,Other,225% of Medicaid,780.95,,,780.95,Other,140% of Medicaid,1255.1,,,1255.1,Other,225% of Medicaid,1450.34,,,1450.34,Other,260% of Medicaid,1807.35,,,1807.35,Other,324% of Medicaid,1199.32,,,1199.32,Other,215% of Medicaid,1199.32,,,1199.32,Other,215% of Medicaid,697.28,,,697.28,Other,125% of Medicaid,311.36,7216,
LUMBAR PUNCTURE W/ FY MOD,62270,CPT,,42662270,CDM,361,RC,,,both,,,1479,1094.46,,,1094.46,Other,150% of Medicare + 9.63% HCRA Surcharge,665.55,45,,665.55,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",732.11,,,732.11,Other,110% of Medicare,1005.72,,,1005.72,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1116.35,,,1116.35,Other,186% of Medicaid,1183.2,,,1183.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1183.2,,,1183.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",3578,,,3578,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1035.3,70,,1035.3,percent of total billed charges,All Other,298.48,,,298.48,Fee Schedule,,252.98,,,252.98,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",600.19,,,600.19,Other,100% of Medicaid,600.19,,,600.19,Other,100% of Medicaid,600.19,,,600.19,Other,100% of Medicaid,600.19,,,600.19,Other,100% of Medicaid,1350.43,,,1350.43,Other,225% of Medicaid,918.29,,,918.29,Other,153% of Medicaid,1350.43,,,1350.43,Other,225% of Medicaid,840.26,,,840.26,Other,140% of Medicaid,1350.43,,,1350.43,Other,225% of Medicaid,1560.49,,,1560.49,Other,260% of Medicaid,1944.61,,,1944.61,Other,324% of Medicaid,1290.41,,,1290.41,Other,215% of Medicaid,1290.41,,,1290.41,Other,215% of Medicaid,750.24,,,750.24,Other,125% of Medicaid,252.98,7216,
DRAIN CEREBRO SPINAL FLUID W/ FY MOD,62272,CPT,,42662272,CDM,361,RC,,,both,,,1452,1074.48,,,1074.48,Other,150% of Medicare + 9.63% HCRA Surcharge,653.4,45,,653.4,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",718.74,,,718.74,Other,110% of Medicare,987.36,,,987.36,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1116.35,,,1116.35,Other,186% of Medicaid,1161.6,,,1161.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1161.6,,,1161.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",3578,,,3578,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1016.4,70,,1016.4,percent of total billed charges,All Other,431.32,,,431.32,Fee Schedule,,365.57,,,365.57,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",600.19,,,600.19,Other,100% of Medicaid,600.19,,,600.19,Other,100% of Medicaid,600.19,,,600.19,Other,100% of Medicaid,600.19,,,600.19,Other,100% of Medicaid,1350.43,,,1350.43,Other,225% of Medicaid,918.29,,,918.29,Other,153% of Medicaid,1350.43,,,1350.43,Other,225% of Medicaid,840.26,,,840.26,Other,140% of Medicaid,1350.43,,,1350.43,Other,225% of Medicaid,1560.49,,,1560.49,Other,260% of Medicaid,1944.61,,,1944.61,Other,324% of Medicaid,1290.41,,,1290.41,Other,215% of Medicaid,1290.41,,,1290.41,Other,215% of Medicaid,750.24,,,750.24,Other,125% of Medicaid,365.57,7216,
LAMINOTOMY SINGLE CERVICAL W/ FY MOD,63040,CPT,,42663040,CDM,361,RC,,,both,,,15553,11509.26,,,11509.26,Other,150% of Medicare + 9.63% HCRA Surcharge,6998.85,45,,6998.85,percent of total billed charges,Critical Access Hospital RCC factor,4827,,,4827,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4344,,,4344,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",7978,,,7978,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",7180,,,7180,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",6781,,,6781,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",7698.74,,,7698.74,Other,110% of Medicare,6152,,,6152,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",5525.48,,,5525.48,Other,186% of Medicaid,7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",12442.4,,,12442.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",10887.1,70,,10887.1,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",6331,,,6331,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",5698,,,5698,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",6331,,,6331,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",5381,,,5381,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2970.69,,,2970.69,Other,100% of Medicaid,2970.69,,,2970.69,Other,100% of Medicaid,2970.69,,,2970.69,Other,100% of Medicaid,2970.69,,,2970.69,Other,100% of Medicaid,6684.05,,,6684.05,Other,225% of Medicaid,4545.16,,,4545.16,Other,153% of Medicaid,6684.05,,,6684.05,Other,225% of Medicaid,4158.97,,,4158.97,Other,140% of Medicaid,6684.05,,,6684.05,Other,225% of Medicaid,7723.79,,,7723.79,Other,260% of Medicaid,9625.03,,,9625.03,Other,324% of Medicaid,6386.98,,,6386.98,Other,215% of Medicaid,6386.98,,,6386.98,Other,215% of Medicaid,3713.36,,,3713.36,Other,125% of Medicaid,2970.69,12442.4,
LAMINOTOMY SINGLE LUMBAR W/ FY MOD,63042,CPT,,42663042,CDM,361,RC,,,both,,,15553,11509.26,,,11509.26,Other,150% of Medicare + 9.63% HCRA Surcharge,6998.85,45,,6998.85,percent of total billed charges,Critical Access Hospital RCC factor,4827,,,4827,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4344,,,4344,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",7978,,,7978,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",7180,,,7180,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",6781,,,6781,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",7698.74,,,7698.74,Other,110% of Medicare,6152,,,6152,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",5525.48,,,5525.48,Other,186% of Medicaid,7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",12442.4,,,12442.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",10887.1,70,,10887.1,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",6331,,,6331,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",5698,,,5698,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",6331,,,6331,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",5381,,,5381,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2970.69,,,2970.69,Other,100% of Medicaid,2970.69,,,2970.69,Other,100% of Medicaid,2970.69,,,2970.69,Other,100% of Medicaid,2970.69,,,2970.69,Other,100% of Medicaid,6684.05,,,6684.05,Other,225% of Medicaid,4545.16,,,4545.16,Other,153% of Medicaid,6684.05,,,6684.05,Other,225% of Medicaid,4158.97,,,4158.97,Other,140% of Medicaid,6684.05,,,6684.05,Other,225% of Medicaid,7723.79,,,7723.79,Other,260% of Medicaid,9625.03,,,9625.03,Other,324% of Medicaid,6386.98,,,6386.98,Other,215% of Medicaid,6386.98,,,6386.98,Other,215% of Medicaid,3713.36,,,3713.36,Other,125% of Medicaid,2970.69,12442.4,
UNLISTED PROCEDURE NERVOUS W/ FY MOD,64999,CPT,,42664999,CDM,361,RC,,,both,,,873,646.02,,,646.02,Other,150% of Medicare + 9.63% HCRA Surcharge,392.85,45,,392.85,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,432.14,,,432.14,Other,110% of Medicare,593.64,,,593.64,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",710.57,,,710.57,Other,186% of Medicaid,698.4,,,698.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",698.4,,,698.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",698.4,,,698.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",611.1,70,,611.1,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",382.03,,,382.03,Other,100% of Medicaid,382.03,,,382.03,Other,100% of Medicaid,382.03,,,382.03,Other,100% of Medicaid,382.03,,,382.03,Other,100% of Medicaid,859.56,,,859.56,Other,225% of Medicaid,584.5,,,584.5,Other,153% of Medicaid,859.56,,,859.56,Other,225% of Medicaid,534.84,,,534.84,Other,140% of Medicaid,859.56,,,859.56,Other,225% of Medicaid,993.27,,,993.27,Other,260% of Medicaid,1237.76,,,1237.76,Other,324% of Medicaid,821.35,,,821.35,Other,215% of Medicaid,821.35,,,821.35,Other,215% of Medicaid,477.53,,,477.53,Other,125% of Medicaid,0.01,7216,
LUMBAR PUNCTURE W/ FY MOD,62270,CPT,FY,43062270,CDM,361,RC,,,both,,,1479,1094.46,,,1094.46,Other,150% of Medicare + 9.63% HCRA Surcharge,665.55,45,,665.55,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",732.11,,,732.11,Other,110% of Medicare,1005.72,,,1005.72,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1116.35,,,1116.35,Other,186% of Medicaid,1183.2,,,1183.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1183.2,,,1183.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",3578,,,3578,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1035.3,70,,1035.3,percent of total billed charges,All Other,298.48,,,298.48,Fee Schedule,,252.98,,,252.98,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",600.19,,,600.19,Other,100% of Medicaid,600.19,,,600.19,Other,100% of Medicaid,600.19,,,600.19,Other,100% of Medicaid,600.19,,,600.19,Other,100% of Medicaid,1350.43,,,1350.43,Other,225% of Medicaid,918.29,,,918.29,Other,153% of Medicaid,1350.43,,,1350.43,Other,225% of Medicaid,840.26,,,840.26,Other,140% of Medicaid,1350.43,,,1350.43,Other,225% of Medicaid,1560.49,,,1560.49,Other,260% of Medicaid,1944.61,,,1944.61,Other,324% of Medicaid,1290.41,,,1290.41,Other,215% of Medicaid,1290.41,,,1290.41,Other,215% of Medicaid,750.24,,,750.24,Other,125% of Medicaid,252.98,7216,
GUIDE CATHET FLUID DRAINAGE,10030,CPT,,44010030,CDM,361,RC,,,both,,,3578,2647.73,,,2647.73,Other,150% of Medicare + 9.63% HCRA Surcharge,1610.1,45,,1610.1,percent of total billed charges,Critical Access Hospital RCC factor,2480,,,2480,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2232,,,2232,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",1771.11,,,1771.11,Other,110% of Medicare,2433.04,,,2433.04,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1207.1,,,1207.1,Other,186% of Medicaid,2862.4,,,2862.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2862.4,,,2862.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2862.4,,,2862.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2504.6,70,,2504.6,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",648.98,,,648.98,Other,100% of Medicaid,648.98,,,648.98,Other,100% of Medicaid,648.98,,,648.98,Other,100% of Medicaid,648.98,,,648.98,Other,100% of Medicaid,1460.2,,,1460.2,Other,225% of Medicaid,992.94,,,992.94,Other,153% of Medicaid,1460.2,,,1460.2,Other,225% of Medicaid,908.57,,,908.57,Other,140% of Medicaid,1460.2,,,1460.2,Other,225% of Medicaid,1687.34,,,1687.34,Other,260% of Medicaid,2102.69,,,2102.69,Other,324% of Medicaid,1395.3,,,1395.3,Other,215% of Medicaid,1395.3,,,1395.3,Other,215% of Medicaid,811.22,,,811.22,Other,125% of Medicaid,648.98,7216,
PUNCT ASP - ABSC HEMAT CYST,10160,CPT,,44010160,CDM,361,RC,,,both,,,841,622.34,,,622.34,Other,150% of Medicare + 9.63% HCRA Surcharge,378.45,45,,378.45,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",416.3,,,416.3,Other,110% of Medicare,571.88,,,571.88,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",733.11,,,733.11,Other,186% of Medicaid,672.8,,,672.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",672.8,,,672.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",672.8,,,672.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",588.7,70,,588.7,percent of total billed charges,All Other,457.56,,,457.56,Fee Schedule,,387.81,,,387.81,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",394.14,,,394.14,Other,100% of Medicaid,394.14,,,394.14,Other,100% of Medicaid,394.14,,,394.14,Other,100% of Medicaid,394.14,,,394.14,Other,100% of Medicaid,886.83,,,886.83,Other,225% of Medicaid,603.04,,,603.04,Other,153% of Medicaid,886.83,,,886.83,Other,225% of Medicaid,551.8,,,551.8,Other,140% of Medicaid,886.83,,,886.83,Other,225% of Medicaid,1024.78,,,1024.78,Other,260% of Medicaid,1277.03,,,1277.03,Other,324% of Medicaid,847.41,,,847.41,Other,215% of Medicaid,847.41,,,847.41,Other,215% of Medicaid,492.68,,,492.68,Other,125% of Medicaid,378.45,7216,
BX BREAST 1ST LESION US IMAG,19083,CPT,,44019083,CDM,361,RC,,,both,,,3377,2498.99,,,2498.99,Other,150% of Medicare + 9.63% HCRA Surcharge,1519.65,45,,1519.65,percent of total billed charges,Critical Access Hospital RCC factor,2480,,,2480,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2232,,,2232,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3648,,,3648,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3283,,,3283,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3101,,,3101,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",1671.62,,,1671.62,Other,110% of Medicare,2296.36,,,2296.36,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2793.39,,,2793.39,Other,186% of Medicaid,2701.6,,,2701.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2701.6,,,2701.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2701.6,,,2701.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2363.9,70,,2363.9,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",4055,,,4055,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3649,,,3649,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4055,,,4055,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3448,,,3448,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",1501.82,,,1501.82,Other,100% of Medicaid,1501.82,,,1501.82,Other,100% of Medicaid,1501.82,,,1501.82,Other,100% of Medicaid,1501.82,,,1501.82,Other,100% of Medicaid,3379.1,,,3379.1,Other,225% of Medicaid,2297.79,,,2297.79,Other,153% of Medicaid,3379.1,,,3379.1,Other,225% of Medicaid,2102.55,,,2102.55,Other,140% of Medicaid,3379.1,,,3379.1,Other,225% of Medicaid,3904.73,,,3904.73,Other,260% of Medicaid,4865.9,,,4865.9,Other,324% of Medicaid,3228.91,,,3228.91,Other,215% of Medicaid,3228.91,,,3228.91,Other,215% of Medicaid,1877.28,,,1877.28,Other,125% of Medicaid,1501.82,7216,
BX BREAST ADD LESION US IMAG,19084,CPT,,44019084,CDM,361,RC,,,both,,,273,202.02,,,202.02,Other,150% of Medicare + 9.63% HCRA Surcharge,122.85,45,,122.85,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3648,,,3648,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3283,,,3283,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3101,,,3101,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",135.14,,,135.14,Other,110% of Medicare,185.64,,,185.64,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2793.39,,,2793.39,Other,186% of Medicaid,218.4,,,218.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",218.4,,,218.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",218.4,,,218.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",191.1,70,,191.1,percent of total billed charges,All Other,369,,,369,Fee Schedule,,312.75,,,312.75,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",1501.82,,,1501.82,Other,100% of Medicaid,1501.82,,,1501.82,Other,100% of Medicaid,1501.82,,,1501.82,Other,100% of Medicaid,1501.82,,,1501.82,Other,100% of Medicaid,3379.1,,,3379.1,Other,225% of Medicaid,2297.79,,,2297.79,Other,153% of Medicaid,3379.1,,,3379.1,Other,225% of Medicaid,2102.55,,,2102.55,Other,140% of Medicaid,3379.1,,,3379.1,Other,225% of Medicaid,3904.73,,,3904.73,Other,260% of Medicaid,4865.9,,,4865.9,Other,324% of Medicaid,3228.91,,,3228.91,Other,215% of Medicaid,3228.91,,,3228.91,Other,215% of Medicaid,1877.28,,,1877.28,Other,125% of Medicaid,122.85,7216,
MUSCLE BX; PERC NDL,20206,CPT,,44020206,CDM,361,RC,,,both,,,3377,2498.99,,,2498.99,Other,150% of Medicare + 9.63% HCRA Surcharge,1519.65,45,,1519.65,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3648,,,3648,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3283,,,3283,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3101,,,3101,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",1671.62,,,1671.62,Other,110% of Medicare,2296.36,,,2296.36,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1037.55,,,1037.55,Other,186% of Medicaid,2701.6,,,2701.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2701.6,,,2701.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",3578,,,3578,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2363.9,70,,2363.9,percent of total billed charges,All Other,273.88,,,273.88,Fee Schedule,,232.13,,,232.13,Fee Schedule,,4055,,,4055,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3649,,,3649,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4055,,,4055,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3448,,,3448,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",557.82,,,557.82,Other,100% of Medicaid,557.82,,,557.82,Other,100% of Medicaid,557.82,,,557.82,Other,100% of Medicaid,557.82,,,557.82,Other,100% of Medicaid,1255.1,,,1255.1,Other,225% of Medicaid,853.47,,,853.47,Other,153% of Medicaid,1255.1,,,1255.1,Other,225% of Medicaid,780.95,,,780.95,Other,140% of Medicaid,1255.1,,,1255.1,Other,225% of Medicaid,1450.34,,,1450.34,Other,260% of Medicaid,1807.35,,,1807.35,Other,324% of Medicaid,1199.32,,,1199.32,Other,215% of Medicaid,1199.32,,,1199.32,Other,215% of Medicaid,697.28,,,697.28,Other,125% of Medicaid,232.13,7216,
DRAIN/INJ INTER JOINT/BURSA W/US,20606,CPT,,44020606,CDM,361,RC,,,both,,,1452,1074.48,,,1074.48,Other,150% of Medicare + 9.63% HCRA Surcharge,653.4,45,,653.4,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",718.74,,,718.74,Other,110% of Medicare,987.36,,,987.36,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1079.62,,,1079.62,Other,186% of Medicaid,1161.6,,,1161.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1161.6,,,1161.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1161.6,,,1161.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1016.4,70,,1016.4,percent of total billed charges,All Other,249.28,,,249.28,Fee Schedule,,211.28,,,211.28,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",580.44,,,580.44,Other,100% of Medicaid,580.44,,,580.44,Other,100% of Medicaid,580.44,,,580.44,Other,100% of Medicaid,580.44,,,580.44,Other,100% of Medicaid,1306,,,1306,Other,225% of Medicaid,888.08,,,888.08,Other,153% of Medicaid,1306,,,1306,Other,225% of Medicaid,812.62,,,812.62,Other,140% of Medicaid,1306,,,1306,Other,225% of Medicaid,1509.15,,,1509.15,Other,260% of Medicaid,1880.64,,,1880.64,Other,324% of Medicaid,1247.95,,,1247.95,Other,215% of Medicaid,1247.95,,,1247.95,Other,215% of Medicaid,725.55,,,725.55,Other,125% of Medicaid,211.28,7216,
DRAIN/INJ MAJOR JOINT/BURSA W/US,20611,CPT,,44020611,CDM,361,RC,,,both,,,991,733.34,,,733.34,Other,150% of Medicare + 9.63% HCRA Surcharge,445.95,45,,445.95,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",490.55,,,490.55,Other,110% of Medicare,673.88,,,673.88,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1079.62,,,1079.62,Other,186% of Medicaid,792.8,,,792.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",792.8,,,792.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",792.8,,,792.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",693.7,70,,693.7,percent of total billed charges,All Other,285.36,,,285.36,Fee Schedule,,241.86,,,241.86,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",580.44,,,580.44,Other,100% of Medicaid,580.44,,,580.44,Other,100% of Medicaid,580.44,,,580.44,Other,100% of Medicaid,580.44,,,580.44,Other,100% of Medicaid,1306,,,1306,Other,225% of Medicaid,888.08,,,888.08,Other,153% of Medicaid,1306,,,1306,Other,225% of Medicaid,812.62,,,812.62,Other,140% of Medicaid,1306,,,1306,Other,225% of Medicaid,1509.15,,,1509.15,Other,260% of Medicaid,1880.64,,,1880.64,Other,324% of Medicaid,1247.95,,,1247.95,Other,215% of Medicaid,1247.95,,,1247.95,Other,215% of Medicaid,725.55,,,725.55,Other,125% of Medicaid,241.86,7216,
I&D DEEP ABSC SFT TISS NK/THOR,21501,CPT,,44021501,CDM,361,RC,,,both,,,5816,4303.85,,,4303.85,Other,150% of Medicare + 9.63% HCRA Surcharge,2617.2,45,,2617.2,percent of total billed charges,Critical Access Hospital RCC factor,2480,,,2480,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2232,,,2232,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4476,,,4476,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4028,,,4028,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3805,,,3805,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2878.92,,,2878.92,Other,110% of Medicare,3954.88,,,3954.88,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",3164.53,,,3164.53,Other,186% of Medicaid,4652.8,,,4652.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",4652.8,,,4652.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",4252,,,4252,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",4071.2,70,,4071.2,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",4531,,,4531,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4079,,,4079,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4531,,,4531,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3852,,,3852,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",1701.36,,,1701.36,Other,100% of Medicaid,1701.36,,,1701.36,Other,100% of Medicaid,1701.36,,,1701.36,Other,100% of Medicaid,1701.36,,,1701.36,Other,100% of Medicaid,3828.06,,,3828.06,Other,225% of Medicaid,2603.08,,,2603.08,Other,153% of Medicaid,3828.06,,,3828.06,Other,225% of Medicaid,2381.9,,,2381.9,Other,140% of Medicaid,3828.06,,,3828.06,Other,225% of Medicaid,4423.54,,,4423.54,Other,260% of Medicaid,5512.41,,,5512.41,Other,324% of Medicaid,3657.92,,,3657.92,Other,215% of Medicaid,3657.92,,,3657.92,Other,215% of Medicaid,2126.7,,,2126.7,Other,125% of Medicaid,1701.36,7216,
SFT TISS BX - NECK/THORAX,21550,CPT,,44021550,CDM,361,RC,,,both,,,4819,3566.07,,,3566.07,Other,150% of Medicare + 9.63% HCRA Surcharge,2168.55,45,,2168.55,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3648,,,3648,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3283,,,3283,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3101,,,3101,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2385.41,,,2385.41,Other,110% of Medicare,3276.92,,,3276.92,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",3164.53,,,3164.53,Other,186% of Medicaid,3855.2,,,3855.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",3855.2,,,3855.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",3855.2,,,3855.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",3373.3,70,,3373.3,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",4055,,,4055,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3649,,,3649,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4055,,,4055,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3448,,,3448,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",1701.36,,,1701.36,Other,100% of Medicaid,1701.36,,,1701.36,Other,100% of Medicaid,1701.36,,,1701.36,Other,100% of Medicaid,1701.36,,,1701.36,Other,100% of Medicaid,3828.06,,,3828.06,Other,225% of Medicaid,2603.08,,,2603.08,Other,153% of Medicaid,3828.06,,,3828.06,Other,225% of Medicaid,2381.9,,,2381.9,Other,140% of Medicaid,3828.06,,,3828.06,Other,225% of Medicaid,4423.54,,,4423.54,Other,260% of Medicaid,5512.41,,,5512.41,Other,324% of Medicaid,3657.92,,,3657.92,Other,215% of Medicaid,3657.92,,,3657.92,Other,215% of Medicaid,2126.7,,,2126.7,Other,125% of Medicaid,1701.36,7216,
INSERT CATH PLEURA W/ IMAGE,32557,CPT,,44032557,CDM,361,RC,,,both,,,3350,2479.01,,,2479.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1507.5,45,,1507.5,percent of total billed charges,Critical Access Hospital RCC factor,2480,,,2480,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2232,,,2232,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3648,,,3648,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3283,,,3283,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3101,,,3101,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",1658.25,,,1658.25,Other,110% of Medicare,2278,,,2278,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1196.64,,,1196.64,Other,186% of Medicaid,2680,,,2680,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2680,,,2680,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2680,,,2680,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2345,70,,2345,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",643.35,,,643.35,Other,100% of Medicaid,643.35,,,643.35,Other,100% of Medicaid,643.35,,,643.35,Other,100% of Medicaid,643.35,,,643.35,Other,100% of Medicaid,1447.55,,,1447.55,Other,225% of Medicaid,984.33,,,984.33,Other,153% of Medicaid,1447.55,,,1447.55,Other,225% of Medicaid,900.7,,,900.7,Other,140% of Medicaid,1447.55,,,1447.55,Other,225% of Medicaid,1672.72,,,1672.72,Other,260% of Medicaid,2084.47,,,2084.47,Other,324% of Medicaid,1383.21,,,1383.21,Other,215% of Medicaid,1383.21,,,1383.21,Other,215% of Medicaid,804.19,,,804.19,Other,125% of Medicaid,643.35,7216,
NEEDLE BIOPSY OF LIVER,47000,CPT,,44047000,CDM,361,RC,,,both,,,3495,2586.31,,,2586.31,Other,150% of Medicare + 9.63% HCRA Surcharge,1572.75,45,,1572.75,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3648,,,3648,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3283,,,3283,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3101,,,3101,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",1730.03,,,1730.03,Other,110% of Medicare,2376.6,,,2376.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1196.64,,,1196.64,Other,186% of Medicaid,2796,,,2796,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2796,,,2796,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",3578,,,3578,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2446.5,70,,2446.5,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",4055,,,4055,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3649,,,3649,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4055,,,4055,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3448,,,3448,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",643.35,,,643.35,Other,100% of Medicaid,643.35,,,643.35,Other,100% of Medicaid,643.35,,,643.35,Other,100% of Medicaid,643.35,,,643.35,Other,100% of Medicaid,1447.55,,,1447.55,Other,225% of Medicaid,984.33,,,984.33,Other,153% of Medicaid,1447.55,,,1447.55,Other,225% of Medicaid,900.7,,,900.7,Other,140% of Medicaid,1447.55,,,1447.55,Other,225% of Medicaid,1672.72,,,1672.72,Other,260% of Medicaid,2084.47,,,2084.47,Other,324% of Medicaid,1383.21,,,1383.21,Other,215% of Medicaid,1383.21,,,1383.21,Other,215% of Medicaid,804.19,,,804.19,Other,125% of Medicaid,643.35,7216,
IMAGE CATH FLUID COLXN VISC,49405,CPT,,44049405,CDM,361,RC,,,both,,,5062,3745.89,,,3745.89,Other,150% of Medicare + 9.63% HCRA Surcharge,2277.9,45,,2277.9,percent of total billed charges,Critical Access Hospital RCC factor,2480,,,2480,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2232,,,2232,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3648,,,3648,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3283,,,3283,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3101,,,3101,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2505.69,,,2505.69,Other,110% of Medicare,3442.16,,,3442.16,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1196.64,,,1196.64,Other,186% of Medicaid,4049.6,,,4049.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",4049.6,,,4049.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",4049.6,,,4049.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",3543.4,70,,3543.4,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",4055,,,4055,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3649,,,3649,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4055,,,4055,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3448,,,3448,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",643.35,,,643.35,Other,100% of Medicaid,643.35,,,643.35,Other,100% of Medicaid,643.35,,,643.35,Other,100% of Medicaid,643.35,,,643.35,Other,100% of Medicaid,1447.55,,,1447.55,Other,225% of Medicaid,984.33,,,984.33,Other,153% of Medicaid,1447.55,,,1447.55,Other,225% of Medicaid,900.7,,,900.7,Other,140% of Medicaid,1447.55,,,1447.55,Other,225% of Medicaid,1672.72,,,1672.72,Other,260% of Medicaid,2084.47,,,2084.47,Other,324% of Medicaid,1383.21,,,1383.21,Other,215% of Medicaid,1383.21,,,1383.21,Other,215% of Medicaid,804.19,,,804.19,Other,125% of Medicaid,643.35,7216,
IMAGE CATH FLUID PERI/RETRO,49406,CPT,,44049406,CDM,361,RC,,,both,,,5417,4008.59,,,4008.59,Other,150% of Medicare + 9.63% HCRA Surcharge,2437.65,45,,2437.65,percent of total billed charges,Critical Access Hospital RCC factor,2480,,,2480,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2232,,,2232,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3648,,,3648,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3283,,,3283,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3101,,,3101,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2681.42,,,2681.42,Other,110% of Medicare,3683.56,,,3683.56,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1196.64,,,1196.64,Other,186% of Medicaid,4333.6,,,4333.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",4333.6,,,4333.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",4333.6,,,4333.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",3791.9,70,,3791.9,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",4055,,,4055,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3649,,,3649,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4055,,,4055,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3448,,,3448,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",643.35,,,643.35,Other,100% of Medicaid,643.35,,,643.35,Other,100% of Medicaid,643.35,,,643.35,Other,100% of Medicaid,643.35,,,643.35,Other,100% of Medicaid,1447.55,,,1447.55,Other,225% of Medicaid,984.33,,,984.33,Other,153% of Medicaid,1447.55,,,1447.55,Other,225% of Medicaid,900.7,,,900.7,Other,140% of Medicaid,1447.55,,,1447.55,Other,225% of Medicaid,1672.72,,,1672.72,Other,260% of Medicaid,2084.47,,,2084.47,Other,324% of Medicaid,1383.21,,,1383.21,Other,215% of Medicaid,1383.21,,,1383.21,Other,215% of Medicaid,804.19,,,804.19,Other,125% of Medicaid,643.35,7216,
IMAGE CATH FLUID TRNS/VGNL,49407,CPT,,44049407,CDM,361,RC,,,both,,,3377,2498.99,,,2498.99,Other,150% of Medicare + 9.63% HCRA Surcharge,1519.65,45,,1519.65,percent of total billed charges,Critical Access Hospital RCC factor,3473,,,3473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3126,,,3126,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3648,,,3648,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3283,,,3283,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3101,,,3101,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",1671.62,,,1671.62,Other,110% of Medicare,6152,,,6152,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1196.64,,,1196.64,Other,186% of Medicaid,7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2701.6,,,2701.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2363.9,70,,2363.9,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",4055,,,4055,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3649,,,3649,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4055,,,4055,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3448,,,3448,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",643.35,,,643.35,Other,100% of Medicaid,643.35,,,643.35,Other,100% of Medicaid,643.35,,,643.35,Other,100% of Medicaid,643.35,,,643.35,Other,100% of Medicaid,1447.55,,,1447.55,Other,225% of Medicaid,984.33,,,984.33,Other,153% of Medicaid,1447.55,,,1447.55,Other,225% of Medicaid,900.7,,,900.7,Other,140% of Medicaid,1447.55,,,1447.55,Other,225% of Medicaid,1672.72,,,1672.72,Other,260% of Medicaid,2084.47,,,2084.47,Other,324% of Medicaid,1383.21,,,1383.21,Other,215% of Medicaid,1383.21,,,1383.21,Other,215% of Medicaid,804.19,,,804.19,Other,125% of Medicaid,643.35,9473,
HYSTEROSON INJECTION,58340,CPT,,44058340,CDM,361,RC,,,both,,,346,256.04,,,256.04,Other,150% of Medicare + 9.63% HCRA Surcharge,155.7,45,,155.7,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",171.27,,,171.27,Other,110% of Medicare,235.28,,,235.28,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",966.93,,,966.93,Other,186% of Medicaid,276.8,,,276.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",276.8,,,276.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",276.8,,,276.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",242.2,70,,242.2,percent of total billed charges,All Other,272.24,,,272.24,Fee Schedule,,230.74,,,230.74,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",519.86,,,519.86,Other,100% of Medicaid,519.86,,,519.86,Other,100% of Medicaid,519.86,,,519.86,Other,100% of Medicaid,519.86,,,519.86,Other,100% of Medicaid,1169.68,,,1169.68,Other,225% of Medicaid,795.38,,,795.38,Other,153% of Medicaid,1169.68,,,1169.68,Other,225% of Medicaid,727.8,,,727.8,Other,140% of Medicaid,1169.68,,,1169.68,Other,225% of Medicaid,1351.62,,,1351.62,Other,260% of Medicaid,1684.33,,,1684.33,Other,324% of Medicaid,1117.69,,,1117.69,Other,215% of Medicaid,1117.69,,,1117.69,Other,215% of Medicaid,649.82,,,649.82,Other,125% of Medicaid,155.7,7216,
BIOPSY THYROID PERC CORE NEEDL,60100,CPT,,44060100,CDM,361,RC,,,both,,,1601,1184.74,,,1184.74,Other,150% of Medicare + 9.63% HCRA Surcharge,720.45,45,,720.45,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",792.5,,,792.5,Other,110% of Medicare,1088.68,,,1088.68,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1037.55,,,1037.55,Other,186% of Medicaid,1280.8,,,1280.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1280.8,,,1280.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1280.8,,,1280.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1120.7,70,,1120.7,percent of total billed charges,All Other,367.36,,,367.36,Fee Schedule,,311.36,,,311.36,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",557.82,,,557.82,Other,100% of Medicaid,557.82,,,557.82,Other,100% of Medicaid,557.82,,,557.82,Other,100% of Medicaid,557.82,,,557.82,Other,100% of Medicaid,1255.1,,,1255.1,Other,225% of Medicaid,853.47,,,853.47,Other,153% of Medicaid,1255.1,,,1255.1,Other,225% of Medicaid,780.95,,,780.95,Other,140% of Medicaid,1255.1,,,1255.1,Other,225% of Medicaid,1450.34,,,1450.34,Other,260% of Medicaid,1807.35,,,1807.35,Other,324% of Medicaid,1199.32,,,1199.32,Other,215% of Medicaid,1199.32,,,1199.32,Other,215% of Medicaid,697.28,,,697.28,Other,125% of Medicaid,311.36,7216,
GUIDE CATHET FLUID DRAINAGE,10030,CPT,,46010030,CDM,361,RC,,,both,,,3578,2647.73,,,2647.73,Other,150% of Medicare + 9.63% HCRA Surcharge,1610.1,45,,1610.1,percent of total billed charges,Critical Access Hospital RCC factor,2480,,,2480,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2232,,,2232,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",1771.11,,,1771.11,Other,110% of Medicare,2433.04,,,2433.04,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1207.1,,,1207.1,Other,186% of Medicaid,2862.4,,,2862.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2862.4,,,2862.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2862.4,,,2862.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2504.6,70,,2504.6,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",648.98,,,648.98,Other,100% of Medicaid,648.98,,,648.98,Other,100% of Medicaid,648.98,,,648.98,Other,100% of Medicaid,648.98,,,648.98,Other,100% of Medicaid,1460.2,,,1460.2,Other,225% of Medicaid,992.94,,,992.94,Other,153% of Medicaid,1460.2,,,1460.2,Other,225% of Medicaid,908.57,,,908.57,Other,140% of Medicaid,1460.2,,,1460.2,Other,225% of Medicaid,1687.34,,,1687.34,Other,260% of Medicaid,2102.69,,,2102.69,Other,324% of Medicaid,1395.3,,,1395.3,Other,215% of Medicaid,1395.3,,,1395.3,Other,215% of Medicaid,811.22,,,811.22,Other,125% of Medicaid,648.98,7216,
INJECTION FOR SHOULDER X-RAY,23350,CPT,,46023350,CDM,361,RC,,,both,,,371,274.54,,,274.54,Other,150% of Medicare + 9.63% HCRA Surcharge,166.95,45,,166.95,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",183.65,,,183.65,Other,110% of Medicare,252.28,,,252.28,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",966.93,,,966.93,Other,186% of Medicaid,296.8,,,296.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",296.8,,,296.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",296.8,,,296.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",259.7,70,,259.7,percent of total billed charges,All Other,239.44,,,239.44,Fee Schedule,,202.94,,,202.94,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",519.86,,,519.86,Other,100% of Medicaid,519.86,,,519.86,Other,100% of Medicaid,519.86,,,519.86,Other,100% of Medicaid,519.86,,,519.86,Other,100% of Medicaid,1169.68,,,1169.68,Other,225% of Medicaid,795.38,,,795.38,Other,153% of Medicaid,1169.68,,,1169.68,Other,225% of Medicaid,727.8,,,727.8,Other,140% of Medicaid,1169.68,,,1169.68,Other,225% of Medicaid,1351.62,,,1351.62,Other,260% of Medicaid,1684.33,,,1684.33,Other,324% of Medicaid,1117.69,,,1117.69,Other,215% of Medicaid,1117.69,,,1117.69,Other,215% of Medicaid,649.82,,,649.82,Other,125% of Medicaid,166.95,7216,
INJECT SACROILIAC JOINT,27096,CPT,,46027096,CDM,361,RC,,,both,,,338,250.12,,,250.12,Other,150% of Medicare + 9.63% HCRA Surcharge,152.1,45,,152.1,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",167.31,,,167.31,Other,110% of Medicare,229.84,,,229.84,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",816.14,,,816.14,Other,186% of Medicaid,270.4,,,270.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",270.4,,,270.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",270.4,,,270.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",236.6,70,,236.6,percent of total billed charges,All Other,395.24,,,395.24,Fee Schedule,,334.99,,,334.99,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",438.79,,,438.79,Other,100% of Medicaid,438.79,,,438.79,Other,100% of Medicaid,438.79,,,438.79,Other,100% of Medicaid,438.79,,,438.79,Other,100% of Medicaid,987.27,,,987.27,Other,225% of Medicaid,671.34,,,671.34,Other,153% of Medicaid,987.27,,,987.27,Other,225% of Medicaid,614.3,,,614.3,Other,140% of Medicaid,987.27,,,987.27,Other,225% of Medicaid,1140.85,,,1140.85,Other,260% of Medicaid,1421.67,,,1421.67,Other,324% of Medicaid,943.39,,,943.39,Other,215% of Medicaid,943.39,,,943.39,Other,215% of Medicaid,548.48,,,548.48,Other,125% of Medicaid,152.1,7216,
INSERT CATH PLEURA W/ IMAGE,32557,CPT,,46032557,CDM,361,RC,,,both,,,3350,2479.01,,,2479.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1507.5,45,,1507.5,percent of total billed charges,Critical Access Hospital RCC factor,2480,,,2480,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2232,,,2232,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3648,,,3648,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3283,,,3283,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3101,,,3101,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",1658.25,,,1658.25,Other,110% of Medicare,2278,,,2278,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1196.64,,,1196.64,Other,186% of Medicaid,2680,,,2680,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2680,,,2680,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2680,,,2680,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2345,70,,2345,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",643.35,,,643.35,Other,100% of Medicaid,643.35,,,643.35,Other,100% of Medicaid,643.35,,,643.35,Other,100% of Medicaid,643.35,,,643.35,Other,100% of Medicaid,1447.55,,,1447.55,Other,225% of Medicaid,984.33,,,984.33,Other,153% of Medicaid,1447.55,,,1447.55,Other,225% of Medicaid,900.7,,,900.7,Other,140% of Medicaid,1447.55,,,1447.55,Other,225% of Medicaid,1672.72,,,1672.72,Other,260% of Medicaid,2084.47,,,2084.47,Other,324% of Medicaid,1383.21,,,1383.21,Other,215% of Medicaid,1383.21,,,1383.21,Other,215% of Medicaid,804.19,,,804.19,Other,125% of Medicaid,643.35,7216,
IMAGE CATH FLUID COLXN VISC,49405,CPT,,46049405,CDM,361,RC,,,both,,,5062,3745.89,,,3745.89,Other,150% of Medicare + 9.63% HCRA Surcharge,2277.9,45,,2277.9,percent of total billed charges,Critical Access Hospital RCC factor,2480,,,2480,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2232,,,2232,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3648,,,3648,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3283,,,3283,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3101,,,3101,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2505.69,,,2505.69,Other,110% of Medicare,3442.16,,,3442.16,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1196.64,,,1196.64,Other,186% of Medicaid,4049.6,,,4049.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",4049.6,,,4049.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",4049.6,,,4049.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",3543.4,70,,3543.4,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",4055,,,4055,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3649,,,3649,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4055,,,4055,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3448,,,3448,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",643.35,,,643.35,Other,100% of Medicaid,643.35,,,643.35,Other,100% of Medicaid,643.35,,,643.35,Other,100% of Medicaid,643.35,,,643.35,Other,100% of Medicaid,1447.55,,,1447.55,Other,225% of Medicaid,984.33,,,984.33,Other,153% of Medicaid,1447.55,,,1447.55,Other,225% of Medicaid,900.7,,,900.7,Other,140% of Medicaid,1447.55,,,1447.55,Other,225% of Medicaid,1672.72,,,1672.72,Other,260% of Medicaid,2084.47,,,2084.47,Other,324% of Medicaid,1383.21,,,1383.21,Other,215% of Medicaid,1383.21,,,1383.21,Other,215% of Medicaid,804.19,,,804.19,Other,125% of Medicaid,643.35,7216,
IMAGE CATH FLUID PERI/RETRO,49406,CPT,,46049406,CDM,361,RC,,,both,,,5417,4008.59,,,4008.59,Other,150% of Medicare + 9.63% HCRA Surcharge,2437.65,45,,2437.65,percent of total billed charges,Critical Access Hospital RCC factor,2480,,,2480,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2232,,,2232,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3648,,,3648,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3283,,,3283,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3101,,,3101,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2681.42,,,2681.42,Other,110% of Medicare,3683.56,,,3683.56,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1196.64,,,1196.64,Other,186% of Medicaid,4333.6,,,4333.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",4333.6,,,4333.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",4333.6,,,4333.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",3791.9,70,,3791.9,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",4055,,,4055,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3649,,,3649,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4055,,,4055,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3448,,,3448,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",643.35,,,643.35,Other,100% of Medicaid,643.35,,,643.35,Other,100% of Medicaid,643.35,,,643.35,Other,100% of Medicaid,643.35,,,643.35,Other,100% of Medicaid,1447.55,,,1447.55,Other,225% of Medicaid,984.33,,,984.33,Other,153% of Medicaid,1447.55,,,1447.55,Other,225% of Medicaid,900.7,,,900.7,Other,140% of Medicaid,1447.55,,,1447.55,Other,225% of Medicaid,1672.72,,,1672.72,Other,260% of Medicaid,2084.47,,,2084.47,Other,324% of Medicaid,1383.21,,,1383.21,Other,215% of Medicaid,1383.21,,,1383.21,Other,215% of Medicaid,804.19,,,804.19,Other,125% of Medicaid,643.35,7216,
IMAGE CATH FLUID TRNS/VGNL,49407,CPT,,46049407,CDM,361,RC,,,both,,,3377,2498.99,,,2498.99,Other,150% of Medicare + 9.63% HCRA Surcharge,1519.65,45,,1519.65,percent of total billed charges,Critical Access Hospital RCC factor,3473,,,3473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3126,,,3126,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3648,,,3648,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3283,,,3283,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3101,,,3101,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",1671.62,,,1671.62,Other,110% of Medicare,6152,,,6152,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1196.64,,,1196.64,Other,186% of Medicaid,7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2701.6,,,2701.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2363.9,70,,2363.9,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",4055,,,4055,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3649,,,3649,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4055,,,4055,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3448,,,3448,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",643.35,,,643.35,Other,100% of Medicaid,643.35,,,643.35,Other,100% of Medicaid,643.35,,,643.35,Other,100% of Medicaid,643.35,,,643.35,Other,100% of Medicaid,1447.55,,,1447.55,Other,225% of Medicaid,984.33,,,984.33,Other,153% of Medicaid,1447.55,,,1447.55,Other,225% of Medicaid,900.7,,,900.7,Other,140% of Medicaid,1447.55,,,1447.55,Other,225% of Medicaid,1672.72,,,1672.72,Other,260% of Medicaid,2084.47,,,2084.47,Other,324% of Medicaid,1383.21,,,1383.21,Other,215% of Medicaid,1383.21,,,1383.21,Other,215% of Medicaid,804.19,,,804.19,Other,125% of Medicaid,643.35,9473,
INTERDISCAL PERQ ASPIR DX,62267,CPT,,46062267,CDM,361,RC,,,both,,,3395,2512.31,,,2512.31,Other,150% of Medicare + 9.63% HCRA Surcharge,1527.75,45,,1527.75,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",1680.53,,,1680.53,Other,110% of Medicare,2308.6,,,2308.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1116.35,,,1116.35,Other,186% of Medicaid,2716,,,2716,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2716,,,2716,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2716,,,2716,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2376.5,70,,2376.5,percent of total billed charges,All Other,738,,,738,Fee Schedule,,625.5,,,625.5,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",600.19,,,600.19,Other,100% of Medicaid,600.19,,,600.19,Other,100% of Medicaid,600.19,,,600.19,Other,100% of Medicaid,600.19,,,600.19,Other,100% of Medicaid,1350.43,,,1350.43,Other,225% of Medicaid,918.29,,,918.29,Other,153% of Medicaid,1350.43,,,1350.43,Other,225% of Medicaid,840.26,,,840.26,Other,140% of Medicaid,1350.43,,,1350.43,Other,225% of Medicaid,1560.49,,,1560.49,Other,260% of Medicaid,1944.61,,,1944.61,Other,324% of Medicaid,1290.41,,,1290.41,Other,215% of Medicaid,1290.41,,,1290.41,Other,215% of Medicaid,750.24,,,750.24,Other,125% of Medicaid,600.19,7216,
I&D ABSC; SMPL OR SGL,10060,CPT,,47010060,CDM,361,RC,,,both,,,587,434.38,,,434.38,Other,150% of Medicare + 9.63% HCRA Surcharge,264.15,45,,264.15,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",290.57,,,290.57,Other,110% of Medicare,399.16,,,399.16,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",733.11,,,733.11,Other,186% of Medicaid,469.6,,,469.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",469.6,,,469.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",469.6,,,469.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",410.9,70,,410.9,percent of total billed charges,All Other,505.12,,,505.12,Fee Schedule,,428.12,,,428.12,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",394.14,,,394.14,Other,100% of Medicaid,394.14,,,394.14,Other,100% of Medicaid,394.14,,,394.14,Other,100% of Medicaid,394.14,,,394.14,Other,100% of Medicaid,886.83,,,886.83,Other,225% of Medicaid,603.04,,,603.04,Other,153% of Medicaid,886.83,,,886.83,Other,225% of Medicaid,551.8,,,551.8,Other,140% of Medicaid,886.83,,,886.83,Other,225% of Medicaid,1024.78,,,1024.78,Other,260% of Medicaid,1277.03,,,1277.03,Other,324% of Medicaid,847.41,,,847.41,Other,215% of Medicaid,847.41,,,847.41,Other,215% of Medicaid,492.68,,,492.68,Other,125% of Medicaid,264.15,7216,
I&D HEMATOMA/FLUID,10140,CPT,,47010140,CDM,361,RC,,,both,,,4951,3663.75,,,3663.75,Other,150% of Medicare + 9.63% HCRA Surcharge,2227.95,45,,2227.95,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3648,,,3648,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3283,,,3283,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3101,,,3101,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2450.75,,,2450.75,Other,110% of Medicare,3366.68,,,3366.68,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1207.1,,,1207.1,Other,186% of Medicaid,3960.8,,,3960.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",3960.8,,,3960.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",3960.8,,,3960.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",3465.7,70,,3465.7,percent of total billed charges,All Other,569.08,,,569.08,Fee Schedule,,482.33,,,482.33,Fee Schedule,,4055,,,4055,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3649,,,3649,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4055,,,4055,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3448,,,3448,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",648.98,,,648.98,Other,100% of Medicaid,648.98,,,648.98,Other,100% of Medicaid,648.98,,,648.98,Other,100% of Medicaid,648.98,,,648.98,Other,100% of Medicaid,1460.2,,,1460.2,Other,225% of Medicaid,992.94,,,992.94,Other,153% of Medicaid,1460.2,,,1460.2,Other,225% of Medicaid,908.57,,,908.57,Other,140% of Medicaid,1460.2,,,1460.2,Other,225% of Medicaid,1687.34,,,1687.34,Other,260% of Medicaid,2102.69,,,2102.69,Other,324% of Medicaid,1395.3,,,1395.3,Other,215% of Medicaid,1395.3,,,1395.3,Other,215% of Medicaid,811.22,,,811.22,Other,125% of Medicaid,482.33,7216,
INJ TENDON SHEATH/LIGAMENT,20550,CPT,,47020550,CDM,361,RC,,,both,,,950,703,,,703,Other,150% of Medicare + 9.63% HCRA Surcharge,427.5,45,,427.5,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",470.25,,,470.25,Other,110% of Medicare,646,,,646,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",685.67,,,685.67,Other,186% of Medicaid,760,,,760,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",760,,,760,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",760,,,760,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",665,70,,665,percent of total billed charges,All Other,188.6,,,188.6,Fee Schedule,,159.85,,,159.85,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",368.64,,,368.64,Other,100% of Medicaid,368.64,,,368.64,Other,100% of Medicaid,368.64,,,368.64,Other,100% of Medicaid,368.64,,,368.64,Other,100% of Medicaid,829.44,,,829.44,Other,225% of Medicaid,564.02,,,564.02,Other,153% of Medicaid,829.44,,,829.44,Other,225% of Medicaid,516.1,,,516.1,Other,140% of Medicaid,829.44,,,829.44,Other,225% of Medicaid,958.46,,,958.46,Other,260% of Medicaid,1194.39,,,1194.39,Other,324% of Medicaid,792.58,,,792.58,Other,215% of Medicaid,792.58,,,792.58,Other,215% of Medicaid,460.8,,,460.8,Other,125% of Medicaid,159.85,7216,
ASPIRATE/INJECT MAJOR JOINT,20610,CPT,,47020610,CDM,361,RC,,,both,,,1017,752.58,,,752.58,Other,150% of Medicare + 9.63% HCRA Surcharge,457.65,45,,457.65,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",503.42,,,503.42,Other,110% of Medicare,691.56,,,691.56,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",685.67,,,685.67,Other,186% of Medicaid,813.6,,,813.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",813.6,,,813.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",813.6,,,813.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",711.9,70,,711.9,percent of total billed charges,All Other,218.12,,,218.12,Fee Schedule,,184.87,,,184.87,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",368.64,,,368.64,Other,100% of Medicaid,368.64,,,368.64,Other,100% of Medicaid,368.64,,,368.64,Other,100% of Medicaid,368.64,,,368.64,Other,100% of Medicaid,829.44,,,829.44,Other,225% of Medicaid,564.02,,,564.02,Other,153% of Medicaid,829.44,,,829.44,Other,225% of Medicaid,516.1,,,516.1,Other,140% of Medicaid,829.44,,,829.44,Other,225% of Medicaid,958.46,,,958.46,Other,260% of Medicaid,1194.39,,,1194.39,Other,324% of Medicaid,792.58,,,792.58,Other,215% of Medicaid,792.58,,,792.58,Other,215% of Medicaid,460.8,,,460.8,Other,125% of Medicaid,184.87,7216,
INJECT SACROILIAC JOINT,27096,CPT,,47027096,CDM,361,RC,,,both,,,338,250.12,,,250.12,Other,150% of Medicare + 9.63% HCRA Surcharge,152.1,45,,152.1,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",167.31,,,167.31,Other,110% of Medicare,229.84,,,229.84,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",816.14,,,816.14,Other,186% of Medicaid,270.4,,,270.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",270.4,,,270.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",270.4,,,270.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",236.6,70,,236.6,percent of total billed charges,All Other,395.24,,,395.24,Fee Schedule,,334.99,,,334.99,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",438.79,,,438.79,Other,100% of Medicaid,438.79,,,438.79,Other,100% of Medicaid,438.79,,,438.79,Other,100% of Medicaid,438.79,,,438.79,Other,100% of Medicaid,987.27,,,987.27,Other,225% of Medicaid,671.34,,,671.34,Other,153% of Medicaid,987.27,,,987.27,Other,225% of Medicaid,614.3,,,614.3,Other,140% of Medicaid,987.27,,,987.27,Other,225% of Medicaid,1140.85,,,1140.85,Other,260% of Medicaid,1421.67,,,1421.67,Other,324% of Medicaid,943.39,,,943.39,Other,215% of Medicaid,943.39,,,943.39,Other,215% of Medicaid,548.48,,,548.48,Other,125% of Medicaid,152.1,7216,
REPLACE DUOD JEJ TUBE PERC,49451,CPT,,47049451,CDM,361,RC,,,both,,,4863,3598.63,,,3598.63,Other,150% of Medicare + 9.63% HCRA Surcharge,2188.35,45,,2188.35,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2407.19,,,2407.19,Other,110% of Medicare,3306.84,,,3306.84,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1030.37,,,1030.37,Other,186% of Medicaid,3890.4,,,3890.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",3890.4,,,3890.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",3890.4,,,3890.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",3404.1,70,,3404.1,percent of total billed charges,All Other,424.76,,,424.76,Fee Schedule,,360.01,,,360.01,Fee Schedule,,4055,,,4055,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3649,,,3649,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4055,,,4055,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3448,,,3448,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",553.96,,,553.96,Other,100% of Medicaid,553.96,,,553.96,Other,100% of Medicaid,553.96,,,553.96,Other,100% of Medicaid,553.96,,,553.96,Other,100% of Medicaid,1246.41,,,1246.41,Other,225% of Medicaid,847.56,,,847.56,Other,153% of Medicaid,1246.41,,,1246.41,Other,225% of Medicaid,775.55,,,775.55,Other,140% of Medicaid,1246.41,,,1246.41,Other,225% of Medicaid,1440.3,,,1440.3,Other,260% of Medicaid,1794.83,,,1794.83,Other,324% of Medicaid,1191.02,,,1191.02,Other,215% of Medicaid,1191.02,,,1191.02,Other,215% of Medicaid,692.45,,,692.45,Other,125% of Medicaid,360.01,7216,
INTERDISCAL PERQ ASPIR DX,62267,CPT,,47062267,CDM,361,RC,,,both,,,3395,2512.31,,,2512.31,Other,150% of Medicare + 9.63% HCRA Surcharge,1527.75,45,,1527.75,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",1680.53,,,1680.53,Other,110% of Medicare,2308.6,,,2308.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1116.35,,,1116.35,Other,186% of Medicaid,2716,,,2716,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2716,,,2716,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2716,,,2716,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2376.5,70,,2376.5,percent of total billed charges,All Other,738,,,738,Fee Schedule,,625.5,,,625.5,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",600.19,,,600.19,Other,100% of Medicaid,600.19,,,600.19,Other,100% of Medicaid,600.19,,,600.19,Other,100% of Medicaid,600.19,,,600.19,Other,100% of Medicaid,1350.43,,,1350.43,Other,225% of Medicaid,918.29,,,918.29,Other,153% of Medicaid,1350.43,,,1350.43,Other,225% of Medicaid,840.26,,,840.26,Other,140% of Medicaid,1350.43,,,1350.43,Other,225% of Medicaid,1560.49,,,1560.49,Other,260% of Medicaid,1944.61,,,1944.61,Other,324% of Medicaid,1290.41,,,1290.41,Other,215% of Medicaid,1290.41,,,1290.41,Other,215% of Medicaid,750.24,,,750.24,Other,125% of Medicaid,600.19,7216,
LUMBAR PUNCTURE,62270,CPT,,47062270,CDM,361,RC,,,both,,,1479,1094.46,,,1094.46,Other,150% of Medicare + 9.63% HCRA Surcharge,665.55,45,,665.55,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",732.11,,,732.11,Other,110% of Medicare,1005.72,,,1005.72,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1116.35,,,1116.35,Other,186% of Medicaid,1183.2,,,1183.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1183.2,,,1183.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",3578,,,3578,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1035.3,70,,1035.3,percent of total billed charges,All Other,298.48,,,298.48,Fee Schedule,,252.98,,,252.98,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",600.19,,,600.19,Other,100% of Medicaid,600.19,,,600.19,Other,100% of Medicaid,600.19,,,600.19,Other,100% of Medicaid,600.19,,,600.19,Other,100% of Medicaid,1350.43,,,1350.43,Other,225% of Medicaid,918.29,,,918.29,Other,153% of Medicaid,1350.43,,,1350.43,Other,225% of Medicaid,840.26,,,840.26,Other,140% of Medicaid,1350.43,,,1350.43,Other,225% of Medicaid,1560.49,,,1560.49,Other,260% of Medicaid,1944.61,,,1944.61,Other,324% of Medicaid,1290.41,,,1290.41,Other,215% of Medicaid,1290.41,,,1290.41,Other,215% of Medicaid,750.24,,,750.24,Other,125% of Medicaid,252.98,7216,
DESTROY CERV/THOR FACET JNT,64633,CPT,,47064633,CDM,361,RC,,,both,,,4047,2994.79,,,2994.79,Other,150% of Medicare + 9.63% HCRA Surcharge,1821.15,45,,1821.15,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3648,,,3648,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3283,,,3283,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3101,,,3101,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2003.27,,,2003.27,Other,110% of Medicare,2751.96,,,2751.96,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1119.84,,,1119.84,Other,186% of Medicaid,3237.6,,,3237.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",3237.6,,,3237.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",3237.6,,,3237.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2832.9,70,,2832.9,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",4531,,,4531,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4079,,,4079,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4531,,,4531,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3852,,,3852,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",602.07,,,602.07,Other,100% of Medicaid,602.07,,,602.07,Other,100% of Medicaid,602.07,,,602.07,Other,100% of Medicaid,602.07,,,602.07,Other,100% of Medicaid,1354.65,,,1354.65,Other,225% of Medicaid,921.16,,,921.16,Other,153% of Medicaid,1354.65,,,1354.65,Other,225% of Medicaid,842.89,,,842.89,Other,140% of Medicaid,1354.65,,,1354.65,Other,225% of Medicaid,1565.37,,,1565.37,Other,260% of Medicaid,1950.69,,,1950.69,Other,324% of Medicaid,1294.44,,,1294.44,Other,215% of Medicaid,1294.44,,,1294.44,Other,215% of Medicaid,752.58,,,752.58,Other,125% of Medicaid,602.07,7216,
DESTROY CERV/THOR FACET JNT ADDL,64634,CPT,,47064634,CDM,361,RC,,,both,,,721,533.54,,,533.54,Other,150% of Medicare + 9.63% HCRA Surcharge,324.45,45,,324.45,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",356.9,,,356.9,Other,110% of Medicare,490.28,,,490.28,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",966.11,,,966.11,Other,186% of Medicaid,576.8,,,576.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",576.8,,,576.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",576.8,,,576.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",504.7,70,,504.7,percent of total billed charges,All Other,321.44,,,321.44,Fee Schedule,,272.44,,,272.44,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",519.42,,,519.42,Other,100% of Medicaid,519.42,,,519.42,Other,100% of Medicaid,519.42,,,519.42,Other,100% of Medicaid,519.42,,,519.42,Other,100% of Medicaid,1168.69,,,1168.69,Other,225% of Medicaid,794.71,,,794.71,Other,153% of Medicaid,1168.69,,,1168.69,Other,225% of Medicaid,727.18,,,727.18,Other,140% of Medicaid,1168.69,,,1168.69,Other,225% of Medicaid,1350.48,,,1350.48,Other,260% of Medicaid,1682.91,,,1682.91,Other,324% of Medicaid,1116.74,,,1116.74,Other,215% of Medicaid,1116.74,,,1116.74,Other,215% of Medicaid,649.27,,,649.27,Other,125% of Medicaid,272.44,7216,
DESTROY LUMB/SAC FACET JNT,64635,CPT,,47064635,CDM,361,RC,,,both,,,4047,2994.79,,,2994.79,Other,150% of Medicare + 9.63% HCRA Surcharge,1821.15,45,,1821.15,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3648,,,3648,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3283,,,3283,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3101,,,3101,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2003.27,,,2003.27,Other,110% of Medicare,2751.96,,,2751.96,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1119.84,,,1119.84,Other,186% of Medicaid,3237.6,,,3237.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",3237.6,,,3237.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",3237.6,,,3237.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2832.9,70,,2832.9,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",4531,,,4531,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4079,,,4079,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4531,,,4531,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3852,,,3852,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",602.07,,,602.07,Other,100% of Medicaid,602.07,,,602.07,Other,100% of Medicaid,602.07,,,602.07,Other,100% of Medicaid,602.07,,,602.07,Other,100% of Medicaid,1354.65,,,1354.65,Other,225% of Medicaid,921.16,,,921.16,Other,153% of Medicaid,1354.65,,,1354.65,Other,225% of Medicaid,842.89,,,842.89,Other,140% of Medicaid,1354.65,,,1354.65,Other,225% of Medicaid,1565.37,,,1565.37,Other,260% of Medicaid,1950.69,,,1950.69,Other,324% of Medicaid,1294.44,,,1294.44,Other,215% of Medicaid,1294.44,,,1294.44,Other,215% of Medicaid,752.58,,,752.58,Other,125% of Medicaid,602.07,7216,
DESTROY LUMB/SAC FACET JNT ADDL,64636,CPT,,47064636,CDM,361,RC,,,both,,,2232,1651.69,,,1651.69,Other,150% of Medicare + 9.63% HCRA Surcharge,1004.4,45,,1004.4,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",1104.84,,,1104.84,Other,110% of Medicare,1517.76,,,1517.76,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1119.84,,,1119.84,Other,186% of Medicaid,1785.6,,,1785.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1785.6,,,1785.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1785.6,,,1785.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1562.4,70,,1562.4,percent of total billed charges,All Other,283.72,,,283.72,Fee Schedule,,240.47,,,240.47,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",602.07,,,602.07,Other,100% of Medicaid,602.07,,,602.07,Other,100% of Medicaid,602.07,,,602.07,Other,100% of Medicaid,602.07,,,602.07,Other,100% of Medicaid,1354.65,,,1354.65,Other,225% of Medicaid,921.16,,,921.16,Other,153% of Medicaid,1354.65,,,1354.65,Other,225% of Medicaid,842.89,,,842.89,Other,140% of Medicaid,1354.65,,,1354.65,Other,225% of Medicaid,1565.37,,,1565.37,Other,260% of Medicaid,1950.69,,,1950.69,Other,324% of Medicaid,1294.44,,,1294.44,Other,215% of Medicaid,1294.44,,,1294.44,Other,215% of Medicaid,752.58,,,752.58,Other,125% of Medicaid,240.47,7216,
LUMBAR PUNCTURE INCOMPLETE AFTER ANES,62270,CPT,74,47162270,CDM,361,RC,,,both,,,1184,876.16,,,876.16,Other,150% of Medicare + 9.63% HCRA Surcharge,532.8,45,,532.8,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",586.08,,,586.08,Other,110% of Medicare,805.12,,,805.12,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1116.35,,,1116.35,Other,186% of Medicaid,947.2,,,947.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",947.2,,,947.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",3578,,,3578,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",828.8,70,,828.8,percent of total billed charges,All Other,298.48,,,298.48,Fee Schedule,,252.98,,,252.98,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",600.19,,,600.19,Other,100% of Medicaid,600.19,,,600.19,Other,100% of Medicaid,600.19,,,600.19,Other,100% of Medicaid,600.19,,,600.19,Other,100% of Medicaid,1350.43,,,1350.43,Other,225% of Medicaid,918.29,,,918.29,Other,153% of Medicaid,1350.43,,,1350.43,Other,225% of Medicaid,840.26,,,840.26,Other,140% of Medicaid,1350.43,,,1350.43,Other,225% of Medicaid,1560.49,,,1560.49,Other,260% of Medicaid,1944.61,,,1944.61,Other,324% of Medicaid,1290.41,,,1290.41,Other,215% of Medicaid,1290.41,,,1290.41,Other,215% of Medicaid,750.24,,,750.24,Other,125% of Medicaid,252.98,7216,
BREAST CYST ASPIRATE,19000,CPT,,54019000,CDM,361,RC,,,both,,,1462,1081.88,,,1081.88,Other,150% of Medicare + 9.63% HCRA Surcharge,657.9,45,,657.9,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",723.69,,,723.69,Other,110% of Medicare,994.16,,,994.16,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1037.55,,,1037.55,Other,186% of Medicaid,1169.6,,,1169.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1169.6,,,1169.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1169.6,,,1169.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1023.4,70,,1023.4,percent of total billed charges,All Other,205,,,205,Fee Schedule,,173.75,,,173.75,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",557.82,,,557.82,Other,100% of Medicaid,557.82,,,557.82,Other,100% of Medicaid,557.82,,,557.82,Other,100% of Medicaid,557.82,,,557.82,Other,100% of Medicaid,1255.1,,,1255.1,Other,225% of Medicaid,853.47,,,853.47,Other,153% of Medicaid,1255.1,,,1255.1,Other,225% of Medicaid,780.95,,,780.95,Other,140% of Medicaid,1255.1,,,1255.1,Other,225% of Medicaid,1450.34,,,1450.34,Other,260% of Medicaid,1807.35,,,1807.35,Other,324% of Medicaid,1199.32,,,1199.32,Other,215% of Medicaid,1199.32,,,1199.32,Other,215% of Medicaid,697.28,,,697.28,Other,125% of Medicaid,173.75,7216,
BX BREAST 1ST LESION STRTCTC,19081,CPT,,54019081,CDM,361,RC,,,both,,,3377,2498.99,,,2498.99,Other,150% of Medicare + 9.63% HCRA Surcharge,1519.65,45,,1519.65,percent of total billed charges,Critical Access Hospital RCC factor,2480,,,2480,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2232,,,2232,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3648,,,3648,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3283,,,3283,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3101,,,3101,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",1671.62,,,1671.62,Other,110% of Medicare,2296.36,,,2296.36,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2793.39,,,2793.39,Other,186% of Medicaid,2701.6,,,2701.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2701.6,,,2701.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2701.6,,,2701.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2363.9,70,,2363.9,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",4055,,,4055,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3649,,,3649,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4055,,,4055,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3448,,,3448,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",1501.82,,,1501.82,Other,100% of Medicaid,1501.82,,,1501.82,Other,100% of Medicaid,1501.82,,,1501.82,Other,100% of Medicaid,1501.82,,,1501.82,Other,100% of Medicaid,3379.1,,,3379.1,Other,225% of Medicaid,2297.79,,,2297.79,Other,153% of Medicaid,3379.1,,,3379.1,Other,225% of Medicaid,2102.55,,,2102.55,Other,140% of Medicaid,3379.1,,,3379.1,Other,225% of Medicaid,3904.73,,,3904.73,Other,260% of Medicaid,4865.9,,,4865.9,Other,324% of Medicaid,3228.91,,,3228.91,Other,215% of Medicaid,3228.91,,,3228.91,Other,215% of Medicaid,1877.28,,,1877.28,Other,125% of Medicaid,1501.82,7216,
BX BREAST ADD LESION STRTCTC,19082,CPT,,54019082,CDM,361,RC,,,both,,,272,201.28,,,201.28,Other,150% of Medicare + 9.63% HCRA Surcharge,122.4,45,,122.4,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3648,,,3648,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3283,,,3283,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3101,,,3101,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",134.64,,,134.64,Other,110% of Medicare,184.96,,,184.96,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2793.39,,,2793.39,Other,186% of Medicaid,217.6,,,217.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",217.6,,,217.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",217.6,,,217.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",190.4,70,,190.4,percent of total billed charges,All Other,396.88,,,396.88,Fee Schedule,,336.38,,,336.38,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",1501.82,,,1501.82,Other,100% of Medicaid,1501.82,,,1501.82,Other,100% of Medicaid,1501.82,,,1501.82,Other,100% of Medicaid,1501.82,,,1501.82,Other,100% of Medicaid,3379.1,,,3379.1,Other,225% of Medicaid,2297.79,,,2297.79,Other,153% of Medicaid,3379.1,,,3379.1,Other,225% of Medicaid,2102.55,,,2102.55,Other,140% of Medicaid,3379.1,,,3379.1,Other,225% of Medicaid,3904.73,,,3904.73,Other,260% of Medicaid,4865.9,,,4865.9,Other,324% of Medicaid,3228.91,,,3228.91,Other,215% of Medicaid,3228.91,,,3228.91,Other,215% of Medicaid,1877.28,,,1877.28,Other,125% of Medicaid,122.4,7216,
BX BREAST 1ST LESION US IMAG,19083,CPT,,54019083,CDM,361,RC,,,both,,,3377,2498.99,,,2498.99,Other,150% of Medicare + 9.63% HCRA Surcharge,1519.65,45,,1519.65,percent of total billed charges,Critical Access Hospital RCC factor,2480,,,2480,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2232,,,2232,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3648,,,3648,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3283,,,3283,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3101,,,3101,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",1671.62,,,1671.62,Other,110% of Medicare,2296.36,,,2296.36,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2793.39,,,2793.39,Other,186% of Medicaid,2701.6,,,2701.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2701.6,,,2701.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2701.6,,,2701.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2363.9,70,,2363.9,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",4055,,,4055,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3649,,,3649,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4055,,,4055,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3448,,,3448,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",1501.82,,,1501.82,Other,100% of Medicaid,1501.82,,,1501.82,Other,100% of Medicaid,1501.82,,,1501.82,Other,100% of Medicaid,1501.82,,,1501.82,Other,100% of Medicaid,3379.1,,,3379.1,Other,225% of Medicaid,2297.79,,,2297.79,Other,153% of Medicaid,3379.1,,,3379.1,Other,225% of Medicaid,2102.55,,,2102.55,Other,140% of Medicaid,3379.1,,,3379.1,Other,225% of Medicaid,3904.73,,,3904.73,Other,260% of Medicaid,4865.9,,,4865.9,Other,324% of Medicaid,3228.91,,,3228.91,Other,215% of Medicaid,3228.91,,,3228.91,Other,215% of Medicaid,1877.28,,,1877.28,Other,125% of Medicaid,1501.82,7216,
BX BREAST ADD LESION US IMAG,19084,CPT,,54019084,CDM,361,RC,,,both,,,273,202.02,,,202.02,Other,150% of Medicare + 9.63% HCRA Surcharge,122.85,45,,122.85,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3648,,,3648,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3283,,,3283,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3101,,,3101,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",135.14,,,135.14,Other,110% of Medicare,185.64,,,185.64,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2793.39,,,2793.39,Other,186% of Medicaid,218.4,,,218.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",218.4,,,218.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",218.4,,,218.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",191.1,70,,191.1,percent of total billed charges,All Other,369,,,369,Fee Schedule,,312.75,,,312.75,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",1501.82,,,1501.82,Other,100% of Medicaid,1501.82,,,1501.82,Other,100% of Medicaid,1501.82,,,1501.82,Other,100% of Medicaid,1501.82,,,1501.82,Other,100% of Medicaid,3379.1,,,3379.1,Other,225% of Medicaid,2297.79,,,2297.79,Other,153% of Medicaid,3379.1,,,3379.1,Other,225% of Medicaid,2102.55,,,2102.55,Other,140% of Medicaid,3379.1,,,3379.1,Other,225% of Medicaid,3904.73,,,3904.73,Other,260% of Medicaid,4865.9,,,4865.9,Other,324% of Medicaid,3228.91,,,3228.91,Other,215% of Medicaid,3228.91,,,3228.91,Other,215% of Medicaid,1877.28,,,1877.28,Other,125% of Medicaid,122.85,7216,
BX BREAST 1ST LESION MR IMAG,19085,CPT,,54019085,CDM,361,RC,,,both,,,4409,3262.67,,,3262.67,Other,150% of Medicare + 9.63% HCRA Surcharge,1984.05,45,,1984.05,percent of total billed charges,Critical Access Hospital RCC factor,3473,,,3473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3126,,,3126,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3648,,,3648,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3283,,,3283,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3101,,,3101,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2182.46,,,2182.46,Other,110% of Medicare,6152,,,6152,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2793.39,,,2793.39,Other,186% of Medicaid,7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",3527.2,,,3527.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",3086.3,70,,3086.3,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",4055,,,4055,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3649,,,3649,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4055,,,4055,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3448,,,3448,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",1501.82,,,1501.82,Other,100% of Medicaid,1501.82,,,1501.82,Other,100% of Medicaid,1501.82,,,1501.82,Other,100% of Medicaid,1501.82,,,1501.82,Other,100% of Medicaid,3379.1,,,3379.1,Other,225% of Medicaid,2297.79,,,2297.79,Other,153% of Medicaid,3379.1,,,3379.1,Other,225% of Medicaid,2102.55,,,2102.55,Other,140% of Medicaid,3379.1,,,3379.1,Other,225% of Medicaid,3904.73,,,3904.73,Other,260% of Medicaid,4865.9,,,4865.9,Other,324% of Medicaid,3228.91,,,3228.91,Other,215% of Medicaid,3228.91,,,3228.91,Other,215% of Medicaid,1877.28,,,1877.28,Other,125% of Medicaid,1501.82,9473,
BX BREAST ADD LESION MR IMAG,19086,CPT,,54019086,CDM,361,RC,,,both,,,1763,1304.62,,,1304.62,Other,150% of Medicare + 9.63% HCRA Surcharge,793.35,45,,793.35,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3648,,,3648,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3283,,,3283,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3101,,,3101,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",872.69,,,872.69,Other,110% of Medicare,1198.84,,,1198.84,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2793.39,,,2793.39,Other,186% of Medicaid,1410.4,,,1410.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1410.4,,,1410.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1410.4,,,1410.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1234.1,70,,1234.1,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",1501.82,,,1501.82,Other,100% of Medicaid,1501.82,,,1501.82,Other,100% of Medicaid,1501.82,,,1501.82,Other,100% of Medicaid,1501.82,,,1501.82,Other,100% of Medicaid,3379.1,,,3379.1,Other,225% of Medicaid,2297.79,,,2297.79,Other,153% of Medicaid,3379.1,,,3379.1,Other,225% of Medicaid,2102.55,,,2102.55,Other,140% of Medicaid,3379.1,,,3379.1,Other,225% of Medicaid,3904.73,,,3904.73,Other,260% of Medicaid,4865.9,,,4865.9,Other,324% of Medicaid,3228.91,,,3228.91,Other,215% of Medicaid,3228.91,,,3228.91,Other,215% of Medicaid,1877.28,,,1877.28,Other,125% of Medicaid,793.35,7216,
PERQ DEVICE BREAST 1ST IMAG,19281,CPT,,54019281,CDM,361,RC,,,both,,,3377,2498.99,,,2498.99,Other,150% of Medicare + 9.63% HCRA Surcharge,1519.65,45,,1519.65,percent of total billed charges,Critical Access Hospital RCC factor,2480,,,2480,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2232,,,2232,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",1671.62,,,1671.62,Other,110% of Medicare,2296.36,,,2296.36,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2793.39,,,2793.39,Other,186% of Medicaid,2701.6,,,2701.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2701.6,,,2701.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2701.6,,,2701.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2363.9,70,,2363.9,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",4055,,,4055,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3649,,,3649,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4055,,,4055,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3448,,,3448,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",1501.82,,,1501.82,Other,100% of Medicaid,1501.82,,,1501.82,Other,100% of Medicaid,1501.82,,,1501.82,Other,100% of Medicaid,1501.82,,,1501.82,Other,100% of Medicaid,3379.1,,,3379.1,Other,225% of Medicaid,2297.79,,,2297.79,Other,153% of Medicaid,3379.1,,,3379.1,Other,225% of Medicaid,2102.55,,,2102.55,Other,140% of Medicaid,3379.1,,,3379.1,Other,225% of Medicaid,3904.73,,,3904.73,Other,260% of Medicaid,4865.9,,,4865.9,Other,324% of Medicaid,3228.91,,,3228.91,Other,215% of Medicaid,3228.91,,,3228.91,Other,215% of Medicaid,1877.28,,,1877.28,Other,125% of Medicaid,1501.82,7216,
PERQ DEVICE BREAST EA IMAG,19282,CPT,,54019282,CDM,361,RC,,,both,,,150,111,,,111,Other,150% of Medicare + 9.63% HCRA Surcharge,67.5,45,,67.5,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",74.25,,,74.25,Other,110% of Medicare,102,,,102,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2793.39,,,2793.39,Other,186% of Medicaid,120,,,120,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",120,,,120,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",120,,,120,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",105,70,,105,percent of total billed charges,All Other,237.8,,,237.8,Fee Schedule,,201.55,,,201.55,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",1501.82,,,1501.82,Other,100% of Medicaid,1501.82,,,1501.82,Other,100% of Medicaid,1501.82,,,1501.82,Other,100% of Medicaid,1501.82,,,1501.82,Other,100% of Medicaid,3379.1,,,3379.1,Other,225% of Medicaid,2297.79,,,2297.79,Other,153% of Medicaid,3379.1,,,3379.1,Other,225% of Medicaid,2102.55,,,2102.55,Other,140% of Medicaid,3379.1,,,3379.1,Other,225% of Medicaid,3904.73,,,3904.73,Other,260% of Medicaid,4865.9,,,4865.9,Other,324% of Medicaid,3228.91,,,3228.91,Other,215% of Medicaid,3228.91,,,3228.91,Other,215% of Medicaid,1877.28,,,1877.28,Other,125% of Medicaid,67.5,7216,
PERQ DEV BREAST 1ST STRTCTC,19283,CPT,,54019283,CDM,361,RC,,,both,,,1462,1081.88,,,1081.88,Other,150% of Medicare + 9.63% HCRA Surcharge,657.9,45,,657.9,percent of total billed charges,Critical Access Hospital RCC factor,2480,,,2480,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2232,,,2232,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",723.69,,,723.69,Other,110% of Medicare,994.16,,,994.16,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2793.39,,,2793.39,Other,186% of Medicaid,1169.6,,,1169.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1169.6,,,1169.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1169.6,,,1169.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1023.4,70,,1023.4,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",1501.82,,,1501.82,Other,100% of Medicaid,1501.82,,,1501.82,Other,100% of Medicaid,1501.82,,,1501.82,Other,100% of Medicaid,1501.82,,,1501.82,Other,100% of Medicaid,3379.1,,,3379.1,Other,225% of Medicaid,2297.79,,,2297.79,Other,153% of Medicaid,3379.1,,,3379.1,Other,225% of Medicaid,2102.55,,,2102.55,Other,140% of Medicaid,3379.1,,,3379.1,Other,225% of Medicaid,3904.73,,,3904.73,Other,260% of Medicaid,4865.9,,,4865.9,Other,324% of Medicaid,3228.91,,,3228.91,Other,215% of Medicaid,3228.91,,,3228.91,Other,215% of Medicaid,1877.28,,,1877.28,Other,125% of Medicaid,657.9,7216,
PERQ DEV BREAST ADD STRTCTC,19284,CPT,,54019284,CDM,361,RC,,,both,,,151,111.74,,,111.74,Other,150% of Medicare + 9.63% HCRA Surcharge,67.95,45,,67.95,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",74.75,,,74.75,Other,110% of Medicare,102.68,,,102.68,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2793.39,,,2793.39,Other,186% of Medicaid,120.8,,,120.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",120.8,,,120.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",120.8,,,120.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",105.7,70,,105.7,percent of total billed charges,All Other,241.08,,,241.08,Fee Schedule,,204.33,,,204.33,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",1501.82,,,1501.82,Other,100% of Medicaid,1501.82,,,1501.82,Other,100% of Medicaid,1501.82,,,1501.82,Other,100% of Medicaid,1501.82,,,1501.82,Other,100% of Medicaid,3379.1,,,3379.1,Other,225% of Medicaid,2297.79,,,2297.79,Other,153% of Medicaid,3379.1,,,3379.1,Other,225% of Medicaid,2102.55,,,2102.55,Other,140% of Medicaid,3379.1,,,3379.1,Other,225% of Medicaid,3904.73,,,3904.73,Other,260% of Medicaid,4865.9,,,4865.9,Other,324% of Medicaid,3228.91,,,3228.91,Other,215% of Medicaid,3228.91,,,3228.91,Other,215% of Medicaid,1877.28,,,1877.28,Other,125% of Medicaid,67.95,7216,
PERQ DEV BREAST 1ST US IMAG,19285,CPT,,54019285,CDM,361,RC,,,both,,,1462,1081.88,,,1081.88,Other,150% of Medicare + 9.63% HCRA Surcharge,657.9,45,,657.9,percent of total billed charges,Critical Access Hospital RCC factor,2480,,,2480,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2232,,,2232,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",723.69,,,723.69,Other,110% of Medicare,994.16,,,994.16,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2793.39,,,2793.39,Other,186% of Medicaid,1169.6,,,1169.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1169.6,,,1169.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1169.6,,,1169.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1023.4,70,,1023.4,percent of total billed charges,All Other,406.72,,,406.72,Fee Schedule,,344.72,,,344.72,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",1501.82,,,1501.82,Other,100% of Medicaid,1501.82,,,1501.82,Other,100% of Medicaid,1501.82,,,1501.82,Other,100% of Medicaid,1501.82,,,1501.82,Other,100% of Medicaid,3379.1,,,3379.1,Other,225% of Medicaid,2297.79,,,2297.79,Other,153% of Medicaid,3379.1,,,3379.1,Other,225% of Medicaid,2102.55,,,2102.55,Other,140% of Medicaid,3379.1,,,3379.1,Other,225% of Medicaid,3904.73,,,3904.73,Other,260% of Medicaid,4865.9,,,4865.9,Other,324% of Medicaid,3228.91,,,3228.91,Other,215% of Medicaid,3228.91,,,3228.91,Other,215% of Medicaid,1877.28,,,1877.28,Other,125% of Medicaid,344.72,7216,
PERQ DEV BREAST ADD US IMAG,19286,CPT,,54019286,CDM,361,RC,,,both,,,129,95.46,,,95.46,Other,150% of Medicare + 9.63% HCRA Surcharge,58.05,45,,58.05,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",63.86,,,63.86,Other,110% of Medicare,87.72,,,87.72,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2793.39,,,2793.39,Other,186% of Medicaid,103.2,,,103.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",103.2,,,103.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",103.2,,,103.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",90.3,70,,90.3,percent of total billed charges,All Other,205,,,205,Fee Schedule,,173.75,,,173.75,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",1501.82,,,1501.82,Other,100% of Medicaid,1501.82,,,1501.82,Other,100% of Medicaid,1501.82,,,1501.82,Other,100% of Medicaid,1501.82,,,1501.82,Other,100% of Medicaid,3379.1,,,3379.1,Other,225% of Medicaid,2297.79,,,2297.79,Other,153% of Medicaid,3379.1,,,3379.1,Other,225% of Medicaid,2102.55,,,2102.55,Other,140% of Medicaid,3379.1,,,3379.1,Other,225% of Medicaid,3904.73,,,3904.73,Other,260% of Medicaid,4865.9,,,4865.9,Other,324% of Medicaid,3228.91,,,3228.91,Other,215% of Medicaid,3228.91,,,3228.91,Other,215% of Medicaid,1877.28,,,1877.28,Other,125% of Medicaid,58.05,7216,
BX BREAST 1ST LESION STRTCTC LT,19081,CPT,LT,54119081,CDM,361,RC,,,both,,,3377,2498.99,,,2498.99,Other,150% of Medicare + 9.63% HCRA Surcharge,1519.65,45,,1519.65,percent of total billed charges,Critical Access Hospital RCC factor,2480,,,2480,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2232,,,2232,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3648,,,3648,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3283,,,3283,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3101,,,3101,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",1671.62,,,1671.62,Other,110% of Medicare,2296.36,,,2296.36,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2793.39,,,2793.39,Other,186% of Medicaid,2701.6,,,2701.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2701.6,,,2701.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2701.6,,,2701.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2363.9,70,,2363.9,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",4055,,,4055,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3649,,,3649,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4055,,,4055,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3448,,,3448,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",1501.82,,,1501.82,Other,100% of Medicaid,1501.82,,,1501.82,Other,100% of Medicaid,1501.82,,,1501.82,Other,100% of Medicaid,1501.82,,,1501.82,Other,100% of Medicaid,3379.1,,,3379.1,Other,225% of Medicaid,2297.79,,,2297.79,Other,153% of Medicaid,3379.1,,,3379.1,Other,225% of Medicaid,2102.55,,,2102.55,Other,140% of Medicaid,3379.1,,,3379.1,Other,225% of Medicaid,3904.73,,,3904.73,Other,260% of Medicaid,4865.9,,,4865.9,Other,324% of Medicaid,3228.91,,,3228.91,Other,215% of Medicaid,3228.91,,,3228.91,Other,215% of Medicaid,1877.28,,,1877.28,Other,125% of Medicaid,1501.82,7216,
BX BREAST ADD LESION STRTCTC LT,19082,CPT,LT,54119082,CDM,361,RC,,,both,,,272,201.28,,,201.28,Other,150% of Medicare + 9.63% HCRA Surcharge,122.4,45,,122.4,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3648,,,3648,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3283,,,3283,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3101,,,3101,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",134.64,,,134.64,Other,110% of Medicare,184.96,,,184.96,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2793.39,,,2793.39,Other,186% of Medicaid,217.6,,,217.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",217.6,,,217.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",217.6,,,217.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",190.4,70,,190.4,percent of total billed charges,All Other,396.88,,,396.88,Fee Schedule,,336.38,,,336.38,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",1501.82,,,1501.82,Other,100% of Medicaid,1501.82,,,1501.82,Other,100% of Medicaid,1501.82,,,1501.82,Other,100% of Medicaid,1501.82,,,1501.82,Other,100% of Medicaid,3379.1,,,3379.1,Other,225% of Medicaid,2297.79,,,2297.79,Other,153% of Medicaid,3379.1,,,3379.1,Other,225% of Medicaid,2102.55,,,2102.55,Other,140% of Medicaid,3379.1,,,3379.1,Other,225% of Medicaid,3904.73,,,3904.73,Other,260% of Medicaid,4865.9,,,4865.9,Other,324% of Medicaid,3228.91,,,3228.91,Other,215% of Medicaid,3228.91,,,3228.91,Other,215% of Medicaid,1877.28,,,1877.28,Other,125% of Medicaid,122.4,7216,
BX BREAST 1ST LESION US IMAG LT,19083,CPT,LT,54119083,CDM,361,RC,,,both,,,3377,2498.99,,,2498.99,Other,150% of Medicare + 9.63% HCRA Surcharge,1519.65,45,,1519.65,percent of total billed charges,Critical Access Hospital RCC factor,2480,,,2480,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2232,,,2232,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3648,,,3648,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3283,,,3283,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3101,,,3101,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",1671.62,,,1671.62,Other,110% of Medicare,2296.36,,,2296.36,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2793.39,,,2793.39,Other,186% of Medicaid,2701.6,,,2701.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2701.6,,,2701.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2701.6,,,2701.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2363.9,70,,2363.9,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",4055,,,4055,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3649,,,3649,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4055,,,4055,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3448,,,3448,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",1501.82,,,1501.82,Other,100% of Medicaid,1501.82,,,1501.82,Other,100% of Medicaid,1501.82,,,1501.82,Other,100% of Medicaid,1501.82,,,1501.82,Other,100% of Medicaid,3379.1,,,3379.1,Other,225% of Medicaid,2297.79,,,2297.79,Other,153% of Medicaid,3379.1,,,3379.1,Other,225% of Medicaid,2102.55,,,2102.55,Other,140% of Medicaid,3379.1,,,3379.1,Other,225% of Medicaid,3904.73,,,3904.73,Other,260% of Medicaid,4865.9,,,4865.9,Other,324% of Medicaid,3228.91,,,3228.91,Other,215% of Medicaid,3228.91,,,3228.91,Other,215% of Medicaid,1877.28,,,1877.28,Other,125% of Medicaid,1501.82,7216,
BX BREAST ADD LESION US IMAG LT,19084,CPT,LT,54119084,CDM,361,RC,,,both,,,273,202.02,,,202.02,Other,150% of Medicare + 9.63% HCRA Surcharge,122.85,45,,122.85,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3648,,,3648,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3283,,,3283,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3101,,,3101,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",135.14,,,135.14,Other,110% of Medicare,185.64,,,185.64,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2793.39,,,2793.39,Other,186% of Medicaid,218.4,,,218.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",218.4,,,218.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",218.4,,,218.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",191.1,70,,191.1,percent of total billed charges,All Other,369,,,369,Fee Schedule,,312.75,,,312.75,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",1501.82,,,1501.82,Other,100% of Medicaid,1501.82,,,1501.82,Other,100% of Medicaid,1501.82,,,1501.82,Other,100% of Medicaid,1501.82,,,1501.82,Other,100% of Medicaid,3379.1,,,3379.1,Other,225% of Medicaid,2297.79,,,2297.79,Other,153% of Medicaid,3379.1,,,3379.1,Other,225% of Medicaid,2102.55,,,2102.55,Other,140% of Medicaid,3379.1,,,3379.1,Other,225% of Medicaid,3904.73,,,3904.73,Other,260% of Medicaid,4865.9,,,4865.9,Other,324% of Medicaid,3228.91,,,3228.91,Other,215% of Medicaid,3228.91,,,3228.91,Other,215% of Medicaid,1877.28,,,1877.28,Other,125% of Medicaid,122.85,7216,
PERQ DEVICE BREAST 1ST IMAG LT,19281,CPT,LT,54119281,CDM,361,RC,,,both,,,3377,2498.99,,,2498.99,Other,150% of Medicare + 9.63% HCRA Surcharge,1519.65,45,,1519.65,percent of total billed charges,Critical Access Hospital RCC factor,2480,,,2480,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2232,,,2232,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",1671.62,,,1671.62,Other,110% of Medicare,2296.36,,,2296.36,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2793.39,,,2793.39,Other,186% of Medicaid,2701.6,,,2701.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2701.6,,,2701.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2701.6,,,2701.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2363.9,70,,2363.9,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",4055,,,4055,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3649,,,3649,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4055,,,4055,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3448,,,3448,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",1501.82,,,1501.82,Other,100% of Medicaid,1501.82,,,1501.82,Other,100% of Medicaid,1501.82,,,1501.82,Other,100% of Medicaid,1501.82,,,1501.82,Other,100% of Medicaid,3379.1,,,3379.1,Other,225% of Medicaid,2297.79,,,2297.79,Other,153% of Medicaid,3379.1,,,3379.1,Other,225% of Medicaid,2102.55,,,2102.55,Other,140% of Medicaid,3379.1,,,3379.1,Other,225% of Medicaid,3904.73,,,3904.73,Other,260% of Medicaid,4865.9,,,4865.9,Other,324% of Medicaid,3228.91,,,3228.91,Other,215% of Medicaid,3228.91,,,3228.91,Other,215% of Medicaid,1877.28,,,1877.28,Other,125% of Medicaid,1501.82,7216,
PERQ DEVICE BREAST EA IMAG LT,19282,CPT,LT,54119282,CDM,361,RC,,,both,,,150,111,,,111,Other,150% of Medicare + 9.63% HCRA Surcharge,67.5,45,,67.5,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",74.25,,,74.25,Other,110% of Medicare,102,,,102,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2793.39,,,2793.39,Other,186% of Medicaid,120,,,120,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",120,,,120,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",120,,,120,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",105,70,,105,percent of total billed charges,All Other,237.8,,,237.8,Fee Schedule,,201.55,,,201.55,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",1501.82,,,1501.82,Other,100% of Medicaid,1501.82,,,1501.82,Other,100% of Medicaid,1501.82,,,1501.82,Other,100% of Medicaid,1501.82,,,1501.82,Other,100% of Medicaid,3379.1,,,3379.1,Other,225% of Medicaid,2297.79,,,2297.79,Other,153% of Medicaid,3379.1,,,3379.1,Other,225% of Medicaid,2102.55,,,2102.55,Other,140% of Medicaid,3379.1,,,3379.1,Other,225% of Medicaid,3904.73,,,3904.73,Other,260% of Medicaid,4865.9,,,4865.9,Other,324% of Medicaid,3228.91,,,3228.91,Other,215% of Medicaid,3228.91,,,3228.91,Other,215% of Medicaid,1877.28,,,1877.28,Other,125% of Medicaid,67.5,7216,
PERQ DEV BREAST 1ST STRTCTC LT,19283,CPT,LT,54119283,CDM,361,RC,,,both,,,1462,1081.88,,,1081.88,Other,150% of Medicare + 9.63% HCRA Surcharge,657.9,45,,657.9,percent of total billed charges,Critical Access Hospital RCC factor,2480,,,2480,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2232,,,2232,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",723.69,,,723.69,Other,110% of Medicare,994.16,,,994.16,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2793.39,,,2793.39,Other,186% of Medicaid,1169.6,,,1169.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1169.6,,,1169.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1169.6,,,1169.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1023.4,70,,1023.4,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",1501.82,,,1501.82,Other,100% of Medicaid,1501.82,,,1501.82,Other,100% of Medicaid,1501.82,,,1501.82,Other,100% of Medicaid,1501.82,,,1501.82,Other,100% of Medicaid,3379.1,,,3379.1,Other,225% of Medicaid,2297.79,,,2297.79,Other,153% of Medicaid,3379.1,,,3379.1,Other,225% of Medicaid,2102.55,,,2102.55,Other,140% of Medicaid,3379.1,,,3379.1,Other,225% of Medicaid,3904.73,,,3904.73,Other,260% of Medicaid,4865.9,,,4865.9,Other,324% of Medicaid,3228.91,,,3228.91,Other,215% of Medicaid,3228.91,,,3228.91,Other,215% of Medicaid,1877.28,,,1877.28,Other,125% of Medicaid,657.9,7216,
PERQ DEV BREAST ADD STRTCTC LT,19284,CPT,LT,54119284,CDM,361,RC,,,both,,,151,111.74,,,111.74,Other,150% of Medicare + 9.63% HCRA Surcharge,67.95,45,,67.95,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",74.75,,,74.75,Other,110% of Medicare,102.68,,,102.68,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2793.39,,,2793.39,Other,186% of Medicaid,120.8,,,120.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",120.8,,,120.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",120.8,,,120.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",105.7,70,,105.7,percent of total billed charges,All Other,241.08,,,241.08,Fee Schedule,,204.33,,,204.33,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",1501.82,,,1501.82,Other,100% of Medicaid,1501.82,,,1501.82,Other,100% of Medicaid,1501.82,,,1501.82,Other,100% of Medicaid,1501.82,,,1501.82,Other,100% of Medicaid,3379.1,,,3379.1,Other,225% of Medicaid,2297.79,,,2297.79,Other,153% of Medicaid,3379.1,,,3379.1,Other,225% of Medicaid,2102.55,,,2102.55,Other,140% of Medicaid,3379.1,,,3379.1,Other,225% of Medicaid,3904.73,,,3904.73,Other,260% of Medicaid,4865.9,,,4865.9,Other,324% of Medicaid,3228.91,,,3228.91,Other,215% of Medicaid,3228.91,,,3228.91,Other,215% of Medicaid,1877.28,,,1877.28,Other,125% of Medicaid,67.95,7216,
PERQ DEV BREAST 1ST US IMAG LT,19285,CPT,LT,54119285,CDM,361,RC,,,both,,,1462,1081.88,,,1081.88,Other,150% of Medicare + 9.63% HCRA Surcharge,657.9,45,,657.9,percent of total billed charges,Critical Access Hospital RCC factor,2480,,,2480,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2232,,,2232,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",723.69,,,723.69,Other,110% of Medicare,994.16,,,994.16,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2793.39,,,2793.39,Other,186% of Medicaid,1169.6,,,1169.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1169.6,,,1169.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1169.6,,,1169.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1023.4,70,,1023.4,percent of total billed charges,All Other,406.72,,,406.72,Fee Schedule,,344.72,,,344.72,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",1501.82,,,1501.82,Other,100% of Medicaid,1501.82,,,1501.82,Other,100% of Medicaid,1501.82,,,1501.82,Other,100% of Medicaid,1501.82,,,1501.82,Other,100% of Medicaid,3379.1,,,3379.1,Other,225% of Medicaid,2297.79,,,2297.79,Other,153% of Medicaid,3379.1,,,3379.1,Other,225% of Medicaid,2102.55,,,2102.55,Other,140% of Medicaid,3379.1,,,3379.1,Other,225% of Medicaid,3904.73,,,3904.73,Other,260% of Medicaid,4865.9,,,4865.9,Other,324% of Medicaid,3228.91,,,3228.91,Other,215% of Medicaid,3228.91,,,3228.91,Other,215% of Medicaid,1877.28,,,1877.28,Other,125% of Medicaid,344.72,7216,
PERQ DEV BREAST ADD US IMAG LT,19286,CPT,LT,54119286,CDM,361,RC,,,both,,,129,95.46,,,95.46,Other,150% of Medicare + 9.63% HCRA Surcharge,58.05,45,,58.05,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",63.86,,,63.86,Other,110% of Medicare,87.72,,,87.72,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2793.39,,,2793.39,Other,186% of Medicaid,103.2,,,103.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",103.2,,,103.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",103.2,,,103.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",90.3,70,,90.3,percent of total billed charges,All Other,205,,,205,Fee Schedule,,173.75,,,173.75,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",1501.82,,,1501.82,Other,100% of Medicaid,1501.82,,,1501.82,Other,100% of Medicaid,1501.82,,,1501.82,Other,100% of Medicaid,1501.82,,,1501.82,Other,100% of Medicaid,3379.1,,,3379.1,Other,225% of Medicaid,2297.79,,,2297.79,Other,153% of Medicaid,3379.1,,,3379.1,Other,225% of Medicaid,2102.55,,,2102.55,Other,140% of Medicaid,3379.1,,,3379.1,Other,225% of Medicaid,3904.73,,,3904.73,Other,260% of Medicaid,4865.9,,,4865.9,Other,324% of Medicaid,3228.91,,,3228.91,Other,215% of Medicaid,3228.91,,,3228.91,Other,215% of Medicaid,1877.28,,,1877.28,Other,125% of Medicaid,58.05,7216,
BX BREAST 1ST LESION STRTCTC RT,19081,CPT,RT,54219081,CDM,361,RC,,,both,,,3377,2498.99,,,2498.99,Other,150% of Medicare + 9.63% HCRA Surcharge,1519.65,45,,1519.65,percent of total billed charges,Critical Access Hospital RCC factor,2480,,,2480,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2232,,,2232,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3648,,,3648,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3283,,,3283,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3101,,,3101,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",1671.62,,,1671.62,Other,110% of Medicare,2296.36,,,2296.36,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2793.39,,,2793.39,Other,186% of Medicaid,2701.6,,,2701.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2701.6,,,2701.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2701.6,,,2701.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2363.9,70,,2363.9,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",4055,,,4055,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3649,,,3649,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4055,,,4055,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3448,,,3448,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",1501.82,,,1501.82,Other,100% of Medicaid,1501.82,,,1501.82,Other,100% of Medicaid,1501.82,,,1501.82,Other,100% of Medicaid,1501.82,,,1501.82,Other,100% of Medicaid,3379.1,,,3379.1,Other,225% of Medicaid,2297.79,,,2297.79,Other,153% of Medicaid,3379.1,,,3379.1,Other,225% of Medicaid,2102.55,,,2102.55,Other,140% of Medicaid,3379.1,,,3379.1,Other,225% of Medicaid,3904.73,,,3904.73,Other,260% of Medicaid,4865.9,,,4865.9,Other,324% of Medicaid,3228.91,,,3228.91,Other,215% of Medicaid,3228.91,,,3228.91,Other,215% of Medicaid,1877.28,,,1877.28,Other,125% of Medicaid,1501.82,7216,
BX BREAST ADD LESION STRTCTC RT,19082,CPT,RT,54219082,CDM,361,RC,,,both,,,272,201.28,,,201.28,Other,150% of Medicare + 9.63% HCRA Surcharge,122.4,45,,122.4,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3648,,,3648,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3283,,,3283,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3101,,,3101,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",134.64,,,134.64,Other,110% of Medicare,184.96,,,184.96,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2793.39,,,2793.39,Other,186% of Medicaid,217.6,,,217.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",217.6,,,217.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",217.6,,,217.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",190.4,70,,190.4,percent of total billed charges,All Other,396.88,,,396.88,Fee Schedule,,336.38,,,336.38,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",1501.82,,,1501.82,Other,100% of Medicaid,1501.82,,,1501.82,Other,100% of Medicaid,1501.82,,,1501.82,Other,100% of Medicaid,1501.82,,,1501.82,Other,100% of Medicaid,3379.1,,,3379.1,Other,225% of Medicaid,2297.79,,,2297.79,Other,153% of Medicaid,3379.1,,,3379.1,Other,225% of Medicaid,2102.55,,,2102.55,Other,140% of Medicaid,3379.1,,,3379.1,Other,225% of Medicaid,3904.73,,,3904.73,Other,260% of Medicaid,4865.9,,,4865.9,Other,324% of Medicaid,3228.91,,,3228.91,Other,215% of Medicaid,3228.91,,,3228.91,Other,215% of Medicaid,1877.28,,,1877.28,Other,125% of Medicaid,122.4,7216,
BX BREAST 1ST LESION US IMAG RT,19083,CPT,RT,54219083,CDM,361,RC,,,both,,,3377,2498.99,,,2498.99,Other,150% of Medicare + 9.63% HCRA Surcharge,1519.65,45,,1519.65,percent of total billed charges,Critical Access Hospital RCC factor,2480,,,2480,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2232,,,2232,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3648,,,3648,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3283,,,3283,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3101,,,3101,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",1671.62,,,1671.62,Other,110% of Medicare,2296.36,,,2296.36,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2793.39,,,2793.39,Other,186% of Medicaid,2701.6,,,2701.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2701.6,,,2701.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2701.6,,,2701.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2363.9,70,,2363.9,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",4055,,,4055,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3649,,,3649,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4055,,,4055,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3448,,,3448,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",1501.82,,,1501.82,Other,100% of Medicaid,1501.82,,,1501.82,Other,100% of Medicaid,1501.82,,,1501.82,Other,100% of Medicaid,1501.82,,,1501.82,Other,100% of Medicaid,3379.1,,,3379.1,Other,225% of Medicaid,2297.79,,,2297.79,Other,153% of Medicaid,3379.1,,,3379.1,Other,225% of Medicaid,2102.55,,,2102.55,Other,140% of Medicaid,3379.1,,,3379.1,Other,225% of Medicaid,3904.73,,,3904.73,Other,260% of Medicaid,4865.9,,,4865.9,Other,324% of Medicaid,3228.91,,,3228.91,Other,215% of Medicaid,3228.91,,,3228.91,Other,215% of Medicaid,1877.28,,,1877.28,Other,125% of Medicaid,1501.82,7216,
BX BREAST ADD LESION US IMAG RT,19084,CPT,RT,54219084,CDM,361,RC,,,both,,,273,202.02,,,202.02,Other,150% of Medicare + 9.63% HCRA Surcharge,122.85,45,,122.85,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3648,,,3648,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3283,,,3283,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3101,,,3101,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",135.14,,,135.14,Other,110% of Medicare,185.64,,,185.64,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2793.39,,,2793.39,Other,186% of Medicaid,218.4,,,218.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",218.4,,,218.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",218.4,,,218.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",191.1,70,,191.1,percent of total billed charges,All Other,369,,,369,Fee Schedule,,312.75,,,312.75,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",1501.82,,,1501.82,Other,100% of Medicaid,1501.82,,,1501.82,Other,100% of Medicaid,1501.82,,,1501.82,Other,100% of Medicaid,1501.82,,,1501.82,Other,100% of Medicaid,3379.1,,,3379.1,Other,225% of Medicaid,2297.79,,,2297.79,Other,153% of Medicaid,3379.1,,,3379.1,Other,225% of Medicaid,2102.55,,,2102.55,Other,140% of Medicaid,3379.1,,,3379.1,Other,225% of Medicaid,3904.73,,,3904.73,Other,260% of Medicaid,4865.9,,,4865.9,Other,324% of Medicaid,3228.91,,,3228.91,Other,215% of Medicaid,3228.91,,,3228.91,Other,215% of Medicaid,1877.28,,,1877.28,Other,125% of Medicaid,122.85,7216,
PERQ DEVICE BREAST 1ST IMAG RT,19281,CPT,RT,54219281,CDM,361,RC,,,both,,,3377,2498.99,,,2498.99,Other,150% of Medicare + 9.63% HCRA Surcharge,1519.65,45,,1519.65,percent of total billed charges,Critical Access Hospital RCC factor,2480,,,2480,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2232,,,2232,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",1671.62,,,1671.62,Other,110% of Medicare,2296.36,,,2296.36,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2793.39,,,2793.39,Other,186% of Medicaid,2701.6,,,2701.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2701.6,,,2701.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2701.6,,,2701.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2363.9,70,,2363.9,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",4055,,,4055,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3649,,,3649,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4055,,,4055,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3448,,,3448,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",1501.82,,,1501.82,Other,100% of Medicaid,1501.82,,,1501.82,Other,100% of Medicaid,1501.82,,,1501.82,Other,100% of Medicaid,1501.82,,,1501.82,Other,100% of Medicaid,3379.1,,,3379.1,Other,225% of Medicaid,2297.79,,,2297.79,Other,153% of Medicaid,3379.1,,,3379.1,Other,225% of Medicaid,2102.55,,,2102.55,Other,140% of Medicaid,3379.1,,,3379.1,Other,225% of Medicaid,3904.73,,,3904.73,Other,260% of Medicaid,4865.9,,,4865.9,Other,324% of Medicaid,3228.91,,,3228.91,Other,215% of Medicaid,3228.91,,,3228.91,Other,215% of Medicaid,1877.28,,,1877.28,Other,125% of Medicaid,1501.82,7216,
PERQ DEVICE BREAST EA IMAG RT,19282,CPT,RT,54219282,CDM,361,RC,,,both,,,150,111,,,111,Other,150% of Medicare + 9.63% HCRA Surcharge,67.5,45,,67.5,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",74.25,,,74.25,Other,110% of Medicare,102,,,102,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2793.39,,,2793.39,Other,186% of Medicaid,120,,,120,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",120,,,120,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",120,,,120,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",105,70,,105,percent of total billed charges,All Other,237.8,,,237.8,Fee Schedule,,201.55,,,201.55,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",1501.82,,,1501.82,Other,100% of Medicaid,1501.82,,,1501.82,Other,100% of Medicaid,1501.82,,,1501.82,Other,100% of Medicaid,1501.82,,,1501.82,Other,100% of Medicaid,3379.1,,,3379.1,Other,225% of Medicaid,2297.79,,,2297.79,Other,153% of Medicaid,3379.1,,,3379.1,Other,225% of Medicaid,2102.55,,,2102.55,Other,140% of Medicaid,3379.1,,,3379.1,Other,225% of Medicaid,3904.73,,,3904.73,Other,260% of Medicaid,4865.9,,,4865.9,Other,324% of Medicaid,3228.91,,,3228.91,Other,215% of Medicaid,3228.91,,,3228.91,Other,215% of Medicaid,1877.28,,,1877.28,Other,125% of Medicaid,67.5,7216,
PERQ DEV BREAST 1ST STRTCTC RT,19283,CPT,RT,54219283,CDM,361,RC,,,both,,,1462,1081.88,,,1081.88,Other,150% of Medicare + 9.63% HCRA Surcharge,657.9,45,,657.9,percent of total billed charges,Critical Access Hospital RCC factor,2480,,,2480,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2232,,,2232,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",723.69,,,723.69,Other,110% of Medicare,994.16,,,994.16,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2793.39,,,2793.39,Other,186% of Medicaid,1169.6,,,1169.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1169.6,,,1169.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1169.6,,,1169.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1023.4,70,,1023.4,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",1501.82,,,1501.82,Other,100% of Medicaid,1501.82,,,1501.82,Other,100% of Medicaid,1501.82,,,1501.82,Other,100% of Medicaid,1501.82,,,1501.82,Other,100% of Medicaid,3379.1,,,3379.1,Other,225% of Medicaid,2297.79,,,2297.79,Other,153% of Medicaid,3379.1,,,3379.1,Other,225% of Medicaid,2102.55,,,2102.55,Other,140% of Medicaid,3379.1,,,3379.1,Other,225% of Medicaid,3904.73,,,3904.73,Other,260% of Medicaid,4865.9,,,4865.9,Other,324% of Medicaid,3228.91,,,3228.91,Other,215% of Medicaid,3228.91,,,3228.91,Other,215% of Medicaid,1877.28,,,1877.28,Other,125% of Medicaid,657.9,7216,
PERQ DEV BREAST ADD STRTCTC RT,19284,CPT,RT,54219284,CDM,361,RC,,,both,,,151,111.74,,,111.74,Other,150% of Medicare + 9.63% HCRA Surcharge,67.95,45,,67.95,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",74.75,,,74.75,Other,110% of Medicare,102.68,,,102.68,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2793.39,,,2793.39,Other,186% of Medicaid,120.8,,,120.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",120.8,,,120.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",120.8,,,120.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",105.7,70,,105.7,percent of total billed charges,All Other,241.08,,,241.08,Fee Schedule,,204.33,,,204.33,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",1501.82,,,1501.82,Other,100% of Medicaid,1501.82,,,1501.82,Other,100% of Medicaid,1501.82,,,1501.82,Other,100% of Medicaid,1501.82,,,1501.82,Other,100% of Medicaid,3379.1,,,3379.1,Other,225% of Medicaid,2297.79,,,2297.79,Other,153% of Medicaid,3379.1,,,3379.1,Other,225% of Medicaid,2102.55,,,2102.55,Other,140% of Medicaid,3379.1,,,3379.1,Other,225% of Medicaid,3904.73,,,3904.73,Other,260% of Medicaid,4865.9,,,4865.9,Other,324% of Medicaid,3228.91,,,3228.91,Other,215% of Medicaid,3228.91,,,3228.91,Other,215% of Medicaid,1877.28,,,1877.28,Other,125% of Medicaid,67.95,7216,
PERQ DEV BREAST 1ST US IMAG RT,19285,CPT,RT,54219285,CDM,361,RC,,,both,,,1462,1081.88,,,1081.88,Other,150% of Medicare + 9.63% HCRA Surcharge,657.9,45,,657.9,percent of total billed charges,Critical Access Hospital RCC factor,2480,,,2480,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2232,,,2232,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",723.69,,,723.69,Other,110% of Medicare,994.16,,,994.16,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2793.39,,,2793.39,Other,186% of Medicaid,1169.6,,,1169.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1169.6,,,1169.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1169.6,,,1169.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1023.4,70,,1023.4,percent of total billed charges,All Other,406.72,,,406.72,Fee Schedule,,344.72,,,344.72,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",1501.82,,,1501.82,Other,100% of Medicaid,1501.82,,,1501.82,Other,100% of Medicaid,1501.82,,,1501.82,Other,100% of Medicaid,1501.82,,,1501.82,Other,100% of Medicaid,3379.1,,,3379.1,Other,225% of Medicaid,2297.79,,,2297.79,Other,153% of Medicaid,3379.1,,,3379.1,Other,225% of Medicaid,2102.55,,,2102.55,Other,140% of Medicaid,3379.1,,,3379.1,Other,225% of Medicaid,3904.73,,,3904.73,Other,260% of Medicaid,4865.9,,,4865.9,Other,324% of Medicaid,3228.91,,,3228.91,Other,215% of Medicaid,3228.91,,,3228.91,Other,215% of Medicaid,1877.28,,,1877.28,Other,125% of Medicaid,344.72,7216,
PERQ DEV BREAST ADD US IMAG RT,19286,CPT,RT,54219286,CDM,361,RC,,,both,,,129,95.46,,,95.46,Other,150% of Medicare + 9.63% HCRA Surcharge,58.05,45,,58.05,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",63.86,,,63.86,Other,110% of Medicare,87.72,,,87.72,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2793.39,,,2793.39,Other,186% of Medicaid,103.2,,,103.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",103.2,,,103.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",103.2,,,103.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",90.3,70,,90.3,percent of total billed charges,All Other,205,,,205,Fee Schedule,,173.75,,,173.75,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",1501.82,,,1501.82,Other,100% of Medicaid,1501.82,,,1501.82,Other,100% of Medicaid,1501.82,,,1501.82,Other,100% of Medicaid,1501.82,,,1501.82,Other,100% of Medicaid,3379.1,,,3379.1,Other,225% of Medicaid,2297.79,,,2297.79,Other,153% of Medicaid,3379.1,,,3379.1,Other,225% of Medicaid,2102.55,,,2102.55,Other,140% of Medicaid,3379.1,,,3379.1,Other,225% of Medicaid,3904.73,,,3904.73,Other,260% of Medicaid,4865.9,,,4865.9,Other,324% of Medicaid,3228.91,,,3228.91,Other,215% of Medicaid,3228.91,,,3228.91,Other,215% of Medicaid,1877.28,,,1877.28,Other,125% of Medicaid,58.05,7216,
BX BREAST 1ST LESION STRTCTC BILAT,19081,CPT,50,54319081,CDM,361,RC,,,both,,,5066,3748.85,,,3748.85,Other,150% of Medicare + 9.63% HCRA Surcharge,2279.7,45,,2279.7,percent of total billed charges,Critical Access Hospital RCC factor,2480,,,2480,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2232,,,2232,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3648,,,3648,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3283,,,3283,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3101,,,3101,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2507.67,,,2507.67,Other,110% of Medicare,3444.88,,,3444.88,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2793.39,,,2793.39,Other,186% of Medicaid,4052.8,,,4052.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",4052.8,,,4052.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",4052.8,,,4052.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",3546.2,70,,3546.2,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",4055,,,4055,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3649,,,3649,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4055,,,4055,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3448,,,3448,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",1501.82,,,1501.82,Other,100% of Medicaid,1501.82,,,1501.82,Other,100% of Medicaid,1501.82,,,1501.82,Other,100% of Medicaid,1501.82,,,1501.82,Other,100% of Medicaid,3379.1,,,3379.1,Other,225% of Medicaid,2297.79,,,2297.79,Other,153% of Medicaid,3379.1,,,3379.1,Other,225% of Medicaid,2102.55,,,2102.55,Other,140% of Medicaid,3379.1,,,3379.1,Other,225% of Medicaid,3904.73,,,3904.73,Other,260% of Medicaid,4865.9,,,4865.9,Other,324% of Medicaid,3228.91,,,3228.91,Other,215% of Medicaid,3228.91,,,3228.91,Other,215% of Medicaid,1877.28,,,1877.28,Other,125% of Medicaid,1501.82,7216,
BX BREAST 1ST LESION US IMAG BILAT,19083,CPT,50,54319083,CDM,361,RC,,,both,,,5066,3748.85,,,3748.85,Other,150% of Medicare + 9.63% HCRA Surcharge,2279.7,45,,2279.7,percent of total billed charges,Critical Access Hospital RCC factor,2480,,,2480,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2232,,,2232,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3648,,,3648,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3283,,,3283,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3101,,,3101,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2507.67,,,2507.67,Other,110% of Medicare,3444.88,,,3444.88,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2793.39,,,2793.39,Other,186% of Medicaid,4052.8,,,4052.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",4052.8,,,4052.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",4052.8,,,4052.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",3546.2,70,,3546.2,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",4055,,,4055,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3649,,,3649,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4055,,,4055,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3448,,,3448,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",1501.82,,,1501.82,Other,100% of Medicaid,1501.82,,,1501.82,Other,100% of Medicaid,1501.82,,,1501.82,Other,100% of Medicaid,1501.82,,,1501.82,Other,100% of Medicaid,3379.1,,,3379.1,Other,225% of Medicaid,2297.79,,,2297.79,Other,153% of Medicaid,3379.1,,,3379.1,Other,225% of Medicaid,2102.55,,,2102.55,Other,140% of Medicaid,3379.1,,,3379.1,Other,225% of Medicaid,3904.73,,,3904.73,Other,260% of Medicaid,4865.9,,,4865.9,Other,324% of Medicaid,3228.91,,,3228.91,Other,215% of Medicaid,3228.91,,,3228.91,Other,215% of Medicaid,1877.28,,,1877.28,Other,125% of Medicaid,1501.82,7216,
PERQ DEVICE BREAST 1ST IMAG BILAT,19281,CPT,50,54319281,CDM,361,RC,,,both,,,5066,3748.85,,,3748.85,Other,150% of Medicare + 9.63% HCRA Surcharge,2279.7,45,,2279.7,percent of total billed charges,Critical Access Hospital RCC factor,2480,,,2480,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2232,,,2232,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2507.67,,,2507.67,Other,110% of Medicare,3444.88,,,3444.88,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2793.39,,,2793.39,Other,186% of Medicaid,4052.8,,,4052.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",4052.8,,,4052.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",4052.8,,,4052.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",3546.2,70,,3546.2,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",4055,,,4055,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3649,,,3649,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4055,,,4055,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3448,,,3448,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",1501.82,,,1501.82,Other,100% of Medicaid,1501.82,,,1501.82,Other,100% of Medicaid,1501.82,,,1501.82,Other,100% of Medicaid,1501.82,,,1501.82,Other,100% of Medicaid,3379.1,,,3379.1,Other,225% of Medicaid,2297.79,,,2297.79,Other,153% of Medicaid,3379.1,,,3379.1,Other,225% of Medicaid,2102.55,,,2102.55,Other,140% of Medicaid,3379.1,,,3379.1,Other,225% of Medicaid,3904.73,,,3904.73,Other,260% of Medicaid,4865.9,,,4865.9,Other,324% of Medicaid,3228.91,,,3228.91,Other,215% of Medicaid,3228.91,,,3228.91,Other,215% of Medicaid,1877.28,,,1877.28,Other,125% of Medicaid,1501.82,7216,
PERQ DEV BREAST 1ST STRTCTC BILAT,19283,CPT,50,54319283,CDM,361,RC,,,both,,,2193,1622.83,,,1622.83,Other,150% of Medicare + 9.63% HCRA Surcharge,986.85,45,,986.85,percent of total billed charges,Critical Access Hospital RCC factor,2480,,,2480,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2232,,,2232,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",1085.54,,,1085.54,Other,110% of Medicare,1491.24,,,1491.24,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2793.39,,,2793.39,Other,186% of Medicaid,1754.4,,,1754.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1754.4,,,1754.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1754.4,,,1754.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1535.1,70,,1535.1,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",1501.82,,,1501.82,Other,100% of Medicaid,1501.82,,,1501.82,Other,100% of Medicaid,1501.82,,,1501.82,Other,100% of Medicaid,1501.82,,,1501.82,Other,100% of Medicaid,3379.1,,,3379.1,Other,225% of Medicaid,2297.79,,,2297.79,Other,153% of Medicaid,3379.1,,,3379.1,Other,225% of Medicaid,2102.55,,,2102.55,Other,140% of Medicaid,3379.1,,,3379.1,Other,225% of Medicaid,3904.73,,,3904.73,Other,260% of Medicaid,4865.9,,,4865.9,Other,324% of Medicaid,3228.91,,,3228.91,Other,215% of Medicaid,3228.91,,,3228.91,Other,215% of Medicaid,1877.28,,,1877.28,Other,125% of Medicaid,986.85,7216,
PERQ DEV BREAST 1ST US IMAG BLIAT,19285,CPT,50,54319285,CDM,361,RC,,,both,,,2193,1622.83,,,1622.83,Other,150% of Medicare + 9.63% HCRA Surcharge,986.85,45,,986.85,percent of total billed charges,Critical Access Hospital RCC factor,2480,,,2480,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2232,,,2232,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",1085.54,,,1085.54,Other,110% of Medicare,1491.24,,,1491.24,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2793.39,,,2793.39,Other,186% of Medicaid,1754.4,,,1754.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1754.4,,,1754.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1754.4,,,1754.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1535.1,70,,1535.1,percent of total billed charges,All Other,406.72,,,406.72,Fee Schedule,,344.72,,,344.72,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",1501.82,,,1501.82,Other,100% of Medicaid,1501.82,,,1501.82,Other,100% of Medicaid,1501.82,,,1501.82,Other,100% of Medicaid,1501.82,,,1501.82,Other,100% of Medicaid,3379.1,,,3379.1,Other,225% of Medicaid,2297.79,,,2297.79,Other,153% of Medicaid,3379.1,,,3379.1,Other,225% of Medicaid,2102.55,,,2102.55,Other,140% of Medicaid,3379.1,,,3379.1,Other,225% of Medicaid,3904.73,,,3904.73,Other,260% of Medicaid,4865.9,,,4865.9,Other,324% of Medicaid,3228.91,,,3228.91,Other,215% of Medicaid,3228.91,,,3228.91,Other,215% of Medicaid,1877.28,,,1877.28,Other,125% of Medicaid,344.72,7216,
INCOMPLETE BX BREAST 1ST LESION STRTCTC,19081,CPT,73,54419081,CDM,361,RC,,,both,,,2702,1999.49,,,1999.49,Other,150% of Medicare + 9.63% HCRA Surcharge,1215.9,45,,1215.9,percent of total billed charges,Critical Access Hospital RCC factor,2480,,,2480,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2232,,,2232,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3648,,,3648,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3283,,,3283,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3101,,,3101,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",1337.49,,,1337.49,Other,110% of Medicare,1837.36,,,1837.36,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2793.39,,,2793.39,Other,186% of Medicaid,2161.6,,,2161.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2161.6,,,2161.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2161.6,,,2161.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1891.4,70,,1891.4,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",4055,,,4055,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3649,,,3649,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4055,,,4055,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3448,,,3448,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",1501.82,,,1501.82,Other,100% of Medicaid,1501.82,,,1501.82,Other,100% of Medicaid,1501.82,,,1501.82,Other,100% of Medicaid,1501.82,,,1501.82,Other,100% of Medicaid,3379.1,,,3379.1,Other,225% of Medicaid,2297.79,,,2297.79,Other,153% of Medicaid,3379.1,,,3379.1,Other,225% of Medicaid,2102.55,,,2102.55,Other,140% of Medicaid,3379.1,,,3379.1,Other,225% of Medicaid,3904.73,,,3904.73,Other,260% of Medicaid,4865.9,,,4865.9,Other,324% of Medicaid,3228.91,,,3228.91,Other,215% of Medicaid,3228.91,,,3228.91,Other,215% of Medicaid,1877.28,,,1877.28,Other,125% of Medicaid,1215.9,7216,
INCOMPLETE BX BREAST ADD LESION STRTCTC,19082,CPT,73,54419082,CDM,361,RC,,,both,,,218,161.32,,,161.32,Other,150% of Medicare + 9.63% HCRA Surcharge,98.1,45,,98.1,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3648,,,3648,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3283,,,3283,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3101,,,3101,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",107.91,,,107.91,Other,110% of Medicare,148.24,,,148.24,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2793.39,,,2793.39,Other,186% of Medicaid,174.4,,,174.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",174.4,,,174.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",174.4,,,174.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",152.6,70,,152.6,percent of total billed charges,All Other,396.88,,,396.88,Fee Schedule,,336.38,,,336.38,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",1501.82,,,1501.82,Other,100% of Medicaid,1501.82,,,1501.82,Other,100% of Medicaid,1501.82,,,1501.82,Other,100% of Medicaid,1501.82,,,1501.82,Other,100% of Medicaid,3379.1,,,3379.1,Other,225% of Medicaid,2297.79,,,2297.79,Other,153% of Medicaid,3379.1,,,3379.1,Other,225% of Medicaid,2102.55,,,2102.55,Other,140% of Medicaid,3379.1,,,3379.1,Other,225% of Medicaid,3904.73,,,3904.73,Other,260% of Medicaid,4865.9,,,4865.9,Other,324% of Medicaid,3228.91,,,3228.91,Other,215% of Medicaid,3228.91,,,3228.91,Other,215% of Medicaid,1877.28,,,1877.28,Other,125% of Medicaid,98.1,7216,
INCOMPLETE BX BREAST 1ST LESION US IMAG,19083,CPT,73,54419083,CDM,361,RC,,,both,,,2702,1999.49,,,1999.49,Other,150% of Medicare + 9.63% HCRA Surcharge,1215.9,45,,1215.9,percent of total billed charges,Critical Access Hospital RCC factor,2480,,,2480,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2232,,,2232,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3648,,,3648,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3283,,,3283,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3101,,,3101,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",1337.49,,,1337.49,Other,110% of Medicare,1837.36,,,1837.36,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2793.39,,,2793.39,Other,186% of Medicaid,2161.6,,,2161.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2161.6,,,2161.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2161.6,,,2161.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1891.4,70,,1891.4,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",4055,,,4055,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3649,,,3649,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4055,,,4055,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3448,,,3448,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",1501.82,,,1501.82,Other,100% of Medicaid,1501.82,,,1501.82,Other,100% of Medicaid,1501.82,,,1501.82,Other,100% of Medicaid,1501.82,,,1501.82,Other,100% of Medicaid,3379.1,,,3379.1,Other,225% of Medicaid,2297.79,,,2297.79,Other,153% of Medicaid,3379.1,,,3379.1,Other,225% of Medicaid,2102.55,,,2102.55,Other,140% of Medicaid,3379.1,,,3379.1,Other,225% of Medicaid,3904.73,,,3904.73,Other,260% of Medicaid,4865.9,,,4865.9,Other,324% of Medicaid,3228.91,,,3228.91,Other,215% of Medicaid,3228.91,,,3228.91,Other,215% of Medicaid,1877.28,,,1877.28,Other,125% of Medicaid,1215.9,7216,
INCOMPLETE BX BREAST ADD LESION US IMAG,19084,CPT,73,54419084,CDM,361,RC,,,both,,,219,162.06,,,162.06,Other,150% of Medicare + 9.63% HCRA Surcharge,98.55,45,,98.55,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3648,,,3648,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3283,,,3283,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3101,,,3101,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",108.41,,,108.41,Other,110% of Medicare,148.92,,,148.92,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2793.39,,,2793.39,Other,186% of Medicaid,175.2,,,175.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",175.2,,,175.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",175.2,,,175.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",153.3,70,,153.3,percent of total billed charges,All Other,369,,,369,Fee Schedule,,312.75,,,312.75,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",1501.82,,,1501.82,Other,100% of Medicaid,1501.82,,,1501.82,Other,100% of Medicaid,1501.82,,,1501.82,Other,100% of Medicaid,1501.82,,,1501.82,Other,100% of Medicaid,3379.1,,,3379.1,Other,225% of Medicaid,2297.79,,,2297.79,Other,153% of Medicaid,3379.1,,,3379.1,Other,225% of Medicaid,2102.55,,,2102.55,Other,140% of Medicaid,3379.1,,,3379.1,Other,225% of Medicaid,3904.73,,,3904.73,Other,260% of Medicaid,4865.9,,,4865.9,Other,324% of Medicaid,3228.91,,,3228.91,Other,215% of Medicaid,3228.91,,,3228.91,Other,215% of Medicaid,1877.28,,,1877.28,Other,125% of Medicaid,98.55,7216,
INCOMPLETE PERQ DEVICE BREAST 1ST IMAG,19281,CPT,73,54419281,CDM,361,RC,,,both,,,2702,1999.49,,,1999.49,Other,150% of Medicare + 9.63% HCRA Surcharge,1215.9,45,,1215.9,percent of total billed charges,Critical Access Hospital RCC factor,2480,,,2480,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2232,,,2232,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",1337.49,,,1337.49,Other,110% of Medicare,1837.36,,,1837.36,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2793.39,,,2793.39,Other,186% of Medicaid,2161.6,,,2161.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2161.6,,,2161.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2161.6,,,2161.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1891.4,70,,1891.4,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",4055,,,4055,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3649,,,3649,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4055,,,4055,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3448,,,3448,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",1501.82,,,1501.82,Other,100% of Medicaid,1501.82,,,1501.82,Other,100% of Medicaid,1501.82,,,1501.82,Other,100% of Medicaid,1501.82,,,1501.82,Other,100% of Medicaid,3379.1,,,3379.1,Other,225% of Medicaid,2297.79,,,2297.79,Other,153% of Medicaid,3379.1,,,3379.1,Other,225% of Medicaid,2102.55,,,2102.55,Other,140% of Medicaid,3379.1,,,3379.1,Other,225% of Medicaid,3904.73,,,3904.73,Other,260% of Medicaid,4865.9,,,4865.9,Other,324% of Medicaid,3228.91,,,3228.91,Other,215% of Medicaid,3228.91,,,3228.91,Other,215% of Medicaid,1877.28,,,1877.28,Other,125% of Medicaid,1215.9,7216,
INCOMPLETE PERQ DEVICE BREAST EA IMAG,19282,CPT,73,54419282,CDM,361,RC,,,both,,,120,88.8,,,88.8,Other,150% of Medicare + 9.63% HCRA Surcharge,54,45,,54,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",59.4,,,59.4,Other,110% of Medicare,81.6,,,81.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2793.39,,,2793.39,Other,186% of Medicaid,96,,,96,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",96,,,96,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",96,,,96,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",84,70,,84,percent of total billed charges,All Other,237.8,,,237.8,Fee Schedule,,201.55,,,201.55,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",1501.82,,,1501.82,Other,100% of Medicaid,1501.82,,,1501.82,Other,100% of Medicaid,1501.82,,,1501.82,Other,100% of Medicaid,1501.82,,,1501.82,Other,100% of Medicaid,3379.1,,,3379.1,Other,225% of Medicaid,2297.79,,,2297.79,Other,153% of Medicaid,3379.1,,,3379.1,Other,225% of Medicaid,2102.55,,,2102.55,Other,140% of Medicaid,3379.1,,,3379.1,Other,225% of Medicaid,3904.73,,,3904.73,Other,260% of Medicaid,4865.9,,,4865.9,Other,324% of Medicaid,3228.91,,,3228.91,Other,215% of Medicaid,3228.91,,,3228.91,Other,215% of Medicaid,1877.28,,,1877.28,Other,125% of Medicaid,54,7216,
INCOMPLETE PERQ DEV BREAST 1ST STRTCTC,19283,CPT,73,54419283,CDM,361,RC,,,both,,,1170,865.8,,,865.8,Other,150% of Medicare + 9.63% HCRA Surcharge,526.5,45,,526.5,percent of total billed charges,Critical Access Hospital RCC factor,2480,,,2480,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2232,,,2232,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",579.15,,,579.15,Other,110% of Medicare,795.6,,,795.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2793.39,,,2793.39,Other,186% of Medicaid,936,,,936,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",936,,,936,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",936,,,936,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",819,70,,819,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",1501.82,,,1501.82,Other,100% of Medicaid,1501.82,,,1501.82,Other,100% of Medicaid,1501.82,,,1501.82,Other,100% of Medicaid,1501.82,,,1501.82,Other,100% of Medicaid,3379.1,,,3379.1,Other,225% of Medicaid,2297.79,,,2297.79,Other,153% of Medicaid,3379.1,,,3379.1,Other,225% of Medicaid,2102.55,,,2102.55,Other,140% of Medicaid,3379.1,,,3379.1,Other,225% of Medicaid,3904.73,,,3904.73,Other,260% of Medicaid,4865.9,,,4865.9,Other,324% of Medicaid,3228.91,,,3228.91,Other,215% of Medicaid,3228.91,,,3228.91,Other,215% of Medicaid,1877.28,,,1877.28,Other,125% of Medicaid,526.5,7216,
INCOMPLETE PERQ DEV BREAST ADD STRTCTC,19284,CPT,73,54419284,CDM,361,RC,,,both,,,122,90.28,,,90.28,Other,150% of Medicare + 9.63% HCRA Surcharge,54.9,45,,54.9,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",60.39,,,60.39,Other,110% of Medicare,82.96,,,82.96,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2793.39,,,2793.39,Other,186% of Medicaid,97.6,,,97.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",97.6,,,97.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",97.6,,,97.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",85.4,70,,85.4,percent of total billed charges,All Other,241.08,,,241.08,Fee Schedule,,204.33,,,204.33,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",1501.82,,,1501.82,Other,100% of Medicaid,1501.82,,,1501.82,Other,100% of Medicaid,1501.82,,,1501.82,Other,100% of Medicaid,1501.82,,,1501.82,Other,100% of Medicaid,3379.1,,,3379.1,Other,225% of Medicaid,2297.79,,,2297.79,Other,153% of Medicaid,3379.1,,,3379.1,Other,225% of Medicaid,2102.55,,,2102.55,Other,140% of Medicaid,3379.1,,,3379.1,Other,225% of Medicaid,3904.73,,,3904.73,Other,260% of Medicaid,4865.9,,,4865.9,Other,324% of Medicaid,3228.91,,,3228.91,Other,215% of Medicaid,3228.91,,,3228.91,Other,215% of Medicaid,1877.28,,,1877.28,Other,125% of Medicaid,54.9,7216,
INCOMPLETE PERQ DEV BREAST 1ST US IMAG,19285,CPT,73,54419285,CDM,361,RC,,,both,,,1171,866.54,,,866.54,Other,150% of Medicare + 9.63% HCRA Surcharge,526.95,45,,526.95,percent of total billed charges,Critical Access Hospital RCC factor,2480,,,2480,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2232,,,2232,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",579.65,,,579.65,Other,110% of Medicare,796.28,,,796.28,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2793.39,,,2793.39,Other,186% of Medicaid,936.8,,,936.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",936.8,,,936.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",936.8,,,936.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",819.7,70,,819.7,percent of total billed charges,All Other,406.72,,,406.72,Fee Schedule,,344.72,,,344.72,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",1501.82,,,1501.82,Other,100% of Medicaid,1501.82,,,1501.82,Other,100% of Medicaid,1501.82,,,1501.82,Other,100% of Medicaid,1501.82,,,1501.82,Other,100% of Medicaid,3379.1,,,3379.1,Other,225% of Medicaid,2297.79,,,2297.79,Other,153% of Medicaid,3379.1,,,3379.1,Other,225% of Medicaid,2102.55,,,2102.55,Other,140% of Medicaid,3379.1,,,3379.1,Other,225% of Medicaid,3904.73,,,3904.73,Other,260% of Medicaid,4865.9,,,4865.9,Other,324% of Medicaid,3228.91,,,3228.91,Other,215% of Medicaid,3228.91,,,3228.91,Other,215% of Medicaid,1877.28,,,1877.28,Other,125% of Medicaid,344.72,7216,
INCOMPLETE PERQ DEV BREAST ADD US IMAG,19286,CPT,73,54419286,CDM,361,RC,,,both,,,104,76.96,,,76.96,Other,150% of Medicare + 9.63% HCRA Surcharge,46.8,45,,46.8,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",51.48,,,51.48,Other,110% of Medicare,70.72,,,70.72,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2793.39,,,2793.39,Other,186% of Medicaid,83.2,,,83.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",83.2,,,83.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",83.2,,,83.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",72.8,70,,72.8,percent of total billed charges,All Other,205,,,205,Fee Schedule,,173.75,,,173.75,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",1501.82,,,1501.82,Other,100% of Medicaid,1501.82,,,1501.82,Other,100% of Medicaid,1501.82,,,1501.82,Other,100% of Medicaid,1501.82,,,1501.82,Other,100% of Medicaid,3379.1,,,3379.1,Other,225% of Medicaid,2297.79,,,2297.79,Other,153% of Medicaid,3379.1,,,3379.1,Other,225% of Medicaid,2102.55,,,2102.55,Other,140% of Medicaid,3379.1,,,3379.1,Other,225% of Medicaid,3904.73,,,3904.73,Other,260% of Medicaid,4865.9,,,4865.9,Other,324% of Medicaid,3228.91,,,3228.91,Other,215% of Medicaid,3228.91,,,3228.91,Other,215% of Medicaid,1877.28,,,1877.28,Other,125% of Medicaid,46.8,7216,
INCOMPLETE BX BREAST 1ST LESION STRTCTC,19081,CPT,74,54519081,CDM,361,RC,,,both,,,2702,1999.49,,,1999.49,Other,150% of Medicare + 9.63% HCRA Surcharge,1215.9,45,,1215.9,percent of total billed charges,Critical Access Hospital RCC factor,2480,,,2480,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2232,,,2232,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3648,,,3648,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3283,,,3283,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3101,,,3101,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",1337.49,,,1337.49,Other,110% of Medicare,1837.36,,,1837.36,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2793.39,,,2793.39,Other,186% of Medicaid,2161.6,,,2161.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2161.6,,,2161.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2161.6,,,2161.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1891.4,70,,1891.4,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",4055,,,4055,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3649,,,3649,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4055,,,4055,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3448,,,3448,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",1501.82,,,1501.82,Other,100% of Medicaid,1501.82,,,1501.82,Other,100% of Medicaid,1501.82,,,1501.82,Other,100% of Medicaid,1501.82,,,1501.82,Other,100% of Medicaid,3379.1,,,3379.1,Other,225% of Medicaid,2297.79,,,2297.79,Other,153% of Medicaid,3379.1,,,3379.1,Other,225% of Medicaid,2102.55,,,2102.55,Other,140% of Medicaid,3379.1,,,3379.1,Other,225% of Medicaid,3904.73,,,3904.73,Other,260% of Medicaid,4865.9,,,4865.9,Other,324% of Medicaid,3228.91,,,3228.91,Other,215% of Medicaid,3228.91,,,3228.91,Other,215% of Medicaid,1877.28,,,1877.28,Other,125% of Medicaid,1215.9,7216,
INCOMPLETE BX BREAST 1ST LESION US IMAG,19083,CPT,74,54519083,CDM,361,RC,,,both,,,2702,1999.49,,,1999.49,Other,150% of Medicare + 9.63% HCRA Surcharge,1215.9,45,,1215.9,percent of total billed charges,Critical Access Hospital RCC factor,2480,,,2480,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2232,,,2232,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3648,,,3648,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3283,,,3283,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3101,,,3101,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",1337.49,,,1337.49,Other,110% of Medicare,1837.36,,,1837.36,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2793.39,,,2793.39,Other,186% of Medicaid,2161.6,,,2161.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2161.6,,,2161.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2161.6,,,2161.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1891.4,70,,1891.4,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",4055,,,4055,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3649,,,3649,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4055,,,4055,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3448,,,3448,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",1501.82,,,1501.82,Other,100% of Medicaid,1501.82,,,1501.82,Other,100% of Medicaid,1501.82,,,1501.82,Other,100% of Medicaid,1501.82,,,1501.82,Other,100% of Medicaid,3379.1,,,3379.1,Other,225% of Medicaid,2297.79,,,2297.79,Other,153% of Medicaid,3379.1,,,3379.1,Other,225% of Medicaid,2102.55,,,2102.55,Other,140% of Medicaid,3379.1,,,3379.1,Other,225% of Medicaid,3904.73,,,3904.73,Other,260% of Medicaid,4865.9,,,4865.9,Other,324% of Medicaid,3228.91,,,3228.91,Other,215% of Medicaid,3228.91,,,3228.91,Other,215% of Medicaid,1877.28,,,1877.28,Other,125% of Medicaid,1215.9,7216,
INCOMPLETE PERQ DEVICE BREAST 1ST IMAG,19281,CPT,74,54519281,CDM,361,RC,,,both,,,2702,1999.49,,,1999.49,Other,150% of Medicare + 9.63% HCRA Surcharge,1215.9,45,,1215.9,percent of total billed charges,Critical Access Hospital RCC factor,2480,,,2480,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2232,,,2232,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",1337.49,,,1337.49,Other,110% of Medicare,1837.36,,,1837.36,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2793.39,,,2793.39,Other,186% of Medicaid,2161.6,,,2161.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2161.6,,,2161.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2161.6,,,2161.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1891.4,70,,1891.4,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",4055,,,4055,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3649,,,3649,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4055,,,4055,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3448,,,3448,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",1501.82,,,1501.82,Other,100% of Medicaid,1501.82,,,1501.82,Other,100% of Medicaid,1501.82,,,1501.82,Other,100% of Medicaid,1501.82,,,1501.82,Other,100% of Medicaid,3379.1,,,3379.1,Other,225% of Medicaid,2297.79,,,2297.79,Other,153% of Medicaid,3379.1,,,3379.1,Other,225% of Medicaid,2102.55,,,2102.55,Other,140% of Medicaid,3379.1,,,3379.1,Other,225% of Medicaid,3904.73,,,3904.73,Other,260% of Medicaid,4865.9,,,4865.9,Other,324% of Medicaid,3228.91,,,3228.91,Other,215% of Medicaid,3228.91,,,3228.91,Other,215% of Medicaid,1877.28,,,1877.28,Other,125% of Medicaid,1215.9,7216,
INCOMPLETE PERQ DEV BREAST 1ST STRTCTC,19283,CPT,74,54519283,CDM,361,RC,,,both,,,1170,865.8,,,865.8,Other,150% of Medicare + 9.63% HCRA Surcharge,526.5,45,,526.5,percent of total billed charges,Critical Access Hospital RCC factor,2480,,,2480,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2232,,,2232,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",579.15,,,579.15,Other,110% of Medicare,795.6,,,795.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2793.39,,,2793.39,Other,186% of Medicaid,936,,,936,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",936,,,936,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",936,,,936,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",819,70,,819,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",1501.82,,,1501.82,Other,100% of Medicaid,1501.82,,,1501.82,Other,100% of Medicaid,1501.82,,,1501.82,Other,100% of Medicaid,1501.82,,,1501.82,Other,100% of Medicaid,3379.1,,,3379.1,Other,225% of Medicaid,2297.79,,,2297.79,Other,153% of Medicaid,3379.1,,,3379.1,Other,225% of Medicaid,2102.55,,,2102.55,Other,140% of Medicaid,3379.1,,,3379.1,Other,225% of Medicaid,3904.73,,,3904.73,Other,260% of Medicaid,4865.9,,,4865.9,Other,324% of Medicaid,3228.91,,,3228.91,Other,215% of Medicaid,3228.91,,,3228.91,Other,215% of Medicaid,1877.28,,,1877.28,Other,125% of Medicaid,526.5,7216,
INCOMPLETE PERQ DEV BREAST 1ST US IMAG,19285,CPT,74,54519285,CDM,361,RC,,,both,,,1171,866.54,,,866.54,Other,150% of Medicare + 9.63% HCRA Surcharge,526.95,45,,526.95,percent of total billed charges,Critical Access Hospital RCC factor,2480,,,2480,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2232,,,2232,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",579.65,,,579.65,Other,110% of Medicare,796.28,,,796.28,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2793.39,,,2793.39,Other,186% of Medicaid,936.8,,,936.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",936.8,,,936.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",936.8,,,936.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",819.7,70,,819.7,percent of total billed charges,All Other,406.72,,,406.72,Fee Schedule,,344.72,,,344.72,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",1501.82,,,1501.82,Other,100% of Medicaid,1501.82,,,1501.82,Other,100% of Medicaid,1501.82,,,1501.82,Other,100% of Medicaid,1501.82,,,1501.82,Other,100% of Medicaid,3379.1,,,3379.1,Other,225% of Medicaid,2297.79,,,2297.79,Other,153% of Medicaid,3379.1,,,3379.1,Other,225% of Medicaid,2102.55,,,2102.55,Other,140% of Medicaid,3379.1,,,3379.1,Other,225% of Medicaid,3904.73,,,3904.73,Other,260% of Medicaid,4865.9,,,4865.9,Other,324% of Medicaid,3228.91,,,3228.91,Other,215% of Medicaid,3228.91,,,3228.91,Other,215% of Medicaid,1877.28,,,1877.28,Other,125% of Medicaid,344.72,7216,
LOW COST SKIN SUBSTITUTE APP,C5271,HCPCS,,73000010,CDM,361,RC,,,both,,,1309,968.66,,,968.66,Other,150% of Medicare + 9.63% HCRA Surcharge,589.05,45,,589.05,percent of total billed charges,Critical Access Hospital RCC factor,2480,,,2480,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2232,,,2232,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",647.96,,,647.96,Other,110% of Medicare,890.12,,,890.12,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2593.54,,,2593.54,Other,186% of Medicaid,1047.2,,,1047.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1047.2,,,1047.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1047.2,,,1047.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",916.3,70,,916.3,percent of total billed charges,All Other,850.85,65,,850.85,percent of total billed charges,Default if not in Fee Schedule,850.85,65,,850.85,percent of total billed charges,Default if not in Fee Schedule,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",1394.38,,,1394.38,Other,100% of Medicaid,1394.38,,,1394.38,Other,100% of Medicaid,1394.38,,,1394.38,Other,100% of Medicaid,1394.38,,,1394.38,Other,100% of Medicaid,3137.35,,,3137.35,Other,225% of Medicaid,2133.39,,,2133.39,Other,153% of Medicaid,3137.35,,,3137.35,Other,225% of Medicaid,1952.13,,,1952.13,Other,140% of Medicaid,3137.35,,,3137.35,Other,225% of Medicaid,3625.38,,,3625.38,Other,260% of Medicaid,4517.78,,,4517.78,Other,324% of Medicaid,2997.91,,,2997.91,Other,215% of Medicaid,2997.91,,,2997.91,Other,215% of Medicaid,1742.97,,,1742.97,Other,125% of Medicaid,589.05,7216,
LOW COST SKIN SUBSTITUTE APP,C5272,HCPCS,,73000011,CDM,361,RC,,,both,,,353,261.22,,,261.22,Other,150% of Medicare + 9.63% HCRA Surcharge,158.85,45,,158.85,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",174.74,,,174.74,Other,110% of Medicare,240.04,,,240.04,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2224.24,,,2224.24,Other,186% of Medicaid,282.4,,,282.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",282.4,,,282.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",282.4,,,282.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",247.1,70,,247.1,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",1195.83,,,1195.83,Other,100% of Medicaid,1195.83,,,1195.83,Other,100% of Medicaid,1195.83,,,1195.83,Other,100% of Medicaid,1195.83,,,1195.83,Other,100% of Medicaid,2690.61,,,2690.61,Other,225% of Medicaid,1829.61,,,1829.61,Other,153% of Medicaid,2690.61,,,2690.61,Other,225% of Medicaid,1674.16,,,1674.16,Other,140% of Medicaid,2690.61,,,2690.61,Other,225% of Medicaid,3109.15,,,3109.15,Other,260% of Medicaid,3874.48,,,3874.48,Other,324% of Medicaid,2571.03,,,2571.03,Other,215% of Medicaid,2571.03,,,2571.03,Other,215% of Medicaid,1494.78,,,1494.78,Other,125% of Medicaid,158.85,7216,
LOW COST SKIN SUBSTITUTE APP,C5273,HCPCS,,73000012,CDM,361,RC,,,both,,,3886,2875.65,,,2875.65,Other,150% of Medicare + 9.63% HCRA Surcharge,1748.7,45,,1748.7,percent of total billed charges,Critical Access Hospital RCC factor,2480,,,2480,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2232,,,2232,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3648,,,3648,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3283,,,3283,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3101,,,3101,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",1923.57,,,1923.57,Other,110% of Medicare,2642.48,,,2642.48,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2593.54,,,2593.54,Other,186% of Medicaid,3108.8,,,3108.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",3108.8,,,3108.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",3108.8,,,3108.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2720.2,70,,2720.2,percent of total billed charges,All Other,2525.9,65,,2525.9,percent of total billed charges,Default if not in Fee Schedule,2525.9,65,,2525.9,percent of total billed charges,Default if not in Fee Schedule,4055,,,4055,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3649,,,3649,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4055,,,4055,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3448,,,3448,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",1394.38,,,1394.38,Other,100% of Medicaid,1394.38,,,1394.38,Other,100% of Medicaid,1394.38,,,1394.38,Other,100% of Medicaid,1394.38,,,1394.38,Other,100% of Medicaid,3137.35,,,3137.35,Other,225% of Medicaid,2133.39,,,2133.39,Other,153% of Medicaid,3137.35,,,3137.35,Other,225% of Medicaid,1952.13,,,1952.13,Other,140% of Medicaid,3137.35,,,3137.35,Other,225% of Medicaid,3625.38,,,3625.38,Other,260% of Medicaid,4517.78,,,4517.78,Other,324% of Medicaid,2997.91,,,2997.91,Other,215% of Medicaid,2997.91,,,2997.91,Other,215% of Medicaid,1742.97,,,1742.97,Other,125% of Medicaid,1394.38,7216,
LOW COST SKIN SUBSTITUTE APP,C5274,HCPCS,,73000013,CDM,361,RC,,,both,,,961,711.14,,,711.14,Other,150% of Medicare + 9.63% HCRA Surcharge,432.45,45,,432.45,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",475.7,,,475.7,Other,110% of Medicare,653.48,,,653.48,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2224.24,,,2224.24,Other,186% of Medicaid,768.8,,,768.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",768.8,,,768.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",768.8,,,768.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",672.7,70,,672.7,percent of total billed charges,All Other,624.65,65,,624.65,percent of total billed charges,Default if not in Fee Schedule,624.65,65,,624.65,percent of total billed charges,Default if not in Fee Schedule,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",1195.83,,,1195.83,Other,100% of Medicaid,1195.83,,,1195.83,Other,100% of Medicaid,1195.83,,,1195.83,Other,100% of Medicaid,1195.83,,,1195.83,Other,100% of Medicaid,2690.61,,,2690.61,Other,225% of Medicaid,1829.61,,,1829.61,Other,153% of Medicaid,2690.61,,,2690.61,Other,225% of Medicaid,1674.16,,,1674.16,Other,140% of Medicaid,2690.61,,,2690.61,Other,225% of Medicaid,3109.15,,,3109.15,Other,260% of Medicaid,3874.48,,,3874.48,Other,324% of Medicaid,2571.03,,,2571.03,Other,215% of Medicaid,2571.03,,,2571.03,Other,215% of Medicaid,1494.78,,,1494.78,Other,125% of Medicaid,432.45,7216,
LOW COST SKIN SUBSTITUTE APP,C5275,HCPCS,,73000014,CDM,361,RC,,,both,,,1309,968.66,,,968.66,Other,150% of Medicare + 9.63% HCRA Surcharge,589.05,45,,589.05,percent of total billed charges,Critical Access Hospital RCC factor,2480,,,2480,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2232,,,2232,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",647.96,,,647.96,Other,110% of Medicare,890.12,,,890.12,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2593.54,,,2593.54,Other,186% of Medicaid,1047.2,,,1047.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1047.2,,,1047.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1047.2,,,1047.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",916.3,70,,916.3,percent of total billed charges,All Other,850.85,65,,850.85,percent of total billed charges,Default if not in Fee Schedule,850.85,65,,850.85,percent of total billed charges,Default if not in Fee Schedule,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",1394.38,,,1394.38,Other,100% of Medicaid,1394.38,,,1394.38,Other,100% of Medicaid,1394.38,,,1394.38,Other,100% of Medicaid,1394.38,,,1394.38,Other,100% of Medicaid,3137.35,,,3137.35,Other,225% of Medicaid,2133.39,,,2133.39,Other,153% of Medicaid,3137.35,,,3137.35,Other,225% of Medicaid,1952.13,,,1952.13,Other,140% of Medicaid,3137.35,,,3137.35,Other,225% of Medicaid,3625.38,,,3625.38,Other,260% of Medicaid,4517.78,,,4517.78,Other,324% of Medicaid,2997.91,,,2997.91,Other,215% of Medicaid,2997.91,,,2997.91,Other,215% of Medicaid,1742.97,,,1742.97,Other,125% of Medicaid,589.05,7216,
LOW COST SKIN SUBSTITUTE APP,C5276,HCPCS,,73000015,CDM,361,RC,,,both,,,353,261.22,,,261.22,Other,150% of Medicare + 9.63% HCRA Surcharge,158.85,45,,158.85,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",174.74,,,174.74,Other,110% of Medicare,240.04,,,240.04,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2224.24,,,2224.24,Other,186% of Medicaid,282.4,,,282.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",282.4,,,282.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",282.4,,,282.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",247.1,70,,247.1,percent of total billed charges,All Other,229.45,65,,229.45,percent of total billed charges,Default if not in Fee Schedule,229.45,65,,229.45,percent of total billed charges,Default if not in Fee Schedule,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",1195.83,,,1195.83,Other,100% of Medicaid,1195.83,,,1195.83,Other,100% of Medicaid,1195.83,,,1195.83,Other,100% of Medicaid,1195.83,,,1195.83,Other,100% of Medicaid,2690.61,,,2690.61,Other,225% of Medicaid,1829.61,,,1829.61,Other,153% of Medicaid,2690.61,,,2690.61,Other,225% of Medicaid,1674.16,,,1674.16,Other,140% of Medicaid,2690.61,,,2690.61,Other,225% of Medicaid,3109.15,,,3109.15,Other,260% of Medicaid,3874.48,,,3874.48,Other,324% of Medicaid,2571.03,,,2571.03,Other,215% of Medicaid,2571.03,,,2571.03,Other,215% of Medicaid,1494.78,,,1494.78,Other,125% of Medicaid,158.85,7216,
LOW COST SKIN SUBSTITUTE APP,C5277,HCPCS,,73000016,CDM,361,RC,,,both,,,1465,1084.1,,,1084.1,Other,150% of Medicare + 9.63% HCRA Surcharge,659.25,45,,659.25,percent of total billed charges,Critical Access Hospital RCC factor,2480,,,2480,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2232,,,2232,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",725.18,,,725.18,Other,110% of Medicare,996.2,,,996.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2593.54,,,2593.54,Other,186% of Medicaid,1172,,,1172,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1172,,,1172,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1172,,,1172,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1025.5,70,,1025.5,percent of total billed charges,All Other,952.25,65,,952.25,percent of total billed charges,Default if not in Fee Schedule,952.25,65,,952.25,percent of total billed charges,Default if not in Fee Schedule,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",1394.38,,,1394.38,Other,100% of Medicaid,1394.38,,,1394.38,Other,100% of Medicaid,1394.38,,,1394.38,Other,100% of Medicaid,1394.38,,,1394.38,Other,100% of Medicaid,3137.35,,,3137.35,Other,225% of Medicaid,2133.39,,,2133.39,Other,153% of Medicaid,3137.35,,,3137.35,Other,225% of Medicaid,1952.13,,,1952.13,Other,140% of Medicaid,3137.35,,,3137.35,Other,225% of Medicaid,3625.38,,,3625.38,Other,260% of Medicaid,4517.78,,,4517.78,Other,324% of Medicaid,2997.91,,,2997.91,Other,215% of Medicaid,2997.91,,,2997.91,Other,215% of Medicaid,1742.97,,,1742.97,Other,125% of Medicaid,659.25,7216,
LOW COST SKIN SUBSTITUTE APP,C5278,HCPCS,,73000017,CDM,361,RC,,,both,,,961,711.14,,,711.14,Other,150% of Medicare + 9.63% HCRA Surcharge,432.45,45,,432.45,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",475.7,,,475.7,Other,110% of Medicare,653.48,,,653.48,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2224.24,,,2224.24,Other,186% of Medicaid,768.8,,,768.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",768.8,,,768.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",768.8,,,768.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",672.7,70,,672.7,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",1195.83,,,1195.83,Other,100% of Medicaid,1195.83,,,1195.83,Other,100% of Medicaid,1195.83,,,1195.83,Other,100% of Medicaid,1195.83,,,1195.83,Other,100% of Medicaid,2690.61,,,2690.61,Other,225% of Medicaid,1829.61,,,1829.61,Other,153% of Medicaid,2690.61,,,2690.61,Other,225% of Medicaid,1674.16,,,1674.16,Other,140% of Medicaid,2690.61,,,2690.61,Other,225% of Medicaid,3109.15,,,3109.15,Other,260% of Medicaid,3874.48,,,3874.48,Other,324% of Medicaid,2571.03,,,2571.03,Other,215% of Medicaid,2571.03,,,2571.03,Other,215% of Medicaid,1494.78,,,1494.78,Other,125% of Medicaid,432.45,7216,
TENOTOMY OP FLEXOR; FT SGL/MULTI,28230,CPT,,73028230,CDM,361,RC,,,both,,,5245,3881.31,,,3881.31,Other,150% of Medicare + 9.63% HCRA Surcharge,2360.25,45,,2360.25,percent of total billed charges,Critical Access Hospital RCC factor,2480,,,2480,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2232,,,2232,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3648,,,3648,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3283,,,3283,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3101,,,3101,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2596.28,,,2596.28,Other,110% of Medicare,3566.6,,,3566.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2891.15,,,2891.15,Other,186% of Medicaid,4196,,,4196,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",4196,,,4196,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",4196,,,4196,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",3671.5,70,,3671.5,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",4531,,,4531,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4079,,,4079,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4531,,,4531,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3852,,,3852,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",1554.38,,,1554.38,Other,100% of Medicaid,1554.38,,,1554.38,Other,100% of Medicaid,1554.38,,,1554.38,Other,100% of Medicaid,1554.38,,,1554.38,Other,100% of Medicaid,3497.36,,,3497.36,Other,225% of Medicaid,2378.21,,,2378.21,Other,153% of Medicaid,3497.36,,,3497.36,Other,225% of Medicaid,2176.14,,,2176.14,Other,140% of Medicaid,3497.36,,,3497.36,Other,225% of Medicaid,4041.4,,,4041.4,Other,260% of Medicaid,5036.2,,,5036.2,Other,324% of Medicaid,3341.93,,,3341.93,Other,215% of Medicaid,3341.93,,,3341.93,Other,215% of Medicaid,1942.98,,,1942.98,Other,125% of Medicaid,1554.38,7216,
INJ ANESTH OTHR PERIPHERA,64450,CPT,,73064450,CDM,361,RC,,,both,,,1479,1094.46,,,1094.46,Other,150% of Medicare + 9.63% HCRA Surcharge,665.55,45,,665.55,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",732.11,,,732.11,Other,110% of Medicare,1005.72,,,1005.72,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",966.11,,,966.11,Other,186% of Medicaid,1183.2,,,1183.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1183.2,,,1183.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1183.2,,,1183.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1035.3,70,,1035.3,percent of total billed charges,All Other,203.36,,,203.36,Fee Schedule,,172.36,,,172.36,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",519.42,,,519.42,Other,100% of Medicaid,519.42,,,519.42,Other,100% of Medicaid,519.42,,,519.42,Other,100% of Medicaid,519.42,,,519.42,Other,100% of Medicaid,1168.69,,,1168.69,Other,225% of Medicaid,794.71,,,794.71,Other,153% of Medicaid,1168.69,,,1168.69,Other,225% of Medicaid,727.18,,,727.18,Other,140% of Medicaid,1168.69,,,1168.69,Other,225% of Medicaid,1350.48,,,1350.48,Other,260% of Medicaid,1682.91,,,1682.91,Other,324% of Medicaid,1116.74,,,1116.74,Other,215% of Medicaid,1116.74,,,1116.74,Other,215% of Medicaid,649.27,,,649.27,Other,125% of Medicaid,172.36,7216,
I&D ABSCESS SIMPLE OR SINGLE,10060,CPT,,82010060,CDM,361,RC,,,both,,,587,434.38,,,434.38,Other,150% of Medicare + 9.63% HCRA Surcharge,264.15,45,,264.15,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",290.57,,,290.57,Other,110% of Medicare,399.16,,,399.16,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",733,,,733,Other,186% of Medicaid,469.6,,,469.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",469.6,,,469.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",469.6,,,469.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",410.9,70,,410.9,percent of total billed charges,All Other,505.12,,,505.12,Fee Schedule,,428.12,,,428.12,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",394.14,,,394.14,Other,100% of Medicaid,394.14,,,394.14,Other,100% of Medicaid,394.14,,,394.14,Other,100% of Medicaid,394.14,,,394.14,Other,100% of Medicaid,886.83,,,886.83,Other,225% of Medicaid,603.04,,,603.04,Other,153% of Medicaid,886.83,,,886.83,Other,225% of Medicaid,551.8,,,551.8,Other,140% of Medicaid,886.83,,,886.83,Other,225% of Medicaid,1024.78,,,1024.78,Other,260% of Medicaid,1277.03,,,1277.03,Other,324% of Medicaid,847.41,,,847.41,Other,215% of Medicaid,847.41,,,847.41,Other,215% of Medicaid,492.68,,,492.68,Other,125% of Medicaid,264.15,7216,
INJECT TRIGGER POINTS 3/>,20553,CPT,,82020553,CDM,361,RC,,,both,,,807,597.18,,,597.18,Other,150% of Medicare + 9.63% HCRA Surcharge,363.15,45,,363.15,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",399.47,,,399.47,Other,110% of Medicare,548.76,,,548.76,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",686,,,686,Other,186% of Medicaid,645.6,,,645.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",645.6,,,645.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",645.6,,,645.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",564.9,70,,564.9,percent of total billed charges,All Other,206.64,,,206.64,Fee Schedule,,175.14,,,175.14,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",368.64,,,368.64,Other,100% of Medicaid,368.64,,,368.64,Other,100% of Medicaid,368.64,,,368.64,Other,100% of Medicaid,368.64,,,368.64,Other,100% of Medicaid,829.44,,,829.44,Other,225% of Medicaid,564.02,,,564.02,Other,153% of Medicaid,829.44,,,829.44,Other,225% of Medicaid,516.1,,,516.1,Other,140% of Medicaid,829.44,,,829.44,Other,225% of Medicaid,958.46,,,958.46,Other,260% of Medicaid,1194.39,,,1194.39,Other,324% of Medicaid,792.58,,,792.58,Other,215% of Medicaid,792.58,,,792.58,Other,215% of Medicaid,460.8,,,460.8,Other,125% of Medicaid,175.14,7216,
ASPIRATE/INJECT MAJOR JOINT,20610,CPT,,82020610,CDM,361,RC,,,both,,,1017,752.58,,,752.58,Other,150% of Medicare + 9.63% HCRA Surcharge,457.65,45,,457.65,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",503.42,,,503.42,Other,110% of Medicare,691.56,,,691.56,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",686,,,686,Other,186% of Medicaid,813.6,,,813.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",813.6,,,813.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",813.6,,,813.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",711.9,70,,711.9,percent of total billed charges,All Other,218.12,,,218.12,Fee Schedule,,184.87,,,184.87,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",368.64,,,368.64,Other,100% of Medicaid,368.64,,,368.64,Other,100% of Medicaid,368.64,,,368.64,Other,100% of Medicaid,368.64,,,368.64,Other,100% of Medicaid,829.44,,,829.44,Other,225% of Medicaid,564.02,,,564.02,Other,153% of Medicaid,829.44,,,829.44,Other,225% of Medicaid,516.1,,,516.1,Other,140% of Medicaid,829.44,,,829.44,Other,225% of Medicaid,958.46,,,958.46,Other,260% of Medicaid,1194.39,,,1194.39,Other,324% of Medicaid,792.58,,,792.58,Other,215% of Medicaid,792.58,,,792.58,Other,215% of Medicaid,460.8,,,460.8,Other,125% of Medicaid,184.87,7216,
INS PICC AGE 5 YRS >,36569,CPT,,82036569,CDM,361,RC,,,both,,,4042,2991.09,,,2991.09,Other,150% of Medicare + 9.63% HCRA Surcharge,1818.9,45,,1818.9,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3648,,,3648,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3283,,,3283,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3101,,,3101,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2000.79,,,2000.79,Other,110% of Medicare,2748.56,,,2748.56,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",586.68,,,586.68,Other,186% of Medicaid,3233.6,,,3233.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",3233.6,,,3233.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",3578,,,3578,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2829.4,70,,2829.4,percent of total billed charges,All Other,449.36,,,449.36,Fee Schedule,,380.86,,,380.86,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",315.42,,,315.42,Other,100% of Medicaid,315.42,,,315.42,Other,100% of Medicaid,315.42,,,315.42,Other,100% of Medicaid,315.42,,,315.42,Other,100% of Medicaid,709.7,,,709.7,Other,225% of Medicaid,482.6,,,482.6,Other,153% of Medicaid,709.7,,,709.7,Other,225% of Medicaid,441.59,,,441.59,Other,140% of Medicaid,709.7,,,709.7,Other,225% of Medicaid,820.1,,,820.1,Other,260% of Medicaid,1021.97,,,1021.97,Other,324% of Medicaid,678.16,,,678.16,Other,215% of Medicaid,678.16,,,678.16,Other,215% of Medicaid,394.28,,,394.28,Other,125% of Medicaid,315.42,7216,
LUMBAR PUNCTURE,62270,CPT,,82062270,CDM,361,RC,,,both,,,1479,1094.46,,,1094.46,Other,150% of Medicare + 9.63% HCRA Surcharge,665.55,45,,665.55,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",732.11,,,732.11,Other,110% of Medicare,1005.72,,,1005.72,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1116,,,1116,Other,186% of Medicaid,1183.2,,,1183.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1183.2,,,1183.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",3578,,,3578,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1035.3,70,,1035.3,percent of total billed charges,All Other,298.48,,,298.48,Fee Schedule,,252.98,,,252.98,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",600.19,,,600.19,Other,100% of Medicaid,600.19,,,600.19,Other,100% of Medicaid,600.19,,,600.19,Other,100% of Medicaid,600.19,,,600.19,Other,100% of Medicaid,1350.43,,,1350.43,Other,225% of Medicaid,918.29,,,918.29,Other,153% of Medicaid,1350.43,,,1350.43,Other,225% of Medicaid,840.26,,,840.26,Other,140% of Medicaid,1350.43,,,1350.43,Other,225% of Medicaid,1560.49,,,1560.49,Other,260% of Medicaid,1944.61,,,1944.61,Other,324% of Medicaid,1290.41,,,1290.41,Other,215% of Medicaid,1290.41,,,1290.41,Other,215% of Medicaid,750.24,,,750.24,Other,125% of Medicaid,252.98,7216,
INJ EPIDURAL BLOOD OR CLOT PATCH,62273,CPT,,82062273,CDM,361,RC,,,both,,,2701,1998.75,,,1998.75,Other,150% of Medicare + 9.63% HCRA Surcharge,1215.45,45,,1215.45,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",1337,,,1337,Other,110% of Medicare,1836.68,,,1836.68,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1116,,,1116,Other,186% of Medicaid,2160.8,,,2160.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2160.8,,,2160.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",3578,,,3578,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1890.7,70,,1890.7,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",600.19,,,600.19,Other,100% of Medicaid,600.19,,,600.19,Other,100% of Medicaid,600.19,,,600.19,Other,100% of Medicaid,600.19,,,600.19,Other,100% of Medicaid,1350.43,,,1350.43,Other,225% of Medicaid,918.29,,,918.29,Other,153% of Medicaid,1350.43,,,1350.43,Other,225% of Medicaid,840.26,,,840.26,Other,140% of Medicaid,1350.43,,,1350.43,Other,225% of Medicaid,1560.49,,,1560.49,Other,260% of Medicaid,1944.61,,,1944.61,Other,324% of Medicaid,1290.41,,,1290.41,Other,215% of Medicaid,1290.41,,,1290.41,Other,215% of Medicaid,750.24,,,750.24,Other,125% of Medicaid,600.19,7216,
INJ ANESTH GREATER OCCIPITAL NERVE,64405,CPT,,82064405,CDM,361,RC,,,both,,,1164,861.36,,,861.36,Other,150% of Medicare + 9.63% HCRA Surcharge,523.8,45,,523.8,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",576.18,,,576.18,Other,110% of Medicare,791.52,,,791.52,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",966,,,966,Other,186% of Medicaid,931.2,,,931.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",931.2,,,931.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",931.2,,,931.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",814.8,70,,814.8,percent of total billed charges,All Other,255.84,,,255.84,Fee Schedule,,216.84,,,216.84,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",519.42,,,519.42,Other,100% of Medicaid,519.42,,,519.42,Other,100% of Medicaid,519.42,,,519.42,Other,100% of Medicaid,519.42,,,519.42,Other,100% of Medicaid,1168.69,,,1168.69,Other,225% of Medicaid,794.71,,,794.71,Other,153% of Medicaid,1168.69,,,1168.69,Other,225% of Medicaid,727.18,,,727.18,Other,140% of Medicaid,1168.69,,,1168.69,Other,225% of Medicaid,1350.48,,,1350.48,Other,260% of Medicaid,1682.91,,,1682.91,Other,324% of Medicaid,1116.74,,,1116.74,Other,215% of Medicaid,1116.74,,,1116.74,Other,215% of Medicaid,649.27,,,649.27,Other,125% of Medicaid,216.84,7216,
INJ ANESTH OTHR PERIPHERA,64450,CPT,,82064450,CDM,361,RC,,,both,,,1479,1094.46,,,1094.46,Other,150% of Medicare + 9.63% HCRA Surcharge,665.55,45,,665.55,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",732.11,,,732.11,Other,110% of Medicare,1005.72,,,1005.72,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",966.11,,,966.11,Other,186% of Medicaid,1183.2,,,1183.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1183.2,,,1183.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1183.2,,,1183.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1035.3,70,,1035.3,percent of total billed charges,All Other,203.36,,,203.36,Fee Schedule,,172.36,,,172.36,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",519.42,,,519.42,Other,100% of Medicaid,519.42,,,519.42,Other,100% of Medicaid,519.42,,,519.42,Other,100% of Medicaid,519.42,,,519.42,Other,100% of Medicaid,1168.69,,,1168.69,Other,225% of Medicaid,794.71,,,794.71,Other,153% of Medicaid,1168.69,,,1168.69,Other,225% of Medicaid,727.18,,,727.18,Other,140% of Medicaid,1168.69,,,1168.69,Other,225% of Medicaid,1350.48,,,1350.48,Other,260% of Medicaid,1682.91,,,1682.91,Other,324% of Medicaid,1116.74,,,1116.74,Other,215% of Medicaid,1116.74,,,1116.74,Other,215% of Medicaid,649.27,,,649.27,Other,125% of Medicaid,172.36,7216,
MOD SED SAME PHYS/QHP 5/>YR FIRST 15 MIN,99152,CPT,,35099152,CDM,370,RC,,,both,,,157,116.18,,,116.18,Other,150% of Medicare + 9.63% HCRA Surcharge,70.65,45,,70.65,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,77.72,,,77.72,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,109.9,70,,109.9,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,116.18,
MOD SED SAME PHYS/QHP EA ADDL 15 MIN,99153,CPT,,35099153,CDM,370,RC,,,both,,,157,116.18,,,116.18,Other,150% of Medicare + 9.63% HCRA Surcharge,70.65,45,,70.65,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,77.72,,,77.72,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,109.9,70,,109.9,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,116.18,
MOD SED SAME PHYS/QHP 5/>YR FIRST 15 MIN,99152,CPT,,49099152,CDM,370,RC,,,both,,,157,116.18,,,116.18,Other,150% of Medicare + 9.63% HCRA Surcharge,70.65,45,,70.65,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,77.72,,,77.72,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,109.9,70,,109.9,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,116.18,
MOD SED SAME PHYS/QHP EA ADDL 15 MIN,99153,CPT,,49099153,CDM,370,RC,,,both,,,157,116.18,,,116.18,Other,150% of Medicare + 9.63% HCRA Surcharge,70.65,45,,70.65,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,77.72,,,77.72,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,109.9,70,,109.9,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,116.18,
MOD SED SAME PHYS/QHP 5/>YR FIRST 15 MIN,99152,CPT,,44099152,CDM,371,RC,,,both,,,157,116.18,,,116.18,Other,150% of Medicare + 9.63% HCRA Surcharge,70.65,45,,70.65,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,77.72,,,77.72,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,109.9,70,,109.9,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,116.18,
MOD SED SAME PHYS/QHP EA ADDL 15 MIN,99153,CPT,,44099153,CDM,371,RC,,,both,,,157,116.18,,,116.18,Other,150% of Medicare + 9.63% HCRA Surcharge,70.65,45,,70.65,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,77.72,,,77.72,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,109.9,70,,109.9,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,116.18,
MOD SED SAME PHYS/QHP 5/>YR FIRST 15 MIN,99152,CPT,,46099152,CDM,371,RC,,,both,,,157,116.18,,,116.18,Other,150% of Medicare + 9.63% HCRA Surcharge,70.65,45,,70.65,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,77.72,,,77.72,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,109.9,70,,109.9,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,116.18,
MOD SED SAME PHYS/QHP EA ADDL 15 MIN,99153,CPT,,46099153,CDM,371,RC,,,both,,,157,116.18,,,116.18,Other,150% of Medicare + 9.63% HCRA Surcharge,70.65,45,,70.65,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,77.72,,,77.72,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,109.9,70,,109.9,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,116.18,
MOD SED SAME PHYS/QHP 5/>YR FIRST 15 MIN,99152,CPT,,47099152,CDM,371,RC,,,both,,,157,116.18,,,116.18,Other,150% of Medicare + 9.63% HCRA Surcharge,70.65,45,,70.65,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,77.72,,,77.72,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,109.9,70,,109.9,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,116.18,
MOD SED SAME PHYS/QHP EA ADDL 15 MIN,99153,CPT,,47099153,CDM,371,RC,,,both,,,157,116.18,,,116.18,Other,150% of Medicare + 9.63% HCRA Surcharge,70.65,45,,70.65,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,77.72,,,77.72,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,109.9,70,,109.9,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,116.18,
CRYOPRECIPITATE EA UNIT,P9012,HCPCS,,77000003,CDM,390,RC,,,both,,,918,679.32,,,679.32,Other,150% of Medicare + 9.63% HCRA Surcharge,413.1,45,,413.1,percent of total billed charges,Critical Access Hospital RCC factor,642.6,70,,642.6,percent of total billed charges,Blood Products,642.6,70,,642.6,percent of total billed charges,Blood Products,642.6,70,,642.6,percent of total billed charges,Blood Products,642.6,70,,642.6,percent of total billed charges,Blood Products,642.6,70,,642.6,percent of total billed charges,Blood Products,454.41,,,454.41,Other,110% of Medicare,615.06,67,,615.06,percent of total billed charges,Blood Products,642.6,70,"If Charge > 500, then 70 percent",642.6,percent of total billed charges,Blood Products,615.06,67,,615.06,percent of total billed charges,Blood Products,615.06,67,,615.06,percent of total billed charges,Blood Products,615.06,67,,615.06,percent of total billed charges,Blood Products,615.06,67,,615.06,percent of total billed charges,Blood Products,615.06,67,,615.06,percent of total billed charges,Blood Products,642.6,70,,642.6,percent of total billed charges,Blood Products,642.6,70,,642.6,percent of total billed charges,All Other,642.6,70,,642.6,percent of total billed charges,Blood Products,642.6,70,,642.6,percent of total billed charges,Blood Products,615.06,67,,615.06,percent of total billed charges,Blood Products,615.06,67,,615.06,percent of total billed charges,Blood Products,615.06,67,,615.06,percent of total billed charges,Blood Products,615.06,67,,615.06,percent of total billed charges,Blood Products,550.62,,,550.62,Other,100% of Medicaid,550.62,,,550.62,Other,100% of Medicaid,550.62,,,550.62,Other,100% of Medicaid,550.62,,,550.62,Other,100% of Medicaid,1238.88,,,1238.88,Other,225% of Medicaid,842.44,,,842.44,Other,153% of Medicaid,1238.88,,,1238.88,Other,225% of Medicaid,770.86,,,770.86,Other,140% of Medicaid,0.01,70,"If Charge > 2,000, then 70 percent",0.01,percent of total billed charges,Blood Products,1431.6,,,1431.6,Other,260% of Medicaid,1783.99,,,1783.99,Other,324% of Medicaid,1183.82,,,1183.82,Other,215% of Medicaid,1183.82,,,1183.82,Other,215% of Medicaid,688.27,,,688.27,Other,125% of Medicaid,0.01,1783.99,
LEUKOCYTE POOR BLOOD EA UNIT,P9016,HCPCS,,77000004,CDM,390,RC,,,both,,,540,399.6,,,399.6,Other,150% of Medicare + 9.63% HCRA Surcharge,243,45,,243,percent of total billed charges,Critical Access Hospital RCC factor,378,70,,378,percent of total billed charges,Blood Products,378,70,,378,percent of total billed charges,Blood Products,378,70,,378,percent of total billed charges,Blood Products,378,70,,378,percent of total billed charges,Blood Products,378,70,,378,percent of total billed charges,Blood Products,267.3,,,267.3,Other,110% of Medicare,361.8,67,,361.8,percent of total billed charges,Blood Products,378,70,"If Charge > 500, then 70 percent",378,percent of total billed charges,Blood Products,361.8,67,,361.8,percent of total billed charges,Blood Products,361.8,67,,361.8,percent of total billed charges,Blood Products,361.8,67,,361.8,percent of total billed charges,Blood Products,361.8,67,,361.8,percent of total billed charges,Blood Products,361.8,67,,361.8,percent of total billed charges,Blood Products,378,70,,378,percent of total billed charges,Blood Products,378,70,,378,percent of total billed charges,All Other,378,70,,378,percent of total billed charges,Blood Products,378,70,,378,percent of total billed charges,Blood Products,361.8,67,,361.8,percent of total billed charges,Blood Products,361.8,67,,361.8,percent of total billed charges,Blood Products,361.8,67,,361.8,percent of total billed charges,Blood Products,361.8,67,,361.8,percent of total billed charges,Blood Products,447.4,,,447.4,Other,100% of Medicaid,447.4,,,447.4,Other,100% of Medicaid,447.4,,,447.4,Other,100% of Medicaid,447.4,,,447.4,Other,100% of Medicaid,1006.66,,,1006.66,Other,225% of Medicaid,684.53,,,684.53,Other,153% of Medicaid,1006.66,,,1006.66,Other,225% of Medicaid,626.36,,,626.36,Other,140% of Medicaid,0.01,70,"If Charge > 2,000, then 70 percent",0.01,percent of total billed charges,Blood Products,1163.25,,,1163.25,Other,260% of Medicaid,1449.59,,,1449.59,Other,324% of Medicaid,961.92,,,961.92,Other,215% of Medicaid,961.92,,,961.92,Other,215% of Medicaid,559.25,,,559.25,Other,125% of Medicaid,0.01,1449.59,
WASHED RED BLOOD CELLS EA UNIT,P9022,HCPCS,,77000008,CDM,390,RC,,,both,,,792,586.08,,,586.08,Other,150% of Medicare + 9.63% HCRA Surcharge,356.4,45,,356.4,percent of total billed charges,Critical Access Hospital RCC factor,554.4,70,,554.4,percent of total billed charges,Blood Products,554.4,70,,554.4,percent of total billed charges,Blood Products,554.4,70,,554.4,percent of total billed charges,Blood Products,554.4,70,,554.4,percent of total billed charges,Blood Products,554.4,70,,554.4,percent of total billed charges,Blood Products,392.04,,,392.04,Other,110% of Medicare,530.64,67,,530.64,percent of total billed charges,Blood Products,554.4,70,"If Charge > 500, then 70 percent",554.4,percent of total billed charges,Blood Products,530.64,67,,530.64,percent of total billed charges,Blood Products,530.64,67,,530.64,percent of total billed charges,Blood Products,530.64,67,,530.64,percent of total billed charges,Blood Products,530.64,67,,530.64,percent of total billed charges,Blood Products,530.64,67,,530.64,percent of total billed charges,Blood Products,554.4,70,,554.4,percent of total billed charges,Blood Products,554.4,70,,554.4,percent of total billed charges,All Other,554.4,70,,554.4,percent of total billed charges,Blood Products,554.4,70,,554.4,percent of total billed charges,Blood Products,530.64,67,,530.64,percent of total billed charges,Blood Products,530.64,67,,530.64,percent of total billed charges,Blood Products,530.64,67,,530.64,percent of total billed charges,Blood Products,530.64,67,,530.64,percent of total billed charges,Blood Products,550.62,,,550.62,Other,100% of Medicaid,550.62,,,550.62,Other,100% of Medicaid,550.62,,,550.62,Other,100% of Medicaid,550.62,,,550.62,Other,100% of Medicaid,1238.88,,,1238.88,Other,225% of Medicaid,842.44,,,842.44,Other,153% of Medicaid,1238.88,,,1238.88,Other,225% of Medicaid,770.86,,,770.86,Other,140% of Medicaid,0.01,70,"If Charge > 2,000, then 70 percent",0.01,percent of total billed charges,Blood Products,1431.6,,,1431.6,Other,260% of Medicaid,1783.99,,,1783.99,Other,324% of Medicaid,1183.82,,,1183.82,Other,215% of Medicaid,1183.82,,,1183.82,Other,215% of Medicaid,688.27,,,688.27,Other,125% of Medicaid,0.01,1783.99,
PLATELETS PHERESIS LR EA UNIT,P9035,HCPCS,,77000011,CDM,390,RC,,,both,,,1317,974.58,,,974.58,Other,150% of Medicare + 9.63% HCRA Surcharge,592.65,45,,592.65,percent of total billed charges,Critical Access Hospital RCC factor,921.9,70,,921.9,percent of total billed charges,Blood Products,921.9,70,,921.9,percent of total billed charges,Blood Products,921.9,70,,921.9,percent of total billed charges,Blood Products,921.9,70,,921.9,percent of total billed charges,Blood Products,921.9,70,,921.9,percent of total billed charges,Blood Products,651.92,,,651.92,Other,110% of Medicare,882.39,67,,882.39,percent of total billed charges,Blood Products,921.9,70,"If Charge > 500, then 70 percent",921.9,percent of total billed charges,Blood Products,882.39,67,,882.39,percent of total billed charges,Blood Products,882.39,67,,882.39,percent of total billed charges,Blood Products,882.39,67,,882.39,percent of total billed charges,Blood Products,882.39,67,,882.39,percent of total billed charges,Blood Products,882.39,67,,882.39,percent of total billed charges,Blood Products,921.9,70,,921.9,percent of total billed charges,Blood Products,921.9,70,,921.9,percent of total billed charges,All Other,921.9,70,,921.9,percent of total billed charges,Blood Products,921.9,70,,921.9,percent of total billed charges,Blood Products,882.39,67,,882.39,percent of total billed charges,Blood Products,882.39,67,,882.39,percent of total billed charges,Blood Products,882.39,67,,882.39,percent of total billed charges,Blood Products,882.39,67,,882.39,percent of total billed charges,Blood Products,550.62,,,550.62,Other,100% of Medicaid,550.62,,,550.62,Other,100% of Medicaid,550.62,,,550.62,Other,100% of Medicaid,550.62,,,550.62,Other,100% of Medicaid,1238.88,,,1238.88,Other,225% of Medicaid,842.44,,,842.44,Other,153% of Medicaid,1238.88,,,1238.88,Other,225% of Medicaid,770.86,,,770.86,Other,140% of Medicaid,0.01,70,"If Charge > 2,000, then 70 percent",0.01,percent of total billed charges,Blood Products,1431.6,,,1431.6,Other,260% of Medicaid,1783.99,,,1783.99,Other,324% of Medicaid,1183.82,,,1183.82,Other,215% of Medicaid,1183.82,,,1183.82,Other,215% of Medicaid,688.27,,,688.27,Other,125% of Medicaid,0.01,1783.99,
PLATELETS PHERESIS LR IRRAD EA UNIT,P9037,HCPCS,,77000013,CDM,390,RC,,,both,,,1409,1042.66,,,1042.66,Other,150% of Medicare + 9.63% HCRA Surcharge,634.05,45,,634.05,percent of total billed charges,Critical Access Hospital RCC factor,986.3,70,,986.3,percent of total billed charges,Blood Products,986.3,70,,986.3,percent of total billed charges,Blood Products,986.3,70,,986.3,percent of total billed charges,Blood Products,986.3,70,,986.3,percent of total billed charges,Blood Products,986.3,70,,986.3,percent of total billed charges,Blood Products,697.46,,,697.46,Other,110% of Medicare,944.03,67,,944.03,percent of total billed charges,Blood Products,986.3,70,"If Charge > 500, then 70 percent",986.3,percent of total billed charges,Blood Products,944.03,67,,944.03,percent of total billed charges,Blood Products,944.03,67,,944.03,percent of total billed charges,Blood Products,944.03,67,,944.03,percent of total billed charges,Blood Products,944.03,67,,944.03,percent of total billed charges,Blood Products,944.03,67,,944.03,percent of total billed charges,Blood Products,986.3,70,,986.3,percent of total billed charges,Blood Products,986.3,70,,986.3,percent of total billed charges,All Other,986.3,70,,986.3,percent of total billed charges,Blood Products,986.3,70,,986.3,percent of total billed charges,Blood Products,944.03,67,,944.03,percent of total billed charges,Blood Products,944.03,67,,944.03,percent of total billed charges,Blood Products,944.03,67,,944.03,percent of total billed charges,Blood Products,944.03,67,,944.03,percent of total billed charges,Blood Products,550.62,,,550.62,Other,100% of Medicaid,550.62,,,550.62,Other,100% of Medicaid,550.62,,,550.62,Other,100% of Medicaid,550.62,,,550.62,Other,100% of Medicaid,1238.88,,,1238.88,Other,225% of Medicaid,842.44,,,842.44,Other,153% of Medicaid,1238.88,,,1238.88,Other,225% of Medicaid,770.86,,,770.86,Other,140% of Medicaid,0.01,70,"If Charge > 2,000, then 70 percent",0.01,percent of total billed charges,Blood Products,1431.6,,,1431.6,Other,260% of Medicaid,1783.99,,,1783.99,Other,324% of Medicaid,1183.82,,,1183.82,Other,215% of Medicaid,1183.82,,,1183.82,Other,215% of Medicaid,688.27,,,688.27,Other,125% of Medicaid,0.01,1783.99,
RBC IRRADIATED EACH UNIT,P9038,HCPCS,,77000014,CDM,390,RC,,,both,,,822,608.28,,,608.28,Other,150% of Medicare + 9.63% HCRA Surcharge,369.9,45,,369.9,percent of total billed charges,Critical Access Hospital RCC factor,575.4,70,,575.4,percent of total billed charges,Blood Products,575.4,70,,575.4,percent of total billed charges,Blood Products,575.4,70,,575.4,percent of total billed charges,Blood Products,575.4,70,,575.4,percent of total billed charges,Blood Products,575.4,70,,575.4,percent of total billed charges,Blood Products,406.89,,,406.89,Other,110% of Medicare,550.74,67,,550.74,percent of total billed charges,Blood Products,575.4,70,"If Charge > 500, then 70 percent",575.4,percent of total billed charges,Blood Products,550.74,67,,550.74,percent of total billed charges,Blood Products,550.74,67,,550.74,percent of total billed charges,Blood Products,550.74,67,,550.74,percent of total billed charges,Blood Products,550.74,67,,550.74,percent of total billed charges,Blood Products,550.74,67,,550.74,percent of total billed charges,Blood Products,575.4,70,,575.4,percent of total billed charges,Blood Products,575.4,70,,575.4,percent of total billed charges,All Other,575.4,70,,575.4,percent of total billed charges,Blood Products,575.4,70,,575.4,percent of total billed charges,Blood Products,550.74,67,,550.74,percent of total billed charges,Blood Products,550.74,67,,550.74,percent of total billed charges,Blood Products,550.74,67,,550.74,percent of total billed charges,Blood Products,550.74,67,,550.74,percent of total billed charges,Blood Products,447.4,,,447.4,Other,100% of Medicaid,447.4,,,447.4,Other,100% of Medicaid,447.4,,,447.4,Other,100% of Medicaid,447.4,,,447.4,Other,100% of Medicaid,1006.66,,,1006.66,Other,225% of Medicaid,684.53,,,684.53,Other,153% of Medicaid,1006.66,,,1006.66,Other,225% of Medicaid,626.36,,,626.36,Other,140% of Medicaid,0.01,70,"If Charge > 2,000, then 70 percent",0.01,percent of total billed charges,Blood Products,1163.25,,,1163.25,Other,260% of Medicaid,1449.59,,,1449.59,Other,324% of Medicaid,961.92,,,961.92,Other,215% of Medicaid,961.92,,,961.92,Other,215% of Medicaid,559.25,,,559.25,Other,125% of Medicaid,0.01,1449.59,
RBC LR IRRADIATED EACH UNIT,P9040,HCPCS,,77000015,CDM,390,RC,,,both,,,638,472.12,,,472.12,Other,150% of Medicare + 9.63% HCRA Surcharge,287.1,45,,287.1,percent of total billed charges,Critical Access Hospital RCC factor,446.6,70,,446.6,percent of total billed charges,Blood Products,446.6,70,,446.6,percent of total billed charges,Blood Products,446.6,70,,446.6,percent of total billed charges,Blood Products,446.6,70,,446.6,percent of total billed charges,Blood Products,446.6,70,,446.6,percent of total billed charges,Blood Products,315.81,,,315.81,Other,110% of Medicare,427.46,67,,427.46,percent of total billed charges,Blood Products,446.6,70,"If Charge > 500, then 70 percent",446.6,percent of total billed charges,Blood Products,427.46,67,,427.46,percent of total billed charges,Blood Products,427.46,67,,427.46,percent of total billed charges,Blood Products,427.46,67,,427.46,percent of total billed charges,Blood Products,427.46,67,,427.46,percent of total billed charges,Blood Products,427.46,67,,427.46,percent of total billed charges,Blood Products,446.6,70,,446.6,percent of total billed charges,Blood Products,446.6,70,,446.6,percent of total billed charges,All Other,446.6,70,,446.6,percent of total billed charges,Blood Products,446.6,70,,446.6,percent of total billed charges,Blood Products,427.46,67,,427.46,percent of total billed charges,Blood Products,427.46,67,,427.46,percent of total billed charges,Blood Products,427.46,67,,427.46,percent of total billed charges,Blood Products,427.46,67,,427.46,percent of total billed charges,Blood Products,447.4,,,447.4,Other,100% of Medicaid,447.4,,,447.4,Other,100% of Medicaid,447.4,,,447.4,Other,100% of Medicaid,447.4,,,447.4,Other,100% of Medicaid,1006.66,,,1006.66,Other,225% of Medicaid,684.53,,,684.53,Other,153% of Medicaid,1006.66,,,1006.66,Other,225% of Medicaid,626.36,,,626.36,Other,140% of Medicaid,0.01,70,"If Charge > 2,000, then 70 percent",0.01,percent of total billed charges,Blood Products,1163.25,,,1163.25,Other,260% of Medicaid,1449.59,,,1449.59,Other,324% of Medicaid,961.92,,,961.92,Other,215% of Medicaid,961.92,,,961.92,Other,215% of Medicaid,559.25,,,559.25,Other,125% of Medicaid,0.01,1449.59,
FFP 8-24 HRS OF COLLECT EA UNIT,P9059,HCPCS,,77000020,CDM,390,RC,,,both,,,174,128.76,,,128.76,Other,150% of Medicare + 9.63% HCRA Surcharge,78.3,45,,78.3,percent of total billed charges,Critical Access Hospital RCC factor,121.8,70,,121.8,percent of total billed charges,Blood Products,121.8,70,,121.8,percent of total billed charges,Blood Products,121.8,70,,121.8,percent of total billed charges,Blood Products,121.8,70,,121.8,percent of total billed charges,Blood Products,121.8,70,,121.8,percent of total billed charges,Blood Products,86.13,,,86.13,Other,110% of Medicare,116.58,67,,116.58,percent of total billed charges,Blood Products,0.01,70,"If Charge > 500, then 70 percent",0.01,percent of total billed charges,Blood Products,116.58,67,,116.58,percent of total billed charges,Blood Products,116.58,67,,116.58,percent of total billed charges,Blood Products,116.58,67,,116.58,percent of total billed charges,Blood Products,116.58,67,,116.58,percent of total billed charges,Blood Products,116.58,67,,116.58,percent of total billed charges,Blood Products,121.8,70,,121.8,percent of total billed charges,Blood Products,121.8,70,,121.8,percent of total billed charges,All Other,121.8,70,,121.8,percent of total billed charges,Blood Products,121.8,70,,121.8,percent of total billed charges,Blood Products,116.58,67,,116.58,percent of total billed charges,Blood Products,116.58,67,,116.58,percent of total billed charges,Blood Products,116.58,67,,116.58,percent of total billed charges,Blood Products,116.58,67,,116.58,percent of total billed charges,Blood Products,447.4,,,447.4,Other,100% of Medicaid,447.4,,,447.4,Other,100% of Medicaid,447.4,,,447.4,Other,100% of Medicaid,447.4,,,447.4,Other,100% of Medicaid,1006.66,,,1006.66,Other,225% of Medicaid,684.53,,,684.53,Other,153% of Medicaid,1006.66,,,1006.66,Other,225% of Medicaid,626.36,,,626.36,Other,140% of Medicaid,0.01,70,"If Charge > 2,000, then 70 percent",0.01,percent of total billed charges,Blood Products,1163.25,,,1163.25,Other,260% of Medicaid,1449.59,,,1449.59,Other,324% of Medicaid,961.92,,,961.92,Other,215% of Medicaid,961.92,,,961.92,Other,215% of Medicaid,559.25,,,559.25,Other,125% of Medicaid,0.01,1449.59,
COVID-19 CONVALESCENT PLASMA,C9507,HCPCS,,77000025,CDM,390,RC,,,both,,,2252,1666.49,,,1666.49,Other,150% of Medicare + 9.63% HCRA Surcharge,1013.4,45,,1013.4,percent of total billed charges,Critical Access Hospital RCC factor,1576.4,70,,1576.4,percent of total billed charges,Blood Products,1576.4,70,,1576.4,percent of total billed charges,Blood Products,1576.4,70,,1576.4,percent of total billed charges,Blood Products,1576.4,70,,1576.4,percent of total billed charges,Blood Products,1576.4,70,,1576.4,percent of total billed charges,Blood Products,1114.74,,,1114.74,Other,110% of Medicare,1508.84,67,,1508.84,percent of total billed charges,Blood Products,1576.4,70,"If Charge > 500, then 70 percent",1576.4,percent of total billed charges,Blood Products,1508.84,67,,1508.84,percent of total billed charges,Blood Products,1508.84,67,,1508.84,percent of total billed charges,Blood Products,1508.84,67,,1508.84,percent of total billed charges,Blood Products,1508.84,67,,1508.84,percent of total billed charges,Blood Products,1508.84,67,,1508.84,percent of total billed charges,Blood Products,1576.4,70,,1576.4,percent of total billed charges,Blood Products,1576.4,70,,1576.4,percent of total billed charges,All Other,1576.4,70,,1576.4,percent of total billed charges,Blood Products,1576.4,70,,1576.4,percent of total billed charges,Blood Products,1508.84,67,,1508.84,percent of total billed charges,Blood Products,1508.84,67,,1508.84,percent of total billed charges,Blood Products,1508.84,67,,1508.84,percent of total billed charges,Blood Products,1508.84,67,,1508.84,percent of total billed charges,Blood Products,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,1576.4,70,"If Charge > 2,000, then 70 percent",1576.4,percent of total billed charges,Blood Products,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1666.49,
PLATLTS PHERES LEUKOCYTES RDUC,P9035,HCPCS,,78000006,CDM,390,RC,,,both,,,921.9,682.22,,,682.22,Other,150% of Medicare + 9.63% HCRA Surcharge,414.86,45,,414.86,percent of total billed charges,Critical Access Hospital RCC factor,645.33,70,,645.33,percent of total billed charges,Blood Products,645.33,70,,645.33,percent of total billed charges,Blood Products,645.33,70,,645.33,percent of total billed charges,Blood Products,645.33,70,,645.33,percent of total billed charges,Blood Products,645.33,70,,645.33,percent of total billed charges,Blood Products,456.35,,,456.35,Other,110% of Medicare,617.67,67,,617.67,percent of total billed charges,Blood Products,645.33,70,"If Charge > 500, then 70 percent",645.33,percent of total billed charges,Blood Products,617.67,67,,617.67,percent of total billed charges,Blood Products,617.67,67,,617.67,percent of total billed charges,Blood Products,617.67,67,,617.67,percent of total billed charges,Blood Products,617.67,67,,617.67,percent of total billed charges,Blood Products,617.67,67,,617.67,percent of total billed charges,Blood Products,645.33,70,,645.33,percent of total billed charges,Blood Products,645.33,70,,645.33,percent of total billed charges,All Other,645.33,70,,645.33,percent of total billed charges,Blood Products,645.33,70,,645.33,percent of total billed charges,Blood Products,617.67,67,,617.67,percent of total billed charges,Blood Products,617.67,67,,617.67,percent of total billed charges,Blood Products,617.67,67,,617.67,percent of total billed charges,Blood Products,617.67,67,,617.67,percent of total billed charges,Blood Products,550.62,,,550.62,Other,100% of Medicaid,550.62,,,550.62,Other,100% of Medicaid,550.62,,,550.62,Other,100% of Medicaid,550.62,,,550.62,Other,100% of Medicaid,1238.88,,,1238.88,Other,225% of Medicaid,842.44,,,842.44,Other,153% of Medicaid,1238.88,,,1238.88,Other,225% of Medicaid,770.86,,,770.86,Other,140% of Medicaid,0.01,70,"If Charge > 2,000, then 70 percent",0.01,percent of total billed charges,Blood Products,1431.6,,,1431.6,Other,260% of Medicaid,1783.99,,,1783.99,Other,324% of Medicaid,1183.82,,,1183.82,Other,215% of Medicaid,1183.82,,,1183.82,Other,215% of Medicaid,688.27,,,688.27,Other,125% of Medicaid,0.01,1783.99,
GRANULOCYTES PHERESIS UNIT,P9050,HCPCS,,78000021,CDM,390,RC,,,both,,,4954,3665.97,,,3665.97,Other,150% of Medicare + 9.63% HCRA Surcharge,2229.3,45,,2229.3,percent of total billed charges,Critical Access Hospital RCC factor,3467.8,70,,3467.8,percent of total billed charges,Blood Products,3467.8,70,,3467.8,percent of total billed charges,Blood Products,3467.8,70,,3467.8,percent of total billed charges,Blood Products,3467.8,70,,3467.8,percent of total billed charges,Blood Products,3467.8,70,,3467.8,percent of total billed charges,Blood Products,2452.23,,,2452.23,Other,110% of Medicare,3319.18,67,,3319.18,percent of total billed charges,Blood Products,3467.8,70,"If Charge > 500, then 70 percent",3467.8,percent of total billed charges,Blood Products,3319.18,67,,3319.18,percent of total billed charges,Blood Products,3319.18,67,,3319.18,percent of total billed charges,Blood Products,3319.18,67,,3319.18,percent of total billed charges,Blood Products,3319.18,67,,3319.18,percent of total billed charges,Blood Products,3319.18,67,,3319.18,percent of total billed charges,Blood Products,3467.8,70,,3467.8,percent of total billed charges,Blood Products,3467.8,70,,3467.8,percent of total billed charges,All Other,3467.8,70,,3467.8,percent of total billed charges,Blood Products,3467.8,70,,3467.8,percent of total billed charges,Blood Products,3319.18,67,,3319.18,percent of total billed charges,Blood Products,3319.18,67,,3319.18,percent of total billed charges,Blood Products,3319.18,67,,3319.18,percent of total billed charges,Blood Products,3319.18,67,,3319.18,percent of total billed charges,Blood Products,550.62,,,550.62,Other,100% of Medicaid,550.62,,,550.62,Other,100% of Medicaid,550.62,,,550.62,Other,100% of Medicaid,550.62,,,550.62,Other,100% of Medicaid,1238.88,,,1238.88,Other,225% of Medicaid,842.44,,,842.44,Other,153% of Medicaid,1238.88,,,1238.88,Other,225% of Medicaid,770.86,,,770.86,Other,140% of Medicaid,3467.8,70,"If Charge > 2,000, then 70 percent",3467.8,percent of total billed charges,Blood Products,1431.6,,,1431.6,Other,260% of Medicaid,1783.99,,,1783.99,Other,324% of Medicaid,1183.82,,,1183.82,Other,215% of Medicaid,1183.82,,,1183.82,Other,215% of Medicaid,688.27,,,688.27,Other,125% of Medicaid,550.62,3665.97,
PLATELETS PHERESIS PATH REDU,P9073,HCPCS,,78000022,CDM,390,RC,,,both,,,1789,1323.86,,,1323.86,Other,150% of Medicare + 9.63% HCRA Surcharge,805.05,45,,805.05,percent of total billed charges,Critical Access Hospital RCC factor,1252.3,70,,1252.3,percent of total billed charges,Blood Products,1252.3,70,,1252.3,percent of total billed charges,Blood Products,1252.3,70,,1252.3,percent of total billed charges,Blood Products,1252.3,70,,1252.3,percent of total billed charges,Blood Products,1252.3,70,,1252.3,percent of total billed charges,Blood Products,885.56,,,885.56,Other,110% of Medicare,1198.63,67,,1198.63,percent of total billed charges,Blood Products,1252.3,70,"If Charge > 500, then 70 percent",1252.3,percent of total billed charges,Blood Products,1198.63,67,,1198.63,percent of total billed charges,Blood Products,1198.63,67,,1198.63,percent of total billed charges,Blood Products,1198.63,67,,1198.63,percent of total billed charges,Blood Products,1198.63,67,,1198.63,percent of total billed charges,Blood Products,1198.63,67,,1198.63,percent of total billed charges,Blood Products,1252.3,70,,1252.3,percent of total billed charges,Blood Products,1252.3,70,,1252.3,percent of total billed charges,All Other,1252.3,70,,1252.3,percent of total billed charges,Blood Products,1252.3,70,,1252.3,percent of total billed charges,Blood Products,1198.63,67,,1198.63,percent of total billed charges,Blood Products,1198.63,67,,1198.63,percent of total billed charges,Blood Products,1198.63,67,,1198.63,percent of total billed charges,Blood Products,1198.63,67,,1198.63,percent of total billed charges,Blood Products,550.62,,,550.62,Other,100% of Medicaid,550.62,,,550.62,Other,100% of Medicaid,550.62,,,550.62,Other,100% of Medicaid,550.62,,,550.62,Other,100% of Medicaid,1238.88,,,1238.88,Other,225% of Medicaid,842.44,,,842.44,Other,153% of Medicaid,1238.88,,,1238.88,Other,225% of Medicaid,770.86,,,770.86,Other,140% of Medicaid,0.01,70,"If Charge > 2,000, then 70 percent",0.01,percent of total billed charges,Blood Products,1431.6,,,1431.6,Other,260% of Medicaid,1783.99,,,1783.99,Other,324% of Medicaid,1183.82,,,1183.82,Other,215% of Medicaid,1183.82,,,1183.82,Other,215% of Medicaid,688.27,,,688.27,Other,125% of Medicaid,0.01,1783.99,
TRANSFUSION BLOOD OR BLOOD COMPONENTS,36430,CPT,,26036430,CDM,391,RC,,,both,,,1109,820.66,,,820.66,Other,150% of Medicare + 9.63% HCRA Surcharge,499.05,45,,499.05,percent of total billed charges,Critical Access Hospital RCC factor,720.85,70,,720.85,percent of total billed charges,Blood Products,654.31,70,,654.31,percent of total billed charges,Blood Products,776.3,70,,776.3,percent of total billed charges,Blood Products,776.3,70,,776.3,percent of total billed charges,Blood Products,776.3,70,,776.3,percent of total billed charges,Blood Products,548.96,,,548.96,Other,110% of Medicare,743.03,67,,743.03,percent of total billed charges,Blood Products,776.3,70,"If Charge > 500, then 70 percent",776.3,percent of total billed charges,Blood Products,743.03,67,,743.03,percent of total billed charges,Blood Products,743.03,67,,743.03,percent of total billed charges,Blood Products,743.03,67,,743.03,percent of total billed charges,Blood Products,743.03,67,,743.03,percent of total billed charges,Blood Products,743.03,67,,743.03,percent of total billed charges,Blood Products,776.3,70,,776.3,percent of total billed charges,Blood Products,776.3,70,,776.3,percent of total billed charges,All Other,776.3,70,,776.3,percent of total billed charges,Blood Products,776.3,70,,776.3,percent of total billed charges,Blood Products,743.03,67,,743.03,percent of total billed charges,Blood Products,743.03,67,,743.03,percent of total billed charges,Blood Products,743.03,67,,743.03,percent of total billed charges,Blood Products,743.03,67,,743.03,percent of total billed charges,Blood Products,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,70,"If Charge > 2,000, then 70 percent",0.01,percent of total billed charges,Blood Products,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,820.66,
BLOOD TRANSFUSION SERVICE,36430,CPT,,30036430,CDM,391,RC,,,both,,,1109,820.66,,,820.66,Other,150% of Medicare + 9.63% HCRA Surcharge,499.05,45,,499.05,percent of total billed charges,Critical Access Hospital RCC factor,720.85,70,,720.85,percent of total billed charges,Blood Products,654.31,70,,654.31,percent of total billed charges,Blood Products,776.3,70,,776.3,percent of total billed charges,Blood Products,776.3,70,,776.3,percent of total billed charges,Blood Products,776.3,70,,776.3,percent of total billed charges,Blood Products,548.96,,,548.96,Other,110% of Medicare,743.03,67,,743.03,percent of total billed charges,Blood Products,776.3,70,"If Charge > 500, then 70 percent",776.3,percent of total billed charges,Blood Products,743.03,67,,743.03,percent of total billed charges,Blood Products,743.03,67,,743.03,percent of total billed charges,Blood Products,743.03,67,,743.03,percent of total billed charges,Blood Products,743.03,67,,743.03,percent of total billed charges,Blood Products,743.03,67,,743.03,percent of total billed charges,Blood Products,776.3,70,,776.3,percent of total billed charges,Blood Products,776.3,70,,776.3,percent of total billed charges,All Other,776.3,70,,776.3,percent of total billed charges,Blood Products,776.3,70,,776.3,percent of total billed charges,Blood Products,743.03,67,,743.03,percent of total billed charges,Blood Products,743.03,67,,743.03,percent of total billed charges,Blood Products,743.03,67,,743.03,percent of total billed charges,Blood Products,743.03,67,,743.03,percent of total billed charges,Blood Products,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,70,"If Charge > 2,000, then 70 percent",0.01,percent of total billed charges,Blood Products,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,820.66,
BLOOD TRANSFUSION SERVICE,36430,CPT,59,30136430,CDM,391,RC,,,both,,,1109,820.66,,,820.66,Other,150% of Medicare + 9.63% HCRA Surcharge,499.05,45,,499.05,percent of total billed charges,Critical Access Hospital RCC factor,720.85,70,,720.85,percent of total billed charges,Blood Products,654.31,70,,654.31,percent of total billed charges,Blood Products,776.3,70,,776.3,percent of total billed charges,Blood Products,776.3,70,,776.3,percent of total billed charges,Blood Products,776.3,70,,776.3,percent of total billed charges,Blood Products,548.96,,,548.96,Other,110% of Medicare,743.03,67,,743.03,percent of total billed charges,Blood Products,776.3,70,"If Charge > 500, then 70 percent",776.3,percent of total billed charges,Blood Products,743.03,67,,743.03,percent of total billed charges,Blood Products,743.03,67,,743.03,percent of total billed charges,Blood Products,743.03,67,,743.03,percent of total billed charges,Blood Products,743.03,67,,743.03,percent of total billed charges,Blood Products,743.03,67,,743.03,percent of total billed charges,Blood Products,776.3,70,,776.3,percent of total billed charges,Blood Products,776.3,70,,776.3,percent of total billed charges,All Other,776.3,70,,776.3,percent of total billed charges,Blood Products,776.3,70,,776.3,percent of total billed charges,Blood Products,743.03,67,,743.03,percent of total billed charges,Blood Products,743.03,67,,743.03,percent of total billed charges,Blood Products,743.03,67,,743.03,percent of total billed charges,Blood Products,743.03,67,,743.03,percent of total billed charges,Blood Products,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,70,"If Charge > 2,000, then 70 percent",0.01,percent of total billed charges,Blood Products,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,820.66,
BLOOD TRANSFUSION SERVICE,36430,CPT,XU,30236430,CDM,391,RC,,,both,,,1109,820.66,,,820.66,Other,150% of Medicare + 9.63% HCRA Surcharge,499.05,45,,499.05,percent of total billed charges,Critical Access Hospital RCC factor,720.85,70,,720.85,percent of total billed charges,Blood Products,654.31,70,,654.31,percent of total billed charges,Blood Products,776.3,70,,776.3,percent of total billed charges,Blood Products,776.3,70,,776.3,percent of total billed charges,Blood Products,776.3,70,,776.3,percent of total billed charges,Blood Products,548.96,,,548.96,Other,110% of Medicare,743.03,67,,743.03,percent of total billed charges,Blood Products,776.3,70,"If Charge > 500, then 70 percent",776.3,percent of total billed charges,Blood Products,743.03,67,,743.03,percent of total billed charges,Blood Products,743.03,67,,743.03,percent of total billed charges,Blood Products,743.03,67,,743.03,percent of total billed charges,Blood Products,743.03,67,,743.03,percent of total billed charges,Blood Products,743.03,67,,743.03,percent of total billed charges,Blood Products,776.3,70,,776.3,percent of total billed charges,Blood Products,776.3,70,,776.3,percent of total billed charges,All Other,776.3,70,,776.3,percent of total billed charges,Blood Products,776.3,70,,776.3,percent of total billed charges,Blood Products,743.03,67,,743.03,percent of total billed charges,Blood Products,743.03,67,,743.03,percent of total billed charges,Blood Products,743.03,67,,743.03,percent of total billed charges,Blood Products,743.03,67,,743.03,percent of total billed charges,Blood Products,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,70,"If Charge > 2,000, then 70 percent",0.01,percent of total billed charges,Blood Products,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,820.66,
TRANSFUSION BLOOD OR BLOOD COMPONENTS,36430,CPT,,34036430,CDM,391,RC,,,both,,,1109,820.66,,,820.66,Other,150% of Medicare + 9.63% HCRA Surcharge,499.05,45,,499.05,percent of total billed charges,Critical Access Hospital RCC factor,720.85,70,,720.85,percent of total billed charges,Blood Products,654.31,70,,654.31,percent of total billed charges,Blood Products,776.3,70,,776.3,percent of total billed charges,Blood Products,776.3,70,,776.3,percent of total billed charges,Blood Products,776.3,70,,776.3,percent of total billed charges,Blood Products,548.96,,,548.96,Other,110% of Medicare,743.03,67,,743.03,percent of total billed charges,Blood Products,776.3,70,"If Charge > 500, then 70 percent",776.3,percent of total billed charges,Blood Products,743.03,67,,743.03,percent of total billed charges,Blood Products,743.03,67,,743.03,percent of total billed charges,Blood Products,743.03,67,,743.03,percent of total billed charges,Blood Products,743.03,67,,743.03,percent of total billed charges,Blood Products,743.03,67,,743.03,percent of total billed charges,Blood Products,776.3,70,,776.3,percent of total billed charges,Blood Products,776.3,70,,776.3,percent of total billed charges,All Other,776.3,70,,776.3,percent of total billed charges,Blood Products,776.3,70,,776.3,percent of total billed charges,Blood Products,743.03,67,,743.03,percent of total billed charges,Blood Products,743.03,67,,743.03,percent of total billed charges,Blood Products,743.03,67,,743.03,percent of total billed charges,Blood Products,743.03,67,,743.03,percent of total billed charges,Blood Products,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,70,"If Charge > 2,000, then 70 percent",0.01,percent of total billed charges,Blood Products,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,820.66,
TRANSFUSION BLOOD SERVICE,36430,CPT,,75036430,CDM,391,RC,,,both,,,1109,820.66,,,820.66,Other,150% of Medicare + 9.63% HCRA Surcharge,499.05,45,,499.05,percent of total billed charges,Critical Access Hospital RCC factor,720.85,70,,720.85,percent of total billed charges,Blood Products,654.31,70,,654.31,percent of total billed charges,Blood Products,776.3,70,,776.3,percent of total billed charges,Blood Products,776.3,70,,776.3,percent of total billed charges,Blood Products,776.3,70,,776.3,percent of total billed charges,Blood Products,548.96,,,548.96,Other,110% of Medicare,743.03,67,,743.03,percent of total billed charges,Blood Products,776.3,70,"If Charge > 500, then 70 percent",776.3,percent of total billed charges,Blood Products,743.03,67,,743.03,percent of total billed charges,Blood Products,743.03,67,,743.03,percent of total billed charges,Blood Products,743.03,67,,743.03,percent of total billed charges,Blood Products,743.03,67,,743.03,percent of total billed charges,Blood Products,743.03,67,,743.03,percent of total billed charges,Blood Products,776.3,70,,776.3,percent of total billed charges,Blood Products,776.3,70,,776.3,percent of total billed charges,All Other,776.3,70,,776.3,percent of total billed charges,Blood Products,776.3,70,,776.3,percent of total billed charges,Blood Products,743.03,67,,743.03,percent of total billed charges,Blood Products,743.03,67,,743.03,percent of total billed charges,Blood Products,743.03,67,,743.03,percent of total billed charges,Blood Products,743.03,67,,743.03,percent of total billed charges,Blood Products,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,70,"If Charge > 2,000, then 70 percent",0.01,percent of total billed charges,Blood Products,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,820.66,
BLOOD TRANSFUSION SERVICE,36430,CPT,,82036430,CDM,391,RC,,,both,,,1109,820.66,,,820.66,Other,150% of Medicare + 9.63% HCRA Surcharge,499.05,45,,499.05,percent of total billed charges,Critical Access Hospital RCC factor,720.85,70,,720.85,percent of total billed charges,Blood Products,654.31,70,,654.31,percent of total billed charges,Blood Products,776.3,70,,776.3,percent of total billed charges,Blood Products,776.3,70,,776.3,percent of total billed charges,Blood Products,776.3,70,,776.3,percent of total billed charges,Blood Products,548.96,,,548.96,Other,110% of Medicare,743.03,67,,743.03,percent of total billed charges,Blood Products,776.3,70,"If Charge > 500, then 70 percent",776.3,percent of total billed charges,Blood Products,743.03,67,,743.03,percent of total billed charges,Blood Products,743.03,67,,743.03,percent of total billed charges,Blood Products,743.03,67,,743.03,percent of total billed charges,Blood Products,743.03,67,,743.03,percent of total billed charges,Blood Products,743.03,67,,743.03,percent of total billed charges,Blood Products,776.3,70,,776.3,percent of total billed charges,Blood Products,776.3,70,,776.3,percent of total billed charges,All Other,776.3,70,,776.3,percent of total billed charges,Blood Products,776.3,70,,776.3,percent of total billed charges,Blood Products,743.03,67,,743.03,percent of total billed charges,Blood Products,743.03,67,,743.03,percent of total billed charges,Blood Products,743.03,67,,743.03,percent of total billed charges,Blood Products,743.03,67,,743.03,percent of total billed charges,Blood Products,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,70,"If Charge > 2,000, then 70 percent",0.01,percent of total billed charges,Blood Products,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,820.66,
DX MAMMO INCL CAD BI,77066,CPT,TC,54077066,CDM,401,RC,,,both,,,1070,791.8,,,791.8,Other,150% of Medicare + 9.63% HCRA Surcharge,481.5,45,,481.5,percent of total billed charges,Critical Access Hospital RCC factor,388.51,,,388.51,Fee Schedule,,349.54,,,349.54,Fee Schedule,,92.79,,,92.79,Fee Schedule,,92.79,,,92.79,Fee Schedule,,92.79,,,92.79,Fee Schedule,,529.65,,,529.65,Other,110% of Medicare,461.58,,,461.58,Fee Schedule,,188,,,188,Other,186% of Medicaid,543.18,,,543.18,Fee Schedule,,663.4,,,663.4,Fee Schedule,,255.76,,,255.76,Fee Schedule,,543.18,,,543.18,Fee Schedule,,663.4,,,663.4,Fee Schedule,,481.07,,,481.07,Fee Schedule,,749,70,,749,percent of total billed charges,All Other,547.76,,,547.76,Fee Schedule,,464.26,,,464.26,Fee Schedule,,192.86,,,192.86,Fee Schedule,,192.86,,,192.86,Fee Schedule,,192.86,,,192.86,Fee Schedule,,192.86,,,192.86,Fee Schedule,,101.09,,,101.09,Other,100% of Medicaid,101.09,,,101.09,Other,100% of Medicaid,101.09,,,101.09,Other,100% of Medicaid,101.09,,,101.09,Other,100% of Medicaid,227.46,,,227.46,Other,225% of Medicaid,154.67,,,154.67,Other,153% of Medicaid,227.46,,,227.46,Other,225% of Medicaid,141.53,,,141.53,Other,140% of Medicaid,227.46,,,227.46,Other,225% of Medicaid,262.84,,,262.84,Other,260% of Medicaid,327.54,,,327.54,Other,324% of Medicaid,217.35,,,217.35,Other,215% of Medicaid,217.35,,,217.35,Other,215% of Medicaid,126.37,,,126.37,Other,125% of Medicaid,92.79,791.8,
DX MAMMO INCL CAD UNI LT,77065,CPT,TCLT,54177065,CDM,401,RC,,,both,,,836,618.64,,,618.64,Other,150% of Medicare + 9.63% HCRA Surcharge,376.2,45,,376.2,percent of total billed charges,Critical Access Hospital RCC factor,302.86,,,302.86,Fee Schedule,,272.48,,,272.48,Fee Schedule,,72.65,,,72.65,Fee Schedule,,72.65,,,72.65,Fee Schedule,,72.65,,,72.65,Fee Schedule,,413.82,,,413.82,Other,110% of Medicare,359.82,,,359.82,Fee Schedule,,188,,,188,Other,186% of Medicaid,423.43,,,423.43,Fee Schedule,,518.32,,,518.32,Fee Schedule,,199.37,,,199.37,Fee Schedule,,423.43,,,423.43,Fee Schedule,,518.32,,,518.32,Fee Schedule,,375.01,,,375.01,Fee Schedule,,585.2,70,,585.2,percent of total billed charges,All Other,429.68,,,429.68,Fee Schedule,,364.18,,,364.18,Fee Schedule,,151.28,,,151.28,Fee Schedule,,151.28,,,151.28,Fee Schedule,,151.28,,,151.28,Fee Schedule,,151.28,,,151.28,Fee Schedule,,101.09,,,101.09,Other,100% of Medicaid,101.09,,,101.09,Other,100% of Medicaid,101.09,,,101.09,Other,100% of Medicaid,101.09,,,101.09,Other,100% of Medicaid,227.46,,,227.46,Other,225% of Medicaid,154.67,,,154.67,Other,153% of Medicaid,227.46,,,227.46,Other,225% of Medicaid,141.53,,,141.53,Other,140% of Medicaid,227.46,,,227.46,Other,225% of Medicaid,262.84,,,262.84,Other,260% of Medicaid,327.54,,,327.54,Other,324% of Medicaid,217.35,,,217.35,Other,215% of Medicaid,217.35,,,217.35,Other,215% of Medicaid,126.37,,,126.37,Other,125% of Medicaid,72.65,618.64,
DX MAMMO INCL CAD UNI RT,77065,CPT,TCRT,54277065,CDM,401,RC,,,both,,,836,618.64,,,618.64,Other,150% of Medicare + 9.63% HCRA Surcharge,376.2,45,,376.2,percent of total billed charges,Critical Access Hospital RCC factor,302.86,,,302.86,Fee Schedule,,272.48,,,272.48,Fee Schedule,,72.65,,,72.65,Fee Schedule,,72.65,,,72.65,Fee Schedule,,72.65,,,72.65,Fee Schedule,,413.82,,,413.82,Other,110% of Medicare,359.82,,,359.82,Fee Schedule,,188,,,188,Other,186% of Medicaid,423.43,,,423.43,Fee Schedule,,518.32,,,518.32,Fee Schedule,,199.37,,,199.37,Fee Schedule,,423.43,,,423.43,Fee Schedule,,518.32,,,518.32,Fee Schedule,,375.01,,,375.01,Fee Schedule,,585.2,70,,585.2,percent of total billed charges,All Other,429.68,,,429.68,Fee Schedule,,364.18,,,364.18,Fee Schedule,,151.28,,,151.28,Fee Schedule,,151.28,,,151.28,Fee Schedule,,151.28,,,151.28,Fee Schedule,,151.28,,,151.28,Fee Schedule,,101.09,,,101.09,Other,100% of Medicaid,101.09,,,101.09,Other,100% of Medicaid,101.09,,,101.09,Other,100% of Medicaid,101.09,,,101.09,Other,100% of Medicaid,227.46,,,227.46,Other,225% of Medicaid,154.67,,,154.67,Other,153% of Medicaid,227.46,,,227.46,Other,225% of Medicaid,141.53,,,141.53,Other,140% of Medicaid,227.46,,,227.46,Other,225% of Medicaid,262.84,,,262.84,Other,260% of Medicaid,327.54,,,327.54,Other,324% of Medicaid,217.35,,,217.35,Other,215% of Medicaid,217.35,,,217.35,Other,215% of Medicaid,126.37,,,126.37,Other,125% of Medicaid,72.65,618.64,
DX MAMMO AFTER SCREENING INCL CAD UNI,77065,CPT,TCGG,54377065,CDM,401,RC,,,both,,,836,618.64,,,618.64,Other,150% of Medicare + 9.63% HCRA Surcharge,376.2,45,,376.2,percent of total billed charges,Critical Access Hospital RCC factor,302.86,,,302.86,Fee Schedule,,272.48,,,272.48,Fee Schedule,,72.65,,,72.65,Fee Schedule,,72.65,,,72.65,Fee Schedule,,72.65,,,72.65,Fee Schedule,,413.82,,,413.82,Other,110% of Medicare,359.82,,,359.82,Fee Schedule,,188,,,188,Other,186% of Medicaid,423.43,,,423.43,Fee Schedule,,518.32,,,518.32,Fee Schedule,,199.37,,,199.37,Fee Schedule,,423.43,,,423.43,Fee Schedule,,518.32,,,518.32,Fee Schedule,,375.01,,,375.01,Fee Schedule,,585.2,70,,585.2,percent of total billed charges,All Other,429.68,,,429.68,Fee Schedule,,364.18,,,364.18,Fee Schedule,,151.28,,,151.28,Fee Schedule,,151.28,,,151.28,Fee Schedule,,151.28,,,151.28,Fee Schedule,,151.28,,,151.28,Fee Schedule,,101.09,,,101.09,Other,100% of Medicaid,101.09,,,101.09,Other,100% of Medicaid,101.09,,,101.09,Other,100% of Medicaid,101.09,,,101.09,Other,100% of Medicaid,227.46,,,227.46,Other,225% of Medicaid,154.67,,,154.67,Other,153% of Medicaid,227.46,,,227.46,Other,225% of Medicaid,141.53,,,141.53,Other,140% of Medicaid,227.46,,,227.46,Other,225% of Medicaid,262.84,,,262.84,Other,260% of Medicaid,327.54,,,327.54,Other,324% of Medicaid,217.35,,,217.35,Other,215% of Medicaid,217.35,,,217.35,Other,215% of Medicaid,126.37,,,126.37,Other,125% of Medicaid,72.65,618.64,
DX MAMMO AFTER SCREENING INCL CAD BI,77066,CPT,TCGG,54377066,CDM,401,RC,,,both,,,1070,791.8,,,791.8,Other,150% of Medicare + 9.63% HCRA Surcharge,481.5,45,,481.5,percent of total billed charges,Critical Access Hospital RCC factor,388.51,,,388.51,Fee Schedule,,349.54,,,349.54,Fee Schedule,,92.79,,,92.79,Fee Schedule,,92.79,,,92.79,Fee Schedule,,92.79,,,92.79,Fee Schedule,,529.65,,,529.65,Other,110% of Medicare,461.58,,,461.58,Fee Schedule,,188,,,188,Other,186% of Medicaid,543.18,,,543.18,Fee Schedule,,663.4,,,663.4,Fee Schedule,,255.76,,,255.76,Fee Schedule,,543.18,,,543.18,Fee Schedule,,663.4,,,663.4,Fee Schedule,,481.07,,,481.07,Fee Schedule,,749,70,,749,percent of total billed charges,All Other,547.76,,,547.76,Fee Schedule,,464.26,,,464.26,Fee Schedule,,192.86,,,192.86,Fee Schedule,,192.86,,,192.86,Fee Schedule,,192.86,,,192.86,Fee Schedule,,192.86,,,192.86,Fee Schedule,,101.09,,,101.09,Other,100% of Medicaid,101.09,,,101.09,Other,100% of Medicaid,101.09,,,101.09,Other,100% of Medicaid,101.09,,,101.09,Other,100% of Medicaid,227.46,,,227.46,Other,225% of Medicaid,154.67,,,154.67,Other,153% of Medicaid,227.46,,,227.46,Other,225% of Medicaid,141.53,,,141.53,Other,140% of Medicaid,227.46,,,227.46,Other,225% of Medicaid,262.84,,,262.84,Other,260% of Medicaid,327.54,,,327.54,Other,324% of Medicaid,217.35,,,217.35,Other,215% of Medicaid,217.35,,,217.35,Other,215% of Medicaid,126.37,,,126.37,Other,125% of Medicaid,92.79,791.8,
US GUIDANCE VASCULAR ACCESS,76937,CPT,TC,30076937,CDM,402,RC,,,both,,,186,137.64,,,137.64,Other,150% of Medicare + 9.63% HCRA Surcharge,83.7,45,,83.7,percent of total billed charges,Critical Access Hospital RCC factor,85.65,,,85.65,Fee Schedule,,77.06,,,77.06,Fee Schedule,,132.8,,,132.8,Fee Schedule,,119.45,,,119.45,Fee Schedule,,112.9,,,112.9,Fee Schedule,,92.07,,,92.07,Other,110% of Medicare,101.76,,,101.76,Fee Schedule,,325,,,325,Other,186% of Medicaid,119.75,,,119.75,Fee Schedule,,115.32,,,115.32,Fee Schedule,,56.39,,,56.39,Fee Schedule,,119.75,,,119.75,Fee Schedule,,115.32,,,115.32,Fee Schedule,,106.06,,,106.06,Fee Schedule,,130.2,70,,130.2,percent of total billed charges,All Other,126.28,,,126.28,Fee Schedule,,107.03,,,107.03,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,174.66,,,174.66,Other,100% of Medicaid,174.66,,,174.66,Other,100% of Medicaid,174.66,,,174.66,Other,100% of Medicaid,174.66,,,174.66,Other,100% of Medicaid,392.98,,,392.98,Other,225% of Medicaid,267.23,,,267.23,Other,153% of Medicaid,392.98,,,392.98,Other,225% of Medicaid,244.52,,,244.52,Other,140% of Medicaid,392.98,,,392.98,Other,225% of Medicaid,454.12,,,454.12,Other,260% of Medicaid,565.9,,,565.9,Other,324% of Medicaid,375.52,,,375.52,Other,215% of Medicaid,375.52,,,375.52,Other,215% of Medicaid,218.32,,,218.32,Other,125% of Medicaid,0.01,565.9,
US GUIDED NEEDLE PLACEMEN,76942,CPT,TC,30076942,CDM,402,RC,,,both,,,1201,888.74,,,888.74,Other,150% of Medicare + 9.63% HCRA Surcharge,540.45,45,,540.45,percent of total billed charges,Critical Access Hospital RCC factor,98.38,,,98.38,Fee Schedule,,88.51,,,88.51,Fee Schedule,,1107.65,,,1107.65,Fee Schedule,,996.25,,,996.25,Fee Schedule,,941.61,,,941.61,Fee Schedule,,594.5,,,594.5,Other,110% of Medicare,116.88,,,116.88,Fee Schedule,,325,,,325,Other,186% of Medicaid,137.55,,,137.55,Fee Schedule,,744.62,,,744.62,Fee Schedule,,64.76,,,64.76,Fee Schedule,,137.55,,,137.55,Fee Schedule,,744.62,,,744.62,Fee Schedule,,121.82,,,121.82,Fee Schedule,,840.7,70,,840.7,percent of total billed charges,All Other,134.48,,,134.48,Fee Schedule,,113.98,,,113.98,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,174.66,,,174.66,Other,100% of Medicaid,174.66,,,174.66,Other,100% of Medicaid,174.66,,,174.66,Other,100% of Medicaid,174.66,,,174.66,Other,100% of Medicaid,392.98,,,392.98,Other,225% of Medicaid,267.23,,,267.23,Other,153% of Medicaid,392.98,,,392.98,Other,225% of Medicaid,244.52,,,244.52,Other,140% of Medicaid,392.98,,,392.98,Other,225% of Medicaid,454.12,,,454.12,Other,260% of Medicaid,565.9,,,565.9,Other,324% of Medicaid,375.52,,,375.52,Other,215% of Medicaid,375.52,,,375.52,Other,215% of Medicaid,218.32,,,218.32,Other,125% of Medicaid,0.01,1107.65,
DRAINAGE CATH UNDER XR,75989,CPT,TC,44075989,CDM,402,RC,,,both,,,2125,1572.51,,,1572.51,Other,150% of Medicare + 9.63% HCRA Surcharge,956.25,45,,956.25,percent of total billed charges,Critical Access Hospital RCC factor,197.72,,,197.72,Fee Schedule,,177.88,,,177.88,Fee Schedule,,521.84,,,521.84,Fee Schedule,,469.35,,,469.35,Fee Schedule,,443.61,,,443.61,Fee Schedule,,1051.88,,,1051.88,Other,110% of Medicare,234.9,,,234.9,Fee Schedule,,544,,,544,Other,186% of Medicaid,276.43,,,276.43,Fee Schedule,,1317.5,,,1317.5,Fee Schedule,,130.16,,,130.16,Fee Schedule,,276.43,,,276.43,Fee Schedule,,1317.5,,,1317.5,Fee Schedule,,244.82,,,244.82,Fee Schedule,,1487.5,70,,1487.5,percent of total billed charges,All Other,291.92,,,291.92,Fee Schedule,,247.42,,,247.42,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,292.43,,,292.43,Other,100% of Medicaid,292.43,,,292.43,Other,100% of Medicaid,292.43,,,292.43,Other,100% of Medicaid,292.43,,,292.43,Other,100% of Medicaid,657.97,,,657.97,Other,225% of Medicaid,447.42,,,447.42,Other,153% of Medicaid,657.97,,,657.97,Other,225% of Medicaid,409.4,,,409.4,Other,140% of Medicaid,657.97,,,657.97,Other,225% of Medicaid,760.32,,,760.32,Other,260% of Medicaid,947.48,,,947.48,Other,324% of Medicaid,628.73,,,628.73,Other,215% of Medicaid,628.73,,,628.73,Other,215% of Medicaid,365.54,,,365.54,Other,125% of Medicaid,0.01,1572.51,
US NEONATAL HEAD,76506,CPT,TC,44076506,CDM,402,RC,,,both,,,676,500.24,,,500.24,Other,150% of Medicare + 9.63% HCRA Surcharge,304.2,45,,304.2,percent of total billed charges,Critical Access Hospital RCC factor,285.51,,,285.51,Fee Schedule,,256.87,,,256.87,Fee Schedule,,421.18,,,421.18,Fee Schedule,,378.82,,,378.82,Fee Schedule,,358.04,,,358.04,Fee Schedule,,334.62,,,334.62,Other,110% of Medicare,339.21,,,339.21,Fee Schedule,,226,,,226,Other,186% of Medicaid,399.17,,,399.17,Fee Schedule,,419.12,,,419.12,Fee Schedule,,187.95,,,187.95,Fee Schedule,,399.17,,,399.17,Fee Schedule,,419.12,,,419.12,Fee Schedule,,353.53,,,353.53,Fee Schedule,,473.2,70,,473.2,percent of total billed charges,All Other,419.84,,,419.84,Fee Schedule,,355.84,,,355.84,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,121.68,,,121.68,Other,100% of Medicaid,121.68,,,121.68,Other,100% of Medicaid,121.68,,,121.68,Other,100% of Medicaid,121.68,,,121.68,Other,100% of Medicaid,273.79,,,273.79,Other,225% of Medicaid,186.18,,,186.18,Other,153% of Medicaid,273.79,,,273.79,Other,225% of Medicaid,170.36,,,170.36,Other,140% of Medicaid,273.79,,,273.79,Other,225% of Medicaid,316.38,,,316.38,Other,260% of Medicaid,394.25,,,394.25,Other,324% of Medicaid,261.62,,,261.62,Other,215% of Medicaid,261.62,,,261.62,Other,215% of Medicaid,152.1,,,152.1,Other,125% of Medicaid,121.68,500.24,
US EXAM OF HEAD AND NECK,76536,CPT,TC,44076536,CDM,402,RC,,,both,,,807,597.18,,,597.18,Other,150% of Medicare + 9.63% HCRA Surcharge,363.15,45,,363.15,percent of total billed charges,Critical Access Hospital RCC factor,291.31,,,291.31,Fee Schedule,,262.09,,,262.09,Fee Schedule,,613.38,,,613.38,Fee Schedule,,551.69,,,551.69,Fee Schedule,,521.43,,,521.43,Fee Schedule,,399.47,,,399.47,Other,110% of Medicare,346.1,,,346.1,Fee Schedule,,226,,,226,Other,186% of Medicaid,407.29,,,407.29,Fee Schedule,,500.34,,,500.34,Fee Schedule,,191.77,,,191.77,Fee Schedule,,407.29,,,407.29,Fee Schedule,,500.34,,,500.34,Fee Schedule,,360.71,,,360.71,Fee Schedule,,564.9,70,,564.9,percent of total billed charges,All Other,419.84,,,419.84,Fee Schedule,,355.84,,,355.84,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,121.68,,,121.68,Other,100% of Medicaid,121.68,,,121.68,Other,100% of Medicaid,121.68,,,121.68,Other,100% of Medicaid,121.68,,,121.68,Other,100% of Medicaid,273.79,,,273.79,Other,225% of Medicaid,186.18,,,186.18,Other,153% of Medicaid,273.79,,,273.79,Other,225% of Medicaid,170.36,,,170.36,Other,140% of Medicaid,273.79,,,273.79,Other,225% of Medicaid,316.38,,,316.38,Other,260% of Medicaid,394.25,,,394.25,Other,324% of Medicaid,261.62,,,261.62,Other,215% of Medicaid,261.62,,,261.62,Other,215% of Medicaid,152.1,,,152.1,Other,125% of Medicaid,121.68,613.38,
US EXAM CHEST,76604,CPT,TC,44076604,CDM,402,RC,,,both,,,550,407,,,407,Other,150% of Medicare + 9.63% HCRA Surcharge,247.5,45,,247.5,percent of total billed charges,Critical Access Hospital RCC factor,105.3,,,105.3,Fee Schedule,,94.74,,,94.74,Fee Schedule,,412.01,,,412.01,Fee Schedule,,370.57,,,370.57,Fee Schedule,,350.25,,,350.25,Fee Schedule,,272.25,,,272.25,Other,110% of Medicare,125.11,,,125.11,Fee Schedule,,226,,,226,Other,186% of Medicaid,147.22,,,147.22,Fee Schedule,,341,,,341,Fee Schedule,,69.32,,,69.32,Fee Schedule,,147.22,,,147.22,Fee Schedule,,341,,,341,Fee Schedule,,130.39,,,130.39,Fee Schedule,,385,70,,385,percent of total billed charges,All Other,150.88,,,150.88,Fee Schedule,,127.88,,,127.88,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,121.68,,,121.68,Other,100% of Medicaid,121.68,,,121.68,Other,100% of Medicaid,121.68,,,121.68,Other,100% of Medicaid,121.68,,,121.68,Other,100% of Medicaid,273.79,,,273.79,Other,225% of Medicaid,186.18,,,186.18,Other,153% of Medicaid,273.79,,,273.79,Other,225% of Medicaid,170.36,,,170.36,Other,140% of Medicaid,273.79,,,273.79,Other,225% of Medicaid,316.38,,,316.38,Other,260% of Medicaid,394.25,,,394.25,Other,324% of Medicaid,261.62,,,261.62,Other,215% of Medicaid,261.62,,,261.62,Other,215% of Medicaid,152.1,,,152.1,Other,125% of Medicaid,69.32,412.01,
US ABDOMEN COMPLETE,76700,CPT,TC,44076700,CDM,402,RC,,,both,,,1165,862.1,,,862.1,Other,150% of Medicare + 9.63% HCRA Surcharge,524.25,45,,524.25,percent of total billed charges,Critical Access Hospital RCC factor,272.97,,,272.97,Fee Schedule,,245.59,,,245.59,Fee Schedule,,647.68,,,647.68,Fee Schedule,,582.55,,,582.55,Fee Schedule,,550.59,,,550.59,Fee Schedule,,576.68,,,576.68,Other,110% of Medicare,324.31,,,324.31,Fee Schedule,,982,,,982,Other,186% of Medicaid,381.64,,,381.64,Fee Schedule,,722.3,,,722.3,Fee Schedule,,179.7,,,179.7,Fee Schedule,,381.64,,,381.64,Fee Schedule,,722.3,,,722.3,Fee Schedule,,338,,,338,Fee Schedule,,815.5,70,,815.5,percent of total billed charges,All Other,391.96,,,391.96,Fee Schedule,,332.21,,,332.21,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,527.83,,,527.83,Other,100% of Medicaid,527.83,,,527.83,Other,100% of Medicaid,527.83,,,527.83,Other,100% of Medicaid,527.83,,,527.83,Other,100% of Medicaid,1187.61,,,1187.61,Other,225% of Medicaid,807.58,,,807.58,Other,153% of Medicaid,1187.61,,,1187.61,Other,225% of Medicaid,738.96,,,738.96,Other,140% of Medicaid,1187.61,,,1187.61,Other,225% of Medicaid,1372.35,,,1372.35,Other,260% of Medicaid,1710.16,,,1710.16,Other,324% of Medicaid,1134.83,,,1134.83,Other,215% of Medicaid,1134.83,,,1134.83,Other,215% of Medicaid,659.78,,,659.78,Other,125% of Medicaid,179.33,1710.16,
US ABDOMEN LIMITED,76705,CPT,TC,44076705,CDM,402,RC,,,both,,,982,726.68,,,726.68,Other,150% of Medicare + 9.63% HCRA Surcharge,441.9,45,,441.9,percent of total billed charges,Critical Access Hospital RCC factor,206.97,,,206.97,Fee Schedule,,186.21,,,186.21,Fee Schedule,,526.42,,,526.42,Fee Schedule,,473.48,,,473.48,Fee Schedule,,447.51,,,447.51,Fee Schedule,,486.09,,,486.09,Other,110% of Medicare,245.9,,,245.9,Fee Schedule,,226,,,226,Other,186% of Medicaid,289.36,,,289.36,Fee Schedule,,608.84,,,608.84,Fee Schedule,,136.25,,,136.25,Fee Schedule,,289.36,,,289.36,Fee Schedule,,608.84,,,608.84,Fee Schedule,,256.28,,,256.28,Fee Schedule,,687.4,70,,687.4,percent of total billed charges,All Other,295.2,,,295.2,Fee Schedule,,250.2,,,250.2,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,121.68,,,121.68,Other,100% of Medicaid,121.68,,,121.68,Other,100% of Medicaid,121.68,,,121.68,Other,100% of Medicaid,121.68,,,121.68,Other,100% of Medicaid,273.79,,,273.79,Other,225% of Medicaid,186.18,,,186.18,Other,153% of Medicaid,273.79,,,273.79,Other,225% of Medicaid,170.36,,,170.36,Other,140% of Medicaid,273.79,,,273.79,Other,225% of Medicaid,316.38,,,316.38,Other,260% of Medicaid,394.25,,,394.25,Other,324% of Medicaid,261.62,,,261.62,Other,215% of Medicaid,261.62,,,261.62,Other,215% of Medicaid,152.1,,,152.1,Other,125% of Medicaid,121.68,726.68,
US ABDL AORTA SCREEN AAA,76706,CPT,TC,44076706,CDM,402,RC,,,both,,,657,486.18,,,486.18,Other,150% of Medicare + 9.63% HCRA Surcharge,295.65,45,,295.65,percent of total billed charges,Critical Access Hospital RCC factor,280.91,,,280.91,Fee Schedule,,252.73,,,252.73,Fee Schedule,,64.79,,,64.79,Fee Schedule,,64.79,,,64.79,Fee Schedule,,64.79,,,64.79,Fee Schedule,,325.22,,,325.22,Other,110% of Medicare,333.75,,,333.75,Fee Schedule,,226,,,226,Other,186% of Medicaid,392.75,,,392.75,Fee Schedule,,407.34,,,407.34,Fee Schedule,,184.93,,,184.93,Fee Schedule,,392.75,,,392.75,Fee Schedule,,407.34,,,407.34,Fee Schedule,,347.84,,,347.84,Fee Schedule,,459.9,70,,459.9,percent of total billed charges,All Other,398.52,,,398.52,Fee Schedule,,337.77,,,337.77,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,121.68,,,121.68,Other,100% of Medicaid,121.68,,,121.68,Other,100% of Medicaid,121.68,,,121.68,Other,100% of Medicaid,121.68,,,121.68,Other,100% of Medicaid,273.79,,,273.79,Other,225% of Medicaid,186.18,,,186.18,Other,153% of Medicaid,273.79,,,273.79,Other,225% of Medicaid,170.36,,,170.36,Other,140% of Medicaid,273.79,,,273.79,Other,225% of Medicaid,316.38,,,316.38,Other,260% of Medicaid,394.25,,,394.25,Other,324% of Medicaid,261.62,,,261.62,Other,215% of Medicaid,261.62,,,261.62,Other,215% of Medicaid,152.1,,,152.1,Other,125% of Medicaid,64.79,486.18,
US RETROPERITONEAL COMPL,76770,CPT,TC,44076770,CDM,402,RC,,,both,,,1039,768.86,,,768.86,Other,150% of Medicare + 9.63% HCRA Surcharge,467.55,45,,467.55,percent of total billed charges,Critical Access Hospital RCC factor,255.49,,,255.49,Fee Schedule,,229.86,,,229.86,Fee Schedule,,647.68,,,647.68,Fee Schedule,,582.55,,,582.55,Fee Schedule,,550.59,,,550.59,Fee Schedule,,514.31,,,514.31,Other,110% of Medicare,303.54,,,303.54,Fee Schedule,,982,,,982,Other,186% of Medicaid,357.2,,,357.2,Fee Schedule,,644.18,,,644.18,Fee Schedule,,168.19,,,168.19,Fee Schedule,,357.2,,,357.2,Fee Schedule,,644.18,,,644.18,Fee Schedule,,316.36,,,316.36,Fee Schedule,,727.3,70,,727.3,percent of total billed charges,All Other,365.72,,,365.72,Fee Schedule,,309.97,,,309.97,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,527.83,,,527.83,Other,100% of Medicaid,527.83,,,527.83,Other,100% of Medicaid,527.83,,,527.83,Other,100% of Medicaid,527.83,,,527.83,Other,100% of Medicaid,1187.61,,,1187.61,Other,225% of Medicaid,807.58,,,807.58,Other,153% of Medicaid,1187.61,,,1187.61,Other,225% of Medicaid,738.96,,,738.96,Other,140% of Medicaid,1187.61,,,1187.61,Other,225% of Medicaid,1372.35,,,1372.35,Other,260% of Medicaid,1710.16,,,1710.16,Other,324% of Medicaid,1134.83,,,1134.83,Other,215% of Medicaid,1134.83,,,1134.83,Other,215% of Medicaid,659.78,,,659.78,Other,125% of Medicaid,168.19,1710.16,
US RETROPERITONEAL LTD,76775,CPT,TC,44076775,CDM,402,RC,,,both,,,1406,1040.44,,,1040.44,Other,150% of Medicare + 9.63% HCRA Surcharge,632.7,45,,632.7,percent of total billed charges,Critical Access Hospital RCC factor,113.37,,,113.37,Fee Schedule,,102,,,102,Fee Schedule,,558.46,,,558.46,Fee Schedule,,502.3,,,502.3,Fee Schedule,,474.75,,,474.75,Fee Schedule,,695.97,,,695.97,Other,110% of Medicare,134.7,,,134.7,Fee Schedule,,226,,,226,Other,186% of Medicaid,158.51,,,158.51,Fee Schedule,,871.72,,,871.72,Fee Schedule,,74.63,,,74.63,Fee Schedule,,158.51,,,158.51,Fee Schedule,,871.72,,,871.72,Fee Schedule,,140.38,,,140.38,Fee Schedule,,984.2,70,,984.2,percent of total billed charges,All Other,149.24,,,149.24,Fee Schedule,,126.49,,,126.49,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,121.68,,,121.68,Other,100% of Medicaid,121.68,,,121.68,Other,100% of Medicaid,121.68,,,121.68,Other,100% of Medicaid,121.68,,,121.68,Other,100% of Medicaid,273.79,,,273.79,Other,225% of Medicaid,186.18,,,186.18,Other,153% of Medicaid,273.79,,,273.79,Other,225% of Medicaid,170.36,,,170.36,Other,140% of Medicaid,273.79,,,273.79,Other,225% of Medicaid,316.38,,,316.38,Other,260% of Medicaid,394.25,,,394.25,Other,324% of Medicaid,261.62,,,261.62,Other,215% of Medicaid,261.62,,,261.62,Other,215% of Medicaid,152.1,,,152.1,Other,125% of Medicaid,74.63,1040.44,
US SPINAL CANAL W CONTENTS,76800,CPT,TC,44076800,CDM,402,RC,,,both,,,816,603.84,,,603.84,Other,150% of Medicare + 9.63% HCRA Surcharge,367.2,45,,367.2,percent of total billed charges,Critical Access Hospital RCC factor,369.85,,,369.85,Fee Schedule,,332.75,,,332.75,Fee Schedule,,531.01,,,531.01,Fee Schedule,,477.6,,,477.6,Fee Schedule,,451.4,,,451.4,Fee Schedule,,403.92,,,403.92,Other,110% of Medicare,439.41,,,439.41,Fee Schedule,,226,,,226,Other,186% of Medicaid,517.09,,,517.09,Fee Schedule,,505.92,,,505.92,Fee Schedule,,243.47,,,243.47,Fee Schedule,,517.09,,,517.09,Fee Schedule,,505.92,,,505.92,Fee Schedule,,457.96,,,457.96,Fee Schedule,,571.2,70,,571.2,percent of total billed charges,All Other,431.32,,,431.32,Fee Schedule,,365.57,,,365.57,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,121.68,,,121.68,Other,100% of Medicaid,121.68,,,121.68,Other,100% of Medicaid,121.68,,,121.68,Other,100% of Medicaid,121.68,,,121.68,Other,100% of Medicaid,273.79,,,273.79,Other,225% of Medicaid,186.18,,,186.18,Other,153% of Medicaid,273.79,,,273.79,Other,225% of Medicaid,170.36,,,170.36,Other,140% of Medicaid,273.79,,,273.79,Other,225% of Medicaid,316.38,,,316.38,Other,260% of Medicaid,394.25,,,394.25,Other,324% of Medicaid,261.62,,,261.62,Other,215% of Medicaid,261.62,,,261.62,Other,215% of Medicaid,152.1,,,152.1,Other,125% of Medicaid,121.68,603.84,
US 1ST TRIMESTER,76801,CPT,TC,44076801,CDM,402,RC,,,both,,,658,486.92,,,486.92,Other,150% of Medicare + 9.63% HCRA Surcharge,296.1,45,,296.1,percent of total billed charges,Critical Access Hospital RCC factor,246.24,,,246.24,Fee Schedule,,221.54,,,221.54,Fee Schedule,,551.61,,,551.61,Fee Schedule,,496.14,,,496.14,Fee Schedule,,468.92,,,468.92,Fee Schedule,,325.71,,,325.71,Other,110% of Medicare,292.55,,,292.55,Fee Schedule,,196,,,196,Other,186% of Medicaid,344.27,,,344.27,Fee Schedule,,407.96,,,407.96,Fee Schedule,,162.1,,,162.1,Fee Schedule,,344.27,,,344.27,Fee Schedule,,407.96,,,407.96,Fee Schedule,,304.9,,,304.9,Fee Schedule,,460.6,70,,460.6,percent of total billed charges,All Other,349.32,,,349.32,Fee Schedule,,296.07,,,296.07,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,105.15,,,105.15,Other,100% of Medicaid,105.15,,,105.15,Other,100% of Medicaid,105.15,,,105.15,Other,100% of Medicaid,105.15,,,105.15,Other,100% of Medicaid,236.6,,,236.6,Other,225% of Medicaid,160.89,,,160.89,Other,153% of Medicaid,236.6,,,236.6,Other,225% of Medicaid,147.22,,,147.22,Other,140% of Medicaid,236.6,,,236.6,Other,225% of Medicaid,273.4,,,273.4,Other,260% of Medicaid,340.7,,,340.7,Other,324% of Medicaid,226.08,,,226.08,Other,215% of Medicaid,226.08,,,226.08,Other,215% of Medicaid,131.44,,,131.44,Other,125% of Medicaid,105.15,551.61,
US 1ST TRIM EA ADD GEST,76802,CPT,TC,44076802,CDM,402,RC,,,both,,,319,236.06,,,236.06,Other,150% of Medicare + 9.63% HCRA Surcharge,143.55,45,,143.55,percent of total billed charges,Critical Access Hospital RCC factor,72.8,,,72.8,Fee Schedule,,65.49,,,65.49,Fee Schedule,,196.89,,,196.89,Fee Schedule,,177.09,,,177.09,Fee Schedule,,167.37,,,167.37,Fee Schedule,,157.91,,,157.91,Other,110% of Medicare,86.49,,,86.49,Fee Schedule,,196,,,196,Other,186% of Medicaid,101.78,,,101.78,Fee Schedule,,197.78,,,197.78,Fee Schedule,,47.92,,,47.92,Fee Schedule,,101.78,,,101.78,Fee Schedule,,197.78,,,197.78,Fee Schedule,,90.14,,,90.14,Fee Schedule,,223.3,70,,223.3,percent of total billed charges,All Other,104.96,,,104.96,Fee Schedule,,88.96,,,88.96,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,105.15,,,105.15,Other,100% of Medicaid,105.15,,,105.15,Other,100% of Medicaid,105.15,,,105.15,Other,100% of Medicaid,105.15,,,105.15,Other,100% of Medicaid,236.6,,,236.6,Other,225% of Medicaid,160.89,,,160.89,Other,153% of Medicaid,236.6,,,236.6,Other,225% of Medicaid,147.22,,,147.22,Other,140% of Medicaid,236.6,,,236.6,Other,225% of Medicaid,273.4,,,273.4,Other,260% of Medicaid,340.7,,,340.7,Other,324% of Medicaid,226.08,,,226.08,Other,215% of Medicaid,226.08,,,226.08,Other,215% of Medicaid,131.44,,,131.44,Other,125% of Medicaid,0.01,340.7,
US 2ND OR 3RD TRIMESTER,76805,CPT,TC,44076805,CDM,402,RC,,,both,,,826,611.24,,,611.24,Other,150% of Medicare + 9.63% HCRA Surcharge,371.7,45,,371.7,percent of total billed charges,Critical Access Hospital RCC factor,308.79,,,308.79,Fee Schedule,,277.82,,,277.82,Fee Schedule,,647.68,,,647.68,Fee Schedule,,582.55,,,582.55,Fee Schedule,,550.59,,,550.59,Fee Schedule,,408.87,,,408.87,Other,110% of Medicare,366.87,,,366.87,Fee Schedule,,196,,,196,Other,186% of Medicaid,431.73,,,431.73,Fee Schedule,,512.12,,,512.12,Fee Schedule,,203.28,,,203.28,Fee Schedule,,431.73,,,431.73,Fee Schedule,,512.12,,,512.12,Fee Schedule,,382.36,,,382.36,Fee Schedule,,578.2,70,,578.2,percent of total billed charges,All Other,434.6,,,434.6,Fee Schedule,,368.35,,,368.35,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,105.15,,,105.15,Other,100% of Medicaid,105.15,,,105.15,Other,100% of Medicaid,105.15,,,105.15,Other,100% of Medicaid,105.15,,,105.15,Other,100% of Medicaid,236.6,,,236.6,Other,225% of Medicaid,160.89,,,160.89,Other,153% of Medicaid,236.6,,,236.6,Other,225% of Medicaid,147.22,,,147.22,Other,140% of Medicaid,236.6,,,236.6,Other,225% of Medicaid,273.4,,,273.4,Other,260% of Medicaid,340.7,,,340.7,Other,324% of Medicaid,226.08,,,226.08,Other,215% of Medicaid,226.08,,,226.08,Other,215% of Medicaid,131.44,,,131.44,Other,125% of Medicaid,105.15,647.68,
US 2ND 3RD TRIMESTER ADDL GEST,76810,CPT,TC,44076810,CDM,402,RC,,,both,,,457,338.18,,,338.18,Other,150% of Medicare + 9.63% HCRA Surcharge,205.65,45,,205.65,percent of total billed charges,Critical Access Hospital RCC factor,143.42,,,143.42,Fee Schedule,,129.04,,,129.04,Fee Schedule,,336.49,,,336.49,Fee Schedule,,302.65,,,302.65,Fee Schedule,,286.05,,,286.05,Fee Schedule,,226.22,,,226.22,Other,110% of Medicare,170.4,,,170.4,Fee Schedule,,196,,,196,Other,186% of Medicaid,200.52,,,200.52,Fee Schedule,,283.34,,,283.34,Fee Schedule,,94.42,,,94.42,Fee Schedule,,200.52,,,200.52,Fee Schedule,,283.34,,,283.34,Fee Schedule,,177.59,,,177.59,Fee Schedule,,319.9,70,,319.9,percent of total billed charges,All Other,205,,,205,Fee Schedule,,173.75,,,173.75,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,105.15,,,105.15,Other,100% of Medicaid,105.15,,,105.15,Other,100% of Medicaid,105.15,,,105.15,Other,100% of Medicaid,105.15,,,105.15,Other,100% of Medicaid,236.6,,,236.6,Other,225% of Medicaid,160.89,,,160.89,Other,153% of Medicaid,236.6,,,236.6,Other,225% of Medicaid,147.22,,,147.22,Other,140% of Medicaid,236.6,,,236.6,Other,225% of Medicaid,273.4,,,273.4,Other,260% of Medicaid,340.7,,,340.7,Other,324% of Medicaid,226.08,,,226.08,Other,215% of Medicaid,226.08,,,226.08,Other,215% of Medicaid,131.44,,,131.44,Other,125% of Medicaid,0.01,340.7,
US DETAILED SNGL FETUS,76811,CPT,TC,44076811,CDM,402,RC,,,both,,,714,528.36,,,528.36,Other,150% of Medicare + 9.63% HCRA Surcharge,321.3,45,,321.3,percent of total billed charges,Critical Access Hospital RCC factor,306.65,,,306.65,Fee Schedule,,275.89,,,275.89,Fee Schedule,,675.14,,,675.14,Fee Schedule,,607.24,,,607.24,Fee Schedule,,573.93,,,573.93,Fee Schedule,,353.43,,,353.43,Other,110% of Medicare,364.33,,,364.33,Fee Schedule,,196,,,196,Other,186% of Medicaid,428.74,,,428.74,Fee Schedule,,442.68,,,442.68,Fee Schedule,,201.87,,,201.87,Fee Schedule,,428.74,,,428.74,Fee Schedule,,442.68,,,442.68,Fee Schedule,,379.71,,,379.71,Fee Schedule,,499.8,70,,499.8,percent of total billed charges,All Other,410,,,410,Fee Schedule,,347.5,,,347.5,Fee Schedule,,372.86,,,372.86,Fee Schedule,,372.86,,,372.86,Fee Schedule,,372.86,,,372.86,Fee Schedule,,372.86,,,372.86,Fee Schedule,,105.15,,,105.15,Other,100% of Medicaid,105.15,,,105.15,Other,100% of Medicaid,105.15,,,105.15,Other,100% of Medicaid,105.15,,,105.15,Other,100% of Medicaid,236.6,,,236.6,Other,225% of Medicaid,160.89,,,160.89,Other,153% of Medicaid,236.6,,,236.6,Other,225% of Medicaid,147.22,,,147.22,Other,140% of Medicaid,236.6,,,236.6,Other,225% of Medicaid,273.4,,,273.4,Other,260% of Medicaid,340.7,,,340.7,Other,324% of Medicaid,226.08,,,226.08,Other,215% of Medicaid,226.08,,,226.08,Other,215% of Medicaid,131.44,,,131.44,Other,125% of Medicaid,105.15,675.14,
US OB DETAILED ADDL FETUS,76812,CPT,TC,44076812,CDM,402,RC,,,both,,,871,644.54,,,644.54,Other,150% of Medicare + 9.63% HCRA Surcharge,391.95,45,,391.95,percent of total billed charges,Critical Access Hospital RCC factor,374.63,,,374.63,Fee Schedule,,337.05,,,337.05,Fee Schedule,,421.18,,,421.18,Fee Schedule,,378.82,,,378.82,Fee Schedule,,358.04,,,358.04,Fee Schedule,,431.15,,,431.15,Other,110% of Medicare,445.1,,,445.1,Fee Schedule,,196,,,196,Other,186% of Medicaid,523.78,,,523.78,Fee Schedule,,540.02,,,540.02,Fee Schedule,,246.62,,,246.62,Fee Schedule,,523.78,,,523.78,Fee Schedule,,540.02,,,540.02,Fee Schedule,,463.89,,,463.89,Fee Schedule,,609.7,70,,609.7,percent of total billed charges,All Other,533,,,533,Fee Schedule,,451.75,,,451.75,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,105.15,,,105.15,Other,100% of Medicaid,105.15,,,105.15,Other,100% of Medicaid,105.15,,,105.15,Other,100% of Medicaid,105.15,,,105.15,Other,100% of Medicaid,236.6,,,236.6,Other,225% of Medicaid,160.89,,,160.89,Other,153% of Medicaid,236.6,,,236.6,Other,225% of Medicaid,147.22,,,147.22,Other,140% of Medicaid,236.6,,,236.6,Other,225% of Medicaid,273.4,,,273.4,Other,260% of Medicaid,340.7,,,340.7,Other,324% of Medicaid,226.08,,,226.08,Other,215% of Medicaid,226.08,,,226.08,Other,215% of Medicaid,131.44,,,131.44,Other,125% of Medicaid,0.01,644.54,
US OB LIMITED 1 OR > GEST,76815,CPT,TC,44076815,CDM,402,RC,,,both,,,466,344.84,,,344.84,Other,150% of Medicare + 9.63% HCRA Surcharge,209.7,45,,209.7,percent of total billed charges,Critical Access Hospital RCC factor,175.77,,,175.77,Fee Schedule,,158.14,,,158.14,Fee Schedule,,405.16,,,405.16,Fee Schedule,,364.41,,,364.41,Fee Schedule,,344.42,,,344.42,Fee Schedule,,230.67,,,230.67,Other,110% of Medicare,208.83,,,208.83,Fee Schedule,,196,,,196,Other,186% of Medicaid,245.75,,,245.75,Fee Schedule,,288.92,,,288.92,Fee Schedule,,115.71,,,115.71,Fee Schedule,,245.75,,,245.75,Fee Schedule,,288.92,,,288.92,Fee Schedule,,217.65,,,217.65,Fee Schedule,,326.2,70,,326.2,percent of total billed charges,All Other,249.28,,,249.28,Fee Schedule,,211.28,,,211.28,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,105.15,,,105.15,Other,100% of Medicaid,105.15,,,105.15,Other,100% of Medicaid,105.15,,,105.15,Other,100% of Medicaid,105.15,,,105.15,Other,100% of Medicaid,236.6,,,236.6,Other,225% of Medicaid,160.89,,,160.89,Other,153% of Medicaid,236.6,,,236.6,Other,225% of Medicaid,147.22,,,147.22,Other,140% of Medicaid,236.6,,,236.6,Other,225% of Medicaid,273.4,,,273.4,Other,260% of Medicaid,340.7,,,340.7,Other,324% of Medicaid,226.08,,,226.08,Other,215% of Medicaid,226.08,,,226.08,Other,215% of Medicaid,131.44,,,131.44,Other,125% of Medicaid,105.15,405.16,
US REPEAT PREGNANCY EXAM,76816,CPT,TC,44076816,CDM,402,RC,,,both,,,646,478.04,,,478.04,Other,150% of Medicare + 9.63% HCRA Surcharge,290.7,45,,290.7,percent of total billed charges,Critical Access Hospital RCC factor,242.79,,,242.79,Fee Schedule,,218.44,,,218.44,Fee Schedule,,418.86,,,418.86,Fee Schedule,,376.74,,,376.74,Fee Schedule,,356.07,,,356.07,Fee Schedule,,319.77,,,319.77,Other,110% of Medicare,288.46,,,288.46,Fee Schedule,,196,,,196,Other,186% of Medicaid,339.45,,,339.45,Fee Schedule,,400.52,,,400.52,Fee Schedule,,159.83,,,159.83,Fee Schedule,,339.45,,,339.45,Fee Schedule,,400.52,,,400.52,Fee Schedule,,300.63,,,300.63,Fee Schedule,,452.2,70,,452.2,percent of total billed charges,All Other,341.12,,,341.12,Fee Schedule,,289.12,,,289.12,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,105.15,,,105.15,Other,100% of Medicaid,105.15,,,105.15,Other,100% of Medicaid,105.15,,,105.15,Other,100% of Medicaid,105.15,,,105.15,Other,100% of Medicaid,236.6,,,236.6,Other,225% of Medicaid,160.89,,,160.89,Other,153% of Medicaid,236.6,,,236.6,Other,225% of Medicaid,147.22,,,147.22,Other,140% of Medicaid,236.6,,,236.6,Other,225% of Medicaid,273.4,,,273.4,Other,260% of Medicaid,340.7,,,340.7,Other,324% of Medicaid,226.08,,,226.08,Other,215% of Medicaid,226.08,,,226.08,Other,215% of Medicaid,131.44,,,131.44,Other,125% of Medicaid,105.15,478.04,
US PREGNANCY TRANSVAGINAL,76817,CPT,TC,44076817,CDM,402,RC,,,both,,,590,436.6,,,436.6,Other,150% of Medicare + 9.63% HCRA Surcharge,265.5,45,,265.5,percent of total billed charges,Critical Access Hospital RCC factor,198.86,,,198.86,Fee Schedule,,178.92,,,178.92,Fee Schedule,,418.86,,,418.86,Fee Schedule,,376.74,,,376.74,Fee Schedule,,356.07,,,356.07,Fee Schedule,,292.05,,,292.05,Other,110% of Medicare,236.27,,,236.27,Fee Schedule,,196,,,196,Other,186% of Medicaid,278.04,,,278.04,Fee Schedule,,365.8,,,365.8,Fee Schedule,,130.91,,,130.91,Fee Schedule,,278.04,,,278.04,Fee Schedule,,365.8,,,365.8,Fee Schedule,,246.24,,,246.24,Fee Schedule,,413,70,,413,percent of total billed charges,All Other,282.08,,,282.08,Fee Schedule,,239.08,,,239.08,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,105.15,,,105.15,Other,100% of Medicaid,105.15,,,105.15,Other,100% of Medicaid,105.15,,,105.15,Other,100% of Medicaid,105.15,,,105.15,Other,100% of Medicaid,236.6,,,236.6,Other,225% of Medicaid,160.89,,,160.89,Other,153% of Medicaid,236.6,,,236.6,Other,225% of Medicaid,147.22,,,147.22,Other,140% of Medicaid,236.6,,,236.6,Other,225% of Medicaid,273.4,,,273.4,Other,260% of Medicaid,340.7,,,340.7,Other,324% of Medicaid,226.08,,,226.08,Other,215% of Medicaid,226.08,,,226.08,Other,215% of Medicaid,131.44,,,131.44,Other,125% of Medicaid,105.15,436.6,
US FETAL BIOPHYSICAL PROFILE,76819,CPT,TC,44076819,CDM,402,RC,,,both,,,855,632.7,,,632.7,Other,150% of Medicare + 9.63% HCRA Surcharge,384.75,45,,384.75,percent of total billed charges,Critical Access Hospital RCC factor,172.48,,,172.48,Fee Schedule,,155.18,,,155.18,Fee Schedule,,363.95,,,363.95,Fee Schedule,,327.34,,,327.34,Fee Schedule,,309.39,,,309.39,Fee Schedule,,423.23,,,423.23,Other,110% of Medicare,204.93,,,204.93,Fee Schedule,,196,,,196,Other,186% of Medicaid,241.15,,,241.15,Fee Schedule,,530.1,,,530.1,Fee Schedule,,113.55,,,113.55,Fee Schedule,,241.15,,,241.15,Fee Schedule,,530.1,,,530.1,Fee Schedule,,213.58,,,213.58,Fee Schedule,,598.5,70,,598.5,percent of total billed charges,All Other,229.6,,,229.6,Fee Schedule,,194.6,,,194.6,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,105.15,,,105.15,Other,100% of Medicaid,105.15,,,105.15,Other,100% of Medicaid,105.15,,,105.15,Other,100% of Medicaid,105.15,,,105.15,Other,100% of Medicaid,236.6,,,236.6,Other,225% of Medicaid,160.89,,,160.89,Other,153% of Medicaid,236.6,,,236.6,Other,225% of Medicaid,147.22,,,147.22,Other,140% of Medicaid,236.6,,,236.6,Other,225% of Medicaid,273.4,,,273.4,Other,260% of Medicaid,340.7,,,340.7,Other,324% of Medicaid,226.08,,,226.08,Other,215% of Medicaid,226.08,,,226.08,Other,215% of Medicaid,131.44,,,131.44,Other,125% of Medicaid,105.15,632.7,
FETAL UMBILICAL ARTERY ECHO,76820,CPT,TC,44076820,CDM,402,RC,,,both,,,273,202.02,,,202.02,Other,150% of Medicare + 9.63% HCRA Surcharge,122.85,45,,122.85,percent of total billed charges,Critical Access Hospital RCC factor,74.1,,,74.1,Fee Schedule,,66.67,,,66.67,Fee Schedule,,151.14,,,151.14,Fee Schedule,,135.94,,,135.94,Fee Schedule,,128.49,,,128.49,Fee Schedule,,135.14,,,135.14,Other,110% of Medicare,88.04,,,88.04,Fee Schedule,,196,,,196,Other,186% of Medicaid,103.61,,,103.61,Fee Schedule,,169.26,,,169.26,Fee Schedule,,48.78,,,48.78,Fee Schedule,,103.61,,,103.61,Fee Schedule,,169.26,,,169.26,Fee Schedule,,91.76,,,91.76,Fee Schedule,,191.1,70,,191.1,percent of total billed charges,All Other,104.96,,,104.96,Fee Schedule,,88.96,,,88.96,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,105.15,,,105.15,Other,100% of Medicaid,105.15,,,105.15,Other,100% of Medicaid,105.15,,,105.15,Other,100% of Medicaid,105.15,,,105.15,Other,100% of Medicaid,236.6,,,236.6,Other,225% of Medicaid,160.89,,,160.89,Other,153% of Medicaid,236.6,,,236.6,Other,225% of Medicaid,147.22,,,147.22,Other,140% of Medicaid,236.6,,,236.6,Other,225% of Medicaid,273.4,,,273.4,Other,260% of Medicaid,340.7,,,340.7,Other,324% of Medicaid,226.08,,,226.08,Other,215% of Medicaid,226.08,,,226.08,Other,215% of Medicaid,131.44,,,131.44,Other,125% of Medicaid,48.78,340.7,
FETAL MIDDLE CEREB ART ECHO,76821,CPT,TC,44076821,CDM,402,RC,,,both,,,437,323.38,,,323.38,Other,150% of Medicare + 9.63% HCRA Surcharge,196.65,45,,196.65,percent of total billed charges,Critical Access Hospital RCC factor,194.24,,,194.24,Fee Schedule,,174.75,,,174.75,Fee Schedule,,418.86,,,418.86,Fee Schedule,,376.74,,,376.74,Fee Schedule,,356.07,,,356.07,Fee Schedule,,216.32,,,216.32,Other,110% of Medicare,230.77,,,230.77,Fee Schedule,,196,,,196,Other,186% of Medicaid,271.57,,,271.57,Fee Schedule,,270.94,,,270.94,Fee Schedule,,127.87,,,127.87,Fee Schedule,,271.57,,,271.57,Fee Schedule,,270.94,,,270.94,Fee Schedule,,240.52,,,240.52,Fee Schedule,,305.9,70,,305.9,percent of total billed charges,All Other,272.24,,,272.24,Fee Schedule,,230.74,,,230.74,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,105.15,,,105.15,Other,100% of Medicaid,105.15,,,105.15,Other,100% of Medicaid,105.15,,,105.15,Other,100% of Medicaid,105.15,,,105.15,Other,100% of Medicaid,236.6,,,236.6,Other,225% of Medicaid,160.89,,,160.89,Other,153% of Medicaid,236.6,,,236.6,Other,225% of Medicaid,147.22,,,147.22,Other,140% of Medicaid,236.6,,,236.6,Other,225% of Medicaid,273.4,,,273.4,Other,260% of Medicaid,340.7,,,340.7,Other,324% of Medicaid,226.08,,,226.08,Other,215% of Medicaid,226.08,,,226.08,Other,215% of Medicaid,131.44,,,131.44,Other,125% of Medicaid,105.15,418.86,
US TRANSVAGINAL NON OB,76830,CPT,TC,44076830,CDM,402,RC,,,both,,,953,705.22,,,705.22,Other,150% of Medicare + 9.63% HCRA Surcharge,428.85,45,,428.85,percent of total billed charges,Critical Access Hospital RCC factor,301.87,,,301.87,Fee Schedule,,271.59,,,271.59,Fee Schedule,,615.64,,,615.64,Fee Schedule,,553.73,,,553.73,Fee Schedule,,523.35,,,523.35,Fee Schedule,,471.74,,,471.74,Other,110% of Medicare,358.65,,,358.65,Fee Schedule,,226,,,226,Other,186% of Medicaid,422.05,,,422.05,Fee Schedule,,590.86,,,590.86,Fee Schedule,,198.72,,,198.72,Fee Schedule,,422.05,,,422.05,Fee Schedule,,590.86,,,590.86,Fee Schedule,,373.79,,,373.79,Fee Schedule,,667.1,70,,667.1,percent of total billed charges,All Other,431.32,,,431.32,Fee Schedule,,365.57,,,365.57,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,121.68,,,121.68,Other,100% of Medicaid,121.68,,,121.68,Other,100% of Medicaid,121.68,,,121.68,Other,100% of Medicaid,121.68,,,121.68,Other,100% of Medicaid,273.79,,,273.79,Other,225% of Medicaid,186.18,,,186.18,Other,153% of Medicaid,273.79,,,273.79,Other,225% of Medicaid,170.36,,,170.36,Other,140% of Medicaid,273.79,,,273.79,Other,225% of Medicaid,316.38,,,316.38,Other,260% of Medicaid,394.25,,,394.25,Other,324% of Medicaid,261.62,,,261.62,Other,215% of Medicaid,261.62,,,261.62,Other,215% of Medicaid,152.1,,,152.1,Other,125% of Medicaid,121.68,705.22,
SALINE INFUSED SONOHYSTEROGRAM,76831,CPT,TC,44076831,CDM,402,RC,,,both,,,682,504.68,,,504.68,Other,150% of Medicare + 9.63% HCRA Surcharge,306.9,45,,306.9,percent of total billed charges,Critical Access Hospital RCC factor,285.51,,,285.51,Fee Schedule,,256.87,,,256.87,Fee Schedule,,608.79,,,608.79,Fee Schedule,,547.56,,,547.56,Fee Schedule,,517.53,,,517.53,Fee Schedule,,337.59,,,337.59,Other,110% of Medicare,339.21,,,339.21,Fee Schedule,,982,,,982,Other,186% of Medicaid,399.17,,,399.17,Fee Schedule,,422.84,,,422.84,Fee Schedule,,187.95,,,187.95,Fee Schedule,,399.17,,,399.17,Fee Schedule,,422.84,,,422.84,Fee Schedule,,353.53,,,353.53,Fee Schedule,,477.4,70,,477.4,percent of total billed charges,All Other,406.72,,,406.72,Fee Schedule,,344.72,,,344.72,Fee Schedule,,372.86,,,372.86,Fee Schedule,,372.86,,,372.86,Fee Schedule,,372.86,,,372.86,Fee Schedule,,372.86,,,372.86,Fee Schedule,,527.83,,,527.83,Other,100% of Medicaid,527.83,,,527.83,Other,100% of Medicaid,527.83,,,527.83,Other,100% of Medicaid,527.83,,,527.83,Other,100% of Medicaid,1187.61,,,1187.61,Other,225% of Medicaid,807.58,,,807.58,Other,153% of Medicaid,1187.61,,,1187.61,Other,225% of Medicaid,738.96,,,738.96,Other,140% of Medicaid,1187.61,,,1187.61,Other,225% of Medicaid,1372.35,,,1372.35,Other,260% of Medicaid,1710.16,,,1710.16,Other,324% of Medicaid,1134.83,,,1134.83,Other,215% of Medicaid,1134.83,,,1134.83,Other,215% of Medicaid,659.78,,,659.78,Other,125% of Medicaid,187.95,1710.16,
US PELVIC COMPLETE,76856,CPT,TC,44076856,CDM,402,RC,,,both,,,809,598.66,,,598.66,Other,150% of Medicare + 9.63% HCRA Surcharge,364.05,45,,364.05,percent of total billed charges,Critical Access Hospital RCC factor,254.34,,,254.34,Fee Schedule,,228.83,,,228.83,Fee Schedule,,613.38,,,613.38,Fee Schedule,,551.69,,,551.69,Fee Schedule,,521.43,,,521.43,Fee Schedule,,400.46,,,400.46,Other,110% of Medicare,302.18,,,302.18,Fee Schedule,,982,,,982,Other,186% of Medicaid,355.6,,,355.6,Fee Schedule,,501.58,,,501.58,Fee Schedule,,167.43,,,167.43,Fee Schedule,,355.6,,,355.6,Fee Schedule,,501.58,,,501.58,Fee Schedule,,314.93,,,314.93,Fee Schedule,,566.3,70,,566.3,percent of total billed charges,All Other,362.44,,,362.44,Fee Schedule,,307.19,,,307.19,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,527.83,,,527.83,Other,100% of Medicaid,527.83,,,527.83,Other,100% of Medicaid,527.83,,,527.83,Other,100% of Medicaid,527.83,,,527.83,Other,100% of Medicaid,1187.61,,,1187.61,Other,225% of Medicaid,807.58,,,807.58,Other,153% of Medicaid,1187.61,,,1187.61,Other,225% of Medicaid,738.96,,,738.96,Other,140% of Medicaid,1187.61,,,1187.61,Other,225% of Medicaid,1372.35,,,1372.35,Other,260% of Medicaid,1710.16,,,1710.16,Other,324% of Medicaid,1134.83,,,1134.83,Other,215% of Medicaid,1134.83,,,1134.83,Other,215% of Medicaid,659.78,,,659.78,Other,125% of Medicaid,167.43,1710.16,
US PELVIS NON OB LIMITED,76857,CPT,TC,44076857,CDM,402,RC,,,both,,,609,450.66,,,450.66,Other,150% of Medicare + 9.63% HCRA Surcharge,274.05,45,,274.05,percent of total billed charges,Critical Access Hospital RCC factor,91.43,,,91.43,Fee Schedule,,82.25,,,82.25,Fee Schedule,,418.86,,,418.86,Fee Schedule,,376.74,,,376.74,Fee Schedule,,356.07,,,356.07,Fee Schedule,,301.46,,,301.46,Other,110% of Medicare,108.62,,,108.62,Fee Schedule,,226,,,226,Other,186% of Medicaid,127.82,,,127.82,Fee Schedule,,377.58,,,377.58,Fee Schedule,,60.19,,,60.19,Fee Schedule,,127.82,,,127.82,Fee Schedule,,377.58,,,377.58,Fee Schedule,,113.21,,,113.21,Fee Schedule,,426.3,70,,426.3,percent of total billed charges,All Other,119.72,,,119.72,Fee Schedule,,101.47,,,101.47,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,121.68,,,121.68,Other,100% of Medicaid,121.68,,,121.68,Other,100% of Medicaid,121.68,,,121.68,Other,100% of Medicaid,121.68,,,121.68,Other,100% of Medicaid,273.79,,,273.79,Other,225% of Medicaid,186.18,,,186.18,Other,153% of Medicaid,273.79,,,273.79,Other,225% of Medicaid,170.36,,,170.36,Other,140% of Medicaid,273.79,,,273.79,Other,225% of Medicaid,316.38,,,316.38,Other,260% of Medicaid,394.25,,,394.25,Other,324% of Medicaid,261.62,,,261.62,Other,215% of Medicaid,261.62,,,261.62,Other,215% of Medicaid,152.1,,,152.1,Other,125% of Medicaid,60.19,450.66,
US TESTICULAR EXAM,76870,CPT,TC,44076870,CDM,402,RC,,,both,,,874,646.76,,,646.76,Other,150% of Medicare + 9.63% HCRA Surcharge,393.3,45,,393.3,percent of total billed charges,Critical Access Hospital RCC factor,243.94,,,243.94,Fee Schedule,,219.47,,,219.47,Fee Schedule,,622.55,,,622.55,Fee Schedule,,559.94,,,559.94,Fee Schedule,,529.22,,,529.22,Fee Schedule,,432.63,,,432.63,Other,110% of Medicare,289.82,,,289.82,Fee Schedule,,226,,,226,Other,186% of Medicaid,341.06,,,341.06,Fee Schedule,,541.88,,,541.88,Fee Schedule,,160.59,,,160.59,Fee Schedule,,341.06,,,341.06,Fee Schedule,,541.88,,,541.88,Fee Schedule,,302.06,,,302.06,Fee Schedule,,611.8,70,,611.8,percent of total billed charges,All Other,349.32,,,349.32,Fee Schedule,,296.07,,,296.07,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,121.68,,,121.68,Other,100% of Medicaid,121.68,,,121.68,Other,100% of Medicaid,121.68,,,121.68,Other,100% of Medicaid,121.68,,,121.68,Other,100% of Medicaid,273.79,,,273.79,Other,225% of Medicaid,186.18,,,186.18,Other,153% of Medicaid,273.79,,,273.79,Other,225% of Medicaid,170.36,,,170.36,Other,140% of Medicaid,273.79,,,273.79,Other,225% of Medicaid,316.38,,,316.38,Other,260% of Medicaid,394.25,,,394.25,Other,324% of Medicaid,261.62,,,261.62,Other,215% of Medicaid,261.62,,,261.62,Other,215% of Medicaid,152.1,,,152.1,Other,125% of Medicaid,121.68,646.76,
US PROSTATE VOLUME FOR BT,76873,CPT,TC,44076873,CDM,402,RC,,,both,,,846,626.04,,,626.04,Other,150% of Medicare + 9.63% HCRA Surcharge,380.7,45,,380.7,percent of total billed charges,Critical Access Hospital RCC factor,348.06,,,348.06,Fee Schedule,,313.15,,,313.15,Fee Schedule,,647.68,,,647.68,Fee Schedule,,582.55,,,582.55,Fee Schedule,,550.59,,,550.59,Fee Schedule,,418.77,,,418.77,Other,110% of Medicare,413.53,,,413.53,Fee Schedule,,982,,,982,Other,186% of Medicaid,486.63,,,486.63,Fee Schedule,,524.52,,,524.52,Fee Schedule,,229.13,,,229.13,Fee Schedule,,486.63,,,486.63,Fee Schedule,,524.52,,,524.52,Fee Schedule,,430.98,,,430.98,Fee Schedule,,592.2,70,,592.2,percent of total billed charges,All Other,483.8,,,483.8,Fee Schedule,,410.05,,,410.05,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,527.83,,,527.83,Other,100% of Medicaid,527.83,,,527.83,Other,100% of Medicaid,527.83,,,527.83,Other,100% of Medicaid,527.83,,,527.83,Other,100% of Medicaid,1187.61,,,1187.61,Other,225% of Medicaid,807.58,,,807.58,Other,153% of Medicaid,1187.61,,,1187.61,Other,225% of Medicaid,738.96,,,738.96,Other,140% of Medicaid,1187.61,,,1187.61,Other,225% of Medicaid,1372.35,,,1372.35,Other,260% of Medicaid,1710.16,,,1710.16,Other,324% of Medicaid,1134.83,,,1134.83,Other,215% of Medicaid,1134.83,,,1134.83,Other,215% of Medicaid,659.78,,,659.78,Other,125% of Medicaid,179.33,1710.16,
US EXTREM NON-VASC COMPL,76881,CPT,TC,44076881,CDM,402,RC,,,both,,,665,492.1,,,492.1,Other,150% of Medicare + 9.63% HCRA Surcharge,299.25,45,,299.25,percent of total billed charges,Critical Access Hospital RCC factor,38.28,,,38.28,Fee Schedule,,34.44,,,34.44,Fee Schedule,,581.33,,,581.33,Fee Schedule,,522.87,,,522.87,Fee Schedule,,494.19,,,494.19,Fee Schedule,,329.18,,,329.18,Other,110% of Medicare,45.48,,,45.48,Fee Schedule,,226,,,226,Other,186% of Medicaid,53.52,,,53.52,Fee Schedule,,412.3,,,412.3,Fee Schedule,,25.2,,,25.2,Fee Schedule,,53.52,,,53.52,Fee Schedule,,412.3,,,412.3,Fee Schedule,,47.4,,,47.4,Fee Schedule,,465.5,70,,465.5,percent of total billed charges,All Other,139.4,,,139.4,Fee Schedule,,118.15,,,118.15,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,121.68,,,121.68,Other,100% of Medicaid,121.68,,,121.68,Other,100% of Medicaid,121.68,,,121.68,Other,100% of Medicaid,121.68,,,121.68,Other,100% of Medicaid,273.79,,,273.79,Other,225% of Medicaid,186.18,,,186.18,Other,153% of Medicaid,273.79,,,273.79,Other,225% of Medicaid,170.36,,,170.36,Other,140% of Medicaid,273.79,,,273.79,Other,225% of Medicaid,316.38,,,316.38,Other,260% of Medicaid,394.25,,,394.25,Other,324% of Medicaid,261.62,,,261.62,Other,215% of Medicaid,261.62,,,261.62,Other,215% of Medicaid,152.1,,,152.1,Other,125% of Medicaid,25.2,581.33,
US XTR NON-VASC LMTD,76882,CPT,TC,44076882,CDM,402,RC,,,both,,,275,203.5,,,203.5,Other,150% of Medicare + 9.63% HCRA Surcharge,123.75,45,,123.75,percent of total billed charges,Critical Access Hospital RCC factor,107.6,,,107.6,Fee Schedule,,96.81,,,96.81,Fee Schedule,,68.77,,,68.77,Fee Schedule,,61.86,,,61.86,Fee Schedule,,58.46,,,58.46,Fee Schedule,,136.13,,,136.13,Other,110% of Medicare,127.84,,,127.84,Fee Schedule,,226,,,226,Other,186% of Medicaid,150.44,,,150.44,Fee Schedule,,170.5,,,170.5,Fee Schedule,,70.83,,,70.83,Fee Schedule,,150.44,,,150.44,Fee Schedule,,170.5,,,170.5,Fee Schedule,,133.23,,,133.23,Fee Schedule,,192.5,70,,192.5,percent of total billed charges,All Other,162.36,,,162.36,Fee Schedule,,137.61,,,137.61,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,121.68,,,121.68,Other,100% of Medicaid,121.68,,,121.68,Other,100% of Medicaid,121.68,,,121.68,Other,100% of Medicaid,121.68,,,121.68,Other,100% of Medicaid,273.79,,,273.79,Other,225% of Medicaid,186.18,,,186.18,Other,153% of Medicaid,273.79,,,273.79,Other,225% of Medicaid,170.36,,,170.36,Other,140% of Medicaid,273.79,,,273.79,Other,225% of Medicaid,316.38,,,316.38,Other,260% of Medicaid,394.25,,,394.25,Other,324% of Medicaid,261.62,,,261.62,Other,215% of Medicaid,261.62,,,261.62,Other,215% of Medicaid,152.1,,,152.1,Other,125% of Medicaid,58.46,394.25,
US PEDIATRIC HIPS,76885,CPT,TC,44076885,CDM,402,RC,,,both,,,842,623.08,,,623.08,Other,150% of Medicare + 9.63% HCRA Surcharge,378.9,45,,378.9,percent of total billed charges,Critical Access Hospital RCC factor,306.5,,,306.5,Fee Schedule,,275.75,,,275.75,Fee Schedule,,421.18,,,421.18,Fee Schedule,,378.82,,,378.82,Fee Schedule,,358.04,,,358.04,Fee Schedule,,416.79,,,416.79,Other,110% of Medicare,364.14,,,364.14,Fee Schedule,,226,,,226,Other,186% of Medicaid,428.52,,,428.52,Fee Schedule,,522.04,,,522.04,Fee Schedule,,201.77,,,201.77,Fee Schedule,,428.52,,,428.52,Fee Schedule,,522.04,,,522.04,Fee Schedule,,379.52,,,379.52,Fee Schedule,,589.4,70,,589.4,percent of total billed charges,All Other,506.76,,,506.76,Fee Schedule,,429.51,,,429.51,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,121.68,,,121.68,Other,100% of Medicaid,121.68,,,121.68,Other,100% of Medicaid,121.68,,,121.68,Other,100% of Medicaid,121.68,,,121.68,Other,100% of Medicaid,273.79,,,273.79,Other,225% of Medicaid,186.18,,,186.18,Other,153% of Medicaid,273.79,,,273.79,Other,225% of Medicaid,170.36,,,170.36,Other,140% of Medicaid,273.79,,,273.79,Other,225% of Medicaid,316.38,,,316.38,Other,260% of Medicaid,394.25,,,394.25,Other,324% of Medicaid,261.62,,,261.62,Other,215% of Medicaid,261.62,,,261.62,Other,215% of Medicaid,152.1,,,152.1,Other,125% of Medicaid,121.68,623.08,
US GUIDED PSEUDOANEURYSM,76936,CPT,TC,44076936,CDM,402,RC,,,both,,,1559,1153.66,,,1153.66,Other,150% of Medicare + 9.63% HCRA Surcharge,701.55,45,,701.55,percent of total billed charges,Critical Access Hospital RCC factor,583.93,,,583.93,Fee Schedule,,525.35,,,525.35,Fee Schedule,,718.62,,,718.62,Fee Schedule,,646.35,,,646.35,Fee Schedule,,610.89,,,610.89,Fee Schedule,,771.71,,,771.71,Other,110% of Medicare,693.76,,,693.76,Fee Schedule,,544,,,544,Other,186% of Medicaid,816.4,,,816.4,Fee Schedule,,966.58,,,966.58,Fee Schedule,,384.41,,,384.41,Fee Schedule,,816.4,,,816.4,Fee Schedule,,966.58,,,966.58,Fee Schedule,,723.05,,,723.05,Fee Schedule,,1091.3,70,,1091.3,percent of total billed charges,All Other,829.84,,,829.84,Fee Schedule,,703.34,,,703.34,Fee Schedule,,404.96,,,404.96,Fee Schedule,,404.96,,,404.96,Fee Schedule,,404.96,,,404.96,Fee Schedule,,404.96,,,404.96,Fee Schedule,,292.43,,,292.43,Other,100% of Medicaid,292.43,,,292.43,Other,100% of Medicaid,292.43,,,292.43,Other,100% of Medicaid,292.43,,,292.43,Other,100% of Medicaid,657.97,,,657.97,Other,225% of Medicaid,447.42,,,447.42,Other,153% of Medicaid,657.97,,,657.97,Other,225% of Medicaid,409.4,,,409.4,Other,140% of Medicaid,657.97,,,657.97,Other,225% of Medicaid,760.32,,,760.32,Other,260% of Medicaid,947.48,,,947.48,Other,324% of Medicaid,628.73,,,628.73,Other,215% of Medicaid,628.73,,,628.73,Other,215% of Medicaid,365.54,,,365.54,Other,125% of Medicaid,292.43,1153.66,
US GUIDANCE VASCULAR ACCESS,76937,CPT,TC,44076937,CDM,402,RC,,,both,,,186,137.64,,,137.64,Other,150% of Medicare + 9.63% HCRA Surcharge,83.7,45,,83.7,percent of total billed charges,Critical Access Hospital RCC factor,85.65,,,85.65,Fee Schedule,,77.06,,,77.06,Fee Schedule,,132.8,,,132.8,Fee Schedule,,119.45,,,119.45,Fee Schedule,,112.9,,,112.9,Fee Schedule,,92.07,,,92.07,Other,110% of Medicare,101.76,,,101.76,Fee Schedule,,325,,,325,Other,186% of Medicaid,119.75,,,119.75,Fee Schedule,,115.32,,,115.32,Fee Schedule,,56.39,,,56.39,Fee Schedule,,119.75,,,119.75,Fee Schedule,,115.32,,,115.32,Fee Schedule,,106.06,,,106.06,Fee Schedule,,130.2,70,,130.2,percent of total billed charges,All Other,126.28,,,126.28,Fee Schedule,,107.03,,,107.03,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,174.66,,,174.66,Other,100% of Medicaid,174.66,,,174.66,Other,100% of Medicaid,174.66,,,174.66,Other,100% of Medicaid,174.66,,,174.66,Other,100% of Medicaid,392.98,,,392.98,Other,225% of Medicaid,267.23,,,267.23,Other,153% of Medicaid,392.98,,,392.98,Other,225% of Medicaid,244.52,,,244.52,Other,140% of Medicaid,392.98,,,392.98,Other,225% of Medicaid,454.12,,,454.12,Other,260% of Medicaid,565.9,,,565.9,Other,324% of Medicaid,375.52,,,375.52,Other,215% of Medicaid,375.52,,,375.52,Other,215% of Medicaid,218.32,,,218.32,Other,125% of Medicaid,0.01,565.9,
US GUIDED NEEDLE PLACEMEN,76942,CPT,TC,44076942,CDM,402,RC,,,both,,,1201,888.74,,,888.74,Other,150% of Medicare + 9.63% HCRA Surcharge,540.45,45,,540.45,percent of total billed charges,Critical Access Hospital RCC factor,98.38,,,98.38,Fee Schedule,,88.51,,,88.51,Fee Schedule,,1107.65,,,1107.65,Fee Schedule,,996.25,,,996.25,Fee Schedule,,941.61,,,941.61,Fee Schedule,,594.5,,,594.5,Other,110% of Medicare,116.88,,,116.88,Fee Schedule,,325,,,325,Other,186% of Medicaid,137.55,,,137.55,Fee Schedule,,744.62,,,744.62,Fee Schedule,,64.76,,,64.76,Fee Schedule,,137.55,,,137.55,Fee Schedule,,744.62,,,744.62,Fee Schedule,,121.82,,,121.82,Fee Schedule,,840.7,70,,840.7,percent of total billed charges,All Other,134.48,,,134.48,Fee Schedule,,113.98,,,113.98,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,174.66,,,174.66,Other,100% of Medicaid,174.66,,,174.66,Other,100% of Medicaid,174.66,,,174.66,Other,100% of Medicaid,174.66,,,174.66,Other,100% of Medicaid,392.98,,,392.98,Other,225% of Medicaid,267.23,,,267.23,Other,153% of Medicaid,392.98,,,392.98,Other,225% of Medicaid,244.52,,,244.52,Other,140% of Medicaid,392.98,,,392.98,Other,225% of Medicaid,454.12,,,454.12,Other,260% of Medicaid,565.9,,,565.9,Other,324% of Medicaid,375.52,,,375.52,Other,215% of Medicaid,375.52,,,375.52,Other,215% of Medicaid,218.32,,,218.32,Other,125% of Medicaid,0.01,1107.65,
US GUIDED AMNIOCENTESIS,76946,CPT,TC,44076946,CDM,402,RC,,,both,,,1207,893.18,,,893.18,Other,150% of Medicare + 9.63% HCRA Surcharge,543.15,45,,543.15,percent of total billed charges,Critical Access Hospital RCC factor,53.3,,,53.3,Fee Schedule,,47.96,,,47.96,Fee Schedule,,130.54,,,130.54,Fee Schedule,,117.41,,,117.41,Fee Schedule,,110.97,,,110.97,Fee Schedule,,597.47,,,597.47,Other,110% of Medicare,63.33,,,63.33,Fee Schedule,,325,,,325,Other,186% of Medicaid,74.53,,,74.53,Fee Schedule,,748.34,,,748.34,Fee Schedule,,35.09,,,35.09,Fee Schedule,,74.53,,,74.53,Fee Schedule,,748.34,,,748.34,Fee Schedule,,66,,,66,Fee Schedule,,844.9,70,,844.9,percent of total billed charges,All Other,68.88,,,68.88,Fee Schedule,,58.38,,,58.38,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,174.66,,,174.66,Other,100% of Medicaid,174.66,,,174.66,Other,100% of Medicaid,174.66,,,174.66,Other,100% of Medicaid,174.66,,,174.66,Other,100% of Medicaid,392.98,,,392.98,Other,225% of Medicaid,267.23,,,267.23,Other,153% of Medicaid,392.98,,,392.98,Other,225% of Medicaid,244.52,,,244.52,Other,140% of Medicaid,392.98,,,392.98,Other,225% of Medicaid,454.12,,,454.12,Other,260% of Medicaid,565.9,,,565.9,Other,324% of Medicaid,375.52,,,375.52,Other,215% of Medicaid,375.52,,,375.52,Other,215% of Medicaid,218.32,,,218.32,Other,125% of Medicaid,0.01,893.18,
US INTERSTITIAL RE APPLIC,76965,CPT,TC,44076965,CDM,402,RC,,,both,,,1150,851,,,851,Other,150% of Medicare + 9.63% HCRA Surcharge,517.5,45,,517.5,percent of total billed charges,Critical Access Hospital RCC factor,96.05,,,96.05,Fee Schedule,,86.42,,,86.42,Fee Schedule,,338.76,,,338.76,Fee Schedule,,304.69,,,304.69,Fee Schedule,,287.97,,,287.97,Fee Schedule,,569.25,,,569.25,Other,110% of Medicare,114.12,,,114.12,Fee Schedule,,325,,,325,Other,186% of Medicaid,134.29,,,134.29,Fee Schedule,,713,,,713,Fee Schedule,,63.23,,,63.23,Fee Schedule,,134.29,,,134.29,Fee Schedule,,713,,,713,Fee Schedule,,118.93,,,118.93,Fee Schedule,,805,70,,805,percent of total billed charges,All Other,127.92,,,127.92,Fee Schedule,,108.42,,,108.42,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,174.66,,,174.66,Other,100% of Medicaid,174.66,,,174.66,Other,100% of Medicaid,174.66,,,174.66,Other,100% of Medicaid,174.66,,,174.66,Other,100% of Medicaid,392.98,,,392.98,Other,225% of Medicaid,267.23,,,267.23,Other,153% of Medicaid,392.98,,,392.98,Other,225% of Medicaid,244.52,,,244.52,Other,140% of Medicaid,392.98,,,392.98,Other,225% of Medicaid,454.12,,,454.12,Other,260% of Medicaid,565.9,,,565.9,Other,324% of Medicaid,375.52,,,375.52,Other,215% of Medicaid,375.52,,,375.52,Other,215% of Medicaid,218.32,,,218.32,Other,125% of Medicaid,0.01,851,
US GUIDE INTRAOP,76998,CPT,TC,44076998,CDM,402,RC,,,both,,,1325,980.5,,,980.5,Other,150% of Medicare + 9.63% HCRA Surcharge,596.25,45,,596.25,percent of total billed charges,Critical Access Hospital RCC factor,861.25,65,,861.25,percent of total billed charges,All Other,781.75,65,,781.75,percent of total billed charges,All Other,70.21,,,70.21,Fee Schedule,,70.21,,,70.21,Fee Schedule,,70.21,,,70.21,Fee Schedule,,655.88,,,655.88,Other,110% of Medicare,901,68,,901,percent of total billed charges,All Other,325,,,325,Other,186% of Medicaid,1060,,,1060,percent of total billed charges,All Other,1099.75,83,,1099.75,percent of total billed charges,All Other,1099.75,83,,1099.75,percent of total billed charges,All Other,1060,80,,1060,percent of total billed charges,All Other,1099.75,83,,1099.75,percent of total billed charges,All Other,1060,80,,1060,percent of total billed charges,All Other,927.5,70,,927.5,percent of total billed charges,All Other,861.25,65,,861.25,percent of total billed charges,Default if not in Fee Schedule,861.25,65,,861.25,percent of total billed charges,Default if not in Fee Schedule,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,174.66,,,174.66,Other,100% of Medicaid,174.66,,,174.66,Other,100% of Medicaid,174.66,,,174.66,Other,100% of Medicaid,174.66,,,174.66,Other,100% of Medicaid,392.98,,,392.98,Other,225% of Medicaid,267.23,,,267.23,Other,153% of Medicaid,392.98,,,392.98,Other,225% of Medicaid,244.52,,,244.52,Other,140% of Medicaid,392.98,,,392.98,Other,225% of Medicaid,454.12,,,454.12,Other,260% of Medicaid,565.9,,,565.9,Other,324% of Medicaid,375.52,,,375.52,Other,215% of Medicaid,375.52,,,375.52,Other,215% of Medicaid,218.32,,,218.32,Other,125% of Medicaid,0.01,1099.75,
US PROCEDURE UNSPEC,76999,CPT,TC,44076999,CDM,402,RC,,,both,,,273,202.02,,,202.02,Other,150% of Medicare + 9.63% HCRA Surcharge,122.85,45,,122.85,percent of total billed charges,Critical Access Hospital RCC factor,177.45,65,,177.45,percent of total billed charges,All Other,161.07,65,,161.07,percent of total billed charges,All Other,66,,,66,Fee Schedule,,66,,,66,Fee Schedule,,66,,,66,Fee Schedule,,135.14,,,135.14,Other,110% of Medicare,185.64,68,,185.64,percent of total billed charges,All Other,226,,,226,Other,186% of Medicaid,218.4,,,218.4,percent of total billed charges,All Other,169.26,62,,169.26,percent of total billed charges,Lab and Radiology,150.15,55,,150.15,percent of total billed charges,Default if not on Fee Schedule,218.4,80,,218.4,percent of total billed charges,All Other,169.26,62,,169.26,percent of total billed charges,Lab and Radiology,218.4,80,,218.4,percent of total billed charges,All Other,191.1,70,,191.1,percent of total billed charges,All Other,177.45,65,,177.45,percent of total billed charges,Default if not in Fee Schedule,177.45,65,,177.45,percent of total billed charges,Default if not in Fee Schedule,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,121.68,,,121.68,Other,100% of Medicaid,121.68,,,121.68,Other,100% of Medicaid,121.68,,,121.68,Other,100% of Medicaid,121.68,,,121.68,Other,100% of Medicaid,273.79,,,273.79,Other,225% of Medicaid,186.18,,,186.18,Other,153% of Medicaid,273.79,,,273.79,Other,225% of Medicaid,170.36,,,170.36,Other,140% of Medicaid,273.79,,,273.79,Other,225% of Medicaid,316.38,,,316.38,Other,260% of Medicaid,394.25,,,394.25,Other,324% of Medicaid,261.62,,,261.62,Other,215% of Medicaid,261.62,,,261.62,Other,215% of Medicaid,152.1,,,152.1,Other,125% of Medicaid,66,394.25,
US BREAST COMPLETE LT,76641,CPT,TCLT,44176641,CDM,402,RC,,,both,,,634,469.16,,,469.16,Other,150% of Medicare + 9.63% HCRA Surcharge,285.3,45,,285.3,percent of total billed charges,Critical Access Hospital RCC factor,236.99,,,236.99,Fee Schedule,,213.21,,,213.21,Fee Schedule,,74.78,,,74.78,Fee Schedule,,74.78,,,74.78,Fee Schedule,,74.78,,,74.78,Fee Schedule,,313.83,,,313.83,Other,110% of Medicare,281.56,,,281.56,Fee Schedule,,226,,,226,Other,186% of Medicaid,331.33,,,331.33,Fee Schedule,,393.08,,,393.08,Fee Schedule,,156.01,,,156.01,Fee Schedule,,331.33,,,331.33,Fee Schedule,,393.08,,,393.08,Fee Schedule,,293.45,,,293.45,Fee Schedule,,443.8,70,,443.8,percent of total billed charges,All Other,339.48,,,339.48,Fee Schedule,,287.73,,,287.73,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,121.68,,,121.68,Other,100% of Medicaid,121.68,,,121.68,Other,100% of Medicaid,121.68,,,121.68,Other,100% of Medicaid,121.68,,,121.68,Other,100% of Medicaid,273.79,,,273.79,Other,225% of Medicaid,186.18,,,186.18,Other,153% of Medicaid,273.79,,,273.79,Other,225% of Medicaid,170.36,,,170.36,Other,140% of Medicaid,273.79,,,273.79,Other,225% of Medicaid,316.38,,,316.38,Other,260% of Medicaid,394.25,,,394.25,Other,324% of Medicaid,261.62,,,261.62,Other,215% of Medicaid,261.62,,,261.62,Other,215% of Medicaid,152.1,,,152.1,Other,125% of Medicaid,74.78,469.16,
US BREAST LIMITED LT,76642,CPT,TCLT,44176642,CDM,402,RC,,,both,,,415,307.1,,,307.1,Other,150% of Medicare + 9.63% HCRA Surcharge,186.75,45,,186.75,percent of total billed charges,Critical Access Hospital RCC factor,183.87,,,183.87,Fee Schedule,,165.43,,,165.43,Fee Schedule,,57.01,,,57.01,Fee Schedule,,57.01,,,57.01,Fee Schedule,,57.01,,,57.01,Fee Schedule,,205.43,,,205.43,Other,110% of Medicare,218.46,,,218.46,Fee Schedule,,226,,,226,Other,186% of Medicaid,257.07,,,257.07,Fee Schedule,,257.3,,,257.3,Fee Schedule,,121.04,,,121.04,Fee Schedule,,257.07,,,257.07,Fee Schedule,,257.3,,,257.3,Fee Schedule,,227.68,,,227.68,Fee Schedule,,290.5,70,,290.5,percent of total billed charges,All Other,259.12,,,259.12,Fee Schedule,,219.62,,,219.62,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,121.68,,,121.68,Other,100% of Medicaid,121.68,,,121.68,Other,100% of Medicaid,121.68,,,121.68,Other,100% of Medicaid,121.68,,,121.68,Other,100% of Medicaid,273.79,,,273.79,Other,225% of Medicaid,186.18,,,186.18,Other,153% of Medicaid,273.79,,,273.79,Other,225% of Medicaid,170.36,,,170.36,Other,140% of Medicaid,273.79,,,273.79,Other,225% of Medicaid,316.38,,,316.38,Other,260% of Medicaid,394.25,,,394.25,Other,324% of Medicaid,261.62,,,261.62,Other,215% of Medicaid,261.62,,,261.62,Other,215% of Medicaid,152.1,,,152.1,Other,125% of Medicaid,57.01,394.25,
US REPEAT PREGNANCY EXAM W MOD,76816,CPT,TC59,44176816,CDM,402,RC,,,both,,,646,478.04,,,478.04,Other,150% of Medicare + 9.63% HCRA Surcharge,290.7,45,,290.7,percent of total billed charges,Critical Access Hospital RCC factor,242.79,,,242.79,Fee Schedule,,218.44,,,218.44,Fee Schedule,,418.86,,,418.86,Fee Schedule,,376.74,,,376.74,Fee Schedule,,356.07,,,356.07,Fee Schedule,,319.77,,,319.77,Other,110% of Medicare,288.46,,,288.46,Fee Schedule,,196,,,196,Other,186% of Medicaid,339.45,,,339.45,Fee Schedule,,400.52,,,400.52,Fee Schedule,,159.83,,,159.83,Fee Schedule,,339.45,,,339.45,Fee Schedule,,400.52,,,400.52,Fee Schedule,,300.63,,,300.63,Fee Schedule,,452.2,70,,452.2,percent of total billed charges,All Other,341.12,,,341.12,Fee Schedule,,289.12,,,289.12,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,105.15,,,105.15,Other,100% of Medicaid,105.15,,,105.15,Other,100% of Medicaid,105.15,,,105.15,Other,100% of Medicaid,105.15,,,105.15,Other,100% of Medicaid,236.6,,,236.6,Other,225% of Medicaid,160.89,,,160.89,Other,153% of Medicaid,236.6,,,236.6,Other,225% of Medicaid,147.22,,,147.22,Other,140% of Medicaid,236.6,,,236.6,Other,225% of Medicaid,273.4,,,273.4,Other,260% of Medicaid,340.7,,,340.7,Other,324% of Medicaid,226.08,,,226.08,Other,215% of Medicaid,226.08,,,226.08,Other,215% of Medicaid,131.44,,,131.44,Other,125% of Medicaid,105.15,478.04,
US FETAL BIOPHYSICAL PROFILE W MOD,76819,CPT,TC59,44176819,CDM,402,RC,,,both,,,855,632.7,,,632.7,Other,150% of Medicare + 9.63% HCRA Surcharge,384.75,45,,384.75,percent of total billed charges,Critical Access Hospital RCC factor,172.48,,,172.48,Fee Schedule,,155.18,,,155.18,Fee Schedule,,363.95,,,363.95,Fee Schedule,,327.34,,,327.34,Fee Schedule,,309.39,,,309.39,Fee Schedule,,423.23,,,423.23,Other,110% of Medicare,204.93,,,204.93,Fee Schedule,,196,,,196,Other,186% of Medicaid,241.15,,,241.15,Fee Schedule,,530.1,,,530.1,Fee Schedule,,113.55,,,113.55,Fee Schedule,,241.15,,,241.15,Fee Schedule,,530.1,,,530.1,Fee Schedule,,213.58,,,213.58,Fee Schedule,,598.5,70,,598.5,percent of total billed charges,All Other,229.6,,,229.6,Fee Schedule,,194.6,,,194.6,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,105.15,,,105.15,Other,100% of Medicaid,105.15,,,105.15,Other,100% of Medicaid,105.15,,,105.15,Other,100% of Medicaid,105.15,,,105.15,Other,100% of Medicaid,236.6,,,236.6,Other,225% of Medicaid,160.89,,,160.89,Other,153% of Medicaid,236.6,,,236.6,Other,225% of Medicaid,147.22,,,147.22,Other,140% of Medicaid,236.6,,,236.6,Other,225% of Medicaid,273.4,,,273.4,Other,260% of Medicaid,340.7,,,340.7,Other,324% of Medicaid,226.08,,,226.08,Other,215% of Medicaid,226.08,,,226.08,Other,215% of Medicaid,131.44,,,131.44,Other,125% of Medicaid,105.15,632.7,
US BREAST COMPLETE RT,76641,CPT,TCRT,44276641,CDM,402,RC,,,both,,,634,469.16,,,469.16,Other,150% of Medicare + 9.63% HCRA Surcharge,285.3,45,,285.3,percent of total billed charges,Critical Access Hospital RCC factor,236.99,,,236.99,Fee Schedule,,213.21,,,213.21,Fee Schedule,,74.78,,,74.78,Fee Schedule,,74.78,,,74.78,Fee Schedule,,74.78,,,74.78,Fee Schedule,,313.83,,,313.83,Other,110% of Medicare,281.56,,,281.56,Fee Schedule,,226,,,226,Other,186% of Medicaid,331.33,,,331.33,Fee Schedule,,393.08,,,393.08,Fee Schedule,,156.01,,,156.01,Fee Schedule,,331.33,,,331.33,Fee Schedule,,393.08,,,393.08,Fee Schedule,,293.45,,,293.45,Fee Schedule,,443.8,70,,443.8,percent of total billed charges,All Other,339.48,,,339.48,Fee Schedule,,287.73,,,287.73,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,121.68,,,121.68,Other,100% of Medicaid,121.68,,,121.68,Other,100% of Medicaid,121.68,,,121.68,Other,100% of Medicaid,121.68,,,121.68,Other,100% of Medicaid,273.79,,,273.79,Other,225% of Medicaid,186.18,,,186.18,Other,153% of Medicaid,273.79,,,273.79,Other,225% of Medicaid,170.36,,,170.36,Other,140% of Medicaid,273.79,,,273.79,Other,225% of Medicaid,316.38,,,316.38,Other,260% of Medicaid,394.25,,,394.25,Other,324% of Medicaid,261.62,,,261.62,Other,215% of Medicaid,261.62,,,261.62,Other,215% of Medicaid,152.1,,,152.1,Other,125% of Medicaid,74.78,469.16,
US BREAST LIMITED RT,76642,CPT,TCRT,44276642,CDM,402,RC,,,both,,,415,307.1,,,307.1,Other,150% of Medicare + 9.63% HCRA Surcharge,186.75,45,,186.75,percent of total billed charges,Critical Access Hospital RCC factor,183.87,,,183.87,Fee Schedule,,165.43,,,165.43,Fee Schedule,,57.01,,,57.01,Fee Schedule,,57.01,,,57.01,Fee Schedule,,57.01,,,57.01,Fee Schedule,,205.43,,,205.43,Other,110% of Medicare,218.46,,,218.46,Fee Schedule,,226,,,226,Other,186% of Medicaid,257.07,,,257.07,Fee Schedule,,257.3,,,257.3,Fee Schedule,,121.04,,,121.04,Fee Schedule,,257.07,,,257.07,Fee Schedule,,257.3,,,257.3,Fee Schedule,,227.68,,,227.68,Fee Schedule,,290.5,70,,290.5,percent of total billed charges,All Other,259.12,,,259.12,Fee Schedule,,219.62,,,219.62,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,121.68,,,121.68,Other,100% of Medicaid,121.68,,,121.68,Other,100% of Medicaid,121.68,,,121.68,Other,100% of Medicaid,121.68,,,121.68,Other,100% of Medicaid,273.79,,,273.79,Other,225% of Medicaid,186.18,,,186.18,Other,153% of Medicaid,273.79,,,273.79,Other,225% of Medicaid,170.36,,,170.36,Other,140% of Medicaid,273.79,,,273.79,Other,225% of Medicaid,316.38,,,316.38,Other,260% of Medicaid,394.25,,,394.25,Other,324% of Medicaid,261.62,,,261.62,Other,215% of Medicaid,261.62,,,261.62,Other,215% of Medicaid,152.1,,,152.1,Other,125% of Medicaid,57.01,394.25,
US BREAST COMPLETE BILATERAL,76641,CPT,TC50,44376641,CDM,402,RC,,,both,,,951,703.74,,,703.74,Other,150% of Medicare + 9.63% HCRA Surcharge,427.95,45,,427.95,percent of total billed charges,Critical Access Hospital RCC factor,236.99,,,236.99,Fee Schedule,,213.21,,,213.21,Fee Schedule,,74.78,,,74.78,Fee Schedule,,74.78,,,74.78,Fee Schedule,,74.78,,,74.78,Fee Schedule,,470.75,,,470.75,Other,110% of Medicare,281.56,,,281.56,Fee Schedule,,226,,,226,Other,186% of Medicaid,331.33,,,331.33,Fee Schedule,,589.62,,,589.62,Fee Schedule,,156.01,,,156.01,Fee Schedule,,331.33,,,331.33,Fee Schedule,,589.62,,,589.62,Fee Schedule,,293.45,,,293.45,Fee Schedule,,665.7,70,,665.7,percent of total billed charges,All Other,339.48,,,339.48,Fee Schedule,,287.73,,,287.73,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,121.68,,,121.68,Other,100% of Medicaid,121.68,,,121.68,Other,100% of Medicaid,121.68,,,121.68,Other,100% of Medicaid,121.68,,,121.68,Other,100% of Medicaid,273.79,,,273.79,Other,225% of Medicaid,186.18,,,186.18,Other,153% of Medicaid,273.79,,,273.79,Other,225% of Medicaid,170.36,,,170.36,Other,140% of Medicaid,273.79,,,273.79,Other,225% of Medicaid,316.38,,,316.38,Other,260% of Medicaid,394.25,,,394.25,Other,324% of Medicaid,261.62,,,261.62,Other,215% of Medicaid,261.62,,,261.62,Other,215% of Medicaid,152.1,,,152.1,Other,125% of Medicaid,74.78,703.74,
US BREAST LIMITED BILATERAL,76642,CPT,TC50,44376642,CDM,402,RC,,,both,,,623,461.02,,,461.02,Other,150% of Medicare + 9.63% HCRA Surcharge,280.35,45,,280.35,percent of total billed charges,Critical Access Hospital RCC factor,183.87,,,183.87,Fee Schedule,,165.43,,,165.43,Fee Schedule,,57.01,,,57.01,Fee Schedule,,57.01,,,57.01,Fee Schedule,,57.01,,,57.01,Fee Schedule,,308.39,,,308.39,Other,110% of Medicare,218.46,,,218.46,Fee Schedule,,226,,,226,Other,186% of Medicaid,257.07,,,257.07,Fee Schedule,,386.26,,,386.26,Fee Schedule,,121.04,,,121.04,Fee Schedule,,257.07,,,257.07,Fee Schedule,,386.26,,,386.26,Fee Schedule,,227.68,,,227.68,Fee Schedule,,436.1,70,,436.1,percent of total billed charges,All Other,259.12,,,259.12,Fee Schedule,,219.62,,,219.62,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,127.7,,,127.7,Fee Schedule,,121.68,,,121.68,Other,100% of Medicaid,121.68,,,121.68,Other,100% of Medicaid,121.68,,,121.68,Other,100% of Medicaid,121.68,,,121.68,Other,100% of Medicaid,273.79,,,273.79,Other,225% of Medicaid,186.18,,,186.18,Other,153% of Medicaid,273.79,,,273.79,Other,225% of Medicaid,170.36,,,170.36,Other,140% of Medicaid,273.79,,,273.79,Other,225% of Medicaid,316.38,,,316.38,Other,260% of Medicaid,394.25,,,394.25,Other,324% of Medicaid,261.62,,,261.62,Other,215% of Medicaid,261.62,,,261.62,Other,215% of Medicaid,152.1,,,152.1,Other,125% of Medicaid,57.01,461.02,
US XTR NON-VASC LMTD BILATERAL,76882,CPT,TC50,44376882,CDM,402,RC,,,both,,,413,305.62,,,305.62,Other,150% of Medicare + 9.63% HCRA Surcharge,185.85,45,,185.85,percent of total billed charges,Critical Access Hospital RCC factor,107.6,,,107.6,Fee Schedule,,96.81,,,96.81,Fee Schedule,,68.77,,,68.77,Fee Schedule,,61.86,,,61.86,Fee Schedule,,58.46,,,58.46,Fee Schedule,,204.44,,,204.44,Other,110% of Medicare,127.84,,,127.84,Fee Schedule,,226,,,226,Other,186% of Medicaid,150.44,,,150.44,Fee Schedule,,256.06,,,256.06,Fee Schedule,,70.83,,,70.83,Fee Schedule,,150.44,,,150.44,Fee Schedule,,256.06,,,256.06,Fee Schedule,,133.23,,,133.23,Fee Schedule,,289.1,70,,289.1,percent of total billed charges,All Other,162.36,,,162.36,Fee Schedule,,137.61,,,137.61,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,121.68,,,121.68,Other,100% of Medicaid,121.68,,,121.68,Other,100% of Medicaid,121.68,,,121.68,Other,100% of Medicaid,121.68,,,121.68,Other,100% of Medicaid,273.79,,,273.79,Other,225% of Medicaid,186.18,,,186.18,Other,153% of Medicaid,273.79,,,273.79,Other,225% of Medicaid,170.36,,,170.36,Other,140% of Medicaid,273.79,,,273.79,Other,225% of Medicaid,316.38,,,316.38,Other,260% of Medicaid,394.25,,,394.25,Other,324% of Medicaid,261.62,,,261.62,Other,215% of Medicaid,261.62,,,261.62,Other,215% of Medicaid,152.1,,,152.1,Other,125% of Medicaid,58.46,394.25,
US GUIDE VASCULAR ACCESS,76937,CPT,TC,47076937,CDM,402,RC,,,both,,,186,137.64,,,137.64,Other,150% of Medicare + 9.63% HCRA Surcharge,83.7,45,,83.7,percent of total billed charges,Critical Access Hospital RCC factor,85.65,,,85.65,Fee Schedule,,77.06,,,77.06,Fee Schedule,,132.8,,,132.8,Fee Schedule,,119.45,,,119.45,Fee Schedule,,112.9,,,112.9,Fee Schedule,,92.07,,,92.07,Other,110% of Medicare,101.76,,,101.76,Fee Schedule,,325,,,325,Other,186% of Medicaid,119.75,,,119.75,Fee Schedule,,115.32,,,115.32,Fee Schedule,,56.39,,,56.39,Fee Schedule,,119.75,,,119.75,Fee Schedule,,115.32,,,115.32,Fee Schedule,,106.06,,,106.06,Fee Schedule,,130.2,70,,130.2,percent of total billed charges,All Other,126.28,,,126.28,Fee Schedule,,107.03,,,107.03,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,174.66,,,174.66,Other,100% of Medicaid,174.66,,,174.66,Other,100% of Medicaid,174.66,,,174.66,Other,100% of Medicaid,174.66,,,174.66,Other,100% of Medicaid,392.98,,,392.98,Other,225% of Medicaid,267.23,,,267.23,Other,153% of Medicaid,392.98,,,392.98,Other,225% of Medicaid,244.52,,,244.52,Other,140% of Medicaid,392.98,,,392.98,Other,225% of Medicaid,454.12,,,454.12,Other,260% of Medicaid,565.9,,,565.9,Other,324% of Medicaid,375.52,,,375.52,Other,215% of Medicaid,375.52,,,375.52,Other,215% of Medicaid,218.32,,,218.32,Other,125% of Medicaid,0.01,565.9,
US GUIDED NEEDLE PLACEMENT,76942,CPT,TC,47076942,CDM,402,RC,,,both,,,1201,888.74,,,888.74,Other,150% of Medicare + 9.63% HCRA Surcharge,540.45,45,,540.45,percent of total billed charges,Critical Access Hospital RCC factor,98.38,,,98.38,Fee Schedule,,88.51,,,88.51,Fee Schedule,,1107.65,,,1107.65,Fee Schedule,,996.25,,,996.25,Fee Schedule,,941.61,,,941.61,Fee Schedule,,594.5,,,594.5,Other,110% of Medicare,116.88,,,116.88,Fee Schedule,,325,,,325,Other,186% of Medicaid,137.55,,,137.55,Fee Schedule,,744.62,,,744.62,Fee Schedule,,64.76,,,64.76,Fee Schedule,,137.55,,,137.55,Fee Schedule,,744.62,,,744.62,Fee Schedule,,121.82,,,121.82,Fee Schedule,,840.7,70,,840.7,percent of total billed charges,All Other,134.48,,,134.48,Fee Schedule,,113.98,,,113.98,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,174.66,,,174.66,Other,100% of Medicaid,174.66,,,174.66,Other,100% of Medicaid,174.66,,,174.66,Other,100% of Medicaid,174.66,,,174.66,Other,100% of Medicaid,392.98,,,392.98,Other,225% of Medicaid,267.23,,,267.23,Other,153% of Medicaid,392.98,,,392.98,Other,225% of Medicaid,244.52,,,244.52,Other,140% of Medicaid,392.98,,,392.98,Other,225% of Medicaid,454.12,,,454.12,Other,260% of Medicaid,565.9,,,565.9,Other,324% of Medicaid,375.52,,,375.52,Other,215% of Medicaid,375.52,,,375.52,Other,215% of Medicaid,218.32,,,218.32,Other,125% of Medicaid,0.01,1107.65,
US GUIDE VASCULAR ACCESS 59 MOD,76937,CPT,TC59,47176937,CDM,402,RC,,,both,,,186,137.64,,,137.64,Other,150% of Medicare + 9.63% HCRA Surcharge,83.7,45,,83.7,percent of total billed charges,Critical Access Hospital RCC factor,85.65,,,85.65,Fee Schedule,,77.06,,,77.06,Fee Schedule,,132.8,,,132.8,Fee Schedule,,119.45,,,119.45,Fee Schedule,,112.9,,,112.9,Fee Schedule,,92.07,,,92.07,Other,110% of Medicare,101.76,,,101.76,Fee Schedule,,325,,,325,Other,186% of Medicaid,119.75,,,119.75,Fee Schedule,,115.32,,,115.32,Fee Schedule,,56.39,,,56.39,Fee Schedule,,119.75,,,119.75,Fee Schedule,,115.32,,,115.32,Fee Schedule,,106.06,,,106.06,Fee Schedule,,130.2,70,,130.2,percent of total billed charges,All Other,126.28,,,126.28,Fee Schedule,,107.03,,,107.03,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,174.66,,,174.66,Other,100% of Medicaid,174.66,,,174.66,Other,100% of Medicaid,174.66,,,174.66,Other,100% of Medicaid,174.66,,,174.66,Other,100% of Medicaid,392.98,,,392.98,Other,225% of Medicaid,267.23,,,267.23,Other,153% of Medicaid,392.98,,,392.98,Other,225% of Medicaid,244.52,,,244.52,Other,140% of Medicaid,392.98,,,392.98,Other,225% of Medicaid,454.12,,,454.12,Other,260% of Medicaid,565.9,,,565.9,Other,324% of Medicaid,375.52,,,375.52,Other,215% of Medicaid,375.52,,,375.52,Other,215% of Medicaid,218.32,,,218.32,Other,125% of Medicaid,0.01,565.9,
SCR MAMMO BI INCL CAD,77067,CPT,TC,54077067,CDM,403,RC,,,both,,,882,652.68,,,652.68,Other,150% of Medicare + 9.63% HCRA Surcharge,396.9,45,,396.9,percent of total billed charges,Critical Access Hospital RCC factor,320.18,,,320.18,Fee Schedule,,288.06,,,288.06,Fee Schedule,,76.73,,,76.73,Fee Schedule,,76.73,,,76.73,Fee Schedule,,76.73,,,76.73,Fee Schedule,,436.59,,,436.59,Other,110% of Medicare,380.4,,,380.4,Fee Schedule,,188,,,188,Other,186% of Medicaid,447.65,,,447.65,Fee Schedule,,546.84,,,546.84,Fee Schedule,,210.78,,,210.78,Fee Schedule,,447.65,,,447.65,Fee Schedule,,546.84,,,546.84,Fee Schedule,,396.46,,,396.46,Fee Schedule,,617.4,70,,617.4,percent of total billed charges,All Other,452.64,,,452.64,Fee Schedule,,383.64,,,383.64,Fee Schedule,,159.95,,,159.95,Fee Schedule,,159.95,,,159.95,Fee Schedule,,159.95,,,159.95,Fee Schedule,,159.95,,,159.95,Fee Schedule,,101.09,,,101.09,Other,100% of Medicaid,101.09,,,101.09,Other,100% of Medicaid,101.09,,,101.09,Other,100% of Medicaid,101.09,,,101.09,Other,100% of Medicaid,227.46,,,227.46,Other,225% of Medicaid,154.67,,,154.67,Other,153% of Medicaid,227.46,,,227.46,Other,225% of Medicaid,141.53,,,141.53,Other,140% of Medicaid,227.46,,,227.46,Other,225% of Medicaid,262.84,,,262.84,Other,260% of Medicaid,327.54,,,327.54,Other,324% of Medicaid,217.35,,,217.35,Other,215% of Medicaid,217.35,,,217.35,Other,215% of Medicaid,126.37,,,126.37,Other,125% of Medicaid,76.73,652.68,
SCREENING MAMMO DIGITAL UNILATERAL,G0202,HCPCS,52LT,54100006,CDM,403,RC,,,both,,,641,474.34,,,474.34,Other,150% of Medicare + 9.63% HCRA Surcharge,288.45,45,,288.45,percent of total billed charges,Critical Access Hospital RCC factor,416.65,65,,416.65,percent of total billed charges,All Other,378.19,65,,378.19,percent of total billed charges,All Other,79.9,,,79.9,Fee Schedule,,79.9,,,79.9,Fee Schedule,,79.9,,,79.9,Fee Schedule,,317.3,,,317.3,Other,110% of Medicare,435.88,68,,435.88,percent of total billed charges,All Other,188,,,188,Other,186% of Medicaid,512.8,,,512.8,percent of total billed charges,All Other,397.42,62,,397.42,percent of total billed charges,Lab and Radiology,352.55,55,,352.55,percent of total billed charges,Default if not on Fee Schedule,512.8,80,,512.8,percent of total billed charges,All Other,397.42,62,,397.42,percent of total billed charges,Lab and Radiology,512.8,80,,512.8,percent of total billed charges,All Other,448.7,70,,448.7,percent of total billed charges,All Other,416.65,65,,416.65,percent of total billed charges,Default if not in Fee Schedule,416.65,65,,416.65,percent of total billed charges,Default if not in Fee Schedule,320.5,,,320.5,Fee Schedule,,320.5,,,320.5,Fee Schedule,,320.5,,,320.5,Fee Schedule,,320.5,,,320.5,Fee Schedule,,101.09,,,101.09,Other,100% of Medicaid,101.09,,,101.09,Other,100% of Medicaid,101.09,,,101.09,Other,100% of Medicaid,101.09,,,101.09,Other,100% of Medicaid,227.46,,,227.46,Other,225% of Medicaid,154.67,,,154.67,Other,153% of Medicaid,227.46,,,227.46,Other,225% of Medicaid,141.53,,,141.53,Other,140% of Medicaid,227.46,,,227.46,Other,225% of Medicaid,262.84,,,262.84,Other,260% of Medicaid,327.54,,,327.54,Other,324% of Medicaid,217.35,,,217.35,Other,215% of Medicaid,217.35,,,217.35,Other,215% of Medicaid,126.37,,,126.37,Other,125% of Medicaid,79.9,512.8,
SCREENING MAMMO DIGITAL UNILATERAL,G0202,HCPCS,52RT,54200006,CDM,403,RC,,,both,,,641,474.34,,,474.34,Other,150% of Medicare + 9.63% HCRA Surcharge,288.45,45,,288.45,percent of total billed charges,Critical Access Hospital RCC factor,416.65,65,,416.65,percent of total billed charges,All Other,378.19,65,,378.19,percent of total billed charges,All Other,79.9,,,79.9,Fee Schedule,,79.9,,,79.9,Fee Schedule,,79.9,,,79.9,Fee Schedule,,317.3,,,317.3,Other,110% of Medicare,435.88,68,,435.88,percent of total billed charges,All Other,188,,,188,Other,186% of Medicaid,512.8,,,512.8,percent of total billed charges,All Other,397.42,62,,397.42,percent of total billed charges,Lab and Radiology,352.55,55,,352.55,percent of total billed charges,Default if not on Fee Schedule,512.8,80,,512.8,percent of total billed charges,All Other,397.42,62,,397.42,percent of total billed charges,Lab and Radiology,512.8,80,,512.8,percent of total billed charges,All Other,448.7,70,,448.7,percent of total billed charges,All Other,416.65,65,,416.65,percent of total billed charges,Default if not in Fee Schedule,416.65,65,,416.65,percent of total billed charges,Default if not in Fee Schedule,320.5,,,320.5,Fee Schedule,,320.5,,,320.5,Fee Schedule,,320.5,,,320.5,Fee Schedule,,320.5,,,320.5,Fee Schedule,,101.09,,,101.09,Other,100% of Medicaid,101.09,,,101.09,Other,100% of Medicaid,101.09,,,101.09,Other,100% of Medicaid,101.09,,,101.09,Other,100% of Medicaid,227.46,,,227.46,Other,225% of Medicaid,154.67,,,154.67,Other,153% of Medicaid,227.46,,,227.46,Other,225% of Medicaid,141.53,,,141.53,Other,140% of Medicaid,227.46,,,227.46,Other,225% of Medicaid,262.84,,,262.84,Other,260% of Medicaid,327.54,,,327.54,Other,324% of Medicaid,217.35,,,217.35,Other,215% of Medicaid,217.35,,,217.35,Other,215% of Medicaid,126.37,,,126.37,Other,125% of Medicaid,79.9,512.8,
AIRWAY INHALATION TREATMENT,94640,CPT,,30094640,CDM,410,RC,,,both,,,433,320.42,,,320.42,Other,150% of Medicare + 9.63% HCRA Surcharge,194.85,45,,194.85,percent of total billed charges,Critical Access Hospital RCC factor,281.45,65,,281.45,percent of total billed charges,All Other,255.47,65,,255.47,percent of total billed charges,All Other,107.67,,,107.67,Fee Schedule,,96.84,,,96.84,Fee Schedule,,91.53,,,91.53,Fee Schedule,,214.34,,,214.34,Other,110% of Medicare,33.12,,,33.12,Fee Schedule,,113,,,113,Other,186% of Medicaid,38.98,,,38.98,Fee Schedule,,268.46,,,268.46,Fee Schedule,,18.35,,,18.35,Fee Schedule,,38.98,,,38.98,Fee Schedule,,268.46,,,268.46,Fee Schedule,,346.4,80,,346.4,percent of total billed charges,All Other,303.1,70,,303.1,percent of total billed charges,All Other,54.12,,,54.12,Fee Schedule,,45.87,,,45.87,Fee Schedule,,143,,,143,Case Rate,,131,,,131,Case Rate,,143,,,143,Case Rate,,122,,,122,Case Rate,,61,,,61,Other,100% of Medicaid,61,,,61,Other,100% of Medicaid,61,,,61,Other,100% of Medicaid,61,,,61,Other,100% of Medicaid,137.24,,,137.24,Other,225% of Medicaid,93.32,,,93.32,Other,153% of Medicaid,137.24,,,137.24,Other,225% of Medicaid,85.39,,,85.39,Other,140% of Medicaid,137.24,,,137.24,Other,225% of Medicaid,158.59,,,158.59,Other,260% of Medicaid,197.63,,,197.63,Other,324% of Medicaid,131.14,,,131.14,Other,215% of Medicaid,131.14,,,131.14,Other,215% of Medicaid,76.24,,,76.24,Other,125% of Medicaid,18.35,346.4,
CONT BRONCH TX 1ST HOUR,94644,CPT,,30094644,CDM,410,RC,,,both,,,336,248.64,,,248.64,Other,150% of Medicare + 9.63% HCRA Surcharge,151.2,45,,151.2,percent of total billed charges,Critical Access Hospital RCC factor,218.4,65,,218.4,percent of total billed charges,All Other,198.24,65,,198.24,percent of total billed charges,All Other,270.14,,,270.14,Fee Schedule,,242.97,,,242.97,Fee Schedule,,229.64,,,229.64,Fee Schedule,,166.32,,,166.32,Other,110% of Medicare,246.08,,,246.08,Fee Schedule,,113,,,113,Other,186% of Medicaid,289.59,,,289.59,Fee Schedule,,208.32,,,208.32,Fee Schedule,,136.35,,,136.35,Fee Schedule,,289.59,,,289.59,Fee Schedule,,208.32,,,208.32,Fee Schedule,,268.8,80,,268.8,percent of total billed charges,All Other,235.2,70,,235.2,percent of total billed charges,All Other,298.48,,,298.48,Fee Schedule,,252.98,,,252.98,Fee Schedule,,143,,,143,Case Rate,,131,,,131,Case Rate,,143,,,143,Case Rate,,122,,,122,Case Rate,,61,,,61,Other,100% of Medicaid,61,,,61,Other,100% of Medicaid,61,,,61,Other,100% of Medicaid,61,,,61,Other,100% of Medicaid,137.24,,,137.24,Other,225% of Medicaid,93.32,,,93.32,Other,153% of Medicaid,137.24,,,137.24,Other,225% of Medicaid,85.39,,,85.39,Other,140% of Medicaid,137.24,,,137.24,Other,225% of Medicaid,158.59,,,158.59,Other,260% of Medicaid,197.63,,,197.63,Other,324% of Medicaid,131.14,,,131.14,Other,215% of Medicaid,131.14,,,131.14,Other,215% of Medicaid,76.24,,,76.24,Other,125% of Medicaid,61,298.48,
CONT BRONCH TX EACH ADDL HOUR,94645,CPT,,30094645,CDM,410,RC,,,both,,,314,232.36,,,232.36,Other,150% of Medicare + 9.63% HCRA Surcharge,141.3,45,,141.3,percent of total billed charges,Critical Access Hospital RCC factor,204.1,65,,204.1,percent of total billed charges,All Other,185.26,65,,185.26,percent of total billed charges,All Other,98.5,,,98.5,Fee Schedule,,88.59,,,88.59,Fee Schedule,,83.73,,,83.73,Fee Schedule,,155.43,,,155.43,Other,110% of Medicare,67.46,,,67.46,Fee Schedule,,113,,,113,Other,186% of Medicaid,79.39,,,79.39,Fee Schedule,,194.68,,,194.68,Fee Schedule,,37.38,,,37.38,Fee Schedule,,79.39,,,79.39,Fee Schedule,,194.68,,,194.68,Fee Schedule,,251.2,80,,251.2,percent of total billed charges,All Other,219.8,70,,219.8,percent of total billed charges,All Other,77.08,,,77.08,Fee Schedule,,65.33,,,65.33,Fee Schedule,,143,,,143,Case Rate,,131,,,131,Case Rate,,143,,,143,Case Rate,,122,,,122,Case Rate,,61,,,61,Other,100% of Medicaid,61,,,61,Other,100% of Medicaid,61,,,61,Other,100% of Medicaid,61,,,61,Other,100% of Medicaid,137.24,,,137.24,Other,225% of Medicaid,93.32,,,93.32,Other,153% of Medicaid,137.24,,,137.24,Other,225% of Medicaid,85.39,,,85.39,Other,140% of Medicaid,137.24,,,137.24,Other,225% of Medicaid,158.59,,,158.59,Other,260% of Medicaid,197.63,,,197.63,Other,324% of Medicaid,131.14,,,131.14,Other,215% of Medicaid,131.14,,,131.14,Other,215% of Medicaid,76.24,,,76.24,Other,125% of Medicaid,37.38,251.2,
EVALUATE PT USE OF INHALER,94664,CPT,,30094664,CDM,410,RC,,,both,,,433,320.42,,,320.42,Other,150% of Medicare + 9.63% HCRA Surcharge,194.85,45,,194.85,percent of total billed charges,Critical Access Hospital RCC factor,281.45,65,,281.45,percent of total billed charges,All Other,255.47,65,,255.47,percent of total billed charges,All Other,107.67,,,107.67,Fee Schedule,,96.84,,,96.84,Fee Schedule,,91.53,,,91.53,Fee Schedule,,214.34,,,214.34,Other,110% of Medicare,74.51,,,74.51,Fee Schedule,,113,,,113,Other,186% of Medicaid,87.68,,,87.68,Fee Schedule,,268.46,,,268.46,Fee Schedule,,41.29,,,41.29,Fee Schedule,,87.68,,,87.68,Fee Schedule,,268.46,,,268.46,Fee Schedule,,346.4,80,,346.4,percent of total billed charges,All Other,303.1,70,,303.1,percent of total billed charges,All Other,82,,,82,Fee Schedule,,69.5,,,69.5,Fee Schedule,,143,,,143,Case Rate,,131,,,131,Case Rate,,143,,,143,Case Rate,,122,,,122,Case Rate,,61,,,61,Other,100% of Medicaid,61,,,61,Other,100% of Medicaid,61,,,61,Other,100% of Medicaid,61,,,61,Other,100% of Medicaid,137.24,,,137.24,Other,225% of Medicaid,93.32,,,93.32,Other,153% of Medicaid,137.24,,,137.24,Other,225% of Medicaid,85.39,,,85.39,Other,140% of Medicaid,137.24,,,137.24,Other,225% of Medicaid,158.59,,,158.59,Other,260% of Medicaid,197.63,,,197.63,Other,324% of Medicaid,131.14,,,131.14,Other,215% of Medicaid,131.14,,,131.14,Other,215% of Medicaid,76.24,,,76.24,Other,125% of Medicaid,41.29,346.4,
AIRWAY INHALATION TREATMENT SU,94640,CPT,76,30194640,CDM,410,RC,,,both,,,433,320.42,,,320.42,Other,150% of Medicare + 9.63% HCRA Surcharge,194.85,45,,194.85,percent of total billed charges,Critical Access Hospital RCC factor,281.45,65,,281.45,percent of total billed charges,All Other,255.47,65,,255.47,percent of total billed charges,All Other,107.67,,,107.67,Fee Schedule,,96.84,,,96.84,Fee Schedule,,91.53,,,91.53,Fee Schedule,,214.34,,,214.34,Other,110% of Medicare,33.12,,,33.12,Fee Schedule,,113,,,113,Other,186% of Medicaid,38.98,,,38.98,Fee Schedule,,268.46,,,268.46,Fee Schedule,,18.35,,,18.35,Fee Schedule,,38.98,,,38.98,Fee Schedule,,268.46,,,268.46,Fee Schedule,,346.4,80,,346.4,percent of total billed charges,All Other,303.1,70,,303.1,percent of total billed charges,All Other,54.12,,,54.12,Fee Schedule,,45.87,,,45.87,Fee Schedule,,143,,,143,Case Rate,,131,,,131,Case Rate,,143,,,143,Case Rate,,122,,,122,Case Rate,,61,,,61,Other,100% of Medicaid,61,,,61,Other,100% of Medicaid,61,,,61,Other,100% of Medicaid,61,,,61,Other,100% of Medicaid,137.24,,,137.24,Other,225% of Medicaid,93.32,,,93.32,Other,153% of Medicaid,137.24,,,137.24,Other,225% of Medicaid,85.39,,,85.39,Other,140% of Medicaid,137.24,,,137.24,Other,225% of Medicaid,158.59,,,158.59,Other,260% of Medicaid,197.63,,,197.63,Other,324% of Medicaid,131.14,,,131.14,Other,215% of Medicaid,131.14,,,131.14,Other,215% of Medicaid,76.24,,,76.24,Other,125% of Medicaid,18.35,346.4,
HIGH FLOW OXYGEN THERAPY,94799,CPT,,71000005,CDM,410,RC,,,both,,,0.01,0.01,,,0.01,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,45,,0.01,percent of total billed charges,Critical Access Hospital RCC factor,0.01,65,,0.01,percent of total billed charges,All Other,0.01,70,,0.01,percent of total billed charges,All Other,0.01,76.5,,0.01,percent of total billed charges,All Other,0.01,69,,0.01,percent of total billed charges,All Other,0.01,65,,0.01,percent of total billed charges,All Other,0.01,,,0.01,Other,110% of Medicare,0.01,68,,0.01,percent of total billed charges,All Other,113,,,113,Other,186% of Medicaid,0.01,,,0.01,percent of total billed charges,All Other,0.01,83,,0.01,percent of total billed charges,All Other,0.01,83,,0.01,percent of total billed charges,All Other,0.01,80,,0.01,percent of total billed charges,All Other,0.01,83,,0.01,percent of total billed charges,All Other,0.01,80,,0.01,percent of total billed charges,All Other,0.01,70,,0.01,percent of total billed charges,All Other,0.01,65,,0.01,percent of total billed charges,Default if not in Fee Schedule,0.01,65,,0.01,percent of total billed charges,Default if not in Fee Schedule,143,,,143,Case Rate,,131,,,131,Case Rate,,143,,,143,Case Rate,,122,,,122,Case Rate,,61,,,61,Other,100% of Medicaid,61,,,61,Other,100% of Medicaid,61,,,61,Other,100% of Medicaid,61,,,61,Other,100% of Medicaid,137.24,,,137.24,Other,225% of Medicaid,93.32,,,93.32,Other,153% of Medicaid,137.24,,,137.24,Other,225% of Medicaid,85.39,,,85.39,Other,140% of Medicaid,137.24,,,137.24,Other,225% of Medicaid,158.59,,,158.59,Other,260% of Medicaid,197.63,,,197.63,Other,324% of Medicaid,131.14,,,131.14,Other,215% of Medicaid,131.14,,,131.14,Other,215% of Medicaid,76.24,,,76.24,Other,125% of Medicaid,0.01,197.63,
RESP CRITICAL CARE TRANSFER,94799,CPT,,71000006,CDM,410,RC,,,both,,,0.01,0.01,,,0.01,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,45,,0.01,percent of total billed charges,Critical Access Hospital RCC factor,0.01,65,,0.01,percent of total billed charges,All Other,0.01,70,,0.01,percent of total billed charges,All Other,0.01,76.5,,0.01,percent of total billed charges,All Other,0.01,69,,0.01,percent of total billed charges,All Other,0.01,65,,0.01,percent of total billed charges,All Other,0.01,,,0.01,Other,110% of Medicare,0.01,68,,0.01,percent of total billed charges,All Other,113,,,113,Other,186% of Medicaid,0.01,,,0.01,percent of total billed charges,All Other,0.01,83,,0.01,percent of total billed charges,All Other,0.01,83,,0.01,percent of total billed charges,All Other,0.01,80,,0.01,percent of total billed charges,All Other,0.01,83,,0.01,percent of total billed charges,All Other,0.01,80,,0.01,percent of total billed charges,All Other,0.01,70,,0.01,percent of total billed charges,All Other,0.01,65,,0.01,percent of total billed charges,Default if not in Fee Schedule,0.01,65,,0.01,percent of total billed charges,Default if not in Fee Schedule,143,,,143,Case Rate,,131,,,131,Case Rate,,143,,,143,Case Rate,,122,,,122,Case Rate,,61,,,61,Other,100% of Medicaid,61,,,61,Other,100% of Medicaid,61,,,61,Other,100% of Medicaid,61,,,61,Other,100% of Medicaid,137.24,,,137.24,Other,225% of Medicaid,93.32,,,93.32,Other,153% of Medicaid,137.24,,,137.24,Other,225% of Medicaid,85.39,,,85.39,Other,140% of Medicaid,137.24,,,137.24,Other,225% of Medicaid,158.59,,,158.59,Other,260% of Medicaid,197.63,,,197.63,Other,324% of Medicaid,131.14,,,131.14,Other,215% of Medicaid,131.14,,,131.14,Other,215% of Medicaid,76.24,,,76.24,Other,125% of Medicaid,0.01,197.63,
RESP CODE BLUE,94799,CPT,,71000007,CDM,410,RC,,,both,,,0.01,0.01,,,0.01,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,45,,0.01,percent of total billed charges,Critical Access Hospital RCC factor,0.01,65,,0.01,percent of total billed charges,All Other,0.01,70,,0.01,percent of total billed charges,All Other,0.01,76.5,,0.01,percent of total billed charges,All Other,0.01,69,,0.01,percent of total billed charges,All Other,0.01,65,,0.01,percent of total billed charges,All Other,0.01,,,0.01,Other,110% of Medicare,0.01,68,,0.01,percent of total billed charges,All Other,113,,,113,Other,186% of Medicaid,0.01,,,0.01,percent of total billed charges,All Other,0.01,83,,0.01,percent of total billed charges,All Other,0.01,83,,0.01,percent of total billed charges,All Other,0.01,80,,0.01,percent of total billed charges,All Other,0.01,83,,0.01,percent of total billed charges,All Other,0.01,80,,0.01,percent of total billed charges,All Other,0.01,70,,0.01,percent of total billed charges,All Other,0.01,65,,0.01,percent of total billed charges,Default if not in Fee Schedule,0.01,65,,0.01,percent of total billed charges,Default if not in Fee Schedule,143,,,143,Case Rate,,131,,,131,Case Rate,,143,,,143,Case Rate,,122,,,122,Case Rate,,61,,,61,Other,100% of Medicaid,61,,,61,Other,100% of Medicaid,61,,,61,Other,100% of Medicaid,61,,,61,Other,100% of Medicaid,137.24,,,137.24,Other,225% of Medicaid,93.32,,,93.32,Other,153% of Medicaid,137.24,,,137.24,Other,225% of Medicaid,85.39,,,85.39,Other,140% of Medicaid,137.24,,,137.24,Other,225% of Medicaid,158.59,,,158.59,Other,260% of Medicaid,197.63,,,197.63,Other,324% of Medicaid,131.14,,,131.14,Other,215% of Medicaid,131.14,,,131.14,Other,215% of Medicaid,76.24,,,76.24,Other,125% of Medicaid,0.01,197.63,
RESP LABOR AND DELIVERY,94799,CPT,,71000008,CDM,410,RC,,,both,,,0.01,0.01,,,0.01,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,45,,0.01,percent of total billed charges,Critical Access Hospital RCC factor,0.01,65,,0.01,percent of total billed charges,All Other,0.01,70,,0.01,percent of total billed charges,All Other,0.01,76.5,,0.01,percent of total billed charges,All Other,0.01,69,,0.01,percent of total billed charges,All Other,0.01,65,,0.01,percent of total billed charges,All Other,0.01,,,0.01,Other,110% of Medicare,0.01,68,,0.01,percent of total billed charges,All Other,113,,,113,Other,186% of Medicaid,0.01,,,0.01,percent of total billed charges,All Other,0.01,83,,0.01,percent of total billed charges,All Other,0.01,83,,0.01,percent of total billed charges,All Other,0.01,80,,0.01,percent of total billed charges,All Other,0.01,83,,0.01,percent of total billed charges,All Other,0.01,80,,0.01,percent of total billed charges,All Other,0.01,70,,0.01,percent of total billed charges,All Other,0.01,65,,0.01,percent of total billed charges,Default if not in Fee Schedule,0.01,65,,0.01,percent of total billed charges,Default if not in Fee Schedule,143,,,143,Case Rate,,131,,,131,Case Rate,,143,,,143,Case Rate,,122,,,122,Case Rate,,61,,,61,Other,100% of Medicaid,61,,,61,Other,100% of Medicaid,61,,,61,Other,100% of Medicaid,61,,,61,Other,100% of Medicaid,137.24,,,137.24,Other,225% of Medicaid,93.32,,,93.32,Other,153% of Medicaid,137.24,,,137.24,Other,225% of Medicaid,85.39,,,85.39,Other,140% of Medicaid,137.24,,,137.24,Other,225% of Medicaid,158.59,,,158.59,Other,260% of Medicaid,197.63,,,197.63,Other,324% of Medicaid,131.14,,,131.14,Other,215% of Medicaid,131.14,,,131.14,Other,215% of Medicaid,76.24,,,76.24,Other,125% of Medicaid,0.01,197.63,
RESP RAPID RESPONSE,94799,CPT,,71000009,CDM,410,RC,,,both,,,0.01,0.01,,,0.01,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,45,,0.01,percent of total billed charges,Critical Access Hospital RCC factor,0.01,65,,0.01,percent of total billed charges,All Other,0.01,70,,0.01,percent of total billed charges,All Other,0.01,76.5,,0.01,percent of total billed charges,All Other,0.01,69,,0.01,percent of total billed charges,All Other,0.01,65,,0.01,percent of total billed charges,All Other,0.01,,,0.01,Other,110% of Medicare,0.01,68,,0.01,percent of total billed charges,All Other,113,,,113,Other,186% of Medicaid,0.01,,,0.01,percent of total billed charges,All Other,0.01,83,,0.01,percent of total billed charges,All Other,0.01,83,,0.01,percent of total billed charges,All Other,0.01,80,,0.01,percent of total billed charges,All Other,0.01,83,,0.01,percent of total billed charges,All Other,0.01,80,,0.01,percent of total billed charges,All Other,0.01,70,,0.01,percent of total billed charges,All Other,0.01,65,,0.01,percent of total billed charges,Default if not in Fee Schedule,0.01,65,,0.01,percent of total billed charges,Default if not in Fee Schedule,143,,,143,Case Rate,,131,,,131,Case Rate,,143,,,143,Case Rate,,122,,,122,Case Rate,,61,,,61,Other,100% of Medicaid,61,,,61,Other,100% of Medicaid,61,,,61,Other,100% of Medicaid,61,,,61,Other,100% of Medicaid,137.24,,,137.24,Other,225% of Medicaid,93.32,,,93.32,Other,153% of Medicaid,137.24,,,137.24,Other,225% of Medicaid,85.39,,,85.39,Other,140% of Medicaid,137.24,,,137.24,Other,225% of Medicaid,158.59,,,158.59,Other,260% of Medicaid,197.63,,,197.63,Other,324% of Medicaid,131.14,,,131.14,Other,215% of Medicaid,131.14,,,131.14,Other,215% of Medicaid,76.24,,,76.24,Other,125% of Medicaid,0.01,197.63,
RESP VENT PATIENT TRANSPORT,94799,CPT,,71000010,CDM,410,RC,,,both,,,0.01,0.01,,,0.01,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,45,,0.01,percent of total billed charges,Critical Access Hospital RCC factor,0.01,65,,0.01,percent of total billed charges,All Other,0.01,70,,0.01,percent of total billed charges,All Other,0.01,76.5,,0.01,percent of total billed charges,All Other,0.01,69,,0.01,percent of total billed charges,All Other,0.01,65,,0.01,percent of total billed charges,All Other,0.01,,,0.01,Other,110% of Medicare,0.01,68,,0.01,percent of total billed charges,All Other,113,,,113,Other,186% of Medicaid,0.01,,,0.01,percent of total billed charges,All Other,0.01,83,,0.01,percent of total billed charges,All Other,0.01,83,,0.01,percent of total billed charges,All Other,0.01,80,,0.01,percent of total billed charges,All Other,0.01,83,,0.01,percent of total billed charges,All Other,0.01,80,,0.01,percent of total billed charges,All Other,0.01,70,,0.01,percent of total billed charges,All Other,0.01,65,,0.01,percent of total billed charges,Default if not in Fee Schedule,0.01,65,,0.01,percent of total billed charges,Default if not in Fee Schedule,143,,,143,Case Rate,,131,,,131,Case Rate,,143,,,143,Case Rate,,122,,,122,Case Rate,,61,,,61,Other,100% of Medicaid,61,,,61,Other,100% of Medicaid,61,,,61,Other,100% of Medicaid,61,,,61,Other,100% of Medicaid,137.24,,,137.24,Other,225% of Medicaid,93.32,,,93.32,Other,153% of Medicaid,137.24,,,137.24,Other,225% of Medicaid,85.39,,,85.39,Other,140% of Medicaid,137.24,,,137.24,Other,225% of Medicaid,158.59,,,158.59,Other,260% of Medicaid,197.63,,,197.63,Other,324% of Medicaid,131.14,,,131.14,Other,215% of Medicaid,131.14,,,131.14,Other,215% of Medicaid,76.24,,,76.24,Other,125% of Medicaid,0.01,197.63,
RESP NIF ASSESMENT,94799,CPT,,71000011,CDM,410,RC,,,both,,,0.01,0.01,,,0.01,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,45,,0.01,percent of total billed charges,Critical Access Hospital RCC factor,0.01,65,,0.01,percent of total billed charges,All Other,0.01,70,,0.01,percent of total billed charges,All Other,0.01,76.5,,0.01,percent of total billed charges,All Other,0.01,69,,0.01,percent of total billed charges,All Other,0.01,65,,0.01,percent of total billed charges,All Other,0.01,,,0.01,Other,110% of Medicare,0.01,68,,0.01,percent of total billed charges,All Other,113,,,113,Other,186% of Medicaid,0.01,,,0.01,percent of total billed charges,All Other,0.01,83,,0.01,percent of total billed charges,All Other,0.01,83,,0.01,percent of total billed charges,All Other,0.01,80,,0.01,percent of total billed charges,All Other,0.01,83,,0.01,percent of total billed charges,All Other,0.01,80,,0.01,percent of total billed charges,All Other,0.01,70,,0.01,percent of total billed charges,All Other,0.01,65,,0.01,percent of total billed charges,Default if not in Fee Schedule,0.01,65,,0.01,percent of total billed charges,Default if not in Fee Schedule,143,,,143,Case Rate,,131,,,131,Case Rate,,143,,,143,Case Rate,,122,,,122,Case Rate,,61,,,61,Other,100% of Medicaid,61,,,61,Other,100% of Medicaid,61,,,61,Other,100% of Medicaid,61,,,61,Other,100% of Medicaid,137.24,,,137.24,Other,225% of Medicaid,93.32,,,93.32,Other,153% of Medicaid,137.24,,,137.24,Other,225% of Medicaid,85.39,,,85.39,Other,140% of Medicaid,137.24,,,137.24,Other,225% of Medicaid,158.59,,,158.59,Other,260% of Medicaid,197.63,,,197.63,Other,324% of Medicaid,131.14,,,131.14,Other,215% of Medicaid,131.14,,,131.14,Other,215% of Medicaid,76.24,,,76.24,Other,125% of Medicaid,0.01,197.63,
RESP ARTERIAL BLOOD DRAW,94799,CPT,,71000012,CDM,410,RC,,,both,,,0.01,0.01,,,0.01,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,45,,0.01,percent of total billed charges,Critical Access Hospital RCC factor,0.01,65,,0.01,percent of total billed charges,All Other,0.01,70,,0.01,percent of total billed charges,All Other,0.01,76.5,,0.01,percent of total billed charges,All Other,0.01,69,,0.01,percent of total billed charges,All Other,0.01,65,,0.01,percent of total billed charges,All Other,0.01,,,0.01,Other,110% of Medicare,0.01,68,,0.01,percent of total billed charges,All Other,113,,,113,Other,186% of Medicaid,0.01,,,0.01,percent of total billed charges,All Other,0.01,83,,0.01,percent of total billed charges,All Other,0.01,83,,0.01,percent of total billed charges,All Other,0.01,80,,0.01,percent of total billed charges,All Other,0.01,83,,0.01,percent of total billed charges,All Other,0.01,80,,0.01,percent of total billed charges,All Other,0.01,70,,0.01,percent of total billed charges,All Other,0.01,65,,0.01,percent of total billed charges,Default if not in Fee Schedule,0.01,65,,0.01,percent of total billed charges,Default if not in Fee Schedule,143,,,143,Case Rate,,131,,,131,Case Rate,,143,,,143,Case Rate,,122,,,122,Case Rate,,61,,,61,Other,100% of Medicaid,61,,,61,Other,100% of Medicaid,61,,,61,Other,100% of Medicaid,61,,,61,Other,100% of Medicaid,137.24,,,137.24,Other,225% of Medicaid,93.32,,,93.32,Other,153% of Medicaid,137.24,,,137.24,Other,225% of Medicaid,85.39,,,85.39,Other,140% of Medicaid,137.24,,,137.24,Other,225% of Medicaid,158.59,,,158.59,Other,260% of Medicaid,197.63,,,197.63,Other,324% of Medicaid,131.14,,,131.14,Other,215% of Medicaid,131.14,,,131.14,Other,215% of Medicaid,76.24,,,76.24,Other,125% of Medicaid,0.01,197.63,
RESP SPECIAL CARE,94799,CPT,,71000013,CDM,410,RC,,,both,,,0.01,0.01,,,0.01,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,45,,0.01,percent of total billed charges,Critical Access Hospital RCC factor,0.01,65,,0.01,percent of total billed charges,All Other,0.01,70,,0.01,percent of total billed charges,All Other,0.01,76.5,,0.01,percent of total billed charges,All Other,0.01,69,,0.01,percent of total billed charges,All Other,0.01,65,,0.01,percent of total billed charges,All Other,0.01,,,0.01,Other,110% of Medicare,0.01,68,,0.01,percent of total billed charges,All Other,113,,,113,Other,186% of Medicaid,0.01,,,0.01,percent of total billed charges,All Other,0.01,83,,0.01,percent of total billed charges,All Other,0.01,83,,0.01,percent of total billed charges,All Other,0.01,80,,0.01,percent of total billed charges,All Other,0.01,83,,0.01,percent of total billed charges,All Other,0.01,80,,0.01,percent of total billed charges,All Other,0.01,70,,0.01,percent of total billed charges,All Other,0.01,65,,0.01,percent of total billed charges,Default if not in Fee Schedule,0.01,65,,0.01,percent of total billed charges,Default if not in Fee Schedule,143,,,143,Case Rate,,131,,,131,Case Rate,,143,,,143,Case Rate,,122,,,122,Case Rate,,61,,,61,Other,100% of Medicaid,61,,,61,Other,100% of Medicaid,61,,,61,Other,100% of Medicaid,61,,,61,Other,100% of Medicaid,137.24,,,137.24,Other,225% of Medicaid,93.32,,,93.32,Other,153% of Medicaid,137.24,,,137.24,Other,225% of Medicaid,85.39,,,85.39,Other,140% of Medicaid,137.24,,,137.24,Other,225% of Medicaid,158.59,,,158.59,Other,260% of Medicaid,197.63,,,197.63,Other,324% of Medicaid,131.14,,,131.14,Other,215% of Medicaid,131.14,,,131.14,Other,215% of Medicaid,76.24,,,76.24,Other,125% of Medicaid,0.01,197.63,
RESP ADDITIONAL BLOOD DRAW,94799,CPT,,71000014,CDM,410,RC,,,both,,,0.01,0.01,,,0.01,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,45,,0.01,percent of total billed charges,Critical Access Hospital RCC factor,0.01,65,,0.01,percent of total billed charges,All Other,0.01,70,,0.01,percent of total billed charges,All Other,0.01,76.5,,0.01,percent of total billed charges,All Other,0.01,69,,0.01,percent of total billed charges,All Other,0.01,65,,0.01,percent of total billed charges,All Other,0.01,,,0.01,Other,110% of Medicare,0.01,68,,0.01,percent of total billed charges,All Other,113,,,113,Other,186% of Medicaid,0.01,,,0.01,percent of total billed charges,All Other,0.01,83,,0.01,percent of total billed charges,All Other,0.01,83,,0.01,percent of total billed charges,All Other,0.01,80,,0.01,percent of total billed charges,All Other,0.01,83,,0.01,percent of total billed charges,All Other,0.01,80,,0.01,percent of total billed charges,All Other,0.01,70,,0.01,percent of total billed charges,All Other,0.01,65,,0.01,percent of total billed charges,Default if not in Fee Schedule,0.01,65,,0.01,percent of total billed charges,Default if not in Fee Schedule,143,,,143,Case Rate,,131,,,131,Case Rate,,143,,,143,Case Rate,,122,,,122,Case Rate,,61,,,61,Other,100% of Medicaid,61,,,61,Other,100% of Medicaid,61,,,61,Other,100% of Medicaid,61,,,61,Other,100% of Medicaid,137.24,,,137.24,Other,225% of Medicaid,93.32,,,93.32,Other,153% of Medicaid,137.24,,,137.24,Other,225% of Medicaid,85.39,,,85.39,Other,140% of Medicaid,137.24,,,137.24,Other,225% of Medicaid,158.59,,,158.59,Other,260% of Medicaid,197.63,,,197.63,Other,324% of Medicaid,131.14,,,131.14,Other,215% of Medicaid,131.14,,,131.14,Other,215% of Medicaid,76.24,,,76.24,Other,125% of Medicaid,0.01,197.63,
RESP SPECIAL CARE,94799,CPT,,71000015,CDM,410,RC,,,both,,,0.01,0.01,,,0.01,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,45,,0.01,percent of total billed charges,Critical Access Hospital RCC factor,0.01,65,,0.01,percent of total billed charges,All Other,0.01,70,,0.01,percent of total billed charges,All Other,0.01,76.5,,0.01,percent of total billed charges,All Other,0.01,69,,0.01,percent of total billed charges,All Other,0.01,65,,0.01,percent of total billed charges,All Other,0.01,,,0.01,Other,110% of Medicare,0.01,68,,0.01,percent of total billed charges,All Other,113,,,113,Other,186% of Medicaid,0.01,,,0.01,percent of total billed charges,All Other,0.01,83,,0.01,percent of total billed charges,All Other,0.01,83,,0.01,percent of total billed charges,All Other,0.01,80,,0.01,percent of total billed charges,All Other,0.01,83,,0.01,percent of total billed charges,All Other,0.01,80,,0.01,percent of total billed charges,All Other,0.01,70,,0.01,percent of total billed charges,All Other,0.01,65,,0.01,percent of total billed charges,Default if not in Fee Schedule,0.01,65,,0.01,percent of total billed charges,Default if not in Fee Schedule,143,,,143,Case Rate,,131,,,131,Case Rate,,143,,,143,Case Rate,,122,,,122,Case Rate,,61,,,61,Other,100% of Medicaid,61,,,61,Other,100% of Medicaid,61,,,61,Other,100% of Medicaid,61,,,61,Other,100% of Medicaid,137.24,,,137.24,Other,225% of Medicaid,93.32,,,93.32,Other,153% of Medicaid,137.24,,,137.24,Other,225% of Medicaid,85.39,,,85.39,Other,140% of Medicaid,137.24,,,137.24,Other,225% of Medicaid,158.59,,,158.59,Other,260% of Medicaid,197.63,,,197.63,Other,324% of Medicaid,131.14,,,131.14,Other,215% of Medicaid,131.14,,,131.14,Other,215% of Medicaid,76.24,,,76.24,Other,125% of Medicaid,0.01,197.63,
RESP VENT MANAGEMENT,94799,CPT,,71000016,CDM,410,RC,,,both,,,0.01,0.01,,,0.01,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,45,,0.01,percent of total billed charges,Critical Access Hospital RCC factor,0.01,65,,0.01,percent of total billed charges,All Other,0.01,70,,0.01,percent of total billed charges,All Other,0.01,76.5,,0.01,percent of total billed charges,All Other,0.01,69,,0.01,percent of total billed charges,All Other,0.01,65,,0.01,percent of total billed charges,All Other,0.01,,,0.01,Other,110% of Medicare,0.01,68,,0.01,percent of total billed charges,All Other,113,,,113,Other,186% of Medicaid,0.01,,,0.01,percent of total billed charges,All Other,0.01,83,,0.01,percent of total billed charges,All Other,0.01,83,,0.01,percent of total billed charges,All Other,0.01,80,,0.01,percent of total billed charges,All Other,0.01,83,,0.01,percent of total billed charges,All Other,0.01,80,,0.01,percent of total billed charges,All Other,0.01,70,,0.01,percent of total billed charges,All Other,0.01,65,,0.01,percent of total billed charges,Default if not in Fee Schedule,0.01,65,,0.01,percent of total billed charges,Default if not in Fee Schedule,143,,,143,Case Rate,,131,,,131,Case Rate,,143,,,143,Case Rate,,122,,,122,Case Rate,,61,,,61,Other,100% of Medicaid,61,,,61,Other,100% of Medicaid,61,,,61,Other,100% of Medicaid,61,,,61,Other,100% of Medicaid,137.24,,,137.24,Other,225% of Medicaid,93.32,,,93.32,Other,153% of Medicaid,137.24,,,137.24,Other,225% of Medicaid,85.39,,,85.39,Other,140% of Medicaid,137.24,,,137.24,Other,225% of Medicaid,158.59,,,158.59,Other,260% of Medicaid,197.63,,,197.63,Other,324% of Medicaid,131.14,,,131.14,Other,215% of Medicaid,131.14,,,131.14,Other,215% of Medicaid,76.24,,,76.24,Other,125% of Medicaid,0.01,197.63,
RESP RT ASSIST,94799,CPT,,71000017,CDM,410,RC,,,both,,,0.01,0.01,,,0.01,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,45,,0.01,percent of total billed charges,Critical Access Hospital RCC factor,0.01,65,,0.01,percent of total billed charges,All Other,0.01,70,,0.01,percent of total billed charges,All Other,0.01,76.5,,0.01,percent of total billed charges,All Other,0.01,69,,0.01,percent of total billed charges,All Other,0.01,65,,0.01,percent of total billed charges,All Other,0.01,,,0.01,Other,110% of Medicare,0.01,68,,0.01,percent of total billed charges,All Other,113,,,113,Other,186% of Medicaid,0.01,,,0.01,percent of total billed charges,All Other,0.01,83,,0.01,percent of total billed charges,All Other,0.01,83,,0.01,percent of total billed charges,All Other,0.01,80,,0.01,percent of total billed charges,All Other,0.01,83,,0.01,percent of total billed charges,All Other,0.01,80,,0.01,percent of total billed charges,All Other,0.01,70,,0.01,percent of total billed charges,All Other,0.01,65,,0.01,percent of total billed charges,Default if not in Fee Schedule,0.01,65,,0.01,percent of total billed charges,Default if not in Fee Schedule,143,,,143,Case Rate,,131,,,131,Case Rate,,143,,,143,Case Rate,,122,,,122,Case Rate,,61,,,61,Other,100% of Medicaid,61,,,61,Other,100% of Medicaid,61,,,61,Other,100% of Medicaid,61,,,61,Other,100% of Medicaid,137.24,,,137.24,Other,225% of Medicaid,93.32,,,93.32,Other,153% of Medicaid,137.24,,,137.24,Other,225% of Medicaid,85.39,,,85.39,Other,140% of Medicaid,137.24,,,137.24,Other,225% of Medicaid,158.59,,,158.59,Other,260% of Medicaid,197.63,,,197.63,Other,324% of Medicaid,131.14,,,131.14,Other,215% of Medicaid,131.14,,,131.14,Other,215% of Medicaid,76.24,,,76.24,Other,125% of Medicaid,0.01,197.63,
RESP INTUBATION,94799,CPT,,71000018,CDM,410,RC,,,both,,,0.01,0.01,,,0.01,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,45,,0.01,percent of total billed charges,Critical Access Hospital RCC factor,0.01,65,,0.01,percent of total billed charges,All Other,0.01,70,,0.01,percent of total billed charges,All Other,0.01,76.5,,0.01,percent of total billed charges,All Other,0.01,69,,0.01,percent of total billed charges,All Other,0.01,65,,0.01,percent of total billed charges,All Other,0.01,,,0.01,Other,110% of Medicare,0.01,68,,0.01,percent of total billed charges,All Other,113,,,113,Other,186% of Medicaid,0.01,,,0.01,percent of total billed charges,All Other,0.01,83,,0.01,percent of total billed charges,All Other,0.01,83,,0.01,percent of total billed charges,All Other,0.01,80,,0.01,percent of total billed charges,All Other,0.01,83,,0.01,percent of total billed charges,All Other,0.01,80,,0.01,percent of total billed charges,All Other,0.01,70,,0.01,percent of total billed charges,All Other,0.01,65,,0.01,percent of total billed charges,Default if not in Fee Schedule,0.01,65,,0.01,percent of total billed charges,Default if not in Fee Schedule,143,,,143,Case Rate,,131,,,131,Case Rate,,143,,,143,Case Rate,,122,,,122,Case Rate,,61,,,61,Other,100% of Medicaid,61,,,61,Other,100% of Medicaid,61,,,61,Other,100% of Medicaid,61,,,61,Other,100% of Medicaid,137.24,,,137.24,Other,225% of Medicaid,93.32,,,93.32,Other,153% of Medicaid,137.24,,,137.24,Other,225% of Medicaid,85.39,,,85.39,Other,140% of Medicaid,137.24,,,137.24,Other,225% of Medicaid,158.59,,,158.59,Other,260% of Medicaid,197.63,,,197.63,Other,324% of Medicaid,131.14,,,131.14,Other,215% of Medicaid,131.14,,,131.14,Other,215% of Medicaid,76.24,,,76.24,Other,125% of Medicaid,0.01,197.63,
RESP TRACH TUBE,94799,CPT,,71000019,CDM,410,RC,,,both,,,0.01,0.01,,,0.01,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,45,,0.01,percent of total billed charges,Critical Access Hospital RCC factor,0.01,65,,0.01,percent of total billed charges,All Other,0.01,70,,0.01,percent of total billed charges,All Other,0.01,76.5,,0.01,percent of total billed charges,All Other,0.01,69,,0.01,percent of total billed charges,All Other,0.01,65,,0.01,percent of total billed charges,All Other,0.01,,,0.01,Other,110% of Medicare,0.01,68,,0.01,percent of total billed charges,All Other,113,,,113,Other,186% of Medicaid,0.01,,,0.01,percent of total billed charges,All Other,0.01,83,,0.01,percent of total billed charges,All Other,0.01,83,,0.01,percent of total billed charges,All Other,0.01,80,,0.01,percent of total billed charges,All Other,0.01,83,,0.01,percent of total billed charges,All Other,0.01,80,,0.01,percent of total billed charges,All Other,0.01,70,,0.01,percent of total billed charges,All Other,0.01,65,,0.01,percent of total billed charges,Default if not in Fee Schedule,0.01,65,,0.01,percent of total billed charges,Default if not in Fee Schedule,143,,,143,Case Rate,,131,,,131,Case Rate,,143,,,143,Case Rate,,122,,,122,Case Rate,,61,,,61,Other,100% of Medicaid,61,,,61,Other,100% of Medicaid,61,,,61,Other,100% of Medicaid,61,,,61,Other,100% of Medicaid,137.24,,,137.24,Other,225% of Medicaid,93.32,,,93.32,Other,153% of Medicaid,137.24,,,137.24,Other,225% of Medicaid,85.39,,,85.39,Other,140% of Medicaid,137.24,,,137.24,Other,225% of Medicaid,158.59,,,158.59,Other,260% of Medicaid,197.63,,,197.63,Other,324% of Medicaid,131.14,,,131.14,Other,215% of Medicaid,131.14,,,131.14,Other,215% of Medicaid,76.24,,,76.24,Other,125% of Medicaid,0.01,197.63,
RESP PATIENT EDUCATION,94799,CPT,,71000020,CDM,410,RC,,,both,,,0.01,0.01,,,0.01,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,45,,0.01,percent of total billed charges,Critical Access Hospital RCC factor,0.01,65,,0.01,percent of total billed charges,All Other,0.01,70,,0.01,percent of total billed charges,All Other,0.01,76.5,,0.01,percent of total billed charges,All Other,0.01,69,,0.01,percent of total billed charges,All Other,0.01,65,,0.01,percent of total billed charges,All Other,0.01,,,0.01,Other,110% of Medicare,0.01,68,,0.01,percent of total billed charges,All Other,113,,,113,Other,186% of Medicaid,0.01,,,0.01,percent of total billed charges,All Other,0.01,83,,0.01,percent of total billed charges,All Other,0.01,83,,0.01,percent of total billed charges,All Other,0.01,80,,0.01,percent of total billed charges,All Other,0.01,83,,0.01,percent of total billed charges,All Other,0.01,80,,0.01,percent of total billed charges,All Other,0.01,70,,0.01,percent of total billed charges,All Other,0.01,65,,0.01,percent of total billed charges,Default if not in Fee Schedule,0.01,65,,0.01,percent of total billed charges,Default if not in Fee Schedule,143,,,143,Case Rate,,131,,,131,Case Rate,,143,,,143,Case Rate,,122,,,122,Case Rate,,61,,,61,Other,100% of Medicaid,61,,,61,Other,100% of Medicaid,61,,,61,Other,100% of Medicaid,61,,,61,Other,100% of Medicaid,137.24,,,137.24,Other,225% of Medicaid,93.32,,,93.32,Other,153% of Medicaid,137.24,,,137.24,Other,225% of Medicaid,85.39,,,85.39,Other,140% of Medicaid,137.24,,,137.24,Other,225% of Medicaid,158.59,,,158.59,Other,260% of Medicaid,197.63,,,197.63,Other,324% of Medicaid,131.14,,,131.14,Other,215% of Medicaid,131.14,,,131.14,Other,215% of Medicaid,76.24,,,76.24,Other,125% of Medicaid,0.01,197.63,
RESP MS THERAPY/15 MIN,G0237,HCPCS,,71000022,CDM,410,RC,,,both,,,127,93.98,,,93.98,Other,150% of Medicare + 9.63% HCRA Surcharge,57.15,45,,57.15,percent of total billed charges,Critical Access Hospital RCC factor,39.46,,,39.46,Fee Schedule,,35.5,,,35.5,Fee Schedule,,67.99,,,67.99,Fee Schedule,,61.2,,,61.2,Fee Schedule,,57.81,,,57.81,Fee Schedule,,62.87,,,62.87,Other,110% of Medicare,46.88,,,46.88,Fee Schedule,,0.01,,,0.01,Other,186% of Medicaid,55.17,,,55.17,Fee Schedule,,25.98,,,25.98,Fee Schedule,,25.98,,,25.98,Fee Schedule,,55.17,,,55.17,Fee Schedule,,25.98,,,25.98,Fee Schedule,,48.86,,,48.86,Fee Schedule,,88.9,70,,88.9,percent of total billed charges,All Other,49.2,,,49.2,Fee Schedule,,41.7,,,41.7,Fee Schedule,,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,93.98,
RESP FCN THERAPY/15 MIN,G0238,HCPCS,,71000023,CDM,410,RC,,,both,,,127,93.98,,,93.98,Other,150% of Medicare + 9.63% HCRA Surcharge,57.15,45,,57.15,percent of total billed charges,Critical Access Hospital RCC factor,35.98,,,35.98,Fee Schedule,,32.37,,,32.37,Fee Schedule,,72.47,,,72.47,Fee Schedule,,65.24,,,65.24,Fee Schedule,,61.62,,,61.62,Fee Schedule,,62.87,,,62.87,Other,110% of Medicare,42.75,,,42.75,Fee Schedule,,0.01,,,0.01,Other,186% of Medicaid,50.31,,,50.31,Fee Schedule,,23.69,,,23.69,Fee Schedule,,23.69,,,23.69,Fee Schedule,,50.31,,,50.31,Fee Schedule,,23.69,,,23.69,Fee Schedule,,44.56,,,44.56,Fee Schedule,,88.9,70,,88.9,percent of total billed charges,All Other,49.2,,,49.2,Fee Schedule,,41.7,,,41.7,Fee Schedule,,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,93.98,
RESP FCN/ STRENG 2/> INDIV,G0239,HCPCS,,71000024,CDM,410,RC,,,both,,,127,93.98,,,93.98,Other,150% of Medicare + 9.63% HCRA Surcharge,57.15,45,,57.15,percent of total billed charges,Critical Access Hospital RCC factor,45.23,,,45.23,Fee Schedule,,40.7,,,40.7,Fee Schedule,,79.3,,,79.3,Fee Schedule,,71.38,,,71.38,Fee Schedule,,67.42,,,67.42,Fee Schedule,,62.87,,,62.87,Other,110% of Medicare,53.74,,,53.74,Fee Schedule,,0.01,,,0.01,Other,186% of Medicaid,63.24,,,63.24,Fee Schedule,,29.78,,,29.78,Fee Schedule,,29.78,,,29.78,Fee Schedule,,63.24,,,63.24,Fee Schedule,,29.78,,,29.78,Fee Schedule,,56.01,,,56.01,Fee Schedule,,88.9,70,,88.9,percent of total billed charges,All Other,62.32,,,62.32,Fee Schedule,,52.82,,,52.82,Fee Schedule,,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,93.98,
INTUBATION ENDOTRACHEAL,31500,CPT,,71031500,CDM,410,RC,,,both,,,903,668.22,,,668.22,Other,150% of Medicare + 9.63% HCRA Surcharge,406.35,45,,406.35,percent of total billed charges,Critical Access Hospital RCC factor,586.95,65,,586.95,percent of total billed charges,All Other,532.77,65,,532.77,percent of total billed charges,All Other,690.8,76.5,,690.8,percent of total billed charges,All Other,641.13,69,,641.13,percent of total billed charges,All Other,623.07,65,,623.07,percent of total billed charges,All Other,446.99,,,446.99,Other,110% of Medicare,558.72,,,558.72,Fee Schedule,,880,,,880,Other,186% of Medicaid,657.49,,,657.49,Fee Schedule,,559.86,,,559.86,Fee Schedule,,309.58,,,309.58,Fee Schedule,,657.49,,,657.49,Fee Schedule,,559.86,,,559.86,Fee Schedule,,722.4,80,,722.4,percent of total billed charges,All Other,632.1,70,,632.1,percent of total billed charges,All Other,680.6,,,680.6,Fee Schedule,,576.85,,,576.85,Fee Schedule,,143,,,143,Case Rate,,131,,,131,Case Rate,,143,,,143,Case Rate,,122,,,122,Case Rate,,472.91,,,472.91,Other,100% of Medicaid,472.91,,,472.91,Other,100% of Medicaid,472.91,,,472.91,Other,100% of Medicaid,472.91,,,472.91,Other,100% of Medicaid,1064.05,,,1064.05,Other,225% of Medicaid,723.55,,,723.55,Other,153% of Medicaid,1064.05,,,1064.05,Other,225% of Medicaid,662.07,,,662.07,Other,140% of Medicaid,1064.05,,,1064.05,Other,225% of Medicaid,1229.57,,,1229.57,Other,260% of Medicaid,1532.23,,,1532.23,Other,324% of Medicaid,1016.76,,,1016.76,Other,215% of Medicaid,1016.76,,,1016.76,Other,215% of Medicaid,591.14,,,591.14,Other,125% of Medicaid,122,1532.23,
WITHDRAWAL OF ARTERIAL BLOOD,36600,CPT,,71036600,CDM,410,RC,,,both,,,263,194.62,,,194.62,Other,150% of Medicare + 9.63% HCRA Surcharge,118.35,45,,118.35,percent of total billed charges,Critical Access Hospital RCC factor,170.95,65,,170.95,percent of total billed charges,All Other,155.17,65,,155.17,percent of total billed charges,All Other,201.2,76.5,,201.2,percent of total billed charges,All Other,186.73,69,,186.73,percent of total billed charges,All Other,181.47,65,,181.47,percent of total billed charges,All Other,130.19,,,130.19,Other,110% of Medicare,58.4,,,58.4,Fee Schedule,,49,,,49,Other,186% of Medicaid,68.73,,,68.73,Fee Schedule,,163.06,,,163.06,Fee Schedule,,32.36,,,32.36,Fee Schedule,,68.73,,,68.73,Fee Schedule,,163.06,,,163.06,Fee Schedule,,210.4,80,,210.4,percent of total billed charges,All Other,184.1,70,,184.1,percent of total billed charges,All Other,75.44,,,75.44,Fee Schedule,,63.94,,,63.94,Fee Schedule,,143,,,143,Case Rate,,131,,,131,Case Rate,,143,,,143,Case Rate,,122,,,122,Case Rate,,26.36,,,26.36,Other,100% of Medicaid,26.36,,,26.36,Other,100% of Medicaid,26.36,,,26.36,Other,100% of Medicaid,26.36,,,26.36,Other,100% of Medicaid,59.32,,,59.32,Other,225% of Medicaid,40.33,,,40.33,Other,153% of Medicaid,59.32,,,59.32,Other,225% of Medicaid,36.91,,,36.91,Other,140% of Medicaid,59.32,,,59.32,Other,225% of Medicaid,68.54,,,68.54,Other,260% of Medicaid,85.41,,,85.41,Other,324% of Medicaid,56.68,,,56.68,Other,215% of Medicaid,56.68,,,56.68,Other,215% of Medicaid,32.95,,,32.95,Other,125% of Medicaid,26.36,210.4,
HEART/LUNG RESUSCITATION CPR,92950,CPT,,71092950,CDM,410,RC,,,both,,,903,668.22,,,668.22,Other,150% of Medicare + 9.63% HCRA Surcharge,406.35,45,,406.35,percent of total billed charges,Critical Access Hospital RCC factor,586.95,65,,586.95,percent of total billed charges,All Other,532.77,65,,532.77,percent of total billed charges,All Other,690.8,76.5,,690.8,percent of total billed charges,All Other,641.13,69,,641.13,percent of total billed charges,All Other,623.07,65,,623.07,percent of total billed charges,All Other,446.99,,,446.99,Other,110% of Medicare,720.86,,,720.86,Fee Schedule,,880,,,880,Other,186% of Medicaid,848.29,,,848.29,Fee Schedule,,559.86,,,559.86,Fee Schedule,,399.42,,,399.42,Fee Schedule,,848.29,,,848.29,Fee Schedule,,559.86,,,559.86,Fee Schedule,,722.4,80,,722.4,percent of total billed charges,All Other,632.1,70,,632.1,percent of total billed charges,All Other,883.96,,,883.96,Fee Schedule,,749.21,,,749.21,Fee Schedule,,143,,,143,Case Rate,,131,,,131,Case Rate,,143,,,143,Case Rate,,122,,,122,Case Rate,,472.91,,,472.91,Other,100% of Medicaid,472.91,,,472.91,Other,100% of Medicaid,472.91,,,472.91,Other,100% of Medicaid,472.91,,,472.91,Other,100% of Medicaid,1064.05,,,1064.05,Other,225% of Medicaid,723.55,,,723.55,Other,153% of Medicaid,1064.05,,,1064.05,Other,225% of Medicaid,662.07,,,662.07,Other,140% of Medicaid,1064.05,,,1064.05,Other,225% of Medicaid,1229.57,,,1229.57,Other,260% of Medicaid,1532.23,,,1532.23,Other,324% of Medicaid,1016.76,,,1016.76,Other,215% of Medicaid,1016.76,,,1016.76,Other,215% of Medicaid,591.14,,,591.14,Other,125% of Medicaid,122,1532.23,
VENT MGMT INPAT INIT DAY,94002,CPT,,71094002,CDM,410,RC,,,both,,,1255,928.7,,,928.7,Other,150% of Medicare + 9.63% HCRA Surcharge,564.75,45,,564.75,percent of total billed charges,Critical Access Hospital RCC factor,815.75,65,,815.75,percent of total billed charges,All Other,740.45,65,,740.45,percent of total billed charges,All Other,960.08,76.5,,960.08,percent of total billed charges,All Other,891.05,69,,891.05,percent of total billed charges,All Other,865.95,65,,865.95,percent of total billed charges,All Other,621.23,,,621.23,Other,110% of Medicare,359.03,,,359.03,Fee Schedule,,289,,,289,Other,186% of Medicaid,422.5,,,422.5,Fee Schedule,,778.1,,,778.1,Fee Schedule,,198.93,,,198.93,Fee Schedule,,422.5,,,422.5,Fee Schedule,,778.1,,,778.1,Fee Schedule,,1004,80,,1004,percent of total billed charges,All Other,878.5,70,,878.5,percent of total billed charges,All Other,442.8,,,442.8,Fee Schedule,,375.3,,,375.3,Fee Schedule,,143,,,143,Case Rate,,131,,,131,Case Rate,,143,,,143,Case Rate,,122,,,122,Case Rate,,155.19,,,155.19,Other,100% of Medicaid,155.19,,,155.19,Other,100% of Medicaid,155.19,,,155.19,Other,100% of Medicaid,155.19,,,155.19,Other,100% of Medicaid,349.18,,,349.18,Other,225% of Medicaid,237.44,,,237.44,Other,153% of Medicaid,349.18,,,349.18,Other,225% of Medicaid,217.27,,,217.27,Other,140% of Medicaid,349.18,,,349.18,Other,225% of Medicaid,403.5,,,403.5,Other,260% of Medicaid,502.82,,,502.82,Other,324% of Medicaid,333.66,,,333.66,Other,215% of Medicaid,333.66,,,333.66,Other,215% of Medicaid,193.99,,,193.99,Other,125% of Medicaid,122,1004,
VENT MGMT INPAT SUBQ DAY,94003,CPT,,71094003,CDM,410,RC,,,both,,,1255,928.7,,,928.7,Other,150% of Medicare + 9.63% HCRA Surcharge,564.75,45,,564.75,percent of total billed charges,Critical Access Hospital RCC factor,815.75,65,,815.75,percent of total billed charges,All Other,740.45,65,,740.45,percent of total billed charges,All Other,960.08,76.5,,960.08,percent of total billed charges,All Other,891.05,69,,891.05,percent of total billed charges,All Other,865.95,65,,865.95,percent of total billed charges,All Other,621.23,,,621.23,Other,110% of Medicare,252.79,,,252.79,Fee Schedule,,289,,,289,Other,186% of Medicaid,297.48,,,297.48,Fee Schedule,,778.1,,,778.1,Fee Schedule,,140.07,,,140.07,Fee Schedule,,297.48,,,297.48,Fee Schedule,,778.1,,,778.1,Fee Schedule,,1004,80,,1004,percent of total billed charges,All Other,878.5,70,,878.5,percent of total billed charges,All Other,311.6,,,311.6,Fee Schedule,,264.1,,,264.1,Fee Schedule,,143,,,143,Case Rate,,131,,,131,Case Rate,,143,,,143,Case Rate,,122,,,122,Case Rate,,155.19,,,155.19,Other,100% of Medicaid,155.19,,,155.19,Other,100% of Medicaid,155.19,,,155.19,Other,100% of Medicaid,155.19,,,155.19,Other,100% of Medicaid,349.18,,,349.18,Other,225% of Medicaid,237.44,,,237.44,Other,153% of Medicaid,349.18,,,349.18,Other,225% of Medicaid,217.27,,,217.27,Other,140% of Medicaid,349.18,,,349.18,Other,225% of Medicaid,403.5,,,403.5,Other,260% of Medicaid,502.82,,,502.82,Other,324% of Medicaid,333.66,,,333.66,Other,215% of Medicaid,333.66,,,333.66,Other,215% of Medicaid,193.99,,,193.99,Other,125% of Medicaid,122,1004,
AIRWAY INHALATION TREATMENT,94640,CPT,,71094640,CDM,410,RC,,,both,,,433,320.42,,,320.42,Other,150% of Medicare + 9.63% HCRA Surcharge,194.85,45,,194.85,percent of total billed charges,Critical Access Hospital RCC factor,281.45,65,,281.45,percent of total billed charges,All Other,255.47,65,,255.47,percent of total billed charges,All Other,107.67,,,107.67,Fee Schedule,,96.84,,,96.84,Fee Schedule,,91.53,,,91.53,Fee Schedule,,214.34,,,214.34,Other,110% of Medicare,33.12,,,33.12,Fee Schedule,,113,,,113,Other,186% of Medicaid,38.98,,,38.98,Fee Schedule,,268.46,,,268.46,Fee Schedule,,18.35,,,18.35,Fee Schedule,,38.98,,,38.98,Fee Schedule,,268.46,,,268.46,Fee Schedule,,346.4,80,,346.4,percent of total billed charges,All Other,303.1,70,,303.1,percent of total billed charges,All Other,54.12,,,54.12,Fee Schedule,,45.87,,,45.87,Fee Schedule,,143,,,143,Case Rate,,131,,,131,Case Rate,,143,,,143,Case Rate,,122,,,122,Case Rate,,61,,,61,Other,100% of Medicaid,61,,,61,Other,100% of Medicaid,61,,,61,Other,100% of Medicaid,61,,,61,Other,100% of Medicaid,137.24,,,137.24,Other,225% of Medicaid,93.32,,,93.32,Other,153% of Medicaid,137.24,,,137.24,Other,225% of Medicaid,85.39,,,85.39,Other,140% of Medicaid,137.24,,,137.24,Other,225% of Medicaid,158.59,,,158.59,Other,260% of Medicaid,197.63,,,197.63,Other,324% of Medicaid,131.14,,,131.14,Other,215% of Medicaid,131.14,,,131.14,Other,215% of Medicaid,76.24,,,76.24,Other,125% of Medicaid,18.35,346.4,
CONT BRONCH TX 1ST HOUR,94644,CPT,,71094644,CDM,410,RC,,,both,,,336,248.64,,,248.64,Other,150% of Medicare + 9.63% HCRA Surcharge,151.2,45,,151.2,percent of total billed charges,Critical Access Hospital RCC factor,218.4,65,,218.4,percent of total billed charges,All Other,198.24,65,,198.24,percent of total billed charges,All Other,270.14,,,270.14,Fee Schedule,,242.97,,,242.97,Fee Schedule,,229.64,,,229.64,Fee Schedule,,166.32,,,166.32,Other,110% of Medicare,246.08,,,246.08,Fee Schedule,,113,,,113,Other,186% of Medicaid,289.59,,,289.59,Fee Schedule,,208.32,,,208.32,Fee Schedule,,136.35,,,136.35,Fee Schedule,,289.59,,,289.59,Fee Schedule,,208.32,,,208.32,Fee Schedule,,268.8,80,,268.8,percent of total billed charges,All Other,235.2,70,,235.2,percent of total billed charges,All Other,298.48,,,298.48,Fee Schedule,,252.98,,,252.98,Fee Schedule,,143,,,143,Case Rate,,131,,,131,Case Rate,,143,,,143,Case Rate,,122,,,122,Case Rate,,61,,,61,Other,100% of Medicaid,61,,,61,Other,100% of Medicaid,61,,,61,Other,100% of Medicaid,61,,,61,Other,100% of Medicaid,137.24,,,137.24,Other,225% of Medicaid,93.32,,,93.32,Other,153% of Medicaid,137.24,,,137.24,Other,225% of Medicaid,85.39,,,85.39,Other,140% of Medicaid,137.24,,,137.24,Other,225% of Medicaid,158.59,,,158.59,Other,260% of Medicaid,197.63,,,197.63,Other,324% of Medicaid,131.14,,,131.14,Other,215% of Medicaid,131.14,,,131.14,Other,215% of Medicaid,76.24,,,76.24,Other,125% of Medicaid,61,298.48,
CONT BRONCH TX EACH ADDL HOUR,94645,CPT,,71094645,CDM,410,RC,,,both,,,314,232.36,,,232.36,Other,150% of Medicare + 9.63% HCRA Surcharge,141.3,45,,141.3,percent of total billed charges,Critical Access Hospital RCC factor,204.1,65,,204.1,percent of total billed charges,All Other,185.26,65,,185.26,percent of total billed charges,All Other,98.5,,,98.5,Fee Schedule,,88.59,,,88.59,Fee Schedule,,83.73,,,83.73,Fee Schedule,,155.43,,,155.43,Other,110% of Medicare,67.46,,,67.46,Fee Schedule,,113,,,113,Other,186% of Medicaid,79.39,,,79.39,Fee Schedule,,194.68,,,194.68,Fee Schedule,,37.38,,,37.38,Fee Schedule,,79.39,,,79.39,Fee Schedule,,194.68,,,194.68,Fee Schedule,,251.2,80,,251.2,percent of total billed charges,All Other,219.8,70,,219.8,percent of total billed charges,All Other,77.08,,,77.08,Fee Schedule,,65.33,,,65.33,Fee Schedule,,143,,,143,Case Rate,,131,,,131,Case Rate,,143,,,143,Case Rate,,122,,,122,Case Rate,,61,,,61,Other,100% of Medicaid,61,,,61,Other,100% of Medicaid,61,,,61,Other,100% of Medicaid,61,,,61,Other,100% of Medicaid,137.24,,,137.24,Other,225% of Medicaid,93.32,,,93.32,Other,153% of Medicaid,137.24,,,137.24,Other,225% of Medicaid,85.39,,,85.39,Other,140% of Medicaid,137.24,,,137.24,Other,225% of Medicaid,158.59,,,158.59,Other,260% of Medicaid,197.63,,,197.63,Other,324% of Medicaid,131.14,,,131.14,Other,215% of Medicaid,131.14,,,131.14,Other,215% of Medicaid,76.24,,,76.24,Other,125% of Medicaid,37.38,251.2,
POS AIRWAY PRESSURE CPAP,94660,CPT,,71094660,CDM,410,RC,,,both,,,535,395.9,,,395.9,Other,150% of Medicare + 9.63% HCRA Surcharge,240.75,45,,240.75,percent of total billed charges,Critical Access Hospital RCC factor,347.75,65,,347.75,percent of total billed charges,All Other,315.65,65,,315.65,percent of total billed charges,All Other,409.28,76.5,,409.28,percent of total billed charges,All Other,379.85,69,,379.85,percent of total billed charges,All Other,369.15,65,,369.15,percent of total billed charges,All Other,264.83,,,264.83,Other,110% of Medicare,146.52,,,146.52,Fee Schedule,,289,,,289,Other,186% of Medicaid,172.42,,,172.42,Fee Schedule,,331.7,,,331.7,Fee Schedule,,81.19,,,81.19,Fee Schedule,,172.42,,,172.42,Fee Schedule,,331.7,,,331.7,Fee Schedule,,428,80,,428,percent of total billed charges,All Other,374.5,70,,374.5,percent of total billed charges,All Other,182.04,,,182.04,Fee Schedule,,154.29,,,154.29,Fee Schedule,,143,,,143,Case Rate,,131,,,131,Case Rate,,143,,,143,Case Rate,,122,,,122,Case Rate,,155.2,,,155.2,Other,100% of Medicaid,155.2,,,155.2,Other,100% of Medicaid,155.2,,,155.2,Other,100% of Medicaid,155.2,,,155.2,Other,100% of Medicaid,349.19,,,349.19,Other,225% of Medicaid,237.45,,,237.45,Other,153% of Medicaid,349.19,,,349.19,Other,225% of Medicaid,217.27,,,217.27,Other,140% of Medicaid,349.19,,,349.19,Other,225% of Medicaid,403.51,,,403.51,Other,260% of Medicaid,502.83,,,502.83,Other,324% of Medicaid,333.67,,,333.67,Other,215% of Medicaid,333.67,,,333.67,Other,215% of Medicaid,193.99,,,193.99,Other,125% of Medicaid,81.19,502.83,
EVALUATE PT USE OF INHALER,94664,CPT,,71094664,CDM,410,RC,,,both,,,433,320.42,,,320.42,Other,150% of Medicare + 9.63% HCRA Surcharge,194.85,45,,194.85,percent of total billed charges,Critical Access Hospital RCC factor,281.45,65,,281.45,percent of total billed charges,All Other,255.47,65,,255.47,percent of total billed charges,All Other,107.67,,,107.67,Fee Schedule,,96.84,,,96.84,Fee Schedule,,91.53,,,91.53,Fee Schedule,,214.34,,,214.34,Other,110% of Medicare,74.51,,,74.51,Fee Schedule,,113,,,113,Other,186% of Medicaid,87.68,,,87.68,Fee Schedule,,268.46,,,268.46,Fee Schedule,,41.29,,,41.29,Fee Schedule,,87.68,,,87.68,Fee Schedule,,268.46,,,268.46,Fee Schedule,,346.4,80,,346.4,percent of total billed charges,All Other,303.1,70,,303.1,percent of total billed charges,All Other,82,,,82,Fee Schedule,,69.5,,,69.5,Fee Schedule,,143,,,143,Case Rate,,131,,,131,Case Rate,,143,,,143,Case Rate,,122,,,122,Case Rate,,61,,,61,Other,100% of Medicaid,61,,,61,Other,100% of Medicaid,61,,,61,Other,100% of Medicaid,61,,,61,Other,100% of Medicaid,137.24,,,137.24,Other,225% of Medicaid,93.32,,,93.32,Other,153% of Medicaid,137.24,,,137.24,Other,225% of Medicaid,85.39,,,85.39,Other,140% of Medicaid,137.24,,,137.24,Other,225% of Medicaid,158.59,,,158.59,Other,260% of Medicaid,197.63,,,197.63,Other,324% of Medicaid,131.14,,,131.14,Other,215% of Medicaid,131.14,,,131.14,Other,215% of Medicaid,76.24,,,76.24,Other,125% of Medicaid,41.29,346.4,
CHEST WALL MANIPULATION INITIA,94667,CPT,,71094667,CDM,410,RC,,,both,,,263,194.62,,,194.62,Other,150% of Medicare + 9.63% HCRA Surcharge,118.35,45,,118.35,percent of total billed charges,Critical Access Hospital RCC factor,170.95,65,,170.95,percent of total billed charges,All Other,155.17,65,,155.17,percent of total billed charges,All Other,151.14,,,151.14,Fee Schedule,,135.94,,,135.94,Fee Schedule,,128.49,,,128.49,Fee Schedule,,130.19,,,130.19,Other,110% of Medicare,103.35,,,103.35,Fee Schedule,,113,,,113,Other,186% of Medicaid,121.62,,,121.62,Fee Schedule,,163.06,,,163.06,Fee Schedule,,57.27,,,57.27,Fee Schedule,,121.62,,,121.62,Fee Schedule,,163.06,,,163.06,Fee Schedule,,210.4,80,,210.4,percent of total billed charges,All Other,184.1,70,,184.1,percent of total billed charges,All Other,109.88,,,109.88,Fee Schedule,,93.13,,,93.13,Fee Schedule,,143,,,143,Case Rate,,131,,,131,Case Rate,,143,,,143,Case Rate,,122,,,122,Case Rate,,61,,,61,Other,100% of Medicaid,61,,,61,Other,100% of Medicaid,61,,,61,Other,100% of Medicaid,61,,,61,Other,100% of Medicaid,137.24,,,137.24,Other,225% of Medicaid,93.32,,,93.32,Other,153% of Medicaid,137.24,,,137.24,Other,225% of Medicaid,85.39,,,85.39,Other,140% of Medicaid,137.24,,,137.24,Other,225% of Medicaid,158.59,,,158.59,Other,260% of Medicaid,197.63,,,197.63,Other,324% of Medicaid,131.14,,,131.14,Other,215% of Medicaid,131.14,,,131.14,Other,215% of Medicaid,76.24,,,76.24,Other,125% of Medicaid,57.27,210.4,
CHEST WALL MANIP SUBSEQUENT,94668,CPT,,71094668,CDM,410,RC,,,both,,,263,194.62,,,194.62,Other,150% of Medicare + 9.63% HCRA Surcharge,118.35,45,,118.35,percent of total billed charges,Critical Access Hospital RCC factor,170.95,65,,170.95,percent of total billed charges,All Other,155.17,65,,155.17,percent of total billed charges,All Other,146.56,,,146.56,Fee Schedule,,131.82,,,131.82,Fee Schedule,,124.59,,,124.59,Fee Schedule,,130.19,,,130.19,Other,110% of Medicare,162.55,,,162.55,Fee Schedule,,113,,,113,Other,186% of Medicaid,191.29,,,191.29,Fee Schedule,,163.06,,,163.06,Fee Schedule,,90.07,,,90.07,Fee Schedule,,191.29,,,191.29,Fee Schedule,,163.06,,,163.06,Fee Schedule,,210.4,80,,210.4,percent of total billed charges,All Other,184.1,70,,184.1,percent of total billed charges,All Other,170.56,,,170.56,Fee Schedule,,144.56,,,144.56,Fee Schedule,,143,,,143,Case Rate,,131,,,131,Case Rate,,143,,,143,Case Rate,,122,,,122,Case Rate,,61,,,61,Other,100% of Medicaid,61,,,61,Other,100% of Medicaid,61,,,61,Other,100% of Medicaid,61,,,61,Other,100% of Medicaid,137.24,,,137.24,Other,225% of Medicaid,93.32,,,93.32,Other,153% of Medicaid,137.24,,,137.24,Other,225% of Medicaid,85.39,,,85.39,Other,140% of Medicaid,137.24,,,137.24,Other,225% of Medicaid,158.59,,,158.59,Other,260% of Medicaid,197.63,,,197.63,Other,324% of Medicaid,131.14,,,131.14,Other,215% of Medicaid,131.14,,,131.14,Other,215% of Medicaid,76.24,,,76.24,Other,125% of Medicaid,61,210.4,
MECHANICAL CHEST WALL OSCILL,94669,CPT,,71094669,CDM,410,RC,,,both,,,1284,950.16,,,950.16,Other,150% of Medicare + 9.63% HCRA Surcharge,577.8,45,,577.8,percent of total billed charges,Critical Access Hospital RCC factor,834.6,65,,834.6,percent of total billed charges,All Other,757.56,65,,757.56,percent of total billed charges,All Other,982.26,76.5,,982.26,percent of total billed charges,All Other,911.64,69,,911.64,percent of total billed charges,All Other,885.96,65,,885.96,percent of total billed charges,All Other,635.58,,,635.58,Other,110% of Medicare,85.5,,,85.5,Fee Schedule,,113,,,113,Other,186% of Medicaid,100.62,,,100.62,Fee Schedule,,796.08,,,796.08,Fee Schedule,,47.38,,,47.38,Fee Schedule,,100.62,,,100.62,Fee Schedule,,796.08,,,796.08,Fee Schedule,,1027.2,80,,1027.2,percent of total billed charges,All Other,898.8,70,,898.8,percent of total billed charges,All Other,90.2,,,90.2,Fee Schedule,,76.45,,,76.45,Fee Schedule,,143,,,143,Case Rate,,131,,,131,Case Rate,,143,,,143,Case Rate,,122,,,122,Case Rate,,61,,,61,Other,100% of Medicaid,61,,,61,Other,100% of Medicaid,61,,,61,Other,100% of Medicaid,61,,,61,Other,100% of Medicaid,137.24,,,137.24,Other,225% of Medicaid,93.32,,,93.32,Other,153% of Medicaid,137.24,,,137.24,Other,225% of Medicaid,85.39,,,85.39,Other,140% of Medicaid,137.24,,,137.24,Other,225% of Medicaid,158.59,,,158.59,Other,260% of Medicaid,197.63,,,197.63,Other,324% of Medicaid,131.14,,,131.14,Other,215% of Medicaid,131.14,,,131.14,Other,215% of Medicaid,76.24,,,76.24,Other,125% of Medicaid,47.38,1027.2,
AIRWAY INHAL TX SUBSEQUENT,94640,CPT,76,71194640,CDM,410,RC,,,both,,,433,320.42,,,320.42,Other,150% of Medicare + 9.63% HCRA Surcharge,194.85,45,,194.85,percent of total billed charges,Critical Access Hospital RCC factor,281.45,65,,281.45,percent of total billed charges,All Other,255.47,65,,255.47,percent of total billed charges,All Other,107.67,,,107.67,Fee Schedule,,96.84,,,96.84,Fee Schedule,,91.53,,,91.53,Fee Schedule,,214.34,,,214.34,Other,110% of Medicare,33.12,,,33.12,Fee Schedule,,113,,,113,Other,186% of Medicaid,38.98,,,38.98,Fee Schedule,,268.46,,,268.46,Fee Schedule,,18.35,,,18.35,Fee Schedule,,38.98,,,38.98,Fee Schedule,,268.46,,,268.46,Fee Schedule,,346.4,80,,346.4,percent of total billed charges,All Other,303.1,70,,303.1,percent of total billed charges,All Other,54.12,,,54.12,Fee Schedule,,45.87,,,45.87,Fee Schedule,,143,,,143,Case Rate,,131,,,131,Case Rate,,143,,,143,Case Rate,,122,,,122,Case Rate,,61,,,61,Other,100% of Medicaid,61,,,61,Other,100% of Medicaid,61,,,61,Other,100% of Medicaid,61,,,61,Other,100% of Medicaid,137.24,,,137.24,Other,225% of Medicaid,93.32,,,93.32,Other,153% of Medicaid,137.24,,,137.24,Other,225% of Medicaid,85.39,,,85.39,Other,140% of Medicaid,137.24,,,137.24,Other,225% of Medicaid,158.59,,,158.59,Other,260% of Medicaid,197.63,,,197.63,Other,324% of Medicaid,131.14,,,131.14,Other,215% of Medicaid,131.14,,,131.14,Other,215% of Medicaid,76.24,,,76.24,Other,125% of Medicaid,18.35,346.4,
ARTERIAL PUNCTURE,36600,CPT,,78036600,CDM,410,RC,,,both,,,263,194.62,,,194.62,Other,150% of Medicare + 9.63% HCRA Surcharge,118.35,45,,118.35,percent of total billed charges,Critical Access Hospital RCC factor,170.95,65,,170.95,percent of total billed charges,All Other,155.17,65,,155.17,percent of total billed charges,All Other,201.2,76.5,,201.2,percent of total billed charges,All Other,186.73,69,,186.73,percent of total billed charges,All Other,181.47,65,,181.47,percent of total billed charges,All Other,130.19,,,130.19,Other,110% of Medicare,58.4,,,58.4,Fee Schedule,,49,,,49,Other,186% of Medicaid,68.73,,,68.73,Fee Schedule,,163.06,,,163.06,Fee Schedule,,32.36,,,32.36,Fee Schedule,,68.73,,,68.73,Fee Schedule,,163.06,,,163.06,Fee Schedule,,210.4,80,,210.4,percent of total billed charges,All Other,184.1,70,,184.1,percent of total billed charges,All Other,75.44,,,75.44,Fee Schedule,,63.94,,,63.94,Fee Schedule,,143,,,143,Case Rate,,131,,,131,Case Rate,,143,,,143,Case Rate,,122,,,122,Case Rate,,26.36,,,26.36,Other,100% of Medicaid,26.36,,,26.36,Other,100% of Medicaid,26.36,,,26.36,Other,100% of Medicaid,26.36,,,26.36,Other,100% of Medicaid,59.32,,,59.32,Other,225% of Medicaid,40.33,,,40.33,Other,153% of Medicaid,59.32,,,59.32,Other,225% of Medicaid,36.91,,,36.91,Other,140% of Medicaid,59.32,,,59.32,Other,225% of Medicaid,68.54,,,68.54,Other,260% of Medicaid,85.41,,,85.41,Other,324% of Medicaid,56.68,,,56.68,Other,215% of Medicaid,56.68,,,56.68,Other,215% of Medicaid,32.95,,,32.95,Other,125% of Medicaid,26.36,210.4,
FBC HBO PER 30 MIN,G0277,HCPCS,,74000001,CDM,413,RC,,,both,,,968,716.32,,,716.32,Other,150% of Medicare + 9.63% HCRA Surcharge,435.6,45,,435.6,percent of total billed charges,Critical Access Hospital RCC factor,2377,,,2377,Case Rate,Hyperbaric Therapy Per Visit,2139,,,2139,Case Rate,Hyperbaric Therapy Per Visit,740.52,76.5,,740.52,percent of total billed charges,All Other,687.28,69,,687.28,percent of total billed charges,All Other,667.92,65,,667.92,percent of total billed charges,All Other,479.16,,,479.16,Other,110% of Medicare,658.24,68,,658.24,percent of total billed charges,All Other,1070,,,1070,Other,186% of Medicaid,774.4,,,774.4,percent of total billed charges,All Other,803.44,83,,803.44,percent of total billed charges,All Other,803.44,83,,803.44,percent of total billed charges,All Other,774.4,80,,774.4,percent of total billed charges,All Other,803.44,83,,803.44,percent of total billed charges,All Other,774.4,80,,774.4,percent of total billed charges,All Other,677.6,70,,677.6,percent of total billed charges,All Other,1841,,,1841,Case Rate,Hyperbaric Therapy Per Visit,1565,,,1565,Case Rate,Hyperbaric Therapy Per Visit,1056,,,1056,Case Rate,Hyperbaric Therapy Per Visit,951,,,951,Case Rate,Hyperbaric Therapy Per Visit,1056,,,1056,Case Rate,Hyperbaric Therapy Per Visit,898,,,898,Case Rate,Hyperbaric Therapy Per Visit,575.25,,,575.25,Other,100% of Medicaid,575.25,,,575.25,Other,100% of Medicaid,575.25,,,575.25,Other,100% of Medicaid,575.25,,,575.25,Other,100% of Medicaid,1294.32,,,1294.32,Other,225% of Medicaid,880.14,,,880.14,Other,153% of Medicaid,1294.32,,,1294.32,Other,225% of Medicaid,805.36,,,805.36,Other,140% of Medicaid,1294.32,,,1294.32,Other,225% of Medicaid,1495.66,,,1495.66,Other,260% of Medicaid,1863.82,,,1863.82,Other,324% of Medicaid,1236.8,,,1236.8,Other,215% of Medicaid,1236.8,,,1236.8,Other,215% of Medicaid,719.07,,,719.07,Other,125% of Medicaid,435.6,2377,
ELECTRICAL STIMULATION EA 15 MINS,G0283,HCPCS,GP,62000001,CDM,420,RC,,,both,,,119,88.06,,,88.06,Other,150% of Medicare + 9.63% HCRA Surcharge,53.55,45,,53.55,percent of total billed charges,Critical Access Hospital RCC factor,180,,,180,Case Rate,Therapy Per Visit,162,,,162,Case Rate,Therapy Per Visit,77.42,,,77.42,Fee Schedule,,69.63,,,69.63,Fee Schedule,,65.81,,,65.81,Fee Schedule,,58.91,,,58.91,Other,110% of Medicare,219,,,219,Case Rate,Therapy Per Visit,39,,,39,Other,186% of Medicaid,257,,,257,Case Rate,Therapy Per Visit,98.77,83,,98.77,percent of total billed charges,Therapy,26,,,26,Case Rate,,257,,,257,Case Rate,Therapy Per Visit,98.77,83,,98.77,percent of total billed charges,Therapy,368,,,368,Case Rate,Therapy Visit,83.3,70,,83.3,percent of total billed charges,All Other,259,,,259,Case Rate,Therapy Visit,220,,,220,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,138,,,138,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,131,,,131,Case Rate,Therapy Visit,20.84,,,20.84,Other,100% of Medicaid,20.84,,,20.84,Other,100% of Medicaid,20.84,,,20.84,Other,100% of Medicaid,20.84,,,20.84,Other,100% of Medicaid,46.9,,,46.9,Other,225% of Medicaid,31.89,,,31.89,Other,153% of Medicaid,46.9,,,46.9,Other,225% of Medicaid,29.18,,,29.18,Other,140% of Medicaid,46.9,,,46.9,Other,225% of Medicaid,54.2,,,54.2,Other,260% of Medicaid,67.54,,,67.54,Other,324% of Medicaid,44.82,,,44.82,Other,215% of Medicaid,44.82,,,44.82,Other,215% of Medicaid,26.06,,,26.06,Other,125% of Medicaid,20.84,368,
STRAPPING OF SHOULDER,29240,CPT,GP,62029240,CDM,420,RC,,,both,,,563,416.62,,,416.62,Other,150% of Medicare + 9.63% HCRA Surcharge,253.35,45,,253.35,percent of total billed charges,Critical Access Hospital RCC factor,180,,,180,Case Rate,Therapy Per Visit,162,,,162,Case Rate,Therapy Per Visit,430.7,76.5,,430.7,percent of total billed charges,All Other,399.73,69,,399.73,percent of total billed charges,All Other,388.47,65,,388.47,percent of total billed charges,All Other,278.69,,,278.69,Other,110% of Medicare,219,,,219,Case Rate,Therapy Per Visit,325,,,325,Other,186% of Medicaid,257,,,257,Case Rate,Therapy Per Visit,467.29,83,,467.29,percent of total billed charges,Therapy,38.91,,,38.91,Fee Schedule,,257,,,257,Case Rate,Therapy Per Visit,467.29,83,,467.29,percent of total billed charges,Therapy,368,,,368,Case Rate,Therapy Visit,394.1,70,,394.1,percent of total billed charges,All Other,259,,,259,Case Rate,Therapy Visit,220,,,220,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,138,,,138,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,131,,,131,Case Rate,Therapy Visit,174.92,,,174.92,Other,100% of Medicaid,174.92,,,174.92,Other,100% of Medicaid,174.92,,,174.92,Other,100% of Medicaid,174.92,,,174.92,Other,100% of Medicaid,393.57,,,393.57,Other,225% of Medicaid,267.62,,,267.62,Other,153% of Medicaid,393.57,,,393.57,Other,225% of Medicaid,244.89,,,244.89,Other,140% of Medicaid,393.57,,,393.57,Other,225% of Medicaid,454.79,,,454.79,Other,260% of Medicaid,566.73,,,566.73,Other,324% of Medicaid,376.07,,,376.07,Other,215% of Medicaid,376.07,,,376.07,Other,215% of Medicaid,218.65,,,218.65,Other,125% of Medicaid,38.91,566.73,
STRAPPING OF ELBOW OR WRIST,29260,CPT,GP,62029260,CDM,420,RC,,,both,,,563,416.62,,,416.62,Other,150% of Medicare + 9.63% HCRA Surcharge,253.35,45,,253.35,percent of total billed charges,Critical Access Hospital RCC factor,180,,,180,Case Rate,Therapy Per Visit,162,,,162,Case Rate,Therapy Per Visit,430.7,76.5,,430.7,percent of total billed charges,All Other,399.73,69,,399.73,percent of total billed charges,All Other,388.47,65,,388.47,percent of total billed charges,All Other,278.69,,,278.69,Other,110% of Medicare,219,,,219,Case Rate,Therapy Per Visit,325,,,325,Other,186% of Medicaid,257,,,257,Case Rate,Therapy Per Visit,467.29,83,,467.29,percent of total billed charges,Therapy,41.31,,,41.31,Fee Schedule,,257,,,257,Case Rate,Therapy Per Visit,467.29,83,,467.29,percent of total billed charges,Therapy,368,,,368,Case Rate,Therapy Visit,394.1,70,,394.1,percent of total billed charges,All Other,259,,,259,Case Rate,Therapy Visit,220,,,220,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,138,,,138,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,131,,,131,Case Rate,Therapy Visit,174.92,,,174.92,Other,100% of Medicaid,174.92,,,174.92,Other,100% of Medicaid,174.92,,,174.92,Other,100% of Medicaid,174.92,,,174.92,Other,100% of Medicaid,393.57,,,393.57,Other,225% of Medicaid,267.62,,,267.62,Other,153% of Medicaid,393.57,,,393.57,Other,225% of Medicaid,244.89,,,244.89,Other,140% of Medicaid,393.57,,,393.57,Other,225% of Medicaid,454.79,,,454.79,Other,260% of Medicaid,566.73,,,566.73,Other,324% of Medicaid,376.07,,,376.07,Other,215% of Medicaid,376.07,,,376.07,Other,215% of Medicaid,218.65,,,218.65,Other,125% of Medicaid,41.31,566.73,
STRAPPING OF KNEE,29530,CPT,GP,62029530,CDM,420,RC,,,both,,,491,363.34,,,363.34,Other,150% of Medicare + 9.63% HCRA Surcharge,220.95,45,,220.95,percent of total billed charges,Critical Access Hospital RCC factor,180,,,180,Case Rate,Therapy Per Visit,162,,,162,Case Rate,Therapy Per Visit,375.62,76.5,,375.62,percent of total billed charges,All Other,348.61,69,,348.61,percent of total billed charges,All Other,338.79,65,,338.79,percent of total billed charges,All Other,243.05,,,243.05,Other,110% of Medicare,219,,,219,Case Rate,Therapy Per Visit,325,,,325,Other,186% of Medicaid,257,,,257,Case Rate,Therapy Per Visit,407.53,83,,407.53,percent of total billed charges,Therapy,38.91,,,38.91,Fee Schedule,,257,,,257,Case Rate,Therapy Per Visit,407.53,83,,407.53,percent of total billed charges,Therapy,368,,,368,Case Rate,Therapy Visit,343.7,70,,343.7,percent of total billed charges,All Other,259,,,259,Case Rate,Therapy Visit,220,,,220,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,138,,,138,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,131,,,131,Case Rate,Therapy Visit,174.92,,,174.92,Other,100% of Medicaid,174.92,,,174.92,Other,100% of Medicaid,174.92,,,174.92,Other,100% of Medicaid,174.92,,,174.92,Other,100% of Medicaid,393.57,,,393.57,Other,225% of Medicaid,267.62,,,267.62,Other,153% of Medicaid,393.57,,,393.57,Other,225% of Medicaid,244.89,,,244.89,Other,140% of Medicaid,393.57,,,393.57,Other,225% of Medicaid,454.79,,,454.79,Other,260% of Medicaid,566.73,,,566.73,Other,324% of Medicaid,376.07,,,376.07,Other,215% of Medicaid,376.07,,,376.07,Other,215% of Medicaid,218.65,,,218.65,Other,125% of Medicaid,38.91,566.73,
STRAPPING OF ANKLE AND/OR FT,29540,CPT,GP,62029540,CDM,420,RC,,,both,,,491,363.34,,,363.34,Other,150% of Medicare + 9.63% HCRA Surcharge,220.95,45,,220.95,percent of total billed charges,Critical Access Hospital RCC factor,180,,,180,Case Rate,Therapy Per Visit,162,,,162,Case Rate,Therapy Per Visit,375.62,76.5,,375.62,percent of total billed charges,All Other,348.61,69,,348.61,percent of total billed charges,All Other,338.79,65,,338.79,percent of total billed charges,All Other,243.05,,,243.05,Other,110% of Medicare,219,,,219,Case Rate,Therapy Per Visit,325,,,325,Other,186% of Medicaid,257,,,257,Case Rate,Therapy Per Visit,407.53,83,,407.53,percent of total billed charges,Therapy,37.51,,,37.51,Fee Schedule,,257,,,257,Case Rate,Therapy Per Visit,407.53,83,,407.53,percent of total billed charges,Therapy,368,,,368,Case Rate,Therapy Visit,343.7,70,,343.7,percent of total billed charges,All Other,259,,,259,Case Rate,Therapy Visit,220,,,220,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,138,,,138,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,131,,,131,Case Rate,Therapy Visit,174.92,,,174.92,Other,100% of Medicaid,174.92,,,174.92,Other,100% of Medicaid,174.92,,,174.92,Other,100% of Medicaid,174.92,,,174.92,Other,100% of Medicaid,393.57,,,393.57,Other,225% of Medicaid,267.62,,,267.62,Other,153% of Medicaid,393.57,,,393.57,Other,225% of Medicaid,244.89,,,244.89,Other,140% of Medicaid,393.57,,,393.57,Other,225% of Medicaid,454.79,,,454.79,Other,260% of Medicaid,566.73,,,566.73,Other,324% of Medicaid,376.07,,,376.07,Other,215% of Medicaid,376.07,,,376.07,Other,215% of Medicaid,218.65,,,218.65,Other,125% of Medicaid,37.51,566.73,
CANALITH REPOSITIONING PROC,95992,CPT,GP,62095992,CDM,420,RC,,,both,,,177,130.98,,,130.98,Other,150% of Medicare + 9.63% HCRA Surcharge,79.65,45,,79.65,percent of total billed charges,Critical Access Hospital RCC factor,180,,,180,Case Rate,Therapy Per Visit,162,,,162,Case Rate,Therapy Per Visit,255.91,,,255.91,Fee Schedule,,230.17,,,230.17,Fee Schedule,,217.55,,,217.55,Fee Schedule,,87.62,,,87.62,Other,110% of Medicare,219,,,219,Case Rate,Therapy Per Visit,109,,,109,Other,186% of Medicaid,257,,,257,Case Rate,Therapy Per Visit,146.91,83,,146.91,percent of total billed charges,Therapy,77.85,,,77.85,Fee Schedule,,257,,,257,Case Rate,Therapy Per Visit,146.91,83,,146.91,percent of total billed charges,Therapy,368,,,368,Case Rate,Therapy Visit,123.9,70,,123.9,percent of total billed charges,All Other,259,,,259,Case Rate,Therapy Visit,220,,,220,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,138,,,138,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,131,,,131,Case Rate,Therapy Visit,58.77,,,58.77,Other,100% of Medicaid,58.77,,,58.77,Other,100% of Medicaid,58.77,,,58.77,Other,100% of Medicaid,58.77,,,58.77,Other,100% of Medicaid,132.23,,,132.23,Other,225% of Medicaid,89.92,,,89.92,Other,153% of Medicaid,132.23,,,132.23,Other,225% of Medicaid,82.28,,,82.28,Other,140% of Medicaid,132.23,,,132.23,Other,225% of Medicaid,152.8,,,152.8,Other,260% of Medicaid,190.42,,,190.42,Other,324% of Medicaid,126.36,,,126.36,Other,215% of Medicaid,126.36,,,126.36,Other,215% of Medicaid,73.46,,,73.46,Other,125% of Medicaid,58.77,368,
HOT OR COLD PACKS THERAPY,97010,CPT,GP,62097010,CDM,420,RC,,,both,,,96,71.04,,,71.04,Other,150% of Medicare + 9.63% HCRA Surcharge,43.2,45,,43.2,percent of total billed charges,Critical Access Hospital RCC factor,180,,,180,Case Rate,Therapy Per Visit,162,,,162,Case Rate,Therapy Per Visit,3.82,,,3.82,Fee Schedule,,3.82,,,3.82,Fee Schedule,,3.82,,,3.82,Fee Schedule,,47.52,,,47.52,Other,110% of Medicare,219,,,219,Case Rate,Therapy Per Visit,39,,,39,Other,186% of Medicaid,257,,,257,Case Rate,Therapy Per Visit,79.68,83,,79.68,percent of total billed charges,Therapy,52.8,83,,52.8,percent of total billed charges,All Other,257,,,257,Case Rate,Therapy Per Visit,79.68,83,,79.68,percent of total billed charges,Therapy,368,,,368,Case Rate,Therapy Visit,67.2,70,,67.2,percent of total billed charges,All Other,259,,,259,Case Rate,Therapy Visit,220,,,220,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,138,,,138,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,131,,,131,Case Rate,Therapy Visit,20.84,,,20.84,Other,100% of Medicaid,20.84,,,20.84,Other,100% of Medicaid,20.84,,,20.84,Other,100% of Medicaid,20.84,,,20.84,Other,100% of Medicaid,46.9,,,46.9,Other,225% of Medicaid,31.89,,,31.89,Other,153% of Medicaid,46.9,,,46.9,Other,225% of Medicaid,29.18,,,29.18,Other,140% of Medicaid,46.9,,,46.9,Other,225% of Medicaid,54.2,,,54.2,Other,260% of Medicaid,67.54,,,67.54,Other,324% of Medicaid,44.82,,,44.82,Other,215% of Medicaid,44.82,,,44.82,Other,215% of Medicaid,26.06,,,26.06,Other,125% of Medicaid,3.82,368,
MECHANICAL TRACTION THERAPY 1+ AREAS,97012,CPT,GP,62097012,CDM,420,RC,,,both,,,119,88.06,,,88.06,Other,150% of Medicare + 9.63% HCRA Surcharge,53.55,45,,53.55,percent of total billed charges,Critical Access Hospital RCC factor,180,,,180,Case Rate,Therapy Per Visit,162,,,162,Case Rate,Therapy Per Visit,92.86,,,92.86,Fee Schedule,,83.52,,,83.52,Fee Schedule,,78.94,,,78.94,Fee Schedule,,58.91,,,58.91,Other,110% of Medicare,219,,,219,Case Rate,Therapy Per Visit,39,,,39,Other,186% of Medicaid,257,,,257,Case Rate,Therapy Per Visit,98.77,83,,98.77,percent of total billed charges,Therapy,31.02,,,31.02,Case Rate,,257,,,257,Case Rate,Therapy Per Visit,98.77,83,,98.77,percent of total billed charges,Therapy,368,,,368,Case Rate,Therapy Visit,83.3,70,,83.3,percent of total billed charges,All Other,259,,,259,Case Rate,Therapy Visit,220,,,220,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,138,,,138,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,131,,,131,Case Rate,Therapy Visit,20.84,,,20.84,Other,100% of Medicaid,20.84,,,20.84,Other,100% of Medicaid,20.84,,,20.84,Other,100% of Medicaid,20.84,,,20.84,Other,100% of Medicaid,46.9,,,46.9,Other,225% of Medicaid,31.89,,,31.89,Other,153% of Medicaid,46.9,,,46.9,Other,225% of Medicaid,29.18,,,29.18,Other,140% of Medicaid,46.9,,,46.9,Other,225% of Medicaid,54.2,,,54.2,Other,260% of Medicaid,67.54,,,67.54,Other,324% of Medicaid,44.82,,,44.82,Other,215% of Medicaid,44.82,,,44.82,Other,215% of Medicaid,26.06,,,26.06,Other,125% of Medicaid,20.84,368,
PARAFFIN BATH THERAPY,97018,CPT,GP,62097018,CDM,420,RC,,,both,,,119,88.06,,,88.06,Other,150% of Medicare + 9.63% HCRA Surcharge,53.55,45,,53.55,percent of total billed charges,Critical Access Hospital RCC factor,180,,,180,Case Rate,Therapy Per Visit,162,,,162,Case Rate,Therapy Per Visit,61.71,,,61.71,Fee Schedule,,55.51,,,55.51,Fee Schedule,,52.46,,,52.46,Fee Schedule,,58.91,,,58.91,Other,110% of Medicare,219,,,219,Case Rate,Therapy Per Visit,39,,,39,Other,186% of Medicaid,257,,,257,Case Rate,Therapy Per Visit,98.77,83,,98.77,percent of total billed charges,Therapy,12.79,,,12.79,Case Rate,,257,,,257,Case Rate,Therapy Per Visit,98.77,83,,98.77,percent of total billed charges,Therapy,368,,,368,Case Rate,Therapy Visit,83.3,70,,83.3,percent of total billed charges,All Other,259,,,259,Case Rate,Therapy Visit,220,,,220,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,138,,,138,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,131,,,131,Case Rate,Therapy Visit,20.84,,,20.84,Other,100% of Medicaid,20.84,,,20.84,Other,100% of Medicaid,20.84,,,20.84,Other,100% of Medicaid,20.84,,,20.84,Other,100% of Medicaid,46.9,,,46.9,Other,225% of Medicaid,31.89,,,31.89,Other,153% of Medicaid,46.9,,,46.9,Other,225% of Medicaid,29.18,,,29.18,Other,140% of Medicaid,46.9,,,46.9,Other,225% of Medicaid,54.2,,,54.2,Other,260% of Medicaid,67.54,,,67.54,Other,324% of Medicaid,44.82,,,44.82,Other,215% of Medicaid,44.82,,,44.82,Other,215% of Medicaid,26.06,,,26.06,Other,125% of Medicaid,12.79,368,
INFRARED THERAPY 1+ AREAS,97026,CPT,GP,62097026,CDM,420,RC,,,both,,,27,19.98,,,19.98,Other,150% of Medicare + 9.63% HCRA Surcharge,12.15,45,,12.15,percent of total billed charges,Critical Access Hospital RCC factor,180,,,180,Case Rate,Therapy Per Visit,162,,,162,Case Rate,Therapy Per Visit,34.26,,,34.26,Fee Schedule,,30.81,,,30.81,Fee Schedule,,29.12,,,29.12,Fee Schedule,,13.37,,,13.37,Other,110% of Medicare,219,,,219,Case Rate,Therapy Per Visit,39,,,39,Other,186% of Medicaid,257,,,257,Case Rate,Therapy Per Visit,22.41,83,,22.41,percent of total billed charges,Therapy,15.08,,,15.08,Case Rate,,257,,,257,Case Rate,Therapy Per Visit,22.41,83,,22.41,percent of total billed charges,Therapy,368,,,368,Case Rate,Therapy Visit,18.9,70,,18.9,percent of total billed charges,All Other,259,,,259,Case Rate,Therapy Visit,220,,,220,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,138,,,138,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,131,,,131,Case Rate,Therapy Visit,20.84,,,20.84,Other,100% of Medicaid,20.84,,,20.84,Other,100% of Medicaid,20.84,,,20.84,Other,100% of Medicaid,20.84,,,20.84,Other,100% of Medicaid,46.9,,,46.9,Other,225% of Medicaid,31.89,,,31.89,Other,153% of Medicaid,46.9,,,46.9,Other,225% of Medicaid,29.18,,,29.18,Other,140% of Medicaid,46.9,,,46.9,Other,225% of Medicaid,54.2,,,54.2,Other,260% of Medicaid,67.54,,,67.54,Other,324% of Medicaid,44.82,,,44.82,Other,215% of Medicaid,44.82,,,44.82,Other,215% of Medicaid,26.06,,,26.06,Other,125% of Medicaid,12.15,368,
ELECTRICAL STIMULATION 15,97032,CPT,GP,62097032,CDM,420,RC,,,both,,,118,87.32,,,87.32,Other,150% of Medicare + 9.63% HCRA Surcharge,53.1,45,,53.1,percent of total billed charges,Critical Access Hospital RCC factor,180,,,180,Case Rate,Therapy Per Visit,162,,,162,Case Rate,Therapy Per Visit,108.88,,,108.88,Fee Schedule,,97.93,,,97.93,Fee Schedule,,92.56,,,92.56,Fee Schedule,,58.41,,,58.41,Other,110% of Medicare,219,,,219,Case Rate,Therapy Per Visit,39,,,39,Other,186% of Medicaid,257,,,257,Case Rate,Therapy Per Visit,97.94,83,,97.94,percent of total billed charges,Therapy,31.77,,,31.77,Case Rate,,257,,,257,Case Rate,Therapy Per Visit,97.94,83,,97.94,percent of total billed charges,Therapy,368,,,368,Case Rate,Therapy Visit,82.6,70,,82.6,percent of total billed charges,All Other,259,,,259,Case Rate,Therapy Visit,220,,,220,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,138,,,138,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,131,,,131,Case Rate,Therapy Visit,20.84,,,20.84,Other,100% of Medicaid,20.84,,,20.84,Other,100% of Medicaid,20.84,,,20.84,Other,100% of Medicaid,20.84,,,20.84,Other,100% of Medicaid,46.9,,,46.9,Other,225% of Medicaid,31.89,,,31.89,Other,153% of Medicaid,46.9,,,46.9,Other,225% of Medicaid,29.18,,,29.18,Other,140% of Medicaid,46.9,,,46.9,Other,225% of Medicaid,54.2,,,54.2,Other,260% of Medicaid,67.54,,,67.54,Other,324% of Medicaid,44.82,,,44.82,Other,215% of Medicaid,44.82,,,44.82,Other,215% of Medicaid,26.06,,,26.06,Other,125% of Medicaid,20.84,368,
IONTOPHORESIS,97033,CPT,GP,62097033,CDM,420,RC,,,both,,,182,134.68,,,134.68,Other,150% of Medicare + 9.63% HCRA Surcharge,81.9,45,,81.9,percent of total billed charges,Critical Access Hospital RCC factor,180,,,180,Case Rate,Therapy Per Visit,162,,,162,Case Rate,Therapy Per Visit,179.44,,,179.44,Fee Schedule,,161.4,,,161.4,Fee Schedule,,152.54,,,152.54,Fee Schedule,,90.09,,,90.09,Other,110% of Medicare,219,,,219,Case Rate,Therapy Per Visit,39,,,39,Other,186% of Medicaid,257,,,257,Case Rate,Therapy Per Visit,151.06,83,,151.06,percent of total billed charges,Therapy,43.16,,,43.16,Case Rate,,257,,,257,Case Rate,Therapy Per Visit,151.06,83,,151.06,percent of total billed charges,Therapy,368,,,368,Case Rate,Therapy Visit,127.4,70,,127.4,percent of total billed charges,All Other,259,,,259,Case Rate,Therapy Visit,220,,,220,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,138,,,138,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,131,,,131,Case Rate,Therapy Visit,20.84,,,20.84,Other,100% of Medicaid,20.84,,,20.84,Other,100% of Medicaid,20.84,,,20.84,Other,100% of Medicaid,20.84,,,20.84,Other,100% of Medicaid,46.9,,,46.9,Other,225% of Medicaid,31.89,,,31.89,Other,153% of Medicaid,46.9,,,46.9,Other,225% of Medicaid,29.18,,,29.18,Other,140% of Medicaid,46.9,,,46.9,Other,225% of Medicaid,54.2,,,54.2,Other,260% of Medicaid,67.54,,,67.54,Other,324% of Medicaid,44.82,,,44.82,Other,215% of Medicaid,44.82,,,44.82,Other,215% of Medicaid,26.06,,,26.06,Other,125% of Medicaid,20.84,368,
ULTRASOUND 15 MINUTES,97035,CPT,GP,62097035,CDM,420,RC,,,both,,,127,93.98,,,93.98,Other,150% of Medicare + 9.63% HCRA Surcharge,57.15,45,,57.15,percent of total billed charges,Critical Access Hospital RCC factor,180,,,180,Case Rate,Therapy Per Visit,162,,,162,Case Rate,Therapy Per Visit,71.62,,,71.62,Fee Schedule,,64.42,,,64.42,Fee Schedule,,60.88,,,60.88,Fee Schedule,,62.87,,,62.87,Other,110% of Medicare,219,,,219,Case Rate,Therapy Per Visit,39,,,39,Other,186% of Medicaid,257,,,257,Case Rate,Therapy Per Visit,105.41,83,,105.41,percent of total billed charges,Therapy,31.19,,,31.19,Case Rate,,257,,,257,Case Rate,Therapy Per Visit,105.41,83,,105.41,percent of total billed charges,Therapy,368,,,368,Case Rate,Therapy Visit,88.9,70,,88.9,percent of total billed charges,All Other,259,,,259,Case Rate,Therapy Visit,220,,,220,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,138,,,138,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,131,,,131,Case Rate,Therapy Visit,20.84,,,20.84,Other,100% of Medicaid,20.84,,,20.84,Other,100% of Medicaid,20.84,,,20.84,Other,100% of Medicaid,20.84,,,20.84,Other,100% of Medicaid,46.9,,,46.9,Other,225% of Medicaid,31.89,,,31.89,Other,153% of Medicaid,46.9,,,46.9,Other,225% of Medicaid,29.18,,,29.18,Other,140% of Medicaid,46.9,,,46.9,Other,225% of Medicaid,54.2,,,54.2,Other,260% of Medicaid,67.54,,,67.54,Other,324% of Medicaid,44.82,,,44.82,Other,215% of Medicaid,44.82,,,44.82,Other,215% of Medicaid,26.06,,,26.06,Other,125% of Medicaid,20.84,368,
THERAPEUTIC EXERCISE 15 MIN,97110,CPT,GP,62097110,CDM,420,RC,,,both,,,187,138.38,,,138.38,Other,150% of Medicare + 9.63% HCRA Surcharge,84.15,45,,84.15,percent of total billed charges,Critical Access Hospital RCC factor,180,,,180,Case Rate,Therapy Per Visit,162,,,162,Case Rate,Therapy Per Visit,180.81,,,180.81,Fee Schedule,,162.63,,,162.63,Fee Schedule,,153.71,,,153.71,Fee Schedule,,92.57,,,92.57,Other,110% of Medicare,219,,,219,Case Rate,Therapy Per Visit,109,,,109,Other,186% of Medicaid,257,,,257,Case Rate,Therapy Per Visit,155.21,83,,155.21,percent of total billed charges,Therapy,65.18,,,65.18,Case Rate,,257,,,257,Case Rate,Therapy Per Visit,155.21,83,,155.21,percent of total billed charges,Therapy,368,,,368,Case Rate,Therapy Visit,130.9,70,,130.9,percent of total billed charges,All Other,259,,,259,Case Rate,Therapy Visit,220,,,220,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,138,,,138,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,131,,,131,Case Rate,Therapy Visit,58.77,,,58.77,Other,100% of Medicaid,58.77,,,58.77,Other,100% of Medicaid,58.77,,,58.77,Other,100% of Medicaid,58.77,,,58.77,Other,100% of Medicaid,132.23,,,132.23,Other,225% of Medicaid,89.92,,,89.92,Other,153% of Medicaid,132.23,,,132.23,Other,225% of Medicaid,82.28,,,82.28,Other,140% of Medicaid,132.23,,,132.23,Other,225% of Medicaid,152.8,,,152.8,Other,260% of Medicaid,190.42,,,190.42,Other,324% of Medicaid,126.36,,,126.36,Other,215% of Medicaid,126.36,,,126.36,Other,215% of Medicaid,73.46,,,73.46,Other,125% of Medicaid,58.77,368,
NEUROMUSC REEDUCATION 15 MIN,97112,CPT,GP,62097112,CDM,420,RC,,,both,,,208,153.92,,,153.92,Other,150% of Medicare + 9.63% HCRA Surcharge,93.6,45,,93.6,percent of total billed charges,Critical Access Hospital RCC factor,180,,,180,Case Rate,Therapy Per Visit,162,,,162,Case Rate,Therapy Per Visit,189.98,,,189.98,Fee Schedule,,170.88,,,170.88,Fee Schedule,,161.5,,,161.5,Fee Schedule,,102.96,,,102.96,Other,110% of Medicare,219,,,219,Case Rate,Therapy Per Visit,109,,,109,Other,186% of Medicaid,257,,,257,Case Rate,Therapy Per Visit,172.64,83,,172.64,percent of total billed charges,Therapy,74.87,,,74.87,Case Rate,,257,,,257,Case Rate,Therapy Per Visit,172.64,83,,172.64,percent of total billed charges,Therapy,368,,,368,Case Rate,Therapy Visit,145.6,70,,145.6,percent of total billed charges,All Other,259,,,259,Case Rate,Therapy Visit,220,,,220,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,138,,,138,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,131,,,131,Case Rate,Therapy Visit,58.77,,,58.77,Other,100% of Medicaid,58.77,,,58.77,Other,100% of Medicaid,58.77,,,58.77,Other,100% of Medicaid,58.77,,,58.77,Other,100% of Medicaid,132.23,,,132.23,Other,225% of Medicaid,89.92,,,89.92,Other,153% of Medicaid,132.23,,,132.23,Other,225% of Medicaid,82.28,,,82.28,Other,140% of Medicaid,132.23,,,132.23,Other,225% of Medicaid,152.8,,,152.8,Other,260% of Medicaid,190.42,,,190.42,Other,324% of Medicaid,126.36,,,126.36,Other,215% of Medicaid,126.36,,,126.36,Other,215% of Medicaid,73.46,,,73.46,Other,125% of Medicaid,58.77,368,
GAIT TRAINING THERAPY,97116,CPT,GP,62097116,CDM,420,RC,,,both,,,209,154.66,,,154.66,Other,150% of Medicare + 9.63% HCRA Surcharge,94.05,45,,94.05,percent of total billed charges,Critical Access Hospital RCC factor,180,,,180,Case Rate,Therapy Per Visit,162,,,162,Case Rate,Therapy Per Visit,160,,,160,Fee Schedule,,143.91,,,143.91,Fee Schedule,,136.01,,,136.01,Fee Schedule,,103.46,,,103.46,Other,110% of Medicare,219,,,219,Case Rate,Therapy Per Visit,39,,,39,Other,186% of Medicaid,257,,,257,Case Rate,Therapy Per Visit,173.47,83,,173.47,percent of total billed charges,Therapy,65.18,,,65.18,Case Rate,,257,,,257,Case Rate,Therapy Per Visit,173.47,83,,173.47,percent of total billed charges,Therapy,368,,,368,Case Rate,Therapy Visit,146.3,70,,146.3,percent of total billed charges,All Other,259,,,259,Case Rate,Therapy Visit,220,,,220,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,138,,,138,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,131,,,131,Case Rate,Therapy Visit,20.84,,,20.84,Other,100% of Medicaid,20.84,,,20.84,Other,100% of Medicaid,20.84,,,20.84,Other,100% of Medicaid,20.84,,,20.84,Other,100% of Medicaid,46.9,,,46.9,Other,225% of Medicaid,31.89,,,31.89,Other,153% of Medicaid,46.9,,,46.9,Other,225% of Medicaid,29.18,,,29.18,Other,140% of Medicaid,46.9,,,46.9,Other,225% of Medicaid,54.2,,,54.2,Other,260% of Medicaid,67.54,,,67.54,Other,324% of Medicaid,44.82,,,44.82,Other,215% of Medicaid,44.82,,,44.82,Other,215% of Medicaid,26.06,,,26.06,Other,125% of Medicaid,20.84,368,
MASSAGE THERAPY,97124,CPT,GP,62097124,CDM,420,RC,,,both,,,145,107.3,,,107.3,Other,150% of Medicare + 9.63% HCRA Surcharge,65.25,45,,65.25,percent of total billed charges,Critical Access Hospital RCC factor,180,,,180,Case Rate,Therapy Per Visit,162,,,162,Case Rate,Therapy Per Visit,148.3,,,148.3,Fee Schedule,,133.38,,,133.38,Fee Schedule,,126.07,,,126.07,Fee Schedule,,71.78,,,71.78,Other,110% of Medicare,219,,,219,Case Rate,Therapy Per Visit,39,,,39,Other,186% of Medicaid,257,,,257,Case Rate,Therapy Per Visit,120.35,83,,120.35,percent of total billed charges,Therapy,67.87,,,67.87,Case Rate,,257,,,257,Case Rate,Therapy Per Visit,120.35,83,,120.35,percent of total billed charges,Therapy,368,,,368,Case Rate,Therapy Visit,101.5,70,,101.5,percent of total billed charges,All Other,259,,,259,Case Rate,Therapy Visit,220,,,220,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,138,,,138,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,131,,,131,Case Rate,Therapy Visit,20.84,,,20.84,Other,100% of Medicaid,20.84,,,20.84,Other,100% of Medicaid,20.84,,,20.84,Other,100% of Medicaid,20.84,,,20.84,Other,100% of Medicaid,46.9,,,46.9,Other,225% of Medicaid,31.89,,,31.89,Other,153% of Medicaid,46.9,,,46.9,Other,225% of Medicaid,29.18,,,29.18,Other,140% of Medicaid,46.9,,,46.9,Other,225% of Medicaid,54.2,,,54.2,Other,260% of Medicaid,67.54,,,67.54,Other,324% of Medicaid,44.82,,,44.82,Other,215% of Medicaid,44.82,,,44.82,Other,215% of Medicaid,26.06,,,26.06,Other,125% of Medicaid,20.84,368,
MANUAL THERAPY,97140,CPT,GP,62097140,CDM,420,RC,,,both,,,198,146.52,,,146.52,Other,150% of Medicare + 9.63% HCRA Surcharge,89.1,45,,89.1,percent of total billed charges,Critical Access Hospital RCC factor,180,,,180,Case Rate,Therapy Per Visit,162,,,162,Case Rate,Therapy Per Visit,170.17,,,170.17,Fee Schedule,,153.05,,,153.05,Fee Schedule,,144.66,,,144.66,Fee Schedule,,98.01,,,98.01,Other,110% of Medicare,219,,,219,Case Rate,Therapy Per Visit,109,,,109,Other,186% of Medicaid,257,,,257,Case Rate,Therapy Per Visit,164.34,83,,164.34,percent of total billed charges,Therapy,59.93,,,59.93,Case Rate,,257,,,257,Case Rate,Therapy Per Visit,164.34,83,,164.34,percent of total billed charges,Therapy,368,,,368,Case Rate,Therapy Visit,138.6,70,,138.6,percent of total billed charges,All Other,259,,,259,Case Rate,Therapy Visit,220,,,220,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,138,,,138,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,131,,,131,Case Rate,Therapy Visit,58.77,,,58.77,Other,100% of Medicaid,58.77,,,58.77,Other,100% of Medicaid,58.77,,,58.77,Other,100% of Medicaid,58.77,,,58.77,Other,100% of Medicaid,132.23,,,132.23,Other,225% of Medicaid,89.92,,,89.92,Other,153% of Medicaid,132.23,,,132.23,Other,225% of Medicaid,82.28,,,82.28,Other,140% of Medicaid,132.23,,,132.23,Other,225% of Medicaid,152.8,,,152.8,Other,260% of Medicaid,190.42,,,190.42,Other,324% of Medicaid,126.36,,,126.36,Other,215% of Medicaid,126.36,,,126.36,Other,215% of Medicaid,73.46,,,73.46,Other,125% of Medicaid,58.77,368,
THERAPEUTIC REHAB GROUP,97150,CPT,GP,62097150,CDM,420,RC,,,both,,,96,71.04,,,71.04,Other,150% of Medicare + 9.63% HCRA Surcharge,43.2,45,,43.2,percent of total billed charges,Critical Access Hospital RCC factor,180,,,180,Case Rate,Therapy Per Visit,162,,,162,Case Rate,Therapy Per Visit,117.2,,,117.2,Fee Schedule,,105.42,,,105.42,Fee Schedule,,99.64,,,99.64,Fee Schedule,,47.52,,,47.52,Other,110% of Medicare,219,,,219,Case Rate,Therapy Per Visit,109,,,109,Other,186% of Medicaid,257,,,257,Case Rate,Therapy Per Visit,79.68,83,,79.68,percent of total billed charges,Therapy,39.98,,,39.98,Case Rate,,257,,,257,Case Rate,Therapy Per Visit,79.68,83,,79.68,percent of total billed charges,Therapy,368,,,368,Case Rate,Therapy Visit,67.2,70,,67.2,percent of total billed charges,All Other,259,,,259,Case Rate,Therapy Visit,220,,,220,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,138,,,138,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,131,,,131,Case Rate,Therapy Visit,58.77,,,58.77,Other,100% of Medicaid,58.77,,,58.77,Other,100% of Medicaid,58.77,,,58.77,Other,100% of Medicaid,58.77,,,58.77,Other,100% of Medicaid,132.23,,,132.23,Other,225% of Medicaid,89.92,,,89.92,Other,153% of Medicaid,132.23,,,132.23,Other,225% of Medicaid,82.28,,,82.28,Other,140% of Medicaid,132.23,,,132.23,Other,225% of Medicaid,152.8,,,152.8,Other,260% of Medicaid,190.42,,,190.42,Other,324% of Medicaid,126.36,,,126.36,Other,215% of Medicaid,126.36,,,126.36,Other,215% of Medicaid,73.46,,,73.46,Other,125% of Medicaid,39.98,368,
THERAPEUTIC ACTIVITY 15 MIN,97530,CPT,GP,62097530,CDM,420,RC,,,both,,,209,154.66,,,154.66,Other,150% of Medicare + 9.63% HCRA Surcharge,94.05,45,,94.05,percent of total billed charges,Critical Access Hospital RCC factor,180,,,180,Case Rate,Therapy Per Visit,162,,,162,Case Rate,Therapy Per Visit,199.52,,,199.52,Fee Schedule,,179.46,,,179.46,Fee Schedule,,169.61,,,169.61,Fee Schedule,,103.46,,,103.46,Other,110% of Medicare,219,,,219,Case Rate,Therapy Per Visit,109,,,109,Other,186% of Medicaid,257,,,257,Case Rate,Therapy Per Visit,173.47,83,,173.47,percent of total billed charges,Therapy,81.96,,,81.96,Case Rate,,257,,,257,Case Rate,Therapy Per Visit,173.47,83,,173.47,percent of total billed charges,Therapy,368,,,368,Case Rate,Therapy Visit,146.3,70,,146.3,percent of total billed charges,All Other,259,,,259,Case Rate,Therapy Visit,220,,,220,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,138,,,138,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,131,,,131,Case Rate,Therapy Visit,58.77,,,58.77,Other,100% of Medicaid,58.77,,,58.77,Other,100% of Medicaid,58.77,,,58.77,Other,100% of Medicaid,58.77,,,58.77,Other,100% of Medicaid,132.23,,,132.23,Other,225% of Medicaid,89.92,,,89.92,Other,153% of Medicaid,132.23,,,132.23,Other,225% of Medicaid,82.28,,,82.28,Other,140% of Medicaid,132.23,,,132.23,Other,225% of Medicaid,152.8,,,152.8,Other,260% of Medicaid,190.42,,,190.42,Other,324% of Medicaid,126.36,,,126.36,Other,215% of Medicaid,126.36,,,126.36,Other,215% of Medicaid,73.46,,,73.46,Other,125% of Medicaid,58.77,368,
SENSORY INTEGRATE TECH 15MIN,97533,CPT,GP,62097533,CDM,420,RC,,,both,,,209,154.66,,,154.66,Other,150% of Medicare + 9.63% HCRA Surcharge,94.05,45,,94.05,percent of total billed charges,Critical Access Hospital RCC factor,180,,,180,Case Rate,Therapy Per Visit,162,,,162,Case Rate,Therapy Per Visit,167.48,,,167.48,Fee Schedule,,150.64,,,150.64,Fee Schedule,,142.37,,,142.37,Fee Schedule,,103.46,,,103.46,Other,110% of Medicare,219,,,219,Case Rate,Therapy Per Visit,109,,,109,Other,186% of Medicaid,257,,,257,Case Rate,Therapy Per Visit,173.47,83,,173.47,percent of total billed charges,Therapy,140.34,,,140.34,Case Rate,,257,,,257,Case Rate,Therapy Per Visit,173.47,83,,173.47,percent of total billed charges,Therapy,368,,,368,Case Rate,Therapy Visit,146.3,70,,146.3,percent of total billed charges,All Other,259,,,259,Case Rate,Therapy Visit,220,,,220,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,138,,,138,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,131,,,131,Case Rate,Therapy Visit,58.77,,,58.77,Other,100% of Medicaid,58.77,,,58.77,Other,100% of Medicaid,58.77,,,58.77,Other,100% of Medicaid,58.77,,,58.77,Other,100% of Medicaid,132.23,,,132.23,Other,225% of Medicaid,89.92,,,89.92,Other,153% of Medicaid,132.23,,,132.23,Other,225% of Medicaid,82.28,,,82.28,Other,140% of Medicaid,132.23,,,132.23,Other,225% of Medicaid,152.8,,,152.8,Other,260% of Medicaid,190.42,,,190.42,Other,324% of Medicaid,126.36,,,126.36,Other,215% of Medicaid,126.36,,,126.36,Other,215% of Medicaid,73.46,,,73.46,Other,125% of Medicaid,58.77,368,
SELF CARE MNGMENT TRAINING,97535,CPT,GP,62097535,CDM,420,RC,,,both,,,193,142.82,,,142.82,Other,150% of Medicare + 9.63% HCRA Surcharge,86.85,45,,86.85,percent of total billed charges,Critical Access Hospital RCC factor,180,,,180,Case Rate,Therapy Per Visit,162,,,162,Case Rate,Therapy Per Visit,199.1,,,199.1,Fee Schedule,,179.08,,,179.08,Fee Schedule,,169.25,,,169.25,Fee Schedule,,95.54,,,95.54,Other,110% of Medicare,219,,,219,Case Rate,Therapy Per Visit,39,,,39,Other,186% of Medicaid,257,,,257,Case Rate,Therapy Per Visit,160.19,83,,160.19,percent of total billed charges,Therapy,72.79,,,72.79,Case Rate,,257,,,257,Case Rate,Therapy Per Visit,160.19,83,,160.19,percent of total billed charges,Therapy,368,,,368,Case Rate,Therapy Visit,135.1,70,,135.1,percent of total billed charges,All Other,259,,,259,Case Rate,Therapy Visit,220,,,220,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,138,,,138,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,131,,,131,Case Rate,Therapy Visit,20.84,,,20.84,Other,100% of Medicaid,20.84,,,20.84,Other,100% of Medicaid,20.84,,,20.84,Other,100% of Medicaid,20.84,,,20.84,Other,100% of Medicaid,46.9,,,46.9,Other,225% of Medicaid,31.89,,,31.89,Other,153% of Medicaid,46.9,,,46.9,Other,225% of Medicaid,29.18,,,29.18,Other,140% of Medicaid,46.9,,,46.9,Other,225% of Medicaid,54.2,,,54.2,Other,260% of Medicaid,67.54,,,67.54,Other,324% of Medicaid,44.82,,,44.82,Other,215% of Medicaid,44.82,,,44.82,Other,215% of Medicaid,26.06,,,26.06,Other,125% of Medicaid,20.84,368,
COMMUNITY/WORK REINTEGRATION EA 15 MIN,97537,CPT,GP,62097537,CDM,420,RC,,,both,,,141,104.34,,,104.34,Other,150% of Medicare + 9.63% HCRA Surcharge,63.45,45,,63.45,percent of total billed charges,Critical Access Hospital RCC factor,180,,,180,Case Rate,Therapy Per Visit,162,,,162,Case Rate,Therapy Per Visit,171.64,,,171.64,Fee Schedule,,154.38,,,154.38,Fee Schedule,,145.91,,,145.91,Fee Schedule,,69.8,,,69.8,Other,110% of Medicare,219,,,219,Case Rate,Therapy Per Visit,109,,,109,Other,186% of Medicaid,257,,,257,Case Rate,Therapy Per Visit,117.03,83,,117.03,percent of total billed charges,Therapy,70.37,,,70.37,Case Rate,,257,,,257,Case Rate,Therapy Per Visit,117.03,83,,117.03,percent of total billed charges,Therapy,368,,,368,Case Rate,Therapy Visit,98.7,70,,98.7,percent of total billed charges,All Other,259,,,259,Case Rate,Therapy Visit,220,,,220,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,138,,,138,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,131,,,131,Case Rate,Therapy Visit,58.77,,,58.77,Other,100% of Medicaid,58.77,,,58.77,Other,100% of Medicaid,58.77,,,58.77,Other,100% of Medicaid,58.77,,,58.77,Other,100% of Medicaid,132.23,,,132.23,Other,225% of Medicaid,89.92,,,89.92,Other,153% of Medicaid,132.23,,,132.23,Other,225% of Medicaid,82.28,,,82.28,Other,140% of Medicaid,132.23,,,132.23,Other,225% of Medicaid,152.8,,,152.8,Other,260% of Medicaid,190.42,,,190.42,Other,324% of Medicaid,126.36,,,126.36,Other,215% of Medicaid,126.36,,,126.36,Other,215% of Medicaid,73.46,,,73.46,Other,125% of Medicaid,58.77,368,
WHEELCHAIR MNGMENT TRAINING,97542,CPT,GP,62097542,CDM,420,RC,,,both,,,190,140.6,,,140.6,Other,150% of Medicare + 9.63% HCRA Surcharge,85.5,45,,85.5,percent of total billed charges,Critical Access Hospital RCC factor,180,,,180,Case Rate,Therapy Per Visit,162,,,162,Case Rate,Therapy Per Visit,173.96,,,173.96,Fee Schedule,,156.47,,,156.47,Fee Schedule,,147.88,,,147.88,Fee Schedule,,94.05,,,94.05,Other,110% of Medicare,219,,,219,Case Rate,Therapy Per Visit,109,,,109,Other,186% of Medicaid,257,,,257,Case Rate,Therapy Per Visit,157.7,83,,157.7,percent of total billed charges,Therapy,70.37,,,70.37,Case Rate,,257,,,257,Case Rate,Therapy Per Visit,157.7,83,,157.7,percent of total billed charges,Therapy,368,,,368,Case Rate,Therapy Visit,133,70,,133,percent of total billed charges,All Other,259,,,259,Case Rate,Therapy Visit,220,,,220,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,138,,,138,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,131,,,131,Case Rate,Therapy Visit,58.77,,,58.77,Other,100% of Medicaid,58.77,,,58.77,Other,100% of Medicaid,58.77,,,58.77,Other,100% of Medicaid,58.77,,,58.77,Other,100% of Medicaid,132.23,,,132.23,Other,225% of Medicaid,89.92,,,89.92,Other,153% of Medicaid,132.23,,,132.23,Other,225% of Medicaid,82.28,,,82.28,Other,140% of Medicaid,132.23,,,132.23,Other,225% of Medicaid,152.8,,,152.8,Other,260% of Medicaid,190.42,,,190.42,Other,324% of Medicaid,126.36,,,126.36,Other,215% of Medicaid,126.36,,,126.36,Other,215% of Medicaid,73.46,,,73.46,Other,125% of Medicaid,58.77,368,
SLCTV WND DEBRIDEM 20 CM OR <,97597,CPT,GP,62097597,CDM,420,RC,,,both,,,573,424.02,,,424.02,Other,150% of Medicare + 9.63% HCRA Surcharge,257.85,45,,257.85,percent of total billed charges,Critical Access Hospital RCC factor,180,,,180,Case Rate,Therapy Per Visit,162,,,162,Case Rate,Therapy Per Visit,438.35,76.5,,438.35,percent of total billed charges,All Other,406.83,69,,406.83,percent of total billed charges,All Other,395.37,65,,395.37,percent of total billed charges,All Other,283.64,,,283.64,Other,110% of Medicare,219,,,219,Case Rate,Therapy Per Visit,703,,,703,Other,186% of Medicaid,257,,,257,Case Rate,Therapy Per Visit,475.59,83,,475.59,percent of total billed charges,Therapy,475.59,,,475.59,Other,Non Covered Service,257,,,257,Case Rate,Therapy Per Visit,475.59,83,,475.59,percent of total billed charges,Therapy,368,,,368,Case Rate,Therapy Visit,401.1,70,,401.1,percent of total billed charges,All Other,259,,,259,Case Rate,Therapy Visit,220,,,220,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,138,,,138,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,131,,,131,Case Rate,Therapy Visit,377.82,,,377.82,Other,100% of Medicaid,377.82,,,377.82,Other,100% of Medicaid,377.82,,,377.82,Other,100% of Medicaid,377.82,,,377.82,Other,100% of Medicaid,850.1,,,850.1,Other,225% of Medicaid,578.07,,,578.07,Other,153% of Medicaid,850.1,,,850.1,Other,225% of Medicaid,528.95,,,528.95,Other,140% of Medicaid,850.1,,,850.1,Other,225% of Medicaid,982.34,,,982.34,Other,260% of Medicaid,1224.15,,,1224.15,Other,324% of Medicaid,812.32,,,812.32,Other,215% of Medicaid,812.32,,,812.32,Other,215% of Medicaid,472.28,,,472.28,Other,125% of Medicaid,131,1224.15,
TH-THERAPEUTIC EXERCISE 15 MIN,97110,CPT,GPGT,62297110,CDM,420,RC,,,both,,,187,138.38,,,138.38,Other,150% of Medicare + 9.63% HCRA Surcharge,84.15,45,,84.15,percent of total billed charges,Critical Access Hospital RCC factor,180,,,180,Case Rate,Therapy Per Visit,162,,,162,Case Rate,Therapy Per Visit,180.81,,,180.81,Fee Schedule,,162.63,,,162.63,Fee Schedule,,153.71,,,153.71,Fee Schedule,,92.57,,,92.57,Other,110% of Medicare,219,,,219,Case Rate,Therapy Per Visit,109,,,109,Other,186% of Medicaid,257,,,257,Case Rate,Therapy Per Visit,155.21,83,,155.21,percent of total billed charges,Therapy,65.18,,,65.18,Case Rate,,257,,,257,Case Rate,Therapy Per Visit,155.21,83,,155.21,percent of total billed charges,Therapy,368,,,368,Case Rate,Therapy Visit,130.9,70,,130.9,percent of total billed charges,All Other,259,,,259,Case Rate,Therapy Visit,220,,,220,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,138,,,138,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,131,,,131,Case Rate,Therapy Visit,58.77,,,58.77,Other,100% of Medicaid,58.77,,,58.77,Other,100% of Medicaid,58.77,,,58.77,Other,100% of Medicaid,58.77,,,58.77,Other,100% of Medicaid,132.23,,,132.23,Other,225% of Medicaid,89.92,,,89.92,Other,153% of Medicaid,132.23,,,132.23,Other,225% of Medicaid,82.28,,,82.28,Other,140% of Medicaid,132.23,,,132.23,Other,225% of Medicaid,152.8,,,152.8,Other,260% of Medicaid,190.42,,,190.42,Other,324% of Medicaid,126.36,,,126.36,Other,215% of Medicaid,126.36,,,126.36,Other,215% of Medicaid,73.46,,,73.46,Other,125% of Medicaid,58.77,368,
TH-NEUROMUSC REEDUCATION 15 MIN,97112,CPT,GPGT,62297112,CDM,420,RC,,,both,,,208,153.92,,,153.92,Other,150% of Medicare + 9.63% HCRA Surcharge,93.6,45,,93.6,percent of total billed charges,Critical Access Hospital RCC factor,180,,,180,Case Rate,Therapy Per Visit,162,,,162,Case Rate,Therapy Per Visit,189.98,,,189.98,Fee Schedule,,170.88,,,170.88,Fee Schedule,,161.5,,,161.5,Fee Schedule,,102.96,,,102.96,Other,110% of Medicare,219,,,219,Case Rate,Therapy Per Visit,109,,,109,Other,186% of Medicaid,257,,,257,Case Rate,Therapy Per Visit,172.64,83,,172.64,percent of total billed charges,Therapy,74.87,,,74.87,Case Rate,,257,,,257,Case Rate,Therapy Per Visit,172.64,83,,172.64,percent of total billed charges,Therapy,368,,,368,Case Rate,Therapy Visit,145.6,70,,145.6,percent of total billed charges,All Other,259,,,259,Case Rate,Therapy Visit,220,,,220,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,138,,,138,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,131,,,131,Case Rate,Therapy Visit,58.77,,,58.77,Other,100% of Medicaid,58.77,,,58.77,Other,100% of Medicaid,58.77,,,58.77,Other,100% of Medicaid,58.77,,,58.77,Other,100% of Medicaid,132.23,,,132.23,Other,225% of Medicaid,89.92,,,89.92,Other,153% of Medicaid,132.23,,,132.23,Other,225% of Medicaid,82.28,,,82.28,Other,140% of Medicaid,132.23,,,132.23,Other,225% of Medicaid,152.8,,,152.8,Other,260% of Medicaid,190.42,,,190.42,Other,324% of Medicaid,126.36,,,126.36,Other,215% of Medicaid,126.36,,,126.36,Other,215% of Medicaid,73.46,,,73.46,Other,125% of Medicaid,58.77,368,
TH-GAIT TRAINING THERAPY,97116,CPT,GPGT,62297116,CDM,420,RC,,,both,,,209,154.66,,,154.66,Other,150% of Medicare + 9.63% HCRA Surcharge,94.05,45,,94.05,percent of total billed charges,Critical Access Hospital RCC factor,180,,,180,Case Rate,Therapy Per Visit,162,,,162,Case Rate,Therapy Per Visit,160,,,160,Fee Schedule,,143.91,,,143.91,Fee Schedule,,136.01,,,136.01,Fee Schedule,,103.46,,,103.46,Other,110% of Medicare,219,,,219,Case Rate,Therapy Per Visit,39,,,39,Other,186% of Medicaid,257,,,257,Case Rate,Therapy Per Visit,173.47,83,,173.47,percent of total billed charges,Therapy,65.18,,,65.18,Case Rate,,257,,,257,Case Rate,Therapy Per Visit,173.47,83,,173.47,percent of total billed charges,Therapy,368,,,368,Case Rate,Therapy Visit,146.3,70,,146.3,percent of total billed charges,All Other,259,,,259,Case Rate,Therapy Visit,220,,,220,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,138,,,138,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,131,,,131,Case Rate,Therapy Visit,20.84,,,20.84,Other,100% of Medicaid,20.84,,,20.84,Other,100% of Medicaid,20.84,,,20.84,Other,100% of Medicaid,20.84,,,20.84,Other,100% of Medicaid,46.9,,,46.9,Other,225% of Medicaid,31.89,,,31.89,Other,153% of Medicaid,46.9,,,46.9,Other,225% of Medicaid,29.18,,,29.18,Other,140% of Medicaid,46.9,,,46.9,Other,225% of Medicaid,54.2,,,54.2,Other,260% of Medicaid,67.54,,,67.54,Other,324% of Medicaid,44.82,,,44.82,Other,215% of Medicaid,44.82,,,44.82,Other,215% of Medicaid,26.06,,,26.06,Other,125% of Medicaid,20.84,368,
TH-THERAPEUTIC ACTIVITY 15 MIN,97530,CPT,GPGT,62297530,CDM,420,RC,,,both,,,209,154.66,,,154.66,Other,150% of Medicare + 9.63% HCRA Surcharge,94.05,45,,94.05,percent of total billed charges,Critical Access Hospital RCC factor,180,,,180,Case Rate,Therapy Per Visit,162,,,162,Case Rate,Therapy Per Visit,199.52,,,199.52,Fee Schedule,,179.46,,,179.46,Fee Schedule,,169.61,,,169.61,Fee Schedule,,103.46,,,103.46,Other,110% of Medicare,219,,,219,Case Rate,Therapy Per Visit,109,,,109,Other,186% of Medicaid,257,,,257,Case Rate,Therapy Per Visit,173.47,83,,173.47,percent of total billed charges,Therapy,81.96,,,81.96,Case Rate,,257,,,257,Case Rate,Therapy Per Visit,173.47,83,,173.47,percent of total billed charges,Therapy,368,,,368,Case Rate,Therapy Visit,146.3,70,,146.3,percent of total billed charges,All Other,259,,,259,Case Rate,Therapy Visit,220,,,220,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,138,,,138,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,131,,,131,Case Rate,Therapy Visit,58.77,,,58.77,Other,100% of Medicaid,58.77,,,58.77,Other,100% of Medicaid,58.77,,,58.77,Other,100% of Medicaid,58.77,,,58.77,Other,100% of Medicaid,132.23,,,132.23,Other,225% of Medicaid,89.92,,,89.92,Other,153% of Medicaid,132.23,,,132.23,Other,225% of Medicaid,82.28,,,82.28,Other,140% of Medicaid,132.23,,,132.23,Other,225% of Medicaid,152.8,,,152.8,Other,260% of Medicaid,190.42,,,190.42,Other,324% of Medicaid,126.36,,,126.36,Other,215% of Medicaid,126.36,,,126.36,Other,215% of Medicaid,73.46,,,73.46,Other,125% of Medicaid,58.77,368,
TH-SELF CARE MNGMENT TRAINING,97535,CPT,GPGT,62297535,CDM,420,RC,,,both,,,193,142.82,,,142.82,Other,150% of Medicare + 9.63% HCRA Surcharge,86.85,45,,86.85,percent of total billed charges,Critical Access Hospital RCC factor,180,,,180,Case Rate,Therapy Per Visit,162,,,162,Case Rate,Therapy Per Visit,199.1,,,199.1,Fee Schedule,,179.08,,,179.08,Fee Schedule,,169.25,,,169.25,Fee Schedule,,95.54,,,95.54,Other,110% of Medicare,219,,,219,Case Rate,Therapy Per Visit,39,,,39,Other,186% of Medicaid,257,,,257,Case Rate,Therapy Per Visit,160.19,83,,160.19,percent of total billed charges,Therapy,72.79,,,72.79,Case Rate,,257,,,257,Case Rate,Therapy Per Visit,160.19,83,,160.19,percent of total billed charges,Therapy,368,,,368,Case Rate,Therapy Visit,135.1,70,,135.1,percent of total billed charges,All Other,259,,,259,Case Rate,Therapy Visit,220,,,220,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,138,,,138,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,131,,,131,Case Rate,Therapy Visit,20.84,,,20.84,Other,100% of Medicaid,20.84,,,20.84,Other,100% of Medicaid,20.84,,,20.84,Other,100% of Medicaid,20.84,,,20.84,Other,100% of Medicaid,46.9,,,46.9,Other,225% of Medicaid,31.89,,,31.89,Other,153% of Medicaid,46.9,,,46.9,Other,225% of Medicaid,29.18,,,29.18,Other,140% of Medicaid,46.9,,,46.9,Other,225% of Medicaid,54.2,,,54.2,Other,260% of Medicaid,67.54,,,67.54,Other,324% of Medicaid,44.82,,,44.82,Other,215% of Medicaid,44.82,,,44.82,Other,215% of Medicaid,26.06,,,26.06,Other,125% of Medicaid,20.84,368,
ELECTRICAL STIMULATION EA 15 MINS,G0283,HCPCS,GP,64000002,CDM,420,RC,,,both,,,119,88.06,,,88.06,Other,150% of Medicare + 9.63% HCRA Surcharge,53.55,45,,53.55,percent of total billed charges,Critical Access Hospital RCC factor,180,,,180,Case Rate,Therapy Per Visit,162,,,162,Case Rate,Therapy Per Visit,77.42,,,77.42,Fee Schedule,,69.63,,,69.63,Fee Schedule,,65.81,,,65.81,Fee Schedule,,58.91,,,58.91,Other,110% of Medicare,219,,,219,Case Rate,Therapy Per Visit,39,,,39,Other,186% of Medicaid,257,,,257,Case Rate,Therapy Per Visit,98.77,83,,98.77,percent of total billed charges,Therapy,26,,,26,Case Rate,,257,,,257,Case Rate,Therapy Per Visit,98.77,83,,98.77,percent of total billed charges,Therapy,368,,,368,Case Rate,Therapy Visit,83.3,70,,83.3,percent of total billed charges,All Other,259,,,259,Case Rate,Therapy Visit,220,,,220,Case Rate,Therapy Visit,0.01,,,0.01,Case Rate,Therapy Visit,0.01,,,0.01,Case Rate,Therapy Visit,0.01,,,0.01,Case Rate,Therapy Visit,0.01,,,0.01,Case Rate,Therapy Visit,20.84,,,20.84,Other,100% of Medicaid,20.84,,,20.84,Other,100% of Medicaid,20.84,,,20.84,Other,100% of Medicaid,20.84,,,20.84,Other,100% of Medicaid,46.9,,,46.9,Other,225% of Medicaid,31.89,,,31.89,Other,153% of Medicaid,46.9,,,46.9,Other,225% of Medicaid,29.18,,,29.18,Other,140% of Medicaid,46.9,,,46.9,Other,225% of Medicaid,54.2,,,54.2,Other,260% of Medicaid,67.54,,,67.54,Other,324% of Medicaid,44.82,,,44.82,Other,215% of Medicaid,44.82,,,44.82,Other,215% of Medicaid,26.06,,,26.06,Other,125% of Medicaid,0.01,368,
STRAPPING OF KNEE,29530,CPT,GP,64029530,CDM,420,RC,,,both,,,491,363.34,,,363.34,Other,150% of Medicare + 9.63% HCRA Surcharge,220.95,45,,220.95,percent of total billed charges,Critical Access Hospital RCC factor,180,,,180,Case Rate,Therapy Per Visit,162,,,162,Case Rate,Therapy Per Visit,375.62,76.5,,375.62,percent of total billed charges,All Other,348.61,69,,348.61,percent of total billed charges,All Other,338.79,65,,338.79,percent of total billed charges,All Other,243.05,,,243.05,Other,110% of Medicare,219,,,219,Case Rate,Therapy Per Visit,325,,,325,Other,186% of Medicaid,257,,,257,Case Rate,Therapy Per Visit,407.53,83,,407.53,percent of total billed charges,Therapy,38.91,,,38.91,Fee Schedule,,257,,,257,Case Rate,Therapy Per Visit,407.53,83,,407.53,percent of total billed charges,Therapy,368,,,368,Case Rate,Therapy Visit,343.7,70,,343.7,percent of total billed charges,All Other,259,,,259,Case Rate,Therapy Visit,220,,,220,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,138,,,138,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,131,,,131,Case Rate,Therapy Visit,174.92,,,174.92,Other,100% of Medicaid,174.92,,,174.92,Other,100% of Medicaid,174.92,,,174.92,Other,100% of Medicaid,174.92,,,174.92,Other,100% of Medicaid,393.57,,,393.57,Other,225% of Medicaid,267.62,,,267.62,Other,153% of Medicaid,393.57,,,393.57,Other,225% of Medicaid,244.89,,,244.89,Other,140% of Medicaid,393.57,,,393.57,Other,225% of Medicaid,454.79,,,454.79,Other,260% of Medicaid,566.73,,,566.73,Other,324% of Medicaid,376.07,,,376.07,Other,215% of Medicaid,376.07,,,376.07,Other,215% of Medicaid,218.65,,,218.65,Other,125% of Medicaid,38.91,566.73,
STRAPPING OF ANKLE AND/OR FT,29540,CPT,GP,64029540,CDM,420,RC,,,both,,,491,363.34,,,363.34,Other,150% of Medicare + 9.63% HCRA Surcharge,220.95,45,,220.95,percent of total billed charges,Critical Access Hospital RCC factor,180,,,180,Case Rate,Therapy Per Visit,162,,,162,Case Rate,Therapy Per Visit,375.62,76.5,,375.62,percent of total billed charges,All Other,348.61,69,,348.61,percent of total billed charges,All Other,338.79,65,,338.79,percent of total billed charges,All Other,243.05,,,243.05,Other,110% of Medicare,219,,,219,Case Rate,Therapy Per Visit,325,,,325,Other,186% of Medicaid,257,,,257,Case Rate,Therapy Per Visit,407.53,83,,407.53,percent of total billed charges,Therapy,37.51,,,37.51,Fee Schedule,,257,,,257,Case Rate,Therapy Per Visit,407.53,83,,407.53,percent of total billed charges,Therapy,368,,,368,Case Rate,Therapy Visit,343.7,70,,343.7,percent of total billed charges,All Other,259,,,259,Case Rate,Therapy Visit,220,,,220,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,138,,,138,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,131,,,131,Case Rate,Therapy Visit,174.92,,,174.92,Other,100% of Medicaid,174.92,,,174.92,Other,100% of Medicaid,174.92,,,174.92,Other,100% of Medicaid,174.92,,,174.92,Other,100% of Medicaid,393.57,,,393.57,Other,225% of Medicaid,267.62,,,267.62,Other,153% of Medicaid,393.57,,,393.57,Other,225% of Medicaid,244.89,,,244.89,Other,140% of Medicaid,393.57,,,393.57,Other,225% of Medicaid,454.79,,,454.79,Other,260% of Medicaid,566.73,,,566.73,Other,324% of Medicaid,376.07,,,376.07,Other,215% of Medicaid,376.07,,,376.07,Other,215% of Medicaid,218.65,,,218.65,Other,125% of Medicaid,37.51,566.73,
CANALITH REPOSITIONING PROC,95992,CPT,GP,64095992,CDM,420,RC,,,both,,,177,130.98,,,130.98,Other,150% of Medicare + 9.63% HCRA Surcharge,79.65,45,,79.65,percent of total billed charges,Critical Access Hospital RCC factor,180,,,180,Case Rate,Therapy Per Visit,162,,,162,Case Rate,Therapy Per Visit,255.91,,,255.91,Fee Schedule,,230.17,,,230.17,Fee Schedule,,217.55,,,217.55,Fee Schedule,,87.62,,,87.62,Other,110% of Medicare,219,,,219,Case Rate,Therapy Per Visit,109,,,109,Other,186% of Medicaid,257,,,257,Case Rate,Therapy Per Visit,146.91,83,,146.91,percent of total billed charges,Therapy,77.85,,,77.85,Fee Schedule,,257,,,257,Case Rate,Therapy Per Visit,146.91,83,,146.91,percent of total billed charges,Therapy,368,,,368,Case Rate,Therapy Visit,123.9,70,,123.9,percent of total billed charges,All Other,259,,,259,Case Rate,Therapy Visit,220,,,220,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,138,,,138,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,131,,,131,Case Rate,Therapy Visit,58.77,,,58.77,Other,100% of Medicaid,58.77,,,58.77,Other,100% of Medicaid,58.77,,,58.77,Other,100% of Medicaid,58.77,,,58.77,Other,100% of Medicaid,132.23,,,132.23,Other,225% of Medicaid,89.92,,,89.92,Other,153% of Medicaid,132.23,,,132.23,Other,225% of Medicaid,82.28,,,82.28,Other,140% of Medicaid,132.23,,,132.23,Other,225% of Medicaid,152.8,,,152.8,Other,260% of Medicaid,190.42,,,190.42,Other,324% of Medicaid,126.36,,,126.36,Other,215% of Medicaid,126.36,,,126.36,Other,215% of Medicaid,73.46,,,73.46,Other,125% of Medicaid,58.77,368,
GAIT TRAINING THERAPY,97116,CPT,GP,64097116,CDM,420,RC,,,both,,,209,154.66,,,154.66,Other,150% of Medicare + 9.63% HCRA Surcharge,94.05,45,,94.05,percent of total billed charges,Critical Access Hospital RCC factor,180,,,180,Case Rate,Therapy Per Visit,162,,,162,Case Rate,Therapy Per Visit,160,,,160,Fee Schedule,,143.91,,,143.91,Fee Schedule,,136.01,,,136.01,Fee Schedule,,103.46,,,103.46,Other,110% of Medicare,219,,,219,Case Rate,Therapy Per Visit,39,,,39,Other,186% of Medicaid,257,,,257,Case Rate,Therapy Per Visit,173.47,83,,173.47,percent of total billed charges,Therapy,65.18,,,65.18,Case Rate,,257,,,257,Case Rate,Therapy Per Visit,173.47,83,,173.47,percent of total billed charges,Therapy,368,,,368,Case Rate,Therapy Visit,146.3,70,,146.3,percent of total billed charges,All Other,259,,,259,Case Rate,Therapy Visit,220,,,220,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,138,,,138,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,131,,,131,Case Rate,Therapy Visit,20.84,,,20.84,Other,100% of Medicaid,20.84,,,20.84,Other,100% of Medicaid,20.84,,,20.84,Other,100% of Medicaid,20.84,,,20.84,Other,100% of Medicaid,46.9,,,46.9,Other,225% of Medicaid,31.89,,,31.89,Other,153% of Medicaid,46.9,,,46.9,Other,225% of Medicaid,29.18,,,29.18,Other,140% of Medicaid,46.9,,,46.9,Other,225% of Medicaid,54.2,,,54.2,Other,260% of Medicaid,67.54,,,67.54,Other,324% of Medicaid,44.82,,,44.82,Other,215% of Medicaid,44.82,,,44.82,Other,215% of Medicaid,26.06,,,26.06,Other,125% of Medicaid,20.84,368,
STRAPPING OF SHOULDER,29240,CPT,GP,64129240,CDM,420,RC,,,both,,,563,416.62,,,416.62,Other,150% of Medicare + 9.63% HCRA Surcharge,253.35,45,,253.35,percent of total billed charges,Critical Access Hospital RCC factor,180,,,180,Case Rate,Therapy Per Visit,162,,,162,Case Rate,Therapy Per Visit,430.7,76.5,,430.7,percent of total billed charges,All Other,399.73,69,,399.73,percent of total billed charges,All Other,388.47,65,,388.47,percent of total billed charges,All Other,278.69,,,278.69,Other,110% of Medicare,219,,,219,Case Rate,Therapy Per Visit,325,,,325,Other,186% of Medicaid,257,,,257,Case Rate,Therapy Per Visit,467.29,83,,467.29,percent of total billed charges,Therapy,38.91,,,38.91,Fee Schedule,,257,,,257,Case Rate,Therapy Per Visit,467.29,83,,467.29,percent of total billed charges,Therapy,368,,,368,Case Rate,Therapy Visit,394.1,70,,394.1,percent of total billed charges,All Other,259,,,259,Case Rate,Therapy Visit,220,,,220,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,138,,,138,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,131,,,131,Case Rate,Therapy Visit,174.92,,,174.92,Other,100% of Medicaid,174.92,,,174.92,Other,100% of Medicaid,174.92,,,174.92,Other,100% of Medicaid,174.92,,,174.92,Other,100% of Medicaid,393.57,,,393.57,Other,225% of Medicaid,267.62,,,267.62,Other,153% of Medicaid,393.57,,,393.57,Other,225% of Medicaid,244.89,,,244.89,Other,140% of Medicaid,393.57,,,393.57,Other,225% of Medicaid,454.79,,,454.79,Other,260% of Medicaid,566.73,,,566.73,Other,324% of Medicaid,376.07,,,376.07,Other,215% of Medicaid,376.07,,,376.07,Other,215% of Medicaid,218.65,,,218.65,Other,125% of Medicaid,38.91,566.73,
STRAPPING OF ELBOW OR WRIST,29260,CPT,GP,64129260,CDM,420,RC,,,both,,,563,416.62,,,416.62,Other,150% of Medicare + 9.63% HCRA Surcharge,253.35,45,,253.35,percent of total billed charges,Critical Access Hospital RCC factor,180,,,180,Case Rate,Therapy Per Visit,162,,,162,Case Rate,Therapy Per Visit,430.7,76.5,,430.7,percent of total billed charges,All Other,399.73,69,,399.73,percent of total billed charges,All Other,388.47,65,,388.47,percent of total billed charges,All Other,278.69,,,278.69,Other,110% of Medicare,219,,,219,Case Rate,Therapy Per Visit,325,,,325,Other,186% of Medicaid,257,,,257,Case Rate,Therapy Per Visit,467.29,83,,467.29,percent of total billed charges,Therapy,41.31,,,41.31,Fee Schedule,,257,,,257,Case Rate,Therapy Per Visit,467.29,83,,467.29,percent of total billed charges,Therapy,368,,,368,Case Rate,Therapy Visit,394.1,70,,394.1,percent of total billed charges,All Other,259,,,259,Case Rate,Therapy Visit,220,,,220,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,138,,,138,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,131,,,131,Case Rate,Therapy Visit,174.92,,,174.92,Other,100% of Medicaid,174.92,,,174.92,Other,100% of Medicaid,174.92,,,174.92,Other,100% of Medicaid,174.92,,,174.92,Other,100% of Medicaid,393.57,,,393.57,Other,225% of Medicaid,267.62,,,267.62,Other,153% of Medicaid,393.57,,,393.57,Other,225% of Medicaid,244.89,,,244.89,Other,140% of Medicaid,393.57,,,393.57,Other,225% of Medicaid,454.79,,,454.79,Other,260% of Medicaid,566.73,,,566.73,Other,324% of Medicaid,376.07,,,376.07,Other,215% of Medicaid,376.07,,,376.07,Other,215% of Medicaid,218.65,,,218.65,Other,125% of Medicaid,41.31,566.73,
HOT OR COLD PACKS THERAPY,97010,CPT,GP,64197010,CDM,420,RC,,,both,,,96,71.04,,,71.04,Other,150% of Medicare + 9.63% HCRA Surcharge,43.2,45,,43.2,percent of total billed charges,Critical Access Hospital RCC factor,180,,,180,Case Rate,Therapy Per Visit,162,,,162,Case Rate,Therapy Per Visit,3.82,,,3.82,Fee Schedule,,3.82,,,3.82,Fee Schedule,,3.82,,,3.82,Fee Schedule,,47.52,,,47.52,Other,110% of Medicare,219,,,219,Case Rate,Therapy Per Visit,39,,,39,Other,186% of Medicaid,257,,,257,Case Rate,Therapy Per Visit,79.68,83,,79.68,percent of total billed charges,Therapy,52.8,83,,52.8,percent of total billed charges,All Other,257,,,257,Case Rate,Therapy Per Visit,79.68,83,,79.68,percent of total billed charges,Therapy,368,,,368,Case Rate,Therapy Visit,67.2,70,,67.2,percent of total billed charges,All Other,259,,,259,Case Rate,Therapy Visit,220,,,220,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,138,,,138,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,131,,,131,Case Rate,Therapy Visit,20.84,,,20.84,Other,100% of Medicaid,20.84,,,20.84,Other,100% of Medicaid,20.84,,,20.84,Other,100% of Medicaid,20.84,,,20.84,Other,100% of Medicaid,46.9,,,46.9,Other,225% of Medicaid,31.89,,,31.89,Other,153% of Medicaid,46.9,,,46.9,Other,225% of Medicaid,29.18,,,29.18,Other,140% of Medicaid,46.9,,,46.9,Other,225% of Medicaid,54.2,,,54.2,Other,260% of Medicaid,67.54,,,67.54,Other,324% of Medicaid,44.82,,,44.82,Other,215% of Medicaid,44.82,,,44.82,Other,215% of Medicaid,26.06,,,26.06,Other,125% of Medicaid,3.82,368,
ELECTRICAL STIMULATION 15,97032,CPT,GP,64197032,CDM,420,RC,,,both,,,118,87.32,,,87.32,Other,150% of Medicare + 9.63% HCRA Surcharge,53.1,45,,53.1,percent of total billed charges,Critical Access Hospital RCC factor,180,,,180,Case Rate,Therapy Per Visit,162,,,162,Case Rate,Therapy Per Visit,108.88,,,108.88,Fee Schedule,,97.93,,,97.93,Fee Schedule,,92.56,,,92.56,Fee Schedule,,58.41,,,58.41,Other,110% of Medicare,219,,,219,Case Rate,Therapy Per Visit,39,,,39,Other,186% of Medicaid,257,,,257,Case Rate,Therapy Per Visit,97.94,83,,97.94,percent of total billed charges,Therapy,31.77,,,31.77,Case Rate,,257,,,257,Case Rate,Therapy Per Visit,97.94,83,,97.94,percent of total billed charges,Therapy,368,,,368,Case Rate,Therapy Visit,82.6,70,,82.6,percent of total billed charges,All Other,259,,,259,Case Rate,Therapy Visit,220,,,220,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,138,,,138,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,131,,,131,Case Rate,Therapy Visit,20.84,,,20.84,Other,100% of Medicaid,20.84,,,20.84,Other,100% of Medicaid,20.84,,,20.84,Other,100% of Medicaid,20.84,,,20.84,Other,100% of Medicaid,46.9,,,46.9,Other,225% of Medicaid,31.89,,,31.89,Other,153% of Medicaid,46.9,,,46.9,Other,225% of Medicaid,29.18,,,29.18,Other,140% of Medicaid,46.9,,,46.9,Other,225% of Medicaid,54.2,,,54.2,Other,260% of Medicaid,67.54,,,67.54,Other,324% of Medicaid,44.82,,,44.82,Other,215% of Medicaid,44.82,,,44.82,Other,215% of Medicaid,26.06,,,26.06,Other,125% of Medicaid,20.84,368,
PT-IONTOPHORESIS,97033,CPT,GP,64197033,CDM,420,RC,,,both,,,182,134.68,,,134.68,Other,150% of Medicare + 9.63% HCRA Surcharge,81.9,45,,81.9,percent of total billed charges,Critical Access Hospital RCC factor,180,,,180,Case Rate,Therapy Per Visit,162,,,162,Case Rate,Therapy Per Visit,179.44,,,179.44,Fee Schedule,,161.4,,,161.4,Fee Schedule,,152.54,,,152.54,Fee Schedule,,90.09,,,90.09,Other,110% of Medicare,219,,,219,Case Rate,Therapy Per Visit,39,,,39,Other,186% of Medicaid,257,,,257,Case Rate,Therapy Per Visit,151.06,83,,151.06,percent of total billed charges,Therapy,43.16,,,43.16,Case Rate,,257,,,257,Case Rate,Therapy Per Visit,151.06,83,,151.06,percent of total billed charges,Therapy,368,,,368,Case Rate,Therapy Visit,127.4,70,,127.4,percent of total billed charges,All Other,259,,,259,Case Rate,Therapy Visit,220,,,220,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,138,,,138,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,131,,,131,Case Rate,Therapy Visit,20.84,,,20.84,Other,100% of Medicaid,20.84,,,20.84,Other,100% of Medicaid,20.84,,,20.84,Other,100% of Medicaid,20.84,,,20.84,Other,100% of Medicaid,46.9,,,46.9,Other,225% of Medicaid,31.89,,,31.89,Other,153% of Medicaid,46.9,,,46.9,Other,225% of Medicaid,29.18,,,29.18,Other,140% of Medicaid,46.9,,,46.9,Other,225% of Medicaid,54.2,,,54.2,Other,260% of Medicaid,67.54,,,67.54,Other,324% of Medicaid,44.82,,,44.82,Other,215% of Medicaid,44.82,,,44.82,Other,215% of Medicaid,26.06,,,26.06,Other,125% of Medicaid,20.84,368,
ULTRASOUND 15 MINUTES,97035,CPT,GP,64197035,CDM,420,RC,,,both,,,127,93.98,,,93.98,Other,150% of Medicare + 9.63% HCRA Surcharge,57.15,45,,57.15,percent of total billed charges,Critical Access Hospital RCC factor,180,,,180,Case Rate,Therapy Per Visit,162,,,162,Case Rate,Therapy Per Visit,71.62,,,71.62,Fee Schedule,,64.42,,,64.42,Fee Schedule,,60.88,,,60.88,Fee Schedule,,62.87,,,62.87,Other,110% of Medicare,219,,,219,Case Rate,Therapy Per Visit,39,,,39,Other,186% of Medicaid,257,,,257,Case Rate,Therapy Per Visit,105.41,83,,105.41,percent of total billed charges,Therapy,31.19,,,31.19,Case Rate,,257,,,257,Case Rate,Therapy Per Visit,105.41,83,,105.41,percent of total billed charges,Therapy,368,,,368,Case Rate,Therapy Visit,88.9,70,,88.9,percent of total billed charges,All Other,259,,,259,Case Rate,Therapy Visit,220,,,220,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,138,,,138,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,131,,,131,Case Rate,Therapy Visit,20.84,,,20.84,Other,100% of Medicaid,20.84,,,20.84,Other,100% of Medicaid,20.84,,,20.84,Other,100% of Medicaid,20.84,,,20.84,Other,100% of Medicaid,46.9,,,46.9,Other,225% of Medicaid,31.89,,,31.89,Other,153% of Medicaid,46.9,,,46.9,Other,225% of Medicaid,29.18,,,29.18,Other,140% of Medicaid,46.9,,,46.9,Other,225% of Medicaid,54.2,,,54.2,Other,260% of Medicaid,67.54,,,67.54,Other,324% of Medicaid,44.82,,,44.82,Other,215% of Medicaid,44.82,,,44.82,Other,215% of Medicaid,26.06,,,26.06,Other,125% of Medicaid,20.84,368,
THERAPEUTIC EXERCISE 15 MIN,97110,CPT,GP,64197110,CDM,420,RC,,,both,,,187,138.38,,,138.38,Other,150% of Medicare + 9.63% HCRA Surcharge,84.15,45,,84.15,percent of total billed charges,Critical Access Hospital RCC factor,180,,,180,Case Rate,Therapy Per Visit,162,,,162,Case Rate,Therapy Per Visit,180.81,,,180.81,Fee Schedule,,162.63,,,162.63,Fee Schedule,,153.71,,,153.71,Fee Schedule,,92.57,,,92.57,Other,110% of Medicare,219,,,219,Case Rate,Therapy Per Visit,109,,,109,Other,186% of Medicaid,257,,,257,Case Rate,Therapy Per Visit,155.21,83,,155.21,percent of total billed charges,Therapy,65.18,,,65.18,Case Rate,,257,,,257,Case Rate,Therapy Per Visit,155.21,83,,155.21,percent of total billed charges,Therapy,368,,,368,Case Rate,Therapy Visit,130.9,70,,130.9,percent of total billed charges,All Other,259,,,259,Case Rate,Therapy Visit,220,,,220,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,138,,,138,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,131,,,131,Case Rate,Therapy Visit,58.77,,,58.77,Other,100% of Medicaid,58.77,,,58.77,Other,100% of Medicaid,58.77,,,58.77,Other,100% of Medicaid,58.77,,,58.77,Other,100% of Medicaid,132.23,,,132.23,Other,225% of Medicaid,89.92,,,89.92,Other,153% of Medicaid,132.23,,,132.23,Other,225% of Medicaid,82.28,,,82.28,Other,140% of Medicaid,132.23,,,132.23,Other,225% of Medicaid,152.8,,,152.8,Other,260% of Medicaid,190.42,,,190.42,Other,324% of Medicaid,126.36,,,126.36,Other,215% of Medicaid,126.36,,,126.36,Other,215% of Medicaid,73.46,,,73.46,Other,125% of Medicaid,58.77,368,
NEUROMUSC REEDUCATION 15 MIN,97112,CPT,GP,64197112,CDM,420,RC,,,both,,,208,153.92,,,153.92,Other,150% of Medicare + 9.63% HCRA Surcharge,93.6,45,,93.6,percent of total billed charges,Critical Access Hospital RCC factor,180,,,180,Case Rate,Therapy Per Visit,162,,,162,Case Rate,Therapy Per Visit,189.98,,,189.98,Fee Schedule,,170.88,,,170.88,Fee Schedule,,161.5,,,161.5,Fee Schedule,,102.96,,,102.96,Other,110% of Medicare,219,,,219,Case Rate,Therapy Per Visit,109,,,109,Other,186% of Medicaid,257,,,257,Case Rate,Therapy Per Visit,172.64,83,,172.64,percent of total billed charges,Therapy,74.87,,,74.87,Case Rate,,257,,,257,Case Rate,Therapy Per Visit,172.64,83,,172.64,percent of total billed charges,Therapy,368,,,368,Case Rate,Therapy Visit,145.6,70,,145.6,percent of total billed charges,All Other,259,,,259,Case Rate,Therapy Visit,220,,,220,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,138,,,138,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,131,,,131,Case Rate,Therapy Visit,58.77,,,58.77,Other,100% of Medicaid,58.77,,,58.77,Other,100% of Medicaid,58.77,,,58.77,Other,100% of Medicaid,58.77,,,58.77,Other,100% of Medicaid,132.23,,,132.23,Other,225% of Medicaid,89.92,,,89.92,Other,153% of Medicaid,132.23,,,132.23,Other,225% of Medicaid,82.28,,,82.28,Other,140% of Medicaid,132.23,,,132.23,Other,225% of Medicaid,152.8,,,152.8,Other,260% of Medicaid,190.42,,,190.42,Other,324% of Medicaid,126.36,,,126.36,Other,215% of Medicaid,126.36,,,126.36,Other,215% of Medicaid,73.46,,,73.46,Other,125% of Medicaid,58.77,368,
MASSAGE THERAPY,97124,CPT,GP,64197124,CDM,420,RC,,,both,,,145,107.3,,,107.3,Other,150% of Medicare + 9.63% HCRA Surcharge,65.25,45,,65.25,percent of total billed charges,Critical Access Hospital RCC factor,180,,,180,Case Rate,Therapy Per Visit,162,,,162,Case Rate,Therapy Per Visit,148.3,,,148.3,Fee Schedule,,133.38,,,133.38,Fee Schedule,,126.07,,,126.07,Fee Schedule,,71.78,,,71.78,Other,110% of Medicare,219,,,219,Case Rate,Therapy Per Visit,39,,,39,Other,186% of Medicaid,257,,,257,Case Rate,Therapy Per Visit,120.35,83,,120.35,percent of total billed charges,Therapy,67.87,,,67.87,Case Rate,,257,,,257,Case Rate,Therapy Per Visit,120.35,83,,120.35,percent of total billed charges,Therapy,368,,,368,Case Rate,Therapy Visit,101.5,70,,101.5,percent of total billed charges,All Other,259,,,259,Case Rate,Therapy Visit,220,,,220,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,138,,,138,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,131,,,131,Case Rate,Therapy Visit,20.84,,,20.84,Other,100% of Medicaid,20.84,,,20.84,Other,100% of Medicaid,20.84,,,20.84,Other,100% of Medicaid,20.84,,,20.84,Other,100% of Medicaid,46.9,,,46.9,Other,225% of Medicaid,31.89,,,31.89,Other,153% of Medicaid,46.9,,,46.9,Other,225% of Medicaid,29.18,,,29.18,Other,140% of Medicaid,46.9,,,46.9,Other,225% of Medicaid,54.2,,,54.2,Other,260% of Medicaid,67.54,,,67.54,Other,324% of Medicaid,44.82,,,44.82,Other,215% of Medicaid,44.82,,,44.82,Other,215% of Medicaid,26.06,,,26.06,Other,125% of Medicaid,20.84,368,
MANUAL THERAPY,97140,CPT,GP,64197140,CDM,420,RC,,,both,,,198,146.52,,,146.52,Other,150% of Medicare + 9.63% HCRA Surcharge,89.1,45,,89.1,percent of total billed charges,Critical Access Hospital RCC factor,180,,,180,Case Rate,Therapy Per Visit,162,,,162,Case Rate,Therapy Per Visit,170.17,,,170.17,Fee Schedule,,153.05,,,153.05,Fee Schedule,,144.66,,,144.66,Fee Schedule,,98.01,,,98.01,Other,110% of Medicare,219,,,219,Case Rate,Therapy Per Visit,109,,,109,Other,186% of Medicaid,257,,,257,Case Rate,Therapy Per Visit,164.34,83,,164.34,percent of total billed charges,Therapy,59.93,,,59.93,Case Rate,,257,,,257,Case Rate,Therapy Per Visit,164.34,83,,164.34,percent of total billed charges,Therapy,368,,,368,Case Rate,Therapy Visit,138.6,70,,138.6,percent of total billed charges,All Other,259,,,259,Case Rate,Therapy Visit,220,,,220,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,138,,,138,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,131,,,131,Case Rate,Therapy Visit,58.77,,,58.77,Other,100% of Medicaid,58.77,,,58.77,Other,100% of Medicaid,58.77,,,58.77,Other,100% of Medicaid,58.77,,,58.77,Other,100% of Medicaid,132.23,,,132.23,Other,225% of Medicaid,89.92,,,89.92,Other,153% of Medicaid,132.23,,,132.23,Other,225% of Medicaid,82.28,,,82.28,Other,140% of Medicaid,132.23,,,132.23,Other,225% of Medicaid,152.8,,,152.8,Other,260% of Medicaid,190.42,,,190.42,Other,324% of Medicaid,126.36,,,126.36,Other,215% of Medicaid,126.36,,,126.36,Other,215% of Medicaid,73.46,,,73.46,Other,125% of Medicaid,58.77,368,
THERAPEUTIC REHAB GROUP,97150,CPT,GP,64197150,CDM,420,RC,,,both,,,96,71.04,,,71.04,Other,150% of Medicare + 9.63% HCRA Surcharge,43.2,45,,43.2,percent of total billed charges,Critical Access Hospital RCC factor,180,,,180,Case Rate,Therapy Per Visit,162,,,162,Case Rate,Therapy Per Visit,117.2,,,117.2,Fee Schedule,,105.42,,,105.42,Fee Schedule,,99.64,,,99.64,Fee Schedule,,47.52,,,47.52,Other,110% of Medicare,219,,,219,Case Rate,Therapy Per Visit,109,,,109,Other,186% of Medicaid,257,,,257,Case Rate,Therapy Per Visit,79.68,83,,79.68,percent of total billed charges,Therapy,39.98,,,39.98,Case Rate,,257,,,257,Case Rate,Therapy Per Visit,79.68,83,,79.68,percent of total billed charges,Therapy,368,,,368,Case Rate,Therapy Visit,67.2,70,,67.2,percent of total billed charges,All Other,259,,,259,Case Rate,Therapy Visit,220,,,220,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,138,,,138,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,131,,,131,Case Rate,Therapy Visit,58.77,,,58.77,Other,100% of Medicaid,58.77,,,58.77,Other,100% of Medicaid,58.77,,,58.77,Other,100% of Medicaid,58.77,,,58.77,Other,100% of Medicaid,132.23,,,132.23,Other,225% of Medicaid,89.92,,,89.92,Other,153% of Medicaid,132.23,,,132.23,Other,225% of Medicaid,82.28,,,82.28,Other,140% of Medicaid,132.23,,,132.23,Other,225% of Medicaid,152.8,,,152.8,Other,260% of Medicaid,190.42,,,190.42,Other,324% of Medicaid,126.36,,,126.36,Other,215% of Medicaid,126.36,,,126.36,Other,215% of Medicaid,73.46,,,73.46,Other,125% of Medicaid,39.98,368,
THERAPEUTIC ACTIVITY 15 MIN,97530,CPT,GP,64197530,CDM,420,RC,,,both,,,209,154.66,,,154.66,Other,150% of Medicare + 9.63% HCRA Surcharge,94.05,45,,94.05,percent of total billed charges,Critical Access Hospital RCC factor,180,,,180,Case Rate,Therapy Per Visit,162,,,162,Case Rate,Therapy Per Visit,199.52,,,199.52,Fee Schedule,,179.46,,,179.46,Fee Schedule,,169.61,,,169.61,Fee Schedule,,103.46,,,103.46,Other,110% of Medicare,219,,,219,Case Rate,Therapy Per Visit,109,,,109,Other,186% of Medicaid,257,,,257,Case Rate,Therapy Per Visit,173.47,83,,173.47,percent of total billed charges,Therapy,81.96,,,81.96,Case Rate,,257,,,257,Case Rate,Therapy Per Visit,173.47,83,,173.47,percent of total billed charges,Therapy,368,,,368,Case Rate,Therapy Visit,146.3,70,,146.3,percent of total billed charges,All Other,259,,,259,Case Rate,Therapy Visit,220,,,220,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,138,,,138,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,131,,,131,Case Rate,Therapy Visit,58.77,,,58.77,Other,100% of Medicaid,58.77,,,58.77,Other,100% of Medicaid,58.77,,,58.77,Other,100% of Medicaid,58.77,,,58.77,Other,100% of Medicaid,132.23,,,132.23,Other,225% of Medicaid,89.92,,,89.92,Other,153% of Medicaid,132.23,,,132.23,Other,225% of Medicaid,82.28,,,82.28,Other,140% of Medicaid,132.23,,,132.23,Other,225% of Medicaid,152.8,,,152.8,Other,260% of Medicaid,190.42,,,190.42,Other,324% of Medicaid,126.36,,,126.36,Other,215% of Medicaid,126.36,,,126.36,Other,215% of Medicaid,73.46,,,73.46,Other,125% of Medicaid,58.77,368,
SENSORY INTEGRATE TECH 15MIN,97533,CPT,GP,64197533,CDM,420,RC,,,both,,,209,154.66,,,154.66,Other,150% of Medicare + 9.63% HCRA Surcharge,94.05,45,,94.05,percent of total billed charges,Critical Access Hospital RCC factor,180,,,180,Case Rate,Therapy Per Visit,162,,,162,Case Rate,Therapy Per Visit,167.48,,,167.48,Fee Schedule,,150.64,,,150.64,Fee Schedule,,142.37,,,142.37,Fee Schedule,,103.46,,,103.46,Other,110% of Medicare,219,,,219,Case Rate,Therapy Per Visit,109,,,109,Other,186% of Medicaid,257,,,257,Case Rate,Therapy Per Visit,173.47,83,,173.47,percent of total billed charges,Therapy,140.34,,,140.34,Case Rate,,257,,,257,Case Rate,Therapy Per Visit,173.47,83,,173.47,percent of total billed charges,Therapy,368,,,368,Case Rate,Therapy Visit,146.3,70,,146.3,percent of total billed charges,All Other,259,,,259,Case Rate,Therapy Visit,220,,,220,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,138,,,138,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,131,,,131,Case Rate,Therapy Visit,58.77,,,58.77,Other,100% of Medicaid,58.77,,,58.77,Other,100% of Medicaid,58.77,,,58.77,Other,100% of Medicaid,58.77,,,58.77,Other,100% of Medicaid,132.23,,,132.23,Other,225% of Medicaid,89.92,,,89.92,Other,153% of Medicaid,132.23,,,132.23,Other,225% of Medicaid,82.28,,,82.28,Other,140% of Medicaid,132.23,,,132.23,Other,225% of Medicaid,152.8,,,152.8,Other,260% of Medicaid,190.42,,,190.42,Other,324% of Medicaid,126.36,,,126.36,Other,215% of Medicaid,126.36,,,126.36,Other,215% of Medicaid,73.46,,,73.46,Other,125% of Medicaid,58.77,368,
SELF CARE MNGMENT TRAINING,97535,CPT,GP,64197535,CDM,420,RC,,,both,,,193,142.82,,,142.82,Other,150% of Medicare + 9.63% HCRA Surcharge,86.85,45,,86.85,percent of total billed charges,Critical Access Hospital RCC factor,180,,,180,Case Rate,Therapy Per Visit,162,,,162,Case Rate,Therapy Per Visit,199.1,,,199.1,Fee Schedule,,179.08,,,179.08,Fee Schedule,,169.25,,,169.25,Fee Schedule,,95.54,,,95.54,Other,110% of Medicare,219,,,219,Case Rate,Therapy Per Visit,39,,,39,Other,186% of Medicaid,257,,,257,Case Rate,Therapy Per Visit,160.19,83,,160.19,percent of total billed charges,Therapy,72.79,,,72.79,Case Rate,,257,,,257,Case Rate,Therapy Per Visit,160.19,83,,160.19,percent of total billed charges,Therapy,368,,,368,Case Rate,Therapy Visit,135.1,70,,135.1,percent of total billed charges,All Other,259,,,259,Case Rate,Therapy Visit,220,,,220,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,138,,,138,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,131,,,131,Case Rate,Therapy Visit,20.84,,,20.84,Other,100% of Medicaid,20.84,,,20.84,Other,100% of Medicaid,20.84,,,20.84,Other,100% of Medicaid,20.84,,,20.84,Other,100% of Medicaid,46.9,,,46.9,Other,225% of Medicaid,31.89,,,31.89,Other,153% of Medicaid,46.9,,,46.9,Other,225% of Medicaid,29.18,,,29.18,Other,140% of Medicaid,46.9,,,46.9,Other,225% of Medicaid,54.2,,,54.2,Other,260% of Medicaid,67.54,,,67.54,Other,324% of Medicaid,44.82,,,44.82,Other,215% of Medicaid,44.82,,,44.82,Other,215% of Medicaid,26.06,,,26.06,Other,125% of Medicaid,20.84,368,
COMMUNITY/WORK REINTEGRATION EA 15 MIN,97537,CPT,GP,64197537,CDM,420,RC,,,both,,,141,104.34,,,104.34,Other,150% of Medicare + 9.63% HCRA Surcharge,63.45,45,,63.45,percent of total billed charges,Critical Access Hospital RCC factor,180,,,180,Case Rate,Therapy Per Visit,162,,,162,Case Rate,Therapy Per Visit,171.64,,,171.64,Fee Schedule,,154.38,,,154.38,Fee Schedule,,145.91,,,145.91,Fee Schedule,,69.8,,,69.8,Other,110% of Medicare,219,,,219,Case Rate,Therapy Per Visit,109,,,109,Other,186% of Medicaid,257,,,257,Case Rate,Therapy Per Visit,117.03,83,,117.03,percent of total billed charges,Therapy,70.37,,,70.37,Case Rate,,257,,,257,Case Rate,Therapy Per Visit,117.03,83,,117.03,percent of total billed charges,Therapy,368,,,368,Case Rate,Therapy Visit,98.7,70,,98.7,percent of total billed charges,All Other,259,,,259,Case Rate,Therapy Visit,220,,,220,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,138,,,138,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,131,,,131,Case Rate,Therapy Visit,58.77,,,58.77,Other,100% of Medicaid,58.77,,,58.77,Other,100% of Medicaid,58.77,,,58.77,Other,100% of Medicaid,58.77,,,58.77,Other,100% of Medicaid,132.23,,,132.23,Other,225% of Medicaid,89.92,,,89.92,Other,153% of Medicaid,132.23,,,132.23,Other,225% of Medicaid,82.28,,,82.28,Other,140% of Medicaid,132.23,,,132.23,Other,225% of Medicaid,152.8,,,152.8,Other,260% of Medicaid,190.42,,,190.42,Other,324% of Medicaid,126.36,,,126.36,Other,215% of Medicaid,126.36,,,126.36,Other,215% of Medicaid,73.46,,,73.46,Other,125% of Medicaid,58.77,368,
WHEELCHAIR MNGMENT TRAINING,97542,CPT,GP,64197542,CDM,420,RC,,,both,,,190,140.6,,,140.6,Other,150% of Medicare + 9.63% HCRA Surcharge,85.5,45,,85.5,percent of total billed charges,Critical Access Hospital RCC factor,180,,,180,Case Rate,Therapy Per Visit,162,,,162,Case Rate,Therapy Per Visit,173.96,,,173.96,Fee Schedule,,156.47,,,156.47,Fee Schedule,,147.88,,,147.88,Fee Schedule,,94.05,,,94.05,Other,110% of Medicare,219,,,219,Case Rate,Therapy Per Visit,109,,,109,Other,186% of Medicaid,257,,,257,Case Rate,Therapy Per Visit,157.7,83,,157.7,percent of total billed charges,Therapy,70.37,,,70.37,Case Rate,,257,,,257,Case Rate,Therapy Per Visit,157.7,83,,157.7,percent of total billed charges,Therapy,368,,,368,Case Rate,Therapy Visit,133,70,,133,percent of total billed charges,All Other,259,,,259,Case Rate,Therapy Visit,220,,,220,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,138,,,138,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,131,,,131,Case Rate,Therapy Visit,58.77,,,58.77,Other,100% of Medicaid,58.77,,,58.77,Other,100% of Medicaid,58.77,,,58.77,Other,100% of Medicaid,58.77,,,58.77,Other,100% of Medicaid,132.23,,,132.23,Other,225% of Medicaid,89.92,,,89.92,Other,153% of Medicaid,132.23,,,132.23,Other,225% of Medicaid,82.28,,,82.28,Other,140% of Medicaid,132.23,,,132.23,Other,225% of Medicaid,152.8,,,152.8,Other,260% of Medicaid,190.42,,,190.42,Other,324% of Medicaid,126.36,,,126.36,Other,215% of Medicaid,126.36,,,126.36,Other,215% of Medicaid,73.46,,,73.46,Other,125% of Medicaid,58.77,368,
SLCTV WND DEBRIDEM 20 CM OR <,97597,CPT,GP,64197597,CDM,420,RC,,,both,,,573,424.02,,,424.02,Other,150% of Medicare + 9.63% HCRA Surcharge,257.85,45,,257.85,percent of total billed charges,Critical Access Hospital RCC factor,180,,,180,Case Rate,Therapy Per Visit,162,,,162,Case Rate,Therapy Per Visit,438.35,76.5,,438.35,percent of total billed charges,All Other,406.83,69,,406.83,percent of total billed charges,All Other,395.37,65,,395.37,percent of total billed charges,All Other,283.64,,,283.64,Other,110% of Medicare,219,,,219,Case Rate,Therapy Per Visit,703,,,703,Other,186% of Medicaid,257,,,257,Case Rate,Therapy Per Visit,475.59,83,,475.59,percent of total billed charges,Therapy,475.59,,,475.59,Other,Non Covered Service,257,,,257,Case Rate,Therapy Per Visit,475.59,83,,475.59,percent of total billed charges,Therapy,368,,,368,Case Rate,Therapy Visit,401.1,70,,401.1,percent of total billed charges,All Other,259,,,259,Case Rate,Therapy Visit,220,,,220,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,138,,,138,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,131,,,131,Case Rate,Therapy Visit,377.82,,,377.82,Other,100% of Medicaid,377.82,,,377.82,Other,100% of Medicaid,377.82,,,377.82,Other,100% of Medicaid,377.82,,,377.82,Other,100% of Medicaid,850.1,,,850.1,Other,225% of Medicaid,578.07,,,578.07,Other,153% of Medicaid,850.1,,,850.1,Other,225% of Medicaid,528.95,,,528.95,Other,140% of Medicaid,850.1,,,850.1,Other,225% of Medicaid,982.34,,,982.34,Other,260% of Medicaid,1224.15,,,1224.15,Other,324% of Medicaid,812.32,,,812.32,Other,215% of Medicaid,812.32,,,812.32,Other,215% of Medicaid,472.28,,,472.28,Other,125% of Medicaid,131,1224.15,
TH-GAIT TRAINING THERAPY,97116,CPT,GPGT,64297116,CDM,420,RC,,,both,,,209,154.66,,,154.66,Other,150% of Medicare + 9.63% HCRA Surcharge,94.05,45,,94.05,percent of total billed charges,Critical Access Hospital RCC factor,180,,,180,Case Rate,Therapy Per Visit,162,,,162,Case Rate,Therapy Per Visit,160,,,160,Fee Schedule,,143.91,,,143.91,Fee Schedule,,136.01,,,136.01,Fee Schedule,,103.46,,,103.46,Other,110% of Medicare,219,,,219,Case Rate,Therapy Per Visit,39,,,39,Other,186% of Medicaid,257,,,257,Case Rate,Therapy Per Visit,173.47,83,,173.47,percent of total billed charges,Therapy,65.18,,,65.18,Case Rate,,257,,,257,Case Rate,Therapy Per Visit,173.47,83,,173.47,percent of total billed charges,Therapy,368,,,368,Case Rate,Therapy Visit,146.3,70,,146.3,percent of total billed charges,All Other,259,,,259,Case Rate,Therapy Visit,220,,,220,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,138,,,138,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,131,,,131,Case Rate,Therapy Visit,20.84,,,20.84,Other,100% of Medicaid,20.84,,,20.84,Other,100% of Medicaid,20.84,,,20.84,Other,100% of Medicaid,20.84,,,20.84,Other,100% of Medicaid,46.9,,,46.9,Other,225% of Medicaid,31.89,,,31.89,Other,153% of Medicaid,46.9,,,46.9,Other,225% of Medicaid,29.18,,,29.18,Other,140% of Medicaid,46.9,,,46.9,Other,225% of Medicaid,54.2,,,54.2,Other,260% of Medicaid,67.54,,,67.54,Other,324% of Medicaid,44.82,,,44.82,Other,215% of Medicaid,44.82,,,44.82,Other,215% of Medicaid,26.06,,,26.06,Other,125% of Medicaid,20.84,368,
TH-THERAPEUTIC EXERCISE 15 MIN,97110,CPT,GPGT,64397110,CDM,420,RC,,,both,,,187,138.38,,,138.38,Other,150% of Medicare + 9.63% HCRA Surcharge,84.15,45,,84.15,percent of total billed charges,Critical Access Hospital RCC factor,180,,,180,Case Rate,Therapy Per Visit,162,,,162,Case Rate,Therapy Per Visit,180.81,,,180.81,Fee Schedule,,162.63,,,162.63,Fee Schedule,,153.71,,,153.71,Fee Schedule,,92.57,,,92.57,Other,110% of Medicare,219,,,219,Case Rate,Therapy Per Visit,109,,,109,Other,186% of Medicaid,257,,,257,Case Rate,Therapy Per Visit,155.21,83,,155.21,percent of total billed charges,Therapy,65.18,,,65.18,Case Rate,,257,,,257,Case Rate,Therapy Per Visit,155.21,83,,155.21,percent of total billed charges,Therapy,368,,,368,Case Rate,Therapy Visit,130.9,70,,130.9,percent of total billed charges,All Other,259,,,259,Case Rate,Therapy Visit,220,,,220,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,138,,,138,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,131,,,131,Case Rate,Therapy Visit,58.77,,,58.77,Other,100% of Medicaid,58.77,,,58.77,Other,100% of Medicaid,58.77,,,58.77,Other,100% of Medicaid,58.77,,,58.77,Other,100% of Medicaid,132.23,,,132.23,Other,225% of Medicaid,89.92,,,89.92,Other,153% of Medicaid,132.23,,,132.23,Other,225% of Medicaid,82.28,,,82.28,Other,140% of Medicaid,132.23,,,132.23,Other,225% of Medicaid,152.8,,,152.8,Other,260% of Medicaid,190.42,,,190.42,Other,324% of Medicaid,126.36,,,126.36,Other,215% of Medicaid,126.36,,,126.36,Other,215% of Medicaid,73.46,,,73.46,Other,125% of Medicaid,58.77,368,
TH-NEUROMUSC REEDUCATION 15 MIN,97112,CPT,GPGT,64397112,CDM,420,RC,,,both,,,208,153.92,,,153.92,Other,150% of Medicare + 9.63% HCRA Surcharge,93.6,45,,93.6,percent of total billed charges,Critical Access Hospital RCC factor,180,,,180,Case Rate,Therapy Per Visit,162,,,162,Case Rate,Therapy Per Visit,189.98,,,189.98,Fee Schedule,,170.88,,,170.88,Fee Schedule,,161.5,,,161.5,Fee Schedule,,102.96,,,102.96,Other,110% of Medicare,219,,,219,Case Rate,Therapy Per Visit,109,,,109,Other,186% of Medicaid,257,,,257,Case Rate,Therapy Per Visit,172.64,83,,172.64,percent of total billed charges,Therapy,74.87,,,74.87,Case Rate,,257,,,257,Case Rate,Therapy Per Visit,172.64,83,,172.64,percent of total billed charges,Therapy,368,,,368,Case Rate,Therapy Visit,145.6,70,,145.6,percent of total billed charges,All Other,259,,,259,Case Rate,Therapy Visit,220,,,220,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,138,,,138,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,131,,,131,Case Rate,Therapy Visit,58.77,,,58.77,Other,100% of Medicaid,58.77,,,58.77,Other,100% of Medicaid,58.77,,,58.77,Other,100% of Medicaid,58.77,,,58.77,Other,100% of Medicaid,132.23,,,132.23,Other,225% of Medicaid,89.92,,,89.92,Other,153% of Medicaid,132.23,,,132.23,Other,225% of Medicaid,82.28,,,82.28,Other,140% of Medicaid,132.23,,,132.23,Other,225% of Medicaid,152.8,,,152.8,Other,260% of Medicaid,190.42,,,190.42,Other,324% of Medicaid,126.36,,,126.36,Other,215% of Medicaid,126.36,,,126.36,Other,215% of Medicaid,73.46,,,73.46,Other,125% of Medicaid,58.77,368,
TH-THERAPEUTIC ACTIVITY 15 MIN,97530,CPT,GPGT,64397530,CDM,420,RC,,,both,,,209,154.66,,,154.66,Other,150% of Medicare + 9.63% HCRA Surcharge,94.05,45,,94.05,percent of total billed charges,Critical Access Hospital RCC factor,180,,,180,Case Rate,Therapy Per Visit,162,,,162,Case Rate,Therapy Per Visit,199.52,,,199.52,Fee Schedule,,179.46,,,179.46,Fee Schedule,,169.61,,,169.61,Fee Schedule,,103.46,,,103.46,Other,110% of Medicare,219,,,219,Case Rate,Therapy Per Visit,109,,,109,Other,186% of Medicaid,257,,,257,Case Rate,Therapy Per Visit,173.47,83,,173.47,percent of total billed charges,Therapy,81.96,,,81.96,Case Rate,,257,,,257,Case Rate,Therapy Per Visit,173.47,83,,173.47,percent of total billed charges,Therapy,368,,,368,Case Rate,Therapy Visit,146.3,70,,146.3,percent of total billed charges,All Other,259,,,259,Case Rate,Therapy Visit,220,,,220,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,138,,,138,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,131,,,131,Case Rate,Therapy Visit,58.77,,,58.77,Other,100% of Medicaid,58.77,,,58.77,Other,100% of Medicaid,58.77,,,58.77,Other,100% of Medicaid,58.77,,,58.77,Other,100% of Medicaid,132.23,,,132.23,Other,225% of Medicaid,89.92,,,89.92,Other,153% of Medicaid,132.23,,,132.23,Other,225% of Medicaid,82.28,,,82.28,Other,140% of Medicaid,132.23,,,132.23,Other,225% of Medicaid,152.8,,,152.8,Other,260% of Medicaid,190.42,,,190.42,Other,324% of Medicaid,126.36,,,126.36,Other,215% of Medicaid,126.36,,,126.36,Other,215% of Medicaid,73.46,,,73.46,Other,125% of Medicaid,58.77,368,
TH-SELF CARE MNGMENT TRAINING,97535,CPT,GPGT,64397535,CDM,420,RC,,,both,,,193,142.82,,,142.82,Other,150% of Medicare + 9.63% HCRA Surcharge,86.85,45,,86.85,percent of total billed charges,Critical Access Hospital RCC factor,180,,,180,Case Rate,Therapy Per Visit,162,,,162,Case Rate,Therapy Per Visit,199.1,,,199.1,Fee Schedule,,179.08,,,179.08,Fee Schedule,,169.25,,,169.25,Fee Schedule,,95.54,,,95.54,Other,110% of Medicare,219,,,219,Case Rate,Therapy Per Visit,39,,,39,Other,186% of Medicaid,257,,,257,Case Rate,Therapy Per Visit,160.19,83,,160.19,percent of total billed charges,Therapy,72.79,,,72.79,Case Rate,,257,,,257,Case Rate,Therapy Per Visit,160.19,83,,160.19,percent of total billed charges,Therapy,368,,,368,Case Rate,Therapy Visit,135.1,70,,135.1,percent of total billed charges,All Other,259,,,259,Case Rate,Therapy Visit,220,,,220,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,138,,,138,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,131,,,131,Case Rate,Therapy Visit,20.84,,,20.84,Other,100% of Medicaid,20.84,,,20.84,Other,100% of Medicaid,20.84,,,20.84,Other,100% of Medicaid,20.84,,,20.84,Other,100% of Medicaid,46.9,,,46.9,Other,225% of Medicaid,31.89,,,31.89,Other,153% of Medicaid,46.9,,,46.9,Other,225% of Medicaid,29.18,,,29.18,Other,140% of Medicaid,46.9,,,46.9,Other,225% of Medicaid,54.2,,,54.2,Other,260% of Medicaid,67.54,,,67.54,Other,324% of Medicaid,44.82,,,44.82,Other,215% of Medicaid,44.82,,,44.82,Other,215% of Medicaid,26.06,,,26.06,Other,125% of Medicaid,20.84,368,
PT EVAL LOW COMPLEX 20 MIN,97161,CPT,GP,62097161,CDM,424,RC,,,both,,,468,346.32,,,346.32,Other,150% of Medicare + 9.63% HCRA Surcharge,210.6,45,,210.6,percent of total billed charges,Critical Access Hospital RCC factor,180,,,180,Case Rate,Therapy Per Visit,162,,,162,Case Rate,Therapy Per Visit,76.19,,,76.19,Fee Schedule,,76.19,,,76.19,Fee Schedule,,76.19,,,76.19,Fee Schedule,,231.66,,,231.66,Other,110% of Medicare,219,,,219,Case Rate,Therapy Per Visit,192,,,192,Other,186% of Medicaid,257,,,257,Case Rate,Therapy Per Visit,388.44,83,,388.44,percent of total billed charges,Therapy,223.02,,,223.02,Case Rate,,257,,,257,Case Rate,Therapy Per Visit,388.44,83,,388.44,percent of total billed charges,Therapy,368,,,368,Case Rate,Therapy Visit,327.6,70,,327.6,percent of total billed charges,All Other,259,,,259,Case Rate,Therapy Visit,220,,,220,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,138,,,138,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,131,,,131,Case Rate,Therapy Visit,103.2,,,103.2,Other,100% of Medicaid,103.2,,,103.2,Other,100% of Medicaid,103.2,,,103.2,Other,100% of Medicaid,103.2,,,103.2,Other,100% of Medicaid,232.2,,,232.2,Other,225% of Medicaid,157.89,,,157.89,Other,153% of Medicaid,232.2,,,232.2,Other,225% of Medicaid,144.48,,,144.48,Other,140% of Medicaid,232.2,,,232.2,Other,225% of Medicaid,268.32,,,268.32,Other,260% of Medicaid,334.36,,,334.36,Other,324% of Medicaid,221.88,,,221.88,Other,215% of Medicaid,221.88,,,221.88,Other,215% of Medicaid,129,,,129,Other,125% of Medicaid,76.19,388.44,
PT EVAL MOD COMPLEX 30 MIN,97162,CPT,GP,62097162,CDM,424,RC,,,both,,,468,346.32,,,346.32,Other,150% of Medicare + 9.63% HCRA Surcharge,210.6,45,,210.6,percent of total billed charges,Critical Access Hospital RCC factor,180,,,180,Case Rate,Therapy Per Visit,162,,,162,Case Rate,Therapy Per Visit,76.19,,,76.19,Fee Schedule,,76.19,,,76.19,Fee Schedule,,76.19,,,76.19,Fee Schedule,,231.66,,,231.66,Other,110% of Medicare,219,,,219,Case Rate,Therapy Per Visit,192,,,192,Other,186% of Medicaid,257,,,257,Case Rate,Therapy Per Visit,388.44,83,,388.44,percent of total billed charges,Therapy,223.02,,,223.02,Case Rate,,257,,,257,Case Rate,Therapy Per Visit,388.44,83,,388.44,percent of total billed charges,Therapy,368,,,368,Case Rate,Therapy Visit,327.6,70,,327.6,percent of total billed charges,All Other,259,,,259,Case Rate,Therapy Visit,220,,,220,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,138,,,138,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,131,,,131,Case Rate,Therapy Visit,103.2,,,103.2,Other,100% of Medicaid,103.2,,,103.2,Other,100% of Medicaid,103.2,,,103.2,Other,100% of Medicaid,103.2,,,103.2,Other,100% of Medicaid,232.2,,,232.2,Other,225% of Medicaid,157.89,,,157.89,Other,153% of Medicaid,232.2,,,232.2,Other,225% of Medicaid,144.48,,,144.48,Other,140% of Medicaid,232.2,,,232.2,Other,225% of Medicaid,268.32,,,268.32,Other,260% of Medicaid,334.36,,,334.36,Other,324% of Medicaid,221.88,,,221.88,Other,215% of Medicaid,221.88,,,221.88,Other,215% of Medicaid,129,,,129,Other,125% of Medicaid,76.19,388.44,
PT EVAL HIGH COMPLEX 45 MIN,97163,CPT,GP,62097163,CDM,424,RC,,,both,,,468,346.32,,,346.32,Other,150% of Medicare + 9.63% HCRA Surcharge,210.6,45,,210.6,percent of total billed charges,Critical Access Hospital RCC factor,180,,,180,Case Rate,Therapy Per Visit,162,,,162,Case Rate,Therapy Per Visit,76.19,,,76.19,Fee Schedule,,76.19,,,76.19,Fee Schedule,,76.19,,,76.19,Fee Schedule,,231.66,,,231.66,Other,110% of Medicare,219,,,219,Case Rate,Therapy Per Visit,192,,,192,Other,186% of Medicaid,257,,,257,Case Rate,Therapy Per Visit,388.44,83,,388.44,percent of total billed charges,Therapy,223.02,,,223.02,Case Rate,,257,,,257,Case Rate,Therapy Per Visit,388.44,83,,388.44,percent of total billed charges,Therapy,368,,,368,Case Rate,Therapy Visit,327.6,70,,327.6,percent of total billed charges,All Other,259,,,259,Case Rate,Therapy Visit,220,,,220,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,138,,,138,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,131,,,131,Case Rate,Therapy Visit,103.2,,,103.2,Other,100% of Medicaid,103.2,,,103.2,Other,100% of Medicaid,103.2,,,103.2,Other,100% of Medicaid,103.2,,,103.2,Other,100% of Medicaid,232.2,,,232.2,Other,225% of Medicaid,157.89,,,157.89,Other,153% of Medicaid,232.2,,,232.2,Other,225% of Medicaid,144.48,,,144.48,Other,140% of Medicaid,232.2,,,232.2,Other,225% of Medicaid,268.32,,,268.32,Other,260% of Medicaid,334.36,,,334.36,Other,324% of Medicaid,221.88,,,221.88,Other,215% of Medicaid,221.88,,,221.88,Other,215% of Medicaid,129,,,129,Other,125% of Medicaid,76.19,388.44,
PT RE-EVAL EST PLAN CARE,97164,CPT,GP,62097164,CDM,424,RC,,,both,,,266,196.84,,,196.84,Other,150% of Medicare + 9.63% HCRA Surcharge,119.7,45,,119.7,percent of total billed charges,Critical Access Hospital RCC factor,180,,,180,Case Rate,Therapy Per Visit,162,,,162,Case Rate,Therapy Per Visit,52.16,,,52.16,Fee Schedule,,52.16,,,52.16,Fee Schedule,,52.16,,,52.16,Fee Schedule,,131.67,,,131.67,Other,110% of Medicare,219,,,219,Case Rate,Therapy Per Visit,192,,,192,Other,186% of Medicaid,257,,,257,Case Rate,Therapy Per Visit,220.78,83,,220.78,percent of total billed charges,Therapy,155.32,,,155.32,Case Rate,,257,,,257,Case Rate,Therapy Per Visit,220.78,83,,220.78,percent of total billed charges,Therapy,368,,,368,Case Rate,Therapy Visit,186.2,70,,186.2,percent of total billed charges,All Other,259,,,259,Case Rate,Therapy Visit,220,,,220,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,138,,,138,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,131,,,131,Case Rate,Therapy Visit,103.2,,,103.2,Other,100% of Medicaid,103.2,,,103.2,Other,100% of Medicaid,103.2,,,103.2,Other,100% of Medicaid,103.2,,,103.2,Other,100% of Medicaid,232.2,,,232.2,Other,225% of Medicaid,157.89,,,157.89,Other,153% of Medicaid,232.2,,,232.2,Other,225% of Medicaid,144.48,,,144.48,Other,140% of Medicaid,232.2,,,232.2,Other,225% of Medicaid,268.32,,,268.32,Other,260% of Medicaid,334.36,,,334.36,Other,324% of Medicaid,221.88,,,221.88,Other,215% of Medicaid,221.88,,,221.88,Other,215% of Medicaid,129,,,129,Other,125% of Medicaid,52.16,368,
ARC SCREEN PT,97162,CPT,GP,62197162,CDM,424,RC,,,both,,,468,346.32,,,346.32,Other,150% of Medicare + 9.63% HCRA Surcharge,210.6,45,,210.6,percent of total billed charges,Critical Access Hospital RCC factor,180,,,180,Case Rate,Therapy Per Visit,162,,,162,Case Rate,Therapy Per Visit,76.19,,,76.19,Fee Schedule,,76.19,,,76.19,Fee Schedule,,76.19,,,76.19,Fee Schedule,,231.66,,,231.66,Other,110% of Medicare,219,,,219,Case Rate,Therapy Per Visit,192,,,192,Other,186% of Medicaid,257,,,257,Case Rate,Therapy Per Visit,388.44,83,,388.44,percent of total billed charges,Therapy,223.02,,,223.02,Case Rate,,257,,,257,Case Rate,Therapy Per Visit,388.44,83,,388.44,percent of total billed charges,Therapy,368,,,368,Case Rate,Therapy Visit,327.6,70,,327.6,percent of total billed charges,All Other,259,,,259,Case Rate,Therapy Visit,220,,,220,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,138,,,138,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,131,,,131,Case Rate,Therapy Visit,103.2,,,103.2,Other,100% of Medicaid,103.2,,,103.2,Other,100% of Medicaid,103.2,,,103.2,Other,100% of Medicaid,103.2,,,103.2,Other,100% of Medicaid,232.2,,,232.2,Other,225% of Medicaid,157.89,,,157.89,Other,153% of Medicaid,232.2,,,232.2,Other,225% of Medicaid,144.48,,,144.48,Other,140% of Medicaid,232.2,,,232.2,Other,225% of Medicaid,268.32,,,268.32,Other,260% of Medicaid,334.36,,,334.36,Other,324% of Medicaid,221.88,,,221.88,Other,215% of Medicaid,221.88,,,221.88,Other,215% of Medicaid,129,,,129,Other,125% of Medicaid,76.19,388.44,
TH-PT EVAL LOW COMPLEX 20 MIN,97161,CPT,GPGT,62297161,CDM,424,RC,,,both,,,468,346.32,,,346.32,Other,150% of Medicare + 9.63% HCRA Surcharge,210.6,45,,210.6,percent of total billed charges,Critical Access Hospital RCC factor,180,,,180,Case Rate,Therapy Per Visit,162,,,162,Case Rate,Therapy Per Visit,76.19,,,76.19,Fee Schedule,,76.19,,,76.19,Fee Schedule,,76.19,,,76.19,Fee Schedule,,231.66,,,231.66,Other,110% of Medicare,219,,,219,Case Rate,Therapy Per Visit,192,,,192,Other,186% of Medicaid,257,,,257,Case Rate,Therapy Per Visit,388.44,83,,388.44,percent of total billed charges,Therapy,223.02,,,223.02,Case Rate,,257,,,257,Case Rate,Therapy Per Visit,388.44,83,,388.44,percent of total billed charges,Therapy,368,,,368,Case Rate,Therapy Visit,327.6,70,,327.6,percent of total billed charges,All Other,259,,,259,Case Rate,Therapy Visit,220,,,220,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,138,,,138,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,131,,,131,Case Rate,Therapy Visit,103.2,,,103.2,Other,100% of Medicaid,103.2,,,103.2,Other,100% of Medicaid,103.2,,,103.2,Other,100% of Medicaid,103.2,,,103.2,Other,100% of Medicaid,232.2,,,232.2,Other,225% of Medicaid,157.89,,,157.89,Other,153% of Medicaid,232.2,,,232.2,Other,225% of Medicaid,144.48,,,144.48,Other,140% of Medicaid,232.2,,,232.2,Other,225% of Medicaid,268.32,,,268.32,Other,260% of Medicaid,334.36,,,334.36,Other,324% of Medicaid,221.88,,,221.88,Other,215% of Medicaid,221.88,,,221.88,Other,215% of Medicaid,129,,,129,Other,125% of Medicaid,76.19,388.44,
TH-PT EVAL MOD COMPLEX 30 MIN,97162,CPT,GPGT,62297162,CDM,424,RC,,,both,,,468,346.32,,,346.32,Other,150% of Medicare + 9.63% HCRA Surcharge,210.6,45,,210.6,percent of total billed charges,Critical Access Hospital RCC factor,180,,,180,Case Rate,Therapy Per Visit,162,,,162,Case Rate,Therapy Per Visit,76.19,,,76.19,Fee Schedule,,76.19,,,76.19,Fee Schedule,,76.19,,,76.19,Fee Schedule,,231.66,,,231.66,Other,110% of Medicare,219,,,219,Case Rate,Therapy Per Visit,192,,,192,Other,186% of Medicaid,257,,,257,Case Rate,Therapy Per Visit,388.44,83,,388.44,percent of total billed charges,Therapy,223.02,,,223.02,Case Rate,,257,,,257,Case Rate,Therapy Per Visit,388.44,83,,388.44,percent of total billed charges,Therapy,368,,,368,Case Rate,Therapy Visit,327.6,70,,327.6,percent of total billed charges,All Other,259,,,259,Case Rate,Therapy Visit,220,,,220,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,138,,,138,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,131,,,131,Case Rate,Therapy Visit,103.2,,,103.2,Other,100% of Medicaid,103.2,,,103.2,Other,100% of Medicaid,103.2,,,103.2,Other,100% of Medicaid,103.2,,,103.2,Other,100% of Medicaid,232.2,,,232.2,Other,225% of Medicaid,157.89,,,157.89,Other,153% of Medicaid,232.2,,,232.2,Other,225% of Medicaid,144.48,,,144.48,Other,140% of Medicaid,232.2,,,232.2,Other,225% of Medicaid,268.32,,,268.32,Other,260% of Medicaid,334.36,,,334.36,Other,324% of Medicaid,221.88,,,221.88,Other,215% of Medicaid,221.88,,,221.88,Other,215% of Medicaid,129,,,129,Other,125% of Medicaid,76.19,388.44,
TH-PT EVAL HIGH COMPLEX 45 MIN,97163,CPT,GPGT,62297163,CDM,424,RC,,,both,,,468,346.32,,,346.32,Other,150% of Medicare + 9.63% HCRA Surcharge,210.6,45,,210.6,percent of total billed charges,Critical Access Hospital RCC factor,180,,,180,Case Rate,Therapy Per Visit,162,,,162,Case Rate,Therapy Per Visit,76.19,,,76.19,Fee Schedule,,76.19,,,76.19,Fee Schedule,,76.19,,,76.19,Fee Schedule,,231.66,,,231.66,Other,110% of Medicare,219,,,219,Case Rate,Therapy Per Visit,192,,,192,Other,186% of Medicaid,257,,,257,Case Rate,Therapy Per Visit,388.44,83,,388.44,percent of total billed charges,Therapy,223.02,,,223.02,Case Rate,,257,,,257,Case Rate,Therapy Per Visit,388.44,83,,388.44,percent of total billed charges,Therapy,368,,,368,Case Rate,Therapy Visit,327.6,70,,327.6,percent of total billed charges,All Other,259,,,259,Case Rate,Therapy Visit,220,,,220,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,138,,,138,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,131,,,131,Case Rate,Therapy Visit,103.2,,,103.2,Other,100% of Medicaid,103.2,,,103.2,Other,100% of Medicaid,103.2,,,103.2,Other,100% of Medicaid,103.2,,,103.2,Other,100% of Medicaid,232.2,,,232.2,Other,225% of Medicaid,157.89,,,157.89,Other,153% of Medicaid,232.2,,,232.2,Other,225% of Medicaid,144.48,,,144.48,Other,140% of Medicaid,232.2,,,232.2,Other,225% of Medicaid,268.32,,,268.32,Other,260% of Medicaid,334.36,,,334.36,Other,324% of Medicaid,221.88,,,221.88,Other,215% of Medicaid,221.88,,,221.88,Other,215% of Medicaid,129,,,129,Other,125% of Medicaid,76.19,388.44,
PT EVAL LOW COMPLEX 20 MIN,97161,CPT,GP,64097161,CDM,424,RC,,,both,,,468,346.32,,,346.32,Other,150% of Medicare + 9.63% HCRA Surcharge,210.6,45,,210.6,percent of total billed charges,Critical Access Hospital RCC factor,180,,,180,Case Rate,Therapy Per Visit,162,,,162,Case Rate,Therapy Per Visit,76.19,,,76.19,Fee Schedule,,76.19,,,76.19,Fee Schedule,,76.19,,,76.19,Fee Schedule,,231.66,,,231.66,Other,110% of Medicare,219,,,219,Case Rate,Therapy Per Visit,192,,,192,Other,186% of Medicaid,257,,,257,Case Rate,Therapy Per Visit,388.44,83,,388.44,percent of total billed charges,Therapy,223.02,,,223.02,Case Rate,,257,,,257,Case Rate,Therapy Per Visit,388.44,83,,388.44,percent of total billed charges,Therapy,368,,,368,Case Rate,Therapy Visit,327.6,70,,327.6,percent of total billed charges,All Other,259,,,259,Case Rate,Therapy Visit,220,,,220,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,138,,,138,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,131,,,131,Case Rate,Therapy Visit,103.2,,,103.2,Other,100% of Medicaid,103.2,,,103.2,Other,100% of Medicaid,103.2,,,103.2,Other,100% of Medicaid,103.2,,,103.2,Other,100% of Medicaid,232.2,,,232.2,Other,225% of Medicaid,157.89,,,157.89,Other,153% of Medicaid,232.2,,,232.2,Other,225% of Medicaid,144.48,,,144.48,Other,140% of Medicaid,232.2,,,232.2,Other,225% of Medicaid,268.32,,,268.32,Other,260% of Medicaid,334.36,,,334.36,Other,324% of Medicaid,221.88,,,221.88,Other,215% of Medicaid,221.88,,,221.88,Other,215% of Medicaid,129,,,129,Other,125% of Medicaid,76.19,388.44,
PT EVAL MOD COMPLEX 30 MIN,97162,CPT,GP,64097162,CDM,424,RC,,,both,,,468,346.32,,,346.32,Other,150% of Medicare + 9.63% HCRA Surcharge,210.6,45,,210.6,percent of total billed charges,Critical Access Hospital RCC factor,180,,,180,Case Rate,Therapy Per Visit,162,,,162,Case Rate,Therapy Per Visit,76.19,,,76.19,Fee Schedule,,76.19,,,76.19,Fee Schedule,,76.19,,,76.19,Fee Schedule,,231.66,,,231.66,Other,110% of Medicare,219,,,219,Case Rate,Therapy Per Visit,192,,,192,Other,186% of Medicaid,257,,,257,Case Rate,Therapy Per Visit,388.44,83,,388.44,percent of total billed charges,Therapy,223.02,,,223.02,Case Rate,,257,,,257,Case Rate,Therapy Per Visit,388.44,83,,388.44,percent of total billed charges,Therapy,368,,,368,Case Rate,Therapy Visit,327.6,70,,327.6,percent of total billed charges,All Other,259,,,259,Case Rate,Therapy Visit,220,,,220,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,138,,,138,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,131,,,131,Case Rate,Therapy Visit,103.2,,,103.2,Other,100% of Medicaid,103.2,,,103.2,Other,100% of Medicaid,103.2,,,103.2,Other,100% of Medicaid,103.2,,,103.2,Other,100% of Medicaid,232.2,,,232.2,Other,225% of Medicaid,157.89,,,157.89,Other,153% of Medicaid,232.2,,,232.2,Other,225% of Medicaid,144.48,,,144.48,Other,140% of Medicaid,232.2,,,232.2,Other,225% of Medicaid,268.32,,,268.32,Other,260% of Medicaid,334.36,,,334.36,Other,324% of Medicaid,221.88,,,221.88,Other,215% of Medicaid,221.88,,,221.88,Other,215% of Medicaid,129,,,129,Other,125% of Medicaid,76.19,388.44,
PT EVAL HIGH COMPLEX 45 MIN,97163,CPT,GP,64097163,CDM,424,RC,,,both,,,468,346.32,,,346.32,Other,150% of Medicare + 9.63% HCRA Surcharge,210.6,45,,210.6,percent of total billed charges,Critical Access Hospital RCC factor,180,,,180,Case Rate,Therapy Per Visit,162,,,162,Case Rate,Therapy Per Visit,76.19,,,76.19,Fee Schedule,,76.19,,,76.19,Fee Schedule,,76.19,,,76.19,Fee Schedule,,231.66,,,231.66,Other,110% of Medicare,219,,,219,Case Rate,Therapy Per Visit,192,,,192,Other,186% of Medicaid,257,,,257,Case Rate,Therapy Per Visit,388.44,83,,388.44,percent of total billed charges,Therapy,223.02,,,223.02,Case Rate,,257,,,257,Case Rate,Therapy Per Visit,388.44,83,,388.44,percent of total billed charges,Therapy,368,,,368,Case Rate,Therapy Visit,327.6,70,,327.6,percent of total billed charges,All Other,259,,,259,Case Rate,Therapy Visit,220,,,220,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,138,,,138,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,131,,,131,Case Rate,Therapy Visit,103.2,,,103.2,Other,100% of Medicaid,103.2,,,103.2,Other,100% of Medicaid,103.2,,,103.2,Other,100% of Medicaid,103.2,,,103.2,Other,100% of Medicaid,232.2,,,232.2,Other,225% of Medicaid,157.89,,,157.89,Other,153% of Medicaid,232.2,,,232.2,Other,225% of Medicaid,144.48,,,144.48,Other,140% of Medicaid,232.2,,,232.2,Other,225% of Medicaid,268.32,,,268.32,Other,260% of Medicaid,334.36,,,334.36,Other,324% of Medicaid,221.88,,,221.88,Other,215% of Medicaid,221.88,,,221.88,Other,215% of Medicaid,129,,,129,Other,125% of Medicaid,76.19,388.44,
PT RE-EVAL EST PLAN CARE,97164,CPT,GP,64097164,CDM,424,RC,,,both,,,266,196.84,,,196.84,Other,150% of Medicare + 9.63% HCRA Surcharge,119.7,45,,119.7,percent of total billed charges,Critical Access Hospital RCC factor,180,,,180,Case Rate,Therapy Per Visit,162,,,162,Case Rate,Therapy Per Visit,52.16,,,52.16,Fee Schedule,,52.16,,,52.16,Fee Schedule,,52.16,,,52.16,Fee Schedule,,131.67,,,131.67,Other,110% of Medicare,219,,,219,Case Rate,Therapy Per Visit,192,,,192,Other,186% of Medicaid,257,,,257,Case Rate,Therapy Per Visit,220.78,83,,220.78,percent of total billed charges,Therapy,155.32,,,155.32,Case Rate,,257,,,257,Case Rate,Therapy Per Visit,220.78,83,,220.78,percent of total billed charges,Therapy,368,,,368,Case Rate,Therapy Visit,186.2,70,,186.2,percent of total billed charges,All Other,259,,,259,Case Rate,Therapy Visit,220,,,220,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,138,,,138,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,131,,,131,Case Rate,Therapy Visit,103.2,,,103.2,Other,100% of Medicaid,103.2,,,103.2,Other,100% of Medicaid,103.2,,,103.2,Other,100% of Medicaid,103.2,,,103.2,Other,100% of Medicaid,232.2,,,232.2,Other,225% of Medicaid,157.89,,,157.89,Other,153% of Medicaid,232.2,,,232.2,Other,225% of Medicaid,144.48,,,144.48,Other,140% of Medicaid,232.2,,,232.2,Other,225% of Medicaid,268.32,,,268.32,Other,260% of Medicaid,334.36,,,334.36,Other,324% of Medicaid,221.88,,,221.88,Other,215% of Medicaid,221.88,,,221.88,Other,215% of Medicaid,129,,,129,Other,125% of Medicaid,52.16,368,
ARC SCREEN PT SAUG,97162,CPT,GP,64197162,CDM,424,RC,,,both,,,468,346.32,,,346.32,Other,150% of Medicare + 9.63% HCRA Surcharge,210.6,45,,210.6,percent of total billed charges,Critical Access Hospital RCC factor,180,,,180,Case Rate,Therapy Per Visit,162,,,162,Case Rate,Therapy Per Visit,76.19,,,76.19,Fee Schedule,,76.19,,,76.19,Fee Schedule,,76.19,,,76.19,Fee Schedule,,231.66,,,231.66,Other,110% of Medicare,219,,,219,Case Rate,Therapy Per Visit,192,,,192,Other,186% of Medicaid,257,,,257,Case Rate,Therapy Per Visit,388.44,83,,388.44,percent of total billed charges,Therapy,223.02,,,223.02,Case Rate,,257,,,257,Case Rate,Therapy Per Visit,388.44,83,,388.44,percent of total billed charges,Therapy,368,,,368,Case Rate,Therapy Visit,327.6,70,,327.6,percent of total billed charges,All Other,259,,,259,Case Rate,Therapy Visit,220,,,220,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,138,,,138,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,131,,,131,Case Rate,Therapy Visit,103.2,,,103.2,Other,100% of Medicaid,103.2,,,103.2,Other,100% of Medicaid,103.2,,,103.2,Other,100% of Medicaid,103.2,,,103.2,Other,100% of Medicaid,232.2,,,232.2,Other,225% of Medicaid,157.89,,,157.89,Other,153% of Medicaid,232.2,,,232.2,Other,225% of Medicaid,144.48,,,144.48,Other,140% of Medicaid,232.2,,,232.2,Other,225% of Medicaid,268.32,,,268.32,Other,260% of Medicaid,334.36,,,334.36,Other,324% of Medicaid,221.88,,,221.88,Other,215% of Medicaid,221.88,,,221.88,Other,215% of Medicaid,129,,,129,Other,125% of Medicaid,76.19,388.44,
TH-PT EVAL LOW COMPLEX 20 MIN,97161,CPT,GPGT,64297161,CDM,424,RC,,,both,,,468,346.32,,,346.32,Other,150% of Medicare + 9.63% HCRA Surcharge,210.6,45,,210.6,percent of total billed charges,Critical Access Hospital RCC factor,180,,,180,Case Rate,Therapy Per Visit,162,,,162,Case Rate,Therapy Per Visit,76.19,,,76.19,Fee Schedule,,76.19,,,76.19,Fee Schedule,,76.19,,,76.19,Fee Schedule,,231.66,,,231.66,Other,110% of Medicare,219,,,219,Case Rate,Therapy Per Visit,192,,,192,Other,186% of Medicaid,257,,,257,Case Rate,Therapy Per Visit,388.44,83,,388.44,percent of total billed charges,Therapy,223.02,,,223.02,Case Rate,,257,,,257,Case Rate,Therapy Per Visit,388.44,83,,388.44,percent of total billed charges,Therapy,368,,,368,Case Rate,Therapy Visit,327.6,70,,327.6,percent of total billed charges,All Other,259,,,259,Case Rate,Therapy Visit,220,,,220,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,138,,,138,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,131,,,131,Case Rate,Therapy Visit,103.2,,,103.2,Other,100% of Medicaid,103.2,,,103.2,Other,100% of Medicaid,103.2,,,103.2,Other,100% of Medicaid,103.2,,,103.2,Other,100% of Medicaid,232.2,,,232.2,Other,225% of Medicaid,157.89,,,157.89,Other,153% of Medicaid,232.2,,,232.2,Other,225% of Medicaid,144.48,,,144.48,Other,140% of Medicaid,232.2,,,232.2,Other,225% of Medicaid,268.32,,,268.32,Other,260% of Medicaid,334.36,,,334.36,Other,324% of Medicaid,221.88,,,221.88,Other,215% of Medicaid,221.88,,,221.88,Other,215% of Medicaid,129,,,129,Other,125% of Medicaid,76.19,388.44,
TH-PT EVAL MOD COMPLEX 30 MIN,97162,CPT,GPGT,64297162,CDM,424,RC,,,both,,,468,346.32,,,346.32,Other,150% of Medicare + 9.63% HCRA Surcharge,210.6,45,,210.6,percent of total billed charges,Critical Access Hospital RCC factor,180,,,180,Case Rate,Therapy Per Visit,162,,,162,Case Rate,Therapy Per Visit,76.19,,,76.19,Fee Schedule,,76.19,,,76.19,Fee Schedule,,76.19,,,76.19,Fee Schedule,,231.66,,,231.66,Other,110% of Medicare,219,,,219,Case Rate,Therapy Per Visit,192,,,192,Other,186% of Medicaid,257,,,257,Case Rate,Therapy Per Visit,388.44,83,,388.44,percent of total billed charges,Therapy,223.02,,,223.02,Case Rate,,257,,,257,Case Rate,Therapy Per Visit,388.44,83,,388.44,percent of total billed charges,Therapy,368,,,368,Case Rate,Therapy Visit,327.6,70,,327.6,percent of total billed charges,All Other,259,,,259,Case Rate,Therapy Visit,220,,,220,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,138,,,138,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,131,,,131,Case Rate,Therapy Visit,103.2,,,103.2,Other,100% of Medicaid,103.2,,,103.2,Other,100% of Medicaid,103.2,,,103.2,Other,100% of Medicaid,103.2,,,103.2,Other,100% of Medicaid,232.2,,,232.2,Other,225% of Medicaid,157.89,,,157.89,Other,153% of Medicaid,232.2,,,232.2,Other,225% of Medicaid,144.48,,,144.48,Other,140% of Medicaid,232.2,,,232.2,Other,225% of Medicaid,268.32,,,268.32,Other,260% of Medicaid,334.36,,,334.36,Other,324% of Medicaid,221.88,,,221.88,Other,215% of Medicaid,221.88,,,221.88,Other,215% of Medicaid,129,,,129,Other,125% of Medicaid,76.19,388.44,
TH-PT EVAL HIGH COMPLEX 45 MIN,97163,CPT,GPGT,64297163,CDM,424,RC,,,both,,,468,346.32,,,346.32,Other,150% of Medicare + 9.63% HCRA Surcharge,210.6,45,,210.6,percent of total billed charges,Critical Access Hospital RCC factor,180,,,180,Case Rate,Therapy Per Visit,162,,,162,Case Rate,Therapy Per Visit,76.19,,,76.19,Fee Schedule,,76.19,,,76.19,Fee Schedule,,76.19,,,76.19,Fee Schedule,,231.66,,,231.66,Other,110% of Medicare,219,,,219,Case Rate,Therapy Per Visit,192,,,192,Other,186% of Medicaid,257,,,257,Case Rate,Therapy Per Visit,388.44,83,,388.44,percent of total billed charges,Therapy,223.02,,,223.02,Case Rate,,257,,,257,Case Rate,Therapy Per Visit,388.44,83,,388.44,percent of total billed charges,Therapy,368,,,368,Case Rate,Therapy Visit,327.6,70,,327.6,percent of total billed charges,All Other,259,,,259,Case Rate,Therapy Visit,220,,,220,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,138,,,138,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,131,,,131,Case Rate,Therapy Visit,103.2,,,103.2,Other,100% of Medicaid,103.2,,,103.2,Other,100% of Medicaid,103.2,,,103.2,Other,100% of Medicaid,103.2,,,103.2,Other,100% of Medicaid,232.2,,,232.2,Other,225% of Medicaid,157.89,,,157.89,Other,153% of Medicaid,232.2,,,232.2,Other,225% of Medicaid,144.48,,,144.48,Other,140% of Medicaid,232.2,,,232.2,Other,225% of Medicaid,268.32,,,268.32,Other,260% of Medicaid,334.36,,,334.36,Other,324% of Medicaid,221.88,,,221.88,Other,215% of Medicaid,221.88,,,221.88,Other,215% of Medicaid,129,,,129,Other,125% of Medicaid,76.19,388.44,
ELECTRICAL STIMULATION EA 15 MINS,G0283,HCPCS,GO,63000001,CDM,430,RC,,,both,,,119,88.06,,,88.06,Other,150% of Medicare + 9.63% HCRA Surcharge,53.55,45,,53.55,percent of total billed charges,Critical Access Hospital RCC factor,180,,,180,Case Rate,Therapy Per Visit,162,,,162,Case Rate,Therapy Per Visit,77.42,,,77.42,Fee Schedule,,69.63,,,69.63,Fee Schedule,,65.81,,,65.81,Fee Schedule,,58.91,,,58.91,Other,110% of Medicare,219,,,219,Case Rate,Therapy Per Visit,39,,,39,Other,186% of Medicaid,257,,,257,Case Rate,Therapy Per Visit,98.77,83,,98.77,percent of total billed charges,Therapy,26,,,26,Case Rate,,257,,,257,Case Rate,Therapy Per Visit,98.77,83,,98.77,percent of total billed charges,Therapy,368,,,368,Case Rate,Therapy Visit,83.3,70,,83.3,percent of total billed charges,All Other,259,,,259,Case Rate,Therapy Visit,220,,,220,Case Rate,Therapy Visit,0.01,,,0.01,Case Rate,Therapy Visit,0.01,,,0.01,Case Rate,Therapy Visit,0.01,,,0.01,Case Rate,Therapy Visit,0.01,,,0.01,Case Rate,Therapy Visit,20.84,,,20.84,Other,100% of Medicaid,20.84,,,20.84,Other,100% of Medicaid,20.84,,,20.84,Other,100% of Medicaid,20.84,,,20.84,Other,100% of Medicaid,46.9,,,46.9,Other,225% of Medicaid,31.89,,,31.89,Other,153% of Medicaid,46.9,,,46.9,Other,225% of Medicaid,29.18,,,29.18,Other,140% of Medicaid,46.9,,,46.9,Other,225% of Medicaid,54.2,,,54.2,Other,260% of Medicaid,67.54,,,67.54,Other,324% of Medicaid,44.82,,,44.82,Other,215% of Medicaid,44.82,,,44.82,Other,215% of Medicaid,26.06,,,26.06,Other,125% of Medicaid,0.01,368,
APPLY LONG ARM SPLINT,29105,CPT,GO,63029105,CDM,430,RC,,,both,,,544,402.56,,,402.56,Other,150% of Medicare + 9.63% HCRA Surcharge,244.8,45,,244.8,percent of total billed charges,Critical Access Hospital RCC factor,180,,,180,Case Rate,Therapy Per Visit,162,,,162,Case Rate,Therapy Per Visit,416.16,76.5,,416.16,percent of total billed charges,All Other,386.24,69,,386.24,percent of total billed charges,All Other,375.36,65,,375.36,percent of total billed charges,All Other,269.28,,,269.28,Other,110% of Medicare,219,,,219,Case Rate,Therapy Per Visit,325,,,325,Other,186% of Medicaid,257,,,257,Case Rate,Therapy Per Visit,451.52,83,,451.52,percent of total billed charges,Therapy,93.56,,,93.56,Fee Schedule,,257,,,257,Case Rate,Therapy Per Visit,451.52,83,,451.52,percent of total billed charges,Therapy,368,,,368,Case Rate,Therapy Visit,380.8,70,,380.8,percent of total billed charges,All Other,259,,,259,Case Rate,Therapy Visit,220,,,220,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,138,,,138,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,131,,,131,Case Rate,Therapy Visit,174.92,,,174.92,Other,100% of Medicaid,174.92,,,174.92,Other,100% of Medicaid,174.92,,,174.92,Other,100% of Medicaid,174.92,,,174.92,Other,100% of Medicaid,393.57,,,393.57,Other,225% of Medicaid,267.62,,,267.62,Other,153% of Medicaid,393.57,,,393.57,Other,225% of Medicaid,244.89,,,244.89,Other,140% of Medicaid,393.57,,,393.57,Other,225% of Medicaid,454.79,,,454.79,Other,260% of Medicaid,566.73,,,566.73,Other,324% of Medicaid,376.07,,,376.07,Other,215% of Medicaid,376.07,,,376.07,Other,215% of Medicaid,218.65,,,218.65,Other,125% of Medicaid,93.56,566.73,
APPLY SHORT ARM SPLINT; STATIC,29125,CPT,GO,63029125,CDM,430,RC,,,both,,,563,416.62,,,416.62,Other,150% of Medicare + 9.63% HCRA Surcharge,253.35,45,,253.35,percent of total billed charges,Critical Access Hospital RCC factor,180,,,180,Case Rate,Therapy Per Visit,162,,,162,Case Rate,Therapy Per Visit,430.7,76.5,,430.7,percent of total billed charges,All Other,399.73,69,,399.73,percent of total billed charges,All Other,388.47,65,,388.47,percent of total billed charges,All Other,278.69,,,278.69,Other,110% of Medicare,219,,,219,Case Rate,Therapy Per Visit,325,,,325,Other,186% of Medicaid,257,,,257,Case Rate,Therapy Per Visit,467.29,83,,467.29,percent of total billed charges,Therapy,91.73,,,91.73,Fee Schedule,,257,,,257,Case Rate,Therapy Per Visit,467.29,83,,467.29,percent of total billed charges,Therapy,368,,,368,Case Rate,Therapy Visit,394.1,70,,394.1,percent of total billed charges,All Other,259,,,259,Case Rate,Therapy Visit,220,,,220,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,138,,,138,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,131,,,131,Case Rate,Therapy Visit,174.92,,,174.92,Other,100% of Medicaid,174.92,,,174.92,Other,100% of Medicaid,174.92,,,174.92,Other,100% of Medicaid,174.92,,,174.92,Other,100% of Medicaid,393.57,,,393.57,Other,225% of Medicaid,267.62,,,267.62,Other,153% of Medicaid,393.57,,,393.57,Other,225% of Medicaid,244.89,,,244.89,Other,140% of Medicaid,393.57,,,393.57,Other,225% of Medicaid,454.79,,,454.79,Other,260% of Medicaid,566.73,,,566.73,Other,324% of Medicaid,376.07,,,376.07,Other,215% of Medicaid,376.07,,,376.07,Other,215% of Medicaid,218.65,,,218.65,Other,125% of Medicaid,91.73,566.73,
APPLY FOREARM SPLINT DYNAMIC,29126,CPT,GO,63029126,CDM,430,RC,,,both,,,452,334.48,,,334.48,Other,150% of Medicare + 9.63% HCRA Surcharge,203.4,45,,203.4,percent of total billed charges,Critical Access Hospital RCC factor,180,,,180,Case Rate,Therapy Per Visit,162,,,162,Case Rate,Therapy Per Visit,345.78,76.5,,345.78,percent of total billed charges,All Other,320.92,69,,320.92,percent of total billed charges,All Other,311.88,65,,311.88,percent of total billed charges,All Other,223.74,,,223.74,Other,110% of Medicare,219,,,219,Case Rate,Therapy Per Visit,552,,,552,Other,186% of Medicaid,257,,,257,Case Rate,Therapy Per Visit,375.16,83,,375.16,percent of total billed charges,Therapy,111.64,,,111.64,Fee Schedule,,257,,,257,Case Rate,Therapy Per Visit,375.16,83,,375.16,percent of total billed charges,Therapy,368,,,368,Case Rate,Therapy Visit,316.4,70,,316.4,percent of total billed charges,All Other,259,,,259,Case Rate,Therapy Visit,220,,,220,Case Rate,Therapy Visit,0.01,,,0.01,Fee Schedule,Therapy Visit,0.01,,,0.01,Fee Schedule,Therapy Visit,0.01,,,0.01,Fee Schedule,Therapy Visit,0.01,,,0.01,Fee Schedule,Therapy Visit,296.74,,,296.74,Other,100% of Medicaid,296.74,,,296.74,Other,100% of Medicaid,296.74,,,296.74,Other,100% of Medicaid,296.74,,,296.74,Other,100% of Medicaid,667.67,,,667.67,Other,225% of Medicaid,454.02,,,454.02,Other,153% of Medicaid,667.67,,,667.67,Other,225% of Medicaid,415.44,,,415.44,Other,140% of Medicaid,667.67,,,667.67,Other,225% of Medicaid,771.53,,,771.53,Other,260% of Medicaid,961.45,,,961.45,Other,324% of Medicaid,638,,,638,Other,215% of Medicaid,638,,,638,Other,215% of Medicaid,370.93,,,370.93,Other,125% of Medicaid,0.01,961.45,
APPLICATION OF FINGER SPLINT,29130,CPT,GO,63029130,CDM,430,RC,,,both,,,563,416.62,,,416.62,Other,150% of Medicare + 9.63% HCRA Surcharge,253.35,45,,253.35,percent of total billed charges,Critical Access Hospital RCC factor,180,,,180,Case Rate,Therapy Per Visit,162,,,162,Case Rate,Therapy Per Visit,430.7,76.5,,430.7,percent of total billed charges,All Other,399.73,69,,399.73,percent of total billed charges,All Other,388.47,65,,388.47,percent of total billed charges,All Other,278.69,,,278.69,Other,110% of Medicare,219,,,219,Case Rate,Therapy Per Visit,325,,,325,Other,186% of Medicaid,257,,,257,Case Rate,Therapy Per Visit,467.29,83,,467.29,percent of total billed charges,Therapy,65.12,,,65.12,Fee Schedule,,257,,,257,Case Rate,Therapy Per Visit,467.29,83,,467.29,percent of total billed charges,Therapy,368,,,368,Case Rate,Therapy Visit,394.1,70,,394.1,percent of total billed charges,All Other,259,,,259,Case Rate,Therapy Visit,220,,,220,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,138,,,138,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,131,,,131,Case Rate,Therapy Visit,174.92,,,174.92,Other,100% of Medicaid,174.92,,,174.92,Other,100% of Medicaid,174.92,,,174.92,Other,100% of Medicaid,174.92,,,174.92,Other,100% of Medicaid,393.57,,,393.57,Other,225% of Medicaid,267.62,,,267.62,Other,153% of Medicaid,393.57,,,393.57,Other,225% of Medicaid,244.89,,,244.89,Other,140% of Medicaid,393.57,,,393.57,Other,225% of Medicaid,454.79,,,454.79,Other,260% of Medicaid,566.73,,,566.73,Other,324% of Medicaid,376.07,,,376.07,Other,215% of Medicaid,376.07,,,376.07,Other,215% of Medicaid,218.65,,,218.65,Other,125% of Medicaid,65.12,566.73,
APPL OF FNGER SPLNT DYNAMIC,29131,CPT,GO,63029131,CDM,430,RC,,,both,,,452,334.48,,,334.48,Other,150% of Medicare + 9.63% HCRA Surcharge,203.4,45,,203.4,percent of total billed charges,Critical Access Hospital RCC factor,180,,,180,Case Rate,Therapy Per Visit,162,,,162,Case Rate,Therapy Per Visit,345.78,76.5,,345.78,percent of total billed charges,All Other,320.92,69,,320.92,percent of total billed charges,All Other,311.88,65,,311.88,percent of total billed charges,All Other,223.74,,,223.74,Other,110% of Medicare,219,,,219,Case Rate,Therapy Per Visit,325,,,325,Other,186% of Medicaid,257,,,257,Case Rate,Therapy Per Visit,375.16,83,,375.16,percent of total billed charges,Therapy,77.83,,,77.83,Fee Schedule,,257,,,257,Case Rate,Therapy Per Visit,375.16,83,,375.16,percent of total billed charges,Therapy,368,,,368,Case Rate,Therapy Visit,316.4,70,,316.4,percent of total billed charges,All Other,259,,,259,Case Rate,Therapy Visit,220,,,220,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,138,,,138,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,131,,,131,Case Rate,Therapy Visit,174.92,,,174.92,Other,100% of Medicaid,174.92,,,174.92,Other,100% of Medicaid,174.92,,,174.92,Other,100% of Medicaid,174.92,,,174.92,Other,100% of Medicaid,393.57,,,393.57,Other,225% of Medicaid,267.62,,,267.62,Other,153% of Medicaid,393.57,,,393.57,Other,225% of Medicaid,244.89,,,244.89,Other,140% of Medicaid,393.57,,,393.57,Other,225% of Medicaid,454.79,,,454.79,Other,260% of Medicaid,566.73,,,566.73,Other,324% of Medicaid,376.07,,,376.07,Other,215% of Medicaid,376.07,,,376.07,Other,215% of Medicaid,218.65,,,218.65,Other,125% of Medicaid,77.83,566.73,
STRAPPING OF SHOULDER,29240,CPT,GO,63029240,CDM,430,RC,,,both,,,563,416.62,,,416.62,Other,150% of Medicare + 9.63% HCRA Surcharge,253.35,45,,253.35,percent of total billed charges,Critical Access Hospital RCC factor,180,,,180,Case Rate,Therapy Per Visit,162,,,162,Case Rate,Therapy Per Visit,430.7,76.5,,430.7,percent of total billed charges,All Other,399.73,69,,399.73,percent of total billed charges,All Other,388.47,65,,388.47,percent of total billed charges,All Other,278.69,,,278.69,Other,110% of Medicare,219,,,219,Case Rate,Therapy Per Visit,325,,,325,Other,186% of Medicaid,257,,,257,Case Rate,Therapy Per Visit,467.29,83,,467.29,percent of total billed charges,Therapy,38.91,,,38.91,Fee Schedule,,257,,,257,Case Rate,Therapy Per Visit,467.29,83,,467.29,percent of total billed charges,Therapy,368,,,368,Case Rate,Therapy Visit,394.1,70,,394.1,percent of total billed charges,All Other,259,,,259,Case Rate,Therapy Visit,220,,,220,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,138,,,138,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,131,,,131,Case Rate,Therapy Visit,174.92,,,174.92,Other,100% of Medicaid,174.92,,,174.92,Other,100% of Medicaid,174.92,,,174.92,Other,100% of Medicaid,174.92,,,174.92,Other,100% of Medicaid,393.57,,,393.57,Other,225% of Medicaid,267.62,,,267.62,Other,153% of Medicaid,393.57,,,393.57,Other,225% of Medicaid,244.89,,,244.89,Other,140% of Medicaid,393.57,,,393.57,Other,225% of Medicaid,454.79,,,454.79,Other,260% of Medicaid,566.73,,,566.73,Other,324% of Medicaid,376.07,,,376.07,Other,215% of Medicaid,376.07,,,376.07,Other,215% of Medicaid,218.65,,,218.65,Other,125% of Medicaid,38.91,566.73,
STRAPPING OF ELBOW OR WRIST,29260,CPT,GO,63029260,CDM,430,RC,,,both,,,563,416.62,,,416.62,Other,150% of Medicare + 9.63% HCRA Surcharge,253.35,45,,253.35,percent of total billed charges,Critical Access Hospital RCC factor,180,,,180,Case Rate,Therapy Per Visit,162,,,162,Case Rate,Therapy Per Visit,430.7,76.5,,430.7,percent of total billed charges,All Other,399.73,69,,399.73,percent of total billed charges,All Other,388.47,65,,388.47,percent of total billed charges,All Other,278.69,,,278.69,Other,110% of Medicare,219,,,219,Case Rate,Therapy Per Visit,325,,,325,Other,186% of Medicaid,257,,,257,Case Rate,Therapy Per Visit,467.29,83,,467.29,percent of total billed charges,Therapy,41.31,,,41.31,Fee Schedule,,257,,,257,Case Rate,Therapy Per Visit,467.29,83,,467.29,percent of total billed charges,Therapy,368,,,368,Case Rate,Therapy Visit,394.1,70,,394.1,percent of total billed charges,All Other,259,,,259,Case Rate,Therapy Visit,220,,,220,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,138,,,138,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,131,,,131,Case Rate,Therapy Visit,174.92,,,174.92,Other,100% of Medicaid,174.92,,,174.92,Other,100% of Medicaid,174.92,,,174.92,Other,100% of Medicaid,174.92,,,174.92,Other,100% of Medicaid,393.57,,,393.57,Other,225% of Medicaid,267.62,,,267.62,Other,153% of Medicaid,393.57,,,393.57,Other,225% of Medicaid,244.89,,,244.89,Other,140% of Medicaid,393.57,,,393.57,Other,225% of Medicaid,454.79,,,454.79,Other,260% of Medicaid,566.73,,,566.73,Other,324% of Medicaid,376.07,,,376.07,Other,215% of Medicaid,376.07,,,376.07,Other,215% of Medicaid,218.65,,,218.65,Other,125% of Medicaid,41.31,566.73,
STRAPPING OF HAND OR FINGER,29280,CPT,GO,63029280,CDM,430,RC,,,both,,,563,416.62,,,416.62,Other,150% of Medicare + 9.63% HCRA Surcharge,253.35,45,,253.35,percent of total billed charges,Critical Access Hospital RCC factor,180,,,180,Case Rate,Therapy Per Visit,162,,,162,Case Rate,Therapy Per Visit,430.7,76.5,,430.7,percent of total billed charges,All Other,399.73,69,,399.73,percent of total billed charges,All Other,388.47,65,,388.47,percent of total billed charges,All Other,278.69,,,278.69,Other,110% of Medicare,219,,,219,Case Rate,Therapy Per Visit,325,,,325,Other,186% of Medicaid,257,,,257,Case Rate,Therapy Per Visit,467.29,83,,467.29,percent of total billed charges,Therapy,44.58,,,44.58,Fee Schedule,,257,,,257,Case Rate,Therapy Per Visit,467.29,83,,467.29,percent of total billed charges,Therapy,368,,,368,Case Rate,Therapy Visit,394.1,70,,394.1,percent of total billed charges,All Other,259,,,259,Case Rate,Therapy Visit,220,,,220,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,138,,,138,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,131,,,131,Case Rate,Therapy Visit,174.92,,,174.92,Other,100% of Medicaid,174.92,,,174.92,Other,100% of Medicaid,174.92,,,174.92,Other,100% of Medicaid,174.92,,,174.92,Other,100% of Medicaid,393.57,,,393.57,Other,225% of Medicaid,267.62,,,267.62,Other,153% of Medicaid,393.57,,,393.57,Other,225% of Medicaid,244.89,,,244.89,Other,140% of Medicaid,393.57,,,393.57,Other,225% of Medicaid,454.79,,,454.79,Other,260% of Medicaid,566.73,,,566.73,Other,324% of Medicaid,376.07,,,376.07,Other,215% of Medicaid,376.07,,,376.07,Other,215% of Medicaid,218.65,,,218.65,Other,125% of Medicaid,44.58,566.73,
HOT OR COLD PACKS THERAPY,97010,CPT,GO,63097010,CDM,430,RC,,,both,,,96,71.04,,,71.04,Other,150% of Medicare + 9.63% HCRA Surcharge,43.2,45,,43.2,percent of total billed charges,Critical Access Hospital RCC factor,180,,,180,Case Rate,Therapy Per Visit,162,,,162,Case Rate,Therapy Per Visit,3.82,,,3.82,Fee Schedule,,3.82,,,3.82,Fee Schedule,,3.82,,,3.82,Fee Schedule,,47.52,,,47.52,Other,110% of Medicare,219,,,219,Case Rate,Therapy Per Visit,39,,,39,Other,186% of Medicaid,257,,,257,Case Rate,Therapy Per Visit,79.68,83,,79.68,percent of total billed charges,Therapy,52.8,83,,52.8,percent of total billed charges,All Other,257,,,257,Case Rate,Therapy Per Visit,79.68,83,,79.68,percent of total billed charges,Therapy,368,,,368,Case Rate,Therapy Visit,67.2,70,,67.2,percent of total billed charges,All Other,259,,,259,Case Rate,Therapy Visit,220,,,220,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,138,,,138,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,131,,,131,Case Rate,Therapy Visit,20.84,,,20.84,Other,100% of Medicaid,20.84,,,20.84,Other,100% of Medicaid,20.84,,,20.84,Other,100% of Medicaid,20.84,,,20.84,Other,100% of Medicaid,46.9,,,46.9,Other,225% of Medicaid,31.89,,,31.89,Other,153% of Medicaid,46.9,,,46.9,Other,225% of Medicaid,29.18,,,29.18,Other,140% of Medicaid,46.9,,,46.9,Other,225% of Medicaid,54.2,,,54.2,Other,260% of Medicaid,67.54,,,67.54,Other,324% of Medicaid,44.82,,,44.82,Other,215% of Medicaid,44.82,,,44.82,Other,215% of Medicaid,26.06,,,26.06,Other,125% of Medicaid,3.82,368,
PARAFFIN BATH THERAPY,97018,CPT,GO,63097018,CDM,430,RC,,,both,,,119,88.06,,,88.06,Other,150% of Medicare + 9.63% HCRA Surcharge,53.55,45,,53.55,percent of total billed charges,Critical Access Hospital RCC factor,180,,,180,Case Rate,Therapy Per Visit,162,,,162,Case Rate,Therapy Per Visit,61.71,,,61.71,Fee Schedule,,55.51,,,55.51,Fee Schedule,,52.46,,,52.46,Fee Schedule,,58.91,,,58.91,Other,110% of Medicare,219,,,219,Case Rate,Therapy Per Visit,39,,,39,Other,186% of Medicaid,257,,,257,Case Rate,Therapy Per Visit,98.77,83,,98.77,percent of total billed charges,Therapy,12.79,,,12.79,Case Rate,,257,,,257,Case Rate,Therapy Per Visit,98.77,83,,98.77,percent of total billed charges,Therapy,368,,,368,Case Rate,Therapy Visit,83.3,70,,83.3,percent of total billed charges,All Other,259,,,259,Case Rate,Therapy Visit,220,,,220,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,138,,,138,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,131,,,131,Case Rate,Therapy Visit,20.84,,,20.84,Other,100% of Medicaid,20.84,,,20.84,Other,100% of Medicaid,20.84,,,20.84,Other,100% of Medicaid,20.84,,,20.84,Other,100% of Medicaid,46.9,,,46.9,Other,225% of Medicaid,31.89,,,31.89,Other,153% of Medicaid,46.9,,,46.9,Other,225% of Medicaid,29.18,,,29.18,Other,140% of Medicaid,46.9,,,46.9,Other,225% of Medicaid,54.2,,,54.2,Other,260% of Medicaid,67.54,,,67.54,Other,324% of Medicaid,44.82,,,44.82,Other,215% of Medicaid,44.82,,,44.82,Other,215% of Medicaid,26.06,,,26.06,Other,125% of Medicaid,12.79,368,
ELECT STIM;MANUAL;EACH 15,97032,CPT,GO,63097032,CDM,430,RC,,,both,,,118,87.32,,,87.32,Other,150% of Medicare + 9.63% HCRA Surcharge,53.1,45,,53.1,percent of total billed charges,Critical Access Hospital RCC factor,180,,,180,Case Rate,Therapy Per Visit,162,,,162,Case Rate,Therapy Per Visit,108.88,,,108.88,Fee Schedule,,97.93,,,97.93,Fee Schedule,,92.56,,,92.56,Fee Schedule,,58.41,,,58.41,Other,110% of Medicare,219,,,219,Case Rate,Therapy Per Visit,39,,,39,Other,186% of Medicaid,257,,,257,Case Rate,Therapy Per Visit,97.94,83,,97.94,percent of total billed charges,Therapy,31.77,,,31.77,Case Rate,,257,,,257,Case Rate,Therapy Per Visit,97.94,83,,97.94,percent of total billed charges,Therapy,368,,,368,Case Rate,Therapy Visit,82.6,70,,82.6,percent of total billed charges,All Other,259,,,259,Case Rate,Therapy Visit,220,,,220,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,138,,,138,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,131,,,131,Case Rate,Therapy Visit,20.84,,,20.84,Other,100% of Medicaid,20.84,,,20.84,Other,100% of Medicaid,20.84,,,20.84,Other,100% of Medicaid,20.84,,,20.84,Other,100% of Medicaid,46.9,,,46.9,Other,225% of Medicaid,31.89,,,31.89,Other,153% of Medicaid,46.9,,,46.9,Other,225% of Medicaid,29.18,,,29.18,Other,140% of Medicaid,46.9,,,46.9,Other,225% of Medicaid,54.2,,,54.2,Other,260% of Medicaid,67.54,,,67.54,Other,324% of Medicaid,44.82,,,44.82,Other,215% of Medicaid,44.82,,,44.82,Other,215% of Medicaid,26.06,,,26.06,Other,125% of Medicaid,20.84,368,
IONTOPHORESIS,97033,CPT,GO,63097033,CDM,430,RC,,,both,,,182,134.68,,,134.68,Other,150% of Medicare + 9.63% HCRA Surcharge,81.9,45,,81.9,percent of total billed charges,Critical Access Hospital RCC factor,180,,,180,Case Rate,Therapy Per Visit,162,,,162,Case Rate,Therapy Per Visit,179.44,,,179.44,Fee Schedule,,161.4,,,161.4,Fee Schedule,,152.54,,,152.54,Fee Schedule,,90.09,,,90.09,Other,110% of Medicare,219,,,219,Case Rate,Therapy Per Visit,39,,,39,Other,186% of Medicaid,257,,,257,Case Rate,Therapy Per Visit,151.06,83,,151.06,percent of total billed charges,Therapy,43.16,,,43.16,Case Rate,,257,,,257,Case Rate,Therapy Per Visit,151.06,83,,151.06,percent of total billed charges,Therapy,368,,,368,Case Rate,Therapy Visit,127.4,70,,127.4,percent of total billed charges,All Other,259,,,259,Case Rate,Therapy Visit,220,,,220,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,138,,,138,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,131,,,131,Case Rate,Therapy Visit,20.84,,,20.84,Other,100% of Medicaid,20.84,,,20.84,Other,100% of Medicaid,20.84,,,20.84,Other,100% of Medicaid,20.84,,,20.84,Other,100% of Medicaid,46.9,,,46.9,Other,225% of Medicaid,31.89,,,31.89,Other,153% of Medicaid,46.9,,,46.9,Other,225% of Medicaid,29.18,,,29.18,Other,140% of Medicaid,46.9,,,46.9,Other,225% of Medicaid,54.2,,,54.2,Other,260% of Medicaid,67.54,,,67.54,Other,324% of Medicaid,44.82,,,44.82,Other,215% of Medicaid,44.82,,,44.82,Other,215% of Medicaid,26.06,,,26.06,Other,125% of Medicaid,20.84,368,
CONTRAST BATH THERAPY,97034,CPT,GO,63097034,CDM,430,RC,,,both,,,82,60.68,,,60.68,Other,150% of Medicare + 9.63% HCRA Surcharge,36.9,45,,36.9,percent of total billed charges,Critical Access Hospital RCC factor,180,,,180,Case Rate,Therapy Per Visit,162,,,162,Case Rate,Therapy Per Visit,101.39,,,101.39,Fee Schedule,,91.2,,,91.2,Fee Schedule,,86.2,,,86.2,Fee Schedule,,40.59,,,40.59,Other,110% of Medicare,219,,,219,Case Rate,Therapy Per Visit,39,,,39,Other,186% of Medicaid,257,,,257,Case Rate,Therapy Per Visit,68.06,83,,68.06,percent of total billed charges,Therapy,31.19,,,31.19,Case Rate,,257,,,257,Case Rate,Therapy Per Visit,68.06,83,,68.06,percent of total billed charges,Therapy,368,,,368,Case Rate,Therapy Visit,57.4,70,,57.4,percent of total billed charges,All Other,259,,,259,Case Rate,Therapy Visit,220,,,220,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,138,,,138,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,131,,,131,Case Rate,Therapy Visit,20.84,,,20.84,Other,100% of Medicaid,20.84,,,20.84,Other,100% of Medicaid,20.84,,,20.84,Other,100% of Medicaid,20.84,,,20.84,Other,100% of Medicaid,46.9,,,46.9,Other,225% of Medicaid,31.89,,,31.89,Other,153% of Medicaid,46.9,,,46.9,Other,225% of Medicaid,29.18,,,29.18,Other,140% of Medicaid,46.9,,,46.9,Other,225% of Medicaid,54.2,,,54.2,Other,260% of Medicaid,67.54,,,67.54,Other,324% of Medicaid,44.82,,,44.82,Other,215% of Medicaid,44.82,,,44.82,Other,215% of Medicaid,26.06,,,26.06,Other,125% of Medicaid,20.84,368,
ULTRASOUND THERAPY,97035,CPT,GO,63097035,CDM,430,RC,,,both,,,127,93.98,,,93.98,Other,150% of Medicare + 9.63% HCRA Surcharge,57.15,45,,57.15,percent of total billed charges,Critical Access Hospital RCC factor,180,,,180,Case Rate,Therapy Per Visit,162,,,162,Case Rate,Therapy Per Visit,71.62,,,71.62,Fee Schedule,,64.42,,,64.42,Fee Schedule,,60.88,,,60.88,Fee Schedule,,62.87,,,62.87,Other,110% of Medicare,219,,,219,Case Rate,Therapy Per Visit,39,,,39,Other,186% of Medicaid,257,,,257,Case Rate,Therapy Per Visit,105.41,83,,105.41,percent of total billed charges,Therapy,31.19,,,31.19,Case Rate,,257,,,257,Case Rate,Therapy Per Visit,105.41,83,,105.41,percent of total billed charges,Therapy,368,,,368,Case Rate,Therapy Visit,88.9,70,,88.9,percent of total billed charges,All Other,259,,,259,Case Rate,Therapy Visit,220,,,220,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,138,,,138,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,131,,,131,Case Rate,Therapy Visit,20.84,,,20.84,Other,100% of Medicaid,20.84,,,20.84,Other,100% of Medicaid,20.84,,,20.84,Other,100% of Medicaid,20.84,,,20.84,Other,100% of Medicaid,46.9,,,46.9,Other,225% of Medicaid,31.89,,,31.89,Other,153% of Medicaid,46.9,,,46.9,Other,225% of Medicaid,29.18,,,29.18,Other,140% of Medicaid,46.9,,,46.9,Other,225% of Medicaid,54.2,,,54.2,Other,260% of Medicaid,67.54,,,67.54,Other,324% of Medicaid,44.82,,,44.82,Other,215% of Medicaid,44.82,,,44.82,Other,215% of Medicaid,26.06,,,26.06,Other,125% of Medicaid,20.84,368,
THERAPEUTIC EXERCISES,97110,CPT,GO,63097110,CDM,430,RC,,,both,,,187,138.38,,,138.38,Other,150% of Medicare + 9.63% HCRA Surcharge,84.15,45,,84.15,percent of total billed charges,Critical Access Hospital RCC factor,180,,,180,Case Rate,Therapy Per Visit,162,,,162,Case Rate,Therapy Per Visit,180.81,,,180.81,Fee Schedule,,162.63,,,162.63,Fee Schedule,,153.71,,,153.71,Fee Schedule,,92.57,,,92.57,Other,110% of Medicare,219,,,219,Case Rate,Therapy Per Visit,109,,,109,Other,186% of Medicaid,257,,,257,Case Rate,Therapy Per Visit,155.21,83,,155.21,percent of total billed charges,Therapy,65.18,,,65.18,Case Rate,,257,,,257,Case Rate,Therapy Per Visit,155.21,83,,155.21,percent of total billed charges,Therapy,368,,,368,Case Rate,Therapy Visit,130.9,70,,130.9,percent of total billed charges,All Other,259,,,259,Case Rate,Therapy Visit,220,,,220,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,138,,,138,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,131,,,131,Case Rate,Therapy Visit,58.77,,,58.77,Other,100% of Medicaid,58.77,,,58.77,Other,100% of Medicaid,58.77,,,58.77,Other,100% of Medicaid,58.77,,,58.77,Other,100% of Medicaid,132.23,,,132.23,Other,225% of Medicaid,89.92,,,89.92,Other,153% of Medicaid,132.23,,,132.23,Other,225% of Medicaid,82.28,,,82.28,Other,140% of Medicaid,132.23,,,132.23,Other,225% of Medicaid,152.8,,,152.8,Other,260% of Medicaid,190.42,,,190.42,Other,324% of Medicaid,126.36,,,126.36,Other,215% of Medicaid,126.36,,,126.36,Other,215% of Medicaid,73.46,,,73.46,Other,125% of Medicaid,58.77,368,
NEUROMUSCULAR REEDUCATION,97112,CPT,GO,63097112,CDM,430,RC,,,both,,,208,153.92,,,153.92,Other,150% of Medicare + 9.63% HCRA Surcharge,93.6,45,,93.6,percent of total billed charges,Critical Access Hospital RCC factor,180,,,180,Case Rate,Therapy Per Visit,162,,,162,Case Rate,Therapy Per Visit,189.98,,,189.98,Fee Schedule,,170.88,,,170.88,Fee Schedule,,161.5,,,161.5,Fee Schedule,,102.96,,,102.96,Other,110% of Medicare,219,,,219,Case Rate,Therapy Per Visit,109,,,109,Other,186% of Medicaid,257,,,257,Case Rate,Therapy Per Visit,172.64,83,,172.64,percent of total billed charges,Therapy,74.87,,,74.87,Case Rate,,257,,,257,Case Rate,Therapy Per Visit,172.64,83,,172.64,percent of total billed charges,Therapy,368,,,368,Case Rate,Therapy Visit,145.6,70,,145.6,percent of total billed charges,All Other,259,,,259,Case Rate,Therapy Visit,220,,,220,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,138,,,138,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,131,,,131,Case Rate,Therapy Visit,58.77,,,58.77,Other,100% of Medicaid,58.77,,,58.77,Other,100% of Medicaid,58.77,,,58.77,Other,100% of Medicaid,58.77,,,58.77,Other,100% of Medicaid,132.23,,,132.23,Other,225% of Medicaid,89.92,,,89.92,Other,153% of Medicaid,132.23,,,132.23,Other,225% of Medicaid,82.28,,,82.28,Other,140% of Medicaid,132.23,,,132.23,Other,225% of Medicaid,152.8,,,152.8,Other,260% of Medicaid,190.42,,,190.42,Other,324% of Medicaid,126.36,,,126.36,Other,215% of Medicaid,126.36,,,126.36,Other,215% of Medicaid,73.46,,,73.46,Other,125% of Medicaid,58.77,368,
MASSAGE THERAPY,97124,CPT,GO,63097124,CDM,430,RC,,,both,,,145,107.3,,,107.3,Other,150% of Medicare + 9.63% HCRA Surcharge,65.25,45,,65.25,percent of total billed charges,Critical Access Hospital RCC factor,180,,,180,Case Rate,Therapy Per Visit,162,,,162,Case Rate,Therapy Per Visit,148.3,,,148.3,Fee Schedule,,133.38,,,133.38,Fee Schedule,,126.07,,,126.07,Fee Schedule,,71.78,,,71.78,Other,110% of Medicare,219,,,219,Case Rate,Therapy Per Visit,39,,,39,Other,186% of Medicaid,257,,,257,Case Rate,Therapy Per Visit,120.35,83,,120.35,percent of total billed charges,Therapy,67.87,,,67.87,Case Rate,,257,,,257,Case Rate,Therapy Per Visit,120.35,83,,120.35,percent of total billed charges,Therapy,368,,,368,Case Rate,Therapy Visit,101.5,70,,101.5,percent of total billed charges,All Other,259,,,259,Case Rate,Therapy Visit,220,,,220,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,138,,,138,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,131,,,131,Case Rate,Therapy Visit,20.84,,,20.84,Other,100% of Medicaid,20.84,,,20.84,Other,100% of Medicaid,20.84,,,20.84,Other,100% of Medicaid,20.84,,,20.84,Other,100% of Medicaid,46.9,,,46.9,Other,225% of Medicaid,31.89,,,31.89,Other,153% of Medicaid,46.9,,,46.9,Other,225% of Medicaid,29.18,,,29.18,Other,140% of Medicaid,46.9,,,46.9,Other,225% of Medicaid,54.2,,,54.2,Other,260% of Medicaid,67.54,,,67.54,Other,324% of Medicaid,44.82,,,44.82,Other,215% of Medicaid,44.82,,,44.82,Other,215% of Medicaid,26.06,,,26.06,Other,125% of Medicaid,20.84,368,
FLUIDOTHERAPY,97039,CPT,GO,63097139,CDM,430,RC,,,both,,,111,82.14,,,82.14,Other,150% of Medicare + 9.63% HCRA Surcharge,49.95,45,,49.95,percent of total billed charges,Critical Access Hospital RCC factor,180,,,180,Case Rate,Therapy Per Visit,162,,,162,Case Rate,Therapy Per Visit,84.92,76.5,,84.92,percent of total billed charges,All Other,78.81,69,,78.81,percent of total billed charges,All Other,76.59,65,,76.59,percent of total billed charges,All Other,54.95,,,54.95,Other,110% of Medicare,219,,,219,Case Rate,Therapy Per Visit,39,,,39,Other,186% of Medicaid,257,,,257,Case Rate,Therapy Per Visit,92.13,83,,92.13,percent of total billed charges,Therapy,61.05,83,,61.05,percent of total billed charges,All Other,257,,,257,Case Rate,Therapy Per Visit,92.13,83,,92.13,percent of total billed charges,Therapy,368,,,368,Case Rate,Therapy Visit,77.7,70,,77.7,percent of total billed charges,All Other,259,,,259,Case Rate,Therapy Visit,220,,,220,Case Rate,Therapy Visit,0.01,,,0.01,Fee Schedule,Therapy Visit,0.01,,,0.01,Fee Schedule,Therapy Visit,0.01,,,0.01,Fee Schedule,Therapy Visit,0.01,,,0.01,Fee Schedule,Therapy Visit,20.84,,,20.84,Other,100% of Medicaid,20.84,,,20.84,Other,100% of Medicaid,20.84,,,20.84,Other,100% of Medicaid,20.84,,,20.84,Other,100% of Medicaid,46.9,,,46.9,Other,225% of Medicaid,31.89,,,31.89,Other,153% of Medicaid,46.9,,,46.9,Other,225% of Medicaid,29.18,,,29.18,Other,140% of Medicaid,46.9,,,46.9,Other,225% of Medicaid,54.2,,,54.2,Other,260% of Medicaid,67.54,,,67.54,Other,324% of Medicaid,44.82,,,44.82,Other,215% of Medicaid,44.82,,,44.82,Other,215% of Medicaid,26.06,,,26.06,Other,125% of Medicaid,0.01,368,
MANUAL THERAPY,97140,CPT,GO,63097140,CDM,430,RC,,,both,,,198,146.52,,,146.52,Other,150% of Medicare + 9.63% HCRA Surcharge,89.1,45,,89.1,percent of total billed charges,Critical Access Hospital RCC factor,180,,,180,Case Rate,Therapy Per Visit,162,,,162,Case Rate,Therapy Per Visit,170.17,,,170.17,Fee Schedule,,153.05,,,153.05,Fee Schedule,,144.66,,,144.66,Fee Schedule,,98.01,,,98.01,Other,110% of Medicare,219,,,219,Case Rate,Therapy Per Visit,109,,,109,Other,186% of Medicaid,257,,,257,Case Rate,Therapy Per Visit,164.34,83,,164.34,percent of total billed charges,Therapy,59.93,,,59.93,Case Rate,,257,,,257,Case Rate,Therapy Per Visit,164.34,83,,164.34,percent of total billed charges,Therapy,368,,,368,Case Rate,Therapy Visit,138.6,70,,138.6,percent of total billed charges,All Other,259,,,259,Case Rate,Therapy Visit,220,,,220,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,138,,,138,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,131,,,131,Case Rate,Therapy Visit,58.77,,,58.77,Other,100% of Medicaid,58.77,,,58.77,Other,100% of Medicaid,58.77,,,58.77,Other,100% of Medicaid,58.77,,,58.77,Other,100% of Medicaid,132.23,,,132.23,Other,225% of Medicaid,89.92,,,89.92,Other,153% of Medicaid,132.23,,,132.23,Other,225% of Medicaid,82.28,,,82.28,Other,140% of Medicaid,132.23,,,132.23,Other,225% of Medicaid,152.8,,,152.8,Other,260% of Medicaid,190.42,,,190.42,Other,324% of Medicaid,126.36,,,126.36,Other,215% of Medicaid,126.36,,,126.36,Other,215% of Medicaid,73.46,,,73.46,Other,125% of Medicaid,58.77,368,
THERAPEUTIC REHAB GROUP,97150,CPT,GO,63097150,CDM,430,RC,,,both,,,96,71.04,,,71.04,Other,150% of Medicare + 9.63% HCRA Surcharge,43.2,45,,43.2,percent of total billed charges,Critical Access Hospital RCC factor,180,,,180,Case Rate,Therapy Per Visit,162,,,162,Case Rate,Therapy Per Visit,117.2,,,117.2,Fee Schedule,,105.42,,,105.42,Fee Schedule,,99.64,,,99.64,Fee Schedule,,47.52,,,47.52,Other,110% of Medicare,219,,,219,Case Rate,Therapy Per Visit,109,,,109,Other,186% of Medicaid,257,,,257,Case Rate,Therapy Per Visit,79.68,83,,79.68,percent of total billed charges,Therapy,39.98,,,39.98,Case Rate,,257,,,257,Case Rate,Therapy Per Visit,79.68,83,,79.68,percent of total billed charges,Therapy,368,,,368,Case Rate,Therapy Visit,67.2,70,,67.2,percent of total billed charges,All Other,259,,,259,Case Rate,Therapy Visit,220,,,220,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,138,,,138,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,131,,,131,Case Rate,Therapy Visit,58.77,,,58.77,Other,100% of Medicaid,58.77,,,58.77,Other,100% of Medicaid,58.77,,,58.77,Other,100% of Medicaid,58.77,,,58.77,Other,100% of Medicaid,132.23,,,132.23,Other,225% of Medicaid,89.92,,,89.92,Other,153% of Medicaid,132.23,,,132.23,Other,225% of Medicaid,82.28,,,82.28,Other,140% of Medicaid,132.23,,,132.23,Other,225% of Medicaid,152.8,,,152.8,Other,260% of Medicaid,190.42,,,190.42,Other,324% of Medicaid,126.36,,,126.36,Other,215% of Medicaid,126.36,,,126.36,Other,215% of Medicaid,73.46,,,73.46,Other,125% of Medicaid,39.98,368,
THERAPEUTIC ACTIVITIES,97530,CPT,GO,63097530,CDM,430,RC,,,both,,,209,154.66,,,154.66,Other,150% of Medicare + 9.63% HCRA Surcharge,94.05,45,,94.05,percent of total billed charges,Critical Access Hospital RCC factor,180,,,180,Case Rate,Therapy Per Visit,162,,,162,Case Rate,Therapy Per Visit,199.52,,,199.52,Fee Schedule,,179.46,,,179.46,Fee Schedule,,169.61,,,169.61,Fee Schedule,,103.46,,,103.46,Other,110% of Medicare,219,,,219,Case Rate,Therapy Per Visit,109,,,109,Other,186% of Medicaid,257,,,257,Case Rate,Therapy Per Visit,173.47,83,,173.47,percent of total billed charges,Therapy,81.96,,,81.96,Case Rate,,257,,,257,Case Rate,Therapy Per Visit,173.47,83,,173.47,percent of total billed charges,Therapy,368,,,368,Case Rate,Therapy Visit,146.3,70,,146.3,percent of total billed charges,All Other,259,,,259,Case Rate,Therapy Visit,220,,,220,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,138,,,138,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,131,,,131,Case Rate,Therapy Visit,58.77,,,58.77,Other,100% of Medicaid,58.77,,,58.77,Other,100% of Medicaid,58.77,,,58.77,Other,100% of Medicaid,58.77,,,58.77,Other,100% of Medicaid,132.23,,,132.23,Other,225% of Medicaid,89.92,,,89.92,Other,153% of Medicaid,132.23,,,132.23,Other,225% of Medicaid,82.28,,,82.28,Other,140% of Medicaid,132.23,,,132.23,Other,225% of Medicaid,152.8,,,152.8,Other,260% of Medicaid,190.42,,,190.42,Other,324% of Medicaid,126.36,,,126.36,Other,215% of Medicaid,126.36,,,126.36,Other,215% of Medicaid,73.46,,,73.46,Other,125% of Medicaid,58.77,368,
SELF CARE MNGMENT TRAINING,97535,CPT,GO,63097535,CDM,430,RC,,,both,,,193,142.82,,,142.82,Other,150% of Medicare + 9.63% HCRA Surcharge,86.85,45,,86.85,percent of total billed charges,Critical Access Hospital RCC factor,180,,,180,Case Rate,Therapy Per Visit,162,,,162,Case Rate,Therapy Per Visit,199.1,,,199.1,Fee Schedule,,179.08,,,179.08,Fee Schedule,,169.25,,,169.25,Fee Schedule,,95.54,,,95.54,Other,110% of Medicare,219,,,219,Case Rate,Therapy Per Visit,39,,,39,Other,186% of Medicaid,257,,,257,Case Rate,Therapy Per Visit,160.19,83,,160.19,percent of total billed charges,Therapy,72.79,,,72.79,Case Rate,,257,,,257,Case Rate,Therapy Per Visit,160.19,83,,160.19,percent of total billed charges,Therapy,368,,,368,Case Rate,Therapy Visit,135.1,70,,135.1,percent of total billed charges,All Other,259,,,259,Case Rate,Therapy Visit,220,,,220,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,138,,,138,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,131,,,131,Case Rate,Therapy Visit,20.84,,,20.84,Other,100% of Medicaid,20.84,,,20.84,Other,100% of Medicaid,20.84,,,20.84,Other,100% of Medicaid,20.84,,,20.84,Other,100% of Medicaid,46.9,,,46.9,Other,225% of Medicaid,31.89,,,31.89,Other,153% of Medicaid,46.9,,,46.9,Other,225% of Medicaid,29.18,,,29.18,Other,140% of Medicaid,46.9,,,46.9,Other,225% of Medicaid,54.2,,,54.2,Other,260% of Medicaid,67.54,,,67.54,Other,324% of Medicaid,44.82,,,44.82,Other,215% of Medicaid,44.82,,,44.82,Other,215% of Medicaid,26.06,,,26.06,Other,125% of Medicaid,20.84,368,
COMMUNITY/WORK REINTEGRATION EA 15 MIN,97537,CPT,GO,63097537,CDM,430,RC,,,both,,,141,104.34,,,104.34,Other,150% of Medicare + 9.63% HCRA Surcharge,63.45,45,,63.45,percent of total billed charges,Critical Access Hospital RCC factor,180,,,180,Case Rate,Therapy Per Visit,162,,,162,Case Rate,Therapy Per Visit,171.64,,,171.64,Fee Schedule,,154.38,,,154.38,Fee Schedule,,145.91,,,145.91,Fee Schedule,,69.8,,,69.8,Other,110% of Medicare,219,,,219,Case Rate,Therapy Per Visit,109,,,109,Other,186% of Medicaid,257,,,257,Case Rate,Therapy Per Visit,117.03,83,,117.03,percent of total billed charges,Therapy,70.37,,,70.37,Case Rate,,257,,,257,Case Rate,Therapy Per Visit,117.03,83,,117.03,percent of total billed charges,Therapy,368,,,368,Case Rate,Therapy Visit,98.7,70,,98.7,percent of total billed charges,All Other,259,,,259,Case Rate,Therapy Visit,220,,,220,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,138,,,138,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,131,,,131,Case Rate,Therapy Visit,58.77,,,58.77,Other,100% of Medicaid,58.77,,,58.77,Other,100% of Medicaid,58.77,,,58.77,Other,100% of Medicaid,58.77,,,58.77,Other,100% of Medicaid,132.23,,,132.23,Other,225% of Medicaid,89.92,,,89.92,Other,153% of Medicaid,132.23,,,132.23,Other,225% of Medicaid,82.28,,,82.28,Other,140% of Medicaid,132.23,,,132.23,Other,225% of Medicaid,152.8,,,152.8,Other,260% of Medicaid,190.42,,,190.42,Other,324% of Medicaid,126.36,,,126.36,Other,215% of Medicaid,126.36,,,126.36,Other,215% of Medicaid,73.46,,,73.46,Other,125% of Medicaid,58.77,368,
WHEELCHAIR MGT TRAINING 15MIN,97542,CPT,GO,63097542,CDM,430,RC,,,both,,,190,140.6,,,140.6,Other,150% of Medicare + 9.63% HCRA Surcharge,85.5,45,,85.5,percent of total billed charges,Critical Access Hospital RCC factor,180,,,180,Case Rate,Therapy Per Visit,162,,,162,Case Rate,Therapy Per Visit,173.96,,,173.96,Fee Schedule,,156.47,,,156.47,Fee Schedule,,147.88,,,147.88,Fee Schedule,,94.05,,,94.05,Other,110% of Medicare,219,,,219,Case Rate,Therapy Per Visit,109,,,109,Other,186% of Medicaid,257,,,257,Case Rate,Therapy Per Visit,157.7,83,,157.7,percent of total billed charges,Therapy,70.37,,,70.37,Case Rate,,257,,,257,Case Rate,Therapy Per Visit,157.7,83,,157.7,percent of total billed charges,Therapy,368,,,368,Case Rate,Therapy Visit,133,70,,133,percent of total billed charges,All Other,259,,,259,Case Rate,Therapy Visit,220,,,220,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,138,,,138,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,131,,,131,Case Rate,Therapy Visit,58.77,,,58.77,Other,100% of Medicaid,58.77,,,58.77,Other,100% of Medicaid,58.77,,,58.77,Other,100% of Medicaid,58.77,,,58.77,Other,100% of Medicaid,132.23,,,132.23,Other,225% of Medicaid,89.92,,,89.92,Other,153% of Medicaid,132.23,,,132.23,Other,225% of Medicaid,82.28,,,82.28,Other,140% of Medicaid,132.23,,,132.23,Other,225% of Medicaid,152.8,,,152.8,Other,260% of Medicaid,190.42,,,190.42,Other,324% of Medicaid,126.36,,,126.36,Other,215% of Medicaid,126.36,,,126.36,Other,215% of Medicaid,73.46,,,73.46,Other,125% of Medicaid,58.77,368,
SLCTV WND DEBRIDEM 20 CM OR <,97597,CPT,GO,63097597,CDM,430,RC,,,both,,,573,424.02,,,424.02,Other,150% of Medicare + 9.63% HCRA Surcharge,257.85,45,,257.85,percent of total billed charges,Critical Access Hospital RCC factor,180,,,180,Case Rate,Therapy Per Visit,162,,,162,Case Rate,Therapy Per Visit,438.35,76.5,,438.35,percent of total billed charges,All Other,406.83,69,,406.83,percent of total billed charges,All Other,395.37,65,,395.37,percent of total billed charges,All Other,283.64,,,283.64,Other,110% of Medicare,219,,,219,Case Rate,Therapy Per Visit,703,,,703,Other,186% of Medicaid,257,,,257,Case Rate,Therapy Per Visit,475.59,83,,475.59,percent of total billed charges,Therapy,475.59,,,475.59,Other,Non Covered Service,257,,,257,Case Rate,Therapy Per Visit,475.59,83,,475.59,percent of total billed charges,Therapy,368,,,368,Case Rate,Therapy Visit,401.1,70,,401.1,percent of total billed charges,All Other,259,,,259,Case Rate,Therapy Visit,220,,,220,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,138,,,138,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,131,,,131,Case Rate,Therapy Visit,377.82,,,377.82,Other,100% of Medicaid,377.82,,,377.82,Other,100% of Medicaid,377.82,,,377.82,Other,100% of Medicaid,377.82,,,377.82,Other,100% of Medicaid,850.1,,,850.1,Other,225% of Medicaid,578.07,,,578.07,Other,153% of Medicaid,850.1,,,850.1,Other,225% of Medicaid,528.95,,,528.95,Other,140% of Medicaid,850.1,,,850.1,Other,225% of Medicaid,982.34,,,982.34,Other,260% of Medicaid,1224.15,,,1224.15,Other,324% of Medicaid,812.32,,,812.32,Other,215% of Medicaid,812.32,,,812.32,Other,215% of Medicaid,472.28,,,472.28,Other,125% of Medicaid,131,1224.15,
ORTHOTIC MGMT AND TRAINING,97760,CPT,GO,63097760,CDM,430,RC,,,both,,,201,148.74,,,148.74,Other,150% of Medicare + 9.63% HCRA Surcharge,90.45,45,,90.45,percent of total billed charges,Critical Access Hospital RCC factor,180,,,180,Case Rate,Therapy Per Visit,162,,,162,Case Rate,Therapy Per Visit,217.65,,,217.65,Fee Schedule,,195.76,,,195.76,Fee Schedule,,185.02,,,185.02,Fee Schedule,,99.5,,,99.5,Other,110% of Medicare,219,,,219,Case Rate,Therapy Per Visit,109,,,109,Other,186% of Medicaid,257,,,257,Case Rate,Therapy Per Visit,166.83,83,,166.83,percent of total billed charges,Therapy,106.81,,,106.81,Fee Schedule,,257,,,257,Case Rate,Therapy Per Visit,166.83,83,,166.83,percent of total billed charges,Therapy,368,,,368,Case Rate,Therapy Visit,140.7,70,,140.7,percent of total billed charges,All Other,259,,,259,Case Rate,Therapy Visit,220,,,220,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,138,,,138,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,131,,,131,Case Rate,Therapy Visit,58.77,,,58.77,Other,100% of Medicaid,58.77,,,58.77,Other,100% of Medicaid,58.77,,,58.77,Other,100% of Medicaid,58.77,,,58.77,Other,100% of Medicaid,132.23,,,132.23,Other,225% of Medicaid,89.92,,,89.92,Other,153% of Medicaid,132.23,,,132.23,Other,225% of Medicaid,82.28,,,82.28,Other,140% of Medicaid,132.23,,,132.23,Other,225% of Medicaid,152.8,,,152.8,Other,260% of Medicaid,190.42,,,190.42,Other,324% of Medicaid,126.36,,,126.36,Other,215% of Medicaid,126.36,,,126.36,Other,215% of Medicaid,73.46,,,73.46,Other,125% of Medicaid,58.77,368,
APPLY LONG ARM SPLINT,29105,CPT,GO,63129105,CDM,430,RC,,,both,,,544,402.56,,,402.56,Other,150% of Medicare + 9.63% HCRA Surcharge,244.8,45,,244.8,percent of total billed charges,Critical Access Hospital RCC factor,180,,,180,Case Rate,Therapy Per Visit,162,,,162,Case Rate,Therapy Per Visit,416.16,76.5,,416.16,percent of total billed charges,All Other,386.24,69,,386.24,percent of total billed charges,All Other,375.36,65,,375.36,percent of total billed charges,All Other,269.28,,,269.28,Other,110% of Medicare,219,,,219,Case Rate,Therapy Per Visit,325,,,325,Other,186% of Medicaid,257,,,257,Case Rate,Therapy Per Visit,451.52,83,,451.52,percent of total billed charges,Therapy,93.56,,,93.56,Fee Schedule,,257,,,257,Case Rate,Therapy Per Visit,451.52,83,,451.52,percent of total billed charges,Therapy,368,,,368,Case Rate,Therapy Visit,380.8,70,,380.8,percent of total billed charges,All Other,259,,,259,Case Rate,Therapy Visit,220,,,220,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,138,,,138,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,131,,,131,Case Rate,Therapy Visit,174.92,,,174.92,Other,100% of Medicaid,174.92,,,174.92,Other,100% of Medicaid,174.92,,,174.92,Other,100% of Medicaid,174.92,,,174.92,Other,100% of Medicaid,393.57,,,393.57,Other,225% of Medicaid,267.62,,,267.62,Other,153% of Medicaid,393.57,,,393.57,Other,225% of Medicaid,244.89,,,244.89,Other,140% of Medicaid,393.57,,,393.57,Other,225% of Medicaid,454.79,,,454.79,Other,260% of Medicaid,566.73,,,566.73,Other,324% of Medicaid,376.07,,,376.07,Other,215% of Medicaid,376.07,,,376.07,Other,215% of Medicaid,218.65,,,218.65,Other,125% of Medicaid,93.56,566.73,
APPLY FOREARM SPLINT,29125,CPT,GO,63129125,CDM,430,RC,,,both,,,563,416.62,,,416.62,Other,150% of Medicare + 9.63% HCRA Surcharge,253.35,45,,253.35,percent of total billed charges,Critical Access Hospital RCC factor,180,,,180,Case Rate,Therapy Per Visit,162,,,162,Case Rate,Therapy Per Visit,430.7,76.5,,430.7,percent of total billed charges,All Other,399.73,69,,399.73,percent of total billed charges,All Other,388.47,65,,388.47,percent of total billed charges,All Other,278.69,,,278.69,Other,110% of Medicare,219,,,219,Case Rate,Therapy Per Visit,325,,,325,Other,186% of Medicaid,257,,,257,Case Rate,Therapy Per Visit,467.29,83,,467.29,percent of total billed charges,Therapy,91.73,,,91.73,Fee Schedule,,257,,,257,Case Rate,Therapy Per Visit,467.29,83,,467.29,percent of total billed charges,Therapy,368,,,368,Case Rate,Therapy Visit,394.1,70,,394.1,percent of total billed charges,All Other,259,,,259,Case Rate,Therapy Visit,220,,,220,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,138,,,138,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,131,,,131,Case Rate,Therapy Visit,174.92,,,174.92,Other,100% of Medicaid,174.92,,,174.92,Other,100% of Medicaid,174.92,,,174.92,Other,100% of Medicaid,174.92,,,174.92,Other,100% of Medicaid,393.57,,,393.57,Other,225% of Medicaid,267.62,,,267.62,Other,153% of Medicaid,393.57,,,393.57,Other,225% of Medicaid,244.89,,,244.89,Other,140% of Medicaid,393.57,,,393.57,Other,225% of Medicaid,454.79,,,454.79,Other,260% of Medicaid,566.73,,,566.73,Other,324% of Medicaid,376.07,,,376.07,Other,215% of Medicaid,376.07,,,376.07,Other,215% of Medicaid,218.65,,,218.65,Other,125% of Medicaid,91.73,566.73,
TH-THERAPEUTIC EXERCISES,97110,CPT,GOGT,63297110,CDM,430,RC,,,both,,,187,138.38,,,138.38,Other,150% of Medicare + 9.63% HCRA Surcharge,84.15,45,,84.15,percent of total billed charges,Critical Access Hospital RCC factor,180,,,180,Case Rate,Therapy Per Visit,162,,,162,Case Rate,Therapy Per Visit,180.81,,,180.81,Fee Schedule,,162.63,,,162.63,Fee Schedule,,153.71,,,153.71,Fee Schedule,,92.57,,,92.57,Other,110% of Medicare,219,,,219,Case Rate,Therapy Per Visit,109,,,109,Other,186% of Medicaid,257,,,257,Case Rate,Therapy Per Visit,155.21,83,,155.21,percent of total billed charges,Therapy,65.18,,,65.18,Case Rate,,257,,,257,Case Rate,Therapy Per Visit,155.21,83,,155.21,percent of total billed charges,Therapy,368,,,368,Case Rate,Therapy Visit,130.9,70,,130.9,percent of total billed charges,All Other,259,,,259,Case Rate,Therapy Visit,220,,,220,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,138,,,138,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,131,,,131,Case Rate,Therapy Visit,58.77,,,58.77,Other,100% of Medicaid,58.77,,,58.77,Other,100% of Medicaid,58.77,,,58.77,Other,100% of Medicaid,58.77,,,58.77,Other,100% of Medicaid,132.23,,,132.23,Other,225% of Medicaid,89.92,,,89.92,Other,153% of Medicaid,132.23,,,132.23,Other,225% of Medicaid,82.28,,,82.28,Other,140% of Medicaid,132.23,,,132.23,Other,225% of Medicaid,152.8,,,152.8,Other,260% of Medicaid,190.42,,,190.42,Other,324% of Medicaid,126.36,,,126.36,Other,215% of Medicaid,126.36,,,126.36,Other,215% of Medicaid,73.46,,,73.46,Other,125% of Medicaid,58.77,368,
TH-NEUROMUSCULAR REEDUCATION,97112,CPT,GOGT,63297112,CDM,430,RC,,,both,,,208,153.92,,,153.92,Other,150% of Medicare + 9.63% HCRA Surcharge,93.6,45,,93.6,percent of total billed charges,Critical Access Hospital RCC factor,180,,,180,Case Rate,Therapy Per Visit,162,,,162,Case Rate,Therapy Per Visit,189.98,,,189.98,Fee Schedule,,170.88,,,170.88,Fee Schedule,,161.5,,,161.5,Fee Schedule,,102.96,,,102.96,Other,110% of Medicare,219,,,219,Case Rate,Therapy Per Visit,109,,,109,Other,186% of Medicaid,257,,,257,Case Rate,Therapy Per Visit,172.64,83,,172.64,percent of total billed charges,Therapy,74.87,,,74.87,Case Rate,,257,,,257,Case Rate,Therapy Per Visit,172.64,83,,172.64,percent of total billed charges,Therapy,368,,,368,Case Rate,Therapy Visit,145.6,70,,145.6,percent of total billed charges,All Other,259,,,259,Case Rate,Therapy Visit,220,,,220,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,138,,,138,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,131,,,131,Case Rate,Therapy Visit,58.77,,,58.77,Other,100% of Medicaid,58.77,,,58.77,Other,100% of Medicaid,58.77,,,58.77,Other,100% of Medicaid,58.77,,,58.77,Other,100% of Medicaid,132.23,,,132.23,Other,225% of Medicaid,89.92,,,89.92,Other,153% of Medicaid,132.23,,,132.23,Other,225% of Medicaid,82.28,,,82.28,Other,140% of Medicaid,132.23,,,132.23,Other,225% of Medicaid,152.8,,,152.8,Other,260% of Medicaid,190.42,,,190.42,Other,324% of Medicaid,126.36,,,126.36,Other,215% of Medicaid,126.36,,,126.36,Other,215% of Medicaid,73.46,,,73.46,Other,125% of Medicaid,58.77,368,
TH-THERAPEUTIC ACTIVITIES,97530,CPT,GOGT,63297530,CDM,430,RC,,,both,,,209,154.66,,,154.66,Other,150% of Medicare + 9.63% HCRA Surcharge,94.05,45,,94.05,percent of total billed charges,Critical Access Hospital RCC factor,180,,,180,Case Rate,Therapy Per Visit,162,,,162,Case Rate,Therapy Per Visit,199.52,,,199.52,Fee Schedule,,179.46,,,179.46,Fee Schedule,,169.61,,,169.61,Fee Schedule,,103.46,,,103.46,Other,110% of Medicare,219,,,219,Case Rate,Therapy Per Visit,109,,,109,Other,186% of Medicaid,257,,,257,Case Rate,Therapy Per Visit,173.47,83,,173.47,percent of total billed charges,Therapy,81.96,,,81.96,Case Rate,,257,,,257,Case Rate,Therapy Per Visit,173.47,83,,173.47,percent of total billed charges,Therapy,368,,,368,Case Rate,Therapy Visit,146.3,70,,146.3,percent of total billed charges,All Other,259,,,259,Case Rate,Therapy Visit,220,,,220,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,138,,,138,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,131,,,131,Case Rate,Therapy Visit,58.77,,,58.77,Other,100% of Medicaid,58.77,,,58.77,Other,100% of Medicaid,58.77,,,58.77,Other,100% of Medicaid,58.77,,,58.77,Other,100% of Medicaid,132.23,,,132.23,Other,225% of Medicaid,89.92,,,89.92,Other,153% of Medicaid,132.23,,,132.23,Other,225% of Medicaid,82.28,,,82.28,Other,140% of Medicaid,132.23,,,132.23,Other,225% of Medicaid,152.8,,,152.8,Other,260% of Medicaid,190.42,,,190.42,Other,324% of Medicaid,126.36,,,126.36,Other,215% of Medicaid,126.36,,,126.36,Other,215% of Medicaid,73.46,,,73.46,Other,125% of Medicaid,58.77,368,
TH-SELF CARE MNGMENT TRAINING,97535,CPT,GOGT,63297535,CDM,430,RC,,,both,,,193,142.82,,,142.82,Other,150% of Medicare + 9.63% HCRA Surcharge,86.85,45,,86.85,percent of total billed charges,Critical Access Hospital RCC factor,180,,,180,Case Rate,Therapy Per Visit,162,,,162,Case Rate,Therapy Per Visit,199.1,,,199.1,Fee Schedule,,179.08,,,179.08,Fee Schedule,,169.25,,,169.25,Fee Schedule,,95.54,,,95.54,Other,110% of Medicare,219,,,219,Case Rate,Therapy Per Visit,39,,,39,Other,186% of Medicaid,257,,,257,Case Rate,Therapy Per Visit,160.19,83,,160.19,percent of total billed charges,Therapy,72.79,,,72.79,Case Rate,,257,,,257,Case Rate,Therapy Per Visit,160.19,83,,160.19,percent of total billed charges,Therapy,368,,,368,Case Rate,Therapy Visit,135.1,70,,135.1,percent of total billed charges,All Other,259,,,259,Case Rate,Therapy Visit,220,,,220,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,138,,,138,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,131,,,131,Case Rate,Therapy Visit,20.84,,,20.84,Other,100% of Medicaid,20.84,,,20.84,Other,100% of Medicaid,20.84,,,20.84,Other,100% of Medicaid,20.84,,,20.84,Other,100% of Medicaid,46.9,,,46.9,Other,225% of Medicaid,31.89,,,31.89,Other,153% of Medicaid,46.9,,,46.9,Other,225% of Medicaid,29.18,,,29.18,Other,140% of Medicaid,46.9,,,46.9,Other,225% of Medicaid,54.2,,,54.2,Other,260% of Medicaid,67.54,,,67.54,Other,324% of Medicaid,44.82,,,44.82,Other,215% of Medicaid,44.82,,,44.82,Other,215% of Medicaid,26.06,,,26.06,Other,125% of Medicaid,20.84,368,
ELECTRICAL STIMULATION EA 15 MINS,G0283,HCPCS,GO,64000001,CDM,430,RC,,,both,,,119,88.06,,,88.06,Other,150% of Medicare + 9.63% HCRA Surcharge,53.55,45,,53.55,percent of total billed charges,Critical Access Hospital RCC factor,180,,,180,Case Rate,Therapy Per Visit,162,,,162,Case Rate,Therapy Per Visit,77.42,,,77.42,Fee Schedule,,69.63,,,69.63,Fee Schedule,,65.81,,,65.81,Fee Schedule,,58.91,,,58.91,Other,110% of Medicare,219,,,219,Case Rate,Therapy Per Visit,39,,,39,Other,186% of Medicaid,257,,,257,Case Rate,Therapy Per Visit,98.77,83,,98.77,percent of total billed charges,Therapy,26,,,26,Case Rate,,257,,,257,Case Rate,Therapy Per Visit,98.77,83,,98.77,percent of total billed charges,Therapy,368,,,368,Case Rate,Therapy Visit,83.3,70,,83.3,percent of total billed charges,All Other,259,,,259,Case Rate,Therapy Visit,220,,,220,Case Rate,Therapy Visit,0.01,,,0.01,Case Rate,Therapy Visit,0.01,,,0.01,Case Rate,Therapy Visit,0.01,,,0.01,Case Rate,Therapy Visit,0.01,,,0.01,Case Rate,Therapy Visit,20.84,,,20.84,Other,100% of Medicaid,20.84,,,20.84,Other,100% of Medicaid,20.84,,,20.84,Other,100% of Medicaid,20.84,,,20.84,Other,100% of Medicaid,46.9,,,46.9,Other,225% of Medicaid,31.89,,,31.89,Other,153% of Medicaid,46.9,,,46.9,Other,225% of Medicaid,29.18,,,29.18,Other,140% of Medicaid,46.9,,,46.9,Other,225% of Medicaid,54.2,,,54.2,Other,260% of Medicaid,67.54,,,67.54,Other,324% of Medicaid,44.82,,,44.82,Other,215% of Medicaid,44.82,,,44.82,Other,215% of Medicaid,26.06,,,26.06,Other,125% of Medicaid,0.01,368,
APPLY LONG ARM SPLINT,29105,CPT,GO,64029105,CDM,430,RC,,,both,,,544,402.56,,,402.56,Other,150% of Medicare + 9.63% HCRA Surcharge,244.8,45,,244.8,percent of total billed charges,Critical Access Hospital RCC factor,180,,,180,Case Rate,Therapy Per Visit,162,,,162,Case Rate,Therapy Per Visit,416.16,76.5,,416.16,percent of total billed charges,All Other,386.24,69,,386.24,percent of total billed charges,All Other,375.36,65,,375.36,percent of total billed charges,All Other,269.28,,,269.28,Other,110% of Medicare,219,,,219,Case Rate,Therapy Per Visit,325,,,325,Other,186% of Medicaid,257,,,257,Case Rate,Therapy Per Visit,451.52,83,,451.52,percent of total billed charges,Therapy,93.56,,,93.56,Fee Schedule,,257,,,257,Case Rate,Therapy Per Visit,451.52,83,,451.52,percent of total billed charges,Therapy,368,,,368,Case Rate,Therapy Visit,380.8,70,,380.8,percent of total billed charges,All Other,259,,,259,Case Rate,Therapy Visit,220,,,220,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,138,,,138,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,131,,,131,Case Rate,Therapy Visit,174.92,,,174.92,Other,100% of Medicaid,174.92,,,174.92,Other,100% of Medicaid,174.92,,,174.92,Other,100% of Medicaid,174.92,,,174.92,Other,100% of Medicaid,393.57,,,393.57,Other,225% of Medicaid,267.62,,,267.62,Other,153% of Medicaid,393.57,,,393.57,Other,225% of Medicaid,244.89,,,244.89,Other,140% of Medicaid,393.57,,,393.57,Other,225% of Medicaid,454.79,,,454.79,Other,260% of Medicaid,566.73,,,566.73,Other,324% of Medicaid,376.07,,,376.07,Other,215% of Medicaid,376.07,,,376.07,Other,215% of Medicaid,218.65,,,218.65,Other,125% of Medicaid,93.56,566.73,
APPLY FOREARM SPLINT,29125,CPT,GO,64029125,CDM,430,RC,,,both,,,563,416.62,,,416.62,Other,150% of Medicare + 9.63% HCRA Surcharge,253.35,45,,253.35,percent of total billed charges,Critical Access Hospital RCC factor,180,,,180,Case Rate,Therapy Per Visit,162,,,162,Case Rate,Therapy Per Visit,430.7,76.5,,430.7,percent of total billed charges,All Other,399.73,69,,399.73,percent of total billed charges,All Other,388.47,65,,388.47,percent of total billed charges,All Other,278.69,,,278.69,Other,110% of Medicare,219,,,219,Case Rate,Therapy Per Visit,325,,,325,Other,186% of Medicaid,257,,,257,Case Rate,Therapy Per Visit,467.29,83,,467.29,percent of total billed charges,Therapy,91.73,,,91.73,Fee Schedule,,257,,,257,Case Rate,Therapy Per Visit,467.29,83,,467.29,percent of total billed charges,Therapy,368,,,368,Case Rate,Therapy Visit,394.1,70,,394.1,percent of total billed charges,All Other,259,,,259,Case Rate,Therapy Visit,220,,,220,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,138,,,138,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,131,,,131,Case Rate,Therapy Visit,174.92,,,174.92,Other,100% of Medicaid,174.92,,,174.92,Other,100% of Medicaid,174.92,,,174.92,Other,100% of Medicaid,174.92,,,174.92,Other,100% of Medicaid,393.57,,,393.57,Other,225% of Medicaid,267.62,,,267.62,Other,153% of Medicaid,393.57,,,393.57,Other,225% of Medicaid,244.89,,,244.89,Other,140% of Medicaid,393.57,,,393.57,Other,225% of Medicaid,454.79,,,454.79,Other,260% of Medicaid,566.73,,,566.73,Other,324% of Medicaid,376.07,,,376.07,Other,215% of Medicaid,376.07,,,376.07,Other,215% of Medicaid,218.65,,,218.65,Other,125% of Medicaid,91.73,566.73,
APPLY FOREARM SPLINT DYNAMIC,29126,CPT,GO,64029126,CDM,430,RC,,,both,,,452,334.48,,,334.48,Other,150% of Medicare + 9.63% HCRA Surcharge,203.4,45,,203.4,percent of total billed charges,Critical Access Hospital RCC factor,180,,,180,Case Rate,Therapy Per Visit,162,,,162,Case Rate,Therapy Per Visit,345.78,76.5,,345.78,percent of total billed charges,All Other,320.92,69,,320.92,percent of total billed charges,All Other,311.88,65,,311.88,percent of total billed charges,All Other,223.74,,,223.74,Other,110% of Medicare,219,,,219,Case Rate,Therapy Per Visit,552,,,552,Other,186% of Medicaid,257,,,257,Case Rate,Therapy Per Visit,375.16,83,,375.16,percent of total billed charges,Therapy,111.64,,,111.64,Fee Schedule,,257,,,257,Case Rate,Therapy Per Visit,375.16,83,,375.16,percent of total billed charges,Therapy,368,,,368,Case Rate,Therapy Visit,316.4,70,,316.4,percent of total billed charges,All Other,259,,,259,Case Rate,Therapy Visit,220,,,220,Case Rate,Therapy Visit,0.01,,,0.01,Fee Schedule,Therapy Visit,0.01,,,0.01,Fee Schedule,Therapy Visit,0.01,,,0.01,Fee Schedule,Therapy Visit,0.01,,,0.01,Fee Schedule,Therapy Visit,296.74,,,296.74,Other,100% of Medicaid,296.74,,,296.74,Other,100% of Medicaid,296.74,,,296.74,Other,100% of Medicaid,296.74,,,296.74,Other,100% of Medicaid,667.67,,,667.67,Other,225% of Medicaid,454.02,,,454.02,Other,153% of Medicaid,667.67,,,667.67,Other,225% of Medicaid,415.44,,,415.44,Other,140% of Medicaid,667.67,,,667.67,Other,225% of Medicaid,771.53,,,771.53,Other,260% of Medicaid,961.45,,,961.45,Other,324% of Medicaid,638,,,638,Other,215% of Medicaid,638,,,638,Other,215% of Medicaid,370.93,,,370.93,Other,125% of Medicaid,0.01,961.45,
APPLICATION OF FINGER SPLINT,29130,CPT,GO,64029130,CDM,430,RC,,,both,,,563,416.62,,,416.62,Other,150% of Medicare + 9.63% HCRA Surcharge,253.35,45,,253.35,percent of total billed charges,Critical Access Hospital RCC factor,180,,,180,Case Rate,Therapy Per Visit,162,,,162,Case Rate,Therapy Per Visit,430.7,76.5,,430.7,percent of total billed charges,All Other,399.73,69,,399.73,percent of total billed charges,All Other,388.47,65,,388.47,percent of total billed charges,All Other,278.69,,,278.69,Other,110% of Medicare,219,,,219,Case Rate,Therapy Per Visit,325,,,325,Other,186% of Medicaid,257,,,257,Case Rate,Therapy Per Visit,467.29,83,,467.29,percent of total billed charges,Therapy,65.12,,,65.12,Fee Schedule,,257,,,257,Case Rate,Therapy Per Visit,467.29,83,,467.29,percent of total billed charges,Therapy,368,,,368,Case Rate,Therapy Visit,394.1,70,,394.1,percent of total billed charges,All Other,259,,,259,Case Rate,Therapy Visit,220,,,220,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,138,,,138,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,131,,,131,Case Rate,Therapy Visit,174.92,,,174.92,Other,100% of Medicaid,174.92,,,174.92,Other,100% of Medicaid,174.92,,,174.92,Other,100% of Medicaid,174.92,,,174.92,Other,100% of Medicaid,393.57,,,393.57,Other,225% of Medicaid,267.62,,,267.62,Other,153% of Medicaid,393.57,,,393.57,Other,225% of Medicaid,244.89,,,244.89,Other,140% of Medicaid,393.57,,,393.57,Other,225% of Medicaid,454.79,,,454.79,Other,260% of Medicaid,566.73,,,566.73,Other,324% of Medicaid,376.07,,,376.07,Other,215% of Medicaid,376.07,,,376.07,Other,215% of Medicaid,218.65,,,218.65,Other,125% of Medicaid,65.12,566.73,
APPL OF FNGER SPLNT DYNAMIC,29131,CPT,GO,64029131,CDM,430,RC,,,both,,,452,334.48,,,334.48,Other,150% of Medicare + 9.63% HCRA Surcharge,203.4,45,,203.4,percent of total billed charges,Critical Access Hospital RCC factor,180,,,180,Case Rate,Therapy Per Visit,162,,,162,Case Rate,Therapy Per Visit,345.78,76.5,,345.78,percent of total billed charges,All Other,320.92,69,,320.92,percent of total billed charges,All Other,311.88,65,,311.88,percent of total billed charges,All Other,223.74,,,223.74,Other,110% of Medicare,219,,,219,Case Rate,Therapy Per Visit,325,,,325,Other,186% of Medicaid,257,,,257,Case Rate,Therapy Per Visit,375.16,83,,375.16,percent of total billed charges,Therapy,77.83,,,77.83,Fee Schedule,,257,,,257,Case Rate,Therapy Per Visit,375.16,83,,375.16,percent of total billed charges,Therapy,368,,,368,Case Rate,Therapy Visit,316.4,70,,316.4,percent of total billed charges,All Other,259,,,259,Case Rate,Therapy Visit,220,,,220,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,138,,,138,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,131,,,131,Case Rate,Therapy Visit,174.92,,,174.92,Other,100% of Medicaid,174.92,,,174.92,Other,100% of Medicaid,174.92,,,174.92,Other,100% of Medicaid,174.92,,,174.92,Other,100% of Medicaid,393.57,,,393.57,Other,225% of Medicaid,267.62,,,267.62,Other,153% of Medicaid,393.57,,,393.57,Other,225% of Medicaid,244.89,,,244.89,Other,140% of Medicaid,393.57,,,393.57,Other,225% of Medicaid,454.79,,,454.79,Other,260% of Medicaid,566.73,,,566.73,Other,324% of Medicaid,376.07,,,376.07,Other,215% of Medicaid,376.07,,,376.07,Other,215% of Medicaid,218.65,,,218.65,Other,125% of Medicaid,77.83,566.73,
STRAPPING OF SHOULDER,29240,CPT,GO,64029240,CDM,430,RC,,,both,,,563,416.62,,,416.62,Other,150% of Medicare + 9.63% HCRA Surcharge,253.35,45,,253.35,percent of total billed charges,Critical Access Hospital RCC factor,180,,,180,Case Rate,Therapy Per Visit,162,,,162,Case Rate,Therapy Per Visit,430.7,76.5,,430.7,percent of total billed charges,All Other,399.73,69,,399.73,percent of total billed charges,All Other,388.47,65,,388.47,percent of total billed charges,All Other,278.69,,,278.69,Other,110% of Medicare,219,,,219,Case Rate,Therapy Per Visit,325,,,325,Other,186% of Medicaid,257,,,257,Case Rate,Therapy Per Visit,467.29,83,,467.29,percent of total billed charges,Therapy,38.91,,,38.91,Fee Schedule,,257,,,257,Case Rate,Therapy Per Visit,467.29,83,,467.29,percent of total billed charges,Therapy,368,,,368,Case Rate,Therapy Visit,394.1,70,,394.1,percent of total billed charges,All Other,259,,,259,Case Rate,Therapy Visit,220,,,220,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,138,,,138,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,131,,,131,Case Rate,Therapy Visit,174.92,,,174.92,Other,100% of Medicaid,174.92,,,174.92,Other,100% of Medicaid,174.92,,,174.92,Other,100% of Medicaid,174.92,,,174.92,Other,100% of Medicaid,393.57,,,393.57,Other,225% of Medicaid,267.62,,,267.62,Other,153% of Medicaid,393.57,,,393.57,Other,225% of Medicaid,244.89,,,244.89,Other,140% of Medicaid,393.57,,,393.57,Other,225% of Medicaid,454.79,,,454.79,Other,260% of Medicaid,566.73,,,566.73,Other,324% of Medicaid,376.07,,,376.07,Other,215% of Medicaid,376.07,,,376.07,Other,215% of Medicaid,218.65,,,218.65,Other,125% of Medicaid,38.91,566.73,
STRAPPING OF ELBOW OR WRIST,29260,CPT,GO,64029260,CDM,430,RC,,,both,,,563,416.62,,,416.62,Other,150% of Medicare + 9.63% HCRA Surcharge,253.35,45,,253.35,percent of total billed charges,Critical Access Hospital RCC factor,180,,,180,Case Rate,Therapy Per Visit,162,,,162,Case Rate,Therapy Per Visit,430.7,76.5,,430.7,percent of total billed charges,All Other,399.73,69,,399.73,percent of total billed charges,All Other,388.47,65,,388.47,percent of total billed charges,All Other,278.69,,,278.69,Other,110% of Medicare,219,,,219,Case Rate,Therapy Per Visit,325,,,325,Other,186% of Medicaid,257,,,257,Case Rate,Therapy Per Visit,467.29,83,,467.29,percent of total billed charges,Therapy,41.31,,,41.31,Fee Schedule,,257,,,257,Case Rate,Therapy Per Visit,467.29,83,,467.29,percent of total billed charges,Therapy,368,,,368,Case Rate,Therapy Visit,394.1,70,,394.1,percent of total billed charges,All Other,259,,,259,Case Rate,Therapy Visit,220,,,220,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,138,,,138,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,131,,,131,Case Rate,Therapy Visit,174.92,,,174.92,Other,100% of Medicaid,174.92,,,174.92,Other,100% of Medicaid,174.92,,,174.92,Other,100% of Medicaid,174.92,,,174.92,Other,100% of Medicaid,393.57,,,393.57,Other,225% of Medicaid,267.62,,,267.62,Other,153% of Medicaid,393.57,,,393.57,Other,225% of Medicaid,244.89,,,244.89,Other,140% of Medicaid,393.57,,,393.57,Other,225% of Medicaid,454.79,,,454.79,Other,260% of Medicaid,566.73,,,566.73,Other,324% of Medicaid,376.07,,,376.07,Other,215% of Medicaid,376.07,,,376.07,Other,215% of Medicaid,218.65,,,218.65,Other,125% of Medicaid,41.31,566.73,
STRAPPING OF HAND OR FINGER,29280,CPT,GO,64029280,CDM,430,RC,,,both,,,563,416.62,,,416.62,Other,150% of Medicare + 9.63% HCRA Surcharge,253.35,45,,253.35,percent of total billed charges,Critical Access Hospital RCC factor,180,,,180,Case Rate,Therapy Per Visit,162,,,162,Case Rate,Therapy Per Visit,430.7,76.5,,430.7,percent of total billed charges,All Other,399.73,69,,399.73,percent of total billed charges,All Other,388.47,65,,388.47,percent of total billed charges,All Other,278.69,,,278.69,Other,110% of Medicare,219,,,219,Case Rate,Therapy Per Visit,325,,,325,Other,186% of Medicaid,257,,,257,Case Rate,Therapy Per Visit,467.29,83,,467.29,percent of total billed charges,Therapy,44.58,,,44.58,Fee Schedule,,257,,,257,Case Rate,Therapy Per Visit,467.29,83,,467.29,percent of total billed charges,Therapy,368,,,368,Case Rate,Therapy Visit,394.1,70,,394.1,percent of total billed charges,All Other,259,,,259,Case Rate,Therapy Visit,220,,,220,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,138,,,138,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,131,,,131,Case Rate,Therapy Visit,174.92,,,174.92,Other,100% of Medicaid,174.92,,,174.92,Other,100% of Medicaid,174.92,,,174.92,Other,100% of Medicaid,174.92,,,174.92,Other,100% of Medicaid,393.57,,,393.57,Other,225% of Medicaid,267.62,,,267.62,Other,153% of Medicaid,393.57,,,393.57,Other,225% of Medicaid,244.89,,,244.89,Other,140% of Medicaid,393.57,,,393.57,Other,225% of Medicaid,454.79,,,454.79,Other,260% of Medicaid,566.73,,,566.73,Other,324% of Medicaid,376.07,,,376.07,Other,215% of Medicaid,376.07,,,376.07,Other,215% of Medicaid,218.65,,,218.65,Other,125% of Medicaid,44.58,566.73,
HOT OR COLD PACKS THERAPY,97010,CPT,GO,64097010,CDM,430,RC,,,both,,,96,71.04,,,71.04,Other,150% of Medicare + 9.63% HCRA Surcharge,43.2,45,,43.2,percent of total billed charges,Critical Access Hospital RCC factor,180,,,180,Case Rate,Therapy Per Visit,162,,,162,Case Rate,Therapy Per Visit,3.82,,,3.82,Fee Schedule,,3.82,,,3.82,Fee Schedule,,3.82,,,3.82,Fee Schedule,,47.52,,,47.52,Other,110% of Medicare,219,,,219,Case Rate,Therapy Per Visit,39,,,39,Other,186% of Medicaid,257,,,257,Case Rate,Therapy Per Visit,79.68,83,,79.68,percent of total billed charges,Therapy,52.8,83,,52.8,percent of total billed charges,All Other,257,,,257,Case Rate,Therapy Per Visit,79.68,83,,79.68,percent of total billed charges,Therapy,368,,,368,Case Rate,Therapy Visit,67.2,70,,67.2,percent of total billed charges,All Other,259,,,259,Case Rate,Therapy Visit,220,,,220,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,138,,,138,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,131,,,131,Case Rate,Therapy Visit,20.84,,,20.84,Other,100% of Medicaid,20.84,,,20.84,Other,100% of Medicaid,20.84,,,20.84,Other,100% of Medicaid,20.84,,,20.84,Other,100% of Medicaid,46.9,,,46.9,Other,225% of Medicaid,31.89,,,31.89,Other,153% of Medicaid,46.9,,,46.9,Other,225% of Medicaid,29.18,,,29.18,Other,140% of Medicaid,46.9,,,46.9,Other,225% of Medicaid,54.2,,,54.2,Other,260% of Medicaid,67.54,,,67.54,Other,324% of Medicaid,44.82,,,44.82,Other,215% of Medicaid,44.82,,,44.82,Other,215% of Medicaid,26.06,,,26.06,Other,125% of Medicaid,3.82,368,
PARAFFIN BATH THERAPY,97018,CPT,GO,64097018,CDM,430,RC,,,both,,,119,88.06,,,88.06,Other,150% of Medicare + 9.63% HCRA Surcharge,53.55,45,,53.55,percent of total billed charges,Critical Access Hospital RCC factor,180,,,180,Case Rate,Therapy Per Visit,162,,,162,Case Rate,Therapy Per Visit,61.71,,,61.71,Fee Schedule,,55.51,,,55.51,Fee Schedule,,52.46,,,52.46,Fee Schedule,,58.91,,,58.91,Other,110% of Medicare,219,,,219,Case Rate,Therapy Per Visit,39,,,39,Other,186% of Medicaid,257,,,257,Case Rate,Therapy Per Visit,98.77,83,,98.77,percent of total billed charges,Therapy,12.79,,,12.79,Case Rate,,257,,,257,Case Rate,Therapy Per Visit,98.77,83,,98.77,percent of total billed charges,Therapy,368,,,368,Case Rate,Therapy Visit,83.3,70,,83.3,percent of total billed charges,All Other,259,,,259,Case Rate,Therapy Visit,220,,,220,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,138,,,138,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,131,,,131,Case Rate,Therapy Visit,20.84,,,20.84,Other,100% of Medicaid,20.84,,,20.84,Other,100% of Medicaid,20.84,,,20.84,Other,100% of Medicaid,20.84,,,20.84,Other,100% of Medicaid,46.9,,,46.9,Other,225% of Medicaid,31.89,,,31.89,Other,153% of Medicaid,46.9,,,46.9,Other,225% of Medicaid,29.18,,,29.18,Other,140% of Medicaid,46.9,,,46.9,Other,225% of Medicaid,54.2,,,54.2,Other,260% of Medicaid,67.54,,,67.54,Other,324% of Medicaid,44.82,,,44.82,Other,215% of Medicaid,44.82,,,44.82,Other,215% of Medicaid,26.06,,,26.06,Other,125% of Medicaid,12.79,368,
ELECT STIM;MANUAL;EACH 15,97032,CPT,GO,64097032,CDM,430,RC,,,both,,,118,87.32,,,87.32,Other,150% of Medicare + 9.63% HCRA Surcharge,53.1,45,,53.1,percent of total billed charges,Critical Access Hospital RCC factor,180,,,180,Case Rate,Therapy Per Visit,162,,,162,Case Rate,Therapy Per Visit,108.88,,,108.88,Fee Schedule,,97.93,,,97.93,Fee Schedule,,92.56,,,92.56,Fee Schedule,,58.41,,,58.41,Other,110% of Medicare,219,,,219,Case Rate,Therapy Per Visit,39,,,39,Other,186% of Medicaid,257,,,257,Case Rate,Therapy Per Visit,97.94,83,,97.94,percent of total billed charges,Therapy,31.77,,,31.77,Case Rate,,257,,,257,Case Rate,Therapy Per Visit,97.94,83,,97.94,percent of total billed charges,Therapy,368,,,368,Case Rate,Therapy Visit,82.6,70,,82.6,percent of total billed charges,All Other,259,,,259,Case Rate,Therapy Visit,220,,,220,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,138,,,138,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,131,,,131,Case Rate,Therapy Visit,20.84,,,20.84,Other,100% of Medicaid,20.84,,,20.84,Other,100% of Medicaid,20.84,,,20.84,Other,100% of Medicaid,20.84,,,20.84,Other,100% of Medicaid,46.9,,,46.9,Other,225% of Medicaid,31.89,,,31.89,Other,153% of Medicaid,46.9,,,46.9,Other,225% of Medicaid,29.18,,,29.18,Other,140% of Medicaid,46.9,,,46.9,Other,225% of Medicaid,54.2,,,54.2,Other,260% of Medicaid,67.54,,,67.54,Other,324% of Medicaid,44.82,,,44.82,Other,215% of Medicaid,44.82,,,44.82,Other,215% of Medicaid,26.06,,,26.06,Other,125% of Medicaid,20.84,368,
OT-IONTOPHORESIS,97033,CPT,GO,64097033,CDM,430,RC,,,both,,,182,134.68,,,134.68,Other,150% of Medicare + 9.63% HCRA Surcharge,81.9,45,,81.9,percent of total billed charges,Critical Access Hospital RCC factor,180,,,180,Case Rate,Therapy Per Visit,162,,,162,Case Rate,Therapy Per Visit,179.44,,,179.44,Fee Schedule,,161.4,,,161.4,Fee Schedule,,152.54,,,152.54,Fee Schedule,,90.09,,,90.09,Other,110% of Medicare,219,,,219,Case Rate,Therapy Per Visit,39,,,39,Other,186% of Medicaid,257,,,257,Case Rate,Therapy Per Visit,151.06,83,,151.06,percent of total billed charges,Therapy,43.16,,,43.16,Case Rate,,257,,,257,Case Rate,Therapy Per Visit,151.06,83,,151.06,percent of total billed charges,Therapy,368,,,368,Case Rate,Therapy Visit,127.4,70,,127.4,percent of total billed charges,All Other,259,,,259,Case Rate,Therapy Visit,220,,,220,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,138,,,138,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,131,,,131,Case Rate,Therapy Visit,20.84,,,20.84,Other,100% of Medicaid,20.84,,,20.84,Other,100% of Medicaid,20.84,,,20.84,Other,100% of Medicaid,20.84,,,20.84,Other,100% of Medicaid,46.9,,,46.9,Other,225% of Medicaid,31.89,,,31.89,Other,153% of Medicaid,46.9,,,46.9,Other,225% of Medicaid,29.18,,,29.18,Other,140% of Medicaid,46.9,,,46.9,Other,225% of Medicaid,54.2,,,54.2,Other,260% of Medicaid,67.54,,,67.54,Other,324% of Medicaid,44.82,,,44.82,Other,215% of Medicaid,44.82,,,44.82,Other,215% of Medicaid,26.06,,,26.06,Other,125% of Medicaid,20.84,368,
CONTRAST BATH THERAPY,97034,CPT,GO,64097034,CDM,430,RC,,,both,,,82,60.68,,,60.68,Other,150% of Medicare + 9.63% HCRA Surcharge,36.9,45,,36.9,percent of total billed charges,Critical Access Hospital RCC factor,180,,,180,Case Rate,Therapy Per Visit,162,,,162,Case Rate,Therapy Per Visit,101.39,,,101.39,Fee Schedule,,91.2,,,91.2,Fee Schedule,,86.2,,,86.2,Fee Schedule,,40.59,,,40.59,Other,110% of Medicare,219,,,219,Case Rate,Therapy Per Visit,39,,,39,Other,186% of Medicaid,257,,,257,Case Rate,Therapy Per Visit,68.06,83,,68.06,percent of total billed charges,Therapy,31.19,,,31.19,Case Rate,,257,,,257,Case Rate,Therapy Per Visit,68.06,83,,68.06,percent of total billed charges,Therapy,368,,,368,Case Rate,Therapy Visit,57.4,70,,57.4,percent of total billed charges,All Other,259,,,259,Case Rate,Therapy Visit,220,,,220,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,138,,,138,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,131,,,131,Case Rate,Therapy Visit,20.84,,,20.84,Other,100% of Medicaid,20.84,,,20.84,Other,100% of Medicaid,20.84,,,20.84,Other,100% of Medicaid,20.84,,,20.84,Other,100% of Medicaid,46.9,,,46.9,Other,225% of Medicaid,31.89,,,31.89,Other,153% of Medicaid,46.9,,,46.9,Other,225% of Medicaid,29.18,,,29.18,Other,140% of Medicaid,46.9,,,46.9,Other,225% of Medicaid,54.2,,,54.2,Other,260% of Medicaid,67.54,,,67.54,Other,324% of Medicaid,44.82,,,44.82,Other,215% of Medicaid,44.82,,,44.82,Other,215% of Medicaid,26.06,,,26.06,Other,125% of Medicaid,20.84,368,
ULTRASOUND THERAPY,97035,CPT,GO,64097035,CDM,430,RC,,,both,,,127,93.98,,,93.98,Other,150% of Medicare + 9.63% HCRA Surcharge,57.15,45,,57.15,percent of total billed charges,Critical Access Hospital RCC factor,180,,,180,Case Rate,Therapy Per Visit,162,,,162,Case Rate,Therapy Per Visit,71.62,,,71.62,Fee Schedule,,64.42,,,64.42,Fee Schedule,,60.88,,,60.88,Fee Schedule,,62.87,,,62.87,Other,110% of Medicare,219,,,219,Case Rate,Therapy Per Visit,39,,,39,Other,186% of Medicaid,257,,,257,Case Rate,Therapy Per Visit,105.41,83,,105.41,percent of total billed charges,Therapy,31.19,,,31.19,Case Rate,,257,,,257,Case Rate,Therapy Per Visit,105.41,83,,105.41,percent of total billed charges,Therapy,368,,,368,Case Rate,Therapy Visit,88.9,70,,88.9,percent of total billed charges,All Other,259,,,259,Case Rate,Therapy Visit,220,,,220,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,138,,,138,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,131,,,131,Case Rate,Therapy Visit,20.84,,,20.84,Other,100% of Medicaid,20.84,,,20.84,Other,100% of Medicaid,20.84,,,20.84,Other,100% of Medicaid,20.84,,,20.84,Other,100% of Medicaid,46.9,,,46.9,Other,225% of Medicaid,31.89,,,31.89,Other,153% of Medicaid,46.9,,,46.9,Other,225% of Medicaid,29.18,,,29.18,Other,140% of Medicaid,46.9,,,46.9,Other,225% of Medicaid,54.2,,,54.2,Other,260% of Medicaid,67.54,,,67.54,Other,324% of Medicaid,44.82,,,44.82,Other,215% of Medicaid,44.82,,,44.82,Other,215% of Medicaid,26.06,,,26.06,Other,125% of Medicaid,20.84,368,
THERAPEUTIC EXERCISES,97110,CPT,GO,64097110,CDM,430,RC,,,both,,,187,138.38,,,138.38,Other,150% of Medicare + 9.63% HCRA Surcharge,84.15,45,,84.15,percent of total billed charges,Critical Access Hospital RCC factor,180,,,180,Case Rate,Therapy Per Visit,162,,,162,Case Rate,Therapy Per Visit,180.81,,,180.81,Fee Schedule,,162.63,,,162.63,Fee Schedule,,153.71,,,153.71,Fee Schedule,,92.57,,,92.57,Other,110% of Medicare,219,,,219,Case Rate,Therapy Per Visit,109,,,109,Other,186% of Medicaid,257,,,257,Case Rate,Therapy Per Visit,155.21,83,,155.21,percent of total billed charges,Therapy,65.18,,,65.18,Case Rate,,257,,,257,Case Rate,Therapy Per Visit,155.21,83,,155.21,percent of total billed charges,Therapy,368,,,368,Case Rate,Therapy Visit,130.9,70,,130.9,percent of total billed charges,All Other,259,,,259,Case Rate,Therapy Visit,220,,,220,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,138,,,138,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,131,,,131,Case Rate,Therapy Visit,58.77,,,58.77,Other,100% of Medicaid,58.77,,,58.77,Other,100% of Medicaid,58.77,,,58.77,Other,100% of Medicaid,58.77,,,58.77,Other,100% of Medicaid,132.23,,,132.23,Other,225% of Medicaid,89.92,,,89.92,Other,153% of Medicaid,132.23,,,132.23,Other,225% of Medicaid,82.28,,,82.28,Other,140% of Medicaid,132.23,,,132.23,Other,225% of Medicaid,152.8,,,152.8,Other,260% of Medicaid,190.42,,,190.42,Other,324% of Medicaid,126.36,,,126.36,Other,215% of Medicaid,126.36,,,126.36,Other,215% of Medicaid,73.46,,,73.46,Other,125% of Medicaid,58.77,368,
NEUROMUSCULAR REEDUCATION,97112,CPT,GO,64097112,CDM,430,RC,,,both,,,208,153.92,,,153.92,Other,150% of Medicare + 9.63% HCRA Surcharge,93.6,45,,93.6,percent of total billed charges,Critical Access Hospital RCC factor,180,,,180,Case Rate,Therapy Per Visit,162,,,162,Case Rate,Therapy Per Visit,189.98,,,189.98,Fee Schedule,,170.88,,,170.88,Fee Schedule,,161.5,,,161.5,Fee Schedule,,102.96,,,102.96,Other,110% of Medicare,219,,,219,Case Rate,Therapy Per Visit,109,,,109,Other,186% of Medicaid,257,,,257,Case Rate,Therapy Per Visit,172.64,83,,172.64,percent of total billed charges,Therapy,74.87,,,74.87,Case Rate,,257,,,257,Case Rate,Therapy Per Visit,172.64,83,,172.64,percent of total billed charges,Therapy,368,,,368,Case Rate,Therapy Visit,145.6,70,,145.6,percent of total billed charges,All Other,259,,,259,Case Rate,Therapy Visit,220,,,220,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,138,,,138,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,131,,,131,Case Rate,Therapy Visit,58.77,,,58.77,Other,100% of Medicaid,58.77,,,58.77,Other,100% of Medicaid,58.77,,,58.77,Other,100% of Medicaid,58.77,,,58.77,Other,100% of Medicaid,132.23,,,132.23,Other,225% of Medicaid,89.92,,,89.92,Other,153% of Medicaid,132.23,,,132.23,Other,225% of Medicaid,82.28,,,82.28,Other,140% of Medicaid,132.23,,,132.23,Other,225% of Medicaid,152.8,,,152.8,Other,260% of Medicaid,190.42,,,190.42,Other,324% of Medicaid,126.36,,,126.36,Other,215% of Medicaid,126.36,,,126.36,Other,215% of Medicaid,73.46,,,73.46,Other,125% of Medicaid,58.77,368,
MASSAGE THERAPY,97124,CPT,GO,64097124,CDM,430,RC,,,both,,,145,107.3,,,107.3,Other,150% of Medicare + 9.63% HCRA Surcharge,65.25,45,,65.25,percent of total billed charges,Critical Access Hospital RCC factor,180,,,180,Case Rate,Therapy Per Visit,162,,,162,Case Rate,Therapy Per Visit,148.3,,,148.3,Fee Schedule,,133.38,,,133.38,Fee Schedule,,126.07,,,126.07,Fee Schedule,,71.78,,,71.78,Other,110% of Medicare,219,,,219,Case Rate,Therapy Per Visit,39,,,39,Other,186% of Medicaid,257,,,257,Case Rate,Therapy Per Visit,120.35,83,,120.35,percent of total billed charges,Therapy,67.87,,,67.87,Case Rate,,257,,,257,Case Rate,Therapy Per Visit,120.35,83,,120.35,percent of total billed charges,Therapy,368,,,368,Case Rate,Therapy Visit,101.5,70,,101.5,percent of total billed charges,All Other,259,,,259,Case Rate,Therapy Visit,220,,,220,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,138,,,138,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,131,,,131,Case Rate,Therapy Visit,20.84,,,20.84,Other,100% of Medicaid,20.84,,,20.84,Other,100% of Medicaid,20.84,,,20.84,Other,100% of Medicaid,20.84,,,20.84,Other,100% of Medicaid,46.9,,,46.9,Other,225% of Medicaid,31.89,,,31.89,Other,153% of Medicaid,46.9,,,46.9,Other,225% of Medicaid,29.18,,,29.18,Other,140% of Medicaid,46.9,,,46.9,Other,225% of Medicaid,54.2,,,54.2,Other,260% of Medicaid,67.54,,,67.54,Other,324% of Medicaid,44.82,,,44.82,Other,215% of Medicaid,44.82,,,44.82,Other,215% of Medicaid,26.06,,,26.06,Other,125% of Medicaid,20.84,368,
FLUIDOTHERAPY,97039,CPT,GO,64097139,CDM,430,RC,,,both,,,111,82.14,,,82.14,Other,150% of Medicare + 9.63% HCRA Surcharge,49.95,45,,49.95,percent of total billed charges,Critical Access Hospital RCC factor,180,,,180,Case Rate,Therapy Per Visit,162,,,162,Case Rate,Therapy Per Visit,84.92,76.5,,84.92,percent of total billed charges,All Other,78.81,69,,78.81,percent of total billed charges,All Other,76.59,65,,76.59,percent of total billed charges,All Other,54.95,,,54.95,Other,110% of Medicare,219,,,219,Case Rate,Therapy Per Visit,39,,,39,Other,186% of Medicaid,257,,,257,Case Rate,Therapy Per Visit,92.13,83,,92.13,percent of total billed charges,Therapy,61.05,83,,61.05,percent of total billed charges,All Other,257,,,257,Case Rate,Therapy Per Visit,92.13,83,,92.13,percent of total billed charges,Therapy,368,,,368,Case Rate,Therapy Visit,77.7,70,,77.7,percent of total billed charges,All Other,259,,,259,Case Rate,Therapy Visit,220,,,220,Case Rate,Therapy Visit,0.01,,,0.01,Fee Schedule,Therapy Visit,0.01,,,0.01,Fee Schedule,Therapy Visit,0.01,,,0.01,Fee Schedule,Therapy Visit,0.01,,,0.01,Fee Schedule,Therapy Visit,20.84,,,20.84,Other,100% of Medicaid,20.84,,,20.84,Other,100% of Medicaid,20.84,,,20.84,Other,100% of Medicaid,20.84,,,20.84,Other,100% of Medicaid,46.9,,,46.9,Other,225% of Medicaid,31.89,,,31.89,Other,153% of Medicaid,46.9,,,46.9,Other,225% of Medicaid,29.18,,,29.18,Other,140% of Medicaid,46.9,,,46.9,Other,225% of Medicaid,54.2,,,54.2,Other,260% of Medicaid,67.54,,,67.54,Other,324% of Medicaid,44.82,,,44.82,Other,215% of Medicaid,44.82,,,44.82,Other,215% of Medicaid,26.06,,,26.06,Other,125% of Medicaid,0.01,368,
MANUAL THERAPY,97140,CPT,GO,64097140,CDM,430,RC,,,both,,,198,146.52,,,146.52,Other,150% of Medicare + 9.63% HCRA Surcharge,89.1,45,,89.1,percent of total billed charges,Critical Access Hospital RCC factor,180,,,180,Case Rate,Therapy Per Visit,162,,,162,Case Rate,Therapy Per Visit,170.17,,,170.17,Fee Schedule,,153.05,,,153.05,Fee Schedule,,144.66,,,144.66,Fee Schedule,,98.01,,,98.01,Other,110% of Medicare,219,,,219,Case Rate,Therapy Per Visit,109,,,109,Other,186% of Medicaid,257,,,257,Case Rate,Therapy Per Visit,164.34,83,,164.34,percent of total billed charges,Therapy,59.93,,,59.93,Case Rate,,257,,,257,Case Rate,Therapy Per Visit,164.34,83,,164.34,percent of total billed charges,Therapy,368,,,368,Case Rate,Therapy Visit,138.6,70,,138.6,percent of total billed charges,All Other,259,,,259,Case Rate,Therapy Visit,220,,,220,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,138,,,138,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,131,,,131,Case Rate,Therapy Visit,58.77,,,58.77,Other,100% of Medicaid,58.77,,,58.77,Other,100% of Medicaid,58.77,,,58.77,Other,100% of Medicaid,58.77,,,58.77,Other,100% of Medicaid,132.23,,,132.23,Other,225% of Medicaid,89.92,,,89.92,Other,153% of Medicaid,132.23,,,132.23,Other,225% of Medicaid,82.28,,,82.28,Other,140% of Medicaid,132.23,,,132.23,Other,225% of Medicaid,152.8,,,152.8,Other,260% of Medicaid,190.42,,,190.42,Other,324% of Medicaid,126.36,,,126.36,Other,215% of Medicaid,126.36,,,126.36,Other,215% of Medicaid,73.46,,,73.46,Other,125% of Medicaid,58.77,368,
THERAPEUTIC REHAB GROUP,97150,CPT,GO,64097150,CDM,430,RC,,,both,,,96,71.04,,,71.04,Other,150% of Medicare + 9.63% HCRA Surcharge,43.2,45,,43.2,percent of total billed charges,Critical Access Hospital RCC factor,180,,,180,Case Rate,Therapy Per Visit,162,,,162,Case Rate,Therapy Per Visit,117.2,,,117.2,Fee Schedule,,105.42,,,105.42,Fee Schedule,,99.64,,,99.64,Fee Schedule,,47.52,,,47.52,Other,110% of Medicare,219,,,219,Case Rate,Therapy Per Visit,109,,,109,Other,186% of Medicaid,257,,,257,Case Rate,Therapy Per Visit,79.68,83,,79.68,percent of total billed charges,Therapy,39.98,,,39.98,Case Rate,,257,,,257,Case Rate,Therapy Per Visit,79.68,83,,79.68,percent of total billed charges,Therapy,368,,,368,Case Rate,Therapy Visit,67.2,70,,67.2,percent of total billed charges,All Other,259,,,259,Case Rate,Therapy Visit,220,,,220,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,138,,,138,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,131,,,131,Case Rate,Therapy Visit,58.77,,,58.77,Other,100% of Medicaid,58.77,,,58.77,Other,100% of Medicaid,58.77,,,58.77,Other,100% of Medicaid,58.77,,,58.77,Other,100% of Medicaid,132.23,,,132.23,Other,225% of Medicaid,89.92,,,89.92,Other,153% of Medicaid,132.23,,,132.23,Other,225% of Medicaid,82.28,,,82.28,Other,140% of Medicaid,132.23,,,132.23,Other,225% of Medicaid,152.8,,,152.8,Other,260% of Medicaid,190.42,,,190.42,Other,324% of Medicaid,126.36,,,126.36,Other,215% of Medicaid,126.36,,,126.36,Other,215% of Medicaid,73.46,,,73.46,Other,125% of Medicaid,39.98,368,
THERAPEUTIC ACTIVITIES,97530,CPT,GO,64097530,CDM,430,RC,,,both,,,209,154.66,,,154.66,Other,150% of Medicare + 9.63% HCRA Surcharge,94.05,45,,94.05,percent of total billed charges,Critical Access Hospital RCC factor,180,,,180,Case Rate,Therapy Per Visit,162,,,162,Case Rate,Therapy Per Visit,199.52,,,199.52,Fee Schedule,,179.46,,,179.46,Fee Schedule,,169.61,,,169.61,Fee Schedule,,103.46,,,103.46,Other,110% of Medicare,219,,,219,Case Rate,Therapy Per Visit,109,,,109,Other,186% of Medicaid,257,,,257,Case Rate,Therapy Per Visit,173.47,83,,173.47,percent of total billed charges,Therapy,81.96,,,81.96,Case Rate,,257,,,257,Case Rate,Therapy Per Visit,173.47,83,,173.47,percent of total billed charges,Therapy,368,,,368,Case Rate,Therapy Visit,146.3,70,,146.3,percent of total billed charges,All Other,259,,,259,Case Rate,Therapy Visit,220,,,220,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,138,,,138,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,131,,,131,Case Rate,Therapy Visit,58.77,,,58.77,Other,100% of Medicaid,58.77,,,58.77,Other,100% of Medicaid,58.77,,,58.77,Other,100% of Medicaid,58.77,,,58.77,Other,100% of Medicaid,132.23,,,132.23,Other,225% of Medicaid,89.92,,,89.92,Other,153% of Medicaid,132.23,,,132.23,Other,225% of Medicaid,82.28,,,82.28,Other,140% of Medicaid,132.23,,,132.23,Other,225% of Medicaid,152.8,,,152.8,Other,260% of Medicaid,190.42,,,190.42,Other,324% of Medicaid,126.36,,,126.36,Other,215% of Medicaid,126.36,,,126.36,Other,215% of Medicaid,73.46,,,73.46,Other,125% of Medicaid,58.77,368,
SELF CARE MNGMENT TRAINING,97535,CPT,GO,64097535,CDM,430,RC,,,both,,,193,142.82,,,142.82,Other,150% of Medicare + 9.63% HCRA Surcharge,86.85,45,,86.85,percent of total billed charges,Critical Access Hospital RCC factor,180,,,180,Case Rate,Therapy Per Visit,162,,,162,Case Rate,Therapy Per Visit,199.1,,,199.1,Fee Schedule,,179.08,,,179.08,Fee Schedule,,169.25,,,169.25,Fee Schedule,,95.54,,,95.54,Other,110% of Medicare,219,,,219,Case Rate,Therapy Per Visit,39,,,39,Other,186% of Medicaid,257,,,257,Case Rate,Therapy Per Visit,160.19,83,,160.19,percent of total billed charges,Therapy,72.79,,,72.79,Case Rate,,257,,,257,Case Rate,Therapy Per Visit,160.19,83,,160.19,percent of total billed charges,Therapy,368,,,368,Case Rate,Therapy Visit,135.1,70,,135.1,percent of total billed charges,All Other,259,,,259,Case Rate,Therapy Visit,220,,,220,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,138,,,138,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,131,,,131,Case Rate,Therapy Visit,20.84,,,20.84,Other,100% of Medicaid,20.84,,,20.84,Other,100% of Medicaid,20.84,,,20.84,Other,100% of Medicaid,20.84,,,20.84,Other,100% of Medicaid,46.9,,,46.9,Other,225% of Medicaid,31.89,,,31.89,Other,153% of Medicaid,46.9,,,46.9,Other,225% of Medicaid,29.18,,,29.18,Other,140% of Medicaid,46.9,,,46.9,Other,225% of Medicaid,54.2,,,54.2,Other,260% of Medicaid,67.54,,,67.54,Other,324% of Medicaid,44.82,,,44.82,Other,215% of Medicaid,44.82,,,44.82,Other,215% of Medicaid,26.06,,,26.06,Other,125% of Medicaid,20.84,368,
COMMUNITY/WORK REINTEGRATION EA 15 MIN,97537,CPT,GO,64097537,CDM,430,RC,,,both,,,141,104.34,,,104.34,Other,150% of Medicare + 9.63% HCRA Surcharge,63.45,45,,63.45,percent of total billed charges,Critical Access Hospital RCC factor,180,,,180,Case Rate,Therapy Per Visit,162,,,162,Case Rate,Therapy Per Visit,171.64,,,171.64,Fee Schedule,,154.38,,,154.38,Fee Schedule,,145.91,,,145.91,Fee Schedule,,69.8,,,69.8,Other,110% of Medicare,219,,,219,Case Rate,Therapy Per Visit,109,,,109,Other,186% of Medicaid,257,,,257,Case Rate,Therapy Per Visit,117.03,83,,117.03,percent of total billed charges,Therapy,70.37,,,70.37,Case Rate,,257,,,257,Case Rate,Therapy Per Visit,117.03,83,,117.03,percent of total billed charges,Therapy,368,,,368,Case Rate,Therapy Visit,98.7,70,,98.7,percent of total billed charges,All Other,259,,,259,Case Rate,Therapy Visit,220,,,220,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,138,,,138,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,131,,,131,Case Rate,Therapy Visit,58.77,,,58.77,Other,100% of Medicaid,58.77,,,58.77,Other,100% of Medicaid,58.77,,,58.77,Other,100% of Medicaid,58.77,,,58.77,Other,100% of Medicaid,132.23,,,132.23,Other,225% of Medicaid,89.92,,,89.92,Other,153% of Medicaid,132.23,,,132.23,Other,225% of Medicaid,82.28,,,82.28,Other,140% of Medicaid,132.23,,,132.23,Other,225% of Medicaid,152.8,,,152.8,Other,260% of Medicaid,190.42,,,190.42,Other,324% of Medicaid,126.36,,,126.36,Other,215% of Medicaid,126.36,,,126.36,Other,215% of Medicaid,73.46,,,73.46,Other,125% of Medicaid,58.77,368,
WHEELCHAIR MGT TRAINING 15MIN,97542,CPT,GO,64097542,CDM,430,RC,,,both,,,190,140.6,,,140.6,Other,150% of Medicare + 9.63% HCRA Surcharge,85.5,45,,85.5,percent of total billed charges,Critical Access Hospital RCC factor,180,,,180,Case Rate,Therapy Per Visit,162,,,162,Case Rate,Therapy Per Visit,173.96,,,173.96,Fee Schedule,,156.47,,,156.47,Fee Schedule,,147.88,,,147.88,Fee Schedule,,94.05,,,94.05,Other,110% of Medicare,219,,,219,Case Rate,Therapy Per Visit,109,,,109,Other,186% of Medicaid,257,,,257,Case Rate,Therapy Per Visit,157.7,83,,157.7,percent of total billed charges,Therapy,70.37,,,70.37,Case Rate,,257,,,257,Case Rate,Therapy Per Visit,157.7,83,,157.7,percent of total billed charges,Therapy,368,,,368,Case Rate,Therapy Visit,133,70,,133,percent of total billed charges,All Other,259,,,259,Case Rate,Therapy Visit,220,,,220,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,138,,,138,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,131,,,131,Case Rate,Therapy Visit,58.77,,,58.77,Other,100% of Medicaid,58.77,,,58.77,Other,100% of Medicaid,58.77,,,58.77,Other,100% of Medicaid,58.77,,,58.77,Other,100% of Medicaid,132.23,,,132.23,Other,225% of Medicaid,89.92,,,89.92,Other,153% of Medicaid,132.23,,,132.23,Other,225% of Medicaid,82.28,,,82.28,Other,140% of Medicaid,132.23,,,132.23,Other,225% of Medicaid,152.8,,,152.8,Other,260% of Medicaid,190.42,,,190.42,Other,324% of Medicaid,126.36,,,126.36,Other,215% of Medicaid,126.36,,,126.36,Other,215% of Medicaid,73.46,,,73.46,Other,125% of Medicaid,58.77,368,
SLCTV WND DEBRIDEM 20 CM OR <,97597,CPT,GO,64097597,CDM,430,RC,,,both,,,573,424.02,,,424.02,Other,150% of Medicare + 9.63% HCRA Surcharge,257.85,45,,257.85,percent of total billed charges,Critical Access Hospital RCC factor,180,,,180,Case Rate,Therapy Per Visit,162,,,162,Case Rate,Therapy Per Visit,438.35,76.5,,438.35,percent of total billed charges,All Other,406.83,69,,406.83,percent of total billed charges,All Other,395.37,65,,395.37,percent of total billed charges,All Other,283.64,,,283.64,Other,110% of Medicare,219,,,219,Case Rate,Therapy Per Visit,703,,,703,Other,186% of Medicaid,257,,,257,Case Rate,Therapy Per Visit,475.59,83,,475.59,percent of total billed charges,Therapy,475.59,,,475.59,Other,Non Covered Service,257,,,257,Case Rate,Therapy Per Visit,475.59,83,,475.59,percent of total billed charges,Therapy,368,,,368,Case Rate,Therapy Visit,401.1,70,,401.1,percent of total billed charges,All Other,259,,,259,Case Rate,Therapy Visit,220,,,220,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,138,,,138,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,131,,,131,Case Rate,Therapy Visit,377.82,,,377.82,Other,100% of Medicaid,377.82,,,377.82,Other,100% of Medicaid,377.82,,,377.82,Other,100% of Medicaid,377.82,,,377.82,Other,100% of Medicaid,850.1,,,850.1,Other,225% of Medicaid,578.07,,,578.07,Other,153% of Medicaid,850.1,,,850.1,Other,225% of Medicaid,528.95,,,528.95,Other,140% of Medicaid,850.1,,,850.1,Other,225% of Medicaid,982.34,,,982.34,Other,260% of Medicaid,1224.15,,,1224.15,Other,324% of Medicaid,812.32,,,812.32,Other,215% of Medicaid,812.32,,,812.32,Other,215% of Medicaid,472.28,,,472.28,Other,125% of Medicaid,131,1224.15,
ORTHOTIC MGMT AND TRAINING,97760,CPT,GO,64097760,CDM,430,RC,,,both,,,201,148.74,,,148.74,Other,150% of Medicare + 9.63% HCRA Surcharge,90.45,45,,90.45,percent of total billed charges,Critical Access Hospital RCC factor,180,,,180,Case Rate,Therapy Per Visit,162,,,162,Case Rate,Therapy Per Visit,217.65,,,217.65,Fee Schedule,,195.76,,,195.76,Fee Schedule,,185.02,,,185.02,Fee Schedule,,99.5,,,99.5,Other,110% of Medicare,219,,,219,Case Rate,Therapy Per Visit,109,,,109,Other,186% of Medicaid,257,,,257,Case Rate,Therapy Per Visit,166.83,83,,166.83,percent of total billed charges,Therapy,106.81,,,106.81,Fee Schedule,,257,,,257,Case Rate,Therapy Per Visit,166.83,83,,166.83,percent of total billed charges,Therapy,368,,,368,Case Rate,Therapy Visit,140.7,70,,140.7,percent of total billed charges,All Other,259,,,259,Case Rate,Therapy Visit,220,,,220,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,138,,,138,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,131,,,131,Case Rate,Therapy Visit,58.77,,,58.77,Other,100% of Medicaid,58.77,,,58.77,Other,100% of Medicaid,58.77,,,58.77,Other,100% of Medicaid,58.77,,,58.77,Other,100% of Medicaid,132.23,,,132.23,Other,225% of Medicaid,89.92,,,89.92,Other,153% of Medicaid,132.23,,,132.23,Other,225% of Medicaid,82.28,,,82.28,Other,140% of Medicaid,132.23,,,132.23,Other,225% of Medicaid,152.8,,,152.8,Other,260% of Medicaid,190.42,,,190.42,Other,324% of Medicaid,126.36,,,126.36,Other,215% of Medicaid,126.36,,,126.36,Other,215% of Medicaid,73.46,,,73.46,Other,125% of Medicaid,58.77,368,
TH-THERAPEUTIC EXERCISES,97110,CPT,GOGT,64297110,CDM,430,RC,,,both,,,187,138.38,,,138.38,Other,150% of Medicare + 9.63% HCRA Surcharge,84.15,45,,84.15,percent of total billed charges,Critical Access Hospital RCC factor,180,,,180,Case Rate,Therapy Per Visit,162,,,162,Case Rate,Therapy Per Visit,180.81,,,180.81,Fee Schedule,,162.63,,,162.63,Fee Schedule,,153.71,,,153.71,Fee Schedule,,92.57,,,92.57,Other,110% of Medicare,219,,,219,Case Rate,Therapy Per Visit,109,,,109,Other,186% of Medicaid,257,,,257,Case Rate,Therapy Per Visit,155.21,83,,155.21,percent of total billed charges,Therapy,65.18,,,65.18,Case Rate,,257,,,257,Case Rate,Therapy Per Visit,155.21,83,,155.21,percent of total billed charges,Therapy,368,,,368,Case Rate,Therapy Visit,130.9,70,,130.9,percent of total billed charges,All Other,259,,,259,Case Rate,Therapy Visit,220,,,220,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,138,,,138,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,131,,,131,Case Rate,Therapy Visit,58.77,,,58.77,Other,100% of Medicaid,58.77,,,58.77,Other,100% of Medicaid,58.77,,,58.77,Other,100% of Medicaid,58.77,,,58.77,Other,100% of Medicaid,132.23,,,132.23,Other,225% of Medicaid,89.92,,,89.92,Other,153% of Medicaid,132.23,,,132.23,Other,225% of Medicaid,82.28,,,82.28,Other,140% of Medicaid,132.23,,,132.23,Other,225% of Medicaid,152.8,,,152.8,Other,260% of Medicaid,190.42,,,190.42,Other,324% of Medicaid,126.36,,,126.36,Other,215% of Medicaid,126.36,,,126.36,Other,215% of Medicaid,73.46,,,73.46,Other,125% of Medicaid,58.77,368,
TH-NEUROMUSCULAR REEDUCATION,97112,CPT,GOGT,64297112,CDM,430,RC,,,both,,,208,153.92,,,153.92,Other,150% of Medicare + 9.63% HCRA Surcharge,93.6,45,,93.6,percent of total billed charges,Critical Access Hospital RCC factor,180,,,180,Case Rate,Therapy Per Visit,162,,,162,Case Rate,Therapy Per Visit,189.98,,,189.98,Fee Schedule,,170.88,,,170.88,Fee Schedule,,161.5,,,161.5,Fee Schedule,,102.96,,,102.96,Other,110% of Medicare,219,,,219,Case Rate,Therapy Per Visit,109,,,109,Other,186% of Medicaid,257,,,257,Case Rate,Therapy Per Visit,172.64,83,,172.64,percent of total billed charges,Therapy,74.87,,,74.87,Case Rate,,257,,,257,Case Rate,Therapy Per Visit,172.64,83,,172.64,percent of total billed charges,Therapy,368,,,368,Case Rate,Therapy Visit,145.6,70,,145.6,percent of total billed charges,All Other,259,,,259,Case Rate,Therapy Visit,220,,,220,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,138,,,138,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,131,,,131,Case Rate,Therapy Visit,58.77,,,58.77,Other,100% of Medicaid,58.77,,,58.77,Other,100% of Medicaid,58.77,,,58.77,Other,100% of Medicaid,58.77,,,58.77,Other,100% of Medicaid,132.23,,,132.23,Other,225% of Medicaid,89.92,,,89.92,Other,153% of Medicaid,132.23,,,132.23,Other,225% of Medicaid,82.28,,,82.28,Other,140% of Medicaid,132.23,,,132.23,Other,225% of Medicaid,152.8,,,152.8,Other,260% of Medicaid,190.42,,,190.42,Other,324% of Medicaid,126.36,,,126.36,Other,215% of Medicaid,126.36,,,126.36,Other,215% of Medicaid,73.46,,,73.46,Other,125% of Medicaid,58.77,368,
TH-THERAPEUTIC ACTIVITIES,97530,CPT,GOGT,64297530,CDM,430,RC,,,both,,,209,154.66,,,154.66,Other,150% of Medicare + 9.63% HCRA Surcharge,94.05,45,,94.05,percent of total billed charges,Critical Access Hospital RCC factor,180,,,180,Case Rate,Therapy Per Visit,162,,,162,Case Rate,Therapy Per Visit,199.52,,,199.52,Fee Schedule,,179.46,,,179.46,Fee Schedule,,169.61,,,169.61,Fee Schedule,,103.46,,,103.46,Other,110% of Medicare,219,,,219,Case Rate,Therapy Per Visit,109,,,109,Other,186% of Medicaid,257,,,257,Case Rate,Therapy Per Visit,173.47,83,,173.47,percent of total billed charges,Therapy,81.96,,,81.96,Case Rate,,257,,,257,Case Rate,Therapy Per Visit,173.47,83,,173.47,percent of total billed charges,Therapy,368,,,368,Case Rate,Therapy Visit,146.3,70,,146.3,percent of total billed charges,All Other,259,,,259,Case Rate,Therapy Visit,220,,,220,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,138,,,138,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,131,,,131,Case Rate,Therapy Visit,58.77,,,58.77,Other,100% of Medicaid,58.77,,,58.77,Other,100% of Medicaid,58.77,,,58.77,Other,100% of Medicaid,58.77,,,58.77,Other,100% of Medicaid,132.23,,,132.23,Other,225% of Medicaid,89.92,,,89.92,Other,153% of Medicaid,132.23,,,132.23,Other,225% of Medicaid,82.28,,,82.28,Other,140% of Medicaid,132.23,,,132.23,Other,225% of Medicaid,152.8,,,152.8,Other,260% of Medicaid,190.42,,,190.42,Other,324% of Medicaid,126.36,,,126.36,Other,215% of Medicaid,126.36,,,126.36,Other,215% of Medicaid,73.46,,,73.46,Other,125% of Medicaid,58.77,368,
TH-SELF CARE MNGMENT TRAINING,97535,CPT,GOGT,64297535,CDM,430,RC,,,both,,,193,142.82,,,142.82,Other,150% of Medicare + 9.63% HCRA Surcharge,86.85,45,,86.85,percent of total billed charges,Critical Access Hospital RCC factor,180,,,180,Case Rate,Therapy Per Visit,162,,,162,Case Rate,Therapy Per Visit,199.1,,,199.1,Fee Schedule,,179.08,,,179.08,Fee Schedule,,169.25,,,169.25,Fee Schedule,,95.54,,,95.54,Other,110% of Medicare,219,,,219,Case Rate,Therapy Per Visit,39,,,39,Other,186% of Medicaid,257,,,257,Case Rate,Therapy Per Visit,160.19,83,,160.19,percent of total billed charges,Therapy,72.79,,,72.79,Case Rate,,257,,,257,Case Rate,Therapy Per Visit,160.19,83,,160.19,percent of total billed charges,Therapy,368,,,368,Case Rate,Therapy Visit,135.1,70,,135.1,percent of total billed charges,All Other,259,,,259,Case Rate,Therapy Visit,220,,,220,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,138,,,138,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,131,,,131,Case Rate,Therapy Visit,20.84,,,20.84,Other,100% of Medicaid,20.84,,,20.84,Other,100% of Medicaid,20.84,,,20.84,Other,100% of Medicaid,20.84,,,20.84,Other,100% of Medicaid,46.9,,,46.9,Other,225% of Medicaid,31.89,,,31.89,Other,153% of Medicaid,46.9,,,46.9,Other,225% of Medicaid,29.18,,,29.18,Other,140% of Medicaid,46.9,,,46.9,Other,225% of Medicaid,54.2,,,54.2,Other,260% of Medicaid,67.54,,,67.54,Other,324% of Medicaid,44.82,,,44.82,Other,215% of Medicaid,44.82,,,44.82,Other,215% of Medicaid,26.06,,,26.06,Other,125% of Medicaid,20.84,368,
SENSORY INTEGRATE TECH 15MIN,97533,CPT,GO,63097533,CDM,431,RC,,,both,,,209,154.66,,,154.66,Other,150% of Medicare + 9.63% HCRA Surcharge,94.05,45,,94.05,percent of total billed charges,Critical Access Hospital RCC factor,180,,,180,Case Rate,Therapy Per Visit,162,,,162,Case Rate,Therapy Per Visit,167.48,,,167.48,Fee Schedule,,150.64,,,150.64,Fee Schedule,,142.37,,,142.37,Fee Schedule,,103.46,,,103.46,Other,110% of Medicare,219,,,219,Case Rate,Therapy Per Visit,109,,,109,Other,186% of Medicaid,257,,,257,Case Rate,Therapy Per Visit,173.47,83,,173.47,percent of total billed charges,Therapy,140.34,,,140.34,Case Rate,,257,,,257,Case Rate,Therapy Per Visit,173.47,83,,173.47,percent of total billed charges,Therapy,368,,,368,Case Rate,Therapy Visit,146.3,70,,146.3,percent of total billed charges,All Other,259,,,259,Case Rate,Therapy Visit,220,,,220,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,138,,,138,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,131,,,131,Case Rate,Therapy Visit,58.77,,,58.77,Other,100% of Medicaid,58.77,,,58.77,Other,100% of Medicaid,58.77,,,58.77,Other,100% of Medicaid,58.77,,,58.77,Other,100% of Medicaid,132.23,,,132.23,Other,225% of Medicaid,89.92,,,89.92,Other,153% of Medicaid,132.23,,,132.23,Other,225% of Medicaid,82.28,,,82.28,Other,140% of Medicaid,132.23,,,132.23,Other,225% of Medicaid,152.8,,,152.8,Other,260% of Medicaid,190.42,,,190.42,Other,324% of Medicaid,126.36,,,126.36,Other,215% of Medicaid,126.36,,,126.36,Other,215% of Medicaid,73.46,,,73.46,Other,125% of Medicaid,58.77,368,
SENSORY INTEGRATE TECH 15MIN,97533,CPT,GO,64097533,CDM,431,RC,,,both,,,209,154.66,,,154.66,Other,150% of Medicare + 9.63% HCRA Surcharge,94.05,45,,94.05,percent of total billed charges,Critical Access Hospital RCC factor,180,,,180,Case Rate,Therapy Per Visit,162,,,162,Case Rate,Therapy Per Visit,167.48,,,167.48,Fee Schedule,,150.64,,,150.64,Fee Schedule,,142.37,,,142.37,Fee Schedule,,103.46,,,103.46,Other,110% of Medicare,219,,,219,Case Rate,Therapy Per Visit,109,,,109,Other,186% of Medicaid,257,,,257,Case Rate,Therapy Per Visit,173.47,83,,173.47,percent of total billed charges,Therapy,140.34,,,140.34,Case Rate,,257,,,257,Case Rate,Therapy Per Visit,173.47,83,,173.47,percent of total billed charges,Therapy,368,,,368,Case Rate,Therapy Visit,146.3,70,,146.3,percent of total billed charges,All Other,259,,,259,Case Rate,Therapy Visit,220,,,220,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,138,,,138,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,131,,,131,Case Rate,Therapy Visit,58.77,,,58.77,Other,100% of Medicaid,58.77,,,58.77,Other,100% of Medicaid,58.77,,,58.77,Other,100% of Medicaid,58.77,,,58.77,Other,100% of Medicaid,132.23,,,132.23,Other,225% of Medicaid,89.92,,,89.92,Other,153% of Medicaid,132.23,,,132.23,Other,225% of Medicaid,82.28,,,82.28,Other,140% of Medicaid,132.23,,,132.23,Other,225% of Medicaid,152.8,,,152.8,Other,260% of Medicaid,190.42,,,190.42,Other,324% of Medicaid,126.36,,,126.36,Other,215% of Medicaid,126.36,,,126.36,Other,215% of Medicaid,73.46,,,73.46,Other,125% of Medicaid,58.77,368,
OT EVAL LOW COMPLEX 30 MIN,97165,CPT,GO,63097165,CDM,434,RC,,,both,,,475,351.5,,,351.5,Other,150% of Medicare + 9.63% HCRA Surcharge,213.75,45,,213.75,percent of total billed charges,Critical Access Hospital RCC factor,180,,,180,Case Rate,Therapy Per Visit,162,,,162,Case Rate,Therapy Per Visit,73.77,,,73.77,Fee Schedule,,73.77,,,73.77,Fee Schedule,,73.77,,,73.77,Fee Schedule,,235.13,,,235.13,Other,110% of Medicare,219,,,219,Case Rate,Therapy Per Visit,204,,,204,Other,186% of Medicaid,257,,,257,Case Rate,Therapy Per Visit,394.25,83,,394.25,percent of total billed charges,Therapy,225.29,,,225.29,Case Rate,,257,,,257,Case Rate,Therapy Per Visit,394.25,83,,394.25,percent of total billed charges,Therapy,368,,,368,Case Rate,Therapy Visit,332.5,70,,332.5,percent of total billed charges,All Other,259,,,259,Case Rate,Therapy Visit,220,,,220,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,138,,,138,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,131,,,131,Case Rate,Therapy Visit,109.45,,,109.45,Other,100% of Medicaid,109.45,,,109.45,Other,100% of Medicaid,109.45,,,109.45,Other,100% of Medicaid,109.45,,,109.45,Other,100% of Medicaid,246.27,,,246.27,Other,225% of Medicaid,167.46,,,167.46,Other,153% of Medicaid,246.27,,,246.27,Other,225% of Medicaid,153.23,,,153.23,Other,140% of Medicaid,246.27,,,246.27,Other,225% of Medicaid,284.58,,,284.58,Other,260% of Medicaid,354.63,,,354.63,Other,324% of Medicaid,235.32,,,235.32,Other,215% of Medicaid,235.32,,,235.32,Other,215% of Medicaid,136.82,,,136.82,Other,125% of Medicaid,73.77,394.25,
OT EVAL MOD COMPLEX 45 MIN,97166,CPT,GO,63097166,CDM,434,RC,,,both,,,475,351.5,,,351.5,Other,150% of Medicare + 9.63% HCRA Surcharge,213.75,45,,213.75,percent of total billed charges,Critical Access Hospital RCC factor,180,,,180,Case Rate,Therapy Per Visit,162,,,162,Case Rate,Therapy Per Visit,73.77,,,73.77,Fee Schedule,,73.77,,,73.77,Fee Schedule,,73.77,,,73.77,Fee Schedule,,235.13,,,235.13,Other,110% of Medicare,219,,,219,Case Rate,Therapy Per Visit,204,,,204,Other,186% of Medicaid,257,,,257,Case Rate,Therapy Per Visit,394.25,83,,394.25,percent of total billed charges,Therapy,225.29,,,225.29,Case Rate,,257,,,257,Case Rate,Therapy Per Visit,394.25,83,,394.25,percent of total billed charges,Therapy,368,,,368,Case Rate,Therapy Visit,332.5,70,,332.5,percent of total billed charges,All Other,259,,,259,Case Rate,Therapy Visit,220,,,220,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,138,,,138,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,131,,,131,Case Rate,Therapy Visit,109.45,,,109.45,Other,100% of Medicaid,109.45,,,109.45,Other,100% of Medicaid,109.45,,,109.45,Other,100% of Medicaid,109.45,,,109.45,Other,100% of Medicaid,246.27,,,246.27,Other,225% of Medicaid,167.46,,,167.46,Other,153% of Medicaid,246.27,,,246.27,Other,225% of Medicaid,153.23,,,153.23,Other,140% of Medicaid,246.27,,,246.27,Other,225% of Medicaid,284.58,,,284.58,Other,260% of Medicaid,354.63,,,354.63,Other,324% of Medicaid,235.32,,,235.32,Other,215% of Medicaid,235.32,,,235.32,Other,215% of Medicaid,136.82,,,136.82,Other,125% of Medicaid,73.77,394.25,
OT EVAL HIGH COMPLEX 60 MIN,97167,CPT,GO,63097167,CDM,434,RC,,,both,,,475,351.5,,,351.5,Other,150% of Medicare + 9.63% HCRA Surcharge,213.75,45,,213.75,percent of total billed charges,Critical Access Hospital RCC factor,180,,,180,Case Rate,Therapy Per Visit,162,,,162,Case Rate,Therapy Per Visit,73.77,,,73.77,Fee Schedule,,73.77,,,73.77,Fee Schedule,,73.77,,,73.77,Fee Schedule,,235.13,,,235.13,Other,110% of Medicare,219,,,219,Case Rate,Therapy Per Visit,204,,,204,Other,186% of Medicaid,257,,,257,Case Rate,Therapy Per Visit,394.25,83,,394.25,percent of total billed charges,Therapy,225.29,,,225.29,Case Rate,,257,,,257,Case Rate,Therapy Per Visit,394.25,83,,394.25,percent of total billed charges,Therapy,368,,,368,Case Rate,Therapy Visit,332.5,70,,332.5,percent of total billed charges,All Other,259,,,259,Case Rate,Therapy Visit,220,,,220,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,138,,,138,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,131,,,131,Case Rate,Therapy Visit,109.45,,,109.45,Other,100% of Medicaid,109.45,,,109.45,Other,100% of Medicaid,109.45,,,109.45,Other,100% of Medicaid,109.45,,,109.45,Other,100% of Medicaid,246.27,,,246.27,Other,225% of Medicaid,167.46,,,167.46,Other,153% of Medicaid,246.27,,,246.27,Other,225% of Medicaid,153.23,,,153.23,Other,140% of Medicaid,246.27,,,246.27,Other,225% of Medicaid,284.58,,,284.58,Other,260% of Medicaid,354.63,,,354.63,Other,324% of Medicaid,235.32,,,235.32,Other,215% of Medicaid,235.32,,,235.32,Other,215% of Medicaid,136.82,,,136.82,Other,125% of Medicaid,73.77,394.25,
OT RE-EVAL EST PLAN CARE,97168,CPT,GO,63097168,CDM,434,RC,,,both,,,266,196.84,,,196.84,Other,150% of Medicare + 9.63% HCRA Surcharge,119.7,45,,119.7,percent of total billed charges,Critical Access Hospital RCC factor,180,,,180,Case Rate,Therapy Per Visit,162,,,162,Case Rate,Therapy Per Visit,48.77,,,48.77,Fee Schedule,,48.77,,,48.77,Fee Schedule,,48.77,,,48.77,Fee Schedule,,131.67,,,131.67,Other,110% of Medicare,219,,,219,Case Rate,Therapy Per Visit,204,,,204,Other,186% of Medicaid,257,,,257,Case Rate,Therapy Per Visit,220.78,83,,220.78,percent of total billed charges,Therapy,156.09,,,156.09,Case Rate,,257,,,257,Case Rate,Therapy Per Visit,220.78,83,,220.78,percent of total billed charges,Therapy,368,,,368,Case Rate,Therapy Visit,186.2,70,,186.2,percent of total billed charges,All Other,259,,,259,Case Rate,Therapy Visit,220,,,220,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,138,,,138,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,131,,,131,Case Rate,Therapy Visit,109.45,,,109.45,Other,100% of Medicaid,109.45,,,109.45,Other,100% of Medicaid,109.45,,,109.45,Other,100% of Medicaid,109.45,,,109.45,Other,100% of Medicaid,246.27,,,246.27,Other,225% of Medicaid,167.46,,,167.46,Other,153% of Medicaid,246.27,,,246.27,Other,225% of Medicaid,153.23,,,153.23,Other,140% of Medicaid,246.27,,,246.27,Other,225% of Medicaid,284.58,,,284.58,Other,260% of Medicaid,354.63,,,354.63,Other,324% of Medicaid,235.32,,,235.32,Other,215% of Medicaid,235.32,,,235.32,Other,215% of Medicaid,136.82,,,136.82,Other,125% of Medicaid,48.77,368,
ARC SCREEN OT,97166,CPT,GO,63197166,CDM,434,RC,,,both,,,475,351.5,,,351.5,Other,150% of Medicare + 9.63% HCRA Surcharge,213.75,45,,213.75,percent of total billed charges,Critical Access Hospital RCC factor,180,,,180,Case Rate,Therapy Per Visit,162,,,162,Case Rate,Therapy Per Visit,73.77,,,73.77,Fee Schedule,,73.77,,,73.77,Fee Schedule,,73.77,,,73.77,Fee Schedule,,235.13,,,235.13,Other,110% of Medicare,219,,,219,Case Rate,Therapy Per Visit,204,,,204,Other,186% of Medicaid,257,,,257,Case Rate,Therapy Per Visit,394.25,83,,394.25,percent of total billed charges,Therapy,225.29,,,225.29,Case Rate,,257,,,257,Case Rate,Therapy Per Visit,394.25,83,,394.25,percent of total billed charges,Therapy,368,,,368,Case Rate,Therapy Visit,332.5,70,,332.5,percent of total billed charges,All Other,259,,,259,Case Rate,Therapy Visit,220,,,220,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,138,,,138,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,131,,,131,Case Rate,Therapy Visit,109.45,,,109.45,Other,100% of Medicaid,109.45,,,109.45,Other,100% of Medicaid,109.45,,,109.45,Other,100% of Medicaid,109.45,,,109.45,Other,100% of Medicaid,246.27,,,246.27,Other,225% of Medicaid,167.46,,,167.46,Other,153% of Medicaid,246.27,,,246.27,Other,225% of Medicaid,153.23,,,153.23,Other,140% of Medicaid,246.27,,,246.27,Other,225% of Medicaid,284.58,,,284.58,Other,260% of Medicaid,354.63,,,354.63,Other,324% of Medicaid,235.32,,,235.32,Other,215% of Medicaid,235.32,,,235.32,Other,215% of Medicaid,136.82,,,136.82,Other,125% of Medicaid,73.77,394.25,
TH-OT EVAL LOW COMPLEX 30 MIN,97165,CPT,GOGT,63297165,CDM,434,RC,,,both,,,475,351.5,,,351.5,Other,150% of Medicare + 9.63% HCRA Surcharge,213.75,45,,213.75,percent of total billed charges,Critical Access Hospital RCC factor,180,,,180,Case Rate,Therapy Per Visit,162,,,162,Case Rate,Therapy Per Visit,73.77,,,73.77,Fee Schedule,,73.77,,,73.77,Fee Schedule,,73.77,,,73.77,Fee Schedule,,235.13,,,235.13,Other,110% of Medicare,219,,,219,Case Rate,Therapy Per Visit,204,,,204,Other,186% of Medicaid,257,,,257,Case Rate,Therapy Per Visit,394.25,83,,394.25,percent of total billed charges,Therapy,225.29,,,225.29,Case Rate,,257,,,257,Case Rate,Therapy Per Visit,394.25,83,,394.25,percent of total billed charges,Therapy,368,,,368,Case Rate,Therapy Visit,332.5,70,,332.5,percent of total billed charges,All Other,259,,,259,Case Rate,Therapy Visit,220,,,220,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,138,,,138,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,131,,,131,Case Rate,Therapy Visit,109.45,,,109.45,Other,100% of Medicaid,109.45,,,109.45,Other,100% of Medicaid,109.45,,,109.45,Other,100% of Medicaid,109.45,,,109.45,Other,100% of Medicaid,246.27,,,246.27,Other,225% of Medicaid,167.46,,,167.46,Other,153% of Medicaid,246.27,,,246.27,Other,225% of Medicaid,153.23,,,153.23,Other,140% of Medicaid,246.27,,,246.27,Other,225% of Medicaid,284.58,,,284.58,Other,260% of Medicaid,354.63,,,354.63,Other,324% of Medicaid,235.32,,,235.32,Other,215% of Medicaid,235.32,,,235.32,Other,215% of Medicaid,136.82,,,136.82,Other,125% of Medicaid,73.77,394.25,
TH-OT EVAL MOD COMPLEX 45 MIN,97166,CPT,GOGT,63297166,CDM,434,RC,,,both,,,475,351.5,,,351.5,Other,150% of Medicare + 9.63% HCRA Surcharge,213.75,45,,213.75,percent of total billed charges,Critical Access Hospital RCC factor,180,,,180,Case Rate,Therapy Per Visit,162,,,162,Case Rate,Therapy Per Visit,73.77,,,73.77,Fee Schedule,,73.77,,,73.77,Fee Schedule,,73.77,,,73.77,Fee Schedule,,235.13,,,235.13,Other,110% of Medicare,219,,,219,Case Rate,Therapy Per Visit,204,,,204,Other,186% of Medicaid,257,,,257,Case Rate,Therapy Per Visit,394.25,83,,394.25,percent of total billed charges,Therapy,225.29,,,225.29,Case Rate,,257,,,257,Case Rate,Therapy Per Visit,394.25,83,,394.25,percent of total billed charges,Therapy,368,,,368,Case Rate,Therapy Visit,332.5,70,,332.5,percent of total billed charges,All Other,259,,,259,Case Rate,Therapy Visit,220,,,220,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,138,,,138,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,131,,,131,Case Rate,Therapy Visit,109.45,,,109.45,Other,100% of Medicaid,109.45,,,109.45,Other,100% of Medicaid,109.45,,,109.45,Other,100% of Medicaid,109.45,,,109.45,Other,100% of Medicaid,246.27,,,246.27,Other,225% of Medicaid,167.46,,,167.46,Other,153% of Medicaid,246.27,,,246.27,Other,225% of Medicaid,153.23,,,153.23,Other,140% of Medicaid,246.27,,,246.27,Other,225% of Medicaid,284.58,,,284.58,Other,260% of Medicaid,354.63,,,354.63,Other,324% of Medicaid,235.32,,,235.32,Other,215% of Medicaid,235.32,,,235.32,Other,215% of Medicaid,136.82,,,136.82,Other,125% of Medicaid,73.77,394.25,
TH-OT EVAL HIGH COMPLEX 60 MIN,97167,CPT,GOGT,63297167,CDM,434,RC,,,both,,,475,351.5,,,351.5,Other,150% of Medicare + 9.63% HCRA Surcharge,213.75,45,,213.75,percent of total billed charges,Critical Access Hospital RCC factor,180,,,180,Case Rate,Therapy Per Visit,162,,,162,Case Rate,Therapy Per Visit,73.77,,,73.77,Fee Schedule,,73.77,,,73.77,Fee Schedule,,73.77,,,73.77,Fee Schedule,,235.13,,,235.13,Other,110% of Medicare,219,,,219,Case Rate,Therapy Per Visit,204,,,204,Other,186% of Medicaid,257,,,257,Case Rate,Therapy Per Visit,394.25,83,,394.25,percent of total billed charges,Therapy,225.29,,,225.29,Case Rate,,257,,,257,Case Rate,Therapy Per Visit,394.25,83,,394.25,percent of total billed charges,Therapy,368,,,368,Case Rate,Therapy Visit,332.5,70,,332.5,percent of total billed charges,All Other,259,,,259,Case Rate,Therapy Visit,220,,,220,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,138,,,138,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,131,,,131,Case Rate,Therapy Visit,109.45,,,109.45,Other,100% of Medicaid,109.45,,,109.45,Other,100% of Medicaid,109.45,,,109.45,Other,100% of Medicaid,109.45,,,109.45,Other,100% of Medicaid,246.27,,,246.27,Other,225% of Medicaid,167.46,,,167.46,Other,153% of Medicaid,246.27,,,246.27,Other,225% of Medicaid,153.23,,,153.23,Other,140% of Medicaid,246.27,,,246.27,Other,225% of Medicaid,284.58,,,284.58,Other,260% of Medicaid,354.63,,,354.63,Other,324% of Medicaid,235.32,,,235.32,Other,215% of Medicaid,235.32,,,235.32,Other,215% of Medicaid,136.82,,,136.82,Other,125% of Medicaid,73.77,394.25,
OT EVAL LOW COMPLEX 30 MIN,97165,CPT,GO,64097165,CDM,434,RC,,,both,,,475,351.5,,,351.5,Other,150% of Medicare + 9.63% HCRA Surcharge,213.75,45,,213.75,percent of total billed charges,Critical Access Hospital RCC factor,180,,,180,Case Rate,Therapy Per Visit,162,,,162,Case Rate,Therapy Per Visit,73.77,,,73.77,Fee Schedule,,73.77,,,73.77,Fee Schedule,,73.77,,,73.77,Fee Schedule,,235.13,,,235.13,Other,110% of Medicare,219,,,219,Case Rate,Therapy Per Visit,204,,,204,Other,186% of Medicaid,257,,,257,Case Rate,Therapy Per Visit,394.25,83,,394.25,percent of total billed charges,Therapy,225.29,,,225.29,Case Rate,,257,,,257,Case Rate,Therapy Per Visit,394.25,83,,394.25,percent of total billed charges,Therapy,368,,,368,Case Rate,Therapy Visit,332.5,70,,332.5,percent of total billed charges,All Other,259,,,259,Case Rate,Therapy Visit,220,,,220,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,138,,,138,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,131,,,131,Case Rate,Therapy Visit,109.45,,,109.45,Other,100% of Medicaid,109.45,,,109.45,Other,100% of Medicaid,109.45,,,109.45,Other,100% of Medicaid,109.45,,,109.45,Other,100% of Medicaid,246.27,,,246.27,Other,225% of Medicaid,167.46,,,167.46,Other,153% of Medicaid,246.27,,,246.27,Other,225% of Medicaid,153.23,,,153.23,Other,140% of Medicaid,246.27,,,246.27,Other,225% of Medicaid,284.58,,,284.58,Other,260% of Medicaid,354.63,,,354.63,Other,324% of Medicaid,235.32,,,235.32,Other,215% of Medicaid,235.32,,,235.32,Other,215% of Medicaid,136.82,,,136.82,Other,125% of Medicaid,73.77,394.25,
OT EVAL MOD COMPLEX 45 MIN,97166,CPT,GO,64097166,CDM,434,RC,,,both,,,475,351.5,,,351.5,Other,150% of Medicare + 9.63% HCRA Surcharge,213.75,45,,213.75,percent of total billed charges,Critical Access Hospital RCC factor,180,,,180,Case Rate,Therapy Per Visit,162,,,162,Case Rate,Therapy Per Visit,73.77,,,73.77,Fee Schedule,,73.77,,,73.77,Fee Schedule,,73.77,,,73.77,Fee Schedule,,235.13,,,235.13,Other,110% of Medicare,219,,,219,Case Rate,Therapy Per Visit,204,,,204,Other,186% of Medicaid,257,,,257,Case Rate,Therapy Per Visit,394.25,83,,394.25,percent of total billed charges,Therapy,225.29,,,225.29,Case Rate,,257,,,257,Case Rate,Therapy Per Visit,394.25,83,,394.25,percent of total billed charges,Therapy,368,,,368,Case Rate,Therapy Visit,332.5,70,,332.5,percent of total billed charges,All Other,259,,,259,Case Rate,Therapy Visit,220,,,220,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,138,,,138,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,131,,,131,Case Rate,Therapy Visit,109.45,,,109.45,Other,100% of Medicaid,109.45,,,109.45,Other,100% of Medicaid,109.45,,,109.45,Other,100% of Medicaid,109.45,,,109.45,Other,100% of Medicaid,246.27,,,246.27,Other,225% of Medicaid,167.46,,,167.46,Other,153% of Medicaid,246.27,,,246.27,Other,225% of Medicaid,153.23,,,153.23,Other,140% of Medicaid,246.27,,,246.27,Other,225% of Medicaid,284.58,,,284.58,Other,260% of Medicaid,354.63,,,354.63,Other,324% of Medicaid,235.32,,,235.32,Other,215% of Medicaid,235.32,,,235.32,Other,215% of Medicaid,136.82,,,136.82,Other,125% of Medicaid,73.77,394.25,
OT EVAL HIGH COMPLEX 60 MIN,97167,CPT,GO,64097167,CDM,434,RC,,,both,,,475,351.5,,,351.5,Other,150% of Medicare + 9.63% HCRA Surcharge,213.75,45,,213.75,percent of total billed charges,Critical Access Hospital RCC factor,180,,,180,Case Rate,Therapy Per Visit,162,,,162,Case Rate,Therapy Per Visit,73.77,,,73.77,Fee Schedule,,73.77,,,73.77,Fee Schedule,,73.77,,,73.77,Fee Schedule,,235.13,,,235.13,Other,110% of Medicare,219,,,219,Case Rate,Therapy Per Visit,204,,,204,Other,186% of Medicaid,257,,,257,Case Rate,Therapy Per Visit,394.25,83,,394.25,percent of total billed charges,Therapy,225.29,,,225.29,Case Rate,,257,,,257,Case Rate,Therapy Per Visit,394.25,83,,394.25,percent of total billed charges,Therapy,368,,,368,Case Rate,Therapy Visit,332.5,70,,332.5,percent of total billed charges,All Other,259,,,259,Case Rate,Therapy Visit,220,,,220,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,138,,,138,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,131,,,131,Case Rate,Therapy Visit,109.45,,,109.45,Other,100% of Medicaid,109.45,,,109.45,Other,100% of Medicaid,109.45,,,109.45,Other,100% of Medicaid,109.45,,,109.45,Other,100% of Medicaid,246.27,,,246.27,Other,225% of Medicaid,167.46,,,167.46,Other,153% of Medicaid,246.27,,,246.27,Other,225% of Medicaid,153.23,,,153.23,Other,140% of Medicaid,246.27,,,246.27,Other,225% of Medicaid,284.58,,,284.58,Other,260% of Medicaid,354.63,,,354.63,Other,324% of Medicaid,235.32,,,235.32,Other,215% of Medicaid,235.32,,,235.32,Other,215% of Medicaid,136.82,,,136.82,Other,125% of Medicaid,73.77,394.25,
OT RE-EVAL EST PLAN CARE,97168,CPT,GO,64097168,CDM,434,RC,,,both,,,266,196.84,,,196.84,Other,150% of Medicare + 9.63% HCRA Surcharge,119.7,45,,119.7,percent of total billed charges,Critical Access Hospital RCC factor,180,,,180,Case Rate,Therapy Per Visit,162,,,162,Case Rate,Therapy Per Visit,48.77,,,48.77,Fee Schedule,,48.77,,,48.77,Fee Schedule,,48.77,,,48.77,Fee Schedule,,131.67,,,131.67,Other,110% of Medicare,219,,,219,Case Rate,Therapy Per Visit,204,,,204,Other,186% of Medicaid,257,,,257,Case Rate,Therapy Per Visit,220.78,83,,220.78,percent of total billed charges,Therapy,156.09,,,156.09,Case Rate,,257,,,257,Case Rate,Therapy Per Visit,220.78,83,,220.78,percent of total billed charges,Therapy,368,,,368,Case Rate,Therapy Visit,186.2,70,,186.2,percent of total billed charges,All Other,259,,,259,Case Rate,Therapy Visit,220,,,220,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,138,,,138,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,131,,,131,Case Rate,Therapy Visit,109.45,,,109.45,Other,100% of Medicaid,109.45,,,109.45,Other,100% of Medicaid,109.45,,,109.45,Other,100% of Medicaid,109.45,,,109.45,Other,100% of Medicaid,246.27,,,246.27,Other,225% of Medicaid,167.46,,,167.46,Other,153% of Medicaid,246.27,,,246.27,Other,225% of Medicaid,153.23,,,153.23,Other,140% of Medicaid,246.27,,,246.27,Other,225% of Medicaid,284.58,,,284.58,Other,260% of Medicaid,354.63,,,354.63,Other,324% of Medicaid,235.32,,,235.32,Other,215% of Medicaid,235.32,,,235.32,Other,215% of Medicaid,136.82,,,136.82,Other,125% of Medicaid,48.77,368,
ARC SCREEN OT SAUG,97166,CPT,GO,64197166,CDM,434,RC,,,both,,,475,351.5,,,351.5,Other,150% of Medicare + 9.63% HCRA Surcharge,213.75,45,,213.75,percent of total billed charges,Critical Access Hospital RCC factor,180,,,180,Case Rate,Therapy Per Visit,162,,,162,Case Rate,Therapy Per Visit,73.77,,,73.77,Fee Schedule,,73.77,,,73.77,Fee Schedule,,73.77,,,73.77,Fee Schedule,,235.13,,,235.13,Other,110% of Medicare,219,,,219,Case Rate,Therapy Per Visit,204,,,204,Other,186% of Medicaid,257,,,257,Case Rate,Therapy Per Visit,394.25,83,,394.25,percent of total billed charges,Therapy,225.29,,,225.29,Case Rate,,257,,,257,Case Rate,Therapy Per Visit,394.25,83,,394.25,percent of total billed charges,Therapy,368,,,368,Case Rate,Therapy Visit,332.5,70,,332.5,percent of total billed charges,All Other,259,,,259,Case Rate,Therapy Visit,220,,,220,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,138,,,138,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,131,,,131,Case Rate,Therapy Visit,109.45,,,109.45,Other,100% of Medicaid,109.45,,,109.45,Other,100% of Medicaid,109.45,,,109.45,Other,100% of Medicaid,109.45,,,109.45,Other,100% of Medicaid,246.27,,,246.27,Other,225% of Medicaid,167.46,,,167.46,Other,153% of Medicaid,246.27,,,246.27,Other,225% of Medicaid,153.23,,,153.23,Other,140% of Medicaid,246.27,,,246.27,Other,225% of Medicaid,284.58,,,284.58,Other,260% of Medicaid,354.63,,,354.63,Other,324% of Medicaid,235.32,,,235.32,Other,215% of Medicaid,235.32,,,235.32,Other,215% of Medicaid,136.82,,,136.82,Other,125% of Medicaid,73.77,394.25,
TH-OT EVAL LOW COMPLEX 30 MIN,97165,CPT,GOGT,64297165,CDM,434,RC,,,both,,,475,351.5,,,351.5,Other,150% of Medicare + 9.63% HCRA Surcharge,213.75,45,,213.75,percent of total billed charges,Critical Access Hospital RCC factor,180,,,180,Case Rate,Therapy Per Visit,162,,,162,Case Rate,Therapy Per Visit,73.77,,,73.77,Fee Schedule,,73.77,,,73.77,Fee Schedule,,73.77,,,73.77,Fee Schedule,,235.13,,,235.13,Other,110% of Medicare,219,,,219,Case Rate,Therapy Per Visit,204,,,204,Other,186% of Medicaid,257,,,257,Case Rate,Therapy Per Visit,394.25,83,,394.25,percent of total billed charges,Therapy,225.29,,,225.29,Case Rate,,257,,,257,Case Rate,Therapy Per Visit,394.25,83,,394.25,percent of total billed charges,Therapy,368,,,368,Case Rate,Therapy Visit,332.5,70,,332.5,percent of total billed charges,All Other,259,,,259,Case Rate,Therapy Visit,220,,,220,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,138,,,138,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,131,,,131,Case Rate,Therapy Visit,109.45,,,109.45,Other,100% of Medicaid,109.45,,,109.45,Other,100% of Medicaid,109.45,,,109.45,Other,100% of Medicaid,109.45,,,109.45,Other,100% of Medicaid,246.27,,,246.27,Other,225% of Medicaid,167.46,,,167.46,Other,153% of Medicaid,246.27,,,246.27,Other,225% of Medicaid,153.23,,,153.23,Other,140% of Medicaid,246.27,,,246.27,Other,225% of Medicaid,284.58,,,284.58,Other,260% of Medicaid,354.63,,,354.63,Other,324% of Medicaid,235.32,,,235.32,Other,215% of Medicaid,235.32,,,235.32,Other,215% of Medicaid,136.82,,,136.82,Other,125% of Medicaid,73.77,394.25,
TH-OT EVAL MOD COMPLEX 45 MIN,97166,CPT,GOGT,64297166,CDM,434,RC,,,both,,,475,351.5,,,351.5,Other,150% of Medicare + 9.63% HCRA Surcharge,213.75,45,,213.75,percent of total billed charges,Critical Access Hospital RCC factor,180,,,180,Case Rate,Therapy Per Visit,162,,,162,Case Rate,Therapy Per Visit,73.77,,,73.77,Fee Schedule,,73.77,,,73.77,Fee Schedule,,73.77,,,73.77,Fee Schedule,,235.13,,,235.13,Other,110% of Medicare,219,,,219,Case Rate,Therapy Per Visit,204,,,204,Other,186% of Medicaid,257,,,257,Case Rate,Therapy Per Visit,394.25,83,,394.25,percent of total billed charges,Therapy,225.29,,,225.29,Case Rate,,257,,,257,Case Rate,Therapy Per Visit,394.25,83,,394.25,percent of total billed charges,Therapy,368,,,368,Case Rate,Therapy Visit,332.5,70,,332.5,percent of total billed charges,All Other,259,,,259,Case Rate,Therapy Visit,220,,,220,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,138,,,138,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,131,,,131,Case Rate,Therapy Visit,109.45,,,109.45,Other,100% of Medicaid,109.45,,,109.45,Other,100% of Medicaid,109.45,,,109.45,Other,100% of Medicaid,109.45,,,109.45,Other,100% of Medicaid,246.27,,,246.27,Other,225% of Medicaid,167.46,,,167.46,Other,153% of Medicaid,246.27,,,246.27,Other,225% of Medicaid,153.23,,,153.23,Other,140% of Medicaid,246.27,,,246.27,Other,225% of Medicaid,284.58,,,284.58,Other,260% of Medicaid,354.63,,,354.63,Other,324% of Medicaid,235.32,,,235.32,Other,215% of Medicaid,235.32,,,235.32,Other,215% of Medicaid,136.82,,,136.82,Other,125% of Medicaid,73.77,394.25,
TH-OT EVAL HIGH COMPLEX 60 MIN,97167,CPT,GOGT,64297167,CDM,434,RC,,,both,,,475,351.5,,,351.5,Other,150% of Medicare + 9.63% HCRA Surcharge,213.75,45,,213.75,percent of total billed charges,Critical Access Hospital RCC factor,180,,,180,Case Rate,Therapy Per Visit,162,,,162,Case Rate,Therapy Per Visit,73.77,,,73.77,Fee Schedule,,73.77,,,73.77,Fee Schedule,,73.77,,,73.77,Fee Schedule,,235.13,,,235.13,Other,110% of Medicare,219,,,219,Case Rate,Therapy Per Visit,204,,,204,Other,186% of Medicaid,257,,,257,Case Rate,Therapy Per Visit,394.25,83,,394.25,percent of total billed charges,Therapy,225.29,,,225.29,Case Rate,,257,,,257,Case Rate,Therapy Per Visit,394.25,83,,394.25,percent of total billed charges,Therapy,368,,,368,Case Rate,Therapy Visit,332.5,70,,332.5,percent of total billed charges,All Other,259,,,259,Case Rate,Therapy Visit,220,,,220,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,138,,,138,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,131,,,131,Case Rate,Therapy Visit,109.45,,,109.45,Other,100% of Medicaid,109.45,,,109.45,Other,100% of Medicaid,109.45,,,109.45,Other,100% of Medicaid,109.45,,,109.45,Other,100% of Medicaid,246.27,,,246.27,Other,225% of Medicaid,167.46,,,167.46,Other,153% of Medicaid,246.27,,,246.27,Other,225% of Medicaid,153.23,,,153.23,Other,140% of Medicaid,246.27,,,246.27,Other,225% of Medicaid,284.58,,,284.58,Other,260% of Medicaid,354.63,,,354.63,Other,324% of Medicaid,235.32,,,235.32,Other,215% of Medicaid,235.32,,,235.32,Other,215% of Medicaid,136.82,,,136.82,Other,125% of Medicaid,73.77,394.25,
TREATMENT SPEECH DISORDER,92507,CPT,GN,65092507,CDM,440,RC,,,both,,,539,398.86,,,398.86,Other,150% of Medicare + 9.63% HCRA Surcharge,242.55,45,,242.55,percent of total billed charges,Critical Access Hospital RCC factor,180,,,180,Case Rate,Therapy Per Visit,162,,,162,Case Rate,Therapy Per Visit,501.44,,,501.44,Fee Schedule,,451.01,,,451.01,Fee Schedule,,426.27,,,426.27,Fee Schedule,,266.81,,,266.81,Other,110% of Medicare,219,,,219,Case Rate,Therapy Per Visit,186,,,186,Other,186% of Medicaid,257,,,257,Case Rate,Therapy Per Visit,447.37,83,,447.37,percent of total billed charges,Therapy,169.13,,,169.13,Case Rate,,257,,,257,Case Rate,Therapy Per Visit,447.37,83,,447.37,percent of total billed charges,Therapy,368,,,368,Case Rate,Therapy Visit,377.3,70,,377.3,percent of total billed charges,All Other,259,,,259,Case Rate,Therapy Visit,220,,,220,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,138,,,138,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,131,,,131,Case Rate,Therapy Visit,100.07,,,100.07,Other,100% of Medicaid,100.07,,,100.07,Other,100% of Medicaid,100.07,,,100.07,Other,100% of Medicaid,100.07,,,100.07,Other,100% of Medicaid,225.16,,,225.16,Other,225% of Medicaid,153.11,,,153.11,Other,153% of Medicaid,225.16,,,225.16,Other,225% of Medicaid,140.1,,,140.1,Other,140% of Medicaid,225.16,,,225.16,Other,225% of Medicaid,260.19,,,260.19,Other,260% of Medicaid,324.23,,,324.23,Other,324% of Medicaid,215.15,,,215.15,Other,215% of Medicaid,215.15,,,215.15,Other,215% of Medicaid,125.09,,,125.09,Other,125% of Medicaid,100.07,501.44,
DYSPHAGIA TREATMENT,92526,CPT,GN,65092526,CDM,440,RC,,,both,,,623,461.02,,,461.02,Other,150% of Medicare + 9.63% HCRA Surcharge,280.35,45,,280.35,percent of total billed charges,Critical Access Hospital RCC factor,180,,,180,Case Rate,Therapy Per Visit,162,,,162,Case Rate,Therapy Per Visit,579.86,,,579.86,Fee Schedule,,521.54,,,521.54,Fee Schedule,,492.93,,,492.93,Fee Schedule,,308.39,,,308.39,Other,110% of Medicare,219,,,219,Case Rate,Therapy Per Visit,109,,,109,Other,186% of Medicaid,257,,,257,Case Rate,Therapy Per Visit,517.09,83,,517.09,percent of total billed charges,Therapy,187.97,,,187.97,Case Rate,,257,,,257,Case Rate,Therapy Per Visit,517.09,83,,517.09,percent of total billed charges,Therapy,368,,,368,Case Rate,Therapy Visit,436.1,70,,436.1,percent of total billed charges,All Other,259,,,259,Case Rate,Therapy Visit,220,,,220,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,138,,,138,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,131,,,131,Case Rate,Therapy Visit,58.77,,,58.77,Other,100% of Medicaid,58.77,,,58.77,Other,100% of Medicaid,58.77,,,58.77,Other,100% of Medicaid,58.77,,,58.77,Other,100% of Medicaid,132.23,,,132.23,Other,225% of Medicaid,89.92,,,89.92,Other,153% of Medicaid,132.23,,,132.23,Other,225% of Medicaid,82.28,,,82.28,Other,140% of Medicaid,132.23,,,132.23,Other,225% of Medicaid,152.8,,,152.8,Other,260% of Medicaid,190.42,,,190.42,Other,324% of Medicaid,126.36,,,126.36,Other,215% of Medicaid,126.36,,,126.36,Other,215% of Medicaid,73.46,,,73.46,Other,125% of Medicaid,58.77,579.86,
TRAINING SPEECH GEN DEVICE,92609,CPT,GN,65092609,CDM,440,RC,,,both,,,707,523.18,,,523.18,Other,150% of Medicare + 9.63% HCRA Surcharge,318.15,45,,318.15,percent of total billed charges,Critical Access Hospital RCC factor,180,,,180,Case Rate,Therapy Per Visit,162,,,162,Case Rate,Therapy Per Visit,719.78,,,719.78,Fee Schedule,,647.39,,,647.39,Fee Schedule,,611.88,,,611.88,Fee Schedule,,349.97,,,349.97,Other,110% of Medicare,219,,,219,Case Rate,Therapy Per Visit,109,,,109,Other,186% of Medicaid,257,,,257,Case Rate,Therapy Per Visit,586.81,83,,586.81,percent of total billed charges,Therapy,230.01,,,230.01,Fee Schedule,,257,,,257,Case Rate,Therapy Per Visit,586.81,83,,586.81,percent of total billed charges,Therapy,368,,,368,Case Rate,Therapy Visit,494.9,70,,494.9,percent of total billed charges,All Other,259,,,259,Case Rate,Therapy Visit,220,,,220,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,138,,,138,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,131,,,131,Case Rate,Therapy Visit,58.77,,,58.77,Other,100% of Medicaid,58.77,,,58.77,Other,100% of Medicaid,58.77,,,58.77,Other,100% of Medicaid,58.77,,,58.77,Other,100% of Medicaid,132.23,,,132.23,Other,225% of Medicaid,89.92,,,89.92,Other,153% of Medicaid,132.23,,,132.23,Other,225% of Medicaid,82.28,,,82.28,Other,140% of Medicaid,132.23,,,132.23,Other,225% of Medicaid,152.8,,,152.8,Other,260% of Medicaid,190.42,,,190.42,Other,324% of Medicaid,126.36,,,126.36,Other,215% of Medicaid,126.36,,,126.36,Other,215% of Medicaid,73.46,,,73.46,Other,125% of Medicaid,58.77,719.78,
THER IVNTJ 1ST 15 MIN,97129,CPT,GN,65097129,CDM,440,RC,,,both,,,158,116.92,,,116.92,Other,150% of Medicare + 9.63% HCRA Surcharge,71.1,45,,71.1,percent of total billed charges,Critical Access Hospital RCC factor,180,,,180,Case Rate,Therapy Per Visit,162,,,162,Case Rate,Therapy Per Visit,22.08,,,22.08,Fee Schedule,,22.08,,,22.08,Fee Schedule,,22.08,,,22.08,Fee Schedule,,78.21,,,78.21,Other,110% of Medicare,219,,,219,Case Rate,Therapy Per Visit,109,,,109,Other,186% of Medicaid,257,,,257,Case Rate,Therapy Per Visit,131.14,83,,131.14,percent of total billed charges,Therapy,48.24,,,48.24,Case Rate,,257,,,257,Case Rate,Therapy Per Visit,131.14,83,,131.14,percent of total billed charges,Therapy,368,,,368,Case Rate,Therapy Visit,110.6,70,,110.6,percent of total billed charges,All Other,259,,,259,Case Rate,Therapy Visit,220,,,220,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,138,,,138,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,131,,,131,Case Rate,Therapy Visit,58.77,,,58.77,Other,100% of Medicaid,58.77,,,58.77,Other,100% of Medicaid,58.77,,,58.77,Other,100% of Medicaid,58.77,,,58.77,Other,100% of Medicaid,132.23,,,132.23,Other,225% of Medicaid,89.92,,,89.92,Other,153% of Medicaid,132.23,,,132.23,Other,225% of Medicaid,82.28,,,82.28,Other,140% of Medicaid,132.23,,,132.23,Other,225% of Medicaid,152.8,,,152.8,Other,260% of Medicaid,190.42,,,190.42,Other,324% of Medicaid,126.36,,,126.36,Other,215% of Medicaid,126.36,,,126.36,Other,215% of Medicaid,73.46,,,73.46,Other,125% of Medicaid,22.08,368,
THER IVNTJ EA ADDL 15MIN,97130,CPT,GN,65097130,CDM,440,RC,,,both,,,158,116.92,,,116.92,Other,150% of Medicare + 9.63% HCRA Surcharge,71.1,45,,71.1,percent of total billed charges,Critical Access Hospital RCC factor,180,,,180,Case Rate,Therapy Per Visit,162,,,162,Case Rate,Therapy Per Visit,21.13,,,21.13,Fee Schedule,,21.13,,,21.13,Fee Schedule,,21.13,,,21.13,Fee Schedule,,78.21,,,78.21,Other,110% of Medicare,219,,,219,Case Rate,Therapy Per Visit,109,,,109,Other,186% of Medicaid,257,,,257,Case Rate,Therapy Per Visit,131.14,83,,131.14,percent of total billed charges,Therapy,46.05,,,46.05,Case Rate,,257,,,257,Case Rate,Therapy Per Visit,131.14,83,,131.14,percent of total billed charges,Therapy,368,,,368,Case Rate,Therapy Visit,110.6,70,,110.6,percent of total billed charges,All Other,259,,,259,Case Rate,Therapy Visit,220,,,220,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,138,,,138,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,131,,,131,Case Rate,Therapy Visit,58.77,,,58.77,Other,100% of Medicaid,58.77,,,58.77,Other,100% of Medicaid,58.77,,,58.77,Other,100% of Medicaid,58.77,,,58.77,Other,100% of Medicaid,132.23,,,132.23,Other,225% of Medicaid,89.92,,,89.92,Other,153% of Medicaid,132.23,,,132.23,Other,225% of Medicaid,82.28,,,82.28,Other,140% of Medicaid,132.23,,,132.23,Other,225% of Medicaid,152.8,,,152.8,Other,260% of Medicaid,190.42,,,190.42,Other,324% of Medicaid,126.36,,,126.36,Other,215% of Medicaid,126.36,,,126.36,Other,215% of Medicaid,73.46,,,73.46,Other,125% of Medicaid,21.13,368,
SENSORY INTEGRATE TECH 15MIN,97533,CPT,GN,65097533,CDM,440,RC,,,both,,,209,154.66,,,154.66,Other,150% of Medicare + 9.63% HCRA Surcharge,94.05,45,,94.05,percent of total billed charges,Critical Access Hospital RCC factor,180,,,180,Case Rate,Therapy Per Visit,162,,,162,Case Rate,Therapy Per Visit,167.48,,,167.48,Fee Schedule,,150.64,,,150.64,Fee Schedule,,142.37,,,142.37,Fee Schedule,,103.46,,,103.46,Other,110% of Medicare,219,,,219,Case Rate,Therapy Per Visit,109,,,109,Other,186% of Medicaid,257,,,257,Case Rate,Therapy Per Visit,173.47,83,,173.47,percent of total billed charges,Therapy,140.34,,,140.34,Case Rate,,257,,,257,Case Rate,Therapy Per Visit,173.47,83,,173.47,percent of total billed charges,Therapy,368,,,368,Case Rate,Therapy Visit,146.3,70,,146.3,percent of total billed charges,All Other,259,,,259,Case Rate,Therapy Visit,220,,,220,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,138,,,138,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,131,,,131,Case Rate,Therapy Visit,58.77,,,58.77,Other,100% of Medicaid,58.77,,,58.77,Other,100% of Medicaid,58.77,,,58.77,Other,100% of Medicaid,58.77,,,58.77,Other,100% of Medicaid,132.23,,,132.23,Other,225% of Medicaid,89.92,,,89.92,Other,153% of Medicaid,132.23,,,132.23,Other,225% of Medicaid,82.28,,,82.28,Other,140% of Medicaid,132.23,,,132.23,Other,225% of Medicaid,152.8,,,152.8,Other,260% of Medicaid,190.42,,,190.42,Other,324% of Medicaid,126.36,,,126.36,Other,215% of Medicaid,126.36,,,126.36,Other,215% of Medicaid,73.46,,,73.46,Other,125% of Medicaid,58.77,368,
EVALUATION OF SPEECH FLUENCY,92521,CPT,GN,65092521,CDM,444,RC,,,both,,,337,249.38,,,249.38,Other,150% of Medicare + 9.63% HCRA Surcharge,151.65,45,,151.65,percent of total billed charges,Critical Access Hospital RCC factor,180,,,180,Case Rate,Therapy Per Visit,162,,,162,Case Rate,Therapy Per Visit,109.85,,,109.85,Fee Schedule,,109.85,,,109.85,Fee Schedule,,109.85,,,109.85,Fee Schedule,,166.82,,,166.82,Other,110% of Medicare,219,,,219,Case Rate,Therapy Per Visit,186,,,186,Other,186% of Medicaid,257,,,257,Case Rate,Therapy Per Visit,279.71,83,,279.71,percent of total billed charges,Therapy,294.88,,,294.88,Case Rate,,257,,,257,Case Rate,Therapy Per Visit,279.71,83,,279.71,percent of total billed charges,Therapy,368,,,368,Case Rate,Therapy Visit,235.9,70,,235.9,percent of total billed charges,All Other,259,,,259,Case Rate,Therapy Visit,220,,,220,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,138,,,138,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,131,,,131,Case Rate,Therapy Visit,100.07,,,100.07,Other,100% of Medicaid,100.07,,,100.07,Other,100% of Medicaid,100.07,,,100.07,Other,100% of Medicaid,100.07,,,100.07,Other,100% of Medicaid,225.16,,,225.16,Other,225% of Medicaid,153.11,,,153.11,Other,153% of Medicaid,225.16,,,225.16,Other,225% of Medicaid,140.1,,,140.1,Other,140% of Medicaid,225.16,,,225.16,Other,225% of Medicaid,260.19,,,260.19,Other,260% of Medicaid,324.23,,,324.23,Other,324% of Medicaid,215.15,,,215.15,Other,215% of Medicaid,215.15,,,215.15,Other,215% of Medicaid,125.09,,,125.09,Other,125% of Medicaid,100.07,368,
EVALUATE SPEECH PRODUCTION,92522,CPT,GN,65092522,CDM,444,RC,,,both,,,297,219.78,,,219.78,Other,150% of Medicare + 9.63% HCRA Surcharge,133.65,45,,133.65,percent of total billed charges,Critical Access Hospital RCC factor,180,,,180,Case Rate,Therapy Per Visit,162,,,162,Case Rate,Therapy Per Visit,88.43,,,88.43,Fee Schedule,,88.43,,,88.43,Fee Schedule,,88.43,,,88.43,Fee Schedule,,147.02,,,147.02,Other,110% of Medicare,219,,,219,Case Rate,Therapy Per Visit,186,,,186,Other,186% of Medicaid,257,,,257,Case Rate,Therapy Per Visit,246.51,83,,246.51,percent of total billed charges,Therapy,246.88,,,246.88,Case Rate,,257,,,257,Case Rate,Therapy Per Visit,246.51,83,,246.51,percent of total billed charges,Therapy,368,,,368,Case Rate,Therapy Visit,207.9,70,,207.9,percent of total billed charges,All Other,259,,,259,Case Rate,Therapy Visit,220,,,220,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,138,,,138,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,131,,,131,Case Rate,Therapy Visit,100.07,,,100.07,Other,100% of Medicaid,100.07,,,100.07,Other,100% of Medicaid,100.07,,,100.07,Other,100% of Medicaid,100.07,,,100.07,Other,100% of Medicaid,225.16,,,225.16,Other,225% of Medicaid,153.11,,,153.11,Other,153% of Medicaid,225.16,,,225.16,Other,225% of Medicaid,140.1,,,140.1,Other,140% of Medicaid,225.16,,,225.16,Other,225% of Medicaid,260.19,,,260.19,Other,260% of Medicaid,324.23,,,324.23,Other,324% of Medicaid,215.15,,,215.15,Other,215% of Medicaid,215.15,,,215.15,Other,215% of Medicaid,125.09,,,125.09,Other,125% of Medicaid,88.43,368,
SPEECH SOUND LANG COMPREHEN,92523,CPT,GN,65092523,CDM,444,RC,,,both,,,660,488.4,,,488.4,Other,150% of Medicare + 9.63% HCRA Surcharge,297,45,,297,percent of total billed charges,Critical Access Hospital RCC factor,180,,,180,Case Rate,Therapy Per Visit,162,,,162,Case Rate,Therapy Per Visit,190.46,,,190.46,Fee Schedule,,190.46,,,190.46,Fee Schedule,,190.46,,,190.46,Fee Schedule,,326.7,,,326.7,Other,110% of Medicare,219,,,219,Case Rate,Therapy Per Visit,186,,,186,Other,186% of Medicaid,257,,,257,Case Rate,Therapy Per Visit,547.8,83,,547.8,percent of total billed charges,Therapy,505.47,,,505.47,Case Rate,,257,,,257,Case Rate,Therapy Per Visit,547.8,83,,547.8,percent of total billed charges,Therapy,368,,,368,Case Rate,Therapy Visit,462,70,,462,percent of total billed charges,All Other,259,,,259,Case Rate,Therapy Visit,220,,,220,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,138,,,138,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,131,,,131,Case Rate,Therapy Visit,100.07,,,100.07,Other,100% of Medicaid,100.07,,,100.07,Other,100% of Medicaid,100.07,,,100.07,Other,100% of Medicaid,100.07,,,100.07,Other,100% of Medicaid,225.16,,,225.16,Other,225% of Medicaid,153.11,,,153.11,Other,153% of Medicaid,225.16,,,225.16,Other,225% of Medicaid,140.1,,,140.1,Other,140% of Medicaid,225.16,,,225.16,Other,225% of Medicaid,260.19,,,260.19,Other,260% of Medicaid,324.23,,,324.23,Other,324% of Medicaid,215.15,,,215.15,Other,215% of Medicaid,215.15,,,215.15,Other,215% of Medicaid,125.09,,,125.09,Other,125% of Medicaid,100.07,547.8,
BEHAVRAL QUALIT ANALYS VOICE,92524,CPT,GN,65092524,CDM,444,RC,,,both,,,308,227.92,,,227.92,Other,150% of Medicare + 9.63% HCRA Surcharge,138.6,45,,138.6,percent of total billed charges,Critical Access Hospital RCC factor,180,,,180,Case Rate,Therapy Per Visit,162,,,162,Case Rate,Therapy Per Visit,84.68,,,84.68,Fee Schedule,,84.68,,,84.68,Fee Schedule,,84.68,,,84.68,Fee Schedule,,152.46,,,152.46,Other,110% of Medicare,219,,,219,Case Rate,Therapy Per Visit,186,,,186,Other,186% of Medicaid,257,,,257,Case Rate,Therapy Per Visit,255.64,83,,255.64,percent of total billed charges,Therapy,243.08,,,243.08,Case Rate,,257,,,257,Case Rate,Therapy Per Visit,255.64,83,,255.64,percent of total billed charges,Therapy,368,,,368,Case Rate,Therapy Visit,215.6,70,,215.6,percent of total billed charges,All Other,259,,,259,Case Rate,Therapy Visit,220,,,220,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,138,,,138,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,131,,,131,Case Rate,Therapy Visit,100.07,,,100.07,Other,100% of Medicaid,100.07,,,100.07,Other,100% of Medicaid,100.07,,,100.07,Other,100% of Medicaid,100.07,,,100.07,Other,100% of Medicaid,225.16,,,225.16,Other,225% of Medicaid,153.11,,,153.11,Other,153% of Medicaid,225.16,,,225.16,Other,225% of Medicaid,140.1,,,140.1,Other,140% of Medicaid,225.16,,,225.16,Other,225% of Medicaid,260.19,,,260.19,Other,260% of Medicaid,324.23,,,324.23,Other,324% of Medicaid,215.15,,,215.15,Other,215% of Medicaid,215.15,,,215.15,Other,215% of Medicaid,125.09,,,125.09,Other,125% of Medicaid,84.68,368,
EVAL TO USE/FIT VOICE PROSTH,92597,CPT,,65092597,CDM,444,RC,,,both,,,249,184.26,,,184.26,Other,150% of Medicare + 9.63% HCRA Surcharge,112.05,45,,112.05,percent of total billed charges,Critical Access Hospital RCC factor,180,,,180,Case Rate,Therapy Per Visit,162,,,162,Case Rate,Therapy Per Visit,608.32,,,608.32,Fee Schedule,,547.14,,,547.14,Fee Schedule,,517.13,,,517.13,Fee Schedule,,123.26,,,123.26,Other,110% of Medicare,219,,,219,Case Rate,Therapy Per Visit,186,,,186,Other,186% of Medicaid,257,,,257,Case Rate,Therapy Per Visit,206.67,83,,206.67,percent of total billed charges,Therapy,160.27,,,160.27,Fee Schedule,,257,,,257,Case Rate,Therapy Per Visit,206.67,83,,206.67,percent of total billed charges,Therapy,368,,,368,Case Rate,Therapy Visit,174.3,70,,174.3,percent of total billed charges,All Other,259,,,259,Case Rate,Therapy Visit,220,,,220,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,138,,,138,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,131,,,131,Case Rate,Therapy Visit,100.07,,,100.07,Other,100% of Medicaid,100.07,,,100.07,Other,100% of Medicaid,100.07,,,100.07,Other,100% of Medicaid,100.07,,,100.07,Other,100% of Medicaid,225.16,,,225.16,Other,225% of Medicaid,153.11,,,153.11,Other,153% of Medicaid,225.16,,,225.16,Other,225% of Medicaid,140.1,,,140.1,Other,140% of Medicaid,225.16,,,225.16,Other,225% of Medicaid,260.19,,,260.19,Other,260% of Medicaid,324.23,,,324.23,Other,324% of Medicaid,215.15,,,215.15,Other,215% of Medicaid,215.15,,,215.15,Other,215% of Medicaid,125.09,,,125.09,Other,125% of Medicaid,100.07,608.32,
EVAL FOR SPEECH DEVICE RX 1HR,92607,CPT,,65092607,CDM,444,RC,,,both,,,441,326.34,,,326.34,Other,150% of Medicare + 9.63% HCRA Surcharge,198.45,45,,198.45,percent of total billed charges,Critical Access Hospital RCC factor,180,,,180,Case Rate,Therapy Per Visit,162,,,162,Case Rate,Therapy Per Visit,1113.13,,,1113.13,Fee Schedule,,1001.18,,,1001.18,Fee Schedule,,946.27,,,946.27,Fee Schedule,,218.3,,,218.3,Other,110% of Medicare,219,,,219,Case Rate,Therapy Per Visit,186,,,186,Other,186% of Medicaid,257,,,257,Case Rate,Therapy Per Visit,366.03,83,,366.03,percent of total billed charges,Therapy,275.84,,,275.84,Fee Schedule,,257,,,257,Case Rate,Therapy Per Visit,366.03,83,,366.03,percent of total billed charges,Therapy,368,,,368,Case Rate,Therapy Visit,308.7,70,,308.7,percent of total billed charges,All Other,259,,,259,Case Rate,Therapy Visit,220,,,220,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,138,,,138,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,131,,,131,Case Rate,Therapy Visit,100.07,,,100.07,Other,100% of Medicaid,100.07,,,100.07,Other,100% of Medicaid,100.07,,,100.07,Other,100% of Medicaid,100.07,,,100.07,Other,100% of Medicaid,225.16,,,225.16,Other,225% of Medicaid,153.11,,,153.11,Other,153% of Medicaid,225.16,,,225.16,Other,225% of Medicaid,140.1,,,140.1,Other,140% of Medicaid,225.16,,,225.16,Other,225% of Medicaid,260.19,,,260.19,Other,260% of Medicaid,324.23,,,324.23,Other,324% of Medicaid,215.15,,,215.15,Other,215% of Medicaid,215.15,,,215.15,Other,215% of Medicaid,125.09,,,125.09,Other,125% of Medicaid,100.07,1113.13,
EX FOR SPEECH DEVICE RX EA ADDL 30 MIN,92608,CPT,,65092608,CDM,444,RC,,,both,,,179,132.46,,,132.46,Other,150% of Medicare + 9.63% HCRA Surcharge,80.55,45,,80.55,percent of total billed charges,Critical Access Hospital RCC factor,180,,,180,Case Rate,Therapy Per Visit,162,,,162,Case Rate,Therapy Per Visit,324.21,,,324.21,Fee Schedule,,291.6,,,291.6,Fee Schedule,,275.61,,,275.61,Fee Schedule,,88.61,,,88.61,Other,110% of Medicare,219,,,219,Case Rate,Therapy Per Visit,186,,,186,Other,186% of Medicaid,257,,,257,Case Rate,Therapy Per Visit,148.57,83,,148.57,percent of total billed charges,Therapy,108.38,,,108.38,Fee Schedule,,257,,,257,Case Rate,Therapy Per Visit,148.57,83,,148.57,percent of total billed charges,Therapy,368,,,368,Case Rate,Therapy Visit,125.3,70,,125.3,percent of total billed charges,All Other,259,,,259,Case Rate,Therapy Visit,220,,,220,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,138,,,138,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,131,,,131,Case Rate,Therapy Visit,100.07,,,100.07,Other,100% of Medicaid,100.07,,,100.07,Other,100% of Medicaid,100.07,,,100.07,Other,100% of Medicaid,100.07,,,100.07,Other,100% of Medicaid,225.16,,,225.16,Other,225% of Medicaid,153.11,,,153.11,Other,153% of Medicaid,225.16,,,225.16,Other,225% of Medicaid,140.1,,,140.1,Other,140% of Medicaid,225.16,,,225.16,Other,225% of Medicaid,260.19,,,260.19,Other,260% of Medicaid,324.23,,,324.23,Other,324% of Medicaid,215.15,,,215.15,Other,215% of Medicaid,215.15,,,215.15,Other,215% of Medicaid,125.09,,,125.09,Other,125% of Medicaid,80.55,368,
INDIRECT SWALLOW ASSESSMENT,92610,CPT,GN,65092610,CDM,444,RC,,,both,,,702,519.48,,,519.48,Other,150% of Medicare + 9.63% HCRA Surcharge,315.9,45,,315.9,percent of total billed charges,Critical Access Hospital RCC factor,180,,,180,Case Rate,Therapy Per Visit,162,,,162,Case Rate,Therapy Per Visit,654.74,,,654.74,Fee Schedule,,588.9,,,588.9,Fee Schedule,,556.6,,,556.6,Fee Schedule,,347.49,,,347.49,Other,110% of Medicare,219,,,219,Case Rate,Therapy Per Visit,186,,,186,Other,186% of Medicaid,257,,,257,Case Rate,Therapy Per Visit,582.66,83,,582.66,percent of total billed charges,Therapy,154.79,,,154.79,Fee Schedule,,257,,,257,Case Rate,Therapy Per Visit,582.66,83,,582.66,percent of total billed charges,Therapy,368,,,368,Case Rate,Therapy Visit,491.4,70,,491.4,percent of total billed charges,All Other,259,,,259,Case Rate,Therapy Visit,220,,,220,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,138,,,138,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,131,,,131,Case Rate,Therapy Visit,100.07,,,100.07,Other,100% of Medicaid,100.07,,,100.07,Other,100% of Medicaid,100.07,,,100.07,Other,100% of Medicaid,100.07,,,100.07,Other,100% of Medicaid,225.16,,,225.16,Other,225% of Medicaid,153.11,,,153.11,Other,153% of Medicaid,225.16,,,225.16,Other,225% of Medicaid,140.1,,,140.1,Other,140% of Medicaid,225.16,,,225.16,Other,225% of Medicaid,260.19,,,260.19,Other,260% of Medicaid,324.23,,,324.23,Other,324% of Medicaid,215.15,,,215.15,Other,215% of Medicaid,215.15,,,215.15,Other,215% of Medicaid,125.09,,,125.09,Other,125% of Medicaid,100.07,654.74,
MOTION FLUOROSCOPY/SWALLOW,92611,CPT,GN,65092611,CDM,444,RC,,,both,,,762,563.88,,,563.88,Other,150% of Medicare + 9.63% HCRA Surcharge,342.9,45,,342.9,percent of total billed charges,Critical Access Hospital RCC factor,180,,,180,Case Rate,Therapy Per Visit,162,,,162,Case Rate,Therapy Per Visit,710.4,,,710.4,Fee Schedule,,638.95,,,638.95,Fee Schedule,,603.9,,,603.9,Fee Schedule,,377.19,,,377.19,Other,110% of Medicare,219,,,219,Case Rate,Therapy Per Visit,392,,,392,Other,186% of Medicaid,257,,,257,Case Rate,Therapy Per Visit,632.46,83,,632.46,percent of total billed charges,Therapy,205.15,,,205.15,Fee Schedule,,257,,,257,Case Rate,Therapy Per Visit,632.46,83,,632.46,percent of total billed charges,Therapy,368,,,368,Case Rate,Therapy Visit,533.4,70,,533.4,percent of total billed charges,All Other,259,,,259,Case Rate,Therapy Visit,220,,,220,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,138,,,138,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,131,,,131,Case Rate,Therapy Visit,210.57,,,210.57,Other,100% of Medicaid,210.57,,,210.57,Other,100% of Medicaid,210.57,,,210.57,Other,100% of Medicaid,210.57,,,210.57,Other,100% of Medicaid,473.77,,,473.77,Other,225% of Medicaid,322.17,,,322.17,Other,153% of Medicaid,473.77,,,473.77,Other,225% of Medicaid,294.79,,,294.79,Other,140% of Medicaid,473.77,,,473.77,Other,225% of Medicaid,547.47,,,547.47,Other,260% of Medicaid,682.23,,,682.23,Other,324% of Medicaid,452.72,,,452.72,Other,215% of Medicaid,452.72,,,452.72,Other,215% of Medicaid,263.21,,,263.21,Other,125% of Medicaid,131,710.4,
APHASIA ASSESMENT PER HR,96105,CPT,GN,65096105,CDM,444,RC,,,both,,,590,436.6,,,436.6,Other,150% of Medicare + 9.63% HCRA Surcharge,265.5,45,,265.5,percent of total billed charges,Critical Access Hospital RCC factor,180,,,180,Case Rate,Therapy Per Visit,162,,,162,Case Rate,Therapy Per Visit,647.52,,,647.52,Fee Schedule,,582.4,,,582.4,Fee Schedule,,550.46,,,550.46,Fee Schedule,,292.05,,,292.05,Other,110% of Medicare,219,,,219,Case Rate,Therapy Per Visit,233,,,233,Other,186% of Medicaid,257,,,257,Case Rate,Therapy Per Visit,489.7,83,,489.7,percent of total billed charges,Therapy,212.58,,,212.58,Fee Schedule,,257,,,257,Case Rate,Therapy Per Visit,489.7,83,,489.7,percent of total billed charges,Therapy,368,,,368,Case Rate,Therapy Visit,413,70,,413,percent of total billed charges,All Other,259,,,259,Case Rate,Therapy Visit,220,,,220,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,138,,,138,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,131,,,131,Case Rate,Therapy Visit,125.09,,,125.09,Other,100% of Medicaid,125.09,,,125.09,Other,100% of Medicaid,125.09,,,125.09,Other,100% of Medicaid,125.09,,,125.09,Other,100% of Medicaid,281.45,,,281.45,Other,225% of Medicaid,191.39,,,191.39,Other,153% of Medicaid,281.45,,,281.45,Other,225% of Medicaid,175.13,,,175.13,Other,140% of Medicaid,281.45,,,281.45,Other,225% of Medicaid,325.23,,,325.23,Other,260% of Medicaid,405.29,,,405.29,Other,324% of Medicaid,268.94,,,268.94,Other,215% of Medicaid,268.94,,,268.94,Other,215% of Medicaid,156.36,,,156.36,Other,125% of Medicaid,125.09,647.52,
COGNITIVE TEST BY HC PRO,96125,CPT,GN,65096125,CDM,444,RC,,,both,,,281,207.94,,,207.94,Other,150% of Medicare + 9.63% HCRA Surcharge,126.45,45,,126.45,percent of total billed charges,Critical Access Hospital RCC factor,180,,,180,Case Rate,Therapy Per Visit,162,,,162,Case Rate,Therapy Per Visit,562.89,,,562.89,Fee Schedule,,506.28,,,506.28,Fee Schedule,,478.51,,,478.51,Fee Schedule,,139.1,,,139.1,Other,110% of Medicare,219,,,219,Case Rate,Therapy Per Visit,233,,,233,Other,186% of Medicaid,257,,,257,Case Rate,Therapy Per Visit,233.23,83,,233.23,percent of total billed charges,Therapy,227.14,,,227.14,Fee Schedule,,257,,,257,Case Rate,Therapy Per Visit,233.23,83,,233.23,percent of total billed charges,Therapy,368,,,368,Case Rate,Therapy Visit,196.7,70,,196.7,percent of total billed charges,All Other,259,,,259,Case Rate,Therapy Visit,220,,,220,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,138,,,138,Case Rate,Therapy Visit,154,,,154,Case Rate,Therapy Visit,131,,,131,Case Rate,Therapy Visit,125.09,,,125.09,Other,100% of Medicaid,125.09,,,125.09,Other,100% of Medicaid,125.09,,,125.09,Other,100% of Medicaid,125.09,,,125.09,Other,100% of Medicaid,281.45,,,281.45,Other,225% of Medicaid,191.39,,,191.39,Other,153% of Medicaid,281.45,,,281.45,Other,225% of Medicaid,175.13,,,175.13,Other,140% of Medicaid,281.45,,,281.45,Other,225% of Medicaid,325.23,,,325.23,Other,260% of Medicaid,405.29,,,405.29,Other,324% of Medicaid,268.94,,,268.94,Other,215% of Medicaid,268.94,,,268.94,Other,215% of Medicaid,156.36,,,156.36,Other,125% of Medicaid,125.09,562.89,
CLEAR EYELID GLAND W HEAT,0207T,HCPCS,,30000001,CDM,450,RC,,,both,,,263,194.62,,,194.62,Other,150% of Medicare + 9.63% HCRA Surcharge,118.35,45,,118.35,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,130.19,,,130.19,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,139,,,139,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,184.1,70,,184.1,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,74.86,,,74.86,Other,100% of Medicaid,74.86,,,74.86,Other,100% of Medicaid,74.86,,,74.86,Other,100% of Medicaid,74.86,,,74.86,Other,100% of Medicaid,168.43,,,168.43,Other,225% of Medicaid,114.53,,,114.53,Other,153% of Medicaid,168.43,,,168.43,Other,225% of Medicaid,104.8,,,104.8,Other,140% of Medicaid,168.43,,,168.43,Other,225% of Medicaid,194.63,,,194.63,Other,260% of Medicaid,242.54,,,242.54,Other,324% of Medicaid,160.94,,,160.94,Other,215% of Medicaid,160.94,,,160.94,Other,215% of Medicaid,93.57,,,93.57,Other,125% of Medicaid,0.01,242.54,
NJX PARAVERT W US CER THOR,0213T,HCPCS,,30000002,CDM,450,RC,,,both,,,2478,1833.73,,,1833.73,Other,150% of Medicare + 9.63% HCRA Surcharge,1115.1,45,,1115.1,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1226.61,,,1226.61,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,850,,,850,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1734.6,70,,1734.6,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,457.15,,,457.15,Other,100% of Medicaid,457.15,,,457.15,Other,100% of Medicaid,457.15,,,457.15,Other,100% of Medicaid,457.15,,,457.15,Other,100% of Medicaid,1028.59,,,1028.59,Other,225% of Medicaid,699.44,,,699.44,Other,153% of Medicaid,1028.59,,,1028.59,Other,225% of Medicaid,640.01,,,640.01,Other,140% of Medicaid,1028.59,,,1028.59,Other,225% of Medicaid,1188.6,,,1188.6,Other,260% of Medicaid,1481.18,,,1481.18,Other,324% of Medicaid,982.88,,,982.88,Other,215% of Medicaid,982.88,,,982.88,Other,215% of Medicaid,571.44,,,571.44,Other,125% of Medicaid,0.01,1833.73,
NJX PARAVERT W/US CER/THOR,0214T,HCPCS,,30000003,CDM,450,RC,,,both,,,872,645.28,,,645.28,Other,150% of Medicare + 9.63% HCRA Surcharge,392.4,45,,392.4,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,431.64,,,431.64,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,850,,,850,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,610.4,70,,610.4,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,457.15,,,457.15,Other,100% of Medicaid,457.15,,,457.15,Other,100% of Medicaid,457.15,,,457.15,Other,100% of Medicaid,457.15,,,457.15,Other,100% of Medicaid,1028.59,,,1028.59,Other,225% of Medicaid,699.44,,,699.44,Other,153% of Medicaid,1028.59,,,1028.59,Other,225% of Medicaid,640.01,,,640.01,Other,140% of Medicaid,1028.59,,,1028.59,Other,225% of Medicaid,1188.6,,,1188.6,Other,260% of Medicaid,1481.18,,,1481.18,Other,324% of Medicaid,982.88,,,982.88,Other,215% of Medicaid,982.88,,,982.88,Other,215% of Medicaid,571.44,,,571.44,Other,125% of Medicaid,0.01,1481.18,
NJX PARAVERT W/US CER/THOR,0215T,HCPCS,,30000004,CDM,450,RC,,,both,,,872,645.28,,,645.28,Other,150% of Medicare + 9.63% HCRA Surcharge,392.4,45,,392.4,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,431.64,,,431.64,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,850,,,850,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,610.4,70,,610.4,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,457.15,,,457.15,Other,100% of Medicaid,457.15,,,457.15,Other,100% of Medicaid,457.15,,,457.15,Other,100% of Medicaid,457.15,,,457.15,Other,100% of Medicaid,1028.59,,,1028.59,Other,225% of Medicaid,699.44,,,699.44,Other,153% of Medicaid,1028.59,,,1028.59,Other,225% of Medicaid,640.01,,,640.01,Other,140% of Medicaid,1028.59,,,1028.59,Other,225% of Medicaid,1188.6,,,1188.6,Other,260% of Medicaid,1481.18,,,1481.18,Other,324% of Medicaid,982.88,,,982.88,Other,215% of Medicaid,982.88,,,982.88,Other,215% of Medicaid,571.44,,,571.44,Other,125% of Medicaid,0.01,1481.18,
NJX PARAVERT W/US LUMB/SAC,0216T,HCPCS,,30000005,CDM,450,RC,,,both,,,2478,1833.73,,,1833.73,Other,150% of Medicare + 9.63% HCRA Surcharge,1115.1,45,,1115.1,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1226.61,,,1226.61,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,850,,,850,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1734.6,70,,1734.6,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,457.15,,,457.15,Other,100% of Medicaid,457.15,,,457.15,Other,100% of Medicaid,457.15,,,457.15,Other,100% of Medicaid,457.15,,,457.15,Other,100% of Medicaid,1028.59,,,1028.59,Other,225% of Medicaid,699.44,,,699.44,Other,153% of Medicaid,1028.59,,,1028.59,Other,225% of Medicaid,640.01,,,640.01,Other,140% of Medicaid,1028.59,,,1028.59,Other,225% of Medicaid,1188.6,,,1188.6,Other,260% of Medicaid,1481.18,,,1481.18,Other,324% of Medicaid,982.88,,,982.88,Other,215% of Medicaid,982.88,,,982.88,Other,215% of Medicaid,571.44,,,571.44,Other,125% of Medicaid,0.01,1833.73,
NJX PARAVERT W US LUMB SAC,0217T,HCPCS,,30000006,CDM,450,RC,,,both,,,872,645.28,,,645.28,Other,150% of Medicare + 9.63% HCRA Surcharge,392.4,45,,392.4,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,431.64,,,431.64,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,850,,,850,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,610.4,70,,610.4,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,457.15,,,457.15,Other,100% of Medicaid,457.15,,,457.15,Other,100% of Medicaid,457.15,,,457.15,Other,100% of Medicaid,457.15,,,457.15,Other,100% of Medicaid,1028.59,,,1028.59,Other,225% of Medicaid,699.44,,,699.44,Other,153% of Medicaid,1028.59,,,1028.59,Other,225% of Medicaid,640.01,,,640.01,Other,140% of Medicaid,1028.59,,,1028.59,Other,225% of Medicaid,1188.6,,,1188.6,Other,260% of Medicaid,1481.18,,,1481.18,Other,324% of Medicaid,982.88,,,982.88,Other,215% of Medicaid,982.88,,,982.88,Other,215% of Medicaid,571.44,,,571.44,Other,125% of Medicaid,0.01,1481.18,
NJX PARAVERT W/US LUMB/SAC,0218T,HCPCS,,30000007,CDM,450,RC,,,both,,,872,645.28,,,645.28,Other,150% of Medicare + 9.63% HCRA Surcharge,392.4,45,,392.4,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,431.64,,,431.64,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,850,,,850,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,610.4,70,,610.4,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,457.15,,,457.15,Other,100% of Medicaid,457.15,,,457.15,Other,100% of Medicaid,457.15,,,457.15,Other,100% of Medicaid,457.15,,,457.15,Other,100% of Medicaid,1028.59,,,1028.59,Other,225% of Medicaid,699.44,,,699.44,Other,153% of Medicaid,1028.59,,,1028.59,Other,225% of Medicaid,640.01,,,640.01,Other,140% of Medicaid,1028.59,,,1028.59,Other,225% of Medicaid,1188.6,,,1188.6,Other,260% of Medicaid,1481.18,,,1481.18,Other,324% of Medicaid,982.88,,,982.88,Other,215% of Medicaid,982.88,,,982.88,Other,215% of Medicaid,571.44,,,571.44,Other,125% of Medicaid,0.01,1481.18,
NJX PLATELET PLASMA,0232T,HCPCS,,30000008,CDM,450,RC,,,both,,,851,629.74,,,629.74,Other,150% of Medicare + 9.63% HCRA Surcharge,382.95,45,,382.95,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,421.25,,,421.25,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,832,,,832,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,595.7,70,,595.7,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,447.4,,,447.4,Other,100% of Medicaid,447.4,,,447.4,Other,100% of Medicaid,447.4,,,447.4,Other,100% of Medicaid,447.4,,,447.4,Other,100% of Medicaid,1006.65,,,1006.65,Other,225% of Medicaid,684.52,,,684.52,Other,153% of Medicaid,1006.65,,,1006.65,Other,225% of Medicaid,626.36,,,626.36,Other,140% of Medicaid,1006.65,,,1006.65,Other,225% of Medicaid,1163.24,,,1163.24,Other,260% of Medicaid,1449.57,,,1449.57,Other,324% of Medicaid,961.91,,,961.91,Other,215% of Medicaid,961.91,,,961.91,Other,215% of Medicaid,559.25,,,559.25,Other,125% of Medicaid,0.01,1449.57,
IV INFUS TX DX INIT PROLNG RQR,C8957,HCPCS,,30000009,CDM,450,RC,,,both,,,977,722.98,,,722.98,Other,150% of Medicare + 9.63% HCRA Surcharge,439.65,45,,439.65,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,483.62,,,483.62,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,1098,,,1098,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,683.9,70,,683.9,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,590.24,,,590.24,Other,100% of Medicaid,590.24,,,590.24,Other,100% of Medicaid,590.24,,,590.24,Other,100% of Medicaid,590.24,,,590.24,Other,100% of Medicaid,1328.05,,,1328.05,Other,225% of Medicaid,903.07,,,903.07,Other,153% of Medicaid,1328.05,,,1328.05,Other,225% of Medicaid,826.34,,,826.34,Other,140% of Medicaid,1328.05,,,1328.05,Other,225% of Medicaid,1534.64,,,1534.64,Other,260% of Medicaid,1912.39,,,1912.39,Other,324% of Medicaid,1269.03,,,1269.03,Other,215% of Medicaid,1269.03,,,1269.03,Other,215% of Medicaid,737.81,,,737.81,Other,125% of Medicaid,0.01,1912.39,
TELEHEALTH FACILITY FEE NEURO,Q3014,HCPCS,GT,30000018,CDM,450,RC,,,both,,,161,119.14,,,119.14,Other,150% of Medicare + 9.63% HCRA Surcharge,72.45,45,,72.45,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,79.7,,,79.7,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,112.7,70,,112.7,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,119.14,
TELEHEALTH FACILITY FEE PSYCH,Q3014,HCPCS,GT,30000023,CDM,450,RC,,,both,,,161,119.14,,,119.14,Other,150% of Medicare + 9.63% HCRA Surcharge,72.45,45,,72.45,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,79.7,,,79.7,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,112.7,70,,112.7,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,119.14,
MMH ED VISIT LEVEL 1,99281,CPT,,30000056,CDM,450,RC,,,both,,,1240,917.6,,,917.6,Other,150% of Medicare + 9.63% HCRA Surcharge,558,45,,558,percent of total billed charges,Critical Access Hospital RCC factor,1648,,,1648,Case Rate,ED per Visit,1483,,,1483,Case Rate,ED per Visit,1710,,,1710,Case Rate,ED per Visit,1539,,,1539,Case Rate,ED per Visit,1454,,,1454,Case Rate,ED per Visit,613.8,,,613.8,Other,110% of Medicare,843.2,68,,843.2,percent of total billed charges,All Other,0.01,,,0.01,Other,186% of Medicaid,992,,,992,Case Rate,ED per Visit,1029.2,,,1029.2,Case Rate,ED per Visit,1029.2,,,1029.2,Case Rate,ED per Visit,992,,,992,Case Rate,ED per Visit,1029.2,,,1029.2,Case Rate,ED per Visit,2018,,,2018,Case Rate,ED per Visit,868,70,,868,percent of total billed charges,All Other,1461,,,1461,Case Rate,ED per Visit,1242,,,1242,Case Rate,ED per Visit,1464,,,1464,Case Rate,ED per Visit,1316,,,1316,Case Rate,ED per Visit,1464,,,1464,Case Rate,ED per Visit,1244,,,1244,Case Rate,ED per Visit,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2018,
MMH ED VISIT LEVEL 1 W/MOD,99281,CPT,25,30000063,CDM,450,RC,,,both,,,1240,917.6,,,917.6,Other,150% of Medicare + 9.63% HCRA Surcharge,558,45,,558,percent of total billed charges,Critical Access Hospital RCC factor,1648,,,1648,Case Rate,ED per Visit,1483,,,1483,Case Rate,ED per Visit,1710,,,1710,Case Rate,ED per Visit,1539,,,1539,Case Rate,ED per Visit,1454,,,1454,Case Rate,ED per Visit,613.8,,,613.8,Other,110% of Medicare,843.2,68,,843.2,percent of total billed charges,All Other,0.01,,,0.01,Other,186% of Medicaid,992,,,992,Case Rate,ED per Visit,1029.2,,,1029.2,Case Rate,ED per Visit,1029.2,,,1029.2,Case Rate,ED per Visit,992,,,992,Case Rate,ED per Visit,1029.2,,,1029.2,Case Rate,ED per Visit,2018,,,2018,Case Rate,ED per Visit,868,70,,868,percent of total billed charges,All Other,1461,,,1461,Case Rate,ED per Visit,1242,,,1242,Case Rate,ED per Visit,1464,,,1464,Case Rate,ED per Visit,1316,,,1316,Case Rate,ED per Visit,1464,,,1464,Case Rate,ED per Visit,1244,,,1244,Case Rate,ED per Visit,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2018,
MMH ED VISIT LEVEL 2 W/MOD,99282,CPT,25,30000064,CDM,450,RC,,,both,,,1661,1229.14,,,1229.14,Other,150% of Medicare + 9.63% HCRA Surcharge,747.45,45,,747.45,percent of total billed charges,Critical Access Hospital RCC factor,1648,,,1648,Case Rate,ED per Visit,1483,,,1483,Case Rate,ED per Visit,1710,,,1710,Case Rate,ED per Visit,1539,,,1539,Case Rate,ED per Visit,1454,,,1454,Case Rate,ED per Visit,822.2,,,822.2,Other,110% of Medicare,1129.48,68,,1129.48,percent of total billed charges,All Other,0.01,,,0.01,Other,186% of Medicaid,1328.8,,,1328.8,Case Rate,ED per Visit,1378.63,,,1378.63,Case Rate,ED per Visit,1378.63,,,1378.63,Case Rate,ED per Visit,1328.8,,,1328.8,Case Rate,ED per Visit,1378.63,,,1378.63,Case Rate,ED per Visit,2018,,,2018,Case Rate,ED per Visit,1162.7,70,,1162.7,percent of total billed charges,All Other,1461,,,1461,Case Rate,ED per Visit,1242,,,1242,Case Rate,ED per Visit,1464,,,1464,Case Rate,ED per Visit,1316,,,1316,Case Rate,ED per Visit,1464,,,1464,Case Rate,ED per Visit,1244,,,1244,Case Rate,ED per Visit,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2018,
MMH ED VISIT LEVEL 3 W/MOD,99283,CPT,25,30000065,CDM,450,RC,,,both,,,2600,1924.01,,,1924.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1170,45,,1170,percent of total billed charges,Critical Access Hospital RCC factor,1648,,,1648,Case Rate,ED per Visit,1483,,,1483,Case Rate,ED per Visit,1710,,,1710,Case Rate,ED per Visit,1539,,,1539,Case Rate,ED per Visit,1454,,,1454,Case Rate,ED per Visit,1287,,,1287,Other,110% of Medicare,1768,68,,1768,percent of total billed charges,All Other,0.01,,,0.01,Other,186% of Medicaid,2080,,,2080,Case Rate,ED per Visit,2158,,,2158,Case Rate,ED per Visit,2158,,,2158,Case Rate,ED per Visit,2080,,,2080,Case Rate,ED per Visit,2158,,,2158,Case Rate,ED per Visit,2018,,,2018,Case Rate,ED per Visit,1820,70,,1820,percent of total billed charges,All Other,1461,,,1461,Case Rate,ED per Visit,1242,,,1242,Case Rate,ED per Visit,1464,,,1464,Case Rate,ED per Visit,1316,,,1316,Case Rate,ED per Visit,1464,,,1464,Case Rate,ED per Visit,1244,,,1244,Case Rate,ED per Visit,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2158,
MMH ED VISIT LEVEL 4 W/MOD,99284,CPT,25,30000066,CDM,450,RC,,,both,,,3200,2368.01,,,2368.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1440,45,,1440,percent of total billed charges,Critical Access Hospital RCC factor,1648,,,1648,Case Rate,ED per Visit,1483,,,1483,Case Rate,ED per Visit,1710,,,1710,Case Rate,ED per Visit,1539,,,1539,Case Rate,ED per Visit,1454,,,1454,Case Rate,ED per Visit,1584,,,1584,Other,110% of Medicare,2176,68,,2176,percent of total billed charges,All Other,0.01,,,0.01,Other,186% of Medicaid,2560,,,2560,Case Rate,ED per Visit,2656,,,2656,Case Rate,ED per Visit,2656,,,2656,Case Rate,ED per Visit,2560,,,2560,Case Rate,ED per Visit,2656,,,2656,Case Rate,ED per Visit,2018,,,2018,Case Rate,ED per Visit,2240,70,,2240,percent of total billed charges,All Other,1461,,,1461,Case Rate,ED per Visit,1242,,,1242,Case Rate,ED per Visit,1464,,,1464,Case Rate,ED per Visit,1316,,,1316,Case Rate,ED per Visit,1464,,,1464,Case Rate,ED per Visit,1244,,,1244,Case Rate,ED per Visit,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2656,
MMH ED VISIT LEVEL 5 W/MOD,99285,CPT,25,30000067,CDM,450,RC,,,both,,,4000,2960.01,,,2960.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1800,45,,1800,percent of total billed charges,Critical Access Hospital RCC factor,1648,,,1648,Case Rate,ED per Visit,1483,,,1483,Case Rate,ED per Visit,1710,,,1710,Case Rate,ED per Visit,1539,,,1539,Case Rate,ED per Visit,1454,,,1454,Case Rate,ED per Visit,1980,,,1980,Other,110% of Medicare,2720,68,,2720,percent of total billed charges,All Other,0.01,,,0.01,Other,186% of Medicaid,3200,,,3200,Case Rate,ED per Visit,3320,,,3320,Case Rate,ED per Visit,3320,,,3320,Case Rate,ED per Visit,3200,,,3200,Case Rate,ED per Visit,3320,,,3320,Case Rate,ED per Visit,2018,,,2018,Case Rate,ED per Visit,2800,70,,2800,percent of total billed charges,All Other,1461,,,1461,Case Rate,ED per Visit,1242,,,1242,Case Rate,ED per Visit,1464,,,1464,Case Rate,ED per Visit,1316,,,1316,Case Rate,ED per Visit,1464,,,1464,Case Rate,ED per Visit,1244,,,1244,Case Rate,ED per Visit,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3320,
MMH CRITICAL CARE FIRST HOUR W/MOD,99291,CPT,25,30000068,CDM,450,RC,,,both,,,5815,4303.11,,,4303.11,Other,150% of Medicare + 9.63% HCRA Surcharge,2616.75,45,,2616.75,percent of total billed charges,Critical Access Hospital RCC factor,1648,,,1648,Case Rate,ED per Visit,1483,,,1483,Case Rate,ED per Visit,1710,,,1710,Case Rate,ED per Visit,1539,,,1539,Case Rate,ED per Visit,1454,,,1454,Case Rate,ED per Visit,2878.43,,,2878.43,Other,110% of Medicare,3954.2,68,,3954.2,percent of total billed charges,All Other,0.01,,,0.01,Other,186% of Medicaid,4652,,,4652,Case Rate,ED per Visit,4826.45,,,4826.45,Case Rate,ED per Visit,4826.45,,,4826.45,Case Rate,ED per Visit,4652,,,4652,Case Rate,ED per Visit,4826.45,,,4826.45,Case Rate,ED per Visit,2018,,,2018,Case Rate,ED per Visit,4070.5,70,,4070.5,percent of total billed charges,All Other,1461,,,1461,Case Rate,ED per Visit,1242,,,1242,Case Rate,ED per Visit,1464,,,1464,Case Rate,ED per Visit,1316,,,1316,Case Rate,ED per Visit,1464,,,1464,Case Rate,ED per Visit,1244,,,1244,Case Rate,ED per Visit,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4826.45,
MMH CRITICAL CARE EA ADDL 30 W/MOD,99292,CPT,25,30000069,CDM,450,RC,,,both,,,1240,917.6,,,917.6,Other,150% of Medicare + 9.63% HCRA Surcharge,558,45,,558,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,613.8,,,613.8,Other,110% of Medicare,843.2,68,,843.2,percent of total billed charges,All Other,0.01,,,0.01,Other,186% of Medicaid,992,,,992,Other,Non Covered Service,1029.2,,,1029.2,Other,Non Covered Service,1029.2,,,1029.2,Other,Non Covered Service,992,,,992,Other,Non Covered Service,1029.2,,,1029.2,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,868,70,,868,percent of total billed charges,All Other,259,,,259,Case Rate,,220,,,220,Case Rate,,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1029.2,
ED VISIT LEVEL 1 W/MOD,99281,CPT,25,30000074,CDM,450,RC,,,both,,,2191,1621.35,,,1621.35,Other,150% of Medicare + 9.63% HCRA Surcharge,985.95,45,,985.95,percent of total billed charges,Critical Access Hospital RCC factor,1648,,,1648,Case Rate,ED per Visit,1483,,,1483,Case Rate,ED per Visit,1710,,,1710,Case Rate,ED per Visit,1539,,,1539,Case Rate,ED per Visit,1454,,,1454,Case Rate,ED per Visit,1084.55,,,1084.55,Other,110% of Medicare,1489.88,68,,1489.88,percent of total billed charges,All Other,0.01,,,0.01,Other,186% of Medicaid,1752.8,,,1752.8,Case Rate,ED per Visit,1818.53,,,1818.53,Case Rate,ED per Visit,1818.53,,,1818.53,Case Rate,ED per Visit,1752.8,,,1752.8,Case Rate,ED per Visit,1818.53,,,1818.53,Case Rate,ED per Visit,2018,,,2018,Case Rate,ED per Visit,1533.7,70,,1533.7,percent of total billed charges,All Other,1461,,,1461,Case Rate,ED per Visit,1242,,,1242,Case Rate,ED per Visit,1464,,,1464,Case Rate,ED per Visit,1316,,,1316,Case Rate,ED per Visit,1464,,,1464,Case Rate,ED per Visit,1244,,,1244,Case Rate,ED per Visit,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2018,
ED VISIT LEVEL 2 W/MOD,99282,CPT,25,30000075,CDM,450,RC,,,both,,,3649,2700.27,,,2700.27,Other,150% of Medicare + 9.63% HCRA Surcharge,1642.05,45,,1642.05,percent of total billed charges,Critical Access Hospital RCC factor,1648,,,1648,Case Rate,ED per Visit,1483,,,1483,Case Rate,ED per Visit,1710,,,1710,Case Rate,ED per Visit,1539,,,1539,Case Rate,ED per Visit,1454,,,1454,Case Rate,ED per Visit,1806.26,,,1806.26,Other,110% of Medicare,2481.32,68,,2481.32,percent of total billed charges,All Other,0.01,,,0.01,Other,186% of Medicaid,2919.2,,,2919.2,Case Rate,ED per Visit,3028.67,,,3028.67,Case Rate,ED per Visit,3028.67,,,3028.67,Case Rate,ED per Visit,2919.2,,,2919.2,Case Rate,ED per Visit,3028.67,,,3028.67,Case Rate,ED per Visit,2018,,,2018,Case Rate,ED per Visit,2554.3,70,,2554.3,percent of total billed charges,All Other,1461,,,1461,Case Rate,ED per Visit,1242,,,1242,Case Rate,ED per Visit,1464,,,1464,Case Rate,ED per Visit,1316,,,1316,Case Rate,ED per Visit,1464,,,1464,Case Rate,ED per Visit,1244,,,1244,Case Rate,ED per Visit,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3028.67,
ED VISIT LEVEL 3 W/MOD,99283,CPT,25,30000076,CDM,450,RC,,,both,,,4816,3563.85,,,3563.85,Other,150% of Medicare + 9.63% HCRA Surcharge,2167.2,45,,2167.2,percent of total billed charges,Critical Access Hospital RCC factor,1648,,,1648,Case Rate,ED per Visit,1483,,,1483,Case Rate,ED per Visit,1710,,,1710,Case Rate,ED per Visit,1539,,,1539,Case Rate,ED per Visit,1454,,,1454,Case Rate,ED per Visit,2383.92,,,2383.92,Other,110% of Medicare,3274.88,68,,3274.88,percent of total billed charges,All Other,0.01,,,0.01,Other,186% of Medicaid,3852.8,,,3852.8,Case Rate,ED per Visit,3997.28,,,3997.28,Case Rate,ED per Visit,3997.28,,,3997.28,Case Rate,ED per Visit,3852.8,,,3852.8,Case Rate,ED per Visit,3997.28,,,3997.28,Case Rate,ED per Visit,2018,,,2018,Case Rate,ED per Visit,3371.2,70,,3371.2,percent of total billed charges,All Other,1461,,,1461,Case Rate,ED per Visit,1242,,,1242,Case Rate,ED per Visit,1464,,,1464,Case Rate,ED per Visit,1316,,,1316,Case Rate,ED per Visit,1464,,,1464,Case Rate,ED per Visit,1244,,,1244,Case Rate,ED per Visit,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3997.28,
ED VISIT LEVEL 4 W/MOD,99284,CPT,25,30000077,CDM,450,RC,,,both,,,6275,4643.52,,,4643.52,Other,150% of Medicare + 9.63% HCRA Surcharge,2823.75,45,,2823.75,percent of total billed charges,Critical Access Hospital RCC factor,1648,,,1648,Case Rate,ED per Visit,1483,,,1483,Case Rate,ED per Visit,1710,,,1710,Case Rate,ED per Visit,1539,,,1539,Case Rate,ED per Visit,1454,,,1454,Case Rate,ED per Visit,3106.13,,,3106.13,Other,110% of Medicare,4267,68,,4267,percent of total billed charges,All Other,0.01,,,0.01,Other,186% of Medicaid,5020,,,5020,Case Rate,ED per Visit,5208.25,,,5208.25,Case Rate,ED per Visit,5208.25,,,5208.25,Case Rate,ED per Visit,5020,,,5020,Case Rate,ED per Visit,5208.25,,,5208.25,Case Rate,ED per Visit,2018,,,2018,Case Rate,ED per Visit,4392.5,70,,4392.5,percent of total billed charges,All Other,1461,,,1461,Case Rate,ED per Visit,1242,,,1242,Case Rate,ED per Visit,1464,,,1464,Case Rate,ED per Visit,1316,,,1316,Case Rate,ED per Visit,1464,,,1464,Case Rate,ED per Visit,1244,,,1244,Case Rate,ED per Visit,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5208.25,
ED VISIT LEVEL 5 W/MOD,99285,CPT,25,30000078,CDM,450,RC,,,both,,,7880,5831.22,,,5831.22,Other,150% of Medicare + 9.63% HCRA Surcharge,3546,45,,3546,percent of total billed charges,Critical Access Hospital RCC factor,1648,,,1648,Case Rate,ED per Visit,1483,,,1483,Case Rate,ED per Visit,1710,,,1710,Case Rate,ED per Visit,1539,,,1539,Case Rate,ED per Visit,1454,,,1454,Case Rate,ED per Visit,3900.6,,,3900.6,Other,110% of Medicare,5358.4,68,,5358.4,percent of total billed charges,All Other,0.01,,,0.01,Other,186% of Medicaid,6304,,,6304,Case Rate,ED per Visit,6540.4,,,6540.4,Case Rate,ED per Visit,6540.4,,,6540.4,Case Rate,ED per Visit,6304,,,6304,Case Rate,ED per Visit,6540.4,,,6540.4,Case Rate,ED per Visit,2018,,,2018,Case Rate,ED per Visit,5516,70,,5516,percent of total billed charges,All Other,1461,,,1461,Case Rate,ED per Visit,1242,,,1242,Case Rate,ED per Visit,1464,,,1464,Case Rate,ED per Visit,1316,,,1316,Case Rate,ED per Visit,1464,,,1464,Case Rate,ED per Visit,1244,,,1244,Case Rate,ED per Visit,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,6540.4,
TH-ED VISIT LEVEL 1,99281,CPT,GT,30000080,CDM,450,RC,,,both,,,2191,1621.35,,,1621.35,Other,150% of Medicare + 9.63% HCRA Surcharge,985.95,45,,985.95,percent of total billed charges,Critical Access Hospital RCC factor,1648,,,1648,Case Rate,ED per Visit,1483,,,1483,Case Rate,ED per Visit,1710,,,1710,Case Rate,ED per Visit,1539,,,1539,Case Rate,ED per Visit,1454,,,1454,Case Rate,ED per Visit,1084.55,,,1084.55,Other,110% of Medicare,1489.88,68,,1489.88,percent of total billed charges,All Other,0.01,,,0.01,Other,186% of Medicaid,1752.8,,,1752.8,Case Rate,ED per Visit,1818.53,,,1818.53,Case Rate,ED per Visit,1818.53,,,1818.53,Case Rate,ED per Visit,1752.8,,,1752.8,Case Rate,ED per Visit,1818.53,,,1818.53,Case Rate,ED per Visit,2018,,,2018,Case Rate,ED per Visit,1533.7,70,,1533.7,percent of total billed charges,All Other,1461,,,1461,Case Rate,ED per Visit,1242,,,1242,Case Rate,ED per Visit,1464,,,1464,Case Rate,ED per Visit,1316,,,1316,Case Rate,ED per Visit,1464,,,1464,Case Rate,ED per Visit,1244,,,1244,Case Rate,ED per Visit,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2018,
TH-ED VISIT LEVEL 4,99284,CPT,GT,30000083,CDM,450,RC,,,both,,,6275,4643.52,,,4643.52,Other,150% of Medicare + 9.63% HCRA Surcharge,2823.75,45,,2823.75,percent of total billed charges,Critical Access Hospital RCC factor,1648,,,1648,Case Rate,ED per Visit,1483,,,1483,Case Rate,ED per Visit,1710,,,1710,Case Rate,ED per Visit,1539,,,1539,Case Rate,ED per Visit,1454,,,1454,Case Rate,ED per Visit,3106.13,,,3106.13,Other,110% of Medicare,4267,68,,4267,percent of total billed charges,All Other,0.01,,,0.01,Other,186% of Medicaid,5020,,,5020,Case Rate,ED per Visit,5208.25,,,5208.25,Case Rate,ED per Visit,5208.25,,,5208.25,Case Rate,ED per Visit,5020,,,5020,Case Rate,ED per Visit,5208.25,,,5208.25,Case Rate,ED per Visit,2018,,,2018,Case Rate,ED per Visit,4392.5,70,,4392.5,percent of total billed charges,All Other,1461,,,1461,Case Rate,ED per Visit,1242,,,1242,Case Rate,ED per Visit,1464,,,1464,Case Rate,ED per Visit,1316,,,1316,Case Rate,ED per Visit,1464,,,1464,Case Rate,ED per Visit,1244,,,1244,Case Rate,ED per Visit,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5208.25,
FNA W O IMAGE,10021,CPT,,30010021,CDM,450,RC,,,both,,,841,622.34,,,622.34,Other,150% of Medicare + 9.63% HCRA Surcharge,378.45,45,,378.45,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,416.3,,,416.3,Other,110% of Medicare,571.88,68,,571.88,percent of total billed charges,All Other,1038,,,1038,Other,186% of Medicaid,672.8,,,672.8,Other,Non Covered Service,698.03,,,698.03,Other,Non Covered Service,698.03,,,698.03,Other,Non Covered Service,672.8,,,672.8,Other,Non Covered Service,698.03,,,698.03,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,588.7,70,,588.7,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,557.82,,,557.82,Other,100% of Medicaid,557.82,,,557.82,Other,100% of Medicaid,557.82,,,557.82,Other,100% of Medicaid,557.82,,,557.82,Other,100% of Medicaid,1255.1,,,1255.1,Other,225% of Medicaid,853.47,,,853.47,Other,153% of Medicaid,1255.1,,,1255.1,Other,225% of Medicaid,780.95,,,780.95,Other,140% of Medicaid,1255.1,,,1255.1,Other,225% of Medicaid,1450.34,,,1450.34,Other,260% of Medicaid,1807.35,,,1807.35,Other,324% of Medicaid,1199.32,,,1199.32,Other,215% of Medicaid,1199.32,,,1199.32,Other,215% of Medicaid,697.28,,,697.28,Other,125% of Medicaid,0.01,1807.35,
I&D ABSCESS SIMPLE/SINGL,10060,CPT,,30010060,CDM,450,RC,,,both,,,587,434.38,,,434.38,Other,150% of Medicare + 9.63% HCRA Surcharge,264.15,45,,264.15,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,290.57,,,290.57,Other,110% of Medicare,399.16,68,,399.16,percent of total billed charges,All Other,733,,,733,Other,186% of Medicaid,469.6,,,469.6,Other,Non Covered Service,487.21,,,487.21,Other,Non Covered Service,487.21,,,487.21,Other,Non Covered Service,469.6,,,469.6,Other,Non Covered Service,487.21,,,487.21,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,410.9,70,,410.9,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,394.14,,,394.14,Other,100% of Medicaid,394.14,,,394.14,Other,100% of Medicaid,394.14,,,394.14,Other,100% of Medicaid,394.14,,,394.14,Other,100% of Medicaid,886.83,,,886.83,Other,225% of Medicaid,603.04,,,603.04,Other,153% of Medicaid,886.83,,,886.83,Other,225% of Medicaid,551.8,,,551.8,Other,140% of Medicaid,886.83,,,886.83,Other,225% of Medicaid,1024.78,,,1024.78,Other,260% of Medicaid,1277.03,,,1277.03,Other,324% of Medicaid,847.41,,,847.41,Other,215% of Medicaid,847.41,,,847.41,Other,215% of Medicaid,492.68,,,492.68,Other,125% of Medicaid,0.01,1277.03,
I AND D ABSCESS COMP MULTIPLE,10061,CPT,,30010061,CDM,450,RC,,,both,,,841,622.34,,,622.34,Other,150% of Medicare + 9.63% HCRA Surcharge,378.45,45,,378.45,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,416.3,,,416.3,Other,110% of Medicare,571.88,68,,571.88,percent of total billed charges,All Other,733,,,733,Other,186% of Medicaid,672.8,,,672.8,Other,Non Covered Service,698.03,,,698.03,Other,Non Covered Service,698.03,,,698.03,Other,Non Covered Service,672.8,,,672.8,Other,Non Covered Service,698.03,,,698.03,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,588.7,70,,588.7,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,394.14,,,394.14,Other,100% of Medicaid,394.14,,,394.14,Other,100% of Medicaid,394.14,,,394.14,Other,100% of Medicaid,394.14,,,394.14,Other,100% of Medicaid,886.83,,,886.83,Other,225% of Medicaid,603.04,,,603.04,Other,153% of Medicaid,886.83,,,886.83,Other,225% of Medicaid,551.8,,,551.8,Other,140% of Medicaid,886.83,,,886.83,Other,225% of Medicaid,1024.78,,,1024.78,Other,260% of Medicaid,1277.03,,,1277.03,Other,324% of Medicaid,847.41,,,847.41,Other,215% of Medicaid,847.41,,,847.41,Other,215% of Medicaid,492.68,,,492.68,Other,125% of Medicaid,0.01,1277.03,
DRAINAGE OF PILONIDAL CYST,10080,CPT,,30010080,CDM,450,RC,,,both,,,1462,1081.88,,,1081.88,Other,150% of Medicare + 9.63% HCRA Surcharge,657.9,45,,657.9,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,723.69,,,723.69,Other,110% of Medicare,994.16,68,,994.16,percent of total billed charges,All Other,733,,,733,Other,186% of Medicaid,1169.6,,,1169.6,Other,Non Covered Service,1213.46,,,1213.46,Other,Non Covered Service,1213.46,,,1213.46,Other,Non Covered Service,1169.6,,,1169.6,Other,Non Covered Service,1213.46,,,1213.46,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1023.4,70,,1023.4,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,394.14,,,394.14,Other,100% of Medicaid,394.14,,,394.14,Other,100% of Medicaid,394.14,,,394.14,Other,100% of Medicaid,394.14,,,394.14,Other,100% of Medicaid,886.83,,,886.83,Other,225% of Medicaid,603.04,,,603.04,Other,153% of Medicaid,886.83,,,886.83,Other,225% of Medicaid,551.8,,,551.8,Other,140% of Medicaid,886.83,,,886.83,Other,225% of Medicaid,1024.78,,,1024.78,Other,260% of Medicaid,1277.03,,,1277.03,Other,324% of Medicaid,847.41,,,847.41,Other,215% of Medicaid,847.41,,,847.41,Other,215% of Medicaid,492.68,,,492.68,Other,125% of Medicaid,0.01,1277.03,
I&D PILONID CYST; CPLX,10081,CPT,,30010081,CDM,450,RC,,,both,,,3098,2292.53,,,2292.53,Other,150% of Medicare + 9.63% HCRA Surcharge,1394.1,45,,1394.1,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1533.51,,,1533.51,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,1207,,,1207,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2168.6,70,,2168.6,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,648.98,,,648.98,Other,100% of Medicaid,648.98,,,648.98,Other,100% of Medicaid,648.98,,,648.98,Other,100% of Medicaid,648.98,,,648.98,Other,100% of Medicaid,1460.2,,,1460.2,Other,225% of Medicaid,992.94,,,992.94,Other,153% of Medicaid,1460.2,,,1460.2,Other,225% of Medicaid,908.57,,,908.57,Other,140% of Medicaid,1460.2,,,1460.2,Other,225% of Medicaid,1687.34,,,1687.34,Other,260% of Medicaid,2102.69,,,2102.69,Other,324% of Medicaid,1395.3,,,1395.3,Other,215% of Medicaid,1395.3,,,1395.3,Other,215% of Medicaid,811.22,,,811.22,Other,125% of Medicaid,0.01,2292.53,
REMOVE FB SKIN SUBCU SIMPLE,10120,CPT,,30010120,CDM,450,RC,,,both,,,1041,770.34,,,770.34,Other,150% of Medicare + 9.63% HCRA Surcharge,468.45,45,,468.45,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,515.3,,,515.3,Other,110% of Medicare,707.88,68,,707.88,percent of total billed charges,All Other,733,,,733,Other,186% of Medicaid,832.8,,,832.8,Other,Non Covered Service,864.03,,,864.03,Other,Non Covered Service,864.03,,,864.03,Other,Non Covered Service,832.8,,,832.8,Other,Non Covered Service,864.03,,,864.03,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,728.7,70,,728.7,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,394.14,,,394.14,Other,100% of Medicaid,394.14,,,394.14,Other,100% of Medicaid,394.14,,,394.14,Other,100% of Medicaid,394.14,,,394.14,Other,100% of Medicaid,886.83,,,886.83,Other,225% of Medicaid,603.04,,,603.04,Other,153% of Medicaid,886.83,,,886.83,Other,225% of Medicaid,551.8,,,551.8,Other,140% of Medicaid,886.83,,,886.83,Other,225% of Medicaid,1024.78,,,1024.78,Other,260% of Medicaid,1277.03,,,1277.03,Other,324% of Medicaid,847.41,,,847.41,Other,215% of Medicaid,847.41,,,847.41,Other,215% of Medicaid,492.68,,,492.68,Other,125% of Medicaid,0.01,1277.03,
INC & REM FB SQ; COMPL,10121,CPT,,30010121,CDM,450,RC,,,both,,,4422,3272.29,,,3272.29,Other,150% of Medicare + 9.63% HCRA Surcharge,1989.9,45,,1989.9,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2188.89,,,2188.89,Other,110% of Medicare,3006.96,68,,3006.96,percent of total billed charges,All Other,2242,,,2242,Other,186% of Medicaid,3537.6,,,3537.6,Other,Non Covered Service,3670.26,,,3670.26,Other,Non Covered Service,3670.26,,,3670.26,Other,Non Covered Service,3537.6,,,3537.6,Other,Non Covered Service,3670.26,,,3670.26,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,3095.4,70,,3095.4,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1205.3,,,1205.3,Other,100% of Medicaid,1205.3,,,1205.3,Other,100% of Medicaid,1205.3,,,1205.3,Other,100% of Medicaid,1205.3,,,1205.3,Other,100% of Medicaid,2711.92,,,2711.92,Other,225% of Medicaid,1844.1,,,1844.1,Other,153% of Medicaid,2711.92,,,2711.92,Other,225% of Medicaid,1687.41,,,1687.41,Other,140% of Medicaid,2711.92,,,2711.92,Other,225% of Medicaid,3133.77,,,3133.77,Other,260% of Medicaid,3905.16,,,3905.16,Other,324% of Medicaid,2591.39,,,2591.39,Other,215% of Medicaid,2591.39,,,2591.39,Other,215% of Medicaid,1506.62,,,1506.62,Other,125% of Medicaid,0.01,3905.16,
DRAINAGE OF HEMATOMA/FLUID,10140,CPT,,30010140,CDM,450,RC,,,both,,,4951,3663.75,,,3663.75,Other,150% of Medicare + 9.63% HCRA Surcharge,2227.95,45,,2227.95,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2450.75,,,2450.75,Other,110% of Medicare,3366.68,68,,3366.68,percent of total billed charges,All Other,1207,,,1207,Other,186% of Medicaid,3960.8,,,3960.8,Other,Non Covered Service,4109.33,,,4109.33,Other,Non Covered Service,4109.33,,,4109.33,Other,Non Covered Service,3960.8,,,3960.8,Other,Non Covered Service,4109.33,,,4109.33,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,3465.7,70,,3465.7,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,648.98,,,648.98,Other,100% of Medicaid,648.98,,,648.98,Other,100% of Medicaid,648.98,,,648.98,Other,100% of Medicaid,648.98,,,648.98,Other,100% of Medicaid,1460.2,,,1460.2,Other,225% of Medicaid,992.94,,,992.94,Other,153% of Medicaid,1460.2,,,1460.2,Other,225% of Medicaid,908.57,,,908.57,Other,140% of Medicaid,1460.2,,,1460.2,Other,225% of Medicaid,1687.34,,,1687.34,Other,260% of Medicaid,2102.69,,,2102.69,Other,324% of Medicaid,1395.3,,,1395.3,Other,215% of Medicaid,1395.3,,,1395.3,Other,215% of Medicaid,811.22,,,811.22,Other,125% of Medicaid,0.01,4109.33,
ASPIRATION ABSCESS HEMA C,10160,CPT,,30010160,CDM,450,RC,,,both,,,841,622.34,,,622.34,Other,150% of Medicare + 9.63% HCRA Surcharge,378.45,45,,378.45,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,416.3,,,416.3,Other,110% of Medicare,571.88,68,,571.88,percent of total billed charges,All Other,733,,,733,Other,186% of Medicaid,672.8,,,672.8,Other,Non Covered Service,698.03,,,698.03,Other,Non Covered Service,698.03,,,698.03,Other,Non Covered Service,672.8,,,672.8,Other,Non Covered Service,698.03,,,698.03,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,588.7,70,,588.7,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,394.14,,,394.14,Other,100% of Medicaid,394.14,,,394.14,Other,100% of Medicaid,394.14,,,394.14,Other,100% of Medicaid,394.14,,,394.14,Other,100% of Medicaid,886.83,,,886.83,Other,225% of Medicaid,603.04,,,603.04,Other,153% of Medicaid,886.83,,,886.83,Other,225% of Medicaid,551.8,,,551.8,Other,140% of Medicaid,886.83,,,886.83,Other,225% of Medicaid,1024.78,,,1024.78,Other,260% of Medicaid,1277.03,,,1277.03,Other,324% of Medicaid,847.41,,,847.41,Other,215% of Medicaid,847.41,,,847.41,Other,215% of Medicaid,492.68,,,492.68,Other,125% of Medicaid,0.01,1277.03,
I&D CPLX POSTOP WND INF,10180,CPT,,30010180,CDM,450,RC,,,both,,,5816,4303.85,,,4303.85,Other,150% of Medicare + 9.63% HCRA Surcharge,2617.2,45,,2617.2,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2878.92,,,2878.92,Other,110% of Medicare,3954.88,68,,3954.88,percent of total billed charges,All Other,2493,,,2493,Other,186% of Medicaid,4652.8,,,4652.8,Other,Non Covered Service,4827.28,,,4827.28,Other,Non Covered Service,4827.28,,,4827.28,Other,Non Covered Service,4652.8,,,4652.8,Other,Non Covered Service,4827.28,,,4827.28,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,4071.2,70,,4071.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1340.24,,,1340.24,Other,100% of Medicaid,1340.24,,,1340.24,Other,100% of Medicaid,1340.24,,,1340.24,Other,100% of Medicaid,1340.24,,,1340.24,Other,100% of Medicaid,3015.54,,,3015.54,Other,225% of Medicaid,2050.57,,,2050.57,Other,153% of Medicaid,3015.54,,,3015.54,Other,225% of Medicaid,1876.34,,,1876.34,Other,140% of Medicaid,3015.54,,,3015.54,Other,225% of Medicaid,3484.62,,,3484.62,Other,260% of Medicaid,4342.38,,,4342.38,Other,324% of Medicaid,2881.52,,,2881.52,Other,215% of Medicaid,2881.52,,,2881.52,Other,215% of Medicaid,1675.3,,,1675.3,Other,125% of Medicaid,0.01,4827.28,
DEBR EXZ/INF SKIN; 10% BS,11000,CPT,,30011000,CDM,450,RC,,,both,,,1309,968.66,,,968.66,Other,150% of Medicare + 9.63% HCRA Surcharge,589.05,45,,589.05,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,647.96,,,647.96,Other,110% of Medicare,890.12,68,,890.12,percent of total billed charges,All Other,1353,,,1353,Other,186% of Medicaid,1047.2,,,1047.2,Other,Non Covered Service,1086.47,,,1086.47,Other,Non Covered Service,1086.47,,,1086.47,Other,Non Covered Service,1047.2,,,1047.2,Other,Non Covered Service,1086.47,,,1086.47,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,916.3,70,,916.3,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,727.17,,,727.17,Other,100% of Medicaid,727.17,,,727.17,Other,100% of Medicaid,727.17,,,727.17,Other,100% of Medicaid,727.17,,,727.17,Other,100% of Medicaid,1636.12,,,1636.12,Other,225% of Medicaid,1112.56,,,1112.56,Other,153% of Medicaid,1636.12,,,1636.12,Other,225% of Medicaid,1018.03,,,1018.03,Other,140% of Medicaid,1636.12,,,1636.12,Other,225% of Medicaid,1890.63,,,1890.63,Other,260% of Medicaid,2356.02,,,2356.02,Other,324% of Medicaid,1563.41,,,1563.41,Other,215% of Medicaid,1563.41,,,1563.41,Other,215% of Medicaid,908.96,,,908.96,Other,125% of Medicaid,0.01,2356.02,
DEBRIDE SKIN AT FX SITE,11010,CPT,,30011010,CDM,450,RC,,,both,,,1528,1130.72,,,1130.72,Other,150% of Medicare + 9.63% HCRA Surcharge,687.6,45,,687.6,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,756.36,,,756.36,Other,110% of Medicare,1039.04,68,,1039.04,percent of total billed charges,All Other,1353,,,1353,Other,186% of Medicaid,1222.4,,,1222.4,Other,Non Covered Service,1268.24,,,1268.24,Other,Non Covered Service,1268.24,,,1268.24,Other,Non Covered Service,1222.4,,,1222.4,Other,Non Covered Service,1268.24,,,1268.24,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1069.6,70,,1069.6,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,727.17,,,727.17,Other,100% of Medicaid,727.17,,,727.17,Other,100% of Medicaid,727.17,,,727.17,Other,100% of Medicaid,727.17,,,727.17,Other,100% of Medicaid,1636.12,,,1636.12,Other,225% of Medicaid,1112.56,,,1112.56,Other,153% of Medicaid,1636.12,,,1636.12,Other,225% of Medicaid,1018.03,,,1018.03,Other,140% of Medicaid,1636.12,,,1636.12,Other,225% of Medicaid,1890.63,,,1890.63,Other,260% of Medicaid,2356.02,,,2356.02,Other,324% of Medicaid,1563.41,,,1563.41,Other,215% of Medicaid,1563.41,,,1563.41,Other,215% of Medicaid,908.96,,,908.96,Other,125% of Medicaid,0.01,2356.02,
DEB SKIN BONE AT FX SITE,11012,CPT,,30011012,CDM,450,RC,,,both,,,7946,5880.06,,,5880.06,Other,150% of Medicare + 9.63% HCRA Surcharge,3575.7,45,,3575.7,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,3933.27,,,3933.27,Other,110% of Medicare,5403.28,68,,5403.28,percent of total billed charges,All Other,2493,,,2493,Other,186% of Medicaid,6356.8,,,6356.8,Other,Non Covered Service,6595.18,,,6595.18,Other,Non Covered Service,6595.18,,,6595.18,Other,Non Covered Service,6356.8,,,6356.8,Other,Non Covered Service,6595.18,,,6595.18,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,5562.2,70,,5562.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1340.24,,,1340.24,Other,100% of Medicaid,1340.24,,,1340.24,Other,100% of Medicaid,1340.24,,,1340.24,Other,100% of Medicaid,1340.24,,,1340.24,Other,100% of Medicaid,3015.54,,,3015.54,Other,225% of Medicaid,2050.57,,,2050.57,Other,153% of Medicaid,3015.54,,,3015.54,Other,225% of Medicaid,1876.34,,,1876.34,Other,140% of Medicaid,3015.54,,,3015.54,Other,225% of Medicaid,3484.62,,,3484.62,Other,260% of Medicaid,4342.38,,,4342.38,Other,324% of Medicaid,2881.52,,,2881.52,Other,215% of Medicaid,2881.52,,,2881.52,Other,215% of Medicaid,1675.3,,,1675.3,Other,125% of Medicaid,0.01,6595.18,
DEB SUBQ TISSUE 20 SQ CM <,11042,CPT,,30011042,CDM,450,RC,,,both,,,1041,770.34,,,770.34,Other,150% of Medicare + 9.63% HCRA Surcharge,468.45,45,,468.45,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,515.3,,,515.3,Other,110% of Medicare,707.88,68,,707.88,percent of total billed charges,All Other,1353,,,1353,Other,186% of Medicaid,832.8,,,832.8,Other,Non Covered Service,864.03,,,864.03,Other,Non Covered Service,864.03,,,864.03,Other,Non Covered Service,832.8,,,832.8,Other,Non Covered Service,864.03,,,864.03,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,728.7,70,,728.7,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,727.17,,,727.17,Other,100% of Medicaid,727.17,,,727.17,Other,100% of Medicaid,727.17,,,727.17,Other,100% of Medicaid,727.17,,,727.17,Other,100% of Medicaid,1636.12,,,1636.12,Other,225% of Medicaid,1112.56,,,1112.56,Other,153% of Medicaid,1636.12,,,1636.12,Other,225% of Medicaid,1018.03,,,1018.03,Other,140% of Medicaid,1636.12,,,1636.12,Other,225% of Medicaid,1890.63,,,1890.63,Other,260% of Medicaid,2356.02,,,2356.02,Other,324% of Medicaid,1563.41,,,1563.41,Other,215% of Medicaid,1563.41,,,1563.41,Other,215% of Medicaid,908.96,,,908.96,Other,125% of Medicaid,0.01,2356.02,
DEB MUSC/FASCIA 20 SQ CM/<,11043,CPT,,30011043,CDM,450,RC,,,both,,,1402,1037.48,,,1037.48,Other,150% of Medicare + 9.63% HCRA Surcharge,630.9,45,,630.9,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,693.99,,,693.99,Other,110% of Medicare,953.36,68,,953.36,percent of total billed charges,All Other,1353,,,1353,Other,186% of Medicaid,1121.6,,,1121.6,Other,Non Covered Service,1163.66,,,1163.66,Other,Non Covered Service,1163.66,,,1163.66,Other,Non Covered Service,1121.6,,,1121.6,Other,Non Covered Service,1163.66,,,1163.66,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,981.4,70,,981.4,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,727.17,,,727.17,Other,100% of Medicaid,727.17,,,727.17,Other,100% of Medicaid,727.17,,,727.17,Other,100% of Medicaid,727.17,,,727.17,Other,100% of Medicaid,1636.12,,,1636.12,Other,225% of Medicaid,1112.56,,,1112.56,Other,153% of Medicaid,1636.12,,,1636.12,Other,225% of Medicaid,1018.03,,,1018.03,Other,140% of Medicaid,1636.12,,,1636.12,Other,225% of Medicaid,1890.63,,,1890.63,Other,260% of Medicaid,2356.02,,,2356.02,Other,324% of Medicaid,1563.41,,,1563.41,Other,215% of Medicaid,1563.41,,,1563.41,Other,215% of Medicaid,908.96,,,908.96,Other,125% of Medicaid,0.01,2356.02,
PARE BENIGN LES; SGL,11055,CPT,,30011055,CDM,450,RC,,,both,,,408,301.92,,,301.92,Other,150% of Medicare + 9.63% HCRA Surcharge,183.6,45,,183.6,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,201.96,,,201.96,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,733,,,733,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,285.6,70,,285.6,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,394.14,,,394.14,Other,100% of Medicaid,394.14,,,394.14,Other,100% of Medicaid,394.14,,,394.14,Other,100% of Medicaid,394.14,,,394.14,Other,100% of Medicaid,886.83,,,886.83,Other,225% of Medicaid,603.04,,,603.04,Other,153% of Medicaid,886.83,,,886.83,Other,225% of Medicaid,551.8,,,551.8,Other,140% of Medicaid,886.83,,,886.83,Other,225% of Medicaid,1024.78,,,1024.78,Other,260% of Medicaid,1277.03,,,1277.03,Other,324% of Medicaid,847.41,,,847.41,Other,215% of Medicaid,847.41,,,847.41,Other,215% of Medicaid,492.68,,,492.68,Other,125% of Medicaid,0.01,1277.03,
REM SKIN TAGS 1 TO 15,11200,CPT,,30011200,CDM,450,RC,,,both,,,439,324.86,,,324.86,Other,150% of Medicare + 9.63% HCRA Surcharge,197.55,45,,197.55,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,217.31,,,217.31,Other,110% of Medicare,298.52,68,,298.52,percent of total billed charges,All Other,733,,,733,Other,186% of Medicaid,351.2,,,351.2,Other,Non Covered Service,364.37,,,364.37,Other,Non Covered Service,364.37,,,364.37,Other,Non Covered Service,351.2,,,351.2,Other,Non Covered Service,364.37,,,364.37,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,307.3,70,,307.3,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,394.14,,,394.14,Other,100% of Medicaid,394.14,,,394.14,Other,100% of Medicaid,394.14,,,394.14,Other,100% of Medicaid,394.14,,,394.14,Other,100% of Medicaid,886.83,,,886.83,Other,225% of Medicaid,603.04,,,603.04,Other,153% of Medicaid,886.83,,,886.83,Other,225% of Medicaid,551.8,,,551.8,Other,140% of Medicaid,886.83,,,886.83,Other,225% of Medicaid,1024.78,,,1024.78,Other,260% of Medicaid,1277.03,,,1277.03,Other,324% of Medicaid,847.41,,,847.41,Other,215% of Medicaid,847.41,,,847.41,Other,215% of Medicaid,492.68,,,492.68,Other,125% of Medicaid,0.01,1277.03,
EXC TR-EXT B9+MARG 0.5CM/<,11400,CPT,,30011400,CDM,450,RC,,,both,,,1732,1281.68,,,1281.68,Other,150% of Medicare + 9.63% HCRA Surcharge,779.4,45,,779.4,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,857.34,,,857.34,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,1241,,,1241,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1212.4,70,,1212.4,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,667.11,,,667.11,Other,100% of Medicaid,667.11,,,667.11,Other,100% of Medicaid,667.11,,,667.11,Other,100% of Medicaid,667.11,,,667.11,Other,100% of Medicaid,1501,,,1501,Other,225% of Medicaid,1020.68,,,1020.68,Other,153% of Medicaid,1501,,,1501,Other,225% of Medicaid,933.96,,,933.96,Other,140% of Medicaid,1501,,,1501,Other,225% of Medicaid,1734.49,,,1734.49,Other,260% of Medicaid,2161.44,,,2161.44,Other,324% of Medicaid,1434.29,,,1434.29,Other,215% of Medicaid,1434.29,,,1434.29,Other,215% of Medicaid,833.89,,,833.89,Other,125% of Medicaid,0.01,2161.44,
EXC BENIGN LESION < 0.5C,11420,CPT,,30011420,CDM,450,RC,,,both,,,3377,2498.99,,,2498.99,Other,150% of Medicare + 9.63% HCRA Surcharge,1519.65,45,,1519.65,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1671.62,,,1671.62,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,2242,,,2242,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2363.9,70,,2363.9,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1205.3,,,1205.3,Other,100% of Medicaid,1205.3,,,1205.3,Other,100% of Medicaid,1205.3,,,1205.3,Other,100% of Medicaid,1205.3,,,1205.3,Other,100% of Medicaid,2711.92,,,2711.92,Other,225% of Medicaid,1844.1,,,1844.1,Other,153% of Medicaid,2711.92,,,2711.92,Other,225% of Medicaid,1687.41,,,1687.41,Other,140% of Medicaid,2711.92,,,2711.92,Other,225% of Medicaid,3133.77,,,3133.77,Other,260% of Medicaid,3905.16,,,3905.16,Other,324% of Medicaid,2591.39,,,2591.39,Other,215% of Medicaid,2591.39,,,2591.39,Other,215% of Medicaid,1506.62,,,1506.62,Other,125% of Medicaid,0.01,3905.16,
EXC BLES S/N/EX G; 0.6-1.0CM,11421,CPT,,30011421,CDM,450,RC,,,both,,,3395,2512.31,,,2512.31,Other,150% of Medicare + 9.63% HCRA Surcharge,1527.75,45,,1527.75,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1680.53,,,1680.53,Other,110% of Medicare,2308.6,68,,2308.6,percent of total billed charges,All Other,1241,,,1241,Other,186% of Medicaid,2716,,,2716,Other,Non Covered Service,2817.85,,,2817.85,Other,Non Covered Service,2817.85,,,2817.85,Other,Non Covered Service,2716,,,2716,Other,Non Covered Service,2817.85,,,2817.85,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2376.5,70,,2376.5,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,667.11,,,667.11,Other,100% of Medicaid,667.11,,,667.11,Other,100% of Medicaid,667.11,,,667.11,Other,100% of Medicaid,667.11,,,667.11,Other,100% of Medicaid,1501,,,1501,Other,225% of Medicaid,1020.68,,,1020.68,Other,153% of Medicaid,1501,,,1501,Other,225% of Medicaid,933.96,,,933.96,Other,140% of Medicaid,1501,,,1501,Other,225% of Medicaid,1734.49,,,1734.49,Other,260% of Medicaid,2161.44,,,2161.44,Other,324% of Medicaid,1434.29,,,1434.29,Other,215% of Medicaid,1434.29,,,1434.29,Other,215% of Medicaid,833.89,,,833.89,Other,125% of Medicaid,0.01,2817.85,
EXC HIDRAD AXIL; S/I REP,11450,CPT,,30011450,CDM,450,RC,,,both,,,7424,5493.78,,,5493.78,Other,150% of Medicare + 9.63% HCRA Surcharge,3340.8,45,,3340.8,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,3674.88,,,3674.88,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,3622,,,3622,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,5196.8,70,,5196.8,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1947.19,,,1947.19,Other,100% of Medicaid,1947.19,,,1947.19,Other,100% of Medicaid,1947.19,,,1947.19,Other,100% of Medicaid,1947.19,,,1947.19,Other,100% of Medicaid,4381.17,,,4381.17,Other,225% of Medicaid,2979.2,,,2979.2,Other,153% of Medicaid,4381.17,,,4381.17,Other,225% of Medicaid,2726.06,,,2726.06,Other,140% of Medicaid,4381.17,,,4381.17,Other,225% of Medicaid,5062.69,,,5062.69,Other,260% of Medicaid,6308.89,,,6308.89,Other,324% of Medicaid,4186.45,,,4186.45,Other,215% of Medicaid,4186.45,,,4186.45,Other,215% of Medicaid,2433.99,,,2433.99,Other,125% of Medicaid,0.01,6308.89,
TRIM ND NAILS,11719,CPT,,30011719,CDM,450,RC,,,both,,,186,137.64,,,137.64,Other,150% of Medicare + 9.63% HCRA Surcharge,83.7,45,,83.7,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,92.07,,,92.07,Other,110% of Medicare,126.48,68,,126.48,percent of total billed charges,All Other,354,,,354,Other,186% of Medicaid,148.8,,,148.8,Other,Non Covered Service,154.38,,,154.38,Other,Non Covered Service,154.38,,,154.38,Other,Non Covered Service,148.8,,,148.8,Other,Non Covered Service,154.38,,,154.38,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,130.2,70,,130.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,190.08,,,190.08,Other,100% of Medicaid,190.08,,,190.08,Other,100% of Medicaid,190.08,,,190.08,Other,100% of Medicaid,190.08,,,190.08,Other,100% of Medicaid,427.68,,,427.68,Other,225% of Medicaid,290.82,,,290.82,Other,153% of Medicaid,427.68,,,427.68,Other,225% of Medicaid,266.11,,,266.11,Other,140% of Medicaid,427.68,,,427.68,Other,225% of Medicaid,494.21,,,494.21,Other,260% of Medicaid,615.86,,,615.86,Other,324% of Medicaid,408.67,,,408.67,Other,215% of Medicaid,408.67,,,408.67,Other,215% of Medicaid,237.6,,,237.6,Other,125% of Medicaid,0.01,615.86,
REMOVAL OF NAIL PLATE,11730,CPT,,30011730,CDM,450,RC,,,both,,,408,301.92,,,301.92,Other,150% of Medicare + 9.63% HCRA Surcharge,183.6,45,,183.6,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,201.96,,,201.96,Other,110% of Medicare,277.44,68,,277.44,percent of total billed charges,All Other,354,,,354,Other,186% of Medicaid,326.4,,,326.4,Other,Non Covered Service,338.64,,,338.64,Other,Non Covered Service,338.64,,,338.64,Other,Non Covered Service,326.4,,,326.4,Other,Non Covered Service,338.64,,,338.64,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,285.6,70,,285.6,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,190.08,,,190.08,Other,100% of Medicaid,190.08,,,190.08,Other,100% of Medicaid,190.08,,,190.08,Other,100% of Medicaid,190.08,,,190.08,Other,100% of Medicaid,427.68,,,427.68,Other,225% of Medicaid,290.82,,,290.82,Other,153% of Medicaid,427.68,,,427.68,Other,225% of Medicaid,266.11,,,266.11,Other,140% of Medicaid,427.68,,,427.68,Other,225% of Medicaid,494.21,,,494.21,Other,260% of Medicaid,615.86,,,615.86,Other,324% of Medicaid,408.67,,,408.67,Other,215% of Medicaid,408.67,,,408.67,Other,215% of Medicaid,237.6,,,237.6,Other,125% of Medicaid,0.01,615.86,
REMOVE NAIL PLATE ADD-ON,11732,CPT,,30011732,CDM,450,RC,,,both,,,300,222,,,222,Other,150% of Medicare + 9.63% HCRA Surcharge,135,45,,135,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,148.5,,,148.5,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,354,,,354,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,210,70,,210,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,190.08,,,190.08,Other,100% of Medicaid,190.08,,,190.08,Other,100% of Medicaid,190.08,,,190.08,Other,100% of Medicaid,190.08,,,190.08,Other,100% of Medicaid,427.68,,,427.68,Other,225% of Medicaid,290.82,,,290.82,Other,153% of Medicaid,427.68,,,427.68,Other,225% of Medicaid,266.11,,,266.11,Other,140% of Medicaid,427.68,,,427.68,Other,225% of Medicaid,494.21,,,494.21,Other,260% of Medicaid,615.86,,,615.86,Other,324% of Medicaid,408.67,,,408.67,Other,215% of Medicaid,408.67,,,408.67,Other,215% of Medicaid,237.6,,,237.6,Other,125% of Medicaid,0.01,615.86,
DRAIN BLOOD FROM UNDER NAIL,11740,CPT,,30011740,CDM,450,RC,,,both,,,263,194.62,,,194.62,Other,150% of Medicare + 9.63% HCRA Surcharge,118.35,45,,118.35,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,130.19,,,130.19,Other,110% of Medicare,178.84,68,,178.84,percent of total billed charges,All Other,354,,,354,Other,186% of Medicaid,210.4,,,210.4,Other,Non Covered Service,218.29,,,218.29,Other,Non Covered Service,218.29,,,218.29,Other,Non Covered Service,210.4,,,210.4,Other,Non Covered Service,218.29,,,218.29,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,184.1,70,,184.1,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,190.08,,,190.08,Other,100% of Medicaid,190.08,,,190.08,Other,100% of Medicaid,190.08,,,190.08,Other,100% of Medicaid,190.08,,,190.08,Other,100% of Medicaid,427.68,,,427.68,Other,225% of Medicaid,290.82,,,290.82,Other,153% of Medicaid,427.68,,,427.68,Other,225% of Medicaid,266.11,,,266.11,Other,140% of Medicaid,427.68,,,427.68,Other,225% of Medicaid,494.21,,,494.21,Other,260% of Medicaid,615.86,,,615.86,Other,324% of Medicaid,408.67,,,408.67,Other,215% of Medicaid,408.67,,,408.67,Other,215% of Medicaid,237.6,,,237.6,Other,125% of Medicaid,0.01,615.86,
REMOVAL OF NAIL BED,11750,CPT,,30011750,CDM,450,RC,,,both,,,1876,1388.24,,,1388.24,Other,150% of Medicare + 9.63% HCRA Surcharge,844.2,45,,844.2,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,928.62,,,928.62,Other,110% of Medicare,1275.68,68,,1275.68,percent of total billed charges,All Other,1241,,,1241,Other,186% of Medicaid,1500.8,,,1500.8,Other,Non Covered Service,1557.08,,,1557.08,Other,Non Covered Service,1557.08,,,1557.08,Other,Non Covered Service,1500.8,,,1500.8,Other,Non Covered Service,1557.08,,,1557.08,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1313.2,70,,1313.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,667.11,,,667.11,Other,100% of Medicaid,667.11,,,667.11,Other,100% of Medicaid,667.11,,,667.11,Other,100% of Medicaid,667.11,,,667.11,Other,100% of Medicaid,1501,,,1501,Other,225% of Medicaid,1020.68,,,1020.68,Other,153% of Medicaid,1501,,,1501,Other,225% of Medicaid,933.96,,,933.96,Other,140% of Medicaid,1501,,,1501,Other,225% of Medicaid,1734.49,,,1734.49,Other,260% of Medicaid,2161.44,,,2161.44,Other,324% of Medicaid,1434.29,,,1434.29,Other,215% of Medicaid,1434.29,,,1434.29,Other,215% of Medicaid,833.89,,,833.89,Other,125% of Medicaid,0.01,2161.44,
BIOPSY NAIL UNIT,11755,CPT,,30011755,CDM,450,RC,,,both,,,1661,1229.14,,,1229.14,Other,150% of Medicare + 9.63% HCRA Surcharge,747.45,45,,747.45,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,822.2,,,822.2,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,1241,,,1241,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1162.7,70,,1162.7,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,667.11,,,667.11,Other,100% of Medicaid,667.11,,,667.11,Other,100% of Medicaid,667.11,,,667.11,Other,100% of Medicaid,667.11,,,667.11,Other,100% of Medicaid,1501,,,1501,Other,225% of Medicaid,1020.68,,,1020.68,Other,153% of Medicaid,1501,,,1501,Other,225% of Medicaid,933.96,,,933.96,Other,140% of Medicaid,1501,,,1501,Other,225% of Medicaid,1734.49,,,1734.49,Other,260% of Medicaid,2161.44,,,2161.44,Other,324% of Medicaid,1434.29,,,1434.29,Other,215% of Medicaid,1434.29,,,1434.29,Other,215% of Medicaid,833.89,,,833.89,Other,125% of Medicaid,0.01,2161.44,
REPAIR NAIL BED,11760,CPT,,30011760,CDM,450,RC,,,both,,,1309,968.66,,,968.66,Other,150% of Medicare + 9.63% HCRA Surcharge,589.05,45,,589.05,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,647.96,,,647.96,Other,110% of Medicare,890.12,68,,890.12,percent of total billed charges,All Other,354,,,354,Other,186% of Medicaid,1047.2,,,1047.2,Other,Non Covered Service,1086.47,,,1086.47,Other,Non Covered Service,1086.47,,,1086.47,Other,Non Covered Service,1047.2,,,1047.2,Other,Non Covered Service,1086.47,,,1086.47,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,916.3,70,,916.3,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,190.08,,,190.08,Other,100% of Medicaid,190.08,,,190.08,Other,100% of Medicaid,190.08,,,190.08,Other,100% of Medicaid,190.08,,,190.08,Other,100% of Medicaid,427.68,,,427.68,Other,225% of Medicaid,290.82,,,290.82,Other,153% of Medicaid,427.68,,,427.68,Other,225% of Medicaid,266.11,,,266.11,Other,140% of Medicaid,427.68,,,427.68,Other,225% of Medicaid,494.21,,,494.21,Other,260% of Medicaid,615.86,,,615.86,Other,324% of Medicaid,408.67,,,408.67,Other,215% of Medicaid,408.67,,,408.67,Other,215% of Medicaid,237.6,,,237.6,Other,125% of Medicaid,0.01,1086.47,
WEDGE EXC NAIL FOLD,11765,CPT,,30011765,CDM,450,RC,,,both,,,841,622.34,,,622.34,Other,150% of Medicare + 9.63% HCRA Surcharge,378.45,45,,378.45,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,416.3,,,416.3,Other,110% of Medicare,571.88,68,,571.88,percent of total billed charges,All Other,354,,,354,Other,186% of Medicaid,672.8,,,672.8,Other,Non Covered Service,698.03,,,698.03,Other,Non Covered Service,698.03,,,698.03,Other,Non Covered Service,672.8,,,672.8,Other,Non Covered Service,698.03,,,698.03,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,588.7,70,,588.7,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,190.08,,,190.08,Other,100% of Medicaid,190.08,,,190.08,Other,100% of Medicaid,190.08,,,190.08,Other,100% of Medicaid,190.08,,,190.08,Other,100% of Medicaid,427.68,,,427.68,Other,225% of Medicaid,290.82,,,290.82,Other,153% of Medicaid,427.68,,,427.68,Other,225% of Medicaid,266.11,,,266.11,Other,140% of Medicaid,427.68,,,427.68,Other,225% of Medicaid,494.21,,,494.21,Other,260% of Medicaid,615.86,,,615.86,Other,324% of Medicaid,408.67,,,408.67,Other,215% of Medicaid,408.67,,,408.67,Other,215% of Medicaid,237.6,,,237.6,Other,125% of Medicaid,0.01,698.03,
REM IMPL CONTRACEP CAPS,11976,CPT,,30011976,CDM,450,RC,,,both,,,1462,1081.88,,,1081.88,Other,150% of Medicare + 9.63% HCRA Surcharge,657.9,45,,657.9,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,723.69,,,723.69,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,1241,,,1241,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1023.4,70,,1023.4,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,667.11,,,667.11,Other,100% of Medicaid,667.11,,,667.11,Other,100% of Medicaid,667.11,,,667.11,Other,100% of Medicaid,667.11,,,667.11,Other,100% of Medicaid,1501,,,1501,Other,225% of Medicaid,1020.68,,,1020.68,Other,153% of Medicaid,1501,,,1501,Other,225% of Medicaid,933.96,,,933.96,Other,140% of Medicaid,1501,,,1501,Other,225% of Medicaid,1734.49,,,1734.49,Other,260% of Medicaid,2161.44,,,2161.44,Other,324% of Medicaid,1434.29,,,1434.29,Other,215% of Medicaid,1434.29,,,1434.29,Other,215% of Medicaid,833.89,,,833.89,Other,125% of Medicaid,0.01,2161.44,
REPAIR SKIN 2.5CM OR LESS,12001,CPT,,30012001,CDM,450,RC,,,both,,,509,376.66,,,376.66,Other,150% of Medicare + 9.63% HCRA Surcharge,229.05,45,,229.05,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,251.96,,,251.96,Other,110% of Medicare,346.12,68,,346.12,percent of total billed charges,All Other,958,,,958,Other,186% of Medicaid,407.2,,,407.2,Other,Non Covered Service,422.47,,,422.47,Other,Non Covered Service,422.47,,,422.47,Other,Non Covered Service,407.2,,,407.2,Other,Non Covered Service,422.47,,,422.47,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,356.3,70,,356.3,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,514.9,,,514.9,Other,100% of Medicaid,514.9,,,514.9,Other,100% of Medicaid,514.9,,,514.9,Other,100% of Medicaid,514.9,,,514.9,Other,100% of Medicaid,1158.52,,,1158.52,Other,225% of Medicaid,787.8,,,787.8,Other,153% of Medicaid,1158.52,,,1158.52,Other,225% of Medicaid,720.86,,,720.86,Other,140% of Medicaid,1158.52,,,1158.52,Other,225% of Medicaid,1338.74,,,1338.74,Other,260% of Medicaid,1668.27,,,1668.27,Other,324% of Medicaid,1107.03,,,1107.03,Other,215% of Medicaid,1107.03,,,1107.03,Other,215% of Medicaid,643.62,,,643.62,Other,125% of Medicaid,0.01,1668.27,
REPAIR SKIN 2.6CM TO 7.5C,12002,CPT,,30012002,CDM,450,RC,,,both,,,509,376.66,,,376.66,Other,150% of Medicare + 9.63% HCRA Surcharge,229.05,45,,229.05,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,251.96,,,251.96,Other,110% of Medicare,346.12,68,,346.12,percent of total billed charges,All Other,958,,,958,Other,186% of Medicaid,407.2,,,407.2,Other,Non Covered Service,422.47,,,422.47,Other,Non Covered Service,422.47,,,422.47,Other,Non Covered Service,407.2,,,407.2,Other,Non Covered Service,422.47,,,422.47,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,356.3,70,,356.3,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,514.9,,,514.9,Other,100% of Medicaid,514.9,,,514.9,Other,100% of Medicaid,514.9,,,514.9,Other,100% of Medicaid,514.9,,,514.9,Other,100% of Medicaid,1158.52,,,1158.52,Other,225% of Medicaid,787.8,,,787.8,Other,153% of Medicaid,1158.52,,,1158.52,Other,225% of Medicaid,720.86,,,720.86,Other,140% of Medicaid,1158.52,,,1158.52,Other,225% of Medicaid,1338.74,,,1338.74,Other,260% of Medicaid,1668.27,,,1668.27,Other,324% of Medicaid,1107.03,,,1107.03,Other,215% of Medicaid,1107.03,,,1107.03,Other,215% of Medicaid,643.62,,,643.62,Other,125% of Medicaid,0.01,1668.27,
REPAIR SKIN 7.6CM TO 12.5,12004,CPT,,30012004,CDM,450,RC,,,both,,,509,376.66,,,376.66,Other,150% of Medicare + 9.63% HCRA Surcharge,229.05,45,,229.05,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,251.96,,,251.96,Other,110% of Medicare,346.12,68,,346.12,percent of total billed charges,All Other,958,,,958,Other,186% of Medicaid,407.2,,,407.2,Other,Non Covered Service,422.47,,,422.47,Other,Non Covered Service,422.47,,,422.47,Other,Non Covered Service,407.2,,,407.2,Other,Non Covered Service,422.47,,,422.47,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,356.3,70,,356.3,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,514.9,,,514.9,Other,100% of Medicaid,514.9,,,514.9,Other,100% of Medicaid,514.9,,,514.9,Other,100% of Medicaid,514.9,,,514.9,Other,100% of Medicaid,1158.52,,,1158.52,Other,225% of Medicaid,787.8,,,787.8,Other,153% of Medicaid,1158.52,,,1158.52,Other,225% of Medicaid,720.86,,,720.86,Other,140% of Medicaid,1158.52,,,1158.52,Other,225% of Medicaid,1338.74,,,1338.74,Other,260% of Medicaid,1668.27,,,1668.27,Other,324% of Medicaid,1107.03,,,1107.03,Other,215% of Medicaid,1107.03,,,1107.03,Other,215% of Medicaid,643.62,,,643.62,Other,125% of Medicaid,0.01,1668.27,
REPAIR SKIN 12.6-20.0 CM,12005,CPT,,30012005,CDM,450,RC,,,both,,,841,622.34,,,622.34,Other,150% of Medicare + 9.63% HCRA Surcharge,378.45,45,,378.45,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,416.3,,,416.3,Other,110% of Medicare,571.88,68,,571.88,percent of total billed charges,All Other,958,,,958,Other,186% of Medicaid,672.8,,,672.8,Other,Non Covered Service,698.03,,,698.03,Other,Non Covered Service,698.03,,,698.03,Other,Non Covered Service,672.8,,,672.8,Other,Non Covered Service,698.03,,,698.03,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,588.7,70,,588.7,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,514.9,,,514.9,Other,100% of Medicaid,514.9,,,514.9,Other,100% of Medicaid,514.9,,,514.9,Other,100% of Medicaid,514.9,,,514.9,Other,100% of Medicaid,1158.52,,,1158.52,Other,225% of Medicaid,787.8,,,787.8,Other,153% of Medicaid,1158.52,,,1158.52,Other,225% of Medicaid,720.86,,,720.86,Other,140% of Medicaid,1158.52,,,1158.52,Other,225% of Medicaid,1338.74,,,1338.74,Other,260% of Medicaid,1668.27,,,1668.27,Other,324% of Medicaid,1107.03,,,1107.03,Other,215% of Medicaid,1107.03,,,1107.03,Other,215% of Medicaid,643.62,,,643.62,Other,125% of Medicaid,0.01,1668.27,
REPAIR SKIN 20.1CM TO 30,12006,CPT,,30012006,CDM,450,RC,,,both,,,841,622.34,,,622.34,Other,150% of Medicare + 9.63% HCRA Surcharge,378.45,45,,378.45,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,416.3,,,416.3,Other,110% of Medicare,571.88,68,,571.88,percent of total billed charges,All Other,958,,,958,Other,186% of Medicaid,672.8,,,672.8,Other,Non Covered Service,698.03,,,698.03,Other,Non Covered Service,698.03,,,698.03,Other,Non Covered Service,672.8,,,672.8,Other,Non Covered Service,698.03,,,698.03,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,588.7,70,,588.7,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,514.9,,,514.9,Other,100% of Medicaid,514.9,,,514.9,Other,100% of Medicaid,514.9,,,514.9,Other,100% of Medicaid,514.9,,,514.9,Other,100% of Medicaid,1158.52,,,1158.52,Other,225% of Medicaid,787.8,,,787.8,Other,153% of Medicaid,1158.52,,,1158.52,Other,225% of Medicaid,720.86,,,720.86,Other,140% of Medicaid,1158.52,,,1158.52,Other,225% of Medicaid,1338.74,,,1338.74,Other,260% of Medicaid,1668.27,,,1668.27,Other,324% of Medicaid,1107.03,,,1107.03,Other,215% of Medicaid,1107.03,,,1107.03,Other,215% of Medicaid,643.62,,,643.62,Other,125% of Medicaid,0.01,1668.27,
SREP S/N/A/G/TR/E; > 30CM,12007,CPT,,30012007,CDM,450,RC,,,both,,,408,301.92,,,301.92,Other,150% of Medicare + 9.63% HCRA Surcharge,183.6,45,,183.6,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,201.96,,,201.96,Other,110% of Medicare,277.44,68,,277.44,percent of total billed charges,All Other,958,,,958,Other,186% of Medicaid,326.4,,,326.4,Other,Non Covered Service,338.64,,,338.64,Other,Non Covered Service,338.64,,,338.64,Other,Non Covered Service,326.4,,,326.4,Other,Non Covered Service,338.64,,,338.64,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,285.6,70,,285.6,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,514.9,,,514.9,Other,100% of Medicaid,514.9,,,514.9,Other,100% of Medicaid,514.9,,,514.9,Other,100% of Medicaid,514.9,,,514.9,Other,100% of Medicaid,1158.52,,,1158.52,Other,225% of Medicaid,787.8,,,787.8,Other,153% of Medicaid,1158.52,,,1158.52,Other,225% of Medicaid,720.86,,,720.86,Other,140% of Medicaid,1158.52,,,1158.52,Other,225% of Medicaid,1338.74,,,1338.74,Other,260% of Medicaid,1668.27,,,1668.27,Other,324% of Medicaid,1107.03,,,1107.03,Other,215% of Medicaid,1107.03,,,1107.03,Other,215% of Medicaid,643.62,,,643.62,Other,125% of Medicaid,0.01,1668.27,
REPAIR SKIN 2.5CM OR LESS,12011,CPT,,30012011,CDM,450,RC,,,both,,,600,444,,,444,Other,150% of Medicare + 9.63% HCRA Surcharge,270,45,,270,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,297,,,297,Other,110% of Medicare,408,68,,408,percent of total billed charges,All Other,958,,,958,Other,186% of Medicaid,480,,,480,Other,Non Covered Service,498,,,498,Other,Non Covered Service,498,,,498,Other,Non Covered Service,480,,,480,Other,Non Covered Service,498,,,498,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,420,70,,420,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,514.9,,,514.9,Other,100% of Medicaid,514.9,,,514.9,Other,100% of Medicaid,514.9,,,514.9,Other,100% of Medicaid,514.9,,,514.9,Other,100% of Medicaid,1158.52,,,1158.52,Other,225% of Medicaid,787.8,,,787.8,Other,153% of Medicaid,1158.52,,,1158.52,Other,225% of Medicaid,720.86,,,720.86,Other,140% of Medicaid,1158.52,,,1158.52,Other,225% of Medicaid,1338.74,,,1338.74,Other,260% of Medicaid,1668.27,,,1668.27,Other,324% of Medicaid,1107.03,,,1107.03,Other,215% of Medicaid,1107.03,,,1107.03,Other,215% of Medicaid,643.62,,,643.62,Other,125% of Medicaid,0.01,1668.27,
REPAIR SKIN 2.6CM TO 5.0C,12013,CPT,,30012013,CDM,450,RC,,,both,,,698,516.52,,,516.52,Other,150% of Medicare + 9.63% HCRA Surcharge,314.1,45,,314.1,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,345.51,,,345.51,Other,110% of Medicare,474.64,68,,474.64,percent of total billed charges,All Other,958,,,958,Other,186% of Medicaid,558.4,,,558.4,Other,Non Covered Service,579.34,,,579.34,Other,Non Covered Service,579.34,,,579.34,Other,Non Covered Service,558.4,,,558.4,Other,Non Covered Service,579.34,,,579.34,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,488.6,70,,488.6,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,514.9,,,514.9,Other,100% of Medicaid,514.9,,,514.9,Other,100% of Medicaid,514.9,,,514.9,Other,100% of Medicaid,514.9,,,514.9,Other,100% of Medicaid,1158.52,,,1158.52,Other,225% of Medicaid,787.8,,,787.8,Other,153% of Medicaid,1158.52,,,1158.52,Other,225% of Medicaid,720.86,,,720.86,Other,140% of Medicaid,1158.52,,,1158.52,Other,225% of Medicaid,1338.74,,,1338.74,Other,260% of Medicaid,1668.27,,,1668.27,Other,324% of Medicaid,1107.03,,,1107.03,Other,215% of Medicaid,1107.03,,,1107.03,Other,215% of Medicaid,643.62,,,643.62,Other,125% of Medicaid,0.01,1668.27,
REPAIR SKIN 5.1CM TO 7.5C,12014,CPT,,30012014,CDM,450,RC,,,both,,,509,376.66,,,376.66,Other,150% of Medicare + 9.63% HCRA Surcharge,229.05,45,,229.05,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,251.96,,,251.96,Other,110% of Medicare,346.12,68,,346.12,percent of total billed charges,All Other,958,,,958,Other,186% of Medicaid,407.2,,,407.2,Other,Non Covered Service,422.47,,,422.47,Other,Non Covered Service,422.47,,,422.47,Other,Non Covered Service,407.2,,,407.2,Other,Non Covered Service,422.47,,,422.47,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,356.3,70,,356.3,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,514.9,,,514.9,Other,100% of Medicaid,514.9,,,514.9,Other,100% of Medicaid,514.9,,,514.9,Other,100% of Medicaid,514.9,,,514.9,Other,100% of Medicaid,1158.52,,,1158.52,Other,225% of Medicaid,787.8,,,787.8,Other,153% of Medicaid,1158.52,,,1158.52,Other,225% of Medicaid,720.86,,,720.86,Other,140% of Medicaid,1158.52,,,1158.52,Other,225% of Medicaid,1338.74,,,1338.74,Other,260% of Medicaid,1668.27,,,1668.27,Other,324% of Medicaid,1107.03,,,1107.03,Other,215% of Medicaid,1107.03,,,1107.03,Other,215% of Medicaid,643.62,,,643.62,Other,125% of Medicaid,0.01,1668.27,
REPAIR SKIN F E E N L 7.6-12,12015,CPT,,30012015,CDM,450,RC,,,both,,,509,376.66,,,376.66,Other,150% of Medicare + 9.63% HCRA Surcharge,229.05,45,,229.05,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,251.96,,,251.96,Other,110% of Medicare,346.12,68,,346.12,percent of total billed charges,All Other,958,,,958,Other,186% of Medicaid,407.2,,,407.2,Other,Non Covered Service,422.47,,,422.47,Other,Non Covered Service,422.47,,,422.47,Other,Non Covered Service,407.2,,,407.2,Other,Non Covered Service,422.47,,,422.47,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,356.3,70,,356.3,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,514.9,,,514.9,Other,100% of Medicaid,514.9,,,514.9,Other,100% of Medicaid,514.9,,,514.9,Other,100% of Medicaid,514.9,,,514.9,Other,100% of Medicaid,1158.52,,,1158.52,Other,225% of Medicaid,787.8,,,787.8,Other,153% of Medicaid,1158.52,,,1158.52,Other,225% of Medicaid,720.86,,,720.86,Other,140% of Medicaid,1158.52,,,1158.52,Other,225% of Medicaid,1338.74,,,1338.74,Other,260% of Medicaid,1668.27,,,1668.27,Other,324% of Medicaid,1107.03,,,1107.03,Other,215% of Medicaid,1107.03,,,1107.03,Other,215% of Medicaid,643.62,,,643.62,Other,125% of Medicaid,0.01,1668.27,
SREP F E N L MM 12.6-20C,12016,CPT,,30012016,CDM,450,RC,,,both,,,841,622.34,,,622.34,Other,150% of Medicare + 9.63% HCRA Surcharge,378.45,45,,378.45,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,416.3,,,416.3,Other,110% of Medicare,571.88,68,,571.88,percent of total billed charges,All Other,958,,,958,Other,186% of Medicaid,672.8,,,672.8,Other,Non Covered Service,698.03,,,698.03,Other,Non Covered Service,698.03,,,698.03,Other,Non Covered Service,672.8,,,672.8,Other,Non Covered Service,698.03,,,698.03,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,588.7,70,,588.7,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,514.9,,,514.9,Other,100% of Medicaid,514.9,,,514.9,Other,100% of Medicaid,514.9,,,514.9,Other,100% of Medicaid,514.9,,,514.9,Other,100% of Medicaid,1158.52,,,1158.52,Other,225% of Medicaid,787.8,,,787.8,Other,153% of Medicaid,1158.52,,,1158.52,Other,225% of Medicaid,720.86,,,720.86,Other,140% of Medicaid,1158.52,,,1158.52,Other,225% of Medicaid,1338.74,,,1338.74,Other,260% of Medicaid,1668.27,,,1668.27,Other,324% of Medicaid,1107.03,,,1107.03,Other,215% of Medicaid,1107.03,,,1107.03,Other,215% of Medicaid,643.62,,,643.62,Other,125% of Medicaid,0.01,1668.27,
REPAIR SKIN F E E N L 20.1-3,12017,CPT,,30012017,CDM,450,RC,,,both,,,841,622.34,,,622.34,Other,150% of Medicare + 9.63% HCRA Surcharge,378.45,45,,378.45,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,416.3,,,416.3,Other,110% of Medicare,571.88,68,,571.88,percent of total billed charges,All Other,958,,,958,Other,186% of Medicaid,672.8,,,672.8,Other,Non Covered Service,698.03,,,698.03,Other,Non Covered Service,698.03,,,698.03,Other,Non Covered Service,672.8,,,672.8,Other,Non Covered Service,698.03,,,698.03,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,588.7,70,,588.7,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,514.9,,,514.9,Other,100% of Medicaid,514.9,,,514.9,Other,100% of Medicaid,514.9,,,514.9,Other,100% of Medicaid,514.9,,,514.9,Other,100% of Medicaid,1158.52,,,1158.52,Other,225% of Medicaid,787.8,,,787.8,Other,153% of Medicaid,1158.52,,,1158.52,Other,225% of Medicaid,720.86,,,720.86,Other,140% of Medicaid,1158.52,,,1158.52,Other,225% of Medicaid,1338.74,,,1338.74,Other,260% of Medicaid,1668.27,,,1668.27,Other,324% of Medicaid,1107.03,,,1107.03,Other,215% of Medicaid,1107.03,,,1107.03,Other,215% of Medicaid,643.62,,,643.62,Other,125% of Medicaid,0.01,1668.27,
REPAIR SKIN F E E N L OVER 3,12018,CPT,,30012018,CDM,450,RC,,,both,,,437,323.38,,,323.38,Other,150% of Medicare + 9.63% HCRA Surcharge,196.65,45,,196.65,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,216.32,,,216.32,Other,110% of Medicare,297.16,68,,297.16,percent of total billed charges,All Other,958,,,958,Other,186% of Medicaid,349.6,,,349.6,Other,Non Covered Service,362.71,,,362.71,Other,Non Covered Service,362.71,,,362.71,Other,Non Covered Service,349.6,,,349.6,Other,Non Covered Service,362.71,,,362.71,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,305.9,70,,305.9,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,514.9,,,514.9,Other,100% of Medicaid,514.9,,,514.9,Other,100% of Medicaid,514.9,,,514.9,Other,100% of Medicaid,514.9,,,514.9,Other,100% of Medicaid,1158.52,,,1158.52,Other,225% of Medicaid,787.8,,,787.8,Other,153% of Medicaid,1158.52,,,1158.52,Other,225% of Medicaid,720.86,,,720.86,Other,140% of Medicaid,1158.52,,,1158.52,Other,225% of Medicaid,1338.74,,,1338.74,Other,260% of Medicaid,1668.27,,,1668.27,Other,324% of Medicaid,1107.03,,,1107.03,Other,215% of Medicaid,1107.03,,,1107.03,Other,215% of Medicaid,643.62,,,643.62,Other,125% of Medicaid,0.01,1668.27,
TX S WND DEHICS SMPL,12020,CPT,,30012020,CDM,450,RC,,,both,,,1653,1223.22,,,1223.22,Other,150% of Medicare + 9.63% HCRA Surcharge,743.85,45,,743.85,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,818.24,,,818.24,Other,110% of Medicare,1124.04,68,,1124.04,percent of total billed charges,All Other,1353,,,1353,Other,186% of Medicaid,1322.4,,,1322.4,Other,Non Covered Service,1371.99,,,1371.99,Other,Non Covered Service,1371.99,,,1371.99,Other,Non Covered Service,1322.4,,,1322.4,Other,Non Covered Service,1371.99,,,1371.99,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1157.1,70,,1157.1,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,727.17,,,727.17,Other,100% of Medicaid,727.17,,,727.17,Other,100% of Medicaid,727.17,,,727.17,Other,100% of Medicaid,727.17,,,727.17,Other,100% of Medicaid,1636.12,,,1636.12,Other,225% of Medicaid,1112.56,,,1112.56,Other,153% of Medicaid,1636.12,,,1636.12,Other,225% of Medicaid,1018.03,,,1018.03,Other,140% of Medicaid,1636.12,,,1636.12,Other,225% of Medicaid,1890.63,,,1890.63,Other,260% of Medicaid,2356.02,,,2356.02,Other,324% of Medicaid,1563.41,,,1563.41,Other,215% of Medicaid,1563.41,,,1563.41,Other,215% of Medicaid,908.96,,,908.96,Other,125% of Medicaid,0.01,2356.02,
CLOSURE OF SPLIT WOUND,12021,CPT,,30012021,CDM,450,RC,,,both,,,1125,832.5,,,832.5,Other,150% of Medicare + 9.63% HCRA Surcharge,506.25,45,,506.25,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,556.88,,,556.88,Other,110% of Medicare,765,68,,765,percent of total billed charges,All Other,1353,,,1353,Other,186% of Medicaid,900,,,900,Other,Non Covered Service,933.75,,,933.75,Other,Non Covered Service,933.75,,,933.75,Other,Non Covered Service,900,,,900,Other,Non Covered Service,933.75,,,933.75,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,787.5,70,,787.5,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,727.17,,,727.17,Other,100% of Medicaid,727.17,,,727.17,Other,100% of Medicaid,727.17,,,727.17,Other,100% of Medicaid,727.17,,,727.17,Other,100% of Medicaid,1636.12,,,1636.12,Other,225% of Medicaid,1112.56,,,1112.56,Other,153% of Medicaid,1636.12,,,1636.12,Other,225% of Medicaid,1018.03,,,1018.03,Other,140% of Medicaid,1636.12,,,1636.12,Other,225% of Medicaid,1890.63,,,1890.63,Other,260% of Medicaid,2356.02,,,2356.02,Other,324% of Medicaid,1563.41,,,1563.41,Other,215% of Medicaid,1563.41,,,1563.41,Other,215% of Medicaid,908.96,,,908.96,Other,125% of Medicaid,0.01,2356.02,
REPAIR INTER SKIN 2.5 OR,12031,CPT,,30012031,CDM,450,RC,,,both,,,841,622.34,,,622.34,Other,150% of Medicare + 9.63% HCRA Surcharge,378.45,45,,378.45,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,416.3,,,416.3,Other,110% of Medicare,571.88,68,,571.88,percent of total billed charges,All Other,1353,,,1353,Other,186% of Medicaid,672.8,,,672.8,Other,Non Covered Service,698.03,,,698.03,Other,Non Covered Service,698.03,,,698.03,Other,Non Covered Service,672.8,,,672.8,Other,Non Covered Service,698.03,,,698.03,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,588.7,70,,588.7,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,727.17,,,727.17,Other,100% of Medicaid,727.17,,,727.17,Other,100% of Medicaid,727.17,,,727.17,Other,100% of Medicaid,727.17,,,727.17,Other,100% of Medicaid,1636.12,,,1636.12,Other,225% of Medicaid,1112.56,,,1112.56,Other,153% of Medicaid,1636.12,,,1636.12,Other,225% of Medicaid,1018.03,,,1018.03,Other,140% of Medicaid,1636.12,,,1636.12,Other,225% of Medicaid,1890.63,,,1890.63,Other,260% of Medicaid,2356.02,,,2356.02,Other,324% of Medicaid,1563.41,,,1563.41,Other,215% of Medicaid,1563.41,,,1563.41,Other,215% of Medicaid,908.96,,,908.96,Other,125% of Medicaid,0.01,2356.02,
REPAIR INTER SKIN 2.6 TO 7.0,12032,CPT,,30012032,CDM,450,RC,,,both,,,1204,890.96,,,890.96,Other,150% of Medicare + 9.63% HCRA Surcharge,541.8,45,,541.8,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,595.98,,,595.98,Other,110% of Medicare,818.72,68,,818.72,percent of total billed charges,All Other,1353,,,1353,Other,186% of Medicaid,963.2,,,963.2,Other,Non Covered Service,999.32,,,999.32,Other,Non Covered Service,999.32,,,999.32,Other,Non Covered Service,963.2,,,963.2,Other,Non Covered Service,999.32,,,999.32,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,842.8,70,,842.8,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,727.17,,,727.17,Other,100% of Medicaid,727.17,,,727.17,Other,100% of Medicaid,727.17,,,727.17,Other,100% of Medicaid,727.17,,,727.17,Other,100% of Medicaid,1636.12,,,1636.12,Other,225% of Medicaid,1112.56,,,1112.56,Other,153% of Medicaid,1636.12,,,1636.12,Other,225% of Medicaid,1018.03,,,1018.03,Other,140% of Medicaid,1636.12,,,1636.12,Other,225% of Medicaid,1890.63,,,1890.63,Other,260% of Medicaid,2356.02,,,2356.02,Other,324% of Medicaid,1563.41,,,1563.41,Other,215% of Medicaid,1563.41,,,1563.41,Other,215% of Medicaid,908.96,,,908.96,Other,125% of Medicaid,0.01,2356.02,
REPAIR INTER SKIN 7.6-12.0,12034,CPT,,30012034,CDM,450,RC,,,both,,,841,622.34,,,622.34,Other,150% of Medicare + 9.63% HCRA Surcharge,378.45,45,,378.45,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,416.3,,,416.3,Other,110% of Medicare,571.88,68,,571.88,percent of total billed charges,All Other,1353,,,1353,Other,186% of Medicaid,672.8,,,672.8,Other,Non Covered Service,698.03,,,698.03,Other,Non Covered Service,698.03,,,698.03,Other,Non Covered Service,672.8,,,672.8,Other,Non Covered Service,698.03,,,698.03,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,588.7,70,,588.7,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,727.17,,,727.17,Other,100% of Medicaid,727.17,,,727.17,Other,100% of Medicaid,727.17,,,727.17,Other,100% of Medicaid,727.17,,,727.17,Other,100% of Medicaid,1636.12,,,1636.12,Other,225% of Medicaid,1112.56,,,1112.56,Other,153% of Medicaid,1636.12,,,1636.12,Other,225% of Medicaid,1018.03,,,1018.03,Other,140% of Medicaid,1636.12,,,1636.12,Other,225% of Medicaid,1890.63,,,1890.63,Other,260% of Medicaid,2356.02,,,2356.02,Other,324% of Medicaid,1563.41,,,1563.41,Other,215% of Medicaid,1563.41,,,1563.41,Other,215% of Medicaid,908.96,,,908.96,Other,125% of Medicaid,0.01,2356.02,
INT REP S/A/EX 12.6-20.OC,12035,CPT,,30012035,CDM,450,RC,,,both,,,1048,775.52,,,775.52,Other,150% of Medicare + 9.63% HCRA Surcharge,471.6,45,,471.6,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,518.76,,,518.76,Other,110% of Medicare,712.64,68,,712.64,percent of total billed charges,All Other,1353,,,1353,Other,186% of Medicaid,838.4,,,838.4,Other,Non Covered Service,869.84,,,869.84,Other,Non Covered Service,869.84,,,869.84,Other,Non Covered Service,838.4,,,838.4,Other,Non Covered Service,869.84,,,869.84,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,733.6,70,,733.6,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,727.17,,,727.17,Other,100% of Medicaid,727.17,,,727.17,Other,100% of Medicaid,727.17,,,727.17,Other,100% of Medicaid,727.17,,,727.17,Other,100% of Medicaid,1636.12,,,1636.12,Other,225% of Medicaid,1112.56,,,1112.56,Other,153% of Medicaid,1636.12,,,1636.12,Other,225% of Medicaid,1018.03,,,1018.03,Other,140% of Medicaid,1636.12,,,1636.12,Other,225% of Medicaid,1890.63,,,1890.63,Other,260% of Medicaid,2356.02,,,2356.02,Other,324% of Medicaid,1563.41,,,1563.41,Other,215% of Medicaid,1563.41,,,1563.41,Other,215% of Medicaid,908.96,,,908.96,Other,125% of Medicaid,0.01,2356.02,
REPAIR INTER SKIN 20.1 - 30,12036,CPT,,30012036,CDM,450,RC,,,both,,,1309,968.66,,,968.66,Other,150% of Medicare + 9.63% HCRA Surcharge,589.05,45,,589.05,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,647.96,,,647.96,Other,110% of Medicare,890.12,68,,890.12,percent of total billed charges,All Other,1353,,,1353,Other,186% of Medicaid,1047.2,,,1047.2,Other,Non Covered Service,1086.47,,,1086.47,Other,Non Covered Service,1086.47,,,1086.47,Other,Non Covered Service,1047.2,,,1047.2,Other,Non Covered Service,1086.47,,,1086.47,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,916.3,70,,916.3,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,727.17,,,727.17,Other,100% of Medicaid,727.17,,,727.17,Other,100% of Medicaid,727.17,,,727.17,Other,100% of Medicaid,727.17,,,727.17,Other,100% of Medicaid,1636.12,,,1636.12,Other,225% of Medicaid,1112.56,,,1112.56,Other,153% of Medicaid,1636.12,,,1636.12,Other,225% of Medicaid,1018.03,,,1018.03,Other,140% of Medicaid,1636.12,,,1636.12,Other,225% of Medicaid,1890.63,,,1890.63,Other,260% of Medicaid,2356.02,,,2356.02,Other,324% of Medicaid,1563.41,,,1563.41,Other,215% of Medicaid,1563.41,,,1563.41,Other,215% of Medicaid,908.96,,,908.96,Other,125% of Medicaid,0.01,2356.02,
REPAIR INTER SKIN OVER 30,12037,CPT,,30012037,CDM,450,RC,,,both,,,3886,2875.65,,,2875.65,Other,150% of Medicare + 9.63% HCRA Surcharge,1748.7,45,,1748.7,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1923.57,,,1923.57,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,1353,,,1353,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2720.2,70,,2720.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,727.17,,,727.17,Other,100% of Medicaid,727.17,,,727.17,Other,100% of Medicaid,727.17,,,727.17,Other,100% of Medicaid,727.17,,,727.17,Other,100% of Medicaid,1636.12,,,1636.12,Other,225% of Medicaid,1112.56,,,1112.56,Other,153% of Medicaid,1636.12,,,1636.12,Other,225% of Medicaid,1018.03,,,1018.03,Other,140% of Medicaid,1636.12,,,1636.12,Other,225% of Medicaid,1890.63,,,1890.63,Other,260% of Medicaid,2356.02,,,2356.02,Other,324% of Medicaid,1563.41,,,1563.41,Other,215% of Medicaid,1563.41,,,1563.41,Other,215% of Medicaid,908.96,,,908.96,Other,125% of Medicaid,0.01,2875.65,
CLOSURE WOUND 2.5 CM OR LESS,12041,CPT,,30012041,CDM,450,RC,,,both,,,841,622.34,,,622.34,Other,150% of Medicare + 9.63% HCRA Surcharge,378.45,45,,378.45,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,416.3,,,416.3,Other,110% of Medicare,571.88,68,,571.88,percent of total billed charges,All Other,1353,,,1353,Other,186% of Medicaid,672.8,,,672.8,Other,Non Covered Service,698.03,,,698.03,Other,Non Covered Service,698.03,,,698.03,Other,Non Covered Service,672.8,,,672.8,Other,Non Covered Service,698.03,,,698.03,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,588.7,70,,588.7,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,727.17,,,727.17,Other,100% of Medicaid,727.17,,,727.17,Other,100% of Medicaid,727.17,,,727.17,Other,100% of Medicaid,727.17,,,727.17,Other,100% of Medicaid,1636.12,,,1636.12,Other,225% of Medicaid,1112.56,,,1112.56,Other,153% of Medicaid,1636.12,,,1636.12,Other,225% of Medicaid,1018.03,,,1018.03,Other,140% of Medicaid,1636.12,,,1636.12,Other,225% of Medicaid,1890.63,,,1890.63,Other,260% of Medicaid,2356.02,,,2356.02,Other,324% of Medicaid,1563.41,,,1563.41,Other,215% of Medicaid,1563.41,,,1563.41,Other,215% of Medicaid,908.96,,,908.96,Other,125% of Medicaid,0.01,2356.02,
CLOSURE WOUND 2.6 CM TO 7.0,12042,CPT,,30012042,CDM,450,RC,,,both,,,841,622.34,,,622.34,Other,150% of Medicare + 9.63% HCRA Surcharge,378.45,45,,378.45,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,416.3,,,416.3,Other,110% of Medicare,571.88,68,,571.88,percent of total billed charges,All Other,1353,,,1353,Other,186% of Medicaid,672.8,,,672.8,Other,Non Covered Service,698.03,,,698.03,Other,Non Covered Service,698.03,,,698.03,Other,Non Covered Service,672.8,,,672.8,Other,Non Covered Service,698.03,,,698.03,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,588.7,70,,588.7,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,727.17,,,727.17,Other,100% of Medicaid,727.17,,,727.17,Other,100% of Medicaid,727.17,,,727.17,Other,100% of Medicaid,727.17,,,727.17,Other,100% of Medicaid,1636.12,,,1636.12,Other,225% of Medicaid,1112.56,,,1112.56,Other,153% of Medicaid,1636.12,,,1636.12,Other,225% of Medicaid,1018.03,,,1018.03,Other,140% of Medicaid,1636.12,,,1636.12,Other,225% of Medicaid,1890.63,,,1890.63,Other,260% of Medicaid,2356.02,,,2356.02,Other,324% of Medicaid,1563.41,,,1563.41,Other,215% of Medicaid,1563.41,,,1563.41,Other,215% of Medicaid,908.96,,,908.96,Other,125% of Medicaid,0.01,2356.02,
CLOSURE WOUND 7.6CM TO 12,12044,CPT,,30012044,CDM,450,RC,,,both,,,1309,968.66,,,968.66,Other,150% of Medicare + 9.63% HCRA Surcharge,589.05,45,,589.05,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,647.96,,,647.96,Other,110% of Medicare,890.12,68,,890.12,percent of total billed charges,All Other,1353,,,1353,Other,186% of Medicaid,1047.2,,,1047.2,Other,Non Covered Service,1086.47,,,1086.47,Other,Non Covered Service,1086.47,,,1086.47,Other,Non Covered Service,1047.2,,,1047.2,Other,Non Covered Service,1086.47,,,1086.47,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,916.3,70,,916.3,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,727.17,,,727.17,Other,100% of Medicaid,727.17,,,727.17,Other,100% of Medicaid,727.17,,,727.17,Other,100% of Medicaid,727.17,,,727.17,Other,100% of Medicaid,1636.12,,,1636.12,Other,225% of Medicaid,1112.56,,,1112.56,Other,153% of Medicaid,1636.12,,,1636.12,Other,225% of Medicaid,1018.03,,,1018.03,Other,140% of Medicaid,1636.12,,,1636.12,Other,225% of Medicaid,1890.63,,,1890.63,Other,260% of Medicaid,2356.02,,,2356.02,Other,324% of Medicaid,1563.41,,,1563.41,Other,215% of Medicaid,1563.41,,,1563.41,Other,215% of Medicaid,908.96,,,908.96,Other,125% of Medicaid,0.01,2356.02,
CLOSURE WOUND 12.6 CM - 20.0,12045,CPT,,30012045,CDM,450,RC,,,both,,,1309,968.66,,,968.66,Other,150% of Medicare + 9.63% HCRA Surcharge,589.05,45,,589.05,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,647.96,,,647.96,Other,110% of Medicare,890.12,68,,890.12,percent of total billed charges,All Other,1353,,,1353,Other,186% of Medicaid,1047.2,,,1047.2,Other,Non Covered Service,1086.47,,,1086.47,Other,Non Covered Service,1086.47,,,1086.47,Other,Non Covered Service,1047.2,,,1047.2,Other,Non Covered Service,1086.47,,,1086.47,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,916.3,70,,916.3,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,727.17,,,727.17,Other,100% of Medicaid,727.17,,,727.17,Other,100% of Medicaid,727.17,,,727.17,Other,100% of Medicaid,727.17,,,727.17,Other,100% of Medicaid,1636.12,,,1636.12,Other,225% of Medicaid,1112.56,,,1112.56,Other,153% of Medicaid,1636.12,,,1636.12,Other,225% of Medicaid,1018.03,,,1018.03,Other,140% of Medicaid,1636.12,,,1636.12,Other,225% of Medicaid,1890.63,,,1890.63,Other,260% of Medicaid,2356.02,,,2356.02,Other,324% of Medicaid,1563.41,,,1563.41,Other,215% of Medicaid,1563.41,,,1563.41,Other,215% of Medicaid,908.96,,,908.96,Other,125% of Medicaid,0.01,2356.02,
CLOSURE WOUND 20.1CM TO 30,12046,CPT,,30012046,CDM,450,RC,,,both,,,1309,968.66,,,968.66,Other,150% of Medicare + 9.63% HCRA Surcharge,589.05,45,,589.05,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,647.96,,,647.96,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,1353,,,1353,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,916.3,70,,916.3,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,727.17,,,727.17,Other,100% of Medicaid,727.17,,,727.17,Other,100% of Medicaid,727.17,,,727.17,Other,100% of Medicaid,727.17,,,727.17,Other,100% of Medicaid,1636.12,,,1636.12,Other,225% of Medicaid,1112.56,,,1112.56,Other,153% of Medicaid,1636.12,,,1636.12,Other,225% of Medicaid,1018.03,,,1018.03,Other,140% of Medicaid,1636.12,,,1636.12,Other,225% of Medicaid,1890.63,,,1890.63,Other,260% of Medicaid,2356.02,,,2356.02,Other,324% of Medicaid,1563.41,,,1563.41,Other,215% of Medicaid,1563.41,,,1563.41,Other,215% of Medicaid,908.96,,,908.96,Other,125% of Medicaid,0.01,2356.02,
CLOSURE WOUND OVER 30.0 C,12047,CPT,,30012047,CDM,450,RC,,,both,,,3886,2875.65,,,2875.65,Other,150% of Medicare + 9.63% HCRA Surcharge,1748.7,45,,1748.7,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1923.57,,,1923.57,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,1353,,,1353,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2720.2,70,,2720.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,727.17,,,727.17,Other,100% of Medicaid,727.17,,,727.17,Other,100% of Medicaid,727.17,,,727.17,Other,100% of Medicaid,727.17,,,727.17,Other,100% of Medicaid,1636.12,,,1636.12,Other,225% of Medicaid,1112.56,,,1112.56,Other,153% of Medicaid,1636.12,,,1636.12,Other,225% of Medicaid,1018.03,,,1018.03,Other,140% of Medicaid,1636.12,,,1636.12,Other,225% of Medicaid,1890.63,,,1890.63,Other,260% of Medicaid,2356.02,,,2356.02,Other,324% of Medicaid,1563.41,,,1563.41,Other,215% of Medicaid,1563.41,,,1563.41,Other,215% of Medicaid,908.96,,,908.96,Other,125% of Medicaid,0.01,2875.65,
REPAIR INTER 2.5CM OR LESS,12051,CPT,,30012051,CDM,450,RC,,,both,,,1204,890.96,,,890.96,Other,150% of Medicare + 9.63% HCRA Surcharge,541.8,45,,541.8,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,595.98,,,595.98,Other,110% of Medicare,818.72,68,,818.72,percent of total billed charges,All Other,1353,,,1353,Other,186% of Medicaid,963.2,,,963.2,Other,Non Covered Service,999.32,,,999.32,Other,Non Covered Service,999.32,,,999.32,Other,Non Covered Service,963.2,,,963.2,Other,Non Covered Service,999.32,,,999.32,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,842.8,70,,842.8,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,727.17,,,727.17,Other,100% of Medicaid,727.17,,,727.17,Other,100% of Medicaid,727.17,,,727.17,Other,100% of Medicaid,727.17,,,727.17,Other,100% of Medicaid,1636.12,,,1636.12,Other,225% of Medicaid,1112.56,,,1112.56,Other,153% of Medicaid,1636.12,,,1636.12,Other,225% of Medicaid,1018.03,,,1018.03,Other,140% of Medicaid,1636.12,,,1636.12,Other,225% of Medicaid,1890.63,,,1890.63,Other,260% of Medicaid,2356.02,,,2356.02,Other,324% of Medicaid,1563.41,,,1563.41,Other,215% of Medicaid,1563.41,,,1563.41,Other,215% of Medicaid,908.96,,,908.96,Other,125% of Medicaid,0.01,2356.02,
REPAIR INTER 2.6 - 5 CM,12052,CPT,,30012052,CDM,450,RC,,,both,,,841,622.34,,,622.34,Other,150% of Medicare + 9.63% HCRA Surcharge,378.45,45,,378.45,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,416.3,,,416.3,Other,110% of Medicare,571.88,68,,571.88,percent of total billed charges,All Other,1353,,,1353,Other,186% of Medicaid,672.8,,,672.8,Other,Non Covered Service,698.03,,,698.03,Other,Non Covered Service,698.03,,,698.03,Other,Non Covered Service,672.8,,,672.8,Other,Non Covered Service,698.03,,,698.03,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,588.7,70,,588.7,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,727.17,,,727.17,Other,100% of Medicaid,727.17,,,727.17,Other,100% of Medicaid,727.17,,,727.17,Other,100% of Medicaid,727.17,,,727.17,Other,100% of Medicaid,1636.12,,,1636.12,Other,225% of Medicaid,1112.56,,,1112.56,Other,153% of Medicaid,1636.12,,,1636.12,Other,225% of Medicaid,1018.03,,,1018.03,Other,140% of Medicaid,1636.12,,,1636.12,Other,225% of Medicaid,1890.63,,,1890.63,Other,260% of Medicaid,2356.02,,,2356.02,Other,324% of Medicaid,1563.41,,,1563.41,Other,215% of Medicaid,1563.41,,,1563.41,Other,215% of Medicaid,908.96,,,908.96,Other,125% of Medicaid,0.01,2356.02,
REPAIR INTER 5 1 TO 7.5 CM,12053,CPT,,30012053,CDM,450,RC,,,both,,,841,622.34,,,622.34,Other,150% of Medicare + 9.63% HCRA Surcharge,378.45,45,,378.45,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,416.3,,,416.3,Other,110% of Medicare,571.88,68,,571.88,percent of total billed charges,All Other,1353,,,1353,Other,186% of Medicaid,672.8,,,672.8,Other,Non Covered Service,698.03,,,698.03,Other,Non Covered Service,698.03,,,698.03,Other,Non Covered Service,672.8,,,672.8,Other,Non Covered Service,698.03,,,698.03,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,588.7,70,,588.7,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,727.17,,,727.17,Other,100% of Medicaid,727.17,,,727.17,Other,100% of Medicaid,727.17,,,727.17,Other,100% of Medicaid,727.17,,,727.17,Other,100% of Medicaid,1636.12,,,1636.12,Other,225% of Medicaid,1112.56,,,1112.56,Other,153% of Medicaid,1636.12,,,1636.12,Other,225% of Medicaid,1018.03,,,1018.03,Other,140% of Medicaid,1636.12,,,1636.12,Other,225% of Medicaid,1890.63,,,1890.63,Other,260% of Medicaid,2356.02,,,2356.02,Other,324% of Medicaid,1563.41,,,1563.41,Other,215% of Medicaid,1563.41,,,1563.41,Other,215% of Medicaid,908.96,,,908.96,Other,125% of Medicaid,0.01,2356.02,
CLS WND F E E N L 7.6-12,12054,CPT,,30012054,CDM,450,RC,,,both,,,841,622.34,,,622.34,Other,150% of Medicare + 9.63% HCRA Surcharge,378.45,45,,378.45,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,416.3,,,416.3,Other,110% of Medicare,571.88,68,,571.88,percent of total billed charges,All Other,1353,,,1353,Other,186% of Medicaid,672.8,,,672.8,Other,Non Covered Service,698.03,,,698.03,Other,Non Covered Service,698.03,,,698.03,Other,Non Covered Service,672.8,,,672.8,Other,Non Covered Service,698.03,,,698.03,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,588.7,70,,588.7,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,727.17,,,727.17,Other,100% of Medicaid,727.17,,,727.17,Other,100% of Medicaid,727.17,,,727.17,Other,100% of Medicaid,727.17,,,727.17,Other,100% of Medicaid,1636.12,,,1636.12,Other,225% of Medicaid,1112.56,,,1112.56,Other,153% of Medicaid,1636.12,,,1636.12,Other,225% of Medicaid,1018.03,,,1018.03,Other,140% of Medicaid,1636.12,,,1636.12,Other,225% of Medicaid,1890.63,,,1890.63,Other,260% of Medicaid,2356.02,,,2356.02,Other,324% of Medicaid,1563.41,,,1563.41,Other,215% of Medicaid,1563.41,,,1563.41,Other,215% of Medicaid,908.96,,,908.96,Other,125% of Medicaid,0.01,2356.02,
CLS WND F E E N L 12.6-20,12055,CPT,,30012055,CDM,450,RC,,,both,,,2356,1743.45,,,1743.45,Other,150% of Medicare + 9.63% HCRA Surcharge,1060.2,45,,1060.2,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1166.22,,,1166.22,Other,110% of Medicare,1602.08,68,,1602.08,percent of total billed charges,All Other,1353,,,1353,Other,186% of Medicaid,1884.8,,,1884.8,Other,Non Covered Service,1955.48,,,1955.48,Other,Non Covered Service,1955.48,,,1955.48,Other,Non Covered Service,1884.8,,,1884.8,Other,Non Covered Service,1955.48,,,1955.48,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1649.2,70,,1649.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,727.17,,,727.17,Other,100% of Medicaid,727.17,,,727.17,Other,100% of Medicaid,727.17,,,727.17,Other,100% of Medicaid,727.17,,,727.17,Other,100% of Medicaid,1636.12,,,1636.12,Other,225% of Medicaid,1112.56,,,1112.56,Other,153% of Medicaid,1636.12,,,1636.12,Other,225% of Medicaid,1018.03,,,1018.03,Other,140% of Medicaid,1636.12,,,1636.12,Other,225% of Medicaid,1890.63,,,1890.63,Other,260% of Medicaid,2356.02,,,2356.02,Other,324% of Medicaid,1563.41,,,1563.41,Other,215% of Medicaid,1563.41,,,1563.41,Other,215% of Medicaid,908.96,,,908.96,Other,125% of Medicaid,0.01,2356.02,
CLS WND F E E N L 20.1-30,12056,CPT,,30012056,CDM,450,RC,,,both,,,3200,2368.01,,,2368.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1440,45,,1440,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1584,,,1584,Other,110% of Medicare,2176,68,,2176,percent of total billed charges,All Other,1353,,,1353,Other,186% of Medicaid,2560,,,2560,Other,Non Covered Service,2656,,,2656,Other,Non Covered Service,2656,,,2656,Other,Non Covered Service,2560,,,2560,Other,Non Covered Service,2656,,,2656,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2240,70,,2240,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,727.17,,,727.17,Other,100% of Medicaid,727.17,,,727.17,Other,100% of Medicaid,727.17,,,727.17,Other,100% of Medicaid,727.17,,,727.17,Other,100% of Medicaid,1636.12,,,1636.12,Other,225% of Medicaid,1112.56,,,1112.56,Other,153% of Medicaid,1636.12,,,1636.12,Other,225% of Medicaid,1018.03,,,1018.03,Other,140% of Medicaid,1636.12,,,1636.12,Other,225% of Medicaid,1890.63,,,1890.63,Other,260% of Medicaid,2356.02,,,2356.02,Other,324% of Medicaid,1563.41,,,1563.41,Other,215% of Medicaid,1563.41,,,1563.41,Other,215% of Medicaid,908.96,,,908.96,Other,125% of Medicaid,0.01,2656,
CLS WND F E E N L OVER 30,12057,CPT,,30012057,CDM,450,RC,,,both,,,1033,764.42,,,764.42,Other,150% of Medicare + 9.63% HCRA Surcharge,464.85,45,,464.85,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,511.34,,,511.34,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,1353,,,1353,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,723.1,70,,723.1,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,727.17,,,727.17,Other,100% of Medicaid,727.17,,,727.17,Other,100% of Medicaid,727.17,,,727.17,Other,100% of Medicaid,727.17,,,727.17,Other,100% of Medicaid,1636.12,,,1636.12,Other,225% of Medicaid,1112.56,,,1112.56,Other,153% of Medicaid,1636.12,,,1636.12,Other,225% of Medicaid,1018.03,,,1018.03,Other,140% of Medicaid,1636.12,,,1636.12,Other,225% of Medicaid,1890.63,,,1890.63,Other,260% of Medicaid,2356.02,,,2356.02,Other,324% of Medicaid,1563.41,,,1563.41,Other,215% of Medicaid,1563.41,,,1563.41,Other,215% of Medicaid,908.96,,,908.96,Other,125% of Medicaid,0.01,2356.02,
REPAIR COMPLEX TRUNK 1.1,13100,CPT,,30013100,CDM,450,RC,,,both,,,1517,1122.58,,,1122.58,Other,150% of Medicare + 9.63% HCRA Surcharge,682.65,45,,682.65,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,750.92,,,750.92,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,1241,,,1241,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1061.9,70,,1061.9,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,667.11,,,667.11,Other,100% of Medicaid,667.11,,,667.11,Other,100% of Medicaid,667.11,,,667.11,Other,100% of Medicaid,667.11,,,667.11,Other,100% of Medicaid,1501,,,1501,Other,225% of Medicaid,1020.68,,,1020.68,Other,153% of Medicaid,1501,,,1501,Other,225% of Medicaid,933.96,,,933.96,Other,140% of Medicaid,1501,,,1501,Other,225% of Medicaid,1734.49,,,1734.49,Other,260% of Medicaid,2161.44,,,2161.44,Other,324% of Medicaid,1434.29,,,1434.29,Other,215% of Medicaid,1434.29,,,1434.29,Other,215% of Medicaid,833.89,,,833.89,Other,125% of Medicaid,0.01,2161.44,
REPAIR COMPLEX TRUNK 2.6 - 7,13101,CPT,,30013101,CDM,450,RC,,,both,,,1517,1122.58,,,1122.58,Other,150% of Medicare + 9.63% HCRA Surcharge,682.65,45,,682.65,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,750.92,,,750.92,Other,110% of Medicare,1031.56,68,,1031.56,percent of total billed charges,All Other,1241,,,1241,Other,186% of Medicaid,1213.6,,,1213.6,Other,Non Covered Service,1259.11,,,1259.11,Other,Non Covered Service,1259.11,,,1259.11,Other,Non Covered Service,1213.6,,,1213.6,Other,Non Covered Service,1259.11,,,1259.11,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1061.9,70,,1061.9,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,667.11,,,667.11,Other,100% of Medicaid,667.11,,,667.11,Other,100% of Medicaid,667.11,,,667.11,Other,100% of Medicaid,667.11,,,667.11,Other,100% of Medicaid,1501,,,1501,Other,225% of Medicaid,1020.68,,,1020.68,Other,153% of Medicaid,1501,,,1501,Other,225% of Medicaid,933.96,,,933.96,Other,140% of Medicaid,1501,,,1501,Other,225% of Medicaid,1734.49,,,1734.49,Other,260% of Medicaid,2161.44,,,2161.44,Other,324% of Medicaid,1434.29,,,1434.29,Other,215% of Medicaid,1434.29,,,1434.29,Other,215% of Medicaid,833.89,,,833.89,Other,125% of Medicaid,0.01,2161.44,
REPAIR CMPLX EA ADDL 5CM,13102,CPT,,30013102,CDM,450,RC,,,both,,,1517,1122.58,,,1122.58,Other,150% of Medicare + 9.63% HCRA Surcharge,682.65,45,,682.65,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,750.92,,,750.92,Other,110% of Medicare,1031.56,68,,1031.56,percent of total billed charges,All Other,1241,,,1241,Other,186% of Medicaid,1213.6,,,1213.6,Other,Non Covered Service,1259.11,,,1259.11,Other,Non Covered Service,1259.11,,,1259.11,Other,Non Covered Service,1213.6,,,1213.6,Other,Non Covered Service,1259.11,,,1259.11,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1061.9,70,,1061.9,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,667.11,,,667.11,Other,100% of Medicaid,667.11,,,667.11,Other,100% of Medicaid,667.11,,,667.11,Other,100% of Medicaid,667.11,,,667.11,Other,100% of Medicaid,1501,,,1501,Other,225% of Medicaid,1020.68,,,1020.68,Other,153% of Medicaid,1501,,,1501,Other,225% of Medicaid,933.96,,,933.96,Other,140% of Medicaid,1501,,,1501,Other,225% of Medicaid,1734.49,,,1734.49,Other,260% of Medicaid,2161.44,,,2161.44,Other,324% of Medicaid,1434.29,,,1434.29,Other,215% of Medicaid,1434.29,,,1434.29,Other,215% of Medicaid,833.89,,,833.89,Other,125% of Medicaid,0.01,2161.44,
REP CPLX S A L 1.1CM - 2,13120,CPT,,30013120,CDM,450,RC,,,both,,,1309,968.66,,,968.66,Other,150% of Medicare + 9.63% HCRA Surcharge,589.05,45,,589.05,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,647.96,,,647.96,Other,110% of Medicare,890.12,68,,890.12,percent of total billed charges,All Other,1241,,,1241,Other,186% of Medicaid,1047.2,,,1047.2,Other,Non Covered Service,1086.47,,,1086.47,Other,Non Covered Service,1086.47,,,1086.47,Other,Non Covered Service,1047.2,,,1047.2,Other,Non Covered Service,1086.47,,,1086.47,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,916.3,70,,916.3,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,667.11,,,667.11,Other,100% of Medicaid,667.11,,,667.11,Other,100% of Medicaid,667.11,,,667.11,Other,100% of Medicaid,667.11,,,667.11,Other,100% of Medicaid,1501,,,1501,Other,225% of Medicaid,1020.68,,,1020.68,Other,153% of Medicaid,1501,,,1501,Other,225% of Medicaid,933.96,,,933.96,Other,140% of Medicaid,1501,,,1501,Other,225% of Medicaid,1734.49,,,1734.49,Other,260% of Medicaid,2161.44,,,2161.44,Other,324% of Medicaid,1434.29,,,1434.29,Other,215% of Medicaid,1434.29,,,1434.29,Other,215% of Medicaid,833.89,,,833.89,Other,125% of Medicaid,0.01,2161.44,
COMPLEX SKIN REPAIR 2.6-7.0,13121,CPT,,30013121,CDM,450,RC,,,both,,,1309,968.66,,,968.66,Other,150% of Medicare + 9.63% HCRA Surcharge,589.05,45,,589.05,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,647.96,,,647.96,Other,110% of Medicare,890.12,68,,890.12,percent of total billed charges,All Other,1241,,,1241,Other,186% of Medicaid,1047.2,,,1047.2,Other,Non Covered Service,1086.47,,,1086.47,Other,Non Covered Service,1086.47,,,1086.47,Other,Non Covered Service,1047.2,,,1047.2,Other,Non Covered Service,1086.47,,,1086.47,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,916.3,70,,916.3,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,667.11,,,667.11,Other,100% of Medicaid,667.11,,,667.11,Other,100% of Medicaid,667.11,,,667.11,Other,100% of Medicaid,667.11,,,667.11,Other,100% of Medicaid,1501,,,1501,Other,225% of Medicaid,1020.68,,,1020.68,Other,153% of Medicaid,1501,,,1501,Other,225% of Medicaid,933.96,,,933.96,Other,140% of Medicaid,1501,,,1501,Other,225% of Medicaid,1734.49,,,1734.49,Other,260% of Medicaid,2161.44,,,2161.44,Other,324% of Medicaid,1434.29,,,1434.29,Other,215% of Medicaid,1434.29,,,1434.29,Other,215% of Medicaid,833.89,,,833.89,Other,125% of Medicaid,0.01,2161.44,
REP CPLX S A L EA ADL 5C,13122,CPT,,30013122,CDM,450,RC,,,both,,,509,376.66,,,376.66,Other,150% of Medicare + 9.63% HCRA Surcharge,229.05,45,,229.05,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,251.96,,,251.96,Other,110% of Medicare,346.12,68,,346.12,percent of total billed charges,All Other,1241,,,1241,Other,186% of Medicaid,407.2,,,407.2,Other,Non Covered Service,422.47,,,422.47,Other,Non Covered Service,422.47,,,422.47,Other,Non Covered Service,407.2,,,407.2,Other,Non Covered Service,422.47,,,422.47,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,356.3,70,,356.3,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,667.11,,,667.11,Other,100% of Medicaid,667.11,,,667.11,Other,100% of Medicaid,667.11,,,667.11,Other,100% of Medicaid,667.11,,,667.11,Other,100% of Medicaid,1501,,,1501,Other,225% of Medicaid,1020.68,,,1020.68,Other,153% of Medicaid,1501,,,1501,Other,225% of Medicaid,933.96,,,933.96,Other,140% of Medicaid,1501,,,1501,Other,225% of Medicaid,1734.49,,,1734.49,Other,260% of Medicaid,2161.44,,,2161.44,Other,324% of Medicaid,1434.29,,,1434.29,Other,215% of Medicaid,1434.29,,,1434.29,Other,215% of Medicaid,833.89,,,833.89,Other,125% of Medicaid,0.01,2161.44,
REP CPLX F C EXT 1.1CM - 2.5,13131,CPT,,30013131,CDM,450,RC,,,both,,,1204,890.96,,,890.96,Other,150% of Medicare + 9.63% HCRA Surcharge,541.8,45,,541.8,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,595.98,,,595.98,Other,110% of Medicare,818.72,68,,818.72,percent of total billed charges,All Other,1241,,,1241,Other,186% of Medicaid,963.2,,,963.2,Other,Non Covered Service,999.32,,,999.32,Other,Non Covered Service,999.32,,,999.32,Other,Non Covered Service,963.2,,,963.2,Other,Non Covered Service,999.32,,,999.32,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,842.8,70,,842.8,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,667.11,,,667.11,Other,100% of Medicaid,667.11,,,667.11,Other,100% of Medicaid,667.11,,,667.11,Other,100% of Medicaid,667.11,,,667.11,Other,100% of Medicaid,1501,,,1501,Other,225% of Medicaid,1020.68,,,1020.68,Other,153% of Medicaid,1501,,,1501,Other,225% of Medicaid,933.96,,,933.96,Other,140% of Medicaid,1501,,,1501,Other,225% of Medicaid,1734.49,,,1734.49,Other,260% of Medicaid,2161.44,,,2161.44,Other,324% of Medicaid,1434.29,,,1434.29,Other,215% of Medicaid,1434.29,,,1434.29,Other,215% of Medicaid,833.89,,,833.89,Other,125% of Medicaid,0.01,2161.44,
COMPLEX REPAIR 2.6 - 7.5 CM,13132,CPT,,30013132,CDM,450,RC,,,both,,,1769,1309.06,,,1309.06,Other,150% of Medicare + 9.63% HCRA Surcharge,796.05,45,,796.05,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,875.66,,,875.66,Other,110% of Medicare,1202.92,68,,1202.92,percent of total billed charges,All Other,1241,,,1241,Other,186% of Medicaid,1415.2,,,1415.2,Other,Non Covered Service,1468.27,,,1468.27,Other,Non Covered Service,1468.27,,,1468.27,Other,Non Covered Service,1415.2,,,1415.2,Other,Non Covered Service,1468.27,,,1468.27,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1238.3,70,,1238.3,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,667.11,,,667.11,Other,100% of Medicaid,667.11,,,667.11,Other,100% of Medicaid,667.11,,,667.11,Other,100% of Medicaid,667.11,,,667.11,Other,100% of Medicaid,1501,,,1501,Other,225% of Medicaid,1020.68,,,1020.68,Other,153% of Medicaid,1501,,,1501,Other,225% of Medicaid,933.96,,,933.96,Other,140% of Medicaid,1501,,,1501,Other,225% of Medicaid,1734.49,,,1734.49,Other,260% of Medicaid,2161.44,,,2161.44,Other,324% of Medicaid,1434.29,,,1434.29,Other,215% of Medicaid,1434.29,,,1434.29,Other,215% of Medicaid,833.89,,,833.89,Other,125% of Medicaid,0.01,2161.44,
REP CPLX F C EXT EA AD 5C,13133,CPT,,30013133,CDM,450,RC,,,both,,,1125,832.5,,,832.5,Other,150% of Medicare + 9.63% HCRA Surcharge,506.25,45,,506.25,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,556.88,,,556.88,Other,110% of Medicare,765,68,,765,percent of total billed charges,All Other,1241,,,1241,Other,186% of Medicaid,900,,,900,Other,Non Covered Service,933.75,,,933.75,Other,Non Covered Service,933.75,,,933.75,Other,Non Covered Service,900,,,900,Other,Non Covered Service,933.75,,,933.75,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,787.5,70,,787.5,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,667.11,,,667.11,Other,100% of Medicaid,667.11,,,667.11,Other,100% of Medicaid,667.11,,,667.11,Other,100% of Medicaid,667.11,,,667.11,Other,100% of Medicaid,1501,,,1501,Other,225% of Medicaid,1020.68,,,1020.68,Other,153% of Medicaid,1501,,,1501,Other,225% of Medicaid,933.96,,,933.96,Other,140% of Medicaid,1501,,,1501,Other,225% of Medicaid,1734.49,,,1734.49,Other,260% of Medicaid,2161.44,,,2161.44,Other,324% of Medicaid,1434.29,,,1434.29,Other,215% of Medicaid,1434.29,,,1434.29,Other,215% of Medicaid,833.89,,,833.89,Other,125% of Medicaid,0.01,2161.44,
REP CPLX E N E L 1.1CM-2.5,13151,CPT,,30013151,CDM,450,RC,,,both,,,1769,1309.06,,,1309.06,Other,150% of Medicare + 9.63% HCRA Surcharge,796.05,45,,796.05,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,875.66,,,875.66,Other,110% of Medicare,1202.92,68,,1202.92,percent of total billed charges,All Other,1241,,,1241,Other,186% of Medicaid,1415.2,,,1415.2,Other,Non Covered Service,1468.27,,,1468.27,Other,Non Covered Service,1468.27,,,1468.27,Other,Non Covered Service,1415.2,,,1415.2,Other,Non Covered Service,1468.27,,,1468.27,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1238.3,70,,1238.3,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,667.11,,,667.11,Other,100% of Medicaid,667.11,,,667.11,Other,100% of Medicaid,667.11,,,667.11,Other,100% of Medicaid,667.11,,,667.11,Other,100% of Medicaid,1501,,,1501,Other,225% of Medicaid,1020.68,,,1020.68,Other,153% of Medicaid,1501,,,1501,Other,225% of Medicaid,933.96,,,933.96,Other,140% of Medicaid,1501,,,1501,Other,225% of Medicaid,1734.49,,,1734.49,Other,260% of Medicaid,2161.44,,,2161.44,Other,324% of Medicaid,1434.29,,,1434.29,Other,215% of Medicaid,1434.29,,,1434.29,Other,215% of Medicaid,833.89,,,833.89,Other,125% of Medicaid,0.01,2161.44,
REP CPLX E N E L 2.6CM - 7,13152,CPT,,30013152,CDM,450,RC,,,both,,,1624,1201.76,,,1201.76,Other,150% of Medicare + 9.63% HCRA Surcharge,730.8,45,,730.8,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,803.88,,,803.88,Other,110% of Medicare,1104.32,68,,1104.32,percent of total billed charges,All Other,1241,,,1241,Other,186% of Medicaid,1299.2,,,1299.2,Other,Non Covered Service,1347.92,,,1347.92,Other,Non Covered Service,1347.92,,,1347.92,Other,Non Covered Service,1299.2,,,1299.2,Other,Non Covered Service,1347.92,,,1347.92,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1136.8,70,,1136.8,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,667.11,,,667.11,Other,100% of Medicaid,667.11,,,667.11,Other,100% of Medicaid,667.11,,,667.11,Other,100% of Medicaid,667.11,,,667.11,Other,100% of Medicaid,1501,,,1501,Other,225% of Medicaid,1020.68,,,1020.68,Other,153% of Medicaid,1501,,,1501,Other,225% of Medicaid,933.96,,,933.96,Other,140% of Medicaid,1501,,,1501,Other,225% of Medicaid,1734.49,,,1734.49,Other,260% of Medicaid,2161.44,,,2161.44,Other,324% of Medicaid,1434.29,,,1434.29,Other,215% of Medicaid,1434.29,,,1434.29,Other,215% of Medicaid,833.89,,,833.89,Other,125% of Medicaid,0.01,2161.44,
REP CPLX E N E L EA AD 5C,13153,CPT,,30013153,CDM,450,RC,,,both,,,1033,764.42,,,764.42,Other,150% of Medicare + 9.63% HCRA Surcharge,464.85,45,,464.85,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,511.34,,,511.34,Other,110% of Medicare,702.44,68,,702.44,percent of total billed charges,All Other,2242,,,2242,Other,186% of Medicaid,826.4,,,826.4,Other,Non Covered Service,857.39,,,857.39,Other,Non Covered Service,857.39,,,857.39,Other,Non Covered Service,826.4,,,826.4,Other,Non Covered Service,857.39,,,857.39,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,723.1,70,,723.1,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1205.3,,,1205.3,Other,100% of Medicaid,1205.3,,,1205.3,Other,100% of Medicaid,1205.3,,,1205.3,Other,100% of Medicaid,1205.3,,,1205.3,Other,100% of Medicaid,2711.92,,,2711.92,Other,225% of Medicaid,1844.1,,,1844.1,Other,153% of Medicaid,2711.92,,,2711.92,Other,225% of Medicaid,1687.41,,,1687.41,Other,140% of Medicaid,2711.92,,,2711.92,Other,225% of Medicaid,3133.77,,,3133.77,Other,260% of Medicaid,3905.16,,,3905.16,Other,324% of Medicaid,2591.39,,,2591.39,Other,215% of Medicaid,2591.39,,,2591.39,Other,215% of Medicaid,1506.62,,,1506.62,Other,125% of Medicaid,0.01,3905.16,
PINCH GRFT SM; DEFECT TO 2CM,15050,CPT,,30015050,CDM,450,RC,,,both,,,1710,1265.4,,,1265.4,Other,150% of Medicare + 9.63% HCRA Surcharge,769.5,45,,769.5,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,846.45,,,846.45,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,1241,,,1241,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1197,70,,1197,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,667.11,,,667.11,Other,100% of Medicaid,667.11,,,667.11,Other,100% of Medicaid,667.11,,,667.11,Other,100% of Medicaid,667.11,,,667.11,Other,100% of Medicaid,1501,,,1501,Other,225% of Medicaid,1020.68,,,1020.68,Other,153% of Medicaid,1501,,,1501,Other,225% of Medicaid,933.96,,,933.96,Other,140% of Medicaid,1501,,,1501,Other,225% of Medicaid,1734.49,,,1734.49,Other,260% of Medicaid,2161.44,,,2161.44,Other,324% of Medicaid,1434.29,,,1434.29,Other,215% of Medicaid,1434.29,,,1434.29,Other,215% of Medicaid,833.89,,,833.89,Other,125% of Medicaid,0.01,2161.44,
FIRST DEGREE BURN LOCAL TREAT,16000,CPT,,30016000,CDM,450,RC,,,both,,,408,301.92,,,301.92,Other,150% of Medicare + 9.63% HCRA Surcharge,183.6,45,,183.6,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,201.96,,,201.96,Other,110% of Medicare,277.44,68,,277.44,percent of total billed charges,All Other,958,,,958,Other,186% of Medicaid,326.4,,,326.4,Other,Non Covered Service,338.64,,,338.64,Other,Non Covered Service,338.64,,,338.64,Other,Non Covered Service,326.4,,,326.4,Other,Non Covered Service,338.64,,,338.64,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,285.6,70,,285.6,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,514.9,,,514.9,Other,100% of Medicaid,514.9,,,514.9,Other,100% of Medicaid,514.9,,,514.9,Other,100% of Medicaid,514.9,,,514.9,Other,100% of Medicaid,1158.52,,,1158.52,Other,225% of Medicaid,787.8,,,787.8,Other,153% of Medicaid,1158.52,,,1158.52,Other,225% of Medicaid,720.86,,,720.86,Other,140% of Medicaid,1158.52,,,1158.52,Other,225% of Medicaid,1338.74,,,1338.74,Other,260% of Medicaid,1668.27,,,1668.27,Other,324% of Medicaid,1107.03,,,1107.03,Other,215% of Medicaid,1107.03,,,1107.03,Other,215% of Medicaid,643.62,,,643.62,Other,125% of Medicaid,0.01,1668.27,
DRESS DEBRID P THICK BURN S,16020,CPT,,30016020,CDM,450,RC,,,both,,,573,424.02,,,424.02,Other,150% of Medicare + 9.63% HCRA Surcharge,257.85,45,,257.85,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,283.64,,,283.64,Other,110% of Medicare,389.64,68,,389.64,percent of total billed charges,All Other,958,,,958,Other,186% of Medicaid,458.4,,,458.4,Other,Non Covered Service,475.59,,,475.59,Other,Non Covered Service,475.59,,,475.59,Other,Non Covered Service,458.4,,,458.4,Other,Non Covered Service,475.59,,,475.59,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,401.1,70,,401.1,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,514.9,,,514.9,Other,100% of Medicaid,514.9,,,514.9,Other,100% of Medicaid,514.9,,,514.9,Other,100% of Medicaid,514.9,,,514.9,Other,100% of Medicaid,1158.52,,,1158.52,Other,225% of Medicaid,787.8,,,787.8,Other,153% of Medicaid,1158.52,,,1158.52,Other,225% of Medicaid,720.86,,,720.86,Other,140% of Medicaid,1158.52,,,1158.52,Other,225% of Medicaid,1338.74,,,1338.74,Other,260% of Medicaid,1668.27,,,1668.27,Other,324% of Medicaid,1107.03,,,1107.03,Other,215% of Medicaid,1107.03,,,1107.03,Other,215% of Medicaid,643.62,,,643.62,Other,125% of Medicaid,0.01,1668.27,
DRESS DEBRID P THICK BURN M,16025,CPT,,30016025,CDM,450,RC,,,both,,,535,395.9,,,395.9,Other,150% of Medicare + 9.63% HCRA Surcharge,240.75,45,,240.75,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,264.83,,,264.83,Other,110% of Medicare,363.8,68,,363.8,percent of total billed charges,All Other,958,,,958,Other,186% of Medicaid,428,,,428,Other,Non Covered Service,444.05,,,444.05,Other,Non Covered Service,444.05,,,444.05,Other,Non Covered Service,428,,,428,Other,Non Covered Service,444.05,,,444.05,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,374.5,70,,374.5,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,514.9,,,514.9,Other,100% of Medicaid,514.9,,,514.9,Other,100% of Medicaid,514.9,,,514.9,Other,100% of Medicaid,514.9,,,514.9,Other,100% of Medicaid,1158.52,,,1158.52,Other,225% of Medicaid,787.8,,,787.8,Other,153% of Medicaid,1158.52,,,1158.52,Other,225% of Medicaid,720.86,,,720.86,Other,140% of Medicaid,1158.52,,,1158.52,Other,225% of Medicaid,1338.74,,,1338.74,Other,260% of Medicaid,1668.27,,,1668.27,Other,324% of Medicaid,1107.03,,,1107.03,Other,215% of Medicaid,1107.03,,,1107.03,Other,215% of Medicaid,643.62,,,643.62,Other,125% of Medicaid,0.01,1668.27,
DRESS DEBRID P THICK BURN L,16030,CPT,,30016030,CDM,450,RC,,,both,,,841,622.34,,,622.34,Other,150% of Medicare + 9.63% HCRA Surcharge,378.45,45,,378.45,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,416.3,,,416.3,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,1353,,,1353,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,588.7,70,,588.7,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,727.17,,,727.17,Other,100% of Medicaid,727.17,,,727.17,Other,100% of Medicaid,727.17,,,727.17,Other,100% of Medicaid,727.17,,,727.17,Other,100% of Medicaid,1636.12,,,1636.12,Other,225% of Medicaid,1112.56,,,1112.56,Other,153% of Medicaid,1636.12,,,1636.12,Other,225% of Medicaid,1018.03,,,1018.03,Other,140% of Medicaid,1636.12,,,1636.12,Other,225% of Medicaid,1890.63,,,1890.63,Other,260% of Medicaid,2356.02,,,2356.02,Other,324% of Medicaid,1563.41,,,1563.41,Other,215% of Medicaid,1563.41,,,1563.41,Other,215% of Medicaid,908.96,,,908.96,Other,125% of Medicaid,0.01,2356.02,
DESTRUCT B9 LESION 1-14,17110,CPT,,30017110,CDM,450,RC,,,both,,,1205,891.7,,,891.7,Other,150% of Medicare + 9.63% HCRA Surcharge,542.25,45,,542.25,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,596.48,,,596.48,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,733,,,733,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,843.5,70,,843.5,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,394.14,,,394.14,Other,100% of Medicaid,394.14,,,394.14,Other,100% of Medicaid,394.14,,,394.14,Other,100% of Medicaid,394.14,,,394.14,Other,100% of Medicaid,886.83,,,886.83,Other,225% of Medicaid,603.04,,,603.04,Other,153% of Medicaid,886.83,,,886.83,Other,225% of Medicaid,551.8,,,551.8,Other,140% of Medicaid,886.83,,,886.83,Other,225% of Medicaid,1024.78,,,1024.78,Other,260% of Medicaid,1277.03,,,1277.03,Other,324% of Medicaid,847.41,,,847.41,Other,215% of Medicaid,847.41,,,847.41,Other,215% of Medicaid,492.68,,,492.68,Other,125% of Medicaid,0.01,1277.03,
CHEM CAUT GRANULATION TISS,17250,CPT,,30017250,CDM,450,RC,,,both,,,697,515.78,,,515.78,Other,150% of Medicare + 9.63% HCRA Surcharge,313.65,45,,313.65,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,345.02,,,345.02,Other,110% of Medicare,473.96,68,,473.96,percent of total billed charges,All Other,733,,,733,Other,186% of Medicaid,557.6,,,557.6,Other,Non Covered Service,578.51,,,578.51,Other,Non Covered Service,578.51,,,578.51,Other,Non Covered Service,557.6,,,557.6,Other,Non Covered Service,578.51,,,578.51,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,487.9,70,,487.9,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,394.14,,,394.14,Other,100% of Medicaid,394.14,,,394.14,Other,100% of Medicaid,394.14,,,394.14,Other,100% of Medicaid,394.14,,,394.14,Other,100% of Medicaid,886.83,,,886.83,Other,225% of Medicaid,603.04,,,603.04,Other,153% of Medicaid,886.83,,,886.83,Other,225% of Medicaid,551.8,,,551.8,Other,140% of Medicaid,886.83,,,886.83,Other,225% of Medicaid,1024.78,,,1024.78,Other,260% of Medicaid,1277.03,,,1277.03,Other,324% of Medicaid,847.41,,,847.41,Other,215% of Medicaid,847.41,,,847.41,Other,215% of Medicaid,492.68,,,492.68,Other,125% of Medicaid,0.01,1277.03,
EXPLORE PENETRATING WOUND NECK,20100,CPT,,30020100,CDM,450,RC,,,both,,,2200,1628.01,,,1628.01,Other,150% of Medicare + 9.63% HCRA Surcharge,990,45,,990,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1089,,,1089,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,2493,,,2493,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1540,70,,1540,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1340.24,,,1340.24,Other,100% of Medicaid,1340.24,,,1340.24,Other,100% of Medicaid,1340.24,,,1340.24,Other,100% of Medicaid,1340.24,,,1340.24,Other,100% of Medicaid,3015.54,,,3015.54,Other,225% of Medicaid,2050.57,,,2050.57,Other,153% of Medicaid,3015.54,,,3015.54,Other,225% of Medicaid,1876.34,,,1876.34,Other,140% of Medicaid,3015.54,,,3015.54,Other,225% of Medicaid,3484.62,,,3484.62,Other,260% of Medicaid,4342.38,,,4342.38,Other,324% of Medicaid,2881.52,,,2881.52,Other,215% of Medicaid,2881.52,,,2881.52,Other,215% of Medicaid,1675.3,,,1675.3,Other,125% of Medicaid,0.01,4342.38,
EXPL P WND ABD FLANK,20102,CPT,,30020102,CDM,450,RC,,,both,,,7270,5379.82,,,5379.82,Other,150% of Medicare + 9.63% HCRA Surcharge,3271.5,45,,3271.5,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,3598.65,,,3598.65,Other,110% of Medicare,4943.6,68,,4943.6,percent of total billed charges,All Other,2493,,,2493,Other,186% of Medicaid,5816,,,5816,Other,Non Covered Service,6034.1,,,6034.1,Other,Non Covered Service,6034.1,,,6034.1,Other,Non Covered Service,5816,,,5816,Other,Non Covered Service,6034.1,,,6034.1,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,5089,70,,5089,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1340.24,,,1340.24,Other,100% of Medicaid,1340.24,,,1340.24,Other,100% of Medicaid,1340.24,,,1340.24,Other,100% of Medicaid,1340.24,,,1340.24,Other,100% of Medicaid,3015.54,,,3015.54,Other,225% of Medicaid,2050.57,,,2050.57,Other,153% of Medicaid,3015.54,,,3015.54,Other,225% of Medicaid,1876.34,,,1876.34,Other,140% of Medicaid,3015.54,,,3015.54,Other,225% of Medicaid,3484.62,,,3484.62,Other,260% of Medicaid,4342.38,,,4342.38,Other,324% of Medicaid,2881.52,,,2881.52,Other,215% of Medicaid,2881.52,,,2881.52,Other,215% of Medicaid,1675.3,,,1675.3,Other,125% of Medicaid,0.01,6034.1,
EXPL PENETRATING WOUND EX,20103,CPT,,30020103,CDM,450,RC,,,both,,,4627,3423.99,,,3423.99,Other,150% of Medicare + 9.63% HCRA Surcharge,2082.15,45,,2082.15,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2290.37,,,2290.37,Other,110% of Medicare,3146.36,68,,3146.36,percent of total billed charges,All Other,1353,,,1353,Other,186% of Medicaid,3701.6,,,3701.6,Other,Non Covered Service,3840.41,,,3840.41,Other,Non Covered Service,3840.41,,,3840.41,Other,Non Covered Service,3701.6,,,3701.6,Other,Non Covered Service,3840.41,,,3840.41,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,3238.9,70,,3238.9,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,727.17,,,727.17,Other,100% of Medicaid,727.17,,,727.17,Other,100% of Medicaid,727.17,,,727.17,Other,100% of Medicaid,727.17,,,727.17,Other,100% of Medicaid,1636.12,,,1636.12,Other,225% of Medicaid,1112.56,,,1112.56,Other,153% of Medicaid,1636.12,,,1636.12,Other,225% of Medicaid,1018.03,,,1018.03,Other,140% of Medicaid,1636.12,,,1636.12,Other,225% of Medicaid,1890.63,,,1890.63,Other,260% of Medicaid,2356.02,,,2356.02,Other,324% of Medicaid,1563.41,,,1563.41,Other,215% of Medicaid,1563.41,,,1563.41,Other,215% of Medicaid,908.96,,,908.96,Other,125% of Medicaid,0.01,3840.41,
INJECTION OF SINUS TRACT,20500,CPT,,30020500,CDM,450,RC,,,both,,,3126,2313.25,,,2313.25,Other,150% of Medicare + 9.63% HCRA Surcharge,1406.7,45,,1406.7,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1547.37,,,1547.37,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,2257,,,2257,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2188.2,70,,2188.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1213.21,,,1213.21,Other,100% of Medicaid,1213.21,,,1213.21,Other,100% of Medicaid,1213.21,,,1213.21,Other,100% of Medicaid,1213.21,,,1213.21,Other,100% of Medicaid,2729.72,,,2729.72,Other,225% of Medicaid,1856.21,,,1856.21,Other,153% of Medicaid,2729.72,,,2729.72,Other,225% of Medicaid,1698.49,,,1698.49,Other,140% of Medicaid,2729.72,,,2729.72,Other,225% of Medicaid,3154.34,,,3154.34,Other,260% of Medicaid,3930.79,,,3930.79,Other,324% of Medicaid,2608.4,,,2608.4,Other,215% of Medicaid,2608.4,,,2608.4,Other,215% of Medicaid,1516.51,,,1516.51,Other,125% of Medicaid,0.01,3930.79,
REMOVE FB MUSCLE TENDN SI,20520,CPT,,30020520,CDM,450,RC,,,both,,,3377,2498.99,,,2498.99,Other,150% of Medicare + 9.63% HCRA Surcharge,1519.65,45,,1519.65,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1671.62,,,1671.62,Other,110% of Medicare,2296.36,68,,2296.36,percent of total billed charges,All Other,1973,,,1973,Other,186% of Medicaid,2701.6,,,2701.6,Other,Non Covered Service,2802.91,,,2802.91,Other,Non Covered Service,2802.91,,,2802.91,Other,Non Covered Service,2701.6,,,2701.6,Other,Non Covered Service,2802.91,,,2802.91,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2363.9,70,,2363.9,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1060.79,,,1060.79,Other,100% of Medicaid,1060.79,,,1060.79,Other,100% of Medicaid,1060.79,,,1060.79,Other,100% of Medicaid,1060.79,,,1060.79,Other,100% of Medicaid,2386.77,,,2386.77,Other,225% of Medicaid,1623,,,1623,Other,153% of Medicaid,2386.77,,,2386.77,Other,225% of Medicaid,1485.1,,,1485.1,Other,140% of Medicaid,2386.77,,,2386.77,Other,225% of Medicaid,2758.05,,,2758.05,Other,260% of Medicaid,3436.95,,,3436.95,Other,324% of Medicaid,2280.69,,,2280.69,Other,215% of Medicaid,2280.69,,,2280.69,Other,215% of Medicaid,1325.98,,,1325.98,Other,125% of Medicaid,0.01,3436.95,
INJ TENDON SHEATH/LIGAMENT,20550,CPT,,30020550,CDM,450,RC,,,both,,,950,703,,,703,Other,150% of Medicare + 9.63% HCRA Surcharge,427.5,45,,427.5,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,470.25,,,470.25,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,686,,,686,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,665,70,,665,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,368.64,,,368.64,Other,100% of Medicaid,368.64,,,368.64,Other,100% of Medicaid,368.64,,,368.64,Other,100% of Medicaid,368.64,,,368.64,Other,100% of Medicaid,829.44,,,829.44,Other,225% of Medicaid,564.02,,,564.02,Other,153% of Medicaid,829.44,,,829.44,Other,225% of Medicaid,516.1,,,516.1,Other,140% of Medicaid,829.44,,,829.44,Other,225% of Medicaid,958.46,,,958.46,Other,260% of Medicaid,1194.39,,,1194.39,Other,324% of Medicaid,792.58,,,792.58,Other,215% of Medicaid,792.58,,,792.58,Other,215% of Medicaid,460.8,,,460.8,Other,125% of Medicaid,0.01,1194.39,
INJ TENDON ORIGIN/INSERT,20551,CPT,,30020551,CDM,450,RC,,,both,,,771,570.54,,,570.54,Other,150% of Medicare + 9.63% HCRA Surcharge,346.95,45,,346.95,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,381.65,,,381.65,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,686,,,686,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,539.7,70,,539.7,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,368.64,,,368.64,Other,100% of Medicaid,368.64,,,368.64,Other,100% of Medicaid,368.64,,,368.64,Other,100% of Medicaid,368.64,,,368.64,Other,100% of Medicaid,829.44,,,829.44,Other,225% of Medicaid,564.02,,,564.02,Other,153% of Medicaid,829.44,,,829.44,Other,225% of Medicaid,516.1,,,516.1,Other,140% of Medicaid,829.44,,,829.44,Other,225% of Medicaid,958.46,,,958.46,Other,260% of Medicaid,1194.39,,,1194.39,Other,324% of Medicaid,792.58,,,792.58,Other,215% of Medicaid,792.58,,,792.58,Other,215% of Medicaid,460.8,,,460.8,Other,125% of Medicaid,0.01,1194.39,
INJ TRIGGER POINT 1/2 MUSCL,20552,CPT,,30020552,CDM,450,RC,,,both,,,842,623.08,,,623.08,Other,150% of Medicare + 9.63% HCRA Surcharge,378.9,45,,378.9,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,416.79,,,416.79,Other,110% of Medicare,572.56,68,,572.56,percent of total billed charges,All Other,686,,,686,Other,186% of Medicaid,673.6,,,673.6,Other,Non Covered Service,698.86,,,698.86,Other,Non Covered Service,698.86,,,698.86,Other,Non Covered Service,673.6,,,673.6,Other,Non Covered Service,698.86,,,698.86,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,589.4,70,,589.4,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,368.64,,,368.64,Other,100% of Medicaid,368.64,,,368.64,Other,100% of Medicaid,368.64,,,368.64,Other,100% of Medicaid,368.64,,,368.64,Other,100% of Medicaid,829.44,,,829.44,Other,225% of Medicaid,564.02,,,564.02,Other,153% of Medicaid,829.44,,,829.44,Other,225% of Medicaid,516.1,,,516.1,Other,140% of Medicaid,829.44,,,829.44,Other,225% of Medicaid,958.46,,,958.46,Other,260% of Medicaid,1194.39,,,1194.39,Other,324% of Medicaid,792.58,,,792.58,Other,215% of Medicaid,792.58,,,792.58,Other,215% of Medicaid,460.8,,,460.8,Other,125% of Medicaid,0.01,1194.39,
ASPIRATE INJ SMALL JOINT,20600,CPT,,30020600,CDM,450,RC,,,both,,,1017,752.58,,,752.58,Other,150% of Medicare + 9.63% HCRA Surcharge,457.65,45,,457.65,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,503.42,,,503.42,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,686,,,686,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,711.9,70,,711.9,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,368.64,,,368.64,Other,100% of Medicaid,368.64,,,368.64,Other,100% of Medicaid,368.64,,,368.64,Other,100% of Medicaid,368.64,,,368.64,Other,100% of Medicaid,829.44,,,829.44,Other,225% of Medicaid,564.02,,,564.02,Other,153% of Medicaid,829.44,,,829.44,Other,225% of Medicaid,516.1,,,516.1,Other,140% of Medicaid,829.44,,,829.44,Other,225% of Medicaid,958.46,,,958.46,Other,260% of Medicaid,1194.39,,,1194.39,Other,324% of Medicaid,792.58,,,792.58,Other,215% of Medicaid,792.58,,,792.58,Other,215% of Medicaid,460.8,,,460.8,Other,125% of Medicaid,0.01,1194.39,
ASPIRATE INJ MED JOINT,20605,CPT,,30020605,CDM,450,RC,,,both,,,1017,752.58,,,752.58,Other,150% of Medicare + 9.63% HCRA Surcharge,457.65,45,,457.65,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,503.42,,,503.42,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,686,,,686,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,711.9,70,,711.9,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,368.64,,,368.64,Other,100% of Medicaid,368.64,,,368.64,Other,100% of Medicaid,368.64,,,368.64,Other,100% of Medicaid,368.64,,,368.64,Other,100% of Medicaid,829.44,,,829.44,Other,225% of Medicaid,564.02,,,564.02,Other,153% of Medicaid,829.44,,,829.44,Other,225% of Medicaid,516.1,,,516.1,Other,140% of Medicaid,829.44,,,829.44,Other,225% of Medicaid,958.46,,,958.46,Other,260% of Medicaid,1194.39,,,1194.39,Other,324% of Medicaid,792.58,,,792.58,Other,215% of Medicaid,792.58,,,792.58,Other,215% of Medicaid,460.8,,,460.8,Other,125% of Medicaid,0.01,1194.39,
ASPIRATE INJ LARGE JOINT,20610,CPT,,30020610,CDM,450,RC,,,both,,,1017,752.58,,,752.58,Other,150% of Medicare + 9.63% HCRA Surcharge,457.65,45,,457.65,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,503.42,,,503.42,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,686,,,686,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,711.9,70,,711.9,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,368.64,,,368.64,Other,100% of Medicaid,368.64,,,368.64,Other,100% of Medicaid,368.64,,,368.64,Other,100% of Medicaid,368.64,,,368.64,Other,100% of Medicaid,829.44,,,829.44,Other,225% of Medicaid,564.02,,,564.02,Other,153% of Medicaid,829.44,,,829.44,Other,225% of Medicaid,516.1,,,516.1,Other,140% of Medicaid,829.44,,,829.44,Other,225% of Medicaid,958.46,,,958.46,Other,260% of Medicaid,1194.39,,,1194.39,Other,324% of Medicaid,792.58,,,792.58,Other,215% of Medicaid,792.58,,,792.58,Other,215% of Medicaid,460.8,,,460.8,Other,125% of Medicaid,0.01,1194.39,
ASPIRATE/INJ GANGLION CYST,20612,CPT,,30020612,CDM,450,RC,,,both,,,1280,947.2,,,947.2,Other,150% of Medicare + 9.63% HCRA Surcharge,576,45,,576,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,633.6,,,633.6,Other,110% of Medicare,870.4,68,,870.4,percent of total billed charges,All Other,686,,,686,Other,186% of Medicaid,1024,,,1024,Other,Non Covered Service,1062.4,,,1062.4,Other,Non Covered Service,1062.4,,,1062.4,Other,Non Covered Service,1024,,,1024,Other,Non Covered Service,1062.4,,,1062.4,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,896,70,,896,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,368.64,,,368.64,Other,100% of Medicaid,368.64,,,368.64,Other,100% of Medicaid,368.64,,,368.64,Other,100% of Medicaid,368.64,,,368.64,Other,100% of Medicaid,829.44,,,829.44,Other,225% of Medicaid,564.02,,,564.02,Other,153% of Medicaid,829.44,,,829.44,Other,225% of Medicaid,516.1,,,516.1,Other,140% of Medicaid,829.44,,,829.44,Other,225% of Medicaid,958.46,,,958.46,Other,260% of Medicaid,1194.39,,,1194.39,Other,324% of Medicaid,792.58,,,792.58,Other,215% of Medicaid,792.58,,,792.58,Other,215% of Medicaid,460.8,,,460.8,Other,125% of Medicaid,0.01,1194.39,
APPLICATION OF PELVIS BRACE,20662,CPT,,30020662,CDM,450,RC,,,both,,,7494,5545.58,,,5545.58,Other,150% of Medicare + 9.63% HCRA Surcharge,3372.3,45,,3372.3,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,3709.53,,,3709.53,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,3028,,,3028,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,5245.8,70,,5245.8,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1628.03,,,1628.03,Other,100% of Medicaid,1628.03,,,1628.03,Other,100% of Medicaid,1628.03,,,1628.03,Other,100% of Medicaid,1628.03,,,1628.03,Other,100% of Medicaid,3663.07,,,3663.07,Other,225% of Medicaid,2490.89,,,2490.89,Other,153% of Medicaid,3663.07,,,3663.07,Other,225% of Medicaid,2279.24,,,2279.24,Other,140% of Medicaid,3663.07,,,3663.07,Other,225% of Medicaid,4232.88,,,4232.88,Other,260% of Medicaid,5274.82,,,5274.82,Other,324% of Medicaid,3500.27,,,3500.27,Other,215% of Medicaid,3500.27,,,3500.27,Other,215% of Medicaid,2035.04,,,2035.04,Other,125% of Medicaid,0.01,5545.58,
APPLICATION OF HALO REMOVAL FE,20663,CPT,,30020663,CDM,450,RC,,,both,,,7494,5545.58,,,5545.58,Other,150% of Medicare + 9.63% HCRA Surcharge,3372.3,45,,3372.3,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,3709.53,,,3709.53,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,3028,,,3028,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,5245.8,70,,5245.8,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1628.03,,,1628.03,Other,100% of Medicaid,1628.03,,,1628.03,Other,100% of Medicaid,1628.03,,,1628.03,Other,100% of Medicaid,1628.03,,,1628.03,Other,100% of Medicaid,3663.07,,,3663.07,Other,225% of Medicaid,2490.89,,,2490.89,Other,153% of Medicaid,3663.07,,,3663.07,Other,225% of Medicaid,2279.24,,,2279.24,Other,140% of Medicaid,3663.07,,,3663.07,Other,225% of Medicaid,4232.88,,,4232.88,Other,260% of Medicaid,5274.82,,,5274.82,Other,324% of Medicaid,3500.27,,,3500.27,Other,215% of Medicaid,3500.27,,,3500.27,Other,215% of Medicaid,2035.04,,,2035.04,Other,125% of Medicaid,0.01,5545.58,
REMOVAL OF SUPPORT IMPLANT,20670,CPT,,30020670,CDM,450,RC,,,both,,,4904,3628.97,,,3628.97,Other,150% of Medicare + 9.63% HCRA Surcharge,2206.8,45,,2206.8,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2427.48,,,2427.48,Other,110% of Medicare,3334.72,68,,3334.72,percent of total billed charges,All Other,3028,,,3028,Other,186% of Medicaid,3923.2,,,3923.2,Other,Non Covered Service,4070.32,,,4070.32,Other,Non Covered Service,4070.32,,,4070.32,Other,Non Covered Service,3923.2,,,3923.2,Other,Non Covered Service,4070.32,,,4070.32,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,3432.8,70,,3432.8,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1628.03,,,1628.03,Other,100% of Medicaid,1628.03,,,1628.03,Other,100% of Medicaid,1628.03,,,1628.03,Other,100% of Medicaid,1628.03,,,1628.03,Other,100% of Medicaid,3663.07,,,3663.07,Other,225% of Medicaid,2490.89,,,2490.89,Other,153% of Medicaid,3663.07,,,3663.07,Other,225% of Medicaid,2279.24,,,2279.24,Other,140% of Medicaid,3663.07,,,3663.07,Other,225% of Medicaid,4232.88,,,4232.88,Other,260% of Medicaid,5274.82,,,5274.82,Other,324% of Medicaid,3500.27,,,3500.27,Other,215% of Medicaid,3500.27,,,3500.27,Other,215% of Medicaid,2035.04,,,2035.04,Other,125% of Medicaid,0.01,5274.82,
CL TX OF NASAL BONE FX W,21315,CPT,,30021315,CDM,450,RC,,,both,,,6166,4562.86,,,4562.86,Other,150% of Medicare + 9.63% HCRA Surcharge,2774.7,45,,2774.7,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,3052.17,,,3052.17,Other,110% of Medicare,4192.88,68,,4192.88,percent of total billed charges,All Other,1031,,,1031,Other,186% of Medicaid,4932.8,,,4932.8,Other,Non Covered Service,5117.78,,,5117.78,Other,Non Covered Service,5117.78,,,5117.78,Other,Non Covered Service,4932.8,,,4932.8,Other,Non Covered Service,5117.78,,,5117.78,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,4316.2,70,,4316.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,554.53,,,554.53,Other,100% of Medicaid,554.53,,,554.53,Other,100% of Medicaid,554.53,,,554.53,Other,100% of Medicaid,554.53,,,554.53,Other,100% of Medicaid,1247.69,,,1247.69,Other,225% of Medicaid,848.43,,,848.43,Other,153% of Medicaid,1247.69,,,1247.69,Other,225% of Medicaid,776.34,,,776.34,Other,140% of Medicaid,1247.69,,,1247.69,Other,225% of Medicaid,1441.78,,,1441.78,Other,260% of Medicaid,1796.68,,,1796.68,Other,324% of Medicaid,1192.24,,,1192.24,Other,215% of Medicaid,1192.24,,,1192.24,Other,215% of Medicaid,693.16,,,693.16,Other,125% of Medicaid,0.01,5117.78,
CL TX OF NASAL BONE FX; W STAB,21320,CPT,,30021320,CDM,450,RC,,,both,,,6405,4739.72,,,4739.72,Other,150% of Medicare + 9.63% HCRA Surcharge,2882.25,45,,2882.25,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,3170.48,,,3170.48,Other,110% of Medicare,4355.4,68,,4355.4,percent of total billed charges,All Other,1031,,,1031,Other,186% of Medicaid,5124,,,5124,Other,Non Covered Service,5316.15,,,5316.15,Other,Non Covered Service,5316.15,,,5316.15,Other,Non Covered Service,5124,,,5124,Other,Non Covered Service,5316.15,,,5316.15,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,4483.5,70,,4483.5,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,554.53,,,554.53,Other,100% of Medicaid,554.53,,,554.53,Other,100% of Medicaid,554.53,,,554.53,Other,100% of Medicaid,554.53,,,554.53,Other,100% of Medicaid,1247.69,,,1247.69,Other,225% of Medicaid,848.43,,,848.43,Other,153% of Medicaid,1247.69,,,1247.69,Other,225% of Medicaid,776.34,,,776.34,Other,140% of Medicaid,1247.69,,,1247.69,Other,225% of Medicaid,1441.78,,,1441.78,Other,260% of Medicaid,1796.68,,,1796.68,Other,324% of Medicaid,1192.24,,,1192.24,Other,215% of Medicaid,1192.24,,,1192.24,Other,215% of Medicaid,693.16,,,693.16,Other,125% of Medicaid,0.01,5316.15,
CL TX NASAL SEPTAL FX,21337,CPT,,30021337,CDM,450,RC,,,both,,,9130,6756.22,,,6756.22,Other,150% of Medicare + 9.63% HCRA Surcharge,4108.5,45,,4108.5,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,4519.35,,,4519.35,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,1031,,,1031,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,6391,70,,6391,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,554.53,,,554.53,Other,100% of Medicaid,554.53,,,554.53,Other,100% of Medicaid,554.53,,,554.53,Other,100% of Medicaid,554.53,,,554.53,Other,100% of Medicaid,1247.69,,,1247.69,Other,225% of Medicaid,848.43,,,848.43,Other,153% of Medicaid,1247.69,,,1247.69,Other,225% of Medicaid,776.34,,,776.34,Other,140% of Medicaid,1247.69,,,1247.69,Other,225% of Medicaid,1441.78,,,1441.78,Other,260% of Medicaid,1796.68,,,1796.68,Other,324% of Medicaid,1192.24,,,1192.24,Other,215% of Medicaid,1192.24,,,1192.24,Other,215% of Medicaid,693.16,,,693.16,Other,125% of Medicaid,0.01,6756.22,
CL TS TMJ DISLOCATION IN,21480,CPT,,30021480,CDM,450,RC,,,both,,,467,345.58,,,345.58,Other,150% of Medicare + 9.63% HCRA Surcharge,210.15,45,,210.15,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,231.17,,,231.17,Other,110% of Medicare,317.56,68,,317.56,percent of total billed charges,All Other,423,,,423,Other,186% of Medicaid,373.6,,,373.6,Other,Non Covered Service,387.61,,,387.61,Other,Non Covered Service,387.61,,,387.61,Other,Non Covered Service,373.6,,,373.6,Other,Non Covered Service,387.61,,,387.61,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,326.9,70,,326.9,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,227.45,,,227.45,Other,100% of Medicaid,227.45,,,227.45,Other,100% of Medicaid,227.45,,,227.45,Other,100% of Medicaid,227.45,,,227.45,Other,100% of Medicaid,511.76,,,511.76,Other,225% of Medicaid,348,,,348,Other,153% of Medicaid,511.76,,,511.76,Other,225% of Medicaid,318.43,,,318.43,Other,140% of Medicaid,511.76,,,511.76,Other,225% of Medicaid,591.37,,,591.37,Other,260% of Medicaid,736.94,,,736.94,Other,324% of Medicaid,489.02,,,489.02,Other,215% of Medicaid,489.02,,,489.02,Other,215% of Medicaid,284.31,,,284.31,Other,125% of Medicaid,0.01,736.94,
REM FB SHOULDER; SQ,23330,CPT,,30023330,CDM,450,RC,,,both,,,3395,2512.31,,,2512.31,Other,150% of Medicare + 9.63% HCRA Surcharge,1527.75,45,,1527.75,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1680.53,,,1680.53,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,1973,,,1973,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2376.5,70,,2376.5,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1060.79,,,1060.79,Other,100% of Medicaid,1060.79,,,1060.79,Other,100% of Medicaid,1060.79,,,1060.79,Other,100% of Medicaid,1060.79,,,1060.79,Other,100% of Medicaid,2386.77,,,2386.77,Other,225% of Medicaid,1623,,,1623,Other,153% of Medicaid,2386.77,,,2386.77,Other,225% of Medicaid,1485.1,,,1485.1,Other,140% of Medicaid,2386.77,,,2386.77,Other,225% of Medicaid,2758.05,,,2758.05,Other,260% of Medicaid,3436.95,,,3436.95,Other,324% of Medicaid,2280.69,,,2280.69,Other,215% of Medicaid,2280.69,,,2280.69,Other,215% of Medicaid,1325.98,,,1325.98,Other,125% of Medicaid,0.01,3436.95,
CL TX CLAVICULAR FX WO M,23500,CPT,,30023500,CDM,450,RC,,,both,,,467,345.58,,,345.58,Other,150% of Medicare + 9.63% HCRA Surcharge,210.15,45,,210.15,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,231.17,,,231.17,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,1031,,,1031,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,326.9,70,,326.9,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,554.53,,,554.53,Other,100% of Medicaid,554.53,,,554.53,Other,100% of Medicaid,554.53,,,554.53,Other,100% of Medicaid,554.53,,,554.53,Other,100% of Medicaid,1247.69,,,1247.69,Other,225% of Medicaid,848.43,,,848.43,Other,153% of Medicaid,1247.69,,,1247.69,Other,225% of Medicaid,776.34,,,776.34,Other,140% of Medicaid,1247.69,,,1247.69,Other,225% of Medicaid,1441.78,,,1441.78,Other,260% of Medicaid,1796.68,,,1796.68,Other,324% of Medicaid,1192.24,,,1192.24,Other,215% of Medicaid,1192.24,,,1192.24,Other,215% of Medicaid,693.16,,,693.16,Other,125% of Medicaid,0.01,1796.68,
CL TX ACLAV DISLOC W MANI,23545,CPT,,30023545,CDM,450,RC,,,both,,,1798,1330.52,,,1330.52,Other,150% of Medicare + 9.63% HCRA Surcharge,809.1,45,,809.1,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,890.01,,,890.01,Other,110% of Medicare,1222.64,68,,1222.64,percent of total billed charges,All Other,1031,,,1031,Other,186% of Medicaid,1438.4,,,1438.4,Other,Non Covered Service,1492.34,,,1492.34,Other,Non Covered Service,1492.34,,,1492.34,Other,Non Covered Service,1438.4,,,1438.4,Other,Non Covered Service,1492.34,,,1492.34,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1258.6,70,,1258.6,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,554.53,,,554.53,Other,100% of Medicaid,554.53,,,554.53,Other,100% of Medicaid,554.53,,,554.53,Other,100% of Medicaid,554.53,,,554.53,Other,100% of Medicaid,1247.69,,,1247.69,Other,225% of Medicaid,848.43,,,848.43,Other,153% of Medicaid,1247.69,,,1247.69,Other,225% of Medicaid,776.34,,,776.34,Other,140% of Medicaid,1247.69,,,1247.69,Other,225% of Medicaid,1441.78,,,1441.78,Other,260% of Medicaid,1796.68,,,1796.68,Other,324% of Medicaid,1192.24,,,1192.24,Other,215% of Medicaid,1192.24,,,1192.24,Other,215% of Medicaid,693.16,,,693.16,Other,125% of Medicaid,0.01,1796.68,
CL TX PROX HUMERAL FX W,23605,CPT,,30023605,CDM,450,RC,,,both,,,7272,5381.3,,,5381.3,Other,150% of Medicare + 9.63% HCRA Surcharge,3272.4,45,,3272.4,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,3599.64,,,3599.64,Other,110% of Medicare,4944.96,68,,4944.96,percent of total billed charges,All Other,1031,,,1031,Other,186% of Medicaid,5817.6,,,5817.6,Other,Non Covered Service,6035.76,,,6035.76,Other,Non Covered Service,6035.76,,,6035.76,Other,Non Covered Service,5817.6,,,5817.6,Other,Non Covered Service,6035.76,,,6035.76,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,5090.4,70,,5090.4,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,554.53,,,554.53,Other,100% of Medicaid,554.53,,,554.53,Other,100% of Medicaid,554.53,,,554.53,Other,100% of Medicaid,554.53,,,554.53,Other,100% of Medicaid,1247.69,,,1247.69,Other,225% of Medicaid,848.43,,,848.43,Other,153% of Medicaid,1247.69,,,1247.69,Other,225% of Medicaid,776.34,,,776.34,Other,140% of Medicaid,1247.69,,,1247.69,Other,225% of Medicaid,1441.78,,,1441.78,Other,260% of Medicaid,1796.68,,,1796.68,Other,324% of Medicaid,1192.24,,,1192.24,Other,215% of Medicaid,1192.24,,,1192.24,Other,215% of Medicaid,693.16,,,693.16,Other,125% of Medicaid,0.01,6035.76,
CL TX GR TUBEROSITY FX; W MANIP,23625,CPT,,30023625,CDM,450,RC,,,both,,,3953,2925.23,,,2925.23,Other,150% of Medicare + 9.63% HCRA Surcharge,1778.85,45,,1778.85,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1956.74,,,1956.74,Other,110% of Medicare,2688.04,68,,2688.04,percent of total billed charges,All Other,1031,,,1031,Other,186% of Medicaid,3162.4,,,3162.4,Other,Non Covered Service,3280.99,,,3280.99,Other,Non Covered Service,3280.99,,,3280.99,Other,Non Covered Service,3162.4,,,3162.4,Other,Non Covered Service,3280.99,,,3280.99,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2767.1,70,,2767.1,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,554.53,,,554.53,Other,100% of Medicaid,554.53,,,554.53,Other,100% of Medicaid,554.53,,,554.53,Other,100% of Medicaid,554.53,,,554.53,Other,100% of Medicaid,1247.69,,,1247.69,Other,225% of Medicaid,848.43,,,848.43,Other,153% of Medicaid,1247.69,,,1247.69,Other,225% of Medicaid,776.34,,,776.34,Other,140% of Medicaid,1247.69,,,1247.69,Other,225% of Medicaid,1441.78,,,1441.78,Other,260% of Medicaid,1796.68,,,1796.68,Other,324% of Medicaid,1192.24,,,1192.24,Other,215% of Medicaid,1192.24,,,1192.24,Other,215% of Medicaid,693.16,,,693.16,Other,125% of Medicaid,0.01,3280.99,
CL TX SHLDR DISL W MANI; WO AN,23650,CPT,,30023650,CDM,450,RC,,,both,,,603,446.22,,,446.22,Other,150% of Medicare + 9.63% HCRA Surcharge,271.35,45,,271.35,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,298.49,,,298.49,Other,110% of Medicare,410.04,68,,410.04,percent of total billed charges,All Other,1031,,,1031,Other,186% of Medicaid,482.4,,,482.4,Other,Non Covered Service,500.49,,,500.49,Other,Non Covered Service,500.49,,,500.49,Other,Non Covered Service,482.4,,,482.4,Other,Non Covered Service,500.49,,,500.49,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,422.1,70,,422.1,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,554.53,,,554.53,Other,100% of Medicaid,554.53,,,554.53,Other,100% of Medicaid,554.53,,,554.53,Other,100% of Medicaid,554.53,,,554.53,Other,100% of Medicaid,1247.69,,,1247.69,Other,225% of Medicaid,848.43,,,848.43,Other,153% of Medicaid,1247.69,,,1247.69,Other,225% of Medicaid,776.34,,,776.34,Other,140% of Medicaid,1247.69,,,1247.69,Other,225% of Medicaid,1441.78,,,1441.78,Other,260% of Medicaid,1796.68,,,1796.68,Other,324% of Medicaid,1192.24,,,1192.24,Other,215% of Medicaid,1192.24,,,1192.24,Other,215% of Medicaid,693.16,,,693.16,Other,125% of Medicaid,0.01,1796.68,
CL TX SHLDR DISL W MANIP; W AN,23655,CPT,,30023655,CDM,450,RC,,,both,,,5919,4380.07,,,4380.07,Other,150% of Medicare + 9.63% HCRA Surcharge,2663.55,45,,2663.55,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2929.91,,,2929.91,Other,110% of Medicare,4024.92,68,,4024.92,percent of total billed charges,All Other,1730,,,1730,Other,186% of Medicaid,4735.2,,,4735.2,Other,Non Covered Service,4912.77,,,4912.77,Other,Non Covered Service,4912.77,,,4912.77,Other,Non Covered Service,4735.2,,,4735.2,Other,Non Covered Service,4912.77,,,4912.77,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,4143.3,70,,4143.3,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,930.31,,,930.31,Other,100% of Medicaid,930.31,,,930.31,Other,100% of Medicaid,930.31,,,930.31,Other,100% of Medicaid,930.31,,,930.31,Other,100% of Medicaid,2093.21,,,2093.21,Other,225% of Medicaid,1423.38,,,1423.38,Other,153% of Medicaid,2093.21,,,2093.21,Other,225% of Medicaid,1302.44,,,1302.44,Other,140% of Medicaid,2093.21,,,2093.21,Other,225% of Medicaid,2418.82,,,2418.82,Other,260% of Medicaid,3014.22,,,3014.22,Other,324% of Medicaid,2000.18,,,2000.18,Other,215% of Medicaid,2000.18,,,2000.18,Other,215% of Medicaid,1162.89,,,1162.89,Other,125% of Medicaid,0.01,4912.77,
CL TX SHLDR DISLOC & FX GT; W MAN,23665,CPT,,30023665,CDM,450,RC,,,both,,,3304,2444.97,,,2444.97,Other,150% of Medicare + 9.63% HCRA Surcharge,1486.8,45,,1486.8,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1635.48,,,1635.48,Other,110% of Medicare,2246.72,68,,2246.72,percent of total billed charges,All Other,1031,,,1031,Other,186% of Medicaid,2643.2,,,2643.2,Other,Non Covered Service,2742.32,,,2742.32,Other,Non Covered Service,2742.32,,,2742.32,Other,Non Covered Service,2643.2,,,2643.2,Other,Non Covered Service,2742.32,,,2742.32,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2312.8,70,,2312.8,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,554.53,,,554.53,Other,100% of Medicaid,554.53,,,554.53,Other,100% of Medicaid,554.53,,,554.53,Other,100% of Medicaid,554.53,,,554.53,Other,100% of Medicaid,1247.69,,,1247.69,Other,225% of Medicaid,848.43,,,848.43,Other,153% of Medicaid,1247.69,,,1247.69,Other,225% of Medicaid,776.34,,,776.34,Other,140% of Medicaid,1247.69,,,1247.69,Other,225% of Medicaid,1441.78,,,1441.78,Other,260% of Medicaid,1796.68,,,1796.68,Other,324% of Medicaid,1192.24,,,1192.24,Other,215% of Medicaid,1192.24,,,1192.24,Other,215% of Medicaid,693.16,,,693.16,Other,125% of Medicaid,0.01,2742.32,
CL TX SHDR DISLOC W NK FX,23675,CPT,,30023675,CDM,450,RC,,,both,,,3230,2390.21,,,2390.21,Other,150% of Medicare + 9.63% HCRA Surcharge,1453.5,45,,1453.5,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1598.85,,,1598.85,Other,110% of Medicare,2196.4,68,,2196.4,percent of total billed charges,All Other,1031,,,1031,Other,186% of Medicaid,2584,,,2584,Other,Non Covered Service,2680.9,,,2680.9,Other,Non Covered Service,2680.9,,,2680.9,Other,Non Covered Service,2584,,,2584,Other,Non Covered Service,2680.9,,,2680.9,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2261,70,,2261,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,554.53,,,554.53,Other,100% of Medicaid,554.53,,,554.53,Other,100% of Medicaid,554.53,,,554.53,Other,100% of Medicaid,554.53,,,554.53,Other,100% of Medicaid,1247.69,,,1247.69,Other,225% of Medicaid,848.43,,,848.43,Other,153% of Medicaid,1247.69,,,1247.69,Other,225% of Medicaid,776.34,,,776.34,Other,140% of Medicaid,1247.69,,,1247.69,Other,225% of Medicaid,1441.78,,,1441.78,Other,260% of Medicaid,1796.68,,,1796.68,Other,324% of Medicaid,1192.24,,,1192.24,Other,215% of Medicaid,1192.24,,,1192.24,Other,215% of Medicaid,693.16,,,693.16,Other,125% of Medicaid,0.01,2680.9,
INCISION & DRAINAGE ARM/ELBOW,23931,CPT,,30023931,CDM,450,RC,,,both,,,5674,4198.77,,,4198.77,Other,150% of Medicare + 9.63% HCRA Surcharge,2553.3,45,,2553.3,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2808.63,,,2808.63,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,1973,,,1973,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,3971.8,70,,3971.8,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1060.79,,,1060.79,Other,100% of Medicaid,1060.79,,,1060.79,Other,100% of Medicaid,1060.79,,,1060.79,Other,100% of Medicaid,1060.79,,,1060.79,Other,100% of Medicaid,2386.77,,,2386.77,Other,225% of Medicaid,1623,,,1623,Other,153% of Medicaid,2386.77,,,2386.77,Other,225% of Medicaid,1485.1,,,1485.1,Other,140% of Medicaid,2386.77,,,2386.77,Other,225% of Medicaid,2758.05,,,2758.05,Other,260% of Medicaid,3436.95,,,3436.95,Other,324% of Medicaid,2280.69,,,2280.69,Other,215% of Medicaid,2280.69,,,2280.69,Other,215% of Medicaid,1325.98,,,1325.98,Other,125% of Medicaid,0.01,4198.77,
CLOSED TX HUMERUS FX W MA,24505,CPT,,30024505,CDM,450,RC,,,both,,,3230,2390.21,,,2390.21,Other,150% of Medicare + 9.63% HCRA Surcharge,1453.5,45,,1453.5,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1598.85,,,1598.85,Other,110% of Medicare,2196.4,68,,2196.4,percent of total billed charges,All Other,1031,,,1031,Other,186% of Medicaid,2584,,,2584,Other,Non Covered Service,2680.9,,,2680.9,Other,Non Covered Service,2680.9,,,2680.9,Other,Non Covered Service,2584,,,2584,Other,Non Covered Service,2680.9,,,2680.9,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2261,70,,2261,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,554.53,,,554.53,Other,100% of Medicaid,554.53,,,554.53,Other,100% of Medicaid,554.53,,,554.53,Other,100% of Medicaid,554.53,,,554.53,Other,100% of Medicaid,1247.69,,,1247.69,Other,225% of Medicaid,848.43,,,848.43,Other,153% of Medicaid,1247.69,,,1247.69,Other,225% of Medicaid,776.34,,,776.34,Other,140% of Medicaid,1247.69,,,1247.69,Other,225% of Medicaid,1441.78,,,1441.78,Other,260% of Medicaid,1796.68,,,1796.68,Other,324% of Medicaid,1192.24,,,1192.24,Other,215% of Medicaid,1192.24,,,1192.24,Other,215% of Medicaid,693.16,,,693.16,Other,125% of Medicaid,0.01,2680.9,
CL TX SC TX HUMERUS SHFT,24535,CPT,,30024535,CDM,450,RC,,,both,,,3230,2390.21,,,2390.21,Other,150% of Medicare + 9.63% HCRA Surcharge,1453.5,45,,1453.5,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1598.85,,,1598.85,Other,110% of Medicare,2196.4,68,,2196.4,percent of total billed charges,All Other,1031,,,1031,Other,186% of Medicaid,2584,,,2584,Other,Non Covered Service,2680.9,,,2680.9,Other,Non Covered Service,2680.9,,,2680.9,Other,Non Covered Service,2584,,,2584,Other,Non Covered Service,2680.9,,,2680.9,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2261,70,,2261,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,554.53,,,554.53,Other,100% of Medicaid,554.53,,,554.53,Other,100% of Medicaid,554.53,,,554.53,Other,100% of Medicaid,554.53,,,554.53,Other,100% of Medicaid,1247.69,,,1247.69,Other,225% of Medicaid,848.43,,,848.43,Other,153% of Medicaid,1247.69,,,1247.69,Other,225% of Medicaid,776.34,,,776.34,Other,140% of Medicaid,1247.69,,,1247.69,Other,225% of Medicaid,1441.78,,,1441.78,Other,260% of Medicaid,1796.68,,,1796.68,Other,324% of Medicaid,1192.24,,,1192.24,Other,215% of Medicaid,1192.24,,,1192.24,Other,215% of Medicaid,693.16,,,693.16,Other,125% of Medicaid,0.01,2680.9,
CL TX EC HUMEROUS FX W MA,24565,CPT,,30024565,CDM,450,RC,,,both,,,3230,2390.21,,,2390.21,Other,150% of Medicare + 9.63% HCRA Surcharge,1453.5,45,,1453.5,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1598.85,,,1598.85,Other,110% of Medicare,2196.4,68,,2196.4,percent of total billed charges,All Other,1031,,,1031,Other,186% of Medicaid,2584,,,2584,Other,Non Covered Service,2680.9,,,2680.9,Other,Non Covered Service,2680.9,,,2680.9,Other,Non Covered Service,2584,,,2584,Other,Non Covered Service,2680.9,,,2680.9,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2261,70,,2261,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,554.53,,,554.53,Other,100% of Medicaid,554.53,,,554.53,Other,100% of Medicaid,554.53,,,554.53,Other,100% of Medicaid,554.53,,,554.53,Other,100% of Medicaid,1247.69,,,1247.69,Other,225% of Medicaid,848.43,,,848.43,Other,153% of Medicaid,1247.69,,,1247.69,Other,225% of Medicaid,776.34,,,776.34,Other,140% of Medicaid,1247.69,,,1247.69,Other,225% of Medicaid,1441.78,,,1441.78,Other,260% of Medicaid,1796.68,,,1796.68,Other,324% of Medicaid,1192.24,,,1192.24,Other,215% of Medicaid,1192.24,,,1192.24,Other,215% of Medicaid,693.16,,,693.16,Other,125% of Medicaid,0.01,2680.9,
CL TX C HUMERUS FX W MANI,24577,CPT,,30024577,CDM,450,RC,,,both,,,3230,2390.21,,,2390.21,Other,150% of Medicare + 9.63% HCRA Surcharge,1453.5,45,,1453.5,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1598.85,,,1598.85,Other,110% of Medicare,2196.4,68,,2196.4,percent of total billed charges,All Other,1031,,,1031,Other,186% of Medicaid,2584,,,2584,Other,Non Covered Service,2680.9,,,2680.9,Other,Non Covered Service,2680.9,,,2680.9,Other,Non Covered Service,2584,,,2584,Other,Non Covered Service,2680.9,,,2680.9,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2261,70,,2261,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,554.53,,,554.53,Other,100% of Medicaid,554.53,,,554.53,Other,100% of Medicaid,554.53,,,554.53,Other,100% of Medicaid,554.53,,,554.53,Other,100% of Medicaid,1247.69,,,1247.69,Other,225% of Medicaid,848.43,,,848.43,Other,153% of Medicaid,1247.69,,,1247.69,Other,225% of Medicaid,776.34,,,776.34,Other,140% of Medicaid,1247.69,,,1247.69,Other,225% of Medicaid,1441.78,,,1441.78,Other,260% of Medicaid,1796.68,,,1796.68,Other,324% of Medicaid,1192.24,,,1192.24,Other,215% of Medicaid,1192.24,,,1192.24,Other,215% of Medicaid,693.16,,,693.16,Other,125% of Medicaid,0.01,2680.9,
TX CL ELBOW DISLOC WO ANE,24600,CPT,,30024600,CDM,450,RC,,,both,,,603,446.22,,,446.22,Other,150% of Medicare + 9.63% HCRA Surcharge,271.35,45,,271.35,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,298.49,,,298.49,Other,110% of Medicare,410.04,68,,410.04,percent of total billed charges,All Other,1031,,,1031,Other,186% of Medicaid,482.4,,,482.4,Other,Non Covered Service,500.49,,,500.49,Other,Non Covered Service,500.49,,,500.49,Other,Non Covered Service,482.4,,,482.4,Other,Non Covered Service,500.49,,,500.49,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,422.1,70,,422.1,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,554.53,,,554.53,Other,100% of Medicaid,554.53,,,554.53,Other,100% of Medicaid,554.53,,,554.53,Other,100% of Medicaid,554.53,,,554.53,Other,100% of Medicaid,1247.69,,,1247.69,Other,225% of Medicaid,848.43,,,848.43,Other,153% of Medicaid,1247.69,,,1247.69,Other,225% of Medicaid,776.34,,,776.34,Other,140% of Medicaid,1247.69,,,1247.69,Other,225% of Medicaid,1441.78,,,1441.78,Other,260% of Medicaid,1796.68,,,1796.68,Other,324% of Medicaid,1192.24,,,1192.24,Other,215% of Medicaid,1192.24,,,1192.24,Other,215% of Medicaid,693.16,,,693.16,Other,125% of Medicaid,0.01,1796.68,
TX CL ELBOW DISLOC W ANES,24605,CPT,,30024605,CDM,450,RC,,,both,,,5531,4092.95,,,4092.95,Other,150% of Medicare + 9.63% HCRA Surcharge,2488.95,45,,2488.95,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2737.85,,,2737.85,Other,110% of Medicare,3761.08,68,,3761.08,percent of total billed charges,All Other,1730,,,1730,Other,186% of Medicaid,4424.8,,,4424.8,Other,Non Covered Service,4590.73,,,4590.73,Other,Non Covered Service,4590.73,,,4590.73,Other,Non Covered Service,4424.8,,,4424.8,Other,Non Covered Service,4590.73,,,4590.73,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,3871.7,70,,3871.7,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,930.31,,,930.31,Other,100% of Medicaid,930.31,,,930.31,Other,100% of Medicaid,930.31,,,930.31,Other,100% of Medicaid,930.31,,,930.31,Other,100% of Medicaid,2093.21,,,2093.21,Other,225% of Medicaid,1423.38,,,1423.38,Other,153% of Medicaid,2093.21,,,2093.21,Other,225% of Medicaid,1302.44,,,1302.44,Other,140% of Medicaid,2093.21,,,2093.21,Other,225% of Medicaid,2418.82,,,2418.82,Other,260% of Medicaid,3014.22,,,3014.22,Other,324% of Medicaid,2000.18,,,2000.18,Other,215% of Medicaid,2000.18,,,2000.18,Other,215% of Medicaid,1162.89,,,1162.89,Other,125% of Medicaid,0.01,4590.73,
CL TX MONTEGGIA ELB FX W MANIP,24620,CPT,,30024620,CDM,450,RC,,,both,,,5382,3982.69,,,3982.69,Other,150% of Medicare + 9.63% HCRA Surcharge,2421.9,45,,2421.9,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2664.09,,,2664.09,Other,110% of Medicare,3659.76,68,,3659.76,percent of total billed charges,All Other,1031,,,1031,Other,186% of Medicaid,4305.6,,,4305.6,Other,Non Covered Service,4467.06,,,4467.06,Other,Non Covered Service,4467.06,,,4467.06,Other,Non Covered Service,4305.6,,,4305.6,Other,Non Covered Service,4467.06,,,4467.06,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,3767.4,70,,3767.4,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,554.53,,,554.53,Other,100% of Medicaid,554.53,,,554.53,Other,100% of Medicaid,554.53,,,554.53,Other,100% of Medicaid,554.53,,,554.53,Other,100% of Medicaid,1247.69,,,1247.69,Other,225% of Medicaid,848.43,,,848.43,Other,153% of Medicaid,1247.69,,,1247.69,Other,225% of Medicaid,776.34,,,776.34,Other,140% of Medicaid,1247.69,,,1247.69,Other,225% of Medicaid,1441.78,,,1441.78,Other,260% of Medicaid,1796.68,,,1796.68,Other,324% of Medicaid,1192.24,,,1192.24,Other,215% of Medicaid,1192.24,,,1192.24,Other,215% of Medicaid,693.16,,,693.16,Other,125% of Medicaid,0.01,4467.06,
CL TX NURSEMAID ELBOW W M,24640,CPT,,30024640,CDM,450,RC,,,both,,,603,446.22,,,446.22,Other,150% of Medicare + 9.63% HCRA Surcharge,271.35,45,,271.35,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,298.49,,,298.49,Other,110% of Medicare,410.04,68,,410.04,percent of total billed charges,All Other,1031,,,1031,Other,186% of Medicaid,482.4,,,482.4,Other,Non Covered Service,500.49,,,500.49,Other,Non Covered Service,500.49,,,500.49,Other,Non Covered Service,482.4,,,482.4,Other,Non Covered Service,500.49,,,500.49,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,422.1,70,,422.1,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,554.53,,,554.53,Other,100% of Medicaid,554.53,,,554.53,Other,100% of Medicaid,554.53,,,554.53,Other,100% of Medicaid,554.53,,,554.53,Other,100% of Medicaid,1247.69,,,1247.69,Other,225% of Medicaid,848.43,,,848.43,Other,153% of Medicaid,1247.69,,,1247.69,Other,225% of Medicaid,776.34,,,776.34,Other,140% of Medicaid,1247.69,,,1247.69,Other,225% of Medicaid,1441.78,,,1441.78,Other,260% of Medicaid,1796.68,,,1796.68,Other,324% of Medicaid,1192.24,,,1192.24,Other,215% of Medicaid,1192.24,,,1192.24,Other,215% of Medicaid,693.16,,,693.16,Other,125% of Medicaid,0.01,1796.68,
CL TX RADIAL HD/NECK FX; W MANIP,24655,CPT,,30024655,CDM,450,RC,,,both,,,3230,2390.21,,,2390.21,Other,150% of Medicare + 9.63% HCRA Surcharge,1453.5,45,,1453.5,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1598.85,,,1598.85,Other,110% of Medicare,2196.4,68,,2196.4,percent of total billed charges,All Other,1031,,,1031,Other,186% of Medicaid,2584,,,2584,Other,Non Covered Service,2680.9,,,2680.9,Other,Non Covered Service,2680.9,,,2680.9,Other,Non Covered Service,2584,,,2584,Other,Non Covered Service,2680.9,,,2680.9,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2261,70,,2261,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,554.53,,,554.53,Other,100% of Medicaid,554.53,,,554.53,Other,100% of Medicaid,554.53,,,554.53,Other,100% of Medicaid,554.53,,,554.53,Other,100% of Medicaid,1247.69,,,1247.69,Other,225% of Medicaid,848.43,,,848.43,Other,153% of Medicaid,1247.69,,,1247.69,Other,225% of Medicaid,776.34,,,776.34,Other,140% of Medicaid,1247.69,,,1247.69,Other,225% of Medicaid,1441.78,,,1441.78,Other,260% of Medicaid,1796.68,,,1796.68,Other,324% of Medicaid,1192.24,,,1192.24,Other,215% of Medicaid,1192.24,,,1192.24,Other,215% of Medicaid,693.16,,,693.16,Other,125% of Medicaid,0.01,2680.9,
CLOSED TX ULNAR FRACTURE PROXIMAL END W,24675,CPT,,30024675,CDM,450,RC,,,both,,,3230,2390.21,,,2390.21,Other,150% of Medicare + 9.63% HCRA Surcharge,1453.5,45,,1453.5,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1598.85,,,1598.85,Other,110% of Medicare,2196.4,68,,2196.4,percent of total billed charges,All Other,1031,,,1031,Other,186% of Medicaid,2584,,,2584,Other,Non Covered Service,2680.9,,,2680.9,Other,Non Covered Service,2680.9,,,2680.9,Other,Non Covered Service,2584,,,2584,Other,Non Covered Service,2680.9,,,2680.9,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2261,70,,2261,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,554.53,,,554.53,Other,100% of Medicaid,554.53,,,554.53,Other,100% of Medicaid,554.53,,,554.53,Other,100% of Medicaid,554.53,,,554.53,Other,100% of Medicaid,1247.69,,,1247.69,Other,225% of Medicaid,848.43,,,848.43,Other,153% of Medicaid,1247.69,,,1247.69,Other,225% of Medicaid,776.34,,,776.34,Other,140% of Medicaid,1247.69,,,1247.69,Other,225% of Medicaid,1441.78,,,1441.78,Other,260% of Medicaid,1796.68,,,1796.68,Other,324% of Medicaid,1192.24,,,1192.24,Other,215% of Medicaid,1192.24,,,1192.24,Other,215% of Medicaid,693.16,,,693.16,Other,125% of Medicaid,0.01,2680.9,
CL TX RADIAL SHAFT FX WO,25500,CPT,,30025500,CDM,450,RC,,,both,,,563,416.62,,,416.62,Other,150% of Medicare + 9.63% HCRA Surcharge,253.35,45,,253.35,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,278.69,,,278.69,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,1031,,,1031,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,394.1,70,,394.1,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,554.53,,,554.53,Other,100% of Medicaid,554.53,,,554.53,Other,100% of Medicaid,554.53,,,554.53,Other,100% of Medicaid,554.53,,,554.53,Other,100% of Medicaid,1247.69,,,1247.69,Other,225% of Medicaid,848.43,,,848.43,Other,153% of Medicaid,1247.69,,,1247.69,Other,225% of Medicaid,776.34,,,776.34,Other,140% of Medicaid,1247.69,,,1247.69,Other,225% of Medicaid,1441.78,,,1441.78,Other,260% of Medicaid,1796.68,,,1796.68,Other,324% of Medicaid,1192.24,,,1192.24,Other,215% of Medicaid,1192.24,,,1192.24,Other,215% of Medicaid,693.16,,,693.16,Other,125% of Medicaid,0.01,1796.68,
CL TX RADIAL SHFT FX W MA,25505,CPT,,30025505,CDM,450,RC,,,both,,,3230,2390.21,,,2390.21,Other,150% of Medicare + 9.63% HCRA Surcharge,1453.5,45,,1453.5,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1598.85,,,1598.85,Other,110% of Medicare,2196.4,68,,2196.4,percent of total billed charges,All Other,1031,,,1031,Other,186% of Medicaid,2584,,,2584,Other,Non Covered Service,2680.9,,,2680.9,Other,Non Covered Service,2680.9,,,2680.9,Other,Non Covered Service,2584,,,2584,Other,Non Covered Service,2680.9,,,2680.9,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2261,70,,2261,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,554.53,,,554.53,Other,100% of Medicaid,554.53,,,554.53,Other,100% of Medicaid,554.53,,,554.53,Other,100% of Medicaid,554.53,,,554.53,Other,100% of Medicaid,1247.69,,,1247.69,Other,225% of Medicaid,848.43,,,848.43,Other,153% of Medicaid,1247.69,,,1247.69,Other,225% of Medicaid,776.34,,,776.34,Other,140% of Medicaid,1247.69,,,1247.69,Other,225% of Medicaid,1441.78,,,1441.78,Other,260% of Medicaid,1796.68,,,1796.68,Other,324% of Medicaid,1192.24,,,1192.24,Other,215% of Medicaid,1192.24,,,1192.24,Other,215% of Medicaid,693.16,,,693.16,Other,125% of Medicaid,0.01,2680.9,
GALEAZZI FX/DISLOC,25520,CPT,,30025520,CDM,450,RC,,,both,,,5210,3855.41,,,3855.41,Other,150% of Medicare + 9.63% HCRA Surcharge,2344.5,45,,2344.5,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2578.95,,,2578.95,Other,110% of Medicare,3542.8,68,,3542.8,percent of total billed charges,All Other,1031,,,1031,Other,186% of Medicaid,4168,,,4168,Other,Non Covered Service,4324.3,,,4324.3,Other,Non Covered Service,4324.3,,,4324.3,Other,Non Covered Service,4168,,,4168,Other,Non Covered Service,4324.3,,,4324.3,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,3647,70,,3647,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,554.53,,,554.53,Other,100% of Medicaid,554.53,,,554.53,Other,100% of Medicaid,554.53,,,554.53,Other,100% of Medicaid,554.53,,,554.53,Other,100% of Medicaid,1247.69,,,1247.69,Other,225% of Medicaid,848.43,,,848.43,Other,153% of Medicaid,1247.69,,,1247.69,Other,225% of Medicaid,776.34,,,776.34,Other,140% of Medicaid,1247.69,,,1247.69,Other,225% of Medicaid,1441.78,,,1441.78,Other,260% of Medicaid,1796.68,,,1796.68,Other,324% of Medicaid,1192.24,,,1192.24,Other,215% of Medicaid,1192.24,,,1192.24,Other,215% of Medicaid,693.16,,,693.16,Other,125% of Medicaid,0.01,4324.3,
CL TX ULNAR SHFT FX W MANIP,25535,CPT,,30025535,CDM,450,RC,,,both,,,714,528.36,,,528.36,Other,150% of Medicare + 9.63% HCRA Surcharge,321.3,45,,321.3,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,353.43,,,353.43,Other,110% of Medicare,485.52,68,,485.52,percent of total billed charges,All Other,1031,,,1031,Other,186% of Medicaid,571.2,,,571.2,Other,Non Covered Service,592.62,,,592.62,Other,Non Covered Service,592.62,,,592.62,Other,Non Covered Service,571.2,,,571.2,Other,Non Covered Service,592.62,,,592.62,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,499.8,70,,499.8,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,554.53,,,554.53,Other,100% of Medicaid,554.53,,,554.53,Other,100% of Medicaid,554.53,,,554.53,Other,100% of Medicaid,554.53,,,554.53,Other,100% of Medicaid,1247.69,,,1247.69,Other,225% of Medicaid,848.43,,,848.43,Other,153% of Medicaid,1247.69,,,1247.69,Other,225% of Medicaid,776.34,,,776.34,Other,140% of Medicaid,1247.69,,,1247.69,Other,225% of Medicaid,1441.78,,,1441.78,Other,260% of Medicaid,1796.68,,,1796.68,Other,324% of Medicaid,1192.24,,,1192.24,Other,215% of Medicaid,1192.24,,,1192.24,Other,215% of Medicaid,693.16,,,693.16,Other,125% of Medicaid,0.01,1796.68,
CL TX RADIAL AND ULNAR SHFT,25560,CPT,,30025560,CDM,450,RC,,,both,,,603,446.22,,,446.22,Other,150% of Medicare + 9.63% HCRA Surcharge,271.35,45,,271.35,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,298.49,,,298.49,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,1031,,,1031,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,422.1,70,,422.1,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,554.53,,,554.53,Other,100% of Medicaid,554.53,,,554.53,Other,100% of Medicaid,554.53,,,554.53,Other,100% of Medicaid,554.53,,,554.53,Other,100% of Medicaid,1247.69,,,1247.69,Other,225% of Medicaid,848.43,,,848.43,Other,153% of Medicaid,1247.69,,,1247.69,Other,225% of Medicaid,776.34,,,776.34,Other,140% of Medicaid,1247.69,,,1247.69,Other,225% of Medicaid,1441.78,,,1441.78,Other,260% of Medicaid,1796.68,,,1796.68,Other,324% of Medicaid,1192.24,,,1192.24,Other,215% of Medicaid,1192.24,,,1192.24,Other,215% of Medicaid,693.16,,,693.16,Other,125% of Medicaid,0.01,1796.68,
CL TX RADIAL AND ULNA FX W,25565,CPT,,30025565,CDM,450,RC,,,both,,,3230,2390.21,,,2390.21,Other,150% of Medicare + 9.63% HCRA Surcharge,1453.5,45,,1453.5,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1598.85,,,1598.85,Other,110% of Medicare,2196.4,68,,2196.4,percent of total billed charges,All Other,1031,,,1031,Other,186% of Medicaid,2584,,,2584,Other,Non Covered Service,2680.9,,,2680.9,Other,Non Covered Service,2680.9,,,2680.9,Other,Non Covered Service,2584,,,2584,Other,Non Covered Service,2680.9,,,2680.9,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2261,70,,2261,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,554.53,,,554.53,Other,100% of Medicaid,554.53,,,554.53,Other,100% of Medicaid,554.53,,,554.53,Other,100% of Medicaid,554.53,,,554.53,Other,100% of Medicaid,1247.69,,,1247.69,Other,225% of Medicaid,848.43,,,848.43,Other,153% of Medicaid,1247.69,,,1247.69,Other,225% of Medicaid,776.34,,,776.34,Other,140% of Medicaid,1247.69,,,1247.69,Other,225% of Medicaid,1441.78,,,1441.78,Other,260% of Medicaid,1796.68,,,1796.68,Other,324% of Medicaid,1192.24,,,1192.24,Other,215% of Medicaid,1192.24,,,1192.24,Other,215% of Medicaid,693.16,,,693.16,Other,125% of Medicaid,0.01,2680.9,
TREAT FRACTURE RADIUS ULNA W,25600,CPT,,30025600,CDM,450,RC,,,both,,,554,409.96,,,409.96,Other,150% of Medicare + 9.63% HCRA Surcharge,249.3,45,,249.3,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,274.23,,,274.23,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,1031,,,1031,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,387.8,70,,387.8,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,554.53,,,554.53,Other,100% of Medicaid,554.53,,,554.53,Other,100% of Medicaid,554.53,,,554.53,Other,100% of Medicaid,554.53,,,554.53,Other,100% of Medicaid,1247.69,,,1247.69,Other,225% of Medicaid,848.43,,,848.43,Other,153% of Medicaid,1247.69,,,1247.69,Other,225% of Medicaid,776.34,,,776.34,Other,140% of Medicaid,1247.69,,,1247.69,Other,225% of Medicaid,1441.78,,,1441.78,Other,260% of Medicaid,1796.68,,,1796.68,Other,324% of Medicaid,1192.24,,,1192.24,Other,215% of Medicaid,1192.24,,,1192.24,Other,215% of Medicaid,693.16,,,693.16,Other,125% of Medicaid,0.01,1796.68,
TREAT FRACTURE RADIUS ULNA,25605,CPT,,30025605,CDM,450,RC,,,both,,,3230,2390.21,,,2390.21,Other,150% of Medicare + 9.63% HCRA Surcharge,1453.5,45,,1453.5,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1598.85,,,1598.85,Other,110% of Medicare,2196.4,68,,2196.4,percent of total billed charges,All Other,1031,,,1031,Other,186% of Medicaid,2584,,,2584,Other,Non Covered Service,2680.9,,,2680.9,Other,Non Covered Service,2680.9,,,2680.9,Other,Non Covered Service,2584,,,2584,Other,Non Covered Service,2680.9,,,2680.9,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2261,70,,2261,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,554.53,,,554.53,Other,100% of Medicaid,554.53,,,554.53,Other,100% of Medicaid,554.53,,,554.53,Other,100% of Medicaid,554.53,,,554.53,Other,100% of Medicaid,1247.69,,,1247.69,Other,225% of Medicaid,848.43,,,848.43,Other,153% of Medicaid,1247.69,,,1247.69,Other,225% of Medicaid,776.34,,,776.34,Other,140% of Medicaid,1247.69,,,1247.69,Other,225% of Medicaid,1441.78,,,1441.78,Other,260% of Medicaid,1796.68,,,1796.68,Other,324% of Medicaid,1192.24,,,1192.24,Other,215% of Medicaid,1192.24,,,1192.24,Other,215% of Medicaid,693.16,,,693.16,Other,125% of Medicaid,0.01,2680.9,
CK TX CARPL SCAPHOID FX W,25624,CPT,,30025624,CDM,450,RC,,,both,,,3230,2390.21,,,2390.21,Other,150% of Medicare + 9.63% HCRA Surcharge,1453.5,45,,1453.5,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1598.85,,,1598.85,Other,110% of Medicare,2196.4,68,,2196.4,percent of total billed charges,All Other,1031,,,1031,Other,186% of Medicaid,2584,,,2584,Other,Non Covered Service,2680.9,,,2680.9,Other,Non Covered Service,2680.9,,,2680.9,Other,Non Covered Service,2584,,,2584,Other,Non Covered Service,2680.9,,,2680.9,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2261,70,,2261,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,554.53,,,554.53,Other,100% of Medicaid,554.53,,,554.53,Other,100% of Medicaid,554.53,,,554.53,Other,100% of Medicaid,554.53,,,554.53,Other,100% of Medicaid,1247.69,,,1247.69,Other,225% of Medicaid,848.43,,,848.43,Other,153% of Medicaid,1247.69,,,1247.69,Other,225% of Medicaid,776.34,,,776.34,Other,140% of Medicaid,1247.69,,,1247.69,Other,225% of Medicaid,1441.78,,,1441.78,Other,260% of Medicaid,1796.68,,,1796.68,Other,324% of Medicaid,1192.24,,,1192.24,Other,215% of Medicaid,1192.24,,,1192.24,Other,215% of Medicaid,693.16,,,693.16,Other,125% of Medicaid,0.01,2680.9,
CLTX CARPL BONE FX W MNP EA BONE,25635,CPT,,30025635,CDM,450,RC,,,both,,,7839,5800.88,,,5800.88,Other,150% of Medicare + 9.63% HCRA Surcharge,3527.55,45,,3527.55,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,3880.31,,,3880.31,Other,110% of Medicare,5330.52,68,,5330.52,percent of total billed charges,All Other,1031,,,1031,Other,186% of Medicaid,6271.2,,,6271.2,Other,Non Covered Service,6506.37,,,6506.37,Other,Non Covered Service,6506.37,,,6506.37,Other,Non Covered Service,6271.2,,,6271.2,Other,Non Covered Service,6506.37,,,6506.37,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,5487.3,70,,5487.3,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,554.53,,,554.53,Other,100% of Medicaid,554.53,,,554.53,Other,100% of Medicaid,554.53,,,554.53,Other,100% of Medicaid,554.53,,,554.53,Other,100% of Medicaid,1247.69,,,1247.69,Other,225% of Medicaid,848.43,,,848.43,Other,153% of Medicaid,1247.69,,,1247.69,Other,225% of Medicaid,776.34,,,776.34,Other,140% of Medicaid,1247.69,,,1247.69,Other,225% of Medicaid,1441.78,,,1441.78,Other,260% of Medicaid,1796.68,,,1796.68,Other,324% of Medicaid,1192.24,,,1192.24,Other,215% of Medicaid,1192.24,,,1192.24,Other,215% of Medicaid,693.16,,,693.16,Other,125% of Medicaid,0.01,6506.37,
CLTX RDCRPL/INTERCARPL DISLC 1+ BONES,25660,CPT,,30025660,CDM,450,RC,,,both,,,758,560.92,,,560.92,Other,150% of Medicare + 9.63% HCRA Surcharge,341.1,45,,341.1,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,375.21,,,375.21,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,1031,,,1031,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,530.6,70,,530.6,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,554.53,,,554.53,Other,100% of Medicaid,554.53,,,554.53,Other,100% of Medicaid,554.53,,,554.53,Other,100% of Medicaid,554.53,,,554.53,Other,100% of Medicaid,1247.69,,,1247.69,Other,225% of Medicaid,848.43,,,848.43,Other,153% of Medicaid,1247.69,,,1247.69,Other,225% of Medicaid,776.34,,,776.34,Other,140% of Medicaid,1247.69,,,1247.69,Other,225% of Medicaid,1441.78,,,1441.78,Other,260% of Medicaid,1796.68,,,1796.68,Other,324% of Medicaid,1192.24,,,1192.24,Other,215% of Medicaid,1192.24,,,1192.24,Other,215% of Medicaid,693.16,,,693.16,Other,125% of Medicaid,0.01,1796.68,
TREAT WRIST DISLOCATION,25675,CPT,,30025675,CDM,450,RC,,,both,,,692,512.08,,,512.08,Other,150% of Medicare + 9.63% HCRA Surcharge,311.4,45,,311.4,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,342.54,,,342.54,Other,110% of Medicare,470.56,68,,470.56,percent of total billed charges,All Other,1031,,,1031,Other,186% of Medicaid,553.6,,,553.6,Other,Non Covered Service,574.36,,,574.36,Other,Non Covered Service,574.36,,,574.36,Other,Non Covered Service,553.6,,,553.6,Other,Non Covered Service,574.36,,,574.36,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,484.4,70,,484.4,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,554.53,,,554.53,Other,100% of Medicaid,554.53,,,554.53,Other,100% of Medicaid,554.53,,,554.53,Other,100% of Medicaid,554.53,,,554.53,Other,100% of Medicaid,1247.69,,,1247.69,Other,225% of Medicaid,848.43,,,848.43,Other,153% of Medicaid,1247.69,,,1247.69,Other,225% of Medicaid,776.34,,,776.34,Other,140% of Medicaid,1247.69,,,1247.69,Other,225% of Medicaid,1441.78,,,1441.78,Other,260% of Medicaid,1796.68,,,1796.68,Other,324% of Medicaid,1192.24,,,1192.24,Other,215% of Medicaid,1192.24,,,1192.24,Other,215% of Medicaid,693.16,,,693.16,Other,125% of Medicaid,0.01,1796.68,
CL TX LUNATE DISLOC W MANIP,25690,CPT,,30025690,CDM,450,RC,,,both,,,5340,3951.61,,,3951.61,Other,150% of Medicare + 9.63% HCRA Surcharge,2403,45,,2403,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2643.3,,,2643.3,Other,110% of Medicare,3631.2,68,,3631.2,percent of total billed charges,All Other,1031,,,1031,Other,186% of Medicaid,4272,,,4272,Other,Non Covered Service,4432.2,,,4432.2,Other,Non Covered Service,4432.2,,,4432.2,Other,Non Covered Service,4272,,,4272,Other,Non Covered Service,4432.2,,,4432.2,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,3738,70,,3738,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,554.53,,,554.53,Other,100% of Medicaid,554.53,,,554.53,Other,100% of Medicaid,554.53,,,554.53,Other,100% of Medicaid,554.53,,,554.53,Other,100% of Medicaid,1247.69,,,1247.69,Other,225% of Medicaid,848.43,,,848.43,Other,153% of Medicaid,1247.69,,,1247.69,Other,225% of Medicaid,776.34,,,776.34,Other,140% of Medicaid,1247.69,,,1247.69,Other,225% of Medicaid,1441.78,,,1441.78,Other,260% of Medicaid,1796.68,,,1796.68,Other,324% of Medicaid,1192.24,,,1192.24,Other,215% of Medicaid,1192.24,,,1192.24,Other,215% of Medicaid,693.16,,,693.16,Other,125% of Medicaid,0.01,4432.2,
I AND D FINGER ABSCESS SIMPLE,26010,CPT,,30026010,CDM,450,RC,,,both,,,570,421.8,,,421.8,Other,150% of Medicare + 9.63% HCRA Surcharge,256.5,45,,256.5,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,282.15,,,282.15,Other,110% of Medicare,387.6,68,,387.6,percent of total billed charges,All Other,733,,,733,Other,186% of Medicaid,456,,,456,Other,Non Covered Service,473.1,,,473.1,Other,Non Covered Service,473.1,,,473.1,Other,Non Covered Service,456,,,456,Other,Non Covered Service,473.1,,,473.1,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,399,70,,399,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,394.14,,,394.14,Other,100% of Medicaid,394.14,,,394.14,Other,100% of Medicaid,394.14,,,394.14,Other,100% of Medicaid,394.14,,,394.14,Other,100% of Medicaid,886.83,,,886.83,Other,225% of Medicaid,603.04,,,603.04,Other,153% of Medicaid,886.83,,,886.83,Other,225% of Medicaid,551.8,,,551.8,Other,140% of Medicaid,886.83,,,886.83,Other,225% of Medicaid,1024.78,,,1024.78,Other,260% of Medicaid,1277.03,,,1277.03,Other,324% of Medicaid,847.41,,,847.41,Other,215% of Medicaid,847.41,,,847.41,Other,215% of Medicaid,492.68,,,492.68,Other,125% of Medicaid,0.01,1277.03,
I AND D FINGER ABSCESS COMPLI,26011,CPT,,30026011,CDM,450,RC,,,both,,,4245,3141.31,,,3141.31,Other,150% of Medicare + 9.63% HCRA Surcharge,1910.25,45,,1910.25,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2101.28,,,2101.28,Other,110% of Medicare,2886.6,68,,2886.6,percent of total billed charges,All Other,1207,,,1207,Other,186% of Medicaid,3396,,,3396,Other,Non Covered Service,3523.35,,,3523.35,Other,Non Covered Service,3523.35,,,3523.35,Other,Non Covered Service,3396,,,3396,Other,Non Covered Service,3523.35,,,3523.35,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2971.5,70,,2971.5,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,648.98,,,648.98,Other,100% of Medicaid,648.98,,,648.98,Other,100% of Medicaid,648.98,,,648.98,Other,100% of Medicaid,648.98,,,648.98,Other,100% of Medicaid,1460.2,,,1460.2,Other,225% of Medicaid,992.94,,,992.94,Other,153% of Medicaid,1460.2,,,1460.2,Other,225% of Medicaid,908.57,,,908.57,Other,140% of Medicaid,1460.2,,,1460.2,Other,225% of Medicaid,1687.34,,,1687.34,Other,260% of Medicaid,2102.69,,,2102.69,Other,324% of Medicaid,1395.3,,,1395.3,Other,215% of Medicaid,1395.3,,,1395.3,Other,215% of Medicaid,811.22,,,811.22,Other,125% of Medicaid,0.01,3523.35,
PARTIAL EXC BONE DISTAL,26236,CPT,,30026236,CDM,450,RC,,,both,,,5598,4142.53,,,4142.53,Other,150% of Medicare + 9.63% HCRA Surcharge,2519.1,45,,2519.1,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2771.01,,,2771.01,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,2290,,,2290,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,3918.6,70,,3918.6,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1231,,,1231,Other,100% of Medicaid,1231,,,1231,Other,100% of Medicaid,1231,,,1231,Other,100% of Medicaid,1231,,,1231,Other,100% of Medicaid,2769.74,,,2769.74,Other,225% of Medicaid,1883.42,,,1883.42,Other,153% of Medicaid,2769.74,,,2769.74,Other,225% of Medicaid,1723.39,,,1723.39,Other,140% of Medicaid,2769.74,,,2769.74,Other,225% of Medicaid,3200.59,,,3200.59,Other,260% of Medicaid,3988.42,,,3988.42,Other,324% of Medicaid,2646.64,,,2646.64,Other,215% of Medicaid,2646.64,,,2646.64,Other,215% of Medicaid,1538.74,,,1538.74,Other,125% of Medicaid,0.01,4142.53,
REP ET HAND WO FG EA T,26410,CPT,,30026410,CDM,450,RC,,,both,,,5990,4432.61,,,4432.61,Other,150% of Medicare + 9.63% HCRA Surcharge,2695.5,45,,2695.5,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2965.05,,,2965.05,Other,110% of Medicare,4073.2,68,,4073.2,percent of total billed charges,All Other,2290,,,2290,Other,186% of Medicaid,4792,,,4792,Other,Non Covered Service,4971.7,,,4971.7,Other,Non Covered Service,4971.7,,,4971.7,Other,Non Covered Service,4792,,,4792,Other,Non Covered Service,4971.7,,,4971.7,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,4193,70,,4193,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1231,,,1231,Other,100% of Medicaid,1231,,,1231,Other,100% of Medicaid,1231,,,1231,Other,100% of Medicaid,1231,,,1231,Other,100% of Medicaid,2769.74,,,2769.74,Other,225% of Medicaid,1883.42,,,1883.42,Other,153% of Medicaid,2769.74,,,2769.74,Other,225% of Medicaid,1723.39,,,1723.39,Other,140% of Medicaid,2769.74,,,2769.74,Other,225% of Medicaid,3200.59,,,3200.59,Other,260% of Medicaid,3988.42,,,3988.42,Other,324% of Medicaid,2646.64,,,2646.64,Other,215% of Medicaid,2646.64,,,2646.64,Other,215% of Medicaid,1538.74,,,1538.74,Other,125% of Medicaid,0.01,4971.7,
REPAIR FINGER TENDON,26418,CPT,,30026418,CDM,450,RC,,,both,,,4665,3452.11,,,3452.11,Other,150% of Medicare + 9.63% HCRA Surcharge,2099.25,45,,2099.25,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2309.18,,,2309.18,Other,110% of Medicare,3172.2,68,,3172.2,percent of total billed charges,All Other,2290,,,2290,Other,186% of Medicaid,3732,,,3732,Other,Non Covered Service,3871.95,,,3871.95,Other,Non Covered Service,3871.95,,,3871.95,Other,Non Covered Service,3732,,,3732,Other,Non Covered Service,3871.95,,,3871.95,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,3265.5,70,,3265.5,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1231,,,1231,Other,100% of Medicaid,1231,,,1231,Other,100% of Medicaid,1231,,,1231,Other,100% of Medicaid,1231,,,1231,Other,100% of Medicaid,2769.74,,,2769.74,Other,225% of Medicaid,1883.42,,,1883.42,Other,153% of Medicaid,2769.74,,,2769.74,Other,225% of Medicaid,1723.39,,,1723.39,Other,140% of Medicaid,2769.74,,,2769.74,Other,225% of Medicaid,3200.59,,,3200.59,Other,260% of Medicaid,3988.42,,,3988.42,Other,324% of Medicaid,2646.64,,,2646.64,Other,215% of Medicaid,2646.64,,,2646.64,Other,215% of Medicaid,1538.74,,,1538.74,Other,125% of Medicaid,0.01,3988.42,
CL TX MC FX SGL; W MANIP,26605,CPT,,30026605,CDM,450,RC,,,both,,,617,456.58,,,456.58,Other,150% of Medicare + 9.63% HCRA Surcharge,277.65,45,,277.65,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,305.42,,,305.42,Other,110% of Medicare,419.56,68,,419.56,percent of total billed charges,All Other,1031,,,1031,Other,186% of Medicaid,493.6,,,493.6,Other,Non Covered Service,512.11,,,512.11,Other,Non Covered Service,512.11,,,512.11,Other,Non Covered Service,493.6,,,493.6,Other,Non Covered Service,512.11,,,512.11,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,431.9,70,,431.9,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,554.53,,,554.53,Other,100% of Medicaid,554.53,,,554.53,Other,100% of Medicaid,554.53,,,554.53,Other,100% of Medicaid,554.53,,,554.53,Other,100% of Medicaid,1247.69,,,1247.69,Other,225% of Medicaid,848.43,,,848.43,Other,153% of Medicaid,1247.69,,,1247.69,Other,225% of Medicaid,776.34,,,776.34,Other,140% of Medicaid,1247.69,,,1247.69,Other,225% of Medicaid,1441.78,,,1441.78,Other,260% of Medicaid,1796.68,,,1796.68,Other,324% of Medicaid,1192.24,,,1192.24,Other,215% of Medicaid,1192.24,,,1192.24,Other,215% of Medicaid,693.16,,,693.16,Other,125% of Medicaid,0.01,1796.68,
CL TX CMC DISLOC THUMB W,26641,CPT,,30026641,CDM,450,RC,,,both,,,563,416.62,,,416.62,Other,150% of Medicare + 9.63% HCRA Surcharge,253.35,45,,253.35,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,278.69,,,278.69,Other,110% of Medicare,382.84,68,,382.84,percent of total billed charges,All Other,1031,,,1031,Other,186% of Medicaid,450.4,,,450.4,Other,Non Covered Service,467.29,,,467.29,Other,Non Covered Service,467.29,,,467.29,Other,Non Covered Service,450.4,,,450.4,Other,Non Covered Service,467.29,,,467.29,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,394.1,70,,394.1,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,554.53,,,554.53,Other,100% of Medicaid,554.53,,,554.53,Other,100% of Medicaid,554.53,,,554.53,Other,100% of Medicaid,554.53,,,554.53,Other,100% of Medicaid,1247.69,,,1247.69,Other,225% of Medicaid,848.43,,,848.43,Other,153% of Medicaid,1247.69,,,1247.69,Other,225% of Medicaid,776.34,,,776.34,Other,140% of Medicaid,1247.69,,,1247.69,Other,225% of Medicaid,1441.78,,,1441.78,Other,260% of Medicaid,1796.68,,,1796.68,Other,324% of Medicaid,1192.24,,,1192.24,Other,215% of Medicaid,1192.24,,,1192.24,Other,215% of Medicaid,693.16,,,693.16,Other,125% of Medicaid,0.01,1796.68,
CL TX CMC DISL W M EA,26670,CPT,,30026670,CDM,450,RC,,,both,,,858,634.92,,,634.92,Other,150% of Medicare + 9.63% HCRA Surcharge,386.1,45,,386.1,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,424.71,,,424.71,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,1031,,,1031,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,600.6,70,,600.6,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,554.53,,,554.53,Other,100% of Medicaid,554.53,,,554.53,Other,100% of Medicaid,554.53,,,554.53,Other,100% of Medicaid,554.53,,,554.53,Other,100% of Medicaid,1247.69,,,1247.69,Other,225% of Medicaid,848.43,,,848.43,Other,153% of Medicaid,1247.69,,,1247.69,Other,225% of Medicaid,776.34,,,776.34,Other,140% of Medicaid,1247.69,,,1247.69,Other,225% of Medicaid,1441.78,,,1441.78,Other,260% of Medicaid,1796.68,,,1796.68,Other,324% of Medicaid,1192.24,,,1192.24,Other,215% of Medicaid,1192.24,,,1192.24,Other,215% of Medicaid,693.16,,,693.16,Other,125% of Medicaid,0.01,1796.68,
CL TX MCP DISLOC SGL W,26700,CPT,,30026700,CDM,450,RC,,,both,,,603,446.22,,,446.22,Other,150% of Medicare + 9.63% HCRA Surcharge,271.35,45,,271.35,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,298.49,,,298.49,Other,110% of Medicare,410.04,68,,410.04,percent of total billed charges,All Other,1031,,,1031,Other,186% of Medicaid,482.4,,,482.4,Other,Non Covered Service,500.49,,,500.49,Other,Non Covered Service,500.49,,,500.49,Other,Non Covered Service,482.4,,,482.4,Other,Non Covered Service,500.49,,,500.49,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,422.1,70,,422.1,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,554.53,,,554.53,Other,100% of Medicaid,554.53,,,554.53,Other,100% of Medicaid,554.53,,,554.53,Other,100% of Medicaid,554.53,,,554.53,Other,100% of Medicaid,1247.69,,,1247.69,Other,225% of Medicaid,848.43,,,848.43,Other,153% of Medicaid,1247.69,,,1247.69,Other,225% of Medicaid,776.34,,,776.34,Other,140% of Medicaid,1247.69,,,1247.69,Other,225% of Medicaid,1441.78,,,1441.78,Other,260% of Medicaid,1796.68,,,1796.68,Other,324% of Medicaid,1192.24,,,1192.24,Other,215% of Medicaid,1192.24,,,1192.24,Other,215% of Medicaid,693.16,,,693.16,Other,125% of Medicaid,0.01,1796.68,
CL TX MCP DISLOC W MANIP & ANESTH,26705,CPT,,30026705,CDM,450,RC,,,both,,,3230,2390.21,,,2390.21,Other,150% of Medicare + 9.63% HCRA Surcharge,1453.5,45,,1453.5,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1598.85,,,1598.85,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,1730,,,1730,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2261,70,,2261,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,930.31,,,930.31,Other,100% of Medicaid,930.31,,,930.31,Other,100% of Medicaid,930.31,,,930.31,Other,100% of Medicaid,930.31,,,930.31,Other,100% of Medicaid,2093.21,,,2093.21,Other,225% of Medicaid,1423.38,,,1423.38,Other,153% of Medicaid,2093.21,,,2093.21,Other,225% of Medicaid,1302.44,,,1302.44,Other,140% of Medicaid,2093.21,,,2093.21,Other,225% of Medicaid,2418.82,,,2418.82,Other,260% of Medicaid,3014.22,,,3014.22,Other,324% of Medicaid,2000.18,,,2000.18,Other,215% of Medicaid,2000.18,,,2000.18,Other,215% of Medicaid,1162.89,,,1162.89,Other,125% of Medicaid,0.01,3014.22,
CL TX PHALANG SHFT FX W,26725,CPT,,30026725,CDM,450,RC,,,both,,,603,446.22,,,446.22,Other,150% of Medicare + 9.63% HCRA Surcharge,271.35,45,,271.35,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,298.49,,,298.49,Other,110% of Medicare,410.04,68,,410.04,percent of total billed charges,All Other,1031,,,1031,Other,186% of Medicaid,482.4,,,482.4,Other,Non Covered Service,500.49,,,500.49,Other,Non Covered Service,500.49,,,500.49,Other,Non Covered Service,482.4,,,482.4,Other,Non Covered Service,500.49,,,500.49,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,422.1,70,,422.1,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,554.53,,,554.53,Other,100% of Medicaid,554.53,,,554.53,Other,100% of Medicaid,554.53,,,554.53,Other,100% of Medicaid,554.53,,,554.53,Other,100% of Medicaid,1247.69,,,1247.69,Other,225% of Medicaid,848.43,,,848.43,Other,153% of Medicaid,1247.69,,,1247.69,Other,225% of Medicaid,776.34,,,776.34,Other,140% of Medicaid,1247.69,,,1247.69,Other,225% of Medicaid,1441.78,,,1441.78,Other,260% of Medicaid,1796.68,,,1796.68,Other,324% of Medicaid,1192.24,,,1192.24,Other,215% of Medicaid,1192.24,,,1192.24,Other,215% of Medicaid,693.16,,,693.16,Other,125% of Medicaid,0.01,1796.68,
CL TX ARTFX MCP IP JNT W,26742,CPT,,30026742,CDM,450,RC,,,both,,,3230,2390.21,,,2390.21,Other,150% of Medicare + 9.63% HCRA Surcharge,1453.5,45,,1453.5,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1598.85,,,1598.85,Other,110% of Medicare,2196.4,68,,2196.4,percent of total billed charges,All Other,1031,,,1031,Other,186% of Medicaid,2584,,,2584,Other,Non Covered Service,2680.9,,,2680.9,Other,Non Covered Service,2680.9,,,2680.9,Other,Non Covered Service,2584,,,2584,Other,Non Covered Service,2680.9,,,2680.9,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2261,70,,2261,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,554.53,,,554.53,Other,100% of Medicaid,554.53,,,554.53,Other,100% of Medicaid,554.53,,,554.53,Other,100% of Medicaid,554.53,,,554.53,Other,100% of Medicaid,1247.69,,,1247.69,Other,225% of Medicaid,848.43,,,848.43,Other,153% of Medicaid,1247.69,,,1247.69,Other,225% of Medicaid,776.34,,,776.34,Other,140% of Medicaid,1247.69,,,1247.69,Other,225% of Medicaid,1441.78,,,1441.78,Other,260% of Medicaid,1796.68,,,1796.68,Other,324% of Medicaid,1192.24,,,1192.24,Other,215% of Medicaid,1192.24,,,1192.24,Other,215% of Medicaid,693.16,,,693.16,Other,125% of Medicaid,0.01,2680.9,
CL TX D PLAL FX FGRR THMB,26755,CPT,,30026755,CDM,450,RC,,,both,,,563,416.62,,,416.62,Other,150% of Medicare + 9.63% HCRA Surcharge,253.35,45,,253.35,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,278.69,,,278.69,Other,110% of Medicare,382.84,68,,382.84,percent of total billed charges,All Other,1031,,,1031,Other,186% of Medicaid,450.4,,,450.4,Other,Non Covered Service,467.29,,,467.29,Other,Non Covered Service,467.29,,,467.29,Other,Non Covered Service,450.4,,,450.4,Other,Non Covered Service,467.29,,,467.29,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,394.1,70,,394.1,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,554.53,,,554.53,Other,100% of Medicaid,554.53,,,554.53,Other,100% of Medicaid,554.53,,,554.53,Other,100% of Medicaid,554.53,,,554.53,Other,100% of Medicaid,1247.69,,,1247.69,Other,225% of Medicaid,848.43,,,848.43,Other,153% of Medicaid,1247.69,,,1247.69,Other,225% of Medicaid,776.34,,,776.34,Other,140% of Medicaid,1247.69,,,1247.69,Other,225% of Medicaid,1441.78,,,1441.78,Other,260% of Medicaid,1796.68,,,1796.68,Other,324% of Medicaid,1192.24,,,1192.24,Other,215% of Medicaid,1192.24,,,1192.24,Other,215% of Medicaid,693.16,,,693.16,Other,125% of Medicaid,0.01,1796.68,
OPEN TX DISTAL PHALANG FRACT EA,26765,CPT,,30026765,CDM,450,RC,,,both,,,8210,6075.42,,,6075.42,Other,150% of Medicare + 9.63% HCRA Surcharge,3694.5,45,,3694.5,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,4063.95,,,4063.95,Other,110% of Medicare,5582.8,68,,5582.8,percent of total billed charges,All Other,5093,,,5093,Other,186% of Medicaid,6568,,,6568,Other,Non Covered Service,6814.3,,,6814.3,Other,Non Covered Service,6814.3,,,6814.3,Other,Non Covered Service,6568,,,6568,Other,Non Covered Service,6814.3,,,6814.3,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,5747,70,,5747,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2737.91,,,2737.91,Other,100% of Medicaid,2737.91,,,2737.91,Other,100% of Medicaid,2737.91,,,2737.91,Other,100% of Medicaid,2737.91,,,2737.91,Other,100% of Medicaid,6160.29,,,6160.29,Other,225% of Medicaid,4189,,,4189,Other,153% of Medicaid,6160.29,,,6160.29,Other,225% of Medicaid,3833.07,,,3833.07,Other,140% of Medicaid,6160.29,,,6160.29,Other,225% of Medicaid,7118.55,,,7118.55,Other,260% of Medicaid,8870.81,,,8870.81,Other,324% of Medicaid,5886.5,,,5886.5,Other,215% of Medicaid,5886.5,,,5886.5,Other,215% of Medicaid,3422.38,,,3422.38,Other,125% of Medicaid,0.01,8870.81,
CL TX IP JNT D W MANIP ; WO AN,26770,CPT,,30026770,CDM,450,RC,,,both,,,603,446.22,,,446.22,Other,150% of Medicare + 9.63% HCRA Surcharge,271.35,45,,271.35,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,298.49,,,298.49,Other,110% of Medicare,410.04,68,,410.04,percent of total billed charges,All Other,1031,,,1031,Other,186% of Medicaid,482.4,,,482.4,Other,Non Covered Service,500.49,,,500.49,Other,Non Covered Service,500.49,,,500.49,Other,Non Covered Service,482.4,,,482.4,Other,Non Covered Service,500.49,,,500.49,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,422.1,70,,422.1,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,554.53,,,554.53,Other,100% of Medicaid,554.53,,,554.53,Other,100% of Medicaid,554.53,,,554.53,Other,100% of Medicaid,554.53,,,554.53,Other,100% of Medicaid,1247.69,,,1247.69,Other,225% of Medicaid,848.43,,,848.43,Other,153% of Medicaid,1247.69,,,1247.69,Other,225% of Medicaid,776.34,,,776.34,Other,140% of Medicaid,1247.69,,,1247.69,Other,225% of Medicaid,1441.78,,,1441.78,Other,260% of Medicaid,1796.68,,,1796.68,Other,324% of Medicaid,1192.24,,,1192.24,Other,215% of Medicaid,1192.24,,,1192.24,Other,215% of Medicaid,693.16,,,693.16,Other,125% of Medicaid,0.01,1796.68,
CL TX IP JT D W MANIP; W ANEST,26775,CPT,,30026775,CDM,450,RC,,,both,,,5431,4018.95,,,4018.95,Other,150% of Medicare + 9.63% HCRA Surcharge,2443.95,45,,2443.95,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2688.35,,,2688.35,Other,110% of Medicare,3693.08,68,,3693.08,percent of total billed charges,All Other,1730,,,1730,Other,186% of Medicaid,4344.8,,,4344.8,Other,Non Covered Service,4507.73,,,4507.73,Other,Non Covered Service,4507.73,,,4507.73,Other,Non Covered Service,4344.8,,,4344.8,Other,Non Covered Service,4507.73,,,4507.73,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,3801.7,70,,3801.7,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,930.31,,,930.31,Other,100% of Medicaid,930.31,,,930.31,Other,100% of Medicaid,930.31,,,930.31,Other,100% of Medicaid,930.31,,,930.31,Other,100% of Medicaid,2093.21,,,2093.21,Other,225% of Medicaid,1423.38,,,1423.38,Other,153% of Medicaid,2093.21,,,2093.21,Other,225% of Medicaid,1302.44,,,1302.44,Other,140% of Medicaid,2093.21,,,2093.21,Other,225% of Medicaid,2418.82,,,2418.82,Other,260% of Medicaid,3014.22,,,3014.22,Other,324% of Medicaid,2000.18,,,2000.18,Other,215% of Medicaid,2000.18,,,2000.18,Other,215% of Medicaid,1162.89,,,1162.89,Other,125% of Medicaid,0.01,4507.73,
AMPUTATE FING/TH SGL; W DIR CL,26951,CPT,,30026951,CDM,450,RC,,,both,,,6701,4958.76,,,4958.76,Other,150% of Medicare + 9.63% HCRA Surcharge,3015.45,45,,3015.45,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,3317,,,3317,Other,110% of Medicare,4556.68,68,,4556.68,percent of total billed charges,All Other,2290,,,2290,Other,186% of Medicaid,5360.8,,,5360.8,Other,Non Covered Service,5561.83,,,5561.83,Other,Non Covered Service,5561.83,,,5561.83,Other,Non Covered Service,5360.8,,,5360.8,Other,Non Covered Service,5561.83,,,5561.83,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,4690.7,70,,4690.7,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1231,,,1231,Other,100% of Medicaid,1231,,,1231,Other,100% of Medicaid,1231,,,1231,Other,100% of Medicaid,1231,,,1231,Other,100% of Medicaid,2769.74,,,2769.74,Other,225% of Medicaid,1883.42,,,1883.42,Other,153% of Medicaid,2769.74,,,2769.74,Other,225% of Medicaid,1723.39,,,1723.39,Other,140% of Medicaid,2769.74,,,2769.74,Other,225% of Medicaid,3200.59,,,3200.59,Other,260% of Medicaid,3988.42,,,3988.42,Other,324% of Medicaid,2646.64,,,2646.64,Other,215% of Medicaid,2646.64,,,2646.64,Other,215% of Medicaid,1538.74,,,1538.74,Other,125% of Medicaid,0.01,5561.83,
AMPUTATE FING/TH SGL; W LOC AD,26952,CPT,,30026952,CDM,450,RC,,,both,,,6701,4958.76,,,4958.76,Other,150% of Medicare + 9.63% HCRA Surcharge,3015.45,45,,3015.45,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,3317,,,3317,Other,110% of Medicare,4556.68,68,,4556.68,percent of total billed charges,All Other,3655,,,3655,Other,186% of Medicaid,5360.8,,,5360.8,Other,Non Covered Service,5561.83,,,5561.83,Other,Non Covered Service,5561.83,,,5561.83,Other,Non Covered Service,5360.8,,,5360.8,Other,Non Covered Service,5561.83,,,5561.83,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,4690.7,70,,4690.7,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1965,,,1965,Other,100% of Medicaid,1965,,,1965,Other,100% of Medicaid,1965,,,1965,Other,100% of Medicaid,1965,,,1965,Other,100% of Medicaid,4421.25,,,4421.25,Other,225% of Medicaid,3006.45,,,3006.45,Other,153% of Medicaid,4421.25,,,4421.25,Other,225% of Medicaid,2751,,,2751,Other,140% of Medicaid,4421.25,,,4421.25,Other,225% of Medicaid,5109,,,5109,Other,260% of Medicaid,6366.6,,,6366.6,Other,324% of Medicaid,4224.75,,,4224.75,Other,215% of Medicaid,4224.75,,,4224.75,Other,215% of Medicaid,2456.25,,,2456.25,Other,125% of Medicaid,0.01,6366.6,
CL TX TRAUMA HIP DISLC WO,27250,CPT,,30027250,CDM,450,RC,,,both,,,554,409.96,,,409.96,Other,150% of Medicare + 9.63% HCRA Surcharge,249.3,45,,249.3,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,274.23,,,274.23,Other,110% of Medicare,376.72,68,,376.72,percent of total billed charges,All Other,1031,,,1031,Other,186% of Medicaid,443.2,,,443.2,Other,Non Covered Service,459.82,,,459.82,Other,Non Covered Service,459.82,,,459.82,Other,Non Covered Service,443.2,,,443.2,Other,Non Covered Service,459.82,,,459.82,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,387.8,70,,387.8,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,554.53,,,554.53,Other,100% of Medicaid,554.53,,,554.53,Other,100% of Medicaid,554.53,,,554.53,Other,100% of Medicaid,554.53,,,554.53,Other,100% of Medicaid,1247.69,,,1247.69,Other,225% of Medicaid,848.43,,,848.43,Other,153% of Medicaid,1247.69,,,1247.69,Other,225% of Medicaid,776.34,,,776.34,Other,140% of Medicaid,1247.69,,,1247.69,Other,225% of Medicaid,1441.78,,,1441.78,Other,260% of Medicaid,1796.68,,,1796.68,Other,324% of Medicaid,1192.24,,,1192.24,Other,215% of Medicaid,1192.24,,,1192.24,Other,215% of Medicaid,693.16,,,693.16,Other,125% of Medicaid,0.01,1796.68,
CL TX TRAUMA HIP DISLC W,27252,CPT,,30027252,CDM,450,RC,,,both,,,5075,3755.51,,,3755.51,Other,150% of Medicare + 9.63% HCRA Surcharge,2283.75,45,,2283.75,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2512.13,,,2512.13,Other,110% of Medicare,3451,68,,3451,percent of total billed charges,All Other,1730,,,1730,Other,186% of Medicaid,4060,,,4060,Other,Non Covered Service,4212.25,,,4212.25,Other,Non Covered Service,4212.25,,,4212.25,Other,Non Covered Service,4060,,,4060,Other,Non Covered Service,4212.25,,,4212.25,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,3552.5,70,,3552.5,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,930.31,,,930.31,Other,100% of Medicaid,930.31,,,930.31,Other,100% of Medicaid,930.31,,,930.31,Other,100% of Medicaid,930.31,,,930.31,Other,100% of Medicaid,2093.21,,,2093.21,Other,225% of Medicaid,1423.38,,,1423.38,Other,153% of Medicaid,2093.21,,,2093.21,Other,225% of Medicaid,1302.44,,,1302.44,Other,140% of Medicaid,2093.21,,,2093.21,Other,225% of Medicaid,2418.82,,,2418.82,Other,260% of Medicaid,3014.22,,,3014.22,Other,324% of Medicaid,2000.18,,,2000.18,Other,215% of Medicaid,2000.18,,,2000.18,Other,215% of Medicaid,1162.89,,,1162.89,Other,125% of Medicaid,0.01,4212.25,
TX SPONTAN HIP DISLOC W A,27257,CPT,,30027257,CDM,450,RC,,,both,,,5531,4092.95,,,4092.95,Other,150% of Medicare + 9.63% HCRA Surcharge,2488.95,45,,2488.95,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2737.85,,,2737.85,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,1730,,,1730,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,3871.7,70,,3871.7,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,930.31,,,930.31,Other,100% of Medicaid,930.31,,,930.31,Other,100% of Medicaid,930.31,,,930.31,Other,100% of Medicaid,930.31,,,930.31,Other,100% of Medicaid,2093.21,,,2093.21,Other,225% of Medicaid,1423.38,,,1423.38,Other,153% of Medicaid,2093.21,,,2093.21,Other,225% of Medicaid,1302.44,,,1302.44,Other,140% of Medicaid,2093.21,,,2093.21,Other,225% of Medicaid,2418.82,,,2418.82,Other,260% of Medicaid,3014.22,,,3014.22,Other,324% of Medicaid,2000.18,,,2000.18,Other,215% of Medicaid,2000.18,,,2000.18,Other,215% of Medicaid,1162.89,,,1162.89,Other,125% of Medicaid,0.01,4092.95,
CL TX POST HIP DISLOC WO,27265,CPT,,30027265,CDM,450,RC,,,both,,,603,446.22,,,446.22,Other,150% of Medicare + 9.63% HCRA Surcharge,271.35,45,,271.35,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,298.49,,,298.49,Other,110% of Medicare,410.04,68,,410.04,percent of total billed charges,All Other,1031,,,1031,Other,186% of Medicaid,482.4,,,482.4,Other,Non Covered Service,500.49,,,500.49,Other,Non Covered Service,500.49,,,500.49,Other,Non Covered Service,482.4,,,482.4,Other,Non Covered Service,500.49,,,500.49,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,422.1,70,,422.1,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,554.53,,,554.53,Other,100% of Medicaid,554.53,,,554.53,Other,100% of Medicaid,554.53,,,554.53,Other,100% of Medicaid,554.53,,,554.53,Other,100% of Medicaid,1247.69,,,1247.69,Other,225% of Medicaid,848.43,,,848.43,Other,153% of Medicaid,1247.69,,,1247.69,Other,225% of Medicaid,776.34,,,776.34,Other,140% of Medicaid,1247.69,,,1247.69,Other,225% of Medicaid,1441.78,,,1441.78,Other,260% of Medicaid,1796.68,,,1796.68,Other,324% of Medicaid,1192.24,,,1192.24,Other,215% of Medicaid,1192.24,,,1192.24,Other,215% of Medicaid,693.16,,,693.16,Other,125% of Medicaid,0.01,1796.68,
CL TX POSTOP HIP DISLOC W,27266,CPT,,30027266,CDM,450,RC,,,both,,,5075,3755.51,,,3755.51,Other,150% of Medicare + 9.63% HCRA Surcharge,2283.75,45,,2283.75,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2512.13,,,2512.13,Other,110% of Medicare,3451,68,,3451,percent of total billed charges,All Other,1730,,,1730,Other,186% of Medicaid,4060,,,4060,Other,Non Covered Service,4212.25,,,4212.25,Other,Non Covered Service,4212.25,,,4212.25,Other,Non Covered Service,4060,,,4060,Other,Non Covered Service,4212.25,,,4212.25,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,3552.5,70,,3552.5,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,930.31,,,930.31,Other,100% of Medicaid,930.31,,,930.31,Other,100% of Medicaid,930.31,,,930.31,Other,100% of Medicaid,930.31,,,930.31,Other,100% of Medicaid,2093.21,,,2093.21,Other,225% of Medicaid,1423.38,,,1423.38,Other,153% of Medicaid,2093.21,,,2093.21,Other,225% of Medicaid,1302.44,,,1302.44,Other,140% of Medicaid,2093.21,,,2093.21,Other,225% of Medicaid,2418.82,,,2418.82,Other,260% of Medicaid,3014.22,,,3014.22,Other,324% of Medicaid,2000.18,,,2000.18,Other,215% of Medicaid,2000.18,,,2000.18,Other,215% of Medicaid,1162.89,,,1162.89,Other,125% of Medicaid,0.01,4212.25,
CLOSED REDUCTION OF FEMUR,27502,CPT,,30027502,CDM,450,RC,,,both,,,7272,5381.3,,,5381.3,Other,150% of Medicare + 9.63% HCRA Surcharge,3272.4,45,,3272.4,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,3599.64,,,3599.64,Other,110% of Medicare,4944.96,68,,4944.96,percent of total billed charges,All Other,1031,,,1031,Other,186% of Medicaid,5817.6,,,5817.6,Other,Non Covered Service,6035.76,,,6035.76,Other,Non Covered Service,6035.76,,,6035.76,Other,Non Covered Service,5817.6,,,5817.6,Other,Non Covered Service,6035.76,,,6035.76,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,5090.4,70,,5090.4,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,554.53,,,554.53,Other,100% of Medicaid,554.53,,,554.53,Other,100% of Medicaid,554.53,,,554.53,Other,100% of Medicaid,554.53,,,554.53,Other,100% of Medicaid,1247.69,,,1247.69,Other,225% of Medicaid,848.43,,,848.43,Other,153% of Medicaid,1247.69,,,1247.69,Other,225% of Medicaid,776.34,,,776.34,Other,140% of Medicaid,1247.69,,,1247.69,Other,225% of Medicaid,1441.78,,,1441.78,Other,260% of Medicaid,1796.68,,,1796.68,Other,324% of Medicaid,1192.24,,,1192.24,Other,215% of Medicaid,1192.24,,,1192.24,Other,215% of Medicaid,693.16,,,693.16,Other,125% of Medicaid,0.01,6035.76,
CL TX PROX TIBIAL FX W SK TRACTION,27532,CPT,,30027532,CDM,450,RC,,,both,,,6701,4958.76,,,4958.76,Other,150% of Medicare + 9.63% HCRA Surcharge,3015.45,45,,3015.45,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,3317,,,3317,Other,110% of Medicare,4556.68,68,,4556.68,percent of total billed charges,All Other,1031,,,1031,Other,186% of Medicaid,5360.8,,,5360.8,Other,Non Covered Service,5561.83,,,5561.83,Other,Non Covered Service,5561.83,,,5561.83,Other,Non Covered Service,5360.8,,,5360.8,Other,Non Covered Service,5561.83,,,5561.83,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,4690.7,70,,4690.7,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,554.53,,,554.53,Other,100% of Medicaid,554.53,,,554.53,Other,100% of Medicaid,554.53,,,554.53,Other,100% of Medicaid,554.53,,,554.53,Other,100% of Medicaid,1247.69,,,1247.69,Other,225% of Medicaid,848.43,,,848.43,Other,153% of Medicaid,1247.69,,,1247.69,Other,225% of Medicaid,776.34,,,776.34,Other,140% of Medicaid,1247.69,,,1247.69,Other,225% of Medicaid,1441.78,,,1441.78,Other,260% of Medicaid,1796.68,,,1796.68,Other,324% of Medicaid,1192.24,,,1192.24,Other,215% of Medicaid,1192.24,,,1192.24,Other,215% of Medicaid,693.16,,,693.16,Other,125% of Medicaid,0.01,5561.83,
CL TX KNEE DISL WO ANEST,27550,CPT,,30027550,CDM,450,RC,,,both,,,563,416.62,,,416.62,Other,150% of Medicare + 9.63% HCRA Surcharge,253.35,45,,253.35,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,278.69,,,278.69,Other,110% of Medicare,382.84,68,,382.84,percent of total billed charges,All Other,1031,,,1031,Other,186% of Medicaid,450.4,,,450.4,Other,Non Covered Service,467.29,,,467.29,Other,Non Covered Service,467.29,,,467.29,Other,Non Covered Service,450.4,,,450.4,Other,Non Covered Service,467.29,,,467.29,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,394.1,70,,394.1,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,554.53,,,554.53,Other,100% of Medicaid,554.53,,,554.53,Other,100% of Medicaid,554.53,,,554.53,Other,100% of Medicaid,554.53,,,554.53,Other,100% of Medicaid,1247.69,,,1247.69,Other,225% of Medicaid,848.43,,,848.43,Other,153% of Medicaid,1247.69,,,1247.69,Other,225% of Medicaid,776.34,,,776.34,Other,140% of Medicaid,1247.69,,,1247.69,Other,225% of Medicaid,1441.78,,,1441.78,Other,260% of Medicaid,1796.68,,,1796.68,Other,324% of Medicaid,1192.24,,,1192.24,Other,215% of Medicaid,1192.24,,,1192.24,Other,215% of Medicaid,693.16,,,693.16,Other,125% of Medicaid,0.01,1796.68,
CL TX KNEE DISL W ANESTH,27552,CPT,,30027552,CDM,450,RC,,,both,,,5075,3755.51,,,3755.51,Other,150% of Medicare + 9.63% HCRA Surcharge,2283.75,45,,2283.75,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2512.13,,,2512.13,Other,110% of Medicare,3451,68,,3451,percent of total billed charges,All Other,1730,,,1730,Other,186% of Medicaid,4060,,,4060,Other,Non Covered Service,4212.25,,,4212.25,Other,Non Covered Service,4212.25,,,4212.25,Other,Non Covered Service,4060,,,4060,Other,Non Covered Service,4212.25,,,4212.25,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,3552.5,70,,3552.5,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,930.31,,,930.31,Other,100% of Medicaid,930.31,,,930.31,Other,100% of Medicaid,930.31,,,930.31,Other,100% of Medicaid,930.31,,,930.31,Other,100% of Medicaid,2093.21,,,2093.21,Other,225% of Medicaid,1423.38,,,1423.38,Other,153% of Medicaid,2093.21,,,2093.21,Other,225% of Medicaid,1302.44,,,1302.44,Other,140% of Medicaid,2093.21,,,2093.21,Other,225% of Medicaid,2418.82,,,2418.82,Other,260% of Medicaid,3014.22,,,3014.22,Other,324% of Medicaid,2000.18,,,2000.18,Other,215% of Medicaid,2000.18,,,2000.18,Other,215% of Medicaid,1162.89,,,1162.89,Other,125% of Medicaid,0.01,4212.25,
CL TX PATELLAR DISLC WO A,27560,CPT,,30027560,CDM,450,RC,,,both,,,603,446.22,,,446.22,Other,150% of Medicare + 9.63% HCRA Surcharge,271.35,45,,271.35,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,298.49,,,298.49,Other,110% of Medicare,410.04,68,,410.04,percent of total billed charges,All Other,1031,,,1031,Other,186% of Medicaid,482.4,,,482.4,Other,Non Covered Service,500.49,,,500.49,Other,Non Covered Service,500.49,,,500.49,Other,Non Covered Service,482.4,,,482.4,Other,Non Covered Service,500.49,,,500.49,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,422.1,70,,422.1,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,554.53,,,554.53,Other,100% of Medicaid,554.53,,,554.53,Other,100% of Medicaid,554.53,,,554.53,Other,100% of Medicaid,554.53,,,554.53,Other,100% of Medicaid,1247.69,,,1247.69,Other,225% of Medicaid,848.43,,,848.43,Other,153% of Medicaid,1247.69,,,1247.69,Other,225% of Medicaid,776.34,,,776.34,Other,140% of Medicaid,1247.69,,,1247.69,Other,225% of Medicaid,1441.78,,,1441.78,Other,260% of Medicaid,1796.68,,,1796.68,Other,324% of Medicaid,1192.24,,,1192.24,Other,215% of Medicaid,1192.24,,,1192.24,Other,215% of Medicaid,693.16,,,693.16,Other,125% of Medicaid,0.01,1796.68,
CL TX PATELLAR DISLOCATE,27562,CPT,,30027562,CDM,450,RC,,,both,,,5075,3755.51,,,3755.51,Other,150% of Medicare + 9.63% HCRA Surcharge,2283.75,45,,2283.75,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2512.13,,,2512.13,Other,110% of Medicare,3451,68,,3451,percent of total billed charges,All Other,1730,,,1730,Other,186% of Medicaid,4060,,,4060,Other,Non Covered Service,4212.25,,,4212.25,Other,Non Covered Service,4212.25,,,4212.25,Other,Non Covered Service,4060,,,4060,Other,Non Covered Service,4212.25,,,4212.25,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,3552.5,70,,3552.5,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,930.31,,,930.31,Other,100% of Medicaid,930.31,,,930.31,Other,100% of Medicaid,930.31,,,930.31,Other,100% of Medicaid,930.31,,,930.31,Other,100% of Medicaid,2093.21,,,2093.21,Other,225% of Medicaid,1423.38,,,1423.38,Other,153% of Medicaid,2093.21,,,2093.21,Other,225% of Medicaid,1302.44,,,1302.44,Other,140% of Medicaid,2093.21,,,2093.21,Other,225% of Medicaid,2418.82,,,2418.82,Other,260% of Medicaid,3014.22,,,3014.22,Other,324% of Medicaid,2000.18,,,2000.18,Other,215% of Medicaid,2000.18,,,2000.18,Other,215% of Medicaid,1162.89,,,1162.89,Other,125% of Medicaid,0.01,4212.25,
CL TX TIB SHFT FX WO MANI,27750,CPT,,30027750,CDM,450,RC,,,both,,,517,382.58,,,382.58,Other,150% of Medicare + 9.63% HCRA Surcharge,232.65,45,,232.65,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,255.92,,,255.92,Other,110% of Medicare,351.56,68,,351.56,percent of total billed charges,All Other,1031,,,1031,Other,186% of Medicaid,413.6,,,413.6,Other,Non Covered Service,429.11,,,429.11,Other,Non Covered Service,429.11,,,429.11,Other,Non Covered Service,413.6,,,413.6,Other,Non Covered Service,429.11,,,429.11,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,361.9,70,,361.9,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,554.53,,,554.53,Other,100% of Medicaid,554.53,,,554.53,Other,100% of Medicaid,554.53,,,554.53,Other,100% of Medicaid,554.53,,,554.53,Other,100% of Medicaid,1247.69,,,1247.69,Other,225% of Medicaid,848.43,,,848.43,Other,153% of Medicaid,1247.69,,,1247.69,Other,225% of Medicaid,776.34,,,776.34,Other,140% of Medicaid,1247.69,,,1247.69,Other,225% of Medicaid,1441.78,,,1441.78,Other,260% of Medicaid,1796.68,,,1796.68,Other,324% of Medicaid,1192.24,,,1192.24,Other,215% of Medicaid,1192.24,,,1192.24,Other,215% of Medicaid,693.16,,,693.16,Other,125% of Medicaid,0.01,1796.68,
CL TX TIB SHFT FX W MANIP,27752,CPT,,30027752,CDM,450,RC,,,both,,,7272,5381.3,,,5381.3,Other,150% of Medicare + 9.63% HCRA Surcharge,3272.4,45,,3272.4,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,3599.64,,,3599.64,Other,110% of Medicare,4944.96,68,,4944.96,percent of total billed charges,All Other,1031,,,1031,Other,186% of Medicaid,5817.6,,,5817.6,Other,Non Covered Service,6035.76,,,6035.76,Other,Non Covered Service,6035.76,,,6035.76,Other,Non Covered Service,5817.6,,,5817.6,Other,Non Covered Service,6035.76,,,6035.76,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,5090.4,70,,5090.4,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,554.53,,,554.53,Other,100% of Medicaid,554.53,,,554.53,Other,100% of Medicaid,554.53,,,554.53,Other,100% of Medicaid,554.53,,,554.53,Other,100% of Medicaid,1247.69,,,1247.69,Other,225% of Medicaid,848.43,,,848.43,Other,153% of Medicaid,1247.69,,,1247.69,Other,225% of Medicaid,776.34,,,776.34,Other,140% of Medicaid,1247.69,,,1247.69,Other,225% of Medicaid,1441.78,,,1441.78,Other,260% of Medicaid,1796.68,,,1796.68,Other,324% of Medicaid,1192.24,,,1192.24,Other,215% of Medicaid,1192.24,,,1192.24,Other,215% of Medicaid,693.16,,,693.16,Other,125% of Medicaid,0.01,6035.76,
CLTX MED ANKLE FX W MNPJ,27762,CPT,,30027762,CDM,450,RC,,,both,,,6796,5029.06,,,5029.06,Other,150% of Medicare + 9.63% HCRA Surcharge,3058.2,45,,3058.2,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,3364.02,,,3364.02,Other,110% of Medicare,4621.28,68,,4621.28,percent of total billed charges,All Other,1031,,,1031,Other,186% of Medicaid,5436.8,,,5436.8,Other,Non Covered Service,5640.68,,,5640.68,Other,Non Covered Service,5640.68,,,5640.68,Other,Non Covered Service,5436.8,,,5436.8,Other,Non Covered Service,5640.68,,,5640.68,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,4757.2,70,,4757.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,554.53,,,554.53,Other,100% of Medicaid,554.53,,,554.53,Other,100% of Medicaid,554.53,,,554.53,Other,100% of Medicaid,554.53,,,554.53,Other,100% of Medicaid,1247.69,,,1247.69,Other,225% of Medicaid,848.43,,,848.43,Other,153% of Medicaid,1247.69,,,1247.69,Other,225% of Medicaid,776.34,,,776.34,Other,140% of Medicaid,1247.69,,,1247.69,Other,225% of Medicaid,1441.78,,,1441.78,Other,260% of Medicaid,1796.68,,,1796.68,Other,324% of Medicaid,1192.24,,,1192.24,Other,215% of Medicaid,1192.24,,,1192.24,Other,215% of Medicaid,693.16,,,693.16,Other,125% of Medicaid,0.01,5640.68,
CLTX POST ANKLE FX W/MNPJ,27768,CPT,,30027768,CDM,450,RC,,,both,,,9625,7122.52,,,7122.52,Other,150% of Medicare + 9.63% HCRA Surcharge,4331.25,45,,4331.25,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,4764.38,,,4764.38,Other,110% of Medicare,6545,68,,6545,percent of total billed charges,All Other,1031,,,1031,Other,186% of Medicaid,7700,,,7700,Other,Non Covered Service,7988.75,,,7988.75,Other,Non Covered Service,7988.75,,,7988.75,Other,Non Covered Service,7700,,,7700,Other,Non Covered Service,7988.75,,,7988.75,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,6737.5,70,,6737.5,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,554.53,,,554.53,Other,100% of Medicaid,554.53,,,554.53,Other,100% of Medicaid,554.53,,,554.53,Other,100% of Medicaid,554.53,,,554.53,Other,100% of Medicaid,1247.69,,,1247.69,Other,225% of Medicaid,848.43,,,848.43,Other,153% of Medicaid,1247.69,,,1247.69,Other,225% of Medicaid,776.34,,,776.34,Other,140% of Medicaid,1247.69,,,1247.69,Other,225% of Medicaid,1441.78,,,1441.78,Other,260% of Medicaid,1796.68,,,1796.68,Other,324% of Medicaid,1192.24,,,1192.24,Other,215% of Medicaid,1192.24,,,1192.24,Other,215% of Medicaid,693.16,,,693.16,Other,125% of Medicaid,0.01,7988.75,
CL TX PROX FIB/SHAFT FX W MANIP,27781,CPT,,30027781,CDM,450,RC,,,both,,,8929,6607.48,,,6607.48,Other,150% of Medicare + 9.63% HCRA Surcharge,4018.05,45,,4018.05,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,4419.86,,,4419.86,Other,110% of Medicare,6071.72,68,,6071.72,percent of total billed charges,All Other,1031,,,1031,Other,186% of Medicaid,7143.2,,,7143.2,Other,Non Covered Service,7411.07,,,7411.07,Other,Non Covered Service,7411.07,,,7411.07,Other,Non Covered Service,7143.2,,,7143.2,Other,Non Covered Service,7411.07,,,7411.07,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,6250.3,70,,6250.3,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,554.53,,,554.53,Other,100% of Medicaid,554.53,,,554.53,Other,100% of Medicaid,554.53,,,554.53,Other,100% of Medicaid,554.53,,,554.53,Other,100% of Medicaid,1247.69,,,1247.69,Other,225% of Medicaid,848.43,,,848.43,Other,153% of Medicaid,1247.69,,,1247.69,Other,225% of Medicaid,776.34,,,776.34,Other,140% of Medicaid,1247.69,,,1247.69,Other,225% of Medicaid,1441.78,,,1441.78,Other,260% of Medicaid,1796.68,,,1796.68,Other,324% of Medicaid,1192.24,,,1192.24,Other,215% of Medicaid,1192.24,,,1192.24,Other,215% of Medicaid,693.16,,,693.16,Other,125% of Medicaid,0.01,7411.07,
CT TX DISTL FIB FX W MANI,27788,CPT,,30027788,CDM,450,RC,,,both,,,563,416.62,,,416.62,Other,150% of Medicare + 9.63% HCRA Surcharge,253.35,45,,253.35,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,278.69,,,278.69,Other,110% of Medicare,382.84,68,,382.84,percent of total billed charges,All Other,1031,,,1031,Other,186% of Medicaid,450.4,,,450.4,Other,Non Covered Service,467.29,,,467.29,Other,Non Covered Service,467.29,,,467.29,Other,Non Covered Service,450.4,,,450.4,Other,Non Covered Service,467.29,,,467.29,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,394.1,70,,394.1,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,554.53,,,554.53,Other,100% of Medicaid,554.53,,,554.53,Other,100% of Medicaid,554.53,,,554.53,Other,100% of Medicaid,554.53,,,554.53,Other,100% of Medicaid,1247.69,,,1247.69,Other,225% of Medicaid,848.43,,,848.43,Other,153% of Medicaid,1247.69,,,1247.69,Other,225% of Medicaid,776.34,,,776.34,Other,140% of Medicaid,1247.69,,,1247.69,Other,225% of Medicaid,1441.78,,,1441.78,Other,260% of Medicaid,1796.68,,,1796.68,Other,324% of Medicaid,1192.24,,,1192.24,Other,215% of Medicaid,1192.24,,,1192.24,Other,215% of Medicaid,693.16,,,693.16,Other,125% of Medicaid,0.01,1796.68,
CLD TRMT ANKLE FRACTURE M,27810,CPT,,30027810,CDM,450,RC,,,both,,,3230,2390.21,,,2390.21,Other,150% of Medicare + 9.63% HCRA Surcharge,1453.5,45,,1453.5,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1598.85,,,1598.85,Other,110% of Medicare,2196.4,68,,2196.4,percent of total billed charges,All Other,1031,,,1031,Other,186% of Medicaid,2584,,,2584,Other,Non Covered Service,2680.9,,,2680.9,Other,Non Covered Service,2680.9,,,2680.9,Other,Non Covered Service,2584,,,2584,Other,Non Covered Service,2680.9,,,2680.9,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2261,70,,2261,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,554.53,,,554.53,Other,100% of Medicaid,554.53,,,554.53,Other,100% of Medicaid,554.53,,,554.53,Other,100% of Medicaid,554.53,,,554.53,Other,100% of Medicaid,1247.69,,,1247.69,Other,225% of Medicaid,848.43,,,848.43,Other,153% of Medicaid,1247.69,,,1247.69,Other,225% of Medicaid,776.34,,,776.34,Other,140% of Medicaid,1247.69,,,1247.69,Other,225% of Medicaid,1441.78,,,1441.78,Other,260% of Medicaid,1796.68,,,1796.68,Other,324% of Medicaid,1192.24,,,1192.24,Other,215% of Medicaid,1192.24,,,1192.24,Other,215% of Medicaid,693.16,,,693.16,Other,125% of Medicaid,0.01,2680.9,
CL TX TRIMALL ANKLE FX WO,27816,CPT,,30027816,CDM,450,RC,,,both,,,517,382.58,,,382.58,Other,150% of Medicare + 9.63% HCRA Surcharge,232.65,45,,232.65,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,255.92,,,255.92,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,1031,,,1031,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,361.9,70,,361.9,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,554.53,,,554.53,Other,100% of Medicaid,554.53,,,554.53,Other,100% of Medicaid,554.53,,,554.53,Other,100% of Medicaid,554.53,,,554.53,Other,100% of Medicaid,1247.69,,,1247.69,Other,225% of Medicaid,848.43,,,848.43,Other,153% of Medicaid,1247.69,,,1247.69,Other,225% of Medicaid,776.34,,,776.34,Other,140% of Medicaid,1247.69,,,1247.69,Other,225% of Medicaid,1441.78,,,1441.78,Other,260% of Medicaid,1796.68,,,1796.68,Other,324% of Medicaid,1192.24,,,1192.24,Other,215% of Medicaid,1192.24,,,1192.24,Other,215% of Medicaid,693.16,,,693.16,Other,125% of Medicaid,0.01,1796.68,
CLOSED REDUCTION ANKLE FRACTUR,27818,CPT,,30027818,CDM,450,RC,,,both,,,3230,2390.21,,,2390.21,Other,150% of Medicare + 9.63% HCRA Surcharge,1453.5,45,,1453.5,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1598.85,,,1598.85,Other,110% of Medicare,2196.4,68,,2196.4,percent of total billed charges,All Other,1031,,,1031,Other,186% of Medicaid,2584,,,2584,Other,Non Covered Service,2680.9,,,2680.9,Other,Non Covered Service,2680.9,,,2680.9,Other,Non Covered Service,2584,,,2584,Other,Non Covered Service,2680.9,,,2680.9,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2261,70,,2261,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,554.53,,,554.53,Other,100% of Medicaid,554.53,,,554.53,Other,100% of Medicaid,554.53,,,554.53,Other,100% of Medicaid,554.53,,,554.53,Other,100% of Medicaid,1247.69,,,1247.69,Other,225% of Medicaid,848.43,,,848.43,Other,153% of Medicaid,1247.69,,,1247.69,Other,225% of Medicaid,776.34,,,776.34,Other,140% of Medicaid,1247.69,,,1247.69,Other,225% of Medicaid,1441.78,,,1441.78,Other,260% of Medicaid,1796.68,,,1796.68,Other,324% of Medicaid,1192.24,,,1192.24,Other,215% of Medicaid,1192.24,,,1192.24,Other,215% of Medicaid,693.16,,,693.16,Other,125% of Medicaid,0.01,2680.9,
CL TX WB DSTL TIB FX W MA,27825,CPT,,30027825,CDM,450,RC,,,both,,,7408,5481.94,,,5481.94,Other,150% of Medicare + 9.63% HCRA Surcharge,3333.6,45,,3333.6,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,3666.96,,,3666.96,Other,110% of Medicare,5037.44,68,,5037.44,percent of total billed charges,All Other,1031,,,1031,Other,186% of Medicaid,5926.4,,,5926.4,Other,Non Covered Service,6148.64,,,6148.64,Other,Non Covered Service,6148.64,,,6148.64,Other,Non Covered Service,5926.4,,,5926.4,Other,Non Covered Service,6148.64,,,6148.64,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,5185.6,70,,5185.6,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,554.53,,,554.53,Other,100% of Medicaid,554.53,,,554.53,Other,100% of Medicaid,554.53,,,554.53,Other,100% of Medicaid,554.53,,,554.53,Other,100% of Medicaid,1247.69,,,1247.69,Other,225% of Medicaid,848.43,,,848.43,Other,153% of Medicaid,1247.69,,,1247.69,Other,225% of Medicaid,776.34,,,776.34,Other,140% of Medicaid,1247.69,,,1247.69,Other,225% of Medicaid,1441.78,,,1441.78,Other,260% of Medicaid,1796.68,,,1796.68,Other,324% of Medicaid,1192.24,,,1192.24,Other,215% of Medicaid,1192.24,,,1192.24,Other,215% of Medicaid,693.16,,,693.16,Other,125% of Medicaid,0.01,6148.64,
CL TX ANKLE DISLOCATION; WO ANES,27840,CPT,,30027840,CDM,450,RC,,,both,,,493,364.82,,,364.82,Other,150% of Medicare + 9.63% HCRA Surcharge,221.85,45,,221.85,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,244.04,,,244.04,Other,110% of Medicare,335.24,68,,335.24,percent of total billed charges,All Other,1031,,,1031,Other,186% of Medicaid,394.4,,,394.4,Other,Non Covered Service,409.19,,,409.19,Other,Non Covered Service,409.19,,,409.19,Other,Non Covered Service,394.4,,,394.4,Other,Non Covered Service,409.19,,,409.19,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,345.1,70,,345.1,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,554.53,,,554.53,Other,100% of Medicaid,554.53,,,554.53,Other,100% of Medicaid,554.53,,,554.53,Other,100% of Medicaid,554.53,,,554.53,Other,100% of Medicaid,1247.69,,,1247.69,Other,225% of Medicaid,848.43,,,848.43,Other,153% of Medicaid,1247.69,,,1247.69,Other,225% of Medicaid,776.34,,,776.34,Other,140% of Medicaid,1247.69,,,1247.69,Other,225% of Medicaid,1441.78,,,1441.78,Other,260% of Medicaid,1796.68,,,1796.68,Other,324% of Medicaid,1192.24,,,1192.24,Other,215% of Medicaid,1192.24,,,1192.24,Other,215% of Medicaid,693.16,,,693.16,Other,125% of Medicaid,0.01,1796.68,
CL TX ANKLE DISLOC W ANES,27842,CPT,,30027842,CDM,450,RC,,,both,,,5531,4092.95,,,4092.95,Other,150% of Medicare + 9.63% HCRA Surcharge,2488.95,45,,2488.95,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2737.85,,,2737.85,Other,110% of Medicare,3761.08,68,,3761.08,percent of total billed charges,All Other,1730,,,1730,Other,186% of Medicaid,4424.8,,,4424.8,Other,Non Covered Service,4590.73,,,4590.73,Other,Non Covered Service,4590.73,,,4590.73,Other,Non Covered Service,4424.8,,,4424.8,Other,Non Covered Service,4590.73,,,4590.73,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,3871.7,70,,3871.7,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,930.31,,,930.31,Other,100% of Medicaid,930.31,,,930.31,Other,100% of Medicaid,930.31,,,930.31,Other,100% of Medicaid,930.31,,,930.31,Other,100% of Medicaid,2093.21,,,2093.21,Other,225% of Medicaid,1423.38,,,1423.38,Other,153% of Medicaid,2093.21,,,2093.21,Other,225% of Medicaid,1302.44,,,1302.44,Other,140% of Medicaid,2093.21,,,2093.21,Other,225% of Medicaid,2418.82,,,2418.82,Other,260% of Medicaid,3014.22,,,3014.22,Other,324% of Medicaid,2000.18,,,2000.18,Other,215% of Medicaid,2000.18,,,2000.18,Other,215% of Medicaid,1162.89,,,1162.89,Other,125% of Medicaid,0.01,4590.73,
LEG OR ANKLE SURGERY PROCEDURE,27899,CPT,,30027899,CDM,450,RC,,,both,,,517,382.58,,,382.58,Other,150% of Medicare + 9.63% HCRA Surcharge,232.65,45,,232.65,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,255.92,,,255.92,Other,110% of Medicare,351.56,68,,351.56,percent of total billed charges,All Other,771,,,771,Other,186% of Medicaid,413.6,,,413.6,Other,Non Covered Service,429.11,,,429.11,Other,Non Covered Service,429.11,,,429.11,Other,Non Covered Service,413.6,,,413.6,Other,Non Covered Service,429.11,,,429.11,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,361.9,70,,361.9,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,414.69,,,414.69,Other,100% of Medicaid,414.69,,,414.69,Other,100% of Medicaid,414.69,,,414.69,Other,100% of Medicaid,414.69,,,414.69,Other,100% of Medicaid,933.04,,,933.04,Other,225% of Medicaid,634.47,,,634.47,Other,153% of Medicaid,933.04,,,933.04,Other,225% of Medicaid,580.56,,,580.56,Other,140% of Medicaid,933.04,,,933.04,Other,225% of Medicaid,1078.18,,,1078.18,Other,260% of Medicaid,1343.58,,,1343.58,Other,324% of Medicaid,891.58,,,891.58,Other,215% of Medicaid,891.58,,,891.58,Other,215% of Medicaid,518.36,,,518.36,Other,125% of Medicaid,0.01,1343.58,
EXC FOOT/TOE TUM SC < 1.5 CM,28043,CPT,,30028043,CDM,450,RC,,,both,,,4678,3461.73,,,3461.73,Other,150% of Medicare + 9.63% HCRA Surcharge,2105.1,45,,2105.1,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2315.61,,,2315.61,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,1973,,,1973,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,3274.6,70,,3274.6,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1060.79,,,1060.79,Other,100% of Medicaid,1060.79,,,1060.79,Other,100% of Medicaid,1060.79,,,1060.79,Other,100% of Medicaid,1060.79,,,1060.79,Other,100% of Medicaid,2386.77,,,2386.77,Other,225% of Medicaid,1623,,,1623,Other,153% of Medicaid,2386.77,,,2386.77,Other,225% of Medicaid,1485.1,,,1485.1,Other,140% of Medicaid,2386.77,,,2386.77,Other,225% of Medicaid,2758.05,,,2758.05,Other,260% of Medicaid,3436.95,,,3436.95,Other,324% of Medicaid,2280.69,,,2280.69,Other,215% of Medicaid,2280.69,,,2280.69,Other,215% of Medicaid,1325.98,,,1325.98,Other,125% of Medicaid,0.01,3461.73,
REM FOREIGN BODY FOOT SQ,28190,CPT,,30028190,CDM,450,RC,,,both,,,3020,2234.81,,,2234.81,Other,150% of Medicare + 9.63% HCRA Surcharge,1359,45,,1359,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1494.9,,,1494.9,Other,110% of Medicare,2053.6,68,,2053.6,percent of total billed charges,All Other,1241,,,1241,Other,186% of Medicaid,2416,,,2416,Other,Non Covered Service,2506.6,,,2506.6,Other,Non Covered Service,2506.6,,,2506.6,Other,Non Covered Service,2416,,,2416,Other,Non Covered Service,2506.6,,,2506.6,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2114,70,,2114,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,667.11,,,667.11,Other,100% of Medicaid,667.11,,,667.11,Other,100% of Medicaid,667.11,,,667.11,Other,100% of Medicaid,667.11,,,667.11,Other,100% of Medicaid,1501,,,1501,Other,225% of Medicaid,1020.68,,,1020.68,Other,153% of Medicaid,1501,,,1501,Other,225% of Medicaid,933.96,,,933.96,Other,140% of Medicaid,1501,,,1501,Other,225% of Medicaid,1734.49,,,1734.49,Other,260% of Medicaid,2161.44,,,2161.44,Other,324% of Medicaid,1434.29,,,1434.29,Other,215% of Medicaid,1434.29,,,1434.29,Other,215% of Medicaid,833.89,,,833.89,Other,125% of Medicaid,0.01,2506.6,
REM DEEP FB OF FOOT,28192,CPT,,30028192,CDM,450,RC,,,both,,,6117,4526.6,,,4526.6,Other,150% of Medicare + 9.63% HCRA Surcharge,2752.65,45,,2752.65,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,3027.92,,,3027.92,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,1973,,,1973,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,4281.9,70,,4281.9,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1060.79,,,1060.79,Other,100% of Medicaid,1060.79,,,1060.79,Other,100% of Medicaid,1060.79,,,1060.79,Other,100% of Medicaid,1060.79,,,1060.79,Other,100% of Medicaid,2386.77,,,2386.77,Other,225% of Medicaid,1623,,,1623,Other,153% of Medicaid,2386.77,,,2386.77,Other,225% of Medicaid,1485.1,,,1485.1,Other,140% of Medicaid,2386.77,,,2386.77,Other,225% of Medicaid,2758.05,,,2758.05,Other,260% of Medicaid,3436.95,,,3436.95,Other,324% of Medicaid,2280.69,,,2280.69,Other,215% of Medicaid,2280.69,,,2280.69,Other,215% of Medicaid,1325.98,,,1325.98,Other,125% of Medicaid,0.01,4526.6,
CL TX CALCANEAL FX W MANIP,28405,CPT,,30028405,CDM,450,RC,,,both,,,1678,1241.72,,,1241.72,Other,150% of Medicare + 9.63% HCRA Surcharge,755.1,45,,755.1,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,830.61,,,830.61,Other,110% of Medicare,1141.04,68,,1141.04,percent of total billed charges,All Other,1031,,,1031,Other,186% of Medicaid,1342.4,,,1342.4,Other,Non Covered Service,1392.74,,,1392.74,Other,Non Covered Service,1392.74,,,1392.74,Other,Non Covered Service,1342.4,,,1342.4,Other,Non Covered Service,1392.74,,,1392.74,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1174.6,70,,1174.6,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,554.53,,,554.53,Other,100% of Medicaid,554.53,,,554.53,Other,100% of Medicaid,554.53,,,554.53,Other,100% of Medicaid,554.53,,,554.53,Other,100% of Medicaid,1247.69,,,1247.69,Other,225% of Medicaid,848.43,,,848.43,Other,153% of Medicaid,1247.69,,,1247.69,Other,225% of Medicaid,776.34,,,776.34,Other,140% of Medicaid,1247.69,,,1247.69,Other,225% of Medicaid,1441.78,,,1441.78,Other,260% of Medicaid,1796.68,,,1796.68,Other,324% of Medicaid,1192.24,,,1192.24,Other,215% of Medicaid,1192.24,,,1192.24,Other,215% of Medicaid,693.16,,,693.16,Other,125% of Medicaid,0.01,1796.68,
TREATMENT OF ANKLE FRACTURE,28435,CPT,,30028435,CDM,450,RC,,,both,,,4304,3184.97,,,3184.97,Other,150% of Medicare + 9.63% HCRA Surcharge,1936.8,45,,1936.8,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2130.48,,,2130.48,Other,110% of Medicare,2926.72,68,,2926.72,percent of total billed charges,All Other,1031,,,1031,Other,186% of Medicaid,3443.2,,,3443.2,Other,Non Covered Service,3572.32,,,3572.32,Other,Non Covered Service,3572.32,,,3572.32,Other,Non Covered Service,3443.2,,,3443.2,Other,Non Covered Service,3572.32,,,3572.32,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,3012.8,70,,3012.8,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,554.53,,,554.53,Other,100% of Medicaid,554.53,,,554.53,Other,100% of Medicaid,554.53,,,554.53,Other,100% of Medicaid,554.53,,,554.53,Other,100% of Medicaid,1247.69,,,1247.69,Other,225% of Medicaid,848.43,,,848.43,Other,153% of Medicaid,1247.69,,,1247.69,Other,225% of Medicaid,776.34,,,776.34,Other,140% of Medicaid,1247.69,,,1247.69,Other,225% of Medicaid,1441.78,,,1441.78,Other,260% of Medicaid,1796.68,,,1796.68,Other,324% of Medicaid,1192.24,,,1192.24,Other,215% of Medicaid,1192.24,,,1192.24,Other,215% of Medicaid,693.16,,,693.16,Other,125% of Medicaid,0.01,3572.32,
CL TX METATARSAL FX; W MANIP,28475,CPT,,30028475,CDM,450,RC,,,both,,,576,426.24,,,426.24,Other,150% of Medicare + 9.63% HCRA Surcharge,259.2,45,,259.2,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,285.12,,,285.12,Other,110% of Medicare,391.68,68,,391.68,percent of total billed charges,All Other,1031,,,1031,Other,186% of Medicaid,460.8,,,460.8,Other,Non Covered Service,478.08,,,478.08,Other,Non Covered Service,478.08,,,478.08,Other,Non Covered Service,460.8,,,460.8,Other,Non Covered Service,478.08,,,478.08,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,403.2,70,,403.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,554.53,,,554.53,Other,100% of Medicaid,554.53,,,554.53,Other,100% of Medicaid,554.53,,,554.53,Other,100% of Medicaid,554.53,,,554.53,Other,100% of Medicaid,1247.69,,,1247.69,Other,225% of Medicaid,848.43,,,848.43,Other,153% of Medicaid,1247.69,,,1247.69,Other,225% of Medicaid,776.34,,,776.34,Other,140% of Medicaid,1247.69,,,1247.69,Other,225% of Medicaid,1441.78,,,1441.78,Other,260% of Medicaid,1796.68,,,1796.68,Other,324% of Medicaid,1192.24,,,1192.24,Other,215% of Medicaid,1192.24,,,1192.24,Other,215% of Medicaid,693.16,,,693.16,Other,125% of Medicaid,0.01,1796.68,
CL TX FX GT PHALANX(S); WO MANIP,28490,CPT,,30028490,CDM,450,RC,,,both,,,714,528.36,,,528.36,Other,150% of Medicare + 9.63% HCRA Surcharge,321.3,45,,321.3,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,353.43,,,353.43,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,1031,,,1031,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,499.8,70,,499.8,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,554.53,,,554.53,Other,100% of Medicaid,554.53,,,554.53,Other,100% of Medicaid,554.53,,,554.53,Other,100% of Medicaid,554.53,,,554.53,Other,100% of Medicaid,1247.69,,,1247.69,Other,225% of Medicaid,848.43,,,848.43,Other,153% of Medicaid,1247.69,,,1247.69,Other,225% of Medicaid,776.34,,,776.34,Other,140% of Medicaid,1247.69,,,1247.69,Other,225% of Medicaid,1441.78,,,1441.78,Other,260% of Medicaid,1796.68,,,1796.68,Other,324% of Medicaid,1192.24,,,1192.24,Other,215% of Medicaid,1192.24,,,1192.24,Other,215% of Medicaid,693.16,,,693.16,Other,125% of Medicaid,0.01,1796.68,
CL TX FX GT PHALANX S W,28495,CPT,,30028495,CDM,450,RC,,,both,,,517,382.58,,,382.58,Other,150% of Medicare + 9.63% HCRA Surcharge,232.65,45,,232.65,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,255.92,,,255.92,Other,110% of Medicare,351.56,68,,351.56,percent of total billed charges,All Other,1031,,,1031,Other,186% of Medicaid,413.6,,,413.6,Other,Non Covered Service,429.11,,,429.11,Other,Non Covered Service,429.11,,,429.11,Other,Non Covered Service,413.6,,,413.6,Other,Non Covered Service,429.11,,,429.11,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,361.9,70,,361.9,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,554.53,,,554.53,Other,100% of Medicaid,554.53,,,554.53,Other,100% of Medicaid,554.53,,,554.53,Other,100% of Medicaid,554.53,,,554.53,Other,100% of Medicaid,1247.69,,,1247.69,Other,225% of Medicaid,848.43,,,848.43,Other,153% of Medicaid,1247.69,,,1247.69,Other,225% of Medicaid,776.34,,,776.34,Other,140% of Medicaid,1247.69,,,1247.69,Other,225% of Medicaid,1441.78,,,1441.78,Other,260% of Medicaid,1796.68,,,1796.68,Other,324% of Medicaid,1192.24,,,1192.24,Other,215% of Medicaid,1192.24,,,1192.24,Other,215% of Medicaid,693.16,,,693.16,Other,125% of Medicaid,0.01,1796.68,
CL TX FX PHALANX PHALANG,28515,CPT,,30028515,CDM,450,RC,,,both,,,517,382.58,,,382.58,Other,150% of Medicare + 9.63% HCRA Surcharge,232.65,45,,232.65,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,255.92,,,255.92,Other,110% of Medicare,351.56,68,,351.56,percent of total billed charges,All Other,1031,,,1031,Other,186% of Medicaid,413.6,,,413.6,Other,Non Covered Service,429.11,,,429.11,Other,Non Covered Service,429.11,,,429.11,Other,Non Covered Service,413.6,,,413.6,Other,Non Covered Service,429.11,,,429.11,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,361.9,70,,361.9,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,554.53,,,554.53,Other,100% of Medicaid,554.53,,,554.53,Other,100% of Medicaid,554.53,,,554.53,Other,100% of Medicaid,554.53,,,554.53,Other,100% of Medicaid,1247.69,,,1247.69,Other,225% of Medicaid,848.43,,,848.43,Other,153% of Medicaid,1247.69,,,1247.69,Other,225% of Medicaid,776.34,,,776.34,Other,140% of Medicaid,1247.69,,,1247.69,Other,225% of Medicaid,1441.78,,,1441.78,Other,260% of Medicaid,1796.68,,,1796.68,Other,324% of Medicaid,1192.24,,,1192.24,Other,215% of Medicaid,1192.24,,,1192.24,Other,215% of Medicaid,693.16,,,693.16,Other,125% of Medicaid,0.01,1796.68,
CL TX TALOTARSAL JOINT DIS WO ANEST,28570,CPT,,30028570,CDM,450,RC,,,both,,,923,683.02,,,683.02,Other,150% of Medicare + 9.63% HCRA Surcharge,415.35,45,,415.35,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,456.89,,,456.89,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,1031,,,1031,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,646.1,70,,646.1,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,554.53,,,554.53,Other,100% of Medicaid,554.53,,,554.53,Other,100% of Medicaid,554.53,,,554.53,Other,100% of Medicaid,554.53,,,554.53,Other,100% of Medicaid,1247.69,,,1247.69,Other,225% of Medicaid,848.43,,,848.43,Other,153% of Medicaid,1247.69,,,1247.69,Other,225% of Medicaid,776.34,,,776.34,Other,140% of Medicaid,1247.69,,,1247.69,Other,225% of Medicaid,1441.78,,,1441.78,Other,260% of Medicaid,1796.68,,,1796.68,Other,324% of Medicaid,1192.24,,,1192.24,Other,215% of Medicaid,1192.24,,,1192.24,Other,215% of Medicaid,693.16,,,693.16,Other,125% of Medicaid,0.01,1796.68,
CL TX TALOTARSAL JOINT DISL W,28575,CPT,,30028575,CDM,450,RC,,,both,,,6701,4958.76,,,4958.76,Other,150% of Medicare + 9.63% HCRA Surcharge,3015.45,45,,3015.45,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,3317,,,3317,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,1730,,,1730,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,4690.7,70,,4690.7,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,930.31,,,930.31,Other,100% of Medicaid,930.31,,,930.31,Other,100% of Medicaid,930.31,,,930.31,Other,100% of Medicaid,930.31,,,930.31,Other,100% of Medicaid,2093.21,,,2093.21,Other,225% of Medicaid,1423.38,,,1423.38,Other,153% of Medicaid,2093.21,,,2093.21,Other,225% of Medicaid,1302.44,,,1302.44,Other,140% of Medicaid,2093.21,,,2093.21,Other,225% of Medicaid,2418.82,,,2418.82,Other,260% of Medicaid,3014.22,,,3014.22,Other,324% of Medicaid,2000.18,,,2000.18,Other,215% of Medicaid,2000.18,,,2000.18,Other,215% of Medicaid,1162.89,,,1162.89,Other,125% of Medicaid,0.01,4958.76,
CLOSED REDUCTION TOE,28630,CPT,,30028630,CDM,450,RC,,,both,,,554,409.96,,,409.96,Other,150% of Medicare + 9.63% HCRA Surcharge,249.3,45,,249.3,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,274.23,,,274.23,Other,110% of Medicare,376.72,68,,376.72,percent of total billed charges,All Other,1031,,,1031,Other,186% of Medicaid,443.2,,,443.2,Other,Non Covered Service,459.82,,,459.82,Other,Non Covered Service,459.82,,,459.82,Other,Non Covered Service,443.2,,,443.2,Other,Non Covered Service,459.82,,,459.82,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,387.8,70,,387.8,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,554.53,,,554.53,Other,100% of Medicaid,554.53,,,554.53,Other,100% of Medicaid,554.53,,,554.53,Other,100% of Medicaid,554.53,,,554.53,Other,100% of Medicaid,1247.69,,,1247.69,Other,225% of Medicaid,848.43,,,848.43,Other,153% of Medicaid,1247.69,,,1247.69,Other,225% of Medicaid,776.34,,,776.34,Other,140% of Medicaid,1247.69,,,1247.69,Other,225% of Medicaid,1441.78,,,1441.78,Other,260% of Medicaid,1796.68,,,1796.68,Other,324% of Medicaid,1192.24,,,1192.24,Other,215% of Medicaid,1192.24,,,1192.24,Other,215% of Medicaid,693.16,,,693.16,Other,125% of Medicaid,0.01,1796.68,
CL TX IP JOINT DSL WO AN,28660,CPT,,30028660,CDM,450,RC,,,both,,,517,382.58,,,382.58,Other,150% of Medicare + 9.63% HCRA Surcharge,232.65,45,,232.65,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,255.92,,,255.92,Other,110% of Medicare,351.56,68,,351.56,percent of total billed charges,All Other,1031,,,1031,Other,186% of Medicaid,413.6,,,413.6,Other,Non Covered Service,429.11,,,429.11,Other,Non Covered Service,429.11,,,429.11,Other,Non Covered Service,413.6,,,413.6,Other,Non Covered Service,429.11,,,429.11,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,361.9,70,,361.9,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,554.53,,,554.53,Other,100% of Medicaid,554.53,,,554.53,Other,100% of Medicaid,554.53,,,554.53,Other,100% of Medicaid,554.53,,,554.53,Other,100% of Medicaid,1247.69,,,1247.69,Other,225% of Medicaid,848.43,,,848.43,Other,153% of Medicaid,1247.69,,,1247.69,Other,225% of Medicaid,776.34,,,776.34,Other,140% of Medicaid,1247.69,,,1247.69,Other,225% of Medicaid,1441.78,,,1441.78,Other,260% of Medicaid,1796.68,,,1796.68,Other,324% of Medicaid,1192.24,,,1192.24,Other,215% of Medicaid,1192.24,,,1192.24,Other,215% of Medicaid,693.16,,,693.16,Other,125% of Medicaid,0.01,1796.68,
APPLICATION OF BODY CAST,29000,CPT,,30029000,CDM,450,RC,,,both,,,541,400.34,,,400.34,Other,150% of Medicare + 9.63% HCRA Surcharge,243.45,45,,243.45,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,267.8,,,267.8,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,680,,,680,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,378.7,70,,378.7,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,365.71,,,365.71,Other,100% of Medicaid,365.71,,,365.71,Other,100% of Medicaid,365.71,,,365.71,Other,100% of Medicaid,365.71,,,365.71,Other,100% of Medicaid,822.84,,,822.84,Other,225% of Medicaid,559.53,,,559.53,Other,153% of Medicaid,822.84,,,822.84,Other,225% of Medicaid,511.99,,,511.99,Other,140% of Medicaid,822.84,,,822.84,Other,225% of Medicaid,950.84,,,950.84,Other,260% of Medicaid,1184.89,,,1184.89,Other,324% of Medicaid,786.27,,,786.27,Other,215% of Medicaid,786.27,,,786.27,Other,215% of Medicaid,457.13,,,457.13,Other,125% of Medicaid,0.01,1184.89,
APPLY FIGURE EIGHT CAST,29049,CPT,,30029049,CDM,450,RC,,,both,,,541,400.34,,,400.34,Other,150% of Medicare + 9.63% HCRA Surcharge,243.45,45,,243.45,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,267.8,,,267.8,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,680,,,680,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,378.7,70,,378.7,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,365.71,,,365.71,Other,100% of Medicaid,365.71,,,365.71,Other,100% of Medicaid,365.71,,,365.71,Other,100% of Medicaid,365.71,,,365.71,Other,100% of Medicaid,822.84,,,822.84,Other,225% of Medicaid,559.53,,,559.53,Other,153% of Medicaid,822.84,,,822.84,Other,225% of Medicaid,511.99,,,511.99,Other,140% of Medicaid,822.84,,,822.84,Other,225% of Medicaid,950.84,,,950.84,Other,260% of Medicaid,1184.89,,,1184.89,Other,324% of Medicaid,786.27,,,786.27,Other,215% of Medicaid,786.27,,,786.27,Other,215% of Medicaid,457.13,,,457.13,Other,125% of Medicaid,0.01,1184.89,
APPLY LONG ARM CAST,29065,CPT,,30029065,CDM,450,RC,,,both,,,750,555,,,555,Other,150% of Medicare + 9.63% HCRA Surcharge,337.5,45,,337.5,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,371.25,,,371.25,Other,110% of Medicare,510,68,,510,percent of total billed charges,All Other,445,,,445,Other,186% of Medicaid,600,,,600,Other,Non Covered Service,622.5,,,622.5,Other,Non Covered Service,622.5,,,622.5,Other,Non Covered Service,600,,,600,Other,Non Covered Service,622.5,,,622.5,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,525,70,,525,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,239.06,,,239.06,Other,100% of Medicaid,239.06,,,239.06,Other,100% of Medicaid,239.06,,,239.06,Other,100% of Medicaid,239.06,,,239.06,Other,100% of Medicaid,537.89,,,537.89,Other,225% of Medicaid,365.76,,,365.76,Other,153% of Medicaid,537.89,,,537.89,Other,225% of Medicaid,334.68,,,334.68,Other,140% of Medicaid,537.89,,,537.89,Other,225% of Medicaid,621.56,,,621.56,Other,260% of Medicaid,774.55,,,774.55,Other,324% of Medicaid,513.98,,,513.98,Other,215% of Medicaid,513.98,,,513.98,Other,215% of Medicaid,298.83,,,298.83,Other,125% of Medicaid,0.01,774.55,
APPLY SHORT ARM CAST,29075,CPT,,30029075,CDM,450,RC,,,both,,,907,671.18,,,671.18,Other,150% of Medicare + 9.63% HCRA Surcharge,408.15,45,,408.15,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,448.97,,,448.97,Other,110% of Medicare,616.76,68,,616.76,percent of total billed charges,All Other,445,,,445,Other,186% of Medicaid,725.6,,,725.6,Other,Non Covered Service,752.81,,,752.81,Other,Non Covered Service,752.81,,,752.81,Other,Non Covered Service,725.6,,,725.6,Other,Non Covered Service,752.81,,,752.81,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,634.9,70,,634.9,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,239.06,,,239.06,Other,100% of Medicaid,239.06,,,239.06,Other,100% of Medicaid,239.06,,,239.06,Other,100% of Medicaid,239.06,,,239.06,Other,100% of Medicaid,537.89,,,537.89,Other,225% of Medicaid,365.76,,,365.76,Other,153% of Medicaid,537.89,,,537.89,Other,225% of Medicaid,334.68,,,334.68,Other,140% of Medicaid,537.89,,,537.89,Other,225% of Medicaid,621.56,,,621.56,Other,260% of Medicaid,774.55,,,774.55,Other,324% of Medicaid,513.98,,,513.98,Other,215% of Medicaid,513.98,,,513.98,Other,215% of Medicaid,298.83,,,298.83,Other,125% of Medicaid,0.01,774.55,
APPLY GAUNTLET CAST,29085,CPT,,30029085,CDM,450,RC,,,both,,,382,282.68,,,282.68,Other,150% of Medicare + 9.63% HCRA Surcharge,171.9,45,,171.9,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,189.09,,,189.09,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,445,,,445,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,267.4,70,,267.4,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,239.06,,,239.06,Other,100% of Medicaid,239.06,,,239.06,Other,100% of Medicaid,239.06,,,239.06,Other,100% of Medicaid,239.06,,,239.06,Other,100% of Medicaid,537.89,,,537.89,Other,225% of Medicaid,365.76,,,365.76,Other,153% of Medicaid,537.89,,,537.89,Other,225% of Medicaid,334.68,,,334.68,Other,140% of Medicaid,537.89,,,537.89,Other,225% of Medicaid,621.56,,,621.56,Other,260% of Medicaid,774.55,,,774.55,Other,324% of Medicaid,513.98,,,513.98,Other,215% of Medicaid,513.98,,,513.98,Other,215% of Medicaid,298.83,,,298.83,Other,125% of Medicaid,0.01,774.55,
APPLY LONG ARM SPLINT,29105,CPT,,30029105,CDM,450,RC,,,both,,,544,402.56,,,402.56,Other,150% of Medicare + 9.63% HCRA Surcharge,244.8,45,,244.8,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,269.28,,,269.28,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,325,,,325,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,380.8,70,,380.8,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,174.92,,,174.92,Other,100% of Medicaid,174.92,,,174.92,Other,100% of Medicaid,174.92,,,174.92,Other,100% of Medicaid,174.92,,,174.92,Other,100% of Medicaid,393.57,,,393.57,Other,225% of Medicaid,267.62,,,267.62,Other,153% of Medicaid,393.57,,,393.57,Other,225% of Medicaid,244.89,,,244.89,Other,140% of Medicaid,393.57,,,393.57,Other,225% of Medicaid,454.79,,,454.79,Other,260% of Medicaid,566.73,,,566.73,Other,324% of Medicaid,376.07,,,376.07,Other,215% of Medicaid,376.07,,,376.07,Other,215% of Medicaid,218.65,,,218.65,Other,125% of Medicaid,0.01,566.73,
APPLY FOREARM SPLINT,29125,CPT,,30029125,CDM,450,RC,,,both,,,563,416.62,,,416.62,Other,150% of Medicare + 9.63% HCRA Surcharge,253.35,45,,253.35,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,278.69,,,278.69,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,325,,,325,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,394.1,70,,394.1,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,174.92,,,174.92,Other,100% of Medicaid,174.92,,,174.92,Other,100% of Medicaid,174.92,,,174.92,Other,100% of Medicaid,174.92,,,174.92,Other,100% of Medicaid,393.57,,,393.57,Other,225% of Medicaid,267.62,,,267.62,Other,153% of Medicaid,393.57,,,393.57,Other,225% of Medicaid,244.89,,,244.89,Other,140% of Medicaid,393.57,,,393.57,Other,225% of Medicaid,454.79,,,454.79,Other,260% of Medicaid,566.73,,,566.73,Other,324% of Medicaid,376.07,,,376.07,Other,215% of Medicaid,376.07,,,376.07,Other,215% of Medicaid,218.65,,,218.65,Other,125% of Medicaid,0.01,566.73,
APPLICATION OF FINGER SPLINT,29130,CPT,,30029130,CDM,450,RC,,,both,,,563,416.62,,,416.62,Other,150% of Medicare + 9.63% HCRA Surcharge,253.35,45,,253.35,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,278.69,,,278.69,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,325,,,325,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,394.1,70,,394.1,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,174.92,,,174.92,Other,100% of Medicaid,174.92,,,174.92,Other,100% of Medicaid,174.92,,,174.92,Other,100% of Medicaid,174.92,,,174.92,Other,100% of Medicaid,393.57,,,393.57,Other,225% of Medicaid,267.62,,,267.62,Other,153% of Medicaid,393.57,,,393.57,Other,225% of Medicaid,244.89,,,244.89,Other,140% of Medicaid,393.57,,,393.57,Other,225% of Medicaid,454.79,,,454.79,Other,260% of Medicaid,566.73,,,566.73,Other,324% of Medicaid,376.07,,,376.07,Other,215% of Medicaid,376.07,,,376.07,Other,215% of Medicaid,218.65,,,218.65,Other,125% of Medicaid,0.01,566.73,
STRAPPING OF SHOULDER,29240,CPT,,30029240,CDM,450,RC,,,both,,,563,416.62,,,416.62,Other,150% of Medicare + 9.63% HCRA Surcharge,253.35,45,,253.35,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,278.69,,,278.69,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,325,,,325,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,394.1,70,,394.1,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,174.92,,,174.92,Other,100% of Medicaid,174.92,,,174.92,Other,100% of Medicaid,174.92,,,174.92,Other,100% of Medicaid,174.92,,,174.92,Other,100% of Medicaid,393.57,,,393.57,Other,225% of Medicaid,267.62,,,267.62,Other,153% of Medicaid,393.57,,,393.57,Other,225% of Medicaid,244.89,,,244.89,Other,140% of Medicaid,393.57,,,393.57,Other,225% of Medicaid,454.79,,,454.79,Other,260% of Medicaid,566.73,,,566.73,Other,324% of Medicaid,376.07,,,376.07,Other,215% of Medicaid,376.07,,,376.07,Other,215% of Medicaid,218.65,,,218.65,Other,125% of Medicaid,0.01,566.73,
STRAPPING OF ELBOW OR WRIST,29260,CPT,,30029260,CDM,450,RC,,,both,,,563,416.62,,,416.62,Other,150% of Medicare + 9.63% HCRA Surcharge,253.35,45,,253.35,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,278.69,,,278.69,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,325,,,325,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,394.1,70,,394.1,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,174.92,,,174.92,Other,100% of Medicaid,174.92,,,174.92,Other,100% of Medicaid,174.92,,,174.92,Other,100% of Medicaid,174.92,,,174.92,Other,100% of Medicaid,393.57,,,393.57,Other,225% of Medicaid,267.62,,,267.62,Other,153% of Medicaid,393.57,,,393.57,Other,225% of Medicaid,244.89,,,244.89,Other,140% of Medicaid,393.57,,,393.57,Other,225% of Medicaid,454.79,,,454.79,Other,260% of Medicaid,566.73,,,566.73,Other,324% of Medicaid,376.07,,,376.07,Other,215% of Medicaid,376.07,,,376.07,Other,215% of Medicaid,218.65,,,218.65,Other,125% of Medicaid,0.01,566.73,
STRAPPING OF HAND OR FINGER,29280,CPT,,30029280,CDM,450,RC,,,both,,,563,416.62,,,416.62,Other,150% of Medicare + 9.63% HCRA Surcharge,253.35,45,,253.35,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,278.69,,,278.69,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,325,,,325,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,394.1,70,,394.1,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,174.92,,,174.92,Other,100% of Medicaid,174.92,,,174.92,Other,100% of Medicaid,174.92,,,174.92,Other,100% of Medicaid,174.92,,,174.92,Other,100% of Medicaid,393.57,,,393.57,Other,225% of Medicaid,267.62,,,267.62,Other,153% of Medicaid,393.57,,,393.57,Other,225% of Medicaid,244.89,,,244.89,Other,140% of Medicaid,393.57,,,393.57,Other,225% of Medicaid,454.79,,,454.79,Other,260% of Medicaid,566.73,,,566.73,Other,324% of Medicaid,376.07,,,376.07,Other,215% of Medicaid,376.07,,,376.07,Other,215% of Medicaid,218.65,,,218.65,Other,125% of Medicaid,0.01,566.73,
APPLICATION OF LONG LEG CAST,29345,CPT,,30029345,CDM,450,RC,,,both,,,831,614.94,,,614.94,Other,150% of Medicare + 9.63% HCRA Surcharge,373.95,45,,373.95,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,411.35,,,411.35,Other,110% of Medicare,565.08,68,,565.08,percent of total billed charges,All Other,445,,,445,Other,186% of Medicaid,664.8,,,664.8,Other,Non Covered Service,689.73,,,689.73,Other,Non Covered Service,689.73,,,689.73,Other,Non Covered Service,664.8,,,664.8,Other,Non Covered Service,689.73,,,689.73,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,581.7,70,,581.7,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,239.06,,,239.06,Other,100% of Medicaid,239.06,,,239.06,Other,100% of Medicaid,239.06,,,239.06,Other,100% of Medicaid,239.06,,,239.06,Other,100% of Medicaid,537.89,,,537.89,Other,225% of Medicaid,365.76,,,365.76,Other,153% of Medicaid,537.89,,,537.89,Other,225% of Medicaid,334.68,,,334.68,Other,140% of Medicaid,537.89,,,537.89,Other,225% of Medicaid,621.56,,,621.56,Other,260% of Medicaid,774.55,,,774.55,Other,324% of Medicaid,513.98,,,513.98,Other,215% of Medicaid,513.98,,,513.98,Other,215% of Medicaid,298.83,,,298.83,Other,125% of Medicaid,0.01,774.55,
APPLICATION OF LONG LEG CAST,29355,CPT,,30029355,CDM,450,RC,,,both,,,831,614.94,,,614.94,Other,150% of Medicare + 9.63% HCRA Surcharge,373.95,45,,373.95,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,411.35,,,411.35,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,680,,,680,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,581.7,70,,581.7,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,365.71,,,365.71,Other,100% of Medicaid,365.71,,,365.71,Other,100% of Medicaid,365.71,,,365.71,Other,100% of Medicaid,365.71,,,365.71,Other,100% of Medicaid,822.84,,,822.84,Other,225% of Medicaid,559.53,,,559.53,Other,153% of Medicaid,822.84,,,822.84,Other,225% of Medicaid,511.99,,,511.99,Other,140% of Medicaid,822.84,,,822.84,Other,225% of Medicaid,950.84,,,950.84,Other,260% of Medicaid,1184.89,,,1184.89,Other,324% of Medicaid,786.27,,,786.27,Other,215% of Medicaid,786.27,,,786.27,Other,215% of Medicaid,457.13,,,457.13,Other,125% of Medicaid,0.01,1184.89,
APPLY LONG LEG CAST BRACE,29358,CPT,,30029358,CDM,450,RC,,,both,,,831,614.94,,,614.94,Other,150% of Medicare + 9.63% HCRA Surcharge,373.95,45,,373.95,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,411.35,,,411.35,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,445,,,445,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,581.7,70,,581.7,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,239.06,,,239.06,Other,100% of Medicaid,239.06,,,239.06,Other,100% of Medicaid,239.06,,,239.06,Other,100% of Medicaid,239.06,,,239.06,Other,100% of Medicaid,537.89,,,537.89,Other,225% of Medicaid,365.76,,,365.76,Other,153% of Medicaid,537.89,,,537.89,Other,225% of Medicaid,334.68,,,334.68,Other,140% of Medicaid,537.89,,,537.89,Other,225% of Medicaid,621.56,,,621.56,Other,260% of Medicaid,774.55,,,774.55,Other,324% of Medicaid,513.98,,,513.98,Other,215% of Medicaid,513.98,,,513.98,Other,215% of Medicaid,298.83,,,298.83,Other,125% of Medicaid,0.01,774.55,
APPLICATION OF LONG LEG CYLIND,29365,CPT,,30029365,CDM,450,RC,,,both,,,831,614.94,,,614.94,Other,150% of Medicare + 9.63% HCRA Surcharge,373.95,45,,373.95,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,411.35,,,411.35,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,445,,,445,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,581.7,70,,581.7,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,239.06,,,239.06,Other,100% of Medicaid,239.06,,,239.06,Other,100% of Medicaid,239.06,,,239.06,Other,100% of Medicaid,239.06,,,239.06,Other,100% of Medicaid,537.89,,,537.89,Other,225% of Medicaid,365.76,,,365.76,Other,153% of Medicaid,537.89,,,537.89,Other,225% of Medicaid,334.68,,,334.68,Other,140% of Medicaid,537.89,,,537.89,Other,225% of Medicaid,621.56,,,621.56,Other,260% of Medicaid,774.55,,,774.55,Other,324% of Medicaid,513.98,,,513.98,Other,215% of Medicaid,513.98,,,513.98,Other,215% of Medicaid,298.83,,,298.83,Other,125% of Medicaid,0.01,774.55,
APPLY SHORT LEG CAST,29405,CPT,,30029405,CDM,450,RC,,,both,,,794,587.56,,,587.56,Other,150% of Medicare + 9.63% HCRA Surcharge,357.3,45,,357.3,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,393.03,,,393.03,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,445,,,445,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,555.8,70,,555.8,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,239.06,,,239.06,Other,100% of Medicaid,239.06,,,239.06,Other,100% of Medicaid,239.06,,,239.06,Other,100% of Medicaid,239.06,,,239.06,Other,100% of Medicaid,537.89,,,537.89,Other,225% of Medicaid,365.76,,,365.76,Other,153% of Medicaid,537.89,,,537.89,Other,225% of Medicaid,334.68,,,334.68,Other,140% of Medicaid,537.89,,,537.89,Other,225% of Medicaid,621.56,,,621.56,Other,260% of Medicaid,774.55,,,774.55,Other,324% of Medicaid,513.98,,,513.98,Other,215% of Medicaid,513.98,,,513.98,Other,215% of Medicaid,298.83,,,298.83,Other,125% of Medicaid,0.01,774.55,
APPLY SHORT LEG CAST PTB,29435,CPT,,30029435,CDM,450,RC,,,both,,,831,614.94,,,614.94,Other,150% of Medicare + 9.63% HCRA Surcharge,373.95,45,,373.95,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,411.35,,,411.35,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,680,,,680,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,581.7,70,,581.7,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,365.71,,,365.71,Other,100% of Medicaid,365.71,,,365.71,Other,100% of Medicaid,365.71,,,365.71,Other,100% of Medicaid,365.71,,,365.71,Other,100% of Medicaid,822.84,,,822.84,Other,225% of Medicaid,559.53,,,559.53,Other,153% of Medicaid,822.84,,,822.84,Other,225% of Medicaid,511.99,,,511.99,Other,140% of Medicaid,822.84,,,822.84,Other,225% of Medicaid,950.84,,,950.84,Other,260% of Medicaid,1184.89,,,1184.89,Other,324% of Medicaid,786.27,,,786.27,Other,215% of Medicaid,786.27,,,786.27,Other,215% of Medicaid,457.13,,,457.13,Other,125% of Medicaid,0.01,1184.89,
ADDITION OF WALKER TO CAST,29440,CPT,,30029440,CDM,450,RC,,,both,,,367,271.58,,,271.58,Other,150% of Medicare + 9.63% HCRA Surcharge,165.15,45,,165.15,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,181.67,,,181.67,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,680,,,680,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,256.9,70,,256.9,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,365.71,,,365.71,Other,100% of Medicaid,365.71,,,365.71,Other,100% of Medicaid,365.71,,,365.71,Other,100% of Medicaid,365.71,,,365.71,Other,100% of Medicaid,822.84,,,822.84,Other,225% of Medicaid,559.53,,,559.53,Other,153% of Medicaid,822.84,,,822.84,Other,225% of Medicaid,511.99,,,511.99,Other,140% of Medicaid,822.84,,,822.84,Other,225% of Medicaid,950.84,,,950.84,Other,260% of Medicaid,1184.89,,,1184.89,Other,324% of Medicaid,786.27,,,786.27,Other,215% of Medicaid,786.27,,,786.27,Other,215% of Medicaid,457.13,,,457.13,Other,125% of Medicaid,0.01,1184.89,
APPLICATION OF CLUBFOOF LEG CA,29450,CPT,,30029450,CDM,450,RC,,,both,,,367,271.58,,,271.58,Other,150% of Medicare + 9.63% HCRA Surcharge,165.15,45,,165.15,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,181.67,,,181.67,Other,110% of Medicare,249.56,68,,249.56,percent of total billed charges,All Other,680,,,680,Other,186% of Medicaid,293.6,,,293.6,Other,Non Covered Service,304.61,,,304.61,Other,Non Covered Service,304.61,,,304.61,Other,Non Covered Service,293.6,,,293.6,Other,Non Covered Service,304.61,,,304.61,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,256.9,70,,256.9,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,365.71,,,365.71,Other,100% of Medicaid,365.71,,,365.71,Other,100% of Medicaid,365.71,,,365.71,Other,100% of Medicaid,365.71,,,365.71,Other,100% of Medicaid,822.84,,,822.84,Other,225% of Medicaid,559.53,,,559.53,Other,153% of Medicaid,822.84,,,822.84,Other,225% of Medicaid,511.99,,,511.99,Other,140% of Medicaid,822.84,,,822.84,Other,225% of Medicaid,950.84,,,950.84,Other,260% of Medicaid,1184.89,,,1184.89,Other,324% of Medicaid,786.27,,,786.27,Other,215% of Medicaid,786.27,,,786.27,Other,215% of Medicaid,457.13,,,457.13,Other,125% of Medicaid,0.01,1184.89,
APPLICATION LONG LEG SPLINT,29505,CPT,,30029505,CDM,450,RC,,,both,,,427,315.98,,,315.98,Other,150% of Medicare + 9.63% HCRA Surcharge,192.15,45,,192.15,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,211.37,,,211.37,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,325,,,325,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,298.9,70,,298.9,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,174.92,,,174.92,Other,100% of Medicaid,174.92,,,174.92,Other,100% of Medicaid,174.92,,,174.92,Other,100% of Medicaid,174.92,,,174.92,Other,100% of Medicaid,393.57,,,393.57,Other,225% of Medicaid,267.62,,,267.62,Other,153% of Medicaid,393.57,,,393.57,Other,225% of Medicaid,244.89,,,244.89,Other,140% of Medicaid,393.57,,,393.57,Other,225% of Medicaid,454.79,,,454.79,Other,260% of Medicaid,566.73,,,566.73,Other,324% of Medicaid,376.07,,,376.07,Other,215% of Medicaid,376.07,,,376.07,Other,215% of Medicaid,218.65,,,218.65,Other,125% of Medicaid,0.01,566.73,
APPLICATION LOWER LEG SPLINT,29515,CPT,,30029515,CDM,450,RC,,,both,,,427,315.98,,,315.98,Other,150% of Medicare + 9.63% HCRA Surcharge,192.15,45,,192.15,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,211.37,,,211.37,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,325,,,325,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,298.9,70,,298.9,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,174.92,,,174.92,Other,100% of Medicaid,174.92,,,174.92,Other,100% of Medicaid,174.92,,,174.92,Other,100% of Medicaid,174.92,,,174.92,Other,100% of Medicaid,393.57,,,393.57,Other,225% of Medicaid,267.62,,,267.62,Other,153% of Medicaid,393.57,,,393.57,Other,225% of Medicaid,244.89,,,244.89,Other,140% of Medicaid,393.57,,,393.57,Other,225% of Medicaid,454.79,,,454.79,Other,260% of Medicaid,566.73,,,566.73,Other,324% of Medicaid,376.07,,,376.07,Other,215% of Medicaid,376.07,,,376.07,Other,215% of Medicaid,218.65,,,218.65,Other,125% of Medicaid,0.01,566.73,
STRAPPING OF HIP,29520,CPT,,30029520,CDM,450,RC,,,both,,,367,271.58,,,271.58,Other,150% of Medicare + 9.63% HCRA Surcharge,165.15,45,,165.15,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,181.67,,,181.67,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,325,,,325,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,256.9,70,,256.9,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,174.92,,,174.92,Other,100% of Medicaid,174.92,,,174.92,Other,100% of Medicaid,174.92,,,174.92,Other,100% of Medicaid,174.92,,,174.92,Other,100% of Medicaid,393.57,,,393.57,Other,225% of Medicaid,267.62,,,267.62,Other,153% of Medicaid,393.57,,,393.57,Other,225% of Medicaid,244.89,,,244.89,Other,140% of Medicaid,393.57,,,393.57,Other,225% of Medicaid,454.79,,,454.79,Other,260% of Medicaid,566.73,,,566.73,Other,324% of Medicaid,376.07,,,376.07,Other,215% of Medicaid,376.07,,,376.07,Other,215% of Medicaid,218.65,,,218.65,Other,125% of Medicaid,0.01,566.73,
STRAPPING OF KNEE,29530,CPT,,30029530,CDM,450,RC,,,both,,,491,363.34,,,363.34,Other,150% of Medicare + 9.63% HCRA Surcharge,220.95,45,,220.95,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,243.05,,,243.05,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,325,,,325,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,343.7,70,,343.7,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,174.92,,,174.92,Other,100% of Medicaid,174.92,,,174.92,Other,100% of Medicaid,174.92,,,174.92,Other,100% of Medicaid,174.92,,,174.92,Other,100% of Medicaid,393.57,,,393.57,Other,225% of Medicaid,267.62,,,267.62,Other,153% of Medicaid,393.57,,,393.57,Other,225% of Medicaid,244.89,,,244.89,Other,140% of Medicaid,393.57,,,393.57,Other,225% of Medicaid,454.79,,,454.79,Other,260% of Medicaid,566.73,,,566.73,Other,324% of Medicaid,376.07,,,376.07,Other,215% of Medicaid,376.07,,,376.07,Other,215% of Medicaid,218.65,,,218.65,Other,125% of Medicaid,0.01,566.73,
STRAPPING OF ANKLE,29540,CPT,,30029540,CDM,450,RC,,,both,,,491,363.34,,,363.34,Other,150% of Medicare + 9.63% HCRA Surcharge,220.95,45,,220.95,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,243.05,,,243.05,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,325,,,325,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,343.7,70,,343.7,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,174.92,,,174.92,Other,100% of Medicaid,174.92,,,174.92,Other,100% of Medicaid,174.92,,,174.92,Other,100% of Medicaid,174.92,,,174.92,Other,100% of Medicaid,393.57,,,393.57,Other,225% of Medicaid,267.62,,,267.62,Other,153% of Medicaid,393.57,,,393.57,Other,225% of Medicaid,244.89,,,244.89,Other,140% of Medicaid,393.57,,,393.57,Other,225% of Medicaid,454.79,,,454.79,Other,260% of Medicaid,566.73,,,566.73,Other,324% of Medicaid,376.07,,,376.07,Other,215% of Medicaid,376.07,,,376.07,Other,215% of Medicaid,218.65,,,218.65,Other,125% of Medicaid,0.01,566.73,
STRAPPING OF TOES,29550,CPT,,30029550,CDM,450,RC,,,both,,,427,315.98,,,315.98,Other,150% of Medicare + 9.63% HCRA Surcharge,192.15,45,,192.15,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,211.37,,,211.37,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,325,,,325,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,298.9,70,,298.9,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,174.92,,,174.92,Other,100% of Medicaid,174.92,,,174.92,Other,100% of Medicaid,174.92,,,174.92,Other,100% of Medicaid,174.92,,,174.92,Other,100% of Medicaid,393.57,,,393.57,Other,225% of Medicaid,267.62,,,267.62,Other,153% of Medicaid,393.57,,,393.57,Other,225% of Medicaid,244.89,,,244.89,Other,140% of Medicaid,393.57,,,393.57,Other,225% of Medicaid,454.79,,,454.79,Other,260% of Medicaid,566.73,,,566.73,Other,324% of Medicaid,376.07,,,376.07,Other,215% of Medicaid,376.07,,,376.07,Other,215% of Medicaid,218.65,,,218.65,Other,125% of Medicaid,0.01,566.73,
UNNA BOOT,29580,CPT,,30029580,CDM,450,RC,,,both,,,427,315.98,,,315.98,Other,150% of Medicare + 9.63% HCRA Surcharge,192.15,45,,192.15,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,211.37,,,211.37,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,445,,,445,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,298.9,70,,298.9,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,239.06,,,239.06,Other,100% of Medicaid,239.06,,,239.06,Other,100% of Medicaid,239.06,,,239.06,Other,100% of Medicaid,239.06,,,239.06,Other,100% of Medicaid,537.89,,,537.89,Other,225% of Medicaid,365.76,,,365.76,Other,153% of Medicaid,537.89,,,537.89,Other,225% of Medicaid,334.68,,,334.68,Other,140% of Medicaid,537.89,,,537.89,Other,225% of Medicaid,621.56,,,621.56,Other,260% of Medicaid,774.55,,,774.55,Other,324% of Medicaid,513.98,,,513.98,Other,215% of Medicaid,513.98,,,513.98,Other,215% of Medicaid,298.83,,,298.83,Other,125% of Medicaid,0.01,774.55,
APPLY MULTLAY COMPRS LWR LEG,29581,CPT,,30029581,CDM,450,RC,,,both,,,393,290.82,,,290.82,Other,150% of Medicare + 9.63% HCRA Surcharge,176.85,45,,176.85,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,194.54,,,194.54,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,445,,,445,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,275.1,70,,275.1,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,239.06,,,239.06,Other,100% of Medicaid,239.06,,,239.06,Other,100% of Medicaid,239.06,,,239.06,Other,100% of Medicaid,239.06,,,239.06,Other,100% of Medicaid,537.89,,,537.89,Other,225% of Medicaid,365.76,,,365.76,Other,153% of Medicaid,537.89,,,537.89,Other,225% of Medicaid,334.68,,,334.68,Other,140% of Medicaid,537.89,,,537.89,Other,225% of Medicaid,621.56,,,621.56,Other,260% of Medicaid,774.55,,,774.55,Other,324% of Medicaid,513.98,,,513.98,Other,215% of Medicaid,513.98,,,513.98,Other,215% of Medicaid,298.83,,,298.83,Other,125% of Medicaid,0.01,774.55,
APPLY MULTLAY COMPRS UPR LEG,29582,CPT,,30029582,CDM,450,RC,,,both,,,421,311.54,,,311.54,Other,150% of Medicare + 9.63% HCRA Surcharge,189.45,45,,189.45,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,208.4,,,208.4,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,325,,,325,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,294.7,70,,294.7,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,174.92,,,174.92,Other,100% of Medicaid,174.92,,,174.92,Other,100% of Medicaid,174.92,,,174.92,Other,100% of Medicaid,174.92,,,174.92,Other,100% of Medicaid,393.57,,,393.57,Other,225% of Medicaid,267.62,,,267.62,Other,153% of Medicaid,393.57,,,393.57,Other,225% of Medicaid,244.89,,,244.89,Other,140% of Medicaid,393.57,,,393.57,Other,225% of Medicaid,454.79,,,454.79,Other,260% of Medicaid,566.73,,,566.73,Other,324% of Medicaid,376.07,,,376.07,Other,215% of Medicaid,376.07,,,376.07,Other,215% of Medicaid,218.65,,,218.65,Other,125% of Medicaid,0.01,566.73,
REMOVAL REVISION OF CAST,29700,CPT,,30029700,CDM,450,RC,,,both,,,541,400.34,,,400.34,Other,150% of Medicare + 9.63% HCRA Surcharge,243.45,45,,243.45,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,267.8,,,267.8,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,680,,,680,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,378.7,70,,378.7,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,365.71,,,365.71,Other,100% of Medicaid,365.71,,,365.71,Other,100% of Medicaid,365.71,,,365.71,Other,100% of Medicaid,365.71,,,365.71,Other,100% of Medicaid,822.84,,,822.84,Other,225% of Medicaid,559.53,,,559.53,Other,153% of Medicaid,822.84,,,822.84,Other,225% of Medicaid,511.99,,,511.99,Other,140% of Medicaid,822.84,,,822.84,Other,225% of Medicaid,950.84,,,950.84,Other,260% of Medicaid,1184.89,,,1184.89,Other,324% of Medicaid,786.27,,,786.27,Other,215% of Medicaid,786.27,,,786.27,Other,215% of Medicaid,457.13,,,457.13,Other,125% of Medicaid,0.01,1184.89,
REMOVAL REVISION FULL ARM LEG,29705,CPT,,30029705,CDM,450,RC,,,both,,,541,400.34,,,400.34,Other,150% of Medicare + 9.63% HCRA Surcharge,243.45,45,,243.45,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,267.8,,,267.8,Other,110% of Medicare,367.88,68,,367.88,percent of total billed charges,All Other,680,,,680,Other,186% of Medicaid,432.8,,,432.8,Other,Non Covered Service,449.03,,,449.03,Other,Non Covered Service,449.03,,,449.03,Other,Non Covered Service,432.8,,,432.8,Other,Non Covered Service,449.03,,,449.03,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,378.7,70,,378.7,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,365.71,,,365.71,Other,100% of Medicaid,365.71,,,365.71,Other,100% of Medicaid,365.71,,,365.71,Other,100% of Medicaid,365.71,,,365.71,Other,100% of Medicaid,822.84,,,822.84,Other,225% of Medicaid,559.53,,,559.53,Other,153% of Medicaid,822.84,,,822.84,Other,225% of Medicaid,511.99,,,511.99,Other,140% of Medicaid,822.84,,,822.84,Other,225% of Medicaid,950.84,,,950.84,Other,260% of Medicaid,1184.89,,,1184.89,Other,324% of Medicaid,786.27,,,786.27,Other,215% of Medicaid,786.27,,,786.27,Other,215% of Medicaid,457.13,,,457.13,Other,125% of Medicaid,0.01,1184.89,
REMOVAL REVISION OF CAST,29710,CPT,,30029710,CDM,450,RC,,,both,,,831,614.94,,,614.94,Other,150% of Medicare + 9.63% HCRA Surcharge,373.95,45,,373.95,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,411.35,,,411.35,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,680,,,680,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,581.7,70,,581.7,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,365.71,,,365.71,Other,100% of Medicaid,365.71,,,365.71,Other,100% of Medicaid,365.71,,,365.71,Other,100% of Medicaid,365.71,,,365.71,Other,100% of Medicaid,822.84,,,822.84,Other,225% of Medicaid,559.53,,,559.53,Other,153% of Medicaid,822.84,,,822.84,Other,225% of Medicaid,511.99,,,511.99,Other,140% of Medicaid,822.84,,,822.84,Other,225% of Medicaid,950.84,,,950.84,Other,260% of Medicaid,1184.89,,,1184.89,Other,324% of Medicaid,786.27,,,786.27,Other,215% of Medicaid,786.27,,,786.27,Other,215% of Medicaid,457.13,,,457.13,Other,125% of Medicaid,0.01,1184.89,
WINDOWING OF CAST,29730,CPT,,30029730,CDM,450,RC,,,both,,,367,271.58,,,271.58,Other,150% of Medicare + 9.63% HCRA Surcharge,165.15,45,,165.15,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,181.67,,,181.67,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,680,,,680,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,256.9,70,,256.9,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,365.71,,,365.71,Other,100% of Medicaid,365.71,,,365.71,Other,100% of Medicaid,365.71,,,365.71,Other,100% of Medicaid,365.71,,,365.71,Other,100% of Medicaid,822.84,,,822.84,Other,225% of Medicaid,559.53,,,559.53,Other,153% of Medicaid,822.84,,,822.84,Other,225% of Medicaid,511.99,,,511.99,Other,140% of Medicaid,822.84,,,822.84,Other,225% of Medicaid,950.84,,,950.84,Other,260% of Medicaid,1184.89,,,1184.89,Other,324% of Medicaid,786.27,,,786.27,Other,215% of Medicaid,786.27,,,786.27,Other,215% of Medicaid,457.13,,,457.13,Other,125% of Medicaid,0.01,1184.89,
WEDGING OF CAST,29740,CPT,,30029740,CDM,450,RC,,,both,,,541,400.34,,,400.34,Other,150% of Medicare + 9.63% HCRA Surcharge,243.45,45,,243.45,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,267.8,,,267.8,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,680,,,680,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,378.7,70,,378.7,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,365.71,,,365.71,Other,100% of Medicaid,365.71,,,365.71,Other,100% of Medicaid,365.71,,,365.71,Other,100% of Medicaid,365.71,,,365.71,Other,100% of Medicaid,822.84,,,822.84,Other,225% of Medicaid,559.53,,,559.53,Other,153% of Medicaid,822.84,,,822.84,Other,225% of Medicaid,511.99,,,511.99,Other,140% of Medicaid,822.84,,,822.84,Other,225% of Medicaid,950.84,,,950.84,Other,260% of Medicaid,1184.89,,,1184.89,Other,324% of Medicaid,786.27,,,786.27,Other,215% of Medicaid,786.27,,,786.27,Other,215% of Medicaid,457.13,,,457.13,Other,125% of Medicaid,0.01,1184.89,
WEDGING OF CLUBFOOT CAST,29750,CPT,,30029750,CDM,450,RC,,,both,,,541,400.34,,,400.34,Other,150% of Medicare + 9.63% HCRA Surcharge,243.45,45,,243.45,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,267.8,,,267.8,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,680,,,680,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,378.7,70,,378.7,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,365.71,,,365.71,Other,100% of Medicaid,365.71,,,365.71,Other,100% of Medicaid,365.71,,,365.71,Other,100% of Medicaid,365.71,,,365.71,Other,100% of Medicaid,822.84,,,822.84,Other,225% of Medicaid,559.53,,,559.53,Other,153% of Medicaid,822.84,,,822.84,Other,225% of Medicaid,511.99,,,511.99,Other,140% of Medicaid,822.84,,,822.84,Other,225% of Medicaid,950.84,,,950.84,Other,260% of Medicaid,1184.89,,,1184.89,Other,324% of Medicaid,786.27,,,786.27,Other,215% of Medicaid,786.27,,,786.27,Other,215% of Medicaid,457.13,,,457.13,Other,125% of Medicaid,0.01,1184.89,
CASTING OR STRAPPING PROCEDURE,29799,CPT,,30029799,CDM,450,RC,,,both,,,427,315.98,,,315.98,Other,150% of Medicare + 9.63% HCRA Surcharge,192.15,45,,192.15,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,211.37,,,211.37,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,325,,,325,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,298.9,70,,298.9,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,174.92,,,174.92,Other,100% of Medicaid,174.92,,,174.92,Other,100% of Medicaid,174.92,,,174.92,Other,100% of Medicaid,174.92,,,174.92,Other,100% of Medicaid,393.57,,,393.57,Other,225% of Medicaid,267.62,,,267.62,Other,153% of Medicaid,393.57,,,393.57,Other,225% of Medicaid,244.89,,,244.89,Other,140% of Medicaid,393.57,,,393.57,Other,225% of Medicaid,454.79,,,454.79,Other,260% of Medicaid,566.73,,,566.73,Other,324% of Medicaid,376.07,,,376.07,Other,215% of Medicaid,376.07,,,376.07,Other,215% of Medicaid,218.65,,,218.65,Other,125% of Medicaid,0.01,566.73,
I AND D ABSCESS OF NASAL SEPT,30020,CPT,,30030020,CDM,450,RC,,,both,,,1160,858.4,,,858.4,Other,150% of Medicare + 9.63% HCRA Surcharge,522,45,,522,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,574.2,,,574.2,Other,110% of Medicare,788.8,68,,788.8,percent of total billed charges,All Other,2257,,,2257,Other,186% of Medicaid,928,,,928,Other,Non Covered Service,962.8,,,962.8,Other,Non Covered Service,962.8,,,962.8,Other,Non Covered Service,928,,,928,Other,Non Covered Service,962.8,,,962.8,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,812,70,,812,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1213.21,,,1213.21,Other,100% of Medicaid,1213.21,,,1213.21,Other,100% of Medicaid,1213.21,,,1213.21,Other,100% of Medicaid,1213.21,,,1213.21,Other,100% of Medicaid,2729.72,,,2729.72,Other,225% of Medicaid,1856.21,,,1856.21,Other,153% of Medicaid,2729.72,,,2729.72,Other,225% of Medicaid,1698.49,,,1698.49,Other,140% of Medicaid,2729.72,,,2729.72,Other,225% of Medicaid,3154.34,,,3154.34,Other,260% of Medicaid,3930.79,,,3930.79,Other,324% of Medicaid,2608.4,,,2608.4,Other,215% of Medicaid,2608.4,,,2608.4,Other,215% of Medicaid,1516.51,,,1516.51,Other,125% of Medicaid,0.01,3930.79,
REMOVE FOREIGN BODY NOSE,30300,CPT,,30030300,CDM,450,RC,,,both,,,271,200.54,,,200.54,Other,150% of Medicare + 9.63% HCRA Surcharge,121.95,45,,121.95,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,134.15,,,134.15,Other,110% of Medicare,184.28,68,,184.28,percent of total billed charges,All Other,423,,,423,Other,186% of Medicaid,216.8,,,216.8,Other,Non Covered Service,224.93,,,224.93,Other,Non Covered Service,224.93,,,224.93,Other,Non Covered Service,216.8,,,216.8,Other,Non Covered Service,224.93,,,224.93,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,189.7,70,,189.7,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,227.45,,,227.45,Other,100% of Medicaid,227.45,,,227.45,Other,100% of Medicaid,227.45,,,227.45,Other,100% of Medicaid,227.45,,,227.45,Other,100% of Medicaid,511.76,,,511.76,Other,225% of Medicaid,348,,,348,Other,153% of Medicaid,511.76,,,511.76,Other,225% of Medicaid,318.43,,,318.43,Other,140% of Medicaid,511.76,,,511.76,Other,225% of Medicaid,591.37,,,591.37,Other,260% of Medicaid,736.94,,,736.94,Other,324% of Medicaid,489.02,,,489.02,Other,215% of Medicaid,489.02,,,489.02,Other,215% of Medicaid,284.31,,,284.31,Other,125% of Medicaid,0.01,736.94,
CONTROL NASAL HEMOR ANT S,30901,CPT,,30030901,CDM,450,RC,,,both,,,433,320.42,,,320.42,Other,150% of Medicare + 9.63% HCRA Surcharge,194.85,45,,194.85,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,214.34,,,214.34,Other,110% of Medicare,294.44,68,,294.44,percent of total billed charges,All Other,423,,,423,Other,186% of Medicaid,346.4,,,346.4,Other,Non Covered Service,359.39,,,359.39,Other,Non Covered Service,359.39,,,359.39,Other,Non Covered Service,346.4,,,346.4,Other,Non Covered Service,359.39,,,359.39,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,303.1,70,,303.1,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,227.45,,,227.45,Other,100% of Medicaid,227.45,,,227.45,Other,100% of Medicaid,227.45,,,227.45,Other,100% of Medicaid,227.45,,,227.45,Other,100% of Medicaid,511.76,,,511.76,Other,225% of Medicaid,348,,,348,Other,153% of Medicaid,511.76,,,511.76,Other,225% of Medicaid,318.43,,,318.43,Other,140% of Medicaid,511.76,,,511.76,Other,225% of Medicaid,591.37,,,591.37,Other,260% of Medicaid,736.94,,,736.94,Other,324% of Medicaid,489.02,,,489.02,Other,215% of Medicaid,489.02,,,489.02,Other,215% of Medicaid,284.31,,,284.31,Other,125% of Medicaid,0.01,736.94,
CONTROL NASAL HEMOR ANT C,30903,CPT,,30030903,CDM,450,RC,,,both,,,433,320.42,,,320.42,Other,150% of Medicare + 9.63% HCRA Surcharge,194.85,45,,194.85,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,214.34,,,214.34,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,423,,,423,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,303.1,70,,303.1,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,227.45,,,227.45,Other,100% of Medicaid,227.45,,,227.45,Other,100% of Medicaid,227.45,,,227.45,Other,100% of Medicaid,227.45,,,227.45,Other,100% of Medicaid,511.76,,,511.76,Other,225% of Medicaid,348,,,348,Other,153% of Medicaid,511.76,,,511.76,Other,225% of Medicaid,318.43,,,318.43,Other,140% of Medicaid,511.76,,,511.76,Other,225% of Medicaid,591.37,,,591.37,Other,260% of Medicaid,736.94,,,736.94,Other,324% of Medicaid,489.02,,,489.02,Other,215% of Medicaid,489.02,,,489.02,Other,215% of Medicaid,284.31,,,284.31,Other,125% of Medicaid,0.01,736.94,
POSTERIOR PACKING NOSE SI,30905,CPT,,30030905,CDM,450,RC,,,both,,,433,320.42,,,320.42,Other,150% of Medicare + 9.63% HCRA Surcharge,194.85,45,,194.85,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,214.34,,,214.34,Other,110% of Medicare,294.44,68,,294.44,percent of total billed charges,All Other,423,,,423,Other,186% of Medicaid,346.4,,,346.4,Other,Non Covered Service,359.39,,,359.39,Other,Non Covered Service,359.39,,,359.39,Other,Non Covered Service,346.4,,,346.4,Other,Non Covered Service,359.39,,,359.39,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,303.1,70,,303.1,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,227.45,,,227.45,Other,100% of Medicaid,227.45,,,227.45,Other,100% of Medicaid,227.45,,,227.45,Other,100% of Medicaid,227.45,,,227.45,Other,100% of Medicaid,511.76,,,511.76,Other,225% of Medicaid,348,,,348,Other,153% of Medicaid,511.76,,,511.76,Other,225% of Medicaid,318.43,,,318.43,Other,140% of Medicaid,511.76,,,511.76,Other,225% of Medicaid,591.37,,,591.37,Other,260% of Medicaid,736.94,,,736.94,Other,324% of Medicaid,489.02,,,489.02,Other,215% of Medicaid,489.02,,,489.02,Other,215% of Medicaid,284.31,,,284.31,Other,125% of Medicaid,0.01,736.94,
CTRL POST EPISTAX SQ,30906,CPT,,30030906,CDM,450,RC,,,both,,,469,347.06,,,347.06,Other,150% of Medicare + 9.63% HCRA Surcharge,211.05,45,,211.05,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,232.16,,,232.16,Other,110% of Medicare,318.92,68,,318.92,percent of total billed charges,All Other,423,,,423,Other,186% of Medicaid,375.2,,,375.2,Other,Non Covered Service,389.27,,,389.27,Other,Non Covered Service,389.27,,,389.27,Other,Non Covered Service,375.2,,,375.2,Other,Non Covered Service,389.27,,,389.27,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,328.3,70,,328.3,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,227.45,,,227.45,Other,100% of Medicaid,227.45,,,227.45,Other,100% of Medicaid,227.45,,,227.45,Other,100% of Medicaid,227.45,,,227.45,Other,100% of Medicaid,511.76,,,511.76,Other,225% of Medicaid,348,,,348,Other,153% of Medicaid,511.76,,,511.76,Other,225% of Medicaid,318.43,,,318.43,Other,140% of Medicaid,511.76,,,511.76,Other,225% of Medicaid,591.37,,,591.37,Other,260% of Medicaid,736.94,,,736.94,Other,324% of Medicaid,489.02,,,489.02,Other,215% of Medicaid,489.02,,,489.02,Other,215% of Medicaid,284.31,,,284.31,Other,125% of Medicaid,0.01,736.94,
INTUBATION ENDOTRACHEAL,31500,CPT,,30031500,CDM,450,RC,,,both,,,903,668.22,,,668.22,Other,150% of Medicare + 9.63% HCRA Surcharge,406.35,45,,406.35,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,446.99,,,446.99,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,880,,,880,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,632.1,70,,632.1,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,472.91,,,472.91,Other,100% of Medicaid,472.91,,,472.91,Other,100% of Medicaid,472.91,,,472.91,Other,100% of Medicaid,472.91,,,472.91,Other,100% of Medicaid,1064.05,,,1064.05,Other,225% of Medicaid,723.55,,,723.55,Other,153% of Medicaid,1064.05,,,1064.05,Other,225% of Medicaid,662.07,,,662.07,Other,140% of Medicaid,1064.05,,,1064.05,Other,225% of Medicaid,1229.57,,,1229.57,Other,260% of Medicaid,1532.23,,,1532.23,Other,324% of Medicaid,1016.76,,,1016.76,Other,215% of Medicaid,1016.76,,,1016.76,Other,215% of Medicaid,591.14,,,591.14,Other,125% of Medicaid,0.01,1532.23,
CHANGE OF WINDPIPE AIRWAY,31502,CPT,,30031502,CDM,450,RC,,,both,,,491,363.34,,,363.34,Other,150% of Medicare + 9.63% HCRA Surcharge,220.95,45,,220.95,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,243.05,,,243.05,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,205,,,205,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,343.7,70,,343.7,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,110.47,,,110.47,Other,100% of Medicaid,110.47,,,110.47,Other,100% of Medicaid,110.47,,,110.47,Other,100% of Medicaid,110.47,,,110.47,Other,100% of Medicaid,248.55,,,248.55,Other,225% of Medicaid,169.02,,,169.02,Other,153% of Medicaid,248.55,,,248.55,Other,225% of Medicaid,154.65,,,154.65,Other,140% of Medicaid,248.55,,,248.55,Other,225% of Medicaid,287.22,,,287.22,Other,260% of Medicaid,357.92,,,357.92,Other,324% of Medicaid,237.51,,,237.51,Other,215% of Medicaid,237.51,,,237.51,Other,215% of Medicaid,138.08,,,138.08,Other,125% of Medicaid,0.01,363.34,
LARYNGOSCOPY IND; DIAGNOSTIC,31505,CPT,,30031505,CDM,450,RC,,,both,,,523,387.02,,,387.02,Other,150% of Medicare + 9.63% HCRA Surcharge,235.35,45,,235.35,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,258.89,,,258.89,Other,110% of Medicare,355.64,68,,355.64,percent of total billed charges,All Other,423,,,423,Other,186% of Medicaid,418.4,,,418.4,Other,Non Covered Service,434.09,,,434.09,Other,Non Covered Service,434.09,,,434.09,Other,Non Covered Service,418.4,,,418.4,Other,Non Covered Service,434.09,,,434.09,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,366.1,70,,366.1,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,227.45,,,227.45,Other,100% of Medicaid,227.45,,,227.45,Other,100% of Medicaid,227.45,,,227.45,Other,100% of Medicaid,227.45,,,227.45,Other,100% of Medicaid,511.76,,,511.76,Other,225% of Medicaid,348,,,348,Other,153% of Medicaid,511.76,,,511.76,Other,225% of Medicaid,318.43,,,318.43,Other,140% of Medicaid,511.76,,,511.76,Other,225% of Medicaid,591.37,,,591.37,Other,260% of Medicaid,736.94,,,736.94,Other,324% of Medicaid,489.02,,,489.02,Other,215% of Medicaid,489.02,,,489.02,Other,215% of Medicaid,284.31,,,284.31,Other,125% of Medicaid,0.01,736.94,
LARYNGOSCOPY W REMOVE FB,31511,CPT,,30031511,CDM,450,RC,,,both,,,657,486.18,,,486.18,Other,150% of Medicare + 9.63% HCRA Surcharge,295.65,45,,295.65,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,325.22,,,325.22,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,423,,,423,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,459.9,70,,459.9,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,227.45,,,227.45,Other,100% of Medicaid,227.45,,,227.45,Other,100% of Medicaid,227.45,,,227.45,Other,100% of Medicaid,227.45,,,227.45,Other,100% of Medicaid,511.76,,,511.76,Other,225% of Medicaid,348,,,348,Other,153% of Medicaid,511.76,,,511.76,Other,225% of Medicaid,318.43,,,318.43,Other,140% of Medicaid,511.76,,,511.76,Other,225% of Medicaid,591.37,,,591.37,Other,260% of Medicaid,736.94,,,736.94,Other,324% of Medicaid,489.02,,,489.02,Other,215% of Medicaid,489.02,,,489.02,Other,215% of Medicaid,284.31,,,284.31,Other,125% of Medicaid,0.01,736.94,
DX LARYNGOSCOPY EXCL NB,31525,CPT,,30031525,CDM,450,RC,,,both,,,5126,3793.25,,,3793.25,Other,150% of Medicare + 9.63% HCRA Surcharge,2306.7,45,,2306.7,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2537.37,,,2537.37,Other,110% of Medicare,3485.68,68,,3485.68,percent of total billed charges,All Other,832,,,832,Other,186% of Medicaid,4100.8,,,4100.8,Other,Non Covered Service,4254.58,,,4254.58,Other,Non Covered Service,4254.58,,,4254.58,Other,Non Covered Service,4100.8,,,4100.8,Other,Non Covered Service,4254.58,,,4254.58,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,3588.2,70,,3588.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,447.09,,,447.09,Other,100% of Medicaid,447.09,,,447.09,Other,100% of Medicaid,447.09,,,447.09,Other,100% of Medicaid,447.09,,,447.09,Other,100% of Medicaid,1005.95,,,1005.95,Other,225% of Medicaid,684.05,,,684.05,Other,153% of Medicaid,1005.95,,,1005.95,Other,225% of Medicaid,625.92,,,625.92,Other,140% of Medicaid,1005.95,,,1005.95,Other,225% of Medicaid,1162.43,,,1162.43,Other,260% of Medicaid,1448.57,,,1448.57,Other,324% of Medicaid,961.24,,,961.24,Other,215% of Medicaid,961.24,,,961.24,Other,215% of Medicaid,558.86,,,558.86,Other,125% of Medicaid,0.01,4254.58,
LARYNGOSCOPY W FB REMOVAL,31530,CPT,,30031530,CDM,450,RC,,,both,,,7157,5296.2,,,5296.2,Other,150% of Medicare + 9.63% HCRA Surcharge,3220.65,45,,3220.65,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,3542.72,,,3542.72,Other,110% of Medicare,4866.76,68,,4866.76,percent of total billed charges,All Other,832,,,832,Other,186% of Medicaid,5725.6,,,5725.6,Other,Non Covered Service,5940.31,,,5940.31,Other,Non Covered Service,5940.31,,,5940.31,Other,Non Covered Service,5725.6,,,5725.6,Other,Non Covered Service,5940.31,,,5940.31,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,5009.9,70,,5009.9,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,447.09,,,447.09,Other,100% of Medicaid,447.09,,,447.09,Other,100% of Medicaid,447.09,,,447.09,Other,100% of Medicaid,447.09,,,447.09,Other,100% of Medicaid,1005.95,,,1005.95,Other,225% of Medicaid,684.05,,,684.05,Other,153% of Medicaid,1005.95,,,1005.95,Other,225% of Medicaid,625.92,,,625.92,Other,140% of Medicaid,1005.95,,,1005.95,Other,225% of Medicaid,1162.43,,,1162.43,Other,260% of Medicaid,1448.57,,,1448.57,Other,324% of Medicaid,961.24,,,961.24,Other,215% of Medicaid,961.24,,,961.24,Other,215% of Medicaid,558.86,,,558.86,Other,125% of Medicaid,0.01,5940.31,
LARYNGOSCOPY FLEX; DIAGNOSTIC,31575,CPT,,30031575,CDM,450,RC,,,both,,,614,454.36,,,454.36,Other,150% of Medicare + 9.63% HCRA Surcharge,276.3,45,,276.3,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,303.93,,,303.93,Other,110% of Medicare,417.52,68,,417.52,percent of total billed charges,All Other,423,,,423,Other,186% of Medicaid,491.2,,,491.2,Other,Non Covered Service,509.62,,,509.62,Other,Non Covered Service,509.62,,,509.62,Other,Non Covered Service,491.2,,,491.2,Other,Non Covered Service,509.62,,,509.62,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,429.8,70,,429.8,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,227.45,,,227.45,Other,100% of Medicaid,227.45,,,227.45,Other,100% of Medicaid,227.45,,,227.45,Other,100% of Medicaid,227.45,,,227.45,Other,100% of Medicaid,511.76,,,511.76,Other,225% of Medicaid,348,,,348,Other,153% of Medicaid,511.76,,,511.76,Other,225% of Medicaid,318.43,,,318.43,Other,140% of Medicaid,511.76,,,511.76,Other,225% of Medicaid,591.37,,,591.37,Other,260% of Medicaid,736.94,,,736.94,Other,324% of Medicaid,489.02,,,489.02,Other,215% of Medicaid,489.02,,,489.02,Other,215% of Medicaid,284.31,,,284.31,Other,125% of Medicaid,0.01,736.94,
TRACHEOSTOMY TRANSTRACHE,31603,CPT,,30031603,CDM,450,RC,,,both,,,3126,2313.25,,,2313.25,Other,150% of Medicare + 9.63% HCRA Surcharge,1406.7,45,,1406.7,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1547.37,,,1547.37,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,3494,,,3494,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2188.2,70,,2188.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1878.34,,,1878.34,Other,100% of Medicaid,1878.34,,,1878.34,Other,100% of Medicaid,1878.34,,,1878.34,Other,100% of Medicaid,1878.34,,,1878.34,Other,100% of Medicaid,4226.27,,,4226.27,Other,225% of Medicaid,2873.87,,,2873.87,Other,153% of Medicaid,4226.27,,,4226.27,Other,225% of Medicaid,2629.68,,,2629.68,Other,140% of Medicaid,4226.27,,,4226.27,Other,225% of Medicaid,4883.69,,,4883.69,Other,260% of Medicaid,6085.83,,,6085.83,Other,324% of Medicaid,4038.44,,,4038.44,Other,215% of Medicaid,4038.44,,,4038.44,Other,215% of Medicaid,2347.93,,,2347.93,Other,125% of Medicaid,0.01,6085.83,
TRACHEOSTOMY CRICOTHYROI,31605,CPT,,30031605,CDM,450,RC,,,both,,,2583,1911.43,,,1911.43,Other,150% of Medicare + 9.63% HCRA Surcharge,1162.35,45,,1162.35,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1278.59,,,1278.59,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,3494,,,3494,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1808.1,70,,1808.1,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1878.34,,,1878.34,Other,100% of Medicaid,1878.34,,,1878.34,Other,100% of Medicaid,1878.34,,,1878.34,Other,100% of Medicaid,1878.34,,,1878.34,Other,100% of Medicaid,4226.27,,,4226.27,Other,225% of Medicaid,2873.87,,,2873.87,Other,153% of Medicaid,4226.27,,,4226.27,Other,225% of Medicaid,2629.68,,,2629.68,Other,140% of Medicaid,4226.27,,,4226.27,Other,225% of Medicaid,4883.69,,,4883.69,Other,260% of Medicaid,6085.83,,,6085.83,Other,324% of Medicaid,4038.44,,,4038.44,Other,215% of Medicaid,4038.44,,,4038.44,Other,215% of Medicaid,2347.93,,,2347.93,Other,125% of Medicaid,0.01,6085.83,
TRACHEOBRONCH THRU OLD INCISION,31615,CPT,,30031615,CDM,450,RC,,,both,,,1998,1478.52,,,1478.52,Other,150% of Medicare + 9.63% HCRA Surcharge,899.1,45,,899.1,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,989.01,,,989.01,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,2135,,,2135,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1398.6,70,,1398.6,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1147.93,,,1147.93,Other,100% of Medicaid,1147.93,,,1147.93,Other,100% of Medicaid,1147.93,,,1147.93,Other,100% of Medicaid,1147.93,,,1147.93,Other,100% of Medicaid,2582.84,,,2582.84,Other,225% of Medicaid,1756.33,,,1756.33,Other,153% of Medicaid,2582.84,,,2582.84,Other,225% of Medicaid,1607.1,,,1607.1,Other,140% of Medicaid,2582.84,,,2582.84,Other,225% of Medicaid,2984.62,,,2984.62,Other,260% of Medicaid,3719.29,,,3719.29,Other,324% of Medicaid,2468.05,,,2468.05,Other,215% of Medicaid,2468.05,,,2468.05,Other,215% of Medicaid,1434.91,,,1434.91,Other,125% of Medicaid,0.01,3719.29,
CORE NDL BX LNG/MED PERQ,32408,CPT,,30032408,CDM,450,RC,,,both,,,4606,3408.45,,,3408.45,Other,150% of Medicare + 9.63% HCRA Surcharge,2072.7,45,,2072.7,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2279.97,,,2279.97,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,1197,,,1197,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,3224.2,70,,3224.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,643.35,,,643.35,Other,100% of Medicaid,643.35,,,643.35,Other,100% of Medicaid,643.35,,,643.35,Other,100% of Medicaid,643.35,,,643.35,Other,100% of Medicaid,1447.55,,,1447.55,Other,225% of Medicaid,984.33,,,984.33,Other,153% of Medicaid,1447.55,,,1447.55,Other,225% of Medicaid,900.7,,,900.7,Other,140% of Medicaid,1447.55,,,1447.55,Other,225% of Medicaid,1672.72,,,1672.72,Other,260% of Medicaid,2084.47,,,2084.47,Other,324% of Medicaid,1383.21,,,1383.21,Other,215% of Medicaid,1383.21,,,1383.21,Other,215% of Medicaid,804.19,,,804.19,Other,125% of Medicaid,0.01,3408.45,
INSERTION CHEST TUBE,32551,CPT,,30032551,CDM,450,RC,,,both,,,3350,2479.01,,,2479.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1507.5,45,,1507.5,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1658.25,,,1658.25,Other,110% of Medicare,2278,68,,2278,percent of total billed charges,All Other,1197,,,1197,Other,186% of Medicaid,2680,,,2680,Other,Non Covered Service,2780.5,,,2780.5,Other,Non Covered Service,2780.5,,,2780.5,Other,Non Covered Service,2680,,,2680,Other,Non Covered Service,2780.5,,,2780.5,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2345,70,,2345,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,643.35,,,643.35,Other,100% of Medicaid,643.35,,,643.35,Other,100% of Medicaid,643.35,,,643.35,Other,100% of Medicaid,643.35,,,643.35,Other,100% of Medicaid,1447.55,,,1447.55,Other,225% of Medicaid,984.33,,,984.33,Other,153% of Medicaid,1447.55,,,1447.55,Other,225% of Medicaid,900.7,,,900.7,Other,140% of Medicaid,1447.55,,,1447.55,Other,225% of Medicaid,1672.72,,,1672.72,Other,260% of Medicaid,2084.47,,,2084.47,Other,324% of Medicaid,1383.21,,,1383.21,Other,215% of Medicaid,1383.21,,,1383.21,Other,215% of Medicaid,804.19,,,804.19,Other,125% of Medicaid,0.01,2780.5,
REMOVE LUNG CATHETER,32552,CPT,,30032552,CDM,450,RC,,,both,,,1304,964.96,,,964.96,Other,150% of Medicare + 9.63% HCRA Surcharge,586.8,45,,586.8,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,645.48,,,645.48,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,1197,,,1197,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,912.8,70,,912.8,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,643.35,,,643.35,Other,100% of Medicaid,643.35,,,643.35,Other,100% of Medicaid,643.35,,,643.35,Other,100% of Medicaid,643.35,,,643.35,Other,100% of Medicaid,1447.55,,,1447.55,Other,225% of Medicaid,984.33,,,984.33,Other,153% of Medicaid,1447.55,,,1447.55,Other,225% of Medicaid,900.7,,,900.7,Other,140% of Medicaid,1447.55,,,1447.55,Other,225% of Medicaid,1672.72,,,1672.72,Other,260% of Medicaid,2084.47,,,2084.47,Other,324% of Medicaid,1383.21,,,1383.21,Other,215% of Medicaid,1383.21,,,1383.21,Other,215% of Medicaid,804.19,,,804.19,Other,125% of Medicaid,0.01,2084.47,
ASPIRATE PLEURA WO IMAGING,32554,CPT,,30032554,CDM,450,RC,,,both,,,1729,1279.46,,,1279.46,Other,150% of Medicare + 9.63% HCRA Surcharge,778.05,45,,778.05,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,855.86,,,855.86,Other,110% of Medicare,1175.72,68,,1175.72,percent of total billed charges,All Other,1197,,,1197,Other,186% of Medicaid,1383.2,,,1383.2,Other,Non Covered Service,1435.07,,,1435.07,Other,Non Covered Service,1435.07,,,1435.07,Other,Non Covered Service,1383.2,,,1383.2,Other,Non Covered Service,1435.07,,,1435.07,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1210.3,70,,1210.3,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,643.35,,,643.35,Other,100% of Medicaid,643.35,,,643.35,Other,100% of Medicaid,643.35,,,643.35,Other,100% of Medicaid,643.35,,,643.35,Other,100% of Medicaid,1447.55,,,1447.55,Other,225% of Medicaid,984.33,,,984.33,Other,153% of Medicaid,1447.55,,,1447.55,Other,225% of Medicaid,900.7,,,900.7,Other,140% of Medicaid,1447.55,,,1447.55,Other,225% of Medicaid,1672.72,,,1672.72,Other,260% of Medicaid,2084.47,,,2084.47,Other,324% of Medicaid,1383.21,,,1383.21,Other,215% of Medicaid,1383.21,,,1383.21,Other,215% of Medicaid,804.19,,,804.19,Other,125% of Medicaid,0.01,2084.47,
ASPIRATE PLEURA W IMAGING,32555,CPT,,30032555,CDM,450,RC,,,both,,,2118,1567.33,,,1567.33,Other,150% of Medicare + 9.63% HCRA Surcharge,953.1,45,,953.1,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1048.41,,,1048.41,Other,110% of Medicare,1440.24,68,,1440.24,percent of total billed charges,All Other,1197,,,1197,Other,186% of Medicaid,1694.4,,,1694.4,Other,Non Covered Service,1757.94,,,1757.94,Other,Non Covered Service,1757.94,,,1757.94,Other,Non Covered Service,1694.4,,,1694.4,Other,Non Covered Service,1757.94,,,1757.94,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1482.6,70,,1482.6,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,643.35,,,643.35,Other,100% of Medicaid,643.35,,,643.35,Other,100% of Medicaid,643.35,,,643.35,Other,100% of Medicaid,643.35,,,643.35,Other,100% of Medicaid,1447.55,,,1447.55,Other,225% of Medicaid,984.33,,,984.33,Other,153% of Medicaid,1447.55,,,1447.55,Other,225% of Medicaid,900.7,,,900.7,Other,140% of Medicaid,1447.55,,,1447.55,Other,225% of Medicaid,1672.72,,,1672.72,Other,260% of Medicaid,2084.47,,,2084.47,Other,324% of Medicaid,1383.21,,,1383.21,Other,215% of Medicaid,1383.21,,,1383.21,Other,215% of Medicaid,804.19,,,804.19,Other,125% of Medicaid,0.01,2084.47,
LYSE CHEST FIBRIN SUBQ DAY,32562,CPT,,30032562,CDM,450,RC,,,both,,,1815,1343.1,,,1343.1,Other,150% of Medicare + 9.63% HCRA Surcharge,816.75,45,,816.75,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,898.43,,,898.43,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,1197,,,1197,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1270.5,70,,1270.5,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,643.35,,,643.35,Other,100% of Medicaid,643.35,,,643.35,Other,100% of Medicaid,643.35,,,643.35,Other,100% of Medicaid,643.35,,,643.35,Other,100% of Medicaid,1447.55,,,1447.55,Other,225% of Medicaid,984.33,,,984.33,Other,153% of Medicaid,1447.55,,,1447.55,Other,225% of Medicaid,900.7,,,900.7,Other,140% of Medicaid,1447.55,,,1447.55,Other,225% of Medicaid,1672.72,,,1672.72,Other,260% of Medicaid,2084.47,,,2084.47,Other,324% of Medicaid,1383.21,,,1383.21,Other,215% of Medicaid,1383.21,,,1383.21,Other,215% of Medicaid,804.19,,,804.19,Other,125% of Medicaid,0.01,2084.47,
INSRT TEMP VENOUS PACEMAK,33210,CPT,,30033210,CDM,450,RC,,,both,,,18374,13596.81,,,13596.81,Other,150% of Medicare + 9.63% HCRA Surcharge,8268.3,45,,8268.3,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,9095.13,,,9095.13,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,4537,,,4537,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,12861.8,70,,12861.8,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2439.2,,,2439.2,Other,100% of Medicaid,2439.2,,,2439.2,Other,100% of Medicaid,2439.2,,,2439.2,Other,100% of Medicaid,2439.2,,,2439.2,Other,100% of Medicaid,5488.2,,,5488.2,Other,225% of Medicaid,3731.98,,,3731.98,Other,153% of Medicaid,5488.2,,,5488.2,Other,225% of Medicaid,3414.88,,,3414.88,Other,140% of Medicaid,5488.2,,,5488.2,Other,225% of Medicaid,6341.92,,,6341.92,Other,260% of Medicaid,7903.01,,,7903.01,Other,324% of Medicaid,5244.28,,,5244.28,Other,215% of Medicaid,5244.28,,,5244.28,Other,215% of Medicaid,3049,,,3049,Other,125% of Medicaid,0.01,13596.81,
REPAIR BLOOD VESSEL DIRECT; UPR EXTREM,35206,CPT,,30035206,CDM,450,RC,,,both,,,11616,8595.87,,,8595.87,Other,150% of Medicare + 9.63% HCRA Surcharge,5227.2,45,,5227.2,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,5749.92,,,5749.92,Other,110% of Medicare,7898.88,68,,7898.88,percent of total billed charges,All Other,4418,,,4418,Other,186% of Medicaid,9292.8,,,9292.8,Other,Non Covered Service,9641.28,,,9641.28,Other,Non Covered Service,9641.28,,,9641.28,Other,Non Covered Service,9292.8,,,9292.8,Other,Non Covered Service,9641.28,,,9641.28,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,8131.2,70,,8131.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2375.46,,,2375.46,Other,100% of Medicaid,2375.46,,,2375.46,Other,100% of Medicaid,2375.46,,,2375.46,Other,100% of Medicaid,2375.46,,,2375.46,Other,100% of Medicaid,5344.79,,,5344.79,Other,225% of Medicaid,3634.45,,,3634.45,Other,153% of Medicaid,5344.79,,,5344.79,Other,225% of Medicaid,3325.64,,,3325.64,Other,140% of Medicaid,5344.79,,,5344.79,Other,225% of Medicaid,6176.2,,,6176.2,Other,260% of Medicaid,7696.49,,,7696.49,Other,324% of Medicaid,5107.24,,,5107.24,Other,215% of Medicaid,5107.24,,,5107.24,Other,215% of Medicaid,2969.33,,,2969.33,Other,125% of Medicaid,0.01,9641.28,
REPAIR BLD VESSEL DIRECT; LWR EXTREM,35226,CPT,,30035226,CDM,450,RC,,,both,,,2302,1703.49,,,1703.49,Other,150% of Medicare + 9.63% HCRA Surcharge,1035.9,45,,1035.9,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1139.49,,,1139.49,Other,110% of Medicare,1565.36,68,,1565.36,percent of total billed charges,All Other,4418,,,4418,Other,186% of Medicaid,1841.6,,,1841.6,Other,Non Covered Service,1910.66,,,1910.66,Other,Non Covered Service,1910.66,,,1910.66,Other,Non Covered Service,1841.6,,,1841.6,Other,Non Covered Service,1910.66,,,1910.66,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1611.4,70,,1611.4,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2375.46,,,2375.46,Other,100% of Medicaid,2375.46,,,2375.46,Other,100% of Medicaid,2375.46,,,2375.46,Other,100% of Medicaid,2375.46,,,2375.46,Other,100% of Medicaid,5344.79,,,5344.79,Other,225% of Medicaid,3634.45,,,3634.45,Other,153% of Medicaid,5344.79,,,5344.79,Other,225% of Medicaid,3325.64,,,3325.64,Other,140% of Medicaid,5344.79,,,5344.79,Other,225% of Medicaid,6176.2,,,6176.2,Other,260% of Medicaid,7696.49,,,7696.49,Other,324% of Medicaid,5107.24,,,5107.24,Other,215% of Medicaid,5107.24,,,5107.24,Other,215% of Medicaid,2969.33,,,2969.33,Other,125% of Medicaid,0.01,7696.49,
BLD DRAW < 3 YRS FEM JUGUL,36400,CPT,,30036400,CDM,450,RC,,,both,,,85,62.9,,,62.9,Other,150% of Medicare + 9.63% HCRA Surcharge,38.25,45,,38.25,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,42.08,,,42.08,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,268,,,268,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,59.5,70,,59.5,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,143.98,,,143.98,Other,100% of Medicaid,143.98,,,143.98,Other,100% of Medicaid,143.98,,,143.98,Other,100% of Medicaid,143.98,,,143.98,Other,100% of Medicaid,323.95,,,323.95,Other,225% of Medicaid,220.29,,,220.29,Other,153% of Medicaid,323.95,,,323.95,Other,225% of Medicaid,201.57,,,201.57,Other,140% of Medicaid,323.95,,,323.95,Other,225% of Medicaid,374.35,,,374.35,Other,260% of Medicaid,466.49,,,466.49,Other,324% of Medicaid,309.56,,,309.56,Other,215% of Medicaid,309.56,,,309.56,Other,215% of Medicaid,179.97,,,179.97,Other,125% of Medicaid,0.01,466.49,
BLOOD DRAW < 3 YEARS SCALP,36405,CPT,,30036405,CDM,450,RC,,,both,,,12,8.88,,,8.88,Other,150% of Medicare + 9.63% HCRA Surcharge,5.4,45,,5.4,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,5.94,,,5.94,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,268,,,268,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,8.4,70,,8.4,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,143.98,,,143.98,Other,100% of Medicaid,143.98,,,143.98,Other,100% of Medicaid,143.98,,,143.98,Other,100% of Medicaid,143.98,,,143.98,Other,100% of Medicaid,323.95,,,323.95,Other,225% of Medicaid,220.29,,,220.29,Other,153% of Medicaid,323.95,,,323.95,Other,225% of Medicaid,201.57,,,201.57,Other,140% of Medicaid,323.95,,,323.95,Other,225% of Medicaid,374.35,,,374.35,Other,260% of Medicaid,466.49,,,466.49,Other,324% of Medicaid,309.56,,,309.56,Other,215% of Medicaid,309.56,,,309.56,Other,215% of Medicaid,179.97,,,179.97,Other,125% of Medicaid,0.01,466.49,
BLD DRAW < 3 YRS OTHER VEIN,36406,CPT,,30036406,CDM,450,RC,,,both,,,45,33.3,,,33.3,Other,150% of Medicare + 9.63% HCRA Surcharge,20.25,45,,20.25,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,22.28,,,22.28,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,268,,,268,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,31.5,70,,31.5,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,143.98,,,143.98,Other,100% of Medicaid,143.98,,,143.98,Other,100% of Medicaid,143.98,,,143.98,Other,100% of Medicaid,143.98,,,143.98,Other,100% of Medicaid,323.95,,,323.95,Other,225% of Medicaid,220.29,,,220.29,Other,153% of Medicaid,323.95,,,323.95,Other,225% of Medicaid,201.57,,,201.57,Other,140% of Medicaid,323.95,,,323.95,Other,225% of Medicaid,374.35,,,374.35,Other,260% of Medicaid,466.49,,,466.49,Other,324% of Medicaid,309.56,,,309.56,Other,215% of Medicaid,309.56,,,309.56,Other,215% of Medicaid,179.97,,,179.97,Other,125% of Medicaid,0.01,466.49,
NON-ROUTINE BLD DRAW >3 YRS,36410,CPT,,30036410,CDM,450,RC,,,both,,,130,96.2,,,96.2,Other,150% of Medicare + 9.63% HCRA Surcharge,58.5,45,,58.5,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,64.35,,,64.35,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,49,,,49,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,91,70,,91,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,26.36,,,26.36,Other,100% of Medicaid,26.36,,,26.36,Other,100% of Medicaid,26.36,,,26.36,Other,100% of Medicaid,26.36,,,26.36,Other,100% of Medicaid,59.32,,,59.32,Other,225% of Medicaid,40.33,,,40.33,Other,153% of Medicaid,59.32,,,59.32,Other,225% of Medicaid,36.91,,,36.91,Other,140% of Medicaid,59.32,,,59.32,Other,225% of Medicaid,68.54,,,68.54,Other,260% of Medicaid,85.41,,,85.41,Other,324% of Medicaid,56.68,,,56.68,Other,215% of Medicaid,56.68,,,56.68,Other,215% of Medicaid,32.95,,,32.95,Other,125% of Medicaid,0.01,96.2,
CAPILLARY BLOOD DRAW,36416,CPT,,30036416,CDM,450,RC,,,both,,,41,30.34,,,30.34,Other,150% of Medicare + 9.63% HCRA Surcharge,18.45,45,,18.45,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,20.3,,,20.3,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,61,,,61,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,28.7,70,,28.7,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,32.83,,,32.83,Other,100% of Medicaid,32.83,,,32.83,Other,100% of Medicaid,32.83,,,32.83,Other,100% of Medicaid,32.83,,,32.83,Other,100% of Medicaid,73.87,,,73.87,Other,225% of Medicaid,50.23,,,50.23,Other,153% of Medicaid,73.87,,,73.87,Other,225% of Medicaid,45.96,,,45.96,Other,140% of Medicaid,73.87,,,73.87,Other,225% of Medicaid,85.36,,,85.36,Other,260% of Medicaid,106.38,,,106.38,Other,324% of Medicaid,70.59,,,70.59,Other,215% of Medicaid,70.59,,,70.59,Other,215% of Medicaid,41.04,,,41.04,Other,125% of Medicaid,0.01,106.38,
VEIN ACCESS CUTDOWN > 1 YR,36425,CPT,,30036425,CDM,450,RC,,,both,,,851,629.74,,,629.74,Other,150% of Medicare + 9.63% HCRA Surcharge,382.95,45,,382.95,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,421.25,,,421.25,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,255,,,255,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,595.7,70,,595.7,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,137.02,,,137.02,Other,100% of Medicaid,137.02,,,137.02,Other,100% of Medicaid,137.02,,,137.02,Other,100% of Medicaid,137.02,,,137.02,Other,100% of Medicaid,308.3,,,308.3,Other,225% of Medicaid,209.65,,,209.65,Other,153% of Medicaid,308.3,,,308.3,Other,225% of Medicaid,191.83,,,191.83,Other,140% of Medicaid,308.3,,,308.3,Other,225% of Medicaid,356.26,,,356.26,Other,260% of Medicaid,443.96,,,443.96,Other,324% of Medicaid,294.6,,,294.6,Other,215% of Medicaid,294.6,,,294.6,Other,215% of Medicaid,171.28,,,171.28,Other,125% of Medicaid,0.01,629.74,
INSERT CATHETER VEIN,36481,CPT,,30036481,CDM,450,RC,,,both,,,2087,1544.39,,,1544.39,Other,150% of Medicare + 9.63% HCRA Surcharge,939.15,45,,939.15,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1033.07,,,1033.07,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,516,,,516,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1460.9,70,,1460.9,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,277.43,,,277.43,Other,100% of Medicaid,277.43,,,277.43,Other,100% of Medicaid,277.43,,,277.43,Other,100% of Medicaid,277.43,,,277.43,Other,100% of Medicaid,624.21,,,624.21,Other,225% of Medicaid,424.47,,,424.47,Other,153% of Medicaid,624.21,,,624.21,Other,225% of Medicaid,388.4,,,388.4,Other,140% of Medicaid,624.21,,,624.21,Other,225% of Medicaid,721.31,,,721.31,Other,260% of Medicaid,898.87,,,898.87,Other,324% of Medicaid,596.47,,,596.47,Other,215% of Medicaid,596.47,,,596.47,Other,215% of Medicaid,346.79,,,346.79,Other,125% of Medicaid,0.01,1544.39,
INSERT NON TUNNEL CV CATH,36556,CPT,,30036556,CDM,450,RC,,,both,,,6707,4963.2,,,4963.2,Other,150% of Medicare + 9.63% HCRA Surcharge,3018.15,45,,3018.15,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,3319.97,,,3319.97,Other,110% of Medicare,4560.76,68,,4560.76,percent of total billed charges,All Other,587,,,587,Other,186% of Medicaid,5365.6,,,5365.6,Other,Non Covered Service,5566.81,,,5566.81,Other,Non Covered Service,5566.81,,,5566.81,Other,Non Covered Service,5365.6,,,5365.6,Other,Non Covered Service,5566.81,,,5566.81,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,4694.9,70,,4694.9,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,315.42,,,315.42,Other,100% of Medicaid,315.42,,,315.42,Other,100% of Medicaid,315.42,,,315.42,Other,100% of Medicaid,315.42,,,315.42,Other,100% of Medicaid,709.7,,,709.7,Other,225% of Medicaid,482.6,,,482.6,Other,153% of Medicaid,709.7,,,709.7,Other,225% of Medicaid,441.59,,,441.59,Other,140% of Medicaid,709.7,,,709.7,Other,225% of Medicaid,820.1,,,820.1,Other,260% of Medicaid,1021.97,,,1021.97,Other,324% of Medicaid,678.16,,,678.16,Other,215% of Medicaid,678.16,,,678.16,Other,215% of Medicaid,394.28,,,394.28,Other,125% of Medicaid,0.01,5566.81,
INS PICC AGE 5 YRS >,36569,CPT,,30036569,CDM,450,RC,,,both,,,4042,2991.09,,,2991.09,Other,150% of Medicare + 9.63% HCRA Surcharge,1818.9,45,,1818.9,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2000.79,,,2000.79,Other,110% of Medicare,2748.56,68,,2748.56,percent of total billed charges,All Other,358,,,358,Other,186% of Medicaid,3233.6,,,3233.6,Other,Non Covered Service,3354.86,,,3354.86,Other,Non Covered Service,3354.86,,,3354.86,Other,Non Covered Service,3233.6,,,3233.6,Other,Non Covered Service,3354.86,,,3354.86,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2829.4,70,,2829.4,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,192.29,,,192.29,Other,100% of Medicaid,192.29,,,192.29,Other,100% of Medicaid,192.29,,,192.29,Other,100% of Medicaid,192.29,,,192.29,Other,100% of Medicaid,432.65,,,432.65,Other,225% of Medicaid,294.2,,,294.2,Other,153% of Medicaid,432.65,,,432.65,Other,225% of Medicaid,269.21,,,269.21,Other,140% of Medicaid,432.65,,,432.65,Other,225% of Medicaid,499.96,,,499.96,Other,260% of Medicaid,623.02,,,623.02,Other,324% of Medicaid,413.42,,,413.42,Other,215% of Medicaid,413.42,,,413.42,Other,215% of Medicaid,240.36,,,240.36,Other,125% of Medicaid,0.01,3354.86,
REPAIR CVA CATHETER,36575,CPT,,30036575,CDM,450,RC,,,both,,,1989,1471.86,,,1471.86,Other,150% of Medicare + 9.63% HCRA Surcharge,895.05,45,,895.05,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,984.56,,,984.56,Other,110% of Medicare,1352.52,68,,1352.52,percent of total billed charges,All Other,1557,,,1557,Other,186% of Medicaid,1591.2,,,1591.2,Other,Non Covered Service,1650.87,,,1650.87,Other,Non Covered Service,1650.87,,,1650.87,Other,Non Covered Service,1591.2,,,1591.2,Other,Non Covered Service,1650.87,,,1650.87,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1392.3,70,,1392.3,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,836.95,,,836.95,Other,100% of Medicaid,836.95,,,836.95,Other,100% of Medicaid,836.95,,,836.95,Other,100% of Medicaid,836.95,,,836.95,Other,100% of Medicaid,1883.13,,,1883.13,Other,225% of Medicaid,1280.53,,,1280.53,Other,153% of Medicaid,1883.13,,,1883.13,Other,225% of Medicaid,1171.73,,,1171.73,Other,140% of Medicaid,1883.13,,,1883.13,Other,225% of Medicaid,2176.07,,,2176.07,Other,260% of Medicaid,2711.71,,,2711.71,Other,324% of Medicaid,1799.44,,,1799.44,Other,215% of Medicaid,1799.44,,,1799.44,Other,215% of Medicaid,1046.19,,,1046.19,Other,125% of Medicaid,0.01,2711.71,
DECLOT VASCULAR DEVICE,36593,CPT,,30036593,CDM,450,RC,,,both,,,896,663.04,,,663.04,Other,150% of Medicare + 9.63% HCRA Surcharge,403.2,45,,403.2,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,443.52,,,443.52,Other,110% of Medicare,609.28,68,,609.28,percent of total billed charges,All Other,411,,,411,Other,186% of Medicaid,716.8,,,716.8,Other,Non Covered Service,743.68,,,743.68,Other,Non Covered Service,743.68,,,743.68,Other,Non Covered Service,716.8,,,716.8,Other,Non Covered Service,743.68,,,743.68,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,627.2,70,,627.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,221.06,,,221.06,Other,100% of Medicaid,221.06,,,221.06,Other,100% of Medicaid,221.06,,,221.06,Other,100% of Medicaid,221.06,,,221.06,Other,100% of Medicaid,497.39,,,497.39,Other,225% of Medicaid,338.22,,,338.22,Other,153% of Medicaid,497.39,,,497.39,Other,225% of Medicaid,309.49,,,309.49,Other,140% of Medicaid,497.39,,,497.39,Other,225% of Medicaid,574.76,,,574.76,Other,260% of Medicaid,716.24,,,716.24,Other,324% of Medicaid,475.28,,,475.28,Other,215% of Medicaid,475.28,,,475.28,Other,215% of Medicaid,276.33,,,276.33,Other,125% of Medicaid,0.01,743.68,
ARTERIAL PUNCTURE,36600,CPT,,30036600,CDM,450,RC,,,both,,,263,194.62,,,194.62,Other,150% of Medicare + 9.63% HCRA Surcharge,118.35,45,,118.35,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,130.19,,,130.19,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,49,,,49,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,184.1,70,,184.1,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,26.36,,,26.36,Other,100% of Medicaid,26.36,,,26.36,Other,100% of Medicaid,26.36,,,26.36,Other,100% of Medicaid,26.36,,,26.36,Other,100% of Medicaid,59.32,,,59.32,Other,225% of Medicaid,40.33,,,40.33,Other,153% of Medicaid,59.32,,,59.32,Other,225% of Medicaid,36.91,,,36.91,Other,140% of Medicaid,59.32,,,59.32,Other,225% of Medicaid,68.54,,,68.54,Other,260% of Medicaid,85.41,,,85.41,Other,324% of Medicaid,56.68,,,56.68,Other,215% of Medicaid,56.68,,,56.68,Other,215% of Medicaid,32.95,,,32.95,Other,125% of Medicaid,0.01,194.62,
INSERT ARTERIAL CATHETER,36620,CPT,,30036620,CDM,450,RC,,,both,,,299,221.26,,,221.26,Other,150% of Medicare + 9.63% HCRA Surcharge,134.55,45,,134.55,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,148.01,,,148.01,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,292,,,292,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,209.3,70,,209.3,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,156.95,,,156.95,Other,100% of Medicaid,156.95,,,156.95,Other,100% of Medicaid,156.95,,,156.95,Other,100% of Medicaid,156.95,,,156.95,Other,100% of Medicaid,353.14,,,353.14,Other,225% of Medicaid,240.14,,,240.14,Other,153% of Medicaid,353.14,,,353.14,Other,225% of Medicaid,219.73,,,219.73,Other,140% of Medicaid,353.14,,,353.14,Other,225% of Medicaid,408.08,,,408.08,Other,260% of Medicaid,508.53,,,508.53,Other,324% of Medicaid,337.45,,,337.45,Other,215% of Medicaid,337.45,,,337.45,Other,215% of Medicaid,196.19,,,196.19,Other,125% of Medicaid,0.01,508.53,
PLACE NEEDLE INTRAOSSEOUS,36680,CPT,,30036680,CDM,450,RC,,,both,,,851,629.74,,,629.74,Other,150% of Medicare + 9.63% HCRA Surcharge,382.95,45,,382.95,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,421.25,,,421.25,Other,110% of Medicare,578.68,68,,578.68,percent of total billed charges,All Other,686,,,686,Other,186% of Medicaid,680.8,,,680.8,Other,Non Covered Service,706.33,,,706.33,Other,Non Covered Service,706.33,,,706.33,Other,Non Covered Service,680.8,,,680.8,Other,Non Covered Service,706.33,,,706.33,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,595.7,70,,595.7,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,368.64,,,368.64,Other,100% of Medicaid,368.64,,,368.64,Other,100% of Medicaid,368.64,,,368.64,Other,100% of Medicaid,368.64,,,368.64,Other,100% of Medicaid,829.44,,,829.44,Other,225% of Medicaid,564.02,,,564.02,Other,153% of Medicaid,829.44,,,829.44,Other,225% of Medicaid,516.1,,,516.1,Other,140% of Medicaid,829.44,,,829.44,Other,225% of Medicaid,958.46,,,958.46,Other,260% of Medicaid,1194.39,,,1194.39,Other,324% of Medicaid,792.58,,,792.58,Other,215% of Medicaid,792.58,,,792.58,Other,215% of Medicaid,460.8,,,460.8,Other,125% of Medicaid,0.01,1194.39,
LIGATE/DIVIDE/EXCISE VEIN 1 LEG,37785,CPT,,30037785,CDM,450,RC,,,both,,,7721,5713.56,,,5713.56,Other,150% of Medicare + 9.63% HCRA Surcharge,3474.45,45,,3474.45,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,3821.9,,,3821.9,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,4156,,,4156,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,5404.7,70,,5404.7,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2234.65,,,2234.65,Other,100% of Medicaid,2234.65,,,2234.65,Other,100% of Medicaid,2234.65,,,2234.65,Other,100% of Medicaid,2234.65,,,2234.65,Other,100% of Medicaid,5027.97,,,5027.97,Other,225% of Medicaid,3419.02,,,3419.02,Other,153% of Medicaid,5027.97,,,5027.97,Other,225% of Medicaid,3128.51,,,3128.51,Other,140% of Medicaid,5027.97,,,5027.97,Other,225% of Medicaid,5810.1,,,5810.1,Other,260% of Medicaid,7240.28,,,7240.28,Other,324% of Medicaid,4804.5,,,4804.5,Other,215% of Medicaid,4804.5,,,4804.5,Other,215% of Medicaid,2793.32,,,2793.32,Other,125% of Medicaid,0.01,7240.28,
BONE MARROW BIOPSY,38221,CPT,,30038221,CDM,450,RC,,,both,,,3926,2905.25,,,2905.25,Other,150% of Medicare + 9.63% HCRA Surcharge,1766.7,45,,1766.7,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1943.37,,,1943.37,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,777,,,777,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2748.2,70,,2748.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,417.75,,,417.75,Other,100% of Medicaid,417.75,,,417.75,Other,100% of Medicaid,417.75,,,417.75,Other,100% of Medicaid,417.75,,,417.75,Other,100% of Medicaid,939.93,,,939.93,Other,225% of Medicaid,639.15,,,639.15,Other,153% of Medicaid,939.93,,,939.93,Other,225% of Medicaid,584.84,,,584.84,Other,140% of Medicaid,939.93,,,939.93,Other,225% of Medicaid,1086.14,,,1086.14,Other,260% of Medicaid,1353.5,,,1353.5,Other,324% of Medicaid,898.15,,,898.15,Other,215% of Medicaid,898.15,,,898.15,Other,215% of Medicaid,522.18,,,522.18,Other,125% of Medicaid,0.01,2905.25,
REPAIR LIP FT VERMILION ONLY,40650,CPT,,30040650,CDM,450,RC,,,both,,,1515,1121.1,,,1121.1,Other,150% of Medicare + 9.63% HCRA Surcharge,681.75,45,,681.75,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,749.93,,,749.93,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,423,,,423,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1060.5,70,,1060.5,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,227.45,,,227.45,Other,100% of Medicaid,227.45,,,227.45,Other,100% of Medicaid,227.45,,,227.45,Other,100% of Medicaid,227.45,,,227.45,Other,100% of Medicaid,511.76,,,511.76,Other,225% of Medicaid,348,,,348,Other,153% of Medicaid,511.76,,,511.76,Other,225% of Medicaid,318.43,,,318.43,Other,140% of Medicaid,511.76,,,511.76,Other,225% of Medicaid,591.37,,,591.37,Other,260% of Medicaid,736.94,,,736.94,Other,324% of Medicaid,489.02,,,489.02,Other,215% of Medicaid,489.02,,,489.02,Other,215% of Medicaid,284.31,,,284.31,Other,125% of Medicaid,0.01,1121.1,
REM EMBEDDED FB MOUTH VESTIB; SIMPLE,40804,CPT,,30040804,CDM,450,RC,,,both,,,1860,1376.4,,,1376.4,Other,150% of Medicare + 9.63% HCRA Surcharge,837,45,,837,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,920.7,,,920.7,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,429,,,429,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1302,70,,1302,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,230.43,,,230.43,Other,100% of Medicaid,230.43,,,230.43,Other,100% of Medicaid,230.43,,,230.43,Other,100% of Medicaid,230.43,,,230.43,Other,100% of Medicaid,518.46,,,518.46,Other,225% of Medicaid,352.55,,,352.55,Other,153% of Medicaid,518.46,,,518.46,Other,225% of Medicaid,322.6,,,322.6,Other,140% of Medicaid,518.46,,,518.46,Other,225% of Medicaid,599.11,,,599.11,Other,260% of Medicaid,746.59,,,746.59,Other,324% of Medicaid,495.42,,,495.42,Other,215% of Medicaid,495.42,,,495.42,Other,215% of Medicaid,288.03,,,288.03,Other,125% of Medicaid,0.01,1376.4,
CL LACERATION MOUTH VESTIB 2.5CM,40830,CPT,,30040830,CDM,450,RC,,,both,,,1263,934.62,,,934.62,Other,150% of Medicare + 9.63% HCRA Surcharge,568.35,45,,568.35,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,625.19,,,625.19,Other,110% of Medicare,858.84,68,,858.84,percent of total billed charges,All Other,423,,,423,Other,186% of Medicaid,1010.4,,,1010.4,Other,Non Covered Service,1048.29,,,1048.29,Other,Non Covered Service,1048.29,,,1048.29,Other,Non Covered Service,1010.4,,,1010.4,Other,Non Covered Service,1048.29,,,1048.29,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,884.1,70,,884.1,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,227.45,,,227.45,Other,100% of Medicaid,227.45,,,227.45,Other,100% of Medicaid,227.45,,,227.45,Other,100% of Medicaid,227.45,,,227.45,Other,100% of Medicaid,511.76,,,511.76,Other,225% of Medicaid,348,,,348,Other,153% of Medicaid,511.76,,,511.76,Other,225% of Medicaid,318.43,,,318.43,Other,140% of Medicaid,511.76,,,511.76,Other,225% of Medicaid,591.37,,,591.37,Other,260% of Medicaid,736.94,,,736.94,Other,324% of Medicaid,489.02,,,489.02,Other,215% of Medicaid,489.02,,,489.02,Other,215% of Medicaid,284.31,,,284.31,Other,125% of Medicaid,0.01,1048.29,
CL LACERATION MOUTH VESTIB >2.5CM,40831,CPT,,30040831,CDM,450,RC,,,both,,,1998,1478.52,,,1478.52,Other,150% of Medicare + 9.63% HCRA Surcharge,899.1,45,,899.1,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,989.01,,,989.01,Other,110% of Medicare,1358.64,68,,1358.64,percent of total billed charges,All Other,429,,,429,Other,186% of Medicaid,1598.4,,,1598.4,Other,Non Covered Service,1658.34,,,1658.34,Other,Non Covered Service,1658.34,,,1658.34,Other,Non Covered Service,1598.4,,,1598.4,Other,Non Covered Service,1658.34,,,1658.34,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1398.6,70,,1398.6,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,230.43,,,230.43,Other,100% of Medicaid,230.43,,,230.43,Other,100% of Medicaid,230.43,,,230.43,Other,100% of Medicaid,230.43,,,230.43,Other,100% of Medicaid,518.46,,,518.46,Other,225% of Medicaid,352.55,,,352.55,Other,153% of Medicaid,518.46,,,518.46,Other,225% of Medicaid,322.6,,,322.6,Other,140% of Medicaid,518.46,,,518.46,Other,225% of Medicaid,599.11,,,599.11,Other,260% of Medicaid,746.59,,,746.59,Other,324% of Medicaid,495.42,,,495.42,Other,215% of Medicaid,495.42,,,495.42,Other,215% of Medicaid,288.03,,,288.03,Other,125% of Medicaid,0.01,1658.34,
EO I&D ABSC/CYS FOM; SUBMAND,41017,CPT,,30041017,CDM,450,RC,,,both,,,7746,5732.06,,,5732.06,Other,150% of Medicare + 9.63% HCRA Surcharge,3485.7,45,,3485.7,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,3834.27,,,3834.27,Other,110% of Medicare,5267.28,68,,5267.28,percent of total billed charges,All Other,829,,,829,Other,186% of Medicaid,6196.8,,,6196.8,Other,Non Covered Service,6429.18,,,6429.18,Other,Non Covered Service,6429.18,,,6429.18,Other,Non Covered Service,6196.8,,,6196.8,Other,Non Covered Service,6429.18,,,6429.18,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,5422.2,70,,5422.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,445.92,,,445.92,Other,100% of Medicaid,445.92,,,445.92,Other,100% of Medicaid,445.92,,,445.92,Other,100% of Medicaid,445.92,,,445.92,Other,100% of Medicaid,1003.32,,,1003.32,Other,225% of Medicaid,682.26,,,682.26,Other,153% of Medicaid,1003.32,,,1003.32,Other,225% of Medicaid,624.29,,,624.29,Other,140% of Medicaid,1003.32,,,1003.32,Other,225% of Medicaid,1159.39,,,1159.39,Other,260% of Medicaid,1444.78,,,1444.78,Other,324% of Medicaid,958.72,,,958.72,Other,215% of Medicaid,958.72,,,958.72,Other,215% of Medicaid,557.4,,,557.4,Other,125% of Medicaid,0.01,6429.18,
REP LACERAT 2.5CM < FLR M,41250,CPT,,30041250,CDM,450,RC,,,both,,,851,629.74,,,629.74,Other,150% of Medicare + 9.63% HCRA Surcharge,382.95,45,,382.95,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,421.25,,,421.25,Other,110% of Medicare,578.68,68,,578.68,percent of total billed charges,All Other,423,,,423,Other,186% of Medicaid,680.8,,,680.8,Other,Non Covered Service,706.33,,,706.33,Other,Non Covered Service,706.33,,,706.33,Other,Non Covered Service,680.8,,,680.8,Other,Non Covered Service,706.33,,,706.33,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,595.7,70,,595.7,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,227.45,,,227.45,Other,100% of Medicaid,227.45,,,227.45,Other,100% of Medicaid,227.45,,,227.45,Other,100% of Medicaid,227.45,,,227.45,Other,100% of Medicaid,511.76,,,511.76,Other,225% of Medicaid,348,,,348,Other,153% of Medicaid,511.76,,,511.76,Other,225% of Medicaid,318.43,,,318.43,Other,140% of Medicaid,511.76,,,511.76,Other,225% of Medicaid,591.37,,,591.37,Other,260% of Medicaid,736.94,,,736.94,Other,324% of Medicaid,489.02,,,489.02,Other,215% of Medicaid,489.02,,,489.02,Other,215% of Medicaid,284.31,,,284.31,Other,125% of Medicaid,0.01,736.94,
REP LACERAT FLR MOUTH>2.5,41252,CPT,,30041252,CDM,450,RC,,,both,,,2583,1911.43,,,1911.43,Other,150% of Medicare + 9.63% HCRA Surcharge,1162.35,45,,1162.35,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1278.59,,,1278.59,Other,110% of Medicare,1756.44,68,,1756.44,percent of total billed charges,All Other,423,,,423,Other,186% of Medicaid,2066.4,,,2066.4,Other,Non Covered Service,2143.89,,,2143.89,Other,Non Covered Service,2143.89,,,2143.89,Other,Non Covered Service,2066.4,,,2066.4,Other,Non Covered Service,2143.89,,,2143.89,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1808.1,70,,1808.1,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,227.45,,,227.45,Other,100% of Medicaid,227.45,,,227.45,Other,100% of Medicaid,227.45,,,227.45,Other,100% of Medicaid,227.45,,,227.45,Other,100% of Medicaid,511.76,,,511.76,Other,225% of Medicaid,348,,,348,Other,153% of Medicaid,511.76,,,511.76,Other,225% of Medicaid,318.43,,,318.43,Other,140% of Medicaid,511.76,,,511.76,Other,225% of Medicaid,591.37,,,591.37,Other,260% of Medicaid,736.94,,,736.94,Other,324% of Medicaid,489.02,,,489.02,Other,215% of Medicaid,489.02,,,489.02,Other,215% of Medicaid,284.31,,,284.31,Other,125% of Medicaid,0.01,2143.89,
DR ABSC CYST HEMATOM DE,41800,CPT,,30041800,CDM,450,RC,,,both,,,570,421.8,,,421.8,Other,150% of Medicare + 9.63% HCRA Surcharge,256.5,45,,256.5,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,282.15,,,282.15,Other,110% of Medicare,387.6,68,,387.6,percent of total billed charges,All Other,423,,,423,Other,186% of Medicaid,456,,,456,Other,Non Covered Service,473.1,,,473.1,Other,Non Covered Service,473.1,,,473.1,Other,Non Covered Service,456,,,456,Other,Non Covered Service,473.1,,,473.1,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,399,70,,399,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,227.45,,,227.45,Other,100% of Medicaid,227.45,,,227.45,Other,100% of Medicaid,227.45,,,227.45,Other,100% of Medicaid,227.45,,,227.45,Other,100% of Medicaid,511.76,,,511.76,Other,225% of Medicaid,348,,,348,Other,153% of Medicaid,511.76,,,511.76,Other,225% of Medicaid,318.43,,,318.43,Other,140% of Medicaid,511.76,,,511.76,Other,225% of Medicaid,591.37,,,591.37,Other,260% of Medicaid,736.94,,,736.94,Other,324% of Medicaid,489.02,,,489.02,Other,215% of Medicaid,489.02,,,489.02,Other,215% of Medicaid,284.31,,,284.31,Other,125% of Medicaid,0.01,736.94,
REM EMB FB FROM DENTOALV SFT TISSUE,41805,CPT,,30041805,CDM,450,RC,,,both,,,4870,3603.81,,,3603.81,Other,150% of Medicare + 9.63% HCRA Surcharge,2191.5,45,,2191.5,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2410.65,,,2410.65,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,429,,,429,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,3409,70,,3409,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,230.43,,,230.43,Other,100% of Medicaid,230.43,,,230.43,Other,100% of Medicaid,230.43,,,230.43,Other,100% of Medicaid,230.43,,,230.43,Other,100% of Medicaid,518.46,,,518.46,Other,225% of Medicaid,352.55,,,352.55,Other,153% of Medicaid,518.46,,,518.46,Other,225% of Medicaid,322.6,,,322.6,Other,140% of Medicaid,518.46,,,518.46,Other,225% of Medicaid,599.11,,,599.11,Other,260% of Medicaid,746.59,,,746.59,Other,324% of Medicaid,495.42,,,495.42,Other,215% of Medicaid,495.42,,,495.42,Other,215% of Medicaid,288.03,,,288.03,Other,125% of Medicaid,0.01,3603.81,
DRAINAGE OF ABSCESS OF PA,42000,CPT,,30042000,CDM,450,RC,,,both,,,1160,858.4,,,858.4,Other,150% of Medicare + 9.63% HCRA Surcharge,522,45,,522,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,574.2,,,574.2,Other,110% of Medicare,788.8,68,,788.8,percent of total billed charges,All Other,423,,,423,Other,186% of Medicaid,928,,,928,Other,Non Covered Service,962.8,,,962.8,Other,Non Covered Service,962.8,,,962.8,Other,Non Covered Service,928,,,928,Other,Non Covered Service,962.8,,,962.8,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,812,70,,812,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,227.45,,,227.45,Other,100% of Medicaid,227.45,,,227.45,Other,100% of Medicaid,227.45,,,227.45,Other,100% of Medicaid,227.45,,,227.45,Other,100% of Medicaid,511.76,,,511.76,Other,225% of Medicaid,348,,,348,Other,153% of Medicaid,511.76,,,511.76,Other,225% of Medicaid,318.43,,,318.43,Other,140% of Medicaid,511.76,,,511.76,Other,225% of Medicaid,591.37,,,591.37,Other,260% of Medicaid,736.94,,,736.94,Other,324% of Medicaid,489.02,,,489.02,Other,215% of Medicaid,489.02,,,489.02,Other,215% of Medicaid,284.31,,,284.31,Other,125% of Medicaid,0.01,962.8,
I AND D TONSIL ABSCESS,42700,CPT,,30042700,CDM,450,RC,,,both,,,1160,858.4,,,858.4,Other,150% of Medicare + 9.63% HCRA Surcharge,522,45,,522,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,574.2,,,574.2,Other,110% of Medicare,788.8,68,,788.8,percent of total billed charges,All Other,423,,,423,Other,186% of Medicaid,928,,,928,Other,Non Covered Service,962.8,,,962.8,Other,Non Covered Service,962.8,,,962.8,Other,Non Covered Service,928,,,928,Other,Non Covered Service,962.8,,,962.8,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,812,70,,812,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,227.45,,,227.45,Other,100% of Medicaid,227.45,,,227.45,Other,100% of Medicaid,227.45,,,227.45,Other,100% of Medicaid,227.45,,,227.45,Other,100% of Medicaid,511.76,,,511.76,Other,225% of Medicaid,348,,,348,Other,153% of Medicaid,511.76,,,511.76,Other,225% of Medicaid,318.43,,,318.43,Other,140% of Medicaid,511.76,,,511.76,Other,225% of Medicaid,591.37,,,591.37,Other,260% of Medicaid,736.94,,,736.94,Other,324% of Medicaid,489.02,,,489.02,Other,215% of Medicaid,489.02,,,489.02,Other,215% of Medicaid,284.31,,,284.31,Other,125% of Medicaid,0.01,962.8,
REMOVE FOREIGN BODY PHARYNX,42809,CPT,,30042809,CDM,450,RC,,,both,,,851,629.74,,,629.74,Other,150% of Medicare + 9.63% HCRA Surcharge,382.95,45,,382.95,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,421.25,,,421.25,Other,110% of Medicare,578.68,68,,578.68,percent of total billed charges,All Other,423,,,423,Other,186% of Medicaid,680.8,,,680.8,Other,Non Covered Service,706.33,,,706.33,Other,Non Covered Service,706.33,,,706.33,Other,Non Covered Service,680.8,,,680.8,Other,Non Covered Service,706.33,,,706.33,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,595.7,70,,595.7,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,227.45,,,227.45,Other,100% of Medicaid,227.45,,,227.45,Other,100% of Medicaid,227.45,,,227.45,Other,100% of Medicaid,227.45,,,227.45,Other,100% of Medicaid,511.76,,,511.76,Other,225% of Medicaid,348,,,348,Other,153% of Medicaid,511.76,,,511.76,Other,225% of Medicaid,318.43,,,318.43,Other,140% of Medicaid,511.76,,,511.76,Other,225% of Medicaid,591.37,,,591.37,Other,260% of Medicaid,736.94,,,736.94,Other,324% of Medicaid,489.02,,,489.02,Other,215% of Medicaid,489.02,,,489.02,Other,215% of Medicaid,284.31,,,284.31,Other,125% of Medicaid,0.01,736.94,
SUTURE PHARYNX FOR WOUND OR INJURY,42900,CPT,,30042900,CDM,450,RC,,,both,,,4533,3354.43,,,3354.43,Other,150% of Medicare + 9.63% HCRA Surcharge,2039.85,45,,2039.85,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2243.84,,,2243.84,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,2257,,,2257,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,3173.1,70,,3173.1,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1213.21,,,1213.21,Other,100% of Medicaid,1213.21,,,1213.21,Other,100% of Medicaid,1213.21,,,1213.21,Other,100% of Medicaid,1213.21,,,1213.21,Other,100% of Medicaid,2729.72,,,2729.72,Other,225% of Medicaid,1856.21,,,1856.21,Other,153% of Medicaid,2729.72,,,2729.72,Other,225% of Medicaid,1698.49,,,1698.49,Other,140% of Medicaid,2729.72,,,2729.72,Other,225% of Medicaid,3154.34,,,3154.34,Other,260% of Medicaid,3930.79,,,3930.79,Other,324% of Medicaid,2608.4,,,2608.4,Other,215% of Medicaid,2608.4,,,2608.4,Other,215% of Medicaid,1516.51,,,1516.51,Other,125% of Medicaid,0.01,3930.79,
ESOPHAGUS ENDOSCOPY,43200,CPT,,30043200,CDM,450,RC,,,both,,,2900,2146.01,,,2146.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1305,45,,1305,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1435.5,,,1435.5,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,1531,,,1531,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2030,70,,2030,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,823.04,,,823.04,Other,100% of Medicaid,823.04,,,823.04,Other,100% of Medicaid,823.04,,,823.04,Other,100% of Medicaid,823.04,,,823.04,Other,100% of Medicaid,1851.85,,,1851.85,Other,225% of Medicaid,1259.26,,,1259.26,Other,153% of Medicaid,1851.85,,,1851.85,Other,225% of Medicaid,1152.26,,,1152.26,Other,140% of Medicaid,1851.85,,,1851.85,Other,225% of Medicaid,2139.92,,,2139.92,Other,260% of Medicaid,2666.66,,,2666.66,Other,324% of Medicaid,1769.55,,,1769.55,Other,215% of Medicaid,1769.55,,,1769.55,Other,215% of Medicaid,1028.81,,,1028.81,Other,125% of Medicaid,0.01,2666.66,
ESOPHAGOSCOPY W FB REMOVAL,43215,CPT,,30043215,CDM,450,RC,,,both,,,3921,2901.55,,,2901.55,Other,150% of Medicare + 9.63% HCRA Surcharge,1764.45,45,,1764.45,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1940.9,,,1940.9,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,1531,,,1531,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2744.7,70,,2744.7,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,823.04,,,823.04,Other,100% of Medicaid,823.04,,,823.04,Other,100% of Medicaid,823.04,,,823.04,Other,100% of Medicaid,823.04,,,823.04,Other,100% of Medicaid,1851.85,,,1851.85,Other,225% of Medicaid,1259.26,,,1259.26,Other,153% of Medicaid,1851.85,,,1851.85,Other,225% of Medicaid,1152.26,,,1152.26,Other,140% of Medicaid,1851.85,,,1851.85,Other,225% of Medicaid,2139.92,,,2139.92,Other,260% of Medicaid,2666.66,,,2666.66,Other,324% of Medicaid,1769.55,,,1769.55,Other,215% of Medicaid,1769.55,,,1769.55,Other,215% of Medicaid,1028.81,,,1028.81,Other,125% of Medicaid,0.01,2901.55,
UGI DIAGNOSTIC,43235,CPT,,30043235,CDM,450,RC,,,both,,,2900,2146.01,,,2146.01,Other,150% of Medicare + 9.63% HCRA Surcharge,1305,45,,1305,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1435.5,,,1435.5,Other,110% of Medicare,1972,68,,1972,percent of total billed charges,All Other,1531,,,1531,Other,186% of Medicaid,2320,,,2320,Other,Non Covered Service,2407,,,2407,Other,Non Covered Service,2407,,,2407,Other,Non Covered Service,2320,,,2320,Other,Non Covered Service,2407,,,2407,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2030,70,,2030,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,823.04,,,823.04,Other,100% of Medicaid,823.04,,,823.04,Other,100% of Medicaid,823.04,,,823.04,Other,100% of Medicaid,823.04,,,823.04,Other,100% of Medicaid,1851.85,,,1851.85,Other,225% of Medicaid,1259.26,,,1259.26,Other,153% of Medicaid,1851.85,,,1851.85,Other,225% of Medicaid,1152.26,,,1152.26,Other,140% of Medicaid,1851.85,,,1851.85,Other,225% of Medicaid,2139.92,,,2139.92,Other,260% of Medicaid,2666.66,,,2666.66,Other,324% of Medicaid,1769.55,,,1769.55,Other,215% of Medicaid,1769.55,,,1769.55,Other,215% of Medicaid,1028.81,,,1028.81,Other,125% of Medicaid,0.01,2666.66,
GASTROSTOMY TUBE PLACEMENT,43246,CPT,,30043246,CDM,450,RC,,,both,,,3921,2901.55,,,2901.55,Other,150% of Medicare + 9.63% HCRA Surcharge,1764.45,45,,1764.45,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1940.9,,,1940.9,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,1531,,,1531,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2744.7,70,,2744.7,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,823.04,,,823.04,Other,100% of Medicaid,823.04,,,823.04,Other,100% of Medicaid,823.04,,,823.04,Other,100% of Medicaid,823.04,,,823.04,Other,100% of Medicaid,1851.85,,,1851.85,Other,225% of Medicaid,1259.26,,,1259.26,Other,153% of Medicaid,1851.85,,,1851.85,Other,225% of Medicaid,1152.26,,,1152.26,Other,140% of Medicaid,1851.85,,,1851.85,Other,225% of Medicaid,2139.92,,,2139.92,Other,260% of Medicaid,2666.66,,,2666.66,Other,324% of Medicaid,1769.55,,,1769.55,Other,215% of Medicaid,1769.55,,,1769.55,Other,215% of Medicaid,1028.81,,,1028.81,Other,125% of Medicaid,0.01,2901.55,
UGI W REMOVAL OF FOREIGN BODY,43247,CPT,,30043247,CDM,450,RC,,,both,,,3382,2502.69,,,2502.69,Other,150% of Medicare + 9.63% HCRA Surcharge,1521.9,45,,1521.9,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1674.09,,,1674.09,Other,110% of Medicare,2299.76,68,,2299.76,percent of total billed charges,All Other,1531,,,1531,Other,186% of Medicaid,2705.6,,,2705.6,Other,Non Covered Service,2807.06,,,2807.06,Other,Non Covered Service,2807.06,,,2807.06,Other,Non Covered Service,2705.6,,,2705.6,Other,Non Covered Service,2807.06,,,2807.06,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2367.4,70,,2367.4,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,823.04,,,823.04,Other,100% of Medicaid,823.04,,,823.04,Other,100% of Medicaid,823.04,,,823.04,Other,100% of Medicaid,823.04,,,823.04,Other,100% of Medicaid,1851.85,,,1851.85,Other,225% of Medicaid,1259.26,,,1259.26,Other,153% of Medicaid,1851.85,,,1851.85,Other,225% of Medicaid,1152.26,,,1152.26,Other,140% of Medicaid,1851.85,,,1851.85,Other,225% of Medicaid,2139.92,,,2139.92,Other,260% of Medicaid,2666.66,,,2666.66,Other,324% of Medicaid,1769.55,,,1769.55,Other,215% of Medicaid,1769.55,,,1769.55,Other,215% of Medicaid,1028.81,,,1028.81,Other,125% of Medicaid,0.01,2807.06,
NASAL /OROGASTRIC W/TUBE PLMT,43752,CPT,,30043752,CDM,450,RC,,,both,,,851,629.74,,,629.74,Other,150% of Medicare + 9.63% HCRA Surcharge,382.95,45,,382.95,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,421.25,,,421.25,Other,110% of Medicare,578.68,68,,578.68,percent of total billed charges,All Other,1030,,,1030,Other,186% of Medicaid,680.8,,,680.8,Other,Non Covered Service,706.33,,,706.33,Other,Non Covered Service,706.33,,,706.33,Other,Non Covered Service,680.8,,,680.8,Other,Non Covered Service,706.33,,,706.33,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,595.7,70,,595.7,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,553.96,,,553.96,Other,100% of Medicaid,553.96,,,553.96,Other,100% of Medicaid,553.96,,,553.96,Other,100% of Medicaid,553.96,,,553.96,Other,100% of Medicaid,1246.41,,,1246.41,Other,225% of Medicaid,847.56,,,847.56,Other,153% of Medicaid,1246.41,,,1246.41,Other,225% of Medicaid,775.55,,,775.55,Other,140% of Medicaid,1246.41,,,1246.41,Other,225% of Medicaid,1440.3,,,1440.3,Other,260% of Medicaid,1794.83,,,1794.83,Other,324% of Medicaid,1191.02,,,1191.02,Other,215% of Medicaid,1191.02,,,1191.02,Other,215% of Medicaid,692.45,,,692.45,Other,125% of Medicaid,0.01,1794.83,
NG TUBE ASPIRATION/LAVAGE,43753,CPT,,30043753,CDM,450,RC,,,both,,,632,467.68,,,467.68,Other,150% of Medicare + 9.63% HCRA Surcharge,284.4,45,,284.4,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,312.84,,,312.84,Other,110% of Medicare,429.76,68,,429.76,percent of total billed charges,All Other,0.01,,,0.01,Other,186% of Medicaid,505.6,,,505.6,Other,Non Covered Service,524.56,,,524.56,Other,Non Covered Service,524.56,,,524.56,Other,Non Covered Service,505.6,,,505.6,Other,Non Covered Service,524.56,,,524.56,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,442.4,70,,442.4,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,524.56,
RPLC GTUBE NO REVJ TRC,43762,CPT,,30043762,CDM,450,RC,,,both,,,1648,1219.52,,,1219.52,Other,150% of Medicare + 9.63% HCRA Surcharge,741.6,45,,741.6,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,815.76,,,815.76,Other,110% of Medicare,1120.64,68,,1120.64,percent of total billed charges,All Other,1030,,,1030,Other,186% of Medicaid,1318.4,,,1318.4,Other,Non Covered Service,1367.84,,,1367.84,Other,Non Covered Service,1367.84,,,1367.84,Other,Non Covered Service,1318.4,,,1318.4,Other,Non Covered Service,1367.84,,,1367.84,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1153.6,70,,1153.6,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,553.96,,,553.96,Other,100% of Medicaid,553.96,,,553.96,Other,100% of Medicaid,553.96,,,553.96,Other,100% of Medicaid,553.96,,,553.96,Other,100% of Medicaid,1246.41,,,1246.41,Other,225% of Medicaid,847.56,,,847.56,Other,153% of Medicaid,1246.41,,,1246.41,Other,225% of Medicaid,775.55,,,775.55,Other,140% of Medicaid,1246.41,,,1246.41,Other,225% of Medicaid,1440.3,,,1440.3,Other,260% of Medicaid,1794.83,,,1794.83,Other,324% of Medicaid,1191.02,,,1191.02,Other,215% of Medicaid,1191.02,,,1191.02,Other,215% of Medicaid,692.45,,,692.45,Other,125% of Medicaid,0.01,1794.83,
RPLC GTUBE REVJ GSTRST TRC,43763,CPT,,30043763,CDM,450,RC,,,both,,,1592,1178.08,,,1178.08,Other,150% of Medicare + 9.63% HCRA Surcharge,716.4,45,,716.4,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,788.04,,,788.04,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,1030,,,1030,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1114.4,70,,1114.4,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,553.96,,,553.96,Other,100% of Medicaid,553.96,,,553.96,Other,100% of Medicaid,553.96,,,553.96,Other,100% of Medicaid,553.96,,,553.96,Other,100% of Medicaid,1246.41,,,1246.41,Other,225% of Medicaid,847.56,,,847.56,Other,153% of Medicaid,1246.41,,,1246.41,Other,225% of Medicaid,775.55,,,775.55,Other,140% of Medicaid,1246.41,,,1246.41,Other,225% of Medicaid,1440.3,,,1440.3,Other,260% of Medicaid,1794.83,,,1794.83,Other,324% of Medicaid,1191.02,,,1191.02,Other,215% of Medicaid,1191.02,,,1191.02,Other,215% of Medicaid,692.45,,,692.45,Other,125% of Medicaid,0.01,1794.83,
PLACE GASTROSTOMY TUBE,43830,CPT,,30043830,CDM,450,RC,,,both,,,5442,4027.09,,,4027.09,Other,150% of Medicare + 9.63% HCRA Surcharge,2448.9,45,,2448.9,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2693.79,,,2693.79,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,3157,,,3157,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,3809.4,70,,3809.4,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1697.49,,,1697.49,Other,100% of Medicaid,1697.49,,,1697.49,Other,100% of Medicaid,1697.49,,,1697.49,Other,100% of Medicaid,1697.49,,,1697.49,Other,100% of Medicaid,3819.36,,,3819.36,Other,225% of Medicaid,2597.16,,,2597.16,Other,153% of Medicaid,3819.36,,,3819.36,Other,225% of Medicaid,2376.49,,,2376.49,Other,140% of Medicaid,3819.36,,,3819.36,Other,225% of Medicaid,4413.48,,,4413.48,Other,260% of Medicaid,5499.87,,,5499.87,Other,324% of Medicaid,3649.61,,,3649.61,Other,215% of Medicaid,3649.61,,,3649.61,Other,215% of Medicaid,2121.86,,,2121.86,Other,125% of Medicaid,0.01,5499.87,
NG TUBE INSERTION,44500,CPT,,30044500,CDM,450,RC,,,both,,,2409,1782.67,,,1782.67,Other,150% of Medicare + 9.63% HCRA Surcharge,1084.05,45,,1084.05,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1192.46,,,1192.46,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,1030,,,1030,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1686.3,70,,1686.3,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,553.96,,,553.96,Other,100% of Medicaid,553.96,,,553.96,Other,100% of Medicaid,553.96,,,553.96,Other,100% of Medicaid,553.96,,,553.96,Other,100% of Medicaid,1246.41,,,1246.41,Other,225% of Medicaid,847.56,,,847.56,Other,153% of Medicaid,1246.41,,,1246.41,Other,225% of Medicaid,775.55,,,775.55,Other,140% of Medicaid,1246.41,,,1246.41,Other,225% of Medicaid,1440.3,,,1440.3,Other,260% of Medicaid,1794.83,,,1794.83,Other,324% of Medicaid,1191.02,,,1191.02,Other,215% of Medicaid,1191.02,,,1191.02,Other,215% of Medicaid,692.45,,,692.45,Other,125% of Medicaid,0.01,1794.83,
SIGMOIDOSCOPY FLEX W REM FB,45332,CPT,,30045332,CDM,450,RC,,,both,,,2439,1804.87,,,1804.87,Other,150% of Medicare + 9.63% HCRA Surcharge,1097.55,45,,1097.55,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1207.31,,,1207.31,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,1479,,,1479,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1707.3,70,,1707.3,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,794.91,,,794.91,Other,100% of Medicaid,794.91,,,794.91,Other,100% of Medicaid,794.91,,,794.91,Other,100% of Medicaid,794.91,,,794.91,Other,100% of Medicaid,1788.55,,,1788.55,Other,225% of Medicaid,1216.22,,,1216.22,Other,153% of Medicaid,1788.55,,,1788.55,Other,225% of Medicaid,1112.88,,,1112.88,Other,140% of Medicaid,1788.55,,,1788.55,Other,225% of Medicaid,2066.77,,,2066.77,Other,260% of Medicaid,2575.52,,,2575.52,Other,324% of Medicaid,1709.06,,,1709.06,Other,215% of Medicaid,1709.06,,,1709.06,Other,215% of Medicaid,993.64,,,993.64,Other,125% of Medicaid,0.01,2575.52,
SIGMOIDOSC W BLEED CONTROL,45334,CPT,,30045334,CDM,450,RC,,,both,,,3099,2293.27,,,2293.27,Other,150% of Medicare + 9.63% HCRA Surcharge,1394.55,45,,1394.55,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1534.01,,,1534.01,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,1479,,,1479,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2169.3,70,,2169.3,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,794.91,,,794.91,Other,100% of Medicaid,794.91,,,794.91,Other,100% of Medicaid,794.91,,,794.91,Other,100% of Medicaid,794.91,,,794.91,Other,100% of Medicaid,1788.55,,,1788.55,Other,225% of Medicaid,1216.22,,,1216.22,Other,153% of Medicaid,1788.55,,,1788.55,Other,225% of Medicaid,1112.88,,,1112.88,Other,140% of Medicaid,1788.55,,,1788.55,Other,225% of Medicaid,2066.77,,,2066.77,Other,260% of Medicaid,2575.52,,,2575.52,Other,324% of Medicaid,1709.06,,,1709.06,Other,215% of Medicaid,1709.06,,,1709.06,Other,215% of Medicaid,993.64,,,993.64,Other,125% of Medicaid,0.01,2575.52,
REDUCTION OF PROCIDENTIA,45900,CPT,,30045900,CDM,450,RC,,,both,,,1963,1452.62,,,1452.62,Other,150% of Medicare + 9.63% HCRA Surcharge,883.35,45,,883.35,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,971.69,,,971.69,Other,110% of Medicare,1334.84,68,,1334.84,percent of total billed charges,All Other,2000,,,2000,Other,186% of Medicaid,1570.4,,,1570.4,Other,Non Covered Service,1629.29,,,1629.29,Other,Non Covered Service,1629.29,,,1629.29,Other,Non Covered Service,1570.4,,,1570.4,Other,Non Covered Service,1629.29,,,1629.29,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1374.1,70,,1374.1,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1075.35,,,1075.35,Other,100% of Medicaid,1075.35,,,1075.35,Other,100% of Medicaid,1075.35,,,1075.35,Other,100% of Medicaid,1075.35,,,1075.35,Other,100% of Medicaid,2419.55,,,2419.55,Other,225% of Medicaid,1645.29,,,1645.29,Other,153% of Medicaid,2419.55,,,2419.55,Other,225% of Medicaid,1505.5,,,1505.5,Other,140% of Medicaid,2419.55,,,2419.55,Other,225% of Medicaid,2795.92,,,2795.92,Other,260% of Medicaid,3484.15,,,3484.15,Other,324% of Medicaid,2312.01,,,2312.01,Other,215% of Medicaid,2312.01,,,2312.01,Other,215% of Medicaid,1344.19,,,1344.19,Other,125% of Medicaid,0.01,3484.15,
REMOVE FECAL IMPACTION OR FB,45915,CPT,,30045915,CDM,450,RC,,,both,,,5394,3991.57,,,3991.57,Other,150% of Medicare + 9.63% HCRA Surcharge,2427.3,45,,2427.3,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2670.03,,,2670.03,Other,110% of Medicare,3667.92,68,,3667.92,percent of total billed charges,All Other,2000,,,2000,Other,186% of Medicaid,4315.2,,,4315.2,Other,Non Covered Service,4477.02,,,4477.02,Other,Non Covered Service,4477.02,,,4477.02,Other,Non Covered Service,4315.2,,,4315.2,Other,Non Covered Service,4477.02,,,4477.02,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,3775.8,70,,3775.8,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1075.35,,,1075.35,Other,100% of Medicaid,1075.35,,,1075.35,Other,100% of Medicaid,1075.35,,,1075.35,Other,100% of Medicaid,1075.35,,,1075.35,Other,100% of Medicaid,2419.55,,,2419.55,Other,225% of Medicaid,1645.29,,,1645.29,Other,153% of Medicaid,2419.55,,,2419.55,Other,225% of Medicaid,1505.5,,,1505.5,Other,140% of Medicaid,2419.55,,,2419.55,Other,225% of Medicaid,2795.92,,,2795.92,Other,260% of Medicaid,3484.15,,,3484.15,Other,324% of Medicaid,2312.01,,,2312.01,Other,215% of Medicaid,2312.01,,,2312.01,Other,215% of Medicaid,1344.19,,,1344.19,Other,125% of Medicaid,0.01,4477.02,
I AND D PERIRECTAL OR ISCHIA,46040,CPT,,30046040,CDM,450,RC,,,both,,,9261,6853.16,,,6853.16,Other,150% of Medicare + 9.63% HCRA Surcharge,4167.45,45,,4167.45,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,4584.2,,,4584.2,Other,110% of Medicare,6297.48,68,,6297.48,percent of total billed charges,All Other,2000,,,2000,Other,186% of Medicaid,7408.8,,,7408.8,Other,Non Covered Service,7686.63,,,7686.63,Other,Non Covered Service,7686.63,,,7686.63,Other,Non Covered Service,7408.8,,,7408.8,Other,Non Covered Service,7686.63,,,7686.63,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,6482.7,70,,6482.7,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1075.35,,,1075.35,Other,100% of Medicaid,1075.35,,,1075.35,Other,100% of Medicaid,1075.35,,,1075.35,Other,100% of Medicaid,1075.35,,,1075.35,Other,100% of Medicaid,2419.55,,,2419.55,Other,225% of Medicaid,1645.29,,,1645.29,Other,153% of Medicaid,2419.55,,,2419.55,Other,225% of Medicaid,1505.5,,,1505.5,Other,140% of Medicaid,2419.55,,,2419.55,Other,225% of Medicaid,2795.92,,,2795.92,Other,260% of Medicaid,3484.15,,,3484.15,Other,324% of Medicaid,2312.01,,,2312.01,Other,215% of Medicaid,2312.01,,,2312.01,Other,215% of Medicaid,1344.19,,,1344.19,Other,125% of Medicaid,0.01,7686.63,
I AND D RECTAL ABSCESS,46045,CPT,,30046045,CDM,450,RC,,,both,,,8500,6290.02,,,6290.02,Other,150% of Medicare + 9.63% HCRA Surcharge,3825,45,,3825,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,4207.5,,,4207.5,Other,110% of Medicare,5780,68,,5780,percent of total billed charges,All Other,2733,,,2733,Other,186% of Medicaid,6800,,,6800,Other,Non Covered Service,7055,,,7055,Other,Non Covered Service,7055,,,7055,Other,Non Covered Service,6800,,,6800,Other,Non Covered Service,7055,,,7055,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,5950,70,,5950,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1469.23,,,1469.23,Other,100% of Medicaid,1469.23,,,1469.23,Other,100% of Medicaid,1469.23,,,1469.23,Other,100% of Medicaid,1469.23,,,1469.23,Other,100% of Medicaid,3305.76,,,3305.76,Other,225% of Medicaid,2247.91,,,2247.91,Other,153% of Medicaid,3305.76,,,3305.76,Other,225% of Medicaid,2056.92,,,2056.92,Other,140% of Medicaid,3305.76,,,3305.76,Other,225% of Medicaid,3819.99,,,3819.99,Other,260% of Medicaid,4760.29,,,4760.29,Other,324% of Medicaid,3158.83,,,3158.83,Other,215% of Medicaid,3158.83,,,3158.83,Other,215% of Medicaid,1836.53,,,1836.53,Other,125% of Medicaid,0.01,7055,
I AND D PERIANAL ABSCESS,46050,CPT,,30046050,CDM,450,RC,,,both,,,5731,4240.95,,,4240.95,Other,150% of Medicare + 9.63% HCRA Surcharge,2578.95,45,,2578.95,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2836.85,,,2836.85,Other,110% of Medicare,3897.08,68,,3897.08,percent of total billed charges,All Other,2000,,,2000,Other,186% of Medicaid,4584.8,,,4584.8,Other,Non Covered Service,4756.73,,,4756.73,Other,Non Covered Service,4756.73,,,4756.73,Other,Non Covered Service,4584.8,,,4584.8,Other,Non Covered Service,4756.73,,,4756.73,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,4011.7,70,,4011.7,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1075.35,,,1075.35,Other,100% of Medicaid,1075.35,,,1075.35,Other,100% of Medicaid,1075.35,,,1075.35,Other,100% of Medicaid,1075.35,,,1075.35,Other,100% of Medicaid,2419.55,,,2419.55,Other,225% of Medicaid,1645.29,,,1645.29,Other,153% of Medicaid,2419.55,,,2419.55,Other,225% of Medicaid,1505.5,,,1505.5,Other,140% of Medicaid,2419.55,,,2419.55,Other,225% of Medicaid,2795.92,,,2795.92,Other,260% of Medicaid,3484.15,,,3484.15,Other,324% of Medicaid,2312.01,,,2312.01,Other,215% of Medicaid,2312.01,,,2312.01,Other,215% of Medicaid,1344.19,,,1344.19,Other,125% of Medicaid,0.01,4756.73,
I AND D THROMB HEMORRHOID EXT,46083,CPT,,30046083,CDM,450,RC,,,both,,,1378,1019.72,,,1019.72,Other,150% of Medicare + 9.63% HCRA Surcharge,620.1,45,,620.1,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,682.11,,,682.11,Other,110% of Medicare,937.04,68,,937.04,percent of total billed charges,All Other,2000,,,2000,Other,186% of Medicaid,1102.4,,,1102.4,Other,Non Covered Service,1143.74,,,1143.74,Other,Non Covered Service,1143.74,,,1143.74,Other,Non Covered Service,1102.4,,,1102.4,Other,Non Covered Service,1143.74,,,1143.74,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,964.6,70,,964.6,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1075.35,,,1075.35,Other,100% of Medicaid,1075.35,,,1075.35,Other,100% of Medicaid,1075.35,,,1075.35,Other,100% of Medicaid,1075.35,,,1075.35,Other,100% of Medicaid,2419.55,,,2419.55,Other,225% of Medicaid,1645.29,,,1645.29,Other,153% of Medicaid,2419.55,,,2419.55,Other,225% of Medicaid,1505.5,,,1505.5,Other,140% of Medicaid,2419.55,,,2419.55,Other,225% of Medicaid,2795.92,,,2795.92,Other,260% of Medicaid,3484.15,,,3484.15,Other,324% of Medicaid,2312.01,,,2312.01,Other,215% of Medicaid,2312.01,,,2312.01,Other,215% of Medicaid,1344.19,,,1344.19,Other,125% of Medicaid,0.01,3484.15,
REMOVE ANAL FIST SUBQ,46270,CPT,,30046270,CDM,450,RC,,,both,,,7901,5846.76,,,5846.76,Other,150% of Medicare + 9.63% HCRA Surcharge,3555.45,45,,3555.45,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,3911,,,3911,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,2733,,,2733,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,5530.7,70,,5530.7,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1469.23,,,1469.23,Other,100% of Medicaid,1469.23,,,1469.23,Other,100% of Medicaid,1469.23,,,1469.23,Other,100% of Medicaid,1469.23,,,1469.23,Other,100% of Medicaid,3305.76,,,3305.76,Other,225% of Medicaid,2247.91,,,2247.91,Other,153% of Medicaid,3305.76,,,3305.76,Other,225% of Medicaid,2056.92,,,2056.92,Other,140% of Medicaid,3305.76,,,3305.76,Other,225% of Medicaid,3819.99,,,3819.99,Other,260% of Medicaid,4760.29,,,4760.29,Other,324% of Medicaid,3158.83,,,3158.83,Other,215% of Medicaid,3158.83,,,3158.83,Other,215% of Medicaid,1836.53,,,1836.53,Other,125% of Medicaid,0.01,5846.76,
REMOVAL OF HEMORRHOID CLOT,46320,CPT,,30046320,CDM,450,RC,,,both,,,5391,3989.35,,,3989.35,Other,150% of Medicare + 9.63% HCRA Surcharge,2425.95,45,,2425.95,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2668.55,,,2668.55,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,2000,,,2000,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,3773.7,70,,3773.7,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1075.35,,,1075.35,Other,100% of Medicaid,1075.35,,,1075.35,Other,100% of Medicaid,1075.35,,,1075.35,Other,100% of Medicaid,1075.35,,,1075.35,Other,100% of Medicaid,2419.55,,,2419.55,Other,225% of Medicaid,1645.29,,,1645.29,Other,153% of Medicaid,2419.55,,,2419.55,Other,225% of Medicaid,1505.5,,,1505.5,Other,140% of Medicaid,2419.55,,,2419.55,Other,225% of Medicaid,2795.92,,,2795.92,Other,260% of Medicaid,3484.15,,,3484.15,Other,324% of Medicaid,2312.01,,,2312.01,Other,215% of Medicaid,2312.01,,,2312.01,Other,215% of Medicaid,1344.19,,,1344.19,Other,125% of Medicaid,0.01,3989.35,
DIAGNOSTIC ANOSCOPY,46600,CPT,,30046600,CDM,450,RC,,,both,,,263,194.62,,,194.62,Other,150% of Medicare + 9.63% HCRA Surcharge,118.35,45,,118.35,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,130.19,,,130.19,Other,110% of Medicare,178.84,68,,178.84,percent of total billed charges,All Other,1030,,,1030,Other,186% of Medicaid,210.4,,,210.4,Other,Non Covered Service,218.29,,,218.29,Other,Non Covered Service,218.29,,,218.29,Other,Non Covered Service,210.4,,,210.4,Other,Non Covered Service,218.29,,,218.29,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,184.1,70,,184.1,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,553.96,,,553.96,Other,100% of Medicaid,553.96,,,553.96,Other,100% of Medicaid,553.96,,,553.96,Other,100% of Medicaid,553.96,,,553.96,Other,100% of Medicaid,1246.41,,,1246.41,Other,225% of Medicaid,847.56,,,847.56,Other,153% of Medicaid,1246.41,,,1246.41,Other,225% of Medicaid,775.55,,,775.55,Other,140% of Medicaid,1246.41,,,1246.41,Other,225% of Medicaid,1440.3,,,1440.3,Other,260% of Medicaid,1794.83,,,1794.83,Other,324% of Medicaid,1191.02,,,1191.02,Other,215% of Medicaid,1191.02,,,1191.02,Other,215% of Medicaid,692.45,,,692.45,Other,125% of Medicaid,0.01,1794.83,
REMOVE FOREIGN BODY RECTUMQ,46608,CPT,,30046608,CDM,450,RC,,,both,,,3099,2293.27,,,2293.27,Other,150% of Medicare + 9.63% HCRA Surcharge,1394.55,45,,1394.55,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1534.01,,,1534.01,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,1479,,,1479,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2169.3,70,,2169.3,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,794.91,,,794.91,Other,100% of Medicaid,794.91,,,794.91,Other,100% of Medicaid,794.91,,,794.91,Other,100% of Medicaid,794.91,,,794.91,Other,100% of Medicaid,1788.55,,,1788.55,Other,225% of Medicaid,1216.22,,,1216.22,Other,153% of Medicaid,1788.55,,,1788.55,Other,225% of Medicaid,1112.88,,,1112.88,Other,140% of Medicaid,1788.55,,,1788.55,Other,225% of Medicaid,2066.77,,,2066.77,Other,260% of Medicaid,2575.52,,,2575.52,Other,324% of Medicaid,1709.06,,,1709.06,Other,215% of Medicaid,1709.06,,,1709.06,Other,215% of Medicaid,993.64,,,993.64,Other,125% of Medicaid,0.01,2575.52,
ABD PARACENTESIS,49082,CPT,,30049082,CDM,450,RC,,,both,,,1860,1376.4,,,1376.4,Other,150% of Medicare + 9.63% HCRA Surcharge,837,45,,837,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,920.7,,,920.7,Other,110% of Medicare,1264.8,68,,1264.8,percent of total billed charges,All Other,1197,,,1197,Other,186% of Medicaid,1488,,,1488,Other,Non Covered Service,1543.8,,,1543.8,Other,Non Covered Service,1543.8,,,1543.8,Other,Non Covered Service,1488,,,1488,Other,Non Covered Service,1543.8,,,1543.8,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1302,70,,1302,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,643.35,,,643.35,Other,100% of Medicaid,643.35,,,643.35,Other,100% of Medicaid,643.35,,,643.35,Other,100% of Medicaid,643.35,,,643.35,Other,100% of Medicaid,1447.55,,,1447.55,Other,225% of Medicaid,984.33,,,984.33,Other,153% of Medicaid,1447.55,,,1447.55,Other,225% of Medicaid,900.7,,,900.7,Other,140% of Medicaid,1447.55,,,1447.55,Other,225% of Medicaid,1672.72,,,1672.72,Other,260% of Medicaid,2084.47,,,2084.47,Other,324% of Medicaid,1383.21,,,1383.21,Other,215% of Medicaid,1383.21,,,1383.21,Other,215% of Medicaid,804.19,,,804.19,Other,125% of Medicaid,0.01,2084.47,
ABD PARACENTESIS W/IMAGING,49083,CPT,,30049083,CDM,450,RC,,,both,,,1893,1400.82,,,1400.82,Other,150% of Medicare + 9.63% HCRA Surcharge,851.85,45,,851.85,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,937.04,,,937.04,Other,110% of Medicare,1287.24,68,,1287.24,percent of total billed charges,All Other,1197,,,1197,Other,186% of Medicaid,1514.4,,,1514.4,Other,Non Covered Service,1571.19,,,1571.19,Other,Non Covered Service,1571.19,,,1571.19,Other,Non Covered Service,1514.4,,,1514.4,Other,Non Covered Service,1571.19,,,1571.19,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1325.1,70,,1325.1,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,643.35,,,643.35,Other,100% of Medicaid,643.35,,,643.35,Other,100% of Medicaid,643.35,,,643.35,Other,100% of Medicaid,643.35,,,643.35,Other,100% of Medicaid,1447.55,,,1447.55,Other,225% of Medicaid,984.33,,,984.33,Other,153% of Medicaid,1447.55,,,1447.55,Other,225% of Medicaid,900.7,,,900.7,Other,140% of Medicaid,1447.55,,,1447.55,Other,225% of Medicaid,1672.72,,,1672.72,Other,260% of Medicaid,2084.47,,,2084.47,Other,324% of Medicaid,1383.21,,,1383.21,Other,215% of Medicaid,1383.21,,,1383.21,Other,215% of Medicaid,804.19,,,804.19,Other,125% of Medicaid,0.01,2084.47,
REPLACE DUOD JEJ TUBE PERC,49451,CPT,,30049451,CDM,450,RC,,,both,,,4863,3598.63,,,3598.63,Other,150% of Medicare + 9.63% HCRA Surcharge,2188.35,45,,2188.35,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2407.19,,,2407.19,Other,110% of Medicare,3306.84,68,,3306.84,percent of total billed charges,All Other,770,,,770,Other,186% of Medicaid,3890.4,,,3890.4,Other,Non Covered Service,4036.29,,,4036.29,Other,Non Covered Service,4036.29,,,4036.29,Other,Non Covered Service,3890.4,,,3890.4,Other,Non Covered Service,4036.29,,,4036.29,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,3404.1,70,,3404.1,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,414.16,,,414.16,Other,100% of Medicaid,414.16,,,414.16,Other,100% of Medicaid,414.16,,,414.16,Other,100% of Medicaid,414.16,,,414.16,Other,100% of Medicaid,931.85,,,931.85,Other,225% of Medicaid,633.66,,,633.66,Other,153% of Medicaid,931.85,,,931.85,Other,225% of Medicaid,579.82,,,579.82,Other,140% of Medicaid,931.85,,,931.85,Other,225% of Medicaid,1076.81,,,1076.81,Other,260% of Medicaid,1341.87,,,1341.87,Other,324% of Medicaid,890.44,,,890.44,Other,215% of Medicaid,890.44,,,890.44,Other,215% of Medicaid,517.7,,,517.7,Other,125% of Medicaid,0.01,4036.29,
PRP I HERN INIT REDUC > 5,49505,CPT,,30049505,CDM,450,RC,,,both,,,10788,7983.15,,,7983.15,Other,150% of Medicare + 9.63% HCRA Surcharge,4854.6,45,,4854.6,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,5340.06,,,5340.06,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,3639,,,3639,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,7551.6,70,,7551.6,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1956.63,,,1956.63,Other,100% of Medicaid,1956.63,,,1956.63,Other,100% of Medicaid,1956.63,,,1956.63,Other,100% of Medicaid,1956.63,,,1956.63,Other,100% of Medicaid,4402.42,,,4402.42,Other,225% of Medicaid,2993.64,,,2993.64,Other,153% of Medicaid,4402.42,,,4402.42,Other,225% of Medicaid,2739.28,,,2739.28,Other,140% of Medicaid,4402.42,,,4402.42,Other,225% of Medicaid,5087.24,,,5087.24,Other,260% of Medicaid,6339.48,,,6339.48,Other,324% of Medicaid,4206.75,,,4206.75,Other,215% of Medicaid,4206.75,,,4206.75,Other,215% of Medicaid,2445.79,,,2445.79,Other,125% of Medicaid,0.01,7983.15,
ASPIR BLADDER SUPRAPUB CA,51102,CPT,,30051102,CDM,450,RC,,,both,,,6552,4848.5,,,4848.5,Other,150% of Medicare + 9.63% HCRA Surcharge,2948.4,45,,2948.4,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,3243.24,,,3243.24,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,2488,,,2488,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,4586.4,70,,4586.4,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1337.43,,,1337.43,Other,100% of Medicaid,1337.43,,,1337.43,Other,100% of Medicaid,1337.43,,,1337.43,Other,100% of Medicaid,1337.43,,,1337.43,Other,100% of Medicaid,3009.23,,,3009.23,Other,225% of Medicaid,2046.27,,,2046.27,Other,153% of Medicaid,3009.23,,,3009.23,Other,225% of Medicaid,1872.41,,,1872.41,Other,140% of Medicaid,3009.23,,,3009.23,Other,225% of Medicaid,3477.33,,,3477.33,Other,260% of Medicaid,4333.28,,,4333.28,Other,324% of Medicaid,2875.48,,,2875.48,Other,215% of Medicaid,2875.48,,,2875.48,Other,215% of Medicaid,1671.79,,,1671.79,Other,125% of Medicaid,0.01,4848.5,
IRRIGATION OF BLADDER,51700,CPT,,30051700,CDM,450,RC,,,both,,,776,574.24,,,574.24,Other,150% of Medicare + 9.63% HCRA Surcharge,349.2,45,,349.2,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,384.12,,,384.12,Other,110% of Medicare,527.68,68,,527.68,percent of total billed charges,All Other,848,,,848,Other,186% of Medicaid,620.8,,,620.8,Other,Non Covered Service,644.08,,,644.08,Other,Non Covered Service,644.08,,,644.08,Other,Non Covered Service,620.8,,,620.8,Other,Non Covered Service,644.08,,,644.08,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,543.2,70,,543.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,455.81,,,455.81,Other,100% of Medicaid,455.81,,,455.81,Other,100% of Medicaid,455.81,,,455.81,Other,100% of Medicaid,455.81,,,455.81,Other,100% of Medicaid,1025.56,,,1025.56,Other,225% of Medicaid,697.38,,,697.38,Other,153% of Medicaid,1025.56,,,1025.56,Other,225% of Medicaid,638.13,,,638.13,Other,140% of Medicaid,1025.56,,,1025.56,Other,225% of Medicaid,1185.1,,,1185.1,Other,260% of Medicaid,1476.81,,,1476.81,Other,324% of Medicaid,979.98,,,979.98,Other,215% of Medicaid,979.98,,,979.98,Other,215% of Medicaid,569.76,,,569.76,Other,125% of Medicaid,0.01,1476.81,
INSERT STRAIGHT CATHETER,51701,CPT,,30051701,CDM,450,RC,,,both,,,263,194.62,,,194.62,Other,150% of Medicare + 9.63% HCRA Surcharge,118.35,45,,118.35,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,130.19,,,130.19,Other,110% of Medicare,178.84,68,,178.84,percent of total billed charges,All Other,601,,,601,Other,186% of Medicaid,210.4,,,210.4,Other,Non Covered Service,218.29,,,218.29,Other,Non Covered Service,218.29,,,218.29,Other,Non Covered Service,210.4,,,210.4,Other,Non Covered Service,218.29,,,218.29,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,184.1,70,,184.1,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,322.86,,,322.86,Other,100% of Medicaid,322.86,,,322.86,Other,100% of Medicaid,322.86,,,322.86,Other,100% of Medicaid,322.86,,,322.86,Other,100% of Medicaid,726.44,,,726.44,Other,225% of Medicaid,493.98,,,493.98,Other,153% of Medicaid,726.44,,,726.44,Other,225% of Medicaid,452.01,,,452.01,Other,140% of Medicaid,726.44,,,726.44,Other,225% of Medicaid,839.44,,,839.44,Other,260% of Medicaid,1046.07,,,1046.07,Other,324% of Medicaid,694.15,,,694.15,Other,215% of Medicaid,694.15,,,694.15,Other,215% of Medicaid,403.58,,,403.58,Other,125% of Medicaid,0.01,1046.07,
INSERT FOLEY CATH SIMPLE,51702,CPT,,30051702,CDM,450,RC,,,both,,,271,200.54,,,200.54,Other,150% of Medicare + 9.63% HCRA Surcharge,121.95,45,,121.95,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,134.15,,,134.15,Other,110% of Medicare,184.28,68,,184.28,percent of total billed charges,All Other,601,,,601,Other,186% of Medicaid,216.8,,,216.8,Other,Non Covered Service,224.93,,,224.93,Other,Non Covered Service,224.93,,,224.93,Other,Non Covered Service,216.8,,,216.8,Other,Non Covered Service,224.93,,,224.93,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,189.7,70,,189.7,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,322.86,,,322.86,Other,100% of Medicaid,322.86,,,322.86,Other,100% of Medicaid,322.86,,,322.86,Other,100% of Medicaid,322.86,,,322.86,Other,100% of Medicaid,726.44,,,726.44,Other,225% of Medicaid,493.98,,,493.98,Other,153% of Medicaid,726.44,,,726.44,Other,225% of Medicaid,452.01,,,452.01,Other,140% of Medicaid,726.44,,,726.44,Other,225% of Medicaid,839.44,,,839.44,Other,260% of Medicaid,1046.07,,,1046.07,Other,324% of Medicaid,694.15,,,694.15,Other,215% of Medicaid,694.15,,,694.15,Other,215% of Medicaid,403.58,,,403.58,Other,125% of Medicaid,0.01,1046.07,
INSERT BLADDER CATH COMPL,51703,CPT,,30051703,CDM,450,RC,,,both,,,424,313.76,,,313.76,Other,150% of Medicare + 9.63% HCRA Surcharge,190.8,45,,190.8,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,209.88,,,209.88,Other,110% of Medicare,288.32,68,,288.32,percent of total billed charges,All Other,848,,,848,Other,186% of Medicaid,339.2,,,339.2,Other,Non Covered Service,351.92,,,351.92,Other,Non Covered Service,351.92,,,351.92,Other,Non Covered Service,339.2,,,339.2,Other,Non Covered Service,351.92,,,351.92,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,296.8,70,,296.8,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,455.81,,,455.81,Other,100% of Medicaid,455.81,,,455.81,Other,100% of Medicaid,455.81,,,455.81,Other,100% of Medicaid,455.81,,,455.81,Other,100% of Medicaid,1025.56,,,1025.56,Other,225% of Medicaid,697.38,,,697.38,Other,153% of Medicaid,1025.56,,,1025.56,Other,225% of Medicaid,638.13,,,638.13,Other,140% of Medicaid,1025.56,,,1025.56,Other,225% of Medicaid,1185.1,,,1185.1,Other,260% of Medicaid,1476.81,,,1476.81,Other,324% of Medicaid,979.98,,,979.98,Other,215% of Medicaid,979.98,,,979.98,Other,215% of Medicaid,569.76,,,569.76,Other,125% of Medicaid,0.01,1476.81,
CYSTOSTOMY TUBE CHANGE,51705,CPT,,30051705,CDM,450,RC,,,both,,,776,574.24,,,574.24,Other,150% of Medicare + 9.63% HCRA Surcharge,349.2,45,,349.2,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,384.12,,,384.12,Other,110% of Medicare,527.68,68,,527.68,percent of total billed charges,All Other,601,,,601,Other,186% of Medicaid,620.8,,,620.8,Other,Non Covered Service,644.08,,,644.08,Other,Non Covered Service,644.08,,,644.08,Other,Non Covered Service,620.8,,,620.8,Other,Non Covered Service,644.08,,,644.08,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,543.2,70,,543.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,322.86,,,322.86,Other,100% of Medicaid,322.86,,,322.86,Other,100% of Medicaid,322.86,,,322.86,Other,100% of Medicaid,322.86,,,322.86,Other,100% of Medicaid,726.44,,,726.44,Other,225% of Medicaid,493.98,,,493.98,Other,153% of Medicaid,726.44,,,726.44,Other,225% of Medicaid,452.01,,,452.01,Other,140% of Medicaid,726.44,,,726.44,Other,225% of Medicaid,839.44,,,839.44,Other,260% of Medicaid,1046.07,,,1046.07,Other,324% of Medicaid,694.15,,,694.15,Other,215% of Medicaid,694.15,,,694.15,Other,215% of Medicaid,403.58,,,403.58,Other,125% of Medicaid,0.01,1046.07,
CHANGE OF CYSTOSTOMY TUBE COMPLICATED,51710,CPT,,30051710,CDM,450,RC,,,both,,,1932,1429.68,,,1429.68,Other,150% of Medicare + 9.63% HCRA Surcharge,869.4,45,,869.4,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,956.34,,,956.34,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,652,,,652,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1352.4,70,,1352.4,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,350.68,,,350.68,Other,100% of Medicaid,350.68,,,350.68,Other,100% of Medicaid,350.68,,,350.68,Other,100% of Medicaid,350.68,,,350.68,Other,100% of Medicaid,789.03,,,789.03,Other,225% of Medicaid,536.54,,,536.54,Other,153% of Medicaid,789.03,,,789.03,Other,225% of Medicaid,490.95,,,490.95,Other,140% of Medicaid,789.03,,,789.03,Other,225% of Medicaid,911.77,,,911.77,Other,260% of Medicaid,1136.21,,,1136.21,Other,324% of Medicaid,753.96,,,753.96,Other,215% of Medicaid,753.96,,,753.96,Other,215% of Medicaid,438.35,,,438.35,Other,125% of Medicaid,0.01,1429.68,
US PV RESIDUAL URINE,51798,CPT,,30051798,CDM,450,RC,,,both,,,258,190.92,,,190.92,Other,150% of Medicare + 9.63% HCRA Surcharge,116.1,45,,116.1,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,127.71,,,127.71,Other,110% of Medicare,175.44,68,,175.44,percent of total billed charges,All Other,601,,,601,Other,186% of Medicaid,206.4,,,206.4,Other,Non Covered Service,214.14,,,214.14,Other,Non Covered Service,214.14,,,214.14,Other,Non Covered Service,206.4,,,206.4,Other,Non Covered Service,214.14,,,214.14,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,180.6,70,,180.6,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,322.86,,,322.86,Other,100% of Medicaid,322.86,,,322.86,Other,100% of Medicaid,322.86,,,322.86,Other,100% of Medicaid,322.86,,,322.86,Other,100% of Medicaid,726.44,,,726.44,Other,225% of Medicaid,493.98,,,493.98,Other,153% of Medicaid,726.44,,,726.44,Other,225% of Medicaid,452.01,,,452.01,Other,140% of Medicaid,726.44,,,726.44,Other,225% of Medicaid,839.44,,,839.44,Other,260% of Medicaid,1046.07,,,1046.07,Other,324% of Medicaid,694.15,,,694.15,Other,215% of Medicaid,694.15,,,694.15,Other,215% of Medicaid,403.58,,,403.58,Other,125% of Medicaid,0.01,1046.07,
CYSTOURETHROSCOPY,52281,CPT,,30052281,CDM,450,RC,,,both,,,5732,4241.69,,,4241.69,Other,150% of Medicare + 9.63% HCRA Surcharge,2579.4,45,,2579.4,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2837.34,,,2837.34,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,2488,,,2488,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,4012.4,70,,4012.4,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1337.43,,,1337.43,Other,100% of Medicaid,1337.43,,,1337.43,Other,100% of Medicaid,1337.43,,,1337.43,Other,100% of Medicaid,1337.43,,,1337.43,Other,100% of Medicaid,3009.23,,,3009.23,Other,225% of Medicaid,2046.27,,,2046.27,Other,153% of Medicaid,3009.23,,,3009.23,Other,225% of Medicaid,1872.41,,,1872.41,Other,140% of Medicaid,3009.23,,,3009.23,Other,225% of Medicaid,3477.33,,,3477.33,Other,260% of Medicaid,4333.28,,,4333.28,Other,324% of Medicaid,2875.48,,,2875.48,Other,215% of Medicaid,2875.48,,,2875.48,Other,215% of Medicaid,1671.79,,,1671.79,Other,125% of Medicaid,0.01,4333.28,
DILATE URETHRA STRICTURE,53600,CPT,,30053600,CDM,450,RC,,,both,,,675,499.5,,,499.5,Other,150% of Medicare + 9.63% HCRA Surcharge,303.75,45,,303.75,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,334.13,,,334.13,Other,110% of Medicare,459,68,,459,percent of total billed charges,All Other,848,,,848,Other,186% of Medicaid,540,,,540,Other,Non Covered Service,560.25,,,560.25,Other,Non Covered Service,560.25,,,560.25,Other,Non Covered Service,540,,,540,Other,Non Covered Service,560.25,,,560.25,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,472.5,70,,472.5,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,455.81,,,455.81,Other,100% of Medicaid,455.81,,,455.81,Other,100% of Medicaid,455.81,,,455.81,Other,100% of Medicaid,455.81,,,455.81,Other,100% of Medicaid,1025.56,,,1025.56,Other,225% of Medicaid,697.38,,,697.38,Other,153% of Medicaid,1025.56,,,1025.56,Other,225% of Medicaid,638.13,,,638.13,Other,140% of Medicaid,1025.56,,,1025.56,Other,225% of Medicaid,1185.1,,,1185.1,Other,260% of Medicaid,1476.81,,,1476.81,Other,324% of Medicaid,979.98,,,979.98,Other,215% of Medicaid,979.98,,,979.98,Other,215% of Medicaid,569.76,,,569.76,Other,125% of Medicaid,0.01,1476.81,
IRRIGATE CORPORA CAVERNOSA FOR PRIAPISM,54220,CPT,,30054220,CDM,450,RC,,,both,,,658,486.92,,,486.92,Other,150% of Medicare + 9.63% HCRA Surcharge,296.1,45,,296.1,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,325.71,,,325.71,Other,110% of Medicare,447.44,68,,447.44,percent of total billed charges,All Other,848,,,848,Other,186% of Medicaid,526.4,,,526.4,Other,Non Covered Service,546.14,,,546.14,Other,Non Covered Service,546.14,,,546.14,Other,Non Covered Service,526.4,,,526.4,Other,Non Covered Service,546.14,,,546.14,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,460.6,70,,460.6,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,455.81,,,455.81,Other,100% of Medicaid,455.81,,,455.81,Other,100% of Medicaid,455.81,,,455.81,Other,100% of Medicaid,455.81,,,455.81,Other,100% of Medicaid,1025.56,,,1025.56,Other,225% of Medicaid,697.38,,,697.38,Other,153% of Medicaid,1025.56,,,1025.56,Other,225% of Medicaid,638.13,,,638.13,Other,140% of Medicaid,1025.56,,,1025.56,Other,225% of Medicaid,1185.1,,,1185.1,Other,260% of Medicaid,1476.81,,,1476.81,Other,324% of Medicaid,979.98,,,979.98,Other,215% of Medicaid,979.98,,,979.98,Other,215% of Medicaid,569.76,,,569.76,Other,125% of Medicaid,0.01,1476.81,
INJ CORPORA CAVERNOSA W P,54235,CPT,,30054235,CDM,450,RC,,,both,,,1143,845.82,,,845.82,Other,150% of Medicare + 9.63% HCRA Surcharge,514.35,45,,514.35,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,565.79,,,565.79,Other,110% of Medicare,777.24,68,,777.24,percent of total billed charges,All Other,848,,,848,Other,186% of Medicaid,914.4,,,914.4,Other,Non Covered Service,948.69,,,948.69,Other,Non Covered Service,948.69,,,948.69,Other,Non Covered Service,914.4,,,914.4,Other,Non Covered Service,948.69,,,948.69,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,800.1,70,,800.1,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,455.81,,,455.81,Other,100% of Medicaid,455.81,,,455.81,Other,100% of Medicaid,455.81,,,455.81,Other,100% of Medicaid,455.81,,,455.81,Other,100% of Medicaid,1025.56,,,1025.56,Other,225% of Medicaid,697.38,,,697.38,Other,153% of Medicaid,1025.56,,,1025.56,Other,225% of Medicaid,638.13,,,638.13,Other,140% of Medicaid,1025.56,,,1025.56,Other,225% of Medicaid,1185.1,,,1185.1,Other,260% of Medicaid,1476.81,,,1476.81,Other,324% of Medicaid,979.98,,,979.98,Other,215% of Medicaid,979.98,,,979.98,Other,215% of Medicaid,569.76,,,569.76,Other,125% of Medicaid,0.01,1476.81,
FORESKIN MANIPULATION,54450,CPT,,30054450,CDM,450,RC,,,both,,,881,651.94,,,651.94,Other,150% of Medicare + 9.63% HCRA Surcharge,396.45,45,,396.45,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,436.1,,,436.1,Other,110% of Medicare,599.08,68,,599.08,percent of total billed charges,All Other,903,,,903,Other,186% of Medicaid,704.8,,,704.8,Other,Non Covered Service,731.23,,,731.23,Other,Non Covered Service,731.23,,,731.23,Other,Non Covered Service,704.8,,,704.8,Other,Non Covered Service,731.23,,,731.23,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,616.7,70,,616.7,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,485.72,,,485.72,Other,100% of Medicaid,485.72,,,485.72,Other,100% of Medicaid,485.72,,,485.72,Other,100% of Medicaid,485.72,,,485.72,Other,100% of Medicaid,1092.86,,,1092.86,Other,225% of Medicaid,743.14,,,743.14,Other,153% of Medicaid,1092.86,,,1092.86,Other,225% of Medicaid,680,,,680,Other,140% of Medicaid,1092.86,,,1092.86,Other,225% of Medicaid,1262.86,,,1262.86,Other,260% of Medicaid,1573.72,,,1573.72,Other,324% of Medicaid,1044.29,,,1044.29,Other,215% of Medicaid,1044.29,,,1044.29,Other,215% of Medicaid,607.14,,,607.14,Other,125% of Medicaid,0.01,1573.72,
I & D EPIDIDYMIS TESTIS/SCROTA,54700,CPT,,30054700,CDM,450,RC,,,both,,,6949,5142.28,,,5142.28,Other,150% of Medicare + 9.63% HCRA Surcharge,3127.05,45,,3127.05,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,3439.76,,,3439.76,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,2347,,,2347,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,4864.3,70,,4864.3,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1261.9,,,1261.9,Other,100% of Medicaid,1261.9,,,1261.9,Other,100% of Medicaid,1261.9,,,1261.9,Other,100% of Medicaid,1261.9,,,1261.9,Other,100% of Medicaid,2839.28,,,2839.28,Other,225% of Medicaid,1930.71,,,1930.71,Other,153% of Medicaid,2839.28,,,2839.28,Other,225% of Medicaid,1766.66,,,1766.66,Other,140% of Medicaid,2839.28,,,2839.28,Other,225% of Medicaid,3280.94,,,3280.94,Other,260% of Medicaid,4088.56,,,4088.56,Other,324% of Medicaid,2713.09,,,2713.09,Other,215% of Medicaid,2713.09,,,2713.09,Other,215% of Medicaid,1577.38,,,1577.38,Other,125% of Medicaid,0.01,5142.28,
DRAINAGE OF SCROTAL WALL,55100,CPT,,30055100,CDM,450,RC,,,both,,,4543,3361.83,,,3361.83,Other,150% of Medicare + 9.63% HCRA Surcharge,2044.35,45,,2044.35,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2248.79,,,2248.79,Other,110% of Medicare,3089.24,68,,3089.24,percent of total billed charges,All Other,2347,,,2347,Other,186% of Medicaid,3634.4,,,3634.4,Other,Non Covered Service,3770.69,,,3770.69,Other,Non Covered Service,3770.69,,,3770.69,Other,Non Covered Service,3634.4,,,3634.4,Other,Non Covered Service,3770.69,,,3770.69,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,3180.1,70,,3180.1,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1261.9,,,1261.9,Other,100% of Medicaid,1261.9,,,1261.9,Other,100% of Medicaid,1261.9,,,1261.9,Other,100% of Medicaid,1261.9,,,1261.9,Other,100% of Medicaid,2839.28,,,2839.28,Other,225% of Medicaid,1930.71,,,1930.71,Other,153% of Medicaid,2839.28,,,2839.28,Other,225% of Medicaid,1766.66,,,1766.66,Other,140% of Medicaid,2839.28,,,2839.28,Other,225% of Medicaid,3280.94,,,3280.94,Other,260% of Medicaid,4088.56,,,4088.56,Other,324% of Medicaid,2713.09,,,2713.09,Other,215% of Medicaid,2713.09,,,2713.09,Other,215% of Medicaid,1577.38,,,1577.38,Other,125% of Medicaid,0.01,4088.56,
I AND D OF VULVA OR PERINEA,56405,CPT,,30056405,CDM,450,RC,,,both,,,659,487.66,,,487.66,Other,150% of Medicare + 9.63% HCRA Surcharge,296.55,45,,296.55,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,326.21,,,326.21,Other,110% of Medicare,448.12,68,,448.12,percent of total billed charges,All Other,445,,,445,Other,186% of Medicaid,527.2,,,527.2,Other,Non Covered Service,546.97,,,546.97,Other,Non Covered Service,546.97,,,546.97,Other,Non Covered Service,527.2,,,527.2,Other,Non Covered Service,546.97,,,546.97,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,461.3,70,,461.3,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,239.36,,,239.36,Other,100% of Medicaid,239.36,,,239.36,Other,100% of Medicaid,239.36,,,239.36,Other,100% of Medicaid,239.36,,,239.36,Other,100% of Medicaid,538.55,,,538.55,Other,225% of Medicaid,366.22,,,366.22,Other,153% of Medicaid,538.55,,,538.55,Other,225% of Medicaid,335.1,,,335.1,Other,140% of Medicaid,538.55,,,538.55,Other,225% of Medicaid,622.33,,,622.33,Other,260% of Medicaid,775.52,,,775.52,Other,324% of Medicaid,514.62,,,514.62,Other,215% of Medicaid,514.62,,,514.62,Other,215% of Medicaid,299.2,,,299.2,Other,125% of Medicaid,0.01,775.52,
I AND D BARTHOLIN GLAND ABSCE,56420,CPT,,30056420,CDM,450,RC,,,both,,,623,461.02,,,461.02,Other,150% of Medicare + 9.63% HCRA Surcharge,280.35,45,,280.35,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,308.39,,,308.39,Other,110% of Medicare,423.64,68,,423.64,percent of total billed charges,All Other,445,,,445,Other,186% of Medicaid,498.4,,,498.4,Other,Non Covered Service,517.09,,,517.09,Other,Non Covered Service,517.09,,,517.09,Other,Non Covered Service,498.4,,,498.4,Other,Non Covered Service,517.09,,,517.09,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,436.1,70,,436.1,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,239.36,,,239.36,Other,100% of Medicaid,239.36,,,239.36,Other,100% of Medicaid,239.36,,,239.36,Other,100% of Medicaid,239.36,,,239.36,Other,100% of Medicaid,538.55,,,538.55,Other,225% of Medicaid,366.22,,,366.22,Other,153% of Medicaid,538.55,,,538.55,Other,225% of Medicaid,335.1,,,335.1,Other,140% of Medicaid,538.55,,,538.55,Other,225% of Medicaid,622.33,,,622.33,Other,260% of Medicaid,775.52,,,775.52,Other,324% of Medicaid,514.62,,,514.62,Other,215% of Medicaid,514.62,,,514.62,Other,215% of Medicaid,299.2,,,299.2,Other,125% of Medicaid,0.01,775.52,
EXCISE BARTHOLIN'S GLAND OR CY,56740,CPT,,30056740,CDM,450,RC,,,both,,,6383,4723.44,,,4723.44,Other,150% of Medicare + 9.63% HCRA Surcharge,2872.35,45,,2872.35,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,3159.59,,,3159.59,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,2339,,,2339,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,4468.1,70,,4468.1,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1257.49,,,1257.49,Other,100% of Medicaid,1257.49,,,1257.49,Other,100% of Medicaid,1257.49,,,1257.49,Other,100% of Medicaid,1257.49,,,1257.49,Other,100% of Medicaid,2829.34,,,2829.34,Other,225% of Medicaid,1923.95,,,1923.95,Other,153% of Medicaid,2829.34,,,2829.34,Other,225% of Medicaid,1760.48,,,1760.48,Other,140% of Medicaid,2829.34,,,2829.34,Other,225% of Medicaid,3269.46,,,3269.46,Other,260% of Medicaid,4074.25,,,4074.25,Other,324% of Medicaid,2703.59,,,2703.59,Other,215% of Medicaid,2703.59,,,2703.59,Other,215% of Medicaid,1571.86,,,1571.86,Other,125% of Medicaid,0.01,4723.44,
INS PACK FOR NON-OB VAG HEMORRHAGE,57180,CPT,,30057180,CDM,450,RC,,,both,,,554,409.96,,,409.96,Other,150% of Medicare + 9.63% HCRA Surcharge,249.3,45,,249.3,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,274.23,,,274.23,Other,110% of Medicare,376.72,68,,376.72,percent of total billed charges,All Other,1132,,,1132,Other,186% of Medicaid,443.2,,,443.2,Other,Non Covered Service,459.82,,,459.82,Other,Non Covered Service,459.82,,,459.82,Other,Non Covered Service,443.2,,,443.2,Other,Non Covered Service,459.82,,,459.82,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,387.8,70,,387.8,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,608.71,,,608.71,Other,100% of Medicaid,608.71,,,608.71,Other,100% of Medicaid,608.71,,,608.71,Other,100% of Medicaid,608.71,,,608.71,Other,100% of Medicaid,1369.59,,,1369.59,Other,225% of Medicaid,931.32,,,931.32,Other,153% of Medicaid,1369.59,,,1369.59,Other,225% of Medicaid,852.19,,,852.19,Other,140% of Medicaid,1369.59,,,1369.59,Other,225% of Medicaid,1582.63,,,1582.63,Other,260% of Medicaid,1972.21,,,1972.21,Other,324% of Medicaid,1308.72,,,1308.72,Other,215% of Medicaid,1308.72,,,1308.72,Other,215% of Medicaid,760.88,,,760.88,Other,125% of Medicaid,0.01,1972.21,
REMOVE IUD,58301,CPT,,30058301,CDM,450,RC,,,both,,,659,487.66,,,487.66,Other,150% of Medicare + 9.63% HCRA Surcharge,296.55,45,,296.55,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,326.21,,,326.21,Other,110% of Medicare,448.12,68,,448.12,percent of total billed charges,All Other,226,,,226,Other,186% of Medicaid,527.2,,,527.2,Other,Non Covered Service,546.97,,,546.97,Other,Non Covered Service,546.97,,,546.97,Other,Non Covered Service,527.2,,,527.2,Other,Non Covered Service,546.97,,,546.97,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,461.3,70,,461.3,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,121.54,,,121.54,Other,100% of Medicaid,121.54,,,121.54,Other,100% of Medicaid,121.54,,,121.54,Other,100% of Medicaid,121.54,,,121.54,Other,100% of Medicaid,273.47,,,273.47,Other,225% of Medicaid,185.96,,,185.96,Other,153% of Medicaid,273.47,,,273.47,Other,225% of Medicaid,170.16,,,170.16,Other,140% of Medicaid,273.47,,,273.47,Other,225% of Medicaid,316.01,,,316.01,Other,260% of Medicaid,393.8,,,393.8,Other,324% of Medicaid,261.32,,,261.32,Other,215% of Medicaid,261.32,,,261.32,Other,215% of Medicaid,151.93,,,151.93,Other,125% of Medicaid,0.01,546.97,
REMOVE FOREIGN BOBY VAGINA,58999,CPT,,30058999,CDM,450,RC,,,both,,,402,297.48,,,297.48,Other,150% of Medicare + 9.63% HCRA Surcharge,180.9,45,,180.9,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,198.99,,,198.99,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,865,,,865,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,281.4,70,,281.4,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,465.07,,,465.07,Other,100% of Medicaid,465.07,,,465.07,Other,100% of Medicaid,465.07,,,465.07,Other,100% of Medicaid,465.07,,,465.07,Other,100% of Medicaid,1046.42,,,1046.42,Other,225% of Medicaid,711.56,,,711.56,Other,153% of Medicaid,1046.42,,,1046.42,Other,225% of Medicaid,651.1,,,651.1,Other,140% of Medicaid,1046.42,,,1046.42,Other,225% of Medicaid,1209.19,,,1209.19,Other,260% of Medicaid,1506.84,,,1506.84,Other,324% of Medicaid,999.91,,,999.91,Other,215% of Medicaid,999.91,,,999.91,Other,215% of Medicaid,581.34,,,581.34,Other,125% of Medicaid,0.01,1506.84,
EPISIOTOMY OR VAGINAL REPAIR,59300,CPT,,30059300,CDM,450,RC,,,both,,,6366,4710.86,,,4710.86,Other,150% of Medicare + 9.63% HCRA Surcharge,2864.7,45,,2864.7,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,3151.17,,,3151.17,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,1581,,,1581,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,4456.2,70,,4456.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,850.18,,,850.18,Other,100% of Medicaid,850.18,,,850.18,Other,100% of Medicaid,850.18,,,850.18,Other,100% of Medicaid,850.18,,,850.18,Other,100% of Medicaid,1912.91,,,1912.91,Other,225% of Medicaid,1300.78,,,1300.78,Other,153% of Medicaid,1912.91,,,1912.91,Other,225% of Medicaid,1190.26,,,1190.26,Other,140% of Medicaid,1912.91,,,1912.91,Other,225% of Medicaid,2210.48,,,2210.48,Other,260% of Medicaid,2754.6,,,2754.6,Other,324% of Medicaid,1827.9,,,1827.9,Other,215% of Medicaid,1827.9,,,1827.9,Other,215% of Medicaid,1062.73,,,1062.73,Other,125% of Medicaid,0.01,4710.86,
VAGINAL DELIVERY,59409,CPT,,30059409,CDM,450,RC,,,both,,,7217,5340.6,,,5340.6,Other,150% of Medicare + 9.63% HCRA Surcharge,3247.65,45,,3247.65,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,3572.42,,,3572.42,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,3500,,,3500,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,5051.9,70,,5051.9,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1881.63,,,1881.63,Other,100% of Medicaid,1881.63,,,1881.63,Other,100% of Medicaid,1881.63,,,1881.63,Other,100% of Medicaid,1881.63,,,1881.63,Other,100% of Medicaid,4233.66,,,4233.66,Other,225% of Medicaid,2878.89,,,2878.89,Other,153% of Medicaid,4233.66,,,4233.66,Other,225% of Medicaid,2634.28,,,2634.28,Other,140% of Medicaid,4233.66,,,4233.66,Other,225% of Medicaid,4892.23,,,4892.23,Other,260% of Medicaid,6096.47,,,6096.47,Other,324% of Medicaid,4045.5,,,4045.5,Other,215% of Medicaid,4045.5,,,4045.5,Other,215% of Medicaid,2352.03,,,2352.03,Other,125% of Medicaid,0.01,6096.47,
DELIVERY OF PLACENTA,59414,CPT,,30059414,CDM,450,RC,,,both,,,6744,4990.58,,,4990.58,Other,150% of Medicare + 9.63% HCRA Surcharge,3034.8,45,,3034.8,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,3338.28,,,3338.28,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,1902,,,1902,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,4720.8,70,,4720.8,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1022.76,,,1022.76,Other,100% of Medicaid,1022.76,,,1022.76,Other,100% of Medicaid,1022.76,,,1022.76,Other,100% of Medicaid,1022.76,,,1022.76,Other,100% of Medicaid,2301.2,,,2301.2,Other,225% of Medicaid,1564.82,,,1564.82,Other,153% of Medicaid,2301.2,,,2301.2,Other,225% of Medicaid,1431.86,,,1431.86,Other,140% of Medicaid,2301.2,,,2301.2,Other,225% of Medicaid,2659.17,,,2659.17,Other,260% of Medicaid,3313.73,,,3313.73,Other,324% of Medicaid,2198.93,,,2198.93,Other,215% of Medicaid,2198.93,,,2198.93,Other,215% of Medicaid,1278.45,,,1278.45,Other,125% of Medicaid,0.01,4990.58,
SURG TX INCOMPL ABORTION,59812,CPT,,30059812,CDM,450,RC,,,both,,,7311,5410.16,,,5410.16,Other,150% of Medicare + 9.63% HCRA Surcharge,3289.95,45,,3289.95,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,3618.95,,,3618.95,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,1456,,,1456,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,5117.7,70,,5117.7,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,782.75,,,782.75,Other,100% of Medicaid,782.75,,,782.75,Other,100% of Medicaid,782.75,,,782.75,Other,100% of Medicaid,782.75,,,782.75,Other,100% of Medicaid,1761.19,,,1761.19,Other,225% of Medicaid,1197.61,,,1197.61,Other,153% of Medicaid,1761.19,,,1761.19,Other,225% of Medicaid,1095.85,,,1095.85,Other,140% of Medicaid,1761.19,,,1761.19,Other,225% of Medicaid,2035.16,,,2035.16,Other,260% of Medicaid,2536.12,,,2536.12,Other,324% of Medicaid,1682.92,,,1682.92,Other,215% of Medicaid,1682.92,,,1682.92,Other,215% of Medicaid,978.44,,,978.44,Other,125% of Medicaid,0.01,5410.16,
LUMBAR PUNCTURE,62270,CPT,,30062270,CDM,450,RC,,,both,,,1479,1094.46,,,1094.46,Other,150% of Medicare + 9.63% HCRA Surcharge,665.55,45,,665.55,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,732.11,,,732.11,Other,110% of Medicare,1005.72,68,,1005.72,percent of total billed charges,All Other,1116,,,1116,Other,186% of Medicaid,1183.2,,,1183.2,Other,Non Covered Service,1227.57,,,1227.57,Other,Non Covered Service,1227.57,,,1227.57,Other,Non Covered Service,1183.2,,,1183.2,Other,Non Covered Service,1227.57,,,1227.57,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1035.3,70,,1035.3,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,600.19,,,600.19,Other,100% of Medicaid,600.19,,,600.19,Other,100% of Medicaid,600.19,,,600.19,Other,100% of Medicaid,600.19,,,600.19,Other,100% of Medicaid,1350.43,,,1350.43,Other,225% of Medicaid,918.29,,,918.29,Other,153% of Medicaid,1350.43,,,1350.43,Other,225% of Medicaid,840.26,,,840.26,Other,140% of Medicaid,1350.43,,,1350.43,Other,225% of Medicaid,1560.49,,,1560.49,Other,260% of Medicaid,1944.61,,,1944.61,Other,324% of Medicaid,1290.41,,,1290.41,Other,215% of Medicaid,1290.41,,,1290.41,Other,215% of Medicaid,750.24,,,750.24,Other,125% of Medicaid,0.01,1944.61,
INJECT EPIDURAL PATCH,62273,CPT,,30062273,CDM,450,RC,,,both,,,2701,1998.75,,,1998.75,Other,150% of Medicare + 9.63% HCRA Surcharge,1215.45,45,,1215.45,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1337,,,1337,Other,110% of Medicare,1836.68,68,,1836.68,percent of total billed charges,All Other,1116,,,1116,Other,186% of Medicaid,2160.8,,,2160.8,Other,Non Covered Service,2241.83,,,2241.83,Other,Non Covered Service,2241.83,,,2241.83,Other,Non Covered Service,2160.8,,,2160.8,Other,Non Covered Service,2241.83,,,2241.83,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1890.7,70,,1890.7,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,600.19,,,600.19,Other,100% of Medicaid,600.19,,,600.19,Other,100% of Medicaid,600.19,,,600.19,Other,100% of Medicaid,600.19,,,600.19,Other,100% of Medicaid,1350.43,,,1350.43,Other,225% of Medicaid,918.29,,,918.29,Other,153% of Medicaid,1350.43,,,1350.43,Other,225% of Medicaid,840.26,,,840.26,Other,140% of Medicaid,1350.43,,,1350.43,Other,225% of Medicaid,1560.49,,,1560.49,Other,260% of Medicaid,1944.61,,,1944.61,Other,324% of Medicaid,1290.41,,,1290.41,Other,215% of Medicaid,1290.41,,,1290.41,Other,215% of Medicaid,750.24,,,750.24,Other,125% of Medicaid,0.01,2241.83,
INJ ANESTH ; TRIGEMINAL NERVE,64400,CPT,,30064400,CDM,450,RC,,,both,,,963,712.62,,,712.62,Other,150% of Medicare + 9.63% HCRA Surcharge,433.35,45,,433.35,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,476.69,,,476.69,Other,110% of Medicare,654.84,68,,654.84,percent of total billed charges,All Other,966,,,966,Other,186% of Medicaid,770.4,,,770.4,Other,Non Covered Service,799.29,,,799.29,Other,Non Covered Service,799.29,,,799.29,Other,Non Covered Service,770.4,,,770.4,Other,Non Covered Service,799.29,,,799.29,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,674.1,70,,674.1,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,519.42,,,519.42,Other,100% of Medicaid,519.42,,,519.42,Other,100% of Medicaid,519.42,,,519.42,Other,100% of Medicaid,519.42,,,519.42,Other,100% of Medicaid,1168.69,,,1168.69,Other,225% of Medicaid,794.71,,,794.71,Other,153% of Medicaid,1168.69,,,1168.69,Other,225% of Medicaid,727.18,,,727.18,Other,140% of Medicaid,1168.69,,,1168.69,Other,225% of Medicaid,1350.48,,,1350.48,Other,260% of Medicaid,1682.91,,,1682.91,Other,324% of Medicaid,1116.74,,,1116.74,Other,215% of Medicaid,1116.74,,,1116.74,Other,215% of Medicaid,649.27,,,649.27,Other,125% of Medicaid,0.01,1682.91,
INJ ANES AGENT ILIOINGUIN,64425,CPT,,30064425,CDM,450,RC,,,both,,,1452,1074.48,,,1074.48,Other,150% of Medicare + 9.63% HCRA Surcharge,653.4,45,,653.4,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,718.74,,,718.74,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,966,,,966,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1016.4,70,,1016.4,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,519.42,,,519.42,Other,100% of Medicaid,519.42,,,519.42,Other,100% of Medicaid,519.42,,,519.42,Other,100% of Medicaid,519.42,,,519.42,Other,100% of Medicaid,1168.69,,,1168.69,Other,225% of Medicaid,794.71,,,794.71,Other,153% of Medicaid,1168.69,,,1168.69,Other,225% of Medicaid,727.18,,,727.18,Other,140% of Medicaid,1168.69,,,1168.69,Other,225% of Medicaid,1350.48,,,1350.48,Other,260% of Medicaid,1682.91,,,1682.91,Other,324% of Medicaid,1116.74,,,1116.74,Other,215% of Medicaid,1116.74,,,1116.74,Other,215% of Medicaid,649.27,,,649.27,Other,125% of Medicaid,0.01,1682.91,
INJECTION AA&/STRD FEMORAL NERVE,64447,CPT,,30064447,CDM,450,RC,,,both,,,2169,1605.07,,,1605.07,Other,150% of Medicare + 9.63% HCRA Surcharge,976.05,45,,976.05,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1073.66,,,1073.66,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,1120,,,1120,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1518.3,70,,1518.3,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,602.07,,,602.07,Other,100% of Medicaid,602.07,,,602.07,Other,100% of Medicaid,602.07,,,602.07,Other,100% of Medicaid,602.07,,,602.07,Other,100% of Medicaid,1354.65,,,1354.65,Other,225% of Medicaid,921.16,,,921.16,Other,153% of Medicaid,1354.65,,,1354.65,Other,225% of Medicaid,842.89,,,842.89,Other,140% of Medicaid,1354.65,,,1354.65,Other,225% of Medicaid,1565.37,,,1565.37,Other,260% of Medicaid,1950.69,,,1950.69,Other,324% of Medicaid,1294.44,,,1294.44,Other,215% of Medicaid,1294.44,,,1294.44,Other,215% of Medicaid,752.58,,,752.58,Other,125% of Medicaid,0.01,1950.69,
INJ ANESTH OTHR PERIPHERA,64450,CPT,,30064450,CDM,450,RC,,,both,,,1479,1094.46,,,1094.46,Other,150% of Medicare + 9.63% HCRA Surcharge,665.55,45,,665.55,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,732.11,,,732.11,Other,110% of Medicare,1005.72,68,,1005.72,percent of total billed charges,All Other,711,,,711,Other,186% of Medicaid,1183.2,,,1183.2,Other,Non Covered Service,1227.57,,,1227.57,Other,Non Covered Service,1227.57,,,1227.57,Other,Non Covered Service,1183.2,,,1183.2,Other,Non Covered Service,1227.57,,,1227.57,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1035.3,70,,1035.3,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,382.03,,,382.03,Other,100% of Medicaid,382.03,,,382.03,Other,100% of Medicaid,382.03,,,382.03,Other,100% of Medicaid,382.03,,,382.03,Other,100% of Medicaid,859.56,,,859.56,Other,225% of Medicaid,584.5,,,584.5,Other,153% of Medicaid,859.56,,,859.56,Other,225% of Medicaid,534.84,,,534.84,Other,140% of Medicaid,859.56,,,859.56,Other,225% of Medicaid,993.27,,,993.27,Other,260% of Medicaid,1237.76,,,1237.76,Other,324% of Medicaid,821.35,,,821.35,Other,215% of Medicaid,821.35,,,821.35,Other,215% of Medicaid,477.53,,,477.53,Other,125% of Medicaid,0.01,1237.76,
REMOVE FB EYE CONJUNCT SU,65205,CPT,,30065205,CDM,450,RC,,,both,,,318,235.32,,,235.32,Other,150% of Medicare + 9.63% HCRA Surcharge,143.1,45,,143.1,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,157.41,,,157.41,Other,110% of Medicare,216.24,68,,216.24,percent of total billed charges,All Other,352,,,352,Other,186% of Medicaid,254.4,,,254.4,Other,Non Covered Service,263.94,,,263.94,Other,Non Covered Service,263.94,,,263.94,Other,Non Covered Service,254.4,,,254.4,Other,Non Covered Service,263.94,,,263.94,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,222.6,70,,222.6,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,189.16,,,189.16,Other,100% of Medicaid,189.16,,,189.16,Other,100% of Medicaid,189.16,,,189.16,Other,100% of Medicaid,189.16,,,189.16,Other,100% of Medicaid,425.62,,,425.62,Other,225% of Medicaid,289.42,,,289.42,Other,153% of Medicaid,425.62,,,425.62,Other,225% of Medicaid,264.83,,,264.83,Other,140% of Medicaid,425.62,,,425.62,Other,225% of Medicaid,491.82,,,491.82,Other,260% of Medicaid,612.89,,,612.89,Other,324% of Medicaid,406.7,,,406.7,Other,215% of Medicaid,406.7,,,406.7,Other,215% of Medicaid,236.45,,,236.45,Other,125% of Medicaid,0.01,612.89,
REMOVE FB EYE CONJUCT EMB,65210,CPT,,30065210,CDM,450,RC,,,both,,,851,629.74,,,629.74,Other,150% of Medicare + 9.63% HCRA Surcharge,382.95,45,,382.95,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,421.25,,,421.25,Other,110% of Medicare,578.68,68,,578.68,percent of total billed charges,All Other,352,,,352,Other,186% of Medicaid,680.8,,,680.8,Other,Non Covered Service,706.33,,,706.33,Other,Non Covered Service,706.33,,,706.33,Other,Non Covered Service,680.8,,,680.8,Other,Non Covered Service,706.33,,,706.33,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,595.7,70,,595.7,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,189.16,,,189.16,Other,100% of Medicaid,189.16,,,189.16,Other,100% of Medicaid,189.16,,,189.16,Other,100% of Medicaid,189.16,,,189.16,Other,100% of Medicaid,425.62,,,425.62,Other,225% of Medicaid,289.42,,,289.42,Other,153% of Medicaid,425.62,,,425.62,Other,225% of Medicaid,264.83,,,264.83,Other,140% of Medicaid,425.62,,,425.62,Other,225% of Medicaid,491.82,,,491.82,Other,260% of Medicaid,612.89,,,612.89,Other,324% of Medicaid,406.7,,,406.7,Other,215% of Medicaid,406.7,,,406.7,Other,215% of Medicaid,236.45,,,236.45,Other,125% of Medicaid,0.01,706.33,
REMOVE FB CORNEAL W O SLI,65220,CPT,,30065220,CDM,450,RC,,,both,,,851,629.74,,,629.74,Other,150% of Medicare + 9.63% HCRA Surcharge,382.95,45,,382.95,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,421.25,,,421.25,Other,110% of Medicare,578.68,68,,578.68,percent of total billed charges,All Other,352,,,352,Other,186% of Medicaid,680.8,,,680.8,Other,Non Covered Service,706.33,,,706.33,Other,Non Covered Service,706.33,,,706.33,Other,Non Covered Service,680.8,,,680.8,Other,Non Covered Service,706.33,,,706.33,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,595.7,70,,595.7,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,189.16,,,189.16,Other,100% of Medicaid,189.16,,,189.16,Other,100% of Medicaid,189.16,,,189.16,Other,100% of Medicaid,189.16,,,189.16,Other,100% of Medicaid,425.62,,,425.62,Other,225% of Medicaid,289.42,,,289.42,Other,153% of Medicaid,425.62,,,425.62,Other,225% of Medicaid,264.83,,,264.83,Other,140% of Medicaid,425.62,,,425.62,Other,225% of Medicaid,491.82,,,491.82,Other,260% of Medicaid,612.89,,,612.89,Other,324% of Medicaid,406.7,,,406.7,Other,215% of Medicaid,406.7,,,406.7,Other,215% of Medicaid,236.45,,,236.45,Other,125% of Medicaid,0.01,706.33,
REMOVE FB EYE CORNEAL W S,65222,CPT,,30065222,CDM,450,RC,,,both,,,371,274.54,,,274.54,Other,150% of Medicare + 9.63% HCRA Surcharge,166.95,45,,166.95,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,183.65,,,183.65,Other,110% of Medicare,252.28,68,,252.28,percent of total billed charges,All Other,352,,,352,Other,186% of Medicaid,296.8,,,296.8,Other,Non Covered Service,307.93,,,307.93,Other,Non Covered Service,307.93,,,307.93,Other,Non Covered Service,296.8,,,296.8,Other,Non Covered Service,307.93,,,307.93,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,259.7,70,,259.7,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,189.16,,,189.16,Other,100% of Medicaid,189.16,,,189.16,Other,100% of Medicaid,189.16,,,189.16,Other,100% of Medicaid,189.16,,,189.16,Other,100% of Medicaid,425.62,,,425.62,Other,225% of Medicaid,289.42,,,289.42,Other,153% of Medicaid,425.62,,,425.62,Other,225% of Medicaid,264.83,,,264.83,Other,140% of Medicaid,425.62,,,425.62,Other,225% of Medicaid,491.82,,,491.82,Other,260% of Medicaid,612.89,,,612.89,Other,324% of Medicaid,406.7,,,406.7,Other,215% of Medicaid,406.7,,,406.7,Other,215% of Medicaid,236.45,,,236.45,Other,125% of Medicaid,0.01,612.89,
DRAINAGE EXT EAR SIMPLE,69000,CPT,,30069000,CDM,450,RC,,,both,,,1462,1081.88,,,1081.88,Other,150% of Medicare + 9.63% HCRA Surcharge,657.9,45,,657.9,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,723.69,,,723.69,Other,110% of Medicare,994.16,68,,994.16,percent of total billed charges,All Other,423,,,423,Other,186% of Medicaid,1169.6,,,1169.6,Other,Non Covered Service,1213.46,,,1213.46,Other,Non Covered Service,1213.46,,,1213.46,Other,Non Covered Service,1169.6,,,1169.6,Other,Non Covered Service,1213.46,,,1213.46,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1023.4,70,,1023.4,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,227.45,,,227.45,Other,100% of Medicaid,227.45,,,227.45,Other,100% of Medicaid,227.45,,,227.45,Other,100% of Medicaid,227.45,,,227.45,Other,100% of Medicaid,511.76,,,511.76,Other,225% of Medicaid,348,,,348,Other,153% of Medicaid,511.76,,,511.76,Other,225% of Medicaid,318.43,,,318.43,Other,140% of Medicaid,511.76,,,511.76,Other,225% of Medicaid,591.37,,,591.37,Other,260% of Medicaid,736.94,,,736.94,Other,324% of Medicaid,489.02,,,489.02,Other,215% of Medicaid,489.02,,,489.02,Other,215% of Medicaid,284.31,,,284.31,Other,125% of Medicaid,0.01,1213.46,
DRAIN EXTERNAL EAR COMPLETE,69005,CPT,,30069005,CDM,450,RC,,,both,,,6590,4876.62,,,4876.62,Other,150% of Medicare + 9.63% HCRA Surcharge,2965.5,45,,2965.5,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,3262.05,,,3262.05,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,2257,,,2257,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,4613,70,,4613,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1213.21,,,1213.21,Other,100% of Medicaid,1213.21,,,1213.21,Other,100% of Medicaid,1213.21,,,1213.21,Other,100% of Medicaid,1213.21,,,1213.21,Other,100% of Medicaid,2729.72,,,2729.72,Other,225% of Medicaid,1856.21,,,1856.21,Other,153% of Medicaid,2729.72,,,2729.72,Other,225% of Medicaid,1698.49,,,1698.49,Other,140% of Medicaid,2729.72,,,2729.72,Other,225% of Medicaid,3154.34,,,3154.34,Other,260% of Medicaid,3930.79,,,3930.79,Other,324% of Medicaid,2608.4,,,2608.4,Other,215% of Medicaid,2608.4,,,2608.4,Other,215% of Medicaid,1516.51,,,1516.51,Other,125% of Medicaid,0.01,4876.62,
DRAIN EXT AUDITORY CANAL ABSC,69020,CPT,,30069020,CDM,450,RC,,,both,,,1462,1081.88,,,1081.88,Other,150% of Medicare + 9.63% HCRA Surcharge,657.9,45,,657.9,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,723.69,,,723.69,Other,110% of Medicare,994.16,68,,994.16,percent of total billed charges,All Other,423,,,423,Other,186% of Medicaid,1169.6,,,1169.6,Other,Non Covered Service,1213.46,,,1213.46,Other,Non Covered Service,1213.46,,,1213.46,Other,Non Covered Service,1169.6,,,1169.6,Other,Non Covered Service,1213.46,,,1213.46,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1023.4,70,,1023.4,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,227.45,,,227.45,Other,100% of Medicaid,227.45,,,227.45,Other,100% of Medicaid,227.45,,,227.45,Other,100% of Medicaid,227.45,,,227.45,Other,100% of Medicaid,511.76,,,511.76,Other,225% of Medicaid,348,,,348,Other,153% of Medicaid,511.76,,,511.76,Other,225% of Medicaid,318.43,,,318.43,Other,140% of Medicaid,511.76,,,511.76,Other,225% of Medicaid,591.37,,,591.37,Other,260% of Medicaid,736.94,,,736.94,Other,324% of Medicaid,489.02,,,489.02,Other,215% of Medicaid,489.02,,,489.02,Other,215% of Medicaid,284.31,,,284.31,Other,125% of Medicaid,0.01,1213.46,
CLEAR OUTER EAR CANAL,69200,CPT,,30069200,CDM,450,RC,,,both,,,271,200.54,,,200.54,Other,150% of Medicare + 9.63% HCRA Surcharge,121.95,45,,121.95,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,134.15,,,134.15,Other,110% of Medicare,184.28,68,,184.28,percent of total billed charges,All Other,0.01,,,0.01,Other,186% of Medicaid,216.8,,,216.8,Other,Non Covered Service,224.93,,,224.93,Other,Non Covered Service,224.93,,,224.93,Other,Non Covered Service,216.8,,,216.8,Other,Non Covered Service,224.93,,,224.93,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,189.7,70,,189.7,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,224.93,
REMOVE IMPACTED EAR WAX UNI,69209,CPT,,30069209,CDM,450,RC,,,both,,,250,185,,,185,Other,150% of Medicare + 9.63% HCRA Surcharge,112.5,45,,112.5,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,123.75,,,123.75,Other,110% of Medicare,170,68,,170,percent of total billed charges,All Other,0.01,,,0.01,Other,186% of Medicaid,200,,,200,Other,Non Covered Service,207.5,,,207.5,Other,Non Covered Service,207.5,,,207.5,Other,Non Covered Service,200,,,200,Other,Non Covered Service,207.5,,,207.5,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,175,70,,175,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,207.5,
REMOVAL IMPACTED CERUMEN,69210,CPT,,30069210,CDM,450,RC,,,both,,,258,190.92,,,190.92,Other,150% of Medicare + 9.63% HCRA Surcharge,116.1,45,,116.1,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,127.71,,,127.71,Other,110% of Medicare,175.44,68,,175.44,percent of total billed charges,All Other,0.01,,,0.01,Other,186% of Medicaid,206.4,,,206.4,Other,Non Covered Service,214.14,,,214.14,Other,Non Covered Service,214.14,,,214.14,Other,Non Covered Service,206.4,,,206.4,Other,Non Covered Service,214.14,,,214.14,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,180.6,70,,180.6,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,214.14,
US EXAM OF HEAD AND NECK,76536,CPT,TC,30076536,CDM,450,RC,,,both,,,807,597.18,,,597.18,Other,150% of Medicare + 9.63% HCRA Surcharge,363.15,45,,363.15,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,399.47,,,399.47,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,226,,,226,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,564.9,70,,564.9,percent of total billed charges,All Other,419.84,,,419.84,Fee Schedule,,355.84,,,355.84,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,121.68,,,121.68,Other,100% of Medicaid,121.68,,,121.68,Other,100% of Medicaid,121.68,,,121.68,Other,100% of Medicaid,121.68,,,121.68,Other,100% of Medicaid,273.79,,,273.79,Other,225% of Medicaid,186.18,,,186.18,Other,153% of Medicaid,273.79,,,273.79,Other,225% of Medicaid,170.36,,,170.36,Other,140% of Medicaid,273.79,,,273.79,Other,225% of Medicaid,316.38,,,316.38,Other,260% of Medicaid,394.25,,,394.25,Other,324% of Medicaid,261.62,,,261.62,Other,215% of Medicaid,261.62,,,261.62,Other,215% of Medicaid,152.1,,,152.1,Other,125% of Medicaid,0.01,597.18,
US ABDOMEN LIMITED,76705,CPT,TC,30076705,CDM,450,RC,,,both,,,982,726.68,,,726.68,Other,150% of Medicare + 9.63% HCRA Surcharge,441.9,45,,441.9,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,486.09,,,486.09,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,226,,,226,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,687.4,70,,687.4,percent of total billed charges,All Other,295.2,,,295.2,Fee Schedule,,250.2,,,250.2,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,121.68,,,121.68,Other,100% of Medicaid,121.68,,,121.68,Other,100% of Medicaid,121.68,,,121.68,Other,100% of Medicaid,121.68,,,121.68,Other,100% of Medicaid,273.79,,,273.79,Other,225% of Medicaid,186.18,,,186.18,Other,153% of Medicaid,273.79,,,273.79,Other,225% of Medicaid,170.36,,,170.36,Other,140% of Medicaid,273.79,,,273.79,Other,225% of Medicaid,316.38,,,316.38,Other,260% of Medicaid,394.25,,,394.25,Other,324% of Medicaid,261.62,,,261.62,Other,215% of Medicaid,261.62,,,261.62,Other,215% of Medicaid,152.1,,,152.1,Other,125% of Medicaid,0.01,726.68,
US RETROPERITONEAL LTD,76775,CPT,TC,30076775,CDM,450,RC,,,both,,,1339,990.86,,,990.86,Other,150% of Medicare + 9.63% HCRA Surcharge,602.55,45,,602.55,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,662.81,,,662.81,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,226,,,226,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,937.3,70,,937.3,percent of total billed charges,All Other,149.24,,,149.24,Fee Schedule,,126.49,,,126.49,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,121.68,,,121.68,Other,100% of Medicaid,121.68,,,121.68,Other,100% of Medicaid,121.68,,,121.68,Other,100% of Medicaid,121.68,,,121.68,Other,100% of Medicaid,273.79,,,273.79,Other,225% of Medicaid,186.18,,,186.18,Other,153% of Medicaid,273.79,,,273.79,Other,225% of Medicaid,170.36,,,170.36,Other,140% of Medicaid,273.79,,,273.79,Other,225% of Medicaid,316.38,,,316.38,Other,260% of Medicaid,394.25,,,394.25,Other,324% of Medicaid,261.62,,,261.62,Other,215% of Medicaid,261.62,,,261.62,Other,215% of Medicaid,152.1,,,152.1,Other,125% of Medicaid,0.01,990.86,
US OB LIMITED 1 OR > GEST,76815,CPT,TC,30076815,CDM,450,RC,,,both,,,443,327.82,,,327.82,Other,150% of Medicare + 9.63% HCRA Surcharge,199.35,45,,199.35,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,219.29,,,219.29,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,196,,,196,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,310.1,70,,310.1,percent of total billed charges,All Other,249.28,,,249.28,Fee Schedule,,211.28,,,211.28,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,105.15,,,105.15,Other,100% of Medicaid,105.15,,,105.15,Other,100% of Medicaid,105.15,,,105.15,Other,100% of Medicaid,105.15,,,105.15,Other,100% of Medicaid,236.6,,,236.6,Other,225% of Medicaid,160.89,,,160.89,Other,153% of Medicaid,236.6,,,236.6,Other,225% of Medicaid,147.22,,,147.22,Other,140% of Medicaid,236.6,,,236.6,Other,225% of Medicaid,273.4,,,273.4,Other,260% of Medicaid,340.7,,,340.7,Other,324% of Medicaid,226.08,,,226.08,Other,215% of Medicaid,226.08,,,226.08,Other,215% of Medicaid,131.44,,,131.44,Other,125% of Medicaid,0.01,340.7,
US PELVIS NON OB LIMITED,76857,CPT,TC,30076857,CDM,450,RC,,,both,,,580,429.2,,,429.2,Other,150% of Medicare + 9.63% HCRA Surcharge,261,45,,261,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,287.1,,,287.1,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,226,,,226,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,406,70,,406,percent of total billed charges,All Other,119.72,,,119.72,Fee Schedule,,101.47,,,101.47,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,121.68,,,121.68,Other,100% of Medicaid,121.68,,,121.68,Other,100% of Medicaid,121.68,,,121.68,Other,100% of Medicaid,121.68,,,121.68,Other,100% of Medicaid,273.79,,,273.79,Other,225% of Medicaid,186.18,,,186.18,Other,153% of Medicaid,273.79,,,273.79,Other,225% of Medicaid,170.36,,,170.36,Other,140% of Medicaid,273.79,,,273.79,Other,225% of Medicaid,316.38,,,316.38,Other,260% of Medicaid,394.25,,,394.25,Other,324% of Medicaid,261.62,,,261.62,Other,215% of Medicaid,261.62,,,261.62,Other,215% of Medicaid,152.1,,,152.1,Other,125% of Medicaid,0.01,429.2,
US XTR NON-VASC LMTD,76882,CPT,TC,30076882,CDM,450,RC,,,both,,,275,203.5,,,203.5,Other,150% of Medicare + 9.63% HCRA Surcharge,123.75,45,,123.75,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,136.13,,,136.13,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,226,,,226,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,192.5,70,,192.5,percent of total billed charges,All Other,162.36,,,162.36,Fee Schedule,,137.61,,,137.61,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,121.68,,,121.68,Other,100% of Medicaid,121.68,,,121.68,Other,100% of Medicaid,121.68,,,121.68,Other,100% of Medicaid,121.68,,,121.68,Other,100% of Medicaid,273.79,,,273.79,Other,225% of Medicaid,186.18,,,186.18,Other,153% of Medicaid,273.79,,,273.79,Other,225% of Medicaid,170.36,,,170.36,Other,140% of Medicaid,273.79,,,273.79,Other,225% of Medicaid,316.38,,,316.38,Other,260% of Medicaid,394.25,,,394.25,Other,324% of Medicaid,261.62,,,261.62,Other,215% of Medicaid,261.62,,,261.62,Other,215% of Medicaid,152.1,,,152.1,Other,125% of Medicaid,0.01,394.25,
SKIN TEST; TB ID,86580,CPT,,30086580,CDM,450,RC,,,both,,,58,42.92,,,42.92,Other,150% of Medicare + 9.63% HCRA Surcharge,26.1,45,,26.1,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,28.71,,,28.71,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,18,,,18,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,40.6,70,,40.6,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,9.88,,,9.88,Other,100% of Medicaid,9.88,,,9.88,Other,100% of Medicaid,9.88,,,9.88,Other,100% of Medicaid,9.88,,,9.88,Other,100% of Medicaid,22.23,,,22.23,Other,225% of Medicaid,15.11,,,15.11,Other,153% of Medicaid,22.23,,,22.23,Other,225% of Medicaid,13.83,,,13.83,Other,140% of Medicaid,22.23,,,22.23,Other,225% of Medicaid,25.68,,,25.68,Other,260% of Medicaid,32.01,,,32.01,Other,324% of Medicaid,21.24,,,21.24,Other,215% of Medicaid,21.24,,,21.24,Other,215% of Medicaid,12.35,,,12.35,Other,125% of Medicaid,0.01,42.92,
EYE WASHING,92499,CPT,,30092499,CDM,450,RC,,,both,,,231,170.94,,,170.94,Other,150% of Medicare + 9.63% HCRA Surcharge,103.95,45,,103.95,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,114.35,,,114.35,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,139,,,139,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,161.7,70,,161.7,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,74.86,,,74.86,Other,100% of Medicaid,74.86,,,74.86,Other,100% of Medicaid,74.86,,,74.86,Other,100% of Medicaid,74.86,,,74.86,Other,100% of Medicaid,168.43,,,168.43,Other,225% of Medicaid,114.53,,,114.53,Other,153% of Medicaid,168.43,,,168.43,Other,225% of Medicaid,104.8,,,104.8,Other,140% of Medicaid,168.43,,,168.43,Other,225% of Medicaid,194.63,,,194.63,Other,260% of Medicaid,242.54,,,242.54,Other,324% of Medicaid,160.94,,,160.94,Other,215% of Medicaid,160.94,,,160.94,Other,215% of Medicaid,93.57,,,93.57,Other,125% of Medicaid,0.01,242.54,
HEART LUNG RESUSCITATION CPR,92950,CPT,,30092950,CDM,450,RC,,,both,,,903,668.22,,,668.22,Other,150% of Medicare + 9.63% HCRA Surcharge,406.35,45,,406.35,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,446.99,,,446.99,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,880,,,880,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,632.1,70,,632.1,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,472.91,,,472.91,Other,100% of Medicaid,472.91,,,472.91,Other,100% of Medicaid,472.91,,,472.91,Other,100% of Medicaid,472.91,,,472.91,Other,100% of Medicaid,1064.05,,,1064.05,Other,225% of Medicaid,723.55,,,723.55,Other,153% of Medicaid,1064.05,,,1064.05,Other,225% of Medicaid,662.07,,,662.07,Other,140% of Medicaid,1064.05,,,1064.05,Other,225% of Medicaid,1229.57,,,1229.57,Other,260% of Medicaid,1532.23,,,1532.23,Other,324% of Medicaid,1016.76,,,1016.76,Other,215% of Medicaid,1016.76,,,1016.76,Other,215% of Medicaid,591.14,,,591.14,Other,125% of Medicaid,0.01,1532.23,
TEMPORARY EXTERNAL PACING,92953,CPT,,30092953,CDM,450,RC,,,both,,,1325,980.5,,,980.5,Other,150% of Medicare + 9.63% HCRA Surcharge,596.25,45,,596.25,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,655.88,,,655.88,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,816,,,816,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,927.5,70,,927.5,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,438.68,,,438.68,Other,100% of Medicaid,438.68,,,438.68,Other,100% of Medicaid,438.68,,,438.68,Other,100% of Medicaid,438.68,,,438.68,Other,100% of Medicaid,987.03,,,987.03,Other,225% of Medicaid,671.18,,,671.18,Other,153% of Medicaid,987.03,,,987.03,Other,225% of Medicaid,614.15,,,614.15,Other,140% of Medicaid,987.03,,,987.03,Other,225% of Medicaid,1140.57,,,1140.57,Other,260% of Medicaid,1421.33,,,1421.33,Other,324% of Medicaid,943.16,,,943.16,Other,215% of Medicaid,943.16,,,943.16,Other,215% of Medicaid,548.35,,,548.35,Other,125% of Medicaid,0.01,1421.33,
CARDIOVERSION,92960,CPT,,30092960,CDM,450,RC,,,both,,,2056,1521.45,,,1521.45,Other,150% of Medicare + 9.63% HCRA Surcharge,925.2,45,,925.2,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1017.72,,,1017.72,Other,110% of Medicare,1398.08,68,,1398.08,percent of total billed charges,All Other,816,,,816,Other,186% of Medicaid,1644.8,,,1644.8,Other,Non Covered Service,1706.48,,,1706.48,Other,Non Covered Service,1706.48,,,1706.48,Other,Non Covered Service,1644.8,,,1644.8,Other,Non Covered Service,1706.48,,,1706.48,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1439.2,70,,1439.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,438.68,,,438.68,Other,100% of Medicaid,438.68,,,438.68,Other,100% of Medicaid,438.68,,,438.68,Other,100% of Medicaid,438.68,,,438.68,Other,100% of Medicaid,987.03,,,987.03,Other,225% of Medicaid,671.18,,,671.18,Other,153% of Medicaid,987.03,,,987.03,Other,225% of Medicaid,614.15,,,614.15,Other,140% of Medicaid,987.03,,,987.03,Other,225% of Medicaid,1140.57,,,1140.57,Other,260% of Medicaid,1421.33,,,1421.33,Other,324% of Medicaid,943.16,,,943.16,Other,215% of Medicaid,943.16,,,943.16,Other,215% of Medicaid,548.35,,,548.35,Other,125% of Medicaid,0.01,1706.48,
TTE F-UP OR LMTD,93308,CPT,TC,30093308,CDM,450,RC,,,both,,,993,734.82,,,734.82,Other,150% of Medicare + 9.63% HCRA Surcharge,446.85,45,,446.85,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,491.54,,,491.54,Other,110% of Medicare,0.68,,,0.68,Fee Schedule,,497,,,497,Other,186% of Medicaid,0.8,,,0.8,Fee Schedule,,0.83,,,0.83,Fee Schedule,,0.83,,,0.83,Fee Schedule,,0.8,,,0.8,Fee Schedule,,0.83,,,0.83,Fee Schedule,,0.01,,,0.01,Other,Non Covered Service,695.1,70,,695.1,percent of total billed charges,All Other,362.44,,,362.44,Fee Schedule,,307.19,,,307.19,Fee Schedule,,1000,,,1000,Case Rate,,900,,,900,Case Rate,,1000,,,1000,Case Rate,,851,,,851,Case Rate,,267.36,,,267.36,Other,100% of Medicaid,267.36,,,267.36,Other,100% of Medicaid,267.36,,,267.36,Other,100% of Medicaid,267.36,,,267.36,Other,100% of Medicaid,601.56,,,601.56,Other,225% of Medicaid,409.06,,,409.06,Other,153% of Medicaid,601.56,,,601.56,Other,225% of Medicaid,374.3,,,374.3,Other,140% of Medicaid,601.56,,,601.56,Other,225% of Medicaid,695.14,,,695.14,Other,260% of Medicaid,866.25,,,866.25,Other,324% of Medicaid,574.82,,,574.82,Other,215% of Medicaid,574.82,,,574.82,Other,215% of Medicaid,334.2,,,334.2,Other,125% of Medicaid,0.01,1000,
SPIROMETRY VITAL CAPACITY,94010,CPT,,30094010,CDM,450,RC,,,both,,,671,496.54,,,496.54,Other,150% of Medicare + 9.63% HCRA Surcharge,301.95,45,,301.95,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,332.15,,,332.15,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,113,,,113,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,469.7,70,,469.7,percent of total billed charges,All Other,90.2,,,90.2,Fee Schedule,,76.45,,,76.45,Fee Schedule,,667,,,667,Case Rate,,600,,,600,Case Rate,,667,,,667,Case Rate,,567,,,567,Case Rate,,61,,,61,Other,100% of Medicaid,61,,,61,Other,100% of Medicaid,61,,,61,Other,100% of Medicaid,61,,,61,Other,100% of Medicaid,137.24,,,137.24,Other,225% of Medicaid,93.32,,,93.32,Other,153% of Medicaid,137.24,,,137.24,Other,225% of Medicaid,85.39,,,85.39,Other,140% of Medicaid,137.24,,,137.24,Other,225% of Medicaid,158.59,,,158.59,Other,260% of Medicaid,197.63,,,197.63,Other,324% of Medicaid,131.14,,,131.14,Other,215% of Medicaid,131.14,,,131.14,Other,215% of Medicaid,76.24,,,76.24,Other,125% of Medicaid,0.01,667,
HYDRATION IV INFUSION INIT,96360,CPT,,30096360,CDM,450,RC,,,both,,,466,344.84,,,344.84,Other,150% of Medicare + 9.63% HCRA Surcharge,209.7,45,,209.7,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,230.67,,,230.67,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,411,,,411,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,326.2,70,,326.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,221.06,,,221.06,Other,100% of Medicaid,221.06,,,221.06,Other,100% of Medicaid,221.06,,,221.06,Other,100% of Medicaid,221.06,,,221.06,Other,100% of Medicaid,497.39,,,497.39,Other,225% of Medicaid,338.22,,,338.22,Other,153% of Medicaid,497.39,,,497.39,Other,225% of Medicaid,309.49,,,309.49,Other,140% of Medicaid,497.39,,,497.39,Other,225% of Medicaid,574.76,,,574.76,Other,260% of Medicaid,716.24,,,716.24,Other,324% of Medicaid,475.28,,,475.28,Other,215% of Medicaid,475.28,,,475.28,Other,215% of Medicaid,276.33,,,276.33,Other,125% of Medicaid,0.01,716.24,
IV HYDRATION EACH ADD ON,96361,CPT,,30096361,CDM,450,RC,,,both,,,460,340.4,,,340.4,Other,150% of Medicare + 9.63% HCRA Surcharge,207,45,,207,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,227.7,,,227.7,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,1098,,,1098,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,322,70,,322,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,590.24,,,590.24,Other,100% of Medicaid,590.24,,,590.24,Other,100% of Medicaid,590.24,,,590.24,Other,100% of Medicaid,590.24,,,590.24,Other,100% of Medicaid,1328.05,,,1328.05,Other,225% of Medicaid,903.07,,,903.07,Other,153% of Medicaid,1328.05,,,1328.05,Other,225% of Medicaid,826.34,,,826.34,Other,140% of Medicaid,1328.05,,,1328.05,Other,225% of Medicaid,1534.64,,,1534.64,Other,260% of Medicaid,1912.39,,,1912.39,Other,324% of Medicaid,1269.03,,,1269.03,Other,215% of Medicaid,1269.03,,,1269.03,Other,215% of Medicaid,737.81,,,737.81,Other,125% of Medicaid,0.01,1912.39,
INFUSION THERAPY 1 HOUR,96365,CPT,,30096365,CDM,450,RC,,,both,,,713,527.62,,,527.62,Other,150% of Medicare + 9.63% HCRA Surcharge,320.85,45,,320.85,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,352.94,,,352.94,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,411,,,411,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,499.1,70,,499.1,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,221.06,,,221.06,Other,100% of Medicaid,221.06,,,221.06,Other,100% of Medicaid,221.06,,,221.06,Other,100% of Medicaid,221.06,,,221.06,Other,100% of Medicaid,497.39,,,497.39,Other,225% of Medicaid,338.22,,,338.22,Other,153% of Medicaid,497.39,,,497.39,Other,225% of Medicaid,309.49,,,309.49,Other,140% of Medicaid,497.39,,,497.39,Other,225% of Medicaid,574.76,,,574.76,Other,260% of Medicaid,716.24,,,716.24,Other,324% of Medicaid,475.28,,,475.28,Other,215% of Medicaid,475.28,,,475.28,Other,215% of Medicaid,276.33,,,276.33,Other,125% of Medicaid,0.01,716.24,
INFUSION THERAPY ADDL HR,96366,CPT,,30096366,CDM,450,RC,,,both,,,460,340.4,,,340.4,Other,150% of Medicare + 9.63% HCRA Surcharge,207,45,,207,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,227.7,,,227.7,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,1098,,,1098,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,322,70,,322,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,590.24,,,590.24,Other,100% of Medicaid,590.24,,,590.24,Other,100% of Medicaid,590.24,,,590.24,Other,100% of Medicaid,590.24,,,590.24,Other,100% of Medicaid,1328.05,,,1328.05,Other,225% of Medicaid,903.07,,,903.07,Other,153% of Medicaid,1328.05,,,1328.05,Other,225% of Medicaid,826.34,,,826.34,Other,140% of Medicaid,1328.05,,,1328.05,Other,225% of Medicaid,1534.64,,,1534.64,Other,260% of Medicaid,1912.39,,,1912.39,Other,324% of Medicaid,1269.03,,,1269.03,Other,215% of Medicaid,1269.03,,,1269.03,Other,215% of Medicaid,737.81,,,737.81,Other,125% of Medicaid,0.01,1912.39,
TX/PROPH/DR ADDL SEQ IV I,96367,CPT,,30096367,CDM,450,RC,,,both,,,458,338.92,,,338.92,Other,150% of Medicare + 9.63% HCRA Surcharge,206.1,45,,206.1,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,226.71,,,226.71,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,411,,,411,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,320.6,70,,320.6,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,221.06,,,221.06,Other,100% of Medicaid,221.06,,,221.06,Other,100% of Medicaid,221.06,,,221.06,Other,100% of Medicaid,221.06,,,221.06,Other,100% of Medicaid,497.39,,,497.39,Other,225% of Medicaid,338.22,,,338.22,Other,153% of Medicaid,497.39,,,497.39,Other,225% of Medicaid,309.49,,,309.49,Other,140% of Medicaid,497.39,,,497.39,Other,225% of Medicaid,574.76,,,574.76,Other,260% of Medicaid,716.24,,,716.24,Other,324% of Medicaid,475.28,,,475.28,Other,215% of Medicaid,475.28,,,475.28,Other,215% of Medicaid,276.33,,,276.33,Other,125% of Medicaid,0.01,716.24,
THER DIAG CONCURRENT INF,96368,CPT,,30096368,CDM,450,RC,,,both,,,460,340.4,,,340.4,Other,150% of Medicare + 9.63% HCRA Surcharge,207,45,,207,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,227.7,,,227.7,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,411,,,411,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,322,70,,322,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,221.06,,,221.06,Other,100% of Medicaid,221.06,,,221.06,Other,100% of Medicaid,221.06,,,221.06,Other,100% of Medicaid,221.06,,,221.06,Other,100% of Medicaid,497.39,,,497.39,Other,225% of Medicaid,338.22,,,338.22,Other,153% of Medicaid,497.39,,,497.39,Other,225% of Medicaid,309.49,,,309.49,Other,140% of Medicaid,497.39,,,497.39,Other,225% of Medicaid,574.76,,,574.76,Other,260% of Medicaid,716.24,,,716.24,Other,324% of Medicaid,475.28,,,475.28,Other,215% of Medicaid,475.28,,,475.28,Other,215% of Medicaid,276.33,,,276.33,Other,125% of Medicaid,0.01,716.24,
SC THER INFUSION UP TO 1 HR,96369,CPT,,30096369,CDM,450,RC,,,both,,,611,452.14,,,452.14,Other,150% of Medicare + 9.63% HCRA Surcharge,274.95,45,,274.95,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,302.45,,,302.45,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,411,,,411,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,427.7,70,,427.7,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,221.06,,,221.06,Other,100% of Medicaid,221.06,,,221.06,Other,100% of Medicaid,221.06,,,221.06,Other,100% of Medicaid,221.06,,,221.06,Other,100% of Medicaid,497.39,,,497.39,Other,225% of Medicaid,338.22,,,338.22,Other,153% of Medicaid,497.39,,,497.39,Other,225% of Medicaid,309.49,,,309.49,Other,140% of Medicaid,497.39,,,497.39,Other,225% of Medicaid,574.76,,,574.76,Other,260% of Medicaid,716.24,,,716.24,Other,324% of Medicaid,475.28,,,475.28,Other,215% of Medicaid,475.28,,,475.28,Other,215% of Medicaid,276.33,,,276.33,Other,125% of Medicaid,0.01,716.24,
SC THER INFUSION ADDL HR,96370,CPT,,30096370,CDM,450,RC,,,both,,,192,142.08,,,142.08,Other,150% of Medicare + 9.63% HCRA Surcharge,86.4,45,,86.4,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,95.04,,,95.04,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,1098,,,1098,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,134.4,70,,134.4,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,590.24,,,590.24,Other,100% of Medicaid,590.24,,,590.24,Other,100% of Medicaid,590.24,,,590.24,Other,100% of Medicaid,590.24,,,590.24,Other,100% of Medicaid,1328.05,,,1328.05,Other,225% of Medicaid,903.07,,,903.07,Other,153% of Medicaid,1328.05,,,1328.05,Other,225% of Medicaid,826.34,,,826.34,Other,140% of Medicaid,1328.05,,,1328.05,Other,225% of Medicaid,1534.64,,,1534.64,Other,260% of Medicaid,1912.39,,,1912.39,Other,324% of Medicaid,1269.03,,,1269.03,Other,215% of Medicaid,1269.03,,,1269.03,Other,215% of Medicaid,737.81,,,737.81,Other,125% of Medicaid,0.01,1912.39,
SC THER INFUSION RESET PUMP,96371,CPT,,30096371,CDM,450,RC,,,both,,,153,113.22,,,113.22,Other,150% of Medicare + 9.63% HCRA Surcharge,68.85,45,,68.85,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,75.74,,,75.74,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,411,,,411,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,107.1,70,,107.1,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,221.06,,,221.06,Other,100% of Medicaid,221.06,,,221.06,Other,100% of Medicaid,221.06,,,221.06,Other,100% of Medicaid,221.06,,,221.06,Other,100% of Medicaid,497.39,,,497.39,Other,225% of Medicaid,338.22,,,338.22,Other,153% of Medicaid,497.39,,,497.39,Other,225% of Medicaid,309.49,,,309.49,Other,140% of Medicaid,497.39,,,497.39,Other,225% of Medicaid,574.76,,,574.76,Other,260% of Medicaid,716.24,,,716.24,Other,324% of Medicaid,475.28,,,475.28,Other,215% of Medicaid,475.28,,,475.28,Other,215% of Medicaid,276.33,,,276.33,Other,125% of Medicaid,0.01,716.24,
THER/PROPH/DIAG INJ SC/IM,96372,CPT,,30096372,CDM,450,RC,,,both,,,460,340.4,,,340.4,Other,150% of Medicare + 9.63% HCRA Surcharge,207,45,,207,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,227.7,,,227.7,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,58,,,58,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,322,70,,322,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,31.2,,,31.2,Other,100% of Medicaid,31.2,,,31.2,Other,100% of Medicaid,31.2,,,31.2,Other,100% of Medicaid,31.2,,,31.2,Other,100% of Medicaid,70.2,,,70.2,Other,225% of Medicaid,47.74,,,47.74,Other,153% of Medicaid,70.2,,,70.2,Other,225% of Medicaid,43.68,,,43.68,Other,140% of Medicaid,70.2,,,70.2,Other,225% of Medicaid,81.12,,,81.12,Other,260% of Medicaid,101.09,,,101.09,Other,324% of Medicaid,67.08,,,67.08,Other,215% of Medicaid,67.08,,,67.08,Other,215% of Medicaid,39,,,39,Other,125% of Medicaid,0.01,340.4,
INJECT ARTERIAL THERAPEUT,96373,CPT,,30096373,CDM,450,RC,,,both,,,466,344.84,,,344.84,Other,150% of Medicare + 9.63% HCRA Surcharge,209.7,45,,209.7,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,230.67,,,230.67,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,58,,,58,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,326.2,70,,326.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,31.2,,,31.2,Other,100% of Medicaid,31.2,,,31.2,Other,100% of Medicaid,31.2,,,31.2,Other,100% of Medicaid,31.2,,,31.2,Other,100% of Medicaid,70.2,,,70.2,Other,225% of Medicaid,47.74,,,47.74,Other,153% of Medicaid,70.2,,,70.2,Other,225% of Medicaid,43.68,,,43.68,Other,140% of Medicaid,70.2,,,70.2,Other,225% of Medicaid,81.12,,,81.12,Other,260% of Medicaid,101.09,,,101.09,Other,324% of Medicaid,67.08,,,67.08,Other,215% of Medicaid,67.08,,,67.08,Other,215% of Medicaid,39,,,39,Other,125% of Medicaid,0.01,344.84,
IV PUSH INITIAL,96374,CPT,,30096374,CDM,450,RC,,,both,,,483,357.42,,,357.42,Other,150% of Medicare + 9.63% HCRA Surcharge,217.35,45,,217.35,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,239.09,,,239.09,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,58,,,58,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,338.1,70,,338.1,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,31.2,,,31.2,Other,100% of Medicaid,31.2,,,31.2,Other,100% of Medicaid,31.2,,,31.2,Other,100% of Medicaid,31.2,,,31.2,Other,100% of Medicaid,70.2,,,70.2,Other,225% of Medicaid,47.74,,,47.74,Other,153% of Medicaid,70.2,,,70.2,Other,225% of Medicaid,43.68,,,43.68,Other,140% of Medicaid,70.2,,,70.2,Other,225% of Medicaid,81.12,,,81.12,Other,260% of Medicaid,101.09,,,101.09,Other,324% of Medicaid,67.08,,,67.08,Other,215% of Medicaid,67.08,,,67.08,Other,215% of Medicaid,39,,,39,Other,125% of Medicaid,0.01,357.42,
TX/PRO/DX/ INJ NEW DRUG A,96375,CPT,,30096375,CDM,450,RC,,,both,,,460,340.4,,,340.4,Other,150% of Medicare + 9.63% HCRA Surcharge,207,45,,207,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,227.7,,,227.7,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,58,,,58,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,322,70,,322,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,31.2,,,31.2,Other,100% of Medicaid,31.2,,,31.2,Other,100% of Medicaid,31.2,,,31.2,Other,100% of Medicaid,31.2,,,31.2,Other,100% of Medicaid,70.2,,,70.2,Other,225% of Medicaid,47.74,,,47.74,Other,153% of Medicaid,70.2,,,70.2,Other,225% of Medicaid,43.68,,,43.68,Other,140% of Medicaid,70.2,,,70.2,Other,225% of Medicaid,81.12,,,81.12,Other,260% of Medicaid,101.09,,,101.09,Other,324% of Medicaid,67.08,,,67.08,Other,215% of Medicaid,67.08,,,67.08,Other,215% of Medicaid,39,,,39,Other,125% of Medicaid,0.01,340.4,
TX/PRO/DX INJ SAME DRUG ADDON,96376,CPT,,30096376,CDM,450,RC,,,both,,,460,340.4,,,340.4,Other,150% of Medicare + 9.63% HCRA Surcharge,207,45,,207,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,227.7,,,227.7,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,58,,,58,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,322,70,,322,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,31.2,,,31.2,Other,100% of Medicaid,31.2,,,31.2,Other,100% of Medicaid,31.2,,,31.2,Other,100% of Medicaid,31.2,,,31.2,Other,100% of Medicaid,70.2,,,70.2,Other,225% of Medicaid,47.74,,,47.74,Other,153% of Medicaid,70.2,,,70.2,Other,225% of Medicaid,43.68,,,43.68,Other,140% of Medicaid,70.2,,,70.2,Other,225% of Medicaid,81.12,,,81.12,Other,260% of Medicaid,101.09,,,101.09,Other,324% of Medicaid,67.08,,,67.08,Other,215% of Medicaid,67.08,,,67.08,Other,215% of Medicaid,39,,,39,Other,125% of Medicaid,0.01,340.4,
IRRIG DRUG DELIVERY DEVICE,96523,CPT,,30096523,CDM,450,RC,,,both,,,243,179.82,,,179.82,Other,150% of Medicare + 9.63% HCRA Surcharge,109.35,45,,109.35,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,120.29,,,120.29,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,58,,,58,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,170.1,70,,170.1,percent of total billed charges,All Other,129.56,,,129.56,Fee Schedule,,109.81,,,109.81,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,31.2,,,31.2,Other,100% of Medicaid,31.2,,,31.2,Other,100% of Medicaid,31.2,,,31.2,Other,100% of Medicaid,31.2,,,31.2,Other,100% of Medicaid,70.2,,,70.2,Other,225% of Medicaid,47.74,,,47.74,Other,153% of Medicaid,70.2,,,70.2,Other,225% of Medicaid,43.68,,,43.68,Other,140% of Medicaid,70.2,,,70.2,Other,225% of Medicaid,81.12,,,81.12,Other,260% of Medicaid,101.09,,,101.09,Other,324% of Medicaid,67.08,,,67.08,Other,215% of Medicaid,67.08,,,67.08,Other,215% of Medicaid,39,,,39,Other,125% of Medicaid,0.01,179.82,
DEBRIDEMENT SKIN PARTIAL,97597,CPT,,30097597,CDM,450,RC,,,both,,,573,424.02,,,424.02,Other,150% of Medicare + 9.63% HCRA Surcharge,257.85,45,,257.85,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,283.64,,,283.64,Other,110% of Medicare,389.64,68,,389.64,percent of total billed charges,All Other,703,,,703,Other,186% of Medicaid,458.4,,,458.4,Other,Non Covered Service,475.59,,,475.59,Other,Non Covered Service,475.59,,,475.59,Other,Non Covered Service,458.4,,,458.4,Other,Non Covered Service,475.59,,,475.59,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,401.1,70,,401.1,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,377.82,,,377.82,Other,100% of Medicaid,377.82,,,377.82,Other,100% of Medicaid,377.82,,,377.82,Other,100% of Medicaid,377.82,,,377.82,Other,100% of Medicaid,850.1,,,850.1,Other,225% of Medicaid,578.07,,,578.07,Other,153% of Medicaid,850.1,,,850.1,Other,225% of Medicaid,528.95,,,528.95,Other,140% of Medicaid,850.1,,,850.1,Other,225% of Medicaid,982.34,,,982.34,Other,260% of Medicaid,1224.15,,,1224.15,Other,324% of Medicaid,812.32,,,812.32,Other,215% of Medicaid,812.32,,,812.32,Other,215% of Medicaid,472.28,,,472.28,Other,125% of Medicaid,0.01,1224.15,
DEBRIDEMENT SKIN FULL THI,97598,CPT,,30097598,CDM,450,RC,,,both,,,573,424.02,,,424.02,Other,150% of Medicare + 9.63% HCRA Surcharge,257.85,45,,257.85,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,283.64,,,283.64,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,2131,,,2131,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,401.1,70,,401.1,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1145.48,,,1145.48,Other,100% of Medicaid,1145.48,,,1145.48,Other,100% of Medicaid,1145.48,,,1145.48,Other,100% of Medicaid,1145.48,,,1145.48,Other,100% of Medicaid,2577.32,,,2577.32,Other,225% of Medicaid,1752.58,,,1752.58,Other,153% of Medicaid,2577.32,,,2577.32,Other,225% of Medicaid,1603.67,,,1603.67,Other,140% of Medicaid,2577.32,,,2577.32,Other,225% of Medicaid,2978.24,,,2978.24,Other,260% of Medicaid,3711.34,,,3711.34,Other,324% of Medicaid,2462.77,,,2462.77,Other,215% of Medicaid,2462.77,,,2462.77,Other,215% of Medicaid,1431.84,,,1431.84,Other,125% of Medicaid,0.01,3711.34,
MOD SED SAME PHYS/QHP <5 YRS,99151,CPT,,30099151,CDM,450,RC,,,both,,,574,424.76,,,424.76,Other,150% of Medicare + 9.63% HCRA Surcharge,258.3,45,,258.3,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,284.13,,,284.13,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,401.8,70,,401.8,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,424.76,
MOD SED SAME PHYS/QHP 5/>YR FIRST 15 MIN,99152,CPT,,30099152,CDM,450,RC,,,both,,,157,116.18,,,116.18,Other,150% of Medicare + 9.63% HCRA Surcharge,70.65,45,,70.65,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,77.72,,,77.72,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,109.9,70,,109.9,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,116.18,
MOD SED SAME PHYS/QHP EA ADDL 15 MIN,99153,CPT,,30099153,CDM,450,RC,,,both,,,157,116.18,,,116.18,Other,150% of Medicare + 9.63% HCRA Surcharge,70.65,45,,70.65,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,77.72,,,77.72,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,109.9,70,,109.9,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,116.18,
MOD SED OTH PHYS/QHP <5 YRS,99155,CPT,,30099155,CDM,450,RC,,,both,,,173,128.02,,,128.02,Other,150% of Medicare + 9.63% HCRA Surcharge,77.85,45,,77.85,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,85.64,,,85.64,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,121.1,70,,121.1,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,128.02,
MOD SED OTH PHYS/QHP 5/>YRS,99156,CPT,,30099156,CDM,450,RC,,,both,,,173,128.02,,,128.02,Other,150% of Medicare + 9.63% HCRA Surcharge,77.85,45,,77.85,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,85.64,,,85.64,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,121.1,70,,121.1,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,128.02,
MOD SED OTHER PHYS/QHP EA,99157,CPT,,30099157,CDM,450,RC,,,both,,,173,128.02,,,128.02,Other,150% of Medicare + 9.63% HCRA Surcharge,77.85,45,,77.85,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,85.64,,,85.64,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,121.1,70,,121.1,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,128.02,
ED VISIT LEVEL 1,99281,CPT,,30099281,CDM,450,RC,,,both,,,2191,1621.35,,,1621.35,Other,150% of Medicare + 9.63% HCRA Surcharge,985.95,45,,985.95,percent of total billed charges,Critical Access Hospital RCC factor,1648,,,1648,Case Rate,ED per Visit,1483,,,1483,Case Rate,ED per Visit,1710,,,1710,Case Rate,ED per Visit,1539,,,1539,Case Rate,ED per Visit,1454,,,1454,Case Rate,ED per Visit,1084.55,,,1084.55,Other,110% of Medicare,1489.88,68,,1489.88,percent of total billed charges,All Other,0.01,,,0.01,Other,186% of Medicaid,1752.8,,,1752.8,Case Rate,ED per Visit,1818.53,,,1818.53,Case Rate,ED per Visit,1818.53,,,1818.53,Case Rate,ED per Visit,1752.8,,,1752.8,Case Rate,ED per Visit,1818.53,,,1818.53,Case Rate,ED per Visit,2018,,,2018,Case Rate,ED per Visit,1533.7,70,,1533.7,percent of total billed charges,All Other,1461,,,1461,Case Rate,ED per Visit,1242,,,1242,Case Rate,ED per Visit,1464,,,1464,Case Rate,ED per Visit,1316,,,1316,Case Rate,ED per Visit,1464,,,1464,Case Rate,ED per Visit,1244,,,1244,Case Rate,ED per Visit,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2018,
ED VISIT LEVEL 2,99282,CPT,,30099282,CDM,450,RC,,,both,,,3649,2700.27,,,2700.27,Other,150% of Medicare + 9.63% HCRA Surcharge,1642.05,45,,1642.05,percent of total billed charges,Critical Access Hospital RCC factor,1648,,,1648,Case Rate,ED per Visit,1483,,,1483,Case Rate,ED per Visit,1710,,,1710,Case Rate,ED per Visit,1539,,,1539,Case Rate,ED per Visit,1454,,,1454,Case Rate,ED per Visit,1806.26,,,1806.26,Other,110% of Medicare,2481.32,68,,2481.32,percent of total billed charges,All Other,0.01,,,0.01,Other,186% of Medicaid,2919.2,,,2919.2,Case Rate,ED per Visit,3028.67,,,3028.67,Case Rate,ED per Visit,3028.67,,,3028.67,Case Rate,ED per Visit,2919.2,,,2919.2,Case Rate,ED per Visit,3028.67,,,3028.67,Case Rate,ED per Visit,2018,,,2018,Case Rate,ED per Visit,2554.3,70,,2554.3,percent of total billed charges,All Other,1461,,,1461,Case Rate,ED per Visit,1242,,,1242,Case Rate,ED per Visit,1464,,,1464,Case Rate,ED per Visit,1316,,,1316,Case Rate,ED per Visit,1464,,,1464,Case Rate,ED per Visit,1244,,,1244,Case Rate,ED per Visit,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3028.67,
ED VISIT LEVEL 3,99283,CPT,,30099283,CDM,450,RC,,,both,,,4816,3563.85,,,3563.85,Other,150% of Medicare + 9.63% HCRA Surcharge,2167.2,45,,2167.2,percent of total billed charges,Critical Access Hospital RCC factor,1648,,,1648,Case Rate,ED per Visit,1483,,,1483,Case Rate,ED per Visit,1710,,,1710,Case Rate,ED per Visit,1539,,,1539,Case Rate,ED per Visit,1454,,,1454,Case Rate,ED per Visit,2383.92,,,2383.92,Other,110% of Medicare,3274.88,68,,3274.88,percent of total billed charges,All Other,0.01,,,0.01,Other,186% of Medicaid,3852.8,,,3852.8,Case Rate,ED per Visit,3997.28,,,3997.28,Case Rate,ED per Visit,3997.28,,,3997.28,Case Rate,ED per Visit,3852.8,,,3852.8,Case Rate,ED per Visit,3997.28,,,3997.28,Case Rate,ED per Visit,2018,,,2018,Case Rate,ED per Visit,3371.2,70,,3371.2,percent of total billed charges,All Other,1461,,,1461,Case Rate,ED per Visit,1242,,,1242,Case Rate,ED per Visit,1464,,,1464,Case Rate,ED per Visit,1316,,,1316,Case Rate,ED per Visit,1464,,,1464,Case Rate,ED per Visit,1244,,,1244,Case Rate,ED per Visit,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3997.28,
ED VISIT LEVEL 4,99284,CPT,,30099284,CDM,450,RC,,,both,,,6275,4643.52,,,4643.52,Other,150% of Medicare + 9.63% HCRA Surcharge,2823.75,45,,2823.75,percent of total billed charges,Critical Access Hospital RCC factor,1648,,,1648,Case Rate,ED per Visit,1483,,,1483,Case Rate,ED per Visit,1710,,,1710,Case Rate,ED per Visit,1539,,,1539,Case Rate,ED per Visit,1454,,,1454,Case Rate,ED per Visit,3106.13,,,3106.13,Other,110% of Medicare,4267,68,,4267,percent of total billed charges,All Other,0.01,,,0.01,Other,186% of Medicaid,5020,,,5020,Case Rate,ED per Visit,5208.25,,,5208.25,Case Rate,ED per Visit,5208.25,,,5208.25,Case Rate,ED per Visit,5020,,,5020,Case Rate,ED per Visit,5208.25,,,5208.25,Case Rate,ED per Visit,2018,,,2018,Case Rate,ED per Visit,4392.5,70,,4392.5,percent of total billed charges,All Other,1461,,,1461,Case Rate,ED per Visit,1242,,,1242,Case Rate,ED per Visit,1464,,,1464,Case Rate,ED per Visit,1316,,,1316,Case Rate,ED per Visit,1464,,,1464,Case Rate,ED per Visit,1244,,,1244,Case Rate,ED per Visit,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5208.25,
ED VISIT LEVEL 5,99285,CPT,,30099285,CDM,450,RC,,,both,,,7880,5831.22,,,5831.22,Other,150% of Medicare + 9.63% HCRA Surcharge,3546,45,,3546,percent of total billed charges,Critical Access Hospital RCC factor,1648,,,1648,Case Rate,ED per Visit,1483,,,1483,Case Rate,ED per Visit,1710,,,1710,Case Rate,ED per Visit,1539,,,1539,Case Rate,ED per Visit,1454,,,1454,Case Rate,ED per Visit,3900.6,,,3900.6,Other,110% of Medicare,5358.4,68,,5358.4,percent of total billed charges,All Other,0.01,,,0.01,Other,186% of Medicaid,6304,,,6304,Case Rate,ED per Visit,6540.4,,,6540.4,Case Rate,ED per Visit,6540.4,,,6540.4,Case Rate,ED per Visit,6304,,,6304,Case Rate,ED per Visit,6540.4,,,6540.4,Case Rate,ED per Visit,2018,,,2018,Case Rate,ED per Visit,5516,70,,5516,percent of total billed charges,All Other,1461,,,1461,Case Rate,ED per Visit,1242,,,1242,Case Rate,ED per Visit,1464,,,1464,Case Rate,ED per Visit,1316,,,1316,Case Rate,ED per Visit,1464,,,1464,Case Rate,ED per Visit,1244,,,1244,Case Rate,ED per Visit,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,6540.4,
CRITICAL CARE FIRST HOUR,99291,CPT,,30099291,CDM,450,RC,,,both,,,6127,4534,,,4534,Other,150% of Medicare + 9.63% HCRA Surcharge,2757.15,45,,2757.15,percent of total billed charges,Critical Access Hospital RCC factor,1648,,,1648,Case Rate,ED per Visit,1483,,,1483,Case Rate,ED per Visit,1710,,,1710,Case Rate,ED per Visit,1539,,,1539,Case Rate,ED per Visit,1454,,,1454,Case Rate,ED per Visit,3032.87,,,3032.87,Other,110% of Medicare,4166.36,68,,4166.36,percent of total billed charges,All Other,0.01,,,0.01,Other,186% of Medicaid,4901.6,,,4901.6,Case Rate,ED per Visit,5085.41,,,5085.41,Case Rate,ED per Visit,5085.41,,,5085.41,Case Rate,ED per Visit,4901.6,,,4901.6,Case Rate,ED per Visit,5085.41,,,5085.41,Case Rate,ED per Visit,2018,,,2018,Case Rate,ED per Visit,4288.9,70,,4288.9,percent of total billed charges,All Other,1461,,,1461,Case Rate,ED per Visit,1242,,,1242,Case Rate,ED per Visit,1464,,,1464,Case Rate,ED per Visit,1316,,,1316,Case Rate,ED per Visit,1464,,,1464,Case Rate,ED per Visit,1244,,,1244,Case Rate,ED per Visit,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5085.41,
CRITICAL CARE EA ADDL 30,99292,CPT,,30099292,CDM,450,RC,,,both,,,1806,1336.44,,,1336.44,Other,150% of Medicare + 9.63% HCRA Surcharge,812.7,45,,812.7,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,893.97,,,893.97,Other,110% of Medicare,1228.08,68,,1228.08,percent of total billed charges,All Other,0.01,,,0.01,Other,186% of Medicaid,1444.8,,,1444.8,Other,Non Covered Service,1498.98,,,1498.98,Other,Non Covered Service,1498.98,,,1498.98,Other,Non Covered Service,1444.8,,,1444.8,Other,Non Covered Service,1498.98,,,1498.98,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1264.2,70,,1264.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1498.98,
PREVENTIVE COUNSELING INDIV; 15 MIN,99401,CPT,,30099401,CDM,450,RC,,,both,,,269,199.06,,,199.06,Other,150% of Medicare + 9.63% HCRA Surcharge,121.05,45,,121.05,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,133.16,,,133.16,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,188.3,70,,188.3,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,199.06,
INSERT FOLEY CATH SIMPLE,51702,CPT,59,30151702,CDM,450,RC,,,both,,,271,200.54,,,200.54,Other,150% of Medicare + 9.63% HCRA Surcharge,121.95,45,,121.95,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,134.15,,,134.15,Other,110% of Medicare,184.28,68,,184.28,percent of total billed charges,All Other,601,,,601,Other,186% of Medicaid,216.8,,,216.8,Other,Non Covered Service,224.93,,,224.93,Other,Non Covered Service,224.93,,,224.93,Other,Non Covered Service,216.8,,,216.8,Other,Non Covered Service,224.93,,,224.93,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,189.7,70,,189.7,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,322.86,,,322.86,Other,100% of Medicaid,322.86,,,322.86,Other,100% of Medicaid,322.86,,,322.86,Other,100% of Medicaid,322.86,,,322.86,Other,100% of Medicaid,726.44,,,726.44,Other,225% of Medicaid,493.98,,,493.98,Other,153% of Medicaid,726.44,,,726.44,Other,225% of Medicaid,452.01,,,452.01,Other,140% of Medicaid,726.44,,,726.44,Other,225% of Medicaid,839.44,,,839.44,Other,260% of Medicaid,1046.07,,,1046.07,Other,324% of Medicaid,694.15,,,694.15,Other,215% of Medicaid,694.15,,,694.15,Other,215% of Medicaid,403.58,,,403.58,Other,125% of Medicaid,0.01,1046.07,
HYDRATION IV INFUSION INIT,96360,CPT,59,30196360,CDM,450,RC,,,both,,,466,344.84,,,344.84,Other,150% of Medicare + 9.63% HCRA Surcharge,209.7,45,,209.7,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,230.67,,,230.67,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,411,,,411,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,326.2,70,,326.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,221.06,,,221.06,Other,100% of Medicaid,221.06,,,221.06,Other,100% of Medicaid,221.06,,,221.06,Other,100% of Medicaid,221.06,,,221.06,Other,100% of Medicaid,497.39,,,497.39,Other,225% of Medicaid,338.22,,,338.22,Other,153% of Medicaid,497.39,,,497.39,Other,225% of Medicaid,309.49,,,309.49,Other,140% of Medicaid,497.39,,,497.39,Other,225% of Medicaid,574.76,,,574.76,Other,260% of Medicaid,716.24,,,716.24,Other,324% of Medicaid,475.28,,,475.28,Other,215% of Medicaid,475.28,,,475.28,Other,215% of Medicaid,276.33,,,276.33,Other,125% of Medicaid,0.01,716.24,
IV HYDRATION EACH ADD ON,96361,CPT,59,30196361,CDM,450,RC,,,both,,,460,340.4,,,340.4,Other,150% of Medicare + 9.63% HCRA Surcharge,207,45,,207,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,227.7,,,227.7,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,1098,,,1098,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,322,70,,322,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,590.24,,,590.24,Other,100% of Medicaid,590.24,,,590.24,Other,100% of Medicaid,590.24,,,590.24,Other,100% of Medicaid,590.24,,,590.24,Other,100% of Medicaid,1328.05,,,1328.05,Other,225% of Medicaid,903.07,,,903.07,Other,153% of Medicaid,1328.05,,,1328.05,Other,225% of Medicaid,826.34,,,826.34,Other,140% of Medicaid,1328.05,,,1328.05,Other,225% of Medicaid,1534.64,,,1534.64,Other,260% of Medicaid,1912.39,,,1912.39,Other,324% of Medicaid,1269.03,,,1269.03,Other,215% of Medicaid,1269.03,,,1269.03,Other,215% of Medicaid,737.81,,,737.81,Other,125% of Medicaid,0.01,1912.39,
INFUSION THERAPY 1 HOUR,96365,CPT,59,30196365,CDM,450,RC,,,both,,,713,527.62,,,527.62,Other,150% of Medicare + 9.63% HCRA Surcharge,320.85,45,,320.85,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,352.94,,,352.94,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,411,,,411,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,499.1,70,,499.1,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,221.06,,,221.06,Other,100% of Medicaid,221.06,,,221.06,Other,100% of Medicaid,221.06,,,221.06,Other,100% of Medicaid,221.06,,,221.06,Other,100% of Medicaid,497.39,,,497.39,Other,225% of Medicaid,338.22,,,338.22,Other,153% of Medicaid,497.39,,,497.39,Other,225% of Medicaid,309.49,,,309.49,Other,140% of Medicaid,497.39,,,497.39,Other,225% of Medicaid,574.76,,,574.76,Other,260% of Medicaid,716.24,,,716.24,Other,324% of Medicaid,475.28,,,475.28,Other,215% of Medicaid,475.28,,,475.28,Other,215% of Medicaid,276.33,,,276.33,Other,125% of Medicaid,0.01,716.24,
INFUSION THERAPY ADDL HR,96366,CPT,59,30196366,CDM,450,RC,,,both,,,460,340.4,,,340.4,Other,150% of Medicare + 9.63% HCRA Surcharge,207,45,,207,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,227.7,,,227.7,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,1098,,,1098,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,322,70,,322,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,590.24,,,590.24,Other,100% of Medicaid,590.24,,,590.24,Other,100% of Medicaid,590.24,,,590.24,Other,100% of Medicaid,590.24,,,590.24,Other,100% of Medicaid,1328.05,,,1328.05,Other,225% of Medicaid,903.07,,,903.07,Other,153% of Medicaid,1328.05,,,1328.05,Other,225% of Medicaid,826.34,,,826.34,Other,140% of Medicaid,1328.05,,,1328.05,Other,225% of Medicaid,1534.64,,,1534.64,Other,260% of Medicaid,1912.39,,,1912.39,Other,324% of Medicaid,1269.03,,,1269.03,Other,215% of Medicaid,1269.03,,,1269.03,Other,215% of Medicaid,737.81,,,737.81,Other,125% of Medicaid,0.01,1912.39,
TX/PROPH/DR ADDL SEQ IV I,96367,CPT,59,30196367,CDM,450,RC,,,both,,,458,338.92,,,338.92,Other,150% of Medicare + 9.63% HCRA Surcharge,206.1,45,,206.1,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,226.71,,,226.71,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,411,,,411,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,320.6,70,,320.6,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,221.06,,,221.06,Other,100% of Medicaid,221.06,,,221.06,Other,100% of Medicaid,221.06,,,221.06,Other,100% of Medicaid,221.06,,,221.06,Other,100% of Medicaid,497.39,,,497.39,Other,225% of Medicaid,338.22,,,338.22,Other,153% of Medicaid,497.39,,,497.39,Other,225% of Medicaid,309.49,,,309.49,Other,140% of Medicaid,497.39,,,497.39,Other,225% of Medicaid,574.76,,,574.76,Other,260% of Medicaid,716.24,,,716.24,Other,324% of Medicaid,475.28,,,475.28,Other,215% of Medicaid,475.28,,,475.28,Other,215% of Medicaid,276.33,,,276.33,Other,125% of Medicaid,0.01,716.24,
THER DIAG CONCURRENT INF,96368,CPT,59,30196368,CDM,450,RC,,,both,,,460,340.4,,,340.4,Other,150% of Medicare + 9.63% HCRA Surcharge,207,45,,207,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,227.7,,,227.7,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,411,,,411,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,322,70,,322,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,221.06,,,221.06,Other,100% of Medicaid,221.06,,,221.06,Other,100% of Medicaid,221.06,,,221.06,Other,100% of Medicaid,221.06,,,221.06,Other,100% of Medicaid,497.39,,,497.39,Other,225% of Medicaid,338.22,,,338.22,Other,153% of Medicaid,497.39,,,497.39,Other,225% of Medicaid,309.49,,,309.49,Other,140% of Medicaid,497.39,,,497.39,Other,225% of Medicaid,574.76,,,574.76,Other,260% of Medicaid,716.24,,,716.24,Other,324% of Medicaid,475.28,,,475.28,Other,215% of Medicaid,475.28,,,475.28,Other,215% of Medicaid,276.33,,,276.33,Other,125% of Medicaid,0.01,716.24,
THER/PROPH/DIAG INJ SC/IM,96372,CPT,59,30196372,CDM,450,RC,,,both,,,460,340.4,,,340.4,Other,150% of Medicare + 9.63% HCRA Surcharge,207,45,,207,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,227.7,,,227.7,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,58,,,58,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,322,70,,322,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,31.2,,,31.2,Other,100% of Medicaid,31.2,,,31.2,Other,100% of Medicaid,31.2,,,31.2,Other,100% of Medicaid,31.2,,,31.2,Other,100% of Medicaid,70.2,,,70.2,Other,225% of Medicaid,47.74,,,47.74,Other,153% of Medicaid,70.2,,,70.2,Other,225% of Medicaid,43.68,,,43.68,Other,140% of Medicaid,70.2,,,70.2,Other,225% of Medicaid,81.12,,,81.12,Other,260% of Medicaid,101.09,,,101.09,Other,324% of Medicaid,67.08,,,67.08,Other,215% of Medicaid,67.08,,,67.08,Other,215% of Medicaid,39,,,39,Other,125% of Medicaid,0.01,340.4,
IV PUSH INITIAL,96374,CPT,59,30196374,CDM,450,RC,,,both,,,483,357.42,,,357.42,Other,150% of Medicare + 9.63% HCRA Surcharge,217.35,45,,217.35,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,239.09,,,239.09,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,58,,,58,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,338.1,70,,338.1,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,31.2,,,31.2,Other,100% of Medicaid,31.2,,,31.2,Other,100% of Medicaid,31.2,,,31.2,Other,100% of Medicaid,31.2,,,31.2,Other,100% of Medicaid,70.2,,,70.2,Other,225% of Medicaid,47.74,,,47.74,Other,153% of Medicaid,70.2,,,70.2,Other,225% of Medicaid,43.68,,,43.68,Other,140% of Medicaid,70.2,,,70.2,Other,225% of Medicaid,81.12,,,81.12,Other,260% of Medicaid,101.09,,,101.09,Other,324% of Medicaid,67.08,,,67.08,Other,215% of Medicaid,67.08,,,67.08,Other,215% of Medicaid,39,,,39,Other,125% of Medicaid,0.01,357.42,
TX/PRO/DX/ INJ NEW DRUG A,96375,CPT,59,30196375,CDM,450,RC,,,both,,,460,340.4,,,340.4,Other,150% of Medicare + 9.63% HCRA Surcharge,207,45,,207,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,227.7,,,227.7,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,58,,,58,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,322,70,,322,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,31.2,,,31.2,Other,100% of Medicaid,31.2,,,31.2,Other,100% of Medicaid,31.2,,,31.2,Other,100% of Medicaid,31.2,,,31.2,Other,100% of Medicaid,70.2,,,70.2,Other,225% of Medicaid,47.74,,,47.74,Other,153% of Medicaid,70.2,,,70.2,Other,225% of Medicaid,43.68,,,43.68,Other,140% of Medicaid,70.2,,,70.2,Other,225% of Medicaid,81.12,,,81.12,Other,260% of Medicaid,101.09,,,101.09,Other,324% of Medicaid,67.08,,,67.08,Other,215% of Medicaid,67.08,,,67.08,Other,215% of Medicaid,39,,,39,Other,125% of Medicaid,0.01,340.4,
TX/PRO/DX INJ SAME DRUG ADDON,96376,CPT,59,30196376,CDM,450,RC,,,both,,,460,340.4,,,340.4,Other,150% of Medicare + 9.63% HCRA Surcharge,207,45,,207,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,227.7,,,227.7,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,58,,,58,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,322,70,,322,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,31.2,,,31.2,Other,100% of Medicaid,31.2,,,31.2,Other,100% of Medicaid,31.2,,,31.2,Other,100% of Medicaid,31.2,,,31.2,Other,100% of Medicaid,70.2,,,70.2,Other,225% of Medicaid,47.74,,,47.74,Other,153% of Medicaid,70.2,,,70.2,Other,225% of Medicaid,43.68,,,43.68,Other,140% of Medicaid,70.2,,,70.2,Other,225% of Medicaid,81.12,,,81.12,Other,260% of Medicaid,101.09,,,101.09,Other,324% of Medicaid,67.08,,,67.08,Other,215% of Medicaid,67.08,,,67.08,Other,215% of Medicaid,39,,,39,Other,125% of Medicaid,0.01,340.4,
INSERT FOLEY CATH SIMPLE,51702,CPT,XU,30251702,CDM,450,RC,,,both,,,271,200.54,,,200.54,Other,150% of Medicare + 9.63% HCRA Surcharge,121.95,45,,121.95,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,134.15,,,134.15,Other,110% of Medicare,184.28,68,,184.28,percent of total billed charges,All Other,601,,,601,Other,186% of Medicaid,216.8,,,216.8,Other,Non Covered Service,224.93,,,224.93,Other,Non Covered Service,224.93,,,224.93,Other,Non Covered Service,216.8,,,216.8,Other,Non Covered Service,224.93,,,224.93,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,189.7,70,,189.7,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,322.86,,,322.86,Other,100% of Medicaid,322.86,,,322.86,Other,100% of Medicaid,322.86,,,322.86,Other,100% of Medicaid,322.86,,,322.86,Other,100% of Medicaid,726.44,,,726.44,Other,225% of Medicaid,493.98,,,493.98,Other,153% of Medicaid,726.44,,,726.44,Other,225% of Medicaid,452.01,,,452.01,Other,140% of Medicaid,726.44,,,726.44,Other,225% of Medicaid,839.44,,,839.44,Other,260% of Medicaid,1046.07,,,1046.07,Other,324% of Medicaid,694.15,,,694.15,Other,215% of Medicaid,694.15,,,694.15,Other,215% of Medicaid,403.58,,,403.58,Other,125% of Medicaid,0.01,1046.07,
HYDRATION IV INFUSION INIT,96360,CPT,XU,30296360,CDM,450,RC,,,both,,,466,344.84,,,344.84,Other,150% of Medicare + 9.63% HCRA Surcharge,209.7,45,,209.7,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,230.67,,,230.67,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,411,,,411,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,326.2,70,,326.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,221.06,,,221.06,Other,100% of Medicaid,221.06,,,221.06,Other,100% of Medicaid,221.06,,,221.06,Other,100% of Medicaid,221.06,,,221.06,Other,100% of Medicaid,497.39,,,497.39,Other,225% of Medicaid,338.22,,,338.22,Other,153% of Medicaid,497.39,,,497.39,Other,225% of Medicaid,309.49,,,309.49,Other,140% of Medicaid,497.39,,,497.39,Other,225% of Medicaid,574.76,,,574.76,Other,260% of Medicaid,716.24,,,716.24,Other,324% of Medicaid,475.28,,,475.28,Other,215% of Medicaid,475.28,,,475.28,Other,215% of Medicaid,276.33,,,276.33,Other,125% of Medicaid,0.01,716.24,
IV HYDRATION EACH ADD ON,96361,CPT,XU,30296361,CDM,450,RC,,,both,,,460,340.4,,,340.4,Other,150% of Medicare + 9.63% HCRA Surcharge,207,45,,207,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,227.7,,,227.7,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,1098,,,1098,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,322,70,,322,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,590.24,,,590.24,Other,100% of Medicaid,590.24,,,590.24,Other,100% of Medicaid,590.24,,,590.24,Other,100% of Medicaid,590.24,,,590.24,Other,100% of Medicaid,1328.05,,,1328.05,Other,225% of Medicaid,903.07,,,903.07,Other,153% of Medicaid,1328.05,,,1328.05,Other,225% of Medicaid,826.34,,,826.34,Other,140% of Medicaid,1328.05,,,1328.05,Other,225% of Medicaid,1534.64,,,1534.64,Other,260% of Medicaid,1912.39,,,1912.39,Other,324% of Medicaid,1269.03,,,1269.03,Other,215% of Medicaid,1269.03,,,1269.03,Other,215% of Medicaid,737.81,,,737.81,Other,125% of Medicaid,0.01,1912.39,
INFUSION THERAPY 1 HOUR,96365,CPT,XU,30296365,CDM,450,RC,,,both,,,713,527.62,,,527.62,Other,150% of Medicare + 9.63% HCRA Surcharge,320.85,45,,320.85,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,352.94,,,352.94,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,411,,,411,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,499.1,70,,499.1,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,221.06,,,221.06,Other,100% of Medicaid,221.06,,,221.06,Other,100% of Medicaid,221.06,,,221.06,Other,100% of Medicaid,221.06,,,221.06,Other,100% of Medicaid,497.39,,,497.39,Other,225% of Medicaid,338.22,,,338.22,Other,153% of Medicaid,497.39,,,497.39,Other,225% of Medicaid,309.49,,,309.49,Other,140% of Medicaid,497.39,,,497.39,Other,225% of Medicaid,574.76,,,574.76,Other,260% of Medicaid,716.24,,,716.24,Other,324% of Medicaid,475.28,,,475.28,Other,215% of Medicaid,475.28,,,475.28,Other,215% of Medicaid,276.33,,,276.33,Other,125% of Medicaid,0.01,716.24,
INFUSION THERAPY ADDL HR,96366,CPT,XU,30296366,CDM,450,RC,,,both,,,460,340.4,,,340.4,Other,150% of Medicare + 9.63% HCRA Surcharge,207,45,,207,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,227.7,,,227.7,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,1098,,,1098,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,322,70,,322,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,590.24,,,590.24,Other,100% of Medicaid,590.24,,,590.24,Other,100% of Medicaid,590.24,,,590.24,Other,100% of Medicaid,590.24,,,590.24,Other,100% of Medicaid,1328.05,,,1328.05,Other,225% of Medicaid,903.07,,,903.07,Other,153% of Medicaid,1328.05,,,1328.05,Other,225% of Medicaid,826.34,,,826.34,Other,140% of Medicaid,1328.05,,,1328.05,Other,225% of Medicaid,1534.64,,,1534.64,Other,260% of Medicaid,1912.39,,,1912.39,Other,324% of Medicaid,1269.03,,,1269.03,Other,215% of Medicaid,1269.03,,,1269.03,Other,215% of Medicaid,737.81,,,737.81,Other,125% of Medicaid,0.01,1912.39,
TX/PROPH/DR ADDL SEQ IV I,96367,CPT,XU,30296367,CDM,450,RC,,,both,,,458,338.92,,,338.92,Other,150% of Medicare + 9.63% HCRA Surcharge,206.1,45,,206.1,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,226.71,,,226.71,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,411,,,411,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,320.6,70,,320.6,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,221.06,,,221.06,Other,100% of Medicaid,221.06,,,221.06,Other,100% of Medicaid,221.06,,,221.06,Other,100% of Medicaid,221.06,,,221.06,Other,100% of Medicaid,497.39,,,497.39,Other,225% of Medicaid,338.22,,,338.22,Other,153% of Medicaid,497.39,,,497.39,Other,225% of Medicaid,309.49,,,309.49,Other,140% of Medicaid,497.39,,,497.39,Other,225% of Medicaid,574.76,,,574.76,Other,260% of Medicaid,716.24,,,716.24,Other,324% of Medicaid,475.28,,,475.28,Other,215% of Medicaid,475.28,,,475.28,Other,215% of Medicaid,276.33,,,276.33,Other,125% of Medicaid,0.01,716.24,
THER DIAG CONCURRENT INF,96368,CPT,XU,30296368,CDM,450,RC,,,both,,,460,340.4,,,340.4,Other,150% of Medicare + 9.63% HCRA Surcharge,207,45,,207,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,227.7,,,227.7,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,411,,,411,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,322,70,,322,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,221.06,,,221.06,Other,100% of Medicaid,221.06,,,221.06,Other,100% of Medicaid,221.06,,,221.06,Other,100% of Medicaid,221.06,,,221.06,Other,100% of Medicaid,497.39,,,497.39,Other,225% of Medicaid,338.22,,,338.22,Other,153% of Medicaid,497.39,,,497.39,Other,225% of Medicaid,309.49,,,309.49,Other,140% of Medicaid,497.39,,,497.39,Other,225% of Medicaid,574.76,,,574.76,Other,260% of Medicaid,716.24,,,716.24,Other,324% of Medicaid,475.28,,,475.28,Other,215% of Medicaid,475.28,,,475.28,Other,215% of Medicaid,276.33,,,276.33,Other,125% of Medicaid,0.01,716.24,
THER/PROPH/DIAG INJ SC/IM,96372,CPT,XU,30296372,CDM,450,RC,,,both,,,460,340.4,,,340.4,Other,150% of Medicare + 9.63% HCRA Surcharge,207,45,,207,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,227.7,,,227.7,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,58,,,58,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,322,70,,322,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,31.2,,,31.2,Other,100% of Medicaid,31.2,,,31.2,Other,100% of Medicaid,31.2,,,31.2,Other,100% of Medicaid,31.2,,,31.2,Other,100% of Medicaid,70.2,,,70.2,Other,225% of Medicaid,47.74,,,47.74,Other,153% of Medicaid,70.2,,,70.2,Other,225% of Medicaid,43.68,,,43.68,Other,140% of Medicaid,70.2,,,70.2,Other,225% of Medicaid,81.12,,,81.12,Other,260% of Medicaid,101.09,,,101.09,Other,324% of Medicaid,67.08,,,67.08,Other,215% of Medicaid,67.08,,,67.08,Other,215% of Medicaid,39,,,39,Other,125% of Medicaid,0.01,340.4,
IV PUSH INITIAL,96374,CPT,XU,30296374,CDM,450,RC,,,both,,,483,357.42,,,357.42,Other,150% of Medicare + 9.63% HCRA Surcharge,217.35,45,,217.35,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,239.09,,,239.09,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,58,,,58,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,338.1,70,,338.1,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,31.2,,,31.2,Other,100% of Medicaid,31.2,,,31.2,Other,100% of Medicaid,31.2,,,31.2,Other,100% of Medicaid,31.2,,,31.2,Other,100% of Medicaid,70.2,,,70.2,Other,225% of Medicaid,47.74,,,47.74,Other,153% of Medicaid,70.2,,,70.2,Other,225% of Medicaid,43.68,,,43.68,Other,140% of Medicaid,70.2,,,70.2,Other,225% of Medicaid,81.12,,,81.12,Other,260% of Medicaid,101.09,,,101.09,Other,324% of Medicaid,67.08,,,67.08,Other,215% of Medicaid,67.08,,,67.08,Other,215% of Medicaid,39,,,39,Other,125% of Medicaid,0.01,357.42,
TX/PRO/DX/ INJ NEW DRUG A,96375,CPT,XU,30296375,CDM,450,RC,,,both,,,460,340.4,,,340.4,Other,150% of Medicare + 9.63% HCRA Surcharge,207,45,,207,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,227.7,,,227.7,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,58,,,58,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,322,70,,322,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,31.2,,,31.2,Other,100% of Medicaid,31.2,,,31.2,Other,100% of Medicaid,31.2,,,31.2,Other,100% of Medicaid,31.2,,,31.2,Other,100% of Medicaid,70.2,,,70.2,Other,225% of Medicaid,47.74,,,47.74,Other,153% of Medicaid,70.2,,,70.2,Other,225% of Medicaid,43.68,,,43.68,Other,140% of Medicaid,70.2,,,70.2,Other,225% of Medicaid,81.12,,,81.12,Other,260% of Medicaid,101.09,,,101.09,Other,324% of Medicaid,67.08,,,67.08,Other,215% of Medicaid,67.08,,,67.08,Other,215% of Medicaid,39,,,39,Other,125% of Medicaid,0.01,340.4,
TX/PRO/DX INJ SAME DRUG ADDON,96376,CPT,XU,30296376,CDM,450,RC,,,both,,,460,340.4,,,340.4,Other,150% of Medicare + 9.63% HCRA Surcharge,207,45,,207,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,227.7,,,227.7,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,58,,,58,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,322,70,,322,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,31.2,,,31.2,Other,100% of Medicaid,31.2,,,31.2,Other,100% of Medicaid,31.2,,,31.2,Other,100% of Medicaid,31.2,,,31.2,Other,100% of Medicaid,70.2,,,70.2,Other,225% of Medicaid,47.74,,,47.74,Other,153% of Medicaid,70.2,,,70.2,Other,225% of Medicaid,43.68,,,43.68,Other,140% of Medicaid,70.2,,,70.2,Other,225% of Medicaid,81.12,,,81.12,Other,260% of Medicaid,101.09,,,101.09,Other,324% of Medicaid,67.08,,,67.08,Other,215% of Medicaid,67.08,,,67.08,Other,215% of Medicaid,39,,,39,Other,125% of Medicaid,0.01,340.4,
HYDRATION IV INFUSION INIT,96360,CPT,XS,30396360,CDM,450,RC,,,both,,,466,344.84,,,344.84,Other,150% of Medicare + 9.63% HCRA Surcharge,209.7,45,,209.7,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,230.67,,,230.67,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,411,,,411,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,326.2,70,,326.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,221.06,,,221.06,Other,100% of Medicaid,221.06,,,221.06,Other,100% of Medicaid,221.06,,,221.06,Other,100% of Medicaid,221.06,,,221.06,Other,100% of Medicaid,497.39,,,497.39,Other,225% of Medicaid,338.22,,,338.22,Other,153% of Medicaid,497.39,,,497.39,Other,225% of Medicaid,309.49,,,309.49,Other,140% of Medicaid,497.39,,,497.39,Other,225% of Medicaid,574.76,,,574.76,Other,260% of Medicaid,716.24,,,716.24,Other,324% of Medicaid,475.28,,,475.28,Other,215% of Medicaid,475.28,,,475.28,Other,215% of Medicaid,276.33,,,276.33,Other,125% of Medicaid,0.01,716.24,
INFUSION THERAPY 1 HOUR,96365,CPT,XS,30396365,CDM,450,RC,,,both,,,713,527.62,,,527.62,Other,150% of Medicare + 9.63% HCRA Surcharge,320.85,45,,320.85,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,352.94,,,352.94,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,411,,,411,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,499.1,70,,499.1,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,221.06,,,221.06,Other,100% of Medicaid,221.06,,,221.06,Other,100% of Medicaid,221.06,,,221.06,Other,100% of Medicaid,221.06,,,221.06,Other,100% of Medicaid,497.39,,,497.39,Other,225% of Medicaid,338.22,,,338.22,Other,153% of Medicaid,497.39,,,497.39,Other,225% of Medicaid,309.49,,,309.49,Other,140% of Medicaid,497.39,,,497.39,Other,225% of Medicaid,574.76,,,574.76,Other,260% of Medicaid,716.24,,,716.24,Other,324% of Medicaid,475.28,,,475.28,Other,215% of Medicaid,475.28,,,475.28,Other,215% of Medicaid,276.33,,,276.33,Other,125% of Medicaid,0.01,716.24,
IV PUSH INITIAL,96374,CPT,XS,30396374,CDM,450,RC,,,both,,,483,357.42,,,357.42,Other,150% of Medicare + 9.63% HCRA Surcharge,217.35,45,,217.35,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,239.09,,,239.09,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,58,,,58,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,338.1,70,,338.1,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,31.2,,,31.2,Other,100% of Medicaid,31.2,,,31.2,Other,100% of Medicaid,31.2,,,31.2,Other,100% of Medicaid,31.2,,,31.2,Other,100% of Medicaid,70.2,,,70.2,Other,225% of Medicaid,47.74,,,47.74,Other,153% of Medicaid,70.2,,,70.2,Other,225% of Medicaid,43.68,,,43.68,Other,140% of Medicaid,70.2,,,70.2,Other,225% of Medicaid,81.12,,,81.12,Other,260% of Medicaid,101.09,,,101.09,Other,324% of Medicaid,67.08,,,67.08,Other,215% of Medicaid,67.08,,,67.08,Other,215% of Medicaid,39,,,39,Other,125% of Medicaid,0.01,357.42,
CRITICAL CARE FIRST HOUR W/MOD,99291,CPT,25,30499291,CDM,450,RC,,,both,,,6127,4534,,,4534,Other,150% of Medicare + 9.63% HCRA Surcharge,2757.15,45,,2757.15,percent of total billed charges,Critical Access Hospital RCC factor,1648,,,1648,Case Rate,ED per Visit,1483,,,1483,Case Rate,ED per Visit,1710,,,1710,Case Rate,ED per Visit,1539,,,1539,Case Rate,ED per Visit,1454,,,1454,Case Rate,ED per Visit,3032.87,,,3032.87,Other,110% of Medicare,4166.36,68,,4166.36,percent of total billed charges,All Other,0.01,,,0.01,Other,186% of Medicaid,4901.6,,,4901.6,Case Rate,ED per Visit,5085.41,,,5085.41,Case Rate,ED per Visit,5085.41,,,5085.41,Case Rate,ED per Visit,4901.6,,,4901.6,Case Rate,ED per Visit,5085.41,,,5085.41,Case Rate,ED per Visit,2018,,,2018,Case Rate,ED per Visit,4288.9,70,,4288.9,percent of total billed charges,All Other,1461,,,1461,Case Rate,ED per Visit,1242,,,1242,Case Rate,ED per Visit,1464,,,1464,Case Rate,ED per Visit,1316,,,1316,Case Rate,ED per Visit,1464,,,1464,Case Rate,ED per Visit,1244,,,1244,Case Rate,ED per Visit,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5085.41,
SKIN TEST; TB ID,86580,CPT,,82086580,CDM,450,RC,,,both,,,58,42.92,,,42.92,Other,150% of Medicare + 9.63% HCRA Surcharge,26.1,45,,26.1,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,28.71,,,28.71,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,18,,,18,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,40.6,70,,40.6,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,9.88,,,9.88,Other,100% of Medicaid,9.88,,,9.88,Other,100% of Medicaid,9.88,,,9.88,Other,100% of Medicaid,9.88,,,9.88,Other,100% of Medicaid,22.23,,,22.23,Other,225% of Medicaid,15.11,,,15.11,Other,153% of Medicaid,22.23,,,22.23,Other,225% of Medicaid,13.83,,,13.83,Other,140% of Medicaid,22.23,,,22.23,Other,225% of Medicaid,25.68,,,25.68,Other,260% of Medicaid,32.01,,,32.01,Other,324% of Medicaid,21.24,,,21.24,Other,215% of Medicaid,21.24,,,21.24,Other,215% of Medicaid,12.35,,,12.35,Other,125% of Medicaid,0.01,42.92,
HEART LUNG RESUSCITATION CPR,92950,CPT,,82092950,CDM,450,RC,,,both,,,903,668.22,,,668.22,Other,150% of Medicare + 9.63% HCRA Surcharge,406.35,45,,406.35,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,446.99,,,446.99,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,880,,,880,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,632.1,70,,632.1,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,472.91,,,472.91,Other,100% of Medicaid,472.91,,,472.91,Other,100% of Medicaid,472.91,,,472.91,Other,100% of Medicaid,472.91,,,472.91,Other,100% of Medicaid,1064.05,,,1064.05,Other,225% of Medicaid,723.55,,,723.55,Other,153% of Medicaid,1064.05,,,1064.05,Other,225% of Medicaid,662.07,,,662.07,Other,140% of Medicaid,1064.05,,,1064.05,Other,225% of Medicaid,1229.57,,,1229.57,Other,260% of Medicaid,1532.23,,,1532.23,Other,324% of Medicaid,1016.76,,,1016.76,Other,215% of Medicaid,1016.76,,,1016.76,Other,215% of Medicaid,591.14,,,591.14,Other,125% of Medicaid,0.01,1532.23,
GALEAZZI FX/DISLOC,25520,CPT,,300025520,CDM,450,RC,,,both,,,5210,3855.41,,,3855.41,Other,150% of Medicare + 9.63% HCRA Surcharge,2344.5,45,,2344.5,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2578.95,,,2578.95,Other,110% of Medicare,3542.8,68,,3542.8,percent of total billed charges,All Other,1031,,,1031,Other,186% of Medicaid,4168,,,4168,Other,Non Covered Service,4324.3,,,4324.3,Other,Non Covered Service,4324.3,,,4324.3,Other,Non Covered Service,4168,,,4168,Other,Non Covered Service,4324.3,,,4324.3,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,3647,70,,3647,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,554.53,,,554.53,Other,100% of Medicaid,554.53,,,554.53,Other,100% of Medicaid,554.53,,,554.53,Other,100% of Medicaid,554.53,,,554.53,Other,100% of Medicaid,1247.69,,,1247.69,Other,225% of Medicaid,848.43,,,848.43,Other,153% of Medicaid,1247.69,,,1247.69,Other,225% of Medicaid,776.34,,,776.34,Other,140% of Medicaid,1247.69,,,1247.69,Other,225% of Medicaid,1441.78,,,1441.78,Other,260% of Medicaid,1796.68,,,1796.68,Other,324% of Medicaid,1192.24,,,1192.24,Other,215% of Medicaid,1192.24,,,1192.24,Other,215% of Medicaid,693.16,,,693.16,Other,125% of Medicaid,0.01,4324.3,
VITAL CAPACITY TEST,94150,CPT,,30094150,CDM,460,RC,,,both,,,329,243.46,,,243.46,Other,150% of Medicare + 9.63% HCRA Surcharge,148.05,45,,148.05,percent of total billed charges,Critical Access Hospital RCC factor,213.85,65,,213.85,percent of total billed charges,All Other,194.11,65,,194.11,percent of total billed charges,All Other,21.09,,,21.09,Fee Schedule,,21.09,,,21.09,Fee Schedule,,21.09,,,21.09,Fee Schedule,,162.86,,,162.86,Other,110% of Medicare,223.72,68,,223.72,percent of total billed charges,All Other,113,,,113,Other,186% of Medicaid,263.2,,,263.2,percent of total billed charges,All Other,203.98,62,,203.98,percent of total billed charges,Lab and Radiology,180.95,83,,180.95,percent of total billed charges,All Other,263.2,80,,263.2,percent of total billed charges,All Other,203.98,62,,203.98,percent of total billed charges,Lab and Radiology,263.2,80,,263.2,percent of total billed charges,All Other,230.3,70,,230.3,percent of total billed charges,All Other,101.68,,,101.68,Fee Schedule,,86.18,,,86.18,Fee Schedule,,667,,,667,Case Rate,,600,,,600,Case Rate,,667,,,667,Case Rate,,567,,,567,Case Rate,,61,,,61,Other,100% of Medicaid,61,,,61,Other,100% of Medicaid,61,,,61,Other,100% of Medicaid,61,,,61,Other,100% of Medicaid,137.24,,,137.24,Other,225% of Medicaid,93.32,,,93.32,Other,153% of Medicaid,137.24,,,137.24,Other,225% of Medicaid,85.39,,,85.39,Other,140% of Medicaid,137.24,,,137.24,Other,225% of Medicaid,158.59,,,158.59,Other,260% of Medicaid,197.63,,,197.63,Other,324% of Medicaid,131.14,,,131.14,Other,215% of Medicaid,131.14,,,131.14,Other,215% of Medicaid,76.24,,,76.24,Other,125% of Medicaid,21.09,667,
PULSE OX FOR O2 SAT,94760,CPT,,30094760,CDM,460,RC,,,both,,,209,154.66,,,154.66,Other,150% of Medicare + 9.63% HCRA Surcharge,94.05,45,,94.05,percent of total billed charges,Critical Access Hospital RCC factor,135.85,65,,135.85,percent of total billed charges,All Other,123.31,65,,123.31,percent of total billed charges,All Other,18.39,,,18.39,Fee Schedule,,16.54,,,16.54,Fee Schedule,,15.64,,,15.64,Fee Schedule,,103.46,,,103.46,Other,110% of Medicare,11.18,,,11.18,Fee Schedule,,0.01,,,0.01,Other,186% of Medicaid,13.16,,,13.16,Fee Schedule,,129.58,,,129.58,Fee Schedule,,6.2,,,6.2,Fee Schedule,,13.16,,,13.16,Fee Schedule,,129.58,,,129.58,Fee Schedule,,167.2,80,,167.2,percent of total billed charges,All Other,146.3,70,,146.3,percent of total billed charges,All Other,11.48,,,11.48,Fee Schedule,,9.73,,,9.73,Fee Schedule,,667,,,667,Case Rate,,600,,,600,Case Rate,,667,,,667,Case Rate,,567,,,567,Case Rate,,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,667,
PULSE OX FOR O2 SAT MULT,94761,CPT,,30094761,CDM,460,RC,,,both,,,528,390.72,,,390.72,Other,150% of Medicare + 9.63% HCRA Surcharge,237.6,45,,237.6,percent of total billed charges,Critical Access Hospital RCC factor,343.2,65,,343.2,percent of total billed charges,All Other,311.52,65,,311.52,percent of total billed charges,All Other,29.83,,,29.83,Fee Schedule,,26.83,,,26.83,Fee Schedule,,25.36,,,25.36,Fee Schedule,,261.36,,,261.36,Other,110% of Medicare,16.68,,,16.68,Fee Schedule,,0.01,,,0.01,Other,186% of Medicaid,19.62,,,19.62,Fee Schedule,,327.36,,,327.36,Fee Schedule,,9.24,,,9.24,Fee Schedule,,19.62,,,19.62,Fee Schedule,,327.36,,,327.36,Fee Schedule,,422.4,80,,422.4,percent of total billed charges,All Other,369.6,70,,369.6,percent of total billed charges,All Other,16.4,,,16.4,Fee Schedule,,13.9,,,13.9,Fee Schedule,,667,,,667,Case Rate,,600,,,600,Case Rate,,667,,,667,Case Rate,,567,,,567,Case Rate,,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,667,
CONTINUOUS PULSE OX,94762,CPT,,30094762,CDM,460,RC,,,both,,,337,249.38,,,249.38,Other,150% of Medicare + 9.63% HCRA Surcharge,151.65,45,,151.65,percent of total billed charges,Critical Access Hospital RCC factor,81.36,,,81.36,Fee Schedule,,73.36,,,73.36,Fee Schedule,,133.58,,,133.58,Fee Schedule,,120.25,,,120.25,Fee Schedule,,113.59,,,113.59,Fee Schedule,,166.82,,,166.82,Other,110% of Medicare,229.16,68,,229.16,percent of total billed charges,All Other,113,,,113,Other,186% of Medicaid,269.6,,,269.6,percent of total billed charges,All Other,279.71,83,,279.71,percent of total billed charges,All Other,279.71,83,,279.71,percent of total billed charges,All Other,269.6,80,,269.6,percent of total billed charges,All Other,279.71,83,,279.71,percent of total billed charges,All Other,108.94,,,108.94,Fee Schedule,,235.9,70,,235.9,percent of total billed charges,All Other,127.92,,,127.92,Fee Schedule,,108.42,,,108.42,Fee Schedule,,667,,,667,Case Rate,,600,,,600,Case Rate,,667,,,667,Case Rate,,567,,,567,Case Rate,,61,,,61,Other,100% of Medicaid,61,,,61,Other,100% of Medicaid,61,,,61,Other,100% of Medicaid,61,,,61,Other,100% of Medicaid,137.24,,,137.24,Other,225% of Medicaid,93.32,,,93.32,Other,153% of Medicaid,137.24,,,137.24,Other,225% of Medicaid,85.39,,,85.39,Other,140% of Medicaid,137.24,,,137.24,Other,225% of Medicaid,158.59,,,158.59,Other,260% of Medicaid,197.63,,,197.63,Other,324% of Medicaid,131.14,,,131.14,Other,215% of Medicaid,131.14,,,131.14,Other,215% of Medicaid,76.24,,,76.24,Other,125% of Medicaid,61,667,
BREATHING CAPACITY TEST,94010,CPT,,71094010,CDM,460,RC,,,both,,,671,496.54,,,496.54,Other,150% of Medicare + 9.63% HCRA Surcharge,301.95,45,,301.95,percent of total billed charges,Critical Access Hospital RCC factor,436.15,65,,436.15,percent of total billed charges,All Other,395.89,65,,395.89,percent of total billed charges,All Other,180.87,,,180.87,Fee Schedule,,162.68,,,162.68,Fee Schedule,,153.75,,,153.75,Fee Schedule,,332.15,,,332.15,Other,110% of Medicare,79.82,,,79.82,Fee Schedule,,113,,,113,Other,186% of Medicaid,93.93,,,93.93,Fee Schedule,,416.02,,,416.02,Fee Schedule,,44.23,,,44.23,Fee Schedule,,93.93,,,93.93,Fee Schedule,,416.02,,,416.02,Fee Schedule,,536.8,80,,536.8,percent of total billed charges,All Other,469.7,70,,469.7,percent of total billed charges,All Other,90.2,,,90.2,Fee Schedule,,76.45,,,76.45,Fee Schedule,,667,,,667,Case Rate,,600,,,600,Case Rate,,667,,,667,Case Rate,,567,,,567,Case Rate,,61,,,61,Other,100% of Medicaid,61,,,61,Other,100% of Medicaid,61,,,61,Other,100% of Medicaid,61,,,61,Other,100% of Medicaid,137.24,,,137.24,Other,225% of Medicaid,93.32,,,93.32,Other,153% of Medicaid,137.24,,,137.24,Other,225% of Medicaid,85.39,,,85.39,Other,140% of Medicaid,137.24,,,137.24,Other,225% of Medicaid,158.59,,,158.59,Other,260% of Medicaid,197.63,,,197.63,Other,324% of Medicaid,131.14,,,131.14,Other,215% of Medicaid,131.14,,,131.14,Other,215% of Medicaid,76.24,,,76.24,Other,125% of Medicaid,44.23,667,
EVALUATION OF WHEEZING,94060,CPT,,71094060,CDM,460,RC,,,both,,,1017,752.58,,,752.58,Other,150% of Medicare + 9.63% HCRA Surcharge,457.65,45,,457.65,percent of total billed charges,Critical Access Hospital RCC factor,661.05,65,,661.05,percent of total billed charges,All Other,600.03,65,,600.03,percent of total billed charges,All Other,311.3,,,311.3,Fee Schedule,,279.99,,,279.99,Fee Schedule,,264.63,,,264.63,Fee Schedule,,503.42,,,503.42,Other,110% of Medicare,119.61,,,119.61,Fee Schedule,,419,,,419,Other,186% of Medicaid,140.76,,,140.76,Fee Schedule,,630.54,,,630.54,Fee Schedule,,66.28,,,66.28,Fee Schedule,,140.76,,,140.76,Fee Schedule,,630.54,,,630.54,Fee Schedule,,813.6,80,,813.6,percent of total billed charges,All Other,711.9,70,,711.9,percent of total billed charges,All Other,139.4,,,139.4,Fee Schedule,,118.15,,,118.15,Fee Schedule,,667,,,667,Case Rate,,600,,,600,Case Rate,,667,,,667,Case Rate,,567,,,567,Case Rate,,225.42,,,225.42,Other,100% of Medicaid,225.42,,,225.42,Other,100% of Medicaid,225.42,,,225.42,Other,100% of Medicaid,225.42,,,225.42,Other,100% of Medicaid,507.19,,,507.19,Other,225% of Medicaid,344.89,,,344.89,Other,153% of Medicaid,507.19,,,507.19,Other,225% of Medicaid,315.58,,,315.58,Other,140% of Medicaid,507.19,,,507.19,Other,225% of Medicaid,586.08,,,586.08,Other,260% of Medicaid,730.35,,,730.35,Other,324% of Medicaid,484.64,,,484.64,Other,215% of Medicaid,484.64,,,484.64,Other,215% of Medicaid,281.77,,,281.77,Other,125% of Medicaid,66.28,813.6,
VITAL CAPACITY TEST,94150,CPT,,71094150,CDM,460,RC,,,both,,,329,243.46,,,243.46,Other,150% of Medicare + 9.63% HCRA Surcharge,148.05,45,,148.05,percent of total billed charges,Critical Access Hospital RCC factor,213.85,65,,213.85,percent of total billed charges,All Other,194.11,65,,194.11,percent of total billed charges,All Other,21.09,,,21.09,Fee Schedule,,21.09,,,21.09,Fee Schedule,,21.09,,,21.09,Fee Schedule,,162.86,,,162.86,Other,110% of Medicare,223.72,68,,223.72,percent of total billed charges,All Other,113,,,113,Other,186% of Medicaid,263.2,,,263.2,percent of total billed charges,All Other,203.98,62,,203.98,percent of total billed charges,Lab and Radiology,180.95,83,,180.95,percent of total billed charges,All Other,263.2,80,,263.2,percent of total billed charges,All Other,203.98,62,,203.98,percent of total billed charges,Lab and Radiology,263.2,80,,263.2,percent of total billed charges,All Other,230.3,70,,230.3,percent of total billed charges,All Other,101.68,,,101.68,Fee Schedule,,86.18,,,86.18,Fee Schedule,,667,,,667,Case Rate,,600,,,600,Case Rate,,667,,,667,Case Rate,,567,,,567,Case Rate,,61,,,61,Other,100% of Medicaid,61,,,61,Other,100% of Medicaid,61,,,61,Other,100% of Medicaid,61,,,61,Other,100% of Medicaid,137.24,,,137.24,Other,225% of Medicaid,93.32,,,93.32,Other,153% of Medicaid,137.24,,,137.24,Other,225% of Medicaid,85.39,,,85.39,Other,140% of Medicaid,137.24,,,137.24,Other,225% of Medicaid,158.59,,,158.59,Other,260% of Medicaid,197.63,,,197.63,Other,324% of Medicaid,131.14,,,131.14,Other,215% of Medicaid,131.14,,,131.14,Other,215% of Medicaid,76.24,,,76.24,Other,125% of Medicaid,21.09,667,
RESP FLOW VOLUME LOOP,94375,CPT,,71094375,CDM,460,RC,,,both,,,639,472.86,,,472.86,Other,150% of Medicare + 9.63% HCRA Surcharge,287.55,45,,287.55,percent of total billed charges,Critical Access Hospital RCC factor,415.35,65,,415.35,percent of total billed charges,All Other,377.01,65,,377.01,percent of total billed charges,All Other,160.26,,,160.26,Fee Schedule,,144.14,,,144.14,Fee Schedule,,136.24,,,136.24,Fee Schedule,,316.31,,,316.31,Other,110% of Medicare,103.13,,,103.13,Fee Schedule,,419,,,419,Other,186% of Medicaid,121.36,,,121.36,Fee Schedule,,396.18,,,396.18,Fee Schedule,,57.14,,,57.14,Fee Schedule,,121.36,,,121.36,Fee Schedule,,396.18,,,396.18,Fee Schedule,,511.2,80,,511.2,percent of total billed charges,All Other,447.3,70,,447.3,percent of total billed charges,All Other,116.44,,,116.44,Fee Schedule,,98.69,,,98.69,Fee Schedule,,667,,,667,Case Rate,,600,,,600,Case Rate,,667,,,667,Case Rate,,567,,,567,Case Rate,,225.42,,,225.42,Other,100% of Medicaid,225.42,,,225.42,Other,100% of Medicaid,225.42,,,225.42,Other,100% of Medicaid,225.42,,,225.42,Other,100% of Medicaid,507.19,,,507.19,Other,225% of Medicaid,344.89,,,344.89,Other,153% of Medicaid,507.19,,,507.19,Other,225% of Medicaid,315.58,,,315.58,Other,140% of Medicaid,507.19,,,507.19,Other,225% of Medicaid,586.08,,,586.08,Other,260% of Medicaid,730.35,,,730.35,Other,324% of Medicaid,484.64,,,484.64,Other,215% of Medicaid,484.64,,,484.64,Other,215% of Medicaid,281.77,,,281.77,Other,125% of Medicaid,57.14,730.35,
EXERCISE TEST FOR BRONCHOSPASM,94617,CPT,,71094617,CDM,460,RC,,,both,,,723,535.02,,,535.02,Other,150% of Medicare + 9.63% HCRA Surcharge,325.35,45,,325.35,percent of total billed charges,Critical Access Hospital RCC factor,186.35,,,186.35,Fee Schedule,,168.03,,,168.03,Fee Schedule,,59.52,,,59.52,Fee Schedule,,59.52,,,59.52,Fee Schedule,,59.52,,,59.52,Fee Schedule,,357.89,,,357.89,Other,110% of Medicare,491.64,68,,491.64,percent of total billed charges,All Other,113,,,113,Other,186% of Medicaid,578.4,,,578.4,percent of total billed charges,All Other,600.09,83,,600.09,percent of total billed charges,All Other,600.09,83,,600.09,percent of total billed charges,All Other,578.4,80,,578.4,percent of total billed charges,All Other,600.09,83,,600.09,percent of total billed charges,All Other,249.52,,,249.52,Fee Schedule,,506.1,70,,506.1,percent of total billed charges,All Other,272.24,,,272.24,Fee Schedule,,230.74,,,230.74,Fee Schedule,,667,,,667,Case Rate,,600,,,600,Case Rate,,667,,,667,Case Rate,,567,,,567,Case Rate,,61,,,61,Other,100% of Medicaid,61,,,61,Other,100% of Medicaid,61,,,61,Other,100% of Medicaid,61,,,61,Other,100% of Medicaid,137.24,,,137.24,Other,225% of Medicaid,93.32,,,93.32,Other,153% of Medicaid,137.24,,,137.24,Other,225% of Medicaid,85.39,,,85.39,Other,140% of Medicaid,137.24,,,137.24,Other,225% of Medicaid,158.59,,,158.59,Other,260% of Medicaid,197.63,,,197.63,Other,324% of Medicaid,131.14,,,131.14,Other,215% of Medicaid,131.14,,,131.14,Other,215% of Medicaid,76.24,,,76.24,Other,125% of Medicaid,59.52,667,
PULMONARY STRESS TESTING,94618,CPT,,71094618,CDM,460,RC,,,both,,,298,220.52,,,220.52,Other,150% of Medicare + 9.63% HCRA Surcharge,134.1,45,,134.1,percent of total billed charges,Critical Access Hospital RCC factor,193.7,65,,193.7,percent of total billed charges,All Other,175.82,65,,175.82,percent of total billed charges,All Other,10.88,,,10.88,Fee Schedule,,10.88,,,10.88,Fee Schedule,,10.88,,,10.88,Fee Schedule,,147.51,,,147.51,Other,110% of Medicare,50.98,,,50.98,Fee Schedule,,113,,,113,Other,186% of Medicaid,59.99,,,59.99,Fee Schedule,,184.76,,,184.76,Fee Schedule,,28.25,,,28.25,Fee Schedule,,59.99,,,59.99,Fee Schedule,,184.76,,,184.76,Fee Schedule,,238.4,80,,238.4,percent of total billed charges,All Other,208.6,70,,208.6,percent of total billed charges,All Other,54.12,,,54.12,Fee Schedule,,45.87,,,45.87,Fee Schedule,,667,,,667,Case Rate,,600,,,600,Case Rate,,667,,,667,Case Rate,,567,,,567,Case Rate,,61,,,61,Other,100% of Medicaid,61,,,61,Other,100% of Medicaid,61,,,61,Other,100% of Medicaid,61,,,61,Other,100% of Medicaid,137.24,,,137.24,Other,225% of Medicaid,93.32,,,93.32,Other,153% of Medicaid,137.24,,,137.24,Other,225% of Medicaid,85.39,,,85.39,Other,140% of Medicaid,137.24,,,137.24,Other,225% of Medicaid,158.59,,,158.59,Other,260% of Medicaid,197.63,,,197.63,Other,324% of Medicaid,131.14,,,131.14,Other,215% of Medicaid,131.14,,,131.14,Other,215% of Medicaid,76.24,,,76.24,Other,125% of Medicaid,10.88,667,
PULM STRESS TEST/COMPLEX,94621,CPT,,71094621,CDM,460,RC,,,both,,,3266,2416.85,,,2416.85,Other,150% of Medicare + 9.63% HCRA Surcharge,1469.7,45,,1469.7,percent of total billed charges,Critical Access Hospital RCC factor,2122.9,65,,2122.9,percent of total billed charges,All Other,1926.94,65,,1926.94,percent of total billed charges,All Other,633.98,,,633.98,Fee Schedule,,570.22,,,570.22,Fee Schedule,,538.94,,,538.94,Fee Schedule,,1616.67,,,1616.67,Other,110% of Medicare,364.33,,,364.33,Fee Schedule,,419,,,419,Other,186% of Medicaid,428.74,,,428.74,Fee Schedule,,2024.92,,,2024.92,Fee Schedule,,201.87,,,201.87,Fee Schedule,,428.74,,,428.74,Fee Schedule,,2024.92,,,2024.92,Fee Schedule,,2612.8,80,,2612.8,percent of total billed charges,All Other,2286.2,70,,2286.2,percent of total billed charges,All Other,419.84,,,419.84,Fee Schedule,,355.84,,,355.84,Fee Schedule,,667,,,667,Case Rate,,600,,,600,Case Rate,,667,,,667,Case Rate,,567,,,567,Case Rate,,225.42,,,225.42,Other,100% of Medicaid,225.42,,,225.42,Other,100% of Medicaid,225.42,,,225.42,Other,100% of Medicaid,225.42,,,225.42,Other,100% of Medicaid,507.19,,,507.19,Other,225% of Medicaid,344.89,,,344.89,Other,153% of Medicaid,507.19,,,507.19,Other,225% of Medicaid,315.58,,,315.58,Other,140% of Medicaid,507.19,,,507.19,Other,225% of Medicaid,586.08,,,586.08,Other,260% of Medicaid,730.35,,,730.35,Other,324% of Medicaid,484.64,,,484.64,Other,215% of Medicaid,484.64,,,484.64,Other,215% of Medicaid,281.77,,,281.77,Other,125% of Medicaid,201.87,2612.8,
PULM FUNCT TST PLETHYSMOGRAP,94726,CPT,,71094726,CDM,460,RC,,,both,,,632,467.68,,,467.68,Other,150% of Medicare + 9.63% HCRA Surcharge,284.4,45,,284.4,percent of total billed charges,Critical Access Hospital RCC factor,410.8,65,,410.8,percent of total billed charges,All Other,372.88,65,,372.88,percent of total billed charges,All Other,41.15,,,41.15,Fee Schedule,,41.15,,,41.15,Fee Schedule,,41.15,,,41.15,Fee Schedule,,312.84,,,312.84,Other,110% of Medicare,182.94,,,182.94,Fee Schedule,,419,,,419,Other,186% of Medicaid,215.28,,,215.28,Fee Schedule,,391.84,,,391.84,Fee Schedule,,101.37,,,101.37,Fee Schedule,,215.28,,,215.28,Fee Schedule,,391.84,,,391.84,Fee Schedule,,505.6,80,,505.6,percent of total billed charges,All Other,442.4,70,,442.4,percent of total billed charges,All Other,206.64,,,206.64,Fee Schedule,,175.14,,,175.14,Fee Schedule,,667,,,667,Case Rate,,600,,,600,Case Rate,,667,,,667,Case Rate,,567,,,567,Case Rate,,225.42,,,225.42,Other,100% of Medicaid,225.42,,,225.42,Other,100% of Medicaid,225.42,,,225.42,Other,100% of Medicaid,225.42,,,225.42,Other,100% of Medicaid,507.19,,,507.19,Other,225% of Medicaid,344.89,,,344.89,Other,153% of Medicaid,507.19,,,507.19,Other,225% of Medicaid,315.58,,,315.58,Other,140% of Medicaid,507.19,,,507.19,Other,225% of Medicaid,586.08,,,586.08,Other,260% of Medicaid,730.35,,,730.35,Other,324% of Medicaid,484.64,,,484.64,Other,215% of Medicaid,484.64,,,484.64,Other,215% of Medicaid,281.77,,,281.77,Other,125% of Medicaid,41.15,730.35,
PFT BY LUNG VOLUME/GAS,94727,CPT,,71094727,CDM,460,RC,,,both,,,329,243.46,,,243.46,Other,150% of Medicare + 9.63% HCRA Surcharge,148.05,45,,148.05,percent of total billed charges,Critical Access Hospital RCC factor,213.85,65,,213.85,percent of total billed charges,All Other,194.11,65,,194.11,percent of total billed charges,All Other,30.61,,,30.61,Fee Schedule,,30.61,,,30.61,Fee Schedule,,30.61,,,30.61,Fee Schedule,,162.86,,,162.86,Other,110% of Medicare,136.1,,,136.1,Fee Schedule,,113,,,113,Other,186% of Medicaid,160.16,,,160.16,Fee Schedule,,203.98,,,203.98,Fee Schedule,,75.41,,,75.41,Fee Schedule,,160.16,,,160.16,Fee Schedule,,203.98,,,203.98,Fee Schedule,,263.2,80,,263.2,percent of total billed charges,All Other,230.3,70,,230.3,percent of total billed charges,All Other,154.16,,,154.16,Fee Schedule,,130.66,,,130.66,Fee Schedule,,667,,,667,Case Rate,,600,,,600,Case Rate,,667,,,667,Case Rate,,567,,,567,Case Rate,,61,,,61,Other,100% of Medicaid,61,,,61,Other,100% of Medicaid,61,,,61,Other,100% of Medicaid,61,,,61,Other,100% of Medicaid,137.24,,,137.24,Other,225% of Medicaid,93.32,,,93.32,Other,153% of Medicaid,137.24,,,137.24,Other,225% of Medicaid,85.39,,,85.39,Other,140% of Medicaid,137.24,,,137.24,Other,225% of Medicaid,158.59,,,158.59,Other,260% of Medicaid,197.63,,,197.63,Other,324% of Medicaid,131.14,,,131.14,Other,215% of Medicaid,131.14,,,131.14,Other,215% of Medicaid,76.24,,,76.24,Other,125% of Medicaid,30.61,667,
CO/MEMBRANE DIFFUSE CAPACITY,94729,CPT,,71094729,CDM,460,RC,,,both,,,301,222.74,,,222.74,Other,150% of Medicare + 9.63% HCRA Surcharge,135.45,45,,135.45,percent of total billed charges,Critical Access Hospital RCC factor,195.65,65,,195.65,percent of total billed charges,All Other,177.59,65,,177.59,percent of total billed charges,All Other,43.87,,,43.87,Fee Schedule,,43.87,,,43.87,Fee Schedule,,43.87,,,43.87,Fee Schedule,,149,,,149,Other,110% of Medicare,197.84,,,197.84,Fee Schedule,,113,,,113,Other,186% of Medicaid,232.81,,,232.81,Fee Schedule,,186.62,,,186.62,Fee Schedule,,109.62,,,109.62,Fee Schedule,,232.81,,,232.81,Fee Schedule,,186.62,,,186.62,Fee Schedule,,240.8,80,,240.8,percent of total billed charges,All Other,210.7,70,,210.7,percent of total billed charges,All Other,241.08,,,241.08,Fee Schedule,,204.33,,,204.33,Fee Schedule,,667,,,667,Case Rate,,600,,,600,Case Rate,,667,,,667,Case Rate,,567,,,567,Case Rate,,61,,,61,Other,100% of Medicaid,61,,,61,Other,100% of Medicaid,61,,,61,Other,100% of Medicaid,61,,,61,Other,100% of Medicaid,137.24,,,137.24,Other,225% of Medicaid,93.32,,,93.32,Other,153% of Medicaid,137.24,,,137.24,Other,225% of Medicaid,85.39,,,85.39,Other,140% of Medicaid,137.24,,,137.24,Other,225% of Medicaid,158.59,,,158.59,Other,260% of Medicaid,197.63,,,197.63,Other,324% of Medicaid,131.14,,,131.14,Other,215% of Medicaid,131.14,,,131.14,Other,215% of Medicaid,76.24,,,76.24,Other,125% of Medicaid,43.87,667,
MEASURE BLOOD OXYGEN LEVEL SINGLE,94760,CPT,,71094760,CDM,460,RC,,,both,,,209,154.66,,,154.66,Other,150% of Medicare + 9.63% HCRA Surcharge,94.05,45,,94.05,percent of total billed charges,Critical Access Hospital RCC factor,135.85,65,,135.85,percent of total billed charges,All Other,123.31,65,,123.31,percent of total billed charges,All Other,18.39,,,18.39,Fee Schedule,,16.54,,,16.54,Fee Schedule,,15.64,,,15.64,Fee Schedule,,103.46,,,103.46,Other,110% of Medicare,11.18,,,11.18,Fee Schedule,,0.01,,,0.01,Other,186% of Medicaid,13.16,,,13.16,Fee Schedule,,129.58,,,129.58,Fee Schedule,,6.2,,,6.2,Fee Schedule,,13.16,,,13.16,Fee Schedule,,129.58,,,129.58,Fee Schedule,,167.2,80,,167.2,percent of total billed charges,All Other,146.3,70,,146.3,percent of total billed charges,All Other,11.48,,,11.48,Fee Schedule,,9.73,,,9.73,Fee Schedule,,667,,,667,Case Rate,,600,,,600,Case Rate,,667,,,667,Case Rate,,567,,,567,Case Rate,,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,667,
MEASURE BLOOD OXYGEN LEVEL MULTI,94761,CPT,,71094761,CDM,460,RC,,,both,,,528,390.72,,,390.72,Other,150% of Medicare + 9.63% HCRA Surcharge,237.6,45,,237.6,percent of total billed charges,Critical Access Hospital RCC factor,343.2,65,,343.2,percent of total billed charges,All Other,311.52,65,,311.52,percent of total billed charges,All Other,29.83,,,29.83,Fee Schedule,,26.83,,,26.83,Fee Schedule,,25.36,,,25.36,Fee Schedule,,261.36,,,261.36,Other,110% of Medicare,16.68,,,16.68,Fee Schedule,,0.01,,,0.01,Other,186% of Medicaid,19.62,,,19.62,Fee Schedule,,327.36,,,327.36,Fee Schedule,,9.24,,,9.24,Fee Schedule,,19.62,,,19.62,Fee Schedule,,327.36,,,327.36,Fee Schedule,,422.4,80,,422.4,percent of total billed charges,All Other,369.6,70,,369.6,percent of total billed charges,All Other,16.4,,,16.4,Fee Schedule,,13.9,,,13.9,Fee Schedule,,667,,,667,Case Rate,,600,,,600,Case Rate,,667,,,667,Case Rate,,567,,,567,Case Rate,,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,667,
MEASURE BLOOD O2 LEVEL CONTINU,94762,CPT,,71094762,CDM,460,RC,,,both,,,337,249.38,,,249.38,Other,150% of Medicare + 9.63% HCRA Surcharge,151.65,45,,151.65,percent of total billed charges,Critical Access Hospital RCC factor,81.36,,,81.36,Fee Schedule,,73.36,,,73.36,Fee Schedule,,133.58,,,133.58,Fee Schedule,,120.25,,,120.25,Fee Schedule,,113.59,,,113.59,Fee Schedule,,166.82,,,166.82,Other,110% of Medicare,229.16,68,,229.16,percent of total billed charges,All Other,113,,,113,Other,186% of Medicaid,269.6,,,269.6,percent of total billed charges,All Other,279.71,83,,279.71,percent of total billed charges,All Other,279.71,83,,279.71,percent of total billed charges,All Other,269.6,80,,269.6,percent of total billed charges,All Other,279.71,83,,279.71,percent of total billed charges,All Other,108.94,,,108.94,Fee Schedule,,235.9,70,,235.9,percent of total billed charges,All Other,127.92,,,127.92,Fee Schedule,,108.42,,,108.42,Fee Schedule,,667,,,667,Case Rate,,600,,,600,Case Rate,,667,,,667,Case Rate,,567,,,567,Case Rate,,61,,,61,Other,100% of Medicaid,61,,,61,Other,100% of Medicaid,61,,,61,Other,100% of Medicaid,61,,,61,Other,100% of Medicaid,137.24,,,137.24,Other,225% of Medicaid,93.32,,,93.32,Other,153% of Medicaid,137.24,,,137.24,Other,225% of Medicaid,85.39,,,85.39,Other,140% of Medicaid,137.24,,,137.24,Other,225% of Medicaid,158.59,,,158.59,Other,260% of Medicaid,197.63,,,197.63,Other,324% of Medicaid,131.14,,,131.14,Other,215% of Medicaid,131.14,,,131.14,Other,215% of Medicaid,76.24,,,76.24,Other,125% of Medicaid,61,667,
EVALUATION OF WHEEZING W/MOD,94060,CPT,59,71194060,CDM,460,RC,,,both,,,1017,752.58,,,752.58,Other,150% of Medicare + 9.63% HCRA Surcharge,457.65,45,,457.65,percent of total billed charges,Critical Access Hospital RCC factor,661.05,65,,661.05,percent of total billed charges,All Other,600.03,65,,600.03,percent of total billed charges,All Other,311.3,,,311.3,Fee Schedule,,279.99,,,279.99,Fee Schedule,,264.63,,,264.63,Fee Schedule,,503.42,,,503.42,Other,110% of Medicare,119.61,,,119.61,Fee Schedule,,419,,,419,Other,186% of Medicaid,140.76,,,140.76,Fee Schedule,,630.54,,,630.54,Fee Schedule,,66.28,,,66.28,Fee Schedule,,140.76,,,140.76,Fee Schedule,,630.54,,,630.54,Fee Schedule,,813.6,80,,813.6,percent of total billed charges,All Other,711.9,70,,711.9,percent of total billed charges,All Other,139.4,,,139.4,Fee Schedule,,118.15,,,118.15,Fee Schedule,,667,,,667,Case Rate,,600,,,600,Case Rate,,667,,,667,Case Rate,,567,,,567,Case Rate,,225.42,,,225.42,Other,100% of Medicaid,225.42,,,225.42,Other,100% of Medicaid,225.42,,,225.42,Other,100% of Medicaid,225.42,,,225.42,Other,100% of Medicaid,507.19,,,507.19,Other,225% of Medicaid,344.89,,,344.89,Other,153% of Medicaid,507.19,,,507.19,Other,225% of Medicaid,315.58,,,315.58,Other,140% of Medicaid,507.19,,,507.19,Other,225% of Medicaid,586.08,,,586.08,Other,260% of Medicaid,730.35,,,730.35,Other,324% of Medicaid,484.64,,,484.64,Other,215% of Medicaid,484.64,,,484.64,Other,215% of Medicaid,281.77,,,281.77,Other,125% of Medicaid,66.28,813.6,
MEASURE BLOOD OXYGEN LEVEL SINGLE 59 MOD,94760,CPT,59,71194760,CDM,460,RC,,,both,,,209,154.66,,,154.66,Other,150% of Medicare + 9.63% HCRA Surcharge,94.05,45,,94.05,percent of total billed charges,Critical Access Hospital RCC factor,135.85,65,,135.85,percent of total billed charges,All Other,123.31,65,,123.31,percent of total billed charges,All Other,18.39,,,18.39,Fee Schedule,,16.54,,,16.54,Fee Schedule,,15.64,,,15.64,Fee Schedule,,103.46,,,103.46,Other,110% of Medicare,11.18,,,11.18,Fee Schedule,,0.01,,,0.01,Other,186% of Medicaid,13.16,,,13.16,Fee Schedule,,129.58,,,129.58,Fee Schedule,,6.2,,,6.2,Fee Schedule,,13.16,,,13.16,Fee Schedule,,129.58,,,129.58,Fee Schedule,,167.2,80,,167.2,percent of total billed charges,All Other,146.3,70,,146.3,percent of total billed charges,All Other,11.48,,,11.48,Fee Schedule,,9.73,,,9.73,Fee Schedule,,667,,,667,Case Rate,,600,,,600,Case Rate,,667,,,667,Case Rate,,567,,,567,Case Rate,,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,667,
MEASURE BLOOD OXYGEN LEVEL MULTI 59 MOD,94761,CPT,59,71194761,CDM,460,RC,,,both,,,528,390.72,,,390.72,Other,150% of Medicare + 9.63% HCRA Surcharge,237.6,45,,237.6,percent of total billed charges,Critical Access Hospital RCC factor,343.2,65,,343.2,percent of total billed charges,All Other,311.52,65,,311.52,percent of total billed charges,All Other,29.83,,,29.83,Fee Schedule,,26.83,,,26.83,Fee Schedule,,25.36,,,25.36,Fee Schedule,,261.36,,,261.36,Other,110% of Medicare,16.68,,,16.68,Fee Schedule,,0.01,,,0.01,Other,186% of Medicaid,19.62,,,19.62,Fee Schedule,,327.36,,,327.36,Fee Schedule,,9.24,,,9.24,Fee Schedule,,19.62,,,19.62,Fee Schedule,,327.36,,,327.36,Fee Schedule,,422.4,80,,422.4,percent of total billed charges,All Other,369.6,70,,369.6,percent of total billed charges,All Other,16.4,,,16.4,Fee Schedule,,13.9,,,13.9,Fee Schedule,,667,,,667,Case Rate,,600,,,600,Case Rate,,667,,,667,Case Rate,,567,,,567,Case Rate,,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,667,
MEASURE BLOOD O2 LEVEL CONTINU 59 MOD,94762,CPT,59,71194762,CDM,460,RC,,,both,,,337,249.38,,,249.38,Other,150% of Medicare + 9.63% HCRA Surcharge,151.65,45,,151.65,percent of total billed charges,Critical Access Hospital RCC factor,81.36,,,81.36,Fee Schedule,,73.36,,,73.36,Fee Schedule,,133.58,,,133.58,Fee Schedule,,120.25,,,120.25,Fee Schedule,,113.59,,,113.59,Fee Schedule,,166.82,,,166.82,Other,110% of Medicare,229.16,68,,229.16,percent of total billed charges,All Other,113,,,113,Other,186% of Medicaid,269.6,,,269.6,percent of total billed charges,All Other,279.71,83,,279.71,percent of total billed charges,All Other,279.71,83,,279.71,percent of total billed charges,All Other,269.6,80,,269.6,percent of total billed charges,All Other,279.71,83,,279.71,percent of total billed charges,All Other,108.94,,,108.94,Fee Schedule,,235.9,70,,235.9,percent of total billed charges,All Other,127.92,,,127.92,Fee Schedule,,108.42,,,108.42,Fee Schedule,,667,,,667,Case Rate,,600,,,600,Case Rate,,667,,,667,Case Rate,,567,,,567,Case Rate,,61,,,61,Other,100% of Medicaid,61,,,61,Other,100% of Medicaid,61,,,61,Other,100% of Medicaid,61,,,61,Other,100% of Medicaid,137.24,,,137.24,Other,225% of Medicaid,93.32,,,93.32,Other,153% of Medicaid,137.24,,,137.24,Other,225% of Medicaid,85.39,,,85.39,Other,140% of Medicaid,137.24,,,137.24,Other,225% of Medicaid,158.59,,,158.59,Other,260% of Medicaid,197.63,,,197.63,Other,324% of Medicaid,131.14,,,131.14,Other,215% of Medicaid,131.14,,,131.14,Other,215% of Medicaid,76.24,,,76.24,Other,125% of Medicaid,61,667,
DISPENSING FEE BINAURAL,V5160,HCPCS,,66000009,CDM,470,RC,,,both,,,1603,1186.22,,,1186.22,Other,150% of Medicare + 9.63% HCRA Surcharge,721.35,45,,721.35,percent of total billed charges,Critical Access Hospital RCC factor,1041.95,65,,1041.95,percent of total billed charges,All Other,945.77,65,,945.77,percent of total billed charges,All Other,1226.3,76.5,,1226.3,percent of total billed charges,All Other,1138.13,69,,1138.13,percent of total billed charges,All Other,1106.07,65,,1106.07,percent of total billed charges,All Other,793.49,,,793.49,Other,110% of Medicare,1090.04,68,,1090.04,percent of total billed charges,All Other,124,,,124,Other,186% of Medicaid,1282.4,,,1282.4,percent of total billed charges,All Other,1330.49,83,,1330.49,percent of total billed charges,All Other,1330.49,83,,1330.49,percent of total billed charges,All Other,1282.4,80,,1282.4,percent of total billed charges,All Other,1330.49,83,,1330.49,percent of total billed charges,All Other,1282.4,80,,1282.4,percent of total billed charges,All Other,1122.1,70,,1122.1,percent of total billed charges,All Other,1041.95,65,,1041.95,percent of total billed charges,Default if not in Fee Schedule,1041.95,65,,1041.95,percent of total billed charges,Default if not in Fee Schedule,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,66.65,,,66.65,Other,100% of Medicaid,66.65,,,66.65,Other,100% of Medicaid,66.65,,,66.65,Other,100% of Medicaid,66.65,,,66.65,Other,100% of Medicaid,149.95,,,149.95,Other,225% of Medicaid,101.97,,,101.97,Other,153% of Medicaid,149.95,,,149.95,Other,225% of Medicaid,93.31,,,93.31,Other,140% of Medicaid,149.95,,,149.95,Other,225% of Medicaid,173.28,,,173.28,Other,260% of Medicaid,215.93,,,215.93,Other,324% of Medicaid,143.29,,,143.29,Other,215% of Medicaid,143.29,,,143.29,Other,215% of Medicaid,83.31,,,83.31,Other,125% of Medicaid,0.01,1330.49,
DISPENSING FEE MONAURAL,V5241,HCPCS,,66000010,CDM,470,RC,,,both,,,1542,1141.08,,,1141.08,Other,150% of Medicare + 9.63% HCRA Surcharge,693.9,45,,693.9,percent of total billed charges,Critical Access Hospital RCC factor,1002.3,65,,1002.3,percent of total billed charges,All Other,909.78,65,,909.78,percent of total billed charges,All Other,1179.63,76.5,,1179.63,percent of total billed charges,All Other,1094.82,69,,1094.82,percent of total billed charges,All Other,1063.98,65,,1063.98,percent of total billed charges,All Other,763.29,,,763.29,Other,110% of Medicare,1048.56,68,,1048.56,percent of total billed charges,All Other,124,,,124,Other,186% of Medicaid,1233.6,,,1233.6,percent of total billed charges,All Other,1279.86,83,,1279.86,percent of total billed charges,All Other,1279.86,83,,1279.86,percent of total billed charges,All Other,1233.6,80,,1233.6,percent of total billed charges,All Other,1279.86,83,,1279.86,percent of total billed charges,All Other,1233.6,80,,1233.6,percent of total billed charges,All Other,1079.4,70,,1079.4,percent of total billed charges,All Other,1002.3,65,,1002.3,percent of total billed charges,Default if not in Fee Schedule,1002.3,65,,1002.3,percent of total billed charges,Default if not in Fee Schedule,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,66.65,,,66.65,Other,100% of Medicaid,66.65,,,66.65,Other,100% of Medicaid,66.65,,,66.65,Other,100% of Medicaid,66.65,,,66.65,Other,100% of Medicaid,149.95,,,149.95,Other,225% of Medicaid,101.97,,,101.97,Other,153% of Medicaid,149.95,,,149.95,Other,225% of Medicaid,93.31,,,93.31,Other,140% of Medicaid,149.95,,,149.95,Other,225% of Medicaid,173.28,,,173.28,Other,260% of Medicaid,215.93,,,215.93,Other,324% of Medicaid,143.29,,,143.29,Other,215% of Medicaid,143.29,,,143.29,Other,215% of Medicaid,83.31,,,83.31,Other,125% of Medicaid,0.01,1279.86,
REPAIR/MOD AUGMENTATION COMMUN,V5336,HCPCS,,66000119,CDM,470,RC,,,both,,,179,132.46,,,132.46,Other,150% of Medicare + 9.63% HCRA Surcharge,80.55,45,,80.55,percent of total billed charges,Critical Access Hospital RCC factor,116.35,65,,116.35,percent of total billed charges,All Other,105.61,65,,105.61,percent of total billed charges,All Other,136.94,76.5,,136.94,percent of total billed charges,All Other,127.09,69,,127.09,percent of total billed charges,All Other,123.51,65,,123.51,percent of total billed charges,All Other,88.61,,,88.61,Other,110% of Medicare,121.72,68,,121.72,percent of total billed charges,All Other,0.01,,,0.01,Other,186% of Medicaid,143.2,,,143.2,percent of total billed charges,All Other,148.57,83,,148.57,percent of total billed charges,All Other,148.57,83,,148.57,percent of total billed charges,All Other,143.2,80,,143.2,percent of total billed charges,All Other,148.57,83,,148.57,percent of total billed charges,All Other,143.2,80,,143.2,percent of total billed charges,All Other,125.3,70,,125.3,percent of total billed charges,All Other,116.35,65,,116.35,percent of total billed charges,Default if not in Fee Schedule,116.35,65,,116.35,percent of total billed charges,Default if not in Fee Schedule,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,148.57,
HEARING SERVICE,V5299,HCPCS,,66000134,CDM,470,RC,,,both,,,40,29.6,,,29.6,Other,150% of Medicare + 9.63% HCRA Surcharge,18,45,,18,percent of total billed charges,Critical Access Hospital RCC factor,26,65,,26,percent of total billed charges,All Other,23.6,65,,23.6,percent of total billed charges,All Other,30.6,76.5,,30.6,percent of total billed charges,All Other,28.4,69,,28.4,percent of total billed charges,All Other,27.6,65,,27.6,percent of total billed charges,All Other,19.8,,,19.8,Other,110% of Medicare,27.2,68,,27.2,percent of total billed charges,All Other,0.01,,,0.01,Other,186% of Medicaid,32,,,32,percent of total billed charges,All Other,33.2,83,,33.2,percent of total billed charges,All Other,33.2,83,,33.2,percent of total billed charges,All Other,32,80,,32,percent of total billed charges,All Other,33.2,83,,33.2,percent of total billed charges,All Other,32,80,,32,percent of total billed charges,All Other,28,70,,28,percent of total billed charges,All Other,26,65,,26,percent of total billed charges,Default if not in Fee Schedule,26,65,,26,percent of total billed charges,Default if not in Fee Schedule,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,33.2,
HEARING AID REPAIR,V5014,HCPCS,,66000135,CDM,470,RC,,,both,,,0.01,0.01,,,0.01,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,45,,0.01,percent of total billed charges,Critical Access Hospital RCC factor,0.01,65,,0.01,percent of total billed charges,All Other,0.01,65,,0.01,percent of total billed charges,All Other,0.01,76.5,,0.01,percent of total billed charges,All Other,0.01,69,,0.01,percent of total billed charges,All Other,0.01,65,,0.01,percent of total billed charges,All Other,0.01,,,0.01,Other,110% of Medicare,0.01,68,,0.01,percent of total billed charges,All Other,124,,,124,Other,186% of Medicaid,0.01,,,0.01,percent of total billed charges,All Other,0.01,83,,0.01,percent of total billed charges,All Other,0.01,83,,0.01,percent of total billed charges,All Other,0.01,80,,0.01,percent of total billed charges,All Other,0.01,83,,0.01,percent of total billed charges,All Other,0.01,80,,0.01,percent of total billed charges,All Other,0.01,70,,0.01,percent of total billed charges,All Other,0.01,65,,0.01,percent of total billed charges,Default if not in Fee Schedule,0.01,65,,0.01,percent of total billed charges,Default if not in Fee Schedule,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,66.65,,,66.65,Other,100% of Medicaid,66.65,,,66.65,Other,100% of Medicaid,66.65,,,66.65,Other,100% of Medicaid,66.65,,,66.65,Other,100% of Medicaid,149.95,,,149.95,Other,225% of Medicaid,101.97,,,101.97,Other,153% of Medicaid,149.95,,,149.95,Other,225% of Medicaid,93.31,,,93.31,Other,140% of Medicaid,149.95,,,149.95,Other,225% of Medicaid,173.28,,,173.28,Other,260% of Medicaid,215.93,,,215.93,Other,324% of Medicaid,143.29,,,143.29,Other,215% of Medicaid,143.29,,,143.29,Other,215% of Medicaid,83.31,,,83.31,Other,125% of Medicaid,0.01,215.93,
DISPENSING FEE BICROS,V5240,HCPCS,,66000140,CDM,470,RC,,,both,,,1470,1087.8,,,1087.8,Other,150% of Medicare + 9.63% HCRA Surcharge,661.5,45,,661.5,percent of total billed charges,Critical Access Hospital RCC factor,955.5,65,,955.5,percent of total billed charges,All Other,867.3,65,,867.3,percent of total billed charges,All Other,1124.55,76.5,,1124.55,percent of total billed charges,All Other,1043.7,69,,1043.7,percent of total billed charges,All Other,1014.3,65,,1014.3,percent of total billed charges,All Other,727.65,,,727.65,Other,110% of Medicare,999.6,68,,999.6,percent of total billed charges,All Other,124,,,124,Other,186% of Medicaid,1176,,,1176,percent of total billed charges,All Other,1220.1,83,,1220.1,percent of total billed charges,All Other,1220.1,83,,1220.1,percent of total billed charges,All Other,1176,80,,1176,percent of total billed charges,All Other,1220.1,83,,1220.1,percent of total billed charges,All Other,1176,80,,1176,percent of total billed charges,All Other,1029,70,,1029,percent of total billed charges,All Other,955.5,65,,955.5,percent of total billed charges,Default if not in Fee Schedule,955.5,65,,955.5,percent of total billed charges,Default if not in Fee Schedule,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,66.65,,,66.65,Other,100% of Medicaid,66.65,,,66.65,Other,100% of Medicaid,66.65,,,66.65,Other,100% of Medicaid,66.65,,,66.65,Other,100% of Medicaid,149.95,,,149.95,Other,225% of Medicaid,101.97,,,101.97,Other,153% of Medicaid,149.95,,,149.95,Other,225% of Medicaid,93.31,,,93.31,Other,140% of Medicaid,149.95,,,149.95,Other,225% of Medicaid,173.28,,,173.28,Other,260% of Medicaid,215.93,,,215.93,Other,324% of Medicaid,143.29,,,143.29,Other,215% of Medicaid,143.29,,,143.29,Other,215% of Medicaid,83.31,,,83.31,Other,125% of Medicaid,0.01,1220.1,
DISPENSING FEE CROS,V5200,HCPCS,,66000141,CDM,470,RC,,,both,,,1542,1141.08,,,1141.08,Other,150% of Medicare + 9.63% HCRA Surcharge,693.9,45,,693.9,percent of total billed charges,Critical Access Hospital RCC factor,1002.3,65,,1002.3,percent of total billed charges,All Other,909.78,65,,909.78,percent of total billed charges,All Other,1179.63,76.5,,1179.63,percent of total billed charges,All Other,1094.82,69,,1094.82,percent of total billed charges,All Other,1063.98,65,,1063.98,percent of total billed charges,All Other,763.29,,,763.29,Other,110% of Medicare,1048.56,68,,1048.56,percent of total billed charges,All Other,124,,,124,Other,186% of Medicaid,1233.6,,,1233.6,percent of total billed charges,All Other,1279.86,83,,1279.86,percent of total billed charges,All Other,1279.86,83,,1279.86,percent of total billed charges,All Other,1233.6,80,,1233.6,percent of total billed charges,All Other,1279.86,83,,1279.86,percent of total billed charges,All Other,1233.6,80,,1233.6,percent of total billed charges,All Other,1079.4,70,,1079.4,percent of total billed charges,All Other,1002.3,65,,1002.3,percent of total billed charges,Default if not in Fee Schedule,1002.3,65,,1002.3,percent of total billed charges,Default if not in Fee Schedule,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,66.65,,,66.65,Other,100% of Medicaid,66.65,,,66.65,Other,100% of Medicaid,66.65,,,66.65,Other,100% of Medicaid,66.65,,,66.65,Other,100% of Medicaid,149.95,,,149.95,Other,225% of Medicaid,101.97,,,101.97,Other,153% of Medicaid,149.95,,,149.95,Other,225% of Medicaid,93.31,,,93.31,Other,140% of Medicaid,149.95,,,149.95,Other,225% of Medicaid,173.28,,,173.28,Other,260% of Medicaid,215.93,,,215.93,Other,324% of Medicaid,143.29,,,143.29,Other,215% of Medicaid,143.29,,,143.29,Other,215% of Medicaid,83.31,,,83.31,Other,125% of Medicaid,0.01,1279.86,
DISPENSING FEE BICROS WITH IMPRESSION,V5240,HCPCS,,66000145,CDM,470,RC,,,both,,,1470,1087.8,,,1087.8,Other,150% of Medicare + 9.63% HCRA Surcharge,661.5,45,,661.5,percent of total billed charges,Critical Access Hospital RCC factor,955.5,65,,955.5,percent of total billed charges,All Other,867.3,65,,867.3,percent of total billed charges,All Other,1124.55,76.5,,1124.55,percent of total billed charges,All Other,1043.7,69,,1043.7,percent of total billed charges,All Other,1014.3,65,,1014.3,percent of total billed charges,All Other,727.65,,,727.65,Other,110% of Medicare,999.6,68,,999.6,percent of total billed charges,All Other,124,,,124,Other,186% of Medicaid,1176,,,1176,percent of total billed charges,All Other,1220.1,83,,1220.1,percent of total billed charges,All Other,1220.1,83,,1220.1,percent of total billed charges,All Other,1176,80,,1176,percent of total billed charges,All Other,1220.1,83,,1220.1,percent of total billed charges,All Other,1176,80,,1176,percent of total billed charges,All Other,1029,70,,1029,percent of total billed charges,All Other,955.5,65,,955.5,percent of total billed charges,Default if not in Fee Schedule,955.5,65,,955.5,percent of total billed charges,Default if not in Fee Schedule,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,66.65,,,66.65,Other,100% of Medicaid,66.65,,,66.65,Other,100% of Medicaid,66.65,,,66.65,Other,100% of Medicaid,66.65,,,66.65,Other,100% of Medicaid,149.95,,,149.95,Other,225% of Medicaid,101.97,,,101.97,Other,153% of Medicaid,149.95,,,149.95,Other,225% of Medicaid,93.31,,,93.31,Other,140% of Medicaid,149.95,,,149.95,Other,225% of Medicaid,173.28,,,173.28,Other,260% of Medicaid,215.93,,,215.93,Other,324% of Medicaid,143.29,,,143.29,Other,215% of Medicaid,143.29,,,143.29,Other,215% of Medicaid,83.31,,,83.31,Other,125% of Medicaid,0.01,1220.1,
DISPENSING FEE BINAURAL WITH IMPRESSION,V5160,HCPCS,,66000146,CDM,470,RC,,,both,,,1603,1186.22,,,1186.22,Other,150% of Medicare + 9.63% HCRA Surcharge,721.35,45,,721.35,percent of total billed charges,Critical Access Hospital RCC factor,1041.95,65,,1041.95,percent of total billed charges,All Other,945.77,65,,945.77,percent of total billed charges,All Other,1226.3,76.5,,1226.3,percent of total billed charges,All Other,1138.13,69,,1138.13,percent of total billed charges,All Other,1106.07,65,,1106.07,percent of total billed charges,All Other,793.49,,,793.49,Other,110% of Medicare,1090.04,68,,1090.04,percent of total billed charges,All Other,124,,,124,Other,186% of Medicaid,1282.4,,,1282.4,percent of total billed charges,All Other,1330.49,83,,1330.49,percent of total billed charges,All Other,1330.49,83,,1330.49,percent of total billed charges,All Other,1282.4,80,,1282.4,percent of total billed charges,All Other,1330.49,83,,1330.49,percent of total billed charges,All Other,1282.4,80,,1282.4,percent of total billed charges,All Other,1122.1,70,,1122.1,percent of total billed charges,All Other,1041.95,65,,1041.95,percent of total billed charges,Default if not in Fee Schedule,1041.95,65,,1041.95,percent of total billed charges,Default if not in Fee Schedule,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,66.65,,,66.65,Other,100% of Medicaid,66.65,,,66.65,Other,100% of Medicaid,66.65,,,66.65,Other,100% of Medicaid,66.65,,,66.65,Other,100% of Medicaid,149.95,,,149.95,Other,225% of Medicaid,101.97,,,101.97,Other,153% of Medicaid,149.95,,,149.95,Other,225% of Medicaid,93.31,,,93.31,Other,140% of Medicaid,149.95,,,149.95,Other,225% of Medicaid,173.28,,,173.28,Other,260% of Medicaid,215.93,,,215.93,Other,324% of Medicaid,143.29,,,143.29,Other,215% of Medicaid,143.29,,,143.29,Other,215% of Medicaid,83.31,,,83.31,Other,125% of Medicaid,0.01,1330.49,
DISPENSING FEE CROS WITH IMPRESSION,V5200,HCPCS,,66000147,CDM,470,RC,,,both,,,1542,1141.08,,,1141.08,Other,150% of Medicare + 9.63% HCRA Surcharge,693.9,45,,693.9,percent of total billed charges,Critical Access Hospital RCC factor,1002.3,65,,1002.3,percent of total billed charges,All Other,909.78,65,,909.78,percent of total billed charges,All Other,1179.63,76.5,,1179.63,percent of total billed charges,All Other,1094.82,69,,1094.82,percent of total billed charges,All Other,1063.98,65,,1063.98,percent of total billed charges,All Other,763.29,,,763.29,Other,110% of Medicare,1048.56,68,,1048.56,percent of total billed charges,All Other,124,,,124,Other,186% of Medicaid,1233.6,,,1233.6,percent of total billed charges,All Other,1279.86,83,,1279.86,percent of total billed charges,All Other,1279.86,83,,1279.86,percent of total billed charges,All Other,1233.6,80,,1233.6,percent of total billed charges,All Other,1279.86,83,,1279.86,percent of total billed charges,All Other,1233.6,80,,1233.6,percent of total billed charges,All Other,1079.4,70,,1079.4,percent of total billed charges,All Other,1002.3,65,,1002.3,percent of total billed charges,Default if not in Fee Schedule,1002.3,65,,1002.3,percent of total billed charges,Default if not in Fee Schedule,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,66.65,,,66.65,Other,100% of Medicaid,66.65,,,66.65,Other,100% of Medicaid,66.65,,,66.65,Other,100% of Medicaid,66.65,,,66.65,Other,100% of Medicaid,149.95,,,149.95,Other,225% of Medicaid,101.97,,,101.97,Other,153% of Medicaid,149.95,,,149.95,Other,225% of Medicaid,93.31,,,93.31,Other,140% of Medicaid,149.95,,,149.95,Other,225% of Medicaid,173.28,,,173.28,Other,260% of Medicaid,215.93,,,215.93,Other,324% of Medicaid,143.29,,,143.29,Other,215% of Medicaid,143.29,,,143.29,Other,215% of Medicaid,83.31,,,83.31,Other,125% of Medicaid,0.01,1279.86,
DISPENSING FEE MONAURAL WITH IMPRESSION,V5241,HCPCS,,66000148,CDM,470,RC,,,both,,,1542,1141.08,,,1141.08,Other,150% of Medicare + 9.63% HCRA Surcharge,693.9,45,,693.9,percent of total billed charges,Critical Access Hospital RCC factor,1002.3,65,,1002.3,percent of total billed charges,All Other,909.78,65,,909.78,percent of total billed charges,All Other,1179.63,76.5,,1179.63,percent of total billed charges,All Other,1094.82,69,,1094.82,percent of total billed charges,All Other,1063.98,65,,1063.98,percent of total billed charges,All Other,763.29,,,763.29,Other,110% of Medicare,1048.56,68,,1048.56,percent of total billed charges,All Other,124,,,124,Other,186% of Medicaid,1233.6,,,1233.6,percent of total billed charges,All Other,1279.86,83,,1279.86,percent of total billed charges,All Other,1279.86,83,,1279.86,percent of total billed charges,All Other,1233.6,80,,1233.6,percent of total billed charges,All Other,1279.86,83,,1279.86,percent of total billed charges,All Other,1233.6,80,,1233.6,percent of total billed charges,All Other,1079.4,70,,1079.4,percent of total billed charges,All Other,1002.3,65,,1002.3,percent of total billed charges,Default if not in Fee Schedule,1002.3,65,,1002.3,percent of total billed charges,Default if not in Fee Schedule,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,66.65,,,66.65,Other,100% of Medicaid,66.65,,,66.65,Other,100% of Medicaid,66.65,,,66.65,Other,100% of Medicaid,66.65,,,66.65,Other,100% of Medicaid,149.95,,,149.95,Other,225% of Medicaid,101.97,,,101.97,Other,153% of Medicaid,149.95,,,149.95,Other,225% of Medicaid,93.31,,,93.31,Other,140% of Medicaid,149.95,,,149.95,Other,225% of Medicaid,173.28,,,173.28,Other,260% of Medicaid,215.93,,,215.93,Other,324% of Medicaid,143.29,,,143.29,Other,215% of Medicaid,143.29,,,143.29,Other,215% of Medicaid,83.31,,,83.31,Other,125% of Medicaid,0.01,1279.86,
CALORIC VSTBLR TEST W/REC,92537,CPT,,66092537,CDM,470,RC,,,both,,,821,607.54,,,607.54,Other,150% of Medicare + 9.63% HCRA Surcharge,369.45,45,,369.45,percent of total billed charges,Critical Access Hospital RCC factor,533.65,65,,533.65,percent of total billed charges,All Other,484.39,65,,484.39,percent of total billed charges,All Other,8.5,,,8.5,Fee Schedule,,8.5,,,8.5,Fee Schedule,,8.5,,,8.5,Fee Schedule,,406.4,,,406.4,Other,110% of Medicare,38.62,,,38.62,Fee Schedule,,207,,,207,Other,186% of Medicaid,45.45,,,45.45,Fee Schedule,,509.02,,,509.02,Fee Schedule,,21.4,,,21.4,Fee Schedule,,45.45,,,45.45,Fee Schedule,,509.02,,,509.02,Fee Schedule,,656.8,80,,656.8,percent of total billed charges,All Other,574.7,70,,574.7,percent of total billed charges,All Other,49.2,,,49.2,Fee Schedule,,41.7,,,41.7,Fee Schedule,,382,,,382,Case Rate,,343,,,343,Case Rate,,382,,,382,Case Rate,,324,,,324,Case Rate,,111.55,,,111.55,Other,100% of Medicaid,111.55,,,111.55,Other,100% of Medicaid,111.55,,,111.55,Other,100% of Medicaid,111.55,,,111.55,Other,100% of Medicaid,251,,,251,Other,225% of Medicaid,170.68,,,170.68,Other,153% of Medicaid,251,,,251,Other,225% of Medicaid,156.17,,,156.17,Other,140% of Medicaid,251,,,251,Other,225% of Medicaid,290.04,,,290.04,Other,260% of Medicaid,361.43,,,361.43,Other,324% of Medicaid,239.84,,,239.84,Other,215% of Medicaid,239.84,,,239.84,Other,215% of Medicaid,139.44,,,139.44,Other,125% of Medicaid,8.5,656.8,
CALORIC VSTBLR TEST W/REC,92538,CPT,,66092538,CDM,470,RC,,,both,,,821,607.54,,,607.54,Other,150% of Medicare + 9.63% HCRA Surcharge,369.45,45,,369.45,percent of total billed charges,Critical Access Hospital RCC factor,533.65,65,,533.65,percent of total billed charges,All Other,484.39,65,,484.39,percent of total billed charges,All Other,4.76,,,4.76,Fee Schedule,,4.76,,,4.76,Fee Schedule,,4.76,,,4.76,Fee Schedule,,406.4,,,406.4,Other,110% of Medicare,27.67,,,27.67,Fee Schedule,,207,,,207,Other,186% of Medicaid,32.56,,,32.56,Fee Schedule,,509.02,,,509.02,Fee Schedule,,15.33,,,15.33,Fee Schedule,,32.56,,,32.56,Fee Schedule,,509.02,,,509.02,Fee Schedule,,656.8,80,,656.8,percent of total billed charges,All Other,574.7,70,,574.7,percent of total billed charges,All Other,32.8,,,32.8,Fee Schedule,,27.8,,,27.8,Fee Schedule,,382,,,382,Case Rate,,343,,,343,Case Rate,,382,,,382,Case Rate,,324,,,324,Case Rate,,111.55,,,111.55,Other,100% of Medicaid,111.55,,,111.55,Other,100% of Medicaid,111.55,,,111.55,Other,100% of Medicaid,111.55,,,111.55,Other,100% of Medicaid,251,,,251,Other,225% of Medicaid,170.68,,,170.68,Other,153% of Medicaid,251,,,251,Other,225% of Medicaid,156.17,,,156.17,Other,140% of Medicaid,251,,,251,Other,225% of Medicaid,290.04,,,290.04,Other,260% of Medicaid,361.43,,,361.43,Other,324% of Medicaid,239.84,,,239.84,Other,215% of Medicaid,239.84,,,239.84,Other,215% of Medicaid,139.44,,,139.44,Other,125% of Medicaid,4.76,656.8,
BASIC VESTIBULAR EVALUATION,92540,CPT,,66092540,CDM,470,RC,,,both,,,472,349.28,,,349.28,Other,150% of Medicare + 9.63% HCRA Surcharge,212.4,45,,212.4,percent of total billed charges,Critical Access Hospital RCC factor,306.8,65,,306.8,percent of total billed charges,All Other,278.48,65,,278.48,percent of total billed charges,All Other,125.95,,,125.95,Fee Schedule,,113.29,,,113.29,Fee Schedule,,107.07,,,107.07,Fee Schedule,,233.64,,,233.64,Other,110% of Medicare,127.84,,,127.84,Fee Schedule,,207,,,207,Other,186% of Medicaid,150.44,,,150.44,Fee Schedule,,292.64,,,292.64,Fee Schedule,,70.83,,,70.83,Fee Schedule,,150.44,,,150.44,Fee Schedule,,292.64,,,292.64,Fee Schedule,,377.6,80,,377.6,percent of total billed charges,All Other,330.4,70,,330.4,percent of total billed charges,All Other,162.36,,,162.36,Fee Schedule,,137.61,,,137.61,Fee Schedule,,382,,,382,Case Rate,,343,,,343,Case Rate,,382,,,382,Case Rate,,324,,,324,Case Rate,,111.55,,,111.55,Other,100% of Medicaid,111.55,,,111.55,Other,100% of Medicaid,111.55,,,111.55,Other,100% of Medicaid,111.55,,,111.55,Other,100% of Medicaid,251,,,251,Other,225% of Medicaid,170.68,,,170.68,Other,153% of Medicaid,251,,,251,Other,225% of Medicaid,156.17,,,156.17,Other,140% of Medicaid,251,,,251,Other,225% of Medicaid,290.04,,,290.04,Other,260% of Medicaid,361.43,,,361.43,Other,324% of Medicaid,239.84,,,239.84,Other,215% of Medicaid,239.84,,,239.84,Other,215% of Medicaid,139.44,,,139.44,Other,125% of Medicaid,70.83,382,
SCREENING PURE TONE AIR ONLY,92551,CPT,,66092551,CDM,470,RC,,,both,,,135,99.9,,,99.9,Other,150% of Medicare + 9.63% HCRA Surcharge,60.75,45,,60.75,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,11.9,,,11.9,Fee Schedule,,11.9,,,11.9,Fee Schedule,,11.9,,,11.9,Fee Schedule,,66.83,,,66.83,Other,110% of Medicare,91.8,68,,91.8,percent of total billed charges,All Other,124,,,124,Other,186% of Medicaid,108,,,108,percent of total billed charges,All Other,83.7,62,,83.7,percent of total billed charges,Lab and Radiology,74.25,83,,74.25,percent of total billed charges,All Other,108,80,,108,percent of total billed charges,All Other,83.7,62,,83.7,percent of total billed charges,Lab and Radiology,368,,,368,Case Rate,Therapy Visit,94.5,70,,94.5,percent of total billed charges,All Other,55.76,,,55.76,Fee Schedule,,47.26,,,47.26,Fee Schedule,,382,,,382,Case Rate,,343,,,343,Case Rate,,382,,,382,Case Rate,,324,,,324,Case Rate,,66.65,,,66.65,Other,100% of Medicaid,66.65,,,66.65,Other,100% of Medicaid,66.65,,,66.65,Other,100% of Medicaid,66.65,,,66.65,Other,100% of Medicaid,149.95,,,149.95,Other,225% of Medicaid,101.97,,,101.97,Other,153% of Medicaid,149.95,,,149.95,Other,225% of Medicaid,93.31,,,93.31,Other,140% of Medicaid,149.95,,,149.95,Other,225% of Medicaid,173.28,,,173.28,Other,260% of Medicaid,215.93,,,215.93,Other,324% of Medicaid,143.29,,,143.29,Other,215% of Medicaid,143.29,,,143.29,Other,215% of Medicaid,83.31,,,83.31,Other,125% of Medicaid,0.01,382,
STENGER PURE TONE,92565,CPT,,66092565,CDM,470,RC,,,both,,,362,267.88,,,267.88,Other,150% of Medicare + 9.63% HCRA Surcharge,162.9,45,,162.9,percent of total billed charges,Critical Access Hospital RCC factor,235.3,65,,235.3,percent of total billed charges,All Other,213.58,65,,213.58,percent of total billed charges,All Other,87.06,,,87.06,Fee Schedule,,78.3,,,78.3,Fee Schedule,,74.01,,,74.01,Fee Schedule,,179.19,,,179.19,Other,110% of Medicare,86.68,,,86.68,Fee Schedule,,124,,,124,Other,186% of Medicaid,102,,,102,Fee Schedule,,224.44,,,224.44,Fee Schedule,,48.03,,,48.03,Fee Schedule,,102,,,102,Fee Schedule,,224.44,,,224.44,Fee Schedule,,289.6,80,,289.6,percent of total billed charges,All Other,253.4,70,,253.4,percent of total billed charges,All Other,91.84,,,91.84,Fee Schedule,,77.84,,,77.84,Fee Schedule,,382,,,382,Case Rate,,343,,,343,Case Rate,,382,,,382,Case Rate,,324,,,324,Case Rate,,66.65,,,66.65,Other,100% of Medicaid,66.65,,,66.65,Other,100% of Medicaid,66.65,,,66.65,Other,100% of Medicaid,66.65,,,66.65,Other,100% of Medicaid,149.95,,,149.95,Other,225% of Medicaid,101.97,,,101.97,Other,153% of Medicaid,149.95,,,149.95,Other,225% of Medicaid,93.31,,,93.31,Other,140% of Medicaid,149.95,,,149.95,Other,225% of Medicaid,173.28,,,173.28,Other,260% of Medicaid,215.93,,,215.93,Other,324% of Medicaid,143.29,,,143.29,Other,215% of Medicaid,143.29,,,143.29,Other,215% of Medicaid,83.31,,,83.31,Other,125% of Medicaid,48.03,382,
FILTERED SPEECH TEST,92571,CPT,,66092571,CDM,470,RC,,,both,,,362,267.88,,,267.88,Other,150% of Medicare + 9.63% HCRA Surcharge,162.9,45,,162.9,percent of total billed charges,Critical Access Hospital RCC factor,235.3,65,,235.3,percent of total billed charges,All Other,213.58,65,,213.58,percent of total billed charges,All Other,133.58,,,133.58,Fee Schedule,,120.25,,,120.25,Fee Schedule,,113.59,,,113.59,Fee Schedule,,179.19,,,179.19,Other,110% of Medicare,246.16,68,,246.16,percent of total billed charges,All Other,124,,,124,Other,186% of Medicaid,289.6,,,289.6,percent of total billed charges,All Other,300.46,83,,300.46,percent of total billed charges,All Other,300.46,83,,300.46,percent of total billed charges,All Other,289.6,80,,289.6,percent of total billed charges,All Other,300.46,83,,300.46,percent of total billed charges,All Other,133.23,,,133.23,Fee Schedule,,253.4,70,,253.4,percent of total billed charges,All Other,137.76,,,137.76,Fee Schedule,,116.76,,,116.76,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,66.65,,,66.65,Other,100% of Medicaid,66.65,,,66.65,Other,100% of Medicaid,66.65,,,66.65,Other,100% of Medicaid,66.65,,,66.65,Other,100% of Medicaid,149.95,,,149.95,Other,225% of Medicaid,101.97,,,101.97,Other,153% of Medicaid,149.95,,,149.95,Other,225% of Medicaid,93.31,,,93.31,Other,140% of Medicaid,149.95,,,149.95,Other,225% of Medicaid,173.28,,,173.28,Other,260% of Medicaid,215.93,,,215.93,Other,324% of Medicaid,143.29,,,143.29,Other,215% of Medicaid,143.29,,,143.29,Other,215% of Medicaid,83.31,,,83.31,Other,125% of Medicaid,0.01,300.46,
ELECTROCOCHLEOGRAPHY,92584,CPT,,66092584,CDM,470,RC,,,both,,,441,326.34,,,326.34,Other,150% of Medicare + 9.63% HCRA Surcharge,198.45,45,,198.45,percent of total billed charges,Critical Access Hospital RCC factor,286.65,65,,286.65,percent of total billed charges,All Other,260.19,65,,260.19,percent of total billed charges,All Other,448.64,,,448.64,Fee Schedule,,403.52,,,403.52,Fee Schedule,,381.38,,,381.38,Fee Schedule,,218.3,,,218.3,Other,110% of Medicare,449.04,,,449.04,Fee Schedule,,118,,,118,Other,186% of Medicaid,528.42,,,528.42,Fee Schedule,,273.42,,,273.42,Fee Schedule,,248.81,,,248.81,Fee Schedule,,528.42,,,528.42,Fee Schedule,,273.42,,,273.42,Fee Schedule,,352.8,80,,352.8,percent of total billed charges,All Other,308.7,70,,308.7,percent of total billed charges,All Other,557.6,,,557.6,Fee Schedule,,472.6,,,472.6,Fee Schedule,,382,,,382,Case Rate,,343,,,343,Case Rate,,382,,,382,Case Rate,,324,,,324,Case Rate,,63.65,,,63.65,Other,100% of Medicaid,63.65,,,63.65,Other,100% of Medicaid,63.65,,,63.65,Other,100% of Medicaid,63.65,,,63.65,Other,100% of Medicaid,143.21,,,143.21,Other,225% of Medicaid,97.39,,,97.39,Other,153% of Medicaid,143.21,,,143.21,Other,225% of Medicaid,89.11,,,89.11,Other,140% of Medicaid,143.21,,,143.21,Other,225% of Medicaid,165.49,,,165.49,Other,260% of Medicaid,206.23,,,206.23,Other,324% of Medicaid,136.85,,,136.85,Other,215% of Medicaid,136.85,,,136.85,Other,215% of Medicaid,79.56,,,79.56,Other,125% of Medicaid,63.65,557.6,
EVOKED AUDITORY TEST LIMITED,92587,CPT,,66092587,CDM,470,RC,,,both,,,759,561.66,,,561.66,Other,150% of Medicare + 9.63% HCRA Surcharge,341.55,45,,341.55,percent of total billed charges,Critical Access Hospital RCC factor,493.35,65,,493.35,percent of total billed charges,All Other,447.81,65,,447.81,percent of total billed charges,All Other,201.47,,,201.47,Fee Schedule,,181.21,,,181.21,Fee Schedule,,171.27,,,171.27,Fee Schedule,,375.71,,,375.71,Other,110% of Medicare,15.31,,,15.31,Fee Schedule,,118,,,118,Other,186% of Medicaid,18.02,,,18.02,Fee Schedule,,470.58,,,470.58,Fee Schedule,,8.48,,,8.48,Fee Schedule,,18.02,,,18.02,Fee Schedule,,470.58,,,470.58,Fee Schedule,,607.2,80,,607.2,percent of total billed charges,All Other,531.3,70,,531.3,percent of total billed charges,All Other,19.68,,,19.68,Fee Schedule,,16.68,,,16.68,Fee Schedule,,382,,,382,Case Rate,,343,,,343,Case Rate,,382,,,382,Case Rate,,324,,,324,Case Rate,,63.65,,,63.65,Other,100% of Medicaid,63.65,,,63.65,Other,100% of Medicaid,63.65,,,63.65,Other,100% of Medicaid,63.65,,,63.65,Other,100% of Medicaid,143.21,,,143.21,Other,225% of Medicaid,97.39,,,97.39,Other,153% of Medicaid,143.21,,,143.21,Other,225% of Medicaid,89.11,,,89.11,Other,140% of Medicaid,143.21,,,143.21,Other,225% of Medicaid,165.49,,,165.49,Other,260% of Medicaid,206.23,,,206.23,Other,324% of Medicaid,136.85,,,136.85,Other,215% of Medicaid,136.85,,,136.85,Other,215% of Medicaid,79.56,,,79.56,Other,125% of Medicaid,8.48,607.2,
EVOKED AUDITORY TST COMPLETE,92588,CPT,,66092588,CDM,470,RC,,,both,,,697,515.78,,,515.78,Other,150% of Medicare + 9.63% HCRA Surcharge,313.65,45,,313.65,percent of total billed charges,Critical Access Hospital RCC factor,453.05,65,,453.05,percent of total billed charges,All Other,411.23,65,,411.23,percent of total billed charges,All Other,320.47,,,320.47,Fee Schedule,,288.24,,,288.24,Fee Schedule,,272.43,,,272.43,Fee Schedule,,345.02,,,345.02,Other,110% of Medicare,20.81,,,20.81,Fee Schedule,,118,,,118,Other,186% of Medicaid,24.49,,,24.49,Fee Schedule,,432.14,,,432.14,Fee Schedule,,11.53,,,11.53,Fee Schedule,,24.49,,,24.49,Fee Schedule,,432.14,,,432.14,Fee Schedule,,557.6,80,,557.6,percent of total billed charges,All Other,487.9,70,,487.9,percent of total billed charges,All Other,26.24,,,26.24,Fee Schedule,,22.24,,,22.24,Fee Schedule,,382,,,382,Case Rate,,343,,,343,Case Rate,,382,,,382,Case Rate,,324,,,324,Case Rate,,63.65,,,63.65,Other,100% of Medicaid,63.65,,,63.65,Other,100% of Medicaid,63.65,,,63.65,Other,100% of Medicaid,63.65,,,63.65,Other,100% of Medicaid,143.21,,,143.21,Other,225% of Medicaid,97.39,,,97.39,Other,153% of Medicaid,143.21,,,143.21,Other,225% of Medicaid,89.11,,,89.11,Other,140% of Medicaid,143.21,,,143.21,Other,225% of Medicaid,165.49,,,165.49,Other,260% of Medicaid,206.23,,,206.23,Other,324% of Medicaid,136.85,,,136.85,Other,215% of Medicaid,136.85,,,136.85,Other,215% of Medicaid,79.56,,,79.56,Other,125% of Medicaid,11.53,557.6,
HEARING AID CHECK ONE EAR,92592,CPT,,66092592,CDM,470,RC,,,both,,,91,67.34,,,67.34,Other,150% of Medicare + 9.63% HCRA Surcharge,40.95,45,,40.95,percent of total billed charges,Critical Access Hospital RCC factor,59.15,65,,59.15,percent of total billed charges,All Other,53.69,65,,53.69,percent of total billed charges,All Other,69.62,76.5,,69.62,percent of total billed charges,All Other,64.61,69,,64.61,percent of total billed charges,All Other,62.79,65,,62.79,percent of total billed charges,All Other,45.05,,,45.05,Other,110% of Medicare,61.88,68,,61.88,percent of total billed charges,All Other,124,,,124,Other,186% of Medicaid,72.8,,,72.8,percent of total billed charges,All Other,75.53,83,,75.53,percent of total billed charges,All Other,75.53,83,,75.53,percent of total billed charges,All Other,72.8,80,,72.8,percent of total billed charges,All Other,75.53,83,,75.53,percent of total billed charges,All Other,72.8,80,,72.8,percent of total billed charges,All Other,63.7,70,,63.7,percent of total billed charges,All Other,59.15,65,,59.15,percent of total billed charges,Default if not in Fee Schedule,59.15,65,,59.15,percent of total billed charges,Default if not in Fee Schedule,382,,,382,Case Rate,,343,,,343,Case Rate,,382,,,382,Case Rate,,324,,,324,Case Rate,,66.65,,,66.65,Other,100% of Medicaid,66.65,,,66.65,Other,100% of Medicaid,66.65,,,66.65,Other,100% of Medicaid,66.65,,,66.65,Other,100% of Medicaid,149.95,,,149.95,Other,225% of Medicaid,101.97,,,101.97,Other,153% of Medicaid,149.95,,,149.95,Other,225% of Medicaid,93.31,,,93.31,Other,140% of Medicaid,149.95,,,149.95,Other,225% of Medicaid,173.28,,,173.28,Other,260% of Medicaid,215.93,,,215.93,Other,324% of Medicaid,143.29,,,143.29,Other,215% of Medicaid,143.29,,,143.29,Other,215% of Medicaid,83.31,,,83.31,Other,125% of Medicaid,40.95,382,
HEARING AID CHECK BOTH,92593,CPT,,66092593,CDM,470,RC,,,both,,,180,133.2,,,133.2,Other,150% of Medicare + 9.63% HCRA Surcharge,81,45,,81,percent of total billed charges,Critical Access Hospital RCC factor,117,65,,117,percent of total billed charges,All Other,106.2,65,,106.2,percent of total billed charges,All Other,137.7,76.5,,137.7,percent of total billed charges,All Other,127.8,69,,127.8,percent of total billed charges,All Other,124.2,65,,124.2,percent of total billed charges,All Other,89.1,,,89.1,Other,110% of Medicare,122.4,68,,122.4,percent of total billed charges,All Other,124,,,124,Other,186% of Medicaid,144,,,144,percent of total billed charges,All Other,149.4,83,,149.4,percent of total billed charges,All Other,149.4,83,,149.4,percent of total billed charges,All Other,144,80,,144,percent of total billed charges,All Other,149.4,83,,149.4,percent of total billed charges,All Other,144,80,,144,percent of total billed charges,All Other,126,70,,126,percent of total billed charges,All Other,117,65,,117,percent of total billed charges,Default if not in Fee Schedule,117,65,,117,percent of total billed charges,Default if not in Fee Schedule,382,,,382,Case Rate,,343,,,343,Case Rate,,382,,,382,Case Rate,,324,,,324,Case Rate,,66.65,,,66.65,Other,100% of Medicaid,66.65,,,66.65,Other,100% of Medicaid,66.65,,,66.65,Other,100% of Medicaid,66.65,,,66.65,Other,100% of Medicaid,149.95,,,149.95,Other,225% of Medicaid,101.97,,,101.97,Other,153% of Medicaid,149.95,,,149.95,Other,225% of Medicaid,93.31,,,93.31,Other,140% of Medicaid,149.95,,,149.95,Other,225% of Medicaid,173.28,,,173.28,Other,260% of Medicaid,215.93,,,215.93,Other,324% of Medicaid,143.29,,,143.29,Other,215% of Medicaid,143.29,,,143.29,Other,215% of Medicaid,83.31,,,83.31,Other,125% of Medicaid,66.65,382,
ELECTRO HEARING AID TEST ONE,92594,CPT,,66092594,CDM,470,RC,,,both,,,118,87.32,,,87.32,Other,150% of Medicare + 9.63% HCRA Surcharge,53.1,45,,53.1,percent of total billed charges,Critical Access Hospital RCC factor,76.7,65,,76.7,percent of total billed charges,All Other,69.62,65,,69.62,percent of total billed charges,All Other,90.27,76.5,,90.27,percent of total billed charges,All Other,83.78,69,,83.78,percent of total billed charges,All Other,81.42,65,,81.42,percent of total billed charges,All Other,58.41,,,58.41,Other,110% of Medicare,80.24,68,,80.24,percent of total billed charges,All Other,124,,,124,Other,186% of Medicaid,94.4,,,94.4,percent of total billed charges,All Other,97.94,83,,97.94,percent of total billed charges,All Other,97.94,83,,97.94,percent of total billed charges,All Other,94.4,80,,94.4,percent of total billed charges,All Other,97.94,83,,97.94,percent of total billed charges,All Other,94.4,80,,94.4,percent of total billed charges,All Other,82.6,70,,82.6,percent of total billed charges,All Other,76.7,65,,76.7,percent of total billed charges,Default if not in Fee Schedule,76.7,65,,76.7,percent of total billed charges,Default if not in Fee Schedule,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,66.65,,,66.65,Other,100% of Medicaid,66.65,,,66.65,Other,100% of Medicaid,66.65,,,66.65,Other,100% of Medicaid,66.65,,,66.65,Other,100% of Medicaid,149.95,,,149.95,Other,225% of Medicaid,101.97,,,101.97,Other,153% of Medicaid,149.95,,,149.95,Other,225% of Medicaid,93.31,,,93.31,Other,140% of Medicaid,149.95,,,149.95,Other,225% of Medicaid,173.28,,,173.28,Other,260% of Medicaid,215.93,,,215.93,Other,324% of Medicaid,143.29,,,143.29,Other,215% of Medicaid,143.29,,,143.29,Other,215% of Medicaid,83.31,,,83.31,Other,125% of Medicaid,0.01,215.93,
ELECTRO HEARING AID TEST BOTH,92595,CPT,,66092595,CDM,470,RC,,,both,,,205,151.7,,,151.7,Other,150% of Medicare + 9.63% HCRA Surcharge,92.25,45,,92.25,percent of total billed charges,Critical Access Hospital RCC factor,133.25,65,,133.25,percent of total billed charges,All Other,120.95,65,,120.95,percent of total billed charges,All Other,156.83,76.5,,156.83,percent of total billed charges,All Other,145.55,69,,145.55,percent of total billed charges,All Other,141.45,65,,141.45,percent of total billed charges,All Other,101.48,,,101.48,Other,110% of Medicare,139.4,68,,139.4,percent of total billed charges,All Other,124,,,124,Other,186% of Medicaid,164,,,164,percent of total billed charges,All Other,170.15,83,,170.15,percent of total billed charges,All Other,170.15,83,,170.15,percent of total billed charges,All Other,164,80,,164,percent of total billed charges,All Other,170.15,83,,170.15,percent of total billed charges,All Other,164,80,,164,percent of total billed charges,All Other,143.5,70,,143.5,percent of total billed charges,All Other,133.25,65,,133.25,percent of total billed charges,Default if not in Fee Schedule,133.25,65,,133.25,percent of total billed charges,Default if not in Fee Schedule,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,66.65,,,66.65,Other,100% of Medicaid,66.65,,,66.65,Other,100% of Medicaid,66.65,,,66.65,Other,100% of Medicaid,66.65,,,66.65,Other,100% of Medicaid,149.95,,,149.95,Other,225% of Medicaid,101.97,,,101.97,Other,153% of Medicaid,149.95,,,149.95,Other,225% of Medicaid,93.31,,,93.31,Other,140% of Medicaid,149.95,,,149.95,Other,225% of Medicaid,173.28,,,173.28,Other,260% of Medicaid,215.93,,,215.93,Other,324% of Medicaid,143.29,,,143.29,Other,215% of Medicaid,143.29,,,143.29,Other,215% of Medicaid,83.31,,,83.31,Other,125% of Medicaid,0.01,215.93,
ASSESSMENT FOR HEARING AID,V5010,HCPCS,,66000002,CDM,471,RC,,,both,,,239,176.86,,,176.86,Other,150% of Medicare + 9.63% HCRA Surcharge,107.55,45,,107.55,percent of total billed charges,Critical Access Hospital RCC factor,155.35,65,,155.35,percent of total billed charges,All Other,141.01,65,,141.01,percent of total billed charges,All Other,182.84,76.5,,182.84,percent of total billed charges,All Other,169.69,69,,169.69,percent of total billed charges,All Other,164.91,65,,164.91,percent of total billed charges,All Other,118.31,,,118.31,Other,110% of Medicare,162.52,68,,162.52,percent of total billed charges,All Other,124,,,124,Other,186% of Medicaid,191.2,,,191.2,percent of total billed charges,All Other,198.37,83,,198.37,percent of total billed charges,All Other,198.37,83,,198.37,percent of total billed charges,All Other,191.2,80,,191.2,percent of total billed charges,All Other,198.37,83,,198.37,percent of total billed charges,All Other,191.2,80,,191.2,percent of total billed charges,All Other,167.3,70,,167.3,percent of total billed charges,All Other,155.35,65,,155.35,percent of total billed charges,Default if not in Fee Schedule,155.35,65,,155.35,percent of total billed charges,Default if not in Fee Schedule,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,66.65,,,66.65,Other,100% of Medicaid,66.65,,,66.65,Other,100% of Medicaid,66.65,,,66.65,Other,100% of Medicaid,66.65,,,66.65,Other,100% of Medicaid,149.95,,,149.95,Other,225% of Medicaid,101.97,,,101.97,Other,153% of Medicaid,149.95,,,149.95,Other,225% of Medicaid,93.31,,,93.31,Other,140% of Medicaid,149.95,,,149.95,Other,225% of Medicaid,173.28,,,173.28,Other,260% of Medicaid,215.93,,,215.93,Other,324% of Medicaid,143.29,,,143.29,Other,215% of Medicaid,143.29,,,143.29,Other,215% of Medicaid,83.31,,,83.31,Other,125% of Medicaid,0.01,215.93,
CONFORMITY EVALUATION,V5020,HCPCS,,66000008,CDM,471,RC,,,both,,,220,162.8,,,162.8,Other,150% of Medicare + 9.63% HCRA Surcharge,99,45,,99,percent of total billed charges,Critical Access Hospital RCC factor,143,65,,143,percent of total billed charges,All Other,129.8,65,,129.8,percent of total billed charges,All Other,168.3,76.5,,168.3,percent of total billed charges,All Other,156.2,69,,156.2,percent of total billed charges,All Other,151.8,65,,151.8,percent of total billed charges,All Other,108.9,,,108.9,Other,110% of Medicare,149.6,68,,149.6,percent of total billed charges,All Other,124,,,124,Other,186% of Medicaid,176,,,176,percent of total billed charges,All Other,182.6,83,,182.6,percent of total billed charges,All Other,182.6,83,,182.6,percent of total billed charges,All Other,176,80,,176,percent of total billed charges,All Other,182.6,83,,182.6,percent of total billed charges,All Other,176,80,,176,percent of total billed charges,All Other,154,70,,154,percent of total billed charges,All Other,143,65,,143,percent of total billed charges,Default if not in Fee Schedule,143,65,,143,percent of total billed charges,Default if not in Fee Schedule,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,66.65,,,66.65,Other,100% of Medicaid,66.65,,,66.65,Other,100% of Medicaid,66.65,,,66.65,Other,100% of Medicaid,66.65,,,66.65,Other,100% of Medicaid,149.95,,,149.95,Other,225% of Medicaid,101.97,,,101.97,Other,153% of Medicaid,149.95,,,149.95,Other,225% of Medicaid,93.31,,,93.31,Other,140% of Medicaid,149.95,,,149.95,Other,225% of Medicaid,173.28,,,173.28,Other,260% of Medicaid,215.93,,,215.93,Other,324% of Medicaid,143.29,,,143.29,Other,215% of Medicaid,143.29,,,143.29,Other,215% of Medicaid,83.31,,,83.31,Other,125% of Medicaid,0.01,215.93,
SPEECH/HEARING THERAPY INDIV,92507,CPT,,66092507,CDM,471,RC,,,both,,,539,398.86,,,398.86,Other,150% of Medicare + 9.63% HCRA Surcharge,242.55,45,,242.55,percent of total billed charges,Critical Access Hospital RCC factor,180,,,180,Fee Schedule,,162,,,162,Fee Schedule,,501.44,,,501.44,Fee Schedule,,451.01,,,451.01,Fee Schedule,,426.27,,,426.27,Fee Schedule,,266.81,,,266.81,Other,110% of Medicare,305.25,,,305.25,Fee Schedule,,186,,,186,Other,186% of Medicaid,359.21,,,359.21,Fee Schedule,,334.18,62,,334.18,percent of total billed charges,Lab and Radiology,169.13,,,169.13,Fee Schedule,,359.21,,,359.21,Fee Schedule,,334.18,62,,334.18,percent of total billed charges,Lab and Radiology,368,,,368,Case Rate,Therapy Visit,377.3,70,,377.3,percent of total billed charges,All Other,370.64,,,370.64,Fee Schedule,,314.14,,,314.14,Fee Schedule,,382,,,382,Case Rate,,343,,,343,Case Rate,,382,,,382,Case Rate,,324,,,324,Case Rate,,100.07,,,100.07,Other,100% of Medicaid,100.07,,,100.07,Other,100% of Medicaid,100.07,,,100.07,Other,100% of Medicaid,100.07,,,100.07,Other,100% of Medicaid,225.16,,,225.16,Other,225% of Medicaid,153.11,,,153.11,Other,153% of Medicaid,225.16,,,225.16,Other,225% of Medicaid,140.1,,,140.1,Other,140% of Medicaid,225.16,,,225.16,Other,225% of Medicaid,260.19,,,260.19,Other,260% of Medicaid,324.23,,,324.23,Other,324% of Medicaid,215.15,,,215.15,Other,215% of Medicaid,215.15,,,215.15,Other,215% of Medicaid,125.09,,,125.09,Other,125% of Medicaid,100.07,501.44,
SPONTANEOUS NYSTAGMUS GAZE & FIX,92541,CPT,,66092541,CDM,471,RC,,,both,,,697,515.78,,,515.78,Other,150% of Medicare + 9.63% HCRA Surcharge,313.65,45,,313.65,percent of total billed charges,Critical Access Hospital RCC factor,453.05,65,,453.05,percent of total billed charges,All Other,411.23,65,,411.23,percent of total billed charges,All Other,169.43,,,169.43,Fee Schedule,,152.39,,,152.39,Fee Schedule,,144.03,,,144.03,Fee Schedule,,345.02,,,345.02,Other,110% of Medicare,18.04,,,18.04,Fee Schedule,,124,,,124,Other,186% of Medicaid,21.23,,,21.23,Fee Schedule,,432.14,,,432.14,Fee Schedule,,10,,,10,Fee Schedule,,21.23,,,21.23,Fee Schedule,,432.14,,,432.14,Fee Schedule,,557.6,80,,557.6,percent of total billed charges,All Other,487.9,70,,487.9,percent of total billed charges,All Other,22.96,,,22.96,Fee Schedule,,19.46,,,19.46,Fee Schedule,,382,,,382,Case Rate,,343,,,343,Case Rate,,382,,,382,Case Rate,,324,,,324,Case Rate,,66.65,,,66.65,Other,100% of Medicaid,66.65,,,66.65,Other,100% of Medicaid,66.65,,,66.65,Other,100% of Medicaid,66.65,,,66.65,Other,100% of Medicaid,149.95,,,149.95,Other,225% of Medicaid,101.97,,,101.97,Other,153% of Medicaid,149.95,,,149.95,Other,225% of Medicaid,93.31,,,93.31,Other,140% of Medicaid,149.95,,,149.95,Other,225% of Medicaid,173.28,,,173.28,Other,260% of Medicaid,215.93,,,215.93,Other,324% of Medicaid,143.29,,,143.29,Other,215% of Medicaid,143.29,,,143.29,Other,215% of Medicaid,83.31,,,83.31,Other,125% of Medicaid,10,557.6,
POSITIONAL NYSTAGMUS MIN 4 POS,92542,CPT,,66092542,CDM,471,RC,,,both,,,697,515.78,,,515.78,Other,150% of Medicare + 9.63% HCRA Surcharge,313.65,45,,313.65,percent of total billed charges,Critical Access Hospital RCC factor,453.05,65,,453.05,percent of total billed charges,All Other,411.23,65,,411.23,percent of total billed charges,All Other,190.04,,,190.04,Fee Schedule,,170.92,,,170.92,Fee Schedule,,161.55,,,161.55,Fee Schedule,,345.02,,,345.02,Other,110% of Medicare,18.04,,,18.04,Fee Schedule,,124,,,124,Other,186% of Medicaid,21.23,,,21.23,Fee Schedule,,432.14,,,432.14,Fee Schedule,,10,,,10,Fee Schedule,,21.23,,,21.23,Fee Schedule,,432.14,,,432.14,Fee Schedule,,557.6,80,,557.6,percent of total billed charges,All Other,487.9,70,,487.9,percent of total billed charges,All Other,21.32,,,21.32,Fee Schedule,,18.07,,,18.07,Fee Schedule,,382,,,382,Case Rate,,343,,,343,Case Rate,,382,,,382,Case Rate,,324,,,324,Case Rate,,66.65,,,66.65,Other,100% of Medicaid,66.65,,,66.65,Other,100% of Medicaid,66.65,,,66.65,Other,100% of Medicaid,66.65,,,66.65,Other,100% of Medicaid,149.95,,,149.95,Other,225% of Medicaid,101.97,,,101.97,Other,153% of Medicaid,149.95,,,149.95,Other,225% of Medicaid,93.31,,,93.31,Other,140% of Medicaid,149.95,,,149.95,Other,225% of Medicaid,173.28,,,173.28,Other,260% of Medicaid,215.93,,,215.93,Other,324% of Medicaid,143.29,,,143.29,Other,215% of Medicaid,143.29,,,143.29,Other,215% of Medicaid,83.31,,,83.31,Other,125% of Medicaid,10,557.6,
OPTOKINETIC NYSTAGMUS W RECORD,92544,CPT,,66092544,CDM,471,RC,,,both,,,697,515.78,,,515.78,Other,150% of Medicare + 9.63% HCRA Surcharge,313.65,45,,313.65,percent of total billed charges,Critical Access Hospital RCC factor,453.05,65,,453.05,percent of total billed charges,All Other,411.23,65,,411.23,percent of total billed charges,All Other,160.26,,,160.26,Fee Schedule,,144.14,,,144.14,Fee Schedule,,136.24,,,136.24,Fee Schedule,,345.02,,,345.02,Other,110% of Medicare,15.31,,,15.31,Fee Schedule,,124,,,124,Other,186% of Medicaid,18.02,,,18.02,Fee Schedule,,432.14,,,432.14,Fee Schedule,,8.48,,,8.48,Fee Schedule,,18.02,,,18.02,Fee Schedule,,432.14,,,432.14,Fee Schedule,,557.6,80,,557.6,percent of total billed charges,All Other,487.9,70,,487.9,percent of total billed charges,All Other,18.04,,,18.04,Fee Schedule,,15.29,,,15.29,Fee Schedule,,382,,,382,Case Rate,,343,,,343,Case Rate,,382,,,382,Case Rate,,324,,,324,Case Rate,,66.65,,,66.65,Other,100% of Medicaid,66.65,,,66.65,Other,100% of Medicaid,66.65,,,66.65,Other,100% of Medicaid,66.65,,,66.65,Other,100% of Medicaid,149.95,,,149.95,Other,225% of Medicaid,101.97,,,101.97,Other,153% of Medicaid,149.95,,,149.95,Other,225% of Medicaid,93.31,,,93.31,Other,140% of Medicaid,149.95,,,149.95,Other,225% of Medicaid,173.28,,,173.28,Other,260% of Medicaid,215.93,,,215.93,Other,324% of Medicaid,143.29,,,143.29,Other,215% of Medicaid,143.29,,,143.29,Other,215% of Medicaid,83.31,,,83.31,Other,125% of Medicaid,8.48,557.6,
OSCILLATING TRACKING W RECORD,92545,CPT,,66092545,CDM,471,RC,,,both,,,697,515.78,,,515.78,Other,150% of Medicare + 9.63% HCRA Surcharge,313.65,45,,313.65,percent of total billed charges,Critical Access Hospital RCC factor,453.05,65,,453.05,percent of total billed charges,All Other,411.23,65,,411.23,percent of total billed charges,All Other,153.41,,,153.41,Fee Schedule,,137.98,,,137.98,Fee Schedule,,130.41,,,130.41,Fee Schedule,,345.02,,,345.02,Other,110% of Medicare,15.31,,,15.31,Fee Schedule,,124,,,124,Other,186% of Medicaid,18.02,,,18.02,Fee Schedule,,432.14,,,432.14,Fee Schedule,,8.48,,,8.48,Fee Schedule,,18.02,,,18.02,Fee Schedule,,432.14,,,432.14,Fee Schedule,,557.6,80,,557.6,percent of total billed charges,All Other,487.9,70,,487.9,percent of total billed charges,All Other,18.04,,,18.04,Fee Schedule,,15.29,,,15.29,Fee Schedule,,382,,,382,Case Rate,,343,,,343,Case Rate,,382,,,382,Case Rate,,324,,,324,Case Rate,,66.65,,,66.65,Other,100% of Medicaid,66.65,,,66.65,Other,100% of Medicaid,66.65,,,66.65,Other,100% of Medicaid,66.65,,,66.65,Other,100% of Medicaid,149.95,,,149.95,Other,225% of Medicaid,101.97,,,101.97,Other,153% of Medicaid,149.95,,,149.95,Other,225% of Medicaid,93.31,,,93.31,Other,140% of Medicaid,149.95,,,149.95,Other,225% of Medicaid,173.28,,,173.28,Other,260% of Medicaid,215.93,,,215.93,Other,324% of Medicaid,143.29,,,143.29,Other,215% of Medicaid,143.29,,,143.29,Other,215% of Medicaid,83.31,,,83.31,Other,125% of Medicaid,8.48,557.6,
USE VERTICAL ELECTRODES,92547,CPT,,66092547,CDM,471,RC,,,both,,,697,515.78,,,515.78,Other,150% of Medicare + 9.63% HCRA Surcharge,313.65,45,,313.65,percent of total billed charges,Critical Access Hospital RCC factor,453.05,65,,453.05,percent of total billed charges,All Other,411.23,65,,411.23,percent of total billed charges,All Other,34.41,,,34.41,Fee Schedule,,30.95,,,30.95,Fee Schedule,,29.25,,,29.25,Fee Schedule,,345.02,,,345.02,Other,110% of Medicare,43.93,,,43.93,Fee Schedule,,207,,,207,Other,186% of Medicaid,51.69,,,51.69,Fee Schedule,,432.14,,,432.14,Fee Schedule,,24.34,,,24.34,Fee Schedule,,51.69,,,51.69,Fee Schedule,,432.14,,,432.14,Fee Schedule,,557.6,80,,557.6,percent of total billed charges,All Other,487.9,70,,487.9,percent of total billed charges,All Other,50.84,,,50.84,Fee Schedule,,43.09,,,43.09,Fee Schedule,,382,,,382,Case Rate,,343,,,343,Case Rate,,382,,,382,Case Rate,,324,,,324,Case Rate,,111.55,,,111.55,Other,100% of Medicaid,111.55,,,111.55,Other,100% of Medicaid,111.55,,,111.55,Other,100% of Medicaid,111.55,,,111.55,Other,100% of Medicaid,251,,,251,Other,225% of Medicaid,170.68,,,170.68,Other,153% of Medicaid,251,,,251,Other,225% of Medicaid,156.17,,,156.17,Other,140% of Medicaid,251,,,251,Other,225% of Medicaid,290.04,,,290.04,Other,260% of Medicaid,361.43,,,361.43,Other,324% of Medicaid,239.84,,,239.84,Other,215% of Medicaid,239.84,,,239.84,Other,215% of Medicaid,139.44,,,139.44,Other,125% of Medicaid,24.34,557.6,
TYMPANOMETRY & REFLEX THRESH,92550,CPT,,66092550,CDM,471,RC,,,both,,,329,243.46,,,243.46,Other,150% of Medicare + 9.63% HCRA Surcharge,148.05,45,,148.05,percent of total billed charges,Critical Access Hospital RCC factor,213.85,65,,213.85,percent of total billed charges,All Other,194.11,65,,194.11,percent of total billed charges,All Other,125.43,,,125.43,Fee Schedule,,112.81,,,112.81,Fee Schedule,,106.62,,,106.62,Fee Schedule,,162.86,,,162.86,Other,110% of Medicare,86.83,,,86.83,Fee Schedule,,118,,,118,Other,186% of Medicaid,102.18,,,102.18,Fee Schedule,,203.98,,,203.98,Fee Schedule,,48.11,,,48.11,Fee Schedule,,102.18,,,102.18,Fee Schedule,,203.98,,,203.98,Fee Schedule,,263.2,80,,263.2,percent of total billed charges,All Other,230.3,70,,230.3,percent of total billed charges,All Other,108.24,,,108.24,Fee Schedule,,91.74,,,91.74,Fee Schedule,,382,,,382,Case Rate,,343,,,343,Case Rate,,382,,,382,Case Rate,,324,,,324,Case Rate,,63.65,,,63.65,Other,100% of Medicaid,63.65,,,63.65,Other,100% of Medicaid,63.65,,,63.65,Other,100% of Medicaid,63.65,,,63.65,Other,100% of Medicaid,143.21,,,143.21,Other,225% of Medicaid,97.39,,,97.39,Other,153% of Medicaid,143.21,,,143.21,Other,225% of Medicaid,89.11,,,89.11,Other,140% of Medicaid,143.21,,,143.21,Other,225% of Medicaid,165.49,,,165.49,Other,260% of Medicaid,206.23,,,206.23,Other,324% of Medicaid,136.85,,,136.85,Other,215% of Medicaid,136.85,,,136.85,Other,215% of Medicaid,79.56,,,79.56,Other,125% of Medicaid,48.11,382,
PTA; AIR ONLY,92552,CPT,,66092552,CDM,471,RC,,,both,,,263,194.62,,,194.62,Other,150% of Medicare + 9.63% HCRA Surcharge,118.35,45,,118.35,percent of total billed charges,Critical Access Hospital RCC factor,170.95,65,,170.95,percent of total billed charges,All Other,155.17,65,,155.17,percent of total billed charges,All Other,171.75,,,171.75,Fee Schedule,,154.48,,,154.48,Fee Schedule,,146,,,146,Fee Schedule,,130.19,,,130.19,Other,110% of Medicare,156.68,,,156.68,Fee Schedule,,124,,,124,Other,186% of Medicaid,184.38,,,184.38,Fee Schedule,,163.06,,,163.06,Fee Schedule,,86.81,,,86.81,Fee Schedule,,184.38,,,184.38,Fee Schedule,,163.06,,,163.06,Fee Schedule,,210.4,80,,210.4,percent of total billed charges,All Other,184.1,70,,184.1,percent of total billed charges,All Other,162.36,,,162.36,Fee Schedule,,137.61,,,137.61,Fee Schedule,,382,,,382,Case Rate,,343,,,343,Case Rate,,382,,,382,Case Rate,,324,,,324,Case Rate,,66.65,,,66.65,Other,100% of Medicaid,66.65,,,66.65,Other,100% of Medicaid,66.65,,,66.65,Other,100% of Medicaid,66.65,,,66.65,Other,100% of Medicaid,149.95,,,149.95,Other,225% of Medicaid,101.97,,,101.97,Other,153% of Medicaid,149.95,,,149.95,Other,225% of Medicaid,93.31,,,93.31,Other,140% of Medicaid,149.95,,,149.95,Other,225% of Medicaid,173.28,,,173.28,Other,260% of Medicaid,215.93,,,215.93,Other,324% of Medicaid,143.29,,,143.29,Other,215% of Medicaid,143.29,,,143.29,Other,215% of Medicaid,83.31,,,83.31,Other,125% of Medicaid,66.65,382,
PTA; AIR AND BONE,92553,CPT,,66092553,CDM,471,RC,,,both,,,329,243.46,,,243.46,Other,150% of Medicare + 9.63% HCRA Surcharge,148.05,45,,148.05,percent of total billed charges,Critical Access Hospital RCC factor,213.85,65,,213.85,percent of total billed charges,All Other,194.11,65,,194.11,percent of total billed charges,All Other,217.49,,,217.49,Fee Schedule,,195.62,,,195.62,Fee Schedule,,184.89,,,184.89,Fee Schedule,,162.86,,,162.86,Other,110% of Medicare,189.61,,,189.61,Fee Schedule,,118,,,118,Other,186% of Medicaid,223.13,,,223.13,Fee Schedule,,203.98,,,203.98,Fee Schedule,,105.06,,,105.06,Fee Schedule,,223.13,,,223.13,Fee Schedule,,203.98,,,203.98,Fee Schedule,,263.2,80,,263.2,percent of total billed charges,All Other,230.3,70,,230.3,percent of total billed charges,All Other,196.8,,,196.8,Fee Schedule,,166.8,,,166.8,Fee Schedule,,382,,,382,Case Rate,,343,,,343,Case Rate,,382,,,382,Case Rate,,324,,,324,Case Rate,,63.65,,,63.65,Other,100% of Medicaid,63.65,,,63.65,Other,100% of Medicaid,63.65,,,63.65,Other,100% of Medicaid,63.65,,,63.65,Other,100% of Medicaid,143.21,,,143.21,Other,225% of Medicaid,97.39,,,97.39,Other,153% of Medicaid,143.21,,,143.21,Other,225% of Medicaid,89.11,,,89.11,Other,140% of Medicaid,143.21,,,143.21,Other,225% of Medicaid,165.49,,,165.49,Other,260% of Medicaid,206.23,,,206.23,Other,324% of Medicaid,136.85,,,136.85,Other,215% of Medicaid,136.85,,,136.85,Other,215% of Medicaid,79.56,,,79.56,Other,125% of Medicaid,63.65,382,
SPEECH AUDIOM THRESHOLD,92555,CPT,,66092555,CDM,471,RC,,,both,,,170,125.8,,,125.8,Other,150% of Medicare + 9.63% HCRA Surcharge,76.5,45,,76.5,percent of total billed charges,Critical Access Hospital RCC factor,110.5,65,,110.5,percent of total billed charges,All Other,100.3,65,,100.3,percent of total billed charges,All Other,125.95,,,125.95,Fee Schedule,,113.29,,,113.29,Fee Schedule,,107.07,,,107.07,Fee Schedule,,84.15,,,84.15,Other,110% of Medicare,119.61,,,119.61,Fee Schedule,,124,,,124,Other,186% of Medicaid,140.76,,,140.76,Fee Schedule,,105.4,,,105.4,Fee Schedule,,66.28,,,66.28,Fee Schedule,,140.76,,,140.76,Fee Schedule,,105.4,,,105.4,Fee Schedule,,136,80,,136,percent of total billed charges,All Other,119,70,,119,percent of total billed charges,All Other,123,,,123,Fee Schedule,,104.25,,,104.25,Fee Schedule,,382,,,382,Case Rate,,343,,,343,Case Rate,,382,,,382,Case Rate,,324,,,324,Case Rate,,66.65,,,66.65,Other,100% of Medicaid,66.65,,,66.65,Other,100% of Medicaid,66.65,,,66.65,Other,100% of Medicaid,66.65,,,66.65,Other,100% of Medicaid,149.95,,,149.95,Other,225% of Medicaid,101.97,,,101.97,Other,153% of Medicaid,149.95,,,149.95,Other,225% of Medicaid,93.31,,,93.31,Other,140% of Medicaid,149.95,,,149.95,Other,225% of Medicaid,173.28,,,173.28,Other,260% of Medicaid,215.93,,,215.93,Other,324% of Medicaid,143.29,,,143.29,Other,215% of Medicaid,143.29,,,143.29,Other,215% of Medicaid,83.31,,,83.31,Other,125% of Medicaid,66.28,382,
SA THRESHOLD; W SR,92556,CPT,,66092556,CDM,471,RC,,,both,,,185,136.9,,,136.9,Other,150% of Medicare + 9.63% HCRA Surcharge,83.25,45,,83.25,percent of total billed charges,Critical Access Hospital RCC factor,120.25,65,,120.25,percent of total billed charges,All Other,109.15,65,,109.15,percent of total billed charges,All Other,194.62,,,194.62,Fee Schedule,,175.05,,,175.05,Fee Schedule,,165.45,,,165.45,Fee Schedule,,91.58,,,91.58,Other,110% of Medicare,185.48,,,185.48,Fee Schedule,,124,,,124,Other,186% of Medicaid,218.27,,,218.27,Fee Schedule,,114.7,,,114.7,Fee Schedule,,102.77,,,102.77,Fee Schedule,,218.27,,,218.27,Fee Schedule,,114.7,,,114.7,Fee Schedule,,148,80,,148,percent of total billed charges,All Other,129.5,70,,129.5,percent of total billed charges,All Other,193.52,,,193.52,Fee Schedule,,164.02,,,164.02,Fee Schedule,,382,,,382,Case Rate,,343,,,343,Case Rate,,382,,,382,Case Rate,,324,,,324,Case Rate,,66.65,,,66.65,Other,100% of Medicaid,66.65,,,66.65,Other,100% of Medicaid,66.65,,,66.65,Other,100% of Medicaid,66.65,,,66.65,Other,100% of Medicaid,149.95,,,149.95,Other,225% of Medicaid,101.97,,,101.97,Other,153% of Medicaid,149.95,,,149.95,Other,225% of Medicaid,93.31,,,93.31,Other,140% of Medicaid,149.95,,,149.95,Other,225% of Medicaid,173.28,,,173.28,Other,260% of Medicaid,215.93,,,215.93,Other,324% of Medicaid,143.29,,,143.29,Other,215% of Medicaid,143.29,,,143.29,Other,215% of Medicaid,83.31,,,83.31,Other,125% of Medicaid,66.65,382,
CAE W SR,92557,CPT,,66092557,CDM,471,RC,,,both,,,378,279.72,,,279.72,Other,150% of Medicare + 9.63% HCRA Surcharge,170.1,45,,170.1,percent of total billed charges,Critical Access Hospital RCC factor,245.7,65,,245.7,percent of total billed charges,All Other,223.02,65,,223.02,percent of total billed charges,All Other,248.11,,,248.11,Fee Schedule,,223.16,,,223.16,Fee Schedule,,210.92,,,210.92,Fee Schedule,,187.11,,,187.11,Other,110% of Medicare,124.96,,,124.96,Fee Schedule,,118,,,118,Other,186% of Medicaid,147.05,,,147.05,Fee Schedule,,234.36,,,234.36,Fee Schedule,,69.24,,,69.24,Fee Schedule,,147.05,,,147.05,Fee Schedule,,234.36,,,234.36,Fee Schedule,,302.4,80,,302.4,percent of total billed charges,All Other,264.6,70,,264.6,percent of total billed charges,All Other,155.8,,,155.8,Fee Schedule,,132.05,,,132.05,Fee Schedule,,382,,,382,Case Rate,,343,,,343,Case Rate,,382,,,382,Case Rate,,324,,,324,Case Rate,,63.65,,,63.65,Other,100% of Medicaid,63.65,,,63.65,Other,100% of Medicaid,63.65,,,63.65,Other,100% of Medicaid,63.65,,,63.65,Other,100% of Medicaid,143.21,,,143.21,Other,225% of Medicaid,97.39,,,97.39,Other,153% of Medicaid,143.21,,,143.21,Other,225% of Medicaid,89.11,,,89.11,Other,140% of Medicaid,143.21,,,143.21,Other,225% of Medicaid,165.49,,,165.49,Other,260% of Medicaid,206.23,,,206.23,Other,324% of Medicaid,136.85,,,136.85,Other,215% of Medicaid,136.85,,,136.85,Other,215% of Medicaid,79.56,,,79.56,Other,125% of Medicaid,63.65,382,
TONE DECAY TEST,92563,CPT,,66092563,CDM,471,RC,,,both,,,362,267.88,,,267.88,Other,150% of Medicare + 9.63% HCRA Surcharge,162.9,45,,162.9,percent of total billed charges,Critical Access Hospital RCC factor,235.3,65,,235.3,percent of total billed charges,All Other,213.58,65,,213.58,percent of total billed charges,All Other,165.26,,,165.26,Fee Schedule,,148.77,,,148.77,Fee Schedule,,140.52,,,140.52,Fee Schedule,,179.19,,,179.19,Other,110% of Medicare,246.16,68,,246.16,percent of total billed charges,All Other,124,,,124,Other,186% of Medicaid,289.6,,,289.6,percent of total billed charges,All Other,300.46,83,,300.46,percent of total billed charges,All Other,300.46,83,,300.46,percent of total billed charges,All Other,289.6,80,,289.6,percent of total billed charges,All Other,300.46,83,,300.46,percent of total billed charges,All Other,148.99,,,148.99,Fee Schedule,,253.4,70,,253.4,percent of total billed charges,All Other,154.16,,,154.16,Fee Schedule,,130.66,,,130.66,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,66.65,,,66.65,Other,100% of Medicaid,66.65,,,66.65,Other,100% of Medicaid,66.65,,,66.65,Other,100% of Medicaid,66.65,,,66.65,Other,100% of Medicaid,149.95,,,149.95,Other,225% of Medicaid,101.97,,,101.97,Other,153% of Medicaid,149.95,,,149.95,Other,225% of Medicaid,93.31,,,93.31,Other,140% of Medicaid,149.95,,,149.95,Other,225% of Medicaid,173.28,,,173.28,Other,260% of Medicaid,215.93,,,215.93,Other,324% of Medicaid,143.29,,,143.29,Other,215% of Medicaid,143.29,,,143.29,Other,215% of Medicaid,83.31,,,83.31,Other,125% of Medicaid,0.01,300.46,
TYMPANOMETRY,92567,CPT,,66092567,CDM,471,RC,,,both,,,185,136.9,,,136.9,Other,150% of Medicare + 9.63% HCRA Surcharge,83.25,45,,83.25,percent of total billed charges,Critical Access Hospital RCC factor,120.25,65,,120.25,percent of total billed charges,All Other,109.15,65,,109.15,percent of total billed charges,All Other,94.91,,,94.91,Fee Schedule,,85.37,,,85.37,Fee Schedule,,80.68,,,80.68,Fee Schedule,,91.58,,,91.58,Other,110% of Medicare,42.64,,,42.64,Fee Schedule,,124,,,124,Other,186% of Medicaid,50.18,,,50.18,Fee Schedule,,114.7,,,114.7,Fee Schedule,,23.63,,,23.63,Fee Schedule,,50.18,,,50.18,Fee Schedule,,114.7,,,114.7,Fee Schedule,,148,80,,148,percent of total billed charges,All Other,129.5,70,,129.5,percent of total billed charges,All Other,50.84,,,50.84,Fee Schedule,,43.09,,,43.09,Fee Schedule,,382,,,382,Case Rate,,343,,,343,Case Rate,,382,,,382,Case Rate,,324,,,324,Case Rate,,66.65,,,66.65,Other,100% of Medicaid,66.65,,,66.65,Other,100% of Medicaid,66.65,,,66.65,Other,100% of Medicaid,66.65,,,66.65,Other,100% of Medicaid,149.95,,,149.95,Other,225% of Medicaid,101.97,,,101.97,Other,153% of Medicaid,149.95,,,149.95,Other,225% of Medicaid,93.31,,,93.31,Other,140% of Medicaid,149.95,,,149.95,Other,225% of Medicaid,173.28,,,173.28,Other,260% of Medicaid,215.93,,,215.93,Other,324% of Medicaid,143.29,,,143.29,Other,215% of Medicaid,143.29,,,143.29,Other,215% of Medicaid,83.31,,,83.31,Other,125% of Medicaid,23.63,382,
ACOUSTIC REFL THRESHOLD TST,92568,CPT,,66092568,CDM,471,RC,,,both,,,362,267.88,,,267.88,Other,150% of Medicare + 9.63% HCRA Surcharge,162.9,45,,162.9,percent of total billed charges,Critical Access Hospital RCC factor,235.3,65,,235.3,percent of total billed charges,All Other,213.58,65,,213.58,percent of total billed charges,All Other,100.39,,,100.39,Fee Schedule,,90.3,,,90.3,Fee Schedule,,85.34,,,85.34,Fee Schedule,,179.19,,,179.19,Other,110% of Medicare,58.44,,,58.44,Fee Schedule,,124,,,124,Other,186% of Medicaid,68.77,,,68.77,Fee Schedule,,224.44,,,224.44,Fee Schedule,,32.38,,,32.38,Fee Schedule,,68.77,,,68.77,Fee Schedule,,224.44,,,224.44,Fee Schedule,,289.6,80,,289.6,percent of total billed charges,All Other,253.4,70,,253.4,percent of total billed charges,All Other,73.8,,,73.8,Fee Schedule,,62.55,,,62.55,Fee Schedule,,382,,,382,Case Rate,,343,,,343,Case Rate,,382,,,382,Case Rate,,324,,,324,Case Rate,,66.65,,,66.65,Other,100% of Medicaid,66.65,,,66.65,Other,100% of Medicaid,66.65,,,66.65,Other,100% of Medicaid,66.65,,,66.65,Other,100% of Medicaid,149.95,,,149.95,Other,225% of Medicaid,101.97,,,101.97,Other,153% of Medicaid,149.95,,,149.95,Other,225% of Medicaid,93.31,,,93.31,Other,140% of Medicaid,149.95,,,149.95,Other,225% of Medicaid,173.28,,,173.28,Other,260% of Medicaid,215.93,,,215.93,Other,324% of Medicaid,143.29,,,143.29,Other,215% of Medicaid,143.29,,,143.29,Other,215% of Medicaid,83.31,,,83.31,Other,125% of Medicaid,32.38,382,
ACOUSTIC IMMITTANCE TESTING,92570,CPT,,66092570,CDM,471,RC,,,both,,,362,267.88,,,267.88,Other,150% of Medicare + 9.63% HCRA Surcharge,162.9,45,,162.9,percent of total billed charges,Critical Access Hospital RCC factor,235.3,65,,235.3,percent of total billed charges,All Other,213.58,65,,213.58,percent of total billed charges,All Other,192.93,,,192.93,Fee Schedule,,173.53,,,173.53,Fee Schedule,,164.01,,,164.01,Fee Schedule,,179.19,,,179.19,Other,110% of Medicare,114.34,,,114.34,Fee Schedule,,118,,,118,Other,186% of Medicaid,134.56,,,134.56,Fee Schedule,,224.44,,,224.44,Fee Schedule,,63.36,,,63.36,Fee Schedule,,134.56,,,134.56,Fee Schedule,,224.44,,,224.44,Fee Schedule,,289.6,80,,289.6,percent of total billed charges,All Other,253.4,70,,253.4,percent of total billed charges,All Other,142.68,,,142.68,Fee Schedule,,120.93,,,120.93,Fee Schedule,,382,,,382,Case Rate,,343,,,343,Case Rate,,382,,,382,Case Rate,,324,,,324,Case Rate,,63.65,,,63.65,Other,100% of Medicaid,63.65,,,63.65,Other,100% of Medicaid,63.65,,,63.65,Other,100% of Medicaid,63.65,,,63.65,Other,100% of Medicaid,143.21,,,143.21,Other,225% of Medicaid,97.39,,,97.39,Other,153% of Medicaid,143.21,,,143.21,Other,225% of Medicaid,89.11,,,89.11,Other,140% of Medicaid,143.21,,,143.21,Other,225% of Medicaid,165.49,,,165.49,Other,260% of Medicaid,206.23,,,206.23,Other,324% of Medicaid,136.85,,,136.85,Other,215% of Medicaid,136.85,,,136.85,Other,215% of Medicaid,79.56,,,79.56,Other,125% of Medicaid,63.36,382,
STAGGERED SPONDAIC WORD TEST,92572,CPT,,66092572,CDM,471,RC,,,both,,,329,243.46,,,243.46,Other,150% of Medicare + 9.63% HCRA Surcharge,148.05,45,,148.05,percent of total billed charges,Critical Access Hospital RCC factor,213.85,65,,213.85,percent of total billed charges,All Other,194.11,65,,194.11,percent of total billed charges,All Other,210.48,,,210.48,Fee Schedule,,189.48,,,189.48,Fee Schedule,,178.97,,,178.97,Fee Schedule,,162.86,,,162.86,Other,110% of Medicare,223.72,68,,223.72,percent of total billed charges,All Other,118,,,118,Other,186% of Medicaid,263.2,,,263.2,percent of total billed charges,All Other,273.07,83,,273.07,percent of total billed charges,All Other,273.07,83,,273.07,percent of total billed charges,All Other,263.2,80,,263.2,percent of total billed charges,All Other,273.07,83,,273.07,percent of total billed charges,All Other,229.1,,,229.1,Fee Schedule,,230.3,70,,230.3,percent of total billed charges,All Other,198.44,,,198.44,Fee Schedule,,168.19,,,168.19,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,63.65,,,63.65,Other,100% of Medicaid,63.65,,,63.65,Other,100% of Medicaid,63.65,,,63.65,Other,100% of Medicaid,63.65,,,63.65,Other,100% of Medicaid,143.21,,,143.21,Other,225% of Medicaid,97.39,,,97.39,Other,153% of Medicaid,143.21,,,143.21,Other,225% of Medicaid,89.11,,,89.11,Other,140% of Medicaid,143.21,,,143.21,Other,225% of Medicaid,165.49,,,165.49,Other,260% of Medicaid,206.23,,,206.23,Other,324% of Medicaid,136.85,,,136.85,Other,215% of Medicaid,136.85,,,136.85,Other,215% of Medicaid,79.56,,,79.56,Other,125% of Medicaid,0.01,273.07,
VRA,92579,CPT,,66092579,CDM,471,RC,,,both,,,394,291.56,,,291.56,Other,150% of Medicare + 9.63% HCRA Surcharge,177.3,45,,177.3,percent of total billed charges,Critical Access Hospital RCC factor,256.1,65,,256.1,percent of total billed charges,All Other,232.46,65,,232.46,percent of total billed charges,All Other,264.66,,,264.66,Fee Schedule,,238.04,,,238.04,Fee Schedule,,224.99,,,224.99,Fee Schedule,,195.03,,,195.03,Other,110% of Medicare,144.82,,,144.82,Fee Schedule,,118,,,118,Other,186% of Medicaid,170.42,,,170.42,Fee Schedule,,244.28,,,244.28,Fee Schedule,,80.24,,,80.24,Fee Schedule,,170.42,,,170.42,Fee Schedule,,244.28,,,244.28,Fee Schedule,,315.2,80,,315.2,percent of total billed charges,All Other,275.8,70,,275.8,percent of total billed charges,All Other,182.04,,,182.04,Fee Schedule,,154.29,,,154.29,Fee Schedule,,382,,,382,Case Rate,,343,,,343,Case Rate,,382,,,382,Case Rate,,324,,,324,Case Rate,,63.65,,,63.65,Other,100% of Medicaid,63.65,,,63.65,Other,100% of Medicaid,63.65,,,63.65,Other,100% of Medicaid,63.65,,,63.65,Other,100% of Medicaid,143.21,,,143.21,Other,225% of Medicaid,97.39,,,97.39,Other,153% of Medicaid,143.21,,,143.21,Other,225% of Medicaid,89.11,,,89.11,Other,140% of Medicaid,143.21,,,143.21,Other,225% of Medicaid,165.49,,,165.49,Other,260% of Medicaid,206.23,,,206.23,Other,324% of Medicaid,136.85,,,136.85,Other,215% of Medicaid,136.85,,,136.85,Other,215% of Medicaid,79.56,,,79.56,Other,125% of Medicaid,63.65,382,
CONDITIONING PLAY AUDIOMETRY,92582,CPT,,66092582,CDM,471,RC,,,both,,,394,291.56,,,291.56,Other,150% of Medicare + 9.63% HCRA Surcharge,177.3,45,,177.3,percent of total billed charges,Critical Access Hospital RCC factor,256.1,65,,256.1,percent of total billed charges,All Other,232.46,65,,232.46,percent of total billed charges,All Other,345.66,,,345.66,Fee Schedule,,310.9,,,310.9,Fee Schedule,,293.84,,,293.84,Fee Schedule,,195.03,,,195.03,Other,110% of Medicare,357.06,,,357.06,Fee Schedule,,118,,,118,Other,186% of Medicaid,420.18,,,420.18,Fee Schedule,,244.28,,,244.28,Fee Schedule,,197.84,,,197.84,Fee Schedule,,420.18,,,420.18,Fee Schedule,,244.28,,,244.28,Fee Schedule,,315.2,80,,315.2,percent of total billed charges,All Other,275.8,70,,275.8,percent of total billed charges,All Other,373.92,,,373.92,Fee Schedule,,316.92,,,316.92,Fee Schedule,,382,,,382,Case Rate,,343,,,343,Case Rate,,382,,,382,Case Rate,,324,,,324,Case Rate,,63.65,,,63.65,Other,100% of Medicaid,63.65,,,63.65,Other,100% of Medicaid,63.65,,,63.65,Other,100% of Medicaid,63.65,,,63.65,Other,100% of Medicaid,143.21,,,143.21,Other,225% of Medicaid,97.39,,,97.39,Other,153% of Medicaid,143.21,,,143.21,Other,225% of Medicaid,89.11,,,89.11,Other,140% of Medicaid,143.21,,,143.21,Other,225% of Medicaid,165.49,,,165.49,Other,260% of Medicaid,206.23,,,206.23,Other,324% of Medicaid,136.85,,,136.85,Other,215% of Medicaid,136.85,,,136.85,Other,215% of Medicaid,79.56,,,79.56,Other,125% of Medicaid,63.65,420.18,
SELECT PICTURE AUDIOMETRY,92583,CPT,,66092583,CDM,471,RC,,,both,,,362,267.88,,,267.88,Other,150% of Medicare + 9.63% HCRA Surcharge,162.9,45,,162.9,percent of total billed charges,Critical Access Hospital RCC factor,235.3,65,,235.3,percent of total billed charges,All Other,213.58,65,,213.58,percent of total billed charges,All Other,237.63,,,237.63,Fee Schedule,,213.91,,,213.91,Fee Schedule,,202.05,,,202.05,Fee Schedule,,179.19,,,179.19,Other,110% of Medicare,246.16,68,,246.16,percent of total billed charges,All Other,124,,,124,Other,186% of Medicaid,289.6,,,289.6,percent of total billed charges,All Other,300.46,83,,300.46,percent of total billed charges,All Other,300.46,83,,300.46,percent of total billed charges,All Other,289.6,80,,289.6,percent of total billed charges,All Other,300.46,83,,300.46,percent of total billed charges,All Other,244.82,,,244.82,Fee Schedule,,253.4,70,,253.4,percent of total billed charges,All Other,244.36,,,244.36,Fee Schedule,,207.11,,,207.11,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,66.65,,,66.65,Other,100% of Medicaid,66.65,,,66.65,Other,100% of Medicaid,66.65,,,66.65,Other,100% of Medicaid,66.65,,,66.65,Other,100% of Medicaid,149.95,,,149.95,Other,225% of Medicaid,101.97,,,101.97,Other,153% of Medicaid,149.95,,,149.95,Other,225% of Medicaid,93.31,,,93.31,Other,140% of Medicaid,149.95,,,149.95,Other,225% of Medicaid,173.28,,,173.28,Other,260% of Medicaid,215.93,,,215.93,Other,324% of Medicaid,143.29,,,143.29,Other,215% of Medicaid,143.29,,,143.29,Other,215% of Medicaid,83.31,,,83.31,Other,125% of Medicaid,0.01,300.46,
EAR PROTECTOR EVAL,92596,CPT,,66092596,CDM,471,RC,,,both,,,78,57.72,,,57.72,Other,150% of Medicare + 9.63% HCRA Surcharge,35.1,45,,35.1,percent of total billed charges,Critical Access Hospital RCC factor,50.7,65,,50.7,percent of total billed charges,All Other,46.02,65,,46.02,percent of total billed charges,All Other,59.67,76.5,,59.67,percent of total billed charges,All Other,55.38,69,,55.38,percent of total billed charges,All Other,53.82,65,,53.82,percent of total billed charges,All Other,38.61,,,38.61,Other,110% of Medicare,53.04,68,,53.04,percent of total billed charges,All Other,124,,,124,Other,186% of Medicaid,62.4,,,62.4,percent of total billed charges,All Other,64.74,83,,64.74,percent of total billed charges,All Other,64.74,83,,64.74,percent of total billed charges,All Other,62.4,80,,62.4,percent of total billed charges,All Other,64.74,83,,64.74,percent of total billed charges,All Other,330.65,,,330.65,Fee Schedule,,54.6,70,,54.6,percent of total billed charges,All Other,331.28,,,331.28,Fee Schedule,,280.78,,,280.78,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,66.65,,,66.65,Other,100% of Medicaid,66.65,,,66.65,Other,100% of Medicaid,66.65,,,66.65,Other,100% of Medicaid,66.65,,,66.65,Other,100% of Medicaid,149.95,,,149.95,Other,225% of Medicaid,101.97,,,101.97,Other,153% of Medicaid,149.95,,,149.95,Other,225% of Medicaid,93.31,,,93.31,Other,140% of Medicaid,149.95,,,149.95,Other,225% of Medicaid,173.28,,,173.28,Other,260% of Medicaid,215.93,,,215.93,Other,324% of Medicaid,143.29,,,143.29,Other,215% of Medicaid,143.29,,,143.29,Other,215% of Medicaid,83.31,,,83.31,Other,125% of Medicaid,0.01,331.28,
CENTRAL AUDITORY FCN INIT 60 MIN,92620,CPT,,66092620,CDM,471,RC,,,both,,,406,300.44,,,300.44,Other,150% of Medicare + 9.63% HCRA Surcharge,182.7,45,,182.7,percent of total billed charges,Critical Access Hospital RCC factor,263.9,65,,263.9,percent of total billed charges,All Other,239.54,65,,239.54,percent of total billed charges,All Other,495.54,,,495.54,Fee Schedule,,445.7,,,445.7,Fee Schedule,,421.25,,,421.25,Fee Schedule,,200.97,,,200.97,Other,110% of Medicare,311.01,,,311.01,Fee Schedule,,186,,,186,Other,186% of Medicaid,365.99,,,365.99,Fee Schedule,,251.72,,,251.72,Fee Schedule,,172.33,,,172.33,Fee Schedule,,365.99,,,365.99,Fee Schedule,,251.72,,,251.72,Fee Schedule,,324.8,80,,324.8,percent of total billed charges,All Other,284.2,70,,284.2,percent of total billed charges,All Other,387.04,,,387.04,Fee Schedule,,328.04,,,328.04,Fee Schedule,,382,,,382,Case Rate,,343,,,343,Case Rate,,382,,,382,Case Rate,,324,,,324,Case Rate,,100.07,,,100.07,Other,100% of Medicaid,100.07,,,100.07,Other,100% of Medicaid,100.07,,,100.07,Other,100% of Medicaid,100.07,,,100.07,Other,100% of Medicaid,225.16,,,225.16,Other,225% of Medicaid,153.11,,,153.11,Other,153% of Medicaid,225.16,,,225.16,Other,225% of Medicaid,140.1,,,140.1,Other,140% of Medicaid,225.16,,,225.16,Other,225% of Medicaid,260.19,,,260.19,Other,260% of Medicaid,324.23,,,324.23,Other,324% of Medicaid,215.15,,,215.15,Other,215% of Medicaid,215.15,,,215.15,Other,215% of Medicaid,125.09,,,125.09,Other,125% of Medicaid,100.07,495.54,
AUDITORY FUNCTION + 15 MIN,92621,CPT,,66092621,CDM,471,RC,,,both,,,93,68.82,,,68.82,Other,150% of Medicare + 9.63% HCRA Surcharge,41.85,45,,41.85,percent of total billed charges,Critical Access Hospital RCC factor,60.45,65,,60.45,percent of total billed charges,All Other,54.87,65,,54.87,percent of total billed charges,All Other,113.94,,,113.94,Fee Schedule,,102.48,,,102.48,Fee Schedule,,96.86,,,96.86,Fee Schedule,,46.04,,,46.04,Other,110% of Medicare,73.07,,,73.07,Fee Schedule,,186,,,186,Other,186% of Medicaid,85.99,,,85.99,Fee Schedule,,57.66,,,57.66,Fee Schedule,,40.49,,,40.49,Fee Schedule,,85.99,,,85.99,Fee Schedule,,57.66,,,57.66,Fee Schedule,,74.4,80,,74.4,percent of total billed charges,All Other,65.1,70,,65.1,percent of total billed charges,All Other,90.2,,,90.2,Fee Schedule,,76.45,,,76.45,Fee Schedule,,382,,,382,Case Rate,,343,,,343,Case Rate,,382,,,382,Case Rate,,324,,,324,Case Rate,,100.07,,,100.07,Other,100% of Medicaid,100.07,,,100.07,Other,100% of Medicaid,100.07,,,100.07,Other,100% of Medicaid,100.07,,,100.07,Other,100% of Medicaid,225.16,,,225.16,Other,225% of Medicaid,153.11,,,153.11,Other,153% of Medicaid,225.16,,,225.16,Other,225% of Medicaid,140.1,,,140.1,Other,140% of Medicaid,225.16,,,225.16,Other,225% of Medicaid,260.19,,,260.19,Other,260% of Medicaid,324.23,,,324.23,Other,324% of Medicaid,215.15,,,215.15,Other,215% of Medicaid,215.15,,,215.15,Other,215% of Medicaid,125.09,,,125.09,Other,125% of Medicaid,40.49,382,
TINNITUS ASSESSMENT,92625,CPT,,66092625,CDM,471,RC,,,both,,,329,243.46,,,243.46,Other,150% of Medicare + 9.63% HCRA Surcharge,148.05,45,,148.05,percent of total billed charges,Critical Access Hospital RCC factor,213.85,65,,213.85,percent of total billed charges,All Other,194.11,65,,194.11,percent of total billed charges,All Other,374.86,,,374.86,Fee Schedule,,337.45,,,337.45,Fee Schedule,,318.74,,,318.74,Fee Schedule,,162.86,,,162.86,Other,110% of Medicare,223.72,68,,223.72,percent of total billed charges,All Other,118,,,118,Other,186% of Medicaid,263.2,,,263.2,percent of total billed charges,All Other,273.07,83,,273.07,percent of total billed charges,All Other,273.07,83,,273.07,percent of total billed charges,All Other,263.2,80,,263.2,percent of total billed charges,All Other,273.07,83,,273.07,percent of total billed charges,All Other,249.4,,,249.4,Fee Schedule,,230.3,70,,230.3,percent of total billed charges,All Other,295.2,,,295.2,Fee Schedule,,250.2,,,250.2,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,63.65,,,63.65,Other,100% of Medicaid,63.65,,,63.65,Other,100% of Medicaid,63.65,,,63.65,Other,100% of Medicaid,63.65,,,63.65,Other,100% of Medicaid,143.21,,,143.21,Other,225% of Medicaid,97.39,,,97.39,Other,153% of Medicaid,143.21,,,143.21,Other,225% of Medicaid,89.11,,,89.11,Other,140% of Medicaid,143.21,,,143.21,Other,225% of Medicaid,165.49,,,165.49,Other,260% of Medicaid,206.23,,,206.23,Other,324% of Medicaid,136.85,,,136.85,Other,215% of Medicaid,136.85,,,136.85,Other,215% of Medicaid,79.56,,,79.56,Other,125% of Medicaid,0.01,374.86,
EVAL AUD REHAB STATUS,92626,CPT,,66092626,CDM,471,RC,,,both,,,441,326.34,,,326.34,Other,150% of Medicare + 9.63% HCRA Surcharge,198.45,45,,198.45,percent of total billed charges,Critical Access Hospital RCC factor,286.65,65,,286.65,percent of total billed charges,All Other,260.19,65,,260.19,percent of total billed charges,All Other,508.77,,,508.77,Fee Schedule,,457.6,,,457.6,Fee Schedule,,432.5,,,432.5,Fee Schedule,,218.3,,,218.3,Other,110% of Medicare,292.36,,,292.36,Fee Schedule,,186,,,186,Other,186% of Medicaid,344.04,,,344.04,Fee Schedule,,273.42,,,273.42,Fee Schedule,,161.99,,,161.99,Fee Schedule,,344.04,,,344.04,Fee Schedule,,273.42,,,273.42,Fee Schedule,,352.8,80,,352.8,percent of total billed charges,All Other,308.7,70,,308.7,percent of total billed charges,All Other,359.16,,,359.16,Fee Schedule,,304.41,,,304.41,Fee Schedule,,382,,,382,Case Rate,,343,,,343,Case Rate,,382,,,382,Case Rate,,324,,,324,Case Rate,,100.07,,,100.07,Other,100% of Medicaid,100.07,,,100.07,Other,100% of Medicaid,100.07,,,100.07,Other,100% of Medicaid,100.07,,,100.07,Other,100% of Medicaid,225.16,,,225.16,Other,225% of Medicaid,153.11,,,153.11,Other,153% of Medicaid,225.16,,,225.16,Other,225% of Medicaid,140.1,,,140.1,Other,140% of Medicaid,225.16,,,225.16,Other,225% of Medicaid,260.19,,,260.19,Other,260% of Medicaid,324.23,,,324.23,Other,324% of Medicaid,215.15,,,215.15,Other,215% of Medicaid,215.15,,,215.15,Other,215% of Medicaid,125.09,,,125.09,Other,125% of Medicaid,100.07,508.77,
EVAL AUD STATUS REHAB EA ADDL 15 MIN,92627,CPT,,66092627,CDM,471,RC,,,both,,,111,82.14,,,82.14,Other,150% of Medicare + 9.63% HCRA Surcharge,49.95,45,,49.95,percent of total billed charges,Critical Access Hospital RCC factor,58.19,,,58.19,Fee Schedule,,52.35,,,52.35,Fee Schedule,,123.95,,,123.95,Fee Schedule,,111.48,,,111.48,Fee Schedule,,105.37,,,105.37,Fee Schedule,,54.95,,,54.95,Other,110% of Medicare,69.13,,,69.13,Fee Schedule,,186,,,186,Other,186% of Medicaid,81.35,,,81.35,Fee Schedule,,68.82,,,68.82,Fee Schedule,,38.3,,,38.3,Fee Schedule,,81.35,,,81.35,Fee Schedule,,68.82,,,68.82,Fee Schedule,,368,,,368,Case Rate,Therapy Visit,77.7,70,,77.7,percent of total billed charges,All Other,85.28,,,85.28,Fee Schedule,,72.28,,,72.28,Fee Schedule,,382,,,382,Case Rate,,343,,,343,Case Rate,,382,,,382,Case Rate,,324,,,324,Case Rate,,100.07,,,100.07,Other,100% of Medicaid,100.07,,,100.07,Other,100% of Medicaid,100.07,,,100.07,Other,100% of Medicaid,100.07,,,100.07,Other,100% of Medicaid,225.16,,,225.16,Other,225% of Medicaid,153.11,,,153.11,Other,153% of Medicaid,225.16,,,225.16,Other,225% of Medicaid,140.1,,,140.1,Other,140% of Medicaid,225.16,,,225.16,Other,225% of Medicaid,260.19,,,260.19,Other,260% of Medicaid,324.23,,,324.23,Other,324% of Medicaid,215.15,,,215.15,Other,215% of Medicaid,215.15,,,215.15,Other,215% of Medicaid,125.09,,,125.09,Other,125% of Medicaid,38.3,382,
AEP HEARING STATUS DETER I&R,92651,CPT,,66092651,CDM,471,RC,,,both,,,457,338.18,,,338.18,Other,150% of Medicare + 9.63% HCRA Surcharge,205.65,45,,205.65,percent of total billed charges,Critical Access Hospital RCC factor,297.05,65,,297.05,percent of total billed charges,All Other,269.63,65,,269.63,percent of total billed charges,All Other,86.57,,,86.57,Fee Schedule,,86.57,,,86.57,Fee Schedule,,86.57,,,86.57,Fee Schedule,,226.22,,,226.22,Other,110% of Medicare,333.97,,,333.97,Fee Schedule,,118,,,118,Other,186% of Medicaid,393.02,,,393.02,Fee Schedule,,283.34,,,283.34,Fee Schedule,,185.05,,,185.05,Fee Schedule,,393.02,,,393.02,Fee Schedule,,283.34,,,283.34,Fee Schedule,,365.6,80,,365.6,percent of total billed charges,All Other,319.9,70,,319.9,percent of total billed charges,All Other,428.04,,,428.04,Fee Schedule,,362.79,,,362.79,Fee Schedule,,382,,,382,Case Rate,,343,,,343,Case Rate,,382,,,382,Case Rate,,324,,,324,Case Rate,,63.65,,,63.65,Other,100% of Medicaid,63.65,,,63.65,Other,100% of Medicaid,63.65,,,63.65,Other,100% of Medicaid,63.65,,,63.65,Other,100% of Medicaid,143.21,,,143.21,Other,225% of Medicaid,97.39,,,97.39,Other,153% of Medicaid,143.21,,,143.21,Other,225% of Medicaid,89.11,,,89.11,Other,140% of Medicaid,143.21,,,143.21,Other,225% of Medicaid,165.49,,,165.49,Other,260% of Medicaid,206.23,,,206.23,Other,324% of Medicaid,136.85,,,136.85,Other,215% of Medicaid,136.85,,,136.85,Other,215% of Medicaid,79.56,,,79.56,Other,125% of Medicaid,63.65,428.04,
HEARING AID FITTING/CHECKING,V5011,HCPCS,,66000003,CDM,472,RC,,,both,,,1166,862.84,,,862.84,Other,150% of Medicare + 9.63% HCRA Surcharge,524.7,45,,524.7,percent of total billed charges,Critical Access Hospital RCC factor,757.9,65,,757.9,percent of total billed charges,All Other,687.94,65,,687.94,percent of total billed charges,All Other,891.99,76.5,,891.99,percent of total billed charges,All Other,827.86,69,,827.86,percent of total billed charges,All Other,804.54,65,,804.54,percent of total billed charges,All Other,577.17,,,577.17,Other,110% of Medicare,792.88,68,,792.88,percent of total billed charges,All Other,124,,,124,Other,186% of Medicaid,932.8,,,932.8,percent of total billed charges,All Other,967.78,83,,967.78,percent of total billed charges,All Other,967.78,83,,967.78,percent of total billed charges,All Other,932.8,80,,932.8,percent of total billed charges,All Other,967.78,83,,967.78,percent of total billed charges,All Other,932.8,80,,932.8,percent of total billed charges,All Other,816.2,70,,816.2,percent of total billed charges,All Other,757.9,65,,757.9,percent of total billed charges,Default if not in Fee Schedule,757.9,65,,757.9,percent of total billed charges,Default if not in Fee Schedule,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,66.65,,,66.65,Other,100% of Medicaid,66.65,,,66.65,Other,100% of Medicaid,66.65,,,66.65,Other,100% of Medicaid,66.65,,,66.65,Other,100% of Medicaid,149.95,,,149.95,Other,225% of Medicaid,101.97,,,101.97,Other,153% of Medicaid,149.95,,,149.95,Other,225% of Medicaid,93.31,,,93.31,Other,140% of Medicaid,149.95,,,149.95,Other,225% of Medicaid,173.28,,,173.28,Other,260% of Medicaid,215.93,,,215.93,Other,324% of Medicaid,143.29,,,143.29,Other,215% of Medicaid,143.29,,,143.29,Other,215% of Medicaid,83.31,,,83.31,Other,125% of Medicaid,0.01,967.78,
CARDIOVERTER DEFIB SYSTEM,93284,CPT,,30093284,CDM,480,RC,,,both,,,168,124.32,,,124.32,Other,150% of Medicare + 9.63% HCRA Surcharge,75.6,45,,75.6,percent of total billed charges,Critical Access Hospital RCC factor,146.53,,,146.53,Fee Schedule,,132.12,,,132.12,Fee Schedule,,192.41,,,192.41,Fee Schedule,,173.2,,,173.2,Fee Schedule,,163.6,,,163.6,Fee Schedule,,83.16,,,83.16,Other,110% of Medicare,114.24,68,,114.24,percent of total billed charges,All Other,128,,,128,Other,186% of Medicaid,134.4,80,,134.4,percent of total billed charges,All Other,139.44,83,,139.44,percent of total billed charges,All Other,139.44,83,,139.44,percent of total billed charges,All Other,134.4,80,,134.4,percent of total billed charges,All Other,139.44,83,,139.44,percent of total billed charges,All Other,134.4,,,134.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",117.6,70,,117.6,percent of total billed charges,All Other,232.88,,,232.88,Fee Schedule,,197.38,,,197.38,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",68.69,,,68.69,Other,100% of Medicaid,68.69,,,68.69,Other,100% of Medicaid,68.69,,,68.69,Other,100% of Medicaid,68.69,,,68.69,Other,100% of Medicaid,154.56,,,154.56,Other,225% of Medicaid,105.1,,,105.1,Other,153% of Medicaid,154.56,,,154.56,Other,225% of Medicaid,96.17,,,96.17,Other,140% of Medicaid,154.56,,,154.56,Other,225% of Medicaid,178.6,,,178.6,Other,260% of Medicaid,222.56,,,222.56,Other,324% of Medicaid,147.69,,,147.69,Other,215% of Medicaid,147.69,,,147.69,Other,215% of Medicaid,85.87,,,85.87,Other,125% of Medicaid,68.69,3227,
INTERROGATION DEVICE EVAL,93288,CPT,,30093288,CDM,480,RC,,,both,,,168,124.32,,,124.32,Other,150% of Medicare + 9.63% HCRA Surcharge,75.6,45,,75.6,percent of total billed charges,Critical Access Hospital RCC factor,115.55,,,115.55,Fee Schedule,,104.19,,,104.19,Fee Schedule,,116.78,,,116.78,Fee Schedule,,105.04,,,105.04,Fee Schedule,,99.28,,,99.28,Fee Schedule,,83.16,,,83.16,Other,110% of Medicare,114.24,68,,114.24,percent of total billed charges,All Other,128,,,128,Other,186% of Medicaid,134.4,80,,134.4,percent of total billed charges,All Other,139.44,83,,139.44,percent of total billed charges,All Other,139.44,83,,139.44,percent of total billed charges,All Other,134.4,80,,134.4,percent of total billed charges,All Other,139.44,83,,139.44,percent of total billed charges,All Other,134.4,,,134.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",117.6,70,,117.6,percent of total billed charges,All Other,183.68,,,183.68,Fee Schedule,,155.68,,,155.68,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",68.69,,,68.69,Other,100% of Medicaid,68.69,,,68.69,Other,100% of Medicaid,68.69,,,68.69,Other,100% of Medicaid,68.69,,,68.69,Other,100% of Medicaid,154.56,,,154.56,Other,225% of Medicaid,105.1,,,105.1,Other,153% of Medicaid,154.56,,,154.56,Other,225% of Medicaid,96.17,,,96.17,Other,140% of Medicaid,154.56,,,154.56,Other,225% of Medicaid,178.6,,,178.6,Other,260% of Medicaid,222.56,,,222.56,Other,324% of Medicaid,147.69,,,147.69,Other,215% of Medicaid,147.69,,,147.69,Other,215% of Medicaid,85.87,,,85.87,Other,125% of Medicaid,68.69,3227,
N-INVAS EST C FFR SW ALY CTA,75580,CPT,,46075580,CDM,480,RC,,,both,,,2989,2211.87,,,2211.87,Other,150% of Medicare + 9.63% HCRA Surcharge,1345.05,45,,1345.05,percent of total billed charges,Critical Access Hospital RCC factor,3013.94,,,3013.94,Fee Schedule,,2711.6,,,2711.6,Fee Schedule,,2286.59,76.5,,2286.59,percent of total billed charges,All Other,2122.19,69,,2122.19,percent of total billed charges,All Other,2062.41,65,,2062.41,percent of total billed charges,All Other,1479.56,,,1479.56,Other,110% of Medicare,3580.83,,,3580.83,Fee Schedule,,580,,,580,Other,186% of Medicaid,4213.85,,,4213.85,Fee Schedule,,1984.1,,,1984.1,Fee Schedule,,1984.1,,,1984.1,Fee Schedule,,4213.85,,,4213.85,Fee Schedule,,1984.1,,,1984.1,Fee Schedule,,2391.2,,,2391.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2092.3,70,,2092.3,percent of total billed charges,All Other,1942.85,65,,1942.85,percent of total billed charges,Default if not in Fee Schedule,1942.85,65,,1942.85,percent of total billed charges,Default if not in Fee Schedule,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",311.93,,,311.93,Other,100% of Medicaid,311.93,,,311.93,Other,100% of Medicaid,311.93,,,311.93,Other,100% of Medicaid,311.93,,,311.93,Other,100% of Medicaid,701.85,,,701.85,Other,225% of Medicaid,477.26,,,477.26,Other,153% of Medicaid,701.85,,,701.85,Other,225% of Medicaid,436.71,,,436.71,Other,140% of Medicaid,701.85,,,701.85,Other,225% of Medicaid,811.02,,,811.02,Other,260% of Medicaid,1010.66,,,1010.66,Other,324% of Medicaid,670.66,,,670.66,Other,215% of Medicaid,670.66,,,670.66,Other,215% of Medicaid,389.92,,,389.92,Other,125% of Medicaid,311.93,4213.85,
CARDIOVERSION ELECTRIC EXT,92960,CPT,,48092960,CDM,480,RC,,,both,,,2056,1521.45,,,1521.45,Other,150% of Medicare + 9.63% HCRA Surcharge,925.2,45,,925.2,percent of total billed charges,Critical Access Hospital RCC factor,330.52,,,330.52,Fee Schedule,,298.03,,,298.03,Fee Schedule,,1531.99,,,1531.99,Fee Schedule,,1377.92,,,1377.92,Fee Schedule,,1302.34,,,1302.34,Fee Schedule,,1017.72,,,1017.72,Other,110% of Medicare,1398.08,68,,1398.08,percent of total billed charges,All Other,816,,,816,Other,186% of Medicaid,1644.8,80,,1644.8,percent of total billed charges,All Other,1706.48,83,,1706.48,percent of total billed charges,All Other,1706.48,83,,1706.48,percent of total billed charges,All Other,1644.8,80,,1644.8,percent of total billed charges,All Other,1706.48,83,,1706.48,percent of total billed charges,All Other,1644.8,,,1644.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1439.2,70,,1439.2,percent of total billed charges,All Other,518.24,,,518.24,Fee Schedule,,439.24,,,439.24,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",438.68,,,438.68,Other,100% of Medicaid,438.68,,,438.68,Other,100% of Medicaid,438.68,,,438.68,Other,100% of Medicaid,438.68,,,438.68,Other,100% of Medicaid,987.03,,,987.03,Other,225% of Medicaid,671.18,,,671.18,Other,153% of Medicaid,987.03,,,987.03,Other,225% of Medicaid,614.15,,,614.15,Other,140% of Medicaid,987.03,,,987.03,Other,225% of Medicaid,1140.57,,,1140.57,Other,260% of Medicaid,1421.33,,,1421.33,Other,324% of Medicaid,943.16,,,943.16,Other,215% of Medicaid,943.16,,,943.16,Other,215% of Medicaid,548.35,,,548.35,Other,125% of Medicaid,298.03,3227,
TTE F-UP OR LMTD,93308,CPT,,48093308,CDM,480,RC,,,both,,,993,734.82,,,734.82,Other,150% of Medicare + 9.63% HCRA Surcharge,446.85,45,,446.85,percent of total billed charges,Critical Access Hospital RCC factor,238.57,,,238.57,Fee Schedule,,215.11,,,215.11,Fee Schedule,,526.42,,,526.42,Fee Schedule,,473.48,,,473.48,Fee Schedule,,447.51,,,447.51,Fee Schedule,,491.54,,,491.54,Other,110% of Medicare,675.24,68,,675.24,percent of total billed charges,All Other,497,,,497,Other,186% of Medicaid,794.4,80,,794.4,percent of total billed charges,All Other,824.19,83,,824.19,percent of total billed charges,All Other,824.19,83,,824.19,percent of total billed charges,All Other,794.4,80,,794.4,percent of total billed charges,All Other,824.19,83,,824.19,percent of total billed charges,All Other,794.4,,,794.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",695.1,70,,695.1,percent of total billed charges,All Other,362.44,,,362.44,Fee Schedule,,307.19,,,307.19,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",267.36,,,267.36,Other,100% of Medicaid,267.36,,,267.36,Other,100% of Medicaid,267.36,,,267.36,Other,100% of Medicaid,267.36,,,267.36,Other,100% of Medicaid,601.56,,,601.56,Other,225% of Medicaid,409.06,,,409.06,Other,153% of Medicaid,601.56,,,601.56,Other,225% of Medicaid,374.3,,,374.3,Other,140% of Medicaid,601.56,,,601.56,Other,225% of Medicaid,695.14,,,695.14,Other,260% of Medicaid,866.25,,,866.25,Other,324% of Medicaid,574.82,,,574.82,Other,215% of Medicaid,574.82,,,574.82,Other,215% of Medicaid,334.2,,,334.2,Other,125% of Medicaid,215.11,3227,
TILT TABLE EVALUATION,93660,CPT,,48093660,CDM,480,RC,,,both,,,2227,1647.99,,,1647.99,Other,150% of Medicare + 9.63% HCRA Surcharge,1002.15,45,,1002.15,percent of total billed charges,Critical Access Hospital RCC factor,234.44,,,234.44,Fee Schedule,,211.39,,,211.39,Fee Schedule,,444.05,,,444.05,Fee Schedule,,399.39,,,399.39,Fee Schedule,,377.48,,,377.48,Fee Schedule,,1102.37,,,1102.37,Other,110% of Medicare,1514.36,68,,1514.36,percent of total billed charges,All Other,255,,,255,Other,186% of Medicaid,1781.6,80,,1781.6,percent of total billed charges,All Other,1848.41,83,,1848.41,percent of total billed charges,All Other,1848.41,83,,1848.41,percent of total billed charges,All Other,1781.6,80,,1781.6,percent of total billed charges,All Other,1848.41,83,,1848.41,percent of total billed charges,All Other,1781.6,,,1781.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1558.9,70,,1558.9,percent of total billed charges,All Other,328,,,328,Fee Schedule,,278,,,278,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",137.34,,,137.34,Other,100% of Medicaid,137.34,,,137.34,Other,100% of Medicaid,137.34,,,137.34,Other,100% of Medicaid,137.34,,,137.34,Other,100% of Medicaid,309.01,,,309.01,Other,225% of Medicaid,210.12,,,210.12,Other,153% of Medicaid,309.01,,,309.01,Other,225% of Medicaid,192.27,,,192.27,Other,140% of Medicaid,309.01,,,309.01,Other,225% of Medicaid,357.07,,,357.07,Other,260% of Medicaid,444.97,,,444.97,Other,324% of Medicaid,295.27,,,295.27,Other,215% of Medicaid,295.27,,,295.27,Other,215% of Medicaid,171.67,,,171.67,Other,125% of Medicaid,137.34,3227,
CARDIOVASCULAR SERVICE UNLISTED,93799,CPT,,48093799,CDM,480,RC,,,both,,,329,243.46,,,243.46,Other,150% of Medicare + 9.63% HCRA Surcharge,148.05,45,,148.05,percent of total billed charges,Critical Access Hospital RCC factor,213.85,65,,213.85,percent of total billed charges,All Other,194.11,65,,194.11,percent of total billed charges,All Other,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,162.86,,,162.86,Other,110% of Medicare,223.72,68,,223.72,percent of total billed charges,All Other,64,,,64,Other,186% of Medicaid,263.2,80,,263.2,percent of total billed charges,All Other,273.07,83,,273.07,percent of total billed charges,All Other,273.07,83,,273.07,percent of total billed charges,All Other,263.2,80,,263.2,percent of total billed charges,All Other,273.07,83,,273.07,percent of total billed charges,All Other,263.2,,,263.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",230.3,70,,230.3,percent of total billed charges,All Other,213.85,65,,213.85,percent of total billed charges,Default if not in Fee Schedule,213.85,65,,213.85,percent of total billed charges,Default if not in Fee Schedule,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",34.6,,,34.6,Other,100% of Medicaid,34.6,,,34.6,Other,100% of Medicaid,34.6,,,34.6,Other,100% of Medicaid,34.6,,,34.6,Other,100% of Medicaid,77.85,,,77.85,Other,225% of Medicaid,52.94,,,52.94,Other,153% of Medicaid,77.85,,,77.85,Other,225% of Medicaid,48.44,,,48.44,Other,140% of Medicaid,77.85,,,77.85,Other,225% of Medicaid,89.97,,,89.97,Other,260% of Medicaid,112.11,,,112.11,Other,324% of Medicaid,74.39,,,74.39,Other,215% of Medicaid,74.39,,,74.39,Other,215% of Medicaid,43.25,,,43.25,Other,125% of Medicaid,0.01,3227,
PRGRMG DEV EVAL ICDS SS IP,0575T,HCPCS,,49000017,CDM,480,RC,,,both,,,119,88.06,,,88.06,Other,150% of Medicare + 9.63% HCRA Surcharge,53.55,45,,53.55,percent of total billed charges,Critical Access Hospital RCC factor,77.35,65,,77.35,percent of total billed charges,All Other,70.21,65,,70.21,percent of total billed charges,All Other,23.74,,,23.74,Fee Schedule,,23.74,,,23.74,Fee Schedule,,23.74,,,23.74,Fee Schedule,,58.91,,,58.91,Other,110% of Medicare,80.92,68,,80.92,percent of total billed charges,All Other,128,,,128,Other,186% of Medicaid,95.2,80,,95.2,percent of total billed charges,All Other,98.77,83,,98.77,percent of total billed charges,All Other,98.77,83,,98.77,percent of total billed charges,All Other,95.2,80,,95.2,percent of total billed charges,All Other,98.77,83,,98.77,percent of total billed charges,All Other,95.2,,,95.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",83.3,70,,83.3,percent of total billed charges,All Other,77.35,65,,77.35,percent of total billed charges,Default if not in Fee Schedule,77.35,65,,77.35,percent of total billed charges,Default if not in Fee Schedule,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",68.69,,,68.69,Other,100% of Medicaid,68.69,,,68.69,Other,100% of Medicaid,68.69,,,68.69,Other,100% of Medicaid,68.69,,,68.69,Other,100% of Medicaid,154.56,,,154.56,Other,225% of Medicaid,105.1,,,105.1,Other,153% of Medicaid,154.56,,,154.56,Other,225% of Medicaid,96.17,,,96.17,Other,140% of Medicaid,154.56,,,154.56,Other,225% of Medicaid,178.6,,,178.6,Other,260% of Medicaid,222.56,,,222.56,Other,324% of Medicaid,147.69,,,147.69,Other,215% of Medicaid,147.69,,,147.69,Other,215% of Medicaid,85.87,,,85.87,Other,125% of Medicaid,23.74,3227,
INTERROG DEV EVAL ICDS SS IP,0576T,HCPCS,,49000018,CDM,480,RC,,,both,,,119,88.06,,,88.06,Other,150% of Medicare + 9.63% HCRA Surcharge,53.55,45,,53.55,percent of total billed charges,Critical Access Hospital RCC factor,77.35,65,,77.35,percent of total billed charges,All Other,70.21,65,,70.21,percent of total billed charges,All Other,23.35,,,23.35,Fee Schedule,,23.35,,,23.35,Fee Schedule,,23.35,,,23.35,Fee Schedule,,58.91,,,58.91,Other,110% of Medicare,80.92,68,,80.92,percent of total billed charges,All Other,128,,,128,Other,186% of Medicaid,95.2,80,,95.2,percent of total billed charges,All Other,98.77,83,,98.77,percent of total billed charges,All Other,98.77,83,,98.77,percent of total billed charges,All Other,95.2,80,,95.2,percent of total billed charges,All Other,98.77,83,,98.77,percent of total billed charges,All Other,95.2,,,95.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",83.3,70,,83.3,percent of total billed charges,All Other,77.35,65,,77.35,percent of total billed charges,Default if not in Fee Schedule,77.35,65,,77.35,percent of total billed charges,Default if not in Fee Schedule,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",68.69,,,68.69,Other,100% of Medicaid,68.69,,,68.69,Other,100% of Medicaid,68.69,,,68.69,Other,100% of Medicaid,68.69,,,68.69,Other,100% of Medicaid,154.56,,,154.56,Other,225% of Medicaid,105.1,,,105.1,Other,153% of Medicaid,154.56,,,154.56,Other,225% of Medicaid,96.17,,,96.17,Other,140% of Medicaid,154.56,,,154.56,Other,225% of Medicaid,178.6,,,178.6,Other,260% of Medicaid,222.56,,,222.56,Other,324% of Medicaid,147.69,,,147.69,Other,215% of Medicaid,147.69,,,147.69,Other,215% of Medicaid,85.87,,,85.87,Other,125% of Medicaid,23.35,3227,
EPHYS EVAL ICDS SS,0577T,HCPCS,,49000019,CDM,480,RC,,,both,,,3234,2393.17,,,2393.17,Other,150% of Medicare + 9.63% HCRA Surcharge,1455.3,45,,1455.3,percent of total billed charges,Critical Access Hospital RCC factor,4565,,,4565,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4109,,,4109,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3648,,,3648,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3283,,,3283,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3101,,,3101,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",1600.83,,,1600.83,Other,110% of Medicare,2199.12,,,2199.12,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",822.56,,,822.56,Other,186% of Medicaid,2587.2,,,2587.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2587.2,,,2587.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2587.2,,,2587.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2263.8,70,,2263.8,percent of total billed charges,All Other,2102.1,65,,2102.1,percent of total billed charges,Default if not in Fee Schedule,2102.1,65,,2102.1,percent of total billed charges,Default if not in Fee Schedule,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",442.24,,,442.24,Other,100% of Medicaid,442.24,,,442.24,Other,100% of Medicaid,442.24,,,442.24,Other,100% of Medicaid,442.24,,,442.24,Other,100% of Medicaid,995.03,,,995.03,Other,225% of Medicaid,676.62,,,676.62,Other,153% of Medicaid,995.03,,,995.03,Other,225% of Medicaid,619.13,,,619.13,Other,140% of Medicaid,995.03,,,995.03,Other,225% of Medicaid,1149.81,,,1149.81,Other,260% of Medicaid,1432.85,,,1432.85,Other,324% of Medicaid,950.81,,,950.81,Other,215% of Medicaid,950.81,,,950.81,Other,215% of Medicaid,552.8,,,552.8,Other,125% of Medicaid,442.24,7216,
REM INTERROG DEV ICDS TECH,0579T,HCPCS,,49000020,CDM,480,RC,,,both,,,119,88.06,,,88.06,Other,150% of Medicare + 9.63% HCRA Surcharge,53.55,45,,53.55,percent of total billed charges,Critical Access Hospital RCC factor,77.35,65,,77.35,percent of total billed charges,All Other,70.21,65,,70.21,percent of total billed charges,All Other,25.51,,,25.51,Fee Schedule,,25.51,,,25.51,Fee Schedule,,25.51,,,25.51,Fee Schedule,,58.91,,,58.91,Other,110% of Medicare,80.92,68,,80.92,percent of total billed charges,All Other,128,,,128,Other,186% of Medicaid,95.2,80,,95.2,percent of total billed charges,All Other,98.77,83,,98.77,percent of total billed charges,All Other,98.77,83,,98.77,percent of total billed charges,All Other,95.2,80,,95.2,percent of total billed charges,All Other,98.77,83,,98.77,percent of total billed charges,All Other,95.2,,,95.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",83.3,70,,83.3,percent of total billed charges,All Other,77.35,65,,77.35,percent of total billed charges,Default if not in Fee Schedule,77.35,65,,77.35,percent of total billed charges,Default if not in Fee Schedule,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",68.69,,,68.69,Other,100% of Medicaid,68.69,,,68.69,Other,100% of Medicaid,68.69,,,68.69,Other,100% of Medicaid,68.69,,,68.69,Other,100% of Medicaid,154.56,,,154.56,Other,225% of Medicaid,105.1,,,105.1,Other,153% of Medicaid,154.56,,,154.56,Other,225% of Medicaid,96.17,,,96.17,Other,140% of Medicaid,154.56,,,154.56,Other,225% of Medicaid,178.6,,,178.6,Other,260% of Medicaid,222.56,,,222.56,Other,324% of Medicaid,147.69,,,147.69,Other,215% of Medicaid,147.69,,,147.69,Other,215% of Medicaid,85.87,,,85.87,Other,125% of Medicaid,25.51,3227,
PRQ CARDIAC ANGIO ADDL ART,92921,CPT,,49000022,CDM,480,RC,,,both,,,8110,6001.42,,,6001.42,Other,150% of Medicare + 9.63% HCRA Surcharge,3649.5,45,,3649.5,percent of total billed charges,Critical Access Hospital RCC factor,4565,,,4565,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4109,,,4109,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,4014.45,,,4014.45,Other,110% of Medicare,5514.8,,,5514.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",4095.6,,,4095.6,Other,186% of Medicaid,6488,,,6488,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",6488,,,6488,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",6488,,,6488,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",5677,70,,5677,percent of total billed charges,All Other,5271.5,65,,5271.5,percent of total billed charges,Default if not in Fee Schedule,5271.5,65,,5271.5,percent of total billed charges,Default if not in Fee Schedule,6331,,,6331,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",5698,,,5698,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",6331,,,6331,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",5381,,,5381,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2201.94,,,2201.94,Other,100% of Medicaid,2201.94,,,2201.94,Other,100% of Medicaid,2201.94,,,2201.94,Other,100% of Medicaid,2201.94,,,2201.94,Other,100% of Medicaid,4954.36,,,4954.36,Other,225% of Medicaid,3368.96,,,3368.96,Other,153% of Medicaid,4954.36,,,4954.36,Other,225% of Medicaid,3082.71,,,3082.71,Other,140% of Medicaid,4954.36,,,4954.36,Other,225% of Medicaid,5725.04,,,5725.04,Other,260% of Medicaid,7134.28,,,7134.28,Other,324% of Medicaid,4734.17,,,4734.17,Other,215% of Medicaid,4734.17,,,4734.17,Other,215% of Medicaid,2752.42,,,2752.42,Other,125% of Medicaid,0.01,7216,
PRQ CARD STENT W/ANGIO ADDL,92929,CPT,,49000023,CDM,480,RC,,,both,,,16219,12002.1,,,12002.1,Other,150% of Medicare + 9.63% HCRA Surcharge,7298.55,45,,7298.55,percent of total billed charges,Critical Access Hospital RCC factor,4565,,,4565,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4109,,,4109,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,8028.41,,,8028.41,Other,110% of Medicare,11028.92,,,11028.92,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",4095.6,,,4095.6,Other,186% of Medicaid,12975.2,,,12975.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",12975.2,,,12975.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",12975.2,,,12975.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",11353.3,70,,11353.3,percent of total billed charges,All Other,10542.35,65,,10542.35,percent of total billed charges,Default if not in Fee Schedule,10542.35,65,,10542.35,percent of total billed charges,Default if not in Fee Schedule,6331,,,6331,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",5698,,,5698,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",6331,,,6331,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",5381,,,5381,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2201.94,,,2201.94,Other,100% of Medicaid,2201.94,,,2201.94,Other,100% of Medicaid,2201.94,,,2201.94,Other,100% of Medicaid,2201.94,,,2201.94,Other,100% of Medicaid,4954.36,,,4954.36,Other,225% of Medicaid,3368.96,,,3368.96,Other,153% of Medicaid,4954.36,,,4954.36,Other,225% of Medicaid,3082.71,,,3082.71,Other,140% of Medicaid,4954.36,,,4954.36,Other,225% of Medicaid,5725.04,,,5725.04,Other,260% of Medicaid,7134.28,,,7134.28,Other,324% of Medicaid,4734.17,,,4734.17,Other,215% of Medicaid,4734.17,,,4734.17,Other,215% of Medicaid,2752.42,,,2752.42,Other,125% of Medicaid,0.01,12975.2,
PRQ REVASC BYP GRAFT ADDL,92938,CPT,,49000024,CDM,480,RC,,,both,,,16219,12002.1,,,12002.1,Other,150% of Medicare + 9.63% HCRA Surcharge,7298.55,45,,7298.55,percent of total billed charges,Critical Access Hospital RCC factor,4565,,,4565,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4109,,,4109,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,8028.41,,,8028.41,Other,110% of Medicare,11028.92,,,11028.92,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",4095.6,,,4095.6,Other,186% of Medicaid,12975.2,,,12975.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",12975.2,,,12975.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",12975.2,,,12975.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",11353.3,70,,11353.3,percent of total billed charges,All Other,10542.35,65,,10542.35,percent of total billed charges,Default if not in Fee Schedule,10542.35,65,,10542.35,percent of total billed charges,Default if not in Fee Schedule,6331,,,6331,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",5698,,,5698,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",6331,,,6331,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",5381,,,5381,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2201.94,,,2201.94,Other,100% of Medicaid,2201.94,,,2201.94,Other,100% of Medicaid,2201.94,,,2201.94,Other,100% of Medicaid,2201.94,,,2201.94,Other,100% of Medicaid,4954.36,,,4954.36,Other,225% of Medicaid,3368.96,,,3368.96,Other,153% of Medicaid,4954.36,,,4954.36,Other,225% of Medicaid,3082.71,,,3082.71,Other,140% of Medicaid,4954.36,,,4954.36,Other,225% of Medicaid,5725.04,,,5725.04,Other,260% of Medicaid,7134.28,,,7134.28,Other,324% of Medicaid,4734.17,,,4734.17,Other,215% of Medicaid,4734.17,,,4734.17,Other,215% of Medicaid,2752.42,,,2752.42,Other,125% of Medicaid,0.01,12975.2,
PRQ CARD REVASC CHRONIC ADDL,92944,CPT,,49000025,CDM,480,RC,,,both,,,16219,12002.1,,,12002.1,Other,150% of Medicare + 9.63% HCRA Surcharge,7298.55,45,,7298.55,percent of total billed charges,Critical Access Hospital RCC factor,4565,,,4565,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4109,,,4109,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,8028.41,,,8028.41,Other,110% of Medicare,11028.92,,,11028.92,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",4095.6,,,4095.6,Other,186% of Medicaid,12975.2,,,12975.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",12975.2,,,12975.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",12975.2,,,12975.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",11353.3,70,,11353.3,percent of total billed charges,All Other,10542.35,65,,10542.35,percent of total billed charges,Default if not in Fee Schedule,10542.35,65,,10542.35,percent of total billed charges,Default if not in Fee Schedule,6331,,,6331,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",5698,,,5698,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",6331,,,6331,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",5381,,,5381,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2201.94,,,2201.94,Other,100% of Medicaid,2201.94,,,2201.94,Other,100% of Medicaid,2201.94,,,2201.94,Other,100% of Medicaid,2201.94,,,2201.94,Other,100% of Medicaid,4954.36,,,4954.36,Other,225% of Medicaid,3368.96,,,3368.96,Other,153% of Medicaid,4954.36,,,4954.36,Other,225% of Medicaid,3082.71,,,3082.71,Other,140% of Medicaid,4954.36,,,4954.36,Other,225% of Medicaid,5725.04,,,5725.04,Other,260% of Medicaid,7134.28,,,7134.28,Other,324% of Medicaid,4734.17,,,4734.17,Other,215% of Medicaid,4734.17,,,4734.17,Other,215% of Medicaid,2752.42,,,2752.42,Other,125% of Medicaid,0.01,12975.2,
PRQ CARDIAC ANGIOPLAST 1 ART,92920,CPT,,49092920,CDM,480,RC,,,both,,,16218,12001.36,,,12001.36,Other,150% of Medicare + 9.63% HCRA Surcharge,7298.1,45,,7298.1,percent of total billed charges,Critical Access Hospital RCC factor,4565,,,4565,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4109,,,4109,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",6807,,,6807,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",6126,,,6126,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",5786,,,5786,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",8027.91,,,8027.91,Other,110% of Medicare,11028.24,,,11028.24,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",4095.6,,,4095.6,Other,186% of Medicaid,12974.4,,,12974.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",12974.4,,,12974.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",12974.4,,,12974.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",11352.6,70,,11352.6,percent of total billed charges,All Other,2546.92,,,2546.92,Fee Schedule,,2158.67,,,2158.67,Fee Schedule,,6331,,,6331,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",5698,,,5698,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",6331,,,6331,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",5381,,,5381,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2201.94,,,2201.94,Other,100% of Medicaid,2201.94,,,2201.94,Other,100% of Medicaid,2201.94,,,2201.94,Other,100% of Medicaid,2201.94,,,2201.94,Other,100% of Medicaid,4954.36,,,4954.36,Other,225% of Medicaid,3368.96,,,3368.96,Other,153% of Medicaid,4954.36,,,4954.36,Other,225% of Medicaid,3082.71,,,3082.71,Other,140% of Medicaid,4954.36,,,4954.36,Other,225% of Medicaid,5725.04,,,5725.04,Other,260% of Medicaid,7134.28,,,7134.28,Other,324% of Medicaid,4734.17,,,4734.17,Other,215% of Medicaid,4734.17,,,4734.17,Other,215% of Medicaid,2752.42,,,2752.42,Other,125% of Medicaid,2158.67,12974.4,
PRQ CARD STENT W/ANGIO 1 VSL,92928,CPT,,49092928,CDM,480,RC,,,both,,,32438,24004.2,,,24004.2,Other,150% of Medicare + 9.63% HCRA Surcharge,14597.1,45,,14597.1,percent of total billed charges,Critical Access Hospital RCC factor,4565,,,4565,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4109,,,4109,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",7978,,,7978,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",7180,,,7180,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",6781,,,6781,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",16056.81,,,16056.81,Other,110% of Medicare,22057.84,,,22057.84,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",4095.6,,,4095.6,Other,186% of Medicaid,25950.4,,,25950.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",25950.4,,,25950.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",25950.4,,,25950.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",22706.6,70,,22706.6,percent of total billed charges,All Other,2833.92,,,2833.92,Fee Schedule,,2401.92,,,2401.92,Fee Schedule,,6331,,,6331,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",5698,,,5698,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",6331,,,6331,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",5381,,,5381,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2201.94,,,2201.94,Other,100% of Medicaid,2201.94,,,2201.94,Other,100% of Medicaid,2201.94,,,2201.94,Other,100% of Medicaid,2201.94,,,2201.94,Other,100% of Medicaid,4954.36,,,4954.36,Other,225% of Medicaid,3368.96,,,3368.96,Other,153% of Medicaid,4954.36,,,4954.36,Other,225% of Medicaid,3082.71,,,3082.71,Other,140% of Medicaid,4954.36,,,4954.36,Other,225% of Medicaid,5725.04,,,5725.04,Other,260% of Medicaid,7134.28,,,7134.28,Other,324% of Medicaid,4734.17,,,4734.17,Other,215% of Medicaid,4734.17,,,4734.17,Other,215% of Medicaid,2752.42,,,2752.42,Other,125% of Medicaid,2201.94,25950.4,
PRQ REVASC BYP GRAFT 1 VSL,92937,CPT,,49092937,CDM,480,RC,,,both,,,32438,24004.2,,,24004.2,Other,150% of Medicare + 9.63% HCRA Surcharge,14597.1,45,,14597.1,percent of total billed charges,Critical Access Hospital RCC factor,4565,,,4565,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4109,,,4109,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",7978,,,7978,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",7180,,,7180,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",6781,,,6781,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",16056.81,,,16056.81,Other,110% of Medicare,22057.84,,,22057.84,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",4095.6,,,4095.6,Other,186% of Medicaid,25950.4,,,25950.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",25950.4,,,25950.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",25950.4,,,25950.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",22706.6,70,,22706.6,percent of total billed charges,All Other,2830.64,,,2830.64,Fee Schedule,,2399.14,,,2399.14,Fee Schedule,,6331,,,6331,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",5698,,,5698,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",6331,,,6331,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",5381,,,5381,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2201.94,,,2201.94,Other,100% of Medicaid,2201.94,,,2201.94,Other,100% of Medicaid,2201.94,,,2201.94,Other,100% of Medicaid,2201.94,,,2201.94,Other,100% of Medicaid,4954.36,,,4954.36,Other,225% of Medicaid,3368.96,,,3368.96,Other,153% of Medicaid,4954.36,,,4954.36,Other,225% of Medicaid,3082.71,,,3082.71,Other,140% of Medicaid,4954.36,,,4954.36,Other,225% of Medicaid,5725.04,,,5725.04,Other,260% of Medicaid,7134.28,,,7134.28,Other,324% of Medicaid,4734.17,,,4734.17,Other,215% of Medicaid,4734.17,,,4734.17,Other,215% of Medicaid,2752.42,,,2752.42,Other,125% of Medicaid,2201.94,25950.4,
PRQ CARD REVASC MI 1 VSL,92941,CPT,,49092941,CDM,480,RC,,,both,,,2458,1818.93,,,1818.93,Other,150% of Medicare + 9.63% HCRA Surcharge,1106.1,45,,1106.1,percent of total billed charges,Critical Access Hospital RCC factor,4565,,,4565,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4109,,,4109,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",7978,,,7978,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",7180,,,7180,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",6781,,,6781,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",1216.71,,,1216.71,Other,110% of Medicare,1671.44,,,1671.44,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",4095.6,,,4095.6,Other,186% of Medicaid,1966.4,,,1966.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1966.4,,,1966.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1966.4,,,1966.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1720.6,70,,1720.6,percent of total billed charges,All Other,3184.88,,,3184.88,Fee Schedule,,2699.38,,,2699.38,Fee Schedule,,6331,,,6331,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",5698,,,5698,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",6331,,,6331,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",5381,,,5381,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2201.94,,,2201.94,Other,100% of Medicaid,2201.94,,,2201.94,Other,100% of Medicaid,2201.94,,,2201.94,Other,100% of Medicaid,2201.94,,,2201.94,Other,100% of Medicaid,4954.36,,,4954.36,Other,225% of Medicaid,3368.96,,,3368.96,Other,153% of Medicaid,4954.36,,,4954.36,Other,225% of Medicaid,3082.71,,,3082.71,Other,140% of Medicaid,4954.36,,,4954.36,Other,225% of Medicaid,5725.04,,,5725.04,Other,260% of Medicaid,7134.28,,,7134.28,Other,324% of Medicaid,4734.17,,,4734.17,Other,215% of Medicaid,4734.17,,,4734.17,Other,215% of Medicaid,2752.42,,,2752.42,Other,125% of Medicaid,1106.1,7978,
PRQ CARD REVASC CHRONIC 1VSL,92943,CPT,,49092943,CDM,480,RC,,,both,,,32438,24004.2,,,24004.2,Other,150% of Medicare + 9.63% HCRA Surcharge,14597.1,45,,14597.1,percent of total billed charges,Critical Access Hospital RCC factor,4565,,,4565,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4109,,,4109,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",7978,,,7978,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",7180,,,7180,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",6781,,,6781,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",16056.81,,,16056.81,Other,110% of Medicare,22057.84,,,22057.84,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",4095.6,,,4095.6,Other,186% of Medicaid,25950.4,,,25950.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",25950.4,,,25950.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",25950.4,,,25950.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",22706.6,70,,22706.6,percent of total billed charges,All Other,3184.88,,,3184.88,Fee Schedule,,2699.38,,,2699.38,Fee Schedule,,6331,,,6331,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",5698,,,5698,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",6331,,,6331,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",5381,,,5381,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2201.94,,,2201.94,Other,100% of Medicaid,2201.94,,,2201.94,Other,100% of Medicaid,2201.94,,,2201.94,Other,100% of Medicaid,2201.94,,,2201.94,Other,100% of Medicaid,4954.36,,,4954.36,Other,225% of Medicaid,3368.96,,,3368.96,Other,153% of Medicaid,4954.36,,,4954.36,Other,225% of Medicaid,3082.71,,,3082.71,Other,140% of Medicaid,4954.36,,,4954.36,Other,225% of Medicaid,5725.04,,,5725.04,Other,260% of Medicaid,7134.28,,,7134.28,Other,324% of Medicaid,4734.17,,,4734.17,Other,215% of Medicaid,4734.17,,,4734.17,Other,215% of Medicaid,2752.42,,,2752.42,Other,125% of Medicaid,2201.94,25950.4,
CARDIOVERSION ELECTRIC EXT,92960,CPT,,49092960,CDM,480,RC,,,both,,,2056,1521.45,,,1521.45,Other,150% of Medicare + 9.63% HCRA Surcharge,925.2,45,,925.2,percent of total billed charges,Critical Access Hospital RCC factor,330.52,,,330.52,Fee Schedule,,298.03,,,298.03,Fee Schedule,,1531.99,,,1531.99,Fee Schedule,,1377.92,,,1377.92,Fee Schedule,,1302.34,,,1302.34,Fee Schedule,,1017.72,,,1017.72,Other,110% of Medicare,1398.08,68,,1398.08,percent of total billed charges,All Other,816,,,816,Other,186% of Medicaid,1644.8,80,,1644.8,percent of total billed charges,All Other,1706.48,83,,1706.48,percent of total billed charges,All Other,1706.48,83,,1706.48,percent of total billed charges,All Other,1644.8,80,,1644.8,percent of total billed charges,All Other,1706.48,83,,1706.48,percent of total billed charges,All Other,1644.8,,,1644.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1439.2,70,,1439.2,percent of total billed charges,All Other,518.24,,,518.24,Fee Schedule,,439.24,,,439.24,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",438.68,,,438.68,Other,100% of Medicaid,438.68,,,438.68,Other,100% of Medicaid,438.68,,,438.68,Other,100% of Medicaid,438.68,,,438.68,Other,100% of Medicaid,987.03,,,987.03,Other,225% of Medicaid,671.18,,,671.18,Other,153% of Medicaid,987.03,,,987.03,Other,225% of Medicaid,614.15,,,614.15,Other,140% of Medicaid,987.03,,,987.03,Other,225% of Medicaid,1140.57,,,1140.57,Other,260% of Medicaid,1421.33,,,1421.33,Other,324% of Medicaid,943.16,,,943.16,Other,215% of Medicaid,943.16,,,943.16,Other,215% of Medicaid,548.35,,,548.35,Other,125% of Medicaid,298.03,3227,
CARDIOVERSION ELECTIVE; INT,92961,CPT,,49092961,CDM,480,RC,,,both,,,1572,1163.28,,,1163.28,Other,150% of Medicare + 9.63% HCRA Surcharge,707.4,45,,707.4,percent of total billed charges,Critical Access Hospital RCC factor,4565,,,4565,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4109,,,4109,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",778.14,,,778.14,Other,110% of Medicare,1068.96,,,1068.96,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",815.95,,,815.95,Other,186% of Medicaid,1257.6,,,1257.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1257.6,,,1257.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1257.6,,,1257.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1100.4,70,,1100.4,percent of total billed charges,All Other,1182.44,,,1182.44,Fee Schedule,,1002.19,,,1002.19,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",438.68,,,438.68,Other,100% of Medicaid,438.68,,,438.68,Other,100% of Medicaid,438.68,,,438.68,Other,100% of Medicaid,438.68,,,438.68,Other,100% of Medicaid,987.03,,,987.03,Other,225% of Medicaid,671.18,,,671.18,Other,153% of Medicaid,987.03,,,987.03,Other,225% of Medicaid,614.15,,,614.15,Other,140% of Medicaid,987.03,,,987.03,Other,225% of Medicaid,1140.57,,,1140.57,Other,260% of Medicaid,1421.33,,,1421.33,Other,324% of Medicaid,943.16,,,943.16,Other,215% of Medicaid,943.16,,,943.16,Other,215% of Medicaid,548.35,,,548.35,Other,125% of Medicaid,438.68,7216,
PRGRMG EVAL IMPLANTABLE DFB,93282,CPT,,49093282,CDM,480,RC,,,both,,,119,88.06,,,88.06,Other,150% of Medicare + 9.63% HCRA Surcharge,53.55,45,,53.55,percent of total billed charges,Critical Access Hospital RCC factor,125.17,,,125.17,Fee Schedule,,112.86,,,112.86,Fee Schedule,,147.13,,,147.13,Fee Schedule,,132.45,,,132.45,Fee Schedule,,125.1,,,125.1,Fee Schedule,,58.91,,,58.91,Other,110% of Medicare,80.92,68,,80.92,percent of total billed charges,All Other,128,,,128,Other,186% of Medicaid,95.2,80,,95.2,percent of total billed charges,All Other,98.77,83,,98.77,percent of total billed charges,All Other,98.77,83,,98.77,percent of total billed charges,All Other,95.2,80,,95.2,percent of total billed charges,All Other,98.77,83,,98.77,percent of total billed charges,All Other,95.2,,,95.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",83.3,70,,83.3,percent of total billed charges,All Other,200.08,,,200.08,Fee Schedule,,169.58,,,169.58,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",68.69,,,68.69,Other,100% of Medicaid,68.69,,,68.69,Other,100% of Medicaid,68.69,,,68.69,Other,100% of Medicaid,68.69,,,68.69,Other,100% of Medicaid,154.56,,,154.56,Other,225% of Medicaid,105.1,,,105.1,Other,153% of Medicaid,154.56,,,154.56,Other,225% of Medicaid,96.17,,,96.17,Other,140% of Medicaid,154.56,,,154.56,Other,225% of Medicaid,178.6,,,178.6,Other,260% of Medicaid,222.56,,,222.56,Other,324% of Medicaid,147.69,,,147.69,Other,215% of Medicaid,147.69,,,147.69,Other,215% of Medicaid,85.87,,,85.87,Other,125% of Medicaid,53.55,3227,
DOPPLER COLOR FLOW,93325,CPT,,49093325,CDM,480,RC,,,both,,,17,12.58,,,12.58,Other,150% of Medicare + 9.63% HCRA Surcharge,7.65,45,,7.65,percent of total billed charges,Critical Access Hospital RCC factor,65.17,,,65.17,Fee Schedule,,58.76,,,58.76,Fee Schedule,,215.23,,,215.23,Fee Schedule,,193.58,,,193.58,Fee Schedule,,182.96,,,182.96,Fee Schedule,,8.42,,,8.42,Other,110% of Medicare,11.56,68,,11.56,percent of total billed charges,All Other,226,,,226,Other,186% of Medicaid,13.6,80,,13.6,percent of total billed charges,All Other,14.11,83,,14.11,percent of total billed charges,All Other,14.11,83,,14.11,percent of total billed charges,All Other,13.6,80,,13.6,percent of total billed charges,All Other,14.11,83,,14.11,percent of total billed charges,All Other,13.6,,,13.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",11.9,70,,11.9,percent of total billed charges,All Other,101.68,,,101.68,Fee Schedule,,86.18,,,86.18,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",121.68,,,121.68,Other,100% of Medicaid,121.68,,,121.68,Other,100% of Medicaid,121.68,,,121.68,Other,100% of Medicaid,121.68,,,121.68,Other,100% of Medicaid,273.79,,,273.79,Other,225% of Medicaid,186.18,,,186.18,Other,153% of Medicaid,273.79,,,273.79,Other,225% of Medicaid,170.36,,,170.36,Other,140% of Medicaid,273.79,,,273.79,Other,225% of Medicaid,316.38,,,316.38,Other,260% of Medicaid,394.25,,,394.25,Other,324% of Medicaid,261.62,,,261.62,Other,215% of Medicaid,261.62,,,261.62,Other,215% of Medicaid,152.1,,,152.1,Other,125% of Medicaid,7.65,3227,
BUNDLE OF HIS RECORDING,93600,CPT,,49093600,CDM,480,RC,,,both,,,15156,11215.48,,,11215.48,Other,150% of Medicare + 9.63% HCRA Surcharge,6820.2,45,,6820.2,percent of total billed charges,Critical Access Hospital RCC factor,5954,,,5954,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",5359,,,5359,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3648,,,3648,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3283,,,3283,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3101,,,3101,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",7502.22,,,7502.22,Other,110% of Medicare,6152,,,6152,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",822.56,,,822.56,Other,186% of Medicaid,7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",12124.8,,,12124.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",10609.2,70,,10609.2,percent of total billed charges,All Other,9851.4,65,,9851.4,percent of total billed charges,Default if not in Fee Schedule,9851.4,65,,9851.4,percent of total billed charges,Default if not in Fee Schedule,4055,,,4055,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3649,,,3649,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4055,,,4055,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3448,,,3448,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",442.24,,,442.24,Other,100% of Medicaid,442.24,,,442.24,Other,100% of Medicaid,442.24,,,442.24,Other,100% of Medicaid,442.24,,,442.24,Other,100% of Medicaid,995.03,,,995.03,Other,225% of Medicaid,676.62,,,676.62,Other,153% of Medicaid,995.03,,,995.03,Other,225% of Medicaid,619.13,,,619.13,Other,140% of Medicaid,995.03,,,995.03,Other,225% of Medicaid,1149.81,,,1149.81,Other,260% of Medicaid,1432.85,,,1432.85,Other,324% of Medicaid,950.81,,,950.81,Other,215% of Medicaid,950.81,,,950.81,Other,215% of Medicaid,552.8,,,552.8,Other,125% of Medicaid,442.24,12124.8,
INTRA-ATRIAL RECORDING,93602,CPT,,49093602,CDM,480,RC,,,both,,,15156,11215.48,,,11215.48,Other,150% of Medicare + 9.63% HCRA Surcharge,6820.2,45,,6820.2,percent of total billed charges,Critical Access Hospital RCC factor,4565,,,4565,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4109,,,4109,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3648,,,3648,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3283,,,3283,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3101,,,3101,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",7502.22,,,7502.22,Other,110% of Medicare,10306.08,,,10306.08,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",822.56,,,822.56,Other,186% of Medicaid,12124.8,,,12124.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",12124.8,,,12124.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",12124.8,,,12124.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",10609.2,70,,10609.2,percent of total billed charges,All Other,9851.4,65,,9851.4,percent of total billed charges,Default if not in Fee Schedule,9851.4,65,,9851.4,percent of total billed charges,Default if not in Fee Schedule,4055,,,4055,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3649,,,3649,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4055,,,4055,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3448,,,3448,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",442.24,,,442.24,Other,100% of Medicaid,442.24,,,442.24,Other,100% of Medicaid,442.24,,,442.24,Other,100% of Medicaid,442.24,,,442.24,Other,100% of Medicaid,995.03,,,995.03,Other,225% of Medicaid,676.62,,,676.62,Other,153% of Medicaid,995.03,,,995.03,Other,225% of Medicaid,619.13,,,619.13,Other,140% of Medicaid,995.03,,,995.03,Other,225% of Medicaid,1149.81,,,1149.81,Other,260% of Medicaid,1432.85,,,1432.85,Other,324% of Medicaid,950.81,,,950.81,Other,215% of Medicaid,950.81,,,950.81,Other,215% of Medicaid,552.8,,,552.8,Other,125% of Medicaid,442.24,12124.8,
RIGHT VENTRICULAR RECORDING,93603,CPT,,49093603,CDM,480,RC,,,both,,,2922,2162.29,,,2162.29,Other,150% of Medicare + 9.63% HCRA Surcharge,1314.9,45,,1314.9,percent of total billed charges,Critical Access Hospital RCC factor,4565,,,4565,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4109,,,4109,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3648,,,3648,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3283,,,3283,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3101,,,3101,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",1446.39,,,1446.39,Other,110% of Medicare,1986.96,,,1986.96,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",822.56,,,822.56,Other,186% of Medicaid,2337.6,,,2337.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2337.6,,,2337.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2337.6,,,2337.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2045.4,70,,2045.4,percent of total billed charges,All Other,1899.3,65,,1899.3,percent of total billed charges,Default if not in Fee Schedule,1899.3,65,,1899.3,percent of total billed charges,Default if not in Fee Schedule,4055,,,4055,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3649,,,3649,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4055,,,4055,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3448,,,3448,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",442.24,,,442.24,Other,100% of Medicaid,442.24,,,442.24,Other,100% of Medicaid,442.24,,,442.24,Other,100% of Medicaid,442.24,,,442.24,Other,100% of Medicaid,995.03,,,995.03,Other,225% of Medicaid,676.62,,,676.62,Other,153% of Medicaid,995.03,,,995.03,Other,225% of Medicaid,619.13,,,619.13,Other,140% of Medicaid,995.03,,,995.03,Other,225% of Medicaid,1149.81,,,1149.81,Other,260% of Medicaid,1432.85,,,1432.85,Other,324% of Medicaid,950.81,,,950.81,Other,215% of Medicaid,950.81,,,950.81,Other,215% of Medicaid,552.8,,,552.8,Other,125% of Medicaid,442.24,7216,
ARRHYTHMIA INDUCTION,93618,CPT,,49093618,CDM,480,RC,,,both,,,2922,2162.29,,,2162.29,Other,150% of Medicare + 9.63% HCRA Surcharge,1314.9,45,,1314.9,percent of total billed charges,Critical Access Hospital RCC factor,5954,,,5954,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",5359,,,5359,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3648,,,3648,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3283,,,3283,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3101,,,3101,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",1446.39,,,1446.39,Other,110% of Medicare,6152,,,6152,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",822.56,,,822.56,Other,186% of Medicaid,7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2337.6,,,2337.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2045.4,70,,2045.4,percent of total billed charges,All Other,1899.3,65,,1899.3,percent of total billed charges,Default if not in Fee Schedule,1899.3,65,,1899.3,percent of total billed charges,Default if not in Fee Schedule,4055,,,4055,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3649,,,3649,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4055,,,4055,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3448,,,3448,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",442.24,,,442.24,Other,100% of Medicaid,442.24,,,442.24,Other,100% of Medicaid,442.24,,,442.24,Other,100% of Medicaid,442.24,,,442.24,Other,100% of Medicaid,995.03,,,995.03,Other,225% of Medicaid,676.62,,,676.62,Other,153% of Medicaid,995.03,,,995.03,Other,225% of Medicaid,619.13,,,619.13,Other,140% of Medicaid,995.03,,,995.03,Other,225% of Medicaid,1149.81,,,1149.81,Other,260% of Medicaid,1432.85,,,1432.85,Other,324% of Medicaid,950.81,,,950.81,Other,215% of Medicaid,950.81,,,950.81,Other,215% of Medicaid,552.8,,,552.8,Other,125% of Medicaid,442.24,9473,
COMP EP EVAL WO A INDUCTION,93619,CPT,,49093619,CDM,480,RC,,,both,,,15819,11706.1,,,11706.1,Other,150% of Medicare + 9.63% HCRA Surcharge,7118.55,45,,7118.55,percent of total billed charges,Critical Access Hospital RCC factor,5954,,,5954,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",5359,,,5359,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3648,,,3648,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3283,,,3283,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3101,,,3101,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",7830.41,,,7830.41,Other,110% of Medicare,6152,,,6152,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",822.56,,,822.56,Other,186% of Medicaid,7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",12655.2,,,12655.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",11073.3,70,,11073.3,percent of total billed charges,All Other,10282.35,65,,10282.35,percent of total billed charges,Default if not in Fee Schedule,10282.35,65,,10282.35,percent of total billed charges,Default if not in Fee Schedule,6331,,,6331,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",5698,,,5698,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",6331,,,6331,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",5381,,,5381,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",442.24,,,442.24,Other,100% of Medicaid,442.24,,,442.24,Other,100% of Medicaid,442.24,,,442.24,Other,100% of Medicaid,442.24,,,442.24,Other,100% of Medicaid,995.03,,,995.03,Other,225% of Medicaid,676.62,,,676.62,Other,153% of Medicaid,995.03,,,995.03,Other,225% of Medicaid,619.13,,,619.13,Other,140% of Medicaid,995.03,,,995.03,Other,225% of Medicaid,1149.81,,,1149.81,Other,260% of Medicaid,1432.85,,,1432.85,Other,324% of Medicaid,950.81,,,950.81,Other,215% of Medicaid,950.81,,,950.81,Other,215% of Medicaid,552.8,,,552.8,Other,125% of Medicaid,442.24,12655.2,
COMP EP EVAL W INDUCTION,93620,CPT,,49093620,CDM,480,RC,,,both,,,15819,11706.1,,,11706.1,Other,150% of Medicare + 9.63% HCRA Surcharge,7118.55,45,,7118.55,percent of total billed charges,Critical Access Hospital RCC factor,5954,,,5954,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",5359,,,5359,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3648,,,3648,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3283,,,3283,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3101,,,3101,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",7830.41,,,7830.41,Other,110% of Medicare,6152,,,6152,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",822.56,,,822.56,Other,186% of Medicaid,7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",12655.2,,,12655.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",11073.3,70,,11073.3,percent of total billed charges,All Other,10282.35,65,,10282.35,percent of total billed charges,Default if not in Fee Schedule,10282.35,65,,10282.35,percent of total billed charges,Default if not in Fee Schedule,6331,,,6331,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",5698,,,5698,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",6331,,,6331,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",5381,,,5381,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",442.24,,,442.24,Other,100% of Medicaid,442.24,,,442.24,Other,100% of Medicaid,442.24,,,442.24,Other,100% of Medicaid,442.24,,,442.24,Other,100% of Medicaid,995.03,,,995.03,Other,225% of Medicaid,676.62,,,676.62,Other,153% of Medicaid,995.03,,,995.03,Other,225% of Medicaid,619.13,,,619.13,Other,140% of Medicaid,995.03,,,995.03,Other,225% of Medicaid,1149.81,,,1149.81,Other,260% of Medicaid,1432.85,,,1432.85,Other,324% of Medicaid,950.81,,,950.81,Other,215% of Medicaid,950.81,,,950.81,Other,215% of Medicaid,552.8,,,552.8,Other,125% of Medicaid,442.24,12655.2,
COMP EP EVAL W RA RECORDING,93621,CPT,,49093621,CDM,480,RC,,,both,,,432,319.68,,,319.68,Other,150% of Medicare + 9.63% HCRA Surcharge,194.4,45,,194.4,percent of total billed charges,Critical Access Hospital RCC factor,5954,,,5954,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",5359,,,5359,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3648,,,3648,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3283,,,3283,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3101,,,3101,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",213.84,,,213.84,Other,110% of Medicare,6152,,,6152,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",822.56,,,822.56,Other,186% of Medicaid,7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",345.6,,,345.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",302.4,70,,302.4,percent of total billed charges,All Other,280.8,65,,280.8,percent of total billed charges,Default if not in Fee Schedule,280.8,65,,280.8,percent of total billed charges,Default if not in Fee Schedule,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",442.24,,,442.24,Other,100% of Medicaid,442.24,,,442.24,Other,100% of Medicaid,442.24,,,442.24,Other,100% of Medicaid,442.24,,,442.24,Other,100% of Medicaid,995.03,,,995.03,Other,225% of Medicaid,676.62,,,676.62,Other,153% of Medicaid,995.03,,,995.03,Other,225% of Medicaid,619.13,,,619.13,Other,140% of Medicaid,995.03,,,995.03,Other,225% of Medicaid,1149.81,,,1149.81,Other,260% of Medicaid,1432.85,,,1432.85,Other,324% of Medicaid,950.81,,,950.81,Other,215% of Medicaid,950.81,,,950.81,Other,215% of Medicaid,552.8,,,552.8,Other,125% of Medicaid,194.4,9473,
COMP EP EVAL W LV RECORDING,93622,CPT,,49093622,CDM,480,RC,,,both,,,639,472.86,,,472.86,Other,150% of Medicare + 9.63% HCRA Surcharge,287.55,45,,287.55,percent of total billed charges,Critical Access Hospital RCC factor,5954,,,5954,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",5359,,,5359,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3648,,,3648,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3283,,,3283,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3101,,,3101,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",316.31,,,316.31,Other,110% of Medicare,6152,,,6152,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",822.56,,,822.56,Other,186% of Medicaid,7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",511.2,,,511.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",447.3,70,,447.3,percent of total billed charges,All Other,415.35,65,,415.35,percent of total billed charges,Default if not in Fee Schedule,415.35,65,,415.35,percent of total billed charges,Default if not in Fee Schedule,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",442.24,,,442.24,Other,100% of Medicaid,442.24,,,442.24,Other,100% of Medicaid,442.24,,,442.24,Other,100% of Medicaid,442.24,,,442.24,Other,100% of Medicaid,995.03,,,995.03,Other,225% of Medicaid,676.62,,,676.62,Other,153% of Medicaid,995.03,,,995.03,Other,225% of Medicaid,619.13,,,619.13,Other,140% of Medicaid,995.03,,,995.03,Other,225% of Medicaid,1149.81,,,1149.81,Other,260% of Medicaid,1432.85,,,1432.85,Other,324% of Medicaid,950.81,,,950.81,Other,215% of Medicaid,950.81,,,950.81,Other,215% of Medicaid,552.8,,,552.8,Other,125% of Medicaid,287.55,9473,
STIM & PACING S/P IV DRUGS,93623,CPT,,49093623,CDM,480,RC,,,both,,,587,434.38,,,434.38,Other,150% of Medicare + 9.63% HCRA Surcharge,264.15,45,,264.15,percent of total billed charges,Critical Access Hospital RCC factor,4565,,,4565,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4109,,,4109,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3648,,,3648,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3283,,,3283,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3101,,,3101,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",290.57,,,290.57,Other,110% of Medicare,399.16,,,399.16,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",822.56,,,822.56,Other,186% of Medicaid,469.6,,,469.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",469.6,,,469.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",469.6,,,469.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",410.9,70,,410.9,percent of total billed charges,All Other,381.55,65,,381.55,percent of total billed charges,Default if not in Fee Schedule,381.55,65,,381.55,percent of total billed charges,Default if not in Fee Schedule,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",442.24,,,442.24,Other,100% of Medicaid,442.24,,,442.24,Other,100% of Medicaid,442.24,,,442.24,Other,100% of Medicaid,442.24,,,442.24,Other,100% of Medicaid,995.03,,,995.03,Other,225% of Medicaid,676.62,,,676.62,Other,153% of Medicaid,995.03,,,995.03,Other,225% of Medicaid,619.13,,,619.13,Other,140% of Medicaid,995.03,,,995.03,Other,225% of Medicaid,1149.81,,,1149.81,Other,260% of Medicaid,1432.85,,,1432.85,Other,324% of Medicaid,950.81,,,950.81,Other,215% of Medicaid,950.81,,,950.81,Other,215% of Medicaid,552.8,,,552.8,Other,125% of Medicaid,264.15,7216,
EP F-UP STUDY W PACING,93624,CPT,,49093624,CDM,480,RC,,,both,,,15819,11706.1,,,11706.1,Other,150% of Medicare + 9.63% HCRA Surcharge,7118.55,45,,7118.55,percent of total billed charges,Critical Access Hospital RCC factor,4565,,,4565,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4109,,,4109,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3648,,,3648,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3283,,,3283,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3101,,,3101,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",7830.41,,,7830.41,Other,110% of Medicare,10756.92,,,10756.92,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",822.56,,,822.56,Other,186% of Medicaid,12655.2,,,12655.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",12655.2,,,12655.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",12655.2,,,12655.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",11073.3,70,,11073.3,percent of total billed charges,All Other,10282.35,65,,10282.35,percent of total billed charges,Default if not in Fee Schedule,10282.35,65,,10282.35,percent of total billed charges,Default if not in Fee Schedule,6331,,,6331,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",5698,,,5698,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",6331,,,6331,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",5381,,,5381,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",442.24,,,442.24,Other,100% of Medicaid,442.24,,,442.24,Other,100% of Medicaid,442.24,,,442.24,Other,100% of Medicaid,442.24,,,442.24,Other,100% of Medicaid,995.03,,,995.03,Other,225% of Medicaid,676.62,,,676.62,Other,153% of Medicaid,995.03,,,995.03,Other,225% of Medicaid,619.13,,,619.13,Other,140% of Medicaid,995.03,,,995.03,Other,225% of Medicaid,1149.81,,,1149.81,Other,260% of Medicaid,1432.85,,,1432.85,Other,324% of Medicaid,950.81,,,950.81,Other,215% of Medicaid,950.81,,,950.81,Other,215% of Medicaid,552.8,,,552.8,Other,125% of Medicaid,442.24,12655.2,
EP EVAL CD LEADS; INIT/REPLACEMENT,93640,CPT,,49093640,CDM,480,RC,,,both,,,724,535.76,,,535.76,Other,150% of Medicare + 9.63% HCRA Surcharge,325.8,45,,325.8,percent of total billed charges,Critical Access Hospital RCC factor,5954,,,5954,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",5359,,,5359,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3648,,,3648,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3283,,,3283,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3101,,,3101,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",358.38,,,358.38,Other,110% of Medicare,6152,,,6152,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",822.56,,,822.56,Other,186% of Medicaid,7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",579.2,,,579.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",506.8,70,,506.8,percent of total billed charges,All Other,470.6,65,,470.6,percent of total billed charges,Default if not in Fee Schedule,470.6,65,,470.6,percent of total billed charges,Default if not in Fee Schedule,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",442.24,,,442.24,Other,100% of Medicaid,442.24,,,442.24,Other,100% of Medicaid,442.24,,,442.24,Other,100% of Medicaid,442.24,,,442.24,Other,100% of Medicaid,995.03,,,995.03,Other,225% of Medicaid,676.62,,,676.62,Other,153% of Medicaid,995.03,,,995.03,Other,225% of Medicaid,619.13,,,619.13,Other,140% of Medicaid,995.03,,,995.03,Other,225% of Medicaid,1149.81,,,1149.81,Other,260% of Medicaid,1432.85,,,1432.85,Other,324% of Medicaid,950.81,,,950.81,Other,215% of Medicaid,950.81,,,950.81,Other,215% of Medicaid,552.8,,,552.8,Other,125% of Medicaid,325.8,9473,
EP EVAL CD; W GENERATOR TEST,93641,CPT,,49093641,CDM,480,RC,,,both,,,1220,902.8,,,902.8,Other,150% of Medicare + 9.63% HCRA Surcharge,549,45,,549,percent of total billed charges,Critical Access Hospital RCC factor,5954,,,5954,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",5359,,,5359,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3648,,,3648,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3283,,,3283,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3101,,,3101,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",603.9,,,603.9,Other,110% of Medicare,6152,,,6152,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",822.56,,,822.56,Other,186% of Medicaid,7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",976,,,976,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",854,70,,854,percent of total billed charges,All Other,793,65,,793,percent of total billed charges,Default if not in Fee Schedule,793,65,,793,percent of total billed charges,Default if not in Fee Schedule,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",442.24,,,442.24,Other,100% of Medicaid,442.24,,,442.24,Other,100% of Medicaid,442.24,,,442.24,Other,100% of Medicaid,442.24,,,442.24,Other,100% of Medicaid,995.03,,,995.03,Other,225% of Medicaid,676.62,,,676.62,Other,153% of Medicaid,995.03,,,995.03,Other,225% of Medicaid,619.13,,,619.13,Other,140% of Medicaid,995.03,,,995.03,Other,225% of Medicaid,1149.81,,,1149.81,Other,260% of Medicaid,1432.85,,,1432.85,Other,324% of Medicaid,950.81,,,950.81,Other,215% of Medicaid,950.81,,,950.81,Other,215% of Medicaid,552.8,,,552.8,Other,125% of Medicaid,442.24,9473,
EP EVAL CD; W PACING,93642,CPT,,49093642,CDM,480,RC,,,both,,,2922,2162.29,,,2162.29,Other,150% of Medicare + 9.63% HCRA Surcharge,1314.9,45,,1314.9,percent of total billed charges,Critical Access Hospital RCC factor,5954,,,5954,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",5359,,,5359,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3648,,,3648,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3283,,,3283,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3101,,,3101,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",1446.39,,,1446.39,Other,110% of Medicare,6152,,,6152,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",822.56,,,822.56,Other,186% of Medicaid,7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2337.6,,,2337.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2045.4,70,,2045.4,percent of total billed charges,All Other,398.52,,,398.52,Fee Schedule,,337.77,,,337.77,Fee Schedule,,4055,,,4055,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3649,,,3649,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4055,,,4055,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3448,,,3448,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",442.24,,,442.24,Other,100% of Medicaid,442.24,,,442.24,Other,100% of Medicaid,442.24,,,442.24,Other,100% of Medicaid,442.24,,,442.24,Other,100% of Medicaid,995.03,,,995.03,Other,225% of Medicaid,676.62,,,676.62,Other,153% of Medicaid,995.03,,,995.03,Other,225% of Medicaid,619.13,,,619.13,Other,140% of Medicaid,995.03,,,995.03,Other,225% of Medicaid,1149.81,,,1149.81,Other,260% of Medicaid,1432.85,,,1432.85,Other,324% of Medicaid,950.81,,,950.81,Other,215% of Medicaid,950.81,,,950.81,Other,215% of Medicaid,552.8,,,552.8,Other,125% of Medicaid,337.77,9473,
EA ANTITACHY PACEMAKER SYS,93724,CPT,,49093724,CDM,480,RC,,,both,,,887,656.38,,,656.38,Other,150% of Medicare + 9.63% HCRA Surcharge,399.15,45,,399.15,percent of total billed charges,Critical Access Hospital RCC factor,148.65,,,148.65,Fee Schedule,,134.04,,,134.04,Fee Schedule,,307.75,,,307.75,Fee Schedule,,277.04,,,277.04,Fee Schedule,,261.68,,,261.68,Fee Schedule,,439.07,,,439.07,Other,110% of Medicare,603.16,68,,603.16,percent of total billed charges,All Other,128,,,128,Other,186% of Medicaid,709.6,80,,709.6,percent of total billed charges,All Other,736.21,83,,736.21,percent of total billed charges,All Other,736.21,83,,736.21,percent of total billed charges,All Other,709.6,80,,709.6,percent of total billed charges,All Other,736.21,83,,736.21,percent of total billed charges,All Other,709.6,,,709.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",620.9,70,,620.9,percent of total billed charges,All Other,226.32,,,226.32,Fee Schedule,,191.82,,,191.82,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",68.69,,,68.69,Other,100% of Medicaid,68.69,,,68.69,Other,100% of Medicaid,68.69,,,68.69,Other,100% of Medicaid,68.69,,,68.69,Other,100% of Medicaid,154.56,,,154.56,Other,225% of Medicaid,105.1,,,105.1,Other,153% of Medicaid,154.56,,,154.56,Other,225% of Medicaid,96.17,,,96.17,Other,140% of Medicaid,154.56,,,154.56,Other,225% of Medicaid,178.6,,,178.6,Other,260% of Medicaid,222.56,,,222.56,Other,324% of Medicaid,147.69,,,147.69,Other,215% of Medicaid,147.69,,,147.69,Other,215% of Medicaid,85.87,,,85.87,Other,125% of Medicaid,68.69,3227,
CARDIOVASCULAR SERVICE UNLISTED,93799,CPT,,49093799,CDM,480,RC,,,both,,,329,243.46,,,243.46,Other,150% of Medicare + 9.63% HCRA Surcharge,148.05,45,,148.05,percent of total billed charges,Critical Access Hospital RCC factor,213.85,65,,213.85,percent of total billed charges,All Other,194.11,65,,194.11,percent of total billed charges,All Other,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,162.86,,,162.86,Other,110% of Medicare,223.72,68,,223.72,percent of total billed charges,All Other,64,,,64,Other,186% of Medicaid,263.2,80,,263.2,percent of total billed charges,All Other,273.07,83,,273.07,percent of total billed charges,All Other,273.07,83,,273.07,percent of total billed charges,All Other,263.2,80,,263.2,percent of total billed charges,All Other,273.07,83,,273.07,percent of total billed charges,All Other,263.2,,,263.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",230.3,70,,230.3,percent of total billed charges,All Other,213.85,65,,213.85,percent of total billed charges,Default if not in Fee Schedule,213.85,65,,213.85,percent of total billed charges,Default if not in Fee Schedule,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",34.6,,,34.6,Other,100% of Medicaid,34.6,,,34.6,Other,100% of Medicaid,34.6,,,34.6,Other,100% of Medicaid,34.6,,,34.6,Other,100% of Medicaid,77.85,,,77.85,Other,225% of Medicaid,52.94,,,52.94,Other,153% of Medicaid,77.85,,,77.85,Other,225% of Medicaid,48.44,,,48.44,Other,140% of Medicaid,77.85,,,77.85,Other,225% of Medicaid,89.97,,,89.97,Other,260% of Medicaid,112.11,,,112.11,Other,324% of Medicaid,74.39,,,74.39,Other,215% of Medicaid,74.39,,,74.39,Other,215% of Medicaid,43.25,,,43.25,Other,125% of Medicaid,0.01,3227,
ILIAC ART ANGIO CARDIAC CATH,G0278,HCPCS,,49000002,CDM,481,RC,,,both,,,51,37.74,,,37.74,Other,150% of Medicare + 9.63% HCRA Surcharge,22.95,45,,22.95,percent of total billed charges,Critical Access Hospital RCC factor,4565,,,4565,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4109,,,4109,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",78.25,,,78.25,Fee Schedule,,70.44,,,70.44,Fee Schedule,,66.54,,,66.54,Fee Schedule,,25.25,,,25.25,Other,110% of Medicare,34.68,,,34.68,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1420.56,,,1420.56,Other,186% of Medicaid,40.8,,,40.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",40.8,,,40.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",40.8,,,40.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",35.7,70,,35.7,percent of total billed charges,All Other,67.24,,,67.24,Fee Schedule,,56.99,,,56.99,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",763.74,,,763.74,Other,100% of Medicaid,763.74,,,763.74,Other,100% of Medicaid,763.74,,,763.74,Other,100% of Medicaid,763.74,,,763.74,Other,100% of Medicaid,1718.42,,,1718.42,Other,225% of Medicaid,1168.52,,,1168.52,Other,153% of Medicaid,1718.42,,,1718.42,Other,225% of Medicaid,1069.24,,,1069.24,Other,140% of Medicaid,1718.42,,,1718.42,Other,225% of Medicaid,1985.73,,,1985.73,Other,260% of Medicaid,2474.52,,,2474.52,Other,324% of Medicaid,1642.04,,,1642.04,Other,215% of Medicaid,1642.04,,,1642.04,Other,215% of Medicaid,954.68,,,954.68,Other,125% of Medicaid,22.95,7216,
IMPL PRESSURE SENSOR W/ANGIO,33289,CPT,,49000003,CDM,481,RC,,,both,,,61460,45480.55,,,45480.55,Other,150% of Medicare + 9.63% HCRA Surcharge,27657,45,,27657,percent of total billed charges,Critical Access Hospital RCC factor,5954,,,5954,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",5359,,,5359,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",7978,,,7978,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",7180,,,7180,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",6781,,,6781,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",30422.7,,,30422.7,Other,110% of Medicare,6152,,,6152,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",23160.14,,,23160.14,Other,186% of Medicaid,7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",49168,,,49168,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",43022,70,,43022,percent of total billed charges,All Other,1612.12,,,1612.12,Fee Schedule,,1366.37,,,1366.37,Fee Schedule,,15267,,,15267,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",13740,,,13740,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",15267,,,15267,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",12977,,,12977,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",12451.69,,,12451.69,Other,100% of Medicaid,12451.69,,,12451.69,Other,100% of Medicaid,12451.69,,,12451.69,Other,100% of Medicaid,12451.69,,,12451.69,Other,100% of Medicaid,28016.3,,,28016.3,Other,225% of Medicaid,19051.08,,,19051.08,Other,153% of Medicaid,28016.3,,,28016.3,Other,225% of Medicaid,17432.36,,,17432.36,Other,140% of Medicaid,28016.3,,,28016.3,Other,225% of Medicaid,32374.39,,,32374.39,Other,260% of Medicaid,40343.47,,,40343.47,Other,324% of Medicaid,26771.13,,,26771.13,Other,215% of Medicaid,26771.13,,,26771.13,Other,215% of Medicaid,15564.61,,,15564.61,Other,125% of Medicaid,1366.37,49168,
INSERT ELECTRD/PM CATH SNGL,33210,CPT,,49033210,CDM,481,RC,,,both,,,18374,13596.81,,,13596.81,Other,150% of Medicare + 9.63% HCRA Surcharge,8268.3,45,,8268.3,percent of total billed charges,Critical Access Hospital RCC factor,3969,,,3969,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3572,,,3572,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",7978,,,7978,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",7180,,,7180,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",6781,,,6781,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",9095.13,,,9095.13,Other,110% of Medicare,6152,,,6152,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",4537,,,4537,Other,186% of Medicaid,7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",14699.2,,,14699.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",12861.8,70,,12861.8,percent of total billed charges,All Other,780.64,,,780.64,Fee Schedule,,661.64,,,661.64,Fee Schedule,,6331,,,6331,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",5698,,,5698,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",6331,,,6331,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",5381,,,5381,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2439.2,,,2439.2,Other,100% of Medicaid,2439.2,,,2439.2,Other,100% of Medicaid,2439.2,,,2439.2,Other,100% of Medicaid,2439.2,,,2439.2,Other,100% of Medicaid,5488.2,,,5488.2,Other,225% of Medicaid,3731.98,,,3731.98,Other,153% of Medicaid,5488.2,,,5488.2,Other,225% of Medicaid,3414.88,,,3414.88,Other,140% of Medicaid,5488.2,,,5488.2,Other,225% of Medicaid,6341.92,,,6341.92,Other,260% of Medicaid,7903.01,,,7903.01,Other,324% of Medicaid,5244.28,,,5244.28,Other,215% of Medicaid,5244.28,,,5244.28,Other,215% of Medicaid,3049,,,3049,Other,125% of Medicaid,661.64,14699.2,
INSERT CARD ELECTRODES DUAL,33211,CPT,,49033211,CDM,481,RC,,,both,,,18374,13596.81,,,13596.81,Other,150% of Medicare + 9.63% HCRA Surcharge,8268.3,45,,8268.3,percent of total billed charges,Critical Access Hospital RCC factor,3969,,,3969,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3572,,,3572,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",7978,,,7978,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",7180,,,7180,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",6781,,,6781,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",9095.13,,,9095.13,Other,110% of Medicare,6152,,,6152,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",4537,,,4537,Other,186% of Medicaid,7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",14699.2,,,14699.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",12861.8,70,,12861.8,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",6331,,,6331,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",5698,,,5698,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",6331,,,6331,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",5381,,,5381,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2439.2,,,2439.2,Other,100% of Medicaid,2439.2,,,2439.2,Other,100% of Medicaid,2439.2,,,2439.2,Other,100% of Medicaid,2439.2,,,2439.2,Other,100% of Medicaid,5488.2,,,5488.2,Other,225% of Medicaid,3731.98,,,3731.98,Other,153% of Medicaid,5488.2,,,5488.2,Other,225% of Medicaid,3414.88,,,3414.88,Other,140% of Medicaid,5488.2,,,5488.2,Other,225% of Medicaid,6341.92,,,6341.92,Other,260% of Medicaid,7903.01,,,7903.01,Other,324% of Medicaid,5244.28,,,5244.28,Other,215% of Medicaid,5244.28,,,5244.28,Other,215% of Medicaid,3049,,,3049,Other,125% of Medicaid,2439.2,14699.2,
INS IA PERC BALLOON,33967,CPT,,49033967,CDM,481,RC,,,both,,,1075,795.5,,,795.5,Other,150% of Medicare + 9.63% HCRA Surcharge,483.75,45,,483.75,percent of total billed charges,Critical Access Hospital RCC factor,4565,,,4565,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4109,,,4109,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3648,,,3648,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3283,,,3283,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3101,,,3101,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",532.13,,,532.13,Other,110% of Medicare,731,,,731,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9748.95,,,9748.95,Other,186% of Medicaid,860,,,860,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",860,,,860,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",860,,,860,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",752.5,70,,752.5,percent of total billed charges,All Other,1244.76,,,1244.76,Fee Schedule,,1055.01,,,1055.01,Fee Schedule,,8589,,,8589,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",7730,,,7730,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",8589,,,8589,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",7301,,,7301,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",5241.37,,,5241.37,Other,100% of Medicaid,5241.37,,,5241.37,Other,100% of Medicaid,5241.37,,,5241.37,Other,100% of Medicaid,5241.37,,,5241.37,Other,100% of Medicaid,11793.09,,,11793.09,Other,225% of Medicaid,8019.3,,,8019.3,Other,153% of Medicaid,11793.09,,,11793.09,Other,225% of Medicaid,7337.92,,,7337.92,Other,140% of Medicaid,11793.09,,,11793.09,Other,225% of Medicaid,13627.57,,,13627.57,Other,260% of Medicaid,16982.05,,,16982.05,Other,324% of Medicaid,11268.95,,,11268.95,Other,215% of Medicaid,11268.95,,,11268.95,Other,215% of Medicaid,6551.72,,,6551.72,Other,125% of Medicaid,483.75,16982.05,
REM IAB ASSIST DEVICE PERCUTANEOUS,33968,CPT,,49033968,CDM,481,RC,,,both,,,128,94.72,,,94.72,Other,150% of Medicare + 9.63% HCRA Surcharge,57.6,45,,57.6,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4476,,,4476,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4028,,,4028,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3805,,,3805,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",63.36,,,63.36,Other,110% of Medicare,87.04,,,87.04,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",3482.94,,,3482.94,Other,186% of Medicaid,102.4,,,102.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",102.4,,,102.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",102.4,,,102.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",89.6,70,,89.6,percent of total billed charges,All Other,159.08,,,159.08,Fee Schedule,,134.83,,,134.83,Fee Schedule,,8589,,,8589,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",7730,,,7730,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",8589,,,8589,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",7301,,,7301,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",1872.55,,,1872.55,Other,100% of Medicaid,1872.55,,,1872.55,Other,100% of Medicaid,1872.55,,,1872.55,Other,100% of Medicaid,1872.55,,,1872.55,Other,100% of Medicaid,4213.23,,,4213.23,Other,225% of Medicaid,2865,,,2865,Other,153% of Medicaid,4213.23,,,4213.23,Other,225% of Medicaid,2621.57,,,2621.57,Other,140% of Medicaid,4213.23,,,4213.23,Other,225% of Medicaid,4868.63,,,4868.63,Other,260% of Medicaid,6067.06,,,6067.06,Other,324% of Medicaid,4025.98,,,4025.98,Other,215% of Medicaid,4025.98,,,4025.98,Other,215% of Medicaid,2340.69,,,2340.69,Other,125% of Medicaid,57.6,8589,
CPR,92950,CPT,,49092950,CDM,481,RC,,,both,,,903,668.22,,,668.22,Other,150% of Medicare + 9.63% HCRA Surcharge,406.35,45,,406.35,percent of total billed charges,Critical Access Hospital RCC factor,586.95,65,,586.95,percent of total billed charges,All Other,532.77,65,,532.77,percent of total billed charges,All Other,690.8,76.5,,690.8,percent of total billed charges,All Other,641.13,69,,641.13,percent of total billed charges,All Other,623.07,65,,623.07,percent of total billed charges,All Other,446.99,,,446.99,Other,110% of Medicare,614.04,68,,614.04,percent of total billed charges,All Other,880,,,880,Other,186% of Medicaid,722.4,80,,722.4,percent of total billed charges,All Other,749.49,83,,749.49,percent of total billed charges,All Other,749.49,83,,749.49,percent of total billed charges,All Other,722.4,80,,722.4,percent of total billed charges,All Other,749.49,83,,749.49,percent of total billed charges,All Other,722.4,,,722.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",632.1,70,,632.1,percent of total billed charges,All Other,883.96,,,883.96,Fee Schedule,,749.21,,,749.21,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",472.91,,,472.91,Other,100% of Medicaid,472.91,,,472.91,Other,100% of Medicaid,472.91,,,472.91,Other,100% of Medicaid,472.91,,,472.91,Other,100% of Medicaid,1064.05,,,1064.05,Other,225% of Medicaid,723.55,,,723.55,Other,153% of Medicaid,1064.05,,,1064.05,Other,225% of Medicaid,662.07,,,662.07,Other,140% of Medicaid,1064.05,,,1064.05,Other,225% of Medicaid,1229.57,,,1229.57,Other,260% of Medicaid,1532.23,,,1532.23,Other,324% of Medicaid,1016.76,,,1016.76,Other,215% of Medicaid,1016.76,,,1016.76,Other,215% of Medicaid,591.14,,,591.14,Other,125% of Medicaid,406.35,3227,
PERC CORON THROMBECTOMY,92973,CPT,,49092973,CDM,481,RC,,,both,,,11972,8859.31,,,8859.31,Other,150% of Medicare + 9.63% HCRA Surcharge,5387.4,45,,5387.4,percent of total billed charges,Critical Access Hospital RCC factor,7781.8,65,,7781.8,percent of total billed charges,All Other,7063.48,65,,7063.48,percent of total billed charges,All Other,9158.58,76.5,,9158.58,percent of total billed charges,All Other,8500.12,69,,8500.12,percent of total billed charges,All Other,8260.68,65,,8260.68,percent of total billed charges,All Other,5926.14,,,5926.14,Other,110% of Medicare,8140.96,68,,8140.96,percent of total billed charges,All Other,4096,,,4096,Other,186% of Medicaid,9577.6,80,,9577.6,percent of total billed charges,All Other,9936.76,83,,9936.76,percent of total billed charges,All Other,9936.76,83,,9936.76,percent of total billed charges,All Other,9577.6,80,,9577.6,percent of total billed charges,All Other,9936.76,83,,9936.76,percent of total billed charges,All Other,9577.6,,,9577.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",8380.4,70,,8380.4,percent of total billed charges,All Other,849.52,,,849.52,Fee Schedule,,720.02,,,720.02,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2201.94,,,2201.94,Other,100% of Medicaid,2201.94,,,2201.94,Other,100% of Medicaid,2201.94,,,2201.94,Other,100% of Medicaid,2201.94,,,2201.94,Other,100% of Medicaid,4954.36,,,4954.36,Other,225% of Medicaid,3368.96,,,3368.96,Other,153% of Medicaid,4954.36,,,4954.36,Other,225% of Medicaid,3082.71,,,3082.71,Other,140% of Medicaid,4954.36,,,4954.36,Other,225% of Medicaid,5725.04,,,5725.04,Other,260% of Medicaid,7134.28,,,7134.28,Other,324% of Medicaid,4734.17,,,4734.17,Other,215% of Medicaid,4734.17,,,4734.17,Other,215% of Medicaid,2752.42,,,2752.42,Other,125% of Medicaid,720.02,9936.76,
CATH - CORON IV BRACHYTX,92974,CPT,,49092974,CDM,481,RC,,,both,,,4788,3543.13,,,3543.13,Other,150% of Medicare + 9.63% HCRA Surcharge,2154.6,45,,2154.6,percent of total billed charges,Critical Access Hospital RCC factor,3112.2,65,,3112.2,percent of total billed charges,All Other,2824.92,65,,2824.92,percent of total billed charges,All Other,3662.82,76.5,,3662.82,percent of total billed charges,All Other,3399.48,69,,3399.48,percent of total billed charges,All Other,3303.72,65,,3303.72,percent of total billed charges,All Other,2370.06,,,2370.06,Other,110% of Medicare,3255.84,68,,3255.84,percent of total billed charges,All Other,0.01,,,0.01,Other,186% of Medicaid,3830.4,80,,3830.4,percent of total billed charges,All Other,3974.04,83,,3974.04,percent of total billed charges,All Other,3974.04,83,,3974.04,percent of total billed charges,All Other,3830.4,80,,3830.4,percent of total billed charges,All Other,3974.04,83,,3974.04,percent of total billed charges,All Other,3830.4,,,3830.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",3351.6,70,,3351.6,percent of total billed charges,All Other,775.72,,,775.72,Fee Schedule,,657.47,,,657.47,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3974.04,
THROMBOLYSIS; IC INFUSION,92975,CPT,,49092975,CDM,481,RC,,,both,,,1481,1095.94,,,1095.94,Other,150% of Medicare + 9.63% HCRA Surcharge,666.45,45,,666.45,percent of total billed charges,Critical Access Hospital RCC factor,4565,,,4565,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4109,,,4109,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",733.1,,,733.1,Other,110% of Medicare,1007.08,,,1007.08,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1420.56,,,1420.56,Other,186% of Medicaid,1184.8,,,1184.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1184.8,,,1184.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1184.8,,,1184.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1036.7,70,,1036.7,percent of total billed charges,All Other,1810.56,,,1810.56,Fee Schedule,,1534.56,,,1534.56,Fee Schedule,,4531,,,4531,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4079,,,4079,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4531,,,4531,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3852,,,3852,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",763.74,,,763.74,Other,100% of Medicaid,763.74,,,763.74,Other,100% of Medicaid,763.74,,,763.74,Other,100% of Medicaid,763.74,,,763.74,Other,100% of Medicaid,1718.42,,,1718.42,Other,225% of Medicaid,1168.52,,,1168.52,Other,153% of Medicaid,1718.42,,,1718.42,Other,225% of Medicaid,1069.24,,,1069.24,Other,140% of Medicaid,1718.42,,,1718.42,Other,225% of Medicaid,1985.73,,,1985.73,Other,260% of Medicaid,2474.52,,,2474.52,Other,324% of Medicaid,1642.04,,,1642.04,Other,215% of Medicaid,1642.04,,,1642.04,Other,215% of Medicaid,954.68,,,954.68,Other,125% of Medicaid,666.45,7216,
THROMBOLYSIS CORON; IV INFUS,92977,CPT,,49092977,CDM,481,RC,,,both,,,769,569.06,,,569.06,Other,150% of Medicare + 9.63% HCRA Surcharge,346.05,45,,346.05,percent of total billed charges,Critical Access Hospital RCC factor,4565,,,4565,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4109,,,4109,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",380.66,,,380.66,Other,110% of Medicare,522.92,,,522.92,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1097.85,,,1097.85,Other,186% of Medicaid,615.2,,,615.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",615.2,,,615.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",615.2,,,615.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",538.3,70,,538.3,percent of total billed charges,All Other,250.92,,,250.92,Fee Schedule,,212.67,,,212.67,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",590.24,,,590.24,Other,100% of Medicaid,590.24,,,590.24,Other,100% of Medicaid,590.24,,,590.24,Other,100% of Medicaid,590.24,,,590.24,Other,100% of Medicaid,1328.05,,,1328.05,Other,225% of Medicaid,903.07,,,903.07,Other,153% of Medicaid,1328.05,,,1328.05,Other,225% of Medicaid,826.34,,,826.34,Other,140% of Medicaid,1328.05,,,1328.05,Other,225% of Medicaid,1534.64,,,1534.64,Other,260% of Medicaid,1912.39,,,1912.39,Other,324% of Medicaid,1269.03,,,1269.03,Other,215% of Medicaid,1269.03,,,1269.03,Other,215% of Medicaid,737.81,,,737.81,Other,125% of Medicaid,212.67,7216,
IV US CORONARY V; INITIAL,92978,CPT,,49092978,CDM,481,RC,,,both,,,349,258.26,,,258.26,Other,150% of Medicare + 9.63% HCRA Surcharge,157.05,45,,157.05,percent of total billed charges,Critical Access Hospital RCC factor,4565,,,4565,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4109,,,4109,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",189.25,,,189.25,Fee Schedule,,189.25,,,189.25,Fee Schedule,,189.25,,,189.25,Fee Schedule,,172.76,,,172.76,Other,110% of Medicare,237.32,,,237.32,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",543.92,,,543.92,Other,186% of Medicaid,279.2,,,279.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",279.2,,,279.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",279.2,,,279.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",244.3,70,,244.3,percent of total billed charges,All Other,226.85,65,,226.85,percent of total billed charges,Default if not in Fee Schedule,226.85,65,,226.85,percent of total billed charges,Default if not in Fee Schedule,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",292.43,,,292.43,Other,100% of Medicaid,292.43,,,292.43,Other,100% of Medicaid,292.43,,,292.43,Other,100% of Medicaid,292.43,,,292.43,Other,100% of Medicaid,657.97,,,657.97,Other,225% of Medicaid,447.42,,,447.42,Other,153% of Medicaid,657.97,,,657.97,Other,225% of Medicaid,409.4,,,409.4,Other,140% of Medicaid,657.97,,,657.97,Other,225% of Medicaid,760.32,,,760.32,Other,260% of Medicaid,947.48,,,947.48,Other,324% of Medicaid,628.73,,,628.73,Other,215% of Medicaid,628.73,,,628.73,Other,215% of Medicaid,365.54,,,365.54,Other,125% of Medicaid,157.05,7216,
IV US CORONARY V; EA ADDTL,92979,CPT,,49092979,CDM,481,RC,,,both,,,281,207.94,,,207.94,Other,150% of Medicare + 9.63% HCRA Surcharge,126.45,45,,126.45,percent of total billed charges,Critical Access Hospital RCC factor,4565,,,4565,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4109,,,4109,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",96.47,,,96.47,Fee Schedule,,96.47,,,96.47,Fee Schedule,,96.47,,,96.47,Fee Schedule,,139.1,,,139.1,Other,110% of Medicare,191.08,,,191.08,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",543.92,,,543.92,Other,186% of Medicaid,224.8,,,224.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",224.8,,,224.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",224.8,,,224.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",196.7,70,,196.7,percent of total billed charges,All Other,182.65,65,,182.65,percent of total billed charges,Default if not in Fee Schedule,182.65,65,,182.65,percent of total billed charges,Default if not in Fee Schedule,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",292.43,,,292.43,Other,100% of Medicaid,292.43,,,292.43,Other,100% of Medicaid,292.43,,,292.43,Other,100% of Medicaid,292.43,,,292.43,Other,100% of Medicaid,657.97,,,657.97,Other,225% of Medicaid,447.42,,,447.42,Other,153% of Medicaid,657.97,,,657.97,Other,225% of Medicaid,409.4,,,409.4,Other,140% of Medicaid,657.97,,,657.97,Other,225% of Medicaid,760.32,,,760.32,Other,260% of Medicaid,947.48,,,947.48,Other,324% of Medicaid,628.73,,,628.73,Other,215% of Medicaid,628.73,,,628.73,Other,215% of Medicaid,365.54,,,365.54,Other,125% of Medicaid,96.47,7216,
RIGHT HEART CATH,93451,CPT,,49093451,CDM,481,RC,,,both,,,12354,9141.99,,,9141.99,Other,150% of Medicare + 9.63% HCRA Surcharge,5559.3,45,,5559.3,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4476,,,4476,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4028,,,4028,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3805,,,3805,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",6115.23,,,6115.23,Other,110% of Medicare,8400.72,,,8400.72,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",3170.73,,,3170.73,Other,186% of Medicaid,9883.2,,,9883.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9883.2,,,9883.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9883.2,,,9883.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",8647.8,70,,8647.8,percent of total billed charges,All Other,3801.52,,,3801.52,Fee Schedule,,3222.02,,,3222.02,Fee Schedule,,6924,,,6924,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",6232,,,6232,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",6924,,,6924,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",5885,,,5885,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",1704.69,,,1704.69,Other,100% of Medicaid,1704.69,,,1704.69,Other,100% of Medicaid,1704.69,,,1704.69,Other,100% of Medicaid,1704.69,,,1704.69,Other,100% of Medicaid,3835.56,,,3835.56,Other,225% of Medicaid,2608.18,,,2608.18,Other,153% of Medicaid,3835.56,,,3835.56,Other,225% of Medicaid,2386.57,,,2386.57,Other,140% of Medicaid,3835.56,,,3835.56,Other,225% of Medicaid,4432.2,,,4432.2,Other,260% of Medicaid,5523.21,,,5523.21,Other,324% of Medicaid,3665.09,,,3665.09,Other,215% of Medicaid,3665.09,,,3665.09,Other,215% of Medicaid,2130.87,,,2130.87,Other,125% of Medicaid,1704.69,9883.2,
LEFT HRT CATH W/VENTRCLGRPHY,93452,CPT,,49093452,CDM,481,RC,,,both,,,12354,9141.99,,,9141.99,Other,150% of Medicare + 9.63% HCRA Surcharge,5559.3,45,,5559.3,percent of total billed charges,Critical Access Hospital RCC factor,5954,,,5954,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",5359,,,5359,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4476,,,4476,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4028,,,4028,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3805,,,3805,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",6115.23,,,6115.23,Other,110% of Medicare,6152,,,6152,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",3170.73,,,3170.73,Other,186% of Medicaid,7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9883.2,,,9883.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",8647.8,70,,8647.8,percent of total billed charges,All Other,3448.92,,,3448.92,Fee Schedule,,2923.17,,,2923.17,Fee Schedule,,6924,,,6924,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",6232,,,6232,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",6924,,,6924,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",5885,,,5885,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",1704.69,,,1704.69,Other,100% of Medicaid,1704.69,,,1704.69,Other,100% of Medicaid,1704.69,,,1704.69,Other,100% of Medicaid,1704.69,,,1704.69,Other,100% of Medicaid,3835.56,,,3835.56,Other,225% of Medicaid,2608.18,,,2608.18,Other,153% of Medicaid,3835.56,,,3835.56,Other,225% of Medicaid,2386.57,,,2386.57,Other,140% of Medicaid,3835.56,,,3835.56,Other,225% of Medicaid,4432.2,,,4432.2,Other,260% of Medicaid,5523.21,,,5523.21,Other,324% of Medicaid,3665.09,,,3665.09,Other,215% of Medicaid,3665.09,,,3665.09,Other,215% of Medicaid,2130.87,,,2130.87,Other,125% of Medicaid,1704.69,9883.2,
R&L HRT CATH W/VENTRICLGRPHY,93453,CPT,,49093453,CDM,481,RC,,,both,,,11335,8387.93,,,8387.93,Other,150% of Medicare + 9.63% HCRA Surcharge,5100.75,45,,5100.75,percent of total billed charges,Critical Access Hospital RCC factor,5954,,,5954,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",5359,,,5359,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4476,,,4476,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4028,,,4028,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3805,,,3805,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",5610.83,,,5610.83,Other,110% of Medicare,6152,,,6152,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",3170.73,,,3170.73,Other,186% of Medicaid,7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9068,,,9068,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7934.5,70,,7934.5,percent of total billed charges,All Other,4300.08,,,4300.08,Fee Schedule,,3644.58,,,3644.58,Fee Schedule,,6924,,,6924,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",6232,,,6232,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",6924,,,6924,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",5885,,,5885,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",1704.69,,,1704.69,Other,100% of Medicaid,1704.69,,,1704.69,Other,100% of Medicaid,1704.69,,,1704.69,Other,100% of Medicaid,1704.69,,,1704.69,Other,100% of Medicaid,3835.56,,,3835.56,Other,225% of Medicaid,2608.18,,,2608.18,Other,153% of Medicaid,3835.56,,,3835.56,Other,225% of Medicaid,2386.57,,,2386.57,Other,140% of Medicaid,3835.56,,,3835.56,Other,225% of Medicaid,4432.2,,,4432.2,Other,260% of Medicaid,5523.21,,,5523.21,Other,324% of Medicaid,3665.09,,,3665.09,Other,215% of Medicaid,3665.09,,,3665.09,Other,215% of Medicaid,2130.87,,,2130.87,Other,125% of Medicaid,1704.69,9473,
CORONARY ARTERY ANGIO S&I,93454,CPT,,49093454,CDM,481,RC,,,both,,,12354,9141.99,,,9141.99,Other,150% of Medicare + 9.63% HCRA Surcharge,5559.3,45,,5559.3,percent of total billed charges,Critical Access Hospital RCC factor,5954,,,5954,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",5359,,,5359,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4476,,,4476,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4028,,,4028,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3805,,,3805,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",6115.23,,,6115.23,Other,110% of Medicare,6152,,,6152,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",3170.73,,,3170.73,Other,186% of Medicaid,7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9883.2,,,9883.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",8647.8,70,,8647.8,percent of total billed charges,All Other,3445.64,,,3445.64,Fee Schedule,,2920.39,,,2920.39,Fee Schedule,,6924,,,6924,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",6232,,,6232,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",6924,,,6924,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",5885,,,5885,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",1704.69,,,1704.69,Other,100% of Medicaid,1704.69,,,1704.69,Other,100% of Medicaid,1704.69,,,1704.69,Other,100% of Medicaid,1704.69,,,1704.69,Other,100% of Medicaid,3835.56,,,3835.56,Other,225% of Medicaid,2608.18,,,2608.18,Other,153% of Medicaid,3835.56,,,3835.56,Other,225% of Medicaid,2386.57,,,2386.57,Other,140% of Medicaid,3835.56,,,3835.56,Other,225% of Medicaid,4432.2,,,4432.2,Other,260% of Medicaid,5523.21,,,5523.21,Other,324% of Medicaid,3665.09,,,3665.09,Other,215% of Medicaid,3665.09,,,3665.09,Other,215% of Medicaid,2130.87,,,2130.87,Other,125% of Medicaid,1704.69,9883.2,
CORONARY ART/GRFT ANGIO S&I,93455,CPT,,49093455,CDM,481,RC,,,both,,,12354,9141.99,,,9141.99,Other,150% of Medicare + 9.63% HCRA Surcharge,5559.3,45,,5559.3,percent of total billed charges,Critical Access Hospital RCC factor,5954,,,5954,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",5359,,,5359,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4476,,,4476,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4028,,,4028,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3805,,,3805,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",6115.23,,,6115.23,Other,110% of Medicare,6152,,,6152,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",3170.73,,,3170.73,Other,186% of Medicaid,7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9883.2,,,9883.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",8647.8,70,,8647.8,percent of total billed charges,All Other,3773.64,,,3773.64,Fee Schedule,,3198.39,,,3198.39,Fee Schedule,,6924,,,6924,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",6232,,,6232,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",6924,,,6924,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",5885,,,5885,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",1704.69,,,1704.69,Other,100% of Medicaid,1704.69,,,1704.69,Other,100% of Medicaid,1704.69,,,1704.69,Other,100% of Medicaid,1704.69,,,1704.69,Other,100% of Medicaid,3835.56,,,3835.56,Other,225% of Medicaid,2608.18,,,2608.18,Other,153% of Medicaid,3835.56,,,3835.56,Other,225% of Medicaid,2386.57,,,2386.57,Other,140% of Medicaid,3835.56,,,3835.56,Other,225% of Medicaid,4432.2,,,4432.2,Other,260% of Medicaid,5523.21,,,5523.21,Other,324% of Medicaid,3665.09,,,3665.09,Other,215% of Medicaid,3665.09,,,3665.09,Other,215% of Medicaid,2130.87,,,2130.87,Other,125% of Medicaid,1704.69,9883.2,
R HRT CORONARY ARTERY ANGIO,93456,CPT,,49093456,CDM,481,RC,,,both,,,12354,9141.99,,,9141.99,Other,150% of Medicare + 9.63% HCRA Surcharge,5559.3,45,,5559.3,percent of total billed charges,Critical Access Hospital RCC factor,5954,,,5954,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",5359,,,5359,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4476,,,4476,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4028,,,4028,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3805,,,3805,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",6115.23,,,6115.23,Other,110% of Medicare,6152,,,6152,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",3170.73,,,3170.73,Other,186% of Medicaid,7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9883.2,,,9883.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",8647.8,70,,8647.8,percent of total billed charges,All Other,4219.72,,,4219.72,Fee Schedule,,3576.47,,,3576.47,Fee Schedule,,6924,,,6924,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",6232,,,6232,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",6924,,,6924,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",5885,,,5885,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",1704.69,,,1704.69,Other,100% of Medicaid,1704.69,,,1704.69,Other,100% of Medicaid,1704.69,,,1704.69,Other,100% of Medicaid,1704.69,,,1704.69,Other,100% of Medicaid,3835.56,,,3835.56,Other,225% of Medicaid,2608.18,,,2608.18,Other,153% of Medicaid,3835.56,,,3835.56,Other,225% of Medicaid,2386.57,,,2386.57,Other,140% of Medicaid,3835.56,,,3835.56,Other,225% of Medicaid,4432.2,,,4432.2,Other,260% of Medicaid,5523.21,,,5523.21,Other,324% of Medicaid,3665.09,,,3665.09,Other,215% of Medicaid,3665.09,,,3665.09,Other,215% of Medicaid,2130.87,,,2130.87,Other,125% of Medicaid,1704.69,9883.2,
R HRT ART/GRFT ANGIO,93457,CPT,,49093457,CDM,481,RC,,,both,,,11335,8387.93,,,8387.93,Other,150% of Medicare + 9.63% HCRA Surcharge,5100.75,45,,5100.75,percent of total billed charges,Critical Access Hospital RCC factor,5954,,,5954,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",5359,,,5359,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4476,,,4476,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4028,,,4028,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3805,,,3805,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",5610.83,,,5610.83,Other,110% of Medicare,6152,,,6152,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",3170.73,,,3170.73,Other,186% of Medicaid,7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9068,,,9068,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7934.5,70,,7934.5,percent of total billed charges,All Other,4547.72,,,4547.72,Fee Schedule,,3854.47,,,3854.47,Fee Schedule,,6924,,,6924,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",6232,,,6232,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",6924,,,6924,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",5885,,,5885,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",1704.69,,,1704.69,Other,100% of Medicaid,1704.69,,,1704.69,Other,100% of Medicaid,1704.69,,,1704.69,Other,100% of Medicaid,1704.69,,,1704.69,Other,100% of Medicaid,3835.56,,,3835.56,Other,225% of Medicaid,2608.18,,,2608.18,Other,153% of Medicaid,3835.56,,,3835.56,Other,225% of Medicaid,2386.57,,,2386.57,Other,140% of Medicaid,3835.56,,,3835.56,Other,225% of Medicaid,4432.2,,,4432.2,Other,260% of Medicaid,5523.21,,,5523.21,Other,324% of Medicaid,3665.09,,,3665.09,Other,215% of Medicaid,3665.09,,,3665.09,Other,215% of Medicaid,2130.87,,,2130.87,Other,125% of Medicaid,1704.69,9473,
L HRT ARTERY/VENTRICLE ANGIO,93458,CPT,,49093458,CDM,481,RC,,,both,,,13219,9782.09,,,9782.09,Other,150% of Medicare + 9.63% HCRA Surcharge,5948.55,45,,5948.55,percent of total billed charges,Critical Access Hospital RCC factor,5954,,,5954,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",5359,,,5359,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4476,,,4476,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4028,,,4028,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3805,,,3805,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",6543.41,,,6543.41,Other,110% of Medicare,6152,,,6152,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",3170.73,,,3170.73,Other,186% of Medicaid,7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",10575.2,,,10575.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9253.3,70,,9253.3,percent of total billed charges,All Other,3854,,,3854,Fee Schedule,,3266.5,,,3266.5,Fee Schedule,,6924,,,6924,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",6232,,,6232,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",6924,,,6924,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",5885,,,5885,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",1704.69,,,1704.69,Other,100% of Medicaid,1704.69,,,1704.69,Other,100% of Medicaid,1704.69,,,1704.69,Other,100% of Medicaid,1704.69,,,1704.69,Other,100% of Medicaid,3835.56,,,3835.56,Other,225% of Medicaid,2608.18,,,2608.18,Other,153% of Medicaid,3835.56,,,3835.56,Other,225% of Medicaid,2386.57,,,2386.57,Other,140% of Medicaid,3835.56,,,3835.56,Other,225% of Medicaid,4432.2,,,4432.2,Other,260% of Medicaid,5523.21,,,5523.21,Other,324% of Medicaid,3665.09,,,3665.09,Other,215% of Medicaid,3665.09,,,3665.09,Other,215% of Medicaid,2130.87,,,2130.87,Other,125% of Medicaid,1704.69,10575.2,
L HRT ART/GRFT ANGIO,93459,CPT,,49093459,CDM,481,RC,,,both,,,11335,8387.93,,,8387.93,Other,150% of Medicare + 9.63% HCRA Surcharge,5100.75,45,,5100.75,percent of total billed charges,Critical Access Hospital RCC factor,5954,,,5954,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",5359,,,5359,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4476,,,4476,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4028,,,4028,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3805,,,3805,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",5610.83,,,5610.83,Other,110% of Medicare,6152,,,6152,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",3170.73,,,3170.73,Other,186% of Medicaid,7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9068,,,9068,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7934.5,70,,7934.5,percent of total billed charges,All Other,4060.64,,,4060.64,Fee Schedule,,3441.64,,,3441.64,Fee Schedule,,6924,,,6924,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",6232,,,6232,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",6924,,,6924,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",5885,,,5885,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",1704.69,,,1704.69,Other,100% of Medicaid,1704.69,,,1704.69,Other,100% of Medicaid,1704.69,,,1704.69,Other,100% of Medicaid,1704.69,,,1704.69,Other,100% of Medicaid,3835.56,,,3835.56,Other,225% of Medicaid,2608.18,,,2608.18,Other,153% of Medicaid,3835.56,,,3835.56,Other,225% of Medicaid,2386.57,,,2386.57,Other,140% of Medicaid,3835.56,,,3835.56,Other,225% of Medicaid,4432.2,,,4432.2,Other,260% of Medicaid,5523.21,,,5523.21,Other,324% of Medicaid,3665.09,,,3665.09,Other,215% of Medicaid,3665.09,,,3665.09,Other,215% of Medicaid,2130.87,,,2130.87,Other,125% of Medicaid,1704.69,9473,
R&L HRT ART/VENTRICLE ANGIO,93460,CPT,,49093460,CDM,481,RC,,,both,,,12354,9141.99,,,9141.99,Other,150% of Medicare + 9.63% HCRA Surcharge,5559.3,45,,5559.3,percent of total billed charges,Critical Access Hospital RCC factor,5954,,,5954,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",5359,,,5359,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4476,,,4476,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4028,,,4028,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3805,,,3805,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",6115.23,,,6115.23,Other,110% of Medicare,6152,,,6152,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",3170.73,,,3170.73,Other,186% of Medicaid,7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9883.2,,,9883.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",8647.8,70,,8647.8,percent of total billed charges,All Other,4498.52,,,4498.52,Fee Schedule,,3812.77,,,3812.77,Fee Schedule,,6924,,,6924,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",6232,,,6232,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",6924,,,6924,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",5885,,,5885,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",1704.69,,,1704.69,Other,100% of Medicaid,1704.69,,,1704.69,Other,100% of Medicaid,1704.69,,,1704.69,Other,100% of Medicaid,1704.69,,,1704.69,Other,100% of Medicaid,3835.56,,,3835.56,Other,225% of Medicaid,2608.18,,,2608.18,Other,153% of Medicaid,3835.56,,,3835.56,Other,225% of Medicaid,2386.57,,,2386.57,Other,140% of Medicaid,3835.56,,,3835.56,Other,225% of Medicaid,4432.2,,,4432.2,Other,260% of Medicaid,5523.21,,,5523.21,Other,324% of Medicaid,3665.09,,,3665.09,Other,215% of Medicaid,3665.09,,,3665.09,Other,215% of Medicaid,2130.87,,,2130.87,Other,125% of Medicaid,1704.69,9883.2,
R&L HRT ART/GRAFT/VENTRICLE ANGIO,93461,CPT,,49093461,CDM,481,RC,,,both,,,11335,8387.93,,,8387.93,Other,150% of Medicare + 9.63% HCRA Surcharge,5100.75,45,,5100.75,percent of total billed charges,Critical Access Hospital RCC factor,5954,,,5954,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",5359,,,5359,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4476,,,4476,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4028,,,4028,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3805,,,3805,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",5610.83,,,5610.83,Other,110% of Medicare,6152,,,6152,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",3170.73,,,3170.73,Other,186% of Medicaid,7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7237,,,7237,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9473,,,9473,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9068,,,9068,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7934.5,70,,7934.5,percent of total billed charges,All Other,4954.44,,,4954.44,Fee Schedule,,4199.19,,,4199.19,Fee Schedule,,6924,,,6924,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",6232,,,6232,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",6924,,,6924,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",5885,,,5885,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",1704.69,,,1704.69,Other,100% of Medicaid,1704.69,,,1704.69,Other,100% of Medicaid,1704.69,,,1704.69,Other,100% of Medicaid,1704.69,,,1704.69,Other,100% of Medicaid,3835.56,,,3835.56,Other,225% of Medicaid,2608.18,,,2608.18,Other,153% of Medicaid,3835.56,,,3835.56,Other,225% of Medicaid,2386.57,,,2386.57,Other,140% of Medicaid,3835.56,,,3835.56,Other,225% of Medicaid,4432.2,,,4432.2,Other,260% of Medicaid,5523.21,,,5523.21,Other,324% of Medicaid,3665.09,,,3665.09,Other,215% of Medicaid,3665.09,,,3665.09,Other,215% of Medicaid,2130.87,,,2130.87,Other,125% of Medicaid,1704.69,9473,
L HRT CATH TRNSPTL PUNCTURE,93462,CPT,,49093462,CDM,481,RC,,,both,,,11335,8387.93,,,8387.93,Other,150% of Medicare + 9.63% HCRA Surcharge,5100.75,45,,5100.75,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4476,,,4476,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4028,,,4028,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3805,,,3805,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",5610.83,,,5610.83,Other,110% of Medicare,7707.8,,,7707.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2761.08,,,2761.08,Other,186% of Medicaid,9068,,,9068,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9068,,,9068,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",9068,,,9068,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7934.5,70,,7934.5,percent of total billed charges,All Other,1011.88,,,1011.88,Fee Schedule,,857.63,,,857.63,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",1484.45,,,1484.45,Other,100% of Medicaid,1484.45,,,1484.45,Other,100% of Medicaid,1484.45,,,1484.45,Other,100% of Medicaid,1484.45,,,1484.45,Other,100% of Medicaid,3340.02,,,3340.02,Other,225% of Medicaid,2271.21,,,2271.21,Other,153% of Medicaid,3340.02,,,3340.02,Other,225% of Medicaid,2078.24,,,2078.24,Other,140% of Medicaid,3340.02,,,3340.02,Other,225% of Medicaid,3859.58,,,3859.58,Other,260% of Medicaid,4809.63,,,4809.63,Other,324% of Medicaid,3191.58,,,3191.58,Other,215% of Medicaid,3191.58,,,3191.58,Other,215% of Medicaid,1855.57,,,1855.57,Other,125% of Medicaid,857.63,9068,
INS SWAN GANZ BEDSIDE,93503,CPT,,49093503,CDM,481,RC,,,both,,,4788,3543.13,,,3543.13,Other,150% of Medicare + 9.63% HCRA Surcharge,2154.6,45,,2154.6,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3648,,,3648,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3283,,,3283,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3101,,,3101,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2370.06,,,2370.06,Other,110% of Medicare,3255.84,,,3255.84,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",586.68,,,586.68,Other,186% of Medicaid,3830.4,,,3830.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",3830.4,,,3830.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",3830.4,,,3830.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",3351.6,70,,3351.6,percent of total billed charges,All Other,423.12,,,423.12,Fee Schedule,,358.62,,,358.62,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",315.42,,,315.42,Other,100% of Medicaid,315.42,,,315.42,Other,100% of Medicaid,315.42,,,315.42,Other,100% of Medicaid,315.42,,,315.42,Other,100% of Medicaid,709.7,,,709.7,Other,225% of Medicaid,482.6,,,482.6,Other,153% of Medicaid,709.7,,,709.7,Other,225% of Medicaid,441.59,,,441.59,Other,140% of Medicaid,709.7,,,709.7,Other,225% of Medicaid,820.1,,,820.1,Other,260% of Medicaid,1021.97,,,1021.97,Other,324% of Medicaid,678.16,,,678.16,Other,215% of Medicaid,678.16,,,678.16,Other,215% of Medicaid,394.28,,,394.28,Other,125% of Medicaid,315.42,7216,
ENDOMYOCARDIAL BX,93505,CPT,,49093505,CDM,481,RC,,,both,,,6707,4963.2,,,4963.2,Other,150% of Medicare + 9.63% HCRA Surcharge,3018.15,45,,3018.15,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4476,,,4476,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4028,,,4028,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3805,,,3805,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3319.97,,,3319.97,Other,110% of Medicare,4560.76,,,4560.76,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",3170.73,,,3170.73,Other,186% of Medicaid,5365.6,,,5365.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",5365.6,,,5365.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",5365.6,,,5365.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",4694.9,70,,4694.9,percent of total billed charges,All Other,2176.28,,,2176.28,Fee Schedule,,1844.53,,,1844.53,Fee Schedule,,4913,,,4913,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4422,,,4422,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4913,,,4913,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4176,,,4176,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",1704.69,,,1704.69,Other,100% of Medicaid,1704.69,,,1704.69,Other,100% of Medicaid,1704.69,,,1704.69,Other,100% of Medicaid,1704.69,,,1704.69,Other,100% of Medicaid,3835.56,,,3835.56,Other,225% of Medicaid,2608.18,,,2608.18,Other,153% of Medicaid,3835.56,,,3835.56,Other,225% of Medicaid,2386.57,,,2386.57,Other,140% of Medicaid,3835.56,,,3835.56,Other,225% of Medicaid,4432.2,,,4432.2,Other,260% of Medicaid,5523.21,,,5523.21,Other,324% of Medicaid,3665.09,,,3665.09,Other,215% of Medicaid,3665.09,,,3665.09,Other,215% of Medicaid,2130.87,,,2130.87,Other,125% of Medicaid,1704.69,7216,
INJECT CONGENITAL CARD CATH,93563,CPT,,49093563,CDM,481,RC,,,both,,,211,156.14,,,156.14,Other,150% of Medicare + 9.63% HCRA Surcharge,94.95,45,,94.95,percent of total billed charges,Critical Access Hospital RCC factor,14237,,,14237,Case Rate,Cardiac Cath Lab Per Case,12813,,,12813,Case Rate,Cardiac Cath Lab Per Case,3648,,,3648,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3283,,,3283,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3101,,,3101,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",104.45,,,104.45,Other,110% of Medicare,143.48,68,,143.48,percent of total billed charges,All Other,711,,,711,Other,186% of Medicaid,168.8,80,,168.8,percent of total billed charges,All Other,175.13,83,,175.13,percent of total billed charges,All Other,175.13,83,,175.13,percent of total billed charges,All Other,168.8,80,,168.8,percent of total billed charges,All Other,175.13,83,,175.13,percent of total billed charges,All Other,168.8,,,168.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",147.7,70,,147.7,percent of total billed charges,All Other,278.8,,,278.8,Fee Schedule,,236.3,,,236.3,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",382.43,,,382.43,Other,100% of Medicaid,382.43,,,382.43,Other,100% of Medicaid,382.43,,,382.43,Other,100% of Medicaid,382.43,,,382.43,Other,100% of Medicaid,860.48,,,860.48,Other,225% of Medicaid,585.13,,,585.13,Other,153% of Medicaid,860.48,,,860.48,Other,225% of Medicaid,535.41,,,535.41,Other,140% of Medicaid,860.48,,,860.48,Other,225% of Medicaid,994.33,,,994.33,Other,260% of Medicaid,1239.09,,,1239.09,Other,324% of Medicaid,822.23,,,822.23,Other,215% of Medicaid,822.23,,,822.23,Other,215% of Medicaid,478.04,,,478.04,Other,125% of Medicaid,94.95,14237,
INJECT L VENTR/ATRIAL ANGIO,93565,CPT,,49093565,CDM,481,RC,,,both,,,163,120.62,,,120.62,Other,150% of Medicare + 9.63% HCRA Surcharge,73.35,45,,73.35,percent of total billed charges,Critical Access Hospital RCC factor,14237,,,14237,Case Rate,Cardiac Cath Lab Per Case,12813,,,12813,Case Rate,Cardiac Cath Lab Per Case,3648,,,3648,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3283,,,3283,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3101,,,3101,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",80.69,,,80.69,Other,110% of Medicare,110.84,68,,110.84,percent of total billed charges,All Other,711,,,711,Other,186% of Medicaid,130.4,80,,130.4,percent of total billed charges,All Other,135.29,83,,135.29,percent of total billed charges,All Other,135.29,83,,135.29,percent of total billed charges,All Other,130.4,80,,130.4,percent of total billed charges,All Other,135.29,83,,135.29,percent of total billed charges,All Other,130.4,,,130.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",114.1,70,,114.1,percent of total billed charges,All Other,223.04,,,223.04,Fee Schedule,,189.04,,,189.04,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",382.43,,,382.43,Other,100% of Medicaid,382.43,,,382.43,Other,100% of Medicaid,382.43,,,382.43,Other,100% of Medicaid,382.43,,,382.43,Other,100% of Medicaid,860.48,,,860.48,Other,225% of Medicaid,585.13,,,585.13,Other,153% of Medicaid,860.48,,,860.48,Other,225% of Medicaid,535.41,,,535.41,Other,140% of Medicaid,860.48,,,860.48,Other,225% of Medicaid,994.33,,,994.33,Other,260% of Medicaid,1239.09,,,1239.09,Other,324% of Medicaid,822.23,,,822.23,Other,215% of Medicaid,822.23,,,822.23,Other,215% of Medicaid,478.04,,,478.04,Other,125% of Medicaid,73.35,14237,
INJECT R VENTR/ATRIAL ANGIO,93566,CPT,,49093566,CDM,481,RC,,,both,,,161,119.14,,,119.14,Other,150% of Medicare + 9.63% HCRA Surcharge,72.45,45,,72.45,percent of total billed charges,Critical Access Hospital RCC factor,14237,,,14237,Case Rate,Cardiac Cath Lab Per Case,12813,,,12813,Case Rate,Cardiac Cath Lab Per Case,3648,,,3648,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3283,,,3283,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3101,,,3101,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",79.7,,,79.7,Other,110% of Medicare,109.48,68,,109.48,percent of total billed charges,All Other,711,,,711,Other,186% of Medicaid,128.8,80,,128.8,percent of total billed charges,All Other,133.63,83,,133.63,percent of total billed charges,All Other,133.63,83,,133.63,percent of total billed charges,All Other,128.8,80,,128.8,percent of total billed charges,All Other,133.63,83,,133.63,percent of total billed charges,All Other,128.8,,,128.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",112.7,70,,112.7,percent of total billed charges,All Other,221.4,,,221.4,Fee Schedule,,187.65,,,187.65,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",382.43,,,382.43,Other,100% of Medicaid,382.43,,,382.43,Other,100% of Medicaid,382.43,,,382.43,Other,100% of Medicaid,382.43,,,382.43,Other,100% of Medicaid,860.48,,,860.48,Other,225% of Medicaid,585.13,,,585.13,Other,153% of Medicaid,860.48,,,860.48,Other,225% of Medicaid,535.41,,,535.41,Other,140% of Medicaid,860.48,,,860.48,Other,225% of Medicaid,994.33,,,994.33,Other,260% of Medicaid,1239.09,,,1239.09,Other,324% of Medicaid,822.23,,,822.23,Other,215% of Medicaid,822.23,,,822.23,Other,215% of Medicaid,478.04,,,478.04,Other,125% of Medicaid,72.45,14237,
INJECT SUPRVLV AORTOGRAPHY,93567,CPT,,49093567,CDM,481,RC,,,both,,,198,146.52,,,146.52,Other,150% of Medicare + 9.63% HCRA Surcharge,89.1,45,,89.1,percent of total billed charges,Critical Access Hospital RCC factor,14237,,,14237,Case Rate,Cardiac Cath Lab Per Case,12813,,,12813,Case Rate,Cardiac Cath Lab Per Case,3648,,,3648,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3283,,,3283,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3101,,,3101,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",98.01,,,98.01,Other,110% of Medicare,134.64,68,,134.64,percent of total billed charges,All Other,711,,,711,Other,186% of Medicaid,158.4,80,,158.4,percent of total billed charges,All Other,164.34,83,,164.34,percent of total billed charges,All Other,164.34,83,,164.34,percent of total billed charges,All Other,158.4,80,,158.4,percent of total billed charges,All Other,164.34,83,,164.34,percent of total billed charges,All Other,158.4,,,158.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",138.6,70,,138.6,percent of total billed charges,All Other,250.92,,,250.92,Fee Schedule,,212.67,,,212.67,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",382.43,,,382.43,Other,100% of Medicaid,382.43,,,382.43,Other,100% of Medicaid,382.43,,,382.43,Other,100% of Medicaid,382.43,,,382.43,Other,100% of Medicaid,860.48,,,860.48,Other,225% of Medicaid,585.13,,,585.13,Other,153% of Medicaid,860.48,,,860.48,Other,225% of Medicaid,535.41,,,535.41,Other,140% of Medicaid,860.48,,,860.48,Other,225% of Medicaid,994.33,,,994.33,Other,260% of Medicaid,1239.09,,,1239.09,Other,324% of Medicaid,822.23,,,822.23,Other,215% of Medicaid,822.23,,,822.23,Other,215% of Medicaid,478.04,,,478.04,Other,125% of Medicaid,89.1,14237,
INJECT PULM ART HRT CATH,93568,CPT,,49093568,CDM,481,RC,,,both,,,159,117.66,,,117.66,Other,150% of Medicare + 9.63% HCRA Surcharge,71.55,45,,71.55,percent of total billed charges,Critical Access Hospital RCC factor,14237,,,14237,Case Rate,Cardiac Cath Lab Per Case,12813,,,12813,Case Rate,Cardiac Cath Lab Per Case,3648,,,3648,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3283,,,3283,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3101,,,3101,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",78.71,,,78.71,Other,110% of Medicare,108.12,68,,108.12,percent of total billed charges,All Other,711,,,711,Other,186% of Medicaid,127.2,80,,127.2,percent of total billed charges,All Other,131.97,83,,131.97,percent of total billed charges,All Other,131.97,83,,131.97,percent of total billed charges,All Other,127.2,80,,127.2,percent of total billed charges,All Other,131.97,83,,131.97,percent of total billed charges,All Other,127.2,,,127.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",111.3,70,,111.3,percent of total billed charges,All Other,229.6,,,229.6,Fee Schedule,,194.6,,,194.6,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",382.43,,,382.43,Other,100% of Medicaid,382.43,,,382.43,Other,100% of Medicaid,382.43,,,382.43,Other,100% of Medicaid,382.43,,,382.43,Other,100% of Medicaid,860.48,,,860.48,Other,225% of Medicaid,585.13,,,585.13,Other,153% of Medicaid,860.48,,,860.48,Other,225% of Medicaid,535.41,,,535.41,Other,140% of Medicaid,860.48,,,860.48,Other,225% of Medicaid,994.33,,,994.33,Other,260% of Medicaid,1239.09,,,1239.09,Other,324% of Medicaid,822.23,,,822.23,Other,215% of Medicaid,822.23,,,822.23,Other,215% of Medicaid,478.04,,,478.04,Other,125% of Medicaid,71.55,14237,
IV DOPPLER; INITIAL VESSEL,93571,CPT,,49093571,CDM,481,RC,,,both,,,349,258.26,,,258.26,Other,150% of Medicare + 9.63% HCRA Surcharge,157.05,45,,157.05,percent of total billed charges,Critical Access Hospital RCC factor,226.85,65,,226.85,percent of total billed charges,All Other,205.91,65,,205.91,percent of total billed charges,All Other,266.99,76.5,,266.99,percent of total billed charges,All Other,247.79,69,,247.79,percent of total billed charges,All Other,240.81,65,,240.81,percent of total billed charges,All Other,172.76,,,172.76,Other,110% of Medicare,237.32,68,,237.32,percent of total billed charges,All Other,544,,,544,Other,186% of Medicaid,279.2,80,,279.2,percent of total billed charges,All Other,289.67,83,,289.67,percent of total billed charges,All Other,289.67,83,,289.67,percent of total billed charges,All Other,279.2,80,,279.2,percent of total billed charges,All Other,289.67,83,,289.67,percent of total billed charges,All Other,279.2,,,279.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",244.3,70,,244.3,percent of total billed charges,All Other,226.85,65,,226.85,percent of total billed charges,Default if not in Fee Schedule,226.85,65,,226.85,percent of total billed charges,Default if not in Fee Schedule,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",292.43,,,292.43,Other,100% of Medicaid,292.43,,,292.43,Other,100% of Medicaid,292.43,,,292.43,Other,100% of Medicaid,292.43,,,292.43,Other,100% of Medicaid,657.98,,,657.98,Other,225% of Medicaid,447.42,,,447.42,Other,153% of Medicaid,657.98,,,657.98,Other,225% of Medicaid,409.41,,,409.41,Other,140% of Medicaid,657.98,,,657.98,Other,225% of Medicaid,760.33,,,760.33,Other,260% of Medicaid,947.49,,,947.49,Other,324% of Medicaid,628.73,,,628.73,Other,215% of Medicaid,628.73,,,628.73,Other,215% of Medicaid,365.54,,,365.54,Other,125% of Medicaid,157.05,3227,
IV DOPPLER; EA ADDTL VESSEL,93572,CPT,,49093572,CDM,481,RC,,,both,,,278,205.72,,,205.72,Other,150% of Medicare + 9.63% HCRA Surcharge,125.1,45,,125.1,percent of total billed charges,Critical Access Hospital RCC factor,180.7,65,,180.7,percent of total billed charges,All Other,164.02,65,,164.02,percent of total billed charges,All Other,212.67,76.5,,212.67,percent of total billed charges,All Other,197.38,69,,197.38,percent of total billed charges,All Other,191.82,65,,191.82,percent of total billed charges,All Other,137.61,,,137.61,Other,110% of Medicare,189.04,68,,189.04,percent of total billed charges,All Other,544,,,544,Other,186% of Medicaid,222.4,80,,222.4,percent of total billed charges,All Other,230.74,83,,230.74,percent of total billed charges,All Other,230.74,83,,230.74,percent of total billed charges,All Other,222.4,80,,222.4,percent of total billed charges,All Other,230.74,83,,230.74,percent of total billed charges,All Other,222.4,,,222.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",194.6,70,,194.6,percent of total billed charges,All Other,180.7,65,,180.7,percent of total billed charges,Default if not in Fee Schedule,180.7,65,,180.7,percent of total billed charges,Default if not in Fee Schedule,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",292.43,,,292.43,Other,100% of Medicaid,292.43,,,292.43,Other,100% of Medicaid,292.43,,,292.43,Other,100% of Medicaid,292.43,,,292.43,Other,100% of Medicaid,657.98,,,657.98,Other,225% of Medicaid,447.42,,,447.42,Other,153% of Medicaid,657.98,,,657.98,Other,225% of Medicaid,409.41,,,409.41,Other,140% of Medicaid,657.98,,,657.98,Other,225% of Medicaid,760.33,,,760.33,Other,260% of Medicaid,947.49,,,947.49,Other,324% of Medicaid,628.73,,,628.73,Other,215% of Medicaid,628.73,,,628.73,Other,215% of Medicaid,365.54,,,365.54,Other,125% of Medicaid,125.1,3227,
STRESS TEST TRACING ONLY,93017,CPT,,48093017,CDM,482,RC,,,both,,,969,717.06,,,717.06,Other,150% of Medicare + 9.63% HCRA Surcharge,436.05,45,,436.05,percent of total billed charges,Critical Access Hospital RCC factor,121.04,,,121.04,Fee Schedule,,109.14,,,109.14,Fee Schedule,,363.95,,,363.95,Fee Schedule,,327.34,,,327.34,Fee Schedule,,309.39,,,309.39,Fee Schedule,,479.66,,,479.66,Other,110% of Medicare,0.68,,,0.68,Fee Schedule,,255,,,255,Other,186% of Medicaid,0.8,,,0.8,Fee Schedule,,0.83,,,0.83,Fee Schedule,,0.83,,,0.83,Fee Schedule,,0.8,,,0.8,Fee Schedule,,0.83,,,0.83,Fee Schedule,,775.2,80,,775.2,percent of total billed charges,All Other,678.3,70,,678.3,percent of total billed charges,All Other,170.56,,,170.56,Fee Schedule,,144.56,,,144.56,Fee Schedule,,526,,,526,Case Rate,,473,,,473,Case Rate,,526,,,526,Case Rate,,447,,,447,Case Rate,,137.34,,,137.34,Other,100% of Medicaid,137.34,,,137.34,Other,100% of Medicaid,137.34,,,137.34,Other,100% of Medicaid,137.34,,,137.34,Other,100% of Medicaid,309.01,,,309.01,Other,225% of Medicaid,210.12,,,210.12,Other,153% of Medicaid,309.01,,,309.01,Other,225% of Medicaid,192.27,,,192.27,Other,140% of Medicaid,309.01,,,309.01,Other,225% of Medicaid,357.07,,,357.07,Other,260% of Medicaid,444.97,,,444.97,Other,324% of Medicaid,295.27,,,295.27,Other,215% of Medicaid,295.27,,,295.27,Other,215% of Medicaid,171.67,,,171.67,Other,125% of Medicaid,0.68,775.2,
2D TTE W OR W/O FOL W/CON FU,C8924,HCPCS,,48000001,CDM,483,RC,,,both,,,2768,2048.33,,,2048.33,Other,150% of Medicare + 9.63% HCRA Surcharge,1245.6,45,,1245.6,percent of total billed charges,Critical Access Hospital RCC factor,1799.2,65,,1799.2,percent of total billed charges,All Other,1633.12,65,,1633.12,percent of total billed charges,All Other,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,1370.16,,,1370.16,Other,110% of Medicare,1882.24,68,,1882.24,percent of total billed charges,All Other,497,,,497,Other,186% of Medicaid,2214.4,,,2214.4,percent of total billed charges,All Other,2297.44,83,,2297.44,percent of total billed charges,All Other,1522.4,83,,1522.4,percent of total billed charges,All Other,2214.4,80,,2214.4,percent of total billed charges,All Other,2297.44,83,,2297.44,percent of total billed charges,All Other,2214.4,80,,2214.4,percent of total billed charges,All Other,1937.6,70,,1937.6,percent of total billed charges,All Other,1799.2,65,,1799.2,percent of total billed charges,Default if not in Fee Schedule,1799.2,65,,1799.2,percent of total billed charges,Default if not in Fee Schedule,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,267.36,,,267.36,Other,100% of Medicaid,267.36,,,267.36,Other,100% of Medicaid,267.36,,,267.36,Other,100% of Medicaid,267.36,,,267.36,Other,100% of Medicaid,601.56,,,601.56,Other,225% of Medicaid,409.06,,,409.06,Other,153% of Medicaid,601.56,,,601.56,Other,225% of Medicaid,374.3,,,374.3,Other,140% of Medicaid,601.56,,,601.56,Other,225% of Medicaid,695.14,,,695.14,Other,260% of Medicaid,866.25,,,866.25,Other,324% of Medicaid,574.82,,,574.82,Other,215% of Medicaid,574.82,,,574.82,Other,215% of Medicaid,334.2,,,334.2,Other,125% of Medicaid,0.01,2297.44,
2D TEE W OR W/O FOL W/CON IN,C8925,HCPCS,,48000002,CDM,483,RC,,,both,,,4962,3671.89,,,3671.89,Other,150% of Medicare + 9.63% HCRA Surcharge,2232.9,45,,2232.9,percent of total billed charges,Critical Access Hospital RCC factor,3225.3,65,,3225.3,percent of total billed charges,All Other,2927.58,65,,2927.58,percent of total billed charges,All Other,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,2456.19,,,2456.19,Other,110% of Medicare,3374.16,68,,3374.16,percent of total billed charges,All Other,497,,,497,Other,186% of Medicaid,3969.6,,,3969.6,percent of total billed charges,All Other,4118.46,83,,4118.46,percent of total billed charges,All Other,2729.1,83,,2729.1,percent of total billed charges,All Other,3969.6,80,,3969.6,percent of total billed charges,All Other,4118.46,83,,4118.46,percent of total billed charges,All Other,3969.6,80,,3969.6,percent of total billed charges,All Other,3473.4,70,,3473.4,percent of total billed charges,All Other,3225.3,65,,3225.3,percent of total billed charges,Default if not in Fee Schedule,3225.3,65,,3225.3,percent of total billed charges,Default if not in Fee Schedule,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,267.36,,,267.36,Other,100% of Medicaid,267.36,,,267.36,Other,100% of Medicaid,267.36,,,267.36,Other,100% of Medicaid,267.36,,,267.36,Other,100% of Medicaid,601.56,,,601.56,Other,225% of Medicaid,409.06,,,409.06,Other,153% of Medicaid,601.56,,,601.56,Other,225% of Medicaid,374.3,,,374.3,Other,140% of Medicaid,601.56,,,601.56,Other,225% of Medicaid,695.14,,,695.14,Other,260% of Medicaid,866.25,,,866.25,Other,324% of Medicaid,574.82,,,574.82,Other,215% of Medicaid,574.82,,,574.82,Other,215% of Medicaid,334.2,,,334.2,Other,125% of Medicaid,0.01,4118.46,
TTE W OR W/O FOL W/CON DOPPLER,C8929,HCPCS,,48000003,CDM,483,RC,,,both,,,4962,3671.89,,,3671.89,Other,150% of Medicare + 9.63% HCRA Surcharge,2232.9,45,,2232.9,percent of total billed charges,Critical Access Hospital RCC factor,3225.3,65,,3225.3,percent of total billed charges,All Other,2927.58,65,,2927.58,percent of total billed charges,All Other,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,2456.19,,,2456.19,Other,110% of Medicare,3374.16,68,,3374.16,percent of total billed charges,All Other,497,,,497,Other,186% of Medicaid,3969.6,,,3969.6,percent of total billed charges,All Other,4118.46,83,,4118.46,percent of total billed charges,All Other,4118.46,83,,4118.46,percent of total billed charges,All Other,3969.6,80,,3969.6,percent of total billed charges,All Other,4118.46,83,,4118.46,percent of total billed charges,All Other,3969.6,80,,3969.6,percent of total billed charges,All Other,3473.4,70,,3473.4,percent of total billed charges,All Other,3225.3,65,,3225.3,percent of total billed charges,Default if not in Fee Schedule,3225.3,65,,3225.3,percent of total billed charges,Default if not in Fee Schedule,0.01,,,0.01,Case Rate,,0.01,,,0.01,Case Rate,,0.01,,,0.01,Case Rate,,0.01,,,0.01,Case Rate,,267.36,,,267.36,Other,100% of Medicaid,267.36,,,267.36,Other,100% of Medicaid,267.36,,,267.36,Other,100% of Medicaid,267.36,,,267.36,Other,100% of Medicaid,601.56,,,601.56,Other,225% of Medicaid,409.06,,,409.06,Other,153% of Medicaid,601.56,,,601.56,Other,225% of Medicaid,374.3,,,374.3,Other,140% of Medicaid,601.56,,,601.56,Other,225% of Medicaid,695.14,,,695.14,Other,260% of Medicaid,866.25,,,866.25,Other,324% of Medicaid,574.82,,,574.82,Other,215% of Medicaid,574.82,,,574.82,Other,215% of Medicaid,334.2,,,334.2,Other,125% of Medicaid,0.01,4118.46,
TTE W OR W/O CONTR CONT ECG,C8930,HCPCS,,48000004,CDM,483,RC,,,both,,,4962,3671.89,,,3671.89,Other,150% of Medicare + 9.63% HCRA Surcharge,2232.9,45,,2232.9,percent of total billed charges,Critical Access Hospital RCC factor,3225.3,65,,3225.3,percent of total billed charges,All Other,2927.58,65,,2927.58,percent of total billed charges,All Other,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,2456.19,,,2456.19,Other,110% of Medicare,3374.16,68,,3374.16,percent of total billed charges,All Other,497,,,497,Other,186% of Medicaid,3969.6,,,3969.6,percent of total billed charges,All Other,4118.46,83,,4118.46,percent of total billed charges,All Other,2729.1,83,,2729.1,percent of total billed charges,All Other,3969.6,80,,3969.6,percent of total billed charges,All Other,4118.46,83,,4118.46,percent of total billed charges,All Other,3969.6,80,,3969.6,percent of total billed charges,All Other,3473.4,70,,3473.4,percent of total billed charges,All Other,3225.3,65,,3225.3,percent of total billed charges,Default if not in Fee Schedule,3225.3,65,,3225.3,percent of total billed charges,Default if not in Fee Schedule,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,267.36,,,267.36,Other,100% of Medicaid,267.36,,,267.36,Other,100% of Medicaid,267.36,,,267.36,Other,100% of Medicaid,267.36,,,267.36,Other,100% of Medicaid,601.56,,,601.56,Other,225% of Medicaid,409.06,,,409.06,Other,153% of Medicaid,601.56,,,601.56,Other,225% of Medicaid,374.3,,,374.3,Other,140% of Medicaid,601.56,,,601.56,Other,225% of Medicaid,695.14,,,695.14,Other,260% of Medicaid,866.25,,,866.25,Other,324% of Medicaid,574.82,,,574.82,Other,215% of Medicaid,574.82,,,574.82,Other,215% of Medicaid,334.2,,,334.2,Other,125% of Medicaid,0.01,4118.46,
FETAL CARDIOVASC 2-D US,76825,CPT,,48076825,CDM,483,RC,,,both,,,2308,1707.93,,,1707.93,Other,150% of Medicare + 9.63% HCRA Surcharge,1038.6,45,,1038.6,percent of total billed charges,Critical Access Hospital RCC factor,637.07,,,637.07,Fee Schedule,,573.17,,,573.17,Fee Schedule,,917.72,,,917.72,Fee Schedule,,825.42,,,825.42,Fee Schedule,,780.15,,,780.15,Fee Schedule,,1142.46,,,1142.46,Other,110% of Medicare,756.9,,,756.9,Fee Schedule,,196,,,196,Other,186% of Medicaid,890.71,,,890.71,Fee Schedule,,419.39,,,419.39,Fee Schedule,,419.39,,,419.39,Fee Schedule,,890.71,,,890.71,Fee Schedule,,419.39,,,419.39,Fee Schedule,,788.85,,,788.85,Fee Schedule,,1615.6,70,,1615.6,percent of total billed charges,All Other,915.12,,,915.12,Fee Schedule,,775.62,,,775.62,Fee Schedule,,770.53,,,770.53,Fee Schedule,,770.53,,,770.53,Fee Schedule,,770.53,,,770.53,Fee Schedule,,770.53,,,770.53,Fee Schedule,,105.15,,,105.15,Other,100% of Medicaid,105.15,,,105.15,Other,100% of Medicaid,105.15,,,105.15,Other,100% of Medicaid,105.15,,,105.15,Other,100% of Medicaid,236.6,,,236.6,Other,225% of Medicaid,160.89,,,160.89,Other,153% of Medicaid,236.6,,,236.6,Other,225% of Medicaid,147.22,,,147.22,Other,140% of Medicaid,236.6,,,236.6,Other,225% of Medicaid,273.4,,,273.4,Other,260% of Medicaid,340.7,,,340.7,Other,324% of Medicaid,226.08,,,226.08,Other,215% of Medicaid,226.08,,,226.08,Other,215% of Medicaid,131.44,,,131.44,Other,125% of Medicaid,105.15,1707.93,
COMPL FETAL DOPPLER ECHOCARGIOGRAM,76827,CPT,TC,48076827,CDM,483,RC,,,both,,,249,184.26,,,184.26,Other,150% of Medicare + 9.63% HCRA Surcharge,112.05,45,,112.05,percent of total billed charges,Critical Access Hospital RCC factor,148.05,,,148.05,Fee Schedule,,133.2,,,133.2,Fee Schedule,,258.7,,,258.7,Fee Schedule,,232.69,,,232.69,Fee Schedule,,219.92,,,219.92,Fee Schedule,,123.26,,,123.26,Other,110% of Medicare,175.89,,,175.89,Fee Schedule,,196,,,196,Other,186% of Medicaid,206.99,,,206.99,Fee Schedule,,97.46,,,97.46,Fee Schedule,,97.46,,,97.46,Fee Schedule,,206.99,,,206.99,Fee Schedule,,97.46,,,97.46,Fee Schedule,,183.32,,,183.32,Fee Schedule,,174.3,70,,174.3,percent of total billed charges,All Other,213.2,,,213.2,Fee Schedule,,180.7,,,180.7,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,179.33,,,179.33,Fee Schedule,,105.15,,,105.15,Other,100% of Medicaid,105.15,,,105.15,Other,100% of Medicaid,105.15,,,105.15,Other,100% of Medicaid,105.15,,,105.15,Other,100% of Medicaid,236.6,,,236.6,Other,225% of Medicaid,160.89,,,160.89,Other,153% of Medicaid,236.6,,,236.6,Other,225% of Medicaid,147.22,,,147.22,Other,140% of Medicaid,236.6,,,236.6,Other,225% of Medicaid,273.4,,,273.4,Other,260% of Medicaid,340.7,,,340.7,Other,324% of Medicaid,226.08,,,226.08,Other,215% of Medicaid,226.08,,,226.08,Other,215% of Medicaid,131.44,,,131.44,Other,125% of Medicaid,97.46,340.7,
TTE CONG ABN COMPLETE,93303,CPT,,48093303,CDM,483,RC,,,both,,,3125,2312.51,,,2312.51,Other,150% of Medicare + 9.63% HCRA Surcharge,1406.25,45,,1406.25,percent of total billed charges,Critical Access Hospital RCC factor,511.15,,,511.15,Fee Schedule,,460.9,,,460.9,Fee Schedule,,970.37,,,970.37,Fee Schedule,,872.78,,,872.78,Fee Schedule,,824.9,,,824.9,Fee Schedule,,1546.88,,,1546.88,Other,110% of Medicare,0.68,,,0.68,Fee Schedule,,497,,,497,Other,186% of Medicaid,0.8,,,0.8,Fee Schedule,,0.83,,,0.83,Fee Schedule,,0.83,,,0.83,Fee Schedule,,0.8,,,0.8,Fee Schedule,,0.83,,,0.83,Fee Schedule,,2500,80,,2500,percent of total billed charges,All Other,2187.5,70,,2187.5,percent of total billed charges,All Other,798.68,,,798.68,Fee Schedule,,676.93,,,676.93,Fee Schedule,,1000,,,1000,Case Rate,,900,,,900,Case Rate,,1000,,,1000,Case Rate,,851,,,851,Case Rate,,267.36,,,267.36,Other,100% of Medicaid,267.36,,,267.36,Other,100% of Medicaid,267.36,,,267.36,Other,100% of Medicaid,267.36,,,267.36,Other,100% of Medicaid,601.56,,,601.56,Other,225% of Medicaid,409.06,,,409.06,Other,153% of Medicaid,601.56,,,601.56,Other,225% of Medicaid,374.3,,,374.3,Other,140% of Medicaid,601.56,,,601.56,Other,225% of Medicaid,695.14,,,695.14,Other,260% of Medicaid,866.25,,,866.25,Other,324% of Medicaid,574.82,,,574.82,Other,215% of Medicaid,574.82,,,574.82,Other,215% of Medicaid,334.2,,,334.2,Other,125% of Medicaid,0.68,2500,
TTE CONG ABN LIMITED/F-UP,93304,CPT,,48093304,CDM,483,RC,,,both,,,3125,2312.51,,,2312.51,Other,150% of Medicare + 9.63% HCRA Surcharge,1406.25,45,,1406.25,percent of total billed charges,Critical Access Hospital RCC factor,385.98,,,385.98,Fee Schedule,,348.03,,,348.03,Fee Schedule,,647.68,,,647.68,Fee Schedule,,582.55,,,582.55,Fee Schedule,,550.59,,,550.59,Fee Schedule,,1546.88,,,1546.88,Other,110% of Medicare,0.68,,,0.68,Fee Schedule,,497,,,497,Other,186% of Medicaid,0.8,,,0.8,Fee Schedule,,0.83,,,0.83,Fee Schedule,,0.83,,,0.83,Fee Schedule,,0.8,,,0.8,Fee Schedule,,0.83,,,0.83,Fee Schedule,,2500,80,,2500,percent of total billed charges,All Other,2187.5,70,,2187.5,percent of total billed charges,All Other,598.6,,,598.6,Fee Schedule,,507.35,,,507.35,Fee Schedule,,1000,,,1000,Case Rate,,900,,,900,Case Rate,,1000,,,1000,Case Rate,,851,,,851,Case Rate,,267.36,,,267.36,Other,100% of Medicaid,267.36,,,267.36,Other,100% of Medicaid,267.36,,,267.36,Other,100% of Medicaid,267.36,,,267.36,Other,100% of Medicaid,601.56,,,601.56,Other,225% of Medicaid,409.06,,,409.06,Other,153% of Medicaid,601.56,,,601.56,Other,225% of Medicaid,374.3,,,374.3,Other,140% of Medicaid,601.56,,,601.56,Other,225% of Medicaid,695.14,,,695.14,Other,260% of Medicaid,866.25,,,866.25,Other,324% of Medicaid,574.82,,,574.82,Other,215% of Medicaid,574.82,,,574.82,Other,215% of Medicaid,334.2,,,334.2,Other,125% of Medicaid,0.68,2500,
TTE W/DOPPLER COMPLETE,93306,CPT,,48093306,CDM,483,RC,,,both,,,2181,1613.95,,,1613.95,Other,150% of Medicare + 9.63% HCRA Surcharge,981.45,45,,981.45,percent of total billed charges,Critical Access Hospital RCC factor,413.91,,,413.91,Fee Schedule,,373.22,,,373.22,Fee Schedule,,1112.23,,,1112.23,Fee Schedule,,1000.38,,,1000.38,Fee Schedule,,945.5,,,945.5,Fee Schedule,,1079.6,,,1079.6,Other,110% of Medicare,0.68,,,0.68,Fee Schedule,,497,,,497,Other,186% of Medicaid,0.8,,,0.8,Fee Schedule,,0.83,,,0.83,Fee Schedule,,0.83,,,0.83,Fee Schedule,,0.8,,,0.8,Fee Schedule,,0.83,,,0.83,Fee Schedule,,1744.8,80,,1744.8,percent of total billed charges,All Other,1526.7,70,,1526.7,percent of total billed charges,All Other,637.96,,,637.96,Fee Schedule,,540.71,,,540.71,Fee Schedule,,1000,,,1000,Case Rate,,900,,,900,Case Rate,,1000,,,1000,Case Rate,,851,,,851,Case Rate,,267.36,,,267.36,Other,100% of Medicaid,267.36,,,267.36,Other,100% of Medicaid,267.36,,,267.36,Other,100% of Medicaid,267.36,,,267.36,Other,100% of Medicaid,601.56,,,601.56,Other,225% of Medicaid,409.06,,,409.06,Other,153% of Medicaid,601.56,,,601.56,Other,225% of Medicaid,374.3,,,374.3,Other,140% of Medicaid,601.56,,,601.56,Other,225% of Medicaid,695.14,,,695.14,Other,260% of Medicaid,866.25,,,866.25,Other,324% of Medicaid,574.82,,,574.82,Other,215% of Medicaid,574.82,,,574.82,Other,215% of Medicaid,334.2,,,334.2,Other,125% of Medicaid,0.68,1744.8,
TTE W/O DOPPLER COMPLETE,93307,CPT,,48093307,CDM,483,RC,,,both,,,1511,1118.14,,,1118.14,Other,150% of Medicare + 9.63% HCRA Surcharge,679.95,45,,679.95,percent of total billed charges,Critical Access Hospital RCC factor,301.58,,,301.58,Fee Schedule,,271.93,,,271.93,Fee Schedule,,669.75,,,669.75,Fee Schedule,,602.9,,,602.9,Fee Schedule,,569.48,,,569.48,Fee Schedule,,747.95,,,747.95,Other,110% of Medicare,0.68,,,0.68,Fee Schedule,,497,,,497,Other,186% of Medicaid,0.8,,,0.8,Fee Schedule,,0.83,,,0.83,Fee Schedule,,0.83,,,0.83,Fee Schedule,,0.8,,,0.8,Fee Schedule,,0.83,,,0.83,Fee Schedule,,403.81,,,403.81,Fee Schedule,,1057.7,70,,1057.7,percent of total billed charges,All Other,469.04,,,469.04,Fee Schedule,,397.54,,,397.54,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,267.36,,,267.36,Other,100% of Medicaid,267.36,,,267.36,Other,100% of Medicaid,267.36,,,267.36,Other,100% of Medicaid,267.36,,,267.36,Other,100% of Medicaid,601.56,,,601.56,Other,225% of Medicaid,409.06,,,409.06,Other,153% of Medicaid,601.56,,,601.56,Other,225% of Medicaid,374.3,,,374.3,Other,140% of Medicaid,601.56,,,601.56,Other,225% of Medicaid,695.14,,,695.14,Other,260% of Medicaid,866.25,,,866.25,Other,324% of Medicaid,574.82,,,574.82,Other,215% of Medicaid,574.82,,,574.82,Other,215% of Medicaid,334.2,,,334.2,Other,125% of Medicaid,0.01,1118.14,
TEE,93312,CPT,,48093312,CDM,483,RC,,,both,,,3048,2255.53,,,2255.53,Other,150% of Medicare + 9.63% HCRA Surcharge,1371.6,45,,1371.6,percent of total billed charges,Critical Access Hospital RCC factor,422.47,,,422.47,Fee Schedule,,380.94,,,380.94,Fee Schedule,,1439.66,,,1439.66,Fee Schedule,,1294.87,,,1294.87,Fee Schedule,,1223.85,,,1223.85,Fee Schedule,,1508.76,,,1508.76,Other,110% of Medicare,0.68,,,0.68,Fee Schedule,,497,,,497,Other,186% of Medicaid,0.8,,,0.8,Fee Schedule,,0.83,,,0.83,Fee Schedule,,0.83,,,0.83,Fee Schedule,,0.8,,,0.8,Fee Schedule,,0.83,,,0.83,Fee Schedule,,2438.4,80,,2438.4,percent of total billed charges,All Other,2133.6,70,,2133.6,percent of total billed charges,All Other,656,,,656,Fee Schedule,,556,,,556,Fee Schedule,,1000,,,1000,Case Rate,,900,,,900,Case Rate,,1000,,,1000,Case Rate,,851,,,851,Case Rate,,267.36,,,267.36,Other,100% of Medicaid,267.36,,,267.36,Other,100% of Medicaid,267.36,,,267.36,Other,100% of Medicaid,267.36,,,267.36,Other,100% of Medicaid,601.56,,,601.56,Other,225% of Medicaid,409.06,,,409.06,Other,153% of Medicaid,601.56,,,601.56,Other,225% of Medicaid,374.3,,,374.3,Other,140% of Medicaid,601.56,,,601.56,Other,225% of Medicaid,695.14,,,695.14,Other,260% of Medicaid,866.25,,,866.25,Other,324% of Medicaid,574.82,,,574.82,Other,215% of Medicaid,574.82,,,574.82,Other,215% of Medicaid,334.2,,,334.2,Other,125% of Medicaid,0.68,2438.4,
DOPPLER ECHO COMPLETE,93320,CPT,,48093320,CDM,483,RC,,,both,,,144,106.56,,,106.56,Other,150% of Medicare + 9.63% HCRA Surcharge,64.8,45,,64.8,percent of total billed charges,Critical Access Hospital RCC factor,107,,,107,Fee Schedule,,96.48,,,96.48,Fee Schedule,,290.75,,,290.75,Fee Schedule,,261.51,,,261.51,Fee Schedule,,247.16,,,247.16,Fee Schedule,,71.28,,,71.28,Other,110% of Medicare,0.68,,,0.68,Fee Schedule,,497,,,497,Other,186% of Medicaid,0.8,,,0.8,Fee Schedule,,0.83,,,0.83,Fee Schedule,,0.83,,,0.83,Fee Schedule,,0.8,,,0.8,Fee Schedule,,0.83,,,0.83,Fee Schedule,,115.2,80,,115.2,percent of total billed charges,All Other,100.8,70,,100.8,percent of total billed charges,All Other,165.64,,,165.64,Fee Schedule,,140.39,,,140.39,Fee Schedule,,1000,,,1000,Case Rate,,900,,,900,Case Rate,,1000,,,1000,Case Rate,,851,,,851,Case Rate,,267.36,,,267.36,Other,100% of Medicaid,267.36,,,267.36,Other,100% of Medicaid,267.36,,,267.36,Other,100% of Medicaid,267.36,,,267.36,Other,100% of Medicaid,601.56,,,601.56,Other,225% of Medicaid,409.06,,,409.06,Other,153% of Medicaid,601.56,,,601.56,Other,225% of Medicaid,374.3,,,374.3,Other,140% of Medicaid,601.56,,,601.56,Other,225% of Medicaid,695.14,,,695.14,Other,260% of Medicaid,866.25,,,866.25,Other,324% of Medicaid,574.82,,,574.82,Other,215% of Medicaid,574.82,,,574.82,Other,215% of Medicaid,334.2,,,334.2,Other,125% of Medicaid,0.68,1000,
DOPPLER ECHO LIMITED/ F-UP,93321,CPT,,48093321,CDM,483,RC,,,both,,,55,40.7,,,40.7,Other,150% of Medicare + 9.63% HCRA Surcharge,24.75,45,,24.75,percent of total billed charges,Critical Access Hospital RCC factor,57.7,,,57.7,Fee Schedule,,52.03,,,52.03,Fee Schedule,,144.29,,,144.29,Fee Schedule,,129.78,,,129.78,Fee Schedule,,122.66,,,122.66,Fee Schedule,,27.23,,,27.23,Other,110% of Medicare,0.68,,,0.68,Fee Schedule,,497,,,497,Other,186% of Medicaid,0.8,,,0.8,Fee Schedule,,0.83,,,0.83,Fee Schedule,,0.83,,,0.83,Fee Schedule,,0.8,,,0.8,Fee Schedule,,0.83,,,0.83,Fee Schedule,,44,80,,44,percent of total billed charges,All Other,38.5,70,,38.5,percent of total billed charges,All Other,90.2,,,90.2,Fee Schedule,,76.45,,,76.45,Fee Schedule,,1000,,,1000,Case Rate,,900,,,900,Case Rate,,1000,,,1000,Case Rate,,851,,,851,Case Rate,,267.36,,,267.36,Other,100% of Medicaid,267.36,,,267.36,Other,100% of Medicaid,267.36,,,267.36,Other,100% of Medicaid,267.36,,,267.36,Other,100% of Medicaid,601.56,,,601.56,Other,225% of Medicaid,409.06,,,409.06,Other,153% of Medicaid,601.56,,,601.56,Other,225% of Medicaid,374.3,,,374.3,Other,140% of Medicaid,601.56,,,601.56,Other,225% of Medicaid,695.14,,,695.14,Other,260% of Medicaid,866.25,,,866.25,Other,324% of Medicaid,574.82,,,574.82,Other,215% of Medicaid,574.82,,,574.82,Other,215% of Medicaid,334.2,,,334.2,Other,125% of Medicaid,0.68,1000,
DOPPLER COLOR FLOW ADD-ON,93325,CPT,,48093325,CDM,483,RC,,,both,,,17,12.58,,,12.58,Other,150% of Medicare + 9.63% HCRA Surcharge,7.65,45,,7.65,percent of total billed charges,Critical Access Hospital RCC factor,65.17,,,65.17,Fee Schedule,,58.76,,,58.76,Fee Schedule,,215.23,,,215.23,Fee Schedule,,193.58,,,193.58,Fee Schedule,,182.96,,,182.96,Fee Schedule,,8.42,,,8.42,Other,110% of Medicare,0.68,,,0.68,Fee Schedule,,226,,,226,Other,186% of Medicaid,0.8,,,0.8,Fee Schedule,,0.83,,,0.83,Fee Schedule,,0.83,,,0.83,Fee Schedule,,0.8,,,0.8,Fee Schedule,,0.83,,,0.83,Fee Schedule,,87.26,,,87.26,Fee Schedule,,11.9,70,,11.9,percent of total billed charges,All Other,101.68,,,101.68,Fee Schedule,,86.18,,,86.18,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,121.68,,,121.68,Other,100% of Medicaid,121.68,,,121.68,Other,100% of Medicaid,121.68,,,121.68,Other,100% of Medicaid,121.68,,,121.68,Other,100% of Medicaid,273.79,,,273.79,Other,225% of Medicaid,186.18,,,186.18,Other,153% of Medicaid,273.79,,,273.79,Other,225% of Medicaid,170.36,,,170.36,Other,140% of Medicaid,273.79,,,273.79,Other,225% of Medicaid,316.38,,,316.38,Other,260% of Medicaid,394.25,,,394.25,Other,324% of Medicaid,261.62,,,261.62,Other,215% of Medicaid,261.62,,,261.62,Other,215% of Medicaid,152.1,,,152.1,Other,125% of Medicaid,0.01,394.25,
ECHO STRESS RE TIME TC,93350,CPT,,48093350,CDM,483,RC,,,both,,,2181,1613.95,,,1613.95,Other,150% of Medicare + 9.63% HCRA Surcharge,981.45,45,,981.45,percent of total billed charges,Critical Access Hospital RCC factor,378.51,,,378.51,Fee Schedule,,341.3,,,341.3,Fee Schedule,,893.72,,,893.72,Fee Schedule,,804.52,,,804.52,Fee Schedule,,759.92,,,759.92,Fee Schedule,,1079.6,,,1079.6,Other,110% of Medicare,0.68,,,0.68,Fee Schedule,,497,,,497,Other,186% of Medicaid,0.8,,,0.8,Fee Schedule,,0.83,,,0.83,Fee Schedule,,0.83,,,0.83,Fee Schedule,,0.8,,,0.8,Fee Schedule,,0.83,,,0.83,Fee Schedule,,506.82,,,506.82,Fee Schedule,,1526.7,70,,1526.7,percent of total billed charges,All Other,588.76,,,588.76,Fee Schedule,,499.01,,,499.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,267.36,,,267.36,Other,100% of Medicaid,267.36,,,267.36,Other,100% of Medicaid,267.36,,,267.36,Other,100% of Medicaid,267.36,,,267.36,Other,100% of Medicaid,601.56,,,601.56,Other,225% of Medicaid,409.06,,,409.06,Other,153% of Medicaid,601.56,,,601.56,Other,225% of Medicaid,374.3,,,374.3,Other,140% of Medicaid,601.56,,,601.56,Other,225% of Medicaid,695.14,,,695.14,Other,260% of Medicaid,866.25,,,866.25,Other,324% of Medicaid,574.82,,,574.82,Other,215% of Medicaid,574.82,,,574.82,Other,215% of Medicaid,334.2,,,334.2,Other,125% of Medicaid,0.01,1613.95,
STRESS TTE COMPLETE,93351,CPT,,48093351,CDM,483,RC,,,both,,,3344,2474.57,,,2474.57,Other,150% of Medicare + 9.63% HCRA Surcharge,1504.8,45,,1504.8,percent of total billed charges,Critical Access Hospital RCC factor,485.66,,,485.66,Fee Schedule,,437.92,,,437.92,Fee Schedule,,1050.63,,,1050.63,Fee Schedule,,944.97,,,944.97,Fee Schedule,,893.13,,,893.13,Fee Schedule,,1655.28,,,1655.28,Other,110% of Medicare,0.68,,,0.68,Fee Schedule,,497,,,497,Other,186% of Medicaid,0.8,,,0.8,Fee Schedule,,0.83,,,0.83,Fee Schedule,,0.83,,,0.83,Fee Schedule,,0.8,,,0.8,Fee Schedule,,0.83,,,0.83,Fee Schedule,,2675.2,80,,2675.2,percent of total billed charges,All Other,2340.8,70,,2340.8,percent of total billed charges,All Other,744.56,,,744.56,Fee Schedule,,631.06,,,631.06,Fee Schedule,,1000,,,1000,Case Rate,,900,,,900,Case Rate,,1000,,,1000,Case Rate,,851,,,851,Case Rate,,267.36,,,267.36,Other,100% of Medicaid,267.36,,,267.36,Other,100% of Medicaid,267.36,,,267.36,Other,100% of Medicaid,267.36,,,267.36,Other,100% of Medicaid,601.56,,,601.56,Other,225% of Medicaid,409.06,,,409.06,Other,153% of Medicaid,601.56,,,601.56,Other,225% of Medicaid,374.3,,,374.3,Other,140% of Medicaid,601.56,,,601.56,Other,225% of Medicaid,695.14,,,695.14,Other,260% of Medicaid,866.25,,,866.25,Other,324% of Medicaid,574.82,,,574.82,Other,215% of Medicaid,574.82,,,574.82,Other,215% of Medicaid,334.2,,,334.2,Other,125% of Medicaid,0.68,2675.2,
ADMIN ECG CONTRAST AGENT,93352,CPT,,48093352,CDM,483,RC,,,both,,,210,155.4,,,155.4,Other,150% of Medicare + 9.63% HCRA Surcharge,94.5,45,,94.5,percent of total billed charges,Critical Access Hospital RCC factor,110.33,,,110.33,Fee Schedule,,99.48,,,99.48,Fee Schedule,,234.5,,,234.5,Fee Schedule,,211.1,,,211.1,Fee Schedule,,199.39,,,199.39,Fee Schedule,,103.95,,,103.95,Other,110% of Medicare,0.68,,,0.68,Fee Schedule,,497,,,497,Other,186% of Medicaid,0.8,,,0.8,Fee Schedule,,0.83,,,0.83,Fee Schedule,,0.83,,,0.83,Fee Schedule,,0.8,,,0.8,Fee Schedule,,0.83,,,0.83,Fee Schedule,,147.73,,,147.73,Fee Schedule,,147,70,,147,percent of total billed charges,All Other,162.36,,,162.36,Fee Schedule,,137.61,,,137.61,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,267.36,,,267.36,Other,100% of Medicaid,267.36,,,267.36,Other,100% of Medicaid,267.36,,,267.36,Other,100% of Medicaid,267.36,,,267.36,Other,100% of Medicaid,601.56,,,601.56,Other,225% of Medicaid,409.06,,,409.06,Other,153% of Medicaid,601.56,,,601.56,Other,225% of Medicaid,374.3,,,374.3,Other,140% of Medicaid,601.56,,,601.56,Other,225% of Medicaid,695.14,,,695.14,Other,260% of Medicaid,866.25,,,866.25,Other,324% of Medicaid,574.82,,,574.82,Other,215% of Medicaid,574.82,,,574.82,Other,215% of Medicaid,334.2,,,334.2,Other,125% of Medicaid,0.01,866.25,
MYOCRD STRAIN IMG SPCKL TRCK,93356,CPT,,48093356,CDM,483,RC,,,both,,,300,222,,,222,Other,150% of Medicare + 9.63% HCRA Surcharge,135,45,,135,percent of total billed charges,Critical Access Hospital RCC factor,35.25,,,35.25,Fee Schedule,,31.79,,,31.79,Fee Schedule,,39.13,,,39.13,Fee Schedule,,39.13,,,39.13,Fee Schedule,,39.13,,,39.13,Fee Schedule,,148.5,,,148.5,Other,110% of Medicare,45.29,,,45.29,Fee Schedule,,497,,,497,Other,186% of Medicaid,53.3,,,53.3,Fee Schedule,,186,,,186,Fee Schedule,,25.1,,,25.1,Fee Schedule,,53.3,,,53.3,Fee Schedule,,186,,,186,Fee Schedule,,240,80,,240,percent of total billed charges,All Other,210,70,,210,percent of total billed charges,All Other,57.4,,,57.4,Fee Schedule,,48.65,,,48.65,Fee Schedule,,1000,,,1000,Case Rate,,900,,,900,Case Rate,,1000,,,1000,Case Rate,,851,,,851,Case Rate,,267.36,,,267.36,Other,100% of Medicaid,267.36,,,267.36,Other,100% of Medicaid,267.36,,,267.36,Other,100% of Medicaid,267.36,,,267.36,Other,100% of Medicaid,601.56,,,601.56,Other,225% of Medicaid,409.06,,,409.06,Other,153% of Medicaid,601.56,,,601.56,Other,225% of Medicaid,374.3,,,374.3,Other,140% of Medicaid,601.56,,,601.56,Other,225% of Medicaid,695.14,,,695.14,Other,260% of Medicaid,866.25,,,866.25,Other,324% of Medicaid,574.82,,,574.82,Other,215% of Medicaid,574.82,,,574.82,Other,215% of Medicaid,334.2,,,334.2,Other,125% of Medicaid,25.1,1000,
PHONE E/M PHYS/QHP 5 TO 10MIN,99441,CPT,,70099441,CDM,510,RC,,,both,,,41,30.34,,,30.34,Other,150% of Medicare + 9.63% HCRA Surcharge,18.45,45,,18.45,percent of total billed charges,Critical Access Hospital RCC factor,26.65,65,,26.65,percent of total billed charges,All Other,24.19,65,,24.19,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,20.3,,,20.3,Other,110% of Medicare,27.88,68,,27.88,percent of total billed charges,All Other,0.01,,,0.01,Other,186% of Medicaid,32.8,,,32.8,percent of total billed charges,All Other,34.03,83,,34.03,percent of total billed charges,All Other,34.03,83,,34.03,percent of total billed charges,All Other,32.8,80,,32.8,percent of total billed charges,All Other,34.03,83,,34.03,percent of total billed charges,All Other,32.8,80,,32.8,percent of total billed charges,All Other,28.7,70,,28.7,percent of total billed charges,All Other,170.56,,,170.56,Fee Schedule,,144.56,,,144.56,Fee Schedule,,28.7,70,,28.7,percent of total billed charges,All Other,28.7,70,,28.7,percent of total billed charges,All Other,28.7,70,,28.7,percent of total billed charges,All Other,28.7,70,,28.7,percent of total billed charges,All Other,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,170.56,
PHONE E/M PHYS/QHP 11 TO 20MIN,99442,CPT,,70099442,CDM,510,RC,,,both,,,76,56.24,,,56.24,Other,150% of Medicare + 9.63% HCRA Surcharge,34.2,45,,34.2,percent of total billed charges,Critical Access Hospital RCC factor,49.4,65,,49.4,percent of total billed charges,All Other,44.84,65,,44.84,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,37.62,,,37.62,Other,110% of Medicare,51.68,68,,51.68,percent of total billed charges,All Other,0.01,,,0.01,Other,186% of Medicaid,60.8,,,60.8,percent of total billed charges,All Other,63.08,83,,63.08,percent of total billed charges,All Other,63.08,83,,63.08,percent of total billed charges,All Other,60.8,80,,60.8,percent of total billed charges,All Other,63.08,83,,63.08,percent of total billed charges,All Other,60.8,80,,60.8,percent of total billed charges,All Other,53.2,70,,53.2,percent of total billed charges,All Other,318.16,,,318.16,Fee Schedule,,269.66,,,269.66,Fee Schedule,,53.2,70,,53.2,percent of total billed charges,All Other,53.2,70,,53.2,percent of total billed charges,All Other,53.2,70,,53.2,percent of total billed charges,All Other,53.2,70,,53.2,percent of total billed charges,All Other,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,318.16,
PHONE E/M PHYS/QHP 21 TO 30MIN,99443,CPT,,70099443,CDM,510,RC,,,both,,,120,88.8,,,88.8,Other,150% of Medicare + 9.63% HCRA Surcharge,54,45,,54,percent of total billed charges,Critical Access Hospital RCC factor,78,65,,78,percent of total billed charges,All Other,70.8,65,,70.8,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,59.4,,,59.4,Other,110% of Medicare,81.6,68,,81.6,percent of total billed charges,All Other,0.01,,,0.01,Other,186% of Medicaid,96,,,96,percent of total billed charges,All Other,99.6,83,,99.6,percent of total billed charges,All Other,99.6,83,,99.6,percent of total billed charges,All Other,96,80,,96,percent of total billed charges,All Other,99.6,83,,99.6,percent of total billed charges,All Other,96,80,,96,percent of total billed charges,All Other,84,70,,84,percent of total billed charges,All Other,469.04,,,469.04,Fee Schedule,,397.54,,,397.54,Fee Schedule,,84,70,,84,percent of total billed charges,All Other,84,70,,84,percent of total billed charges,All Other,84,70,,84,percent of total billed charges,All Other,84,70,,84,percent of total billed charges,All Other,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,469.04,
E&M LOW LEVEL,99211,CPT,,82099211,CDM,510,RC,,,both,,,228,168.72,,,168.72,Other,150% of Medicare + 9.63% HCRA Surcharge,102.6,45,,102.6,percent of total billed charges,Critical Access Hospital RCC factor,148.2,65,,148.2,percent of total billed charges,All Other,134.52,65,,134.52,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,112.86,,,112.86,Other,110% of Medicare,155.04,68,,155.04,percent of total billed charges,All Other,0.01,,,0.01,Other,186% of Medicaid,182.4,,,182.4,percent of total billed charges,All Other,189.24,83,,189.24,percent of total billed charges,All Other,189.24,83,,189.24,percent of total billed charges,All Other,182.4,80,,182.4,percent of total billed charges,All Other,189.24,83,,189.24,percent of total billed charges,All Other,182.4,80,,182.4,percent of total billed charges,All Other,159.6,70,,159.6,percent of total billed charges,All Other,42.64,,,42.64,Fee Schedule,,36.14,,,36.14,Fee Schedule,,159.6,70,,159.6,percent of total billed charges,All Other,159.6,70,,159.6,percent of total billed charges,All Other,159.6,70,,159.6,percent of total billed charges,All Other,159.6,70,,159.6,percent of total billed charges,All Other,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,189.24,
PHONE E/M PHYS/QHP 5 TO 10MIN,99441,CPT,,83099441,CDM,510,RC,,,both,,,41,30.34,,,30.34,Other,150% of Medicare + 9.63% HCRA Surcharge,18.45,45,,18.45,percent of total billed charges,Critical Access Hospital RCC factor,26.65,65,,26.65,percent of total billed charges,All Other,24.19,65,,24.19,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,20.3,,,20.3,Other,110% of Medicare,27.88,68,,27.88,percent of total billed charges,All Other,0.01,,,0.01,Other,186% of Medicaid,32.8,,,32.8,percent of total billed charges,All Other,34.03,83,,34.03,percent of total billed charges,All Other,34.03,83,,34.03,percent of total billed charges,All Other,32.8,80,,32.8,percent of total billed charges,All Other,34.03,83,,34.03,percent of total billed charges,All Other,32.8,80,,32.8,percent of total billed charges,All Other,28.7,70,,28.7,percent of total billed charges,All Other,170.56,,,170.56,Fee Schedule,,144.56,,,144.56,Fee Schedule,,28.7,70,,28.7,percent of total billed charges,All Other,28.7,70,,28.7,percent of total billed charges,All Other,28.7,70,,28.7,percent of total billed charges,All Other,28.7,70,,28.7,percent of total billed charges,All Other,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,170.56,
PHONE E/M PHYS/QHP 11 TO 20MIN,99442,CPT,,83099442,CDM,510,RC,,,both,,,76,56.24,,,56.24,Other,150% of Medicare + 9.63% HCRA Surcharge,34.2,45,,34.2,percent of total billed charges,Critical Access Hospital RCC factor,49.4,65,,49.4,percent of total billed charges,All Other,44.84,65,,44.84,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,37.62,,,37.62,Other,110% of Medicare,51.68,68,,51.68,percent of total billed charges,All Other,0.01,,,0.01,Other,186% of Medicaid,60.8,,,60.8,percent of total billed charges,All Other,63.08,83,,63.08,percent of total billed charges,All Other,63.08,83,,63.08,percent of total billed charges,All Other,60.8,80,,60.8,percent of total billed charges,All Other,63.08,83,,63.08,percent of total billed charges,All Other,60.8,80,,60.8,percent of total billed charges,All Other,53.2,70,,53.2,percent of total billed charges,All Other,318.16,,,318.16,Fee Schedule,,269.66,,,269.66,Fee Schedule,,53.2,70,,53.2,percent of total billed charges,All Other,53.2,70,,53.2,percent of total billed charges,All Other,53.2,70,,53.2,percent of total billed charges,All Other,53.2,70,,53.2,percent of total billed charges,All Other,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,318.16,
PHONE E/M PHYS/QHP 21 TO 30MIN,99443,CPT,,83099443,CDM,510,RC,,,both,,,120,88.8,,,88.8,Other,150% of Medicare + 9.63% HCRA Surcharge,54,45,,54,percent of total billed charges,Critical Access Hospital RCC factor,78,65,,78,percent of total billed charges,All Other,70.8,65,,70.8,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,59.4,,,59.4,Other,110% of Medicare,81.6,68,,81.6,percent of total billed charges,All Other,0.01,,,0.01,Other,186% of Medicaid,96,,,96,percent of total billed charges,All Other,99.6,83,,99.6,percent of total billed charges,All Other,99.6,83,,99.6,percent of total billed charges,All Other,96,80,,96,percent of total billed charges,All Other,99.6,83,,99.6,percent of total billed charges,All Other,96,80,,96,percent of total billed charges,All Other,84,70,,84,percent of total billed charges,All Other,469.04,,,469.04,Fee Schedule,,397.54,,,397.54,Fee Schedule,,84,70,,84,percent of total billed charges,All Other,84,70,,84,percent of total billed charges,All Other,84,70,,84,percent of total billed charges,All Other,84,70,,84,percent of total billed charges,All Other,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,469.04,
GROUND MILEAGE PER STATUTE MILE,A0425,HCPCS,,41000002,CDM,540,RC,,,both,,,32,23.68,,,23.68,Other,150% of Medicare + 9.63% HCRA Surcharge,14.4,45,,14.4,percent of total billed charges,Critical Access Hospital RCC factor,20.8,65,,20.8,percent of total billed charges,All Other,18.88,65,,18.88,percent of total billed charges,All Other,19.84,62,,19.84,percent of total billed charges,Ambulance,18.56,56,,18.56,percent of total billed charges,Ambulance,17.92,53,,17.92,percent of total billed charges,Ambulance,15.84,,,15.84,Other,110% of Medicare,21.76,68,,21.76,percent of total billed charges,All Other,0.01,,,0.01,Other,186% of Medicaid,25.6,,,25.6,percent of total billed charges,All Other,26.56,83,,26.56,percent of total billed charges,All Other,26.56,83,,26.56,percent of total billed charges,All Other,25.6,80,,25.6,percent of total billed charges,All Other,26.56,83,,26.56,percent of total billed charges,All Other,25.6,80,,25.6,percent of total billed charges,All Other,22.4,70,,22.4,percent of total billed charges,All Other,20.8,65,,20.8,percent of total billed charges,Default if not in Fee Schedule,20.8,65,,20.8,percent of total billed charges,Default if not in Fee Schedule,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,26.56,
ALS 1 NON-EMERGENCY,A0426,HCPCS,,41000003,CDM,540,RC,,,both,,,1145,847.3,,,847.3,Other,150% of Medicare + 9.63% HCRA Surcharge,515.25,45,,515.25,percent of total billed charges,Critical Access Hospital RCC factor,744.25,65,,744.25,percent of total billed charges,All Other,675.55,65,,675.55,percent of total billed charges,All Other,709.9,62,,709.9,percent of total billed charges,Ambulance,664.1,56,,664.1,percent of total billed charges,Ambulance,641.2,53,,641.2,percent of total billed charges,Ambulance,566.78,,,566.78,Other,110% of Medicare,778.6,68,,778.6,percent of total billed charges,All Other,0.01,,,0.01,Other,186% of Medicaid,916,,,916,percent of total billed charges,All Other,950.35,83,,950.35,percent of total billed charges,All Other,950.35,83,,950.35,percent of total billed charges,All Other,916,80,,916,percent of total billed charges,All Other,950.35,83,,950.35,percent of total billed charges,All Other,916,80,,916,percent of total billed charges,All Other,801.5,70,,801.5,percent of total billed charges,All Other,744.25,65,,744.25,percent of total billed charges,Default if not in Fee Schedule,744.25,65,,744.25,percent of total billed charges,Default if not in Fee Schedule,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,950.35,
ALS1-EMERGENCY,A0427,HCPCS,,41000004,CDM,540,RC,,,both,,,1897,1403.78,,,1403.78,Other,150% of Medicare + 9.63% HCRA Surcharge,853.65,45,,853.65,percent of total billed charges,Critical Access Hospital RCC factor,1233.05,65,,1233.05,percent of total billed charges,All Other,1119.23,65,,1119.23,percent of total billed charges,All Other,1176.14,62,,1176.14,percent of total billed charges,Ambulance,1100.26,56,,1100.26,percent of total billed charges,Ambulance,1062.32,53,,1062.32,percent of total billed charges,Ambulance,939.02,,,939.02,Other,110% of Medicare,1289.96,68,,1289.96,percent of total billed charges,All Other,0.01,,,0.01,Other,186% of Medicaid,1517.6,,,1517.6,percent of total billed charges,All Other,1574.51,83,,1574.51,percent of total billed charges,All Other,1574.51,83,,1574.51,percent of total billed charges,All Other,1517.6,80,,1517.6,percent of total billed charges,All Other,1574.51,83,,1574.51,percent of total billed charges,All Other,1517.6,80,,1517.6,percent of total billed charges,All Other,1327.9,70,,1327.9,percent of total billed charges,All Other,1233.05,65,,1233.05,percent of total billed charges,Default if not in Fee Schedule,1233.05,65,,1233.05,percent of total billed charges,Default if not in Fee Schedule,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1574.51,
BLS - NON-EMERGENT,A0428,HCPCS,,41000005,CDM,540,RC,,,both,,,999,739.26,,,739.26,Other,150% of Medicare + 9.63% HCRA Surcharge,449.55,45,,449.55,percent of total billed charges,Critical Access Hospital RCC factor,649.35,65,,649.35,percent of total billed charges,All Other,589.41,65,,589.41,percent of total billed charges,All Other,619.38,62,,619.38,percent of total billed charges,Ambulance,579.42,56,,579.42,percent of total billed charges,Ambulance,559.44,53,,559.44,percent of total billed charges,Ambulance,494.51,,,494.51,Other,110% of Medicare,679.32,68,,679.32,percent of total billed charges,All Other,0.01,,,0.01,Other,186% of Medicaid,799.2,,,799.2,percent of total billed charges,All Other,829.17,83,,829.17,percent of total billed charges,All Other,829.17,83,,829.17,percent of total billed charges,All Other,799.2,80,,799.2,percent of total billed charges,All Other,829.17,83,,829.17,percent of total billed charges,All Other,799.2,80,,799.2,percent of total billed charges,All Other,699.3,70,,699.3,percent of total billed charges,All Other,649.35,65,,649.35,percent of total billed charges,Default if not in Fee Schedule,649.35,65,,649.35,percent of total billed charges,Default if not in Fee Schedule,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,829.17,
BLS - EMERGENCY,A0429,HCPCS,,41000006,CDM,540,RC,,,both,,,1598,1182.52,,,1182.52,Other,150% of Medicare + 9.63% HCRA Surcharge,719.1,45,,719.1,percent of total billed charges,Critical Access Hospital RCC factor,1038.7,65,,1038.7,percent of total billed charges,All Other,942.82,65,,942.82,percent of total billed charges,All Other,990.76,62,,990.76,percent of total billed charges,Ambulance,926.84,56,,926.84,percent of total billed charges,Ambulance,894.88,53,,894.88,percent of total billed charges,Ambulance,791.01,,,791.01,Other,110% of Medicare,1086.64,68,,1086.64,percent of total billed charges,All Other,0.01,,,0.01,Other,186% of Medicaid,1278.4,,,1278.4,percent of total billed charges,All Other,1326.34,83,,1326.34,percent of total billed charges,All Other,1326.34,83,,1326.34,percent of total billed charges,All Other,1278.4,80,,1278.4,percent of total billed charges,All Other,1326.34,83,,1326.34,percent of total billed charges,All Other,1278.4,80,,1278.4,percent of total billed charges,All Other,1118.6,70,,1118.6,percent of total billed charges,All Other,1038.7,65,,1038.7,percent of total billed charges,Default if not in Fee Schedule,1038.7,65,,1038.7,percent of total billed charges,Default if not in Fee Schedule,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1326.34,
PARAMED INTERCEPT RURAL,A0432,HCPCS,,41000007,CDM,540,RC,,,both,,,1747,1292.78,,,1292.78,Other,150% of Medicare + 9.63% HCRA Surcharge,786.15,45,,786.15,percent of total billed charges,Critical Access Hospital RCC factor,1135.55,65,,1135.55,percent of total billed charges,All Other,1030.73,65,,1030.73,percent of total billed charges,All Other,1083.14,62,,1083.14,percent of total billed charges,Ambulance,1013.26,56,,1013.26,percent of total billed charges,Ambulance,978.32,53,,978.32,percent of total billed charges,Ambulance,864.77,,,864.77,Other,110% of Medicare,1187.96,68,,1187.96,percent of total billed charges,All Other,0.01,,,0.01,Other,186% of Medicaid,1397.6,,,1397.6,percent of total billed charges,All Other,1450.01,83,,1450.01,percent of total billed charges,All Other,1450.01,83,,1450.01,percent of total billed charges,All Other,1397.6,80,,1397.6,percent of total billed charges,All Other,1450.01,83,,1450.01,percent of total billed charges,All Other,1397.6,80,,1397.6,percent of total billed charges,All Other,1222.9,70,,1222.9,percent of total billed charges,All Other,1135.55,65,,1135.55,percent of total billed charges,Default if not in Fee Schedule,1135.55,65,,1135.55,percent of total billed charges,Default if not in Fee Schedule,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1450.01,
ALS 2,A0433,HCPCS,,41000008,CDM,540,RC,,,both,,,2515,1861.11,,,1861.11,Other,150% of Medicare + 9.63% HCRA Surcharge,1131.75,45,,1131.75,percent of total billed charges,Critical Access Hospital RCC factor,1634.75,65,,1634.75,percent of total billed charges,All Other,1483.85,65,,1483.85,percent of total billed charges,All Other,1559.3,62,,1559.3,percent of total billed charges,Ambulance,1458.7,56,,1458.7,percent of total billed charges,Ambulance,1408.4,53,,1408.4,percent of total billed charges,Ambulance,1244.93,,,1244.93,Other,110% of Medicare,1710.2,68,,1710.2,percent of total billed charges,All Other,0.01,,,0.01,Other,186% of Medicaid,2012,,,2012,percent of total billed charges,All Other,2087.45,83,,2087.45,percent of total billed charges,All Other,2087.45,83,,2087.45,percent of total billed charges,All Other,2012,80,,2012,percent of total billed charges,All Other,2087.45,83,,2087.45,percent of total billed charges,All Other,2012,80,,2012,percent of total billed charges,All Other,1760.5,70,,1760.5,percent of total billed charges,All Other,1634.75,65,,1634.75,percent of total billed charges,Default if not in Fee Schedule,1634.75,65,,1634.75,percent of total billed charges,Default if not in Fee Schedule,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2087.45,
SPECIALTY CARE TRANSPORT,A0434,HCPCS,,41000009,CDM,540,RC,,,both,,,2973,2200.03,,,2200.03,Other,150% of Medicare + 9.63% HCRA Surcharge,1337.85,45,,1337.85,percent of total billed charges,Critical Access Hospital RCC factor,1932.45,65,,1932.45,percent of total billed charges,All Other,1754.07,65,,1754.07,percent of total billed charges,All Other,1843.26,62,,1843.26,percent of total billed charges,Ambulance,1724.34,56,,1724.34,percent of total billed charges,Ambulance,1664.88,53,,1664.88,percent of total billed charges,Ambulance,1471.64,,,1471.64,Other,110% of Medicare,2021.64,68,,2021.64,percent of total billed charges,All Other,0.01,,,0.01,Other,186% of Medicaid,2378.4,,,2378.4,percent of total billed charges,All Other,2467.59,83,,2467.59,percent of total billed charges,All Other,2467.59,83,,2467.59,percent of total billed charges,All Other,2378.4,80,,2378.4,percent of total billed charges,All Other,2467.59,83,,2467.59,percent of total billed charges,All Other,2378.4,80,,2378.4,percent of total billed charges,All Other,2081.1,70,,2081.1,percent of total billed charges,All Other,1932.45,65,,1932.45,percent of total billed charges,Default if not in Fee Schedule,1932.45,65,,1932.45,percent of total billed charges,Default if not in Fee Schedule,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,2467.59,
AMB RESPOND AND TREAT; NO TRANSPORT,A0998,HCPCS,GY,41000010,CDM,540,RC,,,both,,,161,119.14,,,119.14,Other,150% of Medicare + 9.63% HCRA Surcharge,72.45,45,,72.45,percent of total billed charges,Critical Access Hospital RCC factor,104.65,65,,104.65,percent of total billed charges,All Other,94.99,65,,94.99,percent of total billed charges,All Other,99.82,62,,99.82,percent of total billed charges,Ambulance,93.38,56,,93.38,percent of total billed charges,Ambulance,90.16,53,,90.16,percent of total billed charges,Ambulance,79.7,,,79.7,Other,110% of Medicare,109.48,68,,109.48,percent of total billed charges,All Other,0.01,,,0.01,Other,186% of Medicaid,128.8,,,128.8,percent of total billed charges,All Other,133.63,83,,133.63,percent of total billed charges,All Other,133.63,83,,133.63,percent of total billed charges,All Other,128.8,80,,128.8,percent of total billed charges,All Other,133.63,83,,133.63,percent of total billed charges,All Other,128.8,80,,128.8,percent of total billed charges,All Other,112.7,70,,112.7,percent of total billed charges,All Other,104.65,65,,104.65,percent of total billed charges,Default if not in Fee Schedule,104.65,65,,104.65,percent of total billed charges,Default if not in Fee Schedule,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,133.63,
ALS/BLS O2 & SUPPLIES,A0422,HCPCS,,41000001,CDM,544,RC,,,both,,,29,21.46,,,21.46,Other,150% of Medicare + 9.63% HCRA Surcharge,13.05,45,,13.05,percent of total billed charges,Critical Access Hospital RCC factor,18.85,65,,18.85,percent of total billed charges,All Other,17.11,65,,17.11,percent of total billed charges,All Other,17.98,62,,17.98,percent of total billed charges,Ambulance,16.82,56,,16.82,percent of total billed charges,Ambulance,16.24,53,,16.24,percent of total billed charges,Ambulance,14.36,,,14.36,Other,110% of Medicare,19.72,68,,19.72,percent of total billed charges,All Other,0.01,,,0.01,Other,186% of Medicaid,23.2,,,23.2,percent of total billed charges,All Other,24.07,83,,24.07,percent of total billed charges,All Other,24.07,83,,24.07,percent of total billed charges,All Other,23.2,80,,23.2,percent of total billed charges,All Other,24.07,83,,24.07,percent of total billed charges,All Other,23.2,80,,23.2,percent of total billed charges,All Other,20.3,70,,20.3,percent of total billed charges,All Other,18.85,65,,18.85,percent of total billed charges,Default if not in Fee Schedule,18.85,65,,18.85,percent of total billed charges,Default if not in Fee Schedule,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,24.07,
MRI BREAST W AND WO CONTRAST LT,C8905,HCPCS,TCLT,45000005,CDM,610,RC,,,both,,,3440,2545.61,,,2545.61,Other,150% of Medicare + 9.63% HCRA Surcharge,1548,45,,1548,percent of total billed charges,Critical Access Hospital RCC factor,2236,65,,2236,percent of total billed charges,All Other,2029.6,65,,2029.6,percent of total billed charges,All Other,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,1702.8,,,1702.8,Other,110% of Medicare,2339.2,68,,2339.2,percent of total billed charges,All Other,1010,,,1010,Other,186% of Medicaid,2752,,,2752,percent of total billed charges,All Other,2132.8,62,,2132.8,percent of total billed charges,Lab and Radiology,1892,55,,1892,percent of total billed charges,Default if not on Fee Schedule,2752,80,,2752,percent of total billed charges,All Other,2132.8,62,,2132.8,percent of total billed charges,Lab and Radiology,2752,80,,2752,percent of total billed charges,All Other,2408,70,,2408,percent of total billed charges,All Other,2236,65,,2236,percent of total billed charges,Default if not in Fee Schedule,2236,65,,2236,percent of total billed charges,Default if not in Fee Schedule,610.96,,,610.96,Fee Schedule,,610.96,,,610.96,Fee Schedule,,610.96,,,610.96,Fee Schedule,,610.96,,,610.96,Fee Schedule,,542.99,,,542.99,Other,100% of Medicaid,542.99,,,542.99,Other,100% of Medicaid,542.99,,,542.99,Other,100% of Medicaid,542.99,,,542.99,Other,100% of Medicaid,1221.72,,,1221.72,Other,225% of Medicaid,830.77,,,830.77,Other,153% of Medicaid,1221.72,,,1221.72,Other,225% of Medicaid,760.18,,,760.18,Other,140% of Medicaid,1221.72,,,1221.72,Other,225% of Medicaid,1411.76,,,1411.76,Other,260% of Medicaid,1759.27,,,1759.27,Other,324% of Medicaid,1167.42,,,1167.42,Other,215% of Medicaid,1167.42,,,1167.42,Other,215% of Medicaid,678.73,,,678.73,Other,125% of Medicaid,0.01,2752,
MRI BREAST W AND WO CONTRAST RT,C8905,HCPCS,TCRT,45000006,CDM,610,RC,,,both,,,3440,2545.61,,,2545.61,Other,150% of Medicare + 9.63% HCRA Surcharge,1548,45,,1548,percent of total billed charges,Critical Access Hospital RCC factor,2236,65,,2236,percent of total billed charges,All Other,2029.6,65,,2029.6,percent of total billed charges,All Other,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,1702.8,,,1702.8,Other,110% of Medicare,2339.2,68,,2339.2,percent of total billed charges,All Other,1010,,,1010,Other,186% of Medicaid,2752,,,2752,percent of total billed charges,All Other,2132.8,62,,2132.8,percent of total billed charges,Lab and Radiology,1892,55,,1892,percent of total billed charges,Default if not on Fee Schedule,2752,80,,2752,percent of total billed charges,All Other,2132.8,62,,2132.8,percent of total billed charges,Lab and Radiology,2752,80,,2752,percent of total billed charges,All Other,2408,70,,2408,percent of total billed charges,All Other,2236,65,,2236,percent of total billed charges,Default if not in Fee Schedule,2236,65,,2236,percent of total billed charges,Default if not in Fee Schedule,610.96,,,610.96,Fee Schedule,,610.96,,,610.96,Fee Schedule,,610.96,,,610.96,Fee Schedule,,610.96,,,610.96,Fee Schedule,,542.99,,,542.99,Other,100% of Medicaid,542.99,,,542.99,Other,100% of Medicaid,542.99,,,542.99,Other,100% of Medicaid,542.99,,,542.99,Other,100% of Medicaid,1221.72,,,1221.72,Other,225% of Medicaid,830.77,,,830.77,Other,153% of Medicaid,1221.72,,,1221.72,Other,225% of Medicaid,760.18,,,760.18,Other,140% of Medicaid,1221.72,,,1221.72,Other,225% of Medicaid,1411.76,,,1411.76,Other,260% of Medicaid,1759.27,,,1759.27,Other,324% of Medicaid,1167.42,,,1167.42,Other,215% of Medicaid,1167.42,,,1167.42,Other,215% of Medicaid,678.73,,,678.73,Other,125% of Medicaid,0.01,2752,
MRI BREAST W AND WO CONTRAST BILAT,C8908,HCPCS,TC,45000007,CDM,610,RC,,,both,,,5159,3817.67,,,3817.67,Other,150% of Medicare + 9.63% HCRA Surcharge,2321.55,45,,2321.55,percent of total billed charges,Critical Access Hospital RCC factor,3353.35,65,,3353.35,percent of total billed charges,All Other,3043.81,65,,3043.81,percent of total billed charges,All Other,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,2553.71,,,2553.71,Other,110% of Medicare,3508.12,68,,3508.12,percent of total billed charges,All Other,1010,,,1010,Other,186% of Medicaid,4127.2,,,4127.2,percent of total billed charges,All Other,3198.58,62,,3198.58,percent of total billed charges,Lab and Radiology,2837.45,55,,2837.45,percent of total billed charges,Default if not on Fee Schedule,4127.2,80,,4127.2,percent of total billed charges,All Other,3198.58,62,,3198.58,percent of total billed charges,Lab and Radiology,4127.2,80,,4127.2,percent of total billed charges,All Other,3611.3,70,,3611.3,percent of total billed charges,All Other,3353.35,65,,3353.35,percent of total billed charges,Default if not in Fee Schedule,3353.35,65,,3353.35,percent of total billed charges,Default if not in Fee Schedule,610.96,,,610.96,Fee Schedule,,610.96,,,610.96,Fee Schedule,,610.96,,,610.96,Fee Schedule,,610.96,,,610.96,Fee Schedule,,542.99,,,542.99,Other,100% of Medicaid,542.99,,,542.99,Other,100% of Medicaid,542.99,,,542.99,Other,100% of Medicaid,542.99,,,542.99,Other,100% of Medicaid,1221.72,,,1221.72,Other,225% of Medicaid,830.77,,,830.77,Other,153% of Medicaid,1221.72,,,1221.72,Other,225% of Medicaid,760.18,,,760.18,Other,140% of Medicaid,1221.72,,,1221.72,Other,225% of Medicaid,1411.76,,,1411.76,Other,260% of Medicaid,1759.27,,,1759.27,Other,324% of Medicaid,1167.42,,,1167.42,Other,215% of Medicaid,1167.42,,,1167.42,Other,215% of Medicaid,678.73,,,678.73,Other,125% of Medicaid,0.01,4127.2,
MRI TEMPOROMANDIBULAR JOINT,70336,CPT,TC,45070336,CDM,610,RC,,,both,,,2847,2106.79,,,2106.79,Other,150% of Medicare + 9.63% HCRA Surcharge,1281.15,45,,1281.15,percent of total billed charges,Critical Access Hospital RCC factor,702.73,,,702.73,Fee Schedule,,632.23,,,632.23,Fee Schedule,,2309.05,,,2309.05,Fee Schedule,,2076.83,,,2076.83,Fee Schedule,,1962.91,,,1962.91,Fee Schedule,,1409.27,,,1409.27,Other,110% of Medicare,834.9,,,834.9,Fee Schedule,,670,,,670,Other,186% of Medicaid,982.49,,,982.49,Fee Schedule,,1765.14,,,1765.14,Fee Schedule,,462.61,,,462.61,Fee Schedule,,982.49,,,982.49,Fee Schedule,,1765.14,,,1765.14,Fee Schedule,,870.15,,,870.15,Fee Schedule,,1992.9,70,,1992.9,percent of total billed charges,All Other,1772,,,1772,Case Rate,,1506,,,1506,Case Rate,,372.86,,,372.86,Fee Schedule,,372.86,,,372.86,Fee Schedule,,372.86,,,372.86,Fee Schedule,,372.86,,,372.86,Fee Schedule,,360.02,,,360.02,Other,100% of Medicaid,360.02,,,360.02,Other,100% of Medicaid,360.02,,,360.02,Other,100% of Medicaid,360.02,,,360.02,Other,100% of Medicaid,810.04,,,810.04,Other,225% of Medicaid,550.82,,,550.82,Other,153% of Medicaid,810.04,,,810.04,Other,225% of Medicaid,504.02,,,504.02,Other,140% of Medicaid,810.04,,,810.04,Other,225% of Medicaid,936.04,,,936.04,Other,260% of Medicaid,1166.45,,,1166.45,Other,324% of Medicaid,774.04,,,774.04,Other,215% of Medicaid,774.04,,,774.04,Other,215% of Medicaid,450.02,,,450.02,Other,125% of Medicaid,360.02,2309.05,
MRI ORBIT FACE NECK WO CONTRAST,70540,CPT,TC,45070540,CDM,610,RC,,,both,,,2660,1968.41,,,1968.41,Other,150% of Medicare + 9.63% HCRA Surcharge,1197,45,,1197,percent of total billed charges,Critical Access Hospital RCC factor,588.36,,,588.36,Fee Schedule,,529.34,,,529.34,Fee Schedule,,2311.32,,,2311.32,Fee Schedule,,2078.87,,,2078.87,Fee Schedule,,1964.84,,,1964.84,Fee Schedule,,1316.7,,,1316.7,Other,110% of Medicare,699.03,,,699.03,Fee Schedule,,670,,,670,Other,186% of Medicaid,822.6,,,822.6,Fee Schedule,,1649.2,,,1649.2,Fee Schedule,,387.32,,,387.32,Fee Schedule,,822.6,,,822.6,Fee Schedule,,1649.2,,,1649.2,Fee Schedule,,728.54,,,728.54,Fee Schedule,,1862,70,,1862,percent of total billed charges,All Other,1772,,,1772,Case Rate,,1506,,,1506,Case Rate,,372.86,,,372.86,Fee Schedule,,372.86,,,372.86,Fee Schedule,,372.86,,,372.86,Fee Schedule,,372.86,,,372.86,Fee Schedule,,360.02,,,360.02,Other,100% of Medicaid,360.02,,,360.02,Other,100% of Medicaid,360.02,,,360.02,Other,100% of Medicaid,360.02,,,360.02,Other,100% of Medicaid,810.04,,,810.04,Other,225% of Medicaid,550.82,,,550.82,Other,153% of Medicaid,810.04,,,810.04,Other,225% of Medicaid,504.02,,,504.02,Other,140% of Medicaid,810.04,,,810.04,Other,225% of Medicaid,936.04,,,936.04,Other,260% of Medicaid,1166.45,,,1166.45,Other,324% of Medicaid,774.04,,,774.04,Other,215% of Medicaid,774.04,,,774.04,Other,215% of Medicaid,450.02,,,450.02,Other,125% of Medicaid,360.02,2311.32,
MRI ORBIT FACE NECK W CONTRAST,70542,CPT,TC,45070542,CDM,610,RC,,,both,,,3504,2592.97,,,2592.97,Other,150% of Medicare + 9.63% HCRA Surcharge,1576.8,45,,1576.8,percent of total billed charges,Critical Access Hospital RCC factor,694.81,,,694.81,Fee Schedule,,625.11,,,625.11,Fee Schedule,,2942.87,,,2942.87,Fee Schedule,,2646.91,,,2646.91,Fee Schedule,,2501.72,,,2501.72,Fee Schedule,,1734.48,,,1734.48,Other,110% of Medicare,825.5,,,825.5,Fee Schedule,,1010,,,1010,Other,186% of Medicaid,971.43,,,971.43,Fee Schedule,,2172.48,,,2172.48,Fee Schedule,,457.4,,,457.4,Fee Schedule,,971.43,,,971.43,Fee Schedule,,2172.48,,,2172.48,Fee Schedule,,860.35,,,860.35,Fee Schedule,,2452.8,70,,2452.8,percent of total billed charges,All Other,1772,,,1772,Case Rate,,1506,,,1506,Case Rate,,610.96,,,610.96,Fee Schedule,,610.96,,,610.96,Fee Schedule,,610.96,,,610.96,Fee Schedule,,610.96,,,610.96,Fee Schedule,,542.99,,,542.99,Other,100% of Medicaid,542.99,,,542.99,Other,100% of Medicaid,542.99,,,542.99,Other,100% of Medicaid,542.99,,,542.99,Other,100% of Medicaid,1221.72,,,1221.72,Other,225% of Medicaid,830.77,,,830.77,Other,153% of Medicaid,1221.72,,,1221.72,Other,225% of Medicaid,760.18,,,760.18,Other,140% of Medicaid,1221.72,,,1221.72,Other,225% of Medicaid,1411.76,,,1411.76,Other,260% of Medicaid,1759.27,,,1759.27,Other,324% of Medicaid,1167.42,,,1167.42,Other,215% of Medicaid,1167.42,,,1167.42,Other,215% of Medicaid,678.73,,,678.73,Other,125% of Medicaid,457.4,2942.87,
MRI ORBIT FACE NECK  W WO CONT,70543,CPT,TC,45070543,CDM,610,RC,,,both,,,4261,3153.15,,,3153.15,Other,150% of Medicare + 9.63% HCRA Surcharge,1917.45,45,,1917.45,percent of total billed charges,Critical Access Hospital RCC factor,860.02,,,860.02,Fee Schedule,,773.75,,,773.75,Fee Schedule,,3595.09,,,3595.09,Fee Schedule,,3233.53,,,3233.53,Fee Schedule,,3056.17,,,3056.17,Fee Schedule,,2109.2,,,2109.2,Other,110% of Medicare,1021.78,,,1021.78,Fee Schedule,,1010,,,1010,Other,186% of Medicaid,1202.42,,,1202.42,Fee Schedule,,2641.82,,,2641.82,Fee Schedule,,566.16,,,566.16,Fee Schedule,,1202.42,,,1202.42,Fee Schedule,,2641.82,,,2641.82,Fee Schedule,,1064.92,,,1064.92,Fee Schedule,,2982.7,70,,2982.7,percent of total billed charges,All Other,1772,,,1772,Case Rate,,1506,,,1506,Case Rate,,610.96,,,610.96,Fee Schedule,,610.96,,,610.96,Fee Schedule,,610.96,,,610.96,Fee Schedule,,610.96,,,610.96,Fee Schedule,,542.99,,,542.99,Other,100% of Medicaid,542.99,,,542.99,Other,100% of Medicaid,542.99,,,542.99,Other,100% of Medicaid,542.99,,,542.99,Other,100% of Medicaid,1221.72,,,1221.72,Other,225% of Medicaid,830.77,,,830.77,Other,153% of Medicaid,1221.72,,,1221.72,Other,225% of Medicaid,760.18,,,760.18,Other,140% of Medicaid,1221.72,,,1221.72,Other,225% of Medicaid,1411.76,,,1411.76,Other,260% of Medicaid,1759.27,,,1759.27,Other,324% of Medicaid,1167.42,,,1167.42,Other,215% of Medicaid,1167.42,,,1167.42,Other,215% of Medicaid,678.73,,,678.73,Other,125% of Medicaid,542.99,3595.09,
MRA NECK W CONTRAST,70548,CPT,TC,45070548,CDM,610,RC,,,both,,,2873,2126.03,,,2126.03,Other,150% of Medicare + 9.63% HCRA Surcharge,1292.85,45,,1292.85,percent of total billed charges,Critical Access Hospital RCC factor,634.75,,,634.75,Fee Schedule,,571.07,,,571.07,Fee Schedule,,2942.87,,,2942.87,Fee Schedule,,2646.91,,,2646.91,Fee Schedule,,2501.72,,,2501.72,Fee Schedule,,1422.14,,,1422.14,Other,110% of Medicare,754.13,,,754.13,Fee Schedule,,858,,,858,Other,186% of Medicaid,887.45,,,887.45,Fee Schedule,,1781.26,,,1781.26,Fee Schedule,,417.86,,,417.86,Fee Schedule,,887.45,,,887.45,Fee Schedule,,1781.26,,,1781.26,Fee Schedule,,785.97,,,785.97,Fee Schedule,,2011.1,70,,2011.1,percent of total billed charges,All Other,1772,,,1772,Case Rate,,1506,,,1506,Case Rate,,610.96,,,610.96,Fee Schedule,,610.96,,,610.96,Fee Schedule,,610.96,,,610.96,Fee Schedule,,610.96,,,610.96,Fee Schedule,,461.02,,,461.02,Other,100% of Medicaid,461.02,,,461.02,Other,100% of Medicaid,461.02,,,461.02,Other,100% of Medicaid,461.02,,,461.02,Other,100% of Medicaid,1037.31,,,1037.31,Other,225% of Medicaid,705.37,,,705.37,Other,153% of Medicaid,1037.31,,,1037.31,Other,225% of Medicaid,645.43,,,645.43,Other,140% of Medicaid,1037.31,,,1037.31,Other,225% of Medicaid,1198.66,,,1198.66,Other,260% of Medicaid,1493.72,,,1493.72,Other,324% of Medicaid,991.2,,,991.2,Other,215% of Medicaid,991.2,,,991.2,Other,215% of Medicaid,576.28,,,576.28,Other,125% of Medicaid,417.86,2942.87,
MRI CHEST WO CONTRAST,71550,CPT,TC,45071550,CDM,610,RC,,,both,,,3409,2522.67,,,2522.67,Other,150% of Medicare + 9.63% HCRA Surcharge,1534.05,45,,1534.05,percent of total billed charges,Critical Access Hospital RCC factor,824.2,,,824.2,Fee Schedule,,741.52,,,741.52,Fee Schedule,,2311.32,,,2311.32,Fee Schedule,,2078.87,,,2078.87,Fee Schedule,,1964.84,,,1964.84,Fee Schedule,,1687.46,,,1687.46,Other,110% of Medicare,979.22,,,979.22,Fee Schedule,,670,,,670,Other,186% of Medicaid,1152.33,,,1152.33,Fee Schedule,,2113.58,,,2113.58,Fee Schedule,,542.58,,,542.58,Fee Schedule,,1152.33,,,1152.33,Fee Schedule,,2113.58,,,2113.58,Fee Schedule,,1020.56,,,1020.56,Fee Schedule,,2386.3,70,,2386.3,percent of total billed charges,All Other,1772,,,1772,Case Rate,,1506,,,1506,Case Rate,,372.86,,,372.86,Fee Schedule,,372.86,,,372.86,Fee Schedule,,372.86,,,372.86,Fee Schedule,,372.86,,,372.86,Fee Schedule,,360.02,,,360.02,Other,100% of Medicaid,360.02,,,360.02,Other,100% of Medicaid,360.02,,,360.02,Other,100% of Medicaid,360.02,,,360.02,Other,100% of Medicaid,810.04,,,810.04,Other,225% of Medicaid,550.82,,,550.82,Other,153% of Medicaid,810.04,,,810.04,Other,225% of Medicaid,504.02,,,504.02,Other,140% of Medicaid,810.04,,,810.04,Other,225% of Medicaid,936.04,,,936.04,Other,260% of Medicaid,1166.45,,,1166.45,Other,324% of Medicaid,774.04,,,774.04,Other,215% of Medicaid,774.04,,,774.04,Other,215% of Medicaid,450.02,,,450.02,Other,125% of Medicaid,360.02,2522.67,
MRI CHEST W CONTRAST,71551,CPT,TC,45071551,CDM,610,RC,,,both,,,3215,2379.11,,,2379.11,Other,150% of Medicare + 9.63% HCRA Surcharge,1446.75,45,,1446.75,percent of total billed charges,Critical Access Hospital RCC factor,1051.81,,,1051.81,Fee Schedule,,946.3,,,946.3,Fee Schedule,,2942.87,,,2942.87,Fee Schedule,,2646.91,,,2646.91,Fee Schedule,,2501.72,,,2501.72,Fee Schedule,,1591.43,,,1591.43,Other,110% of Medicare,1249.64,,,1249.64,Fee Schedule,,1010,,,1010,Other,186% of Medicaid,1470.55,,,1470.55,Fee Schedule,,1993.3,,,1993.3,Fee Schedule,,692.41,,,692.41,Fee Schedule,,1470.55,,,1470.55,Fee Schedule,,1993.3,,,1993.3,Fee Schedule,,1415.17,,,1415.17,Fee Schedule,,2250.5,70,,2250.5,percent of total billed charges,All Other,1772,,,1772,Case Rate,,1506,,,1506,Case Rate,,1089.31,,,1089.31,Fee Schedule,,1089.31,,,1089.31,Fee Schedule,,1089.31,,,1089.31,Fee Schedule,,1089.31,,,1089.31,Fee Schedule,,542.99,,,542.99,Other,100% of Medicaid,542.99,,,542.99,Other,100% of Medicaid,542.99,,,542.99,Other,100% of Medicaid,542.99,,,542.99,Other,100% of Medicaid,1221.72,,,1221.72,Other,225% of Medicaid,830.77,,,830.77,Other,153% of Medicaid,1221.72,,,1221.72,Other,225% of Medicaid,760.18,,,760.18,Other,140% of Medicaid,1221.72,,,1221.72,Other,225% of Medicaid,1411.76,,,1411.76,Other,260% of Medicaid,1759.27,,,1759.27,Other,324% of Medicaid,1167.42,,,1167.42,Other,215% of Medicaid,1167.42,,,1167.42,Other,215% of Medicaid,678.73,,,678.73,Other,125% of Medicaid,542.99,2942.87,
MRI CHEST W AND WO CONTRAST,71552,CPT,TC,45071552,CDM,610,RC,,,both,,,4261,3153.15,,,3153.15,Other,150% of Medicare + 9.63% HCRA Surcharge,1917.45,45,,1917.45,percent of total billed charges,Critical Access Hospital RCC factor,1293.42,,,1293.42,Fee Schedule,,1163.67,,,1163.67,Fee Schedule,,3595.09,,,3595.09,Fee Schedule,,3233.53,,,3233.53,Fee Schedule,,3056.17,,,3056.17,Fee Schedule,,2109.2,,,2109.2,Other,110% of Medicare,1536.69,,,1536.69,Fee Schedule,,1010,,,1010,Other,186% of Medicaid,1808.35,,,1808.35,Fee Schedule,,2641.82,,,2641.82,Fee Schedule,,851.47,,,851.47,Fee Schedule,,1808.35,,,1808.35,Fee Schedule,,2641.82,,,2641.82,Fee Schedule,,1601.57,,,1601.57,Fee Schedule,,2982.7,70,,2982.7,percent of total billed charges,All Other,1772,,,1772,Case Rate,,1506,,,1506,Case Rate,,610.96,,,610.96,Fee Schedule,,610.96,,,610.96,Fee Schedule,,610.96,,,610.96,Fee Schedule,,610.96,,,610.96,Fee Schedule,,542.99,,,542.99,Other,100% of Medicaid,542.99,,,542.99,Other,100% of Medicaid,542.99,,,542.99,Other,100% of Medicaid,542.99,,,542.99,Other,100% of Medicaid,1221.72,,,1221.72,Other,225% of Medicaid,830.77,,,830.77,Other,153% of Medicaid,1221.72,,,1221.72,Other,225% of Medicaid,760.18,,,760.18,Other,140% of Medicaid,1221.72,,,1221.72,Other,225% of Medicaid,1411.76,,,1411.76,Other,260% of Medicaid,1759.27,,,1759.27,Other,324% of Medicaid,1167.42,,,1167.42,Other,215% of Medicaid,1167.42,,,1167.42,Other,215% of Medicaid,678.73,,,678.73,Other,125% of Medicaid,542.99,3595.09,
MRI PELVIS WO CONTRAST,72195,CPT,TC,45072195,CDM,610,RC,,,both,,,2898,2144.53,,,2144.53,Other,150% of Medicare + 9.63% HCRA Surcharge,1304.1,45,,1304.1,percent of total billed charges,Critical Access Hospital RCC factor,579.11,,,579.11,Fee Schedule,,521.02,,,521.02,Fee Schedule,,2311.32,,,2311.32,Fee Schedule,,2078.87,,,2078.87,Fee Schedule,,1964.84,,,1964.84,Fee Schedule,,1434.51,,,1434.51,Other,110% of Medicare,688.04,,,688.04,Fee Schedule,,670,,,670,Other,186% of Medicaid,809.67,,,809.67,Fee Schedule,,1796.76,,,1796.76,Fee Schedule,,381.23,,,381.23,Fee Schedule,,809.67,,,809.67,Fee Schedule,,1796.76,,,1796.76,Fee Schedule,,717.08,,,717.08,Fee Schedule,,2028.6,70,,2028.6,percent of total billed charges,All Other,1772,,,1772,Case Rate,,1506,,,1506,Case Rate,,372.86,,,372.86,Fee Schedule,,372.86,,,372.86,Fee Schedule,,372.86,,,372.86,Fee Schedule,,372.86,,,372.86,Fee Schedule,,360.02,,,360.02,Other,100% of Medicaid,360.02,,,360.02,Other,100% of Medicaid,360.02,,,360.02,Other,100% of Medicaid,360.02,,,360.02,Other,100% of Medicaid,810.04,,,810.04,Other,225% of Medicaid,550.82,,,550.82,Other,153% of Medicaid,810.04,,,810.04,Other,225% of Medicaid,504.02,,,504.02,Other,140% of Medicaid,810.04,,,810.04,Other,225% of Medicaid,936.04,,,936.04,Other,260% of Medicaid,1166.45,,,1166.45,Other,324% of Medicaid,774.04,,,774.04,Other,215% of Medicaid,774.04,,,774.04,Other,215% of Medicaid,450.02,,,450.02,Other,125% of Medicaid,360.02,2311.32,
MRI PELVIS W CONTRAST,72196,CPT,TC,45072196,CDM,610,RC,,,both,,,2712,2006.89,,,2006.89,Other,150% of Medicare + 9.63% HCRA Surcharge,1220.4,45,,1220.4,percent of total billed charges,Critical Access Hospital RCC factor,677.49,,,677.49,Fee Schedule,,609.53,,,609.53,Fee Schedule,,2942.87,,,2942.87,Fee Schedule,,2646.91,,,2646.91,Fee Schedule,,2501.72,,,2501.72,Fee Schedule,,1342.44,,,1342.44,Other,110% of Medicare,804.92,,,804.92,Fee Schedule,,1010,,,1010,Other,186% of Medicaid,947.21,,,947.21,Fee Schedule,,1681.44,,,1681.44,Fee Schedule,,446,,,446,Fee Schedule,,947.21,,,947.21,Fee Schedule,,1681.44,,,1681.44,Fee Schedule,,838.9,,,838.9,Fee Schedule,,1898.4,70,,1898.4,percent of total billed charges,All Other,1772,,,1772,Case Rate,,1506,,,1506,Case Rate,,610.96,,,610.96,Fee Schedule,,610.96,,,610.96,Fee Schedule,,610.96,,,610.96,Fee Schedule,,610.96,,,610.96,Fee Schedule,,542.99,,,542.99,Other,100% of Medicaid,542.99,,,542.99,Other,100% of Medicaid,542.99,,,542.99,Other,100% of Medicaid,542.99,,,542.99,Other,100% of Medicaid,1221.72,,,1221.72,Other,225% of Medicaid,830.77,,,830.77,Other,153% of Medicaid,1221.72,,,1221.72,Other,225% of Medicaid,760.18,,,760.18,Other,140% of Medicaid,1221.72,,,1221.72,Other,225% of Medicaid,1411.76,,,1411.76,Other,260% of Medicaid,1759.27,,,1759.27,Other,324% of Medicaid,1167.42,,,1167.42,Other,215% of Medicaid,1167.42,,,1167.42,Other,215% of Medicaid,678.73,,,678.73,Other,125% of Medicaid,446,2942.87,
MRI PELVIS W AND WO CONTRAST,72197,CPT,TC,45072197,CDM,610,RC,,,both,,,4261,3153.15,,,3153.15,Other,150% of Medicare + 9.63% HCRA Surcharge,1917.45,45,,1917.45,percent of total billed charges,Critical Access Hospital RCC factor,845,,,845,Fee Schedule,,760.23,,,760.23,Fee Schedule,,3595.09,,,3595.09,Fee Schedule,,3233.53,,,3233.53,Fee Schedule,,3056.17,,,3056.17,Fee Schedule,,2109.2,,,2109.2,Other,110% of Medicare,1003.93,,,1003.93,Fee Schedule,,1010,,,1010,Other,186% of Medicaid,1181.41,,,1181.41,Fee Schedule,,2641.82,,,2641.82,Fee Schedule,,556.27,,,556.27,Fee Schedule,,1181.41,,,1181.41,Fee Schedule,,2641.82,,,2641.82,Fee Schedule,,1046.32,,,1046.32,Fee Schedule,,2982.7,70,,2982.7,percent of total billed charges,All Other,1772,,,1772,Case Rate,,1506,,,1506,Case Rate,,610.96,,,610.96,Fee Schedule,,610.96,,,610.96,Fee Schedule,,610.96,,,610.96,Fee Schedule,,610.96,,,610.96,Fee Schedule,,542.99,,,542.99,Other,100% of Medicaid,542.99,,,542.99,Other,100% of Medicaid,542.99,,,542.99,Other,100% of Medicaid,542.99,,,542.99,Other,100% of Medicaid,1221.72,,,1221.72,Other,225% of Medicaid,830.77,,,830.77,Other,153% of Medicaid,1221.72,,,1221.72,Other,225% of Medicaid,760.18,,,760.18,Other,140% of Medicaid,1221.72,,,1221.72,Other,225% of Medicaid,1411.76,,,1411.76,Other,260% of Medicaid,1759.27,,,1759.27,Other,324% of Medicaid,1167.42,,,1167.42,Other,215% of Medicaid,1167.42,,,1167.42,Other,215% of Medicaid,678.73,,,678.73,Other,125% of Medicaid,542.99,3595.09,
MRI ABDOMEN WO CONTRAST,74181,CPT,TC,45074181,CDM,610,RC,,,both,,,2898,2144.53,,,2144.53,Other,150% of Medicare + 9.63% HCRA Surcharge,1304.1,45,,1304.1,percent of total billed charges,Critical Access Hospital RCC factor,461.27,,,461.27,Fee Schedule,,415,,,415,Fee Schedule,,2309.05,,,2309.05,Fee Schedule,,2076.83,,,2076.83,Fee Schedule,,1962.91,,,1962.91,Fee Schedule,,1434.51,,,1434.51,Other,110% of Medicare,548.03,,,548.03,Fee Schedule,,670,,,670,Other,186% of Medicaid,644.92,,,644.92,Fee Schedule,,1796.76,,,1796.76,Fee Schedule,,303.66,,,303.66,Fee Schedule,,644.92,,,644.92,Fee Schedule,,1796.76,,,1796.76,Fee Schedule,,571.17,,,571.17,Fee Schedule,,2028.6,70,,2028.6,percent of total billed charges,All Other,1772,,,1772,Case Rate,,1506,,,1506,Case Rate,,372.86,,,372.86,Fee Schedule,,372.86,,,372.86,Fee Schedule,,372.86,,,372.86,Fee Schedule,,372.86,,,372.86,Fee Schedule,,360.02,,,360.02,Other,100% of Medicaid,360.02,,,360.02,Other,100% of Medicaid,360.02,,,360.02,Other,100% of Medicaid,360.02,,,360.02,Other,100% of Medicaid,810.04,,,810.04,Other,225% of Medicaid,550.82,,,550.82,Other,153% of Medicaid,810.04,,,810.04,Other,225% of Medicaid,504.02,,,504.02,Other,140% of Medicaid,810.04,,,810.04,Other,225% of Medicaid,936.04,,,936.04,Other,260% of Medicaid,1166.45,,,1166.45,Other,324% of Medicaid,774.04,,,774.04,Other,215% of Medicaid,774.04,,,774.04,Other,215% of Medicaid,450.02,,,450.02,Other,125% of Medicaid,303.66,2309.05,
MRI ABDOMEN W CONTRAST,74182,CPT,TC,45074182,CDM,610,RC,,,both,,,2992,2214.09,,,2214.09,Other,150% of Medicare + 9.63% HCRA Surcharge,1346.4,45,,1346.4,percent of total billed charges,Critical Access Hospital RCC factor,798.81,,,798.81,Fee Schedule,,718.68,,,718.68,Fee Schedule,,2942.87,,,2942.87,Fee Schedule,,2646.91,,,2646.91,Fee Schedule,,2501.72,,,2501.72,Fee Schedule,,1481.04,,,1481.04,Other,110% of Medicare,949.05,,,949.05,Fee Schedule,,1010,,,1010,Other,186% of Medicaid,1116.83,,,1116.83,Fee Schedule,,1855.04,,,1855.04,Fee Schedule,,525.86,,,525.86,Fee Schedule,,1116.83,,,1116.83,Fee Schedule,,1855.04,,,1855.04,Fee Schedule,,989.12,,,989.12,Fee Schedule,,2094.4,70,,2094.4,percent of total billed charges,All Other,1772,,,1772,Case Rate,,1506,,,1506,Case Rate,,610.96,,,610.96,Fee Schedule,,610.96,,,610.96,Fee Schedule,,610.96,,,610.96,Fee Schedule,,610.96,,,610.96,Fee Schedule,,542.99,,,542.99,Other,100% of Medicaid,542.99,,,542.99,Other,100% of Medicaid,542.99,,,542.99,Other,100% of Medicaid,542.99,,,542.99,Other,100% of Medicaid,1221.72,,,1221.72,Other,225% of Medicaid,830.77,,,830.77,Other,153% of Medicaid,1221.72,,,1221.72,Other,225% of Medicaid,760.18,,,760.18,Other,140% of Medicaid,1221.72,,,1221.72,Other,225% of Medicaid,1411.76,,,1411.76,Other,260% of Medicaid,1759.27,,,1759.27,Other,324% of Medicaid,1167.42,,,1167.42,Other,215% of Medicaid,1167.42,,,1167.42,Other,215% of Medicaid,678.73,,,678.73,Other,125% of Medicaid,525.86,2942.87,
MRI ABDOMEN W AND WO CONTRAST,74183,CPT,TC,45074183,CDM,610,RC,,,both,,,4261,3153.15,,,3153.15,Other,150% of Medicare + 9.63% HCRA Surcharge,1917.45,45,,1917.45,percent of total billed charges,Critical Access Hospital RCC factor,849.62,,,849.62,Fee Schedule,,764.4,,,764.4,Fee Schedule,,3595.09,,,3595.09,Fee Schedule,,3233.53,,,3233.53,Fee Schedule,,3056.17,,,3056.17,Fee Schedule,,2109.2,,,2109.2,Other,110% of Medicare,1009.43,,,1009.43,Fee Schedule,,1010,,,1010,Other,186% of Medicaid,1187.88,,,1187.88,Fee Schedule,,2641.82,,,2641.82,Fee Schedule,,559.31,,,559.31,Fee Schedule,,1187.88,,,1187.88,Fee Schedule,,2641.82,,,2641.82,Fee Schedule,,1052.04,,,1052.04,Fee Schedule,,2982.7,70,,2982.7,percent of total billed charges,All Other,1772,,,1772,Case Rate,,1506,,,1506,Case Rate,,610.96,,,610.96,Fee Schedule,,610.96,,,610.96,Fee Schedule,,610.96,,,610.96,Fee Schedule,,610.96,,,610.96,Fee Schedule,,542.99,,,542.99,Other,100% of Medicaid,542.99,,,542.99,Other,100% of Medicaid,542.99,,,542.99,Other,100% of Medicaid,542.99,,,542.99,Other,100% of Medicaid,1221.72,,,1221.72,Other,225% of Medicaid,830.77,,,830.77,Other,153% of Medicaid,1221.72,,,1221.72,Other,225% of Medicaid,760.18,,,760.18,Other,140% of Medicaid,1221.72,,,1221.72,Other,225% of Medicaid,1411.76,,,1411.76,Other,260% of Medicaid,1759.27,,,1759.27,Other,324% of Medicaid,1167.42,,,1167.42,Other,215% of Medicaid,1167.42,,,1167.42,Other,215% of Medicaid,678.73,,,678.73,Other,125% of Medicaid,542.99,3595.09,
CARDIAC MRI MORPH & FUNCTION W/O CONT,75557,CPT,,45075557,CDM,610,RC,,,both,,,737,545.38,,,545.38,Other,150% of Medicare + 9.63% HCRA Surcharge,331.65,45,,331.65,percent of total billed charges,Critical Access Hospital RCC factor,614.94,,,614.94,Fee Schedule,,553.25,,,553.25,Fee Schedule,,2224.36,,,2224.36,Fee Schedule,,2000.66,,,2000.66,Fee Schedule,,1890.92,,,1890.92,Fee Schedule,,364.82,,,364.82,Other,110% of Medicare,730.6,,,730.6,Fee Schedule,,670,,,670,Other,186% of Medicaid,859.75,,,859.75,Fee Schedule,,456.94,,,456.94,Fee Schedule,,404.82,,,404.82,Fee Schedule,,859.75,,,859.75,Fee Schedule,,456.94,,,456.94,Fee Schedule,,761.44,,,761.44,Fee Schedule,,515.9,70,,515.9,percent of total billed charges,All Other,1772,,,1772,Case Rate,,1506,,,1506,Case Rate,,372.86,,,372.86,Fee Schedule,,372.86,,,372.86,Fee Schedule,,372.86,,,372.86,Fee Schedule,,372.86,,,372.86,Fee Schedule,,360.02,,,360.02,Other,100% of Medicaid,360.02,,,360.02,Other,100% of Medicaid,360.02,,,360.02,Other,100% of Medicaid,360.02,,,360.02,Other,100% of Medicaid,810.04,,,810.04,Other,225% of Medicaid,550.82,,,550.82,Other,153% of Medicaid,810.04,,,810.04,Other,225% of Medicaid,504.02,,,504.02,Other,140% of Medicaid,810.04,,,810.04,Other,225% of Medicaid,936.04,,,936.04,Other,260% of Medicaid,1166.45,,,1166.45,Other,324% of Medicaid,774.04,,,774.04,Other,215% of Medicaid,774.04,,,774.04,Other,215% of Medicaid,450.02,,,450.02,Other,125% of Medicaid,331.65,2224.36,
CARDIAC MRI W/WO CONTRAST & FURTHER SEQ,75561,CPT,,45075561,CDM,610,RC,,,both,,,1161,859.14,,,859.14,Other,150% of Medicare + 9.63% HCRA Surcharge,522.45,45,,522.45,percent of total billed charges,Critical Access Hospital RCC factor,878.49,,,878.49,Fee Schedule,,790.37,,,790.37,Fee Schedule,,3208.32,,,3208.32,Fee Schedule,,2885.66,,,2885.66,Fee Schedule,,2727.38,,,2727.38,Fee Schedule,,574.7,,,574.7,Other,110% of Medicare,1043.73,,,1043.73,Fee Schedule,,1010,,,1010,Other,186% of Medicaid,1228.24,,,1228.24,Fee Schedule,,719.82,,,719.82,Fee Schedule,,578.32,,,578.32,Fee Schedule,,1228.24,,,1228.24,Fee Schedule,,719.82,,,719.82,Fee Schedule,,1087.79,,,1087.79,Fee Schedule,,812.7,70,,812.7,percent of total billed charges,All Other,1772,,,1772,Case Rate,,1506,,,1506,Case Rate,,610.96,,,610.96,Fee Schedule,,610.96,,,610.96,Fee Schedule,,610.96,,,610.96,Fee Schedule,,610.96,,,610.96,Fee Schedule,,542.99,,,542.99,Other,100% of Medicaid,542.99,,,542.99,Other,100% of Medicaid,542.99,,,542.99,Other,100% of Medicaid,542.99,,,542.99,Other,100% of Medicaid,1221.72,,,1221.72,Other,225% of Medicaid,830.77,,,830.77,Other,153% of Medicaid,1221.72,,,1221.72,Other,225% of Medicaid,760.18,,,760.18,Other,140% of Medicaid,1221.72,,,1221.72,Other,225% of Medicaid,1411.76,,,1411.76,Other,260% of Medicaid,1759.27,,,1759.27,Other,324% of Medicaid,1167.42,,,1167.42,Other,215% of Medicaid,1167.42,,,1167.42,Other,215% of Medicaid,678.73,,,678.73,Other,125% of Medicaid,522.45,3208.32,
MRI CARD W STRESS IMG & DYE,75563,CPT,TC,45075563,CDM,610,RC,,,both,,,2926,2165.25,,,2165.25,Other,150% of Medicare + 9.63% HCRA Surcharge,1316.7,45,,1316.7,percent of total billed charges,Critical Access Hospital RCC factor,1033.3,,,1033.3,Fee Schedule,,929.65,,,929.65,Fee Schedule,,3595.09,,,3595.09,Fee Schedule,,3233.53,,,3233.53,Fee Schedule,,3056.17,,,3056.17,Fee Schedule,,1448.37,,,1448.37,Other,110% of Medicare,1227.66,,,1227.66,Fee Schedule,,1010,,,1010,Other,186% of Medicaid,1444.68,,,1444.68,Fee Schedule,,1814.12,,,1814.12,Fee Schedule,,680.23,,,680.23,Fee Schedule,,1444.68,,,1444.68,Fee Schedule,,1814.12,,,1814.12,Fee Schedule,,1279.48,,,1279.48,Fee Schedule,,2048.2,70,,2048.2,percent of total billed charges,All Other,1772,,,1772,Case Rate,,1506,,,1506,Case Rate,,1089.31,,,1089.31,Fee Schedule,,1089.31,,,1089.31,Fee Schedule,,1089.31,,,1089.31,Fee Schedule,,1089.31,,,1089.31,Fee Schedule,,542.99,,,542.99,Other,100% of Medicaid,542.99,,,542.99,Other,100% of Medicaid,542.99,,,542.99,Other,100% of Medicaid,542.99,,,542.99,Other,100% of Medicaid,1221.72,,,1221.72,Other,225% of Medicaid,830.77,,,830.77,Other,153% of Medicaid,1221.72,,,1221.72,Other,225% of Medicaid,760.18,,,760.18,Other,140% of Medicaid,1221.72,,,1221.72,Other,225% of Medicaid,1411.76,,,1411.76,Other,260% of Medicaid,1759.27,,,1759.27,Other,324% of Medicaid,1167.42,,,1167.42,Other,215% of Medicaid,1167.42,,,1167.42,Other,215% of Medicaid,678.73,,,678.73,Other,125% of Medicaid,542.99,3595.09,
CARD MRI VEL FLW MAP ADD-ON,75565,CPT,TC,45075565,CDM,610,RC,,,both,,,2354,1741.97,,,1741.97,Other,150% of Medicare + 9.63% HCRA Surcharge,1059.3,45,,1059.3,percent of total billed charges,Critical Access Hospital RCC factor,121.32,,,121.32,Fee Schedule,,109.15,,,109.15,Fee Schedule,,416.59,,,416.59,Fee Schedule,,374.7,,,374.7,Fee Schedule,,354.14,,,354.14,Fee Schedule,,1165.23,,,1165.23,Other,110% of Medicare,144.13,,,144.13,Fee Schedule,,670,,,670,Other,186% of Medicaid,169.61,,,169.61,Fee Schedule,,1459.48,,,1459.48,Fee Schedule,,79.86,,,79.86,Fee Schedule,,169.61,,,169.61,Fee Schedule,,1459.48,,,1459.48,Fee Schedule,,162.98,,,162.98,Fee Schedule,,1647.8,70,,1647.8,percent of total billed charges,All Other,1772,,,1772,Case Rate,,1506,,,1506,Case Rate,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,360.02,,,360.02,Other,100% of Medicaid,360.02,,,360.02,Other,100% of Medicaid,360.02,,,360.02,Other,100% of Medicaid,360.02,,,360.02,Other,100% of Medicaid,810.04,,,810.04,Other,225% of Medicaid,550.82,,,550.82,Other,153% of Medicaid,810.04,,,810.04,Other,225% of Medicaid,504.02,,,504.02,Other,140% of Medicaid,810.04,,,810.04,Other,225% of Medicaid,936.04,,,936.04,Other,260% of Medicaid,1166.45,,,1166.45,Other,324% of Medicaid,774.04,,,774.04,Other,215% of Medicaid,774.04,,,774.04,Other,215% of Medicaid,450.02,,,450.02,Other,125% of Medicaid,0.01,1772,
MAGNETIC RESONANCE SPECTROSCOPY,76390,CPT,TC,45076390,CDM,610,RC,,,both,,,3215,2379.11,,,2379.11,Other,150% of Medicare + 9.63% HCRA Surcharge,1446.75,45,,1446.75,percent of total billed charges,Critical Access Hospital RCC factor,2089.75,65,,2089.75,percent of total billed charges,All Other,1896.85,65,,1896.85,percent of total billed charges,All Other,376.84,,,376.84,Fee Schedule,,376.84,,,376.84,Fee Schedule,,376.84,,,376.84,Fee Schedule,,1591.43,,,1591.43,Other,110% of Medicare,2186.2,68,,2186.2,percent of total billed charges,All Other,670,,,670,Other,186% of Medicaid,2572,,,2572,percent of total billed charges,All Other,1993.3,62,,1993.3,percent of total billed charges,Lab and Radiology,1768.25,55,,1768.25,percent of total billed charges,Default if not on Fee Schedule,2572,80,,2572,percent of total billed charges,All Other,1993.3,62,,1993.3,percent of total billed charges,Lab and Radiology,2572,80,,2572,percent of total billed charges,All Other,2250.5,70,,2250.5,percent of total billed charges,All Other,1772,,,1772,Case Rate,,1506,,,1506,Case Rate,,576.27,,,576.27,Fee Schedule,,576.27,,,576.27,Fee Schedule,,576.27,,,576.27,Fee Schedule,,576.27,,,576.27,Fee Schedule,,360.02,,,360.02,Other,100% of Medicaid,360.02,,,360.02,Other,100% of Medicaid,360.02,,,360.02,Other,100% of Medicaid,360.02,,,360.02,Other,100% of Medicaid,810.04,,,810.04,Other,225% of Medicaid,550.82,,,550.82,Other,153% of Medicaid,810.04,,,810.04,Other,225% of Medicaid,504.02,,,504.02,Other,140% of Medicaid,810.04,,,810.04,Other,225% of Medicaid,936.04,,,936.04,Other,260% of Medicaid,1166.45,,,1166.45,Other,324% of Medicaid,774.04,,,774.04,Other,215% of Medicaid,774.04,,,774.04,Other,215% of Medicaid,450.02,,,450.02,Other,125% of Medicaid,360.02,2572,
MRI U EXT WO CONTRAST LT,73218,CPT,TCLT,45173218,CDM,610,RC,,,both,,,2898,2144.53,,,2144.53,Other,150% of Medicare + 9.63% HCRA Surcharge,1304.1,45,,1304.1,percent of total billed charges,Critical Access Hospital RCC factor,824.2,,,824.2,Fee Schedule,,741.52,,,741.52,Fee Schedule,,2311.32,,,2311.32,Fee Schedule,,2078.87,,,2078.87,Fee Schedule,,1964.84,,,1964.84,Fee Schedule,,1434.51,,,1434.51,Other,110% of Medicare,979.22,,,979.22,Fee Schedule,,670,,,670,Other,186% of Medicaid,1152.33,,,1152.33,Fee Schedule,,1796.76,,,1796.76,Fee Schedule,,542.58,,,542.58,Fee Schedule,,1152.33,,,1152.33,Fee Schedule,,1796.76,,,1796.76,Fee Schedule,,1020.56,,,1020.56,Fee Schedule,,2028.6,70,,2028.6,percent of total billed charges,All Other,1772,,,1772,Case Rate,,1506,,,1506,Case Rate,,372.86,,,372.86,Fee Schedule,,372.86,,,372.86,Fee Schedule,,372.86,,,372.86,Fee Schedule,,372.86,,,372.86,Fee Schedule,,360.02,,,360.02,Other,100% of Medicaid,360.02,,,360.02,Other,100% of Medicaid,360.02,,,360.02,Other,100% of Medicaid,360.02,,,360.02,Other,100% of Medicaid,810.04,,,810.04,Other,225% of Medicaid,550.82,,,550.82,Other,153% of Medicaid,810.04,,,810.04,Other,225% of Medicaid,504.02,,,504.02,Other,140% of Medicaid,810.04,,,810.04,Other,225% of Medicaid,936.04,,,936.04,Other,260% of Medicaid,1166.45,,,1166.45,Other,324% of Medicaid,774.04,,,774.04,Other,215% of Medicaid,774.04,,,774.04,Other,215% of Medicaid,450.02,,,450.02,Other,125% of Medicaid,360.02,2311.32,
MRI U EXT NOT JOINT W CONTRAST LT,73219,CPT,TCLT,45173219,CDM,610,RC,,,both,,,3095,2290.31,,,2290.31,Other,150% of Medicare + 9.63% HCRA Surcharge,1392.75,45,,1392.75,percent of total billed charges,Critical Access Hospital RCC factor,918.94,,,918.94,Fee Schedule,,826.76,,,826.76,Fee Schedule,,2942.87,,,2942.87,Fee Schedule,,2646.91,,,2646.91,Fee Schedule,,2501.72,,,2501.72,Fee Schedule,,1532.03,,,1532.03,Other,110% of Medicare,1091.79,,,1091.79,Fee Schedule,,1010,,,1010,Other,186% of Medicaid,1284.79,,,1284.79,Fee Schedule,,1918.9,,,1918.9,Fee Schedule,,604.95,,,604.95,Fee Schedule,,1284.79,,,1284.79,Fee Schedule,,1918.9,,,1918.9,Fee Schedule,,1137.88,,,1137.88,Fee Schedule,,2166.5,70,,2166.5,percent of total billed charges,All Other,1772,,,1772,Case Rate,,1506,,,1506,Case Rate,,610.96,,,610.96,Fee Schedule,,610.96,,,610.96,Fee Schedule,,610.96,,,610.96,Fee Schedule,,610.96,,,610.96,Fee Schedule,,542.99,,,542.99,Other,100% of Medicaid,542.99,,,542.99,Other,100% of Medicaid,542.99,,,542.99,Other,100% of Medicaid,542.99,,,542.99,Other,100% of Medicaid,1221.72,,,1221.72,Other,225% of Medicaid,830.77,,,830.77,Other,153% of Medicaid,1221.72,,,1221.72,Other,225% of Medicaid,760.18,,,760.18,Other,140% of Medicaid,1221.72,,,1221.72,Other,225% of Medicaid,1411.76,,,1411.76,Other,260% of Medicaid,1759.27,,,1759.27,Other,324% of Medicaid,1167.42,,,1167.42,Other,215% of Medicaid,1167.42,,,1167.42,Other,215% of Medicaid,678.73,,,678.73,Other,125% of Medicaid,542.99,2942.87,
MRI U EXT W AND WO CONTRAST LT,73220,CPT,TCLT,45173220,CDM,610,RC,,,both,,,3910,2893.41,,,2893.41,Other,150% of Medicare + 9.63% HCRA Surcharge,1759.5,45,,1759.5,percent of total billed charges,Critical Access Hospital RCC factor,1113.02,,,1113.02,Fee Schedule,,1001.37,,,1001.37,Fee Schedule,,3595.09,,,3595.09,Fee Schedule,,3233.53,,,3233.53,Fee Schedule,,3056.17,,,3056.17,Fee Schedule,,1935.45,,,1935.45,Other,110% of Medicare,1322.37,,,1322.37,Fee Schedule,,1010,,,1010,Other,186% of Medicaid,1556.14,,,1556.14,Fee Schedule,,2424.2,,,2424.2,Fee Schedule,,732.71,,,732.71,Fee Schedule,,1556.14,,,1556.14,Fee Schedule,,2424.2,,,2424.2,Fee Schedule,,1378.19,,,1378.19,Fee Schedule,,2737,70,,2737,percent of total billed charges,All Other,1772,,,1772,Case Rate,,1506,,,1506,Case Rate,,610.96,,,610.96,Fee Schedule,,610.96,,,610.96,Fee Schedule,,610.96,,,610.96,Fee Schedule,,610.96,,,610.96,Fee Schedule,,542.99,,,542.99,Other,100% of Medicaid,542.99,,,542.99,Other,100% of Medicaid,542.99,,,542.99,Other,100% of Medicaid,542.99,,,542.99,Other,100% of Medicaid,1221.72,,,1221.72,Other,225% of Medicaid,830.77,,,830.77,Other,153% of Medicaid,1221.72,,,1221.72,Other,225% of Medicaid,760.18,,,760.18,Other,140% of Medicaid,1221.72,,,1221.72,Other,225% of Medicaid,1411.76,,,1411.76,Other,260% of Medicaid,1759.27,,,1759.27,Other,324% of Medicaid,1167.42,,,1167.42,Other,215% of Medicaid,1167.42,,,1167.42,Other,215% of Medicaid,678.73,,,678.73,Other,125% of Medicaid,542.99,3595.09,
MRI JOINT U EXT WO CONTRAST LT,73221,CPT,TCLT,45173221,CDM,610,RC,,,both,,,2898,2144.53,,,2144.53,Other,150% of Medicare + 9.63% HCRA Surcharge,1304.1,45,,1304.1,percent of total billed charges,Critical Access Hospital RCC factor,502.87,,,502.87,Fee Schedule,,452.43,,,452.43,Fee Schedule,,2311.32,,,2311.32,Fee Schedule,,2078.87,,,2078.87,Fee Schedule,,1964.84,,,1964.84,Fee Schedule,,1434.51,,,1434.51,Other,110% of Medicare,597.46,,,597.46,Fee Schedule,,670,,,670,Other,186% of Medicaid,703.07,,,703.07,Fee Schedule,,1796.76,,,1796.76,Fee Schedule,,331.04,,,331.04,Fee Schedule,,703.07,,,703.07,Fee Schedule,,1796.76,,,1796.76,Fee Schedule,,622.68,,,622.68,Fee Schedule,,2028.6,70,,2028.6,percent of total billed charges,All Other,1772,,,1772,Case Rate,,1506,,,1506,Case Rate,,372.86,,,372.86,Fee Schedule,,372.86,,,372.86,Fee Schedule,,372.86,,,372.86,Fee Schedule,,372.86,,,372.86,Fee Schedule,,360.02,,,360.02,Other,100% of Medicaid,360.02,,,360.02,Other,100% of Medicaid,360.02,,,360.02,Other,100% of Medicaid,360.02,,,360.02,Other,100% of Medicaid,810.04,,,810.04,Other,225% of Medicaid,550.82,,,550.82,Other,153% of Medicaid,810.04,,,810.04,Other,225% of Medicaid,504.02,,,504.02,Other,140% of Medicaid,810.04,,,810.04,Other,225% of Medicaid,936.04,,,936.04,Other,260% of Medicaid,1166.45,,,1166.45,Other,324% of Medicaid,774.04,,,774.04,Other,215% of Medicaid,774.04,,,774.04,Other,215% of Medicaid,450.02,,,450.02,Other,125% of Medicaid,331.04,2311.32,
MRI JOINT U EXT W CONTRAST LT,73222,CPT,TCLT,45173222,CDM,610,RC,,,both,,,3186,2357.65,,,2357.65,Other,150% of Medicare + 9.63% HCRA Surcharge,1433.7,45,,1433.7,percent of total billed charges,Critical Access Hospital RCC factor,853.1,,,853.1,Fee Schedule,,767.52,,,767.52,Fee Schedule,,2942.87,,,2942.87,Fee Schedule,,2646.91,,,2646.91,Fee Schedule,,2501.72,,,2501.72,Fee Schedule,,1577.07,,,1577.07,Other,110% of Medicare,1013.56,,,1013.56,Fee Schedule,,1010,,,1010,Other,186% of Medicaid,1192.74,,,1192.74,Fee Schedule,,1975.32,,,1975.32,Fee Schedule,,561.6,,,561.6,Fee Schedule,,1192.74,,,1192.74,Fee Schedule,,1975.32,,,1975.32,Fee Schedule,,1056.35,,,1056.35,Fee Schedule,,2230.2,70,,2230.2,percent of total billed charges,All Other,1772,,,1772,Case Rate,,1506,,,1506,Case Rate,,1089.31,,,1089.31,Fee Schedule,,1089.31,,,1089.31,Fee Schedule,,1089.31,,,1089.31,Fee Schedule,,1089.31,,,1089.31,Fee Schedule,,542.99,,,542.99,Other,100% of Medicaid,542.99,,,542.99,Other,100% of Medicaid,542.99,,,542.99,Other,100% of Medicaid,542.99,,,542.99,Other,100% of Medicaid,1221.72,,,1221.72,Other,225% of Medicaid,830.77,,,830.77,Other,153% of Medicaid,1221.72,,,1221.72,Other,225% of Medicaid,760.18,,,760.18,Other,140% of Medicaid,1221.72,,,1221.72,Other,225% of Medicaid,1411.76,,,1411.76,Other,260% of Medicaid,1759.27,,,1759.27,Other,324% of Medicaid,1167.42,,,1167.42,Other,215% of Medicaid,1167.42,,,1167.42,Other,215% of Medicaid,678.73,,,678.73,Other,125% of Medicaid,542.99,2942.87,
MRI JOINT U EXT W AND WO CONTRAST LT,73223,CPT,TCLT,45173223,CDM,610,RC,,,both,,,3910,2893.41,,,2893.41,Other,150% of Medicare + 9.63% HCRA Surcharge,1759.5,45,,1759.5,percent of total billed charges,Critical Access Hospital RCC factor,1031.01,,,1031.01,Fee Schedule,,927.58,,,927.58,Fee Schedule,,3595.09,,,3595.09,Fee Schedule,,3233.53,,,3233.53,Fee Schedule,,3056.17,,,3056.17,Fee Schedule,,1935.45,,,1935.45,Other,110% of Medicare,1224.93,,,1224.93,Fee Schedule,,1010,,,1010,Other,186% of Medicaid,1441.47,,,1441.47,Fee Schedule,,2424.2,,,2424.2,Fee Schedule,,678.72,,,678.72,Fee Schedule,,1441.47,,,1441.47,Fee Schedule,,2424.2,,,2424.2,Fee Schedule,,1276.64,,,1276.64,Fee Schedule,,2737,70,,2737,percent of total billed charges,All Other,1772,,,1772,Case Rate,,1506,,,1506,Case Rate,,610.96,,,610.96,Fee Schedule,,610.96,,,610.96,Fee Schedule,,610.96,,,610.96,Fee Schedule,,610.96,,,610.96,Fee Schedule,,542.99,,,542.99,Other,100% of Medicaid,542.99,,,542.99,Other,100% of Medicaid,542.99,,,542.99,Other,100% of Medicaid,542.99,,,542.99,Other,100% of Medicaid,1221.72,,,1221.72,Other,225% of Medicaid,830.77,,,830.77,Other,153% of Medicaid,1221.72,,,1221.72,Other,225% of Medicaid,760.18,,,760.18,Other,140% of Medicaid,1221.72,,,1221.72,Other,225% of Medicaid,1411.76,,,1411.76,Other,260% of Medicaid,1759.27,,,1759.27,Other,324% of Medicaid,1167.42,,,1167.42,Other,215% of Medicaid,1167.42,,,1167.42,Other,215% of Medicaid,678.73,,,678.73,Other,125% of Medicaid,542.99,3595.09,
MRI L EXT WO CONTRAST LT,73718,CPT,TCLT,45173718,CDM,610,RC,,,both,,,2898,2144.53,,,2144.53,Other,150% of Medicare + 9.63% HCRA Surcharge,1304.1,45,,1304.1,percent of total billed charges,Critical Access Hospital RCC factor,577.96,,,577.96,Fee Schedule,,519.99,,,519.99,Fee Schedule,,2311.32,,,2311.32,Fee Schedule,,2078.87,,,2078.87,Fee Schedule,,1964.84,,,1964.84,Fee Schedule,,1434.51,,,1434.51,Other,110% of Medicare,686.67,,,686.67,Fee Schedule,,670,,,670,Other,186% of Medicaid,808.06,,,808.06,Fee Schedule,,1796.76,,,1796.76,Fee Schedule,,380.48,,,380.48,Fee Schedule,,808.06,,,808.06,Fee Schedule,,1796.76,,,1796.76,Fee Schedule,,715.66,,,715.66,Fee Schedule,,2028.6,70,,2028.6,percent of total billed charges,All Other,1772,,,1772,Case Rate,,1506,,,1506,Case Rate,,372.86,,,372.86,Fee Schedule,,372.86,,,372.86,Fee Schedule,,372.86,,,372.86,Fee Schedule,,372.86,,,372.86,Fee Schedule,,360.02,,,360.02,Other,100% of Medicaid,360.02,,,360.02,Other,100% of Medicaid,360.02,,,360.02,Other,100% of Medicaid,360.02,,,360.02,Other,100% of Medicaid,810.04,,,810.04,Other,225% of Medicaid,550.82,,,550.82,Other,153% of Medicaid,810.04,,,810.04,Other,225% of Medicaid,504.02,,,504.02,Other,140% of Medicaid,810.04,,,810.04,Other,225% of Medicaid,936.04,,,936.04,Other,260% of Medicaid,1166.45,,,1166.45,Other,324% of Medicaid,774.04,,,774.04,Other,215% of Medicaid,774.04,,,774.04,Other,215% of Medicaid,450.02,,,450.02,Other,125% of Medicaid,360.02,2311.32,
MRI L EXT W CONTRAST LT,73719,CPT,TCLT,45173719,CDM,610,RC,,,both,,,2712,2006.89,,,2006.89,Other,150% of Medicare + 9.63% HCRA Surcharge,1220.4,45,,1220.4,percent of total billed charges,Critical Access Hospital RCC factor,676.34,,,676.34,Fee Schedule,,608.5,,,608.5,Fee Schedule,,2942.87,,,2942.87,Fee Schedule,,2646.91,,,2646.91,Fee Schedule,,2501.72,,,2501.72,Fee Schedule,,1342.44,,,1342.44,Other,110% of Medicare,803.56,,,803.56,Fee Schedule,,1010,,,1010,Other,186% of Medicaid,945.61,,,945.61,Fee Schedule,,1681.44,,,1681.44,Fee Schedule,,445.24,,,445.24,Fee Schedule,,945.61,,,945.61,Fee Schedule,,1681.44,,,1681.44,Fee Schedule,,837.48,,,837.48,Fee Schedule,,1898.4,70,,1898.4,percent of total billed charges,All Other,1772,,,1772,Case Rate,,1506,,,1506,Case Rate,,610.96,,,610.96,Fee Schedule,,610.96,,,610.96,Fee Schedule,,610.96,,,610.96,Fee Schedule,,610.96,,,610.96,Fee Schedule,,542.99,,,542.99,Other,100% of Medicaid,542.99,,,542.99,Other,100% of Medicaid,542.99,,,542.99,Other,100% of Medicaid,542.99,,,542.99,Other,100% of Medicaid,1221.72,,,1221.72,Other,225% of Medicaid,830.77,,,830.77,Other,153% of Medicaid,1221.72,,,1221.72,Other,225% of Medicaid,760.18,,,760.18,Other,140% of Medicaid,1221.72,,,1221.72,Other,225% of Medicaid,1411.76,,,1411.76,Other,260% of Medicaid,1759.27,,,1759.27,Other,324% of Medicaid,1167.42,,,1167.42,Other,215% of Medicaid,1167.42,,,1167.42,Other,215% of Medicaid,678.73,,,678.73,Other,125% of Medicaid,445.24,2942.87,
MRI FEMUR W AND WO CONTRAST LT,73720,CPT,TCLT,45173720,CDM,610,RC,,,both,,,3910,2893.41,,,2893.41,Other,150% of Medicare + 9.63% HCRA Surcharge,1759.5,45,,1759.5,percent of total billed charges,Critical Access Hospital RCC factor,854.25,,,854.25,Fee Schedule,,768.56,,,768.56,Fee Schedule,,3595.09,,,3595.09,Fee Schedule,,3233.53,,,3233.53,Fee Schedule,,3056.17,,,3056.17,Fee Schedule,,1935.45,,,1935.45,Other,110% of Medicare,1014.92,,,1014.92,Fee Schedule,,1010,,,1010,Other,186% of Medicaid,1194.34,,,1194.34,Fee Schedule,,2424.2,,,2424.2,Fee Schedule,,562.36,,,562.36,Fee Schedule,,1194.34,,,1194.34,Fee Schedule,,2424.2,,,2424.2,Fee Schedule,,1057.77,,,1057.77,Fee Schedule,,2737,70,,2737,percent of total billed charges,All Other,1772,,,1772,Case Rate,,1506,,,1506,Case Rate,,610.96,,,610.96,Fee Schedule,,610.96,,,610.96,Fee Schedule,,610.96,,,610.96,Fee Schedule,,610.96,,,610.96,Fee Schedule,,542.99,,,542.99,Other,100% of Medicaid,542.99,,,542.99,Other,100% of Medicaid,542.99,,,542.99,Other,100% of Medicaid,542.99,,,542.99,Other,100% of Medicaid,1221.72,,,1221.72,Other,225% of Medicaid,830.77,,,830.77,Other,153% of Medicaid,1221.72,,,1221.72,Other,225% of Medicaid,760.18,,,760.18,Other,140% of Medicaid,1221.72,,,1221.72,Other,225% of Medicaid,1411.76,,,1411.76,Other,260% of Medicaid,1759.27,,,1759.27,Other,324% of Medicaid,1167.42,,,1167.42,Other,215% of Medicaid,1167.42,,,1167.42,Other,215% of Medicaid,678.73,,,678.73,Other,125% of Medicaid,542.99,3595.09,
MRI JOINT L EXT WO CONTRAST LT,73721,CPT,TCLT,45173721,CDM,610,RC,,,both,,,2898,2144.53,,,2144.53,Other,150% of Medicare + 9.63% HCRA Surcharge,1304.1,45,,1304.1,percent of total billed charges,Critical Access Hospital RCC factor,501.72,,,501.72,Fee Schedule,,451.39,,,451.39,Fee Schedule,,2311.32,,,2311.32,Fee Schedule,,2078.87,,,2078.87,Fee Schedule,,1964.84,,,1964.84,Fee Schedule,,1434.51,,,1434.51,Other,110% of Medicare,596.09,,,596.09,Fee Schedule,,670,,,670,Other,186% of Medicaid,701.47,,,701.47,Fee Schedule,,1796.76,,,1796.76,Fee Schedule,,330.29,,,330.29,Fee Schedule,,701.47,,,701.47,Fee Schedule,,1796.76,,,1796.76,Fee Schedule,,621.26,,,621.26,Fee Schedule,,2028.6,70,,2028.6,percent of total billed charges,All Other,1772,,,1772,Case Rate,,1506,,,1506,Case Rate,,372.86,,,372.86,Fee Schedule,,372.86,,,372.86,Fee Schedule,,372.86,,,372.86,Fee Schedule,,372.86,,,372.86,Fee Schedule,,360.02,,,360.02,Other,100% of Medicaid,360.02,,,360.02,Other,100% of Medicaid,360.02,,,360.02,Other,100% of Medicaid,360.02,,,360.02,Other,100% of Medicaid,810.04,,,810.04,Other,225% of Medicaid,550.82,,,550.82,Other,153% of Medicaid,810.04,,,810.04,Other,225% of Medicaid,504.02,,,504.02,Other,140% of Medicaid,810.04,,,810.04,Other,225% of Medicaid,936.04,,,936.04,Other,260% of Medicaid,1166.45,,,1166.45,Other,324% of Medicaid,774.04,,,774.04,Other,215% of Medicaid,774.04,,,774.04,Other,215% of Medicaid,450.02,,,450.02,Other,125% of Medicaid,330.29,2311.32,
MRI JOINT L EXT W CONTRAST LT,73722,CPT,TCLT,45173722,CDM,610,RC,,,both,,,3128,2314.73,,,2314.73,Other,150% of Medicare + 9.63% HCRA Surcharge,1407.6,45,,1407.6,percent of total billed charges,Critical Access Hospital RCC factor,855.4,,,855.4,Fee Schedule,,769.59,,,769.59,Fee Schedule,,2942.87,,,2942.87,Fee Schedule,,2646.91,,,2646.91,Fee Schedule,,2501.72,,,2501.72,Fee Schedule,,1548.36,,,1548.36,Other,110% of Medicare,1016.29,,,1016.29,Fee Schedule,,1010,,,1010,Other,186% of Medicaid,1195.95,,,1195.95,Fee Schedule,,1939.36,,,1939.36,Fee Schedule,,563.12,,,563.12,Fee Schedule,,1195.95,,,1195.95,Fee Schedule,,1939.36,,,1939.36,Fee Schedule,,1059.19,,,1059.19,Fee Schedule,,2189.6,70,,2189.6,percent of total billed charges,All Other,1772,,,1772,Case Rate,,1506,,,1506,Case Rate,,1089.31,,,1089.31,Fee Schedule,,1089.31,,,1089.31,Fee Schedule,,1089.31,,,1089.31,Fee Schedule,,1089.31,,,1089.31,Fee Schedule,,542.99,,,542.99,Other,100% of Medicaid,542.99,,,542.99,Other,100% of Medicaid,542.99,,,542.99,Other,100% of Medicaid,542.99,,,542.99,Other,100% of Medicaid,1221.72,,,1221.72,Other,225% of Medicaid,830.77,,,830.77,Other,153% of Medicaid,1221.72,,,1221.72,Other,225% of Medicaid,760.18,,,760.18,Other,140% of Medicaid,1221.72,,,1221.72,Other,225% of Medicaid,1411.76,,,1411.76,Other,260% of Medicaid,1759.27,,,1759.27,Other,324% of Medicaid,1167.42,,,1167.42,Other,215% of Medicaid,1167.42,,,1167.42,Other,215% of Medicaid,678.73,,,678.73,Other,125% of Medicaid,542.99,2942.87,
MRI JOINT L EXT W AND WO CONTRAST LT,73723,CPT,TCLT,45173723,CDM,610,RC,,,both,,,4261,3153.15,,,3153.15,Other,150% of Medicare + 9.63% HCRA Surcharge,1917.45,45,,1917.45,percent of total billed charges,Critical Access Hospital RCC factor,1026.38,,,1026.38,Fee Schedule,,923.42,,,923.42,Fee Schedule,,3595.09,,,3595.09,Fee Schedule,,3233.53,,,3233.53,Fee Schedule,,3056.17,,,3056.17,Fee Schedule,,2109.2,,,2109.2,Other,110% of Medicare,1219.43,,,1219.43,Fee Schedule,,1010,,,1010,Other,186% of Medicaid,1435.01,,,1435.01,Fee Schedule,,2641.82,,,2641.82,Fee Schedule,,675.68,,,675.68,Fee Schedule,,1435.01,,,1435.01,Fee Schedule,,2641.82,,,2641.82,Fee Schedule,,1270.91,,,1270.91,Fee Schedule,,2982.7,70,,2982.7,percent of total billed charges,All Other,1772,,,1772,Case Rate,,1506,,,1506,Case Rate,,610.96,,,610.96,Fee Schedule,,610.96,,,610.96,Fee Schedule,,610.96,,,610.96,Fee Schedule,,610.96,,,610.96,Fee Schedule,,542.99,,,542.99,Other,100% of Medicaid,542.99,,,542.99,Other,100% of Medicaid,542.99,,,542.99,Other,100% of Medicaid,542.99,,,542.99,Other,100% of Medicaid,1221.72,,,1221.72,Other,225% of Medicaid,830.77,,,830.77,Other,153% of Medicaid,1221.72,,,1221.72,Other,225% of Medicaid,760.18,,,760.18,Other,140% of Medicaid,1221.72,,,1221.72,Other,225% of Medicaid,1411.76,,,1411.76,Other,260% of Medicaid,1759.27,,,1759.27,Other,324% of Medicaid,1167.42,,,1167.42,Other,215% of Medicaid,1167.42,,,1167.42,Other,215% of Medicaid,678.73,,,678.73,Other,125% of Medicaid,542.99,3595.09,
MRI U EXT WO CONTRAST RT,73218,CPT,TCRT,45273218,CDM,610,RC,,,both,,,2898,2144.53,,,2144.53,Other,150% of Medicare + 9.63% HCRA Surcharge,1304.1,45,,1304.1,percent of total billed charges,Critical Access Hospital RCC factor,824.2,,,824.2,Fee Schedule,,741.52,,,741.52,Fee Schedule,,2311.32,,,2311.32,Fee Schedule,,2078.87,,,2078.87,Fee Schedule,,1964.84,,,1964.84,Fee Schedule,,1434.51,,,1434.51,Other,110% of Medicare,979.22,,,979.22,Fee Schedule,,670,,,670,Other,186% of Medicaid,1152.33,,,1152.33,Fee Schedule,,1796.76,,,1796.76,Fee Schedule,,542.58,,,542.58,Fee Schedule,,1152.33,,,1152.33,Fee Schedule,,1796.76,,,1796.76,Fee Schedule,,1020.56,,,1020.56,Fee Schedule,,2028.6,70,,2028.6,percent of total billed charges,All Other,1772,,,1772,Case Rate,,1506,,,1506,Case Rate,,372.86,,,372.86,Fee Schedule,,372.86,,,372.86,Fee Schedule,,372.86,,,372.86,Fee Schedule,,372.86,,,372.86,Fee Schedule,,360.02,,,360.02,Other,100% of Medicaid,360.02,,,360.02,Other,100% of Medicaid,360.02,,,360.02,Other,100% of Medicaid,360.02,,,360.02,Other,100% of Medicaid,810.04,,,810.04,Other,225% of Medicaid,550.82,,,550.82,Other,153% of Medicaid,810.04,,,810.04,Other,225% of Medicaid,504.02,,,504.02,Other,140% of Medicaid,810.04,,,810.04,Other,225% of Medicaid,936.04,,,936.04,Other,260% of Medicaid,1166.45,,,1166.45,Other,324% of Medicaid,774.04,,,774.04,Other,215% of Medicaid,774.04,,,774.04,Other,215% of Medicaid,450.02,,,450.02,Other,125% of Medicaid,360.02,2311.32,
MRI U EXT NOT JOINT W CONTRAST RT,73219,CPT,TCRT,45273219,CDM,610,RC,,,both,,,3095,2290.31,,,2290.31,Other,150% of Medicare + 9.63% HCRA Surcharge,1392.75,45,,1392.75,percent of total billed charges,Critical Access Hospital RCC factor,918.94,,,918.94,Fee Schedule,,826.76,,,826.76,Fee Schedule,,2942.87,,,2942.87,Fee Schedule,,2646.91,,,2646.91,Fee Schedule,,2501.72,,,2501.72,Fee Schedule,,1532.03,,,1532.03,Other,110% of Medicare,1091.79,,,1091.79,Fee Schedule,,1010,,,1010,Other,186% of Medicaid,1284.79,,,1284.79,Fee Schedule,,1918.9,,,1918.9,Fee Schedule,,604.95,,,604.95,Fee Schedule,,1284.79,,,1284.79,Fee Schedule,,1918.9,,,1918.9,Fee Schedule,,1137.88,,,1137.88,Fee Schedule,,2166.5,70,,2166.5,percent of total billed charges,All Other,1772,,,1772,Case Rate,,1506,,,1506,Case Rate,,610.96,,,610.96,Fee Schedule,,610.96,,,610.96,Fee Schedule,,610.96,,,610.96,Fee Schedule,,610.96,,,610.96,Fee Schedule,,542.99,,,542.99,Other,100% of Medicaid,542.99,,,542.99,Other,100% of Medicaid,542.99,,,542.99,Other,100% of Medicaid,542.99,,,542.99,Other,100% of Medicaid,1221.72,,,1221.72,Other,225% of Medicaid,830.77,,,830.77,Other,153% of Medicaid,1221.72,,,1221.72,Other,225% of Medicaid,760.18,,,760.18,Other,140% of Medicaid,1221.72,,,1221.72,Other,225% of Medicaid,1411.76,,,1411.76,Other,260% of Medicaid,1759.27,,,1759.27,Other,324% of Medicaid,1167.42,,,1167.42,Other,215% of Medicaid,1167.42,,,1167.42,Other,215% of Medicaid,678.73,,,678.73,Other,125% of Medicaid,542.99,2942.87,
MRI U EXT W AND WO CONTRAST RT,73220,CPT,TCRT,45273220,CDM,610,RC,,,both,,,3910,2893.41,,,2893.41,Other,150% of Medicare + 9.63% HCRA Surcharge,1759.5,45,,1759.5,percent of total billed charges,Critical Access Hospital RCC factor,1113.02,,,1113.02,Fee Schedule,,1001.37,,,1001.37,Fee Schedule,,3595.09,,,3595.09,Fee Schedule,,3233.53,,,3233.53,Fee Schedule,,3056.17,,,3056.17,Fee Schedule,,1935.45,,,1935.45,Other,110% of Medicare,1322.37,,,1322.37,Fee Schedule,,1010,,,1010,Other,186% of Medicaid,1556.14,,,1556.14,Fee Schedule,,2424.2,,,2424.2,Fee Schedule,,732.71,,,732.71,Fee Schedule,,1556.14,,,1556.14,Fee Schedule,,2424.2,,,2424.2,Fee Schedule,,1378.19,,,1378.19,Fee Schedule,,2737,70,,2737,percent of total billed charges,All Other,1772,,,1772,Case Rate,,1506,,,1506,Case Rate,,610.96,,,610.96,Fee Schedule,,610.96,,,610.96,Fee Schedule,,610.96,,,610.96,Fee Schedule,,610.96,,,610.96,Fee Schedule,,542.99,,,542.99,Other,100% of Medicaid,542.99,,,542.99,Other,100% of Medicaid,542.99,,,542.99,Other,100% of Medicaid,542.99,,,542.99,Other,100% of Medicaid,1221.72,,,1221.72,Other,225% of Medicaid,830.77,,,830.77,Other,153% of Medicaid,1221.72,,,1221.72,Other,225% of Medicaid,760.18,,,760.18,Other,140% of Medicaid,1221.72,,,1221.72,Other,225% of Medicaid,1411.76,,,1411.76,Other,260% of Medicaid,1759.27,,,1759.27,Other,324% of Medicaid,1167.42,,,1167.42,Other,215% of Medicaid,1167.42,,,1167.42,Other,215% of Medicaid,678.73,,,678.73,Other,125% of Medicaid,542.99,3595.09,
MRI JOINT U EXT WO CONTRAST RT,73221,CPT,TCRT,45273221,CDM,610,RC,,,both,,,2898,2144.53,,,2144.53,Other,150% of Medicare + 9.63% HCRA Surcharge,1304.1,45,,1304.1,percent of total billed charges,Critical Access Hospital RCC factor,502.87,,,502.87,Fee Schedule,,452.43,,,452.43,Fee Schedule,,2311.32,,,2311.32,Fee Schedule,,2078.87,,,2078.87,Fee Schedule,,1964.84,,,1964.84,Fee Schedule,,1434.51,,,1434.51,Other,110% of Medicare,597.46,,,597.46,Fee Schedule,,670,,,670,Other,186% of Medicaid,703.07,,,703.07,Fee Schedule,,1796.76,,,1796.76,Fee Schedule,,331.04,,,331.04,Fee Schedule,,703.07,,,703.07,Fee Schedule,,1796.76,,,1796.76,Fee Schedule,,622.68,,,622.68,Fee Schedule,,2028.6,70,,2028.6,percent of total billed charges,All Other,1772,,,1772,Case Rate,,1506,,,1506,Case Rate,,372.86,,,372.86,Fee Schedule,,372.86,,,372.86,Fee Schedule,,372.86,,,372.86,Fee Schedule,,372.86,,,372.86,Fee Schedule,,360.02,,,360.02,Other,100% of Medicaid,360.02,,,360.02,Other,100% of Medicaid,360.02,,,360.02,Other,100% of Medicaid,360.02,,,360.02,Other,100% of Medicaid,810.04,,,810.04,Other,225% of Medicaid,550.82,,,550.82,Other,153% of Medicaid,810.04,,,810.04,Other,225% of Medicaid,504.02,,,504.02,Other,140% of Medicaid,810.04,,,810.04,Other,225% of Medicaid,936.04,,,936.04,Other,260% of Medicaid,1166.45,,,1166.45,Other,324% of Medicaid,774.04,,,774.04,Other,215% of Medicaid,774.04,,,774.04,Other,215% of Medicaid,450.02,,,450.02,Other,125% of Medicaid,331.04,2311.32,
MRI JOINT U EXT W CONTRAST RT,73222,CPT,TCRT,45273222,CDM,610,RC,,,both,,,3186,2357.65,,,2357.65,Other,150% of Medicare + 9.63% HCRA Surcharge,1433.7,45,,1433.7,percent of total billed charges,Critical Access Hospital RCC factor,853.1,,,853.1,Fee Schedule,,767.52,,,767.52,Fee Schedule,,2942.87,,,2942.87,Fee Schedule,,2646.91,,,2646.91,Fee Schedule,,2501.72,,,2501.72,Fee Schedule,,1577.07,,,1577.07,Other,110% of Medicare,1013.56,,,1013.56,Fee Schedule,,1010,,,1010,Other,186% of Medicaid,1192.74,,,1192.74,Fee Schedule,,1975.32,,,1975.32,Fee Schedule,,561.6,,,561.6,Fee Schedule,,1192.74,,,1192.74,Fee Schedule,,1975.32,,,1975.32,Fee Schedule,,1056.35,,,1056.35,Fee Schedule,,2230.2,70,,2230.2,percent of total billed charges,All Other,1772,,,1772,Case Rate,,1506,,,1506,Case Rate,,1089.31,,,1089.31,Fee Schedule,,1089.31,,,1089.31,Fee Schedule,,1089.31,,,1089.31,Fee Schedule,,1089.31,,,1089.31,Fee Schedule,,542.99,,,542.99,Other,100% of Medicaid,542.99,,,542.99,Other,100% of Medicaid,542.99,,,542.99,Other,100% of Medicaid,542.99,,,542.99,Other,100% of Medicaid,1221.72,,,1221.72,Other,225% of Medicaid,830.77,,,830.77,Other,153% of Medicaid,1221.72,,,1221.72,Other,225% of Medicaid,760.18,,,760.18,Other,140% of Medicaid,1221.72,,,1221.72,Other,225% of Medicaid,1411.76,,,1411.76,Other,260% of Medicaid,1759.27,,,1759.27,Other,324% of Medicaid,1167.42,,,1167.42,Other,215% of Medicaid,1167.42,,,1167.42,Other,215% of Medicaid,678.73,,,678.73,Other,125% of Medicaid,542.99,2942.87,
MRI JOINT U EXT W AND WO CONTRAST RT,73223,CPT,TCRT,45273223,CDM,610,RC,,,both,,,3910,2893.41,,,2893.41,Other,150% of Medicare + 9.63% HCRA Surcharge,1759.5,45,,1759.5,percent of total billed charges,Critical Access Hospital RCC factor,1031.01,,,1031.01,Fee Schedule,,927.58,,,927.58,Fee Schedule,,3595.09,,,3595.09,Fee Schedule,,3233.53,,,3233.53,Fee Schedule,,3056.17,,,3056.17,Fee Schedule,,1935.45,,,1935.45,Other,110% of Medicare,1224.93,,,1224.93,Fee Schedule,,1010,,,1010,Other,186% of Medicaid,1441.47,,,1441.47,Fee Schedule,,2424.2,,,2424.2,Fee Schedule,,678.72,,,678.72,Fee Schedule,,1441.47,,,1441.47,Fee Schedule,,2424.2,,,2424.2,Fee Schedule,,1276.64,,,1276.64,Fee Schedule,,2737,70,,2737,percent of total billed charges,All Other,1772,,,1772,Case Rate,,1506,,,1506,Case Rate,,610.96,,,610.96,Fee Schedule,,610.96,,,610.96,Fee Schedule,,610.96,,,610.96,Fee Schedule,,610.96,,,610.96,Fee Schedule,,542.99,,,542.99,Other,100% of Medicaid,542.99,,,542.99,Other,100% of Medicaid,542.99,,,542.99,Other,100% of Medicaid,542.99,,,542.99,Other,100% of Medicaid,1221.72,,,1221.72,Other,225% of Medicaid,830.77,,,830.77,Other,153% of Medicaid,1221.72,,,1221.72,Other,225% of Medicaid,760.18,,,760.18,Other,140% of Medicaid,1221.72,,,1221.72,Other,225% of Medicaid,1411.76,,,1411.76,Other,260% of Medicaid,1759.27,,,1759.27,Other,324% of Medicaid,1167.42,,,1167.42,Other,215% of Medicaid,1167.42,,,1167.42,Other,215% of Medicaid,678.73,,,678.73,Other,125% of Medicaid,542.99,3595.09,
MRI L EXT WO CONTRAST RT,73718,CPT,TCRT,45273718,CDM,610,RC,,,both,,,2898,2144.53,,,2144.53,Other,150% of Medicare + 9.63% HCRA Surcharge,1304.1,45,,1304.1,percent of total billed charges,Critical Access Hospital RCC factor,577.96,,,577.96,Fee Schedule,,519.99,,,519.99,Fee Schedule,,2311.32,,,2311.32,Fee Schedule,,2078.87,,,2078.87,Fee Schedule,,1964.84,,,1964.84,Fee Schedule,,1434.51,,,1434.51,Other,110% of Medicare,686.67,,,686.67,Fee Schedule,,670,,,670,Other,186% of Medicaid,808.06,,,808.06,Fee Schedule,,1796.76,,,1796.76,Fee Schedule,,380.48,,,380.48,Fee Schedule,,808.06,,,808.06,Fee Schedule,,1796.76,,,1796.76,Fee Schedule,,715.66,,,715.66,Fee Schedule,,2028.6,70,,2028.6,percent of total billed charges,All Other,1772,,,1772,Case Rate,,1506,,,1506,Case Rate,,372.86,,,372.86,Fee Schedule,,372.86,,,372.86,Fee Schedule,,372.86,,,372.86,Fee Schedule,,372.86,,,372.86,Fee Schedule,,360.02,,,360.02,Other,100% of Medicaid,360.02,,,360.02,Other,100% of Medicaid,360.02,,,360.02,Other,100% of Medicaid,360.02,,,360.02,Other,100% of Medicaid,810.04,,,810.04,Other,225% of Medicaid,550.82,,,550.82,Other,153% of Medicaid,810.04,,,810.04,Other,225% of Medicaid,504.02,,,504.02,Other,140% of Medicaid,810.04,,,810.04,Other,225% of Medicaid,936.04,,,936.04,Other,260% of Medicaid,1166.45,,,1166.45,Other,324% of Medicaid,774.04,,,774.04,Other,215% of Medicaid,774.04,,,774.04,Other,215% of Medicaid,450.02,,,450.02,Other,125% of Medicaid,360.02,2311.32,
MRI L EXT W CONTRAST RT,73719,CPT,TCRT,45273719,CDM,610,RC,,,both,,,2712,2006.89,,,2006.89,Other,150% of Medicare + 9.63% HCRA Surcharge,1220.4,45,,1220.4,percent of total billed charges,Critical Access Hospital RCC factor,676.34,,,676.34,Fee Schedule,,608.5,,,608.5,Fee Schedule,,2942.87,,,2942.87,Fee Schedule,,2646.91,,,2646.91,Fee Schedule,,2501.72,,,2501.72,Fee Schedule,,1342.44,,,1342.44,Other,110% of Medicare,803.56,,,803.56,Fee Schedule,,1010,,,1010,Other,186% of Medicaid,945.61,,,945.61,Fee Schedule,,1681.44,,,1681.44,Fee Schedule,,445.24,,,445.24,Fee Schedule,,945.61,,,945.61,Fee Schedule,,1681.44,,,1681.44,Fee Schedule,,837.48,,,837.48,Fee Schedule,,1898.4,70,,1898.4,percent of total billed charges,All Other,1772,,,1772,Case Rate,,1506,,,1506,Case Rate,,610.96,,,610.96,Fee Schedule,,610.96,,,610.96,Fee Schedule,,610.96,,,610.96,Fee Schedule,,610.96,,,610.96,Fee Schedule,,542.99,,,542.99,Other,100% of Medicaid,542.99,,,542.99,Other,100% of Medicaid,542.99,,,542.99,Other,100% of Medicaid,542.99,,,542.99,Other,100% of Medicaid,1221.72,,,1221.72,Other,225% of Medicaid,830.77,,,830.77,Other,153% of Medicaid,1221.72,,,1221.72,Other,225% of Medicaid,760.18,,,760.18,Other,140% of Medicaid,1221.72,,,1221.72,Other,225% of Medicaid,1411.76,,,1411.76,Other,260% of Medicaid,1759.27,,,1759.27,Other,324% of Medicaid,1167.42,,,1167.42,Other,215% of Medicaid,1167.42,,,1167.42,Other,215% of Medicaid,678.73,,,678.73,Other,125% of Medicaid,445.24,2942.87,
MRI FEMUR W AND WO CONTRAST RT,73720,CPT,TCRT,45273720,CDM,610,RC,,,both,,,3910,2893.41,,,2893.41,Other,150% of Medicare + 9.63% HCRA Surcharge,1759.5,45,,1759.5,percent of total billed charges,Critical Access Hospital RCC factor,854.25,,,854.25,Fee Schedule,,768.56,,,768.56,Fee Schedule,,3595.09,,,3595.09,Fee Schedule,,3233.53,,,3233.53,Fee Schedule,,3056.17,,,3056.17,Fee Schedule,,1935.45,,,1935.45,Other,110% of Medicare,1014.92,,,1014.92,Fee Schedule,,1010,,,1010,Other,186% of Medicaid,1194.34,,,1194.34,Fee Schedule,,2424.2,,,2424.2,Fee Schedule,,562.36,,,562.36,Fee Schedule,,1194.34,,,1194.34,Fee Schedule,,2424.2,,,2424.2,Fee Schedule,,1057.77,,,1057.77,Fee Schedule,,2737,70,,2737,percent of total billed charges,All Other,1772,,,1772,Case Rate,,1506,,,1506,Case Rate,,610.96,,,610.96,Fee Schedule,,610.96,,,610.96,Fee Schedule,,610.96,,,610.96,Fee Schedule,,610.96,,,610.96,Fee Schedule,,542.99,,,542.99,Other,100% of Medicaid,542.99,,,542.99,Other,100% of Medicaid,542.99,,,542.99,Other,100% of Medicaid,542.99,,,542.99,Other,100% of Medicaid,1221.72,,,1221.72,Other,225% of Medicaid,830.77,,,830.77,Other,153% of Medicaid,1221.72,,,1221.72,Other,225% of Medicaid,760.18,,,760.18,Other,140% of Medicaid,1221.72,,,1221.72,Other,225% of Medicaid,1411.76,,,1411.76,Other,260% of Medicaid,1759.27,,,1759.27,Other,324% of Medicaid,1167.42,,,1167.42,Other,215% of Medicaid,1167.42,,,1167.42,Other,215% of Medicaid,678.73,,,678.73,Other,125% of Medicaid,542.99,3595.09,
MRI JOINT L EXT WO CONTRAST RT,73721,CPT,TCRT,45273721,CDM,610,RC,,,both,,,2898,2144.53,,,2144.53,Other,150% of Medicare + 9.63% HCRA Surcharge,1304.1,45,,1304.1,percent of total billed charges,Critical Access Hospital RCC factor,501.72,,,501.72,Fee Schedule,,451.39,,,451.39,Fee Schedule,,2311.32,,,2311.32,Fee Schedule,,2078.87,,,2078.87,Fee Schedule,,1964.84,,,1964.84,Fee Schedule,,1434.51,,,1434.51,Other,110% of Medicare,596.09,,,596.09,Fee Schedule,,670,,,670,Other,186% of Medicaid,701.47,,,701.47,Fee Schedule,,1796.76,,,1796.76,Fee Schedule,,330.29,,,330.29,Fee Schedule,,701.47,,,701.47,Fee Schedule,,1796.76,,,1796.76,Fee Schedule,,621.26,,,621.26,Fee Schedule,,2028.6,70,,2028.6,percent of total billed charges,All Other,1772,,,1772,Case Rate,,1506,,,1506,Case Rate,,372.86,,,372.86,Fee Schedule,,372.86,,,372.86,Fee Schedule,,372.86,,,372.86,Fee Schedule,,372.86,,,372.86,Fee Schedule,,360.02,,,360.02,Other,100% of Medicaid,360.02,,,360.02,Other,100% of Medicaid,360.02,,,360.02,Other,100% of Medicaid,360.02,,,360.02,Other,100% of Medicaid,810.04,,,810.04,Other,225% of Medicaid,550.82,,,550.82,Other,153% of Medicaid,810.04,,,810.04,Other,225% of Medicaid,504.02,,,504.02,Other,140% of Medicaid,810.04,,,810.04,Other,225% of Medicaid,936.04,,,936.04,Other,260% of Medicaid,1166.45,,,1166.45,Other,324% of Medicaid,774.04,,,774.04,Other,215% of Medicaid,774.04,,,774.04,Other,215% of Medicaid,450.02,,,450.02,Other,125% of Medicaid,330.29,2311.32,
MRI JOINT L EXT W CONTRAST RT,73722,CPT,TCRT,45273722,CDM,610,RC,,,both,,,3128,2314.73,,,2314.73,Other,150% of Medicare + 9.63% HCRA Surcharge,1407.6,45,,1407.6,percent of total billed charges,Critical Access Hospital RCC factor,855.4,,,855.4,Fee Schedule,,769.59,,,769.59,Fee Schedule,,2942.87,,,2942.87,Fee Schedule,,2646.91,,,2646.91,Fee Schedule,,2501.72,,,2501.72,Fee Schedule,,1548.36,,,1548.36,Other,110% of Medicare,1016.29,,,1016.29,Fee Schedule,,1010,,,1010,Other,186% of Medicaid,1195.95,,,1195.95,Fee Schedule,,1939.36,,,1939.36,Fee Schedule,,563.12,,,563.12,Fee Schedule,,1195.95,,,1195.95,Fee Schedule,,1939.36,,,1939.36,Fee Schedule,,1059.19,,,1059.19,Fee Schedule,,2189.6,70,,2189.6,percent of total billed charges,All Other,1772,,,1772,Case Rate,,1506,,,1506,Case Rate,,1089.31,,,1089.31,Fee Schedule,,1089.31,,,1089.31,Fee Schedule,,1089.31,,,1089.31,Fee Schedule,,1089.31,,,1089.31,Fee Schedule,,542.99,,,542.99,Other,100% of Medicaid,542.99,,,542.99,Other,100% of Medicaid,542.99,,,542.99,Other,100% of Medicaid,542.99,,,542.99,Other,100% of Medicaid,1221.72,,,1221.72,Other,225% of Medicaid,830.77,,,830.77,Other,153% of Medicaid,1221.72,,,1221.72,Other,225% of Medicaid,760.18,,,760.18,Other,140% of Medicaid,1221.72,,,1221.72,Other,225% of Medicaid,1411.76,,,1411.76,Other,260% of Medicaid,1759.27,,,1759.27,Other,324% of Medicaid,1167.42,,,1167.42,Other,215% of Medicaid,1167.42,,,1167.42,Other,215% of Medicaid,678.73,,,678.73,Other,125% of Medicaid,542.99,2942.87,
MRI JOINT L EXT W AND WO CONTRAST RT,73723,CPT,TCRT,45273723,CDM,610,RC,,,both,,,4261,3153.15,,,3153.15,Other,150% of Medicare + 9.63% HCRA Surcharge,1917.45,45,,1917.45,percent of total billed charges,Critical Access Hospital RCC factor,1026.38,,,1026.38,Fee Schedule,,923.42,,,923.42,Fee Schedule,,3595.09,,,3595.09,Fee Schedule,,3233.53,,,3233.53,Fee Schedule,,3056.17,,,3056.17,Fee Schedule,,2109.2,,,2109.2,Other,110% of Medicare,1219.43,,,1219.43,Fee Schedule,,1010,,,1010,Other,186% of Medicaid,1435.01,,,1435.01,Fee Schedule,,2641.82,,,2641.82,Fee Schedule,,675.68,,,675.68,Fee Schedule,,1435.01,,,1435.01,Fee Schedule,,2641.82,,,2641.82,Fee Schedule,,1270.91,,,1270.91,Fee Schedule,,2982.7,70,,2982.7,percent of total billed charges,All Other,1772,,,1772,Case Rate,,1506,,,1506,Case Rate,,610.96,,,610.96,Fee Schedule,,610.96,,,610.96,Fee Schedule,,610.96,,,610.96,Fee Schedule,,610.96,,,610.96,Fee Schedule,,542.99,,,542.99,Other,100% of Medicaid,542.99,,,542.99,Other,100% of Medicaid,542.99,,,542.99,Other,100% of Medicaid,542.99,,,542.99,Other,100% of Medicaid,1221.72,,,1221.72,Other,225% of Medicaid,830.77,,,830.77,Other,153% of Medicaid,1221.72,,,1221.72,Other,225% of Medicaid,760.18,,,760.18,Other,140% of Medicaid,1221.72,,,1221.72,Other,225% of Medicaid,1411.76,,,1411.76,Other,260% of Medicaid,1759.27,,,1759.27,Other,324% of Medicaid,1167.42,,,1167.42,Other,215% of Medicaid,1167.42,,,1167.42,Other,215% of Medicaid,678.73,,,678.73,Other,125% of Medicaid,542.99,3595.09,
MRI BRAIN W O CONTRAST,70551,CPT,TC,45070551,CDM,611,RC,,,both,,,2898,2144.53,,,2144.53,Other,150% of Medicare + 9.63% HCRA Surcharge,1304.1,45,,1304.1,percent of total billed charges,Critical Access Hospital RCC factor,458.98,,,458.98,Fee Schedule,,412.94,,,412.94,Fee Schedule,,2311.32,,,2311.32,Fee Schedule,,2078.87,,,2078.87,Fee Schedule,,1964.84,,,1964.84,Fee Schedule,,1434.51,,,1434.51,Other,110% of Medicare,545.31,,,545.31,Fee Schedule,,670,,,670,Other,186% of Medicaid,641.7,,,641.7,Fee Schedule,,1796.76,,,1796.76,Fee Schedule,,302.15,,,302.15,Fee Schedule,,641.7,,,641.7,Fee Schedule,,1796.76,,,1796.76,Fee Schedule,,568.33,,,568.33,Fee Schedule,,2028.6,70,,2028.6,percent of total billed charges,All Other,1772,,,1772,Case Rate,,1506,,,1506,Case Rate,,372.86,,,372.86,Fee Schedule,,372.86,,,372.86,Fee Schedule,,372.86,,,372.86,Fee Schedule,,372.86,,,372.86,Fee Schedule,,360.02,,,360.02,Other,100% of Medicaid,360.02,,,360.02,Other,100% of Medicaid,360.02,,,360.02,Other,100% of Medicaid,360.02,,,360.02,Other,100% of Medicaid,810.04,,,810.04,Other,225% of Medicaid,550.82,,,550.82,Other,153% of Medicaid,810.04,,,810.04,Other,225% of Medicaid,504.02,,,504.02,Other,140% of Medicaid,810.04,,,810.04,Other,225% of Medicaid,936.04,,,936.04,Other,260% of Medicaid,1166.45,,,1166.45,Other,324% of Medicaid,774.04,,,774.04,Other,215% of Medicaid,774.04,,,774.04,Other,215% of Medicaid,450.02,,,450.02,Other,125% of Medicaid,302.15,2311.32,
MRI BRAIN W CONTRAST,70552,CPT,TC,45070552,CDM,611,RC,,,both,,,3410,2523.41,,,2523.41,Other,150% of Medicare + 9.63% HCRA Surcharge,1534.5,45,,1534.5,percent of total billed charges,Critical Access Hospital RCC factor,675.2,,,675.2,Fee Schedule,,607.46,,,607.46,Fee Schedule,,2942.87,,,2942.87,Fee Schedule,,2646.91,,,2646.91,Fee Schedule,,2501.72,,,2501.72,Fee Schedule,,1687.95,,,1687.95,Other,110% of Medicare,802.19,,,802.19,Fee Schedule,,1010,,,1010,Other,186% of Medicaid,944,,,944,Fee Schedule,,2114.2,,,2114.2,Fee Schedule,,444.49,,,444.49,Fee Schedule,,944,,,944,Fee Schedule,,2114.2,,,2114.2,Fee Schedule,,836.06,,,836.06,Fee Schedule,,2387,70,,2387,percent of total billed charges,All Other,1772,,,1772,Case Rate,,1506,,,1506,Case Rate,,610.96,,,610.96,Fee Schedule,,610.96,,,610.96,Fee Schedule,,610.96,,,610.96,Fee Schedule,,610.96,,,610.96,Fee Schedule,,542.99,,,542.99,Other,100% of Medicaid,542.99,,,542.99,Other,100% of Medicaid,542.99,,,542.99,Other,100% of Medicaid,542.99,,,542.99,Other,100% of Medicaid,1221.72,,,1221.72,Other,225% of Medicaid,830.77,,,830.77,Other,153% of Medicaid,1221.72,,,1221.72,Other,225% of Medicaid,760.18,,,760.18,Other,140% of Medicaid,1221.72,,,1221.72,Other,225% of Medicaid,1411.76,,,1411.76,Other,260% of Medicaid,1759.27,,,1759.27,Other,324% of Medicaid,1167.42,,,1167.42,Other,215% of Medicaid,1167.42,,,1167.42,Other,215% of Medicaid,678.73,,,678.73,Other,125% of Medicaid,444.49,2942.87,
MRI BRAIN W AND WO CONTRAST,70553,CPT,TC,45070553,CDM,611,RC,,,both,,,4261,3153.15,,,3153.15,Other,150% of Medicare + 9.63% HCRA Surcharge,1917.45,45,,1917.45,percent of total billed charges,Critical Access Hospital RCC factor,764.13,,,764.13,Fee Schedule,,687.48,,,687.48,Fee Schedule,,3595.09,,,3595.09,Fee Schedule,,3233.53,,,3233.53,Fee Schedule,,3056.17,,,3056.17,Fee Schedule,,2109.2,,,2109.2,Other,110% of Medicare,907.86,,,907.86,Fee Schedule,,1010,,,1010,Other,186% of Medicaid,1068.35,,,1068.35,Fee Schedule,,2641.82,,,2641.82,Fee Schedule,,503.03,,,503.03,Fee Schedule,,1068.35,,,1068.35,Fee Schedule,,2641.82,,,2641.82,Fee Schedule,,946.18,,,946.18,Fee Schedule,,2982.7,70,,2982.7,percent of total billed charges,All Other,1772,,,1772,Case Rate,,1506,,,1506,Case Rate,,610.96,,,610.96,Fee Schedule,,610.96,,,610.96,Fee Schedule,,610.96,,,610.96,Fee Schedule,,610.96,,,610.96,Fee Schedule,,542.99,,,542.99,Other,100% of Medicaid,542.99,,,542.99,Other,100% of Medicaid,542.99,,,542.99,Other,100% of Medicaid,542.99,,,542.99,Other,100% of Medicaid,1221.72,,,1221.72,Other,225% of Medicaid,830.77,,,830.77,Other,153% of Medicaid,1221.72,,,1221.72,Other,225% of Medicaid,760.18,,,760.18,Other,140% of Medicaid,1221.72,,,1221.72,Other,225% of Medicaid,1411.76,,,1411.76,Other,260% of Medicaid,1759.27,,,1759.27,Other,324% of Medicaid,1167.42,,,1167.42,Other,215% of Medicaid,1167.42,,,1167.42,Other,215% of Medicaid,678.73,,,678.73,Other,125% of Medicaid,503.03,3595.09,
MRI BRAIN W/WO CONTRAST W/PITUITARY MOD,70553,CPT,TC59,45170553,CDM,611,RC,,,both,,,4261,3153.15,,,3153.15,Other,150% of Medicare + 9.63% HCRA Surcharge,1917.45,45,,1917.45,percent of total billed charges,Critical Access Hospital RCC factor,764.13,,,764.13,Fee Schedule,,687.48,,,687.48,Fee Schedule,,3595.09,,,3595.09,Fee Schedule,,3233.53,,,3233.53,Fee Schedule,,3056.17,,,3056.17,Fee Schedule,,2109.2,,,2109.2,Other,110% of Medicare,907.86,,,907.86,Fee Schedule,,1010,,,1010,Other,186% of Medicaid,1068.35,,,1068.35,Fee Schedule,,2641.82,,,2641.82,Fee Schedule,,503.03,,,503.03,Fee Schedule,,1068.35,,,1068.35,Fee Schedule,,2641.82,,,2641.82,Fee Schedule,,946.18,,,946.18,Fee Schedule,,2982.7,70,,2982.7,percent of total billed charges,All Other,1772,,,1772,Case Rate,,1506,,,1506,Case Rate,,610.96,,,610.96,Fee Schedule,,610.96,,,610.96,Fee Schedule,,610.96,,,610.96,Fee Schedule,,610.96,,,610.96,Fee Schedule,,542.99,,,542.99,Other,100% of Medicaid,542.99,,,542.99,Other,100% of Medicaid,542.99,,,542.99,Other,100% of Medicaid,542.99,,,542.99,Other,100% of Medicaid,1221.72,,,1221.72,Other,225% of Medicaid,830.77,,,830.77,Other,153% of Medicaid,1221.72,,,1221.72,Other,225% of Medicaid,760.18,,,760.18,Other,140% of Medicaid,1221.72,,,1221.72,Other,225% of Medicaid,1411.76,,,1411.76,Other,260% of Medicaid,1759.27,,,1759.27,Other,324% of Medicaid,1167.42,,,1167.42,Other,215% of Medicaid,1167.42,,,1167.42,Other,215% of Medicaid,678.73,,,678.73,Other,125% of Medicaid,503.03,3595.09,
MRI BRAIN W/WO CONTRAST W/IACS MOD,70553,CPT,TC59,45270553,CDM,611,RC,,,both,,,4261,3153.15,,,3153.15,Other,150% of Medicare + 9.63% HCRA Surcharge,1917.45,45,,1917.45,percent of total billed charges,Critical Access Hospital RCC factor,764.13,,,764.13,Fee Schedule,,687.48,,,687.48,Fee Schedule,,3595.09,,,3595.09,Fee Schedule,,3233.53,,,3233.53,Fee Schedule,,3056.17,,,3056.17,Fee Schedule,,2109.2,,,2109.2,Other,110% of Medicare,907.86,,,907.86,Fee Schedule,,1010,,,1010,Other,186% of Medicaid,1068.35,,,1068.35,Fee Schedule,,2641.82,,,2641.82,Fee Schedule,,503.03,,,503.03,Fee Schedule,,1068.35,,,1068.35,Fee Schedule,,2641.82,,,2641.82,Fee Schedule,,946.18,,,946.18,Fee Schedule,,2982.7,70,,2982.7,percent of total billed charges,All Other,1772,,,1772,Case Rate,,1506,,,1506,Case Rate,,610.96,,,610.96,Fee Schedule,,610.96,,,610.96,Fee Schedule,,610.96,,,610.96,Fee Schedule,,610.96,,,610.96,Fee Schedule,,542.99,,,542.99,Other,100% of Medicaid,542.99,,,542.99,Other,100% of Medicaid,542.99,,,542.99,Other,100% of Medicaid,542.99,,,542.99,Other,100% of Medicaid,1221.72,,,1221.72,Other,225% of Medicaid,830.77,,,830.77,Other,153% of Medicaid,1221.72,,,1221.72,Other,225% of Medicaid,760.18,,,760.18,Other,140% of Medicaid,1221.72,,,1221.72,Other,225% of Medicaid,1411.76,,,1411.76,Other,260% of Medicaid,1759.27,,,1759.27,Other,324% of Medicaid,1167.42,,,1167.42,Other,215% of Medicaid,1167.42,,,1167.42,Other,215% of Medicaid,678.73,,,678.73,Other,125% of Medicaid,503.03,3595.09,
MRI C SPINE WO CONTRAST,72141,CPT,TC,45072141,CDM,612,RC,,,both,,,2898,2144.53,,,2144.53,Other,150% of Medicare + 9.63% HCRA Surcharge,1304.1,45,,1304.1,percent of total billed charges,Critical Access Hospital RCC factor,439.33,,,439.33,Fee Schedule,,395.26,,,395.26,Fee Schedule,,2309.05,,,2309.05,Fee Schedule,,2076.83,,,2076.83,Fee Schedule,,1962.91,,,1962.91,Fee Schedule,,1434.51,,,1434.51,Other,110% of Medicare,521.96,,,521.96,Fee Schedule,,670,,,670,Other,186% of Medicaid,614.23,,,614.23,Fee Schedule,,1796.76,,,1796.76,Fee Schedule,,289.21,,,289.21,Fee Schedule,,614.23,,,614.23,Fee Schedule,,1796.76,,,1796.76,Fee Schedule,,543.99,,,543.99,Fee Schedule,,2028.6,70,,2028.6,percent of total billed charges,All Other,1772,,,1772,Case Rate,,1506,,,1506,Case Rate,,372.86,,,372.86,Fee Schedule,,372.86,,,372.86,Fee Schedule,,372.86,,,372.86,Fee Schedule,,372.86,,,372.86,Fee Schedule,,360.02,,,360.02,Other,100% of Medicaid,360.02,,,360.02,Other,100% of Medicaid,360.02,,,360.02,Other,100% of Medicaid,360.02,,,360.02,Other,100% of Medicaid,810.04,,,810.04,Other,225% of Medicaid,550.82,,,550.82,Other,153% of Medicaid,810.04,,,810.04,Other,225% of Medicaid,504.02,,,504.02,Other,140% of Medicaid,810.04,,,810.04,Other,225% of Medicaid,936.04,,,936.04,Other,260% of Medicaid,1166.45,,,1166.45,Other,324% of Medicaid,774.04,,,774.04,Other,215% of Medicaid,774.04,,,774.04,Other,215% of Medicaid,450.02,,,450.02,Other,125% of Medicaid,289.21,2309.05,
MRI C SPINE W CONTRAST,72142,CPT,TC,45072142,CDM,612,RC,,,both,,,3348,2477.53,,,2477.53,Other,150% of Medicare + 9.63% HCRA Surcharge,1506.6,45,,1506.6,percent of total billed charges,Critical Access Hospital RCC factor,691.37,,,691.37,Fee Schedule,,622.02,,,622.02,Fee Schedule,,2942.87,,,2942.87,Fee Schedule,,2646.91,,,2646.91,Fee Schedule,,2501.72,,,2501.72,Fee Schedule,,1657.26,,,1657.26,Other,110% of Medicare,821.41,,,821.41,Fee Schedule,,1010,,,1010,Other,186% of Medicaid,966.62,,,966.62,Fee Schedule,,2075.76,,,2075.76,Fee Schedule,,455.13,,,455.13,Fee Schedule,,966.62,,,966.62,Fee Schedule,,2075.76,,,2075.76,Fee Schedule,,856.08,,,856.08,Fee Schedule,,2343.6,70,,2343.6,percent of total billed charges,All Other,1772,,,1772,Case Rate,,1506,,,1506,Case Rate,,610.96,,,610.96,Fee Schedule,,610.96,,,610.96,Fee Schedule,,610.96,,,610.96,Fee Schedule,,610.96,,,610.96,Fee Schedule,,542.99,,,542.99,Other,100% of Medicaid,542.99,,,542.99,Other,100% of Medicaid,542.99,,,542.99,Other,100% of Medicaid,542.99,,,542.99,Other,100% of Medicaid,1221.72,,,1221.72,Other,225% of Medicaid,830.77,,,830.77,Other,153% of Medicaid,1221.72,,,1221.72,Other,225% of Medicaid,760.18,,,760.18,Other,140% of Medicaid,1221.72,,,1221.72,Other,225% of Medicaid,1411.76,,,1411.76,Other,260% of Medicaid,1759.27,,,1759.27,Other,324% of Medicaid,1167.42,,,1167.42,Other,215% of Medicaid,1167.42,,,1167.42,Other,215% of Medicaid,678.73,,,678.73,Other,125% of Medicaid,455.13,2942.87,
MRI T SPINE WO CONTRAST,72146,CPT,TC,45072146,CDM,612,RC,,,both,,,2898,2144.53,,,2144.53,Other,150% of Medicare + 9.63% HCRA Surcharge,1304.1,45,,1304.1,percent of total billed charges,Critical Access Hospital RCC factor,438.18,,,438.18,Fee Schedule,,394.22,,,394.22,Fee Schedule,,2309.05,,,2309.05,Fee Schedule,,2076.83,,,2076.83,Fee Schedule,,1962.91,,,1962.91,Fee Schedule,,1434.51,,,1434.51,Other,110% of Medicare,520.59,,,520.59,Fee Schedule,,670,,,670,Other,186% of Medicaid,612.63,,,612.63,Fee Schedule,,1796.76,,,1796.76,Fee Schedule,,288.46,,,288.46,Fee Schedule,,612.63,,,612.63,Fee Schedule,,1796.76,,,1796.76,Fee Schedule,,542.57,,,542.57,Fee Schedule,,2028.6,70,,2028.6,percent of total billed charges,All Other,1772,,,1772,Case Rate,,1506,,,1506,Case Rate,,372.86,,,372.86,Fee Schedule,,372.86,,,372.86,Fee Schedule,,372.86,,,372.86,Fee Schedule,,372.86,,,372.86,Fee Schedule,,360.02,,,360.02,Other,100% of Medicaid,360.02,,,360.02,Other,100% of Medicaid,360.02,,,360.02,Other,100% of Medicaid,360.02,,,360.02,Other,100% of Medicaid,810.04,,,810.04,Other,225% of Medicaid,550.82,,,550.82,Other,153% of Medicaid,810.04,,,810.04,Other,225% of Medicaid,504.02,,,504.02,Other,140% of Medicaid,810.04,,,810.04,Other,225% of Medicaid,936.04,,,936.04,Other,260% of Medicaid,1166.45,,,1166.45,Other,324% of Medicaid,774.04,,,774.04,Other,215% of Medicaid,774.04,,,774.04,Other,215% of Medicaid,450.02,,,450.02,Other,125% of Medicaid,288.46,2309.05,
MRI SPINE THORACIC W CONTRAST,72147,CPT,TC,45072147,CDM,612,RC,,,both,,,3791,2805.35,,,2805.35,Other,150% of Medicare + 9.63% HCRA Surcharge,1705.95,45,,1705.95,percent of total billed charges,Critical Access Hospital RCC factor,684.41,,,684.41,Fee Schedule,,615.76,,,615.76,Fee Schedule,,2913.15,,,2913.15,Fee Schedule,,2620.18,,,2620.18,Fee Schedule,,2476.45,,,2476.45,Fee Schedule,,1876.55,,,1876.55,Other,110% of Medicare,813.14,,,813.14,Fee Schedule,,1010,,,1010,Other,186% of Medicaid,956.89,,,956.89,Fee Schedule,,2350.42,,,2350.42,Fee Schedule,,450.56,,,450.56,Fee Schedule,,956.89,,,956.89,Fee Schedule,,2350.42,,,2350.42,Fee Schedule,,847.47,,,847.47,Fee Schedule,,2653.7,70,,2653.7,percent of total billed charges,All Other,1772,,,1772,Case Rate,,1506,,,1506,Case Rate,,610.96,,,610.96,Fee Schedule,,610.96,,,610.96,Fee Schedule,,610.96,,,610.96,Fee Schedule,,610.96,,,610.96,Fee Schedule,,542.99,,,542.99,Other,100% of Medicaid,542.99,,,542.99,Other,100% of Medicaid,542.99,,,542.99,Other,100% of Medicaid,542.99,,,542.99,Other,100% of Medicaid,1221.72,,,1221.72,Other,225% of Medicaid,830.77,,,830.77,Other,153% of Medicaid,1221.72,,,1221.72,Other,225% of Medicaid,760.18,,,760.18,Other,140% of Medicaid,1221.72,,,1221.72,Other,225% of Medicaid,1411.76,,,1411.76,Other,260% of Medicaid,1759.27,,,1759.27,Other,324% of Medicaid,1167.42,,,1167.42,Other,215% of Medicaid,1167.42,,,1167.42,Other,215% of Medicaid,678.73,,,678.73,Other,125% of Medicaid,450.56,2913.15,
MRI L SPINE WO CONTRAST,72148,CPT,TC,45072148,CDM,612,RC,,,both,,,2898,2144.53,,,2144.53,Other,150% of Medicare + 9.63% HCRA Surcharge,1304.1,45,,1304.1,percent of total billed charges,Critical Access Hospital RCC factor,440.51,,,440.51,Fee Schedule,,396.32,,,396.32,Fee Schedule,,2309.05,,,2309.05,Fee Schedule,,2076.83,,,2076.83,Fee Schedule,,1962.91,,,1962.91,Fee Schedule,,1434.51,,,1434.51,Other,110% of Medicare,523.36,,,523.36,Fee Schedule,,670,,,670,Other,186% of Medicaid,615.88,,,615.88,Fee Schedule,,1796.76,,,1796.76,Fee Schedule,,289.99,,,289.99,Fee Schedule,,615.88,,,615.88,Fee Schedule,,1796.76,,,1796.76,Fee Schedule,,545.46,,,545.46,Fee Schedule,,2028.6,70,,2028.6,percent of total billed charges,All Other,1772,,,1772,Case Rate,,1506,,,1506,Case Rate,,372.86,,,372.86,Fee Schedule,,372.86,,,372.86,Fee Schedule,,372.86,,,372.86,Fee Schedule,,372.86,,,372.86,Fee Schedule,,360.02,,,360.02,Other,100% of Medicaid,360.02,,,360.02,Other,100% of Medicaid,360.02,,,360.02,Other,100% of Medicaid,360.02,,,360.02,Other,100% of Medicaid,810.04,,,810.04,Other,225% of Medicaid,550.82,,,550.82,Other,153% of Medicaid,810.04,,,810.04,Other,225% of Medicaid,504.02,,,504.02,Other,140% of Medicaid,810.04,,,810.04,Other,225% of Medicaid,936.04,,,936.04,Other,260% of Medicaid,1166.45,,,1166.45,Other,324% of Medicaid,774.04,,,774.04,Other,215% of Medicaid,774.04,,,774.04,Other,215% of Medicaid,450.02,,,450.02,Other,125% of Medicaid,289.99,2309.05,
MRI L SPINE W CONTRAST,72149,CPT,TC,45072149,CDM,612,RC,,,both,,,3648,2699.53,,,2699.53,Other,150% of Medicare + 9.63% HCRA Surcharge,1641.6,45,,1641.6,percent of total billed charges,Critical Access Hospital RCC factor,675.2,,,675.2,Fee Schedule,,607.46,,,607.46,Fee Schedule,,2942.87,,,2942.87,Fee Schedule,,2646.91,,,2646.91,Fee Schedule,,2501.72,,,2501.72,Fee Schedule,,1805.76,,,1805.76,Other,110% of Medicare,802.19,,,802.19,Fee Schedule,,1010,,,1010,Other,186% of Medicaid,944,,,944,Fee Schedule,,2261.76,,,2261.76,Fee Schedule,,444.49,,,444.49,Fee Schedule,,944,,,944,Fee Schedule,,2261.76,,,2261.76,Fee Schedule,,836.06,,,836.06,Fee Schedule,,2553.6,70,,2553.6,percent of total billed charges,All Other,1772,,,1772,Case Rate,,1506,,,1506,Case Rate,,610.96,,,610.96,Fee Schedule,,610.96,,,610.96,Fee Schedule,,610.96,,,610.96,Fee Schedule,,610.96,,,610.96,Fee Schedule,,542.99,,,542.99,Other,100% of Medicaid,542.99,,,542.99,Other,100% of Medicaid,542.99,,,542.99,Other,100% of Medicaid,542.99,,,542.99,Other,100% of Medicaid,1221.72,,,1221.72,Other,225% of Medicaid,830.77,,,830.77,Other,153% of Medicaid,1221.72,,,1221.72,Other,225% of Medicaid,760.18,,,760.18,Other,140% of Medicaid,1221.72,,,1221.72,Other,225% of Medicaid,1411.76,,,1411.76,Other,260% of Medicaid,1759.27,,,1759.27,Other,324% of Medicaid,1167.42,,,1167.42,Other,215% of Medicaid,1167.42,,,1167.42,Other,215% of Medicaid,678.73,,,678.73,Other,125% of Medicaid,444.49,2942.87,
MRI C SPINE W AND WO CONTRAST,72156,CPT,TC,45072156,CDM,612,RC,,,both,,,4261,3153.15,,,3153.15,Other,150% of Medicare + 9.63% HCRA Surcharge,1917.45,45,,1917.45,percent of total billed charges,Critical Access Hospital RCC factor,768.76,,,768.76,Fee Schedule,,691.64,,,691.64,Fee Schedule,,3595.09,,,3595.09,Fee Schedule,,3233.53,,,3233.53,Fee Schedule,,3056.17,,,3056.17,Fee Schedule,,2109.2,,,2109.2,Other,110% of Medicare,913.35,,,913.35,Fee Schedule,,1010,,,1010,Other,186% of Medicaid,1074.82,,,1074.82,Fee Schedule,,2641.82,,,2641.82,Fee Schedule,,506.08,,,506.08,Fee Schedule,,1074.82,,,1074.82,Fee Schedule,,2641.82,,,2641.82,Fee Schedule,,951.91,,,951.91,Fee Schedule,,2982.7,70,,2982.7,percent of total billed charges,All Other,1772,,,1772,Case Rate,,1506,,,1506,Case Rate,,610.96,,,610.96,Fee Schedule,,610.96,,,610.96,Fee Schedule,,610.96,,,610.96,Fee Schedule,,610.96,,,610.96,Fee Schedule,,542.99,,,542.99,Other,100% of Medicaid,542.99,,,542.99,Other,100% of Medicaid,542.99,,,542.99,Other,100% of Medicaid,542.99,,,542.99,Other,100% of Medicaid,1221.72,,,1221.72,Other,225% of Medicaid,830.77,,,830.77,Other,153% of Medicaid,1221.72,,,1221.72,Other,225% of Medicaid,760.18,,,760.18,Other,140% of Medicaid,1221.72,,,1221.72,Other,225% of Medicaid,1411.76,,,1411.76,Other,260% of Medicaid,1759.27,,,1759.27,Other,324% of Medicaid,1167.42,,,1167.42,Other,215% of Medicaid,1167.42,,,1167.42,Other,215% of Medicaid,678.73,,,678.73,Other,125% of Medicaid,506.08,3595.09,
MRI T SPINE W AND WO CONTRAST,72157,CPT,TC,45072157,CDM,612,RC,,,both,,,4261,3153.15,,,3153.15,Other,150% of Medicare + 9.63% HCRA Surcharge,1917.45,45,,1917.45,percent of total billed charges,Critical Access Hospital RCC factor,771.05,,,771.05,Fee Schedule,,693.71,,,693.71,Fee Schedule,,3595.09,,,3595.09,Fee Schedule,,3233.53,,,3233.53,Fee Schedule,,3056.17,,,3056.17,Fee Schedule,,2109.2,,,2109.2,Other,110% of Medicare,916.08,,,916.08,Fee Schedule,,1010,,,1010,Other,186% of Medicaid,1078.03,,,1078.03,Fee Schedule,,2641.82,,,2641.82,Fee Schedule,,507.59,,,507.59,Fee Schedule,,1078.03,,,1078.03,Fee Schedule,,2641.82,,,2641.82,Fee Schedule,,954.75,,,954.75,Fee Schedule,,2982.7,70,,2982.7,percent of total billed charges,All Other,1772,,,1772,Case Rate,,1506,,,1506,Case Rate,,610.96,,,610.96,Fee Schedule,,610.96,,,610.96,Fee Schedule,,610.96,,,610.96,Fee Schedule,,610.96,,,610.96,Fee Schedule,,542.99,,,542.99,Other,100% of Medicaid,542.99,,,542.99,Other,100% of Medicaid,542.99,,,542.99,Other,100% of Medicaid,542.99,,,542.99,Other,100% of Medicaid,1221.72,,,1221.72,Other,225% of Medicaid,830.77,,,830.77,Other,153% of Medicaid,1221.72,,,1221.72,Other,225% of Medicaid,760.18,,,760.18,Other,140% of Medicaid,1221.72,,,1221.72,Other,225% of Medicaid,1411.76,,,1411.76,Other,260% of Medicaid,1759.27,,,1759.27,Other,324% of Medicaid,1167.42,,,1167.42,Other,215% of Medicaid,1167.42,,,1167.42,Other,215% of Medicaid,678.73,,,678.73,Other,125% of Medicaid,507.59,3595.09,
MRI L SPINE W AND WO CONTRAST,72158,CPT,TC,45072158,CDM,612,RC,,,both,,,4261,3153.15,,,3153.15,Other,150% of Medicare + 9.63% HCRA Surcharge,1917.45,45,,1917.45,percent of total billed charges,Critical Access Hospital RCC factor,766.46,,,766.46,Fee Schedule,,689.57,,,689.57,Fee Schedule,,3595.09,,,3595.09,Fee Schedule,,3233.53,,,3233.53,Fee Schedule,,3056.17,,,3056.17,Fee Schedule,,2109.2,,,2109.2,Other,110% of Medicare,910.62,,,910.62,Fee Schedule,,1010,,,1010,Other,186% of Medicaid,1071.6,,,1071.6,Fee Schedule,,2641.82,,,2641.82,Fee Schedule,,504.57,,,504.57,Fee Schedule,,1071.6,,,1071.6,Fee Schedule,,2641.82,,,2641.82,Fee Schedule,,949.07,,,949.07,Fee Schedule,,2982.7,70,,2982.7,percent of total billed charges,All Other,1772,,,1772,Case Rate,,1506,,,1506,Case Rate,,610.96,,,610.96,Fee Schedule,,610.96,,,610.96,Fee Schedule,,610.96,,,610.96,Fee Schedule,,610.96,,,610.96,Fee Schedule,,542.99,,,542.99,Other,100% of Medicaid,542.99,,,542.99,Other,100% of Medicaid,542.99,,,542.99,Other,100% of Medicaid,542.99,,,542.99,Other,100% of Medicaid,1221.72,,,1221.72,Other,225% of Medicaid,830.77,,,830.77,Other,153% of Medicaid,1221.72,,,1221.72,Other,225% of Medicaid,760.18,,,760.18,Other,140% of Medicaid,1221.72,,,1221.72,Other,225% of Medicaid,1411.76,,,1411.76,Other,260% of Medicaid,1759.27,,,1759.27,Other,324% of Medicaid,1167.42,,,1167.42,Other,215% of Medicaid,1167.42,,,1167.42,Other,215% of Medicaid,678.73,,,678.73,Other,125% of Medicaid,504.57,3595.09,
MRA HEAD WO CONTRAST,70544,CPT,TC,45070544,CDM,615,RC,,,both,,,2947,2180.79,,,2180.79,Other,150% of Medicare + 9.63% HCRA Surcharge,1326.15,45,,1326.15,percent of total billed charges,Critical Access Hospital RCC factor,574.68,,,574.68,Fee Schedule,,517.03,,,517.03,Fee Schedule,,2311.32,,,2311.32,Fee Schedule,,2078.87,,,2078.87,Fee Schedule,,1964.84,,,1964.84,Fee Schedule,,1458.77,,,1458.77,Other,110% of Medicare,682.77,,,682.77,Fee Schedule,,858,,,858,Other,186% of Medicaid,803.47,,,803.47,Fee Schedule,,1827.14,,,1827.14,Fee Schedule,,378.32,,,378.32,Fee Schedule,,803.47,,,803.47,Fee Schedule,,1827.14,,,1827.14,Fee Schedule,,711.59,,,711.59,Fee Schedule,,2062.9,70,,2062.9,percent of total billed charges,All Other,1772,,,1772,Case Rate,,1506,,,1506,Case Rate,,372.86,,,372.86,Fee Schedule,,372.86,,,372.86,Fee Schedule,,372.86,,,372.86,Fee Schedule,,372.86,,,372.86,Fee Schedule,,461.02,,,461.02,Other,100% of Medicaid,461.02,,,461.02,Other,100% of Medicaid,461.02,,,461.02,Other,100% of Medicaid,461.02,,,461.02,Other,100% of Medicaid,1037.31,,,1037.31,Other,225% of Medicaid,705.37,,,705.37,Other,153% of Medicaid,1037.31,,,1037.31,Other,225% of Medicaid,645.43,,,645.43,Other,140% of Medicaid,1037.31,,,1037.31,Other,225% of Medicaid,1198.66,,,1198.66,Other,260% of Medicaid,1493.72,,,1493.72,Other,324% of Medicaid,991.2,,,991.2,Other,215% of Medicaid,991.2,,,991.2,Other,215% of Medicaid,576.28,,,576.28,Other,125% of Medicaid,372.86,2311.32,
MRA HEAD W CONTRAST,70545,CPT,TC,45070545,CDM,615,RC,,,both,,,2816,2083.85,,,2083.85,Other,150% of Medicare + 9.63% HCRA Surcharge,1267.2,45,,1267.2,percent of total billed charges,Critical Access Hospital RCC factor,616.28,,,616.28,Fee Schedule,,554.46,,,554.46,Fee Schedule,,2942.87,,,2942.87,Fee Schedule,,2646.91,,,2646.91,Fee Schedule,,2501.72,,,2501.72,Fee Schedule,,1393.92,,,1393.92,Other,110% of Medicare,732.19,,,732.19,Fee Schedule,,858,,,858,Other,186% of Medicaid,861.63,,,861.63,Fee Schedule,,1745.92,,,1745.92,Fee Schedule,,405.7,,,405.7,Fee Schedule,,861.63,,,861.63,Fee Schedule,,1745.92,,,1745.92,Fee Schedule,,763.1,,,763.1,Fee Schedule,,1971.2,70,,1971.2,percent of total billed charges,All Other,1772,,,1772,Case Rate,,1506,,,1506,Case Rate,,610.96,,,610.96,Fee Schedule,,610.96,,,610.96,Fee Schedule,,610.96,,,610.96,Fee Schedule,,610.96,,,610.96,Fee Schedule,,461.02,,,461.02,Other,100% of Medicaid,461.02,,,461.02,Other,100% of Medicaid,461.02,,,461.02,Other,100% of Medicaid,461.02,,,461.02,Other,100% of Medicaid,1037.31,,,1037.31,Other,225% of Medicaid,705.37,,,705.37,Other,153% of Medicaid,1037.31,,,1037.31,Other,225% of Medicaid,645.43,,,645.43,Other,140% of Medicaid,1037.31,,,1037.31,Other,225% of Medicaid,1198.66,,,1198.66,Other,260% of Medicaid,1493.72,,,1493.72,Other,324% of Medicaid,991.2,,,991.2,Other,215% of Medicaid,991.2,,,991.2,Other,215% of Medicaid,576.28,,,576.28,Other,125% of Medicaid,405.7,2942.87,
MRA HEAD W AND WO CONTRAST,70546,CPT,TC,45070546,CDM,615,RC,,,both,,,4144,3066.57,,,3066.57,Other,150% of Medicare + 9.63% HCRA Surcharge,1864.8,45,,1864.8,percent of total billed charges,Critical Access Hospital RCC factor,937.6,,,937.6,Fee Schedule,,843.55,,,843.55,Fee Schedule,,3595.09,,,3595.09,Fee Schedule,,3233.53,,,3233.53,Fee Schedule,,3056.17,,,3056.17,Fee Schedule,,2051.28,,,2051.28,Other,110% of Medicare,1113.96,,,1113.96,Fee Schedule,,858,,,858,Other,186% of Medicaid,1310.88,,,1310.88,Fee Schedule,,2569.28,,,2569.28,Fee Schedule,,617.23,,,617.23,Fee Schedule,,1310.88,,,1310.88,Fee Schedule,,2569.28,,,2569.28,Fee Schedule,,1160.98,,,1160.98,Fee Schedule,,2900.8,70,,2900.8,percent of total billed charges,All Other,1772,,,1772,Case Rate,,1506,,,1506,Case Rate,,610.96,,,610.96,Fee Schedule,,610.96,,,610.96,Fee Schedule,,610.96,,,610.96,Fee Schedule,,610.96,,,610.96,Fee Schedule,,461.02,,,461.02,Other,100% of Medicaid,461.02,,,461.02,Other,100% of Medicaid,461.02,,,461.02,Other,100% of Medicaid,461.02,,,461.02,Other,100% of Medicaid,1037.31,,,1037.31,Other,225% of Medicaid,705.37,,,705.37,Other,153% of Medicaid,1037.31,,,1037.31,Other,225% of Medicaid,645.43,,,645.43,Other,140% of Medicaid,1037.31,,,1037.31,Other,225% of Medicaid,1198.66,,,1198.66,Other,260% of Medicaid,1493.72,,,1493.72,Other,324% of Medicaid,991.2,,,991.2,Other,215% of Medicaid,991.2,,,991.2,Other,215% of Medicaid,576.28,,,576.28,Other,125% of Medicaid,461.02,3595.09,
MRA NECK WO CONTRAST,70547,CPT,TC,45070547,CDM,615,RC,,,both,,,2963,2192.63,,,2192.63,Other,150% of Medicare + 9.63% HCRA Surcharge,1333.35,45,,1333.35,percent of total billed charges,Critical Access Hospital RCC factor,575.83,,,575.83,Fee Schedule,,518.06,,,518.06,Fee Schedule,,2311.32,,,2311.32,Fee Schedule,,2078.87,,,2078.87,Fee Schedule,,1964.84,,,1964.84,Fee Schedule,,1466.69,,,1466.69,Other,110% of Medicare,684.13,,,684.13,Fee Schedule,,858,,,858,Other,186% of Medicaid,805.07,,,805.07,Fee Schedule,,1837.06,,,1837.06,Fee Schedule,,379.07,,,379.07,Fee Schedule,,805.07,,,805.07,Fee Schedule,,1837.06,,,1837.06,Fee Schedule,,713.01,,,713.01,Fee Schedule,,2074.1,70,,2074.1,percent of total billed charges,All Other,1772,,,1772,Case Rate,,1506,,,1506,Case Rate,,372.86,,,372.86,Fee Schedule,,372.86,,,372.86,Fee Schedule,,372.86,,,372.86,Fee Schedule,,372.86,,,372.86,Fee Schedule,,461.02,,,461.02,Other,100% of Medicaid,461.02,,,461.02,Other,100% of Medicaid,461.02,,,461.02,Other,100% of Medicaid,461.02,,,461.02,Other,100% of Medicaid,1037.31,,,1037.31,Other,225% of Medicaid,705.37,,,705.37,Other,153% of Medicaid,1037.31,,,1037.31,Other,225% of Medicaid,645.43,,,645.43,Other,140% of Medicaid,1037.31,,,1037.31,Other,225% of Medicaid,1198.66,,,1198.66,Other,260% of Medicaid,1493.72,,,1493.72,Other,324% of Medicaid,991.2,,,991.2,Other,215% of Medicaid,991.2,,,991.2,Other,215% of Medicaid,576.28,,,576.28,Other,125% of Medicaid,372.86,2311.32,
MRA NECK W AND WO CONTRAST,70549,CPT,TC,45070549,CDM,615,RC,,,both,,,4547,3364.79,,,3364.79,Other,150% of Medicare + 9.63% HCRA Surcharge,2046.15,45,,2046.15,percent of total billed charges,Critical Access Hospital RCC factor,941.05,,,941.05,Fee Schedule,,846.65,,,846.65,Fee Schedule,,3595.09,,,3595.09,Fee Schedule,,3233.53,,,3233.53,Fee Schedule,,3056.17,,,3056.17,Fee Schedule,,2250.77,,,2250.77,Other,110% of Medicare,1118.05,,,1118.05,Fee Schedule,,858,,,858,Other,186% of Medicaid,1315.7,,,1315.7,Fee Schedule,,2819.14,,,2819.14,Fee Schedule,,619.5,,,619.5,Fee Schedule,,1315.7,,,1315.7,Fee Schedule,,2819.14,,,2819.14,Fee Schedule,,1165.25,,,1165.25,Fee Schedule,,3182.9,70,,3182.9,percent of total billed charges,All Other,1772,,,1772,Case Rate,,1506,,,1506,Case Rate,,610.96,,,610.96,Fee Schedule,,610.96,,,610.96,Fee Schedule,,610.96,,,610.96,Fee Schedule,,610.96,,,610.96,Fee Schedule,,461.02,,,461.02,Other,100% of Medicaid,461.02,,,461.02,Other,100% of Medicaid,461.02,,,461.02,Other,100% of Medicaid,461.02,,,461.02,Other,100% of Medicaid,1037.31,,,1037.31,Other,225% of Medicaid,705.37,,,705.37,Other,153% of Medicaid,1037.31,,,1037.31,Other,225% of Medicaid,645.43,,,645.43,Other,140% of Medicaid,1037.31,,,1037.31,Other,225% of Medicaid,1198.66,,,1198.66,Other,260% of Medicaid,1493.72,,,1493.72,Other,324% of Medicaid,991.2,,,991.2,Other,215% of Medicaid,991.2,,,991.2,Other,215% of Medicaid,576.28,,,576.28,Other,125% of Medicaid,461.02,3595.09,
MRA L EXT W AND WO CONTRAST LT,C8914,HCPCS,TCLT,45000011,CDM,616,RC,,,both,,,3440,2545.61,,,2545.61,Other,150% of Medicare + 9.63% HCRA Surcharge,1548,45,,1548,percent of total billed charges,Critical Access Hospital RCC factor,2236,65,,2236,percent of total billed charges,All Other,2029.6,65,,2029.6,percent of total billed charges,All Other,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,1702.8,,,1702.8,Other,110% of Medicare,2339.2,68,,2339.2,percent of total billed charges,All Other,858,,,858,Other,186% of Medicaid,2752,,,2752,percent of total billed charges,All Other,2132.8,62,,2132.8,percent of total billed charges,Lab and Radiology,1892,55,,1892,percent of total billed charges,Default if not on Fee Schedule,2752,80,,2752,percent of total billed charges,All Other,2132.8,62,,2132.8,percent of total billed charges,Lab and Radiology,2752,80,,2752,percent of total billed charges,All Other,2408,70,,2408,percent of total billed charges,All Other,2236,65,,2236,percent of total billed charges,Default if not in Fee Schedule,2236,65,,2236,percent of total billed charges,Default if not in Fee Schedule,610.96,,,610.96,Fee Schedule,,610.96,,,610.96,Fee Schedule,,610.96,,,610.96,Fee Schedule,,610.96,,,610.96,Fee Schedule,,461.02,,,461.02,Other,100% of Medicaid,461.02,,,461.02,Other,100% of Medicaid,461.02,,,461.02,Other,100% of Medicaid,461.02,,,461.02,Other,100% of Medicaid,1037.31,,,1037.31,Other,225% of Medicaid,705.37,,,705.37,Other,153% of Medicaid,1037.31,,,1037.31,Other,225% of Medicaid,645.43,,,645.43,Other,140% of Medicaid,1037.31,,,1037.31,Other,225% of Medicaid,1198.66,,,1198.66,Other,260% of Medicaid,1493.72,,,1493.72,Other,324% of Medicaid,991.2,,,991.2,Other,215% of Medicaid,991.2,,,991.2,Other,215% of Medicaid,576.28,,,576.28,Other,125% of Medicaid,0.01,2752,
MRA L EXT W AND WO CONTRAST RT,C8914,HCPCS,TCRT,45000012,CDM,616,RC,,,both,,,3440,2545.61,,,2545.61,Other,150% of Medicare + 9.63% HCRA Surcharge,1548,45,,1548,percent of total billed charges,Critical Access Hospital RCC factor,2236,65,,2236,percent of total billed charges,All Other,2029.6,65,,2029.6,percent of total billed charges,All Other,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,1702.8,,,1702.8,Other,110% of Medicare,2339.2,68,,2339.2,percent of total billed charges,All Other,858,,,858,Other,186% of Medicaid,2752,,,2752,percent of total billed charges,All Other,2132.8,62,,2132.8,percent of total billed charges,Lab and Radiology,1892,55,,1892,percent of total billed charges,Default if not on Fee Schedule,2752,80,,2752,percent of total billed charges,All Other,2132.8,62,,2132.8,percent of total billed charges,Lab and Radiology,2752,80,,2752,percent of total billed charges,All Other,2408,70,,2408,percent of total billed charges,All Other,2236,65,,2236,percent of total billed charges,Default if not in Fee Schedule,2236,65,,2236,percent of total billed charges,Default if not in Fee Schedule,610.96,,,610.96,Fee Schedule,,610.96,,,610.96,Fee Schedule,,610.96,,,610.96,Fee Schedule,,610.96,,,610.96,Fee Schedule,,461.02,,,461.02,Other,100% of Medicaid,461.02,,,461.02,Other,100% of Medicaid,461.02,,,461.02,Other,100% of Medicaid,461.02,,,461.02,Other,100% of Medicaid,1037.31,,,1037.31,Other,225% of Medicaid,705.37,,,705.37,Other,153% of Medicaid,1037.31,,,1037.31,Other,225% of Medicaid,645.43,,,645.43,Other,140% of Medicaid,1037.31,,,1037.31,Other,225% of Medicaid,1198.66,,,1198.66,Other,260% of Medicaid,1493.72,,,1493.72,Other,324% of Medicaid,991.2,,,991.2,Other,215% of Medicaid,991.2,,,991.2,Other,215% of Medicaid,576.28,,,576.28,Other,125% of Medicaid,0.01,2752,
MRA ABD W CONTRAST,C8900,HCPCS,TC,45000002,CDM,618,RC,,,both,,,1815,1343.1,,,1343.1,Other,150% of Medicare + 9.63% HCRA Surcharge,816.75,45,,816.75,percent of total billed charges,Critical Access Hospital RCC factor,1179.75,65,,1179.75,percent of total billed charges,All Other,1070.85,65,,1070.85,percent of total billed charges,All Other,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,898.43,,,898.43,Other,110% of Medicare,1234.2,68,,1234.2,percent of total billed charges,All Other,858,,,858,Other,186% of Medicaid,1452,,,1452,percent of total billed charges,All Other,1125.3,62,,1125.3,percent of total billed charges,Lab and Radiology,998.25,55,,998.25,percent of total billed charges,Default if not on Fee Schedule,1452,80,,1452,percent of total billed charges,All Other,1125.3,62,,1125.3,percent of total billed charges,Lab and Radiology,1452,80,,1452,percent of total billed charges,All Other,1270.5,70,,1270.5,percent of total billed charges,All Other,1179.75,65,,1179.75,percent of total billed charges,Default if not in Fee Schedule,1179.75,65,,1179.75,percent of total billed charges,Default if not in Fee Schedule,610.96,,,610.96,Fee Schedule,,610.96,,,610.96,Fee Schedule,,610.96,,,610.96,Fee Schedule,,610.96,,,610.96,Fee Schedule,,461.02,,,461.02,Other,100% of Medicaid,461.02,,,461.02,Other,100% of Medicaid,461.02,,,461.02,Other,100% of Medicaid,461.02,,,461.02,Other,100% of Medicaid,1037.31,,,1037.31,Other,225% of Medicaid,705.37,,,705.37,Other,153% of Medicaid,1037.31,,,1037.31,Other,225% of Medicaid,645.43,,,645.43,Other,140% of Medicaid,1037.31,,,1037.31,Other,225% of Medicaid,1198.66,,,1198.66,Other,260% of Medicaid,1493.72,,,1493.72,Other,324% of Medicaid,991.2,,,991.2,Other,215% of Medicaid,991.2,,,991.2,Other,215% of Medicaid,576.28,,,576.28,Other,125% of Medicaid,0.01,1493.72,
MRA ABD WO CONTRAST,C8901,HCPCS,,45000003,CDM,618,RC,,,both,,,1332,985.68,,,985.68,Other,150% of Medicare + 9.63% HCRA Surcharge,599.4,45,,599.4,percent of total billed charges,Critical Access Hospital RCC factor,865.8,65,,865.8,percent of total billed charges,All Other,785.88,65,,785.88,percent of total billed charges,All Other,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,659.34,,,659.34,Other,110% of Medicare,905.76,68,,905.76,percent of total billed charges,All Other,858,,,858,Other,186% of Medicaid,1065.6,,,1065.6,percent of total billed charges,All Other,825.84,62,,825.84,percent of total billed charges,Lab and Radiology,732.6,55,,732.6,percent of total billed charges,Default if not on Fee Schedule,1065.6,80,,1065.6,percent of total billed charges,All Other,825.84,62,,825.84,percent of total billed charges,Lab and Radiology,1065.6,80,,1065.6,percent of total billed charges,All Other,932.4,70,,932.4,percent of total billed charges,All Other,865.8,65,,865.8,percent of total billed charges,Default if not in Fee Schedule,865.8,65,,865.8,percent of total billed charges,Default if not in Fee Schedule,372.86,,,372.86,Fee Schedule,,372.86,,,372.86,Fee Schedule,,372.86,,,372.86,Fee Schedule,,372.86,,,372.86,Fee Schedule,,461.02,,,461.02,Other,100% of Medicaid,461.02,,,461.02,Other,100% of Medicaid,461.02,,,461.02,Other,100% of Medicaid,461.02,,,461.02,Other,100% of Medicaid,1037.31,,,1037.31,Other,225% of Medicaid,705.37,,,705.37,Other,153% of Medicaid,1037.31,,,1037.31,Other,225% of Medicaid,645.43,,,645.43,Other,140% of Medicaid,1037.31,,,1037.31,Other,225% of Medicaid,1198.66,,,1198.66,Other,260% of Medicaid,1493.72,,,1493.72,Other,324% of Medicaid,991.2,,,991.2,Other,215% of Medicaid,991.2,,,991.2,Other,215% of Medicaid,576.28,,,576.28,Other,125% of Medicaid,0.01,1493.72,
MRA ABD W AND WO CONTRAST,C8902,HCPCS,,45000004,CDM,618,RC,,,both,,,3751,2775.75,,,2775.75,Other,150% of Medicare + 9.63% HCRA Surcharge,1687.95,45,,1687.95,percent of total billed charges,Critical Access Hospital RCC factor,2438.15,65,,2438.15,percent of total billed charges,All Other,2213.09,65,,2213.09,percent of total billed charges,All Other,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,1856.75,,,1856.75,Other,110% of Medicare,2550.68,68,,2550.68,percent of total billed charges,All Other,858,,,858,Other,186% of Medicaid,3000.8,,,3000.8,percent of total billed charges,All Other,2325.62,62,,2325.62,percent of total billed charges,Lab and Radiology,2063.05,55,,2063.05,percent of total billed charges,Default if not on Fee Schedule,3000.8,80,,3000.8,percent of total billed charges,All Other,2325.62,62,,2325.62,percent of total billed charges,Lab and Radiology,3000.8,80,,3000.8,percent of total billed charges,All Other,2625.7,70,,2625.7,percent of total billed charges,All Other,2438.15,65,,2438.15,percent of total billed charges,Default if not in Fee Schedule,2438.15,65,,2438.15,percent of total billed charges,Default if not in Fee Schedule,610.96,,,610.96,Fee Schedule,,610.96,,,610.96,Fee Schedule,,610.96,,,610.96,Fee Schedule,,610.96,,,610.96,Fee Schedule,,461.02,,,461.02,Other,100% of Medicaid,461.02,,,461.02,Other,100% of Medicaid,461.02,,,461.02,Other,100% of Medicaid,461.02,,,461.02,Other,100% of Medicaid,1037.31,,,1037.31,Other,225% of Medicaid,705.37,,,705.37,Other,153% of Medicaid,1037.31,,,1037.31,Other,225% of Medicaid,645.43,,,645.43,Other,140% of Medicaid,1037.31,,,1037.31,Other,225% of Medicaid,1198.66,,,1198.66,Other,260% of Medicaid,1493.72,,,1493.72,Other,324% of Medicaid,991.2,,,991.2,Other,215% of Medicaid,991.2,,,991.2,Other,215% of Medicaid,576.28,,,576.28,Other,125% of Medicaid,0.01,3000.8,
MRA CHEST W CONTRAST,C8909,HCPCS,,45000008,CDM,618,RC,,,both,,,1815,1343.1,,,1343.1,Other,150% of Medicare + 9.63% HCRA Surcharge,816.75,45,,816.75,percent of total billed charges,Critical Access Hospital RCC factor,1179.75,65,,1179.75,percent of total billed charges,All Other,1070.85,65,,1070.85,percent of total billed charges,All Other,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,898.43,,,898.43,Other,110% of Medicare,1234.2,68,,1234.2,percent of total billed charges,All Other,858,,,858,Other,186% of Medicaid,1452,,,1452,percent of total billed charges,All Other,1125.3,62,,1125.3,percent of total billed charges,Lab and Radiology,998.25,55,,998.25,percent of total billed charges,Default if not on Fee Schedule,1452,80,,1452,percent of total billed charges,All Other,1125.3,62,,1125.3,percent of total billed charges,Lab and Radiology,1452,80,,1452,percent of total billed charges,All Other,1270.5,70,,1270.5,percent of total billed charges,All Other,1179.75,65,,1179.75,percent of total billed charges,Default if not in Fee Schedule,1179.75,65,,1179.75,percent of total billed charges,Default if not in Fee Schedule,610.96,,,610.96,Fee Schedule,,610.96,,,610.96,Fee Schedule,,610.96,,,610.96,Fee Schedule,,610.96,,,610.96,Fee Schedule,,461.02,,,461.02,Other,100% of Medicaid,461.02,,,461.02,Other,100% of Medicaid,461.02,,,461.02,Other,100% of Medicaid,461.02,,,461.02,Other,100% of Medicaid,1037.31,,,1037.31,Other,225% of Medicaid,705.37,,,705.37,Other,153% of Medicaid,1037.31,,,1037.31,Other,225% of Medicaid,645.43,,,645.43,Other,140% of Medicaid,1037.31,,,1037.31,Other,225% of Medicaid,1198.66,,,1198.66,Other,260% of Medicaid,1493.72,,,1493.72,Other,324% of Medicaid,991.2,,,991.2,Other,215% of Medicaid,991.2,,,991.2,Other,215% of Medicaid,576.28,,,576.28,Other,125% of Medicaid,0.01,1493.72,
MRA CHEST WO CONTRAST,C8910,HCPCS,,45000009,CDM,618,RC,,,both,,,1553,1149.22,,,1149.22,Other,150% of Medicare + 9.63% HCRA Surcharge,698.85,45,,698.85,percent of total billed charges,Critical Access Hospital RCC factor,1009.45,65,,1009.45,percent of total billed charges,All Other,916.27,65,,916.27,percent of total billed charges,All Other,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,768.74,,,768.74,Other,110% of Medicare,1056.04,68,,1056.04,percent of total billed charges,All Other,858,,,858,Other,186% of Medicaid,1242.4,,,1242.4,percent of total billed charges,All Other,962.86,62,,962.86,percent of total billed charges,Lab and Radiology,854.15,55,,854.15,percent of total billed charges,Default if not on Fee Schedule,1242.4,80,,1242.4,percent of total billed charges,All Other,962.86,62,,962.86,percent of total billed charges,Lab and Radiology,1242.4,80,,1242.4,percent of total billed charges,All Other,1087.1,70,,1087.1,percent of total billed charges,All Other,1009.45,65,,1009.45,percent of total billed charges,Default if not in Fee Schedule,1009.45,65,,1009.45,percent of total billed charges,Default if not in Fee Schedule,372.86,,,372.86,Fee Schedule,,372.86,,,372.86,Fee Schedule,,372.86,,,372.86,Fee Schedule,,372.86,,,372.86,Fee Schedule,,461.02,,,461.02,Other,100% of Medicaid,461.02,,,461.02,Other,100% of Medicaid,461.02,,,461.02,Other,100% of Medicaid,461.02,,,461.02,Other,100% of Medicaid,1037.31,,,1037.31,Other,225% of Medicaid,705.37,,,705.37,Other,153% of Medicaid,1037.31,,,1037.31,Other,225% of Medicaid,645.43,,,645.43,Other,140% of Medicaid,1037.31,,,1037.31,Other,225% of Medicaid,1198.66,,,1198.66,Other,260% of Medicaid,1493.72,,,1493.72,Other,324% of Medicaid,991.2,,,991.2,Other,215% of Medicaid,991.2,,,991.2,Other,215% of Medicaid,576.28,,,576.28,Other,125% of Medicaid,0.01,1493.72,
MRA CHEST W AND WO CONTRAST,C8911,HCPCS,,45000010,CDM,618,RC,,,both,,,3751,2775.75,,,2775.75,Other,150% of Medicare + 9.63% HCRA Surcharge,1687.95,45,,1687.95,percent of total billed charges,Critical Access Hospital RCC factor,2438.15,65,,2438.15,percent of total billed charges,All Other,2213.09,65,,2213.09,percent of total billed charges,All Other,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,1856.75,,,1856.75,Other,110% of Medicare,2550.68,68,,2550.68,percent of total billed charges,All Other,858,,,858,Other,186% of Medicaid,3000.8,,,3000.8,percent of total billed charges,All Other,2325.62,62,,2325.62,percent of total billed charges,Lab and Radiology,2063.05,55,,2063.05,percent of total billed charges,Default if not on Fee Schedule,3000.8,80,,3000.8,percent of total billed charges,All Other,2325.62,62,,2325.62,percent of total billed charges,Lab and Radiology,3000.8,80,,3000.8,percent of total billed charges,All Other,2625.7,70,,2625.7,percent of total billed charges,All Other,2438.15,65,,2438.15,percent of total billed charges,Default if not in Fee Schedule,2438.15,65,,2438.15,percent of total billed charges,Default if not in Fee Schedule,610.96,,,610.96,Fee Schedule,,610.96,,,610.96,Fee Schedule,,610.96,,,610.96,Fee Schedule,,610.96,,,610.96,Fee Schedule,,461.02,,,461.02,Other,100% of Medicaid,461.02,,,461.02,Other,100% of Medicaid,461.02,,,461.02,Other,100% of Medicaid,461.02,,,461.02,Other,100% of Medicaid,1037.31,,,1037.31,Other,225% of Medicaid,705.37,,,705.37,Other,153% of Medicaid,1037.31,,,1037.31,Other,225% of Medicaid,645.43,,,645.43,Other,140% of Medicaid,1037.31,,,1037.31,Other,225% of Medicaid,1198.66,,,1198.66,Other,260% of Medicaid,1493.72,,,1493.72,Other,324% of Medicaid,991.2,,,991.2,Other,215% of Medicaid,991.2,,,991.2,Other,215% of Medicaid,576.28,,,576.28,Other,125% of Medicaid,0.01,3000.8,
MRA PELVIS W AND WO CONTRAST,C8920,HCPCS,TC,45000013,CDM,618,RC,,,both,,,3441,2546.35,,,2546.35,Other,150% of Medicare + 9.63% HCRA Surcharge,1548.45,45,,1548.45,percent of total billed charges,Critical Access Hospital RCC factor,2236.65,65,,2236.65,percent of total billed charges,All Other,2030.19,65,,2030.19,percent of total billed charges,All Other,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,1703.3,,,1703.3,Other,110% of Medicare,2339.88,68,,2339.88,percent of total billed charges,All Other,858,,,858,Other,186% of Medicaid,2752.8,,,2752.8,percent of total billed charges,All Other,2133.42,62,,2133.42,percent of total billed charges,Lab and Radiology,1892.55,55,,1892.55,percent of total billed charges,Default if not on Fee Schedule,2752.8,80,,2752.8,percent of total billed charges,All Other,2133.42,62,,2133.42,percent of total billed charges,Lab and Radiology,2752.8,80,,2752.8,percent of total billed charges,All Other,2408.7,70,,2408.7,percent of total billed charges,All Other,2236.65,65,,2236.65,percent of total billed charges,Default if not in Fee Schedule,2236.65,65,,2236.65,percent of total billed charges,Default if not in Fee Schedule,610.96,,,610.96,Fee Schedule,,610.96,,,610.96,Fee Schedule,,610.96,,,610.96,Fee Schedule,,610.96,,,610.96,Fee Schedule,,461.02,,,461.02,Other,100% of Medicaid,461.02,,,461.02,Other,100% of Medicaid,461.02,,,461.02,Other,100% of Medicaid,461.02,,,461.02,Other,100% of Medicaid,1037.31,,,1037.31,Other,225% of Medicaid,705.37,,,705.37,Other,153% of Medicaid,1037.31,,,1037.31,Other,225% of Medicaid,645.43,,,645.43,Other,140% of Medicaid,1037.31,,,1037.31,Other,225% of Medicaid,1198.66,,,1198.66,Other,260% of Medicaid,1493.72,,,1493.72,Other,324% of Medicaid,991.2,,,991.2,Other,215% of Medicaid,991.2,,,991.2,Other,215% of Medicaid,576.28,,,576.28,Other,125% of Medicaid,0.01,2752.8,
"MRA W/O CONT, PELVIS",C8919,HCPCS,,45000015,CDM,618,RC,,,both,,,1165,862.1,,,862.1,Other,150% of Medicare + 9.63% HCRA Surcharge,524.25,45,,524.25,percent of total billed charges,Critical Access Hospital RCC factor,757.25,65,,757.25,percent of total billed charges,All Other,687.35,65,,687.35,percent of total billed charges,All Other,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,576.68,,,576.68,Other,110% of Medicare,792.2,68,,792.2,percent of total billed charges,All Other,858,,,858,Other,186% of Medicaid,932,,,932,percent of total billed charges,All Other,722.3,62,,722.3,percent of total billed charges,Lab and Radiology,640.75,55,,640.75,percent of total billed charges,Default if not on Fee Schedule,932,80,,932,percent of total billed charges,All Other,722.3,62,,722.3,percent of total billed charges,Lab and Radiology,932,80,,932,percent of total billed charges,All Other,815.5,70,,815.5,percent of total billed charges,All Other,757.25,65,,757.25,percent of total billed charges,Default if not in Fee Schedule,757.25,65,,757.25,percent of total billed charges,Default if not in Fee Schedule,372.86,,,372.86,Fee Schedule,,372.86,,,372.86,Fee Schedule,,372.86,,,372.86,Fee Schedule,,372.86,,,372.86,Fee Schedule,,461.02,,,461.02,Other,100% of Medicaid,461.02,,,461.02,Other,100% of Medicaid,461.02,,,461.02,Other,100% of Medicaid,461.02,,,461.02,Other,100% of Medicaid,1037.31,,,1037.31,Other,225% of Medicaid,705.37,,,705.37,Other,153% of Medicaid,1037.31,,,1037.31,Other,225% of Medicaid,645.43,,,645.43,Other,140% of Medicaid,1037.31,,,1037.31,Other,225% of Medicaid,1198.66,,,1198.66,Other,260% of Medicaid,1493.72,,,1493.72,Other,324% of Medicaid,991.2,,,991.2,Other,215% of Medicaid,991.2,,,991.2,Other,215% of Medicaid,576.28,,,576.28,Other,125% of Medicaid,0.01,1493.72,
ACETADOTE 200 MG/ML,J0132,HCPCS,,80000012,CDM,636,RC,55150025930,NDC,both,4,ML,68.9,6.95,,,6.95,Other,150% of Medicare + 9.63% HCRA Surcharge,4.22,,,4.22,Fee Schedule,Average Sale Price (ASP) x 6,24.11,35,,24.11,percent of total billed charges,Drugs,24.11,35,,24.11,percent of total billed charges,Drugs,23.42,34,,23.42,percent of total billed charges,Drugs,23.42,34,,23.42,percent of total billed charges,Drugs,23.42,34,,23.42,percent of total billed charges,Drugs,23.42,34,,23.42,percent of total billed charges,Drugs,24.11,35,,24.11,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,24.11,35,,24.11,percent of total billed charges,Drugs,24.11,35,,24.11,percent of total billed charges,Drugs,24.11,35,,24.11,percent of total billed charges,Drugs,24.11,35,,24.11,percent of total billed charges,Drugs,24.11,35,,24.11,percent of total billed charges,Drugs,27.56,40,,27.56,percent of total billed charges,Drugs,48.23,70,,48.23,percent of total billed charges,All Other,24.8,36,,24.8,percent of total billed charges,Drugs,24.8,36,,24.8,percent of total billed charges,Drugs,24.11,35,,24.11,percent of total billed charges,Drugs,24.11,35,,24.11,percent of total billed charges,Drugs,24.11,35,,24.11,percent of total billed charges,Drugs,24.11,35,,24.11,percent of total billed charges,Drugs,22.97,,,22.97,Other,Drug Cost,22.97,,,22.97,Other,Drug Cost,22.97,,,22.97,Other,Drug Cost,22.97,,,22.97,Other,Drug Cost,22.97,,,22.97,Other,Drug Cost,22.97,,,22.97,Other,Drug Cost,51.67,,,51.67,Other,225% of Medicaid,32.15,,,32.15,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,6.76,,,6.76,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",49.37,,,49.37,Other,215% Medicaid APG methodology,49.37,,,49.37,Other,215% Medicaid APG methodology,28.71,,,28.71,Other,125% Medicaid APG methodology,0.01,51.67,
ACETAMINOPHEN 1000MG/100ML INJ,J0136,HCPCS,,80000013,CDM,636,RC,143938610,NDC,both,10,ML,9.51,0.55,,,0.55,Other,150% of Medicare + 9.63% HCRA Surcharge,0.34,,,0.34,Fee Schedule,Average Sale Price (ASP) x 6,3.33,35,,3.33,percent of total billed charges,Drugs,3.33,35,,3.33,percent of total billed charges,Drugs,3.23,34,,3.23,percent of total billed charges,Drugs,3.23,34,,3.23,percent of total billed charges,Drugs,3.23,34,,3.23,percent of total billed charges,Drugs,3.23,34,,3.23,percent of total billed charges,Drugs,3.33,35,,3.33,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,3.33,35,,3.33,percent of total billed charges,Drugs,3.33,35,,3.33,percent of total billed charges,Drugs,3.33,35,,3.33,percent of total billed charges,Drugs,3.33,35,,3.33,percent of total billed charges,Drugs,3.33,35,,3.33,percent of total billed charges,Drugs,3.81,40,,3.81,percent of total billed charges,Drugs,6.66,70,,6.66,percent of total billed charges,All Other,3.42,36,,3.42,percent of total billed charges,Drugs,3.42,36,,3.42,percent of total billed charges,Drugs,3.33,35,,3.33,percent of total billed charges,Drugs,3.33,35,,3.33,percent of total billed charges,Drugs,3.33,35,,3.33,percent of total billed charges,Drugs,3.33,35,,3.33,percent of total billed charges,Drugs,3.17,,,3.17,Other,Drug Cost,3.17,,,3.17,Other,Drug Cost,3.17,,,3.17,Other,Drug Cost,3.17,,,3.17,Other,Drug Cost,3.17,,,3.17,Other,Drug Cost,3.17,,,3.17,Other,Drug Cost,7.13,,,7.13,Other,225% of Medicaid,4.44,,,4.44,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,0.54,,,0.54,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",6.82,,,6.82,Other,215% Medicaid APG methodology,6.82,,,6.82,Other,215% Medicaid APG methodology,3.96,,,3.96,Other,125% Medicaid APG methodology,0.01,7.13,
ACETAZOLAMID SODIUM INJ 500 MG,J1120,HCPCS,,80000024,CDM,636,RC,39822019001,NDC,both,1,EA,31.95,277.44,,,277.44,Other,150% of Medicare + 9.63% HCRA Surcharge,168.71,,,168.71,Fee Schedule,Average Sale Price (ASP) x 6,11.18,35,,11.18,percent of total billed charges,Drugs,11.18,35,,11.18,percent of total billed charges,Drugs,10.86,34,,10.86,percent of total billed charges,Drugs,10.86,34,,10.86,percent of total billed charges,Drugs,10.86,34,,10.86,percent of total billed charges,Drugs,10.86,34,,10.86,percent of total billed charges,Drugs,11.18,35,,11.18,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,11.18,35,,11.18,percent of total billed charges,Drugs,11.18,35,,11.18,percent of total billed charges,Drugs,11.18,35,,11.18,percent of total billed charges,Drugs,11.18,35,,11.18,percent of total billed charges,Drugs,11.18,35,,11.18,percent of total billed charges,Drugs,12.78,40,,12.78,percent of total billed charges,Drugs,22.37,70,,22.37,percent of total billed charges,All Other,11.5,36,,11.5,percent of total billed charges,Drugs,11.5,36,,11.5,percent of total billed charges,Drugs,11.18,35,,11.18,percent of total billed charges,Drugs,11.18,35,,11.18,percent of total billed charges,Drugs,11.18,35,,11.18,percent of total billed charges,Drugs,11.18,35,,11.18,percent of total billed charges,Drugs,10.65,,,10.65,Other,Drug Cost,10.65,,,10.65,Other,Drug Cost,10.65,,,10.65,Other,Drug Cost,10.65,,,10.65,Other,Drug Cost,10.65,,,10.65,Other,Drug Cost,10.65,,,10.65,Other,Drug Cost,23.96,,,23.96,Other,225% of Medicaid,14.91,,,14.91,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,269.94,,,269.94,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",22.9,,,22.9,Other,215% Medicaid APG methodology,22.9,,,22.9,Other,215% Medicaid APG methodology,13.31,,,13.31,Other,125% Medicaid APG methodology,0.01,277.44,
ACYCLOVIR INJ 50 MG/ML 10 ML,J0133,HCPCS,,80000047,CDM,636,RC,55150015410,NDC,both,10,ML,5.01,0.55,,,0.55,Other,150% of Medicare + 9.63% HCRA Surcharge,0.34,,,0.34,Fee Schedule,Average Sale Price (ASP) x 6,1.75,35,,1.75,percent of total billed charges,Drugs,1.75,35,,1.75,percent of total billed charges,Drugs,1.7,34,,1.7,percent of total billed charges,Drugs,1.7,34,,1.7,percent of total billed charges,Drugs,1.7,34,,1.7,percent of total billed charges,Drugs,1.7,34,,1.7,percent of total billed charges,Drugs,1.75,35,,1.75,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,1.75,35,,1.75,percent of total billed charges,Drugs,1.75,35,,1.75,percent of total billed charges,Drugs,1.75,35,,1.75,percent of total billed charges,Drugs,1.75,35,,1.75,percent of total billed charges,Drugs,1.75,35,,1.75,percent of total billed charges,Drugs,2,40,,2,percent of total billed charges,Drugs,3.51,70,,3.51,percent of total billed charges,All Other,1.8,36,,1.8,percent of total billed charges,Drugs,1.8,36,,1.8,percent of total billed charges,Drugs,1.75,35,,1.75,percent of total billed charges,Drugs,1.75,35,,1.75,percent of total billed charges,Drugs,1.75,35,,1.75,percent of total billed charges,Drugs,1.75,35,,1.75,percent of total billed charges,Drugs,1.67,,,1.67,Other,Drug Cost,1.67,,,1.67,Other,Drug Cost,1.67,,,1.67,Other,Drug Cost,1.67,,,1.67,Other,Drug Cost,1.67,,,1.67,Other,Drug Cost,1.67,,,1.67,Other,Drug Cost,3.76,,,3.76,Other,225% of Medicaid,2.34,,,2.34,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,0.54,,,0.54,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",3.59,,,3.59,Other,215% Medicaid APG methodology,3.59,,,3.59,Other,215% Medicaid APG methodology,2.09,,,2.09,Other,125% Medicaid APG methodology,0.01,3.76,
ADENOSINE 3MG/ML 2ML INJ,J0153,HCPCS,,80000048,CDM,636,RC,63323065102,NDC,both,10,ML,17.31,5.93,,,5.93,Other,150% of Medicare + 9.63% HCRA Surcharge,3.61,,,3.61,Fee Schedule,Average Sale Price (ASP) x 6,6.06,35,,6.06,percent of total billed charges,Drugs,6.06,35,,6.06,percent of total billed charges,Drugs,5.89,34,,5.89,percent of total billed charges,Drugs,5.89,34,,5.89,percent of total billed charges,Drugs,5.89,34,,5.89,percent of total billed charges,Drugs,5.89,34,,5.89,percent of total billed charges,Drugs,6.06,35,,6.06,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,6.06,35,,6.06,percent of total billed charges,Drugs,6.06,35,,6.06,percent of total billed charges,Drugs,6.06,35,,6.06,percent of total billed charges,Drugs,6.06,35,,6.06,percent of total billed charges,Drugs,6.06,35,,6.06,percent of total billed charges,Drugs,6.92,40,,6.92,percent of total billed charges,Drugs,12.12,70,,12.12,percent of total billed charges,All Other,6.23,36,,6.23,percent of total billed charges,Drugs,6.23,36,,6.23,percent of total billed charges,Drugs,6.06,35,,6.06,percent of total billed charges,Drugs,6.06,35,,6.06,percent of total billed charges,Drugs,6.06,35,,6.06,percent of total billed charges,Drugs,6.06,35,,6.06,percent of total billed charges,Drugs,5.77,,,5.77,Other,Drug Cost,5.77,,,5.77,Other,Drug Cost,5.77,,,5.77,Other,Drug Cost,5.77,,,5.77,Other,Drug Cost,5.77,,,5.77,Other,Drug Cost,5.77,,,5.77,Other,Drug Cost,12.98,,,12.98,Other,225% of Medicaid,8.08,,,8.08,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,5.77,,,5.77,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",12.41,,,12.41,Other,215% Medicaid APG methodology,12.41,,,12.41,Other,215% Medicaid APG methodology,7.21,,,7.21,Other,125% Medicaid APG methodology,0.01,12.98,
ADRENALIN EPINEPHRINE INJ 0.1 MG 10 ML,J0171,HCPCS,,80000050,CDM,636,RC,76329331801,NDC,both,10,ML,17.34,7.38,,,7.38,Other,150% of Medicare + 9.63% HCRA Surcharge,4.49,,,4.49,Fee Schedule,Average Sale Price (ASP) x 6,6.07,35,,6.07,percent of total billed charges,Drugs,6.07,35,,6.07,percent of total billed charges,Drugs,5.9,34,,5.9,percent of total billed charges,Drugs,5.9,34,,5.9,percent of total billed charges,Drugs,5.9,34,,5.9,percent of total billed charges,Drugs,5.9,34,,5.9,percent of total billed charges,Drugs,6.07,35,,6.07,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,6.07,35,,6.07,percent of total billed charges,Drugs,6.07,35,,6.07,percent of total billed charges,Drugs,6.07,35,,6.07,percent of total billed charges,Drugs,6.07,35,,6.07,percent of total billed charges,Drugs,6.07,35,,6.07,percent of total billed charges,Drugs,6.94,40,,6.94,percent of total billed charges,Drugs,12.14,70,,12.14,percent of total billed charges,All Other,6.24,36,,6.24,percent of total billed charges,Drugs,6.24,36,,6.24,percent of total billed charges,Drugs,6.07,35,,6.07,percent of total billed charges,Drugs,6.07,35,,6.07,percent of total billed charges,Drugs,6.07,35,,6.07,percent of total billed charges,Drugs,6.07,35,,6.07,percent of total billed charges,Drugs,5.78,,,5.78,Other,Drug Cost,5.78,,,5.78,Other,Drug Cost,5.78,,,5.78,Other,Drug Cost,5.78,,,5.78,Other,Drug Cost,5.78,,,5.78,Other,Drug Cost,5.78,,,5.78,Other,Drug Cost,13.01,,,13.01,Other,225% of Medicaid,8.09,,,8.09,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,7.18,,,7.18,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",12.43,,,12.43,Other,215% Medicaid APG methodology,12.43,,,12.43,Other,215% Medicaid APG methodology,7.23,,,7.23,Other,125% Medicaid APG methodology,0.01,13.01,
EPINEPHRINE INJ 1 MG/ML 1ML,J0171,HCPCS,,80000051,CDM,636,RC,42023015925,NDC,both,25,ML,1.22,7.38,,,7.38,Other,150% of Medicare + 9.63% HCRA Surcharge,4.49,,,4.49,Fee Schedule,Average Sale Price (ASP) x 6,0.43,35,,0.43,percent of total billed charges,Drugs,0.43,35,,0.43,percent of total billed charges,Drugs,0.41,34,,0.41,percent of total billed charges,Drugs,0.41,34,,0.41,percent of total billed charges,Drugs,0.41,34,,0.41,percent of total billed charges,Drugs,0.41,34,,0.41,percent of total billed charges,Drugs,0.43,35,,0.43,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,0.43,35,,0.43,percent of total billed charges,Drugs,0.43,35,,0.43,percent of total billed charges,Drugs,0.43,35,,0.43,percent of total billed charges,Drugs,0.43,35,,0.43,percent of total billed charges,Drugs,0.43,35,,0.43,percent of total billed charges,Drugs,0.49,40,,0.49,percent of total billed charges,Drugs,0.85,70,,0.85,percent of total billed charges,All Other,0.44,36,,0.44,percent of total billed charges,Drugs,0.44,36,,0.44,percent of total billed charges,Drugs,0.43,35,,0.43,percent of total billed charges,Drugs,0.43,35,,0.43,percent of total billed charges,Drugs,0.43,35,,0.43,percent of total billed charges,Drugs,0.43,35,,0.43,percent of total billed charges,Drugs,0.41,,,0.41,Other,Drug Cost,0.41,,,0.41,Other,Drug Cost,0.41,,,0.41,Other,Drug Cost,0.41,,,0.41,Other,Drug Cost,0.41,,,0.41,Other,Drug Cost,0.41,,,0.41,Other,Drug Cost,0.92,,,0.92,Other,225% of Medicaid,0.57,,,0.57,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,7.18,,,7.18,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",0.87,,,0.87,Other,215% Medicaid APG methodology,0.87,,,0.87,Other,215% Medicaid APG methodology,0.51,,,0.51,Other,125% Medicaid APG methodology,0.01,7.38,
EPINEPHRINE INJ 1 MG/ML 30 ML,J0171,HCPCS,,80000052,CDM,636,RC,42023016801,NDC,both,1,ML,0.81,7.38,,,7.38,Other,150% of Medicare + 9.63% HCRA Surcharge,4.49,,,4.49,Fee Schedule,Average Sale Price (ASP) x 6,0.28,35,,0.28,percent of total billed charges,Drugs,0.28,35,,0.28,percent of total billed charges,Drugs,0.28,34,,0.28,percent of total billed charges,Drugs,0.28,34,,0.28,percent of total billed charges,Drugs,0.28,34,,0.28,percent of total billed charges,Drugs,0.28,34,,0.28,percent of total billed charges,Drugs,0.28,35,,0.28,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,0.28,35,,0.28,percent of total billed charges,Drugs,0.28,35,,0.28,percent of total billed charges,Drugs,0.28,35,,0.28,percent of total billed charges,Drugs,0.28,35,,0.28,percent of total billed charges,Drugs,0.28,35,,0.28,percent of total billed charges,Drugs,0.32,40,,0.32,percent of total billed charges,Drugs,0.57,70,,0.57,percent of total billed charges,All Other,0.29,36,,0.29,percent of total billed charges,Drugs,0.29,36,,0.29,percent of total billed charges,Drugs,0.28,35,,0.28,percent of total billed charges,Drugs,0.28,35,,0.28,percent of total billed charges,Drugs,0.28,35,,0.28,percent of total billed charges,Drugs,0.28,35,,0.28,percent of total billed charges,Drugs,0.27,,,0.27,Other,Drug Cost,0.27,,,0.27,Other,Drug Cost,0.27,,,0.27,Other,Drug Cost,0.27,,,0.27,Other,Drug Cost,0.27,,,0.27,Other,Drug Cost,0.27,,,0.27,Other,Drug Cost,0.61,,,0.61,Other,225% of Medicaid,0.38,,,0.38,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,7.18,,,7.18,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",0.58,,,0.58,Other,215% Medicaid APG methodology,0.58,,,0.58,Other,215% Medicaid APG methodology,0.34,,,0.34,Other,125% Medicaid APG methodology,0.01,7.38,
ALBUMIN HUMAN 25% 50ML,P9047,HCPCS,,80000053,CDM,636,RC,944049301,NDC,both,24,ML,77.61,523.69,,,523.69,Other,150% of Medicare + 9.63% HCRA Surcharge,318.46,,,318.46,Fee Schedule,Average Sale Price (ASP) x 6,27.16,35,,27.16,percent of total billed charges,Drugs,27.16,35,,27.16,percent of total billed charges,Drugs,26.39,34,,26.39,percent of total billed charges,Drugs,26.39,34,,26.39,percent of total billed charges,Drugs,26.39,34,,26.39,percent of total billed charges,Drugs,26.39,34,,26.39,percent of total billed charges,Drugs,27.16,35,,27.16,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,27.16,35,,27.16,percent of total billed charges,Drugs,27.16,35,,27.16,percent of total billed charges,Drugs,27.16,35,,27.16,percent of total billed charges,Drugs,27.16,35,,27.16,percent of total billed charges,Drugs,27.16,35,,27.16,percent of total billed charges,Drugs,31.05,40,,31.05,percent of total billed charges,Drugs,54.33,70,,54.33,percent of total billed charges,All Other,27.94,36,,27.94,percent of total billed charges,Drugs,27.94,36,,27.94,percent of total billed charges,Drugs,27.16,35,,27.16,percent of total billed charges,Drugs,27.16,35,,27.16,percent of total billed charges,Drugs,27.16,35,,27.16,percent of total billed charges,Drugs,27.16,35,,27.16,percent of total billed charges,Drugs,25.87,,,25.87,Other,Drug Cost,25.87,,,25.87,Other,Drug Cost,25.87,,,25.87,Other,Drug Cost,25.87,,,25.87,Other,Drug Cost,25.87,,,25.87,Other,Drug Cost,25.87,,,25.87,Other,Drug Cost,58.21,,,58.21,Other,225% of Medicaid,36.22,,,36.22,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,509.54,,,509.54,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",55.62,,,55.62,Other,215% Medicaid APG methodology,55.62,,,55.62,Other,215% Medicaid APG methodology,32.34,,,32.34,Other,125% Medicaid APG methodology,0.01,523.69,
ALBUMIN HUMAN 5% 250ML,P9045,HCPCS,,80000054,CDM,636,RC,44206031025,NDC,both,1,ML,74.85,523.69,,,523.69,Other,150% of Medicare + 9.63% HCRA Surcharge,318.46,,,318.46,Fee Schedule,Average Sale Price (ASP) x 6,26.2,35,,26.2,percent of total billed charges,Drugs,26.2,35,,26.2,percent of total billed charges,Drugs,25.45,34,,25.45,percent of total billed charges,Drugs,25.45,34,,25.45,percent of total billed charges,Drugs,25.45,34,,25.45,percent of total billed charges,Drugs,25.45,34,,25.45,percent of total billed charges,Drugs,26.2,35,,26.2,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,26.2,35,,26.2,percent of total billed charges,Drugs,26.2,35,,26.2,percent of total billed charges,Drugs,26.2,35,,26.2,percent of total billed charges,Drugs,26.2,35,,26.2,percent of total billed charges,Drugs,26.2,35,,26.2,percent of total billed charges,Drugs,29.94,40,,29.94,percent of total billed charges,Drugs,52.4,70,,52.4,percent of total billed charges,All Other,26.95,36,,26.95,percent of total billed charges,Drugs,26.95,36,,26.95,percent of total billed charges,Drugs,26.2,35,,26.2,percent of total billed charges,Drugs,26.2,35,,26.2,percent of total billed charges,Drugs,26.2,35,,26.2,percent of total billed charges,Drugs,26.2,35,,26.2,percent of total billed charges,Drugs,24.95,,,24.95,Other,Drug Cost,24.95,,,24.95,Other,Drug Cost,24.95,,,24.95,Other,Drug Cost,24.95,,,24.95,Other,Drug Cost,24.95,,,24.95,Other,Drug Cost,24.95,,,24.95,Other,Drug Cost,56.14,,,56.14,Other,225% of Medicaid,34.93,,,34.93,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,509.54,,,509.54,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",53.64,,,53.64,Other,215% Medicaid APG methodology,53.64,,,53.64,Other,215% Medicaid APG methodology,31.19,,,31.19,Other,125% Medicaid APG methodology,0.01,523.69,
AMIKACIN (PF) 250MG/ML 2ML,J0278,HCPCS,,80000078,CDM,636,RC,23155029041,NDC,both,10,ML,6.67,8.18,,,8.18,Other,150% of Medicare + 9.63% HCRA Surcharge,4.97,,,4.97,Fee Schedule,Average Sale Price (ASP) x 6,2.34,35,,2.34,percent of total billed charges,Drugs,2.34,35,,2.34,percent of total billed charges,Drugs,2.27,34,,2.27,percent of total billed charges,Drugs,2.27,34,,2.27,percent of total billed charges,Drugs,2.27,34,,2.27,percent of total billed charges,Drugs,2.27,34,,2.27,percent of total billed charges,Drugs,2.34,35,,2.34,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,2.34,35,,2.34,percent of total billed charges,Drugs,2.34,35,,2.34,percent of total billed charges,Drugs,2.34,35,,2.34,percent of total billed charges,Drugs,2.34,35,,2.34,percent of total billed charges,Drugs,2.34,35,,2.34,percent of total billed charges,Drugs,2.67,40,,2.67,percent of total billed charges,Drugs,4.67,70,,4.67,percent of total billed charges,All Other,2.4,36,,2.4,percent of total billed charges,Drugs,2.4,36,,2.4,percent of total billed charges,Drugs,2.34,35,,2.34,percent of total billed charges,Drugs,2.34,35,,2.34,percent of total billed charges,Drugs,2.34,35,,2.34,percent of total billed charges,Drugs,2.34,35,,2.34,percent of total billed charges,Drugs,2.22,,,2.22,Other,Drug Cost,2.22,,,2.22,Other,Drug Cost,2.22,,,2.22,Other,Drug Cost,2.22,,,2.22,Other,Drug Cost,2.22,,,2.22,Other,Drug Cost,2.22,,,2.22,Other,Drug Cost,5,,,5,Other,225% of Medicaid,3.11,,,3.11,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,7.96,,,7.96,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",4.78,,,4.78,Other,215% Medicaid APG methodology,4.78,,,4.78,Other,215% Medicaid APG methodology,2.78,,,2.78,Other,125% Medicaid APG methodology,0.01,8.18,
AMIKACIN SULFATE 250MG/ML 4ML INJ,J0278,HCPCS,,80000079,CDM,636,RC,703904003,NDC,both,10,ML,66.61,8.18,,,8.18,Other,150% of Medicare + 9.63% HCRA Surcharge,4.97,,,4.97,Fee Schedule,Average Sale Price (ASP) x 6,23.31,35,,23.31,percent of total billed charges,Drugs,23.31,35,,23.31,percent of total billed charges,Drugs,22.65,34,,22.65,percent of total billed charges,Drugs,22.65,34,,22.65,percent of total billed charges,Drugs,22.65,34,,22.65,percent of total billed charges,Drugs,22.65,34,,22.65,percent of total billed charges,Drugs,23.31,35,,23.31,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,23.31,35,,23.31,percent of total billed charges,Drugs,23.31,35,,23.31,percent of total billed charges,Drugs,23.31,35,,23.31,percent of total billed charges,Drugs,23.31,35,,23.31,percent of total billed charges,Drugs,23.31,35,,23.31,percent of total billed charges,Drugs,26.64,40,,26.64,percent of total billed charges,Drugs,46.63,70,,46.63,percent of total billed charges,All Other,23.98,36,,23.98,percent of total billed charges,Drugs,23.98,36,,23.98,percent of total billed charges,Drugs,23.31,35,,23.31,percent of total billed charges,Drugs,23.31,35,,23.31,percent of total billed charges,Drugs,23.31,35,,23.31,percent of total billed charges,Drugs,23.31,35,,23.31,percent of total billed charges,Drugs,22.2,,,22.2,Other,Drug Cost,22.2,,,22.2,Other,Drug Cost,22.2,,,22.2,Other,Drug Cost,22.2,,,22.2,Other,Drug Cost,22.2,,,22.2,Other,Drug Cost,22.2,,,22.2,Other,Drug Cost,49.96,,,49.96,Other,225% of Medicaid,31.09,,,31.09,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,7.96,,,7.96,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",47.74,,,47.74,Other,215% Medicaid APG methodology,47.74,,,47.74,Other,215% Medicaid APG methodology,27.76,,,27.76,Other,125% Medicaid APG methodology,0.01,49.96,
AMINOPHYLLINE 500MG/20ML INJ,J0280,HCPCS,,80000090,CDM,636,RC,409592201,NDC,both,25,ML,15.14,50.64,,,50.64,Other,150% of Medicare + 9.63% HCRA Surcharge,30.79,,,30.79,Fee Schedule,Average Sale Price (ASP) x 6,5.3,35,,5.3,percent of total billed charges,Drugs,5.3,35,,5.3,percent of total billed charges,Drugs,5.15,34,,5.15,percent of total billed charges,Drugs,5.15,34,,5.15,percent of total billed charges,Drugs,5.15,34,,5.15,percent of total billed charges,Drugs,5.15,34,,5.15,percent of total billed charges,Drugs,5.3,35,,5.3,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,5.3,35,,5.3,percent of total billed charges,Drugs,5.3,35,,5.3,percent of total billed charges,Drugs,5.3,35,,5.3,percent of total billed charges,Drugs,5.3,35,,5.3,percent of total billed charges,Drugs,5.3,35,,5.3,percent of total billed charges,Drugs,6.06,40,,6.06,percent of total billed charges,Drugs,10.6,70,,10.6,percent of total billed charges,All Other,5.45,36,,5.45,percent of total billed charges,Drugs,5.45,36,,5.45,percent of total billed charges,Drugs,5.3,35,,5.3,percent of total billed charges,Drugs,5.3,35,,5.3,percent of total billed charges,Drugs,5.3,35,,5.3,percent of total billed charges,Drugs,5.3,35,,5.3,percent of total billed charges,Drugs,5.05,,,5.05,Other,Drug Cost,5.05,,,5.05,Other,Drug Cost,5.05,,,5.05,Other,Drug Cost,5.05,,,5.05,Other,Drug Cost,5.05,,,5.05,Other,Drug Cost,5.05,,,5.05,Other,Drug Cost,11.36,,,11.36,Other,225% of Medicaid,7.07,,,7.07,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,49.27,,,49.27,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",10.85,,,10.85,Other,215% Medicaid APG methodology,10.85,,,10.85,Other,215% Medicaid APG methodology,6.31,,,6.31,Other,125% Medicaid APG methodology,0.01,50.64,
AMIODARON HCL INJ 30 MG (150MG/3ML),J0282,HCPCS,,80000094,CDM,636,RC,63323061603,NDC,both,25,ML,2.42,0.95,39.4668,,0.95,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.85,35,,0.85,percent of total billed charges,Drugs,0.85,35,,0.85,percent of total billed charges,Drugs,0.82,34,,0.82,percent of total billed charges,Drugs,0.82,34,,0.82,percent of total billed charges,Drugs,0.82,34,,0.82,percent of total billed charges,Drugs,0.82,34,,0.82,percent of total billed charges,Drugs,0.85,35,,0.85,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,0.85,35,,0.85,percent of total billed charges,Drugs,0.85,35,,0.85,percent of total billed charges,Drugs,0.85,35,,0.85,percent of total billed charges,Drugs,0.85,35,,0.85,percent of total billed charges,Drugs,0.85,35,,0.85,percent of total billed charges,Drugs,0.97,40,,0.97,percent of total billed charges,Drugs,1.69,70,,1.69,percent of total billed charges,All Other,0.87,36,,0.87,percent of total billed charges,Drugs,0.87,36,,0.87,percent of total billed charges,Drugs,0.85,35,,0.85,percent of total billed charges,Drugs,0.85,35,,0.85,percent of total billed charges,Drugs,0.85,35,,0.85,percent of total billed charges,Drugs,0.85,35,,0.85,percent of total billed charges,Drugs,0.81,,,0.81,Other,Drug Cost,0.81,,,0.81,Other,Drug Cost,0.81,,,0.81,Other,Drug Cost,0.81,,,0.81,Other,Drug Cost,0.81,,,0.81,Other,Drug Cost,0.81,,,0.81,Other,Drug Cost,1.81,,,1.81,Other,225% of Medicaid,1.13,,,1.13,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",1.73,,,1.73,Other,215% Medicaid APG methodology,1.73,,,1.73,Other,215% Medicaid APG methodology,1.01,,,1.01,Other,125% Medicaid APG methodology,0.01,1.81,
AMIODARON HCL INJ 30 MG (900MG/18ML),J0282,HCPCS,,80000095,CDM,636,RC,67457015318,NDC,both,1,ML,23.37,9.22,39.4668,,9.22,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,8.18,35,,8.18,percent of total billed charges,Drugs,8.18,35,,8.18,percent of total billed charges,Drugs,7.95,34,,7.95,percent of total billed charges,Drugs,7.95,34,,7.95,percent of total billed charges,Drugs,7.95,34,,7.95,percent of total billed charges,Drugs,7.95,34,,7.95,percent of total billed charges,Drugs,8.18,35,,8.18,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,8.18,35,,8.18,percent of total billed charges,Drugs,8.18,35,,8.18,percent of total billed charges,Drugs,8.18,35,,8.18,percent of total billed charges,Drugs,8.18,35,,8.18,percent of total billed charges,Drugs,8.18,35,,8.18,percent of total billed charges,Drugs,9.35,40,,9.35,percent of total billed charges,Drugs,16.36,70,,16.36,percent of total billed charges,All Other,8.41,36,,8.41,percent of total billed charges,Drugs,8.41,36,,8.41,percent of total billed charges,Drugs,8.18,35,,8.18,percent of total billed charges,Drugs,8.18,35,,8.18,percent of total billed charges,Drugs,8.18,35,,8.18,percent of total billed charges,Drugs,8.18,35,,8.18,percent of total billed charges,Drugs,7.79,,,7.79,Other,Drug Cost,7.79,,,7.79,Other,Drug Cost,7.79,,,7.79,Other,Drug Cost,7.79,,,7.79,Other,Drug Cost,7.79,,,7.79,Other,Drug Cost,7.79,,,7.79,Other,Drug Cost,17.53,,,17.53,Other,225% of Medicaid,10.91,,,10.91,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",16.75,,,16.75,Other,215% Medicaid APG methodology,16.75,,,16.75,Other,215% Medicaid APG methodology,9.74,,,9.74,Other,125% Medicaid APG methodology,0.01,17.53,
AMPHOTERICIN B 50MG INJ,J0285,HCPCS,,80000133,CDM,636,RC,39822105505,NDC,both,1,EA,41.01,94.09,,,94.09,Other,150% of Medicare + 9.63% HCRA Surcharge,57.22,,,57.22,Fee Schedule,Average Sale Price (ASP) x 6,14.35,35,,14.35,percent of total billed charges,Drugs,14.35,35,,14.35,percent of total billed charges,Drugs,13.94,34,,13.94,percent of total billed charges,Drugs,13.94,34,,13.94,percent of total billed charges,Drugs,13.94,34,,13.94,percent of total billed charges,Drugs,13.94,34,,13.94,percent of total billed charges,Drugs,14.35,35,,14.35,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,14.35,35,,14.35,percent of total billed charges,Drugs,14.35,35,,14.35,percent of total billed charges,Drugs,14.35,35,,14.35,percent of total billed charges,Drugs,14.35,35,,14.35,percent of total billed charges,Drugs,14.35,35,,14.35,percent of total billed charges,Drugs,16.4,40,,16.4,percent of total billed charges,Drugs,28.71,70,,28.71,percent of total billed charges,All Other,14.76,36,,14.76,percent of total billed charges,Drugs,14.76,36,,14.76,percent of total billed charges,Drugs,14.35,35,,14.35,percent of total billed charges,Drugs,14.35,35,,14.35,percent of total billed charges,Drugs,14.35,35,,14.35,percent of total billed charges,Drugs,14.35,35,,14.35,percent of total billed charges,Drugs,13.67,,,13.67,Other,Drug Cost,13.67,,,13.67,Other,Drug Cost,13.67,,,13.67,Other,Drug Cost,13.67,,,13.67,Other,Drug Cost,13.67,,,13.67,Other,Drug Cost,13.67,,,13.67,Other,Drug Cost,30.76,,,30.76,Other,225% of Medicaid,19.14,,,19.14,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,91.55,,,91.55,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",29.39,,,29.39,Other,215% Medicaid APG methodology,29.39,,,29.39,Other,215% Medicaid APG methodology,17.09,,,17.09,Other,125% Medicaid APG methodology,0.01,94.09,
AMPHOTERICIN B 50MG LIPID CMPLX,J0287,HCPCS,,80000134,CDM,636,RC,57665010141,NDC,both,1,ML,204.9,80.87,39.4668,,80.87,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,71.72,35,,71.72,percent of total billed charges,Drugs,71.72,35,,71.72,percent of total billed charges,Drugs,69.67,34,,69.67,percent of total billed charges,Drugs,69.67,34,,69.67,percent of total billed charges,Drugs,69.67,34,,69.67,percent of total billed charges,Drugs,69.67,34,,69.67,percent of total billed charges,Drugs,71.72,35,,71.72,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,71.72,35,,71.72,percent of total billed charges,Drugs,71.72,35,,71.72,percent of total billed charges,Drugs,71.72,35,,71.72,percent of total billed charges,Drugs,71.72,35,,71.72,percent of total billed charges,Drugs,71.72,35,,71.72,percent of total billed charges,Drugs,81.96,40,,81.96,percent of total billed charges,Drugs,143.43,70,,143.43,percent of total billed charges,All Other,73.76,36,,73.76,percent of total billed charges,Drugs,73.76,36,,73.76,percent of total billed charges,Drugs,71.72,35,,71.72,percent of total billed charges,Drugs,71.72,35,,71.72,percent of total billed charges,Drugs,71.72,35,,71.72,percent of total billed charges,Drugs,71.72,35,,71.72,percent of total billed charges,Drugs,68.3,,,68.3,Other,Drug Cost,68.3,,,68.3,Other,Drug Cost,68.3,,,68.3,Other,Drug Cost,68.3,,,68.3,Other,Drug Cost,68.3,,,68.3,Other,Drug Cost,68.3,,,68.3,Other,Drug Cost,153.68,,,153.68,Other,225% of Medicaid,95.62,,,95.62,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",146.85,,,146.85,Other,215% Medicaid APG methodology,146.85,,,146.85,Other,215% Medicaid APG methodology,85.38,,,85.38,Other,125% Medicaid APG methodology,0.01,153.68,
AMPHOTERICIN B LIPOSOMAL 50 MG INJ,J0289,HCPCS,,80000135,CDM,636,RC,469305130,NDC,both,1,EA,839.88,263.03,,,263.03,Other,150% of Medicare + 9.63% HCRA Surcharge,159.95,,,159.95,Fee Schedule,Average Sale Price (ASP) x 6,293.96,35,,293.96,percent of total billed charges,Drugs,293.96,35,,293.96,percent of total billed charges,Drugs,285.56,34,,285.56,percent of total billed charges,Drugs,285.56,34,,285.56,percent of total billed charges,Drugs,285.56,34,,285.56,percent of total billed charges,Drugs,285.56,34,,285.56,percent of total billed charges,Drugs,293.96,35,,293.96,percent of total billed charges,Drugs,285.56,34,"If Charge > 500, then 34 percent",285.56,percent of total billed charges,Drugs,293.96,35,,293.96,percent of total billed charges,Drugs,293.96,35,,293.96,percent of total billed charges,Drugs,293.96,35,,293.96,percent of total billed charges,Drugs,293.96,35,,293.96,percent of total billed charges,Drugs,293.96,35,,293.96,percent of total billed charges,Drugs,335.95,40,,335.95,percent of total billed charges,Drugs,587.92,70,,587.92,percent of total billed charges,All Other,302.36,36,,302.36,percent of total billed charges,Drugs,302.36,36,,302.36,percent of total billed charges,Drugs,293.96,35,,293.96,percent of total billed charges,Drugs,293.96,35,,293.96,percent of total billed charges,Drugs,293.96,35,,293.96,percent of total billed charges,Drugs,293.96,35,,293.96,percent of total billed charges,Drugs,279.96,,,279.96,Other,Drug Cost,279.96,,,279.96,Other,Drug Cost,279.96,,,279.96,Other,Drug Cost,279.96,,,279.96,Other,Drug Cost,279.96,,,279.96,Other,Drug Cost,279.96,,,279.96,Other,Drug Cost,629.91,,,629.91,Other,225% of Medicaid,391.94,,,391.94,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,255.92,,,255.92,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",601.91,,,601.91,Other,215% Medicaid APG methodology,601.91,,,601.91,Other,215% Medicaid APG methodology,349.95,,,349.95,Other,125% Medicaid APG methodology,0.01,629.91,
AMPICILLIN 2G INJ,J0290,HCPCS,,80000139,CDM,636,RC,55150011420,NDC,both,10,EA,6.88,9.98,,,9.98,Other,150% of Medicare + 9.63% HCRA Surcharge,6.07,,,6.07,Fee Schedule,Average Sale Price (ASP) x 6,2.41,35,,2.41,percent of total billed charges,Drugs,2.41,35,,2.41,percent of total billed charges,Drugs,2.34,34,,2.34,percent of total billed charges,Drugs,2.34,34,,2.34,percent of total billed charges,Drugs,2.34,34,,2.34,percent of total billed charges,Drugs,2.34,34,,2.34,percent of total billed charges,Drugs,2.41,35,,2.41,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,2.41,35,,2.41,percent of total billed charges,Drugs,2.41,35,,2.41,percent of total billed charges,Drugs,2.41,35,,2.41,percent of total billed charges,Drugs,2.41,35,,2.41,percent of total billed charges,Drugs,2.41,35,,2.41,percent of total billed charges,Drugs,2.75,40,,2.75,percent of total billed charges,Drugs,4.82,70,,4.82,percent of total billed charges,All Other,2.48,36,,2.48,percent of total billed charges,Drugs,2.48,36,,2.48,percent of total billed charges,Drugs,2.41,35,,2.41,percent of total billed charges,Drugs,2.41,35,,2.41,percent of total billed charges,Drugs,2.41,35,,2.41,percent of total billed charges,Drugs,2.41,35,,2.41,percent of total billed charges,Drugs,2.29,,,2.29,Other,Drug Cost,2.29,,,2.29,Other,Drug Cost,2.29,,,2.29,Other,Drug Cost,2.29,,,2.29,Other,Drug Cost,2.29,,,2.29,Other,Drug Cost,2.29,,,2.29,Other,Drug Cost,5.16,,,5.16,Other,225% of Medicaid,3.21,,,3.21,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,9.71,,,9.71,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",4.93,,,4.93,Other,215% Medicaid APG methodology,4.93,,,4.93,Other,215% Medicaid APG methodology,2.87,,,2.87,Other,125% Medicaid APG methodology,0.01,9.98,
AMPICILLIN 500MG INJECTION,J0290,HCPCS,,80000140,CDM,636,RC,44567010110,NDC,both,10,EA,5.11,9.98,,,9.98,Other,150% of Medicare + 9.63% HCRA Surcharge,6.07,,,6.07,Fee Schedule,Average Sale Price (ASP) x 6,1.79,35,,1.79,percent of total billed charges,Drugs,1.79,35,,1.79,percent of total billed charges,Drugs,1.74,34,,1.74,percent of total billed charges,Drugs,1.74,34,,1.74,percent of total billed charges,Drugs,1.74,34,,1.74,percent of total billed charges,Drugs,1.74,34,,1.74,percent of total billed charges,Drugs,1.79,35,,1.79,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,1.79,35,,1.79,percent of total billed charges,Drugs,1.79,35,,1.79,percent of total billed charges,Drugs,1.79,35,,1.79,percent of total billed charges,Drugs,1.79,35,,1.79,percent of total billed charges,Drugs,1.79,35,,1.79,percent of total billed charges,Drugs,2.04,40,,2.04,percent of total billed charges,Drugs,3.58,70,,3.58,percent of total billed charges,All Other,1.84,36,,1.84,percent of total billed charges,Drugs,1.84,36,,1.84,percent of total billed charges,Drugs,1.79,35,,1.79,percent of total billed charges,Drugs,1.79,35,,1.79,percent of total billed charges,Drugs,1.79,35,,1.79,percent of total billed charges,Drugs,1.79,35,,1.79,percent of total billed charges,Drugs,1.7,,,1.7,Other,Drug Cost,1.7,,,1.7,Other,Drug Cost,1.7,,,1.7,Other,Drug Cost,1.7,,,1.7,Other,Drug Cost,1.7,,,1.7,Other,Drug Cost,1.7,,,1.7,Other,Drug Cost,3.83,,,3.83,Other,225% of Medicaid,2.38,,,2.38,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,9.71,,,9.71,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",3.66,,,3.66,Other,215% Medicaid APG methodology,3.66,,,3.66,Other,215% Medicaid APG methodology,2.13,,,2.13,Other,125% Medicaid APG methodology,0.01,9.98,
AMPICILLIN/SULBACTAM (UNASYN) 1.5 GM INJ,J0295,HCPCS,,80000142,CDM,636,RC,55150011620,NDC,both,10,EA,2.46,17.45,,,17.45,Other,150% of Medicare + 9.63% HCRA Surcharge,10.61,,,10.61,Fee Schedule,Average Sale Price (ASP) x 6,0.86,35,,0.86,percent of total billed charges,Drugs,0.86,35,,0.86,percent of total billed charges,Drugs,0.84,34,,0.84,percent of total billed charges,Drugs,0.84,34,,0.84,percent of total billed charges,Drugs,0.84,34,,0.84,percent of total billed charges,Drugs,0.84,34,,0.84,percent of total billed charges,Drugs,0.86,35,,0.86,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,0.86,35,,0.86,percent of total billed charges,Drugs,0.86,35,,0.86,percent of total billed charges,Drugs,0.86,35,,0.86,percent of total billed charges,Drugs,0.86,35,,0.86,percent of total billed charges,Drugs,0.86,35,,0.86,percent of total billed charges,Drugs,0.99,40,,0.99,percent of total billed charges,Drugs,1.72,70,,1.72,percent of total billed charges,All Other,0.89,36,,0.89,percent of total billed charges,Drugs,0.89,36,,0.89,percent of total billed charges,Drugs,0.86,35,,0.86,percent of total billed charges,Drugs,0.86,35,,0.86,percent of total billed charges,Drugs,0.86,35,,0.86,percent of total billed charges,Drugs,0.86,35,,0.86,percent of total billed charges,Drugs,0.82,,,0.82,Other,Drug Cost,0.82,,,0.82,Other,Drug Cost,0.82,,,0.82,Other,Drug Cost,0.82,,,0.82,Other,Drug Cost,0.82,,,0.82,Other,Drug Cost,0.82,,,0.82,Other,Drug Cost,1.85,,,1.85,Other,225% of Medicaid,1.15,,,1.15,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,16.98,,,16.98,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",1.77,,,1.77,Other,215% Medicaid APG methodology,1.77,,,1.77,Other,215% Medicaid APG methodology,1.03,,,1.03,Other,125% Medicaid APG methodology,0.01,17.45,
AMPICILLIN/SULBACTAM (UNASYN) 3 GM INJ,J0295,HCPCS,,80000143,CDM,636,RC,55150011720,NDC,both,10,EA,6.64,17.45,,,17.45,Other,150% of Medicare + 9.63% HCRA Surcharge,10.61,,,10.61,Fee Schedule,Average Sale Price (ASP) x 6,2.32,35,,2.32,percent of total billed charges,Drugs,2.32,35,,2.32,percent of total billed charges,Drugs,2.26,34,,2.26,percent of total billed charges,Drugs,2.26,34,,2.26,percent of total billed charges,Drugs,2.26,34,,2.26,percent of total billed charges,Drugs,2.26,34,,2.26,percent of total billed charges,Drugs,2.32,35,,2.32,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,2.32,35,,2.32,percent of total billed charges,Drugs,2.32,35,,2.32,percent of total billed charges,Drugs,2.32,35,,2.32,percent of total billed charges,Drugs,2.32,35,,2.32,percent of total billed charges,Drugs,2.32,35,,2.32,percent of total billed charges,Drugs,2.65,40,,2.65,percent of total billed charges,Drugs,4.65,70,,4.65,percent of total billed charges,All Other,2.39,36,,2.39,percent of total billed charges,Drugs,2.39,36,,2.39,percent of total billed charges,Drugs,2.32,35,,2.32,percent of total billed charges,Drugs,2.32,35,,2.32,percent of total billed charges,Drugs,2.32,35,,2.32,percent of total billed charges,Drugs,2.32,35,,2.32,percent of total billed charges,Drugs,2.21,,,2.21,Other,Drug Cost,2.21,,,2.21,Other,Drug Cost,2.21,,,2.21,Other,Drug Cost,2.21,,,2.21,Other,Drug Cost,2.21,,,2.21,Other,Drug Cost,2.21,,,2.21,Other,Drug Cost,4.98,,,4.98,Other,225% of Medicaid,3.1,,,3.1,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,16.98,,,16.98,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",4.76,,,4.76,Other,215% Medicaid APG methodology,4.76,,,4.76,Other,215% Medicaid APG methodology,2.77,,,2.77,Other,125% Medicaid APG methodology,0.01,17.45,
AMPICILLIN/SULBACTAM 1.5GM/50ML NS,J0295,HCPCS,,80000144,CDM,636,RC,409268901,NDC,both,10,EA,7.48,17.45,,,17.45,Other,150% of Medicare + 9.63% HCRA Surcharge,10.61,,,10.61,Fee Schedule,Average Sale Price (ASP) x 6,2.62,35,,2.62,percent of total billed charges,Drugs,2.62,35,,2.62,percent of total billed charges,Drugs,2.54,34,,2.54,percent of total billed charges,Drugs,2.54,34,,2.54,percent of total billed charges,Drugs,2.54,34,,2.54,percent of total billed charges,Drugs,2.54,34,,2.54,percent of total billed charges,Drugs,2.62,35,,2.62,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,2.62,35,,2.62,percent of total billed charges,Drugs,2.62,35,,2.62,percent of total billed charges,Drugs,2.62,35,,2.62,percent of total billed charges,Drugs,2.62,35,,2.62,percent of total billed charges,Drugs,2.62,35,,2.62,percent of total billed charges,Drugs,2.99,40,,2.99,percent of total billed charges,Drugs,5.24,70,,5.24,percent of total billed charges,All Other,2.69,36,,2.69,percent of total billed charges,Drugs,2.69,36,,2.69,percent of total billed charges,Drugs,2.62,35,,2.62,percent of total billed charges,Drugs,2.62,35,,2.62,percent of total billed charges,Drugs,2.62,35,,2.62,percent of total billed charges,Drugs,2.62,35,,2.62,percent of total billed charges,Drugs,2.49,,,2.49,Other,Drug Cost,2.49,,,2.49,Other,Drug Cost,2.49,,,2.49,Other,Drug Cost,2.49,,,2.49,Other,Drug Cost,2.49,,,2.49,Other,Drug Cost,2.49,,,2.49,Other,Drug Cost,5.61,,,5.61,Other,225% of Medicaid,3.49,,,3.49,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,16.98,,,16.98,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",5.36,,,5.36,Other,215% Medicaid APG methodology,5.36,,,5.36,Other,215% Medicaid APG methodology,3.12,,,3.12,Other,125% Medicaid APG methodology,0.01,17.45,
ANTITHYMOCYTE GLOB EQUINE 250MG,J7504,HCPCS,,80000152,CDM,636,RC,9722402,NDC,both,5,ML,0.14,35435.84,,,35435.84,Other,150% of Medicare + 9.63% HCRA Surcharge,21548.75,,,21548.75,Fee Schedule,Average Sale Price (ASP) x 6,0.05,35,,0.05,percent of total billed charges,Drugs,0.05,35,,0.05,percent of total billed charges,Drugs,0.05,34,,0.05,percent of total billed charges,Drugs,0.05,34,,0.05,percent of total billed charges,Drugs,0.05,34,,0.05,percent of total billed charges,Drugs,0.05,34,,0.05,percent of total billed charges,Drugs,0.05,35,,0.05,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,0.05,35,,0.05,percent of total billed charges,Drugs,0.05,35,,0.05,percent of total billed charges,Drugs,0.05,35,,0.05,percent of total billed charges,Drugs,0.05,35,,0.05,percent of total billed charges,Drugs,0.05,35,,0.05,percent of total billed charges,Drugs,0.06,40,,0.06,percent of total billed charges,Drugs,0.1,70,,0.1,percent of total billed charges,All Other,0.05,36,,0.05,percent of total billed charges,Drugs,0.05,36,,0.05,percent of total billed charges,Drugs,0.05,35,,0.05,percent of total billed charges,Drugs,0.05,35,,0.05,percent of total billed charges,Drugs,0.05,35,,0.05,percent of total billed charges,Drugs,0.05,35,,0.05,percent of total billed charges,Drugs,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.1,,,0.1,Other,225% of Medicaid,0.06,,,0.06,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,34478,,,34478,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",0.1,,,0.1,Other,215% Medicaid APG methodology,0.1,,,0.1,Other,215% Medicaid APG methodology,0.06,,,0.06,Other,125% Medicaid APG methodology,0.01,35435.84,
ANTIVENIN (CROTALIDAE) POLYVALENT INJ,J0840,HCPCS,,80000153,CDM,636,RC,50633011012,NDC,both,2,EA,3558.23,19239.25,,,19239.25,Other,150% of Medicare + 9.63% HCRA Surcharge,11699.5,,,11699.5,Fee Schedule,Average Sale Price (ASP) x 6,1245.38,35,,1245.38,percent of total billed charges,Drugs,1245.38,35,,1245.38,percent of total billed charges,Drugs,1209.8,34,,1209.8,percent of total billed charges,Drugs,1209.8,34,,1209.8,percent of total billed charges,Drugs,1209.8,34,,1209.8,percent of total billed charges,Drugs,1209.8,34,,1209.8,percent of total billed charges,Drugs,1245.38,35,,1245.38,percent of total billed charges,Drugs,1209.8,34,"If Charge > 500, then 34 percent",1209.8,percent of total billed charges,Drugs,1245.38,35,,1245.38,percent of total billed charges,Drugs,1245.38,35,,1245.38,percent of total billed charges,Drugs,1245.38,35,,1245.38,percent of total billed charges,Drugs,1245.38,35,,1245.38,percent of total billed charges,Drugs,1245.38,35,,1245.38,percent of total billed charges,Drugs,1423.29,40,,1423.29,percent of total billed charges,Drugs,2490.76,70,,2490.76,percent of total billed charges,All Other,1280.96,36,,1280.96,percent of total billed charges,Drugs,1280.96,36,,1280.96,percent of total billed charges,Drugs,1245.38,35,,1245.38,percent of total billed charges,Drugs,1245.38,35,,1245.38,percent of total billed charges,Drugs,1245.38,35,,1245.38,percent of total billed charges,Drugs,1245.38,35,,1245.38,percent of total billed charges,Drugs,1186.08,,,1186.08,Other,Drug Cost,1186.08,,,1186.08,Other,Drug Cost,1186.08,,,1186.08,Other,Drug Cost,1186.08,,,1186.08,Other,Drug Cost,1186.08,,,1186.08,Other,Drug Cost,1186.08,,,1186.08,Other,Drug Cost,2668.67,,,2668.67,Other,225% of Medicaid,1660.51,,,1660.51,Other,140% of Medicaid,1209.8,34,"If Charge > 2,000, then 34 percent",1209.8,percent of total billed charges,Drugs,18719.2,,,18719.2,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",2550.06,,,2550.06,Other,215% Medicaid APG methodology,2550.06,,,2550.06,Other,215% Medicaid APG methodology,1482.59,,,1482.59,Other,125% Medicaid APG methodology,0.01,19239.25,
ARANESP (POLYSORBATE) 150MCG/0.3ML,J0882,HCPCS,,80000161,CDM,636,RC,55513002704,NDC,both,4,ML,795.04,28.91,,,28.91,Other,150% of Medicare + 9.63% HCRA Surcharge,17.58,,,17.58,Fee Schedule,Average Sale Price (ASP) x 6,278.26,35,,278.26,percent of total billed charges,Drugs,278.26,35,,278.26,percent of total billed charges,Drugs,270.31,34,,270.31,percent of total billed charges,Drugs,270.31,34,,270.31,percent of total billed charges,Drugs,270.31,34,,270.31,percent of total billed charges,Drugs,270.31,34,,270.31,percent of total billed charges,Drugs,278.26,35,,278.26,percent of total billed charges,Drugs,270.31,34,"If Charge > 500, then 34 percent",270.31,percent of total billed charges,Drugs,278.26,35,,278.26,percent of total billed charges,Drugs,278.26,35,,278.26,percent of total billed charges,Drugs,278.26,35,,278.26,percent of total billed charges,Drugs,278.26,35,,278.26,percent of total billed charges,Drugs,278.26,35,,278.26,percent of total billed charges,Drugs,318.02,40,,318.02,percent of total billed charges,Drugs,556.53,70,,556.53,percent of total billed charges,All Other,286.21,36,,286.21,percent of total billed charges,Drugs,286.21,36,,286.21,percent of total billed charges,Drugs,278.26,35,,278.26,percent of total billed charges,Drugs,278.26,35,,278.26,percent of total billed charges,Drugs,278.26,35,,278.26,percent of total billed charges,Drugs,278.26,35,,278.26,percent of total billed charges,Drugs,265.01,,,265.01,Other,Drug Cost,265.01,,,265.01,Other,Drug Cost,265.01,,,265.01,Other,Drug Cost,265.01,,,265.01,Other,Drug Cost,265.01,,,265.01,Other,Drug Cost,265.01,,,265.01,Other,Drug Cost,596.28,,,596.28,Other,225% of Medicaid,371.02,,,371.02,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,28.13,,,28.13,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",569.78,,,569.78,Other,215% Medicaid APG methodology,569.78,,,569.78,Other,215% Medicaid APG methodology,331.27,,,331.27,Other,125% Medicaid APG methodology,0.01,596.28,
ATROPINE SULFATE INJECTION 0.1MG 10 ML,J0461,HCPCS,,80000197,CDM,636,RC,409163010,NDC,both,10,ML,7.19,0.75,,,0.75,Other,150% of Medicare + 9.63% HCRA Surcharge,0.46,,,0.46,Fee Schedule,Average Sale Price (ASP) x 6,2.52,35,,2.52,percent of total billed charges,Drugs,2.52,35,,2.52,percent of total billed charges,Drugs,2.44,34,,2.44,percent of total billed charges,Drugs,2.44,34,,2.44,percent of total billed charges,Drugs,2.44,34,,2.44,percent of total billed charges,Drugs,2.44,34,,2.44,percent of total billed charges,Drugs,2.52,35,,2.52,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,2.52,35,,2.52,percent of total billed charges,Drugs,2.52,35,,2.52,percent of total billed charges,Drugs,2.52,35,,2.52,percent of total billed charges,Drugs,2.52,35,,2.52,percent of total billed charges,Drugs,2.52,35,,2.52,percent of total billed charges,Drugs,2.88,40,,2.88,percent of total billed charges,Drugs,5.03,70,,5.03,percent of total billed charges,All Other,2.59,36,,2.59,percent of total billed charges,Drugs,2.59,36,,2.59,percent of total billed charges,Drugs,2.52,35,,2.52,percent of total billed charges,Drugs,2.52,35,,2.52,percent of total billed charges,Drugs,2.52,35,,2.52,percent of total billed charges,Drugs,2.52,35,,2.52,percent of total billed charges,Drugs,2.4,,,2.4,Other,Drug Cost,2.4,,,2.4,Other,Drug Cost,2.4,,,2.4,Other,Drug Cost,2.4,,,2.4,Other,Drug Cost,2.4,,,2.4,Other,Drug Cost,2.4,,,2.4,Other,Drug Cost,5.39,,,5.39,Other,225% of Medicaid,3.36,,,3.36,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,0.73,,,0.73,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",5.15,,,5.15,Other,215% Medicaid APG methodology,5.15,,,5.15,Other,215% Medicaid APG methodology,3,,,3,Other,125% Medicaid APG methodology,0.01,5.39,
ATROPINE SULFATE INJECTION 0.1MG 5 ML,J0461,HCPCS,,80000198,CDM,636,RC,409491034,NDC,both,10,ML,25.38,0.75,,,0.75,Other,150% of Medicare + 9.63% HCRA Surcharge,0.46,,,0.46,Fee Schedule,Average Sale Price (ASP) x 6,8.88,35,,8.88,percent of total billed charges,Drugs,8.88,35,,8.88,percent of total billed charges,Drugs,8.63,34,,8.63,percent of total billed charges,Drugs,8.63,34,,8.63,percent of total billed charges,Drugs,8.63,34,,8.63,percent of total billed charges,Drugs,8.63,34,,8.63,percent of total billed charges,Drugs,8.88,35,,8.88,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,8.88,35,,8.88,percent of total billed charges,Drugs,8.88,35,,8.88,percent of total billed charges,Drugs,8.88,35,,8.88,percent of total billed charges,Drugs,8.88,35,,8.88,percent of total billed charges,Drugs,8.88,35,,8.88,percent of total billed charges,Drugs,10.15,40,,10.15,percent of total billed charges,Drugs,17.77,70,,17.77,percent of total billed charges,All Other,9.14,36,,9.14,percent of total billed charges,Drugs,9.14,36,,9.14,percent of total billed charges,Drugs,8.88,35,,8.88,percent of total billed charges,Drugs,8.88,35,,8.88,percent of total billed charges,Drugs,8.88,35,,8.88,percent of total billed charges,Drugs,8.88,35,,8.88,percent of total billed charges,Drugs,8.46,,,8.46,Other,Drug Cost,8.46,,,8.46,Other,Drug Cost,8.46,,,8.46,Other,Drug Cost,8.46,,,8.46,Other,Drug Cost,8.46,,,8.46,Other,Drug Cost,8.46,,,8.46,Other,Drug Cost,19.04,,,19.04,Other,225% of Medicaid,11.84,,,11.84,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,0.73,,,0.73,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",18.19,,,18.19,Other,215% Medicaid APG methodology,18.19,,,18.19,Other,215% Medicaid APG methodology,10.58,,,10.58,Other,125% Medicaid APG methodology,0.01,19.04,
AZACITIDINE INJECTION 100 MG,J9025,HCPCS,,80000203,CDM,636,RC,59572010201,NDC,both,1,EA,1737.27,3.48,,,3.48,Other,150% of Medicare + 9.63% HCRA Surcharge,2.12,,,2.12,Fee Schedule,Average Sale Price (ASP) x 6,608.04,35,,608.04,percent of total billed charges,Drugs,608.04,35,,608.04,percent of total billed charges,Drugs,590.67,34,,590.67,percent of total billed charges,Drugs,590.67,34,,590.67,percent of total billed charges,Drugs,590.67,34,,590.67,percent of total billed charges,Drugs,590.67,34,,590.67,percent of total billed charges,Drugs,608.04,35,,608.04,percent of total billed charges,Drugs,590.67,34,"If Charge > 500, then 34 percent",590.67,percent of total billed charges,Drugs,608.04,35,,608.04,percent of total billed charges,Drugs,608.04,35,,608.04,percent of total billed charges,Drugs,608.04,35,,608.04,percent of total billed charges,Drugs,608.04,35,,608.04,percent of total billed charges,Drugs,608.04,35,,608.04,percent of total billed charges,Drugs,694.91,40,,694.91,percent of total billed charges,Drugs,1216.09,70,,1216.09,percent of total billed charges,All Other,625.42,36,,625.42,percent of total billed charges,Drugs,625.42,36,,625.42,percent of total billed charges,Drugs,608.04,35,,608.04,percent of total billed charges,Drugs,608.04,35,,608.04,percent of total billed charges,Drugs,608.04,35,,608.04,percent of total billed charges,Drugs,608.04,35,,608.04,percent of total billed charges,Drugs,579.09,,,579.09,Other,Drug Cost,579.09,,,579.09,Other,Drug Cost,579.09,,,579.09,Other,Drug Cost,579.09,,,579.09,Other,Drug Cost,579.09,,,579.09,Other,Drug Cost,579.09,,,579.09,Other,Drug Cost,1302.95,,,1302.95,Other,225% of Medicaid,810.73,,,810.73,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,3.39,,,3.39,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",1245.04,,,1245.04,Other,215% Medicaid APG methodology,1245.04,,,1245.04,Other,215% Medicaid APG methodology,723.86,,,723.86,Other,125% Medicaid APG methodology,0.01,1302.95,
AZATHIOPRINE-ORAL TAB 50 MG,J7500,HCPCS,,80000204,CDM,636,RC,67877049301,NDC,both,100,EA,0.18,44.98,,,44.98,Other,150% of Medicare + 9.63% HCRA Surcharge,27.35,,,27.35,Fee Schedule,Average Sale Price (ASP) x 6,0.06,35,,0.06,percent of total billed charges,Drugs,0.06,35,,0.06,percent of total billed charges,Drugs,0.06,34,,0.06,percent of total billed charges,Drugs,0.06,34,,0.06,percent of total billed charges,Drugs,0.06,34,,0.06,percent of total billed charges,Drugs,0.06,34,,0.06,percent of total billed charges,Drugs,0.06,35,,0.06,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,0.06,35,,0.06,percent of total billed charges,Drugs,0.06,35,,0.06,percent of total billed charges,Drugs,0.06,35,,0.06,percent of total billed charges,Drugs,0.06,35,,0.06,percent of total billed charges,Drugs,0.06,35,,0.06,percent of total billed charges,Drugs,0.07,40,,0.07,percent of total billed charges,Drugs,0.12,70,,0.12,percent of total billed charges,All Other,0.06,36,,0.06,percent of total billed charges,Drugs,0.06,36,,0.06,percent of total billed charges,Drugs,0.06,35,,0.06,percent of total billed charges,Drugs,0.06,35,,0.06,percent of total billed charges,Drugs,0.06,35,,0.06,percent of total billed charges,Drugs,0.06,35,,0.06,percent of total billed charges,Drugs,0.06,,,0.06,Other,Drug Cost,0.06,,,0.06,Other,Drug Cost,0.06,,,0.06,Other,Drug Cost,0.06,,,0.06,Other,Drug Cost,0.06,,,0.06,Other,Drug Cost,0.06,,,0.06,Other,Drug Cost,0.13,,,0.13,Other,225% of Medicaid,0.08,,,0.08,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,43.77,,,43.77,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",0.13,,,0.13,Other,215% Medicaid APG methodology,0.13,,,0.13,Other,215% Medicaid APG methodology,0.07,,,0.07,Other,125% Medicaid APG methodology,0.01,44.98,
AZITHROMYCIN 500 MG INJ,J0456,HCPCS,,80000208,CDM,636,RC,70860010010,NDC,both,10,EA,3.33,25.65,,,25.65,Other,150% of Medicare + 9.63% HCRA Surcharge,15.6,,,15.6,Fee Schedule,Average Sale Price (ASP) x 6,1.17,35,,1.17,percent of total billed charges,Drugs,1.17,35,,1.17,percent of total billed charges,Drugs,1.13,34,,1.13,percent of total billed charges,Drugs,1.13,34,,1.13,percent of total billed charges,Drugs,1.13,34,,1.13,percent of total billed charges,Drugs,1.13,34,,1.13,percent of total billed charges,Drugs,1.17,35,,1.17,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,1.17,35,,1.17,percent of total billed charges,Drugs,1.17,35,,1.17,percent of total billed charges,Drugs,1.17,35,,1.17,percent of total billed charges,Drugs,1.17,35,,1.17,percent of total billed charges,Drugs,1.17,35,,1.17,percent of total billed charges,Drugs,1.33,40,,1.33,percent of total billed charges,Drugs,2.33,70,,2.33,percent of total billed charges,All Other,1.2,36,,1.2,percent of total billed charges,Drugs,1.2,36,,1.2,percent of total billed charges,Drugs,1.17,35,,1.17,percent of total billed charges,Drugs,1.17,35,,1.17,percent of total billed charges,Drugs,1.17,35,,1.17,percent of total billed charges,Drugs,1.17,35,,1.17,percent of total billed charges,Drugs,1.11,,,1.11,Other,Drug Cost,1.11,,,1.11,Other,Drug Cost,1.11,,,1.11,Other,Drug Cost,1.11,,,1.11,Other,Drug Cost,1.11,,,1.11,Other,Drug Cost,1.11,,,1.11,Other,Drug Cost,2.5,,,2.5,Other,225% of Medicaid,1.56,,,1.56,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,24.96,,,24.96,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",2.39,,,2.39,Other,215% Medicaid APG methodology,2.39,,,2.39,Other,215% Medicaid APG methodology,1.39,,,1.39,Other,125% Medicaid APG methodology,0.01,25.65,
AZTREONAM (AZACTAM) 1 GM IV,J0457,HCPCS,,80000210,CDM,636,RC,63323040120,NDC,both,10,EA,29.9,25.05,,,25.05,Other,150% of Medicare + 9.63% HCRA Surcharge,15.23,,,15.23,Fee Schedule,Average Sale Price (ASP) x 6,10.46,35,,10.46,percent of total billed charges,Drugs,10.46,35,,10.46,percent of total billed charges,Drugs,10.16,34,,10.16,percent of total billed charges,Drugs,10.16,34,,10.16,percent of total billed charges,Drugs,10.16,34,,10.16,percent of total billed charges,Drugs,10.16,34,,10.16,percent of total billed charges,Drugs,10.46,35,,10.46,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,10.46,35,,10.46,percent of total billed charges,Drugs,10.46,35,,10.46,percent of total billed charges,Drugs,10.46,35,,10.46,percent of total billed charges,Drugs,10.46,35,,10.46,percent of total billed charges,Drugs,10.46,35,,10.46,percent of total billed charges,Drugs,11.96,40,,11.96,percent of total billed charges,Drugs,20.93,70,,20.93,percent of total billed charges,All Other,10.76,36,,10.76,percent of total billed charges,Drugs,10.76,36,,10.76,percent of total billed charges,Drugs,10.46,35,,10.46,percent of total billed charges,Drugs,10.46,35,,10.46,percent of total billed charges,Drugs,10.46,35,,10.46,percent of total billed charges,Drugs,10.46,35,,10.46,percent of total billed charges,Drugs,9.97,,,9.97,Other,Drug Cost,9.97,,,9.97,Other,Drug Cost,9.97,,,9.97,Other,Drug Cost,9.97,,,9.97,Other,Drug Cost,9.97,,,9.97,Other,Drug Cost,9.97,,,9.97,Other,Drug Cost,22.42,,,22.42,Other,225% of Medicaid,13.95,,,13.95,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,24.37,,,24.37,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",21.42,,,21.42,Other,215% Medicaid APG methodology,21.42,,,21.42,Other,215% Medicaid APG methodology,12.46,,,12.46,Other,125% Medicaid APG methodology,0.01,25.05,
AZACTAM 1GM/50ML NS,J0457,HCPCS,,80000211,CDM,636,RC,409082901,NDC,both,10,EA,57.63,25.05,,,25.05,Other,150% of Medicare + 9.63% HCRA Surcharge,15.23,,,15.23,Fee Schedule,Average Sale Price (ASP) x 6,20.17,35,,20.17,percent of total billed charges,Drugs,20.17,35,,20.17,percent of total billed charges,Drugs,19.6,34,,19.6,percent of total billed charges,Drugs,19.6,34,,19.6,percent of total billed charges,Drugs,19.6,34,,19.6,percent of total billed charges,Drugs,19.6,34,,19.6,percent of total billed charges,Drugs,20.17,35,,20.17,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,20.17,35,,20.17,percent of total billed charges,Drugs,20.17,35,,20.17,percent of total billed charges,Drugs,20.17,35,,20.17,percent of total billed charges,Drugs,20.17,35,,20.17,percent of total billed charges,Drugs,20.17,35,,20.17,percent of total billed charges,Drugs,23.05,40,,23.05,percent of total billed charges,Drugs,40.34,70,,40.34,percent of total billed charges,All Other,20.75,36,,20.75,percent of total billed charges,Drugs,20.75,36,,20.75,percent of total billed charges,Drugs,20.17,35,,20.17,percent of total billed charges,Drugs,20.17,35,,20.17,percent of total billed charges,Drugs,20.17,35,,20.17,percent of total billed charges,Drugs,20.17,35,,20.17,percent of total billed charges,Drugs,19.21,,,19.21,Other,Drug Cost,19.21,,,19.21,Other,Drug Cost,19.21,,,19.21,Other,Drug Cost,19.21,,,19.21,Other,Drug Cost,19.21,,,19.21,Other,Drug Cost,19.21,,,19.21,Other,Drug Cost,43.22,,,43.22,Other,225% of Medicaid,26.9,,,26.9,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,24.37,,,24.37,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",41.3,,,41.3,Other,215% Medicaid APG methodology,41.3,,,41.3,Other,215% Medicaid APG methodology,24.01,,,24.01,Other,125% Medicaid APG methodology,0.01,43.22,
AZTREONAM (AZACTAM) 2 G,J0457,HCPCS,,80000212,CDM,636,RC,63323040220,NDC,both,10,EA,59.79,25.05,,,25.05,Other,150% of Medicare + 9.63% HCRA Surcharge,15.23,,,15.23,Fee Schedule,Average Sale Price (ASP) x 6,20.93,35,,20.93,percent of total billed charges,Drugs,20.93,35,,20.93,percent of total billed charges,Drugs,20.33,34,,20.33,percent of total billed charges,Drugs,20.33,34,,20.33,percent of total billed charges,Drugs,20.33,34,,20.33,percent of total billed charges,Drugs,20.33,34,,20.33,percent of total billed charges,Drugs,20.93,35,,20.93,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,20.93,35,,20.93,percent of total billed charges,Drugs,20.93,35,,20.93,percent of total billed charges,Drugs,20.93,35,,20.93,percent of total billed charges,Drugs,20.93,35,,20.93,percent of total billed charges,Drugs,20.93,35,,20.93,percent of total billed charges,Drugs,23.92,40,,23.92,percent of total billed charges,Drugs,41.85,70,,41.85,percent of total billed charges,All Other,21.52,36,,21.52,percent of total billed charges,Drugs,21.52,36,,21.52,percent of total billed charges,Drugs,20.93,35,,20.93,percent of total billed charges,Drugs,20.93,35,,20.93,percent of total billed charges,Drugs,20.93,35,,20.93,percent of total billed charges,Drugs,20.93,35,,20.93,percent of total billed charges,Drugs,19.93,,,19.93,Other,Drug Cost,19.93,,,19.93,Other,Drug Cost,19.93,,,19.93,Other,Drug Cost,19.93,,,19.93,Other,Drug Cost,19.93,,,19.93,Other,Drug Cost,19.93,,,19.93,Other,Drug Cost,44.84,,,44.84,Other,225% of Medicaid,27.9,,,27.9,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,24.37,,,24.37,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",42.85,,,42.85,Other,215% Medicaid APG methodology,42.85,,,42.85,Other,215% Medicaid APG methodology,24.91,,,24.91,Other,125% Medicaid APG methodology,0.01,44.84,
BENZTROPINE 2 MG/ 2ML INJECTION,J0515,HCPCS,,80000242,CDM,636,RC,63323097002,NDC,both,5,ML,54.94,162.16,,,162.16,Other,150% of Medicare + 9.63% HCRA Surcharge,98.61,,,98.61,Fee Schedule,Average Sale Price (ASP) x 6,19.23,35,,19.23,percent of total billed charges,Drugs,19.23,35,,19.23,percent of total billed charges,Drugs,18.68,34,,18.68,percent of total billed charges,Drugs,18.68,34,,18.68,percent of total billed charges,Drugs,18.68,34,,18.68,percent of total billed charges,Drugs,18.68,34,,18.68,percent of total billed charges,Drugs,19.23,35,,19.23,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,19.23,35,,19.23,percent of total billed charges,Drugs,19.23,35,,19.23,percent of total billed charges,Drugs,19.23,35,,19.23,percent of total billed charges,Drugs,19.23,35,,19.23,percent of total billed charges,Drugs,19.23,35,,19.23,percent of total billed charges,Drugs,21.97,40,,21.97,percent of total billed charges,Drugs,38.46,70,,38.46,percent of total billed charges,All Other,19.78,36,,19.78,percent of total billed charges,Drugs,19.78,36,,19.78,percent of total billed charges,Drugs,19.23,35,,19.23,percent of total billed charges,Drugs,19.23,35,,19.23,percent of total billed charges,Drugs,19.23,35,,19.23,percent of total billed charges,Drugs,19.23,35,,19.23,percent of total billed charges,Drugs,18.31,,,18.31,Other,Drug Cost,18.31,,,18.31,Other,Drug Cost,18.31,,,18.31,Other,Drug Cost,18.31,,,18.31,Other,Drug Cost,18.31,,,18.31,Other,Drug Cost,18.31,,,18.31,Other,Drug Cost,41.2,,,41.2,Other,225% of Medicaid,25.64,,,25.64,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,157.78,,,157.78,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",39.37,,,39.37,Other,215% Medicaid APG methodology,39.37,,,39.37,Other,215% Medicaid APG methodology,22.89,,,22.89,Other,125% Medicaid APG methodology,0.01,162.16,
BETAMETHASONE ACET&SOD PHOSP 3MG,J0702,HCPCS,,80000249,CDM,636,RC,78206011801,NDC,both,1,ML,53.4,67.25,,,67.25,Other,150% of Medicare + 9.63% HCRA Surcharge,40.9,,,40.9,Fee Schedule,Average Sale Price (ASP) x 6,18.69,35,,18.69,percent of total billed charges,Drugs,18.69,35,,18.69,percent of total billed charges,Drugs,18.16,34,,18.16,percent of total billed charges,Drugs,18.16,34,,18.16,percent of total billed charges,Drugs,18.16,34,,18.16,percent of total billed charges,Drugs,18.16,34,,18.16,percent of total billed charges,Drugs,18.69,35,,18.69,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,18.69,35,,18.69,percent of total billed charges,Drugs,18.69,35,,18.69,percent of total billed charges,Drugs,18.69,35,,18.69,percent of total billed charges,Drugs,18.69,35,,18.69,percent of total billed charges,Drugs,18.69,35,,18.69,percent of total billed charges,Drugs,21.36,40,,21.36,percent of total billed charges,Drugs,37.38,70,,37.38,percent of total billed charges,All Other,19.22,36,,19.22,percent of total billed charges,Drugs,19.22,36,,19.22,percent of total billed charges,Drugs,18.69,35,,18.69,percent of total billed charges,Drugs,18.69,35,,18.69,percent of total billed charges,Drugs,18.69,35,,18.69,percent of total billed charges,Drugs,18.69,35,,18.69,percent of total billed charges,Drugs,17.8,,,17.8,Other,Drug Cost,17.8,,,17.8,Other,Drug Cost,17.8,,,17.8,Other,Drug Cost,17.8,,,17.8,Other,Drug Cost,17.8,,,17.8,Other,Drug Cost,17.8,,,17.8,Other,Drug Cost,40.05,,,40.05,Other,225% of Medicaid,24.92,,,24.92,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,65.43,,,65.43,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",38.27,,,38.27,Other,215% Medicaid APG methodology,38.27,,,38.27,Other,215% Medicaid APG methodology,22.25,,,22.25,Other,125% Medicaid APG methodology,0.01,67.25,
BLEOMYCIN SULFATE INJECTION 15 UNITS,J9040,HCPCS,,80000268,CDM,636,RC,703315401,NDC,both,1,EA,155.46,207.44,,,207.44,Other,150% of Medicare + 9.63% HCRA Surcharge,126.14,,,126.14,Fee Schedule,Average Sale Price (ASP) x 6,54.41,35,,54.41,percent of total billed charges,Drugs,54.41,35,,54.41,percent of total billed charges,Drugs,52.86,34,,52.86,percent of total billed charges,Drugs,52.86,34,,52.86,percent of total billed charges,Drugs,52.86,34,,52.86,percent of total billed charges,Drugs,52.86,34,,52.86,percent of total billed charges,Drugs,54.41,35,,54.41,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,54.41,35,,54.41,percent of total billed charges,Drugs,54.41,35,,54.41,percent of total billed charges,Drugs,54.41,35,,54.41,percent of total billed charges,Drugs,54.41,35,,54.41,percent of total billed charges,Drugs,54.41,35,,54.41,percent of total billed charges,Drugs,62.18,40,,62.18,percent of total billed charges,Drugs,108.82,70,,108.82,percent of total billed charges,All Other,55.97,36,,55.97,percent of total billed charges,Drugs,55.97,36,,55.97,percent of total billed charges,Drugs,54.41,35,,54.41,percent of total billed charges,Drugs,54.41,35,,54.41,percent of total billed charges,Drugs,54.41,35,,54.41,percent of total billed charges,Drugs,54.41,35,,54.41,percent of total billed charges,Drugs,51.82,,,51.82,Other,Drug Cost,51.82,,,51.82,Other,Drug Cost,51.82,,,51.82,Other,Drug Cost,51.82,,,51.82,Other,Drug Cost,51.82,,,51.82,Other,Drug Cost,51.82,,,51.82,Other,Drug Cost,116.6,,,116.6,Other,225% of Medicaid,72.55,,,72.55,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,201.83,,,201.83,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",111.41,,,111.41,Other,215% Medicaid APG methodology,111.41,,,111.41,Other,215% Medicaid APG methodology,64.78,,,64.78,Other,125% Medicaid APG methodology,0.01,207.44,
BORTEZOMIB (VELCADE) 3.5 MG INJ,J9041,HCPCS,,80000270,CDM,636,RC,63020004901,NDC,both,1,EA,4809,19.33,,,19.33,Other,150% of Medicare + 9.63% HCRA Surcharge,11.75,,,11.75,Fee Schedule,Average Sale Price (ASP) x 6,1683.15,35,,1683.15,percent of total billed charges,Drugs,1683.15,35,,1683.15,percent of total billed charges,Drugs,1635.06,34,,1635.06,percent of total billed charges,Drugs,1635.06,34,,1635.06,percent of total billed charges,Drugs,1635.06,34,,1635.06,percent of total billed charges,Drugs,1635.06,34,,1635.06,percent of total billed charges,Drugs,1683.15,35,,1683.15,percent of total billed charges,Drugs,1635.06,34,"If Charge > 500, then 34 percent",1635.06,percent of total billed charges,Drugs,1683.15,35,,1683.15,percent of total billed charges,Drugs,1683.15,35,,1683.15,percent of total billed charges,Drugs,1683.15,35,,1683.15,percent of total billed charges,Drugs,1683.15,35,,1683.15,percent of total billed charges,Drugs,1683.15,35,,1683.15,percent of total billed charges,Drugs,1923.6,40,,1923.6,percent of total billed charges,Drugs,3366.3,70,,3366.3,percent of total billed charges,All Other,1731.24,36,,1731.24,percent of total billed charges,Drugs,1731.24,36,,1731.24,percent of total billed charges,Drugs,1683.15,35,,1683.15,percent of total billed charges,Drugs,1683.15,35,,1683.15,percent of total billed charges,Drugs,1683.15,35,,1683.15,percent of total billed charges,Drugs,1683.15,35,,1683.15,percent of total billed charges,Drugs,1603,,,1603,Other,Drug Cost,1603,,,1603,Other,Drug Cost,1603,,,1603,Other,Drug Cost,1603,,,1603,Other,Drug Cost,1603,,,1603,Other,Drug Cost,1603,,,1603,Other,Drug Cost,3606.75,,,3606.75,Other,225% of Medicaid,2244.2,,,2244.2,Other,140% of Medicaid,1635.06,34,"If Charge > 2,000, then 34 percent",1635.06,percent of total billed charges,Drugs,18.81,,,18.81,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",3446.45,,,3446.45,Other,215% Medicaid APG methodology,3446.45,,,3446.45,Other,215% Medicaid APG methodology,2003.75,,,2003.75,Other,125% Medicaid APG methodology,0.01,3606.75,
BRENTUXIMAB VEDOTIN (ADCETRIS) 50 MG,J9042,HCPCS,,80000271,CDM,636,RC,51144005001,NDC,both,1,EA,35226,2275.4,,,2275.4,Other,150% of Medicare + 9.63% HCRA Surcharge,1383.68,,,1383.68,Fee Schedule,Average Sale Price (ASP) x 6,12329.1,35,,12329.1,percent of total billed charges,Drugs,12329.1,35,,12329.1,percent of total billed charges,Drugs,11976.84,34,,11976.84,percent of total billed charges,Drugs,11976.84,34,,11976.84,percent of total billed charges,Drugs,11976.84,34,,11976.84,percent of total billed charges,Drugs,11976.84,34,,11976.84,percent of total billed charges,Drugs,12329.1,35,,12329.1,percent of total billed charges,Drugs,11976.84,34,"If Charge > 500, then 34 percent",11976.84,percent of total billed charges,Drugs,12329.1,35,,12329.1,percent of total billed charges,Drugs,12329.1,35,,12329.1,percent of total billed charges,Drugs,12329.1,35,,12329.1,percent of total billed charges,Drugs,12329.1,35,,12329.1,percent of total billed charges,Drugs,12329.1,35,,12329.1,percent of total billed charges,Drugs,14090.4,40,,14090.4,percent of total billed charges,Drugs,24658.2,70,,24658.2,percent of total billed charges,All Other,12681.36,36,,12681.36,percent of total billed charges,Drugs,12681.36,36,,12681.36,percent of total billed charges,Drugs,12329.1,35,,12329.1,percent of total billed charges,Drugs,12329.1,35,,12329.1,percent of total billed charges,Drugs,12329.1,35,,12329.1,percent of total billed charges,Drugs,12329.1,35,,12329.1,percent of total billed charges,Drugs,11742,,,11742,Other,Drug Cost,11742,,,11742,Other,Drug Cost,11742,,,11742,Other,Drug Cost,11742,,,11742,Other,Drug Cost,11742,,,11742,Other,Drug Cost,11742,,,11742,Other,Drug Cost,26419.5,,,26419.5,Other,225% of Medicaid,16438.8,,,16438.8,Other,140% of Medicaid,11976.84,34,"If Charge > 2,000, then 34 percent",11976.84,percent of total billed charges,Drugs,2213.89,,,2213.89,Other,160% Medicare Fee Schedule,11976.84,34,,11976.84,Other,"Drug Charges > 20,000, then 34% of Charges",25245.3,,,25245.3,Other,215% Medicaid APG methodology,25245.3,,,25245.3,Other,215% Medicaid APG methodology,14677.5,,,14677.5,Other,125% Medicaid APG methodology,1383.68,26419.5,
BREVIBLOC 2500MG/250ML IV,J3490,HCPCS,,80000273,CDM,636,RC,10019005561,NDC,both,10,ML,126.02,49.74,39.4668,,49.74,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,44.11,35,,44.11,percent of total billed charges,Drugs,44.11,35,,44.11,percent of total billed charges,Drugs,42.85,34,,42.85,percent of total billed charges,Drugs,42.85,34,,42.85,percent of total billed charges,Drugs,42.85,34,,42.85,percent of total billed charges,Drugs,42.85,34,,42.85,percent of total billed charges,Drugs,44.11,35,,44.11,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,44.11,35,,44.11,percent of total billed charges,Drugs,44.11,35,,44.11,percent of total billed charges,Drugs,44.11,35,,44.11,percent of total billed charges,Drugs,44.11,35,,44.11,percent of total billed charges,Drugs,44.11,35,,44.11,percent of total billed charges,Drugs,50.41,40,,50.41,percent of total billed charges,Drugs,88.21,70,,88.21,percent of total billed charges,All Other,45.37,36,,45.37,percent of total billed charges,Drugs,45.37,36,,45.37,percent of total billed charges,Drugs,44.11,35,,44.11,percent of total billed charges,Drugs,44.11,35,,44.11,percent of total billed charges,Drugs,44.11,35,,44.11,percent of total billed charges,Drugs,44.11,35,,44.11,percent of total billed charges,Drugs,42.01,,,42.01,Other,Drug Cost,42.01,,,42.01,Other,Drug Cost,42.01,,,42.01,Other,Drug Cost,42.01,,,42.01,Other,Drug Cost,42.01,,,42.01,Other,Drug Cost,42.01,,,42.01,Other,Drug Cost,94.52,,,94.52,Other,225% of Medicaid,58.81,,,58.81,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",90.32,,,90.32,Other,215% Medicaid APG methodology,90.32,,,90.32,Other,215% Medicaid APG methodology,52.51,,,52.51,Other,125% Medicaid APG methodology,0.01,94.52,
CABAZITAXEL 60MG/1.5ML INJECTION,J9043,HCPCS,,80000317,CDM,636,RC,24582411,NDC,both,1,ML,24731.97,2076.48,,,2076.48,Other,150% of Medicare + 9.63% HCRA Surcharge,1262.72,,,1262.72,Fee Schedule,Average Sale Price (ASP) x 6,8656.19,35,,8656.19,percent of total billed charges,Drugs,8656.19,35,,8656.19,percent of total billed charges,Drugs,8408.87,34,,8408.87,percent of total billed charges,Drugs,8408.87,34,,8408.87,percent of total billed charges,Drugs,8408.87,34,,8408.87,percent of total billed charges,Drugs,8408.87,34,,8408.87,percent of total billed charges,Drugs,8656.19,35,,8656.19,percent of total billed charges,Drugs,8408.87,34,"If Charge > 500, then 34 percent",8408.87,percent of total billed charges,Drugs,8656.19,35,,8656.19,percent of total billed charges,Drugs,8656.19,35,,8656.19,percent of total billed charges,Drugs,8656.19,35,,8656.19,percent of total billed charges,Drugs,8656.19,35,,8656.19,percent of total billed charges,Drugs,8656.19,35,,8656.19,percent of total billed charges,Drugs,9892.79,40,,9892.79,percent of total billed charges,Drugs,17312.38,70,,17312.38,percent of total billed charges,All Other,8903.51,36,,8903.51,percent of total billed charges,Drugs,8903.51,36,,8903.51,percent of total billed charges,Drugs,8656.19,35,,8656.19,percent of total billed charges,Drugs,8656.19,35,,8656.19,percent of total billed charges,Drugs,8656.19,35,,8656.19,percent of total billed charges,Drugs,8656.19,35,,8656.19,percent of total billed charges,Drugs,8243.99,,,8243.99,Other,Drug Cost,8243.99,,,8243.99,Other,Drug Cost,8243.99,,,8243.99,Other,Drug Cost,8243.99,,,8243.99,Other,Drug Cost,8243.99,,,8243.99,Other,Drug Cost,8243.99,,,8243.99,Other,Drug Cost,18548.98,,,18548.98,Other,225% of Medicaid,11541.59,,,11541.59,Other,140% of Medicaid,8408.87,34,"If Charge > 2,000, then 34 percent",8408.87,percent of total billed charges,Drugs,2020.35,,,2020.35,Other,160% Medicare Fee Schedule,8408.87,34,,8408.87,Other,"Drug Charges > 20,000, then 34% of Charges",17724.58,,,17724.58,Other,215% Medicaid APG methodology,17724.58,,,17724.58,Other,215% Medicaid APG methodology,10304.99,,,10304.99,Other,125% Medicaid APG methodology,1262.72,18548.98,
CALCIUM GLUCONATE INJECTION 10 ML,J0612,HCPCS,,80000331,CDM,636,RC,63323036019,NDC,both,25,ML,4.24,0.49,,,0.49,Other,150% of Medicare + 9.63% HCRA Surcharge,0.3,,,0.3,Fee Schedule,Average Sale Price (ASP) x 6,1.48,35,,1.48,percent of total billed charges,Drugs,1.48,35,,1.48,percent of total billed charges,Drugs,1.44,34,,1.44,percent of total billed charges,Drugs,1.44,34,,1.44,percent of total billed charges,Drugs,1.44,34,,1.44,percent of total billed charges,Drugs,1.44,34,,1.44,percent of total billed charges,Drugs,1.48,35,,1.48,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,1.48,35,,1.48,percent of total billed charges,Drugs,1.48,35,,1.48,percent of total billed charges,Drugs,1.48,35,,1.48,percent of total billed charges,Drugs,1.48,35,,1.48,percent of total billed charges,Drugs,1.48,35,,1.48,percent of total billed charges,Drugs,1.7,40,,1.7,percent of total billed charges,Drugs,2.97,70,,2.97,percent of total billed charges,All Other,1.53,36,,1.53,percent of total billed charges,Drugs,1.53,36,,1.53,percent of total billed charges,Drugs,1.48,35,,1.48,percent of total billed charges,Drugs,1.48,35,,1.48,percent of total billed charges,Drugs,1.48,35,,1.48,percent of total billed charges,Drugs,1.48,35,,1.48,percent of total billed charges,Drugs,1.41,,,1.41,Other,Drug Cost,1.41,,,1.41,Other,Drug Cost,1.41,,,1.41,Other,Drug Cost,1.41,,,1.41,Other,Drug Cost,1.41,,,1.41,Other,Drug Cost,1.41,,,1.41,Other,Drug Cost,3.18,,,3.18,Other,225% of Medicaid,1.98,,,1.98,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,0.48,,,0.48,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",3.04,,,3.04,Other,215% Medicaid APG methodology,3.04,,,3.04,Other,215% Medicaid APG methodology,1.77,,,1.77,Other,125% Medicaid APG methodology,0.01,3.18,
CAPECITABINE ORAL 500 MG,J8521,HCPCS,,80000338,CDM,636,RC,16729007329,NDC,both,120,EA,1.73,5.66,,,5.66,Other,150% of Medicare + 9.63% HCRA Surcharge,3.44,,,3.44,Fee Schedule,Average Sale Price (ASP) x 6,0.61,35,,0.61,percent of total billed charges,Drugs,0.61,35,,0.61,percent of total billed charges,Drugs,0.59,34,,0.59,percent of total billed charges,Drugs,0.59,34,,0.59,percent of total billed charges,Drugs,0.59,34,,0.59,percent of total billed charges,Drugs,0.59,34,,0.59,percent of total billed charges,Drugs,0.61,35,,0.61,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,0.61,35,,0.61,percent of total billed charges,Drugs,0.61,35,,0.61,percent of total billed charges,Drugs,0.61,35,,0.61,percent of total billed charges,Drugs,0.61,35,,0.61,percent of total billed charges,Drugs,0.61,35,,0.61,percent of total billed charges,Drugs,0.69,40,,0.69,percent of total billed charges,Drugs,1.21,70,,1.21,percent of total billed charges,All Other,0.62,36,,0.62,percent of total billed charges,Drugs,0.62,36,,0.62,percent of total billed charges,Drugs,0.61,35,,0.61,percent of total billed charges,Drugs,0.61,35,,0.61,percent of total billed charges,Drugs,0.61,35,,0.61,percent of total billed charges,Drugs,0.61,35,,0.61,percent of total billed charges,Drugs,0.58,,,0.58,Other,Drug Cost,0.58,,,0.58,Other,Drug Cost,0.58,,,0.58,Other,Drug Cost,0.58,,,0.58,Other,Drug Cost,0.58,,,0.58,Other,Drug Cost,0.58,,,0.58,Other,Drug Cost,1.3,,,1.3,Other,225% of Medicaid,0.81,,,0.81,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,5.51,,,5.51,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",1.24,,,1.24,Other,215% Medicaid APG methodology,1.24,,,1.24,Other,215% Medicaid APG methodology,0.72,,,0.72,Other,125% Medicaid APG methodology,0.01,5.66,
CARBOPLATIN INJECTION 50 MG/5ML,J9045,HCPCS,,80000370,CDM,636,RC,61703033918,NDC,both,1,ML,7.86,35.51,,,35.51,Other,150% of Medicare + 9.63% HCRA Surcharge,21.59,,,21.59,Fee Schedule,Average Sale Price (ASP) x 6,2.75,35,,2.75,percent of total billed charges,Drugs,2.75,35,,2.75,percent of total billed charges,Drugs,2.67,34,,2.67,percent of total billed charges,Drugs,2.67,34,,2.67,percent of total billed charges,Drugs,2.67,34,,2.67,percent of total billed charges,Drugs,2.67,34,,2.67,percent of total billed charges,Drugs,2.75,35,,2.75,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,2.75,35,,2.75,percent of total billed charges,Drugs,2.75,35,,2.75,percent of total billed charges,Drugs,2.75,35,,2.75,percent of total billed charges,Drugs,2.75,35,,2.75,percent of total billed charges,Drugs,2.75,35,,2.75,percent of total billed charges,Drugs,3.14,40,,3.14,percent of total billed charges,Drugs,5.5,70,,5.5,percent of total billed charges,All Other,2.83,36,,2.83,percent of total billed charges,Drugs,2.83,36,,2.83,percent of total billed charges,Drugs,2.75,35,,2.75,percent of total billed charges,Drugs,2.75,35,,2.75,percent of total billed charges,Drugs,2.75,35,,2.75,percent of total billed charges,Drugs,2.75,35,,2.75,percent of total billed charges,Drugs,2.62,,,2.62,Other,Drug Cost,2.62,,,2.62,Other,Drug Cost,2.62,,,2.62,Other,Drug Cost,2.62,,,2.62,Other,Drug Cost,2.62,,,2.62,Other,Drug Cost,2.62,,,2.62,Other,Drug Cost,5.9,,,5.9,Other,225% of Medicaid,3.67,,,3.67,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,34.55,,,34.55,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",5.63,,,5.63,Other,215% Medicaid APG methodology,5.63,,,5.63,Other,215% Medicaid APG methodology,3.28,,,3.28,Other,125% Medicaid APG methodology,0.01,35.51,
CEFAZOLIN SODIUM 1GM,J0690,HCPCS,,80000387,CDM,636,RC,781345196,NDC,both,25,EA,1.63,7.53,,,7.53,Other,150% of Medicare + 9.63% HCRA Surcharge,4.58,,,4.58,Fee Schedule,Average Sale Price (ASP) x 6,0.57,35,,0.57,percent of total billed charges,Drugs,0.57,35,,0.57,percent of total billed charges,Drugs,0.55,34,,0.55,percent of total billed charges,Drugs,0.55,34,,0.55,percent of total billed charges,Drugs,0.55,34,,0.55,percent of total billed charges,Drugs,0.55,34,,0.55,percent of total billed charges,Drugs,0.57,35,,0.57,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,0.57,35,,0.57,percent of total billed charges,Drugs,0.57,35,,0.57,percent of total billed charges,Drugs,0.57,35,,0.57,percent of total billed charges,Drugs,0.57,35,,0.57,percent of total billed charges,Drugs,0.57,35,,0.57,percent of total billed charges,Drugs,0.65,40,,0.65,percent of total billed charges,Drugs,1.14,70,,1.14,percent of total billed charges,All Other,0.59,36,,0.59,percent of total billed charges,Drugs,0.59,36,,0.59,percent of total billed charges,Drugs,0.57,35,,0.57,percent of total billed charges,Drugs,0.57,35,,0.57,percent of total billed charges,Drugs,0.57,35,,0.57,percent of total billed charges,Drugs,0.57,35,,0.57,percent of total billed charges,Drugs,0.54,,,0.54,Other,Drug Cost,0.54,,,0.54,Other,Drug Cost,0.54,,,0.54,Other,Drug Cost,0.54,,,0.54,Other,Drug Cost,0.54,,,0.54,Other,Drug Cost,0.54,,,0.54,Other,Drug Cost,1.22,,,1.22,Other,225% of Medicaid,0.76,,,0.76,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,7.32,,,7.32,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",1.17,,,1.17,Other,215% Medicaid APG methodology,1.17,,,1.17,Other,215% Medicaid APG methodology,0.68,,,0.68,Other,125% Medicaid APG methodology,0.01,7.53,
CEFAZOLIN SODIUM 500MG,J0690,HCPCS,,80000388,CDM,636,RC,143992390,NDC,both,25,EA,2.96,7.53,,,7.53,Other,150% of Medicare + 9.63% HCRA Surcharge,4.58,,,4.58,Fee Schedule,Average Sale Price (ASP) x 6,1.04,35,,1.04,percent of total billed charges,Drugs,1.04,35,,1.04,percent of total billed charges,Drugs,1.01,34,,1.01,percent of total billed charges,Drugs,1.01,34,,1.01,percent of total billed charges,Drugs,1.01,34,,1.01,percent of total billed charges,Drugs,1.01,34,,1.01,percent of total billed charges,Drugs,1.04,35,,1.04,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,1.04,35,,1.04,percent of total billed charges,Drugs,1.04,35,,1.04,percent of total billed charges,Drugs,1.04,35,,1.04,percent of total billed charges,Drugs,1.04,35,,1.04,percent of total billed charges,Drugs,1.04,35,,1.04,percent of total billed charges,Drugs,1.19,40,,1.19,percent of total billed charges,Drugs,2.07,70,,2.07,percent of total billed charges,All Other,1.07,36,,1.07,percent of total billed charges,Drugs,1.07,36,,1.07,percent of total billed charges,Drugs,1.04,35,,1.04,percent of total billed charges,Drugs,1.04,35,,1.04,percent of total billed charges,Drugs,1.04,35,,1.04,percent of total billed charges,Drugs,1.04,35,,1.04,percent of total billed charges,Drugs,0.99,,,0.99,Other,Drug Cost,0.99,,,0.99,Other,Drug Cost,0.99,,,0.99,Other,Drug Cost,0.99,,,0.99,Other,Drug Cost,0.99,,,0.99,Other,Drug Cost,0.99,,,0.99,Other,Drug Cost,2.22,,,2.22,Other,225% of Medicaid,1.38,,,1.38,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,7.32,,,7.32,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",2.12,,,2.12,Other,215% Medicaid APG methodology,2.12,,,2.12,Other,215% Medicaid APG methodology,1.23,,,1.23,Other,125% Medicaid APG methodology,0.01,7.53,
CEFEPIME HCL INJ 1GM,J0692,HCPCS,,80000389,CDM,636,RC,44567024010,NDC,both,10,EA,6.31,12.45,,,12.45,Other,150% of Medicare + 9.63% HCRA Surcharge,7.57,,,7.57,Fee Schedule,Average Sale Price (ASP) x 6,2.21,35,,2.21,percent of total billed charges,Drugs,2.21,35,,2.21,percent of total billed charges,Drugs,2.14,34,,2.14,percent of total billed charges,Drugs,2.14,34,,2.14,percent of total billed charges,Drugs,2.14,34,,2.14,percent of total billed charges,Drugs,2.14,34,,2.14,percent of total billed charges,Drugs,2.21,35,,2.21,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,2.21,35,,2.21,percent of total billed charges,Drugs,2.21,35,,2.21,percent of total billed charges,Drugs,2.21,35,,2.21,percent of total billed charges,Drugs,2.21,35,,2.21,percent of total billed charges,Drugs,2.21,35,,2.21,percent of total billed charges,Drugs,2.52,40,,2.52,percent of total billed charges,Drugs,4.41,70,,4.41,percent of total billed charges,All Other,2.27,36,,2.27,percent of total billed charges,Drugs,2.27,36,,2.27,percent of total billed charges,Drugs,2.21,35,,2.21,percent of total billed charges,Drugs,2.21,35,,2.21,percent of total billed charges,Drugs,2.21,35,,2.21,percent of total billed charges,Drugs,2.21,35,,2.21,percent of total billed charges,Drugs,2.1,,,2.1,Other,Drug Cost,2.1,,,2.1,Other,Drug Cost,2.1,,,2.1,Other,Drug Cost,2.1,,,2.1,Other,Drug Cost,2.1,,,2.1,Other,Drug Cost,2.1,,,2.1,Other,Drug Cost,4.73,,,4.73,Other,225% of Medicaid,2.94,,,2.94,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,12.12,,,12.12,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",4.52,,,4.52,Other,215% Medicaid APG methodology,4.52,,,4.52,Other,215% Medicaid APG methodology,2.63,,,2.63,Other,125% Medicaid APG methodology,0.01,12.45,
CEFEPIME HCL INJ 2GM,J0692,HCPCS,,80000390,CDM,636,RC,60505614700,NDC,both,1,EA,11.01,12.45,,,12.45,Other,150% of Medicare + 9.63% HCRA Surcharge,7.57,,,7.57,Fee Schedule,Average Sale Price (ASP) x 6,3.85,35,,3.85,percent of total billed charges,Drugs,3.85,35,,3.85,percent of total billed charges,Drugs,3.74,34,,3.74,percent of total billed charges,Drugs,3.74,34,,3.74,percent of total billed charges,Drugs,3.74,34,,3.74,percent of total billed charges,Drugs,3.74,34,,3.74,percent of total billed charges,Drugs,3.85,35,,3.85,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,3.85,35,,3.85,percent of total billed charges,Drugs,3.85,35,,3.85,percent of total billed charges,Drugs,3.85,35,,3.85,percent of total billed charges,Drugs,3.85,35,,3.85,percent of total billed charges,Drugs,3.85,35,,3.85,percent of total billed charges,Drugs,4.4,40,,4.4,percent of total billed charges,Drugs,7.71,70,,7.71,percent of total billed charges,All Other,3.96,36,,3.96,percent of total billed charges,Drugs,3.96,36,,3.96,percent of total billed charges,Drugs,3.85,35,,3.85,percent of total billed charges,Drugs,3.85,35,,3.85,percent of total billed charges,Drugs,3.85,35,,3.85,percent of total billed charges,Drugs,3.85,35,,3.85,percent of total billed charges,Drugs,3.67,,,3.67,Other,Drug Cost,3.67,,,3.67,Other,Drug Cost,3.67,,,3.67,Other,Drug Cost,3.67,,,3.67,Other,Drug Cost,3.67,,,3.67,Other,Drug Cost,3.67,,,3.67,Other,Drug Cost,8.26,,,8.26,Other,225% of Medicaid,5.14,,,5.14,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,12.12,,,12.12,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",7.89,,,7.89,Other,215% Medicaid APG methodology,7.89,,,7.89,Other,215% Medicaid APG methodology,4.59,,,4.59,Other,125% Medicaid APG methodology,0.01,12.45,
CEFOXITIN SODIUM INJ 1 GM,J0694,HCPCS,,80000395,CDM,636,RC,63323034125,NDC,both,25,EA,8.29,50.11,,,50.11,Other,150% of Medicare + 9.63% HCRA Surcharge,30.47,,,30.47,Fee Schedule,Average Sale Price (ASP) x 6,2.9,35,,2.9,percent of total billed charges,Drugs,2.9,35,,2.9,percent of total billed charges,Drugs,2.82,34,,2.82,percent of total billed charges,Drugs,2.82,34,,2.82,percent of total billed charges,Drugs,2.82,34,,2.82,percent of total billed charges,Drugs,2.82,34,,2.82,percent of total billed charges,Drugs,2.9,35,,2.9,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,2.9,35,,2.9,percent of total billed charges,Drugs,2.9,35,,2.9,percent of total billed charges,Drugs,2.9,35,,2.9,percent of total billed charges,Drugs,2.9,35,,2.9,percent of total billed charges,Drugs,2.9,35,,2.9,percent of total billed charges,Drugs,3.32,40,,3.32,percent of total billed charges,Drugs,5.8,70,,5.8,percent of total billed charges,All Other,2.98,36,,2.98,percent of total billed charges,Drugs,2.98,36,,2.98,percent of total billed charges,Drugs,2.9,35,,2.9,percent of total billed charges,Drugs,2.9,35,,2.9,percent of total billed charges,Drugs,2.9,35,,2.9,percent of total billed charges,Drugs,2.9,35,,2.9,percent of total billed charges,Drugs,2.76,,,2.76,Other,Drug Cost,2.76,,,2.76,Other,Drug Cost,2.76,,,2.76,Other,Drug Cost,2.76,,,2.76,Other,Drug Cost,2.76,,,2.76,Other,Drug Cost,2.76,,,2.76,Other,Drug Cost,6.22,,,6.22,Other,225% of Medicaid,3.87,,,3.87,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,48.76,,,48.76,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",5.94,,,5.94,Other,215% Medicaid APG methodology,5.94,,,5.94,Other,215% Medicaid APG methodology,3.45,,,3.45,Other,125% Medicaid APG methodology,0.01,50.11,
CEFOXITIN SODIUM INJ 2 GM,J0694,HCPCS,,80000396,CDM,636,RC,63323034225,NDC,both,25,EA,16.06,50.11,,,50.11,Other,150% of Medicare + 9.63% HCRA Surcharge,30.47,,,30.47,Fee Schedule,Average Sale Price (ASP) x 6,5.62,35,,5.62,percent of total billed charges,Drugs,5.62,35,,5.62,percent of total billed charges,Drugs,5.46,34,,5.46,percent of total billed charges,Drugs,5.46,34,,5.46,percent of total billed charges,Drugs,5.46,34,,5.46,percent of total billed charges,Drugs,5.46,34,,5.46,percent of total billed charges,Drugs,5.62,35,,5.62,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,5.62,35,,5.62,percent of total billed charges,Drugs,5.62,35,,5.62,percent of total billed charges,Drugs,5.62,35,,5.62,percent of total billed charges,Drugs,5.62,35,,5.62,percent of total billed charges,Drugs,5.62,35,,5.62,percent of total billed charges,Drugs,6.42,40,,6.42,percent of total billed charges,Drugs,11.24,70,,11.24,percent of total billed charges,All Other,5.78,36,,5.78,percent of total billed charges,Drugs,5.78,36,,5.78,percent of total billed charges,Drugs,5.62,35,,5.62,percent of total billed charges,Drugs,5.62,35,,5.62,percent of total billed charges,Drugs,5.62,35,,5.62,percent of total billed charges,Drugs,5.62,35,,5.62,percent of total billed charges,Drugs,5.35,,,5.35,Other,Drug Cost,5.35,,,5.35,Other,Drug Cost,5.35,,,5.35,Other,Drug Cost,5.35,,,5.35,Other,Drug Cost,5.35,,,5.35,Other,Drug Cost,5.35,,,5.35,Other,Drug Cost,12.05,,,12.05,Other,225% of Medicaid,7.5,,,7.5,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,48.76,,,48.76,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",11.51,,,11.51,Other,215% Medicaid APG methodology,11.51,,,11.51,Other,215% Medicaid APG methodology,6.69,,,6.69,Other,125% Medicaid APG methodology,0.01,50.11,
CEFTAROLINE FOSAMIL INJ 400MG,J0712,HCPCS,,80000398,CDM,636,RC,456040010,NDC,both,10,EA,11.06,37.84,,,37.84,Other,150% of Medicare + 9.63% HCRA Surcharge,23.01,,,23.01,Fee Schedule,Average Sale Price (ASP) x 6,3.87,35,,3.87,percent of total billed charges,Drugs,3.87,35,,3.87,percent of total billed charges,Drugs,3.76,34,,3.76,percent of total billed charges,Drugs,3.76,34,,3.76,percent of total billed charges,Drugs,3.76,34,,3.76,percent of total billed charges,Drugs,3.76,34,,3.76,percent of total billed charges,Drugs,3.87,35,,3.87,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,3.87,35,,3.87,percent of total billed charges,Drugs,3.87,35,,3.87,percent of total billed charges,Drugs,3.87,35,,3.87,percent of total billed charges,Drugs,3.87,35,,3.87,percent of total billed charges,Drugs,3.87,35,,3.87,percent of total billed charges,Drugs,4.42,40,,4.42,percent of total billed charges,Drugs,7.74,70,,7.74,percent of total billed charges,All Other,3.98,36,,3.98,percent of total billed charges,Drugs,3.98,36,,3.98,percent of total billed charges,Drugs,3.87,35,,3.87,percent of total billed charges,Drugs,3.87,35,,3.87,percent of total billed charges,Drugs,3.87,35,,3.87,percent of total billed charges,Drugs,3.87,35,,3.87,percent of total billed charges,Drugs,3.69,,,3.69,Other,Drug Cost,3.69,,,3.69,Other,Drug Cost,3.69,,,3.69,Other,Drug Cost,3.69,,,3.69,Other,Drug Cost,3.69,,,3.69,Other,Drug Cost,3.69,,,3.69,Other,Drug Cost,8.29,,,8.29,Other,225% of Medicaid,5.16,,,5.16,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,36.82,,,36.82,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",7.92,,,7.92,Other,215% Medicaid APG methodology,7.92,,,7.92,Other,215% Medicaid APG methodology,4.61,,,4.61,Other,125% Medicaid APG methodology,0.01,37.84,
CEFTAROLINE FOSAMIL INJ 600MG,J0712,HCPCS,,80000399,CDM,636,RC,456060010,NDC,both,10,EA,14.41,37.84,,,37.84,Other,150% of Medicare + 9.63% HCRA Surcharge,23.01,,,23.01,Fee Schedule,Average Sale Price (ASP) x 6,5.04,35,,5.04,percent of total billed charges,Drugs,5.04,35,,5.04,percent of total billed charges,Drugs,4.9,34,,4.9,percent of total billed charges,Drugs,4.9,34,,4.9,percent of total billed charges,Drugs,4.9,34,,4.9,percent of total billed charges,Drugs,4.9,34,,4.9,percent of total billed charges,Drugs,5.04,35,,5.04,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,5.04,35,,5.04,percent of total billed charges,Drugs,5.04,35,,5.04,percent of total billed charges,Drugs,5.04,35,,5.04,percent of total billed charges,Drugs,5.04,35,,5.04,percent of total billed charges,Drugs,5.04,35,,5.04,percent of total billed charges,Drugs,5.76,40,,5.76,percent of total billed charges,Drugs,10.08,70,,10.08,percent of total billed charges,All Other,5.19,36,,5.19,percent of total billed charges,Drugs,5.19,36,,5.19,percent of total billed charges,Drugs,5.04,35,,5.04,percent of total billed charges,Drugs,5.04,35,,5.04,percent of total billed charges,Drugs,5.04,35,,5.04,percent of total billed charges,Drugs,5.04,35,,5.04,percent of total billed charges,Drugs,4.8,,,4.8,Other,Drug Cost,4.8,,,4.8,Other,Drug Cost,4.8,,,4.8,Other,Drug Cost,4.8,,,4.8,Other,Drug Cost,4.8,,,4.8,Other,Drug Cost,4.8,,,4.8,Other,Drug Cost,10.8,,,10.8,Other,225% of Medicaid,6.72,,,6.72,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,36.82,,,36.82,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",10.32,,,10.32,Other,215% Medicaid APG methodology,10.32,,,10.32,Other,215% Medicaid APG methodology,6,,,6,Other,125% Medicaid APG methodology,0.01,37.84,
CEFTAZADIME (FORTAZ)  2GM INJ,J0713,HCPCS,,80000400,CDM,636,RC,25021012850,NDC,both,10,EA,15.12,16.71,,,16.71,Other,150% of Medicare + 9.63% HCRA Surcharge,10.16,,,10.16,Fee Schedule,Average Sale Price (ASP) x 6,5.29,35,,5.29,percent of total billed charges,Drugs,5.29,35,,5.29,percent of total billed charges,Drugs,5.14,34,,5.14,percent of total billed charges,Drugs,5.14,34,,5.14,percent of total billed charges,Drugs,5.14,34,,5.14,percent of total billed charges,Drugs,5.14,34,,5.14,percent of total billed charges,Drugs,5.29,35,,5.29,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,5.29,35,,5.29,percent of total billed charges,Drugs,5.29,35,,5.29,percent of total billed charges,Drugs,5.29,35,,5.29,percent of total billed charges,Drugs,5.29,35,,5.29,percent of total billed charges,Drugs,5.29,35,,5.29,percent of total billed charges,Drugs,6.05,40,,6.05,percent of total billed charges,Drugs,10.59,70,,10.59,percent of total billed charges,All Other,5.44,36,,5.44,percent of total billed charges,Drugs,5.44,36,,5.44,percent of total billed charges,Drugs,5.29,35,,5.29,percent of total billed charges,Drugs,5.29,35,,5.29,percent of total billed charges,Drugs,5.29,35,,5.29,percent of total billed charges,Drugs,5.29,35,,5.29,percent of total billed charges,Drugs,5.04,,,5.04,Other,Drug Cost,5.04,,,5.04,Other,Drug Cost,5.04,,,5.04,Other,Drug Cost,5.04,,,5.04,Other,Drug Cost,5.04,,,5.04,Other,Drug Cost,5.04,,,5.04,Other,Drug Cost,11.34,,,11.34,Other,225% of Medicaid,7.06,,,7.06,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,16.26,,,16.26,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",10.84,,,10.84,Other,215% Medicaid APG methodology,10.84,,,10.84,Other,215% Medicaid APG methodology,6.3,,,6.3,Other,125% Medicaid APG methodology,0.01,16.71,
CEFTAZIDIME 1GM INJ,J0713,HCPCS,,80000402,CDM,636,RC,409508216,NDC,both,25,EA,8.02,16.71,,,16.71,Other,150% of Medicare + 9.63% HCRA Surcharge,10.16,,,10.16,Fee Schedule,Average Sale Price (ASP) x 6,2.81,35,,2.81,percent of total billed charges,Drugs,2.81,35,,2.81,percent of total billed charges,Drugs,2.73,34,,2.73,percent of total billed charges,Drugs,2.73,34,,2.73,percent of total billed charges,Drugs,2.73,34,,2.73,percent of total billed charges,Drugs,2.73,34,,2.73,percent of total billed charges,Drugs,2.81,35,,2.81,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,2.81,35,,2.81,percent of total billed charges,Drugs,2.81,35,,2.81,percent of total billed charges,Drugs,2.81,35,,2.81,percent of total billed charges,Drugs,2.81,35,,2.81,percent of total billed charges,Drugs,2.81,35,,2.81,percent of total billed charges,Drugs,3.21,40,,3.21,percent of total billed charges,Drugs,5.61,70,,5.61,percent of total billed charges,All Other,2.89,36,,2.89,percent of total billed charges,Drugs,2.89,36,,2.89,percent of total billed charges,Drugs,2.81,35,,2.81,percent of total billed charges,Drugs,2.81,35,,2.81,percent of total billed charges,Drugs,2.81,35,,2.81,percent of total billed charges,Drugs,2.81,35,,2.81,percent of total billed charges,Drugs,2.67,,,2.67,Other,Drug Cost,2.67,,,2.67,Other,Drug Cost,2.67,,,2.67,Other,Drug Cost,2.67,,,2.67,Other,Drug Cost,2.67,,,2.67,Other,Drug Cost,2.67,,,2.67,Other,Drug Cost,6.01,,,6.01,Other,225% of Medicaid,3.74,,,3.74,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,16.26,,,16.26,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",5.75,,,5.75,Other,215% Medicaid APG methodology,5.75,,,5.75,Other,215% Medicaid APG methodology,3.34,,,3.34,Other,125% Medicaid APG methodology,0.01,16.71,
CEFTRIAXONE 1GM INJ,J0696,HCPCS,,80000405,CDM,636,RC,781320885,NDC,both,1,EA,1.14,4.84,,,4.84,Other,150% of Medicare + 9.63% HCRA Surcharge,2.95,,,2.95,Fee Schedule,Average Sale Price (ASP) x 6,0.4,35,,0.4,percent of total billed charges,Drugs,0.4,35,,0.4,percent of total billed charges,Drugs,0.39,34,,0.39,percent of total billed charges,Drugs,0.39,34,,0.39,percent of total billed charges,Drugs,0.39,34,,0.39,percent of total billed charges,Drugs,0.39,34,,0.39,percent of total billed charges,Drugs,0.4,35,,0.4,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,0.4,35,,0.4,percent of total billed charges,Drugs,0.4,35,,0.4,percent of total billed charges,Drugs,0.4,35,,0.4,percent of total billed charges,Drugs,0.4,35,,0.4,percent of total billed charges,Drugs,0.4,35,,0.4,percent of total billed charges,Drugs,0.46,40,,0.46,percent of total billed charges,Drugs,0.8,70,,0.8,percent of total billed charges,All Other,0.41,36,,0.41,percent of total billed charges,Drugs,0.41,36,,0.41,percent of total billed charges,Drugs,0.4,35,,0.4,percent of total billed charges,Drugs,0.4,35,,0.4,percent of total billed charges,Drugs,0.4,35,,0.4,percent of total billed charges,Drugs,0.4,35,,0.4,percent of total billed charges,Drugs,0.38,,,0.38,Other,Drug Cost,0.38,,,0.38,Other,Drug Cost,0.38,,,0.38,Other,Drug Cost,0.38,,,0.38,Other,Drug Cost,0.38,,,0.38,Other,Drug Cost,0.38,,,0.38,Other,Drug Cost,0.86,,,0.86,Other,225% of Medicaid,0.53,,,0.53,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,4.71,,,4.71,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",0.82,,,0.82,Other,215% Medicaid APG methodology,0.82,,,0.82,Other,215% Medicaid APG methodology,0.48,,,0.48,Other,125% Medicaid APG methodology,0.01,4.84,
CEFTRIAXONE 2GM INJ,J0696,HCPCS,,80000406,CDM,636,RC,143985625,NDC,both,25,EA,4.53,4.84,,,4.84,Other,150% of Medicare + 9.63% HCRA Surcharge,2.95,,,2.95,Fee Schedule,Average Sale Price (ASP) x 6,1.59,35,,1.59,percent of total billed charges,Drugs,1.59,35,,1.59,percent of total billed charges,Drugs,1.54,34,,1.54,percent of total billed charges,Drugs,1.54,34,,1.54,percent of total billed charges,Drugs,1.54,34,,1.54,percent of total billed charges,Drugs,1.54,34,,1.54,percent of total billed charges,Drugs,1.59,35,,1.59,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,1.59,35,,1.59,percent of total billed charges,Drugs,1.59,35,,1.59,percent of total billed charges,Drugs,1.59,35,,1.59,percent of total billed charges,Drugs,1.59,35,,1.59,percent of total billed charges,Drugs,1.59,35,,1.59,percent of total billed charges,Drugs,1.81,40,,1.81,percent of total billed charges,Drugs,3.17,70,,3.17,percent of total billed charges,All Other,1.63,36,,1.63,percent of total billed charges,Drugs,1.63,36,,1.63,percent of total billed charges,Drugs,1.59,35,,1.59,percent of total billed charges,Drugs,1.59,35,,1.59,percent of total billed charges,Drugs,1.59,35,,1.59,percent of total billed charges,Drugs,1.59,35,,1.59,percent of total billed charges,Drugs,1.51,,,1.51,Other,Drug Cost,1.51,,,1.51,Other,Drug Cost,1.51,,,1.51,Other,Drug Cost,1.51,,,1.51,Other,Drug Cost,1.51,,,1.51,Other,Drug Cost,1.51,,,1.51,Other,Drug Cost,3.4,,,3.4,Other,225% of Medicaid,2.12,,,2.12,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,4.71,,,4.71,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",3.25,,,3.25,Other,215% Medicaid APG methodology,3.25,,,3.25,Other,215% Medicaid APG methodology,1.89,,,1.89,Other,125% Medicaid APG methodology,0.01,4.84,
CEFTRIAXONE 500MG INJ,J0696,HCPCS,,80000407,CDM,636,RC,409733801,NDC,both,10,EA,1.72,4.84,,,4.84,Other,150% of Medicare + 9.63% HCRA Surcharge,2.95,,,2.95,Fee Schedule,Average Sale Price (ASP) x 6,0.6,35,,0.6,percent of total billed charges,Drugs,0.6,35,,0.6,percent of total billed charges,Drugs,0.59,34,,0.59,percent of total billed charges,Drugs,0.59,34,,0.59,percent of total billed charges,Drugs,0.59,34,,0.59,percent of total billed charges,Drugs,0.59,34,,0.59,percent of total billed charges,Drugs,0.6,35,,0.6,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,0.6,35,,0.6,percent of total billed charges,Drugs,0.6,35,,0.6,percent of total billed charges,Drugs,0.6,35,,0.6,percent of total billed charges,Drugs,0.6,35,,0.6,percent of total billed charges,Drugs,0.6,35,,0.6,percent of total billed charges,Drugs,0.69,40,,0.69,percent of total billed charges,Drugs,1.21,70,,1.21,percent of total billed charges,All Other,0.62,36,,0.62,percent of total billed charges,Drugs,0.62,36,,0.62,percent of total billed charges,Drugs,0.6,35,,0.6,percent of total billed charges,Drugs,0.6,35,,0.6,percent of total billed charges,Drugs,0.6,35,,0.6,percent of total billed charges,Drugs,0.6,35,,0.6,percent of total billed charges,Drugs,0.57,,,0.57,Other,Drug Cost,0.57,,,0.57,Other,Drug Cost,0.57,,,0.57,Other,Drug Cost,0.57,,,0.57,Other,Drug Cost,0.57,,,0.57,Other,Drug Cost,0.57,,,0.57,Other,Drug Cost,1.29,,,1.29,Other,225% of Medicaid,0.8,,,0.8,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,4.71,,,4.71,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",1.23,,,1.23,Other,215% Medicaid APG methodology,1.23,,,1.23,Other,215% Medicaid APG methodology,0.72,,,0.72,Other,125% Medicaid APG methodology,0.01,4.84,
CETUXIMAB 100MG/50ML INJ,J9055,HCPCS,,80000419,CDM,636,RC,66733094823,NDC,both,1,ML,2303.73,727.37,,,727.37,Other,150% of Medicare + 9.63% HCRA Surcharge,442.32,,,442.32,Fee Schedule,Average Sale Price (ASP) x 6,806.31,35,,806.31,percent of total billed charges,Drugs,806.31,35,,806.31,percent of total billed charges,Drugs,783.27,34,,783.27,percent of total billed charges,Drugs,783.27,34,,783.27,percent of total billed charges,Drugs,783.27,34,,783.27,percent of total billed charges,Drugs,783.27,34,,783.27,percent of total billed charges,Drugs,806.31,35,,806.31,percent of total billed charges,Drugs,783.27,34,"If Charge > 500, then 34 percent",783.27,percent of total billed charges,Drugs,806.31,35,,806.31,percent of total billed charges,Drugs,806.31,35,,806.31,percent of total billed charges,Drugs,806.31,35,,806.31,percent of total billed charges,Drugs,806.31,35,,806.31,percent of total billed charges,Drugs,806.31,35,,806.31,percent of total billed charges,Drugs,921.49,40,,921.49,percent of total billed charges,Drugs,1612.61,70,,1612.61,percent of total billed charges,All Other,829.34,36,,829.34,percent of total billed charges,Drugs,829.34,36,,829.34,percent of total billed charges,Drugs,806.31,35,,806.31,percent of total billed charges,Drugs,806.31,35,,806.31,percent of total billed charges,Drugs,806.31,35,,806.31,percent of total billed charges,Drugs,806.31,35,,806.31,percent of total billed charges,Drugs,767.91,,,767.91,Other,Drug Cost,767.91,,,767.91,Other,Drug Cost,767.91,,,767.91,Other,Drug Cost,767.91,,,767.91,Other,Drug Cost,767.91,,,767.91,Other,Drug Cost,767.91,,,767.91,Other,Drug Cost,1727.8,,,1727.8,Other,225% of Medicaid,1075.07,,,1075.07,Other,140% of Medicaid,783.27,34,"If Charge > 2,000, then 34 percent",783.27,percent of total billed charges,Drugs,707.71,,,707.71,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",1651.01,,,1651.01,Other,215% Medicaid APG methodology,1651.01,,,1651.01,Other,215% Medicaid APG methodology,959.89,,,959.89,Other,125% Medicaid APG methodology,0.01,1727.8,
CHLORPROMAZINE HCL INJ 25 MG/1ML,J3230,HCPCS,,80000441,CDM,636,RC,641139735,NDC,both,25,ML,37.89,293.89,,,293.89,Other,150% of Medicare + 9.63% HCRA Surcharge,178.72,,,178.72,Fee Schedule,Average Sale Price (ASP) x 6,13.26,35,,13.26,percent of total billed charges,Drugs,13.26,35,,13.26,percent of total billed charges,Drugs,12.88,34,,12.88,percent of total billed charges,Drugs,12.88,34,,12.88,percent of total billed charges,Drugs,12.88,34,,12.88,percent of total billed charges,Drugs,12.88,34,,12.88,percent of total billed charges,Drugs,13.26,35,,13.26,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,13.26,35,,13.26,percent of total billed charges,Drugs,13.26,35,,13.26,percent of total billed charges,Drugs,13.26,35,,13.26,percent of total billed charges,Drugs,13.26,35,,13.26,percent of total billed charges,Drugs,13.26,35,,13.26,percent of total billed charges,Drugs,15.15,40,,15.15,percent of total billed charges,Drugs,26.52,70,,26.52,percent of total billed charges,All Other,13.64,36,,13.64,percent of total billed charges,Drugs,13.64,36,,13.64,percent of total billed charges,Drugs,13.26,35,,13.26,percent of total billed charges,Drugs,13.26,35,,13.26,percent of total billed charges,Drugs,13.26,35,,13.26,percent of total billed charges,Drugs,13.26,35,,13.26,percent of total billed charges,Drugs,12.63,,,12.63,Other,Drug Cost,12.63,,,12.63,Other,Drug Cost,12.63,,,12.63,Other,Drug Cost,12.63,,,12.63,Other,Drug Cost,12.63,,,12.63,Other,Drug Cost,12.63,,,12.63,Other,Drug Cost,28.41,,,28.41,Other,225% of Medicaid,17.68,,,17.68,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,285.95,,,285.95,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",27.15,,,27.15,Other,215% Medicaid APG methodology,27.15,,,27.15,Other,215% Medicaid APG methodology,15.79,,,15.79,Other,125% Medicaid APG methodology,0.01,293.89,
CIDOFOVIR 375 MG/ 5 ML INJ,J0740,HCPCS,,80000449,CDM,636,RC,23155021631,NDC,both,1,ML,1299.75,5468.05,,,5468.05,Other,150% of Medicare + 9.63% HCRA Surcharge,3325.15,,,3325.15,Fee Schedule,Average Sale Price (ASP) x 6,454.91,35,,454.91,percent of total billed charges,Drugs,454.91,35,,454.91,percent of total billed charges,Drugs,441.92,34,,441.92,percent of total billed charges,Drugs,441.92,34,,441.92,percent of total billed charges,Drugs,441.92,34,,441.92,percent of total billed charges,Drugs,441.92,34,,441.92,percent of total billed charges,Drugs,454.91,35,,454.91,percent of total billed charges,Drugs,441.92,34,"If Charge > 500, then 34 percent",441.92,percent of total billed charges,Drugs,454.91,35,,454.91,percent of total billed charges,Drugs,454.91,35,,454.91,percent of total billed charges,Drugs,454.91,35,,454.91,percent of total billed charges,Drugs,454.91,35,,454.91,percent of total billed charges,Drugs,454.91,35,,454.91,percent of total billed charges,Drugs,519.9,40,,519.9,percent of total billed charges,Drugs,909.83,70,,909.83,percent of total billed charges,All Other,467.91,36,,467.91,percent of total billed charges,Drugs,467.91,36,,467.91,percent of total billed charges,Drugs,454.91,35,,454.91,percent of total billed charges,Drugs,454.91,35,,454.91,percent of total billed charges,Drugs,454.91,35,,454.91,percent of total billed charges,Drugs,454.91,35,,454.91,percent of total billed charges,Drugs,433.25,,,433.25,Other,Drug Cost,433.25,,,433.25,Other,Drug Cost,433.25,,,433.25,Other,Drug Cost,433.25,,,433.25,Other,Drug Cost,433.25,,,433.25,Other,Drug Cost,433.25,,,433.25,Other,Drug Cost,974.81,,,974.81,Other,225% of Medicaid,606.55,,,606.55,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,5320.24,,,5320.24,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",931.49,,,931.49,Other,215% Medicaid APG methodology,931.49,,,931.49,Other,215% Medicaid APG methodology,541.56,,,541.56,Other,125% Medicaid APG methodology,0.01,5468.05,
CIPROFLOXACIN IV 400MG,J0744,HCPCS,,80000460,CDM,636,RC,25021011487,NDC,both,24,ML,8.05,19.07,,,19.07,Other,150% of Medicare + 9.63% HCRA Surcharge,11.6,,,11.6,Fee Schedule,Average Sale Price (ASP) x 6,2.82,35,,2.82,percent of total billed charges,Drugs,2.82,35,,2.82,percent of total billed charges,Drugs,2.74,34,,2.74,percent of total billed charges,Drugs,2.74,34,,2.74,percent of total billed charges,Drugs,2.74,34,,2.74,percent of total billed charges,Drugs,2.74,34,,2.74,percent of total billed charges,Drugs,2.82,35,,2.82,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,2.82,35,,2.82,percent of total billed charges,Drugs,2.82,35,,2.82,percent of total billed charges,Drugs,2.82,35,,2.82,percent of total billed charges,Drugs,2.82,35,,2.82,percent of total billed charges,Drugs,2.82,35,,2.82,percent of total billed charges,Drugs,3.22,40,,3.22,percent of total billed charges,Drugs,5.64,70,,5.64,percent of total billed charges,All Other,2.9,36,,2.9,percent of total billed charges,Drugs,2.9,36,,2.9,percent of total billed charges,Drugs,2.82,35,,2.82,percent of total billed charges,Drugs,2.82,35,,2.82,percent of total billed charges,Drugs,2.82,35,,2.82,percent of total billed charges,Drugs,2.82,35,,2.82,percent of total billed charges,Drugs,2.68,,,2.68,Other,Drug Cost,2.68,,,2.68,Other,Drug Cost,2.68,,,2.68,Other,Drug Cost,2.68,,,2.68,Other,Drug Cost,2.68,,,2.68,Other,Drug Cost,2.68,,,2.68,Other,Drug Cost,6.04,,,6.04,Other,225% of Medicaid,3.76,,,3.76,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,18.56,,,18.56,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",5.77,,,5.77,Other,215% Medicaid APG methodology,5.77,,,5.77,Other,215% Medicaid APG methodology,3.36,,,3.36,Other,125% Medicaid APG methodology,0.01,19.07,
CISPLATIN 1MG/ML INJECTION 50ML,J9060,HCPCS,,80000463,CDM,636,RC,16729028811,NDC,both,1,ML,26.4,39.85,,,39.85,Other,150% of Medicare + 9.63% HCRA Surcharge,24.23,,,24.23,Fee Schedule,Average Sale Price (ASP) x 6,9.24,35,,9.24,percent of total billed charges,Drugs,9.24,35,,9.24,percent of total billed charges,Drugs,8.98,34,,8.98,percent of total billed charges,Drugs,8.98,34,,8.98,percent of total billed charges,Drugs,8.98,34,,8.98,percent of total billed charges,Drugs,8.98,34,,8.98,percent of total billed charges,Drugs,9.24,35,,9.24,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,9.24,35,,9.24,percent of total billed charges,Drugs,9.24,35,,9.24,percent of total billed charges,Drugs,9.24,35,,9.24,percent of total billed charges,Drugs,9.24,35,,9.24,percent of total billed charges,Drugs,9.24,35,,9.24,percent of total billed charges,Drugs,10.56,40,,10.56,percent of total billed charges,Drugs,18.48,70,,18.48,percent of total billed charges,All Other,9.5,36,,9.5,percent of total billed charges,Drugs,9.5,36,,9.5,percent of total billed charges,Drugs,9.24,35,,9.24,percent of total billed charges,Drugs,9.24,35,,9.24,percent of total billed charges,Drugs,9.24,35,,9.24,percent of total billed charges,Drugs,9.24,35,,9.24,percent of total billed charges,Drugs,8.8,,,8.8,Other,Drug Cost,8.8,,,8.8,Other,Drug Cost,8.8,,,8.8,Other,Drug Cost,8.8,,,8.8,Other,Drug Cost,8.8,,,8.8,Other,Drug Cost,8.8,,,8.8,Other,Drug Cost,19.8,,,19.8,Other,225% of Medicaid,12.32,,,12.32,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,38.77,,,38.77,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",18.92,,,18.92,Other,215% Medicaid APG methodology,18.92,,,18.92,Other,215% Medicaid APG methodology,11,,,11,Other,125% Medicaid APG methodology,0.01,39.85,
CLADRIBINE 1 MG/ML 10ML INJ,J9065,HCPCS,,80000471,CDM,636,RC,63323014010,NDC,both,1,ML,319.56,155.63,,,155.63,Other,150% of Medicare + 9.63% HCRA Surcharge,94.64,,,94.64,Fee Schedule,Average Sale Price (ASP) x 6,111.85,35,,111.85,percent of total billed charges,Drugs,111.85,35,,111.85,percent of total billed charges,Drugs,108.65,34,,108.65,percent of total billed charges,Drugs,108.65,34,,108.65,percent of total billed charges,Drugs,108.65,34,,108.65,percent of total billed charges,Drugs,108.65,34,,108.65,percent of total billed charges,Drugs,111.85,35,,111.85,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,111.85,35,,111.85,percent of total billed charges,Drugs,111.85,35,,111.85,percent of total billed charges,Drugs,111.85,35,,111.85,percent of total billed charges,Drugs,111.85,35,,111.85,percent of total billed charges,Drugs,111.85,35,,111.85,percent of total billed charges,Drugs,127.82,40,,127.82,percent of total billed charges,Drugs,223.69,70,,223.69,percent of total billed charges,All Other,115.04,36,,115.04,percent of total billed charges,Drugs,115.04,36,,115.04,percent of total billed charges,Drugs,111.85,35,,111.85,percent of total billed charges,Drugs,111.85,35,,111.85,percent of total billed charges,Drugs,111.85,35,,111.85,percent of total billed charges,Drugs,111.85,35,,111.85,percent of total billed charges,Drugs,106.52,,,106.52,Other,Drug Cost,106.52,,,106.52,Other,Drug Cost,106.52,,,106.52,Other,Drug Cost,106.52,,,106.52,Other,Drug Cost,106.52,,,106.52,Other,Drug Cost,106.52,,,106.52,Other,Drug Cost,239.67,,,239.67,Other,225% of Medicaid,149.13,,,149.13,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,151.42,,,151.42,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",229.02,,,229.02,Other,215% Medicaid APG methodology,229.02,,,229.02,Other,215% Medicaid APG methodology,133.15,,,133.15,Other,125% Medicaid APG methodology,0.01,239.67,
COSYNTROPIN (CORTROSYN) INJ 0.25 MG,J0834,HCPCS,,80000535,CDM,636,RC,548590000,NDC,both,10,EA,16.44,267.53,,,267.53,Other,150% of Medicare + 9.63% HCRA Surcharge,162.68,,,162.68,Fee Schedule,Average Sale Price (ASP) x 6,5.76,35,,5.76,percent of total billed charges,Drugs,5.76,35,,5.76,percent of total billed charges,Drugs,5.59,34,,5.59,percent of total billed charges,Drugs,5.59,34,,5.59,percent of total billed charges,Drugs,5.59,34,,5.59,percent of total billed charges,Drugs,5.59,34,,5.59,percent of total billed charges,Drugs,5.76,35,,5.76,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,5.76,35,,5.76,percent of total billed charges,Drugs,5.76,35,,5.76,percent of total billed charges,Drugs,5.76,35,,5.76,percent of total billed charges,Drugs,5.76,35,,5.76,percent of total billed charges,Drugs,5.76,35,,5.76,percent of total billed charges,Drugs,6.58,40,,6.58,percent of total billed charges,Drugs,11.51,70,,11.51,percent of total billed charges,All Other,5.92,36,,5.92,percent of total billed charges,Drugs,5.92,36,,5.92,percent of total billed charges,Drugs,5.76,35,,5.76,percent of total billed charges,Drugs,5.76,35,,5.76,percent of total billed charges,Drugs,5.76,35,,5.76,percent of total billed charges,Drugs,5.76,35,,5.76,percent of total billed charges,Drugs,5.48,,,5.48,Other,Drug Cost,5.48,,,5.48,Other,Drug Cost,5.48,,,5.48,Other,Drug Cost,5.48,,,5.48,Other,Drug Cost,5.48,,,5.48,Other,Drug Cost,5.48,,,5.48,Other,Drug Cost,12.33,,,12.33,Other,225% of Medicaid,7.67,,,7.67,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,260.29,,,260.29,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",11.78,,,11.78,Other,215% Medicaid APG methodology,11.78,,,11.78,Other,215% Medicaid APG methodology,6.85,,,6.85,Other,125% Medicaid APG methodology,0.01,267.53,
CYCLOPHOSPHAMIDE 1GM INJ,J9070,HCPCS,,80000545,CDM,636,RC,781324494,NDC,both,1,EA,312.84,198.84,,,198.84,Other,150% of Medicare + 9.63% HCRA Surcharge,120.92,,,120.92,Fee Schedule,Average Sale Price (ASP) x 6,109.49,35,,109.49,percent of total billed charges,Drugs,109.49,35,,109.49,percent of total billed charges,Drugs,106.37,34,,106.37,percent of total billed charges,Drugs,106.37,34,,106.37,percent of total billed charges,Drugs,106.37,34,,106.37,percent of total billed charges,Drugs,106.37,34,,106.37,percent of total billed charges,Drugs,109.49,35,,109.49,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,109.49,35,,109.49,percent of total billed charges,Drugs,109.49,35,,109.49,percent of total billed charges,Drugs,109.49,35,,109.49,percent of total billed charges,Drugs,109.49,35,,109.49,percent of total billed charges,Drugs,109.49,35,,109.49,percent of total billed charges,Drugs,125.14,40,,125.14,percent of total billed charges,Drugs,218.99,70,,218.99,percent of total billed charges,All Other,112.62,36,,112.62,percent of total billed charges,Drugs,112.62,36,,112.62,percent of total billed charges,Drugs,109.49,35,,109.49,percent of total billed charges,Drugs,109.49,35,,109.49,percent of total billed charges,Drugs,109.49,35,,109.49,percent of total billed charges,Drugs,109.49,35,,109.49,percent of total billed charges,Drugs,104.28,,,104.28,Other,Drug Cost,104.28,,,104.28,Other,Drug Cost,104.28,,,104.28,Other,Drug Cost,104.28,,,104.28,Other,Drug Cost,104.28,,,104.28,Other,Drug Cost,104.28,,,104.28,Other,Drug Cost,234.63,,,234.63,Other,225% of Medicaid,145.99,,,145.99,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,193.47,,,193.47,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",224.2,,,224.2,Other,215% Medicaid APG methodology,224.2,,,224.2,Other,215% Medicaid APG methodology,130.35,,,130.35,Other,125% Medicaid APG methodology,0.01,234.63,
CYCLOPHOSPHAMIDE 2GM INJ,J9070,HCPCS,,80000547,CDM,636,RC,10019095701,NDC,both,1,EA,316.2,198.84,,,198.84,Other,150% of Medicare + 9.63% HCRA Surcharge,120.92,,,120.92,Fee Schedule,Average Sale Price (ASP) x 6,110.67,35,,110.67,percent of total billed charges,Drugs,110.67,35,,110.67,percent of total billed charges,Drugs,107.51,34,,107.51,percent of total billed charges,Drugs,107.51,34,,107.51,percent of total billed charges,Drugs,107.51,34,,107.51,percent of total billed charges,Drugs,107.51,34,,107.51,percent of total billed charges,Drugs,110.67,35,,110.67,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,110.67,35,,110.67,percent of total billed charges,Drugs,110.67,35,,110.67,percent of total billed charges,Drugs,110.67,35,,110.67,percent of total billed charges,Drugs,110.67,35,,110.67,percent of total billed charges,Drugs,110.67,35,,110.67,percent of total billed charges,Drugs,126.48,40,,126.48,percent of total billed charges,Drugs,221.34,70,,221.34,percent of total billed charges,All Other,113.83,36,,113.83,percent of total billed charges,Drugs,113.83,36,,113.83,percent of total billed charges,Drugs,110.67,35,,110.67,percent of total billed charges,Drugs,110.67,35,,110.67,percent of total billed charges,Drugs,110.67,35,,110.67,percent of total billed charges,Drugs,110.67,35,,110.67,percent of total billed charges,Drugs,105.4,,,105.4,Other,Drug Cost,105.4,,,105.4,Other,Drug Cost,105.4,,,105.4,Other,Drug Cost,105.4,,,105.4,Other,Drug Cost,105.4,,,105.4,Other,Drug Cost,105.4,,,105.4,Other,Drug Cost,237.15,,,237.15,Other,225% of Medicaid,147.56,,,147.56,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,193.47,,,193.47,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",226.61,,,226.61,Other,215% Medicaid APG methodology,226.61,,,226.61,Other,215% Medicaid APG methodology,131.75,,,131.75,Other,125% Medicaid APG methodology,0.01,237.15,
CYCLOPHOSPHAMIDE 500MG INJ,J9070,HCPCS,,80000548,CDM,636,RC,70121123801,NDC,both,1,EA,186.42,198.84,,,198.84,Other,150% of Medicare + 9.63% HCRA Surcharge,120.92,,,120.92,Fee Schedule,Average Sale Price (ASP) x 6,65.25,35,,65.25,percent of total billed charges,Drugs,65.25,35,,65.25,percent of total billed charges,Drugs,63.38,34,,63.38,percent of total billed charges,Drugs,63.38,34,,63.38,percent of total billed charges,Drugs,63.38,34,,63.38,percent of total billed charges,Drugs,63.38,34,,63.38,percent of total billed charges,Drugs,65.25,35,,65.25,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,65.25,35,,65.25,percent of total billed charges,Drugs,65.25,35,,65.25,percent of total billed charges,Drugs,65.25,35,,65.25,percent of total billed charges,Drugs,65.25,35,,65.25,percent of total billed charges,Drugs,65.25,35,,65.25,percent of total billed charges,Drugs,74.57,40,,74.57,percent of total billed charges,Drugs,130.49,70,,130.49,percent of total billed charges,All Other,67.11,36,,67.11,percent of total billed charges,Drugs,67.11,36,,67.11,percent of total billed charges,Drugs,65.25,35,,65.25,percent of total billed charges,Drugs,65.25,35,,65.25,percent of total billed charges,Drugs,65.25,35,,65.25,percent of total billed charges,Drugs,65.25,35,,65.25,percent of total billed charges,Drugs,62.14,,,62.14,Other,Drug Cost,62.14,,,62.14,Other,Drug Cost,62.14,,,62.14,Other,Drug Cost,62.14,,,62.14,Other,Drug Cost,62.14,,,62.14,Other,Drug Cost,62.14,,,62.14,Other,Drug Cost,139.82,,,139.82,Other,225% of Medicaid,87,,,87,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,193.47,,,193.47,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",133.6,,,133.6,Other,215% Medicaid APG methodology,133.6,,,133.6,Other,215% Medicaid APG methodology,77.68,,,77.68,Other,125% Medicaid APG methodology,0.01,198.84,
CYCLOSPORINE 25MG CAPS,J7515,HCPCS,,80000554,CDM,636,RC,60505013300,NDC,both,30,EA,1.81,8.26,,,8.26,Other,150% of Medicare + 9.63% HCRA Surcharge,5.02,,,5.02,Fee Schedule,Average Sale Price (ASP) x 6,0.63,35,,0.63,percent of total billed charges,Drugs,0.63,35,,0.63,percent of total billed charges,Drugs,0.62,34,,0.62,percent of total billed charges,Drugs,0.62,34,,0.62,percent of total billed charges,Drugs,0.62,34,,0.62,percent of total billed charges,Drugs,0.62,34,,0.62,percent of total billed charges,Drugs,0.63,35,,0.63,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,0.63,35,,0.63,percent of total billed charges,Drugs,0.63,35,,0.63,percent of total billed charges,Drugs,0.63,35,,0.63,percent of total billed charges,Drugs,0.63,35,,0.63,percent of total billed charges,Drugs,0.63,35,,0.63,percent of total billed charges,Drugs,0.73,40,,0.73,percent of total billed charges,Drugs,1.27,70,,1.27,percent of total billed charges,All Other,0.65,36,,0.65,percent of total billed charges,Drugs,0.65,36,,0.65,percent of total billed charges,Drugs,0.63,35,,0.63,percent of total billed charges,Drugs,0.63,35,,0.63,percent of total billed charges,Drugs,0.63,35,,0.63,percent of total billed charges,Drugs,0.63,35,,0.63,percent of total billed charges,Drugs,0.6,,,0.6,Other,Drug Cost,0.6,,,0.6,Other,Drug Cost,0.6,,,0.6,Other,Drug Cost,0.6,,,0.6,Other,Drug Cost,0.6,,,0.6,Other,Drug Cost,0.6,,,0.6,Other,Drug Cost,1.36,,,1.36,Other,225% of Medicaid,0.85,,,0.85,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,8.04,,,8.04,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",1.3,,,1.3,Other,215% Medicaid APG methodology,1.3,,,1.3,Other,215% Medicaid APG methodology,0.76,,,0.76,Other,125% Medicaid APG methodology,0.01,8.26,
D5W / NORMAL SALINE (500 ML=1 UNIT),J7042,HCPCS,,80000568,CDM,636,RC,264761010,NDC,both,24,ML,1.32,15.66,,,15.66,Other,150% of Medicare + 9.63% HCRA Surcharge,9.52,,,9.52,Fee Schedule,Average Sale Price (ASP) x 6,0.46,35,,0.46,percent of total billed charges,Drugs,0.46,35,,0.46,percent of total billed charges,Drugs,0.45,34,,0.45,percent of total billed charges,Drugs,0.45,34,,0.45,percent of total billed charges,Drugs,0.45,34,,0.45,percent of total billed charges,Drugs,0.45,34,,0.45,percent of total billed charges,Drugs,0.46,35,,0.46,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,0.46,35,,0.46,percent of total billed charges,Drugs,0.46,35,,0.46,percent of total billed charges,Drugs,0.46,35,,0.46,percent of total billed charges,Drugs,0.46,35,,0.46,percent of total billed charges,Drugs,0.46,35,,0.46,percent of total billed charges,Drugs,0.53,40,,0.53,percent of total billed charges,Drugs,0.92,70,,0.92,percent of total billed charges,All Other,0.47,36,,0.47,percent of total billed charges,Drugs,0.47,36,,0.47,percent of total billed charges,Drugs,0.46,35,,0.46,percent of total billed charges,Drugs,0.46,35,,0.46,percent of total billed charges,Drugs,0.46,35,,0.46,percent of total billed charges,Drugs,0.46,35,,0.46,percent of total billed charges,Drugs,0.44,,,0.44,Other,Drug Cost,0.44,,,0.44,Other,Drug Cost,0.44,,,0.44,Other,Drug Cost,0.44,,,0.44,Other,Drug Cost,0.44,,,0.44,Other,Drug Cost,0.44,,,0.44,Other,Drug Cost,0.99,,,0.99,Other,225% of Medicaid,0.62,,,0.62,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,15.24,,,15.24,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",0.95,,,0.95,Other,215% Medicaid APG methodology,0.95,,,0.95,Other,215% Medicaid APG methodology,0.55,,,0.55,Other,125% Medicaid APG methodology,0.01,15.66,
D5W 1000 ML(500 ML = 1 UNIT),J7060,HCPCS,,80000570,CDM,636,RC,338001704,NDC,both,14,ML,5.41,19.05,,,19.05,Other,150% of Medicare + 9.63% HCRA Surcharge,11.59,,,11.59,Fee Schedule,Average Sale Price (ASP) x 6,1.89,35,,1.89,percent of total billed charges,Drugs,1.89,35,,1.89,percent of total billed charges,Drugs,1.84,34,,1.84,percent of total billed charges,Drugs,1.84,34,,1.84,percent of total billed charges,Drugs,1.84,34,,1.84,percent of total billed charges,Drugs,1.84,34,,1.84,percent of total billed charges,Drugs,1.89,35,,1.89,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,1.89,35,,1.89,percent of total billed charges,Drugs,1.89,35,,1.89,percent of total billed charges,Drugs,1.89,35,,1.89,percent of total billed charges,Drugs,1.89,35,,1.89,percent of total billed charges,Drugs,1.89,35,,1.89,percent of total billed charges,Drugs,2.16,40,,2.16,percent of total billed charges,Drugs,3.79,70,,3.79,percent of total billed charges,All Other,1.95,36,,1.95,percent of total billed charges,Drugs,1.95,36,,1.95,percent of total billed charges,Drugs,1.89,35,,1.89,percent of total billed charges,Drugs,1.89,35,,1.89,percent of total billed charges,Drugs,1.89,35,,1.89,percent of total billed charges,Drugs,1.89,35,,1.89,percent of total billed charges,Drugs,1.8,,,1.8,Other,Drug Cost,1.8,,,1.8,Other,Drug Cost,1.8,,,1.8,Other,Drug Cost,1.8,,,1.8,Other,Drug Cost,1.8,,,1.8,Other,Drug Cost,1.8,,,1.8,Other,Drug Cost,4.06,,,4.06,Other,225% of Medicaid,2.52,,,2.52,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,18.54,,,18.54,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",3.88,,,3.88,Other,215% Medicaid APG methodology,3.88,,,3.88,Other,215% Medicaid APG methodology,2.25,,,2.25,Other,125% Medicaid APG methodology,0.01,19.05,
D5W 250ML  (500 ML = 1 UNIT),J7060,HCPCS,,80000571,CDM,636,RC,264751020,NDC,both,24,ML,1.52,19.05,,,19.05,Other,150% of Medicare + 9.63% HCRA Surcharge,11.59,,,11.59,Fee Schedule,Average Sale Price (ASP) x 6,0.53,35,,0.53,percent of total billed charges,Drugs,0.53,35,,0.53,percent of total billed charges,Drugs,0.52,34,,0.52,percent of total billed charges,Drugs,0.52,34,,0.52,percent of total billed charges,Drugs,0.52,34,,0.52,percent of total billed charges,Drugs,0.52,34,,0.52,percent of total billed charges,Drugs,0.53,35,,0.53,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,0.53,35,,0.53,percent of total billed charges,Drugs,0.53,35,,0.53,percent of total billed charges,Drugs,0.53,35,,0.53,percent of total billed charges,Drugs,0.53,35,,0.53,percent of total billed charges,Drugs,0.53,35,,0.53,percent of total billed charges,Drugs,0.61,40,,0.61,percent of total billed charges,Drugs,1.06,70,,1.06,percent of total billed charges,All Other,0.55,36,,0.55,percent of total billed charges,Drugs,0.55,36,,0.55,percent of total billed charges,Drugs,0.53,35,,0.53,percent of total billed charges,Drugs,0.53,35,,0.53,percent of total billed charges,Drugs,0.53,35,,0.53,percent of total billed charges,Drugs,0.53,35,,0.53,percent of total billed charges,Drugs,0.51,,,0.51,Other,Drug Cost,0.51,,,0.51,Other,Drug Cost,0.51,,,0.51,Other,Drug Cost,0.51,,,0.51,Other,Drug Cost,0.51,,,0.51,Other,Drug Cost,0.51,,,0.51,Other,Drug Cost,1.14,,,1.14,Other,225% of Medicaid,0.71,,,0.71,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,18.54,,,18.54,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",1.09,,,1.09,Other,215% Medicaid APG methodology,1.09,,,1.09,Other,215% Medicaid APG methodology,0.63,,,0.63,Other,125% Medicaid APG methodology,0.01,19.05,
D5W 500ML  (500 ML = 1 UNIT),J7060,HCPCS,,80000572,CDM,636,RC,264751010,NDC,both,24,ML,3.04,19.05,,,19.05,Other,150% of Medicare + 9.63% HCRA Surcharge,11.59,,,11.59,Fee Schedule,Average Sale Price (ASP) x 6,1.06,35,,1.06,percent of total billed charges,Drugs,1.06,35,,1.06,percent of total billed charges,Drugs,1.03,34,,1.03,percent of total billed charges,Drugs,1.03,34,,1.03,percent of total billed charges,Drugs,1.03,34,,1.03,percent of total billed charges,Drugs,1.03,34,,1.03,percent of total billed charges,Drugs,1.06,35,,1.06,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,1.06,35,,1.06,percent of total billed charges,Drugs,1.06,35,,1.06,percent of total billed charges,Drugs,1.06,35,,1.06,percent of total billed charges,Drugs,1.06,35,,1.06,percent of total billed charges,Drugs,1.06,35,,1.06,percent of total billed charges,Drugs,1.22,40,,1.22,percent of total billed charges,Drugs,2.13,70,,2.13,percent of total billed charges,All Other,1.09,36,,1.09,percent of total billed charges,Drugs,1.09,36,,1.09,percent of total billed charges,Drugs,1.06,35,,1.06,percent of total billed charges,Drugs,1.06,35,,1.06,percent of total billed charges,Drugs,1.06,35,,1.06,percent of total billed charges,Drugs,1.06,35,,1.06,percent of total billed charges,Drugs,1.01,,,1.01,Other,Drug Cost,1.01,,,1.01,Other,Drug Cost,1.01,,,1.01,Other,Drug Cost,1.01,,,1.01,Other,Drug Cost,1.01,,,1.01,Other,Drug Cost,1.01,,,1.01,Other,Drug Cost,2.28,,,2.28,Other,225% of Medicaid,1.42,,,1.42,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,18.54,,,18.54,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",2.18,,,2.18,Other,215% Medicaid APG methodology,2.18,,,2.18,Other,215% Medicaid APG methodology,1.27,,,1.27,Other,125% Medicaid APG methodology,0.01,19.05,
DACARBAZINE 200 MG INJ,J9130,HCPCS,,80000578,CDM,636,RC,703507501,NDC,both,1,EA,44.61,36.83,,,36.83,Other,150% of Medicare + 9.63% HCRA Surcharge,22.4,,,22.4,Fee Schedule,Average Sale Price (ASP) x 6,15.61,35,,15.61,percent of total billed charges,Drugs,15.61,35,,15.61,percent of total billed charges,Drugs,15.17,34,,15.17,percent of total billed charges,Drugs,15.17,34,,15.17,percent of total billed charges,Drugs,15.17,34,,15.17,percent of total billed charges,Drugs,15.17,34,,15.17,percent of total billed charges,Drugs,15.61,35,,15.61,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,15.61,35,,15.61,percent of total billed charges,Drugs,15.61,35,,15.61,percent of total billed charges,Drugs,15.61,35,,15.61,percent of total billed charges,Drugs,15.61,35,,15.61,percent of total billed charges,Drugs,15.61,35,,15.61,percent of total billed charges,Drugs,17.84,40,,17.84,percent of total billed charges,Drugs,31.23,70,,31.23,percent of total billed charges,All Other,16.06,36,,16.06,percent of total billed charges,Drugs,16.06,36,,16.06,percent of total billed charges,Drugs,15.61,35,,15.61,percent of total billed charges,Drugs,15.61,35,,15.61,percent of total billed charges,Drugs,15.61,35,,15.61,percent of total billed charges,Drugs,15.61,35,,15.61,percent of total billed charges,Drugs,14.87,,,14.87,Other,Drug Cost,14.87,,,14.87,Other,Drug Cost,14.87,,,14.87,Other,Drug Cost,14.87,,,14.87,Other,Drug Cost,14.87,,,14.87,Other,Drug Cost,14.87,,,14.87,Other,Drug Cost,33.46,,,33.46,Other,225% of Medicaid,20.82,,,20.82,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,35.84,,,35.84,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",31.97,,,31.97,Other,215% Medicaid APG methodology,31.97,,,31.97,Other,215% Medicaid APG methodology,18.59,,,18.59,Other,125% Medicaid APG methodology,0.01,36.83,
DAPTOMYCIN (CUBICIN) 500 MG INJ,J0878,HCPCS,,80000584,CDM,636,RC,55150034401,NDC,both,1,EA,33.81,0.37,,,0.37,Other,150% of Medicare + 9.63% HCRA Surcharge,0.23,,,0.23,Fee Schedule,Average Sale Price (ASP) x 6,11.83,35,,11.83,percent of total billed charges,Drugs,11.83,35,,11.83,percent of total billed charges,Drugs,11.5,34,,11.5,percent of total billed charges,Drugs,11.5,34,,11.5,percent of total billed charges,Drugs,11.5,34,,11.5,percent of total billed charges,Drugs,11.5,34,,11.5,percent of total billed charges,Drugs,11.83,35,,11.83,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,11.83,35,,11.83,percent of total billed charges,Drugs,11.83,35,,11.83,percent of total billed charges,Drugs,11.83,35,,11.83,percent of total billed charges,Drugs,11.83,35,,11.83,percent of total billed charges,Drugs,11.83,35,,11.83,percent of total billed charges,Drugs,13.52,40,,13.52,percent of total billed charges,Drugs,23.67,70,,23.67,percent of total billed charges,All Other,12.17,36,,12.17,percent of total billed charges,Drugs,12.17,36,,12.17,percent of total billed charges,Drugs,11.83,35,,11.83,percent of total billed charges,Drugs,11.83,35,,11.83,percent of total billed charges,Drugs,11.83,35,,11.83,percent of total billed charges,Drugs,11.83,35,,11.83,percent of total billed charges,Drugs,11.27,,,11.27,Other,Drug Cost,11.27,,,11.27,Other,Drug Cost,11.27,,,11.27,Other,Drug Cost,11.27,,,11.27,Other,Drug Cost,11.27,,,11.27,Other,Drug Cost,11.27,,,11.27,Other,Drug Cost,25.36,,,25.36,Other,225% of Medicaid,15.78,,,15.78,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,0.36,,,0.36,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",24.23,,,24.23,Other,215% Medicaid APG methodology,24.23,,,24.23,Other,215% Medicaid APG methodology,14.09,,,14.09,Other,125% Medicaid APG methodology,0.01,25.36,
DARBEPOETIN ALFA ESRD USE 100MCG,J0882,HCPCS,,80000585,CDM,636,RC,55513002504,NDC,both,4,ML,530.03,28.91,,,28.91,Other,150% of Medicare + 9.63% HCRA Surcharge,17.58,,,17.58,Fee Schedule,Average Sale Price (ASP) x 6,185.51,35,,185.51,percent of total billed charges,Drugs,185.51,35,,185.51,percent of total billed charges,Drugs,180.21,34,,180.21,percent of total billed charges,Drugs,180.21,34,,180.21,percent of total billed charges,Drugs,180.21,34,,180.21,percent of total billed charges,Drugs,180.21,34,,180.21,percent of total billed charges,Drugs,185.51,35,,185.51,percent of total billed charges,Drugs,180.21,34,"If Charge > 500, then 34 percent",180.21,percent of total billed charges,Drugs,185.51,35,,185.51,percent of total billed charges,Drugs,185.51,35,,185.51,percent of total billed charges,Drugs,185.51,35,,185.51,percent of total billed charges,Drugs,185.51,35,,185.51,percent of total billed charges,Drugs,185.51,35,,185.51,percent of total billed charges,Drugs,212.01,40,,212.01,percent of total billed charges,Drugs,371.02,70,,371.02,percent of total billed charges,All Other,190.81,36,,190.81,percent of total billed charges,Drugs,190.81,36,,190.81,percent of total billed charges,Drugs,185.51,35,,185.51,percent of total billed charges,Drugs,185.51,35,,185.51,percent of total billed charges,Drugs,185.51,35,,185.51,percent of total billed charges,Drugs,185.51,35,,185.51,percent of total billed charges,Drugs,176.68,,,176.68,Other,Drug Cost,176.68,,,176.68,Other,Drug Cost,176.68,,,176.68,Other,Drug Cost,176.68,,,176.68,Other,Drug Cost,176.68,,,176.68,Other,Drug Cost,176.68,,,176.68,Other,Drug Cost,397.52,,,397.52,Other,225% of Medicaid,247.35,,,247.35,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,28.13,,,28.13,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",379.85,,,379.85,Other,215% Medicaid APG methodology,379.85,,,379.85,Other,215% Medicaid APG methodology,220.84,,,220.84,Other,125% Medicaid APG methodology,0.01,397.52,
DARBEPOETIN ALFA ESRD USE 25MCG,J0882,HCPCS,,80000586,CDM,636,RC,55513005704,NDC,both,4,ML,114.37,28.91,,,28.91,Other,150% of Medicare + 9.63% HCRA Surcharge,17.58,,,17.58,Fee Schedule,Average Sale Price (ASP) x 6,40.03,35,,40.03,percent of total billed charges,Drugs,40.03,35,,40.03,percent of total billed charges,Drugs,38.88,34,,38.88,percent of total billed charges,Drugs,38.88,34,,38.88,percent of total billed charges,Drugs,38.88,34,,38.88,percent of total billed charges,Drugs,38.88,34,,38.88,percent of total billed charges,Drugs,40.03,35,,40.03,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,40.03,35,,40.03,percent of total billed charges,Drugs,40.03,35,,40.03,percent of total billed charges,Drugs,40.03,35,,40.03,percent of total billed charges,Drugs,40.03,35,,40.03,percent of total billed charges,Drugs,40.03,35,,40.03,percent of total billed charges,Drugs,45.75,40,,45.75,percent of total billed charges,Drugs,80.06,70,,80.06,percent of total billed charges,All Other,41.17,36,,41.17,percent of total billed charges,Drugs,41.17,36,,41.17,percent of total billed charges,Drugs,40.03,35,,40.03,percent of total billed charges,Drugs,40.03,35,,40.03,percent of total billed charges,Drugs,40.03,35,,40.03,percent of total billed charges,Drugs,40.03,35,,40.03,percent of total billed charges,Drugs,38.12,,,38.12,Other,Drug Cost,38.12,,,38.12,Other,Drug Cost,38.12,,,38.12,Other,Drug Cost,38.12,,,38.12,Other,Drug Cost,38.12,,,38.12,Other,Drug Cost,38.12,,,38.12,Other,Drug Cost,85.78,,,85.78,Other,225% of Medicaid,53.37,,,53.37,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,28.13,,,28.13,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",81.96,,,81.96,Other,215% Medicaid APG methodology,81.96,,,81.96,Other,215% Medicaid APG methodology,47.65,,,47.65,Other,125% Medicaid APG methodology,0.01,85.78,
DARBEPOETIN ALFA ESRD USE 40MCG,J0882,HCPCS,,80000587,CDM,636,RC,55513002104,NDC,both,4,ML,212.01,28.91,,,28.91,Other,150% of Medicare + 9.63% HCRA Surcharge,17.58,,,17.58,Fee Schedule,Average Sale Price (ASP) x 6,74.2,35,,74.2,percent of total billed charges,Drugs,74.2,35,,74.2,percent of total billed charges,Drugs,72.08,34,,72.08,percent of total billed charges,Drugs,72.08,34,,72.08,percent of total billed charges,Drugs,72.08,34,,72.08,percent of total billed charges,Drugs,72.08,34,,72.08,percent of total billed charges,Drugs,74.2,35,,74.2,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,74.2,35,,74.2,percent of total billed charges,Drugs,74.2,35,,74.2,percent of total billed charges,Drugs,74.2,35,,74.2,percent of total billed charges,Drugs,74.2,35,,74.2,percent of total billed charges,Drugs,74.2,35,,74.2,percent of total billed charges,Drugs,84.8,40,,84.8,percent of total billed charges,Drugs,148.41,70,,148.41,percent of total billed charges,All Other,76.32,36,,76.32,percent of total billed charges,Drugs,76.32,36,,76.32,percent of total billed charges,Drugs,74.2,35,,74.2,percent of total billed charges,Drugs,74.2,35,,74.2,percent of total billed charges,Drugs,74.2,35,,74.2,percent of total billed charges,Drugs,74.2,35,,74.2,percent of total billed charges,Drugs,70.67,,,70.67,Other,Drug Cost,70.67,,,70.67,Other,Drug Cost,70.67,,,70.67,Other,Drug Cost,70.67,,,70.67,Other,Drug Cost,70.67,,,70.67,Other,Drug Cost,70.67,,,70.67,Other,Drug Cost,159.01,,,159.01,Other,225% of Medicaid,98.94,,,98.94,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,28.13,,,28.13,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",151.94,,,151.94,Other,215% Medicaid APG methodology,151.94,,,151.94,Other,215% Medicaid APG methodology,88.34,,,88.34,Other,125% Medicaid APG methodology,0.01,159.01,
DARBEPOETIN ALFA ESRD USE 60MCG,J0882,HCPCS,,80000588,CDM,636,RC,55513002304,NDC,both,4,ML,318.02,28.91,,,28.91,Other,150% of Medicare + 9.63% HCRA Surcharge,17.58,,,17.58,Fee Schedule,Average Sale Price (ASP) x 6,111.31,35,,111.31,percent of total billed charges,Drugs,111.31,35,,111.31,percent of total billed charges,Drugs,108.13,34,,108.13,percent of total billed charges,Drugs,108.13,34,,108.13,percent of total billed charges,Drugs,108.13,34,,108.13,percent of total billed charges,Drugs,108.13,34,,108.13,percent of total billed charges,Drugs,111.31,35,,111.31,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,111.31,35,,111.31,percent of total billed charges,Drugs,111.31,35,,111.31,percent of total billed charges,Drugs,111.31,35,,111.31,percent of total billed charges,Drugs,111.31,35,,111.31,percent of total billed charges,Drugs,111.31,35,,111.31,percent of total billed charges,Drugs,127.21,40,,127.21,percent of total billed charges,Drugs,222.61,70,,222.61,percent of total billed charges,All Other,114.49,36,,114.49,percent of total billed charges,Drugs,114.49,36,,114.49,percent of total billed charges,Drugs,111.31,35,,111.31,percent of total billed charges,Drugs,111.31,35,,111.31,percent of total billed charges,Drugs,111.31,35,,111.31,percent of total billed charges,Drugs,111.31,35,,111.31,percent of total billed charges,Drugs,106.01,,,106.01,Other,Drug Cost,106.01,,,106.01,Other,Drug Cost,106.01,,,106.01,Other,Drug Cost,106.01,,,106.01,Other,Drug Cost,106.01,,,106.01,Other,Drug Cost,106.01,,,106.01,Other,Drug Cost,238.51,,,238.51,Other,225% of Medicaid,148.41,,,148.41,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,28.13,,,28.13,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",227.91,,,227.91,Other,215% Medicaid APG methodology,227.91,,,227.91,Other,215% Medicaid APG methodology,132.51,,,132.51,Other,125% Medicaid APG methodology,0.01,238.51,
DECITABINE INJECTION 50 MG,J0894,HCPCS,,80000592,CDM,636,RC,55111055610,NDC,both,1,EA,77.46,16.71,,,16.71,Other,150% of Medicare + 9.63% HCRA Surcharge,10.16,,,10.16,Fee Schedule,Average Sale Price (ASP) x 6,27.11,35,,27.11,percent of total billed charges,Drugs,27.11,35,,27.11,percent of total billed charges,Drugs,26.34,34,,26.34,percent of total billed charges,Drugs,26.34,34,,26.34,percent of total billed charges,Drugs,26.34,34,,26.34,percent of total billed charges,Drugs,26.34,34,,26.34,percent of total billed charges,Drugs,27.11,35,,27.11,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,27.11,35,,27.11,percent of total billed charges,Drugs,27.11,35,,27.11,percent of total billed charges,Drugs,27.11,35,,27.11,percent of total billed charges,Drugs,27.11,35,,27.11,percent of total billed charges,Drugs,27.11,35,,27.11,percent of total billed charges,Drugs,30.98,40,,30.98,percent of total billed charges,Drugs,54.22,70,,54.22,percent of total billed charges,All Other,27.89,36,,27.89,percent of total billed charges,Drugs,27.89,36,,27.89,percent of total billed charges,Drugs,27.11,35,,27.11,percent of total billed charges,Drugs,27.11,35,,27.11,percent of total billed charges,Drugs,27.11,35,,27.11,percent of total billed charges,Drugs,27.11,35,,27.11,percent of total billed charges,Drugs,25.82,,,25.82,Other,Drug Cost,25.82,,,25.82,Other,Drug Cost,25.82,,,25.82,Other,Drug Cost,25.82,,,25.82,Other,Drug Cost,25.82,,,25.82,Other,Drug Cost,25.82,,,25.82,Other,Drug Cost,58.1,,,58.1,Other,225% of Medicaid,36.15,,,36.15,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,16.26,,,16.26,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",55.51,,,55.51,Other,215% Medicaid APG methodology,55.51,,,55.51,Other,215% Medicaid APG methodology,32.28,,,32.28,Other,125% Medicaid APG methodology,0.01,58.1,
DEFEROXAMINE 500MG INJ,J0895,HCPCS,,80000593,CDM,636,RC,78046791,NDC,both,4,EA,17.86,84.82,,,84.82,Other,150% of Medicare + 9.63% HCRA Surcharge,51.58,,,51.58,Fee Schedule,Average Sale Price (ASP) x 6,6.25,35,,6.25,percent of total billed charges,Drugs,6.25,35,,6.25,percent of total billed charges,Drugs,6.07,34,,6.07,percent of total billed charges,Drugs,6.07,34,,6.07,percent of total billed charges,Drugs,6.07,34,,6.07,percent of total billed charges,Drugs,6.07,34,,6.07,percent of total billed charges,Drugs,6.25,35,,6.25,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,6.25,35,,6.25,percent of total billed charges,Drugs,6.25,35,,6.25,percent of total billed charges,Drugs,6.25,35,,6.25,percent of total billed charges,Drugs,6.25,35,,6.25,percent of total billed charges,Drugs,6.25,35,,6.25,percent of total billed charges,Drugs,7.14,40,,7.14,percent of total billed charges,Drugs,12.5,70,,12.5,percent of total billed charges,All Other,6.43,36,,6.43,percent of total billed charges,Drugs,6.43,36,,6.43,percent of total billed charges,Drugs,6.25,35,,6.25,percent of total billed charges,Drugs,6.25,35,,6.25,percent of total billed charges,Drugs,6.25,35,,6.25,percent of total billed charges,Drugs,6.25,35,,6.25,percent of total billed charges,Drugs,5.95,,,5.95,Other,Drug Cost,5.95,,,5.95,Other,Drug Cost,5.95,,,5.95,Other,Drug Cost,5.95,,,5.95,Other,Drug Cost,5.95,,,5.95,Other,Drug Cost,5.95,,,5.95,Other,Drug Cost,13.39,,,13.39,Other,225% of Medicaid,8.33,,,8.33,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,82.53,,,82.53,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",12.8,,,12.8,Other,215% Medicaid APG methodology,12.8,,,12.8,Other,215% Medicaid APG methodology,7.44,,,7.44,Other,125% Medicaid APG methodology,0.01,84.82,
DESMOPRESSIN ACETATE 4MCG/ML INJ,J2597,HCPCS,,80000603,CDM,636,RC,55566220000,NDC,both,10,ML,22.45,62.44,,,62.44,Other,150% of Medicare + 9.63% HCRA Surcharge,37.97,,,37.97,Fee Schedule,Average Sale Price (ASP) x 6,7.86,35,,7.86,percent of total billed charges,Drugs,7.86,35,,7.86,percent of total billed charges,Drugs,7.63,34,,7.63,percent of total billed charges,Drugs,7.63,34,,7.63,percent of total billed charges,Drugs,7.63,34,,7.63,percent of total billed charges,Drugs,7.63,34,,7.63,percent of total billed charges,Drugs,7.86,35,,7.86,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,7.86,35,,7.86,percent of total billed charges,Drugs,7.86,35,,7.86,percent of total billed charges,Drugs,7.86,35,,7.86,percent of total billed charges,Drugs,7.86,35,,7.86,percent of total billed charges,Drugs,7.86,35,,7.86,percent of total billed charges,Drugs,8.98,40,,8.98,percent of total billed charges,Drugs,15.72,70,,15.72,percent of total billed charges,All Other,8.08,36,,8.08,percent of total billed charges,Drugs,8.08,36,,8.08,percent of total billed charges,Drugs,7.86,35,,7.86,percent of total billed charges,Drugs,7.86,35,,7.86,percent of total billed charges,Drugs,7.86,35,,7.86,percent of total billed charges,Drugs,7.86,35,,7.86,percent of total billed charges,Drugs,7.48,,,7.48,Other,Drug Cost,7.48,,,7.48,Other,Drug Cost,7.48,,,7.48,Other,Drug Cost,7.48,,,7.48,Other,Drug Cost,7.48,,,7.48,Other,Drug Cost,7.48,,,7.48,Other,Drug Cost,16.84,,,16.84,Other,225% of Medicaid,10.48,,,10.48,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,60.75,,,60.75,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",16.09,,,16.09,Other,215% Medicaid APG methodology,16.09,,,16.09,Other,215% Medicaid APG methodology,9.36,,,9.36,Other,125% Medicaid APG methodology,0.01,62.44,
DEXAMETH SOD  4MG INJ,J1100,HCPCS,,80000608,CDM,636,RC,641614525,NDC,both,25,ML,1.07,1.17,,,1.17,Other,150% of Medicare + 9.63% HCRA Surcharge,0.71,,,0.71,Fee Schedule,Average Sale Price (ASP) x 6,0.38,35,,0.38,percent of total billed charges,Drugs,0.38,35,,0.38,percent of total billed charges,Drugs,0.37,34,,0.37,percent of total billed charges,Drugs,0.37,34,,0.37,percent of total billed charges,Drugs,0.37,34,,0.37,percent of total billed charges,Drugs,0.37,34,,0.37,percent of total billed charges,Drugs,0.38,35,,0.38,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,0.38,35,,0.38,percent of total billed charges,Drugs,0.38,35,,0.38,percent of total billed charges,Drugs,0.38,35,,0.38,percent of total billed charges,Drugs,0.38,35,,0.38,percent of total billed charges,Drugs,0.38,35,,0.38,percent of total billed charges,Drugs,0.43,40,,0.43,percent of total billed charges,Drugs,0.75,70,,0.75,percent of total billed charges,All Other,0.39,36,,0.39,percent of total billed charges,Drugs,0.39,36,,0.39,percent of total billed charges,Drugs,0.38,35,,0.38,percent of total billed charges,Drugs,0.38,35,,0.38,percent of total billed charges,Drugs,0.38,35,,0.38,percent of total billed charges,Drugs,0.38,35,,0.38,percent of total billed charges,Drugs,0.36,,,0.36,Other,Drug Cost,0.36,,,0.36,Other,Drug Cost,0.36,,,0.36,Other,Drug Cost,0.36,,,0.36,Other,Drug Cost,0.36,,,0.36,Other,Drug Cost,0.36,,,0.36,Other,Drug Cost,0.81,,,0.81,Other,225% of Medicaid,0.5,,,0.5,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,1.14,,,1.14,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",0.77,,,0.77,Other,215% Medicaid APG methodology,0.77,,,0.77,Other,215% Medicaid APG methodology,0.45,,,0.45,Other,125% Medicaid APG methodology,0.01,1.17,
DEXAMETH SOD 20MG INJ,J1100,HCPCS,,80000609,CDM,636,RC,67457042254,NDC,both,25,ML,1.36,1.17,,,1.17,Other,150% of Medicare + 9.63% HCRA Surcharge,0.71,,,0.71,Fee Schedule,Average Sale Price (ASP) x 6,0.48,35,,0.48,percent of total billed charges,Drugs,0.48,35,,0.48,percent of total billed charges,Drugs,0.46,34,,0.46,percent of total billed charges,Drugs,0.46,34,,0.46,percent of total billed charges,Drugs,0.46,34,,0.46,percent of total billed charges,Drugs,0.46,34,,0.46,percent of total billed charges,Drugs,0.48,35,,0.48,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,0.48,35,,0.48,percent of total billed charges,Drugs,0.48,35,,0.48,percent of total billed charges,Drugs,0.48,35,,0.48,percent of total billed charges,Drugs,0.48,35,,0.48,percent of total billed charges,Drugs,0.48,35,,0.48,percent of total billed charges,Drugs,0.55,40,,0.55,percent of total billed charges,Drugs,0.95,70,,0.95,percent of total billed charges,All Other,0.49,36,,0.49,percent of total billed charges,Drugs,0.49,36,,0.49,percent of total billed charges,Drugs,0.48,35,,0.48,percent of total billed charges,Drugs,0.48,35,,0.48,percent of total billed charges,Drugs,0.48,35,,0.48,percent of total billed charges,Drugs,0.48,35,,0.48,percent of total billed charges,Drugs,0.45,,,0.45,Other,Drug Cost,0.45,,,0.45,Other,Drug Cost,0.45,,,0.45,Other,Drug Cost,0.45,,,0.45,Other,Drug Cost,0.45,,,0.45,Other,Drug Cost,0.45,,,0.45,Other,Drug Cost,1.02,,,1.02,Other,225% of Medicaid,0.64,,,0.64,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,1.14,,,1.14,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",0.98,,,0.98,Other,215% Medicaid APG methodology,0.98,,,0.98,Other,215% Medicaid APG methodology,0.57,,,0.57,Other,125% Medicaid APG methodology,0.01,1.17,
DEXAMETHASONE 0.5 MG TAB,J8540,HCPCS,,80000610,CDM,636,RC,54417925,NDC,both,100,EA,0.12,0.82,,,0.82,Other,150% of Medicare + 9.63% HCRA Surcharge,0.5,,,0.5,Fee Schedule,Average Sale Price (ASP) x 6,0.04,35,,0.04,percent of total billed charges,Drugs,0.04,35,,0.04,percent of total billed charges,Drugs,0.04,34,,0.04,percent of total billed charges,Drugs,0.04,34,,0.04,percent of total billed charges,Drugs,0.04,34,,0.04,percent of total billed charges,Drugs,0.04,34,,0.04,percent of total billed charges,Drugs,0.04,35,,0.04,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,0.04,35,,0.04,percent of total billed charges,Drugs,0.04,35,,0.04,percent of total billed charges,Drugs,0.04,35,,0.04,percent of total billed charges,Drugs,0.04,35,,0.04,percent of total billed charges,Drugs,0.04,35,,0.04,percent of total billed charges,Drugs,0.05,40,,0.05,percent of total billed charges,Drugs,0.08,70,,0.08,percent of total billed charges,All Other,0.04,36,,0.04,percent of total billed charges,Drugs,0.04,36,,0.04,percent of total billed charges,Drugs,0.04,35,,0.04,percent of total billed charges,Drugs,0.04,35,,0.04,percent of total billed charges,Drugs,0.04,35,,0.04,percent of total billed charges,Drugs,0.04,35,,0.04,percent of total billed charges,Drugs,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.09,,,0.09,Other,225% of Medicaid,0.06,,,0.06,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,0.8,,,0.8,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",0.09,,,0.09,Other,215% Medicaid APG methodology,0.09,,,0.09,Other,215% Medicaid APG methodology,0.05,,,0.05,Other,125% Medicaid APG methodology,0.01,0.82,
DEXAMETHASONE 0.75 MG TAB,J8540,HCPCS,,80000611,CDM,636,RC,54418025,NDC,both,100,EA,0.18,0.82,,,0.82,Other,150% of Medicare + 9.63% HCRA Surcharge,0.5,,,0.5,Fee Schedule,Average Sale Price (ASP) x 6,0.06,35,,0.06,percent of total billed charges,Drugs,0.06,35,,0.06,percent of total billed charges,Drugs,0.06,34,,0.06,percent of total billed charges,Drugs,0.06,34,,0.06,percent of total billed charges,Drugs,0.06,34,,0.06,percent of total billed charges,Drugs,0.06,34,,0.06,percent of total billed charges,Drugs,0.06,35,,0.06,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,0.06,35,,0.06,percent of total billed charges,Drugs,0.06,35,,0.06,percent of total billed charges,Drugs,0.06,35,,0.06,percent of total billed charges,Drugs,0.06,35,,0.06,percent of total billed charges,Drugs,0.06,35,,0.06,percent of total billed charges,Drugs,0.07,40,,0.07,percent of total billed charges,Drugs,0.12,70,,0.12,percent of total billed charges,All Other,0.06,36,,0.06,percent of total billed charges,Drugs,0.06,36,,0.06,percent of total billed charges,Drugs,0.06,35,,0.06,percent of total billed charges,Drugs,0.06,35,,0.06,percent of total billed charges,Drugs,0.06,35,,0.06,percent of total billed charges,Drugs,0.06,35,,0.06,percent of total billed charges,Drugs,0.06,,,0.06,Other,Drug Cost,0.06,,,0.06,Other,Drug Cost,0.06,,,0.06,Other,Drug Cost,0.06,,,0.06,Other,Drug Cost,0.06,,,0.06,Other,Drug Cost,0.06,,,0.06,Other,Drug Cost,0.13,,,0.13,Other,225% of Medicaid,0.08,,,0.08,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,0.8,,,0.8,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",0.13,,,0.13,Other,215% Medicaid APG methodology,0.13,,,0.13,Other,215% Medicaid APG methodology,0.07,,,0.07,Other,125% Medicaid APG methodology,0.01,0.82,
DEXAMETHASONE 4 MG TAB,J8540,HCPCS,,80000612,CDM,636,RC,54418425,NDC,both,100,EA,0.04,0.82,,,0.82,Other,150% of Medicare + 9.63% HCRA Surcharge,0.5,,,0.5,Fee Schedule,Average Sale Price (ASP) x 6,0.01,35,,0.01,percent of total billed charges,Drugs,0.01,35,,0.01,percent of total billed charges,Drugs,0.01,34,,0.01,percent of total billed charges,Drugs,0.01,34,,0.01,percent of total billed charges,Drugs,0.01,34,,0.01,percent of total billed charges,Drugs,0.01,34,,0.01,percent of total billed charges,Drugs,0.01,35,,0.01,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,0.01,35,,0.01,percent of total billed charges,Drugs,0.01,35,,0.01,percent of total billed charges,Drugs,0.01,35,,0.01,percent of total billed charges,Drugs,0.01,35,,0.01,percent of total billed charges,Drugs,0.01,35,,0.01,percent of total billed charges,Drugs,0.01,40,,0.01,percent of total billed charges,Drugs,0.03,70,,0.03,percent of total billed charges,All Other,0.01,36,,0.01,percent of total billed charges,Drugs,0.01,36,,0.01,percent of total billed charges,Drugs,0.01,35,,0.01,percent of total billed charges,Drugs,0.01,35,,0.01,percent of total billed charges,Drugs,0.01,35,,0.01,percent of total billed charges,Drugs,0.01,35,,0.01,percent of total billed charges,Drugs,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.03,,,0.03,Other,225% of Medicaid,0.02,,,0.02,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,0.8,,,0.8,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",0.03,,,0.03,Other,215% Medicaid APG methodology,0.03,,,0.03,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,125% Medicaid APG methodology,0.01,0.82,
DEXRAZOXANE HCL 500 MG INJ,J1190,HCPCS,,80000614,CDM,636,RC,72611071601,NDC,both,1,EA,396.78,1065.66,,,1065.66,Other,150% of Medicare + 9.63% HCRA Surcharge,648.04,,,648.04,Fee Schedule,Average Sale Price (ASP) x 6,138.87,35,,138.87,percent of total billed charges,Drugs,138.87,35,,138.87,percent of total billed charges,Drugs,134.91,34,,134.91,percent of total billed charges,Drugs,134.91,34,,134.91,percent of total billed charges,Drugs,134.91,34,,134.91,percent of total billed charges,Drugs,134.91,34,,134.91,percent of total billed charges,Drugs,138.87,35,,138.87,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,138.87,35,,138.87,percent of total billed charges,Drugs,138.87,35,,138.87,percent of total billed charges,Drugs,138.87,35,,138.87,percent of total billed charges,Drugs,138.87,35,,138.87,percent of total billed charges,Drugs,138.87,35,,138.87,percent of total billed charges,Drugs,158.71,40,,158.71,percent of total billed charges,Drugs,277.75,70,,277.75,percent of total billed charges,All Other,142.84,36,,142.84,percent of total billed charges,Drugs,142.84,36,,142.84,percent of total billed charges,Drugs,138.87,35,,138.87,percent of total billed charges,Drugs,138.87,35,,138.87,percent of total billed charges,Drugs,138.87,35,,138.87,percent of total billed charges,Drugs,138.87,35,,138.87,percent of total billed charges,Drugs,132.26,,,132.26,Other,Drug Cost,132.26,,,132.26,Other,Drug Cost,132.26,,,132.26,Other,Drug Cost,132.26,,,132.26,Other,Drug Cost,132.26,,,132.26,Other,Drug Cost,132.26,,,132.26,Other,Drug Cost,297.59,,,297.59,Other,225% of Medicaid,185.16,,,185.16,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,1036.86,,,1036.86,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",284.36,,,284.36,Other,215% Medicaid APG methodology,284.36,,,284.36,Other,215% Medicaid APG methodology,165.33,,,165.33,Other,125% Medicaid APG methodology,0.01,1065.66,
DEXTRAN 40/ NS 500 ML,J7100,HCPCS,,80000615,CDM,636,RC,409741903,NDC,both,12,ML,52.94,20.9,39.4668,,20.9,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,18.53,35,,18.53,percent of total billed charges,Drugs,18.53,35,,18.53,percent of total billed charges,Drugs,18,34,,18,percent of total billed charges,Drugs,18,34,,18,percent of total billed charges,Drugs,18,34,,18,percent of total billed charges,Drugs,18,34,,18,percent of total billed charges,Drugs,18.53,35,,18.53,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,18.53,35,,18.53,percent of total billed charges,Drugs,18.53,35,,18.53,percent of total billed charges,Drugs,18.53,35,,18.53,percent of total billed charges,Drugs,18.53,35,,18.53,percent of total billed charges,Drugs,18.53,35,,18.53,percent of total billed charges,Drugs,21.18,40,,21.18,percent of total billed charges,Drugs,37.06,70,,37.06,percent of total billed charges,All Other,19.06,36,,19.06,percent of total billed charges,Drugs,19.06,36,,19.06,percent of total billed charges,Drugs,18.53,35,,18.53,percent of total billed charges,Drugs,18.53,35,,18.53,percent of total billed charges,Drugs,18.53,35,,18.53,percent of total billed charges,Drugs,18.53,35,,18.53,percent of total billed charges,Drugs,17.65,,,17.65,Other,Drug Cost,17.65,,,17.65,Other,Drug Cost,17.65,,,17.65,Other,Drug Cost,17.65,,,17.65,Other,Drug Cost,17.65,,,17.65,Other,Drug Cost,17.65,,,17.65,Other,Drug Cost,39.71,,,39.71,Other,225% of Medicaid,24.71,,,24.71,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",37.94,,,37.94,Other,215% Medicaid APG methodology,37.94,,,37.94,Other,215% Medicaid APG methodology,22.06,,,22.06,Other,125% Medicaid APG methodology,0.01,39.71,
DIAZEPAM  5 MG/ML 2ML INJ,J3360,HCPCS,,80000635,CDM,636,RC,409127332,NDC,both,10,ML,28.22,53.92,,,53.92,Other,150% of Medicare + 9.63% HCRA Surcharge,32.79,,,32.79,Fee Schedule,Average Sale Price (ASP) x 6,9.88,35,,9.88,percent of total billed charges,Drugs,9.88,35,,9.88,percent of total billed charges,Drugs,9.6,34,,9.6,percent of total billed charges,Drugs,9.6,34,,9.6,percent of total billed charges,Drugs,9.6,34,,9.6,percent of total billed charges,Drugs,9.6,34,,9.6,percent of total billed charges,Drugs,9.88,35,,9.88,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,9.88,35,,9.88,percent of total billed charges,Drugs,9.88,35,,9.88,percent of total billed charges,Drugs,9.88,35,,9.88,percent of total billed charges,Drugs,9.88,35,,9.88,percent of total billed charges,Drugs,9.88,35,,9.88,percent of total billed charges,Drugs,11.29,40,,11.29,percent of total billed charges,Drugs,19.75,70,,19.75,percent of total billed charges,All Other,10.16,36,,10.16,percent of total billed charges,Drugs,10.16,36,,10.16,percent of total billed charges,Drugs,9.88,35,,9.88,percent of total billed charges,Drugs,9.88,35,,9.88,percent of total billed charges,Drugs,9.88,35,,9.88,percent of total billed charges,Drugs,9.88,35,,9.88,percent of total billed charges,Drugs,9.41,,,9.41,Other,Drug Cost,9.41,,,9.41,Other,Drug Cost,9.41,,,9.41,Other,Drug Cost,9.41,,,9.41,Other,Drug Cost,9.41,,,9.41,Other,Drug Cost,9.41,,,9.41,Other,Drug Cost,21.17,,,21.17,Other,225% of Medicaid,13.17,,,13.17,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,52.46,,,52.46,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",20.23,,,20.23,Other,215% Medicaid APG methodology,20.23,,,20.23,Other,215% Medicaid APG methodology,11.76,,,11.76,Other,125% Medicaid APG methodology,0.01,53.92,
DICYCLOMINE 10MG/ML 2ML INJ,J0500,HCPCS,,80000645,CDM,636,RC,58914008052,NDC,both,5,ML,0.05,246.32,,,246.32,Other,150% of Medicare + 9.63% HCRA Surcharge,149.79,,,149.79,Fee Schedule,Average Sale Price (ASP) x 6,0.02,35,,0.02,percent of total billed charges,Drugs,0.02,35,,0.02,percent of total billed charges,Drugs,0.02,34,,0.02,percent of total billed charges,Drugs,0.02,34,,0.02,percent of total billed charges,Drugs,0.02,34,,0.02,percent of total billed charges,Drugs,0.02,34,,0.02,percent of total billed charges,Drugs,0.02,35,,0.02,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,0.02,35,,0.02,percent of total billed charges,Drugs,0.02,35,,0.02,percent of total billed charges,Drugs,0.02,35,,0.02,percent of total billed charges,Drugs,0.02,35,,0.02,percent of total billed charges,Drugs,0.02,35,,0.02,percent of total billed charges,Drugs,0.02,40,,0.02,percent of total billed charges,Drugs,0.04,70,,0.04,percent of total billed charges,All Other,0.02,36,,0.02,percent of total billed charges,Drugs,0.02,36,,0.02,percent of total billed charges,Drugs,0.02,35,,0.02,percent of total billed charges,Drugs,0.02,35,,0.02,percent of total billed charges,Drugs,0.02,35,,0.02,percent of total billed charges,Drugs,0.02,35,,0.02,percent of total billed charges,Drugs,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.04,,,0.04,Other,225% of Medicaid,0.03,,,0.03,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,239.66,,,239.66,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",0.04,,,0.04,Other,215% Medicaid APG methodology,0.04,,,0.04,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,125% Medicaid APG methodology,0.01,246.32,
DIGOXIN IMMUNE FAB (OVINE) PER VIAL,J1162,HCPCS,,80000653,CDM,636,RC,50633012011,NDC,both,1,EA,12998.76,47137.58,,,47137.58,Other,150% of Medicare + 9.63% HCRA Surcharge,28664.65,,,28664.65,Fee Schedule,Average Sale Price (ASP) x 6,4549.57,35,,4549.57,percent of total billed charges,Drugs,4549.57,35,,4549.57,percent of total billed charges,Drugs,4419.58,34,,4419.58,percent of total billed charges,Drugs,4419.58,34,,4419.58,percent of total billed charges,Drugs,4419.58,34,,4419.58,percent of total billed charges,Drugs,4419.58,34,,4419.58,percent of total billed charges,Drugs,4549.57,35,,4549.57,percent of total billed charges,Drugs,4419.58,34,"If Charge > 500, then 34 percent",4419.58,percent of total billed charges,Drugs,4549.57,35,,4549.57,percent of total billed charges,Drugs,4549.57,35,,4549.57,percent of total billed charges,Drugs,4549.57,35,,4549.57,percent of total billed charges,Drugs,4549.57,35,,4549.57,percent of total billed charges,Drugs,4549.57,35,,4549.57,percent of total billed charges,Drugs,5199.5,40,,5199.5,percent of total billed charges,Drugs,9099.13,70,,9099.13,percent of total billed charges,All Other,4679.55,36,,4679.55,percent of total billed charges,Drugs,4679.55,36,,4679.55,percent of total billed charges,Drugs,4549.57,35,,4549.57,percent of total billed charges,Drugs,4549.57,35,,4549.57,percent of total billed charges,Drugs,4549.57,35,,4549.57,percent of total billed charges,Drugs,4549.57,35,,4549.57,percent of total billed charges,Drugs,4332.92,,,4332.92,Other,Drug Cost,4332.92,,,4332.92,Other,Drug Cost,4332.92,,,4332.92,Other,Drug Cost,4332.92,,,4332.92,Other,Drug Cost,4332.92,,,4332.92,Other,Drug Cost,4332.92,,,4332.92,Other,Drug Cost,9749.07,,,9749.07,Other,225% of Medicaid,6066.09,,,6066.09,Other,140% of Medicaid,4419.58,34,"If Charge > 2,000, then 34 percent",4419.58,percent of total billed charges,Drugs,45863.43,,,45863.43,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",9315.78,,,9315.78,Other,215% Medicaid APG methodology,9315.78,,,9315.78,Other,215% Medicaid APG methodology,5416.15,,,5416.15,Other,125% Medicaid APG methodology,0.01,47137.58,
DIGOXIN INJ 0.25MG/ML 2ML,J1160,HCPCS,,80000655,CDM,636,RC,781305995,NDC,both,10,ML,5.1,92.83,,,92.83,Other,150% of Medicare + 9.63% HCRA Surcharge,56.45,,,56.45,Fee Schedule,Average Sale Price (ASP) x 6,1.78,35,,1.78,percent of total billed charges,Drugs,1.78,35,,1.78,percent of total billed charges,Drugs,1.73,34,,1.73,percent of total billed charges,Drugs,1.73,34,,1.73,percent of total billed charges,Drugs,1.73,34,,1.73,percent of total billed charges,Drugs,1.73,34,,1.73,percent of total billed charges,Drugs,1.78,35,,1.78,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,1.78,35,,1.78,percent of total billed charges,Drugs,1.78,35,,1.78,percent of total billed charges,Drugs,1.78,35,,1.78,percent of total billed charges,Drugs,1.78,35,,1.78,percent of total billed charges,Drugs,1.78,35,,1.78,percent of total billed charges,Drugs,2.04,40,,2.04,percent of total billed charges,Drugs,3.57,70,,3.57,percent of total billed charges,All Other,1.83,36,,1.83,percent of total billed charges,Drugs,1.83,36,,1.83,percent of total billed charges,Drugs,1.78,35,,1.78,percent of total billed charges,Drugs,1.78,35,,1.78,percent of total billed charges,Drugs,1.78,35,,1.78,percent of total billed charges,Drugs,1.78,35,,1.78,percent of total billed charges,Drugs,1.7,,,1.7,Other,Drug Cost,1.7,,,1.7,Other,Drug Cost,1.7,,,1.7,Other,Drug Cost,1.7,,,1.7,Other,Drug Cost,1.7,,,1.7,Other,Drug Cost,1.7,,,1.7,Other,Drug Cost,3.82,,,3.82,Other,225% of Medicaid,2.38,,,2.38,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,90.32,,,90.32,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",3.65,,,3.65,Other,215% Medicaid APG methodology,3.65,,,3.65,Other,215% Medicaid APG methodology,2.12,,,2.12,Other,125% Medicaid APG methodology,0.01,92.83,
DIPHENHYDRAMINE (BENADRYL) INJ 50MG,J1200,HCPCS,,80000673,CDM,636,RC,641037625,NDC,both,25,ML,1.47,7.93,,,7.93,Other,150% of Medicare + 9.63% HCRA Surcharge,4.82,,,4.82,Fee Schedule,Average Sale Price (ASP) x 6,0.51,35,,0.51,percent of total billed charges,Drugs,0.51,35,,0.51,percent of total billed charges,Drugs,0.5,34,,0.5,percent of total billed charges,Drugs,0.5,34,,0.5,percent of total billed charges,Drugs,0.5,34,,0.5,percent of total billed charges,Drugs,0.5,34,,0.5,percent of total billed charges,Drugs,0.51,35,,0.51,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,0.51,35,,0.51,percent of total billed charges,Drugs,0.51,35,,0.51,percent of total billed charges,Drugs,0.51,35,,0.51,percent of total billed charges,Drugs,0.51,35,,0.51,percent of total billed charges,Drugs,0.51,35,,0.51,percent of total billed charges,Drugs,0.59,40,,0.59,percent of total billed charges,Drugs,1.03,70,,1.03,percent of total billed charges,All Other,0.53,36,,0.53,percent of total billed charges,Drugs,0.53,36,,0.53,percent of total billed charges,Drugs,0.51,35,,0.51,percent of total billed charges,Drugs,0.51,35,,0.51,percent of total billed charges,Drugs,0.51,35,,0.51,percent of total billed charges,Drugs,0.51,35,,0.51,percent of total billed charges,Drugs,0.49,,,0.49,Other,Drug Cost,0.49,,,0.49,Other,Drug Cost,0.49,,,0.49,Other,Drug Cost,0.49,,,0.49,Other,Drug Cost,0.49,,,0.49,Other,Drug Cost,0.49,,,0.49,Other,Drug Cost,1.1,,,1.1,Other,225% of Medicaid,0.68,,,0.68,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,7.72,,,7.72,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",1.05,,,1.05,Other,215% Medicaid APG methodology,1.05,,,1.05,Other,215% Medicaid APG methodology,0.61,,,0.61,Other,125% Medicaid APG methodology,0.01,7.93,
DIPHTH PERTUSS (ACELL) TET,90715,HCPCS,,80000679,CDM,636,RC,58160084211,NDC,both,10,ML,113.32,44.72,39.4668,,44.72,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,39.66,35,,39.66,percent of total billed charges,Drugs,39.66,35,,39.66,percent of total billed charges,Drugs,38.53,34,,38.53,percent of total billed charges,Drugs,38.53,34,,38.53,percent of total billed charges,Drugs,38.53,34,,38.53,percent of total billed charges,Drugs,38.53,34,,38.53,percent of total billed charges,Drugs,39.66,35,,39.66,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,39.66,35,,39.66,percent of total billed charges,Drugs,39.66,35,,39.66,percent of total billed charges,Drugs,39.66,35,,39.66,percent of total billed charges,Drugs,39.66,35,,39.66,percent of total billed charges,Drugs,39.66,35,,39.66,percent of total billed charges,Drugs,45.33,40,,45.33,percent of total billed charges,Drugs,79.32,70,,79.32,percent of total billed charges,All Other,40.79,36,,40.79,percent of total billed charges,Drugs,40.79,36,,40.79,percent of total billed charges,Drugs,39.66,35,,39.66,percent of total billed charges,Drugs,39.66,35,,39.66,percent of total billed charges,Drugs,39.66,35,,39.66,percent of total billed charges,Drugs,39.66,35,,39.66,percent of total billed charges,Drugs,37.77,,,37.77,Other,Drug Cost,37.77,,,37.77,Other,Drug Cost,37.77,,,37.77,Other,Drug Cost,37.77,,,37.77,Other,Drug Cost,37.77,,,37.77,Other,Drug Cost,37.77,,,37.77,Other,Drug Cost,84.99,,,84.99,Other,225% of Medicaid,52.88,,,52.88,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",81.21,,,81.21,Other,215% Medicaid APG methodology,81.21,,,81.21,Other,215% Medicaid APG methodology,47.22,,,47.22,Other,125% Medicaid APG methodology,0.01,84.99,
DOBUTAMINE (DOBUTREX) INJ 250MG/20ML,J1250,HCPCS,,80000692,CDM,636,RC,409234402,NDC,both,10,ML,12.2,97.17,,,97.17,Other,150% of Medicare + 9.63% HCRA Surcharge,59.09,,,59.09,Fee Schedule,Average Sale Price (ASP) x 6,4.27,35,,4.27,percent of total billed charges,Drugs,4.27,35,,4.27,percent of total billed charges,Drugs,4.15,34,,4.15,percent of total billed charges,Drugs,4.15,34,,4.15,percent of total billed charges,Drugs,4.15,34,,4.15,percent of total billed charges,Drugs,4.15,34,,4.15,percent of total billed charges,Drugs,4.27,35,,4.27,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,4.27,35,,4.27,percent of total billed charges,Drugs,4.27,35,,4.27,percent of total billed charges,Drugs,4.27,35,,4.27,percent of total billed charges,Drugs,4.27,35,,4.27,percent of total billed charges,Drugs,4.27,35,,4.27,percent of total billed charges,Drugs,4.88,40,,4.88,percent of total billed charges,Drugs,8.54,70,,8.54,percent of total billed charges,All Other,4.39,36,,4.39,percent of total billed charges,Drugs,4.39,36,,4.39,percent of total billed charges,Drugs,4.27,35,,4.27,percent of total billed charges,Drugs,4.27,35,,4.27,percent of total billed charges,Drugs,4.27,35,,4.27,percent of total billed charges,Drugs,4.27,35,,4.27,percent of total billed charges,Drugs,4.07,,,4.07,Other,Drug Cost,4.07,,,4.07,Other,Drug Cost,4.07,,,4.07,Other,Drug Cost,4.07,,,4.07,Other,Drug Cost,4.07,,,4.07,Other,Drug Cost,4.07,,,4.07,Other,Drug Cost,9.15,,,9.15,Other,225% of Medicaid,5.69,,,5.69,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,94.54,,,94.54,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",8.74,,,8.74,Other,215% Medicaid APG methodology,8.74,,,8.74,Other,215% Medicaid APG methodology,5.08,,,5.08,Other,125% Medicaid APG methodology,0.01,97.17,
DOBUTAMINE (DOBUTREX) INJ 250MG/250ML,J1250,HCPCS,,80000693,CDM,636,RC,338107302,NDC,both,18,ML,6.8,97.17,,,97.17,Other,150% of Medicare + 9.63% HCRA Surcharge,59.09,,,59.09,Fee Schedule,Average Sale Price (ASP) x 6,2.38,35,,2.38,percent of total billed charges,Drugs,2.38,35,,2.38,percent of total billed charges,Drugs,2.31,34,,2.31,percent of total billed charges,Drugs,2.31,34,,2.31,percent of total billed charges,Drugs,2.31,34,,2.31,percent of total billed charges,Drugs,2.31,34,,2.31,percent of total billed charges,Drugs,2.38,35,,2.38,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,2.38,35,,2.38,percent of total billed charges,Drugs,2.38,35,,2.38,percent of total billed charges,Drugs,2.38,35,,2.38,percent of total billed charges,Drugs,2.38,35,,2.38,percent of total billed charges,Drugs,2.38,35,,2.38,percent of total billed charges,Drugs,2.72,40,,2.72,percent of total billed charges,Drugs,4.76,70,,4.76,percent of total billed charges,All Other,2.45,36,,2.45,percent of total billed charges,Drugs,2.45,36,,2.45,percent of total billed charges,Drugs,2.38,35,,2.38,percent of total billed charges,Drugs,2.38,35,,2.38,percent of total billed charges,Drugs,2.38,35,,2.38,percent of total billed charges,Drugs,2.38,35,,2.38,percent of total billed charges,Drugs,2.27,,,2.27,Other,Drug Cost,2.27,,,2.27,Other,Drug Cost,2.27,,,2.27,Other,Drug Cost,2.27,,,2.27,Other,Drug Cost,2.27,,,2.27,Other,Drug Cost,2.27,,,2.27,Other,Drug Cost,5.1,,,5.1,Other,225% of Medicaid,3.17,,,3.17,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,94.54,,,94.54,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",4.87,,,4.87,Other,215% Medicaid APG methodology,4.87,,,4.87,Other,215% Medicaid APG methodology,2.83,,,2.83,Other,125% Medicaid APG methodology,0.01,97.17,
DOCETAXEL INJECTION 20 MG/1ML,J9171,HCPCS,,80000694,CDM,636,RC,16729026763,NDC,both,1,ML,20.22,9.82,,,9.82,Other,150% of Medicare + 9.63% HCRA Surcharge,5.97,,,5.97,Fee Schedule,Average Sale Price (ASP) x 6,7.08,35,,7.08,percent of total billed charges,Drugs,7.08,35,,7.08,percent of total billed charges,Drugs,6.87,34,,6.87,percent of total billed charges,Drugs,6.87,34,,6.87,percent of total billed charges,Drugs,6.87,34,,6.87,percent of total billed charges,Drugs,6.87,34,,6.87,percent of total billed charges,Drugs,7.08,35,,7.08,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,7.08,35,,7.08,percent of total billed charges,Drugs,7.08,35,,7.08,percent of total billed charges,Drugs,7.08,35,,7.08,percent of total billed charges,Drugs,7.08,35,,7.08,percent of total billed charges,Drugs,7.08,35,,7.08,percent of total billed charges,Drugs,8.09,40,,8.09,percent of total billed charges,Drugs,14.15,70,,14.15,percent of total billed charges,All Other,7.28,36,,7.28,percent of total billed charges,Drugs,7.28,36,,7.28,percent of total billed charges,Drugs,7.08,35,,7.08,percent of total billed charges,Drugs,7.08,35,,7.08,percent of total billed charges,Drugs,7.08,35,,7.08,percent of total billed charges,Drugs,7.08,35,,7.08,percent of total billed charges,Drugs,6.74,,,6.74,Other,Drug Cost,6.74,,,6.74,Other,Drug Cost,6.74,,,6.74,Other,Drug Cost,6.74,,,6.74,Other,Drug Cost,6.74,,,6.74,Other,Drug Cost,6.74,,,6.74,Other,Drug Cost,15.17,,,15.17,Other,225% of Medicaid,9.44,,,9.44,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,9.55,,,9.55,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",14.49,,,14.49,Other,215% Medicaid APG methodology,14.49,,,14.49,Other,215% Medicaid APG methodology,8.43,,,8.43,Other,125% Medicaid APG methodology,0.01,15.17,
DOPAMINE INJECTION 400MG/10ML,J1265,HCPCS,,80000706,CDM,636,RC,409910420,NDC,both,25,ML,4.48,7.62,,,7.62,Other,150% of Medicare + 9.63% HCRA Surcharge,4.63,,,4.63,Fee Schedule,Average Sale Price (ASP) x 6,1.57,35,,1.57,percent of total billed charges,Drugs,1.57,35,,1.57,percent of total billed charges,Drugs,1.52,34,,1.52,percent of total billed charges,Drugs,1.52,34,,1.52,percent of total billed charges,Drugs,1.52,34,,1.52,percent of total billed charges,Drugs,1.52,34,,1.52,percent of total billed charges,Drugs,1.57,35,,1.57,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,1.57,35,,1.57,percent of total billed charges,Drugs,1.57,35,,1.57,percent of total billed charges,Drugs,1.57,35,,1.57,percent of total billed charges,Drugs,1.57,35,,1.57,percent of total billed charges,Drugs,1.57,35,,1.57,percent of total billed charges,Drugs,1.79,40,,1.79,percent of total billed charges,Drugs,3.14,70,,3.14,percent of total billed charges,All Other,1.61,36,,1.61,percent of total billed charges,Drugs,1.61,36,,1.61,percent of total billed charges,Drugs,1.57,35,,1.57,percent of total billed charges,Drugs,1.57,35,,1.57,percent of total billed charges,Drugs,1.57,35,,1.57,percent of total billed charges,Drugs,1.57,35,,1.57,percent of total billed charges,Drugs,1.49,,,1.49,Other,Drug Cost,1.49,,,1.49,Other,Drug Cost,1.49,,,1.49,Other,Drug Cost,1.49,,,1.49,Other,Drug Cost,1.49,,,1.49,Other,Drug Cost,1.49,,,1.49,Other,Drug Cost,3.36,,,3.36,Other,225% of Medicaid,2.09,,,2.09,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,7.41,,,7.41,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",3.21,,,3.21,Other,215% Medicaid APG methodology,3.21,,,3.21,Other,215% Medicaid APG methodology,1.87,,,1.87,Other,125% Medicaid APG methodology,0.01,7.62,
DOPAMINE INJECTION 400MG/250ML,J1265,HCPCS,,80000707,CDM,636,RC,338100702,NDC,both,18,ML,10.63,7.62,,,7.62,Other,150% of Medicare + 9.63% HCRA Surcharge,4.63,,,4.63,Fee Schedule,Average Sale Price (ASP) x 6,3.72,35,,3.72,percent of total billed charges,Drugs,3.72,35,,3.72,percent of total billed charges,Drugs,3.61,34,,3.61,percent of total billed charges,Drugs,3.61,34,,3.61,percent of total billed charges,Drugs,3.61,34,,3.61,percent of total billed charges,Drugs,3.61,34,,3.61,percent of total billed charges,Drugs,3.72,35,,3.72,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,3.72,35,,3.72,percent of total billed charges,Drugs,3.72,35,,3.72,percent of total billed charges,Drugs,3.72,35,,3.72,percent of total billed charges,Drugs,3.72,35,,3.72,percent of total billed charges,Drugs,3.72,35,,3.72,percent of total billed charges,Drugs,4.25,40,,4.25,percent of total billed charges,Drugs,7.44,70,,7.44,percent of total billed charges,All Other,3.83,36,,3.83,percent of total billed charges,Drugs,3.83,36,,3.83,percent of total billed charges,Drugs,3.72,35,,3.72,percent of total billed charges,Drugs,3.72,35,,3.72,percent of total billed charges,Drugs,3.72,35,,3.72,percent of total billed charges,Drugs,3.72,35,,3.72,percent of total billed charges,Drugs,3.54,,,3.54,Other,Drug Cost,3.54,,,3.54,Other,Drug Cost,3.54,,,3.54,Other,Drug Cost,3.54,,,3.54,Other,Drug Cost,3.54,,,3.54,Other,Drug Cost,3.54,,,3.54,Other,Drug Cost,7.97,,,7.97,Other,225% of Medicaid,4.96,,,4.96,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,7.41,,,7.41,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",7.62,,,7.62,Other,215% Medicaid APG methodology,7.62,,,7.62,Other,215% Medicaid APG methodology,4.43,,,4.43,Other,125% Medicaid APG methodology,0.01,7.97,
DOPAMINE INJECTION 800MG/500ML,J1265,HCPCS,,80000708,CDM,636,RC,338100703,NDC,both,12,ML,21.25,7.62,,,7.62,Other,150% of Medicare + 9.63% HCRA Surcharge,4.63,,,4.63,Fee Schedule,Average Sale Price (ASP) x 6,7.44,35,,7.44,percent of total billed charges,Drugs,7.44,35,,7.44,percent of total billed charges,Drugs,7.23,34,,7.23,percent of total billed charges,Drugs,7.23,34,,7.23,percent of total billed charges,Drugs,7.23,34,,7.23,percent of total billed charges,Drugs,7.23,34,,7.23,percent of total billed charges,Drugs,7.44,35,,7.44,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,7.44,35,,7.44,percent of total billed charges,Drugs,7.44,35,,7.44,percent of total billed charges,Drugs,7.44,35,,7.44,percent of total billed charges,Drugs,7.44,35,,7.44,percent of total billed charges,Drugs,7.44,35,,7.44,percent of total billed charges,Drugs,8.5,40,,8.5,percent of total billed charges,Drugs,14.88,70,,14.88,percent of total billed charges,All Other,7.65,36,,7.65,percent of total billed charges,Drugs,7.65,36,,7.65,percent of total billed charges,Drugs,7.44,35,,7.44,percent of total billed charges,Drugs,7.44,35,,7.44,percent of total billed charges,Drugs,7.44,35,,7.44,percent of total billed charges,Drugs,7.44,35,,7.44,percent of total billed charges,Drugs,7.08,,,7.08,Other,Drug Cost,7.08,,,7.08,Other,Drug Cost,7.08,,,7.08,Other,Drug Cost,7.08,,,7.08,Other,Drug Cost,7.08,,,7.08,Other,Drug Cost,7.08,,,7.08,Other,Drug Cost,15.94,,,15.94,Other,225% of Medicaid,9.92,,,9.92,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,7.41,,,7.41,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",15.23,,,15.23,Other,215% Medicaid APG methodology,15.23,,,15.23,Other,215% Medicaid APG methodology,8.86,,,8.86,Other,125% Medicaid APG methodology,0.01,15.94,
DOXORUBICIN HCL INJECTION 50MG,J9000,HCPCS,,80000724,CDM,636,RC,69303220,NDC,both,1,ML,20.52,32.35,,,32.35,Other,150% of Medicare + 9.63% HCRA Surcharge,19.67,,,19.67,Fee Schedule,Average Sale Price (ASP) x 6,7.18,35,,7.18,percent of total billed charges,Drugs,7.18,35,,7.18,percent of total billed charges,Drugs,6.98,34,,6.98,percent of total billed charges,Drugs,6.98,34,,6.98,percent of total billed charges,Drugs,6.98,34,,6.98,percent of total billed charges,Drugs,6.98,34,,6.98,percent of total billed charges,Drugs,7.18,35,,7.18,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,7.18,35,,7.18,percent of total billed charges,Drugs,7.18,35,,7.18,percent of total billed charges,Drugs,7.18,35,,7.18,percent of total billed charges,Drugs,7.18,35,,7.18,percent of total billed charges,Drugs,7.18,35,,7.18,percent of total billed charges,Drugs,8.21,40,,8.21,percent of total billed charges,Drugs,14.36,70,,14.36,percent of total billed charges,All Other,7.39,36,,7.39,percent of total billed charges,Drugs,7.39,36,,7.39,percent of total billed charges,Drugs,7.18,35,,7.18,percent of total billed charges,Drugs,7.18,35,,7.18,percent of total billed charges,Drugs,7.18,35,,7.18,percent of total billed charges,Drugs,7.18,35,,7.18,percent of total billed charges,Drugs,6.84,,,6.84,Other,Drug Cost,6.84,,,6.84,Other,Drug Cost,6.84,,,6.84,Other,Drug Cost,6.84,,,6.84,Other,Drug Cost,6.84,,,6.84,Other,Drug Cost,6.84,,,6.84,Other,Drug Cost,15.39,,,15.39,Other,225% of Medicaid,9.58,,,9.58,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,31.48,,,31.48,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",14.71,,,14.71,Other,215% Medicaid APG methodology,14.71,,,14.71,Other,215% Medicaid APG methodology,8.55,,,8.55,Other,125% Medicaid APG methodology,0.01,32.35,
DOXORUBICIN HCL LIPOSOME  2 MG/ML 25ML,Q2050,HCPCS,,80000725,CDM,636,RC,338006301,NDC,both,1,ML,296.16,843.44,,,843.44,Other,150% of Medicare + 9.63% HCRA Surcharge,512.9,,,512.9,Fee Schedule,Average Sale Price (ASP) x 6,103.66,35,,103.66,percent of total billed charges,Drugs,103.66,35,,103.66,percent of total billed charges,Drugs,100.69,34,,100.69,percent of total billed charges,Drugs,100.69,34,,100.69,percent of total billed charges,Drugs,100.69,34,,100.69,percent of total billed charges,Drugs,100.69,34,,100.69,percent of total billed charges,Drugs,103.66,35,,103.66,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,103.66,35,,103.66,percent of total billed charges,Drugs,103.66,35,,103.66,percent of total billed charges,Drugs,103.66,35,,103.66,percent of total billed charges,Drugs,103.66,35,,103.66,percent of total billed charges,Drugs,103.66,35,,103.66,percent of total billed charges,Drugs,118.46,40,,118.46,percent of total billed charges,Drugs,207.31,70,,207.31,percent of total billed charges,All Other,106.62,36,,106.62,percent of total billed charges,Drugs,106.62,36,,106.62,percent of total billed charges,Drugs,103.66,35,,103.66,percent of total billed charges,Drugs,103.66,35,,103.66,percent of total billed charges,Drugs,103.66,35,,103.66,percent of total billed charges,Drugs,103.66,35,,103.66,percent of total billed charges,Drugs,98.72,,,98.72,Other,Drug Cost,98.72,,,98.72,Other,Drug Cost,98.72,,,98.72,Other,Drug Cost,98.72,,,98.72,Other,Drug Cost,98.72,,,98.72,Other,Drug Cost,98.72,,,98.72,Other,Drug Cost,222.12,,,222.12,Other,225% of Medicaid,138.21,,,138.21,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,820.65,,,820.65,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",212.25,,,212.25,Other,215% Medicaid APG methodology,212.25,,,212.25,Other,215% Medicaid APG methodology,123.4,,,123.4,Other,125% Medicaid APG methodology,0.01,843.44,
DRONABINOL 2.5 MG CAPS,Q0167,HCPCS,,80000729,CDM,636,RC,67877075360,NDC,both,60,EA,1.59,8,,,8,Other,150% of Medicare + 9.63% HCRA Surcharge,4.87,,,4.87,Fee Schedule,Average Sale Price (ASP) x 6,0.56,35,,0.56,percent of total billed charges,Drugs,0.56,35,,0.56,percent of total billed charges,Drugs,0.54,34,,0.54,percent of total billed charges,Drugs,0.54,34,,0.54,percent of total billed charges,Drugs,0.54,34,,0.54,percent of total billed charges,Drugs,0.54,34,,0.54,percent of total billed charges,Drugs,0.56,35,,0.56,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,0.56,35,,0.56,percent of total billed charges,Drugs,0.56,35,,0.56,percent of total billed charges,Drugs,0.56,35,,0.56,percent of total billed charges,Drugs,0.56,35,,0.56,percent of total billed charges,Drugs,0.56,35,,0.56,percent of total billed charges,Drugs,0.64,40,,0.64,percent of total billed charges,Drugs,1.11,70,,1.11,percent of total billed charges,All Other,0.57,36,,0.57,percent of total billed charges,Drugs,0.57,36,,0.57,percent of total billed charges,Drugs,0.56,35,,0.56,percent of total billed charges,Drugs,0.56,35,,0.56,percent of total billed charges,Drugs,0.56,35,,0.56,percent of total billed charges,Drugs,0.56,35,,0.56,percent of total billed charges,Drugs,0.53,,,0.53,Other,Drug Cost,0.53,,,0.53,Other,Drug Cost,0.53,,,0.53,Other,Drug Cost,0.53,,,0.53,Other,Drug Cost,0.53,,,0.53,Other,Drug Cost,0.53,,,0.53,Other,Drug Cost,1.19,,,1.19,Other,225% of Medicaid,0.74,,,0.74,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,7.79,,,7.79,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",1.14,,,1.14,Other,215% Medicaid APG methodology,1.14,,,1.14,Other,215% Medicaid APG methodology,0.66,,,0.66,Other,125% Medicaid APG methodology,0.01,8,
DROPERIDOL INJ TO 5 MG,J1790,HCPCS,,80000731,CDM,636,RC,517970225,NDC,both,25,ML,8.1,3.2,39.4668,,3.2,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,2.84,35,,2.84,percent of total billed charges,Drugs,2.84,35,,2.84,percent of total billed charges,Drugs,2.76,34,,2.76,percent of total billed charges,Drugs,2.76,34,,2.76,percent of total billed charges,Drugs,2.76,34,,2.76,percent of total billed charges,Drugs,2.76,34,,2.76,percent of total billed charges,Drugs,2.84,35,,2.84,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,2.84,35,,2.84,percent of total billed charges,Drugs,2.84,35,,2.84,percent of total billed charges,Drugs,2.84,35,,2.84,percent of total billed charges,Drugs,2.84,35,,2.84,percent of total billed charges,Drugs,2.84,35,,2.84,percent of total billed charges,Drugs,3.24,40,,3.24,percent of total billed charges,Drugs,5.67,70,,5.67,percent of total billed charges,All Other,2.92,36,,2.92,percent of total billed charges,Drugs,2.92,36,,2.92,percent of total billed charges,Drugs,2.84,35,,2.84,percent of total billed charges,Drugs,2.84,35,,2.84,percent of total billed charges,Drugs,2.84,35,,2.84,percent of total billed charges,Drugs,2.84,35,,2.84,percent of total billed charges,Drugs,2.7,,,2.7,Other,Drug Cost,2.7,,,2.7,Other,Drug Cost,2.7,,,2.7,Other,Drug Cost,2.7,,,2.7,Other,Drug Cost,2.7,,,2.7,Other,Drug Cost,2.7,,,2.7,Other,Drug Cost,6.08,,,6.08,Other,225% of Medicaid,3.78,,,3.78,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",5.81,,,5.81,Other,215% Medicaid APG methodology,5.81,,,5.81,Other,215% Medicaid APG methodology,3.38,,,3.38,Other,125% Medicaid APG methodology,0.01,6.08,
ENOXAPARIN (LOVENOX) 100MG INJ,J1650,HCPCS,,80000752,CDM,636,RC,955101010,NDC,both,10,ML,12.77,6.71,,,6.71,Other,150% of Medicare + 9.63% HCRA Surcharge,4.08,,,4.08,Fee Schedule,Average Sale Price (ASP) x 6,4.47,35,,4.47,percent of total billed charges,Drugs,4.47,35,,4.47,percent of total billed charges,Drugs,4.34,34,,4.34,percent of total billed charges,Drugs,4.34,34,,4.34,percent of total billed charges,Drugs,4.34,34,,4.34,percent of total billed charges,Drugs,4.34,34,,4.34,percent of total billed charges,Drugs,4.47,35,,4.47,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,4.47,35,,4.47,percent of total billed charges,Drugs,4.47,35,,4.47,percent of total billed charges,Drugs,4.47,35,,4.47,percent of total billed charges,Drugs,4.47,35,,4.47,percent of total billed charges,Drugs,4.47,35,,4.47,percent of total billed charges,Drugs,5.11,40,,5.11,percent of total billed charges,Drugs,8.94,70,,8.94,percent of total billed charges,All Other,4.6,36,,4.6,percent of total billed charges,Drugs,4.6,36,,4.6,percent of total billed charges,Drugs,4.47,35,,4.47,percent of total billed charges,Drugs,4.47,35,,4.47,percent of total billed charges,Drugs,4.47,35,,4.47,percent of total billed charges,Drugs,4.47,35,,4.47,percent of total billed charges,Drugs,4.26,,,4.26,Other,Drug Cost,4.26,,,4.26,Other,Drug Cost,4.26,,,4.26,Other,Drug Cost,4.26,,,4.26,Other,Drug Cost,4.26,,,4.26,Other,Drug Cost,4.26,,,4.26,Other,Drug Cost,9.58,,,9.58,Other,225% of Medicaid,5.96,,,5.96,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,6.53,,,6.53,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",9.15,,,9.15,Other,215% Medicaid APG methodology,9.15,,,9.15,Other,215% Medicaid APG methodology,5.32,,,5.32,Other,125% Medicaid APG methodology,0.01,9.58,
ENOXAPARIN (LOVENOX) 120MG INJ,J1650,HCPCS,,80000753,CDM,636,RC,75291201,NDC,both,10,ML,15.49,6.71,,,6.71,Other,150% of Medicare + 9.63% HCRA Surcharge,4.08,,,4.08,Fee Schedule,Average Sale Price (ASP) x 6,5.42,35,,5.42,percent of total billed charges,Drugs,5.42,35,,5.42,percent of total billed charges,Drugs,5.27,34,,5.27,percent of total billed charges,Drugs,5.27,34,,5.27,percent of total billed charges,Drugs,5.27,34,,5.27,percent of total billed charges,Drugs,5.27,34,,5.27,percent of total billed charges,Drugs,5.42,35,,5.42,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,5.42,35,,5.42,percent of total billed charges,Drugs,5.42,35,,5.42,percent of total billed charges,Drugs,5.42,35,,5.42,percent of total billed charges,Drugs,5.42,35,,5.42,percent of total billed charges,Drugs,5.42,35,,5.42,percent of total billed charges,Drugs,6.2,40,,6.2,percent of total billed charges,Drugs,10.84,70,,10.84,percent of total billed charges,All Other,5.58,36,,5.58,percent of total billed charges,Drugs,5.58,36,,5.58,percent of total billed charges,Drugs,5.42,35,,5.42,percent of total billed charges,Drugs,5.42,35,,5.42,percent of total billed charges,Drugs,5.42,35,,5.42,percent of total billed charges,Drugs,5.42,35,,5.42,percent of total billed charges,Drugs,5.16,,,5.16,Other,Drug Cost,5.16,,,5.16,Other,Drug Cost,5.16,,,5.16,Other,Drug Cost,5.16,,,5.16,Other,Drug Cost,5.16,,,5.16,Other,Drug Cost,5.16,,,5.16,Other,Drug Cost,11.62,,,11.62,Other,225% of Medicaid,7.23,,,7.23,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,6.53,,,6.53,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",11.1,,,11.1,Other,215% Medicaid APG methodology,11.1,,,11.1,Other,215% Medicaid APG methodology,6.46,,,6.46,Other,125% Medicaid APG methodology,0.01,11.62,
ENOXAPARIN (LOVENOX) 150MG INJ,J1650,HCPCS,,80000754,CDM,636,RC,955101510,NDC,both,10,ML,17.85,6.71,,,6.71,Other,150% of Medicare + 9.63% HCRA Surcharge,4.08,,,4.08,Fee Schedule,Average Sale Price (ASP) x 6,6.25,35,,6.25,percent of total billed charges,Drugs,6.25,35,,6.25,percent of total billed charges,Drugs,6.07,34,,6.07,percent of total billed charges,Drugs,6.07,34,,6.07,percent of total billed charges,Drugs,6.07,34,,6.07,percent of total billed charges,Drugs,6.07,34,,6.07,percent of total billed charges,Drugs,6.25,35,,6.25,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,6.25,35,,6.25,percent of total billed charges,Drugs,6.25,35,,6.25,percent of total billed charges,Drugs,6.25,35,,6.25,percent of total billed charges,Drugs,6.25,35,,6.25,percent of total billed charges,Drugs,6.25,35,,6.25,percent of total billed charges,Drugs,7.14,40,,7.14,percent of total billed charges,Drugs,12.5,70,,12.5,percent of total billed charges,All Other,6.43,36,,6.43,percent of total billed charges,Drugs,6.43,36,,6.43,percent of total billed charges,Drugs,6.25,35,,6.25,percent of total billed charges,Drugs,6.25,35,,6.25,percent of total billed charges,Drugs,6.25,35,,6.25,percent of total billed charges,Drugs,6.25,35,,6.25,percent of total billed charges,Drugs,5.95,,,5.95,Other,Drug Cost,5.95,,,5.95,Other,Drug Cost,5.95,,,5.95,Other,Drug Cost,5.95,,,5.95,Other,Drug Cost,5.95,,,5.95,Other,Drug Cost,5.95,,,5.95,Other,Drug Cost,13.39,,,13.39,Other,225% of Medicaid,8.33,,,8.33,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,6.53,,,6.53,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",12.79,,,12.79,Other,215% Medicaid APG methodology,12.79,,,12.79,Other,215% Medicaid APG methodology,7.44,,,7.44,Other,125% Medicaid APG methodology,0.01,13.39,
ENOXAPARIN (LOVENOX) 30MG INJ,J1650,HCPCS,,80000755,CDM,636,RC,955100310,NDC,both,10,ML,4.61,6.71,,,6.71,Other,150% of Medicare + 9.63% HCRA Surcharge,4.08,,,4.08,Fee Schedule,Average Sale Price (ASP) x 6,1.61,35,,1.61,percent of total billed charges,Drugs,1.61,35,,1.61,percent of total billed charges,Drugs,1.57,34,,1.57,percent of total billed charges,Drugs,1.57,34,,1.57,percent of total billed charges,Drugs,1.57,34,,1.57,percent of total billed charges,Drugs,1.57,34,,1.57,percent of total billed charges,Drugs,1.61,35,,1.61,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,1.61,35,,1.61,percent of total billed charges,Drugs,1.61,35,,1.61,percent of total billed charges,Drugs,1.61,35,,1.61,percent of total billed charges,Drugs,1.61,35,,1.61,percent of total billed charges,Drugs,1.61,35,,1.61,percent of total billed charges,Drugs,1.85,40,,1.85,percent of total billed charges,Drugs,3.23,70,,3.23,percent of total billed charges,All Other,1.66,36,,1.66,percent of total billed charges,Drugs,1.66,36,,1.66,percent of total billed charges,Drugs,1.61,35,,1.61,percent of total billed charges,Drugs,1.61,35,,1.61,percent of total billed charges,Drugs,1.61,35,,1.61,percent of total billed charges,Drugs,1.61,35,,1.61,percent of total billed charges,Drugs,1.54,,,1.54,Other,Drug Cost,1.54,,,1.54,Other,Drug Cost,1.54,,,1.54,Other,Drug Cost,1.54,,,1.54,Other,Drug Cost,1.54,,,1.54,Other,Drug Cost,1.54,,,1.54,Other,Drug Cost,3.46,,,3.46,Other,225% of Medicaid,2.15,,,2.15,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,6.53,,,6.53,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",3.31,,,3.31,Other,215% Medicaid APG methodology,3.31,,,3.31,Other,215% Medicaid APG methodology,1.92,,,1.92,Other,125% Medicaid APG methodology,0.01,6.71,
ENOXAPARIN (LOVENOX) 40MG INJ,J1650,HCPCS,,80000756,CDM,636,RC,955100410,NDC,both,10,ML,5.41,6.71,,,6.71,Other,150% of Medicare + 9.63% HCRA Surcharge,4.08,,,4.08,Fee Schedule,Average Sale Price (ASP) x 6,1.89,35,,1.89,percent of total billed charges,Drugs,1.89,35,,1.89,percent of total billed charges,Drugs,1.84,34,,1.84,percent of total billed charges,Drugs,1.84,34,,1.84,percent of total billed charges,Drugs,1.84,34,,1.84,percent of total billed charges,Drugs,1.84,34,,1.84,percent of total billed charges,Drugs,1.89,35,,1.89,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,1.89,35,,1.89,percent of total billed charges,Drugs,1.89,35,,1.89,percent of total billed charges,Drugs,1.89,35,,1.89,percent of total billed charges,Drugs,1.89,35,,1.89,percent of total billed charges,Drugs,1.89,35,,1.89,percent of total billed charges,Drugs,2.16,40,,2.16,percent of total billed charges,Drugs,3.79,70,,3.79,percent of total billed charges,All Other,1.95,36,,1.95,percent of total billed charges,Drugs,1.95,36,,1.95,percent of total billed charges,Drugs,1.89,35,,1.89,percent of total billed charges,Drugs,1.89,35,,1.89,percent of total billed charges,Drugs,1.89,35,,1.89,percent of total billed charges,Drugs,1.89,35,,1.89,percent of total billed charges,Drugs,1.8,,,1.8,Other,Drug Cost,1.8,,,1.8,Other,Drug Cost,1.8,,,1.8,Other,Drug Cost,1.8,,,1.8,Other,Drug Cost,1.8,,,1.8,Other,Drug Cost,1.8,,,1.8,Other,Drug Cost,4.06,,,4.06,Other,225% of Medicaid,2.53,,,2.53,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,6.53,,,6.53,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",3.88,,,3.88,Other,215% Medicaid APG methodology,3.88,,,3.88,Other,215% Medicaid APG methodology,2.26,,,2.26,Other,125% Medicaid APG methodology,0.01,6.71,
ENOXAPARIN (LOVENOX) 60MG INJ,J1650,HCPCS,,80000757,CDM,636,RC,955100610,NDC,both,10,ML,8.42,6.71,,,6.71,Other,150% of Medicare + 9.63% HCRA Surcharge,4.08,,,4.08,Fee Schedule,Average Sale Price (ASP) x 6,2.95,35,,2.95,percent of total billed charges,Drugs,2.95,35,,2.95,percent of total billed charges,Drugs,2.86,34,,2.86,percent of total billed charges,Drugs,2.86,34,,2.86,percent of total billed charges,Drugs,2.86,34,,2.86,percent of total billed charges,Drugs,2.86,34,,2.86,percent of total billed charges,Drugs,2.95,35,,2.95,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,2.95,35,,2.95,percent of total billed charges,Drugs,2.95,35,,2.95,percent of total billed charges,Drugs,2.95,35,,2.95,percent of total billed charges,Drugs,2.95,35,,2.95,percent of total billed charges,Drugs,2.95,35,,2.95,percent of total billed charges,Drugs,3.37,40,,3.37,percent of total billed charges,Drugs,5.9,70,,5.9,percent of total billed charges,All Other,3.03,36,,3.03,percent of total billed charges,Drugs,3.03,36,,3.03,percent of total billed charges,Drugs,2.95,35,,2.95,percent of total billed charges,Drugs,2.95,35,,2.95,percent of total billed charges,Drugs,2.95,35,,2.95,percent of total billed charges,Drugs,2.95,35,,2.95,percent of total billed charges,Drugs,2.81,,,2.81,Other,Drug Cost,2.81,,,2.81,Other,Drug Cost,2.81,,,2.81,Other,Drug Cost,2.81,,,2.81,Other,Drug Cost,2.81,,,2.81,Other,Drug Cost,2.81,,,2.81,Other,Drug Cost,6.32,,,6.32,Other,225% of Medicaid,3.93,,,3.93,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,6.53,,,6.53,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",6.04,,,6.04,Other,215% Medicaid APG methodology,6.04,,,6.04,Other,215% Medicaid APG methodology,3.51,,,3.51,Other,125% Medicaid APG methodology,0.01,6.71,
ENOXAPARIN (LOVENOX) 80MG INJ,J1650,HCPCS,,80000758,CDM,636,RC,75062280,NDC,both,10,ML,10.33,6.71,,,6.71,Other,150% of Medicare + 9.63% HCRA Surcharge,4.08,,,4.08,Fee Schedule,Average Sale Price (ASP) x 6,3.61,35,,3.61,percent of total billed charges,Drugs,3.61,35,,3.61,percent of total billed charges,Drugs,3.51,34,,3.51,percent of total billed charges,Drugs,3.51,34,,3.51,percent of total billed charges,Drugs,3.51,34,,3.51,percent of total billed charges,Drugs,3.51,34,,3.51,percent of total billed charges,Drugs,3.61,35,,3.61,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,3.61,35,,3.61,percent of total billed charges,Drugs,3.61,35,,3.61,percent of total billed charges,Drugs,3.61,35,,3.61,percent of total billed charges,Drugs,3.61,35,,3.61,percent of total billed charges,Drugs,3.61,35,,3.61,percent of total billed charges,Drugs,4.13,40,,4.13,percent of total billed charges,Drugs,7.23,70,,7.23,percent of total billed charges,All Other,3.72,36,,3.72,percent of total billed charges,Drugs,3.72,36,,3.72,percent of total billed charges,Drugs,3.61,35,,3.61,percent of total billed charges,Drugs,3.61,35,,3.61,percent of total billed charges,Drugs,3.61,35,,3.61,percent of total billed charges,Drugs,3.61,35,,3.61,percent of total billed charges,Drugs,3.44,,,3.44,Other,Drug Cost,3.44,,,3.44,Other,Drug Cost,3.44,,,3.44,Other,Drug Cost,3.44,,,3.44,Other,Drug Cost,3.44,,,3.44,Other,Drug Cost,3.44,,,3.44,Other,Drug Cost,7.74,,,7.74,Other,225% of Medicaid,4.82,,,4.82,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,6.53,,,6.53,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",7.4,,,7.4,Other,215% Medicaid APG methodology,7.4,,,7.4,Other,215% Medicaid APG methodology,4.3,,,4.3,Other,125% Medicaid APG methodology,0.01,7.74,
EPINEPHRINE (EPIPEN) 1:1000 INJ,J0171,HCPCS,,80000761,CDM,636,RC,49502050002,NDC,both,2,EA,0.06,7.38,,,7.38,Other,150% of Medicare + 9.63% HCRA Surcharge,4.49,,,4.49,Fee Schedule,Average Sale Price (ASP) x 6,0.02,35,,0.02,percent of total billed charges,Drugs,0.02,35,,0.02,percent of total billed charges,Drugs,0.02,34,,0.02,percent of total billed charges,Drugs,0.02,34,,0.02,percent of total billed charges,Drugs,0.02,34,,0.02,percent of total billed charges,Drugs,0.02,34,,0.02,percent of total billed charges,Drugs,0.02,35,,0.02,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,0.02,35,,0.02,percent of total billed charges,Drugs,0.02,35,,0.02,percent of total billed charges,Drugs,0.02,35,,0.02,percent of total billed charges,Drugs,0.02,35,,0.02,percent of total billed charges,Drugs,0.02,35,,0.02,percent of total billed charges,Drugs,0.02,40,,0.02,percent of total billed charges,Drugs,0.04,70,,0.04,percent of total billed charges,All Other,0.02,36,,0.02,percent of total billed charges,Drugs,0.02,36,,0.02,percent of total billed charges,Drugs,0.02,35,,0.02,percent of total billed charges,Drugs,0.02,35,,0.02,percent of total billed charges,Drugs,0.02,35,,0.02,percent of total billed charges,Drugs,0.02,35,,0.02,percent of total billed charges,Drugs,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.05,,,0.05,Other,225% of Medicaid,0.03,,,0.03,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,7.18,,,7.18,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",0.04,,,0.04,Other,215% Medicaid APG methodology,0.04,,,0.04,Other,215% Medicaid APG methodology,0.03,,,0.03,Other,125% Medicaid APG methodology,0.01,7.38,
EPOETIN ALFA NON-ESRD 10000 UNITS,J0885,HCPCS,,80000764,CDM,636,RC,59676031002,NDC,both,25,ML,422.11,87.68,,,87.68,Other,150% of Medicare + 9.63% HCRA Surcharge,53.32,,,53.32,Fee Schedule,Average Sale Price (ASP) x 6,147.74,35,,147.74,percent of total billed charges,Drugs,147.74,35,,147.74,percent of total billed charges,Drugs,143.52,34,,143.52,percent of total billed charges,Drugs,143.52,34,,143.52,percent of total billed charges,Drugs,143.52,34,,143.52,percent of total billed charges,Drugs,143.52,34,,143.52,percent of total billed charges,Drugs,147.74,35,,147.74,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,147.74,35,,147.74,percent of total billed charges,Drugs,147.74,35,,147.74,percent of total billed charges,Drugs,147.74,35,,147.74,percent of total billed charges,Drugs,147.74,35,,147.74,percent of total billed charges,Drugs,147.74,35,,147.74,percent of total billed charges,Drugs,168.84,40,,168.84,percent of total billed charges,Drugs,295.47,70,,295.47,percent of total billed charges,All Other,151.96,36,,151.96,percent of total billed charges,Drugs,151.96,36,,151.96,percent of total billed charges,Drugs,147.74,35,,147.74,percent of total billed charges,Drugs,147.74,35,,147.74,percent of total billed charges,Drugs,147.74,35,,147.74,percent of total billed charges,Drugs,147.74,35,,147.74,percent of total billed charges,Drugs,140.7,,,140.7,Other,Drug Cost,140.7,,,140.7,Other,Drug Cost,140.7,,,140.7,Other,Drug Cost,140.7,,,140.7,Other,Drug Cost,140.7,,,140.7,Other,Drug Cost,140.7,,,140.7,Other,Drug Cost,316.58,,,316.58,Other,225% of Medicaid,196.98,,,196.98,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,85.31,,,85.31,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",302.51,,,302.51,Other,215% Medicaid APG methodology,302.51,,,302.51,Other,215% Medicaid APG methodology,175.88,,,175.88,Other,125% Medicaid APG methodology,0.01,316.58,
EPOETIN ALFA NON-ESRD 2000 UNITS,J0885,HCPCS,,80000765,CDM,636,RC,55513012610,NDC,both,10,ML,95,87.68,,,87.68,Other,150% of Medicare + 9.63% HCRA Surcharge,53.32,,,53.32,Fee Schedule,Average Sale Price (ASP) x 6,33.25,35,,33.25,percent of total billed charges,Drugs,33.25,35,,33.25,percent of total billed charges,Drugs,32.3,34,,32.3,percent of total billed charges,Drugs,32.3,34,,32.3,percent of total billed charges,Drugs,32.3,34,,32.3,percent of total billed charges,Drugs,32.3,34,,32.3,percent of total billed charges,Drugs,33.25,35,,33.25,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,33.25,35,,33.25,percent of total billed charges,Drugs,33.25,35,,33.25,percent of total billed charges,Drugs,33.25,35,,33.25,percent of total billed charges,Drugs,33.25,35,,33.25,percent of total billed charges,Drugs,33.25,35,,33.25,percent of total billed charges,Drugs,38,40,,38,percent of total billed charges,Drugs,66.5,70,,66.5,percent of total billed charges,All Other,34.2,36,,34.2,percent of total billed charges,Drugs,34.2,36,,34.2,percent of total billed charges,Drugs,33.25,35,,33.25,percent of total billed charges,Drugs,33.25,35,,33.25,percent of total billed charges,Drugs,33.25,35,,33.25,percent of total billed charges,Drugs,33.25,35,,33.25,percent of total billed charges,Drugs,31.67,,,31.67,Other,Drug Cost,31.67,,,31.67,Other,Drug Cost,31.67,,,31.67,Other,Drug Cost,31.67,,,31.67,Other,Drug Cost,31.67,,,31.67,Other,Drug Cost,31.67,,,31.67,Other,Drug Cost,71.25,,,71.25,Other,225% of Medicaid,44.34,,,44.34,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,85.31,,,85.31,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",68.09,,,68.09,Other,215% Medicaid APG methodology,68.09,,,68.09,Other,215% Medicaid APG methodology,39.59,,,39.59,Other,125% Medicaid APG methodology,0.01,87.68,
EPOETIN ALFA NON-ESRD 20000 UNITS,J0885,HCPCS,,80000766,CDM,636,RC,59676032004,NDC,both,4,ML,844.25,87.68,,,87.68,Other,150% of Medicare + 9.63% HCRA Surcharge,53.32,,,53.32,Fee Schedule,Average Sale Price (ASP) x 6,295.49,35,,295.49,percent of total billed charges,Drugs,295.49,35,,295.49,percent of total billed charges,Drugs,287.04,34,,287.04,percent of total billed charges,Drugs,287.04,34,,287.04,percent of total billed charges,Drugs,287.04,34,,287.04,percent of total billed charges,Drugs,287.04,34,,287.04,percent of total billed charges,Drugs,295.49,35,,295.49,percent of total billed charges,Drugs,287.04,34,"If Charge > 500, then 34 percent",287.04,percent of total billed charges,Drugs,295.49,35,,295.49,percent of total billed charges,Drugs,295.49,35,,295.49,percent of total billed charges,Drugs,295.49,35,,295.49,percent of total billed charges,Drugs,295.49,35,,295.49,percent of total billed charges,Drugs,295.49,35,,295.49,percent of total billed charges,Drugs,337.7,40,,337.7,percent of total billed charges,Drugs,590.97,70,,590.97,percent of total billed charges,All Other,303.93,36,,303.93,percent of total billed charges,Drugs,303.93,36,,303.93,percent of total billed charges,Drugs,295.49,35,,295.49,percent of total billed charges,Drugs,295.49,35,,295.49,percent of total billed charges,Drugs,295.49,35,,295.49,percent of total billed charges,Drugs,295.49,35,,295.49,percent of total billed charges,Drugs,281.42,,,281.42,Other,Drug Cost,281.42,,,281.42,Other,Drug Cost,281.42,,,281.42,Other,Drug Cost,281.42,,,281.42,Other,Drug Cost,281.42,,,281.42,Other,Drug Cost,281.42,,,281.42,Other,Drug Cost,633.18,,,633.18,Other,225% of Medicaid,393.98,,,393.98,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,85.31,,,85.31,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",605.04,,,605.04,Other,215% Medicaid APG methodology,605.04,,,605.04,Other,215% Medicaid APG methodology,351.77,,,351.77,Other,125% Medicaid APG methodology,0.01,633.18,
EPOETIN ALFA NON-ESRD 4000 UNITS,J0885,HCPCS,,80000767,CDM,636,RC,55513014810,NDC,both,10,ML,190.01,87.68,,,87.68,Other,150% of Medicare + 9.63% HCRA Surcharge,53.32,,,53.32,Fee Schedule,Average Sale Price (ASP) x 6,66.5,35,,66.5,percent of total billed charges,Drugs,66.5,35,,66.5,percent of total billed charges,Drugs,64.6,34,,64.6,percent of total billed charges,Drugs,64.6,34,,64.6,percent of total billed charges,Drugs,64.6,34,,64.6,percent of total billed charges,Drugs,64.6,34,,64.6,percent of total billed charges,Drugs,66.5,35,,66.5,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,66.5,35,,66.5,percent of total billed charges,Drugs,66.5,35,,66.5,percent of total billed charges,Drugs,66.5,35,,66.5,percent of total billed charges,Drugs,66.5,35,,66.5,percent of total billed charges,Drugs,66.5,35,,66.5,percent of total billed charges,Drugs,76,40,,76,percent of total billed charges,Drugs,133.01,70,,133.01,percent of total billed charges,All Other,68.4,36,,68.4,percent of total billed charges,Drugs,68.4,36,,68.4,percent of total billed charges,Drugs,66.5,35,,66.5,percent of total billed charges,Drugs,66.5,35,,66.5,percent of total billed charges,Drugs,66.5,35,,66.5,percent of total billed charges,Drugs,66.5,35,,66.5,percent of total billed charges,Drugs,63.34,,,63.34,Other,Drug Cost,63.34,,,63.34,Other,Drug Cost,63.34,,,63.34,Other,Drug Cost,63.34,,,63.34,Other,Drug Cost,63.34,,,63.34,Other,Drug Cost,63.34,,,63.34,Other,Drug Cost,142.51,,,142.51,Other,225% of Medicaid,88.67,,,88.67,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,85.31,,,85.31,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",136.17,,,136.17,Other,215% Medicaid APG methodology,136.17,,,136.17,Other,215% Medicaid APG methodology,79.17,,,79.17,Other,125% Medicaid APG methodology,0.01,142.51,
EPOETIN ALFA NON-ESRD 40000 UNITS,J0885,HCPCS,,80000768,CDM,636,RC,59676034001,NDC,both,4,ML,1688.48,87.68,,,87.68,Other,150% of Medicare + 9.63% HCRA Surcharge,53.32,,,53.32,Fee Schedule,Average Sale Price (ASP) x 6,590.97,35,,590.97,percent of total billed charges,Drugs,590.97,35,,590.97,percent of total billed charges,Drugs,574.08,34,,574.08,percent of total billed charges,Drugs,574.08,34,,574.08,percent of total billed charges,Drugs,574.08,34,,574.08,percent of total billed charges,Drugs,574.08,34,,574.08,percent of total billed charges,Drugs,590.97,35,,590.97,percent of total billed charges,Drugs,574.08,34,"If Charge > 500, then 34 percent",574.08,percent of total billed charges,Drugs,590.97,35,,590.97,percent of total billed charges,Drugs,590.97,35,,590.97,percent of total billed charges,Drugs,590.97,35,,590.97,percent of total billed charges,Drugs,590.97,35,,590.97,percent of total billed charges,Drugs,590.97,35,,590.97,percent of total billed charges,Drugs,675.39,40,,675.39,percent of total billed charges,Drugs,1181.94,70,,1181.94,percent of total billed charges,All Other,607.85,36,,607.85,percent of total billed charges,Drugs,607.85,36,,607.85,percent of total billed charges,Drugs,590.97,35,,590.97,percent of total billed charges,Drugs,590.97,35,,590.97,percent of total billed charges,Drugs,590.97,35,,590.97,percent of total billed charges,Drugs,590.97,35,,590.97,percent of total billed charges,Drugs,562.83,,,562.83,Other,Drug Cost,562.83,,,562.83,Other,Drug Cost,562.83,,,562.83,Other,Drug Cost,562.83,,,562.83,Other,Drug Cost,562.83,,,562.83,Other,Drug Cost,562.83,,,562.83,Other,Drug Cost,1266.36,,,1266.36,Other,225% of Medicaid,787.96,,,787.96,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,85.31,,,85.31,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",1210.08,,,1210.08,Other,215% Medicaid APG methodology,1210.08,,,1210.08,Other,215% Medicaid APG methodology,703.53,,,703.53,Other,125% Medicaid APG methodology,0.01,1266.36,
EPTIFIBATIDE 0.75MG/ML INJ 100ML,J1327,HCPCS,,80000770,CDM,636,RC,70436002780,NDC,both,1,ML,26.91,10.62,39.4668,,10.62,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,9.42,35,,9.42,percent of total billed charges,Drugs,9.42,35,,9.42,percent of total billed charges,Drugs,9.15,34,,9.15,percent of total billed charges,Drugs,9.15,34,,9.15,percent of total billed charges,Drugs,9.15,34,,9.15,percent of total billed charges,Drugs,9.15,34,,9.15,percent of total billed charges,Drugs,9.42,35,,9.42,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,9.42,35,,9.42,percent of total billed charges,Drugs,9.42,35,,9.42,percent of total billed charges,Drugs,9.42,35,,9.42,percent of total billed charges,Drugs,9.42,35,,9.42,percent of total billed charges,Drugs,9.42,35,,9.42,percent of total billed charges,Drugs,10.76,40,,10.76,percent of total billed charges,Drugs,18.84,70,,18.84,percent of total billed charges,All Other,9.69,36,,9.69,percent of total billed charges,Drugs,9.69,36,,9.69,percent of total billed charges,Drugs,9.42,35,,9.42,percent of total billed charges,Drugs,9.42,35,,9.42,percent of total billed charges,Drugs,9.42,35,,9.42,percent of total billed charges,Drugs,9.42,35,,9.42,percent of total billed charges,Drugs,8.97,,,8.97,Other,Drug Cost,8.97,,,8.97,Other,Drug Cost,8.97,,,8.97,Other,Drug Cost,8.97,,,8.97,Other,Drug Cost,8.97,,,8.97,Other,Drug Cost,8.97,,,8.97,Other,Drug Cost,20.18,,,20.18,Other,225% of Medicaid,12.56,,,12.56,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",19.29,,,19.29,Other,215% Medicaid APG methodology,19.29,,,19.29,Other,215% Medicaid APG methodology,11.21,,,11.21,Other,125% Medicaid APG methodology,0.01,20.18,
EPTIFIBATIDE 2MG/ML INJ 10ML,J1327,HCPCS,,80000772,CDM,636,RC,67457062910,NDC,both,1,ML,41.7,16.46,39.4668,,16.46,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,14.6,35,,14.6,percent of total billed charges,Drugs,14.6,35,,14.6,percent of total billed charges,Drugs,14.18,34,,14.18,percent of total billed charges,Drugs,14.18,34,,14.18,percent of total billed charges,Drugs,14.18,34,,14.18,percent of total billed charges,Drugs,14.18,34,,14.18,percent of total billed charges,Drugs,14.6,35,,14.6,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,14.6,35,,14.6,percent of total billed charges,Drugs,14.6,35,,14.6,percent of total billed charges,Drugs,14.6,35,,14.6,percent of total billed charges,Drugs,14.6,35,,14.6,percent of total billed charges,Drugs,14.6,35,,14.6,percent of total billed charges,Drugs,16.68,40,,16.68,percent of total billed charges,Drugs,29.19,70,,29.19,percent of total billed charges,All Other,15.01,36,,15.01,percent of total billed charges,Drugs,15.01,36,,15.01,percent of total billed charges,Drugs,14.6,35,,14.6,percent of total billed charges,Drugs,14.6,35,,14.6,percent of total billed charges,Drugs,14.6,35,,14.6,percent of total billed charges,Drugs,14.6,35,,14.6,percent of total billed charges,Drugs,13.9,,,13.9,Other,Drug Cost,13.9,,,13.9,Other,Drug Cost,13.9,,,13.9,Other,Drug Cost,13.9,,,13.9,Other,Drug Cost,13.9,,,13.9,Other,Drug Cost,13.9,,,13.9,Other,Drug Cost,31.28,,,31.28,Other,225% of Medicaid,19.46,,,19.46,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",29.89,,,29.89,Other,215% Medicaid APG methodology,29.89,,,29.89,Other,215% Medicaid APG methodology,17.38,,,17.38,Other,125% Medicaid APG methodology,0.01,31.28,
ERIBULIN MESYLATE 1MG/2ML INJECTION,J9179,HCPCS,,80000776,CDM,636,RC,62856038901,NDC,both,1,ML,2589.69,1322.31,,,1322.31,Other,150% of Medicare + 9.63% HCRA Surcharge,804.1,,,804.1,Fee Schedule,Average Sale Price (ASP) x 6,906.39,35,,906.39,percent of total billed charges,Drugs,906.39,35,,906.39,percent of total billed charges,Drugs,880.49,34,,880.49,percent of total billed charges,Drugs,880.49,34,,880.49,percent of total billed charges,Drugs,880.49,34,,880.49,percent of total billed charges,Drugs,880.49,34,,880.49,percent of total billed charges,Drugs,906.39,35,,906.39,percent of total billed charges,Drugs,880.49,34,"If Charge > 500, then 34 percent",880.49,percent of total billed charges,Drugs,906.39,35,,906.39,percent of total billed charges,Drugs,906.39,35,,906.39,percent of total billed charges,Drugs,906.39,35,,906.39,percent of total billed charges,Drugs,906.39,35,,906.39,percent of total billed charges,Drugs,906.39,35,,906.39,percent of total billed charges,Drugs,1035.88,40,,1035.88,percent of total billed charges,Drugs,1812.78,70,,1812.78,percent of total billed charges,All Other,932.29,36,,932.29,percent of total billed charges,Drugs,932.29,36,,932.29,percent of total billed charges,Drugs,906.39,35,,906.39,percent of total billed charges,Drugs,906.39,35,,906.39,percent of total billed charges,Drugs,906.39,35,,906.39,percent of total billed charges,Drugs,906.39,35,,906.39,percent of total billed charges,Drugs,863.23,,,863.23,Other,Drug Cost,863.23,,,863.23,Other,Drug Cost,863.23,,,863.23,Other,Drug Cost,863.23,,,863.23,Other,Drug Cost,863.23,,,863.23,Other,Drug Cost,863.23,,,863.23,Other,Drug Cost,1942.27,,,1942.27,Other,225% of Medicaid,1208.52,,,1208.52,Other,140% of Medicaid,880.49,34,"If Charge > 2,000, then 34 percent",880.49,percent of total billed charges,Drugs,1286.56,,,1286.56,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",1855.94,,,1855.94,Other,215% Medicaid APG methodology,1855.94,,,1855.94,Other,215% Medicaid APG methodology,1079.04,,,1079.04,Other,125% Medicaid APG methodology,0.01,1942.27,
ERTAPENEM SODIUM 1GM INJ,J1335,HCPCS,,80000778,CDM,636,RC,55150028220,NDC,both,10,EA,48.77,127.92,,,127.92,Other,150% of Medicare + 9.63% HCRA Surcharge,77.79,,,77.79,Fee Schedule,Average Sale Price (ASP) x 6,17.07,35,,17.07,percent of total billed charges,Drugs,17.07,35,,17.07,percent of total billed charges,Drugs,16.58,34,,16.58,percent of total billed charges,Drugs,16.58,34,,16.58,percent of total billed charges,Drugs,16.58,34,,16.58,percent of total billed charges,Drugs,16.58,34,,16.58,percent of total billed charges,Drugs,17.07,35,,17.07,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,17.07,35,,17.07,percent of total billed charges,Drugs,17.07,35,,17.07,percent of total billed charges,Drugs,17.07,35,,17.07,percent of total billed charges,Drugs,17.07,35,,17.07,percent of total billed charges,Drugs,17.07,35,,17.07,percent of total billed charges,Drugs,19.51,40,,19.51,percent of total billed charges,Drugs,34.14,70,,34.14,percent of total billed charges,All Other,17.56,36,,17.56,percent of total billed charges,Drugs,17.56,36,,17.56,percent of total billed charges,Drugs,17.07,35,,17.07,percent of total billed charges,Drugs,17.07,35,,17.07,percent of total billed charges,Drugs,17.07,35,,17.07,percent of total billed charges,Drugs,17.07,35,,17.07,percent of total billed charges,Drugs,16.26,,,16.26,Other,Drug Cost,16.26,,,16.26,Other,Drug Cost,16.26,,,16.26,Other,Drug Cost,16.26,,,16.26,Other,Drug Cost,16.26,,,16.26,Other,Drug Cost,16.26,,,16.26,Other,Drug Cost,36.58,,,36.58,Other,225% of Medicaid,22.76,,,22.76,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,124.46,,,124.46,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",34.95,,,34.95,Other,215% Medicaid APG methodology,34.95,,,34.95,Other,215% Medicaid APG methodology,20.32,,,20.32,Other,125% Medicaid APG methodology,0.01,127.92,
ERTAPENEM SODIUM 500 MG INJ,J1335,HCPCS,,80000779,CDM,636,RC,42023022110,NDC,both,10,EA,48.8,127.92,,,127.92,Other,150% of Medicare + 9.63% HCRA Surcharge,77.79,,,77.79,Fee Schedule,Average Sale Price (ASP) x 6,17.08,35,,17.08,percent of total billed charges,Drugs,17.08,35,,17.08,percent of total billed charges,Drugs,16.59,34,,16.59,percent of total billed charges,Drugs,16.59,34,,16.59,percent of total billed charges,Drugs,16.59,34,,16.59,percent of total billed charges,Drugs,16.59,34,,16.59,percent of total billed charges,Drugs,17.08,35,,17.08,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,17.08,35,,17.08,percent of total billed charges,Drugs,17.08,35,,17.08,percent of total billed charges,Drugs,17.08,35,,17.08,percent of total billed charges,Drugs,17.08,35,,17.08,percent of total billed charges,Drugs,17.08,35,,17.08,percent of total billed charges,Drugs,19.52,40,,19.52,percent of total billed charges,Drugs,34.16,70,,34.16,percent of total billed charges,All Other,17.57,36,,17.57,percent of total billed charges,Drugs,17.57,36,,17.57,percent of total billed charges,Drugs,17.08,35,,17.08,percent of total billed charges,Drugs,17.08,35,,17.08,percent of total billed charges,Drugs,17.08,35,,17.08,percent of total billed charges,Drugs,17.08,35,,17.08,percent of total billed charges,Drugs,16.27,,,16.27,Other,Drug Cost,16.27,,,16.27,Other,Drug Cost,16.27,,,16.27,Other,Drug Cost,16.27,,,16.27,Other,Drug Cost,16.27,,,16.27,Other,Drug Cost,16.27,,,16.27,Other,Drug Cost,36.6,,,36.6,Other,225% of Medicaid,22.78,,,22.78,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,124.46,,,124.46,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",34.98,,,34.98,Other,215% Medicaid APG methodology,34.98,,,34.98,Other,215% Medicaid APG methodology,20.34,,,20.34,Other,125% Medicaid APG methodology,0.01,127.92,
ERYTHROCIN 500 MG INJ,J1364,HCPCS,,80000780,CDM,636,RC,409648201,NDC,both,10,EA,0.03,796.98,,,796.98,Other,150% of Medicare + 9.63% HCRA Surcharge,484.65,,,484.65,Fee Schedule,Average Sale Price (ASP) x 6,0.01,35,,0.01,percent of total billed charges,Drugs,0.01,35,,0.01,percent of total billed charges,Drugs,0.01,34,,0.01,percent of total billed charges,Drugs,0.01,34,,0.01,percent of total billed charges,Drugs,0.01,34,,0.01,percent of total billed charges,Drugs,0.01,34,,0.01,percent of total billed charges,Drugs,0.01,35,,0.01,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,0.01,35,,0.01,percent of total billed charges,Drugs,0.01,35,,0.01,percent of total billed charges,Drugs,0.01,35,,0.01,percent of total billed charges,Drugs,0.01,35,,0.01,percent of total billed charges,Drugs,0.01,35,,0.01,percent of total billed charges,Drugs,0.01,40,,0.01,percent of total billed charges,Drugs,0.02,70,,0.02,percent of total billed charges,All Other,0.01,36,,0.01,percent of total billed charges,Drugs,0.01,36,,0.01,percent of total billed charges,Drugs,0.01,35,,0.01,percent of total billed charges,Drugs,0.01,35,,0.01,percent of total billed charges,Drugs,0.01,35,,0.01,percent of total billed charges,Drugs,0.01,35,,0.01,percent of total billed charges,Drugs,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.02,,,0.02,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,775.44,,,775.44,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,796.98,
ESTRADIOL VALERATE 20 MG/ML 5ML  INJ,J1380,HCPCS,,80000790,CDM,636,RC,42023011101,NDC,both,1,ML,76.53,91.13,,,91.13,Other,150% of Medicare + 9.63% HCRA Surcharge,55.42,,,55.42,Fee Schedule,Average Sale Price (ASP) x 6,26.79,35,,26.79,percent of total billed charges,Drugs,26.79,35,,26.79,percent of total billed charges,Drugs,26.02,34,,26.02,percent of total billed charges,Drugs,26.02,34,,26.02,percent of total billed charges,Drugs,26.02,34,,26.02,percent of total billed charges,Drugs,26.02,34,,26.02,percent of total billed charges,Drugs,26.79,35,,26.79,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,26.79,35,,26.79,percent of total billed charges,Drugs,26.79,35,,26.79,percent of total billed charges,Drugs,26.79,35,,26.79,percent of total billed charges,Drugs,26.79,35,,26.79,percent of total billed charges,Drugs,26.79,35,,26.79,percent of total billed charges,Drugs,30.61,40,,30.61,percent of total billed charges,Drugs,53.57,70,,53.57,percent of total billed charges,All Other,27.55,36,,27.55,percent of total billed charges,Drugs,27.55,36,,27.55,percent of total billed charges,Drugs,26.79,35,,26.79,percent of total billed charges,Drugs,26.79,35,,26.79,percent of total billed charges,Drugs,26.79,35,,26.79,percent of total billed charges,Drugs,26.79,35,,26.79,percent of total billed charges,Drugs,25.51,,,25.51,Other,Drug Cost,25.51,,,25.51,Other,Drug Cost,25.51,,,25.51,Other,Drug Cost,25.51,,,25.51,Other,Drug Cost,25.51,,,25.51,Other,Drug Cost,25.51,,,25.51,Other,Drug Cost,57.4,,,57.4,Other,225% of Medicaid,35.71,,,35.71,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,88.67,,,88.67,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",54.85,,,54.85,Other,215% Medicaid APG methodology,54.85,,,54.85,Other,215% Medicaid APG methodology,31.89,,,31.89,Other,125% Medicaid APG methodology,0.01,91.13,
ESTROGEN (PREMARIN) 25MG INJ,J1410,HCPCS,,80000791,CDM,636,RC,46074905,NDC,both,1,EA,0.03,3671.85,,,3671.85,Other,150% of Medicare + 9.63% HCRA Surcharge,2232.88,,,2232.88,Fee Schedule,Average Sale Price (ASP) x 6,0.01,35,,0.01,percent of total billed charges,Drugs,0.01,35,,0.01,percent of total billed charges,Drugs,0.01,34,,0.01,percent of total billed charges,Drugs,0.01,34,,0.01,percent of total billed charges,Drugs,0.01,34,,0.01,percent of total billed charges,Drugs,0.01,34,,0.01,percent of total billed charges,Drugs,0.01,35,,0.01,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,0.01,35,,0.01,percent of total billed charges,Drugs,0.01,35,,0.01,percent of total billed charges,Drugs,0.01,35,,0.01,percent of total billed charges,Drugs,0.01,35,,0.01,percent of total billed charges,Drugs,0.01,35,,0.01,percent of total billed charges,Drugs,0.01,40,,0.01,percent of total billed charges,Drugs,0.02,70,,0.02,percent of total billed charges,All Other,0.01,36,,0.01,percent of total billed charges,Drugs,0.01,36,,0.01,percent of total billed charges,Drugs,0.01,35,,0.01,percent of total billed charges,Drugs,0.01,35,,0.01,percent of total billed charges,Drugs,0.01,35,,0.01,percent of total billed charges,Drugs,0.01,35,,0.01,percent of total billed charges,Drugs,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.02,,,0.02,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,3572.6,,,3572.6,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,3671.85,
ETOPOSIDE 20MG/ML 5ML INJECTION,J9181,HCPCS,,80000802,CDM,636,RC,16729011431,NDC,both,1,ML,12.24,9.8,,,9.8,Other,150% of Medicare + 9.63% HCRA Surcharge,5.96,,,5.96,Fee Schedule,Average Sale Price (ASP) x 6,4.28,35,,4.28,percent of total billed charges,Drugs,4.28,35,,4.28,percent of total billed charges,Drugs,4.16,34,,4.16,percent of total billed charges,Drugs,4.16,34,,4.16,percent of total billed charges,Drugs,4.16,34,,4.16,percent of total billed charges,Drugs,4.16,34,,4.16,percent of total billed charges,Drugs,4.28,35,,4.28,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,4.28,35,,4.28,percent of total billed charges,Drugs,4.28,35,,4.28,percent of total billed charges,Drugs,4.28,35,,4.28,percent of total billed charges,Drugs,4.28,35,,4.28,percent of total billed charges,Drugs,4.28,35,,4.28,percent of total billed charges,Drugs,4.9,40,,4.9,percent of total billed charges,Drugs,8.57,70,,8.57,percent of total billed charges,All Other,4.41,36,,4.41,percent of total billed charges,Drugs,4.41,36,,4.41,percent of total billed charges,Drugs,4.28,35,,4.28,percent of total billed charges,Drugs,4.28,35,,4.28,percent of total billed charges,Drugs,4.28,35,,4.28,percent of total billed charges,Drugs,4.28,35,,4.28,percent of total billed charges,Drugs,4.08,,,4.08,Other,Drug Cost,4.08,,,4.08,Other,Drug Cost,4.08,,,4.08,Other,Drug Cost,4.08,,,4.08,Other,Drug Cost,4.08,,,4.08,Other,Drug Cost,4.08,,,4.08,Other,Drug Cost,9.18,,,9.18,Other,225% of Medicaid,5.71,,,5.71,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,9.53,,,9.53,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",8.77,,,8.77,Other,215% Medicaid APG methodology,8.77,,,8.77,Other,215% Medicaid APG methodology,5.1,,,5.1,Other,125% Medicaid APG methodology,0.01,9.8,
FENTANYL CITRATE INJ 1000MCG/20ML,J3010,HCPCS,,80000835,CDM,636,RC,409909431,NDC,both,25,ML,10.07,9.55,,,9.55,Other,150% of Medicare + 9.63% HCRA Surcharge,5.81,,,5.81,Fee Schedule,Average Sale Price (ASP) x 6,3.52,35,,3.52,percent of total billed charges,Drugs,3.52,35,,3.52,percent of total billed charges,Drugs,3.42,34,,3.42,percent of total billed charges,Drugs,3.42,34,,3.42,percent of total billed charges,Drugs,3.42,34,,3.42,percent of total billed charges,Drugs,3.42,34,,3.42,percent of total billed charges,Drugs,3.52,35,,3.52,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,3.52,35,,3.52,percent of total billed charges,Drugs,3.52,35,,3.52,percent of total billed charges,Drugs,3.52,35,,3.52,percent of total billed charges,Drugs,3.52,35,,3.52,percent of total billed charges,Drugs,3.52,35,,3.52,percent of total billed charges,Drugs,4.03,40,,4.03,percent of total billed charges,Drugs,7.05,70,,7.05,percent of total billed charges,All Other,3.62,36,,3.62,percent of total billed charges,Drugs,3.62,36,,3.62,percent of total billed charges,Drugs,3.52,35,,3.52,percent of total billed charges,Drugs,3.52,35,,3.52,percent of total billed charges,Drugs,3.52,35,,3.52,percent of total billed charges,Drugs,3.52,35,,3.52,percent of total billed charges,Drugs,3.36,,,3.36,Other,Drug Cost,3.36,,,3.36,Other,Drug Cost,3.36,,,3.36,Other,Drug Cost,3.36,,,3.36,Other,Drug Cost,3.36,,,3.36,Other,Drug Cost,3.36,,,3.36,Other,Drug Cost,7.55,,,7.55,Other,225% of Medicaid,4.7,,,4.7,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,9.29,,,9.29,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",7.22,,,7.22,Other,215% Medicaid APG methodology,7.22,,,7.22,Other,215% Medicaid APG methodology,4.2,,,4.2,Other,125% Medicaid APG methodology,0.01,9.55,
FENTANYL CITRATE INJ 100MCG/2ML,J3010,HCPCS,,80000836,CDM,636,RC,409909332,NDC,both,10,ML,1.22,9.55,,,9.55,Other,150% of Medicare + 9.63% HCRA Surcharge,5.81,,,5.81,Fee Schedule,Average Sale Price (ASP) x 6,0.43,35,,0.43,percent of total billed charges,Drugs,0.43,35,,0.43,percent of total billed charges,Drugs,0.41,34,,0.41,percent of total billed charges,Drugs,0.41,34,,0.41,percent of total billed charges,Drugs,0.41,34,,0.41,percent of total billed charges,Drugs,0.41,34,,0.41,percent of total billed charges,Drugs,0.43,35,,0.43,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,0.43,35,,0.43,percent of total billed charges,Drugs,0.43,35,,0.43,percent of total billed charges,Drugs,0.43,35,,0.43,percent of total billed charges,Drugs,0.43,35,,0.43,percent of total billed charges,Drugs,0.43,35,,0.43,percent of total billed charges,Drugs,0.49,40,,0.49,percent of total billed charges,Drugs,0.85,70,,0.85,percent of total billed charges,All Other,0.44,36,,0.44,percent of total billed charges,Drugs,0.44,36,,0.44,percent of total billed charges,Drugs,0.43,35,,0.43,percent of total billed charges,Drugs,0.43,35,,0.43,percent of total billed charges,Drugs,0.43,35,,0.43,percent of total billed charges,Drugs,0.43,35,,0.43,percent of total billed charges,Drugs,0.41,,,0.41,Other,Drug Cost,0.41,,,0.41,Other,Drug Cost,0.41,,,0.41,Other,Drug Cost,0.41,,,0.41,Other,Drug Cost,0.41,,,0.41,Other,Drug Cost,0.41,,,0.41,Other,Drug Cost,0.91,,,0.91,Other,225% of Medicaid,0.57,,,0.57,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,9.29,,,9.29,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",0.87,,,0.87,Other,215% Medicaid APG methodology,0.87,,,0.87,Other,215% Medicaid APG methodology,0.51,,,0.51,Other,125% Medicaid APG methodology,0.01,9.55,
FENTANYL CITRATE INJ 250MCG/5ML,J3010,HCPCS,,80000837,CDM,636,RC,409909335,NDC,both,10,ML,3.05,9.55,,,9.55,Other,150% of Medicare + 9.63% HCRA Surcharge,5.81,,,5.81,Fee Schedule,Average Sale Price (ASP) x 6,1.07,35,,1.07,percent of total billed charges,Drugs,1.07,35,,1.07,percent of total billed charges,Drugs,1.04,34,,1.04,percent of total billed charges,Drugs,1.04,34,,1.04,percent of total billed charges,Drugs,1.04,34,,1.04,percent of total billed charges,Drugs,1.04,34,,1.04,percent of total billed charges,Drugs,1.07,35,,1.07,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,1.07,35,,1.07,percent of total billed charges,Drugs,1.07,35,,1.07,percent of total billed charges,Drugs,1.07,35,,1.07,percent of total billed charges,Drugs,1.07,35,,1.07,percent of total billed charges,Drugs,1.07,35,,1.07,percent of total billed charges,Drugs,1.22,40,,1.22,percent of total billed charges,Drugs,2.13,70,,2.13,percent of total billed charges,All Other,1.1,36,,1.1,percent of total billed charges,Drugs,1.1,36,,1.1,percent of total billed charges,Drugs,1.07,35,,1.07,percent of total billed charges,Drugs,1.07,35,,1.07,percent of total billed charges,Drugs,1.07,35,,1.07,percent of total billed charges,Drugs,1.07,35,,1.07,percent of total billed charges,Drugs,1.02,,,1.02,Other,Drug Cost,1.02,,,1.02,Other,Drug Cost,1.02,,,1.02,Other,Drug Cost,1.02,,,1.02,Other,Drug Cost,1.02,,,1.02,Other,Drug Cost,1.02,,,1.02,Other,Drug Cost,2.29,,,2.29,Other,225% of Medicaid,1.42,,,1.42,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,9.29,,,9.29,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",2.18,,,2.18,Other,215% Medicaid APG methodology,2.18,,,2.18,Other,215% Medicaid APG methodology,1.27,,,1.27,Other,125% Medicaid APG methodology,0.01,9.55,
FERRLECIT 62.5MG/5ML INJ,J2916,HCPCS,,80000840,CDM,636,RC,24279210,NDC,both,10,ML,19.02,23.42,,,23.42,Other,150% of Medicare + 9.63% HCRA Surcharge,14.24,,,14.24,Fee Schedule,Average Sale Price (ASP) x 6,6.66,35,,6.66,percent of total billed charges,Drugs,6.66,35,,6.66,percent of total billed charges,Drugs,6.47,34,,6.47,percent of total billed charges,Drugs,6.47,34,,6.47,percent of total billed charges,Drugs,6.47,34,,6.47,percent of total billed charges,Drugs,6.47,34,,6.47,percent of total billed charges,Drugs,6.66,35,,6.66,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,6.66,35,,6.66,percent of total billed charges,Drugs,6.66,35,,6.66,percent of total billed charges,Drugs,6.66,35,,6.66,percent of total billed charges,Drugs,6.66,35,,6.66,percent of total billed charges,Drugs,6.66,35,,6.66,percent of total billed charges,Drugs,7.61,40,,7.61,percent of total billed charges,Drugs,13.32,70,,13.32,percent of total billed charges,All Other,6.85,36,,6.85,percent of total billed charges,Drugs,6.85,36,,6.85,percent of total billed charges,Drugs,6.66,35,,6.66,percent of total billed charges,Drugs,6.66,35,,6.66,percent of total billed charges,Drugs,6.66,35,,6.66,percent of total billed charges,Drugs,6.66,35,,6.66,percent of total billed charges,Drugs,6.34,,,6.34,Other,Drug Cost,6.34,,,6.34,Other,Drug Cost,6.34,,,6.34,Other,Drug Cost,6.34,,,6.34,Other,Drug Cost,6.34,,,6.34,Other,Drug Cost,6.34,,,6.34,Other,Drug Cost,14.27,,,14.27,Other,225% of Medicaid,8.88,,,8.88,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,22.79,,,22.79,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",13.63,,,13.63,Other,215% Medicaid APG methodology,13.63,,,13.63,Other,215% Medicaid APG methodology,7.93,,,7.93,Other,125% Medicaid APG methodology,0.01,23.42,
FILGRASTIM 480 MCG INJ,J1442,HCPCS,,80000848,CDM,636,RC,55513054610,NDC,both,10,ML,1434.87,9.72,,,9.72,Other,150% of Medicare + 9.63% HCRA Surcharge,5.91,,,5.91,Fee Schedule,Average Sale Price (ASP) x 6,502.21,35,,502.21,percent of total billed charges,Drugs,502.21,35,,502.21,percent of total billed charges,Drugs,487.86,34,,487.86,percent of total billed charges,Drugs,487.86,34,,487.86,percent of total billed charges,Drugs,487.86,34,,487.86,percent of total billed charges,Drugs,487.86,34,,487.86,percent of total billed charges,Drugs,502.21,35,,502.21,percent of total billed charges,Drugs,487.86,34,"If Charge > 500, then 34 percent",487.86,percent of total billed charges,Drugs,502.21,35,,502.21,percent of total billed charges,Drugs,502.21,35,,502.21,percent of total billed charges,Drugs,502.21,35,,502.21,percent of total billed charges,Drugs,502.21,35,,502.21,percent of total billed charges,Drugs,502.21,35,,502.21,percent of total billed charges,Drugs,573.95,40,,573.95,percent of total billed charges,Drugs,1004.41,70,,1004.41,percent of total billed charges,All Other,516.55,36,,516.55,percent of total billed charges,Drugs,516.55,36,,516.55,percent of total billed charges,Drugs,502.21,35,,502.21,percent of total billed charges,Drugs,502.21,35,,502.21,percent of total billed charges,Drugs,502.21,35,,502.21,percent of total billed charges,Drugs,502.21,35,,502.21,percent of total billed charges,Drugs,478.29,,,478.29,Other,Drug Cost,478.29,,,478.29,Other,Drug Cost,478.29,,,478.29,Other,Drug Cost,478.29,,,478.29,Other,Drug Cost,478.29,,,478.29,Other,Drug Cost,478.29,,,478.29,Other,Drug Cost,1076.15,,,1076.15,Other,225% of Medicaid,669.61,,,669.61,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,9.46,,,9.46,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",1028.33,,,1028.33,Other,215% Medicaid APG methodology,1028.33,,,1028.33,Other,215% Medicaid APG methodology,597.86,,,597.86,Other,125% Medicaid APG methodology,0.01,1076.15,
FLUCONAZOLE (DIFLUCAN) 200MG/NS 100ML,J1450,HCPCS,,80000854,CDM,636,RC,25021018482,NDC,both,10,ML,8.8,27.6,,,27.6,Other,150% of Medicare + 9.63% HCRA Surcharge,16.78,,,16.78,Fee Schedule,Average Sale Price (ASP) x 6,3.08,35,,3.08,percent of total billed charges,Drugs,3.08,35,,3.08,percent of total billed charges,Drugs,2.99,34,,2.99,percent of total billed charges,Drugs,2.99,34,,2.99,percent of total billed charges,Drugs,2.99,34,,2.99,percent of total billed charges,Drugs,2.99,34,,2.99,percent of total billed charges,Drugs,3.08,35,,3.08,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,3.08,35,,3.08,percent of total billed charges,Drugs,3.08,35,,3.08,percent of total billed charges,Drugs,3.08,35,,3.08,percent of total billed charges,Drugs,3.08,35,,3.08,percent of total billed charges,Drugs,3.08,35,,3.08,percent of total billed charges,Drugs,3.52,40,,3.52,percent of total billed charges,Drugs,6.16,70,,6.16,percent of total billed charges,All Other,3.17,36,,3.17,percent of total billed charges,Drugs,3.17,36,,3.17,percent of total billed charges,Drugs,3.08,35,,3.08,percent of total billed charges,Drugs,3.08,35,,3.08,percent of total billed charges,Drugs,3.08,35,,3.08,percent of total billed charges,Drugs,3.08,35,,3.08,percent of total billed charges,Drugs,2.93,,,2.93,Other,Drug Cost,2.93,,,2.93,Other,Drug Cost,2.93,,,2.93,Other,Drug Cost,2.93,,,2.93,Other,Drug Cost,2.93,,,2.93,Other,Drug Cost,2.93,,,2.93,Other,Drug Cost,6.6,,,6.6,Other,225% of Medicaid,4.11,,,4.11,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,26.85,,,26.85,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",6.31,,,6.31,Other,215% Medicaid APG methodology,6.31,,,6.31,Other,215% Medicaid APG methodology,3.67,,,3.67,Other,125% Medicaid APG methodology,0.01,27.6,
FLUCONAZOLE (DIFLUCAN) 400MG/NS 200ML,J1450,HCPCS,,80000855,CDM,636,RC,25021018487,NDC,both,10,ML,12.24,27.6,,,27.6,Other,150% of Medicare + 9.63% HCRA Surcharge,16.78,,,16.78,Fee Schedule,Average Sale Price (ASP) x 6,4.28,35,,4.28,percent of total billed charges,Drugs,4.28,35,,4.28,percent of total billed charges,Drugs,4.16,34,,4.16,percent of total billed charges,Drugs,4.16,34,,4.16,percent of total billed charges,Drugs,4.16,34,,4.16,percent of total billed charges,Drugs,4.16,34,,4.16,percent of total billed charges,Drugs,4.28,35,,4.28,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,4.28,35,,4.28,percent of total billed charges,Drugs,4.28,35,,4.28,percent of total billed charges,Drugs,4.28,35,,4.28,percent of total billed charges,Drugs,4.28,35,,4.28,percent of total billed charges,Drugs,4.28,35,,4.28,percent of total billed charges,Drugs,4.9,40,,4.9,percent of total billed charges,Drugs,8.57,70,,8.57,percent of total billed charges,All Other,4.41,36,,4.41,percent of total billed charges,Drugs,4.41,36,,4.41,percent of total billed charges,Drugs,4.28,35,,4.28,percent of total billed charges,Drugs,4.28,35,,4.28,percent of total billed charges,Drugs,4.28,35,,4.28,percent of total billed charges,Drugs,4.28,35,,4.28,percent of total billed charges,Drugs,4.08,,,4.08,Other,Drug Cost,4.08,,,4.08,Other,Drug Cost,4.08,,,4.08,Other,Drug Cost,4.08,,,4.08,Other,Drug Cost,4.08,,,4.08,Other,Drug Cost,4.08,,,4.08,Other,Drug Cost,9.18,,,9.18,Other,225% of Medicaid,5.71,,,5.71,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,26.85,,,26.85,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",8.77,,,8.77,Other,215% Medicaid APG methodology,8.77,,,8.77,Other,215% Medicaid APG methodology,5.1,,,5.1,Other,125% Medicaid APG methodology,0.01,27.6,
FLUDARABINE PHOSPHATE INJ 25 MG/ML 2ML,J9185,HCPCS,,80000861,CDM,636,RC,63323019202,NDC,both,1,ML,114.96,1716.5,,,1716.5,Other,150% of Medicare + 9.63% HCRA Surcharge,1043.81,,,1043.81,Fee Schedule,Average Sale Price (ASP) x 6,40.24,35,,40.24,percent of total billed charges,Drugs,40.24,35,,40.24,percent of total billed charges,Drugs,39.09,34,,39.09,percent of total billed charges,Drugs,39.09,34,,39.09,percent of total billed charges,Drugs,39.09,34,,39.09,percent of total billed charges,Drugs,39.09,34,,39.09,percent of total billed charges,Drugs,40.24,35,,40.24,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,40.24,35,,40.24,percent of total billed charges,Drugs,40.24,35,,40.24,percent of total billed charges,Drugs,40.24,35,,40.24,percent of total billed charges,Drugs,40.24,35,,40.24,percent of total billed charges,Drugs,40.24,35,,40.24,percent of total billed charges,Drugs,45.98,40,,45.98,percent of total billed charges,Drugs,80.47,70,,80.47,percent of total billed charges,All Other,41.39,36,,41.39,percent of total billed charges,Drugs,41.39,36,,41.39,percent of total billed charges,Drugs,40.24,35,,40.24,percent of total billed charges,Drugs,40.24,35,,40.24,percent of total billed charges,Drugs,40.24,35,,40.24,percent of total billed charges,Drugs,40.24,35,,40.24,percent of total billed charges,Drugs,38.32,,,38.32,Other,Drug Cost,38.32,,,38.32,Other,Drug Cost,38.32,,,38.32,Other,Drug Cost,38.32,,,38.32,Other,Drug Cost,38.32,,,38.32,Other,Drug Cost,38.32,,,38.32,Other,Drug Cost,86.22,,,86.22,Other,225% of Medicaid,53.65,,,53.65,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,1670.1,,,1670.1,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",82.39,,,82.39,Other,215% Medicaid APG methodology,82.39,,,82.39,Other,215% Medicaid APG methodology,47.9,,,47.9,Other,125% Medicaid APG methodology,0.01,1716.5,
FLUOROURACIL 50 MG/ML 10ML INJ,J9190,HCPCS,,80000876,CDM,636,RC,70700018623,NDC,both,10,ML,4.29,31.72,,,31.72,Other,150% of Medicare + 9.63% HCRA Surcharge,19.29,,,19.29,Fee Schedule,Average Sale Price (ASP) x 6,1.5,35,,1.5,percent of total billed charges,Drugs,1.5,35,,1.5,percent of total billed charges,Drugs,1.46,34,,1.46,percent of total billed charges,Drugs,1.46,34,,1.46,percent of total billed charges,Drugs,1.46,34,,1.46,percent of total billed charges,Drugs,1.46,34,,1.46,percent of total billed charges,Drugs,1.5,35,,1.5,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,1.5,35,,1.5,percent of total billed charges,Drugs,1.5,35,,1.5,percent of total billed charges,Drugs,1.5,35,,1.5,percent of total billed charges,Drugs,1.5,35,,1.5,percent of total billed charges,Drugs,1.5,35,,1.5,percent of total billed charges,Drugs,1.72,40,,1.72,percent of total billed charges,Drugs,3.01,70,,3.01,percent of total billed charges,All Other,1.55,36,,1.55,percent of total billed charges,Drugs,1.55,36,,1.55,percent of total billed charges,Drugs,1.5,35,,1.5,percent of total billed charges,Drugs,1.5,35,,1.5,percent of total billed charges,Drugs,1.5,35,,1.5,percent of total billed charges,Drugs,1.5,35,,1.5,percent of total billed charges,Drugs,1.43,,,1.43,Other,Drug Cost,1.43,,,1.43,Other,Drug Cost,1.43,,,1.43,Other,Drug Cost,1.43,,,1.43,Other,Drug Cost,1.43,,,1.43,Other,Drug Cost,1.43,,,1.43,Other,Drug Cost,3.22,,,3.22,Other,225% of Medicaid,2,,,2,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,30.86,,,30.86,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",3.08,,,3.08,Other,215% Medicaid APG methodology,3.08,,,3.08,Other,215% Medicaid APG methodology,1.79,,,1.79,Other,125% Medicaid APG methodology,0.01,31.72,
FLUOROURACIL 50 MG/ML 50ML INJ,J9190,HCPCS,,80000877,CDM,636,RC,63323011751,NDC,both,1,ML,22.86,31.72,,,31.72,Other,150% of Medicare + 9.63% HCRA Surcharge,19.29,,,19.29,Fee Schedule,Average Sale Price (ASP) x 6,8,35,,8,percent of total billed charges,Drugs,8,35,,8,percent of total billed charges,Drugs,7.77,34,,7.77,percent of total billed charges,Drugs,7.77,34,,7.77,percent of total billed charges,Drugs,7.77,34,,7.77,percent of total billed charges,Drugs,7.77,34,,7.77,percent of total billed charges,Drugs,8,35,,8,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,8,35,,8,percent of total billed charges,Drugs,8,35,,8,percent of total billed charges,Drugs,8,35,,8,percent of total billed charges,Drugs,8,35,,8,percent of total billed charges,Drugs,8,35,,8,percent of total billed charges,Drugs,9.14,40,,9.14,percent of total billed charges,Drugs,16,70,,16,percent of total billed charges,All Other,8.23,36,,8.23,percent of total billed charges,Drugs,8.23,36,,8.23,percent of total billed charges,Drugs,8,35,,8,percent of total billed charges,Drugs,8,35,,8,percent of total billed charges,Drugs,8,35,,8,percent of total billed charges,Drugs,8,35,,8,percent of total billed charges,Drugs,7.62,,,7.62,Other,Drug Cost,7.62,,,7.62,Other,Drug Cost,7.62,,,7.62,Other,Drug Cost,7.62,,,7.62,Other,Drug Cost,7.62,,,7.62,Other,Drug Cost,7.62,,,7.62,Other,Drug Cost,17.15,,,17.15,Other,225% of Medicaid,10.67,,,10.67,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,30.86,,,30.86,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",16.38,,,16.38,Other,215% Medicaid APG methodology,16.38,,,16.38,Other,215% Medicaid APG methodology,9.53,,,9.53,Other,125% Medicaid APG methodology,0.01,31.72,
FOMEPIZOLE 1 G/ML 1.5ML SOLN,J1451,HCPCS,,80000908,CDM,636,RC,67457021102,NDC,both,1,ML,1241.43,489.95,39.4668,,489.95,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,434.5,35,,434.5,percent of total billed charges,Drugs,434.5,35,,434.5,percent of total billed charges,Drugs,422.09,34,,422.09,percent of total billed charges,Drugs,422.09,34,,422.09,percent of total billed charges,Drugs,422.09,34,,422.09,percent of total billed charges,Drugs,422.09,34,,422.09,percent of total billed charges,Drugs,434.5,35,,434.5,percent of total billed charges,Drugs,422.09,34,"If Charge > 500, then 34 percent",422.09,percent of total billed charges,Drugs,434.5,35,,434.5,percent of total billed charges,Drugs,434.5,35,,434.5,percent of total billed charges,Drugs,434.5,35,,434.5,percent of total billed charges,Drugs,434.5,35,,434.5,percent of total billed charges,Drugs,434.5,35,,434.5,percent of total billed charges,Drugs,496.57,40,,496.57,percent of total billed charges,Drugs,869,70,,869,percent of total billed charges,All Other,446.91,36,,446.91,percent of total billed charges,Drugs,446.91,36,,446.91,percent of total billed charges,Drugs,434.5,35,,434.5,percent of total billed charges,Drugs,434.5,35,,434.5,percent of total billed charges,Drugs,434.5,35,,434.5,percent of total billed charges,Drugs,434.5,35,,434.5,percent of total billed charges,Drugs,413.81,,,413.81,Other,Drug Cost,413.81,,,413.81,Other,Drug Cost,413.81,,,413.81,Other,Drug Cost,413.81,,,413.81,Other,Drug Cost,413.81,,,413.81,Other,Drug Cost,413.81,,,413.81,Other,Drug Cost,931.07,,,931.07,Other,225% of Medicaid,579.33,,,579.33,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",889.69,,,889.69,Other,215% Medicaid APG methodology,889.69,,,889.69,Other,215% Medicaid APG methodology,517.26,,,517.26,Other,125% Medicaid APG methodology,0.01,931.07,
FONDAPARINUX SODIUM (ARIXTRA) 7.5MG,J1652,HCPCS,,80000910,CDM,636,RC,67457058406,NDC,both,10,ML,23.04,10.78,,,10.78,Other,150% of Medicare + 9.63% HCRA Surcharge,6.56,,,6.56,Fee Schedule,Average Sale Price (ASP) x 6,8.06,35,,8.06,percent of total billed charges,Drugs,8.06,35,,8.06,percent of total billed charges,Drugs,7.83,34,,7.83,percent of total billed charges,Drugs,7.83,34,,7.83,percent of total billed charges,Drugs,7.83,34,,7.83,percent of total billed charges,Drugs,7.83,34,,7.83,percent of total billed charges,Drugs,8.06,35,,8.06,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,8.06,35,,8.06,percent of total billed charges,Drugs,8.06,35,,8.06,percent of total billed charges,Drugs,8.06,35,,8.06,percent of total billed charges,Drugs,8.06,35,,8.06,percent of total billed charges,Drugs,8.06,35,,8.06,percent of total billed charges,Drugs,9.22,40,,9.22,percent of total billed charges,Drugs,16.13,70,,16.13,percent of total billed charges,All Other,8.29,36,,8.29,percent of total billed charges,Drugs,8.29,36,,8.29,percent of total billed charges,Drugs,8.06,35,,8.06,percent of total billed charges,Drugs,8.06,35,,8.06,percent of total billed charges,Drugs,8.06,35,,8.06,percent of total billed charges,Drugs,8.06,35,,8.06,percent of total billed charges,Drugs,7.68,,,7.68,Other,Drug Cost,7.68,,,7.68,Other,Drug Cost,7.68,,,7.68,Other,Drug Cost,7.68,,,7.68,Other,Drug Cost,7.68,,,7.68,Other,Drug Cost,7.68,,,7.68,Other,Drug Cost,17.28,,,17.28,Other,225% of Medicaid,10.75,,,10.75,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,10.49,,,10.49,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",16.51,,,16.51,Other,215% Medicaid APG methodology,16.51,,,16.51,Other,215% Medicaid APG methodology,9.6,,,9.6,Other,125% Medicaid APG methodology,0.01,17.28,
FOSPHENYTOIN 50MG/ML 10ML INJ,Q2009,HCPCS,,80000914,CDM,636,RC,63323040310,NDC,both,10,ML,21.96,8.67,39.4668,,8.67,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,7.69,35,,7.69,percent of total billed charges,Drugs,7.69,35,,7.69,percent of total billed charges,Drugs,7.47,34,,7.47,percent of total billed charges,Drugs,7.47,34,,7.47,percent of total billed charges,Drugs,7.47,34,,7.47,percent of total billed charges,Drugs,7.47,34,,7.47,percent of total billed charges,Drugs,7.69,35,,7.69,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,7.69,35,,7.69,percent of total billed charges,Drugs,7.69,35,,7.69,percent of total billed charges,Drugs,7.69,35,,7.69,percent of total billed charges,Drugs,7.69,35,,7.69,percent of total billed charges,Drugs,7.69,35,,7.69,percent of total billed charges,Drugs,8.78,40,,8.78,percent of total billed charges,Drugs,15.37,70,,15.37,percent of total billed charges,All Other,7.91,36,,7.91,percent of total billed charges,Drugs,7.91,36,,7.91,percent of total billed charges,Drugs,7.69,35,,7.69,percent of total billed charges,Drugs,7.69,35,,7.69,percent of total billed charges,Drugs,7.69,35,,7.69,percent of total billed charges,Drugs,7.69,35,,7.69,percent of total billed charges,Drugs,7.32,,,7.32,Other,Drug Cost,7.32,,,7.32,Other,Drug Cost,7.32,,,7.32,Other,Drug Cost,7.32,,,7.32,Other,Drug Cost,7.32,,,7.32,Other,Drug Cost,7.32,,,7.32,Other,Drug Cost,16.47,,,16.47,Other,225% of Medicaid,10.25,,,10.25,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",15.74,,,15.74,Other,215% Medicaid APG methodology,15.74,,,15.74,Other,215% Medicaid APG methodology,9.15,,,9.15,Other,125% Medicaid APG methodology,0.01,16.47,
FOSPHENYTOIN 50MG/ML 2ML INJ,Q2009,HCPCS,,80000915,CDM,636,RC,63323040302,NDC,both,25,ML,4.38,1.73,39.4668,,1.73,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,1.53,35,,1.53,percent of total billed charges,Drugs,1.53,35,,1.53,percent of total billed charges,Drugs,1.49,34,,1.49,percent of total billed charges,Drugs,1.49,34,,1.49,percent of total billed charges,Drugs,1.49,34,,1.49,percent of total billed charges,Drugs,1.49,34,,1.49,percent of total billed charges,Drugs,1.53,35,,1.53,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,1.53,35,,1.53,percent of total billed charges,Drugs,1.53,35,,1.53,percent of total billed charges,Drugs,1.53,35,,1.53,percent of total billed charges,Drugs,1.53,35,,1.53,percent of total billed charges,Drugs,1.53,35,,1.53,percent of total billed charges,Drugs,1.75,40,,1.75,percent of total billed charges,Drugs,3.06,70,,3.06,percent of total billed charges,All Other,1.58,36,,1.58,percent of total billed charges,Drugs,1.58,36,,1.58,percent of total billed charges,Drugs,1.53,35,,1.53,percent of total billed charges,Drugs,1.53,35,,1.53,percent of total billed charges,Drugs,1.53,35,,1.53,percent of total billed charges,Drugs,1.53,35,,1.53,percent of total billed charges,Drugs,1.46,,,1.46,Other,Drug Cost,1.46,,,1.46,Other,Drug Cost,1.46,,,1.46,Other,Drug Cost,1.46,,,1.46,Other,Drug Cost,1.46,,,1.46,Other,Drug Cost,1.46,,,1.46,Other,Drug Cost,3.28,,,3.28,Other,225% of Medicaid,2.04,,,2.04,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",3.14,,,3.14,Other,215% Medicaid APG methodology,3.14,,,3.14,Other,215% Medicaid APG methodology,1.82,,,1.82,Other,125% Medicaid APG methodology,0.01,3.28,
FULVESTRANT 50MG/ML 5ML INJ,J9395,HCPCS,,80000916,CDM,636,RC,43598026202,NDC,both,2,ML,33.33,83.32,,,83.32,Other,150% of Medicare + 9.63% HCRA Surcharge,50.67,,,50.67,Fee Schedule,Average Sale Price (ASP) x 6,11.67,35,,11.67,percent of total billed charges,Drugs,11.67,35,,11.67,percent of total billed charges,Drugs,11.33,34,,11.33,percent of total billed charges,Drugs,11.33,34,,11.33,percent of total billed charges,Drugs,11.33,34,,11.33,percent of total billed charges,Drugs,11.33,34,,11.33,percent of total billed charges,Drugs,11.67,35,,11.67,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,11.67,35,,11.67,percent of total billed charges,Drugs,11.67,35,,11.67,percent of total billed charges,Drugs,11.67,35,,11.67,percent of total billed charges,Drugs,11.67,35,,11.67,percent of total billed charges,Drugs,11.67,35,,11.67,percent of total billed charges,Drugs,13.33,40,,13.33,percent of total billed charges,Drugs,23.33,70,,23.33,percent of total billed charges,All Other,12,36,,12,percent of total billed charges,Drugs,12,36,,12,percent of total billed charges,Drugs,11.67,35,,11.67,percent of total billed charges,Drugs,11.67,35,,11.67,percent of total billed charges,Drugs,11.67,35,,11.67,percent of total billed charges,Drugs,11.67,35,,11.67,percent of total billed charges,Drugs,11.11,,,11.11,Other,Drug Cost,11.11,,,11.11,Other,Drug Cost,11.11,,,11.11,Other,Drug Cost,11.11,,,11.11,Other,Drug Cost,11.11,,,11.11,Other,Drug Cost,11.11,,,11.11,Other,Drug Cost,25,,,25,Other,225% of Medicaid,15.55,,,15.55,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,81.07,,,81.07,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",23.89,,,23.89,Other,215% Medicaid APG methodology,23.89,,,23.89,Other,215% Medicaid APG methodology,13.89,,,13.89,Other,125% Medicaid APG methodology,0.01,83.32,
FUROSEMIDE (LASIX) INJ 100MG,J1940,HCPCS,,80000917,CDM,636,RC,36000028425,NDC,both,25,ML,2.28,5.65,,,5.65,Other,150% of Medicare + 9.63% HCRA Surcharge,3.44,,,3.44,Fee Schedule,Average Sale Price (ASP) x 6,0.8,35,,0.8,percent of total billed charges,Drugs,0.8,35,,0.8,percent of total billed charges,Drugs,0.78,34,,0.78,percent of total billed charges,Drugs,0.78,34,,0.78,percent of total billed charges,Drugs,0.78,34,,0.78,percent of total billed charges,Drugs,0.78,34,,0.78,percent of total billed charges,Drugs,0.8,35,,0.8,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,0.8,35,,0.8,percent of total billed charges,Drugs,0.8,35,,0.8,percent of total billed charges,Drugs,0.8,35,,0.8,percent of total billed charges,Drugs,0.8,35,,0.8,percent of total billed charges,Drugs,0.8,35,,0.8,percent of total billed charges,Drugs,0.91,40,,0.91,percent of total billed charges,Drugs,1.6,70,,1.6,percent of total billed charges,All Other,0.82,36,,0.82,percent of total billed charges,Drugs,0.82,36,,0.82,percent of total billed charges,Drugs,0.8,35,,0.8,percent of total billed charges,Drugs,0.8,35,,0.8,percent of total billed charges,Drugs,0.8,35,,0.8,percent of total billed charges,Drugs,0.8,35,,0.8,percent of total billed charges,Drugs,0.76,,,0.76,Other,Drug Cost,0.76,,,0.76,Other,Drug Cost,0.76,,,0.76,Other,Drug Cost,0.76,,,0.76,Other,Drug Cost,0.76,,,0.76,Other,Drug Cost,0.76,,,0.76,Other,Drug Cost,1.71,,,1.71,Other,225% of Medicaid,1.07,,,1.07,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,5.5,,,5.5,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",1.64,,,1.64,Other,215% Medicaid APG methodology,1.64,,,1.64,Other,215% Medicaid APG methodology,0.95,,,0.95,Other,125% Medicaid APG methodology,0.01,5.65,
FUROSEMIDE (LASIX) INJ 20MG,J1940,HCPCS,,80000918,CDM,636,RC,36000028225,NDC,both,25,ML,0.9,5.65,,,5.65,Other,150% of Medicare + 9.63% HCRA Surcharge,3.44,,,3.44,Fee Schedule,Average Sale Price (ASP) x 6,0.31,35,,0.31,percent of total billed charges,Drugs,0.31,35,,0.31,percent of total billed charges,Drugs,0.3,34,,0.3,percent of total billed charges,Drugs,0.3,34,,0.3,percent of total billed charges,Drugs,0.3,34,,0.3,percent of total billed charges,Drugs,0.3,34,,0.3,percent of total billed charges,Drugs,0.31,35,,0.31,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,0.31,35,,0.31,percent of total billed charges,Drugs,0.31,35,,0.31,percent of total billed charges,Drugs,0.31,35,,0.31,percent of total billed charges,Drugs,0.31,35,,0.31,percent of total billed charges,Drugs,0.31,35,,0.31,percent of total billed charges,Drugs,0.36,40,,0.36,percent of total billed charges,Drugs,0.63,70,,0.63,percent of total billed charges,All Other,0.32,36,,0.32,percent of total billed charges,Drugs,0.32,36,,0.32,percent of total billed charges,Drugs,0.31,35,,0.31,percent of total billed charges,Drugs,0.31,35,,0.31,percent of total billed charges,Drugs,0.31,35,,0.31,percent of total billed charges,Drugs,0.31,35,,0.31,percent of total billed charges,Drugs,0.3,,,0.3,Other,Drug Cost,0.3,,,0.3,Other,Drug Cost,0.3,,,0.3,Other,Drug Cost,0.3,,,0.3,Other,Drug Cost,0.3,,,0.3,Other,Drug Cost,0.3,,,0.3,Other,Drug Cost,0.67,,,0.67,Other,225% of Medicaid,0.42,,,0.42,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,5.5,,,5.5,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",0.64,,,0.64,Other,215% Medicaid APG methodology,0.64,,,0.64,Other,215% Medicaid APG methodology,0.37,,,0.37,Other,125% Medicaid APG methodology,0.01,5.65,
FUROSEMIDE (LASIX) INJ 40MG,J1940,HCPCS,,80000919,CDM,636,RC,36000028325,NDC,both,25,ML,1.14,5.65,,,5.65,Other,150% of Medicare + 9.63% HCRA Surcharge,3.44,,,3.44,Fee Schedule,Average Sale Price (ASP) x 6,0.4,35,,0.4,percent of total billed charges,Drugs,0.4,35,,0.4,percent of total billed charges,Drugs,0.39,34,,0.39,percent of total billed charges,Drugs,0.39,34,,0.39,percent of total billed charges,Drugs,0.39,34,,0.39,percent of total billed charges,Drugs,0.39,34,,0.39,percent of total billed charges,Drugs,0.4,35,,0.4,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,0.4,35,,0.4,percent of total billed charges,Drugs,0.4,35,,0.4,percent of total billed charges,Drugs,0.4,35,,0.4,percent of total billed charges,Drugs,0.4,35,,0.4,percent of total billed charges,Drugs,0.4,35,,0.4,percent of total billed charges,Drugs,0.46,40,,0.46,percent of total billed charges,Drugs,0.8,70,,0.8,percent of total billed charges,All Other,0.41,36,,0.41,percent of total billed charges,Drugs,0.41,36,,0.41,percent of total billed charges,Drugs,0.4,35,,0.4,percent of total billed charges,Drugs,0.4,35,,0.4,percent of total billed charges,Drugs,0.4,35,,0.4,percent of total billed charges,Drugs,0.4,35,,0.4,percent of total billed charges,Drugs,0.38,,,0.38,Other,Drug Cost,0.38,,,0.38,Other,Drug Cost,0.38,,,0.38,Other,Drug Cost,0.38,,,0.38,Other,Drug Cost,0.38,,,0.38,Other,Drug Cost,0.38,,,0.38,Other,Drug Cost,0.86,,,0.86,Other,225% of Medicaid,0.53,,,0.53,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,5.5,,,5.5,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",0.82,,,0.82,Other,215% Medicaid APG methodology,0.82,,,0.82,Other,215% Medicaid APG methodology,0.48,,,0.48,Other,125% Medicaid APG methodology,0.01,5.65,
GANCICLOVIR SODIUM 500 MG,J1570,HCPCS,,80000931,CDM,636,RC,70436008955,NDC,both,25,EA,27.34,443.23,,,443.23,Other,150% of Medicare + 9.63% HCRA Surcharge,269.53,,,269.53,Fee Schedule,Average Sale Price (ASP) x 6,9.57,35,,9.57,percent of total billed charges,Drugs,9.57,35,,9.57,percent of total billed charges,Drugs,9.3,34,,9.3,percent of total billed charges,Drugs,9.3,34,,9.3,percent of total billed charges,Drugs,9.3,34,,9.3,percent of total billed charges,Drugs,9.3,34,,9.3,percent of total billed charges,Drugs,9.57,35,,9.57,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,9.57,35,,9.57,percent of total billed charges,Drugs,9.57,35,,9.57,percent of total billed charges,Drugs,9.57,35,,9.57,percent of total billed charges,Drugs,9.57,35,,9.57,percent of total billed charges,Drugs,9.57,35,,9.57,percent of total billed charges,Drugs,10.94,40,,10.94,percent of total billed charges,Drugs,19.14,70,,19.14,percent of total billed charges,All Other,9.84,36,,9.84,percent of total billed charges,Drugs,9.84,36,,9.84,percent of total billed charges,Drugs,9.57,35,,9.57,percent of total billed charges,Drugs,9.57,35,,9.57,percent of total billed charges,Drugs,9.57,35,,9.57,percent of total billed charges,Drugs,9.57,35,,9.57,percent of total billed charges,Drugs,9.11,,,9.11,Other,Drug Cost,9.11,,,9.11,Other,Drug Cost,9.11,,,9.11,Other,Drug Cost,9.11,,,9.11,Other,Drug Cost,9.11,,,9.11,Other,Drug Cost,9.11,,,9.11,Other,Drug Cost,20.5,,,20.5,Other,225% of Medicaid,12.76,,,12.76,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,431.25,,,431.25,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",19.59,,,19.59,Other,215% Medicaid APG methodology,19.59,,,19.59,Other,215% Medicaid APG methodology,11.39,,,11.39,Other,125% Medicaid APG methodology,0.01,443.23,
GEMCITABINE HCL INJECTION 200 MG,J9201,HCPCS,,80000934,CDM,636,RC,63323010213,NDC,both,1,EA,12.15,36.02,,,36.02,Other,150% of Medicare + 9.63% HCRA Surcharge,21.91,,,21.91,Fee Schedule,Average Sale Price (ASP) x 6,4.25,35,,4.25,percent of total billed charges,Drugs,4.25,35,,4.25,percent of total billed charges,Drugs,4.13,34,,4.13,percent of total billed charges,Drugs,4.13,34,,4.13,percent of total billed charges,Drugs,4.13,34,,4.13,percent of total billed charges,Drugs,4.13,34,,4.13,percent of total billed charges,Drugs,4.25,35,,4.25,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,4.25,35,,4.25,percent of total billed charges,Drugs,4.25,35,,4.25,percent of total billed charges,Drugs,4.25,35,,4.25,percent of total billed charges,Drugs,4.25,35,,4.25,percent of total billed charges,Drugs,4.25,35,,4.25,percent of total billed charges,Drugs,4.86,40,,4.86,percent of total billed charges,Drugs,8.51,70,,8.51,percent of total billed charges,All Other,4.37,36,,4.37,percent of total billed charges,Drugs,4.37,36,,4.37,percent of total billed charges,Drugs,4.25,35,,4.25,percent of total billed charges,Drugs,4.25,35,,4.25,percent of total billed charges,Drugs,4.25,35,,4.25,percent of total billed charges,Drugs,4.25,35,,4.25,percent of total billed charges,Drugs,4.05,,,4.05,Other,Drug Cost,4.05,,,4.05,Other,Drug Cost,4.05,,,4.05,Other,Drug Cost,4.05,,,4.05,Other,Drug Cost,4.05,,,4.05,Other,Drug Cost,4.05,,,4.05,Other,Drug Cost,9.11,,,9.11,Other,225% of Medicaid,5.67,,,5.67,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,35.05,,,35.05,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",8.71,,,8.71,Other,215% Medicaid APG methodology,8.71,,,8.71,Other,215% Medicaid APG methodology,5.06,,,5.06,Other,125% Medicaid APG methodology,0.01,36.02,
GENTAMICIN (GARAMYCIN) 20MG/2ML INJ,J1580,HCPCS,,80000937,CDM,636,RC,63323017302,NDC,both,25,ML,3.75,26.49,,,26.49,Other,150% of Medicare + 9.63% HCRA Surcharge,16.11,,,16.11,Fee Schedule,Average Sale Price (ASP) x 6,1.31,35,,1.31,percent of total billed charges,Drugs,1.31,35,,1.31,percent of total billed charges,Drugs,1.28,34,,1.28,percent of total billed charges,Drugs,1.28,34,,1.28,percent of total billed charges,Drugs,1.28,34,,1.28,percent of total billed charges,Drugs,1.28,34,,1.28,percent of total billed charges,Drugs,1.31,35,,1.31,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,1.31,35,,1.31,percent of total billed charges,Drugs,1.31,35,,1.31,percent of total billed charges,Drugs,1.31,35,,1.31,percent of total billed charges,Drugs,1.31,35,,1.31,percent of total billed charges,Drugs,1.31,35,,1.31,percent of total billed charges,Drugs,1.5,40,,1.5,percent of total billed charges,Drugs,2.63,70,,2.63,percent of total billed charges,All Other,1.35,36,,1.35,percent of total billed charges,Drugs,1.35,36,,1.35,percent of total billed charges,Drugs,1.31,35,,1.31,percent of total billed charges,Drugs,1.31,35,,1.31,percent of total billed charges,Drugs,1.31,35,,1.31,percent of total billed charges,Drugs,1.31,35,,1.31,percent of total billed charges,Drugs,1.25,,,1.25,Other,Drug Cost,1.25,,,1.25,Other,Drug Cost,1.25,,,1.25,Other,Drug Cost,1.25,,,1.25,Other,Drug Cost,1.25,,,1.25,Other,Drug Cost,1.25,,,1.25,Other,Drug Cost,2.81,,,2.81,Other,225% of Medicaid,1.75,,,1.75,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,25.78,,,25.78,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",2.69,,,2.69,Other,215% Medicaid APG methodology,2.69,,,2.69,Other,215% Medicaid APG methodology,1.56,,,1.56,Other,125% Medicaid APG methodology,0.01,26.49,
GENTAMICIN (GARAMYCIN) 40MG/ML 20ML INJ,J1580,HCPCS,,80000938,CDM,636,RC,63323001020,NDC,both,25,ML,35.93,26.49,,,26.49,Other,150% of Medicare + 9.63% HCRA Surcharge,16.11,,,16.11,Fee Schedule,Average Sale Price (ASP) x 6,12.57,35,,12.57,percent of total billed charges,Drugs,12.57,35,,12.57,percent of total billed charges,Drugs,12.22,34,,12.22,percent of total billed charges,Drugs,12.22,34,,12.22,percent of total billed charges,Drugs,12.22,34,,12.22,percent of total billed charges,Drugs,12.22,34,,12.22,percent of total billed charges,Drugs,12.57,35,,12.57,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,12.57,35,,12.57,percent of total billed charges,Drugs,12.57,35,,12.57,percent of total billed charges,Drugs,12.57,35,,12.57,percent of total billed charges,Drugs,12.57,35,,12.57,percent of total billed charges,Drugs,12.57,35,,12.57,percent of total billed charges,Drugs,14.37,40,,14.37,percent of total billed charges,Drugs,25.15,70,,25.15,percent of total billed charges,All Other,12.93,36,,12.93,percent of total billed charges,Drugs,12.93,36,,12.93,percent of total billed charges,Drugs,12.57,35,,12.57,percent of total billed charges,Drugs,12.57,35,,12.57,percent of total billed charges,Drugs,12.57,35,,12.57,percent of total billed charges,Drugs,12.57,35,,12.57,percent of total billed charges,Drugs,11.98,,,11.98,Other,Drug Cost,11.98,,,11.98,Other,Drug Cost,11.98,,,11.98,Other,Drug Cost,11.98,,,11.98,Other,Drug Cost,11.98,,,11.98,Other,Drug Cost,11.98,,,11.98,Other,Drug Cost,26.95,,,26.95,Other,225% of Medicaid,16.77,,,16.77,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,25.78,,,25.78,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",25.75,,,25.75,Other,215% Medicaid APG methodology,25.75,,,25.75,Other,215% Medicaid APG methodology,14.97,,,14.97,Other,125% Medicaid APG methodology,0.01,26.95,
GLUCAGON HCL 1 MG KIT,J1610,HCPCS,,80000952,CDM,636,RC,63323059303,NDC,both,1,EA,271.05,1858.56,,,1858.56,Other,150% of Medicare + 9.63% HCRA Surcharge,1130.2,,,1130.2,Fee Schedule,Average Sale Price (ASP) x 6,94.87,35,,94.87,percent of total billed charges,Drugs,94.87,35,,94.87,percent of total billed charges,Drugs,92.16,34,,92.16,percent of total billed charges,Drugs,92.16,34,,92.16,percent of total billed charges,Drugs,92.16,34,,92.16,percent of total billed charges,Drugs,92.16,34,,92.16,percent of total billed charges,Drugs,94.87,35,,94.87,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,94.87,35,,94.87,percent of total billed charges,Drugs,94.87,35,,94.87,percent of total billed charges,Drugs,94.87,35,,94.87,percent of total billed charges,Drugs,94.87,35,,94.87,percent of total billed charges,Drugs,94.87,35,,94.87,percent of total billed charges,Drugs,108.42,40,,108.42,percent of total billed charges,Drugs,189.74,70,,189.74,percent of total billed charges,All Other,97.58,36,,97.58,percent of total billed charges,Drugs,97.58,36,,97.58,percent of total billed charges,Drugs,94.87,35,,94.87,percent of total billed charges,Drugs,94.87,35,,94.87,percent of total billed charges,Drugs,94.87,35,,94.87,percent of total billed charges,Drugs,94.87,35,,94.87,percent of total billed charges,Drugs,90.35,,,90.35,Other,Drug Cost,90.35,,,90.35,Other,Drug Cost,90.35,,,90.35,Other,Drug Cost,90.35,,,90.35,Other,Drug Cost,90.35,,,90.35,Other,Drug Cost,90.35,,,90.35,Other,Drug Cost,203.29,,,203.29,Other,225% of Medicaid,126.49,,,126.49,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,1808.32,,,1808.32,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",194.25,,,194.25,Other,215% Medicaid APG methodology,194.25,,,194.25,Other,215% Medicaid APG methodology,112.94,,,112.94,Other,125% Medicaid APG methodology,0.01,1858.56,
GRANISETRON HCL (KYTRIL) 1MG/1ML INJ,J1626,HCPCS,,80000963,CDM,636,RC,143974410,NDC,both,10,ML,7.08,3.76,,,3.76,Other,150% of Medicare + 9.63% HCRA Surcharge,2.29,,,2.29,Fee Schedule,Average Sale Price (ASP) x 6,2.48,35,,2.48,percent of total billed charges,Drugs,2.48,35,,2.48,percent of total billed charges,Drugs,2.41,34,,2.41,percent of total billed charges,Drugs,2.41,34,,2.41,percent of total billed charges,Drugs,2.41,34,,2.41,percent of total billed charges,Drugs,2.41,34,,2.41,percent of total billed charges,Drugs,2.48,35,,2.48,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,2.48,35,,2.48,percent of total billed charges,Drugs,2.48,35,,2.48,percent of total billed charges,Drugs,2.48,35,,2.48,percent of total billed charges,Drugs,2.48,35,,2.48,percent of total billed charges,Drugs,2.48,35,,2.48,percent of total billed charges,Drugs,2.83,40,,2.83,percent of total billed charges,Drugs,4.95,70,,4.95,percent of total billed charges,All Other,2.55,36,,2.55,percent of total billed charges,Drugs,2.55,36,,2.55,percent of total billed charges,Drugs,2.48,35,,2.48,percent of total billed charges,Drugs,2.48,35,,2.48,percent of total billed charges,Drugs,2.48,35,,2.48,percent of total billed charges,Drugs,2.48,35,,2.48,percent of total billed charges,Drugs,2.36,,,2.36,Other,Drug Cost,2.36,,,2.36,Other,Drug Cost,2.36,,,2.36,Other,Drug Cost,2.36,,,2.36,Other,Drug Cost,2.36,,,2.36,Other,Drug Cost,2.36,,,2.36,Other,Drug Cost,5.31,,,5.31,Other,225% of Medicaid,3.3,,,3.3,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,3.66,,,3.66,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",5.07,,,5.07,Other,215% Medicaid APG methodology,5.07,,,5.07,Other,215% Medicaid APG methodology,2.95,,,2.95,Other,125% Medicaid APG methodology,0.01,5.31,
GRANISETRON HCL INJECTION 1MG/1ML,J1626,HCPCS,,80000964,CDM,636,RC,67457086301,NDC,both,1,ML,5.7,3.76,,,3.76,Other,150% of Medicare + 9.63% HCRA Surcharge,2.29,,,2.29,Fee Schedule,Average Sale Price (ASP) x 6,2,35,,2,percent of total billed charges,Drugs,2,35,,2,percent of total billed charges,Drugs,1.94,34,,1.94,percent of total billed charges,Drugs,1.94,34,,1.94,percent of total billed charges,Drugs,1.94,34,,1.94,percent of total billed charges,Drugs,1.94,34,,1.94,percent of total billed charges,Drugs,2,35,,2,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,2,35,,2,percent of total billed charges,Drugs,2,35,,2,percent of total billed charges,Drugs,2,35,,2,percent of total billed charges,Drugs,2,35,,2,percent of total billed charges,Drugs,2,35,,2,percent of total billed charges,Drugs,2.28,40,,2.28,percent of total billed charges,Drugs,3.99,70,,3.99,percent of total billed charges,All Other,2.05,36,,2.05,percent of total billed charges,Drugs,2.05,36,,2.05,percent of total billed charges,Drugs,2,35,,2,percent of total billed charges,Drugs,2,35,,2,percent of total billed charges,Drugs,2,35,,2,percent of total billed charges,Drugs,2,35,,2,percent of total billed charges,Drugs,1.9,,,1.9,Other,Drug Cost,1.9,,,1.9,Other,Drug Cost,1.9,,,1.9,Other,Drug Cost,1.9,,,1.9,Other,Drug Cost,1.9,,,1.9,Other,Drug Cost,1.9,,,1.9,Other,Drug Cost,4.28,,,4.28,Other,225% of Medicaid,2.66,,,2.66,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,3.66,,,3.66,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",4.09,,,4.09,Other,215% Medicaid APG methodology,4.09,,,4.09,Other,215% Medicaid APG methodology,2.38,,,2.38,Other,125% Medicaid APG methodology,0.01,4.28,
HALOPERIDOL  5 MG/1ML INJ,J1630,HCPCS,,80000974,CDM,636,RC,67457042612,NDC,both,25,ML,1.55,13.97,,,13.97,Other,150% of Medicare + 9.63% HCRA Surcharge,8.5,,,8.5,Fee Schedule,Average Sale Price (ASP) x 6,0.54,35,,0.54,percent of total billed charges,Drugs,0.54,35,,0.54,percent of total billed charges,Drugs,0.53,34,,0.53,percent of total billed charges,Drugs,0.53,34,,0.53,percent of total billed charges,Drugs,0.53,34,,0.53,percent of total billed charges,Drugs,0.53,34,,0.53,percent of total billed charges,Drugs,0.54,35,,0.54,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,0.54,35,,0.54,percent of total billed charges,Drugs,0.54,35,,0.54,percent of total billed charges,Drugs,0.54,35,,0.54,percent of total billed charges,Drugs,0.54,35,,0.54,percent of total billed charges,Drugs,0.54,35,,0.54,percent of total billed charges,Drugs,0.62,40,,0.62,percent of total billed charges,Drugs,1.08,70,,1.08,percent of total billed charges,All Other,0.56,36,,0.56,percent of total billed charges,Drugs,0.56,36,,0.56,percent of total billed charges,Drugs,0.54,35,,0.54,percent of total billed charges,Drugs,0.54,35,,0.54,percent of total billed charges,Drugs,0.54,35,,0.54,percent of total billed charges,Drugs,0.54,35,,0.54,percent of total billed charges,Drugs,0.52,,,0.52,Other,Drug Cost,0.52,,,0.52,Other,Drug Cost,0.52,,,0.52,Other,Drug Cost,0.52,,,0.52,Other,Drug Cost,0.52,,,0.52,Other,Drug Cost,0.52,,,0.52,Other,Drug Cost,1.16,,,1.16,Other,225% of Medicaid,0.72,,,0.72,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,13.59,,,13.59,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",1.11,,,1.11,Other,215% Medicaid APG methodology,1.11,,,1.11,Other,215% Medicaid APG methodology,0.64,,,0.64,Other,125% Medicaid APG methodology,0.01,13.97,
HALOPERIDOL DECANOATE 100MG/ML,J1631,HCPCS,,80000979,CDM,636,RC,50458025414,NDC,both,5,ML,0.03,86.6,,,86.6,Other,150% of Medicare + 9.63% HCRA Surcharge,52.66,,,52.66,Fee Schedule,Average Sale Price (ASP) x 6,0.01,35,,0.01,percent of total billed charges,Drugs,0.01,35,,0.01,percent of total billed charges,Drugs,0.01,34,,0.01,percent of total billed charges,Drugs,0.01,34,,0.01,percent of total billed charges,Drugs,0.01,34,,0.01,percent of total billed charges,Drugs,0.01,34,,0.01,percent of total billed charges,Drugs,0.01,35,,0.01,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,0.01,35,,0.01,percent of total billed charges,Drugs,0.01,35,,0.01,percent of total billed charges,Drugs,0.01,35,,0.01,percent of total billed charges,Drugs,0.01,35,,0.01,percent of total billed charges,Drugs,0.01,35,,0.01,percent of total billed charges,Drugs,0.01,40,,0.01,percent of total billed charges,Drugs,0.02,70,,0.02,percent of total billed charges,All Other,0.01,36,,0.01,percent of total billed charges,Drugs,0.01,36,,0.01,percent of total billed charges,Drugs,0.01,35,,0.01,percent of total billed charges,Drugs,0.01,35,,0.01,percent of total billed charges,Drugs,0.01,35,,0.01,percent of total billed charges,Drugs,0.01,35,,0.01,percent of total billed charges,Drugs,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.02,,,0.02,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,84.26,,,84.26,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,86.6,
HALOPERIDOL DECANOATE 50MG/ML,J1631,HCPCS,,80000981,CDM,636,RC,25021083101,NDC,both,10,ML,9.16,86.6,,,86.6,Other,150% of Medicare + 9.63% HCRA Surcharge,52.66,,,52.66,Fee Schedule,Average Sale Price (ASP) x 6,3.21,35,,3.21,percent of total billed charges,Drugs,3.21,35,,3.21,percent of total billed charges,Drugs,3.11,34,,3.11,percent of total billed charges,Drugs,3.11,34,,3.11,percent of total billed charges,Drugs,3.11,34,,3.11,percent of total billed charges,Drugs,3.11,34,,3.11,percent of total billed charges,Drugs,3.21,35,,3.21,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,3.21,35,,3.21,percent of total billed charges,Drugs,3.21,35,,3.21,percent of total billed charges,Drugs,3.21,35,,3.21,percent of total billed charges,Drugs,3.21,35,,3.21,percent of total billed charges,Drugs,3.21,35,,3.21,percent of total billed charges,Drugs,3.66,40,,3.66,percent of total billed charges,Drugs,6.41,70,,6.41,percent of total billed charges,All Other,3.3,36,,3.3,percent of total billed charges,Drugs,3.3,36,,3.3,percent of total billed charges,Drugs,3.21,35,,3.21,percent of total billed charges,Drugs,3.21,35,,3.21,percent of total billed charges,Drugs,3.21,35,,3.21,percent of total billed charges,Drugs,3.21,35,,3.21,percent of total billed charges,Drugs,3.05,,,3.05,Other,Drug Cost,3.05,,,3.05,Other,Drug Cost,3.05,,,3.05,Other,Drug Cost,3.05,,,3.05,Other,Drug Cost,3.05,,,3.05,Other,Drug Cost,3.05,,,3.05,Other,Drug Cost,6.87,,,6.87,Other,225% of Medicaid,4.27,,,4.27,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,84.26,,,84.26,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",6.56,,,6.56,Other,215% Medicaid APG methodology,6.56,,,6.56,Other,215% Medicaid APG methodology,3.82,,,3.82,Other,125% Medicaid APG methodology,0.01,86.6,
HEP B IG HUMAN 312UNITS/ML IM 5ML,90371,HCPCS,,80000984,CDM,636,RC,69800420301,NDC,both,1,ML,948.21,374.23,39.4668,,374.23,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,331.87,35,,331.87,percent of total billed charges,Drugs,331.87,35,,331.87,percent of total billed charges,Drugs,322.39,34,,322.39,percent of total billed charges,Drugs,322.39,34,,322.39,percent of total billed charges,Drugs,322.39,34,,322.39,percent of total billed charges,Drugs,322.39,34,,322.39,percent of total billed charges,Drugs,331.87,35,,331.87,percent of total billed charges,Drugs,322.39,34,"If Charge > 500, then 34 percent",322.39,percent of total billed charges,Drugs,331.87,35,,331.87,percent of total billed charges,Drugs,331.87,35,,331.87,percent of total billed charges,Drugs,331.87,35,,331.87,percent of total billed charges,Drugs,331.87,35,,331.87,percent of total billed charges,Drugs,331.87,35,,331.87,percent of total billed charges,Drugs,379.28,40,,379.28,percent of total billed charges,Drugs,663.75,70,,663.75,percent of total billed charges,All Other,341.36,36,,341.36,percent of total billed charges,Drugs,341.36,36,,341.36,percent of total billed charges,Drugs,331.87,35,,331.87,percent of total billed charges,Drugs,331.87,35,,331.87,percent of total billed charges,Drugs,331.87,35,,331.87,percent of total billed charges,Drugs,331.87,35,,331.87,percent of total billed charges,Drugs,316.07,,,316.07,Other,Drug Cost,316.07,,,316.07,Other,Drug Cost,316.07,,,316.07,Other,Drug Cost,316.07,,,316.07,Other,Drug Cost,316.07,,,316.07,Other,Drug Cost,316.07,,,316.07,Other,Drug Cost,711.16,,,711.16,Other,225% of Medicaid,442.5,,,442.5,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",679.55,,,679.55,Other,215% Medicaid APG methodology,679.55,,,679.55,Other,215% Medicaid APG methodology,395.09,,,395.09,Other,125% Medicaid APG methodology,0.01,711.16,
HEP B IG HUMAN IM 312 UNIT/ML 1ML,90371,HCPCS,,80000985,CDM,636,RC,69800420201,NDC,both,1,ML,189.63,74.84,39.4668,,74.84,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,66.37,35,,66.37,percent of total billed charges,Drugs,66.37,35,,66.37,percent of total billed charges,Drugs,64.47,34,,64.47,percent of total billed charges,Drugs,64.47,34,,64.47,percent of total billed charges,Drugs,64.47,34,,64.47,percent of total billed charges,Drugs,64.47,34,,64.47,percent of total billed charges,Drugs,66.37,35,,66.37,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,66.37,35,,66.37,percent of total billed charges,Drugs,66.37,35,,66.37,percent of total billed charges,Drugs,66.37,35,,66.37,percent of total billed charges,Drugs,66.37,35,,66.37,percent of total billed charges,Drugs,66.37,35,,66.37,percent of total billed charges,Drugs,75.85,40,,75.85,percent of total billed charges,Drugs,132.74,70,,132.74,percent of total billed charges,All Other,68.27,36,,68.27,percent of total billed charges,Drugs,68.27,36,,68.27,percent of total billed charges,Drugs,66.37,35,,66.37,percent of total billed charges,Drugs,66.37,35,,66.37,percent of total billed charges,Drugs,66.37,35,,66.37,percent of total billed charges,Drugs,66.37,35,,66.37,percent of total billed charges,Drugs,63.21,,,63.21,Other,Drug Cost,63.21,,,63.21,Other,Drug Cost,63.21,,,63.21,Other,Drug Cost,63.21,,,63.21,Other,Drug Cost,63.21,,,63.21,Other,Drug Cost,63.21,,,63.21,Other,Drug Cost,142.22,,,142.22,Other,225% of Medicaid,88.49,,,88.49,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",135.9,,,135.9,Other,215% Medicaid APG methodology,135.9,,,135.9,Other,215% Medicaid APG methodology,79.01,,,79.01,Other,125% Medicaid APG methodology,0.01,142.22,
HEP B VACC 10MCG/0.5ML,90743,HCPCS,,80000986,CDM,636,RC,58160082052,NDC,both,10,ML,52.1,20.56,39.4668,,20.56,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,18.23,35,,18.23,percent of total billed charges,Drugs,18.23,35,,18.23,percent of total billed charges,Drugs,17.71,34,,17.71,percent of total billed charges,Drugs,17.71,34,,17.71,percent of total billed charges,Drugs,17.71,34,,17.71,percent of total billed charges,Drugs,17.71,34,,17.71,percent of total billed charges,Drugs,18.23,35,,18.23,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,18.23,35,,18.23,percent of total billed charges,Drugs,18.23,35,,18.23,percent of total billed charges,Drugs,18.23,35,,18.23,percent of total billed charges,Drugs,18.23,35,,18.23,percent of total billed charges,Drugs,18.23,35,,18.23,percent of total billed charges,Drugs,20.84,40,,20.84,percent of total billed charges,Drugs,36.47,70,,36.47,percent of total billed charges,All Other,18.75,36,,18.75,percent of total billed charges,Drugs,18.75,36,,18.75,percent of total billed charges,Drugs,18.23,35,,18.23,percent of total billed charges,Drugs,18.23,35,,18.23,percent of total billed charges,Drugs,18.23,35,,18.23,percent of total billed charges,Drugs,18.23,35,,18.23,percent of total billed charges,Drugs,17.37,,,17.37,Other,Drug Cost,17.37,,,17.37,Other,Drug Cost,17.37,,,17.37,Other,Drug Cost,17.37,,,17.37,Other,Drug Cost,17.37,,,17.37,Other,Drug Cost,17.37,,,17.37,Other,Drug Cost,39.07,,,39.07,Other,225% of Medicaid,24.31,,,24.31,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",37.33,,,37.33,Other,215% Medicaid APG methodology,37.33,,,37.33,Other,215% Medicaid APG methodology,21.71,,,21.71,Other,125% Medicaid APG methodology,0.01,39.07,
HEPARIN SODIUM 1000 UNIT/ML INJ,J1644,HCPCS,,80000992,CDM,636,RC,409272001,NDC,both,25,ML,0.33,2.64,,,2.64,Other,150% of Medicare + 9.63% HCRA Surcharge,1.61,,,1.61,Fee Schedule,Average Sale Price (ASP) x 6,0.11,35,,0.11,percent of total billed charges,Drugs,0.11,35,,0.11,percent of total billed charges,Drugs,0.11,34,,0.11,percent of total billed charges,Drugs,0.11,34,,0.11,percent of total billed charges,Drugs,0.11,34,,0.11,percent of total billed charges,Drugs,0.11,34,,0.11,percent of total billed charges,Drugs,0.11,35,,0.11,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,0.11,35,,0.11,percent of total billed charges,Drugs,0.11,35,,0.11,percent of total billed charges,Drugs,0.11,35,,0.11,percent of total billed charges,Drugs,0.11,35,,0.11,percent of total billed charges,Drugs,0.11,35,,0.11,percent of total billed charges,Drugs,0.13,40,,0.13,percent of total billed charges,Drugs,0.23,70,,0.23,percent of total billed charges,All Other,0.12,36,,0.12,percent of total billed charges,Drugs,0.12,36,,0.12,percent of total billed charges,Drugs,0.11,35,,0.11,percent of total billed charges,Drugs,0.11,35,,0.11,percent of total billed charges,Drugs,0.11,35,,0.11,percent of total billed charges,Drugs,0.11,35,,0.11,percent of total billed charges,Drugs,0.11,,,0.11,Other,Drug Cost,0.11,,,0.11,Other,Drug Cost,0.11,,,0.11,Other,Drug Cost,0.11,,,0.11,Other,Drug Cost,0.11,,,0.11,Other,Drug Cost,0.11,,,0.11,Other,Drug Cost,0.24,,,0.24,Other,225% of Medicaid,0.15,,,0.15,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,2.57,,,2.57,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",0.23,,,0.23,Other,215% Medicaid APG methodology,0.23,,,0.23,Other,215% Medicaid APG methodology,0.14,,,0.14,Other,125% Medicaid APG methodology,0.01,2.64,
HEPARIN SODIUM 5000 UNIT/ML INJ,J1644,HCPCS,,80000996,CDM,636,RC,69005903,NDC,both,25,ML,0.34,2.64,,,2.64,Other,150% of Medicare + 9.63% HCRA Surcharge,1.61,,,1.61,Fee Schedule,Average Sale Price (ASP) x 6,0.12,35,,0.12,percent of total billed charges,Drugs,0.12,35,,0.12,percent of total billed charges,Drugs,0.12,34,,0.12,percent of total billed charges,Drugs,0.12,34,,0.12,percent of total billed charges,Drugs,0.12,34,,0.12,percent of total billed charges,Drugs,0.12,34,,0.12,percent of total billed charges,Drugs,0.12,35,,0.12,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,0.12,35,,0.12,percent of total billed charges,Drugs,0.12,35,,0.12,percent of total billed charges,Drugs,0.12,35,,0.12,percent of total billed charges,Drugs,0.12,35,,0.12,percent of total billed charges,Drugs,0.12,35,,0.12,percent of total billed charges,Drugs,0.14,40,,0.14,percent of total billed charges,Drugs,0.24,70,,0.24,percent of total billed charges,All Other,0.12,36,,0.12,percent of total billed charges,Drugs,0.12,36,,0.12,percent of total billed charges,Drugs,0.12,35,,0.12,percent of total billed charges,Drugs,0.12,35,,0.12,percent of total billed charges,Drugs,0.12,35,,0.12,percent of total billed charges,Drugs,0.12,35,,0.12,percent of total billed charges,Drugs,0.11,,,0.11,Other,Drug Cost,0.11,,,0.11,Other,Drug Cost,0.11,,,0.11,Other,Drug Cost,0.11,,,0.11,Other,Drug Cost,0.11,,,0.11,Other,Drug Cost,0.11,,,0.11,Other,Drug Cost,0.26,,,0.26,Other,225% of Medicaid,0.16,,,0.16,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,2.57,,,2.57,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",0.24,,,0.24,Other,215% Medicaid APG methodology,0.24,,,0.24,Other,215% Medicaid APG methodology,0.14,,,0.14,Other,125% Medicaid APG methodology,0.01,2.64,
HYDRALAZINE HCL 20 MG/1ML INJ,J0360,HCPCS,,80001008,CDM,636,RC,517090125,NDC,both,25,ML,2.76,55.13,,,55.13,Other,150% of Medicare + 9.63% HCRA Surcharge,33.52,,,33.52,Fee Schedule,Average Sale Price (ASP) x 6,0.97,35,,0.97,percent of total billed charges,Drugs,0.97,35,,0.97,percent of total billed charges,Drugs,0.94,34,,0.94,percent of total billed charges,Drugs,0.94,34,,0.94,percent of total billed charges,Drugs,0.94,34,,0.94,percent of total billed charges,Drugs,0.94,34,,0.94,percent of total billed charges,Drugs,0.97,35,,0.97,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,0.97,35,,0.97,percent of total billed charges,Drugs,0.97,35,,0.97,percent of total billed charges,Drugs,0.97,35,,0.97,percent of total billed charges,Drugs,0.97,35,,0.97,percent of total billed charges,Drugs,0.97,35,,0.97,percent of total billed charges,Drugs,1.1,40,,1.1,percent of total billed charges,Drugs,1.93,70,,1.93,percent of total billed charges,All Other,0.99,36,,0.99,percent of total billed charges,Drugs,0.99,36,,0.99,percent of total billed charges,Drugs,0.97,35,,0.97,percent of total billed charges,Drugs,0.97,35,,0.97,percent of total billed charges,Drugs,0.97,35,,0.97,percent of total billed charges,Drugs,0.97,35,,0.97,percent of total billed charges,Drugs,0.92,,,0.92,Other,Drug Cost,0.92,,,0.92,Other,Drug Cost,0.92,,,0.92,Other,Drug Cost,0.92,,,0.92,Other,Drug Cost,0.92,,,0.92,Other,Drug Cost,0.92,,,0.92,Other,Drug Cost,2.07,,,2.07,Other,225% of Medicaid,1.29,,,1.29,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,53.64,,,53.64,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",1.98,,,1.98,Other,215% Medicaid APG methodology,1.98,,,1.98,Other,215% Medicaid APG methodology,1.15,,,1.15,Other,125% Medicaid APG methodology,0.01,55.13,
HYDROCORT SOD SUCC 100MG INJ,J1720,HCPCS,,80001019,CDM,636,RC,9001104,NDC,both,25,EA,0.03,176.07,,,176.07,Other,150% of Medicare + 9.63% HCRA Surcharge,107.07,,,107.07,Fee Schedule,Average Sale Price (ASP) x 6,0.01,35,,0.01,percent of total billed charges,Drugs,0.01,35,,0.01,percent of total billed charges,Drugs,0.01,34,,0.01,percent of total billed charges,Drugs,0.01,34,,0.01,percent of total billed charges,Drugs,0.01,34,,0.01,percent of total billed charges,Drugs,0.01,34,,0.01,percent of total billed charges,Drugs,0.01,35,,0.01,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,0.01,35,,0.01,percent of total billed charges,Drugs,0.01,35,,0.01,percent of total billed charges,Drugs,0.01,35,,0.01,percent of total billed charges,Drugs,0.01,35,,0.01,percent of total billed charges,Drugs,0.01,35,,0.01,percent of total billed charges,Drugs,0.01,40,,0.01,percent of total billed charges,Drugs,0.02,70,,0.02,percent of total billed charges,All Other,0.01,36,,0.01,percent of total billed charges,Drugs,0.01,36,,0.01,percent of total billed charges,Drugs,0.01,35,,0.01,percent of total billed charges,Drugs,0.01,35,,0.01,percent of total billed charges,Drugs,0.01,35,,0.01,percent of total billed charges,Drugs,0.01,35,,0.01,percent of total billed charges,Drugs,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.02,,,0.02,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,171.31,,,171.31,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,176.07,
HYDROMORPHONE (DILAUDID) 2MG/1ML INJ,J1170,HCPCS,,80001032,CDM,636,RC,409131230,NDC,both,10,ML,0.74,45.3,,,45.3,Other,150% of Medicare + 9.63% HCRA Surcharge,27.55,,,27.55,Fee Schedule,Average Sale Price (ASP) x 6,0.26,35,,0.26,percent of total billed charges,Drugs,0.26,35,,0.26,percent of total billed charges,Drugs,0.25,34,,0.25,percent of total billed charges,Drugs,0.25,34,,0.25,percent of total billed charges,Drugs,0.25,34,,0.25,percent of total billed charges,Drugs,0.25,34,,0.25,percent of total billed charges,Drugs,0.26,35,,0.26,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,0.26,35,,0.26,percent of total billed charges,Drugs,0.26,35,,0.26,percent of total billed charges,Drugs,0.26,35,,0.26,percent of total billed charges,Drugs,0.26,35,,0.26,percent of total billed charges,Drugs,0.26,35,,0.26,percent of total billed charges,Drugs,0.29,40,,0.29,percent of total billed charges,Drugs,0.51,70,,0.51,percent of total billed charges,All Other,0.26,36,,0.26,percent of total billed charges,Drugs,0.26,36,,0.26,percent of total billed charges,Drugs,0.26,35,,0.26,percent of total billed charges,Drugs,0.26,35,,0.26,percent of total billed charges,Drugs,0.26,35,,0.26,percent of total billed charges,Drugs,0.26,35,,0.26,percent of total billed charges,Drugs,0.25,,,0.25,Other,Drug Cost,0.25,,,0.25,Other,Drug Cost,0.25,,,0.25,Other,Drug Cost,0.25,,,0.25,Other,Drug Cost,0.25,,,0.25,Other,Drug Cost,0.25,,,0.25,Other,Drug Cost,0.55,,,0.55,Other,225% of Medicaid,0.34,,,0.34,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,44.07,,,44.07,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",0.53,,,0.53,Other,215% Medicaid APG methodology,0.53,,,0.53,Other,215% Medicaid APG methodology,0.31,,,0.31,Other,125% Medicaid APG methodology,0.01,45.3,
HYDROMORPHONE HCL 10MG/1ML INJ,J1170,HCPCS,,80001036,CDM,636,RC,409263401,NDC,both,10,ML,4.64,45.3,,,45.3,Other,150% of Medicare + 9.63% HCRA Surcharge,27.55,,,27.55,Fee Schedule,Average Sale Price (ASP) x 6,1.62,35,,1.62,percent of total billed charges,Drugs,1.62,35,,1.62,percent of total billed charges,Drugs,1.58,34,,1.58,percent of total billed charges,Drugs,1.58,34,,1.58,percent of total billed charges,Drugs,1.58,34,,1.58,percent of total billed charges,Drugs,1.58,34,,1.58,percent of total billed charges,Drugs,1.62,35,,1.62,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,1.62,35,,1.62,percent of total billed charges,Drugs,1.62,35,,1.62,percent of total billed charges,Drugs,1.62,35,,1.62,percent of total billed charges,Drugs,1.62,35,,1.62,percent of total billed charges,Drugs,1.62,35,,1.62,percent of total billed charges,Drugs,1.86,40,,1.86,percent of total billed charges,Drugs,3.25,70,,3.25,percent of total billed charges,All Other,1.67,36,,1.67,percent of total billed charges,Drugs,1.67,36,,1.67,percent of total billed charges,Drugs,1.62,35,,1.62,percent of total billed charges,Drugs,1.62,35,,1.62,percent of total billed charges,Drugs,1.62,35,,1.62,percent of total billed charges,Drugs,1.62,35,,1.62,percent of total billed charges,Drugs,1.55,,,1.55,Other,Drug Cost,1.55,,,1.55,Other,Drug Cost,1.55,,,1.55,Other,Drug Cost,1.55,,,1.55,Other,Drug Cost,1.55,,,1.55,Other,Drug Cost,1.55,,,1.55,Other,Drug Cost,3.48,,,3.48,Other,225% of Medicaid,2.17,,,2.17,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,44.07,,,44.07,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",3.33,,,3.33,Other,215% Medicaid APG methodology,3.33,,,3.33,Other,215% Medicaid APG methodology,1.93,,,1.93,Other,125% Medicaid APG methodology,0.01,45.3,
HYDROMORPHONE HCL 10MG/ML 50ML INJ,J1170,HCPCS,,80001037,CDM,636,RC,409263450,NDC,both,1,ML,232.08,45.3,,,45.3,Other,150% of Medicare + 9.63% HCRA Surcharge,27.55,,,27.55,Fee Schedule,Average Sale Price (ASP) x 6,81.23,35,,81.23,percent of total billed charges,Drugs,81.23,35,,81.23,percent of total billed charges,Drugs,78.91,34,,78.91,percent of total billed charges,Drugs,78.91,34,,78.91,percent of total billed charges,Drugs,78.91,34,,78.91,percent of total billed charges,Drugs,78.91,34,,78.91,percent of total billed charges,Drugs,81.23,35,,81.23,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,81.23,35,,81.23,percent of total billed charges,Drugs,81.23,35,,81.23,percent of total billed charges,Drugs,81.23,35,,81.23,percent of total billed charges,Drugs,81.23,35,,81.23,percent of total billed charges,Drugs,81.23,35,,81.23,percent of total billed charges,Drugs,92.83,40,,92.83,percent of total billed charges,Drugs,162.46,70,,162.46,percent of total billed charges,All Other,83.55,36,,83.55,percent of total billed charges,Drugs,83.55,36,,83.55,percent of total billed charges,Drugs,81.23,35,,81.23,percent of total billed charges,Drugs,81.23,35,,81.23,percent of total billed charges,Drugs,81.23,35,,81.23,percent of total billed charges,Drugs,81.23,35,,81.23,percent of total billed charges,Drugs,77.36,,,77.36,Other,Drug Cost,77.36,,,77.36,Other,Drug Cost,77.36,,,77.36,Other,Drug Cost,77.36,,,77.36,Other,Drug Cost,77.36,,,77.36,Other,Drug Cost,77.36,,,77.36,Other,Drug Cost,174.06,,,174.06,Other,225% of Medicaid,108.3,,,108.3,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,44.07,,,44.07,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",166.32,,,166.32,Other,215% Medicaid APG methodology,166.32,,,166.32,Other,215% Medicaid APG methodology,96.7,,,96.7,Other,125% Medicaid APG methodology,0.01,174.06,
HYDROXYZINE HCL 50MG/1ML INJ,J3410,HCPCS,,80001046,CDM,636,RC,517560125,NDC,both,25,ML,0.03,97.76,,,97.76,Other,150% of Medicare + 9.63% HCRA Surcharge,59.45,,,59.45,Fee Schedule,Average Sale Price (ASP) x 6,0.01,35,,0.01,percent of total billed charges,Drugs,0.01,35,,0.01,percent of total billed charges,Drugs,0.01,34,,0.01,percent of total billed charges,Drugs,0.01,34,,0.01,percent of total billed charges,Drugs,0.01,34,,0.01,percent of total billed charges,Drugs,0.01,34,,0.01,percent of total billed charges,Drugs,0.01,35,,0.01,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,0.01,35,,0.01,percent of total billed charges,Drugs,0.01,35,,0.01,percent of total billed charges,Drugs,0.01,35,,0.01,percent of total billed charges,Drugs,0.01,35,,0.01,percent of total billed charges,Drugs,0.01,35,,0.01,percent of total billed charges,Drugs,0.01,40,,0.01,percent of total billed charges,Drugs,0.02,70,,0.02,percent of total billed charges,All Other,0.01,36,,0.01,percent of total billed charges,Drugs,0.01,36,,0.01,percent of total billed charges,Drugs,0.01,35,,0.01,percent of total billed charges,Drugs,0.01,35,,0.01,percent of total billed charges,Drugs,0.01,35,,0.01,percent of total billed charges,Drugs,0.01,35,,0.01,percent of total billed charges,Drugs,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.02,,,0.02,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,95.12,,,95.12,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,97.76,
IBUTILIDE FUMARATE 1MG/10ML INJ,J1742,HCPCS,,80001058,CDM,636,RC,9379401,NDC,both,1,ML,60.24,23.77,39.4668,,23.77,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,21.08,35,,21.08,percent of total billed charges,Drugs,21.08,35,,21.08,percent of total billed charges,Drugs,20.48,34,,20.48,percent of total billed charges,Drugs,20.48,34,,20.48,percent of total billed charges,Drugs,20.48,34,,20.48,percent of total billed charges,Drugs,20.48,34,,20.48,percent of total billed charges,Drugs,21.08,35,,21.08,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,21.08,35,,21.08,percent of total billed charges,Drugs,21.08,35,,21.08,percent of total billed charges,Drugs,21.08,35,,21.08,percent of total billed charges,Drugs,21.08,35,,21.08,percent of total billed charges,Drugs,21.08,35,,21.08,percent of total billed charges,Drugs,24.1,40,,24.1,percent of total billed charges,Drugs,42.17,70,,42.17,percent of total billed charges,All Other,21.69,36,,21.69,percent of total billed charges,Drugs,21.69,36,,21.69,percent of total billed charges,Drugs,21.08,35,,21.08,percent of total billed charges,Drugs,21.08,35,,21.08,percent of total billed charges,Drugs,21.08,35,,21.08,percent of total billed charges,Drugs,21.08,35,,21.08,percent of total billed charges,Drugs,20.08,,,20.08,Other,Drug Cost,20.08,,,20.08,Other,Drug Cost,20.08,,,20.08,Other,Drug Cost,20.08,,,20.08,Other,Drug Cost,20.08,,,20.08,Other,Drug Cost,20.08,,,20.08,Other,Drug Cost,45.18,,,45.18,Other,225% of Medicaid,28.11,,,28.11,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",43.17,,,43.17,Other,215% Medicaid APG methodology,43.17,,,43.17,Other,215% Medicaid APG methodology,25.1,,,25.1,Other,125% Medicaid APG methodology,0.01,45.18,
IDARUBICIN HCL INJECTION 10MG/10ML,J9211,HCPCS,,80001059,CDM,636,RC,13258691,NDC,both,1,ML,180.42,423.58,,,423.58,Other,150% of Medicare + 9.63% HCRA Surcharge,257.58,,,257.58,Fee Schedule,Average Sale Price (ASP) x 6,63.15,35,,63.15,percent of total billed charges,Drugs,63.15,35,,63.15,percent of total billed charges,Drugs,61.34,34,,61.34,percent of total billed charges,Drugs,61.34,34,,61.34,percent of total billed charges,Drugs,61.34,34,,61.34,percent of total billed charges,Drugs,61.34,34,,61.34,percent of total billed charges,Drugs,63.15,35,,63.15,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,63.15,35,,63.15,percent of total billed charges,Drugs,63.15,35,,63.15,percent of total billed charges,Drugs,63.15,35,,63.15,percent of total billed charges,Drugs,63.15,35,,63.15,percent of total billed charges,Drugs,63.15,35,,63.15,percent of total billed charges,Drugs,72.17,40,,72.17,percent of total billed charges,Drugs,126.29,70,,126.29,percent of total billed charges,All Other,64.95,36,,64.95,percent of total billed charges,Drugs,64.95,36,,64.95,percent of total billed charges,Drugs,63.15,35,,63.15,percent of total billed charges,Drugs,63.15,35,,63.15,percent of total billed charges,Drugs,63.15,35,,63.15,percent of total billed charges,Drugs,63.15,35,,63.15,percent of total billed charges,Drugs,60.14,,,60.14,Other,Drug Cost,60.14,,,60.14,Other,Drug Cost,60.14,,,60.14,Other,Drug Cost,60.14,,,60.14,Other,Drug Cost,60.14,,,60.14,Other,Drug Cost,60.14,,,60.14,Other,Drug Cost,135.32,,,135.32,Other,225% of Medicaid,84.2,,,84.2,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,412.13,,,412.13,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",129.3,,,129.3,Other,215% Medicaid APG methodology,129.3,,,129.3,Other,215% Medicaid APG methodology,75.18,,,75.18,Other,125% Medicaid APG methodology,0.01,423.58,
IDARUBICIN HCL INJECTION 5 MG/5ML,J9211,HCPCS,,80001060,CDM,636,RC,13257691,NDC,both,1,ML,92.91,423.58,,,423.58,Other,150% of Medicare + 9.63% HCRA Surcharge,257.58,,,257.58,Fee Schedule,Average Sale Price (ASP) x 6,32.52,35,,32.52,percent of total billed charges,Drugs,32.52,35,,32.52,percent of total billed charges,Drugs,31.59,34,,31.59,percent of total billed charges,Drugs,31.59,34,,31.59,percent of total billed charges,Drugs,31.59,34,,31.59,percent of total billed charges,Drugs,31.59,34,,31.59,percent of total billed charges,Drugs,32.52,35,,32.52,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,32.52,35,,32.52,percent of total billed charges,Drugs,32.52,35,,32.52,percent of total billed charges,Drugs,32.52,35,,32.52,percent of total billed charges,Drugs,32.52,35,,32.52,percent of total billed charges,Drugs,32.52,35,,32.52,percent of total billed charges,Drugs,37.16,40,,37.16,percent of total billed charges,Drugs,65.04,70,,65.04,percent of total billed charges,All Other,33.45,36,,33.45,percent of total billed charges,Drugs,33.45,36,,33.45,percent of total billed charges,Drugs,32.52,35,,32.52,percent of total billed charges,Drugs,32.52,35,,32.52,percent of total billed charges,Drugs,32.52,35,,32.52,percent of total billed charges,Drugs,32.52,35,,32.52,percent of total billed charges,Drugs,30.97,,,30.97,Other,Drug Cost,30.97,,,30.97,Other,Drug Cost,30.97,,,30.97,Other,Drug Cost,30.97,,,30.97,Other,Drug Cost,30.97,,,30.97,Other,Drug Cost,30.97,,,30.97,Other,Drug Cost,69.68,,,69.68,Other,225% of Medicaid,43.36,,,43.36,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,412.13,,,412.13,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",66.59,,,66.59,Other,215% Medicaid APG methodology,66.59,,,66.59,Other,215% Medicaid APG methodology,38.71,,,38.71,Other,125% Medicaid APG methodology,0.01,423.58,
IFOSFAMIDE INJECTION 1GM,J9208,HCPCS,,80001061,CDM,636,RC,63323014210,NDC,both,1,EA,71.52,263.95,,,263.95,Other,150% of Medicare + 9.63% HCRA Surcharge,160.51,,,160.51,Fee Schedule,Average Sale Price (ASP) x 6,25.03,35,,25.03,percent of total billed charges,Drugs,25.03,35,,25.03,percent of total billed charges,Drugs,24.32,34,,24.32,percent of total billed charges,Drugs,24.32,34,,24.32,percent of total billed charges,Drugs,24.32,34,,24.32,percent of total billed charges,Drugs,24.32,34,,24.32,percent of total billed charges,Drugs,25.03,35,,25.03,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,25.03,35,,25.03,percent of total billed charges,Drugs,25.03,35,,25.03,percent of total billed charges,Drugs,25.03,35,,25.03,percent of total billed charges,Drugs,25.03,35,,25.03,percent of total billed charges,Drugs,25.03,35,,25.03,percent of total billed charges,Drugs,28.61,40,,28.61,percent of total billed charges,Drugs,50.06,70,,50.06,percent of total billed charges,All Other,25.75,36,,25.75,percent of total billed charges,Drugs,25.75,36,,25.75,percent of total billed charges,Drugs,25.03,35,,25.03,percent of total billed charges,Drugs,25.03,35,,25.03,percent of total billed charges,Drugs,25.03,35,,25.03,percent of total billed charges,Drugs,25.03,35,,25.03,percent of total billed charges,Drugs,23.84,,,23.84,Other,Drug Cost,23.84,,,23.84,Other,Drug Cost,23.84,,,23.84,Other,Drug Cost,23.84,,,23.84,Other,Drug Cost,23.84,,,23.84,Other,Drug Cost,23.84,,,23.84,Other,Drug Cost,53.64,,,53.64,Other,225% of Medicaid,33.38,,,33.38,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,256.82,,,256.82,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",51.26,,,51.26,Other,215% Medicaid APG methodology,51.26,,,51.26,Other,215% Medicaid APG methodology,29.8,,,29.8,Other,125% Medicaid APG methodology,0.01,263.95,
IFOSFAMIDE INJECTION 3GM,J9208,HCPCS,,80001062,CDM,636,RC,10019092602,NDC,both,1,EA,77.1,263.95,,,263.95,Other,150% of Medicare + 9.63% HCRA Surcharge,160.51,,,160.51,Fee Schedule,Average Sale Price (ASP) x 6,26.99,35,,26.99,percent of total billed charges,Drugs,26.99,35,,26.99,percent of total billed charges,Drugs,26.21,34,,26.21,percent of total billed charges,Drugs,26.21,34,,26.21,percent of total billed charges,Drugs,26.21,34,,26.21,percent of total billed charges,Drugs,26.21,34,,26.21,percent of total billed charges,Drugs,26.99,35,,26.99,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,26.99,35,,26.99,percent of total billed charges,Drugs,26.99,35,,26.99,percent of total billed charges,Drugs,26.99,35,,26.99,percent of total billed charges,Drugs,26.99,35,,26.99,percent of total billed charges,Drugs,26.99,35,,26.99,percent of total billed charges,Drugs,30.84,40,,30.84,percent of total billed charges,Drugs,53.97,70,,53.97,percent of total billed charges,All Other,27.76,36,,27.76,percent of total billed charges,Drugs,27.76,36,,27.76,percent of total billed charges,Drugs,26.99,35,,26.99,percent of total billed charges,Drugs,26.99,35,,26.99,percent of total billed charges,Drugs,26.99,35,,26.99,percent of total billed charges,Drugs,26.99,35,,26.99,percent of total billed charges,Drugs,25.7,,,25.7,Other,Drug Cost,25.7,,,25.7,Other,Drug Cost,25.7,,,25.7,Other,Drug Cost,25.7,,,25.7,Other,Drug Cost,25.7,,,25.7,Other,Drug Cost,25.7,,,25.7,Other,Drug Cost,57.83,,,57.83,Other,225% of Medicaid,35.98,,,35.98,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,256.82,,,256.82,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",55.26,,,55.26,Other,215% Medicaid APG methodology,55.26,,,55.26,Other,215% Medicaid APG methodology,32.13,,,32.13,Other,125% Medicaid APG methodology,0.01,263.95,
INFLIXIMAB INJ 100 MG,J1745,HCPCS,,80001080,CDM,636,RC,57894016001,NDC,both,1,EA,1360.89,317.32,,,317.32,Other,150% of Medicare + 9.63% HCRA Surcharge,192.97,,,192.97,Fee Schedule,Average Sale Price (ASP) x 6,476.31,35,,476.31,percent of total billed charges,Drugs,476.31,35,,476.31,percent of total billed charges,Drugs,462.7,34,,462.7,percent of total billed charges,Drugs,462.7,34,,462.7,percent of total billed charges,Drugs,462.7,34,,462.7,percent of total billed charges,Drugs,462.7,34,,462.7,percent of total billed charges,Drugs,476.31,35,,476.31,percent of total billed charges,Drugs,462.7,34,"If Charge > 500, then 34 percent",462.7,percent of total billed charges,Drugs,476.31,35,,476.31,percent of total billed charges,Drugs,476.31,35,,476.31,percent of total billed charges,Drugs,476.31,35,,476.31,percent of total billed charges,Drugs,476.31,35,,476.31,percent of total billed charges,Drugs,476.31,35,,476.31,percent of total billed charges,Drugs,544.36,40,,544.36,percent of total billed charges,Drugs,952.62,70,,952.62,percent of total billed charges,All Other,489.92,36,,489.92,percent of total billed charges,Drugs,489.92,36,,489.92,percent of total billed charges,Drugs,476.31,35,,476.31,percent of total billed charges,Drugs,476.31,35,,476.31,percent of total billed charges,Drugs,476.31,35,,476.31,percent of total billed charges,Drugs,476.31,35,,476.31,percent of total billed charges,Drugs,453.63,,,453.63,Other,Drug Cost,453.63,,,453.63,Other,Drug Cost,453.63,,,453.63,Other,Drug Cost,453.63,,,453.63,Other,Drug Cost,453.63,,,453.63,Other,Drug Cost,453.63,,,453.63,Other,Drug Cost,1020.67,,,1020.67,Other,225% of Medicaid,635.08,,,635.08,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,308.75,,,308.75,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",975.3,,,975.3,Other,215% Medicaid APG methodology,975.3,,,975.3,Other,215% Medicaid APG methodology,567.04,,,567.04,Other,125% Medicaid APG methodology,0.01,1020.67,
IPILIMUMAB (YERVOY) 5MG/ML 10ML INJ,J9228,HCPCS,,80001093,CDM,636,RC,3232711,NDC,both,1,ML,25835.28,1701.21,,,1701.21,Other,150% of Medicare + 9.63% HCRA Surcharge,1034.51,,,1034.51,Fee Schedule,Average Sale Price (ASP) x 6,9042.35,35,,9042.35,percent of total billed charges,Drugs,9042.35,35,,9042.35,percent of total billed charges,Drugs,8784,34,,8784,percent of total billed charges,Drugs,8784,34,,8784,percent of total billed charges,Drugs,8784,34,,8784,percent of total billed charges,Drugs,8784,34,,8784,percent of total billed charges,Drugs,9042.35,35,,9042.35,percent of total billed charges,Drugs,8784,34,"If Charge > 500, then 34 percent",8784,percent of total billed charges,Drugs,9042.35,35,,9042.35,percent of total billed charges,Drugs,9042.35,35,,9042.35,percent of total billed charges,Drugs,9042.35,35,,9042.35,percent of total billed charges,Drugs,9042.35,35,,9042.35,percent of total billed charges,Drugs,9042.35,35,,9042.35,percent of total billed charges,Drugs,10334.11,40,,10334.11,percent of total billed charges,Drugs,18084.7,70,,18084.7,percent of total billed charges,All Other,9300.7,36,,9300.7,percent of total billed charges,Drugs,9300.7,36,,9300.7,percent of total billed charges,Drugs,9042.35,35,,9042.35,percent of total billed charges,Drugs,9042.35,35,,9042.35,percent of total billed charges,Drugs,9042.35,35,,9042.35,percent of total billed charges,Drugs,9042.35,35,,9042.35,percent of total billed charges,Drugs,8611.76,,,8611.76,Other,Drug Cost,8611.76,,,8611.76,Other,Drug Cost,8611.76,,,8611.76,Other,Drug Cost,8611.76,,,8611.76,Other,Drug Cost,8611.76,,,8611.76,Other,Drug Cost,8611.76,,,8611.76,Other,Drug Cost,19376.46,,,19376.46,Other,225% of Medicaid,12056.46,,,12056.46,Other,140% of Medicaid,8784,34,"If Charge > 2,000, then 34 percent",8784,percent of total billed charges,Drugs,1655.22,,,1655.22,Other,160% Medicare Fee Schedule,8784,34,,8784,Other,"Drug Charges > 20,000, then 34% of Charges",18515.28,,,18515.28,Other,215% Medicaid APG methodology,18515.28,,,18515.28,Other,215% Medicaid APG methodology,10764.7,,,10764.7,Other,125% Medicaid APG methodology,1034.51,19376.46,
IRON SUCROSE (VENOFER) INJ 20MG/ML 5ML,J1756,HCPCS,,80001102,CDM,636,RC,517234010,NDC,both,10,ML,74.74,2.18,,,2.18,Other,150% of Medicare + 9.63% HCRA Surcharge,1.33,,,1.33,Fee Schedule,Average Sale Price (ASP) x 6,26.16,35,,26.16,percent of total billed charges,Drugs,26.16,35,,26.16,percent of total billed charges,Drugs,25.41,34,,25.41,percent of total billed charges,Drugs,25.41,34,,25.41,percent of total billed charges,Drugs,25.41,34,,25.41,percent of total billed charges,Drugs,25.41,34,,25.41,percent of total billed charges,Drugs,26.16,35,,26.16,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,26.16,35,,26.16,percent of total billed charges,Drugs,26.16,35,,26.16,percent of total billed charges,Drugs,26.16,35,,26.16,percent of total billed charges,Drugs,26.16,35,,26.16,percent of total billed charges,Drugs,26.16,35,,26.16,percent of total billed charges,Drugs,29.89,40,,29.89,percent of total billed charges,Drugs,52.32,70,,52.32,percent of total billed charges,All Other,26.9,36,,26.9,percent of total billed charges,Drugs,26.9,36,,26.9,percent of total billed charges,Drugs,26.16,35,,26.16,percent of total billed charges,Drugs,26.16,35,,26.16,percent of total billed charges,Drugs,26.16,35,,26.16,percent of total billed charges,Drugs,26.16,35,,26.16,percent of total billed charges,Drugs,24.91,,,24.91,Other,Drug Cost,24.91,,,24.91,Other,Drug Cost,24.91,,,24.91,Other,Drug Cost,24.91,,,24.91,Other,Drug Cost,24.91,,,24.91,Other,Drug Cost,24.91,,,24.91,Other,Drug Cost,56.05,,,56.05,Other,225% of Medicaid,34.88,,,34.88,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,2.12,,,2.12,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",53.56,,,53.56,Other,215% Medicaid APG methodology,53.56,,,53.56,Other,215% Medicaid APG methodology,31.14,,,31.14,Other,125% Medicaid APG methodology,0.01,56.05,
LACOSAMIDE (VIMPAT) 10MG/ML 20ML INJ,C9254,HCPCS,,80001135,CDM,636,RC,131181067,NDC,both,10,ML,88.19,34.81,39.4668,,34.81,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,30.87,35,,30.87,percent of total billed charges,Drugs,30.87,35,,30.87,percent of total billed charges,Drugs,29.98,34,,29.98,percent of total billed charges,Drugs,29.98,34,,29.98,percent of total billed charges,Drugs,29.98,34,,29.98,percent of total billed charges,Drugs,29.98,34,,29.98,percent of total billed charges,Drugs,30.87,35,,30.87,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,30.87,35,,30.87,percent of total billed charges,Drugs,30.87,35,,30.87,percent of total billed charges,Drugs,30.87,35,,30.87,percent of total billed charges,Drugs,30.87,35,,30.87,percent of total billed charges,Drugs,30.87,35,,30.87,percent of total billed charges,Drugs,35.28,40,,35.28,percent of total billed charges,Drugs,61.73,70,,61.73,percent of total billed charges,All Other,31.75,36,,31.75,percent of total billed charges,Drugs,31.75,36,,31.75,percent of total billed charges,Drugs,30.87,35,,30.87,percent of total billed charges,Drugs,30.87,35,,30.87,percent of total billed charges,Drugs,30.87,35,,30.87,percent of total billed charges,Drugs,30.87,35,,30.87,percent of total billed charges,Drugs,29.4,,,29.4,Other,Drug Cost,29.4,,,29.4,Other,Drug Cost,29.4,,,29.4,Other,Drug Cost,29.4,,,29.4,Other,Drug Cost,29.4,,,29.4,Other,Drug Cost,29.4,,,29.4,Other,Drug Cost,66.14,,,66.14,Other,225% of Medicaid,41.16,,,41.16,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",63.2,,,63.2,Other,215% Medicaid APG methodology,63.2,,,63.2,Other,215% Medicaid APG methodology,36.75,,,36.75,Other,125% Medicaid APG methodology,0.01,66.14,
LACTATED RINGERS 1000ML,J7120,HCPCS,,80001139,CDM,636,RC,264775000,NDC,both,1000,ML,2.91,25.56,,,25.56,Other,150% of Medicare + 9.63% HCRA Surcharge,15.55,,,15.55,Fee Schedule,Average Sale Price (ASP) x 6,1.02,35,,1.02,percent of total billed charges,Drugs,1.02,35,,1.02,percent of total billed charges,Drugs,0.99,34,,0.99,percent of total billed charges,Drugs,0.99,34,,0.99,percent of total billed charges,Drugs,0.99,34,,0.99,percent of total billed charges,Drugs,0.99,34,,0.99,percent of total billed charges,Drugs,1.02,35,,1.02,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,1.02,35,,1.02,percent of total billed charges,Drugs,1.02,35,,1.02,percent of total billed charges,Drugs,1.02,35,,1.02,percent of total billed charges,Drugs,1.02,35,,1.02,percent of total billed charges,Drugs,1.02,35,,1.02,percent of total billed charges,Drugs,1.16,40,,1.16,percent of total billed charges,Drugs,2.03,70,,2.03,percent of total billed charges,All Other,1.05,36,,1.05,percent of total billed charges,Drugs,1.05,36,,1.05,percent of total billed charges,Drugs,1.02,35,,1.02,percent of total billed charges,Drugs,1.02,35,,1.02,percent of total billed charges,Drugs,1.02,35,,1.02,percent of total billed charges,Drugs,1.02,35,,1.02,percent of total billed charges,Drugs,0.97,,,0.97,Other,Drug Cost,0.97,,,0.97,Other,Drug Cost,0.97,,,0.97,Other,Drug Cost,0.97,,,0.97,Other,Drug Cost,0.97,,,0.97,Other,Drug Cost,0.97,,,0.97,Other,Drug Cost,2.18,,,2.18,Other,225% of Medicaid,1.36,,,1.36,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,24.87,,,24.87,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",2.08,,,2.08,Other,215% Medicaid APG methodology,2.08,,,2.08,Other,215% Medicaid APG methodology,1.21,,,1.21,Other,125% Medicaid APG methodology,0.01,25.56,
LACTATED RINGERS 500ML,J7120,HCPCS,,80001140,CDM,636,RC,264775010,NDC,both,24,ML,1.45,25.56,,,25.56,Other,150% of Medicare + 9.63% HCRA Surcharge,15.55,,,15.55,Fee Schedule,Average Sale Price (ASP) x 6,0.51,35,,0.51,percent of total billed charges,Drugs,0.51,35,,0.51,percent of total billed charges,Drugs,0.49,34,,0.49,percent of total billed charges,Drugs,0.49,34,,0.49,percent of total billed charges,Drugs,0.49,34,,0.49,percent of total billed charges,Drugs,0.49,34,,0.49,percent of total billed charges,Drugs,0.51,35,,0.51,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,0.51,35,,0.51,percent of total billed charges,Drugs,0.51,35,,0.51,percent of total billed charges,Drugs,0.51,35,,0.51,percent of total billed charges,Drugs,0.51,35,,0.51,percent of total billed charges,Drugs,0.51,35,,0.51,percent of total billed charges,Drugs,0.58,40,,0.58,percent of total billed charges,Drugs,1.02,70,,1.02,percent of total billed charges,All Other,0.52,36,,0.52,percent of total billed charges,Drugs,0.52,36,,0.52,percent of total billed charges,Drugs,0.51,35,,0.51,percent of total billed charges,Drugs,0.51,35,,0.51,percent of total billed charges,Drugs,0.51,35,,0.51,percent of total billed charges,Drugs,0.51,35,,0.51,percent of total billed charges,Drugs,0.48,,,0.48,Other,Drug Cost,0.48,,,0.48,Other,Drug Cost,0.48,,,0.48,Other,Drug Cost,0.48,,,0.48,Other,Drug Cost,0.48,,,0.48,Other,Drug Cost,0.48,,,0.48,Other,Drug Cost,1.09,,,1.09,Other,225% of Medicaid,0.68,,,0.68,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,24.87,,,24.87,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",1.04,,,1.04,Other,215% Medicaid APG methodology,1.04,,,1.04,Other,215% Medicaid APG methodology,0.61,,,0.61,Other,125% Medicaid APG methodology,0.01,25.56,
LEUCOVORIN CALCIUM 100MG INJ,J0640,HCPCS,,80001152,CDM,636,RC,25021081430,NDC,both,1,EA,19.32,44.1,,,44.1,Other,150% of Medicare + 9.63% HCRA Surcharge,26.82,,,26.82,Fee Schedule,Average Sale Price (ASP) x 6,6.76,35,,6.76,percent of total billed charges,Drugs,6.76,35,,6.76,percent of total billed charges,Drugs,6.57,34,,6.57,percent of total billed charges,Drugs,6.57,34,,6.57,percent of total billed charges,Drugs,6.57,34,,6.57,percent of total billed charges,Drugs,6.57,34,,6.57,percent of total billed charges,Drugs,6.76,35,,6.76,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,6.76,35,,6.76,percent of total billed charges,Drugs,6.76,35,,6.76,percent of total billed charges,Drugs,6.76,35,,6.76,percent of total billed charges,Drugs,6.76,35,,6.76,percent of total billed charges,Drugs,6.76,35,,6.76,percent of total billed charges,Drugs,7.73,40,,7.73,percent of total billed charges,Drugs,13.52,70,,13.52,percent of total billed charges,All Other,6.96,36,,6.96,percent of total billed charges,Drugs,6.96,36,,6.96,percent of total billed charges,Drugs,6.76,35,,6.76,percent of total billed charges,Drugs,6.76,35,,6.76,percent of total billed charges,Drugs,6.76,35,,6.76,percent of total billed charges,Drugs,6.76,35,,6.76,percent of total billed charges,Drugs,6.44,,,6.44,Other,Drug Cost,6.44,,,6.44,Other,Drug Cost,6.44,,,6.44,Other,Drug Cost,6.44,,,6.44,Other,Drug Cost,6.44,,,6.44,Other,Drug Cost,6.44,,,6.44,Other,Drug Cost,14.49,,,14.49,Other,225% of Medicaid,9.02,,,9.02,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,42.91,,,42.91,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",13.85,,,13.85,Other,215% Medicaid APG methodology,13.85,,,13.85,Other,215% Medicaid APG methodology,8.05,,,8.05,Other,125% Medicaid APG methodology,0.01,44.1,
LEUCOVORIN CALCIUM 200MG INJ,J0640,HCPCS,,80001153,CDM,636,RC,143936801,NDC,both,1,EA,27.3,44.1,,,44.1,Other,150% of Medicare + 9.63% HCRA Surcharge,26.82,,,26.82,Fee Schedule,Average Sale Price (ASP) x 6,9.56,35,,9.56,percent of total billed charges,Drugs,9.56,35,,9.56,percent of total billed charges,Drugs,9.28,34,,9.28,percent of total billed charges,Drugs,9.28,34,,9.28,percent of total billed charges,Drugs,9.28,34,,9.28,percent of total billed charges,Drugs,9.28,34,,9.28,percent of total billed charges,Drugs,9.56,35,,9.56,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,9.56,35,,9.56,percent of total billed charges,Drugs,9.56,35,,9.56,percent of total billed charges,Drugs,9.56,35,,9.56,percent of total billed charges,Drugs,9.56,35,,9.56,percent of total billed charges,Drugs,9.56,35,,9.56,percent of total billed charges,Drugs,10.92,40,,10.92,percent of total billed charges,Drugs,19.11,70,,19.11,percent of total billed charges,All Other,9.83,36,,9.83,percent of total billed charges,Drugs,9.83,36,,9.83,percent of total billed charges,Drugs,9.56,35,,9.56,percent of total billed charges,Drugs,9.56,35,,9.56,percent of total billed charges,Drugs,9.56,35,,9.56,percent of total billed charges,Drugs,9.56,35,,9.56,percent of total billed charges,Drugs,9.1,,,9.1,Other,Drug Cost,9.1,,,9.1,Other,Drug Cost,9.1,,,9.1,Other,Drug Cost,9.1,,,9.1,Other,Drug Cost,9.1,,,9.1,Other,Drug Cost,9.1,,,9.1,Other,Drug Cost,20.48,,,20.48,Other,225% of Medicaid,12.74,,,12.74,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,42.91,,,42.91,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",19.57,,,19.57,Other,215% Medicaid APG methodology,19.57,,,19.57,Other,215% Medicaid APG methodology,11.38,,,11.38,Other,125% Medicaid APG methodology,0.01,44.1,
LEUCOVORIN CALCIUM 50MG INJ,J0640,HCPCS,,80001154,CDM,636,RC,143955501,NDC,both,1,EA,2.76,44.1,,,44.1,Other,150% of Medicare + 9.63% HCRA Surcharge,26.82,,,26.82,Fee Schedule,Average Sale Price (ASP) x 6,0.97,35,,0.97,percent of total billed charges,Drugs,0.97,35,,0.97,percent of total billed charges,Drugs,0.94,34,,0.94,percent of total billed charges,Drugs,0.94,34,,0.94,percent of total billed charges,Drugs,0.94,34,,0.94,percent of total billed charges,Drugs,0.94,34,,0.94,percent of total billed charges,Drugs,0.97,35,,0.97,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,0.97,35,,0.97,percent of total billed charges,Drugs,0.97,35,,0.97,percent of total billed charges,Drugs,0.97,35,,0.97,percent of total billed charges,Drugs,0.97,35,,0.97,percent of total billed charges,Drugs,0.97,35,,0.97,percent of total billed charges,Drugs,1.1,40,,1.1,percent of total billed charges,Drugs,1.93,70,,1.93,percent of total billed charges,All Other,0.99,36,,0.99,percent of total billed charges,Drugs,0.99,36,,0.99,percent of total billed charges,Drugs,0.97,35,,0.97,percent of total billed charges,Drugs,0.97,35,,0.97,percent of total billed charges,Drugs,0.97,35,,0.97,percent of total billed charges,Drugs,0.97,35,,0.97,percent of total billed charges,Drugs,0.92,,,0.92,Other,Drug Cost,0.92,,,0.92,Other,Drug Cost,0.92,,,0.92,Other,Drug Cost,0.92,,,0.92,Other,Drug Cost,0.92,,,0.92,Other,Drug Cost,0.92,,,0.92,Other,Drug Cost,2.07,,,2.07,Other,225% of Medicaid,1.29,,,1.29,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,42.91,,,42.91,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",1.98,,,1.98,Other,215% Medicaid APG methodology,1.98,,,1.98,Other,215% Medicaid APG methodology,1.15,,,1.15,Other,125% Medicaid APG methodology,0.01,44.1,
LEUPROLIDE ACETATE (LUPRON DEPOT) 3.75MG,J1950,HCPCS,,80001156,CDM,636,RC,74364103,NDC,both,1,EA,4661.79,15437.48,,,15437.48,Other,150% of Medicare + 9.63% HCRA Surcharge,9387.62,,,9387.62,Fee Schedule,Average Sale Price (ASP) x 6,1631.63,35,,1631.63,percent of total billed charges,Drugs,1631.63,35,,1631.63,percent of total billed charges,Drugs,1585.01,34,,1585.01,percent of total billed charges,Drugs,1585.01,34,,1585.01,percent of total billed charges,Drugs,1585.01,34,,1585.01,percent of total billed charges,Drugs,1585.01,34,,1585.01,percent of total billed charges,Drugs,1631.63,35,,1631.63,percent of total billed charges,Drugs,1585.01,34,"If Charge > 500, then 34 percent",1585.01,percent of total billed charges,Drugs,1631.63,35,,1631.63,percent of total billed charges,Drugs,1631.63,35,,1631.63,percent of total billed charges,Drugs,1631.63,35,,1631.63,percent of total billed charges,Drugs,1631.63,35,,1631.63,percent of total billed charges,Drugs,1631.63,35,,1631.63,percent of total billed charges,Drugs,1864.72,40,,1864.72,percent of total billed charges,Drugs,3263.25,70,,3263.25,percent of total billed charges,All Other,1678.24,36,,1678.24,percent of total billed charges,Drugs,1678.24,36,,1678.24,percent of total billed charges,Drugs,1631.63,35,,1631.63,percent of total billed charges,Drugs,1631.63,35,,1631.63,percent of total billed charges,Drugs,1631.63,35,,1631.63,percent of total billed charges,Drugs,1631.63,35,,1631.63,percent of total billed charges,Drugs,1553.93,,,1553.93,Other,Drug Cost,1553.93,,,1553.93,Other,Drug Cost,1553.93,,,1553.93,Other,Drug Cost,1553.93,,,1553.93,Other,Drug Cost,1553.93,,,1553.93,Other,Drug Cost,1553.93,,,1553.93,Other,Drug Cost,3496.34,,,3496.34,Other,225% of Medicaid,2175.5,,,2175.5,Other,140% of Medicaid,1585.01,34,"If Charge > 2,000, then 34 percent",1585.01,percent of total billed charges,Drugs,15020.2,,,15020.2,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",3340.95,,,3340.95,Other,215% Medicaid APG methodology,3340.95,,,3340.95,Other,215% Medicaid APG methodology,1942.41,,,1942.41,Other,125% Medicaid APG methodology,0.01,15437.48,
LEVETIRACETAM INJECTION 500MG/5ML,J1953,HCPCS,,80001163,CDM,636,RC,25021078005,NDC,both,10,ML,3.13,0.62,,,0.62,Other,150% of Medicare + 9.63% HCRA Surcharge,0.38,,,0.38,Fee Schedule,Average Sale Price (ASP) x 6,1.09,35,,1.09,percent of total billed charges,Drugs,1.09,35,,1.09,percent of total billed charges,Drugs,1.06,34,,1.06,percent of total billed charges,Drugs,1.06,34,,1.06,percent of total billed charges,Drugs,1.06,34,,1.06,percent of total billed charges,Drugs,1.06,34,,1.06,percent of total billed charges,Drugs,1.09,35,,1.09,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,1.09,35,,1.09,percent of total billed charges,Drugs,1.09,35,,1.09,percent of total billed charges,Drugs,1.09,35,,1.09,percent of total billed charges,Drugs,1.09,35,,1.09,percent of total billed charges,Drugs,1.09,35,,1.09,percent of total billed charges,Drugs,1.25,40,,1.25,percent of total billed charges,Drugs,2.19,70,,2.19,percent of total billed charges,All Other,1.13,36,,1.13,percent of total billed charges,Drugs,1.13,36,,1.13,percent of total billed charges,Drugs,1.09,35,,1.09,percent of total billed charges,Drugs,1.09,35,,1.09,percent of total billed charges,Drugs,1.09,35,,1.09,percent of total billed charges,Drugs,1.09,35,,1.09,percent of total billed charges,Drugs,1.04,,,1.04,Other,Drug Cost,1.04,,,1.04,Other,Drug Cost,1.04,,,1.04,Other,Drug Cost,1.04,,,1.04,Other,Drug Cost,1.04,,,1.04,Other,Drug Cost,1.04,,,1.04,Other,Drug Cost,2.34,,,2.34,Other,225% of Medicaid,1.46,,,1.46,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,0.6,,,0.6,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",2.24,,,2.24,Other,215% Medicaid APG methodology,2.24,,,2.24,Other,215% Medicaid APG methodology,1.3,,,1.3,Other,125% Medicaid APG methodology,0.01,2.34,
LEVOFLOXACIN 250 MG/50ML IV,J1956,HCPCS,,80001170,CDM,636,RC,25021013281,NDC,both,24,ML,4.03,8.96,,,8.96,Other,150% of Medicare + 9.63% HCRA Surcharge,5.45,,,5.45,Fee Schedule,Average Sale Price (ASP) x 6,1.41,35,,1.41,percent of total billed charges,Drugs,1.41,35,,1.41,percent of total billed charges,Drugs,1.37,34,,1.37,percent of total billed charges,Drugs,1.37,34,,1.37,percent of total billed charges,Drugs,1.37,34,,1.37,percent of total billed charges,Drugs,1.37,34,,1.37,percent of total billed charges,Drugs,1.41,35,,1.41,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,1.41,35,,1.41,percent of total billed charges,Drugs,1.41,35,,1.41,percent of total billed charges,Drugs,1.41,35,,1.41,percent of total billed charges,Drugs,1.41,35,,1.41,percent of total billed charges,Drugs,1.41,35,,1.41,percent of total billed charges,Drugs,1.61,40,,1.61,percent of total billed charges,Drugs,2.82,70,,2.82,percent of total billed charges,All Other,1.45,36,,1.45,percent of total billed charges,Drugs,1.45,36,,1.45,percent of total billed charges,Drugs,1.41,35,,1.41,percent of total billed charges,Drugs,1.41,35,,1.41,percent of total billed charges,Drugs,1.41,35,,1.41,percent of total billed charges,Drugs,1.41,35,,1.41,percent of total billed charges,Drugs,1.34,,,1.34,Other,Drug Cost,1.34,,,1.34,Other,Drug Cost,1.34,,,1.34,Other,Drug Cost,1.34,,,1.34,Other,Drug Cost,1.34,,,1.34,Other,Drug Cost,1.34,,,1.34,Other,Drug Cost,3.02,,,3.02,Other,225% of Medicaid,1.88,,,1.88,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,8.72,,,8.72,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",2.89,,,2.89,Other,215% Medicaid APG methodology,2.89,,,2.89,Other,215% Medicaid APG methodology,1.68,,,1.68,Other,125% Medicaid APG methodology,0.01,8.96,
LEVOFLOXACIN 500MG/100ML IV,J1956,HCPCS,,80001173,CDM,636,RC,143972124,NDC,both,24,ML,4.59,8.96,,,8.96,Other,150% of Medicare + 9.63% HCRA Surcharge,5.45,,,5.45,Fee Schedule,Average Sale Price (ASP) x 6,1.61,35,,1.61,percent of total billed charges,Drugs,1.61,35,,1.61,percent of total billed charges,Drugs,1.56,34,,1.56,percent of total billed charges,Drugs,1.56,34,,1.56,percent of total billed charges,Drugs,1.56,34,,1.56,percent of total billed charges,Drugs,1.56,34,,1.56,percent of total billed charges,Drugs,1.61,35,,1.61,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,1.61,35,,1.61,percent of total billed charges,Drugs,1.61,35,,1.61,percent of total billed charges,Drugs,1.61,35,,1.61,percent of total billed charges,Drugs,1.61,35,,1.61,percent of total billed charges,Drugs,1.61,35,,1.61,percent of total billed charges,Drugs,1.84,40,,1.84,percent of total billed charges,Drugs,3.21,70,,3.21,percent of total billed charges,All Other,1.65,36,,1.65,percent of total billed charges,Drugs,1.65,36,,1.65,percent of total billed charges,Drugs,1.61,35,,1.61,percent of total billed charges,Drugs,1.61,35,,1.61,percent of total billed charges,Drugs,1.61,35,,1.61,percent of total billed charges,Drugs,1.61,35,,1.61,percent of total billed charges,Drugs,1.53,,,1.53,Other,Drug Cost,1.53,,,1.53,Other,Drug Cost,1.53,,,1.53,Other,Drug Cost,1.53,,,1.53,Other,Drug Cost,1.53,,,1.53,Other,Drug Cost,1.53,,,1.53,Other,Drug Cost,3.44,,,3.44,Other,225% of Medicaid,2.14,,,2.14,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,8.72,,,8.72,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",3.29,,,3.29,Other,215% Medicaid APG methodology,3.29,,,3.29,Other,215% Medicaid APG methodology,1.91,,,1.91,Other,125% Medicaid APG methodology,0.01,8.96,
LEVOFLOXACIN 750MG/150ML IV,J1956,HCPCS,,80001175,CDM,636,RC,409052835,NDC,both,24,ML,4.25,8.96,,,8.96,Other,150% of Medicare + 9.63% HCRA Surcharge,5.45,,,5.45,Fee Schedule,Average Sale Price (ASP) x 6,1.49,35,,1.49,percent of total billed charges,Drugs,1.49,35,,1.49,percent of total billed charges,Drugs,1.45,34,,1.45,percent of total billed charges,Drugs,1.45,34,,1.45,percent of total billed charges,Drugs,1.45,34,,1.45,percent of total billed charges,Drugs,1.45,34,,1.45,percent of total billed charges,Drugs,1.49,35,,1.49,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,1.49,35,,1.49,percent of total billed charges,Drugs,1.49,35,,1.49,percent of total billed charges,Drugs,1.49,35,,1.49,percent of total billed charges,Drugs,1.49,35,,1.49,percent of total billed charges,Drugs,1.49,35,,1.49,percent of total billed charges,Drugs,1.7,40,,1.7,percent of total billed charges,Drugs,2.98,70,,2.98,percent of total billed charges,All Other,1.53,36,,1.53,percent of total billed charges,Drugs,1.53,36,,1.53,percent of total billed charges,Drugs,1.49,35,,1.49,percent of total billed charges,Drugs,1.49,35,,1.49,percent of total billed charges,Drugs,1.49,35,,1.49,percent of total billed charges,Drugs,1.49,35,,1.49,percent of total billed charges,Drugs,1.42,,,1.42,Other,Drug Cost,1.42,,,1.42,Other,Drug Cost,1.42,,,1.42,Other,Drug Cost,1.42,,,1.42,Other,Drug Cost,1.42,,,1.42,Other,Drug Cost,1.42,,,1.42,Other,Drug Cost,3.19,,,3.19,Other,225% of Medicaid,1.98,,,1.98,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,8.72,,,8.72,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",3.05,,,3.05,Other,215% Medicaid APG methodology,3.05,,,3.05,Other,215% Medicaid APG methodology,1.77,,,1.77,Other,125% Medicaid APG methodology,0.01,8.96,
LIDOCAINE HCL  2GM/500ML IV,J2001,HCPCS,,80001200,CDM,636,RC,338040903,NDC,both,18,ML,10.84,0.27,,,0.27,Other,150% of Medicare + 9.63% HCRA Surcharge,0.16,,,0.16,Fee Schedule,Average Sale Price (ASP) x 6,3.79,35,,3.79,percent of total billed charges,Drugs,3.79,35,,3.79,percent of total billed charges,Drugs,3.69,34,,3.69,percent of total billed charges,Drugs,3.69,34,,3.69,percent of total billed charges,Drugs,3.69,34,,3.69,percent of total billed charges,Drugs,3.69,34,,3.69,percent of total billed charges,Drugs,3.79,35,,3.79,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,3.79,35,,3.79,percent of total billed charges,Drugs,3.79,35,,3.79,percent of total billed charges,Drugs,3.79,35,,3.79,percent of total billed charges,Drugs,3.79,35,,3.79,percent of total billed charges,Drugs,3.79,35,,3.79,percent of total billed charges,Drugs,4.34,40,,4.34,percent of total billed charges,Drugs,7.59,70,,7.59,percent of total billed charges,All Other,3.9,36,,3.9,percent of total billed charges,Drugs,3.9,36,,3.9,percent of total billed charges,Drugs,3.79,35,,3.79,percent of total billed charges,Drugs,3.79,35,,3.79,percent of total billed charges,Drugs,3.79,35,,3.79,percent of total billed charges,Drugs,3.79,35,,3.79,percent of total billed charges,Drugs,3.61,,,3.61,Other,Drug Cost,3.61,,,3.61,Other,Drug Cost,3.61,,,3.61,Other,Drug Cost,3.61,,,3.61,Other,Drug Cost,3.61,,,3.61,Other,Drug Cost,3.61,,,3.61,Other,Drug Cost,8.13,,,8.13,Other,225% of Medicaid,5.06,,,5.06,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,0.26,,,0.26,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",7.77,,,7.77,Other,215% Medicaid APG methodology,7.77,,,7.77,Other,215% Medicaid APG methodology,4.52,,,4.52,Other,125% Medicaid APG methodology,0.01,8.13,
LIDOCAINE HCL 20 MG/ML 5ML ABBOJ,J2001,HCPCS,,80001202,CDM,636,RC,409132305,NDC,both,10,ML,5.77,0.27,,,0.27,Other,150% of Medicare + 9.63% HCRA Surcharge,0.16,,,0.16,Fee Schedule,Average Sale Price (ASP) x 6,2.02,35,,2.02,percent of total billed charges,Drugs,2.02,35,,2.02,percent of total billed charges,Drugs,1.96,34,,1.96,percent of total billed charges,Drugs,1.96,34,,1.96,percent of total billed charges,Drugs,1.96,34,,1.96,percent of total billed charges,Drugs,1.96,34,,1.96,percent of total billed charges,Drugs,2.02,35,,2.02,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,2.02,35,,2.02,percent of total billed charges,Drugs,2.02,35,,2.02,percent of total billed charges,Drugs,2.02,35,,2.02,percent of total billed charges,Drugs,2.02,35,,2.02,percent of total billed charges,Drugs,2.02,35,,2.02,percent of total billed charges,Drugs,2.31,40,,2.31,percent of total billed charges,Drugs,4.04,70,,4.04,percent of total billed charges,All Other,2.08,36,,2.08,percent of total billed charges,Drugs,2.08,36,,2.08,percent of total billed charges,Drugs,2.02,35,,2.02,percent of total billed charges,Drugs,2.02,35,,2.02,percent of total billed charges,Drugs,2.02,35,,2.02,percent of total billed charges,Drugs,2.02,35,,2.02,percent of total billed charges,Drugs,1.92,,,1.92,Other,Drug Cost,1.92,,,1.92,Other,Drug Cost,1.92,,,1.92,Other,Drug Cost,1.92,,,1.92,Other,Drug Cost,1.92,,,1.92,Other,Drug Cost,1.92,,,1.92,Other,Drug Cost,4.33,,,4.33,Other,225% of Medicaid,2.69,,,2.69,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,0.26,,,0.26,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",4.14,,,4.14,Other,215% Medicaid APG methodology,4.14,,,4.14,Other,215% Medicaid APG methodology,2.41,,,2.41,Other,125% Medicaid APG methodology,0.01,4.33,
LINEZOLID 600MG/300ML IV,J2020,HCPCS,,80001217,CDM,636,RC,55150024251,NDC,both,10,ML,14.25,32.54,,,32.54,Other,150% of Medicare + 9.63% HCRA Surcharge,19.79,,,19.79,Fee Schedule,Average Sale Price (ASP) x 6,4.99,35,,4.99,percent of total billed charges,Drugs,4.99,35,,4.99,percent of total billed charges,Drugs,4.85,34,,4.85,percent of total billed charges,Drugs,4.85,34,,4.85,percent of total billed charges,Drugs,4.85,34,,4.85,percent of total billed charges,Drugs,4.85,34,,4.85,percent of total billed charges,Drugs,4.99,35,,4.99,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,4.99,35,,4.99,percent of total billed charges,Drugs,4.99,35,,4.99,percent of total billed charges,Drugs,4.99,35,,4.99,percent of total billed charges,Drugs,4.99,35,,4.99,percent of total billed charges,Drugs,4.99,35,,4.99,percent of total billed charges,Drugs,5.7,40,,5.7,percent of total billed charges,Drugs,9.98,70,,9.98,percent of total billed charges,All Other,5.13,36,,5.13,percent of total billed charges,Drugs,5.13,36,,5.13,percent of total billed charges,Drugs,4.99,35,,4.99,percent of total billed charges,Drugs,4.99,35,,4.99,percent of total billed charges,Drugs,4.99,35,,4.99,percent of total billed charges,Drugs,4.99,35,,4.99,percent of total billed charges,Drugs,4.75,,,4.75,Other,Drug Cost,4.75,,,4.75,Other,Drug Cost,4.75,,,4.75,Other,Drug Cost,4.75,,,4.75,Other,Drug Cost,4.75,,,4.75,Other,Drug Cost,4.75,,,4.75,Other,Drug Cost,10.69,,,10.69,Other,225% of Medicaid,6.65,,,6.65,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,31.66,,,31.66,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",10.21,,,10.21,Other,215% Medicaid APG methodology,10.21,,,10.21,Other,215% Medicaid APG methodology,5.94,,,5.94,Other,125% Medicaid APG methodology,0.01,32.54,
LORAZEPAM INJ 2 MG/ML,J2060,HCPCS,,80001244,CDM,636,RC,641604425,NDC,both,25,ML,1.08,11.07,,,11.07,Other,150% of Medicare + 9.63% HCRA Surcharge,6.73,,,6.73,Fee Schedule,Average Sale Price (ASP) x 6,0.38,35,,0.38,percent of total billed charges,Drugs,0.38,35,,0.38,percent of total billed charges,Drugs,0.37,34,,0.37,percent of total billed charges,Drugs,0.37,34,,0.37,percent of total billed charges,Drugs,0.37,34,,0.37,percent of total billed charges,Drugs,0.37,34,,0.37,percent of total billed charges,Drugs,0.38,35,,0.38,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,0.38,35,,0.38,percent of total billed charges,Drugs,0.38,35,,0.38,percent of total billed charges,Drugs,0.38,35,,0.38,percent of total billed charges,Drugs,0.38,35,,0.38,percent of total billed charges,Drugs,0.38,35,,0.38,percent of total billed charges,Drugs,0.43,40,,0.43,percent of total billed charges,Drugs,0.76,70,,0.76,percent of total billed charges,All Other,0.39,36,,0.39,percent of total billed charges,Drugs,0.39,36,,0.39,percent of total billed charges,Drugs,0.38,35,,0.38,percent of total billed charges,Drugs,0.38,35,,0.38,percent of total billed charges,Drugs,0.38,35,,0.38,percent of total billed charges,Drugs,0.38,35,,0.38,percent of total billed charges,Drugs,0.36,,,0.36,Other,Drug Cost,0.36,,,0.36,Other,Drug Cost,0.36,,,0.36,Other,Drug Cost,0.36,,,0.36,Other,Drug Cost,0.36,,,0.36,Other,Drug Cost,0.36,,,0.36,Other,Drug Cost,0.81,,,0.81,Other,225% of Medicaid,0.5,,,0.5,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,10.77,,,10.77,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",0.77,,,0.77,Other,215% Medicaid APG methodology,0.77,,,0.77,Other,215% Medicaid APG methodology,0.45,,,0.45,Other,125% Medicaid APG methodology,0.01,11.07,
MAGNESIUM SULFATE 2GM/50ML,J3475,HCPCS,,80001263,CDM,636,RC,25021061281,NDC,both,10,ML,4.08,6.82,,,6.82,Other,150% of Medicare + 9.63% HCRA Surcharge,4.15,,,4.15,Fee Schedule,Average Sale Price (ASP) x 6,1.43,35,,1.43,percent of total billed charges,Drugs,1.43,35,,1.43,percent of total billed charges,Drugs,1.39,34,,1.39,percent of total billed charges,Drugs,1.39,34,,1.39,percent of total billed charges,Drugs,1.39,34,,1.39,percent of total billed charges,Drugs,1.39,34,,1.39,percent of total billed charges,Drugs,1.43,35,,1.43,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,1.43,35,,1.43,percent of total billed charges,Drugs,1.43,35,,1.43,percent of total billed charges,Drugs,1.43,35,,1.43,percent of total billed charges,Drugs,1.43,35,,1.43,percent of total billed charges,Drugs,1.43,35,,1.43,percent of total billed charges,Drugs,1.63,40,,1.63,percent of total billed charges,Drugs,2.85,70,,2.85,percent of total billed charges,All Other,1.47,36,,1.47,percent of total billed charges,Drugs,1.47,36,,1.47,percent of total billed charges,Drugs,1.43,35,,1.43,percent of total billed charges,Drugs,1.43,35,,1.43,percent of total billed charges,Drugs,1.43,35,,1.43,percent of total billed charges,Drugs,1.43,35,,1.43,percent of total billed charges,Drugs,1.36,,,1.36,Other,Drug Cost,1.36,,,1.36,Other,Drug Cost,1.36,,,1.36,Other,Drug Cost,1.36,,,1.36,Other,Drug Cost,1.36,,,1.36,Other,Drug Cost,1.36,,,1.36,Other,Drug Cost,3.06,,,3.06,Other,225% of Medicaid,1.9,,,1.9,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,6.63,,,6.63,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",2.92,,,2.92,Other,215% Medicaid APG methodology,2.92,,,2.92,Other,215% Medicaid APG methodology,1.7,,,1.7,Other,125% Medicaid APG methodology,0.01,6.82,
MAGNESIUM SULFATE 4MEQ/ML 2ML INJ,J3475,HCPCS,,80001265,CDM,636,RC,63323006403,NDC,both,25,ML,0.81,6.82,,,6.82,Other,150% of Medicare + 9.63% HCRA Surcharge,4.15,,,4.15,Fee Schedule,Average Sale Price (ASP) x 6,0.29,35,,0.29,percent of total billed charges,Drugs,0.29,35,,0.29,percent of total billed charges,Drugs,0.28,34,,0.28,percent of total billed charges,Drugs,0.28,34,,0.28,percent of total billed charges,Drugs,0.28,34,,0.28,percent of total billed charges,Drugs,0.28,34,,0.28,percent of total billed charges,Drugs,0.29,35,,0.29,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,0.29,35,,0.29,percent of total billed charges,Drugs,0.29,35,,0.29,percent of total billed charges,Drugs,0.29,35,,0.29,percent of total billed charges,Drugs,0.29,35,,0.29,percent of total billed charges,Drugs,0.29,35,,0.29,percent of total billed charges,Drugs,0.33,40,,0.33,percent of total billed charges,Drugs,0.57,70,,0.57,percent of total billed charges,All Other,0.29,36,,0.29,percent of total billed charges,Drugs,0.29,36,,0.29,percent of total billed charges,Drugs,0.29,35,,0.29,percent of total billed charges,Drugs,0.29,35,,0.29,percent of total billed charges,Drugs,0.29,35,,0.29,percent of total billed charges,Drugs,0.29,35,,0.29,percent of total billed charges,Drugs,0.27,,,0.27,Other,Drug Cost,0.27,,,0.27,Other,Drug Cost,0.27,,,0.27,Other,Drug Cost,0.27,,,0.27,Other,Drug Cost,0.27,,,0.27,Other,Drug Cost,0.27,,,0.27,Other,Drug Cost,0.61,,,0.61,Other,225% of Medicaid,0.38,,,0.38,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,6.63,,,6.63,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",0.58,,,0.58,Other,215% Medicaid APG methodology,0.58,,,0.58,Other,215% Medicaid APG methodology,0.34,,,0.34,Other,125% Medicaid APG methodology,0.01,6.82,
MANNITOL INJ 25% IN 50 ML,J2150,HCPCS,,80001267,CDM,636,RC,409403101,NDC,both,25,ML,4.42,25.6,,,25.6,Other,150% of Medicare + 9.63% HCRA Surcharge,15.57,,,15.57,Fee Schedule,Average Sale Price (ASP) x 6,1.55,35,,1.55,percent of total billed charges,Drugs,1.55,35,,1.55,percent of total billed charges,Drugs,1.5,34,,1.5,percent of total billed charges,Drugs,1.5,34,,1.5,percent of total billed charges,Drugs,1.5,34,,1.5,percent of total billed charges,Drugs,1.5,34,,1.5,percent of total billed charges,Drugs,1.55,35,,1.55,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,1.55,35,,1.55,percent of total billed charges,Drugs,1.55,35,,1.55,percent of total billed charges,Drugs,1.55,35,,1.55,percent of total billed charges,Drugs,1.55,35,,1.55,percent of total billed charges,Drugs,1.55,35,,1.55,percent of total billed charges,Drugs,1.77,40,,1.77,percent of total billed charges,Drugs,3.09,70,,3.09,percent of total billed charges,All Other,1.59,36,,1.59,percent of total billed charges,Drugs,1.59,36,,1.59,percent of total billed charges,Drugs,1.55,35,,1.55,percent of total billed charges,Drugs,1.55,35,,1.55,percent of total billed charges,Drugs,1.55,35,,1.55,percent of total billed charges,Drugs,1.55,35,,1.55,percent of total billed charges,Drugs,1.47,,,1.47,Other,Drug Cost,1.47,,,1.47,Other,Drug Cost,1.47,,,1.47,Other,Drug Cost,1.47,,,1.47,Other,Drug Cost,1.47,,,1.47,Other,Drug Cost,1.47,,,1.47,Other,Drug Cost,3.32,,,3.32,Other,225% of Medicaid,2.06,,,2.06,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,24.91,,,24.91,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",3.17,,,3.17,Other,215% Medicaid APG methodology,3.17,,,3.17,Other,215% Medicaid APG methodology,1.84,,,1.84,Other,125% Medicaid APG methodology,0.01,25.6,
MEPERIDINE (DEMEROL) HCL 50MG INJ,J2175,HCPCS,,80001289,CDM,636,RC,409117830,NDC,both,10,ML,0.03,72.02,,,72.02,Other,150% of Medicare + 9.63% HCRA Surcharge,43.79,,,43.79,Fee Schedule,Average Sale Price (ASP) x 6,0.01,35,,0.01,percent of total billed charges,Drugs,0.01,35,,0.01,percent of total billed charges,Drugs,0.01,34,,0.01,percent of total billed charges,Drugs,0.01,34,,0.01,percent of total billed charges,Drugs,0.01,34,,0.01,percent of total billed charges,Drugs,0.01,34,,0.01,percent of total billed charges,Drugs,0.01,35,,0.01,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,0.01,35,,0.01,percent of total billed charges,Drugs,0.01,35,,0.01,percent of total billed charges,Drugs,0.01,35,,0.01,percent of total billed charges,Drugs,0.01,35,,0.01,percent of total billed charges,Drugs,0.01,35,,0.01,percent of total billed charges,Drugs,0.01,40,,0.01,percent of total billed charges,Drugs,0.02,70,,0.02,percent of total billed charges,All Other,0.01,36,,0.01,percent of total billed charges,Drugs,0.01,36,,0.01,percent of total billed charges,Drugs,0.01,35,,0.01,percent of total billed charges,Drugs,0.01,35,,0.01,percent of total billed charges,Drugs,0.01,35,,0.01,percent of total billed charges,Drugs,0.01,35,,0.01,percent of total billed charges,Drugs,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.02,,,0.02,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,70.07,,,70.07,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,72.02,
MEPIVACAINE 1.5% 30ML INJ,J0670,HCPCS,,80001292,CDM,636,RC,63323029337,NDC,both,25,ML,19.08,32.46,,,32.46,Other,150% of Medicare + 9.63% HCRA Surcharge,19.74,,,19.74,Fee Schedule,Average Sale Price (ASP) x 6,6.68,35,,6.68,percent of total billed charges,Drugs,6.68,35,,6.68,percent of total billed charges,Drugs,6.49,34,,6.49,percent of total billed charges,Drugs,6.49,34,,6.49,percent of total billed charges,Drugs,6.49,34,,6.49,percent of total billed charges,Drugs,6.49,34,,6.49,percent of total billed charges,Drugs,6.68,35,,6.68,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,6.68,35,,6.68,percent of total billed charges,Drugs,6.68,35,,6.68,percent of total billed charges,Drugs,6.68,35,,6.68,percent of total billed charges,Drugs,6.68,35,,6.68,percent of total billed charges,Drugs,6.68,35,,6.68,percent of total billed charges,Drugs,7.63,40,,7.63,percent of total billed charges,Drugs,13.36,70,,13.36,percent of total billed charges,All Other,6.87,36,,6.87,percent of total billed charges,Drugs,6.87,36,,6.87,percent of total billed charges,Drugs,6.68,35,,6.68,percent of total billed charges,Drugs,6.68,35,,6.68,percent of total billed charges,Drugs,6.68,35,,6.68,percent of total billed charges,Drugs,6.68,35,,6.68,percent of total billed charges,Drugs,6.36,,,6.36,Other,Drug Cost,6.36,,,6.36,Other,Drug Cost,6.36,,,6.36,Other,Drug Cost,6.36,,,6.36,Other,Drug Cost,6.36,,,6.36,Other,Drug Cost,6.36,,,6.36,Other,Drug Cost,14.31,,,14.31,Other,225% of Medicaid,8.9,,,8.9,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,31.58,,,31.58,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",13.67,,,13.67,Other,215% Medicaid APG methodology,13.67,,,13.67,Other,215% Medicaid APG methodology,7.95,,,7.95,Other,125% Medicaid APG methodology,0.01,32.46,
MEPIVACAINE HCL 1% INJ 30ML,J0670,HCPCS,,80001296,CDM,636,RC,63323026037,NDC,both,25,ML,11.96,32.46,,,32.46,Other,150% of Medicare + 9.63% HCRA Surcharge,19.74,,,19.74,Fee Schedule,Average Sale Price (ASP) x 6,4.19,35,,4.19,percent of total billed charges,Drugs,4.19,35,,4.19,percent of total billed charges,Drugs,4.07,34,,4.07,percent of total billed charges,Drugs,4.07,34,,4.07,percent of total billed charges,Drugs,4.07,34,,4.07,percent of total billed charges,Drugs,4.07,34,,4.07,percent of total billed charges,Drugs,4.19,35,,4.19,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,4.19,35,,4.19,percent of total billed charges,Drugs,4.19,35,,4.19,percent of total billed charges,Drugs,4.19,35,,4.19,percent of total billed charges,Drugs,4.19,35,,4.19,percent of total billed charges,Drugs,4.19,35,,4.19,percent of total billed charges,Drugs,4.78,40,,4.78,percent of total billed charges,Drugs,8.37,70,,8.37,percent of total billed charges,All Other,4.3,36,,4.3,percent of total billed charges,Drugs,4.3,36,,4.3,percent of total billed charges,Drugs,4.19,35,,4.19,percent of total billed charges,Drugs,4.19,35,,4.19,percent of total billed charges,Drugs,4.19,35,,4.19,percent of total billed charges,Drugs,4.19,35,,4.19,percent of total billed charges,Drugs,3.99,,,3.99,Other,Drug Cost,3.99,,,3.99,Other,Drug Cost,3.99,,,3.99,Other,Drug Cost,3.99,,,3.99,Other,Drug Cost,3.99,,,3.99,Other,Drug Cost,3.99,,,3.99,Other,Drug Cost,8.97,,,8.97,Other,225% of Medicaid,5.58,,,5.58,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,31.58,,,31.58,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",8.57,,,8.57,Other,215% Medicaid APG methodology,8.57,,,8.57,Other,215% Medicaid APG methodology,4.98,,,4.98,Other,125% Medicaid APG methodology,0.01,32.46,
MEROPENEM 100 MG INJ,J2185,HCPCS,,80001301,CDM,636,RC,63323050830,NDC,both,10,EA,6.16,4.46,,,4.46,Other,150% of Medicare + 9.63% HCRA Surcharge,2.71,,,2.71,Fee Schedule,Average Sale Price (ASP) x 6,2.16,35,,2.16,percent of total billed charges,Drugs,2.16,35,,2.16,percent of total billed charges,Drugs,2.1,34,,2.1,percent of total billed charges,Drugs,2.1,34,,2.1,percent of total billed charges,Drugs,2.1,34,,2.1,percent of total billed charges,Drugs,2.1,34,,2.1,percent of total billed charges,Drugs,2.16,35,,2.16,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,2.16,35,,2.16,percent of total billed charges,Drugs,2.16,35,,2.16,percent of total billed charges,Drugs,2.16,35,,2.16,percent of total billed charges,Drugs,2.16,35,,2.16,percent of total billed charges,Drugs,2.16,35,,2.16,percent of total billed charges,Drugs,2.46,40,,2.46,percent of total billed charges,Drugs,4.31,70,,4.31,percent of total billed charges,All Other,2.22,36,,2.22,percent of total billed charges,Drugs,2.22,36,,2.22,percent of total billed charges,Drugs,2.16,35,,2.16,percent of total billed charges,Drugs,2.16,35,,2.16,percent of total billed charges,Drugs,2.16,35,,2.16,percent of total billed charges,Drugs,2.16,35,,2.16,percent of total billed charges,Drugs,2.05,,,2.05,Other,Drug Cost,2.05,,,2.05,Other,Drug Cost,2.05,,,2.05,Other,Drug Cost,2.05,,,2.05,Other,Drug Cost,2.05,,,2.05,Other,Drug Cost,2.05,,,2.05,Other,Drug Cost,4.62,,,4.62,Other,225% of Medicaid,2.88,,,2.88,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,4.34,,,4.34,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",4.42,,,4.42,Other,215% Medicaid APG methodology,4.42,,,4.42,Other,215% Medicaid APG methodology,2.57,,,2.57,Other,125% Medicaid APG methodology,0.01,4.62,
MESNA 200MG INJ,J9209,HCPCS,,80001308,CDM,636,RC,25021020110,NDC,both,1,ML,14.4,13.54,,,13.54,Other,150% of Medicare + 9.63% HCRA Surcharge,8.23,,,8.23,Fee Schedule,Average Sale Price (ASP) x 6,5.04,35,,5.04,percent of total billed charges,Drugs,5.04,35,,5.04,percent of total billed charges,Drugs,4.9,34,,4.9,percent of total billed charges,Drugs,4.9,34,,4.9,percent of total billed charges,Drugs,4.9,34,,4.9,percent of total billed charges,Drugs,4.9,34,,4.9,percent of total billed charges,Drugs,5.04,35,,5.04,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,5.04,35,,5.04,percent of total billed charges,Drugs,5.04,35,,5.04,percent of total billed charges,Drugs,5.04,35,,5.04,percent of total billed charges,Drugs,5.04,35,,5.04,percent of total billed charges,Drugs,5.04,35,,5.04,percent of total billed charges,Drugs,5.76,40,,5.76,percent of total billed charges,Drugs,10.08,70,,10.08,percent of total billed charges,All Other,5.18,36,,5.18,percent of total billed charges,Drugs,5.18,36,,5.18,percent of total billed charges,Drugs,5.04,35,,5.04,percent of total billed charges,Drugs,5.04,35,,5.04,percent of total billed charges,Drugs,5.04,35,,5.04,percent of total billed charges,Drugs,5.04,35,,5.04,percent of total billed charges,Drugs,4.8,,,4.8,Other,Drug Cost,4.8,,,4.8,Other,Drug Cost,4.8,,,4.8,Other,Drug Cost,4.8,,,4.8,Other,Drug Cost,4.8,,,4.8,Other,Drug Cost,4.8,,,4.8,Other,Drug Cost,10.8,,,10.8,Other,225% of Medicaid,6.72,,,6.72,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,13.17,,,13.17,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",10.32,,,10.32,Other,215% Medicaid APG methodology,10.32,,,10.32,Other,215% Medicaid APG methodology,6,,,6,Other,125% Medicaid APG methodology,0.01,13.54,
METHOTREXATE 100MG/4ML INJ,J9250,HCPCS,,80001329,CDM,636,RC,61703035038,NDC,both,5,ML,8.36,3.03,,,3.03,Other,150% of Medicare + 9.63% HCRA Surcharge,1.84,,,1.84,Fee Schedule,Average Sale Price (ASP) x 6,2.93,35,,2.93,percent of total billed charges,Drugs,2.93,35,,2.93,percent of total billed charges,Drugs,2.84,34,,2.84,percent of total billed charges,Drugs,2.84,34,,2.84,percent of total billed charges,Drugs,2.84,34,,2.84,percent of total billed charges,Drugs,2.84,34,,2.84,percent of total billed charges,Drugs,2.93,35,,2.93,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,2.93,35,,2.93,percent of total billed charges,Drugs,2.93,35,,2.93,percent of total billed charges,Drugs,2.93,35,,2.93,percent of total billed charges,Drugs,2.93,35,,2.93,percent of total billed charges,Drugs,2.93,35,,2.93,percent of total billed charges,Drugs,3.34,40,,3.34,percent of total billed charges,Drugs,5.85,70,,5.85,percent of total billed charges,All Other,3.01,36,,3.01,percent of total billed charges,Drugs,3.01,36,,3.01,percent of total billed charges,Drugs,2.93,35,,2.93,percent of total billed charges,Drugs,2.93,35,,2.93,percent of total billed charges,Drugs,2.93,35,,2.93,percent of total billed charges,Drugs,2.93,35,,2.93,percent of total billed charges,Drugs,2.79,,,2.79,Other,Drug Cost,2.79,,,2.79,Other,Drug Cost,2.79,,,2.79,Other,Drug Cost,2.79,,,2.79,Other,Drug Cost,2.79,,,2.79,Other,Drug Cost,2.79,,,2.79,Other,Drug Cost,6.27,,,6.27,Other,225% of Medicaid,3.9,,,3.9,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,2.95,,,2.95,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",5.99,,,5.99,Other,215% Medicaid APG methodology,5.99,,,5.99,Other,215% Medicaid APG methodology,3.48,,,3.48,Other,125% Medicaid APG methodology,0.01,6.27,
METHOTREXATE 2.5MG TAB,J8610,HCPCS,,80001330,CDM,636,RC,54455025,NDC,both,100,EA,0.1,2.63,,,2.63,Other,150% of Medicare + 9.63% HCRA Surcharge,1.6,,,1.6,Fee Schedule,Average Sale Price (ASP) x 6,0.04,35,,0.04,percent of total billed charges,Drugs,0.04,35,,0.04,percent of total billed charges,Drugs,0.03,34,,0.03,percent of total billed charges,Drugs,0.03,34,,0.03,percent of total billed charges,Drugs,0.03,34,,0.03,percent of total billed charges,Drugs,0.03,34,,0.03,percent of total billed charges,Drugs,0.04,35,,0.04,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,0.04,35,,0.04,percent of total billed charges,Drugs,0.04,35,,0.04,percent of total billed charges,Drugs,0.04,35,,0.04,percent of total billed charges,Drugs,0.04,35,,0.04,percent of total billed charges,Drugs,0.04,35,,0.04,percent of total billed charges,Drugs,0.04,40,,0.04,percent of total billed charges,Drugs,0.07,70,,0.07,percent of total billed charges,All Other,0.04,36,,0.04,percent of total billed charges,Drugs,0.04,36,,0.04,percent of total billed charges,Drugs,0.04,35,,0.04,percent of total billed charges,Drugs,0.04,35,,0.04,percent of total billed charges,Drugs,0.04,35,,0.04,percent of total billed charges,Drugs,0.04,35,,0.04,percent of total billed charges,Drugs,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.08,,,0.08,Other,225% of Medicaid,0.05,,,0.05,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,2.56,,,2.56,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",0.07,,,0.07,Other,215% Medicaid APG methodology,0.07,,,0.07,Other,215% Medicaid APG methodology,0.04,,,0.04,Other,125% Medicaid APG methodology,0.01,2.63,
METHYLNALTREXONE 12MG INJ,J2212,HCPCS,,80001335,CDM,636,RC,65649055103,NDC,both,7,ML,0.03,0.01,39.4668,,0.01,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,35,,0.01,percent of total billed charges,Drugs,0.01,35,,0.01,percent of total billed charges,Drugs,0.01,34,,0.01,percent of total billed charges,Drugs,0.01,34,,0.01,percent of total billed charges,Drugs,0.01,34,,0.01,percent of total billed charges,Drugs,0.01,34,,0.01,percent of total billed charges,Drugs,0.01,35,,0.01,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,0.01,35,,0.01,percent of total billed charges,Drugs,0.01,35,,0.01,percent of total billed charges,Drugs,0.01,35,,0.01,percent of total billed charges,Drugs,0.01,35,,0.01,percent of total billed charges,Drugs,0.01,35,,0.01,percent of total billed charges,Drugs,0.01,40,,0.01,percent of total billed charges,Drugs,0.02,70,,0.02,percent of total billed charges,All Other,0.01,36,,0.01,percent of total billed charges,Drugs,0.01,36,,0.01,percent of total billed charges,Drugs,0.01,35,,0.01,percent of total billed charges,Drugs,0.01,35,,0.01,percent of total billed charges,Drugs,0.01,35,,0.01,percent of total billed charges,Drugs,0.01,35,,0.01,percent of total billed charges,Drugs,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.02,,,0.02,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,0.02,
METHYLPREDNISOLONE 125 MG INJ,J2930,HCPCS,,80001338,CDM,636,RC,9004722,NDC,both,25,EA,3.05,58.04,,,58.04,Other,150% of Medicare + 9.63% HCRA Surcharge,35.29,,,35.29,Fee Schedule,Average Sale Price (ASP) x 6,1.07,35,,1.07,percent of total billed charges,Drugs,1.07,35,,1.07,percent of total billed charges,Drugs,1.04,34,,1.04,percent of total billed charges,Drugs,1.04,34,,1.04,percent of total billed charges,Drugs,1.04,34,,1.04,percent of total billed charges,Drugs,1.04,34,,1.04,percent of total billed charges,Drugs,1.07,35,,1.07,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,1.07,35,,1.07,percent of total billed charges,Drugs,1.07,35,,1.07,percent of total billed charges,Drugs,1.07,35,,1.07,percent of total billed charges,Drugs,1.07,35,,1.07,percent of total billed charges,Drugs,1.07,35,,1.07,percent of total billed charges,Drugs,1.22,40,,1.22,percent of total billed charges,Drugs,2.14,70,,2.14,percent of total billed charges,All Other,1.1,36,,1.1,percent of total billed charges,Drugs,1.1,36,,1.1,percent of total billed charges,Drugs,1.07,35,,1.07,percent of total billed charges,Drugs,1.07,35,,1.07,percent of total billed charges,Drugs,1.07,35,,1.07,percent of total billed charges,Drugs,1.07,35,,1.07,percent of total billed charges,Drugs,1.02,,,1.02,Other,Drug Cost,1.02,,,1.02,Other,Drug Cost,1.02,,,1.02,Other,Drug Cost,1.02,,,1.02,Other,Drug Cost,1.02,,,1.02,Other,Drug Cost,1.02,,,1.02,Other,Drug Cost,2.29,,,2.29,Other,225% of Medicaid,1.42,,,1.42,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,56.47,,,56.47,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",2.19,,,2.19,Other,215% Medicaid APG methodology,2.19,,,2.19,Other,215% Medicaid APG methodology,1.27,,,1.27,Other,125% Medicaid APG methodology,0.01,58.04,
METHYLPREDNISOLONE 4 MG TAB,J7509,HCPCS,,80001339,CDM,636,RC,603459321,NDC,both,100,EA,0.03,2.24,,,2.24,Other,150% of Medicare + 9.63% HCRA Surcharge,1.36,,,1.36,Fee Schedule,Average Sale Price (ASP) x 6,0.01,35,,0.01,percent of total billed charges,Drugs,0.01,35,,0.01,percent of total billed charges,Drugs,0.01,34,,0.01,percent of total billed charges,Drugs,0.01,34,,0.01,percent of total billed charges,Drugs,0.01,34,,0.01,percent of total billed charges,Drugs,0.01,34,,0.01,percent of total billed charges,Drugs,0.01,35,,0.01,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,0.01,35,,0.01,percent of total billed charges,Drugs,0.01,35,,0.01,percent of total billed charges,Drugs,0.01,35,,0.01,percent of total billed charges,Drugs,0.01,35,,0.01,percent of total billed charges,Drugs,0.01,35,,0.01,percent of total billed charges,Drugs,0.01,40,,0.01,percent of total billed charges,Drugs,0.02,70,,0.02,percent of total billed charges,All Other,0.01,36,,0.01,percent of total billed charges,Drugs,0.01,36,,0.01,percent of total billed charges,Drugs,0.01,35,,0.01,percent of total billed charges,Drugs,0.01,35,,0.01,percent of total billed charges,Drugs,0.01,35,,0.01,percent of total billed charges,Drugs,0.01,35,,0.01,percent of total billed charges,Drugs,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.02,,,0.02,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,2.18,,,2.18,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,2.24,
METHYLPREDNISOLONE ACETATE 80 MG INJ,J1040,HCPCS,,80001340,CDM,636,RC,9347501,NDC,both,1,ML,6.57,96.72,,,96.72,Other,150% of Medicare + 9.63% HCRA Surcharge,58.82,,,58.82,Fee Schedule,Average Sale Price (ASP) x 6,2.3,35,,2.3,percent of total billed charges,Drugs,2.3,35,,2.3,percent of total billed charges,Drugs,2.23,34,,2.23,percent of total billed charges,Drugs,2.23,34,,2.23,percent of total billed charges,Drugs,2.23,34,,2.23,percent of total billed charges,Drugs,2.23,34,,2.23,percent of total billed charges,Drugs,2.3,35,,2.3,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,2.3,35,,2.3,percent of total billed charges,Drugs,2.3,35,,2.3,percent of total billed charges,Drugs,2.3,35,,2.3,percent of total billed charges,Drugs,2.3,35,,2.3,percent of total billed charges,Drugs,2.3,35,,2.3,percent of total billed charges,Drugs,2.63,40,,2.63,percent of total billed charges,Drugs,4.6,70,,4.6,percent of total billed charges,All Other,2.37,36,,2.37,percent of total billed charges,Drugs,2.37,36,,2.37,percent of total billed charges,Drugs,2.3,35,,2.3,percent of total billed charges,Drugs,2.3,35,,2.3,percent of total billed charges,Drugs,2.3,35,,2.3,percent of total billed charges,Drugs,2.3,35,,2.3,percent of total billed charges,Drugs,2.19,,,2.19,Other,Drug Cost,2.19,,,2.19,Other,Drug Cost,2.19,,,2.19,Other,Drug Cost,2.19,,,2.19,Other,Drug Cost,2.19,,,2.19,Other,Drug Cost,2.19,,,2.19,Other,Drug Cost,4.93,,,4.93,Other,225% of Medicaid,3.07,,,3.07,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,94.11,,,94.11,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",4.71,,,4.71,Other,215% Medicaid APG methodology,4.71,,,4.71,Other,215% Medicaid APG methodology,2.74,,,2.74,Other,125% Medicaid APG methodology,0.01,96.72,
METHYLPREDNISOLONE INJ 40MG/ML,J2920,HCPCS,,80001342,CDM,636,RC,9003928,NDC,both,25,EA,1.43,41.32,,,41.32,Other,150% of Medicare + 9.63% HCRA Surcharge,25.13,,,25.13,Fee Schedule,Average Sale Price (ASP) x 6,0.5,35,,0.5,percent of total billed charges,Drugs,0.5,35,,0.5,percent of total billed charges,Drugs,0.48,34,,0.48,percent of total billed charges,Drugs,0.48,34,,0.48,percent of total billed charges,Drugs,0.48,34,,0.48,percent of total billed charges,Drugs,0.48,34,,0.48,percent of total billed charges,Drugs,0.5,35,,0.5,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,0.5,35,,0.5,percent of total billed charges,Drugs,0.5,35,,0.5,percent of total billed charges,Drugs,0.5,35,,0.5,percent of total billed charges,Drugs,0.5,35,,0.5,percent of total billed charges,Drugs,0.5,35,,0.5,percent of total billed charges,Drugs,0.57,40,,0.57,percent of total billed charges,Drugs,1,70,,1,percent of total billed charges,All Other,0.51,36,,0.51,percent of total billed charges,Drugs,0.51,36,,0.51,percent of total billed charges,Drugs,0.5,35,,0.5,percent of total billed charges,Drugs,0.5,35,,0.5,percent of total billed charges,Drugs,0.5,35,,0.5,percent of total billed charges,Drugs,0.5,35,,0.5,percent of total billed charges,Drugs,0.48,,,0.48,Other,Drug Cost,0.48,,,0.48,Other,Drug Cost,0.48,,,0.48,Other,Drug Cost,0.48,,,0.48,Other,Drug Cost,0.48,,,0.48,Other,Drug Cost,0.48,,,0.48,Other,Drug Cost,1.07,,,1.07,Other,225% of Medicaid,0.67,,,0.67,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,40.2,,,40.2,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",1.02,,,1.02,Other,215% Medicaid APG methodology,1.02,,,1.02,Other,215% Medicaid APG methodology,0.59,,,0.59,Other,125% Medicaid APG methodology,0.01,41.32,
METOCLOPRAMIDE 10MG INJ,J2765,HCPCS,,80001343,CDM,636,RC,703450204,NDC,both,25,ML,1.03,10.79,,,10.79,Other,150% of Medicare + 9.63% HCRA Surcharge,6.56,,,6.56,Fee Schedule,Average Sale Price (ASP) x 6,0.36,35,,0.36,percent of total billed charges,Drugs,0.36,35,,0.36,percent of total billed charges,Drugs,0.35,34,,0.35,percent of total billed charges,Drugs,0.35,34,,0.35,percent of total billed charges,Drugs,0.35,34,,0.35,percent of total billed charges,Drugs,0.35,34,,0.35,percent of total billed charges,Drugs,0.36,35,,0.36,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,0.36,35,,0.36,percent of total billed charges,Drugs,0.36,35,,0.36,percent of total billed charges,Drugs,0.36,35,,0.36,percent of total billed charges,Drugs,0.36,35,,0.36,percent of total billed charges,Drugs,0.36,35,,0.36,percent of total billed charges,Drugs,0.41,40,,0.41,percent of total billed charges,Drugs,0.72,70,,0.72,percent of total billed charges,All Other,0.37,36,,0.37,percent of total billed charges,Drugs,0.37,36,,0.37,percent of total billed charges,Drugs,0.36,35,,0.36,percent of total billed charges,Drugs,0.36,35,,0.36,percent of total billed charges,Drugs,0.36,35,,0.36,percent of total billed charges,Drugs,0.36,35,,0.36,percent of total billed charges,Drugs,0.34,,,0.34,Other,Drug Cost,0.34,,,0.34,Other,Drug Cost,0.34,,,0.34,Other,Drug Cost,0.34,,,0.34,Other,Drug Cost,0.34,,,0.34,Other,Drug Cost,0.34,,,0.34,Other,Drug Cost,0.77,,,0.77,Other,225% of Medicaid,0.48,,,0.48,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,10.5,,,10.5,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",0.74,,,0.74,Other,215% Medicaid APG methodology,0.74,,,0.74,Other,215% Medicaid APG methodology,0.43,,,0.43,Other,125% Medicaid APG methodology,0.01,10.79,
MICAFUNGIN 100MG INJ,J2248,HCPCS,,80001360,CDM,636,RC,25021019110,NDC,both,1,EA,84.39,7.47,,,7.47,Other,150% of Medicare + 9.63% HCRA Surcharge,4.54,,,4.54,Fee Schedule,Average Sale Price (ASP) x 6,29.54,35,,29.54,percent of total billed charges,Drugs,29.54,35,,29.54,percent of total billed charges,Drugs,28.69,34,,28.69,percent of total billed charges,Drugs,28.69,34,,28.69,percent of total billed charges,Drugs,28.69,34,,28.69,percent of total billed charges,Drugs,28.69,34,,28.69,percent of total billed charges,Drugs,29.54,35,,29.54,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,29.54,35,,29.54,percent of total billed charges,Drugs,29.54,35,,29.54,percent of total billed charges,Drugs,29.54,35,,29.54,percent of total billed charges,Drugs,29.54,35,,29.54,percent of total billed charges,Drugs,29.54,35,,29.54,percent of total billed charges,Drugs,33.76,40,,33.76,percent of total billed charges,Drugs,59.07,70,,59.07,percent of total billed charges,All Other,30.38,36,,30.38,percent of total billed charges,Drugs,30.38,36,,30.38,percent of total billed charges,Drugs,29.54,35,,29.54,percent of total billed charges,Drugs,29.54,35,,29.54,percent of total billed charges,Drugs,29.54,35,,29.54,percent of total billed charges,Drugs,29.54,35,,29.54,percent of total billed charges,Drugs,28.13,,,28.13,Other,Drug Cost,28.13,,,28.13,Other,Drug Cost,28.13,,,28.13,Other,Drug Cost,28.13,,,28.13,Other,Drug Cost,28.13,,,28.13,Other,Drug Cost,28.13,,,28.13,Other,Drug Cost,63.29,,,63.29,Other,225% of Medicaid,39.38,,,39.38,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,7.27,,,7.27,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",60.48,,,60.48,Other,215% Medicaid APG methodology,60.48,,,60.48,Other,215% Medicaid APG methodology,35.16,,,35.16,Other,125% Medicaid APG methodology,0.01,63.29,
MICAFUNGIN 50MG INJ,J2248,HCPCS,,80001361,CDM,636,RC,469325010,NDC,both,1,EA,68.61,7.47,,,7.47,Other,150% of Medicare + 9.63% HCRA Surcharge,4.54,,,4.54,Fee Schedule,Average Sale Price (ASP) x 6,24.01,35,,24.01,percent of total billed charges,Drugs,24.01,35,,24.01,percent of total billed charges,Drugs,23.33,34,,23.33,percent of total billed charges,Drugs,23.33,34,,23.33,percent of total billed charges,Drugs,23.33,34,,23.33,percent of total billed charges,Drugs,23.33,34,,23.33,percent of total billed charges,Drugs,24.01,35,,24.01,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,24.01,35,,24.01,percent of total billed charges,Drugs,24.01,35,,24.01,percent of total billed charges,Drugs,24.01,35,,24.01,percent of total billed charges,Drugs,24.01,35,,24.01,percent of total billed charges,Drugs,24.01,35,,24.01,percent of total billed charges,Drugs,27.44,40,,27.44,percent of total billed charges,Drugs,48.03,70,,48.03,percent of total billed charges,All Other,24.7,36,,24.7,percent of total billed charges,Drugs,24.7,36,,24.7,percent of total billed charges,Drugs,24.01,35,,24.01,percent of total billed charges,Drugs,24.01,35,,24.01,percent of total billed charges,Drugs,24.01,35,,24.01,percent of total billed charges,Drugs,24.01,35,,24.01,percent of total billed charges,Drugs,22.87,,,22.87,Other,Drug Cost,22.87,,,22.87,Other,Drug Cost,22.87,,,22.87,Other,Drug Cost,22.87,,,22.87,Other,Drug Cost,22.87,,,22.87,Other,Drug Cost,22.87,,,22.87,Other,Drug Cost,51.46,,,51.46,Other,225% of Medicaid,32.02,,,32.02,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,7.27,,,7.27,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",49.17,,,49.17,Other,215% Medicaid APG methodology,49.17,,,49.17,Other,215% Medicaid APG methodology,28.59,,,28.59,Other,125% Medicaid APG methodology,0.01,51.46,
MIDAZOLAM  INJ 2MG/2ML,J2250,HCPCS,,80001369,CDM,636,RC,63323041112,NDC,both,25,ML,0.79,1.4,,,1.4,Other,150% of Medicare + 9.63% HCRA Surcharge,0.85,,,0.85,Fee Schedule,Average Sale Price (ASP) x 6,0.28,35,,0.28,percent of total billed charges,Drugs,0.28,35,,0.28,percent of total billed charges,Drugs,0.27,34,,0.27,percent of total billed charges,Drugs,0.27,34,,0.27,percent of total billed charges,Drugs,0.27,34,,0.27,percent of total billed charges,Drugs,0.27,34,,0.27,percent of total billed charges,Drugs,0.28,35,,0.28,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,0.28,35,,0.28,percent of total billed charges,Drugs,0.28,35,,0.28,percent of total billed charges,Drugs,0.28,35,,0.28,percent of total billed charges,Drugs,0.28,35,,0.28,percent of total billed charges,Drugs,0.28,35,,0.28,percent of total billed charges,Drugs,0.32,40,,0.32,percent of total billed charges,Drugs,0.55,70,,0.55,percent of total billed charges,All Other,0.28,36,,0.28,percent of total billed charges,Drugs,0.28,36,,0.28,percent of total billed charges,Drugs,0.28,35,,0.28,percent of total billed charges,Drugs,0.28,35,,0.28,percent of total billed charges,Drugs,0.28,35,,0.28,percent of total billed charges,Drugs,0.28,35,,0.28,percent of total billed charges,Drugs,0.26,,,0.26,Other,Drug Cost,0.26,,,0.26,Other,Drug Cost,0.26,,,0.26,Other,Drug Cost,0.26,,,0.26,Other,Drug Cost,0.26,,,0.26,Other,Drug Cost,0.26,,,0.26,Other,Drug Cost,0.59,,,0.59,Other,225% of Medicaid,0.37,,,0.37,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,1.36,,,1.36,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",0.57,,,0.57,Other,215% Medicaid APG methodology,0.57,,,0.57,Other,215% Medicaid APG methodology,0.33,,,0.33,Other,125% Medicaid APG methodology,0.01,1.4,
MIDAZOLAM  INJ 5MG/5ML,J2250,HCPCS,,80001370,CDM,636,RC,63323041125,NDC,both,25,ML,2.01,1.4,,,1.4,Other,150% of Medicare + 9.63% HCRA Surcharge,0.85,,,0.85,Fee Schedule,Average Sale Price (ASP) x 6,0.7,35,,0.7,percent of total billed charges,Drugs,0.7,35,,0.7,percent of total billed charges,Drugs,0.68,34,,0.68,percent of total billed charges,Drugs,0.68,34,,0.68,percent of total billed charges,Drugs,0.68,34,,0.68,percent of total billed charges,Drugs,0.68,34,,0.68,percent of total billed charges,Drugs,0.7,35,,0.7,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,0.7,35,,0.7,percent of total billed charges,Drugs,0.7,35,,0.7,percent of total billed charges,Drugs,0.7,35,,0.7,percent of total billed charges,Drugs,0.7,35,,0.7,percent of total billed charges,Drugs,0.7,35,,0.7,percent of total billed charges,Drugs,0.8,40,,0.8,percent of total billed charges,Drugs,1.41,70,,1.41,percent of total billed charges,All Other,0.72,36,,0.72,percent of total billed charges,Drugs,0.72,36,,0.72,percent of total billed charges,Drugs,0.7,35,,0.7,percent of total billed charges,Drugs,0.7,35,,0.7,percent of total billed charges,Drugs,0.7,35,,0.7,percent of total billed charges,Drugs,0.7,35,,0.7,percent of total billed charges,Drugs,0.67,,,0.67,Other,Drug Cost,0.67,,,0.67,Other,Drug Cost,0.67,,,0.67,Other,Drug Cost,0.67,,,0.67,Other,Drug Cost,0.67,,,0.67,Other,Drug Cost,0.67,,,0.67,Other,Drug Cost,1.51,,,1.51,Other,225% of Medicaid,0.94,,,0.94,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,1.36,,,1.36,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",1.44,,,1.44,Other,215% Medicaid APG methodology,1.44,,,1.44,Other,215% Medicaid APG methodology,0.84,,,0.84,Other,125% Medicaid APG methodology,0.01,1.51,
MILRINONE 10MG/10ML INJ,J2260,HCPCS,,80001376,CDM,636,RC,409021201,NDC,both,10,ML,4.67,15.41,,,15.41,Other,150% of Medicare + 9.63% HCRA Surcharge,9.37,,,9.37,Fee Schedule,Average Sale Price (ASP) x 6,1.63,35,,1.63,percent of total billed charges,Drugs,1.63,35,,1.63,percent of total billed charges,Drugs,1.59,34,,1.59,percent of total billed charges,Drugs,1.59,34,,1.59,percent of total billed charges,Drugs,1.59,34,,1.59,percent of total billed charges,Drugs,1.59,34,,1.59,percent of total billed charges,Drugs,1.63,35,,1.63,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,1.63,35,,1.63,percent of total billed charges,Drugs,1.63,35,,1.63,percent of total billed charges,Drugs,1.63,35,,1.63,percent of total billed charges,Drugs,1.63,35,,1.63,percent of total billed charges,Drugs,1.63,35,,1.63,percent of total billed charges,Drugs,1.87,40,,1.87,percent of total billed charges,Drugs,3.27,70,,3.27,percent of total billed charges,All Other,1.68,36,,1.68,percent of total billed charges,Drugs,1.68,36,,1.68,percent of total billed charges,Drugs,1.63,35,,1.63,percent of total billed charges,Drugs,1.63,35,,1.63,percent of total billed charges,Drugs,1.63,35,,1.63,percent of total billed charges,Drugs,1.63,35,,1.63,percent of total billed charges,Drugs,1.56,,,1.56,Other,Drug Cost,1.56,,,1.56,Other,Drug Cost,1.56,,,1.56,Other,Drug Cost,1.56,,,1.56,Other,Drug Cost,1.56,,,1.56,Other,Drug Cost,1.56,,,1.56,Other,Drug Cost,3.5,,,3.5,Other,225% of Medicaid,2.18,,,2.18,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,15,,,15,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",3.34,,,3.34,Other,215% Medicaid APG methodology,3.34,,,3.34,Other,215% Medicaid APG methodology,1.94,,,1.94,Other,125% Medicaid APG methodology,0.01,15.41,
MILRINONE 20MG/100ML INJ,J2260,HCPCS,,80001377,CDM,636,RC,143971910,NDC,both,10,ML,13.21,15.41,,,15.41,Other,150% of Medicare + 9.63% HCRA Surcharge,9.37,,,9.37,Fee Schedule,Average Sale Price (ASP) x 6,4.62,35,,4.62,percent of total billed charges,Drugs,4.62,35,,4.62,percent of total billed charges,Drugs,4.49,34,,4.49,percent of total billed charges,Drugs,4.49,34,,4.49,percent of total billed charges,Drugs,4.49,34,,4.49,percent of total billed charges,Drugs,4.49,34,,4.49,percent of total billed charges,Drugs,4.62,35,,4.62,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,4.62,35,,4.62,percent of total billed charges,Drugs,4.62,35,,4.62,percent of total billed charges,Drugs,4.62,35,,4.62,percent of total billed charges,Drugs,4.62,35,,4.62,percent of total billed charges,Drugs,4.62,35,,4.62,percent of total billed charges,Drugs,5.28,40,,5.28,percent of total billed charges,Drugs,9.25,70,,9.25,percent of total billed charges,All Other,4.76,36,,4.76,percent of total billed charges,Drugs,4.76,36,,4.76,percent of total billed charges,Drugs,4.62,35,,4.62,percent of total billed charges,Drugs,4.62,35,,4.62,percent of total billed charges,Drugs,4.62,35,,4.62,percent of total billed charges,Drugs,4.62,35,,4.62,percent of total billed charges,Drugs,4.4,,,4.4,Other,Drug Cost,4.4,,,4.4,Other,Drug Cost,4.4,,,4.4,Other,Drug Cost,4.4,,,4.4,Other,Drug Cost,4.4,,,4.4,Other,Drug Cost,4.4,,,4.4,Other,Drug Cost,9.91,,,9.91,Other,225% of Medicaid,6.16,,,6.16,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,15,,,15,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",9.47,,,9.47,Other,215% Medicaid APG methodology,9.47,,,9.47,Other,215% Medicaid APG methodology,5.5,,,5.5,Other,125% Medicaid APG methodology,0.01,15.41,
MITOMYCIN 20MG INJ,J9280,HCPCS,,80001390,CDM,636,RC,16729010811,NDC,both,1,EA,173.52,625.04,,,625.04,Other,150% of Medicare + 9.63% HCRA Surcharge,380.09,,,380.09,Fee Schedule,Average Sale Price (ASP) x 6,60.73,35,,60.73,percent of total billed charges,Drugs,60.73,35,,60.73,percent of total billed charges,Drugs,59,34,,59,percent of total billed charges,Drugs,59,34,,59,percent of total billed charges,Drugs,59,34,,59,percent of total billed charges,Drugs,59,34,,59,percent of total billed charges,Drugs,60.73,35,,60.73,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,60.73,35,,60.73,percent of total billed charges,Drugs,60.73,35,,60.73,percent of total billed charges,Drugs,60.73,35,,60.73,percent of total billed charges,Drugs,60.73,35,,60.73,percent of total billed charges,Drugs,60.73,35,,60.73,percent of total billed charges,Drugs,69.41,40,,69.41,percent of total billed charges,Drugs,121.46,70,,121.46,percent of total billed charges,All Other,62.47,36,,62.47,percent of total billed charges,Drugs,62.47,36,,62.47,percent of total billed charges,Drugs,60.73,35,,60.73,percent of total billed charges,Drugs,60.73,35,,60.73,percent of total billed charges,Drugs,60.73,35,,60.73,percent of total billed charges,Drugs,60.73,35,,60.73,percent of total billed charges,Drugs,57.84,,,57.84,Other,Drug Cost,57.84,,,57.84,Other,Drug Cost,57.84,,,57.84,Other,Drug Cost,57.84,,,57.84,Other,Drug Cost,57.84,,,57.84,Other,Drug Cost,57.84,,,57.84,Other,Drug Cost,130.14,,,130.14,Other,225% of Medicaid,80.98,,,80.98,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,608.14,,,608.14,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",124.36,,,124.36,Other,215% Medicaid APG methodology,124.36,,,124.36,Other,215% Medicaid APG methodology,72.3,,,72.3,Other,125% Medicaid APG methodology,0.01,625.04,
MITOMYCIN 40MG INJ,J9280,HCPCS,,80001391,CDM,636,RC,16729011638,NDC,both,1,EA,538.59,625.04,,,625.04,Other,150% of Medicare + 9.63% HCRA Surcharge,380.09,,,380.09,Fee Schedule,Average Sale Price (ASP) x 6,188.51,35,,188.51,percent of total billed charges,Drugs,188.51,35,,188.51,percent of total billed charges,Drugs,183.12,34,,183.12,percent of total billed charges,Drugs,183.12,34,,183.12,percent of total billed charges,Drugs,183.12,34,,183.12,percent of total billed charges,Drugs,183.12,34,,183.12,percent of total billed charges,Drugs,188.51,35,,188.51,percent of total billed charges,Drugs,183.12,34,"If Charge > 500, then 34 percent",183.12,percent of total billed charges,Drugs,188.51,35,,188.51,percent of total billed charges,Drugs,188.51,35,,188.51,percent of total billed charges,Drugs,188.51,35,,188.51,percent of total billed charges,Drugs,188.51,35,,188.51,percent of total billed charges,Drugs,188.51,35,,188.51,percent of total billed charges,Drugs,215.44,40,,215.44,percent of total billed charges,Drugs,377.01,70,,377.01,percent of total billed charges,All Other,193.89,36,,193.89,percent of total billed charges,Drugs,193.89,36,,193.89,percent of total billed charges,Drugs,188.51,35,,188.51,percent of total billed charges,Drugs,188.51,35,,188.51,percent of total billed charges,Drugs,188.51,35,,188.51,percent of total billed charges,Drugs,188.51,35,,188.51,percent of total billed charges,Drugs,179.53,,,179.53,Other,Drug Cost,179.53,,,179.53,Other,Drug Cost,179.53,,,179.53,Other,Drug Cost,179.53,,,179.53,Other,Drug Cost,179.53,,,179.53,Other,Drug Cost,179.53,,,179.53,Other,Drug Cost,403.94,,,403.94,Other,225% of Medicaid,251.34,,,251.34,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,608.14,,,608.14,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",385.99,,,385.99,Other,215% Medicaid APG methodology,385.99,,,385.99,Other,215% Medicaid APG methodology,224.41,,,224.41,Other,125% Medicaid APG methodology,0.01,625.04,
MITOXANTRONE 20MG/10ML INJ,J9293,HCPCS,,80001392,CDM,636,RC,61703034318,NDC,both,1,ML,339.21,429.97,,,429.97,Other,150% of Medicare + 9.63% HCRA Surcharge,261.47,,,261.47,Fee Schedule,Average Sale Price (ASP) x 6,118.72,35,,118.72,percent of total billed charges,Drugs,118.72,35,,118.72,percent of total billed charges,Drugs,115.33,34,,115.33,percent of total billed charges,Drugs,115.33,34,,115.33,percent of total billed charges,Drugs,115.33,34,,115.33,percent of total billed charges,Drugs,115.33,34,,115.33,percent of total billed charges,Drugs,118.72,35,,118.72,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,118.72,35,,118.72,percent of total billed charges,Drugs,118.72,35,,118.72,percent of total billed charges,Drugs,118.72,35,,118.72,percent of total billed charges,Drugs,118.72,35,,118.72,percent of total billed charges,Drugs,118.72,35,,118.72,percent of total billed charges,Drugs,135.68,40,,135.68,percent of total billed charges,Drugs,237.45,70,,237.45,percent of total billed charges,All Other,122.12,36,,122.12,percent of total billed charges,Drugs,122.12,36,,122.12,percent of total billed charges,Drugs,118.72,35,,118.72,percent of total billed charges,Drugs,118.72,35,,118.72,percent of total billed charges,Drugs,118.72,35,,118.72,percent of total billed charges,Drugs,118.72,35,,118.72,percent of total billed charges,Drugs,113.07,,,113.07,Other,Drug Cost,113.07,,,113.07,Other,Drug Cost,113.07,,,113.07,Other,Drug Cost,113.07,,,113.07,Other,Drug Cost,113.07,,,113.07,Other,Drug Cost,113.07,,,113.07,Other,Drug Cost,254.41,,,254.41,Other,225% of Medicaid,158.3,,,158.3,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,418.35,,,418.35,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",243.1,,,243.1,Other,215% Medicaid APG methodology,243.1,,,243.1,Other,215% Medicaid APG methodology,141.34,,,141.34,Other,125% Medicaid APG methodology,0.01,429.97,
MYCOPHENOLATE MOFETIL 250MG CAP,J7517,HCPCS,,80001424,CDM,636,RC,16729009401,NDC,both,100,EA,0.09,1.85,,,1.85,Other,150% of Medicare + 9.63% HCRA Surcharge,1.13,,,1.13,Fee Schedule,Average Sale Price (ASP) x 6,0.03,35,,0.03,percent of total billed charges,Drugs,0.03,35,,0.03,percent of total billed charges,Drugs,0.03,34,,0.03,percent of total billed charges,Drugs,0.03,34,,0.03,percent of total billed charges,Drugs,0.03,34,,0.03,percent of total billed charges,Drugs,0.03,34,,0.03,percent of total billed charges,Drugs,0.03,35,,0.03,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,0.03,35,,0.03,percent of total billed charges,Drugs,0.03,35,,0.03,percent of total billed charges,Drugs,0.03,35,,0.03,percent of total billed charges,Drugs,0.03,35,,0.03,percent of total billed charges,Drugs,0.03,35,,0.03,percent of total billed charges,Drugs,0.04,40,,0.04,percent of total billed charges,Drugs,0.06,70,,0.06,percent of total billed charges,All Other,0.03,36,,0.03,percent of total billed charges,Drugs,0.03,36,,0.03,percent of total billed charges,Drugs,0.03,35,,0.03,percent of total billed charges,Drugs,0.03,35,,0.03,percent of total billed charges,Drugs,0.03,35,,0.03,percent of total billed charges,Drugs,0.03,35,,0.03,percent of total billed charges,Drugs,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.07,,,0.07,Other,225% of Medicaid,0.04,,,0.04,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,1.8,,,1.8,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",0.07,,,0.07,Other,215% Medicaid APG methodology,0.07,,,0.07,Other,215% Medicaid APG methodology,0.04,,,0.04,Other,125% Medicaid APG methodology,0.01,1.85,
MYCOPHENOLATE MOFETIL 500MG CAP,J7517,HCPCS,,80001425,CDM,636,RC,16729001901,NDC,both,100,EA,0.38,1.85,,,1.85,Other,150% of Medicare + 9.63% HCRA Surcharge,1.13,,,1.13,Fee Schedule,Average Sale Price (ASP) x 6,0.13,35,,0.13,percent of total billed charges,Drugs,0.13,35,,0.13,percent of total billed charges,Drugs,0.13,34,,0.13,percent of total billed charges,Drugs,0.13,34,,0.13,percent of total billed charges,Drugs,0.13,34,,0.13,percent of total billed charges,Drugs,0.13,34,,0.13,percent of total billed charges,Drugs,0.13,35,,0.13,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,0.13,35,,0.13,percent of total billed charges,Drugs,0.13,35,,0.13,percent of total billed charges,Drugs,0.13,35,,0.13,percent of total billed charges,Drugs,0.13,35,,0.13,percent of total billed charges,Drugs,0.13,35,,0.13,percent of total billed charges,Drugs,0.15,40,,0.15,percent of total billed charges,Drugs,0.26,70,,0.26,percent of total billed charges,All Other,0.14,36,,0.14,percent of total billed charges,Drugs,0.14,36,,0.14,percent of total billed charges,Drugs,0.13,35,,0.13,percent of total billed charges,Drugs,0.13,35,,0.13,percent of total billed charges,Drugs,0.13,35,,0.13,percent of total billed charges,Drugs,0.13,35,,0.13,percent of total billed charges,Drugs,0.13,,,0.13,Other,Drug Cost,0.13,,,0.13,Other,Drug Cost,0.13,,,0.13,Other,Drug Cost,0.13,,,0.13,Other,Drug Cost,0.13,,,0.13,Other,Drug Cost,0.13,,,0.13,Other,Drug Cost,0.28,,,0.28,Other,225% of Medicaid,0.18,,,0.18,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,1.8,,,1.8,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",0.27,,,0.27,Other,215% Medicaid APG methodology,0.27,,,0.27,Other,215% Medicaid APG methodology,0.16,,,0.16,Other,125% Medicaid APG methodology,0.01,1.85,
NALOXONE INJ 0.4MG/1ML,J2310,HCPCS,,80001431,CDM,636,RC,641613225,NDC,both,25,ML,6.17,71.91,,,71.91,Other,150% of Medicare + 9.63% HCRA Surcharge,43.73,,,43.73,Fee Schedule,Average Sale Price (ASP) x 6,2.16,35,,2.16,percent of total billed charges,Drugs,2.16,35,,2.16,percent of total billed charges,Drugs,2.1,34,,2.1,percent of total billed charges,Drugs,2.1,34,,2.1,percent of total billed charges,Drugs,2.1,34,,2.1,percent of total billed charges,Drugs,2.1,34,,2.1,percent of total billed charges,Drugs,2.16,35,,2.16,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,2.16,35,,2.16,percent of total billed charges,Drugs,2.16,35,,2.16,percent of total billed charges,Drugs,2.16,35,,2.16,percent of total billed charges,Drugs,2.16,35,,2.16,percent of total billed charges,Drugs,2.16,35,,2.16,percent of total billed charges,Drugs,2.47,40,,2.47,percent of total billed charges,Drugs,4.32,70,,4.32,percent of total billed charges,All Other,2.22,36,,2.22,percent of total billed charges,Drugs,2.22,36,,2.22,percent of total billed charges,Drugs,2.16,35,,2.16,percent of total billed charges,Drugs,2.16,35,,2.16,percent of total billed charges,Drugs,2.16,35,,2.16,percent of total billed charges,Drugs,2.16,35,,2.16,percent of total billed charges,Drugs,2.06,,,2.06,Other,Drug Cost,2.06,,,2.06,Other,Drug Cost,2.06,,,2.06,Other,Drug Cost,2.06,,,2.06,Other,Drug Cost,2.06,,,2.06,Other,Drug Cost,2.06,,,2.06,Other,Drug Cost,4.63,,,4.63,Other,225% of Medicaid,2.88,,,2.88,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,69.96,,,69.96,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",4.42,,,4.42,Other,215% Medicaid APG methodology,4.42,,,4.42,Other,215% Medicaid APG methodology,2.57,,,2.57,Other,125% Medicaid APG methodology,0.01,71.91,
NALOXONE INJ 2MG/2ML,J2310,HCPCS,,80001432,CDM,636,RC,641620510,NDC,both,10,ML,27.14,71.91,,,71.91,Other,150% of Medicare + 9.63% HCRA Surcharge,43.73,,,43.73,Fee Schedule,Average Sale Price (ASP) x 6,9.5,35,,9.5,percent of total billed charges,Drugs,9.5,35,,9.5,percent of total billed charges,Drugs,9.23,34,,9.23,percent of total billed charges,Drugs,9.23,34,,9.23,percent of total billed charges,Drugs,9.23,34,,9.23,percent of total billed charges,Drugs,9.23,34,,9.23,percent of total billed charges,Drugs,9.5,35,,9.5,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,9.5,35,,9.5,percent of total billed charges,Drugs,9.5,35,,9.5,percent of total billed charges,Drugs,9.5,35,,9.5,percent of total billed charges,Drugs,9.5,35,,9.5,percent of total billed charges,Drugs,9.5,35,,9.5,percent of total billed charges,Drugs,10.86,40,,10.86,percent of total billed charges,Drugs,19,70,,19,percent of total billed charges,All Other,9.77,36,,9.77,percent of total billed charges,Drugs,9.77,36,,9.77,percent of total billed charges,Drugs,9.5,35,,9.5,percent of total billed charges,Drugs,9.5,35,,9.5,percent of total billed charges,Drugs,9.5,35,,9.5,percent of total billed charges,Drugs,9.5,35,,9.5,percent of total billed charges,Drugs,9.05,,,9.05,Other,Drug Cost,9.05,,,9.05,Other,Drug Cost,9.05,,,9.05,Other,Drug Cost,9.05,,,9.05,Other,Drug Cost,9.05,,,9.05,Other,Drug Cost,9.05,,,9.05,Other,Drug Cost,20.36,,,20.36,Other,225% of Medicaid,12.67,,,12.67,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,69.96,,,69.96,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",19.45,,,19.45,Other,215% Medicaid APG methodology,19.45,,,19.45,Other,215% Medicaid APG methodology,11.31,,,11.31,Other,125% Medicaid APG methodology,0.01,71.91,
OCTREOTIDE 1000MCG/5ML INJ,J2354,HCPCS,,80001524,CDM,636,RC,703334301,NDC,both,1,ML,652.26,11.72,,,11.72,Other,150% of Medicare + 9.63% HCRA Surcharge,7.13,,,7.13,Fee Schedule,Average Sale Price (ASP) x 6,228.29,35,,228.29,percent of total billed charges,Drugs,228.29,35,,228.29,percent of total billed charges,Drugs,221.77,34,,221.77,percent of total billed charges,Drugs,221.77,34,,221.77,percent of total billed charges,Drugs,221.77,34,,221.77,percent of total billed charges,Drugs,221.77,34,,221.77,percent of total billed charges,Drugs,228.29,35,,228.29,percent of total billed charges,Drugs,221.77,34,"If Charge > 500, then 34 percent",221.77,percent of total billed charges,Drugs,228.29,35,,228.29,percent of total billed charges,Drugs,228.29,35,,228.29,percent of total billed charges,Drugs,228.29,35,,228.29,percent of total billed charges,Drugs,228.29,35,,228.29,percent of total billed charges,Drugs,228.29,35,,228.29,percent of total billed charges,Drugs,260.9,40,,260.9,percent of total billed charges,Drugs,456.58,70,,456.58,percent of total billed charges,All Other,234.81,36,,234.81,percent of total billed charges,Drugs,234.81,36,,234.81,percent of total billed charges,Drugs,228.29,35,,228.29,percent of total billed charges,Drugs,228.29,35,,228.29,percent of total billed charges,Drugs,228.29,35,,228.29,percent of total billed charges,Drugs,228.29,35,,228.29,percent of total billed charges,Drugs,217.42,,,217.42,Other,Drug Cost,217.42,,,217.42,Other,Drug Cost,217.42,,,217.42,Other,Drug Cost,217.42,,,217.42,Other,Drug Cost,217.42,,,217.42,Other,Drug Cost,217.42,,,217.42,Other,Drug Cost,489.2,,,489.2,Other,225% of Medicaid,304.39,,,304.39,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,11.4,,,11.4,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",467.45,,,467.45,Other,215% Medicaid APG methodology,467.45,,,467.45,Other,215% Medicaid APG methodology,271.78,,,271.78,Other,125% Medicaid APG methodology,0.01,489.2,
ONABOTULINUMTOXINA 100 UNIT,J0585,HCPCS,,80001536,CDM,636,RC,23114501,NDC,both,1,EA,1938,62.43,,,62.43,Other,150% of Medicare + 9.63% HCRA Surcharge,37.96,,,37.96,Fee Schedule,Average Sale Price (ASP) x 6,678.3,35,,678.3,percent of total billed charges,Drugs,678.3,35,,678.3,percent of total billed charges,Drugs,658.92,34,,658.92,percent of total billed charges,Drugs,658.92,34,,658.92,percent of total billed charges,Drugs,658.92,34,,658.92,percent of total billed charges,Drugs,658.92,34,,658.92,percent of total billed charges,Drugs,678.3,35,,678.3,percent of total billed charges,Drugs,658.92,34,"If Charge > 500, then 34 percent",658.92,percent of total billed charges,Drugs,678.3,35,,678.3,percent of total billed charges,Drugs,678.3,35,,678.3,percent of total billed charges,Drugs,678.3,35,,678.3,percent of total billed charges,Drugs,678.3,35,,678.3,percent of total billed charges,Drugs,678.3,35,,678.3,percent of total billed charges,Drugs,775.2,40,,775.2,percent of total billed charges,Drugs,1356.6,70,,1356.6,percent of total billed charges,All Other,697.68,36,,697.68,percent of total billed charges,Drugs,697.68,36,,697.68,percent of total billed charges,Drugs,678.3,35,,678.3,percent of total billed charges,Drugs,678.3,35,,678.3,percent of total billed charges,Drugs,678.3,35,,678.3,percent of total billed charges,Drugs,678.3,35,,678.3,percent of total billed charges,Drugs,646,,,646,Other,Drug Cost,646,,,646,Other,Drug Cost,646,,,646,Other,Drug Cost,646,,,646,Other,Drug Cost,646,,,646,Other,Drug Cost,646,,,646,Other,Drug Cost,1453.5,,,1453.5,Other,225% of Medicaid,904.4,,,904.4,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,60.74,,,60.74,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",1388.9,,,1388.9,Other,215% Medicaid APG methodology,1388.9,,,1388.9,Other,215% Medicaid APG methodology,807.5,,,807.5,Other,125% Medicaid APG methodology,0.01,1453.5,
ONDANSETRON INJ 4MG/2ML,J2405,HCPCS,,80001538,CDM,636,RC,60505613005,NDC,both,25,ML,0.59,0.99,,,0.99,Other,150% of Medicare + 9.63% HCRA Surcharge,0.6,,,0.6,Fee Schedule,Average Sale Price (ASP) x 6,0.2,35,,0.2,percent of total billed charges,Drugs,0.2,35,,0.2,percent of total billed charges,Drugs,0.2,34,,0.2,percent of total billed charges,Drugs,0.2,34,,0.2,percent of total billed charges,Drugs,0.2,34,,0.2,percent of total billed charges,Drugs,0.2,34,,0.2,percent of total billed charges,Drugs,0.2,35,,0.2,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,0.2,35,,0.2,percent of total billed charges,Drugs,0.2,35,,0.2,percent of total billed charges,Drugs,0.2,35,,0.2,percent of total billed charges,Drugs,0.2,35,,0.2,percent of total billed charges,Drugs,0.2,35,,0.2,percent of total billed charges,Drugs,0.23,40,,0.23,percent of total billed charges,Drugs,0.41,70,,0.41,percent of total billed charges,All Other,0.21,36,,0.21,percent of total billed charges,Drugs,0.21,36,,0.21,percent of total billed charges,Drugs,0.2,35,,0.2,percent of total billed charges,Drugs,0.2,35,,0.2,percent of total billed charges,Drugs,0.2,35,,0.2,percent of total billed charges,Drugs,0.2,35,,0.2,percent of total billed charges,Drugs,0.2,,,0.2,Other,Drug Cost,0.2,,,0.2,Other,Drug Cost,0.2,,,0.2,Other,Drug Cost,0.2,,,0.2,Other,Drug Cost,0.2,,,0.2,Other,Drug Cost,0.2,,,0.2,Other,Drug Cost,0.44,,,0.44,Other,225% of Medicaid,0.27,,,0.27,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,0.96,,,0.96,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",0.42,,,0.42,Other,215% Medicaid APG methodology,0.42,,,0.42,Other,215% Medicaid APG methodology,0.24,,,0.24,Other,125% Medicaid APG methodology,0.01,0.99,
ONDANSETRON ODT 4MG,Q0162,HCPCS,,80001539,CDM,636,RC,68462015713,NDC,both,30,EA,0.15,0.14,,,0.14,Other,150% of Medicare + 9.63% HCRA Surcharge,0.08,,,0.08,Fee Schedule,Average Sale Price (ASP) x 6,0.05,35,,0.05,percent of total billed charges,Drugs,0.05,35,,0.05,percent of total billed charges,Drugs,0.05,34,,0.05,percent of total billed charges,Drugs,0.05,34,,0.05,percent of total billed charges,Drugs,0.05,34,,0.05,percent of total billed charges,Drugs,0.05,34,,0.05,percent of total billed charges,Drugs,0.05,35,,0.05,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,0.05,35,,0.05,percent of total billed charges,Drugs,0.05,35,,0.05,percent of total billed charges,Drugs,0.05,35,,0.05,percent of total billed charges,Drugs,0.05,35,,0.05,percent of total billed charges,Drugs,0.05,35,,0.05,percent of total billed charges,Drugs,0.06,40,,0.06,percent of total billed charges,Drugs,0.11,70,,0.11,percent of total billed charges,All Other,0.05,36,,0.05,percent of total billed charges,Drugs,0.05,36,,0.05,percent of total billed charges,Drugs,0.05,35,,0.05,percent of total billed charges,Drugs,0.05,35,,0.05,percent of total billed charges,Drugs,0.05,35,,0.05,percent of total billed charges,Drugs,0.05,35,,0.05,percent of total billed charges,Drugs,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.11,,,0.11,Other,225% of Medicaid,0.07,,,0.07,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,0.13,,,0.13,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",0.11,,,0.11,Other,215% Medicaid APG methodology,0.11,,,0.11,Other,215% Medicaid APG methodology,0.06,,,0.06,Other,125% Medicaid APG methodology,0.01,0.14,
OXALIPLATIN 50MG/10ML,J9263,HCPCS,,80001546,CDM,636,RC,60505613206,NDC,both,1,ML,4.44,0.7,,,0.7,Other,150% of Medicare + 9.63% HCRA Surcharge,0.43,,,0.43,Fee Schedule,Average Sale Price (ASP) x 6,1.55,35,,1.55,percent of total billed charges,Drugs,1.55,35,,1.55,percent of total billed charges,Drugs,1.51,34,,1.51,percent of total billed charges,Drugs,1.51,34,,1.51,percent of total billed charges,Drugs,1.51,34,,1.51,percent of total billed charges,Drugs,1.51,34,,1.51,percent of total billed charges,Drugs,1.55,35,,1.55,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,1.55,35,,1.55,percent of total billed charges,Drugs,1.55,35,,1.55,percent of total billed charges,Drugs,1.55,35,,1.55,percent of total billed charges,Drugs,1.55,35,,1.55,percent of total billed charges,Drugs,1.55,35,,1.55,percent of total billed charges,Drugs,1.78,40,,1.78,percent of total billed charges,Drugs,3.11,70,,3.11,percent of total billed charges,All Other,1.6,36,,1.6,percent of total billed charges,Drugs,1.6,36,,1.6,percent of total billed charges,Drugs,1.55,35,,1.55,percent of total billed charges,Drugs,1.55,35,,1.55,percent of total billed charges,Drugs,1.55,35,,1.55,percent of total billed charges,Drugs,1.55,35,,1.55,percent of total billed charges,Drugs,1.48,,,1.48,Other,Drug Cost,1.48,,,1.48,Other,Drug Cost,1.48,,,1.48,Other,Drug Cost,1.48,,,1.48,Other,Drug Cost,1.48,,,1.48,Other,Drug Cost,1.48,,,1.48,Other,Drug Cost,3.33,,,3.33,Other,225% of Medicaid,2.07,,,2.07,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,0.68,,,0.68,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",3.18,,,3.18,Other,215% Medicaid APG methodology,3.18,,,3.18,Other,215% Medicaid APG methodology,1.85,,,1.85,Other,125% Medicaid APG methodology,0.01,3.33,
OXYTOCIN 10UNITS/ML INJ,J2590,HCPCS,,80001562,CDM,636,RC,42023011625,NDC,both,25,ML,1.35,0.53,39.4668,,0.53,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.47,35,,0.47,percent of total billed charges,Drugs,0.47,35,,0.47,percent of total billed charges,Drugs,0.46,34,,0.46,percent of total billed charges,Drugs,0.46,34,,0.46,percent of total billed charges,Drugs,0.46,34,,0.46,percent of total billed charges,Drugs,0.46,34,,0.46,percent of total billed charges,Drugs,0.47,35,,0.47,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,0.47,35,,0.47,percent of total billed charges,Drugs,0.47,35,,0.47,percent of total billed charges,Drugs,0.47,35,,0.47,percent of total billed charges,Drugs,0.47,35,,0.47,percent of total billed charges,Drugs,0.47,35,,0.47,percent of total billed charges,Drugs,0.54,40,,0.54,percent of total billed charges,Drugs,0.94,70,,0.94,percent of total billed charges,All Other,0.49,36,,0.49,percent of total billed charges,Drugs,0.49,36,,0.49,percent of total billed charges,Drugs,0.47,35,,0.47,percent of total billed charges,Drugs,0.47,35,,0.47,percent of total billed charges,Drugs,0.47,35,,0.47,percent of total billed charges,Drugs,0.47,35,,0.47,percent of total billed charges,Drugs,0.45,,,0.45,Other,Drug Cost,0.45,,,0.45,Other,Drug Cost,0.45,,,0.45,Other,Drug Cost,0.45,,,0.45,Other,Drug Cost,0.45,,,0.45,Other,Drug Cost,0.45,,,0.45,Other,Drug Cost,1.01,,,1.01,Other,225% of Medicaid,0.63,,,0.63,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",0.97,,,0.97,Other,215% Medicaid APG methodology,0.97,,,0.97,Other,215% Medicaid APG methodology,0.56,,,0.56,Other,125% Medicaid APG methodology,0.01,1.01,
PACLITAXEL 6MG/ML 5ML,J9267,HCPCS,,80001567,CDM,636,RC,61703034209,NDC,both,1,ML,6,1.07,,,1.07,Other,150% of Medicare + 9.63% HCRA Surcharge,0.65,,,0.65,Fee Schedule,Average Sale Price (ASP) x 6,2.1,35,,2.1,percent of total billed charges,Drugs,2.1,35,,2.1,percent of total billed charges,Drugs,2.04,34,,2.04,percent of total billed charges,Drugs,2.04,34,,2.04,percent of total billed charges,Drugs,2.04,34,,2.04,percent of total billed charges,Drugs,2.04,34,,2.04,percent of total billed charges,Drugs,2.1,35,,2.1,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,2.1,35,,2.1,percent of total billed charges,Drugs,2.1,35,,2.1,percent of total billed charges,Drugs,2.1,35,,2.1,percent of total billed charges,Drugs,2.1,35,,2.1,percent of total billed charges,Drugs,2.1,35,,2.1,percent of total billed charges,Drugs,2.4,40,,2.4,percent of total billed charges,Drugs,4.2,70,,4.2,percent of total billed charges,All Other,2.16,36,,2.16,percent of total billed charges,Drugs,2.16,36,,2.16,percent of total billed charges,Drugs,2.1,35,,2.1,percent of total billed charges,Drugs,2.1,35,,2.1,percent of total billed charges,Drugs,2.1,35,,2.1,percent of total billed charges,Drugs,2.1,35,,2.1,percent of total billed charges,Drugs,2,,,2,Other,Drug Cost,2,,,2,Other,Drug Cost,2,,,2,Other,Drug Cost,2,,,2,Other,Drug Cost,2,,,2,Other,Drug Cost,2,,,2,Other,Drug Cost,4.5,,,4.5,Other,225% of Medicaid,2.8,,,2.8,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,1.04,,,1.04,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",4.3,,,4.3,Other,215% Medicaid APG methodology,4.3,,,4.3,Other,215% Medicaid APG methodology,2.5,,,2.5,Other,125% Medicaid APG methodology,0.01,4.5,
PACLITAXEL PROTEIN BOUND 100MG INJ,J9264,HCPCS,,80001568,CDM,636,RC,68817013450,NDC,both,1,EA,4526.88,141.03,,,141.03,Other,150% of Medicare + 9.63% HCRA Surcharge,85.76,,,85.76,Fee Schedule,Average Sale Price (ASP) x 6,1584.41,35,,1584.41,percent of total billed charges,Drugs,1584.41,35,,1584.41,percent of total billed charges,Drugs,1539.14,34,,1539.14,percent of total billed charges,Drugs,1539.14,34,,1539.14,percent of total billed charges,Drugs,1539.14,34,,1539.14,percent of total billed charges,Drugs,1539.14,34,,1539.14,percent of total billed charges,Drugs,1584.41,35,,1584.41,percent of total billed charges,Drugs,1539.14,34,"If Charge > 500, then 34 percent",1539.14,percent of total billed charges,Drugs,1584.41,35,,1584.41,percent of total billed charges,Drugs,1584.41,35,,1584.41,percent of total billed charges,Drugs,1584.41,35,,1584.41,percent of total billed charges,Drugs,1584.41,35,,1584.41,percent of total billed charges,Drugs,1584.41,35,,1584.41,percent of total billed charges,Drugs,1810.75,40,,1810.75,percent of total billed charges,Drugs,3168.82,70,,3168.82,percent of total billed charges,All Other,1629.68,36,,1629.68,percent of total billed charges,Drugs,1629.68,36,,1629.68,percent of total billed charges,Drugs,1584.41,35,,1584.41,percent of total billed charges,Drugs,1584.41,35,,1584.41,percent of total billed charges,Drugs,1584.41,35,,1584.41,percent of total billed charges,Drugs,1584.41,35,,1584.41,percent of total billed charges,Drugs,1508.96,,,1508.96,Other,Drug Cost,1508.96,,,1508.96,Other,Drug Cost,1508.96,,,1508.96,Other,Drug Cost,1508.96,,,1508.96,Other,Drug Cost,1508.96,,,1508.96,Other,Drug Cost,1508.96,,,1508.96,Other,Drug Cost,3395.16,,,3395.16,Other,225% of Medicaid,2112.54,,,2112.54,Other,140% of Medicaid,1539.14,34,"If Charge > 2,000, then 34 percent",1539.14,percent of total billed charges,Drugs,137.22,,,137.22,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",3244.26,,,3244.26,Other,215% Medicaid APG methodology,3244.26,,,3244.26,Other,215% Medicaid APG methodology,1886.2,,,1886.2,Other,125% Medicaid APG methodology,0.01,3395.16,
PALIPERIDONE PALMITATE 117MG INJ,J2426,HCPCS,,80001572,CDM,636,RC,50458056201,NDC,both,1,ML,1784.79,141.27,,,141.27,Other,150% of Medicare + 9.63% HCRA Surcharge,85.91,,,85.91,Fee Schedule,Average Sale Price (ASP) x 6,624.68,35,,624.68,percent of total billed charges,Drugs,624.68,35,,624.68,percent of total billed charges,Drugs,606.83,34,,606.83,percent of total billed charges,Drugs,606.83,34,,606.83,percent of total billed charges,Drugs,606.83,34,,606.83,percent of total billed charges,Drugs,606.83,34,,606.83,percent of total billed charges,Drugs,624.68,35,,624.68,percent of total billed charges,Drugs,606.83,34,"If Charge > 500, then 34 percent",606.83,percent of total billed charges,Drugs,624.68,35,,624.68,percent of total billed charges,Drugs,624.68,35,,624.68,percent of total billed charges,Drugs,624.68,35,,624.68,percent of total billed charges,Drugs,624.68,35,,624.68,percent of total billed charges,Drugs,624.68,35,,624.68,percent of total billed charges,Drugs,713.92,40,,713.92,percent of total billed charges,Drugs,1249.35,70,,1249.35,percent of total billed charges,All Other,642.52,36,,642.52,percent of total billed charges,Drugs,642.52,36,,642.52,percent of total billed charges,Drugs,624.68,35,,624.68,percent of total billed charges,Drugs,624.68,35,,624.68,percent of total billed charges,Drugs,624.68,35,,624.68,percent of total billed charges,Drugs,624.68,35,,624.68,percent of total billed charges,Drugs,594.93,,,594.93,Other,Drug Cost,594.93,,,594.93,Other,Drug Cost,594.93,,,594.93,Other,Drug Cost,594.93,,,594.93,Other,Drug Cost,594.93,,,594.93,Other,Drug Cost,594.93,,,594.93,Other,Drug Cost,1338.59,,,1338.59,Other,225% of Medicaid,832.9,,,832.9,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,137.45,,,137.45,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",1279.1,,,1279.1,Other,215% Medicaid APG methodology,1279.1,,,1279.1,Other,215% Medicaid APG methodology,743.66,,,743.66,Other,125% Medicaid APG methodology,0.01,1338.59,
PALIPERIDONE PALMITATE 156MG INJ,J2426,HCPCS,,80001573,CDM,636,RC,50458056301,NDC,both,1,ML,2283.75,141.27,,,141.27,Other,150% of Medicare + 9.63% HCRA Surcharge,85.91,,,85.91,Fee Schedule,Average Sale Price (ASP) x 6,799.31,35,,799.31,percent of total billed charges,Drugs,799.31,35,,799.31,percent of total billed charges,Drugs,776.48,34,,776.48,percent of total billed charges,Drugs,776.48,34,,776.48,percent of total billed charges,Drugs,776.48,34,,776.48,percent of total billed charges,Drugs,776.48,34,,776.48,percent of total billed charges,Drugs,799.31,35,,799.31,percent of total billed charges,Drugs,776.48,34,"If Charge > 500, then 34 percent",776.48,percent of total billed charges,Drugs,799.31,35,,799.31,percent of total billed charges,Drugs,799.31,35,,799.31,percent of total billed charges,Drugs,799.31,35,,799.31,percent of total billed charges,Drugs,799.31,35,,799.31,percent of total billed charges,Drugs,799.31,35,,799.31,percent of total billed charges,Drugs,913.5,40,,913.5,percent of total billed charges,Drugs,1598.63,70,,1598.63,percent of total billed charges,All Other,822.15,36,,822.15,percent of total billed charges,Drugs,822.15,36,,822.15,percent of total billed charges,Drugs,799.31,35,,799.31,percent of total billed charges,Drugs,799.31,35,,799.31,percent of total billed charges,Drugs,799.31,35,,799.31,percent of total billed charges,Drugs,799.31,35,,799.31,percent of total billed charges,Drugs,761.25,,,761.25,Other,Drug Cost,761.25,,,761.25,Other,Drug Cost,761.25,,,761.25,Other,Drug Cost,761.25,,,761.25,Other,Drug Cost,761.25,,,761.25,Other,Drug Cost,761.25,,,761.25,Other,Drug Cost,1712.81,,,1712.81,Other,225% of Medicaid,1065.75,,,1065.75,Other,140% of Medicaid,776.48,34,"If Charge > 2,000, then 34 percent",776.48,percent of total billed charges,Drugs,137.45,,,137.45,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",1636.69,,,1636.69,Other,215% Medicaid APG methodology,1636.69,,,1636.69,Other,215% Medicaid APG methodology,951.56,,,951.56,Other,125% Medicaid APG methodology,0.01,1712.81,
PALIPERIDONE PALMITATE 234MG INJ,J2426,HCPCS,,80001574,CDM,636,RC,50458056401,NDC,both,1,ML,3433.47,141.27,,,141.27,Other,150% of Medicare + 9.63% HCRA Surcharge,85.91,,,85.91,Fee Schedule,Average Sale Price (ASP) x 6,1201.71,35,,1201.71,percent of total billed charges,Drugs,1201.71,35,,1201.71,percent of total billed charges,Drugs,1167.38,34,,1167.38,percent of total billed charges,Drugs,1167.38,34,,1167.38,percent of total billed charges,Drugs,1167.38,34,,1167.38,percent of total billed charges,Drugs,1167.38,34,,1167.38,percent of total billed charges,Drugs,1201.71,35,,1201.71,percent of total billed charges,Drugs,1167.38,34,"If Charge > 500, then 34 percent",1167.38,percent of total billed charges,Drugs,1201.71,35,,1201.71,percent of total billed charges,Drugs,1201.71,35,,1201.71,percent of total billed charges,Drugs,1201.71,35,,1201.71,percent of total billed charges,Drugs,1201.71,35,,1201.71,percent of total billed charges,Drugs,1201.71,35,,1201.71,percent of total billed charges,Drugs,1373.39,40,,1373.39,percent of total billed charges,Drugs,2403.43,70,,2403.43,percent of total billed charges,All Other,1236.05,36,,1236.05,percent of total billed charges,Drugs,1236.05,36,,1236.05,percent of total billed charges,Drugs,1201.71,35,,1201.71,percent of total billed charges,Drugs,1201.71,35,,1201.71,percent of total billed charges,Drugs,1201.71,35,,1201.71,percent of total billed charges,Drugs,1201.71,35,,1201.71,percent of total billed charges,Drugs,1144.49,,,1144.49,Other,Drug Cost,1144.49,,,1144.49,Other,Drug Cost,1144.49,,,1144.49,Other,Drug Cost,1144.49,,,1144.49,Other,Drug Cost,1144.49,,,1144.49,Other,Drug Cost,1144.49,,,1144.49,Other,Drug Cost,2575.1,,,2575.1,Other,225% of Medicaid,1602.29,,,1602.29,Other,140% of Medicaid,1167.38,34,"If Charge > 2,000, then 34 percent",1167.38,percent of total billed charges,Drugs,137.45,,,137.45,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",2460.65,,,2460.65,Other,215% Medicaid APG methodology,2460.65,,,2460.65,Other,215% Medicaid APG methodology,1430.61,,,1430.61,Other,125% Medicaid APG methodology,0.01,2575.1,
PALONOSETRON HCL 25MCG TO 0.25MG INJ,J2469,HCPCS,,80001576,CDM,636,RC,60505619301,NDC,both,1,ML,1.8,8.34,,,8.34,Other,150% of Medicare + 9.63% HCRA Surcharge,5.07,,,5.07,Fee Schedule,Average Sale Price (ASP) x 6,0.63,35,,0.63,percent of total billed charges,Drugs,0.63,35,,0.63,percent of total billed charges,Drugs,0.61,34,,0.61,percent of total billed charges,Drugs,0.61,34,,0.61,percent of total billed charges,Drugs,0.61,34,,0.61,percent of total billed charges,Drugs,0.61,34,,0.61,percent of total billed charges,Drugs,0.63,35,,0.63,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,0.63,35,,0.63,percent of total billed charges,Drugs,0.63,35,,0.63,percent of total billed charges,Drugs,0.63,35,,0.63,percent of total billed charges,Drugs,0.63,35,,0.63,percent of total billed charges,Drugs,0.63,35,,0.63,percent of total billed charges,Drugs,0.72,40,,0.72,percent of total billed charges,Drugs,1.26,70,,1.26,percent of total billed charges,All Other,0.65,36,,0.65,percent of total billed charges,Drugs,0.65,36,,0.65,percent of total billed charges,Drugs,0.63,35,,0.63,percent of total billed charges,Drugs,0.63,35,,0.63,percent of total billed charges,Drugs,0.63,35,,0.63,percent of total billed charges,Drugs,0.63,35,,0.63,percent of total billed charges,Drugs,0.6,,,0.6,Other,Drug Cost,0.6,,,0.6,Other,Drug Cost,0.6,,,0.6,Other,Drug Cost,0.6,,,0.6,Other,Drug Cost,0.6,,,0.6,Other,Drug Cost,0.6,,,0.6,Other,Drug Cost,1.35,,,1.35,Other,225% of Medicaid,0.84,,,0.84,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,8.11,,,8.11,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",1.29,,,1.29,Other,215% Medicaid APG methodology,1.29,,,1.29,Other,215% Medicaid APG methodology,0.75,,,0.75,Other,125% Medicaid APG methodology,0.01,8.34,
PAMIDRONATE DISODIUM 3MG/ML 10ML,J2430,HCPCS,,80001578,CDM,636,RC,67457043010,NDC,both,1,ML,25.65,87.56,,,87.56,Other,150% of Medicare + 9.63% HCRA Surcharge,53.24,,,53.24,Fee Schedule,Average Sale Price (ASP) x 6,8.98,35,,8.98,percent of total billed charges,Drugs,8.98,35,,8.98,percent of total billed charges,Drugs,8.72,34,,8.72,percent of total billed charges,Drugs,8.72,34,,8.72,percent of total billed charges,Drugs,8.72,34,,8.72,percent of total billed charges,Drugs,8.72,34,,8.72,percent of total billed charges,Drugs,8.98,35,,8.98,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,8.98,35,,8.98,percent of total billed charges,Drugs,8.98,35,,8.98,percent of total billed charges,Drugs,8.98,35,,8.98,percent of total billed charges,Drugs,8.98,35,,8.98,percent of total billed charges,Drugs,8.98,35,,8.98,percent of total billed charges,Drugs,10.26,40,,10.26,percent of total billed charges,Drugs,17.96,70,,17.96,percent of total billed charges,All Other,9.23,36,,9.23,percent of total billed charges,Drugs,9.23,36,,9.23,percent of total billed charges,Drugs,8.98,35,,8.98,percent of total billed charges,Drugs,8.98,35,,8.98,percent of total billed charges,Drugs,8.98,35,,8.98,percent of total billed charges,Drugs,8.98,35,,8.98,percent of total billed charges,Drugs,8.55,,,8.55,Other,Drug Cost,8.55,,,8.55,Other,Drug Cost,8.55,,,8.55,Other,Drug Cost,8.55,,,8.55,Other,Drug Cost,8.55,,,8.55,Other,Drug Cost,8.55,,,8.55,Other,Drug Cost,19.24,,,19.24,Other,225% of Medicaid,11.97,,,11.97,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,85.19,,,85.19,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",18.38,,,18.38,Other,215% Medicaid APG methodology,18.38,,,18.38,Other,215% Medicaid APG methodology,10.69,,,10.69,Other,125% Medicaid APG methodology,0.01,87.56,
PAMIDRONATE DISODIUM 9MG/ML 10ML,J2430,HCPCS,,80001580,CDM,636,RC,61703032618,NDC,both,1,ML,70.11,87.56,,,87.56,Other,150% of Medicare + 9.63% HCRA Surcharge,53.24,,,53.24,Fee Schedule,Average Sale Price (ASP) x 6,24.54,35,,24.54,percent of total billed charges,Drugs,24.54,35,,24.54,percent of total billed charges,Drugs,23.84,34,,23.84,percent of total billed charges,Drugs,23.84,34,,23.84,percent of total billed charges,Drugs,23.84,34,,23.84,percent of total billed charges,Drugs,23.84,34,,23.84,percent of total billed charges,Drugs,24.54,35,,24.54,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,24.54,35,,24.54,percent of total billed charges,Drugs,24.54,35,,24.54,percent of total billed charges,Drugs,24.54,35,,24.54,percent of total billed charges,Drugs,24.54,35,,24.54,percent of total billed charges,Drugs,24.54,35,,24.54,percent of total billed charges,Drugs,28.04,40,,28.04,percent of total billed charges,Drugs,49.08,70,,49.08,percent of total billed charges,All Other,25.24,36,,25.24,percent of total billed charges,Drugs,25.24,36,,25.24,percent of total billed charges,Drugs,24.54,35,,24.54,percent of total billed charges,Drugs,24.54,35,,24.54,percent of total billed charges,Drugs,24.54,35,,24.54,percent of total billed charges,Drugs,24.54,35,,24.54,percent of total billed charges,Drugs,23.37,,,23.37,Other,Drug Cost,23.37,,,23.37,Other,Drug Cost,23.37,,,23.37,Other,Drug Cost,23.37,,,23.37,Other,Drug Cost,23.37,,,23.37,Other,Drug Cost,23.37,,,23.37,Other,Drug Cost,52.58,,,52.58,Other,225% of Medicaid,32.72,,,32.72,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,85.19,,,85.19,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",50.25,,,50.25,Other,215% Medicaid APG methodology,50.25,,,50.25,Other,215% Medicaid APG methodology,29.21,,,29.21,Other,125% Medicaid APG methodology,0.01,87.56,
PANITUMUMAB INJECTION 100MG INJ,J9303,HCPCS,,80001581,CDM,636,RC,55513095401,NDC,both,1,ML,2467.17,1486.51,,,1486.51,Other,150% of Medicare + 9.63% HCRA Surcharge,903.95,,,903.95,Fee Schedule,Average Sale Price (ASP) x 6,863.51,35,,863.51,percent of total billed charges,Drugs,863.51,35,,863.51,percent of total billed charges,Drugs,838.84,34,,838.84,percent of total billed charges,Drugs,838.84,34,,838.84,percent of total billed charges,Drugs,838.84,34,,838.84,percent of total billed charges,Drugs,838.84,34,,838.84,percent of total billed charges,Drugs,863.51,35,,863.51,percent of total billed charges,Drugs,838.84,34,"If Charge > 500, then 34 percent",838.84,percent of total billed charges,Drugs,863.51,35,,863.51,percent of total billed charges,Drugs,863.51,35,,863.51,percent of total billed charges,Drugs,863.51,35,,863.51,percent of total billed charges,Drugs,863.51,35,,863.51,percent of total billed charges,Drugs,863.51,35,,863.51,percent of total billed charges,Drugs,986.87,40,,986.87,percent of total billed charges,Drugs,1727.02,70,,1727.02,percent of total billed charges,All Other,888.18,36,,888.18,percent of total billed charges,Drugs,888.18,36,,888.18,percent of total billed charges,Drugs,863.51,35,,863.51,percent of total billed charges,Drugs,863.51,35,,863.51,percent of total billed charges,Drugs,863.51,35,,863.51,percent of total billed charges,Drugs,863.51,35,,863.51,percent of total billed charges,Drugs,822.39,,,822.39,Other,Drug Cost,822.39,,,822.39,Other,Drug Cost,822.39,,,822.39,Other,Drug Cost,822.39,,,822.39,Other,Drug Cost,822.39,,,822.39,Other,Drug Cost,822.39,,,822.39,Other,Drug Cost,1850.38,,,1850.38,Other,225% of Medicaid,1151.35,,,1151.35,Other,140% of Medicaid,838.84,34,"If Charge > 2,000, then 34 percent",838.84,percent of total billed charges,Drugs,1446.33,,,1446.33,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",1768.14,,,1768.14,Other,215% Medicaid APG methodology,1768.14,,,1768.14,Other,215% Medicaid APG methodology,1027.99,,,1027.99,Other,125% Medicaid APG methodology,0.01,1850.38,
PANTOPRAZOLE SODIUM 40MG INJ,C9113,HCPCS,,80001582,CDM,636,RC,8092355,NDC,both,10,EA,0.03,0.01,39.4668,,0.01,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,35,,0.01,percent of total billed charges,Drugs,0.01,35,,0.01,percent of total billed charges,Drugs,0.01,34,,0.01,percent of total billed charges,Drugs,0.01,34,,0.01,percent of total billed charges,Drugs,0.01,34,,0.01,percent of total billed charges,Drugs,0.01,34,,0.01,percent of total billed charges,Drugs,0.01,35,,0.01,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,0.01,35,,0.01,percent of total billed charges,Drugs,0.01,35,,0.01,percent of total billed charges,Drugs,0.01,35,,0.01,percent of total billed charges,Drugs,0.01,35,,0.01,percent of total billed charges,Drugs,0.01,35,,0.01,percent of total billed charges,Drugs,0.01,40,,0.01,percent of total billed charges,Drugs,0.02,70,,0.02,percent of total billed charges,All Other,0.01,36,,0.01,percent of total billed charges,Drugs,0.01,36,,0.01,percent of total billed charges,Drugs,0.01,35,,0.01,percent of total billed charges,Drugs,0.01,35,,0.01,percent of total billed charges,Drugs,0.01,35,,0.01,percent of total billed charges,Drugs,0.01,35,,0.01,percent of total billed charges,Drugs,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.02,,,0.02,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,0.02,
PARICALCITOL 2MCG/ML INJ,J2501,HCPCS,,80001586,CDM,636,RC,74463701,NDC,both,25,ML,11.13,6.56,,,6.56,Other,150% of Medicare + 9.63% HCRA Surcharge,3.99,,,3.99,Fee Schedule,Average Sale Price (ASP) x 6,3.89,35,,3.89,percent of total billed charges,Drugs,3.89,35,,3.89,percent of total billed charges,Drugs,3.78,34,,3.78,percent of total billed charges,Drugs,3.78,34,,3.78,percent of total billed charges,Drugs,3.78,34,,3.78,percent of total billed charges,Drugs,3.78,34,,3.78,percent of total billed charges,Drugs,3.89,35,,3.89,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,3.89,35,,3.89,percent of total billed charges,Drugs,3.89,35,,3.89,percent of total billed charges,Drugs,3.89,35,,3.89,percent of total billed charges,Drugs,3.89,35,,3.89,percent of total billed charges,Drugs,3.89,35,,3.89,percent of total billed charges,Drugs,4.45,40,,4.45,percent of total billed charges,Drugs,7.79,70,,7.79,percent of total billed charges,All Other,4.01,36,,4.01,percent of total billed charges,Drugs,4.01,36,,4.01,percent of total billed charges,Drugs,3.89,35,,3.89,percent of total billed charges,Drugs,3.89,35,,3.89,percent of total billed charges,Drugs,3.89,35,,3.89,percent of total billed charges,Drugs,3.89,35,,3.89,percent of total billed charges,Drugs,3.71,,,3.71,Other,Drug Cost,3.71,,,3.71,Other,Drug Cost,3.71,,,3.71,Other,Drug Cost,3.71,,,3.71,Other,Drug Cost,3.71,,,3.71,Other,Drug Cost,3.71,,,3.71,Other,Drug Cost,8.34,,,8.34,Other,225% of Medicaid,5.19,,,5.19,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,6.38,,,6.38,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",7.97,,,7.97,Other,215% Medicaid APG methodology,7.97,,,7.97,Other,215% Medicaid APG methodology,4.64,,,4.64,Other,125% Medicaid APG methodology,0.01,8.34,
PARICALCITOL 5MCG/ML INJ,J2501,HCPCS,,80001588,CDM,636,RC,74165801,NDC,both,25,ML,27.81,6.56,,,6.56,Other,150% of Medicare + 9.63% HCRA Surcharge,3.99,,,3.99,Fee Schedule,Average Sale Price (ASP) x 6,9.73,35,,9.73,percent of total billed charges,Drugs,9.73,35,,9.73,percent of total billed charges,Drugs,9.46,34,,9.46,percent of total billed charges,Drugs,9.46,34,,9.46,percent of total billed charges,Drugs,9.46,34,,9.46,percent of total billed charges,Drugs,9.46,34,,9.46,percent of total billed charges,Drugs,9.73,35,,9.73,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,9.73,35,,9.73,percent of total billed charges,Drugs,9.73,35,,9.73,percent of total billed charges,Drugs,9.73,35,,9.73,percent of total billed charges,Drugs,9.73,35,,9.73,percent of total billed charges,Drugs,9.73,35,,9.73,percent of total billed charges,Drugs,11.13,40,,11.13,percent of total billed charges,Drugs,19.47,70,,19.47,percent of total billed charges,All Other,10.01,36,,10.01,percent of total billed charges,Drugs,10.01,36,,10.01,percent of total billed charges,Drugs,9.73,35,,9.73,percent of total billed charges,Drugs,9.73,35,,9.73,percent of total billed charges,Drugs,9.73,35,,9.73,percent of total billed charges,Drugs,9.73,35,,9.73,percent of total billed charges,Drugs,9.27,,,9.27,Other,Drug Cost,9.27,,,9.27,Other,Drug Cost,9.27,,,9.27,Other,Drug Cost,9.27,,,9.27,Other,Drug Cost,9.27,,,9.27,Other,Drug Cost,9.27,,,9.27,Other,Drug Cost,20.86,,,20.86,Other,225% of Medicaid,12.98,,,12.98,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,6.38,,,6.38,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",19.93,,,19.93,Other,215% Medicaid APG methodology,19.93,,,19.93,Other,215% Medicaid APG methodology,11.59,,,11.59,Other,125% Medicaid APG methodology,0.01,20.86,
PEGFILGRASTIM 6 MG INJ,J2506,HCPCS,,80001594,CDM,636,RC,55513019001,NDC,both,1,ML,12577.5,500.02,,,500.02,Other,150% of Medicare + 9.63% HCRA Surcharge,304.07,,,304.07,Fee Schedule,Average Sale Price (ASP) x 6,4402.13,35,,4402.13,percent of total billed charges,Drugs,4402.13,35,,4402.13,percent of total billed charges,Drugs,4276.35,34,,4276.35,percent of total billed charges,Drugs,4276.35,34,,4276.35,percent of total billed charges,Drugs,4276.35,34,,4276.35,percent of total billed charges,Drugs,4276.35,34,,4276.35,percent of total billed charges,Drugs,4402.13,35,,4402.13,percent of total billed charges,Drugs,4276.35,34,"If Charge > 500, then 34 percent",4276.35,percent of total billed charges,Drugs,4402.13,35,,4402.13,percent of total billed charges,Drugs,4402.13,35,,4402.13,percent of total billed charges,Drugs,4402.13,35,,4402.13,percent of total billed charges,Drugs,4402.13,35,,4402.13,percent of total billed charges,Drugs,4402.13,35,,4402.13,percent of total billed charges,Drugs,5031,40,,5031,percent of total billed charges,Drugs,8804.25,70,,8804.25,percent of total billed charges,All Other,4527.9,36,,4527.9,percent of total billed charges,Drugs,4527.9,36,,4527.9,percent of total billed charges,Drugs,4402.13,35,,4402.13,percent of total billed charges,Drugs,4402.13,35,,4402.13,percent of total billed charges,Drugs,4402.13,35,,4402.13,percent of total billed charges,Drugs,4402.13,35,,4402.13,percent of total billed charges,Drugs,4192.5,,,4192.5,Other,Drug Cost,4192.5,,,4192.5,Other,Drug Cost,4192.5,,,4192.5,Other,Drug Cost,4192.5,,,4192.5,Other,Drug Cost,4192.5,,,4192.5,Other,Drug Cost,4192.5,,,4192.5,Other,Drug Cost,9433.13,,,9433.13,Other,225% of Medicaid,5869.5,,,5869.5,Other,140% of Medicaid,4276.35,34,"If Charge > 2,000, then 34 percent",4276.35,percent of total billed charges,Drugs,486.51,,,486.51,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",9013.88,,,9013.88,Other,215% Medicaid APG methodology,9013.88,,,9013.88,Other,215% Medicaid APG methodology,5240.63,,,5240.63,Other,125% Medicaid APG methodology,0.01,9433.13,
PEMETREXED 500MG INJ,J9305,HCPCS,,80001595,CDM,636,RC,71288016795,NDC,both,1,EA,143.79,43.13,,,43.13,Other,150% of Medicare + 9.63% HCRA Surcharge,26.23,,,26.23,Fee Schedule,Average Sale Price (ASP) x 6,50.33,35,,50.33,percent of total billed charges,Drugs,50.33,35,,50.33,percent of total billed charges,Drugs,48.89,34,,48.89,percent of total billed charges,Drugs,48.89,34,,48.89,percent of total billed charges,Drugs,48.89,34,,48.89,percent of total billed charges,Drugs,48.89,34,,48.89,percent of total billed charges,Drugs,50.33,35,,50.33,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,50.33,35,,50.33,percent of total billed charges,Drugs,50.33,35,,50.33,percent of total billed charges,Drugs,50.33,35,,50.33,percent of total billed charges,Drugs,50.33,35,,50.33,percent of total billed charges,Drugs,50.33,35,,50.33,percent of total billed charges,Drugs,57.52,40,,57.52,percent of total billed charges,Drugs,100.65,70,,100.65,percent of total billed charges,All Other,51.76,36,,51.76,percent of total billed charges,Drugs,51.76,36,,51.76,percent of total billed charges,Drugs,50.33,35,,50.33,percent of total billed charges,Drugs,50.33,35,,50.33,percent of total billed charges,Drugs,50.33,35,,50.33,percent of total billed charges,Drugs,50.33,35,,50.33,percent of total billed charges,Drugs,47.93,,,47.93,Other,Drug Cost,47.93,,,47.93,Other,Drug Cost,47.93,,,47.93,Other,Drug Cost,47.93,,,47.93,Other,Drug Cost,47.93,,,47.93,Other,Drug Cost,47.93,,,47.93,Other,Drug Cost,107.84,,,107.84,Other,225% of Medicaid,67.1,,,67.1,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,41.96,,,41.96,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",103.05,,,103.05,Other,215% Medicaid APG methodology,103.05,,,103.05,Other,215% Medicaid APG methodology,59.91,,,59.91,Other,125% Medicaid APG methodology,0.01,107.84,
PENTOSTATIN 10MG INJ,J9268,HCPCS,,80001602,CDM,636,RC,409080101,NDC,both,1,EA,5290.68,22428.52,,,22428.52,Other,150% of Medicare + 9.63% HCRA Surcharge,13638.92,,,13638.92,Fee Schedule,Average Sale Price (ASP) x 6,1851.74,35,,1851.74,percent of total billed charges,Drugs,1851.74,35,,1851.74,percent of total billed charges,Drugs,1798.83,34,,1798.83,percent of total billed charges,Drugs,1798.83,34,,1798.83,percent of total billed charges,Drugs,1798.83,34,,1798.83,percent of total billed charges,Drugs,1798.83,34,,1798.83,percent of total billed charges,Drugs,1851.74,35,,1851.74,percent of total billed charges,Drugs,1798.83,34,"If Charge > 500, then 34 percent",1798.83,percent of total billed charges,Drugs,1851.74,35,,1851.74,percent of total billed charges,Drugs,1851.74,35,,1851.74,percent of total billed charges,Drugs,1851.74,35,,1851.74,percent of total billed charges,Drugs,1851.74,35,,1851.74,percent of total billed charges,Drugs,1851.74,35,,1851.74,percent of total billed charges,Drugs,2116.27,40,,2116.27,percent of total billed charges,Drugs,3703.48,70,,3703.48,percent of total billed charges,All Other,1904.64,36,,1904.64,percent of total billed charges,Drugs,1904.64,36,,1904.64,percent of total billed charges,Drugs,1851.74,35,,1851.74,percent of total billed charges,Drugs,1851.74,35,,1851.74,percent of total billed charges,Drugs,1851.74,35,,1851.74,percent of total billed charges,Drugs,1851.74,35,,1851.74,percent of total billed charges,Drugs,1763.56,,,1763.56,Other,Drug Cost,1763.56,,,1763.56,Other,Drug Cost,1763.56,,,1763.56,Other,Drug Cost,1763.56,,,1763.56,Other,Drug Cost,1763.56,,,1763.56,Other,Drug Cost,1763.56,,,1763.56,Other,Drug Cost,3968.01,,,3968.01,Other,225% of Medicaid,2468.98,,,2468.98,Other,140% of Medicaid,1798.83,34,"If Charge > 2,000, then 34 percent",1798.83,percent of total billed charges,Drugs,21822.27,,,21822.27,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",3791.65,,,3791.65,Other,215% Medicaid APG methodology,3791.65,,,3791.65,Other,215% Medicaid APG methodology,2204.45,,,2204.45,Other,125% Medicaid APG methodology,0.01,22428.52,
PHENOBARBITAL 130MG INJ,J2560,HCPCS,,80001621,CDM,636,RC,641047725,NDC,both,25,ML,52.72,310.13,,,310.13,Other,150% of Medicare + 9.63% HCRA Surcharge,188.59,,,188.59,Fee Schedule,Average Sale Price (ASP) x 6,18.45,35,,18.45,percent of total billed charges,Drugs,18.45,35,,18.45,percent of total billed charges,Drugs,17.93,34,,17.93,percent of total billed charges,Drugs,17.93,34,,17.93,percent of total billed charges,Drugs,17.93,34,,17.93,percent of total billed charges,Drugs,17.93,34,,17.93,percent of total billed charges,Drugs,18.45,35,,18.45,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,18.45,35,,18.45,percent of total billed charges,Drugs,18.45,35,,18.45,percent of total billed charges,Drugs,18.45,35,,18.45,percent of total billed charges,Drugs,18.45,35,,18.45,percent of total billed charges,Drugs,18.45,35,,18.45,percent of total billed charges,Drugs,21.09,40,,21.09,percent of total billed charges,Drugs,36.91,70,,36.91,percent of total billed charges,All Other,18.98,36,,18.98,percent of total billed charges,Drugs,18.98,36,,18.98,percent of total billed charges,Drugs,18.45,35,,18.45,percent of total billed charges,Drugs,18.45,35,,18.45,percent of total billed charges,Drugs,18.45,35,,18.45,percent of total billed charges,Drugs,18.45,35,,18.45,percent of total billed charges,Drugs,17.57,,,17.57,Other,Drug Cost,17.57,,,17.57,Other,Drug Cost,17.57,,,17.57,Other,Drug Cost,17.57,,,17.57,Other,Drug Cost,17.57,,,17.57,Other,Drug Cost,17.57,,,17.57,Other,Drug Cost,39.54,,,39.54,Other,225% of Medicaid,24.6,,,24.6,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,301.75,,,301.75,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",37.78,,,37.78,Other,215% Medicaid APG methodology,37.78,,,37.78,Other,215% Medicaid APG methodology,21.97,,,21.97,Other,125% Medicaid APG methodology,0.01,310.13,
PHENYLEPHRINE 10MG/ML INJ,J2371,HCPCS,,80001632,CDM,636,RC,641614225,NDC,both,25,ML,2.12,0.84,39.4668,,0.84,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.74,35,,0.74,percent of total billed charges,Drugs,0.74,35,,0.74,percent of total billed charges,Drugs,0.72,34,,0.72,percent of total billed charges,Drugs,0.72,34,,0.72,percent of total billed charges,Drugs,0.72,34,,0.72,percent of total billed charges,Drugs,0.72,34,,0.72,percent of total billed charges,Drugs,0.74,35,,0.74,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,0.74,35,,0.74,percent of total billed charges,Drugs,0.74,35,,0.74,percent of total billed charges,Drugs,0.74,35,,0.74,percent of total billed charges,Drugs,0.74,35,,0.74,percent of total billed charges,Drugs,0.74,35,,0.74,percent of total billed charges,Drugs,0.85,40,,0.85,percent of total billed charges,Drugs,1.48,70,,1.48,percent of total billed charges,All Other,0.76,36,,0.76,percent of total billed charges,Drugs,0.76,36,,0.76,percent of total billed charges,Drugs,0.74,35,,0.74,percent of total billed charges,Drugs,0.74,35,,0.74,percent of total billed charges,Drugs,0.74,35,,0.74,percent of total billed charges,Drugs,0.74,35,,0.74,percent of total billed charges,Drugs,0.71,,,0.71,Other,Drug Cost,0.71,,,0.71,Other,Drug Cost,0.71,,,0.71,Other,Drug Cost,0.71,,,0.71,Other,Drug Cost,0.71,,,0.71,Other,Drug Cost,0.71,,,0.71,Other,Drug Cost,1.59,,,1.59,Other,225% of Medicaid,0.99,,,0.99,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",1.52,,,1.52,Other,215% Medicaid APG methodology,1.52,,,1.52,Other,215% Medicaid APG methodology,0.88,,,0.88,Other,125% Medicaid APG methodology,0.01,1.59,
PHENYTOIN (DILANTIN) INJ 100MG/2ML,J1165,HCPCS,,80001637,CDM,636,RC,641049325,NDC,both,25,ML,2.26,6.22,,,6.22,Other,150% of Medicare + 9.63% HCRA Surcharge,3.78,,,3.78,Fee Schedule,Average Sale Price (ASP) x 6,0.79,35,,0.79,percent of total billed charges,Drugs,0.79,35,,0.79,percent of total billed charges,Drugs,0.77,34,,0.77,percent of total billed charges,Drugs,0.77,34,,0.77,percent of total billed charges,Drugs,0.77,34,,0.77,percent of total billed charges,Drugs,0.77,34,,0.77,percent of total billed charges,Drugs,0.79,35,,0.79,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,0.79,35,,0.79,percent of total billed charges,Drugs,0.79,35,,0.79,percent of total billed charges,Drugs,0.79,35,,0.79,percent of total billed charges,Drugs,0.79,35,,0.79,percent of total billed charges,Drugs,0.79,35,,0.79,percent of total billed charges,Drugs,0.9,40,,0.9,percent of total billed charges,Drugs,1.58,70,,1.58,percent of total billed charges,All Other,0.81,36,,0.81,percent of total billed charges,Drugs,0.81,36,,0.81,percent of total billed charges,Drugs,0.79,35,,0.79,percent of total billed charges,Drugs,0.79,35,,0.79,percent of total billed charges,Drugs,0.79,35,,0.79,percent of total billed charges,Drugs,0.79,35,,0.79,percent of total billed charges,Drugs,0.75,,,0.75,Other,Drug Cost,0.75,,,0.75,Other,Drug Cost,0.75,,,0.75,Other,Drug Cost,0.75,,,0.75,Other,Drug Cost,0.75,,,0.75,Other,Drug Cost,0.75,,,0.75,Other,Drug Cost,1.69,,,1.69,Other,225% of Medicaid,1.05,,,1.05,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,6.05,,,6.05,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",1.62,,,1.62,Other,215% Medicaid APG methodology,1.62,,,1.62,Other,215% Medicaid APG methodology,0.94,,,0.94,Other,125% Medicaid APG methodology,0.01,6.22,
PIPERACILLIN/TAZOBACTAMINJ 3.375GM,J2543,HCPCS,,80001655,CDM,636,RC,781311395,NDC,both,10,EA,0.03,11.61,,,11.61,Other,150% of Medicare + 9.63% HCRA Surcharge,7.06,,,7.06,Fee Schedule,Average Sale Price (ASP) x 6,0.01,35,,0.01,percent of total billed charges,Drugs,0.01,35,,0.01,percent of total billed charges,Drugs,0.01,34,,0.01,percent of total billed charges,Drugs,0.01,34,,0.01,percent of total billed charges,Drugs,0.01,34,,0.01,percent of total billed charges,Drugs,0.01,34,,0.01,percent of total billed charges,Drugs,0.01,35,,0.01,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,0.01,35,,0.01,percent of total billed charges,Drugs,0.01,35,,0.01,percent of total billed charges,Drugs,0.01,35,,0.01,percent of total billed charges,Drugs,0.01,35,,0.01,percent of total billed charges,Drugs,0.01,35,,0.01,percent of total billed charges,Drugs,0.01,40,,0.01,percent of total billed charges,Drugs,0.02,70,,0.02,percent of total billed charges,All Other,0.01,36,,0.01,percent of total billed charges,Drugs,0.01,36,,0.01,percent of total billed charges,Drugs,0.01,35,,0.01,percent of total billed charges,Drugs,0.01,35,,0.01,percent of total billed charges,Drugs,0.01,35,,0.01,percent of total billed charges,Drugs,0.01,35,,0.01,percent of total billed charges,Drugs,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.02,,,0.02,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,11.3,,,11.3,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,11.61,
PIPERACILLIN/TAZOBACTAMINJ 4.5GM,J2543,HCPCS,,80001656,CDM,636,RC,781311495,NDC,both,10,EA,0.1,11.61,,,11.61,Other,150% of Medicare + 9.63% HCRA Surcharge,7.06,,,7.06,Fee Schedule,Average Sale Price (ASP) x 6,0.04,35,,0.04,percent of total billed charges,Drugs,0.04,35,,0.04,percent of total billed charges,Drugs,0.03,34,,0.03,percent of total billed charges,Drugs,0.03,34,,0.03,percent of total billed charges,Drugs,0.03,34,,0.03,percent of total billed charges,Drugs,0.03,34,,0.03,percent of total billed charges,Drugs,0.04,35,,0.04,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,0.04,35,,0.04,percent of total billed charges,Drugs,0.04,35,,0.04,percent of total billed charges,Drugs,0.04,35,,0.04,percent of total billed charges,Drugs,0.04,35,,0.04,percent of total billed charges,Drugs,0.04,35,,0.04,percent of total billed charges,Drugs,0.04,40,,0.04,percent of total billed charges,Drugs,0.07,70,,0.07,percent of total billed charges,All Other,0.04,36,,0.04,percent of total billed charges,Drugs,0.04,36,,0.04,percent of total billed charges,Drugs,0.04,35,,0.04,percent of total billed charges,Drugs,0.04,35,,0.04,percent of total billed charges,Drugs,0.04,35,,0.04,percent of total billed charges,Drugs,0.04,35,,0.04,percent of total billed charges,Drugs,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.08,,,0.08,Other,225% of Medicaid,0.05,,,0.05,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,11.3,,,11.3,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",0.07,,,0.07,Other,215% Medicaid APG methodology,0.07,,,0.07,Other,215% Medicaid APG methodology,0.04,,,0.04,Other,125% Medicaid APG methodology,0.01,11.61,
PNEUMOCOCCAL VACCINE 23 VALENT,90732,HCPCS,,80001661,CDM,636,RC,6483703,NDC,both,10,ML,318.19,125.58,39.4668,,125.58,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,111.37,35,,111.37,percent of total billed charges,Drugs,111.37,35,,111.37,percent of total billed charges,Drugs,108.19,34,,108.19,percent of total billed charges,Drugs,108.19,34,,108.19,percent of total billed charges,Drugs,108.19,34,,108.19,percent of total billed charges,Drugs,108.19,34,,108.19,percent of total billed charges,Drugs,111.37,35,,111.37,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,111.37,35,,111.37,percent of total billed charges,Drugs,111.37,35,,111.37,percent of total billed charges,Drugs,111.37,35,,111.37,percent of total billed charges,Drugs,111.37,35,,111.37,percent of total billed charges,Drugs,111.37,35,,111.37,percent of total billed charges,Drugs,127.28,40,,127.28,percent of total billed charges,Drugs,222.73,70,,222.73,percent of total billed charges,All Other,114.55,36,,114.55,percent of total billed charges,Drugs,114.55,36,,114.55,percent of total billed charges,Drugs,111.37,35,,111.37,percent of total billed charges,Drugs,111.37,35,,111.37,percent of total billed charges,Drugs,111.37,35,,111.37,percent of total billed charges,Drugs,111.37,35,,111.37,percent of total billed charges,Drugs,106.06,,,106.06,Other,Drug Cost,106.06,,,106.06,Other,Drug Cost,106.06,,,106.06,Other,Drug Cost,106.06,,,106.06,Other,Drug Cost,106.06,,,106.06,Other,Drug Cost,106.06,,,106.06,Other,Drug Cost,238.64,,,238.64,Other,225% of Medicaid,148.49,,,148.49,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",228.04,,,228.04,Other,215% Medicaid APG methodology,228.04,,,228.04,Other,215% Medicaid APG methodology,132.58,,,132.58,Other,125% Medicaid APG methodology,0.01,238.64,
POTASS CL 10 MEQ/100 ML INJ,J3480,HCPCS,,80001668,CDM,636,RC,990707426,NDC,both,24,ML,3.29,1.18,,,1.18,Other,150% of Medicare + 9.63% HCRA Surcharge,0.72,,,0.72,Fee Schedule,Average Sale Price (ASP) x 6,1.15,35,,1.15,percent of total billed charges,Drugs,1.15,35,,1.15,percent of total billed charges,Drugs,1.12,34,,1.12,percent of total billed charges,Drugs,1.12,34,,1.12,percent of total billed charges,Drugs,1.12,34,,1.12,percent of total billed charges,Drugs,1.12,34,,1.12,percent of total billed charges,Drugs,1.15,35,,1.15,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,1.15,35,,1.15,percent of total billed charges,Drugs,1.15,35,,1.15,percent of total billed charges,Drugs,1.15,35,,1.15,percent of total billed charges,Drugs,1.15,35,,1.15,percent of total billed charges,Drugs,1.15,35,,1.15,percent of total billed charges,Drugs,1.32,40,,1.32,percent of total billed charges,Drugs,2.3,70,,2.3,percent of total billed charges,All Other,1.18,36,,1.18,percent of total billed charges,Drugs,1.18,36,,1.18,percent of total billed charges,Drugs,1.15,35,,1.15,percent of total billed charges,Drugs,1.15,35,,1.15,percent of total billed charges,Drugs,1.15,35,,1.15,percent of total billed charges,Drugs,1.15,35,,1.15,percent of total billed charges,Drugs,1.1,,,1.1,Other,Drug Cost,1.1,,,1.1,Other,Drug Cost,1.1,,,1.1,Other,Drug Cost,1.1,,,1.1,Other,Drug Cost,1.1,,,1.1,Other,Drug Cost,1.1,,,1.1,Other,Drug Cost,2.47,,,2.47,Other,225% of Medicaid,1.53,,,1.53,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,1.15,,,1.15,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",2.36,,,2.36,Other,215% Medicaid APG methodology,2.36,,,2.36,Other,215% Medicaid APG methodology,1.37,,,1.37,Other,125% Medicaid APG methodology,0.01,2.47,
POTASS CL 20 MEQ/100 ML INJ,J3480,HCPCS,,80001669,CDM,636,RC,990707526,NDC,both,24,ML,3.56,1.18,,,1.18,Other,150% of Medicare + 9.63% HCRA Surcharge,0.72,,,0.72,Fee Schedule,Average Sale Price (ASP) x 6,1.25,35,,1.25,percent of total billed charges,Drugs,1.25,35,,1.25,percent of total billed charges,Drugs,1.21,34,,1.21,percent of total billed charges,Drugs,1.21,34,,1.21,percent of total billed charges,Drugs,1.21,34,,1.21,percent of total billed charges,Drugs,1.21,34,,1.21,percent of total billed charges,Drugs,1.25,35,,1.25,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,1.25,35,,1.25,percent of total billed charges,Drugs,1.25,35,,1.25,percent of total billed charges,Drugs,1.25,35,,1.25,percent of total billed charges,Drugs,1.25,35,,1.25,percent of total billed charges,Drugs,1.25,35,,1.25,percent of total billed charges,Drugs,1.42,40,,1.42,percent of total billed charges,Drugs,2.49,70,,2.49,percent of total billed charges,All Other,1.28,36,,1.28,percent of total billed charges,Drugs,1.28,36,,1.28,percent of total billed charges,Drugs,1.25,35,,1.25,percent of total billed charges,Drugs,1.25,35,,1.25,percent of total billed charges,Drugs,1.25,35,,1.25,percent of total billed charges,Drugs,1.25,35,,1.25,percent of total billed charges,Drugs,1.19,,,1.19,Other,Drug Cost,1.19,,,1.19,Other,Drug Cost,1.19,,,1.19,Other,Drug Cost,1.19,,,1.19,Other,Drug Cost,1.19,,,1.19,Other,Drug Cost,1.19,,,1.19,Other,Drug Cost,2.67,,,2.67,Other,225% of Medicaid,1.66,,,1.66,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,1.15,,,1.15,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",2.55,,,2.55,Other,215% Medicaid APG methodology,2.55,,,2.55,Other,215% Medicaid APG methodology,1.48,,,1.48,Other,125% Medicaid APG methodology,0.01,2.67,
PREDNISONE 1 MG TAB,J7512,HCPCS,,80001692,CDM,636,RC,54474125,NDC,both,100,EA,0.1,0.07,,,0.07,Other,150% of Medicare + 9.63% HCRA Surcharge,0.04,,,0.04,Fee Schedule,Average Sale Price (ASP) x 6,0.03,35,,0.03,percent of total billed charges,Drugs,0.03,35,,0.03,percent of total billed charges,Drugs,0.03,34,,0.03,percent of total billed charges,Drugs,0.03,34,,0.03,percent of total billed charges,Drugs,0.03,34,,0.03,percent of total billed charges,Drugs,0.03,34,,0.03,percent of total billed charges,Drugs,0.03,35,,0.03,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,0.03,35,,0.03,percent of total billed charges,Drugs,0.03,35,,0.03,percent of total billed charges,Drugs,0.03,35,,0.03,percent of total billed charges,Drugs,0.03,35,,0.03,percent of total billed charges,Drugs,0.03,35,,0.03,percent of total billed charges,Drugs,0.04,40,,0.04,percent of total billed charges,Drugs,0.07,70,,0.07,percent of total billed charges,All Other,0.03,36,,0.03,percent of total billed charges,Drugs,0.03,36,,0.03,percent of total billed charges,Drugs,0.03,35,,0.03,percent of total billed charges,Drugs,0.03,35,,0.03,percent of total billed charges,Drugs,0.03,35,,0.03,percent of total billed charges,Drugs,0.03,35,,0.03,percent of total billed charges,Drugs,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.07,,,0.07,Other,225% of Medicaid,0.05,,,0.05,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,0.07,,,0.07,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",0.07,,,0.07,Other,215% Medicaid APG methodology,0.07,,,0.07,Other,215% Medicaid APG methodology,0.04,,,0.04,Other,125% Medicaid APG methodology,0.01,0.07,
PREDNISONE 10 MG TAB,J7512,HCPCS,,80001693,CDM,636,RC,603533821,NDC,both,100,EA,0.18,0.07,,,0.07,Other,150% of Medicare + 9.63% HCRA Surcharge,0.04,,,0.04,Fee Schedule,Average Sale Price (ASP) x 6,0.06,35,,0.06,percent of total billed charges,Drugs,0.06,35,,0.06,percent of total billed charges,Drugs,0.06,34,,0.06,percent of total billed charges,Drugs,0.06,34,,0.06,percent of total billed charges,Drugs,0.06,34,,0.06,percent of total billed charges,Drugs,0.06,34,,0.06,percent of total billed charges,Drugs,0.06,35,,0.06,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,0.06,35,,0.06,percent of total billed charges,Drugs,0.06,35,,0.06,percent of total billed charges,Drugs,0.06,35,,0.06,percent of total billed charges,Drugs,0.06,35,,0.06,percent of total billed charges,Drugs,0.06,35,,0.06,percent of total billed charges,Drugs,0.07,40,,0.07,percent of total billed charges,Drugs,0.12,70,,0.12,percent of total billed charges,All Other,0.06,36,,0.06,percent of total billed charges,Drugs,0.06,36,,0.06,percent of total billed charges,Drugs,0.06,35,,0.06,percent of total billed charges,Drugs,0.06,35,,0.06,percent of total billed charges,Drugs,0.06,35,,0.06,percent of total billed charges,Drugs,0.06,35,,0.06,percent of total billed charges,Drugs,0.06,,,0.06,Other,Drug Cost,0.06,,,0.06,Other,Drug Cost,0.06,,,0.06,Other,Drug Cost,0.06,,,0.06,Other,Drug Cost,0.06,,,0.06,Other,Drug Cost,0.06,,,0.06,Other,Drug Cost,0.13,,,0.13,Other,225% of Medicaid,0.08,,,0.08,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,0.07,,,0.07,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",0.13,,,0.13,Other,215% Medicaid APG methodology,0.13,,,0.13,Other,215% Medicaid APG methodology,0.07,,,0.07,Other,125% Medicaid APG methodology,0.01,0.13,
PREDNISONE 20 MG TAB,J7512,HCPCS,,80001694,CDM,636,RC,59746017506,NDC,both,100,EA,0.07,0.07,,,0.07,Other,150% of Medicare + 9.63% HCRA Surcharge,0.04,,,0.04,Fee Schedule,Average Sale Price (ASP) x 6,0.03,35,,0.03,percent of total billed charges,Drugs,0.03,35,,0.03,percent of total billed charges,Drugs,0.02,34,,0.02,percent of total billed charges,Drugs,0.02,34,,0.02,percent of total billed charges,Drugs,0.02,34,,0.02,percent of total billed charges,Drugs,0.02,34,,0.02,percent of total billed charges,Drugs,0.03,35,,0.03,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,0.03,35,,0.03,percent of total billed charges,Drugs,0.03,35,,0.03,percent of total billed charges,Drugs,0.03,35,,0.03,percent of total billed charges,Drugs,0.03,35,,0.03,percent of total billed charges,Drugs,0.03,35,,0.03,percent of total billed charges,Drugs,0.03,40,,0.03,percent of total billed charges,Drugs,0.05,70,,0.05,percent of total billed charges,All Other,0.03,36,,0.03,percent of total billed charges,Drugs,0.03,36,,0.03,percent of total billed charges,Drugs,0.03,35,,0.03,percent of total billed charges,Drugs,0.03,35,,0.03,percent of total billed charges,Drugs,0.03,35,,0.03,percent of total billed charges,Drugs,0.03,35,,0.03,percent of total billed charges,Drugs,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.05,,,0.05,Other,225% of Medicaid,0.03,,,0.03,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,0.07,,,0.07,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",0.05,,,0.05,Other,215% Medicaid APG methodology,0.05,,,0.05,Other,215% Medicaid APG methodology,0.03,,,0.03,Other,125% Medicaid APG methodology,0.01,0.07,
PREDNISONE 50 MG TAB,J7512,HCPCS,,80001696,CDM,636,RC,54001925,NDC,both,100,EA,0.25,0.07,,,0.07,Other,150% of Medicare + 9.63% HCRA Surcharge,0.04,,,0.04,Fee Schedule,Average Sale Price (ASP) x 6,0.09,35,,0.09,percent of total billed charges,Drugs,0.09,35,,0.09,percent of total billed charges,Drugs,0.08,34,,0.08,percent of total billed charges,Drugs,0.08,34,,0.08,percent of total billed charges,Drugs,0.08,34,,0.08,percent of total billed charges,Drugs,0.08,34,,0.08,percent of total billed charges,Drugs,0.09,35,,0.09,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,0.09,35,,0.09,percent of total billed charges,Drugs,0.09,35,,0.09,percent of total billed charges,Drugs,0.09,35,,0.09,percent of total billed charges,Drugs,0.09,35,,0.09,percent of total billed charges,Drugs,0.09,35,,0.09,percent of total billed charges,Drugs,0.1,40,,0.1,percent of total billed charges,Drugs,0.17,70,,0.17,percent of total billed charges,All Other,0.09,36,,0.09,percent of total billed charges,Drugs,0.09,36,,0.09,percent of total billed charges,Drugs,0.09,35,,0.09,percent of total billed charges,Drugs,0.09,35,,0.09,percent of total billed charges,Drugs,0.09,35,,0.09,percent of total billed charges,Drugs,0.09,35,,0.09,percent of total billed charges,Drugs,0.08,,,0.08,Other,Drug Cost,0.08,,,0.08,Other,Drug Cost,0.08,,,0.08,Other,Drug Cost,0.08,,,0.08,Other,Drug Cost,0.08,,,0.08,Other,Drug Cost,0.08,,,0.08,Other,Drug Cost,0.19,,,0.19,Other,225% of Medicaid,0.12,,,0.12,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,0.07,,,0.07,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",0.18,,,0.18,Other,215% Medicaid APG methodology,0.18,,,0.18,Other,215% Medicaid APG methodology,0.1,,,0.1,Other,125% Medicaid APG methodology,0.01,0.19,
PROPOFOL (DIPRIVAN) 10MG/ML  20ML,J2704,HCPCS,,80001718,CDM,636,RC,63323026929,NDC,both,10,ML,4.5,1.26,,,1.26,Other,150% of Medicare + 9.63% HCRA Surcharge,0.77,,,0.77,Fee Schedule,Average Sale Price (ASP) x 6,1.57,35,,1.57,percent of total billed charges,Drugs,1.57,35,,1.57,percent of total billed charges,Drugs,1.53,34,,1.53,percent of total billed charges,Drugs,1.53,34,,1.53,percent of total billed charges,Drugs,1.53,34,,1.53,percent of total billed charges,Drugs,1.53,34,,1.53,percent of total billed charges,Drugs,1.57,35,,1.57,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,1.57,35,,1.57,percent of total billed charges,Drugs,1.57,35,,1.57,percent of total billed charges,Drugs,1.57,35,,1.57,percent of total billed charges,Drugs,1.57,35,,1.57,percent of total billed charges,Drugs,1.57,35,,1.57,percent of total billed charges,Drugs,1.8,40,,1.8,percent of total billed charges,Drugs,3.15,70,,3.15,percent of total billed charges,All Other,1.62,36,,1.62,percent of total billed charges,Drugs,1.62,36,,1.62,percent of total billed charges,Drugs,1.57,35,,1.57,percent of total billed charges,Drugs,1.57,35,,1.57,percent of total billed charges,Drugs,1.57,35,,1.57,percent of total billed charges,Drugs,1.57,35,,1.57,percent of total billed charges,Drugs,1.5,,,1.5,Other,Drug Cost,1.5,,,1.5,Other,Drug Cost,1.5,,,1.5,Other,Drug Cost,1.5,,,1.5,Other,Drug Cost,1.5,,,1.5,Other,Drug Cost,1.5,,,1.5,Other,Drug Cost,3.37,,,3.37,Other,225% of Medicaid,2.1,,,2.1,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,1.23,,,1.23,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",3.22,,,3.22,Other,215% Medicaid APG methodology,3.22,,,3.22,Other,215% Medicaid APG methodology,1.87,,,1.87,Other,125% Medicaid APG methodology,0.01,3.37,
PROPOFOL (DIPRIVAN) 10MG/ML 100ML,J2704,HCPCS,,80001719,CDM,636,RC,409469924,NDC,both,10,ML,20.79,1.26,,,1.26,Other,150% of Medicare + 9.63% HCRA Surcharge,0.77,,,0.77,Fee Schedule,Average Sale Price (ASP) x 6,7.28,35,,7.28,percent of total billed charges,Drugs,7.28,35,,7.28,percent of total billed charges,Drugs,7.07,34,,7.07,percent of total billed charges,Drugs,7.07,34,,7.07,percent of total billed charges,Drugs,7.07,34,,7.07,percent of total billed charges,Drugs,7.07,34,,7.07,percent of total billed charges,Drugs,7.28,35,,7.28,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,7.28,35,,7.28,percent of total billed charges,Drugs,7.28,35,,7.28,percent of total billed charges,Drugs,7.28,35,,7.28,percent of total billed charges,Drugs,7.28,35,,7.28,percent of total billed charges,Drugs,7.28,35,,7.28,percent of total billed charges,Drugs,8.32,40,,8.32,percent of total billed charges,Drugs,14.55,70,,14.55,percent of total billed charges,All Other,7.48,36,,7.48,percent of total billed charges,Drugs,7.48,36,,7.48,percent of total billed charges,Drugs,7.28,35,,7.28,percent of total billed charges,Drugs,7.28,35,,7.28,percent of total billed charges,Drugs,7.28,35,,7.28,percent of total billed charges,Drugs,7.28,35,,7.28,percent of total billed charges,Drugs,6.93,,,6.93,Other,Drug Cost,6.93,,,6.93,Other,Drug Cost,6.93,,,6.93,Other,Drug Cost,6.93,,,6.93,Other,Drug Cost,6.93,,,6.93,Other,Drug Cost,6.93,,,6.93,Other,Drug Cost,15.59,,,15.59,Other,225% of Medicaid,9.7,,,9.7,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,1.23,,,1.23,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",14.9,,,14.9,Other,215% Medicaid APG methodology,14.9,,,14.9,Other,215% Medicaid APG methodology,8.66,,,8.66,Other,125% Medicaid APG methodology,0.01,15.59,
PROPOFOL (DIPRIVAN) 10MG/ML 50ML,J2704,HCPCS,,80001720,CDM,636,RC,409469933,NDC,both,20,ML,10.4,1.26,,,1.26,Other,150% of Medicare + 9.63% HCRA Surcharge,0.77,,,0.77,Fee Schedule,Average Sale Price (ASP) x 6,3.64,35,,3.64,percent of total billed charges,Drugs,3.64,35,,3.64,percent of total billed charges,Drugs,3.53,34,,3.53,percent of total billed charges,Drugs,3.53,34,,3.53,percent of total billed charges,Drugs,3.53,34,,3.53,percent of total billed charges,Drugs,3.53,34,,3.53,percent of total billed charges,Drugs,3.64,35,,3.64,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,3.64,35,,3.64,percent of total billed charges,Drugs,3.64,35,,3.64,percent of total billed charges,Drugs,3.64,35,,3.64,percent of total billed charges,Drugs,3.64,35,,3.64,percent of total billed charges,Drugs,3.64,35,,3.64,percent of total billed charges,Drugs,4.16,40,,4.16,percent of total billed charges,Drugs,7.28,70,,7.28,percent of total billed charges,All Other,3.74,36,,3.74,percent of total billed charges,Drugs,3.74,36,,3.74,percent of total billed charges,Drugs,3.64,35,,3.64,percent of total billed charges,Drugs,3.64,35,,3.64,percent of total billed charges,Drugs,3.64,35,,3.64,percent of total billed charges,Drugs,3.64,35,,3.64,percent of total billed charges,Drugs,3.47,,,3.47,Other,Drug Cost,3.47,,,3.47,Other,Drug Cost,3.47,,,3.47,Other,Drug Cost,3.47,,,3.47,Other,Drug Cost,3.47,,,3.47,Other,Drug Cost,3.47,,,3.47,Other,Drug Cost,7.8,,,7.8,Other,225% of Medicaid,4.85,,,4.85,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,1.23,,,1.23,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",7.45,,,7.45,Other,215% Medicaid APG methodology,7.45,,,7.45,Other,215% Medicaid APG methodology,4.33,,,4.33,Other,125% Medicaid APG methodology,0.01,7.8,
PROTAMINE 50MG INJ,J2720,HCPCS,,80001732,CDM,636,RC,63323022905,NDC,both,25,ML,9.87,16.36,,,16.36,Other,150% of Medicare + 9.63% HCRA Surcharge,9.95,,,9.95,Fee Schedule,Average Sale Price (ASP) x 6,3.45,35,,3.45,percent of total billed charges,Drugs,3.45,35,,3.45,percent of total billed charges,Drugs,3.35,34,,3.35,percent of total billed charges,Drugs,3.35,34,,3.35,percent of total billed charges,Drugs,3.35,34,,3.35,percent of total billed charges,Drugs,3.35,34,,3.35,percent of total billed charges,Drugs,3.45,35,,3.45,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,3.45,35,,3.45,percent of total billed charges,Drugs,3.45,35,,3.45,percent of total billed charges,Drugs,3.45,35,,3.45,percent of total billed charges,Drugs,3.45,35,,3.45,percent of total billed charges,Drugs,3.45,35,,3.45,percent of total billed charges,Drugs,3.95,40,,3.95,percent of total billed charges,Drugs,6.91,70,,6.91,percent of total billed charges,All Other,3.55,36,,3.55,percent of total billed charges,Drugs,3.55,36,,3.55,percent of total billed charges,Drugs,3.45,35,,3.45,percent of total billed charges,Drugs,3.45,35,,3.45,percent of total billed charges,Drugs,3.45,35,,3.45,percent of total billed charges,Drugs,3.45,35,,3.45,percent of total billed charges,Drugs,3.29,,,3.29,Other,Drug Cost,3.29,,,3.29,Other,Drug Cost,3.29,,,3.29,Other,Drug Cost,3.29,,,3.29,Other,Drug Cost,3.29,,,3.29,Other,Drug Cost,3.29,,,3.29,Other,Drug Cost,7.4,,,7.4,Other,225% of Medicaid,4.6,,,4.6,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,15.92,,,15.92,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",7.07,,,7.07,Other,215% Medicaid APG methodology,7.07,,,7.07,Other,215% Medicaid APG methodology,4.11,,,4.11,Other,125% Medicaid APG methodology,0.01,16.36,
RABIES IMMUNE GLOB HUMAN 300IU/1ML INJ,90375,HCPCS,,80001755,CDM,636,RC,13533031801,NDC,both,1,ML,1237.77,488.51,39.4668,,488.51,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,433.22,35,,433.22,percent of total billed charges,Drugs,433.22,35,,433.22,percent of total billed charges,Drugs,420.84,34,,420.84,percent of total billed charges,Drugs,420.84,34,,420.84,percent of total billed charges,Drugs,420.84,34,,420.84,percent of total billed charges,Drugs,420.84,34,,420.84,percent of total billed charges,Drugs,433.22,35,,433.22,percent of total billed charges,Drugs,420.84,34,"If Charge > 500, then 34 percent",420.84,percent of total billed charges,Drugs,433.22,35,,433.22,percent of total billed charges,Drugs,433.22,35,,433.22,percent of total billed charges,Drugs,433.22,35,,433.22,percent of total billed charges,Drugs,433.22,35,,433.22,percent of total billed charges,Drugs,433.22,35,,433.22,percent of total billed charges,Drugs,495.11,40,,495.11,percent of total billed charges,Drugs,866.44,70,,866.44,percent of total billed charges,All Other,445.6,36,,445.6,percent of total billed charges,Drugs,445.6,36,,445.6,percent of total billed charges,Drugs,433.22,35,,433.22,percent of total billed charges,Drugs,433.22,35,,433.22,percent of total billed charges,Drugs,433.22,35,,433.22,percent of total billed charges,Drugs,433.22,35,,433.22,percent of total billed charges,Drugs,412.59,,,412.59,Other,Drug Cost,412.59,,,412.59,Other,Drug Cost,412.59,,,412.59,Other,Drug Cost,412.59,,,412.59,Other,Drug Cost,412.59,,,412.59,Other,Drug Cost,412.59,,,412.59,Other,Drug Cost,928.33,,,928.33,Other,225% of Medicaid,577.63,,,577.63,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",887.07,,,887.07,Other,215% Medicaid APG methodology,887.07,,,887.07,Other,215% Medicaid APG methodology,515.74,,,515.74,Other,125% Medicaid APG methodology,0.01,928.33,
RABIES VACCINE (IMOVAX) 2.5 UNITS IM,90675,HCPCS,,80001756,CDM,636,RC,50632001001,NDC,both,1,EA,847.17,334.35,39.4668,,334.35,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,296.51,35,,296.51,percent of total billed charges,Drugs,296.51,35,,296.51,percent of total billed charges,Drugs,288.04,34,,288.04,percent of total billed charges,Drugs,288.04,34,,288.04,percent of total billed charges,Drugs,288.04,34,,288.04,percent of total billed charges,Drugs,288.04,34,,288.04,percent of total billed charges,Drugs,296.51,35,,296.51,percent of total billed charges,Drugs,288.04,34,"If Charge > 500, then 34 percent",288.04,percent of total billed charges,Drugs,296.51,35,,296.51,percent of total billed charges,Drugs,296.51,35,,296.51,percent of total billed charges,Drugs,296.51,35,,296.51,percent of total billed charges,Drugs,296.51,35,,296.51,percent of total billed charges,Drugs,296.51,35,,296.51,percent of total billed charges,Drugs,338.87,40,,338.87,percent of total billed charges,Drugs,593.02,70,,593.02,percent of total billed charges,All Other,304.98,36,,304.98,percent of total billed charges,Drugs,304.98,36,,304.98,percent of total billed charges,Drugs,296.51,35,,296.51,percent of total billed charges,Drugs,296.51,35,,296.51,percent of total billed charges,Drugs,296.51,35,,296.51,percent of total billed charges,Drugs,296.51,35,,296.51,percent of total billed charges,Drugs,282.39,,,282.39,Other,Drug Cost,282.39,,,282.39,Other,Drug Cost,282.39,,,282.39,Other,Drug Cost,282.39,,,282.39,Other,Drug Cost,282.39,,,282.39,Other,Drug Cost,282.39,,,282.39,Other,Drug Cost,635.38,,,635.38,Other,225% of Medicaid,395.35,,,395.35,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",607.14,,,607.14,Other,215% Medicaid APG methodology,607.14,,,607.14,Other,215% Medicaid APG methodology,352.99,,,352.99,Other,125% Medicaid APG methodology,0.01,635.38,
RASBURICASE 1.5MG,J2783,HCPCS,,80001766,CDM,636,RC,24515010,NDC,both,3,EA,3189.7,3623.72,,,3623.72,Other,150% of Medicare + 9.63% HCRA Surcharge,2203.61,,,2203.61,Fee Schedule,Average Sale Price (ASP) x 6,1116.4,35,,1116.4,percent of total billed charges,Drugs,1116.4,35,,1116.4,percent of total billed charges,Drugs,1084.5,34,,1084.5,percent of total billed charges,Drugs,1084.5,34,,1084.5,percent of total billed charges,Drugs,1084.5,34,,1084.5,percent of total billed charges,Drugs,1084.5,34,,1084.5,percent of total billed charges,Drugs,1116.4,35,,1116.4,percent of total billed charges,Drugs,1084.5,34,"If Charge > 500, then 34 percent",1084.5,percent of total billed charges,Drugs,1116.4,35,,1116.4,percent of total billed charges,Drugs,1116.4,35,,1116.4,percent of total billed charges,Drugs,1116.4,35,,1116.4,percent of total billed charges,Drugs,1116.4,35,,1116.4,percent of total billed charges,Drugs,1116.4,35,,1116.4,percent of total billed charges,Drugs,1275.88,40,,1275.88,percent of total billed charges,Drugs,2232.79,70,,2232.79,percent of total billed charges,All Other,1148.29,36,,1148.29,percent of total billed charges,Drugs,1148.29,36,,1148.29,percent of total billed charges,Drugs,1116.4,35,,1116.4,percent of total billed charges,Drugs,1116.4,35,,1116.4,percent of total billed charges,Drugs,1116.4,35,,1116.4,percent of total billed charges,Drugs,1116.4,35,,1116.4,percent of total billed charges,Drugs,1063.23,,,1063.23,Other,Drug Cost,1063.23,,,1063.23,Other,Drug Cost,1063.23,,,1063.23,Other,Drug Cost,1063.23,,,1063.23,Other,Drug Cost,1063.23,,,1063.23,Other,Drug Cost,1063.23,,,1063.23,Other,Drug Cost,2392.27,,,2392.27,Other,225% of Medicaid,1488.53,,,1488.53,Other,140% of Medicaid,1084.5,34,"If Charge > 2,000, then 34 percent",1084.5,percent of total billed charges,Drugs,3525.77,,,3525.77,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",2285.95,,,2285.95,Other,215% Medicaid APG methodology,2285.95,,,2285.95,Other,215% Medicaid APG methodology,1329.04,,,1329.04,Other,125% Medicaid APG methodology,0.01,3623.72,
RASBURICASE 7.5MG,J2783,HCPCS,,80001767,CDM,636,RC,24515175,NDC,both,1,EA,15948.48,3623.72,,,3623.72,Other,150% of Medicare + 9.63% HCRA Surcharge,2203.61,,,2203.61,Fee Schedule,Average Sale Price (ASP) x 6,5581.97,35,,5581.97,percent of total billed charges,Drugs,5581.97,35,,5581.97,percent of total billed charges,Drugs,5422.48,34,,5422.48,percent of total billed charges,Drugs,5422.48,34,,5422.48,percent of total billed charges,Drugs,5422.48,34,,5422.48,percent of total billed charges,Drugs,5422.48,34,,5422.48,percent of total billed charges,Drugs,5581.97,35,,5581.97,percent of total billed charges,Drugs,5422.48,34,"If Charge > 500, then 34 percent",5422.48,percent of total billed charges,Drugs,5581.97,35,,5581.97,percent of total billed charges,Drugs,5581.97,35,,5581.97,percent of total billed charges,Drugs,5581.97,35,,5581.97,percent of total billed charges,Drugs,5581.97,35,,5581.97,percent of total billed charges,Drugs,5581.97,35,,5581.97,percent of total billed charges,Drugs,6379.39,40,,6379.39,percent of total billed charges,Drugs,11163.94,70,,11163.94,percent of total billed charges,All Other,5741.45,36,,5741.45,percent of total billed charges,Drugs,5741.45,36,,5741.45,percent of total billed charges,Drugs,5581.97,35,,5581.97,percent of total billed charges,Drugs,5581.97,35,,5581.97,percent of total billed charges,Drugs,5581.97,35,,5581.97,percent of total billed charges,Drugs,5581.97,35,,5581.97,percent of total billed charges,Drugs,5316.16,,,5316.16,Other,Drug Cost,5316.16,,,5316.16,Other,Drug Cost,5316.16,,,5316.16,Other,Drug Cost,5316.16,,,5316.16,Other,Drug Cost,5316.16,,,5316.16,Other,Drug Cost,5316.16,,,5316.16,Other,Drug Cost,11961.36,,,11961.36,Other,225% of Medicaid,7442.62,,,7442.62,Other,140% of Medicaid,5422.48,34,"If Charge > 2,000, then 34 percent",5422.48,percent of total billed charges,Drugs,3525.77,,,3525.77,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",11429.74,,,11429.74,Other,215% Medicaid APG methodology,11429.74,,,11429.74,Other,215% Medicaid APG methodology,6645.2,,,6645.2,Other,125% Medicaid APG methodology,0.01,11961.36,
REGADENOSON INJECTION 0.1 MG,J2785,HCPCS,,80001768,CDM,636,RC,60505611600,NDC,both,1,ML,8.82,140.9,,,140.9,Other,150% of Medicare + 9.63% HCRA Surcharge,85.68,,,85.68,Fee Schedule,Average Sale Price (ASP) x 6,3.09,35,,3.09,percent of total billed charges,Drugs,3.09,35,,3.09,percent of total billed charges,Drugs,3,34,,3,percent of total billed charges,Drugs,3,34,,3,percent of total billed charges,Drugs,3,34,,3,percent of total billed charges,Drugs,3,34,,3,percent of total billed charges,Drugs,3.09,35,,3.09,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,3.09,35,,3.09,percent of total billed charges,Drugs,3.09,35,,3.09,percent of total billed charges,Drugs,3.09,35,,3.09,percent of total billed charges,Drugs,3.09,35,,3.09,percent of total billed charges,Drugs,3.09,35,,3.09,percent of total billed charges,Drugs,3.53,40,,3.53,percent of total billed charges,Drugs,6.17,70,,6.17,percent of total billed charges,All Other,3.18,36,,3.18,percent of total billed charges,Drugs,3.18,36,,3.18,percent of total billed charges,Drugs,3.09,35,,3.09,percent of total billed charges,Drugs,3.09,35,,3.09,percent of total billed charges,Drugs,3.09,35,,3.09,percent of total billed charges,Drugs,3.09,35,,3.09,percent of total billed charges,Drugs,2.94,,,2.94,Other,Drug Cost,2.94,,,2.94,Other,Drug Cost,2.94,,,2.94,Other,Drug Cost,2.94,,,2.94,Other,Drug Cost,2.94,,,2.94,Other,Drug Cost,2.94,,,2.94,Other,Drug Cost,6.62,,,6.62,Other,225% of Medicaid,4.12,,,4.12,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,137.09,,,137.09,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",6.32,,,6.32,Other,215% Medicaid APG methodology,6.32,,,6.32,Other,215% Medicaid APG methodology,3.68,,,3.68,Other,125% Medicaid APG methodology,0.01,140.9,
RISPERIDONE LG ACTNG 25MG/2ML INJ,J2794,HCPCS,,80001795,CDM,636,RC,50458030611,NDC,both,1,EA,609.18,119.89,,,119.89,Other,150% of Medicare + 9.63% HCRA Surcharge,72.91,,,72.91,Fee Schedule,Average Sale Price (ASP) x 6,213.21,35,,213.21,percent of total billed charges,Drugs,213.21,35,,213.21,percent of total billed charges,Drugs,207.12,34,,207.12,percent of total billed charges,Drugs,207.12,34,,207.12,percent of total billed charges,Drugs,207.12,34,,207.12,percent of total billed charges,Drugs,207.12,34,,207.12,percent of total billed charges,Drugs,213.21,35,,213.21,percent of total billed charges,Drugs,207.12,34,"If Charge > 500, then 34 percent",207.12,percent of total billed charges,Drugs,213.21,35,,213.21,percent of total billed charges,Drugs,213.21,35,,213.21,percent of total billed charges,Drugs,213.21,35,,213.21,percent of total billed charges,Drugs,213.21,35,,213.21,percent of total billed charges,Drugs,213.21,35,,213.21,percent of total billed charges,Drugs,243.67,40,,243.67,percent of total billed charges,Drugs,426.43,70,,426.43,percent of total billed charges,All Other,219.3,36,,219.3,percent of total billed charges,Drugs,219.3,36,,219.3,percent of total billed charges,Drugs,213.21,35,,213.21,percent of total billed charges,Drugs,213.21,35,,213.21,percent of total billed charges,Drugs,213.21,35,,213.21,percent of total billed charges,Drugs,213.21,35,,213.21,percent of total billed charges,Drugs,203.06,,,203.06,Other,Drug Cost,203.06,,,203.06,Other,Drug Cost,203.06,,,203.06,Other,Drug Cost,203.06,,,203.06,Other,Drug Cost,203.06,,,203.06,Other,Drug Cost,203.06,,,203.06,Other,Drug Cost,456.89,,,456.89,Other,225% of Medicaid,284.28,,,284.28,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,116.65,,,116.65,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",436.58,,,436.58,Other,215% Medicaid APG methodology,436.58,,,436.58,Other,215% Medicaid APG methodology,253.83,,,253.83,Other,125% Medicaid APG methodology,0.01,456.89,
RISPERIDONE LG ACTNG 37.5MG/2ML INJ,J2794,HCPCS,,80001796,CDM,636,RC,50458030711,NDC,both,1,EA,901.38,119.89,,,119.89,Other,150% of Medicare + 9.63% HCRA Surcharge,72.91,,,72.91,Fee Schedule,Average Sale Price (ASP) x 6,315.48,35,,315.48,percent of total billed charges,Drugs,315.48,35,,315.48,percent of total billed charges,Drugs,306.47,34,,306.47,percent of total billed charges,Drugs,306.47,34,,306.47,percent of total billed charges,Drugs,306.47,34,,306.47,percent of total billed charges,Drugs,306.47,34,,306.47,percent of total billed charges,Drugs,315.48,35,,315.48,percent of total billed charges,Drugs,306.47,34,"If Charge > 500, then 34 percent",306.47,percent of total billed charges,Drugs,315.48,35,,315.48,percent of total billed charges,Drugs,315.48,35,,315.48,percent of total billed charges,Drugs,315.48,35,,315.48,percent of total billed charges,Drugs,315.48,35,,315.48,percent of total billed charges,Drugs,315.48,35,,315.48,percent of total billed charges,Drugs,360.55,40,,360.55,percent of total billed charges,Drugs,630.97,70,,630.97,percent of total billed charges,All Other,324.5,36,,324.5,percent of total billed charges,Drugs,324.5,36,,324.5,percent of total billed charges,Drugs,315.48,35,,315.48,percent of total billed charges,Drugs,315.48,35,,315.48,percent of total billed charges,Drugs,315.48,35,,315.48,percent of total billed charges,Drugs,315.48,35,,315.48,percent of total billed charges,Drugs,300.46,,,300.46,Other,Drug Cost,300.46,,,300.46,Other,Drug Cost,300.46,,,300.46,Other,Drug Cost,300.46,,,300.46,Other,Drug Cost,300.46,,,300.46,Other,Drug Cost,300.46,,,300.46,Other,Drug Cost,676.04,,,676.04,Other,225% of Medicaid,420.64,,,420.64,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,116.65,,,116.65,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",645.99,,,645.99,Other,215% Medicaid APG methodology,645.99,,,645.99,Other,215% Medicaid APG methodology,375.58,,,375.58,Other,125% Medicaid APG methodology,0.01,676.04,
RISPERIDONE LG ACTNG 50MG/2ML INJ,J2794,HCPCS,,80001797,CDM,636,RC,50458030811,NDC,both,1,EA,1221.54,119.89,,,119.89,Other,150% of Medicare + 9.63% HCRA Surcharge,72.91,,,72.91,Fee Schedule,Average Sale Price (ASP) x 6,427.54,35,,427.54,percent of total billed charges,Drugs,427.54,35,,427.54,percent of total billed charges,Drugs,415.32,34,,415.32,percent of total billed charges,Drugs,415.32,34,,415.32,percent of total billed charges,Drugs,415.32,34,,415.32,percent of total billed charges,Drugs,415.32,34,,415.32,percent of total billed charges,Drugs,427.54,35,,427.54,percent of total billed charges,Drugs,415.32,34,"If Charge > 500, then 34 percent",415.32,percent of total billed charges,Drugs,427.54,35,,427.54,percent of total billed charges,Drugs,427.54,35,,427.54,percent of total billed charges,Drugs,427.54,35,,427.54,percent of total billed charges,Drugs,427.54,35,,427.54,percent of total billed charges,Drugs,427.54,35,,427.54,percent of total billed charges,Drugs,488.62,40,,488.62,percent of total billed charges,Drugs,855.08,70,,855.08,percent of total billed charges,All Other,439.75,36,,439.75,percent of total billed charges,Drugs,439.75,36,,439.75,percent of total billed charges,Drugs,427.54,35,,427.54,percent of total billed charges,Drugs,427.54,35,,427.54,percent of total billed charges,Drugs,427.54,35,,427.54,percent of total billed charges,Drugs,427.54,35,,427.54,percent of total billed charges,Drugs,407.18,,,407.18,Other,Drug Cost,407.18,,,407.18,Other,Drug Cost,407.18,,,407.18,Other,Drug Cost,407.18,,,407.18,Other,Drug Cost,407.18,,,407.18,Other,Drug Cost,407.18,,,407.18,Other,Drug Cost,916.16,,,916.16,Other,225% of Medicaid,570.05,,,570.05,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,116.65,,,116.65,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",875.44,,,875.44,Other,215% Medicaid APG methodology,875.44,,,875.44,Other,215% Medicaid APG methodology,508.98,,,508.98,Other,125% Medicaid APG methodology,0.01,916.16,
RITUXIMAB INJECTION 100 MG,J9312,HCPCS,,80001799,CDM,636,RC,50242005121,NDC,both,1,ML,2788.98,781.42,,,781.42,Other,150% of Medicare + 9.63% HCRA Surcharge,475.19,,,475.19,Fee Schedule,Average Sale Price (ASP) x 6,976.14,35,,976.14,percent of total billed charges,Drugs,976.14,35,,976.14,percent of total billed charges,Drugs,948.25,34,,948.25,percent of total billed charges,Drugs,948.25,34,,948.25,percent of total billed charges,Drugs,948.25,34,,948.25,percent of total billed charges,Drugs,948.25,34,,948.25,percent of total billed charges,Drugs,976.14,35,,976.14,percent of total billed charges,Drugs,948.25,34,"If Charge > 500, then 34 percent",948.25,percent of total billed charges,Drugs,976.14,35,,976.14,percent of total billed charges,Drugs,976.14,35,,976.14,percent of total billed charges,Drugs,976.14,35,,976.14,percent of total billed charges,Drugs,976.14,35,,976.14,percent of total billed charges,Drugs,976.14,35,,976.14,percent of total billed charges,Drugs,1115.59,40,,1115.59,percent of total billed charges,Drugs,1952.29,70,,1952.29,percent of total billed charges,All Other,1004.03,36,,1004.03,percent of total billed charges,Drugs,1004.03,36,,1004.03,percent of total billed charges,Drugs,976.14,35,,976.14,percent of total billed charges,Drugs,976.14,35,,976.14,percent of total billed charges,Drugs,976.14,35,,976.14,percent of total billed charges,Drugs,976.14,35,,976.14,percent of total billed charges,Drugs,929.66,,,929.66,Other,Drug Cost,929.66,,,929.66,Other,Drug Cost,929.66,,,929.66,Other,Drug Cost,929.66,,,929.66,Other,Drug Cost,929.66,,,929.66,Other,Drug Cost,929.66,,,929.66,Other,Drug Cost,2091.74,,,2091.74,Other,225% of Medicaid,1301.52,,,1301.52,Other,140% of Medicaid,948.25,34,"If Charge > 2,000, then 34 percent",948.25,percent of total billed charges,Drugs,760.3,,,760.3,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",1998.77,,,1998.77,Other,215% Medicaid APG methodology,1998.77,,,1998.77,Other,215% Medicaid APG methodology,1162.08,,,1162.08,Other,125% Medicaid APG methodology,0.01,2091.74,
ROMIPLOSTIM 500MCG INJ,J2796,HCPCS,,80001805,CDM,636,RC,55513022201,NDC,both,1,EA,15566.31,947.47,,,947.47,Other,150% of Medicare + 9.63% HCRA Surcharge,576.16,,,576.16,Fee Schedule,Average Sale Price (ASP) x 6,5448.21,35,,5448.21,percent of total billed charges,Drugs,5448.21,35,,5448.21,percent of total billed charges,Drugs,5292.55,34,,5292.55,percent of total billed charges,Drugs,5292.55,34,,5292.55,percent of total billed charges,Drugs,5292.55,34,,5292.55,percent of total billed charges,Drugs,5292.55,34,,5292.55,percent of total billed charges,Drugs,5448.21,35,,5448.21,percent of total billed charges,Drugs,5292.55,34,"If Charge > 500, then 34 percent",5292.55,percent of total billed charges,Drugs,5448.21,35,,5448.21,percent of total billed charges,Drugs,5448.21,35,,5448.21,percent of total billed charges,Drugs,5448.21,35,,5448.21,percent of total billed charges,Drugs,5448.21,35,,5448.21,percent of total billed charges,Drugs,5448.21,35,,5448.21,percent of total billed charges,Drugs,6226.52,40,,6226.52,percent of total billed charges,Drugs,10896.42,70,,10896.42,percent of total billed charges,All Other,5603.87,36,,5603.87,percent of total billed charges,Drugs,5603.87,36,,5603.87,percent of total billed charges,Drugs,5448.21,35,,5448.21,percent of total billed charges,Drugs,5448.21,35,,5448.21,percent of total billed charges,Drugs,5448.21,35,,5448.21,percent of total billed charges,Drugs,5448.21,35,,5448.21,percent of total billed charges,Drugs,5188.77,,,5188.77,Other,Drug Cost,5188.77,,,5188.77,Other,Drug Cost,5188.77,,,5188.77,Other,Drug Cost,5188.77,,,5188.77,Other,Drug Cost,5188.77,,,5188.77,Other,Drug Cost,5188.77,,,5188.77,Other,Drug Cost,11674.73,,,11674.73,Other,225% of Medicaid,7264.28,,,7264.28,Other,140% of Medicaid,5292.55,34,"If Charge > 2,000, then 34 percent",5292.55,percent of total billed charges,Drugs,921.86,,,921.86,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",11155.86,,,11155.86,Other,215% Medicaid APG methodology,11155.86,,,11155.86,Other,215% Medicaid APG methodology,6485.96,,,6485.96,Other,125% Medicaid APG methodology,0.01,11674.73,
ROPIVACAINE 0.5% INJECTION,J2795,HCPCS,,80001810,CDM,636,RC,55150019720,NDC,both,25,ML,6.48,0.76,,,0.76,Other,150% of Medicare + 9.63% HCRA Surcharge,0.46,,,0.46,Fee Schedule,Average Sale Price (ASP) x 6,2.27,35,,2.27,percent of total billed charges,Drugs,2.27,35,,2.27,percent of total billed charges,Drugs,2.2,34,,2.2,percent of total billed charges,Drugs,2.2,34,,2.2,percent of total billed charges,Drugs,2.2,34,,2.2,percent of total billed charges,Drugs,2.2,34,,2.2,percent of total billed charges,Drugs,2.27,35,,2.27,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,2.27,35,,2.27,percent of total billed charges,Drugs,2.27,35,,2.27,percent of total billed charges,Drugs,2.27,35,,2.27,percent of total billed charges,Drugs,2.27,35,,2.27,percent of total billed charges,Drugs,2.27,35,,2.27,percent of total billed charges,Drugs,2.59,40,,2.59,percent of total billed charges,Drugs,4.53,70,,4.53,percent of total billed charges,All Other,2.33,36,,2.33,percent of total billed charges,Drugs,2.33,36,,2.33,percent of total billed charges,Drugs,2.27,35,,2.27,percent of total billed charges,Drugs,2.27,35,,2.27,percent of total billed charges,Drugs,2.27,35,,2.27,percent of total billed charges,Drugs,2.27,35,,2.27,percent of total billed charges,Drugs,2.16,,,2.16,Other,Drug Cost,2.16,,,2.16,Other,Drug Cost,2.16,,,2.16,Other,Drug Cost,2.16,,,2.16,Other,Drug Cost,2.16,,,2.16,Other,Drug Cost,2.16,,,2.16,Other,Drug Cost,4.86,,,4.86,Other,225% of Medicaid,3.02,,,3.02,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,0.74,,,0.74,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",4.64,,,4.64,Other,215% Medicaid APG methodology,4.64,,,4.64,Other,215% Medicaid APG methodology,2.7,,,2.7,Other,125% Medicaid APG methodology,0.01,4.86,
ROPIVACAINE 0.75% INJECTION,J2795,HCPCS,,80001811,CDM,636,RC,63323028720,NDC,both,5,ML,11.3,0.76,,,0.76,Other,150% of Medicare + 9.63% HCRA Surcharge,0.46,,,0.46,Fee Schedule,Average Sale Price (ASP) x 6,3.96,35,,3.96,percent of total billed charges,Drugs,3.96,35,,3.96,percent of total billed charges,Drugs,3.84,34,,3.84,percent of total billed charges,Drugs,3.84,34,,3.84,percent of total billed charges,Drugs,3.84,34,,3.84,percent of total billed charges,Drugs,3.84,34,,3.84,percent of total billed charges,Drugs,3.96,35,,3.96,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,3.96,35,,3.96,percent of total billed charges,Drugs,3.96,35,,3.96,percent of total billed charges,Drugs,3.96,35,,3.96,percent of total billed charges,Drugs,3.96,35,,3.96,percent of total billed charges,Drugs,3.96,35,,3.96,percent of total billed charges,Drugs,4.52,40,,4.52,percent of total billed charges,Drugs,7.91,70,,7.91,percent of total billed charges,All Other,4.07,36,,4.07,percent of total billed charges,Drugs,4.07,36,,4.07,percent of total billed charges,Drugs,3.96,35,,3.96,percent of total billed charges,Drugs,3.96,35,,3.96,percent of total billed charges,Drugs,3.96,35,,3.96,percent of total billed charges,Drugs,3.96,35,,3.96,percent of total billed charges,Drugs,3.77,,,3.77,Other,Drug Cost,3.77,,,3.77,Other,Drug Cost,3.77,,,3.77,Other,Drug Cost,3.77,,,3.77,Other,Drug Cost,3.77,,,3.77,Other,Drug Cost,3.77,,,3.77,Other,Drug Cost,8.48,,,8.48,Other,225% of Medicaid,5.28,,,5.28,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,0.74,,,0.74,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",8.1,,,8.1,Other,215% Medicaid APG methodology,8.1,,,8.1,Other,215% Medicaid APG methodology,4.71,,,4.71,Other,125% Medicaid APG methodology,0.01,8.48,
ROPIVACAINE HCL INJ 0.2% 100ML,J2795,HCPCS,,80001812,CDM,636,RC,63323028565,NDC,both,12,ML,32.32,0.76,,,0.76,Other,150% of Medicare + 9.63% HCRA Surcharge,0.46,,,0.46,Fee Schedule,Average Sale Price (ASP) x 6,11.31,35,,11.31,percent of total billed charges,Drugs,11.31,35,,11.31,percent of total billed charges,Drugs,10.99,34,,10.99,percent of total billed charges,Drugs,10.99,34,,10.99,percent of total billed charges,Drugs,10.99,34,,10.99,percent of total billed charges,Drugs,10.99,34,,10.99,percent of total billed charges,Drugs,11.31,35,,11.31,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,11.31,35,,11.31,percent of total billed charges,Drugs,11.31,35,,11.31,percent of total billed charges,Drugs,11.31,35,,11.31,percent of total billed charges,Drugs,11.31,35,,11.31,percent of total billed charges,Drugs,11.31,35,,11.31,percent of total billed charges,Drugs,12.93,40,,12.93,percent of total billed charges,Drugs,22.62,70,,22.62,percent of total billed charges,All Other,11.63,36,,11.63,percent of total billed charges,Drugs,11.63,36,,11.63,percent of total billed charges,Drugs,11.31,35,,11.31,percent of total billed charges,Drugs,11.31,35,,11.31,percent of total billed charges,Drugs,11.31,35,,11.31,percent of total billed charges,Drugs,11.31,35,,11.31,percent of total billed charges,Drugs,10.77,,,10.77,Other,Drug Cost,10.77,,,10.77,Other,Drug Cost,10.77,,,10.77,Other,Drug Cost,10.77,,,10.77,Other,Drug Cost,10.77,,,10.77,Other,Drug Cost,10.77,,,10.77,Other,Drug Cost,24.24,,,24.24,Other,225% of Medicaid,15.08,,,15.08,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,0.74,,,0.74,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",23.16,,,23.16,Other,215% Medicaid APG methodology,23.16,,,23.16,Other,215% Medicaid APG methodology,13.46,,,13.46,Other,125% Medicaid APG methodology,0.01,24.24,
ROPIVACAINE HCL INJ 0.2% 200ML,J2795,HCPCS,,80001813,CDM,636,RC,63323028564,NDC,both,12,ML,64.63,0.76,,,0.76,Other,150% of Medicare + 9.63% HCRA Surcharge,0.46,,,0.46,Fee Schedule,Average Sale Price (ASP) x 6,22.62,35,,22.62,percent of total billed charges,Drugs,22.62,35,,22.62,percent of total billed charges,Drugs,21.97,34,,21.97,percent of total billed charges,Drugs,21.97,34,,21.97,percent of total billed charges,Drugs,21.97,34,,21.97,percent of total billed charges,Drugs,21.97,34,,21.97,percent of total billed charges,Drugs,22.62,35,,22.62,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,22.62,35,,22.62,percent of total billed charges,Drugs,22.62,35,,22.62,percent of total billed charges,Drugs,22.62,35,,22.62,percent of total billed charges,Drugs,22.62,35,,22.62,percent of total billed charges,Drugs,22.62,35,,22.62,percent of total billed charges,Drugs,25.85,40,,25.85,percent of total billed charges,Drugs,45.24,70,,45.24,percent of total billed charges,All Other,23.27,36,,23.27,percent of total billed charges,Drugs,23.27,36,,23.27,percent of total billed charges,Drugs,22.62,35,,22.62,percent of total billed charges,Drugs,22.62,35,,22.62,percent of total billed charges,Drugs,22.62,35,,22.62,percent of total billed charges,Drugs,22.62,35,,22.62,percent of total billed charges,Drugs,21.54,,,21.54,Other,Drug Cost,21.54,,,21.54,Other,Drug Cost,21.54,,,21.54,Other,Drug Cost,21.54,,,21.54,Other,Drug Cost,21.54,,,21.54,Other,Drug Cost,21.54,,,21.54,Other,Drug Cost,48.47,,,48.47,Other,225% of Medicaid,30.16,,,30.16,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,0.74,,,0.74,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",46.32,,,46.32,Other,215% Medicaid APG methodology,46.32,,,46.32,Other,215% Medicaid APG methodology,26.93,,,26.93,Other,125% Medicaid APG methodology,0.01,48.47,
SINCALIDE INJECTION 5 MICROGRAMS,J2805,HCPCS,,80001854,CDM,636,RC,270055615,NDC,both,10,EA,354.56,1313.25,,,1313.25,Other,150% of Medicare + 9.63% HCRA Surcharge,798.59,,,798.59,Fee Schedule,Average Sale Price (ASP) x 6,124.1,35,,124.1,percent of total billed charges,Drugs,124.1,35,,124.1,percent of total billed charges,Drugs,120.55,34,,120.55,percent of total billed charges,Drugs,120.55,34,,120.55,percent of total billed charges,Drugs,120.55,34,,120.55,percent of total billed charges,Drugs,120.55,34,,120.55,percent of total billed charges,Drugs,124.1,35,,124.1,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,124.1,35,,124.1,percent of total billed charges,Drugs,124.1,35,,124.1,percent of total billed charges,Drugs,124.1,35,,124.1,percent of total billed charges,Drugs,124.1,35,,124.1,percent of total billed charges,Drugs,124.1,35,,124.1,percent of total billed charges,Drugs,141.82,40,,141.82,percent of total billed charges,Drugs,248.19,70,,248.19,percent of total billed charges,All Other,127.64,36,,127.64,percent of total billed charges,Drugs,127.64,36,,127.64,percent of total billed charges,Drugs,124.1,35,,124.1,percent of total billed charges,Drugs,124.1,35,,124.1,percent of total billed charges,Drugs,124.1,35,,124.1,percent of total billed charges,Drugs,124.1,35,,124.1,percent of total billed charges,Drugs,118.19,,,118.19,Other,Drug Cost,118.19,,,118.19,Other,Drug Cost,118.19,,,118.19,Other,Drug Cost,118.19,,,118.19,Other,Drug Cost,118.19,,,118.19,Other,Drug Cost,118.19,,,118.19,Other,Drug Cost,265.92,,,265.92,Other,225% of Medicaid,165.46,,,165.46,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,1277.75,,,1277.75,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",254.1,,,254.1,Other,215% Medicaid APG methodology,254.1,,,254.1,Other,215% Medicaid APG methodology,147.73,,,147.73,Other,125% Medicaid APG methodology,0.01,1313.25,
SODIUM CHLORIDE 0.9% 250ML,J7050,HCPCS,,80001878,CDM,636,RC,264780020,NDC,both,24,ML,0.76,6.64,,,6.64,Other,150% of Medicare + 9.63% HCRA Surcharge,4.04,,,4.04,Fee Schedule,Average Sale Price (ASP) x 6,0.27,35,,0.27,percent of total billed charges,Drugs,0.27,35,,0.27,percent of total billed charges,Drugs,0.26,34,,0.26,percent of total billed charges,Drugs,0.26,34,,0.26,percent of total billed charges,Drugs,0.26,34,,0.26,percent of total billed charges,Drugs,0.26,34,,0.26,percent of total billed charges,Drugs,0.27,35,,0.27,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,0.27,35,,0.27,percent of total billed charges,Drugs,0.27,35,,0.27,percent of total billed charges,Drugs,0.27,35,,0.27,percent of total billed charges,Drugs,0.27,35,,0.27,percent of total billed charges,Drugs,0.27,35,,0.27,percent of total billed charges,Drugs,0.31,40,,0.31,percent of total billed charges,Drugs,0.53,70,,0.53,percent of total billed charges,All Other,0.27,36,,0.27,percent of total billed charges,Drugs,0.27,36,,0.27,percent of total billed charges,Drugs,0.27,35,,0.27,percent of total billed charges,Drugs,0.27,35,,0.27,percent of total billed charges,Drugs,0.27,35,,0.27,percent of total billed charges,Drugs,0.27,35,,0.27,percent of total billed charges,Drugs,0.25,,,0.25,Other,Drug Cost,0.25,,,0.25,Other,Drug Cost,0.25,,,0.25,Other,Drug Cost,0.25,,,0.25,Other,Drug Cost,0.25,,,0.25,Other,Drug Cost,0.25,,,0.25,Other,Drug Cost,0.57,,,0.57,Other,225% of Medicaid,0.36,,,0.36,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,6.46,,,6.46,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",0.55,,,0.55,Other,215% Medicaid APG methodology,0.55,,,0.55,Other,215% Medicaid APG methodology,0.32,,,0.32,Other,125% Medicaid APG methodology,0.01,6.64,
SODIUM CHLORIDE 1000ML,J7030,HCPCS,,80001882,CDM,636,RC,264780000,NDC,both,12,ML,3.06,26.55,,,26.55,Other,150% of Medicare + 9.63% HCRA Surcharge,16.15,,,16.15,Fee Schedule,Average Sale Price (ASP) x 6,1.07,35,,1.07,percent of total billed charges,Drugs,1.07,35,,1.07,percent of total billed charges,Drugs,1.04,34,,1.04,percent of total billed charges,Drugs,1.04,34,,1.04,percent of total billed charges,Drugs,1.04,34,,1.04,percent of total billed charges,Drugs,1.04,34,,1.04,percent of total billed charges,Drugs,1.07,35,,1.07,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,1.07,35,,1.07,percent of total billed charges,Drugs,1.07,35,,1.07,percent of total billed charges,Drugs,1.07,35,,1.07,percent of total billed charges,Drugs,1.07,35,,1.07,percent of total billed charges,Drugs,1.07,35,,1.07,percent of total billed charges,Drugs,1.22,40,,1.22,percent of total billed charges,Drugs,2.14,70,,2.14,percent of total billed charges,All Other,1.1,36,,1.1,percent of total billed charges,Drugs,1.1,36,,1.1,percent of total billed charges,Drugs,1.07,35,,1.07,percent of total billed charges,Drugs,1.07,35,,1.07,percent of total billed charges,Drugs,1.07,35,,1.07,percent of total billed charges,Drugs,1.07,35,,1.07,percent of total billed charges,Drugs,1.02,,,1.02,Other,Drug Cost,1.02,,,1.02,Other,Drug Cost,1.02,,,1.02,Other,Drug Cost,1.02,,,1.02,Other,Drug Cost,1.02,,,1.02,Other,Drug Cost,1.02,,,1.02,Other,Drug Cost,2.29,,,2.29,Other,225% of Medicaid,1.43,,,1.43,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,25.83,,,25.83,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",2.19,,,2.19,Other,215% Medicaid APG methodology,2.19,,,2.19,Other,215% Medicaid APG methodology,1.27,,,1.27,Other,125% Medicaid APG methodology,0.01,26.55,
ECULIZUMAB 10MG/ML 30 ML,J1300,HCPCS,,80001898,CDM,636,RC,25682000101,NDC,both,1,ML,19569,2226.77,,,2226.77,Other,150% of Medicare + 9.63% HCRA Surcharge,1354.11,,,1354.11,Fee Schedule,Average Sale Price (ASP) x 6,6849.15,35,,6849.15,percent of total billed charges,Drugs,6849.15,35,,6849.15,percent of total billed charges,Drugs,6653.46,34,,6653.46,percent of total billed charges,Drugs,6653.46,34,,6653.46,percent of total billed charges,Drugs,6653.46,34,,6653.46,percent of total billed charges,Drugs,6653.46,34,,6653.46,percent of total billed charges,Drugs,6849.15,35,,6849.15,percent of total billed charges,Drugs,6653.46,34,"If Charge > 500, then 34 percent",6653.46,percent of total billed charges,Drugs,6849.15,35,,6849.15,percent of total billed charges,Drugs,6849.15,35,,6849.15,percent of total billed charges,Drugs,6849.15,35,,6849.15,percent of total billed charges,Drugs,6849.15,35,,6849.15,percent of total billed charges,Drugs,6849.15,35,,6849.15,percent of total billed charges,Drugs,7827.6,40,,7827.6,percent of total billed charges,Drugs,13698.3,70,,13698.3,percent of total billed charges,All Other,7044.84,36,,7044.84,percent of total billed charges,Drugs,7044.84,36,,7044.84,percent of total billed charges,Drugs,6849.15,35,,6849.15,percent of total billed charges,Drugs,6849.15,35,,6849.15,percent of total billed charges,Drugs,6849.15,35,,6849.15,percent of total billed charges,Drugs,6849.15,35,,6849.15,percent of total billed charges,Drugs,6523,,,6523,Other,Drug Cost,6523,,,6523,Other,Drug Cost,6523,,,6523,Other,Drug Cost,6523,,,6523,Other,Drug Cost,6523,,,6523,Other,Drug Cost,6523,,,6523,Other,Drug Cost,14676.75,,,14676.75,Other,225% of Medicaid,9132.2,,,9132.2,Other,140% of Medicaid,6653.46,34,"If Charge > 2,000, then 34 percent",6653.46,percent of total billed charges,Drugs,2166.58,,,2166.58,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",14024.45,,,14024.45,Other,215% Medicaid APG methodology,14024.45,,,14024.45,Other,215% Medicaid APG methodology,8153.75,,,8153.75,Other,125% Medicaid APG methodology,0.01,14676.75,
STREPTOMYCIN 1GM INJ,J3000,HCPCS,,80001915,CDM,636,RC,39822070602,NDC,both,10,EA,31.97,320.83,,,320.83,Other,150% of Medicare + 9.63% HCRA Surcharge,195.1,,,195.1,Fee Schedule,Average Sale Price (ASP) x 6,11.19,35,,11.19,percent of total billed charges,Drugs,11.19,35,,11.19,percent of total billed charges,Drugs,10.87,34,,10.87,percent of total billed charges,Drugs,10.87,34,,10.87,percent of total billed charges,Drugs,10.87,34,,10.87,percent of total billed charges,Drugs,10.87,34,,10.87,percent of total billed charges,Drugs,11.19,35,,11.19,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,11.19,35,,11.19,percent of total billed charges,Drugs,11.19,35,,11.19,percent of total billed charges,Drugs,11.19,35,,11.19,percent of total billed charges,Drugs,11.19,35,,11.19,percent of total billed charges,Drugs,11.19,35,,11.19,percent of total billed charges,Drugs,12.79,40,,12.79,percent of total billed charges,Drugs,22.38,70,,22.38,percent of total billed charges,All Other,11.51,36,,11.51,percent of total billed charges,Drugs,11.51,36,,11.51,percent of total billed charges,Drugs,11.19,35,,11.19,percent of total billed charges,Drugs,11.19,35,,11.19,percent of total billed charges,Drugs,11.19,35,,11.19,percent of total billed charges,Drugs,11.19,35,,11.19,percent of total billed charges,Drugs,10.66,,,10.66,Other,Drug Cost,10.66,,,10.66,Other,Drug Cost,10.66,,,10.66,Other,Drug Cost,10.66,,,10.66,Other,Drug Cost,10.66,,,10.66,Other,Drug Cost,10.66,,,10.66,Other,Drug Cost,23.98,,,23.98,Other,225% of Medicaid,14.92,,,14.92,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,312.15,,,312.15,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",22.91,,,22.91,Other,215% Medicaid APG methodology,22.91,,,22.91,Other,215% Medicaid APG methodology,13.32,,,13.32,Other,125% Medicaid APG methodology,0.01,320.83,
SUCCINYLCHOLINE CHLORIDE 20MG INJ,J0330,HCPCS,,80001918,CDM,636,RC,409662902,NDC,both,25,ML,0.27,0.11,39.4668,,0.11,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.09,35,,0.09,percent of total billed charges,Drugs,0.09,35,,0.09,percent of total billed charges,Drugs,0.09,34,,0.09,percent of total billed charges,Drugs,0.09,34,,0.09,percent of total billed charges,Drugs,0.09,34,,0.09,percent of total billed charges,Drugs,0.09,34,,0.09,percent of total billed charges,Drugs,0.09,35,,0.09,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,0.09,35,,0.09,percent of total billed charges,Drugs,0.09,35,,0.09,percent of total billed charges,Drugs,0.09,35,,0.09,percent of total billed charges,Drugs,0.09,35,,0.09,percent of total billed charges,Drugs,0.09,35,,0.09,percent of total billed charges,Drugs,0.11,40,,0.11,percent of total billed charges,Drugs,0.19,70,,0.19,percent of total billed charges,All Other,0.1,36,,0.1,percent of total billed charges,Drugs,0.1,36,,0.1,percent of total billed charges,Drugs,0.09,35,,0.09,percent of total billed charges,Drugs,0.09,35,,0.09,percent of total billed charges,Drugs,0.09,35,,0.09,percent of total billed charges,Drugs,0.09,35,,0.09,percent of total billed charges,Drugs,0.09,,,0.09,Other,Drug Cost,0.09,,,0.09,Other,Drug Cost,0.09,,,0.09,Other,Drug Cost,0.09,,,0.09,Other,Drug Cost,0.09,,,0.09,Other,Drug Cost,0.09,,,0.09,Other,Drug Cost,0.2,,,0.2,Other,225% of Medicaid,0.13,,,0.13,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",0.19,,,0.19,Other,215% Medicaid APG methodology,0.19,,,0.19,Other,215% Medicaid APG methodology,0.11,,,0.11,Other,125% Medicaid APG methodology,0.01,0.2,
SUMATRIPTAN SUCC (IMITREX) 6MG/0.5ML INJ,J3030,HCPCS,,80001928,CDM,636,RC,55150017301,NDC,both,5,ML,8.8,3.47,39.4668,,3.47,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,3.08,35,,3.08,percent of total billed charges,Drugs,3.08,35,,3.08,percent of total billed charges,Drugs,2.99,34,,2.99,percent of total billed charges,Drugs,2.99,34,,2.99,percent of total billed charges,Drugs,2.99,34,,2.99,percent of total billed charges,Drugs,2.99,34,,2.99,percent of total billed charges,Drugs,3.08,35,,3.08,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,3.08,35,,3.08,percent of total billed charges,Drugs,3.08,35,,3.08,percent of total billed charges,Drugs,3.08,35,,3.08,percent of total billed charges,Drugs,3.08,35,,3.08,percent of total billed charges,Drugs,3.08,35,,3.08,percent of total billed charges,Drugs,3.52,40,,3.52,percent of total billed charges,Drugs,6.16,70,,6.16,percent of total billed charges,All Other,3.17,36,,3.17,percent of total billed charges,Drugs,3.17,36,,3.17,percent of total billed charges,Drugs,3.08,35,,3.08,percent of total billed charges,Drugs,3.08,35,,3.08,percent of total billed charges,Drugs,3.08,35,,3.08,percent of total billed charges,Drugs,3.08,35,,3.08,percent of total billed charges,Drugs,2.93,,,2.93,Other,Drug Cost,2.93,,,2.93,Other,Drug Cost,2.93,,,2.93,Other,Drug Cost,2.93,,,2.93,Other,Drug Cost,2.93,,,2.93,Other,Drug Cost,2.93,,,2.93,Other,Drug Cost,6.6,,,6.6,Other,225% of Medicaid,4.1,,,4.1,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",6.3,,,6.3,Other,215% Medicaid APG methodology,6.3,,,6.3,Other,215% Medicaid APG methodology,3.67,,,3.67,Other,125% Medicaid APG methodology,0.01,6.6,
TACROLIMUS 1 MG CAP,J7507,HCPCS,,80001932,CDM,636,RC,16729004201,NDC,both,100,EA,0.21,2.33,,,2.33,Other,150% of Medicare + 9.63% HCRA Surcharge,1.42,,,1.42,Fee Schedule,Average Sale Price (ASP) x 6,0.07,35,,0.07,percent of total billed charges,Drugs,0.07,35,,0.07,percent of total billed charges,Drugs,0.07,34,,0.07,percent of total billed charges,Drugs,0.07,34,,0.07,percent of total billed charges,Drugs,0.07,34,,0.07,percent of total billed charges,Drugs,0.07,34,,0.07,percent of total billed charges,Drugs,0.07,35,,0.07,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,0.07,35,,0.07,percent of total billed charges,Drugs,0.07,35,,0.07,percent of total billed charges,Drugs,0.07,35,,0.07,percent of total billed charges,Drugs,0.07,35,,0.07,percent of total billed charges,Drugs,0.07,35,,0.07,percent of total billed charges,Drugs,0.08,40,,0.08,percent of total billed charges,Drugs,0.15,70,,0.15,percent of total billed charges,All Other,0.08,36,,0.08,percent of total billed charges,Drugs,0.08,36,,0.08,percent of total billed charges,Drugs,0.07,35,,0.07,percent of total billed charges,Drugs,0.07,35,,0.07,percent of total billed charges,Drugs,0.07,35,,0.07,percent of total billed charges,Drugs,0.07,35,,0.07,percent of total billed charges,Drugs,0.07,,,0.07,Other,Drug Cost,0.07,,,0.07,Other,Drug Cost,0.07,,,0.07,Other,Drug Cost,0.07,,,0.07,Other,Drug Cost,0.07,,,0.07,Other,Drug Cost,0.07,,,0.07,Other,Drug Cost,0.16,,,0.16,Other,225% of Medicaid,0.1,,,0.1,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,2.27,,,2.27,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",0.15,,,0.15,Other,215% Medicaid APG methodology,0.15,,,0.15,Other,215% Medicaid APG methodology,0.09,,,0.09,Other,125% Medicaid APG methodology,0.01,2.33,
TEMOZOLAMIDE 140MG CASULE,J8700,HCPCS,,80001941,CDM,636,RC,67877054007,NDC,both,5,EA,138.11,2.77,,,2.77,Other,150% of Medicare + 9.63% HCRA Surcharge,1.69,,,1.69,Fee Schedule,Average Sale Price (ASP) x 6,48.34,35,,48.34,percent of total billed charges,Drugs,48.34,35,,48.34,percent of total billed charges,Drugs,46.96,34,,46.96,percent of total billed charges,Drugs,46.96,34,,46.96,percent of total billed charges,Drugs,46.96,34,,46.96,percent of total billed charges,Drugs,46.96,34,,46.96,percent of total billed charges,Drugs,48.34,35,,48.34,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,48.34,35,,48.34,percent of total billed charges,Drugs,48.34,35,,48.34,percent of total billed charges,Drugs,48.34,35,,48.34,percent of total billed charges,Drugs,48.34,35,,48.34,percent of total billed charges,Drugs,48.34,35,,48.34,percent of total billed charges,Drugs,55.25,40,,55.25,percent of total billed charges,Drugs,96.68,70,,96.68,percent of total billed charges,All Other,49.72,36,,49.72,percent of total billed charges,Drugs,49.72,36,,49.72,percent of total billed charges,Drugs,48.34,35,,48.34,percent of total billed charges,Drugs,48.34,35,,48.34,percent of total billed charges,Drugs,48.34,35,,48.34,percent of total billed charges,Drugs,48.34,35,,48.34,percent of total billed charges,Drugs,46.04,,,46.04,Other,Drug Cost,46.04,,,46.04,Other,Drug Cost,46.04,,,46.04,Other,Drug Cost,46.04,,,46.04,Other,Drug Cost,46.04,,,46.04,Other,Drug Cost,46.04,,,46.04,Other,Drug Cost,103.59,,,103.59,Other,225% of Medicaid,64.45,,,64.45,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,2.7,,,2.7,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",98.98,,,98.98,Other,215% Medicaid APG methodology,98.98,,,98.98,Other,215% Medicaid APG methodology,57.55,,,57.55,Other,125% Medicaid APG methodology,0.01,103.59,
TENECTEPLASE INJECTION 50 MG VIAL,J3101,HCPCS,,80001942,CDM,636,RC,50242012047,NDC,both,1,EA,5580.57,1510.73,,,1510.73,Other,150% of Medicare + 9.63% HCRA Surcharge,918.68,,,918.68,Fee Schedule,Average Sale Price (ASP) x 6,1953.2,35,,1953.2,percent of total billed charges,Drugs,1953.2,35,,1953.2,percent of total billed charges,Drugs,1897.39,34,,1897.39,percent of total billed charges,Drugs,1897.39,34,,1897.39,percent of total billed charges,Drugs,1897.39,34,,1897.39,percent of total billed charges,Drugs,1897.39,34,,1897.39,percent of total billed charges,Drugs,1953.2,35,,1953.2,percent of total billed charges,Drugs,1897.39,34,"If Charge > 500, then 34 percent",1897.39,percent of total billed charges,Drugs,1953.2,35,,1953.2,percent of total billed charges,Drugs,1953.2,35,,1953.2,percent of total billed charges,Drugs,1953.2,35,,1953.2,percent of total billed charges,Drugs,1953.2,35,,1953.2,percent of total billed charges,Drugs,1953.2,35,,1953.2,percent of total billed charges,Drugs,2232.23,40,,2232.23,percent of total billed charges,Drugs,3906.4,70,,3906.4,percent of total billed charges,All Other,2009.01,36,,2009.01,percent of total billed charges,Drugs,2009.01,36,,2009.01,percent of total billed charges,Drugs,1953.2,35,,1953.2,percent of total billed charges,Drugs,1953.2,35,,1953.2,percent of total billed charges,Drugs,1953.2,35,,1953.2,percent of total billed charges,Drugs,1953.2,35,,1953.2,percent of total billed charges,Drugs,1860.19,,,1860.19,Other,Drug Cost,1860.19,,,1860.19,Other,Drug Cost,1860.19,,,1860.19,Other,Drug Cost,1860.19,,,1860.19,Other,Drug Cost,1860.19,,,1860.19,Other,Drug Cost,1860.19,,,1860.19,Other,Drug Cost,4185.43,,,4185.43,Other,225% of Medicaid,2604.27,,,2604.27,Other,140% of Medicaid,1897.39,34,"If Charge > 2,000, then 34 percent",1897.39,percent of total billed charges,Drugs,1469.89,,,1469.89,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",3999.41,,,3999.41,Other,215% Medicaid APG methodology,3999.41,,,3999.41,Other,215% Medicaid APG methodology,2325.24,,,2325.24,Other,125% Medicaid APG methodology,0.01,4185.43,
TERBUTALINE SULFATE INJ TO 1 MG,J3105,HCPCS,,80001949,CDM,636,RC,143974610,NDC,both,10,ML,3.56,76.9,,,76.9,Other,150% of Medicare + 9.63% HCRA Surcharge,46.76,,,46.76,Fee Schedule,Average Sale Price (ASP) x 6,1.25,35,,1.25,percent of total billed charges,Drugs,1.25,35,,1.25,percent of total billed charges,Drugs,1.21,34,,1.21,percent of total billed charges,Drugs,1.21,34,,1.21,percent of total billed charges,Drugs,1.21,34,,1.21,percent of total billed charges,Drugs,1.21,34,,1.21,percent of total billed charges,Drugs,1.25,35,,1.25,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,1.25,35,,1.25,percent of total billed charges,Drugs,1.25,35,,1.25,percent of total billed charges,Drugs,1.25,35,,1.25,percent of total billed charges,Drugs,1.25,35,,1.25,percent of total billed charges,Drugs,1.25,35,,1.25,percent of total billed charges,Drugs,1.42,40,,1.42,percent of total billed charges,Drugs,2.49,70,,2.49,percent of total billed charges,All Other,1.28,36,,1.28,percent of total billed charges,Drugs,1.28,36,,1.28,percent of total billed charges,Drugs,1.25,35,,1.25,percent of total billed charges,Drugs,1.25,35,,1.25,percent of total billed charges,Drugs,1.25,35,,1.25,percent of total billed charges,Drugs,1.25,35,,1.25,percent of total billed charges,Drugs,1.19,,,1.19,Other,Drug Cost,1.19,,,1.19,Other,Drug Cost,1.19,,,1.19,Other,Drug Cost,1.19,,,1.19,Other,Drug Cost,1.19,,,1.19,Other,Drug Cost,1.19,,,1.19,Other,Drug Cost,2.67,,,2.67,Other,225% of Medicaid,1.66,,,1.66,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,74.82,,,74.82,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",2.55,,,2.55,Other,215% Medicaid APG methodology,2.55,,,2.55,Other,215% Medicaid APG methodology,1.48,,,1.48,Other,125% Medicaid APG methodology,0.01,76.9,
TESTOSTERONE CYPIONATE 200MG/ML INJ,J1071,HCPCS,,80001953,CDM,636,RC,9041701,NDC,both,1,ML,11.61,0.27,,,0.27,Other,150% of Medicare + 9.63% HCRA Surcharge,0.16,,,0.16,Fee Schedule,Average Sale Price (ASP) x 6,4.06,35,,4.06,percent of total billed charges,Drugs,4.06,35,,4.06,percent of total billed charges,Drugs,3.95,34,,3.95,percent of total billed charges,Drugs,3.95,34,,3.95,percent of total billed charges,Drugs,3.95,34,,3.95,percent of total billed charges,Drugs,3.95,34,,3.95,percent of total billed charges,Drugs,4.06,35,,4.06,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,4.06,35,,4.06,percent of total billed charges,Drugs,4.06,35,,4.06,percent of total billed charges,Drugs,4.06,35,,4.06,percent of total billed charges,Drugs,4.06,35,,4.06,percent of total billed charges,Drugs,4.06,35,,4.06,percent of total billed charges,Drugs,4.64,40,,4.64,percent of total billed charges,Drugs,8.13,70,,8.13,percent of total billed charges,All Other,4.18,36,,4.18,percent of total billed charges,Drugs,4.18,36,,4.18,percent of total billed charges,Drugs,4.06,35,,4.06,percent of total billed charges,Drugs,4.06,35,,4.06,percent of total billed charges,Drugs,4.06,35,,4.06,percent of total billed charges,Drugs,4.06,35,,4.06,percent of total billed charges,Drugs,3.87,,,3.87,Other,Drug Cost,3.87,,,3.87,Other,Drug Cost,3.87,,,3.87,Other,Drug Cost,3.87,,,3.87,Other,Drug Cost,3.87,,,3.87,Other,Drug Cost,3.87,,,3.87,Other,Drug Cost,8.71,,,8.71,Other,225% of Medicaid,5.42,,,5.42,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,0.26,,,0.26,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",8.32,,,8.32,Other,215% Medicaid APG methodology,8.32,,,8.32,Other,215% Medicaid APG methodology,4.84,,,4.84,Other,125% Medicaid APG methodology,0.01,8.71,
TETANUS IMMUNE GLOBULIN 250 U INJ,J1670,HCPCS,,80001954,CDM,636,RC,13533063402,NDC,both,1,ML,0.03,5709,,,5709,Other,150% of Medicare + 9.63% HCRA Surcharge,3471.68,,,3471.68,Fee Schedule,Average Sale Price (ASP) x 6,0.01,35,,0.01,percent of total billed charges,Drugs,0.01,35,,0.01,percent of total billed charges,Drugs,0.01,34,,0.01,percent of total billed charges,Drugs,0.01,34,,0.01,percent of total billed charges,Drugs,0.01,34,,0.01,percent of total billed charges,Drugs,0.01,34,,0.01,percent of total billed charges,Drugs,0.01,35,,0.01,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,0.01,35,,0.01,percent of total billed charges,Drugs,0.01,35,,0.01,percent of total billed charges,Drugs,0.01,35,,0.01,percent of total billed charges,Drugs,0.01,35,,0.01,percent of total billed charges,Drugs,0.01,35,,0.01,percent of total billed charges,Drugs,0.01,40,,0.01,percent of total billed charges,Drugs,0.02,70,,0.02,percent of total billed charges,All Other,0.01,36,,0.01,percent of total billed charges,Drugs,0.01,36,,0.01,percent of total billed charges,Drugs,0.01,35,,0.01,percent of total billed charges,Drugs,0.01,35,,0.01,percent of total billed charges,Drugs,0.01,35,,0.01,percent of total billed charges,Drugs,0.01,35,,0.01,percent of total billed charges,Drugs,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.02,,,0.02,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,5554.68,,,5554.68,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,5709,
THIAMINE HCL 100 MG INJ,J3411,HCPCS,,80001965,CDM,636,RC,25021050002,NDC,both,25,ML,9.3,24.25,,,24.25,Other,150% of Medicare + 9.63% HCRA Surcharge,14.75,,,14.75,Fee Schedule,Average Sale Price (ASP) x 6,3.25,35,,3.25,percent of total billed charges,Drugs,3.25,35,,3.25,percent of total billed charges,Drugs,3.16,34,,3.16,percent of total billed charges,Drugs,3.16,34,,3.16,percent of total billed charges,Drugs,3.16,34,,3.16,percent of total billed charges,Drugs,3.16,34,,3.16,percent of total billed charges,Drugs,3.25,35,,3.25,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,3.25,35,,3.25,percent of total billed charges,Drugs,3.25,35,,3.25,percent of total billed charges,Drugs,3.25,35,,3.25,percent of total billed charges,Drugs,3.25,35,,3.25,percent of total billed charges,Drugs,3.25,35,,3.25,percent of total billed charges,Drugs,3.72,40,,3.72,percent of total billed charges,Drugs,6.51,70,,6.51,percent of total billed charges,All Other,3.35,36,,3.35,percent of total billed charges,Drugs,3.35,36,,3.35,percent of total billed charges,Drugs,3.25,35,,3.25,percent of total billed charges,Drugs,3.25,35,,3.25,percent of total billed charges,Drugs,3.25,35,,3.25,percent of total billed charges,Drugs,3.25,35,,3.25,percent of total billed charges,Drugs,3.1,,,3.1,Other,Drug Cost,3.1,,,3.1,Other,Drug Cost,3.1,,,3.1,Other,Drug Cost,3.1,,,3.1,Other,Drug Cost,3.1,,,3.1,Other,Drug Cost,3.1,,,3.1,Other,Drug Cost,6.97,,,6.97,Other,225% of Medicaid,4.34,,,4.34,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,23.6,,,23.6,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",6.66,,,6.66,Other,215% Medicaid APG methodology,6.66,,,6.66,Other,215% Medicaid APG methodology,3.87,,,3.87,Other,125% Medicaid APG methodology,0.01,24.25,
TIGECYCLINE 50MG INJ,J3243,HCPCS,,80001974,CDM,636,RC,8499020,NDC,both,10,EA,20.4,7.26,,,7.26,Other,150% of Medicare + 9.63% HCRA Surcharge,4.42,,,4.42,Fee Schedule,Average Sale Price (ASP) x 6,7.14,35,,7.14,percent of total billed charges,Drugs,7.14,35,,7.14,percent of total billed charges,Drugs,6.94,34,,6.94,percent of total billed charges,Drugs,6.94,34,,6.94,percent of total billed charges,Drugs,6.94,34,,6.94,percent of total billed charges,Drugs,6.94,34,,6.94,percent of total billed charges,Drugs,7.14,35,,7.14,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,7.14,35,,7.14,percent of total billed charges,Drugs,7.14,35,,7.14,percent of total billed charges,Drugs,7.14,35,,7.14,percent of total billed charges,Drugs,7.14,35,,7.14,percent of total billed charges,Drugs,7.14,35,,7.14,percent of total billed charges,Drugs,8.16,40,,8.16,percent of total billed charges,Drugs,14.28,70,,14.28,percent of total billed charges,All Other,7.34,36,,7.34,percent of total billed charges,Drugs,7.34,36,,7.34,percent of total billed charges,Drugs,7.14,35,,7.14,percent of total billed charges,Drugs,7.14,35,,7.14,percent of total billed charges,Drugs,7.14,35,,7.14,percent of total billed charges,Drugs,7.14,35,,7.14,percent of total billed charges,Drugs,6.8,,,6.8,Other,Drug Cost,6.8,,,6.8,Other,Drug Cost,6.8,,,6.8,Other,Drug Cost,6.8,,,6.8,Other,Drug Cost,6.8,,,6.8,Other,Drug Cost,6.8,,,6.8,Other,Drug Cost,15.3,,,15.3,Other,225% of Medicaid,9.52,,,9.52,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,7.07,,,7.07,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",14.62,,,14.62,Other,215% Medicaid APG methodology,14.62,,,14.62,Other,215% Medicaid APG methodology,8.5,,,8.5,Other,125% Medicaid APG methodology,0.01,15.3,
TOBRAMYCIN SULFATE INJ TO 80 MG,J3260,HCPCS,,80001993,CDM,636,RC,63323030602,NDC,both,25,ML,2.55,26.28,,,26.28,Other,150% of Medicare + 9.63% HCRA Surcharge,15.98,,,15.98,Fee Schedule,Average Sale Price (ASP) x 6,0.89,35,,0.89,percent of total billed charges,Drugs,0.89,35,,0.89,percent of total billed charges,Drugs,0.87,34,,0.87,percent of total billed charges,Drugs,0.87,34,,0.87,percent of total billed charges,Drugs,0.87,34,,0.87,percent of total billed charges,Drugs,0.87,34,,0.87,percent of total billed charges,Drugs,0.89,35,,0.89,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,0.89,35,,0.89,percent of total billed charges,Drugs,0.89,35,,0.89,percent of total billed charges,Drugs,0.89,35,,0.89,percent of total billed charges,Drugs,0.89,35,,0.89,percent of total billed charges,Drugs,0.89,35,,0.89,percent of total billed charges,Drugs,1.02,40,,1.02,percent of total billed charges,Drugs,1.79,70,,1.79,percent of total billed charges,All Other,0.92,36,,0.92,percent of total billed charges,Drugs,0.92,36,,0.92,percent of total billed charges,Drugs,0.89,35,,0.89,percent of total billed charges,Drugs,0.89,35,,0.89,percent of total billed charges,Drugs,0.89,35,,0.89,percent of total billed charges,Drugs,0.89,35,,0.89,percent of total billed charges,Drugs,0.85,,,0.85,Other,Drug Cost,0.85,,,0.85,Other,Drug Cost,0.85,,,0.85,Other,Drug Cost,0.85,,,0.85,Other,Drug Cost,0.85,,,0.85,Other,Drug Cost,0.85,,,0.85,Other,Drug Cost,1.92,,,1.92,Other,225% of Medicaid,1.19,,,1.19,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,25.57,,,25.57,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",1.83,,,1.83,Other,215% Medicaid APG methodology,1.83,,,1.83,Other,215% Medicaid APG methodology,1.06,,,1.06,Other,125% Medicaid APG methodology,0.01,26.28,
TORADOL INJ 30MG,J1885,HCPCS,,80002002,CDM,636,RC,25021070101,NDC,both,25,ML,1.08,4.81,,,4.81,Other,150% of Medicare + 9.63% HCRA Surcharge,2.93,,,2.93,Fee Schedule,Average Sale Price (ASP) x 6,0.38,35,,0.38,percent of total billed charges,Drugs,0.38,35,,0.38,percent of total billed charges,Drugs,0.37,34,,0.37,percent of total billed charges,Drugs,0.37,34,,0.37,percent of total billed charges,Drugs,0.37,34,,0.37,percent of total billed charges,Drugs,0.37,34,,0.37,percent of total billed charges,Drugs,0.38,35,,0.38,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,0.38,35,,0.38,percent of total billed charges,Drugs,0.38,35,,0.38,percent of total billed charges,Drugs,0.38,35,,0.38,percent of total billed charges,Drugs,0.38,35,,0.38,percent of total billed charges,Drugs,0.38,35,,0.38,percent of total billed charges,Drugs,0.43,40,,0.43,percent of total billed charges,Drugs,0.75,70,,0.75,percent of total billed charges,All Other,0.39,36,,0.39,percent of total billed charges,Drugs,0.39,36,,0.39,percent of total billed charges,Drugs,0.38,35,,0.38,percent of total billed charges,Drugs,0.38,35,,0.38,percent of total billed charges,Drugs,0.38,35,,0.38,percent of total billed charges,Drugs,0.38,35,,0.38,percent of total billed charges,Drugs,0.36,,,0.36,Other,Drug Cost,0.36,,,0.36,Other,Drug Cost,0.36,,,0.36,Other,Drug Cost,0.36,,,0.36,Other,Drug Cost,0.36,,,0.36,Other,Drug Cost,0.36,,,0.36,Other,Drug Cost,0.81,,,0.81,Other,225% of Medicaid,0.5,,,0.5,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,4.68,,,4.68,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",0.77,,,0.77,Other,215% Medicaid APG methodology,0.77,,,0.77,Other,215% Medicaid APG methodology,0.45,,,0.45,Other,125% Medicaid APG methodology,0.01,4.81,
TORADOL INJ 60MG,J1885,HCPCS,,80002003,CDM,636,RC,63323016202,NDC,both,25,ML,2.39,4.81,,,4.81,Other,150% of Medicare + 9.63% HCRA Surcharge,2.93,,,2.93,Fee Schedule,Average Sale Price (ASP) x 6,0.84,35,,0.84,percent of total billed charges,Drugs,0.84,35,,0.84,percent of total billed charges,Drugs,0.81,34,,0.81,percent of total billed charges,Drugs,0.81,34,,0.81,percent of total billed charges,Drugs,0.81,34,,0.81,percent of total billed charges,Drugs,0.81,34,,0.81,percent of total billed charges,Drugs,0.84,35,,0.84,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,0.84,35,,0.84,percent of total billed charges,Drugs,0.84,35,,0.84,percent of total billed charges,Drugs,0.84,35,,0.84,percent of total billed charges,Drugs,0.84,35,,0.84,percent of total billed charges,Drugs,0.84,35,,0.84,percent of total billed charges,Drugs,0.96,40,,0.96,percent of total billed charges,Drugs,1.67,70,,1.67,percent of total billed charges,All Other,0.86,36,,0.86,percent of total billed charges,Drugs,0.86,36,,0.86,percent of total billed charges,Drugs,0.84,35,,0.84,percent of total billed charges,Drugs,0.84,35,,0.84,percent of total billed charges,Drugs,0.84,35,,0.84,percent of total billed charges,Drugs,0.84,35,,0.84,percent of total billed charges,Drugs,0.8,,,0.8,Other,Drug Cost,0.8,,,0.8,Other,Drug Cost,0.8,,,0.8,Other,Drug Cost,0.8,,,0.8,Other,Drug Cost,0.8,,,0.8,Other,Drug Cost,0.8,,,0.8,Other,Drug Cost,1.79,,,1.79,Other,225% of Medicaid,1.12,,,1.12,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,4.68,,,4.68,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",1.71,,,1.71,Other,215% Medicaid APG methodology,1.71,,,1.71,Other,215% Medicaid APG methodology,1,,,1,Other,125% Medicaid APG methodology,0.01,4.81,
TPA INJ 100MG,J2997,HCPCS,,80002007,CDM,636,RC,50242008527,NDC,both,1,EA,23916.75,877.88,,,877.88,Other,150% of Medicare + 9.63% HCRA Surcharge,533.84,,,533.84,Fee Schedule,Average Sale Price (ASP) x 6,8370.86,35,,8370.86,percent of total billed charges,Drugs,8370.86,35,,8370.86,percent of total billed charges,Drugs,8131.7,34,,8131.7,percent of total billed charges,Drugs,8131.7,34,,8131.7,percent of total billed charges,Drugs,8131.7,34,,8131.7,percent of total billed charges,Drugs,8131.7,34,,8131.7,percent of total billed charges,Drugs,8370.86,35,,8370.86,percent of total billed charges,Drugs,8131.7,34,"If Charge > 500, then 34 percent",8131.7,percent of total billed charges,Drugs,8370.86,35,,8370.86,percent of total billed charges,Drugs,8370.86,35,,8370.86,percent of total billed charges,Drugs,8370.86,35,,8370.86,percent of total billed charges,Drugs,8370.86,35,,8370.86,percent of total billed charges,Drugs,8370.86,35,,8370.86,percent of total billed charges,Drugs,9566.7,40,,9566.7,percent of total billed charges,Drugs,16741.73,70,,16741.73,percent of total billed charges,All Other,8610.03,36,,8610.03,percent of total billed charges,Drugs,8610.03,36,,8610.03,percent of total billed charges,Drugs,8370.86,35,,8370.86,percent of total billed charges,Drugs,8370.86,35,,8370.86,percent of total billed charges,Drugs,8370.86,35,,8370.86,percent of total billed charges,Drugs,8370.86,35,,8370.86,percent of total billed charges,Drugs,7972.25,,,7972.25,Other,Drug Cost,7972.25,,,7972.25,Other,Drug Cost,7972.25,,,7972.25,Other,Drug Cost,7972.25,,,7972.25,Other,Drug Cost,7972.25,,,7972.25,Other,Drug Cost,7972.25,,,7972.25,Other,Drug Cost,17937.56,,,17937.56,Other,225% of Medicaid,11161.15,,,11161.15,Other,140% of Medicaid,8131.7,34,"If Charge > 2,000, then 34 percent",8131.7,percent of total billed charges,Drugs,854.15,,,854.15,Other,160% Medicare Fee Schedule,8131.7,34,,8131.7,Other,"Drug Charges > 20,000, then 34% of Charges",17140.34,,,17140.34,Other,215% Medicaid APG methodology,17140.34,,,17140.34,Other,215% Medicaid APG methodology,9965.31,,,9965.31,Other,125% Medicaid APG methodology,533.84,17937.56,
TPA INJ 2 MG (CATHFLO),J2997,HCPCS,,80002008,CDM,636,RC,50242004164,NDC,both,1,EA,130.68,877.88,,,877.88,Other,150% of Medicare + 9.63% HCRA Surcharge,533.84,,,533.84,Fee Schedule,Average Sale Price (ASP) x 6,45.74,35,,45.74,percent of total billed charges,Drugs,45.74,35,,45.74,percent of total billed charges,Drugs,44.43,34,,44.43,percent of total billed charges,Drugs,44.43,34,,44.43,percent of total billed charges,Drugs,44.43,34,,44.43,percent of total billed charges,Drugs,44.43,34,,44.43,percent of total billed charges,Drugs,45.74,35,,45.74,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,45.74,35,,45.74,percent of total billed charges,Drugs,45.74,35,,45.74,percent of total billed charges,Drugs,45.74,35,,45.74,percent of total billed charges,Drugs,45.74,35,,45.74,percent of total billed charges,Drugs,45.74,35,,45.74,percent of total billed charges,Drugs,52.27,40,,52.27,percent of total billed charges,Drugs,91.48,70,,91.48,percent of total billed charges,All Other,47.04,36,,47.04,percent of total billed charges,Drugs,47.04,36,,47.04,percent of total billed charges,Drugs,45.74,35,,45.74,percent of total billed charges,Drugs,45.74,35,,45.74,percent of total billed charges,Drugs,45.74,35,,45.74,percent of total billed charges,Drugs,45.74,35,,45.74,percent of total billed charges,Drugs,43.56,,,43.56,Other,Drug Cost,43.56,,,43.56,Other,Drug Cost,43.56,,,43.56,Other,Drug Cost,43.56,,,43.56,Other,Drug Cost,43.56,,,43.56,Other,Drug Cost,43.56,,,43.56,Other,Drug Cost,98.01,,,98.01,Other,225% of Medicaid,60.98,,,60.98,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,854.15,,,854.15,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",93.65,,,93.65,Other,215% Medicaid APG methodology,93.65,,,93.65,Other,215% Medicaid APG methodology,54.45,,,54.45,Other,125% Medicaid APG methodology,0.01,877.88,
TRIAMCINOLONE ACET INJ 50MG/5ML,J3301,HCPCS,,80002023,CDM,636,RC,3049420,NDC,both,1,ML,15.99,9.33,,,9.33,Other,150% of Medicare + 9.63% HCRA Surcharge,5.68,,,5.68,Fee Schedule,Average Sale Price (ASP) x 6,5.6,35,,5.6,percent of total billed charges,Drugs,5.6,35,,5.6,percent of total billed charges,Drugs,5.44,34,,5.44,percent of total billed charges,Drugs,5.44,34,,5.44,percent of total billed charges,Drugs,5.44,34,,5.44,percent of total billed charges,Drugs,5.44,34,,5.44,percent of total billed charges,Drugs,5.6,35,,5.6,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,5.6,35,,5.6,percent of total billed charges,Drugs,5.6,35,,5.6,percent of total billed charges,Drugs,5.6,35,,5.6,percent of total billed charges,Drugs,5.6,35,,5.6,percent of total billed charges,Drugs,5.6,35,,5.6,percent of total billed charges,Drugs,6.4,40,,6.4,percent of total billed charges,Drugs,11.19,70,,11.19,percent of total billed charges,All Other,5.76,36,,5.76,percent of total billed charges,Drugs,5.76,36,,5.76,percent of total billed charges,Drugs,5.6,35,,5.6,percent of total billed charges,Drugs,5.6,35,,5.6,percent of total billed charges,Drugs,5.6,35,,5.6,percent of total billed charges,Drugs,5.6,35,,5.6,percent of total billed charges,Drugs,5.33,,,5.33,Other,Drug Cost,5.33,,,5.33,Other,Drug Cost,5.33,,,5.33,Other,Drug Cost,5.33,,,5.33,Other,Drug Cost,5.33,,,5.33,Other,Drug Cost,5.33,,,5.33,Other,Drug Cost,11.99,,,11.99,Other,225% of Medicaid,7.46,,,7.46,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,9.08,,,9.08,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",11.46,,,11.46,Other,215% Medicaid APG methodology,11.46,,,11.46,Other,215% Medicaid APG methodology,6.66,,,6.66,Other,125% Medicaid APG methodology,0.01,11.99,
VANCOMYCIN HCL 1000MG INJ,J3370,HCPCS,,80002066,CDM,636,RC,70436002182,NDC,both,10,EA,2.04,22.76,,,22.76,Other,150% of Medicare + 9.63% HCRA Surcharge,13.84,,,13.84,Fee Schedule,Average Sale Price (ASP) x 6,0.71,35,,0.71,percent of total billed charges,Drugs,0.71,35,,0.71,percent of total billed charges,Drugs,0.69,34,,0.69,percent of total billed charges,Drugs,0.69,34,,0.69,percent of total billed charges,Drugs,0.69,34,,0.69,percent of total billed charges,Drugs,0.69,34,,0.69,percent of total billed charges,Drugs,0.71,35,,0.71,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,0.71,35,,0.71,percent of total billed charges,Drugs,0.71,35,,0.71,percent of total billed charges,Drugs,0.71,35,,0.71,percent of total billed charges,Drugs,0.71,35,,0.71,percent of total billed charges,Drugs,0.71,35,,0.71,percent of total billed charges,Drugs,0.81,40,,0.81,percent of total billed charges,Drugs,1.43,70,,1.43,percent of total billed charges,All Other,0.73,36,,0.73,percent of total billed charges,Drugs,0.73,36,,0.73,percent of total billed charges,Drugs,0.71,35,,0.71,percent of total billed charges,Drugs,0.71,35,,0.71,percent of total billed charges,Drugs,0.71,35,,0.71,percent of total billed charges,Drugs,0.71,35,,0.71,percent of total billed charges,Drugs,0.68,,,0.68,Other,Drug Cost,0.68,,,0.68,Other,Drug Cost,0.68,,,0.68,Other,Drug Cost,0.68,,,0.68,Other,Drug Cost,0.68,,,0.68,Other,Drug Cost,0.68,,,0.68,Other,Drug Cost,1.53,,,1.53,Other,225% of Medicaid,0.95,,,0.95,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,22.15,,,22.15,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",1.46,,,1.46,Other,215% Medicaid APG methodology,1.46,,,1.46,Other,215% Medicaid APG methodology,0.85,,,0.85,Other,125% Medicaid APG methodology,0.01,22.76,
VANCOMYCIN HCL 500 MG INJ,J3370,HCPCS,,80002067,CDM,636,RC,70436002082,NDC,both,10,EA,3.83,22.76,,,22.76,Other,150% of Medicare + 9.63% HCRA Surcharge,13.84,,,13.84,Fee Schedule,Average Sale Price (ASP) x 6,1.34,35,,1.34,percent of total billed charges,Drugs,1.34,35,,1.34,percent of total billed charges,Drugs,1.3,34,,1.3,percent of total billed charges,Drugs,1.3,34,,1.3,percent of total billed charges,Drugs,1.3,34,,1.3,percent of total billed charges,Drugs,1.3,34,,1.3,percent of total billed charges,Drugs,1.34,35,,1.34,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,1.34,35,,1.34,percent of total billed charges,Drugs,1.34,35,,1.34,percent of total billed charges,Drugs,1.34,35,,1.34,percent of total billed charges,Drugs,1.34,35,,1.34,percent of total billed charges,Drugs,1.34,35,,1.34,percent of total billed charges,Drugs,1.53,40,,1.53,percent of total billed charges,Drugs,2.68,70,,2.68,percent of total billed charges,All Other,1.38,36,,1.38,percent of total billed charges,Drugs,1.38,36,,1.38,percent of total billed charges,Drugs,1.34,35,,1.34,percent of total billed charges,Drugs,1.34,35,,1.34,percent of total billed charges,Drugs,1.34,35,,1.34,percent of total billed charges,Drugs,1.34,35,,1.34,percent of total billed charges,Drugs,1.28,,,1.28,Other,Drug Cost,1.28,,,1.28,Other,Drug Cost,1.28,,,1.28,Other,Drug Cost,1.28,,,1.28,Other,Drug Cost,1.28,,,1.28,Other,Drug Cost,1.28,,,1.28,Other,Drug Cost,2.87,,,2.87,Other,225% of Medicaid,1.79,,,1.79,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,22.15,,,22.15,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",2.75,,,2.75,Other,215% Medicaid APG methodology,2.75,,,2.75,Other,215% Medicaid APG methodology,1.6,,,1.6,Other,125% Medicaid APG methodology,0.01,22.76,
VANCOMYCIN 750MG/250ML NS,J3370,HCPCS,,80002068,CDM,636,RC,338358048,NDC,both,6,ML,0.01,22.76,,,22.76,Other,150% of Medicare + 9.63% HCRA Surcharge,13.84,,,13.84,Fee Schedule,Average Sale Price (ASP) x 6,0.01,35,,0.01,percent of total billed charges,Drugs,0.01,35,,0.01,percent of total billed charges,Drugs,0.01,34,,0.01,percent of total billed charges,Drugs,0.01,34,,0.01,percent of total billed charges,Drugs,0.01,34,,0.01,percent of total billed charges,Drugs,0.01,34,,0.01,percent of total billed charges,Drugs,0.01,35,,0.01,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,0.01,35,,0.01,percent of total billed charges,Drugs,0.01,35,,0.01,percent of total billed charges,Drugs,0.01,35,,0.01,percent of total billed charges,Drugs,0.01,35,,0.01,percent of total billed charges,Drugs,0.01,35,,0.01,percent of total billed charges,Drugs,0.01,40,,0.01,percent of total billed charges,Drugs,0.01,70,,0.01,percent of total billed charges,All Other,0.01,36,,0.01,percent of total billed charges,Drugs,0.01,36,,0.01,percent of total billed charges,Drugs,0.01,35,,0.01,percent of total billed charges,Drugs,0.01,35,,0.01,percent of total billed charges,Drugs,0.01,35,,0.01,percent of total billed charges,Drugs,0.01,35,,0.01,percent of total billed charges,Drugs,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,22.15,,,22.15,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",0.01,,,0.01,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,22.76,
VAPRISOL 20MG/100ML,C9488,HCPCS,,80002070,CDM,636,RC,66220016010,NDC,both,1,ML,1196.49,472.22,39.4668,,472.22,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,418.77,35,,418.77,percent of total billed charges,Drugs,418.77,35,,418.77,percent of total billed charges,Drugs,406.81,34,,406.81,percent of total billed charges,Drugs,406.81,34,,406.81,percent of total billed charges,Drugs,406.81,34,,406.81,percent of total billed charges,Drugs,406.81,34,,406.81,percent of total billed charges,Drugs,418.77,35,,418.77,percent of total billed charges,Drugs,406.81,34,"If Charge > 500, then 34 percent",406.81,percent of total billed charges,Drugs,418.77,35,,418.77,percent of total billed charges,Drugs,418.77,35,,418.77,percent of total billed charges,Drugs,418.77,35,,418.77,percent of total billed charges,Drugs,418.77,35,,418.77,percent of total billed charges,Drugs,418.77,35,,418.77,percent of total billed charges,Drugs,478.6,40,,478.6,percent of total billed charges,Drugs,837.54,70,,837.54,percent of total billed charges,All Other,430.74,36,,430.74,percent of total billed charges,Drugs,430.74,36,,430.74,percent of total billed charges,Drugs,418.77,35,,418.77,percent of total billed charges,Drugs,418.77,35,,418.77,percent of total billed charges,Drugs,418.77,35,,418.77,percent of total billed charges,Drugs,418.77,35,,418.77,percent of total billed charges,Drugs,398.83,,,398.83,Other,Drug Cost,398.83,,,398.83,Other,Drug Cost,398.83,,,398.83,Other,Drug Cost,398.83,,,398.83,Other,Drug Cost,398.83,,,398.83,Other,Drug Cost,398.83,,,398.83,Other,Drug Cost,897.37,,,897.37,Other,225% of Medicaid,558.36,,,558.36,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",857.48,,,857.48,Other,215% Medicaid APG methodology,857.48,,,857.48,Other,215% Medicaid APG methodology,498.54,,,498.54,Other,125% Medicaid APG methodology,0.01,897.37,
VINBLASTINE SULFATE INJ 1 MG,J9360,HCPCS,,80002088,CDM,636,RC,63323027810,NDC,both,1,ML,62.67,41.6,,,41.6,Other,150% of Medicare + 9.63% HCRA Surcharge,25.3,,,25.3,Fee Schedule,Average Sale Price (ASP) x 6,21.93,35,,21.93,percent of total billed charges,Drugs,21.93,35,,21.93,percent of total billed charges,Drugs,21.31,34,,21.31,percent of total billed charges,Drugs,21.31,34,,21.31,percent of total billed charges,Drugs,21.31,34,,21.31,percent of total billed charges,Drugs,21.31,34,,21.31,percent of total billed charges,Drugs,21.93,35,,21.93,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,21.93,35,,21.93,percent of total billed charges,Drugs,21.93,35,,21.93,percent of total billed charges,Drugs,21.93,35,,21.93,percent of total billed charges,Drugs,21.93,35,,21.93,percent of total billed charges,Drugs,21.93,35,,21.93,percent of total billed charges,Drugs,25.07,40,,25.07,percent of total billed charges,Drugs,43.87,70,,43.87,percent of total billed charges,All Other,22.56,36,,22.56,percent of total billed charges,Drugs,22.56,36,,22.56,percent of total billed charges,Drugs,21.93,35,,21.93,percent of total billed charges,Drugs,21.93,35,,21.93,percent of total billed charges,Drugs,21.93,35,,21.93,percent of total billed charges,Drugs,21.93,35,,21.93,percent of total billed charges,Drugs,20.89,,,20.89,Other,Drug Cost,20.89,,,20.89,Other,Drug Cost,20.89,,,20.89,Other,Drug Cost,20.89,,,20.89,Other,Drug Cost,20.89,,,20.89,Other,Drug Cost,20.89,,,20.89,Other,Drug Cost,47,,,47,Other,225% of Medicaid,29.25,,,29.25,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,40.47,,,40.47,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",44.91,,,44.91,Other,215% Medicaid APG methodology,44.91,,,44.91,Other,215% Medicaid APG methodology,26.11,,,26.11,Other,125% Medicaid APG methodology,0.01,47,
VINCRISTINE SULFATE 1 MG,J9370,HCPCS,,80002089,CDM,636,RC,61703030906,NDC,both,1,ML,12.51,76.22,,,76.22,Other,150% of Medicare + 9.63% HCRA Surcharge,46.35,,,46.35,Fee Schedule,Average Sale Price (ASP) x 6,4.38,35,,4.38,percent of total billed charges,Drugs,4.38,35,,4.38,percent of total billed charges,Drugs,4.25,34,,4.25,percent of total billed charges,Drugs,4.25,34,,4.25,percent of total billed charges,Drugs,4.25,34,,4.25,percent of total billed charges,Drugs,4.25,34,,4.25,percent of total billed charges,Drugs,4.38,35,,4.38,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,4.38,35,,4.38,percent of total billed charges,Drugs,4.38,35,,4.38,percent of total billed charges,Drugs,4.38,35,,4.38,percent of total billed charges,Drugs,4.38,35,,4.38,percent of total billed charges,Drugs,4.38,35,,4.38,percent of total billed charges,Drugs,5,40,,5,percent of total billed charges,Drugs,8.76,70,,8.76,percent of total billed charges,All Other,4.5,36,,4.5,percent of total billed charges,Drugs,4.5,36,,4.5,percent of total billed charges,Drugs,4.38,35,,4.38,percent of total billed charges,Drugs,4.38,35,,4.38,percent of total billed charges,Drugs,4.38,35,,4.38,percent of total billed charges,Drugs,4.38,35,,4.38,percent of total billed charges,Drugs,4.17,,,4.17,Other,Drug Cost,4.17,,,4.17,Other,Drug Cost,4.17,,,4.17,Other,Drug Cost,4.17,,,4.17,Other,Drug Cost,4.17,,,4.17,Other,Drug Cost,4.17,,,4.17,Other,Drug Cost,9.38,,,9.38,Other,225% of Medicaid,5.84,,,5.84,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,74.16,,,74.16,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",8.97,,,8.97,Other,215% Medicaid APG methodology,8.97,,,8.97,Other,215% Medicaid APG methodology,5.21,,,5.21,Other,125% Medicaid APG methodology,0.01,76.22,
VINORELBINE TARTRATE INJ 10 MG,J9390,HCPCS,,80002090,CDM,636,RC,25021020405,NDC,both,1,ML,95.97,73.17,,,73.17,Other,150% of Medicare + 9.63% HCRA Surcharge,44.5,,,44.5,Fee Schedule,Average Sale Price (ASP) x 6,33.59,35,,33.59,percent of total billed charges,Drugs,33.59,35,,33.59,percent of total billed charges,Drugs,32.63,34,,32.63,percent of total billed charges,Drugs,32.63,34,,32.63,percent of total billed charges,Drugs,32.63,34,,32.63,percent of total billed charges,Drugs,32.63,34,,32.63,percent of total billed charges,Drugs,33.59,35,,33.59,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,33.59,35,,33.59,percent of total billed charges,Drugs,33.59,35,,33.59,percent of total billed charges,Drugs,33.59,35,,33.59,percent of total billed charges,Drugs,33.59,35,,33.59,percent of total billed charges,Drugs,33.59,35,,33.59,percent of total billed charges,Drugs,38.39,40,,38.39,percent of total billed charges,Drugs,67.18,70,,67.18,percent of total billed charges,All Other,34.55,36,,34.55,percent of total billed charges,Drugs,34.55,36,,34.55,percent of total billed charges,Drugs,33.59,35,,33.59,percent of total billed charges,Drugs,33.59,35,,33.59,percent of total billed charges,Drugs,33.59,35,,33.59,percent of total billed charges,Drugs,33.59,35,,33.59,percent of total billed charges,Drugs,31.99,,,31.99,Other,Drug Cost,31.99,,,31.99,Other,Drug Cost,31.99,,,31.99,Other,Drug Cost,31.99,,,31.99,Other,Drug Cost,31.99,,,31.99,Other,Drug Cost,31.99,,,31.99,Other,Drug Cost,71.98,,,71.98,Other,225% of Medicaid,44.79,,,44.79,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,71.19,,,71.19,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",68.78,,,68.78,Other,215% Medicaid APG methodology,68.78,,,68.78,Other,215% Medicaid APG methodology,39.99,,,39.99,Other,125% Medicaid APG methodology,0.01,73.17,
VITAMIN B-12 INJECTION TO 1000 MCG,J3420,HCPCS,,80002099,CDM,636,RC,517003125,NDC,both,25,ML,0.85,14.24,,,14.24,Other,150% of Medicare + 9.63% HCRA Surcharge,8.66,,,8.66,Fee Schedule,Average Sale Price (ASP) x 6,0.3,35,,0.3,percent of total billed charges,Drugs,0.3,35,,0.3,percent of total billed charges,Drugs,0.29,34,,0.29,percent of total billed charges,Drugs,0.29,34,,0.29,percent of total billed charges,Drugs,0.29,34,,0.29,percent of total billed charges,Drugs,0.29,34,,0.29,percent of total billed charges,Drugs,0.3,35,,0.3,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,0.3,35,,0.3,percent of total billed charges,Drugs,0.3,35,,0.3,percent of total billed charges,Drugs,0.3,35,,0.3,percent of total billed charges,Drugs,0.3,35,,0.3,percent of total billed charges,Drugs,0.3,35,,0.3,percent of total billed charges,Drugs,0.34,40,,0.34,percent of total billed charges,Drugs,0.59,70,,0.59,percent of total billed charges,All Other,0.31,36,,0.31,percent of total billed charges,Drugs,0.31,36,,0.31,percent of total billed charges,Drugs,0.3,35,,0.3,percent of total billed charges,Drugs,0.3,35,,0.3,percent of total billed charges,Drugs,0.3,35,,0.3,percent of total billed charges,Drugs,0.3,35,,0.3,percent of total billed charges,Drugs,0.28,,,0.28,Other,Drug Cost,0.28,,,0.28,Other,Drug Cost,0.28,,,0.28,Other,Drug Cost,0.28,,,0.28,Other,Drug Cost,0.28,,,0.28,Other,Drug Cost,0.28,,,0.28,Other,Drug Cost,0.64,,,0.64,Other,225% of Medicaid,0.4,,,0.4,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,13.85,,,13.85,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",0.61,,,0.61,Other,215% Medicaid APG methodology,0.61,,,0.61,Other,215% Medicaid APG methodology,0.35,,,0.35,Other,125% Medicaid APG methodology,0.01,14.24,
PHYTONADIONE INJ 1MG/0.5ML SYRINGE,J3430,HCPCS,,80002108,CDM,636,RC,76329124001,NDC,both,10,ML,3.83,28.6,,,28.6,Other,150% of Medicare + 9.63% HCRA Surcharge,17.39,,,17.39,Fee Schedule,Average Sale Price (ASP) x 6,1.34,35,,1.34,percent of total billed charges,Drugs,1.34,35,,1.34,percent of total billed charges,Drugs,1.3,34,,1.3,percent of total billed charges,Drugs,1.3,34,,1.3,percent of total billed charges,Drugs,1.3,34,,1.3,percent of total billed charges,Drugs,1.3,34,,1.3,percent of total billed charges,Drugs,1.34,35,,1.34,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,1.34,35,,1.34,percent of total billed charges,Drugs,1.34,35,,1.34,percent of total billed charges,Drugs,1.34,35,,1.34,percent of total billed charges,Drugs,1.34,35,,1.34,percent of total billed charges,Drugs,1.34,35,,1.34,percent of total billed charges,Drugs,1.53,40,,1.53,percent of total billed charges,Drugs,2.68,70,,2.68,percent of total billed charges,All Other,1.38,36,,1.38,percent of total billed charges,Drugs,1.38,36,,1.38,percent of total billed charges,Drugs,1.34,35,,1.34,percent of total billed charges,Drugs,1.34,35,,1.34,percent of total billed charges,Drugs,1.34,35,,1.34,percent of total billed charges,Drugs,1.34,35,,1.34,percent of total billed charges,Drugs,1.28,,,1.28,Other,Drug Cost,1.28,,,1.28,Other,Drug Cost,1.28,,,1.28,Other,Drug Cost,1.28,,,1.28,Other,Drug Cost,1.28,,,1.28,Other,Drug Cost,1.28,,,1.28,Other,Drug Cost,2.87,,,2.87,Other,225% of Medicaid,1.79,,,1.79,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,27.83,,,27.83,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",2.75,,,2.75,Other,215% Medicaid APG methodology,2.75,,,2.75,Other,215% Medicaid APG methodology,1.6,,,1.6,Other,125% Medicaid APG methodology,0.01,28.6,
ZIDOVUDINE (AZT) INJ 10MG/ML 20ML,J3485,HCPCS,,80002125,CDM,636,RC,49702021326,NDC,both,5,ML,64.1,14.91,,,14.91,Other,150% of Medicare + 9.63% HCRA Surcharge,9.07,,,9.07,Fee Schedule,Average Sale Price (ASP) x 6,22.43,35,,22.43,percent of total billed charges,Drugs,22.43,35,,22.43,percent of total billed charges,Drugs,21.79,34,,21.79,percent of total billed charges,Drugs,21.79,34,,21.79,percent of total billed charges,Drugs,21.79,34,,21.79,percent of total billed charges,Drugs,21.79,34,,21.79,percent of total billed charges,Drugs,22.43,35,,22.43,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,22.43,35,,22.43,percent of total billed charges,Drugs,22.43,35,,22.43,percent of total billed charges,Drugs,22.43,35,,22.43,percent of total billed charges,Drugs,22.43,35,,22.43,percent of total billed charges,Drugs,22.43,35,,22.43,percent of total billed charges,Drugs,25.64,40,,25.64,percent of total billed charges,Drugs,44.87,70,,44.87,percent of total billed charges,All Other,23.08,36,,23.08,percent of total billed charges,Drugs,23.08,36,,23.08,percent of total billed charges,Drugs,22.43,35,,22.43,percent of total billed charges,Drugs,22.43,35,,22.43,percent of total billed charges,Drugs,22.43,35,,22.43,percent of total billed charges,Drugs,22.43,35,,22.43,percent of total billed charges,Drugs,21.37,,,21.37,Other,Drug Cost,21.37,,,21.37,Other,Drug Cost,21.37,,,21.37,Other,Drug Cost,21.37,,,21.37,Other,Drug Cost,21.37,,,21.37,Other,Drug Cost,21.37,,,21.37,Other,Drug Cost,48.07,,,48.07,Other,225% of Medicaid,29.91,,,29.91,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,14.51,,,14.51,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",45.94,,,45.94,Other,215% Medicaid APG methodology,45.94,,,45.94,Other,215% Medicaid APG methodology,26.71,,,26.71,Other,125% Medicaid APG methodology,0.01,48.07,
ZIPRASIDONE MESYLATE 10 MG INJ,J3486,HCPCS,,80002137,CDM,636,RC,72266016042,NDC,both,10,EA,35.66,96.25,,,96.25,Other,150% of Medicare + 9.63% HCRA Surcharge,58.53,,,58.53,Fee Schedule,Average Sale Price (ASP) x 6,12.48,35,,12.48,percent of total billed charges,Drugs,12.48,35,,12.48,percent of total billed charges,Drugs,12.12,34,,12.12,percent of total billed charges,Drugs,12.12,34,,12.12,percent of total billed charges,Drugs,12.12,34,,12.12,percent of total billed charges,Drugs,12.12,34,,12.12,percent of total billed charges,Drugs,12.48,35,,12.48,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,12.48,35,,12.48,percent of total billed charges,Drugs,12.48,35,,12.48,percent of total billed charges,Drugs,12.48,35,,12.48,percent of total billed charges,Drugs,12.48,35,,12.48,percent of total billed charges,Drugs,12.48,35,,12.48,percent of total billed charges,Drugs,14.26,40,,14.26,percent of total billed charges,Drugs,24.96,70,,24.96,percent of total billed charges,All Other,12.84,36,,12.84,percent of total billed charges,Drugs,12.84,36,,12.84,percent of total billed charges,Drugs,12.48,35,,12.48,percent of total billed charges,Drugs,12.48,35,,12.48,percent of total billed charges,Drugs,12.48,35,,12.48,percent of total billed charges,Drugs,12.48,35,,12.48,percent of total billed charges,Drugs,11.89,,,11.89,Other,Drug Cost,11.89,,,11.89,Other,Drug Cost,11.89,,,11.89,Other,Drug Cost,11.89,,,11.89,Other,Drug Cost,11.89,,,11.89,Other,Drug Cost,11.89,,,11.89,Other,Drug Cost,26.75,,,26.75,Other,225% of Medicaid,16.64,,,16.64,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,93.65,,,93.65,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",25.56,,,25.56,Other,215% Medicaid APG methodology,25.56,,,25.56,Other,215% Medicaid APG methodology,14.86,,,14.86,Other,125% Medicaid APG methodology,0.01,96.25,
ZOLEDRONIC ACID 4MG/100ML,J3489,HCPCS,,80002140,CDM,636,RC,25021082682,NDC,both,1,ML,20.37,71.17,,,71.17,Other,150% of Medicare + 9.63% HCRA Surcharge,43.28,,,43.28,Fee Schedule,Average Sale Price (ASP) x 6,7.13,35,,7.13,percent of total billed charges,Drugs,7.13,35,,7.13,percent of total billed charges,Drugs,6.93,34,,6.93,percent of total billed charges,Drugs,6.93,34,,6.93,percent of total billed charges,Drugs,6.93,34,,6.93,percent of total billed charges,Drugs,6.93,34,,6.93,percent of total billed charges,Drugs,7.13,35,,7.13,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,7.13,35,,7.13,percent of total billed charges,Drugs,7.13,35,,7.13,percent of total billed charges,Drugs,7.13,35,,7.13,percent of total billed charges,Drugs,7.13,35,,7.13,percent of total billed charges,Drugs,7.13,35,,7.13,percent of total billed charges,Drugs,8.15,40,,8.15,percent of total billed charges,Drugs,14.26,70,,14.26,percent of total billed charges,All Other,7.33,36,,7.33,percent of total billed charges,Drugs,7.33,36,,7.33,percent of total billed charges,Drugs,7.13,35,,7.13,percent of total billed charges,Drugs,7.13,35,,7.13,percent of total billed charges,Drugs,7.13,35,,7.13,percent of total billed charges,Drugs,7.13,35,,7.13,percent of total billed charges,Drugs,6.79,,,6.79,Other,Drug Cost,6.79,,,6.79,Other,Drug Cost,6.79,,,6.79,Other,Drug Cost,6.79,,,6.79,Other,Drug Cost,6.79,,,6.79,Other,Drug Cost,6.79,,,6.79,Other,Drug Cost,15.28,,,15.28,Other,225% of Medicaid,9.51,,,9.51,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,69.24,,,69.24,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",14.6,,,14.6,Other,215% Medicaid APG methodology,14.6,,,14.6,Other,215% Medicaid APG methodology,8.49,,,8.49,Other,125% Medicaid APG methodology,0.01,71.17,
ZOLEDRONIC ACID 4MG/5ML,J3489,HCPCS,,80002141,CDM,636,RC,67457039054,NDC,both,1,ML,61.95,71.17,,,71.17,Other,150% of Medicare + 9.63% HCRA Surcharge,43.28,,,43.28,Fee Schedule,Average Sale Price (ASP) x 6,21.68,35,,21.68,percent of total billed charges,Drugs,21.68,35,,21.68,percent of total billed charges,Drugs,21.06,34,,21.06,percent of total billed charges,Drugs,21.06,34,,21.06,percent of total billed charges,Drugs,21.06,34,,21.06,percent of total billed charges,Drugs,21.06,34,,21.06,percent of total billed charges,Drugs,21.68,35,,21.68,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,21.68,35,,21.68,percent of total billed charges,Drugs,21.68,35,,21.68,percent of total billed charges,Drugs,21.68,35,,21.68,percent of total billed charges,Drugs,21.68,35,,21.68,percent of total billed charges,Drugs,21.68,35,,21.68,percent of total billed charges,Drugs,24.78,40,,24.78,percent of total billed charges,Drugs,43.37,70,,43.37,percent of total billed charges,All Other,22.3,36,,22.3,percent of total billed charges,Drugs,22.3,36,,22.3,percent of total billed charges,Drugs,21.68,35,,21.68,percent of total billed charges,Drugs,21.68,35,,21.68,percent of total billed charges,Drugs,21.68,35,,21.68,percent of total billed charges,Drugs,21.68,35,,21.68,percent of total billed charges,Drugs,20.65,,,20.65,Other,Drug Cost,20.65,,,20.65,Other,Drug Cost,20.65,,,20.65,Other,Drug Cost,20.65,,,20.65,Other,Drug Cost,20.65,,,20.65,Other,Drug Cost,20.65,,,20.65,Other,Drug Cost,46.46,,,46.46,Other,225% of Medicaid,28.91,,,28.91,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,69.24,,,69.24,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",44.4,,,44.4,Other,215% Medicaid APG methodology,44.4,,,44.4,Other,215% Medicaid APG methodology,25.81,,,25.81,Other,125% Medicaid APG methodology,0.01,71.17,
CEFAZOLIN 1GM/50ML NS,J0690,HCPCS,,80002162,CDM,636,RC,264310311,NDC,both,24,EA,9.17,7.53,,,7.53,Other,150% of Medicare + 9.63% HCRA Surcharge,4.58,,,4.58,Fee Schedule,Average Sale Price (ASP) x 6,3.21,35,,3.21,percent of total billed charges,Drugs,3.21,35,,3.21,percent of total billed charges,Drugs,3.12,34,,3.12,percent of total billed charges,Drugs,3.12,34,,3.12,percent of total billed charges,Drugs,3.12,34,,3.12,percent of total billed charges,Drugs,3.12,34,,3.12,percent of total billed charges,Drugs,3.21,35,,3.21,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,3.21,35,,3.21,percent of total billed charges,Drugs,3.21,35,,3.21,percent of total billed charges,Drugs,3.21,35,,3.21,percent of total billed charges,Drugs,3.21,35,,3.21,percent of total billed charges,Drugs,3.21,35,,3.21,percent of total billed charges,Drugs,3.67,40,,3.67,percent of total billed charges,Drugs,6.42,70,,6.42,percent of total billed charges,All Other,3.3,36,,3.3,percent of total billed charges,Drugs,3.3,36,,3.3,percent of total billed charges,Drugs,3.21,35,,3.21,percent of total billed charges,Drugs,3.21,35,,3.21,percent of total billed charges,Drugs,3.21,35,,3.21,percent of total billed charges,Drugs,3.21,35,,3.21,percent of total billed charges,Drugs,3.06,,,3.06,Other,Drug Cost,3.06,,,3.06,Other,Drug Cost,3.06,,,3.06,Other,Drug Cost,3.06,,,3.06,Other,Drug Cost,3.06,,,3.06,Other,Drug Cost,3.06,,,3.06,Other,Drug Cost,6.88,,,6.88,Other,225% of Medicaid,4.28,,,4.28,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,7.32,,,7.32,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",6.57,,,6.57,Other,215% Medicaid APG methodology,6.57,,,6.57,Other,215% Medicaid APG methodology,3.82,,,3.82,Other,125% Medicaid APG methodology,0.01,7.53,
CEFTRIAXONE 250MG INJ,J0696,HCPCS,,80002168,CDM,636,RC,781320695,NDC,both,10,EA,1.22,4.84,,,4.84,Other,150% of Medicare + 9.63% HCRA Surcharge,2.95,,,2.95,Fee Schedule,Average Sale Price (ASP) x 6,0.43,35,,0.43,percent of total billed charges,Drugs,0.43,35,,0.43,percent of total billed charges,Drugs,0.41,34,,0.41,percent of total billed charges,Drugs,0.41,34,,0.41,percent of total billed charges,Drugs,0.41,34,,0.41,percent of total billed charges,Drugs,0.41,34,,0.41,percent of total billed charges,Drugs,0.43,35,,0.43,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,0.43,35,,0.43,percent of total billed charges,Drugs,0.43,35,,0.43,percent of total billed charges,Drugs,0.43,35,,0.43,percent of total billed charges,Drugs,0.43,35,,0.43,percent of total billed charges,Drugs,0.43,35,,0.43,percent of total billed charges,Drugs,0.49,40,,0.49,percent of total billed charges,Drugs,0.85,70,,0.85,percent of total billed charges,All Other,0.44,36,,0.44,percent of total billed charges,Drugs,0.44,36,,0.44,percent of total billed charges,Drugs,0.43,35,,0.43,percent of total billed charges,Drugs,0.43,35,,0.43,percent of total billed charges,Drugs,0.43,35,,0.43,percent of total billed charges,Drugs,0.43,35,,0.43,percent of total billed charges,Drugs,0.41,,,0.41,Other,Drug Cost,0.41,,,0.41,Other,Drug Cost,0.41,,,0.41,Other,Drug Cost,0.41,,,0.41,Other,Drug Cost,0.41,,,0.41,Other,Drug Cost,0.41,,,0.41,Other,Drug Cost,0.91,,,0.91,Other,225% of Medicaid,0.57,,,0.57,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,4.71,,,4.71,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",0.87,,,0.87,Other,215% Medicaid APG methodology,0.87,,,0.87,Other,215% Medicaid APG methodology,0.51,,,0.51,Other,125% Medicaid APG methodology,0.01,4.84,
GENTAMICIN 80MG/2ML INJ,J1580,HCPCS,,80002177,CDM,636,RC,63323001002,NDC,both,25,ML,3.59,26.49,,,26.49,Other,150% of Medicare + 9.63% HCRA Surcharge,16.11,,,16.11,Fee Schedule,Average Sale Price (ASP) x 6,1.26,35,,1.26,percent of total billed charges,Drugs,1.26,35,,1.26,percent of total billed charges,Drugs,1.22,34,,1.22,percent of total billed charges,Drugs,1.22,34,,1.22,percent of total billed charges,Drugs,1.22,34,,1.22,percent of total billed charges,Drugs,1.22,34,,1.22,percent of total billed charges,Drugs,1.26,35,,1.26,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,1.26,35,,1.26,percent of total billed charges,Drugs,1.26,35,,1.26,percent of total billed charges,Drugs,1.26,35,,1.26,percent of total billed charges,Drugs,1.26,35,,1.26,percent of total billed charges,Drugs,1.26,35,,1.26,percent of total billed charges,Drugs,1.43,40,,1.43,percent of total billed charges,Drugs,2.51,70,,2.51,percent of total billed charges,All Other,1.29,36,,1.29,percent of total billed charges,Drugs,1.29,36,,1.29,percent of total billed charges,Drugs,1.26,35,,1.26,percent of total billed charges,Drugs,1.26,35,,1.26,percent of total billed charges,Drugs,1.26,35,,1.26,percent of total billed charges,Drugs,1.26,35,,1.26,percent of total billed charges,Drugs,1.2,,,1.2,Other,Drug Cost,1.2,,,1.2,Other,Drug Cost,1.2,,,1.2,Other,Drug Cost,1.2,,,1.2,Other,Drug Cost,1.2,,,1.2,Other,Drug Cost,1.2,,,1.2,Other,Drug Cost,2.69,,,2.69,Other,225% of Medicaid,1.67,,,1.67,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,25.78,,,25.78,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",2.57,,,2.57,Other,215% Medicaid APG methodology,2.57,,,2.57,Other,215% Medicaid APG methodology,1.49,,,1.49,Other,125% Medicaid APG methodology,0.01,26.49,
ARGATROBAN 50MG/50ML IV,J0883,HCPCS,,80002190,CDM,636,RC,55150024101,NDC,both,1,ML,49.68,19.61,39.4668,,19.61,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,17.39,35,,17.39,percent of total billed charges,Drugs,17.39,35,,17.39,percent of total billed charges,Drugs,16.89,34,,16.89,percent of total billed charges,Drugs,16.89,34,,16.89,percent of total billed charges,Drugs,16.89,34,,16.89,percent of total billed charges,Drugs,16.89,34,,16.89,percent of total billed charges,Drugs,17.39,35,,17.39,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,17.39,35,,17.39,percent of total billed charges,Drugs,17.39,35,,17.39,percent of total billed charges,Drugs,17.39,35,,17.39,percent of total billed charges,Drugs,17.39,35,,17.39,percent of total billed charges,Drugs,17.39,35,,17.39,percent of total billed charges,Drugs,19.87,40,,19.87,percent of total billed charges,Drugs,34.78,70,,34.78,percent of total billed charges,All Other,17.88,36,,17.88,percent of total billed charges,Drugs,17.88,36,,17.88,percent of total billed charges,Drugs,17.39,35,,17.39,percent of total billed charges,Drugs,17.39,35,,17.39,percent of total billed charges,Drugs,17.39,35,,17.39,percent of total billed charges,Drugs,17.39,35,,17.39,percent of total billed charges,Drugs,16.56,,,16.56,Other,Drug Cost,16.56,,,16.56,Other,Drug Cost,16.56,,,16.56,Other,Drug Cost,16.56,,,16.56,Other,Drug Cost,16.56,,,16.56,Other,Drug Cost,16.56,,,16.56,Other,Drug Cost,37.26,,,37.26,Other,225% of Medicaid,23.18,,,23.18,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",35.6,,,35.6,Other,215% Medicaid APG methodology,35.6,,,35.6,Other,215% Medicaid APG methodology,20.7,,,20.7,Other,125% Medicaid APG methodology,0.01,37.26,
KETOROLAC 15MG/ML INJ,J1885,HCPCS,,80002200,CDM,636,RC,25021070001,NDC,both,25,ML,1.52,4.81,,,4.81,Other,150% of Medicare + 9.63% HCRA Surcharge,2.93,,,2.93,Fee Schedule,Average Sale Price (ASP) x 6,0.53,35,,0.53,percent of total billed charges,Drugs,0.53,35,,0.53,percent of total billed charges,Drugs,0.52,34,,0.52,percent of total billed charges,Drugs,0.52,34,,0.52,percent of total billed charges,Drugs,0.52,34,,0.52,percent of total billed charges,Drugs,0.52,34,,0.52,percent of total billed charges,Drugs,0.53,35,,0.53,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,0.53,35,,0.53,percent of total billed charges,Drugs,0.53,35,,0.53,percent of total billed charges,Drugs,0.53,35,,0.53,percent of total billed charges,Drugs,0.53,35,,0.53,percent of total billed charges,Drugs,0.53,35,,0.53,percent of total billed charges,Drugs,0.61,40,,0.61,percent of total billed charges,Drugs,1.07,70,,1.07,percent of total billed charges,All Other,0.55,36,,0.55,percent of total billed charges,Drugs,0.55,36,,0.55,percent of total billed charges,Drugs,0.53,35,,0.53,percent of total billed charges,Drugs,0.53,35,,0.53,percent of total billed charges,Drugs,0.53,35,,0.53,percent of total billed charges,Drugs,0.53,35,,0.53,percent of total billed charges,Drugs,0.51,,,0.51,Other,Drug Cost,0.51,,,0.51,Other,Drug Cost,0.51,,,0.51,Other,Drug Cost,0.51,,,0.51,Other,Drug Cost,0.51,,,0.51,Other,Drug Cost,0.51,,,0.51,Other,Drug Cost,1.14,,,1.14,Other,225% of Medicaid,0.71,,,0.71,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,4.68,,,4.68,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",1.09,,,1.09,Other,215% Medicaid APG methodology,1.09,,,1.09,Other,215% Medicaid APG methodology,0.63,,,0.63,Other,125% Medicaid APG methodology,0.01,4.81,
PROMETHAZINE 25MG/1ML AMP,J2550,HCPCS,,80002207,CDM,636,RC,641092825,NDC,both,25,ML,1.97,35.42,,,35.42,Other,150% of Medicare + 9.63% HCRA Surcharge,21.54,,,21.54,Fee Schedule,Average Sale Price (ASP) x 6,0.69,35,,0.69,percent of total billed charges,Drugs,0.69,35,,0.69,percent of total billed charges,Drugs,0.67,34,,0.67,percent of total billed charges,Drugs,0.67,34,,0.67,percent of total billed charges,Drugs,0.67,34,,0.67,percent of total billed charges,Drugs,0.67,34,,0.67,percent of total billed charges,Drugs,0.69,35,,0.69,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,0.69,35,,0.69,percent of total billed charges,Drugs,0.69,35,,0.69,percent of total billed charges,Drugs,0.69,35,,0.69,percent of total billed charges,Drugs,0.69,35,,0.69,percent of total billed charges,Drugs,0.69,35,,0.69,percent of total billed charges,Drugs,0.79,40,,0.79,percent of total billed charges,Drugs,1.38,70,,1.38,percent of total billed charges,All Other,0.71,36,,0.71,percent of total billed charges,Drugs,0.71,36,,0.71,percent of total billed charges,Drugs,0.69,35,,0.69,percent of total billed charges,Drugs,0.69,35,,0.69,percent of total billed charges,Drugs,0.69,35,,0.69,percent of total billed charges,Drugs,0.69,35,,0.69,percent of total billed charges,Drugs,0.66,,,0.66,Other,Drug Cost,0.66,,,0.66,Other,Drug Cost,0.66,,,0.66,Other,Drug Cost,0.66,,,0.66,Other,Drug Cost,0.66,,,0.66,Other,Drug Cost,0.66,,,0.66,Other,Drug Cost,1.48,,,1.48,Other,225% of Medicaid,0.92,,,0.92,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,34.46,,,34.46,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",1.41,,,1.41,Other,215% Medicaid APG methodology,1.41,,,1.41,Other,215% Medicaid APG methodology,0.82,,,0.82,Other,125% Medicaid APG methodology,0.01,35.42,
METHYLPREDNISOLONE ACETATE 40MG/ML INJ,J1030,HCPCS,,80002208,CDM,636,RC,9307301,NDC,both,1,ML,7.44,63.33,,,63.33,Other,150% of Medicare + 9.63% HCRA Surcharge,38.51,,,38.51,Fee Schedule,Average Sale Price (ASP) x 6,2.6,35,,2.6,percent of total billed charges,Drugs,2.6,35,,2.6,percent of total billed charges,Drugs,2.53,34,,2.53,percent of total billed charges,Drugs,2.53,34,,2.53,percent of total billed charges,Drugs,2.53,34,,2.53,percent of total billed charges,Drugs,2.53,34,,2.53,percent of total billed charges,Drugs,2.6,35,,2.6,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,2.6,35,,2.6,percent of total billed charges,Drugs,2.6,35,,2.6,percent of total billed charges,Drugs,2.6,35,,2.6,percent of total billed charges,Drugs,2.6,35,,2.6,percent of total billed charges,Drugs,2.6,35,,2.6,percent of total billed charges,Drugs,2.98,40,,2.98,percent of total billed charges,Drugs,5.21,70,,5.21,percent of total billed charges,All Other,2.68,36,,2.68,percent of total billed charges,Drugs,2.68,36,,2.68,percent of total billed charges,Drugs,2.6,35,,2.6,percent of total billed charges,Drugs,2.6,35,,2.6,percent of total billed charges,Drugs,2.6,35,,2.6,percent of total billed charges,Drugs,2.6,35,,2.6,percent of total billed charges,Drugs,2.48,,,2.48,Other,Drug Cost,2.48,,,2.48,Other,Drug Cost,2.48,,,2.48,Other,Drug Cost,2.48,,,2.48,Other,Drug Cost,2.48,,,2.48,Other,Drug Cost,2.48,,,2.48,Other,Drug Cost,5.58,,,5.58,Other,225% of Medicaid,3.47,,,3.47,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,61.62,,,61.62,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",5.33,,,5.33,Other,215% Medicaid APG methodology,5.33,,,5.33,Other,215% Medicaid APG methodology,3.1,,,3.1,Other,125% Medicaid APG methodology,0.01,63.33,
LIDOCAINE 0.5% 50ML VIAL,J2001,HCPCS,,80002209,CDM,636,RC,409427801,NDC,both,25,ML,6.4,0.27,,,0.27,Other,150% of Medicare + 9.63% HCRA Surcharge,0.16,,,0.16,Fee Schedule,Average Sale Price (ASP) x 6,2.24,35,,2.24,percent of total billed charges,Drugs,2.24,35,,2.24,percent of total billed charges,Drugs,2.18,34,,2.18,percent of total billed charges,Drugs,2.18,34,,2.18,percent of total billed charges,Drugs,2.18,34,,2.18,percent of total billed charges,Drugs,2.18,34,,2.18,percent of total billed charges,Drugs,2.24,35,,2.24,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,2.24,35,,2.24,percent of total billed charges,Drugs,2.24,35,,2.24,percent of total billed charges,Drugs,2.24,35,,2.24,percent of total billed charges,Drugs,2.24,35,,2.24,percent of total billed charges,Drugs,2.24,35,,2.24,percent of total billed charges,Drugs,2.56,40,,2.56,percent of total billed charges,Drugs,4.48,70,,4.48,percent of total billed charges,All Other,2.3,36,,2.3,percent of total billed charges,Drugs,2.3,36,,2.3,percent of total billed charges,Drugs,2.24,35,,2.24,percent of total billed charges,Drugs,2.24,35,,2.24,percent of total billed charges,Drugs,2.24,35,,2.24,percent of total billed charges,Drugs,2.24,35,,2.24,percent of total billed charges,Drugs,2.13,,,2.13,Other,Drug Cost,2.13,,,2.13,Other,Drug Cost,2.13,,,2.13,Other,Drug Cost,2.13,,,2.13,Other,Drug Cost,2.13,,,2.13,Other,Drug Cost,2.13,,,2.13,Other,Drug Cost,4.8,,,4.8,Other,225% of Medicaid,2.99,,,2.99,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,0.26,,,0.26,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",4.58,,,4.58,Other,215% Medicaid APG methodology,4.58,,,4.58,Other,215% Medicaid APG methodology,2.67,,,2.67,Other,125% Medicaid APG methodology,0.01,4.8,
CEFAZOLIN 2GM/50ML NS,J0690,HCPCS,,80002226,CDM,636,RC,264310511,NDC,both,24,EA,19.05,7.53,,,7.53,Other,150% of Medicare + 9.63% HCRA Surcharge,4.58,,,4.58,Fee Schedule,Average Sale Price (ASP) x 6,6.67,35,,6.67,percent of total billed charges,Drugs,6.67,35,,6.67,percent of total billed charges,Drugs,6.48,34,,6.48,percent of total billed charges,Drugs,6.48,34,,6.48,percent of total billed charges,Drugs,6.48,34,,6.48,percent of total billed charges,Drugs,6.48,34,,6.48,percent of total billed charges,Drugs,6.67,35,,6.67,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,6.67,35,,6.67,percent of total billed charges,Drugs,6.67,35,,6.67,percent of total billed charges,Drugs,6.67,35,,6.67,percent of total billed charges,Drugs,6.67,35,,6.67,percent of total billed charges,Drugs,6.67,35,,6.67,percent of total billed charges,Drugs,7.62,40,,7.62,percent of total billed charges,Drugs,13.34,70,,13.34,percent of total billed charges,All Other,6.86,36,,6.86,percent of total billed charges,Drugs,6.86,36,,6.86,percent of total billed charges,Drugs,6.67,35,,6.67,percent of total billed charges,Drugs,6.67,35,,6.67,percent of total billed charges,Drugs,6.67,35,,6.67,percent of total billed charges,Drugs,6.67,35,,6.67,percent of total billed charges,Drugs,6.35,,,6.35,Other,Drug Cost,6.35,,,6.35,Other,Drug Cost,6.35,,,6.35,Other,Drug Cost,6.35,,,6.35,Other,Drug Cost,6.35,,,6.35,Other,Drug Cost,6.35,,,6.35,Other,Drug Cost,14.29,,,14.29,Other,225% of Medicaid,8.89,,,8.89,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,7.32,,,7.32,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",13.66,,,13.66,Other,215% Medicaid APG methodology,13.66,,,13.66,Other,215% Medicaid APG methodology,7.94,,,7.94,Other,125% Medicaid APG methodology,0.01,14.29,
CEFOXITIN 1GM/50ML NS,J0694,HCPCS,,80002230,CDM,636,RC,143987825,NDC,both,25,EA,7.61,50.11,,,50.11,Other,150% of Medicare + 9.63% HCRA Surcharge,30.47,,,30.47,Fee Schedule,Average Sale Price (ASP) x 6,2.66,35,,2.66,percent of total billed charges,Drugs,2.66,35,,2.66,percent of total billed charges,Drugs,2.59,34,,2.59,percent of total billed charges,Drugs,2.59,34,,2.59,percent of total billed charges,Drugs,2.59,34,,2.59,percent of total billed charges,Drugs,2.59,34,,2.59,percent of total billed charges,Drugs,2.66,35,,2.66,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,2.66,35,,2.66,percent of total billed charges,Drugs,2.66,35,,2.66,percent of total billed charges,Drugs,2.66,35,,2.66,percent of total billed charges,Drugs,2.66,35,,2.66,percent of total billed charges,Drugs,2.66,35,,2.66,percent of total billed charges,Drugs,3.04,40,,3.04,percent of total billed charges,Drugs,5.33,70,,5.33,percent of total billed charges,All Other,2.74,36,,2.74,percent of total billed charges,Drugs,2.74,36,,2.74,percent of total billed charges,Drugs,2.66,35,,2.66,percent of total billed charges,Drugs,2.66,35,,2.66,percent of total billed charges,Drugs,2.66,35,,2.66,percent of total billed charges,Drugs,2.66,35,,2.66,percent of total billed charges,Drugs,2.54,,,2.54,Other,Drug Cost,2.54,,,2.54,Other,Drug Cost,2.54,,,2.54,Other,Drug Cost,2.54,,,2.54,Other,Drug Cost,2.54,,,2.54,Other,Drug Cost,2.54,,,2.54,Other,Drug Cost,5.71,,,5.71,Other,225% of Medicaid,3.55,,,3.55,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,48.76,,,48.76,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",5.45,,,5.45,Other,215% Medicaid APG methodology,5.45,,,5.45,Other,215% Medicaid APG methodology,3.17,,,3.17,Other,125% Medicaid APG methodology,0.01,50.11,
CEFOXITIN 2GM/50ML NS,J0694,HCPCS,,80002231,CDM,636,RC,143987725,NDC,both,25,EA,10.77,50.11,,,50.11,Other,150% of Medicare + 9.63% HCRA Surcharge,30.47,,,30.47,Fee Schedule,Average Sale Price (ASP) x 6,3.77,35,,3.77,percent of total billed charges,Drugs,3.77,35,,3.77,percent of total billed charges,Drugs,3.66,34,,3.66,percent of total billed charges,Drugs,3.66,34,,3.66,percent of total billed charges,Drugs,3.66,34,,3.66,percent of total billed charges,Drugs,3.66,34,,3.66,percent of total billed charges,Drugs,3.77,35,,3.77,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,3.77,35,,3.77,percent of total billed charges,Drugs,3.77,35,,3.77,percent of total billed charges,Drugs,3.77,35,,3.77,percent of total billed charges,Drugs,3.77,35,,3.77,percent of total billed charges,Drugs,3.77,35,,3.77,percent of total billed charges,Drugs,4.31,40,,4.31,percent of total billed charges,Drugs,7.54,70,,7.54,percent of total billed charges,All Other,3.88,36,,3.88,percent of total billed charges,Drugs,3.88,36,,3.88,percent of total billed charges,Drugs,3.77,35,,3.77,percent of total billed charges,Drugs,3.77,35,,3.77,percent of total billed charges,Drugs,3.77,35,,3.77,percent of total billed charges,Drugs,3.77,35,,3.77,percent of total billed charges,Drugs,3.59,,,3.59,Other,Drug Cost,3.59,,,3.59,Other,Drug Cost,3.59,,,3.59,Other,Drug Cost,3.59,,,3.59,Other,Drug Cost,3.59,,,3.59,Other,Drug Cost,3.59,,,3.59,Other,Drug Cost,8.07,,,8.07,Other,225% of Medicaid,5.02,,,5.02,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,48.76,,,48.76,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",7.72,,,7.72,Other,215% Medicaid APG methodology,7.72,,,7.72,Other,215% Medicaid APG methodology,4.49,,,4.49,Other,125% Medicaid APG methodology,0.01,50.11,
CEFTRIAXONE 1GM/50ML NS,J0696,HCPCS,,80002235,CDM,636,RC,409733220,NDC,both,10,EA,2.8,4.84,,,4.84,Other,150% of Medicare + 9.63% HCRA Surcharge,2.95,,,2.95,Fee Schedule,Average Sale Price (ASP) x 6,0.98,35,,0.98,percent of total billed charges,Drugs,0.98,35,,0.98,percent of total billed charges,Drugs,0.95,34,,0.95,percent of total billed charges,Drugs,0.95,34,,0.95,percent of total billed charges,Drugs,0.95,34,,0.95,percent of total billed charges,Drugs,0.95,34,,0.95,percent of total billed charges,Drugs,0.98,35,,0.98,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,0.98,35,,0.98,percent of total billed charges,Drugs,0.98,35,,0.98,percent of total billed charges,Drugs,0.98,35,,0.98,percent of total billed charges,Drugs,0.98,35,,0.98,percent of total billed charges,Drugs,0.98,35,,0.98,percent of total billed charges,Drugs,1.12,40,,1.12,percent of total billed charges,Drugs,1.96,70,,1.96,percent of total billed charges,All Other,1.01,36,,1.01,percent of total billed charges,Drugs,1.01,36,,1.01,percent of total billed charges,Drugs,0.98,35,,0.98,percent of total billed charges,Drugs,0.98,35,,0.98,percent of total billed charges,Drugs,0.98,35,,0.98,percent of total billed charges,Drugs,0.98,35,,0.98,percent of total billed charges,Drugs,0.93,,,0.93,Other,Drug Cost,0.93,,,0.93,Other,Drug Cost,0.93,,,0.93,Other,Drug Cost,0.93,,,0.93,Other,Drug Cost,0.93,,,0.93,Other,Drug Cost,0.93,,,0.93,Other,Drug Cost,2.1,,,2.1,Other,225% of Medicaid,1.3,,,1.3,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,4.71,,,4.71,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",2,,,2,Other,215% Medicaid APG methodology,2,,,2,Other,215% Medicaid APG methodology,1.17,,,1.17,Other,125% Medicaid APG methodology,0.01,4.84,
CEFTRIAXONE 2GM/100ML NS,J0696,HCPCS,,80002237,CDM,636,RC,60505614904,NDC,both,10,EA,4.52,4.84,,,4.84,Other,150% of Medicare + 9.63% HCRA Surcharge,2.95,,,2.95,Fee Schedule,Average Sale Price (ASP) x 6,1.58,35,,1.58,percent of total billed charges,Drugs,1.58,35,,1.58,percent of total billed charges,Drugs,1.54,34,,1.54,percent of total billed charges,Drugs,1.54,34,,1.54,percent of total billed charges,Drugs,1.54,34,,1.54,percent of total billed charges,Drugs,1.54,34,,1.54,percent of total billed charges,Drugs,1.58,35,,1.58,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,1.58,35,,1.58,percent of total billed charges,Drugs,1.58,35,,1.58,percent of total billed charges,Drugs,1.58,35,,1.58,percent of total billed charges,Drugs,1.58,35,,1.58,percent of total billed charges,Drugs,1.58,35,,1.58,percent of total billed charges,Drugs,1.81,40,,1.81,percent of total billed charges,Drugs,3.17,70,,3.17,percent of total billed charges,All Other,1.63,36,,1.63,percent of total billed charges,Drugs,1.63,36,,1.63,percent of total billed charges,Drugs,1.58,35,,1.58,percent of total billed charges,Drugs,1.58,35,,1.58,percent of total billed charges,Drugs,1.58,35,,1.58,percent of total billed charges,Drugs,1.58,35,,1.58,percent of total billed charges,Drugs,1.51,,,1.51,Other,Drug Cost,1.51,,,1.51,Other,Drug Cost,1.51,,,1.51,Other,Drug Cost,1.51,,,1.51,Other,Drug Cost,1.51,,,1.51,Other,Drug Cost,1.51,,,1.51,Other,Drug Cost,3.39,,,3.39,Other,225% of Medicaid,2.11,,,2.11,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,4.71,,,4.71,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",3.24,,,3.24,Other,215% Medicaid APG methodology,3.24,,,3.24,Other,215% Medicaid APG methodology,1.89,,,1.89,Other,125% Medicaid APG methodology,0.01,4.84,
TYGACIL 50MG/100ML NS,J3243,HCPCS,,80002250,CDM,636,RC,70121164707,NDC,both,10,EA,42.94,7.26,,,7.26,Other,150% of Medicare + 9.63% HCRA Surcharge,4.42,,,4.42,Fee Schedule,Average Sale Price (ASP) x 6,15.03,35,,15.03,percent of total billed charges,Drugs,15.03,35,,15.03,percent of total billed charges,Drugs,14.6,34,,14.6,percent of total billed charges,Drugs,14.6,34,,14.6,percent of total billed charges,Drugs,14.6,34,,14.6,percent of total billed charges,Drugs,14.6,34,,14.6,percent of total billed charges,Drugs,15.03,35,,15.03,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,15.03,35,,15.03,percent of total billed charges,Drugs,15.03,35,,15.03,percent of total billed charges,Drugs,15.03,35,,15.03,percent of total billed charges,Drugs,15.03,35,,15.03,percent of total billed charges,Drugs,15.03,35,,15.03,percent of total billed charges,Drugs,17.18,40,,17.18,percent of total billed charges,Drugs,30.06,70,,30.06,percent of total billed charges,All Other,15.46,36,,15.46,percent of total billed charges,Drugs,15.46,36,,15.46,percent of total billed charges,Drugs,15.03,35,,15.03,percent of total billed charges,Drugs,15.03,35,,15.03,percent of total billed charges,Drugs,15.03,35,,15.03,percent of total billed charges,Drugs,15.03,35,,15.03,percent of total billed charges,Drugs,14.31,,,14.31,Other,Drug Cost,14.31,,,14.31,Other,Drug Cost,14.31,,,14.31,Other,Drug Cost,14.31,,,14.31,Other,Drug Cost,14.31,,,14.31,Other,Drug Cost,14.31,,,14.31,Other,Drug Cost,32.2,,,32.2,Other,225% of Medicaid,20.04,,,20.04,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,7.07,,,7.07,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",30.77,,,30.77,Other,215% Medicaid APG methodology,30.77,,,30.77,Other,215% Medicaid APG methodology,17.89,,,17.89,Other,125% Medicaid APG methodology,0.01,32.2,
VANCOMYCIN 1GM/250ML NS,J3370,HCPCS,,80002252,CDM,636,RC,67457034001,NDC,both,10,EA,3.64,22.76,,,22.76,Other,150% of Medicare + 9.63% HCRA Surcharge,13.84,,,13.84,Fee Schedule,Average Sale Price (ASP) x 6,1.27,35,,1.27,percent of total billed charges,Drugs,1.27,35,,1.27,percent of total billed charges,Drugs,1.24,34,,1.24,percent of total billed charges,Drugs,1.24,34,,1.24,percent of total billed charges,Drugs,1.24,34,,1.24,percent of total billed charges,Drugs,1.24,34,,1.24,percent of total billed charges,Drugs,1.27,35,,1.27,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,1.27,35,,1.27,percent of total billed charges,Drugs,1.27,35,,1.27,percent of total billed charges,Drugs,1.27,35,,1.27,percent of total billed charges,Drugs,1.27,35,,1.27,percent of total billed charges,Drugs,1.27,35,,1.27,percent of total billed charges,Drugs,1.46,40,,1.46,percent of total billed charges,Drugs,2.55,70,,2.55,percent of total billed charges,All Other,1.31,36,,1.31,percent of total billed charges,Drugs,1.31,36,,1.31,percent of total billed charges,Drugs,1.27,35,,1.27,percent of total billed charges,Drugs,1.27,35,,1.27,percent of total billed charges,Drugs,1.27,35,,1.27,percent of total billed charges,Drugs,1.27,35,,1.27,percent of total billed charges,Drugs,1.21,,,1.21,Other,Drug Cost,1.21,,,1.21,Other,Drug Cost,1.21,,,1.21,Other,Drug Cost,1.21,,,1.21,Other,Drug Cost,1.21,,,1.21,Other,Drug Cost,1.21,,,1.21,Other,Drug Cost,2.73,,,2.73,Other,225% of Medicaid,1.7,,,1.7,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,22.15,,,22.15,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",2.61,,,2.61,Other,215% Medicaid APG methodology,2.61,,,2.61,Other,215% Medicaid APG methodology,1.52,,,1.52,Other,125% Medicaid APG methodology,0.01,22.76,
ZOSYN 2.25GM/50ML NS,J2543,HCPCS,,80002254,CDM,636,RC,781311095,NDC,both,10,EA,0.03,11.61,,,11.61,Other,150% of Medicare + 9.63% HCRA Surcharge,7.06,,,7.06,Fee Schedule,Average Sale Price (ASP) x 6,0.01,35,,0.01,percent of total billed charges,Drugs,0.01,35,,0.01,percent of total billed charges,Drugs,0.01,34,,0.01,percent of total billed charges,Drugs,0.01,34,,0.01,percent of total billed charges,Drugs,0.01,34,,0.01,percent of total billed charges,Drugs,0.01,34,,0.01,percent of total billed charges,Drugs,0.01,35,,0.01,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,0.01,35,,0.01,percent of total billed charges,Drugs,0.01,35,,0.01,percent of total billed charges,Drugs,0.01,35,,0.01,percent of total billed charges,Drugs,0.01,35,,0.01,percent of total billed charges,Drugs,0.01,35,,0.01,percent of total billed charges,Drugs,0.01,40,,0.01,percent of total billed charges,Drugs,0.02,70,,0.02,percent of total billed charges,All Other,0.01,36,,0.01,percent of total billed charges,Drugs,0.01,36,,0.01,percent of total billed charges,Drugs,0.01,35,,0.01,percent of total billed charges,Drugs,0.01,35,,0.01,percent of total billed charges,Drugs,0.01,35,,0.01,percent of total billed charges,Drugs,0.01,35,,0.01,percent of total billed charges,Drugs,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.02,,,0.02,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,11.3,,,11.3,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,11.61,
RHO D IMMUNE GLOBULIN INJ 300MCG,J2790,HCPCS,,80002259,CDM,636,RC,44206030001,NDC,both,1,ML,157.53,800.79,,,800.79,Other,150% of Medicare + 9.63% HCRA Surcharge,486.97,,,486.97,Fee Schedule,Average Sale Price (ASP) x 6,55.14,35,,55.14,percent of total billed charges,Drugs,55.14,35,,55.14,percent of total billed charges,Drugs,53.56,34,,53.56,percent of total billed charges,Drugs,53.56,34,,53.56,percent of total billed charges,Drugs,53.56,34,,53.56,percent of total billed charges,Drugs,53.56,34,,53.56,percent of total billed charges,Drugs,55.14,35,,55.14,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,55.14,35,,55.14,percent of total billed charges,Drugs,55.14,35,,55.14,percent of total billed charges,Drugs,55.14,35,,55.14,percent of total billed charges,Drugs,55.14,35,,55.14,percent of total billed charges,Drugs,55.14,35,,55.14,percent of total billed charges,Drugs,63.01,40,,63.01,percent of total billed charges,Drugs,110.27,70,,110.27,percent of total billed charges,All Other,56.71,36,,56.71,percent of total billed charges,Drugs,56.71,36,,56.71,percent of total billed charges,Drugs,55.14,35,,55.14,percent of total billed charges,Drugs,55.14,35,,55.14,percent of total billed charges,Drugs,55.14,35,,55.14,percent of total billed charges,Drugs,55.14,35,,55.14,percent of total billed charges,Drugs,52.51,,,52.51,Other,Drug Cost,52.51,,,52.51,Other,Drug Cost,52.51,,,52.51,Other,Drug Cost,52.51,,,52.51,Other,Drug Cost,52.51,,,52.51,Other,Drug Cost,52.51,,,52.51,Other,Drug Cost,118.15,,,118.15,Other,225% of Medicaid,73.51,,,73.51,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,779.15,,,779.15,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",112.9,,,112.9,Other,215% Medicaid APG methodology,112.9,,,112.9,Other,215% Medicaid APG methodology,65.64,,,65.64,Other,125% Medicaid APG methodology,0.01,800.79,
D5W 50ML,J7060,HCPCS,,80002262,CDM,636,RC,264151031,NDC,both,84,ML,1.89,19.05,,,19.05,Other,150% of Medicare + 9.63% HCRA Surcharge,11.59,,,11.59,Fee Schedule,Average Sale Price (ASP) x 6,0.66,35,,0.66,percent of total billed charges,Drugs,0.66,35,,0.66,percent of total billed charges,Drugs,0.64,34,,0.64,percent of total billed charges,Drugs,0.64,34,,0.64,percent of total billed charges,Drugs,0.64,34,,0.64,percent of total billed charges,Drugs,0.64,34,,0.64,percent of total billed charges,Drugs,0.66,35,,0.66,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,0.66,35,,0.66,percent of total billed charges,Drugs,0.66,35,,0.66,percent of total billed charges,Drugs,0.66,35,,0.66,percent of total billed charges,Drugs,0.66,35,,0.66,percent of total billed charges,Drugs,0.66,35,,0.66,percent of total billed charges,Drugs,0.76,40,,0.76,percent of total billed charges,Drugs,1.32,70,,1.32,percent of total billed charges,All Other,0.68,36,,0.68,percent of total billed charges,Drugs,0.68,36,,0.68,percent of total billed charges,Drugs,0.66,35,,0.66,percent of total billed charges,Drugs,0.66,35,,0.66,percent of total billed charges,Drugs,0.66,35,,0.66,percent of total billed charges,Drugs,0.66,35,,0.66,percent of total billed charges,Drugs,0.63,,,0.63,Other,Drug Cost,0.63,,,0.63,Other,Drug Cost,0.63,,,0.63,Other,Drug Cost,0.63,,,0.63,Other,Drug Cost,0.63,,,0.63,Other,Drug Cost,0.63,,,0.63,Other,Drug Cost,1.42,,,1.42,Other,225% of Medicaid,0.88,,,0.88,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,18.54,,,18.54,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",1.36,,,1.36,Other,215% Medicaid APG methodology,1.36,,,1.36,Other,215% Medicaid APG methodology,0.79,,,0.79,Other,125% Medicaid APG methodology,0.01,19.05,
HEPATITIS B 20MCG/ML 1ML,90746,HCPCS,,80002264,CDM,636,RC,58160082111,NDC,both,10,ML,135.24,53.37,39.4668,,53.37,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,47.33,35,,47.33,percent of total billed charges,Drugs,47.33,35,,47.33,percent of total billed charges,Drugs,45.98,34,,45.98,percent of total billed charges,Drugs,45.98,34,,45.98,percent of total billed charges,Drugs,45.98,34,,45.98,percent of total billed charges,Drugs,45.98,34,,45.98,percent of total billed charges,Drugs,47.33,35,,47.33,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,47.33,35,,47.33,percent of total billed charges,Drugs,47.33,35,,47.33,percent of total billed charges,Drugs,47.33,35,,47.33,percent of total billed charges,Drugs,47.33,35,,47.33,percent of total billed charges,Drugs,47.33,35,,47.33,percent of total billed charges,Drugs,54.1,40,,54.1,percent of total billed charges,Drugs,94.67,70,,94.67,percent of total billed charges,All Other,48.69,36,,48.69,percent of total billed charges,Drugs,48.69,36,,48.69,percent of total billed charges,Drugs,47.33,35,,47.33,percent of total billed charges,Drugs,47.33,35,,47.33,percent of total billed charges,Drugs,47.33,35,,47.33,percent of total billed charges,Drugs,47.33,35,,47.33,percent of total billed charges,Drugs,45.08,,,45.08,Other,Drug Cost,45.08,,,45.08,Other,Drug Cost,45.08,,,45.08,Other,Drug Cost,45.08,,,45.08,Other,Drug Cost,45.08,,,45.08,Other,Drug Cost,45.08,,,45.08,Other,Drug Cost,101.43,,,101.43,Other,225% of Medicaid,63.11,,,63.11,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",96.92,,,96.92,Other,215% Medicaid APG methodology,96.92,,,96.92,Other,215% Medicaid APG methodology,56.35,,,56.35,Other,125% Medicaid APG methodology,0.01,101.43,
HYDROMORPHONE 1MG/ML,J1170,HCPCS,,80002265,CDM,636,RC,409128331,NDC,both,10,ML,0.42,45.3,,,45.3,Other,150% of Medicare + 9.63% HCRA Surcharge,27.55,,,27.55,Fee Schedule,Average Sale Price (ASP) x 6,0.15,35,,0.15,percent of total billed charges,Drugs,0.15,35,,0.15,percent of total billed charges,Drugs,0.14,34,,0.14,percent of total billed charges,Drugs,0.14,34,,0.14,percent of total billed charges,Drugs,0.14,34,,0.14,percent of total billed charges,Drugs,0.14,34,,0.14,percent of total billed charges,Drugs,0.15,35,,0.15,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,0.15,35,,0.15,percent of total billed charges,Drugs,0.15,35,,0.15,percent of total billed charges,Drugs,0.15,35,,0.15,percent of total billed charges,Drugs,0.15,35,,0.15,percent of total billed charges,Drugs,0.15,35,,0.15,percent of total billed charges,Drugs,0.17,40,,0.17,percent of total billed charges,Drugs,0.29,70,,0.29,percent of total billed charges,All Other,0.15,36,,0.15,percent of total billed charges,Drugs,0.15,36,,0.15,percent of total billed charges,Drugs,0.15,35,,0.15,percent of total billed charges,Drugs,0.15,35,,0.15,percent of total billed charges,Drugs,0.15,35,,0.15,percent of total billed charges,Drugs,0.15,35,,0.15,percent of total billed charges,Drugs,0.14,,,0.14,Other,Drug Cost,0.14,,,0.14,Other,Drug Cost,0.14,,,0.14,Other,Drug Cost,0.14,,,0.14,Other,Drug Cost,0.14,,,0.14,Other,Drug Cost,0.14,,,0.14,Other,Drug Cost,0.32,,,0.32,Other,225% of Medicaid,0.2,,,0.2,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,44.07,,,44.07,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",0.3,,,0.3,Other,215% Medicaid APG methodology,0.3,,,0.3,Other,215% Medicaid APG methodology,0.18,,,0.18,Other,125% Medicaid APG methodology,0.01,45.3,
BEVACIZUMAB 100MG/4ML INJ,J9035,HCPCS,,80002281,CDM,636,RC,50242006001,NDC,both,1,ML,2365.71,730.86,,,730.86,Other,150% of Medicare + 9.63% HCRA Surcharge,444.44,,,444.44,Fee Schedule,Average Sale Price (ASP) x 6,828,35,,828,percent of total billed charges,Drugs,828,35,,828,percent of total billed charges,Drugs,804.34,34,,804.34,percent of total billed charges,Drugs,804.34,34,,804.34,percent of total billed charges,Drugs,804.34,34,,804.34,percent of total billed charges,Drugs,804.34,34,,804.34,percent of total billed charges,Drugs,828,35,,828,percent of total billed charges,Drugs,804.34,34,"If Charge > 500, then 34 percent",804.34,percent of total billed charges,Drugs,828,35,,828,percent of total billed charges,Drugs,828,35,,828,percent of total billed charges,Drugs,828,35,,828,percent of total billed charges,Drugs,828,35,,828,percent of total billed charges,Drugs,828,35,,828,percent of total billed charges,Drugs,946.28,40,,946.28,percent of total billed charges,Drugs,1656,70,,1656,percent of total billed charges,All Other,851.66,36,,851.66,percent of total billed charges,Drugs,851.66,36,,851.66,percent of total billed charges,Drugs,828,35,,828,percent of total billed charges,Drugs,828,35,,828,percent of total billed charges,Drugs,828,35,,828,percent of total billed charges,Drugs,828,35,,828,percent of total billed charges,Drugs,788.57,,,788.57,Other,Drug Cost,788.57,,,788.57,Other,Drug Cost,788.57,,,788.57,Other,Drug Cost,788.57,,,788.57,Other,Drug Cost,788.57,,,788.57,Other,Drug Cost,788.57,,,788.57,Other,Drug Cost,1774.28,,,1774.28,Other,225% of Medicaid,1104,,,1104,Other,140% of Medicaid,804.34,34,"If Charge > 2,000, then 34 percent",804.34,percent of total billed charges,Drugs,711.1,,,711.1,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",1695.43,,,1695.43,Other,215% Medicaid APG methodology,1695.43,,,1695.43,Other,215% Medicaid APG methodology,985.71,,,985.71,Other,125% Medicaid APG methodology,0.01,1774.28,
RHO D IMMUNE GLOBULIN 50MCG INJ,J2788,HCPCS,,80002282,CDM,636,RC,562780601,NDC,both,1,EA,55.77,234.82,,,234.82,Other,150% of Medicare + 9.63% HCRA Surcharge,142.79,,,142.79,Fee Schedule,Average Sale Price (ASP) x 6,19.52,35,,19.52,percent of total billed charges,Drugs,19.52,35,,19.52,percent of total billed charges,Drugs,18.96,34,,18.96,percent of total billed charges,Drugs,18.96,34,,18.96,percent of total billed charges,Drugs,18.96,34,,18.96,percent of total billed charges,Drugs,18.96,34,,18.96,percent of total billed charges,Drugs,19.52,35,,19.52,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,19.52,35,,19.52,percent of total billed charges,Drugs,19.52,35,,19.52,percent of total billed charges,Drugs,19.52,35,,19.52,percent of total billed charges,Drugs,19.52,35,,19.52,percent of total billed charges,Drugs,19.52,35,,19.52,percent of total billed charges,Drugs,22.31,40,,22.31,percent of total billed charges,Drugs,39.04,70,,39.04,percent of total billed charges,All Other,20.08,36,,20.08,percent of total billed charges,Drugs,20.08,36,,20.08,percent of total billed charges,Drugs,19.52,35,,19.52,percent of total billed charges,Drugs,19.52,35,,19.52,percent of total billed charges,Drugs,19.52,35,,19.52,percent of total billed charges,Drugs,19.52,35,,19.52,percent of total billed charges,Drugs,18.59,,,18.59,Other,Drug Cost,18.59,,,18.59,Other,Drug Cost,18.59,,,18.59,Other,Drug Cost,18.59,,,18.59,Other,Drug Cost,18.59,,,18.59,Other,Drug Cost,18.59,,,18.59,Other,Drug Cost,41.83,,,41.83,Other,225% of Medicaid,26.03,,,26.03,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,228.47,,,228.47,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",39.97,,,39.97,Other,215% Medicaid APG methodology,39.97,,,39.97,Other,215% Medicaid APG methodology,23.24,,,23.24,Other,125% Medicaid APG methodology,0.01,234.82,
CEFUROXIME 750MG ADVANTAGE 750MG VIAL,J0697,HCPCS,,80002295,CDM,636,RC,25021011810,NDC,both,25,EA,6.2,19.99,,,19.99,Other,150% of Medicare + 9.63% HCRA Surcharge,12.16,,,12.16,Fee Schedule,Average Sale Price (ASP) x 6,2.17,35,,2.17,percent of total billed charges,Drugs,2.17,35,,2.17,percent of total billed charges,Drugs,2.11,34,,2.11,percent of total billed charges,Drugs,2.11,34,,2.11,percent of total billed charges,Drugs,2.11,34,,2.11,percent of total billed charges,Drugs,2.11,34,,2.11,percent of total billed charges,Drugs,2.17,35,,2.17,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,2.17,35,,2.17,percent of total billed charges,Drugs,2.17,35,,2.17,percent of total billed charges,Drugs,2.17,35,,2.17,percent of total billed charges,Drugs,2.17,35,,2.17,percent of total billed charges,Drugs,2.17,35,,2.17,percent of total billed charges,Drugs,2.48,40,,2.48,percent of total billed charges,Drugs,4.34,70,,4.34,percent of total billed charges,All Other,2.23,36,,2.23,percent of total billed charges,Drugs,2.23,36,,2.23,percent of total billed charges,Drugs,2.17,35,,2.17,percent of total billed charges,Drugs,2.17,35,,2.17,percent of total billed charges,Drugs,2.17,35,,2.17,percent of total billed charges,Drugs,2.17,35,,2.17,percent of total billed charges,Drugs,2.07,,,2.07,Other,Drug Cost,2.07,,,2.07,Other,Drug Cost,2.07,,,2.07,Other,Drug Cost,2.07,,,2.07,Other,Drug Cost,2.07,,,2.07,Other,Drug Cost,2.07,,,2.07,Other,Drug Cost,4.65,,,4.65,Other,225% of Medicaid,2.89,,,2.89,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,19.45,,,19.45,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",4.44,,,4.44,Other,215% Medicaid APG methodology,4.44,,,4.44,Other,215% Medicaid APG methodology,2.58,,,2.58,Other,125% Medicaid APG methodology,0.01,19.99,
MIDAZOLAM HCL 5MG/ML 1ML VIAL,J2250,HCPCS,,80002344,CDM,636,RC,63323041225,NDC,both,25,ML,1.25,1.4,,,1.4,Other,150% of Medicare + 9.63% HCRA Surcharge,0.85,,,0.85,Fee Schedule,Average Sale Price (ASP) x 6,0.44,35,,0.44,percent of total billed charges,Drugs,0.44,35,,0.44,percent of total billed charges,Drugs,0.43,34,,0.43,percent of total billed charges,Drugs,0.43,34,,0.43,percent of total billed charges,Drugs,0.43,34,,0.43,percent of total billed charges,Drugs,0.43,34,,0.43,percent of total billed charges,Drugs,0.44,35,,0.44,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,0.44,35,,0.44,percent of total billed charges,Drugs,0.44,35,,0.44,percent of total billed charges,Drugs,0.44,35,,0.44,percent of total billed charges,Drugs,0.44,35,,0.44,percent of total billed charges,Drugs,0.44,35,,0.44,percent of total billed charges,Drugs,0.5,40,,0.5,percent of total billed charges,Drugs,0.88,70,,0.88,percent of total billed charges,All Other,0.45,36,,0.45,percent of total billed charges,Drugs,0.45,36,,0.45,percent of total billed charges,Drugs,0.44,35,,0.44,percent of total billed charges,Drugs,0.44,35,,0.44,percent of total billed charges,Drugs,0.44,35,,0.44,percent of total billed charges,Drugs,0.44,35,,0.44,percent of total billed charges,Drugs,0.42,,,0.42,Other,Drug Cost,0.42,,,0.42,Other,Drug Cost,0.42,,,0.42,Other,Drug Cost,0.42,,,0.42,Other,Drug Cost,0.42,,,0.42,Other,Drug Cost,0.42,,,0.42,Other,Drug Cost,0.94,,,0.94,Other,225% of Medicaid,0.58,,,0.58,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,1.36,,,1.36,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",0.9,,,0.9,Other,215% Medicaid APG methodology,0.9,,,0.9,Other,215% Medicaid APG methodology,0.52,,,0.52,Other,125% Medicaid APG methodology,0.01,1.4,
MORPHINE SULF (1MG/ML) 10MG/10ML AMP,J2270,HCPCS,,80002349,CDM,636,RC,641601910,NDC,both,10,ML,0.27,46.03,,,46.03,Other,150% of Medicare + 9.63% HCRA Surcharge,27.99,,,27.99,Fee Schedule,Average Sale Price (ASP) x 6,0.1,35,,0.1,percent of total billed charges,Drugs,0.1,35,,0.1,percent of total billed charges,Drugs,0.09,34,,0.09,percent of total billed charges,Drugs,0.09,34,,0.09,percent of total billed charges,Drugs,0.09,34,,0.09,percent of total billed charges,Drugs,0.09,34,,0.09,percent of total billed charges,Drugs,0.1,35,,0.1,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,0.1,35,,0.1,percent of total billed charges,Drugs,0.1,35,,0.1,percent of total billed charges,Drugs,0.1,35,,0.1,percent of total billed charges,Drugs,0.1,35,,0.1,percent of total billed charges,Drugs,0.1,35,,0.1,percent of total billed charges,Drugs,0.11,40,,0.11,percent of total billed charges,Drugs,0.19,70,,0.19,percent of total billed charges,All Other,0.1,36,,0.1,percent of total billed charges,Drugs,0.1,36,,0.1,percent of total billed charges,Drugs,0.1,35,,0.1,percent of total billed charges,Drugs,0.1,35,,0.1,percent of total billed charges,Drugs,0.1,35,,0.1,percent of total billed charges,Drugs,0.1,35,,0.1,percent of total billed charges,Drugs,0.09,,,0.09,Other,Drug Cost,0.09,,,0.09,Other,Drug Cost,0.09,,,0.09,Other,Drug Cost,0.09,,,0.09,Other,Drug Cost,0.09,,,0.09,Other,Drug Cost,0.09,,,0.09,Other,Drug Cost,0.2,,,0.2,Other,225% of Medicaid,0.13,,,0.13,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,44.78,,,44.78,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",0.2,,,0.2,Other,215% Medicaid APG methodology,0.2,,,0.2,Other,215% Medicaid APG methodology,0.11,,,0.11,Other,125% Medicaid APG methodology,0.01,46.03,
MORPHINE SULFATE 10MG/ML 1ML VIAL,J2270,HCPCS,,80002350,CDM,636,RC,641612725,NDC,both,25,ML,2.39,46.03,,,46.03,Other,150% of Medicare + 9.63% HCRA Surcharge,27.99,,,27.99,Fee Schedule,Average Sale Price (ASP) x 6,0.84,35,,0.84,percent of total billed charges,Drugs,0.84,35,,0.84,percent of total billed charges,Drugs,0.81,34,,0.81,percent of total billed charges,Drugs,0.81,34,,0.81,percent of total billed charges,Drugs,0.81,34,,0.81,percent of total billed charges,Drugs,0.81,34,,0.81,percent of total billed charges,Drugs,0.84,35,,0.84,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,0.84,35,,0.84,percent of total billed charges,Drugs,0.84,35,,0.84,percent of total billed charges,Drugs,0.84,35,,0.84,percent of total billed charges,Drugs,0.84,35,,0.84,percent of total billed charges,Drugs,0.84,35,,0.84,percent of total billed charges,Drugs,0.96,40,,0.96,percent of total billed charges,Drugs,1.67,70,,1.67,percent of total billed charges,All Other,0.86,36,,0.86,percent of total billed charges,Drugs,0.86,36,,0.86,percent of total billed charges,Drugs,0.84,35,,0.84,percent of total billed charges,Drugs,0.84,35,,0.84,percent of total billed charges,Drugs,0.84,35,,0.84,percent of total billed charges,Drugs,0.84,35,,0.84,percent of total billed charges,Drugs,0.8,,,0.8,Other,Drug Cost,0.8,,,0.8,Other,Drug Cost,0.8,,,0.8,Other,Drug Cost,0.8,,,0.8,Other,Drug Cost,0.8,,,0.8,Other,Drug Cost,0.8,,,0.8,Other,Drug Cost,1.79,,,1.79,Other,225% of Medicaid,1.11,,,1.11,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,44.78,,,44.78,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",1.71,,,1.71,Other,215% Medicaid APG methodology,1.71,,,1.71,Other,215% Medicaid APG methodology,1,,,1,Other,125% Medicaid APG methodology,0.01,46.03,
NALBUPHINE HCL 10MG/ML 1ML AMP,J2300,HCPCS,,80002354,CDM,636,RC,409146301,NDC,both,10,ML,1.94,27.74,,,27.74,Other,150% of Medicare + 9.63% HCRA Surcharge,16.87,,,16.87,Fee Schedule,Average Sale Price (ASP) x 6,0.68,35,,0.68,percent of total billed charges,Drugs,0.68,35,,0.68,percent of total billed charges,Drugs,0.66,34,,0.66,percent of total billed charges,Drugs,0.66,34,,0.66,percent of total billed charges,Drugs,0.66,34,,0.66,percent of total billed charges,Drugs,0.66,34,,0.66,percent of total billed charges,Drugs,0.68,35,,0.68,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,0.68,35,,0.68,percent of total billed charges,Drugs,0.68,35,,0.68,percent of total billed charges,Drugs,0.68,35,,0.68,percent of total billed charges,Drugs,0.68,35,,0.68,percent of total billed charges,Drugs,0.68,35,,0.68,percent of total billed charges,Drugs,0.78,40,,0.78,percent of total billed charges,Drugs,1.36,70,,1.36,percent of total billed charges,All Other,0.7,36,,0.7,percent of total billed charges,Drugs,0.7,36,,0.7,percent of total billed charges,Drugs,0.68,35,,0.68,percent of total billed charges,Drugs,0.68,35,,0.68,percent of total billed charges,Drugs,0.68,35,,0.68,percent of total billed charges,Drugs,0.68,35,,0.68,percent of total billed charges,Drugs,0.65,,,0.65,Other,Drug Cost,0.65,,,0.65,Other,Drug Cost,0.65,,,0.65,Other,Drug Cost,0.65,,,0.65,Other,Drug Cost,0.65,,,0.65,Other,Drug Cost,0.65,,,0.65,Other,Drug Cost,1.46,,,1.46,Other,225% of Medicaid,0.91,,,0.91,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,26.99,,,26.99,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",1.39,,,1.39,Other,215% Medicaid APG methodology,1.39,,,1.39,Other,215% Medicaid APG methodology,0.81,,,0.81,Other,125% Medicaid APG methodology,0.01,27.74,
NEOSTIGMINE METHYLSULF 1:1000 10ML VIAL,J2710,HCPCS,,80002357,CDM,636,RC,25021061110,NDC,both,10,ML,4.35,1.72,39.4668,,1.72,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,1.52,35,,1.52,percent of total billed charges,Drugs,1.52,35,,1.52,percent of total billed charges,Drugs,1.48,34,,1.48,percent of total billed charges,Drugs,1.48,34,,1.48,percent of total billed charges,Drugs,1.48,34,,1.48,percent of total billed charges,Drugs,1.48,34,,1.48,percent of total billed charges,Drugs,1.52,35,,1.52,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,1.52,35,,1.52,percent of total billed charges,Drugs,1.52,35,,1.52,percent of total billed charges,Drugs,1.52,35,,1.52,percent of total billed charges,Drugs,1.52,35,,1.52,percent of total billed charges,Drugs,1.52,35,,1.52,percent of total billed charges,Drugs,1.74,40,,1.74,percent of total billed charges,Drugs,3.04,70,,3.04,percent of total billed charges,All Other,1.56,36,,1.56,percent of total billed charges,Drugs,1.56,36,,1.56,percent of total billed charges,Drugs,1.52,35,,1.52,percent of total billed charges,Drugs,1.52,35,,1.52,percent of total billed charges,Drugs,1.52,35,,1.52,percent of total billed charges,Drugs,1.52,35,,1.52,percent of total billed charges,Drugs,1.45,,,1.45,Other,Drug Cost,1.45,,,1.45,Other,Drug Cost,1.45,,,1.45,Other,Drug Cost,1.45,,,1.45,Other,Drug Cost,1.45,,,1.45,Other,Drug Cost,1.45,,,1.45,Other,Drug Cost,3.26,,,3.26,Other,225% of Medicaid,2.03,,,2.03,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",3.12,,,3.12,Other,215% Medicaid APG methodology,3.12,,,3.12,Other,215% Medicaid APG methodology,1.81,,,1.81,Other,125% Medicaid APG methodology,0.01,3.26,
PENICILLIN G BENZATHINE 1.2 MILLION SYR,J0561,HCPCS,,80002361,CDM,636,RC,60793070110,NDC,both,10,ML,0.05,214.4,,,214.4,Other,150% of Medicare + 9.63% HCRA Surcharge,130.38,,,130.38,Fee Schedule,Average Sale Price (ASP) x 6,0.02,35,,0.02,percent of total billed charges,Drugs,0.02,35,,0.02,percent of total billed charges,Drugs,0.02,34,,0.02,percent of total billed charges,Drugs,0.02,34,,0.02,percent of total billed charges,Drugs,0.02,34,,0.02,percent of total billed charges,Drugs,0.02,34,,0.02,percent of total billed charges,Drugs,0.02,35,,0.02,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,0.02,35,,0.02,percent of total billed charges,Drugs,0.02,35,,0.02,percent of total billed charges,Drugs,0.02,35,,0.02,percent of total billed charges,Drugs,0.02,35,,0.02,percent of total billed charges,Drugs,0.02,35,,0.02,percent of total billed charges,Drugs,0.02,40,,0.02,percent of total billed charges,Drugs,0.04,70,,0.04,percent of total billed charges,All Other,0.02,36,,0.02,percent of total billed charges,Drugs,0.02,36,,0.02,percent of total billed charges,Drugs,0.02,35,,0.02,percent of total billed charges,Drugs,0.02,35,,0.02,percent of total billed charges,Drugs,0.02,35,,0.02,percent of total billed charges,Drugs,0.02,35,,0.02,percent of total billed charges,Drugs,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.04,,,0.04,Other,225% of Medicaid,0.03,,,0.03,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,208.61,,,208.61,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",0.04,,,0.04,Other,215% Medicaid APG methodology,0.04,,,0.04,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,125% Medicaid APG methodology,0.01,214.4,
PROCHLORPERAZINE EDISYL 5MG/ML 2ML VIAL,J0780,HCPCS,,80002370,CDM,636,RC,25021079002,NDC,both,10,ML,4.7,33.83,,,33.83,Other,150% of Medicare + 9.63% HCRA Surcharge,20.57,,,20.57,Fee Schedule,Average Sale Price (ASP) x 6,1.65,35,,1.65,percent of total billed charges,Drugs,1.65,35,,1.65,percent of total billed charges,Drugs,1.6,34,,1.6,percent of total billed charges,Drugs,1.6,34,,1.6,percent of total billed charges,Drugs,1.6,34,,1.6,percent of total billed charges,Drugs,1.6,34,,1.6,percent of total billed charges,Drugs,1.65,35,,1.65,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,1.65,35,,1.65,percent of total billed charges,Drugs,1.65,35,,1.65,percent of total billed charges,Drugs,1.65,35,,1.65,percent of total billed charges,Drugs,1.65,35,,1.65,percent of total billed charges,Drugs,1.65,35,,1.65,percent of total billed charges,Drugs,1.88,40,,1.88,percent of total billed charges,Drugs,3.29,70,,3.29,percent of total billed charges,All Other,1.69,36,,1.69,percent of total billed charges,Drugs,1.69,36,,1.69,percent of total billed charges,Drugs,1.65,35,,1.65,percent of total billed charges,Drugs,1.65,35,,1.65,percent of total billed charges,Drugs,1.65,35,,1.65,percent of total billed charges,Drugs,1.65,35,,1.65,percent of total billed charges,Drugs,1.57,,,1.57,Other,Drug Cost,1.57,,,1.57,Other,Drug Cost,1.57,,,1.57,Other,Drug Cost,1.57,,,1.57,Other,Drug Cost,1.57,,,1.57,Other,Drug Cost,1.57,,,1.57,Other,Drug Cost,3.53,,,3.53,Other,225% of Medicaid,2.19,,,2.19,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,32.92,,,32.92,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",3.37,,,3.37,Other,215% Medicaid APG methodology,3.37,,,3.37,Other,215% Medicaid APG methodology,1.96,,,1.96,Other,125% Medicaid APG methodology,0.01,33.83,
PROMETHAZINE HCL 12.5MG SUPP RECT,J8498,HCPCS,,80002372,CDM,636,RC,713053612,NDC,both,12,EA,2.5,0.99,39.4668,,0.99,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.88,35,,0.88,percent of total billed charges,Drugs,0.88,35,,0.88,percent of total billed charges,Drugs,0.85,34,,0.85,percent of total billed charges,Drugs,0.85,34,,0.85,percent of total billed charges,Drugs,0.85,34,,0.85,percent of total billed charges,Drugs,0.85,34,,0.85,percent of total billed charges,Drugs,0.88,35,,0.88,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,0.88,35,,0.88,percent of total billed charges,Drugs,0.88,35,,0.88,percent of total billed charges,Drugs,0.88,35,,0.88,percent of total billed charges,Drugs,0.88,35,,0.88,percent of total billed charges,Drugs,0.88,35,,0.88,percent of total billed charges,Drugs,1,40,,1,percent of total billed charges,Drugs,1.75,70,,1.75,percent of total billed charges,All Other,0.9,36,,0.9,percent of total billed charges,Drugs,0.9,36,,0.9,percent of total billed charges,Drugs,0.88,35,,0.88,percent of total billed charges,Drugs,0.88,35,,0.88,percent of total billed charges,Drugs,0.88,35,,0.88,percent of total billed charges,Drugs,0.88,35,,0.88,percent of total billed charges,Drugs,0.83,,,0.83,Other,Drug Cost,0.83,,,0.83,Other,Drug Cost,0.83,,,0.83,Other,Drug Cost,0.83,,,0.83,Other,Drug Cost,0.83,,,0.83,Other,Drug Cost,0.83,,,0.83,Other,Drug Cost,1.88,,,1.88,Other,225% of Medicaid,1.17,,,1.17,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",1.79,,,1.79,Other,215% Medicaid APG methodology,1.79,,,1.79,Other,215% Medicaid APG methodology,1.04,,,1.04,Other,125% Medicaid APG methodology,0.01,1.88,
ROCURONIUM BROMIDE 10MG/ML 5ML VIAL,J3490,HCPCS,,80002375,CDM,636,RC,63323042605,NDC,both,10,ML,3.86,1.52,39.4668,,1.52,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,1.35,35,,1.35,percent of total billed charges,Drugs,1.35,35,,1.35,percent of total billed charges,Drugs,1.31,34,,1.31,percent of total billed charges,Drugs,1.31,34,,1.31,percent of total billed charges,Drugs,1.31,34,,1.31,percent of total billed charges,Drugs,1.31,34,,1.31,percent of total billed charges,Drugs,1.35,35,,1.35,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,1.35,35,,1.35,percent of total billed charges,Drugs,1.35,35,,1.35,percent of total billed charges,Drugs,1.35,35,,1.35,percent of total billed charges,Drugs,1.35,35,,1.35,percent of total billed charges,Drugs,1.35,35,,1.35,percent of total billed charges,Drugs,1.54,40,,1.54,percent of total billed charges,Drugs,2.7,70,,2.7,percent of total billed charges,All Other,1.39,36,,1.39,percent of total billed charges,Drugs,1.39,36,,1.39,percent of total billed charges,Drugs,1.35,35,,1.35,percent of total billed charges,Drugs,1.35,35,,1.35,percent of total billed charges,Drugs,1.35,35,,1.35,percent of total billed charges,Drugs,1.35,35,,1.35,percent of total billed charges,Drugs,1.29,,,1.29,Other,Drug Cost,1.29,,,1.29,Other,Drug Cost,1.29,,,1.29,Other,Drug Cost,1.29,,,1.29,Other,Drug Cost,1.29,,,1.29,Other,Drug Cost,1.29,,,1.29,Other,Drug Cost,2.89,,,2.89,Other,225% of Medicaid,1.8,,,1.8,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",2.76,,,2.76,Other,215% Medicaid APG methodology,2.76,,,2.76,Other,215% Medicaid APG methodology,1.61,,,1.61,Other,125% Medicaid APG methodology,0.01,2.89,
PHYTONADIONE 10MG/ML INJ,J3430,HCPCS,,80002405,CDM,636,RC,409915801,NDC,both,25,ML,65.1,28.6,,,28.6,Other,150% of Medicare + 9.63% HCRA Surcharge,17.39,,,17.39,Fee Schedule,Average Sale Price (ASP) x 6,22.79,35,,22.79,percent of total billed charges,Drugs,22.79,35,,22.79,percent of total billed charges,Drugs,22.13,34,,22.13,percent of total billed charges,Drugs,22.13,34,,22.13,percent of total billed charges,Drugs,22.13,34,,22.13,percent of total billed charges,Drugs,22.13,34,,22.13,percent of total billed charges,Drugs,22.79,35,,22.79,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,22.79,35,,22.79,percent of total billed charges,Drugs,22.79,35,,22.79,percent of total billed charges,Drugs,22.79,35,,22.79,percent of total billed charges,Drugs,22.79,35,,22.79,percent of total billed charges,Drugs,22.79,35,,22.79,percent of total billed charges,Drugs,26.04,40,,26.04,percent of total billed charges,Drugs,45.57,70,,45.57,percent of total billed charges,All Other,23.44,36,,23.44,percent of total billed charges,Drugs,23.44,36,,23.44,percent of total billed charges,Drugs,22.79,35,,22.79,percent of total billed charges,Drugs,22.79,35,,22.79,percent of total billed charges,Drugs,22.79,35,,22.79,percent of total billed charges,Drugs,22.79,35,,22.79,percent of total billed charges,Drugs,21.7,,,21.7,Other,Drug Cost,21.7,,,21.7,Other,Drug Cost,21.7,,,21.7,Other,Drug Cost,21.7,,,21.7,Other,Drug Cost,21.7,,,21.7,Other,Drug Cost,21.7,,,21.7,Other,Drug Cost,48.83,,,48.83,Other,225% of Medicaid,30.38,,,30.38,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,27.83,,,27.83,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",46.66,,,46.66,Other,215% Medicaid APG methodology,46.66,,,46.66,Other,215% Medicaid APG methodology,27.13,,,27.13,Other,125% Medicaid APG methodology,0.01,48.83,
MEASLES/MUMPS/RUBELLA VACC,90707,HCPCS,,80002423,CDM,636,RC,6468100,NDC,both,10,EA,259.36,102.36,39.4668,,102.36,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,90.78,35,,90.78,percent of total billed charges,Drugs,90.78,35,,90.78,percent of total billed charges,Drugs,88.18,34,,88.18,percent of total billed charges,Drugs,88.18,34,,88.18,percent of total billed charges,Drugs,88.18,34,,88.18,percent of total billed charges,Drugs,88.18,34,,88.18,percent of total billed charges,Drugs,90.78,35,,90.78,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,90.78,35,,90.78,percent of total billed charges,Drugs,90.78,35,,90.78,percent of total billed charges,Drugs,90.78,35,,90.78,percent of total billed charges,Drugs,90.78,35,,90.78,percent of total billed charges,Drugs,90.78,35,,90.78,percent of total billed charges,Drugs,103.74,40,,103.74,percent of total billed charges,Drugs,181.55,70,,181.55,percent of total billed charges,All Other,93.37,36,,93.37,percent of total billed charges,Drugs,93.37,36,,93.37,percent of total billed charges,Drugs,90.78,35,,90.78,percent of total billed charges,Drugs,90.78,35,,90.78,percent of total billed charges,Drugs,90.78,35,,90.78,percent of total billed charges,Drugs,90.78,35,,90.78,percent of total billed charges,Drugs,86.45,,,86.45,Other,Drug Cost,86.45,,,86.45,Other,Drug Cost,86.45,,,86.45,Other,Drug Cost,86.45,,,86.45,Other,Drug Cost,86.45,,,86.45,Other,Drug Cost,86.45,,,86.45,Other,Drug Cost,194.52,,,194.52,Other,225% of Medicaid,121.04,,,121.04,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",185.88,,,185.88,Other,215% Medicaid APG methodology,185.88,,,185.88,Other,215% Medicaid APG methodology,108.07,,,108.07,Other,125% Medicaid APG methodology,0.01,194.52,
0.9% NACL  WITH KCL 20MEQ 1000ML,J3480,HCPCS,,80002434,CDM,636,RC,264786500,NDC,both,1000,ML,3.39,1.18,,,1.18,Other,150% of Medicare + 9.63% HCRA Surcharge,0.72,,,0.72,Fee Schedule,Average Sale Price (ASP) x 6,1.19,35,,1.19,percent of total billed charges,Drugs,1.19,35,,1.19,percent of total billed charges,Drugs,1.15,34,,1.15,percent of total billed charges,Drugs,1.15,34,,1.15,percent of total billed charges,Drugs,1.15,34,,1.15,percent of total billed charges,Drugs,1.15,34,,1.15,percent of total billed charges,Drugs,1.19,35,,1.19,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,1.19,35,,1.19,percent of total billed charges,Drugs,1.19,35,,1.19,percent of total billed charges,Drugs,1.19,35,,1.19,percent of total billed charges,Drugs,1.19,35,,1.19,percent of total billed charges,Drugs,1.19,35,,1.19,percent of total billed charges,Drugs,1.36,40,,1.36,percent of total billed charges,Drugs,2.37,70,,2.37,percent of total billed charges,All Other,1.22,36,,1.22,percent of total billed charges,Drugs,1.22,36,,1.22,percent of total billed charges,Drugs,1.19,35,,1.19,percent of total billed charges,Drugs,1.19,35,,1.19,percent of total billed charges,Drugs,1.19,35,,1.19,percent of total billed charges,Drugs,1.19,35,,1.19,percent of total billed charges,Drugs,1.13,,,1.13,Other,Drug Cost,1.13,,,1.13,Other,Drug Cost,1.13,,,1.13,Other,Drug Cost,1.13,,,1.13,Other,Drug Cost,1.13,,,1.13,Other,Drug Cost,1.13,,,1.13,Other,Drug Cost,2.54,,,2.54,Other,225% of Medicaid,1.58,,,1.58,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,1.15,,,1.15,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",2.43,,,2.43,Other,215% Medicaid APG methodology,2.43,,,2.43,Other,215% Medicaid APG methodology,1.41,,,1.41,Other,125% Medicaid APG methodology,0.01,2.54,
POTASSIUM CHLORIDE 40MEQ/20ML INJ,J3480,HCPCS,,80002436,CDM,636,RC,63323096520,NDC,both,25,ML,2.64,1.18,,,1.18,Other,150% of Medicare + 9.63% HCRA Surcharge,0.72,,,0.72,Fee Schedule,Average Sale Price (ASP) x 6,0.92,35,,0.92,percent of total billed charges,Drugs,0.92,35,,0.92,percent of total billed charges,Drugs,0.9,34,,0.9,percent of total billed charges,Drugs,0.9,34,,0.9,percent of total billed charges,Drugs,0.9,34,,0.9,percent of total billed charges,Drugs,0.9,34,,0.9,percent of total billed charges,Drugs,0.92,35,,0.92,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,0.92,35,,0.92,percent of total billed charges,Drugs,0.92,35,,0.92,percent of total billed charges,Drugs,0.92,35,,0.92,percent of total billed charges,Drugs,0.92,35,,0.92,percent of total billed charges,Drugs,0.92,35,,0.92,percent of total billed charges,Drugs,1.05,40,,1.05,percent of total billed charges,Drugs,1.85,70,,1.85,percent of total billed charges,All Other,0.95,36,,0.95,percent of total billed charges,Drugs,0.95,36,,0.95,percent of total billed charges,Drugs,0.92,35,,0.92,percent of total billed charges,Drugs,0.92,35,,0.92,percent of total billed charges,Drugs,0.92,35,,0.92,percent of total billed charges,Drugs,0.92,35,,0.92,percent of total billed charges,Drugs,0.88,,,0.88,Other,Drug Cost,0.88,,,0.88,Other,Drug Cost,0.88,,,0.88,Other,Drug Cost,0.88,,,0.88,Other,Drug Cost,0.88,,,0.88,Other,Drug Cost,0.88,,,0.88,Other,Drug Cost,1.98,,,1.98,Other,225% of Medicaid,1.23,,,1.23,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,1.15,,,1.15,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",1.89,,,1.89,Other,215% Medicaid APG methodology,1.89,,,1.89,Other,215% Medicaid APG methodology,1.1,,,1.1,Other,125% Medicaid APG methodology,0.01,1.98,
GENTAMICIN 80MG/NACL 50ML,J1580,HCPCS,,80002444,CDM,636,RC,338050941,NDC,both,24,ML,5.9,26.49,,,26.49,Other,150% of Medicare + 9.63% HCRA Surcharge,16.11,,,16.11,Fee Schedule,Average Sale Price (ASP) x 6,2.06,35,,2.06,percent of total billed charges,Drugs,2.06,35,,2.06,percent of total billed charges,Drugs,2.01,34,,2.01,percent of total billed charges,Drugs,2.01,34,,2.01,percent of total billed charges,Drugs,2.01,34,,2.01,percent of total billed charges,Drugs,2.01,34,,2.01,percent of total billed charges,Drugs,2.06,35,,2.06,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,2.06,35,,2.06,percent of total billed charges,Drugs,2.06,35,,2.06,percent of total billed charges,Drugs,2.06,35,,2.06,percent of total billed charges,Drugs,2.06,35,,2.06,percent of total billed charges,Drugs,2.06,35,,2.06,percent of total billed charges,Drugs,2.36,40,,2.36,percent of total billed charges,Drugs,4.13,70,,4.13,percent of total billed charges,All Other,2.12,36,,2.12,percent of total billed charges,Drugs,2.12,36,,2.12,percent of total billed charges,Drugs,2.06,35,,2.06,percent of total billed charges,Drugs,2.06,35,,2.06,percent of total billed charges,Drugs,2.06,35,,2.06,percent of total billed charges,Drugs,2.06,35,,2.06,percent of total billed charges,Drugs,1.97,,,1.97,Other,Drug Cost,1.97,,,1.97,Other,Drug Cost,1.97,,,1.97,Other,Drug Cost,1.97,,,1.97,Other,Drug Cost,1.97,,,1.97,Other,Drug Cost,1.97,,,1.97,Other,Drug Cost,4.42,,,4.42,Other,225% of Medicaid,2.75,,,2.75,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,25.78,,,25.78,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",4.23,,,4.23,Other,215% Medicaid APG methodology,4.23,,,4.23,Other,215% Medicaid APG methodology,2.46,,,2.46,Other,125% Medicaid APG methodology,0.01,26.49,
METHYLPREDNISOLONE 1GM INJ,J2930,HCPCS,,80002485,CDM,636,RC,9069801,NDC,both,1,EA,0.03,58.04,,,58.04,Other,150% of Medicare + 9.63% HCRA Surcharge,35.29,,,35.29,Fee Schedule,Average Sale Price (ASP) x 6,0.01,35,,0.01,percent of total billed charges,Drugs,0.01,35,,0.01,percent of total billed charges,Drugs,0.01,34,,0.01,percent of total billed charges,Drugs,0.01,34,,0.01,percent of total billed charges,Drugs,0.01,34,,0.01,percent of total billed charges,Drugs,0.01,34,,0.01,percent of total billed charges,Drugs,0.01,35,,0.01,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,0.01,35,,0.01,percent of total billed charges,Drugs,0.01,35,,0.01,percent of total billed charges,Drugs,0.01,35,,0.01,percent of total billed charges,Drugs,0.01,35,,0.01,percent of total billed charges,Drugs,0.01,35,,0.01,percent of total billed charges,Drugs,0.01,40,,0.01,percent of total billed charges,Drugs,0.02,70,,0.02,percent of total billed charges,All Other,0.01,36,,0.01,percent of total billed charges,Drugs,0.01,36,,0.01,percent of total billed charges,Drugs,0.01,35,,0.01,percent of total billed charges,Drugs,0.01,35,,0.01,percent of total billed charges,Drugs,0.01,35,,0.01,percent of total billed charges,Drugs,0.01,35,,0.01,percent of total billed charges,Drugs,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.02,,,0.02,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,56.47,,,56.47,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,58.04,
DOBUTAMINE 500MG/250ML IV,J1250,HCPCS,,80002540,CDM,636,RC,338107502,NDC,both,18,ML,6.8,97.17,,,97.17,Other,150% of Medicare + 9.63% HCRA Surcharge,59.09,,,59.09,Fee Schedule,Average Sale Price (ASP) x 6,2.38,35,,2.38,percent of total billed charges,Drugs,2.38,35,,2.38,percent of total billed charges,Drugs,2.31,34,,2.31,percent of total billed charges,Drugs,2.31,34,,2.31,percent of total billed charges,Drugs,2.31,34,,2.31,percent of total billed charges,Drugs,2.31,34,,2.31,percent of total billed charges,Drugs,2.38,35,,2.38,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,2.38,35,,2.38,percent of total billed charges,Drugs,2.38,35,,2.38,percent of total billed charges,Drugs,2.38,35,,2.38,percent of total billed charges,Drugs,2.38,35,,2.38,percent of total billed charges,Drugs,2.38,35,,2.38,percent of total billed charges,Drugs,2.72,40,,2.72,percent of total billed charges,Drugs,4.76,70,,4.76,percent of total billed charges,All Other,2.45,36,,2.45,percent of total billed charges,Drugs,2.45,36,,2.45,percent of total billed charges,Drugs,2.38,35,,2.38,percent of total billed charges,Drugs,2.38,35,,2.38,percent of total billed charges,Drugs,2.38,35,,2.38,percent of total billed charges,Drugs,2.38,35,,2.38,percent of total billed charges,Drugs,2.27,,,2.27,Other,Drug Cost,2.27,,,2.27,Other,Drug Cost,2.27,,,2.27,Other,Drug Cost,2.27,,,2.27,Other,Drug Cost,2.27,,,2.27,Other,Drug Cost,2.27,,,2.27,Other,Drug Cost,5.1,,,5.1,Other,225% of Medicaid,3.17,,,3.17,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,94.54,,,94.54,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",4.87,,,4.87,Other,215% Medicaid APG methodology,4.87,,,4.87,Other,215% Medicaid APG methodology,2.83,,,2.83,Other,125% Medicaid APG methodology,0.01,97.17,
HYDROMORPHONE 10MG/ML 5ML INJ,J1170,HCPCS,,80002553,CDM,636,RC,409263405,NDC,both,10,ML,23.21,45.3,,,45.3,Other,150% of Medicare + 9.63% HCRA Surcharge,27.55,,,27.55,Fee Schedule,Average Sale Price (ASP) x 6,8.12,35,,8.12,percent of total billed charges,Drugs,8.12,35,,8.12,percent of total billed charges,Drugs,7.89,34,,7.89,percent of total billed charges,Drugs,7.89,34,,7.89,percent of total billed charges,Drugs,7.89,34,,7.89,percent of total billed charges,Drugs,7.89,34,,7.89,percent of total billed charges,Drugs,8.12,35,,8.12,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,8.12,35,,8.12,percent of total billed charges,Drugs,8.12,35,,8.12,percent of total billed charges,Drugs,8.12,35,,8.12,percent of total billed charges,Drugs,8.12,35,,8.12,percent of total billed charges,Drugs,8.12,35,,8.12,percent of total billed charges,Drugs,9.28,40,,9.28,percent of total billed charges,Drugs,16.25,70,,16.25,percent of total billed charges,All Other,8.35,36,,8.35,percent of total billed charges,Drugs,8.35,36,,8.35,percent of total billed charges,Drugs,8.12,35,,8.12,percent of total billed charges,Drugs,8.12,35,,8.12,percent of total billed charges,Drugs,8.12,35,,8.12,percent of total billed charges,Drugs,8.12,35,,8.12,percent of total billed charges,Drugs,7.74,,,7.74,Other,Drug Cost,7.74,,,7.74,Other,Drug Cost,7.74,,,7.74,Other,Drug Cost,7.74,,,7.74,Other,Drug Cost,7.74,,,7.74,Other,Drug Cost,7.74,,,7.74,Other,Drug Cost,17.41,,,17.41,Other,225% of Medicaid,10.83,,,10.83,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,44.07,,,44.07,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",16.63,,,16.63,Other,215% Medicaid APG methodology,16.63,,,16.63,Other,215% Medicaid APG methodology,9.67,,,9.67,Other,125% Medicaid APG methodology,0.01,45.3,
IMMUNE GLOBULIN(PRIVIGEN) LIQUID 20GM,J1459,HCPCS,,80002554,CDM,636,RC,44206043820,NDC,both,1,ML,4281.33,476.46,,,476.46,Other,150% of Medicare + 9.63% HCRA Surcharge,289.74,,,289.74,Fee Schedule,Average Sale Price (ASP) x 6,1498.47,35,,1498.47,percent of total billed charges,Drugs,1498.47,35,,1498.47,percent of total billed charges,Drugs,1455.65,34,,1455.65,percent of total billed charges,Drugs,1455.65,34,,1455.65,percent of total billed charges,Drugs,1455.65,34,,1455.65,percent of total billed charges,Drugs,1455.65,34,,1455.65,percent of total billed charges,Drugs,1498.47,35,,1498.47,percent of total billed charges,Drugs,1455.65,34,"If Charge > 500, then 34 percent",1455.65,percent of total billed charges,Drugs,1498.47,35,,1498.47,percent of total billed charges,Drugs,1498.47,35,,1498.47,percent of total billed charges,Drugs,1498.47,35,,1498.47,percent of total billed charges,Drugs,1498.47,35,,1498.47,percent of total billed charges,Drugs,1498.47,35,,1498.47,percent of total billed charges,Drugs,1712.53,40,,1712.53,percent of total billed charges,Drugs,2996.93,70,,2996.93,percent of total billed charges,All Other,1541.28,36,,1541.28,percent of total billed charges,Drugs,1541.28,36,,1541.28,percent of total billed charges,Drugs,1498.47,35,,1498.47,percent of total billed charges,Drugs,1498.47,35,,1498.47,percent of total billed charges,Drugs,1498.47,35,,1498.47,percent of total billed charges,Drugs,1498.47,35,,1498.47,percent of total billed charges,Drugs,1427.11,,,1427.11,Other,Drug Cost,1427.11,,,1427.11,Other,Drug Cost,1427.11,,,1427.11,Other,Drug Cost,1427.11,,,1427.11,Other,Drug Cost,1427.11,,,1427.11,Other,Drug Cost,1427.11,,,1427.11,Other,Drug Cost,3211,,,3211,Other,225% of Medicaid,1997.95,,,1997.95,Other,140% of Medicaid,1455.65,34,"If Charge > 2,000, then 34 percent",1455.65,percent of total billed charges,Drugs,463.58,,,463.58,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",3068.29,,,3068.29,Other,215% Medicaid APG methodology,3068.29,,,3068.29,Other,215% Medicaid APG methodology,1783.89,,,1783.89,Other,125% Medicaid APG methodology,0.01,3211,
IMMUNE GLOBULIN(PRIVIGEN) LIQUID 10GM,J1459,HCPCS,,80002555,CDM,636,RC,44206043710,NDC,both,1,ML,2122.65,476.46,,,476.46,Other,150% of Medicare + 9.63% HCRA Surcharge,289.74,,,289.74,Fee Schedule,Average Sale Price (ASP) x 6,742.93,35,,742.93,percent of total billed charges,Drugs,742.93,35,,742.93,percent of total billed charges,Drugs,721.7,34,,721.7,percent of total billed charges,Drugs,721.7,34,,721.7,percent of total billed charges,Drugs,721.7,34,,721.7,percent of total billed charges,Drugs,721.7,34,,721.7,percent of total billed charges,Drugs,742.93,35,,742.93,percent of total billed charges,Drugs,721.7,34,"If Charge > 500, then 34 percent",721.7,percent of total billed charges,Drugs,742.93,35,,742.93,percent of total billed charges,Drugs,742.93,35,,742.93,percent of total billed charges,Drugs,742.93,35,,742.93,percent of total billed charges,Drugs,742.93,35,,742.93,percent of total billed charges,Drugs,742.93,35,,742.93,percent of total billed charges,Drugs,849.06,40,,849.06,percent of total billed charges,Drugs,1485.86,70,,1485.86,percent of total billed charges,All Other,764.15,36,,764.15,percent of total billed charges,Drugs,764.15,36,,764.15,percent of total billed charges,Drugs,742.93,35,,742.93,percent of total billed charges,Drugs,742.93,35,,742.93,percent of total billed charges,Drugs,742.93,35,,742.93,percent of total billed charges,Drugs,742.93,35,,742.93,percent of total billed charges,Drugs,707.55,,,707.55,Other,Drug Cost,707.55,,,707.55,Other,Drug Cost,707.55,,,707.55,Other,Drug Cost,707.55,,,707.55,Other,Drug Cost,707.55,,,707.55,Other,Drug Cost,707.55,,,707.55,Other,Drug Cost,1591.99,,,1591.99,Other,225% of Medicaid,990.57,,,990.57,Other,140% of Medicaid,721.7,34,"If Charge > 2,000, then 34 percent",721.7,percent of total billed charges,Drugs,463.58,,,463.58,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",1521.23,,,1521.23,Other,215% Medicaid APG methodology,1521.23,,,1521.23,Other,215% Medicaid APG methodology,884.44,,,884.44,Other,125% Medicaid APG methodology,0.01,1591.99,
METHYLPREDNISOLONE (PF) 500MG INJ,J2930,HCPCS,,80002564,CDM,636,RC,9000302,NDC,both,1,EA,0.24,58.04,,,58.04,Other,150% of Medicare + 9.63% HCRA Surcharge,35.29,,,35.29,Fee Schedule,Average Sale Price (ASP) x 6,0.08,35,,0.08,percent of total billed charges,Drugs,0.08,35,,0.08,percent of total billed charges,Drugs,0.08,34,,0.08,percent of total billed charges,Drugs,0.08,34,,0.08,percent of total billed charges,Drugs,0.08,34,,0.08,percent of total billed charges,Drugs,0.08,34,,0.08,percent of total billed charges,Drugs,0.08,35,,0.08,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,0.08,35,,0.08,percent of total billed charges,Drugs,0.08,35,,0.08,percent of total billed charges,Drugs,0.08,35,,0.08,percent of total billed charges,Drugs,0.08,35,,0.08,percent of total billed charges,Drugs,0.08,35,,0.08,percent of total billed charges,Drugs,0.1,40,,0.1,percent of total billed charges,Drugs,0.17,70,,0.17,percent of total billed charges,All Other,0.09,36,,0.09,percent of total billed charges,Drugs,0.09,36,,0.09,percent of total billed charges,Drugs,0.08,35,,0.08,percent of total billed charges,Drugs,0.08,35,,0.08,percent of total billed charges,Drugs,0.08,35,,0.08,percent of total billed charges,Drugs,0.08,35,,0.08,percent of total billed charges,Drugs,0.08,,,0.08,Other,Drug Cost,0.08,,,0.08,Other,Drug Cost,0.08,,,0.08,Other,Drug Cost,0.08,,,0.08,Other,Drug Cost,0.08,,,0.08,Other,Drug Cost,0.08,,,0.08,Other,Drug Cost,0.18,,,0.18,Other,225% of Medicaid,0.11,,,0.11,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,56.47,,,56.47,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",0.17,,,0.17,Other,215% Medicaid APG methodology,0.17,,,0.17,Other,215% Medicaid APG methodology,0.1,,,0.1,Other,125% Medicaid APG methodology,0.01,58.04,
MORPHINE PF 4MG/ML CARP,J2270,HCPCS,,80002570,CDM,636,RC,409189101,NDC,both,10,ML,2.39,46.03,,,46.03,Other,150% of Medicare + 9.63% HCRA Surcharge,27.99,,,27.99,Fee Schedule,Average Sale Price (ASP) x 6,0.84,35,,0.84,percent of total billed charges,Drugs,0.84,35,,0.84,percent of total billed charges,Drugs,0.81,34,,0.81,percent of total billed charges,Drugs,0.81,34,,0.81,percent of total billed charges,Drugs,0.81,34,,0.81,percent of total billed charges,Drugs,0.81,34,,0.81,percent of total billed charges,Drugs,0.84,35,,0.84,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,0.84,35,,0.84,percent of total billed charges,Drugs,0.84,35,,0.84,percent of total billed charges,Drugs,0.84,35,,0.84,percent of total billed charges,Drugs,0.84,35,,0.84,percent of total billed charges,Drugs,0.84,35,,0.84,percent of total billed charges,Drugs,0.96,40,,0.96,percent of total billed charges,Drugs,1.67,70,,1.67,percent of total billed charges,All Other,0.86,36,,0.86,percent of total billed charges,Drugs,0.86,36,,0.86,percent of total billed charges,Drugs,0.84,35,,0.84,percent of total billed charges,Drugs,0.84,35,,0.84,percent of total billed charges,Drugs,0.84,35,,0.84,percent of total billed charges,Drugs,0.84,35,,0.84,percent of total billed charges,Drugs,0.8,,,0.8,Other,Drug Cost,0.8,,,0.8,Other,Drug Cost,0.8,,,0.8,Other,Drug Cost,0.8,,,0.8,Other,Drug Cost,0.8,,,0.8,Other,Drug Cost,0.8,,,0.8,Other,Drug Cost,1.79,,,1.79,Other,225% of Medicaid,1.12,,,1.12,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,44.78,,,44.78,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",1.71,,,1.71,Other,215% Medicaid APG methodology,1.71,,,1.71,Other,215% Medicaid APG methodology,1,,,1,Other,125% Medicaid APG methodology,0.01,46.03,
MORPHINE 5MG/10ML INJ,J2274,HCPCS,,80002571,CDM,636,RC,641602010,NDC,both,10,ML,2.26,110.94,,,110.94,Other,150% of Medicare + 9.63% HCRA Surcharge,67.46,,,67.46,Fee Schedule,Average Sale Price (ASP) x 6,0.79,35,,0.79,percent of total billed charges,Drugs,0.79,35,,0.79,percent of total billed charges,Drugs,0.77,34,,0.77,percent of total billed charges,Drugs,0.77,34,,0.77,percent of total billed charges,Drugs,0.77,34,,0.77,percent of total billed charges,Drugs,0.77,34,,0.77,percent of total billed charges,Drugs,0.79,35,,0.79,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,0.79,35,,0.79,percent of total billed charges,Drugs,0.79,35,,0.79,percent of total billed charges,Drugs,0.79,35,,0.79,percent of total billed charges,Drugs,0.79,35,,0.79,percent of total billed charges,Drugs,0.79,35,,0.79,percent of total billed charges,Drugs,0.9,40,,0.9,percent of total billed charges,Drugs,1.58,70,,1.58,percent of total billed charges,All Other,0.81,36,,0.81,percent of total billed charges,Drugs,0.81,36,,0.81,percent of total billed charges,Drugs,0.79,35,,0.79,percent of total billed charges,Drugs,0.79,35,,0.79,percent of total billed charges,Drugs,0.79,35,,0.79,percent of total billed charges,Drugs,0.79,35,,0.79,percent of total billed charges,Drugs,0.75,,,0.75,Other,Drug Cost,0.75,,,0.75,Other,Drug Cost,0.75,,,0.75,Other,Drug Cost,0.75,,,0.75,Other,Drug Cost,0.75,,,0.75,Other,Drug Cost,0.75,,,0.75,Other,Drug Cost,1.69,,,1.69,Other,225% of Medicaid,1.05,,,1.05,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,107.94,,,107.94,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",1.62,,,1.62,Other,215% Medicaid APG methodology,1.62,,,1.62,Other,215% Medicaid APG methodology,0.94,,,0.94,Other,125% Medicaid APG methodology,0.01,110.94,
TETANUS- DIPHTHERIA TOXOIDS FOR 7YRS &UP,90714,HCPCS,,80002599,CDM,636,RC,49281021515,NDC,both,10,ML,101.26,39.96,39.4668,,39.96,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,35.44,35,,35.44,percent of total billed charges,Drugs,35.44,35,,35.44,percent of total billed charges,Drugs,34.43,34,,34.43,percent of total billed charges,Drugs,34.43,34,,34.43,percent of total billed charges,Drugs,34.43,34,,34.43,percent of total billed charges,Drugs,34.43,34,,34.43,percent of total billed charges,Drugs,35.44,35,,35.44,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,35.44,35,,35.44,percent of total billed charges,Drugs,35.44,35,,35.44,percent of total billed charges,Drugs,35.44,35,,35.44,percent of total billed charges,Drugs,35.44,35,,35.44,percent of total billed charges,Drugs,35.44,35,,35.44,percent of total billed charges,Drugs,40.5,40,,40.5,percent of total billed charges,Drugs,70.88,70,,70.88,percent of total billed charges,All Other,36.45,36,,36.45,percent of total billed charges,Drugs,36.45,36,,36.45,percent of total billed charges,Drugs,35.44,35,,35.44,percent of total billed charges,Drugs,35.44,35,,35.44,percent of total billed charges,Drugs,35.44,35,,35.44,percent of total billed charges,Drugs,35.44,35,,35.44,percent of total billed charges,Drugs,33.75,,,33.75,Other,Drug Cost,33.75,,,33.75,Other,Drug Cost,33.75,,,33.75,Other,Drug Cost,33.75,,,33.75,Other,Drug Cost,33.75,,,33.75,Other,Drug Cost,33.75,,,33.75,Other,Drug Cost,75.94,,,75.94,Other,225% of Medicaid,47.25,,,47.25,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",72.57,,,72.57,Other,215% Medicaid APG methodology,72.57,,,72.57,Other,215% Medicaid APG methodology,42.19,,,42.19,Other,125% Medicaid APG methodology,0.01,75.94,
BUPIV LIPOSOME 266MG/20ML,C9290,HCPCS,,80002613,CDM,636,RC,65250026609,NDC,both,10,ML,823.39,324.96,39.4668,,324.96,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,288.19,35,,288.19,percent of total billed charges,Drugs,288.19,35,,288.19,percent of total billed charges,Drugs,279.95,34,,279.95,percent of total billed charges,Drugs,279.95,34,,279.95,percent of total billed charges,Drugs,279.95,34,,279.95,percent of total billed charges,Drugs,279.95,34,,279.95,percent of total billed charges,Drugs,288.19,35,,288.19,percent of total billed charges,Drugs,279.95,34,"If Charge > 500, then 34 percent",279.95,percent of total billed charges,Drugs,288.19,35,,288.19,percent of total billed charges,Drugs,288.19,35,,288.19,percent of total billed charges,Drugs,288.19,35,,288.19,percent of total billed charges,Drugs,288.19,35,,288.19,percent of total billed charges,Drugs,288.19,35,,288.19,percent of total billed charges,Drugs,329.35,40,,329.35,percent of total billed charges,Drugs,576.37,70,,576.37,percent of total billed charges,All Other,296.42,36,,296.42,percent of total billed charges,Drugs,296.42,36,,296.42,percent of total billed charges,Drugs,288.19,35,,288.19,percent of total billed charges,Drugs,288.19,35,,288.19,percent of total billed charges,Drugs,288.19,35,,288.19,percent of total billed charges,Drugs,288.19,35,,288.19,percent of total billed charges,Drugs,274.46,,,274.46,Other,Drug Cost,274.46,,,274.46,Other,Drug Cost,274.46,,,274.46,Other,Drug Cost,274.46,,,274.46,Other,Drug Cost,274.46,,,274.46,Other,Drug Cost,274.46,,,274.46,Other,Drug Cost,617.54,,,617.54,Other,225% of Medicaid,384.25,,,384.25,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",590.09,,,590.09,Other,215% Medicaid APG methodology,590.09,,,590.09,Other,215% Medicaid APG methodology,343.08,,,343.08,Other,125% Medicaid APG methodology,0.01,617.54,
PERTUZUMAB 30MG/ML 14ML,J9306,HCPCS,,80002619,CDM,636,RC,50242014501,NDC,both,1,ML,11848.02,152.21,,,152.21,Other,150% of Medicare + 9.63% HCRA Surcharge,92.56,,,92.56,Fee Schedule,Average Sale Price (ASP) x 6,4146.81,35,,4146.81,percent of total billed charges,Drugs,4146.81,35,,4146.81,percent of total billed charges,Drugs,4028.33,34,,4028.33,percent of total billed charges,Drugs,4028.33,34,,4028.33,percent of total billed charges,Drugs,4028.33,34,,4028.33,percent of total billed charges,Drugs,4028.33,34,,4028.33,percent of total billed charges,Drugs,4146.81,35,,4146.81,percent of total billed charges,Drugs,4028.33,34,"If Charge > 500, then 34 percent",4028.33,percent of total billed charges,Drugs,4146.81,35,,4146.81,percent of total billed charges,Drugs,4146.81,35,,4146.81,percent of total billed charges,Drugs,4146.81,35,,4146.81,percent of total billed charges,Drugs,4146.81,35,,4146.81,percent of total billed charges,Drugs,4146.81,35,,4146.81,percent of total billed charges,Drugs,4739.21,40,,4739.21,percent of total billed charges,Drugs,8293.61,70,,8293.61,percent of total billed charges,All Other,4265.29,36,,4265.29,percent of total billed charges,Drugs,4265.29,36,,4265.29,percent of total billed charges,Drugs,4146.81,35,,4146.81,percent of total billed charges,Drugs,4146.81,35,,4146.81,percent of total billed charges,Drugs,4146.81,35,,4146.81,percent of total billed charges,Drugs,4146.81,35,,4146.81,percent of total billed charges,Drugs,3949.34,,,3949.34,Other,Drug Cost,3949.34,,,3949.34,Other,Drug Cost,3949.34,,,3949.34,Other,Drug Cost,3949.34,,,3949.34,Other,Drug Cost,3949.34,,,3949.34,Other,Drug Cost,3949.34,,,3949.34,Other,Drug Cost,8886.02,,,8886.02,Other,225% of Medicaid,5529.08,,,5529.08,Other,140% of Medicaid,4028.33,34,"If Charge > 2,000, then 34 percent",4028.33,percent of total billed charges,Drugs,148.1,,,148.1,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",8491.08,,,8491.08,Other,215% Medicaid APG methodology,8491.08,,,8491.08,Other,215% Medicaid APG methodology,4936.68,,,4936.68,Other,125% Medicaid APG methodology,0.01,8886.02,
GOSERELIN ACETATE 3.6MG IMPLANT,J9202,HCPCS,,80002623,CDM,636,RC,70720095036,NDC,both,1,EA,2243.82,6008.91,,,6008.91,Other,150% of Medicare + 9.63% HCRA Surcharge,3654.05,,,3654.05,Fee Schedule,Average Sale Price (ASP) x 6,785.34,35,,785.34,percent of total billed charges,Drugs,785.34,35,,785.34,percent of total billed charges,Drugs,762.9,34,,762.9,percent of total billed charges,Drugs,762.9,34,,762.9,percent of total billed charges,Drugs,762.9,34,,762.9,percent of total billed charges,Drugs,762.9,34,,762.9,percent of total billed charges,Drugs,785.34,35,,785.34,percent of total billed charges,Drugs,762.9,34,"If Charge > 500, then 34 percent",762.9,percent of total billed charges,Drugs,785.34,35,,785.34,percent of total billed charges,Drugs,785.34,35,,785.34,percent of total billed charges,Drugs,785.34,35,,785.34,percent of total billed charges,Drugs,785.34,35,,785.34,percent of total billed charges,Drugs,785.34,35,,785.34,percent of total billed charges,Drugs,897.53,40,,897.53,percent of total billed charges,Drugs,1570.67,70,,1570.67,percent of total billed charges,All Other,807.78,36,,807.78,percent of total billed charges,Drugs,807.78,36,,807.78,percent of total billed charges,Drugs,785.34,35,,785.34,percent of total billed charges,Drugs,785.34,35,,785.34,percent of total billed charges,Drugs,785.34,35,,785.34,percent of total billed charges,Drugs,785.34,35,,785.34,percent of total billed charges,Drugs,747.94,,,747.94,Other,Drug Cost,747.94,,,747.94,Other,Drug Cost,747.94,,,747.94,Other,Drug Cost,747.94,,,747.94,Other,Drug Cost,747.94,,,747.94,Other,Drug Cost,747.94,,,747.94,Other,Drug Cost,1682.87,,,1682.87,Other,225% of Medicaid,1047.12,,,1047.12,Other,140% of Medicaid,762.9,34,"If Charge > 2,000, then 34 percent",762.9,percent of total billed charges,Drugs,5846.49,,,5846.49,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",1608.07,,,1608.07,Other,215% Medicaid APG methodology,1608.07,,,1608.07,Other,215% Medicaid APG methodology,934.93,,,934.93,Other,125% Medicaid APG methodology,0.01,6008.91,
IOTHALAMATE MEGLUMINE 60% 50ML,Q9961,HCPCS,,80002632,CDM,636,RC,19095305,NDC,both,25,ML,35.05,2.72,,,2.72,Other,150% of Medicare + 9.63% HCRA Surcharge,1.66,,,1.66,Fee Schedule,Average Sale Price (ASP) x 6,12.27,35,,12.27,percent of total billed charges,Drugs,12.27,35,,12.27,percent of total billed charges,Drugs,11.92,34,,11.92,percent of total billed charges,Drugs,11.92,34,,11.92,percent of total billed charges,Drugs,11.92,34,,11.92,percent of total billed charges,Drugs,11.92,34,,11.92,percent of total billed charges,Drugs,12.27,35,,12.27,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,12.27,35,,12.27,percent of total billed charges,Drugs,12.27,35,,12.27,percent of total billed charges,Drugs,12.27,35,,12.27,percent of total billed charges,Drugs,12.27,35,,12.27,percent of total billed charges,Drugs,12.27,35,,12.27,percent of total billed charges,Drugs,14.02,40,,14.02,percent of total billed charges,Drugs,24.53,70,,24.53,percent of total billed charges,All Other,12.62,36,,12.62,percent of total billed charges,Drugs,12.62,36,,12.62,percent of total billed charges,Drugs,12.27,35,,12.27,percent of total billed charges,Drugs,12.27,35,,12.27,percent of total billed charges,Drugs,12.27,35,,12.27,percent of total billed charges,Drugs,12.27,35,,12.27,percent of total billed charges,Drugs,11.68,,,11.68,Other,Drug Cost,11.68,,,11.68,Other,Drug Cost,11.68,,,11.68,Other,Drug Cost,11.68,,,11.68,Other,Drug Cost,11.68,,,11.68,Other,Drug Cost,11.68,,,11.68,Other,Drug Cost,26.29,,,26.29,Other,225% of Medicaid,16.36,,,16.36,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,2.65,,,2.65,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",25.12,,,25.12,Other,215% Medicaid APG methodology,25.12,,,25.12,Other,215% Medicaid APG methodology,14.6,,,14.6,Other,125% Medicaid APG methodology,0.01,26.29,
PREDNISOLONE 15MG 5ML SYRUP,J7510,HCPCS,,80002635,CDM,636,RC,121075908,NDC,both,1,ML,8.04,4.13,,,4.13,Other,150% of Medicare + 9.63% HCRA Surcharge,2.51,,,2.51,Fee Schedule,Average Sale Price (ASP) x 6,2.81,35,,2.81,percent of total billed charges,Drugs,2.81,35,,2.81,percent of total billed charges,Drugs,2.73,34,,2.73,percent of total billed charges,Drugs,2.73,34,,2.73,percent of total billed charges,Drugs,2.73,34,,2.73,percent of total billed charges,Drugs,2.73,34,,2.73,percent of total billed charges,Drugs,2.81,35,,2.81,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,2.81,35,,2.81,percent of total billed charges,Drugs,2.81,35,,2.81,percent of total billed charges,Drugs,2.81,35,,2.81,percent of total billed charges,Drugs,2.81,35,,2.81,percent of total billed charges,Drugs,2.81,35,,2.81,percent of total billed charges,Drugs,3.22,40,,3.22,percent of total billed charges,Drugs,5.63,70,,5.63,percent of total billed charges,All Other,2.89,36,,2.89,percent of total billed charges,Drugs,2.89,36,,2.89,percent of total billed charges,Drugs,2.81,35,,2.81,percent of total billed charges,Drugs,2.81,35,,2.81,percent of total billed charges,Drugs,2.81,35,,2.81,percent of total billed charges,Drugs,2.81,35,,2.81,percent of total billed charges,Drugs,2.68,,,2.68,Other,Drug Cost,2.68,,,2.68,Other,Drug Cost,2.68,,,2.68,Other,Drug Cost,2.68,,,2.68,Other,Drug Cost,2.68,,,2.68,Other,Drug Cost,2.68,,,2.68,Other,Drug Cost,6.03,,,6.03,Other,225% of Medicaid,3.75,,,3.75,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,4.02,,,4.02,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",5.76,,,5.76,Other,215% Medicaid APG methodology,5.76,,,5.76,Other,215% Medicaid APG methodology,3.35,,,3.35,Other,125% Medicaid APG methodology,0.01,6.03,
ALBUMIN 5% 500ML,P9045,HCPCS,,80002639,CDM,636,RC,68516521402,NDC,both,1,ML,165.69,523.69,,,523.69,Other,150% of Medicare + 9.63% HCRA Surcharge,318.46,,,318.46,Fee Schedule,Average Sale Price (ASP) x 6,57.99,35,,57.99,percent of total billed charges,Drugs,57.99,35,,57.99,percent of total billed charges,Drugs,56.33,34,,56.33,percent of total billed charges,Drugs,56.33,34,,56.33,percent of total billed charges,Drugs,56.33,34,,56.33,percent of total billed charges,Drugs,56.33,34,,56.33,percent of total billed charges,Drugs,57.99,35,,57.99,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,57.99,35,,57.99,percent of total billed charges,Drugs,57.99,35,,57.99,percent of total billed charges,Drugs,57.99,35,,57.99,percent of total billed charges,Drugs,57.99,35,,57.99,percent of total billed charges,Drugs,57.99,35,,57.99,percent of total billed charges,Drugs,66.28,40,,66.28,percent of total billed charges,Drugs,115.98,70,,115.98,percent of total billed charges,All Other,59.65,36,,59.65,percent of total billed charges,Drugs,59.65,36,,59.65,percent of total billed charges,Drugs,57.99,35,,57.99,percent of total billed charges,Drugs,57.99,35,,57.99,percent of total billed charges,Drugs,57.99,35,,57.99,percent of total billed charges,Drugs,57.99,35,,57.99,percent of total billed charges,Drugs,55.23,,,55.23,Other,Drug Cost,55.23,,,55.23,Other,Drug Cost,55.23,,,55.23,Other,Drug Cost,55.23,,,55.23,Other,Drug Cost,55.23,,,55.23,Other,Drug Cost,55.23,,,55.23,Other,Drug Cost,124.27,,,124.27,Other,225% of Medicaid,77.32,,,77.32,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,509.54,,,509.54,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",118.74,,,118.74,Other,215% Medicaid APG methodology,118.74,,,118.74,Other,215% Medicaid APG methodology,69.04,,,69.04,Other,125% Medicaid APG methodology,0.01,523.69,
AMINOPHYLLINE 250MG 10ML VIAL,J0280,HCPCS,,80002640,CDM,636,RC,409592101,NDC,both,25,ML,7.8,50.64,,,50.64,Other,150% of Medicare + 9.63% HCRA Surcharge,30.79,,,30.79,Fee Schedule,Average Sale Price (ASP) x 6,2.73,35,,2.73,percent of total billed charges,Drugs,2.73,35,,2.73,percent of total billed charges,Drugs,2.65,34,,2.65,percent of total billed charges,Drugs,2.65,34,,2.65,percent of total billed charges,Drugs,2.65,34,,2.65,percent of total billed charges,Drugs,2.65,34,,2.65,percent of total billed charges,Drugs,2.73,35,,2.73,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,2.73,35,,2.73,percent of total billed charges,Drugs,2.73,35,,2.73,percent of total billed charges,Drugs,2.73,35,,2.73,percent of total billed charges,Drugs,2.73,35,,2.73,percent of total billed charges,Drugs,2.73,35,,2.73,percent of total billed charges,Drugs,3.12,40,,3.12,percent of total billed charges,Drugs,5.46,70,,5.46,percent of total billed charges,All Other,2.81,36,,2.81,percent of total billed charges,Drugs,2.81,36,,2.81,percent of total billed charges,Drugs,2.73,35,,2.73,percent of total billed charges,Drugs,2.73,35,,2.73,percent of total billed charges,Drugs,2.73,35,,2.73,percent of total billed charges,Drugs,2.73,35,,2.73,percent of total billed charges,Drugs,2.6,,,2.6,Other,Drug Cost,2.6,,,2.6,Other,Drug Cost,2.6,,,2.6,Other,Drug Cost,2.6,,,2.6,Other,Drug Cost,2.6,,,2.6,Other,Drug Cost,2.6,,,2.6,Other,Drug Cost,5.85,,,5.85,Other,225% of Medicaid,3.64,,,3.64,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,49.27,,,49.27,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",5.59,,,5.59,Other,215% Medicaid APG methodology,5.59,,,5.59,Other,215% Medicaid APG methodology,3.25,,,3.25,Other,125% Medicaid APG methodology,0.01,50.64,
RECLAST 5MG/100ML,J3489,HCPCS,,80002648,CDM,636,RC,25021083082,NDC,both,1,ML,38.46,71.17,,,71.17,Other,150% of Medicare + 9.63% HCRA Surcharge,43.28,,,43.28,Fee Schedule,Average Sale Price (ASP) x 6,13.46,35,,13.46,percent of total billed charges,Drugs,13.46,35,,13.46,percent of total billed charges,Drugs,13.08,34,,13.08,percent of total billed charges,Drugs,13.08,34,,13.08,percent of total billed charges,Drugs,13.08,34,,13.08,percent of total billed charges,Drugs,13.08,34,,13.08,percent of total billed charges,Drugs,13.46,35,,13.46,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,13.46,35,,13.46,percent of total billed charges,Drugs,13.46,35,,13.46,percent of total billed charges,Drugs,13.46,35,,13.46,percent of total billed charges,Drugs,13.46,35,,13.46,percent of total billed charges,Drugs,13.46,35,,13.46,percent of total billed charges,Drugs,15.38,40,,15.38,percent of total billed charges,Drugs,26.92,70,,26.92,percent of total billed charges,All Other,13.85,36,,13.85,percent of total billed charges,Drugs,13.85,36,,13.85,percent of total billed charges,Drugs,13.46,35,,13.46,percent of total billed charges,Drugs,13.46,35,,13.46,percent of total billed charges,Drugs,13.46,35,,13.46,percent of total billed charges,Drugs,13.46,35,,13.46,percent of total billed charges,Drugs,12.82,,,12.82,Other,Drug Cost,12.82,,,12.82,Other,Drug Cost,12.82,,,12.82,Other,Drug Cost,12.82,,,12.82,Other,Drug Cost,12.82,,,12.82,Other,Drug Cost,12.82,,,12.82,Other,Drug Cost,28.85,,,28.85,Other,225% of Medicaid,17.95,,,17.95,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,69.24,,,69.24,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",27.56,,,27.56,Other,215% Medicaid APG methodology,27.56,,,27.56,Other,215% Medicaid APG methodology,16.03,,,16.03,Other,125% Medicaid APG methodology,0.01,71.17,
RISPERIDONE LG ACTING 12.5MG/2ML INJ,J2794,HCPCS,,80002659,CDM,636,RC,50458030911,NDC,both,1,EA,283.29,119.89,,,119.89,Other,150% of Medicare + 9.63% HCRA Surcharge,72.91,,,72.91,Fee Schedule,Average Sale Price (ASP) x 6,99.15,35,,99.15,percent of total billed charges,Drugs,99.15,35,,99.15,percent of total billed charges,Drugs,96.32,34,,96.32,percent of total billed charges,Drugs,96.32,34,,96.32,percent of total billed charges,Drugs,96.32,34,,96.32,percent of total billed charges,Drugs,96.32,34,,96.32,percent of total billed charges,Drugs,99.15,35,,99.15,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,99.15,35,,99.15,percent of total billed charges,Drugs,99.15,35,,99.15,percent of total billed charges,Drugs,99.15,35,,99.15,percent of total billed charges,Drugs,99.15,35,,99.15,percent of total billed charges,Drugs,99.15,35,,99.15,percent of total billed charges,Drugs,113.32,40,,113.32,percent of total billed charges,Drugs,198.3,70,,198.3,percent of total billed charges,All Other,101.98,36,,101.98,percent of total billed charges,Drugs,101.98,36,,101.98,percent of total billed charges,Drugs,99.15,35,,99.15,percent of total billed charges,Drugs,99.15,35,,99.15,percent of total billed charges,Drugs,99.15,35,,99.15,percent of total billed charges,Drugs,99.15,35,,99.15,percent of total billed charges,Drugs,94.43,,,94.43,Other,Drug Cost,94.43,,,94.43,Other,Drug Cost,94.43,,,94.43,Other,Drug Cost,94.43,,,94.43,Other,Drug Cost,94.43,,,94.43,Other,Drug Cost,94.43,,,94.43,Other,Drug Cost,212.47,,,212.47,Other,225% of Medicaid,132.2,,,132.2,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,116.65,,,116.65,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",203.02,,,203.02,Other,215% Medicaid APG methodology,203.02,,,203.02,Other,215% Medicaid APG methodology,118.04,,,118.04,Other,125% Medicaid APG methodology,0.01,212.47,
FOSAPREPITANT 150MG INJ,J1453,HCPCS,,80002661,CDM,636,RC,72205005401,NDC,both,1,EA,22.02,1.36,,,1.36,Other,150% of Medicare + 9.63% HCRA Surcharge,0.83,,,0.83,Fee Schedule,Average Sale Price (ASP) x 6,7.71,35,,7.71,percent of total billed charges,Drugs,7.71,35,,7.71,percent of total billed charges,Drugs,7.49,34,,7.49,percent of total billed charges,Drugs,7.49,34,,7.49,percent of total billed charges,Drugs,7.49,34,,7.49,percent of total billed charges,Drugs,7.49,34,,7.49,percent of total billed charges,Drugs,7.71,35,,7.71,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,7.71,35,,7.71,percent of total billed charges,Drugs,7.71,35,,7.71,percent of total billed charges,Drugs,7.71,35,,7.71,percent of total billed charges,Drugs,7.71,35,,7.71,percent of total billed charges,Drugs,7.71,35,,7.71,percent of total billed charges,Drugs,8.81,40,,8.81,percent of total billed charges,Drugs,15.41,70,,15.41,percent of total billed charges,All Other,7.93,36,,7.93,percent of total billed charges,Drugs,7.93,36,,7.93,percent of total billed charges,Drugs,7.71,35,,7.71,percent of total billed charges,Drugs,7.71,35,,7.71,percent of total billed charges,Drugs,7.71,35,,7.71,percent of total billed charges,Drugs,7.71,35,,7.71,percent of total billed charges,Drugs,7.34,,,7.34,Other,Drug Cost,7.34,,,7.34,Other,Drug Cost,7.34,,,7.34,Other,Drug Cost,7.34,,,7.34,Other,Drug Cost,7.34,,,7.34,Other,Drug Cost,7.34,,,7.34,Other,Drug Cost,16.52,,,16.52,Other,225% of Medicaid,10.28,,,10.28,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,1.33,,,1.33,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",15.78,,,15.78,Other,215% Medicaid APG methodology,15.78,,,15.78,Other,215% Medicaid APG methodology,9.18,,,9.18,Other,125% Medicaid APG methodology,0.01,16.52,
FLU VAC NO PRSV 4 VAL 6 MOS+,90686,HCPCS,,80002671,CDM,636,RC,49281042350,NDC,both,10,ML,58.67,23.15,39.4668,,23.15,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,20.53,35,,20.53,percent of total billed charges,Drugs,20.53,35,,20.53,percent of total billed charges,Drugs,19.95,34,,19.95,percent of total billed charges,Drugs,19.95,34,,19.95,percent of total billed charges,Drugs,19.95,34,,19.95,percent of total billed charges,Drugs,19.95,34,,19.95,percent of total billed charges,Drugs,20.53,35,,20.53,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,20.53,35,,20.53,percent of total billed charges,Drugs,20.53,35,,20.53,percent of total billed charges,Drugs,20.53,35,,20.53,percent of total billed charges,Drugs,20.53,35,,20.53,percent of total billed charges,Drugs,20.53,35,,20.53,percent of total billed charges,Drugs,23.47,40,,23.47,percent of total billed charges,Drugs,41.07,70,,41.07,percent of total billed charges,All Other,21.12,36,,21.12,percent of total billed charges,Drugs,21.12,36,,21.12,percent of total billed charges,Drugs,20.53,35,,20.53,percent of total billed charges,Drugs,20.53,35,,20.53,percent of total billed charges,Drugs,20.53,35,,20.53,percent of total billed charges,Drugs,20.53,35,,20.53,percent of total billed charges,Drugs,19.56,,,19.56,Other,Drug Cost,19.56,,,19.56,Other,Drug Cost,19.56,,,19.56,Other,Drug Cost,19.56,,,19.56,Other,Drug Cost,19.56,,,19.56,Other,Drug Cost,19.56,,,19.56,Other,Drug Cost,44,,,44,Other,225% of Medicaid,27.38,,,27.38,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",42.05,,,42.05,Other,215% Medicaid APG methodology,42.05,,,42.05,Other,215% Medicaid APG methodology,24.45,,,24.45,Other,125% Medicaid APG methodology,0.01,44,
ANTIHEMOPHILIC FACTOR 1974 IU,J7187,HCPCS,,80002678,CDM,636,RC,63833061702,NDC,both,1,EA,4275.18,13.3,,,13.3,Other,150% of Medicare + 9.63% HCRA Surcharge,8.09,,,8.09,Fee Schedule,Average Sale Price (ASP) x 6,1496.31,35,,1496.31,percent of total billed charges,Drugs,1496.31,35,,1496.31,percent of total billed charges,Drugs,1453.56,34,,1453.56,percent of total billed charges,Drugs,1453.56,34,,1453.56,percent of total billed charges,Drugs,1453.56,34,,1453.56,percent of total billed charges,Drugs,1453.56,34,,1453.56,percent of total billed charges,Drugs,1496.31,35,,1496.31,percent of total billed charges,Drugs,1453.56,34,"If Charge > 500, then 34 percent",1453.56,percent of total billed charges,Drugs,1496.31,35,,1496.31,percent of total billed charges,Drugs,1496.31,35,,1496.31,percent of total billed charges,Drugs,1496.31,35,,1496.31,percent of total billed charges,Drugs,1496.31,35,,1496.31,percent of total billed charges,Drugs,1496.31,35,,1496.31,percent of total billed charges,Drugs,1710.07,40,,1710.07,percent of total billed charges,Drugs,2992.63,70,,2992.63,percent of total billed charges,All Other,1539.06,36,,1539.06,percent of total billed charges,Drugs,1539.06,36,,1539.06,percent of total billed charges,Drugs,1496.31,35,,1496.31,percent of total billed charges,Drugs,1496.31,35,,1496.31,percent of total billed charges,Drugs,1496.31,35,,1496.31,percent of total billed charges,Drugs,1496.31,35,,1496.31,percent of total billed charges,Drugs,1425.06,,,1425.06,Other,Drug Cost,1425.06,,,1425.06,Other,Drug Cost,1425.06,,,1425.06,Other,Drug Cost,1425.06,,,1425.06,Other,Drug Cost,1425.06,,,1425.06,Other,Drug Cost,1425.06,,,1425.06,Other,Drug Cost,3206.39,,,3206.39,Other,225% of Medicaid,1995.08,,,1995.08,Other,140% of Medicaid,1453.56,34,"If Charge > 2,000, then 34 percent",1453.56,percent of total billed charges,Drugs,12.94,,,12.94,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",3063.88,,,3063.88,Other,215% Medicaid APG methodology,3063.88,,,3063.88,Other,215% Medicaid APG methodology,1781.33,,,1781.33,Other,125% Medicaid APG methodology,0.01,3206.39,
ANTIHEMOPHILIC FACTOR 492 IU,J7187,HCPCS,,80002679,CDM,636,RC,63833061502,NDC,both,1,EA,1124.91,13.3,,,13.3,Other,150% of Medicare + 9.63% HCRA Surcharge,8.09,,,8.09,Fee Schedule,Average Sale Price (ASP) x 6,393.72,35,,393.72,percent of total billed charges,Drugs,393.72,35,,393.72,percent of total billed charges,Drugs,382.47,34,,382.47,percent of total billed charges,Drugs,382.47,34,,382.47,percent of total billed charges,Drugs,382.47,34,,382.47,percent of total billed charges,Drugs,382.47,34,,382.47,percent of total billed charges,Drugs,393.72,35,,393.72,percent of total billed charges,Drugs,382.47,34,"If Charge > 500, then 34 percent",382.47,percent of total billed charges,Drugs,393.72,35,,393.72,percent of total billed charges,Drugs,393.72,35,,393.72,percent of total billed charges,Drugs,393.72,35,,393.72,percent of total billed charges,Drugs,393.72,35,,393.72,percent of total billed charges,Drugs,393.72,35,,393.72,percent of total billed charges,Drugs,449.96,40,,449.96,percent of total billed charges,Drugs,787.44,70,,787.44,percent of total billed charges,All Other,404.97,36,,404.97,percent of total billed charges,Drugs,404.97,36,,404.97,percent of total billed charges,Drugs,393.72,35,,393.72,percent of total billed charges,Drugs,393.72,35,,393.72,percent of total billed charges,Drugs,393.72,35,,393.72,percent of total billed charges,Drugs,393.72,35,,393.72,percent of total billed charges,Drugs,374.97,,,374.97,Other,Drug Cost,374.97,,,374.97,Other,Drug Cost,374.97,,,374.97,Other,Drug Cost,374.97,,,374.97,Other,Drug Cost,374.97,,,374.97,Other,Drug Cost,374.97,,,374.97,Other,Drug Cost,843.68,,,843.68,Other,225% of Medicaid,524.96,,,524.96,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,12.94,,,12.94,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",806.19,,,806.19,Other,215% Medicaid APG methodology,806.19,,,806.19,Other,215% Medicaid APG methodology,468.71,,,468.71,Other,125% Medicaid APG methodology,0.01,843.68,
VORICONAZOLE 200MG INJ,J3465,HCPCS,,80002684,CDM,636,RC,49319028,NDC,both,1,EA,9.12,11.43,,,11.43,Other,150% of Medicare + 9.63% HCRA Surcharge,6.95,,,6.95,Fee Schedule,Average Sale Price (ASP) x 6,3.19,35,,3.19,percent of total billed charges,Drugs,3.19,35,,3.19,percent of total billed charges,Drugs,3.1,34,,3.1,percent of total billed charges,Drugs,3.1,34,,3.1,percent of total billed charges,Drugs,3.1,34,,3.1,percent of total billed charges,Drugs,3.1,34,,3.1,percent of total billed charges,Drugs,3.19,35,,3.19,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,3.19,35,,3.19,percent of total billed charges,Drugs,3.19,35,,3.19,percent of total billed charges,Drugs,3.19,35,,3.19,percent of total billed charges,Drugs,3.19,35,,3.19,percent of total billed charges,Drugs,3.19,35,,3.19,percent of total billed charges,Drugs,3.65,40,,3.65,percent of total billed charges,Drugs,6.38,70,,6.38,percent of total billed charges,All Other,3.28,36,,3.28,percent of total billed charges,Drugs,3.28,36,,3.28,percent of total billed charges,Drugs,3.19,35,,3.19,percent of total billed charges,Drugs,3.19,35,,3.19,percent of total billed charges,Drugs,3.19,35,,3.19,percent of total billed charges,Drugs,3.19,35,,3.19,percent of total billed charges,Drugs,3.04,,,3.04,Other,Drug Cost,3.04,,,3.04,Other,Drug Cost,3.04,,,3.04,Other,Drug Cost,3.04,,,3.04,Other,Drug Cost,3.04,,,3.04,Other,Drug Cost,3.04,,,3.04,Other,Drug Cost,6.84,,,6.84,Other,225% of Medicaid,4.26,,,4.26,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,11.12,,,11.12,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",6.54,,,6.54,Other,215% Medicaid APG methodology,6.54,,,6.54,Other,215% Medicaid APG methodology,3.8,,,3.8,Other,125% Medicaid APG methodology,0.01,11.43,
BCG LIVE INTRAVESICAL INSTILLATION 1MG,J9030,HCPCS,,80002694,CDM,636,RC,52060202,NDC,both,1,EA,343.98,28.51,,,28.51,Other,150% of Medicare + 9.63% HCRA Surcharge,17.34,,,17.34,Fee Schedule,Average Sale Price (ASP) x 6,120.39,35,,120.39,percent of total billed charges,Drugs,120.39,35,,120.39,percent of total billed charges,Drugs,116.95,34,,116.95,percent of total billed charges,Drugs,116.95,34,,116.95,percent of total billed charges,Drugs,116.95,34,,116.95,percent of total billed charges,Drugs,116.95,34,,116.95,percent of total billed charges,Drugs,120.39,35,,120.39,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,120.39,35,,120.39,percent of total billed charges,Drugs,120.39,35,,120.39,percent of total billed charges,Drugs,120.39,35,,120.39,percent of total billed charges,Drugs,120.39,35,,120.39,percent of total billed charges,Drugs,120.39,35,,120.39,percent of total billed charges,Drugs,137.59,40,,137.59,percent of total billed charges,Drugs,240.79,70,,240.79,percent of total billed charges,All Other,123.83,36,,123.83,percent of total billed charges,Drugs,123.83,36,,123.83,percent of total billed charges,Drugs,120.39,35,,120.39,percent of total billed charges,Drugs,120.39,35,,120.39,percent of total billed charges,Drugs,120.39,35,,120.39,percent of total billed charges,Drugs,120.39,35,,120.39,percent of total billed charges,Drugs,114.66,,,114.66,Other,Drug Cost,114.66,,,114.66,Other,Drug Cost,114.66,,,114.66,Other,Drug Cost,114.66,,,114.66,Other,Drug Cost,114.66,,,114.66,Other,Drug Cost,114.66,,,114.66,Other,Drug Cost,257.99,,,257.99,Other,225% of Medicaid,160.52,,,160.52,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,27.74,,,27.74,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",246.52,,,246.52,Other,215% Medicaid APG methodology,246.52,,,246.52,Other,215% Medicaid APG methodology,143.33,,,143.33,Other,125% Medicaid APG methodology,0.01,257.99,
TBO-FILGRASTIM 300MCG INJ,J1447,HCPCS,,80002702,CDM,636,RC,63459091015,NDC,both,10,ML,163.31,4.33,,,4.33,Other,150% of Medicare + 9.63% HCRA Surcharge,2.63,,,2.63,Fee Schedule,Average Sale Price (ASP) x 6,57.16,35,,57.16,percent of total billed charges,Drugs,57.16,35,,57.16,percent of total billed charges,Drugs,55.52,34,,55.52,percent of total billed charges,Drugs,55.52,34,,55.52,percent of total billed charges,Drugs,55.52,34,,55.52,percent of total billed charges,Drugs,55.52,34,,55.52,percent of total billed charges,Drugs,57.16,35,,57.16,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,57.16,35,,57.16,percent of total billed charges,Drugs,57.16,35,,57.16,percent of total billed charges,Drugs,57.16,35,,57.16,percent of total billed charges,Drugs,57.16,35,,57.16,percent of total billed charges,Drugs,57.16,35,,57.16,percent of total billed charges,Drugs,65.32,40,,65.32,percent of total billed charges,Drugs,114.31,70,,114.31,percent of total billed charges,All Other,58.79,36,,58.79,percent of total billed charges,Drugs,58.79,36,,58.79,percent of total billed charges,Drugs,57.16,35,,57.16,percent of total billed charges,Drugs,57.16,35,,57.16,percent of total billed charges,Drugs,57.16,35,,57.16,percent of total billed charges,Drugs,57.16,35,,57.16,percent of total billed charges,Drugs,54.44,,,54.44,Other,Drug Cost,54.44,,,54.44,Other,Drug Cost,54.44,,,54.44,Other,Drug Cost,54.44,,,54.44,Other,Drug Cost,54.44,,,54.44,Other,Drug Cost,54.44,,,54.44,Other,Drug Cost,122.48,,,122.48,Other,225% of Medicaid,76.21,,,76.21,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,4.21,,,4.21,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",117.04,,,117.04,Other,215% Medicaid APG methodology,117.04,,,117.04,Other,215% Medicaid APG methodology,68.04,,,68.04,Other,125% Medicaid APG methodology,0.01,122.48,
TBO-FILGRASTIM 480MCG INJ,J1447,HCPCS,,80002703,CDM,636,RC,63459091211,NDC,both,1,ML,259.59,4.33,,,4.33,Other,150% of Medicare + 9.63% HCRA Surcharge,2.63,,,2.63,Fee Schedule,Average Sale Price (ASP) x 6,90.86,35,,90.86,percent of total billed charges,Drugs,90.86,35,,90.86,percent of total billed charges,Drugs,88.26,34,,88.26,percent of total billed charges,Drugs,88.26,34,,88.26,percent of total billed charges,Drugs,88.26,34,,88.26,percent of total billed charges,Drugs,88.26,34,,88.26,percent of total billed charges,Drugs,90.86,35,,90.86,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,90.86,35,,90.86,percent of total billed charges,Drugs,90.86,35,,90.86,percent of total billed charges,Drugs,90.86,35,,90.86,percent of total billed charges,Drugs,90.86,35,,90.86,percent of total billed charges,Drugs,90.86,35,,90.86,percent of total billed charges,Drugs,103.84,40,,103.84,percent of total billed charges,Drugs,181.71,70,,181.71,percent of total billed charges,All Other,93.45,36,,93.45,percent of total billed charges,Drugs,93.45,36,,93.45,percent of total billed charges,Drugs,90.86,35,,90.86,percent of total billed charges,Drugs,90.86,35,,90.86,percent of total billed charges,Drugs,90.86,35,,90.86,percent of total billed charges,Drugs,90.86,35,,90.86,percent of total billed charges,Drugs,86.53,,,86.53,Other,Drug Cost,86.53,,,86.53,Other,Drug Cost,86.53,,,86.53,Other,Drug Cost,86.53,,,86.53,Other,Drug Cost,86.53,,,86.53,Other,Drug Cost,86.53,,,86.53,Other,Drug Cost,194.69,,,194.69,Other,225% of Medicaid,121.14,,,121.14,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,4.21,,,4.21,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",186.04,,,186.04,Other,215% Medicaid APG methodology,186.04,,,186.04,Other,215% Medicaid APG methodology,108.16,,,108.16,Other,125% Medicaid APG methodology,0.01,194.69,
D5W/ NS 1000ML,J7042,HCPCS,,80002727,CDM,636,RC,264761000,NDC,both,1000,ML,2.64,15.66,,,15.66,Other,150% of Medicare + 9.63% HCRA Surcharge,9.52,,,9.52,Fee Schedule,Average Sale Price (ASP) x 6,0.92,35,,0.92,percent of total billed charges,Drugs,0.92,35,,0.92,percent of total billed charges,Drugs,0.9,34,,0.9,percent of total billed charges,Drugs,0.9,34,,0.9,percent of total billed charges,Drugs,0.9,34,,0.9,percent of total billed charges,Drugs,0.9,34,,0.9,percent of total billed charges,Drugs,0.92,35,,0.92,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,0.92,35,,0.92,percent of total billed charges,Drugs,0.92,35,,0.92,percent of total billed charges,Drugs,0.92,35,,0.92,percent of total billed charges,Drugs,0.92,35,,0.92,percent of total billed charges,Drugs,0.92,35,,0.92,percent of total billed charges,Drugs,1.06,40,,1.06,percent of total billed charges,Drugs,1.85,70,,1.85,percent of total billed charges,All Other,0.95,36,,0.95,percent of total billed charges,Drugs,0.95,36,,0.95,percent of total billed charges,Drugs,0.92,35,,0.92,percent of total billed charges,Drugs,0.92,35,,0.92,percent of total billed charges,Drugs,0.92,35,,0.92,percent of total billed charges,Drugs,0.92,35,,0.92,percent of total billed charges,Drugs,0.88,,,0.88,Other,Drug Cost,0.88,,,0.88,Other,Drug Cost,0.88,,,0.88,Other,Drug Cost,0.88,,,0.88,Other,Drug Cost,0.88,,,0.88,Other,Drug Cost,0.88,,,0.88,Other,Drug Cost,1.98,,,1.98,Other,225% of Medicaid,1.23,,,1.23,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,15.24,,,15.24,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",1.89,,,1.89,Other,215% Medicaid APG methodology,1.89,,,1.89,Other,215% Medicaid APG methodology,1.1,,,1.1,Other,125% Medicaid APG methodology,0.01,15.66,
SOD CHLORIDE 3% 500ML,J7131,HCPCS,,80002728,CDM,636,RC,264780510,NDC,both,24,ML,4.84,1.91,39.4668,,1.91,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,1.69,35,,1.69,percent of total billed charges,Drugs,1.69,35,,1.69,percent of total billed charges,Drugs,1.64,34,,1.64,percent of total billed charges,Drugs,1.64,34,,1.64,percent of total billed charges,Drugs,1.64,34,,1.64,percent of total billed charges,Drugs,1.64,34,,1.64,percent of total billed charges,Drugs,1.69,35,,1.69,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,1.69,35,,1.69,percent of total billed charges,Drugs,1.69,35,,1.69,percent of total billed charges,Drugs,1.69,35,,1.69,percent of total billed charges,Drugs,1.69,35,,1.69,percent of total billed charges,Drugs,1.69,35,,1.69,percent of total billed charges,Drugs,1.93,40,,1.93,percent of total billed charges,Drugs,3.38,70,,3.38,percent of total billed charges,All Other,1.74,36,,1.74,percent of total billed charges,Drugs,1.74,36,,1.74,percent of total billed charges,Drugs,1.69,35,,1.69,percent of total billed charges,Drugs,1.69,35,,1.69,percent of total billed charges,Drugs,1.69,35,,1.69,percent of total billed charges,Drugs,1.69,35,,1.69,percent of total billed charges,Drugs,1.61,,,1.61,Other,Drug Cost,1.61,,,1.61,Other,Drug Cost,1.61,,,1.61,Other,Drug Cost,1.61,,,1.61,Other,Drug Cost,1.61,,,1.61,Other,Drug Cost,1.61,,,1.61,Other,Drug Cost,3.63,,,3.63,Other,225% of Medicaid,2.26,,,2.26,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",3.47,,,3.47,Other,215% Medicaid APG methodology,3.47,,,3.47,Other,215% Medicaid APG methodology,2.01,,,2.01,Other,125% Medicaid APG methodology,0.01,3.63,
TEMOZOLAMIDE 100MG INJ,J9328,HCPCS,,80002737,CDM,636,RC,85138101,NDC,both,1,EA,1259.37,102.64,,,102.64,Other,150% of Medicare + 9.63% HCRA Surcharge,62.42,,,62.42,Fee Schedule,Average Sale Price (ASP) x 6,440.78,35,,440.78,percent of total billed charges,Drugs,440.78,35,,440.78,percent of total billed charges,Drugs,428.19,34,,428.19,percent of total billed charges,Drugs,428.19,34,,428.19,percent of total billed charges,Drugs,428.19,34,,428.19,percent of total billed charges,Drugs,428.19,34,,428.19,percent of total billed charges,Drugs,440.78,35,,440.78,percent of total billed charges,Drugs,428.19,34,"If Charge > 500, then 34 percent",428.19,percent of total billed charges,Drugs,440.78,35,,440.78,percent of total billed charges,Drugs,440.78,35,,440.78,percent of total billed charges,Drugs,440.78,35,,440.78,percent of total billed charges,Drugs,440.78,35,,440.78,percent of total billed charges,Drugs,440.78,35,,440.78,percent of total billed charges,Drugs,503.75,40,,503.75,percent of total billed charges,Drugs,881.56,70,,881.56,percent of total billed charges,All Other,453.37,36,,453.37,percent of total billed charges,Drugs,453.37,36,,453.37,percent of total billed charges,Drugs,440.78,35,,440.78,percent of total billed charges,Drugs,440.78,35,,440.78,percent of total billed charges,Drugs,440.78,35,,440.78,percent of total billed charges,Drugs,440.78,35,,440.78,percent of total billed charges,Drugs,419.79,,,419.79,Other,Drug Cost,419.79,,,419.79,Other,Drug Cost,419.79,,,419.79,Other,Drug Cost,419.79,,,419.79,Other,Drug Cost,419.79,,,419.79,Other,Drug Cost,419.79,,,419.79,Other,Drug Cost,944.53,,,944.53,Other,225% of Medicaid,587.71,,,587.71,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,99.87,,,99.87,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",902.55,,,902.55,Other,215% Medicaid APG methodology,902.55,,,902.55,Other,215% Medicaid APG methodology,524.74,,,524.74,Other,125% Medicaid APG methodology,0.01,944.53,
HEPARIN 1000UN/NS 500ML,J1644,HCPCS,,80002743,CDM,636,RC,264987210,NDC,both,24,ML,5.95,2.64,,,2.64,Other,150% of Medicare + 9.63% HCRA Surcharge,1.61,,,1.61,Fee Schedule,Average Sale Price (ASP) x 6,2.08,35,,2.08,percent of total billed charges,Drugs,2.08,35,,2.08,percent of total billed charges,Drugs,2.02,34,,2.02,percent of total billed charges,Drugs,2.02,34,,2.02,percent of total billed charges,Drugs,2.02,34,,2.02,percent of total billed charges,Drugs,2.02,34,,2.02,percent of total billed charges,Drugs,2.08,35,,2.08,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,2.08,35,,2.08,percent of total billed charges,Drugs,2.08,35,,2.08,percent of total billed charges,Drugs,2.08,35,,2.08,percent of total billed charges,Drugs,2.08,35,,2.08,percent of total billed charges,Drugs,2.08,35,,2.08,percent of total billed charges,Drugs,2.38,40,,2.38,percent of total billed charges,Drugs,4.16,70,,4.16,percent of total billed charges,All Other,2.14,36,,2.14,percent of total billed charges,Drugs,2.14,36,,2.14,percent of total billed charges,Drugs,2.08,35,,2.08,percent of total billed charges,Drugs,2.08,35,,2.08,percent of total billed charges,Drugs,2.08,35,,2.08,percent of total billed charges,Drugs,2.08,35,,2.08,percent of total billed charges,Drugs,1.98,,,1.98,Other,Drug Cost,1.98,,,1.98,Other,Drug Cost,1.98,,,1.98,Other,Drug Cost,1.98,,,1.98,Other,Drug Cost,1.98,,,1.98,Other,Drug Cost,1.98,,,1.98,Other,Drug Cost,4.46,,,4.46,Other,225% of Medicaid,2.77,,,2.77,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,2.57,,,2.57,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",4.26,,,4.26,Other,215% Medicaid APG methodology,4.26,,,4.26,Other,215% Medicaid APG methodology,2.48,,,2.48,Other,125% Medicaid APG methodology,0.01,4.46,
CARFILZOMIB 60MG INJ,J9047,HCPCS,,80002748,CDM,636,RC,76075010101,NDC,both,1,EA,9722.37,464.57,,,464.57,Other,150% of Medicare + 9.63% HCRA Surcharge,282.51,,,282.51,Fee Schedule,Average Sale Price (ASP) x 6,3402.83,35,,3402.83,percent of total billed charges,Drugs,3402.83,35,,3402.83,percent of total billed charges,Drugs,3305.61,34,,3305.61,percent of total billed charges,Drugs,3305.61,34,,3305.61,percent of total billed charges,Drugs,3305.61,34,,3305.61,percent of total billed charges,Drugs,3305.61,34,,3305.61,percent of total billed charges,Drugs,3402.83,35,,3402.83,percent of total billed charges,Drugs,3305.61,34,"If Charge > 500, then 34 percent",3305.61,percent of total billed charges,Drugs,3402.83,35,,3402.83,percent of total billed charges,Drugs,3402.83,35,,3402.83,percent of total billed charges,Drugs,3402.83,35,,3402.83,percent of total billed charges,Drugs,3402.83,35,,3402.83,percent of total billed charges,Drugs,3402.83,35,,3402.83,percent of total billed charges,Drugs,3888.95,40,,3888.95,percent of total billed charges,Drugs,6805.66,70,,6805.66,percent of total billed charges,All Other,3500.05,36,,3500.05,percent of total billed charges,Drugs,3500.05,36,,3500.05,percent of total billed charges,Drugs,3402.83,35,,3402.83,percent of total billed charges,Drugs,3402.83,35,,3402.83,percent of total billed charges,Drugs,3402.83,35,,3402.83,percent of total billed charges,Drugs,3402.83,35,,3402.83,percent of total billed charges,Drugs,3240.79,,,3240.79,Other,Drug Cost,3240.79,,,3240.79,Other,Drug Cost,3240.79,,,3240.79,Other,Drug Cost,3240.79,,,3240.79,Other,Drug Cost,3240.79,,,3240.79,Other,Drug Cost,3240.79,,,3240.79,Other,Drug Cost,7291.78,,,7291.78,Other,225% of Medicaid,4537.11,,,4537.11,Other,140% of Medicaid,3305.61,34,"If Charge > 2,000, then 34 percent",3305.61,percent of total billed charges,Drugs,452.02,,,452.02,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",6967.7,,,6967.7,Other,215% Medicaid APG methodology,6967.7,,,6967.7,Other,215% Medicaid APG methodology,4050.99,,,4050.99,Other,125% Medicaid APG methodology,0.01,7291.78,
RAMUCIRUMAB 10MG/ML,J9308,HCPCS,,80002749,CDM,636,RC,2766901,NDC,both,1,ML,4324.47,693.08,,,693.08,Other,150% of Medicare + 9.63% HCRA Surcharge,421.46,,,421.46,Fee Schedule,Average Sale Price (ASP) x 6,1513.56,35,,1513.56,percent of total billed charges,Drugs,1513.56,35,,1513.56,percent of total billed charges,Drugs,1470.32,34,,1470.32,percent of total billed charges,Drugs,1470.32,34,,1470.32,percent of total billed charges,Drugs,1470.32,34,,1470.32,percent of total billed charges,Drugs,1470.32,34,,1470.32,percent of total billed charges,Drugs,1513.56,35,,1513.56,percent of total billed charges,Drugs,1470.32,34,"If Charge > 500, then 34 percent",1470.32,percent of total billed charges,Drugs,1513.56,35,,1513.56,percent of total billed charges,Drugs,1513.56,35,,1513.56,percent of total billed charges,Drugs,1513.56,35,,1513.56,percent of total billed charges,Drugs,1513.56,35,,1513.56,percent of total billed charges,Drugs,1513.56,35,,1513.56,percent of total billed charges,Drugs,1729.79,40,,1729.79,percent of total billed charges,Drugs,3027.13,70,,3027.13,percent of total billed charges,All Other,1556.81,36,,1556.81,percent of total billed charges,Drugs,1556.81,36,,1556.81,percent of total billed charges,Drugs,1513.56,35,,1513.56,percent of total billed charges,Drugs,1513.56,35,,1513.56,percent of total billed charges,Drugs,1513.56,35,,1513.56,percent of total billed charges,Drugs,1513.56,35,,1513.56,percent of total billed charges,Drugs,1441.49,,,1441.49,Other,Drug Cost,1441.49,,,1441.49,Other,Drug Cost,1441.49,,,1441.49,Other,Drug Cost,1441.49,,,1441.49,Other,Drug Cost,1441.49,,,1441.49,Other,Drug Cost,1441.49,,,1441.49,Other,Drug Cost,3243.35,,,3243.35,Other,225% of Medicaid,2018.09,,,2018.09,Other,140% of Medicaid,1470.32,34,"If Charge > 2,000, then 34 percent",1470.32,percent of total billed charges,Drugs,674.34,,,674.34,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",3099.2,,,3099.2,Other,215% Medicaid APG methodology,3099.2,,,3099.2,Other,215% Medicaid APG methodology,1801.86,,,1801.86,Other,125% Medicaid APG methodology,0.01,3243.35,
GOLIMUMAB 12.5 MG/ML 4ML INJ,J1602,HCPCS,,80002755,CDM,636,RC,57894035001,NDC,both,1,ML,5727.69,121.76,,,121.76,Other,150% of Medicare + 9.63% HCRA Surcharge,74.05,,,74.05,Fee Schedule,Average Sale Price (ASP) x 6,2004.69,35,,2004.69,percent of total billed charges,Drugs,2004.69,35,,2004.69,percent of total billed charges,Drugs,1947.41,34,,1947.41,percent of total billed charges,Drugs,1947.41,34,,1947.41,percent of total billed charges,Drugs,1947.41,34,,1947.41,percent of total billed charges,Drugs,1947.41,34,,1947.41,percent of total billed charges,Drugs,2004.69,35,,2004.69,percent of total billed charges,Drugs,1947.41,34,"If Charge > 500, then 34 percent",1947.41,percent of total billed charges,Drugs,2004.69,35,,2004.69,percent of total billed charges,Drugs,2004.69,35,,2004.69,percent of total billed charges,Drugs,2004.69,35,,2004.69,percent of total billed charges,Drugs,2004.69,35,,2004.69,percent of total billed charges,Drugs,2004.69,35,,2004.69,percent of total billed charges,Drugs,2291.08,40,,2291.08,percent of total billed charges,Drugs,4009.38,70,,4009.38,percent of total billed charges,All Other,2061.97,36,,2061.97,percent of total billed charges,Drugs,2061.97,36,,2061.97,percent of total billed charges,Drugs,2004.69,35,,2004.69,percent of total billed charges,Drugs,2004.69,35,,2004.69,percent of total billed charges,Drugs,2004.69,35,,2004.69,percent of total billed charges,Drugs,2004.69,35,,2004.69,percent of total billed charges,Drugs,1909.23,,,1909.23,Other,Drug Cost,1909.23,,,1909.23,Other,Drug Cost,1909.23,,,1909.23,Other,Drug Cost,1909.23,,,1909.23,Other,Drug Cost,1909.23,,,1909.23,Other,Drug Cost,1909.23,,,1909.23,Other,Drug Cost,4295.77,,,4295.77,Other,225% of Medicaid,2672.92,,,2672.92,Other,140% of Medicaid,1947.41,34,"If Charge > 2,000, then 34 percent",1947.41,percent of total billed charges,Drugs,118.47,,,118.47,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",4104.84,,,4104.84,Other,215% Medicaid APG methodology,4104.84,,,4104.84,Other,215% Medicaid APG methodology,2386.54,,,2386.54,Other,125% Medicaid APG methodology,0.01,4295.77,
ABILIFY MAINTENA 400MG INJECTION,J0401,HCPCS,,80002758,CDM,636,RC,59148001971,NDC,both,1,EA,3491.52,67.18,,,67.18,Other,150% of Medicare + 9.63% HCRA Surcharge,40.85,,,40.85,Fee Schedule,Average Sale Price (ASP) x 6,1222.03,35,,1222.03,percent of total billed charges,Drugs,1222.03,35,,1222.03,percent of total billed charges,Drugs,1187.12,34,,1187.12,percent of total billed charges,Drugs,1187.12,34,,1187.12,percent of total billed charges,Drugs,1187.12,34,,1187.12,percent of total billed charges,Drugs,1187.12,34,,1187.12,percent of total billed charges,Drugs,1222.03,35,,1222.03,percent of total billed charges,Drugs,1187.12,34,"If Charge > 500, then 34 percent",1187.12,percent of total billed charges,Drugs,1222.03,35,,1222.03,percent of total billed charges,Drugs,1222.03,35,,1222.03,percent of total billed charges,Drugs,1222.03,35,,1222.03,percent of total billed charges,Drugs,1222.03,35,,1222.03,percent of total billed charges,Drugs,1222.03,35,,1222.03,percent of total billed charges,Drugs,1396.61,40,,1396.61,percent of total billed charges,Drugs,2444.06,70,,2444.06,percent of total billed charges,All Other,1256.95,36,,1256.95,percent of total billed charges,Drugs,1256.95,36,,1256.95,percent of total billed charges,Drugs,1222.03,35,,1222.03,percent of total billed charges,Drugs,1222.03,35,,1222.03,percent of total billed charges,Drugs,1222.03,35,,1222.03,percent of total billed charges,Drugs,1222.03,35,,1222.03,percent of total billed charges,Drugs,1163.84,,,1163.84,Other,Drug Cost,1163.84,,,1163.84,Other,Drug Cost,1163.84,,,1163.84,Other,Drug Cost,1163.84,,,1163.84,Other,Drug Cost,1163.84,,,1163.84,Other,Drug Cost,1163.84,,,1163.84,Other,Drug Cost,2618.64,,,2618.64,Other,225% of Medicaid,1629.38,,,1629.38,Other,140% of Medicaid,1187.12,34,"If Charge > 2,000, then 34 percent",1187.12,percent of total billed charges,Drugs,65.37,,,65.37,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",2502.26,,,2502.26,Other,215% Medicaid APG methodology,2502.26,,,2502.26,Other,215% Medicaid APG methodology,1454.8,,,1454.8,Other,125% Medicaid APG methodology,0.01,2618.64,
ECALLANTIDE 10MG/ML INJ,J1290,HCPCS,,80002760,CDM,636,RC,47783010101,NDC,both,3,ML,14767.63,5321.38,,,5321.38,Other,150% of Medicare + 9.63% HCRA Surcharge,3235.96,,,3235.96,Fee Schedule,Average Sale Price (ASP) x 6,5168.67,35,,5168.67,percent of total billed charges,Drugs,5168.67,35,,5168.67,percent of total billed charges,Drugs,5020.99,34,,5020.99,percent of total billed charges,Drugs,5020.99,34,,5020.99,percent of total billed charges,Drugs,5020.99,34,,5020.99,percent of total billed charges,Drugs,5020.99,34,,5020.99,percent of total billed charges,Drugs,5168.67,35,,5168.67,percent of total billed charges,Drugs,5020.99,34,"If Charge > 500, then 34 percent",5020.99,percent of total billed charges,Drugs,5168.67,35,,5168.67,percent of total billed charges,Drugs,5168.67,35,,5168.67,percent of total billed charges,Drugs,5168.67,35,,5168.67,percent of total billed charges,Drugs,5168.67,35,,5168.67,percent of total billed charges,Drugs,5168.67,35,,5168.67,percent of total billed charges,Drugs,5907.05,40,,5907.05,percent of total billed charges,Drugs,10337.34,70,,10337.34,percent of total billed charges,All Other,5316.35,36,,5316.35,percent of total billed charges,Drugs,5316.35,36,,5316.35,percent of total billed charges,Drugs,5168.67,35,,5168.67,percent of total billed charges,Drugs,5168.67,35,,5168.67,percent of total billed charges,Drugs,5168.67,35,,5168.67,percent of total billed charges,Drugs,5168.67,35,,5168.67,percent of total billed charges,Drugs,4922.54,,,4922.54,Other,Drug Cost,4922.54,,,4922.54,Other,Drug Cost,4922.54,,,4922.54,Other,Drug Cost,4922.54,,,4922.54,Other,Drug Cost,4922.54,,,4922.54,Other,Drug Cost,4922.54,,,4922.54,Other,Drug Cost,11075.72,,,11075.72,Other,225% of Medicaid,6891.56,,,6891.56,Other,140% of Medicaid,5020.99,34,"If Charge > 2,000, then 34 percent",5020.99,percent of total billed charges,Drugs,5177.54,,,5177.54,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",10583.47,,,10583.47,Other,215% Medicaid APG methodology,10583.47,,,10583.47,Other,215% Medicaid APG methodology,6153.18,,,6153.18,Other,125% Medicaid APG methodology,0.01,11075.72,
PROTHROMBIN COMPLEX CONCENTRATE 500U INJ,J7168,HCPCS,,80002764,CDM,636,RC,63833038602,NDC,both,1,EA,1797.9,709.57,39.4668,,709.57,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,629.27,35,,629.27,percent of total billed charges,Drugs,629.27,35,,629.27,percent of total billed charges,Drugs,611.29,34,,611.29,percent of total billed charges,Drugs,611.29,34,,611.29,percent of total billed charges,Drugs,611.29,34,,611.29,percent of total billed charges,Drugs,611.29,34,,611.29,percent of total billed charges,Drugs,629.27,35,,629.27,percent of total billed charges,Drugs,611.29,34,"If Charge > 500, then 34 percent",611.29,percent of total billed charges,Drugs,629.27,35,,629.27,percent of total billed charges,Drugs,629.27,35,,629.27,percent of total billed charges,Drugs,629.27,35,,629.27,percent of total billed charges,Drugs,629.27,35,,629.27,percent of total billed charges,Drugs,629.27,35,,629.27,percent of total billed charges,Drugs,719.16,40,,719.16,percent of total billed charges,Drugs,1258.53,70,,1258.53,percent of total billed charges,All Other,647.24,36,,647.24,percent of total billed charges,Drugs,647.24,36,,647.24,percent of total billed charges,Drugs,629.27,35,,629.27,percent of total billed charges,Drugs,629.27,35,,629.27,percent of total billed charges,Drugs,629.27,35,,629.27,percent of total billed charges,Drugs,629.27,35,,629.27,percent of total billed charges,Drugs,599.3,,,599.3,Other,Drug Cost,599.3,,,599.3,Other,Drug Cost,599.3,,,599.3,Other,Drug Cost,599.3,,,599.3,Other,Drug Cost,599.3,,,599.3,Other,Drug Cost,599.3,,,599.3,Other,Drug Cost,1348.43,,,1348.43,Other,225% of Medicaid,839.02,,,839.02,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",1288.5,,,1288.5,Other,215% Medicaid APG methodology,1288.5,,,1288.5,Other,215% Medicaid APG methodology,749.13,,,749.13,Other,125% Medicaid APG methodology,0.01,1348.43,
LEVETIRACETAM 1000MG/100ML IV,J1953,HCPCS,,80002765,CDM,636,RC,70860060382,NDC,both,10,ML,11.06,0.62,,,0.62,Other,150% of Medicare + 9.63% HCRA Surcharge,0.38,,,0.38,Fee Schedule,Average Sale Price (ASP) x 6,3.87,35,,3.87,percent of total billed charges,Drugs,3.87,35,,3.87,percent of total billed charges,Drugs,3.76,34,,3.76,percent of total billed charges,Drugs,3.76,34,,3.76,percent of total billed charges,Drugs,3.76,34,,3.76,percent of total billed charges,Drugs,3.76,34,,3.76,percent of total billed charges,Drugs,3.87,35,,3.87,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,3.87,35,,3.87,percent of total billed charges,Drugs,3.87,35,,3.87,percent of total billed charges,Drugs,3.87,35,,3.87,percent of total billed charges,Drugs,3.87,35,,3.87,percent of total billed charges,Drugs,3.87,35,,3.87,percent of total billed charges,Drugs,4.42,40,,4.42,percent of total billed charges,Drugs,7.74,70,,7.74,percent of total billed charges,All Other,3.98,36,,3.98,percent of total billed charges,Drugs,3.98,36,,3.98,percent of total billed charges,Drugs,3.87,35,,3.87,percent of total billed charges,Drugs,3.87,35,,3.87,percent of total billed charges,Drugs,3.87,35,,3.87,percent of total billed charges,Drugs,3.87,35,,3.87,percent of total billed charges,Drugs,3.69,,,3.69,Other,Drug Cost,3.69,,,3.69,Other,Drug Cost,3.69,,,3.69,Other,Drug Cost,3.69,,,3.69,Other,Drug Cost,3.69,,,3.69,Other,Drug Cost,3.69,,,3.69,Other,Drug Cost,8.29,,,8.29,Other,225% of Medicaid,5.16,,,5.16,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,0.6,,,0.6,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",7.92,,,7.92,Other,215% Medicaid APG methodology,7.92,,,7.92,Other,215% Medicaid APG methodology,4.61,,,4.61,Other,125% Medicaid APG methodology,0.01,8.29,
VEDOLIZUMAB 300MG VIAL,J3380,HCPCS,,80002766,CDM,636,RC,64764030020,NDC,both,1,EA,14057.7,217.69,,,217.69,Other,150% of Medicare + 9.63% HCRA Surcharge,132.38,,,132.38,Fee Schedule,Average Sale Price (ASP) x 6,4920.2,35,,4920.2,percent of total billed charges,Drugs,4920.2,35,,4920.2,percent of total billed charges,Drugs,4779.62,34,,4779.62,percent of total billed charges,Drugs,4779.62,34,,4779.62,percent of total billed charges,Drugs,4779.62,34,,4779.62,percent of total billed charges,Drugs,4779.62,34,,4779.62,percent of total billed charges,Drugs,4920.2,35,,4920.2,percent of total billed charges,Drugs,4779.62,34,"If Charge > 500, then 34 percent",4779.62,percent of total billed charges,Drugs,4920.2,35,,4920.2,percent of total billed charges,Drugs,4920.2,35,,4920.2,percent of total billed charges,Drugs,4920.2,35,,4920.2,percent of total billed charges,Drugs,4920.2,35,,4920.2,percent of total billed charges,Drugs,4920.2,35,,4920.2,percent of total billed charges,Drugs,5623.08,40,,5623.08,percent of total billed charges,Drugs,9840.39,70,,9840.39,percent of total billed charges,All Other,5060.77,36,,5060.77,percent of total billed charges,Drugs,5060.77,36,,5060.77,percent of total billed charges,Drugs,4920.2,35,,4920.2,percent of total billed charges,Drugs,4920.2,35,,4920.2,percent of total billed charges,Drugs,4920.2,35,,4920.2,percent of total billed charges,Drugs,4920.2,35,,4920.2,percent of total billed charges,Drugs,4685.9,,,4685.9,Other,Drug Cost,4685.9,,,4685.9,Other,Drug Cost,4685.9,,,4685.9,Other,Drug Cost,4685.9,,,4685.9,Other,Drug Cost,4685.9,,,4685.9,Other,Drug Cost,4685.9,,,4685.9,Other,Drug Cost,10543.28,,,10543.28,Other,225% of Medicaid,6560.26,,,6560.26,Other,140% of Medicaid,4779.62,34,"If Charge > 2,000, then 34 percent",4779.62,percent of total billed charges,Drugs,211.8,,,211.8,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",10074.69,,,10074.69,Other,215% Medicaid APG methodology,10074.69,,,10074.69,Other,215% Medicaid APG methodology,5857.38,,,5857.38,Other,125% Medicaid APG methodology,0.01,10543.28,
TEMSIROLIIMUS 25MG/1ML,J9330,HCPCS,,80002771,CDM,636,RC,8117901,NDC,both,1,ML,3528.63,305.8,,,305.8,Other,150% of Medicare + 9.63% HCRA Surcharge,185.96,,,185.96,Fee Schedule,Average Sale Price (ASP) x 6,1235.02,35,,1235.02,percent of total billed charges,Drugs,1235.02,35,,1235.02,percent of total billed charges,Drugs,1199.73,34,,1199.73,percent of total billed charges,Drugs,1199.73,34,,1199.73,percent of total billed charges,Drugs,1199.73,34,,1199.73,percent of total billed charges,Drugs,1199.73,34,,1199.73,percent of total billed charges,Drugs,1235.02,35,,1235.02,percent of total billed charges,Drugs,1199.73,34,"If Charge > 500, then 34 percent",1199.73,percent of total billed charges,Drugs,1235.02,35,,1235.02,percent of total billed charges,Drugs,1235.02,35,,1235.02,percent of total billed charges,Drugs,1235.02,35,,1235.02,percent of total billed charges,Drugs,1235.02,35,,1235.02,percent of total billed charges,Drugs,1235.02,35,,1235.02,percent of total billed charges,Drugs,1411.45,40,,1411.45,percent of total billed charges,Drugs,2470.04,70,,2470.04,percent of total billed charges,All Other,1270.31,36,,1270.31,percent of total billed charges,Drugs,1270.31,36,,1270.31,percent of total billed charges,Drugs,1235.02,35,,1235.02,percent of total billed charges,Drugs,1235.02,35,,1235.02,percent of total billed charges,Drugs,1235.02,35,,1235.02,percent of total billed charges,Drugs,1235.02,35,,1235.02,percent of total billed charges,Drugs,1176.21,,,1176.21,Other,Drug Cost,1176.21,,,1176.21,Other,Drug Cost,1176.21,,,1176.21,Other,Drug Cost,1176.21,,,1176.21,Other,Drug Cost,1176.21,,,1176.21,Other,Drug Cost,1176.21,,,1176.21,Other,Drug Cost,2646.47,,,2646.47,Other,225% of Medicaid,1646.69,,,1646.69,Other,140% of Medicaid,1199.73,34,"If Charge > 2,000, then 34 percent",1199.73,percent of total billed charges,Drugs,297.53,,,297.53,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",2528.85,,,2528.85,Other,215% Medicaid APG methodology,2528.85,,,2528.85,Other,215% Medicaid APG methodology,1470.26,,,1470.26,Other,125% Medicaid APG methodology,0.01,2646.47,
BUTORPHANOL 1MG/ML INJ,J0595,HCPCS,,80002776,CDM,636,RC,409162301,NDC,both,10,ML,7.39,27.61,,,27.61,Other,150% of Medicare + 9.63% HCRA Surcharge,16.79,,,16.79,Fee Schedule,Average Sale Price (ASP) x 6,2.59,35,,2.59,percent of total billed charges,Drugs,2.59,35,,2.59,percent of total billed charges,Drugs,2.51,34,,2.51,percent of total billed charges,Drugs,2.51,34,,2.51,percent of total billed charges,Drugs,2.51,34,,2.51,percent of total billed charges,Drugs,2.51,34,,2.51,percent of total billed charges,Drugs,2.59,35,,2.59,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,2.59,35,,2.59,percent of total billed charges,Drugs,2.59,35,,2.59,percent of total billed charges,Drugs,2.59,35,,2.59,percent of total billed charges,Drugs,2.59,35,,2.59,percent of total billed charges,Drugs,2.59,35,,2.59,percent of total billed charges,Drugs,2.96,40,,2.96,percent of total billed charges,Drugs,5.17,70,,5.17,percent of total billed charges,All Other,2.66,36,,2.66,percent of total billed charges,Drugs,2.66,36,,2.66,percent of total billed charges,Drugs,2.59,35,,2.59,percent of total billed charges,Drugs,2.59,35,,2.59,percent of total billed charges,Drugs,2.59,35,,2.59,percent of total billed charges,Drugs,2.59,35,,2.59,percent of total billed charges,Drugs,2.46,,,2.46,Other,Drug Cost,2.46,,,2.46,Other,Drug Cost,2.46,,,2.46,Other,Drug Cost,2.46,,,2.46,Other,Drug Cost,2.46,,,2.46,Other,Drug Cost,2.46,,,2.46,Other,Drug Cost,5.54,,,5.54,Other,225% of Medicaid,3.45,,,3.45,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,26.86,,,26.86,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",5.3,,,5.3,Other,215% Medicaid APG methodology,5.3,,,5.3,Other,215% Medicaid APG methodology,3.08,,,3.08,Other,125% Medicaid APG methodology,0.01,27.61,
DANTROLENE 250MG VIAL,J3490,HCPCS,,80002777,CDM,636,RC,42367054032,NDC,both,1,EA,2921.7,1153.1,39.4668,,1153.1,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,1022.6,35,,1022.6,percent of total billed charges,Drugs,1022.6,35,,1022.6,percent of total billed charges,Drugs,993.38,34,,993.38,percent of total billed charges,Drugs,993.38,34,,993.38,percent of total billed charges,Drugs,993.38,34,,993.38,percent of total billed charges,Drugs,993.38,34,,993.38,percent of total billed charges,Drugs,1022.6,35,,1022.6,percent of total billed charges,Drugs,993.38,34,"If Charge > 500, then 34 percent",993.38,percent of total billed charges,Drugs,1022.6,35,,1022.6,percent of total billed charges,Drugs,1022.6,35,,1022.6,percent of total billed charges,Drugs,1022.6,35,,1022.6,percent of total billed charges,Drugs,1022.6,35,,1022.6,percent of total billed charges,Drugs,1022.6,35,,1022.6,percent of total billed charges,Drugs,1168.68,40,,1168.68,percent of total billed charges,Drugs,2045.19,70,,2045.19,percent of total billed charges,All Other,1051.81,36,,1051.81,percent of total billed charges,Drugs,1051.81,36,,1051.81,percent of total billed charges,Drugs,1022.6,35,,1022.6,percent of total billed charges,Drugs,1022.6,35,,1022.6,percent of total billed charges,Drugs,1022.6,35,,1022.6,percent of total billed charges,Drugs,1022.6,35,,1022.6,percent of total billed charges,Drugs,973.9,,,973.9,Other,Drug Cost,973.9,,,973.9,Other,Drug Cost,973.9,,,973.9,Other,Drug Cost,973.9,,,973.9,Other,Drug Cost,973.9,,,973.9,Other,Drug Cost,973.9,,,973.9,Other,Drug Cost,2191.28,,,2191.28,Other,225% of Medicaid,1363.46,,,1363.46,Other,140% of Medicaid,993.38,34,"If Charge > 2,000, then 34 percent",993.38,percent of total billed charges,Drugs,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",2093.89,,,2093.89,Other,215% Medicaid APG methodology,2093.89,,,2093.89,Other,215% Medicaid APG methodology,1217.38,,,1217.38,Other,125% Medicaid APG methodology,0.01,2191.28,
LEVETIRACETAM 500MG/100ML IV,J1953,HCPCS,,80002781,CDM,636,RC,70860060282,NDC,both,10,ML,1.11,0.62,,,0.62,Other,150% of Medicare + 9.63% HCRA Surcharge,0.38,,,0.38,Fee Schedule,Average Sale Price (ASP) x 6,0.39,35,,0.39,percent of total billed charges,Drugs,0.39,35,,0.39,percent of total billed charges,Drugs,0.38,34,,0.38,percent of total billed charges,Drugs,0.38,34,,0.38,percent of total billed charges,Drugs,0.38,34,,0.38,percent of total billed charges,Drugs,0.38,34,,0.38,percent of total billed charges,Drugs,0.39,35,,0.39,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,0.39,35,,0.39,percent of total billed charges,Drugs,0.39,35,,0.39,percent of total billed charges,Drugs,0.39,35,,0.39,percent of total billed charges,Drugs,0.39,35,,0.39,percent of total billed charges,Drugs,0.39,35,,0.39,percent of total billed charges,Drugs,0.44,40,,0.44,percent of total billed charges,Drugs,0.78,70,,0.78,percent of total billed charges,All Other,0.4,36,,0.4,percent of total billed charges,Drugs,0.4,36,,0.4,percent of total billed charges,Drugs,0.39,35,,0.39,percent of total billed charges,Drugs,0.39,35,,0.39,percent of total billed charges,Drugs,0.39,35,,0.39,percent of total billed charges,Drugs,0.39,35,,0.39,percent of total billed charges,Drugs,0.37,,,0.37,Other,Drug Cost,0.37,,,0.37,Other,Drug Cost,0.37,,,0.37,Other,Drug Cost,0.37,,,0.37,Other,Drug Cost,0.37,,,0.37,Other,Drug Cost,0.37,,,0.37,Other,Drug Cost,0.83,,,0.83,Other,225% of Medicaid,0.52,,,0.52,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,0.6,,,0.6,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",0.8,,,0.8,Other,215% Medicaid APG methodology,0.8,,,0.8,Other,215% Medicaid APG methodology,0.46,,,0.46,Other,125% Medicaid APG methodology,0.01,0.83,
MEROPENEM 500MG / VIAL,J2185,HCPCS,,80002793,CDM,636,RC,63323050720,NDC,both,10,EA,3.28,4.46,,,4.46,Other,150% of Medicare + 9.63% HCRA Surcharge,2.71,,,2.71,Fee Schedule,Average Sale Price (ASP) x 6,1.15,35,,1.15,percent of total billed charges,Drugs,1.15,35,,1.15,percent of total billed charges,Drugs,1.11,34,,1.11,percent of total billed charges,Drugs,1.11,34,,1.11,percent of total billed charges,Drugs,1.11,34,,1.11,percent of total billed charges,Drugs,1.11,34,,1.11,percent of total billed charges,Drugs,1.15,35,,1.15,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,1.15,35,,1.15,percent of total billed charges,Drugs,1.15,35,,1.15,percent of total billed charges,Drugs,1.15,35,,1.15,percent of total billed charges,Drugs,1.15,35,,1.15,percent of total billed charges,Drugs,1.15,35,,1.15,percent of total billed charges,Drugs,1.31,40,,1.31,percent of total billed charges,Drugs,2.3,70,,2.3,percent of total billed charges,All Other,1.18,36,,1.18,percent of total billed charges,Drugs,1.18,36,,1.18,percent of total billed charges,Drugs,1.15,35,,1.15,percent of total billed charges,Drugs,1.15,35,,1.15,percent of total billed charges,Drugs,1.15,35,,1.15,percent of total billed charges,Drugs,1.15,35,,1.15,percent of total billed charges,Drugs,1.09,,,1.09,Other,Drug Cost,1.09,,,1.09,Other,Drug Cost,1.09,,,1.09,Other,Drug Cost,1.09,,,1.09,Other,Drug Cost,1.09,,,1.09,Other,Drug Cost,1.09,,,1.09,Other,Drug Cost,2.46,,,2.46,Other,225% of Medicaid,1.53,,,1.53,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,4.34,,,4.34,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",2.35,,,2.35,Other,215% Medicaid APG methodology,2.35,,,2.35,Other,215% Medicaid APG methodology,1.37,,,1.37,Other,125% Medicaid APG methodology,0.01,4.46,
CEFTAZIDIME-AVIBACTAM 2.5GM INJ,J3490,HCPCS,,80002795,CDM,636,RC,456270010,NDC,both,10,EA,750.92,296.36,39.4668,,296.36,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,262.82,35,,262.82,percent of total billed charges,Drugs,262.82,35,,262.82,percent of total billed charges,Drugs,255.31,34,,255.31,percent of total billed charges,Drugs,255.31,34,,255.31,percent of total billed charges,Drugs,255.31,34,,255.31,percent of total billed charges,Drugs,255.31,34,,255.31,percent of total billed charges,Drugs,262.82,35,,262.82,percent of total billed charges,Drugs,255.31,34,"If Charge > 500, then 34 percent",255.31,percent of total billed charges,Drugs,262.82,35,,262.82,percent of total billed charges,Drugs,262.82,35,,262.82,percent of total billed charges,Drugs,262.82,35,,262.82,percent of total billed charges,Drugs,262.82,35,,262.82,percent of total billed charges,Drugs,262.82,35,,262.82,percent of total billed charges,Drugs,300.37,40,,300.37,percent of total billed charges,Drugs,525.64,70,,525.64,percent of total billed charges,All Other,270.33,36,,270.33,percent of total billed charges,Drugs,270.33,36,,270.33,percent of total billed charges,Drugs,262.82,35,,262.82,percent of total billed charges,Drugs,262.82,35,,262.82,percent of total billed charges,Drugs,262.82,35,,262.82,percent of total billed charges,Drugs,262.82,35,,262.82,percent of total billed charges,Drugs,250.31,,,250.31,Other,Drug Cost,250.31,,,250.31,Other,Drug Cost,250.31,,,250.31,Other,Drug Cost,250.31,,,250.31,Other,Drug Cost,250.31,,,250.31,Other,Drug Cost,250.31,,,250.31,Other,Drug Cost,563.19,,,563.19,Other,225% of Medicaid,350.43,,,350.43,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",538.16,,,538.16,Other,215% Medicaid APG methodology,538.16,,,538.16,Other,215% Medicaid APG methodology,312.88,,,312.88,Other,125% Medicaid APG methodology,0.01,563.19,
NIVOLUMAB 10MG/ML 10ML VIAL,J9299,HCPCS,,80002797,CDM,636,RC,3377412,NDC,both,1,ML,9443.07,306.75,,,306.75,Other,150% of Medicare + 9.63% HCRA Surcharge,186.53,,,186.53,Fee Schedule,Average Sale Price (ASP) x 6,3305.07,35,,3305.07,percent of total billed charges,Drugs,3305.07,35,,3305.07,percent of total billed charges,Drugs,3210.64,34,,3210.64,percent of total billed charges,Drugs,3210.64,34,,3210.64,percent of total billed charges,Drugs,3210.64,34,,3210.64,percent of total billed charges,Drugs,3210.64,34,,3210.64,percent of total billed charges,Drugs,3305.07,35,,3305.07,percent of total billed charges,Drugs,3210.64,34,"If Charge > 500, then 34 percent",3210.64,percent of total billed charges,Drugs,3305.07,35,,3305.07,percent of total billed charges,Drugs,3305.07,35,,3305.07,percent of total billed charges,Drugs,3305.07,35,,3305.07,percent of total billed charges,Drugs,3305.07,35,,3305.07,percent of total billed charges,Drugs,3305.07,35,,3305.07,percent of total billed charges,Drugs,3777.23,40,,3777.23,percent of total billed charges,Drugs,6610.15,70,,6610.15,percent of total billed charges,All Other,3399.51,36,,3399.51,percent of total billed charges,Drugs,3399.51,36,,3399.51,percent of total billed charges,Drugs,3305.07,35,,3305.07,percent of total billed charges,Drugs,3305.07,35,,3305.07,percent of total billed charges,Drugs,3305.07,35,,3305.07,percent of total billed charges,Drugs,3305.07,35,,3305.07,percent of total billed charges,Drugs,3147.69,,,3147.69,Other,Drug Cost,3147.69,,,3147.69,Other,Drug Cost,3147.69,,,3147.69,Other,Drug Cost,3147.69,,,3147.69,Other,Drug Cost,3147.69,,,3147.69,Other,Drug Cost,3147.69,,,3147.69,Other,Drug Cost,7082.3,,,7082.3,Other,225% of Medicaid,4406.77,,,4406.77,Other,140% of Medicaid,3210.64,34,"If Charge > 2,000, then 34 percent",3210.64,percent of total billed charges,Drugs,298.45,,,298.45,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",6767.53,,,6767.53,Other,215% Medicaid APG methodology,6767.53,,,6767.53,Other,215% Medicaid APG methodology,3934.61,,,3934.61,Other,125% Medicaid APG methodology,0.01,7082.3,
NIVOLUMAB 10MG/ML 4ML VIAL,J9299,HCPCS,,80002798,CDM,636,RC,3377211,NDC,both,1,ML,3777.24,306.75,,,306.75,Other,150% of Medicare + 9.63% HCRA Surcharge,186.53,,,186.53,Fee Schedule,Average Sale Price (ASP) x 6,1322.03,35,,1322.03,percent of total billed charges,Drugs,1322.03,35,,1322.03,percent of total billed charges,Drugs,1284.26,34,,1284.26,percent of total billed charges,Drugs,1284.26,34,,1284.26,percent of total billed charges,Drugs,1284.26,34,,1284.26,percent of total billed charges,Drugs,1284.26,34,,1284.26,percent of total billed charges,Drugs,1322.03,35,,1322.03,percent of total billed charges,Drugs,1284.26,34,"If Charge > 500, then 34 percent",1284.26,percent of total billed charges,Drugs,1322.03,35,,1322.03,percent of total billed charges,Drugs,1322.03,35,,1322.03,percent of total billed charges,Drugs,1322.03,35,,1322.03,percent of total billed charges,Drugs,1322.03,35,,1322.03,percent of total billed charges,Drugs,1322.03,35,,1322.03,percent of total billed charges,Drugs,1510.9,40,,1510.9,percent of total billed charges,Drugs,2644.07,70,,2644.07,percent of total billed charges,All Other,1359.81,36,,1359.81,percent of total billed charges,Drugs,1359.81,36,,1359.81,percent of total billed charges,Drugs,1322.03,35,,1322.03,percent of total billed charges,Drugs,1322.03,35,,1322.03,percent of total billed charges,Drugs,1322.03,35,,1322.03,percent of total billed charges,Drugs,1322.03,35,,1322.03,percent of total billed charges,Drugs,1259.08,,,1259.08,Other,Drug Cost,1259.08,,,1259.08,Other,Drug Cost,1259.08,,,1259.08,Other,Drug Cost,1259.08,,,1259.08,Other,Drug Cost,1259.08,,,1259.08,Other,Drug Cost,1259.08,,,1259.08,Other,Drug Cost,2832.93,,,2832.93,Other,225% of Medicaid,1762.71,,,1762.71,Other,140% of Medicaid,1284.26,34,"If Charge > 2,000, then 34 percent",1284.26,percent of total billed charges,Drugs,298.45,,,298.45,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",2707.02,,,2707.02,Other,215% Medicaid APG methodology,2707.02,,,2707.02,Other,215% Medicaid APG methodology,1573.85,,,1573.85,Other,125% Medicaid APG methodology,0.01,2832.93,
CEFTOLOZANE/TAZOBACTAM 1.5GM INJ,J0695,HCPCS,,80002800,CDM,636,RC,67919003001,NDC,both,10,EA,193.92,72.72,,,72.72,Other,150% of Medicare + 9.63% HCRA Surcharge,44.22,,,44.22,Fee Schedule,Average Sale Price (ASP) x 6,67.87,35,,67.87,percent of total billed charges,Drugs,67.87,35,,67.87,percent of total billed charges,Drugs,65.93,34,,65.93,percent of total billed charges,Drugs,65.93,34,,65.93,percent of total billed charges,Drugs,65.93,34,,65.93,percent of total billed charges,Drugs,65.93,34,,65.93,percent of total billed charges,Drugs,67.87,35,,67.87,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,67.87,35,,67.87,percent of total billed charges,Drugs,67.87,35,,67.87,percent of total billed charges,Drugs,67.87,35,,67.87,percent of total billed charges,Drugs,67.87,35,,67.87,percent of total billed charges,Drugs,67.87,35,,67.87,percent of total billed charges,Drugs,77.57,40,,77.57,percent of total billed charges,Drugs,135.75,70,,135.75,percent of total billed charges,All Other,69.81,36,,69.81,percent of total billed charges,Drugs,69.81,36,,69.81,percent of total billed charges,Drugs,67.87,35,,67.87,percent of total billed charges,Drugs,67.87,35,,67.87,percent of total billed charges,Drugs,67.87,35,,67.87,percent of total billed charges,Drugs,67.87,35,,67.87,percent of total billed charges,Drugs,64.64,,,64.64,Other,Drug Cost,64.64,,,64.64,Other,Drug Cost,64.64,,,64.64,Other,Drug Cost,64.64,,,64.64,Other,Drug Cost,64.64,,,64.64,Other,Drug Cost,64.64,,,64.64,Other,Drug Cost,145.44,,,145.44,Other,225% of Medicaid,90.5,,,90.5,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,70.75,,,70.75,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",138.98,,,138.98,Other,215% Medicaid APG methodology,138.98,,,138.98,Other,215% Medicaid APG methodology,80.8,,,80.8,Other,125% Medicaid APG methodology,0.01,145.44,
ROMIDEPSIN 10MG INJ,J9319,HCPCS,,80002801,CDM,636,RC,59572098401,NDC,both,1,EA,9495.18,315.35,,,315.35,Other,150% of Medicare + 9.63% HCRA Surcharge,191.77,,,191.77,Fee Schedule,Average Sale Price (ASP) x 6,3323.31,35,,3323.31,percent of total billed charges,Drugs,3323.31,35,,3323.31,percent of total billed charges,Drugs,3228.36,34,,3228.36,percent of total billed charges,Drugs,3228.36,34,,3228.36,percent of total billed charges,Drugs,3228.36,34,,3228.36,percent of total billed charges,Drugs,3228.36,34,,3228.36,percent of total billed charges,Drugs,3323.31,35,,3323.31,percent of total billed charges,Drugs,3228.36,34,"If Charge > 500, then 34 percent",3228.36,percent of total billed charges,Drugs,3323.31,35,,3323.31,percent of total billed charges,Drugs,3323.31,35,,3323.31,percent of total billed charges,Drugs,3323.31,35,,3323.31,percent of total billed charges,Drugs,3323.31,35,,3323.31,percent of total billed charges,Drugs,3323.31,35,,3323.31,percent of total billed charges,Drugs,3798.07,40,,3798.07,percent of total billed charges,Drugs,6646.63,70,,6646.63,percent of total billed charges,All Other,3418.26,36,,3418.26,percent of total billed charges,Drugs,3418.26,36,,3418.26,percent of total billed charges,Drugs,3323.31,35,,3323.31,percent of total billed charges,Drugs,3323.31,35,,3323.31,percent of total billed charges,Drugs,3323.31,35,,3323.31,percent of total billed charges,Drugs,3323.31,35,,3323.31,percent of total billed charges,Drugs,3165.06,,,3165.06,Other,Drug Cost,3165.06,,,3165.06,Other,Drug Cost,3165.06,,,3165.06,Other,Drug Cost,3165.06,,,3165.06,Other,Drug Cost,3165.06,,,3165.06,Other,Drug Cost,3165.06,,,3165.06,Other,Drug Cost,7121.39,,,7121.39,Other,225% of Medicaid,4431.08,,,4431.08,Other,140% of Medicaid,3228.36,34,"If Charge > 2,000, then 34 percent",3228.36,percent of total billed charges,Drugs,306.83,,,306.83,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",6804.88,,,6804.88,Other,215% Medicaid APG methodology,6804.88,,,6804.88,Other,215% Medicaid APG methodology,3956.33,,,3956.33,Other,125% Medicaid APG methodology,0.01,7121.39,
DARATUMUMAB 400MG/20ML INJECTION,J9145,HCPCS,,80002821,CDM,636,RC,57894050220,NDC,both,1,ML,8731.26,608.82,,,608.82,Other,150% of Medicare + 9.63% HCRA Surcharge,370.23,,,370.23,Fee Schedule,Average Sale Price (ASP) x 6,3055.94,35,,3055.94,percent of total billed charges,Drugs,3055.94,35,,3055.94,percent of total billed charges,Drugs,2968.63,34,,2968.63,percent of total billed charges,Drugs,2968.63,34,,2968.63,percent of total billed charges,Drugs,2968.63,34,,2968.63,percent of total billed charges,Drugs,2968.63,34,,2968.63,percent of total billed charges,Drugs,3055.94,35,,3055.94,percent of total billed charges,Drugs,2968.63,34,"If Charge > 500, then 34 percent",2968.63,percent of total billed charges,Drugs,3055.94,35,,3055.94,percent of total billed charges,Drugs,3055.94,35,,3055.94,percent of total billed charges,Drugs,3055.94,35,,3055.94,percent of total billed charges,Drugs,3055.94,35,,3055.94,percent of total billed charges,Drugs,3055.94,35,,3055.94,percent of total billed charges,Drugs,3492.5,40,,3492.5,percent of total billed charges,Drugs,6111.88,70,,6111.88,percent of total billed charges,All Other,3143.25,36,,3143.25,percent of total billed charges,Drugs,3143.25,36,,3143.25,percent of total billed charges,Drugs,3055.94,35,,3055.94,percent of total billed charges,Drugs,3055.94,35,,3055.94,percent of total billed charges,Drugs,3055.94,35,,3055.94,percent of total billed charges,Drugs,3055.94,35,,3055.94,percent of total billed charges,Drugs,2910.42,,,2910.42,Other,Drug Cost,2910.42,,,2910.42,Other,Drug Cost,2910.42,,,2910.42,Other,Drug Cost,2910.42,,,2910.42,Other,Drug Cost,2910.42,,,2910.42,Other,Drug Cost,2910.42,,,2910.42,Other,Drug Cost,6548.45,,,6548.45,Other,225% of Medicaid,4074.59,,,4074.59,Other,140% of Medicaid,2968.63,34,"If Charge > 2,000, then 34 percent",2968.63,percent of total billed charges,Drugs,592.37,,,592.37,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",6257.4,,,6257.4,Other,215% Medicaid APG methodology,6257.4,,,6257.4,Other,215% Medicaid APG methodology,3638.03,,,3638.03,Other,125% Medicaid APG methodology,0.01,6548.45,
IRINOTECAN LIPOSOMAL 4.3MG/ML (10ML),J9205,HCPCS,,80002830,CDM,636,RC,15054004301,NDC,both,1,ML,8415.69,611.93,,,611.93,Other,150% of Medicare + 9.63% HCRA Surcharge,372.12,,,372.12,Fee Schedule,Average Sale Price (ASP) x 6,2945.49,35,,2945.49,percent of total billed charges,Drugs,2945.49,35,,2945.49,percent of total billed charges,Drugs,2861.33,34,,2861.33,percent of total billed charges,Drugs,2861.33,34,,2861.33,percent of total billed charges,Drugs,2861.33,34,,2861.33,percent of total billed charges,Drugs,2861.33,34,,2861.33,percent of total billed charges,Drugs,2945.49,35,,2945.49,percent of total billed charges,Drugs,2861.33,34,"If Charge > 500, then 34 percent",2861.33,percent of total billed charges,Drugs,2945.49,35,,2945.49,percent of total billed charges,Drugs,2945.49,35,,2945.49,percent of total billed charges,Drugs,2945.49,35,,2945.49,percent of total billed charges,Drugs,2945.49,35,,2945.49,percent of total billed charges,Drugs,2945.49,35,,2945.49,percent of total billed charges,Drugs,3366.28,40,,3366.28,percent of total billed charges,Drugs,5890.98,70,,5890.98,percent of total billed charges,All Other,3029.65,36,,3029.65,percent of total billed charges,Drugs,3029.65,36,,3029.65,percent of total billed charges,Drugs,2945.49,35,,2945.49,percent of total billed charges,Drugs,2945.49,35,,2945.49,percent of total billed charges,Drugs,2945.49,35,,2945.49,percent of total billed charges,Drugs,2945.49,35,,2945.49,percent of total billed charges,Drugs,2805.23,,,2805.23,Other,Drug Cost,2805.23,,,2805.23,Other,Drug Cost,2805.23,,,2805.23,Other,Drug Cost,2805.23,,,2805.23,Other,Drug Cost,2805.23,,,2805.23,Other,Drug Cost,2805.23,,,2805.23,Other,Drug Cost,6311.77,,,6311.77,Other,225% of Medicaid,3927.32,,,3927.32,Other,140% of Medicaid,2861.33,34,"If Charge > 2,000, then 34 percent",2861.33,percent of total billed charges,Drugs,595.39,,,595.39,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",6031.24,,,6031.24,Other,215% Medicaid APG methodology,6031.24,,,6031.24,Other,215% Medicaid APG methodology,3506.54,,,3506.54,Other,125% Medicaid APG methodology,0.01,6311.77,
PRAXBIND 50MG/ML 50ML,C9399,HCPCS,,80002835,CDM,636,RC,597019705,NDC,both,2,ML,5137.53,2027.62,39.4668,,2027.62,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,1798.14,35,,1798.14,percent of total billed charges,Drugs,1798.14,35,,1798.14,percent of total billed charges,Drugs,1746.76,34,,1746.76,percent of total billed charges,Drugs,1746.76,34,,1746.76,percent of total billed charges,Drugs,1746.76,34,,1746.76,percent of total billed charges,Drugs,1746.76,34,,1746.76,percent of total billed charges,Drugs,1798.14,35,,1798.14,percent of total billed charges,Drugs,1746.76,34,"If Charge > 500, then 34 percent",1746.76,percent of total billed charges,Drugs,1798.14,35,,1798.14,percent of total billed charges,Drugs,1798.14,35,,1798.14,percent of total billed charges,Drugs,1798.14,35,,1798.14,percent of total billed charges,Drugs,1798.14,35,,1798.14,percent of total billed charges,Drugs,1798.14,35,,1798.14,percent of total billed charges,Drugs,2055.01,40,,2055.01,percent of total billed charges,Drugs,3596.27,70,,3596.27,percent of total billed charges,All Other,1849.51,36,,1849.51,percent of total billed charges,Drugs,1849.51,36,,1849.51,percent of total billed charges,Drugs,1798.14,35,,1798.14,percent of total billed charges,Drugs,1798.14,35,,1798.14,percent of total billed charges,Drugs,1798.14,35,,1798.14,percent of total billed charges,Drugs,1798.14,35,,1798.14,percent of total billed charges,Drugs,1712.51,,,1712.51,Other,Drug Cost,1712.51,,,1712.51,Other,Drug Cost,1712.51,,,1712.51,Other,Drug Cost,1712.51,,,1712.51,Other,Drug Cost,1712.51,,,1712.51,Other,Drug Cost,1712.51,,,1712.51,Other,Drug Cost,3853.15,,,3853.15,Other,225% of Medicaid,2397.51,,,2397.51,Other,140% of Medicaid,1746.76,34,"If Charge > 2,000, then 34 percent",1746.76,percent of total billed charges,Drugs,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",3681.9,,,3681.9,Other,215% Medicaid APG methodology,3681.9,,,3681.9,Other,215% Medicaid APG methodology,2140.64,,,2140.64,Other,125% Medicaid APG methodology,0.01,3853.15,
DOPAMINE HCL 200MG/D5W 250ML,J1265,HCPCS,,80002838,CDM,636,RC,338100502,NDC,both,18,ML,8.67,7.62,,,7.62,Other,150% of Medicare + 9.63% HCRA Surcharge,4.63,,,4.63,Fee Schedule,Average Sale Price (ASP) x 6,3.03,35,,3.03,percent of total billed charges,Drugs,3.03,35,,3.03,percent of total billed charges,Drugs,2.95,34,,2.95,percent of total billed charges,Drugs,2.95,34,,2.95,percent of total billed charges,Drugs,2.95,34,,2.95,percent of total billed charges,Drugs,2.95,34,,2.95,percent of total billed charges,Drugs,3.03,35,,3.03,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,3.03,35,,3.03,percent of total billed charges,Drugs,3.03,35,,3.03,percent of total billed charges,Drugs,3.03,35,,3.03,percent of total billed charges,Drugs,3.03,35,,3.03,percent of total billed charges,Drugs,3.03,35,,3.03,percent of total billed charges,Drugs,3.47,40,,3.47,percent of total billed charges,Drugs,6.07,70,,6.07,percent of total billed charges,All Other,3.12,36,,3.12,percent of total billed charges,Drugs,3.12,36,,3.12,percent of total billed charges,Drugs,3.03,35,,3.03,percent of total billed charges,Drugs,3.03,35,,3.03,percent of total billed charges,Drugs,3.03,35,,3.03,percent of total billed charges,Drugs,3.03,35,,3.03,percent of total billed charges,Drugs,2.89,,,2.89,Other,Drug Cost,2.89,,,2.89,Other,Drug Cost,2.89,,,2.89,Other,Drug Cost,2.89,,,2.89,Other,Drug Cost,2.89,,,2.89,Other,Drug Cost,2.89,,,2.89,Other,Drug Cost,6.5,,,6.5,Other,225% of Medicaid,4.05,,,4.05,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,7.41,,,7.41,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",6.21,,,6.21,Other,215% Medicaid APG methodology,6.21,,,6.21,Other,215% Medicaid APG methodology,3.61,,,3.61,Other,125% Medicaid APG methodology,0.01,7.62,
BENDAMUSTINE 25MG/ML,J9034,HCPCS,,80002840,CDM,636,RC,63459034804,NDC,both,1,ML,2806.53,145.59,,,145.59,Other,150% of Medicare + 9.63% HCRA Surcharge,88.54,,,88.54,Fee Schedule,Average Sale Price (ASP) x 6,982.29,35,,982.29,percent of total billed charges,Drugs,982.29,35,,982.29,percent of total billed charges,Drugs,954.22,34,,954.22,percent of total billed charges,Drugs,954.22,34,,954.22,percent of total billed charges,Drugs,954.22,34,,954.22,percent of total billed charges,Drugs,954.22,34,,954.22,percent of total billed charges,Drugs,982.29,35,,982.29,percent of total billed charges,Drugs,954.22,34,"If Charge > 500, then 34 percent",954.22,percent of total billed charges,Drugs,982.29,35,,982.29,percent of total billed charges,Drugs,982.29,35,,982.29,percent of total billed charges,Drugs,982.29,35,,982.29,percent of total billed charges,Drugs,982.29,35,,982.29,percent of total billed charges,Drugs,982.29,35,,982.29,percent of total billed charges,Drugs,1122.61,40,,1122.61,percent of total billed charges,Drugs,1964.57,70,,1964.57,percent of total billed charges,All Other,1010.35,36,,1010.35,percent of total billed charges,Drugs,1010.35,36,,1010.35,percent of total billed charges,Drugs,982.29,35,,982.29,percent of total billed charges,Drugs,982.29,35,,982.29,percent of total billed charges,Drugs,982.29,35,,982.29,percent of total billed charges,Drugs,982.29,35,,982.29,percent of total billed charges,Drugs,935.51,,,935.51,Other,Drug Cost,935.51,,,935.51,Other,Drug Cost,935.51,,,935.51,Other,Drug Cost,935.51,,,935.51,Other,Drug Cost,935.51,,,935.51,Other,Drug Cost,935.51,,,935.51,Other,Drug Cost,2104.9,,,2104.9,Other,225% of Medicaid,1309.71,,,1309.71,Other,140% of Medicaid,954.22,34,"If Charge > 2,000, then 34 percent",954.22,percent of total billed charges,Drugs,141.66,,,141.66,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",2011.35,,,2011.35,Other,215% Medicaid APG methodology,2011.35,,,2011.35,Other,215% Medicaid APG methodology,1169.39,,,1169.39,Other,125% Medicaid APG methodology,0.01,2104.9,
MAGNESIUM 20GM/500ML,J3475,HCPCS,,80023640,CDM,636,RC,63323010615,NDC,both,24,ML,10.6,6.82,,,6.82,Other,150% of Medicare + 9.63% HCRA Surcharge,4.15,,,4.15,Fee Schedule,Average Sale Price (ASP) x 6,3.71,35,,3.71,percent of total billed charges,Drugs,3.71,35,,3.71,percent of total billed charges,Drugs,3.6,34,,3.6,percent of total billed charges,Drugs,3.6,34,,3.6,percent of total billed charges,Drugs,3.6,34,,3.6,percent of total billed charges,Drugs,3.6,34,,3.6,percent of total billed charges,Drugs,3.71,35,,3.71,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,3.71,35,,3.71,percent of total billed charges,Drugs,3.71,35,,3.71,percent of total billed charges,Drugs,3.71,35,,3.71,percent of total billed charges,Drugs,3.71,35,,3.71,percent of total billed charges,Drugs,3.71,35,,3.71,percent of total billed charges,Drugs,4.24,40,,4.24,percent of total billed charges,Drugs,7.42,70,,7.42,percent of total billed charges,All Other,3.82,36,,3.82,percent of total billed charges,Drugs,3.82,36,,3.82,percent of total billed charges,Drugs,3.71,35,,3.71,percent of total billed charges,Drugs,3.71,35,,3.71,percent of total billed charges,Drugs,3.71,35,,3.71,percent of total billed charges,Drugs,3.71,35,,3.71,percent of total billed charges,Drugs,3.53,,,3.53,Other,Drug Cost,3.53,,,3.53,Other,Drug Cost,3.53,,,3.53,Other,Drug Cost,3.53,,,3.53,Other,Drug Cost,3.53,,,3.53,Other,Drug Cost,3.53,,,3.53,Other,Drug Cost,7.95,,,7.95,Other,225% of Medicaid,4.95,,,4.95,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,6.63,,,6.63,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",7.59,,,7.59,Other,215% Medicaid APG methodology,7.59,,,7.59,Other,215% Medicaid APG methodology,4.42,,,4.42,Other,125% Medicaid APG methodology,0.01,7.95,
CEFEPIME 1GM/ D5W50ML,J0692,HCPCS,,80023642,CDM,636,RC,264319311,NDC,both,24,EA,27.3,12.45,,,12.45,Other,150% of Medicare + 9.63% HCRA Surcharge,7.57,,,7.57,Fee Schedule,Average Sale Price (ASP) x 6,9.56,35,,9.56,percent of total billed charges,Drugs,9.56,35,,9.56,percent of total billed charges,Drugs,9.28,34,,9.28,percent of total billed charges,Drugs,9.28,34,,9.28,percent of total billed charges,Drugs,9.28,34,,9.28,percent of total billed charges,Drugs,9.28,34,,9.28,percent of total billed charges,Drugs,9.56,35,,9.56,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,9.56,35,,9.56,percent of total billed charges,Drugs,9.56,35,,9.56,percent of total billed charges,Drugs,9.56,35,,9.56,percent of total billed charges,Drugs,9.56,35,,9.56,percent of total billed charges,Drugs,9.56,35,,9.56,percent of total billed charges,Drugs,10.92,40,,10.92,percent of total billed charges,Drugs,19.11,70,,19.11,percent of total billed charges,All Other,9.83,36,,9.83,percent of total billed charges,Drugs,9.83,36,,9.83,percent of total billed charges,Drugs,9.56,35,,9.56,percent of total billed charges,Drugs,9.56,35,,9.56,percent of total billed charges,Drugs,9.56,35,,9.56,percent of total billed charges,Drugs,9.56,35,,9.56,percent of total billed charges,Drugs,9.1,,,9.1,Other,Drug Cost,9.1,,,9.1,Other,Drug Cost,9.1,,,9.1,Other,Drug Cost,9.1,,,9.1,Other,Drug Cost,9.1,,,9.1,Other,Drug Cost,9.1,,,9.1,Other,Drug Cost,20.48,,,20.48,Other,225% of Medicaid,12.74,,,12.74,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,12.12,,,12.12,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",19.57,,,19.57,Other,215% Medicaid APG methodology,19.57,,,19.57,Other,215% Medicaid APG methodology,11.38,,,11.38,Other,125% Medicaid APG methodology,0.01,20.48,
OCTREOTIDE DEPOT 20 MG INJ,J2353,HCPCS,,80023644,CDM,636,RC,78081881,NDC,both,1,EA,12545.73,2080.19,,,2080.19,Other,150% of Medicare + 9.63% HCRA Surcharge,1264.97,,,1264.97,Fee Schedule,Average Sale Price (ASP) x 6,4391.01,35,,4391.01,percent of total billed charges,Drugs,4391.01,35,,4391.01,percent of total billed charges,Drugs,4265.55,34,,4265.55,percent of total billed charges,Drugs,4265.55,34,,4265.55,percent of total billed charges,Drugs,4265.55,34,,4265.55,percent of total billed charges,Drugs,4265.55,34,,4265.55,percent of total billed charges,Drugs,4391.01,35,,4391.01,percent of total billed charges,Drugs,4265.55,34,"If Charge > 500, then 34 percent",4265.55,percent of total billed charges,Drugs,4391.01,35,,4391.01,percent of total billed charges,Drugs,4391.01,35,,4391.01,percent of total billed charges,Drugs,4391.01,35,,4391.01,percent of total billed charges,Drugs,4391.01,35,,4391.01,percent of total billed charges,Drugs,4391.01,35,,4391.01,percent of total billed charges,Drugs,5018.29,40,,5018.29,percent of total billed charges,Drugs,8782.01,70,,8782.01,percent of total billed charges,All Other,4516.46,36,,4516.46,percent of total billed charges,Drugs,4516.46,36,,4516.46,percent of total billed charges,Drugs,4391.01,35,,4391.01,percent of total billed charges,Drugs,4391.01,35,,4391.01,percent of total billed charges,Drugs,4391.01,35,,4391.01,percent of total billed charges,Drugs,4391.01,35,,4391.01,percent of total billed charges,Drugs,4181.91,,,4181.91,Other,Drug Cost,4181.91,,,4181.91,Other,Drug Cost,4181.91,,,4181.91,Other,Drug Cost,4181.91,,,4181.91,Other,Drug Cost,4181.91,,,4181.91,Other,Drug Cost,4181.91,,,4181.91,Other,Drug Cost,9409.3,,,9409.3,Other,225% of Medicaid,5854.67,,,5854.67,Other,140% of Medicaid,4265.55,34,"If Charge > 2,000, then 34 percent",4265.55,percent of total billed charges,Drugs,2023.96,,,2023.96,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",8991.11,,,8991.11,Other,215% Medicaid APG methodology,8991.11,,,8991.11,Other,215% Medicaid APG methodology,5227.39,,,5227.39,Other,125% Medicaid APG methodology,0.01,9409.3,
PROCAINAMIDE HCL 1GM/2ML,J2690,HCPCS,,80023645,CDM,636,RC,14789090002,NDC,both,10,ML,113.06,1443.67,,,1443.67,Other,150% of Medicare + 9.63% HCRA Surcharge,877.9,,,877.9,Fee Schedule,Average Sale Price (ASP) x 6,39.57,35,,39.57,percent of total billed charges,Drugs,39.57,35,,39.57,percent of total billed charges,Drugs,38.44,34,,38.44,percent of total billed charges,Drugs,38.44,34,,38.44,percent of total billed charges,Drugs,38.44,34,,38.44,percent of total billed charges,Drugs,38.44,34,,38.44,percent of total billed charges,Drugs,39.57,35,,39.57,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,39.57,35,,39.57,percent of total billed charges,Drugs,39.57,35,,39.57,percent of total billed charges,Drugs,39.57,35,,39.57,percent of total billed charges,Drugs,39.57,35,,39.57,percent of total billed charges,Drugs,39.57,35,,39.57,percent of total billed charges,Drugs,45.22,40,,45.22,percent of total billed charges,Drugs,79.14,70,,79.14,percent of total billed charges,All Other,40.7,36,,40.7,percent of total billed charges,Drugs,40.7,36,,40.7,percent of total billed charges,Drugs,39.57,35,,39.57,percent of total billed charges,Drugs,39.57,35,,39.57,percent of total billed charges,Drugs,39.57,35,,39.57,percent of total billed charges,Drugs,39.57,35,,39.57,percent of total billed charges,Drugs,37.69,,,37.69,Other,Drug Cost,37.69,,,37.69,Other,Drug Cost,37.69,,,37.69,Other,Drug Cost,37.69,,,37.69,Other,Drug Cost,37.69,,,37.69,Other,Drug Cost,37.69,,,37.69,Other,Drug Cost,84.79,,,84.79,Other,225% of Medicaid,52.76,,,52.76,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,1404.64,,,1404.64,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",81.02,,,81.02,Other,215% Medicaid APG methodology,81.02,,,81.02,Other,215% Medicaid APG methodology,47.11,,,47.11,Other,125% Medicaid APG methodology,0.01,1443.67,
KEYTRUDA 25MG/ML 4ML,J9271,HCPCS,,80023648,CDM,636,RC,6302604,NDC,both,2,ML,12264.38,549.87,,,549.87,Other,150% of Medicare + 9.63% HCRA Surcharge,334.38,,,334.38,Fee Schedule,Average Sale Price (ASP) x 6,4292.53,35,,4292.53,percent of total billed charges,Drugs,4292.53,35,,4292.53,percent of total billed charges,Drugs,4169.89,34,,4169.89,percent of total billed charges,Drugs,4169.89,34,,4169.89,percent of total billed charges,Drugs,4169.89,34,,4169.89,percent of total billed charges,Drugs,4169.89,34,,4169.89,percent of total billed charges,Drugs,4292.53,35,,4292.53,percent of total billed charges,Drugs,4169.89,34,"If Charge > 500, then 34 percent",4169.89,percent of total billed charges,Drugs,4292.53,35,,4292.53,percent of total billed charges,Drugs,4292.53,35,,4292.53,percent of total billed charges,Drugs,4292.53,35,,4292.53,percent of total billed charges,Drugs,4292.53,35,,4292.53,percent of total billed charges,Drugs,4292.53,35,,4292.53,percent of total billed charges,Drugs,4905.75,40,,4905.75,percent of total billed charges,Drugs,8585.06,70,,8585.06,percent of total billed charges,All Other,4415.18,36,,4415.18,percent of total billed charges,Drugs,4415.18,36,,4415.18,percent of total billed charges,Drugs,4292.53,35,,4292.53,percent of total billed charges,Drugs,4292.53,35,,4292.53,percent of total billed charges,Drugs,4292.53,35,,4292.53,percent of total billed charges,Drugs,4292.53,35,,4292.53,percent of total billed charges,Drugs,4088.13,,,4088.13,Other,Drug Cost,4088.13,,,4088.13,Other,Drug Cost,4088.13,,,4088.13,Other,Drug Cost,4088.13,,,4088.13,Other,Drug Cost,4088.13,,,4088.13,Other,Drug Cost,4088.13,,,4088.13,Other,Drug Cost,9198.28,,,9198.28,Other,225% of Medicaid,5723.38,,,5723.38,Other,140% of Medicaid,4169.89,34,"If Charge > 2,000, then 34 percent",4169.89,percent of total billed charges,Drugs,535.01,,,535.01,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",8789.47,,,8789.47,Other,215% Medicaid APG methodology,8789.47,,,8789.47,Other,215% Medicaid APG methodology,5110.16,,,5110.16,Other,125% Medicaid APG methodology,0.01,9198.28,
ABILIFY MAINTENA 300 MG INJECTION,J0401,HCPCS,,80023650,CDM,636,RC,59148001871,NDC,both,1,EA,2619.72,67.18,,,67.18,Other,150% of Medicare + 9.63% HCRA Surcharge,40.85,,,40.85,Fee Schedule,Average Sale Price (ASP) x 6,916.9,35,,916.9,percent of total billed charges,Drugs,916.9,35,,916.9,percent of total billed charges,Drugs,890.7,34,,890.7,percent of total billed charges,Drugs,890.7,34,,890.7,percent of total billed charges,Drugs,890.7,34,,890.7,percent of total billed charges,Drugs,890.7,34,,890.7,percent of total billed charges,Drugs,916.9,35,,916.9,percent of total billed charges,Drugs,890.7,34,"If Charge > 500, then 34 percent",890.7,percent of total billed charges,Drugs,916.9,35,,916.9,percent of total billed charges,Drugs,916.9,35,,916.9,percent of total billed charges,Drugs,916.9,35,,916.9,percent of total billed charges,Drugs,916.9,35,,916.9,percent of total billed charges,Drugs,916.9,35,,916.9,percent of total billed charges,Drugs,1047.89,40,,1047.89,percent of total billed charges,Drugs,1833.8,70,,1833.8,percent of total billed charges,All Other,943.1,36,,943.1,percent of total billed charges,Drugs,943.1,36,,943.1,percent of total billed charges,Drugs,916.9,35,,916.9,percent of total billed charges,Drugs,916.9,35,,916.9,percent of total billed charges,Drugs,916.9,35,,916.9,percent of total billed charges,Drugs,916.9,35,,916.9,percent of total billed charges,Drugs,873.24,,,873.24,Other,Drug Cost,873.24,,,873.24,Other,Drug Cost,873.24,,,873.24,Other,Drug Cost,873.24,,,873.24,Other,Drug Cost,873.24,,,873.24,Other,Drug Cost,873.24,,,873.24,Other,Drug Cost,1964.79,,,1964.79,Other,225% of Medicaid,1222.54,,,1222.54,Other,140% of Medicaid,890.7,34,"If Charge > 2,000, then 34 percent",890.7,percent of total billed charges,Drugs,65.37,,,65.37,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",1877.47,,,1877.47,Other,215% Medicaid APG methodology,1877.47,,,1877.47,Other,215% Medicaid APG methodology,1091.55,,,1091.55,Other,125% Medicaid APG methodology,0.01,1964.79,
BUPRENORPHINE 2 MG TABLET,J0571,HCPCS,,80023653,CDM,636,RC,42858050103,NDC,both,30,EA,0.54,0.21,39.4668,,0.21,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.19,35,,0.19,percent of total billed charges,Drugs,0.19,35,,0.19,percent of total billed charges,Drugs,0.18,34,,0.18,percent of total billed charges,Drugs,0.18,34,,0.18,percent of total billed charges,Drugs,0.18,34,,0.18,percent of total billed charges,Drugs,0.18,34,,0.18,percent of total billed charges,Drugs,0.19,35,,0.19,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,0.19,35,,0.19,percent of total billed charges,Drugs,0.19,35,,0.19,percent of total billed charges,Drugs,0.19,35,,0.19,percent of total billed charges,Drugs,0.19,35,,0.19,percent of total billed charges,Drugs,0.19,35,,0.19,percent of total billed charges,Drugs,0.21,40,,0.21,percent of total billed charges,Drugs,0.38,70,,0.38,percent of total billed charges,All Other,0.19,36,,0.19,percent of total billed charges,Drugs,0.19,36,,0.19,percent of total billed charges,Drugs,0.19,35,,0.19,percent of total billed charges,Drugs,0.19,35,,0.19,percent of total billed charges,Drugs,0.19,35,,0.19,percent of total billed charges,Drugs,0.19,35,,0.19,percent of total billed charges,Drugs,0.18,,,0.18,Other,Drug Cost,0.18,,,0.18,Other,Drug Cost,0.18,,,0.18,Other,Drug Cost,0.18,,,0.18,Other,Drug Cost,0.18,,,0.18,Other,Drug Cost,0.18,,,0.18,Other,Drug Cost,0.4,,,0.4,Other,225% of Medicaid,0.25,,,0.25,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",0.38,,,0.38,Other,215% Medicaid APG methodology,0.38,,,0.38,Other,215% Medicaid APG methodology,0.22,,,0.22,Other,125% Medicaid APG methodology,0.01,0.4,
BUPRENORPHINE 8 MG TABLET,J0571,HCPCS,,80023654,CDM,636,RC,54017713,NDC,both,30,EA,1.23,0.48,39.4668,,0.48,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.43,35,,0.43,percent of total billed charges,Drugs,0.43,35,,0.43,percent of total billed charges,Drugs,0.42,34,,0.42,percent of total billed charges,Drugs,0.42,34,,0.42,percent of total billed charges,Drugs,0.42,34,,0.42,percent of total billed charges,Drugs,0.42,34,,0.42,percent of total billed charges,Drugs,0.43,35,,0.43,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,0.43,35,,0.43,percent of total billed charges,Drugs,0.43,35,,0.43,percent of total billed charges,Drugs,0.43,35,,0.43,percent of total billed charges,Drugs,0.43,35,,0.43,percent of total billed charges,Drugs,0.43,35,,0.43,percent of total billed charges,Drugs,0.49,40,,0.49,percent of total billed charges,Drugs,0.86,70,,0.86,percent of total billed charges,All Other,0.44,36,,0.44,percent of total billed charges,Drugs,0.44,36,,0.44,percent of total billed charges,Drugs,0.43,35,,0.43,percent of total billed charges,Drugs,0.43,35,,0.43,percent of total billed charges,Drugs,0.43,35,,0.43,percent of total billed charges,Drugs,0.43,35,,0.43,percent of total billed charges,Drugs,0.41,,,0.41,Other,Drug Cost,0.41,,,0.41,Other,Drug Cost,0.41,,,0.41,Other,Drug Cost,0.41,,,0.41,Other,Drug Cost,0.41,,,0.41,Other,Drug Cost,0.41,,,0.41,Other,Drug Cost,0.92,,,0.92,Other,225% of Medicaid,0.57,,,0.57,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",0.88,,,0.88,Other,215% Medicaid APG methodology,0.88,,,0.88,Other,215% Medicaid APG methodology,0.51,,,0.51,Other,125% Medicaid APG methodology,0.01,0.92,
HYDROMORPHONE 0.5MG/0.5ML INJ,J1170,HCPCS,,80023657,CDM,636,RC,76045000906,NDC,both,10,ML,1.48,45.3,,,45.3,Other,150% of Medicare + 9.63% HCRA Surcharge,27.55,,,27.55,Fee Schedule,Average Sale Price (ASP) x 6,0.52,35,,0.52,percent of total billed charges,Drugs,0.52,35,,0.52,percent of total billed charges,Drugs,0.5,34,,0.5,percent of total billed charges,Drugs,0.5,34,,0.5,percent of total billed charges,Drugs,0.5,34,,0.5,percent of total billed charges,Drugs,0.5,34,,0.5,percent of total billed charges,Drugs,0.52,35,,0.52,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,0.52,35,,0.52,percent of total billed charges,Drugs,0.52,35,,0.52,percent of total billed charges,Drugs,0.52,35,,0.52,percent of total billed charges,Drugs,0.52,35,,0.52,percent of total billed charges,Drugs,0.52,35,,0.52,percent of total billed charges,Drugs,0.59,40,,0.59,percent of total billed charges,Drugs,1.04,70,,1.04,percent of total billed charges,All Other,0.53,36,,0.53,percent of total billed charges,Drugs,0.53,36,,0.53,percent of total billed charges,Drugs,0.52,35,,0.52,percent of total billed charges,Drugs,0.52,35,,0.52,percent of total billed charges,Drugs,0.52,35,,0.52,percent of total billed charges,Drugs,0.52,35,,0.52,percent of total billed charges,Drugs,0.49,,,0.49,Other,Drug Cost,0.49,,,0.49,Other,Drug Cost,0.49,,,0.49,Other,Drug Cost,0.49,,,0.49,Other,Drug Cost,0.49,,,0.49,Other,Drug Cost,0.49,,,0.49,Other,Drug Cost,1.11,,,1.11,Other,225% of Medicaid,0.69,,,0.69,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,44.07,,,44.07,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",1.06,,,1.06,Other,215% Medicaid APG methodology,1.06,,,1.06,Other,215% Medicaid APG methodology,0.62,,,0.62,Other,125% Medicaid APG methodology,0.01,45.3,
GAMMAGARD LIQUID 5GM,J1569,HCPCS,,80023663,CDM,636,RC,944270004,NDC,both,1,ML,930.18,435.63,,,435.63,Other,150% of Medicare + 9.63% HCRA Surcharge,264.91,,,264.91,Fee Schedule,Average Sale Price (ASP) x 6,325.56,35,,325.56,percent of total billed charges,Drugs,325.56,35,,325.56,percent of total billed charges,Drugs,316.26,34,,316.26,percent of total billed charges,Drugs,316.26,34,,316.26,percent of total billed charges,Drugs,316.26,34,,316.26,percent of total billed charges,Drugs,316.26,34,,316.26,percent of total billed charges,Drugs,325.56,35,,325.56,percent of total billed charges,Drugs,316.26,34,"If Charge > 500, then 34 percent",316.26,percent of total billed charges,Drugs,325.56,35,,325.56,percent of total billed charges,Drugs,325.56,35,,325.56,percent of total billed charges,Drugs,325.56,35,,325.56,percent of total billed charges,Drugs,325.56,35,,325.56,percent of total billed charges,Drugs,325.56,35,,325.56,percent of total billed charges,Drugs,372.07,40,,372.07,percent of total billed charges,Drugs,651.13,70,,651.13,percent of total billed charges,All Other,334.86,36,,334.86,percent of total billed charges,Drugs,334.86,36,,334.86,percent of total billed charges,Drugs,325.56,35,,325.56,percent of total billed charges,Drugs,325.56,35,,325.56,percent of total billed charges,Drugs,325.56,35,,325.56,percent of total billed charges,Drugs,325.56,35,,325.56,percent of total billed charges,Drugs,310.06,,,310.06,Other,Drug Cost,310.06,,,310.06,Other,Drug Cost,310.06,,,310.06,Other,Drug Cost,310.06,,,310.06,Other,Drug Cost,310.06,,,310.06,Other,Drug Cost,310.06,,,310.06,Other,Drug Cost,697.64,,,697.64,Other,225% of Medicaid,434.08,,,434.08,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,423.86,,,423.86,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",666.63,,,666.63,Other,215% Medicaid APG methodology,666.63,,,666.63,Other,215% Medicaid APG methodology,387.58,,,387.58,Other,125% Medicaid APG methodology,0.01,697.64,
MEPOLIZUMAB 100MG INJ,J2182,HCPCS,,80023664,CDM,636,RC,173088101,NDC,both,1,EA,8938.65,300.98,,,300.98,Other,150% of Medicare + 9.63% HCRA Surcharge,183.03,,,183.03,Fee Schedule,Average Sale Price (ASP) x 6,3128.53,35,,3128.53,percent of total billed charges,Drugs,3128.53,35,,3128.53,percent of total billed charges,Drugs,3039.14,34,,3039.14,percent of total billed charges,Drugs,3039.14,34,,3039.14,percent of total billed charges,Drugs,3039.14,34,,3039.14,percent of total billed charges,Drugs,3039.14,34,,3039.14,percent of total billed charges,Drugs,3128.53,35,,3128.53,percent of total billed charges,Drugs,3039.14,34,"If Charge > 500, then 34 percent",3039.14,percent of total billed charges,Drugs,3128.53,35,,3128.53,percent of total billed charges,Drugs,3128.53,35,,3128.53,percent of total billed charges,Drugs,3128.53,35,,3128.53,percent of total billed charges,Drugs,3128.53,35,,3128.53,percent of total billed charges,Drugs,3128.53,35,,3128.53,percent of total billed charges,Drugs,3575.46,40,,3575.46,percent of total billed charges,Drugs,6257.06,70,,6257.06,percent of total billed charges,All Other,3217.91,36,,3217.91,percent of total billed charges,Drugs,3217.91,36,,3217.91,percent of total billed charges,Drugs,3128.53,35,,3128.53,percent of total billed charges,Drugs,3128.53,35,,3128.53,percent of total billed charges,Drugs,3128.53,35,,3128.53,percent of total billed charges,Drugs,3128.53,35,,3128.53,percent of total billed charges,Drugs,2979.55,,,2979.55,Other,Drug Cost,2979.55,,,2979.55,Other,Drug Cost,2979.55,,,2979.55,Other,Drug Cost,2979.55,,,2979.55,Other,Drug Cost,2979.55,,,2979.55,Other,Drug Cost,2979.55,,,2979.55,Other,Drug Cost,6703.99,,,6703.99,Other,225% of Medicaid,4171.37,,,4171.37,Other,140% of Medicaid,3039.14,34,"If Charge > 2,000, then 34 percent",3039.14,percent of total billed charges,Drugs,292.85,,,292.85,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",6406.03,,,6406.03,Other,215% Medicaid APG methodology,6406.03,,,6406.03,Other,215% Medicaid APG methodology,3724.44,,,3724.44,Other,125% Medicaid APG methodology,0.01,6703.99,
ARIPIPRAZOLE LAUROXIL 441MG INJ,J1944,HCPCS,,80023665,CDM,636,RC,65757040103,NDC,both,1,ML,2752.38,30.68,,,30.68,Other,150% of Medicare + 9.63% HCRA Surcharge,18.65,,,18.65,Fee Schedule,Average Sale Price (ASP) x 6,963.33,35,,963.33,percent of total billed charges,Drugs,963.33,35,,963.33,percent of total billed charges,Drugs,935.81,34,,935.81,percent of total billed charges,Drugs,935.81,34,,935.81,percent of total billed charges,Drugs,935.81,34,,935.81,percent of total billed charges,Drugs,935.81,34,,935.81,percent of total billed charges,Drugs,963.33,35,,963.33,percent of total billed charges,Drugs,935.81,34,"If Charge > 500, then 34 percent",935.81,percent of total billed charges,Drugs,963.33,35,,963.33,percent of total billed charges,Drugs,963.33,35,,963.33,percent of total billed charges,Drugs,963.33,35,,963.33,percent of total billed charges,Drugs,963.33,35,,963.33,percent of total billed charges,Drugs,963.33,35,,963.33,percent of total billed charges,Drugs,1100.95,40,,1100.95,percent of total billed charges,Drugs,1926.67,70,,1926.67,percent of total billed charges,All Other,990.86,36,,990.86,percent of total billed charges,Drugs,990.86,36,,990.86,percent of total billed charges,Drugs,963.33,35,,963.33,percent of total billed charges,Drugs,963.33,35,,963.33,percent of total billed charges,Drugs,963.33,35,,963.33,percent of total billed charges,Drugs,963.33,35,,963.33,percent of total billed charges,Drugs,917.46,,,917.46,Other,Drug Cost,917.46,,,917.46,Other,Drug Cost,917.46,,,917.46,Other,Drug Cost,917.46,,,917.46,Other,Drug Cost,917.46,,,917.46,Other,Drug Cost,917.46,,,917.46,Other,Drug Cost,2064.29,,,2064.29,Other,225% of Medicaid,1284.44,,,1284.44,Other,140% of Medicaid,935.81,34,"If Charge > 2,000, then 34 percent",935.81,percent of total billed charges,Drugs,29.85,,,29.85,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",1972.54,,,1972.54,Other,215% Medicaid APG methodology,1972.54,,,1972.54,Other,215% Medicaid APG methodology,1146.83,,,1146.83,Other,125% Medicaid APG methodology,0.01,2064.29,
ARIPIPRAZOLE LAUROXIL 662MG INJ,J1944,HCPCS,,80023666,CDM,636,RC,65757040203,NDC,both,1,ML,4114.08,30.68,,,30.68,Other,150% of Medicare + 9.63% HCRA Surcharge,18.65,,,18.65,Fee Schedule,Average Sale Price (ASP) x 6,1439.93,35,,1439.93,percent of total billed charges,Drugs,1439.93,35,,1439.93,percent of total billed charges,Drugs,1398.79,34,,1398.79,percent of total billed charges,Drugs,1398.79,34,,1398.79,percent of total billed charges,Drugs,1398.79,34,,1398.79,percent of total billed charges,Drugs,1398.79,34,,1398.79,percent of total billed charges,Drugs,1439.93,35,,1439.93,percent of total billed charges,Drugs,1398.79,34,"If Charge > 500, then 34 percent",1398.79,percent of total billed charges,Drugs,1439.93,35,,1439.93,percent of total billed charges,Drugs,1439.93,35,,1439.93,percent of total billed charges,Drugs,1439.93,35,,1439.93,percent of total billed charges,Drugs,1439.93,35,,1439.93,percent of total billed charges,Drugs,1439.93,35,,1439.93,percent of total billed charges,Drugs,1645.63,40,,1645.63,percent of total billed charges,Drugs,2879.86,70,,2879.86,percent of total billed charges,All Other,1481.07,36,,1481.07,percent of total billed charges,Drugs,1481.07,36,,1481.07,percent of total billed charges,Drugs,1439.93,35,,1439.93,percent of total billed charges,Drugs,1439.93,35,,1439.93,percent of total billed charges,Drugs,1439.93,35,,1439.93,percent of total billed charges,Drugs,1439.93,35,,1439.93,percent of total billed charges,Drugs,1371.36,,,1371.36,Other,Drug Cost,1371.36,,,1371.36,Other,Drug Cost,1371.36,,,1371.36,Other,Drug Cost,1371.36,,,1371.36,Other,Drug Cost,1371.36,,,1371.36,Other,Drug Cost,1371.36,,,1371.36,Other,Drug Cost,3085.56,,,3085.56,Other,225% of Medicaid,1919.9,,,1919.9,Other,140% of Medicaid,1398.79,34,"If Charge > 2,000, then 34 percent",1398.79,percent of total billed charges,Drugs,29.85,,,29.85,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",2948.42,,,2948.42,Other,215% Medicaid APG methodology,2948.42,,,2948.42,Other,215% Medicaid APG methodology,1714.2,,,1714.2,Other,125% Medicaid APG methodology,0.01,3085.56,
ARIPIPRAZOLE LAUROXIL 882MG INJ,J1944,HCPCS,,80023667,CDM,636,RC,65757040303,NDC,both,1,ML,5469.69,30.68,,,30.68,Other,150% of Medicare + 9.63% HCRA Surcharge,18.65,,,18.65,Fee Schedule,Average Sale Price (ASP) x 6,1914.39,35,,1914.39,percent of total billed charges,Drugs,1914.39,35,,1914.39,percent of total billed charges,Drugs,1859.69,34,,1859.69,percent of total billed charges,Drugs,1859.69,34,,1859.69,percent of total billed charges,Drugs,1859.69,34,,1859.69,percent of total billed charges,Drugs,1859.69,34,,1859.69,percent of total billed charges,Drugs,1914.39,35,,1914.39,percent of total billed charges,Drugs,1859.69,34,"If Charge > 500, then 34 percent",1859.69,percent of total billed charges,Drugs,1914.39,35,,1914.39,percent of total billed charges,Drugs,1914.39,35,,1914.39,percent of total billed charges,Drugs,1914.39,35,,1914.39,percent of total billed charges,Drugs,1914.39,35,,1914.39,percent of total billed charges,Drugs,1914.39,35,,1914.39,percent of total billed charges,Drugs,2187.88,40,,2187.88,percent of total billed charges,Drugs,3828.78,70,,3828.78,percent of total billed charges,All Other,1969.09,36,,1969.09,percent of total billed charges,Drugs,1969.09,36,,1969.09,percent of total billed charges,Drugs,1914.39,35,,1914.39,percent of total billed charges,Drugs,1914.39,35,,1914.39,percent of total billed charges,Drugs,1914.39,35,,1914.39,percent of total billed charges,Drugs,1914.39,35,,1914.39,percent of total billed charges,Drugs,1823.23,,,1823.23,Other,Drug Cost,1823.23,,,1823.23,Other,Drug Cost,1823.23,,,1823.23,Other,Drug Cost,1823.23,,,1823.23,Other,Drug Cost,1823.23,,,1823.23,Other,Drug Cost,1823.23,,,1823.23,Other,Drug Cost,4102.27,,,4102.27,Other,225% of Medicaid,2552.52,,,2552.52,Other,140% of Medicaid,1859.69,34,"If Charge > 2,000, then 34 percent",1859.69,percent of total billed charges,Drugs,29.85,,,29.85,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",3919.94,,,3919.94,Other,215% Medicaid APG methodology,3919.94,,,3919.94,Other,215% Medicaid APG methodology,2279.04,,,2279.04,Other,125% Medicaid APG methodology,0.01,4102.27,
ATEZOLIZUMAB 1200MG/20ML,J9022,HCPCS,,80023669,CDM,636,RC,50242091701,NDC,both,1,ML,32428.17,838.78,,,838.78,Other,150% of Medicare + 9.63% HCRA Surcharge,510.07,,,510.07,Fee Schedule,Average Sale Price (ASP) x 6,11349.86,35,,11349.86,percent of total billed charges,Drugs,11349.86,35,,11349.86,percent of total billed charges,Drugs,11025.58,34,,11025.58,percent of total billed charges,Drugs,11025.58,34,,11025.58,percent of total billed charges,Drugs,11025.58,34,,11025.58,percent of total billed charges,Drugs,11025.58,34,,11025.58,percent of total billed charges,Drugs,11349.86,35,,11349.86,percent of total billed charges,Drugs,11025.58,34,"If Charge > 500, then 34 percent",11025.58,percent of total billed charges,Drugs,11349.86,35,,11349.86,percent of total billed charges,Drugs,11349.86,35,,11349.86,percent of total billed charges,Drugs,11349.86,35,,11349.86,percent of total billed charges,Drugs,11349.86,35,,11349.86,percent of total billed charges,Drugs,11349.86,35,,11349.86,percent of total billed charges,Drugs,12971.27,40,,12971.27,percent of total billed charges,Drugs,22699.72,70,,22699.72,percent of total billed charges,All Other,11674.14,36,,11674.14,percent of total billed charges,Drugs,11674.14,36,,11674.14,percent of total billed charges,Drugs,11349.86,35,,11349.86,percent of total billed charges,Drugs,11349.86,35,,11349.86,percent of total billed charges,Drugs,11349.86,35,,11349.86,percent of total billed charges,Drugs,11349.86,35,,11349.86,percent of total billed charges,Drugs,10809.39,,,10809.39,Other,Drug Cost,10809.39,,,10809.39,Other,Drug Cost,10809.39,,,10809.39,Other,Drug Cost,10809.39,,,10809.39,Other,Drug Cost,10809.39,,,10809.39,Other,Drug Cost,10809.39,,,10809.39,Other,Drug Cost,24321.13,,,24321.13,Other,225% of Medicaid,15133.15,,,15133.15,Other,140% of Medicaid,11025.58,34,"If Charge > 2,000, then 34 percent",11025.58,percent of total billed charges,Drugs,816.11,,,816.11,Other,160% Medicare Fee Schedule,11025.58,34,,11025.58,Other,"Drug Charges > 20,000, then 34% of Charges",23240.19,,,23240.19,Other,215% Medicaid APG methodology,23240.19,,,23240.19,Other,215% Medicaid APG methodology,13511.74,,,13511.74,Other,125% Medicaid APG methodology,510.07,24321.13,
MAGNESIUM SULFATE 4G/100ML,J3475,HCPCS,,80023671,CDM,636,RC,63323010601,NDC,both,24,ML,6.54,6.82,,,6.82,Other,150% of Medicare + 9.63% HCRA Surcharge,4.15,,,4.15,Fee Schedule,Average Sale Price (ASP) x 6,2.29,35,,2.29,percent of total billed charges,Drugs,2.29,35,,2.29,percent of total billed charges,Drugs,2.22,34,,2.22,percent of total billed charges,Drugs,2.22,34,,2.22,percent of total billed charges,Drugs,2.22,34,,2.22,percent of total billed charges,Drugs,2.22,34,,2.22,percent of total billed charges,Drugs,2.29,35,,2.29,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,2.29,35,,2.29,percent of total billed charges,Drugs,2.29,35,,2.29,percent of total billed charges,Drugs,2.29,35,,2.29,percent of total billed charges,Drugs,2.29,35,,2.29,percent of total billed charges,Drugs,2.29,35,,2.29,percent of total billed charges,Drugs,2.61,40,,2.61,percent of total billed charges,Drugs,4.58,70,,4.58,percent of total billed charges,All Other,2.35,36,,2.35,percent of total billed charges,Drugs,2.35,36,,2.35,percent of total billed charges,Drugs,2.29,35,,2.29,percent of total billed charges,Drugs,2.29,35,,2.29,percent of total billed charges,Drugs,2.29,35,,2.29,percent of total billed charges,Drugs,2.29,35,,2.29,percent of total billed charges,Drugs,2.18,,,2.18,Other,Drug Cost,2.18,,,2.18,Other,Drug Cost,2.18,,,2.18,Other,Drug Cost,2.18,,,2.18,Other,Drug Cost,2.18,,,2.18,Other,Drug Cost,2.18,,,2.18,Other,Drug Cost,4.9,,,4.9,Other,225% of Medicaid,3.05,,,3.05,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,6.63,,,6.63,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",4.68,,,4.68,Other,215% Medicaid APG methodology,4.68,,,4.68,Other,215% Medicaid APG methodology,2.72,,,2.72,Other,125% Medicaid APG methodology,0.01,6.82,
HEMIN 350MG,J1640,HCPCS,,80023673,CDM,636,RC,55292070255,NDC,both,1,EA,19762.83,309.3,,,309.3,Other,150% of Medicare + 9.63% HCRA Surcharge,188.09,,,188.09,Fee Schedule,Average Sale Price (ASP) x 6,6916.99,35,,6916.99,percent of total billed charges,Drugs,6916.99,35,,6916.99,percent of total billed charges,Drugs,6719.36,34,,6719.36,percent of total billed charges,Drugs,6719.36,34,,6719.36,percent of total billed charges,Drugs,6719.36,34,,6719.36,percent of total billed charges,Drugs,6719.36,34,,6719.36,percent of total billed charges,Drugs,6916.99,35,,6916.99,percent of total billed charges,Drugs,6719.36,34,"If Charge > 500, then 34 percent",6719.36,percent of total billed charges,Drugs,6916.99,35,,6916.99,percent of total billed charges,Drugs,6916.99,35,,6916.99,percent of total billed charges,Drugs,6916.99,35,,6916.99,percent of total billed charges,Drugs,6916.99,35,,6916.99,percent of total billed charges,Drugs,6916.99,35,,6916.99,percent of total billed charges,Drugs,7905.13,40,,7905.13,percent of total billed charges,Drugs,13833.98,70,,13833.98,percent of total billed charges,All Other,7114.62,36,,7114.62,percent of total billed charges,Drugs,7114.62,36,,7114.62,percent of total billed charges,Drugs,6916.99,35,,6916.99,percent of total billed charges,Drugs,6916.99,35,,6916.99,percent of total billed charges,Drugs,6916.99,35,,6916.99,percent of total billed charges,Drugs,6916.99,35,,6916.99,percent of total billed charges,Drugs,6587.61,,,6587.61,Other,Drug Cost,6587.61,,,6587.61,Other,Drug Cost,6587.61,,,6587.61,Other,Drug Cost,6587.61,,,6587.61,Other,Drug Cost,6587.61,,,6587.61,Other,Drug Cost,6587.61,,,6587.61,Other,Drug Cost,14822.12,,,14822.12,Other,225% of Medicaid,9222.65,,,9222.65,Other,140% of Medicaid,6719.36,34,"If Charge > 2,000, then 34 percent",6719.36,percent of total billed charges,Drugs,300.94,,,300.94,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",14163.36,,,14163.36,Other,215% Medicaid APG methodology,14163.36,,,14163.36,Other,215% Medicaid APG methodology,8234.51,,,8234.51,Other,125% Medicaid APG methodology,0.01,14822.12,
HERCEPTIN 150MG,J9355,HCPCS,,80023674,CDM,636,RC,50242013201,NDC,both,1,EA,4626.18,793.92,,,793.92,Other,150% of Medicare + 9.63% HCRA Surcharge,482.79,,,482.79,Fee Schedule,Average Sale Price (ASP) x 6,1619.16,35,,1619.16,percent of total billed charges,Drugs,1619.16,35,,1619.16,percent of total billed charges,Drugs,1572.9,34,,1572.9,percent of total billed charges,Drugs,1572.9,34,,1572.9,percent of total billed charges,Drugs,1572.9,34,,1572.9,percent of total billed charges,Drugs,1572.9,34,,1572.9,percent of total billed charges,Drugs,1619.16,35,,1619.16,percent of total billed charges,Drugs,1572.9,34,"If Charge > 500, then 34 percent",1572.9,percent of total billed charges,Drugs,1619.16,35,,1619.16,percent of total billed charges,Drugs,1619.16,35,,1619.16,percent of total billed charges,Drugs,1619.16,35,,1619.16,percent of total billed charges,Drugs,1619.16,35,,1619.16,percent of total billed charges,Drugs,1619.16,35,,1619.16,percent of total billed charges,Drugs,1850.47,40,,1850.47,percent of total billed charges,Drugs,3238.33,70,,3238.33,percent of total billed charges,All Other,1665.42,36,,1665.42,percent of total billed charges,Drugs,1665.42,36,,1665.42,percent of total billed charges,Drugs,1619.16,35,,1619.16,percent of total billed charges,Drugs,1619.16,35,,1619.16,percent of total billed charges,Drugs,1619.16,35,,1619.16,percent of total billed charges,Drugs,1619.16,35,,1619.16,percent of total billed charges,Drugs,1542.06,,,1542.06,Other,Drug Cost,1542.06,,,1542.06,Other,Drug Cost,1542.06,,,1542.06,Other,Drug Cost,1542.06,,,1542.06,Other,Drug Cost,1542.06,,,1542.06,Other,Drug Cost,1542.06,,,1542.06,Other,Drug Cost,3469.64,,,3469.64,Other,225% of Medicaid,2158.88,,,2158.88,Other,140% of Medicaid,1572.9,34,"If Charge > 2,000, then 34 percent",1572.9,percent of total billed charges,Drugs,772.46,,,772.46,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",3315.43,,,3315.43,Other,215% Medicaid APG methodology,3315.43,,,3315.43,Other,215% Medicaid APG methodology,1927.58,,,1927.58,Other,125% Medicaid APG methodology,0.01,3469.64,
DALBAVANCIN 500MG INJ,J0875,HCPCS,,80023679,CDM,636,RC,57970010001,NDC,both,1,EA,2174.16,150.89,,,150.89,Other,150% of Medicare + 9.63% HCRA Surcharge,91.76,,,91.76,Fee Schedule,Average Sale Price (ASP) x 6,760.96,35,,760.96,percent of total billed charges,Drugs,760.96,35,,760.96,percent of total billed charges,Drugs,739.21,34,,739.21,percent of total billed charges,Drugs,739.21,34,,739.21,percent of total billed charges,Drugs,739.21,34,,739.21,percent of total billed charges,Drugs,739.21,34,,739.21,percent of total billed charges,Drugs,760.96,35,,760.96,percent of total billed charges,Drugs,739.21,34,"If Charge > 500, then 34 percent",739.21,percent of total billed charges,Drugs,760.96,35,,760.96,percent of total billed charges,Drugs,760.96,35,,760.96,percent of total billed charges,Drugs,760.96,35,,760.96,percent of total billed charges,Drugs,760.96,35,,760.96,percent of total billed charges,Drugs,760.96,35,,760.96,percent of total billed charges,Drugs,869.66,40,,869.66,percent of total billed charges,Drugs,1521.91,70,,1521.91,percent of total billed charges,All Other,782.7,36,,782.7,percent of total billed charges,Drugs,782.7,36,,782.7,percent of total billed charges,Drugs,760.96,35,,760.96,percent of total billed charges,Drugs,760.96,35,,760.96,percent of total billed charges,Drugs,760.96,35,,760.96,percent of total billed charges,Drugs,760.96,35,,760.96,percent of total billed charges,Drugs,724.72,,,724.72,Other,Drug Cost,724.72,,,724.72,Other,Drug Cost,724.72,,,724.72,Other,Drug Cost,724.72,,,724.72,Other,Drug Cost,724.72,,,724.72,Other,Drug Cost,724.72,,,724.72,Other,Drug Cost,1630.62,,,1630.62,Other,225% of Medicaid,1014.61,,,1014.61,Other,140% of Medicaid,739.21,34,"If Charge > 2,000, then 34 percent",739.21,percent of total billed charges,Drugs,146.81,,,146.81,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",1558.15,,,1558.15,Other,215% Medicaid APG methodology,1558.15,,,1558.15,Other,215% Medicaid APG methodology,905.9,,,905.9,Other,125% Medicaid APG methodology,0.01,1630.62,
DURVALUMAB 50 MG/ML 2.4ML,J9173,HCPCS,,80023766,CDM,636,RC,310450012,NDC,both,1,ML,2940.9,796.3,,,796.3,Other,150% of Medicare + 9.63% HCRA Surcharge,484.24,,,484.24,Fee Schedule,Average Sale Price (ASP) x 6,1029.32,35,,1029.32,percent of total billed charges,Drugs,1029.32,35,,1029.32,percent of total billed charges,Drugs,999.91,34,,999.91,percent of total billed charges,Drugs,999.91,34,,999.91,percent of total billed charges,Drugs,999.91,34,,999.91,percent of total billed charges,Drugs,999.91,34,,999.91,percent of total billed charges,Drugs,1029.32,35,,1029.32,percent of total billed charges,Drugs,999.91,34,"If Charge > 500, then 34 percent",999.91,percent of total billed charges,Drugs,1029.32,35,,1029.32,percent of total billed charges,Drugs,1029.32,35,,1029.32,percent of total billed charges,Drugs,1029.32,35,,1029.32,percent of total billed charges,Drugs,1029.32,35,,1029.32,percent of total billed charges,Drugs,1029.32,35,,1029.32,percent of total billed charges,Drugs,1176.36,40,,1176.36,percent of total billed charges,Drugs,2058.63,70,,2058.63,percent of total billed charges,All Other,1058.72,36,,1058.72,percent of total billed charges,Drugs,1058.72,36,,1058.72,percent of total billed charges,Drugs,1029.32,35,,1029.32,percent of total billed charges,Drugs,1029.32,35,,1029.32,percent of total billed charges,Drugs,1029.32,35,,1029.32,percent of total billed charges,Drugs,1029.32,35,,1029.32,percent of total billed charges,Drugs,980.3,,,980.3,Other,Drug Cost,980.3,,,980.3,Other,Drug Cost,980.3,,,980.3,Other,Drug Cost,980.3,,,980.3,Other,Drug Cost,980.3,,,980.3,Other,Drug Cost,980.3,,,980.3,Other,Drug Cost,2205.68,,,2205.68,Other,225% of Medicaid,1372.42,,,1372.42,Other,140% of Medicaid,999.91,34,"If Charge > 2,000, then 34 percent",999.91,percent of total billed charges,Drugs,774.78,,,774.78,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",2107.65,,,2107.65,Other,215% Medicaid APG methodology,2107.65,,,2107.65,Other,215% Medicaid APG methodology,1225.38,,,1225.38,Other,125% Medicaid APG methodology,0.01,2205.68,
BENRALIZUMAB 30MG/1ML INJ,J0517,HCPCS,,80023778,CDM,636,RC,310173030,NDC,both,1,ML,10918.23,1672.42,,,1672.42,Other,150% of Medicare + 9.63% HCRA Surcharge,1017.01,,,1017.01,Fee Schedule,Average Sale Price (ASP) x 6,3821.38,35,,3821.38,percent of total billed charges,Drugs,3821.38,35,,3821.38,percent of total billed charges,Drugs,3712.2,34,,3712.2,percent of total billed charges,Drugs,3712.2,34,,3712.2,percent of total billed charges,Drugs,3712.2,34,,3712.2,percent of total billed charges,Drugs,3712.2,34,,3712.2,percent of total billed charges,Drugs,3821.38,35,,3821.38,percent of total billed charges,Drugs,3712.2,34,"If Charge > 500, then 34 percent",3712.2,percent of total billed charges,Drugs,3821.38,35,,3821.38,percent of total billed charges,Drugs,3821.38,35,,3821.38,percent of total billed charges,Drugs,3821.38,35,,3821.38,percent of total billed charges,Drugs,3821.38,35,,3821.38,percent of total billed charges,Drugs,3821.38,35,,3821.38,percent of total billed charges,Drugs,4367.29,40,,4367.29,percent of total billed charges,Drugs,7642.76,70,,7642.76,percent of total billed charges,All Other,3930.56,36,,3930.56,percent of total billed charges,Drugs,3930.56,36,,3930.56,percent of total billed charges,Drugs,3821.38,35,,3821.38,percent of total billed charges,Drugs,3821.38,35,,3821.38,percent of total billed charges,Drugs,3821.38,35,,3821.38,percent of total billed charges,Drugs,3821.38,35,,3821.38,percent of total billed charges,Drugs,3639.41,,,3639.41,Other,Drug Cost,3639.41,,,3639.41,Other,Drug Cost,3639.41,,,3639.41,Other,Drug Cost,3639.41,,,3639.41,Other,Drug Cost,3639.41,,,3639.41,Other,Drug Cost,3639.41,,,3639.41,Other,Drug Cost,8188.67,,,8188.67,Other,225% of Medicaid,5095.17,,,5095.17,Other,140% of Medicaid,3712.2,34,"If Charge > 2,000, then 34 percent",3712.2,percent of total billed charges,Drugs,1627.21,,,1627.21,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",7824.73,,,7824.73,Other,215% Medicaid APG methodology,7824.73,,,7824.73,Other,215% Medicaid APG methodology,4549.26,,,4549.26,Other,125% Medicaid APG methodology,0.01,8188.67,
ETELCALCETIDE 2.5MG/0.5ML,J0606,HCPCS,,80023809,CDM,636,RC,55513074010,NDC,both,10,ML,268.49,105.96,39.4668,,105.96,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,93.97,35,,93.97,percent of total billed charges,Drugs,93.97,35,,93.97,percent of total billed charges,Drugs,91.28,34,,91.28,percent of total billed charges,Drugs,91.28,34,,91.28,percent of total billed charges,Drugs,91.28,34,,91.28,percent of total billed charges,Drugs,91.28,34,,91.28,percent of total billed charges,Drugs,93.97,35,,93.97,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,93.97,35,,93.97,percent of total billed charges,Drugs,93.97,35,,93.97,percent of total billed charges,Drugs,93.97,35,,93.97,percent of total billed charges,Drugs,93.97,35,,93.97,percent of total billed charges,Drugs,93.97,35,,93.97,percent of total billed charges,Drugs,107.39,40,,107.39,percent of total billed charges,Drugs,187.94,70,,187.94,percent of total billed charges,All Other,96.65,36,,96.65,percent of total billed charges,Drugs,96.65,36,,96.65,percent of total billed charges,Drugs,93.97,35,,93.97,percent of total billed charges,Drugs,93.97,35,,93.97,percent of total billed charges,Drugs,93.97,35,,93.97,percent of total billed charges,Drugs,93.97,35,,93.97,percent of total billed charges,Drugs,89.5,,,89.5,Other,Drug Cost,89.5,,,89.5,Other,Drug Cost,89.5,,,89.5,Other,Drug Cost,89.5,,,89.5,Other,Drug Cost,89.5,,,89.5,Other,Drug Cost,89.5,,,89.5,Other,Drug Cost,201.36,,,201.36,Other,225% of Medicaid,125.29,,,125.29,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",192.41,,,192.41,Other,215% Medicaid APG methodology,192.41,,,192.41,Other,215% Medicaid APG methodology,111.87,,,111.87,Other,125% Medicaid APG methodology,0.01,201.36,
ETELCALCETIDE 5MG/ML,J0606,HCPCS,,80023810,CDM,636,RC,55513074110,NDC,both,10,ML,536.98,211.93,39.4668,,211.93,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,187.94,35,,187.94,percent of total billed charges,Drugs,187.94,35,,187.94,percent of total billed charges,Drugs,182.57,34,,182.57,percent of total billed charges,Drugs,182.57,34,,182.57,percent of total billed charges,Drugs,182.57,34,,182.57,percent of total billed charges,Drugs,182.57,34,,182.57,percent of total billed charges,Drugs,187.94,35,,187.94,percent of total billed charges,Drugs,182.57,34,"If Charge > 500, then 34 percent",182.57,percent of total billed charges,Drugs,187.94,35,,187.94,percent of total billed charges,Drugs,187.94,35,,187.94,percent of total billed charges,Drugs,187.94,35,,187.94,percent of total billed charges,Drugs,187.94,35,,187.94,percent of total billed charges,Drugs,187.94,35,,187.94,percent of total billed charges,Drugs,214.79,40,,214.79,percent of total billed charges,Drugs,375.88,70,,375.88,percent of total billed charges,All Other,193.31,36,,193.31,percent of total billed charges,Drugs,193.31,36,,193.31,percent of total billed charges,Drugs,187.94,35,,187.94,percent of total billed charges,Drugs,187.94,35,,187.94,percent of total billed charges,Drugs,187.94,35,,187.94,percent of total billed charges,Drugs,187.94,35,,187.94,percent of total billed charges,Drugs,178.99,,,178.99,Other,Drug Cost,178.99,,,178.99,Other,Drug Cost,178.99,,,178.99,Other,Drug Cost,178.99,,,178.99,Other,Drug Cost,178.99,,,178.99,Other,Drug Cost,178.99,,,178.99,Other,Drug Cost,402.73,,,402.73,Other,225% of Medicaid,250.59,,,250.59,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",384.83,,,384.83,Other,215% Medicaid APG methodology,384.83,,,384.83,Other,215% Medicaid APG methodology,223.74,,,223.74,Other,125% Medicaid APG methodology,0.01,402.73,
ETELCALCETIDE 10MG/2ML,J0606,HCPCS,,80023811,CDM,636,RC,55513074210,NDC,both,10,ML,1073.95,423.85,39.4668,,423.85,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,375.88,35,,375.88,percent of total billed charges,Drugs,375.88,35,,375.88,percent of total billed charges,Drugs,365.14,34,,365.14,percent of total billed charges,Drugs,365.14,34,,365.14,percent of total billed charges,Drugs,365.14,34,,365.14,percent of total billed charges,Drugs,365.14,34,,365.14,percent of total billed charges,Drugs,375.88,35,,375.88,percent of total billed charges,Drugs,365.14,34,"If Charge > 500, then 34 percent",365.14,percent of total billed charges,Drugs,375.88,35,,375.88,percent of total billed charges,Drugs,375.88,35,,375.88,percent of total billed charges,Drugs,375.88,35,,375.88,percent of total billed charges,Drugs,375.88,35,,375.88,percent of total billed charges,Drugs,375.88,35,,375.88,percent of total billed charges,Drugs,429.58,40,,429.58,percent of total billed charges,Drugs,751.77,70,,751.77,percent of total billed charges,All Other,386.62,36,,386.62,percent of total billed charges,Drugs,386.62,36,,386.62,percent of total billed charges,Drugs,375.88,35,,375.88,percent of total billed charges,Drugs,375.88,35,,375.88,percent of total billed charges,Drugs,375.88,35,,375.88,percent of total billed charges,Drugs,375.88,35,,375.88,percent of total billed charges,Drugs,357.98,,,357.98,Other,Drug Cost,357.98,,,357.98,Other,Drug Cost,357.98,,,357.98,Other,Drug Cost,357.98,,,357.98,Other,Drug Cost,357.98,,,357.98,Other,Drug Cost,357.98,,,357.98,Other,Drug Cost,805.46,,,805.46,Other,225% of Medicaid,501.18,,,501.18,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",769.67,,,769.67,Other,215% Medicaid APG methodology,769.67,,,769.67,Other,215% Medicaid APG methodology,447.48,,,447.48,Other,125% Medicaid APG methodology,0.01,805.46,
OBINUTUZUMAB 25MG/ML 40 ML,J9301,HCPCS,,80023814,CDM,636,RC,50242007001,NDC,both,1,ML,24465.9,694.04,,,694.04,Other,150% of Medicare + 9.63% HCRA Surcharge,422.05,,,422.05,Fee Schedule,Average Sale Price (ASP) x 6,8563.07,35,,8563.07,percent of total billed charges,Drugs,8563.07,35,,8563.07,percent of total billed charges,Drugs,8318.41,34,,8318.41,percent of total billed charges,Drugs,8318.41,34,,8318.41,percent of total billed charges,Drugs,8318.41,34,,8318.41,percent of total billed charges,Drugs,8318.41,34,,8318.41,percent of total billed charges,Drugs,8563.07,35,,8563.07,percent of total billed charges,Drugs,8318.41,34,"If Charge > 500, then 34 percent",8318.41,percent of total billed charges,Drugs,8563.07,35,,8563.07,percent of total billed charges,Drugs,8563.07,35,,8563.07,percent of total billed charges,Drugs,8563.07,35,,8563.07,percent of total billed charges,Drugs,8563.07,35,,8563.07,percent of total billed charges,Drugs,8563.07,35,,8563.07,percent of total billed charges,Drugs,9786.36,40,,9786.36,percent of total billed charges,Drugs,17126.13,70,,17126.13,percent of total billed charges,All Other,8807.72,36,,8807.72,percent of total billed charges,Drugs,8807.72,36,,8807.72,percent of total billed charges,Drugs,8563.07,35,,8563.07,percent of total billed charges,Drugs,8563.07,35,,8563.07,percent of total billed charges,Drugs,8563.07,35,,8563.07,percent of total billed charges,Drugs,8563.07,35,,8563.07,percent of total billed charges,Drugs,8155.3,,,8155.3,Other,Drug Cost,8155.3,,,8155.3,Other,Drug Cost,8155.3,,,8155.3,Other,Drug Cost,8155.3,,,8155.3,Other,Drug Cost,8155.3,,,8155.3,Other,Drug Cost,8155.3,,,8155.3,Other,Drug Cost,18349.43,,,18349.43,Other,225% of Medicaid,11417.42,,,11417.42,Other,140% of Medicaid,8318.41,34,"If Charge > 2,000, then 34 percent",8318.41,percent of total billed charges,Drugs,675.28,,,675.28,Other,160% Medicare Fee Schedule,8318.41,34,,8318.41,Other,"Drug Charges > 20,000, then 34% of Charges",17533.9,,,17533.9,Other,215% Medicaid APG methodology,17533.9,,,17533.9,Other,215% Medicaid APG methodology,10194.13,,,10194.13,Other,125% Medicaid APG methodology,422.05,18349.43,
CAFFEINE CITRATE 60 MG/ 3 ML,J0706,HCPCS,,80023830,CDM,636,RC,51754050001,NDC,both,1,ML,17.25,6.81,39.4668,,6.81,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,6.04,35,,6.04,percent of total billed charges,Drugs,6.04,35,,6.04,percent of total billed charges,Drugs,5.87,34,,5.87,percent of total billed charges,Drugs,5.87,34,,5.87,percent of total billed charges,Drugs,5.87,34,,5.87,percent of total billed charges,Drugs,5.87,34,,5.87,percent of total billed charges,Drugs,6.04,35,,6.04,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,6.04,35,,6.04,percent of total billed charges,Drugs,6.04,35,,6.04,percent of total billed charges,Drugs,6.04,35,,6.04,percent of total billed charges,Drugs,6.04,35,,6.04,percent of total billed charges,Drugs,6.04,35,,6.04,percent of total billed charges,Drugs,6.9,40,,6.9,percent of total billed charges,Drugs,12.08,70,,12.08,percent of total billed charges,All Other,6.21,36,,6.21,percent of total billed charges,Drugs,6.21,36,,6.21,percent of total billed charges,Drugs,6.04,35,,6.04,percent of total billed charges,Drugs,6.04,35,,6.04,percent of total billed charges,Drugs,6.04,35,,6.04,percent of total billed charges,Drugs,6.04,35,,6.04,percent of total billed charges,Drugs,5.75,,,5.75,Other,Drug Cost,5.75,,,5.75,Other,Drug Cost,5.75,,,5.75,Other,Drug Cost,5.75,,,5.75,Other,Drug Cost,5.75,,,5.75,Other,Drug Cost,5.75,,,5.75,Other,Drug Cost,12.94,,,12.94,Other,225% of Medicaid,8.05,,,8.05,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",12.36,,,12.36,Other,215% Medicaid APG methodology,12.36,,,12.36,Other,215% Medicaid APG methodology,7.19,,,7.19,Other,125% Medicaid APG methodology,0.01,12.94,
ARIPIPRAZOLE LAUROXIL 675MG/2.4ML ER INJ,J1943,HCPCS,,80023835,CDM,636,RC,65757050003,NDC,both,1,ML,4350.09,30.5,,,30.5,Other,150% of Medicare + 9.63% HCRA Surcharge,18.55,,,18.55,Fee Schedule,Average Sale Price (ASP) x 6,1522.53,35,,1522.53,percent of total billed charges,Drugs,1522.53,35,,1522.53,percent of total billed charges,Drugs,1479.03,34,,1479.03,percent of total billed charges,Drugs,1479.03,34,,1479.03,percent of total billed charges,Drugs,1479.03,34,,1479.03,percent of total billed charges,Drugs,1479.03,34,,1479.03,percent of total billed charges,Drugs,1522.53,35,,1522.53,percent of total billed charges,Drugs,1479.03,34,"If Charge > 500, then 34 percent",1479.03,percent of total billed charges,Drugs,1522.53,35,,1522.53,percent of total billed charges,Drugs,1522.53,35,,1522.53,percent of total billed charges,Drugs,1522.53,35,,1522.53,percent of total billed charges,Drugs,1522.53,35,,1522.53,percent of total billed charges,Drugs,1522.53,35,,1522.53,percent of total billed charges,Drugs,1740.04,40,,1740.04,percent of total billed charges,Drugs,3045.06,70,,3045.06,percent of total billed charges,All Other,1566.03,36,,1566.03,percent of total billed charges,Drugs,1566.03,36,,1566.03,percent of total billed charges,Drugs,1522.53,35,,1522.53,percent of total billed charges,Drugs,1522.53,35,,1522.53,percent of total billed charges,Drugs,1522.53,35,,1522.53,percent of total billed charges,Drugs,1522.53,35,,1522.53,percent of total billed charges,Drugs,1450.03,,,1450.03,Other,Drug Cost,1450.03,,,1450.03,Other,Drug Cost,1450.03,,,1450.03,Other,Drug Cost,1450.03,,,1450.03,Other,Drug Cost,1450.03,,,1450.03,Other,Drug Cost,1450.03,,,1450.03,Other,Drug Cost,3262.57,,,3262.57,Other,225% of Medicaid,2030.04,,,2030.04,Other,140% of Medicaid,1479.03,34,"If Charge > 2,000, then 34 percent",1479.03,percent of total billed charges,Drugs,29.67,,,29.67,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",3117.56,,,3117.56,Other,215% Medicaid APG methodology,3117.56,,,3117.56,Other,215% Medicaid APG methodology,1812.54,,,1812.54,Other,125% Medicaid APG methodology,0.01,3262.57,
OCRELIZUMAB 300MG/10ML INJ,J2350,HCPCS,,80023836,CDM,636,RC,50242015001,NDC,both,1,ML,39308.07,589.55,,,589.55,Other,150% of Medicare + 9.63% HCRA Surcharge,358.51,,,358.51,Fee Schedule,Average Sale Price (ASP) x 6,13757.82,35,,13757.82,percent of total billed charges,Drugs,13757.82,35,,13757.82,percent of total billed charges,Drugs,13364.74,34,,13364.74,percent of total billed charges,Drugs,13364.74,34,,13364.74,percent of total billed charges,Drugs,13364.74,34,,13364.74,percent of total billed charges,Drugs,13364.74,34,,13364.74,percent of total billed charges,Drugs,13757.82,35,,13757.82,percent of total billed charges,Drugs,13364.74,34,"If Charge > 500, then 34 percent",13364.74,percent of total billed charges,Drugs,13757.82,35,,13757.82,percent of total billed charges,Drugs,13757.82,35,,13757.82,percent of total billed charges,Drugs,13757.82,35,,13757.82,percent of total billed charges,Drugs,13757.82,35,,13757.82,percent of total billed charges,Drugs,13757.82,35,,13757.82,percent of total billed charges,Drugs,15723.23,40,,15723.23,percent of total billed charges,Drugs,27515.65,70,,27515.65,percent of total billed charges,All Other,14150.91,36,,14150.91,percent of total billed charges,Drugs,14150.91,36,,14150.91,percent of total billed charges,Drugs,13757.82,35,,13757.82,percent of total billed charges,Drugs,13757.82,35,,13757.82,percent of total billed charges,Drugs,13757.82,35,,13757.82,percent of total billed charges,Drugs,13757.82,35,,13757.82,percent of total billed charges,Drugs,13102.69,,,13102.69,Other,Drug Cost,13102.69,,,13102.69,Other,Drug Cost,13102.69,,,13102.69,Other,Drug Cost,13102.69,,,13102.69,Other,Drug Cost,13102.69,,,13102.69,Other,Drug Cost,13102.69,,,13102.69,Other,Drug Cost,29481.05,,,29481.05,Other,225% of Medicaid,18343.77,,,18343.77,Other,140% of Medicaid,13364.74,34,"If Charge > 2,000, then 34 percent",13364.74,percent of total billed charges,Drugs,573.61,,,573.61,Other,160% Medicare Fee Schedule,13364.74,34,,13364.74,Other,"Drug Charges > 20,000, then 34% of Charges",28170.78,,,28170.78,Other,215% Medicaid APG methodology,28170.78,,,28170.78,Other,215% Medicaid APG methodology,16378.36,,,16378.36,Other,125% Medicaid APG methodology,358.51,29481.05,
FILGRASTIM-SNDZ 300 MCG/0.5ML,Q5101,HCPCS,,80023837,CDM,636,RC,61314031801,NDC,both,1,ML,225,3.15,,,3.15,Other,150% of Medicare + 9.63% HCRA Surcharge,1.91,,,1.91,Fee Schedule,Average Sale Price (ASP) x 6,78.75,35,,78.75,percent of total billed charges,Drugs,78.75,35,,78.75,percent of total billed charges,Drugs,76.5,34,,76.5,percent of total billed charges,Drugs,76.5,34,,76.5,percent of total billed charges,Drugs,76.5,34,,76.5,percent of total billed charges,Drugs,76.5,34,,76.5,percent of total billed charges,Drugs,78.75,35,,78.75,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,78.75,35,,78.75,percent of total billed charges,Drugs,78.75,35,,78.75,percent of total billed charges,Drugs,78.75,35,,78.75,percent of total billed charges,Drugs,78.75,35,,78.75,percent of total billed charges,Drugs,78.75,35,,78.75,percent of total billed charges,Drugs,90,40,,90,percent of total billed charges,Drugs,157.5,70,,157.5,percent of total billed charges,All Other,81,36,,81,percent of total billed charges,Drugs,81,36,,81,percent of total billed charges,Drugs,78.75,35,,78.75,percent of total billed charges,Drugs,78.75,35,,78.75,percent of total billed charges,Drugs,78.75,35,,78.75,percent of total billed charges,Drugs,78.75,35,,78.75,percent of total billed charges,Drugs,75,,,75,Other,Drug Cost,75,,,75,Other,Drug Cost,75,,,75,Other,Drug Cost,75,,,75,Other,Drug Cost,75,,,75,Other,Drug Cost,75,,,75,Other,Drug Cost,168.75,,,168.75,Other,225% of Medicaid,105,,,105,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,3.06,,,3.06,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",161.25,,,161.25,Other,215% Medicaid APG methodology,161.25,,,161.25,Other,215% Medicaid APG methodology,93.75,,,93.75,Other,125% Medicaid APG methodology,0.01,168.75,
FILGRASTIM-SNDZ 480 MCG/ 0.8ML,Q5101,HCPCS,,80023838,CDM,636,RC,61314032601,NDC,both,1,ML,344.43,3.15,,,3.15,Other,150% of Medicare + 9.63% HCRA Surcharge,1.91,,,1.91,Fee Schedule,Average Sale Price (ASP) x 6,120.55,35,,120.55,percent of total billed charges,Drugs,120.55,35,,120.55,percent of total billed charges,Drugs,117.11,34,,117.11,percent of total billed charges,Drugs,117.11,34,,117.11,percent of total billed charges,Drugs,117.11,34,,117.11,percent of total billed charges,Drugs,117.11,34,,117.11,percent of total billed charges,Drugs,120.55,35,,120.55,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,120.55,35,,120.55,percent of total billed charges,Drugs,120.55,35,,120.55,percent of total billed charges,Drugs,120.55,35,,120.55,percent of total billed charges,Drugs,120.55,35,,120.55,percent of total billed charges,Drugs,120.55,35,,120.55,percent of total billed charges,Drugs,137.77,40,,137.77,percent of total billed charges,Drugs,241.1,70,,241.1,percent of total billed charges,All Other,123.99,36,,123.99,percent of total billed charges,Drugs,123.99,36,,123.99,percent of total billed charges,Drugs,120.55,35,,120.55,percent of total billed charges,Drugs,120.55,35,,120.55,percent of total billed charges,Drugs,120.55,35,,120.55,percent of total billed charges,Drugs,120.55,35,,120.55,percent of total billed charges,Drugs,114.81,,,114.81,Other,Drug Cost,114.81,,,114.81,Other,Drug Cost,114.81,,,114.81,Other,Drug Cost,114.81,,,114.81,Other,Drug Cost,114.81,,,114.81,Other,Drug Cost,114.81,,,114.81,Other,Drug Cost,258.32,,,258.32,Other,225% of Medicaid,160.73,,,160.73,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,3.06,,,3.06,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",246.84,,,246.84,Other,215% Medicaid APG methodology,246.84,,,246.84,Other,215% Medicaid APG methodology,143.51,,,143.51,Other,125% Medicaid APG methodology,0.01,258.32,
OCTAGAM 10% 5 GM LIQUID,J1568,HCPCS,,80023839,CDM,636,RC,68982085002,NDC,both,1,ML,951.15,443.78,,,443.78,Other,150% of Medicare + 9.63% HCRA Surcharge,269.87,,,269.87,Fee Schedule,Average Sale Price (ASP) x 6,332.9,35,,332.9,percent of total billed charges,Drugs,332.9,35,,332.9,percent of total billed charges,Drugs,323.39,34,,323.39,percent of total billed charges,Drugs,323.39,34,,323.39,percent of total billed charges,Drugs,323.39,34,,323.39,percent of total billed charges,Drugs,323.39,34,,323.39,percent of total billed charges,Drugs,332.9,35,,332.9,percent of total billed charges,Drugs,323.39,34,"If Charge > 500, then 34 percent",323.39,percent of total billed charges,Drugs,332.9,35,,332.9,percent of total billed charges,Drugs,332.9,35,,332.9,percent of total billed charges,Drugs,332.9,35,,332.9,percent of total billed charges,Drugs,332.9,35,,332.9,percent of total billed charges,Drugs,332.9,35,,332.9,percent of total billed charges,Drugs,380.46,40,,380.46,percent of total billed charges,Drugs,665.81,70,,665.81,percent of total billed charges,All Other,342.41,36,,342.41,percent of total billed charges,Drugs,342.41,36,,342.41,percent of total billed charges,Drugs,332.9,35,,332.9,percent of total billed charges,Drugs,332.9,35,,332.9,percent of total billed charges,Drugs,332.9,35,,332.9,percent of total billed charges,Drugs,332.9,35,,332.9,percent of total billed charges,Drugs,317.05,,,317.05,Other,Drug Cost,317.05,,,317.05,Other,Drug Cost,317.05,,,317.05,Other,Drug Cost,317.05,,,317.05,Other,Drug Cost,317.05,,,317.05,Other,Drug Cost,317.05,,,317.05,Other,Drug Cost,713.36,,,713.36,Other,225% of Medicaid,443.87,,,443.87,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,431.79,,,431.79,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",681.66,,,681.66,Other,215% Medicaid APG methodology,681.66,,,681.66,Other,215% Medicaid APG methodology,396.31,,,396.31,Other,125% Medicaid APG methodology,0.01,713.36,
BELATACEPT 250MG INJ,J0485,HCPCS,,80023854,CDM,636,RC,3037113,NDC,both,1,EA,2879.1,38.22,,,38.22,Other,150% of Medicare + 9.63% HCRA Surcharge,23.24,,,23.24,Fee Schedule,Average Sale Price (ASP) x 6,1007.69,35,,1007.69,percent of total billed charges,Drugs,1007.69,35,,1007.69,percent of total billed charges,Drugs,978.89,34,,978.89,percent of total billed charges,Drugs,978.89,34,,978.89,percent of total billed charges,Drugs,978.89,34,,978.89,percent of total billed charges,Drugs,978.89,34,,978.89,percent of total billed charges,Drugs,1007.69,35,,1007.69,percent of total billed charges,Drugs,978.89,34,"If Charge > 500, then 34 percent",978.89,percent of total billed charges,Drugs,1007.69,35,,1007.69,percent of total billed charges,Drugs,1007.69,35,,1007.69,percent of total billed charges,Drugs,1007.69,35,,1007.69,percent of total billed charges,Drugs,1007.69,35,,1007.69,percent of total billed charges,Drugs,1007.69,35,,1007.69,percent of total billed charges,Drugs,1151.64,40,,1151.64,percent of total billed charges,Drugs,2015.37,70,,2015.37,percent of total billed charges,All Other,1036.48,36,,1036.48,percent of total billed charges,Drugs,1036.48,36,,1036.48,percent of total billed charges,Drugs,1007.69,35,,1007.69,percent of total billed charges,Drugs,1007.69,35,,1007.69,percent of total billed charges,Drugs,1007.69,35,,1007.69,percent of total billed charges,Drugs,1007.69,35,,1007.69,percent of total billed charges,Drugs,959.7,,,959.7,Other,Drug Cost,959.7,,,959.7,Other,Drug Cost,959.7,,,959.7,Other,Drug Cost,959.7,,,959.7,Other,Drug Cost,959.7,,,959.7,Other,Drug Cost,959.7,,,959.7,Other,Drug Cost,2159.33,,,2159.33,Other,225% of Medicaid,1343.58,,,1343.58,Other,140% of Medicaid,978.89,34,"If Charge > 2,000, then 34 percent",978.89,percent of total billed charges,Drugs,37.19,,,37.19,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",2063.36,,,2063.36,Other,215% Medicaid APG methodology,2063.36,,,2063.36,Other,215% Medicaid APG methodology,1199.63,,,1199.63,Other,125% Medicaid APG methodology,0.01,2159.33,
IGG - HYALURONIDASE 5GM,J1575,HCPCS,,80023860,CDM,636,RC,944251102,NDC,both,1,ML,1492.8,168.57,,,168.57,Other,150% of Medicare + 9.63% HCRA Surcharge,102.51,,,102.51,Fee Schedule,Average Sale Price (ASP) x 6,522.48,35,,522.48,percent of total billed charges,Drugs,522.48,35,,522.48,percent of total billed charges,Drugs,507.55,34,,507.55,percent of total billed charges,Drugs,507.55,34,,507.55,percent of total billed charges,Drugs,507.55,34,,507.55,percent of total billed charges,Drugs,507.55,34,,507.55,percent of total billed charges,Drugs,522.48,35,,522.48,percent of total billed charges,Drugs,507.55,34,"If Charge > 500, then 34 percent",507.55,percent of total billed charges,Drugs,522.48,35,,522.48,percent of total billed charges,Drugs,522.48,35,,522.48,percent of total billed charges,Drugs,522.48,35,,522.48,percent of total billed charges,Drugs,522.48,35,,522.48,percent of total billed charges,Drugs,522.48,35,,522.48,percent of total billed charges,Drugs,597.12,40,,597.12,percent of total billed charges,Drugs,1044.96,70,,1044.96,percent of total billed charges,All Other,537.41,36,,537.41,percent of total billed charges,Drugs,537.41,36,,537.41,percent of total billed charges,Drugs,522.48,35,,522.48,percent of total billed charges,Drugs,522.48,35,,522.48,percent of total billed charges,Drugs,522.48,35,,522.48,percent of total billed charges,Drugs,522.48,35,,522.48,percent of total billed charges,Drugs,497.6,,,497.6,Other,Drug Cost,497.6,,,497.6,Other,Drug Cost,497.6,,,497.6,Other,Drug Cost,497.6,,,497.6,Other,Drug Cost,497.6,,,497.6,Other,Drug Cost,497.6,,,497.6,Other,Drug Cost,1119.6,,,1119.6,Other,225% of Medicaid,696.64,,,696.64,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,164.02,,,164.02,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",1069.84,,,1069.84,Other,215% Medicaid APG methodology,1069.84,,,1069.84,Other,215% Medicaid APG methodology,622,,,622,Other,125% Medicaid APG methodology,0.01,1119.6,
CYCLOPHOSPHAMIDE 25MG CAPS,J8530,HCPCS,,80023866,CDM,636,RC,54038225,NDC,both,100,EA,2.6,6.1,,,6.1,Other,150% of Medicare + 9.63% HCRA Surcharge,3.71,,,3.71,Fee Schedule,Average Sale Price (ASP) x 6,0.91,35,,0.91,percent of total billed charges,Drugs,0.91,35,,0.91,percent of total billed charges,Drugs,0.88,34,,0.88,percent of total billed charges,Drugs,0.88,34,,0.88,percent of total billed charges,Drugs,0.88,34,,0.88,percent of total billed charges,Drugs,0.88,34,,0.88,percent of total billed charges,Drugs,0.91,35,,0.91,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,0.91,35,,0.91,percent of total billed charges,Drugs,0.91,35,,0.91,percent of total billed charges,Drugs,0.91,35,,0.91,percent of total billed charges,Drugs,0.91,35,,0.91,percent of total billed charges,Drugs,0.91,35,,0.91,percent of total billed charges,Drugs,1.04,40,,1.04,percent of total billed charges,Drugs,1.82,70,,1.82,percent of total billed charges,All Other,0.93,36,,0.93,percent of total billed charges,Drugs,0.93,36,,0.93,percent of total billed charges,Drugs,0.91,35,,0.91,percent of total billed charges,Drugs,0.91,35,,0.91,percent of total billed charges,Drugs,0.91,35,,0.91,percent of total billed charges,Drugs,0.91,35,,0.91,percent of total billed charges,Drugs,0.87,,,0.87,Other,Drug Cost,0.87,,,0.87,Other,Drug Cost,0.87,,,0.87,Other,Drug Cost,0.87,,,0.87,Other,Drug Cost,0.87,,,0.87,Other,Drug Cost,0.87,,,0.87,Other,Drug Cost,1.95,,,1.95,Other,225% of Medicaid,1.21,,,1.21,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,5.93,,,5.93,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",1.86,,,1.86,Other,215% Medicaid APG methodology,1.86,,,1.86,Other,215% Medicaid APG methodology,1.08,,,1.08,Other,125% Medicaid APG methodology,0.01,6.1,
CEFEPIME 2GM/ D5W 50ML,J0692,HCPCS,,80023872,CDM,636,RC,264319511,NDC,both,24,EA,40.96,12.45,,,12.45,Other,150% of Medicare + 9.63% HCRA Surcharge,7.57,,,7.57,Fee Schedule,Average Sale Price (ASP) x 6,14.34,35,,14.34,percent of total billed charges,Drugs,14.34,35,,14.34,percent of total billed charges,Drugs,13.93,34,,13.93,percent of total billed charges,Drugs,13.93,34,,13.93,percent of total billed charges,Drugs,13.93,34,,13.93,percent of total billed charges,Drugs,13.93,34,,13.93,percent of total billed charges,Drugs,14.34,35,,14.34,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,14.34,35,,14.34,percent of total billed charges,Drugs,14.34,35,,14.34,percent of total billed charges,Drugs,14.34,35,,14.34,percent of total billed charges,Drugs,14.34,35,,14.34,percent of total billed charges,Drugs,14.34,35,,14.34,percent of total billed charges,Drugs,16.38,40,,16.38,percent of total billed charges,Drugs,28.67,70,,28.67,percent of total billed charges,All Other,14.74,36,,14.74,percent of total billed charges,Drugs,14.74,36,,14.74,percent of total billed charges,Drugs,14.34,35,,14.34,percent of total billed charges,Drugs,14.34,35,,14.34,percent of total billed charges,Drugs,14.34,35,,14.34,percent of total billed charges,Drugs,14.34,35,,14.34,percent of total billed charges,Drugs,13.65,,,13.65,Other,Drug Cost,13.65,,,13.65,Other,Drug Cost,13.65,,,13.65,Other,Drug Cost,13.65,,,13.65,Other,Drug Cost,13.65,,,13.65,Other,Drug Cost,13.65,,,13.65,Other,Drug Cost,30.72,,,30.72,Other,225% of Medicaid,19.11,,,19.11,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,12.12,,,12.12,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",29.35,,,29.35,Other,215% Medicaid APG methodology,29.35,,,29.35,Other,215% Medicaid APG methodology,17.07,,,17.07,Other,125% Medicaid APG methodology,0.01,30.72,
CEFOXITIN 2G/ 50ML DEXTROSE,J0694,HCPCS,,80023874,CDM,636,RC,264312511,NDC,both,24,EA,50.33,50.11,,,50.11,Other,150% of Medicare + 9.63% HCRA Surcharge,30.47,,,30.47,Fee Schedule,Average Sale Price (ASP) x 6,17.61,35,,17.61,percent of total billed charges,Drugs,17.61,35,,17.61,percent of total billed charges,Drugs,17.11,34,,17.11,percent of total billed charges,Drugs,17.11,34,,17.11,percent of total billed charges,Drugs,17.11,34,,17.11,percent of total billed charges,Drugs,17.11,34,,17.11,percent of total billed charges,Drugs,17.61,35,,17.61,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,17.61,35,,17.61,percent of total billed charges,Drugs,17.61,35,,17.61,percent of total billed charges,Drugs,17.61,35,,17.61,percent of total billed charges,Drugs,17.61,35,,17.61,percent of total billed charges,Drugs,17.61,35,,17.61,percent of total billed charges,Drugs,20.13,40,,20.13,percent of total billed charges,Drugs,35.23,70,,35.23,percent of total billed charges,All Other,18.12,36,,18.12,percent of total billed charges,Drugs,18.12,36,,18.12,percent of total billed charges,Drugs,17.61,35,,17.61,percent of total billed charges,Drugs,17.61,35,,17.61,percent of total billed charges,Drugs,17.61,35,,17.61,percent of total billed charges,Drugs,17.61,35,,17.61,percent of total billed charges,Drugs,16.78,,,16.78,Other,Drug Cost,16.78,,,16.78,Other,Drug Cost,16.78,,,16.78,Other,Drug Cost,16.78,,,16.78,Other,Drug Cost,16.78,,,16.78,Other,Drug Cost,16.78,,,16.78,Other,Drug Cost,37.75,,,37.75,Other,225% of Medicaid,23.49,,,23.49,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,48.76,,,48.76,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",36.07,,,36.07,Other,215% Medicaid APG methodology,36.07,,,36.07,Other,215% Medicaid APG methodology,20.97,,,20.97,Other,125% Medicaid APG methodology,0.01,50.11,
OMALIZUMAB 150MG INJ,J2357,HCPCS,,80023879,CDM,636,RC,50242004062,NDC,both,1,EA,1362.84,389.33,,,389.33,Other,150% of Medicare + 9.63% HCRA Surcharge,236.75,,,236.75,Fee Schedule,Average Sale Price (ASP) x 6,476.99,35,,476.99,percent of total billed charges,Drugs,476.99,35,,476.99,percent of total billed charges,Drugs,463.37,34,,463.37,percent of total billed charges,Drugs,463.37,34,,463.37,percent of total billed charges,Drugs,463.37,34,,463.37,percent of total billed charges,Drugs,463.37,34,,463.37,percent of total billed charges,Drugs,476.99,35,,476.99,percent of total billed charges,Drugs,463.37,34,"If Charge > 500, then 34 percent",463.37,percent of total billed charges,Drugs,476.99,35,,476.99,percent of total billed charges,Drugs,476.99,35,,476.99,percent of total billed charges,Drugs,476.99,35,,476.99,percent of total billed charges,Drugs,476.99,35,,476.99,percent of total billed charges,Drugs,476.99,35,,476.99,percent of total billed charges,Drugs,545.14,40,,545.14,percent of total billed charges,Drugs,953.99,70,,953.99,percent of total billed charges,All Other,490.62,36,,490.62,percent of total billed charges,Drugs,490.62,36,,490.62,percent of total billed charges,Drugs,476.99,35,,476.99,percent of total billed charges,Drugs,476.99,35,,476.99,percent of total billed charges,Drugs,476.99,35,,476.99,percent of total billed charges,Drugs,476.99,35,,476.99,percent of total billed charges,Drugs,454.28,,,454.28,Other,Drug Cost,454.28,,,454.28,Other,Drug Cost,454.28,,,454.28,Other,Drug Cost,454.28,,,454.28,Other,Drug Cost,454.28,,,454.28,Other,Drug Cost,454.28,,,454.28,Other,Drug Cost,1022.13,,,1022.13,Other,225% of Medicaid,635.99,,,635.99,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,378.81,,,378.81,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",976.7,,,976.7,Other,215% Medicaid APG methodology,976.7,,,976.7,Other,215% Medicaid APG methodology,567.85,,,567.85,Other,125% Medicaid APG methodology,0.01,1022.13,
CEFOXITIN 1GM/50ML DEXTROSE,J0694,HCPCS,,80023882,CDM,636,RC,264312311,NDC,both,24,EA,26.73,50.11,,,50.11,Other,150% of Medicare + 9.63% HCRA Surcharge,30.47,,,30.47,Fee Schedule,Average Sale Price (ASP) x 6,9.36,35,,9.36,percent of total billed charges,Drugs,9.36,35,,9.36,percent of total billed charges,Drugs,9.09,34,,9.09,percent of total billed charges,Drugs,9.09,34,,9.09,percent of total billed charges,Drugs,9.09,34,,9.09,percent of total billed charges,Drugs,9.09,34,,9.09,percent of total billed charges,Drugs,9.36,35,,9.36,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,9.36,35,,9.36,percent of total billed charges,Drugs,9.36,35,,9.36,percent of total billed charges,Drugs,9.36,35,,9.36,percent of total billed charges,Drugs,9.36,35,,9.36,percent of total billed charges,Drugs,9.36,35,,9.36,percent of total billed charges,Drugs,10.69,40,,10.69,percent of total billed charges,Drugs,18.71,70,,18.71,percent of total billed charges,All Other,9.62,36,,9.62,percent of total billed charges,Drugs,9.62,36,,9.62,percent of total billed charges,Drugs,9.36,35,,9.36,percent of total billed charges,Drugs,9.36,35,,9.36,percent of total billed charges,Drugs,9.36,35,,9.36,percent of total billed charges,Drugs,9.36,35,,9.36,percent of total billed charges,Drugs,8.91,,,8.91,Other,Drug Cost,8.91,,,8.91,Other,Drug Cost,8.91,,,8.91,Other,Drug Cost,8.91,,,8.91,Other,Drug Cost,8.91,,,8.91,Other,Drug Cost,8.91,,,8.91,Other,Drug Cost,20.05,,,20.05,Other,225% of Medicaid,12.48,,,12.48,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,48.76,,,48.76,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",19.16,,,19.16,Other,215% Medicaid APG methodology,19.16,,,19.16,Other,215% Medicaid APG methodology,11.14,,,11.14,Other,125% Medicaid APG methodology,0.01,50.11,
LEUPROLIDE 22.5MG INJ,J9217,HCPCS,,80023886,CDM,636,RC,74334603,NDC,both,1,EA,16665.66,1788.85,,,1788.85,Other,150% of Medicare + 9.63% HCRA Surcharge,1087.81,,,1087.81,Fee Schedule,Average Sale Price (ASP) x 6,5832.98,35,,5832.98,percent of total billed charges,Drugs,5832.98,35,,5832.98,percent of total billed charges,Drugs,5666.32,34,,5666.32,percent of total billed charges,Drugs,5666.32,34,,5666.32,percent of total billed charges,Drugs,5666.32,34,,5666.32,percent of total billed charges,Drugs,5666.32,34,,5666.32,percent of total billed charges,Drugs,5832.98,35,,5832.98,percent of total billed charges,Drugs,5666.32,34,"If Charge > 500, then 34 percent",5666.32,percent of total billed charges,Drugs,5832.98,35,,5832.98,percent of total billed charges,Drugs,5832.98,35,,5832.98,percent of total billed charges,Drugs,5832.98,35,,5832.98,percent of total billed charges,Drugs,5832.98,35,,5832.98,percent of total billed charges,Drugs,5832.98,35,,5832.98,percent of total billed charges,Drugs,6666.26,40,,6666.26,percent of total billed charges,Drugs,11665.96,70,,11665.96,percent of total billed charges,All Other,5999.64,36,,5999.64,percent of total billed charges,Drugs,5999.64,36,,5999.64,percent of total billed charges,Drugs,5832.98,35,,5832.98,percent of total billed charges,Drugs,5832.98,35,,5832.98,percent of total billed charges,Drugs,5832.98,35,,5832.98,percent of total billed charges,Drugs,5832.98,35,,5832.98,percent of total billed charges,Drugs,5555.22,,,5555.22,Other,Drug Cost,5555.22,,,5555.22,Other,Drug Cost,5555.22,,,5555.22,Other,Drug Cost,5555.22,,,5555.22,Other,Drug Cost,5555.22,,,5555.22,Other,Drug Cost,5555.22,,,5555.22,Other,Drug Cost,12499.25,,,12499.25,Other,225% of Medicaid,7777.31,,,7777.31,Other,140% of Medicaid,5666.32,34,"If Charge > 2,000, then 34 percent",5666.32,percent of total billed charges,Drugs,1740.5,,,1740.5,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",11943.72,,,11943.72,Other,215% Medicaid APG methodology,11943.72,,,11943.72,Other,215% Medicaid APG methodology,6944.03,,,6944.03,Other,125% Medicaid APG methodology,0.01,12499.25,
OCTREOTIDE ACETATE 30MG INJ,J2353,HCPCS,,80023887,CDM,636,RC,78082581,NDC,both,1,EA,18786.27,2080.19,,,2080.19,Other,150% of Medicare + 9.63% HCRA Surcharge,1264.97,,,1264.97,Fee Schedule,Average Sale Price (ASP) x 6,6575.19,35,,6575.19,percent of total billed charges,Drugs,6575.19,35,,6575.19,percent of total billed charges,Drugs,6387.33,34,,6387.33,percent of total billed charges,Drugs,6387.33,34,,6387.33,percent of total billed charges,Drugs,6387.33,34,,6387.33,percent of total billed charges,Drugs,6387.33,34,,6387.33,percent of total billed charges,Drugs,6575.19,35,,6575.19,percent of total billed charges,Drugs,6387.33,34,"If Charge > 500, then 34 percent",6387.33,percent of total billed charges,Drugs,6575.19,35,,6575.19,percent of total billed charges,Drugs,6575.19,35,,6575.19,percent of total billed charges,Drugs,6575.19,35,,6575.19,percent of total billed charges,Drugs,6575.19,35,,6575.19,percent of total billed charges,Drugs,6575.19,35,,6575.19,percent of total billed charges,Drugs,7514.51,40,,7514.51,percent of total billed charges,Drugs,13150.39,70,,13150.39,percent of total billed charges,All Other,6763.06,36,,6763.06,percent of total billed charges,Drugs,6763.06,36,,6763.06,percent of total billed charges,Drugs,6575.19,35,,6575.19,percent of total billed charges,Drugs,6575.19,35,,6575.19,percent of total billed charges,Drugs,6575.19,35,,6575.19,percent of total billed charges,Drugs,6575.19,35,,6575.19,percent of total billed charges,Drugs,6262.09,,,6262.09,Other,Drug Cost,6262.09,,,6262.09,Other,Drug Cost,6262.09,,,6262.09,Other,Drug Cost,6262.09,,,6262.09,Other,Drug Cost,6262.09,,,6262.09,Other,Drug Cost,6262.09,,,6262.09,Other,Drug Cost,14089.7,,,14089.7,Other,225% of Medicaid,8766.93,,,8766.93,Other,140% of Medicaid,6387.33,34,"If Charge > 2,000, then 34 percent",6387.33,percent of total billed charges,Drugs,2023.96,,,2023.96,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",13463.49,,,13463.49,Other,215% Medicaid APG methodology,13463.49,,,13463.49,Other,215% Medicaid APG methodology,7827.61,,,7827.61,Other,125% Medicaid APG methodology,0.01,14089.7,
METHYLENE BLUE 0.5% 10ML,Q9968,HCPCS,,80023888,CDM,636,RC,517037405,NDC,both,5,ML,271.77,107.26,39.4668,,107.26,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,95.12,35,,95.12,percent of total billed charges,Drugs,95.12,35,,95.12,percent of total billed charges,Drugs,92.4,34,,92.4,percent of total billed charges,Drugs,92.4,34,,92.4,percent of total billed charges,Drugs,92.4,34,,92.4,percent of total billed charges,Drugs,92.4,34,,92.4,percent of total billed charges,Drugs,95.12,35,,95.12,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,95.12,35,,95.12,percent of total billed charges,Drugs,95.12,35,,95.12,percent of total billed charges,Drugs,95.12,35,,95.12,percent of total billed charges,Drugs,95.12,35,,95.12,percent of total billed charges,Drugs,95.12,35,,95.12,percent of total billed charges,Drugs,108.71,40,,108.71,percent of total billed charges,Drugs,190.24,70,,190.24,percent of total billed charges,All Other,97.84,36,,97.84,percent of total billed charges,Drugs,97.84,36,,97.84,percent of total billed charges,Drugs,95.12,35,,95.12,percent of total billed charges,Drugs,95.12,35,,95.12,percent of total billed charges,Drugs,95.12,35,,95.12,percent of total billed charges,Drugs,95.12,35,,95.12,percent of total billed charges,Drugs,90.59,,,90.59,Other,Drug Cost,90.59,,,90.59,Other,Drug Cost,90.59,,,90.59,Other,Drug Cost,90.59,,,90.59,Other,Drug Cost,90.59,,,90.59,Other,Drug Cost,90.59,,,90.59,Other,Drug Cost,203.83,,,203.83,Other,225% of Medicaid,126.83,,,126.83,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",194.77,,,194.77,Other,215% Medicaid APG methodology,194.77,,,194.77,Other,215% Medicaid APG methodology,113.24,,,113.24,Other,125% Medicaid APG methodology,0.01,203.83,
LANREOTIDE 120MG INJECTION,J1930,HCPCS,,80023890,CDM,636,RC,15054112004,NDC,both,1,ML,28384.8,477.97,,,477.97,Other,150% of Medicare + 9.63% HCRA Surcharge,290.66,,,290.66,Fee Schedule,Average Sale Price (ASP) x 6,9934.68,35,,9934.68,percent of total billed charges,Drugs,9934.68,35,,9934.68,percent of total billed charges,Drugs,9650.83,34,,9650.83,percent of total billed charges,Drugs,9650.83,34,,9650.83,percent of total billed charges,Drugs,9650.83,34,,9650.83,percent of total billed charges,Drugs,9650.83,34,,9650.83,percent of total billed charges,Drugs,9934.68,35,,9934.68,percent of total billed charges,Drugs,9650.83,34,"If Charge > 500, then 34 percent",9650.83,percent of total billed charges,Drugs,9934.68,35,,9934.68,percent of total billed charges,Drugs,9934.68,35,,9934.68,percent of total billed charges,Drugs,9934.68,35,,9934.68,percent of total billed charges,Drugs,9934.68,35,,9934.68,percent of total billed charges,Drugs,9934.68,35,,9934.68,percent of total billed charges,Drugs,11353.92,40,,11353.92,percent of total billed charges,Drugs,19869.36,70,,19869.36,percent of total billed charges,All Other,10218.53,36,,10218.53,percent of total billed charges,Drugs,10218.53,36,,10218.53,percent of total billed charges,Drugs,9934.68,35,,9934.68,percent of total billed charges,Drugs,9934.68,35,,9934.68,percent of total billed charges,Drugs,9934.68,35,,9934.68,percent of total billed charges,Drugs,9934.68,35,,9934.68,percent of total billed charges,Drugs,9461.6,,,9461.6,Other,Drug Cost,9461.6,,,9461.6,Other,Drug Cost,9461.6,,,9461.6,Other,Drug Cost,9461.6,,,9461.6,Other,Drug Cost,9461.6,,,9461.6,Other,Drug Cost,9461.6,,,9461.6,Other,Drug Cost,21288.6,,,21288.6,Other,225% of Medicaid,13246.24,,,13246.24,Other,140% of Medicaid,9650.83,34,"If Charge > 2,000, then 34 percent",9650.83,percent of total billed charges,Drugs,465.05,,,465.05,Other,160% Medicare Fee Schedule,9650.83,34,,9650.83,Other,"Drug Charges > 20,000, then 34% of Charges",20342.44,,,20342.44,Other,215% Medicaid APG methodology,20342.44,,,20342.44,Other,215% Medicaid APG methodology,11827,,,11827,Other,125% Medicaid APG methodology,290.66,21288.6,
PEGLOTICASE 1MG/1ML INJ,J2507,HCPCS,,80023892,CDM,636,RC,75987008010,NDC,both,1,ML,79930.05,33261.4,,,33261.4,Other,150% of Medicare + 9.63% HCRA Surcharge,20226.46,,,20226.46,Fee Schedule,Average Sale Price (ASP) x 6,27975.52,35,,27975.52,percent of total billed charges,Drugs,27975.52,35,,27975.52,percent of total billed charges,Drugs,27176.22,34,,27176.22,percent of total billed charges,Drugs,27176.22,34,,27176.22,percent of total billed charges,Drugs,27176.22,34,,27176.22,percent of total billed charges,Drugs,27176.22,34,,27176.22,percent of total billed charges,Drugs,27975.52,35,,27975.52,percent of total billed charges,Drugs,27176.22,34,"If Charge > 500, then 34 percent",27176.22,percent of total billed charges,Drugs,27975.52,35,,27975.52,percent of total billed charges,Drugs,27975.52,35,,27975.52,percent of total billed charges,Drugs,27975.52,35,,27975.52,percent of total billed charges,Drugs,27975.52,35,,27975.52,percent of total billed charges,Drugs,27975.52,35,,27975.52,percent of total billed charges,Drugs,31972.02,40,,31972.02,percent of total billed charges,Drugs,55951.04,70,,55951.04,percent of total billed charges,All Other,28774.82,36,,28774.82,percent of total billed charges,Drugs,28774.82,36,,28774.82,percent of total billed charges,Drugs,27975.52,35,,27975.52,percent of total billed charges,Drugs,27975.52,35,,27975.52,percent of total billed charges,Drugs,27975.52,35,,27975.52,percent of total billed charges,Drugs,27975.52,35,,27975.52,percent of total billed charges,Drugs,26643.35,,,26643.35,Other,Drug Cost,26643.35,,,26643.35,Other,Drug Cost,26643.35,,,26643.35,Other,Drug Cost,26643.35,,,26643.35,Other,Drug Cost,26643.35,,,26643.35,Other,Drug Cost,26643.35,,,26643.35,Other,Drug Cost,59947.54,,,59947.54,Other,225% of Medicaid,37300.69,,,37300.69,Other,140% of Medicaid,27176.22,34,"If Charge > 2,000, then 34 percent",27176.22,percent of total billed charges,Drugs,32362.33,,,32362.33,Other,160% Medicare Fee Schedule,27176.22,34,,27176.22,Other,"Drug Charges > 20,000, then 34% of Charges",57283.2,,,57283.2,Other,215% Medicaid APG methodology,57283.2,,,57283.2,Other,215% Medicaid APG methodology,33304.19,,,33304.19,Other,125% Medicaid APG methodology,20226.46,59947.54,
LEUPROLIDE ACETATE 7.5MG INJ,J9217,HCPCS,,80023893,CDM,636,RC,74364203,NDC,both,1,EA,5555.25,1788.85,,,1788.85,Other,150% of Medicare + 9.63% HCRA Surcharge,1087.81,,,1087.81,Fee Schedule,Average Sale Price (ASP) x 6,1944.34,35,,1944.34,percent of total billed charges,Drugs,1944.34,35,,1944.34,percent of total billed charges,Drugs,1888.79,34,,1888.79,percent of total billed charges,Drugs,1888.79,34,,1888.79,percent of total billed charges,Drugs,1888.79,34,,1888.79,percent of total billed charges,Drugs,1888.79,34,,1888.79,percent of total billed charges,Drugs,1944.34,35,,1944.34,percent of total billed charges,Drugs,1888.79,34,"If Charge > 500, then 34 percent",1888.79,percent of total billed charges,Drugs,1944.34,35,,1944.34,percent of total billed charges,Drugs,1944.34,35,,1944.34,percent of total billed charges,Drugs,1944.34,35,,1944.34,percent of total billed charges,Drugs,1944.34,35,,1944.34,percent of total billed charges,Drugs,1944.34,35,,1944.34,percent of total billed charges,Drugs,2222.1,40,,2222.1,percent of total billed charges,Drugs,3888.68,70,,3888.68,percent of total billed charges,All Other,1999.89,36,,1999.89,percent of total billed charges,Drugs,1999.89,36,,1999.89,percent of total billed charges,Drugs,1944.34,35,,1944.34,percent of total billed charges,Drugs,1944.34,35,,1944.34,percent of total billed charges,Drugs,1944.34,35,,1944.34,percent of total billed charges,Drugs,1944.34,35,,1944.34,percent of total billed charges,Drugs,1851.75,,,1851.75,Other,Drug Cost,1851.75,,,1851.75,Other,Drug Cost,1851.75,,,1851.75,Other,Drug Cost,1851.75,,,1851.75,Other,Drug Cost,1851.75,,,1851.75,Other,Drug Cost,1851.75,,,1851.75,Other,Drug Cost,4166.44,,,4166.44,Other,225% of Medicaid,2592.45,,,2592.45,Other,140% of Medicaid,1888.79,34,"If Charge > 2,000, then 34 percent",1888.79,percent of total billed charges,Drugs,1740.5,,,1740.5,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",3981.26,,,3981.26,Other,215% Medicaid APG methodology,3981.26,,,3981.26,Other,215% Medicaid APG methodology,2314.69,,,2314.69,Other,125% Medicaid APG methodology,0.01,4166.44,
DENOSUMAB 60MG INJ,J0897,HCPCS,,80023894,CDM,636,RC,55513071001,NDC,both,1,ML,2161.71,248.62,,,248.62,Other,150% of Medicare + 9.63% HCRA Surcharge,151.19,,,151.19,Fee Schedule,Average Sale Price (ASP) x 6,756.6,35,,756.6,percent of total billed charges,Drugs,756.6,35,,756.6,percent of total billed charges,Drugs,734.98,34,,734.98,percent of total billed charges,Drugs,734.98,34,,734.98,percent of total billed charges,Drugs,734.98,34,,734.98,percent of total billed charges,Drugs,734.98,34,,734.98,percent of total billed charges,Drugs,756.6,35,,756.6,percent of total billed charges,Drugs,734.98,34,"If Charge > 500, then 34 percent",734.98,percent of total billed charges,Drugs,756.6,35,,756.6,percent of total billed charges,Drugs,756.6,35,,756.6,percent of total billed charges,Drugs,756.6,35,,756.6,percent of total billed charges,Drugs,756.6,35,,756.6,percent of total billed charges,Drugs,756.6,35,,756.6,percent of total billed charges,Drugs,864.68,40,,864.68,percent of total billed charges,Drugs,1513.2,70,,1513.2,percent of total billed charges,All Other,778.22,36,,778.22,percent of total billed charges,Drugs,778.22,36,,778.22,percent of total billed charges,Drugs,756.6,35,,756.6,percent of total billed charges,Drugs,756.6,35,,756.6,percent of total billed charges,Drugs,756.6,35,,756.6,percent of total billed charges,Drugs,756.6,35,,756.6,percent of total billed charges,Drugs,720.57,,,720.57,Other,Drug Cost,720.57,,,720.57,Other,Drug Cost,720.57,,,720.57,Other,Drug Cost,720.57,,,720.57,Other,Drug Cost,720.57,,,720.57,Other,Drug Cost,720.57,,,720.57,Other,Drug Cost,1621.28,,,1621.28,Other,225% of Medicaid,1008.8,,,1008.8,Other,140% of Medicaid,734.98,34,"If Charge > 2,000, then 34 percent",734.98,percent of total billed charges,Drugs,241.9,,,241.9,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",1549.23,,,1549.23,Other,215% Medicaid APG methodology,1549.23,,,1549.23,Other,215% Medicaid APG methodology,900.71,,,900.71,Other,125% Medicaid APG methodology,0.01,1621.28,
GAMUNEX-C 5GM/50ML,J1561,HCPCS,,80023896,CDM,636,RC,13533080020,NDC,both,1,ML,1005,491.22,,,491.22,Other,150% of Medicare + 9.63% HCRA Surcharge,298.72,,,298.72,Fee Schedule,Average Sale Price (ASP) x 6,351.75,35,,351.75,percent of total billed charges,Drugs,351.75,35,,351.75,percent of total billed charges,Drugs,341.7,34,,341.7,percent of total billed charges,Drugs,341.7,34,,341.7,percent of total billed charges,Drugs,341.7,34,,341.7,percent of total billed charges,Drugs,341.7,34,,341.7,percent of total billed charges,Drugs,351.75,35,,351.75,percent of total billed charges,Drugs,341.7,34,"If Charge > 500, then 34 percent",341.7,percent of total billed charges,Drugs,351.75,35,,351.75,percent of total billed charges,Drugs,351.75,35,,351.75,percent of total billed charges,Drugs,351.75,35,,351.75,percent of total billed charges,Drugs,351.75,35,,351.75,percent of total billed charges,Drugs,351.75,35,,351.75,percent of total billed charges,Drugs,402,40,,402,percent of total billed charges,Drugs,703.5,70,,703.5,percent of total billed charges,All Other,361.8,36,,361.8,percent of total billed charges,Drugs,361.8,36,,361.8,percent of total billed charges,Drugs,351.75,35,,351.75,percent of total billed charges,Drugs,351.75,35,,351.75,percent of total billed charges,Drugs,351.75,35,,351.75,percent of total billed charges,Drugs,351.75,35,,351.75,percent of total billed charges,Drugs,335,,,335,Other,Drug Cost,335,,,335,Other,Drug Cost,335,,,335,Other,Drug Cost,335,,,335,Other,Drug Cost,335,,,335,Other,Drug Cost,335,,,335,Other,Drug Cost,753.75,,,753.75,Other,225% of Medicaid,469,,,469,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,477.95,,,477.95,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",720.25,,,720.25,Other,215% Medicaid APG methodology,720.25,,,720.25,Other,215% Medicaid APG methodology,418.75,,,418.75,Other,125% Medicaid APG methodology,0.01,753.75,
ELOTUZUMAB 300MG INJ,J9176,HCPCS,,80023897,CDM,636,RC,3229111,NDC,both,1,EA,6622.83,72.82,,,72.82,Other,150% of Medicare + 9.63% HCRA Surcharge,44.28,,,44.28,Fee Schedule,Average Sale Price (ASP) x 6,2317.99,35,,2317.99,percent of total billed charges,Drugs,2317.99,35,,2317.99,percent of total billed charges,Drugs,2251.76,34,,2251.76,percent of total billed charges,Drugs,2251.76,34,,2251.76,percent of total billed charges,Drugs,2251.76,34,,2251.76,percent of total billed charges,Drugs,2251.76,34,,2251.76,percent of total billed charges,Drugs,2317.99,35,,2317.99,percent of total billed charges,Drugs,2251.76,34,"If Charge > 500, then 34 percent",2251.76,percent of total billed charges,Drugs,2317.99,35,,2317.99,percent of total billed charges,Drugs,2317.99,35,,2317.99,percent of total billed charges,Drugs,2317.99,35,,2317.99,percent of total billed charges,Drugs,2317.99,35,,2317.99,percent of total billed charges,Drugs,2317.99,35,,2317.99,percent of total billed charges,Drugs,2649.13,40,,2649.13,percent of total billed charges,Drugs,4635.98,70,,4635.98,percent of total billed charges,All Other,2384.22,36,,2384.22,percent of total billed charges,Drugs,2384.22,36,,2384.22,percent of total billed charges,Drugs,2317.99,35,,2317.99,percent of total billed charges,Drugs,2317.99,35,,2317.99,percent of total billed charges,Drugs,2317.99,35,,2317.99,percent of total billed charges,Drugs,2317.99,35,,2317.99,percent of total billed charges,Drugs,2207.61,,,2207.61,Other,Drug Cost,2207.61,,,2207.61,Other,Drug Cost,2207.61,,,2207.61,Other,Drug Cost,2207.61,,,2207.61,Other,Drug Cost,2207.61,,,2207.61,Other,Drug Cost,2207.61,,,2207.61,Other,Drug Cost,4967.12,,,4967.12,Other,225% of Medicaid,3090.65,,,3090.65,Other,140% of Medicaid,2251.76,34,"If Charge > 2,000, then 34 percent",2251.76,percent of total billed charges,Drugs,70.85,,,70.85,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",4746.36,,,4746.36,Other,215% Medicaid APG methodology,4746.36,,,4746.36,Other,215% Medicaid APG methodology,2759.51,,,2759.51,Other,125% Medicaid APG methodology,0.01,4967.12,
ADO-TRASTUZUMAB EMT 100MG INJ,J9354,HCPCS,,80023901,CDM,636,RC,50242008801,NDC,both,1,EA,8257.59,378.57,,,378.57,Other,150% of Medicare + 9.63% HCRA Surcharge,230.21,,,230.21,Fee Schedule,Average Sale Price (ASP) x 6,2890.16,35,,2890.16,percent of total billed charges,Drugs,2890.16,35,,2890.16,percent of total billed charges,Drugs,2807.58,34,,2807.58,percent of total billed charges,Drugs,2807.58,34,,2807.58,percent of total billed charges,Drugs,2807.58,34,,2807.58,percent of total billed charges,Drugs,2807.58,34,,2807.58,percent of total billed charges,Drugs,2890.16,35,,2890.16,percent of total billed charges,Drugs,2807.58,34,"If Charge > 500, then 34 percent",2807.58,percent of total billed charges,Drugs,2890.16,35,,2890.16,percent of total billed charges,Drugs,2890.16,35,,2890.16,percent of total billed charges,Drugs,2890.16,35,,2890.16,percent of total billed charges,Drugs,2890.16,35,,2890.16,percent of total billed charges,Drugs,2890.16,35,,2890.16,percent of total billed charges,Drugs,3303.04,40,,3303.04,percent of total billed charges,Drugs,5780.31,70,,5780.31,percent of total billed charges,All Other,2972.73,36,,2972.73,percent of total billed charges,Drugs,2972.73,36,,2972.73,percent of total billed charges,Drugs,2890.16,35,,2890.16,percent of total billed charges,Drugs,2890.16,35,,2890.16,percent of total billed charges,Drugs,2890.16,35,,2890.16,percent of total billed charges,Drugs,2890.16,35,,2890.16,percent of total billed charges,Drugs,2752.53,,,2752.53,Other,Drug Cost,2752.53,,,2752.53,Other,Drug Cost,2752.53,,,2752.53,Other,Drug Cost,2752.53,,,2752.53,Other,Drug Cost,2752.53,,,2752.53,Other,Drug Cost,2752.53,,,2752.53,Other,Drug Cost,6193.19,,,6193.19,Other,225% of Medicaid,3853.54,,,3853.54,Other,140% of Medicaid,2807.58,34,"If Charge > 2,000, then 34 percent",2807.58,percent of total billed charges,Drugs,368.33,,,368.33,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",5917.94,,,5917.94,Other,215% Medicaid APG methodology,5917.94,,,5917.94,Other,215% Medicaid APG methodology,3440.66,,,3440.66,Other,125% Medicaid APG methodology,0.01,6193.19,
DENOSUMAB 120MG/1.7ML,J0897,HCPCS,,80023902,CDM,636,RC,55513073001,NDC,both,1,ML,8928.03,248.62,,,248.62,Other,150% of Medicare + 9.63% HCRA Surcharge,151.19,,,151.19,Fee Schedule,Average Sale Price (ASP) x 6,3124.81,35,,3124.81,percent of total billed charges,Drugs,3124.81,35,,3124.81,percent of total billed charges,Drugs,3035.53,34,,3035.53,percent of total billed charges,Drugs,3035.53,34,,3035.53,percent of total billed charges,Drugs,3035.53,34,,3035.53,percent of total billed charges,Drugs,3035.53,34,,3035.53,percent of total billed charges,Drugs,3124.81,35,,3124.81,percent of total billed charges,Drugs,3035.53,34,"If Charge > 500, then 34 percent",3035.53,percent of total billed charges,Drugs,3124.81,35,,3124.81,percent of total billed charges,Drugs,3124.81,35,,3124.81,percent of total billed charges,Drugs,3124.81,35,,3124.81,percent of total billed charges,Drugs,3124.81,35,,3124.81,percent of total billed charges,Drugs,3124.81,35,,3124.81,percent of total billed charges,Drugs,3571.21,40,,3571.21,percent of total billed charges,Drugs,6249.62,70,,6249.62,percent of total billed charges,All Other,3214.09,36,,3214.09,percent of total billed charges,Drugs,3214.09,36,,3214.09,percent of total billed charges,Drugs,3124.81,35,,3124.81,percent of total billed charges,Drugs,3124.81,35,,3124.81,percent of total billed charges,Drugs,3124.81,35,,3124.81,percent of total billed charges,Drugs,3124.81,35,,3124.81,percent of total billed charges,Drugs,2976.01,,,2976.01,Other,Drug Cost,2976.01,,,2976.01,Other,Drug Cost,2976.01,,,2976.01,Other,Drug Cost,2976.01,,,2976.01,Other,Drug Cost,2976.01,,,2976.01,Other,Drug Cost,2976.01,,,2976.01,Other,Drug Cost,6696.02,,,6696.02,Other,225% of Medicaid,4166.41,,,4166.41,Other,140% of Medicaid,3035.53,34,"If Charge > 2,000, then 34 percent",3035.53,percent of total billed charges,Drugs,241.9,,,241.9,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",6398.42,,,6398.42,Other,215% Medicaid APG methodology,6398.42,,,6398.42,Other,215% Medicaid APG methodology,3720.01,,,3720.01,Other,125% Medicaid APG methodology,0.01,6696.02,
PEGFILGRASTIM ONPRO 6MG/0.6ML,J2506,HCPCS,,80023903,CDM,636,RC,55513019201,NDC,both,1,ML,12577.5,500.02,,,500.02,Other,150% of Medicare + 9.63% HCRA Surcharge,304.07,,,304.07,Fee Schedule,Average Sale Price (ASP) x 6,4402.13,35,,4402.13,percent of total billed charges,Drugs,4402.13,35,,4402.13,percent of total billed charges,Drugs,4276.35,34,,4276.35,percent of total billed charges,Drugs,4276.35,34,,4276.35,percent of total billed charges,Drugs,4276.35,34,,4276.35,percent of total billed charges,Drugs,4276.35,34,,4276.35,percent of total billed charges,Drugs,4402.13,35,,4402.13,percent of total billed charges,Drugs,4276.35,34,"If Charge > 500, then 34 percent",4276.35,percent of total billed charges,Drugs,4402.13,35,,4402.13,percent of total billed charges,Drugs,4402.13,35,,4402.13,percent of total billed charges,Drugs,4402.13,35,,4402.13,percent of total billed charges,Drugs,4402.13,35,,4402.13,percent of total billed charges,Drugs,4402.13,35,,4402.13,percent of total billed charges,Drugs,5031,40,,5031,percent of total billed charges,Drugs,8804.25,70,,8804.25,percent of total billed charges,All Other,4527.9,36,,4527.9,percent of total billed charges,Drugs,4527.9,36,,4527.9,percent of total billed charges,Drugs,4402.13,35,,4402.13,percent of total billed charges,Drugs,4402.13,35,,4402.13,percent of total billed charges,Drugs,4402.13,35,,4402.13,percent of total billed charges,Drugs,4402.13,35,,4402.13,percent of total billed charges,Drugs,4192.5,,,4192.5,Other,Drug Cost,4192.5,,,4192.5,Other,Drug Cost,4192.5,,,4192.5,Other,Drug Cost,4192.5,,,4192.5,Other,Drug Cost,4192.5,,,4192.5,Other,Drug Cost,4192.5,,,4192.5,Other,Drug Cost,9433.13,,,9433.13,Other,225% of Medicaid,5869.5,,,5869.5,Other,140% of Medicaid,4276.35,34,"If Charge > 2,000, then 34 percent",4276.35,percent of total billed charges,Drugs,486.51,,,486.51,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",9013.88,,,9013.88,Other,215% Medicaid APG methodology,9013.88,,,9013.88,Other,215% Medicaid APG methodology,5240.63,,,5240.63,Other,125% Medicaid APG methodology,0.01,9433.13,
IBANDRONATE SODIUM 3MG/ML 3ML,J1740,HCPCS,,80023904,CDM,636,RC,67457052433,NDC,both,1,ML,131.04,252.55,,,252.55,Other,150% of Medicare + 9.63% HCRA Surcharge,153.58,,,153.58,Fee Schedule,Average Sale Price (ASP) x 6,45.86,35,,45.86,percent of total billed charges,Drugs,45.86,35,,45.86,percent of total billed charges,Drugs,44.55,34,,44.55,percent of total billed charges,Drugs,44.55,34,,44.55,percent of total billed charges,Drugs,44.55,34,,44.55,percent of total billed charges,Drugs,44.55,34,,44.55,percent of total billed charges,Drugs,45.86,35,,45.86,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,45.86,35,,45.86,percent of total billed charges,Drugs,45.86,35,,45.86,percent of total billed charges,Drugs,45.86,35,,45.86,percent of total billed charges,Drugs,45.86,35,,45.86,percent of total billed charges,Drugs,45.86,35,,45.86,percent of total billed charges,Drugs,52.42,40,,52.42,percent of total billed charges,Drugs,91.73,70,,91.73,percent of total billed charges,All Other,47.17,36,,47.17,percent of total billed charges,Drugs,47.17,36,,47.17,percent of total billed charges,Drugs,45.86,35,,45.86,percent of total billed charges,Drugs,45.86,35,,45.86,percent of total billed charges,Drugs,45.86,35,,45.86,percent of total billed charges,Drugs,45.86,35,,45.86,percent of total billed charges,Drugs,43.68,,,43.68,Other,Drug Cost,43.68,,,43.68,Other,Drug Cost,43.68,,,43.68,Other,Drug Cost,43.68,,,43.68,Other,Drug Cost,43.68,,,43.68,Other,Drug Cost,43.68,,,43.68,Other,Drug Cost,98.28,,,98.28,Other,225% of Medicaid,61.15,,,61.15,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,245.72,,,245.72,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",93.91,,,93.91,Other,215% Medicaid APG methodology,93.91,,,93.91,Other,215% Medicaid APG methodology,54.6,,,54.6,Other,125% Medicaid APG methodology,0.01,252.55,
FERRIC CARBOXYMALTOS 50MG/ML 15ML INJ,J1439,HCPCS,,80023907,CDM,636,RC,517065001,NDC,both,1,ML,1704.18,11.32,,,11.32,Other,150% of Medicare + 9.63% HCRA Surcharge,6.88,,,6.88,Fee Schedule,Average Sale Price (ASP) x 6,596.46,35,,596.46,percent of total billed charges,Drugs,596.46,35,,596.46,percent of total billed charges,Drugs,579.42,34,,579.42,percent of total billed charges,Drugs,579.42,34,,579.42,percent of total billed charges,Drugs,579.42,34,,579.42,percent of total billed charges,Drugs,579.42,34,,579.42,percent of total billed charges,Drugs,596.46,35,,596.46,percent of total billed charges,Drugs,579.42,34,"If Charge > 500, then 34 percent",579.42,percent of total billed charges,Drugs,596.46,35,,596.46,percent of total billed charges,Drugs,596.46,35,,596.46,percent of total billed charges,Drugs,596.46,35,,596.46,percent of total billed charges,Drugs,596.46,35,,596.46,percent of total billed charges,Drugs,596.46,35,,596.46,percent of total billed charges,Drugs,681.67,40,,681.67,percent of total billed charges,Drugs,1192.93,70,,1192.93,percent of total billed charges,All Other,613.5,36,,613.5,percent of total billed charges,Drugs,613.5,36,,613.5,percent of total billed charges,Drugs,596.46,35,,596.46,percent of total billed charges,Drugs,596.46,35,,596.46,percent of total billed charges,Drugs,596.46,35,,596.46,percent of total billed charges,Drugs,596.46,35,,596.46,percent of total billed charges,Drugs,568.06,,,568.06,Other,Drug Cost,568.06,,,568.06,Other,Drug Cost,568.06,,,568.06,Other,Drug Cost,568.06,,,568.06,Other,Drug Cost,568.06,,,568.06,Other,Drug Cost,568.06,,,568.06,Other,Drug Cost,1278.14,,,1278.14,Other,225% of Medicaid,795.28,,,795.28,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,11.01,,,11.01,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",1221.33,,,1221.33,Other,215% Medicaid APG methodology,1221.33,,,1221.33,Other,215% Medicaid APG methodology,710.08,,,710.08,Other,125% Medicaid APG methodology,0.01,1278.14,
DIPHENHYDRAMINE 25MG/50ML,J1200,HCPCS,,80023908,CDM,636,RC,67457012410,NDC,both,1,ML,19.98,7.93,,,7.93,Other,150% of Medicare + 9.63% HCRA Surcharge,4.82,,,4.82,Fee Schedule,Average Sale Price (ASP) x 6,6.99,35,,6.99,percent of total billed charges,Drugs,6.99,35,,6.99,percent of total billed charges,Drugs,6.79,34,,6.79,percent of total billed charges,Drugs,6.79,34,,6.79,percent of total billed charges,Drugs,6.79,34,,6.79,percent of total billed charges,Drugs,6.79,34,,6.79,percent of total billed charges,Drugs,6.99,35,,6.99,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,6.99,35,,6.99,percent of total billed charges,Drugs,6.99,35,,6.99,percent of total billed charges,Drugs,6.99,35,,6.99,percent of total billed charges,Drugs,6.99,35,,6.99,percent of total billed charges,Drugs,6.99,35,,6.99,percent of total billed charges,Drugs,7.99,40,,7.99,percent of total billed charges,Drugs,13.99,70,,13.99,percent of total billed charges,All Other,7.19,36,,7.19,percent of total billed charges,Drugs,7.19,36,,7.19,percent of total billed charges,Drugs,6.99,35,,6.99,percent of total billed charges,Drugs,6.99,35,,6.99,percent of total billed charges,Drugs,6.99,35,,6.99,percent of total billed charges,Drugs,6.99,35,,6.99,percent of total billed charges,Drugs,6.66,,,6.66,Other,Drug Cost,6.66,,,6.66,Other,Drug Cost,6.66,,,6.66,Other,Drug Cost,6.66,,,6.66,Other,Drug Cost,6.66,,,6.66,Other,Drug Cost,6.66,,,6.66,Other,Drug Cost,14.99,,,14.99,Other,225% of Medicaid,9.32,,,9.32,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,7.72,,,7.72,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",14.32,,,14.32,Other,215% Medicaid APG methodology,14.32,,,14.32,Other,215% Medicaid APG methodology,8.33,,,8.33,Other,125% Medicaid APG methodology,0.01,14.99,
PEGFILGRASTIM-CBQV 6MG/0.6ML INJ,Q5111,HCPCS,,80023909,CDM,636,RC,70114010101,NDC,both,1,ML,3575.52,1204.75,,,1204.75,Other,150% of Medicare + 9.63% HCRA Surcharge,732.62,,,732.62,Fee Schedule,Average Sale Price (ASP) x 6,1251.43,35,,1251.43,percent of total billed charges,Drugs,1251.43,35,,1251.43,percent of total billed charges,Drugs,1215.68,34,,1215.68,percent of total billed charges,Drugs,1215.68,34,,1215.68,percent of total billed charges,Drugs,1215.68,34,,1215.68,percent of total billed charges,Drugs,1215.68,34,,1215.68,percent of total billed charges,Drugs,1251.43,35,,1251.43,percent of total billed charges,Drugs,1215.68,34,"If Charge > 500, then 34 percent",1215.68,percent of total billed charges,Drugs,1251.43,35,,1251.43,percent of total billed charges,Drugs,1251.43,35,,1251.43,percent of total billed charges,Drugs,1251.43,35,,1251.43,percent of total billed charges,Drugs,1251.43,35,,1251.43,percent of total billed charges,Drugs,1251.43,35,,1251.43,percent of total billed charges,Drugs,1430.21,40,,1430.21,percent of total billed charges,Drugs,2502.86,70,,2502.86,percent of total billed charges,All Other,1287.19,36,,1287.19,percent of total billed charges,Drugs,1287.19,36,,1287.19,percent of total billed charges,Drugs,1251.43,35,,1251.43,percent of total billed charges,Drugs,1251.43,35,,1251.43,percent of total billed charges,Drugs,1251.43,35,,1251.43,percent of total billed charges,Drugs,1251.43,35,,1251.43,percent of total billed charges,Drugs,1191.84,,,1191.84,Other,Drug Cost,1191.84,,,1191.84,Other,Drug Cost,1191.84,,,1191.84,Other,Drug Cost,1191.84,,,1191.84,Other,Drug Cost,1191.84,,,1191.84,Other,Drug Cost,1191.84,,,1191.84,Other,Drug Cost,2681.64,,,2681.64,Other,225% of Medicaid,1668.58,,,1668.58,Other,140% of Medicaid,1215.68,34,"If Charge > 2,000, then 34 percent",1215.68,percent of total billed charges,Drugs,1172.19,,,1172.19,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",2562.46,,,2562.46,Other,215% Medicaid APG methodology,2562.46,,,2562.46,Other,215% Medicaid APG methodology,1489.8,,,1489.8,Other,125% Medicaid APG methodology,0.01,2681.64,
ONDANSETRON INJ 12 MG/50 ML,J2405,HCPCS,,80023917,CDM,636,RC,72266012401,NDC,both,1,ML,7.47,0.99,,,0.99,Other,150% of Medicare + 9.63% HCRA Surcharge,0.6,,,0.6,Fee Schedule,Average Sale Price (ASP) x 6,2.61,35,,2.61,percent of total billed charges,Drugs,2.61,35,,2.61,percent of total billed charges,Drugs,2.54,34,,2.54,percent of total billed charges,Drugs,2.54,34,,2.54,percent of total billed charges,Drugs,2.54,34,,2.54,percent of total billed charges,Drugs,2.54,34,,2.54,percent of total billed charges,Drugs,2.61,35,,2.61,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,2.61,35,,2.61,percent of total billed charges,Drugs,2.61,35,,2.61,percent of total billed charges,Drugs,2.61,35,,2.61,percent of total billed charges,Drugs,2.61,35,,2.61,percent of total billed charges,Drugs,2.61,35,,2.61,percent of total billed charges,Drugs,2.99,40,,2.99,percent of total billed charges,Drugs,5.23,70,,5.23,percent of total billed charges,All Other,2.69,36,,2.69,percent of total billed charges,Drugs,2.69,36,,2.69,percent of total billed charges,Drugs,2.61,35,,2.61,percent of total billed charges,Drugs,2.61,35,,2.61,percent of total billed charges,Drugs,2.61,35,,2.61,percent of total billed charges,Drugs,2.61,35,,2.61,percent of total billed charges,Drugs,2.49,,,2.49,Other,Drug Cost,2.49,,,2.49,Other,Drug Cost,2.49,,,2.49,Other,Drug Cost,2.49,,,2.49,Other,Drug Cost,2.49,,,2.49,Other,Drug Cost,2.49,,,2.49,Other,Drug Cost,5.6,,,5.6,Other,225% of Medicaid,3.49,,,3.49,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,0.96,,,0.96,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",5.35,,,5.35,Other,215% Medicaid APG methodology,5.35,,,5.35,Other,215% Medicaid APG methodology,3.11,,,3.11,Other,125% Medicaid APG methodology,0.01,5.6,
DEXAMETHASONE INJ 10 MG/50 ML,J1100,HCPCS,,80023919,CDM,636,RC,67457042130,NDC,both,25,ML,15.1,1.17,,,1.17,Other,150% of Medicare + 9.63% HCRA Surcharge,0.71,,,0.71,Fee Schedule,Average Sale Price (ASP) x 6,5.28,35,,5.28,percent of total billed charges,Drugs,5.28,35,,5.28,percent of total billed charges,Drugs,5.13,34,,5.13,percent of total billed charges,Drugs,5.13,34,,5.13,percent of total billed charges,Drugs,5.13,34,,5.13,percent of total billed charges,Drugs,5.13,34,,5.13,percent of total billed charges,Drugs,5.28,35,,5.28,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,5.28,35,,5.28,percent of total billed charges,Drugs,5.28,35,,5.28,percent of total billed charges,Drugs,5.28,35,,5.28,percent of total billed charges,Drugs,5.28,35,,5.28,percent of total billed charges,Drugs,5.28,35,,5.28,percent of total billed charges,Drugs,6.04,40,,6.04,percent of total billed charges,Drugs,10.57,70,,10.57,percent of total billed charges,All Other,5.43,36,,5.43,percent of total billed charges,Drugs,5.43,36,,5.43,percent of total billed charges,Drugs,5.28,35,,5.28,percent of total billed charges,Drugs,5.28,35,,5.28,percent of total billed charges,Drugs,5.28,35,,5.28,percent of total billed charges,Drugs,5.28,35,,5.28,percent of total billed charges,Drugs,5.03,,,5.03,Other,Drug Cost,5.03,,,5.03,Other,Drug Cost,5.03,,,5.03,Other,Drug Cost,5.03,,,5.03,Other,Drug Cost,5.03,,,5.03,Other,Drug Cost,5.03,,,5.03,Other,Drug Cost,11.32,,,11.32,Other,225% of Medicaid,7.05,,,7.05,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,1.14,,,1.14,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",10.82,,,10.82,Other,215% Medicaid APG methodology,10.82,,,10.82,Other,215% Medicaid APG methodology,6.29,,,6.29,Other,125% Medicaid APG methodology,0.01,11.32,
DEXAMETHASONE INJ 16 MG/50 ML,J1100,HCPCS,,80023920,CDM,636,RC,55150023930,NDC,both,25,ML,14,1.17,,,1.17,Other,150% of Medicare + 9.63% HCRA Surcharge,0.71,,,0.71,Fee Schedule,Average Sale Price (ASP) x 6,4.9,35,,4.9,percent of total billed charges,Drugs,4.9,35,,4.9,percent of total billed charges,Drugs,4.76,34,,4.76,percent of total billed charges,Drugs,4.76,34,,4.76,percent of total billed charges,Drugs,4.76,34,,4.76,percent of total billed charges,Drugs,4.76,34,,4.76,percent of total billed charges,Drugs,4.9,35,,4.9,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,4.9,35,,4.9,percent of total billed charges,Drugs,4.9,35,,4.9,percent of total billed charges,Drugs,4.9,35,,4.9,percent of total billed charges,Drugs,4.9,35,,4.9,percent of total billed charges,Drugs,4.9,35,,4.9,percent of total billed charges,Drugs,5.6,40,,5.6,percent of total billed charges,Drugs,9.8,70,,9.8,percent of total billed charges,All Other,5.04,36,,5.04,percent of total billed charges,Drugs,5.04,36,,5.04,percent of total billed charges,Drugs,4.9,35,,4.9,percent of total billed charges,Drugs,4.9,35,,4.9,percent of total billed charges,Drugs,4.9,35,,4.9,percent of total billed charges,Drugs,4.9,35,,4.9,percent of total billed charges,Drugs,4.67,,,4.67,Other,Drug Cost,4.67,,,4.67,Other,Drug Cost,4.67,,,4.67,Other,Drug Cost,4.67,,,4.67,Other,Drug Cost,4.67,,,4.67,Other,Drug Cost,4.67,,,4.67,Other,Drug Cost,10.5,,,10.5,Other,225% of Medicaid,6.54,,,6.54,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,1.14,,,1.14,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",10.04,,,10.04,Other,215% Medicaid APG methodology,10.04,,,10.04,Other,215% Medicaid APG methodology,5.84,,,5.84,Other,125% Medicaid APG methodology,0.01,10.5,
DEXAMETHASONE INJ 20 MG/50 ML,J1100,HCPCS,,80023921,CDM,636,RC,63323016530,NDC,both,1,ML,55.59,1.17,,,1.17,Other,150% of Medicare + 9.63% HCRA Surcharge,0.71,,,0.71,Fee Schedule,Average Sale Price (ASP) x 6,19.46,35,,19.46,percent of total billed charges,Drugs,19.46,35,,19.46,percent of total billed charges,Drugs,18.9,34,,18.9,percent of total billed charges,Drugs,18.9,34,,18.9,percent of total billed charges,Drugs,18.9,34,,18.9,percent of total billed charges,Drugs,18.9,34,,18.9,percent of total billed charges,Drugs,19.46,35,,19.46,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,19.46,35,,19.46,percent of total billed charges,Drugs,19.46,35,,19.46,percent of total billed charges,Drugs,19.46,35,,19.46,percent of total billed charges,Drugs,19.46,35,,19.46,percent of total billed charges,Drugs,19.46,35,,19.46,percent of total billed charges,Drugs,22.24,40,,22.24,percent of total billed charges,Drugs,38.91,70,,38.91,percent of total billed charges,All Other,20.01,36,,20.01,percent of total billed charges,Drugs,20.01,36,,20.01,percent of total billed charges,Drugs,19.46,35,,19.46,percent of total billed charges,Drugs,19.46,35,,19.46,percent of total billed charges,Drugs,19.46,35,,19.46,percent of total billed charges,Drugs,19.46,35,,19.46,percent of total billed charges,Drugs,18.53,,,18.53,Other,Drug Cost,18.53,,,18.53,Other,Drug Cost,18.53,,,18.53,Other,Drug Cost,18.53,,,18.53,Other,Drug Cost,18.53,,,18.53,Other,Drug Cost,18.53,,,18.53,Other,Drug Cost,41.69,,,41.69,Other,225% of Medicaid,25.94,,,25.94,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,1.14,,,1.14,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",39.84,,,39.84,Other,215% Medicaid APG methodology,39.84,,,39.84,Other,215% Medicaid APG methodology,23.16,,,23.16,Other,125% Medicaid APG methodology,0.01,41.69,
CISTRACURIUM 200MG/ 20ML INJ,J3490,HCPCS,,80023924,CDM,636,RC,74438220,NDC,both,10,ML,807.15,318.56,39.4668,,318.56,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,282.5,35,,282.5,percent of total billed charges,Drugs,282.5,35,,282.5,percent of total billed charges,Drugs,274.43,34,,274.43,percent of total billed charges,Drugs,274.43,34,,274.43,percent of total billed charges,Drugs,274.43,34,,274.43,percent of total billed charges,Drugs,274.43,34,,274.43,percent of total billed charges,Drugs,282.5,35,,282.5,percent of total billed charges,Drugs,274.43,34,"If Charge > 500, then 34 percent",274.43,percent of total billed charges,Drugs,282.5,35,,282.5,percent of total billed charges,Drugs,282.5,35,,282.5,percent of total billed charges,Drugs,282.5,35,,282.5,percent of total billed charges,Drugs,282.5,35,,282.5,percent of total billed charges,Drugs,282.5,35,,282.5,percent of total billed charges,Drugs,322.86,40,,322.86,percent of total billed charges,Drugs,565.01,70,,565.01,percent of total billed charges,All Other,290.57,36,,290.57,percent of total billed charges,Drugs,290.57,36,,290.57,percent of total billed charges,Drugs,282.5,35,,282.5,percent of total billed charges,Drugs,282.5,35,,282.5,percent of total billed charges,Drugs,282.5,35,,282.5,percent of total billed charges,Drugs,282.5,35,,282.5,percent of total billed charges,Drugs,269.05,,,269.05,Other,Drug Cost,269.05,,,269.05,Other,Drug Cost,269.05,,,269.05,Other,Drug Cost,269.05,,,269.05,Other,Drug Cost,269.05,,,269.05,Other,Drug Cost,269.05,,,269.05,Other,Drug Cost,605.36,,,605.36,Other,225% of Medicaid,376.67,,,376.67,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",578.46,,,578.46,Other,215% Medicaid APG methodology,578.46,,,578.46,Other,215% Medicaid APG methodology,336.31,,,336.31,Other,125% Medicaid APG methodology,0.01,605.36,
TERIPARATIDE ACETATE 20MCG/ DOSE 2.4ML,J3110,HCPCS,,80023926,CDM,636,RC,2840001,NDC,both,1,ML,11658.63,4601.29,39.4668,,4601.29,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,4080.52,35,,4080.52,percent of total billed charges,Drugs,4080.52,35,,4080.52,percent of total billed charges,Drugs,3963.93,34,,3963.93,percent of total billed charges,Drugs,3963.93,34,,3963.93,percent of total billed charges,Drugs,3963.93,34,,3963.93,percent of total billed charges,Drugs,3963.93,34,,3963.93,percent of total billed charges,Drugs,4080.52,35,,4080.52,percent of total billed charges,Drugs,3963.93,34,"If Charge > 500, then 34 percent",3963.93,percent of total billed charges,Drugs,4080.52,35,,4080.52,percent of total billed charges,Drugs,4080.52,35,,4080.52,percent of total billed charges,Drugs,4080.52,35,,4080.52,percent of total billed charges,Drugs,4080.52,35,,4080.52,percent of total billed charges,Drugs,4080.52,35,,4080.52,percent of total billed charges,Drugs,4663.45,40,,4663.45,percent of total billed charges,Drugs,8161.04,70,,8161.04,percent of total billed charges,All Other,4197.11,36,,4197.11,percent of total billed charges,Drugs,4197.11,36,,4197.11,percent of total billed charges,Drugs,4080.52,35,,4080.52,percent of total billed charges,Drugs,4080.52,35,,4080.52,percent of total billed charges,Drugs,4080.52,35,,4080.52,percent of total billed charges,Drugs,4080.52,35,,4080.52,percent of total billed charges,Drugs,3886.21,,,3886.21,Other,Drug Cost,3886.21,,,3886.21,Other,Drug Cost,3886.21,,,3886.21,Other,Drug Cost,3886.21,,,3886.21,Other,Drug Cost,3886.21,,,3886.21,Other,Drug Cost,3886.21,,,3886.21,Other,Drug Cost,8743.97,,,8743.97,Other,225% of Medicaid,5440.69,,,5440.69,Other,140% of Medicaid,3963.93,34,"If Charge > 2,000, then 34 percent",3963.93,percent of total billed charges,Drugs,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",8355.35,,,8355.35,Other,215% Medicaid APG methodology,8355.35,,,8355.35,Other,215% Medicaid APG methodology,4857.76,,,4857.76,Other,125% Medicaid APG methodology,0.01,8743.97,
MOXIFLOXACIN 400MG/250ML,J2280,HCPCS,,80023927,CDM,636,RC,63323085074,NDC,both,12,ML,62.19,93,,,93,Other,150% of Medicare + 9.63% HCRA Surcharge,56.56,,,56.56,Fee Schedule,Average Sale Price (ASP) x 6,21.77,35,,21.77,percent of total billed charges,Drugs,21.77,35,,21.77,percent of total billed charges,Drugs,21.15,34,,21.15,percent of total billed charges,Drugs,21.15,34,,21.15,percent of total billed charges,Drugs,21.15,34,,21.15,percent of total billed charges,Drugs,21.15,34,,21.15,percent of total billed charges,Drugs,21.77,35,,21.77,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,21.77,35,,21.77,percent of total billed charges,Drugs,21.77,35,,21.77,percent of total billed charges,Drugs,21.77,35,,21.77,percent of total billed charges,Drugs,21.77,35,,21.77,percent of total billed charges,Drugs,21.77,35,,21.77,percent of total billed charges,Drugs,24.88,40,,24.88,percent of total billed charges,Drugs,43.53,70,,43.53,percent of total billed charges,All Other,22.39,36,,22.39,percent of total billed charges,Drugs,22.39,36,,22.39,percent of total billed charges,Drugs,21.77,35,,21.77,percent of total billed charges,Drugs,21.77,35,,21.77,percent of total billed charges,Drugs,21.77,35,,21.77,percent of total billed charges,Drugs,21.77,35,,21.77,percent of total billed charges,Drugs,20.73,,,20.73,Other,Drug Cost,20.73,,,20.73,Other,Drug Cost,20.73,,,20.73,Other,Drug Cost,20.73,,,20.73,Other,Drug Cost,20.73,,,20.73,Other,Drug Cost,20.73,,,20.73,Other,Drug Cost,46.64,,,46.64,Other,225% of Medicaid,29.02,,,29.02,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,90.49,,,90.49,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",44.57,,,44.57,Other,215% Medicaid APG methodology,44.57,,,44.57,Other,215% Medicaid APG methodology,25.91,,,25.91,Other,125% Medicaid APG methodology,0.01,93,
Dextrose 10% 250mL,J7799,HCPCS,,80023933,CDM,636,RC,338002302,NDC,both,36,ML,6.65,2.63,39.4668,,2.63,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,2.33,35,,2.33,percent of total billed charges,Drugs,2.33,35,,2.33,percent of total billed charges,Drugs,2.26,34,,2.26,percent of total billed charges,Drugs,2.26,34,,2.26,percent of total billed charges,Drugs,2.26,34,,2.26,percent of total billed charges,Drugs,2.26,34,,2.26,percent of total billed charges,Drugs,2.33,35,,2.33,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,2.33,35,,2.33,percent of total billed charges,Drugs,2.33,35,,2.33,percent of total billed charges,Drugs,2.33,35,,2.33,percent of total billed charges,Drugs,2.33,35,,2.33,percent of total billed charges,Drugs,2.33,35,,2.33,percent of total billed charges,Drugs,2.66,40,,2.66,percent of total billed charges,Drugs,4.66,70,,4.66,percent of total billed charges,All Other,2.4,36,,2.4,percent of total billed charges,Drugs,2.4,36,,2.4,percent of total billed charges,Drugs,2.33,35,,2.33,percent of total billed charges,Drugs,2.33,35,,2.33,percent of total billed charges,Drugs,2.33,35,,2.33,percent of total billed charges,Drugs,2.33,35,,2.33,percent of total billed charges,Drugs,2.22,,,2.22,Other,Drug Cost,2.22,,,2.22,Other,Drug Cost,2.22,,,2.22,Other,Drug Cost,2.22,,,2.22,Other,Drug Cost,2.22,,,2.22,Other,Drug Cost,2.22,,,2.22,Other,Drug Cost,4.99,,,4.99,Other,225% of Medicaid,3.1,,,3.1,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",4.77,,,4.77,Other,215% Medicaid APG methodology,4.77,,,4.77,Other,215% Medicaid APG methodology,2.77,,,2.77,Other,125% Medicaid APG methodology,0.01,4.99,
Hyaluronidase inj 150unit/mL (1mL),J3470,HCPCS,,80023936,CDM,636,RC,548909010,NDC,both,10,ML,49.22,19.42,39.4668,,19.42,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,17.23,35,,17.23,percent of total billed charges,Drugs,17.23,35,,17.23,percent of total billed charges,Drugs,16.73,34,,16.73,percent of total billed charges,Drugs,16.73,34,,16.73,percent of total billed charges,Drugs,16.73,34,,16.73,percent of total billed charges,Drugs,16.73,34,,16.73,percent of total billed charges,Drugs,17.23,35,,17.23,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,17.23,35,,17.23,percent of total billed charges,Drugs,17.23,35,,17.23,percent of total billed charges,Drugs,17.23,35,,17.23,percent of total billed charges,Drugs,17.23,35,,17.23,percent of total billed charges,Drugs,17.23,35,,17.23,percent of total billed charges,Drugs,19.69,40,,19.69,percent of total billed charges,Drugs,34.45,70,,34.45,percent of total billed charges,All Other,17.72,36,,17.72,percent of total billed charges,Drugs,17.72,36,,17.72,percent of total billed charges,Drugs,17.23,35,,17.23,percent of total billed charges,Drugs,17.23,35,,17.23,percent of total billed charges,Drugs,17.23,35,,17.23,percent of total billed charges,Drugs,17.23,35,,17.23,percent of total billed charges,Drugs,16.41,,,16.41,Other,Drug Cost,16.41,,,16.41,Other,Drug Cost,16.41,,,16.41,Other,Drug Cost,16.41,,,16.41,Other,Drug Cost,16.41,,,16.41,Other,Drug Cost,16.41,,,16.41,Other,Drug Cost,36.91,,,36.91,Other,225% of Medicaid,22.97,,,22.97,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",35.27,,,35.27,Other,215% Medicaid APG methodology,35.27,,,35.27,Other,215% Medicaid APG methodology,20.51,,,20.51,Other,125% Medicaid APG methodology,0.01,36.91,
FAM-TRASTUZUMAB DERUXTECN- NXKI 100MG,J9358,HCPCS,,80023938,CDM,636,RC,65597040601,NDC,both,1,EA,8336.64,268.77,,,268.77,Other,150% of Medicare + 9.63% HCRA Surcharge,163.44,,,163.44,Fee Schedule,Average Sale Price (ASP) x 6,2917.82,35,,2917.82,percent of total billed charges,Drugs,2917.82,35,,2917.82,percent of total billed charges,Drugs,2834.46,34,,2834.46,percent of total billed charges,Drugs,2834.46,34,,2834.46,percent of total billed charges,Drugs,2834.46,34,,2834.46,percent of total billed charges,Drugs,2834.46,34,,2834.46,percent of total billed charges,Drugs,2917.82,35,,2917.82,percent of total billed charges,Drugs,2834.46,34,"If Charge > 500, then 34 percent",2834.46,percent of total billed charges,Drugs,2917.82,35,,2917.82,percent of total billed charges,Drugs,2917.82,35,,2917.82,percent of total billed charges,Drugs,2917.82,35,,2917.82,percent of total billed charges,Drugs,2917.82,35,,2917.82,percent of total billed charges,Drugs,2917.82,35,,2917.82,percent of total billed charges,Drugs,3334.66,40,,3334.66,percent of total billed charges,Drugs,5835.65,70,,5835.65,percent of total billed charges,All Other,3001.19,36,,3001.19,percent of total billed charges,Drugs,3001.19,36,,3001.19,percent of total billed charges,Drugs,2917.82,35,,2917.82,percent of total billed charges,Drugs,2917.82,35,,2917.82,percent of total billed charges,Drugs,2917.82,35,,2917.82,percent of total billed charges,Drugs,2917.82,35,,2917.82,percent of total billed charges,Drugs,2778.88,,,2778.88,Other,Drug Cost,2778.88,,,2778.88,Other,Drug Cost,2778.88,,,2778.88,Other,Drug Cost,2778.88,,,2778.88,Other,Drug Cost,2778.88,,,2778.88,Other,Drug Cost,2778.88,,,2778.88,Other,Drug Cost,6252.48,,,6252.48,Other,225% of Medicaid,3890.43,,,3890.43,Other,140% of Medicaid,2834.46,34,"If Charge > 2,000, then 34 percent",2834.46,percent of total billed charges,Drugs,261.5,,,261.5,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",5974.59,,,5974.59,Other,215% Medicaid APG methodology,5974.59,,,5974.59,Other,215% Medicaid APG methodology,3473.6,,,3473.6,Other,125% Medicaid APG methodology,0.01,6252.48,
TOCILIZUMAB 400 MG/20 ML INJ,J3262,HCPCS,,80023940,CDM,636,RC,50242013701,NDC,both,1,ML,7608.93,60.38,,,60.38,Other,150% of Medicare + 9.63% HCRA Surcharge,36.72,,,36.72,Fee Schedule,Average Sale Price (ASP) x 6,2663.13,35,,2663.13,percent of total billed charges,Drugs,2663.13,35,,2663.13,percent of total billed charges,Drugs,2587.04,34,,2587.04,percent of total billed charges,Drugs,2587.04,34,,2587.04,percent of total billed charges,Drugs,2587.04,34,,2587.04,percent of total billed charges,Drugs,2587.04,34,,2587.04,percent of total billed charges,Drugs,2663.13,35,,2663.13,percent of total billed charges,Drugs,2587.04,34,"If Charge > 500, then 34 percent",2587.04,percent of total billed charges,Drugs,2663.13,35,,2663.13,percent of total billed charges,Drugs,2663.13,35,,2663.13,percent of total billed charges,Drugs,2663.13,35,,2663.13,percent of total billed charges,Drugs,2663.13,35,,2663.13,percent of total billed charges,Drugs,2663.13,35,,2663.13,percent of total billed charges,Drugs,3043.57,40,,3043.57,percent of total billed charges,Drugs,5326.25,70,,5326.25,percent of total billed charges,All Other,2739.21,36,,2739.21,percent of total billed charges,Drugs,2739.21,36,,2739.21,percent of total billed charges,Drugs,2663.13,35,,2663.13,percent of total billed charges,Drugs,2663.13,35,,2663.13,percent of total billed charges,Drugs,2663.13,35,,2663.13,percent of total billed charges,Drugs,2663.13,35,,2663.13,percent of total billed charges,Drugs,2536.31,,,2536.31,Other,Drug Cost,2536.31,,,2536.31,Other,Drug Cost,2536.31,,,2536.31,Other,Drug Cost,2536.31,,,2536.31,Other,Drug Cost,2536.31,,,2536.31,Other,Drug Cost,2536.31,,,2536.31,Other,Drug Cost,5706.7,,,5706.7,Other,225% of Medicaid,3550.83,,,3550.83,Other,140% of Medicaid,2587.04,34,"If Charge > 2,000, then 34 percent",2587.04,percent of total billed charges,Drugs,58.75,,,58.75,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",5453.07,,,5453.07,Other,215% Medicaid APG methodology,5453.07,,,5453.07,Other,215% Medicaid APG methodology,3170.39,,,3170.39,Other,125% Medicaid APG methodology,0.01,5706.7,
DEXAMETHASONE 2 MG TABLET,J8540,HCPCS,,80023951,CDM,636,RC,54418325,NDC,both,100,EA,0.52,0.82,,,0.82,Other,150% of Medicare + 9.63% HCRA Surcharge,0.5,,,0.5,Fee Schedule,Average Sale Price (ASP) x 6,0.18,35,,0.18,percent of total billed charges,Drugs,0.18,35,,0.18,percent of total billed charges,Drugs,0.18,34,,0.18,percent of total billed charges,Drugs,0.18,34,,0.18,percent of total billed charges,Drugs,0.18,34,,0.18,percent of total billed charges,Drugs,0.18,34,,0.18,percent of total billed charges,Drugs,0.18,35,,0.18,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,0.18,35,,0.18,percent of total billed charges,Drugs,0.18,35,,0.18,percent of total billed charges,Drugs,0.18,35,,0.18,percent of total billed charges,Drugs,0.18,35,,0.18,percent of total billed charges,Drugs,0.18,35,,0.18,percent of total billed charges,Drugs,0.21,40,,0.21,percent of total billed charges,Drugs,0.36,70,,0.36,percent of total billed charges,All Other,0.19,36,,0.19,percent of total billed charges,Drugs,0.19,36,,0.19,percent of total billed charges,Drugs,0.18,35,,0.18,percent of total billed charges,Drugs,0.18,35,,0.18,percent of total billed charges,Drugs,0.18,35,,0.18,percent of total billed charges,Drugs,0.18,35,,0.18,percent of total billed charges,Drugs,0.17,,,0.17,Other,Drug Cost,0.17,,,0.17,Other,Drug Cost,0.17,,,0.17,Other,Drug Cost,0.17,,,0.17,Other,Drug Cost,0.17,,,0.17,Other,Drug Cost,0.17,,,0.17,Other,Drug Cost,0.39,,,0.39,Other,225% of Medicaid,0.24,,,0.24,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,0.8,,,0.8,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",0.37,,,0.37,Other,215% Medicaid APG methodology,0.37,,,0.37,Other,215% Medicaid APG methodology,0.22,,,0.22,Other,125% Medicaid APG methodology,0.01,0.82,
DEXAMETHASONE 6MG TABLET,J8540,HCPCS,,80023956,CDM,636,RC,54418625,NDC,both,100,EA,0.07,0.82,,,0.82,Other,150% of Medicare + 9.63% HCRA Surcharge,0.5,,,0.5,Fee Schedule,Average Sale Price (ASP) x 6,0.03,35,,0.03,percent of total billed charges,Drugs,0.03,35,,0.03,percent of total billed charges,Drugs,0.02,34,,0.02,percent of total billed charges,Drugs,0.02,34,,0.02,percent of total billed charges,Drugs,0.02,34,,0.02,percent of total billed charges,Drugs,0.02,34,,0.02,percent of total billed charges,Drugs,0.03,35,,0.03,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,0.03,35,,0.03,percent of total billed charges,Drugs,0.03,35,,0.03,percent of total billed charges,Drugs,0.03,35,,0.03,percent of total billed charges,Drugs,0.03,35,,0.03,percent of total billed charges,Drugs,0.03,35,,0.03,percent of total billed charges,Drugs,0.03,40,,0.03,percent of total billed charges,Drugs,0.05,70,,0.05,percent of total billed charges,All Other,0.03,36,,0.03,percent of total billed charges,Drugs,0.03,36,,0.03,percent of total billed charges,Drugs,0.03,35,,0.03,percent of total billed charges,Drugs,0.03,35,,0.03,percent of total billed charges,Drugs,0.03,35,,0.03,percent of total billed charges,Drugs,0.03,35,,0.03,percent of total billed charges,Drugs,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.05,,,0.05,Other,225% of Medicaid,0.03,,,0.03,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,0.8,,,0.8,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",0.05,,,0.05,Other,215% Medicaid APG methodology,0.05,,,0.05,Other,215% Medicaid APG methodology,0.03,,,0.03,Other,125% Medicaid APG methodology,0.01,0.82,
"EPOETIN ALA-EPBX 40,000 UNIT",Q5106,HCPCS,,80023957,CDM,636,RC,69130904,NDC,both,4,ML,559.87,77.2,,,77.2,Other,150% of Medicare + 9.63% HCRA Surcharge,46.94,,,46.94,Fee Schedule,Average Sale Price (ASP) x 6,195.95,35,,195.95,percent of total billed charges,Drugs,195.95,35,,195.95,percent of total billed charges,Drugs,190.35,34,,190.35,percent of total billed charges,Drugs,190.35,34,,190.35,percent of total billed charges,Drugs,190.35,34,,190.35,percent of total billed charges,Drugs,190.35,34,,190.35,percent of total billed charges,Drugs,195.95,35,,195.95,percent of total billed charges,Drugs,190.35,34,"If Charge > 500, then 34 percent",190.35,percent of total billed charges,Drugs,195.95,35,,195.95,percent of total billed charges,Drugs,195.95,35,,195.95,percent of total billed charges,Drugs,195.95,35,,195.95,percent of total billed charges,Drugs,195.95,35,,195.95,percent of total billed charges,Drugs,195.95,35,,195.95,percent of total billed charges,Drugs,223.95,40,,223.95,percent of total billed charges,Drugs,391.91,70,,391.91,percent of total billed charges,All Other,201.55,36,,201.55,percent of total billed charges,Drugs,201.55,36,,201.55,percent of total billed charges,Drugs,195.95,35,,195.95,percent of total billed charges,Drugs,195.95,35,,195.95,percent of total billed charges,Drugs,195.95,35,,195.95,percent of total billed charges,Drugs,195.95,35,,195.95,percent of total billed charges,Drugs,186.62,,,186.62,Other,Drug Cost,186.62,,,186.62,Other,Drug Cost,186.62,,,186.62,Other,Drug Cost,186.62,,,186.62,Other,Drug Cost,186.62,,,186.62,Other,Drug Cost,186.62,,,186.62,Other,Drug Cost,419.9,,,419.9,Other,225% of Medicaid,261.27,,,261.27,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,75.11,,,75.11,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",401.24,,,401.24,Other,215% Medicaid APG methodology,401.24,,,401.24,Other,215% Medicaid APG methodology,233.28,,,233.28,Other,125% Medicaid APG methodology,0.01,419.9,
FLU VACC HIGH-DOSE QUAD 65YRS+,90662,HCPCS,,80023966,CDM,636,RC,49281012365,NDC,both,10,ML,191.53,75.59,39.4668,,75.59,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,67.04,35,,67.04,percent of total billed charges,Drugs,67.04,35,,67.04,percent of total billed charges,Drugs,65.12,34,,65.12,percent of total billed charges,Drugs,65.12,34,,65.12,percent of total billed charges,Drugs,65.12,34,,65.12,percent of total billed charges,Drugs,65.12,34,,65.12,percent of total billed charges,Drugs,67.04,35,,67.04,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,67.04,35,,67.04,percent of total billed charges,Drugs,67.04,35,,67.04,percent of total billed charges,Drugs,67.04,35,,67.04,percent of total billed charges,Drugs,67.04,35,,67.04,percent of total billed charges,Drugs,67.04,35,,67.04,percent of total billed charges,Drugs,76.61,40,,76.61,percent of total billed charges,Drugs,134.07,70,,134.07,percent of total billed charges,All Other,68.95,36,,68.95,percent of total billed charges,Drugs,68.95,36,,68.95,percent of total billed charges,Drugs,67.04,35,,67.04,percent of total billed charges,Drugs,67.04,35,,67.04,percent of total billed charges,Drugs,67.04,35,,67.04,percent of total billed charges,Drugs,67.04,35,,67.04,percent of total billed charges,Drugs,63.84,,,63.84,Other,Drug Cost,63.84,,,63.84,Other,Drug Cost,63.84,,,63.84,Other,Drug Cost,63.84,,,63.84,Other,Drug Cost,63.84,,,63.84,Other,Drug Cost,63.84,,,63.84,Other,Drug Cost,143.65,,,143.65,Other,225% of Medicaid,89.38,,,89.38,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",137.26,,,137.26,Other,215% Medicaid APG methodology,137.26,,,137.26,Other,215% Medicaid APG methodology,79.8,,,79.8,Other,125% Medicaid APG methodology,0.01,143.65,
FERUMOXYTOL 510MG/17ML,Q0138,HCPCS,,80023967,CDM,636,RC,59338077501,NDC,both,1,ML,345.27,3.52,,,3.52,Other,150% of Medicare + 9.63% HCRA Surcharge,2.14,,,2.14,Fee Schedule,Average Sale Price (ASP) x 6,120.84,35,,120.84,percent of total billed charges,Drugs,120.84,35,,120.84,percent of total billed charges,Drugs,117.39,34,,117.39,percent of total billed charges,Drugs,117.39,34,,117.39,percent of total billed charges,Drugs,117.39,34,,117.39,percent of total billed charges,Drugs,117.39,34,,117.39,percent of total billed charges,Drugs,120.84,35,,120.84,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,120.84,35,,120.84,percent of total billed charges,Drugs,120.84,35,,120.84,percent of total billed charges,Drugs,120.84,35,,120.84,percent of total billed charges,Drugs,120.84,35,,120.84,percent of total billed charges,Drugs,120.84,35,,120.84,percent of total billed charges,Drugs,138.11,40,,138.11,percent of total billed charges,Drugs,241.69,70,,241.69,percent of total billed charges,All Other,124.3,36,,124.3,percent of total billed charges,Drugs,124.3,36,,124.3,percent of total billed charges,Drugs,120.84,35,,120.84,percent of total billed charges,Drugs,120.84,35,,120.84,percent of total billed charges,Drugs,120.84,35,,120.84,percent of total billed charges,Drugs,120.84,35,,120.84,percent of total billed charges,Drugs,115.09,,,115.09,Other,Drug Cost,115.09,,,115.09,Other,Drug Cost,115.09,,,115.09,Other,Drug Cost,115.09,,,115.09,Other,Drug Cost,115.09,,,115.09,Other,Drug Cost,115.09,,,115.09,Other,Drug Cost,258.95,,,258.95,Other,225% of Medicaid,161.13,,,161.13,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,3.43,,,3.43,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",247.44,,,247.44,Other,215% Medicaid APG methodology,247.44,,,247.44,Other,215% Medicaid APG methodology,143.86,,,143.86,Other,125% Medicaid APG methodology,0.01,258.95,
FACTOR X-A INACTIVATED-ZHZO 200MG INJ,J7169,HCPCS,,80023968,CDM,636,RC,69853010201,NDC,both,4,EA,7421.25,2928.93,39.4668,,2928.93,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,2597.44,35,,2597.44,percent of total billed charges,Drugs,2597.44,35,,2597.44,percent of total billed charges,Drugs,2523.23,34,,2523.23,percent of total billed charges,Drugs,2523.23,34,,2523.23,percent of total billed charges,Drugs,2523.23,34,,2523.23,percent of total billed charges,Drugs,2523.23,34,,2523.23,percent of total billed charges,Drugs,2597.44,35,,2597.44,percent of total billed charges,Drugs,2523.23,34,"If Charge > 500, then 34 percent",2523.23,percent of total billed charges,Drugs,2597.44,35,,2597.44,percent of total billed charges,Drugs,2597.44,35,,2597.44,percent of total billed charges,Drugs,2597.44,35,,2597.44,percent of total billed charges,Drugs,2597.44,35,,2597.44,percent of total billed charges,Drugs,2597.44,35,,2597.44,percent of total billed charges,Drugs,2968.5,40,,2968.5,percent of total billed charges,Drugs,5194.88,70,,5194.88,percent of total billed charges,All Other,2671.65,36,,2671.65,percent of total billed charges,Drugs,2671.65,36,,2671.65,percent of total billed charges,Drugs,2597.44,35,,2597.44,percent of total billed charges,Drugs,2597.44,35,,2597.44,percent of total billed charges,Drugs,2597.44,35,,2597.44,percent of total billed charges,Drugs,2597.44,35,,2597.44,percent of total billed charges,Drugs,2473.75,,,2473.75,Other,Drug Cost,2473.75,,,2473.75,Other,Drug Cost,2473.75,,,2473.75,Other,Drug Cost,2473.75,,,2473.75,Other,Drug Cost,2473.75,,,2473.75,Other,Drug Cost,2473.75,,,2473.75,Other,Drug Cost,5565.94,,,5565.94,Other,225% of Medicaid,3463.25,,,3463.25,Other,140% of Medicaid,2523.23,34,"If Charge > 2,000, then 34 percent",2523.23,percent of total billed charges,Drugs,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",5318.56,,,5318.56,Other,215% Medicaid APG methodology,5318.56,,,5318.56,Other,215% Medicaid APG methodology,3092.19,,,3092.19,Other,125% Medicaid APG methodology,0.01,5565.94,
RITUXIMAB-PVVR 10MG/ML 10ML,Q5119,HCPCS,,80023969,CDM,636,RC,69023801,NDC,both,1,ML,242.01,201.74,,,201.74,Other,150% of Medicare + 9.63% HCRA Surcharge,122.68,,,122.68,Fee Schedule,Average Sale Price (ASP) x 6,84.7,35,,84.7,percent of total billed charges,Drugs,84.7,35,,84.7,percent of total billed charges,Drugs,82.28,34,,82.28,percent of total billed charges,Drugs,82.28,34,,82.28,percent of total billed charges,Drugs,82.28,34,,82.28,percent of total billed charges,Drugs,82.28,34,,82.28,percent of total billed charges,Drugs,84.7,35,,84.7,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,84.7,35,,84.7,percent of total billed charges,Drugs,84.7,35,,84.7,percent of total billed charges,Drugs,84.7,35,,84.7,percent of total billed charges,Drugs,84.7,35,,84.7,percent of total billed charges,Drugs,84.7,35,,84.7,percent of total billed charges,Drugs,96.8,40,,96.8,percent of total billed charges,Drugs,169.41,70,,169.41,percent of total billed charges,All Other,87.12,36,,87.12,percent of total billed charges,Drugs,87.12,36,,87.12,percent of total billed charges,Drugs,84.7,35,,84.7,percent of total billed charges,Drugs,84.7,35,,84.7,percent of total billed charges,Drugs,84.7,35,,84.7,percent of total billed charges,Drugs,84.7,35,,84.7,percent of total billed charges,Drugs,80.67,,,80.67,Other,Drug Cost,80.67,,,80.67,Other,Drug Cost,80.67,,,80.67,Other,Drug Cost,80.67,,,80.67,Other,Drug Cost,80.67,,,80.67,Other,Drug Cost,80.67,,,80.67,Other,Drug Cost,181.51,,,181.51,Other,225% of Medicaid,112.94,,,112.94,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,196.29,,,196.29,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",173.44,,,173.44,Other,215% Medicaid APG methodology,173.44,,,173.44,Other,215% Medicaid APG methodology,100.84,,,100.84,Other,125% Medicaid APG methodology,0.01,201.74,
ISATUXIMAB-IRFC 100MG/5ML,J9227,HCPCS,,80023971,CDM,636,RC,24065401,NDC,both,1,ML,2349.54,754.77,,,754.77,Other,150% of Medicare + 9.63% HCRA Surcharge,458.98,,,458.98,Fee Schedule,Average Sale Price (ASP) x 6,822.34,35,,822.34,percent of total billed charges,Drugs,822.34,35,,822.34,percent of total billed charges,Drugs,798.84,34,,798.84,percent of total billed charges,Drugs,798.84,34,,798.84,percent of total billed charges,Drugs,798.84,34,,798.84,percent of total billed charges,Drugs,798.84,34,,798.84,percent of total billed charges,Drugs,822.34,35,,822.34,percent of total billed charges,Drugs,798.84,34,"If Charge > 500, then 34 percent",798.84,percent of total billed charges,Drugs,822.34,35,,822.34,percent of total billed charges,Drugs,822.34,35,,822.34,percent of total billed charges,Drugs,822.34,35,,822.34,percent of total billed charges,Drugs,822.34,35,,822.34,percent of total billed charges,Drugs,822.34,35,,822.34,percent of total billed charges,Drugs,939.82,40,,939.82,percent of total billed charges,Drugs,1644.68,70,,1644.68,percent of total billed charges,All Other,845.83,36,,845.83,percent of total billed charges,Drugs,845.83,36,,845.83,percent of total billed charges,Drugs,822.34,35,,822.34,percent of total billed charges,Drugs,822.34,35,,822.34,percent of total billed charges,Drugs,822.34,35,,822.34,percent of total billed charges,Drugs,822.34,35,,822.34,percent of total billed charges,Drugs,783.18,,,783.18,Other,Drug Cost,783.18,,,783.18,Other,Drug Cost,783.18,,,783.18,Other,Drug Cost,783.18,,,783.18,Other,Drug Cost,783.18,,,783.18,Other,Drug Cost,783.18,,,783.18,Other,Drug Cost,1762.16,,,1762.16,Other,225% of Medicaid,1096.45,,,1096.45,Other,140% of Medicaid,798.84,34,"If Charge > 2,000, then 34 percent",798.84,percent of total billed charges,Drugs,734.37,,,734.37,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",1683.84,,,1683.84,Other,215% Medicaid APG methodology,1683.84,,,1683.84,Other,215% Medicaid APG methodology,978.98,,,978.98,Other,125% Medicaid APG methodology,0.01,1762.16,
INFLIXIMAB-DYYB 100MG INJ,Q5103,HCPCS,,80023972,CDM,636,RC,69080901,NDC,both,1,EA,224.4,141.03,,,141.03,Other,150% of Medicare + 9.63% HCRA Surcharge,85.76,,,85.76,Fee Schedule,Average Sale Price (ASP) x 6,78.54,35,,78.54,percent of total billed charges,Drugs,78.54,35,,78.54,percent of total billed charges,Drugs,76.3,34,,76.3,percent of total billed charges,Drugs,76.3,34,,76.3,percent of total billed charges,Drugs,76.3,34,,76.3,percent of total billed charges,Drugs,76.3,34,,76.3,percent of total billed charges,Drugs,78.54,35,,78.54,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,78.54,35,,78.54,percent of total billed charges,Drugs,78.54,35,,78.54,percent of total billed charges,Drugs,78.54,35,,78.54,percent of total billed charges,Drugs,78.54,35,,78.54,percent of total billed charges,Drugs,78.54,35,,78.54,percent of total billed charges,Drugs,89.76,40,,89.76,percent of total billed charges,Drugs,157.08,70,,157.08,percent of total billed charges,All Other,80.78,36,,80.78,percent of total billed charges,Drugs,80.78,36,,80.78,percent of total billed charges,Drugs,78.54,35,,78.54,percent of total billed charges,Drugs,78.54,35,,78.54,percent of total billed charges,Drugs,78.54,35,,78.54,percent of total billed charges,Drugs,78.54,35,,78.54,percent of total billed charges,Drugs,74.8,,,74.8,Other,Drug Cost,74.8,,,74.8,Other,Drug Cost,74.8,,,74.8,Other,Drug Cost,74.8,,,74.8,Other,Drug Cost,74.8,,,74.8,Other,Drug Cost,74.8,,,74.8,Other,Drug Cost,168.3,,,168.3,Other,225% of Medicaid,104.72,,,104.72,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,137.22,,,137.22,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",160.82,,,160.82,Other,215% Medicaid APG methodology,160.82,,,160.82,Other,215% Medicaid APG methodology,93.5,,,93.5,Other,125% Medicaid APG methodology,0.01,168.3,
DARZALEX FASPRO 1800MG-30000UN/15ML INJ,J9144,HCPCS,,80023975,CDM,636,RC,57894050301,NDC,both,1,ML,29752.17,483.97,,,483.97,Other,150% of Medicare + 9.63% HCRA Surcharge,294.31,,,294.31,Fee Schedule,Average Sale Price (ASP) x 6,10413.26,35,,10413.26,percent of total billed charges,Drugs,10413.26,35,,10413.26,percent of total billed charges,Drugs,10115.74,34,,10115.74,percent of total billed charges,Drugs,10115.74,34,,10115.74,percent of total billed charges,Drugs,10115.74,34,,10115.74,percent of total billed charges,Drugs,10115.74,34,,10115.74,percent of total billed charges,Drugs,10413.26,35,,10413.26,percent of total billed charges,Drugs,10115.74,34,"If Charge > 500, then 34 percent",10115.74,percent of total billed charges,Drugs,10413.26,35,,10413.26,percent of total billed charges,Drugs,10413.26,35,,10413.26,percent of total billed charges,Drugs,10413.26,35,,10413.26,percent of total billed charges,Drugs,10413.26,35,,10413.26,percent of total billed charges,Drugs,10413.26,35,,10413.26,percent of total billed charges,Drugs,11900.87,40,,11900.87,percent of total billed charges,Drugs,20826.52,70,,20826.52,percent of total billed charges,All Other,10710.78,36,,10710.78,percent of total billed charges,Drugs,10710.78,36,,10710.78,percent of total billed charges,Drugs,10413.26,35,,10413.26,percent of total billed charges,Drugs,10413.26,35,,10413.26,percent of total billed charges,Drugs,10413.26,35,,10413.26,percent of total billed charges,Drugs,10413.26,35,,10413.26,percent of total billed charges,Drugs,9917.39,,,9917.39,Other,Drug Cost,9917.39,,,9917.39,Other,Drug Cost,9917.39,,,9917.39,Other,Drug Cost,9917.39,,,9917.39,Other,Drug Cost,9917.39,,,9917.39,Other,Drug Cost,9917.39,,,9917.39,Other,Drug Cost,22314.13,,,22314.13,Other,225% of Medicaid,13884.35,,,13884.35,Other,140% of Medicaid,10115.74,34,"If Charge > 2,000, then 34 percent",10115.74,percent of total billed charges,Drugs,470.89,,,470.89,Other,160% Medicare Fee Schedule,10115.74,34,,10115.74,Other,"Drug Charges > 20,000, then 34% of Charges",21322.39,,,21322.39,Other,215% Medicaid APG methodology,21322.39,,,21322.39,Other,215% Medicaid APG methodology,12396.74,,,12396.74,Other,125% Medicaid APG methodology,294.31,22314.13,
LEUPROLIDE 30MG INJ,J9217,HCPCS,,80023977,CDM,636,RC,74368303,NDC,both,1,EA,22220.94,1788.85,,,1788.85,Other,150% of Medicare + 9.63% HCRA Surcharge,1087.81,,,1087.81,Fee Schedule,Average Sale Price (ASP) x 6,7777.33,35,,7777.33,percent of total billed charges,Drugs,7777.33,35,,7777.33,percent of total billed charges,Drugs,7555.12,34,,7555.12,percent of total billed charges,Drugs,7555.12,34,,7555.12,percent of total billed charges,Drugs,7555.12,34,,7555.12,percent of total billed charges,Drugs,7555.12,34,,7555.12,percent of total billed charges,Drugs,7777.33,35,,7777.33,percent of total billed charges,Drugs,7555.12,34,"If Charge > 500, then 34 percent",7555.12,percent of total billed charges,Drugs,7777.33,35,,7777.33,percent of total billed charges,Drugs,7777.33,35,,7777.33,percent of total billed charges,Drugs,7777.33,35,,7777.33,percent of total billed charges,Drugs,7777.33,35,,7777.33,percent of total billed charges,Drugs,7777.33,35,,7777.33,percent of total billed charges,Drugs,8888.38,40,,8888.38,percent of total billed charges,Drugs,15554.66,70,,15554.66,percent of total billed charges,All Other,7999.54,36,,7999.54,percent of total billed charges,Drugs,7999.54,36,,7999.54,percent of total billed charges,Drugs,7777.33,35,,7777.33,percent of total billed charges,Drugs,7777.33,35,,7777.33,percent of total billed charges,Drugs,7777.33,35,,7777.33,percent of total billed charges,Drugs,7777.33,35,,7777.33,percent of total billed charges,Drugs,7406.98,,,7406.98,Other,Drug Cost,7406.98,,,7406.98,Other,Drug Cost,7406.98,,,7406.98,Other,Drug Cost,7406.98,,,7406.98,Other,Drug Cost,7406.98,,,7406.98,Other,Drug Cost,7406.98,,,7406.98,Other,Drug Cost,16665.71,,,16665.71,Other,225% of Medicaid,10369.77,,,10369.77,Other,140% of Medicaid,7555.12,34,"If Charge > 2,000, then 34 percent",7555.12,percent of total billed charges,Drugs,1740.5,,,1740.5,Other,160% Medicare Fee Schedule,7555.12,34,,7555.12,Other,"Drug Charges > 20,000, then 34% of Charges",15925.01,,,15925.01,Other,215% Medicaid APG methodology,15925.01,,,15925.01,Other,215% Medicaid APG methodology,9258.73,,,9258.73,Other,125% Medicaid APG methodology,1087.81,16665.71,
USTEKINUMAB 130MG/26ML,J3358,HCPCS,,80023987,CDM,636,RC,57894005427,NDC,both,1,ML,6009.75,124.51,,,124.51,Other,150% of Medicare + 9.63% HCRA Surcharge,75.71,,,75.71,Fee Schedule,Average Sale Price (ASP) x 6,2103.41,35,,2103.41,percent of total billed charges,Drugs,2103.41,35,,2103.41,percent of total billed charges,Drugs,2043.32,34,,2043.32,percent of total billed charges,Drugs,2043.32,34,,2043.32,percent of total billed charges,Drugs,2043.32,34,,2043.32,percent of total billed charges,Drugs,2043.32,34,,2043.32,percent of total billed charges,Drugs,2103.41,35,,2103.41,percent of total billed charges,Drugs,2043.32,34,"If Charge > 500, then 34 percent",2043.32,percent of total billed charges,Drugs,2103.41,35,,2103.41,percent of total billed charges,Drugs,2103.41,35,,2103.41,percent of total billed charges,Drugs,2103.41,35,,2103.41,percent of total billed charges,Drugs,2103.41,35,,2103.41,percent of total billed charges,Drugs,2103.41,35,,2103.41,percent of total billed charges,Drugs,2403.9,40,,2403.9,percent of total billed charges,Drugs,4206.83,70,,4206.83,percent of total billed charges,All Other,2163.51,36,,2163.51,percent of total billed charges,Drugs,2163.51,36,,2163.51,percent of total billed charges,Drugs,2103.41,35,,2103.41,percent of total billed charges,Drugs,2103.41,35,,2103.41,percent of total billed charges,Drugs,2103.41,35,,2103.41,percent of total billed charges,Drugs,2103.41,35,,2103.41,percent of total billed charges,Drugs,2003.25,,,2003.25,Other,Drug Cost,2003.25,,,2003.25,Other,Drug Cost,2003.25,,,2003.25,Other,Drug Cost,2003.25,,,2003.25,Other,Drug Cost,2003.25,,,2003.25,Other,Drug Cost,2003.25,,,2003.25,Other,Drug Cost,4507.31,,,4507.31,Other,225% of Medicaid,2804.55,,,2804.55,Other,140% of Medicaid,2043.32,34,"If Charge > 2,000, then 34 percent",2043.32,percent of total billed charges,Drugs,121.14,,,121.14,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",4306.99,,,4306.99,Other,215% Medicaid APG methodology,4306.99,,,4306.99,Other,215% Medicaid APG methodology,2504.06,,,2504.06,Other,125% Medicaid APG methodology,0.01,4507.31,
CEFIDEROCOL 1GM,J0693,HCPCS,,80023988,CDM,636,RC,59630026610,NDC,both,10,EA,454.97,179.56,39.4668,,179.56,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,159.24,35,,159.24,percent of total billed charges,Drugs,159.24,35,,159.24,percent of total billed charges,Drugs,154.69,34,,154.69,percent of total billed charges,Drugs,154.69,34,,154.69,percent of total billed charges,Drugs,154.69,34,,154.69,percent of total billed charges,Drugs,154.69,34,,154.69,percent of total billed charges,Drugs,159.24,35,,159.24,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,159.24,35,,159.24,percent of total billed charges,Drugs,159.24,35,,159.24,percent of total billed charges,Drugs,159.24,35,,159.24,percent of total billed charges,Drugs,159.24,35,,159.24,percent of total billed charges,Drugs,159.24,35,,159.24,percent of total billed charges,Drugs,181.99,40,,181.99,percent of total billed charges,Drugs,318.48,70,,318.48,percent of total billed charges,All Other,163.79,36,,163.79,percent of total billed charges,Drugs,163.79,36,,163.79,percent of total billed charges,Drugs,159.24,35,,159.24,percent of total billed charges,Drugs,159.24,35,,159.24,percent of total billed charges,Drugs,159.24,35,,159.24,percent of total billed charges,Drugs,159.24,35,,159.24,percent of total billed charges,Drugs,151.66,,,151.66,Other,Drug Cost,151.66,,,151.66,Other,Drug Cost,151.66,,,151.66,Other,Drug Cost,151.66,,,151.66,Other,Drug Cost,151.66,,,151.66,Other,Drug Cost,151.66,,,151.66,Other,Drug Cost,341.23,,,341.23,Other,225% of Medicaid,212.32,,,212.32,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",326.06,,,326.06,Other,215% Medicaid APG methodology,326.06,,,326.06,Other,215% Medicaid APG methodology,189.57,,,189.57,Other,125% Medicaid APG methodology,0.01,341.23,
DARBEPOETIN ALFA NON ESRD 200MCG,J0881,HCPCS,,80023989,CDM,636,RC,55513002801,NDC,both,1,ML,1060.05,28.91,,,28.91,Other,150% of Medicare + 9.63% HCRA Surcharge,17.58,,,17.58,Fee Schedule,Average Sale Price (ASP) x 6,371.02,35,,371.02,percent of total billed charges,Drugs,371.02,35,,371.02,percent of total billed charges,Drugs,360.42,34,,360.42,percent of total billed charges,Drugs,360.42,34,,360.42,percent of total billed charges,Drugs,360.42,34,,360.42,percent of total billed charges,Drugs,360.42,34,,360.42,percent of total billed charges,Drugs,371.02,35,,371.02,percent of total billed charges,Drugs,360.42,34,"If Charge > 500, then 34 percent",360.42,percent of total billed charges,Drugs,371.02,35,,371.02,percent of total billed charges,Drugs,371.02,35,,371.02,percent of total billed charges,Drugs,371.02,35,,371.02,percent of total billed charges,Drugs,371.02,35,,371.02,percent of total billed charges,Drugs,371.02,35,,371.02,percent of total billed charges,Drugs,424.02,40,,424.02,percent of total billed charges,Drugs,742.04,70,,742.04,percent of total billed charges,All Other,381.62,36,,381.62,percent of total billed charges,Drugs,381.62,36,,381.62,percent of total billed charges,Drugs,371.02,35,,371.02,percent of total billed charges,Drugs,371.02,35,,371.02,percent of total billed charges,Drugs,371.02,35,,371.02,percent of total billed charges,Drugs,371.02,35,,371.02,percent of total billed charges,Drugs,353.35,,,353.35,Other,Drug Cost,353.35,,,353.35,Other,Drug Cost,353.35,,,353.35,Other,Drug Cost,353.35,,,353.35,Other,Drug Cost,353.35,,,353.35,Other,Drug Cost,353.35,,,353.35,Other,Drug Cost,795.04,,,795.04,Other,225% of Medicaid,494.69,,,494.69,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,28.13,,,28.13,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",759.7,,,759.7,Other,215% Medicaid APG methodology,759.7,,,759.7,Other,215% Medicaid APG methodology,441.69,,,441.69,Other,125% Medicaid APG methodology,0.01,795.04,
BIVALIRUDIN 250 MG VIAL,J0583,HCPCS,,80024002,CDM,636,RC,70860040210,NDC,both,10,EA,104.57,2.11,,,2.11,Other,150% of Medicare + 9.63% HCRA Surcharge,1.28,,,1.28,Fee Schedule,Average Sale Price (ASP) x 6,36.6,35,,36.6,percent of total billed charges,Drugs,36.6,35,,36.6,percent of total billed charges,Drugs,35.55,34,,35.55,percent of total billed charges,Drugs,35.55,34,,35.55,percent of total billed charges,Drugs,35.55,34,,35.55,percent of total billed charges,Drugs,35.55,34,,35.55,percent of total billed charges,Drugs,36.6,35,,36.6,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,36.6,35,,36.6,percent of total billed charges,Drugs,36.6,35,,36.6,percent of total billed charges,Drugs,36.6,35,,36.6,percent of total billed charges,Drugs,36.6,35,,36.6,percent of total billed charges,Drugs,36.6,35,,36.6,percent of total billed charges,Drugs,41.83,40,,41.83,percent of total billed charges,Drugs,73.2,70,,73.2,percent of total billed charges,All Other,37.64,36,,37.64,percent of total billed charges,Drugs,37.64,36,,37.64,percent of total billed charges,Drugs,36.6,35,,36.6,percent of total billed charges,Drugs,36.6,35,,36.6,percent of total billed charges,Drugs,36.6,35,,36.6,percent of total billed charges,Drugs,36.6,35,,36.6,percent of total billed charges,Drugs,34.86,,,34.86,Other,Drug Cost,34.86,,,34.86,Other,Drug Cost,34.86,,,34.86,Other,Drug Cost,34.86,,,34.86,Other,Drug Cost,34.86,,,34.86,Other,Drug Cost,34.86,,,34.86,Other,Drug Cost,78.42,,,78.42,Other,225% of Medicaid,48.8,,,48.8,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,2.05,,,2.05,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",74.94,,,74.94,Other,215% Medicaid APG methodology,74.94,,,74.94,Other,215% Medicaid APG methodology,43.57,,,43.57,Other,125% Medicaid APG methodology,0.01,78.42,
CANGRELOR 50 MG INJ,C9460,HCPCS,,80024003,CDM,636,RC,10122062010,NDC,both,10,EA,1849.99,730.13,39.4668,,730.13,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,647.5,35,,647.5,percent of total billed charges,Drugs,647.5,35,,647.5,percent of total billed charges,Drugs,629,34,,629,percent of total billed charges,Drugs,629,34,,629,percent of total billed charges,Drugs,629,34,,629,percent of total billed charges,Drugs,629,34,,629,percent of total billed charges,Drugs,647.5,35,,647.5,percent of total billed charges,Drugs,629,34,"If Charge > 500, then 34 percent",629,percent of total billed charges,Drugs,647.5,35,,647.5,percent of total billed charges,Drugs,647.5,35,,647.5,percent of total billed charges,Drugs,647.5,35,,647.5,percent of total billed charges,Drugs,647.5,35,,647.5,percent of total billed charges,Drugs,647.5,35,,647.5,percent of total billed charges,Drugs,740,40,,740,percent of total billed charges,Drugs,1294.99,70,,1294.99,percent of total billed charges,All Other,666,36,,666,percent of total billed charges,Drugs,666,36,,666,percent of total billed charges,Drugs,647.5,35,,647.5,percent of total billed charges,Drugs,647.5,35,,647.5,percent of total billed charges,Drugs,647.5,35,,647.5,percent of total billed charges,Drugs,647.5,35,,647.5,percent of total billed charges,Drugs,616.66,,,616.66,Other,Drug Cost,616.66,,,616.66,Other,Drug Cost,616.66,,,616.66,Other,Drug Cost,616.66,,,616.66,Other,Drug Cost,616.66,,,616.66,Other,Drug Cost,616.66,,,616.66,Other,Drug Cost,1387.49,,,1387.49,Other,225% of Medicaid,863.33,,,863.33,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",1325.83,,,1325.83,Other,215% Medicaid APG methodology,1325.83,,,1325.83,Other,215% Medicaid APG methodology,770.83,,,770.83,Other,125% Medicaid APG methodology,0.01,1387.49,
BEVACIZUMAB-AWWB 25MG/ML 4ML,Q5107,HCPCS,,80024008,CDM,636,RC,55513020601,NDC,both,1,ML,421.5,252.78,,,252.78,Other,150% of Medicare + 9.63% HCRA Surcharge,153.72,,,153.72,Fee Schedule,Average Sale Price (ASP) x 6,147.53,35,,147.53,percent of total billed charges,Drugs,147.53,35,,147.53,percent of total billed charges,Drugs,143.31,34,,143.31,percent of total billed charges,Drugs,143.31,34,,143.31,percent of total billed charges,Drugs,143.31,34,,143.31,percent of total billed charges,Drugs,143.31,34,,143.31,percent of total billed charges,Drugs,147.53,35,,147.53,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,147.53,35,,147.53,percent of total billed charges,Drugs,147.53,35,,147.53,percent of total billed charges,Drugs,147.53,35,,147.53,percent of total billed charges,Drugs,147.53,35,,147.53,percent of total billed charges,Drugs,147.53,35,,147.53,percent of total billed charges,Drugs,168.6,40,,168.6,percent of total billed charges,Drugs,295.05,70,,295.05,percent of total billed charges,All Other,151.74,36,,151.74,percent of total billed charges,Drugs,151.74,36,,151.74,percent of total billed charges,Drugs,147.53,35,,147.53,percent of total billed charges,Drugs,147.53,35,,147.53,percent of total billed charges,Drugs,147.53,35,,147.53,percent of total billed charges,Drugs,147.53,35,,147.53,percent of total billed charges,Drugs,140.5,,,140.5,Other,Drug Cost,140.5,,,140.5,Other,Drug Cost,140.5,,,140.5,Other,Drug Cost,140.5,,,140.5,Other,Drug Cost,140.5,,,140.5,Other,Drug Cost,140.5,,,140.5,Other,Drug Cost,316.13,,,316.13,Other,225% of Medicaid,196.7,,,196.7,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,245.95,,,245.95,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",302.08,,,302.08,Other,215% Medicaid APG methodology,302.08,,,302.08,Other,215% Medicaid APG methodology,175.63,,,175.63,Other,125% Medicaid APG methodology,0.01,316.13,
ADENSOINE 90MG/30ML INJ,J0153,HCPCS,,80024010,CDM,636,RC,55150019301,NDC,both,1,ML,51.27,5.93,,,5.93,Other,150% of Medicare + 9.63% HCRA Surcharge,3.61,,,3.61,Fee Schedule,Average Sale Price (ASP) x 6,17.94,35,,17.94,percent of total billed charges,Drugs,17.94,35,,17.94,percent of total billed charges,Drugs,17.43,34,,17.43,percent of total billed charges,Drugs,17.43,34,,17.43,percent of total billed charges,Drugs,17.43,34,,17.43,percent of total billed charges,Drugs,17.43,34,,17.43,percent of total billed charges,Drugs,17.94,35,,17.94,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,17.94,35,,17.94,percent of total billed charges,Drugs,17.94,35,,17.94,percent of total billed charges,Drugs,17.94,35,,17.94,percent of total billed charges,Drugs,17.94,35,,17.94,percent of total billed charges,Drugs,17.94,35,,17.94,percent of total billed charges,Drugs,20.51,40,,20.51,percent of total billed charges,Drugs,35.89,70,,35.89,percent of total billed charges,All Other,18.46,36,,18.46,percent of total billed charges,Drugs,18.46,36,,18.46,percent of total billed charges,Drugs,17.94,35,,17.94,percent of total billed charges,Drugs,17.94,35,,17.94,percent of total billed charges,Drugs,17.94,35,,17.94,percent of total billed charges,Drugs,17.94,35,,17.94,percent of total billed charges,Drugs,17.09,,,17.09,Other,Drug Cost,17.09,,,17.09,Other,Drug Cost,17.09,,,17.09,Other,Drug Cost,17.09,,,17.09,Other,Drug Cost,17.09,,,17.09,Other,Drug Cost,17.09,,,17.09,Other,Drug Cost,38.45,,,38.45,Other,225% of Medicaid,23.93,,,23.93,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,5.77,,,5.77,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",36.74,,,36.74,Other,215% Medicaid APG methodology,36.74,,,36.74,Other,215% Medicaid APG methodology,21.36,,,21.36,Other,125% Medicaid APG methodology,0.01,38.45,
RAVULIZUMAB-CWVZ 100MG/ML 11ML,J1303,HCPCS,,80024011,CDM,636,RC,25682002801,NDC,both,1,ML,70443.99,2188.17,,,2188.17,Other,150% of Medicare + 9.63% HCRA Surcharge,1330.64,,,1330.64,Fee Schedule,Average Sale Price (ASP) x 6,24655.4,35,,24655.4,percent of total billed charges,Drugs,24655.4,35,,24655.4,percent of total billed charges,Drugs,23950.96,34,,23950.96,percent of total billed charges,Drugs,23950.96,34,,23950.96,percent of total billed charges,Drugs,23950.96,34,,23950.96,percent of total billed charges,Drugs,23950.96,34,,23950.96,percent of total billed charges,Drugs,24655.4,35,,24655.4,percent of total billed charges,Drugs,23950.96,34,"If Charge > 500, then 34 percent",23950.96,percent of total billed charges,Drugs,24655.4,35,,24655.4,percent of total billed charges,Drugs,24655.4,35,,24655.4,percent of total billed charges,Drugs,24655.4,35,,24655.4,percent of total billed charges,Drugs,24655.4,35,,24655.4,percent of total billed charges,Drugs,24655.4,35,,24655.4,percent of total billed charges,Drugs,28177.6,40,,28177.6,percent of total billed charges,Drugs,49310.79,70,,49310.79,percent of total billed charges,All Other,25359.84,36,,25359.84,percent of total billed charges,Drugs,25359.84,36,,25359.84,percent of total billed charges,Drugs,24655.4,35,,24655.4,percent of total billed charges,Drugs,24655.4,35,,24655.4,percent of total billed charges,Drugs,24655.4,35,,24655.4,percent of total billed charges,Drugs,24655.4,35,,24655.4,percent of total billed charges,Drugs,23481.33,,,23481.33,Other,Drug Cost,23481.33,,,23481.33,Other,Drug Cost,23481.33,,,23481.33,Other,Drug Cost,23481.33,,,23481.33,Other,Drug Cost,23481.33,,,23481.33,Other,Drug Cost,23481.33,,,23481.33,Other,Drug Cost,52832.99,,,52832.99,Other,225% of Medicaid,32873.86,,,32873.86,Other,140% of Medicaid,23950.96,34,"If Charge > 2,000, then 34 percent",23950.96,percent of total billed charges,Drugs,2129.02,,,2129.02,Other,160% Medicare Fee Schedule,23950.96,34,,23950.96,Other,"Drug Charges > 20,000, then 34% of Charges",50484.86,,,50484.86,Other,215% Medicaid APG methodology,50484.86,,,50484.86,Other,215% Medicaid APG methodology,29351.66,,,29351.66,Other,125% Medicaid APG methodology,1330.64,52832.99,
AVELUMAB 20MG/ML 10ML,J9023,HCPCS,,80024015,CDM,636,RC,44087353501,NDC,both,1,ML,5747.13,911.38,,,911.38,Other,150% of Medicare + 9.63% HCRA Surcharge,554.21,,,554.21,Fee Schedule,Average Sale Price (ASP) x 6,2011.5,35,,2011.5,percent of total billed charges,Drugs,2011.5,35,,2011.5,percent of total billed charges,Drugs,1954.02,34,,1954.02,percent of total billed charges,Drugs,1954.02,34,,1954.02,percent of total billed charges,Drugs,1954.02,34,,1954.02,percent of total billed charges,Drugs,1954.02,34,,1954.02,percent of total billed charges,Drugs,2011.5,35,,2011.5,percent of total billed charges,Drugs,1954.02,34,"If Charge > 500, then 34 percent",1954.02,percent of total billed charges,Drugs,2011.5,35,,2011.5,percent of total billed charges,Drugs,2011.5,35,,2011.5,percent of total billed charges,Drugs,2011.5,35,,2011.5,percent of total billed charges,Drugs,2011.5,35,,2011.5,percent of total billed charges,Drugs,2011.5,35,,2011.5,percent of total billed charges,Drugs,2298.85,40,,2298.85,percent of total billed charges,Drugs,4022.99,70,,4022.99,percent of total billed charges,All Other,2068.97,36,,2068.97,percent of total billed charges,Drugs,2068.97,36,,2068.97,percent of total billed charges,Drugs,2011.5,35,,2011.5,percent of total billed charges,Drugs,2011.5,35,,2011.5,percent of total billed charges,Drugs,2011.5,35,,2011.5,percent of total billed charges,Drugs,2011.5,35,,2011.5,percent of total billed charges,Drugs,1915.71,,,1915.71,Other,Drug Cost,1915.71,,,1915.71,Other,Drug Cost,1915.71,,,1915.71,Other,Drug Cost,1915.71,,,1915.71,Other,Drug Cost,1915.71,,,1915.71,Other,Drug Cost,1915.71,,,1915.71,Other,Drug Cost,4310.35,,,4310.35,Other,225% of Medicaid,2681.99,,,2681.99,Other,140% of Medicaid,1954.02,34,"If Charge > 2,000, then 34 percent",1954.02,percent of total billed charges,Drugs,886.74,,,886.74,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",4118.78,,,4118.78,Other,215% Medicaid APG methodology,4118.78,,,4118.78,Other,215% Medicaid APG methodology,2394.64,,,2394.64,Other,125% Medicaid APG methodology,0.01,4310.35,
DOSTARLIMAB-GXLY 50MG/ML 10ML,J9272,HCPCS,,80024017,CDM,636,RC,173089803,NDC,both,1,ML,25487.64,2301.49,,,2301.49,Other,150% of Medicare + 9.63% HCRA Surcharge,1399.55,,,1399.55,Fee Schedule,Average Sale Price (ASP) x 6,8920.67,35,,8920.67,percent of total billed charges,Drugs,8920.67,35,,8920.67,percent of total billed charges,Drugs,8665.8,34,,8665.8,percent of total billed charges,Drugs,8665.8,34,,8665.8,percent of total billed charges,Drugs,8665.8,34,,8665.8,percent of total billed charges,Drugs,8665.8,34,,8665.8,percent of total billed charges,Drugs,8920.67,35,,8920.67,percent of total billed charges,Drugs,8665.8,34,"If Charge > 500, then 34 percent",8665.8,percent of total billed charges,Drugs,8920.67,35,,8920.67,percent of total billed charges,Drugs,8920.67,35,,8920.67,percent of total billed charges,Drugs,8920.67,35,,8920.67,percent of total billed charges,Drugs,8920.67,35,,8920.67,percent of total billed charges,Drugs,8920.67,35,,8920.67,percent of total billed charges,Drugs,10195.06,40,,10195.06,percent of total billed charges,Drugs,17841.35,70,,17841.35,percent of total billed charges,All Other,9175.55,36,,9175.55,percent of total billed charges,Drugs,9175.55,36,,9175.55,percent of total billed charges,Drugs,8920.67,35,,8920.67,percent of total billed charges,Drugs,8920.67,35,,8920.67,percent of total billed charges,Drugs,8920.67,35,,8920.67,percent of total billed charges,Drugs,8920.67,35,,8920.67,percent of total billed charges,Drugs,8495.88,,,8495.88,Other,Drug Cost,8495.88,,,8495.88,Other,Drug Cost,8495.88,,,8495.88,Other,Drug Cost,8495.88,,,8495.88,Other,Drug Cost,8495.88,,,8495.88,Other,Drug Cost,8495.88,,,8495.88,Other,Drug Cost,19115.73,,,19115.73,Other,225% of Medicaid,11894.23,,,11894.23,Other,140% of Medicaid,8665.8,34,"If Charge > 2,000, then 34 percent",8665.8,percent of total billed charges,Drugs,2239.28,,,2239.28,Other,160% Medicare Fee Schedule,8665.8,34,,8665.8,Other,"Drug Charges > 20,000, then 34% of Charges",18266.14,,,18266.14,Other,215% Medicaid APG methodology,18266.14,,,18266.14,Other,215% Medicaid APG methodology,10619.85,,,10619.85,Other,125% Medicaid APG methodology,1399.55,19115.73,
"EPOETIN ALFA-EPBX 20,000 UNIT NON-ESRD",Q5106,HCPCS,,80024019,CDM,636,RC,69131110,NDC,both,10,ML,279.93,77.2,,,77.2,Other,150% of Medicare + 9.63% HCRA Surcharge,46.94,,,46.94,Fee Schedule,Average Sale Price (ASP) x 6,97.98,35,,97.98,percent of total billed charges,Drugs,97.98,35,,97.98,percent of total billed charges,Drugs,95.18,34,,95.18,percent of total billed charges,Drugs,95.18,34,,95.18,percent of total billed charges,Drugs,95.18,34,,95.18,percent of total billed charges,Drugs,95.18,34,,95.18,percent of total billed charges,Drugs,97.98,35,,97.98,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,97.98,35,,97.98,percent of total billed charges,Drugs,97.98,35,,97.98,percent of total billed charges,Drugs,97.98,35,,97.98,percent of total billed charges,Drugs,97.98,35,,97.98,percent of total billed charges,Drugs,97.98,35,,97.98,percent of total billed charges,Drugs,111.97,40,,111.97,percent of total billed charges,Drugs,195.95,70,,195.95,percent of total billed charges,All Other,100.78,36,,100.78,percent of total billed charges,Drugs,100.78,36,,100.78,percent of total billed charges,Drugs,97.98,35,,97.98,percent of total billed charges,Drugs,97.98,35,,97.98,percent of total billed charges,Drugs,97.98,35,,97.98,percent of total billed charges,Drugs,97.98,35,,97.98,percent of total billed charges,Drugs,93.31,,,93.31,Other,Drug Cost,93.31,,,93.31,Other,Drug Cost,93.31,,,93.31,Other,Drug Cost,93.31,,,93.31,Other,Drug Cost,93.31,,,93.31,Other,Drug Cost,93.31,,,93.31,Other,Drug Cost,209.95,,,209.95,Other,225% of Medicaid,130.64,,,130.64,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,75.11,,,75.11,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",200.62,,,200.62,Other,215% Medicaid APG methodology,200.62,,,200.62,Other,215% Medicaid APG methodology,116.64,,,116.64,Other,125% Medicaid APG methodology,0.01,209.95,
TRASTUZUMAB-ANNS 150MG,Q5117,HCPCS,,80024023,CDM,636,RC,55513014101,NDC,both,1,EA,131.31,132.71,,,132.71,Other,150% of Medicare + 9.63% HCRA Surcharge,80.7,,,80.7,Fee Schedule,Average Sale Price (ASP) x 6,45.96,35,,45.96,percent of total billed charges,Drugs,45.96,35,,45.96,percent of total billed charges,Drugs,44.65,34,,44.65,percent of total billed charges,Drugs,44.65,34,,44.65,percent of total billed charges,Drugs,44.65,34,,44.65,percent of total billed charges,Drugs,44.65,34,,44.65,percent of total billed charges,Drugs,45.96,35,,45.96,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,45.96,35,,45.96,percent of total billed charges,Drugs,45.96,35,,45.96,percent of total billed charges,Drugs,45.96,35,,45.96,percent of total billed charges,Drugs,45.96,35,,45.96,percent of total billed charges,Drugs,45.96,35,,45.96,percent of total billed charges,Drugs,52.52,40,,52.52,percent of total billed charges,Drugs,91.92,70,,91.92,percent of total billed charges,All Other,47.27,36,,47.27,percent of total billed charges,Drugs,47.27,36,,47.27,percent of total billed charges,Drugs,45.96,35,,45.96,percent of total billed charges,Drugs,45.96,35,,45.96,percent of total billed charges,Drugs,45.96,35,,45.96,percent of total billed charges,Drugs,45.96,35,,45.96,percent of total billed charges,Drugs,43.77,,,43.77,Other,Drug Cost,43.77,,,43.77,Other,Drug Cost,43.77,,,43.77,Other,Drug Cost,43.77,,,43.77,Other,Drug Cost,43.77,,,43.77,Other,Drug Cost,43.77,,,43.77,Other,Drug Cost,98.48,,,98.48,Other,225% of Medicaid,61.28,,,61.28,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,129.12,,,129.12,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",94.11,,,94.11,Other,215% Medicaid APG methodology,94.11,,,94.11,Other,215% Medicaid APG methodology,54.71,,,54.71,Other,125% Medicaid APG methodology,0.01,132.71,
SACITUZUMAB GOVITECAN-HZIY 180MG VIAL,J9317,HCPCS,,80024024,CDM,636,RC,55135013201,NDC,both,1,EA,5375.22,336.23,,,336.23,Other,150% of Medicare + 9.63% HCRA Surcharge,204.46,,,204.46,Fee Schedule,Average Sale Price (ASP) x 6,1881.33,35,,1881.33,percent of total billed charges,Drugs,1881.33,35,,1881.33,percent of total billed charges,Drugs,1827.57,34,,1827.57,percent of total billed charges,Drugs,1827.57,34,,1827.57,percent of total billed charges,Drugs,1827.57,34,,1827.57,percent of total billed charges,Drugs,1827.57,34,,1827.57,percent of total billed charges,Drugs,1881.33,35,,1881.33,percent of total billed charges,Drugs,1827.57,34,"If Charge > 500, then 34 percent",1827.57,percent of total billed charges,Drugs,1881.33,35,,1881.33,percent of total billed charges,Drugs,1881.33,35,,1881.33,percent of total billed charges,Drugs,1881.33,35,,1881.33,percent of total billed charges,Drugs,1881.33,35,,1881.33,percent of total billed charges,Drugs,1881.33,35,,1881.33,percent of total billed charges,Drugs,2150.09,40,,2150.09,percent of total billed charges,Drugs,3762.65,70,,3762.65,percent of total billed charges,All Other,1935.08,36,,1935.08,percent of total billed charges,Drugs,1935.08,36,,1935.08,percent of total billed charges,Drugs,1881.33,35,,1881.33,percent of total billed charges,Drugs,1881.33,35,,1881.33,percent of total billed charges,Drugs,1881.33,35,,1881.33,percent of total billed charges,Drugs,1881.33,35,,1881.33,percent of total billed charges,Drugs,1791.74,,,1791.74,Other,Drug Cost,1791.74,,,1791.74,Other,Drug Cost,1791.74,,,1791.74,Other,Drug Cost,1791.74,,,1791.74,Other,Drug Cost,1791.74,,,1791.74,Other,Drug Cost,1791.74,,,1791.74,Other,Drug Cost,4031.42,,,4031.42,Other,225% of Medicaid,2508.44,,,2508.44,Other,140% of Medicaid,1827.57,34,"If Charge > 2,000, then 34 percent",1827.57,percent of total billed charges,Drugs,327.14,,,327.14,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",3852.24,,,3852.24,Other,215% Medicaid APG methodology,3852.24,,,3852.24,Other,215% Medicaid APG methodology,2239.68,,,2239.68,Other,125% Medicaid APG methodology,0.01,4031.42,
TAFASITAMAB-CXIX 200MG INJ,J9349,HCPCS,,80024025,CDM,636,RC,73535020801,NDC,both,1,EA,4002.12,134.15,,,134.15,Other,150% of Medicare + 9.63% HCRA Surcharge,81.58,,,81.58,Fee Schedule,Average Sale Price (ASP) x 6,1400.74,35,,1400.74,percent of total billed charges,Drugs,1400.74,35,,1400.74,percent of total billed charges,Drugs,1360.72,34,,1360.72,percent of total billed charges,Drugs,1360.72,34,,1360.72,percent of total billed charges,Drugs,1360.72,34,,1360.72,percent of total billed charges,Drugs,1360.72,34,,1360.72,percent of total billed charges,Drugs,1400.74,35,,1400.74,percent of total billed charges,Drugs,1360.72,34,"If Charge > 500, then 34 percent",1360.72,percent of total billed charges,Drugs,1400.74,35,,1400.74,percent of total billed charges,Drugs,1400.74,35,,1400.74,percent of total billed charges,Drugs,1400.74,35,,1400.74,percent of total billed charges,Drugs,1400.74,35,,1400.74,percent of total billed charges,Drugs,1400.74,35,,1400.74,percent of total billed charges,Drugs,1600.85,40,,1600.85,percent of total billed charges,Drugs,2801.48,70,,2801.48,percent of total billed charges,All Other,1440.76,36,,1440.76,percent of total billed charges,Drugs,1440.76,36,,1440.76,percent of total billed charges,Drugs,1400.74,35,,1400.74,percent of total billed charges,Drugs,1400.74,35,,1400.74,percent of total billed charges,Drugs,1400.74,35,,1400.74,percent of total billed charges,Drugs,1400.74,35,,1400.74,percent of total billed charges,Drugs,1334.04,,,1334.04,Other,Drug Cost,1334.04,,,1334.04,Other,Drug Cost,1334.04,,,1334.04,Other,Drug Cost,1334.04,,,1334.04,Other,Drug Cost,1334.04,,,1334.04,Other,Drug Cost,1334.04,,,1334.04,Other,Drug Cost,3001.59,,,3001.59,Other,225% of Medicaid,1867.66,,,1867.66,Other,140% of Medicaid,1360.72,34,"If Charge > 2,000, then 34 percent",1360.72,percent of total billed charges,Drugs,130.52,,,130.52,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",2868.19,,,2868.19,Other,215% Medicaid APG methodology,2868.19,,,2868.19,Other,215% Medicaid APG methodology,1667.55,,,1667.55,Other,125% Medicaid APG methodology,0.01,3001.59,
FILGRASTIM 480MCG/0.8ML INJ,J1442,HCPCS,,80024028,CDM,636,RC,55513020991,NDC,both,1,ML,1521.03,9.72,,,9.72,Other,150% of Medicare + 9.63% HCRA Surcharge,5.91,,,5.91,Fee Schedule,Average Sale Price (ASP) x 6,532.36,35,,532.36,percent of total billed charges,Drugs,532.36,35,,532.36,percent of total billed charges,Drugs,517.15,34,,517.15,percent of total billed charges,Drugs,517.15,34,,517.15,percent of total billed charges,Drugs,517.15,34,,517.15,percent of total billed charges,Drugs,517.15,34,,517.15,percent of total billed charges,Drugs,532.36,35,,532.36,percent of total billed charges,Drugs,517.15,34,"If Charge > 500, then 34 percent",517.15,percent of total billed charges,Drugs,532.36,35,,532.36,percent of total billed charges,Drugs,532.36,35,,532.36,percent of total billed charges,Drugs,532.36,35,,532.36,percent of total billed charges,Drugs,532.36,35,,532.36,percent of total billed charges,Drugs,532.36,35,,532.36,percent of total billed charges,Drugs,608.41,40,,608.41,percent of total billed charges,Drugs,1064.72,70,,1064.72,percent of total billed charges,All Other,547.57,36,,547.57,percent of total billed charges,Drugs,547.57,36,,547.57,percent of total billed charges,Drugs,532.36,35,,532.36,percent of total billed charges,Drugs,532.36,35,,532.36,percent of total billed charges,Drugs,532.36,35,,532.36,percent of total billed charges,Drugs,532.36,35,,532.36,percent of total billed charges,Drugs,507.01,,,507.01,Other,Drug Cost,507.01,,,507.01,Other,Drug Cost,507.01,,,507.01,Other,Drug Cost,507.01,,,507.01,Other,Drug Cost,507.01,,,507.01,Other,Drug Cost,507.01,,,507.01,Other,Drug Cost,1140.77,,,1140.77,Other,225% of Medicaid,709.81,,,709.81,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,9.46,,,9.46,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",1090.07,,,1090.07,Other,215% Medicaid APG methodology,1090.07,,,1090.07,Other,215% Medicaid APG methodology,633.76,,,633.76,Other,125% Medicaid APG methodology,0.01,1140.77,
BEVACIZUMAB-BVZR 25MG/ML,Q5118,HCPCS,,80024032,CDM,636,RC,69031501,NDC,both,1,ML,246.96,212.24,,,212.24,Other,150% of Medicare + 9.63% HCRA Surcharge,129.07,,,129.07,Fee Schedule,Average Sale Price (ASP) x 6,86.44,35,,86.44,percent of total billed charges,Drugs,86.44,35,,86.44,percent of total billed charges,Drugs,83.97,34,,83.97,percent of total billed charges,Drugs,83.97,34,,83.97,percent of total billed charges,Drugs,83.97,34,,83.97,percent of total billed charges,Drugs,83.97,34,,83.97,percent of total billed charges,Drugs,86.44,35,,86.44,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,86.44,35,,86.44,percent of total billed charges,Drugs,86.44,35,,86.44,percent of total billed charges,Drugs,86.44,35,,86.44,percent of total billed charges,Drugs,86.44,35,,86.44,percent of total billed charges,Drugs,86.44,35,,86.44,percent of total billed charges,Drugs,98.78,40,,98.78,percent of total billed charges,Drugs,172.87,70,,172.87,percent of total billed charges,All Other,88.91,36,,88.91,percent of total billed charges,Drugs,88.91,36,,88.91,percent of total billed charges,Drugs,86.44,35,,86.44,percent of total billed charges,Drugs,86.44,35,,86.44,percent of total billed charges,Drugs,86.44,35,,86.44,percent of total billed charges,Drugs,86.44,35,,86.44,percent of total billed charges,Drugs,82.32,,,82.32,Other,Drug Cost,82.32,,,82.32,Other,Drug Cost,82.32,,,82.32,Other,Drug Cost,82.32,,,82.32,Other,Drug Cost,82.32,,,82.32,Other,Drug Cost,82.32,,,82.32,Other,Drug Cost,185.22,,,185.22,Other,225% of Medicaid,115.25,,,115.25,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,206.51,,,206.51,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",176.99,,,176.99,Other,215% Medicaid APG methodology,176.99,,,176.99,Other,215% Medicaid APG methodology,102.9,,,102.9,Other,125% Medicaid APG methodology,0.01,212.24,
ENFORTUMAB VEDOTIN-EJFV 30MG INJ,J9177,HCPCS,,80024046,CDM,636,RC,51144003001,NDC,both,1,EA,8495.37,345.61,,,345.61,Other,150% of Medicare + 9.63% HCRA Surcharge,210.17,,,210.17,Fee Schedule,Average Sale Price (ASP) x 6,2973.38,35,,2973.38,percent of total billed charges,Drugs,2973.38,35,,2973.38,percent of total billed charges,Drugs,2888.43,34,,2888.43,percent of total billed charges,Drugs,2888.43,34,,2888.43,percent of total billed charges,Drugs,2888.43,34,,2888.43,percent of total billed charges,Drugs,2888.43,34,,2888.43,percent of total billed charges,Drugs,2973.38,35,,2973.38,percent of total billed charges,Drugs,2888.43,34,"If Charge > 500, then 34 percent",2888.43,percent of total billed charges,Drugs,2973.38,35,,2973.38,percent of total billed charges,Drugs,2973.38,35,,2973.38,percent of total billed charges,Drugs,2973.38,35,,2973.38,percent of total billed charges,Drugs,2973.38,35,,2973.38,percent of total billed charges,Drugs,2973.38,35,,2973.38,percent of total billed charges,Drugs,3398.15,40,,3398.15,percent of total billed charges,Drugs,5946.76,70,,5946.76,percent of total billed charges,All Other,3058.33,36,,3058.33,percent of total billed charges,Drugs,3058.33,36,,3058.33,percent of total billed charges,Drugs,2973.38,35,,2973.38,percent of total billed charges,Drugs,2973.38,35,,2973.38,percent of total billed charges,Drugs,2973.38,35,,2973.38,percent of total billed charges,Drugs,2973.38,35,,2973.38,percent of total billed charges,Drugs,2831.79,,,2831.79,Other,Drug Cost,2831.79,,,2831.79,Other,Drug Cost,2831.79,,,2831.79,Other,Drug Cost,2831.79,,,2831.79,Other,Drug Cost,2831.79,,,2831.79,Other,Drug Cost,2831.79,,,2831.79,Other,Drug Cost,6371.53,,,6371.53,Other,225% of Medicaid,3964.51,,,3964.51,Other,140% of Medicaid,2888.43,34,"If Charge > 2,000, then 34 percent",2888.43,percent of total billed charges,Drugs,336.27,,,336.27,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",6088.35,,,6088.35,Other,215% Medicaid APG methodology,6088.35,,,6088.35,Other,215% Medicaid APG methodology,3539.74,,,3539.74,Other,125% Medicaid APG methodology,0.01,6371.53,
TRILACICLIB 300 MG INJ,J1448,HCPCS,,80024054,CDM,636,RC,73462010101,NDC,both,1,EA,3415.2,51.32,,,51.32,Other,150% of Medicare + 9.63% HCRA Surcharge,31.21,,,31.21,Fee Schedule,Average Sale Price (ASP) x 6,1195.32,35,,1195.32,percent of total billed charges,Drugs,1195.32,35,,1195.32,percent of total billed charges,Drugs,1161.17,34,,1161.17,percent of total billed charges,Drugs,1161.17,34,,1161.17,percent of total billed charges,Drugs,1161.17,34,,1161.17,percent of total billed charges,Drugs,1161.17,34,,1161.17,percent of total billed charges,Drugs,1195.32,35,,1195.32,percent of total billed charges,Drugs,1161.17,34,"If Charge > 500, then 34 percent",1161.17,percent of total billed charges,Drugs,1195.32,35,,1195.32,percent of total billed charges,Drugs,1195.32,35,,1195.32,percent of total billed charges,Drugs,1195.32,35,,1195.32,percent of total billed charges,Drugs,1195.32,35,,1195.32,percent of total billed charges,Drugs,1195.32,35,,1195.32,percent of total billed charges,Drugs,1366.08,40,,1366.08,percent of total billed charges,Drugs,2390.64,70,,2390.64,percent of total billed charges,All Other,1229.47,36,,1229.47,percent of total billed charges,Drugs,1229.47,36,,1229.47,percent of total billed charges,Drugs,1195.32,35,,1195.32,percent of total billed charges,Drugs,1195.32,35,,1195.32,percent of total billed charges,Drugs,1195.32,35,,1195.32,percent of total billed charges,Drugs,1195.32,35,,1195.32,percent of total billed charges,Drugs,1138.4,,,1138.4,Other,Drug Cost,1138.4,,,1138.4,Other,Drug Cost,1138.4,,,1138.4,Other,Drug Cost,1138.4,,,1138.4,Other,Drug Cost,1138.4,,,1138.4,Other,Drug Cost,1138.4,,,1138.4,Other,Drug Cost,2561.4,,,2561.4,Other,225% of Medicaid,1593.76,,,1593.76,Other,140% of Medicaid,1161.17,34,"If Charge > 2,000, then 34 percent",1161.17,percent of total billed charges,Drugs,49.93,,,49.93,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",2447.56,,,2447.56,Other,215% Medicaid APG methodology,2447.56,,,2447.56,Other,215% Medicaid APG methodology,1423,,,1423,Other,125% Medicaid APG methodology,0.01,2561.4,
DEGARELIX ACETATE 1240MG INJ,J9155,HCPCS,,80024056,CDM,636,RC,55566840301,NDC,both,2,EA,938.64,41.31,,,41.31,Other,150% of Medicare + 9.63% HCRA Surcharge,25.12,,,25.12,Fee Schedule,Average Sale Price (ASP) x 6,328.52,35,,328.52,percent of total billed charges,Drugs,328.52,35,,328.52,percent of total billed charges,Drugs,319.14,34,,319.14,percent of total billed charges,Drugs,319.14,34,,319.14,percent of total billed charges,Drugs,319.14,34,,319.14,percent of total billed charges,Drugs,319.14,34,,319.14,percent of total billed charges,Drugs,328.52,35,,328.52,percent of total billed charges,Drugs,319.14,34,"If Charge > 500, then 34 percent",319.14,percent of total billed charges,Drugs,328.52,35,,328.52,percent of total billed charges,Drugs,328.52,35,,328.52,percent of total billed charges,Drugs,328.52,35,,328.52,percent of total billed charges,Drugs,328.52,35,,328.52,percent of total billed charges,Drugs,328.52,35,,328.52,percent of total billed charges,Drugs,375.46,40,,375.46,percent of total billed charges,Drugs,657.05,70,,657.05,percent of total billed charges,All Other,337.91,36,,337.91,percent of total billed charges,Drugs,337.91,36,,337.91,percent of total billed charges,Drugs,328.52,35,,328.52,percent of total billed charges,Drugs,328.52,35,,328.52,percent of total billed charges,Drugs,328.52,35,,328.52,percent of total billed charges,Drugs,328.52,35,,328.52,percent of total billed charges,Drugs,312.88,,,312.88,Other,Drug Cost,312.88,,,312.88,Other,Drug Cost,312.88,,,312.88,Other,Drug Cost,312.88,,,312.88,Other,Drug Cost,312.88,,,312.88,Other,Drug Cost,312.88,,,312.88,Other,Drug Cost,703.98,,,703.98,Other,225% of Medicaid,438.03,,,438.03,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,40.2,,,40.2,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",672.69,,,672.69,Other,215% Medicaid APG methodology,672.69,,,672.69,Other,215% Medicaid APG methodology,391.1,,,391.1,Other,125% Medicaid APG methodology,0.01,703.98,
LURBINECTEDIN 4MG INJ,J9223,HCPCS,,80024057,CDM,636,RC,68727071201,NDC,both,1,EA,23837.07,1973.43,,,1973.43,Other,150% of Medicare + 9.63% HCRA Surcharge,1200.05,,,1200.05,Fee Schedule,Average Sale Price (ASP) x 6,8342.97,35,,8342.97,percent of total billed charges,Drugs,8342.97,35,,8342.97,percent of total billed charges,Drugs,8104.6,34,,8104.6,percent of total billed charges,Drugs,8104.6,34,,8104.6,percent of total billed charges,Drugs,8104.6,34,,8104.6,percent of total billed charges,Drugs,8104.6,34,,8104.6,percent of total billed charges,Drugs,8342.97,35,,8342.97,percent of total billed charges,Drugs,8104.6,34,"If Charge > 500, then 34 percent",8104.6,percent of total billed charges,Drugs,8342.97,35,,8342.97,percent of total billed charges,Drugs,8342.97,35,,8342.97,percent of total billed charges,Drugs,8342.97,35,,8342.97,percent of total billed charges,Drugs,8342.97,35,,8342.97,percent of total billed charges,Drugs,8342.97,35,,8342.97,percent of total billed charges,Drugs,9534.83,40,,9534.83,percent of total billed charges,Drugs,16685.95,70,,16685.95,percent of total billed charges,All Other,8581.35,36,,8581.35,percent of total billed charges,Drugs,8581.35,36,,8581.35,percent of total billed charges,Drugs,8342.97,35,,8342.97,percent of total billed charges,Drugs,8342.97,35,,8342.97,percent of total billed charges,Drugs,8342.97,35,,8342.97,percent of total billed charges,Drugs,8342.97,35,,8342.97,percent of total billed charges,Drugs,7945.69,,,7945.69,Other,Drug Cost,7945.69,,,7945.69,Other,Drug Cost,7945.69,,,7945.69,Other,Drug Cost,7945.69,,,7945.69,Other,Drug Cost,7945.69,,,7945.69,Other,Drug Cost,7945.69,,,7945.69,Other,Drug Cost,17877.8,,,17877.8,Other,225% of Medicaid,11123.97,,,11123.97,Other,140% of Medicaid,8104.6,34,"If Charge > 2,000, then 34 percent",8104.6,percent of total billed charges,Drugs,1920.09,,,1920.09,Other,160% Medicare Fee Schedule,8104.6,34,,8104.6,Other,"Drug Charges > 20,000, then 34% of Charges",17083.23,,,17083.23,Other,215% Medicaid APG methodology,17083.23,,,17083.23,Other,215% Medicaid APG methodology,9932.11,,,9932.11,Other,125% Medicaid APG methodology,1200.05,17877.8,
DEGARELIX 80MG INJ,J9155,HCPCS,,80024058,CDM,636,RC,55566830301,NDC,both,1,EA,650.46,41.31,,,41.31,Other,150% of Medicare + 9.63% HCRA Surcharge,25.12,,,25.12,Fee Schedule,Average Sale Price (ASP) x 6,227.66,35,,227.66,percent of total billed charges,Drugs,227.66,35,,227.66,percent of total billed charges,Drugs,221.16,34,,221.16,percent of total billed charges,Drugs,221.16,34,,221.16,percent of total billed charges,Drugs,221.16,34,,221.16,percent of total billed charges,Drugs,221.16,34,,221.16,percent of total billed charges,Drugs,227.66,35,,227.66,percent of total billed charges,Drugs,221.16,34,"If Charge > 500, then 34 percent",221.16,percent of total billed charges,Drugs,227.66,35,,227.66,percent of total billed charges,Drugs,227.66,35,,227.66,percent of total billed charges,Drugs,227.66,35,,227.66,percent of total billed charges,Drugs,227.66,35,,227.66,percent of total billed charges,Drugs,227.66,35,,227.66,percent of total billed charges,Drugs,260.18,40,,260.18,percent of total billed charges,Drugs,455.32,70,,455.32,percent of total billed charges,All Other,234.17,36,,234.17,percent of total billed charges,Drugs,234.17,36,,234.17,percent of total billed charges,Drugs,227.66,35,,227.66,percent of total billed charges,Drugs,227.66,35,,227.66,percent of total billed charges,Drugs,227.66,35,,227.66,percent of total billed charges,Drugs,227.66,35,,227.66,percent of total billed charges,Drugs,216.82,,,216.82,Other,Drug Cost,216.82,,,216.82,Other,Drug Cost,216.82,,,216.82,Other,Drug Cost,216.82,,,216.82,Other,Drug Cost,216.82,,,216.82,Other,Drug Cost,216.82,,,216.82,Other,Drug Cost,487.85,,,487.85,Other,225% of Medicaid,303.55,,,303.55,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,40.2,,,40.2,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",466.16,,,466.16,Other,215% Medicaid APG methodology,466.16,,,466.16,Other,215% Medicaid APG methodology,271.03,,,271.03,Other,125% Medicaid APG methodology,0.01,487.85,
EFGARTIGIMOD ALFA-FCAB 400MG/20ML INJ,J9332,HCPCS,,80024063,CDM,636,RC,73475304105,NDC,both,1,ML,18571.14,316.52,,,316.52,Other,150% of Medicare + 9.63% HCRA Surcharge,192.48,,,192.48,Fee Schedule,Average Sale Price (ASP) x 6,6499.9,35,,6499.9,percent of total billed charges,Drugs,6499.9,35,,6499.9,percent of total billed charges,Drugs,6314.19,34,,6314.19,percent of total billed charges,Drugs,6314.19,34,,6314.19,percent of total billed charges,Drugs,6314.19,34,,6314.19,percent of total billed charges,Drugs,6314.19,34,,6314.19,percent of total billed charges,Drugs,6499.9,35,,6499.9,percent of total billed charges,Drugs,6314.19,34,"If Charge > 500, then 34 percent",6314.19,percent of total billed charges,Drugs,6499.9,35,,6499.9,percent of total billed charges,Drugs,6499.9,35,,6499.9,percent of total billed charges,Drugs,6499.9,35,,6499.9,percent of total billed charges,Drugs,6499.9,35,,6499.9,percent of total billed charges,Drugs,6499.9,35,,6499.9,percent of total billed charges,Drugs,7428.46,40,,7428.46,percent of total billed charges,Drugs,12999.8,70,,12999.8,percent of total billed charges,All Other,6685.61,36,,6685.61,percent of total billed charges,Drugs,6685.61,36,,6685.61,percent of total billed charges,Drugs,6499.9,35,,6499.9,percent of total billed charges,Drugs,6499.9,35,,6499.9,percent of total billed charges,Drugs,6499.9,35,,6499.9,percent of total billed charges,Drugs,6499.9,35,,6499.9,percent of total billed charges,Drugs,6190.38,,,6190.38,Other,Drug Cost,6190.38,,,6190.38,Other,Drug Cost,6190.38,,,6190.38,Other,Drug Cost,6190.38,,,6190.38,Other,Drug Cost,6190.38,,,6190.38,Other,Drug Cost,6190.38,,,6190.38,Other,Drug Cost,13928.36,,,13928.36,Other,225% of Medicaid,8666.53,,,8666.53,Other,140% of Medicaid,6314.19,34,"If Charge > 2,000, then 34 percent",6314.19,percent of total billed charges,Drugs,307.97,,,307.97,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",13309.32,,,13309.32,Other,215% Medicaid APG methodology,13309.32,,,13309.32,Other,215% Medicaid APG methodology,7737.98,,,7737.98,Other,125% Medicaid APG methodology,0.01,13928.36,
AMIODARONE 360MG/200ML,J0282,HCPCS,,80024065,CDM,636,RC,43066036020,NDC,both,10,ML,66.39,26.2,39.4668,,26.2,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,23.24,35,,23.24,percent of total billed charges,Drugs,23.24,35,,23.24,percent of total billed charges,Drugs,22.57,34,,22.57,percent of total billed charges,Drugs,22.57,34,,22.57,percent of total billed charges,Drugs,22.57,34,,22.57,percent of total billed charges,Drugs,22.57,34,,22.57,percent of total billed charges,Drugs,23.24,35,,23.24,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,23.24,35,,23.24,percent of total billed charges,Drugs,23.24,35,,23.24,percent of total billed charges,Drugs,23.24,35,,23.24,percent of total billed charges,Drugs,23.24,35,,23.24,percent of total billed charges,Drugs,23.24,35,,23.24,percent of total billed charges,Drugs,26.56,40,,26.56,percent of total billed charges,Drugs,46.48,70,,46.48,percent of total billed charges,All Other,23.9,36,,23.9,percent of total billed charges,Drugs,23.9,36,,23.9,percent of total billed charges,Drugs,23.24,35,,23.24,percent of total billed charges,Drugs,23.24,35,,23.24,percent of total billed charges,Drugs,23.24,35,,23.24,percent of total billed charges,Drugs,23.24,35,,23.24,percent of total billed charges,Drugs,22.13,,,22.13,Other,Drug Cost,22.13,,,22.13,Other,Drug Cost,22.13,,,22.13,Other,Drug Cost,22.13,,,22.13,Other,Drug Cost,22.13,,,22.13,Other,Drug Cost,22.13,,,22.13,Other,Drug Cost,49.79,,,49.79,Other,225% of Medicaid,30.98,,,30.98,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",47.58,,,47.58,Other,215% Medicaid APG methodology,47.58,,,47.58,Other,215% Medicaid APG methodology,27.66,,,27.66,Other,125% Medicaid APG methodology,0.01,49.79,
BUPIVACAINE/MELOXICAM ER 400MG/12MG SOLN,C9088,HCPCS,,80024066,CDM,636,RC,47426030102,NDC,both,1,ML,609.51,240.55,39.4668,,240.55,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,213.33,35,,213.33,percent of total billed charges,Drugs,213.33,35,,213.33,percent of total billed charges,Drugs,207.23,34,,207.23,percent of total billed charges,Drugs,207.23,34,,207.23,percent of total billed charges,Drugs,207.23,34,,207.23,percent of total billed charges,Drugs,207.23,34,,207.23,percent of total billed charges,Drugs,213.33,35,,213.33,percent of total billed charges,Drugs,207.23,34,"If Charge > 500, then 34 percent",207.23,percent of total billed charges,Drugs,213.33,35,,213.33,percent of total billed charges,Drugs,213.33,35,,213.33,percent of total billed charges,Drugs,213.33,35,,213.33,percent of total billed charges,Drugs,213.33,35,,213.33,percent of total billed charges,Drugs,213.33,35,,213.33,percent of total billed charges,Drugs,243.8,40,,243.8,percent of total billed charges,Drugs,426.66,70,,426.66,percent of total billed charges,All Other,219.42,36,,219.42,percent of total billed charges,Drugs,219.42,36,,219.42,percent of total billed charges,Drugs,213.33,35,,213.33,percent of total billed charges,Drugs,213.33,35,,213.33,percent of total billed charges,Drugs,213.33,35,,213.33,percent of total billed charges,Drugs,213.33,35,,213.33,percent of total billed charges,Drugs,203.17,,,203.17,Other,Drug Cost,203.17,,,203.17,Other,Drug Cost,203.17,,,203.17,Other,Drug Cost,203.17,,,203.17,Other,Drug Cost,203.17,,,203.17,Other,Drug Cost,203.17,,,203.17,Other,Drug Cost,457.13,,,457.13,Other,225% of Medicaid,284.44,,,284.44,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",436.82,,,436.82,Other,215% Medicaid APG methodology,436.82,,,436.82,Other,215% Medicaid APG methodology,253.96,,,253.96,Other,125% Medicaid APG methodology,0.01,457.13,
BUPIVACIANE/MELOXICAM ER 200MG/6MG SOLN,C9088,HCPCS,,80024067,CDM,636,RC,47426030301,NDC,both,1,ML,309.24,122.05,39.4668,,122.05,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,108.23,35,,108.23,percent of total billed charges,Drugs,108.23,35,,108.23,percent of total billed charges,Drugs,105.14,34,,105.14,percent of total billed charges,Drugs,105.14,34,,105.14,percent of total billed charges,Drugs,105.14,34,,105.14,percent of total billed charges,Drugs,105.14,34,,105.14,percent of total billed charges,Drugs,108.23,35,,108.23,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,108.23,35,,108.23,percent of total billed charges,Drugs,108.23,35,,108.23,percent of total billed charges,Drugs,108.23,35,,108.23,percent of total billed charges,Drugs,108.23,35,,108.23,percent of total billed charges,Drugs,108.23,35,,108.23,percent of total billed charges,Drugs,123.7,40,,123.7,percent of total billed charges,Drugs,216.47,70,,216.47,percent of total billed charges,All Other,111.33,36,,111.33,percent of total billed charges,Drugs,111.33,36,,111.33,percent of total billed charges,Drugs,108.23,35,,108.23,percent of total billed charges,Drugs,108.23,35,,108.23,percent of total billed charges,Drugs,108.23,35,,108.23,percent of total billed charges,Drugs,108.23,35,,108.23,percent of total billed charges,Drugs,103.08,,,103.08,Other,Drug Cost,103.08,,,103.08,Other,Drug Cost,103.08,,,103.08,Other,Drug Cost,103.08,,,103.08,Other,Drug Cost,103.08,,,103.08,Other,Drug Cost,103.08,,,103.08,Other,Drug Cost,231.93,,,231.93,Other,225% of Medicaid,144.31,,,144.31,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",221.62,,,221.62,Other,215% Medicaid APG methodology,221.62,,,221.62,Other,215% Medicaid APG methodology,128.85,,,128.85,Other,125% Medicaid APG methodology,0.01,231.93,
LUSPATERCEPT-AAMT 25 MG INJ,J0896,HCPCS,,80024069,CDM,636,RC,59572071101,NDC,both,1,EA,11735.73,394.38,,,394.38,Other,150% of Medicare + 9.63% HCRA Surcharge,239.83,,,239.83,Fee Schedule,Average Sale Price (ASP) x 6,4107.51,35,,4107.51,percent of total billed charges,Drugs,4107.51,35,,4107.51,percent of total billed charges,Drugs,3990.15,34,,3990.15,percent of total billed charges,Drugs,3990.15,34,,3990.15,percent of total billed charges,Drugs,3990.15,34,,3990.15,percent of total billed charges,Drugs,3990.15,34,,3990.15,percent of total billed charges,Drugs,4107.51,35,,4107.51,percent of total billed charges,Drugs,3990.15,34,"If Charge > 500, then 34 percent",3990.15,percent of total billed charges,Drugs,4107.51,35,,4107.51,percent of total billed charges,Drugs,4107.51,35,,4107.51,percent of total billed charges,Drugs,4107.51,35,,4107.51,percent of total billed charges,Drugs,4107.51,35,,4107.51,percent of total billed charges,Drugs,4107.51,35,,4107.51,percent of total billed charges,Drugs,4694.29,40,,4694.29,percent of total billed charges,Drugs,8215.01,70,,8215.01,percent of total billed charges,All Other,4224.86,36,,4224.86,percent of total billed charges,Drugs,4224.86,36,,4224.86,percent of total billed charges,Drugs,4107.51,35,,4107.51,percent of total billed charges,Drugs,4107.51,35,,4107.51,percent of total billed charges,Drugs,4107.51,35,,4107.51,percent of total billed charges,Drugs,4107.51,35,,4107.51,percent of total billed charges,Drugs,3911.91,,,3911.91,Other,Drug Cost,3911.91,,,3911.91,Other,Drug Cost,3911.91,,,3911.91,Other,Drug Cost,3911.91,,,3911.91,Other,Drug Cost,3911.91,,,3911.91,Other,Drug Cost,3911.91,,,3911.91,Other,Drug Cost,8801.8,,,8801.8,Other,225% of Medicaid,5476.67,,,5476.67,Other,140% of Medicaid,3990.15,34,"If Charge > 2,000, then 34 percent",3990.15,percent of total billed charges,Drugs,383.72,,,383.72,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",8410.61,,,8410.61,Other,215% Medicaid APG methodology,8410.61,,,8410.61,Other,215% Medicaid APG methodology,4889.89,,,4889.89,Other,125% Medicaid APG methodology,0.01,8801.8,
PNEUMOCOCCAL 20 VALENT CONJUGATED VACC,90677,HCPCS,,80024076,CDM,636,RC,5200010,NDC,both,10,ML,682.7,269.44,39.4668,,269.44,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,238.95,35,,238.95,percent of total billed charges,Drugs,238.95,35,,238.95,percent of total billed charges,Drugs,232.12,34,,232.12,percent of total billed charges,Drugs,232.12,34,,232.12,percent of total billed charges,Drugs,232.12,34,,232.12,percent of total billed charges,Drugs,232.12,34,,232.12,percent of total billed charges,Drugs,238.95,35,,238.95,percent of total billed charges,Drugs,232.12,34,"If Charge > 500, then 34 percent",232.12,percent of total billed charges,Drugs,238.95,35,,238.95,percent of total billed charges,Drugs,238.95,35,,238.95,percent of total billed charges,Drugs,238.95,35,,238.95,percent of total billed charges,Drugs,238.95,35,,238.95,percent of total billed charges,Drugs,238.95,35,,238.95,percent of total billed charges,Drugs,273.08,40,,273.08,percent of total billed charges,Drugs,477.89,70,,477.89,percent of total billed charges,All Other,245.77,36,,245.77,percent of total billed charges,Drugs,245.77,36,,245.77,percent of total billed charges,Drugs,238.95,35,,238.95,percent of total billed charges,Drugs,238.95,35,,238.95,percent of total billed charges,Drugs,238.95,35,,238.95,percent of total billed charges,Drugs,238.95,35,,238.95,percent of total billed charges,Drugs,227.57,,,227.57,Other,Drug Cost,227.57,,,227.57,Other,Drug Cost,227.57,,,227.57,Other,Drug Cost,227.57,,,227.57,Other,Drug Cost,227.57,,,227.57,Other,Drug Cost,227.57,,,227.57,Other,Drug Cost,512.03,,,512.03,Other,225% of Medicaid,318.59,,,318.59,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",489.27,,,489.27,Other,215% Medicaid APG methodology,489.27,,,489.27,Other,215% Medicaid APG methodology,284.46,,,284.46,Other,125% Medicaid APG methodology,0.01,512.03,
"EPOETIN ALFA-EPBX 10,000 UNIT",Q5106,HCPCS,,80024077,CDM,636,RC,69130810,NDC,both,10,ML,43.94,77.2,,,77.2,Other,150% of Medicare + 9.63% HCRA Surcharge,46.94,,,46.94,Fee Schedule,Average Sale Price (ASP) x 6,15.38,35,,15.38,percent of total billed charges,Drugs,15.38,35,,15.38,percent of total billed charges,Drugs,14.94,34,,14.94,percent of total billed charges,Drugs,14.94,34,,14.94,percent of total billed charges,Drugs,14.94,34,,14.94,percent of total billed charges,Drugs,14.94,34,,14.94,percent of total billed charges,Drugs,15.38,35,,15.38,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,15.38,35,,15.38,percent of total billed charges,Drugs,15.38,35,,15.38,percent of total billed charges,Drugs,15.38,35,,15.38,percent of total billed charges,Drugs,15.38,35,,15.38,percent of total billed charges,Drugs,15.38,35,,15.38,percent of total billed charges,Drugs,17.58,40,,17.58,percent of total billed charges,Drugs,30.76,70,,30.76,percent of total billed charges,All Other,15.82,36,,15.82,percent of total billed charges,Drugs,15.82,36,,15.82,percent of total billed charges,Drugs,15.38,35,,15.38,percent of total billed charges,Drugs,15.38,35,,15.38,percent of total billed charges,Drugs,15.38,35,,15.38,percent of total billed charges,Drugs,15.38,35,,15.38,percent of total billed charges,Drugs,14.65,,,14.65,Other,Drug Cost,14.65,,,14.65,Other,Drug Cost,14.65,,,14.65,Other,Drug Cost,14.65,,,14.65,Other,Drug Cost,14.65,,,14.65,Other,Drug Cost,14.65,,,14.65,Other,Drug Cost,32.96,,,32.96,Other,225% of Medicaid,20.51,,,20.51,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,75.11,,,75.11,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",31.49,,,31.49,Other,215% Medicaid APG methodology,31.49,,,31.49,Other,215% Medicaid APG methodology,18.31,,,18.31,Other,125% Medicaid APG methodology,0.01,77.2,
DARBEPOETIN ALFA 300MCG/0.6ML NON-ESRD,J0881,HCPCS,,80024080,CDM,636,RC,55513011101,NDC,both,1,ML,1608.87,28.91,,,28.91,Other,150% of Medicare + 9.63% HCRA Surcharge,17.58,,,17.58,Fee Schedule,Average Sale Price (ASP) x 6,563.1,35,,563.1,percent of total billed charges,Drugs,563.1,35,,563.1,percent of total billed charges,Drugs,547.02,34,,547.02,percent of total billed charges,Drugs,547.02,34,,547.02,percent of total billed charges,Drugs,547.02,34,,547.02,percent of total billed charges,Drugs,547.02,34,,547.02,percent of total billed charges,Drugs,563.1,35,,563.1,percent of total billed charges,Drugs,547.02,34,"If Charge > 500, then 34 percent",547.02,percent of total billed charges,Drugs,563.1,35,,563.1,percent of total billed charges,Drugs,563.1,35,,563.1,percent of total billed charges,Drugs,563.1,35,,563.1,percent of total billed charges,Drugs,563.1,35,,563.1,percent of total billed charges,Drugs,563.1,35,,563.1,percent of total billed charges,Drugs,643.55,40,,643.55,percent of total billed charges,Drugs,1126.21,70,,1126.21,percent of total billed charges,All Other,579.19,36,,579.19,percent of total billed charges,Drugs,579.19,36,,579.19,percent of total billed charges,Drugs,563.1,35,,563.1,percent of total billed charges,Drugs,563.1,35,,563.1,percent of total billed charges,Drugs,563.1,35,,563.1,percent of total billed charges,Drugs,563.1,35,,563.1,percent of total billed charges,Drugs,536.29,,,536.29,Other,Drug Cost,536.29,,,536.29,Other,Drug Cost,536.29,,,536.29,Other,Drug Cost,536.29,,,536.29,Other,Drug Cost,536.29,,,536.29,Other,Drug Cost,536.29,,,536.29,Other,Drug Cost,1206.65,,,1206.65,Other,225% of Medicaid,750.81,,,750.81,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,28.13,,,28.13,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",1153.02,,,1153.02,Other,215% Medicaid APG methodology,1153.02,,,1153.02,Other,215% Medicaid APG methodology,670.36,,,670.36,Other,125% Medicaid APG methodology,0.01,1206.65,
EPTINEZUMAB-JJMR 100MG/ML INJ,J3032,HCPCS,,80024086,CDM,636,RC,67386013051,NDC,both,1,ML,4016.04,178.18,,,178.18,Other,150% of Medicare + 9.63% HCRA Surcharge,108.35,,,108.35,Fee Schedule,Average Sale Price (ASP) x 6,1405.61,35,,1405.61,percent of total billed charges,Drugs,1405.61,35,,1405.61,percent of total billed charges,Drugs,1365.45,34,,1365.45,percent of total billed charges,Drugs,1365.45,34,,1365.45,percent of total billed charges,Drugs,1365.45,34,,1365.45,percent of total billed charges,Drugs,1365.45,34,,1365.45,percent of total billed charges,Drugs,1405.61,35,,1405.61,percent of total billed charges,Drugs,1365.45,34,"If Charge > 500, then 34 percent",1365.45,percent of total billed charges,Drugs,1405.61,35,,1405.61,percent of total billed charges,Drugs,1405.61,35,,1405.61,percent of total billed charges,Drugs,1405.61,35,,1405.61,percent of total billed charges,Drugs,1405.61,35,,1405.61,percent of total billed charges,Drugs,1405.61,35,,1405.61,percent of total billed charges,Drugs,1606.42,40,,1606.42,percent of total billed charges,Drugs,2811.23,70,,2811.23,percent of total billed charges,All Other,1445.77,36,,1445.77,percent of total billed charges,Drugs,1445.77,36,,1445.77,percent of total billed charges,Drugs,1405.61,35,,1405.61,percent of total billed charges,Drugs,1405.61,35,,1405.61,percent of total billed charges,Drugs,1405.61,35,,1405.61,percent of total billed charges,Drugs,1405.61,35,,1405.61,percent of total billed charges,Drugs,1338.68,,,1338.68,Other,Drug Cost,1338.68,,,1338.68,Other,Drug Cost,1338.68,,,1338.68,Other,Drug Cost,1338.68,,,1338.68,Other,Drug Cost,1338.68,,,1338.68,Other,Drug Cost,1338.68,,,1338.68,Other,Drug Cost,3012.03,,,3012.03,Other,225% of Medicaid,1874.15,,,1874.15,Other,140% of Medicaid,1365.45,34,"If Charge > 2,000, then 34 percent",1365.45,percent of total billed charges,Drugs,173.37,,,173.37,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",2878.16,,,2878.16,Other,215% Medicaid APG methodology,2878.16,,,2878.16,Other,215% Medicaid APG methodology,1673.35,,,1673.35,Other,125% Medicaid APG methodology,0.01,3012.03,
CALCIUM GLUCONATE 2GM/100ML,J0613,HCPCS,,80024092,CDM,636,RC,44567062124,NDC,both,24,ML,37.66,0.88,,,0.88,Other,150% of Medicare + 9.63% HCRA Surcharge,0.53,,,0.53,Fee Schedule,Average Sale Price (ASP) x 6,13.18,35,,13.18,percent of total billed charges,Drugs,13.18,35,,13.18,percent of total billed charges,Drugs,12.81,34,,12.81,percent of total billed charges,Drugs,12.81,34,,12.81,percent of total billed charges,Drugs,12.81,34,,12.81,percent of total billed charges,Drugs,12.81,34,,12.81,percent of total billed charges,Drugs,13.18,35,,13.18,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,13.18,35,,13.18,percent of total billed charges,Drugs,13.18,35,,13.18,percent of total billed charges,Drugs,13.18,35,,13.18,percent of total billed charges,Drugs,13.18,35,,13.18,percent of total billed charges,Drugs,13.18,35,,13.18,percent of total billed charges,Drugs,15.07,40,,15.07,percent of total billed charges,Drugs,26.36,70,,26.36,percent of total billed charges,All Other,13.56,36,,13.56,percent of total billed charges,Drugs,13.56,36,,13.56,percent of total billed charges,Drugs,13.18,35,,13.18,percent of total billed charges,Drugs,13.18,35,,13.18,percent of total billed charges,Drugs,13.18,35,,13.18,percent of total billed charges,Drugs,13.18,35,,13.18,percent of total billed charges,Drugs,12.55,,,12.55,Other,Drug Cost,12.55,,,12.55,Other,Drug Cost,12.55,,,12.55,Other,Drug Cost,12.55,,,12.55,Other,Drug Cost,12.55,,,12.55,Other,Drug Cost,12.55,,,12.55,Other,Drug Cost,28.25,,,28.25,Other,225% of Medicaid,17.58,,,17.58,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,0.85,,,0.85,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",26.99,,,26.99,Other,215% Medicaid APG methodology,26.99,,,26.99,Other,215% Medicaid APG methodology,15.69,,,15.69,Other,125% Medicaid APG methodology,0.01,28.25,
POLATUZUMAB VEDOTIN-PIIQ 140MG INJ,J9309,HCPCS,,80024098,CDM,636,RC,50242010501,NDC,both,1,EA,53638.8,1226.32,,,1226.32,Other,150% of Medicare + 9.63% HCRA Surcharge,745.73,,,745.73,Fee Schedule,Average Sale Price (ASP) x 6,18773.58,35,,18773.58,percent of total billed charges,Drugs,18773.58,35,,18773.58,percent of total billed charges,Drugs,18237.19,34,,18237.19,percent of total billed charges,Drugs,18237.19,34,,18237.19,percent of total billed charges,Drugs,18237.19,34,,18237.19,percent of total billed charges,Drugs,18237.19,34,,18237.19,percent of total billed charges,Drugs,18773.58,35,,18773.58,percent of total billed charges,Drugs,18237.19,34,"If Charge > 500, then 34 percent",18237.19,percent of total billed charges,Drugs,18773.58,35,,18773.58,percent of total billed charges,Drugs,18773.58,35,,18773.58,percent of total billed charges,Drugs,18773.58,35,,18773.58,percent of total billed charges,Drugs,18773.58,35,,18773.58,percent of total billed charges,Drugs,18773.58,35,,18773.58,percent of total billed charges,Drugs,21455.52,40,,21455.52,percent of total billed charges,Drugs,37547.16,70,,37547.16,percent of total billed charges,All Other,19309.97,36,,19309.97,percent of total billed charges,Drugs,19309.97,36,,19309.97,percent of total billed charges,Drugs,18773.58,35,,18773.58,percent of total billed charges,Drugs,18773.58,35,,18773.58,percent of total billed charges,Drugs,18773.58,35,,18773.58,percent of total billed charges,Drugs,18773.58,35,,18773.58,percent of total billed charges,Drugs,17879.6,,,17879.6,Other,Drug Cost,17879.6,,,17879.6,Other,Drug Cost,17879.6,,,17879.6,Other,Drug Cost,17879.6,,,17879.6,Other,Drug Cost,17879.6,,,17879.6,Other,Drug Cost,17879.6,,,17879.6,Other,Drug Cost,40229.1,,,40229.1,Other,225% of Medicaid,25031.44,,,25031.44,Other,140% of Medicaid,18237.19,34,"If Charge > 2,000, then 34 percent",18237.19,percent of total billed charges,Drugs,1193.17,,,1193.17,Other,160% Medicare Fee Schedule,18237.19,34,,18237.19,Other,"Drug Charges > 20,000, then 34% of Charges",38441.14,,,38441.14,Other,215% Medicaid APG methodology,38441.14,,,38441.14,Other,215% Medicaid APG methodology,22349.5,,,22349.5,Other,125% Medicaid APG methodology,745.73,40229.1,
POLATUZUMAB VEDOTIN-PIIQ 30MG INJ,J9309,HCPCS,,80024099,CDM,636,RC,50242010301,NDC,both,1,EA,11494.05,1226.32,,,1226.32,Other,150% of Medicare + 9.63% HCRA Surcharge,745.73,,,745.73,Fee Schedule,Average Sale Price (ASP) x 6,4022.92,35,,4022.92,percent of total billed charges,Drugs,4022.92,35,,4022.92,percent of total billed charges,Drugs,3907.98,34,,3907.98,percent of total billed charges,Drugs,3907.98,34,,3907.98,percent of total billed charges,Drugs,3907.98,34,,3907.98,percent of total billed charges,Drugs,3907.98,34,,3907.98,percent of total billed charges,Drugs,4022.92,35,,4022.92,percent of total billed charges,Drugs,3907.98,34,"If Charge > 500, then 34 percent",3907.98,percent of total billed charges,Drugs,4022.92,35,,4022.92,percent of total billed charges,Drugs,4022.92,35,,4022.92,percent of total billed charges,Drugs,4022.92,35,,4022.92,percent of total billed charges,Drugs,4022.92,35,,4022.92,percent of total billed charges,Drugs,4022.92,35,,4022.92,percent of total billed charges,Drugs,4597.62,40,,4597.62,percent of total billed charges,Drugs,8045.84,70,,8045.84,percent of total billed charges,All Other,4137.86,36,,4137.86,percent of total billed charges,Drugs,4137.86,36,,4137.86,percent of total billed charges,Drugs,4022.92,35,,4022.92,percent of total billed charges,Drugs,4022.92,35,,4022.92,percent of total billed charges,Drugs,4022.92,35,,4022.92,percent of total billed charges,Drugs,4022.92,35,,4022.92,percent of total billed charges,Drugs,3831.35,,,3831.35,Other,Drug Cost,3831.35,,,3831.35,Other,Drug Cost,3831.35,,,3831.35,Other,Drug Cost,3831.35,,,3831.35,Other,Drug Cost,3831.35,,,3831.35,Other,Drug Cost,3831.35,,,3831.35,Other,Drug Cost,8620.54,,,8620.54,Other,225% of Medicaid,5363.89,,,5363.89,Other,140% of Medicaid,3907.98,34,"If Charge > 2,000, then 34 percent",3907.98,percent of total billed charges,Drugs,1193.17,,,1193.17,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",8237.4,,,8237.4,Other,215% Medicaid APG methodology,8237.4,,,8237.4,Other,215% Medicaid APG methodology,4789.19,,,4789.19,Other,125% Medicaid APG methodology,0.01,8620.54,
GLUCAGON 1MG VIAL,J1611,HCPCS,,80024101,CDM,636,RC,63323059613,NDC,both,10,EA,271.05,1221.79,,,1221.79,Other,150% of Medicare + 9.63% HCRA Surcharge,742.98,,,742.98,Fee Schedule,Average Sale Price (ASP) x 6,94.87,35,,94.87,percent of total billed charges,Drugs,94.87,35,,94.87,percent of total billed charges,Drugs,92.16,34,,92.16,percent of total billed charges,Drugs,92.16,34,,92.16,percent of total billed charges,Drugs,92.16,34,,92.16,percent of total billed charges,Drugs,92.16,34,,92.16,percent of total billed charges,Drugs,94.87,35,,94.87,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,94.87,35,,94.87,percent of total billed charges,Drugs,94.87,35,,94.87,percent of total billed charges,Drugs,94.87,35,,94.87,percent of total billed charges,Drugs,94.87,35,,94.87,percent of total billed charges,Drugs,94.87,35,,94.87,percent of total billed charges,Drugs,108.42,40,,108.42,percent of total billed charges,Drugs,189.73,70,,189.73,percent of total billed charges,All Other,97.58,36,,97.58,percent of total billed charges,Drugs,97.58,36,,97.58,percent of total billed charges,Drugs,94.87,35,,94.87,percent of total billed charges,Drugs,94.87,35,,94.87,percent of total billed charges,Drugs,94.87,35,,94.87,percent of total billed charges,Drugs,94.87,35,,94.87,percent of total billed charges,Drugs,90.35,,,90.35,Other,Drug Cost,90.35,,,90.35,Other,Drug Cost,90.35,,,90.35,Other,Drug Cost,90.35,,,90.35,Other,Drug Cost,90.35,,,90.35,Other,Drug Cost,90.35,,,90.35,Other,Drug Cost,203.29,,,203.29,Other,225% of Medicaid,126.49,,,126.49,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,1188.77,,,1188.77,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",194.25,,,194.25,Other,215% Medicaid APG methodology,194.25,,,194.25,Other,215% Medicaid APG methodology,112.94,,,112.94,Other,125% Medicaid APG methodology,0.01,1221.79,
FONDAPARINUX 5 MG/ 0.4ML INJ,J1652,HCPCS,,80024103,CDM,636,RC,55111067910,NDC,both,10,ML,39.64,10.78,,,10.78,Other,150% of Medicare + 9.63% HCRA Surcharge,6.56,,,6.56,Fee Schedule,Average Sale Price (ASP) x 6,13.87,35,,13.87,percent of total billed charges,Drugs,13.87,35,,13.87,percent of total billed charges,Drugs,13.48,34,,13.48,percent of total billed charges,Drugs,13.48,34,,13.48,percent of total billed charges,Drugs,13.48,34,,13.48,percent of total billed charges,Drugs,13.48,34,,13.48,percent of total billed charges,Drugs,13.87,35,,13.87,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,13.87,35,,13.87,percent of total billed charges,Drugs,13.87,35,,13.87,percent of total billed charges,Drugs,13.87,35,,13.87,percent of total billed charges,Drugs,13.87,35,,13.87,percent of total billed charges,Drugs,13.87,35,,13.87,percent of total billed charges,Drugs,15.86,40,,15.86,percent of total billed charges,Drugs,27.75,70,,27.75,percent of total billed charges,All Other,14.27,36,,14.27,percent of total billed charges,Drugs,14.27,36,,14.27,percent of total billed charges,Drugs,13.87,35,,13.87,percent of total billed charges,Drugs,13.87,35,,13.87,percent of total billed charges,Drugs,13.87,35,,13.87,percent of total billed charges,Drugs,13.87,35,,13.87,percent of total billed charges,Drugs,13.21,,,13.21,Other,Drug Cost,13.21,,,13.21,Other,Drug Cost,13.21,,,13.21,Other,Drug Cost,13.21,,,13.21,Other,Drug Cost,13.21,,,13.21,Other,Drug Cost,13.21,,,13.21,Other,Drug Cost,29.73,,,29.73,Other,225% of Medicaid,18.5,,,18.5,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,10.49,,,10.49,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",28.41,,,28.41,Other,215% Medicaid APG methodology,28.41,,,28.41,Other,215% Medicaid APG methodology,16.52,,,16.52,Other,125% Medicaid APG methodology,0.01,29.73,
FILGRASTIM-AAFI 480MCG/0.8ML,Q5110,HCPCS,,80024105,CDM,636,RC,69029201,NDC,both,1,ML,222.72,2.87,,,2.87,Other,150% of Medicare + 9.63% HCRA Surcharge,1.75,,,1.75,Fee Schedule,Average Sale Price (ASP) x 6,77.95,35,,77.95,percent of total billed charges,Drugs,77.95,35,,77.95,percent of total billed charges,Drugs,75.72,34,,75.72,percent of total billed charges,Drugs,75.72,34,,75.72,percent of total billed charges,Drugs,75.72,34,,75.72,percent of total billed charges,Drugs,75.72,34,,75.72,percent of total billed charges,Drugs,77.95,35,,77.95,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,77.95,35,,77.95,percent of total billed charges,Drugs,77.95,35,,77.95,percent of total billed charges,Drugs,77.95,35,,77.95,percent of total billed charges,Drugs,77.95,35,,77.95,percent of total billed charges,Drugs,77.95,35,,77.95,percent of total billed charges,Drugs,89.09,40,,89.09,percent of total billed charges,Drugs,155.9,70,,155.9,percent of total billed charges,All Other,80.18,36,,80.18,percent of total billed charges,Drugs,80.18,36,,80.18,percent of total billed charges,Drugs,77.95,35,,77.95,percent of total billed charges,Drugs,77.95,35,,77.95,percent of total billed charges,Drugs,77.95,35,,77.95,percent of total billed charges,Drugs,77.95,35,,77.95,percent of total billed charges,Drugs,74.24,,,74.24,Other,Drug Cost,74.24,,,74.24,Other,Drug Cost,74.24,,,74.24,Other,Drug Cost,74.24,,,74.24,Other,Drug Cost,74.24,,,74.24,Other,Drug Cost,74.24,,,74.24,Other,Drug Cost,167.04,,,167.04,Other,225% of Medicaid,103.94,,,103.94,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,2.79,,,2.79,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",159.62,,,159.62,Other,215% Medicaid APG methodology,159.62,,,159.62,Other,215% Medicaid APG methodology,92.8,,,92.8,Other,125% Medicaid APG methodology,0.01,167.04,
RITUXIMAB-ABBS 10MG/ML 10 ML,Q5115,HCPCS,,80024107,CDM,636,RC,63459010310,NDC,both,1,ML,372.6,354.14,,,354.14,Other,150% of Medicare + 9.63% HCRA Surcharge,215.35,,,215.35,Fee Schedule,Average Sale Price (ASP) x 6,130.41,35,,130.41,percent of total billed charges,Drugs,130.41,35,,130.41,percent of total billed charges,Drugs,126.68,34,,126.68,percent of total billed charges,Drugs,126.68,34,,126.68,percent of total billed charges,Drugs,126.68,34,,126.68,percent of total billed charges,Drugs,126.68,34,,126.68,percent of total billed charges,Drugs,130.41,35,,130.41,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,130.41,35,,130.41,percent of total billed charges,Drugs,130.41,35,,130.41,percent of total billed charges,Drugs,130.41,35,,130.41,percent of total billed charges,Drugs,130.41,35,,130.41,percent of total billed charges,Drugs,130.41,35,,130.41,percent of total billed charges,Drugs,149.04,40,,149.04,percent of total billed charges,Drugs,260.82,70,,260.82,percent of total billed charges,All Other,134.14,36,,134.14,percent of total billed charges,Drugs,134.14,36,,134.14,percent of total billed charges,Drugs,130.41,35,,130.41,percent of total billed charges,Drugs,130.41,35,,130.41,percent of total billed charges,Drugs,130.41,35,,130.41,percent of total billed charges,Drugs,130.41,35,,130.41,percent of total billed charges,Drugs,124.2,,,124.2,Other,Drug Cost,124.2,,,124.2,Other,Drug Cost,124.2,,,124.2,Other,Drug Cost,124.2,,,124.2,Other,Drug Cost,124.2,,,124.2,Other,Drug Cost,124.2,,,124.2,Other,Drug Cost,279.45,,,279.45,Other,225% of Medicaid,173.88,,,173.88,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,344.56,,,344.56,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",267.03,,,267.03,Other,215% Medicaid APG methodology,267.03,,,267.03,Other,215% Medicaid APG methodology,155.25,,,155.25,Other,125% Medicaid APG methodology,0.01,354.14,
"EPOETIN ALFA-EPBX 20,000 UN/ 2ML",Q5106,HCPCS,,80024111,CDM,636,RC,69131810,NDC,both,10,ML,87.89,77.2,,,77.2,Other,150% of Medicare + 9.63% HCRA Surcharge,46.94,,,46.94,Fee Schedule,Average Sale Price (ASP) x 6,30.76,35,,30.76,percent of total billed charges,Drugs,30.76,35,,30.76,percent of total billed charges,Drugs,29.88,34,,29.88,percent of total billed charges,Drugs,29.88,34,,29.88,percent of total billed charges,Drugs,29.88,34,,29.88,percent of total billed charges,Drugs,29.88,34,,29.88,percent of total billed charges,Drugs,30.76,35,,30.76,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,30.76,35,,30.76,percent of total billed charges,Drugs,30.76,35,,30.76,percent of total billed charges,Drugs,30.76,35,,30.76,percent of total billed charges,Drugs,30.76,35,,30.76,percent of total billed charges,Drugs,30.76,35,,30.76,percent of total billed charges,Drugs,35.16,40,,35.16,percent of total billed charges,Drugs,61.52,70,,61.52,percent of total billed charges,All Other,31.64,36,,31.64,percent of total billed charges,Drugs,31.64,36,,31.64,percent of total billed charges,Drugs,30.76,35,,30.76,percent of total billed charges,Drugs,30.76,35,,30.76,percent of total billed charges,Drugs,30.76,35,,30.76,percent of total billed charges,Drugs,30.76,35,,30.76,percent of total billed charges,Drugs,29.3,,,29.3,Other,Drug Cost,29.3,,,29.3,Other,Drug Cost,29.3,,,29.3,Other,Drug Cost,29.3,,,29.3,Other,Drug Cost,29.3,,,29.3,Other,Drug Cost,29.3,,,29.3,Other,Drug Cost,65.92,,,65.92,Other,225% of Medicaid,41.01,,,41.01,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,75.11,,,75.11,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",62.99,,,62.99,Other,215% Medicaid APG methodology,62.99,,,62.99,Other,215% Medicaid APG methodology,36.62,,,36.62,Other,125% Medicaid APG methodology,0.01,77.2,
"Mening Vac A,CY,W135 10mcg/0.5mL",90619,HCPCS,,80024112,CDM,636,RC,49281059005,NDC,both,5,ML,432.35,170.64,39.4668,,170.64,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,151.32,35,,151.32,percent of total billed charges,Drugs,151.32,35,,151.32,percent of total billed charges,Drugs,147,34,,147,percent of total billed charges,Drugs,147,34,,147,percent of total billed charges,Drugs,147,34,,147,percent of total billed charges,Drugs,147,34,,147,percent of total billed charges,Drugs,151.32,35,,151.32,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,151.32,35,,151.32,percent of total billed charges,Drugs,151.32,35,,151.32,percent of total billed charges,Drugs,151.32,35,,151.32,percent of total billed charges,Drugs,151.32,35,,151.32,percent of total billed charges,Drugs,151.32,35,,151.32,percent of total billed charges,Drugs,172.94,40,,172.94,percent of total billed charges,Drugs,302.65,70,,302.65,percent of total billed charges,All Other,155.65,36,,155.65,percent of total billed charges,Drugs,155.65,36,,155.65,percent of total billed charges,Drugs,151.32,35,,151.32,percent of total billed charges,Drugs,151.32,35,,151.32,percent of total billed charges,Drugs,151.32,35,,151.32,percent of total billed charges,Drugs,151.32,35,,151.32,percent of total billed charges,Drugs,144.12,,,144.12,Other,Drug Cost,144.12,,,144.12,Other,Drug Cost,144.12,,,144.12,Other,Drug Cost,144.12,,,144.12,Other,Drug Cost,144.12,,,144.12,Other,Drug Cost,144.12,,,144.12,Other,Drug Cost,324.27,,,324.27,Other,225% of Medicaid,201.77,,,201.77,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",309.85,,,309.85,Other,215% Medicaid APG methodology,309.85,,,309.85,Other,215% Medicaid APG methodology,180.15,,,180.15,Other,125% Medicaid APG methodology,0.01,324.27,
GLATIRAMER ACETATE 40MG INJ,J1595,HCPCS,,80024119,CDM,636,RC,68546032512,NDC,both,12,ML,1392.39,549.53,39.4668,,549.53,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,487.34,35,,487.34,percent of total billed charges,Drugs,487.34,35,,487.34,percent of total billed charges,Drugs,473.41,34,,473.41,percent of total billed charges,Drugs,473.41,34,,473.41,percent of total billed charges,Drugs,473.41,34,,473.41,percent of total billed charges,Drugs,473.41,34,,473.41,percent of total billed charges,Drugs,487.34,35,,487.34,percent of total billed charges,Drugs,473.41,34,"If Charge > 500, then 34 percent",473.41,percent of total billed charges,Drugs,487.34,35,,487.34,percent of total billed charges,Drugs,487.34,35,,487.34,percent of total billed charges,Drugs,487.34,35,,487.34,percent of total billed charges,Drugs,487.34,35,,487.34,percent of total billed charges,Drugs,487.34,35,,487.34,percent of total billed charges,Drugs,556.96,40,,556.96,percent of total billed charges,Drugs,974.67,70,,974.67,percent of total billed charges,All Other,501.26,36,,501.26,percent of total billed charges,Drugs,501.26,36,,501.26,percent of total billed charges,Drugs,487.34,35,,487.34,percent of total billed charges,Drugs,487.34,35,,487.34,percent of total billed charges,Drugs,487.34,35,,487.34,percent of total billed charges,Drugs,487.34,35,,487.34,percent of total billed charges,Drugs,464.13,,,464.13,Other,Drug Cost,464.13,,,464.13,Other,Drug Cost,464.13,,,464.13,Other,Drug Cost,464.13,,,464.13,Other,Drug Cost,464.13,,,464.13,Other,Drug Cost,464.13,,,464.13,Other,Drug Cost,1044.29,,,1044.29,Other,225% of Medicaid,649.78,,,649.78,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",997.88,,,997.88,Other,215% Medicaid APG methodology,997.88,,,997.88,Other,215% Medicaid APG methodology,580.16,,,580.16,Other,125% Medicaid APG methodology,0.01,1044.29,
RABIES IMMUNE GLOBULIN 150 UNITS/ML,90377,HCPCS,,80024122,CDM,636,RC,76125015002,NDC,both,1,ML,1152.09,454.69,39.4668,,454.69,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,403.23,35,,403.23,percent of total billed charges,Drugs,403.23,35,,403.23,percent of total billed charges,Drugs,391.71,34,,391.71,percent of total billed charges,Drugs,391.71,34,,391.71,percent of total billed charges,Drugs,391.71,34,,391.71,percent of total billed charges,Drugs,391.71,34,,391.71,percent of total billed charges,Drugs,403.23,35,,403.23,percent of total billed charges,Drugs,391.71,34,"If Charge > 500, then 34 percent",391.71,percent of total billed charges,Drugs,403.23,35,,403.23,percent of total billed charges,Drugs,403.23,35,,403.23,percent of total billed charges,Drugs,403.23,35,,403.23,percent of total billed charges,Drugs,403.23,35,,403.23,percent of total billed charges,Drugs,403.23,35,,403.23,percent of total billed charges,Drugs,460.84,40,,460.84,percent of total billed charges,Drugs,806.46,70,,806.46,percent of total billed charges,All Other,414.75,36,,414.75,percent of total billed charges,Drugs,414.75,36,,414.75,percent of total billed charges,Drugs,403.23,35,,403.23,percent of total billed charges,Drugs,403.23,35,,403.23,percent of total billed charges,Drugs,403.23,35,,403.23,percent of total billed charges,Drugs,403.23,35,,403.23,percent of total billed charges,Drugs,384.03,,,384.03,Other,Drug Cost,384.03,,,384.03,Other,Drug Cost,384.03,,,384.03,Other,Drug Cost,384.03,,,384.03,Other,Drug Cost,384.03,,,384.03,Other,Drug Cost,384.03,,,384.03,Other,Drug Cost,864.07,,,864.07,Other,225% of Medicaid,537.64,,,537.64,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",825.66,,,825.66,Other,215% Medicaid APG methodology,825.66,,,825.66,Other,215% Medicaid APG methodology,480.04,,,480.04,Other,125% Medicaid APG methodology,0.01,864.07,
BIVALIRUDIN 5MG/ML 50ML,J0583,HCPCS,,80024125,CDM,636,RC,42023062210,NDC,both,10,ML,67.94,2.11,,,2.11,Other,150% of Medicare + 9.63% HCRA Surcharge,1.28,,,1.28,Fee Schedule,Average Sale Price (ASP) x 6,23.78,35,,23.78,percent of total billed charges,Drugs,23.78,35,,23.78,percent of total billed charges,Drugs,23.1,34,,23.1,percent of total billed charges,Drugs,23.1,34,,23.1,percent of total billed charges,Drugs,23.1,34,,23.1,percent of total billed charges,Drugs,23.1,34,,23.1,percent of total billed charges,Drugs,23.78,35,,23.78,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,23.78,35,,23.78,percent of total billed charges,Drugs,23.78,35,,23.78,percent of total billed charges,Drugs,23.78,35,,23.78,percent of total billed charges,Drugs,23.78,35,,23.78,percent of total billed charges,Drugs,23.78,35,,23.78,percent of total billed charges,Drugs,27.18,40,,27.18,percent of total billed charges,Drugs,47.56,70,,47.56,percent of total billed charges,All Other,24.46,36,,24.46,percent of total billed charges,Drugs,24.46,36,,24.46,percent of total billed charges,Drugs,23.78,35,,23.78,percent of total billed charges,Drugs,23.78,35,,23.78,percent of total billed charges,Drugs,23.78,35,,23.78,percent of total billed charges,Drugs,23.78,35,,23.78,percent of total billed charges,Drugs,22.65,,,22.65,Other,Drug Cost,22.65,,,22.65,Other,Drug Cost,22.65,,,22.65,Other,Drug Cost,22.65,,,22.65,Other,Drug Cost,22.65,,,22.65,Other,Drug Cost,22.65,,,22.65,Other,Drug Cost,50.96,,,50.96,Other,225% of Medicaid,31.71,,,31.71,Other,140% of Medicaid,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,2.05,,,2.05,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",48.69,,,48.69,Other,215% Medicaid APG methodology,48.69,,,48.69,Other,215% Medicaid APG methodology,28.31,,,28.31,Other,125% Medicaid APG methodology,0.01,50.96,
MARGETUXIMAB-CMKB 25 MG/ML 10 ML VIAL,J9353,HCPCS,,80024127,CDM,636,RC,74527002202,NDC,both,1,ML,5183.31,464.24,,,464.24,Other,150% of Medicare + 9.63% HCRA Surcharge,282.31,,,282.31,Fee Schedule,Average Sale Price (ASP) x 6,1814.16,35,,1814.16,percent of total billed charges,Drugs,1814.16,35,,1814.16,percent of total billed charges,Drugs,1762.33,34,,1762.33,percent of total billed charges,Drugs,1762.33,34,,1762.33,percent of total billed charges,Drugs,1762.33,34,,1762.33,percent of total billed charges,Drugs,1762.33,34,,1762.33,percent of total billed charges,Drugs,1814.16,35,,1814.16,percent of total billed charges,Drugs,1762.33,34,"If Charge > 500, then 34 percent",1762.33,percent of total billed charges,Drugs,1814.16,35,,1814.16,percent of total billed charges,Drugs,1814.16,35,,1814.16,percent of total billed charges,Drugs,1814.16,35,,1814.16,percent of total billed charges,Drugs,1814.16,35,,1814.16,percent of total billed charges,Drugs,1814.16,35,,1814.16,percent of total billed charges,Drugs,2073.32,40,,2073.32,percent of total billed charges,Drugs,3628.32,70,,3628.32,percent of total billed charges,All Other,1865.99,36,,1865.99,percent of total billed charges,Drugs,1865.99,36,,1865.99,percent of total billed charges,Drugs,1814.16,35,,1814.16,percent of total billed charges,Drugs,1814.16,35,,1814.16,percent of total billed charges,Drugs,1814.16,35,,1814.16,percent of total billed charges,Drugs,1814.16,35,,1814.16,percent of total billed charges,Drugs,1727.77,,,1727.77,Other,Drug Cost,1727.77,,,1727.77,Other,Drug Cost,1727.77,,,1727.77,Other,Drug Cost,1727.77,,,1727.77,Other,Drug Cost,1727.77,,,1727.77,Other,Drug Cost,1727.77,,,1727.77,Other,Drug Cost,3887.48,,,3887.48,Other,225% of Medicaid,2418.88,,,2418.88,Other,140% of Medicaid,1762.33,34,"If Charge > 2,000, then 34 percent",1762.33,percent of total billed charges,Drugs,451.69,,,451.69,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",3714.71,,,3714.71,Other,215% Medicaid APG methodology,3714.71,,,3714.71,Other,215% Medicaid APG methodology,2159.71,,,2159.71,Other,125% Medicaid APG methodology,0.01,3887.48,
ALPROSTADIL 500MCG INJ,J0270,HCPCS,,80000071,CDM,637,RC,9316906,NDC,both,5,ML,260.61,102.85,39.4668,,102.85,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,91.21,35,,91.21,percent of total billed charges,Drugs,91.21,35,,91.21,percent of total billed charges,Drugs,88.61,34,,88.61,percent of total billed charges,Drugs,88.61,34,,88.61,percent of total billed charges,Drugs,88.61,34,,88.61,percent of total billed charges,Drugs,88.61,34,,88.61,percent of total billed charges,Drugs,91.21,35,,91.21,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,91.21,35,,91.21,percent of total billed charges,Drugs,91.21,35,,91.21,percent of total billed charges,Drugs,91.21,35,,91.21,percent of total billed charges,Drugs,91.21,35,,91.21,percent of total billed charges,Drugs,91.21,35,,91.21,percent of total billed charges,Drugs,104.24,40,,104.24,percent of total billed charges,Drugs,182.43,70,,182.43,percent of total billed charges,All Other,93.82,36,,93.82,percent of total billed charges,Drugs,93.82,36,,93.82,percent of total billed charges,Drugs,91.21,35,,91.21,percent of total billed charges,Drugs,91.21,35,,91.21,percent of total billed charges,Drugs,91.21,35,,91.21,percent of total billed charges,Drugs,91.21,35,,91.21,percent of total billed charges,Drugs,86.87,,,86.87,Other,Drug Cost,86.87,,,86.87,Other,Drug Cost,86.87,,,86.87,Other,Drug Cost,86.87,,,86.87,Other,Drug Cost,86.87,,,86.87,Other,Drug Cost,86.87,,,86.87,Other,Drug Cost,195.46,,,195.46,Other,225% of Medicaid,121.62,,,121.62,Other,140% of Medicaid,0.01,34,,0.01,Other,"Drug Charges > 2,000, then 34% of Charges",0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",186.77,,,186.77,Other,215% Medicaid APG methodology,186.77,,,186.77,Other,215% Medicaid APG methodology,108.59,,,108.59,Other,125% Medicaid APG methodology,0.01,195.46,
CALCITONIN SALMON INJ TO 400 UNITS,J0630,HCPCS,,80000325,CDM,637,RC,67457067502,NDC,both,1,ML,0.06,10552.43,,,10552.43,Other,150% of Medicare + 9.63% HCRA Surcharge,6416.99,,,6416.99,Fee Schedule,Average Sale Price (ASP) x 6,0.02,35,,0.02,percent of total billed charges,Drugs,0.02,35,,0.02,percent of total billed charges,Drugs,0.02,34,,0.02,percent of total billed charges,Drugs,0.02,34,,0.02,percent of total billed charges,Drugs,0.02,34,,0.02,percent of total billed charges,Drugs,0.02,34,,0.02,percent of total billed charges,Drugs,0.02,35,,0.02,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,0.02,35,,0.02,percent of total billed charges,Drugs,0.02,35,,0.02,percent of total billed charges,Drugs,0.02,35,,0.02,percent of total billed charges,Drugs,0.02,35,,0.02,percent of total billed charges,Drugs,0.02,35,,0.02,percent of total billed charges,Drugs,0.02,40,,0.02,percent of total billed charges,Drugs,0.04,70,,0.04,percent of total billed charges,All Other,0.02,36,,0.02,percent of total billed charges,Drugs,0.02,36,,0.02,percent of total billed charges,Drugs,0.02,35,,0.02,percent of total billed charges,Drugs,0.02,35,,0.02,percent of total billed charges,Drugs,0.02,35,,0.02,percent of total billed charges,Drugs,0.02,35,,0.02,percent of total billed charges,Drugs,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.05,,,0.05,Other,225% of Medicaid,0.03,,,0.03,Other,140% of Medicaid,0.01,34,,0.01,Other,"Drug Charges > 2,000, then 34% of Charges",10267.19,,,10267.19,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",0.04,,,0.04,Other,215% Medicaid APG methodology,0.04,,,0.04,Other,215% Medicaid APG methodology,0.03,,,0.03,Other,125% Medicaid APG methodology,0.01,10552.43,
OCTREOTIDE 500MCG/1ML INJ,J2354,HCPCS,,80001525,CDM,637,RC,63323037701,NDC,both,10,ML,32.69,11.72,,,11.72,Other,150% of Medicare + 9.63% HCRA Surcharge,7.13,,,7.13,Fee Schedule,Average Sale Price (ASP) x 6,11.44,35,,11.44,percent of total billed charges,Drugs,11.44,35,,11.44,percent of total billed charges,Drugs,11.11,34,,11.11,percent of total billed charges,Drugs,11.11,34,,11.11,percent of total billed charges,Drugs,11.11,34,,11.11,percent of total billed charges,Drugs,11.11,34,,11.11,percent of total billed charges,Drugs,11.44,35,,11.44,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,11.44,35,,11.44,percent of total billed charges,Drugs,11.44,35,,11.44,percent of total billed charges,Drugs,11.44,35,,11.44,percent of total billed charges,Drugs,11.44,35,,11.44,percent of total billed charges,Drugs,11.44,35,,11.44,percent of total billed charges,Drugs,13.07,40,,13.07,percent of total billed charges,Drugs,22.88,70,,22.88,percent of total billed charges,All Other,11.77,36,,11.77,percent of total billed charges,Drugs,11.77,36,,11.77,percent of total billed charges,Drugs,11.44,35,,11.44,percent of total billed charges,Drugs,11.44,35,,11.44,percent of total billed charges,Drugs,11.44,35,,11.44,percent of total billed charges,Drugs,11.44,35,,11.44,percent of total billed charges,Drugs,10.9,,,10.9,Other,Drug Cost,10.9,,,10.9,Other,Drug Cost,10.9,,,10.9,Other,Drug Cost,10.9,,,10.9,Other,Drug Cost,10.9,,,10.9,Other,Drug Cost,10.9,,,10.9,Other,Drug Cost,24.51,,,24.51,Other,225% of Medicaid,15.25,,,15.25,Other,140% of Medicaid,0.01,34,,0.01,Other,"Drug Charges > 2,000, then 34% of Charges",11.4,,,11.4,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",23.42,,,23.42,Other,215% Medicaid APG methodology,23.42,,,23.42,Other,215% Medicaid APG methodology,13.62,,,13.62,Other,125% Medicaid APG methodology,0.01,24.51,
PAPAVERIN HCL 60MG/2ML INJ,J2440,HCPCS,,80001584,CDM,637,RC,517400225,NDC,both,25,ML,24.63,9.72,39.4668,,9.72,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,8.62,35,,8.62,percent of total billed charges,Drugs,8.62,35,,8.62,percent of total billed charges,Drugs,8.38,34,,8.38,percent of total billed charges,Drugs,8.38,34,,8.38,percent of total billed charges,Drugs,8.38,34,,8.38,percent of total billed charges,Drugs,8.38,34,,8.38,percent of total billed charges,Drugs,8.62,35,,8.62,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,8.62,35,,8.62,percent of total billed charges,Drugs,8.62,35,,8.62,percent of total billed charges,Drugs,8.62,35,,8.62,percent of total billed charges,Drugs,8.62,35,,8.62,percent of total billed charges,Drugs,8.62,35,,8.62,percent of total billed charges,Drugs,9.85,40,,9.85,percent of total billed charges,Drugs,17.24,70,,17.24,percent of total billed charges,All Other,8.87,36,,8.87,percent of total billed charges,Drugs,8.87,36,,8.87,percent of total billed charges,Drugs,8.62,35,,8.62,percent of total billed charges,Drugs,8.62,35,,8.62,percent of total billed charges,Drugs,8.62,35,,8.62,percent of total billed charges,Drugs,8.62,35,,8.62,percent of total billed charges,Drugs,8.21,,,8.21,Other,Drug Cost,8.21,,,8.21,Other,Drug Cost,8.21,,,8.21,Other,Drug Cost,8.21,,,8.21,Other,Drug Cost,8.21,,,8.21,Other,Drug Cost,8.21,,,8.21,Other,Drug Cost,18.48,,,18.48,Other,225% of Medicaid,11.5,,,11.5,Other,140% of Medicaid,0.01,34,,0.01,Other,"Drug Charges > 2,000, then 34% of Charges",0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",17.65,,,17.65,Other,215% Medicaid APG methodology,17.65,,,17.65,Other,215% Medicaid APG methodology,10.26,,,10.26,Other,125% Medicaid APG methodology,0.01,18.48,
PHENTOLAMINE MESYLATE 5MG VIAL,J2760,HCPCS,,80002366,CDM,637,RC,51224001220,NDC,both,1,EA,809.01,4408.41,,,4408.41,Other,150% of Medicare + 9.63% HCRA Surcharge,2680.78,,,2680.78,Fee Schedule,Average Sale Price (ASP) x 6,283.15,35,,283.15,percent of total billed charges,Drugs,283.15,35,,283.15,percent of total billed charges,Drugs,275.06,34,,275.06,percent of total billed charges,Drugs,275.06,34,,275.06,percent of total billed charges,Drugs,275.06,34,,275.06,percent of total billed charges,Drugs,275.06,34,,275.06,percent of total billed charges,Drugs,283.15,35,,283.15,percent of total billed charges,Drugs,275.06,34,"If Charge > 500, then 34 percent",275.06,percent of total billed charges,Drugs,283.15,35,,283.15,percent of total billed charges,Drugs,283.15,35,,283.15,percent of total billed charges,Drugs,283.15,35,,283.15,percent of total billed charges,Drugs,283.15,35,,283.15,percent of total billed charges,Drugs,283.15,35,,283.15,percent of total billed charges,Drugs,323.6,40,,323.6,percent of total billed charges,Drugs,566.31,70,,566.31,percent of total billed charges,All Other,291.24,36,,291.24,percent of total billed charges,Drugs,291.24,36,,291.24,percent of total billed charges,Drugs,283.15,35,,283.15,percent of total billed charges,Drugs,283.15,35,,283.15,percent of total billed charges,Drugs,283.15,35,,283.15,percent of total billed charges,Drugs,283.15,35,,283.15,percent of total billed charges,Drugs,269.67,,,269.67,Other,Drug Cost,269.67,,,269.67,Other,Drug Cost,269.67,,,269.67,Other,Drug Cost,269.67,,,269.67,Other,Drug Cost,269.67,,,269.67,Other,Drug Cost,269.67,,,269.67,Other,Drug Cost,606.76,,,606.76,Other,225% of Medicaid,377.54,,,377.54,Other,140% of Medicaid,0.01,34,,0.01,Other,"Drug Charges > 2,000, then 34% of Charges",4289.25,,,4289.25,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",579.79,,,579.79,Other,215% Medicaid APG methodology,579.79,,,579.79,Other,215% Medicaid APG methodology,337.09,,,337.09,Other,125% Medicaid APG methodology,0.01,4408.41,
OCTREOTIDE 50MCG/1ML INJ,J2354,HCPCS,,80002641,CDM,637,RC,67457023901,NDC,both,10,ML,8.1,11.72,,,11.72,Other,150% of Medicare + 9.63% HCRA Surcharge,7.13,,,7.13,Fee Schedule,Average Sale Price (ASP) x 6,2.84,35,,2.84,percent of total billed charges,Drugs,2.84,35,,2.84,percent of total billed charges,Drugs,2.75,34,,2.75,percent of total billed charges,Drugs,2.75,34,,2.75,percent of total billed charges,Drugs,2.75,34,,2.75,percent of total billed charges,Drugs,2.75,34,,2.75,percent of total billed charges,Drugs,2.84,35,,2.84,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,2.84,35,,2.84,percent of total billed charges,Drugs,2.84,35,,2.84,percent of total billed charges,Drugs,2.84,35,,2.84,percent of total billed charges,Drugs,2.84,35,,2.84,percent of total billed charges,Drugs,2.84,35,,2.84,percent of total billed charges,Drugs,3.24,40,,3.24,percent of total billed charges,Drugs,5.67,70,,5.67,percent of total billed charges,All Other,2.92,36,,2.92,percent of total billed charges,Drugs,2.92,36,,2.92,percent of total billed charges,Drugs,2.84,35,,2.84,percent of total billed charges,Drugs,2.84,35,,2.84,percent of total billed charges,Drugs,2.84,35,,2.84,percent of total billed charges,Drugs,2.84,35,,2.84,percent of total billed charges,Drugs,2.7,,,2.7,Other,Drug Cost,2.7,,,2.7,Other,Drug Cost,2.7,,,2.7,Other,Drug Cost,2.7,,,2.7,Other,Drug Cost,2.7,,,2.7,Other,Drug Cost,2.7,,,2.7,Other,Drug Cost,6.08,,,6.08,Other,225% of Medicaid,3.78,,,3.78,Other,140% of Medicaid,0.01,34,,0.01,Other,"Drug Charges > 2,000, then 34% of Charges",11.4,,,11.4,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",5.81,,,5.81,Other,215% Medicaid APG methodology,5.81,,,5.81,Other,215% Medicaid APG methodology,3.38,,,3.38,Other,125% Medicaid APG methodology,0.01,11.72,
OCTREOTIDE 100MCG/1ML INJ,J2354,HCPCS,,80002658,CDM,637,RC,63323037601,NDC,both,10,ML,6.98,11.72,,,11.72,Other,150% of Medicare + 9.63% HCRA Surcharge,7.13,,,7.13,Fee Schedule,Average Sale Price (ASP) x 6,2.44,35,,2.44,percent of total billed charges,Drugs,2.44,35,,2.44,percent of total billed charges,Drugs,2.37,34,,2.37,percent of total billed charges,Drugs,2.37,34,,2.37,percent of total billed charges,Drugs,2.37,34,,2.37,percent of total billed charges,Drugs,2.37,34,,2.37,percent of total billed charges,Drugs,2.44,35,,2.44,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,2.44,35,,2.44,percent of total billed charges,Drugs,2.44,35,,2.44,percent of total billed charges,Drugs,2.44,35,,2.44,percent of total billed charges,Drugs,2.44,35,,2.44,percent of total billed charges,Drugs,2.44,35,,2.44,percent of total billed charges,Drugs,2.79,40,,2.79,percent of total billed charges,Drugs,4.89,70,,4.89,percent of total billed charges,All Other,2.51,36,,2.51,percent of total billed charges,Drugs,2.51,36,,2.51,percent of total billed charges,Drugs,2.44,35,,2.44,percent of total billed charges,Drugs,2.44,35,,2.44,percent of total billed charges,Drugs,2.44,35,,2.44,percent of total billed charges,Drugs,2.44,35,,2.44,percent of total billed charges,Drugs,2.33,,,2.33,Other,Drug Cost,2.33,,,2.33,Other,Drug Cost,2.33,,,2.33,Other,Drug Cost,2.33,,,2.33,Other,Drug Cost,2.33,,,2.33,Other,Drug Cost,2.33,,,2.33,Other,Drug Cost,5.24,,,5.24,Other,225% of Medicaid,3.26,,,3.26,Other,140% of Medicaid,0.01,34,,0.01,Other,"Drug Charges > 2,000, then 34% of Charges",11.4,,,11.4,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",5,,,5,Other,215% Medicaid APG methodology,5,,,5,Other,215% Medicaid APG methodology,2.91,,,2.91,Other,125% Medicaid APG methodology,0.01,11.72,
ADALIMUMAB PEN 40MG/0.8ML,J0135,HCPCS,,80002759,CDM,637,RC,74433902,NDC,both,2,EA,9916.65,3913.78,39.4668,,3913.78,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,3470.83,35,,3470.83,percent of total billed charges,Drugs,3470.83,35,,3470.83,percent of total billed charges,Drugs,3371.66,34,,3371.66,percent of total billed charges,Drugs,3371.66,34,,3371.66,percent of total billed charges,Drugs,3371.66,34,,3371.66,percent of total billed charges,Drugs,3371.66,34,,3371.66,percent of total billed charges,Drugs,3470.83,35,,3470.83,percent of total billed charges,Drugs,3371.66,34,"If Charge > 500, then 34 percent",3371.66,percent of total billed charges,Drugs,3470.83,35,,3470.83,percent of total billed charges,Drugs,3470.83,35,,3470.83,percent of total billed charges,Drugs,3470.83,35,,3470.83,percent of total billed charges,Drugs,3470.83,35,,3470.83,percent of total billed charges,Drugs,3470.83,35,,3470.83,percent of total billed charges,Drugs,3966.66,40,,3966.66,percent of total billed charges,Drugs,6941.66,70,,6941.66,percent of total billed charges,All Other,3569.99,36,,3569.99,percent of total billed charges,Drugs,3569.99,36,,3569.99,percent of total billed charges,Drugs,3470.83,35,,3470.83,percent of total billed charges,Drugs,3470.83,35,,3470.83,percent of total billed charges,Drugs,3470.83,35,,3470.83,percent of total billed charges,Drugs,3470.83,35,,3470.83,percent of total billed charges,Drugs,3305.55,,,3305.55,Other,Drug Cost,3305.55,,,3305.55,Other,Drug Cost,3305.55,,,3305.55,Other,Drug Cost,3305.55,,,3305.55,Other,Drug Cost,3305.55,,,3305.55,Other,Drug Cost,3305.55,,,3305.55,Other,Drug Cost,7437.49,,,7437.49,Other,225% of Medicaid,4627.77,,,4627.77,Other,140% of Medicaid,3371.66,34,,3371.66,Other,"Drug Charges > 2,000, then 34% of Charges",0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",7106.93,,,7106.93,Other,215% Medicaid APG methodology,7106.93,,,7106.93,Other,215% Medicaid APG methodology,4131.94,,,4131.94,Other,125% Medicaid APG methodology,0.01,7437.49,
TRAUMA RESPONSE LEVEL ONE,G0390,HCPCS,,30000070,CDM,681,RC,,,both,,,7478,5533.74,,,5533.74,Other,150% of Medicare + 9.63% HCRA Surcharge,3365.1,45,,3365.1,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,3701.61,,,3701.61,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,5234.6,70,,5234.6,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,5533.74,
TRAUMA RESPONSE LEVEL TWO,G0390,HCPCS,,30000071,CDM,681,RC,,,both,,,5981,4425.95,,,4425.95,Other,150% of Medicare + 9.63% HCRA Surcharge,2691.45,45,,2691.45,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2960.6,,,2960.6,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,4186.7,70,,4186.7,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,4425.95,
TRAUMA RESPONS W/ HOSP CRITI LV3,G0390,HCPCS,,30000092,CDM,683,RC,,,both,,,4786,3541.65,,,3541.65,Other,150% of Medicare + 9.63% HCRA Surcharge,2153.7,45,,2153.7,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,2369.07,,,2369.07,Other,110% of Medicare,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,186% of Medicaid,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,3350.2,70,,3350.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3541.65,
INSERT CERVICAL DILATOR,59200,CPT,,26059200,CDM,720,RC,,,both,,,690,510.6,,,510.6,Other,150% of Medicare + 9.63% HCRA Surcharge,310.5,45,,310.5,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",341.55,,,341.55,Other,110% of Medicare,469.2,68,,469.2,percent of total billed charges,All Other,1164,,,1164,Other,186% of Medicaid,552,80,,552,percent of total billed charges,All Other,572.7,83,,572.7,percent of total billed charges,All Other,572.7,83,,572.7,percent of total billed charges,All Other,552,80,,552,percent of total billed charges,All Other,572.7,83,,572.7,percent of total billed charges,All Other,552,80,,552,percent of total billed charges,All Other,483,70,,483,percent of total billed charges,All Other,214.84,,,214.84,Fee Schedule,,182.09,,,182.09,Fee Schedule,,1713,,,1713,Case Rate,,1541,,,1541,Case Rate,,1713,,,1713,Case Rate,,1456,,,1456,Case Rate,,625.74,,,625.74,Other,100% of Medicaid,625.74,,,625.74,Other,100% of Medicaid,625.74,,,625.74,Other,100% of Medicaid,625.74,,,625.74,Other,100% of Medicaid,1407.92,,,1407.92,Other,225% of Medicaid,957.39,,,957.39,Other,153% of Medicaid,1407.92,,,1407.92,Other,225% of Medicaid,876.04,,,876.04,Other,140% of Medicaid,1407.92,,,1407.92,Other,225% of Medicaid,1626.93,,,1626.93,Other,260% of Medicaid,2027.4,,,2027.4,Other,324% of Medicaid,1345.35,,,1345.35,Other,215% of Medicaid,1345.35,,,1345.35,Other,215% of Medicaid,782.18,,,782.18,Other,125% of Medicaid,182.09,3024,
CIRCUMCISION W/REGIONL BLOCK,54150,CPT,,26054150,CDM,723,RC,,,both,,,4256,3149.45,,,3149.45,Other,150% of Medicare + 9.63% HCRA Surcharge,1915.2,45,,1915.2,percent of total billed charges,Critical Access Hospital RCC factor,2766.4,65,,2766.4,percent of total billed charges,All Other,2511.04,65,,2511.04,percent of total billed charges,All Other,3255.84,76.5,,3255.84,percent of total billed charges,All Other,3021.76,69,,3021.76,percent of total billed charges,All Other,2936.64,65,,2936.64,percent of total billed charges,All Other,2106.72,,,2106.72,Other,110% of Medicare,2894.08,68,,2894.08,percent of total billed charges,All Other,1451,,,1451,Other,186% of Medicaid,3404.8,80,,3404.8,percent of total billed charges,All Other,3532.48,83,,3532.48,percent of total billed charges,All Other,3532.48,83,,3532.48,percent of total billed charges,All Other,3404.8,80,,3404.8,percent of total billed charges,All Other,3532.48,83,,3532.48,percent of total billed charges,All Other,3404.8,80,,3404.8,percent of total billed charges,All Other,2979.2,70,,2979.2,percent of total billed charges,All Other,465.76,,,465.76,Fee Schedule,,394.76,,,394.76,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,780.25,,,780.25,Other,100% of Medicaid,780.25,,,780.25,Other,100% of Medicaid,780.25,,,780.25,Other,100% of Medicaid,780.25,,,780.25,Other,100% of Medicaid,1755.56,,,1755.56,Other,225% of Medicaid,1193.78,,,1193.78,Other,153% of Medicaid,1755.56,,,1755.56,Other,225% of Medicaid,1092.35,,,1092.35,Other,140% of Medicaid,1755.56,,,1755.56,Other,225% of Medicaid,2028.64,,,2028.64,Other,260% of Medicaid,2528,,,2528,Other,324% of Medicaid,1677.53,,,1677.53,Other,215% of Medicaid,1677.53,,,1677.53,Other,215% of Medicaid,975.31,,,975.31,Other,125% of Medicaid,0.01,3532.48,
CIRCUM 28 DAYS OR OLDER,54161,CPT,,26054161,CDM,723,RC,,,both,,,4176,3090.25,,,3090.25,Other,150% of Medicare + 9.63% HCRA Surcharge,1879.2,45,,1879.2,percent of total billed charges,Critical Access Hospital RCC factor,2480,,,2480,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2232,,,2232,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3648,,,3648,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3283,,,3283,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3101,,,3101,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2067.12,,,2067.12,Other,110% of Medicare,2839.68,,,2839.68,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1762,,,1762,Other,186% of Medicaid,3340.8,,,3340.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",3340.8,,,3340.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",3340.8,80,,3340.8,percent of total billed charges,All Other,2923.2,70,,2923.2,percent of total billed charges,All Other,947.92,,,947.92,Fee Schedule,,803.42,,,803.42,Fee Schedule,,2923.2,70,,2923.2,percent of total billed charges,All Other,2923.2,70,,2923.2,percent of total billed charges,All Other,2923.2,70,,2923.2,percent of total billed charges,All Other,2923.2,70,,2923.2,percent of total billed charges,All Other,947.56,,,947.56,Other,100% of Medicaid,947.56,,,947.56,Other,100% of Medicaid,947.56,,,947.56,Other,100% of Medicaid,947.56,,,947.56,Other,100% of Medicaid,2132.02,,,2132.02,Other,225% of Medicaid,1449.77,,,1449.77,Other,153% of Medicaid,2132.02,,,2132.02,Other,225% of Medicaid,1326.59,,,1326.59,Other,140% of Medicaid,2132.02,,,2132.02,Other,225% of Medicaid,2463.67,,,2463.67,Other,260% of Medicaid,3070.11,,,3070.11,Other,324% of Medicaid,2037.26,,,2037.26,Other,215% of Medicaid,2037.26,,,2037.26,Other,215% of Medicaid,1184.46,,,1184.46,Other,125% of Medicaid,803.42,7216,
CIRCUMCISION W/O REGIONL BLOCK,54150,CPT,52,26154150,CDM,723,RC,,,both,,,3405,2519.71,,,2519.71,Other,150% of Medicare + 9.63% HCRA Surcharge,1532.25,45,,1532.25,percent of total billed charges,Critical Access Hospital RCC factor,2213.25,65,,2213.25,percent of total billed charges,All Other,2008.95,65,,2008.95,percent of total billed charges,All Other,2604.83,76.5,,2604.83,percent of total billed charges,All Other,2417.55,69,,2417.55,percent of total billed charges,All Other,2349.45,65,,2349.45,percent of total billed charges,All Other,1685.48,,,1685.48,Other,110% of Medicare,2315.4,68,,2315.4,percent of total billed charges,All Other,1451,,,1451,Other,186% of Medicaid,2724,80,,2724,percent of total billed charges,All Other,2826.15,83,,2826.15,percent of total billed charges,All Other,2826.15,83,,2826.15,percent of total billed charges,All Other,2724,80,,2724,percent of total billed charges,All Other,2826.15,83,,2826.15,percent of total billed charges,All Other,2724,80,,2724,percent of total billed charges,All Other,2383.5,70,,2383.5,percent of total billed charges,All Other,465.76,,,465.76,Fee Schedule,,394.76,,,394.76,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,780.25,,,780.25,Other,100% of Medicaid,780.25,,,780.25,Other,100% of Medicaid,780.25,,,780.25,Other,100% of Medicaid,780.25,,,780.25,Other,100% of Medicaid,1755.56,,,1755.56,Other,225% of Medicaid,1193.78,,,1193.78,Other,153% of Medicaid,1755.56,,,1755.56,Other,225% of Medicaid,1092.35,,,1092.35,Other,140% of Medicaid,1755.56,,,1755.56,Other,225% of Medicaid,2028.64,,,2028.64,Other,260% of Medicaid,2528,,,2528,Other,324% of Medicaid,1677.53,,,1677.53,Other,215% of Medicaid,1677.53,,,1677.53,Other,215% of Medicaid,975.31,,,975.31,Other,125% of Medicaid,0.01,2826.15,
12 LEAD EKG; TRACING ONLY,93005,CPT,,48093005,CDM,730,RC,,,both,,,149,110.26,,,110.26,Other,150% of Medicare + 9.63% HCRA Surcharge,67.05,45,,67.05,percent of total billed charges,Critical Access Hospital RCC factor,20.44,,,20.44,Fee Schedule,,18.43,,,18.43,Fee Schedule,,73.31,,,73.31,Fee Schedule,,65.93,,,65.93,Fee Schedule,,62.32,,,62.32,Fee Schedule,,73.76,,,73.76,Other,110% of Medicare,0.68,,,0.68,Fee Schedule,,64,,,64,Other,186% of Medicaid,0.8,,,0.8,Fee Schedule,,0.83,,,0.83,Fee Schedule,,0.83,,,0.83,Fee Schedule,,0.8,,,0.8,Fee Schedule,,0.83,,,0.83,Fee Schedule,,119.2,80,,119.2,percent of total billed charges,All Other,104.3,70,,104.3,percent of total billed charges,All Other,29.52,,,29.52,Fee Schedule,,25.02,,,25.02,Fee Schedule,,667,,,667,Case Rate,,600,,,600,Case Rate,,667,,,667,Case Rate,,567,,,567,Case Rate,,34.6,,,34.6,Other,100% of Medicaid,34.6,,,34.6,Other,100% of Medicaid,34.6,,,34.6,Other,100% of Medicaid,34.6,,,34.6,Other,100% of Medicaid,77.85,,,77.85,Other,225% of Medicaid,52.94,,,52.94,Other,153% of Medicaid,77.85,,,77.85,Other,225% of Medicaid,48.44,,,48.44,Other,140% of Medicaid,77.85,,,77.85,Other,225% of Medicaid,89.97,,,89.97,Other,260% of Medicaid,112.11,,,112.11,Other,324% of Medicaid,74.39,,,74.39,Other,215% of Medicaid,74.39,,,74.39,Other,215% of Medicaid,43.25,,,43.25,Other,125% of Medicaid,0.68,667,
EKG SIGNAL-AVERAGED,93278,CPT,,48093278,CDM,730,RC,,,both,,,131,96.94,,,96.94,Other,150% of Medicare + 9.63% HCRA Surcharge,58.95,45,,58.95,percent of total billed charges,Critical Access Hospital RCC factor,62.13,,,62.13,Fee Schedule,,56.02,,,56.02,Fee Schedule,,100.22,76.5,,100.22,percent of total billed charges,All Other,93.01,69,,93.01,percent of total billed charges,All Other,90.39,65,,90.39,percent of total billed charges,All Other,64.85,,,64.85,Other,110% of Medicare,89.08,68,,89.08,percent of total billed charges,All Other,64,,,64,Other,186% of Medicaid,104.8,80,,104.8,percent of total billed charges,All Other,81.22,62,,81.22,percent of total billed charges,Lab and Radiology,72.05,83,,72.05,percent of total billed charges,All Other,104.8,80,,104.8,percent of total billed charges,All Other,81.22,62,,81.22,percent of total billed charges,Lab and Radiology,83.19,,,83.19,Fee Schedule,,91.7,70,,91.7,percent of total billed charges,All Other,80.36,,,80.36,Fee Schedule,,68.11,,,68.11,Fee Schedule,,667,,,667,Case Rate,,600,,,600,Case Rate,,667,,,667,Case Rate,,567,,,567,Case Rate,,34.6,,,34.6,Other,100% of Medicaid,34.6,,,34.6,Other,100% of Medicaid,34.6,,,34.6,Other,100% of Medicaid,34.6,,,34.6,Other,100% of Medicaid,77.85,,,77.85,Other,225% of Medicaid,52.94,,,52.94,Other,153% of Medicaid,77.85,,,77.85,Other,225% of Medicaid,48.44,,,48.44,Other,140% of Medicaid,77.85,,,77.85,Other,225% of Medicaid,89.97,,,89.97,Other,260% of Medicaid,112.11,,,112.11,Other,324% of Medicaid,74.39,,,74.39,Other,215% of Medicaid,74.39,,,74.39,Other,215% of Medicaid,43.25,,,43.25,Other,125% of Medicaid,34.6,667,
EKG,93005,CPT,,51093005,CDM,730,RC,,,both,,,149,110.26,,,110.26,Other,150% of Medicare + 9.63% HCRA Surcharge,67.05,45,,67.05,percent of total billed charges,Critical Access Hospital RCC factor,20.44,,,20.44,Fee Schedule,,18.43,,,18.43,Fee Schedule,,73.31,,,73.31,Fee Schedule,,65.93,,,65.93,Fee Schedule,,62.32,,,62.32,Fee Schedule,,73.76,,,73.76,Other,110% of Medicare,0.68,,,0.68,Fee Schedule,,64,,,64,Other,186% of Medicaid,0.8,,,0.8,Fee Schedule,,0.83,,,0.83,Fee Schedule,,0.83,,,0.83,Fee Schedule,,0.8,,,0.8,Fee Schedule,,0.83,,,0.83,Fee Schedule,,119.2,80,,119.2,percent of total billed charges,All Other,104.3,70,,104.3,percent of total billed charges,All Other,29.52,,,29.52,Fee Schedule,,25.02,,,25.02,Fee Schedule,,667,,,667,Case Rate,,600,,,600,Case Rate,,667,,,667,Case Rate,,567,,,567,Case Rate,,34.6,,,34.6,Other,100% of Medicaid,34.6,,,34.6,Other,100% of Medicaid,34.6,,,34.6,Other,100% of Medicaid,34.6,,,34.6,Other,100% of Medicaid,77.85,,,77.85,Other,225% of Medicaid,52.94,,,52.94,Other,153% of Medicaid,77.85,,,77.85,Other,225% of Medicaid,48.44,,,48.44,Other,140% of Medicaid,77.85,,,77.85,Other,225% of Medicaid,89.97,,,89.97,Other,260% of Medicaid,112.11,,,112.11,Other,324% of Medicaid,74.39,,,74.39,Other,215% of Medicaid,74.39,,,74.39,Other,215% of Medicaid,43.25,,,43.25,Other,125% of Medicaid,0.68,667,
ECG UP TO 48 HRS RECORDING,93225,CPT,,48093225,CDM,731,RC,,,both,,,1087,804.38,,,804.38,Other,150% of Medicare + 9.63% HCRA Surcharge,489.15,45,,489.15,percent of total billed charges,Critical Access Hospital RCC factor,58.91,,,58.91,Fee Schedule,,53.12,,,53.12,Fee Schedule,,210.64,,,210.64,Fee Schedule,,189.46,,,189.46,Fee Schedule,,179.07,,,179.07,Fee Schedule,,538.07,,,538.07,Other,110% of Medicare,0.68,,,0.68,Fee Schedule,,285,,,285,Other,186% of Medicaid,0.8,,,0.8,Fee Schedule,,0.83,,,0.83,Fee Schedule,,0.83,,,0.83,Fee Schedule,,0.8,,,0.8,Fee Schedule,,0.83,,,0.83,Fee Schedule,,869.6,80,,869.6,percent of total billed charges,All Other,760.9,70,,760.9,percent of total billed charges,All Other,93.48,,,93.48,Fee Schedule,,79.23,,,79.23,Fee Schedule,,438,,,438,Case Rate,,394,,,394,Case Rate,,438,,,438,Case Rate,,372,,,372,Case Rate,,153.11,,,153.11,Other,100% of Medicaid,153.11,,,153.11,Other,100% of Medicaid,153.11,,,153.11,Other,100% of Medicaid,153.11,,,153.11,Other,100% of Medicaid,344.49,,,344.49,Other,225% of Medicaid,234.25,,,234.25,Other,153% of Medicaid,344.49,,,344.49,Other,225% of Medicaid,214.35,,,214.35,Other,140% of Medicaid,344.49,,,344.49,Other,225% of Medicaid,398.08,,,398.08,Other,260% of Medicaid,496.07,,,496.07,Other,324% of Medicaid,329.18,,,329.18,Other,215% of Medicaid,329.18,,,329.18,Other,215% of Medicaid,191.38,,,191.38,Other,125% of Medicaid,0.68,869.6,
ECG MONIT/ W REPRT UP TO 48 HR,93226,CPT,,48093226,CDM,731,RC,,,both,,,846,626.04,,,626.04,Other,150% of Medicare + 9.63% HCRA Surcharge,380.7,45,,380.7,percent of total billed charges,Critical Access Hospital RCC factor,114.46,,,114.46,Fee Schedule,,103.21,,,103.21,Fee Schedule,,311.3,,,311.3,Fee Schedule,,279.99,,,279.99,Fee Schedule,,264.63,,,264.63,Fee Schedule,,418.77,,,418.77,Other,110% of Medicare,0.68,,,0.68,Fee Schedule,,285,,,285,Other,186% of Medicaid,0.8,,,0.8,Fee Schedule,,0.83,,,0.83,Fee Schedule,,0.83,,,0.83,Fee Schedule,,0.8,,,0.8,Fee Schedule,,0.83,,,0.83,Fee Schedule,,676.8,80,,676.8,percent of total billed charges,All Other,592.2,70,,592.2,percent of total billed charges,All Other,183.68,,,183.68,Fee Schedule,,155.68,,,155.68,Fee Schedule,,438,,,438,Case Rate,,394,,,394,Case Rate,,438,,,438,Case Rate,,372,,,372,Case Rate,,153.11,,,153.11,Other,100% of Medicaid,153.11,,,153.11,Other,100% of Medicaid,153.11,,,153.11,Other,100% of Medicaid,153.11,,,153.11,Other,100% of Medicaid,344.49,,,344.49,Other,225% of Medicaid,234.25,,,234.25,Other,153% of Medicaid,344.49,,,344.49,Other,225% of Medicaid,214.35,,,214.35,Other,140% of Medicaid,344.49,,,344.49,Other,225% of Medicaid,398.08,,,398.08,Other,260% of Medicaid,496.07,,,496.07,Other,324% of Medicaid,329.18,,,329.18,Other,215% of Medicaid,329.18,,,329.18,Other,215% of Medicaid,191.38,,,191.38,Other,125% of Medicaid,0.68,676.8,
REMOTE 30 DAY ECG REV REPORT,93270,CPT,,48093270,CDM,731,RC,,,both,,,337,249.38,,,249.38,Other,150% of Medicare + 9.63% HCRA Surcharge,151.65,45,,151.65,percent of total billed charges,Critical Access Hospital RCC factor,26.87,,,26.87,Fee Schedule,,24.23,,,24.23,Fee Schedule,,101.91,,,101.91,Fee Schedule,,91.74,,,91.74,Fee Schedule,,86.65,,,86.65,Fee Schedule,,166.82,,,166.82,Other,110% of Medicare,229.16,68,,229.16,percent of total billed charges,All Other,0.01,,,0.01,Other,186% of Medicaid,269.6,80,,269.6,percent of total billed charges,All Other,208.94,62,,208.94,percent of total billed charges,Lab and Radiology,185.35,83,,185.35,percent of total billed charges,All Other,269.6,80,,269.6,percent of total billed charges,All Other,208.94,62,,208.94,percent of total billed charges,Lab and Radiology,35.98,,,35.98,Fee Schedule,,235.9,70,,235.9,percent of total billed charges,All Other,41,,,41,Fee Schedule,,34.75,,,34.75,Fee Schedule,,438,,,438,Case Rate,,394,,,394,Case Rate,,438,,,438,Case Rate,,372,,,372,Case Rate,,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,438,
TELEMETRY,93799,CPT,,23093041,CDM,732,RC,,,both,,,176,130.24,,,130.24,Other,150% of Medicare + 9.63% HCRA Surcharge,79.2,45,,79.2,percent of total billed charges,Critical Access Hospital RCC factor,114.4,65,,114.4,percent of total billed charges,All Other,103.84,65,,103.84,percent of total billed charges,All Other,134.64,76.5,,134.64,percent of total billed charges,All Other,124.96,69,,124.96,percent of total billed charges,All Other,121.44,65,,121.44,percent of total billed charges,All Other,87.12,,,87.12,Other,110% of Medicare,119.68,68,,119.68,percent of total billed charges,All Other,64,,,64,Other,186% of Medicaid,140.8,80,,140.8,percent of total billed charges,All Other,109.12,62,,109.12,percent of total billed charges,Lab and Radiology,96.8,83,,96.8,percent of total billed charges,All Other,140.8,80,,140.8,percent of total billed charges,All Other,109.12,62,,109.12,percent of total billed charges,Lab and Radiology,140.8,80,,140.8,percent of total billed charges,All Other,123.2,70,,123.2,percent of total billed charges,All Other,114.4,65,,114.4,percent of total billed charges,Default if not in Fee Schedule,114.4,65,,114.4,percent of total billed charges,Default if not in Fee Schedule,438,,,438,Case Rate,,394,,,394,Case Rate,,438,,,438,Case Rate,,372,,,372,Case Rate,,34.6,,,34.6,Other,100% of Medicaid,34.6,,,34.6,Other,100% of Medicaid,34.6,,,34.6,Other,100% of Medicaid,34.6,,,34.6,Other,100% of Medicaid,77.85,,,77.85,Other,225% of Medicaid,52.94,,,52.94,Other,153% of Medicaid,77.85,,,77.85,Other,225% of Medicaid,48.44,,,48.44,Other,140% of Medicaid,77.85,,,77.85,Other,225% of Medicaid,89.97,,,89.97,Other,260% of Medicaid,112.11,,,112.11,Other,324% of Medicaid,74.39,,,74.39,Other,215% of Medicaid,74.39,,,74.39,Other,215% of Medicaid,43.25,,,43.25,Other,125% of Medicaid,34.6,438,
TELEMETRY,93799,CPT,,30093041,CDM,732,RC,,,both,,,176,130.24,,,130.24,Other,150% of Medicare + 9.63% HCRA Surcharge,79.2,45,,79.2,percent of total billed charges,Critical Access Hospital RCC factor,114.4,65,,114.4,percent of total billed charges,All Other,103.84,65,,103.84,percent of total billed charges,All Other,134.64,76.5,,134.64,percent of total billed charges,All Other,124.96,69,,124.96,percent of total billed charges,All Other,121.44,65,,121.44,percent of total billed charges,All Other,87.12,,,87.12,Other,110% of Medicare,119.68,68,,119.68,percent of total billed charges,All Other,64,,,64,Other,186% of Medicaid,140.8,80,,140.8,percent of total billed charges,All Other,109.12,62,,109.12,percent of total billed charges,Lab and Radiology,96.8,83,,96.8,percent of total billed charges,All Other,140.8,80,,140.8,percent of total billed charges,All Other,109.12,62,,109.12,percent of total billed charges,Lab and Radiology,140.8,80,,140.8,percent of total billed charges,All Other,123.2,70,,123.2,percent of total billed charges,All Other,114.4,65,,114.4,percent of total billed charges,Default if not in Fee Schedule,114.4,65,,114.4,percent of total billed charges,Default if not in Fee Schedule,438,,,438,Case Rate,,394,,,394,Case Rate,,438,,,438,Case Rate,,372,,,372,Case Rate,,34.6,,,34.6,Other,100% of Medicaid,34.6,,,34.6,Other,100% of Medicaid,34.6,,,34.6,Other,100% of Medicaid,34.6,,,34.6,Other,100% of Medicaid,77.85,,,77.85,Other,225% of Medicaid,52.94,,,52.94,Other,153% of Medicaid,77.85,,,77.85,Other,225% of Medicaid,48.44,,,48.44,Other,140% of Medicaid,77.85,,,77.85,Other,225% of Medicaid,89.97,,,89.97,Other,260% of Medicaid,112.11,,,112.11,Other,324% of Medicaid,74.39,,,74.39,Other,215% of Medicaid,74.39,,,74.39,Other,215% of Medicaid,43.25,,,43.25,Other,125% of Medicaid,34.6,438,
TELEMETRY,93799,CPT,,51093041,CDM,732,RC,,,both,,,176,130.24,,,130.24,Other,150% of Medicare + 9.63% HCRA Surcharge,79.2,45,,79.2,percent of total billed charges,Critical Access Hospital RCC factor,114.4,65,,114.4,percent of total billed charges,All Other,103.84,65,,103.84,percent of total billed charges,All Other,134.64,76.5,,134.64,percent of total billed charges,All Other,124.96,69,,124.96,percent of total billed charges,All Other,121.44,65,,121.44,percent of total billed charges,All Other,87.12,,,87.12,Other,110% of Medicare,119.68,68,,119.68,percent of total billed charges,All Other,64,,,64,Other,186% of Medicaid,140.8,80,,140.8,percent of total billed charges,All Other,109.12,62,,109.12,percent of total billed charges,Lab and Radiology,96.8,83,,96.8,percent of total billed charges,All Other,140.8,80,,140.8,percent of total billed charges,All Other,109.12,62,,109.12,percent of total billed charges,Lab and Radiology,140.8,80,,140.8,percent of total billed charges,All Other,123.2,70,,123.2,percent of total billed charges,All Other,114.4,65,,114.4,percent of total billed charges,Default if not in Fee Schedule,114.4,65,,114.4,percent of total billed charges,Default if not in Fee Schedule,438,,,438,Case Rate,,394,,,394,Case Rate,,438,,,438,Case Rate,,372,,,372,Case Rate,,34.6,,,34.6,Other,100% of Medicaid,34.6,,,34.6,Other,100% of Medicaid,34.6,,,34.6,Other,100% of Medicaid,34.6,,,34.6,Other,100% of Medicaid,77.85,,,77.85,Other,225% of Medicaid,52.94,,,52.94,Other,153% of Medicaid,77.85,,,77.85,Other,225% of Medicaid,48.44,,,48.44,Other,140% of Medicaid,77.85,,,77.85,Other,225% of Medicaid,89.97,,,89.97,Other,260% of Medicaid,112.11,,,112.11,Other,324% of Medicaid,74.39,,,74.39,Other,215% of Medicaid,74.39,,,74.39,Other,215% of Medicaid,43.25,,,43.25,Other,125% of Medicaid,34.6,438,
EEG CONT REC W/ VID EEG TECH,95700,CPT,,48095700,CDM,740,RC,,,both,,,940,695.6,,,695.6,Other,150% of Medicare + 9.63% HCRA Surcharge,423,45,,423,percent of total billed charges,Critical Access Hospital RCC factor,611,65,,611,percent of total billed charges,All Other,554.6,65,,554.6,percent of total billed charges,All Other,307.45,,,307.45,Fee Schedule,,307.45,,,307.45,Fee Schedule,,307.45,,,307.45,Fee Schedule,,465.3,,,465.3,Other,110% of Medicare,639.2,68,,639.2,percent of total billed charges,All Other,273,,,273,Other,186% of Medicaid,752,80,,752,percent of total billed charges,All Other,780.2,83,,780.2,percent of total billed charges,All Other,780.2,83,,780.2,percent of total billed charges,All Other,752,80,,752,percent of total billed charges,All Other,780.2,83,,780.2,percent of total billed charges,All Other,752,80,,752,percent of total billed charges,All Other,658,70,,658,percent of total billed charges,All Other,611,65,,611,percent of total billed charges,Default if not in Fee Schedule,611,65,,611,percent of total billed charges,Default if not in Fee Schedule,906,,,906,Case Rate,,816,,,816,Case Rate,,906,,,906,Case Rate,,770,,,770,Case Rate,,146.84,,,146.84,Other,100% of Medicaid,146.84,,,146.84,Other,100% of Medicaid,146.84,,,146.84,Other,100% of Medicaid,146.84,,,146.84,Other,100% of Medicaid,330.39,,,330.39,Other,225% of Medicaid,224.66,,,224.66,Other,153% of Medicaid,330.39,,,330.39,Other,225% of Medicaid,205.57,,,205.57,Other,140% of Medicaid,330.39,,,330.39,Other,225% of Medicaid,381.78,,,381.78,Other,260% of Medicaid,475.76,,,475.76,Other,324% of Medicaid,315.7,,,315.7,Other,215% of Medicaid,315.7,,,315.7,Other,215% of Medicaid,183.55,,,183.55,Other,125% of Medicaid,146.84,906,
EEG W/O VID 2-12 HR UNMNTR,95705,CPT,,48095705,CDM,740,RC,,,both,,,940,695.6,,,695.6,Other,150% of Medicare + 9.63% HCRA Surcharge,423,45,,423,percent of total billed charges,Critical Access Hospital RCC factor,611,65,,611,percent of total billed charges,All Other,554.6,65,,554.6,percent of total billed charges,All Other,550.28,,,550.28,Fee Schedule,,550.28,,,550.28,Fee Schedule,,550.28,,,550.28,Fee Schedule,,465.3,,,465.3,Other,110% of Medicare,639.2,68,,639.2,percent of total billed charges,All Other,273,,,273,Other,186% of Medicaid,752,80,,752,percent of total billed charges,All Other,780.2,83,,780.2,percent of total billed charges,All Other,780.2,83,,780.2,percent of total billed charges,All Other,752,80,,752,percent of total billed charges,All Other,780.2,83,,780.2,percent of total billed charges,All Other,752,80,,752,percent of total billed charges,All Other,658,70,,658,percent of total billed charges,All Other,611,65,,611,percent of total billed charges,Default if not in Fee Schedule,611,65,,611,percent of total billed charges,Default if not in Fee Schedule,906,,,906,Case Rate,,816,,,816,Case Rate,,906,,,906,Case Rate,,770,,,770,Case Rate,,146.84,,,146.84,Other,100% of Medicaid,146.84,,,146.84,Other,100% of Medicaid,146.84,,,146.84,Other,100% of Medicaid,146.84,,,146.84,Other,100% of Medicaid,330.39,,,330.39,Other,225% of Medicaid,224.66,,,224.66,Other,153% of Medicaid,330.39,,,330.39,Other,225% of Medicaid,205.57,,,205.57,Other,140% of Medicaid,330.39,,,330.39,Other,225% of Medicaid,381.78,,,381.78,Other,260% of Medicaid,475.76,,,475.76,Other,324% of Medicaid,315.7,,,315.7,Other,215% of Medicaid,315.7,,,315.7,Other,215% of Medicaid,183.55,,,183.55,Other,125% of Medicaid,146.84,906,
EEG W/O VID 2-12 HR INTMT MNTR,95706,CPT,,48095706,CDM,740,RC,,,both,,,878,649.72,,,649.72,Other,150% of Medicare + 9.63% HCRA Surcharge,395.1,45,,395.1,percent of total billed charges,Critical Access Hospital RCC factor,570.7,65,,570.7,percent of total billed charges,All Other,518.02,65,,518.02,percent of total billed charges,All Other,671.67,76.5,,671.67,percent of total billed charges,All Other,623.38,69,,623.38,percent of total billed charges,All Other,605.82,65,,605.82,percent of total billed charges,All Other,434.61,,,434.61,Other,110% of Medicare,597.04,68,,597.04,percent of total billed charges,All Other,273,,,273,Other,186% of Medicaid,702.4,80,,702.4,percent of total billed charges,All Other,728.74,83,,728.74,percent of total billed charges,All Other,728.74,83,,728.74,percent of total billed charges,All Other,702.4,80,,702.4,percent of total billed charges,All Other,728.74,83,,728.74,percent of total billed charges,All Other,702.4,80,,702.4,percent of total billed charges,All Other,614.6,70,,614.6,percent of total billed charges,All Other,570.7,65,,570.7,percent of total billed charges,Default if not in Fee Schedule,570.7,65,,570.7,percent of total billed charges,Default if not in Fee Schedule,906,,,906,Case Rate,,816,,,816,Case Rate,,906,,,906,Case Rate,,770,,,770,Case Rate,,146.84,,,146.84,Other,100% of Medicaid,146.84,,,146.84,Other,100% of Medicaid,146.84,,,146.84,Other,100% of Medicaid,146.84,,,146.84,Other,100% of Medicaid,330.39,,,330.39,Other,225% of Medicaid,224.66,,,224.66,Other,153% of Medicaid,330.39,,,330.39,Other,225% of Medicaid,205.57,,,205.57,Other,140% of Medicaid,330.39,,,330.39,Other,225% of Medicaid,381.78,,,381.78,Other,260% of Medicaid,475.76,,,475.76,Other,324% of Medicaid,315.7,,,315.7,Other,215% of Medicaid,315.7,,,315.7,Other,215% of Medicaid,183.55,,,183.55,Other,125% of Medicaid,146.84,906,
EEG W/O VID 2-12 HR CONT MNTR,95707,CPT,,48095707,CDM,740,RC,,,both,,,878,649.72,,,649.72,Other,150% of Medicare + 9.63% HCRA Surcharge,395.1,45,,395.1,percent of total billed charges,Critical Access Hospital RCC factor,570.7,65,,570.7,percent of total billed charges,All Other,518.02,65,,518.02,percent of total billed charges,All Other,671.67,76.5,,671.67,percent of total billed charges,All Other,623.38,69,,623.38,percent of total billed charges,All Other,605.82,65,,605.82,percent of total billed charges,All Other,434.61,,,434.61,Other,110% of Medicare,597.04,68,,597.04,percent of total billed charges,All Other,273,,,273,Other,186% of Medicaid,702.4,80,,702.4,percent of total billed charges,All Other,544.36,62,,544.36,percent of total billed charges,Lab and Radiology,482.9,83,,482.9,percent of total billed charges,All Other,702.4,80,,702.4,percent of total billed charges,All Other,544.36,62,,544.36,percent of total billed charges,Lab and Radiology,702.4,80,,702.4,percent of total billed charges,All Other,614.6,70,,614.6,percent of total billed charges,All Other,570.7,65,,570.7,percent of total billed charges,Default if not in Fee Schedule,570.7,65,,570.7,percent of total billed charges,Default if not in Fee Schedule,906,,,906,Case Rate,,816,,,816,Case Rate,,906,,,906,Case Rate,,770,,,770,Case Rate,,146.84,,,146.84,Other,100% of Medicaid,146.84,,,146.84,Other,100% of Medicaid,146.84,,,146.84,Other,100% of Medicaid,146.84,,,146.84,Other,100% of Medicaid,330.39,,,330.39,Other,225% of Medicaid,224.66,,,224.66,Other,153% of Medicaid,330.39,,,330.39,Other,225% of Medicaid,205.57,,,205.57,Other,140% of Medicaid,330.39,,,330.39,Other,225% of Medicaid,381.78,,,381.78,Other,260% of Medicaid,475.76,,,475.76,Other,324% of Medicaid,315.7,,,315.7,Other,215% of Medicaid,315.7,,,315.7,Other,215% of Medicaid,183.55,,,183.55,Other,125% of Medicaid,146.84,906,
EEG W/O VID EA 12-26 HR UNMNTR,95708,CPT,,48095708,CDM,740,RC,,,both,,,1805,1335.7,,,1335.7,Other,150% of Medicare + 9.63% HCRA Surcharge,812.25,45,,812.25,percent of total billed charges,Critical Access Hospital RCC factor,1173.25,65,,1173.25,percent of total billed charges,All Other,1064.95,65,,1064.95,percent of total billed charges,All Other,550.28,,,550.28,Fee Schedule,,550.28,,,550.28,Fee Schedule,,550.28,,,550.28,Fee Schedule,,893.48,,,893.48,Other,110% of Medicare,1227.4,68,,1227.4,percent of total billed charges,All Other,495,,,495,Other,186% of Medicaid,1444,80,,1444,percent of total billed charges,All Other,1498.15,83,,1498.15,percent of total billed charges,All Other,1498.15,83,,1498.15,percent of total billed charges,All Other,1444,80,,1444,percent of total billed charges,All Other,1498.15,83,,1498.15,percent of total billed charges,All Other,1444,80,,1444,percent of total billed charges,All Other,1263.5,70,,1263.5,percent of total billed charges,All Other,1173.25,65,,1173.25,percent of total billed charges,Default if not in Fee Schedule,1173.25,65,,1173.25,percent of total billed charges,Default if not in Fee Schedule,906,,,906,Case Rate,,816,,,816,Case Rate,,906,,,906,Case Rate,,770,,,770,Case Rate,,265.87,,,265.87,Other,100% of Medicaid,265.87,,,265.87,Other,100% of Medicaid,265.87,,,265.87,Other,100% of Medicaid,265.87,,,265.87,Other,100% of Medicaid,598.21,,,598.21,Other,225% of Medicaid,406.78,,,406.78,Other,153% of Medicaid,598.21,,,598.21,Other,225% of Medicaid,372.22,,,372.22,Other,140% of Medicaid,598.21,,,598.21,Other,225% of Medicaid,691.27,,,691.27,Other,260% of Medicaid,861.42,,,861.42,Other,324% of Medicaid,571.62,,,571.62,Other,215% of Medicaid,571.62,,,571.62,Other,215% of Medicaid,332.34,,,332.34,Other,125% of Medicaid,265.87,1498.15,
EEG W/O VID EA 12-26 HR INTMT,95709,CPT,,48095709,CDM,740,RC,,,both,,,1686,1247.64,,,1247.64,Other,150% of Medicare + 9.63% HCRA Surcharge,758.7,45,,758.7,percent of total billed charges,Critical Access Hospital RCC factor,1095.9,65,,1095.9,percent of total billed charges,All Other,994.74,65,,994.74,percent of total billed charges,All Other,1289.79,76.5,,1289.79,percent of total billed charges,All Other,1197.06,69,,1197.06,percent of total billed charges,All Other,1163.34,65,,1163.34,percent of total billed charges,All Other,834.57,,,834.57,Other,110% of Medicare,1146.48,68,,1146.48,percent of total billed charges,All Other,495,,,495,Other,186% of Medicaid,1348.8,80,,1348.8,percent of total billed charges,All Other,1399.38,83,,1399.38,percent of total billed charges,All Other,1399.38,83,,1399.38,percent of total billed charges,All Other,1348.8,80,,1348.8,percent of total billed charges,All Other,1399.38,83,,1399.38,percent of total billed charges,All Other,1348.8,80,,1348.8,percent of total billed charges,All Other,1180.2,70,,1180.2,percent of total billed charges,All Other,1095.9,65,,1095.9,percent of total billed charges,Default if not in Fee Schedule,1095.9,65,,1095.9,percent of total billed charges,Default if not in Fee Schedule,906,,,906,Case Rate,,816,,,816,Case Rate,,906,,,906,Case Rate,,770,,,770,Case Rate,,265.87,,,265.87,Other,100% of Medicaid,265.87,,,265.87,Other,100% of Medicaid,265.87,,,265.87,Other,100% of Medicaid,265.87,,,265.87,Other,100% of Medicaid,598.21,,,598.21,Other,225% of Medicaid,406.78,,,406.78,Other,153% of Medicaid,598.21,,,598.21,Other,225% of Medicaid,372.22,,,372.22,Other,140% of Medicaid,598.21,,,598.21,Other,225% of Medicaid,691.27,,,691.27,Other,260% of Medicaid,861.42,,,861.42,Other,324% of Medicaid,571.62,,,571.62,Other,215% of Medicaid,571.62,,,571.62,Other,215% of Medicaid,332.34,,,332.34,Other,125% of Medicaid,265.87,1399.38,
EEG W/O VID EA 12-26 HR CONT,95710,CPT,,48095710,CDM,740,RC,,,both,,,1686,1247.64,,,1247.64,Other,150% of Medicare + 9.63% HCRA Surcharge,758.7,45,,758.7,percent of total billed charges,Critical Access Hospital RCC factor,1095.9,65,,1095.9,percent of total billed charges,All Other,994.74,65,,994.74,percent of total billed charges,All Other,253.03,,,253.03,Fee Schedule,,253.03,,,253.03,Fee Schedule,,253.03,,,253.03,Fee Schedule,,834.57,,,834.57,Other,110% of Medicare,1146.48,68,,1146.48,percent of total billed charges,All Other,495,,,495,Other,186% of Medicaid,1348.8,80,,1348.8,percent of total billed charges,All Other,1045.32,62,,1045.32,percent of total billed charges,Lab and Radiology,927.3,83,,927.3,percent of total billed charges,All Other,1348.8,80,,1348.8,percent of total billed charges,All Other,1045.32,62,,1045.32,percent of total billed charges,Lab and Radiology,1348.8,80,,1348.8,percent of total billed charges,All Other,1180.2,70,,1180.2,percent of total billed charges,All Other,1095.9,65,,1095.9,percent of total billed charges,Default if not in Fee Schedule,1095.9,65,,1095.9,percent of total billed charges,Default if not in Fee Schedule,906,,,906,Case Rate,,816,,,816,Case Rate,,906,,,906,Case Rate,,770,,,770,Case Rate,,265.87,,,265.87,Other,100% of Medicaid,265.87,,,265.87,Other,100% of Medicaid,265.87,,,265.87,Other,100% of Medicaid,265.87,,,265.87,Other,100% of Medicaid,598.21,,,598.21,Other,225% of Medicaid,406.78,,,406.78,Other,153% of Medicaid,598.21,,,598.21,Other,225% of Medicaid,372.22,,,372.22,Other,140% of Medicaid,598.21,,,598.21,Other,225% of Medicaid,691.27,,,691.27,Other,260% of Medicaid,861.42,,,861.42,Other,324% of Medicaid,571.62,,,571.62,Other,215% of Medicaid,571.62,,,571.62,Other,215% of Medicaid,332.34,,,332.34,Other,125% of Medicaid,253.03,1348.8,
VEEG 2-12 HR UNMONITORED,95711,CPT,,48095711,CDM,740,RC,,,both,,,878,649.72,,,649.72,Other,150% of Medicare + 9.63% HCRA Surcharge,395.1,45,,395.1,percent of total billed charges,Critical Access Hospital RCC factor,570.7,65,,570.7,percent of total billed charges,All Other,518.02,65,,518.02,percent of total billed charges,All Other,550.28,,,550.28,Fee Schedule,,550.28,,,550.28,Fee Schedule,,550.28,,,550.28,Fee Schedule,,434.61,,,434.61,Other,110% of Medicare,597.04,68,,597.04,percent of total billed charges,All Other,273,,,273,Other,186% of Medicaid,702.4,80,,702.4,percent of total billed charges,All Other,544.36,62,,544.36,percent of total billed charges,Lab and Radiology,482.9,83,,482.9,percent of total billed charges,All Other,702.4,80,,702.4,percent of total billed charges,All Other,544.36,62,,544.36,percent of total billed charges,Lab and Radiology,702.4,80,,702.4,percent of total billed charges,All Other,614.6,70,,614.6,percent of total billed charges,All Other,570.7,65,,570.7,percent of total billed charges,Default if not in Fee Schedule,570.7,65,,570.7,percent of total billed charges,Default if not in Fee Schedule,906,,,906,Case Rate,,816,,,816,Case Rate,,906,,,906,Case Rate,,770,,,770,Case Rate,,146.84,,,146.84,Other,100% of Medicaid,146.84,,,146.84,Other,100% of Medicaid,146.84,,,146.84,Other,100% of Medicaid,146.84,,,146.84,Other,100% of Medicaid,330.39,,,330.39,Other,225% of Medicaid,224.66,,,224.66,Other,153% of Medicaid,330.39,,,330.39,Other,225% of Medicaid,205.57,,,205.57,Other,140% of Medicaid,330.39,,,330.39,Other,225% of Medicaid,381.78,,,381.78,Other,260% of Medicaid,475.76,,,475.76,Other,324% of Medicaid,315.7,,,315.7,Other,215% of Medicaid,315.7,,,315.7,Other,215% of Medicaid,183.55,,,183.55,Other,125% of Medicaid,146.84,906,
VEEG 2-12 HR INTMT MNTR,95712,CPT,,48095712,CDM,740,RC,,,both,,,940,695.6,,,695.6,Other,150% of Medicare + 9.63% HCRA Surcharge,423,45,,423,percent of total billed charges,Critical Access Hospital RCC factor,611,65,,611,percent of total billed charges,All Other,554.6,65,,554.6,percent of total billed charges,All Other,550.28,,,550.28,Fee Schedule,,550.28,,,550.28,Fee Schedule,,550.28,,,550.28,Fee Schedule,,465.3,,,465.3,Other,110% of Medicare,639.2,68,,639.2,percent of total billed charges,All Other,273,,,273,Other,186% of Medicaid,752,80,,752,percent of total billed charges,All Other,780.2,83,,780.2,percent of total billed charges,All Other,780.2,83,,780.2,percent of total billed charges,All Other,752,80,,752,percent of total billed charges,All Other,780.2,83,,780.2,percent of total billed charges,All Other,752,80,,752,percent of total billed charges,All Other,658,70,,658,percent of total billed charges,All Other,611,65,,611,percent of total billed charges,Default if not in Fee Schedule,611,65,,611,percent of total billed charges,Default if not in Fee Schedule,906,,,906,Case Rate,,816,,,816,Case Rate,,906,,,906,Case Rate,,770,,,770,Case Rate,,146.84,,,146.84,Other,100% of Medicaid,146.84,,,146.84,Other,100% of Medicaid,146.84,,,146.84,Other,100% of Medicaid,146.84,,,146.84,Other,100% of Medicaid,330.39,,,330.39,Other,225% of Medicaid,224.66,,,224.66,Other,153% of Medicaid,330.39,,,330.39,Other,225% of Medicaid,205.57,,,205.57,Other,140% of Medicaid,330.39,,,330.39,Other,225% of Medicaid,381.78,,,381.78,Other,260% of Medicaid,475.76,,,475.76,Other,324% of Medicaid,315.7,,,315.7,Other,215% of Medicaid,315.7,,,315.7,Other,215% of Medicaid,183.55,,,183.55,Other,125% of Medicaid,146.84,906,
VEEG 2-12 HR CONT MNTR,95713,CPT,,48095713,CDM,740,RC,,,both,,,1686,1247.64,,,1247.64,Other,150% of Medicare + 9.63% HCRA Surcharge,758.7,45,,758.7,percent of total billed charges,Critical Access Hospital RCC factor,1095.9,65,,1095.9,percent of total billed charges,All Other,994.74,65,,994.74,percent of total billed charges,All Other,550.28,,,550.28,Fee Schedule,,550.28,,,550.28,Fee Schedule,,550.28,,,550.28,Fee Schedule,,834.57,,,834.57,Other,110% of Medicare,1146.48,68,,1146.48,percent of total billed charges,All Other,273,,,273,Other,186% of Medicaid,1348.8,80,,1348.8,percent of total billed charges,All Other,1399.38,83,,1399.38,percent of total billed charges,All Other,1399.38,83,,1399.38,percent of total billed charges,All Other,1348.8,80,,1348.8,percent of total billed charges,All Other,1399.38,83,,1399.38,percent of total billed charges,All Other,1348.8,80,,1348.8,percent of total billed charges,All Other,1180.2,70,,1180.2,percent of total billed charges,All Other,1095.9,65,,1095.9,percent of total billed charges,Default if not in Fee Schedule,1095.9,65,,1095.9,percent of total billed charges,Default if not in Fee Schedule,906,,,906,Case Rate,,816,,,816,Case Rate,,906,,,906,Case Rate,,770,,,770,Case Rate,,146.84,,,146.84,Other,100% of Medicaid,146.84,,,146.84,Other,100% of Medicaid,146.84,,,146.84,Other,100% of Medicaid,146.84,,,146.84,Other,100% of Medicaid,330.39,,,330.39,Other,225% of Medicaid,224.66,,,224.66,Other,153% of Medicaid,330.39,,,330.39,Other,225% of Medicaid,205.57,,,205.57,Other,140% of Medicaid,330.39,,,330.39,Other,225% of Medicaid,381.78,,,381.78,Other,260% of Medicaid,475.76,,,475.76,Other,324% of Medicaid,315.7,,,315.7,Other,215% of Medicaid,315.7,,,315.7,Other,215% of Medicaid,183.55,,,183.55,Other,125% of Medicaid,146.84,1399.38,
VEEG EA 12-26 HR UNMNTR,95714,CPT,,48095714,CDM,740,RC,,,both,,,1686,1247.64,,,1247.64,Other,150% of Medicare + 9.63% HCRA Surcharge,758.7,45,,758.7,percent of total billed charges,Critical Access Hospital RCC factor,1095.9,65,,1095.9,percent of total billed charges,All Other,994.74,65,,994.74,percent of total billed charges,All Other,260.82,,,260.82,Fee Schedule,,260.82,,,260.82,Fee Schedule,,260.82,,,260.82,Fee Schedule,,834.57,,,834.57,Other,110% of Medicare,1146.48,68,,1146.48,percent of total billed charges,All Other,495,,,495,Other,186% of Medicaid,1348.8,80,,1348.8,percent of total billed charges,All Other,1045.32,62,,1045.32,percent of total billed charges,Lab and Radiology,927.3,83,,927.3,percent of total billed charges,All Other,1348.8,80,,1348.8,percent of total billed charges,All Other,1045.32,62,,1045.32,percent of total billed charges,Lab and Radiology,1348.8,80,,1348.8,percent of total billed charges,All Other,1180.2,70,,1180.2,percent of total billed charges,All Other,1095.9,65,,1095.9,percent of total billed charges,Default if not in Fee Schedule,1095.9,65,,1095.9,percent of total billed charges,Default if not in Fee Schedule,906,,,906,Case Rate,,816,,,816,Case Rate,,906,,,906,Case Rate,,770,,,770,Case Rate,,265.87,,,265.87,Other,100% of Medicaid,265.87,,,265.87,Other,100% of Medicaid,265.87,,,265.87,Other,100% of Medicaid,265.87,,,265.87,Other,100% of Medicaid,598.21,,,598.21,Other,225% of Medicaid,406.78,,,406.78,Other,153% of Medicaid,598.21,,,598.21,Other,225% of Medicaid,372.22,,,372.22,Other,140% of Medicaid,598.21,,,598.21,Other,225% of Medicaid,691.27,,,691.27,Other,260% of Medicaid,861.42,,,861.42,Other,324% of Medicaid,571.62,,,571.62,Other,215% of Medicaid,571.62,,,571.62,Other,215% of Medicaid,332.34,,,332.34,Other,125% of Medicaid,260.82,1348.8,
VEEG EA 12-26 HR INTMT MNTR,95715,CPT,,48095715,CDM,740,RC,,,both,,,1805,1335.7,,,1335.7,Other,150% of Medicare + 9.63% HCRA Surcharge,812.25,45,,812.25,percent of total billed charges,Critical Access Hospital RCC factor,1173.25,65,,1173.25,percent of total billed charges,All Other,1064.95,65,,1064.95,percent of total billed charges,All Other,1361.61,,,1361.61,Fee Schedule,,1361.61,,,1361.61,Fee Schedule,,1361.61,,,1361.61,Fee Schedule,,893.48,,,893.48,Other,110% of Medicare,1227.4,68,,1227.4,percent of total billed charges,All Other,495,,,495,Other,186% of Medicaid,1444,80,,1444,percent of total billed charges,All Other,1498.15,83,,1498.15,percent of total billed charges,All Other,1498.15,83,,1498.15,percent of total billed charges,All Other,1444,80,,1444,percent of total billed charges,All Other,1498.15,83,,1498.15,percent of total billed charges,All Other,1444,80,,1444,percent of total billed charges,All Other,1263.5,70,,1263.5,percent of total billed charges,All Other,1173.25,65,,1173.25,percent of total billed charges,Default if not in Fee Schedule,1173.25,65,,1173.25,percent of total billed charges,Default if not in Fee Schedule,906,,,906,Case Rate,,816,,,816,Case Rate,,906,,,906,Case Rate,,770,,,770,Case Rate,,265.87,,,265.87,Other,100% of Medicaid,265.87,,,265.87,Other,100% of Medicaid,265.87,,,265.87,Other,100% of Medicaid,265.87,,,265.87,Other,100% of Medicaid,598.21,,,598.21,Other,225% of Medicaid,406.78,,,406.78,Other,153% of Medicaid,598.21,,,598.21,Other,225% of Medicaid,372.22,,,372.22,Other,140% of Medicaid,598.21,,,598.21,Other,225% of Medicaid,691.27,,,691.27,Other,260% of Medicaid,861.42,,,861.42,Other,324% of Medicaid,571.62,,,571.62,Other,215% of Medicaid,571.62,,,571.62,Other,215% of Medicaid,332.34,,,332.34,Other,125% of Medicaid,265.87,1498.15,
VEEG EA 12-26 HR CONT MNTR,95716,CPT,,48095716,CDM,740,RC,,,both,,,3154,2333.97,,,2333.97,Other,150% of Medicare + 9.63% HCRA Surcharge,1419.3,45,,1419.3,percent of total billed charges,Critical Access Hospital RCC factor,2050.1,65,,2050.1,percent of total billed charges,All Other,1860.86,65,,1860.86,percent of total billed charges,All Other,1361.61,,,1361.61,Fee Schedule,,1361.61,,,1361.61,Fee Schedule,,1361.61,,,1361.61,Fee Schedule,,1561.23,,,1561.23,Other,110% of Medicare,2144.72,68,,2144.72,percent of total billed charges,All Other,495,,,495,Other,186% of Medicaid,2523.2,80,,2523.2,percent of total billed charges,All Other,2617.82,83,,2617.82,percent of total billed charges,All Other,2617.82,83,,2617.82,percent of total billed charges,All Other,2523.2,80,,2523.2,percent of total billed charges,All Other,2617.82,83,,2617.82,percent of total billed charges,All Other,2523.2,80,,2523.2,percent of total billed charges,All Other,2207.8,70,,2207.8,percent of total billed charges,All Other,2050.1,65,,2050.1,percent of total billed charges,Default if not in Fee Schedule,2050.1,65,,2050.1,percent of total billed charges,Default if not in Fee Schedule,906,,,906,Case Rate,,816,,,816,Case Rate,,906,,,906,Case Rate,,770,,,770,Case Rate,,265.87,,,265.87,Other,100% of Medicaid,265.87,,,265.87,Other,100% of Medicaid,265.87,,,265.87,Other,100% of Medicaid,265.87,,,265.87,Other,100% of Medicaid,598.21,,,598.21,Other,225% of Medicaid,406.78,,,406.78,Other,153% of Medicaid,598.21,,,598.21,Other,225% of Medicaid,372.22,,,372.22,Other,140% of Medicaid,598.21,,,598.21,Other,225% of Medicaid,691.27,,,691.27,Other,260% of Medicaid,861.42,,,861.42,Other,324% of Medicaid,571.62,,,571.62,Other,215% of Medicaid,571.62,,,571.62,Other,215% of Medicaid,332.34,,,332.34,Other,125% of Medicaid,265.87,2617.82,
EEG 41-60 MINUTES,95812,CPT,TC,53095812,CDM,740,RC,,,both,,,966,714.84,,,714.84,Other,150% of Medicare + 9.63% HCRA Surcharge,434.7,45,,434.7,percent of total billed charges,Critical Access Hospital RCC factor,946.12,,,946.12,Fee Schedule,,853.12,,,853.12,Fee Schedule,,1757.76,,,1757.76,Fee Schedule,,1580.98,,,1580.98,Fee Schedule,,1494.26,,,1494.26,Fee Schedule,,478.17,,,478.17,Other,110% of Medicare,1215.53,,,1215.53,Fee Schedule,,495,,,495,Other,186% of Medicaid,1430.41,,,1430.41,Fee Schedule,,598.92,,,598.92,Fee Schedule,,673.51,,,673.51,Fee Schedule,,1430.41,,,1430.41,Fee Schedule,,598.92,,,598.92,Fee Schedule,,772.8,80,,772.8,percent of total billed charges,All Other,676.2,70,,676.2,percent of total billed charges,All Other,1413.68,,,1413.68,Fee Schedule,,1198.18,,,1198.18,Fee Schedule,,906,,,906,Case Rate,,816,,,816,Case Rate,,906,,,906,Case Rate,,770,,,770,Case Rate,,265.87,,,265.87,Other,100% of Medicaid,265.87,,,265.87,Other,100% of Medicaid,265.87,,,265.87,Other,100% of Medicaid,265.87,,,265.87,Other,100% of Medicaid,598.21,,,598.21,Other,225% of Medicaid,406.78,,,406.78,Other,153% of Medicaid,598.21,,,598.21,Other,225% of Medicaid,372.22,,,372.22,Other,140% of Medicaid,598.21,,,598.21,Other,225% of Medicaid,691.27,,,691.27,Other,260% of Medicaid,861.42,,,861.42,Other,324% of Medicaid,571.62,,,571.62,Other,215% of Medicaid,571.62,,,571.62,Other,215% of Medicaid,332.34,,,332.34,Other,125% of Medicaid,265.87,1757.76,
EEG OVER 1 HOUR,95813,CPT,TC,53095813,CDM,740,RC,,,both,,,1083,801.42,,,801.42,Other,150% of Medicare + 9.63% HCRA Surcharge,487.35,45,,487.35,percent of total billed charges,Critical Access Hospital RCC factor,1152.48,,,1152.48,Fee Schedule,,1039.18,,,1039.18,Fee Schedule,,1810.46,,,1810.46,Fee Schedule,,1628.38,,,1628.38,Fee Schedule,,1539.06,,,1539.06,Fee Schedule,,536.09,,,536.09,Other,110% of Medicare,1480.64,,,1480.64,Fee Schedule,,495,,,495,Other,186% of Medicaid,1742.39,,,1742.39,Fee Schedule,,671.46,,,671.46,Fee Schedule,,820.41,,,820.41,Fee Schedule,,1742.39,,,1742.39,Fee Schedule,,671.46,,,671.46,Fee Schedule,,866.4,80,,866.4,percent of total billed charges,All Other,758.1,70,,758.1,percent of total billed charges,All Other,1671.16,,,1671.16,Fee Schedule,,1416.41,,,1416.41,Fee Schedule,,906,,,906,Case Rate,,816,,,816,Case Rate,,906,,,906,Case Rate,,770,,,770,Case Rate,,265.87,,,265.87,Other,100% of Medicaid,265.87,,,265.87,Other,100% of Medicaid,265.87,,,265.87,Other,100% of Medicaid,265.87,,,265.87,Other,100% of Medicaid,598.21,,,598.21,Other,225% of Medicaid,406.78,,,406.78,Other,153% of Medicaid,598.21,,,598.21,Other,225% of Medicaid,372.22,,,372.22,Other,140% of Medicaid,598.21,,,598.21,Other,225% of Medicaid,691.27,,,691.27,Other,260% of Medicaid,861.42,,,861.42,Other,324% of Medicaid,571.62,,,571.62,Other,215% of Medicaid,571.62,,,571.62,Other,215% of Medicaid,332.34,,,332.34,Other,125% of Medicaid,265.87,1810.46,
EEG AWAKE AND DROWSY,95816,CPT,TC,53095816,CDM,740,RC,,,both,,,1711,1266.14,,,1266.14,Other,150% of Medicare + 9.63% HCRA Surcharge,769.95,45,,769.95,percent of total billed charges,Critical Access Hospital RCC factor,1088.37,,,1088.37,Fee Schedule,,981.38,,,981.38,Fee Schedule,,1597.55,,,1597.55,Fee Schedule,,1436.88,,,1436.88,Fee Schedule,,1358.07,,,1358.07,Fee Schedule,,846.95,,,846.95,Other,110% of Medicare,1398.28,,,1398.28,Fee Schedule,,273,,,273,Other,186% of Medicaid,1645.47,,,1645.47,Fee Schedule,,1060.82,,,1060.82,Fee Schedule,,774.77,,,774.77,Fee Schedule,,1645.47,,,1645.47,Fee Schedule,,1060.82,,,1060.82,Fee Schedule,,1368.8,80,,1368.8,percent of total billed charges,All Other,1197.7,70,,1197.7,percent of total billed charges,All Other,1587.52,,,1587.52,Fee Schedule,,1345.52,,,1345.52,Fee Schedule,,906,,,906,Case Rate,,816,,,816,Case Rate,,906,,,906,Case Rate,,770,,,770,Case Rate,,146.84,,,146.84,Other,100% of Medicaid,146.84,,,146.84,Other,100% of Medicaid,146.84,,,146.84,Other,100% of Medicaid,146.84,,,146.84,Other,100% of Medicaid,330.39,,,330.39,Other,225% of Medicaid,224.66,,,224.66,Other,153% of Medicaid,330.39,,,330.39,Other,225% of Medicaid,205.57,,,205.57,Other,140% of Medicaid,330.39,,,330.39,Other,225% of Medicaid,381.78,,,381.78,Other,260% of Medicaid,475.76,,,475.76,Other,324% of Medicaid,315.7,,,315.7,Other,215% of Medicaid,315.7,,,315.7,Other,215% of Medicaid,183.55,,,183.55,Other,125% of Medicaid,146.84,1645.47,
EEG AWAKE AND ASLEEP STUDY,95819,CPT,TC,53095819,CDM,740,RC,,,both,,,1597,1181.78,,,1181.78,Other,150% of Medicare + 9.63% HCRA Surcharge,718.65,45,,718.65,percent of total billed charges,Critical Access Hospital RCC factor,1280.83,,,1280.83,Fee Schedule,,1154.92,,,1154.92,Fee Schedule,,1826.37,,,1826.37,Fee Schedule,,1642.69,,,1642.69,Fee Schedule,,1552.59,,,1552.59,Fee Schedule,,790.52,,,790.52,Other,110% of Medicare,1645.54,,,1645.54,Fee Schedule,,273,,,273,Other,186% of Medicaid,1936.44,,,1936.44,Fee Schedule,,990.14,,,990.14,Fee Schedule,,911.78,,,911.78,Fee Schedule,,1936.44,,,1936.44,Fee Schedule,,990.14,,,990.14,Fee Schedule,,1277.6,80,,1277.6,percent of total billed charges,All Other,1117.9,70,,1117.9,percent of total billed charges,All Other,1908.96,,,1908.96,Fee Schedule,,1617.96,,,1617.96,Fee Schedule,,906,,,906,Case Rate,,816,,,816,Case Rate,,906,,,906,Case Rate,,770,,,770,Case Rate,,146.84,,,146.84,Other,100% of Medicaid,146.84,,,146.84,Other,100% of Medicaid,146.84,,,146.84,Other,100% of Medicaid,146.84,,,146.84,Other,100% of Medicaid,330.39,,,330.39,Other,225% of Medicaid,224.66,,,224.66,Other,153% of Medicaid,330.39,,,330.39,Other,225% of Medicaid,205.57,,,205.57,Other,140% of Medicaid,330.39,,,330.39,Other,225% of Medicaid,381.78,,,381.78,Other,260% of Medicaid,475.76,,,475.76,Other,324% of Medicaid,315.7,,,315.7,Other,215% of Medicaid,315.7,,,315.7,Other,215% of Medicaid,183.55,,,183.55,Other,125% of Medicaid,146.84,1936.44,
EEG COMA OR SLEEP ONLY,95822,CPT,TC,53095822,CDM,740,RC,,,both,,,850,629,,,629,Other,150% of Medicare + 9.63% HCRA Surcharge,382.5,45,,382.5,percent of total billed charges,Critical Access Hospital RCC factor,1147.11,,,1147.11,Fee Schedule,,1034.34,,,1034.34,Fee Schedule,,1684.5,,,1684.5,Fee Schedule,,1515.09,,,1515.09,Fee Schedule,,1431.99,,,1431.99,Fee Schedule,,420.75,,,420.75,Other,110% of Medicare,1473.74,,,1473.74,Fee Schedule,,273,,,273,Other,186% of Medicaid,1734.27,,,1734.27,Fee Schedule,,527,,,527,Fee Schedule,,816.59,,,816.59,Fee Schedule,,1734.27,,,1734.27,Fee Schedule,,527,,,527,Fee Schedule,,680,80,,680,percent of total billed charges,All Other,595,70,,595,percent of total billed charges,All Other,1753.16,,,1753.16,Fee Schedule,,1485.91,,,1485.91,Fee Schedule,,906,,,906,Case Rate,,816,,,816,Case Rate,,906,,,906,Case Rate,,770,,,770,Case Rate,,146.84,,,146.84,Other,100% of Medicaid,146.84,,,146.84,Other,100% of Medicaid,146.84,,,146.84,Other,100% of Medicaid,146.84,,,146.84,Other,100% of Medicaid,330.39,,,330.39,Other,225% of Medicaid,224.66,,,224.66,Other,153% of Medicaid,330.39,,,330.39,Other,225% of Medicaid,205.57,,,205.57,Other,140% of Medicaid,330.39,,,330.39,Other,225% of Medicaid,381.78,,,381.78,Other,260% of Medicaid,475.76,,,475.76,Other,324% of Medicaid,315.7,,,315.7,Other,215% of Medicaid,315.7,,,315.7,Other,215% of Medicaid,183.55,,,183.55,Other,125% of Medicaid,146.84,1753.16,
EEG; CEREBRAL SILENCE,95824,CPT,TC,53095824,CDM,740,RC,,,both,,,3139,2322.87,,,2322.87,Other,150% of Medicare + 9.63% HCRA Surcharge,1412.55,45,,1412.55,percent of total billed charges,Critical Access Hospital RCC factor,2040.35,65,,2040.35,percent of total billed charges,All Other,1852.01,65,,1852.01,percent of total billed charges,All Other,60.2,,,60.2,Fee Schedule,,60.2,,,60.2,Fee Schedule,,60.2,,,60.2,Fee Schedule,,1553.81,,,1553.81,Other,110% of Medicare,2134.52,68,,2134.52,percent of total billed charges,All Other,273,,,273,Other,186% of Medicaid,2511.2,80,,2511.2,percent of total billed charges,All Other,2605.37,83,,2605.37,percent of total billed charges,All Other,2605.37,83,,2605.37,percent of total billed charges,All Other,2511.2,80,,2511.2,percent of total billed charges,All Other,2605.37,83,,2605.37,percent of total billed charges,All Other,2511.2,80,,2511.2,percent of total billed charges,All Other,2197.3,70,,2197.3,percent of total billed charges,All Other,2040.35,65,,2040.35,percent of total billed charges,Default if not in Fee Schedule,2040.35,65,,2040.35,percent of total billed charges,Default if not in Fee Schedule,906,,,906,Case Rate,,816,,,816,Case Rate,,906,,,906,Case Rate,,770,,,770,Case Rate,,146.84,,,146.84,Other,100% of Medicaid,146.84,,,146.84,Other,100% of Medicaid,146.84,,,146.84,Other,100% of Medicaid,146.84,,,146.84,Other,100% of Medicaid,330.39,,,330.39,Other,225% of Medicaid,224.66,,,224.66,Other,153% of Medicaid,330.39,,,330.39,Other,225% of Medicaid,205.57,,,205.57,Other,140% of Medicaid,330.39,,,330.39,Other,225% of Medicaid,381.78,,,381.78,Other,260% of Medicaid,475.76,,,475.76,Other,324% of Medicaid,315.7,,,315.7,Other,215% of Medicaid,315.7,,,315.7,Other,215% of Medicaid,183.55,,,183.55,Other,125% of Medicaid,60.2,2605.37,
EEG AWAKE AND DROWSY LIMITED,95816,CPT,52TC,53195816,CDM,740,RC,,,both,,,1369,1013.06,,,1013.06,Other,150% of Medicare + 9.63% HCRA Surcharge,616.05,45,,616.05,percent of total billed charges,Critical Access Hospital RCC factor,1088.37,,,1088.37,Fee Schedule,,981.38,,,981.38,Fee Schedule,,1597.55,,,1597.55,Fee Schedule,,1436.88,,,1436.88,Fee Schedule,,1358.07,,,1358.07,Fee Schedule,,677.66,,,677.66,Other,110% of Medicare,1398.28,,,1398.28,Fee Schedule,,273,,,273,Other,186% of Medicaid,1645.47,,,1645.47,Fee Schedule,,848.78,,,848.78,Fee Schedule,,774.77,,,774.77,Fee Schedule,,1645.47,,,1645.47,Fee Schedule,,848.78,,,848.78,Fee Schedule,,1095.2,80,,1095.2,percent of total billed charges,All Other,958.3,70,,958.3,percent of total billed charges,All Other,1587.52,,,1587.52,Fee Schedule,,1345.52,,,1345.52,Fee Schedule,,906,,,906,Case Rate,,816,,,816,Case Rate,,906,,,906,Case Rate,,770,,,770,Case Rate,,146.84,,,146.84,Other,100% of Medicaid,146.84,,,146.84,Other,100% of Medicaid,146.84,,,146.84,Other,100% of Medicaid,146.84,,,146.84,Other,100% of Medicaid,330.39,,,330.39,Other,225% of Medicaid,224.66,,,224.66,Other,153% of Medicaid,330.39,,,330.39,Other,225% of Medicaid,205.57,,,205.57,Other,140% of Medicaid,330.39,,,330.39,Other,225% of Medicaid,381.78,,,381.78,Other,260% of Medicaid,475.76,,,475.76,Other,324% of Medicaid,315.7,,,315.7,Other,215% of Medicaid,315.7,,,315.7,Other,215% of Medicaid,183.55,,,183.55,Other,125% of Medicaid,146.84,1645.47,
SLEEP STUDY ATTENDED (PAP NAP),95807,CPT,52,72095807,CDM,740,RC,,,both,,,1790,1324.6,,,1324.6,Other,150% of Medicare + 9.63% HCRA Surcharge,805.5,45,,805.5,percent of total billed charges,Critical Access Hospital RCC factor,2882,,,2882,Case Rate,Sleep Study,2594,,,2594,Case Rate,Sleep Study,2740.14,,,2740.14,Fee Schedule,,2464.56,,,2464.56,Fee Schedule,,2329.38,,,2329.38,Fee Schedule,,886.05,,,886.05,Other,110% of Medicare,1217.2,68,,1217.2,percent of total billed charges,All Other,1316,,,1316,Other,186% of Medicaid,1432,80,,1432,percent of total billed charges,All Other,5564,,,5564,Case Rate,Sleep Study,5564,,,5564,Case Rate,Sleep Study,1432,80,,1432,percent of total billed charges,All Other,5564,,,5564,Case Rate,Sleep Study,1432,80,,1432,percent of total billed charges,All Other,1253,70,,1253,percent of total billed charges,All Other,1551.44,,,1551.44,Fee Schedule,,1314.94,,,1314.94,Fee Schedule,,3524,,,3524,Case Rate,Sleep Study,3171,,,3171,Case Rate,Sleep Study,3524,,,3524,Case Rate,Sleep Study,2995,,,2995,Case Rate,Sleep Study,707.27,,,707.27,Other,100% of Medicaid,707.27,,,707.27,Other,100% of Medicaid,707.27,,,707.27,Other,100% of Medicaid,707.27,,,707.27,Other,100% of Medicaid,1591.35,,,1591.35,Other,225% of Medicaid,1082.12,,,1082.12,Other,153% of Medicaid,1591.35,,,1591.35,Other,225% of Medicaid,990.17,,,990.17,Other,140% of Medicaid,1591.35,,,1591.35,Other,225% of Medicaid,1838.89,,,1838.89,Other,260% of Medicaid,2291.55,,,2291.55,Other,324% of Medicaid,1520.62,,,1520.62,Other,215% of Medicaid,1520.62,,,1520.62,Other,215% of Medicaid,884.08,,,884.08,Other,125% of Medicaid,707.27,5564,
UGI W BX SGL MULTIPLE,43249,CPT,,30043249,CDM,750,RC,,,both,,,3921,2901.55,,,2901.55,Other,150% of Medicare + 9.63% HCRA Surcharge,1764.45,45,,1764.45,percent of total billed charges,Critical Access Hospital RCC factor,2480,,,2480,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2232,,,2232,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3648,,,3648,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3283,,,3283,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3101,,,3101,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",1940.9,,,1940.9,Other,110% of Medicare,2666.28,,,2666.28,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1531,,,1531,Other,186% of Medicaid,3136.8,,,3136.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",3136.8,,,3136.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",4252,,,4252,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2744.7,70,,2744.7,percent of total billed charges,All Other,3387,,,3387,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",2879,,,2879,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",2744.7,70,,2744.7,percent of total billed charges,All Other,2744.7,70,,2744.7,percent of total billed charges,All Other,2744.7,70,,2744.7,percent of total billed charges,All Other,2744.7,70,,2744.7,percent of total billed charges,All Other,823.04,,,823.04,Other,100% of Medicaid,823.04,,,823.04,Other,100% of Medicaid,823.04,,,823.04,Other,100% of Medicaid,823.04,,,823.04,Other,100% of Medicaid,1851.85,,,1851.85,Other,225% of Medicaid,1259.26,,,1259.26,Other,153% of Medicaid,1851.85,,,1851.85,Other,225% of Medicaid,1152.26,,,1152.26,Other,140% of Medicaid,1851.85,,,1851.85,Other,225% of Medicaid,2139.92,,,2139.92,Other,260% of Medicaid,2666.66,,,2666.66,Other,324% of Medicaid,1769.55,,,1769.55,Other,215% of Medicaid,1769.55,,,1769.55,Other,215% of Medicaid,1028.81,,,1028.81,Other,125% of Medicaid,823.04,7216,
UGI BALLOON DIL ESOPH - < 30 MM DIA,43249,CPT,,34043249,CDM,750,RC,,,both,,,3921,2901.55,,,2901.55,Other,150% of Medicare + 9.63% HCRA Surcharge,1764.45,45,,1764.45,percent of total billed charges,Critical Access Hospital RCC factor,2480,,,2480,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2232,,,2232,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3648,,,3648,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3283,,,3283,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3101,,,3101,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",1940.9,,,1940.9,Other,110% of Medicare,2666.28,,,2666.28,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1531,,,1531,Other,186% of Medicaid,3136.8,,,3136.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",3136.8,,,3136.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",4252,,,4252,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2744.7,70,,2744.7,percent of total billed charges,All Other,3387,,,3387,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",2879,,,2879,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",2744.7,70,,2744.7,percent of total billed charges,All Other,2744.7,70,,2744.7,percent of total billed charges,All Other,2744.7,70,,2744.7,percent of total billed charges,All Other,2744.7,70,,2744.7,percent of total billed charges,All Other,823.04,,,823.04,Other,100% of Medicaid,823.04,,,823.04,Other,100% of Medicaid,823.04,,,823.04,Other,100% of Medicaid,823.04,,,823.04,Other,100% of Medicaid,1851.85,,,1851.85,Other,225% of Medicaid,1259.26,,,1259.26,Other,153% of Medicaid,1851.85,,,1851.85,Other,225% of Medicaid,1152.26,,,1152.26,Other,140% of Medicaid,1851.85,,,1851.85,Other,225% of Medicaid,2139.92,,,2139.92,Other,260% of Medicaid,2666.66,,,2666.66,Other,324% of Medicaid,1769.55,,,1769.55,Other,215% of Medicaid,1769.55,,,1769.55,Other,215% of Medicaid,1028.81,,,1028.81,Other,125% of Medicaid,823.04,7216,
GI TRACT CAPSULE ENDOSCOPY,91110,CPT,,34091110,CDM,750,RC,,,both,,,3976,2942.25,,,2942.25,Other,150% of Medicare + 9.63% HCRA Surcharge,1789.2,45,,1789.2,percent of total billed charges,Critical Access Hospital RCC factor,2584.4,65,,2584.4,percent of total billed charges,All Other,2345.84,65,,2345.84,percent of total billed charges,All Other,4869.69,,,4869.69,Fee Schedule,,4379.95,,,4379.95,Fee Schedule,,4139.7,,,4139.7,Fee Schedule,,1968.12,,,1968.12,Other,110% of Medicare,2703.68,68,,2703.68,percent of total billed charges,All Other,770,,,770,Other,186% of Medicaid,3180.8,80,,3180.8,percent of total billed charges,All Other,3300.08,83,,3300.08,percent of total billed charges,All Other,3300.08,83,,3300.08,percent of total billed charges,All Other,3180.8,80,,3180.8,percent of total billed charges,All Other,3300.08,83,,3300.08,percent of total billed charges,All Other,3180.8,80,,3180.8,percent of total billed charges,All Other,2783.2,70,,2783.2,percent of total billed charges,All Other,3280,,,3280,Fee Schedule,,2780,,,2780,Fee Schedule,,2783.2,70,,2783.2,percent of total billed charges,All Other,2783.2,70,,2783.2,percent of total billed charges,All Other,2783.2,70,,2783.2,percent of total billed charges,All Other,2783.2,70,,2783.2,percent of total billed charges,All Other,414.16,,,414.16,Other,100% of Medicaid,414.16,,,414.16,Other,100% of Medicaid,414.16,,,414.16,Other,100% of Medicaid,414.16,,,414.16,Other,100% of Medicaid,931.85,,,931.85,Other,225% of Medicaid,633.66,,,633.66,Other,153% of Medicaid,931.85,,,931.85,Other,225% of Medicaid,579.82,,,579.82,Other,140% of Medicaid,931.85,,,931.85,Other,225% of Medicaid,1076.81,,,1076.81,Other,260% of Medicaid,1341.87,,,1341.87,Other,324% of Medicaid,890.44,,,890.44,Other,215% of Medicaid,890.44,,,890.44,Other,215% of Medicaid,517.7,,,517.7,Other,125% of Medicaid,414.16,4869.69,
G-ESOPH REFLUX W MUCOSAL PH,91035,CPT,,35091035,CDM,750,RC,,,both,,,1275,943.5,,,943.5,Other,150% of Medicare + 9.63% HCRA Surcharge,573.75,45,,573.75,percent of total billed charges,Critical Access Hospital RCC factor,4565,,,4565,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4109,,,4109,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2671.84,,,2671.84,Fee Schedule,,2405.17,,,2405.17,Fee Schedule,,2271.84,,,2271.84,Fee Schedule,,631.13,,,631.13,Other,110% of Medicare,867,,,867,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",770,,,770,Other,186% of Medicaid,1020,,,1020,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1020,,,1020,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1020,80,,1020,percent of total billed charges,All Other,892.5,70,,892.5,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",892.5,70,,892.5,percent of total billed charges,All Other,892.5,70,,892.5,percent of total billed charges,All Other,892.5,70,,892.5,percent of total billed charges,All Other,892.5,70,,892.5,percent of total billed charges,All Other,414.16,,,414.16,Other,100% of Medicaid,414.16,,,414.16,Other,100% of Medicaid,414.16,,,414.16,Other,100% of Medicaid,414.16,,,414.16,Other,100% of Medicaid,931.85,,,931.85,Other,225% of Medicaid,633.66,,,633.66,Other,153% of Medicaid,931.85,,,931.85,Other,225% of Medicaid,579.82,,,579.82,Other,140% of Medicaid,931.85,,,931.85,Other,225% of Medicaid,1076.81,,,1076.81,Other,260% of Medicaid,1341.87,,,1341.87,Other,324% of Medicaid,890.44,,,890.44,Other,215% of Medicaid,890.44,,,890.44,Other,215% of Medicaid,517.7,,,517.7,Other,125% of Medicaid,414.16,7216,
GI TRACT CAPSULE ENDOSCOPY,91110,CPT,,35091110,CDM,750,RC,,,both,,,3976,2942.25,,,2942.25,Other,150% of Medicare + 9.63% HCRA Surcharge,1789.2,45,,1789.2,percent of total billed charges,Critical Access Hospital RCC factor,2584.4,65,,2584.4,percent of total billed charges,All Other,2345.84,65,,2345.84,percent of total billed charges,All Other,4869.69,,,4869.69,Fee Schedule,,4379.95,,,4379.95,Fee Schedule,,4139.7,,,4139.7,Fee Schedule,,1968.12,,,1968.12,Other,110% of Medicare,2703.68,68,,2703.68,percent of total billed charges,All Other,770,,,770,Other,186% of Medicaid,3180.8,80,,3180.8,percent of total billed charges,All Other,3300.08,83,,3300.08,percent of total billed charges,All Other,3300.08,83,,3300.08,percent of total billed charges,All Other,3180.8,80,,3180.8,percent of total billed charges,All Other,3300.08,83,,3300.08,percent of total billed charges,All Other,3180.8,80,,3180.8,percent of total billed charges,All Other,2783.2,70,,2783.2,percent of total billed charges,All Other,3280,,,3280,Fee Schedule,,2780,,,2780,Fee Schedule,,2783.2,70,,2783.2,percent of total billed charges,All Other,2783.2,70,,2783.2,percent of total billed charges,All Other,2783.2,70,,2783.2,percent of total billed charges,All Other,2783.2,70,,2783.2,percent of total billed charges,All Other,414.16,,,414.16,Other,100% of Medicaid,414.16,,,414.16,Other,100% of Medicaid,414.16,,,414.16,Other,100% of Medicaid,414.16,,,414.16,Other,100% of Medicaid,931.85,,,931.85,Other,225% of Medicaid,633.66,,,633.66,Other,153% of Medicaid,931.85,,,931.85,Other,225% of Medicaid,579.82,,,579.82,Other,140% of Medicaid,931.85,,,931.85,Other,225% of Medicaid,1076.81,,,1076.81,Other,260% of Medicaid,1341.87,,,1341.87,Other,324% of Medicaid,890.44,,,890.44,Other,215% of Medicaid,890.44,,,890.44,Other,215% of Medicaid,517.7,,,517.7,Other,125% of Medicaid,414.16,4869.69,
INTROD LONG GI TUBE,44500,CPT,,82044500,CDM,750,RC,,,both,,,2409,1782.67,,,1782.67,Other,150% of Medicare + 9.63% HCRA Surcharge,1084.05,45,,1084.05,percent of total billed charges,Critical Access Hospital RCC factor,4565,,,4565,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4109,,,4109,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",1192.46,,,1192.46,Other,110% of Medicare,1638.12,,,1638.12,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1030,,,1030,Other,186% of Medicaid,1927.2,,,1927.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1927.2,,,1927.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1927.2,80,,1927.2,percent of total billed charges,All Other,1686.3,70,,1686.3,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",1686.3,70,,1686.3,percent of total billed charges,All Other,1686.3,70,,1686.3,percent of total billed charges,All Other,1686.3,70,,1686.3,percent of total billed charges,All Other,1686.3,70,,1686.3,percent of total billed charges,All Other,553.96,,,553.96,Other,100% of Medicaid,553.96,,,553.96,Other,100% of Medicaid,553.96,,,553.96,Other,100% of Medicaid,553.96,,,553.96,Other,100% of Medicaid,1246.41,,,1246.41,Other,225% of Medicaid,847.56,,,847.56,Other,153% of Medicaid,1246.41,,,1246.41,Other,225% of Medicaid,775.55,,,775.55,Other,140% of Medicaid,1246.41,,,1246.41,Other,225% of Medicaid,1440.3,,,1440.3,Other,260% of Medicaid,1794.83,,,1794.83,Other,324% of Medicaid,1191.02,,,1191.02,Other,215% of Medicaid,1191.02,,,1191.02,Other,215% of Medicaid,692.45,,,692.45,Other,125% of Medicaid,553.96,7216,
DRESS/DEBRID P-THICK BURN S,16020,CPT,,34016020,CDM,761,RC,,,both,,,573,424.02,,,424.02,Other,150% of Medicare + 9.63% HCRA Surcharge,257.85,45,,257.85,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",283.64,,,283.64,Other,110% of Medicare,389.64,,,389.64,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",958,,,958,Other,186% of Medicaid,458.4,,,458.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",458.4,,,458.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",458.4,,,458.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",401.1,70,,401.1,percent of total billed charges,All Other,262.4,,,262.4,Fee Schedule,,222.4,,,222.4,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",514.9,,,514.9,Other,100% of Medicaid,514.9,,,514.9,Other,100% of Medicaid,514.9,,,514.9,Other,100% of Medicaid,514.9,,,514.9,Other,100% of Medicaid,1158.52,,,1158.52,Other,225% of Medicaid,787.8,,,787.8,Other,153% of Medicaid,1158.52,,,1158.52,Other,225% of Medicaid,720.86,,,720.86,Other,140% of Medicaid,1158.52,,,1158.52,Other,225% of Medicaid,1338.74,,,1338.74,Other,260% of Medicaid,1668.27,,,1668.27,Other,324% of Medicaid,1107.03,,,1107.03,Other,215% of Medicaid,1107.03,,,1107.03,Other,215% of Medicaid,643.62,,,643.62,Other,125% of Medicaid,222.4,7216,
DRESS/DEBRID P-THICK BURN M,16025,CPT,,34016025,CDM,761,RC,,,both,,,535,395.9,,,395.9,Other,150% of Medicare + 9.63% HCRA Surcharge,240.75,45,,240.75,percent of total billed charges,Critical Access Hospital RCC factor,2480,,,2480,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2232,,,2232,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",264.83,,,264.83,Other,110% of Medicare,363.8,,,363.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",958,,,958,Other,186% of Medicaid,428,,,428,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",428,,,428,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",4252,,,4252,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",374.5,70,,374.5,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",514.9,,,514.9,Other,100% of Medicaid,514.9,,,514.9,Other,100% of Medicaid,514.9,,,514.9,Other,100% of Medicaid,514.9,,,514.9,Other,100% of Medicaid,1158.52,,,1158.52,Other,225% of Medicaid,787.8,,,787.8,Other,153% of Medicaid,1158.52,,,1158.52,Other,225% of Medicaid,720.86,,,720.86,Other,140% of Medicaid,1158.52,,,1158.52,Other,225% of Medicaid,1338.74,,,1338.74,Other,260% of Medicaid,1668.27,,,1668.27,Other,324% of Medicaid,1107.03,,,1107.03,Other,215% of Medicaid,1107.03,,,1107.03,Other,215% of Medicaid,643.62,,,643.62,Other,125% of Medicaid,240.75,7216,
UNNA BOOT STRAPPING,29580,CPT,,34029580,CDM,761,RC,,,both,,,427,315.98,,,315.98,Other,150% of Medicare + 9.63% HCRA Surcharge,192.15,45,,192.15,percent of total billed charges,Critical Access Hospital RCC factor,277.55,65,,277.55,percent of total billed charges,All Other,251.93,65,,251.93,percent of total billed charges,All Other,3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",211.37,,,211.37,Other,110% of Medicare,290.36,68,,290.36,percent of total billed charges,All Other,445,,,445,Other,186% of Medicaid,341.6,80,,341.6,percent of total billed charges,All Other,354.41,83,,354.41,percent of total billed charges,All Other,354.41,83,,354.41,percent of total billed charges,All Other,341.6,80,,341.6,percent of total billed charges,All Other,354.41,83,,354.41,percent of total billed charges,All Other,341.6,,,341.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",298.9,70,,298.9,percent of total billed charges,All Other,129.56,,,129.56,Fee Schedule,,109.81,,,109.81,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",239.06,,,239.06,Other,100% of Medicaid,239.06,,,239.06,Other,100% of Medicaid,239.06,,,239.06,Other,100% of Medicaid,239.06,,,239.06,Other,100% of Medicaid,537.89,,,537.89,Other,225% of Medicaid,365.76,,,365.76,Other,153% of Medicaid,537.89,,,537.89,Other,225% of Medicaid,334.68,,,334.68,Other,140% of Medicaid,537.89,,,537.89,Other,225% of Medicaid,621.56,,,621.56,Other,260% of Medicaid,774.55,,,774.55,Other,324% of Medicaid,513.98,,,513.98,Other,215% of Medicaid,513.98,,,513.98,Other,215% of Medicaid,298.83,,,298.83,Other,125% of Medicaid,109.81,3227,
APPLY MULTLAY COMPRS LWR LEG,29581,CPT,,34029581,CDM,761,RC,,,both,,,393,290.82,,,290.82,Other,150% of Medicare + 9.63% HCRA Surcharge,176.85,45,,176.85,percent of total billed charges,Critical Access Hospital RCC factor,255.45,65,,255.45,percent of total billed charges,All Other,231.87,65,,231.87,percent of total billed charges,All Other,3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",194.54,,,194.54,Other,110% of Medicare,267.24,68,,267.24,percent of total billed charges,All Other,445,,,445,Other,186% of Medicaid,314.4,80,,314.4,percent of total billed charges,All Other,326.19,83,,326.19,percent of total billed charges,All Other,326.19,83,,326.19,percent of total billed charges,All Other,314.4,80,,314.4,percent of total billed charges,All Other,326.19,83,,326.19,percent of total billed charges,All Other,314.4,80,,314.4,percent of total billed charges,All Other,275.1,70,,275.1,percent of total billed charges,All Other,131.2,,,131.2,Fee Schedule,,111.2,,,111.2,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",239.06,,,239.06,Other,100% of Medicaid,239.06,,,239.06,Other,100% of Medicaid,239.06,,,239.06,Other,100% of Medicaid,239.06,,,239.06,Other,100% of Medicaid,537.89,,,537.89,Other,225% of Medicaid,365.76,,,365.76,Other,153% of Medicaid,537.89,,,537.89,Other,225% of Medicaid,334.68,,,334.68,Other,140% of Medicaid,537.89,,,537.89,Other,225% of Medicaid,621.56,,,621.56,Other,260% of Medicaid,774.55,,,774.55,Other,324% of Medicaid,513.98,,,513.98,Other,215% of Medicaid,513.98,,,513.98,Other,215% of Medicaid,298.83,,,298.83,Other,125% of Medicaid,111.2,3227,
TRACH TUBE CHG BEFORE FISTULA TRACT,31502,CPT,,34031502,CDM,761,RC,,,both,,,491,363.34,,,363.34,Other,150% of Medicare + 9.63% HCRA Surcharge,220.95,45,,220.95,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",243.05,,,243.05,Other,110% of Medicare,333.88,,,333.88,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",205.47,,,205.47,Other,186% of Medicaid,392.8,,,392.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",392.8,,,392.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",392.8,,,392.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",343.7,70,,343.7,percent of total billed charges,All Other,168.92,,,168.92,Fee Schedule,,143.17,,,143.17,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",110.47,,,110.47,Other,100% of Medicaid,110.47,,,110.47,Other,100% of Medicaid,110.47,,,110.47,Other,100% of Medicaid,110.47,,,110.47,Other,100% of Medicaid,248.55,,,248.55,Other,225% of Medicaid,169.02,,,169.02,Other,153% of Medicaid,248.55,,,248.55,Other,225% of Medicaid,154.65,,,154.65,Other,140% of Medicaid,248.55,,,248.55,Other,225% of Medicaid,287.22,,,287.22,Other,260% of Medicaid,357.92,,,357.92,Other,324% of Medicaid,237.51,,,237.51,Other,215% of Medicaid,237.51,,,237.51,Other,215% of Medicaid,138.08,,,138.08,Other,125% of Medicaid,110.47,7216,
NONSELECTIVE CATH PLACEMENT IN VEIN,36000,CPT,,34036000,CDM,761,RC,,,both,,,248,183.52,,,183.52,Other,150% of Medicare + 9.63% HCRA Surcharge,111.6,45,,111.6,percent of total billed charges,Critical Access Hospital RCC factor,4565,,,4565,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4565,,,4565,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",122.76,,,122.76,Other,110% of Medicare,168.64,,,168.64,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",49.03,,,49.03,Other,186% of Medicaid,198.4,,,198.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",198.4,,,198.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",198.4,,,198.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",173.6,70,,173.6,percent of total billed charges,All Other,42.64,,,42.64,Fee Schedule,,36.14,,,36.14,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",26.36,,,26.36,Other,100% of Medicaid,26.36,,,26.36,Other,100% of Medicaid,26.36,,,26.36,Other,100% of Medicaid,26.36,,,26.36,Other,100% of Medicaid,59.32,,,59.32,Other,225% of Medicaid,40.33,,,40.33,Other,153% of Medicaid,59.32,,,59.32,Other,225% of Medicaid,36.91,,,36.91,Other,140% of Medicaid,59.32,,,59.32,Other,225% of Medicaid,68.54,,,68.54,Other,260% of Medicaid,85.41,,,85.41,Other,324% of Medicaid,56.68,,,56.68,Other,215% of Medicaid,56.68,,,56.68,Other,215% of Medicaid,32.95,,,32.95,Other,125% of Medicaid,26.36,7216,
COLLECT BLOOD FROM VAD,36591,CPT,,34036591,CDM,761,RC,,,both,,,263,194.62,,,194.62,Other,150% of Medicare + 9.63% HCRA Surcharge,118.35,45,,118.35,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,155.73,,,155.73,Fee Schedule,,140.07,,,140.07,Fee Schedule,,132.38,,,132.38,Fee Schedule,,130.19,,,130.19,Other,110% of Medicare,178.84,68,,178.84,percent of total billed charges,All Other,49,,,49,Other,186% of Medicaid,210.4,80,,210.4,percent of total billed charges,All Other,218.29,83,,218.29,percent of total billed charges,All Other,218.29,83,,218.29,percent of total billed charges,All Other,210.4,80,,210.4,percent of total billed charges,All Other,218.29,83,,218.29,percent of total billed charges,All Other,210.4,,,210.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",184.1,70,,184.1,percent of total billed charges,All Other,129.56,,,129.56,Fee Schedule,,109.81,,,109.81,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",26.36,,,26.36,Other,100% of Medicaid,26.36,,,26.36,Other,100% of Medicaid,26.36,,,26.36,Other,100% of Medicaid,26.36,,,26.36,Other,100% of Medicaid,59.32,,,59.32,Other,225% of Medicaid,40.33,,,40.33,Other,153% of Medicaid,59.32,,,59.32,Other,225% of Medicaid,36.91,,,36.91,Other,140% of Medicaid,59.32,,,59.32,Other,225% of Medicaid,68.54,,,68.54,Other,260% of Medicaid,85.41,,,85.41,Other,324% of Medicaid,56.68,,,56.68,Other,215% of Medicaid,56.68,,,56.68,Other,215% of Medicaid,32.95,,,32.95,Other,125% of Medicaid,0.01,3227,
DECLOT VASCULAR DEVICE,36593,CPT,,34036593,CDM,761,RC,,,both,,,896,663.04,,,663.04,Other,150% of Medicare + 9.63% HCRA Surcharge,403.2,45,,403.2,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",443.52,,,443.52,Other,110% of Medicare,609.28,,,609.28,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",411.17,,,411.17,Other,186% of Medicaid,716.8,,,716.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",716.8,,,716.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",716.8,,,716.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",627.2,70,,627.2,percent of total billed charges,All Other,159.08,,,159.08,Fee Schedule,,134.83,,,134.83,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",221.06,,,221.06,Other,100% of Medicaid,221.06,,,221.06,Other,100% of Medicaid,221.06,,,221.06,Other,100% of Medicaid,221.06,,,221.06,Other,100% of Medicaid,497.39,,,497.39,Other,225% of Medicaid,338.22,,,338.22,Other,153% of Medicaid,497.39,,,497.39,Other,225% of Medicaid,309.49,,,309.49,Other,140% of Medicaid,497.39,,,497.39,Other,225% of Medicaid,574.76,,,574.76,Other,260% of Medicaid,716.24,,,716.24,Other,324% of Medicaid,475.28,,,475.28,Other,215% of Medicaid,475.28,,,475.28,Other,215% of Medicaid,276.33,,,276.33,Other,125% of Medicaid,134.83,7216,
BONE MARROW BIOPSY,38221,CPT,,34038221,CDM,761,RC,,,both,,,3926,2905.25,,,2905.25,Other,150% of Medicare + 9.63% HCRA Surcharge,1766.7,45,,1766.7,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3648,,,3648,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3283,,,3283,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3101,,,3101,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",1943.37,,,1943.37,Other,110% of Medicare,2669.68,,,2669.68,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",777.01,,,777.01,Other,186% of Medicaid,3140.8,,,3140.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",3140.8,,,3140.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",3140.8,,,3140.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2748.2,70,,2748.2,percent of total billed charges,All Other,339.48,,,339.48,Fee Schedule,,287.73,,,287.73,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",417.75,,,417.75,Other,100% of Medicaid,417.75,,,417.75,Other,100% of Medicaid,417.75,,,417.75,Other,100% of Medicaid,417.75,,,417.75,Other,100% of Medicaid,939.93,,,939.93,Other,225% of Medicaid,639.15,,,639.15,Other,153% of Medicaid,939.93,,,939.93,Other,225% of Medicaid,584.84,,,584.84,Other,140% of Medicaid,939.93,,,939.93,Other,225% of Medicaid,1086.14,,,1086.14,Other,260% of Medicaid,1353.5,,,1353.5,Other,324% of Medicaid,898.15,,,898.15,Other,215% of Medicaid,898.15,,,898.15,Other,215% of Medicaid,522.18,,,522.18,Other,125% of Medicaid,287.73,7216,
NEEDLE BX LIVER; PERCUTANEOUS,47000,CPT,,34047000,CDM,761,RC,,,both,,,3495,2586.31,,,2586.31,Other,150% of Medicare + 9.63% HCRA Surcharge,1572.75,45,,1572.75,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3648,,,3648,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3283,,,3283,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3101,,,3101,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",1730.03,,,1730.03,Other,110% of Medicare,2376.6,,,2376.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1197,,,1197,Other,186% of Medicaid,2796,,,2796,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2796,,,2796,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",3578,,,3578,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2446.5,70,,2446.5,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",4055,,,4055,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3649,,,3649,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4055,,,4055,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3448,,,3448,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",643.35,,,643.35,Other,100% of Medicaid,643.35,,,643.35,Other,100% of Medicaid,643.35,,,643.35,Other,100% of Medicaid,643.35,,,643.35,Other,100% of Medicaid,1447.55,,,1447.55,Other,225% of Medicaid,984.33,,,984.33,Other,153% of Medicaid,1447.55,,,1447.55,Other,225% of Medicaid,900.7,,,900.7,Other,140% of Medicaid,1447.55,,,1447.55,Other,225% of Medicaid,1672.72,,,1672.72,Other,260% of Medicaid,2084.47,,,2084.47,Other,324% of Medicaid,1383.21,,,1383.21,Other,215% of Medicaid,1383.21,,,1383.21,Other,215% of Medicaid,804.19,,,804.19,Other,125% of Medicaid,643.35,7216,
ABD PARACENTESIS,49082,CPT,,34049082,CDM,761,RC,,,both,,,1860,1376.4,,,1376.4,Other,150% of Medicare + 9.63% HCRA Surcharge,837,45,,837,percent of total billed charges,Critical Access Hospital RCC factor,2480,,,2480,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2232,,,2232,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",920.7,,,920.7,Other,110% of Medicare,1264.8,,,1264.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1197,,,1197,Other,186% of Medicaid,1488,,,1488,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1488,,,1488,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1488,,,1488,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1302,70,,1302,percent of total billed charges,All Other,354.24,,,354.24,Fee Schedule,,300.24,,,300.24,Fee Schedule,,4055,,,4055,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3649,,,3649,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4055,,,4055,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3448,,,3448,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",643.35,,,643.35,Other,100% of Medicaid,643.35,,,643.35,Other,100% of Medicaid,643.35,,,643.35,Other,100% of Medicaid,643.35,,,643.35,Other,100% of Medicaid,1447.55,,,1447.55,Other,225% of Medicaid,984.33,,,984.33,Other,153% of Medicaid,1447.55,,,1447.55,Other,225% of Medicaid,900.7,,,900.7,Other,140% of Medicaid,1447.55,,,1447.55,Other,225% of Medicaid,1672.72,,,1672.72,Other,260% of Medicaid,2084.47,,,2084.47,Other,324% of Medicaid,1383.21,,,1383.21,Other,215% of Medicaid,1383.21,,,1383.21,Other,215% of Medicaid,804.19,,,804.19,Other,125% of Medicaid,300.24,7216,
SIMPLE BLADDER IRRIGATE LAVAGE/INSTILL,51700,CPT,,34051700,CDM,761,RC,,,both,,,776,574.24,,,574.24,Other,150% of Medicare + 9.63% HCRA Surcharge,349.2,45,,349.2,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",384.12,,,384.12,Other,110% of Medicare,527.68,,,527.68,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",848,,,848,Other,186% of Medicaid,620.8,,,620.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",620.8,,,620.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",620.8,,,620.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",543.2,70,,543.2,percent of total billed charges,All Other,147.6,,,147.6,Fee Schedule,,125.1,,,125.1,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",455.81,,,455.81,Other,100% of Medicaid,455.81,,,455.81,Other,100% of Medicaid,455.81,,,455.81,Other,100% of Medicaid,455.81,,,455.81,Other,100% of Medicaid,1025.56,,,1025.56,Other,225% of Medicaid,697.38,,,697.38,Other,153% of Medicaid,1025.56,,,1025.56,Other,225% of Medicaid,638.13,,,638.13,Other,140% of Medicaid,1025.56,,,1025.56,Other,225% of Medicaid,1185.1,,,1185.1,Other,260% of Medicaid,1476.81,,,1476.81,Other,324% of Medicaid,979.98,,,979.98,Other,215% of Medicaid,979.98,,,979.98,Other,215% of Medicaid,569.76,,,569.76,Other,125% of Medicaid,125.1,7216,
INS TEMP BLADDER CATH,51702,CPT,,34051702,CDM,761,RC,,,both,,,263,194.62,,,194.62,Other,150% of Medicare + 9.63% HCRA Surcharge,118.35,45,,118.35,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",130.19,,,130.19,Other,110% of Medicare,178.84,,,178.84,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",600.52,,,600.52,Other,186% of Medicaid,210.4,,,210.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",210.4,,,210.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",210.4,,,210.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",184.1,70,,184.1,percent of total billed charges,All Other,123,,,123,Fee Schedule,,104.25,,,104.25,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",322.86,,,322.86,Other,100% of Medicaid,322.86,,,322.86,Other,100% of Medicaid,322.86,,,322.86,Other,100% of Medicaid,322.86,,,322.86,Other,100% of Medicaid,726.44,,,726.44,Other,225% of Medicaid,493.98,,,493.98,Other,153% of Medicaid,726.44,,,726.44,Other,225% of Medicaid,452.01,,,452.01,Other,140% of Medicaid,726.44,,,726.44,Other,225% of Medicaid,839.44,,,839.44,Other,260% of Medicaid,1046.07,,,1046.07,Other,324% of Medicaid,694.15,,,694.15,Other,215% of Medicaid,694.15,,,694.15,Other,215% of Medicaid,403.58,,,403.58,Other,125% of Medicaid,104.25,7216,
NJX INTERLAMINAR LMBR/SAC,62322,CPT,,34062322,CDM,761,RC,,,both,,,2579,1908.47,,,1908.47,Other,150% of Medicare + 9.63% HCRA Surcharge,1160.55,45,,1160.55,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",1276.61,,,1276.61,Other,110% of Medicare,1753.72,,,1753.72,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1116,,,1116,Other,186% of Medicaid,2063.2,,,2063.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2063.2,,,2063.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2063.2,,,2063.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1805.3,70,,1805.3,percent of total billed charges,All Other,390.32,,,390.32,Fee Schedule,,330.82,,,330.82,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",600.19,,,600.19,Other,100% of Medicaid,600.19,,,600.19,Other,100% of Medicaid,600.19,,,600.19,Other,100% of Medicaid,600.19,,,600.19,Other,100% of Medicaid,1350.43,,,1350.43,Other,225% of Medicaid,918.29,,,918.29,Other,153% of Medicaid,1350.43,,,1350.43,Other,225% of Medicaid,840.26,,,840.26,Other,140% of Medicaid,1350.43,,,1350.43,Other,225% of Medicaid,1560.49,,,1560.49,Other,260% of Medicaid,1944.61,,,1944.61,Other,324% of Medicaid,1290.41,,,1290.41,Other,215% of Medicaid,1290.41,,,1290.41,Other,215% of Medicaid,750.24,,,750.24,Other,125% of Medicaid,330.82,7216,
ANALYZE SP INF PUMP W/REPROG,62368,CPT,,34062368,CDM,761,RC,,,both,,,624,461.76,,,461.76,Other,150% of Medicare + 9.63% HCRA Surcharge,280.8,45,,280.8,percent of total billed charges,Critical Access Hospital RCC factor,2480,,,2480,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2232,,,2232,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",308.88,,,308.88,Other,110% of Medicare,424.32,,,424.32,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",127.77,,,127.77,Other,186% of Medicaid,499.2,,,499.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",499.2,,,499.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",499.2,,,499.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",436.8,70,,436.8,percent of total billed charges,All Other,168.92,,,168.92,Fee Schedule,,143.17,,,143.17,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",68.69,,,68.69,Other,100% of Medicaid,68.69,,,68.69,Other,100% of Medicaid,68.69,,,68.69,Other,100% of Medicaid,68.69,,,68.69,Other,100% of Medicaid,154.56,,,154.56,Other,225% of Medicaid,105.1,,,105.1,Other,153% of Medicaid,154.56,,,154.56,Other,225% of Medicaid,96.17,,,96.17,Other,140% of Medicaid,154.56,,,154.56,Other,225% of Medicaid,178.6,,,178.6,Other,260% of Medicaid,222.56,,,222.56,Other,324% of Medicaid,147.69,,,147.69,Other,215% of Medicaid,147.69,,,147.69,Other,215% of Medicaid,85.87,,,85.87,Other,125% of Medicaid,68.69,7216,
PRO ALLERG IMT,95115,CPT,,34095115,CDM,761,RC,,,both,,,266,196.84,,,196.84,Other,150% of Medicare + 9.63% HCRA Surcharge,119.7,45,,119.7,percent of total billed charges,Critical Access Hospital RCC factor,172.9,65,,172.9,percent of total billed charges,All Other,156.94,65,,156.94,percent of total billed charges,All Other,67.99,,,67.99,Fee Schedule,,61.2,,,61.2,Fee Schedule,,57.81,,,57.81,Fee Schedule,,131.67,,,131.67,Other,110% of Medicare,180.88,68,,180.88,percent of total billed charges,All Other,50,,,50,Other,186% of Medicaid,212.8,80,,212.8,percent of total billed charges,All Other,220.78,83,,220.78,percent of total billed charges,All Other,220.78,83,,220.78,percent of total billed charges,All Other,212.8,80,,212.8,percent of total billed charges,All Other,220.78,83,,220.78,percent of total billed charges,All Other,212.8,,,212.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",186.2,70,,186.2,percent of total billed charges,All Other,45.92,,,45.92,Fee Schedule,,38.92,,,38.92,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",27.11,,,27.11,Other,100% of Medicaid,27.11,,,27.11,Other,100% of Medicaid,27.11,,,27.11,Other,100% of Medicaid,27.11,,,27.11,Other,100% of Medicaid,60.99,,,60.99,Other,225% of Medicaid,41.47,,,41.47,Other,153% of Medicaid,60.99,,,60.99,Other,225% of Medicaid,37.95,,,37.95,Other,140% of Medicaid,60.99,,,60.99,Other,225% of Medicaid,70.47,,,70.47,Other,260% of Medicaid,87.82,,,87.82,Other,324% of Medicaid,58.28,,,58.28,Other,215% of Medicaid,58.28,,,58.28,Other,215% of Medicaid,33.88,,,33.88,Other,125% of Medicaid,27.11,3227,
IMMUNOTHERAPY 2+ INJECTIONS,95117,CPT,,34095117,CDM,761,RC,,,both,,,285,210.9,,,210.9,Other,150% of Medicare + 9.63% HCRA Surcharge,128.25,45,,128.25,percent of total billed charges,Critical Access Hospital RCC factor,185.25,65,,185.25,percent of total billed charges,All Other,168.15,65,,168.15,percent of total billed charges,All Other,83.83,,,83.83,Fee Schedule,,75.46,,,75.46,Fee Schedule,,71.28,,,71.28,Fee Schedule,,141.08,,,141.08,Other,110% of Medicare,193.8,68,,193.8,percent of total billed charges,All Other,50,,,50,Other,186% of Medicaid,228,80,,228,percent of total billed charges,All Other,236.55,83,,236.55,percent of total billed charges,All Other,236.55,83,,236.55,percent of total billed charges,All Other,228,80,,228,percent of total billed charges,All Other,236.55,83,,236.55,percent of total billed charges,All Other,228,,,228,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",199.5,70,,199.5,percent of total billed charges,All Other,55.76,,,55.76,Fee Schedule,,47.26,,,47.26,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",27.11,,,27.11,Other,100% of Medicaid,27.11,,,27.11,Other,100% of Medicaid,27.11,,,27.11,Other,100% of Medicaid,27.11,,,27.11,Other,100% of Medicaid,60.99,,,60.99,Other,225% of Medicaid,41.47,,,41.47,Other,153% of Medicaid,60.99,,,60.99,Other,225% of Medicaid,37.95,,,37.95,Other,140% of Medicaid,60.99,,,60.99,Other,225% of Medicaid,70.47,,,70.47,Other,260% of Medicaid,87.82,,,87.82,Other,324% of Medicaid,58.28,,,58.28,Other,215% of Medicaid,58.28,,,58.28,Other,215% of Medicaid,33.88,,,33.88,Other,125% of Medicaid,27.11,3227,
NEG PRESS WOUND TX < 50 CM,97605,CPT,,34097605,CDM,761,RC,,,both,,,408,301.92,,,301.92,Other,150% of Medicare + 9.63% HCRA Surcharge,183.6,45,,183.6,percent of total billed charges,Critical Access Hospital RCC factor,265.2,65,,265.2,percent of total billed charges,All Other,240.72,65,,240.72,percent of total billed charges,All Other,312.12,76.5,,312.12,percent of total billed charges,All Other,289.68,69,,289.68,percent of total billed charges,All Other,281.52,65,,281.52,percent of total billed charges,All Other,201.96,,,201.96,Other,110% of Medicare,277.44,68,,277.44,percent of total billed charges,All Other,703,,,703,Other,186% of Medicaid,326.4,80,,326.4,percent of total billed charges,All Other,338.64,83,,338.64,percent of total billed charges,All Other,338.64,83,,338.64,percent of total billed charges,All Other,326.4,80,,326.4,percent of total billed charges,All Other,338.64,83,,338.64,percent of total billed charges,All Other,326.4,,,326.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",285.6,70,,285.6,percent of total billed charges,All Other,119.72,,,119.72,Fee Schedule,,101.47,,,101.47,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",377.82,,,377.82,Other,100% of Medicaid,377.82,,,377.82,Other,100% of Medicaid,377.82,,,377.82,Other,100% of Medicaid,377.82,,,377.82,Other,100% of Medicaid,850.1,,,850.1,Other,225% of Medicaid,578.07,,,578.07,Other,153% of Medicaid,850.1,,,850.1,Other,225% of Medicaid,528.95,,,528.95,Other,140% of Medicaid,850.1,,,850.1,Other,225% of Medicaid,982.34,,,982.34,Other,260% of Medicaid,1224.15,,,1224.15,Other,324% of Medicaid,812.32,,,812.32,Other,215% of Medicaid,812.32,,,812.32,Other,215% of Medicaid,472.28,,,472.28,Other,125% of Medicaid,101.47,3227,
NEG PRESS WOUND TX > 50 CM,97606,CPT,,34097606,CDM,761,RC,,,both,,,841,622.34,,,622.34,Other,150% of Medicare + 9.63% HCRA Surcharge,378.45,45,,378.45,percent of total billed charges,Critical Access Hospital RCC factor,546.65,65,,546.65,percent of total billed charges,All Other,496.19,65,,496.19,percent of total billed charges,All Other,643.37,76.5,,643.37,percent of total billed charges,All Other,597.11,69,,597.11,percent of total billed charges,All Other,580.29,65,,580.29,percent of total billed charges,All Other,416.3,,,416.3,Other,110% of Medicare,571.88,68,,571.88,percent of total billed charges,All Other,1070,,,1070,Other,186% of Medicaid,672.8,80,,672.8,percent of total billed charges,All Other,698.03,83,,698.03,percent of total billed charges,All Other,698.03,83,,698.03,percent of total billed charges,All Other,672.8,80,,672.8,percent of total billed charges,All Other,698.03,83,,698.03,percent of total billed charges,All Other,672.8,,,672.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",588.7,70,,588.7,percent of total billed charges,All Other,131.2,,,131.2,Fee Schedule,,111.2,,,111.2,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",575.25,,,575.25,Other,100% of Medicaid,575.25,,,575.25,Other,100% of Medicaid,575.25,,,575.25,Other,100% of Medicaid,575.25,,,575.25,Other,100% of Medicaid,1294.32,,,1294.32,Other,225% of Medicaid,880.14,,,880.14,Other,153% of Medicaid,1294.32,,,1294.32,Other,225% of Medicaid,805.36,,,805.36,Other,140% of Medicaid,1294.32,,,1294.32,Other,225% of Medicaid,1495.66,,,1495.66,Other,260% of Medicaid,1863.82,,,1863.82,Other,324% of Medicaid,1236.8,,,1236.8,Other,215% of Medicaid,1236.8,,,1236.8,Other,215% of Medicaid,719.07,,,719.07,Other,125% of Medicaid,111.2,3227,
OFFICE/OUTPATIENT VISIT NEW LVL 2,99202,CPT,,34099202,CDM,761,RC,,,both,,,252,186.48,,,186.48,Other,150% of Medicare + 9.63% HCRA Surcharge,113.4,45,,113.4,percent of total billed charges,Critical Access Hospital RCC factor,163.8,65,,163.8,percent of total billed charges,All Other,148.68,65,,148.68,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,124.74,,,124.74,Other,110% of Medicare,171.36,68,,171.36,percent of total billed charges,All Other,0.01,,,0.01,Other,186% of Medicaid,201.6,80,,201.6,percent of total billed charges,All Other,209.16,83,,209.16,percent of total billed charges,All Other,209.16,83,,209.16,percent of total billed charges,All Other,201.6,80,,201.6,percent of total billed charges,All Other,209.16,83,,209.16,percent of total billed charges,All Other,201.6,,,201.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",176.4,70,,176.4,percent of total billed charges,All Other,234.52,,,234.52,Fee Schedule,,198.77,,,198.77,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3227,
OFFICE/OUTPATIENT VISIT NEW LVL 3,99203,CPT,,34099203,CDM,761,RC,,,both,,,345,255.3,,,255.3,Other,150% of Medicare + 9.63% HCRA Surcharge,155.25,45,,155.25,percent of total billed charges,Critical Access Hospital RCC factor,224.25,65,,224.25,percent of total billed charges,All Other,203.55,65,,203.55,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,170.78,,,170.78,Other,110% of Medicare,234.6,68,,234.6,percent of total billed charges,All Other,0.01,,,0.01,Other,186% of Medicaid,276,80,,276,percent of total billed charges,All Other,286.35,83,,286.35,percent of total billed charges,All Other,286.35,83,,286.35,percent of total billed charges,All Other,276,80,,276,percent of total billed charges,All Other,286.35,83,,286.35,percent of total billed charges,All Other,276,,,276,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",241.5,70,,241.5,percent of total billed charges,All Other,400.16,,,400.16,Fee Schedule,,339.16,,,339.16,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3227,
OFFICE/OUTPATIENT VISIT NEW LVL 4,99204,CPT,,34099204,CDM,761,RC,,,both,,,460,340.4,,,340.4,Other,150% of Medicare + 9.63% HCRA Surcharge,207,45,,207,percent of total billed charges,Critical Access Hospital RCC factor,299,65,,299,percent of total billed charges,All Other,271.4,65,,271.4,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,227.7,,,227.7,Other,110% of Medicare,312.8,68,,312.8,percent of total billed charges,All Other,0.01,,,0.01,Other,186% of Medicaid,368,80,,368,percent of total billed charges,All Other,381.8,83,,381.8,percent of total billed charges,All Other,381.8,83,,381.8,percent of total billed charges,All Other,368,80,,368,percent of total billed charges,All Other,381.8,83,,381.8,percent of total billed charges,All Other,368,,,368,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",322,70,,322,percent of total billed charges,All Other,647.8,,,647.8,Fee Schedule,,549.05,,,549.05,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3227,
OFFICE/OUTPATIENT VISIT NEW LVL 5,99205,CPT,,34099205,CDM,761,RC,,,both,,,628,464.72,,,464.72,Other,150% of Medicare + 9.63% HCRA Surcharge,282.6,45,,282.6,percent of total billed charges,Critical Access Hospital RCC factor,408.2,65,,408.2,percent of total billed charges,All Other,370.52,65,,370.52,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,310.86,,,310.86,Other,110% of Medicare,427.04,68,,427.04,percent of total billed charges,All Other,0.01,,,0.01,Other,186% of Medicaid,502.4,80,,502.4,percent of total billed charges,All Other,521.24,83,,521.24,percent of total billed charges,All Other,521.24,83,,521.24,percent of total billed charges,All Other,502.4,80,,502.4,percent of total billed charges,All Other,521.24,83,,521.24,percent of total billed charges,All Other,502.4,,,502.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",439.6,70,,439.6,percent of total billed charges,All Other,879.04,,,879.04,Fee Schedule,,745.04,,,745.04,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3227,
OFFICE/OUTPATIENT VISIT EST LVL 1,99211,CPT,,34099211,CDM,761,RC,,,both,,,228,168.72,,,168.72,Other,150% of Medicare + 9.63% HCRA Surcharge,102.6,45,,102.6,percent of total billed charges,Critical Access Hospital RCC factor,148.2,65,,148.2,percent of total billed charges,All Other,134.52,65,,134.52,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,112.86,,,112.86,Other,110% of Medicare,155.04,68,,155.04,percent of total billed charges,All Other,0.01,,,0.01,Other,186% of Medicaid,182.4,80,,182.4,percent of total billed charges,All Other,189.24,83,,189.24,percent of total billed charges,All Other,189.24,83,,189.24,percent of total billed charges,All Other,182.4,80,,182.4,percent of total billed charges,All Other,189.24,83,,189.24,percent of total billed charges,All Other,182.4,,,182.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",159.6,70,,159.6,percent of total billed charges,All Other,42.64,,,42.64,Fee Schedule,,36.14,,,36.14,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3227,
OFFICE/OUTPATIENT VISIT EST LVL 2,99212,CPT,,34099212,CDM,761,RC,,,both,,,259,191.66,,,191.66,Other,150% of Medicare + 9.63% HCRA Surcharge,116.55,45,,116.55,percent of total billed charges,Critical Access Hospital RCC factor,168.35,65,,168.35,percent of total billed charges,All Other,152.81,65,,152.81,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,128.21,,,128.21,Other,110% of Medicare,176.12,68,,176.12,percent of total billed charges,All Other,0.01,,,0.01,Other,186% of Medicaid,207.2,80,,207.2,percent of total billed charges,All Other,214.97,83,,214.97,percent of total billed charges,All Other,214.97,83,,214.97,percent of total billed charges,All Other,207.2,80,,207.2,percent of total billed charges,All Other,214.97,83,,214.97,percent of total billed charges,All Other,207.2,,,207.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",181.3,70,,181.3,percent of total billed charges,All Other,173.84,,,173.84,Fee Schedule,,147.34,,,147.34,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3227,
OFFICE/OUTPATIENT VISIT EST LVL 3,99213,CPT,,34099213,CDM,761,RC,,,both,,,259,191.66,,,191.66,Other,150% of Medicare + 9.63% HCRA Surcharge,116.55,45,,116.55,percent of total billed charges,Critical Access Hospital RCC factor,168.35,65,,168.35,percent of total billed charges,All Other,152.81,65,,152.81,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,128.21,,,128.21,Other,110% of Medicare,176.12,68,,176.12,percent of total billed charges,All Other,0.01,,,0.01,Other,186% of Medicaid,207.2,80,,207.2,percent of total billed charges,All Other,214.97,83,,214.97,percent of total billed charges,All Other,214.97,83,,214.97,percent of total billed charges,All Other,207.2,80,,207.2,percent of total billed charges,All Other,214.97,83,,214.97,percent of total billed charges,All Other,207.2,,,207.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",181.3,70,,181.3,percent of total billed charges,All Other,319.8,,,319.8,Fee Schedule,,271.05,,,271.05,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3227,
OFFICE/OUTPATIENT VISIT EST LVL 4,99214,CPT,,34099214,CDM,761,RC,,,both,,,340,251.6,,,251.6,Other,150% of Medicare + 9.63% HCRA Surcharge,153,45,,153,percent of total billed charges,Critical Access Hospital RCC factor,221,65,,221,percent of total billed charges,All Other,200.6,65,,200.6,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,168.3,,,168.3,Other,110% of Medicare,231.2,68,,231.2,percent of total billed charges,All Other,0.01,,,0.01,Other,186% of Medicaid,272,80,,272,percent of total billed charges,All Other,282.2,83,,282.2,percent of total billed charges,All Other,282.2,83,,282.2,percent of total billed charges,All Other,272,80,,272,percent of total billed charges,All Other,282.2,83,,282.2,percent of total billed charges,All Other,272,,,272,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",238,70,,238,percent of total billed charges,All Other,469.04,,,469.04,Fee Schedule,,397.54,,,397.54,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3227,
OFFICE/OUTPATIENT VISIT EST LVL 5,99215,CPT,,34099215,CDM,761,RC,,,both,,,440,325.6,,,325.6,Other,150% of Medicare + 9.63% HCRA Surcharge,198,45,,198,percent of total billed charges,Critical Access Hospital RCC factor,286,65,,286,percent of total billed charges,All Other,259.6,65,,259.6,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,217.8,,,217.8,Other,110% of Medicare,299.2,68,,299.2,percent of total billed charges,All Other,0.01,,,0.01,Other,186% of Medicaid,352,80,,352,percent of total billed charges,All Other,365.2,83,,365.2,percent of total billed charges,All Other,365.2,83,,365.2,percent of total billed charges,All Other,352,80,,352,percent of total billed charges,All Other,365.2,83,,365.2,percent of total billed charges,All Other,352,,,352,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",308,70,,308,percent of total billed charges,All Other,697,,,697,Fee Schedule,,590.75,,,590.75,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3227,
UNNA BOOT STRAPPING BILATERAL,29580,CPT,50,34129580,CDM,761,RC,,,both,,,641,474.34,,,474.34,Other,150% of Medicare + 9.63% HCRA Surcharge,288.45,45,,288.45,percent of total billed charges,Critical Access Hospital RCC factor,416.65,65,,416.65,percent of total billed charges,All Other,378.19,65,,378.19,percent of total billed charges,All Other,3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",317.3,,,317.3,Other,110% of Medicare,435.88,68,,435.88,percent of total billed charges,All Other,445,,,445,Other,186% of Medicaid,512.8,80,,512.8,percent of total billed charges,All Other,532.03,83,,532.03,percent of total billed charges,All Other,532.03,83,,532.03,percent of total billed charges,All Other,512.8,80,,512.8,percent of total billed charges,All Other,532.03,83,,532.03,percent of total billed charges,All Other,512.8,,,512.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",448.7,70,,448.7,percent of total billed charges,All Other,129.56,,,129.56,Fee Schedule,,109.81,,,109.81,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",239.06,,,239.06,Other,100% of Medicaid,239.06,,,239.06,Other,100% of Medicaid,239.06,,,239.06,Other,100% of Medicaid,239.06,,,239.06,Other,100% of Medicaid,537.89,,,537.89,Other,225% of Medicaid,365.76,,,365.76,Other,153% of Medicaid,537.89,,,537.89,Other,225% of Medicaid,334.68,,,334.68,Other,140% of Medicaid,537.89,,,537.89,Other,225% of Medicaid,621.56,,,621.56,Other,260% of Medicaid,774.55,,,774.55,Other,324% of Medicaid,513.98,,,513.98,Other,215% of Medicaid,513.98,,,513.98,Other,215% of Medicaid,298.83,,,298.83,Other,125% of Medicaid,109.81,3227,
APPLY MULTLAY COMPRS LWR LEG BILATERAL,29581,CPT,50,34129581,CDM,761,RC,,,both,,,590,436.6,,,436.6,Other,150% of Medicare + 9.63% HCRA Surcharge,265.5,45,,265.5,percent of total billed charges,Critical Access Hospital RCC factor,383.5,65,,383.5,percent of total billed charges,All Other,348.1,65,,348.1,percent of total billed charges,All Other,3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",292.05,,,292.05,Other,110% of Medicare,401.2,68,,401.2,percent of total billed charges,All Other,445,,,445,Other,186% of Medicaid,472,80,,472,percent of total billed charges,All Other,489.7,83,,489.7,percent of total billed charges,All Other,489.7,83,,489.7,percent of total billed charges,All Other,472,80,,472,percent of total billed charges,All Other,489.7,83,,489.7,percent of total billed charges,All Other,472,80,,472,percent of total billed charges,All Other,413,70,,413,percent of total billed charges,All Other,131.2,,,131.2,Fee Schedule,,111.2,,,111.2,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",239.06,,,239.06,Other,100% of Medicaid,239.06,,,239.06,Other,100% of Medicaid,239.06,,,239.06,Other,100% of Medicaid,239.06,,,239.06,Other,100% of Medicaid,537.89,,,537.89,Other,225% of Medicaid,365.76,,,365.76,Other,153% of Medicaid,537.89,,,537.89,Other,225% of Medicaid,334.68,,,334.68,Other,140% of Medicaid,537.89,,,537.89,Other,225% of Medicaid,621.56,,,621.56,Other,260% of Medicaid,774.55,,,774.55,Other,324% of Medicaid,513.98,,,513.98,Other,215% of Medicaid,513.98,,,513.98,Other,215% of Medicaid,298.83,,,298.83,Other,125% of Medicaid,111.2,3227,
REMOVAL GASTROSTOMY TUBE,99213,CPT,,34999213,CDM,761,RC,,,both,,,259,191.66,,,191.66,Other,150% of Medicare + 9.63% HCRA Surcharge,116.55,45,,116.55,percent of total billed charges,Critical Access Hospital RCC factor,168.35,65,,168.35,percent of total billed charges,All Other,152.81,65,,152.81,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,128.21,,,128.21,Other,110% of Medicare,176.12,68,,176.12,percent of total billed charges,All Other,0.01,,,0.01,Other,186% of Medicaid,207.2,80,,207.2,percent of total billed charges,All Other,214.97,83,,214.97,percent of total billed charges,All Other,214.97,83,,214.97,percent of total billed charges,All Other,207.2,80,,207.2,percent of total billed charges,All Other,214.97,83,,214.97,percent of total billed charges,All Other,207.2,,,207.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",181.3,70,,181.3,percent of total billed charges,All Other,319.8,,,319.8,Fee Schedule,,271.05,,,271.05,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3227,
REMOVAL GASTROSTOMY TUBE,99213,CPT,,35099213,CDM,761,RC,,,both,,,259,191.66,,,191.66,Other,150% of Medicare + 9.63% HCRA Surcharge,116.55,45,,116.55,percent of total billed charges,Critical Access Hospital RCC factor,168.35,65,,168.35,percent of total billed charges,All Other,152.81,65,,152.81,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,128.21,,,128.21,Other,110% of Medicare,176.12,68,,176.12,percent of total billed charges,All Other,0.01,,,0.01,Other,186% of Medicaid,207.2,80,,207.2,percent of total billed charges,All Other,214.97,83,,214.97,percent of total billed charges,All Other,214.97,83,,214.97,percent of total billed charges,All Other,207.2,80,,207.2,percent of total billed charges,All Other,214.97,83,,214.97,percent of total billed charges,All Other,207.2,,,207.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",181.3,70,,181.3,percent of total billed charges,All Other,319.8,,,319.8,Fee Schedule,,271.05,,,271.05,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3227,
INJ W/FLUOR EVAL CV DEVICE,36598,CPT,,42036598,CDM,761,RC,,,both,,,794,587.56,,,587.56,Other,150% of Medicare + 9.63% HCRA Surcharge,357.3,45,,357.3,percent of total billed charges,Critical Access Hospital RCC factor,2480,,,2480,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2232,,,2232,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",393.03,,,393.03,Other,110% of Medicare,539.92,,,539.92,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",967,,,967,Other,186% of Medicaid,635.2,,,635.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",635.2,,,635.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",635.2,,,635.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",555.8,70,,555.8,percent of total billed charges,All Other,173.84,,,173.84,Fee Schedule,,147.34,,,147.34,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",519.86,,,519.86,Other,100% of Medicaid,519.86,,,519.86,Other,100% of Medicaid,519.86,,,519.86,Other,100% of Medicaid,519.86,,,519.86,Other,100% of Medicaid,1169.68,,,1169.68,Other,225% of Medicaid,795.38,,,795.38,Other,153% of Medicaid,1169.68,,,1169.68,Other,225% of Medicaid,727.8,,,727.8,Other,140% of Medicaid,1169.68,,,1169.68,Other,225% of Medicaid,1351.62,,,1351.62,Other,260% of Medicaid,1684.33,,,1684.33,Other,324% of Medicaid,1117.69,,,1117.69,Other,215% of Medicaid,1117.69,,,1117.69,Other,215% of Medicaid,649.82,,,649.82,Other,125% of Medicaid,147.34,7216,
PORT FLUSH SUBSEQUENT,96523,CPT,,45096523,CDM,761,RC,,,both,,,243,179.82,,,179.82,Other,150% of Medicare + 9.63% HCRA Surcharge,109.35,45,,109.35,percent of total billed charges,Critical Access Hospital RCC factor,598,,,598,Fee Schedule,,538,,,538,Fee Schedule,,170.12,,,170.12,Fee Schedule,,153.01,,,153.01,Fee Schedule,,144.61,,,144.61,Fee Schedule,,120.29,,,120.29,Other,110% of Medicare,165.24,68,,165.24,percent of total billed charges,All Other,58,,,58,Other,186% of Medicaid,201.69,,,201.69,Case Rate,,201.69,,,201.69,Case Rate,,201.69,,,201.69,Case Rate,,201.69,,,201.69,Case Rate,,201.69,,,201.69,Case Rate,,194.4,,,194.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",170.1,70,,170.1,percent of total billed charges,All Other,129.56,,,129.56,Fee Schedule,,109.81,,,109.81,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",31.2,,,31.2,Other,100% of Medicaid,31.2,,,31.2,Other,100% of Medicaid,31.2,,,31.2,Other,100% of Medicaid,31.2,,,31.2,Other,100% of Medicaid,70.2,,,70.2,Other,225% of Medicaid,47.74,,,47.74,Other,153% of Medicaid,70.2,,,70.2,Other,225% of Medicaid,43.68,,,43.68,Other,140% of Medicaid,70.2,,,70.2,Other,225% of Medicaid,81.12,,,81.12,Other,260% of Medicaid,101.09,,,101.09,Other,324% of Medicaid,67.08,,,67.08,Other,215% of Medicaid,67.08,,,67.08,Other,215% of Medicaid,39,,,39,Other,125% of Medicaid,31.2,3227,
OFFICE/OUTPATIENT VISIT EST LV,99211,CPT,,46099211,CDM,761,RC,,,both,,,228,168.72,,,168.72,Other,150% of Medicare + 9.63% HCRA Surcharge,102.6,45,,102.6,percent of total billed charges,Critical Access Hospital RCC factor,148.2,65,,148.2,percent of total billed charges,All Other,134.52,65,,134.52,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,112.86,,,112.86,Other,110% of Medicare,155.04,68,,155.04,percent of total billed charges,All Other,0.01,,,0.01,Other,186% of Medicaid,182.4,80,,182.4,percent of total billed charges,All Other,189.24,83,,189.24,percent of total billed charges,All Other,189.24,83,,189.24,percent of total billed charges,All Other,182.4,80,,182.4,percent of total billed charges,All Other,189.24,83,,189.24,percent of total billed charges,All Other,182.4,,,182.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",159.6,70,,159.6,percent of total billed charges,All Other,42.64,,,42.64,Fee Schedule,,36.14,,,36.14,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3227,
OFFICE/OUTPATIENT VISIT EST LV,99211,CPT,,47099211,CDM,761,RC,,,both,,,228,168.72,,,168.72,Other,150% of Medicare + 9.63% HCRA Surcharge,102.6,45,,102.6,percent of total billed charges,Critical Access Hospital RCC factor,148.2,65,,148.2,percent of total billed charges,All Other,134.52,65,,134.52,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,112.86,,,112.86,Other,110% of Medicare,155.04,68,,155.04,percent of total billed charges,All Other,0.01,,,0.01,Other,186% of Medicaid,182.4,80,,182.4,percent of total billed charges,All Other,189.24,83,,189.24,percent of total billed charges,All Other,189.24,83,,189.24,percent of total billed charges,All Other,182.4,80,,182.4,percent of total billed charges,All Other,189.24,83,,189.24,percent of total billed charges,All Other,182.4,,,182.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",159.6,70,,159.6,percent of total billed charges,All Other,42.64,,,42.64,Fee Schedule,,36.14,,,36.14,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3227,
OFFICE/OUTPATIENT VISIT EST LV,99211,CPT,,49099211,CDM,761,RC,,,both,,,228,168.72,,,168.72,Other,150% of Medicare + 9.63% HCRA Surcharge,102.6,45,,102.6,percent of total billed charges,Critical Access Hospital RCC factor,148.2,65,,148.2,percent of total billed charges,All Other,134.52,65,,134.52,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,112.86,,,112.86,Other,110% of Medicare,155.04,68,,155.04,percent of total billed charges,All Other,0.01,,,0.01,Other,186% of Medicaid,182.4,80,,182.4,percent of total billed charges,All Other,189.24,83,,189.24,percent of total billed charges,All Other,189.24,83,,189.24,percent of total billed charges,All Other,182.4,80,,182.4,percent of total billed charges,All Other,189.24,83,,189.24,percent of total billed charges,All Other,182.4,,,182.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",159.6,70,,159.6,percent of total billed charges,All Other,42.64,,,42.64,Fee Schedule,,36.14,,,36.14,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3227,
PUNCH BX SKIN SINGLE LESION,11104,CPT,,54011104,CDM,761,RC,,,both,,,841,622.34,,,622.34,Other,150% of Medicare + 9.63% HCRA Surcharge,378.45,45,,378.45,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",416.3,,,416.3,Other,110% of Medicare,571.88,,,571.88,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1241,,,1241,Other,186% of Medicaid,672.8,,,672.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",672.8,,,672.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",672.8,,,672.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",588.7,70,,588.7,percent of total billed charges,All Other,224.68,,,224.68,Fee Schedule,,190.43,,,190.43,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",667.11,,,667.11,Other,100% of Medicaid,667.11,,,667.11,Other,100% of Medicaid,667.11,,,667.11,Other,100% of Medicaid,667.11,,,667.11,Other,100% of Medicaid,1501,,,1501,Other,225% of Medicaid,1020.68,,,1020.68,Other,153% of Medicaid,1501,,,1501,Other,225% of Medicaid,933.96,,,933.96,Other,140% of Medicaid,1501,,,1501,Other,225% of Medicaid,1734.49,,,1734.49,Other,260% of Medicaid,2161.44,,,2161.44,Other,324% of Medicaid,1434.29,,,1434.29,Other,215% of Medicaid,1434.29,,,1434.29,Other,215% of Medicaid,833.89,,,833.89,Other,125% of Medicaid,190.43,7216,
OFFICE/OUTPAT VISIT EST 5 MIN,99211,CPT,,54099211,CDM,761,RC,,,both,,,228,168.72,,,168.72,Other,150% of Medicare + 9.63% HCRA Surcharge,102.6,45,,102.6,percent of total billed charges,Critical Access Hospital RCC factor,148.2,65,,148.2,percent of total billed charges,All Other,134.52,65,,134.52,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,112.86,,,112.86,Other,110% of Medicare,155.04,68,,155.04,percent of total billed charges,All Other,0.01,,,0.01,Other,186% of Medicaid,182.4,80,,182.4,percent of total billed charges,All Other,189.24,83,,189.24,percent of total billed charges,All Other,189.24,83,,189.24,percent of total billed charges,All Other,182.4,80,,182.4,percent of total billed charges,All Other,189.24,83,,189.24,percent of total billed charges,All Other,182.4,,,182.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",159.6,70,,159.6,percent of total billed charges,All Other,42.64,,,42.64,Fee Schedule,,36.14,,,36.14,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3227,
I&D ABSC; SMPL OR SGL,10060,CPT,,73010060,CDM,761,RC,,,both,,,587,434.38,,,434.38,Other,150% of Medicare + 9.63% HCRA Surcharge,264.15,45,,264.15,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",290.57,,,290.57,Other,110% of Medicare,399.16,,,399.16,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",733,,,733,Other,186% of Medicaid,469.6,,,469.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",469.6,,,469.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",469.6,,,469.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",410.9,70,,410.9,percent of total billed charges,All Other,505.12,,,505.12,Fee Schedule,,428.12,,,428.12,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",394.14,,,394.14,Other,100% of Medicaid,394.14,,,394.14,Other,100% of Medicaid,394.14,,,394.14,Other,100% of Medicaid,394.14,,,394.14,Other,100% of Medicaid,886.83,,,886.83,Other,225% of Medicaid,603.04,,,603.04,Other,153% of Medicaid,886.83,,,886.83,Other,225% of Medicaid,551.8,,,551.8,Other,140% of Medicaid,886.83,,,886.83,Other,225% of Medicaid,1024.78,,,1024.78,Other,260% of Medicaid,1277.03,,,1277.03,Other,324% of Medicaid,847.41,,,847.41,Other,215% of Medicaid,847.41,,,847.41,Other,215% of Medicaid,492.68,,,492.68,Other,125% of Medicaid,264.15,7216,
I&D ABSC; COMPL OR MULTI,10061,CPT,,73010061,CDM,761,RC,,,both,,,841,622.34,,,622.34,Other,150% of Medicare + 9.63% HCRA Surcharge,378.45,45,,378.45,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",416.3,,,416.3,Other,110% of Medicare,571.88,,,571.88,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",733,,,733,Other,186% of Medicaid,672.8,,,672.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",672.8,,,672.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",672.8,,,672.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",588.7,70,,588.7,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",394.14,,,394.14,Other,100% of Medicaid,394.14,,,394.14,Other,100% of Medicaid,394.14,,,394.14,Other,100% of Medicaid,394.14,,,394.14,Other,100% of Medicaid,886.83,,,886.83,Other,225% of Medicaid,603.04,,,603.04,Other,153% of Medicaid,886.83,,,886.83,Other,225% of Medicaid,551.8,,,551.8,Other,140% of Medicaid,886.83,,,886.83,Other,225% of Medicaid,1024.78,,,1024.78,Other,260% of Medicaid,1277.03,,,1277.03,Other,324% of Medicaid,847.41,,,847.41,Other,215% of Medicaid,847.41,,,847.41,Other,215% of Medicaid,492.68,,,492.68,Other,125% of Medicaid,378.45,7216,
I&D PILONID CYS; SMPL,10080,CPT,,73010080,CDM,761,RC,,,both,,,1462,1081.88,,,1081.88,Other,150% of Medicare + 9.63% HCRA Surcharge,657.9,45,,657.9,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",723.69,,,723.69,Other,110% of Medicare,994.16,,,994.16,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",733,,,733,Other,186% of Medicaid,1169.6,,,1169.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1169.6,,,1169.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1169.6,,,1169.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1023.4,70,,1023.4,percent of total billed charges,All Other,506.76,,,506.76,Fee Schedule,,429.51,,,429.51,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",394.14,,,394.14,Other,100% of Medicaid,394.14,,,394.14,Other,100% of Medicaid,394.14,,,394.14,Other,100% of Medicaid,394.14,,,394.14,Other,100% of Medicaid,886.83,,,886.83,Other,225% of Medicaid,603.04,,,603.04,Other,153% of Medicaid,886.83,,,886.83,Other,225% of Medicaid,551.8,,,551.8,Other,140% of Medicaid,886.83,,,886.83,Other,225% of Medicaid,1024.78,,,1024.78,Other,260% of Medicaid,1277.03,,,1277.03,Other,324% of Medicaid,847.41,,,847.41,Other,215% of Medicaid,847.41,,,847.41,Other,215% of Medicaid,492.68,,,492.68,Other,125% of Medicaid,394.14,7216,
I&D PILONID CYST; CPLX,10081,CPT,,73010081,CDM,761,RC,,,both,,,3098,2292.53,,,2292.53,Other,150% of Medicare + 9.63% HCRA Surcharge,1394.1,45,,1394.1,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",1533.51,,,1533.51,Other,110% of Medicare,2106.64,,,2106.64,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1207,,,1207,Other,186% of Medicaid,2478.4,,,2478.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2478.4,,,2478.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2478.4,,,2478.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2168.6,70,,2168.6,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",648.98,,,648.98,Other,100% of Medicaid,648.98,,,648.98,Other,100% of Medicaid,648.98,,,648.98,Other,100% of Medicaid,648.98,,,648.98,Other,100% of Medicaid,1460.2,,,1460.2,Other,225% of Medicaid,992.94,,,992.94,Other,153% of Medicaid,1460.2,,,1460.2,Other,225% of Medicaid,908.57,,,908.57,Other,140% of Medicaid,1460.2,,,1460.2,Other,225% of Medicaid,1687.34,,,1687.34,Other,260% of Medicaid,2102.69,,,2102.69,Other,324% of Medicaid,1395.3,,,1395.3,Other,215% of Medicaid,1395.3,,,1395.3,Other,215% of Medicaid,811.22,,,811.22,Other,125% of Medicaid,648.98,7216,
I&D HEMATOMA/FLUID,10140,CPT,,73010140,CDM,761,RC,,,both,,,4951,3663.75,,,3663.75,Other,150% of Medicare + 9.63% HCRA Surcharge,2227.95,45,,2227.95,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3648,,,3648,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3283,,,3283,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3101,,,3101,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2450.75,,,2450.75,Other,110% of Medicare,3366.68,,,3366.68,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1207,,,1207,Other,186% of Medicaid,3960.8,,,3960.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",3960.8,,,3960.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",3960.8,,,3960.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",3465.7,70,,3465.7,percent of total billed charges,All Other,569.08,,,569.08,Fee Schedule,,482.33,,,482.33,Fee Schedule,,4055,,,4055,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3649,,,3649,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4055,,,4055,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3448,,,3448,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",648.98,,,648.98,Other,100% of Medicaid,648.98,,,648.98,Other,100% of Medicaid,648.98,,,648.98,Other,100% of Medicaid,648.98,,,648.98,Other,100% of Medicaid,1460.2,,,1460.2,Other,225% of Medicaid,992.94,,,992.94,Other,153% of Medicaid,1460.2,,,1460.2,Other,225% of Medicaid,908.57,,,908.57,Other,140% of Medicaid,1460.2,,,1460.2,Other,225% of Medicaid,1687.34,,,1687.34,Other,260% of Medicaid,2102.69,,,2102.69,Other,324% of Medicaid,1395.3,,,1395.3,Other,215% of Medicaid,1395.3,,,1395.3,Other,215% of Medicaid,811.22,,,811.22,Other,125% of Medicaid,482.33,7216,
PUNCT ASP - ABSC HEMAT CYST,10160,CPT,,73010160,CDM,761,RC,,,both,,,841,622.34,,,622.34,Other,150% of Medicare + 9.63% HCRA Surcharge,378.45,45,,378.45,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",416.3,,,416.3,Other,110% of Medicare,571.88,,,571.88,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",733,,,733,Other,186% of Medicaid,672.8,,,672.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",672.8,,,672.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",672.8,,,672.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",588.7,70,,588.7,percent of total billed charges,All Other,457.56,,,457.56,Fee Schedule,,387.81,,,387.81,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",394.14,,,394.14,Other,100% of Medicaid,394.14,,,394.14,Other,100% of Medicaid,394.14,,,394.14,Other,100% of Medicaid,394.14,,,394.14,Other,100% of Medicaid,886.83,,,886.83,Other,225% of Medicaid,603.04,,,603.04,Other,153% of Medicaid,886.83,,,886.83,Other,225% of Medicaid,551.8,,,551.8,Other,140% of Medicaid,886.83,,,886.83,Other,225% of Medicaid,1024.78,,,1024.78,Other,260% of Medicaid,1277.03,,,1277.03,Other,324% of Medicaid,847.41,,,847.41,Other,215% of Medicaid,847.41,,,847.41,Other,215% of Medicaid,492.68,,,492.68,Other,125% of Medicaid,378.45,7216,
I&D CPLX POSTOP WND INF,10180,CPT,,73010180,CDM,761,RC,,,both,,,5816,4303.85,,,4303.85,Other,150% of Medicare + 9.63% HCRA Surcharge,2617.2,45,,2617.2,percent of total billed charges,Critical Access Hospital RCC factor,2480,,,2480,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2232,,,2232,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4476,,,4476,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4028,,,4028,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3805,,,3805,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2878.92,,,2878.92,Other,110% of Medicare,3954.88,,,3954.88,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2493,,,2493,Other,186% of Medicaid,4652.8,,,4652.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",4652.8,,,4652.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",4252,,,4252,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",4071.2,70,,4071.2,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",4531,,,4531,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4079,,,4079,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4531,,,4531,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3852,,,3852,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",1340.24,,,1340.24,Other,100% of Medicaid,1340.24,,,1340.24,Other,100% of Medicaid,1340.24,,,1340.24,Other,100% of Medicaid,1340.24,,,1340.24,Other,100% of Medicaid,3015.54,,,3015.54,Other,225% of Medicaid,2050.57,,,2050.57,Other,153% of Medicaid,3015.54,,,3015.54,Other,225% of Medicaid,1876.34,,,1876.34,Other,140% of Medicaid,3015.54,,,3015.54,Other,225% of Medicaid,3484.62,,,3484.62,Other,260% of Medicaid,4342.38,,,4342.38,Other,324% of Medicaid,2881.52,,,2881.52,Other,215% of Medicaid,2881.52,,,2881.52,Other,215% of Medicaid,1675.3,,,1675.3,Other,125% of Medicaid,1340.24,7216,
DEBR EXZ/INF SKIN; 10% BS,11000,CPT,,73011000,CDM,761,RC,,,both,,,1309,968.66,,,968.66,Other,150% of Medicare + 9.63% HCRA Surcharge,589.05,45,,589.05,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",647.96,,,647.96,Other,110% of Medicare,890.12,,,890.12,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1353,,,1353,Other,186% of Medicaid,1047.2,,,1047.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1047.2,,,1047.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1047.2,,,1047.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",916.3,70,,916.3,percent of total billed charges,All Other,132.84,,,132.84,Fee Schedule,,112.59,,,112.59,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",727.17,,,727.17,Other,100% of Medicaid,727.17,,,727.17,Other,100% of Medicaid,727.17,,,727.17,Other,100% of Medicaid,727.17,,,727.17,Other,100% of Medicaid,1636.12,,,1636.12,Other,225% of Medicaid,1112.56,,,1112.56,Other,153% of Medicaid,1636.12,,,1636.12,Other,225% of Medicaid,1018.03,,,1018.03,Other,140% of Medicaid,1636.12,,,1636.12,Other,225% of Medicaid,1890.63,,,1890.63,Other,260% of Medicaid,2356.02,,,2356.02,Other,324% of Medicaid,1563.41,,,1563.41,Other,215% of Medicaid,1563.41,,,1563.41,Other,215% of Medicaid,908.96,,,908.96,Other,125% of Medicaid,112.59,7216,
DEBRIDE INFECTED SKIN ADD-ON =<10% BS,11001,CPT,,73011001,CDM,761,RC,,,both,,,225,166.5,,,166.5,Other,150% of Medicare + 9.63% HCRA Surcharge,101.25,45,,101.25,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",111.38,,,111.38,Other,110% of Medicare,153,,,153,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1353,,,1353,Other,186% of Medicaid,180,,,180,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",180,,,180,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",180,,,180,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",157.5,70,,157.5,percent of total billed charges,All Other,68.88,,,68.88,Fee Schedule,,58.38,,,58.38,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",727.17,,,727.17,Other,100% of Medicaid,727.17,,,727.17,Other,100% of Medicaid,727.17,,,727.17,Other,100% of Medicaid,727.17,,,727.17,Other,100% of Medicaid,1636.12,,,1636.12,Other,225% of Medicaid,1112.56,,,1112.56,Other,153% of Medicaid,1636.12,,,1636.12,Other,225% of Medicaid,1018.03,,,1018.03,Other,140% of Medicaid,1636.12,,,1636.12,Other,225% of Medicaid,1890.63,,,1890.63,Other,260% of Medicaid,2356.02,,,2356.02,Other,324% of Medicaid,1563.41,,,1563.41,Other,215% of Medicaid,1563.41,,,1563.41,Other,215% of Medicaid,908.96,,,908.96,Other,125% of Medicaid,58.38,7216,
DEBRIDE SKIN AT FX SITE,11010,CPT,,73011010,CDM,761,RC,,,both,,,1528,1130.72,,,1130.72,Other,150% of Medicare + 9.63% HCRA Surcharge,687.6,45,,687.6,percent of total billed charges,Critical Access Hospital RCC factor,2480,,,2480,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2232,,,2232,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",756.36,,,756.36,Other,110% of Medicare,1039.04,,,1039.04,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1353,,,1353,Other,186% of Medicaid,1222.4,,,1222.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1222.4,,,1222.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",4252,,,4252,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1069.6,70,,1069.6,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",727.17,,,727.17,Other,100% of Medicaid,727.17,,,727.17,Other,100% of Medicaid,727.17,,,727.17,Other,100% of Medicaid,727.17,,,727.17,Other,100% of Medicaid,1636.12,,,1636.12,Other,225% of Medicaid,1112.56,,,1112.56,Other,153% of Medicaid,1636.12,,,1636.12,Other,225% of Medicaid,1018.03,,,1018.03,Other,140% of Medicaid,1636.12,,,1636.12,Other,225% of Medicaid,1890.63,,,1890.63,Other,260% of Medicaid,2356.02,,,2356.02,Other,324% of Medicaid,1563.41,,,1563.41,Other,215% of Medicaid,1563.41,,,1563.41,Other,215% of Medicaid,908.96,,,908.96,Other,125% of Medicaid,687.6,7216,
DEB SUBQ TISSUE 20 SQ CM/<,11042,CPT,,73011042,CDM,761,RC,,,both,,,1041,770.34,,,770.34,Other,150% of Medicare + 9.63% HCRA Surcharge,468.45,45,,468.45,percent of total billed charges,Critical Access Hospital RCC factor,2480,,,2480,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2232,,,2232,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",515.3,,,515.3,Other,110% of Medicare,707.88,,,707.88,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1353,,,1353,Other,186% of Medicaid,832.8,,,832.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",832.8,,,832.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",4252,,,4252,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",728.7,70,,728.7,percent of total billed charges,All Other,288.64,,,288.64,Fee Schedule,,244.64,,,244.64,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",727.17,,,727.17,Other,100% of Medicaid,727.17,,,727.17,Other,100% of Medicaid,727.17,,,727.17,Other,100% of Medicaid,727.17,,,727.17,Other,100% of Medicaid,1636.12,,,1636.12,Other,225% of Medicaid,1112.56,,,1112.56,Other,153% of Medicaid,1636.12,,,1636.12,Other,225% of Medicaid,1018.03,,,1018.03,Other,140% of Medicaid,1636.12,,,1636.12,Other,225% of Medicaid,1890.63,,,1890.63,Other,260% of Medicaid,2356.02,,,2356.02,Other,324% of Medicaid,1563.41,,,1563.41,Other,215% of Medicaid,1563.41,,,1563.41,Other,215% of Medicaid,908.96,,,908.96,Other,125% of Medicaid,244.64,7216,
DEB MUSC/FASCIA 20 SQ CM/<,11043,CPT,,73011043,CDM,761,RC,,,both,,,1402,1037.48,,,1037.48,Other,150% of Medicare + 9.63% HCRA Surcharge,630.9,45,,630.9,percent of total billed charges,Critical Access Hospital RCC factor,2480,,,2480,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2232,,,2232,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",693.99,,,693.99,Other,110% of Medicare,953.36,,,953.36,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1353,,,1353,Other,186% of Medicaid,1121.6,,,1121.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1121.6,,,1121.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",4252,,,4252,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",981.4,70,,981.4,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",727.17,,,727.17,Other,100% of Medicaid,727.17,,,727.17,Other,100% of Medicaid,727.17,,,727.17,Other,100% of Medicaid,727.17,,,727.17,Other,100% of Medicaid,1636.12,,,1636.12,Other,225% of Medicaid,1112.56,,,1112.56,Other,153% of Medicaid,1636.12,,,1636.12,Other,225% of Medicaid,1018.03,,,1018.03,Other,140% of Medicaid,1636.12,,,1636.12,Other,225% of Medicaid,1890.63,,,1890.63,Other,260% of Medicaid,2356.02,,,2356.02,Other,324% of Medicaid,1563.41,,,1563.41,Other,215% of Medicaid,1563.41,,,1563.41,Other,215% of Medicaid,908.96,,,908.96,Other,125% of Medicaid,630.9,7216,
DEB BONE 20 SQ CM/<,11044,CPT,,73011044,CDM,761,RC,,,both,,,3377,2498.99,,,2498.99,Other,150% of Medicare + 9.63% HCRA Surcharge,1519.65,45,,1519.65,percent of total billed charges,Critical Access Hospital RCC factor,2480,,,2480,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2232,,,2232,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3648,,,3648,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3283,,,3283,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3101,,,3101,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",1671.62,,,1671.62,Other,110% of Medicare,2296.36,,,2296.36,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2493,,,2493,Other,186% of Medicaid,2701.6,,,2701.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2701.6,,,2701.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",4252,,,4252,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2363.9,70,,2363.9,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",1340.24,,,1340.24,Other,100% of Medicaid,1340.24,,,1340.24,Other,100% of Medicaid,1340.24,,,1340.24,Other,100% of Medicaid,1340.24,,,1340.24,Other,100% of Medicaid,3015.54,,,3015.54,Other,225% of Medicaid,2050.57,,,2050.57,Other,153% of Medicaid,3015.54,,,3015.54,Other,225% of Medicaid,1876.34,,,1876.34,Other,140% of Medicaid,3015.54,,,3015.54,Other,225% of Medicaid,3484.62,,,3484.62,Other,260% of Medicaid,4342.38,,,4342.38,Other,324% of Medicaid,2881.52,,,2881.52,Other,215% of Medicaid,2881.52,,,2881.52,Other,215% of Medicaid,1675.3,,,1675.3,Other,125% of Medicaid,1340.24,7216,
DEB SUBQ TISSUE ADD-ON =<20 SQ CM,11045,CPT,,73011045,CDM,761,RC,,,both,,,930,688.2,,,688.2,Other,150% of Medicare + 9.63% HCRA Surcharge,418.5,45,,418.5,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3648,,,3648,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3283,,,3283,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3101,,,3101,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",460.35,,,460.35,Other,110% of Medicare,632.4,,,632.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2493,,,2493,Other,186% of Medicaid,744,,,744,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",744,,,744,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",744,,,744,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",651,70,,651,percent of total billed charges,All Other,126.28,,,126.28,Fee Schedule,,107.03,,,107.03,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",1340.24,,,1340.24,Other,100% of Medicaid,1340.24,,,1340.24,Other,100% of Medicaid,1340.24,,,1340.24,Other,100% of Medicaid,1340.24,,,1340.24,Other,100% of Medicaid,3015.54,,,3015.54,Other,225% of Medicaid,2050.57,,,2050.57,Other,153% of Medicaid,3015.54,,,3015.54,Other,225% of Medicaid,1876.34,,,1876.34,Other,140% of Medicaid,3015.54,,,3015.54,Other,225% of Medicaid,3484.62,,,3484.62,Other,260% of Medicaid,4342.38,,,4342.38,Other,324% of Medicaid,2881.52,,,2881.52,Other,215% of Medicaid,2881.52,,,2881.52,Other,215% of Medicaid,1675.3,,,1675.3,Other,125% of Medicaid,107.03,7216,
DEB MUSC/FASCIA ADD-ON =<20 SQ CM,11046,CPT,,73011046,CDM,761,RC,,,both,,,930,688.2,,,688.2,Other,150% of Medicare + 9.63% HCRA Surcharge,418.5,45,,418.5,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3648,,,3648,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3283,,,3283,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3101,,,3101,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",460.35,,,460.35,Other,110% of Medicare,632.4,,,632.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2493,,,2493,Other,186% of Medicaid,744,,,744,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",744,,,744,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",744,,,744,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",651,70,,651,percent of total billed charges,All Other,267.32,,,267.32,Fee Schedule,,226.57,,,226.57,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",1340.24,,,1340.24,Other,100% of Medicaid,1340.24,,,1340.24,Other,100% of Medicaid,1340.24,,,1340.24,Other,100% of Medicaid,1340.24,,,1340.24,Other,100% of Medicaid,3015.54,,,3015.54,Other,225% of Medicaid,2050.57,,,2050.57,Other,153% of Medicaid,3015.54,,,3015.54,Other,225% of Medicaid,1876.34,,,1876.34,Other,140% of Medicaid,3015.54,,,3015.54,Other,225% of Medicaid,3484.62,,,3484.62,Other,260% of Medicaid,4342.38,,,4342.38,Other,324% of Medicaid,2881.52,,,2881.52,Other,215% of Medicaid,2881.52,,,2881.52,Other,215% of Medicaid,1675.3,,,1675.3,Other,125% of Medicaid,226.57,7216,
DEB BONE ADD-ON =<20 SQ CM,11047,CPT,,73011047,CDM,761,RC,,,both,,,2327,1721.99,,,1721.99,Other,150% of Medicare + 9.63% HCRA Surcharge,1047.15,45,,1047.15,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4476,,,4476,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4028,,,4028,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3805,,,3805,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",1151.87,,,1151.87,Other,110% of Medicare,1582.36,,,1582.36,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2493,,,2493,Other,186% of Medicaid,1861.6,,,1861.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1861.6,,,1861.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1861.6,,,1861.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1628.9,70,,1628.9,percent of total billed charges,All Other,467.4,,,467.4,Fee Schedule,,396.15,,,396.15,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",1340.24,,,1340.24,Other,100% of Medicaid,1340.24,,,1340.24,Other,100% of Medicaid,1340.24,,,1340.24,Other,100% of Medicaid,1340.24,,,1340.24,Other,100% of Medicaid,3015.54,,,3015.54,Other,225% of Medicaid,2050.57,,,2050.57,Other,153% of Medicaid,3015.54,,,3015.54,Other,225% of Medicaid,1876.34,,,1876.34,Other,140% of Medicaid,3015.54,,,3015.54,Other,225% of Medicaid,3484.62,,,3484.62,Other,260% of Medicaid,4342.38,,,4342.38,Other,324% of Medicaid,2881.52,,,2881.52,Other,215% of Medicaid,2881.52,,,2881.52,Other,215% of Medicaid,1675.3,,,1675.3,Other,125% of Medicaid,396.15,7216,
PARE BENIGN LES; SGL,11055,CPT,,73011055,CDM,761,RC,,,both,,,408,301.92,,,301.92,Other,150% of Medicare + 9.63% HCRA Surcharge,183.6,45,,183.6,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",201.96,,,201.96,Other,110% of Medicare,277.44,,,277.44,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",733,,,733,Other,186% of Medicaid,326.4,,,326.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",326.4,,,326.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",326.4,,,326.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",285.6,70,,285.6,percent of total billed charges,All Other,77.08,,,77.08,Fee Schedule,,65.33,,,65.33,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",394.14,,,394.14,Other,100% of Medicaid,394.14,,,394.14,Other,100% of Medicaid,394.14,,,394.14,Other,100% of Medicaid,394.14,,,394.14,Other,100% of Medicaid,886.83,,,886.83,Other,225% of Medicaid,603.04,,,603.04,Other,153% of Medicaid,886.83,,,886.83,Other,225% of Medicaid,551.8,,,551.8,Other,140% of Medicaid,886.83,,,886.83,Other,225% of Medicaid,1024.78,,,1024.78,Other,260% of Medicaid,1277.03,,,1277.03,Other,324% of Medicaid,847.41,,,847.41,Other,215% of Medicaid,847.41,,,847.41,Other,215% of Medicaid,492.68,,,492.68,Other,125% of Medicaid,65.33,7216,
TRIM SKIN LESIONS 2 TO 4,11056,CPT,,73011056,CDM,761,RC,,,both,,,408,301.92,,,301.92,Other,150% of Medicare + 9.63% HCRA Surcharge,183.6,45,,183.6,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",201.96,,,201.96,Other,110% of Medicare,277.44,,,277.44,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",733,,,733,Other,186% of Medicaid,326.4,,,326.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",326.4,,,326.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",326.4,,,326.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",285.6,70,,285.6,percent of total billed charges,All Other,106.6,,,106.6,Fee Schedule,,90.35,,,90.35,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",394.14,,,394.14,Other,100% of Medicaid,394.14,,,394.14,Other,100% of Medicaid,394.14,,,394.14,Other,100% of Medicaid,394.14,,,394.14,Other,100% of Medicaid,886.83,,,886.83,Other,225% of Medicaid,603.04,,,603.04,Other,153% of Medicaid,886.83,,,886.83,Other,225% of Medicaid,551.8,,,551.8,Other,140% of Medicaid,886.83,,,886.83,Other,225% of Medicaid,1024.78,,,1024.78,Other,260% of Medicaid,1277.03,,,1277.03,Other,324% of Medicaid,847.41,,,847.41,Other,215% of Medicaid,847.41,,,847.41,Other,215% of Medicaid,492.68,,,492.68,Other,125% of Medicaid,90.35,7216,
TRIM SKIN LESIONS OVER 4,11057,CPT,,73011057,CDM,761,RC,,,both,,,460,340.4,,,340.4,Other,150% of Medicare + 9.63% HCRA Surcharge,207,45,,207,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",227.7,,,227.7,Other,110% of Medicare,312.8,,,312.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",733,,,733,Other,186% of Medicaid,368,,,368,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",368,,,368,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",368,,,368,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",322,70,,322,percent of total billed charges,All Other,137.76,,,137.76,Fee Schedule,,116.76,,,116.76,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",394.14,,,394.14,Other,100% of Medicaid,394.14,,,394.14,Other,100% of Medicaid,394.14,,,394.14,Other,100% of Medicaid,394.14,,,394.14,Other,100% of Medicaid,886.83,,,886.83,Other,225% of Medicaid,603.04,,,603.04,Other,153% of Medicaid,886.83,,,886.83,Other,225% of Medicaid,551.8,,,551.8,Other,140% of Medicaid,886.83,,,886.83,Other,225% of Medicaid,1024.78,,,1024.78,Other,260% of Medicaid,1277.03,,,1277.03,Other,324% of Medicaid,847.41,,,847.41,Other,215% of Medicaid,847.41,,,847.41,Other,215% of Medicaid,492.68,,,492.68,Other,125% of Medicaid,116.76,7216,
PUNCH BX SKIN SINGLE LESION,11104,CPT,,73011104,CDM,761,RC,,,both,,,841,622.34,,,622.34,Other,150% of Medicare + 9.63% HCRA Surcharge,378.45,45,,378.45,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",416.3,,,416.3,Other,110% of Medicare,571.88,,,571.88,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1241,,,1241,Other,186% of Medicaid,672.8,,,672.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",672.8,,,672.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",672.8,,,672.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",588.7,70,,588.7,percent of total billed charges,All Other,224.68,,,224.68,Fee Schedule,,190.43,,,190.43,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",667.11,,,667.11,Other,100% of Medicaid,667.11,,,667.11,Other,100% of Medicaid,667.11,,,667.11,Other,100% of Medicaid,667.11,,,667.11,Other,100% of Medicaid,1501,,,1501,Other,225% of Medicaid,1020.68,,,1020.68,Other,153% of Medicaid,1501,,,1501,Other,225% of Medicaid,933.96,,,933.96,Other,140% of Medicaid,1501,,,1501,Other,225% of Medicaid,1734.49,,,1734.49,Other,260% of Medicaid,2161.44,,,2161.44,Other,324% of Medicaid,1434.29,,,1434.29,Other,215% of Medicaid,1434.29,,,1434.29,Other,215% of Medicaid,833.89,,,833.89,Other,125% of Medicaid,190.43,7216,
PUNCH BX SKIN EA SEP/ADDL,11105,CPT,,73011105,CDM,761,RC,,,both,,,695,514.3,,,514.3,Other,150% of Medicare + 9.63% HCRA Surcharge,312.75,45,,312.75,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",344.03,,,344.03,Other,110% of Medicare,472.6,,,472.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1241,,,1241,Other,186% of Medicaid,556,,,556,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",556,,,556,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",556,,,556,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",486.5,70,,486.5,percent of total billed charges,All Other,123,,,123,Fee Schedule,,104.25,,,104.25,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",667.11,,,667.11,Other,100% of Medicaid,667.11,,,667.11,Other,100% of Medicaid,667.11,,,667.11,Other,100% of Medicaid,667.11,,,667.11,Other,100% of Medicaid,1501,,,1501,Other,225% of Medicaid,1020.68,,,1020.68,Other,153% of Medicaid,1501,,,1501,Other,225% of Medicaid,933.96,,,933.96,Other,140% of Medicaid,1501,,,1501,Other,225% of Medicaid,1734.49,,,1734.49,Other,260% of Medicaid,2161.44,,,2161.44,Other,324% of Medicaid,1434.29,,,1434.29,Other,215% of Medicaid,1434.29,,,1434.29,Other,215% of Medicaid,833.89,,,833.89,Other,125% of Medicaid,104.25,7216,
INCAL BX SKN SINGLE LES,11106,CPT,,73011106,CDM,761,RC,,,both,,,1353,1001.22,,,1001.22,Other,150% of Medicare + 9.63% HCRA Surcharge,608.85,45,,608.85,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",669.74,,,669.74,Other,110% of Medicare,920.04,,,920.04,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1241,,,1241,Other,186% of Medicaid,1082.4,,,1082.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1082.4,,,1082.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1082.4,,,1082.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",947.1,70,,947.1,percent of total billed charges,All Other,272.24,,,272.24,Fee Schedule,,230.74,,,230.74,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",667.11,,,667.11,Other,100% of Medicaid,667.11,,,667.11,Other,100% of Medicaid,667.11,,,667.11,Other,100% of Medicaid,667.11,,,667.11,Other,100% of Medicaid,1501,,,1501,Other,225% of Medicaid,1020.68,,,1020.68,Other,153% of Medicaid,1501,,,1501,Other,225% of Medicaid,933.96,,,933.96,Other,140% of Medicaid,1501,,,1501,Other,225% of Medicaid,1734.49,,,1734.49,Other,260% of Medicaid,2161.44,,,2161.44,Other,324% of Medicaid,1434.29,,,1434.29,Other,215% of Medicaid,1434.29,,,1434.29,Other,215% of Medicaid,833.89,,,833.89,Other,125% of Medicaid,230.74,7216,
INCAL BX SKN EA SEP/ADDL,11107,CPT,,73011107,CDM,761,RC,,,both,,,445,329.3,,,329.3,Other,150% of Medicare + 9.63% HCRA Surcharge,200.25,45,,200.25,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",220.28,,,220.28,Other,110% of Medicare,302.6,,,302.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1241,,,1241,Other,186% of Medicaid,356,,,356,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",356,,,356,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",356,,,356,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",311.5,70,,311.5,percent of total billed charges,All Other,149.24,,,149.24,Fee Schedule,,126.49,,,126.49,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",667.11,,,667.11,Other,100% of Medicaid,667.11,,,667.11,Other,100% of Medicaid,667.11,,,667.11,Other,100% of Medicaid,667.11,,,667.11,Other,100% of Medicaid,1501,,,1501,Other,225% of Medicaid,1020.68,,,1020.68,Other,153% of Medicaid,1501,,,1501,Other,225% of Medicaid,933.96,,,933.96,Other,140% of Medicaid,1501,,,1501,Other,225% of Medicaid,1734.49,,,1734.49,Other,260% of Medicaid,2161.44,,,2161.44,Other,324% of Medicaid,1434.29,,,1434.29,Other,215% of Medicaid,1434.29,,,1434.29,Other,215% of Medicaid,833.89,,,833.89,Other,125% of Medicaid,126.49,7216,
REM SKIN TAGS; <=15 LESIONS,11200,CPT,,73011200,CDM,761,RC,,,both,,,439,324.86,,,324.86,Other,150% of Medicare + 9.63% HCRA Surcharge,197.55,45,,197.55,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",217.31,,,217.31,Other,110% of Medicare,298.52,,,298.52,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",733,,,733,Other,186% of Medicaid,351.2,,,351.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",351.2,,,351.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",351.2,,,351.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",307.3,70,,307.3,percent of total billed charges,All Other,364.08,,,364.08,Fee Schedule,,308.58,,,308.58,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",394.14,,,394.14,Other,100% of Medicaid,394.14,,,394.14,Other,100% of Medicaid,394.14,,,394.14,Other,100% of Medicaid,394.14,,,394.14,Other,100% of Medicaid,886.83,,,886.83,Other,225% of Medicaid,603.04,,,603.04,Other,153% of Medicaid,886.83,,,886.83,Other,225% of Medicaid,551.8,,,551.8,Other,140% of Medicaid,886.83,,,886.83,Other,225% of Medicaid,1024.78,,,1024.78,Other,260% of Medicaid,1277.03,,,1277.03,Other,324% of Medicaid,847.41,,,847.41,Other,215% of Medicaid,847.41,,,847.41,Other,215% of Medicaid,492.68,,,492.68,Other,125% of Medicaid,197.55,7216,
DEBRIDE NAIL 1-5,11720,CPT,,73011720,CDM,761,RC,,,both,,,198,146.52,,,146.52,Other,150% of Medicare + 9.63% HCRA Surcharge,89.1,45,,89.1,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",98.01,,,98.01,Other,110% of Medicare,134.64,,,134.64,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",354,,,354,Other,186% of Medicaid,158.4,,,158.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",158.4,,,158.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",158.4,,,158.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",138.6,70,,138.6,percent of total billed charges,All Other,70.52,,,70.52,Fee Schedule,,59.77,,,59.77,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",190.08,,,190.08,Other,100% of Medicaid,190.08,,,190.08,Other,100% of Medicaid,190.08,,,190.08,Other,100% of Medicaid,190.08,,,190.08,Other,100% of Medicaid,427.68,,,427.68,Other,225% of Medicaid,290.82,,,290.82,Other,153% of Medicaid,427.68,,,427.68,Other,225% of Medicaid,266.11,,,266.11,Other,140% of Medicaid,427.68,,,427.68,Other,225% of Medicaid,494.21,,,494.21,Other,260% of Medicaid,615.86,,,615.86,Other,324% of Medicaid,408.67,,,408.67,Other,215% of Medicaid,408.67,,,408.67,Other,215% of Medicaid,237.6,,,237.6,Other,125% of Medicaid,59.77,7216,
DEBRIDE NAIL 6 OR MORE,11721,CPT,,73011721,CDM,761,RC,,,both,,,212,156.88,,,156.88,Other,150% of Medicare + 9.63% HCRA Surcharge,95.4,45,,95.4,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",104.94,,,104.94,Other,110% of Medicare,144.16,,,144.16,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",354,,,354,Other,186% of Medicaid,169.6,,,169.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",169.6,,,169.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",169.6,,,169.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",148.4,70,,148.4,percent of total billed charges,All Other,114.8,,,114.8,Fee Schedule,,97.3,,,97.3,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",190.08,,,190.08,Other,100% of Medicaid,190.08,,,190.08,Other,100% of Medicaid,190.08,,,190.08,Other,100% of Medicaid,190.08,,,190.08,Other,100% of Medicaid,427.68,,,427.68,Other,225% of Medicaid,290.82,,,290.82,Other,153% of Medicaid,427.68,,,427.68,Other,225% of Medicaid,266.11,,,266.11,Other,140% of Medicaid,427.68,,,427.68,Other,225% of Medicaid,494.21,,,494.21,Other,260% of Medicaid,615.86,,,615.86,Other,324% of Medicaid,408.67,,,408.67,Other,215% of Medicaid,408.67,,,408.67,Other,215% of Medicaid,237.6,,,237.6,Other,125% of Medicaid,95.4,7216,
SPL AVULSE NP; SGL,11730,CPT,,73011730,CDM,761,RC,,,both,,,408,301.92,,,301.92,Other,150% of Medicare + 9.63% HCRA Surcharge,183.6,45,,183.6,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",201.96,,,201.96,Other,110% of Medicare,277.44,,,277.44,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",354,,,354,Other,186% of Medicaid,326.4,,,326.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",326.4,,,326.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",326.4,,,326.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",285.6,70,,285.6,percent of total billed charges,All Other,257.48,,,257.48,Fee Schedule,,218.23,,,218.23,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",190.08,,,190.08,Other,100% of Medicaid,190.08,,,190.08,Other,100% of Medicaid,190.08,,,190.08,Other,100% of Medicaid,190.08,,,190.08,Other,100% of Medicaid,427.68,,,427.68,Other,225% of Medicaid,290.82,,,290.82,Other,153% of Medicaid,427.68,,,427.68,Other,225% of Medicaid,266.11,,,266.11,Other,140% of Medicaid,427.68,,,427.68,Other,225% of Medicaid,494.21,,,494.21,Other,260% of Medicaid,615.86,,,615.86,Other,324% of Medicaid,408.67,,,408.67,Other,215% of Medicaid,408.67,,,408.67,Other,215% of Medicaid,237.6,,,237.6,Other,125% of Medicaid,183.6,7216,
SPL AVULSE NP; EA ADDTL,11732,CPT,,73011732,CDM,761,RC,,,both,,,300,222,,,222,Other,150% of Medicare + 9.63% HCRA Surcharge,135,45,,135,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",148.5,,,148.5,Other,110% of Medicare,204,,,204,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",354,,,354,Other,186% of Medicaid,240,,,240,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",240,,,240,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",240,,,240,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",210,70,,210,percent of total billed charges,All Other,83.64,,,83.64,Fee Schedule,,70.89,,,70.89,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",190.08,,,190.08,Other,100% of Medicaid,190.08,,,190.08,Other,100% of Medicaid,190.08,,,190.08,Other,100% of Medicaid,190.08,,,190.08,Other,100% of Medicaid,427.68,,,427.68,Other,225% of Medicaid,290.82,,,290.82,Other,153% of Medicaid,427.68,,,427.68,Other,225% of Medicaid,266.11,,,266.11,Other,140% of Medicaid,427.68,,,427.68,Other,225% of Medicaid,494.21,,,494.21,Other,260% of Medicaid,615.86,,,615.86,Other,324% of Medicaid,408.67,,,408.67,Other,215% of Medicaid,408.67,,,408.67,Other,215% of Medicaid,237.6,,,237.6,Other,125% of Medicaid,70.89,7216,
REMOVAL OF NAIL BED,11750,CPT,,73011750,CDM,761,RC,,,both,,,1876,1388.24,,,1388.24,Other,150% of Medicare + 9.63% HCRA Surcharge,844.2,45,,844.2,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",928.62,,,928.62,Other,110% of Medicare,1275.68,,,1275.68,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1241,,,1241,Other,186% of Medicaid,1500.8,,,1500.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1500.8,,,1500.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1500.8,,,1500.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1313.2,70,,1313.2,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",667.11,,,667.11,Other,100% of Medicaid,667.11,,,667.11,Other,100% of Medicaid,667.11,,,667.11,Other,100% of Medicaid,667.11,,,667.11,Other,100% of Medicaid,1501,,,1501,Other,225% of Medicaid,1020.68,,,1020.68,Other,153% of Medicaid,1501,,,1501,Other,225% of Medicaid,933.96,,,933.96,Other,140% of Medicaid,1501,,,1501,Other,225% of Medicaid,1734.49,,,1734.49,Other,260% of Medicaid,2161.44,,,2161.44,Other,324% of Medicaid,1434.29,,,1434.29,Other,215% of Medicaid,1434.29,,,1434.29,Other,215% of Medicaid,833.89,,,833.89,Other,125% of Medicaid,667.11,7216,
LCL SURG WND/DEH EXTENS,13160,CPT,,73013160,CDM,761,RC,,,both,,,5981,4425.95,,,4425.95,Other,150% of Medicare + 9.63% HCRA Surcharge,2691.45,45,,2691.45,percent of total billed charges,Critical Access Hospital RCC factor,2480,,,2480,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2232,,,2232,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3648,,,3648,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3283,,,3283,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3101,,,3101,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2960.6,,,2960.6,Other,110% of Medicare,4067.08,,,4067.08,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2493,,,2493,Other,186% of Medicaid,4784.8,,,4784.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",4784.8,,,4784.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",4252,,,4252,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",4186.7,70,,4186.7,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",4055,,,4055,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3649,,,3649,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4055,,,4055,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3448,,,3448,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",1340.24,,,1340.24,Other,100% of Medicaid,1340.24,,,1340.24,Other,100% of Medicaid,1340.24,,,1340.24,Other,100% of Medicaid,1340.24,,,1340.24,Other,100% of Medicaid,3015.54,,,3015.54,Other,225% of Medicaid,2050.57,,,2050.57,Other,153% of Medicaid,3015.54,,,3015.54,Other,225% of Medicaid,1876.34,,,1876.34,Other,140% of Medicaid,3015.54,,,3015.54,Other,225% of Medicaid,3484.62,,,3484.62,Other,260% of Medicaid,4342.38,,,4342.38,Other,324% of Medicaid,2881.52,,,2881.52,Other,215% of Medicaid,2881.52,,,2881.52,Other,215% of Medicaid,1675.3,,,1675.3,Other,125% of Medicaid,1340.24,7216,
WOUND PREP TRK/ARM/LEG 100 SQ CM/1% BA,15002,CPT,,73015002,CDM,761,RC,,,both,,,3886,2875.65,,,2875.65,Other,150% of Medicare + 9.63% HCRA Surcharge,1748.7,45,,1748.7,percent of total billed charges,Critical Access Hospital RCC factor,2480,,,2480,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2232,,,2232,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3648,,,3648,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3283,,,3283,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3101,,,3101,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",1923.57,,,1923.57,Other,110% of Medicare,2642.48,,,2642.48,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2493,,,2493,Other,186% of Medicaid,3108.8,,,3108.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",3108.8,,,3108.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",4252,,,4252,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2720.2,70,,2720.2,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",4055,,,4055,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3649,,,3649,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4055,,,4055,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3448,,,3448,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",1340.24,,,1340.24,Other,100% of Medicaid,1340.24,,,1340.24,Other,100% of Medicaid,1340.24,,,1340.24,Other,100% of Medicaid,1340.24,,,1340.24,Other,100% of Medicaid,3015.54,,,3015.54,Other,225% of Medicaid,2050.57,,,2050.57,Other,153% of Medicaid,3015.54,,,3015.54,Other,225% of Medicaid,1876.34,,,1876.34,Other,140% of Medicaid,3015.54,,,3015.54,Other,225% of Medicaid,3484.62,,,3484.62,Other,260% of Medicaid,4342.38,,,4342.38,Other,324% of Medicaid,2881.52,,,2881.52,Other,215% of Medicaid,2881.52,,,2881.52,Other,215% of Medicaid,1675.3,,,1675.3,Other,125% of Medicaid,1340.24,7216,
WOUND PREP ADDL 100 CM,15003,CPT,,73015003,CDM,761,RC,,,both,,,1710,1265.4,,,1265.4,Other,150% of Medicare + 9.63% HCRA Surcharge,769.5,45,,769.5,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",846.45,,,846.45,Other,110% of Medicare,1162.8,,,1162.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1353,,,1353,Other,186% of Medicaid,1368,,,1368,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1368,,,1368,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",3578,,,3578,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1197,70,,1197,percent of total billed charges,All Other,219.76,,,219.76,Fee Schedule,,186.26,,,186.26,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",727.17,,,727.17,Other,100% of Medicaid,727.17,,,727.17,Other,100% of Medicaid,727.17,,,727.17,Other,100% of Medicaid,727.17,,,727.17,Other,100% of Medicaid,1636.12,,,1636.12,Other,225% of Medicaid,1112.56,,,1112.56,Other,153% of Medicaid,1636.12,,,1636.12,Other,225% of Medicaid,1018.03,,,1018.03,Other,140% of Medicaid,1636.12,,,1636.12,Other,225% of Medicaid,1890.63,,,1890.63,Other,260% of Medicaid,2356.02,,,2356.02,Other,324% of Medicaid,1563.41,,,1563.41,Other,215% of Medicaid,1563.41,,,1563.41,Other,215% of Medicaid,908.96,,,908.96,Other,125% of Medicaid,186.26,7216,
WOUND PREP F/N/HF/G 100 SQ CM/1% BA,15004,CPT,,73015004,CDM,761,RC,,,both,,,1309,968.66,,,968.66,Other,150% of Medicare + 9.63% HCRA Surcharge,589.05,45,,589.05,percent of total billed charges,Critical Access Hospital RCC factor,2480,,,2480,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2232,,,2232,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",647.96,,,647.96,Other,110% of Medicare,890.12,,,890.12,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2493,,,2493,Other,186% of Medicaid,1047.2,,,1047.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1047.2,,,1047.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",4252,,,4252,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",916.3,70,,916.3,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",1340.24,,,1340.24,Other,100% of Medicaid,1340.24,,,1340.24,Other,100% of Medicaid,1340.24,,,1340.24,Other,100% of Medicaid,1340.24,,,1340.24,Other,100% of Medicaid,3015.54,,,3015.54,Other,225% of Medicaid,2050.57,,,2050.57,Other,153% of Medicaid,3015.54,,,3015.54,Other,225% of Medicaid,1876.34,,,1876.34,Other,140% of Medicaid,3015.54,,,3015.54,Other,225% of Medicaid,3484.62,,,3484.62,Other,260% of Medicaid,4342.38,,,4342.38,Other,324% of Medicaid,2881.52,,,2881.52,Other,215% of Medicaid,2881.52,,,2881.52,Other,215% of Medicaid,1675.3,,,1675.3,Other,125% of Medicaid,589.05,7216,
WND PREP F/N/HF/G ADDL 100 SQ CM/1% BA,15005,CPT,,73015005,CDM,761,RC,,,both,,,1492,1104.08,,,1104.08,Other,150% of Medicare + 9.63% HCRA Surcharge,671.4,45,,671.4,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",738.54,,,738.54,Other,110% of Medicare,1014.56,,,1014.56,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1353,,,1353,Other,186% of Medicaid,1193.6,,,1193.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1193.6,,,1193.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",3578,,,3578,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1044.4,70,,1044.4,percent of total billed charges,All Other,439.52,,,439.52,Fee Schedule,,372.52,,,372.52,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",727.17,,,727.17,Other,100% of Medicaid,727.17,,,727.17,Other,100% of Medicaid,727.17,,,727.17,Other,100% of Medicaid,727.17,,,727.17,Other,100% of Medicaid,1636.12,,,1636.12,Other,225% of Medicaid,1112.56,,,1112.56,Other,153% of Medicaid,1636.12,,,1636.12,Other,225% of Medicaid,1018.03,,,1018.03,Other,140% of Medicaid,1636.12,,,1636.12,Other,225% of Medicaid,1890.63,,,1890.63,Other,260% of Medicaid,2356.02,,,2356.02,Other,324% of Medicaid,1563.41,,,1563.41,Other,215% of Medicaid,1563.41,,,1563.41,Other,215% of Medicaid,908.96,,,908.96,Other,125% of Medicaid,372.52,7216,
PINCH GRFT SM; DEFECT TO 2CM,15050,CPT,,73015050,CDM,761,RC,,,both,,,1710,1265.4,,,1265.4,Other,150% of Medicare + 9.63% HCRA Surcharge,769.5,45,,769.5,percent of total billed charges,Critical Access Hospital RCC factor,2480,,,2480,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2232,,,2232,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",846.45,,,846.45,Other,110% of Medicare,1162.8,,,1162.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1241,,,1241,Other,186% of Medicaid,1368,,,1368,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1368,,,1368,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",4252,,,4252,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1197,70,,1197,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",667.11,,,667.11,Other,100% of Medicaid,667.11,,,667.11,Other,100% of Medicaid,667.11,,,667.11,Other,100% of Medicaid,667.11,,,667.11,Other,100% of Medicaid,1501,,,1501,Other,225% of Medicaid,1020.68,,,1020.68,Other,153% of Medicaid,1501,,,1501,Other,225% of Medicaid,933.96,,,933.96,Other,140% of Medicaid,1501,,,1501,Other,225% of Medicaid,1734.49,,,1734.49,Other,260% of Medicaid,2161.44,,,2161.44,Other,324% of Medicaid,1434.29,,,1434.29,Other,215% of Medicaid,1434.29,,,1434.29,Other,215% of Medicaid,833.89,,,833.89,Other,125% of Medicaid,667.11,7216,
SKIN SUB GRAFT TRNK/ARM/LEG,15271,CPT,,73015271,CDM,761,RC,,,both,,,3886,2875.65,,,2875.65,Other,150% of Medicare + 9.63% HCRA Surcharge,1748.7,45,,1748.7,percent of total billed charges,Critical Access Hospital RCC factor,2480,,,2480,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2232,,,2232,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3648,,,3648,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3283,,,3283,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3101,,,3101,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",1923.57,,,1923.57,Other,110% of Medicare,2642.48,,,2642.48,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2594,,,2594,Other,186% of Medicaid,3108.8,,,3108.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",3108.8,,,3108.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",3108.8,,,3108.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2720.2,70,,2720.2,percent of total billed charges,All Other,403.44,,,403.44,Fee Schedule,,341.94,,,341.94,Fee Schedule,,4055,,,4055,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3649,,,3649,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4055,,,4055,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3448,,,3448,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",1394.38,,,1394.38,Other,100% of Medicaid,1394.38,,,1394.38,Other,100% of Medicaid,1394.38,,,1394.38,Other,100% of Medicaid,1394.38,,,1394.38,Other,100% of Medicaid,3137.35,,,3137.35,Other,225% of Medicaid,2133.39,,,2133.39,Other,153% of Medicaid,3137.35,,,3137.35,Other,225% of Medicaid,1952.13,,,1952.13,Other,140% of Medicaid,3137.35,,,3137.35,Other,225% of Medicaid,3625.38,,,3625.38,Other,260% of Medicaid,4517.78,,,4517.78,Other,324% of Medicaid,2997.91,,,2997.91,Other,215% of Medicaid,2997.91,,,2997.91,Other,215% of Medicaid,1742.97,,,1742.97,Other,125% of Medicaid,341.94,7216,
SKIN SUB GRAFT T/A/L ADD-ON,15272,CPT,,73015272,CDM,761,RC,,,both,,,414,306.36,,,306.36,Other,150% of Medicare + 9.63% HCRA Surcharge,186.3,45,,186.3,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",204.93,,,204.93,Other,110% of Medicare,281.52,,,281.52,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2594,,,2594,Other,186% of Medicaid,331.2,,,331.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",331.2,,,331.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",331.2,,,331.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",289.8,70,,289.8,percent of total billed charges,All Other,85.28,,,85.28,Fee Schedule,,72.28,,,72.28,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",1394.38,,,1394.38,Other,100% of Medicaid,1394.38,,,1394.38,Other,100% of Medicaid,1394.38,,,1394.38,Other,100% of Medicaid,1394.38,,,1394.38,Other,100% of Medicaid,3137.35,,,3137.35,Other,225% of Medicaid,2133.39,,,2133.39,Other,153% of Medicaid,3137.35,,,3137.35,Other,225% of Medicaid,1952.13,,,1952.13,Other,140% of Medicaid,3137.35,,,3137.35,Other,225% of Medicaid,3625.38,,,3625.38,Other,260% of Medicaid,4517.78,,,4517.78,Other,324% of Medicaid,2997.91,,,2997.91,Other,215% of Medicaid,2997.91,,,2997.91,Other,215% of Medicaid,1742.97,,,1742.97,Other,125% of Medicaid,72.28,7216,
SKIN SUB GRFT T/ARM/LG CHILD,15273,CPT,,73015273,CDM,761,RC,,,both,,,7323,5419.04,,,5419.04,Other,150% of Medicare + 9.63% HCRA Surcharge,3295.35,45,,3295.35,percent of total billed charges,Critical Access Hospital RCC factor,2480,,,2480,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2232,,,2232,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4476,,,4476,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4028,,,4028,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3805,,,3805,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3624.89,,,3624.89,Other,110% of Medicare,4979.64,,,4979.64,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2594,,,2594,Other,186% of Medicaid,5858.4,,,5858.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",5858.4,,,5858.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",5858.4,,,5858.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",5126.1,70,,5126.1,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",4913,,,4913,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4422,,,4422,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4913,,,4913,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4176,,,4176,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",1394.38,,,1394.38,Other,100% of Medicaid,1394.38,,,1394.38,Other,100% of Medicaid,1394.38,,,1394.38,Other,100% of Medicaid,1394.38,,,1394.38,Other,100% of Medicaid,3137.35,,,3137.35,Other,225% of Medicaid,2133.39,,,2133.39,Other,153% of Medicaid,3137.35,,,3137.35,Other,225% of Medicaid,1952.13,,,1952.13,Other,140% of Medicaid,3137.35,,,3137.35,Other,225% of Medicaid,3625.38,,,3625.38,Other,260% of Medicaid,4517.78,,,4517.78,Other,324% of Medicaid,2997.91,,,2997.91,Other,215% of Medicaid,2997.91,,,2997.91,Other,215% of Medicaid,1742.97,,,1742.97,Other,125% of Medicaid,1394.38,7216,
SKN SUB GRFT T/A/L CHILD ADD,15274,CPT,,73015274,CDM,761,RC,,,both,,,961,711.14,,,711.14,Other,150% of Medicare + 9.63% HCRA Surcharge,432.45,45,,432.45,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",475.7,,,475.7,Other,110% of Medicare,653.48,,,653.48,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2594,,,2594,Other,186% of Medicaid,768.8,,,768.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",768.8,,,768.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",768.8,,,768.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",672.7,70,,672.7,percent of total billed charges,All Other,219.76,,,219.76,Fee Schedule,,186.26,,,186.26,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",1394.38,,,1394.38,Other,100% of Medicaid,1394.38,,,1394.38,Other,100% of Medicaid,1394.38,,,1394.38,Other,100% of Medicaid,1394.38,,,1394.38,Other,100% of Medicaid,3137.35,,,3137.35,Other,225% of Medicaid,2133.39,,,2133.39,Other,153% of Medicaid,3137.35,,,3137.35,Other,225% of Medicaid,1952.13,,,1952.13,Other,140% of Medicaid,3137.35,,,3137.35,Other,225% of Medicaid,3625.38,,,3625.38,Other,260% of Medicaid,4517.78,,,4517.78,Other,324% of Medicaid,2997.91,,,2997.91,Other,215% of Medicaid,2997.91,,,2997.91,Other,215% of Medicaid,1742.97,,,1742.97,Other,125% of Medicaid,186.26,7216,
SKIN SUB GRAFT FACE/NK/HF/G,15275,CPT,,73015275,CDM,761,RC,,,both,,,3886,2875.65,,,2875.65,Other,150% of Medicare + 9.63% HCRA Surcharge,1748.7,45,,1748.7,percent of total billed charges,Critical Access Hospital RCC factor,2480,,,2480,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2232,,,2232,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3648,,,3648,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3283,,,3283,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3101,,,3101,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",1923.57,,,1923.57,Other,110% of Medicare,2642.48,,,2642.48,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2594,,,2594,Other,186% of Medicaid,3108.8,,,3108.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",3108.8,,,3108.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",3108.8,,,3108.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2720.2,70,,2720.2,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",4055,,,4055,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3649,,,3649,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4055,,,4055,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3448,,,3448,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",1394.38,,,1394.38,Other,100% of Medicaid,1394.38,,,1394.38,Other,100% of Medicaid,1394.38,,,1394.38,Other,100% of Medicaid,1394.38,,,1394.38,Other,100% of Medicaid,3137.35,,,3137.35,Other,225% of Medicaid,2133.39,,,2133.39,Other,153% of Medicaid,3137.35,,,3137.35,Other,225% of Medicaid,1952.13,,,1952.13,Other,140% of Medicaid,3137.35,,,3137.35,Other,225% of Medicaid,3625.38,,,3625.38,Other,260% of Medicaid,4517.78,,,4517.78,Other,324% of Medicaid,2997.91,,,2997.91,Other,215% of Medicaid,2997.91,,,2997.91,Other,215% of Medicaid,1742.97,,,1742.97,Other,125% of Medicaid,1394.38,7216,
SKIN SUB GRAFT F/N/HF/G ADDL,15276,CPT,,73015276,CDM,761,RC,,,both,,,378,279.72,,,279.72,Other,150% of Medicare + 9.63% HCRA Surcharge,170.1,45,,170.1,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",187.11,,,187.11,Other,110% of Medicare,257.04,,,257.04,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2594,,,2594,Other,186% of Medicaid,302.4,,,302.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",302.4,,,302.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",302.4,,,302.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",264.6,70,,264.6,percent of total billed charges,All Other,123,,,123,Fee Schedule,,104.25,,,104.25,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",1394.38,,,1394.38,Other,100% of Medicaid,1394.38,,,1394.38,Other,100% of Medicaid,1394.38,,,1394.38,Other,100% of Medicaid,1394.38,,,1394.38,Other,100% of Medicaid,3137.35,,,3137.35,Other,225% of Medicaid,2133.39,,,2133.39,Other,153% of Medicaid,3137.35,,,3137.35,Other,225% of Medicaid,1952.13,,,1952.13,Other,140% of Medicaid,3137.35,,,3137.35,Other,225% of Medicaid,3625.38,,,3625.38,Other,260% of Medicaid,4517.78,,,4517.78,Other,324% of Medicaid,2997.91,,,2997.91,Other,215% of Medicaid,2997.91,,,2997.91,Other,215% of Medicaid,1742.97,,,1742.97,Other,125% of Medicaid,104.25,7216,
SKN SUB GRFT F/N/HF/G CHILD,15277,CPT,,73015277,CDM,761,RC,,,both,,,3886,2875.65,,,2875.65,Other,150% of Medicare + 9.63% HCRA Surcharge,1748.7,45,,1748.7,percent of total billed charges,Critical Access Hospital RCC factor,2480,,,2480,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2232,,,2232,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3648,,,3648,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3283,,,3283,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3101,,,3101,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",1923.57,,,1923.57,Other,110% of Medicare,2642.48,,,2642.48,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2594,,,2594,Other,186% of Medicaid,3108.8,,,3108.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",3108.8,,,3108.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",3108.8,,,3108.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2720.2,70,,2720.2,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",4055,,,4055,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3649,,,3649,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4055,,,4055,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3448,,,3448,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",1394.38,,,1394.38,Other,100% of Medicaid,1394.38,,,1394.38,Other,100% of Medicaid,1394.38,,,1394.38,Other,100% of Medicaid,1394.38,,,1394.38,Other,100% of Medicaid,3137.35,,,3137.35,Other,225% of Medicaid,2133.39,,,2133.39,Other,153% of Medicaid,3137.35,,,3137.35,Other,225% of Medicaid,1952.13,,,1952.13,Other,140% of Medicaid,3137.35,,,3137.35,Other,225% of Medicaid,3625.38,,,3625.38,Other,260% of Medicaid,4517.78,,,4517.78,Other,324% of Medicaid,2997.91,,,2997.91,Other,215% of Medicaid,2997.91,,,2997.91,Other,215% of Medicaid,1742.97,,,1742.97,Other,125% of Medicaid,1394.38,7216,
SKN SUB GRFT F/N/HF/G CH ADD,15278,CPT,,73015278,CDM,761,RC,,,both,,,961,711.14,,,711.14,Other,150% of Medicare + 9.63% HCRA Surcharge,432.45,45,,432.45,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",475.7,,,475.7,Other,110% of Medicare,653.48,,,653.48,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2594,,,2594,Other,186% of Medicaid,768.8,,,768.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",768.8,,,768.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",768.8,,,768.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",672.7,70,,672.7,percent of total billed charges,All Other,273.88,,,273.88,Fee Schedule,,232.13,,,232.13,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",1394.38,,,1394.38,Other,100% of Medicaid,1394.38,,,1394.38,Other,100% of Medicaid,1394.38,,,1394.38,Other,100% of Medicaid,1394.38,,,1394.38,Other,100% of Medicaid,3137.35,,,3137.35,Other,225% of Medicaid,2133.39,,,2133.39,Other,153% of Medicaid,3137.35,,,3137.35,Other,225% of Medicaid,1952.13,,,1952.13,Other,140% of Medicaid,3137.35,,,3137.35,Other,225% of Medicaid,3625.38,,,3625.38,Other,260% of Medicaid,4517.78,,,4517.78,Other,324% of Medicaid,2997.91,,,2997.91,Other,215% of Medicaid,2997.91,,,2997.91,Other,215% of Medicaid,1742.97,,,1742.97,Other,125% of Medicaid,232.13,7216,
DRESS/DEBRID P-THICK BURN S,16020,CPT,,73016020,CDM,761,RC,,,both,,,573,424.02,,,424.02,Other,150% of Medicare + 9.63% HCRA Surcharge,257.85,45,,257.85,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",283.64,,,283.64,Other,110% of Medicare,389.64,,,389.64,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",958,,,958,Other,186% of Medicaid,458.4,,,458.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",458.4,,,458.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",458.4,,,458.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",401.1,70,,401.1,percent of total billed charges,All Other,262.4,,,262.4,Fee Schedule,,222.4,,,222.4,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",514.9,,,514.9,Other,100% of Medicaid,514.9,,,514.9,Other,100% of Medicaid,514.9,,,514.9,Other,100% of Medicaid,514.9,,,514.9,Other,100% of Medicaid,1158.52,,,1158.52,Other,225% of Medicaid,787.8,,,787.8,Other,153% of Medicaid,1158.52,,,1158.52,Other,225% of Medicaid,720.86,,,720.86,Other,140% of Medicaid,1158.52,,,1158.52,Other,225% of Medicaid,1338.74,,,1338.74,Other,260% of Medicaid,1668.27,,,1668.27,Other,324% of Medicaid,1107.03,,,1107.03,Other,215% of Medicaid,1107.03,,,1107.03,Other,215% of Medicaid,643.62,,,643.62,Other,125% of Medicaid,222.4,7216,
DRESS/DEBRID P-THICK BURN M,16025,CPT,,73016025,CDM,761,RC,,,both,,,535,395.9,,,395.9,Other,150% of Medicare + 9.63% HCRA Surcharge,240.75,45,,240.75,percent of total billed charges,Critical Access Hospital RCC factor,2480,,,2480,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2232,,,2232,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",264.83,,,264.83,Other,110% of Medicare,363.8,,,363.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",958,,,958,Other,186% of Medicaid,428,,,428,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",428,,,428,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",4252,,,4252,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",374.5,70,,374.5,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",514.9,,,514.9,Other,100% of Medicaid,514.9,,,514.9,Other,100% of Medicaid,514.9,,,514.9,Other,100% of Medicaid,514.9,,,514.9,Other,100% of Medicaid,1158.52,,,1158.52,Other,225% of Medicaid,787.8,,,787.8,Other,153% of Medicaid,1158.52,,,1158.52,Other,225% of Medicaid,720.86,,,720.86,Other,140% of Medicaid,1158.52,,,1158.52,Other,225% of Medicaid,1338.74,,,1338.74,Other,260% of Medicaid,1668.27,,,1668.27,Other,324% of Medicaid,1107.03,,,1107.03,Other,215% of Medicaid,1107.03,,,1107.03,Other,215% of Medicaid,643.62,,,643.62,Other,125% of Medicaid,240.75,7216,
DRESS/DEBRID P-THICK BURN L,16030,CPT,,73016030,CDM,761,RC,,,both,,,841,622.34,,,622.34,Other,150% of Medicare + 9.63% HCRA Surcharge,378.45,45,,378.45,percent of total billed charges,Critical Access Hospital RCC factor,2480,,,2480,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2232,,,2232,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",416.3,,,416.3,Other,110% of Medicare,571.88,,,571.88,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1353,,,1353,Other,186% of Medicaid,672.8,,,672.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",672.8,,,672.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",4252,,,4252,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",588.7,70,,588.7,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",727.17,,,727.17,Other,100% of Medicaid,727.17,,,727.17,Other,100% of Medicaid,727.17,,,727.17,Other,100% of Medicaid,727.17,,,727.17,Other,100% of Medicaid,1636.12,,,1636.12,Other,225% of Medicaid,1112.56,,,1112.56,Other,153% of Medicaid,1636.12,,,1636.12,Other,225% of Medicaid,1018.03,,,1018.03,Other,140% of Medicaid,1636.12,,,1636.12,Other,225% of Medicaid,1890.63,,,1890.63,Other,260% of Medicaid,2356.02,,,2356.02,Other,324% of Medicaid,1563.41,,,1563.41,Other,215% of Medicaid,1563.41,,,1563.41,Other,215% of Medicaid,908.96,,,908.96,Other,125% of Medicaid,378.45,7216,
DESTRUCT PREMALG LESION,17000,CPT,,73017000,CDM,761,RC,,,both,,,408,301.92,,,301.92,Other,150% of Medicare + 9.63% HCRA Surcharge,183.6,45,,183.6,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",201.96,,,201.96,Other,110% of Medicare,277.44,,,277.44,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",733,,,733,Other,186% of Medicaid,326.4,,,326.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",326.4,,,326.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",326.4,,,326.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",285.6,70,,285.6,percent of total billed charges,All Other,264.04,,,264.04,Fee Schedule,,223.79,,,223.79,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",394.14,,,394.14,Other,100% of Medicaid,394.14,,,394.14,Other,100% of Medicaid,394.14,,,394.14,Other,100% of Medicaid,394.14,,,394.14,Other,100% of Medicaid,886.83,,,886.83,Other,225% of Medicaid,603.04,,,603.04,Other,153% of Medicaid,886.83,,,886.83,Other,225% of Medicaid,551.8,,,551.8,Other,140% of Medicaid,886.83,,,886.83,Other,225% of Medicaid,1024.78,,,1024.78,Other,260% of Medicaid,1277.03,,,1277.03,Other,324% of Medicaid,847.41,,,847.41,Other,215% of Medicaid,847.41,,,847.41,Other,215% of Medicaid,492.68,,,492.68,Other,125% of Medicaid,183.6,7216,
DESTRUCT PREMALG LES 2-14,17003,CPT,,73017003,CDM,761,RC,,,both,,,184,136.16,,,136.16,Other,150% of Medicare + 9.63% HCRA Surcharge,82.8,45,,82.8,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",91.08,,,91.08,Other,110% of Medicare,125.12,,,125.12,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",733,,,733,Other,186% of Medicaid,147.2,,,147.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",147.2,,,147.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",147.2,,,147.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",128.8,70,,128.8,percent of total billed charges,All Other,9.84,,,9.84,Fee Schedule,,8.34,,,8.34,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",394.14,,,394.14,Other,100% of Medicaid,394.14,,,394.14,Other,100% of Medicaid,394.14,,,394.14,Other,100% of Medicaid,394.14,,,394.14,Other,100% of Medicaid,886.83,,,886.83,Other,225% of Medicaid,603.04,,,603.04,Other,153% of Medicaid,886.83,,,886.83,Other,225% of Medicaid,551.8,,,551.8,Other,140% of Medicaid,886.83,,,886.83,Other,225% of Medicaid,1024.78,,,1024.78,Other,260% of Medicaid,1277.03,,,1277.03,Other,324% of Medicaid,847.41,,,847.41,Other,215% of Medicaid,847.41,,,847.41,Other,215% of Medicaid,492.68,,,492.68,Other,125% of Medicaid,8.34,7216,
DESTRUCT B9 LESION 1-14,17110,CPT,,73017110,CDM,761,RC,,,both,,,1205,891.7,,,891.7,Other,150% of Medicare + 9.63% HCRA Surcharge,542.25,45,,542.25,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",596.48,,,596.48,Other,110% of Medicare,819.4,,,819.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",733,,,733,Other,186% of Medicaid,964,,,964,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",964,,,964,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",964,,,964,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",843.5,70,,843.5,percent of total billed charges,All Other,319.8,,,319.8,Fee Schedule,,271.05,,,271.05,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",394.14,,,394.14,Other,100% of Medicaid,394.14,,,394.14,Other,100% of Medicaid,394.14,,,394.14,Other,100% of Medicaid,394.14,,,394.14,Other,100% of Medicaid,886.83,,,886.83,Other,225% of Medicaid,603.04,,,603.04,Other,153% of Medicaid,886.83,,,886.83,Other,225% of Medicaid,551.8,,,551.8,Other,140% of Medicaid,886.83,,,886.83,Other,225% of Medicaid,1024.78,,,1024.78,Other,260% of Medicaid,1277.03,,,1277.03,Other,324% of Medicaid,847.41,,,847.41,Other,215% of Medicaid,847.41,,,847.41,Other,215% of Medicaid,492.68,,,492.68,Other,125% of Medicaid,271.05,7216,
CHEM CAUT GRANULATION TISS,17250,CPT,,73017250,CDM,761,RC,,,both,,,697,515.78,,,515.78,Other,150% of Medicare + 9.63% HCRA Surcharge,313.65,45,,313.65,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",345.02,,,345.02,Other,110% of Medicare,473.96,,,473.96,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",733,,,733,Other,186% of Medicaid,557.6,,,557.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",557.6,,,557.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",557.6,,,557.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",487.9,70,,487.9,percent of total billed charges,All Other,180.4,,,180.4,Fee Schedule,,152.9,,,152.9,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",394.14,,,394.14,Other,100% of Medicaid,394.14,,,394.14,Other,100% of Medicaid,394.14,,,394.14,Other,100% of Medicaid,394.14,,,394.14,Other,100% of Medicaid,886.83,,,886.83,Other,225% of Medicaid,603.04,,,603.04,Other,153% of Medicaid,886.83,,,886.83,Other,225% of Medicaid,551.8,,,551.8,Other,140% of Medicaid,886.83,,,886.83,Other,225% of Medicaid,1024.78,,,1024.78,Other,260% of Medicaid,1277.03,,,1277.03,Other,324% of Medicaid,847.41,,,847.41,Other,215% of Medicaid,847.41,,,847.41,Other,215% of Medicaid,492.68,,,492.68,Other,125% of Medicaid,152.9,7216,
BONE BX TR/NDL; SUPERF,20220,CPT,,73020220,CDM,761,RC,,,both,,,3426,2535.25,,,2535.25,Other,150% of Medicare + 9.63% HCRA Surcharge,1541.7,45,,1541.7,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3648,,,3648,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3283,,,3283,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3101,,,3101,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",1695.87,,,1695.87,Other,110% of Medicare,2329.68,,,2329.68,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1038,,,1038,Other,186% of Medicaid,2740.8,,,2740.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2740.8,,,2740.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",3578,,,3578,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2398.2,70,,2398.2,percent of total billed charges,All Other,416.56,,,416.56,Fee Schedule,,353.06,,,353.06,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",557.82,,,557.82,Other,100% of Medicaid,557.82,,,557.82,Other,100% of Medicaid,557.82,,,557.82,Other,100% of Medicaid,557.82,,,557.82,Other,100% of Medicaid,1255.1,,,1255.1,Other,225% of Medicaid,853.47,,,853.47,Other,153% of Medicaid,1255.1,,,1255.1,Other,225% of Medicaid,780.95,,,780.95,Other,140% of Medicaid,1255.1,,,1255.1,Other,225% of Medicaid,1450.34,,,1450.34,Other,260% of Medicaid,1807.35,,,1807.35,Other,324% of Medicaid,1199.32,,,1199.32,Other,215% of Medicaid,1199.32,,,1199.32,Other,215% of Medicaid,697.28,,,697.28,Other,125% of Medicaid,353.06,7216,
OPEN SUPERF BONE BX,20240,CPT,,73020240,CDM,761,RC,,,both,,,5816,4303.85,,,4303.85,Other,150% of Medicare + 9.63% HCRA Surcharge,2617.2,45,,2617.2,percent of total billed charges,Critical Access Hospital RCC factor,2480,,,2480,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2232,,,2232,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4476,,,4476,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4028,,,4028,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3805,,,3805,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2878.92,,,2878.92,Other,110% of Medicare,3954.88,,,3954.88,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1647.13,,,1647.13,Other,186% of Medicaid,4652.8,,,4652.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",4652.8,,,4652.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",4252,,,4252,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",4071.2,70,,4071.2,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",4531,,,4531,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4079,,,4079,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4531,,,4531,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3852,,,3852,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",885.56,,,885.56,Other,100% of Medicaid,885.56,,,885.56,Other,100% of Medicaid,885.56,,,885.56,Other,100% of Medicaid,885.56,,,885.56,Other,100% of Medicaid,1992.5,,,1992.5,Other,225% of Medicaid,1354.9,,,1354.9,Other,153% of Medicaid,1992.5,,,1992.5,Other,225% of Medicaid,1239.78,,,1239.78,Other,140% of Medicaid,1992.5,,,1992.5,Other,225% of Medicaid,2302.44,,,2302.44,Other,260% of Medicaid,2869.2,,,2869.2,Other,324% of Medicaid,1903.94,,,1903.94,Other,215% of Medicaid,1903.94,,,1903.94,Other,215% of Medicaid,1106.94,,,1106.94,Other,125% of Medicaid,885.56,7216,
APPLY SH LEG CAST,29405,CPT,,73029405,CDM,761,RC,,,both,,,794,587.56,,,587.56,Other,150% of Medicare + 9.63% HCRA Surcharge,357.3,45,,357.3,percent of total billed charges,Critical Access Hospital RCC factor,516.1,65,,516.1,percent of total billed charges,All Other,468.46,65,,468.46,percent of total billed charges,All Other,3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",393.03,,,393.03,Other,110% of Medicare,539.92,68,,539.92,percent of total billed charges,All Other,445,,,445,Other,186% of Medicaid,635.2,80,,635.2,percent of total billed charges,All Other,659.02,83,,659.02,percent of total billed charges,All Other,659.02,83,,659.02,percent of total billed charges,All Other,635.2,80,,635.2,percent of total billed charges,All Other,659.02,83,,659.02,percent of total billed charges,All Other,635.2,80,,635.2,percent of total billed charges,All Other,555.8,70,,555.8,percent of total billed charges,All Other,278.8,,,278.8,Fee Schedule,,236.3,,,236.3,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",239.06,,,239.06,Other,100% of Medicaid,239.06,,,239.06,Other,100% of Medicaid,239.06,,,239.06,Other,100% of Medicaid,239.06,,,239.06,Other,100% of Medicaid,537.89,,,537.89,Other,225% of Medicaid,365.76,,,365.76,Other,153% of Medicaid,537.89,,,537.89,Other,225% of Medicaid,334.68,,,334.68,Other,140% of Medicaid,537.89,,,537.89,Other,225% of Medicaid,621.56,,,621.56,Other,260% of Medicaid,774.55,,,774.55,Other,324% of Medicaid,513.98,,,513.98,Other,215% of Medicaid,513.98,,,513.98,Other,215% of Medicaid,298.83,,,298.83,Other,125% of Medicaid,236.3,3227,
APPLY WLKR SH LEG CAST,29425,CPT,,73029425,CDM,761,RC,,,both,,,721,533.54,,,533.54,Other,150% of Medicare + 9.63% HCRA Surcharge,324.45,45,,324.45,percent of total billed charges,Critical Access Hospital RCC factor,4565,,,4565,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",4565,,,4565,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",356.9,,,356.9,Other,110% of Medicare,490.28,,,490.28,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",680,,,680,Other,186% of Medicaid,576.8,,,576.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",576.8,,,576.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",576.8,,,576.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",504.7,70,,504.7,percent of total billed charges,All Other,259.12,,,259.12,Fee Schedule,,219.62,,,219.62,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",365.71,,,365.71,Other,100% of Medicaid,365.71,,,365.71,Other,100% of Medicaid,365.71,,,365.71,Other,100% of Medicaid,365.71,,,365.71,Other,100% of Medicaid,822.84,,,822.84,Other,225% of Medicaid,559.53,,,559.53,Other,153% of Medicaid,822.84,,,822.84,Other,225% of Medicaid,511.99,,,511.99,Other,140% of Medicaid,822.84,,,822.84,Other,225% of Medicaid,950.84,,,950.84,Other,260% of Medicaid,1184.89,,,1184.89,Other,324% of Medicaid,786.27,,,786.27,Other,215% of Medicaid,786.27,,,786.27,Other,215% of Medicaid,457.13,,,457.13,Other,125% of Medicaid,219.62,7216,
APPLY RIGID TOTAL CONTACT LEG CAST,29445,CPT,,73029445,CDM,761,RC,,,both,,,842,623.08,,,623.08,Other,150% of Medicare + 9.63% HCRA Surcharge,378.9,45,,378.9,percent of total billed charges,Critical Access Hospital RCC factor,547.3,65,,547.3,percent of total billed charges,All Other,496.78,65,,496.78,percent of total billed charges,All Other,3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",416.79,,,416.79,Other,110% of Medicare,572.56,68,,572.56,percent of total billed charges,All Other,445,,,445,Other,186% of Medicaid,673.6,80,,673.6,percent of total billed charges,All Other,698.86,83,,698.86,percent of total billed charges,All Other,698.86,83,,698.86,percent of total billed charges,All Other,673.6,80,,673.6,percent of total billed charges,All Other,698.86,83,,698.86,percent of total billed charges,All Other,673.6,,,673.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",589.4,70,,589.4,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",239.06,,,239.06,Other,100% of Medicaid,239.06,,,239.06,Other,100% of Medicaid,239.06,,,239.06,Other,100% of Medicaid,239.06,,,239.06,Other,100% of Medicaid,537.89,,,537.89,Other,225% of Medicaid,365.76,,,365.76,Other,153% of Medicaid,537.89,,,537.89,Other,225% of Medicaid,334.68,,,334.68,Other,140% of Medicaid,537.89,,,537.89,Other,225% of Medicaid,621.56,,,621.56,Other,260% of Medicaid,774.55,,,774.55,Other,324% of Medicaid,513.98,,,513.98,Other,215% of Medicaid,513.98,,,513.98,Other,215% of Medicaid,298.83,,,298.83,Other,125% of Medicaid,239.06,3933,
UNNA BOOT STRAPPING,29580,CPT,,73029580,CDM,761,RC,,,both,,,427,315.98,,,315.98,Other,150% of Medicare + 9.63% HCRA Surcharge,192.15,45,,192.15,percent of total billed charges,Critical Access Hospital RCC factor,277.55,65,,277.55,percent of total billed charges,All Other,251.93,65,,251.93,percent of total billed charges,All Other,3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",211.37,,,211.37,Other,110% of Medicare,290.36,68,,290.36,percent of total billed charges,All Other,445,,,445,Other,186% of Medicaid,341.6,80,,341.6,percent of total billed charges,All Other,354.41,83,,354.41,percent of total billed charges,All Other,354.41,83,,354.41,percent of total billed charges,All Other,341.6,80,,341.6,percent of total billed charges,All Other,354.41,83,,354.41,percent of total billed charges,All Other,341.6,,,341.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",298.9,70,,298.9,percent of total billed charges,All Other,129.56,,,129.56,Fee Schedule,,109.81,,,109.81,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",239.06,,,239.06,Other,100% of Medicaid,239.06,,,239.06,Other,100% of Medicaid,239.06,,,239.06,Other,100% of Medicaid,239.06,,,239.06,Other,100% of Medicaid,537.89,,,537.89,Other,225% of Medicaid,365.76,,,365.76,Other,153% of Medicaid,537.89,,,537.89,Other,225% of Medicaid,334.68,,,334.68,Other,140% of Medicaid,537.89,,,537.89,Other,225% of Medicaid,621.56,,,621.56,Other,260% of Medicaid,774.55,,,774.55,Other,324% of Medicaid,513.98,,,513.98,Other,215% of Medicaid,513.98,,,513.98,Other,215% of Medicaid,298.83,,,298.83,Other,125% of Medicaid,109.81,3227,
APPLY MULTLAY COMPRS LWR LEG,29581,CPT,,73029581,CDM,761,RC,,,both,,,393,290.82,,,290.82,Other,150% of Medicare + 9.63% HCRA Surcharge,176.85,45,,176.85,percent of total billed charges,Critical Access Hospital RCC factor,255.45,65,,255.45,percent of total billed charges,All Other,231.87,65,,231.87,percent of total billed charges,All Other,3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",194.54,,,194.54,Other,110% of Medicare,267.24,68,,267.24,percent of total billed charges,All Other,445,,,445,Other,186% of Medicaid,314.4,80,,314.4,percent of total billed charges,All Other,326.19,83,,326.19,percent of total billed charges,All Other,326.19,83,,326.19,percent of total billed charges,All Other,314.4,80,,314.4,percent of total billed charges,All Other,326.19,83,,326.19,percent of total billed charges,All Other,314.4,80,,314.4,percent of total billed charges,All Other,275.1,70,,275.1,percent of total billed charges,All Other,131.2,,,131.2,Fee Schedule,,111.2,,,111.2,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",239.06,,,239.06,Other,100% of Medicaid,239.06,,,239.06,Other,100% of Medicaid,239.06,,,239.06,Other,100% of Medicaid,239.06,,,239.06,Other,100% of Medicaid,537.89,,,537.89,Other,225% of Medicaid,365.76,,,365.76,Other,153% of Medicaid,537.89,,,537.89,Other,225% of Medicaid,334.68,,,334.68,Other,140% of Medicaid,537.89,,,537.89,Other,225% of Medicaid,621.56,,,621.56,Other,260% of Medicaid,774.55,,,774.55,Other,324% of Medicaid,513.98,,,513.98,Other,215% of Medicaid,513.98,,,513.98,Other,215% of Medicaid,298.83,,,298.83,Other,125% of Medicaid,111.2,3227,
REMOVE IMPACTED EAR WAX 1-2 EARS,69210,CPT,,73069210,CDM,761,RC,,,both,,,258,190.92,,,190.92,Other,150% of Medicare + 9.63% HCRA Surcharge,116.1,45,,116.1,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",127.71,,,127.71,Other,110% of Medicare,175.44,,,175.44,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",0.01,,,0.01,Other,186% of Medicaid,206.4,,,206.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",206.4,,,206.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",206.4,,,206.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",180.6,70,,180.6,percent of total billed charges,All Other,159.08,,,159.08,Fee Schedule,,134.83,,,134.83,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,7216,
UPR/LXTR ART STDY 3+ LVLS,93923,CPT,,73093923,CDM,761,RC,,,both,,,1054,779.96,,,779.96,Other,150% of Medicare + 9.63% HCRA Surcharge,474.3,45,,474.3,percent of total billed charges,Critical Access Hospital RCC factor,349.81,,,349.81,Fee Schedule,,315.42,,,315.42,Fee Schedule,,997.82,,,997.82,Fee Schedule,,897.47,,,897.47,Fee Schedule,,848.24,,,848.24,Fee Schedule,,521.73,,,521.73,Other,110% of Medicare,716.72,68,,716.72,percent of total billed charges,All Other,255,,,255,Other,186% of Medicaid,843.2,80,,843.2,percent of total billed charges,All Other,874.82,83,,874.82,percent of total billed charges,All Other,874.82,83,,874.82,percent of total billed charges,All Other,843.2,80,,843.2,percent of total billed charges,All Other,874.82,83,,874.82,percent of total billed charges,All Other,843.2,,,843.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",737.8,70,,737.8,percent of total billed charges,All Other,523.16,,,523.16,Fee Schedule,,443.41,,,443.41,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",137.34,,,137.34,Other,100% of Medicaid,137.34,,,137.34,Other,100% of Medicaid,137.34,,,137.34,Other,100% of Medicaid,137.34,,,137.34,Other,100% of Medicaid,309.01,,,309.01,Other,225% of Medicaid,210.12,,,210.12,Other,153% of Medicaid,309.01,,,309.01,Other,225% of Medicaid,192.27,,,192.27,Other,140% of Medicaid,309.01,,,309.01,Other,225% of Medicaid,357.07,,,357.07,Other,260% of Medicaid,444.97,,,444.97,Other,324% of Medicaid,295.27,,,295.27,Other,215% of Medicaid,295.27,,,295.27,Other,215% of Medicaid,171.67,,,171.67,Other,125% of Medicaid,137.34,3227,
THER/PROPH/DIAG INJ SC/IM,96372,CPT,,73096372,CDM,761,RC,,,both,,,460,340.4,,,340.4,Other,150% of Medicare + 9.63% HCRA Surcharge,207,45,,207,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,351.9,76.5,,351.9,percent of total billed charges,All Other,326.6,69,,326.6,percent of total billed charges,All Other,317.4,65,,317.4,percent of total billed charges,All Other,227.7,,,227.7,Other,110% of Medicare,312.8,68,,312.8,percent of total billed charges,All Other,58,,,58,Other,186% of Medicaid,381.8,,,381.8,Case Rate,,381.8,,,381.8,Case Rate,,381.8,,,381.8,Case Rate,,381.8,,,381.8,Case Rate,,381.8,,,381.8,Case Rate,,368,,,368,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",322,70,,322,percent of total billed charges,All Other,68.88,,,68.88,Fee Schedule,,58.38,,,58.38,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",31.2,,,31.2,Other,100% of Medicaid,31.2,,,31.2,Other,100% of Medicaid,31.2,,,31.2,Other,100% of Medicaid,31.2,,,31.2,Other,100% of Medicaid,70.2,,,70.2,Other,225% of Medicaid,47.74,,,47.74,Other,153% of Medicaid,70.2,,,70.2,Other,225% of Medicaid,43.68,,,43.68,Other,140% of Medicaid,70.2,,,70.2,Other,225% of Medicaid,81.12,,,81.12,Other,260% of Medicaid,101.09,,,101.09,Other,324% of Medicaid,67.08,,,67.08,Other,215% of Medicaid,67.08,,,67.08,Other,215% of Medicaid,39,,,39,Other,125% of Medicaid,0.01,3227,
SLCTV WND DEBRIDEM 20 CM OR <,97597,CPT,,73097597,CDM,761,RC,,,both,,,573,424.02,,,424.02,Other,150% of Medicare + 9.63% HCRA Surcharge,257.85,45,,257.85,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",283.64,,,283.64,Other,110% of Medicare,389.64,,,389.64,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",702.75,,,702.75,Other,186% of Medicaid,458.4,,,458.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",458.4,,,458.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",458.4,,,458.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",401.1,70,,401.1,percent of total billed charges,All Other,173.84,,,173.84,Fee Schedule,,147.34,,,147.34,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",377.82,,,377.82,Other,100% of Medicaid,377.82,,,377.82,Other,100% of Medicaid,377.82,,,377.82,Other,100% of Medicaid,377.82,,,377.82,Other,100% of Medicaid,850.1,,,850.1,Other,225% of Medicaid,578.07,,,578.07,Other,153% of Medicaid,850.1,,,850.1,Other,225% of Medicaid,528.95,,,528.95,Other,140% of Medicaid,850.1,,,850.1,Other,225% of Medicaid,982.34,,,982.34,Other,260% of Medicaid,1224.15,,,1224.15,Other,324% of Medicaid,812.32,,,812.32,Other,215% of Medicaid,812.32,,,812.32,Other,215% of Medicaid,472.28,,,472.28,Other,125% of Medicaid,147.34,7216,
SLCTV WND DEBRIDEM ADDL 20 CM/<,97598,CPT,,73097598,CDM,761,RC,,,both,,,573,424.02,,,424.02,Other,150% of Medicare + 9.63% HCRA Surcharge,257.85,45,,257.85,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",283.64,,,283.64,Other,110% of Medicare,389.64,,,389.64,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2130.58,,,2130.58,Other,186% of Medicaid,458.4,,,458.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",458.4,,,458.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",458.4,,,458.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",401.1,70,,401.1,percent of total billed charges,All Other,121.36,,,121.36,Fee Schedule,,102.86,,,102.86,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",1145.48,,,1145.48,Other,100% of Medicaid,1145.48,,,1145.48,Other,100% of Medicaid,1145.48,,,1145.48,Other,100% of Medicaid,1145.48,,,1145.48,Other,100% of Medicaid,2577.32,,,2577.32,Other,225% of Medicaid,1752.58,,,1752.58,Other,153% of Medicaid,2577.32,,,2577.32,Other,225% of Medicaid,1603.67,,,1603.67,Other,140% of Medicaid,2577.32,,,2577.32,Other,225% of Medicaid,2978.24,,,2978.24,Other,260% of Medicaid,3711.34,,,3711.34,Other,324% of Medicaid,2462.77,,,2462.77,Other,215% of Medicaid,2462.77,,,2462.77,Other,215% of Medicaid,1431.84,,,1431.84,Other,125% of Medicaid,102.86,7216,
NSW DEBRIDEM WO A/SESSION,97602,CPT,,73097602,CDM,761,RC,,,both,,,408,301.92,,,301.92,Other,150% of Medicare + 9.63% HCRA Surcharge,183.6,45,,183.6,percent of total billed charges,Critical Access Hospital RCC factor,265.2,65,,265.2,percent of total billed charges,All Other,240.72,65,,240.72,percent of total billed charges,All Other,3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",201.96,,,201.96,Other,110% of Medicare,277.44,68,,277.44,percent of total billed charges,All Other,1070,,,1070,Other,186% of Medicaid,326.4,80,,326.4,percent of total billed charges,All Other,338.64,83,,338.64,percent of total billed charges,All Other,338.64,83,,338.64,percent of total billed charges,All Other,326.4,80,,326.4,percent of total billed charges,All Other,338.64,83,,338.64,percent of total billed charges,All Other,326.4,,,326.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",285.6,70,,285.6,percent of total billed charges,All Other,265.2,65,,265.2,percent of total billed charges,Default if not in Fee Schedule,265.2,65,,265.2,percent of total billed charges,Default if not in Fee Schedule,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",575.25,,,575.25,Other,100% of Medicaid,575.25,,,575.25,Other,100% of Medicaid,575.25,,,575.25,Other,100% of Medicaid,575.25,,,575.25,Other,100% of Medicaid,1294.32,,,1294.32,Other,225% of Medicaid,880.14,,,880.14,Other,153% of Medicaid,1294.32,,,1294.32,Other,225% of Medicaid,805.36,,,805.36,Other,140% of Medicaid,1294.32,,,1294.32,Other,225% of Medicaid,1495.66,,,1495.66,Other,260% of Medicaid,1863.82,,,1863.82,Other,324% of Medicaid,1236.8,,,1236.8,Other,215% of Medicaid,1236.8,,,1236.8,Other,215% of Medicaid,719.07,,,719.07,Other,125% of Medicaid,183.6,3227,
NEG PRESS WOUND TX < 50 CM,97605,CPT,,73097605,CDM,761,RC,,,both,,,408,301.92,,,301.92,Other,150% of Medicare + 9.63% HCRA Surcharge,183.6,45,,183.6,percent of total billed charges,Critical Access Hospital RCC factor,265.2,65,,265.2,percent of total billed charges,All Other,240.72,65,,240.72,percent of total billed charges,All Other,312.12,76.5,,312.12,percent of total billed charges,All Other,289.68,69,,289.68,percent of total billed charges,All Other,281.52,65,,281.52,percent of total billed charges,All Other,201.96,,,201.96,Other,110% of Medicare,277.44,68,,277.44,percent of total billed charges,All Other,703,,,703,Other,186% of Medicaid,326.4,80,,326.4,percent of total billed charges,All Other,338.64,83,,338.64,percent of total billed charges,All Other,338.64,83,,338.64,percent of total billed charges,All Other,326.4,80,,326.4,percent of total billed charges,All Other,338.64,83,,338.64,percent of total billed charges,All Other,326.4,,,326.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",285.6,70,,285.6,percent of total billed charges,All Other,119.72,,,119.72,Fee Schedule,,101.47,,,101.47,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",377.82,,,377.82,Other,100% of Medicaid,377.82,,,377.82,Other,100% of Medicaid,377.82,,,377.82,Other,100% of Medicaid,377.82,,,377.82,Other,100% of Medicaid,850.1,,,850.1,Other,225% of Medicaid,578.07,,,578.07,Other,153% of Medicaid,850.1,,,850.1,Other,225% of Medicaid,528.95,,,528.95,Other,140% of Medicaid,850.1,,,850.1,Other,225% of Medicaid,982.34,,,982.34,Other,260% of Medicaid,1224.15,,,1224.15,Other,324% of Medicaid,812.32,,,812.32,Other,215% of Medicaid,812.32,,,812.32,Other,215% of Medicaid,472.28,,,472.28,Other,125% of Medicaid,101.47,3227,
NEG PRESS WOUND TX > 50 CM,97606,CPT,,73097606,CDM,761,RC,,,both,,,841,622.34,,,622.34,Other,150% of Medicare + 9.63% HCRA Surcharge,378.45,45,,378.45,percent of total billed charges,Critical Access Hospital RCC factor,546.65,65,,546.65,percent of total billed charges,All Other,496.19,65,,496.19,percent of total billed charges,All Other,643.37,76.5,,643.37,percent of total billed charges,All Other,597.11,69,,597.11,percent of total billed charges,All Other,580.29,65,,580.29,percent of total billed charges,All Other,416.3,,,416.3,Other,110% of Medicare,571.88,68,,571.88,percent of total billed charges,All Other,1070,,,1070,Other,186% of Medicaid,672.8,80,,672.8,percent of total billed charges,All Other,698.03,83,,698.03,percent of total billed charges,All Other,698.03,83,,698.03,percent of total billed charges,All Other,672.8,80,,672.8,percent of total billed charges,All Other,698.03,83,,698.03,percent of total billed charges,All Other,672.8,,,672.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",588.7,70,,588.7,percent of total billed charges,All Other,131.2,,,131.2,Fee Schedule,,111.2,,,111.2,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",575.25,,,575.25,Other,100% of Medicaid,575.25,,,575.25,Other,100% of Medicaid,575.25,,,575.25,Other,100% of Medicaid,575.25,,,575.25,Other,100% of Medicaid,1294.32,,,1294.32,Other,225% of Medicaid,880.14,,,880.14,Other,153% of Medicaid,1294.32,,,1294.32,Other,225% of Medicaid,805.36,,,805.36,Other,140% of Medicaid,1294.32,,,1294.32,Other,225% of Medicaid,1495.66,,,1495.66,Other,260% of Medicaid,1863.82,,,1863.82,Other,324% of Medicaid,1236.8,,,1236.8,Other,215% of Medicaid,1236.8,,,1236.8,Other,215% of Medicaid,719.07,,,719.07,Other,125% of Medicaid,111.2,3227,
NEG PRESS WND TX < =50 SQ CM,97607,CPT,,73097607,CDM,761,RC,,,both,,,1119,828.06,,,828.06,Other,150% of Medicare + 9.63% HCRA Surcharge,503.55,45,,503.55,percent of total billed charges,Critical Access Hospital RCC factor,727.35,65,,727.35,percent of total billed charges,All Other,660.21,65,,660.21,percent of total billed charges,All Other,856.04,76.5,,856.04,percent of total billed charges,All Other,794.49,69,,794.49,percent of total billed charges,All Other,772.11,65,,772.11,percent of total billed charges,All Other,553.91,,,553.91,Other,110% of Medicare,760.92,68,,760.92,percent of total billed charges,All Other,1070,,,1070,Other,186% of Medicaid,895.2,80,,895.2,percent of total billed charges,All Other,928.77,83,,928.77,percent of total billed charges,All Other,928.77,83,,928.77,percent of total billed charges,All Other,895.2,80,,895.2,percent of total billed charges,All Other,928.77,83,,928.77,percent of total billed charges,All Other,895.2,,,895.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",783.3,70,,783.3,percent of total billed charges,All Other,108.24,,,108.24,Fee Schedule,,91.74,,,91.74,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",575.25,,,575.25,Other,100% of Medicaid,575.25,,,575.25,Other,100% of Medicaid,575.25,,,575.25,Other,100% of Medicaid,575.25,,,575.25,Other,100% of Medicaid,1294.32,,,1294.32,Other,225% of Medicaid,880.14,,,880.14,Other,153% of Medicaid,1294.32,,,1294.32,Other,225% of Medicaid,805.36,,,805.36,Other,140% of Medicaid,1294.32,,,1294.32,Other,225% of Medicaid,1495.66,,,1495.66,Other,260% of Medicaid,1863.82,,,1863.82,Other,324% of Medicaid,1236.8,,,1236.8,Other,215% of Medicaid,1236.8,,,1236.8,Other,215% of Medicaid,719.07,,,719.07,Other,125% of Medicaid,91.74,3227,
NEG PRESS WOUND TX > 50CM,97608,CPT,,73097608,CDM,761,RC,,,both,,,1119,828.06,,,828.06,Other,150% of Medicare + 9.63% HCRA Surcharge,503.55,45,,503.55,percent of total billed charges,Critical Access Hospital RCC factor,727.35,65,,727.35,percent of total billed charges,All Other,660.21,65,,660.21,percent of total billed charges,All Other,856.04,76.5,,856.04,percent of total billed charges,All Other,794.49,69,,794.49,percent of total billed charges,All Other,772.11,65,,772.11,percent of total billed charges,All Other,553.91,,,553.91,Other,110% of Medicare,760.92,68,,760.92,percent of total billed charges,All Other,1070,,,1070,Other,186% of Medicaid,895.2,80,,895.2,percent of total billed charges,All Other,928.77,83,,928.77,percent of total billed charges,All Other,928.77,83,,928.77,percent of total billed charges,All Other,895.2,80,,895.2,percent of total billed charges,All Other,928.77,83,,928.77,percent of total billed charges,All Other,895.2,,,895.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",783.3,70,,783.3,percent of total billed charges,All Other,121.36,,,121.36,Fee Schedule,,102.86,,,102.86,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",575.25,,,575.25,Other,100% of Medicaid,575.25,,,575.25,Other,100% of Medicaid,575.25,,,575.25,Other,100% of Medicaid,575.25,,,575.25,Other,100% of Medicaid,1294.32,,,1294.32,Other,225% of Medicaid,880.14,,,880.14,Other,153% of Medicaid,1294.32,,,1294.32,Other,225% of Medicaid,805.36,,,805.36,Other,140% of Medicaid,1294.32,,,1294.32,Other,225% of Medicaid,1495.66,,,1495.66,Other,260% of Medicaid,1863.82,,,1863.82,Other,324% of Medicaid,1236.8,,,1236.8,Other,215% of Medicaid,1236.8,,,1236.8,Other,215% of Medicaid,719.07,,,719.07,Other,125% of Medicaid,102.86,3227,
OFFICE/OUTPATIENT VISIT NEW LVL 2,99202,CPT,,73099202,CDM,761,RC,,,both,,,252,186.48,,,186.48,Other,150% of Medicare + 9.63% HCRA Surcharge,113.4,45,,113.4,percent of total billed charges,Critical Access Hospital RCC factor,163.8,65,,163.8,percent of total billed charges,All Other,148.68,65,,148.68,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,124.74,,,124.74,Other,110% of Medicare,171.36,68,,171.36,percent of total billed charges,All Other,0.01,,,0.01,Other,186% of Medicaid,201.6,80,,201.6,percent of total billed charges,All Other,209.16,83,,209.16,percent of total billed charges,All Other,209.16,83,,209.16,percent of total billed charges,All Other,201.6,80,,201.6,percent of total billed charges,All Other,209.16,83,,209.16,percent of total billed charges,All Other,201.6,,,201.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",176.4,70,,176.4,percent of total billed charges,All Other,234.52,,,234.52,Fee Schedule,,198.77,,,198.77,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3227,
OFFICE/OUTPATIENT VISIT NEW LVL 3,99203,CPT,,73099203,CDM,761,RC,,,both,,,345,255.3,,,255.3,Other,150% of Medicare + 9.63% HCRA Surcharge,155.25,45,,155.25,percent of total billed charges,Critical Access Hospital RCC factor,224.25,65,,224.25,percent of total billed charges,All Other,203.55,65,,203.55,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,170.78,,,170.78,Other,110% of Medicare,234.6,68,,234.6,percent of total billed charges,All Other,0.01,,,0.01,Other,186% of Medicaid,276,80,,276,percent of total billed charges,All Other,286.35,83,,286.35,percent of total billed charges,All Other,286.35,83,,286.35,percent of total billed charges,All Other,276,80,,276,percent of total billed charges,All Other,286.35,83,,286.35,percent of total billed charges,All Other,276,,,276,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",241.5,70,,241.5,percent of total billed charges,All Other,400.16,,,400.16,Fee Schedule,,339.16,,,339.16,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3227,
OFFICE/OUTPATIENT VISIT NEW LVL 4,99204,CPT,,73099204,CDM,761,RC,,,both,,,460,340.4,,,340.4,Other,150% of Medicare + 9.63% HCRA Surcharge,207,45,,207,percent of total billed charges,Critical Access Hospital RCC factor,299,65,,299,percent of total billed charges,All Other,271.4,65,,271.4,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,227.7,,,227.7,Other,110% of Medicare,312.8,68,,312.8,percent of total billed charges,All Other,0.01,,,0.01,Other,186% of Medicaid,368,80,,368,percent of total billed charges,All Other,381.8,83,,381.8,percent of total billed charges,All Other,381.8,83,,381.8,percent of total billed charges,All Other,368,80,,368,percent of total billed charges,All Other,381.8,83,,381.8,percent of total billed charges,All Other,368,,,368,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",322,70,,322,percent of total billed charges,All Other,647.8,,,647.8,Fee Schedule,,549.05,,,549.05,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3227,
OFFICE/OUTPATIENT VISIT NEW LVL 5,99205,CPT,,73099205,CDM,761,RC,,,both,,,628,464.72,,,464.72,Other,150% of Medicare + 9.63% HCRA Surcharge,282.6,45,,282.6,percent of total billed charges,Critical Access Hospital RCC factor,408.2,65,,408.2,percent of total billed charges,All Other,370.52,65,,370.52,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,310.86,,,310.86,Other,110% of Medicare,427.04,68,,427.04,percent of total billed charges,All Other,0.01,,,0.01,Other,186% of Medicaid,502.4,80,,502.4,percent of total billed charges,All Other,521.24,83,,521.24,percent of total billed charges,All Other,521.24,83,,521.24,percent of total billed charges,All Other,502.4,80,,502.4,percent of total billed charges,All Other,521.24,83,,521.24,percent of total billed charges,All Other,502.4,,,502.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",439.6,70,,439.6,percent of total billed charges,All Other,879.04,,,879.04,Fee Schedule,,745.04,,,745.04,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3227,
OFFICE/OUTPATIENT VISIT EST LVL 1,99211,CPT,,73099211,CDM,761,RC,,,both,,,228,168.72,,,168.72,Other,150% of Medicare + 9.63% HCRA Surcharge,102.6,45,,102.6,percent of total billed charges,Critical Access Hospital RCC factor,148.2,65,,148.2,percent of total billed charges,All Other,134.52,65,,134.52,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,112.86,,,112.86,Other,110% of Medicare,155.04,68,,155.04,percent of total billed charges,All Other,0.01,,,0.01,Other,186% of Medicaid,182.4,80,,182.4,percent of total billed charges,All Other,189.24,83,,189.24,percent of total billed charges,All Other,189.24,83,,189.24,percent of total billed charges,All Other,182.4,80,,182.4,percent of total billed charges,All Other,189.24,83,,189.24,percent of total billed charges,All Other,182.4,,,182.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",159.6,70,,159.6,percent of total billed charges,All Other,42.64,,,42.64,Fee Schedule,,36.14,,,36.14,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3227,
OFFICE/OUTPATIENT VISIT EST LVL 2,99212,CPT,,73099212,CDM,761,RC,,,both,,,259,191.66,,,191.66,Other,150% of Medicare + 9.63% HCRA Surcharge,116.55,45,,116.55,percent of total billed charges,Critical Access Hospital RCC factor,168.35,65,,168.35,percent of total billed charges,All Other,152.81,65,,152.81,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,128.21,,,128.21,Other,110% of Medicare,176.12,68,,176.12,percent of total billed charges,All Other,0.01,,,0.01,Other,186% of Medicaid,207.2,80,,207.2,percent of total billed charges,All Other,214.97,83,,214.97,percent of total billed charges,All Other,214.97,83,,214.97,percent of total billed charges,All Other,207.2,80,,207.2,percent of total billed charges,All Other,214.97,83,,214.97,percent of total billed charges,All Other,207.2,,,207.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",181.3,70,,181.3,percent of total billed charges,All Other,173.84,,,173.84,Fee Schedule,,147.34,,,147.34,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3227,
OFFICE/OUTPATIENT VISIT EST LVL 3,99213,CPT,,73099213,CDM,761,RC,,,both,,,259,191.66,,,191.66,Other,150% of Medicare + 9.63% HCRA Surcharge,116.55,45,,116.55,percent of total billed charges,Critical Access Hospital RCC factor,168.35,65,,168.35,percent of total billed charges,All Other,152.81,65,,152.81,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,128.21,,,128.21,Other,110% of Medicare,176.12,68,,176.12,percent of total billed charges,All Other,0.01,,,0.01,Other,186% of Medicaid,207.2,80,,207.2,percent of total billed charges,All Other,214.97,83,,214.97,percent of total billed charges,All Other,214.97,83,,214.97,percent of total billed charges,All Other,207.2,80,,207.2,percent of total billed charges,All Other,214.97,83,,214.97,percent of total billed charges,All Other,207.2,,,207.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",181.3,70,,181.3,percent of total billed charges,All Other,319.8,,,319.8,Fee Schedule,,271.05,,,271.05,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3227,
OFFICE/OUTPATIENT VISIT EST LVL 4,99214,CPT,,73099214,CDM,761,RC,,,both,,,340,251.6,,,251.6,Other,150% of Medicare + 9.63% HCRA Surcharge,153,45,,153,percent of total billed charges,Critical Access Hospital RCC factor,221,65,,221,percent of total billed charges,All Other,200.6,65,,200.6,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,168.3,,,168.3,Other,110% of Medicare,231.2,68,,231.2,percent of total billed charges,All Other,0.01,,,0.01,Other,186% of Medicaid,272,80,,272,percent of total billed charges,All Other,282.2,83,,282.2,percent of total billed charges,All Other,282.2,83,,282.2,percent of total billed charges,All Other,272,80,,272,percent of total billed charges,All Other,282.2,83,,282.2,percent of total billed charges,All Other,272,,,272,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",238,70,,238,percent of total billed charges,All Other,469.04,,,469.04,Fee Schedule,,397.54,,,397.54,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3227,
OFFICE/OUTPATIENT VISIT EST LVL 5,99215,CPT,,73099215,CDM,761,RC,,,both,,,440,325.6,,,325.6,Other,150% of Medicare + 9.63% HCRA Surcharge,198,45,,198,percent of total billed charges,Critical Access Hospital RCC factor,286,65,,286,percent of total billed charges,All Other,259.6,65,,259.6,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,217.8,,,217.8,Other,110% of Medicare,299.2,68,,299.2,percent of total billed charges,All Other,0.01,,,0.01,Other,186% of Medicaid,352,80,,352,percent of total billed charges,All Other,365.2,83,,365.2,percent of total billed charges,All Other,365.2,83,,365.2,percent of total billed charges,All Other,352,80,,352,percent of total billed charges,All Other,365.2,83,,365.2,percent of total billed charges,All Other,352,,,352,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",308,70,,308,percent of total billed charges,All Other,697,,,697,Fee Schedule,,590.75,,,590.75,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3227,
APPLY RIGID TOTAL CONTACT LEG CAST W/MOD,29445,CPT,59,73129445,CDM,761,RC,,,both,,,842,623.08,,,623.08,Other,150% of Medicare + 9.63% HCRA Surcharge,378.9,45,,378.9,percent of total billed charges,Critical Access Hospital RCC factor,547.3,65,,547.3,percent of total billed charges,All Other,496.78,65,,496.78,percent of total billed charges,All Other,3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",416.79,,,416.79,Other,110% of Medicare,572.56,68,,572.56,percent of total billed charges,All Other,445,,,445,Other,186% of Medicaid,673.6,80,,673.6,percent of total billed charges,All Other,698.86,83,,698.86,percent of total billed charges,All Other,698.86,83,,698.86,percent of total billed charges,All Other,673.6,80,,673.6,percent of total billed charges,All Other,698.86,83,,698.86,percent of total billed charges,All Other,673.6,,,673.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",589.4,70,,589.4,percent of total billed charges,All Other,3933,,,3933,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3343,,,3343,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 50% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",239.06,,,239.06,Other,100% of Medicaid,239.06,,,239.06,Other,100% of Medicaid,239.06,,,239.06,Other,100% of Medicaid,239.06,,,239.06,Other,100% of Medicaid,537.89,,,537.89,Other,225% of Medicaid,365.76,,,365.76,Other,153% of Medicaid,537.89,,,537.89,Other,225% of Medicaid,334.68,,,334.68,Other,140% of Medicaid,537.89,,,537.89,Other,225% of Medicaid,621.56,,,621.56,Other,260% of Medicaid,774.55,,,774.55,Other,324% of Medicaid,513.98,,,513.98,Other,215% of Medicaid,513.98,,,513.98,Other,215% of Medicaid,298.83,,,298.83,Other,125% of Medicaid,239.06,3933,
UNNA BOOT STRAPPING BILATERAL,29580,CPT,50,73129580,CDM,761,RC,,,both,,,641,474.34,,,474.34,Other,150% of Medicare + 9.63% HCRA Surcharge,288.45,45,,288.45,percent of total billed charges,Critical Access Hospital RCC factor,416.65,65,,416.65,percent of total billed charges,All Other,378.19,65,,378.19,percent of total billed charges,All Other,3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",317.3,,,317.3,Other,110% of Medicare,435.88,68,,435.88,percent of total billed charges,All Other,445,,,445,Other,186% of Medicaid,512.8,80,,512.8,percent of total billed charges,All Other,532.03,83,,532.03,percent of total billed charges,All Other,532.03,83,,532.03,percent of total billed charges,All Other,512.8,80,,512.8,percent of total billed charges,All Other,532.03,83,,532.03,percent of total billed charges,All Other,512.8,,,512.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",448.7,70,,448.7,percent of total billed charges,All Other,129.56,,,129.56,Fee Schedule,,109.81,,,109.81,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",239.06,,,239.06,Other,100% of Medicaid,239.06,,,239.06,Other,100% of Medicaid,239.06,,,239.06,Other,100% of Medicaid,239.06,,,239.06,Other,100% of Medicaid,537.89,,,537.89,Other,225% of Medicaid,365.76,,,365.76,Other,153% of Medicaid,537.89,,,537.89,Other,225% of Medicaid,334.68,,,334.68,Other,140% of Medicaid,537.89,,,537.89,Other,225% of Medicaid,621.56,,,621.56,Other,260% of Medicaid,774.55,,,774.55,Other,324% of Medicaid,513.98,,,513.98,Other,215% of Medicaid,513.98,,,513.98,Other,215% of Medicaid,298.83,,,298.83,Other,125% of Medicaid,109.81,3227,
APPLY MULTLAY COMPRS LWR LEG,29581,CPT,,73129581,CDM,761,RC,,,both,,,393,290.82,,,290.82,Other,150% of Medicare + 9.63% HCRA Surcharge,176.85,45,,176.85,percent of total billed charges,Critical Access Hospital RCC factor,255.45,65,,255.45,percent of total billed charges,All Other,231.87,65,,231.87,percent of total billed charges,All Other,3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",194.54,,,194.54,Other,110% of Medicare,267.24,68,,267.24,percent of total billed charges,All Other,445,,,445,Other,186% of Medicaid,314.4,80,,314.4,percent of total billed charges,All Other,326.19,83,,326.19,percent of total billed charges,All Other,326.19,83,,326.19,percent of total billed charges,All Other,314.4,80,,314.4,percent of total billed charges,All Other,326.19,83,,326.19,percent of total billed charges,All Other,314.4,80,,314.4,percent of total billed charges,All Other,275.1,70,,275.1,percent of total billed charges,All Other,131.2,,,131.2,Fee Schedule,,111.2,,,111.2,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",239.06,,,239.06,Other,100% of Medicaid,239.06,,,239.06,Other,100% of Medicaid,239.06,,,239.06,Other,100% of Medicaid,239.06,,,239.06,Other,100% of Medicaid,537.89,,,537.89,Other,225% of Medicaid,365.76,,,365.76,Other,153% of Medicaid,537.89,,,537.89,Other,225% of Medicaid,334.68,,,334.68,Other,140% of Medicaid,537.89,,,537.89,Other,225% of Medicaid,621.56,,,621.56,Other,260% of Medicaid,774.55,,,774.55,Other,324% of Medicaid,513.98,,,513.98,Other,215% of Medicaid,513.98,,,513.98,Other,215% of Medicaid,298.83,,,298.83,Other,125% of Medicaid,111.2,3227,
OFFICE/OUTPATIENT VISIT NEW LVL 2,99202,CPT,25,73199202,CDM,761,RC,,,both,,,252,186.48,,,186.48,Other,150% of Medicare + 9.63% HCRA Surcharge,113.4,45,,113.4,percent of total billed charges,Critical Access Hospital RCC factor,163.8,65,,163.8,percent of total billed charges,All Other,148.68,65,,148.68,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,124.74,,,124.74,Other,110% of Medicare,171.36,68,,171.36,percent of total billed charges,All Other,0.01,,,0.01,Other,186% of Medicaid,201.6,80,,201.6,percent of total billed charges,All Other,209.16,83,,209.16,percent of total billed charges,All Other,209.16,83,,209.16,percent of total billed charges,All Other,201.6,80,,201.6,percent of total billed charges,All Other,209.16,83,,209.16,percent of total billed charges,All Other,201.6,,,201.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",176.4,70,,176.4,percent of total billed charges,All Other,234.52,,,234.52,Fee Schedule,,198.77,,,198.77,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3227,
OFFICE/OUTPATIENT VISIT NEW LVL 3,99203,CPT,25,73199203,CDM,761,RC,,,both,,,345,255.3,,,255.3,Other,150% of Medicare + 9.63% HCRA Surcharge,155.25,45,,155.25,percent of total billed charges,Critical Access Hospital RCC factor,224.25,65,,224.25,percent of total billed charges,All Other,203.55,65,,203.55,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,170.78,,,170.78,Other,110% of Medicare,234.6,68,,234.6,percent of total billed charges,All Other,0.01,,,0.01,Other,186% of Medicaid,276,80,,276,percent of total billed charges,All Other,286.35,83,,286.35,percent of total billed charges,All Other,286.35,83,,286.35,percent of total billed charges,All Other,276,80,,276,percent of total billed charges,All Other,286.35,83,,286.35,percent of total billed charges,All Other,276,,,276,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",241.5,70,,241.5,percent of total billed charges,All Other,400.16,,,400.16,Fee Schedule,,339.16,,,339.16,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3227,
OFFICE/OUTPATIENT VISIT NEW LVL 4,99204,CPT,25,73199204,CDM,761,RC,,,both,,,460,340.4,,,340.4,Other,150% of Medicare + 9.63% HCRA Surcharge,207,45,,207,percent of total billed charges,Critical Access Hospital RCC factor,299,65,,299,percent of total billed charges,All Other,271.4,65,,271.4,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,227.7,,,227.7,Other,110% of Medicare,312.8,68,,312.8,percent of total billed charges,All Other,0.01,,,0.01,Other,186% of Medicaid,368,80,,368,percent of total billed charges,All Other,381.8,83,,381.8,percent of total billed charges,All Other,381.8,83,,381.8,percent of total billed charges,All Other,368,80,,368,percent of total billed charges,All Other,381.8,83,,381.8,percent of total billed charges,All Other,368,,,368,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",322,70,,322,percent of total billed charges,All Other,647.8,,,647.8,Fee Schedule,,549.05,,,549.05,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3227,
OFFICE/OUTPATIENT VISIT NEW LVL 5,99205,CPT,25,73199205,CDM,761,RC,,,both,,,628,464.72,,,464.72,Other,150% of Medicare + 9.63% HCRA Surcharge,282.6,45,,282.6,percent of total billed charges,Critical Access Hospital RCC factor,408.2,65,,408.2,percent of total billed charges,All Other,370.52,65,,370.52,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,310.86,,,310.86,Other,110% of Medicare,427.04,68,,427.04,percent of total billed charges,All Other,0.01,,,0.01,Other,186% of Medicaid,502.4,80,,502.4,percent of total billed charges,All Other,521.24,83,,521.24,percent of total billed charges,All Other,521.24,83,,521.24,percent of total billed charges,All Other,502.4,80,,502.4,percent of total billed charges,All Other,521.24,83,,521.24,percent of total billed charges,All Other,502.4,,,502.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",439.6,70,,439.6,percent of total billed charges,All Other,879.04,,,879.04,Fee Schedule,,745.04,,,745.04,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3227,
OFFICE/OUTPATIENT VISIT EST LVL 1,99211,CPT,25,73199211,CDM,761,RC,,,both,,,228,168.72,,,168.72,Other,150% of Medicare + 9.63% HCRA Surcharge,102.6,45,,102.6,percent of total billed charges,Critical Access Hospital RCC factor,148.2,65,,148.2,percent of total billed charges,All Other,134.52,65,,134.52,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,112.86,,,112.86,Other,110% of Medicare,155.04,68,,155.04,percent of total billed charges,All Other,0.01,,,0.01,Other,186% of Medicaid,182.4,80,,182.4,percent of total billed charges,All Other,189.24,83,,189.24,percent of total billed charges,All Other,189.24,83,,189.24,percent of total billed charges,All Other,182.4,80,,182.4,percent of total billed charges,All Other,189.24,83,,189.24,percent of total billed charges,All Other,182.4,,,182.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",159.6,70,,159.6,percent of total billed charges,All Other,42.64,,,42.64,Fee Schedule,,36.14,,,36.14,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3227,
OFFICE/OUTPATIENT VISIT EST LVL 2,99212,CPT,25,73199212,CDM,761,RC,,,both,,,259,191.66,,,191.66,Other,150% of Medicare + 9.63% HCRA Surcharge,116.55,45,,116.55,percent of total billed charges,Critical Access Hospital RCC factor,168.35,65,,168.35,percent of total billed charges,All Other,152.81,65,,152.81,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,128.21,,,128.21,Other,110% of Medicare,176.12,68,,176.12,percent of total billed charges,All Other,0.01,,,0.01,Other,186% of Medicaid,207.2,80,,207.2,percent of total billed charges,All Other,214.97,83,,214.97,percent of total billed charges,All Other,214.97,83,,214.97,percent of total billed charges,All Other,207.2,80,,207.2,percent of total billed charges,All Other,214.97,83,,214.97,percent of total billed charges,All Other,207.2,,,207.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",181.3,70,,181.3,percent of total billed charges,All Other,173.84,,,173.84,Fee Schedule,,147.34,,,147.34,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3227,
OFFICE/OUTPATIENT VISIT EST LVL 3,99213,CPT,25,73199213,CDM,761,RC,,,both,,,259,191.66,,,191.66,Other,150% of Medicare + 9.63% HCRA Surcharge,116.55,45,,116.55,percent of total billed charges,Critical Access Hospital RCC factor,168.35,65,,168.35,percent of total billed charges,All Other,152.81,65,,152.81,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,128.21,,,128.21,Other,110% of Medicare,176.12,68,,176.12,percent of total billed charges,All Other,0.01,,,0.01,Other,186% of Medicaid,207.2,80,,207.2,percent of total billed charges,All Other,214.97,83,,214.97,percent of total billed charges,All Other,214.97,83,,214.97,percent of total billed charges,All Other,207.2,80,,207.2,percent of total billed charges,All Other,214.97,83,,214.97,percent of total billed charges,All Other,207.2,,,207.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",181.3,70,,181.3,percent of total billed charges,All Other,319.8,,,319.8,Fee Schedule,,271.05,,,271.05,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3227,
OFFICE/OUTPATIENT VISIT EST LVL 4,99214,CPT,25,73199214,CDM,761,RC,,,both,,,340,251.6,,,251.6,Other,150% of Medicare + 9.63% HCRA Surcharge,153,45,,153,percent of total billed charges,Critical Access Hospital RCC factor,221,65,,221,percent of total billed charges,All Other,200.6,65,,200.6,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,168.3,,,168.3,Other,110% of Medicare,231.2,68,,231.2,percent of total billed charges,All Other,0.01,,,0.01,Other,186% of Medicaid,272,80,,272,percent of total billed charges,All Other,282.2,83,,282.2,percent of total billed charges,All Other,282.2,83,,282.2,percent of total billed charges,All Other,272,80,,272,percent of total billed charges,All Other,282.2,83,,282.2,percent of total billed charges,All Other,272,,,272,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",238,70,,238,percent of total billed charges,All Other,469.04,,,469.04,Fee Schedule,,397.54,,,397.54,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3227,
OFFICE/OUTPATIENT VISIT EST LVL 5,99215,CPT,25,73199215,CDM,761,RC,,,both,,,440,325.6,,,325.6,Other,150% of Medicare + 9.63% HCRA Surcharge,198,45,,198,percent of total billed charges,Critical Access Hospital RCC factor,286,65,,286,percent of total billed charges,All Other,259.6,65,,259.6,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,217.8,,,217.8,Other,110% of Medicare,299.2,68,,299.2,percent of total billed charges,All Other,0.01,,,0.01,Other,186% of Medicaid,352,80,,352,percent of total billed charges,All Other,365.2,83,,365.2,percent of total billed charges,All Other,365.2,83,,365.2,percent of total billed charges,All Other,352,80,,352,percent of total billed charges,All Other,365.2,83,,365.2,percent of total billed charges,All Other,352,,,352,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",308,70,,308,percent of total billed charges,All Other,697,,,697,Fee Schedule,,590.75,,,590.75,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3227,
UNNA BOOT STRAPPING W/59 MOD,29580,CPT,59,73229580,CDM,761,RC,,,both,,,427,315.98,,,315.98,Other,150% of Medicare + 9.63% HCRA Surcharge,192.15,45,,192.15,percent of total billed charges,Critical Access Hospital RCC factor,277.55,65,,277.55,percent of total billed charges,All Other,251.93,65,,251.93,percent of total billed charges,All Other,3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",211.37,,,211.37,Other,110% of Medicare,290.36,68,,290.36,percent of total billed charges,All Other,445,,,445,Other,186% of Medicaid,341.6,80,,341.6,percent of total billed charges,All Other,354.41,83,,354.41,percent of total billed charges,All Other,354.41,83,,354.41,percent of total billed charges,All Other,341.6,80,,341.6,percent of total billed charges,All Other,354.41,83,,354.41,percent of total billed charges,All Other,341.6,,,341.6,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",298.9,70,,298.9,percent of total billed charges,All Other,129.56,,,129.56,Fee Schedule,,109.81,,,109.81,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",239.06,,,239.06,Other,100% of Medicaid,239.06,,,239.06,Other,100% of Medicaid,239.06,,,239.06,Other,100% of Medicaid,239.06,,,239.06,Other,100% of Medicaid,537.89,,,537.89,Other,225% of Medicaid,365.76,,,365.76,Other,153% of Medicaid,537.89,,,537.89,Other,225% of Medicaid,334.68,,,334.68,Other,140% of Medicaid,537.89,,,537.89,Other,225% of Medicaid,621.56,,,621.56,Other,260% of Medicaid,774.55,,,774.55,Other,324% of Medicaid,513.98,,,513.98,Other,215% of Medicaid,513.98,,,513.98,Other,215% of Medicaid,298.83,,,298.83,Other,125% of Medicaid,109.81,3227,
UNNA BOOT STRAPPING BILATERAL W/59 MOD,29580,CPT,5059,73329580,CDM,761,RC,,,both,,,641,474.34,,,474.34,Other,150% of Medicare + 9.63% HCRA Surcharge,288.45,45,,288.45,percent of total billed charges,Critical Access Hospital RCC factor,416.65,65,,416.65,percent of total billed charges,All Other,378.19,65,,378.19,percent of total billed charges,All Other,3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",317.3,,,317.3,Other,110% of Medicare,435.88,68,,435.88,percent of total billed charges,All Other,445,,,445,Other,186% of Medicaid,512.8,80,,512.8,percent of total billed charges,All Other,532.03,83,,532.03,percent of total billed charges,All Other,532.03,83,,532.03,percent of total billed charges,All Other,512.8,80,,512.8,percent of total billed charges,All Other,532.03,83,,532.03,percent of total billed charges,All Other,512.8,,,512.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",448.7,70,,448.7,percent of total billed charges,All Other,129.56,,,129.56,Fee Schedule,,109.81,,,109.81,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",239.06,,,239.06,Other,100% of Medicaid,239.06,,,239.06,Other,100% of Medicaid,239.06,,,239.06,Other,100% of Medicaid,239.06,,,239.06,Other,100% of Medicaid,537.89,,,537.89,Other,225% of Medicaid,365.76,,,365.76,Other,153% of Medicaid,537.89,,,537.89,Other,225% of Medicaid,334.68,,,334.68,Other,140% of Medicaid,537.89,,,537.89,Other,225% of Medicaid,621.56,,,621.56,Other,260% of Medicaid,774.55,,,774.55,Other,324% of Medicaid,513.98,,,513.98,Other,215% of Medicaid,513.98,,,513.98,Other,215% of Medicaid,298.83,,,298.83,Other,125% of Medicaid,109.81,3227,
UPR/LXTR ART STDY 3+ LVLS,93923,CPT,,74093923,CDM,761,RC,,,both,,,1054,779.96,,,779.96,Other,150% of Medicare + 9.63% HCRA Surcharge,474.3,45,,474.3,percent of total billed charges,Critical Access Hospital RCC factor,349.81,,,349.81,Fee Schedule,,315.42,,,315.42,Fee Schedule,,997.82,,,997.82,Fee Schedule,,897.47,,,897.47,Fee Schedule,,848.24,,,848.24,Fee Schedule,,521.73,,,521.73,Other,110% of Medicare,716.72,68,,716.72,percent of total billed charges,All Other,255,,,255,Other,186% of Medicaid,843.2,80,,843.2,percent of total billed charges,All Other,874.82,83,,874.82,percent of total billed charges,All Other,874.82,83,,874.82,percent of total billed charges,All Other,843.2,80,,843.2,percent of total billed charges,All Other,874.82,83,,874.82,percent of total billed charges,All Other,843.2,,,843.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",737.8,70,,737.8,percent of total billed charges,All Other,523.16,,,523.16,Fee Schedule,,443.41,,,443.41,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",137.34,,,137.34,Other,100% of Medicaid,137.34,,,137.34,Other,100% of Medicaid,137.34,,,137.34,Other,100% of Medicaid,137.34,,,137.34,Other,100% of Medicaid,309.01,,,309.01,Other,225% of Medicaid,210.12,,,210.12,Other,153% of Medicaid,309.01,,,309.01,Other,225% of Medicaid,192.27,,,192.27,Other,140% of Medicaid,309.01,,,309.01,Other,225% of Medicaid,357.07,,,357.07,Other,260% of Medicaid,444.97,,,444.97,Other,324% of Medicaid,295.27,,,295.27,Other,215% of Medicaid,295.27,,,295.27,Other,215% of Medicaid,171.67,,,171.67,Other,125% of Medicaid,137.34,3227,
COLLECT BLOOD FROM VAD,36591,CPT,,75036591,CDM,761,RC,,,both,,,263,194.62,,,194.62,Other,150% of Medicare + 9.63% HCRA Surcharge,118.35,45,,118.35,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,155.73,,,155.73,Fee Schedule,,140.07,,,140.07,Fee Schedule,,132.38,,,132.38,Fee Schedule,,130.19,,,130.19,Other,110% of Medicare,178.84,68,,178.84,percent of total billed charges,All Other,49,,,49,Other,186% of Medicaid,210.4,80,,210.4,percent of total billed charges,All Other,218.29,83,,218.29,percent of total billed charges,All Other,218.29,83,,218.29,percent of total billed charges,All Other,210.4,80,,210.4,percent of total billed charges,All Other,218.29,83,,218.29,percent of total billed charges,All Other,210.4,,,210.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",184.1,70,,184.1,percent of total billed charges,All Other,129.56,,,129.56,Fee Schedule,,109.81,,,109.81,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",26.36,,,26.36,Other,100% of Medicaid,26.36,,,26.36,Other,100% of Medicaid,26.36,,,26.36,Other,100% of Medicaid,26.36,,,26.36,Other,100% of Medicaid,59.32,,,59.32,Other,225% of Medicaid,40.33,,,40.33,Other,153% of Medicaid,59.32,,,59.32,Other,225% of Medicaid,36.91,,,36.91,Other,140% of Medicaid,59.32,,,59.32,Other,225% of Medicaid,68.54,,,68.54,Other,260% of Medicaid,85.41,,,85.41,Other,324% of Medicaid,56.68,,,56.68,Other,215% of Medicaid,56.68,,,56.68,Other,215% of Medicaid,32.95,,,32.95,Other,125% of Medicaid,0.01,3227,
COLLECT BLOOD FROM PICC,36592,CPT,,75036592,CDM,761,RC,,,both,,,263,194.62,,,194.62,Other,150% of Medicare + 9.63% HCRA Surcharge,118.35,45,,118.35,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,174.02,,,174.02,Fee Schedule,,156.51,,,156.51,Fee Schedule,,147.93,,,147.93,Fee Schedule,,130.19,,,130.19,Other,110% of Medicare,178.84,68,,178.84,percent of total billed charges,All Other,49,,,49,Other,186% of Medicaid,210.4,80,,210.4,percent of total billed charges,All Other,218.29,83,,218.29,percent of total billed charges,All Other,218.29,83,,218.29,percent of total billed charges,All Other,210.4,80,,210.4,percent of total billed charges,All Other,218.29,83,,218.29,percent of total billed charges,All Other,210.4,,,210.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",184.1,70,,184.1,percent of total billed charges,All Other,144.32,,,144.32,Fee Schedule,,122.32,,,122.32,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",26.36,,,26.36,Other,100% of Medicaid,26.36,,,26.36,Other,100% of Medicaid,26.36,,,26.36,Other,100% of Medicaid,26.36,,,26.36,Other,100% of Medicaid,59.32,,,59.32,Other,225% of Medicaid,40.33,,,40.33,Other,153% of Medicaid,59.32,,,59.32,Other,225% of Medicaid,36.91,,,36.91,Other,140% of Medicaid,59.32,,,59.32,Other,225% of Medicaid,68.54,,,68.54,Other,260% of Medicaid,85.41,,,85.41,Other,324% of Medicaid,56.68,,,56.68,Other,215% of Medicaid,56.68,,,56.68,Other,215% of Medicaid,32.95,,,32.95,Other,125% of Medicaid,0.01,3227,
DECLOT VASCULAR DEVICE,36593,CPT,,75036593,CDM,761,RC,,,both,,,896,663.04,,,663.04,Other,150% of Medicare + 9.63% HCRA Surcharge,403.2,45,,403.2,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",443.52,,,443.52,Other,110% of Medicare,609.28,,,609.28,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",411.17,,,411.17,Other,186% of Medicaid,716.8,,,716.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",716.8,,,716.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",716.8,,,716.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",627.2,70,,627.2,percent of total billed charges,All Other,159.08,,,159.08,Fee Schedule,,134.83,,,134.83,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",221.06,,,221.06,Other,100% of Medicaid,221.06,,,221.06,Other,100% of Medicaid,221.06,,,221.06,Other,100% of Medicaid,221.06,,,221.06,Other,100% of Medicaid,497.39,,,497.39,Other,225% of Medicaid,338.22,,,338.22,Other,153% of Medicaid,497.39,,,497.39,Other,225% of Medicaid,309.49,,,309.49,Other,140% of Medicaid,497.39,,,497.39,Other,225% of Medicaid,574.76,,,574.76,Other,260% of Medicaid,716.24,,,716.24,Other,324% of Medicaid,475.28,,,475.28,Other,215% of Medicaid,475.28,,,475.28,Other,215% of Medicaid,276.33,,,276.33,Other,125% of Medicaid,134.83,7216,
BONE MARROW BIOPSY,38221,CPT,,75038221,CDM,761,RC,,,both,,,3926,2905.25,,,2905.25,Other,150% of Medicare + 9.63% HCRA Surcharge,1766.7,45,,1766.7,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3648,,,3648,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3283,,,3283,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3101,,,3101,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",1943.37,,,1943.37,Other,110% of Medicare,2669.68,,,2669.68,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",777.01,,,777.01,Other,186% of Medicaid,3140.8,,,3140.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",3140.8,,,3140.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",3140.8,,,3140.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2748.2,70,,2748.2,percent of total billed charges,All Other,339.48,,,339.48,Fee Schedule,,287.73,,,287.73,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",417.75,,,417.75,Other,100% of Medicaid,417.75,,,417.75,Other,100% of Medicaid,417.75,,,417.75,Other,100% of Medicaid,417.75,,,417.75,Other,100% of Medicaid,939.93,,,939.93,Other,225% of Medicaid,639.15,,,639.15,Other,153% of Medicaid,939.93,,,939.93,Other,225% of Medicaid,584.84,,,584.84,Other,140% of Medicaid,939.93,,,939.93,Other,225% of Medicaid,1086.14,,,1086.14,Other,260% of Medicaid,1353.5,,,1353.5,Other,324% of Medicaid,898.15,,,898.15,Other,215% of Medicaid,898.15,,,898.15,Other,215% of Medicaid,522.18,,,522.18,Other,125% of Medicaid,287.73,7216,
INS TEMP BLADDER CATH,51702,CPT,,75051702,CDM,761,RC,,,both,,,263,194.62,,,194.62,Other,150% of Medicare + 9.63% HCRA Surcharge,118.35,45,,118.35,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",130.19,,,130.19,Other,110% of Medicare,178.84,,,178.84,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",600.52,,,600.52,Other,186% of Medicaid,210.4,,,210.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",210.4,,,210.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",210.4,,,210.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",184.1,70,,184.1,percent of total billed charges,All Other,123,,,123,Fee Schedule,,104.25,,,104.25,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",322.86,,,322.86,Other,100% of Medicaid,322.86,,,322.86,Other,100% of Medicaid,322.86,,,322.86,Other,100% of Medicaid,322.86,,,322.86,Other,100% of Medicaid,726.44,,,726.44,Other,225% of Medicaid,493.98,,,493.98,Other,153% of Medicaid,726.44,,,726.44,Other,225% of Medicaid,452.01,,,452.01,Other,140% of Medicaid,726.44,,,726.44,Other,225% of Medicaid,839.44,,,839.44,Other,260% of Medicaid,1046.07,,,1046.07,Other,324% of Medicaid,694.15,,,694.15,Other,215% of Medicaid,694.15,,,694.15,Other,215% of Medicaid,403.58,,,403.58,Other,125% of Medicaid,104.25,7216,
TREATMENT OF BLADDER LESION,51720,CPT,,75051720,CDM,761,RC,,,both,,,1409,1042.66,,,1042.66,Other,150% of Medicare + 9.63% HCRA Surcharge,634.05,45,,634.05,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",697.46,,,697.46,Other,110% of Medicare,958.12,,,958.12,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",903,,,903,Other,186% of Medicaid,1127.2,,,1127.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1127.2,,,1127.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",1127.2,,,1127.2,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",986.3,70,,986.3,percent of total billed charges,All Other,208.28,,,208.28,Fee Schedule,,176.53,,,176.53,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",485.72,,,485.72,Other,100% of Medicaid,485.72,,,485.72,Other,100% of Medicaid,485.72,,,485.72,Other,100% of Medicaid,485.72,,,485.72,Other,100% of Medicaid,1092.86,,,1092.86,Other,225% of Medicaid,743.14,,,743.14,Other,153% of Medicaid,1092.86,,,1092.86,Other,225% of Medicaid,680,,,680,Other,140% of Medicaid,1092.86,,,1092.86,Other,225% of Medicaid,1262.86,,,1262.86,Other,260% of Medicaid,1573.72,,,1573.72,Other,324% of Medicaid,1044.29,,,1044.29,Other,215% of Medicaid,1044.29,,,1044.29,Other,215% of Medicaid,607.14,,,607.14,Other,125% of Medicaid,176.53,7216,
PORT FLUSH SUBSEQUENT,96523,CPT,,75096523,CDM,761,RC,,,both,,,243,179.82,,,179.82,Other,150% of Medicare + 9.63% HCRA Surcharge,109.35,45,,109.35,percent of total billed charges,Critical Access Hospital RCC factor,598,,,598,Fee Schedule,,538,,,538,Fee Schedule,,170.12,,,170.12,Fee Schedule,,153.01,,,153.01,Fee Schedule,,144.61,,,144.61,Fee Schedule,,120.29,,,120.29,Other,110% of Medicare,165.24,68,,165.24,percent of total billed charges,All Other,58,,,58,Other,186% of Medicaid,201.69,,,201.69,Case Rate,,201.69,,,201.69,Case Rate,,201.69,,,201.69,Case Rate,,201.69,,,201.69,Case Rate,,201.69,,,201.69,Case Rate,,194.4,,,194.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",170.1,70,,170.1,percent of total billed charges,All Other,129.56,,,129.56,Fee Schedule,,109.81,,,109.81,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",31.2,,,31.2,Other,100% of Medicaid,31.2,,,31.2,Other,100% of Medicaid,31.2,,,31.2,Other,100% of Medicaid,31.2,,,31.2,Other,100% of Medicaid,70.2,,,70.2,Other,225% of Medicaid,47.74,,,47.74,Other,153% of Medicaid,70.2,,,70.2,Other,225% of Medicaid,43.68,,,43.68,Other,140% of Medicaid,70.2,,,70.2,Other,225% of Medicaid,81.12,,,81.12,Other,260% of Medicaid,101.09,,,101.09,Other,324% of Medicaid,67.08,,,67.08,Other,215% of Medicaid,67.08,,,67.08,Other,215% of Medicaid,39,,,39,Other,125% of Medicaid,31.2,3227,
E & M LOW LEVEL,99211,CPT,,75099211,CDM,761,RC,,,both,,,228,168.72,,,168.72,Other,150% of Medicare + 9.63% HCRA Surcharge,102.6,45,,102.6,percent of total billed charges,Critical Access Hospital RCC factor,148.2,65,,148.2,percent of total billed charges,All Other,134.52,65,,134.52,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,112.86,,,112.86,Other,110% of Medicare,155.04,68,,155.04,percent of total billed charges,All Other,0.01,,,0.01,Other,186% of Medicaid,182.4,80,,182.4,percent of total billed charges,All Other,189.24,83,,189.24,percent of total billed charges,All Other,189.24,83,,189.24,percent of total billed charges,All Other,182.4,80,,182.4,percent of total billed charges,All Other,189.24,83,,189.24,percent of total billed charges,All Other,182.4,,,182.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",159.6,70,,159.6,percent of total billed charges,All Other,42.64,,,42.64,Fee Schedule,,36.14,,,36.14,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3227,
REMOVAL OF PICC LINE OP,99211,CPT,,75199211,CDM,761,RC,,,both,,,228,168.72,,,168.72,Other,150% of Medicare + 9.63% HCRA Surcharge,102.6,45,,102.6,percent of total billed charges,Critical Access Hospital RCC factor,148.2,65,,148.2,percent of total billed charges,All Other,134.52,65,,134.52,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,112.86,,,112.86,Other,110% of Medicare,155.04,68,,155.04,percent of total billed charges,All Other,0.01,,,0.01,Other,186% of Medicaid,182.4,80,,182.4,percent of total billed charges,All Other,189.24,83,,189.24,percent of total billed charges,All Other,189.24,83,,189.24,percent of total billed charges,All Other,182.4,80,,182.4,percent of total billed charges,All Other,189.24,83,,189.24,percent of total billed charges,All Other,182.4,,,182.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",159.6,70,,159.6,percent of total billed charges,All Other,42.64,,,42.64,Fee Schedule,,36.14,,,36.14,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,3227,
APHERESIS PLASMA,36514,CPT,,77036514,CDM,761,RC,,,both,,,3431,2538.95,,,2538.95,Other,150% of Medicare + 9.63% HCRA Surcharge,1543.95,45,,1543.95,percent of total billed charges,Critical Access Hospital RCC factor,2480,,,2480,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2232,,,2232,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3648,,,3648,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3283,,,3283,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3101,,,3101,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",1698.35,,,1698.35,Other,110% of Medicare,2333.08,,,2333.08,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",3574,,,3574,Other,186% of Medicaid,2744.8,,,2744.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2744.8,,,2744.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2744.8,,,2744.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2401.7,70,,2401.7,percent of total billed charges,All Other,449.36,,,449.36,Fee Schedule,,380.86,,,380.86,Fee Schedule,,4055,,,4055,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3649,,,3649,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",4055,,,4055,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3448,,,3448,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",1921.43,,,1921.43,Other,100% of Medicaid,1921.43,,,1921.43,Other,100% of Medicaid,1921.43,,,1921.43,Other,100% of Medicaid,1921.43,,,1921.43,Other,100% of Medicaid,4323.22,,,4323.22,Other,225% of Medicaid,2939.79,,,2939.79,Other,153% of Medicaid,4323.22,,,4323.22,Other,225% of Medicaid,2690.01,,,2690.01,Other,140% of Medicaid,4323.22,,,4323.22,Other,225% of Medicaid,4995.72,,,4995.72,Other,260% of Medicaid,6225.44,,,6225.44,Other,324% of Medicaid,4131.08,,,4131.08,Other,215% of Medicaid,4131.08,,,4131.08,Other,215% of Medicaid,2401.79,,,2401.79,Other,125% of Medicaid,380.86,7216,
COLLECT BLOOD FROM VAD,36591,CPT,,82036591,CDM,761,RC,,,both,,,263,194.62,,,194.62,Other,150% of Medicare + 9.63% HCRA Surcharge,118.35,45,,118.35,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,155.73,,,155.73,Fee Schedule,,140.07,,,140.07,Fee Schedule,,132.38,,,132.38,Fee Schedule,,130.19,,,130.19,Other,110% of Medicare,178.84,68,,178.84,percent of total billed charges,All Other,49,,,49,Other,186% of Medicaid,210.4,80,,210.4,percent of total billed charges,All Other,218.29,83,,218.29,percent of total billed charges,All Other,218.29,83,,218.29,percent of total billed charges,All Other,210.4,80,,210.4,percent of total billed charges,All Other,218.29,83,,218.29,percent of total billed charges,All Other,210.4,,,210.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",184.1,70,,184.1,percent of total billed charges,All Other,129.56,,,129.56,Fee Schedule,,109.81,,,109.81,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",26.36,,,26.36,Other,100% of Medicaid,26.36,,,26.36,Other,100% of Medicaid,26.36,,,26.36,Other,100% of Medicaid,26.36,,,26.36,Other,100% of Medicaid,59.32,,,59.32,Other,225% of Medicaid,40.33,,,40.33,Other,153% of Medicaid,59.32,,,59.32,Other,225% of Medicaid,36.91,,,36.91,Other,140% of Medicaid,59.32,,,59.32,Other,225% of Medicaid,68.54,,,68.54,Other,260% of Medicaid,85.41,,,85.41,Other,324% of Medicaid,56.68,,,56.68,Other,215% of Medicaid,56.68,,,56.68,Other,215% of Medicaid,32.95,,,32.95,Other,125% of Medicaid,0.01,3227,
BONE MARROW BIOPSY,38221,CPT,,82038221,CDM,761,RC,,,both,,,3926,2905.25,,,2905.25,Other,150% of Medicare + 9.63% HCRA Surcharge,1766.7,45,,1766.7,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3648,,,3648,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3283,,,3283,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3101,,,3101,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",1943.37,,,1943.37,Other,110% of Medicare,2669.68,,,2669.68,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",777.01,,,777.01,Other,186% of Medicaid,3140.8,,,3140.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",3140.8,,,3140.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",3140.8,,,3140.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",2748.2,70,,2748.2,percent of total billed charges,All Other,339.48,,,339.48,Fee Schedule,,287.73,,,287.73,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",417.75,,,417.75,Other,100% of Medicaid,417.75,,,417.75,Other,100% of Medicaid,417.75,,,417.75,Other,100% of Medicaid,417.75,,,417.75,Other,100% of Medicaid,939.93,,,939.93,Other,225% of Medicaid,639.15,,,639.15,Other,153% of Medicaid,939.93,,,939.93,Other,225% of Medicaid,584.84,,,584.84,Other,140% of Medicaid,939.93,,,939.93,Other,225% of Medicaid,1086.14,,,1086.14,Other,260% of Medicaid,1353.5,,,1353.5,Other,324% of Medicaid,898.15,,,898.15,Other,215% of Medicaid,898.15,,,898.15,Other,215% of Medicaid,522.18,,,522.18,Other,125% of Medicaid,287.73,7216,
INS TEMP BLADDER CATH,51702,CPT,,82051702,CDM,761,RC,,,both,,,271,200.54,,,200.54,Other,150% of Medicare + 9.63% HCRA Surcharge,121.95,45,,121.95,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",134.15,,,134.15,Other,110% of Medicare,184.28,,,184.28,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",600.52,,,600.52,Other,186% of Medicaid,216.8,,,216.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",216.8,,,216.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",216.8,,,216.8,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",189.7,70,,189.7,percent of total billed charges,All Other,123,,,123,Fee Schedule,,104.25,,,104.25,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",322.86,,,322.86,Other,100% of Medicaid,322.86,,,322.86,Other,100% of Medicaid,322.86,,,322.86,Other,100% of Medicaid,322.86,,,322.86,Other,100% of Medicaid,726.44,,,726.44,Other,225% of Medicaid,493.98,,,493.98,Other,153% of Medicaid,726.44,,,726.44,Other,225% of Medicaid,452.01,,,452.01,Other,140% of Medicaid,726.44,,,726.44,Other,225% of Medicaid,839.44,,,839.44,Other,260% of Medicaid,1046.07,,,1046.07,Other,324% of Medicaid,694.15,,,694.15,Other,215% of Medicaid,694.15,,,694.15,Other,215% of Medicaid,403.58,,,403.58,Other,125% of Medicaid,104.25,7216,
US PV RESIDUAL URINE,51798,CPT,,82051798,CDM,761,RC,,,both,,,258,190.92,,,190.92,Other,150% of Medicare + 9.63% HCRA Surcharge,116.1,45,,116.1,percent of total billed charges,Critical Access Hospital RCC factor,167.7,65,,167.7,percent of total billed charges,All Other,152.22,65,,152.22,percent of total billed charges,All Other,132.8,,,132.8,Fee Schedule,,119.45,,,119.45,Fee Schedule,,112.9,,,112.9,Fee Schedule,,127.71,,,127.71,Other,110% of Medicare,175.44,68,,175.44,percent of total billed charges,All Other,601,,,601,Other,186% of Medicaid,206.4,80,,206.4,percent of total billed charges,All Other,214.14,83,,214.14,percent of total billed charges,All Other,214.14,83,,214.14,percent of total billed charges,All Other,206.4,80,,206.4,percent of total billed charges,All Other,214.14,83,,214.14,percent of total billed charges,All Other,206.4,,,206.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",180.6,70,,180.6,percent of total billed charges,All Other,50.84,,,50.84,Fee Schedule,,43.09,,,43.09,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",322.86,,,322.86,Other,100% of Medicaid,322.86,,,322.86,Other,100% of Medicaid,322.86,,,322.86,Other,100% of Medicaid,322.86,,,322.86,Other,100% of Medicaid,726.44,,,726.44,Other,225% of Medicaid,493.98,,,493.98,Other,153% of Medicaid,726.44,,,726.44,Other,225% of Medicaid,452.01,,,452.01,Other,140% of Medicaid,726.44,,,726.44,Other,225% of Medicaid,839.44,,,839.44,Other,260% of Medicaid,1046.07,,,1046.07,Other,324% of Medicaid,694.15,,,694.15,Other,215% of Medicaid,694.15,,,694.15,Other,215% of Medicaid,403.58,,,403.58,Other,125% of Medicaid,43.09,3227,
RAPID DESENSITIZATION,95180,CPT,,82095180,CDM,761,RC,,,both,,,853,631.22,,,631.22,Other,150% of Medicare + 9.63% HCRA Surcharge,383.85,45,,383.85,percent of total billed charges,Critical Access Hospital RCC factor,554.45,65,,554.45,percent of total billed charges,All Other,503.27,65,,503.27,percent of total billed charges,All Other,858.45,,,858.45,Fee Schedule,,772.77,,,772.77,Fee Schedule,,729.93,,,729.93,Fee Schedule,,422.24,,,422.24,Other,110% of Medicare,580.04,68,,580.04,percent of total billed charges,All Other,388,,,388,Other,186% of Medicaid,682.4,80,,682.4,percent of total billed charges,All Other,707.99,83,,707.99,percent of total billed charges,All Other,707.99,83,,707.99,percent of total billed charges,All Other,682.4,80,,682.4,percent of total billed charges,All Other,707.99,83,,707.99,percent of total billed charges,All Other,682.4,,,682.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",597.1,70,,597.1,percent of total billed charges,All Other,490.36,,,490.36,Fee Schedule,,415.61,,,415.61,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",208.59,,,208.59,Other,100% of Medicaid,208.59,,,208.59,Other,100% of Medicaid,208.59,,,208.59,Other,100% of Medicaid,208.59,,,208.59,Other,100% of Medicaid,469.32,,,469.32,Other,225% of Medicaid,319.14,,,319.14,Other,153% of Medicaid,469.32,,,469.32,Other,225% of Medicaid,292.02,,,292.02,Other,140% of Medicaid,469.32,,,469.32,Other,225% of Medicaid,542.32,,,542.32,Other,260% of Medicaid,675.82,,,675.82,Other,324% of Medicaid,448.46,,,448.46,Other,215% of Medicaid,448.46,,,448.46,Other,215% of Medicaid,260.73,,,260.73,Other,125% of Medicaid,208.59,3227,
PORT FLUSH,96523,CPT,,82096523,CDM,761,RC,,,both,,,243,179.82,,,179.82,Other,150% of Medicare + 9.63% HCRA Surcharge,109.35,45,,109.35,percent of total billed charges,Critical Access Hospital RCC factor,598,,,598,Fee Schedule,,538,,,538,Fee Schedule,,170.12,,,170.12,Fee Schedule,,153.01,,,153.01,Fee Schedule,,144.61,,,144.61,Fee Schedule,,120.29,,,120.29,Other,110% of Medicare,165.24,68,,165.24,percent of total billed charges,All Other,58,,,58,Other,186% of Medicaid,201.69,,,201.69,Case Rate,,201.69,,,201.69,Case Rate,,201.69,,,201.69,Case Rate,,201.69,,,201.69,Case Rate,,201.69,,,201.69,Case Rate,,194.4,,,194.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",170.1,70,,170.1,percent of total billed charges,All Other,129.56,,,129.56,Fee Schedule,,109.81,,,109.81,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",31.2,,,31.2,Other,100% of Medicaid,31.2,,,31.2,Other,100% of Medicaid,31.2,,,31.2,Other,100% of Medicaid,31.2,,,31.2,Other,100% of Medicaid,70.2,,,70.2,Other,225% of Medicaid,47.74,,,47.74,Other,153% of Medicaid,70.2,,,70.2,Other,225% of Medicaid,43.68,,,43.68,Other,140% of Medicaid,70.2,,,70.2,Other,225% of Medicaid,81.12,,,81.12,Other,260% of Medicaid,101.09,,,101.09,Other,324% of Medicaid,67.08,,,67.08,Other,215% of Medicaid,67.08,,,67.08,Other,215% of Medicaid,39,,,39,Other,125% of Medicaid,31.2,3227,
SLCTV WND DEBRIDEM 20 CM OR <,97597,CPT,,82097597,CDM,761,RC,,,both,,,573,424.02,,,424.02,Other,150% of Medicare + 9.63% HCRA Surcharge,257.85,45,,257.85,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",283.64,,,283.64,Other,110% of Medicare,389.64,,,389.64,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",702.75,,,702.75,Other,186% of Medicaid,458.4,,,458.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",458.4,,,458.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",458.4,,,458.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",401.1,70,,401.1,percent of total billed charges,All Other,173.84,,,173.84,Fee Schedule,,147.34,,,147.34,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",377.82,,,377.82,Other,100% of Medicaid,377.82,,,377.82,Other,100% of Medicaid,377.82,,,377.82,Other,100% of Medicaid,377.82,,,377.82,Other,100% of Medicaid,850.1,,,850.1,Other,225% of Medicaid,578.07,,,578.07,Other,153% of Medicaid,850.1,,,850.1,Other,225% of Medicaid,528.95,,,528.95,Other,140% of Medicaid,850.1,,,850.1,Other,225% of Medicaid,982.34,,,982.34,Other,260% of Medicaid,1224.15,,,1224.15,Other,324% of Medicaid,812.32,,,812.32,Other,215% of Medicaid,812.32,,,812.32,Other,215% of Medicaid,472.28,,,472.28,Other,125% of Medicaid,147.34,7216,
NSW DEBRIDEM WO A/SESSION,97602,CPT,,82097602,CDM,761,RC,,,both,,,408,301.92,,,301.92,Other,150% of Medicare + 9.63% HCRA Surcharge,183.6,45,,183.6,percent of total billed charges,Critical Access Hospital RCC factor,265.2,65,,265.2,percent of total billed charges,All Other,240.72,65,,240.72,percent of total billed charges,All Other,3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",201.96,,,201.96,Other,110% of Medicare,277.44,68,,277.44,percent of total billed charges,All Other,1070,,,1070,Other,186% of Medicaid,326.4,80,,326.4,percent of total billed charges,All Other,338.64,83,,338.64,percent of total billed charges,All Other,338.64,83,,338.64,percent of total billed charges,All Other,326.4,80,,326.4,percent of total billed charges,All Other,338.64,83,,338.64,percent of total billed charges,All Other,326.4,,,326.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",285.6,70,,285.6,percent of total billed charges,All Other,265.2,65,,265.2,percent of total billed charges,Default if not in Fee Schedule,265.2,65,,265.2,percent of total billed charges,Default if not in Fee Schedule,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",575.25,,,575.25,Other,100% of Medicaid,575.25,,,575.25,Other,100% of Medicaid,575.25,,,575.25,Other,100% of Medicaid,575.25,,,575.25,Other,100% of Medicaid,1294.32,,,1294.32,Other,225% of Medicaid,880.14,,,880.14,Other,153% of Medicaid,1294.32,,,1294.32,Other,225% of Medicaid,805.36,,,805.36,Other,140% of Medicaid,1294.32,,,1294.32,Other,225% of Medicaid,1495.66,,,1495.66,Other,260% of Medicaid,1863.82,,,1863.82,Other,324% of Medicaid,1236.8,,,1236.8,Other,215% of Medicaid,1236.8,,,1236.8,Other,215% of Medicaid,719.07,,,719.07,Other,125% of Medicaid,183.6,3227,
INSERT STRAIGHT CATHETER,51701,CPT,,82151701,CDM,761,RC,,,both,,,263,194.62,,,194.62,Other,150% of Medicare + 9.63% HCRA Surcharge,118.35,45,,118.35,percent of total billed charges,Critical Access Hospital RCC factor,2281,,,2281,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2053,,,2053,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",3024,,,3024,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2722,,,2722,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",2570,,,2570,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% subsequent",130.19,,,130.19,Other,110% of Medicare,178.84,,,178.84,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",600.52,,,600.52,Other,186% of Medicaid,210.4,,,210.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",210.4,,,210.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",7216,,,7216,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",210.4,,,210.4,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, subsequent 25%",184.1,70,,184.1,percent of total billed charges,All Other,124.64,,,124.64,Fee Schedule,,105.64,,,105.64,Fee Schedule,,3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2904,,,2904,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",3227,,,3227,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",2743,,,2743,Other,"ASC Grouper table. Multiple procedure discount 100% 1st, 50% 2nd, 25% 3rd",322.86,,,322.86,Other,100% of Medicaid,322.86,,,322.86,Other,100% of Medicaid,322.86,,,322.86,Other,100% of Medicaid,322.86,,,322.86,Other,100% of Medicaid,726.44,,,726.44,Other,225% of Medicaid,493.98,,,493.98,Other,153% of Medicaid,726.44,,,726.44,Other,225% of Medicaid,452.01,,,452.01,Other,140% of Medicaid,726.44,,,726.44,Other,225% of Medicaid,839.44,,,839.44,Other,260% of Medicaid,1046.07,,,1046.07,Other,324% of Medicaid,694.15,,,694.15,Other,215% of Medicaid,694.15,,,694.15,Other,215% of Medicaid,403.58,,,403.58,Other,125% of Medicaid,105.64,7216,
OBSERVATION HRLY 3 BWAY,G0378,HCPCS,,10000002,CDM,762,RC,,,both,,,2480,1835.21,,,1835.21,Other,150% of Medicare + 9.63% HCRA Surcharge,1116,45,,1116,percent of total billed charges,Critical Access Hospital RCC factor,5767,,,5767,Case Rate,Observation Per Case,5190,,,5190,Case Rate,Observation Per Case,8005,,,8005,Case Rate,Observation Per Case,7205,,,7205,Case Rate,Observation Per Case,6804,,,6804,Case Rate,Observation Per Case,1227.6,,,1227.6,Other,110% of Medicare,1686.4,68,,1686.4,percent of total billed charges,All Other,44,,,44,Other,186% of Medicaid,1984,80,,1984,percent of total billed charges,All Other,2058.4,83,,2058.4,percent of total billed charges,All Other,2058.4,83,,2058.4,percent of total billed charges,All Other,1984,80,,1984,percent of total billed charges,All Other,2058.4,83,,2058.4,percent of total billed charges,All Other,5529,,,5529,Case Rate,Observation Per Case,1736,70,,1736,percent of total billed charges,All Other,6578,,,6578,Case Rate,Observation Per Case,5591,,,5591,Case Rate,Observation Per Case,3973,,,3973,Case Rate,Observation Per Case,3576,,,3576,Case Rate,Observation Per Case,3973,,,3973,Case Rate,Observation Per Case,3377,,,3377,Case Rate,Observation Per Case,23.63,,,23.63,Other,100% of Medicaid,23.63,,,23.63,Other,100% of Medicaid,23.63,,,23.63,Other,100% of Medicaid,23.63,,,23.63,Other,100% of Medicaid,53.16,,,53.16,Other,225% of Medicaid,36.15,,,36.15,Other,153% of Medicaid,53.16,,,53.16,Other,225% of Medicaid,33.08,,,33.08,Other,140% of Medicaid,53.16,,,53.16,Other,225% of Medicaid,61.43,,,61.43,Other,260% of Medicaid,76.55,,,76.55,Other,324% of Medicaid,50.8,,,50.8,Other,215% of Medicaid,50.8,,,50.8,Other,215% of Medicaid,29.53,,,29.53,Other,125% of Medicaid,23.63,8005,
OBSERVATION DIRECT ADMIT 3 BWAY,G0379,HCPCS,,10000003,CDM,762,RC,,,both,,,2480,1835.21,,,1835.21,Other,150% of Medicare + 9.63% HCRA Surcharge,1116,45,,1116,percent of total billed charges,Critical Access Hospital RCC factor,5767,,,5767,Case Rate,Observation Per Case,5190,,,5190,Case Rate,Observation Per Case,8005,,,8005,Case Rate,Observation Per Case,7205,,,7205,Case Rate,Observation Per Case,6804,,,6804,Case Rate,Observation Per Case,1227.6,,,1227.6,Other,110% of Medicare,1686.4,68,,1686.4,percent of total billed charges,All Other,0.01,,,0.01,Other,186% of Medicaid,1984,80,,1984,percent of total billed charges,All Other,2058.4,83,,2058.4,percent of total billed charges,All Other,2058.4,83,,2058.4,percent of total billed charges,All Other,1984,80,,1984,percent of total billed charges,All Other,2058.4,83,,2058.4,percent of total billed charges,All Other,5529,,,5529,Case Rate,Observation Per Case,1736,70,,1736,percent of total billed charges,All Other,6578,,,6578,Case Rate,Observation Per Case,5591,,,5591,Case Rate,Observation Per Case,3973,,,3973,Case Rate,Observation Per Case,3576,,,3576,Case Rate,Observation Per Case,3973,,,3973,Case Rate,Observation Per Case,3377,,,3377,Case Rate,Observation Per Case,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,8005,
OBSERVATION HRLY 2 BWAY,G0378,HCPCS,,11000002,CDM,762,RC,,,both,,,2480,1835.21,,,1835.21,Other,150% of Medicare + 9.63% HCRA Surcharge,1116,45,,1116,percent of total billed charges,Critical Access Hospital RCC factor,5767,,,5767,Case Rate,Observation Per Case,5190,,,5190,Case Rate,Observation Per Case,8005,,,8005,Case Rate,Observation Per Case,7205,,,7205,Case Rate,Observation Per Case,6804,,,6804,Case Rate,Observation Per Case,1227.6,,,1227.6,Other,110% of Medicare,1686.4,68,,1686.4,percent of total billed charges,All Other,44,,,44,Other,186% of Medicaid,1984,80,,1984,percent of total billed charges,All Other,2058.4,83,,2058.4,percent of total billed charges,All Other,2058.4,83,,2058.4,percent of total billed charges,All Other,1984,80,,1984,percent of total billed charges,All Other,2058.4,83,,2058.4,percent of total billed charges,All Other,5529,,,5529,Case Rate,Observation Per Case,1736,70,,1736,percent of total billed charges,All Other,6578,,,6578,Case Rate,Observation Per Case,5591,,,5591,Case Rate,Observation Per Case,3973,,,3973,Case Rate,Observation Per Case,3576,,,3576,Case Rate,Observation Per Case,3973,,,3973,Case Rate,Observation Per Case,3377,,,3377,Case Rate,Observation Per Case,23.63,,,23.63,Other,100% of Medicaid,23.63,,,23.63,Other,100% of Medicaid,23.63,,,23.63,Other,100% of Medicaid,23.63,,,23.63,Other,100% of Medicaid,53.16,,,53.16,Other,225% of Medicaid,36.15,,,36.15,Other,153% of Medicaid,53.16,,,53.16,Other,225% of Medicaid,33.08,,,33.08,Other,140% of Medicaid,53.16,,,53.16,Other,225% of Medicaid,61.43,,,61.43,Other,260% of Medicaid,76.55,,,76.55,Other,324% of Medicaid,50.8,,,50.8,Other,215% of Medicaid,50.8,,,50.8,Other,215% of Medicaid,29.53,,,29.53,Other,125% of Medicaid,23.63,8005,
OBSERVATION DIRECT ADMIT 2 BWAY,G0379,HCPCS,,11000004,CDM,762,RC,,,both,,,2480,1835.21,,,1835.21,Other,150% of Medicare + 9.63% HCRA Surcharge,1116,45,,1116,percent of total billed charges,Critical Access Hospital RCC factor,5767,,,5767,Case Rate,Observation Per Case,5190,,,5190,Case Rate,Observation Per Case,8005,,,8005,Case Rate,Observation Per Case,7205,,,7205,Case Rate,Observation Per Case,6804,,,6804,Case Rate,Observation Per Case,1227.6,,,1227.6,Other,110% of Medicare,1686.4,68,,1686.4,percent of total billed charges,All Other,0.01,,,0.01,Other,186% of Medicaid,1984,80,,1984,percent of total billed charges,All Other,2058.4,83,,2058.4,percent of total billed charges,All Other,2058.4,83,,2058.4,percent of total billed charges,All Other,1984,80,,1984,percent of total billed charges,All Other,2058.4,83,,2058.4,percent of total billed charges,All Other,5529,,,5529,Case Rate,Observation Per Case,1736,70,,1736,percent of total billed charges,All Other,6578,,,6578,Case Rate,Observation Per Case,5591,,,5591,Case Rate,Observation Per Case,3973,,,3973,Case Rate,Observation Per Case,3576,,,3576,Case Rate,Observation Per Case,3973,,,3973,Case Rate,Observation Per Case,3377,,,3377,Case Rate,Observation Per Case,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,8005,
OBSERVATION HRLY 2 WEST,G0378,HCPCS,,12000002,CDM,762,RC,,,both,,,2480,1835.21,,,1835.21,Other,150% of Medicare + 9.63% HCRA Surcharge,1116,45,,1116,percent of total billed charges,Critical Access Hospital RCC factor,5767,,,5767,Case Rate,Observation Per Case,5190,,,5190,Case Rate,Observation Per Case,8005,,,8005,Case Rate,Observation Per Case,7205,,,7205,Case Rate,Observation Per Case,6804,,,6804,Case Rate,Observation Per Case,1227.6,,,1227.6,Other,110% of Medicare,1686.4,68,,1686.4,percent of total billed charges,All Other,44,,,44,Other,186% of Medicaid,1984,80,,1984,percent of total billed charges,All Other,2058.4,83,,2058.4,percent of total billed charges,All Other,2058.4,83,,2058.4,percent of total billed charges,All Other,1984,80,,1984,percent of total billed charges,All Other,2058.4,83,,2058.4,percent of total billed charges,All Other,5529,,,5529,Case Rate,Observation Per Case,1736,70,,1736,percent of total billed charges,All Other,6578,,,6578,Case Rate,Observation Per Case,5591,,,5591,Case Rate,Observation Per Case,3973,,,3973,Case Rate,Observation Per Case,3576,,,3576,Case Rate,Observation Per Case,3973,,,3973,Case Rate,Observation Per Case,3377,,,3377,Case Rate,Observation Per Case,23.63,,,23.63,Other,100% of Medicaid,23.63,,,23.63,Other,100% of Medicaid,23.63,,,23.63,Other,100% of Medicaid,23.63,,,23.63,Other,100% of Medicaid,53.16,,,53.16,Other,225% of Medicaid,36.15,,,36.15,Other,153% of Medicaid,53.16,,,53.16,Other,225% of Medicaid,33.08,,,33.08,Other,140% of Medicaid,53.16,,,53.16,Other,225% of Medicaid,61.43,,,61.43,Other,260% of Medicaid,76.55,,,76.55,Other,324% of Medicaid,50.8,,,50.8,Other,215% of Medicaid,50.8,,,50.8,Other,215% of Medicaid,29.53,,,29.53,Other,125% of Medicaid,23.63,8005,
OBSERVATION DIRECT ADMIT 2 WEST,G0379,HCPCS,,12000003,CDM,762,RC,,,both,,,2480,1835.21,,,1835.21,Other,150% of Medicare + 9.63% HCRA Surcharge,1116,45,,1116,percent of total billed charges,Critical Access Hospital RCC factor,5767,,,5767,Case Rate,Observation Per Case,5190,,,5190,Case Rate,Observation Per Case,8005,,,8005,Case Rate,Observation Per Case,7205,,,7205,Case Rate,Observation Per Case,6804,,,6804,Case Rate,Observation Per Case,1227.6,,,1227.6,Other,110% of Medicare,1686.4,68,,1686.4,percent of total billed charges,All Other,0.01,,,0.01,Other,186% of Medicaid,1984,80,,1984,percent of total billed charges,All Other,2058.4,83,,2058.4,percent of total billed charges,All Other,2058.4,83,,2058.4,percent of total billed charges,All Other,1984,80,,1984,percent of total billed charges,All Other,2058.4,83,,2058.4,percent of total billed charges,All Other,5529,,,5529,Case Rate,Observation Per Case,1736,70,,1736,percent of total billed charges,All Other,6578,,,6578,Case Rate,Observation Per Case,5591,,,5591,Case Rate,Observation Per Case,3973,,,3973,Case Rate,Observation Per Case,3576,,,3576,Case Rate,Observation Per Case,3973,,,3973,Case Rate,Observation Per Case,3377,,,3377,Case Rate,Observation Per Case,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,8005,
OBSERVATION HRLY 3 EAST,G0378,HCPCS,,13000002,CDM,762,RC,,,both,,,2480,1835.21,,,1835.21,Other,150% of Medicare + 9.63% HCRA Surcharge,1116,45,,1116,percent of total billed charges,Critical Access Hospital RCC factor,5767,,,5767,Case Rate,Observation Per Case,5190,,,5190,Case Rate,Observation Per Case,8005,,,8005,Case Rate,Observation Per Case,7205,,,7205,Case Rate,Observation Per Case,6804,,,6804,Case Rate,Observation Per Case,1227.6,,,1227.6,Other,110% of Medicare,1686.4,68,,1686.4,percent of total billed charges,All Other,44,,,44,Other,186% of Medicaid,1984,80,,1984,percent of total billed charges,All Other,2058.4,83,,2058.4,percent of total billed charges,All Other,2058.4,83,,2058.4,percent of total billed charges,All Other,1984,80,,1984,percent of total billed charges,All Other,2058.4,83,,2058.4,percent of total billed charges,All Other,5529,,,5529,Case Rate,Observation Per Case,1736,70,,1736,percent of total billed charges,All Other,6578,,,6578,Case Rate,Observation Per Case,5591,,,5591,Case Rate,Observation Per Case,3973,,,3973,Case Rate,Observation Per Case,3576,,,3576,Case Rate,Observation Per Case,3973,,,3973,Case Rate,Observation Per Case,3377,,,3377,Case Rate,Observation Per Case,23.63,,,23.63,Other,100% of Medicaid,23.63,,,23.63,Other,100% of Medicaid,23.63,,,23.63,Other,100% of Medicaid,23.63,,,23.63,Other,100% of Medicaid,53.16,,,53.16,Other,225% of Medicaid,36.15,,,36.15,Other,153% of Medicaid,53.16,,,53.16,Other,225% of Medicaid,33.08,,,33.08,Other,140% of Medicaid,53.16,,,53.16,Other,225% of Medicaid,61.43,,,61.43,Other,260% of Medicaid,76.55,,,76.55,Other,324% of Medicaid,50.8,,,50.8,Other,215% of Medicaid,50.8,,,50.8,Other,215% of Medicaid,29.53,,,29.53,Other,125% of Medicaid,23.63,8005,
OBSERVATION DIRECT ADMIT 3 EAST,G0379,HCPCS,,13000003,CDM,762,RC,,,both,,,2480,1835.21,,,1835.21,Other,150% of Medicare + 9.63% HCRA Surcharge,1116,45,,1116,percent of total billed charges,Critical Access Hospital RCC factor,5767,,,5767,Case Rate,Observation Per Case,5190,,,5190,Case Rate,Observation Per Case,8005,,,8005,Case Rate,Observation Per Case,7205,,,7205,Case Rate,Observation Per Case,6804,,,6804,Case Rate,Observation Per Case,1227.6,,,1227.6,Other,110% of Medicare,1686.4,68,,1686.4,percent of total billed charges,All Other,0.01,,,0.01,Other,186% of Medicaid,1984,80,,1984,percent of total billed charges,All Other,2058.4,83,,2058.4,percent of total billed charges,All Other,2058.4,83,,2058.4,percent of total billed charges,All Other,1984,80,,1984,percent of total billed charges,All Other,2058.4,83,,2058.4,percent of total billed charges,All Other,5529,,,5529,Case Rate,Observation Per Case,1736,70,,1736,percent of total billed charges,All Other,6578,,,6578,Case Rate,Observation Per Case,5591,,,5591,Case Rate,Observation Per Case,3973,,,3973,Case Rate,Observation Per Case,3576,,,3576,Case Rate,Observation Per Case,3973,,,3973,Case Rate,Observation Per Case,3377,,,3377,Case Rate,Observation Per Case,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,8005,
OBSERVATION HRLY 3 WEST,G0378,HCPCS,,14000002,CDM,762,RC,,,both,,,2480,1835.21,,,1835.21,Other,150% of Medicare + 9.63% HCRA Surcharge,1116,45,,1116,percent of total billed charges,Critical Access Hospital RCC factor,5767,,,5767,Case Rate,Observation Per Case,5190,,,5190,Case Rate,Observation Per Case,8005,,,8005,Case Rate,Observation Per Case,7205,,,7205,Case Rate,Observation Per Case,6804,,,6804,Case Rate,Observation Per Case,1227.6,,,1227.6,Other,110% of Medicare,1686.4,68,,1686.4,percent of total billed charges,All Other,44,,,44,Other,186% of Medicaid,1984,80,,1984,percent of total billed charges,All Other,2058.4,83,,2058.4,percent of total billed charges,All Other,2058.4,83,,2058.4,percent of total billed charges,All Other,1984,80,,1984,percent of total billed charges,All Other,2058.4,83,,2058.4,percent of total billed charges,All Other,5529,,,5529,Case Rate,Observation Per Case,1736,70,,1736,percent of total billed charges,All Other,6578,,,6578,Case Rate,Observation Per Case,5591,,,5591,Case Rate,Observation Per Case,3973,,,3973,Case Rate,Observation Per Case,3576,,,3576,Case Rate,Observation Per Case,3973,,,3973,Case Rate,Observation Per Case,3377,,,3377,Case Rate,Observation Per Case,23.63,,,23.63,Other,100% of Medicaid,23.63,,,23.63,Other,100% of Medicaid,23.63,,,23.63,Other,100% of Medicaid,23.63,,,23.63,Other,100% of Medicaid,53.16,,,53.16,Other,225% of Medicaid,36.15,,,36.15,Other,153% of Medicaid,53.16,,,53.16,Other,225% of Medicaid,33.08,,,33.08,Other,140% of Medicaid,53.16,,,53.16,Other,225% of Medicaid,61.43,,,61.43,Other,260% of Medicaid,76.55,,,76.55,Other,324% of Medicaid,50.8,,,50.8,Other,215% of Medicaid,50.8,,,50.8,Other,215% of Medicaid,29.53,,,29.53,Other,125% of Medicaid,23.63,8005,
OBSERVATION DIRECT ADMIT 3 WEST,G0379,HCPCS,,14000003,CDM,762,RC,,,both,,,2480,1835.21,,,1835.21,Other,150% of Medicare + 9.63% HCRA Surcharge,1116,45,,1116,percent of total billed charges,Critical Access Hospital RCC factor,5767,,,5767,Case Rate,Observation Per Case,5190,,,5190,Case Rate,Observation Per Case,8005,,,8005,Case Rate,Observation Per Case,7205,,,7205,Case Rate,Observation Per Case,6804,,,6804,Case Rate,Observation Per Case,1227.6,,,1227.6,Other,110% of Medicare,1686.4,68,,1686.4,percent of total billed charges,All Other,0.01,,,0.01,Other,186% of Medicaid,1984,80,,1984,percent of total billed charges,All Other,2058.4,83,,2058.4,percent of total billed charges,All Other,2058.4,83,,2058.4,percent of total billed charges,All Other,1984,80,,1984,percent of total billed charges,All Other,2058.4,83,,2058.4,percent of total billed charges,All Other,5529,,,5529,Case Rate,Observation Per Case,1736,70,,1736,percent of total billed charges,All Other,6578,,,6578,Case Rate,Observation Per Case,5591,,,5591,Case Rate,Observation Per Case,3973,,,3973,Case Rate,Observation Per Case,3576,,,3576,Case Rate,Observation Per Case,3973,,,3973,Case Rate,Observation Per Case,3377,,,3377,Case Rate,Observation Per Case,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,8005,
OBSERVATION HRLY 3 SPELL,G0378,HCPCS,,15000002,CDM,762,RC,,,both,,,2480,1835.21,,,1835.21,Other,150% of Medicare + 9.63% HCRA Surcharge,1116,45,,1116,percent of total billed charges,Critical Access Hospital RCC factor,5767,,,5767,Case Rate,Observation Per Case,5190,,,5190,Case Rate,Observation Per Case,8005,,,8005,Case Rate,Observation Per Case,7205,,,7205,Case Rate,Observation Per Case,6804,,,6804,Case Rate,Observation Per Case,1227.6,,,1227.6,Other,110% of Medicare,1686.4,68,,1686.4,percent of total billed charges,All Other,44,,,44,Other,186% of Medicaid,1984,80,,1984,percent of total billed charges,All Other,2058.4,83,,2058.4,percent of total billed charges,All Other,2058.4,83,,2058.4,percent of total billed charges,All Other,1984,80,,1984,percent of total billed charges,All Other,2058.4,83,,2058.4,percent of total billed charges,All Other,5529,,,5529,Case Rate,Observation Per Case,1736,70,,1736,percent of total billed charges,All Other,6578,,,6578,Case Rate,Observation Per Case,5591,,,5591,Case Rate,Observation Per Case,3973,,,3973,Case Rate,Observation Per Case,3576,,,3576,Case Rate,Observation Per Case,3973,,,3973,Case Rate,Observation Per Case,3377,,,3377,Case Rate,Observation Per Case,23.63,,,23.63,Other,100% of Medicaid,23.63,,,23.63,Other,100% of Medicaid,23.63,,,23.63,Other,100% of Medicaid,23.63,,,23.63,Other,100% of Medicaid,53.16,,,53.16,Other,225% of Medicaid,36.15,,,36.15,Other,153% of Medicaid,53.16,,,53.16,Other,225% of Medicaid,33.08,,,33.08,Other,140% of Medicaid,53.16,,,53.16,Other,225% of Medicaid,61.43,,,61.43,Other,260% of Medicaid,76.55,,,76.55,Other,324% of Medicaid,50.8,,,50.8,Other,215% of Medicaid,50.8,,,50.8,Other,215% of Medicaid,29.53,,,29.53,Other,125% of Medicaid,23.63,8005,
OBSERVATION HRLY 3 SMC,G0378,HCPCS,,16000002,CDM,762,RC,,,both,,,2480,1835.21,,,1835.21,Other,150% of Medicare + 9.63% HCRA Surcharge,1116,45,,1116,percent of total billed charges,Critical Access Hospital RCC factor,5767,,,5767,Case Rate,Observation Per Case,5190,,,5190,Case Rate,Observation Per Case,8005,,,8005,Case Rate,Observation Per Case,7205,,,7205,Case Rate,Observation Per Case,6804,,,6804,Case Rate,Observation Per Case,1227.6,,,1227.6,Other,110% of Medicare,1686.4,68,,1686.4,percent of total billed charges,All Other,44,,,44,Other,186% of Medicaid,1984,80,,1984,percent of total billed charges,All Other,2058.4,83,,2058.4,percent of total billed charges,All Other,2058.4,83,,2058.4,percent of total billed charges,All Other,1984,80,,1984,percent of total billed charges,All Other,2058.4,83,,2058.4,percent of total billed charges,All Other,5529,,,5529,Case Rate,Observation Per Case,1736,70,,1736,percent of total billed charges,All Other,6578,,,6578,Case Rate,Observation Per Case,5591,,,5591,Case Rate,Observation Per Case,3973,,,3973,Case Rate,Observation Per Case,3576,,,3576,Case Rate,Observation Per Case,3973,,,3973,Case Rate,Observation Per Case,3377,,,3377,Case Rate,Observation Per Case,23.63,,,23.63,Other,100% of Medicaid,23.63,,,23.63,Other,100% of Medicaid,23.63,,,23.63,Other,100% of Medicaid,23.63,,,23.63,Other,100% of Medicaid,53.16,,,53.16,Other,225% of Medicaid,36.15,,,36.15,Other,153% of Medicaid,53.16,,,53.16,Other,225% of Medicaid,33.08,,,33.08,Other,140% of Medicaid,53.16,,,53.16,Other,225% of Medicaid,61.43,,,61.43,Other,260% of Medicaid,76.55,,,76.55,Other,324% of Medicaid,50.8,,,50.8,Other,215% of Medicaid,50.8,,,50.8,Other,215% of Medicaid,29.53,,,29.53,Other,125% of Medicaid,23.63,8005,
OBSERVATION HRLY 4 SMC,G0378,HCPCS,,17000005,CDM,762,RC,,,both,,,2480,1835.21,,,1835.21,Other,150% of Medicare + 9.63% HCRA Surcharge,1116,45,,1116,percent of total billed charges,Critical Access Hospital RCC factor,5767,,,5767,Case Rate,Observation Per Case,5190,,,5190,Case Rate,Observation Per Case,8005,,,8005,Case Rate,Observation Per Case,7205,,,7205,Case Rate,Observation Per Case,6804,,,6804,Case Rate,Observation Per Case,1227.6,,,1227.6,Other,110% of Medicare,1686.4,68,,1686.4,percent of total billed charges,All Other,44,,,44,Other,186% of Medicaid,1984,80,,1984,percent of total billed charges,All Other,2058.4,83,,2058.4,percent of total billed charges,All Other,2058.4,83,,2058.4,percent of total billed charges,All Other,1984,80,,1984,percent of total billed charges,All Other,2058.4,83,,2058.4,percent of total billed charges,All Other,5529,,,5529,Case Rate,Observation Per Case,1736,70,,1736,percent of total billed charges,All Other,6578,,,6578,Case Rate,Observation Per Case,5591,,,5591,Case Rate,Observation Per Case,3973,,,3973,Case Rate,Observation Per Case,3576,,,3576,Case Rate,Observation Per Case,3973,,,3973,Case Rate,Observation Per Case,3377,,,3377,Case Rate,Observation Per Case,23.63,,,23.63,Other,100% of Medicaid,23.63,,,23.63,Other,100% of Medicaid,23.63,,,23.63,Other,100% of Medicaid,23.63,,,23.63,Other,100% of Medicaid,53.16,,,53.16,Other,225% of Medicaid,36.15,,,36.15,Other,153% of Medicaid,53.16,,,53.16,Other,225% of Medicaid,33.08,,,33.08,Other,140% of Medicaid,53.16,,,53.16,Other,225% of Medicaid,61.43,,,61.43,Other,260% of Medicaid,76.55,,,76.55,Other,324% of Medicaid,50.8,,,50.8,Other,215% of Medicaid,50.8,,,50.8,Other,215% of Medicaid,29.53,,,29.53,Other,125% of Medicaid,23.63,8005,
OBSERVATION HRLY 4 SPELL,G0378,HCPCS,,18000002,CDM,762,RC,,,both,,,2480,1835.21,,,1835.21,Other,150% of Medicare + 9.63% HCRA Surcharge,1116,45,,1116,percent of total billed charges,Critical Access Hospital RCC factor,5767,,,5767,Case Rate,Observation Per Case,5190,,,5190,Case Rate,Observation Per Case,8005,,,8005,Case Rate,Observation Per Case,7205,,,7205,Case Rate,Observation Per Case,6804,,,6804,Case Rate,Observation Per Case,1227.6,,,1227.6,Other,110% of Medicare,1686.4,68,,1686.4,percent of total billed charges,All Other,44,,,44,Other,186% of Medicaid,1984,80,,1984,percent of total billed charges,All Other,2058.4,83,,2058.4,percent of total billed charges,All Other,2058.4,83,,2058.4,percent of total billed charges,All Other,1984,80,,1984,percent of total billed charges,All Other,2058.4,83,,2058.4,percent of total billed charges,All Other,5529,,,5529,Case Rate,Observation Per Case,1736,70,,1736,percent of total billed charges,All Other,6578,,,6578,Case Rate,Observation Per Case,5591,,,5591,Case Rate,Observation Per Case,3973,,,3973,Case Rate,Observation Per Case,3576,,,3576,Case Rate,Observation Per Case,3973,,,3973,Case Rate,Observation Per Case,3377,,,3377,Case Rate,Observation Per Case,23.63,,,23.63,Other,100% of Medicaid,23.63,,,23.63,Other,100% of Medicaid,23.63,,,23.63,Other,100% of Medicaid,23.63,,,23.63,Other,100% of Medicaid,53.16,,,53.16,Other,225% of Medicaid,36.15,,,36.15,Other,153% of Medicaid,53.16,,,53.16,Other,225% of Medicaid,33.08,,,33.08,Other,140% of Medicaid,53.16,,,53.16,Other,225% of Medicaid,61.43,,,61.43,Other,260% of Medicaid,76.55,,,76.55,Other,324% of Medicaid,50.8,,,50.8,Other,215% of Medicaid,50.8,,,50.8,Other,215% of Medicaid,29.53,,,29.53,Other,125% of Medicaid,23.63,8005,
OBSERVATION DIRECT ADMIT 4 SPELL,G0379,HCPCS,,18000003,CDM,762,RC,,,both,,,2480,1835.21,,,1835.21,Other,150% of Medicare + 9.63% HCRA Surcharge,1116,45,,1116,percent of total billed charges,Critical Access Hospital RCC factor,5767,,,5767,Case Rate,Observation Per Case,5190,,,5190,Case Rate,Observation Per Case,8005,,,8005,Case Rate,Observation Per Case,7205,,,7205,Case Rate,Observation Per Case,6804,,,6804,Case Rate,Observation Per Case,1227.6,,,1227.6,Other,110% of Medicare,1686.4,68,,1686.4,percent of total billed charges,All Other,0.01,,,0.01,Other,186% of Medicaid,1984,80,,1984,percent of total billed charges,All Other,2058.4,83,,2058.4,percent of total billed charges,All Other,2058.4,83,,2058.4,percent of total billed charges,All Other,1984,80,,1984,percent of total billed charges,All Other,2058.4,83,,2058.4,percent of total billed charges,All Other,5529,,,5529,Case Rate,Observation Per Case,1736,70,,1736,percent of total billed charges,All Other,6578,,,6578,Case Rate,Observation Per Case,5591,,,5591,Case Rate,Observation Per Case,3973,,,3973,Case Rate,Observation Per Case,3576,,,3576,Case Rate,Observation Per Case,3973,,,3973,Case Rate,Observation Per Case,3377,,,3377,Case Rate,Observation Per Case,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,8005,
OBSERVATION HRLY ICU,G0378,HCPCS,,24000003,CDM,762,RC,,,both,,,2480,1835.21,,,1835.21,Other,150% of Medicare + 9.63% HCRA Surcharge,1116,45,,1116,percent of total billed charges,Critical Access Hospital RCC factor,5767,,,5767,Case Rate,Observation Per Case,5190,,,5190,Case Rate,Observation Per Case,8005,,,8005,Case Rate,Observation Per Case,7205,,,7205,Case Rate,Observation Per Case,6804,,,6804,Case Rate,Observation Per Case,1227.6,,,1227.6,Other,110% of Medicare,1686.4,68,,1686.4,percent of total billed charges,All Other,44,,,44,Other,186% of Medicaid,1984,80,,1984,percent of total billed charges,All Other,2058.4,83,,2058.4,percent of total billed charges,All Other,2058.4,83,,2058.4,percent of total billed charges,All Other,1984,80,,1984,percent of total billed charges,All Other,2058.4,83,,2058.4,percent of total billed charges,All Other,5529,,,5529,Case Rate,Observation Per Case,1736,70,,1736,percent of total billed charges,All Other,6578,,,6578,Case Rate,Observation Per Case,5591,,,5591,Case Rate,Observation Per Case,3973,,,3973,Case Rate,Observation Per Case,3576,,,3576,Case Rate,Observation Per Case,3973,,,3973,Case Rate,Observation Per Case,3377,,,3377,Case Rate,Observation Per Case,23.63,,,23.63,Other,100% of Medicaid,23.63,,,23.63,Other,100% of Medicaid,23.63,,,23.63,Other,100% of Medicaid,23.63,,,23.63,Other,100% of Medicaid,53.16,,,53.16,Other,225% of Medicaid,36.15,,,36.15,Other,153% of Medicaid,53.16,,,53.16,Other,225% of Medicaid,33.08,,,33.08,Other,140% of Medicaid,53.16,,,53.16,Other,225% of Medicaid,61.43,,,61.43,Other,260% of Medicaid,76.55,,,76.55,Other,324% of Medicaid,50.8,,,50.8,Other,215% of Medicaid,50.8,,,50.8,Other,215% of Medicaid,29.53,,,29.53,Other,125% of Medicaid,23.63,8005,
OBSERVATION HRLY DIRECT ADMIT ICU,G0378,HCPCS,,24000009,CDM,762,RC,,,both,,,2480,1835.21,,,1835.21,Other,150% of Medicare + 9.63% HCRA Surcharge,1116,45,,1116,percent of total billed charges,Critical Access Hospital RCC factor,5767,,,5767,Case Rate,Observation Per Case,5190,,,5190,Case Rate,Observation Per Case,8005,,,8005,Case Rate,Observation Per Case,7205,,,7205,Case Rate,Observation Per Case,6804,,,6804,Case Rate,Observation Per Case,1227.6,,,1227.6,Other,110% of Medicare,1686.4,68,,1686.4,percent of total billed charges,All Other,44,,,44,Other,186% of Medicaid,1984,80,,1984,percent of total billed charges,All Other,2058.4,83,,2058.4,percent of total billed charges,All Other,2058.4,83,,2058.4,percent of total billed charges,All Other,1984,80,,1984,percent of total billed charges,All Other,2058.4,83,,2058.4,percent of total billed charges,All Other,5529,,,5529,Case Rate,Observation Per Case,1736,70,,1736,percent of total billed charges,All Other,6578,,,6578,Case Rate,Observation Per Case,5591,,,5591,Case Rate,Observation Per Case,3973,,,3973,Case Rate,Observation Per Case,3576,,,3576,Case Rate,Observation Per Case,3973,,,3973,Case Rate,Observation Per Case,3377,,,3377,Case Rate,Observation Per Case,23.63,,,23.63,Other,100% of Medicaid,23.63,,,23.63,Other,100% of Medicaid,23.63,,,23.63,Other,100% of Medicaid,23.63,,,23.63,Other,100% of Medicaid,53.16,,,53.16,Other,225% of Medicaid,36.15,,,36.15,Other,153% of Medicaid,53.16,,,53.16,Other,225% of Medicaid,33.08,,,33.08,Other,140% of Medicaid,53.16,,,53.16,Other,225% of Medicaid,61.43,,,61.43,Other,260% of Medicaid,76.55,,,76.55,Other,324% of Medicaid,50.8,,,50.8,Other,215% of Medicaid,50.8,,,50.8,Other,215% of Medicaid,29.53,,,29.53,Other,125% of Medicaid,23.63,8005,
OBSERVATION HRLY OB,G0378,HCPCS,,25000002,CDM,762,RC,,,both,,,2480,1835.21,,,1835.21,Other,150% of Medicare + 9.63% HCRA Surcharge,1116,45,,1116,percent of total billed charges,Critical Access Hospital RCC factor,5767,,,5767,Case Rate,Observation Per Case,5190,,,5190,Case Rate,Observation Per Case,8005,,,8005,Case Rate,Observation Per Case,7205,,,7205,Case Rate,Observation Per Case,6804,,,6804,Case Rate,Observation Per Case,1227.6,,,1227.6,Other,110% of Medicare,1686.4,68,,1686.4,percent of total billed charges,All Other,44,,,44,Other,186% of Medicaid,1984,80,,1984,percent of total billed charges,All Other,2058.4,83,,2058.4,percent of total billed charges,All Other,2058.4,83,,2058.4,percent of total billed charges,All Other,1984,80,,1984,percent of total billed charges,All Other,2058.4,83,,2058.4,percent of total billed charges,All Other,5529,,,5529,Case Rate,Observation Per Case,1736,70,,1736,percent of total billed charges,All Other,6578,,,6578,Case Rate,Observation Per Case,5591,,,5591,Case Rate,Observation Per Case,3973,,,3973,Case Rate,Observation Per Case,3576,,,3576,Case Rate,Observation Per Case,3973,,,3973,Case Rate,Observation Per Case,3377,,,3377,Case Rate,Observation Per Case,23.63,,,23.63,Other,100% of Medicaid,23.63,,,23.63,Other,100% of Medicaid,23.63,,,23.63,Other,100% of Medicaid,23.63,,,23.63,Other,100% of Medicaid,53.16,,,53.16,Other,225% of Medicaid,36.15,,,36.15,Other,153% of Medicaid,53.16,,,53.16,Other,225% of Medicaid,33.08,,,33.08,Other,140% of Medicaid,53.16,,,53.16,Other,225% of Medicaid,61.43,,,61.43,Other,260% of Medicaid,76.55,,,76.55,Other,324% of Medicaid,50.8,,,50.8,Other,215% of Medicaid,50.8,,,50.8,Other,215% of Medicaid,29.53,,,29.53,Other,125% of Medicaid,23.63,8005,
HRLY OBSERVATION,G0378,HCPCS,,30000010,CDM,762,RC,,,both,,,2480,1835.21,,,1835.21,Other,150% of Medicare + 9.63% HCRA Surcharge,1116,45,,1116,percent of total billed charges,Critical Access Hospital RCC factor,5767,,,5767,Case Rate,Observation Per Case,5190,,,5190,Case Rate,Observation Per Case,8005,,,8005,Case Rate,Observation Per Case,7205,,,7205,Case Rate,Observation Per Case,6804,,,6804,Case Rate,Observation Per Case,1227.6,,,1227.6,Other,110% of Medicare,1686.4,68,,1686.4,percent of total billed charges,All Other,44,,,44,Other,186% of Medicaid,1984,80,,1984,percent of total billed charges,All Other,2058.4,83,,2058.4,percent of total billed charges,All Other,2058.4,83,,2058.4,percent of total billed charges,All Other,1984,80,,1984,percent of total billed charges,All Other,2058.4,83,,2058.4,percent of total billed charges,All Other,5529,,,5529,Case Rate,Observation Per Case,1736,70,,1736,percent of total billed charges,All Other,6578,,,6578,Case Rate,Observation Per Case,5591,,,5591,Case Rate,Observation Per Case,3973,,,3973,Case Rate,Observation Per Case,3576,,,3576,Case Rate,Observation Per Case,3973,,,3973,Case Rate,Observation Per Case,3377,,,3377,Case Rate,Observation Per Case,23.63,,,23.63,Other,100% of Medicaid,23.63,,,23.63,Other,100% of Medicaid,23.63,,,23.63,Other,100% of Medicaid,23.63,,,23.63,Other,100% of Medicaid,53.16,,,53.16,Other,225% of Medicaid,36.15,,,36.15,Other,153% of Medicaid,53.16,,,53.16,Other,225% of Medicaid,33.08,,,33.08,Other,140% of Medicaid,53.16,,,53.16,Other,225% of Medicaid,61.43,,,61.43,Other,260% of Medicaid,76.55,,,76.55,Other,324% of Medicaid,50.8,,,50.8,Other,215% of Medicaid,50.8,,,50.8,Other,215% of Medicaid,29.53,,,29.53,Other,125% of Medicaid,23.63,8005,
OBSERVATION HRLY MAIN ED,G0378,HCPCS,,30000021,CDM,762,RC,,,both,,,2480,1835.21,,,1835.21,Other,150% of Medicare + 9.63% HCRA Surcharge,1116,45,,1116,percent of total billed charges,Critical Access Hospital RCC factor,5767,,,5767,Case Rate,Observation Per Case,5190,,,5190,Case Rate,Observation Per Case,8005,,,8005,Case Rate,Observation Per Case,7205,,,7205,Case Rate,Observation Per Case,6804,,,6804,Case Rate,Observation Per Case,1227.6,,,1227.6,Other,110% of Medicare,1686.4,68,,1686.4,percent of total billed charges,All Other,44,,,44,Other,186% of Medicaid,1984,80,,1984,percent of total billed charges,All Other,2058.4,83,,2058.4,percent of total billed charges,All Other,2058.4,83,,2058.4,percent of total billed charges,All Other,1984,80,,1984,percent of total billed charges,All Other,2058.4,83,,2058.4,percent of total billed charges,All Other,5529,,,5529,Case Rate,Observation Per Case,1736,70,,1736,percent of total billed charges,All Other,6578,,,6578,Case Rate,Observation Per Case,5591,,,5591,Case Rate,Observation Per Case,3973,,,3973,Case Rate,Observation Per Case,3576,,,3576,Case Rate,Observation Per Case,3973,,,3973,Case Rate,Observation Per Case,3377,,,3377,Case Rate,Observation Per Case,23.63,,,23.63,Other,100% of Medicaid,23.63,,,23.63,Other,100% of Medicaid,23.63,,,23.63,Other,100% of Medicaid,23.63,,,23.63,Other,100% of Medicaid,53.16,,,53.16,Other,225% of Medicaid,36.15,,,36.15,Other,153% of Medicaid,53.16,,,53.16,Other,225% of Medicaid,33.08,,,33.08,Other,140% of Medicaid,53.16,,,53.16,Other,225% of Medicaid,61.43,,,61.43,Other,260% of Medicaid,76.55,,,76.55,Other,324% of Medicaid,50.8,,,50.8,Other,215% of Medicaid,50.8,,,50.8,Other,215% of Medicaid,29.53,,,29.53,Other,125% of Medicaid,23.63,8005,
OBSERVATION HRLY AMB SURG,G0378,HCPCS,,34000027,CDM,762,RC,,,both,,,2480,1835.21,,,1835.21,Other,150% of Medicare + 9.63% HCRA Surcharge,1116,45,,1116,percent of total billed charges,Critical Access Hospital RCC factor,5767,,,5767,Case Rate,Observation Per Case,5190,,,5190,Case Rate,Observation Per Case,8005,,,8005,Case Rate,Observation Per Case,7205,,,7205,Case Rate,Observation Per Case,6804,,,6804,Case Rate,Observation Per Case,1227.6,,,1227.6,Other,110% of Medicare,1686.4,68,,1686.4,percent of total billed charges,All Other,44,,,44,Other,186% of Medicaid,1984,80,,1984,percent of total billed charges,All Other,2058.4,83,,2058.4,percent of total billed charges,All Other,2058.4,83,,2058.4,percent of total billed charges,All Other,1984,80,,1984,percent of total billed charges,All Other,2058.4,83,,2058.4,percent of total billed charges,All Other,5529,,,5529,Case Rate,Observation Per Case,1736,70,,1736,percent of total billed charges,All Other,6578,,,6578,Case Rate,Observation Per Case,5591,,,5591,Case Rate,Observation Per Case,3973,,,3973,Case Rate,Observation Per Case,3576,,,3576,Case Rate,Observation Per Case,3973,,,3973,Case Rate,Observation Per Case,3377,,,3377,Case Rate,Observation Per Case,23.63,,,23.63,Other,100% of Medicaid,23.63,,,23.63,Other,100% of Medicaid,23.63,,,23.63,Other,100% of Medicaid,23.63,,,23.63,Other,100% of Medicaid,53.16,,,53.16,Other,225% of Medicaid,36.15,,,36.15,Other,153% of Medicaid,53.16,,,53.16,Other,225% of Medicaid,33.08,,,33.08,Other,140% of Medicaid,53.16,,,53.16,Other,225% of Medicaid,61.43,,,61.43,Other,260% of Medicaid,76.55,,,76.55,Other,324% of Medicaid,50.8,,,50.8,Other,215% of Medicaid,50.8,,,50.8,Other,215% of Medicaid,29.53,,,29.53,Other,125% of Medicaid,23.63,8005,
OBSERVATION HRLY 5 SPELLMAN,G0378,HCPCS,,86000003,CDM,762,RC,,,both,,,2480,1835.21,,,1835.21,Other,150% of Medicare + 9.63% HCRA Surcharge,1116,45,,1116,percent of total billed charges,Critical Access Hospital RCC factor,5767,,,5767,Case Rate,Observation Per Case,5190,,,5190,Case Rate,Observation Per Case,8005,,,8005,Case Rate,Observation Per Case,7205,,,7205,Case Rate,Observation Per Case,6804,,,6804,Case Rate,Observation Per Case,1227.6,,,1227.6,Other,110% of Medicare,1686.4,68,,1686.4,percent of total billed charges,All Other,44,,,44,Other,186% of Medicaid,1984,80,,1984,percent of total billed charges,All Other,2058.4,83,,2058.4,percent of total billed charges,All Other,2058.4,83,,2058.4,percent of total billed charges,All Other,1984,80,,1984,percent of total billed charges,All Other,2058.4,83,,2058.4,percent of total billed charges,All Other,5529,,,5529,Case Rate,Observation Per Case,1736,70,,1736,percent of total billed charges,All Other,6578,,,6578,Case Rate,Observation Per Case,5591,,,5591,Case Rate,Observation Per Case,3973,,,3973,Case Rate,Observation Per Case,3576,,,3576,Case Rate,Observation Per Case,3973,,,3973,Case Rate,Observation Per Case,3377,,,3377,Case Rate,Observation Per Case,23.63,,,23.63,Other,100% of Medicaid,23.63,,,23.63,Other,100% of Medicaid,23.63,,,23.63,Other,100% of Medicaid,23.63,,,23.63,Other,100% of Medicaid,53.16,,,53.16,Other,225% of Medicaid,36.15,,,36.15,Other,153% of Medicaid,53.16,,,53.16,Other,225% of Medicaid,33.08,,,33.08,Other,140% of Medicaid,53.16,,,53.16,Other,225% of Medicaid,61.43,,,61.43,Other,260% of Medicaid,76.55,,,76.55,Other,324% of Medicaid,50.8,,,50.8,Other,215% of Medicaid,50.8,,,50.8,Other,215% of Medicaid,29.53,,,29.53,Other,125% of Medicaid,23.63,8005,
OBSERVATION HRLY 5 SMC,G0378,HCPCS,,87000003,CDM,762,RC,,,both,,,2480,1835.21,,,1835.21,Other,150% of Medicare + 9.63% HCRA Surcharge,1116,45,,1116,percent of total billed charges,Critical Access Hospital RCC factor,5767,,,5767,Case Rate,Observation Per Case,5190,,,5190,Case Rate,Observation Per Case,8005,,,8005,Case Rate,Observation Per Case,7205,,,7205,Case Rate,Observation Per Case,6804,,,6804,Case Rate,Observation Per Case,1227.6,,,1227.6,Other,110% of Medicare,1686.4,68,,1686.4,percent of total billed charges,All Other,44,,,44,Other,186% of Medicaid,1984,80,,1984,percent of total billed charges,All Other,2058.4,83,,2058.4,percent of total billed charges,All Other,2058.4,83,,2058.4,percent of total billed charges,All Other,1984,80,,1984,percent of total billed charges,All Other,2058.4,83,,2058.4,percent of total billed charges,All Other,5529,,,5529,Case Rate,Observation Per Case,1736,70,,1736,percent of total billed charges,All Other,6578,,,6578,Case Rate,Observation Per Case,5591,,,5591,Case Rate,Observation Per Case,3973,,,3973,Case Rate,Observation Per Case,3576,,,3576,Case Rate,Observation Per Case,3973,,,3973,Case Rate,Observation Per Case,3377,,,3377,Case Rate,Observation Per Case,23.63,,,23.63,Other,100% of Medicaid,23.63,,,23.63,Other,100% of Medicaid,23.63,,,23.63,Other,100% of Medicaid,23.63,,,23.63,Other,100% of Medicaid,53.16,,,53.16,Other,225% of Medicaid,36.15,,,36.15,Other,153% of Medicaid,53.16,,,53.16,Other,225% of Medicaid,33.08,,,33.08,Other,140% of Medicaid,53.16,,,53.16,Other,225% of Medicaid,61.43,,,61.43,Other,260% of Medicaid,76.55,,,76.55,Other,324% of Medicaid,50.8,,,50.8,Other,215% of Medicaid,50.8,,,50.8,Other,215% of Medicaid,29.53,,,29.53,Other,125% of Medicaid,23.63,8005,
OBSERVATION HRLY STEP DOWN,G0378,HCPCS,,88000003,CDM,762,RC,,,both,,,2480,1835.21,,,1835.21,Other,150% of Medicare + 9.63% HCRA Surcharge,1116,45,,1116,percent of total billed charges,Critical Access Hospital RCC factor,5767,,,5767,Case Rate,Observation Per Case,5190,,,5190,Case Rate,Observation Per Case,8005,,,8005,Case Rate,Observation Per Case,7205,,,7205,Case Rate,Observation Per Case,6804,,,6804,Case Rate,Observation Per Case,1227.6,,,1227.6,Other,110% of Medicare,1686.4,68,,1686.4,percent of total billed charges,All Other,44,,,44,Other,186% of Medicaid,1984,80,,1984,percent of total billed charges,All Other,2058.4,83,,2058.4,percent of total billed charges,All Other,2058.4,83,,2058.4,percent of total billed charges,All Other,1984,80,,1984,percent of total billed charges,All Other,2058.4,83,,2058.4,percent of total billed charges,All Other,5529,,,5529,Case Rate,Observation Per Case,1736,70,,1736,percent of total billed charges,All Other,6578,,,6578,Case Rate,Observation Per Case,5591,,,5591,Case Rate,Observation Per Case,3973,,,3973,Case Rate,Observation Per Case,3576,,,3576,Case Rate,Observation Per Case,3973,,,3973,Case Rate,Observation Per Case,3377,,,3377,Case Rate,Observation Per Case,23.63,,,23.63,Other,100% of Medicaid,23.63,,,23.63,Other,100% of Medicaid,23.63,,,23.63,Other,100% of Medicaid,23.63,,,23.63,Other,100% of Medicaid,53.16,,,53.16,Other,225% of Medicaid,36.15,,,36.15,Other,153% of Medicaid,53.16,,,53.16,Other,225% of Medicaid,33.08,,,33.08,Other,140% of Medicaid,53.16,,,53.16,Other,225% of Medicaid,61.43,,,61.43,Other,260% of Medicaid,76.55,,,76.55,Other,324% of Medicaid,50.8,,,50.8,Other,215% of Medicaid,50.8,,,50.8,Other,215% of Medicaid,29.53,,,29.53,Other,125% of Medicaid,23.63,8005,
IMMUNIZATION ADMIN 1 VACCINE,90471,CPT,,26090471,CDM,771,RC,,,both,,,153,113.22,,,113.22,Other,150% of Medicare + 9.63% HCRA Surcharge,68.85,45,,68.85,percent of total billed charges,Critical Access Hospital RCC factor,99.45,65,,99.45,percent of total billed charges,All Other,90.27,65,,90.27,percent of total billed charges,All Other,117.05,76.5,,117.05,percent of total billed charges,All Other,108.63,69,,108.63,percent of total billed charges,All Other,105.57,65,,105.57,percent of total billed charges,All Other,75.74,,,75.74,Other,110% of Medicare,104.04,68,,104.04,percent of total billed charges,All Other,23,,,23,Other,186% of Medicaid,122.4,80,,122.4,percent of total billed charges,All Other,126.99,83,,126.99,percent of total billed charges,All Other,126.99,83,,126.99,percent of total billed charges,All Other,122.4,80,,122.4,percent of total billed charges,All Other,126.99,83,,126.99,percent of total billed charges,All Other,122.4,80,,122.4,percent of total billed charges,All Other,107.1,70,,107.1,percent of total billed charges,All Other,80.36,,,80.36,Fee Schedule,,68.11,,,68.11,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,12.5,,,12.5,Other,100% of Medicaid,12.5,,,12.5,Other,100% of Medicaid,12.5,,,12.5,Other,100% of Medicaid,12.5,,,12.5,Other,100% of Medicaid,28.12,,,28.12,Other,225% of Medicaid,19.12,,,19.12,Other,153% of Medicaid,28.12,,,28.12,Other,225% of Medicaid,17.5,,,17.5,Other,140% of Medicaid,28.12,,,28.12,Other,225% of Medicaid,32.5,,,32.5,Other,260% of Medicaid,40.5,,,40.5,Other,324% of Medicaid,26.87,,,26.87,Other,215% of Medicaid,26.87,,,26.87,Other,215% of Medicaid,15.62,,,15.62,Other,125% of Medicaid,0.01,126.99,
ADMIN FLU VIRUS VACCINE,G0008,HCPCS,,30000054,CDM,771,RC,,,both,,,97,71.78,,,71.78,Other,150% of Medicare + 9.63% HCRA Surcharge,43.65,45,,43.65,percent of total billed charges,Critical Access Hospital RCC factor,63.05,65,,63.05,percent of total billed charges,All Other,57.23,65,,57.23,percent of total billed charges,All Other,74.21,76.5,,74.21,percent of total billed charges,All Other,68.87,69,,68.87,percent of total billed charges,All Other,66.93,65,,66.93,percent of total billed charges,All Other,48.02,,,48.02,Other,110% of Medicare,65.96,68,,65.96,percent of total billed charges,All Other,23,,,23,Other,186% of Medicaid,77.6,80,,77.6,percent of total billed charges,All Other,80.51,83,,80.51,percent of total billed charges,All Other,80.51,83,,80.51,percent of total billed charges,All Other,77.6,80,,77.6,percent of total billed charges,All Other,80.51,83,,80.51,percent of total billed charges,All Other,77.6,80,,77.6,percent of total billed charges,All Other,67.9,70,,67.9,percent of total billed charges,All Other,80.36,,,80.36,Fee Schedule,,68.11,,,68.11,Fee Schedule,,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,12.5,,,12.5,Other,100% of Medicaid,12.5,,,12.5,Other,100% of Medicaid,12.5,,,12.5,Other,100% of Medicaid,12.5,,,12.5,Other,100% of Medicaid,28.12,,,28.12,Other,225% of Medicaid,19.12,,,19.12,Other,153% of Medicaid,28.12,,,28.12,Other,225% of Medicaid,17.5,,,17.5,Other,140% of Medicaid,28.12,,,28.12,Other,225% of Medicaid,32.5,,,32.5,Other,260% of Medicaid,40.5,,,40.5,Other,324% of Medicaid,26.87,,,26.87,Other,215% of Medicaid,26.87,,,26.87,Other,215% of Medicaid,15.62,,,15.62,Other,125% of Medicaid,0.01,80.51,
ADMIN HEPATITIS B VACCINE,G0010,HCPCS,,30000055,CDM,771,RC,,,both,,,97,71.78,,,71.78,Other,150% of Medicare + 9.63% HCRA Surcharge,43.65,45,,43.65,percent of total billed charges,Critical Access Hospital RCC factor,63.05,65,,63.05,percent of total billed charges,All Other,57.23,65,,57.23,percent of total billed charges,All Other,74.21,76.5,,74.21,percent of total billed charges,All Other,68.87,69,,68.87,percent of total billed charges,All Other,66.93,65,,66.93,percent of total billed charges,All Other,48.02,,,48.02,Other,110% of Medicare,65.96,68,,65.96,percent of total billed charges,All Other,23,,,23,Other,186% of Medicaid,77.6,80,,77.6,percent of total billed charges,All Other,80.51,83,,80.51,percent of total billed charges,All Other,80.51,83,,80.51,percent of total billed charges,All Other,77.6,80,,77.6,percent of total billed charges,All Other,80.51,83,,80.51,percent of total billed charges,All Other,77.6,80,,77.6,percent of total billed charges,All Other,67.9,70,,67.9,percent of total billed charges,All Other,63.05,65,,63.05,percent of total billed charges,Default if not in Fee Schedule,63.05,65,,63.05,percent of total billed charges,Default if not in Fee Schedule,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,12.5,,,12.5,Other,100% of Medicaid,12.5,,,12.5,Other,100% of Medicaid,12.5,,,12.5,Other,100% of Medicaid,12.5,,,12.5,Other,100% of Medicaid,28.12,,,28.12,Other,225% of Medicaid,19.12,,,19.12,Other,153% of Medicaid,28.12,,,28.12,Other,225% of Medicaid,17.5,,,17.5,Other,140% of Medicaid,28.12,,,28.12,Other,225% of Medicaid,32.5,,,32.5,Other,260% of Medicaid,40.5,,,40.5,Other,324% of Medicaid,26.87,,,26.87,Other,215% of Medicaid,26.87,,,26.87,Other,215% of Medicaid,15.62,,,15.62,Other,125% of Medicaid,0.01,80.51,
BAMLANIVIMAB-XXXX INFUSION,M0239,HCPCS,,30000084,CDM,771,RC,,,both,,,1875,1387.5,,,1387.5,Other,150% of Medicare + 9.63% HCRA Surcharge,843.75,45,,843.75,percent of total billed charges,Critical Access Hospital RCC factor,309.6,,,309.6,Fee Schedule,,309.6,,,309.6,Fee Schedule,,1434.38,76.5,,1434.38,percent of total billed charges,All Other,1331.25,69,,1331.25,percent of total billed charges,All Other,1293.75,65,,1293.75,percent of total billed charges,All Other,928.13,,,928.13,Other,110% of Medicare,309.6,,,309.6,Fee Schedule,,411,,,411,Other,186% of Medicaid,309.6,,,309.6,Fee Schedule,,309.6,,,309.6,Fee Schedule,,309.6,,,309.6,Fee Schedule,,309.6,,,309.6,Fee Schedule,,309.6,,,309.6,Fee Schedule,,309.6,,,309.6,Fee Schedule,,1312.5,70,,1312.5,percent of total billed charges,All Other,1218.75,65,,1218.75,percent of total billed charges,Default if not in Fee Schedule,1218.75,65,,1218.75,percent of total billed charges,Default if not in Fee Schedule,238,,,238,Case Rate,,214,,,214,Case Rate,,238,,,238,Case Rate,,202,,,202,Case Rate,,221.06,,,221.06,Other,100% of Medicaid,221.06,,,221.06,Other,100% of Medicaid,221.06,,,221.06,Other,100% of Medicaid,221.06,,,221.06,Other,100% of Medicaid,497.39,,,497.39,Other,225% of Medicaid,338.22,,,338.22,Other,153% of Medicaid,497.39,,,497.39,Other,225% of Medicaid,309.49,,,309.49,Other,140% of Medicaid,497.39,,,497.39,Other,225% of Medicaid,574.76,,,574.76,Other,260% of Medicaid,716.24,,,716.24,Other,324% of Medicaid,475.28,,,475.28,Other,215% of Medicaid,475.28,,,475.28,Other,215% of Medicaid,276.33,,,276.33,Other,125% of Medicaid,202,1434.38,
CASIRIVI AND IMDEVI INFUSION,M0243,HCPCS,,30000085,CDM,771,RC,,,both,,,1875,1387.5,,,1387.5,Other,150% of Medicare + 9.63% HCRA Surcharge,843.75,45,,843.75,percent of total billed charges,Critical Access Hospital RCC factor,309.6,,,309.6,Fee Schedule,,309.6,,,309.6,Fee Schedule,,1434.38,76.5,,1434.38,percent of total billed charges,All Other,1331.25,69,,1331.25,percent of total billed charges,All Other,1293.75,65,,1293.75,percent of total billed charges,All Other,928.13,,,928.13,Other,110% of Medicare,309.6,,,309.6,Fee Schedule,,411,,,411,Other,186% of Medicaid,309.6,,,309.6,Fee Schedule,,309.6,,,309.6,Fee Schedule,,309.6,,,309.6,Fee Schedule,,309.6,,,309.6,Fee Schedule,,309.6,,,309.6,Fee Schedule,,1500,80,,1500,percent of total billed charges,All Other,1312.5,70,,1312.5,percent of total billed charges,All Other,1218.75,65,,1218.75,percent of total billed charges,Default if not in Fee Schedule,1218.75,65,,1218.75,percent of total billed charges,Default if not in Fee Schedule,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,221.06,,,221.06,Other,100% of Medicaid,221.06,,,221.06,Other,100% of Medicaid,221.06,,,221.06,Other,100% of Medicaid,221.06,,,221.06,Other,100% of Medicaid,497.39,,,497.39,Other,225% of Medicaid,338.22,,,338.22,Other,153% of Medicaid,497.39,,,497.39,Other,225% of Medicaid,309.49,,,309.49,Other,140% of Medicaid,497.39,,,497.39,Other,225% of Medicaid,574.76,,,574.76,Other,260% of Medicaid,716.24,,,716.24,Other,324% of Medicaid,475.28,,,475.28,Other,215% of Medicaid,475.28,,,475.28,Other,215% of Medicaid,276.33,,,276.33,Other,125% of Medicaid,0.01,1500,
BAMLAN AND ETESEV INFUSION,M0245,HCPCS,,30000087,CDM,771,RC,,,both,,,1875,1387.5,,,1387.5,Other,150% of Medicare + 9.63% HCRA Surcharge,843.75,45,,843.75,percent of total billed charges,Critical Access Hospital RCC factor,309.6,,,309.6,Fee Schedule,,309.6,,,309.6,Fee Schedule,,450,,,450,Fee Schedule,,450,,,450,Fee Schedule,,450,,,450,Fee Schedule,,928.13,,,928.13,Other,110% of Medicare,309.6,,,309.6,Fee Schedule,,411,,,411,Other,186% of Medicaid,309.6,,,309.6,Fee Schedule,,309.6,,,309.6,Fee Schedule,,309.6,,,309.6,Fee Schedule,,309.6,,,309.6,Fee Schedule,,309.6,,,309.6,Fee Schedule,,1500,80,,1500,percent of total billed charges,All Other,1312.5,70,,1312.5,percent of total billed charges,All Other,1218.75,65,,1218.75,percent of total billed charges,Default if not in Fee Schedule,1218.75,65,,1218.75,percent of total billed charges,Default if not in Fee Schedule,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,221.06,,,221.06,Other,100% of Medicaid,221.06,,,221.06,Other,100% of Medicaid,221.06,,,221.06,Other,100% of Medicaid,221.06,,,221.06,Other,100% of Medicaid,497.39,,,497.39,Other,225% of Medicaid,338.22,,,338.22,Other,153% of Medicaid,497.39,,,497.39,Other,225% of Medicaid,309.49,,,309.49,Other,140% of Medicaid,497.39,,,497.39,Other,225% of Medicaid,574.76,,,574.76,Other,260% of Medicaid,716.24,,,716.24,Other,324% of Medicaid,475.28,,,475.28,Other,215% of Medicaid,475.28,,,475.28,Other,215% of Medicaid,276.33,,,276.33,Other,125% of Medicaid,0.01,1500,
SOTROVIMAB INFUSION,M0247,HCPCS,,30000088,CDM,771,RC,,,both,,,1875,1387.5,,,1387.5,Other,150% of Medicare + 9.63% HCRA Surcharge,843.75,45,,843.75,percent of total billed charges,Critical Access Hospital RCC factor,1218.75,65,,1218.75,percent of total billed charges,All Other,1106.25,65,,1106.25,percent of total billed charges,All Other,1434.38,76.5,,1434.38,percent of total billed charges,All Other,1331.25,69,,1331.25,percent of total billed charges,All Other,1293.75,65,,1293.75,percent of total billed charges,All Other,928.13,,,928.13,Other,110% of Medicare,1275,68,,1275,percent of total billed charges,All Other,411,,,411,Other,186% of Medicaid,1500,80,,1500,percent of total billed charges,All Other,1556.25,83,,1556.25,percent of total billed charges,All Other,1556.25,83,,1556.25,percent of total billed charges,All Other,1500,80,,1500,percent of total billed charges,All Other,1556.25,83,,1556.25,percent of total billed charges,All Other,1500,80,,1500,percent of total billed charges,All Other,1312.5,70,,1312.5,percent of total billed charges,All Other,1218.75,65,,1218.75,percent of total billed charges,Default if not in Fee Schedule,1218.75,65,,1218.75,percent of total billed charges,Default if not in Fee Schedule,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,221.06,,,221.06,Other,100% of Medicaid,221.06,,,221.06,Other,100% of Medicaid,221.06,,,221.06,Other,100% of Medicaid,221.06,,,221.06,Other,100% of Medicaid,497.39,,,497.39,Other,225% of Medicaid,338.22,,,338.22,Other,153% of Medicaid,497.39,,,497.39,Other,225% of Medicaid,309.49,,,309.49,Other,140% of Medicaid,497.39,,,497.39,Other,225% of Medicaid,574.76,,,574.76,Other,260% of Medicaid,716.24,,,716.24,Other,324% of Medicaid,475.28,,,475.28,Other,215% of Medicaid,475.28,,,475.28,Other,215% of Medicaid,276.33,,,276.33,Other,125% of Medicaid,0.01,1556.25,
BEBTELOVIMAB INJ,M0222,HCPCS,,30000089,CDM,771,RC,,,both,,,1875,1387.5,,,1387.5,Other,150% of Medicare + 9.63% HCRA Surcharge,843.75,45,,843.75,percent of total billed charges,Critical Access Hospital RCC factor,1218.75,65,,1218.75,percent of total billed charges,All Other,1106.25,65,,1106.25,percent of total billed charges,All Other,1434.38,76.5,,1434.38,percent of total billed charges,All Other,1331.25,69,,1331.25,percent of total billed charges,All Other,1293.75,65,,1293.75,percent of total billed charges,All Other,928.13,,,928.13,Other,110% of Medicare,1275,68,,1275,percent of total billed charges,All Other,58,,,58,Other,186% of Medicaid,1500,80,,1500,percent of total billed charges,All Other,1556.25,83,,1556.25,percent of total billed charges,All Other,1556.25,83,,1556.25,percent of total billed charges,All Other,1500,80,,1500,percent of total billed charges,All Other,1556.25,83,,1556.25,percent of total billed charges,All Other,1500,80,,1500,percent of total billed charges,All Other,1312.5,70,,1312.5,percent of total billed charges,All Other,1218.75,65,,1218.75,percent of total billed charges,Default if not in Fee Schedule,1218.75,65,,1218.75,percent of total billed charges,Default if not in Fee Schedule,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,31.2,,,31.2,Other,100% of Medicaid,31.2,,,31.2,Other,100% of Medicaid,31.2,,,31.2,Other,100% of Medicaid,31.2,,,31.2,Other,100% of Medicaid,70.2,,,70.2,Other,225% of Medicaid,47.74,,,47.74,Other,153% of Medicaid,70.2,,,70.2,Other,225% of Medicaid,43.68,,,43.68,Other,140% of Medicaid,70.2,,,70.2,Other,225% of Medicaid,81.12,,,81.12,Other,260% of Medicaid,101.09,,,101.09,Other,324% of Medicaid,67.08,,,67.08,Other,215% of Medicaid,67.08,,,67.08,Other,215% of Medicaid,39,,,39,Other,125% of Medicaid,0.01,1556.25,
BEBTELOVIMAB INJ HOME,M0223,HCPCS,,30000090,CDM,771,RC,,,both,,,1875,1387.5,,,1387.5,Other,150% of Medicare + 9.63% HCRA Surcharge,843.75,45,,843.75,percent of total billed charges,Critical Access Hospital RCC factor,1218.75,65,,1218.75,percent of total billed charges,All Other,1106.25,65,,1106.25,percent of total billed charges,All Other,1434.38,76.5,,1434.38,percent of total billed charges,All Other,1331.25,69,,1331.25,percent of total billed charges,All Other,1293.75,65,,1293.75,percent of total billed charges,All Other,928.13,,,928.13,Other,110% of Medicare,1275,68,,1275,percent of total billed charges,All Other,0.01,,,0.01,Other,186% of Medicaid,1500,80,,1500,percent of total billed charges,All Other,1162.5,62,,1162.5,percent of total billed charges,Lab and Radiology,1031.25,55,,1031.25,percent of total billed charges,Default if not on Fee Schedule,1500,80,,1500,percent of total billed charges,All Other,1162.5,62,,1162.5,percent of total billed charges,Lab and Radiology,1500,80,,1500,percent of total billed charges,All Other,1312.5,70,,1312.5,percent of total billed charges,All Other,1218.75,65,,1218.75,percent of total billed charges,Default if not in Fee Schedule,1218.75,65,,1218.75,percent of total billed charges,Default if not in Fee Schedule,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1500,
TIXAGEV AND CILGAV INJ HM,M0221,HCPCS,,30000091,CDM,771,RC,,,both,,,1875,1387.5,,,1387.5,Other,150% of Medicare + 9.63% HCRA Surcharge,843.75,45,,843.75,percent of total billed charges,Critical Access Hospital RCC factor,1218.75,65,,1218.75,percent of total billed charges,All Other,1106.25,65,,1106.25,percent of total billed charges,All Other,1434.38,76.5,,1434.38,percent of total billed charges,All Other,1331.25,69,,1331.25,percent of total billed charges,All Other,1293.75,65,,1293.75,percent of total billed charges,All Other,928.13,,,928.13,Other,110% of Medicare,1275,68,,1275,percent of total billed charges,All Other,58,,,58,Other,186% of Medicaid,1500,80,,1500,percent of total billed charges,All Other,1556.25,83,,1556.25,percent of total billed charges,All Other,1556.25,83,,1556.25,percent of total billed charges,All Other,1500,80,,1500,percent of total billed charges,All Other,1556.25,83,,1556.25,percent of total billed charges,All Other,1500,80,,1500,percent of total billed charges,All Other,1312.5,70,,1312.5,percent of total billed charges,All Other,1218.75,65,,1218.75,percent of total billed charges,Default if not in Fee Schedule,1218.75,65,,1218.75,percent of total billed charges,Default if not in Fee Schedule,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,31.2,,,31.2,Other,100% of Medicaid,31.2,,,31.2,Other,100% of Medicaid,31.2,,,31.2,Other,100% of Medicaid,31.2,,,31.2,Other,100% of Medicaid,70.2,,,70.2,Other,225% of Medicaid,47.74,,,47.74,Other,153% of Medicaid,70.2,,,70.2,Other,225% of Medicaid,43.68,,,43.68,Other,140% of Medicaid,70.2,,,70.2,Other,225% of Medicaid,81.12,,,81.12,Other,260% of Medicaid,101.09,,,101.09,Other,324% of Medicaid,67.08,,,67.08,Other,215% of Medicaid,67.08,,,67.08,Other,215% of Medicaid,39,,,39,Other,125% of Medicaid,0.01,1556.25,
IMMUNIZATION ADMINISTRATION,90471,CPT,,30090471,CDM,771,RC,,,both,,,153,113.22,,,113.22,Other,150% of Medicare + 9.63% HCRA Surcharge,68.85,45,,68.85,percent of total billed charges,Critical Access Hospital RCC factor,99.45,65,,99.45,percent of total billed charges,All Other,90.27,65,,90.27,percent of total billed charges,All Other,117.05,76.5,,117.05,percent of total billed charges,All Other,108.63,69,,108.63,percent of total billed charges,All Other,105.57,65,,105.57,percent of total billed charges,All Other,75.74,,,75.74,Other,110% of Medicare,104.04,68,,104.04,percent of total billed charges,All Other,23,,,23,Other,186% of Medicaid,122.4,80,,122.4,percent of total billed charges,All Other,126.99,83,,126.99,percent of total billed charges,All Other,126.99,83,,126.99,percent of total billed charges,All Other,122.4,80,,122.4,percent of total billed charges,All Other,126.99,83,,126.99,percent of total billed charges,All Other,122.4,80,,122.4,percent of total billed charges,All Other,107.1,70,,107.1,percent of total billed charges,All Other,80.36,,,80.36,Fee Schedule,,68.11,,,68.11,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,12.5,,,12.5,Other,100% of Medicaid,12.5,,,12.5,Other,100% of Medicaid,12.5,,,12.5,Other,100% of Medicaid,12.5,,,12.5,Other,100% of Medicaid,28.12,,,28.12,Other,225% of Medicaid,19.12,,,19.12,Other,153% of Medicaid,28.12,,,28.12,Other,225% of Medicaid,17.5,,,17.5,Other,140% of Medicaid,28.12,,,28.12,Other,225% of Medicaid,32.5,,,32.5,Other,260% of Medicaid,40.5,,,40.5,Other,324% of Medicaid,26.87,,,26.87,Other,215% of Medicaid,26.87,,,26.87,Other,215% of Medicaid,15.62,,,15.62,Other,125% of Medicaid,0.01,126.99,
IMMUNIZATION ADM EA ADDL,90472,CPT,,30090472,CDM,771,RC,,,both,,,22,16.28,,,16.28,Other,150% of Medicare + 9.63% HCRA Surcharge,9.9,45,,9.9,percent of total billed charges,Critical Access Hospital RCC factor,47.23,,,47.23,Fee Schedule,,42.52,,,42.52,Fee Schedule,,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,10.89,,,10.89,Other,110% of Medicare,14.96,68,,14.96,percent of total billed charges,All Other,23,,,23,Other,186% of Medicaid,17.6,,,17.6,Other,Non Covered Service,18.26,,,18.26,Other,Non Covered Service,18.26,,,18.26,Other,Non Covered Service,17.6,,,17.6,Other,Non Covered Service,18.26,,,18.26,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,15.4,70,,15.4,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,12.5,,,12.5,Other,100% of Medicaid,12.5,,,12.5,Other,100% of Medicaid,12.5,,,12.5,Other,100% of Medicaid,12.5,,,12.5,Other,100% of Medicaid,28.12,,,28.12,Other,225% of Medicaid,19.12,,,19.12,Other,153% of Medicaid,28.12,,,28.12,Other,225% of Medicaid,17.5,,,17.5,Other,140% of Medicaid,28.12,,,28.12,Other,225% of Medicaid,32.5,,,32.5,Other,260% of Medicaid,40.5,,,40.5,Other,324% of Medicaid,26.87,,,26.87,Other,215% of Medicaid,26.87,,,26.87,Other,215% of Medicaid,15.62,,,15.62,Other,125% of Medicaid,0.01,47.23,
BAMLANIVIMAB-XXXX-INFUSION,M0239,HCPCS,,34000019,CDM,771,RC,,,both,,,1875,1387.5,,,1387.5,Other,150% of Medicare + 9.63% HCRA Surcharge,843.75,45,,843.75,percent of total billed charges,Critical Access Hospital RCC factor,309.6,,,309.6,Fee Schedule,,309.6,,,309.6,Fee Schedule,,1434.38,76.5,,1434.38,percent of total billed charges,All Other,1331.25,69,,1331.25,percent of total billed charges,All Other,1293.75,65,,1293.75,percent of total billed charges,All Other,928.13,,,928.13,Other,110% of Medicare,309.6,,,309.6,Fee Schedule,,411,,,411,Other,186% of Medicaid,309.6,,,309.6,Fee Schedule,,309.6,,,309.6,Fee Schedule,,309.6,,,309.6,Fee Schedule,,309.6,,,309.6,Fee Schedule,,309.6,,,309.6,Fee Schedule,,309.6,,,309.6,Fee Schedule,,1312.5,70,,1312.5,percent of total billed charges,All Other,1218.75,65,,1218.75,percent of total billed charges,Default if not in Fee Schedule,1218.75,65,,1218.75,percent of total billed charges,Default if not in Fee Schedule,238,,,238,Case Rate,,214,,,214,Case Rate,,238,,,238,Case Rate,,202,,,202,Case Rate,,221.06,,,221.06,Other,100% of Medicaid,221.06,,,221.06,Other,100% of Medicaid,221.06,,,221.06,Other,100% of Medicaid,221.06,,,221.06,Other,100% of Medicaid,497.39,,,497.39,Other,225% of Medicaid,338.22,,,338.22,Other,153% of Medicaid,497.39,,,497.39,Other,225% of Medicaid,309.49,,,309.49,Other,140% of Medicaid,497.39,,,497.39,Other,225% of Medicaid,574.76,,,574.76,Other,260% of Medicaid,716.24,,,716.24,Other,324% of Medicaid,475.28,,,475.28,Other,215% of Medicaid,475.28,,,475.28,Other,215% of Medicaid,276.33,,,276.33,Other,125% of Medicaid,202,1434.38,
CASIRIVI AND IMDEVI INFUSION,M0243,HCPCS,,34000020,CDM,771,RC,,,both,,,1875,1387.5,,,1387.5,Other,150% of Medicare + 9.63% HCRA Surcharge,843.75,45,,843.75,percent of total billed charges,Critical Access Hospital RCC factor,309.6,,,309.6,Fee Schedule,,309.6,,,309.6,Fee Schedule,,1434.38,76.5,,1434.38,percent of total billed charges,All Other,1331.25,69,,1331.25,percent of total billed charges,All Other,1293.75,65,,1293.75,percent of total billed charges,All Other,928.13,,,928.13,Other,110% of Medicare,309.6,,,309.6,Fee Schedule,,411,,,411,Other,186% of Medicaid,309.6,,,309.6,Fee Schedule,,309.6,,,309.6,Fee Schedule,,309.6,,,309.6,Fee Schedule,,309.6,,,309.6,Fee Schedule,,309.6,,,309.6,Fee Schedule,,1500,80,,1500,percent of total billed charges,All Other,1312.5,70,,1312.5,percent of total billed charges,All Other,1218.75,65,,1218.75,percent of total billed charges,Default if not in Fee Schedule,1218.75,65,,1218.75,percent of total billed charges,Default if not in Fee Schedule,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,221.06,,,221.06,Other,100% of Medicaid,221.06,,,221.06,Other,100% of Medicaid,221.06,,,221.06,Other,100% of Medicaid,221.06,,,221.06,Other,100% of Medicaid,497.39,,,497.39,Other,225% of Medicaid,338.22,,,338.22,Other,153% of Medicaid,497.39,,,497.39,Other,225% of Medicaid,309.49,,,309.49,Other,140% of Medicaid,497.39,,,497.39,Other,225% of Medicaid,574.76,,,574.76,Other,260% of Medicaid,716.24,,,716.24,Other,324% of Medicaid,475.28,,,475.28,Other,215% of Medicaid,475.28,,,475.28,Other,215% of Medicaid,276.33,,,276.33,Other,125% of Medicaid,0.01,1500,
SOTROVIMAB INFUSION,M0247,HCPCS,,34000021,CDM,771,RC,,,both,,,1875,1387.5,,,1387.5,Other,150% of Medicare + 9.63% HCRA Surcharge,843.75,45,,843.75,percent of total billed charges,Critical Access Hospital RCC factor,1218.75,65,,1218.75,percent of total billed charges,All Other,1106.25,65,,1106.25,percent of total billed charges,All Other,1434.38,76.5,,1434.38,percent of total billed charges,All Other,1331.25,69,,1331.25,percent of total billed charges,All Other,1293.75,65,,1293.75,percent of total billed charges,All Other,928.13,,,928.13,Other,110% of Medicare,1275,68,,1275,percent of total billed charges,All Other,411,,,411,Other,186% of Medicaid,1500,80,,1500,percent of total billed charges,All Other,1556.25,83,,1556.25,percent of total billed charges,All Other,1556.25,83,,1556.25,percent of total billed charges,All Other,1500,80,,1500,percent of total billed charges,All Other,1556.25,83,,1556.25,percent of total billed charges,All Other,1500,80,,1500,percent of total billed charges,All Other,1312.5,70,,1312.5,percent of total billed charges,All Other,1218.75,65,,1218.75,percent of total billed charges,Default if not in Fee Schedule,1218.75,65,,1218.75,percent of total billed charges,Default if not in Fee Schedule,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,221.06,,,221.06,Other,100% of Medicaid,221.06,,,221.06,Other,100% of Medicaid,221.06,,,221.06,Other,100% of Medicaid,221.06,,,221.06,Other,100% of Medicaid,497.39,,,497.39,Other,225% of Medicaid,338.22,,,338.22,Other,153% of Medicaid,497.39,,,497.39,Other,225% of Medicaid,309.49,,,309.49,Other,140% of Medicaid,497.39,,,497.39,Other,225% of Medicaid,574.76,,,574.76,Other,260% of Medicaid,716.24,,,716.24,Other,324% of Medicaid,475.28,,,475.28,Other,215% of Medicaid,475.28,,,475.28,Other,215% of Medicaid,276.33,,,276.33,Other,125% of Medicaid,0.01,1556.25,
TIXAGEV AND CILGAV INJ,M0220,HCPCS,,34000022,CDM,771,RC,,,both,,,1875,1387.5,,,1387.5,Other,150% of Medicare + 9.63% HCRA Surcharge,843.75,45,,843.75,percent of total billed charges,Critical Access Hospital RCC factor,150.5,,,150.5,Fee Schedule,,150.5,,,150.5,Fee Schedule,,150.5,,,150.5,Fee Schedule,,150.5,,,150.5,Fee Schedule,,150.5,,,150.5,Fee Schedule,,928.13,,,928.13,Other,110% of Medicare,150.5,,,150.5,Fee Schedule,,58,,,58,Other,186% of Medicaid,150.5,80,,150.5,percent of total billed charges,All Other,150.5,83,,150.5,percent of total billed charges,All Other,150.5,83,,150.5,percent of total billed charges,All Other,150.5,80,,150.5,percent of total billed charges,All Other,150.5,83,,150.5,percent of total billed charges,All Other,1500,80,,1500,percent of total billed charges,All Other,1312.5,70,,1312.5,percent of total billed charges,All Other,1218.75,65,,1218.75,percent of total billed charges,Default if not in Fee Schedule,1218.75,65,,1218.75,percent of total billed charges,Default if not in Fee Schedule,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,31.2,,,31.2,Other,100% of Medicaid,31.2,,,31.2,Other,100% of Medicaid,31.2,,,31.2,Other,100% of Medicaid,31.2,,,31.2,Other,100% of Medicaid,70.2,,,70.2,Other,225% of Medicaid,47.74,,,47.74,Other,153% of Medicaid,70.2,,,70.2,Other,225% of Medicaid,43.68,,,43.68,Other,140% of Medicaid,70.2,,,70.2,Other,225% of Medicaid,81.12,,,81.12,Other,260% of Medicaid,101.09,,,101.09,Other,324% of Medicaid,67.08,,,67.08,Other,215% of Medicaid,67.08,,,67.08,Other,215% of Medicaid,39,,,39,Other,125% of Medicaid,0.01,1500,
BEBTELOVIMAB INJ,M0222,HCPCS,,34000023,CDM,771,RC,,,both,,,1875,1387.5,,,1387.5,Other,150% of Medicare + 9.63% HCRA Surcharge,843.75,45,,843.75,percent of total billed charges,Critical Access Hospital RCC factor,1218.75,65,,1218.75,percent of total billed charges,All Other,1106.25,65,,1106.25,percent of total billed charges,All Other,1434.38,76.5,,1434.38,percent of total billed charges,All Other,1331.25,69,,1331.25,percent of total billed charges,All Other,1293.75,65,,1293.75,percent of total billed charges,All Other,928.13,,,928.13,Other,110% of Medicare,1275,68,,1275,percent of total billed charges,All Other,58,,,58,Other,186% of Medicaid,1500,80,,1500,percent of total billed charges,All Other,1556.25,83,,1556.25,percent of total billed charges,All Other,1556.25,83,,1556.25,percent of total billed charges,All Other,1500,80,,1500,percent of total billed charges,All Other,1556.25,83,,1556.25,percent of total billed charges,All Other,1500,80,,1500,percent of total billed charges,All Other,1312.5,70,,1312.5,percent of total billed charges,All Other,1218.75,65,,1218.75,percent of total billed charges,Default if not in Fee Schedule,1218.75,65,,1218.75,percent of total billed charges,Default if not in Fee Schedule,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,31.2,,,31.2,Other,100% of Medicaid,31.2,,,31.2,Other,100% of Medicaid,31.2,,,31.2,Other,100% of Medicaid,31.2,,,31.2,Other,100% of Medicaid,70.2,,,70.2,Other,225% of Medicaid,47.74,,,47.74,Other,153% of Medicaid,70.2,,,70.2,Other,225% of Medicaid,43.68,,,43.68,Other,140% of Medicaid,70.2,,,70.2,Other,225% of Medicaid,81.12,,,81.12,Other,260% of Medicaid,101.09,,,101.09,Other,324% of Medicaid,67.08,,,67.08,Other,215% of Medicaid,67.08,,,67.08,Other,215% of Medicaid,39,,,39,Other,125% of Medicaid,0.01,1556.25,
BEBTELOVIMAB INJ HOME,M0223,HCPCS,,34000024,CDM,771,RC,,,both,,,1875,1387.5,,,1387.5,Other,150% of Medicare + 9.63% HCRA Surcharge,843.75,45,,843.75,percent of total billed charges,Critical Access Hospital RCC factor,1218.75,65,,1218.75,percent of total billed charges,All Other,1106.25,65,,1106.25,percent of total billed charges,All Other,1434.38,76.5,,1434.38,percent of total billed charges,All Other,1331.25,69,,1331.25,percent of total billed charges,All Other,1293.75,65,,1293.75,percent of total billed charges,All Other,928.13,,,928.13,Other,110% of Medicare,1275,68,,1275,percent of total billed charges,All Other,0.01,,,0.01,Other,186% of Medicaid,1500,80,,1500,percent of total billed charges,All Other,1162.5,62,,1162.5,percent of total billed charges,Lab and Radiology,1031.25,55,,1031.25,percent of total billed charges,Default if not on Fee Schedule,1500,80,,1500,percent of total billed charges,All Other,1162.5,62,,1162.5,percent of total billed charges,Lab and Radiology,1500,80,,1500,percent of total billed charges,All Other,1312.5,70,,1312.5,percent of total billed charges,All Other,1218.75,65,,1218.75,percent of total billed charges,Default if not in Fee Schedule,1218.75,65,,1218.75,percent of total billed charges,Default if not in Fee Schedule,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1500,
TIXAGEV AND CILGAV INJ HM,M0221,HCPCS,,34000025,CDM,771,RC,,,both,,,1875,1387.5,,,1387.5,Other,150% of Medicare + 9.63% HCRA Surcharge,843.75,45,,843.75,percent of total billed charges,Critical Access Hospital RCC factor,1218.75,65,,1218.75,percent of total billed charges,All Other,1106.25,65,,1106.25,percent of total billed charges,All Other,1434.38,76.5,,1434.38,percent of total billed charges,All Other,1331.25,69,,1331.25,percent of total billed charges,All Other,1293.75,65,,1293.75,percent of total billed charges,All Other,928.13,,,928.13,Other,110% of Medicare,1275,68,,1275,percent of total billed charges,All Other,58,,,58,Other,186% of Medicaid,1500,80,,1500,percent of total billed charges,All Other,1556.25,83,,1556.25,percent of total billed charges,All Other,1556.25,83,,1556.25,percent of total billed charges,All Other,1500,80,,1500,percent of total billed charges,All Other,1556.25,83,,1556.25,percent of total billed charges,All Other,1500,80,,1500,percent of total billed charges,All Other,1312.5,70,,1312.5,percent of total billed charges,All Other,1218.75,65,,1218.75,percent of total billed charges,Default if not in Fee Schedule,1218.75,65,,1218.75,percent of total billed charges,Default if not in Fee Schedule,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,31.2,,,31.2,Other,100% of Medicaid,31.2,,,31.2,Other,100% of Medicaid,31.2,,,31.2,Other,100% of Medicaid,31.2,,,31.2,Other,100% of Medicaid,70.2,,,70.2,Other,225% of Medicaid,47.74,,,47.74,Other,153% of Medicaid,70.2,,,70.2,Other,225% of Medicaid,43.68,,,43.68,Other,140% of Medicaid,70.2,,,70.2,Other,225% of Medicaid,81.12,,,81.12,Other,260% of Medicaid,101.09,,,101.09,Other,324% of Medicaid,67.08,,,67.08,Other,215% of Medicaid,67.08,,,67.08,Other,215% of Medicaid,39,,,39,Other,125% of Medicaid,0.01,1556.25,
IMMUNIZATION ADMIN 1 VACCINE,90471,CPT,,34090471,CDM,771,RC,,,both,,,153,113.22,,,113.22,Other,150% of Medicare + 9.63% HCRA Surcharge,68.85,45,,68.85,percent of total billed charges,Critical Access Hospital RCC factor,99.45,65,,99.45,percent of total billed charges,All Other,90.27,65,,90.27,percent of total billed charges,All Other,117.05,76.5,,117.05,percent of total billed charges,All Other,108.63,69,,108.63,percent of total billed charges,All Other,105.57,65,,105.57,percent of total billed charges,All Other,75.74,,,75.74,Other,110% of Medicare,104.04,68,,104.04,percent of total billed charges,All Other,23,,,23,Other,186% of Medicaid,122.4,80,,122.4,percent of total billed charges,All Other,126.99,83,,126.99,percent of total billed charges,All Other,126.99,83,,126.99,percent of total billed charges,All Other,122.4,80,,122.4,percent of total billed charges,All Other,126.99,83,,126.99,percent of total billed charges,All Other,122.4,80,,122.4,percent of total billed charges,All Other,107.1,70,,107.1,percent of total billed charges,All Other,80.36,,,80.36,Fee Schedule,,68.11,,,68.11,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,12.5,,,12.5,Other,100% of Medicaid,12.5,,,12.5,Other,100% of Medicaid,12.5,,,12.5,Other,100% of Medicaid,12.5,,,12.5,Other,100% of Medicaid,28.12,,,28.12,Other,225% of Medicaid,19.12,,,19.12,Other,153% of Medicaid,28.12,,,28.12,Other,225% of Medicaid,17.5,,,17.5,Other,140% of Medicaid,28.12,,,28.12,Other,225% of Medicaid,32.5,,,32.5,Other,260% of Medicaid,40.5,,,40.5,Other,324% of Medicaid,26.87,,,26.87,Other,215% of Medicaid,26.87,,,26.87,Other,215% of Medicaid,15.62,,,15.62,Other,125% of Medicaid,0.01,126.99,
ADMIN FLU VIRUS VACCINE,G0008,HCPCS,,40000001,CDM,771,RC,,,both,,,97,71.78,,,71.78,Other,150% of Medicare + 9.63% HCRA Surcharge,43.65,45,,43.65,percent of total billed charges,Critical Access Hospital RCC factor,63.05,65,,63.05,percent of total billed charges,All Other,57.23,65,,57.23,percent of total billed charges,All Other,74.21,76.5,,74.21,percent of total billed charges,All Other,68.87,69,,68.87,percent of total billed charges,All Other,66.93,65,,66.93,percent of total billed charges,All Other,48.02,,,48.02,Other,110% of Medicare,65.96,68,,65.96,percent of total billed charges,All Other,23,,,23,Other,186% of Medicaid,77.6,80,,77.6,percent of total billed charges,All Other,80.51,83,,80.51,percent of total billed charges,All Other,80.51,83,,80.51,percent of total billed charges,All Other,77.6,80,,77.6,percent of total billed charges,All Other,80.51,83,,80.51,percent of total billed charges,All Other,77.6,80,,77.6,percent of total billed charges,All Other,67.9,70,,67.9,percent of total billed charges,All Other,80.36,,,80.36,Fee Schedule,,68.11,,,68.11,Fee Schedule,,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,12.5,,,12.5,Other,100% of Medicaid,12.5,,,12.5,Other,100% of Medicaid,12.5,,,12.5,Other,100% of Medicaid,12.5,,,12.5,Other,100% of Medicaid,28.12,,,28.12,Other,225% of Medicaid,19.12,,,19.12,Other,153% of Medicaid,28.12,,,28.12,Other,225% of Medicaid,17.5,,,17.5,Other,140% of Medicaid,28.12,,,28.12,Other,225% of Medicaid,32.5,,,32.5,Other,260% of Medicaid,40.5,,,40.5,Other,324% of Medicaid,26.87,,,26.87,Other,215% of Medicaid,26.87,,,26.87,Other,215% of Medicaid,15.62,,,15.62,Other,125% of Medicaid,0.01,80.51,
BAMLANIVIMAB-XXXX INFUSION,M0239,HCPCS,,75000001,CDM,771,RC,,,both,,,1875,1387.5,,,1387.5,Other,150% of Medicare + 9.63% HCRA Surcharge,843.75,45,,843.75,percent of total billed charges,Critical Access Hospital RCC factor,309.6,,,309.6,Fee Schedule,,309.6,,,309.6,Fee Schedule,,1434.38,76.5,,1434.38,percent of total billed charges,All Other,1331.25,69,,1331.25,percent of total billed charges,All Other,1293.75,65,,1293.75,percent of total billed charges,All Other,928.13,,,928.13,Other,110% of Medicare,309.6,,,309.6,Fee Schedule,,411,,,411,Other,186% of Medicaid,309.6,,,309.6,Fee Schedule,,309.6,,,309.6,Fee Schedule,,309.6,,,309.6,Fee Schedule,,309.6,,,309.6,Fee Schedule,,309.6,,,309.6,Fee Schedule,,309.6,,,309.6,Fee Schedule,,1312.5,70,,1312.5,percent of total billed charges,All Other,1218.75,65,,1218.75,percent of total billed charges,Default if not in Fee Schedule,1218.75,65,,1218.75,percent of total billed charges,Default if not in Fee Schedule,238,,,238,Case Rate,,214,,,214,Case Rate,,238,,,238,Case Rate,,202,,,202,Case Rate,,221.06,,,221.06,Other,100% of Medicaid,221.06,,,221.06,Other,100% of Medicaid,221.06,,,221.06,Other,100% of Medicaid,221.06,,,221.06,Other,100% of Medicaid,497.39,,,497.39,Other,225% of Medicaid,338.22,,,338.22,Other,153% of Medicaid,497.39,,,497.39,Other,225% of Medicaid,309.49,,,309.49,Other,140% of Medicaid,497.39,,,497.39,Other,225% of Medicaid,574.76,,,574.76,Other,260% of Medicaid,716.24,,,716.24,Other,324% of Medicaid,475.28,,,475.28,Other,215% of Medicaid,475.28,,,475.28,Other,215% of Medicaid,276.33,,,276.33,Other,125% of Medicaid,202,1434.38,
CASIRIVI AND IMDEVI INFUSION,M0243,HCPCS,,75000002,CDM,771,RC,,,both,,,1875,1387.5,,,1387.5,Other,150% of Medicare + 9.63% HCRA Surcharge,843.75,45,,843.75,percent of total billed charges,Critical Access Hospital RCC factor,309.6,,,309.6,Fee Schedule,,309.6,,,309.6,Fee Schedule,,1434.38,76.5,,1434.38,percent of total billed charges,All Other,1331.25,69,,1331.25,percent of total billed charges,All Other,1293.75,65,,1293.75,percent of total billed charges,All Other,928.13,,,928.13,Other,110% of Medicare,309.6,,,309.6,Fee Schedule,,411,,,411,Other,186% of Medicaid,309.6,,,309.6,Fee Schedule,,309.6,,,309.6,Fee Schedule,,309.6,,,309.6,Fee Schedule,,309.6,,,309.6,Fee Schedule,,309.6,,,309.6,Fee Schedule,,1500,80,,1500,percent of total billed charges,All Other,1312.5,70,,1312.5,percent of total billed charges,All Other,1218.75,65,,1218.75,percent of total billed charges,Default if not in Fee Schedule,1218.75,65,,1218.75,percent of total billed charges,Default if not in Fee Schedule,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,221.06,,,221.06,Other,100% of Medicaid,221.06,,,221.06,Other,100% of Medicaid,221.06,,,221.06,Other,100% of Medicaid,221.06,,,221.06,Other,100% of Medicaid,497.39,,,497.39,Other,225% of Medicaid,338.22,,,338.22,Other,153% of Medicaid,497.39,,,497.39,Other,225% of Medicaid,309.49,,,309.49,Other,140% of Medicaid,497.39,,,497.39,Other,225% of Medicaid,574.76,,,574.76,Other,260% of Medicaid,716.24,,,716.24,Other,324% of Medicaid,475.28,,,475.28,Other,215% of Medicaid,475.28,,,475.28,Other,215% of Medicaid,276.33,,,276.33,Other,125% of Medicaid,0.01,1500,
BAMLAN AND ETESEV INFUSION,M0245,HCPCS,,75000003,CDM,771,RC,,,both,,,1875,1387.5,,,1387.5,Other,150% of Medicare + 9.63% HCRA Surcharge,843.75,45,,843.75,percent of total billed charges,Critical Access Hospital RCC factor,309.6,,,309.6,Fee Schedule,,309.6,,,309.6,Fee Schedule,,450,,,450,Fee Schedule,,450,,,450,Fee Schedule,,450,,,450,Fee Schedule,,928.13,,,928.13,Other,110% of Medicare,309.6,,,309.6,Fee Schedule,,411,,,411,Other,186% of Medicaid,309.6,,,309.6,Fee Schedule,,309.6,,,309.6,Fee Schedule,,309.6,,,309.6,Fee Schedule,,309.6,,,309.6,Fee Schedule,,309.6,,,309.6,Fee Schedule,,1500,80,,1500,percent of total billed charges,All Other,1312.5,70,,1312.5,percent of total billed charges,All Other,1218.75,65,,1218.75,percent of total billed charges,Default if not in Fee Schedule,1218.75,65,,1218.75,percent of total billed charges,Default if not in Fee Schedule,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,221.06,,,221.06,Other,100% of Medicaid,221.06,,,221.06,Other,100% of Medicaid,221.06,,,221.06,Other,100% of Medicaid,221.06,,,221.06,Other,100% of Medicaid,497.39,,,497.39,Other,225% of Medicaid,338.22,,,338.22,Other,153% of Medicaid,497.39,,,497.39,Other,225% of Medicaid,309.49,,,309.49,Other,140% of Medicaid,497.39,,,497.39,Other,225% of Medicaid,574.76,,,574.76,Other,260% of Medicaid,716.24,,,716.24,Other,324% of Medicaid,475.28,,,475.28,Other,215% of Medicaid,475.28,,,475.28,Other,215% of Medicaid,276.33,,,276.33,Other,125% of Medicaid,0.01,1500,
SOTROVIMAB INFUSION,M0247,HCPCS,,75000004,CDM,771,RC,,,both,,,1875,1387.5,,,1387.5,Other,150% of Medicare + 9.63% HCRA Surcharge,843.75,45,,843.75,percent of total billed charges,Critical Access Hospital RCC factor,1218.75,65,,1218.75,percent of total billed charges,All Other,1106.25,65,,1106.25,percent of total billed charges,All Other,1434.38,76.5,,1434.38,percent of total billed charges,All Other,1331.25,69,,1331.25,percent of total billed charges,All Other,1293.75,65,,1293.75,percent of total billed charges,All Other,928.13,,,928.13,Other,110% of Medicare,1275,68,,1275,percent of total billed charges,All Other,411,,,411,Other,186% of Medicaid,1500,80,,1500,percent of total billed charges,All Other,1556.25,83,,1556.25,percent of total billed charges,All Other,1556.25,83,,1556.25,percent of total billed charges,All Other,1500,80,,1500,percent of total billed charges,All Other,1556.25,83,,1556.25,percent of total billed charges,All Other,1500,80,,1500,percent of total billed charges,All Other,1312.5,70,,1312.5,percent of total billed charges,All Other,1218.75,65,,1218.75,percent of total billed charges,Default if not in Fee Schedule,1218.75,65,,1218.75,percent of total billed charges,Default if not in Fee Schedule,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,221.06,,,221.06,Other,100% of Medicaid,221.06,,,221.06,Other,100% of Medicaid,221.06,,,221.06,Other,100% of Medicaid,221.06,,,221.06,Other,100% of Medicaid,497.39,,,497.39,Other,225% of Medicaid,338.22,,,338.22,Other,153% of Medicaid,497.39,,,497.39,Other,225% of Medicaid,309.49,,,309.49,Other,140% of Medicaid,497.39,,,497.39,Other,225% of Medicaid,574.76,,,574.76,Other,260% of Medicaid,716.24,,,716.24,Other,324% of Medicaid,475.28,,,475.28,Other,215% of Medicaid,475.28,,,475.28,Other,215% of Medicaid,276.33,,,276.33,Other,125% of Medicaid,0.01,1556.25,
TIXAGEV AND CILGAV INJ,M0220,HCPCS,,75000005,CDM,771,RC,,,both,,,1875,1387.5,,,1387.5,Other,150% of Medicare + 9.63% HCRA Surcharge,843.75,45,,843.75,percent of total billed charges,Critical Access Hospital RCC factor,150.5,,,150.5,Fee Schedule,,150.5,,,150.5,Fee Schedule,,150.5,,,150.5,Fee Schedule,,150.5,,,150.5,Fee Schedule,,150.5,,,150.5,Fee Schedule,,928.13,,,928.13,Other,110% of Medicare,150.5,,,150.5,Fee Schedule,,58,,,58,Other,186% of Medicaid,150.5,,,150.5,Fee Schedule,,150.5,,,150.5,Fee Schedule,,150.5,,,150.5,Fee Schedule,,150.5,,,150.5,Fee Schedule,,150.5,,,150.5,Fee Schedule,,1500,80,,1500,percent of total billed charges,All Other,1312.5,70,,1312.5,percent of total billed charges,All Other,1218.75,65,,1218.75,percent of total billed charges,Default if not in Fee Schedule,1218.75,65,,1218.75,percent of total billed charges,Default if not in Fee Schedule,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,31.2,,,31.2,Other,100% of Medicaid,31.2,,,31.2,Other,100% of Medicaid,31.2,,,31.2,Other,100% of Medicaid,31.2,,,31.2,Other,100% of Medicaid,70.2,,,70.2,Other,225% of Medicaid,47.74,,,47.74,Other,153% of Medicaid,70.2,,,70.2,Other,225% of Medicaid,43.68,,,43.68,Other,140% of Medicaid,70.2,,,70.2,Other,225% of Medicaid,81.12,,,81.12,Other,260% of Medicaid,101.09,,,101.09,Other,324% of Medicaid,67.08,,,67.08,Other,215% of Medicaid,67.08,,,67.08,Other,215% of Medicaid,39,,,39,Other,125% of Medicaid,0.01,1500,
BEBTELOVIMAB INJ,M0222,HCPCS,,75000006,CDM,771,RC,,,both,,,1875,1387.5,,,1387.5,Other,150% of Medicare + 9.63% HCRA Surcharge,843.75,45,,843.75,percent of total billed charges,Critical Access Hospital RCC factor,1218.75,65,,1218.75,percent of total billed charges,All Other,1106.25,65,,1106.25,percent of total billed charges,All Other,1434.38,76.5,,1434.38,percent of total billed charges,All Other,1331.25,69,,1331.25,percent of total billed charges,All Other,1293.75,65,,1293.75,percent of total billed charges,All Other,928.13,,,928.13,Other,110% of Medicare,1275,68,,1275,percent of total billed charges,All Other,58,,,58,Other,186% of Medicaid,1500,80,,1500,percent of total billed charges,All Other,1556.25,83,,1556.25,percent of total billed charges,All Other,1556.25,83,,1556.25,percent of total billed charges,All Other,1500,80,,1500,percent of total billed charges,All Other,1556.25,83,,1556.25,percent of total billed charges,All Other,1500,80,,1500,percent of total billed charges,All Other,1312.5,70,,1312.5,percent of total billed charges,All Other,1218.75,65,,1218.75,percent of total billed charges,Default if not in Fee Schedule,1218.75,65,,1218.75,percent of total billed charges,Default if not in Fee Schedule,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,31.2,,,31.2,Other,100% of Medicaid,31.2,,,31.2,Other,100% of Medicaid,31.2,,,31.2,Other,100% of Medicaid,31.2,,,31.2,Other,100% of Medicaid,70.2,,,70.2,Other,225% of Medicaid,47.74,,,47.74,Other,153% of Medicaid,70.2,,,70.2,Other,225% of Medicaid,43.68,,,43.68,Other,140% of Medicaid,70.2,,,70.2,Other,225% of Medicaid,81.12,,,81.12,Other,260% of Medicaid,101.09,,,101.09,Other,324% of Medicaid,67.08,,,67.08,Other,215% of Medicaid,67.08,,,67.08,Other,215% of Medicaid,39,,,39,Other,125% of Medicaid,0.01,1556.25,
BEBTELOVIMAB INJ HOME,M0223,HCPCS,,75000007,CDM,771,RC,,,both,,,1875,1387.5,,,1387.5,Other,150% of Medicare + 9.63% HCRA Surcharge,843.75,45,,843.75,percent of total billed charges,Critical Access Hospital RCC factor,1218.75,65,,1218.75,percent of total billed charges,All Other,1106.25,65,,1106.25,percent of total billed charges,All Other,1434.38,76.5,,1434.38,percent of total billed charges,All Other,1331.25,69,,1331.25,percent of total billed charges,All Other,1293.75,65,,1293.75,percent of total billed charges,All Other,928.13,,,928.13,Other,110% of Medicare,1275,68,,1275,percent of total billed charges,All Other,0.01,,,0.01,Other,186% of Medicaid,1500,,,1500,percent of total billed charges,All Other,1162.5,83,,1162.5,percent of total billed charges,All Other,1031.25,83,,1031.25,percent of total billed charges,All Other,1500,80,,1500,percent of total billed charges,All Other,1162.5,83,,1162.5,percent of total billed charges,All Other,1500,80,,1500,percent of total billed charges,All Other,1312.5,70,,1312.5,percent of total billed charges,All Other,1218.75,65,,1218.75,percent of total billed charges,Default if not in Fee Schedule,1218.75,65,,1218.75,percent of total billed charges,Default if not in Fee Schedule,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,1500,
TIXAGEV AND CILGAV INJ HM,M0221,HCPCS,,75000008,CDM,771,RC,,,both,,,1875,1387.5,,,1387.5,Other,150% of Medicare + 9.63% HCRA Surcharge,843.75,45,,843.75,percent of total billed charges,Critical Access Hospital RCC factor,1218.75,65,,1218.75,percent of total billed charges,All Other,1106.25,65,,1106.25,percent of total billed charges,All Other,1434.38,76.5,,1434.38,percent of total billed charges,All Other,1331.25,69,,1331.25,percent of total billed charges,All Other,1293.75,65,,1293.75,percent of total billed charges,All Other,928.13,,,928.13,Other,110% of Medicare,1275,68,,1275,percent of total billed charges,All Other,58,,,58,Other,186% of Medicaid,1500,,,1500,percent of total billed charges,All Other,1556.25,83,,1556.25,percent of total billed charges,All Other,1556.25,83,,1556.25,percent of total billed charges,All Other,1500,80,,1500,percent of total billed charges,All Other,1556.25,83,,1556.25,percent of total billed charges,All Other,1500,80,,1500,percent of total billed charges,All Other,1312.5,70,,1312.5,percent of total billed charges,All Other,1218.75,65,,1218.75,percent of total billed charges,Default if not in Fee Schedule,1218.75,65,,1218.75,percent of total billed charges,Default if not in Fee Schedule,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,31.2,,,31.2,Other,100% of Medicaid,31.2,,,31.2,Other,100% of Medicaid,31.2,,,31.2,Other,100% of Medicaid,31.2,,,31.2,Other,100% of Medicaid,70.2,,,70.2,Other,225% of Medicaid,47.74,,,47.74,Other,153% of Medicaid,70.2,,,70.2,Other,225% of Medicaid,43.68,,,43.68,Other,140% of Medicaid,70.2,,,70.2,Other,225% of Medicaid,81.12,,,81.12,Other,260% of Medicaid,101.09,,,101.09,Other,324% of Medicaid,67.08,,,67.08,Other,215% of Medicaid,67.08,,,67.08,Other,215% of Medicaid,39,,,39,Other,125% of Medicaid,0.01,1556.25,
IMMUNIZATION ADMIN 1ST,90471,CPT,,75090471,CDM,771,RC,,,both,,,153,113.22,,,113.22,Other,150% of Medicare + 9.63% HCRA Surcharge,68.85,45,,68.85,percent of total billed charges,Critical Access Hospital RCC factor,99.45,65,,99.45,percent of total billed charges,All Other,90.27,65,,90.27,percent of total billed charges,All Other,117.05,76.5,,117.05,percent of total billed charges,All Other,108.63,69,,108.63,percent of total billed charges,All Other,105.57,65,,105.57,percent of total billed charges,All Other,75.74,,,75.74,Other,110% of Medicare,104.04,68,,104.04,percent of total billed charges,All Other,23,,,23,Other,186% of Medicaid,122.4,,,122.4,percent of total billed charges,All Other,126.99,83,,126.99,percent of total billed charges,All Other,126.99,83,,126.99,percent of total billed charges,All Other,122.4,80,,122.4,percent of total billed charges,All Other,126.99,83,,126.99,percent of total billed charges,All Other,122.4,80,,122.4,percent of total billed charges,All Other,107.1,70,,107.1,percent of total billed charges,All Other,80.36,,,80.36,Fee Schedule,,68.11,,,68.11,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,12.5,,,12.5,Other,100% of Medicaid,12.5,,,12.5,Other,100% of Medicaid,12.5,,,12.5,Other,100% of Medicaid,12.5,,,12.5,Other,100% of Medicaid,28.12,,,28.12,Other,225% of Medicaid,19.12,,,19.12,Other,153% of Medicaid,28.12,,,28.12,Other,225% of Medicaid,17.5,,,17.5,Other,140% of Medicaid,28.12,,,28.12,Other,225% of Medicaid,32.5,,,32.5,Other,260% of Medicaid,40.5,,,40.5,Other,324% of Medicaid,26.87,,,26.87,Other,215% of Medicaid,26.87,,,26.87,Other,215% of Medicaid,15.62,,,15.62,Other,125% of Medicaid,0.01,126.99,
PFIZER ADM SARSCOV2 30MCG/0.3ML 1ST,0001A,HCPCS,,80023980,CDM,771,RC,,,both,,,120,88.8,,,88.8,Other,150% of Medicare + 9.63% HCRA Surcharge,54,45,,54,percent of total billed charges,Critical Access Hospital RCC factor,40,,,40,Fee Schedule,,40,,,40,Fee Schedule,,40,,,40,Fee Schedule,,40,,,40,Fee Schedule,,40,,,40,Fee Schedule,,59.4,,,59.4,Other,110% of Medicare,40,,,40,Fee Schedule,,23,,,23,Other,186% of Medicaid,40,,,40,Fee Schedule,,40,,,40,Fee Schedule,,40,,,40,Fee Schedule,,40,,,40,Fee Schedule,,40,,,40,Fee Schedule,,40,,,40,Fee Schedule,,84,70,,84,percent of total billed charges,All Other,78,65,,78,percent of total billed charges,Default if not in Fee Schedule,78,65,,78,percent of total billed charges,Default if not in Fee Schedule,238,,,238,Case Rate,,214,,,214,Case Rate,,238,,,238,Case Rate,,202,,,202,Case Rate,,12.5,,,12.5,Other,100% of Medicaid,12.5,,,12.5,Other,100% of Medicaid,12.5,,,12.5,Other,100% of Medicaid,12.5,,,12.5,Other,100% of Medicaid,28.12,,,28.12,Other,225% of Medicaid,19.12,,,19.12,Other,153% of Medicaid,28.12,,,28.12,Other,225% of Medicaid,17.5,,,17.5,Other,140% of Medicaid,28.12,,,28.12,Other,225% of Medicaid,32.5,,,32.5,Other,260% of Medicaid,40.5,,,40.5,Other,324% of Medicaid,26.87,,,26.87,Other,215% of Medicaid,26.87,,,26.87,Other,215% of Medicaid,15.62,,,15.62,Other,125% of Medicaid,12.5,238,
MODERNA ADM SARSCOV2 100MCG/0.5ML 1ST,0011A,HCPCS,,80023981,CDM,771,RC,,,both,,,120,88.8,,,88.8,Other,150% of Medicare + 9.63% HCRA Surcharge,54,45,,54,percent of total billed charges,Critical Access Hospital RCC factor,40,,,40,Fee Schedule,,40,,,40,Fee Schedule,,40,,,40,Fee Schedule,,40,,,40,Fee Schedule,,40,,,40,Fee Schedule,,59.4,,,59.4,Other,110% of Medicare,40,,,40,Fee Schedule,,23,,,23,Other,186% of Medicaid,40,,,40,Fee Schedule,,40,,,40,Fee Schedule,,40,,,40,Fee Schedule,,40,,,40,Fee Schedule,,40,,,40,Fee Schedule,,96,80,,96,percent of total billed charges,All Other,84,70,,84,percent of total billed charges,All Other,78,65,,78,percent of total billed charges,Default if not in Fee Schedule,78,65,,78,percent of total billed charges,Default if not in Fee Schedule,238,,,238,Case Rate,,214,,,214,Case Rate,,238,,,238,Case Rate,,202,,,202,Case Rate,,12.5,,,12.5,Other,100% of Medicaid,12.5,,,12.5,Other,100% of Medicaid,12.5,,,12.5,Other,100% of Medicaid,12.5,,,12.5,Other,100% of Medicaid,28.12,,,28.12,Other,225% of Medicaid,19.12,,,19.12,Other,153% of Medicaid,28.12,,,28.12,Other,225% of Medicaid,17.5,,,17.5,Other,140% of Medicaid,28.12,,,28.12,Other,225% of Medicaid,32.5,,,32.5,Other,260% of Medicaid,40.5,,,40.5,Other,324% of Medicaid,26.87,,,26.87,Other,215% of Medicaid,26.87,,,26.87,Other,215% of Medicaid,15.62,,,15.62,Other,125% of Medicaid,12.5,238,
PFIZER ADM SARSCOV2 30MCG/0.3ML 2ND,0002A,HCPCS,,80023982,CDM,771,RC,,,both,,,120,88.8,,,88.8,Other,150% of Medicare + 9.63% HCRA Surcharge,54,45,,54,percent of total billed charges,Critical Access Hospital RCC factor,40,,,40,Fee Schedule,,40,,,40,Fee Schedule,,40,,,40,Fee Schedule,,40,,,40,Fee Schedule,,40,,,40,Fee Schedule,,59.4,,,59.4,Other,110% of Medicare,40,,,40,Fee Schedule,,23,,,23,Other,186% of Medicaid,40,,,40,Fee Schedule,,40,,,40,Fee Schedule,,40,,,40,Fee Schedule,,40,,,40,Fee Schedule,,40,,,40,Fee Schedule,,96,80,,96,percent of total billed charges,All Other,84,70,,84,percent of total billed charges,All Other,78,65,,78,percent of total billed charges,Default if not in Fee Schedule,78,65,,78,percent of total billed charges,Default if not in Fee Schedule,238,,,238,Case Rate,,214,,,214,Case Rate,,238,,,238,Case Rate,,202,,,202,Case Rate,,12.5,,,12.5,Other,100% of Medicaid,12.5,,,12.5,Other,100% of Medicaid,12.5,,,12.5,Other,100% of Medicaid,12.5,,,12.5,Other,100% of Medicaid,28.12,,,28.12,Other,225% of Medicaid,19.12,,,19.12,Other,153% of Medicaid,28.12,,,28.12,Other,225% of Medicaid,17.5,,,17.5,Other,140% of Medicaid,28.12,,,28.12,Other,225% of Medicaid,32.5,,,32.5,Other,260% of Medicaid,40.5,,,40.5,Other,324% of Medicaid,26.87,,,26.87,Other,215% of Medicaid,26.87,,,26.87,Other,215% of Medicaid,15.62,,,15.62,Other,125% of Medicaid,12.5,238,
MODERNA ADM SARSCOV2 100MCG/0.5ML 2ND,0012A,HCPCS,,80023983,CDM,771,RC,,,both,,,120,88.8,,,88.8,Other,150% of Medicare + 9.63% HCRA Surcharge,54,45,,54,percent of total billed charges,Critical Access Hospital RCC factor,40,,,40,Fee Schedule,,40,,,40,Fee Schedule,,40,,,40,Fee Schedule,,40,,,40,Fee Schedule,,40,,,40,Fee Schedule,,59.4,,,59.4,Other,110% of Medicare,40,,,40,Fee Schedule,,23,,,23,Other,186% of Medicaid,40,,,40,Fee Schedule,,40,,,40,Fee Schedule,,40,,,40,Fee Schedule,,40,,,40,Fee Schedule,,40,,,40,Fee Schedule,,40,,,40,Fee Schedule,,84,70,,84,percent of total billed charges,All Other,78,65,,78,percent of total billed charges,Default if not in Fee Schedule,78,65,,78,percent of total billed charges,Default if not in Fee Schedule,238,,,238,Case Rate,,214,,,214,Case Rate,,238,,,238,Case Rate,,202,,,202,Case Rate,,12.5,,,12.5,Other,100% of Medicaid,12.5,,,12.5,Other,100% of Medicaid,12.5,,,12.5,Other,100% of Medicaid,12.5,,,12.5,Other,100% of Medicaid,28.12,,,28.12,Other,225% of Medicaid,19.12,,,19.12,Other,153% of Medicaid,28.12,,,28.12,Other,225% of Medicaid,17.5,,,17.5,Other,140% of Medicaid,28.12,,,28.12,Other,225% of Medicaid,32.5,,,32.5,Other,260% of Medicaid,40.5,,,40.5,Other,324% of Medicaid,26.87,,,26.87,Other,215% of Medicaid,26.87,,,26.87,Other,215% of Medicaid,15.62,,,15.62,Other,125% of Medicaid,12.5,238,
J&J ADM SARSCOV2VAC AD26 .5ML,0031A,HCPCS,,80023999,CDM,771,RC,,,both,,,120,88.8,,,88.8,Other,150% of Medicare + 9.63% HCRA Surcharge,54,45,,54,percent of total billed charges,Critical Access Hospital RCC factor,40,,,40,Fee Schedule,,40,,,40,Fee Schedule,,40,,,40,Fee Schedule,,40,,,40,Fee Schedule,,40,,,40,Fee Schedule,,59.4,,,59.4,Other,110% of Medicare,40,,,40,Fee Schedule,,23,,,23,Other,186% of Medicaid,40,,,40,Fee Schedule,,40,,,40,Fee Schedule,,40,,,40,Fee Schedule,,40,,,40,Fee Schedule,,40,,,40,Fee Schedule,,40,,,40,Fee Schedule,,84,70,,84,percent of total billed charges,All Other,78,65,,78,percent of total billed charges,Default if not in Fee Schedule,78,65,,78,percent of total billed charges,Default if not in Fee Schedule,238,,,238,Case Rate,,214,,,214,Case Rate,,238,,,238,Case Rate,,202,,,202,Case Rate,,12.5,,,12.5,Other,100% of Medicaid,12.5,,,12.5,Other,100% of Medicaid,12.5,,,12.5,Other,100% of Medicaid,12.5,,,12.5,Other,100% of Medicaid,28.12,,,28.12,Other,225% of Medicaid,19.12,,,19.12,Other,153% of Medicaid,28.12,,,28.12,Other,225% of Medicaid,17.5,,,17.5,Other,140% of Medicaid,28.12,,,28.12,Other,225% of Medicaid,32.5,,,32.5,Other,260% of Medicaid,40.5,,,40.5,Other,324% of Medicaid,26.87,,,26.87,Other,215% of Medicaid,26.87,,,26.87,Other,215% of Medicaid,15.62,,,15.62,Other,125% of Medicaid,12.5,238,
PFIZER ADM SARSOV2 30MCG/0.3ML 3RD,0003A,HCPCS,,80024029,CDM,771,RC,,,both,,,120,88.8,,,88.8,Other,150% of Medicare + 9.63% HCRA Surcharge,54,45,,54,percent of total billed charges,Critical Access Hospital RCC factor,40,,,40,Fee Schedule,,40,,,40,Fee Schedule,,40,,,40,Fee Schedule,,40,,,40,Fee Schedule,,40,,,40,Fee Schedule,,59.4,,,59.4,Other,110% of Medicare,40,,,40,Fee Schedule,,23,,,23,Other,186% of Medicaid,40,,,40,Fee Schedule,,40,,,40,Fee Schedule,,40,,,40,Fee Schedule,,40,,,40,Fee Schedule,,40,,,40,Fee Schedule,,40,,,40,Fee Schedule,,84,70,,84,percent of total billed charges,All Other,78,65,,78,percent of total billed charges,Default if not in Fee Schedule,78,65,,78,percent of total billed charges,Default if not in Fee Schedule,238,,,238,Case Rate,,214,,,214,Case Rate,,238,,,238,Case Rate,,202,,,202,Case Rate,,12.5,,,12.5,Other,100% of Medicaid,12.5,,,12.5,Other,100% of Medicaid,12.5,,,12.5,Other,100% of Medicaid,12.5,,,12.5,Other,100% of Medicaid,28.12,,,28.12,Other,225% of Medicaid,19.12,,,19.12,Other,153% of Medicaid,28.12,,,28.12,Other,225% of Medicaid,17.5,,,17.5,Other,140% of Medicaid,28.12,,,28.12,Other,225% of Medicaid,32.5,,,32.5,Other,260% of Medicaid,40.5,,,40.5,Other,324% of Medicaid,26.87,,,26.87,Other,215% of Medicaid,26.87,,,26.87,Other,215% of Medicaid,15.62,,,15.62,Other,125% of Medicaid,12.5,238,
MODERNA ADM SARSOV2 100MCG/0.5ML 3RD,0013A,HCPCS,,80024030,CDM,771,RC,,,both,,,120,88.8,,,88.8,Other,150% of Medicare + 9.63% HCRA Surcharge,54,45,,54,percent of total billed charges,Critical Access Hospital RCC factor,40,,,40,Fee Schedule,,40,,,40,Fee Schedule,,40,,,40,Fee Schedule,,40,,,40,Fee Schedule,,40,,,40,Fee Schedule,,59.4,,,59.4,Other,110% of Medicare,40,,,40,Fee Schedule,,23,,,23,Other,186% of Medicaid,40,,,40,Fee Schedule,,40,,,40,Fee Schedule,,40,,,40,Fee Schedule,,40,,,40,Fee Schedule,,40,,,40,Fee Schedule,,40,,,40,Fee Schedule,,84,70,,84,percent of total billed charges,All Other,78,65,,78,percent of total billed charges,Default if not in Fee Schedule,78,65,,78,percent of total billed charges,Default if not in Fee Schedule,238,,,238,Case Rate,,214,,,214,Case Rate,,238,,,238,Case Rate,,202,,,202,Case Rate,,12.5,,,12.5,Other,100% of Medicaid,12.5,,,12.5,Other,100% of Medicaid,12.5,,,12.5,Other,100% of Medicaid,12.5,,,12.5,Other,100% of Medicaid,28.12,,,28.12,Other,225% of Medicaid,19.12,,,19.12,Other,153% of Medicaid,28.12,,,28.12,Other,225% of Medicaid,17.5,,,17.5,Other,140% of Medicaid,28.12,,,28.12,Other,225% of Medicaid,32.5,,,32.5,Other,260% of Medicaid,40.5,,,40.5,Other,324% of Medicaid,26.87,,,26.87,Other,215% of Medicaid,26.87,,,26.87,Other,215% of Medicaid,15.62,,,15.62,Other,125% of Medicaid,12.5,238,
PFIZER ADM SARSCOV2 30MCG/0.3ML BST,0004A,HCPCS,,80024033,CDM,771,RC,,,both,,,120,88.8,,,88.8,Other,150% of Medicare + 9.63% HCRA Surcharge,54,45,,54,percent of total billed charges,Critical Access Hospital RCC factor,40,,,40,Fee Schedule,,40,,,40,Fee Schedule,,40,,,40,Fee Schedule,,40,,,40,Fee Schedule,,40,,,40,Fee Schedule,,59.4,,,59.4,Other,110% of Medicare,40,,,40,Fee Schedule,,23,,,23,Other,186% of Medicaid,40,,,40,Fee Schedule,,40,,,40,Fee Schedule,,40,,,40,Fee Schedule,,40,,,40,Fee Schedule,,40,,,40,Fee Schedule,,40,,,40,Fee Schedule,,84,70,,84,percent of total billed charges,All Other,78,65,,78,percent of total billed charges,Default if not in Fee Schedule,78,65,,78,percent of total billed charges,Default if not in Fee Schedule,238,,,238,Case Rate,,214,,,214,Case Rate,,238,,,238,Case Rate,,202,,,202,Case Rate,,12.5,,,12.5,Other,100% of Medicaid,12.5,,,12.5,Other,100% of Medicaid,12.5,,,12.5,Other,100% of Medicaid,12.5,,,12.5,Other,100% of Medicaid,28.12,,,28.12,Other,225% of Medicaid,19.12,,,19.12,Other,153% of Medicaid,28.12,,,28.12,Other,225% of Medicaid,17.5,,,17.5,Other,140% of Medicaid,28.12,,,28.12,Other,225% of Medicaid,32.5,,,32.5,Other,260% of Medicaid,40.5,,,40.5,Other,324% of Medicaid,26.87,,,26.87,Other,215% of Medicaid,26.87,,,26.87,Other,215% of Medicaid,15.62,,,15.62,Other,125% of Medicaid,12.5,238,
MODERNA ADM SARSCOV2 50MCG/0.25ML BST,0064A,HCPCS,,80024035,CDM,771,RC,,,both,,,120,88.8,,,88.8,Other,150% of Medicare + 9.63% HCRA Surcharge,54,45,,54,percent of total billed charges,Critical Access Hospital RCC factor,40,,,40,Fee Schedule,,40,,,40,Fee Schedule,,40,,,40,Fee Schedule,,40,,,40,Fee Schedule,,40,,,40,Fee Schedule,,59.4,,,59.4,Other,110% of Medicare,40,,,40,Fee Schedule,,23,,,23,Other,186% of Medicaid,40,,,40,Fee Schedule,,40,,,40,Fee Schedule,,40,,,40,Fee Schedule,,40,,,40,Fee Schedule,,40,,,40,Fee Schedule,,40,,,40,Fee Schedule,,84,70,,84,percent of total billed charges,All Other,78,65,,78,percent of total billed charges,Default if not in Fee Schedule,78,65,,78,percent of total billed charges,Default if not in Fee Schedule,238,,,238,Case Rate,,214,,,214,Case Rate,,238,,,238,Case Rate,,202,,,202,Case Rate,,12.5,,,12.5,Other,100% of Medicaid,12.5,,,12.5,Other,100% of Medicaid,12.5,,,12.5,Other,100% of Medicaid,12.5,,,12.5,Other,100% of Medicaid,28.12,,,28.12,Other,225% of Medicaid,19.12,,,19.12,Other,153% of Medicaid,28.12,,,28.12,Other,225% of Medicaid,17.5,,,17.5,Other,140% of Medicaid,28.12,,,28.12,Other,225% of Medicaid,32.5,,,32.5,Other,260% of Medicaid,40.5,,,40.5,Other,324% of Medicaid,26.87,,,26.87,Other,215% of Medicaid,26.87,,,26.87,Other,215% of Medicaid,15.62,,,15.62,Other,125% of Medicaid,12.5,238,
J&J ADM SARSCOV2 VAC AD26 .5ML BST,0034A,HCPCS,,80024036,CDM,771,RC,,,both,,,120,88.8,,,88.8,Other,150% of Medicare + 9.63% HCRA Surcharge,54,45,,54,percent of total billed charges,Critical Access Hospital RCC factor,40,,,40,Fee Schedule,,40,,,40,Fee Schedule,,91.8,76.5,,91.8,percent of total billed charges,All Other,85.2,69,,85.2,percent of total billed charges,All Other,82.8,65,,82.8,percent of total billed charges,All Other,59.4,,,59.4,Other,110% of Medicare,40,,,40,Fee Schedule,,23,,,23,Other,186% of Medicaid,40,,,40,Fee Schedule,,40,,,40,Fee Schedule,,40,,,40,Fee Schedule,,40,,,40,Fee Schedule,,40,,,40,Fee Schedule,,40,,,40,Fee Schedule,,84,70,,84,percent of total billed charges,All Other,78,65,,78,percent of total billed charges,Default if not in Fee Schedule,78,65,,78,percent of total billed charges,Default if not in Fee Schedule,238,,,238,Case Rate,,214,,,214,Case Rate,,238,,,238,Case Rate,,202,,,202,Case Rate,,12.5,,,12.5,Other,100% of Medicaid,12.5,,,12.5,Other,100% of Medicaid,12.5,,,12.5,Other,100% of Medicaid,12.5,,,12.5,Other,100% of Medicaid,28.12,,,28.12,Other,225% of Medicaid,19.12,,,19.12,Other,153% of Medicaid,28.12,,,28.12,Other,225% of Medicaid,17.5,,,17.5,Other,140% of Medicaid,28.12,,,28.12,Other,225% of Medicaid,32.5,,,32.5,Other,260% of Medicaid,40.5,,,40.5,Other,324% of Medicaid,26.87,,,26.87,Other,215% of Medicaid,26.87,,,26.87,Other,215% of Medicaid,15.62,,,15.62,Other,125% of Medicaid,12.5,238,
PFIZER PED ADM SARCV2 10MCG TRS-SUCR 1,0071A,HCPCS,,80024038,CDM,771,RC,,,both,,,40,29.6,,,29.6,Other,150% of Medicare + 9.63% HCRA Surcharge,18,45,,18,percent of total billed charges,Critical Access Hospital RCC factor,40,,,40,Fee Schedule,,40,,,40,Fee Schedule,,40,,,40,Fee Schedule,,40,,,40,Fee Schedule,,40,,,40,Fee Schedule,,19.8,,,19.8,Other,110% of Medicare,40,,,40,Fee Schedule,,23,,,23,Other,186% of Medicaid,40,,,40,Fee Schedule,,40,,,40,Fee Schedule,,40,,,40,Fee Schedule,,40,,,40,Fee Schedule,,40,,,40,Fee Schedule,,32,80,,32,percent of total billed charges,All Other,28,70,,28,percent of total billed charges,All Other,26,65,,26,percent of total billed charges,Default if not in Fee Schedule,26,65,,26,percent of total billed charges,Default if not in Fee Schedule,238,,,238,Case Rate,,214,,,214,Case Rate,,238,,,238,Case Rate,,202,,,202,Case Rate,,12.5,,,12.5,Other,100% of Medicaid,12.5,,,12.5,Other,100% of Medicaid,12.5,,,12.5,Other,100% of Medicaid,12.5,,,12.5,Other,100% of Medicaid,28.12,,,28.12,Other,225% of Medicaid,19.12,,,19.12,Other,153% of Medicaid,28.12,,,28.12,Other,225% of Medicaid,17.5,,,17.5,Other,140% of Medicaid,28.12,,,28.12,Other,225% of Medicaid,32.5,,,32.5,Other,260% of Medicaid,40.5,,,40.5,Other,324% of Medicaid,26.87,,,26.87,Other,215% of Medicaid,26.87,,,26.87,Other,215% of Medicaid,15.62,,,15.62,Other,125% of Medicaid,12.5,238,
PFIZER PED ADM SARSCV2 10MCG TRS-SUCR 2,0072A,HCPCS,,80024039,CDM,771,RC,,,both,,,40,29.6,,,29.6,Other,150% of Medicare + 9.63% HCRA Surcharge,18,45,,18,percent of total billed charges,Critical Access Hospital RCC factor,40,,,40,Fee Schedule,,40,,,40,Fee Schedule,,40,,,40,Fee Schedule,,40,,,40,Fee Schedule,,40,,,40,Fee Schedule,,19.8,,,19.8,Other,110% of Medicare,40,,,40,Fee Schedule,,23,,,23,Other,186% of Medicaid,40,,,40,Fee Schedule,,40,,,40,Fee Schedule,,40,,,40,Fee Schedule,,40,,,40,Fee Schedule,,40,,,40,Fee Schedule,,32,80,,32,percent of total billed charges,All Other,28,70,,28,percent of total billed charges,All Other,26,65,,26,percent of total billed charges,Default if not in Fee Schedule,26,65,,26,percent of total billed charges,Default if not in Fee Schedule,238,,,238,Case Rate,,214,,,214,Case Rate,,238,,,238,Case Rate,,202,,,202,Case Rate,,12.5,,,12.5,Other,100% of Medicaid,12.5,,,12.5,Other,100% of Medicaid,12.5,,,12.5,Other,100% of Medicaid,12.5,,,12.5,Other,100% of Medicaid,28.12,,,28.12,Other,225% of Medicaid,19.12,,,19.12,Other,153% of Medicaid,28.12,,,28.12,Other,225% of Medicaid,17.5,,,17.5,Other,140% of Medicaid,28.12,,,28.12,Other,225% of Medicaid,32.5,,,32.5,Other,260% of Medicaid,40.5,,,40.5,Other,324% of Medicaid,26.87,,,26.87,Other,215% of Medicaid,26.87,,,26.87,Other,215% of Medicaid,15.62,,,15.62,Other,125% of Medicaid,12.5,238,
PFIZER ADM SARSCV2 3MCG TRS-SUCR 1,0081A,HCPCS,,80024051,CDM,771,RC,,,both,,,120,88.8,,,88.8,Other,150% of Medicare + 9.63% HCRA Surcharge,54,45,,54,percent of total billed charges,Critical Access Hospital RCC factor,78,65,,78,percent of total billed charges,All Other,70.8,65,,70.8,percent of total billed charges,All Other,91.8,76.5,,91.8,percent of total billed charges,All Other,85.2,69,,85.2,percent of total billed charges,All Other,82.8,65,,82.8,percent of total billed charges,All Other,59.4,,,59.4,Other,110% of Medicare,81.6,68,,81.6,percent of total billed charges,All Other,23,,,23,Other,186% of Medicaid,96,,,96,percent of total billed charges,All Other,99.6,83,,99.6,percent of total billed charges,All Other,99.6,83,,99.6,percent of total billed charges,All Other,96,80,,96,percent of total billed charges,All Other,99.6,83,,99.6,percent of total billed charges,All Other,96,80,,96,percent of total billed charges,All Other,84,70,,84,percent of total billed charges,All Other,78,65,,78,percent of total billed charges,Default if not in Fee Schedule,78,65,,78,percent of total billed charges,Default if not in Fee Schedule,238,,,238,Case Rate,,214,,,214,Case Rate,,238,,,238,Case Rate,,202,,,202,Case Rate,,12.5,,,12.5,Other,100% of Medicaid,12.5,,,12.5,Other,100% of Medicaid,12.5,,,12.5,Other,100% of Medicaid,12.5,,,12.5,Other,100% of Medicaid,28.12,,,28.12,Other,225% of Medicaid,19.12,,,19.12,Other,153% of Medicaid,28.12,,,28.12,Other,225% of Medicaid,17.5,,,17.5,Other,140% of Medicaid,28.12,,,28.12,Other,225% of Medicaid,32.5,,,32.5,Other,260% of Medicaid,40.5,,,40.5,Other,324% of Medicaid,26.87,,,26.87,Other,215% of Medicaid,26.87,,,26.87,Other,215% of Medicaid,15.62,,,15.62,Other,125% of Medicaid,12.5,238,
PFIZER ADM SARSCV2 3MCG TRS-SUCR 2,0082A,HCPCS,,80024052,CDM,771,RC,,,both,,,120,88.8,,,88.8,Other,150% of Medicare + 9.63% HCRA Surcharge,54,45,,54,percent of total billed charges,Critical Access Hospital RCC factor,78,65,,78,percent of total billed charges,All Other,70.8,65,,70.8,percent of total billed charges,All Other,91.8,76.5,,91.8,percent of total billed charges,All Other,85.2,69,,85.2,percent of total billed charges,All Other,82.8,65,,82.8,percent of total billed charges,All Other,59.4,,,59.4,Other,110% of Medicare,81.6,68,,81.6,percent of total billed charges,All Other,23,,,23,Other,186% of Medicaid,96,,,96,percent of total billed charges,All Other,99.6,83,,99.6,percent of total billed charges,All Other,99.6,83,,99.6,percent of total billed charges,All Other,96,80,,96,percent of total billed charges,All Other,99.6,83,,99.6,percent of total billed charges,All Other,96,80,,96,percent of total billed charges,All Other,84,70,,84,percent of total billed charges,All Other,78,65,,78,percent of total billed charges,Default if not in Fee Schedule,78,65,,78,percent of total billed charges,Default if not in Fee Schedule,238,,,238,Case Rate,,214,,,214,Case Rate,,238,,,238,Case Rate,,202,,,202,Case Rate,,12.5,,,12.5,Other,100% of Medicaid,12.5,,,12.5,Other,100% of Medicaid,12.5,,,12.5,Other,100% of Medicaid,12.5,,,12.5,Other,100% of Medicaid,28.12,,,28.12,Other,225% of Medicaid,19.12,,,19.12,Other,153% of Medicaid,28.12,,,28.12,Other,225% of Medicaid,17.5,,,17.5,Other,140% of Medicaid,28.12,,,28.12,Other,225% of Medicaid,32.5,,,32.5,Other,260% of Medicaid,40.5,,,40.5,Other,324% of Medicaid,26.87,,,26.87,Other,215% of Medicaid,26.87,,,26.87,Other,215% of Medicaid,15.62,,,15.62,Other,125% of Medicaid,12.5,238,
MODERNA ADM SARSCOV2 50MCG/0.5ML  2NDBST,0094A,HCPCS,,80024061,CDM,771,RC,,,both,,,120,88.8,,,88.8,Other,150% of Medicare + 9.63% HCRA Surcharge,54,45,,54,percent of total billed charges,Critical Access Hospital RCC factor,40,,,40,Fee Schedule,,40,,,40,Fee Schedule,,91.8,76.5,,91.8,percent of total billed charges,All Other,85.2,69,,85.2,percent of total billed charges,All Other,82.8,65,,82.8,percent of total billed charges,All Other,59.4,,,59.4,Other,110% of Medicare,40,,,40,Fee Schedule,,23,,,23,Other,186% of Medicaid,40,,,40,Fee Schedule,,40,,,40,Fee Schedule,,40,,,40,Fee Schedule,,40,,,40,Fee Schedule,,40,,,40,Fee Schedule,,40,,,40,Fee Schedule,,84,70,,84,percent of total billed charges,All Other,78,65,,78,percent of total billed charges,Default if not in Fee Schedule,78,65,,78,percent of total billed charges,Default if not in Fee Schedule,238,,,238,Case Rate,,214,,,214,Case Rate,,238,,,238,Case Rate,,202,,,202,Case Rate,,12.5,,,12.5,Other,100% of Medicaid,12.5,,,12.5,Other,100% of Medicaid,12.5,,,12.5,Other,100% of Medicaid,12.5,,,12.5,Other,100% of Medicaid,28.12,,,28.12,Other,225% of Medicaid,19.12,,,19.12,Other,153% of Medicaid,28.12,,,28.12,Other,225% of Medicaid,17.5,,,17.5,Other,140% of Medicaid,28.12,,,28.12,Other,225% of Medicaid,32.5,,,32.5,Other,260% of Medicaid,40.5,,,40.5,Other,324% of Medicaid,26.87,,,26.87,Other,215% of Medicaid,26.87,,,26.87,Other,215% of Medicaid,15.62,,,15.62,Other,125% of Medicaid,12.5,238,
PFIZER ADM SARSCOV2 30MCG/0.3ML BST,0124A,HCPCS,,80024082,CDM,771,RC,,,both,,,120,88.8,,,88.8,Other,150% of Medicare + 9.63% HCRA Surcharge,54,45,,54,percent of total billed charges,Critical Access Hospital RCC factor,78,65,,78,percent of total billed charges,All Other,70.8,65,,70.8,percent of total billed charges,All Other,91.8,76.5,,91.8,percent of total billed charges,All Other,85.2,69,,85.2,percent of total billed charges,All Other,82.8,65,,82.8,percent of total billed charges,All Other,59.4,,,59.4,Other,110% of Medicare,81.6,68,,81.6,percent of total billed charges,All Other,23,,,23,Other,186% of Medicaid,96,,,96,percent of total billed charges,All Other,99.6,83,,99.6,percent of total billed charges,All Other,99.6,83,,99.6,percent of total billed charges,All Other,96,80,,96,percent of total billed charges,All Other,99.6,83,,99.6,percent of total billed charges,All Other,96,80,,96,percent of total billed charges,All Other,84,70,,84,percent of total billed charges,All Other,78,65,,78,percent of total billed charges,Default if not in Fee Schedule,78,65,,78,percent of total billed charges,Default if not in Fee Schedule,238,,,238,Case Rate,,214,,,214,Case Rate,,238,,,238,Case Rate,,202,,,202,Case Rate,,12.5,,,12.5,Other,100% of Medicaid,12.5,,,12.5,Other,100% of Medicaid,12.5,,,12.5,Other,100% of Medicaid,12.5,,,12.5,Other,100% of Medicaid,28.12,,,28.12,Other,225% of Medicaid,19.12,,,19.12,Other,153% of Medicaid,28.12,,,28.12,Other,225% of Medicaid,17.5,,,17.5,Other,140% of Medicaid,28.12,,,28.12,Other,225% of Medicaid,32.5,,,32.5,Other,260% of Medicaid,40.5,,,40.5,Other,324% of Medicaid,26.87,,,26.87,Other,215% of Medicaid,26.87,,,26.87,Other,215% of Medicaid,15.62,,,15.62,Other,125% of Medicaid,12.5,238,
MODERNA ADM SARSCOV2 50MCG/0.5ML BST,0134A,HCPCS,,80024084,CDM,771,RC,,,both,,,120,88.8,,,88.8,Other,150% of Medicare + 9.63% HCRA Surcharge,54,45,,54,percent of total billed charges,Critical Access Hospital RCC factor,78,65,,78,percent of total billed charges,All Other,70.8,65,,70.8,percent of total billed charges,All Other,91.8,76.5,,91.8,percent of total billed charges,All Other,85.2,69,,85.2,percent of total billed charges,All Other,82.8,65,,82.8,percent of total billed charges,All Other,59.4,,,59.4,Other,110% of Medicare,81.6,68,,81.6,percent of total billed charges,All Other,23,,,23,Other,186% of Medicaid,96,,,96,percent of total billed charges,All Other,99.6,83,,99.6,percent of total billed charges,All Other,99.6,83,,99.6,percent of total billed charges,All Other,96,80,,96,percent of total billed charges,All Other,99.6,83,,99.6,percent of total billed charges,All Other,96,80,,96,percent of total billed charges,All Other,84,70,,84,percent of total billed charges,All Other,78,65,,78,percent of total billed charges,Default if not in Fee Schedule,78,65,,78,percent of total billed charges,Default if not in Fee Schedule,238,,,238,Case Rate,,214,,,214,Case Rate,,238,,,238,Case Rate,,202,,,202,Case Rate,,12.5,,,12.5,Other,100% of Medicaid,12.5,,,12.5,Other,100% of Medicaid,12.5,,,12.5,Other,100% of Medicaid,12.5,,,12.5,Other,100% of Medicaid,28.12,,,28.12,Other,225% of Medicaid,19.12,,,19.12,Other,153% of Medicaid,28.12,,,28.12,Other,225% of Medicaid,17.5,,,17.5,Other,140% of Medicaid,28.12,,,28.12,Other,225% of Medicaid,32.5,,,32.5,Other,260% of Medicaid,40.5,,,40.5,Other,324% of Medicaid,26.87,,,26.87,Other,215% of Medicaid,26.87,,,26.87,Other,215% of Medicaid,15.62,,,15.62,Other,125% of Medicaid,12.5,238,
ADMN SARSCOV2 VACC 1 DOSE,90480,CPT,,80024129,CDM,771,RC,,,both,,,120,88.8,,,88.8,Other,150% of Medicare + 9.63% HCRA Surcharge,54,45,,54,percent of total billed charges,Critical Access Hospital RCC factor,78,65,,78,percent of total billed charges,All Other,70.8,65,,70.8,percent of total billed charges,All Other,91.8,76.5,,91.8,percent of total billed charges,All Other,85.2,69,,85.2,percent of total billed charges,All Other,82.8,65,,82.8,percent of total billed charges,All Other,59.4,,,59.4,Other,110% of Medicare,81.6,68,,81.6,percent of total billed charges,All Other,23,,,23,Other,186% of Medicaid,96,,,96,percent of total billed charges,All Other,99.6,83,,99.6,percent of total billed charges,All Other,99.6,83,,99.6,percent of total billed charges,All Other,96,80,,96,percent of total billed charges,All Other,99.6,83,,99.6,percent of total billed charges,All Other,96,80,,96,percent of total billed charges,All Other,84,70,,84,percent of total billed charges,All Other,78,65,,78,percent of total billed charges,Default if not in Fee Schedule,78,65,,78,percent of total billed charges,Default if not in Fee Schedule,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,12.5,,,12.5,Other,100% of Medicaid,12.5,,,12.5,Other,100% of Medicaid,12.5,,,12.5,Other,100% of Medicaid,12.5,,,12.5,Other,100% of Medicaid,28.12,,,28.12,Other,225% of Medicaid,19.12,,,19.12,Other,153% of Medicaid,28.12,,,28.12,Other,225% of Medicaid,17.5,,,17.5,Other,140% of Medicaid,28.12,,,28.12,Other,225% of Medicaid,32.5,,,32.5,Other,260% of Medicaid,40.5,,,40.5,Other,324% of Medicaid,26.87,,,26.87,Other,215% of Medicaid,26.87,,,26.87,Other,215% of Medicaid,15.62,,,15.62,Other,125% of Medicaid,0.01,99.6,
ADMIN INFLUENZA VACCINE,G0008,HCPCS,,81000001,CDM,771,RC,,,both,,,97,71.78,,,71.78,Other,150% of Medicare + 9.63% HCRA Surcharge,43.65,45,,43.65,percent of total billed charges,Critical Access Hospital RCC factor,63.05,65,,63.05,percent of total billed charges,All Other,57.23,65,,57.23,percent of total billed charges,All Other,74.21,76.5,,74.21,percent of total billed charges,All Other,68.87,69,,68.87,percent of total billed charges,All Other,66.93,65,,66.93,percent of total billed charges,All Other,48.02,,,48.02,Other,110% of Medicare,65.96,68,,65.96,percent of total billed charges,All Other,23,,,23,Other,186% of Medicaid,77.6,,,77.6,percent of total billed charges,All Other,80.51,83,,80.51,percent of total billed charges,All Other,80.51,83,,80.51,percent of total billed charges,All Other,77.6,80,,77.6,percent of total billed charges,All Other,80.51,83,,80.51,percent of total billed charges,All Other,77.6,80,,77.6,percent of total billed charges,All Other,67.9,70,,67.9,percent of total billed charges,All Other,80.36,,,80.36,Fee Schedule,,68.11,,,68.11,Fee Schedule,,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,12.5,,,12.5,Other,100% of Medicaid,12.5,,,12.5,Other,100% of Medicaid,12.5,,,12.5,Other,100% of Medicaid,12.5,,,12.5,Other,100% of Medicaid,28.12,,,28.12,Other,225% of Medicaid,19.12,,,19.12,Other,153% of Medicaid,28.12,,,28.12,Other,225% of Medicaid,17.5,,,17.5,Other,140% of Medicaid,28.12,,,28.12,Other,225% of Medicaid,32.5,,,32.5,Other,260% of Medicaid,40.5,,,40.5,Other,324% of Medicaid,26.87,,,26.87,Other,215% of Medicaid,26.87,,,26.87,Other,215% of Medicaid,15.62,,,15.62,Other,125% of Medicaid,0.01,80.51,
ADMIN HIGH DOSE INFLUENZA VACC,G0008,HCPCS,,81000002,CDM,771,RC,,,both,,,97,71.78,,,71.78,Other,150% of Medicare + 9.63% HCRA Surcharge,43.65,45,,43.65,percent of total billed charges,Critical Access Hospital RCC factor,63.05,65,,63.05,percent of total billed charges,All Other,57.23,65,,57.23,percent of total billed charges,All Other,74.21,76.5,,74.21,percent of total billed charges,All Other,68.87,69,,68.87,percent of total billed charges,All Other,66.93,65,,66.93,percent of total billed charges,All Other,48.02,,,48.02,Other,110% of Medicare,65.96,68,,65.96,percent of total billed charges,All Other,23,,,23,Other,186% of Medicaid,77.6,,,77.6,percent of total billed charges,All Other,80.51,83,,80.51,percent of total billed charges,All Other,80.51,83,,80.51,percent of total billed charges,All Other,77.6,80,,77.6,percent of total billed charges,All Other,80.51,83,,80.51,percent of total billed charges,All Other,77.6,80,,77.6,percent of total billed charges,All Other,67.9,70,,67.9,percent of total billed charges,All Other,80.36,,,80.36,Fee Schedule,,68.11,,,68.11,Fee Schedule,,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,12.5,,,12.5,Other,100% of Medicaid,12.5,,,12.5,Other,100% of Medicaid,12.5,,,12.5,Other,100% of Medicaid,12.5,,,12.5,Other,100% of Medicaid,28.12,,,28.12,Other,225% of Medicaid,19.12,,,19.12,Other,153% of Medicaid,28.12,,,28.12,Other,225% of Medicaid,17.5,,,17.5,Other,140% of Medicaid,28.12,,,28.12,Other,225% of Medicaid,32.5,,,32.5,Other,260% of Medicaid,40.5,,,40.5,Other,324% of Medicaid,26.87,,,26.87,Other,215% of Medicaid,26.87,,,26.87,Other,215% of Medicaid,15.62,,,15.62,Other,125% of Medicaid,0.01,80.51,
ADMIN FLU VIRUS VACCINE,G0008,HCPCS,,82000001,CDM,771,RC,,,both,,,97,71.78,,,71.78,Other,150% of Medicare + 9.63% HCRA Surcharge,43.65,45,,43.65,percent of total billed charges,Critical Access Hospital RCC factor,63.05,65,,63.05,percent of total billed charges,All Other,57.23,65,,57.23,percent of total billed charges,All Other,74.21,76.5,,74.21,percent of total billed charges,All Other,68.87,69,,68.87,percent of total billed charges,All Other,66.93,65,,66.93,percent of total billed charges,All Other,48.02,,,48.02,Other,110% of Medicare,65.96,68,,65.96,percent of total billed charges,All Other,23,,,23,Other,186% of Medicaid,77.6,,,77.6,percent of total billed charges,All Other,80.51,83,,80.51,percent of total billed charges,All Other,80.51,83,,80.51,percent of total billed charges,All Other,77.6,80,,77.6,percent of total billed charges,All Other,80.51,83,,80.51,percent of total billed charges,All Other,77.6,80,,77.6,percent of total billed charges,All Other,67.9,70,,67.9,percent of total billed charges,All Other,80.36,,,80.36,Fee Schedule,,68.11,,,68.11,Fee Schedule,,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,12.5,,,12.5,Other,100% of Medicaid,12.5,,,12.5,Other,100% of Medicaid,12.5,,,12.5,Other,100% of Medicaid,12.5,,,12.5,Other,100% of Medicaid,28.12,,,28.12,Other,225% of Medicaid,19.12,,,19.12,Other,153% of Medicaid,28.12,,,28.12,Other,225% of Medicaid,17.5,,,17.5,Other,140% of Medicaid,28.12,,,28.12,Other,225% of Medicaid,32.5,,,32.5,Other,260% of Medicaid,40.5,,,40.5,Other,324% of Medicaid,26.87,,,26.87,Other,215% of Medicaid,26.87,,,26.87,Other,215% of Medicaid,15.62,,,15.62,Other,125% of Medicaid,0.01,80.51,
ADMIN PNEUMONIA VACCINE,G0009,HCPCS,,82000002,CDM,771,RC,,,both,,,97,71.78,,,71.78,Other,150% of Medicare + 9.63% HCRA Surcharge,43.65,45,,43.65,percent of total billed charges,Critical Access Hospital RCC factor,63.05,65,,63.05,percent of total billed charges,All Other,57.23,65,,57.23,percent of total billed charges,All Other,74.21,76.5,,74.21,percent of total billed charges,All Other,68.87,69,,68.87,percent of total billed charges,All Other,66.93,65,,66.93,percent of total billed charges,All Other,48.02,,,48.02,Other,110% of Medicare,65.96,68,,65.96,percent of total billed charges,All Other,23,,,23,Other,186% of Medicaid,77.6,,,77.6,percent of total billed charges,All Other,80.51,83,,80.51,percent of total billed charges,All Other,80.51,83,,80.51,percent of total billed charges,All Other,77.6,80,,77.6,percent of total billed charges,All Other,80.51,83,,80.51,percent of total billed charges,All Other,77.6,80,,77.6,percent of total billed charges,All Other,67.9,70,,67.9,percent of total billed charges,All Other,80.36,,,80.36,Fee Schedule,,68.11,,,68.11,Fee Schedule,,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,12.5,,,12.5,Other,100% of Medicaid,12.5,,,12.5,Other,100% of Medicaid,12.5,,,12.5,Other,100% of Medicaid,12.5,,,12.5,Other,100% of Medicaid,28.12,,,28.12,Other,225% of Medicaid,19.12,,,19.12,Other,153% of Medicaid,28.12,,,28.12,Other,225% of Medicaid,17.5,,,17.5,Other,140% of Medicaid,28.12,,,28.12,Other,225% of Medicaid,32.5,,,32.5,Other,260% of Medicaid,40.5,,,40.5,Other,324% of Medicaid,26.87,,,26.87,Other,215% of Medicaid,26.87,,,26.87,Other,215% of Medicaid,15.62,,,15.62,Other,125% of Medicaid,0.01,80.51,
IMMUNIZATION ADMIN 1 VACCINE,90471,CPT,,82090471,CDM,771,RC,,,both,,,153,113.22,,,113.22,Other,150% of Medicare + 9.63% HCRA Surcharge,68.85,45,,68.85,percent of total billed charges,Critical Access Hospital RCC factor,99.45,65,,99.45,percent of total billed charges,All Other,90.27,65,,90.27,percent of total billed charges,All Other,117.05,76.5,,117.05,percent of total billed charges,All Other,108.63,69,,108.63,percent of total billed charges,All Other,105.57,65,,105.57,percent of total billed charges,All Other,75.74,,,75.74,Other,110% of Medicare,104.04,68,,104.04,percent of total billed charges,All Other,23,,,23,Other,186% of Medicaid,122.4,,,122.4,percent of total billed charges,All Other,126.99,83,,126.99,percent of total billed charges,All Other,126.99,83,,126.99,percent of total billed charges,All Other,122.4,80,,122.4,percent of total billed charges,All Other,126.99,83,,126.99,percent of total billed charges,All Other,122.4,80,,122.4,percent of total billed charges,All Other,107.1,70,,107.1,percent of total billed charges,All Other,80.36,,,80.36,Fee Schedule,,68.11,,,68.11,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,12.5,,,12.5,Other,100% of Medicaid,12.5,,,12.5,Other,100% of Medicaid,12.5,,,12.5,Other,100% of Medicaid,12.5,,,12.5,Other,100% of Medicaid,28.12,,,28.12,Other,225% of Medicaid,19.12,,,19.12,Other,153% of Medicaid,28.12,,,28.12,Other,225% of Medicaid,17.5,,,17.5,Other,140% of Medicaid,28.12,,,28.12,Other,225% of Medicaid,32.5,,,32.5,Other,260% of Medicaid,40.5,,,40.5,Other,324% of Medicaid,26.87,,,26.87,Other,215% of Medicaid,26.87,,,26.87,Other,215% of Medicaid,15.62,,,15.62,Other,125% of Medicaid,0.01,126.99,
TELEHEALTH FACILITY FEE,Q3014,HCPCS,GT,34000016,CDM,780,RC,,,both,,,161,119.14,,,119.14,Other,150% of Medicare + 9.63% HCRA Surcharge,72.45,45,,72.45,percent of total billed charges,Critical Access Hospital RCC factor,104.65,65,,104.65,percent of total billed charges,All Other,94.99,65,,94.99,percent of total billed charges,All Other,123.17,76.5,,123.17,percent of total billed charges,All Other,114.31,69,,114.31,percent of total billed charges,All Other,111.09,65,,111.09,percent of total billed charges,All Other,79.7,,,79.7,Other,110% of Medicare,109.48,68,,109.48,percent of total billed charges,All Other,0.01,,,0.01,Other,186% of Medicaid,128.8,,,128.8,percent of total billed charges,All Other,133.63,83,,133.63,percent of total billed charges,All Other,133.63,83,,133.63,percent of total billed charges,All Other,128.8,80,,128.8,percent of total billed charges,All Other,133.63,83,,133.63,percent of total billed charges,All Other,128.8,80,,128.8,percent of total billed charges,All Other,112.7,70,,112.7,percent of total billed charges,All Other,104.65,65,,104.65,percent of total billed charges,Default if not in Fee Schedule,104.65,65,,104.65,percent of total billed charges,Default if not in Fee Schedule,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,133.63,
HEMODIALYSIS ONE EVALUATION,90935,CPT,,68090935,CDM,821,RC,,,both,,,2133,1578.43,,,1578.43,Other,150% of Medicare + 9.63% HCRA Surcharge,959.85,45,,959.85,percent of total billed charges,Critical Access Hospital RCC factor,289.33,,,289.33,Fee Schedule,,260.61,,,260.61,Fee Schedule,,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1055.84,,,1055.84,Other,110% of Medicare,1450.44,68,,1450.44,percent of total billed charges,All Other,384,,,384,Other,186% of Medicaid,1706.4,,,1706.4,Other,Non Covered Service,1770.39,,,1770.39,Other,Non Covered Service,1770.39,,,1770.39,Other,Non Covered Service,1706.4,,,1706.4,Other,Non Covered Service,1770.39,,,1770.39,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1493.1,70,,1493.1,percent of total billed charges,All Other,1211,,,1211,Case Rate,,1029,,,1029,Case Rate,,743,,,743,Case Rate,,669,,,669,Case Rate,,743,,,743,Case Rate,,631,,,631,Case Rate,,206.35,,,206.35,Other,100% of Medicaid,206.35,,,206.35,Other,100% of Medicaid,206.35,,,206.35,Other,100% of Medicaid,206.35,,,206.35,Other,100% of Medicaid,464.3,,,464.3,Other,225% of Medicaid,315.72,,,315.72,Other,153% of Medicaid,464.3,,,464.3,Other,225% of Medicaid,288.9,,,288.9,Other,140% of Medicaid,464.3,,,464.3,Other,225% of Medicaid,536.52,,,536.52,Other,260% of Medicaid,668.59,,,668.59,Other,324% of Medicaid,443.66,,,443.66,Other,215% of Medicaid,443.66,,,443.66,Other,215% of Medicaid,257.94,,,257.94,Other,125% of Medicaid,0.01,1770.39,
HEMODIALYSIS OP,90937,CPT,,68090937,CDM,821,RC,,,both,,,1821,1347.54,,,1347.54,Other,150% of Medicare + 9.63% HCRA Surcharge,819.45,45,,819.45,percent of total billed charges,Critical Access Hospital RCC factor,416.27,,,416.27,Fee Schedule,,374.96,,,374.96,Fee Schedule,,1750,,,1750,Case Rate,Hemodialysis Per Visit,1575,,,1575,Case Rate,Hemodialysis Per Visit,1488,,,1488,Case Rate,Hemodialysis Per Visit,901.4,,,901.4,Other,110% of Medicare,1238.28,68,,1238.28,percent of total billed charges,All Other,384,,,384,Other,186% of Medicaid,1456.8,,,1456.8,Case Rate,Hemodialysis Per Visit,2029,,,2029,Case Rate,Hemodialysis Per Visit,2029,,,2029,Case Rate,Hemodialysis Per Visit,1456.8,,,1456.8,Case Rate,Hemodialysis Per Visit,2029,,,2029,Case Rate,Hemodialysis Per Visit,1778,,,1778,Case Rate,Hemodialysis Per Visit,1274.7,70,,1274.7,percent of total billed charges,All Other,1211,,,1211,Case Rate,Hemodialysis Per Visit,1029,,,1029,Case Rate,Hemodialysis Per Visit,743,,,743,Case Rate,Hemodialysis Per Visit,669,,,669,Case Rate,Hemodialysis Per Visit,743,,,743,Case Rate,Hemodialysis Per Visit,631,,,631,Case Rate,Hemodialysis Per Visit,206.35,,,206.35,Other,100% of Medicaid,206.35,,,206.35,Other,100% of Medicaid,206.35,,,206.35,Other,100% of Medicaid,206.35,,,206.35,Other,100% of Medicaid,464.3,,,464.3,Other,225% of Medicaid,315.72,,,315.72,Other,153% of Medicaid,464.3,,,464.3,Other,225% of Medicaid,288.9,,,288.9,Other,140% of Medicaid,464.3,,,464.3,Other,225% of Medicaid,536.52,,,536.52,Other,260% of Medicaid,668.59,,,668.59,Other,324% of Medicaid,443.66,,,443.66,Other,215% of Medicaid,443.66,,,443.66,Other,215% of Medicaid,257.94,,,257.94,Other,125% of Medicaid,206.35,2029,
EMERG DIALYSIS ESRD PT,G0257,HCPCS,,68000007,CDM,880,RC,,,both,,,2217,1640.59,,,1640.59,Other,150% of Medicare + 9.63% HCRA Surcharge,997.65,45,,997.65,percent of total billed charges,Critical Access Hospital RCC factor,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1097.42,,,1097.42,Other,110% of Medicare,1507.56,68,,1507.56,percent of total billed charges,All Other,384,,,384,Other,186% of Medicaid,1773.6,,,1773.6,Other,Non Covered Service,1840.11,,,1840.11,Other,Non Covered Service,1840.11,,,1840.11,Other,Non Covered Service,1773.6,,,1773.6,Other,Non Covered Service,1840.11,,,1840.11,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,1551.9,70,,1551.9,percent of total billed charges,All Other,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,0.01,,,0.01,Other,Non Covered Service,206.35,,,206.35,Other,100% of Medicaid,206.35,,,206.35,Other,100% of Medicaid,206.35,,,206.35,Other,100% of Medicaid,206.35,,,206.35,Other,100% of Medicaid,464.3,,,464.3,Other,225% of Medicaid,315.72,,,315.72,Other,153% of Medicaid,464.3,,,464.3,Other,225% of Medicaid,288.9,,,288.9,Other,140% of Medicaid,464.3,,,464.3,Other,225% of Medicaid,536.52,,,536.52,Other,260% of Medicaid,668.59,,,668.59,Other,324% of Medicaid,443.66,,,443.66,Other,215% of Medicaid,443.66,,,443.66,Other,215% of Medicaid,257.94,,,257.94,Other,125% of Medicaid,0.01,1840.11,
PSYCH DIAGNOSTIC EVALUATION,90791,CPT,,36090791,CDM,900,RC,,,both,,,399,295.26,,,295.26,Other,150% of Medicare + 9.63% HCRA Surcharge,179.55,45,,179.55,percent of total billed charges,Critical Access Hospital RCC factor,259.35,65,,259.35,percent of total billed charges,All Other,235.41,65,,235.41,percent of total billed charges,All Other,190,,,190,Fee Schedule,Behavioral Health,171,,,171,Fee Schedule,Behavioral Health,162,,,162,Fee Schedule,Behavioral Health,197.51,,,197.51,Other,110% of Medicare,230.13,,,230.13,Fee Schedule,Behavioral Health,291,,,291,Other,186% of Medicaid,230.13,,,230.13,Fee Schedule,Behavioral Health,230.13,,,230.13,Fee Schedule,Behavioral Health,230.13,,,230.13,Fee Schedule,Behavioral Health,230.13,,,230.13,Fee Schedule,Behavioral Health,230.13,,,230.13,Fee Schedule,Behavioral Health,319.2,80,,319.2,percent of total billed charges,All Other,279.3,70,,279.3,percent of total billed charges,All Other,217,,,217,Fee Schedule,Behavioral Health,184,,,184,Fee Schedule,Behavioral Health,139.73,,,139.73,Fee Schedule,Behavioral Health,139.73,,,139.73,Fee Schedule,Behavioral Health,139.73,,,139.73,Fee Schedule,Behavioral Health,139.73,,,139.73,Fee Schedule,Behavioral Health,156.36,,,156.36,Other,100% of Medicaid,156.36,,,156.36,Other,100% of Medicaid,156.36,,,156.36,Other,100% of Medicaid,156.36,,,156.36,Other,100% of Medicaid,351.81,,,351.81,Other,225% of Medicaid,239.23,,,239.23,Other,153% of Medicaid,351.81,,,351.81,Other,225% of Medicaid,218.91,,,218.91,Other,140% of Medicaid,351.81,,,351.81,Other,225% of Medicaid,406.54,,,406.54,Other,260% of Medicaid,506.61,,,506.61,Other,324% of Medicaid,336.18,,,336.18,Other,215% of Medicaid,336.18,,,336.18,Other,215% of Medicaid,195.45,,,195.45,Other,125% of Medicaid,139.73,506.61,
EVAL WITH MED MANAGEMENT,90792,CPT,,36090792,CDM,900,RC,,,both,,,399,295.26,,,295.26,Other,150% of Medicare + 9.63% HCRA Surcharge,179.55,45,,179.55,percent of total billed charges,Critical Access Hospital RCC factor,259.35,65,,259.35,percent of total billed charges,All Other,235.41,65,,235.41,percent of total billed charges,All Other,190,,,190,Fee Schedule,Behavioral Health,171,,,171,Fee Schedule,Behavioral Health,162,,,162,Fee Schedule,Behavioral Health,197.51,,,197.51,Other,110% of Medicare,265.07,,,265.07,Fee Schedule,Behavioral Health,291,,,291,Other,186% of Medicaid,265.07,,,265.07,Fee Schedule,Behavioral Health,265.07,,,265.07,Fee Schedule,Behavioral Health,265.07,,,265.07,Fee Schedule,Behavioral Health,265.07,,,265.07,Fee Schedule,Behavioral Health,265.07,,,265.07,Fee Schedule,Behavioral Health,319.2,80,,319.2,percent of total billed charges,All Other,279.3,70,,279.3,percent of total billed charges,All Other,217,,,217,Fee Schedule,Behavioral Health,184,,,184,Fee Schedule,Behavioral Health,139.73,,,139.73,Fee Schedule,Behavioral Health,139.73,,,139.73,Fee Schedule,Behavioral Health,139.73,,,139.73,Fee Schedule,Behavioral Health,139.73,,,139.73,Fee Schedule,Behavioral Health,156.36,,,156.36,Other,100% of Medicaid,156.36,,,156.36,Other,100% of Medicaid,156.36,,,156.36,Other,100% of Medicaid,156.36,,,156.36,Other,100% of Medicaid,351.81,,,351.81,Other,225% of Medicaid,239.23,,,239.23,Other,153% of Medicaid,351.81,,,351.81,Other,225% of Medicaid,218.91,,,218.91,Other,140% of Medicaid,351.81,,,351.81,Other,225% of Medicaid,406.54,,,406.54,Other,260% of Medicaid,506.61,,,506.61,Other,324% of Medicaid,336.18,,,336.18,Other,215% of Medicaid,336.18,,,336.18,Other,215% of Medicaid,195.45,,,195.45,Other,125% of Medicaid,139.73,506.61,
OFFICE/OUTPAT VISIT NEW 15 MIN,99202,CPT,,36099202,CDM,900,RC,,,both,,,252,186.48,,,186.48,Other,150% of Medicare + 9.63% HCRA Surcharge,113.4,45,,113.4,percent of total billed charges,Critical Access Hospital RCC factor,163.8,65,,163.8,percent of total billed charges,All Other,148.68,65,,148.68,percent of total billed charges,All Other,156.24,62,,156.24,percent of total billed charges,Behavioral Health,146.16,56,,146.16,percent of total billed charges,Behavioral Health,141.12,53,,141.12,percent of total billed charges,Behavioral Health,124.74,,,124.74,Other,110% of Medicare,171.36,68,,171.36,percent of total billed charges,All Other,0.01,,,0.01,Other,186% of Medicaid,201.6,,,201.6,percent of total billed charges,All Other,209.16,83,,209.16,percent of total billed charges,All Other,209.16,83,,209.16,percent of total billed charges,All Other,201.6,80,,201.6,percent of total billed charges,All Other,209.16,83,,209.16,percent of total billed charges,All Other,201.6,80,,201.6,percent of total billed charges,All Other,64.56,70,,64.56,percent of total billed charges,All Other,64.56,,,64.56,Other,130% of Medicare,64.56,,,64.56,Other,130% of Medicare,23.95,,,23.95,Fee Schedule,Behavioral Health,23.95,,,23.95,Fee Schedule,Behavioral Health,23.95,,,23.95,Fee Schedule,Behavioral Health,23.95,,,23.95,Fee Schedule,Behavioral Health,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,209.16,
OFFICE/OUTPAT VISIT NEW 30 MIN,99203,CPT,,36099203,CDM,900,RC,,,both,,,345,255.3,,,255.3,Other,150% of Medicare + 9.63% HCRA Surcharge,155.25,45,,155.25,percent of total billed charges,Critical Access Hospital RCC factor,224.25,65,,224.25,percent of total billed charges,All Other,203.55,65,,203.55,percent of total billed charges,All Other,213.9,62,,213.9,percent of total billed charges,Behavioral Health,200.1,56,,200.1,percent of total billed charges,Behavioral Health,193.2,53,,193.2,percent of total billed charges,Behavioral Health,170.78,,,170.78,Other,110% of Medicare,234.6,68,,234.6,percent of total billed charges,All Other,0.01,,,0.01,Other,186% of Medicaid,276,,,276,percent of total billed charges,All Other,286.35,83,,286.35,percent of total billed charges,All Other,286.35,83,,286.35,percent of total billed charges,All Other,276,80,,276,percent of total billed charges,All Other,286.35,83,,286.35,percent of total billed charges,All Other,276,80,,276,percent of total billed charges,All Other,241.5,70,,241.5,percent of total billed charges,All Other,111.9,,,111.9,Other,130% of Medicare,111.9,,,111.9,Other,130% of Medicare,41.89,,,41.89,Fee Schedule,Behavioral Health,41.89,,,41.89,Fee Schedule,Behavioral Health,41.89,,,41.89,Fee Schedule,Behavioral Health,41.89,,,41.89,Fee Schedule,Behavioral Health,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,286.35,
OFFICE/OUTPAT VISIT NEW 45 MIN,99204,CPT,,36099204,CDM,900,RC,,,both,,,460,340.4,,,340.4,Other,150% of Medicare + 9.63% HCRA Surcharge,207,45,,207,percent of total billed charges,Critical Access Hospital RCC factor,299,65,,299,percent of total billed charges,All Other,271.4,65,,271.4,percent of total billed charges,All Other,285.2,62,,285.2,percent of total billed charges,Behavioral Health,266.8,56,,266.8,percent of total billed charges,Behavioral Health,257.6,53,,257.6,percent of total billed charges,Behavioral Health,227.7,,,227.7,Other,110% of Medicare,312.8,68,,312.8,percent of total billed charges,All Other,0.01,,,0.01,Other,186% of Medicaid,368,,,368,percent of total billed charges,All Other,381.8,83,,381.8,percent of total billed charges,All Other,381.8,83,,381.8,percent of total billed charges,All Other,368,80,,368,percent of total billed charges,All Other,381.8,83,,381.8,percent of total billed charges,All Other,368,80,,368,percent of total billed charges,All Other,322,70,,322,percent of total billed charges,All Other,181.94,,,181.94,Other,130% of Medicare,181.94,,,181.94,Other,130% of Medicare,68.97,,,68.97,Fee Schedule,Behavioral Health,68.97,,,68.97,Fee Schedule,Behavioral Health,68.97,,,68.97,Fee Schedule,Behavioral Health,68.97,,,68.97,Fee Schedule,Behavioral Health,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,381.8,
OFFICE/OUTPAT VISIT NEW 60 MIN,99205,CPT,,36099205,CDM,900,RC,,,both,,,628,464.72,,,464.72,Other,150% of Medicare + 9.63% HCRA Surcharge,282.6,45,,282.6,percent of total billed charges,Critical Access Hospital RCC factor,408.2,65,,408.2,percent of total billed charges,All Other,370.52,65,,370.52,percent of total billed charges,All Other,389.36,62,,389.36,percent of total billed charges,Behavioral Health,364.24,56,,364.24,percent of total billed charges,Behavioral Health,351.68,53,,351.68,percent of total billed charges,Behavioral Health,310.86,,,310.86,Other,110% of Medicare,427.04,68,,427.04,percent of total billed charges,All Other,0.01,,,0.01,Other,186% of Medicaid,502.4,,,502.4,percent of total billed charges,All Other,521.24,83,,521.24,percent of total billed charges,All Other,521.24,83,,521.24,percent of total billed charges,All Other,502.4,80,,502.4,percent of total billed charges,All Other,521.24,83,,521.24,percent of total billed charges,All Other,502.4,80,,502.4,percent of total billed charges,All Other,439.6,70,,439.6,percent of total billed charges,All Other,247.59,,,247.59,Other,130% of Medicare,247.59,,,247.59,Other,130% of Medicare,98.55,,,98.55,Fee Schedule,Behavioral Health,98.55,,,98.55,Fee Schedule,Behavioral Health,98.55,,,98.55,Fee Schedule,Behavioral Health,98.55,,,98.55,Fee Schedule,Behavioral Health,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,521.24,
OFFICE/OUTPAT VISIT EST 5 MIN,99211,CPT,,36099211,CDM,900,RC,,,both,,,228,168.72,,,168.72,Other,150% of Medicare + 9.63% HCRA Surcharge,102.6,45,,102.6,percent of total billed charges,Critical Access Hospital RCC factor,148.2,65,,148.2,percent of total billed charges,All Other,134.52,65,,134.52,percent of total billed charges,All Other,141.36,62,,141.36,percent of total billed charges,Behavioral Health,132.24,56,,132.24,percent of total billed charges,Behavioral Health,127.68,53,,127.68,percent of total billed charges,Behavioral Health,112.86,,,112.86,Other,110% of Medicare,155.04,68,,155.04,percent of total billed charges,All Other,0.01,,,0.01,Other,186% of Medicaid,182.4,,,182.4,percent of total billed charges,All Other,189.24,83,,189.24,percent of total billed charges,All Other,189.24,83,,189.24,percent of total billed charges,All Other,182.4,80,,182.4,percent of total billed charges,All Other,189.24,83,,189.24,percent of total billed charges,All Other,182.4,80,,182.4,percent of total billed charges,All Other,159.6,70,,159.6,percent of total billed charges,All Other,52,,,52,Fee Schedule,Behavioral Health,44,,,44,Fee Schedule,Behavioral Health,48.23,,,48.23,Fee Schedule,Behavioral Health,48.23,,,48.23,Fee Schedule,Behavioral Health,48.23,,,48.23,Fee Schedule,Behavioral Health,48.23,,,48.23,Fee Schedule,Behavioral Health,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,189.24,
OFFICE/OUTPAT VISIT EST 10 MIN,99212,CPT,,36099212,CDM,900,RC,,,both,,,259,191.66,,,191.66,Other,150% of Medicare + 9.63% HCRA Surcharge,116.55,45,,116.55,percent of total billed charges,Critical Access Hospital RCC factor,168.35,65,,168.35,percent of total billed charges,All Other,152.81,65,,152.81,percent of total billed charges,All Other,160.58,62,,160.58,percent of total billed charges,Behavioral Health,150.22,56,,150.22,percent of total billed charges,Behavioral Health,145.04,53,,145.04,percent of total billed charges,Behavioral Health,128.21,,,128.21,Other,110% of Medicare,176.12,68,,176.12,percent of total billed charges,All Other,0.01,,,0.01,Other,186% of Medicaid,207.2,,,207.2,percent of total billed charges,All Other,214.97,83,,214.97,percent of total billed charges,All Other,214.97,83,,214.97,percent of total billed charges,All Other,207.2,80,,207.2,percent of total billed charges,All Other,214.97,83,,214.97,percent of total billed charges,All Other,207.2,80,,207.2,percent of total billed charges,All Other,181.3,70,,181.3,percent of total billed charges,All Other,97,,,97,Fee Schedule,Behavioral Health,82,,,82,Fee Schedule,Behavioral Health,55.27,,,55.27,Fee Schedule,Behavioral Health,55.27,,,55.27,Fee Schedule,Behavioral Health,55.27,,,55.27,Fee Schedule,Behavioral Health,55.27,,,55.27,Fee Schedule,Behavioral Health,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,214.97,
OFFICE/OUTPAT VISIT EST 20 MIN,99213,CPT,,36099213,CDM,900,RC,,,both,,,259,191.66,,,191.66,Other,150% of Medicare + 9.63% HCRA Surcharge,116.55,45,,116.55,percent of total billed charges,Critical Access Hospital RCC factor,168.35,65,,168.35,percent of total billed charges,All Other,152.81,65,,152.81,percent of total billed charges,All Other,160.58,62,,160.58,percent of total billed charges,Behavioral Health,150.22,56,,150.22,percent of total billed charges,Behavioral Health,145.04,53,,145.04,percent of total billed charges,Behavioral Health,128.21,,,128.21,Other,110% of Medicare,176.12,68,,176.12,percent of total billed charges,All Other,0.01,,,0.01,Other,186% of Medicaid,207.2,,,207.2,percent of total billed charges,All Other,214.97,83,,214.97,percent of total billed charges,All Other,214.97,83,,214.97,percent of total billed charges,All Other,207.2,80,,207.2,percent of total billed charges,All Other,214.97,83,,214.97,percent of total billed charges,All Other,207.2,80,,207.2,percent of total billed charges,All Other,181.3,70,,181.3,percent of total billed charges,All Other,115,,,115,Fee Schedule,Behavioral Health,98,,,98,Fee Schedule,Behavioral Health,55.27,,,55.27,Fee Schedule,Behavioral Health,55.27,,,55.27,Fee Schedule,Behavioral Health,55.27,,,55.27,Fee Schedule,Behavioral Health,55.27,,,55.27,Fee Schedule,Behavioral Health,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,214.97,
OFFICE/OUTPAT VISIT EST 30 MIN,99214,CPT,,36099214,CDM,900,RC,,,both,,,340,251.6,,,251.6,Other,150% of Medicare + 9.63% HCRA Surcharge,153,45,,153,percent of total billed charges,Critical Access Hospital RCC factor,221,65,,221,percent of total billed charges,All Other,200.6,65,,200.6,percent of total billed charges,All Other,210.8,62,,210.8,percent of total billed charges,Behavioral Health,197.2,56,,197.2,percent of total billed charges,Behavioral Health,190.4,53,,190.4,percent of total billed charges,Behavioral Health,168.3,,,168.3,Other,110% of Medicare,231.2,68,,231.2,percent of total billed charges,All Other,0.01,,,0.01,Other,186% of Medicaid,272,,,272,percent of total billed charges,All Other,282.2,83,,282.2,percent of total billed charges,All Other,282.2,83,,282.2,percent of total billed charges,All Other,272,80,,272,percent of total billed charges,All Other,282.2,83,,282.2,percent of total billed charges,All Other,272,80,,272,percent of total billed charges,All Other,238,70,,238,percent of total billed charges,All Other,130,,,130,Fee Schedule,Behavioral Health,111,,,111,Fee Schedule,Behavioral Health,77.42,,,77.42,Fee Schedule,Behavioral Health,77.42,,,77.42,Fee Schedule,Behavioral Health,77.42,,,77.42,Fee Schedule,Behavioral Health,77.42,,,77.42,Fee Schedule,Behavioral Health,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,282.2,
OFFICE/OUTPAT VISIT EST 40 MIN,99215,CPT,,36099215,CDM,900,RC,,,both,,,440,325.6,,,325.6,Other,150% of Medicare + 9.63% HCRA Surcharge,198,45,,198,percent of total billed charges,Critical Access Hospital RCC factor,286,65,,286,percent of total billed charges,All Other,259.6,65,,259.6,percent of total billed charges,All Other,272.8,62,,272.8,percent of total billed charges,Behavioral Health,255.2,56,,255.2,percent of total billed charges,Behavioral Health,246.4,53,,246.4,percent of total billed charges,Behavioral Health,217.8,,,217.8,Other,110% of Medicare,299.2,68,,299.2,percent of total billed charges,All Other,0.01,,,0.01,Other,186% of Medicaid,352,,,352,percent of total billed charges,All Other,365.2,83,,365.2,percent of total billed charges,All Other,365.2,83,,365.2,percent of total billed charges,All Other,352,80,,352,percent of total billed charges,All Other,365.2,83,,365.2,percent of total billed charges,All Other,352,80,,352,percent of total billed charges,All Other,308,70,,308,percent of total billed charges,All Other,209,,,209,Fee Schedule,Behavioral Health,178,,,178,Fee Schedule,Behavioral Health,114.4,,,114.4,Fee Schedule,Behavioral Health,114.4,,,114.4,Fee Schedule,Behavioral Health,114.4,,,114.4,Fee Schedule,Behavioral Health,114.4,,,114.4,Fee Schedule,Behavioral Health,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,365.2,
OFFICE/OUTPAT VISIT EST 5 MIN 25 MOD,99211,CPT,25,36199211,CDM,900,RC,,,both,,,228,168.72,,,168.72,Other,150% of Medicare + 9.63% HCRA Surcharge,102.6,45,,102.6,percent of total billed charges,Critical Access Hospital RCC factor,148.2,65,,148.2,percent of total billed charges,All Other,134.52,65,,134.52,percent of total billed charges,All Other,141.36,62,,141.36,percent of total billed charges,Behavioral Health,132.24,56,,132.24,percent of total billed charges,Behavioral Health,127.68,53,,127.68,percent of total billed charges,Behavioral Health,112.86,,,112.86,Other,110% of Medicare,155.04,68,,155.04,percent of total billed charges,All Other,0.01,,,0.01,Other,186% of Medicaid,182.4,,,182.4,percent of total billed charges,All Other,189.24,83,,189.24,percent of total billed charges,All Other,189.24,83,,189.24,percent of total billed charges,All Other,182.4,80,,182.4,percent of total billed charges,All Other,189.24,83,,189.24,percent of total billed charges,All Other,182.4,80,,182.4,percent of total billed charges,All Other,159.6,70,,159.6,percent of total billed charges,All Other,52,,,52,Fee Schedule,Behavioral Health,44,,,44,Fee Schedule,Behavioral Health,48.23,,,48.23,Fee Schedule,Behavioral Health,48.23,,,48.23,Fee Schedule,Behavioral Health,48.23,,,48.23,Fee Schedule,Behavioral Health,48.23,,,48.23,Fee Schedule,Behavioral Health,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,189.24,
OFFICE/OUTPAT VISIT EST 10 MIN 25 MOD,99212,CPT,25,36199212,CDM,900,RC,,,both,,,259,191.66,,,191.66,Other,150% of Medicare + 9.63% HCRA Surcharge,116.55,45,,116.55,percent of total billed charges,Critical Access Hospital RCC factor,168.35,65,,168.35,percent of total billed charges,All Other,152.81,65,,152.81,percent of total billed charges,All Other,160.58,62,,160.58,percent of total billed charges,Behavioral Health,150.22,56,,150.22,percent of total billed charges,Behavioral Health,145.04,53,,145.04,percent of total billed charges,Behavioral Health,128.21,,,128.21,Other,110% of Medicare,176.12,68,,176.12,percent of total billed charges,All Other,0.01,,,0.01,Other,186% of Medicaid,207.2,,,207.2,percent of total billed charges,All Other,214.97,83,,214.97,percent of total billed charges,All Other,214.97,83,,214.97,percent of total billed charges,All Other,207.2,80,,207.2,percent of total billed charges,All Other,214.97,83,,214.97,percent of total billed charges,All Other,207.2,80,,207.2,percent of total billed charges,All Other,181.3,70,,181.3,percent of total billed charges,All Other,97,,,97,Fee Schedule,Behavioral Health,82,,,82,Fee Schedule,Behavioral Health,55.27,,,55.27,Fee Schedule,Behavioral Health,55.27,,,55.27,Fee Schedule,Behavioral Health,55.27,,,55.27,Fee Schedule,Behavioral Health,55.27,,,55.27,Fee Schedule,Behavioral Health,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,214.97,
OFFICE/OUTPAT VISIT EST 20 MIN 25 MOD,99213,CPT,25,36199213,CDM,900,RC,,,both,,,259,191.66,,,191.66,Other,150% of Medicare + 9.63% HCRA Surcharge,116.55,45,,116.55,percent of total billed charges,Critical Access Hospital RCC factor,168.35,65,,168.35,percent of total billed charges,All Other,152.81,65,,152.81,percent of total billed charges,All Other,160.58,62,,160.58,percent of total billed charges,Behavioral Health,150.22,56,,150.22,percent of total billed charges,Behavioral Health,145.04,53,,145.04,percent of total billed charges,Behavioral Health,128.21,,,128.21,Other,110% of Medicare,176.12,68,,176.12,percent of total billed charges,All Other,0.01,,,0.01,Other,186% of Medicaid,207.2,,,207.2,percent of total billed charges,All Other,214.97,83,,214.97,percent of total billed charges,All Other,214.97,83,,214.97,percent of total billed charges,All Other,207.2,80,,207.2,percent of total billed charges,All Other,214.97,83,,214.97,percent of total billed charges,All Other,207.2,80,,207.2,percent of total billed charges,All Other,181.3,70,,181.3,percent of total billed charges,All Other,115,,,115,Fee Schedule,Behavioral Health,98,,,98,Fee Schedule,Behavioral Health,55.27,,,55.27,Fee Schedule,Behavioral Health,55.27,,,55.27,Fee Schedule,Behavioral Health,55.27,,,55.27,Fee Schedule,Behavioral Health,55.27,,,55.27,Fee Schedule,Behavioral Health,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,214.97,
OFFICE/OUTPAT VISIT EST 30 MIN 25 MOD,99214,CPT,25,36199214,CDM,900,RC,,,both,,,340,251.6,,,251.6,Other,150% of Medicare + 9.63% HCRA Surcharge,153,45,,153,percent of total billed charges,Critical Access Hospital RCC factor,221,65,,221,percent of total billed charges,All Other,200.6,65,,200.6,percent of total billed charges,All Other,210.8,62,,210.8,percent of total billed charges,Behavioral Health,197.2,56,,197.2,percent of total billed charges,Behavioral Health,190.4,53,,190.4,percent of total billed charges,Behavioral Health,168.3,,,168.3,Other,110% of Medicare,231.2,68,,231.2,percent of total billed charges,All Other,0.01,,,0.01,Other,186% of Medicaid,272,,,272,percent of total billed charges,All Other,282.2,83,,282.2,percent of total billed charges,All Other,282.2,83,,282.2,percent of total billed charges,All Other,272,80,,272,percent of total billed charges,All Other,282.2,83,,282.2,percent of total billed charges,All Other,272,80,,272,percent of total billed charges,All Other,238,70,,238,percent of total billed charges,All Other,130,,,130,Fee Schedule,Behavioral Health,111,,,111,Fee Schedule,Behavioral Health,77.42,,,77.42,Fee Schedule,Behavioral Health,77.42,,,77.42,Fee Schedule,Behavioral Health,77.42,,,77.42,Fee Schedule,Behavioral Health,77.42,,,77.42,Fee Schedule,Behavioral Health,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,282.2,
OFFICE/OUTPAT VISIT EST 40 MIN 25 MOD,99215,CPT,25,36199215,CDM,900,RC,,,both,,,440,325.6,,,325.6,Other,150% of Medicare + 9.63% HCRA Surcharge,198,45,,198,percent of total billed charges,Critical Access Hospital RCC factor,286,65,,286,percent of total billed charges,All Other,259.6,65,,259.6,percent of total billed charges,All Other,272.8,62,,272.8,percent of total billed charges,Behavioral Health,255.2,56,,255.2,percent of total billed charges,Behavioral Health,246.4,53,,246.4,percent of total billed charges,Behavioral Health,217.8,,,217.8,Other,110% of Medicare,299.2,68,,299.2,percent of total billed charges,All Other,0.01,,,0.01,Other,186% of Medicaid,352,,,352,percent of total billed charges,All Other,365.2,83,,365.2,percent of total billed charges,All Other,365.2,83,,365.2,percent of total billed charges,All Other,352,80,,352,percent of total billed charges,All Other,365.2,83,,365.2,percent of total billed charges,All Other,352,80,,352,percent of total billed charges,All Other,308,70,,308,percent of total billed charges,All Other,209,,,209,Fee Schedule,Behavioral Health,178,,,178,Fee Schedule,Behavioral Health,114.4,,,114.4,Fee Schedule,Behavioral Health,114.4,,,114.4,Fee Schedule,Behavioral Health,114.4,,,114.4,Fee Schedule,Behavioral Health,114.4,,,114.4,Fee Schedule,Behavioral Health,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,365.2,
TH-PSYCH DIAGNOSTIC EVALUATION,90791,CPT,95,36490791,CDM,900,RC,,,both,,,399,295.26,,,295.26,Other,150% of Medicare + 9.63% HCRA Surcharge,179.55,45,,179.55,percent of total billed charges,Critical Access Hospital RCC factor,259.35,65,,259.35,percent of total billed charges,All Other,235.41,65,,235.41,percent of total billed charges,All Other,190,,,190,Fee Schedule,Behavioral Health,171,,,171,Fee Schedule,Behavioral Health,162,,,162,Fee Schedule,Behavioral Health,197.51,,,197.51,Other,110% of Medicare,230.13,,,230.13,Fee Schedule,Behavioral Health,291,,,291,Other,186% of Medicaid,230.13,,,230.13,Fee Schedule,Behavioral Health,230.13,,,230.13,Fee Schedule,Behavioral Health,230.13,,,230.13,Fee Schedule,Behavioral Health,230.13,,,230.13,Fee Schedule,Behavioral Health,230.13,,,230.13,Fee Schedule,Behavioral Health,319.2,80,,319.2,percent of total billed charges,All Other,279.3,70,,279.3,percent of total billed charges,All Other,217,,,217,Fee Schedule,Behavioral Health,184,,,184,Fee Schedule,Behavioral Health,139.73,,,139.73,Fee Schedule,Behavioral Health,139.73,,,139.73,Fee Schedule,Behavioral Health,139.73,,,139.73,Fee Schedule,Behavioral Health,139.73,,,139.73,Fee Schedule,Behavioral Health,156.36,,,156.36,Other,100% of Medicaid,156.36,,,156.36,Other,100% of Medicaid,156.36,,,156.36,Other,100% of Medicaid,156.36,,,156.36,Other,100% of Medicaid,351.81,,,351.81,Other,225% of Medicaid,239.23,,,239.23,Other,153% of Medicaid,351.81,,,351.81,Other,225% of Medicaid,218.91,,,218.91,Other,140% of Medicaid,351.81,,,351.81,Other,225% of Medicaid,406.54,,,406.54,Other,260% of Medicaid,506.61,,,506.61,Other,324% of Medicaid,336.18,,,336.18,Other,215% of Medicaid,336.18,,,336.18,Other,215% of Medicaid,195.45,,,195.45,Other,125% of Medicaid,139.73,506.61,
TH- EVAL WITH MED MANAGEMENT,90792,CPT,95,36490792,CDM,900,RC,,,both,,,399,295.26,,,295.26,Other,150% of Medicare + 9.63% HCRA Surcharge,179.55,45,,179.55,percent of total billed charges,Critical Access Hospital RCC factor,259.35,65,,259.35,percent of total billed charges,All Other,235.41,65,,235.41,percent of total billed charges,All Other,190,,,190,Fee Schedule,Behavioral Health,171,,,171,Fee Schedule,Behavioral Health,162,,,162,Fee Schedule,Behavioral Health,197.51,,,197.51,Other,110% of Medicare,265.07,,,265.07,Fee Schedule,Behavioral Health,291,,,291,Other,186% of Medicaid,265.07,,,265.07,Fee Schedule,Behavioral Health,265.07,,,265.07,Fee Schedule,Behavioral Health,265.07,,,265.07,Fee Schedule,Behavioral Health,265.07,,,265.07,Fee Schedule,Behavioral Health,265.07,,,265.07,Fee Schedule,Behavioral Health,319.2,80,,319.2,percent of total billed charges,All Other,279.3,70,,279.3,percent of total billed charges,All Other,217,,,217,Fee Schedule,Behavioral Health,184,,,184,Fee Schedule,Behavioral Health,139.73,,,139.73,Fee Schedule,Behavioral Health,139.73,,,139.73,Fee Schedule,Behavioral Health,139.73,,,139.73,Fee Schedule,Behavioral Health,139.73,,,139.73,Fee Schedule,Behavioral Health,156.36,,,156.36,Other,100% of Medicaid,156.36,,,156.36,Other,100% of Medicaid,156.36,,,156.36,Other,100% of Medicaid,156.36,,,156.36,Other,100% of Medicaid,351.81,,,351.81,Other,225% of Medicaid,239.23,,,239.23,Other,153% of Medicaid,351.81,,,351.81,Other,225% of Medicaid,218.91,,,218.91,Other,140% of Medicaid,351.81,,,351.81,Other,225% of Medicaid,406.54,,,406.54,Other,260% of Medicaid,506.61,,,506.61,Other,324% of Medicaid,336.18,,,336.18,Other,215% of Medicaid,336.18,,,336.18,Other,215% of Medicaid,195.45,,,195.45,Other,125% of Medicaid,139.73,506.61,
TH-OFFICE/OUTPAT VISIT NEW 15 MIN,99202,CPT,95,36499202,CDM,900,RC,,,both,,,252,186.48,,,186.48,Other,150% of Medicare + 9.63% HCRA Surcharge,113.4,45,,113.4,percent of total billed charges,Critical Access Hospital RCC factor,163.8,65,,163.8,percent of total billed charges,All Other,148.68,65,,148.68,percent of total billed charges,All Other,156.24,62,,156.24,percent of total billed charges,Behavioral Health,146.16,56,,146.16,percent of total billed charges,Behavioral Health,141.12,53,,141.12,percent of total billed charges,Behavioral Health,124.74,,,124.74,Other,110% of Medicare,171.36,68,,171.36,percent of total billed charges,All Other,0.01,,,0.01,Other,186% of Medicaid,201.6,,,201.6,percent of total billed charges,All Other,209.16,83,,209.16,percent of total billed charges,All Other,209.16,83,,209.16,percent of total billed charges,All Other,201.6,80,,201.6,percent of total billed charges,All Other,209.16,83,,209.16,percent of total billed charges,All Other,201.6,80,,201.6,percent of total billed charges,All Other,64.56,70,,64.56,percent of total billed charges,All Other,64.56,,,64.56,Other,130% of Medicare,64.56,,,64.56,Other,130% of Medicare,23.95,,,23.95,Fee Schedule,Behavioral Health,23.95,,,23.95,Fee Schedule,Behavioral Health,23.95,,,23.95,Fee Schedule,Behavioral Health,23.95,,,23.95,Fee Schedule,Behavioral Health,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,209.16,
TH-OFFICE/OUTPAT VISIT NEW 30 MIN,99203,CPT,95,36499203,CDM,900,RC,,,both,,,345,255.3,,,255.3,Other,150% of Medicare + 9.63% HCRA Surcharge,155.25,45,,155.25,percent of total billed charges,Critical Access Hospital RCC factor,224.25,65,,224.25,percent of total billed charges,All Other,203.55,65,,203.55,percent of total billed charges,All Other,213.9,62,,213.9,percent of total billed charges,Behavioral Health,200.1,56,,200.1,percent of total billed charges,Behavioral Health,193.2,53,,193.2,percent of total billed charges,Behavioral Health,170.78,,,170.78,Other,110% of Medicare,234.6,68,,234.6,percent of total billed charges,All Other,0.01,,,0.01,Other,186% of Medicaid,276,,,276,percent of total billed charges,All Other,286.35,83,,286.35,percent of total billed charges,All Other,286.35,83,,286.35,percent of total billed charges,All Other,276,80,,276,percent of total billed charges,All Other,286.35,83,,286.35,percent of total billed charges,All Other,276,80,,276,percent of total billed charges,All Other,241.5,70,,241.5,percent of total billed charges,All Other,111.9,,,111.9,Other,130% of Medicare,111.9,,,111.9,Other,130% of Medicare,41.89,,,41.89,Fee Schedule,Behavioral Health,41.89,,,41.89,Fee Schedule,Behavioral Health,41.89,,,41.89,Fee Schedule,Behavioral Health,41.89,,,41.89,Fee Schedule,Behavioral Health,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,286.35,
TH-OFFICE/OUTPAT VISIT NEW 45 MIN,99204,CPT,95,36499204,CDM,900,RC,,,both,,,460,340.4,,,340.4,Other,150% of Medicare + 9.63% HCRA Surcharge,207,45,,207,percent of total billed charges,Critical Access Hospital RCC factor,299,65,,299,percent of total billed charges,All Other,271.4,65,,271.4,percent of total billed charges,All Other,285.2,62,,285.2,percent of total billed charges,Behavioral Health,266.8,56,,266.8,percent of total billed charges,Behavioral Health,257.6,53,,257.6,percent of total billed charges,Behavioral Health,227.7,,,227.7,Other,110% of Medicare,312.8,68,,312.8,percent of total billed charges,All Other,0.01,,,0.01,Other,186% of Medicaid,368,,,368,percent of total billed charges,All Other,381.8,83,,381.8,percent of total billed charges,All Other,381.8,83,,381.8,percent of total billed charges,All Other,368,80,,368,percent of total billed charges,All Other,381.8,83,,381.8,percent of total billed charges,All Other,368,80,,368,percent of total billed charges,All Other,322,70,,322,percent of total billed charges,All Other,181.94,,,181.94,Other,130% of Medicare,181.94,,,181.94,Other,130% of Medicare,68.97,,,68.97,Fee Schedule,Behavioral Health,68.97,,,68.97,Fee Schedule,Behavioral Health,68.97,,,68.97,Fee Schedule,Behavioral Health,68.97,,,68.97,Fee Schedule,Behavioral Health,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,381.8,
TH-OFFICE/OUTPAT VISIT NEW 60 MIN,99205,CPT,95,36499205,CDM,900,RC,,,both,,,628,464.72,,,464.72,Other,150% of Medicare + 9.63% HCRA Surcharge,282.6,45,,282.6,percent of total billed charges,Critical Access Hospital RCC factor,408.2,65,,408.2,percent of total billed charges,All Other,370.52,65,,370.52,percent of total billed charges,All Other,389.36,62,,389.36,percent of total billed charges,Behavioral Health,364.24,56,,364.24,percent of total billed charges,Behavioral Health,351.68,53,,351.68,percent of total billed charges,Behavioral Health,310.86,,,310.86,Other,110% of Medicare,427.04,68,,427.04,percent of total billed charges,All Other,0.01,,,0.01,Other,186% of Medicaid,502.4,,,502.4,percent of total billed charges,All Other,521.24,83,,521.24,percent of total billed charges,All Other,521.24,83,,521.24,percent of total billed charges,All Other,502.4,80,,502.4,percent of total billed charges,All Other,521.24,83,,521.24,percent of total billed charges,All Other,502.4,80,,502.4,percent of total billed charges,All Other,439.6,70,,439.6,percent of total billed charges,All Other,247.59,,,247.59,Other,130% of Medicare,247.59,,,247.59,Other,130% of Medicare,98.55,,,98.55,Fee Schedule,Behavioral Health,98.55,,,98.55,Fee Schedule,Behavioral Health,98.55,,,98.55,Fee Schedule,Behavioral Health,98.55,,,98.55,Fee Schedule,Behavioral Health,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,521.24,
TH-OFFICE/OUTPAT VISIT EST 10 MIN 25 MOD,99212,CPT,2595,36499212,CDM,900,RC,,,both,,,259,191.66,,,191.66,Other,150% of Medicare + 9.63% HCRA Surcharge,116.55,45,,116.55,percent of total billed charges,Critical Access Hospital RCC factor,168.35,65,,168.35,percent of total billed charges,All Other,152.81,65,,152.81,percent of total billed charges,All Other,160.58,62,,160.58,percent of total billed charges,Behavioral Health,150.22,56,,150.22,percent of total billed charges,Behavioral Health,145.04,53,,145.04,percent of total billed charges,Behavioral Health,128.21,,,128.21,Other,110% of Medicare,176.12,68,,176.12,percent of total billed charges,All Other,0.01,,,0.01,Other,186% of Medicaid,207.2,,,207.2,percent of total billed charges,All Other,214.97,83,,214.97,percent of total billed charges,All Other,214.97,83,,214.97,percent of total billed charges,All Other,207.2,80,,207.2,percent of total billed charges,All Other,214.97,83,,214.97,percent of total billed charges,All Other,207.2,80,,207.2,percent of total billed charges,All Other,181.3,70,,181.3,percent of total billed charges,All Other,97,,,97,Fee Schedule,Behavioral Health,82,,,82,Fee Schedule,Behavioral Health,55.27,,,55.27,Fee Schedule,Behavioral Health,55.27,,,55.27,Fee Schedule,Behavioral Health,55.27,,,55.27,Fee Schedule,Behavioral Health,55.27,,,55.27,Fee Schedule,Behavioral Health,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,214.97,
TH-OFFICE/OUTPAT VISIT EST 20 MIN,99213,CPT,95,36499213,CDM,900,RC,,,both,,,259,191.66,,,191.66,Other,150% of Medicare + 9.63% HCRA Surcharge,116.55,45,,116.55,percent of total billed charges,Critical Access Hospital RCC factor,168.35,65,,168.35,percent of total billed charges,All Other,152.81,65,,152.81,percent of total billed charges,All Other,160.58,62,,160.58,percent of total billed charges,Behavioral Health,150.22,56,,150.22,percent of total billed charges,Behavioral Health,145.04,53,,145.04,percent of total billed charges,Behavioral Health,128.21,,,128.21,Other,110% of Medicare,176.12,68,,176.12,percent of total billed charges,All Other,0.01,,,0.01,Other,186% of Medicaid,207.2,,,207.2,percent of total billed charges,All Other,214.97,83,,214.97,percent of total billed charges,All Other,214.97,83,,214.97,percent of total billed charges,All Other,207.2,80,,207.2,percent of total billed charges,All Other,214.97,83,,214.97,percent of total billed charges,All Other,207.2,80,,207.2,percent of total billed charges,All Other,181.3,70,,181.3,percent of total billed charges,All Other,115,,,115,Fee Schedule,Behavioral Health,98,,,98,Fee Schedule,Behavioral Health,55.27,,,55.27,Fee Schedule,Behavioral Health,55.27,,,55.27,Fee Schedule,Behavioral Health,55.27,,,55.27,Fee Schedule,Behavioral Health,55.27,,,55.27,Fee Schedule,Behavioral Health,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,214.97,
TH-OFFICE/OUTPAT VISIT EST 30 MIN,99214,CPT,95,36499214,CDM,900,RC,,,both,,,340,251.6,,,251.6,Other,150% of Medicare + 9.63% HCRA Surcharge,153,45,,153,percent of total billed charges,Critical Access Hospital RCC factor,221,65,,221,percent of total billed charges,All Other,200.6,65,,200.6,percent of total billed charges,All Other,210.8,62,,210.8,percent of total billed charges,Behavioral Health,197.2,56,,197.2,percent of total billed charges,Behavioral Health,190.4,53,,190.4,percent of total billed charges,Behavioral Health,168.3,,,168.3,Other,110% of Medicare,231.2,68,,231.2,percent of total billed charges,All Other,0.01,,,0.01,Other,186% of Medicaid,272,,,272,percent of total billed charges,All Other,282.2,83,,282.2,percent of total billed charges,All Other,282.2,83,,282.2,percent of total billed charges,All Other,272,80,,272,percent of total billed charges,All Other,282.2,83,,282.2,percent of total billed charges,All Other,272,80,,272,percent of total billed charges,All Other,238,70,,238,percent of total billed charges,All Other,130,,,130,Fee Schedule,Behavioral Health,111,,,111,Fee Schedule,Behavioral Health,77.42,,,77.42,Fee Schedule,Behavioral Health,77.42,,,77.42,Fee Schedule,Behavioral Health,77.42,,,77.42,Fee Schedule,Behavioral Health,77.42,,,77.42,Fee Schedule,Behavioral Health,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,282.2,
TH-OFFICE/OUTPAT VISIT EST 40 MIN,99215,CPT,95,36499215,CDM,900,RC,,,both,,,440,325.6,,,325.6,Other,150% of Medicare + 9.63% HCRA Surcharge,198,45,,198,percent of total billed charges,Critical Access Hospital RCC factor,286,65,,286,percent of total billed charges,All Other,259.6,65,,259.6,percent of total billed charges,All Other,272.8,62,,272.8,percent of total billed charges,Behavioral Health,255.2,56,,255.2,percent of total billed charges,Behavioral Health,246.4,53,,246.4,percent of total billed charges,Behavioral Health,217.8,,,217.8,Other,110% of Medicare,299.2,68,,299.2,percent of total billed charges,All Other,0.01,,,0.01,Other,186% of Medicaid,352,,,352,percent of total billed charges,All Other,365.2,83,,365.2,percent of total billed charges,All Other,365.2,83,,365.2,percent of total billed charges,All Other,352,80,,352,percent of total billed charges,All Other,365.2,83,,365.2,percent of total billed charges,All Other,352,80,,352,percent of total billed charges,All Other,308,70,,308,percent of total billed charges,All Other,209,,,209,Fee Schedule,Behavioral Health,178,,,178,Fee Schedule,Behavioral Health,114.4,,,114.4,Fee Schedule,Behavioral Health,114.4,,,114.4,Fee Schedule,Behavioral Health,114.4,,,114.4,Fee Schedule,Behavioral Health,114.4,,,114.4,Fee Schedule,Behavioral Health,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,365.2,
TH-OFFICE/OUTPAT VISIT EST 10 MIN 25 MOD,99212,CPT,2595,36599212,CDM,900,RC,,,both,,,259,191.66,,,191.66,Other,150% of Medicare + 9.63% HCRA Surcharge,116.55,45,,116.55,percent of total billed charges,Critical Access Hospital RCC factor,168.35,65,,168.35,percent of total billed charges,All Other,152.81,65,,152.81,percent of total billed charges,All Other,160.58,62,,160.58,percent of total billed charges,Behavioral Health,150.22,56,,150.22,percent of total billed charges,Behavioral Health,145.04,53,,145.04,percent of total billed charges,Behavioral Health,128.21,,,128.21,Other,110% of Medicare,176.12,68,,176.12,percent of total billed charges,All Other,0.01,,,0.01,Other,186% of Medicaid,207.2,,,207.2,percent of total billed charges,All Other,214.97,83,,214.97,percent of total billed charges,All Other,214.97,83,,214.97,percent of total billed charges,All Other,207.2,80,,207.2,percent of total billed charges,All Other,214.97,83,,214.97,percent of total billed charges,All Other,207.2,80,,207.2,percent of total billed charges,All Other,181.3,70,,181.3,percent of total billed charges,All Other,97,,,97,Fee Schedule,Behavioral Health,82,,,82,Fee Schedule,Behavioral Health,55.27,,,55.27,Fee Schedule,Behavioral Health,55.27,,,55.27,Fee Schedule,Behavioral Health,55.27,,,55.27,Fee Schedule,Behavioral Health,55.27,,,55.27,Fee Schedule,Behavioral Health,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,214.97,
TH-OFFICE/OUTPAT VISIT EST 20 MIN 25 MOD,99213,CPT,2595,36599213,CDM,900,RC,,,both,,,259,191.66,,,191.66,Other,150% of Medicare + 9.63% HCRA Surcharge,116.55,45,,116.55,percent of total billed charges,Critical Access Hospital RCC factor,168.35,65,,168.35,percent of total billed charges,All Other,152.81,65,,152.81,percent of total billed charges,All Other,160.58,62,,160.58,percent of total billed charges,Behavioral Health,150.22,56,,150.22,percent of total billed charges,Behavioral Health,145.04,53,,145.04,percent of total billed charges,Behavioral Health,128.21,,,128.21,Other,110% of Medicare,176.12,68,,176.12,percent of total billed charges,All Other,0.01,,,0.01,Other,186% of Medicaid,207.2,,,207.2,percent of total billed charges,All Other,214.97,83,,214.97,percent of total billed charges,All Other,214.97,83,,214.97,percent of total billed charges,All Other,207.2,80,,207.2,percent of total billed charges,All Other,214.97,83,,214.97,percent of total billed charges,All Other,207.2,80,,207.2,percent of total billed charges,All Other,181.3,70,,181.3,percent of total billed charges,All Other,115,,,115,Fee Schedule,Behavioral Health,98,,,98,Fee Schedule,Behavioral Health,55.27,,,55.27,Fee Schedule,Behavioral Health,55.27,,,55.27,Fee Schedule,Behavioral Health,55.27,,,55.27,Fee Schedule,Behavioral Health,55.27,,,55.27,Fee Schedule,Behavioral Health,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,214.97,
TH-OFFICE/OUTPAT VISIT EST 30 MIN 25 MOD,99214,CPT,2595,36599214,CDM,900,RC,,,both,,,340,251.6,,,251.6,Other,150% of Medicare + 9.63% HCRA Surcharge,153,45,,153,percent of total billed charges,Critical Access Hospital RCC factor,221,65,,221,percent of total billed charges,All Other,200.6,65,,200.6,percent of total billed charges,All Other,210.8,62,,210.8,percent of total billed charges,Behavioral Health,197.2,56,,197.2,percent of total billed charges,Behavioral Health,190.4,53,,190.4,percent of total billed charges,Behavioral Health,168.3,,,168.3,Other,110% of Medicare,231.2,68,,231.2,percent of total billed charges,All Other,0.01,,,0.01,Other,186% of Medicaid,272,,,272,percent of total billed charges,All Other,282.2,83,,282.2,percent of total billed charges,All Other,282.2,83,,282.2,percent of total billed charges,All Other,272,80,,272,percent of total billed charges,All Other,282.2,83,,282.2,percent of total billed charges,All Other,272,80,,272,percent of total billed charges,All Other,238,70,,238,percent of total billed charges,All Other,130,,,130,Fee Schedule,Behavioral Health,111,,,111,Fee Schedule,Behavioral Health,77.42,,,77.42,Fee Schedule,Behavioral Health,77.42,,,77.42,Fee Schedule,Behavioral Health,77.42,,,77.42,Fee Schedule,Behavioral Health,77.42,,,77.42,Fee Schedule,Behavioral Health,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,282.2,
TH-OFFICE/OUTPAT VISIT EST 40 MIN 25 MOD,99215,CPT,2595,36599215,CDM,900,RC,,,both,,,440,325.6,,,325.6,Other,150% of Medicare + 9.63% HCRA Surcharge,198,45,,198,percent of total billed charges,Critical Access Hospital RCC factor,286,65,,286,percent of total billed charges,All Other,259.6,65,,259.6,percent of total billed charges,All Other,272.8,62,,272.8,percent of total billed charges,Behavioral Health,255.2,56,,255.2,percent of total billed charges,Behavioral Health,246.4,53,,246.4,percent of total billed charges,Behavioral Health,217.8,,,217.8,Other,110% of Medicare,299.2,68,,299.2,percent of total billed charges,All Other,0.01,,,0.01,Other,186% of Medicaid,352,,,352,percent of total billed charges,All Other,365.2,83,,365.2,percent of total billed charges,All Other,365.2,83,,365.2,percent of total billed charges,All Other,352,80,,352,percent of total billed charges,All Other,365.2,83,,365.2,percent of total billed charges,All Other,352,80,,352,percent of total billed charges,All Other,308,70,,308,percent of total billed charges,All Other,209,,,209,Fee Schedule,Behavioral Health,178,,,178,Fee Schedule,Behavioral Health,114.4,,,114.4,Fee Schedule,Behavioral Health,114.4,,,114.4,Fee Schedule,Behavioral Health,114.4,,,114.4,Fee Schedule,Behavioral Health,114.4,,,114.4,Fee Schedule,Behavioral Health,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,365.2,
PSYCH DIAGNOSTIC EVALUATION,90791,CPT,,37090791,CDM,900,RC,,,both,,,399,295.26,,,295.26,Other,150% of Medicare + 9.63% HCRA Surcharge,179.55,45,,179.55,percent of total billed charges,Critical Access Hospital RCC factor,259.35,65,,259.35,percent of total billed charges,All Other,235.41,65,,235.41,percent of total billed charges,All Other,190,,,190,Fee Schedule,Behavioral Health,171,,,171,Fee Schedule,Behavioral Health,162,,,162,Fee Schedule,Behavioral Health,197.51,,,197.51,Other,110% of Medicare,230.13,,,230.13,Fee Schedule,Behavioral Health,291,,,291,Other,186% of Medicaid,230.13,,,230.13,Fee Schedule,Behavioral Health,230.13,,,230.13,Fee Schedule,Behavioral Health,230.13,,,230.13,Fee Schedule,Behavioral Health,230.13,,,230.13,Fee Schedule,Behavioral Health,230.13,,,230.13,Fee Schedule,Behavioral Health,319.2,80,,319.2,percent of total billed charges,All Other,279.3,70,,279.3,percent of total billed charges,All Other,217,,,217,Fee Schedule,Behavioral Health,184,,,184,Fee Schedule,Behavioral Health,139.73,,,139.73,Fee Schedule,Behavioral Health,139.73,,,139.73,Fee Schedule,Behavioral Health,139.73,,,139.73,Fee Schedule,Behavioral Health,139.73,,,139.73,Fee Schedule,Behavioral Health,156.36,,,156.36,Other,100% of Medicaid,156.36,,,156.36,Other,100% of Medicaid,156.36,,,156.36,Other,100% of Medicaid,156.36,,,156.36,Other,100% of Medicaid,351.81,,,351.81,Other,225% of Medicaid,239.23,,,239.23,Other,153% of Medicaid,351.81,,,351.81,Other,225% of Medicaid,218.91,,,218.91,Other,140% of Medicaid,351.81,,,351.81,Other,225% of Medicaid,406.54,,,406.54,Other,260% of Medicaid,506.61,,,506.61,Other,324% of Medicaid,336.18,,,336.18,Other,215% of Medicaid,336.18,,,336.18,Other,215% of Medicaid,195.45,,,195.45,Other,125% of Medicaid,139.73,506.61,
PSYCH DIAG EVAL W/MD,90792,CPT,,37090792,CDM,900,RC,,,both,,,399,295.26,,,295.26,Other,150% of Medicare + 9.63% HCRA Surcharge,179.55,45,,179.55,percent of total billed charges,Critical Access Hospital RCC factor,259.35,65,,259.35,percent of total billed charges,All Other,235.41,65,,235.41,percent of total billed charges,All Other,190,,,190,Fee Schedule,Behavioral Health,171,,,171,Fee Schedule,Behavioral Health,162,,,162,Fee Schedule,Behavioral Health,197.51,,,197.51,Other,110% of Medicare,265.07,,,265.07,Fee Schedule,Behavioral Health,291,,,291,Other,186% of Medicaid,265.07,,,265.07,Fee Schedule,Behavioral Health,265.07,,,265.07,Fee Schedule,Behavioral Health,265.07,,,265.07,Fee Schedule,Behavioral Health,265.07,,,265.07,Fee Schedule,Behavioral Health,265.07,,,265.07,Fee Schedule,Behavioral Health,319.2,80,,319.2,percent of total billed charges,All Other,279.3,70,,279.3,percent of total billed charges,All Other,217,,,217,Fee Schedule,Behavioral Health,184,,,184,Fee Schedule,Behavioral Health,139.73,,,139.73,Fee Schedule,Behavioral Health,139.73,,,139.73,Fee Schedule,Behavioral Health,139.73,,,139.73,Fee Schedule,Behavioral Health,139.73,,,139.73,Fee Schedule,Behavioral Health,156.36,,,156.36,Other,100% of Medicaid,156.36,,,156.36,Other,100% of Medicaid,156.36,,,156.36,Other,100% of Medicaid,156.36,,,156.36,Other,100% of Medicaid,351.81,,,351.81,Other,225% of Medicaid,239.23,,,239.23,Other,153% of Medicaid,351.81,,,351.81,Other,225% of Medicaid,218.91,,,218.91,Other,140% of Medicaid,351.81,,,351.81,Other,225% of Medicaid,406.54,,,406.54,Other,260% of Medicaid,506.61,,,506.61,Other,324% of Medicaid,336.18,,,336.18,Other,215% of Medicaid,336.18,,,336.18,Other,215% of Medicaid,195.45,,,195.45,Other,125% of Medicaid,139.73,506.61,
OFFICE/OUTPAT VISIT NEW 15 MIN,99202,CPT,,37099202,CDM,900,RC,,,both,,,252,186.48,,,186.48,Other,150% of Medicare + 9.63% HCRA Surcharge,113.4,45,,113.4,percent of total billed charges,Critical Access Hospital RCC factor,163.8,65,,163.8,percent of total billed charges,All Other,148.68,65,,148.68,percent of total billed charges,All Other,156.24,62,,156.24,percent of total billed charges,Behavioral Health,146.16,56,,146.16,percent of total billed charges,Behavioral Health,141.12,53,,141.12,percent of total billed charges,Behavioral Health,124.74,,,124.74,Other,110% of Medicare,171.36,68,,171.36,percent of total billed charges,All Other,0.01,,,0.01,Other,186% of Medicaid,201.6,80,,201.6,percent of total billed charges,All Other,209.16,83,,209.16,percent of total billed charges,All Other,209.16,83,,209.16,percent of total billed charges,All Other,201.6,80,,201.6,percent of total billed charges,All Other,209.16,83,,209.16,percent of total billed charges,All Other,201.6,80,,201.6,percent of total billed charges,All Other,64.56,70,,64.56,percent of total billed charges,All Other,64.56,,,64.56,Other,130% of Medicare,64.56,,,64.56,Other,130% of Medicare,23.95,,,23.95,Fee Schedule,Behavioral Health,23.95,,,23.95,Fee Schedule,Behavioral Health,23.95,,,23.95,Fee Schedule,Behavioral Health,23.95,,,23.95,Fee Schedule,Behavioral Health,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,209.16,
OFFICE/OUTPAT VISIT NEW 30 MIN,99203,CPT,,37099203,CDM,900,RC,,,both,,,345,255.3,,,255.3,Other,150% of Medicare + 9.63% HCRA Surcharge,155.25,45,,155.25,percent of total billed charges,Critical Access Hospital RCC factor,224.25,65,,224.25,percent of total billed charges,All Other,203.55,65,,203.55,percent of total billed charges,All Other,213.9,62,,213.9,percent of total billed charges,Behavioral Health,200.1,56,,200.1,percent of total billed charges,Behavioral Health,193.2,53,,193.2,percent of total billed charges,Behavioral Health,170.78,,,170.78,Other,110% of Medicare,234.6,68,,234.6,percent of total billed charges,All Other,0.01,,,0.01,Other,186% of Medicaid,276,80,,276,percent of total billed charges,All Other,286.35,83,,286.35,percent of total billed charges,All Other,286.35,83,,286.35,percent of total billed charges,All Other,276,80,,276,percent of total billed charges,All Other,286.35,83,,286.35,percent of total billed charges,All Other,276,80,,276,percent of total billed charges,All Other,241.5,70,,241.5,percent of total billed charges,All Other,111.9,,,111.9,Other,130% of Medicare,111.9,,,111.9,Other,130% of Medicare,41.89,,,41.89,Fee Schedule,Behavioral Health,41.89,,,41.89,Fee Schedule,Behavioral Health,41.89,,,41.89,Fee Schedule,Behavioral Health,41.89,,,41.89,Fee Schedule,Behavioral Health,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,286.35,
OFFICE/OUTPAT VISIT NEW 45 MIN,99204,CPT,,37099204,CDM,900,RC,,,both,,,460,340.4,,,340.4,Other,150% of Medicare + 9.63% HCRA Surcharge,207,45,,207,percent of total billed charges,Critical Access Hospital RCC factor,299,65,,299,percent of total billed charges,All Other,271.4,65,,271.4,percent of total billed charges,All Other,285.2,62,,285.2,percent of total billed charges,Behavioral Health,266.8,56,,266.8,percent of total billed charges,Behavioral Health,257.6,53,,257.6,percent of total billed charges,Behavioral Health,227.7,,,227.7,Other,110% of Medicare,312.8,68,,312.8,percent of total billed charges,All Other,0.01,,,0.01,Other,186% of Medicaid,368,80,,368,percent of total billed charges,All Other,381.8,83,,381.8,percent of total billed charges,All Other,381.8,83,,381.8,percent of total billed charges,All Other,368,80,,368,percent of total billed charges,All Other,381.8,83,,381.8,percent of total billed charges,All Other,368,80,,368,percent of total billed charges,All Other,322,70,,322,percent of total billed charges,All Other,181.94,,,181.94,Other,130% of Medicare,181.94,,,181.94,Other,130% of Medicare,68.97,,,68.97,Fee Schedule,Behavioral Health,68.97,,,68.97,Fee Schedule,Behavioral Health,68.97,,,68.97,Fee Schedule,Behavioral Health,68.97,,,68.97,Fee Schedule,Behavioral Health,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,381.8,
OFFICE/OUTPAT VISIT NEW 60 MIN,99205,CPT,,37099205,CDM,900,RC,,,both,,,628,464.72,,,464.72,Other,150% of Medicare + 9.63% HCRA Surcharge,282.6,45,,282.6,percent of total billed charges,Critical Access Hospital RCC factor,408.2,65,,408.2,percent of total billed charges,All Other,370.52,65,,370.52,percent of total billed charges,All Other,389.36,62,,389.36,percent of total billed charges,Behavioral Health,364.24,56,,364.24,percent of total billed charges,Behavioral Health,351.68,53,,351.68,percent of total billed charges,Behavioral Health,310.86,,,310.86,Other,110% of Medicare,427.04,68,,427.04,percent of total billed charges,All Other,0.01,,,0.01,Other,186% of Medicaid,502.4,80,,502.4,percent of total billed charges,All Other,521.24,83,,521.24,percent of total billed charges,All Other,521.24,83,,521.24,percent of total billed charges,All Other,502.4,80,,502.4,percent of total billed charges,All Other,521.24,83,,521.24,percent of total billed charges,All Other,502.4,80,,502.4,percent of total billed charges,All Other,439.6,70,,439.6,percent of total billed charges,All Other,247.59,,,247.59,Other,130% of Medicare,247.59,,,247.59,Other,130% of Medicare,98.55,,,98.55,Fee Schedule,Behavioral Health,98.55,,,98.55,Fee Schedule,Behavioral Health,98.55,,,98.55,Fee Schedule,Behavioral Health,98.55,,,98.55,Fee Schedule,Behavioral Health,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,521.24,
OFFICE/OUTPAT VISIT EST 5 MIN,99211,CPT,,37099211,CDM,900,RC,,,both,,,228,168.72,,,168.72,Other,150% of Medicare + 9.63% HCRA Surcharge,102.6,45,,102.6,percent of total billed charges,Critical Access Hospital RCC factor,148.2,65,,148.2,percent of total billed charges,All Other,134.52,65,,134.52,percent of total billed charges,All Other,141.36,62,,141.36,percent of total billed charges,Behavioral Health,132.24,56,,132.24,percent of total billed charges,Behavioral Health,127.68,53,,127.68,percent of total billed charges,Behavioral Health,112.86,,,112.86,Other,110% of Medicare,155.04,68,,155.04,percent of total billed charges,All Other,0.01,,,0.01,Other,186% of Medicaid,182.4,80,,182.4,percent of total billed charges,All Other,189.24,83,,189.24,percent of total billed charges,All Other,189.24,83,,189.24,percent of total billed charges,All Other,182.4,80,,182.4,percent of total billed charges,All Other,189.24,83,,189.24,percent of total billed charges,All Other,182.4,80,,182.4,percent of total billed charges,All Other,159.6,70,,159.6,percent of total billed charges,All Other,52,,,52,Fee Schedule,Behavioral Health,44,,,44,Fee Schedule,Behavioral Health,48.23,,,48.23,Fee Schedule,Behavioral Health,48.23,,,48.23,Fee Schedule,Behavioral Health,48.23,,,48.23,Fee Schedule,Behavioral Health,48.23,,,48.23,Fee Schedule,Behavioral Health,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,189.24,
OFFICE/OUTPAT VISIT EST 10 MIN,99212,CPT,,37099212,CDM,900,RC,,,both,,,259,191.66,,,191.66,Other,150% of Medicare + 9.63% HCRA Surcharge,116.55,45,,116.55,percent of total billed charges,Critical Access Hospital RCC factor,168.35,65,,168.35,percent of total billed charges,All Other,152.81,65,,152.81,percent of total billed charges,All Other,160.58,62,,160.58,percent of total billed charges,Behavioral Health,150.22,56,,150.22,percent of total billed charges,Behavioral Health,145.04,53,,145.04,percent of total billed charges,Behavioral Health,128.21,,,128.21,Other,110% of Medicare,176.12,68,,176.12,percent of total billed charges,All Other,0.01,,,0.01,Other,186% of Medicaid,207.2,80,,207.2,percent of total billed charges,All Other,214.97,83,,214.97,percent of total billed charges,All Other,214.97,83,,214.97,percent of total billed charges,All Other,207.2,80,,207.2,percent of total billed charges,All Other,214.97,83,,214.97,percent of total billed charges,All Other,207.2,80,,207.2,percent of total billed charges,All Other,181.3,70,,181.3,percent of total billed charges,All Other,97,,,97,Fee Schedule,Behavioral Health,82,,,82,Fee Schedule,Behavioral Health,55.27,,,55.27,Fee Schedule,Behavioral Health,55.27,,,55.27,Fee Schedule,Behavioral Health,55.27,,,55.27,Fee Schedule,Behavioral Health,55.27,,,55.27,Fee Schedule,Behavioral Health,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,214.97,
OFFICE/OUTPAT VISIT EST 20 MIN,99213,CPT,,37099213,CDM,900,RC,,,both,,,259,191.66,,,191.66,Other,150% of Medicare + 9.63% HCRA Surcharge,116.55,45,,116.55,percent of total billed charges,Critical Access Hospital RCC factor,168.35,65,,168.35,percent of total billed charges,All Other,152.81,65,,152.81,percent of total billed charges,All Other,160.58,62,,160.58,percent of total billed charges,Behavioral Health,150.22,56,,150.22,percent of total billed charges,Behavioral Health,145.04,53,,145.04,percent of total billed charges,Behavioral Health,128.21,,,128.21,Other,110% of Medicare,176.12,68,,176.12,percent of total billed charges,All Other,0.01,,,0.01,Other,186% of Medicaid,207.2,80,,207.2,percent of total billed charges,All Other,214.97,83,,214.97,percent of total billed charges,All Other,214.97,83,,214.97,percent of total billed charges,All Other,207.2,80,,207.2,percent of total billed charges,All Other,214.97,83,,214.97,percent of total billed charges,All Other,207.2,80,,207.2,percent of total billed charges,All Other,181.3,70,,181.3,percent of total billed charges,All Other,115,,,115,Fee Schedule,Behavioral Health,98,,,98,Fee Schedule,Behavioral Health,55.27,,,55.27,Fee Schedule,Behavioral Health,55.27,,,55.27,Fee Schedule,Behavioral Health,55.27,,,55.27,Fee Schedule,Behavioral Health,55.27,,,55.27,Fee Schedule,Behavioral Health,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,214.97,
OFFICE/OUTPAT VISIT EST 30 MIN,99214,CPT,,37099214,CDM,900,RC,,,both,,,340,251.6,,,251.6,Other,150% of Medicare + 9.63% HCRA Surcharge,153,45,,153,percent of total billed charges,Critical Access Hospital RCC factor,221,65,,221,percent of total billed charges,All Other,200.6,65,,200.6,percent of total billed charges,All Other,210.8,62,,210.8,percent of total billed charges,Behavioral Health,197.2,56,,197.2,percent of total billed charges,Behavioral Health,190.4,53,,190.4,percent of total billed charges,Behavioral Health,168.3,,,168.3,Other,110% of Medicare,231.2,68,,231.2,percent of total billed charges,All Other,0.01,,,0.01,Other,186% of Medicaid,272,80,,272,percent of total billed charges,All Other,282.2,83,,282.2,percent of total billed charges,All Other,282.2,83,,282.2,percent of total billed charges,All Other,272,80,,272,percent of total billed charges,All Other,282.2,83,,282.2,percent of total billed charges,All Other,272,80,,272,percent of total billed charges,All Other,238,70,,238,percent of total billed charges,All Other,130,,,130,Fee Schedule,Behavioral Health,111,,,111,Fee Schedule,Behavioral Health,77.42,,,77.42,Fee Schedule,Behavioral Health,77.42,,,77.42,Fee Schedule,Behavioral Health,77.42,,,77.42,Fee Schedule,Behavioral Health,77.42,,,77.42,Fee Schedule,Behavioral Health,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,282.2,
OFFICE/OUTPAT VISIT EST 40 MIN,99215,CPT,,37099215,CDM,900,RC,,,both,,,440,325.6,,,325.6,Other,150% of Medicare + 9.63% HCRA Surcharge,198,45,,198,percent of total billed charges,Critical Access Hospital RCC factor,286,65,,286,percent of total billed charges,All Other,259.6,65,,259.6,percent of total billed charges,All Other,272.8,62,,272.8,percent of total billed charges,Behavioral Health,255.2,56,,255.2,percent of total billed charges,Behavioral Health,246.4,53,,246.4,percent of total billed charges,Behavioral Health,217.8,,,217.8,Other,110% of Medicare,299.2,68,,299.2,percent of total billed charges,All Other,0.01,,,0.01,Other,186% of Medicaid,352,80,,352,percent of total billed charges,All Other,365.2,83,,365.2,percent of total billed charges,All Other,365.2,83,,365.2,percent of total billed charges,All Other,352,80,,352,percent of total billed charges,All Other,365.2,83,,365.2,percent of total billed charges,All Other,352,80,,352,percent of total billed charges,All Other,308,70,,308,percent of total billed charges,All Other,209,,,209,Fee Schedule,Behavioral Health,178,,,178,Fee Schedule,Behavioral Health,114.4,,,114.4,Fee Schedule,Behavioral Health,114.4,,,114.4,Fee Schedule,Behavioral Health,114.4,,,114.4,Fee Schedule,Behavioral Health,114.4,,,114.4,Fee Schedule,Behavioral Health,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,365.2,
OFFICE/OUTPAT VISIT EST 5 MIN 25 MOD,99211,CPT,25,37199211,CDM,900,RC,,,both,,,228,168.72,,,168.72,Other,150% of Medicare + 9.63% HCRA Surcharge,102.6,45,,102.6,percent of total billed charges,Critical Access Hospital RCC factor,148.2,65,,148.2,percent of total billed charges,All Other,134.52,65,,134.52,percent of total billed charges,All Other,141.36,62,,141.36,percent of total billed charges,Behavioral Health,132.24,56,,132.24,percent of total billed charges,Behavioral Health,127.68,53,,127.68,percent of total billed charges,Behavioral Health,112.86,,,112.86,Other,110% of Medicare,155.04,68,,155.04,percent of total billed charges,All Other,0.01,,,0.01,Other,186% of Medicaid,182.4,80,,182.4,percent of total billed charges,All Other,189.24,83,,189.24,percent of total billed charges,All Other,189.24,83,,189.24,percent of total billed charges,All Other,182.4,80,,182.4,percent of total billed charges,All Other,189.24,83,,189.24,percent of total billed charges,All Other,182.4,80,,182.4,percent of total billed charges,All Other,159.6,70,,159.6,percent of total billed charges,All Other,52,,,52,Fee Schedule,Behavioral Health,44,,,44,Fee Schedule,Behavioral Health,48.23,,,48.23,Fee Schedule,Behavioral Health,48.23,,,48.23,Fee Schedule,Behavioral Health,48.23,,,48.23,Fee Schedule,Behavioral Health,48.23,,,48.23,Fee Schedule,Behavioral Health,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,189.24,
OFFICE/OUTPAT VISIT EST 10 MIN 25 MOD,99212,CPT,25,37199212,CDM,900,RC,,,both,,,259,191.66,,,191.66,Other,150% of Medicare + 9.63% HCRA Surcharge,116.55,45,,116.55,percent of total billed charges,Critical Access Hospital RCC factor,168.35,65,,168.35,percent of total billed charges,All Other,152.81,65,,152.81,percent of total billed charges,All Other,160.58,62,,160.58,percent of total billed charges,Behavioral Health,150.22,56,,150.22,percent of total billed charges,Behavioral Health,145.04,53,,145.04,percent of total billed charges,Behavioral Health,128.21,,,128.21,Other,110% of Medicare,176.12,68,,176.12,percent of total billed charges,All Other,0.01,,,0.01,Other,186% of Medicaid,207.2,80,,207.2,percent of total billed charges,All Other,214.97,83,,214.97,percent of total billed charges,All Other,214.97,83,,214.97,percent of total billed charges,All Other,207.2,80,,207.2,percent of total billed charges,All Other,214.97,83,,214.97,percent of total billed charges,All Other,207.2,80,,207.2,percent of total billed charges,All Other,181.3,70,,181.3,percent of total billed charges,All Other,97,,,97,Fee Schedule,Behavioral Health,82,,,82,Fee Schedule,Behavioral Health,55.27,,,55.27,Fee Schedule,Behavioral Health,55.27,,,55.27,Fee Schedule,Behavioral Health,55.27,,,55.27,Fee Schedule,Behavioral Health,55.27,,,55.27,Fee Schedule,Behavioral Health,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,214.97,
OFFICE/OUTPAT VISIT EST 20 MIN 25 MOD,99213,CPT,25,37199213,CDM,900,RC,,,both,,,259,191.66,,,191.66,Other,150% of Medicare + 9.63% HCRA Surcharge,116.55,45,,116.55,percent of total billed charges,Critical Access Hospital RCC factor,168.35,65,,168.35,percent of total billed charges,All Other,152.81,65,,152.81,percent of total billed charges,All Other,160.58,62,,160.58,percent of total billed charges,Behavioral Health,150.22,56,,150.22,percent of total billed charges,Behavioral Health,145.04,53,,145.04,percent of total billed charges,Behavioral Health,128.21,,,128.21,Other,110% of Medicare,176.12,68,,176.12,percent of total billed charges,All Other,0.01,,,0.01,Other,186% of Medicaid,207.2,80,,207.2,percent of total billed charges,All Other,214.97,83,,214.97,percent of total billed charges,All Other,214.97,83,,214.97,percent of total billed charges,All Other,207.2,80,,207.2,percent of total billed charges,All Other,214.97,83,,214.97,percent of total billed charges,All Other,207.2,80,,207.2,percent of total billed charges,All Other,181.3,70,,181.3,percent of total billed charges,All Other,115,,,115,Fee Schedule,Behavioral Health,98,,,98,Fee Schedule,Behavioral Health,55.27,,,55.27,Fee Schedule,Behavioral Health,55.27,,,55.27,Fee Schedule,Behavioral Health,55.27,,,55.27,Fee Schedule,Behavioral Health,55.27,,,55.27,Fee Schedule,Behavioral Health,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,214.97,
OFFICE/OUTPAT VISIT EST 30 MIN 25 MOD,99214,CPT,25,37199214,CDM,900,RC,,,both,,,340,251.6,,,251.6,Other,150% of Medicare + 9.63% HCRA Surcharge,153,45,,153,percent of total billed charges,Critical Access Hospital RCC factor,221,65,,221,percent of total billed charges,All Other,200.6,65,,200.6,percent of total billed charges,All Other,210.8,62,,210.8,percent of total billed charges,Behavioral Health,197.2,56,,197.2,percent of total billed charges,Behavioral Health,190.4,53,,190.4,percent of total billed charges,Behavioral Health,168.3,,,168.3,Other,110% of Medicare,231.2,68,,231.2,percent of total billed charges,All Other,0.01,,,0.01,Other,186% of Medicaid,272,80,,272,percent of total billed charges,All Other,282.2,83,,282.2,percent of total billed charges,All Other,282.2,83,,282.2,percent of total billed charges,All Other,272,80,,272,percent of total billed charges,All Other,282.2,83,,282.2,percent of total billed charges,All Other,272,80,,272,percent of total billed charges,All Other,238,70,,238,percent of total billed charges,All Other,130,,,130,Fee Schedule,Behavioral Health,111,,,111,Fee Schedule,Behavioral Health,77.42,,,77.42,Fee Schedule,Behavioral Health,77.42,,,77.42,Fee Schedule,Behavioral Health,77.42,,,77.42,Fee Schedule,Behavioral Health,77.42,,,77.42,Fee Schedule,Behavioral Health,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,282.2,
OFFICE/OUTPAT VISIT EST 40 MIN 25 MOD,99215,CPT,25,37199215,CDM,900,RC,,,both,,,440,325.6,,,325.6,Other,150% of Medicare + 9.63% HCRA Surcharge,198,45,,198,percent of total billed charges,Critical Access Hospital RCC factor,286,65,,286,percent of total billed charges,All Other,259.6,65,,259.6,percent of total billed charges,All Other,272.8,62,,272.8,percent of total billed charges,Behavioral Health,255.2,56,,255.2,percent of total billed charges,Behavioral Health,246.4,53,,246.4,percent of total billed charges,Behavioral Health,217.8,,,217.8,Other,110% of Medicare,299.2,68,,299.2,percent of total billed charges,All Other,0.01,,,0.01,Other,186% of Medicaid,352,80,,352,percent of total billed charges,All Other,365.2,83,,365.2,percent of total billed charges,All Other,365.2,83,,365.2,percent of total billed charges,All Other,352,80,,352,percent of total billed charges,All Other,365.2,83,,365.2,percent of total billed charges,All Other,352,80,,352,percent of total billed charges,All Other,308,70,,308,percent of total billed charges,All Other,209,,,209,Fee Schedule,Behavioral Health,178,,,178,Fee Schedule,Behavioral Health,114.4,,,114.4,Fee Schedule,Behavioral Health,114.4,,,114.4,Fee Schedule,Behavioral Health,114.4,,,114.4,Fee Schedule,Behavioral Health,114.4,,,114.4,Fee Schedule,Behavioral Health,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,365.2,
TH-PSYCH DIAGNOSTIC EVALUATION,90791,CPT,95,37490791,CDM,900,RC,,,both,,,399,295.26,,,295.26,Other,150% of Medicare + 9.63% HCRA Surcharge,179.55,45,,179.55,percent of total billed charges,Critical Access Hospital RCC factor,259.35,65,,259.35,percent of total billed charges,All Other,235.41,65,,235.41,percent of total billed charges,All Other,190,,,190,Fee Schedule,Behavioral Health,171,,,171,Fee Schedule,Behavioral Health,162,,,162,Fee Schedule,Behavioral Health,197.51,,,197.51,Other,110% of Medicare,230.13,,,230.13,Fee Schedule,Behavioral Health,291,,,291,Other,186% of Medicaid,230.13,,,230.13,Fee Schedule,Behavioral Health,230.13,,,230.13,Fee Schedule,Behavioral Health,230.13,,,230.13,Fee Schedule,Behavioral Health,230.13,,,230.13,Fee Schedule,Behavioral Health,230.13,,,230.13,Fee Schedule,Behavioral Health,319.2,80,,319.2,percent of total billed charges,All Other,279.3,70,,279.3,percent of total billed charges,All Other,217,,,217,Fee Schedule,Behavioral Health,184,,,184,Fee Schedule,Behavioral Health,139.73,,,139.73,Fee Schedule,Behavioral Health,139.73,,,139.73,Fee Schedule,Behavioral Health,139.73,,,139.73,Fee Schedule,Behavioral Health,139.73,,,139.73,Fee Schedule,Behavioral Health,156.36,,,156.36,Other,100% of Medicaid,156.36,,,156.36,Other,100% of Medicaid,156.36,,,156.36,Other,100% of Medicaid,156.36,,,156.36,Other,100% of Medicaid,351.81,,,351.81,Other,225% of Medicaid,239.23,,,239.23,Other,153% of Medicaid,351.81,,,351.81,Other,225% of Medicaid,218.91,,,218.91,Other,140% of Medicaid,351.81,,,351.81,Other,225% of Medicaid,406.54,,,406.54,Other,260% of Medicaid,506.61,,,506.61,Other,324% of Medicaid,336.18,,,336.18,Other,215% of Medicaid,336.18,,,336.18,Other,215% of Medicaid,195.45,,,195.45,Other,125% of Medicaid,139.73,506.61,
TH-PSYCH DIAG EVAL W/MD,90792,CPT,95,37490792,CDM,900,RC,,,both,,,399,295.26,,,295.26,Other,150% of Medicare + 9.63% HCRA Surcharge,179.55,45,,179.55,percent of total billed charges,Critical Access Hospital RCC factor,259.35,65,,259.35,percent of total billed charges,All Other,235.41,65,,235.41,percent of total billed charges,All Other,190,,,190,Fee Schedule,Behavioral Health,171,,,171,Fee Schedule,Behavioral Health,162,,,162,Fee Schedule,Behavioral Health,197.51,,,197.51,Other,110% of Medicare,265.07,,,265.07,Fee Schedule,Behavioral Health,291,,,291,Other,186% of Medicaid,265.07,,,265.07,Fee Schedule,Behavioral Health,265.07,,,265.07,Fee Schedule,Behavioral Health,265.07,,,265.07,Fee Schedule,Behavioral Health,265.07,,,265.07,Fee Schedule,Behavioral Health,265.07,,,265.07,Fee Schedule,Behavioral Health,319.2,80,,319.2,percent of total billed charges,All Other,279.3,70,,279.3,percent of total billed charges,All Other,217,,,217,Fee Schedule,Behavioral Health,184,,,184,Fee Schedule,Behavioral Health,139.73,,,139.73,Fee Schedule,Behavioral Health,139.73,,,139.73,Fee Schedule,Behavioral Health,139.73,,,139.73,Fee Schedule,Behavioral Health,139.73,,,139.73,Fee Schedule,Behavioral Health,156.36,,,156.36,Other,100% of Medicaid,156.36,,,156.36,Other,100% of Medicaid,156.36,,,156.36,Other,100% of Medicaid,156.36,,,156.36,Other,100% of Medicaid,351.81,,,351.81,Other,225% of Medicaid,239.23,,,239.23,Other,153% of Medicaid,351.81,,,351.81,Other,225% of Medicaid,218.91,,,218.91,Other,140% of Medicaid,351.81,,,351.81,Other,225% of Medicaid,406.54,,,406.54,Other,260% of Medicaid,506.61,,,506.61,Other,324% of Medicaid,336.18,,,336.18,Other,215% of Medicaid,336.18,,,336.18,Other,215% of Medicaid,195.45,,,195.45,Other,125% of Medicaid,139.73,506.61,
TH-OFFICE/OUTPAT VISIT NEW 15 MIN,99202,CPT,95,37499202,CDM,900,RC,,,both,,,252,186.48,,,186.48,Other,150% of Medicare + 9.63% HCRA Surcharge,113.4,45,,113.4,percent of total billed charges,Critical Access Hospital RCC factor,163.8,65,,163.8,percent of total billed charges,All Other,148.68,65,,148.68,percent of total billed charges,All Other,156.24,62,,156.24,percent of total billed charges,Behavioral Health,146.16,56,,146.16,percent of total billed charges,Behavioral Health,141.12,53,,141.12,percent of total billed charges,Behavioral Health,124.74,,,124.74,Other,110% of Medicare,171.36,68,,171.36,percent of total billed charges,All Other,0.01,,,0.01,Other,186% of Medicaid,201.6,80,,201.6,percent of total billed charges,All Other,209.16,83,,209.16,percent of total billed charges,All Other,209.16,83,,209.16,percent of total billed charges,All Other,201.6,80,,201.6,percent of total billed charges,All Other,209.16,83,,209.16,percent of total billed charges,All Other,201.6,80,,201.6,percent of total billed charges,All Other,64.56,70,,64.56,percent of total billed charges,All Other,64.56,,,64.56,Other,130% of Medicare,64.56,,,64.56,Other,130% of Medicare,23.95,,,23.95,Fee Schedule,Behavioral Health,23.95,,,23.95,Fee Schedule,Behavioral Health,23.95,,,23.95,Fee Schedule,Behavioral Health,23.95,,,23.95,Fee Schedule,Behavioral Health,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,209.16,
TH-OFFICE/OUTPAT VISIT NEW 30 MIN,99203,CPT,95,37499203,CDM,900,RC,,,both,,,345,255.3,,,255.3,Other,150% of Medicare + 9.63% HCRA Surcharge,155.25,45,,155.25,percent of total billed charges,Critical Access Hospital RCC factor,224.25,65,,224.25,percent of total billed charges,All Other,203.55,65,,203.55,percent of total billed charges,All Other,213.9,62,,213.9,percent of total billed charges,Behavioral Health,200.1,56,,200.1,percent of total billed charges,Behavioral Health,193.2,53,,193.2,percent of total billed charges,Behavioral Health,170.78,,,170.78,Other,110% of Medicare,234.6,68,,234.6,percent of total billed charges,All Other,0.01,,,0.01,Other,186% of Medicaid,276,80,,276,percent of total billed charges,All Other,286.35,83,,286.35,percent of total billed charges,All Other,286.35,83,,286.35,percent of total billed charges,All Other,276,80,,276,percent of total billed charges,All Other,286.35,83,,286.35,percent of total billed charges,All Other,276,80,,276,percent of total billed charges,All Other,241.5,70,,241.5,percent of total billed charges,All Other,111.9,,,111.9,Other,130% of Medicare,111.9,,,111.9,Other,130% of Medicare,41.89,,,41.89,Fee Schedule,Behavioral Health,41.89,,,41.89,Fee Schedule,Behavioral Health,41.89,,,41.89,Fee Schedule,Behavioral Health,41.89,,,41.89,Fee Schedule,Behavioral Health,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,286.35,
TH-OFFICE/OUTPAT VISIT NEW 45 MIN,99204,CPT,95,37499204,CDM,900,RC,,,both,,,460,340.4,,,340.4,Other,150% of Medicare + 9.63% HCRA Surcharge,207,45,,207,percent of total billed charges,Critical Access Hospital RCC factor,299,65,,299,percent of total billed charges,All Other,271.4,65,,271.4,percent of total billed charges,All Other,285.2,62,,285.2,percent of total billed charges,Behavioral Health,266.8,56,,266.8,percent of total billed charges,Behavioral Health,257.6,53,,257.6,percent of total billed charges,Behavioral Health,227.7,,,227.7,Other,110% of Medicare,312.8,68,,312.8,percent of total billed charges,All Other,0.01,,,0.01,Other,186% of Medicaid,368,80,,368,percent of total billed charges,All Other,381.8,83,,381.8,percent of total billed charges,All Other,381.8,83,,381.8,percent of total billed charges,All Other,368,80,,368,percent of total billed charges,All Other,381.8,83,,381.8,percent of total billed charges,All Other,368,80,,368,percent of total billed charges,All Other,322,70,,322,percent of total billed charges,All Other,181.94,,,181.94,Other,130% of Medicare,181.94,,,181.94,Other,130% of Medicare,68.97,,,68.97,Fee Schedule,Behavioral Health,68.97,,,68.97,Fee Schedule,Behavioral Health,68.97,,,68.97,Fee Schedule,Behavioral Health,68.97,,,68.97,Fee Schedule,Behavioral Health,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,381.8,
TH-OFFICE/OUTPAT VISIT NEW 60 MIN,99205,CPT,95,37499205,CDM,900,RC,,,both,,,628,464.72,,,464.72,Other,150% of Medicare + 9.63% HCRA Surcharge,282.6,45,,282.6,percent of total billed charges,Critical Access Hospital RCC factor,408.2,65,,408.2,percent of total billed charges,All Other,370.52,65,,370.52,percent of total billed charges,All Other,389.36,62,,389.36,percent of total billed charges,Behavioral Health,364.24,56,,364.24,percent of total billed charges,Behavioral Health,351.68,53,,351.68,percent of total billed charges,Behavioral Health,310.86,,,310.86,Other,110% of Medicare,427.04,68,,427.04,percent of total billed charges,All Other,0.01,,,0.01,Other,186% of Medicaid,502.4,80,,502.4,percent of total billed charges,All Other,521.24,83,,521.24,percent of total billed charges,All Other,521.24,83,,521.24,percent of total billed charges,All Other,502.4,80,,502.4,percent of total billed charges,All Other,521.24,83,,521.24,percent of total billed charges,All Other,502.4,80,,502.4,percent of total billed charges,All Other,439.6,70,,439.6,percent of total billed charges,All Other,247.59,,,247.59,Other,130% of Medicare,247.59,,,247.59,Other,130% of Medicare,98.55,,,98.55,Fee Schedule,Behavioral Health,98.55,,,98.55,Fee Schedule,Behavioral Health,98.55,,,98.55,Fee Schedule,Behavioral Health,98.55,,,98.55,Fee Schedule,Behavioral Health,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,521.24,
TH-OFFICE/OUTPAT VISIT EST 10 MIN 25 MOD,99212,CPT,2595,37499212,CDM,900,RC,,,both,,,259,191.66,,,191.66,Other,150% of Medicare + 9.63% HCRA Surcharge,116.55,45,,116.55,percent of total billed charges,Critical Access Hospital RCC factor,168.35,65,,168.35,percent of total billed charges,All Other,152.81,65,,152.81,percent of total billed charges,All Other,160.58,62,,160.58,percent of total billed charges,Behavioral Health,150.22,56,,150.22,percent of total billed charges,Behavioral Health,145.04,53,,145.04,percent of total billed charges,Behavioral Health,128.21,,,128.21,Other,110% of Medicare,176.12,68,,176.12,percent of total billed charges,All Other,0.01,,,0.01,Other,186% of Medicaid,207.2,80,,207.2,percent of total billed charges,All Other,214.97,83,,214.97,percent of total billed charges,All Other,214.97,83,,214.97,percent of total billed charges,All Other,207.2,80,,207.2,percent of total billed charges,All Other,214.97,83,,214.97,percent of total billed charges,All Other,207.2,80,,207.2,percent of total billed charges,All Other,181.3,70,,181.3,percent of total billed charges,All Other,97,,,97,Fee Schedule,Behavioral Health,82,,,82,Fee Schedule,Behavioral Health,55.27,,,55.27,Fee Schedule,Behavioral Health,55.27,,,55.27,Fee Schedule,Behavioral Health,55.27,,,55.27,Fee Schedule,Behavioral Health,55.27,,,55.27,Fee Schedule,Behavioral Health,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,214.97,
TH-OFFICE/OUTPAT VISIT EST 20 MIN,99213,CPT,95,37499213,CDM,900,RC,,,both,,,259,191.66,,,191.66,Other,150% of Medicare + 9.63% HCRA Surcharge,116.55,45,,116.55,percent of total billed charges,Critical Access Hospital RCC factor,168.35,65,,168.35,percent of total billed charges,All Other,152.81,65,,152.81,percent of total billed charges,All Other,160.58,62,,160.58,percent of total billed charges,Behavioral Health,150.22,56,,150.22,percent of total billed charges,Behavioral Health,145.04,53,,145.04,percent of total billed charges,Behavioral Health,128.21,,,128.21,Other,110% of Medicare,176.12,68,,176.12,percent of total billed charges,All Other,0.01,,,0.01,Other,186% of Medicaid,207.2,80,,207.2,percent of total billed charges,All Other,214.97,83,,214.97,percent of total billed charges,All Other,214.97,83,,214.97,percent of total billed charges,All Other,207.2,80,,207.2,percent of total billed charges,All Other,214.97,83,,214.97,percent of total billed charges,All Other,207.2,80,,207.2,percent of total billed charges,All Other,181.3,70,,181.3,percent of total billed charges,All Other,115,,,115,Fee Schedule,Behavioral Health,98,,,98,Fee Schedule,Behavioral Health,55.27,,,55.27,Fee Schedule,Behavioral Health,55.27,,,55.27,Fee Schedule,Behavioral Health,55.27,,,55.27,Fee Schedule,Behavioral Health,55.27,,,55.27,Fee Schedule,Behavioral Health,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,214.97,
TH-OFFICE/OUTPAT VISIT EST 30 MIN,99214,CPT,95,37499214,CDM,900,RC,,,both,,,340,251.6,,,251.6,Other,150% of Medicare + 9.63% HCRA Surcharge,153,45,,153,percent of total billed charges,Critical Access Hospital RCC factor,221,65,,221,percent of total billed charges,All Other,200.6,65,,200.6,percent of total billed charges,All Other,210.8,62,,210.8,percent of total billed charges,Behavioral Health,197.2,56,,197.2,percent of total billed charges,Behavioral Health,190.4,53,,190.4,percent of total billed charges,Behavioral Health,168.3,,,168.3,Other,110% of Medicare,231.2,68,,231.2,percent of total billed charges,All Other,0.01,,,0.01,Other,186% of Medicaid,272,80,,272,percent of total billed charges,All Other,282.2,83,,282.2,percent of total billed charges,All Other,282.2,83,,282.2,percent of total billed charges,All Other,272,80,,272,percent of total billed charges,All Other,282.2,83,,282.2,percent of total billed charges,All Other,272,80,,272,percent of total billed charges,All Other,238,70,,238,percent of total billed charges,All Other,130,,,130,Fee Schedule,Behavioral Health,111,,,111,Fee Schedule,Behavioral Health,77.42,,,77.42,Fee Schedule,Behavioral Health,77.42,,,77.42,Fee Schedule,Behavioral Health,77.42,,,77.42,Fee Schedule,Behavioral Health,77.42,,,77.42,Fee Schedule,Behavioral Health,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,282.2,
TH-OFFICE/OUTPAT VISIT EST 40 MIN,99215,CPT,95,37499215,CDM,900,RC,,,both,,,440,325.6,,,325.6,Other,150% of Medicare + 9.63% HCRA Surcharge,198,45,,198,percent of total billed charges,Critical Access Hospital RCC factor,286,65,,286,percent of total billed charges,All Other,259.6,65,,259.6,percent of total billed charges,All Other,272.8,62,,272.8,percent of total billed charges,Behavioral Health,255.2,56,,255.2,percent of total billed charges,Behavioral Health,246.4,53,,246.4,percent of total billed charges,Behavioral Health,217.8,,,217.8,Other,110% of Medicare,299.2,68,,299.2,percent of total billed charges,All Other,0.01,,,0.01,Other,186% of Medicaid,352,80,,352,percent of total billed charges,All Other,365.2,83,,365.2,percent of total billed charges,All Other,365.2,83,,365.2,percent of total billed charges,All Other,352,80,,352,percent of total billed charges,All Other,365.2,83,,365.2,percent of total billed charges,All Other,352,80,,352,percent of total billed charges,All Other,308,70,,308,percent of total billed charges,All Other,209,,,209,Fee Schedule,Behavioral Health,178,,,178,Fee Schedule,Behavioral Health,114.4,,,114.4,Fee Schedule,Behavioral Health,114.4,,,114.4,Fee Schedule,Behavioral Health,114.4,,,114.4,Fee Schedule,Behavioral Health,114.4,,,114.4,Fee Schedule,Behavioral Health,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,365.2,
TH-OFFICE/OUTPAT VISIT EST 10 MIN 25 MOD,99212,CPT,2595,37599212,CDM,900,RC,,,both,,,259,191.66,,,191.66,Other,150% of Medicare + 9.63% HCRA Surcharge,116.55,45,,116.55,percent of total billed charges,Critical Access Hospital RCC factor,168.35,65,,168.35,percent of total billed charges,All Other,152.81,65,,152.81,percent of total billed charges,All Other,160.58,62,,160.58,percent of total billed charges,Behavioral Health,150.22,56,,150.22,percent of total billed charges,Behavioral Health,145.04,53,,145.04,percent of total billed charges,Behavioral Health,128.21,,,128.21,Other,110% of Medicare,176.12,68,,176.12,percent of total billed charges,All Other,0.01,,,0.01,Other,186% of Medicaid,207.2,80,,207.2,percent of total billed charges,All Other,214.97,83,,214.97,percent of total billed charges,All Other,214.97,83,,214.97,percent of total billed charges,All Other,207.2,80,,207.2,percent of total billed charges,All Other,214.97,83,,214.97,percent of total billed charges,All Other,207.2,80,,207.2,percent of total billed charges,All Other,181.3,70,,181.3,percent of total billed charges,All Other,97,,,97,Fee Schedule,Behavioral Health,82,,,82,Fee Schedule,Behavioral Health,55.27,,,55.27,Fee Schedule,Behavioral Health,55.27,,,55.27,Fee Schedule,Behavioral Health,55.27,,,55.27,Fee Schedule,Behavioral Health,55.27,,,55.27,Fee Schedule,Behavioral Health,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,214.97,
TH-OFFICE/OUTPAT VISIT EST 20 MIN 25 MOD,99213,CPT,2595,37599213,CDM,900,RC,,,both,,,259,191.66,,,191.66,Other,150% of Medicare + 9.63% HCRA Surcharge,116.55,45,,116.55,percent of total billed charges,Critical Access Hospital RCC factor,168.35,65,,168.35,percent of total billed charges,All Other,152.81,65,,152.81,percent of total billed charges,All Other,160.58,62,,160.58,percent of total billed charges,Behavioral Health,150.22,56,,150.22,percent of total billed charges,Behavioral Health,145.04,53,,145.04,percent of total billed charges,Behavioral Health,128.21,,,128.21,Other,110% of Medicare,176.12,68,,176.12,percent of total billed charges,All Other,0.01,,,0.01,Other,186% of Medicaid,207.2,80,,207.2,percent of total billed charges,All Other,214.97,83,,214.97,percent of total billed charges,All Other,214.97,83,,214.97,percent of total billed charges,All Other,207.2,80,,207.2,percent of total billed charges,All Other,214.97,83,,214.97,percent of total billed charges,All Other,207.2,80,,207.2,percent of total billed charges,All Other,181.3,70,,181.3,percent of total billed charges,All Other,115,,,115,Fee Schedule,Behavioral Health,98,,,98,Fee Schedule,Behavioral Health,55.27,,,55.27,Fee Schedule,Behavioral Health,55.27,,,55.27,Fee Schedule,Behavioral Health,55.27,,,55.27,Fee Schedule,Behavioral Health,55.27,,,55.27,Fee Schedule,Behavioral Health,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,214.97,
TH-OFFICE/OUTPAT VISIT EST 30 MIN 25 MOD,99214,CPT,2595,37599214,CDM,900,RC,,,both,,,340,251.6,,,251.6,Other,150% of Medicare + 9.63% HCRA Surcharge,153,45,,153,percent of total billed charges,Critical Access Hospital RCC factor,221,65,,221,percent of total billed charges,All Other,200.6,65,,200.6,percent of total billed charges,All Other,210.8,62,,210.8,percent of total billed charges,Behavioral Health,197.2,56,,197.2,percent of total billed charges,Behavioral Health,190.4,53,,190.4,percent of total billed charges,Behavioral Health,168.3,,,168.3,Other,110% of Medicare,231.2,68,,231.2,percent of total billed charges,All Other,0.01,,,0.01,Other,186% of Medicaid,272,80,,272,percent of total billed charges,All Other,282.2,83,,282.2,percent of total billed charges,All Other,282.2,83,,282.2,percent of total billed charges,All Other,272,80,,272,percent of total billed charges,All Other,282.2,83,,282.2,percent of total billed charges,All Other,272,80,,272,percent of total billed charges,All Other,238,70,,238,percent of total billed charges,All Other,130,,,130,Fee Schedule,Behavioral Health,111,,,111,Fee Schedule,Behavioral Health,77.42,,,77.42,Fee Schedule,Behavioral Health,77.42,,,77.42,Fee Schedule,Behavioral Health,77.42,,,77.42,Fee Schedule,Behavioral Health,77.42,,,77.42,Fee Schedule,Behavioral Health,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,282.2,
TH-OFFICE/OUTPAT VISIT EST 40 MIN 25 MOD,99215,CPT,2595,37599215,CDM,900,RC,,,both,,,440,325.6,,,325.6,Other,150% of Medicare + 9.63% HCRA Surcharge,198,45,,198,percent of total billed charges,Critical Access Hospital RCC factor,286,65,,286,percent of total billed charges,All Other,259.6,65,,259.6,percent of total billed charges,All Other,272.8,62,,272.8,percent of total billed charges,Behavioral Health,255.2,56,,255.2,percent of total billed charges,Behavioral Health,246.4,53,,246.4,percent of total billed charges,Behavioral Health,217.8,,,217.8,Other,110% of Medicare,299.2,68,,299.2,percent of total billed charges,All Other,0.01,,,0.01,Other,186% of Medicaid,352,80,,352,percent of total billed charges,All Other,365.2,83,,365.2,percent of total billed charges,All Other,365.2,83,,365.2,percent of total billed charges,All Other,352,80,,352,percent of total billed charges,All Other,365.2,83,,365.2,percent of total billed charges,All Other,352,80,,352,percent of total billed charges,All Other,308,70,,308,percent of total billed charges,All Other,209,,,209,Fee Schedule,Behavioral Health,178,,,178,Fee Schedule,Behavioral Health,114.4,,,114.4,Fee Schedule,Behavioral Health,114.4,,,114.4,Fee Schedule,Behavioral Health,114.4,,,114.4,Fee Schedule,Behavioral Health,114.4,,,114.4,Fee Schedule,Behavioral Health,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,365.2,
ALCOHOL/DRUG; METHADONE TX,H0020,HCPCS,,38000002,CDM,900,RC,,,both,,,45,33.3,,,33.3,Other,150% of Medicare + 9.63% HCRA Surcharge,20.25,45,,20.25,percent of total billed charges,Critical Access Hospital RCC factor,29.25,65,,29.25,percent of total billed charges,All Other,26.55,65,,26.55,percent of total billed charges,All Other,27.9,62,,27.9,percent of total billed charges,Behavioral Health,26.1,56,,26.1,percent of total billed charges,Behavioral Health,25.2,53,,25.2,percent of total billed charges,Behavioral Health,22.28,,,22.28,Other,110% of Medicare,22.5,50,,22.5,percent of total billed charges,Behavioral Health,38,,,38,Other,186% of Medicaid,22.5,50,,22.5,percent of total billed charges,Behavioral Health,22.5,50,,22.5,percent of total billed charges,Behavioral Health,22.5,50,,22.5,percent of total billed charges,Behavioral Health,22.5,50,,22.5,percent of total billed charges,Behavioral Health,22.5,50,,22.5,percent of total billed charges,Behavioral Health,36,80,,36,percent of total billed charges,All Other,31.5,70,,31.5,percent of total billed charges,All Other,218,,,218,Fee Schedule,Behavioral Health,185,,,185,Fee Schedule,Behavioral Health,0.01,,,0.01,Fee Schedule,Behavioral Health,0.01,,,0.01,Fee Schedule,Behavioral Health,0.01,,,0.01,Fee Schedule,Behavioral Health,0.01,,,0.01,Fee Schedule,Behavioral Health,20.18,,,20.18,Other,100% of Medicaid,20.18,,,20.18,Other,100% of Medicaid,20.18,,,20.18,Other,100% of Medicaid,20.18,,,20.18,Other,100% of Medicaid,45.4,,,45.4,Other,225% of Medicaid,30.88,,,30.88,Other,153% of Medicaid,45.4,,,45.4,Other,225% of Medicaid,28.25,,,28.25,Other,140% of Medicaid,45.4,,,45.4,Other,225% of Medicaid,52.47,,,52.47,Other,260% of Medicaid,65.38,,,65.38,Other,324% of Medicaid,43.39,,,43.39,Other,215% of Medicaid,43.39,,,43.39,Other,215% of Medicaid,25.22,,,25.22,Other,125% of Medicaid,0.01,218,
METHADONE GUEST TREATMENT,H0020,HCPCS,,38000004,CDM,900,RC,,,both,,,45,33.3,,,33.3,Other,150% of Medicare + 9.63% HCRA Surcharge,20.25,45,,20.25,percent of total billed charges,Critical Access Hospital RCC factor,29.25,65,,29.25,percent of total billed charges,All Other,26.55,65,,26.55,percent of total billed charges,All Other,27.9,62,,27.9,percent of total billed charges,Behavioral Health,26.1,56,,26.1,percent of total billed charges,Behavioral Health,25.2,53,,25.2,percent of total billed charges,Behavioral Health,22.28,,,22.28,Other,110% of Medicare,22.5,50,,22.5,percent of total billed charges,Behavioral Health,38,,,38,Other,186% of Medicaid,22.5,50,,22.5,percent of total billed charges,Behavioral Health,22.5,50,,22.5,percent of total billed charges,Behavioral Health,22.5,50,,22.5,percent of total billed charges,Behavioral Health,22.5,50,,22.5,percent of total billed charges,Behavioral Health,22.5,50,,22.5,percent of total billed charges,Behavioral Health,36,80,,36,percent of total billed charges,All Other,31.5,70,,31.5,percent of total billed charges,All Other,218,,,218,Fee Schedule,Behavioral Health,185,,,185,Fee Schedule,Behavioral Health,0.01,,,0.01,Fee Schedule,Behavioral Health,0.01,,,0.01,Fee Schedule,Behavioral Health,0.01,,,0.01,Fee Schedule,Behavioral Health,0.01,,,0.01,Fee Schedule,Behavioral Health,20.18,,,20.18,Other,100% of Medicaid,20.18,,,20.18,Other,100% of Medicaid,20.18,,,20.18,Other,100% of Medicaid,20.18,,,20.18,Other,100% of Medicaid,45.4,,,45.4,Other,225% of Medicaid,30.88,,,30.88,Other,153% of Medicaid,45.4,,,45.4,Other,225% of Medicaid,28.25,,,28.25,Other,140% of Medicaid,45.4,,,45.4,Other,225% of Medicaid,52.47,,,52.47,Other,260% of Medicaid,65.38,,,65.38,Other,324% of Medicaid,43.39,,,43.39,Other,215% of Medicaid,43.39,,,43.39,Other,215% of Medicaid,25.22,,,25.22,Other,125% of Medicaid,0.01,218,
ALCOHOL/DRUG; METHADONE TX FIRST WEEKLY,H0020,HCPCS,KP,38000007,CDM,900,RC,,,both,,,45,33.3,,,33.3,Other,150% of Medicare + 9.63% HCRA Surcharge,20.25,45,,20.25,percent of total billed charges,Critical Access Hospital RCC factor,29.25,65,,29.25,percent of total billed charges,All Other,26.55,65,,26.55,percent of total billed charges,All Other,27.9,62,,27.9,percent of total billed charges,Behavioral Health,26.1,56,,26.1,percent of total billed charges,Behavioral Health,25.2,53,,25.2,percent of total billed charges,Behavioral Health,22.28,,,22.28,Other,110% of Medicare,22.5,50,,22.5,percent of total billed charges,Behavioral Health,38,,,38,Other,186% of Medicaid,22.5,50,,22.5,percent of total billed charges,Behavioral Health,22.5,50,,22.5,percent of total billed charges,Behavioral Health,22.5,50,,22.5,percent of total billed charges,Behavioral Health,22.5,50,,22.5,percent of total billed charges,Behavioral Health,22.5,50,,22.5,percent of total billed charges,Behavioral Health,36,80,,36,percent of total billed charges,All Other,31.5,70,,31.5,percent of total billed charges,All Other,218,,,218,Fee Schedule,Behavioral Health,185,,,185,Fee Schedule,Behavioral Health,0.01,,,0.01,Fee Schedule,Behavioral Health,0.01,,,0.01,Fee Schedule,Behavioral Health,0.01,,,0.01,Fee Schedule,Behavioral Health,0.01,,,0.01,Fee Schedule,Behavioral Health,20.18,,,20.18,Other,100% of Medicaid,20.18,,,20.18,Other,100% of Medicaid,20.18,,,20.18,Other,100% of Medicaid,20.18,,,20.18,Other,100% of Medicaid,45.4,,,45.4,Other,225% of Medicaid,30.88,,,30.88,Other,153% of Medicaid,45.4,,,45.4,Other,225% of Medicaid,28.25,,,28.25,Other,140% of Medicaid,45.4,,,45.4,Other,225% of Medicaid,52.47,,,52.47,Other,260% of Medicaid,65.38,,,65.38,Other,324% of Medicaid,43.39,,,43.39,Other,215% of Medicaid,43.39,,,43.39,Other,215% of Medicaid,25.22,,,25.22,Other,125% of Medicaid,0.01,218,
MED ASSIST TX METH WEEKLY,G2067,HCPCS,,38000009,CDM,900,RC,,,both,,,234,173.16,,,173.16,Other,150% of Medicare + 9.63% HCRA Surcharge,105.3,45,,105.3,percent of total billed charges,Critical Access Hospital RCC factor,152.1,65,,152.1,percent of total billed charges,All Other,138.06,65,,138.06,percent of total billed charges,All Other,145.08,62,,145.08,percent of total billed charges,Behavioral Health,135.72,56,,135.72,percent of total billed charges,Behavioral Health,131.04,53,,131.04,percent of total billed charges,Behavioral Health,115.83,,,115.83,Other,110% of Medicare,117,50,,117,percent of total billed charges,Behavioral Health,0.01,,,0.01,Other,186% of Medicaid,117,50,,117,percent of total billed charges,Behavioral Health,117,50,,117,percent of total billed charges,Behavioral Health,117,50,,117,percent of total billed charges,Behavioral Health,117,50,,117,percent of total billed charges,Behavioral Health,117,50,,117,percent of total billed charges,Behavioral Health,187.2,80,,187.2,percent of total billed charges,All Other,163.8,70,,163.8,percent of total billed charges,All Other,152.1,65,,152.1,percent of total billed charges,Default if not in Fee Schedule,152.1,65,,152.1,percent of total billed charges,Default if not in Fee Schedule,0.01,,,0.01,Fee Schedule,Behavioral Health,0.01,,,0.01,Fee Schedule,Behavioral Health,0.01,,,0.01,Fee Schedule,Behavioral Health,0.01,,,0.01,Fee Schedule,Behavioral Health,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,187.2,
PSYCH DIAGNOSTIC EVALUATION,90791,CPT,,38090791,CDM,900,RC,,,both,,,399,295.26,,,295.26,Other,150% of Medicare + 9.63% HCRA Surcharge,179.55,45,,179.55,percent of total billed charges,Critical Access Hospital RCC factor,259.35,65,,259.35,percent of total billed charges,All Other,235.41,65,,235.41,percent of total billed charges,All Other,190,,,190,Fee Schedule,Behavioral Health,171,,,171,Fee Schedule,Behavioral Health,162,,,162,Fee Schedule,Behavioral Health,197.51,,,197.51,Other,110% of Medicare,230.13,,,230.13,Fee Schedule,Behavioral Health,291,,,291,Other,186% of Medicaid,230.13,,,230.13,Fee Schedule,Behavioral Health,230.13,,,230.13,Fee Schedule,Behavioral Health,230.13,,,230.13,Fee Schedule,Behavioral Health,230.13,,,230.13,Fee Schedule,Behavioral Health,230.13,,,230.13,Fee Schedule,Behavioral Health,319.2,80,,319.2,percent of total billed charges,All Other,279.3,70,,279.3,percent of total billed charges,All Other,217,,,217,Fee Schedule,Behavioral Health,184,,,184,Fee Schedule,Behavioral Health,139.73,,,139.73,Fee Schedule,Behavioral Health,139.73,,,139.73,Fee Schedule,Behavioral Health,139.73,,,139.73,Fee Schedule,Behavioral Health,139.73,,,139.73,Fee Schedule,Behavioral Health,156.36,,,156.36,Other,100% of Medicaid,156.36,,,156.36,Other,100% of Medicaid,156.36,,,156.36,Other,100% of Medicaid,156.36,,,156.36,Other,100% of Medicaid,351.81,,,351.81,Other,225% of Medicaid,239.23,,,239.23,Other,153% of Medicaid,351.81,,,351.81,Other,225% of Medicaid,218.91,,,218.91,Other,140% of Medicaid,351.81,,,351.81,Other,225% of Medicaid,406.54,,,406.54,Other,260% of Medicaid,506.61,,,506.61,Other,324% of Medicaid,336.18,,,336.18,Other,215% of Medicaid,336.18,,,336.18,Other,215% of Medicaid,195.45,,,195.45,Other,125% of Medicaid,139.73,506.61,
PSYCH DIAG EVAL W/MD,90792,CPT,,38090792,CDM,900,RC,,,both,,,399,295.26,,,295.26,Other,150% of Medicare + 9.63% HCRA Surcharge,179.55,45,,179.55,percent of total billed charges,Critical Access Hospital RCC factor,259.35,65,,259.35,percent of total billed charges,All Other,235.41,65,,235.41,percent of total billed charges,All Other,190,,,190,Fee Schedule,Behavioral Health,171,,,171,Fee Schedule,Behavioral Health,162,,,162,Fee Schedule,Behavioral Health,197.51,,,197.51,Other,110% of Medicare,265.07,,,265.07,Fee Schedule,Behavioral Health,291,,,291,Other,186% of Medicaid,265.07,,,265.07,Fee Schedule,Behavioral Health,265.07,,,265.07,Fee Schedule,Behavioral Health,265.07,,,265.07,Fee Schedule,Behavioral Health,265.07,,,265.07,Fee Schedule,Behavioral Health,265.07,,,265.07,Fee Schedule,Behavioral Health,319.2,80,,319.2,percent of total billed charges,All Other,279.3,70,,279.3,percent of total billed charges,All Other,217,,,217,Fee Schedule,Behavioral Health,184,,,184,Fee Schedule,Behavioral Health,139.73,,,139.73,Fee Schedule,Behavioral Health,139.73,,,139.73,Fee Schedule,Behavioral Health,139.73,,,139.73,Fee Schedule,Behavioral Health,139.73,,,139.73,Fee Schedule,Behavioral Health,156.36,,,156.36,Other,100% of Medicaid,156.36,,,156.36,Other,100% of Medicaid,156.36,,,156.36,Other,100% of Medicaid,156.36,,,156.36,Other,100% of Medicaid,351.81,,,351.81,Other,225% of Medicaid,239.23,,,239.23,Other,153% of Medicaid,351.81,,,351.81,Other,225% of Medicaid,218.91,,,218.91,Other,140% of Medicaid,351.81,,,351.81,Other,225% of Medicaid,406.54,,,406.54,Other,260% of Medicaid,506.61,,,506.61,Other,324% of Medicaid,336.18,,,336.18,Other,215% of Medicaid,336.18,,,336.18,Other,215% of Medicaid,195.45,,,195.45,Other,125% of Medicaid,139.73,506.61,
OFFICE/OUTPAT VISIT NEW 15 MIN,99202,CPT,,38099202,CDM,900,RC,,,both,,,252,186.48,,,186.48,Other,150% of Medicare + 9.63% HCRA Surcharge,113.4,45,,113.4,percent of total billed charges,Critical Access Hospital RCC factor,163.8,65,,163.8,percent of total billed charges,All Other,148.68,65,,148.68,percent of total billed charges,All Other,156.24,62,,156.24,percent of total billed charges,Behavioral Health,146.16,56,,146.16,percent of total billed charges,Behavioral Health,141.12,53,,141.12,percent of total billed charges,Behavioral Health,124.74,,,124.74,Other,110% of Medicare,171.36,68,,171.36,percent of total billed charges,All Other,0.01,,,0.01,Other,186% of Medicaid,201.6,50,,201.6,percent of total billed charges,Behavioral Health,209.16,50,,209.16,percent of total billed charges,Behavioral Health,209.16,50,,209.16,percent of total billed charges,Behavioral Health,201.6,50,,201.6,percent of total billed charges,Behavioral Health,209.16,50,,209.16,percent of total billed charges,Behavioral Health,201.6,80,,201.6,percent of total billed charges,All Other,64.56,70,,64.56,percent of total billed charges,All Other,64.56,,,64.56,Other,130% of Medicare,64.56,,,64.56,Other,130% of Medicare,23.95,,,23.95,Fee Schedule,Behavioral Health,23.95,,,23.95,Fee Schedule,Behavioral Health,23.95,,,23.95,Fee Schedule,Behavioral Health,23.95,,,23.95,Fee Schedule,Behavioral Health,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,209.16,
OFFICE/OUTPAT VISIT NEW 30 MIN,99203,CPT,,38099203,CDM,900,RC,,,both,,,345,255.3,,,255.3,Other,150% of Medicare + 9.63% HCRA Surcharge,155.25,45,,155.25,percent of total billed charges,Critical Access Hospital RCC factor,224.25,65,,224.25,percent of total billed charges,All Other,203.55,65,,203.55,percent of total billed charges,All Other,213.9,62,,213.9,percent of total billed charges,Behavioral Health,200.1,56,,200.1,percent of total billed charges,Behavioral Health,193.2,53,,193.2,percent of total billed charges,Behavioral Health,170.78,,,170.78,Other,110% of Medicare,234.6,68,,234.6,percent of total billed charges,All Other,0.01,,,0.01,Other,186% of Medicaid,276,80,,276,percent of total billed charges,All Other,286.35,83,,286.35,percent of total billed charges,All Other,286.35,83,,286.35,percent of total billed charges,All Other,276,80,,276,percent of total billed charges,All Other,286.35,83,,286.35,percent of total billed charges,All Other,276,80,,276,percent of total billed charges,All Other,241.5,70,,241.5,percent of total billed charges,All Other,111.9,,,111.9,Other,130% of Medicare,111.9,,,111.9,Other,130% of Medicare,41.89,,,41.89,Fee Schedule,Behavioral Health,41.89,,,41.89,Fee Schedule,Behavioral Health,41.89,,,41.89,Fee Schedule,Behavioral Health,41.89,,,41.89,Fee Schedule,Behavioral Health,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,286.35,
OFFICE/OUTPAT VISIT NEW 45 MIN,99204,CPT,,38099204,CDM,900,RC,,,both,,,460,340.4,,,340.4,Other,150% of Medicare + 9.63% HCRA Surcharge,207,45,,207,percent of total billed charges,Critical Access Hospital RCC factor,299,65,,299,percent of total billed charges,All Other,271.4,65,,271.4,percent of total billed charges,All Other,285.2,62,,285.2,percent of total billed charges,Behavioral Health,266.8,56,,266.8,percent of total billed charges,Behavioral Health,257.6,53,,257.6,percent of total billed charges,Behavioral Health,227.7,,,227.7,Other,110% of Medicare,312.8,68,,312.8,percent of total billed charges,All Other,0.01,,,0.01,Other,186% of Medicaid,368,80,,368,percent of total billed charges,All Other,381.8,83,,381.8,percent of total billed charges,All Other,381.8,83,,381.8,percent of total billed charges,All Other,368,80,,368,percent of total billed charges,All Other,381.8,83,,381.8,percent of total billed charges,All Other,368,80,,368,percent of total billed charges,All Other,322,70,,322,percent of total billed charges,All Other,181.94,,,181.94,Other,130% of Medicare,181.94,,,181.94,Other,130% of Medicare,68.97,,,68.97,Fee Schedule,Behavioral Health,68.97,,,68.97,Fee Schedule,Behavioral Health,68.97,,,68.97,Fee Schedule,Behavioral Health,68.97,,,68.97,Fee Schedule,Behavioral Health,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,381.8,
OFFICE/OUTPAT VISIT NEW 60 MIN,99205,CPT,,38099205,CDM,900,RC,,,both,,,628,464.72,,,464.72,Other,150% of Medicare + 9.63% HCRA Surcharge,282.6,45,,282.6,percent of total billed charges,Critical Access Hospital RCC factor,408.2,65,,408.2,percent of total billed charges,All Other,370.52,65,,370.52,percent of total billed charges,All Other,389.36,62,,389.36,percent of total billed charges,Behavioral Health,364.24,56,,364.24,percent of total billed charges,Behavioral Health,351.68,53,,351.68,percent of total billed charges,Behavioral Health,310.86,,,310.86,Other,110% of Medicare,427.04,68,,427.04,percent of total billed charges,All Other,0.01,,,0.01,Other,186% of Medicaid,502.4,80,,502.4,percent of total billed charges,All Other,521.24,83,,521.24,percent of total billed charges,All Other,521.24,83,,521.24,percent of total billed charges,All Other,502.4,80,,502.4,percent of total billed charges,All Other,521.24,83,,521.24,percent of total billed charges,All Other,502.4,80,,502.4,percent of total billed charges,All Other,439.6,70,,439.6,percent of total billed charges,All Other,247.59,,,247.59,Other,130% of Medicare,247.59,,,247.59,Other,130% of Medicare,98.55,,,98.55,Fee Schedule,Behavioral Health,98.55,,,98.55,Fee Schedule,Behavioral Health,98.55,,,98.55,Fee Schedule,Behavioral Health,98.55,,,98.55,Fee Schedule,Behavioral Health,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,521.24,
OFFICE/OUTPAT VISIT EST 5 MIN,99211,CPT,,38099211,CDM,900,RC,,,both,,,228,168.72,,,168.72,Other,150% of Medicare + 9.63% HCRA Surcharge,102.6,45,,102.6,percent of total billed charges,Critical Access Hospital RCC factor,148.2,65,,148.2,percent of total billed charges,All Other,134.52,65,,134.52,percent of total billed charges,All Other,141.36,62,,141.36,percent of total billed charges,Behavioral Health,132.24,56,,132.24,percent of total billed charges,Behavioral Health,127.68,53,,127.68,percent of total billed charges,Behavioral Health,112.86,,,112.86,Other,110% of Medicare,155.04,68,,155.04,percent of total billed charges,All Other,0.01,,,0.01,Other,186% of Medicaid,182.4,80,,182.4,percent of total billed charges,All Other,189.24,83,,189.24,percent of total billed charges,All Other,189.24,83,,189.24,percent of total billed charges,All Other,182.4,80,,182.4,percent of total billed charges,All Other,189.24,83,,189.24,percent of total billed charges,All Other,182.4,80,,182.4,percent of total billed charges,All Other,159.6,70,,159.6,percent of total billed charges,All Other,52,,,52,Fee Schedule,Behavioral Health,44,,,44,Fee Schedule,Behavioral Health,48.23,,,48.23,Fee Schedule,Behavioral Health,48.23,,,48.23,Fee Schedule,Behavioral Health,48.23,,,48.23,Fee Schedule,Behavioral Health,48.23,,,48.23,Fee Schedule,Behavioral Health,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,189.24,
OFFICE/OUTPAT VISIT EST 10 MIN,99212,CPT,,38099212,CDM,900,RC,,,both,,,259,191.66,,,191.66,Other,150% of Medicare + 9.63% HCRA Surcharge,116.55,45,,116.55,percent of total billed charges,Critical Access Hospital RCC factor,168.35,65,,168.35,percent of total billed charges,All Other,152.81,65,,152.81,percent of total billed charges,All Other,160.58,62,,160.58,percent of total billed charges,Behavioral Health,150.22,56,,150.22,percent of total billed charges,Behavioral Health,145.04,53,,145.04,percent of total billed charges,Behavioral Health,128.21,,,128.21,Other,110% of Medicare,176.12,68,,176.12,percent of total billed charges,All Other,0.01,,,0.01,Other,186% of Medicaid,207.2,80,,207.2,percent of total billed charges,All Other,214.97,83,,214.97,percent of total billed charges,All Other,214.97,83,,214.97,percent of total billed charges,All Other,207.2,80,,207.2,percent of total billed charges,All Other,214.97,83,,214.97,percent of total billed charges,All Other,207.2,80,,207.2,percent of total billed charges,All Other,181.3,70,,181.3,percent of total billed charges,All Other,97,,,97,Fee Schedule,Behavioral Health,82,,,82,Fee Schedule,Behavioral Health,55.27,,,55.27,Fee Schedule,Behavioral Health,55.27,,,55.27,Fee Schedule,Behavioral Health,55.27,,,55.27,Fee Schedule,Behavioral Health,55.27,,,55.27,Fee Schedule,Behavioral Health,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,214.97,
OFFICE/OUTPAT VISIT EST 20 MIN,99213,CPT,,38099213,CDM,900,RC,,,both,,,259,191.66,,,191.66,Other,150% of Medicare + 9.63% HCRA Surcharge,116.55,45,,116.55,percent of total billed charges,Critical Access Hospital RCC factor,168.35,65,,168.35,percent of total billed charges,All Other,152.81,65,,152.81,percent of total billed charges,All Other,160.58,62,,160.58,percent of total billed charges,Behavioral Health,150.22,56,,150.22,percent of total billed charges,Behavioral Health,145.04,53,,145.04,percent of total billed charges,Behavioral Health,128.21,,,128.21,Other,110% of Medicare,176.12,68,,176.12,percent of total billed charges,All Other,0.01,,,0.01,Other,186% of Medicaid,207.2,80,,207.2,percent of total billed charges,All Other,214.97,83,,214.97,percent of total billed charges,All Other,214.97,83,,214.97,percent of total billed charges,All Other,207.2,80,,207.2,percent of total billed charges,All Other,214.97,83,,214.97,percent of total billed charges,All Other,207.2,80,,207.2,percent of total billed charges,All Other,181.3,70,,181.3,percent of total billed charges,All Other,115,,,115,Fee Schedule,Behavioral Health,98,,,98,Fee Schedule,Behavioral Health,55.27,,,55.27,Fee Schedule,Behavioral Health,55.27,,,55.27,Fee Schedule,Behavioral Health,55.27,,,55.27,Fee Schedule,Behavioral Health,55.27,,,55.27,Fee Schedule,Behavioral Health,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,214.97,
OFFICE/OUTPAT VISIT EST 30 MIN,99214,CPT,,38099214,CDM,900,RC,,,both,,,340,251.6,,,251.6,Other,150% of Medicare + 9.63% HCRA Surcharge,153,45,,153,percent of total billed charges,Critical Access Hospital RCC factor,221,65,,221,percent of total billed charges,All Other,200.6,65,,200.6,percent of total billed charges,All Other,210.8,62,,210.8,percent of total billed charges,Behavioral Health,197.2,56,,197.2,percent of total billed charges,Behavioral Health,190.4,53,,190.4,percent of total billed charges,Behavioral Health,168.3,,,168.3,Other,110% of Medicare,231.2,68,,231.2,percent of total billed charges,All Other,0.01,,,0.01,Other,186% of Medicaid,272,80,,272,percent of total billed charges,All Other,282.2,83,,282.2,percent of total billed charges,All Other,282.2,83,,282.2,percent of total billed charges,All Other,272,80,,272,percent of total billed charges,All Other,282.2,83,,282.2,percent of total billed charges,All Other,272,80,,272,percent of total billed charges,All Other,238,70,,238,percent of total billed charges,All Other,130,,,130,Fee Schedule,Behavioral Health,111,,,111,Fee Schedule,Behavioral Health,77.42,,,77.42,Fee Schedule,Behavioral Health,77.42,,,77.42,Fee Schedule,Behavioral Health,77.42,,,77.42,Fee Schedule,Behavioral Health,77.42,,,77.42,Fee Schedule,Behavioral Health,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,282.2,
OFFICE/OUTPAT VISIT EST 40 MIN,99215,CPT,,38099215,CDM,900,RC,,,both,,,440,325.6,,,325.6,Other,150% of Medicare + 9.63% HCRA Surcharge,198,45,,198,percent of total billed charges,Critical Access Hospital RCC factor,286,65,,286,percent of total billed charges,All Other,259.6,65,,259.6,percent of total billed charges,All Other,272.8,62,,272.8,percent of total billed charges,Behavioral Health,255.2,56,,255.2,percent of total billed charges,Behavioral Health,246.4,53,,246.4,percent of total billed charges,Behavioral Health,217.8,,,217.8,Other,110% of Medicare,299.2,68,,299.2,percent of total billed charges,All Other,0.01,,,0.01,Other,186% of Medicaid,352,80,,352,percent of total billed charges,All Other,365.2,83,,365.2,percent of total billed charges,All Other,365.2,83,,365.2,percent of total billed charges,All Other,352,80,,352,percent of total billed charges,All Other,365.2,83,,365.2,percent of total billed charges,All Other,352,80,,352,percent of total billed charges,All Other,308,70,,308,percent of total billed charges,All Other,209,,,209,Fee Schedule,Behavioral Health,178,,,178,Fee Schedule,Behavioral Health,114.4,,,114.4,Fee Schedule,Behavioral Health,114.4,,,114.4,Fee Schedule,Behavioral Health,114.4,,,114.4,Fee Schedule,Behavioral Health,114.4,,,114.4,Fee Schedule,Behavioral Health,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,365.2,
OFFICE/OUTPAT VISIT EST 5 MIN 25 MOD,99211,CPT,25,38199211,CDM,900,RC,,,both,,,228,168.72,,,168.72,Other,150% of Medicare + 9.63% HCRA Surcharge,102.6,45,,102.6,percent of total billed charges,Critical Access Hospital RCC factor,148.2,65,,148.2,percent of total billed charges,All Other,134.52,65,,134.52,percent of total billed charges,All Other,141.36,62,,141.36,percent of total billed charges,Behavioral Health,132.24,56,,132.24,percent of total billed charges,Behavioral Health,127.68,53,,127.68,percent of total billed charges,Behavioral Health,112.86,,,112.86,Other,110% of Medicare,155.04,68,,155.04,percent of total billed charges,All Other,0.01,,,0.01,Other,186% of Medicaid,182.4,80,,182.4,percent of total billed charges,All Other,189.24,83,,189.24,percent of total billed charges,All Other,189.24,83,,189.24,percent of total billed charges,All Other,182.4,80,,182.4,percent of total billed charges,All Other,189.24,83,,189.24,percent of total billed charges,All Other,182.4,80,,182.4,percent of total billed charges,All Other,159.6,70,,159.6,percent of total billed charges,All Other,52,,,52,Fee Schedule,Behavioral Health,44,,,44,Fee Schedule,Behavioral Health,48.23,,,48.23,Fee Schedule,Behavioral Health,48.23,,,48.23,Fee Schedule,Behavioral Health,48.23,,,48.23,Fee Schedule,Behavioral Health,48.23,,,48.23,Fee Schedule,Behavioral Health,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,189.24,
OFFICE/OUTPAT VISIT EST 10 MIN 25 MOD,99212,CPT,25,38199212,CDM,900,RC,,,both,,,259,191.66,,,191.66,Other,150% of Medicare + 9.63% HCRA Surcharge,116.55,45,,116.55,percent of total billed charges,Critical Access Hospital RCC factor,168.35,65,,168.35,percent of total billed charges,All Other,152.81,65,,152.81,percent of total billed charges,All Other,160.58,62,,160.58,percent of total billed charges,Behavioral Health,150.22,56,,150.22,percent of total billed charges,Behavioral Health,145.04,53,,145.04,percent of total billed charges,Behavioral Health,128.21,,,128.21,Other,110% of Medicare,176.12,68,,176.12,percent of total billed charges,All Other,0.01,,,0.01,Other,186% of Medicaid,207.2,80,,207.2,percent of total billed charges,All Other,214.97,83,,214.97,percent of total billed charges,All Other,214.97,83,,214.97,percent of total billed charges,All Other,207.2,80,,207.2,percent of total billed charges,All Other,214.97,83,,214.97,percent of total billed charges,All Other,207.2,80,,207.2,percent of total billed charges,All Other,181.3,70,,181.3,percent of total billed charges,All Other,97,,,97,Fee Schedule,Behavioral Health,82,,,82,Fee Schedule,Behavioral Health,55.27,,,55.27,Fee Schedule,Behavioral Health,55.27,,,55.27,Fee Schedule,Behavioral Health,55.27,,,55.27,Fee Schedule,Behavioral Health,55.27,,,55.27,Fee Schedule,Behavioral Health,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,214.97,
OFFICE/OUTPAT VISIT EST 20 MIN 25 MOD,99213,CPT,25,38199213,CDM,900,RC,,,both,,,259,191.66,,,191.66,Other,150% of Medicare + 9.63% HCRA Surcharge,116.55,45,,116.55,percent of total billed charges,Critical Access Hospital RCC factor,168.35,65,,168.35,percent of total billed charges,All Other,152.81,65,,152.81,percent of total billed charges,All Other,160.58,62,,160.58,percent of total billed charges,Behavioral Health,150.22,56,,150.22,percent of total billed charges,Behavioral Health,145.04,53,,145.04,percent of total billed charges,Behavioral Health,128.21,,,128.21,Other,110% of Medicare,176.12,68,,176.12,percent of total billed charges,All Other,0.01,,,0.01,Other,186% of Medicaid,207.2,80,,207.2,percent of total billed charges,All Other,214.97,83,,214.97,percent of total billed charges,All Other,214.97,83,,214.97,percent of total billed charges,All Other,207.2,80,,207.2,percent of total billed charges,All Other,214.97,83,,214.97,percent of total billed charges,All Other,207.2,80,,207.2,percent of total billed charges,All Other,181.3,70,,181.3,percent of total billed charges,All Other,115,,,115,Fee Schedule,Behavioral Health,98,,,98,Fee Schedule,Behavioral Health,55.27,,,55.27,Fee Schedule,Behavioral Health,55.27,,,55.27,Fee Schedule,Behavioral Health,55.27,,,55.27,Fee Schedule,Behavioral Health,55.27,,,55.27,Fee Schedule,Behavioral Health,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,214.97,
OFFICE/OUTPAT VISIT EST 30 MIN 25 MOD,99214,CPT,25,38199214,CDM,900,RC,,,both,,,340,251.6,,,251.6,Other,150% of Medicare + 9.63% HCRA Surcharge,153,45,,153,percent of total billed charges,Critical Access Hospital RCC factor,221,65,,221,percent of total billed charges,All Other,200.6,65,,200.6,percent of total billed charges,All Other,210.8,62,,210.8,percent of total billed charges,Behavioral Health,197.2,56,,197.2,percent of total billed charges,Behavioral Health,190.4,53,,190.4,percent of total billed charges,Behavioral Health,168.3,,,168.3,Other,110% of Medicare,231.2,68,,231.2,percent of total billed charges,All Other,0.01,,,0.01,Other,186% of Medicaid,272,80,,272,percent of total billed charges,All Other,282.2,83,,282.2,percent of total billed charges,All Other,282.2,83,,282.2,percent of total billed charges,All Other,272,80,,272,percent of total billed charges,All Other,282.2,83,,282.2,percent of total billed charges,All Other,272,80,,272,percent of total billed charges,All Other,238,70,,238,percent of total billed charges,All Other,130,,,130,Fee Schedule,Behavioral Health,111,,,111,Fee Schedule,Behavioral Health,77.42,,,77.42,Fee Schedule,Behavioral Health,77.42,,,77.42,Fee Schedule,Behavioral Health,77.42,,,77.42,Fee Schedule,Behavioral Health,77.42,,,77.42,Fee Schedule,Behavioral Health,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,282.2,
OFFICE/OUTPAT VISIT EST 40 MIN 25 MOD,99215,CPT,25,38199215,CDM,900,RC,,,both,,,440,325.6,,,325.6,Other,150% of Medicare + 9.63% HCRA Surcharge,198,45,,198,percent of total billed charges,Critical Access Hospital RCC factor,286,65,,286,percent of total billed charges,All Other,259.6,65,,259.6,percent of total billed charges,All Other,272.8,62,,272.8,percent of total billed charges,Behavioral Health,255.2,56,,255.2,percent of total billed charges,Behavioral Health,246.4,53,,246.4,percent of total billed charges,Behavioral Health,217.8,,,217.8,Other,110% of Medicare,299.2,68,,299.2,percent of total billed charges,All Other,0.01,,,0.01,Other,186% of Medicaid,352,80,,352,percent of total billed charges,All Other,365.2,83,,365.2,percent of total billed charges,All Other,365.2,83,,365.2,percent of total billed charges,All Other,352,80,,352,percent of total billed charges,All Other,365.2,83,,365.2,percent of total billed charges,All Other,352,80,,352,percent of total billed charges,All Other,308,70,,308,percent of total billed charges,All Other,209,,,209,Fee Schedule,Behavioral Health,178,,,178,Fee Schedule,Behavioral Health,114.4,,,114.4,Fee Schedule,Behavioral Health,114.4,,,114.4,Fee Schedule,Behavioral Health,114.4,,,114.4,Fee Schedule,Behavioral Health,114.4,,,114.4,Fee Schedule,Behavioral Health,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,365.2,
PSYCH DIAGNOSTIC EVALUATION-TH,90791,CPT,95,38390791,CDM,900,RC,,,both,,,399,295.26,,,295.26,Other,150% of Medicare + 9.63% HCRA Surcharge,179.55,45,,179.55,percent of total billed charges,Critical Access Hospital RCC factor,259.35,65,,259.35,percent of total billed charges,All Other,235.41,65,,235.41,percent of total billed charges,All Other,190,,,190,Fee Schedule,Behavioral Health,171,,,171,Fee Schedule,Behavioral Health,162,,,162,Fee Schedule,Behavioral Health,197.51,,,197.51,Other,110% of Medicare,230.13,,,230.13,Fee Schedule,Behavioral Health,291,,,291,Other,186% of Medicaid,230.13,,,230.13,Fee Schedule,Behavioral Health,230.13,,,230.13,Fee Schedule,Behavioral Health,230.13,,,230.13,Fee Schedule,Behavioral Health,230.13,,,230.13,Fee Schedule,Behavioral Health,230.13,,,230.13,Fee Schedule,Behavioral Health,319.2,80,,319.2,percent of total billed charges,All Other,279.3,70,,279.3,percent of total billed charges,All Other,217,,,217,Fee Schedule,Behavioral Health,184,,,184,Fee Schedule,Behavioral Health,139.73,,,139.73,Fee Schedule,Behavioral Health,139.73,,,139.73,Fee Schedule,Behavioral Health,139.73,,,139.73,Fee Schedule,Behavioral Health,139.73,,,139.73,Fee Schedule,Behavioral Health,156.36,,,156.36,Other,100% of Medicaid,156.36,,,156.36,Other,100% of Medicaid,156.36,,,156.36,Other,100% of Medicaid,156.36,,,156.36,Other,100% of Medicaid,351.81,,,351.81,Other,225% of Medicaid,239.23,,,239.23,Other,153% of Medicaid,351.81,,,351.81,Other,225% of Medicaid,218.91,,,218.91,Other,140% of Medicaid,351.81,,,351.81,Other,225% of Medicaid,406.54,,,406.54,Other,260% of Medicaid,506.61,,,506.61,Other,324% of Medicaid,336.18,,,336.18,Other,215% of Medicaid,336.18,,,336.18,Other,215% of Medicaid,195.45,,,195.45,Other,125% of Medicaid,139.73,506.61,
PSYCH DIAG EVAL W/MD-TH,90792,CPT,95,38390792,CDM,900,RC,,,both,,,399,295.26,,,295.26,Other,150% of Medicare + 9.63% HCRA Surcharge,179.55,45,,179.55,percent of total billed charges,Critical Access Hospital RCC factor,259.35,65,,259.35,percent of total billed charges,All Other,235.41,65,,235.41,percent of total billed charges,All Other,190,,,190,Fee Schedule,Behavioral Health,171,,,171,Fee Schedule,Behavioral Health,162,,,162,Fee Schedule,Behavioral Health,197.51,,,197.51,Other,110% of Medicare,265.07,,,265.07,Fee Schedule,Behavioral Health,291,,,291,Other,186% of Medicaid,265.07,,,265.07,Fee Schedule,Behavioral Health,265.07,,,265.07,Fee Schedule,Behavioral Health,265.07,,,265.07,Fee Schedule,Behavioral Health,265.07,,,265.07,Fee Schedule,Behavioral Health,265.07,,,265.07,Fee Schedule,Behavioral Health,319.2,80,,319.2,percent of total billed charges,All Other,279.3,70,,279.3,percent of total billed charges,All Other,217,,,217,Fee Schedule,Behavioral Health,184,,,184,Fee Schedule,Behavioral Health,139.73,,,139.73,Fee Schedule,Behavioral Health,139.73,,,139.73,Fee Schedule,Behavioral Health,139.73,,,139.73,Fee Schedule,Behavioral Health,139.73,,,139.73,Fee Schedule,Behavioral Health,156.36,,,156.36,Other,100% of Medicaid,156.36,,,156.36,Other,100% of Medicaid,156.36,,,156.36,Other,100% of Medicaid,156.36,,,156.36,Other,100% of Medicaid,351.81,,,351.81,Other,225% of Medicaid,239.23,,,239.23,Other,153% of Medicaid,351.81,,,351.81,Other,225% of Medicaid,218.91,,,218.91,Other,140% of Medicaid,351.81,,,351.81,Other,225% of Medicaid,406.54,,,406.54,Other,260% of Medicaid,506.61,,,506.61,Other,324% of Medicaid,336.18,,,336.18,Other,215% of Medicaid,336.18,,,336.18,Other,215% of Medicaid,195.45,,,195.45,Other,125% of Medicaid,139.73,506.61,
OFFICE/OUTPAT VISIT NEW 15 MIN-TH,99202,CPT,95,38399202,CDM,900,RC,,,both,,,252,186.48,,,186.48,Other,150% of Medicare + 9.63% HCRA Surcharge,113.4,45,,113.4,percent of total billed charges,Critical Access Hospital RCC factor,163.8,65,,163.8,percent of total billed charges,All Other,148.68,65,,148.68,percent of total billed charges,All Other,156.24,62,,156.24,percent of total billed charges,Behavioral Health,146.16,56,,146.16,percent of total billed charges,Behavioral Health,141.12,53,,141.12,percent of total billed charges,Behavioral Health,124.74,,,124.74,Other,110% of Medicare,171.36,68,,171.36,percent of total billed charges,All Other,0.01,,,0.01,Other,186% of Medicaid,201.6,80,,201.6,percent of total billed charges,All Other,209.16,83,,209.16,percent of total billed charges,All Other,209.16,83,,209.16,percent of total billed charges,All Other,201.6,80,,201.6,percent of total billed charges,All Other,209.16,83,,209.16,percent of total billed charges,All Other,201.6,80,,201.6,percent of total billed charges,All Other,64.56,70,,64.56,percent of total billed charges,All Other,64.56,,,64.56,Other,130% of Medicare,64.56,,,64.56,Other,130% of Medicare,23.95,,,23.95,Fee Schedule,Behavioral Health,23.95,,,23.95,Fee Schedule,Behavioral Health,23.95,,,23.95,Fee Schedule,Behavioral Health,23.95,,,23.95,Fee Schedule,Behavioral Health,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,209.16,
OFFICE/OUTPAT VISIT NEW 30 MIN-TH,99203,CPT,95,38399203,CDM,900,RC,,,both,,,345,255.3,,,255.3,Other,150% of Medicare + 9.63% HCRA Surcharge,155.25,45,,155.25,percent of total billed charges,Critical Access Hospital RCC factor,224.25,65,,224.25,percent of total billed charges,All Other,203.55,65,,203.55,percent of total billed charges,All Other,213.9,62,,213.9,percent of total billed charges,Behavioral Health,200.1,56,,200.1,percent of total billed charges,Behavioral Health,193.2,53,,193.2,percent of total billed charges,Behavioral Health,170.78,,,170.78,Other,110% of Medicare,234.6,68,,234.6,percent of total billed charges,All Other,0.01,,,0.01,Other,186% of Medicaid,276,80,,276,percent of total billed charges,All Other,286.35,83,,286.35,percent of total billed charges,All Other,286.35,83,,286.35,percent of total billed charges,All Other,276,80,,276,percent of total billed charges,All Other,286.35,83,,286.35,percent of total billed charges,All Other,276,80,,276,percent of total billed charges,All Other,241.5,70,,241.5,percent of total billed charges,All Other,111.9,,,111.9,Other,130% of Medicare,111.9,,,111.9,Other,130% of Medicare,41.89,,,41.89,Fee Schedule,Behavioral Health,41.89,,,41.89,Fee Schedule,Behavioral Health,41.89,,,41.89,Fee Schedule,Behavioral Health,41.89,,,41.89,Fee Schedule,Behavioral Health,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,286.35,
OFFICE/OUTPAT VISIT NEW 45 MIN-TH,99204,CPT,95,38399204,CDM,900,RC,,,both,,,460,340.4,,,340.4,Other,150% of Medicare + 9.63% HCRA Surcharge,207,45,,207,percent of total billed charges,Critical Access Hospital RCC factor,299,65,,299,percent of total billed charges,All Other,271.4,65,,271.4,percent of total billed charges,All Other,285.2,62,,285.2,percent of total billed charges,Behavioral Health,266.8,56,,266.8,percent of total billed charges,Behavioral Health,257.6,53,,257.6,percent of total billed charges,Behavioral Health,227.7,,,227.7,Other,110% of Medicare,312.8,68,,312.8,percent of total billed charges,All Other,0.01,,,0.01,Other,186% of Medicaid,368,80,,368,percent of total billed charges,All Other,381.8,83,,381.8,percent of total billed charges,All Other,381.8,83,,381.8,percent of total billed charges,All Other,368,80,,368,percent of total billed charges,All Other,381.8,83,,381.8,percent of total billed charges,All Other,368,80,,368,percent of total billed charges,All Other,322,70,,322,percent of total billed charges,All Other,181.94,,,181.94,Other,130% of Medicare,181.94,,,181.94,Other,130% of Medicare,68.97,,,68.97,Fee Schedule,Behavioral Health,68.97,,,68.97,Fee Schedule,Behavioral Health,68.97,,,68.97,Fee Schedule,Behavioral Health,68.97,,,68.97,Fee Schedule,Behavioral Health,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,381.8,
TH-OFFICE/OUTPAT VISIT NEW 60 MIN,99205,CPT,95,38399205,CDM,900,RC,,,both,,,628,464.72,,,464.72,Other,150% of Medicare + 9.63% HCRA Surcharge,282.6,45,,282.6,percent of total billed charges,Critical Access Hospital RCC factor,408.2,65,,408.2,percent of total billed charges,All Other,370.52,65,,370.52,percent of total billed charges,All Other,389.36,62,,389.36,percent of total billed charges,Behavioral Health,364.24,56,,364.24,percent of total billed charges,Behavioral Health,351.68,53,,351.68,percent of total billed charges,Behavioral Health,310.86,,,310.86,Other,110% of Medicare,427.04,68,,427.04,percent of total billed charges,All Other,0.01,,,0.01,Other,186% of Medicaid,502.4,80,,502.4,percent of total billed charges,All Other,521.24,83,,521.24,percent of total billed charges,All Other,521.24,83,,521.24,percent of total billed charges,All Other,502.4,80,,502.4,percent of total billed charges,All Other,521.24,83,,521.24,percent of total billed charges,All Other,502.4,80,,502.4,percent of total billed charges,All Other,439.6,70,,439.6,percent of total billed charges,All Other,247.59,,,247.59,Other,130% of Medicare,247.59,,,247.59,Other,130% of Medicare,98.55,,,98.55,Fee Schedule,Behavioral Health,98.55,,,98.55,Fee Schedule,Behavioral Health,98.55,,,98.55,Fee Schedule,Behavioral Health,98.55,,,98.55,Fee Schedule,Behavioral Health,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,521.24,
OFFICE/OUTPAT VISIT EST 10 MIN-TH,99212,CPT,95,38399212,CDM,900,RC,,,both,,,259,191.66,,,191.66,Other,150% of Medicare + 9.63% HCRA Surcharge,116.55,45,,116.55,percent of total billed charges,Critical Access Hospital RCC factor,168.35,65,,168.35,percent of total billed charges,All Other,152.81,65,,152.81,percent of total billed charges,All Other,160.58,62,,160.58,percent of total billed charges,Behavioral Health,150.22,56,,150.22,percent of total billed charges,Behavioral Health,145.04,53,,145.04,percent of total billed charges,Behavioral Health,128.21,,,128.21,Other,110% of Medicare,176.12,68,,176.12,percent of total billed charges,All Other,0.01,,,0.01,Other,186% of Medicaid,207.2,80,,207.2,percent of total billed charges,All Other,214.97,83,,214.97,percent of total billed charges,All Other,214.97,83,,214.97,percent of total billed charges,All Other,207.2,80,,207.2,percent of total billed charges,All Other,214.97,83,,214.97,percent of total billed charges,All Other,207.2,80,,207.2,percent of total billed charges,All Other,181.3,70,,181.3,percent of total billed charges,All Other,97,,,97,Fee Schedule,Behavioral Health,82,,,82,Fee Schedule,Behavioral Health,55.27,,,55.27,Fee Schedule,Behavioral Health,55.27,,,55.27,Fee Schedule,Behavioral Health,55.27,,,55.27,Fee Schedule,Behavioral Health,55.27,,,55.27,Fee Schedule,Behavioral Health,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,214.97,
OFFICE/OUTPAT VISIT EST 20 MIN-TH,99213,CPT,95,38399213,CDM,900,RC,,,both,,,259,191.66,,,191.66,Other,150% of Medicare + 9.63% HCRA Surcharge,116.55,45,,116.55,percent of total billed charges,Critical Access Hospital RCC factor,168.35,65,,168.35,percent of total billed charges,All Other,152.81,65,,152.81,percent of total billed charges,All Other,160.58,62,,160.58,percent of total billed charges,Behavioral Health,150.22,56,,150.22,percent of total billed charges,Behavioral Health,145.04,53,,145.04,percent of total billed charges,Behavioral Health,128.21,,,128.21,Other,110% of Medicare,176.12,68,,176.12,percent of total billed charges,All Other,0.01,,,0.01,Other,186% of Medicaid,207.2,80,,207.2,percent of total billed charges,All Other,214.97,83,,214.97,percent of total billed charges,All Other,214.97,83,,214.97,percent of total billed charges,All Other,207.2,80,,207.2,percent of total billed charges,All Other,214.97,83,,214.97,percent of total billed charges,All Other,207.2,80,,207.2,percent of total billed charges,All Other,181.3,70,,181.3,percent of total billed charges,All Other,115,,,115,Fee Schedule,Behavioral Health,98,,,98,Fee Schedule,Behavioral Health,55.27,,,55.27,Fee Schedule,Behavioral Health,55.27,,,55.27,Fee Schedule,Behavioral Health,55.27,,,55.27,Fee Schedule,Behavioral Health,55.27,,,55.27,Fee Schedule,Behavioral Health,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,214.97,
OFFICE/OUTPAT VISIT EST 30 MIN-TH,99214,CPT,95,38399214,CDM,900,RC,,,both,,,340,251.6,,,251.6,Other,150% of Medicare + 9.63% HCRA Surcharge,153,45,,153,percent of total billed charges,Critical Access Hospital RCC factor,221,65,,221,percent of total billed charges,All Other,200.6,65,,200.6,percent of total billed charges,All Other,210.8,62,,210.8,percent of total billed charges,Behavioral Health,197.2,56,,197.2,percent of total billed charges,Behavioral Health,190.4,53,,190.4,percent of total billed charges,Behavioral Health,168.3,,,168.3,Other,110% of Medicare,231.2,68,,231.2,percent of total billed charges,All Other,0.01,,,0.01,Other,186% of Medicaid,272,80,,272,percent of total billed charges,All Other,282.2,83,,282.2,percent of total billed charges,All Other,282.2,83,,282.2,percent of total billed charges,All Other,272,80,,272,percent of total billed charges,All Other,282.2,83,,282.2,percent of total billed charges,All Other,272,80,,272,percent of total billed charges,All Other,238,70,,238,percent of total billed charges,All Other,130,,,130,Fee Schedule,Behavioral Health,111,,,111,Fee Schedule,Behavioral Health,77.42,,,77.42,Fee Schedule,Behavioral Health,77.42,,,77.42,Fee Schedule,Behavioral Health,77.42,,,77.42,Fee Schedule,Behavioral Health,77.42,,,77.42,Fee Schedule,Behavioral Health,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,282.2,
OFFICE/OUTPAT VISIT EST 40 MIN-TH,99215,CPT,95,38399215,CDM,900,RC,,,both,,,440,325.6,,,325.6,Other,150% of Medicare + 9.63% HCRA Surcharge,198,45,,198,percent of total billed charges,Critical Access Hospital RCC factor,286,65,,286,percent of total billed charges,All Other,259.6,65,,259.6,percent of total billed charges,All Other,272.8,62,,272.8,percent of total billed charges,Behavioral Health,255.2,56,,255.2,percent of total billed charges,Behavioral Health,246.4,53,,246.4,percent of total billed charges,Behavioral Health,217.8,,,217.8,Other,110% of Medicare,299.2,68,,299.2,percent of total billed charges,All Other,0.01,,,0.01,Other,186% of Medicaid,352,80,,352,percent of total billed charges,All Other,365.2,83,,365.2,percent of total billed charges,All Other,365.2,83,,365.2,percent of total billed charges,All Other,352,80,,352,percent of total billed charges,All Other,365.2,83,,365.2,percent of total billed charges,All Other,352,80,,352,percent of total billed charges,All Other,308,70,,308,percent of total billed charges,All Other,209,,,209,Fee Schedule,Behavioral Health,178,,,178,Fee Schedule,Behavioral Health,114.4,,,114.4,Fee Schedule,Behavioral Health,114.4,,,114.4,Fee Schedule,Behavioral Health,114.4,,,114.4,Fee Schedule,Behavioral Health,114.4,,,114.4,Fee Schedule,Behavioral Health,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,365.2,
OFFICE/OUTPAT VISIT EST 10 MIN 25 MOD-TH,99212,CPT,9525,38499212,CDM,900,RC,,,both,,,259,191.66,,,191.66,Other,150% of Medicare + 9.63% HCRA Surcharge,116.55,45,,116.55,percent of total billed charges,Critical Access Hospital RCC factor,168.35,65,,168.35,percent of total billed charges,All Other,152.81,65,,152.81,percent of total billed charges,All Other,160.58,62,,160.58,percent of total billed charges,Behavioral Health,150.22,56,,150.22,percent of total billed charges,Behavioral Health,145.04,53,,145.04,percent of total billed charges,Behavioral Health,128.21,,,128.21,Other,110% of Medicare,176.12,68,,176.12,percent of total billed charges,All Other,0.01,,,0.01,Other,186% of Medicaid,207.2,80,,207.2,percent of total billed charges,All Other,214.97,83,,214.97,percent of total billed charges,All Other,214.97,83,,214.97,percent of total billed charges,All Other,207.2,80,,207.2,percent of total billed charges,All Other,214.97,83,,214.97,percent of total billed charges,All Other,207.2,80,,207.2,percent of total billed charges,All Other,181.3,70,,181.3,percent of total billed charges,All Other,97,,,97,Fee Schedule,Behavioral Health,82,,,82,Fee Schedule,Behavioral Health,55.27,,,55.27,Fee Schedule,Behavioral Health,55.27,,,55.27,Fee Schedule,Behavioral Health,55.27,,,55.27,Fee Schedule,Behavioral Health,55.27,,,55.27,Fee Schedule,Behavioral Health,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,214.97,
OFFICE/OUTPAT VISIT EST 20 MIN 25 MOD-TH,99213,CPT,2595,38499213,CDM,900,RC,,,both,,,259,191.66,,,191.66,Other,150% of Medicare + 9.63% HCRA Surcharge,116.55,45,,116.55,percent of total billed charges,Critical Access Hospital RCC factor,168.35,65,,168.35,percent of total billed charges,All Other,152.81,65,,152.81,percent of total billed charges,All Other,160.58,62,,160.58,percent of total billed charges,Behavioral Health,150.22,56,,150.22,percent of total billed charges,Behavioral Health,145.04,53,,145.04,percent of total billed charges,Behavioral Health,128.21,,,128.21,Other,110% of Medicare,176.12,68,,176.12,percent of total billed charges,All Other,0.01,,,0.01,Other,186% of Medicaid,207.2,80,,207.2,percent of total billed charges,All Other,214.97,83,,214.97,percent of total billed charges,All Other,214.97,83,,214.97,percent of total billed charges,All Other,207.2,80,,207.2,percent of total billed charges,All Other,214.97,83,,214.97,percent of total billed charges,All Other,207.2,80,,207.2,percent of total billed charges,All Other,181.3,70,,181.3,percent of total billed charges,All Other,115,,,115,Fee Schedule,Behavioral Health,98,,,98,Fee Schedule,Behavioral Health,55.27,,,55.27,Fee Schedule,Behavioral Health,55.27,,,55.27,Fee Schedule,Behavioral Health,55.27,,,55.27,Fee Schedule,Behavioral Health,55.27,,,55.27,Fee Schedule,Behavioral Health,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,214.97,
OFFICE/OUTPAT VISIT EST 30 MIN 25 MOD-TH,99214,CPT,2595,38499214,CDM,900,RC,,,both,,,340,251.6,,,251.6,Other,150% of Medicare + 9.63% HCRA Surcharge,153,45,,153,percent of total billed charges,Critical Access Hospital RCC factor,221,65,,221,percent of total billed charges,All Other,200.6,65,,200.6,percent of total billed charges,All Other,210.8,62,,210.8,percent of total billed charges,Behavioral Health,197.2,56,,197.2,percent of total billed charges,Behavioral Health,190.4,53,,190.4,percent of total billed charges,Behavioral Health,168.3,,,168.3,Other,110% of Medicare,231.2,68,,231.2,percent of total billed charges,All Other,0.01,,,0.01,Other,186% of Medicaid,272,80,,272,percent of total billed charges,All Other,282.2,83,,282.2,percent of total billed charges,All Other,282.2,83,,282.2,percent of total billed charges,All Other,272,80,,272,percent of total billed charges,All Other,282.2,83,,282.2,percent of total billed charges,All Other,272,80,,272,percent of total billed charges,All Other,238,70,,238,percent of total billed charges,All Other,130,,,130,Fee Schedule,Behavioral Health,111,,,111,Fee Schedule,Behavioral Health,77.42,,,77.42,Fee Schedule,Behavioral Health,77.42,,,77.42,Fee Schedule,Behavioral Health,77.42,,,77.42,Fee Schedule,Behavioral Health,77.42,,,77.42,Fee Schedule,Behavioral Health,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,282.2,
OFFICE/OUTPAT VISIT EST 40 MIN 25 MOD-TH,99215,CPT,2595,38499215,CDM,900,RC,,,both,,,440,325.6,,,325.6,Other,150% of Medicare + 9.63% HCRA Surcharge,198,45,,198,percent of total billed charges,Critical Access Hospital RCC factor,286,65,,286,percent of total billed charges,All Other,259.6,65,,259.6,percent of total billed charges,All Other,272.8,62,,272.8,percent of total billed charges,Behavioral Health,255.2,56,,255.2,percent of total billed charges,Behavioral Health,246.4,53,,246.4,percent of total billed charges,Behavioral Health,217.8,,,217.8,Other,110% of Medicare,299.2,68,,299.2,percent of total billed charges,All Other,0.01,,,0.01,Other,186% of Medicaid,352,80,,352,percent of total billed charges,All Other,365.2,83,,365.2,percent of total billed charges,All Other,365.2,83,,365.2,percent of total billed charges,All Other,352,80,,352,percent of total billed charges,All Other,365.2,83,,365.2,percent of total billed charges,All Other,352,80,,352,percent of total billed charges,All Other,308,70,,308,percent of total billed charges,All Other,209,,,209,Fee Schedule,Behavioral Health,178,,,178,Fee Schedule,Behavioral Health,114.4,,,114.4,Fee Schedule,Behavioral Health,114.4,,,114.4,Fee Schedule,Behavioral Health,114.4,,,114.4,Fee Schedule,Behavioral Health,114.4,,,114.4,Fee Schedule,Behavioral Health,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,365.2,
PSYCH DIAGNOSTIC EVALUATION,90791,CPT,,39090791,CDM,900,RC,,,both,,,399,295.26,,,295.26,Other,150% of Medicare + 9.63% HCRA Surcharge,179.55,45,,179.55,percent of total billed charges,Critical Access Hospital RCC factor,259.35,65,,259.35,percent of total billed charges,All Other,235.41,65,,235.41,percent of total billed charges,All Other,190,,,190,Fee Schedule,Behavioral Health,171,,,171,Fee Schedule,Behavioral Health,162,,,162,Fee Schedule,Behavioral Health,197.51,,,197.51,Other,110% of Medicare,230.13,,,230.13,Fee Schedule,Behavioral Health,291,,,291,Other,186% of Medicaid,230.13,,,230.13,Fee Schedule,Behavioral Health,230.13,,,230.13,Fee Schedule,Behavioral Health,230.13,,,230.13,Fee Schedule,Behavioral Health,230.13,,,230.13,Fee Schedule,Behavioral Health,230.13,,,230.13,Fee Schedule,Behavioral Health,319.2,80,,319.2,percent of total billed charges,All Other,279.3,70,,279.3,percent of total billed charges,All Other,217,,,217,Fee Schedule,Behavioral Health,184,,,184,Fee Schedule,Behavioral Health,139.73,,,139.73,Fee Schedule,Behavioral Health,139.73,,,139.73,Fee Schedule,Behavioral Health,139.73,,,139.73,Fee Schedule,Behavioral Health,139.73,,,139.73,Fee Schedule,Behavioral Health,156.36,,,156.36,Other,100% of Medicaid,156.36,,,156.36,Other,100% of Medicaid,156.36,,,156.36,Other,100% of Medicaid,156.36,,,156.36,Other,100% of Medicaid,351.81,,,351.81,Other,225% of Medicaid,239.23,,,239.23,Other,153% of Medicaid,351.81,,,351.81,Other,225% of Medicaid,218.91,,,218.91,Other,140% of Medicaid,351.81,,,351.81,Other,225% of Medicaid,406.54,,,406.54,Other,260% of Medicaid,506.61,,,506.61,Other,324% of Medicaid,336.18,,,336.18,Other,215% of Medicaid,336.18,,,336.18,Other,215% of Medicaid,195.45,,,195.45,Other,125% of Medicaid,139.73,506.61,
OFFICE/OUTPAT VISIT NEW 15 MIN,99202,CPT,HE,39099202,CDM,900,RC,,,both,,,252,186.48,,,186.48,Other,150% of Medicare + 9.63% HCRA Surcharge,113.4,45,,113.4,percent of total billed charges,Critical Access Hospital RCC factor,163.8,65,,163.8,percent of total billed charges,All Other,148.68,65,,148.68,percent of total billed charges,All Other,156.24,62,,156.24,percent of total billed charges,Behavioral Health,146.16,56,,146.16,percent of total billed charges,Behavioral Health,141.12,53,,141.12,percent of total billed charges,Behavioral Health,124.74,,,124.74,Other,110% of Medicare,171.36,68,,171.36,percent of total billed charges,All Other,0.01,,,0.01,Other,186% of Medicaid,201.6,80,,201.6,percent of total billed charges,All Other,209.16,83,,209.16,percent of total billed charges,All Other,209.16,83,,209.16,percent of total billed charges,All Other,201.6,80,,201.6,percent of total billed charges,All Other,209.16,83,,209.16,percent of total billed charges,All Other,201.6,80,,201.6,percent of total billed charges,All Other,64.56,70,,64.56,percent of total billed charges,All Other,64.56,,,64.56,Other,130% of Medicare,64.56,,,64.56,Other,130% of Medicare,23.95,,,23.95,Fee Schedule,Behavioral Health,23.95,,,23.95,Fee Schedule,Behavioral Health,23.95,,,23.95,Fee Schedule,Behavioral Health,23.95,,,23.95,Fee Schedule,Behavioral Health,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,209.16,
OFFICE/OUTPAT VISIT NEW 30 MIN,99203,CPT,HE,39099203,CDM,900,RC,,,both,,,345,255.3,,,255.3,Other,150% of Medicare + 9.63% HCRA Surcharge,155.25,45,,155.25,percent of total billed charges,Critical Access Hospital RCC factor,224.25,65,,224.25,percent of total billed charges,All Other,203.55,65,,203.55,percent of total billed charges,All Other,213.9,62,,213.9,percent of total billed charges,Behavioral Health,200.1,56,,200.1,percent of total billed charges,Behavioral Health,193.2,53,,193.2,percent of total billed charges,Behavioral Health,170.78,,,170.78,Other,110% of Medicare,234.6,68,,234.6,percent of total billed charges,All Other,0.01,,,0.01,Other,186% of Medicaid,276,80,,276,percent of total billed charges,All Other,286.35,83,,286.35,percent of total billed charges,All Other,286.35,83,,286.35,percent of total billed charges,All Other,276,80,,276,percent of total billed charges,All Other,286.35,83,,286.35,percent of total billed charges,All Other,276,80,,276,percent of total billed charges,All Other,241.5,70,,241.5,percent of total billed charges,All Other,111.9,,,111.9,Other,130% of Medicare,111.9,,,111.9,Other,130% of Medicare,41.89,,,41.89,Fee Schedule,Behavioral Health,41.89,,,41.89,Fee Schedule,Behavioral Health,41.89,,,41.89,Fee Schedule,Behavioral Health,41.89,,,41.89,Fee Schedule,Behavioral Health,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,286.35,
OFFICE/OUTPAT VISIT NEW 45 MIN,99204,CPT,HE,39099204,CDM,900,RC,,,both,,,460,340.4,,,340.4,Other,150% of Medicare + 9.63% HCRA Surcharge,207,45,,207,percent of total billed charges,Critical Access Hospital RCC factor,299,65,,299,percent of total billed charges,All Other,271.4,65,,271.4,percent of total billed charges,All Other,285.2,62,,285.2,percent of total billed charges,Behavioral Health,266.8,56,,266.8,percent of total billed charges,Behavioral Health,257.6,53,,257.6,percent of total billed charges,Behavioral Health,227.7,,,227.7,Other,110% of Medicare,312.8,68,,312.8,percent of total billed charges,All Other,0.01,,,0.01,Other,186% of Medicaid,368,80,,368,percent of total billed charges,All Other,381.8,83,,381.8,percent of total billed charges,All Other,381.8,83,,381.8,percent of total billed charges,All Other,368,80,,368,percent of total billed charges,All Other,381.8,83,,381.8,percent of total billed charges,All Other,368,80,,368,percent of total billed charges,All Other,322,70,,322,percent of total billed charges,All Other,181.94,,,181.94,Other,130% of Medicare,181.94,,,181.94,Other,130% of Medicare,68.97,,,68.97,Fee Schedule,Behavioral Health,68.97,,,68.97,Fee Schedule,Behavioral Health,68.97,,,68.97,Fee Schedule,Behavioral Health,68.97,,,68.97,Fee Schedule,Behavioral Health,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,381.8,
OFFICE/OUTPAT VISIT NEW 60 MIN,99205,CPT,HE,39099205,CDM,900,RC,,,both,,,628,464.72,,,464.72,Other,150% of Medicare + 9.63% HCRA Surcharge,282.6,45,,282.6,percent of total billed charges,Critical Access Hospital RCC factor,408.2,65,,408.2,percent of total billed charges,All Other,370.52,65,,370.52,percent of total billed charges,All Other,389.36,62,,389.36,percent of total billed charges,Behavioral Health,364.24,56,,364.24,percent of total billed charges,Behavioral Health,351.68,53,,351.68,percent of total billed charges,Behavioral Health,310.86,,,310.86,Other,110% of Medicare,427.04,68,,427.04,percent of total billed charges,All Other,0.01,,,0.01,Other,186% of Medicaid,502.4,80,,502.4,percent of total billed charges,All Other,521.24,83,,521.24,percent of total billed charges,All Other,521.24,83,,521.24,percent of total billed charges,All Other,502.4,80,,502.4,percent of total billed charges,All Other,521.24,83,,521.24,percent of total billed charges,All Other,502.4,80,,502.4,percent of total billed charges,All Other,439.6,70,,439.6,percent of total billed charges,All Other,247.59,,,247.59,Other,130% of Medicare,247.59,,,247.59,Other,130% of Medicare,98.55,,,98.55,Fee Schedule,Behavioral Health,98.55,,,98.55,Fee Schedule,Behavioral Health,98.55,,,98.55,Fee Schedule,Behavioral Health,98.55,,,98.55,Fee Schedule,Behavioral Health,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,521.24,
OFFICE/OUTPAT VISIT EST 5 MIN,99211,CPT,HE,39099211,CDM,900,RC,,,both,,,228,168.72,,,168.72,Other,150% of Medicare + 9.63% HCRA Surcharge,102.6,45,,102.6,percent of total billed charges,Critical Access Hospital RCC factor,148.2,65,,148.2,percent of total billed charges,All Other,134.52,65,,134.52,percent of total billed charges,All Other,141.36,62,,141.36,percent of total billed charges,Behavioral Health,132.24,56,,132.24,percent of total billed charges,Behavioral Health,127.68,53,,127.68,percent of total billed charges,Behavioral Health,112.86,,,112.86,Other,110% of Medicare,155.04,68,,155.04,percent of total billed charges,All Other,0.01,,,0.01,Other,186% of Medicaid,182.4,80,,182.4,percent of total billed charges,All Other,189.24,83,,189.24,percent of total billed charges,All Other,189.24,83,,189.24,percent of total billed charges,All Other,182.4,80,,182.4,percent of total billed charges,All Other,189.24,83,,189.24,percent of total billed charges,All Other,182.4,80,,182.4,percent of total billed charges,All Other,159.6,70,,159.6,percent of total billed charges,All Other,52,,,52,Fee Schedule,Behavioral Health,44,,,44,Fee Schedule,Behavioral Health,48.23,,,48.23,Fee Schedule,Behavioral Health,48.23,,,48.23,Fee Schedule,Behavioral Health,48.23,,,48.23,Fee Schedule,Behavioral Health,48.23,,,48.23,Fee Schedule,Behavioral Health,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,189.24,
OFFICE/OUTPAT VISIT EST 10 MIN,99212,CPT,HE,39099212,CDM,900,RC,,,both,,,259,191.66,,,191.66,Other,150% of Medicare + 9.63% HCRA Surcharge,116.55,45,,116.55,percent of total billed charges,Critical Access Hospital RCC factor,168.35,65,,168.35,percent of total billed charges,All Other,152.81,65,,152.81,percent of total billed charges,All Other,160.58,62,,160.58,percent of total billed charges,Behavioral Health,150.22,56,,150.22,percent of total billed charges,Behavioral Health,145.04,53,,145.04,percent of total billed charges,Behavioral Health,128.21,,,128.21,Other,110% of Medicare,176.12,68,,176.12,percent of total billed charges,All Other,0.01,,,0.01,Other,186% of Medicaid,207.2,80,,207.2,percent of total billed charges,All Other,214.97,83,,214.97,percent of total billed charges,All Other,214.97,83,,214.97,percent of total billed charges,All Other,207.2,80,,207.2,percent of total billed charges,All Other,214.97,83,,214.97,percent of total billed charges,All Other,207.2,80,,207.2,percent of total billed charges,All Other,181.3,70,,181.3,percent of total billed charges,All Other,97,,,97,Fee Schedule,Behavioral Health,82,,,82,Fee Schedule,Behavioral Health,55.27,,,55.27,Fee Schedule,Behavioral Health,55.27,,,55.27,Fee Schedule,Behavioral Health,55.27,,,55.27,Fee Schedule,Behavioral Health,55.27,,,55.27,Fee Schedule,Behavioral Health,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,214.97,
OFFICE/OUTPAT VISIT EST 20 MIN,99213,CPT,HE,39099213,CDM,900,RC,,,both,,,259,191.66,,,191.66,Other,150% of Medicare + 9.63% HCRA Surcharge,116.55,45,,116.55,percent of total billed charges,Critical Access Hospital RCC factor,168.35,65,,168.35,percent of total billed charges,All Other,152.81,65,,152.81,percent of total billed charges,All Other,160.58,62,,160.58,percent of total billed charges,Behavioral Health,150.22,56,,150.22,percent of total billed charges,Behavioral Health,145.04,53,,145.04,percent of total billed charges,Behavioral Health,128.21,,,128.21,Other,110% of Medicare,176.12,68,,176.12,percent of total billed charges,All Other,0.01,,,0.01,Other,186% of Medicaid,207.2,80,,207.2,percent of total billed charges,All Other,214.97,83,,214.97,percent of total billed charges,All Other,214.97,83,,214.97,percent of total billed charges,All Other,207.2,80,,207.2,percent of total billed charges,All Other,214.97,83,,214.97,percent of total billed charges,All Other,207.2,80,,207.2,percent of total billed charges,All Other,181.3,70,,181.3,percent of total billed charges,All Other,115,,,115,Fee Schedule,Behavioral Health,98,,,98,Fee Schedule,Behavioral Health,55.27,,,55.27,Fee Schedule,Behavioral Health,55.27,,,55.27,Fee Schedule,Behavioral Health,55.27,,,55.27,Fee Schedule,Behavioral Health,55.27,,,55.27,Fee Schedule,Behavioral Health,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,214.97,
OFFICE/OUTPAT VISIT EST 30 MIN,99214,CPT,HE,39099214,CDM,900,RC,,,both,,,340,251.6,,,251.6,Other,150% of Medicare + 9.63% HCRA Surcharge,153,45,,153,percent of total billed charges,Critical Access Hospital RCC factor,221,65,,221,percent of total billed charges,All Other,200.6,65,,200.6,percent of total billed charges,All Other,210.8,62,,210.8,percent of total billed charges,Behavioral Health,197.2,56,,197.2,percent of total billed charges,Behavioral Health,190.4,53,,190.4,percent of total billed charges,Behavioral Health,168.3,,,168.3,Other,110% of Medicare,231.2,68,,231.2,percent of total billed charges,All Other,0.01,,,0.01,Other,186% of Medicaid,272,80,,272,percent of total billed charges,All Other,282.2,83,,282.2,percent of total billed charges,All Other,282.2,83,,282.2,percent of total billed charges,All Other,272,80,,272,percent of total billed charges,All Other,282.2,83,,282.2,percent of total billed charges,All Other,272,80,,272,percent of total billed charges,All Other,238,70,,238,percent of total billed charges,All Other,130,,,130,Fee Schedule,Behavioral Health,111,,,111,Fee Schedule,Behavioral Health,77.42,,,77.42,Fee Schedule,Behavioral Health,77.42,,,77.42,Fee Schedule,Behavioral Health,77.42,,,77.42,Fee Schedule,Behavioral Health,77.42,,,77.42,Fee Schedule,Behavioral Health,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,282.2,
OFFICE/OUTPAT VISIT EST 40 MIN,99215,CPT,HE,39099215,CDM,900,RC,,,both,,,440,325.6,,,325.6,Other,150% of Medicare + 9.63% HCRA Surcharge,198,45,,198,percent of total billed charges,Critical Access Hospital RCC factor,286,65,,286,percent of total billed charges,All Other,259.6,65,,259.6,percent of total billed charges,All Other,272.8,62,,272.8,percent of total billed charges,Behavioral Health,255.2,56,,255.2,percent of total billed charges,Behavioral Health,246.4,53,,246.4,percent of total billed charges,Behavioral Health,217.8,,,217.8,Other,110% of Medicare,299.2,68,,299.2,percent of total billed charges,All Other,0.01,,,0.01,Other,186% of Medicaid,352,80,,352,percent of total billed charges,All Other,365.2,83,,365.2,percent of total billed charges,All Other,365.2,83,,365.2,percent of total billed charges,All Other,352,80,,352,percent of total billed charges,All Other,365.2,83,,365.2,percent of total billed charges,All Other,352,80,,352,percent of total billed charges,All Other,308,70,,308,percent of total billed charges,All Other,209,,,209,Fee Schedule,Behavioral Health,178,,,178,Fee Schedule,Behavioral Health,114.4,,,114.4,Fee Schedule,Behavioral Health,114.4,,,114.4,Fee Schedule,Behavioral Health,114.4,,,114.4,Fee Schedule,Behavioral Health,114.4,,,114.4,Fee Schedule,Behavioral Health,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,365.2,
PSYCH DIAGNOSTIC EVALUATION - TH,90791,CPT,,39190791,CDM,900,RC,,,both,,,399,295.26,,,295.26,Other,150% of Medicare + 9.63% HCRA Surcharge,179.55,45,,179.55,percent of total billed charges,Critical Access Hospital RCC factor,259.35,65,,259.35,percent of total billed charges,All Other,235.41,65,,235.41,percent of total billed charges,All Other,190,,,190,Fee Schedule,Behavioral Health,171,,,171,Fee Schedule,Behavioral Health,162,,,162,Fee Schedule,Behavioral Health,197.51,,,197.51,Other,110% of Medicare,230.13,,,230.13,Fee Schedule,Behavioral Health,291,,,291,Other,186% of Medicaid,230.13,,,230.13,Fee Schedule,Behavioral Health,230.13,,,230.13,Fee Schedule,Behavioral Health,230.13,,,230.13,Fee Schedule,Behavioral Health,230.13,,,230.13,Fee Schedule,Behavioral Health,230.13,,,230.13,Fee Schedule,Behavioral Health,319.2,80,,319.2,percent of total billed charges,All Other,279.3,70,,279.3,percent of total billed charges,All Other,217,,,217,Fee Schedule,Behavioral Health,184,,,184,Fee Schedule,Behavioral Health,139.73,,,139.73,Fee Schedule,Behavioral Health,139.73,,,139.73,Fee Schedule,Behavioral Health,139.73,,,139.73,Fee Schedule,Behavioral Health,139.73,,,139.73,Fee Schedule,Behavioral Health,156.36,,,156.36,Other,100% of Medicaid,156.36,,,156.36,Other,100% of Medicaid,156.36,,,156.36,Other,100% of Medicaid,156.36,,,156.36,Other,100% of Medicaid,351.81,,,351.81,Other,225% of Medicaid,239.23,,,239.23,Other,153% of Medicaid,351.81,,,351.81,Other,225% of Medicaid,218.91,,,218.91,Other,140% of Medicaid,351.81,,,351.81,Other,225% of Medicaid,406.54,,,406.54,Other,260% of Medicaid,506.61,,,506.61,Other,324% of Medicaid,336.18,,,336.18,Other,215% of Medicaid,336.18,,,336.18,Other,215% of Medicaid,195.45,,,195.45,Other,125% of Medicaid,139.73,506.61,
OFFICE/OUTPAT VISIT NEW 15 MIN TELEPSYCH,99202,CPT,HE95,39199202,CDM,900,RC,,,both,,,252,186.48,,,186.48,Other,150% of Medicare + 9.63% HCRA Surcharge,113.4,45,,113.4,percent of total billed charges,Critical Access Hospital RCC factor,163.8,65,,163.8,percent of total billed charges,All Other,148.68,65,,148.68,percent of total billed charges,All Other,156.24,62,,156.24,percent of total billed charges,Behavioral Health,146.16,56,,146.16,percent of total billed charges,Behavioral Health,141.12,53,,141.12,percent of total billed charges,Behavioral Health,124.74,,,124.74,Other,110% of Medicare,171.36,68,,171.36,percent of total billed charges,All Other,0.01,,,0.01,Other,186% of Medicaid,201.6,80,,201.6,percent of total billed charges,All Other,209.16,83,,209.16,percent of total billed charges,All Other,209.16,83,,209.16,percent of total billed charges,All Other,201.6,80,,201.6,percent of total billed charges,All Other,209.16,83,,209.16,percent of total billed charges,All Other,201.6,80,,201.6,percent of total billed charges,All Other,64.56,70,,64.56,percent of total billed charges,All Other,64.56,,,64.56,Other,130% of Medicare,64.56,,,64.56,Other,130% of Medicare,23.95,,,23.95,Fee Schedule,Behavioral Health,23.95,,,23.95,Fee Schedule,Behavioral Health,23.95,,,23.95,Fee Schedule,Behavioral Health,23.95,,,23.95,Fee Schedule,Behavioral Health,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,209.16,
OFFICE/OUTPAT VISIT NEW 30 MIN TELEPSYCH,99203,CPT,HE95,39199203,CDM,900,RC,,,both,,,345,255.3,,,255.3,Other,150% of Medicare + 9.63% HCRA Surcharge,155.25,45,,155.25,percent of total billed charges,Critical Access Hospital RCC factor,224.25,65,,224.25,percent of total billed charges,All Other,203.55,65,,203.55,percent of total billed charges,All Other,213.9,62,,213.9,percent of total billed charges,Behavioral Health,200.1,56,,200.1,percent of total billed charges,Behavioral Health,193.2,53,,193.2,percent of total billed charges,Behavioral Health,170.78,,,170.78,Other,110% of Medicare,234.6,68,,234.6,percent of total billed charges,All Other,0.01,,,0.01,Other,186% of Medicaid,276,80,,276,percent of total billed charges,All Other,286.35,83,,286.35,percent of total billed charges,All Other,286.35,83,,286.35,percent of total billed charges,All Other,276,80,,276,percent of total billed charges,All Other,286.35,83,,286.35,percent of total billed charges,All Other,276,80,,276,percent of total billed charges,All Other,241.5,70,,241.5,percent of total billed charges,All Other,111.9,,,111.9,Other,130% of Medicare,111.9,,,111.9,Other,130% of Medicare,41.89,,,41.89,Fee Schedule,Behavioral Health,41.89,,,41.89,Fee Schedule,Behavioral Health,41.89,,,41.89,Fee Schedule,Behavioral Health,41.89,,,41.89,Fee Schedule,Behavioral Health,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,286.35,
OFFICE/OUTPAT VISIT NEW 45 MIN TELEPSYCH,99204,CPT,HE95,39199204,CDM,900,RC,,,both,,,460,340.4,,,340.4,Other,150% of Medicare + 9.63% HCRA Surcharge,207,45,,207,percent of total billed charges,Critical Access Hospital RCC factor,299,65,,299,percent of total billed charges,All Other,271.4,65,,271.4,percent of total billed charges,All Other,285.2,62,,285.2,percent of total billed charges,Behavioral Health,266.8,56,,266.8,percent of total billed charges,Behavioral Health,257.6,53,,257.6,percent of total billed charges,Behavioral Health,227.7,,,227.7,Other,110% of Medicare,312.8,68,,312.8,percent of total billed charges,All Other,0.01,,,0.01,Other,186% of Medicaid,368,80,,368,percent of total billed charges,All Other,381.8,83,,381.8,percent of total billed charges,All Other,381.8,83,,381.8,percent of total billed charges,All Other,368,80,,368,percent of total billed charges,All Other,381.8,83,,381.8,percent of total billed charges,All Other,368,80,,368,percent of total billed charges,All Other,322,70,,322,percent of total billed charges,All Other,181.94,,,181.94,Other,130% of Medicare,181.94,,,181.94,Other,130% of Medicare,68.97,,,68.97,Fee Schedule,Behavioral Health,68.97,,,68.97,Fee Schedule,Behavioral Health,68.97,,,68.97,Fee Schedule,Behavioral Health,68.97,,,68.97,Fee Schedule,Behavioral Health,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,381.8,
OFFICE/OUTPAT VISIT NEW 60 MIN TELEPSYCH,99205,CPT,HE95,39199205,CDM,900,RC,,,both,,,628,464.72,,,464.72,Other,150% of Medicare + 9.63% HCRA Surcharge,282.6,45,,282.6,percent of total billed charges,Critical Access Hospital RCC factor,408.2,65,,408.2,percent of total billed charges,All Other,370.52,65,,370.52,percent of total billed charges,All Other,389.36,62,,389.36,percent of total billed charges,Behavioral Health,364.24,56,,364.24,percent of total billed charges,Behavioral Health,351.68,53,,351.68,percent of total billed charges,Behavioral Health,310.86,,,310.86,Other,110% of Medicare,427.04,68,,427.04,percent of total billed charges,All Other,0.01,,,0.01,Other,186% of Medicaid,502.4,80,,502.4,percent of total billed charges,All Other,521.24,83,,521.24,percent of total billed charges,All Other,521.24,83,,521.24,percent of total billed charges,All Other,502.4,80,,502.4,percent of total billed charges,All Other,521.24,83,,521.24,percent of total billed charges,All Other,502.4,80,,502.4,percent of total billed charges,All Other,439.6,70,,439.6,percent of total billed charges,All Other,247.59,,,247.59,Other,130% of Medicare,247.59,,,247.59,Other,130% of Medicare,98.55,,,98.55,Fee Schedule,Behavioral Health,98.55,,,98.55,Fee Schedule,Behavioral Health,98.55,,,98.55,Fee Schedule,Behavioral Health,98.55,,,98.55,Fee Schedule,Behavioral Health,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,521.24,
OFFICE/OUTPAT VISIT EST 5 MIN TELEPSYCH,99211,CPT,HEGT,39199211,CDM,900,RC,,,both,,,228,168.72,,,168.72,Other,150% of Medicare + 9.63% HCRA Surcharge,102.6,45,,102.6,percent of total billed charges,Critical Access Hospital RCC factor,148.2,65,,148.2,percent of total billed charges,All Other,134.52,65,,134.52,percent of total billed charges,All Other,141.36,62,,141.36,percent of total billed charges,Behavioral Health,132.24,56,,132.24,percent of total billed charges,Behavioral Health,127.68,53,,127.68,percent of total billed charges,Behavioral Health,112.86,,,112.86,Other,110% of Medicare,155.04,68,,155.04,percent of total billed charges,All Other,0.01,,,0.01,Other,186% of Medicaid,182.4,80,,182.4,percent of total billed charges,All Other,189.24,83,,189.24,percent of total billed charges,All Other,189.24,83,,189.24,percent of total billed charges,All Other,182.4,80,,182.4,percent of total billed charges,All Other,189.24,83,,189.24,percent of total billed charges,All Other,182.4,80,,182.4,percent of total billed charges,All Other,159.6,70,,159.6,percent of total billed charges,All Other,52,,,52,Fee Schedule,Behavioral Health,44,,,44,Fee Schedule,Behavioral Health,48.23,,,48.23,Fee Schedule,Behavioral Health,48.23,,,48.23,Fee Schedule,Behavioral Health,48.23,,,48.23,Fee Schedule,Behavioral Health,48.23,,,48.23,Fee Schedule,Behavioral Health,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,189.24,
OFFICE/OUTPAT VISIT EST 10 MIN TELEPSYCH,99212,CPT,HE95,39199212,CDM,900,RC,,,both,,,259,191.66,,,191.66,Other,150% of Medicare + 9.63% HCRA Surcharge,116.55,45,,116.55,percent of total billed charges,Critical Access Hospital RCC factor,168.35,65,,168.35,percent of total billed charges,All Other,152.81,65,,152.81,percent of total billed charges,All Other,160.58,62,,160.58,percent of total billed charges,Behavioral Health,150.22,56,,150.22,percent of total billed charges,Behavioral Health,145.04,53,,145.04,percent of total billed charges,Behavioral Health,128.21,,,128.21,Other,110% of Medicare,176.12,68,,176.12,percent of total billed charges,All Other,0.01,,,0.01,Other,186% of Medicaid,207.2,80,,207.2,percent of total billed charges,All Other,214.97,83,,214.97,percent of total billed charges,All Other,214.97,83,,214.97,percent of total billed charges,All Other,207.2,80,,207.2,percent of total billed charges,All Other,214.97,83,,214.97,percent of total billed charges,All Other,207.2,80,,207.2,percent of total billed charges,All Other,181.3,70,,181.3,percent of total billed charges,All Other,97,,,97,Fee Schedule,Behavioral Health,82,,,82,Fee Schedule,Behavioral Health,55.27,,,55.27,Fee Schedule,Behavioral Health,55.27,,,55.27,Fee Schedule,Behavioral Health,55.27,,,55.27,Fee Schedule,Behavioral Health,55.27,,,55.27,Fee Schedule,Behavioral Health,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,214.97,
OFFICE/OUTPAT VISIT EST 20 MIN TELEPSYCH,99213,CPT,HE95,39199213,CDM,900,RC,,,both,,,259,191.66,,,191.66,Other,150% of Medicare + 9.63% HCRA Surcharge,116.55,45,,116.55,percent of total billed charges,Critical Access Hospital RCC factor,168.35,65,,168.35,percent of total billed charges,All Other,152.81,65,,152.81,percent of total billed charges,All Other,160.58,62,,160.58,percent of total billed charges,Behavioral Health,150.22,56,,150.22,percent of total billed charges,Behavioral Health,145.04,53,,145.04,percent of total billed charges,Behavioral Health,128.21,,,128.21,Other,110% of Medicare,176.12,68,,176.12,percent of total billed charges,All Other,0.01,,,0.01,Other,186% of Medicaid,207.2,80,,207.2,percent of total billed charges,All Other,214.97,83,,214.97,percent of total billed charges,All Other,214.97,83,,214.97,percent of total billed charges,All Other,207.2,80,,207.2,percent of total billed charges,All Other,214.97,83,,214.97,percent of total billed charges,All Other,207.2,80,,207.2,percent of total billed charges,All Other,181.3,70,,181.3,percent of total billed charges,All Other,115,,,115,Fee Schedule,Behavioral Health,98,,,98,Fee Schedule,Behavioral Health,55.27,,,55.27,Fee Schedule,Behavioral Health,55.27,,,55.27,Fee Schedule,Behavioral Health,55.27,,,55.27,Fee Schedule,Behavioral Health,55.27,,,55.27,Fee Schedule,Behavioral Health,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,214.97,
OFFICE/OUTPAT VISIT EST 30 MIN TELEPSYCH,99214,CPT,HEGT,39199214,CDM,900,RC,,,both,,,340,251.6,,,251.6,Other,150% of Medicare + 9.63% HCRA Surcharge,153,45,,153,percent of total billed charges,Critical Access Hospital RCC factor,221,65,,221,percent of total billed charges,All Other,200.6,65,,200.6,percent of total billed charges,All Other,210.8,62,,210.8,percent of total billed charges,Behavioral Health,197.2,56,,197.2,percent of total billed charges,Behavioral Health,190.4,53,,190.4,percent of total billed charges,Behavioral Health,168.3,,,168.3,Other,110% of Medicare,231.2,68,,231.2,percent of total billed charges,All Other,0.01,,,0.01,Other,186% of Medicaid,272,80,,272,percent of total billed charges,All Other,282.2,83,,282.2,percent of total billed charges,All Other,282.2,83,,282.2,percent of total billed charges,All Other,272,80,,272,percent of total billed charges,All Other,282.2,83,,282.2,percent of total billed charges,All Other,272,80,,272,percent of total billed charges,All Other,238,70,,238,percent of total billed charges,All Other,130,,,130,Fee Schedule,Behavioral Health,111,,,111,Fee Schedule,Behavioral Health,77.42,,,77.42,Fee Schedule,Behavioral Health,77.42,,,77.42,Fee Schedule,Behavioral Health,77.42,,,77.42,Fee Schedule,Behavioral Health,77.42,,,77.42,Fee Schedule,Behavioral Health,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,282.2,
OFFICE/OUTPAT VISIT EST 40 MIN TELEPSYCH,99215,CPT,HE95,39199215,CDM,900,RC,,,both,,,440,325.6,,,325.6,Other,150% of Medicare + 9.63% HCRA Surcharge,198,45,,198,percent of total billed charges,Critical Access Hospital RCC factor,286,65,,286,percent of total billed charges,All Other,259.6,65,,259.6,percent of total billed charges,All Other,272.8,62,,272.8,percent of total billed charges,Behavioral Health,255.2,56,,255.2,percent of total billed charges,Behavioral Health,246.4,53,,246.4,percent of total billed charges,Behavioral Health,217.8,,,217.8,Other,110% of Medicare,299.2,68,,299.2,percent of total billed charges,All Other,0.01,,,0.01,Other,186% of Medicaid,352,80,,352,percent of total billed charges,All Other,365.2,83,,365.2,percent of total billed charges,All Other,365.2,83,,365.2,percent of total billed charges,All Other,352,80,,352,percent of total billed charges,All Other,365.2,83,,365.2,percent of total billed charges,All Other,352,80,,352,percent of total billed charges,All Other,308,70,,308,percent of total billed charges,All Other,209,,,209,Fee Schedule,Behavioral Health,178,,,178,Fee Schedule,Behavioral Health,114.4,,,114.4,Fee Schedule,Behavioral Health,114.4,,,114.4,Fee Schedule,Behavioral Health,114.4,,,114.4,Fee Schedule,Behavioral Health,114.4,,,114.4,Fee Schedule,Behavioral Health,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,365.2,
PSYCH DIAGNOSTIC EVALUATION,90791,CPT,,40090791,CDM,900,RC,,,both,,,399,295.26,,,295.26,Other,150% of Medicare + 9.63% HCRA Surcharge,179.55,45,,179.55,percent of total billed charges,Critical Access Hospital RCC factor,259.35,65,,259.35,percent of total billed charges,All Other,235.41,65,,235.41,percent of total billed charges,All Other,190,,,190,Fee Schedule,Behavioral Health,171,,,171,Fee Schedule,Behavioral Health,162,,,162,Fee Schedule,Behavioral Health,197.51,,,197.51,Other,110% of Medicare,230.13,,,230.13,Fee Schedule,Behavioral Health,291,,,291,Other,186% of Medicaid,230.13,,,230.13,Fee Schedule,Behavioral Health,230.13,,,230.13,Fee Schedule,Behavioral Health,230.13,,,230.13,Fee Schedule,Behavioral Health,230.13,,,230.13,Fee Schedule,Behavioral Health,230.13,,,230.13,Fee Schedule,Behavioral Health,319.2,80,,319.2,percent of total billed charges,All Other,279.3,70,,279.3,percent of total billed charges,All Other,217,,,217,Fee Schedule,Behavioral Health,184,,,184,Fee Schedule,Behavioral Health,139.73,,,139.73,Fee Schedule,Behavioral Health,139.73,,,139.73,Fee Schedule,Behavioral Health,139.73,,,139.73,Fee Schedule,Behavioral Health,139.73,,,139.73,Fee Schedule,Behavioral Health,156.36,,,156.36,Other,100% of Medicaid,156.36,,,156.36,Other,100% of Medicaid,156.36,,,156.36,Other,100% of Medicaid,156.36,,,156.36,Other,100% of Medicaid,351.81,,,351.81,Other,225% of Medicaid,239.23,,,239.23,Other,153% of Medicaid,351.81,,,351.81,Other,225% of Medicaid,218.91,,,218.91,Other,140% of Medicaid,351.81,,,351.81,Other,225% of Medicaid,406.54,,,406.54,Other,260% of Medicaid,506.61,,,506.61,Other,324% of Medicaid,336.18,,,336.18,Other,215% of Medicaid,336.18,,,336.18,Other,215% of Medicaid,195.45,,,195.45,Other,125% of Medicaid,139.73,506.61,
OFFICE/OUTPAT VISIT NEW 15 MIN,99202,CPT,HE,40099202,CDM,900,RC,,,both,,,252,186.48,,,186.48,Other,150% of Medicare + 9.63% HCRA Surcharge,113.4,45,,113.4,percent of total billed charges,Critical Access Hospital RCC factor,163.8,65,,163.8,percent of total billed charges,All Other,148.68,65,,148.68,percent of total billed charges,All Other,156.24,62,,156.24,percent of total billed charges,Behavioral Health,146.16,56,,146.16,percent of total billed charges,Behavioral Health,141.12,53,,141.12,percent of total billed charges,Behavioral Health,124.74,,,124.74,Other,110% of Medicare,171.36,68,,171.36,percent of total billed charges,All Other,0.01,,,0.01,Other,186% of Medicaid,201.6,80,,201.6,percent of total billed charges,All Other,209.16,83,,209.16,percent of total billed charges,All Other,209.16,83,,209.16,percent of total billed charges,All Other,201.6,80,,201.6,percent of total billed charges,All Other,209.16,83,,209.16,percent of total billed charges,All Other,201.6,80,,201.6,percent of total billed charges,All Other,64.56,70,,64.56,percent of total billed charges,All Other,64.56,,,64.56,Other,130% of Medicare,64.56,,,64.56,Other,130% of Medicare,23.95,,,23.95,Fee Schedule,Behavioral Health,23.95,,,23.95,Fee Schedule,Behavioral Health,23.95,,,23.95,Fee Schedule,Behavioral Health,23.95,,,23.95,Fee Schedule,Behavioral Health,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,209.16,
OFFICE/OUTPAT VISIT NEW 30 MIN,99203,CPT,HE,40099203,CDM,900,RC,,,both,,,345,255.3,,,255.3,Other,150% of Medicare + 9.63% HCRA Surcharge,155.25,45,,155.25,percent of total billed charges,Critical Access Hospital RCC factor,224.25,65,,224.25,percent of total billed charges,All Other,203.55,65,,203.55,percent of total billed charges,All Other,213.9,62,,213.9,percent of total billed charges,Behavioral Health,200.1,56,,200.1,percent of total billed charges,Behavioral Health,193.2,53,,193.2,percent of total billed charges,Behavioral Health,170.78,,,170.78,Other,110% of Medicare,234.6,68,,234.6,percent of total billed charges,All Other,0.01,,,0.01,Other,186% of Medicaid,276,80,,276,percent of total billed charges,All Other,286.35,83,,286.35,percent of total billed charges,All Other,286.35,83,,286.35,percent of total billed charges,All Other,276,80,,276,percent of total billed charges,All Other,286.35,83,,286.35,percent of total billed charges,All Other,276,80,,276,percent of total billed charges,All Other,241.5,70,,241.5,percent of total billed charges,All Other,111.9,,,111.9,Other,130% of Medicare,111.9,,,111.9,Other,130% of Medicare,41.89,,,41.89,Fee Schedule,Behavioral Health,41.89,,,41.89,Fee Schedule,Behavioral Health,41.89,,,41.89,Fee Schedule,Behavioral Health,41.89,,,41.89,Fee Schedule,Behavioral Health,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,286.35,
OFFICE/OUTPAT VISIT NEW 45 MIN,99204,CPT,HE,40099204,CDM,900,RC,,,both,,,460,340.4,,,340.4,Other,150% of Medicare + 9.63% HCRA Surcharge,207,45,,207,percent of total billed charges,Critical Access Hospital RCC factor,299,65,,299,percent of total billed charges,All Other,271.4,65,,271.4,percent of total billed charges,All Other,285.2,62,,285.2,percent of total billed charges,Behavioral Health,266.8,56,,266.8,percent of total billed charges,Behavioral Health,257.6,53,,257.6,percent of total billed charges,Behavioral Health,227.7,,,227.7,Other,110% of Medicare,312.8,68,,312.8,percent of total billed charges,All Other,0.01,,,0.01,Other,186% of Medicaid,368,80,,368,percent of total billed charges,All Other,381.8,83,,381.8,percent of total billed charges,All Other,381.8,83,,381.8,percent of total billed charges,All Other,368,80,,368,percent of total billed charges,All Other,381.8,83,,381.8,percent of total billed charges,All Other,368,80,,368,percent of total billed charges,All Other,322,70,,322,percent of total billed charges,All Other,181.94,,,181.94,Other,130% of Medicare,181.94,,,181.94,Other,130% of Medicare,68.97,,,68.97,Fee Schedule,Behavioral Health,68.97,,,68.97,Fee Schedule,Behavioral Health,68.97,,,68.97,Fee Schedule,Behavioral Health,68.97,,,68.97,Fee Schedule,Behavioral Health,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,381.8,
OFFICE/OUTPAT VISIT NEW 60 MIN,99205,CPT,HE,40099205,CDM,900,RC,,,both,,,628,464.72,,,464.72,Other,150% of Medicare + 9.63% HCRA Surcharge,282.6,45,,282.6,percent of total billed charges,Critical Access Hospital RCC factor,408.2,65,,408.2,percent of total billed charges,All Other,370.52,65,,370.52,percent of total billed charges,All Other,389.36,62,,389.36,percent of total billed charges,Behavioral Health,364.24,56,,364.24,percent of total billed charges,Behavioral Health,351.68,53,,351.68,percent of total billed charges,Behavioral Health,310.86,,,310.86,Other,110% of Medicare,427.04,68,,427.04,percent of total billed charges,All Other,0.01,,,0.01,Other,186% of Medicaid,502.4,80,,502.4,percent of total billed charges,All Other,521.24,83,,521.24,percent of total billed charges,All Other,521.24,83,,521.24,percent of total billed charges,All Other,502.4,80,,502.4,percent of total billed charges,All Other,521.24,83,,521.24,percent of total billed charges,All Other,502.4,80,,502.4,percent of total billed charges,All Other,439.6,70,,439.6,percent of total billed charges,All Other,247.59,,,247.59,Other,130% of Medicare,247.59,,,247.59,Other,130% of Medicare,98.55,,,98.55,Fee Schedule,Behavioral Health,98.55,,,98.55,Fee Schedule,Behavioral Health,98.55,,,98.55,Fee Schedule,Behavioral Health,98.55,,,98.55,Fee Schedule,Behavioral Health,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,521.24,
OFFICE/OUTPAT VISIT EST 5 MIN,99211,CPT,HE,40099211,CDM,900,RC,,,both,,,228,168.72,,,168.72,Other,150% of Medicare + 9.63% HCRA Surcharge,102.6,45,,102.6,percent of total billed charges,Critical Access Hospital RCC factor,148.2,65,,148.2,percent of total billed charges,All Other,134.52,65,,134.52,percent of total billed charges,All Other,141.36,62,,141.36,percent of total billed charges,Behavioral Health,132.24,56,,132.24,percent of total billed charges,Behavioral Health,127.68,53,,127.68,percent of total billed charges,Behavioral Health,112.86,,,112.86,Other,110% of Medicare,155.04,68,,155.04,percent of total billed charges,All Other,0.01,,,0.01,Other,186% of Medicaid,182.4,80,,182.4,percent of total billed charges,All Other,189.24,83,,189.24,percent of total billed charges,All Other,189.24,83,,189.24,percent of total billed charges,All Other,182.4,80,,182.4,percent of total billed charges,All Other,189.24,83,,189.24,percent of total billed charges,All Other,182.4,80,,182.4,percent of total billed charges,All Other,159.6,70,,159.6,percent of total billed charges,All Other,52,,,52,Fee Schedule,Behavioral Health,44,,,44,Fee Schedule,Behavioral Health,48.23,,,48.23,Fee Schedule,Behavioral Health,48.23,,,48.23,Fee Schedule,Behavioral Health,48.23,,,48.23,Fee Schedule,Behavioral Health,48.23,,,48.23,Fee Schedule,Behavioral Health,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,189.24,
OFFICE/OUTPAT VISIT EST 10 MIN,99212,CPT,HE,40099212,CDM,900,RC,,,both,,,259,191.66,,,191.66,Other,150% of Medicare + 9.63% HCRA Surcharge,116.55,45,,116.55,percent of total billed charges,Critical Access Hospital RCC factor,168.35,65,,168.35,percent of total billed charges,All Other,152.81,65,,152.81,percent of total billed charges,All Other,160.58,62,,160.58,percent of total billed charges,Behavioral Health,150.22,56,,150.22,percent of total billed charges,Behavioral Health,145.04,53,,145.04,percent of total billed charges,Behavioral Health,128.21,,,128.21,Other,110% of Medicare,176.12,68,,176.12,percent of total billed charges,All Other,0.01,,,0.01,Other,186% of Medicaid,207.2,80,,207.2,percent of total billed charges,All Other,214.97,83,,214.97,percent of total billed charges,All Other,214.97,83,,214.97,percent of total billed charges,All Other,207.2,80,,207.2,percent of total billed charges,All Other,214.97,83,,214.97,percent of total billed charges,All Other,207.2,80,,207.2,percent of total billed charges,All Other,181.3,70,,181.3,percent of total billed charges,All Other,97,,,97,Fee Schedule,Behavioral Health,82,,,82,Fee Schedule,Behavioral Health,55.27,,,55.27,Fee Schedule,Behavioral Health,55.27,,,55.27,Fee Schedule,Behavioral Health,55.27,,,55.27,Fee Schedule,Behavioral Health,55.27,,,55.27,Fee Schedule,Behavioral Health,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,214.97,
OFFICE/OUTPAT VISIT EST 20 MIN,99213,CPT,HE,40099213,CDM,900,RC,,,both,,,259,191.66,,,191.66,Other,150% of Medicare + 9.63% HCRA Surcharge,116.55,45,,116.55,percent of total billed charges,Critical Access Hospital RCC factor,168.35,65,,168.35,percent of total billed charges,All Other,152.81,65,,152.81,percent of total billed charges,All Other,160.58,62,,160.58,percent of total billed charges,Behavioral Health,150.22,56,,150.22,percent of total billed charges,Behavioral Health,145.04,53,,145.04,percent of total billed charges,Behavioral Health,128.21,,,128.21,Other,110% of Medicare,176.12,68,,176.12,percent of total billed charges,All Other,0.01,,,0.01,Other,186% of Medicaid,207.2,80,,207.2,percent of total billed charges,All Other,214.97,83,,214.97,percent of total billed charges,All Other,214.97,83,,214.97,percent of total billed charges,All Other,207.2,80,,207.2,percent of total billed charges,All Other,214.97,83,,214.97,percent of total billed charges,All Other,207.2,80,,207.2,percent of total billed charges,All Other,181.3,70,,181.3,percent of total billed charges,All Other,115,,,115,Fee Schedule,Behavioral Health,98,,,98,Fee Schedule,Behavioral Health,55.27,,,55.27,Fee Schedule,Behavioral Health,55.27,,,55.27,Fee Schedule,Behavioral Health,55.27,,,55.27,Fee Schedule,Behavioral Health,55.27,,,55.27,Fee Schedule,Behavioral Health,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,214.97,
OFFICE/OUTPAT VISIT EST 30 MIN,99214,CPT,HE,40099214,CDM,900,RC,,,both,,,340,251.6,,,251.6,Other,150% of Medicare + 9.63% HCRA Surcharge,153,45,,153,percent of total billed charges,Critical Access Hospital RCC factor,221,65,,221,percent of total billed charges,All Other,200.6,65,,200.6,percent of total billed charges,All Other,210.8,62,,210.8,percent of total billed charges,Behavioral Health,197.2,56,,197.2,percent of total billed charges,Behavioral Health,190.4,53,,190.4,percent of total billed charges,Behavioral Health,168.3,,,168.3,Other,110% of Medicare,231.2,68,,231.2,percent of total billed charges,All Other,0.01,,,0.01,Other,186% of Medicaid,272,80,,272,percent of total billed charges,All Other,282.2,83,,282.2,percent of total billed charges,All Other,282.2,83,,282.2,percent of total billed charges,All Other,272,80,,272,percent of total billed charges,All Other,282.2,83,,282.2,percent of total billed charges,All Other,272,80,,272,percent of total billed charges,All Other,238,70,,238,percent of total billed charges,All Other,130,,,130,Fee Schedule,Behavioral Health,111,,,111,Fee Schedule,Behavioral Health,77.42,,,77.42,Fee Schedule,Behavioral Health,77.42,,,77.42,Fee Schedule,Behavioral Health,77.42,,,77.42,Fee Schedule,Behavioral Health,77.42,,,77.42,Fee Schedule,Behavioral Health,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,282.2,
OFFICE/OUTPAT VISIT EST 40 MIN,99215,CPT,HE,40099215,CDM,900,RC,,,both,,,440,325.6,,,325.6,Other,150% of Medicare + 9.63% HCRA Surcharge,198,45,,198,percent of total billed charges,Critical Access Hospital RCC factor,286,65,,286,percent of total billed charges,All Other,259.6,65,,259.6,percent of total billed charges,All Other,272.8,62,,272.8,percent of total billed charges,Behavioral Health,255.2,56,,255.2,percent of total billed charges,Behavioral Health,246.4,53,,246.4,percent of total billed charges,Behavioral Health,217.8,,,217.8,Other,110% of Medicare,299.2,68,,299.2,percent of total billed charges,All Other,0.01,,,0.01,Other,186% of Medicaid,352,80,,352,percent of total billed charges,All Other,365.2,83,,365.2,percent of total billed charges,All Other,365.2,83,,365.2,percent of total billed charges,All Other,352,80,,352,percent of total billed charges,All Other,365.2,83,,365.2,percent of total billed charges,All Other,352,80,,352,percent of total billed charges,All Other,308,70,,308,percent of total billed charges,All Other,209,,,209,Fee Schedule,Behavioral Health,178,,,178,Fee Schedule,Behavioral Health,114.4,,,114.4,Fee Schedule,Behavioral Health,114.4,,,114.4,Fee Schedule,Behavioral Health,114.4,,,114.4,Fee Schedule,Behavioral Health,114.4,,,114.4,Fee Schedule,Behavioral Health,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,365.2,
PSYCH DIAGNOSTIC EVALUATION - TELEPSYCH,90791,CPT,95,40190791,CDM,900,RC,,,both,,,399,295.26,,,295.26,Other,150% of Medicare + 9.63% HCRA Surcharge,179.55,45,,179.55,percent of total billed charges,Critical Access Hospital RCC factor,259.35,65,,259.35,percent of total billed charges,All Other,235.41,65,,235.41,percent of total billed charges,All Other,190,,,190,Fee Schedule,Behavioral Health,171,,,171,Fee Schedule,Behavioral Health,162,,,162,Fee Schedule,Behavioral Health,197.51,,,197.51,Other,110% of Medicare,230.13,,,230.13,Fee Schedule,Behavioral Health,291,,,291,Other,186% of Medicaid,230.13,,,230.13,Fee Schedule,Behavioral Health,230.13,,,230.13,Fee Schedule,Behavioral Health,230.13,,,230.13,Fee Schedule,Behavioral Health,230.13,,,230.13,Fee Schedule,Behavioral Health,230.13,,,230.13,Fee Schedule,Behavioral Health,319.2,80,,319.2,percent of total billed charges,All Other,279.3,70,,279.3,percent of total billed charges,All Other,217,,,217,Fee Schedule,Behavioral Health,184,,,184,Fee Schedule,Behavioral Health,139.73,,,139.73,Fee Schedule,Behavioral Health,139.73,,,139.73,Fee Schedule,Behavioral Health,139.73,,,139.73,Fee Schedule,Behavioral Health,139.73,,,139.73,Fee Schedule,Behavioral Health,156.36,,,156.36,Other,100% of Medicaid,156.36,,,156.36,Other,100% of Medicaid,156.36,,,156.36,Other,100% of Medicaid,156.36,,,156.36,Other,100% of Medicaid,351.81,,,351.81,Other,225% of Medicaid,239.23,,,239.23,Other,153% of Medicaid,351.81,,,351.81,Other,225% of Medicaid,218.91,,,218.91,Other,140% of Medicaid,351.81,,,351.81,Other,225% of Medicaid,406.54,,,406.54,Other,260% of Medicaid,506.61,,,506.61,Other,324% of Medicaid,336.18,,,336.18,Other,215% of Medicaid,336.18,,,336.18,Other,215% of Medicaid,195.45,,,195.45,Other,125% of Medicaid,139.73,506.61,
OFFICE/OUTPAT VISIT NEW 15 MIN TELEPSYCH,99202,CPT,HE95,40199202,CDM,900,RC,,,both,,,252,186.48,,,186.48,Other,150% of Medicare + 9.63% HCRA Surcharge,113.4,45,,113.4,percent of total billed charges,Critical Access Hospital RCC factor,163.8,65,,163.8,percent of total billed charges,All Other,148.68,65,,148.68,percent of total billed charges,All Other,156.24,62,,156.24,percent of total billed charges,Behavioral Health,146.16,56,,146.16,percent of total billed charges,Behavioral Health,141.12,53,,141.12,percent of total billed charges,Behavioral Health,124.74,,,124.74,Other,110% of Medicare,171.36,68,,171.36,percent of total billed charges,All Other,0.01,,,0.01,Other,186% of Medicaid,201.6,80,,201.6,percent of total billed charges,All Other,209.16,83,,209.16,percent of total billed charges,All Other,209.16,83,,209.16,percent of total billed charges,All Other,201.6,80,,201.6,percent of total billed charges,All Other,209.16,83,,209.16,percent of total billed charges,All Other,201.6,80,,201.6,percent of total billed charges,All Other,64.56,70,,64.56,percent of total billed charges,All Other,64.56,,,64.56,Other,130% of Medicare,64.56,,,64.56,Other,130% of Medicare,23.95,,,23.95,Fee Schedule,Behavioral Health,23.95,,,23.95,Fee Schedule,Behavioral Health,23.95,,,23.95,Fee Schedule,Behavioral Health,23.95,,,23.95,Fee Schedule,Behavioral Health,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,209.16,
OFFICE/OUTPAT VISIT NEW 30 MIN TELEPSYCH,99203,CPT,HE95,40199203,CDM,900,RC,,,both,,,345,255.3,,,255.3,Other,150% of Medicare + 9.63% HCRA Surcharge,155.25,45,,155.25,percent of total billed charges,Critical Access Hospital RCC factor,224.25,65,,224.25,percent of total billed charges,All Other,203.55,65,,203.55,percent of total billed charges,All Other,213.9,62,,213.9,percent of total billed charges,Behavioral Health,200.1,56,,200.1,percent of total billed charges,Behavioral Health,193.2,53,,193.2,percent of total billed charges,Behavioral Health,170.78,,,170.78,Other,110% of Medicare,234.6,68,,234.6,percent of total billed charges,All Other,0.01,,,0.01,Other,186% of Medicaid,276,80,,276,percent of total billed charges,All Other,286.35,83,,286.35,percent of total billed charges,All Other,286.35,83,,286.35,percent of total billed charges,All Other,276,80,,276,percent of total billed charges,All Other,286.35,83,,286.35,percent of total billed charges,All Other,276,80,,276,percent of total billed charges,All Other,241.5,70,,241.5,percent of total billed charges,All Other,111.9,,,111.9,Other,130% of Medicare,111.9,,,111.9,Other,130% of Medicare,41.89,,,41.89,Fee Schedule,Behavioral Health,41.89,,,41.89,Fee Schedule,Behavioral Health,41.89,,,41.89,Fee Schedule,Behavioral Health,41.89,,,41.89,Fee Schedule,Behavioral Health,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,286.35,
OFFICE/OUTPAT VISIT NEW 45 MIN TELEPSYCH,99204,CPT,HE95,40199204,CDM,900,RC,,,both,,,460,340.4,,,340.4,Other,150% of Medicare + 9.63% HCRA Surcharge,207,45,,207,percent of total billed charges,Critical Access Hospital RCC factor,299,65,,299,percent of total billed charges,All Other,271.4,65,,271.4,percent of total billed charges,All Other,285.2,62,,285.2,percent of total billed charges,Behavioral Health,266.8,56,,266.8,percent of total billed charges,Behavioral Health,257.6,53,,257.6,percent of total billed charges,Behavioral Health,227.7,,,227.7,Other,110% of Medicare,312.8,68,,312.8,percent of total billed charges,All Other,0.01,,,0.01,Other,186% of Medicaid,368,80,,368,percent of total billed charges,All Other,381.8,83,,381.8,percent of total billed charges,All Other,381.8,83,,381.8,percent of total billed charges,All Other,368,80,,368,percent of total billed charges,All Other,381.8,83,,381.8,percent of total billed charges,All Other,368,80,,368,percent of total billed charges,All Other,322,70,,322,percent of total billed charges,All Other,181.94,,,181.94,Other,130% of Medicare,181.94,,,181.94,Other,130% of Medicare,68.97,,,68.97,Fee Schedule,Behavioral Health,68.97,,,68.97,Fee Schedule,Behavioral Health,68.97,,,68.97,Fee Schedule,Behavioral Health,68.97,,,68.97,Fee Schedule,Behavioral Health,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,381.8,
OFFICE/OUTPAT VISIT NEW 60 MIN TELEPSYCH,99205,CPT,HE95,40199205,CDM,900,RC,,,both,,,628,464.72,,,464.72,Other,150% of Medicare + 9.63% HCRA Surcharge,282.6,45,,282.6,percent of total billed charges,Critical Access Hospital RCC factor,408.2,65,,408.2,percent of total billed charges,All Other,370.52,65,,370.52,percent of total billed charges,All Other,389.36,62,,389.36,percent of total billed charges,Behavioral Health,364.24,56,,364.24,percent of total billed charges,Behavioral Health,351.68,53,,351.68,percent of total billed charges,Behavioral Health,310.86,,,310.86,Other,110% of Medicare,427.04,68,,427.04,percent of total billed charges,All Other,0.01,,,0.01,Other,186% of Medicaid,502.4,80,,502.4,percent of total billed charges,All Other,521.24,83,,521.24,percent of total billed charges,All Other,521.24,83,,521.24,percent of total billed charges,All Other,502.4,80,,502.4,percent of total billed charges,All Other,521.24,83,,521.24,percent of total billed charges,All Other,502.4,80,,502.4,percent of total billed charges,All Other,439.6,70,,439.6,percent of total billed charges,All Other,247.59,,,247.59,Other,130% of Medicare,247.59,,,247.59,Other,130% of Medicare,98.55,,,98.55,Fee Schedule,Behavioral Health,98.55,,,98.55,Fee Schedule,Behavioral Health,98.55,,,98.55,Fee Schedule,Behavioral Health,98.55,,,98.55,Fee Schedule,Behavioral Health,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,521.24,
OFFICE/OUTPAT VISIT EST 5 MIN TELEPSYCH,99211,CPT,HEGT,40199211,CDM,900,RC,,,both,,,228,168.72,,,168.72,Other,150% of Medicare + 9.63% HCRA Surcharge,102.6,45,,102.6,percent of total billed charges,Critical Access Hospital RCC factor,148.2,65,,148.2,percent of total billed charges,All Other,134.52,65,,134.52,percent of total billed charges,All Other,141.36,62,,141.36,percent of total billed charges,Behavioral Health,132.24,56,,132.24,percent of total billed charges,Behavioral Health,127.68,53,,127.68,percent of total billed charges,Behavioral Health,112.86,,,112.86,Other,110% of Medicare,155.04,68,,155.04,percent of total billed charges,All Other,0.01,,,0.01,Other,186% of Medicaid,182.4,80,,182.4,percent of total billed charges,All Other,189.24,83,,189.24,percent of total billed charges,All Other,189.24,83,,189.24,percent of total billed charges,All Other,182.4,80,,182.4,percent of total billed charges,All Other,189.24,83,,189.24,percent of total billed charges,All Other,182.4,80,,182.4,percent of total billed charges,All Other,159.6,70,,159.6,percent of total billed charges,All Other,52,,,52,Fee Schedule,Behavioral Health,44,,,44,Fee Schedule,Behavioral Health,48.23,,,48.23,Fee Schedule,Behavioral Health,48.23,,,48.23,Fee Schedule,Behavioral Health,48.23,,,48.23,Fee Schedule,Behavioral Health,48.23,,,48.23,Fee Schedule,Behavioral Health,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,189.24,
OFFICE/OUTPAT VISIT EST 10 MIN TELEPSYCH,99212,CPT,HE95,40199212,CDM,900,RC,,,both,,,259,191.66,,,191.66,Other,150% of Medicare + 9.63% HCRA Surcharge,116.55,45,,116.55,percent of total billed charges,Critical Access Hospital RCC factor,168.35,65,,168.35,percent of total billed charges,All Other,152.81,65,,152.81,percent of total billed charges,All Other,160.58,62,,160.58,percent of total billed charges,Behavioral Health,150.22,56,,150.22,percent of total billed charges,Behavioral Health,145.04,53,,145.04,percent of total billed charges,Behavioral Health,128.21,,,128.21,Other,110% of Medicare,176.12,68,,176.12,percent of total billed charges,All Other,0.01,,,0.01,Other,186% of Medicaid,207.2,80,,207.2,percent of total billed charges,All Other,214.97,83,,214.97,percent of total billed charges,All Other,214.97,83,,214.97,percent of total billed charges,All Other,207.2,80,,207.2,percent of total billed charges,All Other,214.97,83,,214.97,percent of total billed charges,All Other,207.2,80,,207.2,percent of total billed charges,All Other,181.3,70,,181.3,percent of total billed charges,All Other,97,,,97,Fee Schedule,Behavioral Health,82,,,82,Fee Schedule,Behavioral Health,55.27,,,55.27,Fee Schedule,Behavioral Health,55.27,,,55.27,Fee Schedule,Behavioral Health,55.27,,,55.27,Fee Schedule,Behavioral Health,55.27,,,55.27,Fee Schedule,Behavioral Health,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,214.97,
OFFICE/OUTPAT VISIT EST 20 MIN TELEPSYCH,99213,CPT,HE95,40199213,CDM,900,RC,,,both,,,259,191.66,,,191.66,Other,150% of Medicare + 9.63% HCRA Surcharge,116.55,45,,116.55,percent of total billed charges,Critical Access Hospital RCC factor,168.35,65,,168.35,percent of total billed charges,All Other,152.81,65,,152.81,percent of total billed charges,All Other,160.58,62,,160.58,percent of total billed charges,Behavioral Health,150.22,56,,150.22,percent of total billed charges,Behavioral Health,145.04,53,,145.04,percent of total billed charges,Behavioral Health,128.21,,,128.21,Other,110% of Medicare,176.12,68,,176.12,percent of total billed charges,All Other,0.01,,,0.01,Other,186% of Medicaid,207.2,80,,207.2,percent of total billed charges,All Other,214.97,83,,214.97,percent of total billed charges,All Other,214.97,83,,214.97,percent of total billed charges,All Other,207.2,80,,207.2,percent of total billed charges,All Other,214.97,83,,214.97,percent of total billed charges,All Other,207.2,80,,207.2,percent of total billed charges,All Other,181.3,70,,181.3,percent of total billed charges,All Other,115,,,115,Fee Schedule,Behavioral Health,98,,,98,Fee Schedule,Behavioral Health,55.27,,,55.27,Fee Schedule,Behavioral Health,55.27,,,55.27,Fee Schedule,Behavioral Health,55.27,,,55.27,Fee Schedule,Behavioral Health,55.27,,,55.27,Fee Schedule,Behavioral Health,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,214.97,
OFFICE/OUTPAT VISIT EST 30 MIN TELEPSYCH,99214,CPT,HE95,40199214,CDM,900,RC,,,both,,,340,251.6,,,251.6,Other,150% of Medicare + 9.63% HCRA Surcharge,153,45,,153,percent of total billed charges,Critical Access Hospital RCC factor,221,65,,221,percent of total billed charges,All Other,200.6,65,,200.6,percent of total billed charges,All Other,210.8,62,,210.8,percent of total billed charges,Behavioral Health,197.2,56,,197.2,percent of total billed charges,Behavioral Health,190.4,53,,190.4,percent of total billed charges,Behavioral Health,168.3,,,168.3,Other,110% of Medicare,231.2,68,,231.2,percent of total billed charges,All Other,0.01,,,0.01,Other,186% of Medicaid,272,80,,272,percent of total billed charges,All Other,282.2,83,,282.2,percent of total billed charges,All Other,282.2,83,,282.2,percent of total billed charges,All Other,272,80,,272,percent of total billed charges,All Other,282.2,83,,282.2,percent of total billed charges,All Other,272,80,,272,percent of total billed charges,All Other,238,70,,238,percent of total billed charges,All Other,130,,,130,Fee Schedule,Behavioral Health,111,,,111,Fee Schedule,Behavioral Health,77.42,,,77.42,Fee Schedule,Behavioral Health,77.42,,,77.42,Fee Schedule,Behavioral Health,77.42,,,77.42,Fee Schedule,Behavioral Health,77.42,,,77.42,Fee Schedule,Behavioral Health,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,282.2,
OFFICE/OUTPAT VISIT EST 40 MIN TELEPSYCH,99215,CPT,HE95,40199215,CDM,900,RC,,,both,,,440,325.6,,,325.6,Other,150% of Medicare + 9.63% HCRA Surcharge,198,45,,198,percent of total billed charges,Critical Access Hospital RCC factor,286,65,,286,percent of total billed charges,All Other,259.6,65,,259.6,percent of total billed charges,All Other,272.8,62,,272.8,percent of total billed charges,Behavioral Health,255.2,56,,255.2,percent of total billed charges,Behavioral Health,246.4,53,,246.4,percent of total billed charges,Behavioral Health,217.8,,,217.8,Other,110% of Medicare,299.2,68,,299.2,percent of total billed charges,All Other,0.01,,,0.01,Other,186% of Medicaid,352,80,,352,percent of total billed charges,All Other,365.2,83,,365.2,percent of total billed charges,All Other,365.2,83,,365.2,percent of total billed charges,All Other,352,80,,352,percent of total billed charges,All Other,365.2,83,,365.2,percent of total billed charges,All Other,352,80,,352,percent of total billed charges,All Other,308,70,,308,percent of total billed charges,All Other,209,,,209,Fee Schedule,Behavioral Health,178,,,178,Fee Schedule,Behavioral Health,114.4,,,114.4,Fee Schedule,Behavioral Health,114.4,,,114.4,Fee Schedule,Behavioral Health,114.4,,,114.4,Fee Schedule,Behavioral Health,114.4,,,114.4,Fee Schedule,Behavioral Health,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,365.2,
OFFICE/OUTPAT VISIT NEW 60 MIN,99205,CPT,,48099205,CDM,900,RC,,,both,,,628,464.72,,,464.72,Other,150% of Medicare + 9.63% HCRA Surcharge,282.6,45,,282.6,percent of total billed charges,Critical Access Hospital RCC factor,408.2,65,,408.2,percent of total billed charges,All Other,370.52,65,,370.52,percent of total billed charges,All Other,389.36,62,,389.36,percent of total billed charges,Behavioral Health,364.24,56,,364.24,percent of total billed charges,Behavioral Health,351.68,53,,351.68,percent of total billed charges,Behavioral Health,310.86,,,310.86,Other,110% of Medicare,427.04,68,,427.04,percent of total billed charges,All Other,0.01,,,0.01,Other,186% of Medicaid,502.4,80,,502.4,percent of total billed charges,All Other,521.24,83,,521.24,percent of total billed charges,All Other,521.24,83,,521.24,percent of total billed charges,All Other,502.4,80,,502.4,percent of total billed charges,All Other,521.24,83,,521.24,percent of total billed charges,All Other,502.4,80,,502.4,percent of total billed charges,All Other,439.6,70,,439.6,percent of total billed charges,All Other,247.59,,,247.59,Other,130% of Medicare,247.59,,,247.59,Other,130% of Medicare,98.55,,,98.55,Fee Schedule,Behavioral Health,98.55,,,98.55,Fee Schedule,Behavioral Health,98.55,,,98.55,Fee Schedule,Behavioral Health,98.55,,,98.55,Fee Schedule,Behavioral Health,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,521.24,
ADOL ACT THRPY PER SESS 45+ MINS,G0176,HCPCS,,39000001,CDM,904,RC,,,both,,,105,77.7,,,77.7,Other,150% of Medicare + 9.63% HCRA Surcharge,47.25,45,,47.25,percent of total billed charges,Critical Access Hospital RCC factor,68.25,65,,68.25,percent of total billed charges,All Other,61.95,65,,61.95,percent of total billed charges,All Other,65.1,62,,65.1,percent of total billed charges,Behavioral Health,60.9,56,,60.9,percent of total billed charges,Behavioral Health,58.8,53,,58.8,percent of total billed charges,,51.98,,,51.98,Other,110% of Medicare,52.5,50,,52.5,percent of total billed charges,Behavioral Health,0.01,,,0.01,Other,186% of Medicaid,52.5,50,,52.5,percent of total billed charges,Behavioral Health,52.5,50,,52.5,percent of total billed charges,Behavioral Health,52.5,50,,52.5,percent of total billed charges,Behavioral Health,52.5,50,,52.5,percent of total billed charges,Behavioral Health,52.5,50,,52.5,percent of total billed charges,Behavioral Health,84,80,,84,percent of total billed charges,All Other,73.5,70,,73.5,percent of total billed charges,All Other,68.25,65,,68.25,percent of total billed charges,Default if not in Fee Schedule,68.25,65,,68.25,percent of total billed charges,Default if not in Fee Schedule,0.01,,,0.01,Fee Schedule,Behavioral Health,0.01,,,0.01,Fee Schedule,Behavioral Health,0.01,,,0.01,Fee Schedule,Behavioral Health,0.01,,,0.01,Fee Schedule,Behavioral Health,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,84,
ADOL ACT THRPY PER SESS 45+ MINS-TH,G0176,HCPCS,GT,39100001,CDM,904,RC,,,both,,,105,77.7,,,77.7,Other,150% of Medicare + 9.63% HCRA Surcharge,47.25,45,,47.25,percent of total billed charges,Critical Access Hospital RCC factor,68.25,65,,68.25,percent of total billed charges,All Other,61.95,65,,61.95,percent of total billed charges,All Other,65.1,62,,65.1,percent of total billed charges,Behavioral Health,60.9,56,,60.9,percent of total billed charges,Behavioral Health,58.8,53,,58.8,percent of total billed charges,Behavioral Health,51.98,,,51.98,Other,110% of Medicare,52.5,50,,52.5,percent of total billed charges,Behavioral Health,0.01,,,0.01,Other,186% of Medicaid,52.5,50,,52.5,percent of total billed charges,Behavioral Health,52.5,50,,52.5,percent of total billed charges,Behavioral Health,52.5,50,,52.5,percent of total billed charges,Behavioral Health,52.5,50,,52.5,percent of total billed charges,Behavioral Health,52.5,50,,52.5,percent of total billed charges,Behavioral Health,84,80,,84,percent of total billed charges,All Other,73.5,70,,73.5,percent of total billed charges,All Other,68.25,65,,68.25,percent of total billed charges,Default if not in Fee Schedule,68.25,65,,68.25,percent of total billed charges,Default if not in Fee Schedule,0.01,,,0.01,Fee Schedule,Behavioral Health,0.01,,,0.01,Fee Schedule,Behavioral Health,0.01,,,0.01,Fee Schedule,Behavioral Health,0.01,,,0.01,Fee Schedule,Behavioral Health,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,84,
ACTIVITY THERAPY PER SESS 45+ MINS,G0176,HCPCS,,40000002,CDM,904,RC,,,both,,,105,77.7,,,77.7,Other,150% of Medicare + 9.63% HCRA Surcharge,47.25,45,,47.25,percent of total billed charges,Critical Access Hospital RCC factor,68.25,65,,68.25,percent of total billed charges,All Other,61.95,65,,61.95,percent of total billed charges,All Other,65.1,62,,65.1,percent of total billed charges,Behavioral Health,60.9,56,,60.9,percent of total billed charges,Behavioral Health,58.8,53,,58.8,percent of total billed charges,Behavioral Health,51.98,,,51.98,Other,110% of Medicare,52.5,50,,52.5,percent of total billed charges,Behavioral Health,0.01,,,0.01,Other,186% of Medicaid,52.5,50,,52.5,percent of total billed charges,Behavioral Health,52.5,50,,52.5,percent of total billed charges,Behavioral Health,52.5,50,,52.5,percent of total billed charges,Behavioral Health,52.5,50,,52.5,percent of total billed charges,Behavioral Health,52.5,50,,52.5,percent of total billed charges,Behavioral Health,84,80,,84,percent of total billed charges,All Other,73.5,70,,73.5,percent of total billed charges,All Other,68.25,65,,68.25,percent of total billed charges,Default if not in Fee Schedule,68.25,65,,68.25,percent of total billed charges,Default if not in Fee Schedule,0.01,,,0.01,Fee Schedule,Behavioral Health,0.01,,,0.01,Fee Schedule,Behavioral Health,0.01,,,0.01,Fee Schedule,Behavioral Health,0.01,,,0.01,Fee Schedule,Behavioral Health,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,84,
ACTIVITY THERAPY PER SESS 45+ MINS-TH,G0176,HCPCS,GT,40100001,CDM,904,RC,,,both,,,105,77.7,,,77.7,Other,150% of Medicare + 9.63% HCRA Surcharge,47.25,45,,47.25,percent of total billed charges,Critical Access Hospital RCC factor,68.25,65,,68.25,percent of total billed charges,All Other,61.95,65,,61.95,percent of total billed charges,All Other,65.1,62,,65.1,percent of total billed charges,Behavioral Health,60.9,56,,60.9,percent of total billed charges,Behavioral Health,58.8,53,,58.8,percent of total billed charges,Behavioral Health,51.98,,,51.98,Other,110% of Medicare,52.5,50,,52.5,percent of total billed charges,Behavioral Health,0.01,,,0.01,Other,186% of Medicaid,52.5,50,,52.5,percent of total billed charges,Behavioral Health,52.5,50,,52.5,percent of total billed charges,Behavioral Health,52.5,50,,52.5,percent of total billed charges,Behavioral Health,52.5,50,,52.5,percent of total billed charges,Behavioral Health,52.5,50,,52.5,percent of total billed charges,Behavioral Health,84,80,,84,percent of total billed charges,All Other,73.5,70,,73.5,percent of total billed charges,All Other,68.25,65,,68.25,percent of total billed charges,Default if not in Fee Schedule,68.25,65,,68.25,percent of total billed charges,Default if not in Fee Schedule,0.01,,,0.01,Fee Schedule,Behavioral Health,0.01,,,0.01,Fee Schedule,Behavioral Health,0.01,,,0.01,Fee Schedule,Behavioral Health,0.01,,,0.01,Fee Schedule,Behavioral Health,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,84,
PSYTX PT&/FAMILY 30 MIN,90832,CPT,,36090832,CDM,914,RC,,,both,,,329,243.46,,,243.46,Other,150% of Medicare + 9.63% HCRA Surcharge,148.05,45,,148.05,percent of total billed charges,Critical Access Hospital RCC factor,213.85,65,,213.85,percent of total billed charges,All Other,194.11,65,,194.11,percent of total billed charges,All Other,82,,,82,Fee Schedule,Behavioral Health,74,,,74,Fee Schedule,Behavioral Health,70,,,70,Fee Schedule,Behavioral Health,162.86,,,162.86,Other,110% of Medicare,106.52,,,106.52,Fee Schedule,Behavioral Health,174,,,174,Other,186% of Medicaid,106.52,,,106.52,Fee Schedule,Behavioral Health,106.52,,,106.52,Fee Schedule,Behavioral Health,106.52,,,106.52,Fee Schedule,Behavioral Health,106.52,,,106.52,Fee Schedule,Behavioral Health,106.52,,,106.52,Fee Schedule,Behavioral Health,263.2,80,,263.2,percent of total billed charges,All Other,230.3,70,,230.3,percent of total billed charges,All Other,99,,,99,Fee Schedule,Behavioral Health,84,,,84,Fee Schedule,Behavioral Health,69.32,,,69.32,Fee Schedule,Behavioral Health,69.32,,,69.32,Fee Schedule,Behavioral Health,69.32,,,69.32,Fee Schedule,Behavioral Health,69.32,,,69.32,Fee Schedule,Behavioral Health,93.82,,,93.82,Other,100% of Medicaid,93.82,,,93.82,Other,100% of Medicaid,93.82,,,93.82,Other,100% of Medicaid,93.82,,,93.82,Other,100% of Medicaid,211.09,,,211.09,Other,225% of Medicaid,143.54,,,143.54,Other,153% of Medicaid,211.09,,,211.09,Other,225% of Medicaid,131.34,,,131.34,Other,140% of Medicaid,211.09,,,211.09,Other,225% of Medicaid,243.92,,,243.92,Other,260% of Medicaid,303.97,,,303.97,Other,324% of Medicaid,201.71,,,201.71,Other,215% of Medicaid,201.71,,,201.71,Other,215% of Medicaid,117.27,,,117.27,Other,125% of Medicaid,69.32,303.97,
PSYTX PT&/FAM W/MD 30 MIN,90833,CPT,,36090833,CDM,914,RC,,,both,,,108,79.92,,,79.92,Other,150% of Medicare + 9.63% HCRA Surcharge,48.6,45,,48.6,percent of total billed charges,Critical Access Hospital RCC factor,70.2,65,,70.2,percent of total billed charges,All Other,63.72,65,,63.72,percent of total billed charges,All Other,82.62,76.5,,82.62,percent of total billed charges,All Other,76.68,69,,76.68,percent of total billed charges,All Other,74.52,65,,74.52,percent of total billed charges,All Other,53.46,,,53.46,Other,110% of Medicare,100.23,,,100.23,Fee Schedule,Behavioral Health,174,,,174,Other,186% of Medicaid,100.23,,,100.23,Fee Schedule,Behavioral Health,100.23,,,100.23,Fee Schedule,Behavioral Health,100.23,,,100.23,Fee Schedule,Behavioral Health,100.23,,,100.23,Fee Schedule,Behavioral Health,100.23,,,100.23,Fee Schedule,Behavioral Health,86.4,80,,86.4,percent of total billed charges,All Other,75.6,70,,75.6,percent of total billed charges,All Other,28,,,28,Fee Schedule,Behavioral Health,24,,,24,Fee Schedule,Behavioral Health,52.8,,,52.8,Fee Schedule,Behavioral Health,52.8,,,52.8,Fee Schedule,Behavioral Health,52.8,,,52.8,Fee Schedule,Behavioral Health,52.8,,,52.8,Fee Schedule,Behavioral Health,93.82,,,93.82,Other,100% of Medicaid,93.82,,,93.82,Other,100% of Medicaid,93.82,,,93.82,Other,100% of Medicaid,93.82,,,93.82,Other,100% of Medicaid,211.09,,,211.09,Other,225% of Medicaid,143.54,,,143.54,Other,153% of Medicaid,211.09,,,211.09,Other,225% of Medicaid,131.34,,,131.34,Other,140% of Medicaid,211.09,,,211.09,Other,225% of Medicaid,243.92,,,243.92,Other,260% of Medicaid,303.97,,,303.97,Other,324% of Medicaid,201.71,,,201.71,Other,215% of Medicaid,201.71,,,201.71,Other,215% of Medicaid,117.27,,,117.27,Other,125% of Medicaid,24,303.97,
PSYTX PT&/FAMILY 45 MIN,90834,CPT,,36090834,CDM,914,RC,,,both,,,399,295.26,,,295.26,Other,150% of Medicare + 9.63% HCRA Surcharge,179.55,45,,179.55,percent of total billed charges,Critical Access Hospital RCC factor,259.35,65,,259.35,percent of total billed charges,All Other,235.41,65,,235.41,percent of total billed charges,All Other,158,,,158,Fee Schedule,Behavioral Health,142,,,142,Fee Schedule,Behavioral Health,134,,,134,Fee Schedule,Behavioral Health,197.51,,,197.51,Other,110% of Medicare,140.78,,,140.78,Fee Schedule,Behavioral Health,233,,,233,Other,186% of Medicaid,140.78,,,140.78,Fee Schedule,Behavioral Health,140.78,,,140.78,Fee Schedule,Behavioral Health,140.78,,,140.78,Fee Schedule,Behavioral Health,140.78,,,140.78,Fee Schedule,Behavioral Health,140.78,,,140.78,Fee Schedule,Behavioral Health,319.2,80,,319.2,percent of total billed charges,All Other,279.3,70,,279.3,percent of total billed charges,All Other,154,,,154,Fee Schedule,Behavioral Health,131,,,131,Fee Schedule,Behavioral Health,104.53,,,104.53,Fee Schedule,Behavioral Health,104.53,,,104.53,Fee Schedule,Behavioral Health,104.53,,,104.53,Fee Schedule,Behavioral Health,104.53,,,104.53,Fee Schedule,Behavioral Health,125.09,,,125.09,Other,100% of Medicaid,125.09,,,125.09,Other,100% of Medicaid,125.09,,,125.09,Other,100% of Medicaid,125.09,,,125.09,Other,100% of Medicaid,281.45,,,281.45,Other,225% of Medicaid,191.39,,,191.39,Other,153% of Medicaid,281.45,,,281.45,Other,225% of Medicaid,175.13,,,175.13,Other,140% of Medicaid,281.45,,,281.45,Other,225% of Medicaid,325.23,,,325.23,Other,260% of Medicaid,405.29,,,405.29,Other,324% of Medicaid,268.94,,,268.94,Other,215% of Medicaid,268.94,,,268.94,Other,215% of Medicaid,156.36,,,156.36,Other,125% of Medicaid,104.53,405.29,
PSYTX PT&/FAM W/MD 45 MIN,90836,CPT,,36090836,CDM,914,RC,,,both,,,175,129.5,,,129.5,Other,150% of Medicare + 9.63% HCRA Surcharge,78.75,45,,78.75,percent of total billed charges,Critical Access Hospital RCC factor,113.75,65,,113.75,percent of total billed charges,All Other,103.25,65,,103.25,percent of total billed charges,All Other,133.88,76.5,,133.88,percent of total billed charges,All Other,124.25,69,,124.25,percent of total billed charges,All Other,120.75,65,,120.75,percent of total billed charges,All Other,86.63,,,86.63,Other,110% of Medicare,126.78,,,126.78,Fee Schedule,Behavioral Health,233,,,233,Other,186% of Medicaid,126.78,,,126.78,Fee Schedule,Behavioral Health,126.78,,,126.78,Fee Schedule,Behavioral Health,126.78,,,126.78,Fee Schedule,Behavioral Health,126.78,,,126.78,Fee Schedule,Behavioral Health,126.78,,,126.78,Fee Schedule,Behavioral Health,140,80,,140,percent of total billed charges,All Other,122.5,70,,122.5,percent of total billed charges,All Other,100,,,100,Fee Schedule,Behavioral Health,85,,,85,Fee Schedule,Behavioral Health,79.55,,,79.55,Fee Schedule,Behavioral Health,79.55,,,79.55,Fee Schedule,Behavioral Health,79.55,,,79.55,Fee Schedule,Behavioral Health,79.55,,,79.55,Fee Schedule,Behavioral Health,125.09,,,125.09,Other,100% of Medicaid,125.09,,,125.09,Other,100% of Medicaid,125.09,,,125.09,Other,100% of Medicaid,125.09,,,125.09,Other,100% of Medicaid,281.45,,,281.45,Other,225% of Medicaid,191.39,,,191.39,Other,153% of Medicaid,281.45,,,281.45,Other,225% of Medicaid,175.13,,,175.13,Other,140% of Medicaid,281.45,,,281.45,Other,225% of Medicaid,325.23,,,325.23,Other,260% of Medicaid,405.29,,,405.29,Other,324% of Medicaid,268.94,,,268.94,Other,215% of Medicaid,268.94,,,268.94,Other,215% of Medicaid,156.36,,,156.36,Other,125% of Medicaid,78.75,405.29,
PSYTX PT&/FAMILY 60 MIN,90837,CPT,,36090837,CDM,914,RC,,,both,,,399,295.26,,,295.26,Other,150% of Medicare + 9.63% HCRA Surcharge,179.55,45,,179.55,percent of total billed charges,Critical Access Hospital RCC factor,259.35,65,,259.35,percent of total billed charges,All Other,235.41,65,,235.41,percent of total billed charges,All Other,158,,,158,Fee Schedule,Behavioral Health,142,,,142,Fee Schedule,Behavioral Health,134,,,134,Fee Schedule,Behavioral Health,197.51,,,197.51,Other,110% of Medicare,207.78,,,207.78,Fee Schedule,Behavioral Health,233,,,233,Other,186% of Medicaid,207.78,,,207.78,Fee Schedule,Behavioral Health,207.78,,,207.78,Fee Schedule,Behavioral Health,207.78,,,207.78,Fee Schedule,Behavioral Health,207.78,,,207.78,Fee Schedule,Behavioral Health,207.78,,,207.78,Fee Schedule,Behavioral Health,319.2,80,,319.2,percent of total billed charges,All Other,279.3,70,,279.3,percent of total billed charges,All Other,154,,,154,Fee Schedule,Behavioral Health,131,,,131,Fee Schedule,Behavioral Health,110.87,,,110.87,Fee Schedule,Behavioral Health,110.87,,,110.87,Fee Schedule,Behavioral Health,110.87,,,110.87,Fee Schedule,Behavioral Health,110.87,,,110.87,Fee Schedule,Behavioral Health,125.09,,,125.09,Other,100% of Medicaid,125.09,,,125.09,Other,100% of Medicaid,125.09,,,125.09,Other,100% of Medicaid,125.09,,,125.09,Other,100% of Medicaid,281.45,,,281.45,Other,225% of Medicaid,191.39,,,191.39,Other,153% of Medicaid,281.45,,,281.45,Other,225% of Medicaid,175.13,,,175.13,Other,140% of Medicaid,281.45,,,281.45,Other,225% of Medicaid,325.23,,,325.23,Other,260% of Medicaid,405.29,,,405.29,Other,324% of Medicaid,268.94,,,268.94,Other,215% of Medicaid,268.94,,,268.94,Other,215% of Medicaid,156.36,,,156.36,Other,125% of Medicaid,110.87,405.29,
PSYTX PT&/FAM W/MD 60 MIN,90838,CPT,,36090838,CDM,914,RC,,,both,,,282,208.68,,,208.68,Other,150% of Medicare + 9.63% HCRA Surcharge,126.9,45,,126.9,percent of total billed charges,Critical Access Hospital RCC factor,183.3,65,,183.3,percent of total billed charges,All Other,166.38,65,,166.38,percent of total billed charges,All Other,215.73,76.5,,215.73,percent of total billed charges,All Other,200.22,69,,200.22,percent of total billed charges,All Other,194.58,65,,194.58,percent of total billed charges,All Other,139.59,,,139.59,Other,110% of Medicare,168.08,,,168.08,Fee Schedule,Behavioral Health,233,,,233,Other,186% of Medicaid,168.08,,,168.08,Fee Schedule,Behavioral Health,168.08,,,168.08,Fee Schedule,Behavioral Health,168.08,,,168.08,Fee Schedule,Behavioral Health,168.08,,,168.08,Fee Schedule,Behavioral Health,168.08,,,168.08,Fee Schedule,Behavioral Health,225.6,80,,225.6,percent of total billed charges,All Other,197.4,70,,197.4,percent of total billed charges,All Other,121,,,121,Fee Schedule,Behavioral Health,103,,,103,Fee Schedule,Behavioral Health,106.31,,,106.31,Fee Schedule,Behavioral Health,106.31,,,106.31,Fee Schedule,Behavioral Health,106.31,,,106.31,Fee Schedule,Behavioral Health,106.31,,,106.31,Fee Schedule,Behavioral Health,125.09,,,125.09,Other,100% of Medicaid,125.09,,,125.09,Other,100% of Medicaid,125.09,,,125.09,Other,100% of Medicaid,125.09,,,125.09,Other,100% of Medicaid,281.45,,,281.45,Other,225% of Medicaid,191.39,,,191.39,Other,153% of Medicaid,281.45,,,281.45,Other,225% of Medicaid,175.13,,,175.13,Other,140% of Medicaid,281.45,,,281.45,Other,225% of Medicaid,325.23,,,325.23,Other,260% of Medicaid,405.29,,,405.29,Other,324% of Medicaid,268.94,,,268.94,Other,215% of Medicaid,268.94,,,268.94,Other,215% of Medicaid,156.36,,,156.36,Other,125% of Medicaid,103,405.29,
IOP PSYTX PT&/FAMILY 30 MIN,90832,CPT,,36190832,CDM,914,RC,,,both,,,329,243.46,,,243.46,Other,150% of Medicare + 9.63% HCRA Surcharge,148.05,45,,148.05,percent of total billed charges,Critical Access Hospital RCC factor,213.85,65,,213.85,percent of total billed charges,All Other,194.11,65,,194.11,percent of total billed charges,All Other,82,,,82,Fee Schedule,Behavioral Health,74,,,74,Fee Schedule,Behavioral Health,70,,,70,Fee Schedule,Behavioral Health,162.86,,,162.86,Other,110% of Medicare,106.52,,,106.52,Fee Schedule,Behavioral Health,174,,,174,Other,186% of Medicaid,106.52,,,106.52,Fee Schedule,Behavioral Health,106.52,,,106.52,Fee Schedule,Behavioral Health,106.52,,,106.52,Fee Schedule,Behavioral Health,106.52,,,106.52,Fee Schedule,Behavioral Health,106.52,,,106.52,Fee Schedule,Behavioral Health,263.2,80,,263.2,percent of total billed charges,All Other,230.3,70,,230.3,percent of total billed charges,All Other,99,,,99,Fee Schedule,Behavioral Health,84,,,84,Fee Schedule,Behavioral Health,69.32,,,69.32,Fee Schedule,Behavioral Health,69.32,,,69.32,Fee Schedule,Behavioral Health,69.32,,,69.32,Fee Schedule,Behavioral Health,69.32,,,69.32,Fee Schedule,Behavioral Health,93.82,,,93.82,Other,100% of Medicaid,93.82,,,93.82,Other,100% of Medicaid,93.82,,,93.82,Other,100% of Medicaid,93.82,,,93.82,Other,100% of Medicaid,211.09,,,211.09,Other,225% of Medicaid,143.54,,,143.54,Other,153% of Medicaid,211.09,,,211.09,Other,225% of Medicaid,131.34,,,131.34,Other,140% of Medicaid,211.09,,,211.09,Other,225% of Medicaid,243.92,,,243.92,Other,260% of Medicaid,303.97,,,303.97,Other,324% of Medicaid,201.71,,,201.71,Other,215% of Medicaid,201.71,,,201.71,Other,215% of Medicaid,117.27,,,117.27,Other,125% of Medicaid,69.32,303.97,
PSYTX PT&/FAM W/PSYCH 30 MIN,90833,CPT,,36190833,CDM,914,RC,,,both,,,108,79.92,,,79.92,Other,150% of Medicare + 9.63% HCRA Surcharge,48.6,45,,48.6,percent of total billed charges,Critical Access Hospital RCC factor,70.2,65,,70.2,percent of total billed charges,All Other,63.72,65,,63.72,percent of total billed charges,All Other,82.62,76.5,,82.62,percent of total billed charges,All Other,76.68,69,,76.68,percent of total billed charges,All Other,74.52,65,,74.52,percent of total billed charges,All Other,53.46,,,53.46,Other,110% of Medicare,100.23,,,100.23,Fee Schedule,Behavioral Health,174,,,174,Other,186% of Medicaid,100.23,,,100.23,Fee Schedule,Behavioral Health,100.23,,,100.23,Fee Schedule,Behavioral Health,100.23,,,100.23,Fee Schedule,Behavioral Health,100.23,,,100.23,Fee Schedule,Behavioral Health,100.23,,,100.23,Fee Schedule,Behavioral Health,86.4,80,,86.4,percent of total billed charges,All Other,75.6,70,,75.6,percent of total billed charges,All Other,28,,,28,Fee Schedule,Behavioral Health,24,,,24,Fee Schedule,Behavioral Health,52.8,,,52.8,Fee Schedule,Behavioral Health,52.8,,,52.8,Fee Schedule,Behavioral Health,52.8,,,52.8,Fee Schedule,Behavioral Health,52.8,,,52.8,Fee Schedule,Behavioral Health,93.82,,,93.82,Other,100% of Medicaid,93.82,,,93.82,Other,100% of Medicaid,93.82,,,93.82,Other,100% of Medicaid,93.82,,,93.82,Other,100% of Medicaid,211.09,,,211.09,Other,225% of Medicaid,143.54,,,143.54,Other,153% of Medicaid,211.09,,,211.09,Other,225% of Medicaid,131.34,,,131.34,Other,140% of Medicaid,211.09,,,211.09,Other,225% of Medicaid,243.92,,,243.92,Other,260% of Medicaid,303.97,,,303.97,Other,324% of Medicaid,201.71,,,201.71,Other,215% of Medicaid,201.71,,,201.71,Other,215% of Medicaid,117.27,,,117.27,Other,125% of Medicaid,24,303.97,
IOP PSYTX PT&/FAMILY 45 MIN,90834,CPT,,36190834,CDM,914,RC,,,both,,,399,295.26,,,295.26,Other,150% of Medicare + 9.63% HCRA Surcharge,179.55,45,,179.55,percent of total billed charges,Critical Access Hospital RCC factor,259.35,65,,259.35,percent of total billed charges,All Other,235.41,65,,235.41,percent of total billed charges,All Other,158,,,158,Fee Schedule,Behavioral Health,142,,,142,Fee Schedule,Behavioral Health,134,,,134,Fee Schedule,Behavioral Health,197.51,,,197.51,Other,110% of Medicare,140.78,,,140.78,Fee Schedule,Behavioral Health,233,,,233,Other,186% of Medicaid,140.78,,,140.78,Fee Schedule,Behavioral Health,140.78,,,140.78,Fee Schedule,Behavioral Health,140.78,,,140.78,Fee Schedule,Behavioral Health,140.78,,,140.78,Fee Schedule,Behavioral Health,140.78,,,140.78,Fee Schedule,Behavioral Health,319.2,80,,319.2,percent of total billed charges,All Other,279.3,70,,279.3,percent of total billed charges,All Other,154,,,154,Fee Schedule,Behavioral Health,131,,,131,Fee Schedule,Behavioral Health,104.53,,,104.53,Fee Schedule,Behavioral Health,104.53,,,104.53,Fee Schedule,Behavioral Health,104.53,,,104.53,Fee Schedule,Behavioral Health,104.53,,,104.53,Fee Schedule,Behavioral Health,125.09,,,125.09,Other,100% of Medicaid,125.09,,,125.09,Other,100% of Medicaid,125.09,,,125.09,Other,100% of Medicaid,125.09,,,125.09,Other,100% of Medicaid,281.45,,,281.45,Other,225% of Medicaid,191.39,,,191.39,Other,153% of Medicaid,281.45,,,281.45,Other,225% of Medicaid,175.13,,,175.13,Other,140% of Medicaid,281.45,,,281.45,Other,225% of Medicaid,325.23,,,325.23,Other,260% of Medicaid,405.29,,,405.29,Other,324% of Medicaid,268.94,,,268.94,Other,215% of Medicaid,268.94,,,268.94,Other,215% of Medicaid,156.36,,,156.36,Other,125% of Medicaid,104.53,405.29,
PSYTX PT&/FAM W/PSYCH 45 MIN,90836,CPT,,36190836,CDM,914,RC,,,both,,,175,129.5,,,129.5,Other,150% of Medicare + 9.63% HCRA Surcharge,78.75,45,,78.75,percent of total billed charges,Critical Access Hospital RCC factor,113.75,65,,113.75,percent of total billed charges,All Other,103.25,65,,103.25,percent of total billed charges,All Other,133.88,76.5,,133.88,percent of total billed charges,All Other,124.25,69,,124.25,percent of total billed charges,All Other,120.75,65,,120.75,percent of total billed charges,All Other,86.63,,,86.63,Other,110% of Medicare,126.78,,,126.78,Fee Schedule,Behavioral Health,233,,,233,Other,186% of Medicaid,126.78,,,126.78,Fee Schedule,Behavioral Health,126.78,,,126.78,Fee Schedule,Behavioral Health,126.78,,,126.78,Fee Schedule,Behavioral Health,126.78,,,126.78,Fee Schedule,Behavioral Health,126.78,,,126.78,Fee Schedule,Behavioral Health,140,80,,140,percent of total billed charges,All Other,122.5,70,,122.5,percent of total billed charges,All Other,100,,,100,Fee Schedule,Behavioral Health,85,,,85,Fee Schedule,Behavioral Health,79.55,,,79.55,Fee Schedule,Behavioral Health,79.55,,,79.55,Fee Schedule,Behavioral Health,79.55,,,79.55,Fee Schedule,Behavioral Health,79.55,,,79.55,Fee Schedule,Behavioral Health,125.09,,,125.09,Other,100% of Medicaid,125.09,,,125.09,Other,100% of Medicaid,125.09,,,125.09,Other,100% of Medicaid,125.09,,,125.09,Other,100% of Medicaid,281.45,,,281.45,Other,225% of Medicaid,191.39,,,191.39,Other,153% of Medicaid,281.45,,,281.45,Other,225% of Medicaid,175.13,,,175.13,Other,140% of Medicaid,281.45,,,281.45,Other,225% of Medicaid,325.23,,,325.23,Other,260% of Medicaid,405.29,,,405.29,Other,324% of Medicaid,268.94,,,268.94,Other,215% of Medicaid,268.94,,,268.94,Other,215% of Medicaid,156.36,,,156.36,Other,125% of Medicaid,78.75,405.29,
IOP PSYTX PT&/FAMILY 60 MIN,90837,CPT,,36190837,CDM,914,RC,,,both,,,399,295.26,,,295.26,Other,150% of Medicare + 9.63% HCRA Surcharge,179.55,45,,179.55,percent of total billed charges,Critical Access Hospital RCC factor,259.35,65,,259.35,percent of total billed charges,All Other,235.41,65,,235.41,percent of total billed charges,All Other,158,,,158,Fee Schedule,Behavioral Health,142,,,142,Fee Schedule,Behavioral Health,134,,,134,Fee Schedule,Behavioral Health,197.51,,,197.51,Other,110% of Medicare,207.78,,,207.78,Fee Schedule,Behavioral Health,233,,,233,Other,186% of Medicaid,207.78,,,207.78,Fee Schedule,Behavioral Health,207.78,,,207.78,Fee Schedule,Behavioral Health,207.78,,,207.78,Fee Schedule,Behavioral Health,207.78,,,207.78,Fee Schedule,Behavioral Health,207.78,,,207.78,Fee Schedule,Behavioral Health,319.2,80,,319.2,percent of total billed charges,All Other,279.3,70,,279.3,percent of total billed charges,All Other,154,,,154,Fee Schedule,Behavioral Health,131,,,131,Fee Schedule,Behavioral Health,110.87,,,110.87,Fee Schedule,Behavioral Health,110.87,,,110.87,Fee Schedule,Behavioral Health,110.87,,,110.87,Fee Schedule,Behavioral Health,110.87,,,110.87,Fee Schedule,Behavioral Health,125.09,,,125.09,Other,100% of Medicaid,125.09,,,125.09,Other,100% of Medicaid,125.09,,,125.09,Other,100% of Medicaid,125.09,,,125.09,Other,100% of Medicaid,281.45,,,281.45,Other,225% of Medicaid,191.39,,,191.39,Other,153% of Medicaid,281.45,,,281.45,Other,225% of Medicaid,175.13,,,175.13,Other,140% of Medicaid,281.45,,,281.45,Other,225% of Medicaid,325.23,,,325.23,Other,260% of Medicaid,405.29,,,405.29,Other,324% of Medicaid,268.94,,,268.94,Other,215% of Medicaid,268.94,,,268.94,Other,215% of Medicaid,156.36,,,156.36,Other,125% of Medicaid,110.87,405.29,
PSYTX PT&/FAM W/PSYCH 60 MIN,90838,CPT,,36190838,CDM,914,RC,,,both,,,282,208.68,,,208.68,Other,150% of Medicare + 9.63% HCRA Surcharge,126.9,45,,126.9,percent of total billed charges,Critical Access Hospital RCC factor,183.3,65,,183.3,percent of total billed charges,All Other,166.38,65,,166.38,percent of total billed charges,All Other,215.73,76.5,,215.73,percent of total billed charges,All Other,200.22,69,,200.22,percent of total billed charges,All Other,194.58,65,,194.58,percent of total billed charges,All Other,139.59,,,139.59,Other,110% of Medicare,168.08,,,168.08,Fee Schedule,Behavioral Health,233,,,233,Other,186% of Medicaid,168.08,,,168.08,Fee Schedule,Behavioral Health,168.08,,,168.08,Fee Schedule,Behavioral Health,168.08,,,168.08,Fee Schedule,Behavioral Health,168.08,,,168.08,Fee Schedule,Behavioral Health,168.08,,,168.08,Fee Schedule,Behavioral Health,225.6,80,,225.6,percent of total billed charges,All Other,197.4,70,,197.4,percent of total billed charges,All Other,121,,,121,Fee Schedule,Behavioral Health,103,,,103,Fee Schedule,Behavioral Health,106.31,,,106.31,Fee Schedule,Behavioral Health,106.31,,,106.31,Fee Schedule,Behavioral Health,106.31,,,106.31,Fee Schedule,Behavioral Health,106.31,,,106.31,Fee Schedule,Behavioral Health,125.09,,,125.09,Other,100% of Medicaid,125.09,,,125.09,Other,100% of Medicaid,125.09,,,125.09,Other,100% of Medicaid,125.09,,,125.09,Other,100% of Medicaid,281.45,,,281.45,Other,225% of Medicaid,191.39,,,191.39,Other,153% of Medicaid,281.45,,,281.45,Other,225% of Medicaid,175.13,,,175.13,Other,140% of Medicaid,281.45,,,281.45,Other,225% of Medicaid,325.23,,,325.23,Other,260% of Medicaid,405.29,,,405.29,Other,324% of Medicaid,268.94,,,268.94,Other,215% of Medicaid,268.94,,,268.94,Other,215% of Medicaid,156.36,,,156.36,Other,125% of Medicaid,103,405.29,
TH- ADR ALCOHOL/DRUG C&T PER 15 MINS,H0004,HCPCS,GT,36200001,CDM,914,RC,,,both,,,72,53.28,,,53.28,Other,150% of Medicare + 9.63% HCRA Surcharge,32.4,45,,32.4,percent of total billed charges,Critical Access Hospital RCC factor,46.8,65,,46.8,percent of total billed charges,All Other,42.48,65,,42.48,percent of total billed charges,All Other,44.64,62,,44.64,percent of total billed charges,Behavioral Health,41.76,56,,41.76,percent of total billed charges,Behavioral Health,40.32,53,,40.32,percent of total billed charges,Behavioral Health,35.64,,,35.64,Other,110% of Medicare,36,50,,36,percent of total billed charges,Behavioral Health,174,,,174,Other,186% of Medicaid,36,50,,36,percent of total billed charges,Behavioral Health,36,50,,36,percent of total billed charges,Behavioral Health,36,50,,36,percent of total billed charges,Behavioral Health,36,50,,36,percent of total billed charges,Behavioral Health,36,50,,36,percent of total billed charges,Behavioral Health,57.6,80,,57.6,percent of total billed charges,All Other,50.4,70,,50.4,percent of total billed charges,All Other,46.8,65,,46.8,percent of total billed charges,Default if not in Fee Schedule,46.8,65,,46.8,percent of total billed charges,Default if not in Fee Schedule,0.01,,,0.01,Fee Schedule,Behavioral Health,0.01,,,0.01,Fee Schedule,Behavioral Health,0.01,,,0.01,Fee Schedule,Behavioral Health,0.01,,,0.01,Fee Schedule,Behavioral Health,93.82,,,93.82,Other,100% of Medicaid,93.82,,,93.82,Other,100% of Medicaid,93.82,,,93.82,Other,100% of Medicaid,93.82,,,93.82,Other,100% of Medicaid,211.09,,,211.09,Other,225% of Medicaid,143.54,,,143.54,Other,153% of Medicaid,211.09,,,211.09,Other,225% of Medicaid,131.34,,,131.34,Other,140% of Medicaid,211.09,,,211.09,Other,225% of Medicaid,243.92,,,243.92,Other,260% of Medicaid,303.97,,,303.97,Other,324% of Medicaid,201.71,,,201.71,Other,215% of Medicaid,201.71,,,201.71,Other,215% of Medicaid,117.27,,,117.27,Other,125% of Medicaid,0.01,303.97,
ATP PSYTX PT&/FAMILY 30 MIN,90832,CPT,,36290832,CDM,914,RC,,,both,,,329,243.46,,,243.46,Other,150% of Medicare + 9.63% HCRA Surcharge,148.05,45,,148.05,percent of total billed charges,Critical Access Hospital RCC factor,213.85,65,,213.85,percent of total billed charges,All Other,194.11,65,,194.11,percent of total billed charges,All Other,82,,,82,Fee Schedule,Behavioral Health,74,,,74,Fee Schedule,Behavioral Health,70,,,70,Fee Schedule,Behavioral Health,162.86,,,162.86,Other,110% of Medicare,106.52,,,106.52,Fee Schedule,Behavioral Health,174,,,174,Other,186% of Medicaid,106.52,,,106.52,Fee Schedule,Behavioral Health,106.52,,,106.52,Fee Schedule,Behavioral Health,106.52,,,106.52,Fee Schedule,Behavioral Health,106.52,,,106.52,Fee Schedule,Behavioral Health,106.52,,,106.52,Fee Schedule,Behavioral Health,263.2,80,,263.2,percent of total billed charges,All Other,230.3,70,,230.3,percent of total billed charges,All Other,99,,,99,Fee Schedule,Behavioral Health,84,,,84,Fee Schedule,Behavioral Health,69.32,,,69.32,Fee Schedule,Behavioral Health,69.32,,,69.32,Fee Schedule,Behavioral Health,69.32,,,69.32,Fee Schedule,Behavioral Health,69.32,,,69.32,Fee Schedule,Behavioral Health,93.82,,,93.82,Other,100% of Medicaid,93.82,,,93.82,Other,100% of Medicaid,93.82,,,93.82,Other,100% of Medicaid,93.82,,,93.82,Other,100% of Medicaid,211.09,,,211.09,Other,225% of Medicaid,143.54,,,143.54,Other,153% of Medicaid,211.09,,,211.09,Other,225% of Medicaid,131.34,,,131.34,Other,140% of Medicaid,211.09,,,211.09,Other,225% of Medicaid,243.92,,,243.92,Other,260% of Medicaid,303.97,,,303.97,Other,324% of Medicaid,201.71,,,201.71,Other,215% of Medicaid,201.71,,,201.71,Other,215% of Medicaid,117.27,,,117.27,Other,125% of Medicaid,69.32,303.97,
TH-PSYTX PT&/FAM W/PSYCH 30 MIN,90833,CPT,,36290833,CDM,914,RC,,,both,,,108,79.92,,,79.92,Other,150% of Medicare + 9.63% HCRA Surcharge,48.6,45,,48.6,percent of total billed charges,Critical Access Hospital RCC factor,70.2,65,,70.2,percent of total billed charges,All Other,63.72,65,,63.72,percent of total billed charges,All Other,82.62,76.5,,82.62,percent of total billed charges,All Other,76.68,69,,76.68,percent of total billed charges,All Other,74.52,65,,74.52,percent of total billed charges,All Other,53.46,,,53.46,Other,110% of Medicare,100.23,,,100.23,Fee Schedule,Behavioral Health,174,,,174,Other,186% of Medicaid,100.23,,,100.23,Fee Schedule,Behavioral Health,100.23,,,100.23,Fee Schedule,Behavioral Health,100.23,,,100.23,Fee Schedule,Behavioral Health,100.23,,,100.23,Fee Schedule,Behavioral Health,100.23,,,100.23,Fee Schedule,Behavioral Health,86.4,80,,86.4,percent of total billed charges,All Other,75.6,70,,75.6,percent of total billed charges,All Other,28,,,28,Fee Schedule,Behavioral Health,24,,,24,Fee Schedule,Behavioral Health,52.8,,,52.8,Fee Schedule,Behavioral Health,52.8,,,52.8,Fee Schedule,Behavioral Health,52.8,,,52.8,Fee Schedule,Behavioral Health,52.8,,,52.8,Fee Schedule,Behavioral Health,93.82,,,93.82,Other,100% of Medicaid,93.82,,,93.82,Other,100% of Medicaid,93.82,,,93.82,Other,100% of Medicaid,93.82,,,93.82,Other,100% of Medicaid,211.09,,,211.09,Other,225% of Medicaid,143.54,,,143.54,Other,153% of Medicaid,211.09,,,211.09,Other,225% of Medicaid,131.34,,,131.34,Other,140% of Medicaid,211.09,,,211.09,Other,225% of Medicaid,243.92,,,243.92,Other,260% of Medicaid,303.97,,,303.97,Other,324% of Medicaid,201.71,,,201.71,Other,215% of Medicaid,201.71,,,201.71,Other,215% of Medicaid,117.27,,,117.27,Other,125% of Medicaid,24,303.97,
ATP PSYTX PT&/FAMILY 45 MIN,90834,CPT,,36290834,CDM,914,RC,,,both,,,399,295.26,,,295.26,Other,150% of Medicare + 9.63% HCRA Surcharge,179.55,45,,179.55,percent of total billed charges,Critical Access Hospital RCC factor,259.35,65,,259.35,percent of total billed charges,All Other,235.41,65,,235.41,percent of total billed charges,All Other,158,,,158,Fee Schedule,Behavioral Health,142,,,142,Fee Schedule,Behavioral Health,134,,,134,Fee Schedule,Behavioral Health,197.51,,,197.51,Other,110% of Medicare,140.78,,,140.78,Fee Schedule,Behavioral Health,233,,,233,Other,186% of Medicaid,140.78,,,140.78,Fee Schedule,Behavioral Health,140.78,,,140.78,Fee Schedule,Behavioral Health,140.78,,,140.78,Fee Schedule,Behavioral Health,140.78,,,140.78,Fee Schedule,Behavioral Health,140.78,,,140.78,Fee Schedule,Behavioral Health,319.2,80,,319.2,percent of total billed charges,All Other,279.3,70,,279.3,percent of total billed charges,All Other,154,,,154,Fee Schedule,Behavioral Health,131,,,131,Fee Schedule,Behavioral Health,104.53,,,104.53,Fee Schedule,Behavioral Health,104.53,,,104.53,Fee Schedule,Behavioral Health,104.53,,,104.53,Fee Schedule,Behavioral Health,104.53,,,104.53,Fee Schedule,Behavioral Health,125.09,,,125.09,Other,100% of Medicaid,125.09,,,125.09,Other,100% of Medicaid,125.09,,,125.09,Other,100% of Medicaid,125.09,,,125.09,Other,100% of Medicaid,281.45,,,281.45,Other,225% of Medicaid,191.39,,,191.39,Other,153% of Medicaid,281.45,,,281.45,Other,225% of Medicaid,175.13,,,175.13,Other,140% of Medicaid,281.45,,,281.45,Other,225% of Medicaid,325.23,,,325.23,Other,260% of Medicaid,405.29,,,405.29,Other,324% of Medicaid,268.94,,,268.94,Other,215% of Medicaid,268.94,,,268.94,Other,215% of Medicaid,156.36,,,156.36,Other,125% of Medicaid,104.53,405.29,
TH-PSYTX PT&/FAM W/PSYCH 45 MIN,90836,CPT,,36290836,CDM,914,RC,,,both,,,175,129.5,,,129.5,Other,150% of Medicare + 9.63% HCRA Surcharge,78.75,45,,78.75,percent of total billed charges,Critical Access Hospital RCC factor,113.75,65,,113.75,percent of total billed charges,All Other,103.25,65,,103.25,percent of total billed charges,All Other,133.88,76.5,,133.88,percent of total billed charges,All Other,124.25,69,,124.25,percent of total billed charges,All Other,120.75,65,,120.75,percent of total billed charges,All Other,86.63,,,86.63,Other,110% of Medicare,126.78,,,126.78,Fee Schedule,Behavioral Health,233,,,233,Other,186% of Medicaid,126.78,,,126.78,Fee Schedule,Behavioral Health,126.78,,,126.78,Fee Schedule,Behavioral Health,126.78,,,126.78,Fee Schedule,Behavioral Health,126.78,,,126.78,Fee Schedule,Behavioral Health,126.78,,,126.78,Fee Schedule,Behavioral Health,140,80,,140,percent of total billed charges,All Other,122.5,70,,122.5,percent of total billed charges,All Other,100,,,100,Fee Schedule,Behavioral Health,85,,,85,Fee Schedule,Behavioral Health,79.55,,,79.55,Fee Schedule,Behavioral Health,79.55,,,79.55,Fee Schedule,Behavioral Health,79.55,,,79.55,Fee Schedule,Behavioral Health,79.55,,,79.55,Fee Schedule,Behavioral Health,125.09,,,125.09,Other,100% of Medicaid,125.09,,,125.09,Other,100% of Medicaid,125.09,,,125.09,Other,100% of Medicaid,125.09,,,125.09,Other,100% of Medicaid,281.45,,,281.45,Other,225% of Medicaid,191.39,,,191.39,Other,153% of Medicaid,281.45,,,281.45,Other,225% of Medicaid,175.13,,,175.13,Other,140% of Medicaid,281.45,,,281.45,Other,225% of Medicaid,325.23,,,325.23,Other,260% of Medicaid,405.29,,,405.29,Other,324% of Medicaid,268.94,,,268.94,Other,215% of Medicaid,268.94,,,268.94,Other,215% of Medicaid,156.36,,,156.36,Other,125% of Medicaid,78.75,405.29,
TH-IOP PSYTX PT&/FAMILY 30 MIN,90832,CPT,95,36490832,CDM,914,RC,,,both,,,329,243.46,,,243.46,Other,150% of Medicare + 9.63% HCRA Surcharge,148.05,45,,148.05,percent of total billed charges,Critical Access Hospital RCC factor,213.85,65,,213.85,percent of total billed charges,All Other,194.11,65,,194.11,percent of total billed charges,All Other,82,,,82,Fee Schedule,Behavioral Health,74,,,74,Fee Schedule,Behavioral Health,70,,,70,Fee Schedule,Behavioral Health,162.86,,,162.86,Other,110% of Medicare,106.52,,,106.52,Fee Schedule,Behavioral Health,174,,,174,Other,186% of Medicaid,106.52,,,106.52,Fee Schedule,Behavioral Health,106.52,,,106.52,Fee Schedule,Behavioral Health,106.52,,,106.52,Fee Schedule,Behavioral Health,106.52,,,106.52,Fee Schedule,Behavioral Health,106.52,,,106.52,Fee Schedule,Behavioral Health,263.2,80,,263.2,percent of total billed charges,All Other,230.3,70,,230.3,percent of total billed charges,All Other,99,,,99,Fee Schedule,Behavioral Health,84,,,84,Fee Schedule,Behavioral Health,69.32,,,69.32,Fee Schedule,Behavioral Health,69.32,,,69.32,Fee Schedule,Behavioral Health,69.32,,,69.32,Fee Schedule,Behavioral Health,69.32,,,69.32,Fee Schedule,Behavioral Health,93.82,,,93.82,Other,100% of Medicaid,93.82,,,93.82,Other,100% of Medicaid,93.82,,,93.82,Other,100% of Medicaid,93.82,,,93.82,Other,100% of Medicaid,211.09,,,211.09,Other,225% of Medicaid,143.54,,,143.54,Other,153% of Medicaid,211.09,,,211.09,Other,225% of Medicaid,131.34,,,131.34,Other,140% of Medicaid,211.09,,,211.09,Other,225% of Medicaid,243.92,,,243.92,Other,260% of Medicaid,303.97,,,303.97,Other,324% of Medicaid,201.71,,,201.71,Other,215% of Medicaid,201.71,,,201.71,Other,215% of Medicaid,117.27,,,117.27,Other,125% of Medicaid,69.32,303.97,
TH-PSYTX PT&/FAMILY 45 MIN,90834,CPT,95,36490834,CDM,914,RC,,,both,,,399,295.26,,,295.26,Other,150% of Medicare + 9.63% HCRA Surcharge,179.55,45,,179.55,percent of total billed charges,Critical Access Hospital RCC factor,259.35,65,,259.35,percent of total billed charges,All Other,235.41,65,,235.41,percent of total billed charges,All Other,158,,,158,Fee Schedule,Behavioral Health,142,,,142,Fee Schedule,Behavioral Health,134,,,134,Fee Schedule,Behavioral Health,197.51,,,197.51,Other,110% of Medicare,140.78,,,140.78,Fee Schedule,Behavioral Health,233,,,233,Other,186% of Medicaid,140.78,,,140.78,Fee Schedule,Behavioral Health,140.78,,,140.78,Fee Schedule,Behavioral Health,140.78,,,140.78,Fee Schedule,Behavioral Health,140.78,,,140.78,Fee Schedule,Behavioral Health,140.78,,,140.78,Fee Schedule,Behavioral Health,319.2,80,,319.2,percent of total billed charges,All Other,279.3,70,,279.3,percent of total billed charges,All Other,154,,,154,Fee Schedule,Behavioral Health,131,,,131,Fee Schedule,Behavioral Health,104.53,,,104.53,Fee Schedule,Behavioral Health,104.53,,,104.53,Fee Schedule,Behavioral Health,104.53,,,104.53,Fee Schedule,Behavioral Health,104.53,,,104.53,Fee Schedule,Behavioral Health,125.09,,,125.09,Other,100% of Medicaid,125.09,,,125.09,Other,100% of Medicaid,125.09,,,125.09,Other,100% of Medicaid,125.09,,,125.09,Other,100% of Medicaid,281.45,,,281.45,Other,225% of Medicaid,191.39,,,191.39,Other,153% of Medicaid,281.45,,,281.45,Other,225% of Medicaid,175.13,,,175.13,Other,140% of Medicaid,281.45,,,281.45,Other,225% of Medicaid,325.23,,,325.23,Other,260% of Medicaid,405.29,,,405.29,Other,324% of Medicaid,268.94,,,268.94,Other,215% of Medicaid,268.94,,,268.94,Other,215% of Medicaid,156.36,,,156.36,Other,125% of Medicaid,104.53,405.29,
TH -PSYTX PT&/FAMILY 60 MIN,90837,CPT,95,36490837,CDM,914,RC,,,both,,,399,295.26,,,295.26,Other,150% of Medicare + 9.63% HCRA Surcharge,179.55,45,,179.55,percent of total billed charges,Critical Access Hospital RCC factor,259.35,65,,259.35,percent of total billed charges,All Other,235.41,65,,235.41,percent of total billed charges,All Other,158,,,158,Fee Schedule,Behavioral Health,142,,,142,Fee Schedule,Behavioral Health,134,,,134,Fee Schedule,Behavioral Health,197.51,,,197.51,Other,110% of Medicare,207.78,,,207.78,Fee Schedule,Behavioral Health,233,,,233,Other,186% of Medicaid,207.78,,,207.78,Fee Schedule,Behavioral Health,207.78,,,207.78,Fee Schedule,Behavioral Health,207.78,,,207.78,Fee Schedule,Behavioral Health,207.78,,,207.78,Fee Schedule,Behavioral Health,207.78,,,207.78,Fee Schedule,Behavioral Health,319.2,80,,319.2,percent of total billed charges,All Other,279.3,70,,279.3,percent of total billed charges,All Other,154,,,154,Fee Schedule,Behavioral Health,131,,,131,Fee Schedule,Behavioral Health,110.87,,,110.87,Fee Schedule,Behavioral Health,110.87,,,110.87,Fee Schedule,Behavioral Health,110.87,,,110.87,Fee Schedule,Behavioral Health,110.87,,,110.87,Fee Schedule,Behavioral Health,125.09,,,125.09,Other,100% of Medicaid,125.09,,,125.09,Other,100% of Medicaid,125.09,,,125.09,Other,100% of Medicaid,125.09,,,125.09,Other,100% of Medicaid,281.45,,,281.45,Other,225% of Medicaid,191.39,,,191.39,Other,153% of Medicaid,281.45,,,281.45,Other,225% of Medicaid,175.13,,,175.13,Other,140% of Medicaid,281.45,,,281.45,Other,225% of Medicaid,325.23,,,325.23,Other,260% of Medicaid,405.29,,,405.29,Other,324% of Medicaid,268.94,,,268.94,Other,215% of Medicaid,268.94,,,268.94,Other,215% of Medicaid,156.36,,,156.36,Other,125% of Medicaid,110.87,405.29,
TH-PSYTX PT&/FAM W/MD 60 MIN,90838,CPT,95,36490838,CDM,914,RC,,,both,,,282,208.68,,,208.68,Other,150% of Medicare + 9.63% HCRA Surcharge,126.9,45,,126.9,percent of total billed charges,Critical Access Hospital RCC factor,183.3,65,,183.3,percent of total billed charges,All Other,166.38,65,,166.38,percent of total billed charges,All Other,215.73,76.5,,215.73,percent of total billed charges,All Other,200.22,69,,200.22,percent of total billed charges,All Other,194.58,65,,194.58,percent of total billed charges,All Other,139.59,,,139.59,Other,110% of Medicare,168.08,,,168.08,Fee Schedule,Behavioral Health,233,,,233,Other,186% of Medicaid,168.08,,,168.08,Fee Schedule,Behavioral Health,168.08,,,168.08,Fee Schedule,Behavioral Health,168.08,,,168.08,Fee Schedule,Behavioral Health,168.08,,,168.08,Fee Schedule,Behavioral Health,168.08,,,168.08,Fee Schedule,Behavioral Health,225.6,80,,225.6,percent of total billed charges,All Other,197.4,70,,197.4,percent of total billed charges,All Other,121,,,121,Fee Schedule,Behavioral Health,103,,,103,Fee Schedule,Behavioral Health,106.31,,,106.31,Fee Schedule,Behavioral Health,106.31,,,106.31,Fee Schedule,Behavioral Health,106.31,,,106.31,Fee Schedule,Behavioral Health,106.31,,,106.31,Fee Schedule,Behavioral Health,125.09,,,125.09,Other,100% of Medicaid,125.09,,,125.09,Other,100% of Medicaid,125.09,,,125.09,Other,100% of Medicaid,125.09,,,125.09,Other,100% of Medicaid,281.45,,,281.45,Other,225% of Medicaid,191.39,,,191.39,Other,153% of Medicaid,281.45,,,281.45,Other,225% of Medicaid,175.13,,,175.13,Other,140% of Medicaid,281.45,,,281.45,Other,225% of Medicaid,325.23,,,325.23,Other,260% of Medicaid,405.29,,,405.29,Other,324% of Medicaid,268.94,,,268.94,Other,215% of Medicaid,268.94,,,268.94,Other,215% of Medicaid,156.36,,,156.36,Other,125% of Medicaid,103,405.29,
TH-IOP PSYTX PT&/FAMILY 30 MIN,90832,CPT,95,36590832,CDM,914,RC,,,both,,,329,243.46,,,243.46,Other,150% of Medicare + 9.63% HCRA Surcharge,148.05,45,,148.05,percent of total billed charges,Critical Access Hospital RCC factor,213.85,65,,213.85,percent of total billed charges,All Other,194.11,65,,194.11,percent of total billed charges,All Other,82,,,82,Fee Schedule,Behavioral Health,74,,,74,Fee Schedule,Behavioral Health,70,,,70,Fee Schedule,Behavioral Health,162.86,,,162.86,Other,110% of Medicare,106.52,,,106.52,Fee Schedule,Behavioral Health,174,,,174,Other,186% of Medicaid,106.52,,,106.52,Fee Schedule,Behavioral Health,106.52,,,106.52,Fee Schedule,Behavioral Health,106.52,,,106.52,Fee Schedule,Behavioral Health,106.52,,,106.52,Fee Schedule,Behavioral Health,106.52,,,106.52,Fee Schedule,Behavioral Health,263.2,80,,263.2,percent of total billed charges,All Other,230.3,70,,230.3,percent of total billed charges,All Other,99,,,99,Fee Schedule,Behavioral Health,84,,,84,Fee Schedule,Behavioral Health,69.32,,,69.32,Fee Schedule,Behavioral Health,69.32,,,69.32,Fee Schedule,Behavioral Health,69.32,,,69.32,Fee Schedule,Behavioral Health,69.32,,,69.32,Fee Schedule,Behavioral Health,93.82,,,93.82,Other,100% of Medicaid,93.82,,,93.82,Other,100% of Medicaid,93.82,,,93.82,Other,100% of Medicaid,93.82,,,93.82,Other,100% of Medicaid,211.09,,,211.09,Other,225% of Medicaid,143.54,,,143.54,Other,153% of Medicaid,211.09,,,211.09,Other,225% of Medicaid,131.34,,,131.34,Other,140% of Medicaid,211.09,,,211.09,Other,225% of Medicaid,243.92,,,243.92,Other,260% of Medicaid,303.97,,,303.97,Other,324% of Medicaid,201.71,,,201.71,Other,215% of Medicaid,201.71,,,201.71,Other,215% of Medicaid,117.27,,,117.27,Other,125% of Medicaid,69.32,303.97,
TH-IOP PSYTX PT&/FAMILY 45 MIN,90834,CPT,95,36590834,CDM,914,RC,,,both,,,399,295.26,,,295.26,Other,150% of Medicare + 9.63% HCRA Surcharge,179.55,45,,179.55,percent of total billed charges,Critical Access Hospital RCC factor,259.35,65,,259.35,percent of total billed charges,All Other,235.41,65,,235.41,percent of total billed charges,All Other,158,,,158,Fee Schedule,Behavioral Health,142,,,142,Fee Schedule,Behavioral Health,134,,,134,Fee Schedule,Behavioral Health,197.51,,,197.51,Other,110% of Medicare,140.78,,,140.78,Fee Schedule,Behavioral Health,233,,,233,Other,186% of Medicaid,140.78,,,140.78,Fee Schedule,Behavioral Health,140.78,,,140.78,Fee Schedule,Behavioral Health,140.78,,,140.78,Fee Schedule,Behavioral Health,140.78,,,140.78,Fee Schedule,Behavioral Health,140.78,,,140.78,Fee Schedule,Behavioral Health,319.2,80,,319.2,percent of total billed charges,All Other,279.3,70,,279.3,percent of total billed charges,All Other,154,,,154,Fee Schedule,Behavioral Health,131,,,131,Fee Schedule,Behavioral Health,104.53,,,104.53,Fee Schedule,Behavioral Health,104.53,,,104.53,Fee Schedule,Behavioral Health,104.53,,,104.53,Fee Schedule,Behavioral Health,104.53,,,104.53,Fee Schedule,Behavioral Health,125.09,,,125.09,Other,100% of Medicaid,125.09,,,125.09,Other,100% of Medicaid,125.09,,,125.09,Other,100% of Medicaid,125.09,,,125.09,Other,100% of Medicaid,281.45,,,281.45,Other,225% of Medicaid,191.39,,,191.39,Other,153% of Medicaid,281.45,,,281.45,Other,225% of Medicaid,175.13,,,175.13,Other,140% of Medicaid,281.45,,,281.45,Other,225% of Medicaid,325.23,,,325.23,Other,260% of Medicaid,405.29,,,405.29,Other,324% of Medicaid,268.94,,,268.94,Other,215% of Medicaid,268.94,,,268.94,Other,215% of Medicaid,156.36,,,156.36,Other,125% of Medicaid,104.53,405.29,
TH-PSYTX PT&/FAM W/PSYCH 60 MIN,90838,CPT,95,36590838,CDM,914,RC,,,both,,,282,208.68,,,208.68,Other,150% of Medicare + 9.63% HCRA Surcharge,126.9,45,,126.9,percent of total billed charges,Critical Access Hospital RCC factor,183.3,65,,183.3,percent of total billed charges,All Other,166.38,65,,166.38,percent of total billed charges,All Other,215.73,76.5,,215.73,percent of total billed charges,All Other,200.22,69,,200.22,percent of total billed charges,All Other,194.58,65,,194.58,percent of total billed charges,All Other,139.59,,,139.59,Other,110% of Medicare,168.08,,,168.08,Fee Schedule,Behavioral Health,233,,,233,Other,186% of Medicaid,168.08,,,168.08,Fee Schedule,Behavioral Health,168.08,,,168.08,Fee Schedule,Behavioral Health,168.08,,,168.08,Fee Schedule,Behavioral Health,168.08,,,168.08,Fee Schedule,Behavioral Health,168.08,,,168.08,Fee Schedule,Behavioral Health,225.6,80,,225.6,percent of total billed charges,All Other,197.4,70,,197.4,percent of total billed charges,All Other,121,,,121,Fee Schedule,Behavioral Health,103,,,103,Fee Schedule,Behavioral Health,106.31,,,106.31,Fee Schedule,Behavioral Health,106.31,,,106.31,Fee Schedule,Behavioral Health,106.31,,,106.31,Fee Schedule,Behavioral Health,106.31,,,106.31,Fee Schedule,Behavioral Health,125.09,,,125.09,Other,100% of Medicaid,125.09,,,125.09,Other,100% of Medicaid,125.09,,,125.09,Other,100% of Medicaid,125.09,,,125.09,Other,100% of Medicaid,281.45,,,281.45,Other,225% of Medicaid,191.39,,,191.39,Other,153% of Medicaid,281.45,,,281.45,Other,225% of Medicaid,175.13,,,175.13,Other,140% of Medicaid,281.45,,,281.45,Other,225% of Medicaid,325.23,,,325.23,Other,260% of Medicaid,405.29,,,405.29,Other,324% of Medicaid,268.94,,,268.94,Other,215% of Medicaid,268.94,,,268.94,Other,215% of Medicaid,156.36,,,156.36,Other,125% of Medicaid,103,405.29,
TH-ATP PSYTX PT&/FAMILY 30 MIN,90832,CPT,95,36690832,CDM,914,RC,,,both,,,329,243.46,,,243.46,Other,150% of Medicare + 9.63% HCRA Surcharge,148.05,45,,148.05,percent of total billed charges,Critical Access Hospital RCC factor,213.85,65,,213.85,percent of total billed charges,All Other,194.11,65,,194.11,percent of total billed charges,All Other,82,,,82,Fee Schedule,Behavioral Health,74,,,74,Fee Schedule,Behavioral Health,70,,,70,Fee Schedule,Behavioral Health,162.86,,,162.86,Other,110% of Medicare,106.52,,,106.52,Fee Schedule,Behavioral Health,174,,,174,Other,186% of Medicaid,106.52,,,106.52,Fee Schedule,Behavioral Health,106.52,,,106.52,Fee Schedule,Behavioral Health,106.52,,,106.52,Fee Schedule,Behavioral Health,106.52,,,106.52,Fee Schedule,Behavioral Health,106.52,,,106.52,Fee Schedule,Behavioral Health,263.2,80,,263.2,percent of total billed charges,All Other,230.3,70,,230.3,percent of total billed charges,All Other,99,,,99,Fee Schedule,Behavioral Health,84,,,84,Fee Schedule,Behavioral Health,69.32,,,69.32,Fee Schedule,Behavioral Health,69.32,,,69.32,Fee Schedule,Behavioral Health,69.32,,,69.32,Fee Schedule,Behavioral Health,69.32,,,69.32,Fee Schedule,Behavioral Health,93.82,,,93.82,Other,100% of Medicaid,93.82,,,93.82,Other,100% of Medicaid,93.82,,,93.82,Other,100% of Medicaid,93.82,,,93.82,Other,100% of Medicaid,211.09,,,211.09,Other,225% of Medicaid,143.54,,,143.54,Other,153% of Medicaid,211.09,,,211.09,Other,225% of Medicaid,131.34,,,131.34,Other,140% of Medicaid,211.09,,,211.09,Other,225% of Medicaid,243.92,,,243.92,Other,260% of Medicaid,303.97,,,303.97,Other,324% of Medicaid,201.71,,,201.71,Other,215% of Medicaid,201.71,,,201.71,Other,215% of Medicaid,117.27,,,117.27,Other,125% of Medicaid,69.32,303.97,
TH-ATP PSYTX PT&/FAMILY 45 MIN,90834,CPT,95,36690834,CDM,914,RC,,,both,,,399,295.26,,,295.26,Other,150% of Medicare + 9.63% HCRA Surcharge,179.55,45,,179.55,percent of total billed charges,Critical Access Hospital RCC factor,259.35,65,,259.35,percent of total billed charges,All Other,235.41,65,,235.41,percent of total billed charges,All Other,158,,,158,Fee Schedule,Behavioral Health,142,,,142,Fee Schedule,Behavioral Health,134,,,134,Fee Schedule,Behavioral Health,197.51,,,197.51,Other,110% of Medicare,140.78,,,140.78,Fee Schedule,Behavioral Health,233,,,233,Other,186% of Medicaid,140.78,,,140.78,Fee Schedule,Behavioral Health,140.78,,,140.78,Fee Schedule,Behavioral Health,140.78,,,140.78,Fee Schedule,Behavioral Health,140.78,,,140.78,Fee Schedule,Behavioral Health,140.78,,,140.78,Fee Schedule,Behavioral Health,319.2,80,,319.2,percent of total billed charges,All Other,279.3,70,,279.3,percent of total billed charges,All Other,154,,,154,Fee Schedule,Behavioral Health,131,,,131,Fee Schedule,Behavioral Health,104.53,,,104.53,Fee Schedule,Behavioral Health,104.53,,,104.53,Fee Schedule,Behavioral Health,104.53,,,104.53,Fee Schedule,Behavioral Health,104.53,,,104.53,Fee Schedule,Behavioral Health,125.09,,,125.09,Other,100% of Medicaid,125.09,,,125.09,Other,100% of Medicaid,125.09,,,125.09,Other,100% of Medicaid,125.09,,,125.09,Other,100% of Medicaid,281.45,,,281.45,Other,225% of Medicaid,191.39,,,191.39,Other,153% of Medicaid,281.45,,,281.45,Other,225% of Medicaid,175.13,,,175.13,Other,140% of Medicaid,281.45,,,281.45,Other,225% of Medicaid,325.23,,,325.23,Other,260% of Medicaid,405.29,,,405.29,Other,324% of Medicaid,268.94,,,268.94,Other,215% of Medicaid,268.94,,,268.94,Other,215% of Medicaid,156.36,,,156.36,Other,125% of Medicaid,104.53,405.29,
TH-ADR PSYTX PT&/FAMILY 30 MIN,90832,CPT,95,36790832,CDM,914,RC,,,both,,,329,243.46,,,243.46,Other,150% of Medicare + 9.63% HCRA Surcharge,148.05,45,,148.05,percent of total billed charges,Critical Access Hospital RCC factor,213.85,65,,213.85,percent of total billed charges,All Other,194.11,65,,194.11,percent of total billed charges,All Other,82,,,82,Fee Schedule,Behavioral Health,74,,,74,Fee Schedule,Behavioral Health,70,,,70,Fee Schedule,Behavioral Health,162.86,,,162.86,Other,110% of Medicare,106.52,,,106.52,Fee Schedule,Behavioral Health,174,,,174,Other,186% of Medicaid,106.52,,,106.52,Fee Schedule,Behavioral Health,106.52,,,106.52,Fee Schedule,Behavioral Health,106.52,,,106.52,Fee Schedule,Behavioral Health,106.52,,,106.52,Fee Schedule,Behavioral Health,106.52,,,106.52,Fee Schedule,Behavioral Health,263.2,80,,263.2,percent of total billed charges,All Other,230.3,70,,230.3,percent of total billed charges,All Other,99,,,99,Fee Schedule,Behavioral Health,84,,,84,Fee Schedule,Behavioral Health,69.32,,,69.32,Fee Schedule,Behavioral Health,69.32,,,69.32,Fee Schedule,Behavioral Health,69.32,,,69.32,Fee Schedule,Behavioral Health,69.32,,,69.32,Fee Schedule,Behavioral Health,93.82,,,93.82,Other,100% of Medicaid,93.82,,,93.82,Other,100% of Medicaid,93.82,,,93.82,Other,100% of Medicaid,93.82,,,93.82,Other,100% of Medicaid,211.09,,,211.09,Other,225% of Medicaid,143.54,,,143.54,Other,153% of Medicaid,211.09,,,211.09,Other,225% of Medicaid,131.34,,,131.34,Other,140% of Medicaid,211.09,,,211.09,Other,225% of Medicaid,243.92,,,243.92,Other,260% of Medicaid,303.97,,,303.97,Other,324% of Medicaid,201.71,,,201.71,Other,215% of Medicaid,201.71,,,201.71,Other,215% of Medicaid,117.27,,,117.27,Other,125% of Medicaid,69.32,303.97,
TH-ADR PSYTX PT&/FAMILY 45 MIN,90834,CPT,95,36790834,CDM,914,RC,,,both,,,399,295.26,,,295.26,Other,150% of Medicare + 9.63% HCRA Surcharge,179.55,45,,179.55,percent of total billed charges,Critical Access Hospital RCC factor,259.35,65,,259.35,percent of total billed charges,All Other,235.41,65,,235.41,percent of total billed charges,All Other,158,,,158,Fee Schedule,Behavioral Health,142,,,142,Fee Schedule,Behavioral Health,134,,,134,Fee Schedule,Behavioral Health,197.51,,,197.51,Other,110% of Medicare,140.78,,,140.78,Fee Schedule,Behavioral Health,233,,,233,Other,186% of Medicaid,140.78,,,140.78,Fee Schedule,Behavioral Health,140.78,,,140.78,Fee Schedule,Behavioral Health,140.78,,,140.78,Fee Schedule,Behavioral Health,140.78,,,140.78,Fee Schedule,Behavioral Health,140.78,,,140.78,Fee Schedule,Behavioral Health,319.2,80,,319.2,percent of total billed charges,All Other,279.3,70,,279.3,percent of total billed charges,All Other,154,,,154,Fee Schedule,Behavioral Health,131,,,131,Fee Schedule,Behavioral Health,104.53,,,104.53,Fee Schedule,Behavioral Health,104.53,,,104.53,Fee Schedule,Behavioral Health,104.53,,,104.53,Fee Schedule,Behavioral Health,104.53,,,104.53,Fee Schedule,Behavioral Health,125.09,,,125.09,Other,100% of Medicaid,125.09,,,125.09,Other,100% of Medicaid,125.09,,,125.09,Other,100% of Medicaid,125.09,,,125.09,Other,100% of Medicaid,281.45,,,281.45,Other,225% of Medicaid,191.39,,,191.39,Other,153% of Medicaid,281.45,,,281.45,Other,225% of Medicaid,175.13,,,175.13,Other,140% of Medicaid,281.45,,,281.45,Other,225% of Medicaid,325.23,,,325.23,Other,260% of Medicaid,405.29,,,405.29,Other,324% of Medicaid,268.94,,,268.94,Other,215% of Medicaid,268.94,,,268.94,Other,215% of Medicaid,156.36,,,156.36,Other,125% of Medicaid,104.53,405.29,
ADR PSYTX PT&/FAMILY 30 MIN,90832,CPT,,36890832,CDM,914,RC,,,both,,,329,243.46,,,243.46,Other,150% of Medicare + 9.63% HCRA Surcharge,148.05,45,,148.05,percent of total billed charges,Critical Access Hospital RCC factor,213.85,65,,213.85,percent of total billed charges,All Other,194.11,65,,194.11,percent of total billed charges,All Other,82,,,82,Fee Schedule,Behavioral Health,74,,,74,Fee Schedule,Behavioral Health,70,,,70,Fee Schedule,Behavioral Health,162.86,,,162.86,Other,110% of Medicare,106.52,,,106.52,Fee Schedule,Behavioral Health,174,,,174,Other,186% of Medicaid,106.52,,,106.52,Fee Schedule,Behavioral Health,106.52,,,106.52,Fee Schedule,Behavioral Health,106.52,,,106.52,Fee Schedule,Behavioral Health,106.52,,,106.52,Fee Schedule,Behavioral Health,106.52,,,106.52,Fee Schedule,Behavioral Health,263.2,80,,263.2,percent of total billed charges,All Other,230.3,70,,230.3,percent of total billed charges,All Other,99,,,99,Fee Schedule,Behavioral Health,84,,,84,Fee Schedule,Behavioral Health,69.32,,,69.32,Fee Schedule,Behavioral Health,69.32,,,69.32,Fee Schedule,Behavioral Health,69.32,,,69.32,Fee Schedule,Behavioral Health,69.32,,,69.32,Fee Schedule,Behavioral Health,93.82,,,93.82,Other,100% of Medicaid,93.82,,,93.82,Other,100% of Medicaid,93.82,,,93.82,Other,100% of Medicaid,93.82,,,93.82,Other,100% of Medicaid,211.09,,,211.09,Other,225% of Medicaid,143.54,,,143.54,Other,153% of Medicaid,211.09,,,211.09,Other,225% of Medicaid,131.34,,,131.34,Other,140% of Medicaid,211.09,,,211.09,Other,225% of Medicaid,243.92,,,243.92,Other,260% of Medicaid,303.97,,,303.97,Other,324% of Medicaid,201.71,,,201.71,Other,215% of Medicaid,201.71,,,201.71,Other,215% of Medicaid,117.27,,,117.27,Other,125% of Medicaid,69.32,303.97,
ADR PSYTX PT&/FAMILY 45 MIN,90834,CPT,,36890834,CDM,914,RC,,,both,,,399,295.26,,,295.26,Other,150% of Medicare + 9.63% HCRA Surcharge,179.55,45,,179.55,percent of total billed charges,Critical Access Hospital RCC factor,259.35,65,,259.35,percent of total billed charges,All Other,235.41,65,,235.41,percent of total billed charges,All Other,158,,,158,Fee Schedule,Behavioral Health,142,,,142,Fee Schedule,Behavioral Health,134,,,134,Fee Schedule,Behavioral Health,197.51,,,197.51,Other,110% of Medicare,140.78,,,140.78,Fee Schedule,Behavioral Health,233,,,233,Other,186% of Medicaid,140.78,,,140.78,Fee Schedule,Behavioral Health,140.78,,,140.78,Fee Schedule,Behavioral Health,140.78,,,140.78,Fee Schedule,Behavioral Health,140.78,,,140.78,Fee Schedule,Behavioral Health,140.78,,,140.78,Fee Schedule,Behavioral Health,319.2,80,,319.2,percent of total billed charges,All Other,279.3,70,,279.3,percent of total billed charges,All Other,154,,,154,Fee Schedule,Behavioral Health,131,,,131,Fee Schedule,Behavioral Health,104.53,,,104.53,Fee Schedule,Behavioral Health,104.53,,,104.53,Fee Schedule,Behavioral Health,104.53,,,104.53,Fee Schedule,Behavioral Health,104.53,,,104.53,Fee Schedule,Behavioral Health,125.09,,,125.09,Other,100% of Medicaid,125.09,,,125.09,Other,100% of Medicaid,125.09,,,125.09,Other,100% of Medicaid,125.09,,,125.09,Other,100% of Medicaid,281.45,,,281.45,Other,225% of Medicaid,191.39,,,191.39,Other,153% of Medicaid,281.45,,,281.45,Other,225% of Medicaid,175.13,,,175.13,Other,140% of Medicaid,281.45,,,281.45,Other,225% of Medicaid,325.23,,,325.23,Other,260% of Medicaid,405.29,,,405.29,Other,324% of Medicaid,268.94,,,268.94,Other,215% of Medicaid,268.94,,,268.94,Other,215% of Medicaid,156.36,,,156.36,Other,125% of Medicaid,104.53,405.29,
TH-ALCOHOL/DRUG SERVICES C&T PER 15 MINS,H0004,HCPCS,GT,37000001,CDM,914,RC,,,both,,,72,53.28,,,53.28,Other,150% of Medicare + 9.63% HCRA Surcharge,32.4,45,,32.4,percent of total billed charges,Critical Access Hospital RCC factor,46.8,65,,46.8,percent of total billed charges,All Other,42.48,65,,42.48,percent of total billed charges,All Other,44.64,62,,44.64,percent of total billed charges,Behavioral Health,41.76,56,,41.76,percent of total billed charges,Behavioral Health,40.32,53,,40.32,percent of total billed charges,Behavioral Health,35.64,,,35.64,Other,110% of Medicare,36,50,,36,percent of total billed charges,Behavioral Health,174,,,174,Other,186% of Medicaid,36,50,,36,percent of total billed charges,Behavioral Health,36,50,,36,percent of total billed charges,Behavioral Health,36,50,,36,percent of total billed charges,Behavioral Health,36,50,,36,percent of total billed charges,Behavioral Health,36,50,,36,percent of total billed charges,Behavioral Health,57.6,80,,57.6,percent of total billed charges,All Other,50.4,70,,50.4,percent of total billed charges,All Other,46.8,65,,46.8,percent of total billed charges,Default if not in Fee Schedule,46.8,65,,46.8,percent of total billed charges,Default if not in Fee Schedule,0.01,,,0.01,Fee Schedule,Behavioral Health,0.01,,,0.01,Fee Schedule,Behavioral Health,0.01,,,0.01,Fee Schedule,Behavioral Health,0.01,,,0.01,Fee Schedule,Behavioral Health,93.82,,,93.82,Other,100% of Medicaid,93.82,,,93.82,Other,100% of Medicaid,93.82,,,93.82,Other,100% of Medicaid,93.82,,,93.82,Other,100% of Medicaid,211.09,,,211.09,Other,225% of Medicaid,143.54,,,143.54,Other,153% of Medicaid,211.09,,,211.09,Other,225% of Medicaid,131.34,,,131.34,Other,140% of Medicaid,211.09,,,211.09,Other,225% of Medicaid,243.92,,,243.92,Other,260% of Medicaid,303.97,,,303.97,Other,324% of Medicaid,201.71,,,201.71,Other,215% of Medicaid,201.71,,,201.71,Other,215% of Medicaid,117.27,,,117.27,Other,125% of Medicaid,0.01,303.97,
PSYTX PT&/FAMILY 30 MIN,90832,CPT,,37090832,CDM,914,RC,,,both,,,329,243.46,,,243.46,Other,150% of Medicare + 9.63% HCRA Surcharge,148.05,45,,148.05,percent of total billed charges,Critical Access Hospital RCC factor,213.85,65,,213.85,percent of total billed charges,All Other,194.11,65,,194.11,percent of total billed charges,All Other,82,,,82,Fee Schedule,Behavioral Health,74,,,74,Fee Schedule,Behavioral Health,70,,,70,Fee Schedule,Behavioral Health,162.86,,,162.86,Other,110% of Medicare,106.52,,,106.52,Fee Schedule,Behavioral Health,174,,,174,Other,186% of Medicaid,106.52,,,106.52,Fee Schedule,Behavioral Health,106.52,,,106.52,Fee Schedule,Behavioral Health,106.52,,,106.52,Fee Schedule,Behavioral Health,106.52,,,106.52,Fee Schedule,Behavioral Health,106.52,,,106.52,Fee Schedule,Behavioral Health,263.2,80,,263.2,percent of total billed charges,All Other,230.3,70,,230.3,percent of total billed charges,All Other,99,,,99,Fee Schedule,Behavioral Health,84,,,84,Fee Schedule,Behavioral Health,69.32,,,69.32,Fee Schedule,Behavioral Health,69.32,,,69.32,Fee Schedule,Behavioral Health,69.32,,,69.32,Fee Schedule,Behavioral Health,69.32,,,69.32,Fee Schedule,Behavioral Health,93.82,,,93.82,Other,100% of Medicaid,93.82,,,93.82,Other,100% of Medicaid,93.82,,,93.82,Other,100% of Medicaid,93.82,,,93.82,Other,100% of Medicaid,211.09,,,211.09,Other,225% of Medicaid,143.54,,,143.54,Other,153% of Medicaid,211.09,,,211.09,Other,225% of Medicaid,131.34,,,131.34,Other,140% of Medicaid,211.09,,,211.09,Other,225% of Medicaid,243.92,,,243.92,Other,260% of Medicaid,303.97,,,303.97,Other,324% of Medicaid,201.71,,,201.71,Other,215% of Medicaid,201.71,,,201.71,Other,215% of Medicaid,117.27,,,117.27,Other,125% of Medicaid,69.32,303.97,
PSYTX PT&/FAM W/MD 30 MIN,90833,CPT,,37090833,CDM,914,RC,,,both,,,108,79.92,,,79.92,Other,150% of Medicare + 9.63% HCRA Surcharge,48.6,45,,48.6,percent of total billed charges,Critical Access Hospital RCC factor,70.2,65,,70.2,percent of total billed charges,All Other,63.72,65,,63.72,percent of total billed charges,All Other,82.62,76.5,,82.62,percent of total billed charges,All Other,76.68,69,,76.68,percent of total billed charges,All Other,74.52,65,,74.52,percent of total billed charges,All Other,53.46,,,53.46,Other,110% of Medicare,100.23,,,100.23,Fee Schedule,Behavioral Health,174,,,174,Other,186% of Medicaid,100.23,,,100.23,Fee Schedule,Behavioral Health,100.23,,,100.23,Fee Schedule,Behavioral Health,100.23,,,100.23,Fee Schedule,Behavioral Health,100.23,,,100.23,Fee Schedule,Behavioral Health,100.23,,,100.23,Fee Schedule,Behavioral Health,86.4,80,,86.4,percent of total billed charges,All Other,75.6,70,,75.6,percent of total billed charges,All Other,28,,,28,Fee Schedule,Behavioral Health,24,,,24,Fee Schedule,Behavioral Health,52.8,,,52.8,Fee Schedule,Behavioral Health,52.8,,,52.8,Fee Schedule,Behavioral Health,52.8,,,52.8,Fee Schedule,Behavioral Health,52.8,,,52.8,Fee Schedule,Behavioral Health,93.82,,,93.82,Other,100% of Medicaid,93.82,,,93.82,Other,100% of Medicaid,93.82,,,93.82,Other,100% of Medicaid,93.82,,,93.82,Other,100% of Medicaid,211.09,,,211.09,Other,225% of Medicaid,143.54,,,143.54,Other,153% of Medicaid,211.09,,,211.09,Other,225% of Medicaid,131.34,,,131.34,Other,140% of Medicaid,211.09,,,211.09,Other,225% of Medicaid,243.92,,,243.92,Other,260% of Medicaid,303.97,,,303.97,Other,324% of Medicaid,201.71,,,201.71,Other,215% of Medicaid,201.71,,,201.71,Other,215% of Medicaid,117.27,,,117.27,Other,125% of Medicaid,24,303.97,
PSYTX PT&/FAMILY 45 MIN,90834,CPT,,37090834,CDM,914,RC,,,both,,,399,295.26,,,295.26,Other,150% of Medicare + 9.63% HCRA Surcharge,179.55,45,,179.55,percent of total billed charges,Critical Access Hospital RCC factor,259.35,65,,259.35,percent of total billed charges,All Other,235.41,65,,235.41,percent of total billed charges,All Other,158,,,158,Fee Schedule,Behavioral Health,142,,,142,Fee Schedule,Behavioral Health,134,,,134,Fee Schedule,Behavioral Health,197.51,,,197.51,Other,110% of Medicare,140.78,,,140.78,Fee Schedule,Behavioral Health,233,,,233,Other,186% of Medicaid,140.78,,,140.78,Fee Schedule,Behavioral Health,140.78,,,140.78,Fee Schedule,Behavioral Health,140.78,,,140.78,Fee Schedule,Behavioral Health,140.78,,,140.78,Fee Schedule,Behavioral Health,140.78,,,140.78,Fee Schedule,Behavioral Health,319.2,80,,319.2,percent of total billed charges,All Other,279.3,70,,279.3,percent of total billed charges,All Other,154,,,154,Fee Schedule,Behavioral Health,131,,,131,Fee Schedule,Behavioral Health,104.53,,,104.53,Fee Schedule,Behavioral Health,104.53,,,104.53,Fee Schedule,Behavioral Health,104.53,,,104.53,Fee Schedule,Behavioral Health,104.53,,,104.53,Fee Schedule,Behavioral Health,125.09,,,125.09,Other,100% of Medicaid,125.09,,,125.09,Other,100% of Medicaid,125.09,,,125.09,Other,100% of Medicaid,125.09,,,125.09,Other,100% of Medicaid,281.45,,,281.45,Other,225% of Medicaid,191.39,,,191.39,Other,153% of Medicaid,281.45,,,281.45,Other,225% of Medicaid,175.13,,,175.13,Other,140% of Medicaid,281.45,,,281.45,Other,225% of Medicaid,325.23,,,325.23,Other,260% of Medicaid,405.29,,,405.29,Other,324% of Medicaid,268.94,,,268.94,Other,215% of Medicaid,268.94,,,268.94,Other,215% of Medicaid,156.36,,,156.36,Other,125% of Medicaid,104.53,405.29,
PSYTX PT&/FAM W/MD 45 MIN,90836,CPT,,37090836,CDM,914,RC,,,both,,,175,129.5,,,129.5,Other,150% of Medicare + 9.63% HCRA Surcharge,78.75,45,,78.75,percent of total billed charges,Critical Access Hospital RCC factor,113.75,65,,113.75,percent of total billed charges,All Other,103.25,65,,103.25,percent of total billed charges,All Other,133.88,76.5,,133.88,percent of total billed charges,All Other,124.25,69,,124.25,percent of total billed charges,All Other,120.75,65,,120.75,percent of total billed charges,All Other,86.63,,,86.63,Other,110% of Medicare,126.78,,,126.78,Fee Schedule,Behavioral Health,233,,,233,Other,186% of Medicaid,126.78,,,126.78,Fee Schedule,Behavioral Health,126.78,,,126.78,Fee Schedule,Behavioral Health,126.78,,,126.78,Fee Schedule,Behavioral Health,126.78,,,126.78,Fee Schedule,Behavioral Health,126.78,,,126.78,Fee Schedule,Behavioral Health,140,80,,140,percent of total billed charges,All Other,122.5,70,,122.5,percent of total billed charges,All Other,100,,,100,Fee Schedule,Behavioral Health,85,,,85,Fee Schedule,Behavioral Health,79.55,,,79.55,Fee Schedule,Behavioral Health,79.55,,,79.55,Fee Schedule,Behavioral Health,79.55,,,79.55,Fee Schedule,Behavioral Health,79.55,,,79.55,Fee Schedule,Behavioral Health,125.09,,,125.09,Other,100% of Medicaid,125.09,,,125.09,Other,100% of Medicaid,125.09,,,125.09,Other,100% of Medicaid,125.09,,,125.09,Other,100% of Medicaid,281.45,,,281.45,Other,225% of Medicaid,191.39,,,191.39,Other,153% of Medicaid,281.45,,,281.45,Other,225% of Medicaid,175.13,,,175.13,Other,140% of Medicaid,281.45,,,281.45,Other,225% of Medicaid,325.23,,,325.23,Other,260% of Medicaid,405.29,,,405.29,Other,324% of Medicaid,268.94,,,268.94,Other,215% of Medicaid,268.94,,,268.94,Other,215% of Medicaid,156.36,,,156.36,Other,125% of Medicaid,78.75,405.29,
PSYTX PT&/FAMILY 60 MIN,90837,CPT,,37090837,CDM,914,RC,,,both,,,399,295.26,,,295.26,Other,150% of Medicare + 9.63% HCRA Surcharge,179.55,45,,179.55,percent of total billed charges,Critical Access Hospital RCC factor,259.35,65,,259.35,percent of total billed charges,All Other,235.41,65,,235.41,percent of total billed charges,All Other,158,,,158,Fee Schedule,Behavioral Health,142,,,142,Fee Schedule,Behavioral Health,134,,,134,Fee Schedule,Behavioral Health,197.51,,,197.51,Other,110% of Medicare,207.78,,,207.78,Fee Schedule,Behavioral Health,233,,,233,Other,186% of Medicaid,207.78,,,207.78,Fee Schedule,Behavioral Health,207.78,,,207.78,Fee Schedule,Behavioral Health,207.78,,,207.78,Fee Schedule,Behavioral Health,207.78,,,207.78,Fee Schedule,Behavioral Health,207.78,,,207.78,Fee Schedule,Behavioral Health,319.2,80,,319.2,percent of total billed charges,All Other,279.3,70,,279.3,percent of total billed charges,All Other,154,,,154,Fee Schedule,Behavioral Health,131,,,131,Fee Schedule,Behavioral Health,110.87,,,110.87,Fee Schedule,Behavioral Health,110.87,,,110.87,Fee Schedule,Behavioral Health,110.87,,,110.87,Fee Schedule,Behavioral Health,110.87,,,110.87,Fee Schedule,Behavioral Health,125.09,,,125.09,Other,100% of Medicaid,125.09,,,125.09,Other,100% of Medicaid,125.09,,,125.09,Other,100% of Medicaid,125.09,,,125.09,Other,100% of Medicaid,281.45,,,281.45,Other,225% of Medicaid,191.39,,,191.39,Other,153% of Medicaid,281.45,,,281.45,Other,225% of Medicaid,175.13,,,175.13,Other,140% of Medicaid,281.45,,,281.45,Other,225% of Medicaid,325.23,,,325.23,Other,260% of Medicaid,405.29,,,405.29,Other,324% of Medicaid,268.94,,,268.94,Other,215% of Medicaid,268.94,,,268.94,Other,215% of Medicaid,156.36,,,156.36,Other,125% of Medicaid,110.87,405.29,
PSYTX PT&/FAM W/MD 60 MIN,90838,CPT,,37090838,CDM,914,RC,,,both,,,282,208.68,,,208.68,Other,150% of Medicare + 9.63% HCRA Surcharge,126.9,45,,126.9,percent of total billed charges,Critical Access Hospital RCC factor,183.3,65,,183.3,percent of total billed charges,All Other,166.38,65,,166.38,percent of total billed charges,All Other,215.73,76.5,,215.73,percent of total billed charges,All Other,200.22,69,,200.22,percent of total billed charges,All Other,194.58,65,,194.58,percent of total billed charges,All Other,139.59,,,139.59,Other,110% of Medicare,168.08,,,168.08,Fee Schedule,Behavioral Health,233,,,233,Other,186% of Medicaid,168.08,,,168.08,Fee Schedule,Behavioral Health,168.08,,,168.08,Fee Schedule,Behavioral Health,168.08,,,168.08,Fee Schedule,Behavioral Health,168.08,,,168.08,Fee Schedule,Behavioral Health,168.08,,,168.08,Fee Schedule,Behavioral Health,225.6,80,,225.6,percent of total billed charges,All Other,197.4,70,,197.4,percent of total billed charges,All Other,121,,,121,Fee Schedule,Behavioral Health,103,,,103,Fee Schedule,Behavioral Health,106.31,,,106.31,Fee Schedule,Behavioral Health,106.31,,,106.31,Fee Schedule,Behavioral Health,106.31,,,106.31,Fee Schedule,Behavioral Health,106.31,,,106.31,Fee Schedule,Behavioral Health,125.09,,,125.09,Other,100% of Medicaid,125.09,,,125.09,Other,100% of Medicaid,125.09,,,125.09,Other,100% of Medicaid,125.09,,,125.09,Other,100% of Medicaid,281.45,,,281.45,Other,225% of Medicaid,191.39,,,191.39,Other,153% of Medicaid,281.45,,,281.45,Other,225% of Medicaid,175.13,,,175.13,Other,140% of Medicaid,281.45,,,281.45,Other,225% of Medicaid,325.23,,,325.23,Other,260% of Medicaid,405.29,,,405.29,Other,324% of Medicaid,268.94,,,268.94,Other,215% of Medicaid,268.94,,,268.94,Other,215% of Medicaid,156.36,,,156.36,Other,125% of Medicaid,103,405.29,
IOP PSYTX PT&/FAMILY 30 MIN,90832,CPT,,37190832,CDM,914,RC,,,both,,,329,243.46,,,243.46,Other,150% of Medicare + 9.63% HCRA Surcharge,148.05,45,,148.05,percent of total billed charges,Critical Access Hospital RCC factor,213.85,65,,213.85,percent of total billed charges,All Other,194.11,65,,194.11,percent of total billed charges,All Other,82,,,82,Fee Schedule,Behavioral Health,74,,,74,Fee Schedule,Behavioral Health,70,,,70,Fee Schedule,Behavioral Health,162.86,,,162.86,Other,110% of Medicare,106.52,,,106.52,Fee Schedule,Behavioral Health,174,,,174,Other,186% of Medicaid,106.52,,,106.52,Fee Schedule,Behavioral Health,106.52,,,106.52,Fee Schedule,Behavioral Health,106.52,,,106.52,Fee Schedule,Behavioral Health,106.52,,,106.52,Fee Schedule,Behavioral Health,106.52,,,106.52,Fee Schedule,Behavioral Health,263.2,80,,263.2,percent of total billed charges,All Other,230.3,70,,230.3,percent of total billed charges,All Other,99,,,99,Fee Schedule,Behavioral Health,84,,,84,Fee Schedule,Behavioral Health,69.32,,,69.32,Fee Schedule,Behavioral Health,69.32,,,69.32,Fee Schedule,Behavioral Health,69.32,,,69.32,Fee Schedule,Behavioral Health,69.32,,,69.32,Fee Schedule,Behavioral Health,93.82,,,93.82,Other,100% of Medicaid,93.82,,,93.82,Other,100% of Medicaid,93.82,,,93.82,Other,100% of Medicaid,93.82,,,93.82,Other,100% of Medicaid,211.09,,,211.09,Other,225% of Medicaid,143.54,,,143.54,Other,153% of Medicaid,211.09,,,211.09,Other,225% of Medicaid,131.34,,,131.34,Other,140% of Medicaid,211.09,,,211.09,Other,225% of Medicaid,243.92,,,243.92,Other,260% of Medicaid,303.97,,,303.97,Other,324% of Medicaid,201.71,,,201.71,Other,215% of Medicaid,201.71,,,201.71,Other,215% of Medicaid,117.27,,,117.27,Other,125% of Medicaid,69.32,303.97,
PSYTX PT&/FAM W/PSYCH 30 MIN,90833,CPT,,37190833,CDM,914,RC,,,both,,,108,79.92,,,79.92,Other,150% of Medicare + 9.63% HCRA Surcharge,48.6,45,,48.6,percent of total billed charges,Critical Access Hospital RCC factor,70.2,65,,70.2,percent of total billed charges,All Other,63.72,65,,63.72,percent of total billed charges,All Other,82.62,76.5,,82.62,percent of total billed charges,All Other,76.68,69,,76.68,percent of total billed charges,All Other,74.52,65,,74.52,percent of total billed charges,All Other,53.46,,,53.46,Other,110% of Medicare,100.23,,,100.23,Fee Schedule,Behavioral Health,174,,,174,Other,186% of Medicaid,100.23,,,100.23,Fee Schedule,Behavioral Health,100.23,,,100.23,Fee Schedule,Behavioral Health,100.23,,,100.23,Fee Schedule,Behavioral Health,100.23,,,100.23,Fee Schedule,Behavioral Health,100.23,,,100.23,Fee Schedule,Behavioral Health,86.4,80,,86.4,percent of total billed charges,All Other,75.6,70,,75.6,percent of total billed charges,All Other,28,,,28,Fee Schedule,Behavioral Health,24,,,24,Fee Schedule,Behavioral Health,52.8,,,52.8,Fee Schedule,Behavioral Health,52.8,,,52.8,Fee Schedule,Behavioral Health,52.8,,,52.8,Fee Schedule,Behavioral Health,52.8,,,52.8,Fee Schedule,Behavioral Health,93.82,,,93.82,Other,100% of Medicaid,93.82,,,93.82,Other,100% of Medicaid,93.82,,,93.82,Other,100% of Medicaid,93.82,,,93.82,Other,100% of Medicaid,211.09,,,211.09,Other,225% of Medicaid,143.54,,,143.54,Other,153% of Medicaid,211.09,,,211.09,Other,225% of Medicaid,131.34,,,131.34,Other,140% of Medicaid,211.09,,,211.09,Other,225% of Medicaid,243.92,,,243.92,Other,260% of Medicaid,303.97,,,303.97,Other,324% of Medicaid,201.71,,,201.71,Other,215% of Medicaid,201.71,,,201.71,Other,215% of Medicaid,117.27,,,117.27,Other,125% of Medicaid,24,303.97,
IOP PSYTX PT&/FAMILY 45 MIN,90834,CPT,,37190834,CDM,914,RC,,,both,,,399,295.26,,,295.26,Other,150% of Medicare + 9.63% HCRA Surcharge,179.55,45,,179.55,percent of total billed charges,Critical Access Hospital RCC factor,259.35,65,,259.35,percent of total billed charges,All Other,235.41,65,,235.41,percent of total billed charges,All Other,158,,,158,Fee Schedule,Behavioral Health,142,,,142,Fee Schedule,Behavioral Health,134,,,134,Fee Schedule,Behavioral Health,197.51,,,197.51,Other,110% of Medicare,140.78,,,140.78,Fee Schedule,Behavioral Health,233,,,233,Other,186% of Medicaid,140.78,,,140.78,Fee Schedule,Behavioral Health,140.78,,,140.78,Fee Schedule,Behavioral Health,140.78,,,140.78,Fee Schedule,Behavioral Health,140.78,,,140.78,Fee Schedule,Behavioral Health,140.78,,,140.78,Fee Schedule,Behavioral Health,319.2,80,,319.2,percent of total billed charges,All Other,279.3,70,,279.3,percent of total billed charges,All Other,154,,,154,Fee Schedule,Behavioral Health,131,,,131,Fee Schedule,Behavioral Health,104.53,,,104.53,Fee Schedule,Behavioral Health,104.53,,,104.53,Fee Schedule,Behavioral Health,104.53,,,104.53,Fee Schedule,Behavioral Health,104.53,,,104.53,Fee Schedule,Behavioral Health,125.09,,,125.09,Other,100% of Medicaid,125.09,,,125.09,Other,100% of Medicaid,125.09,,,125.09,Other,100% of Medicaid,125.09,,,125.09,Other,100% of Medicaid,281.45,,,281.45,Other,225% of Medicaid,191.39,,,191.39,Other,153% of Medicaid,281.45,,,281.45,Other,225% of Medicaid,175.13,,,175.13,Other,140% of Medicaid,281.45,,,281.45,Other,225% of Medicaid,325.23,,,325.23,Other,260% of Medicaid,405.29,,,405.29,Other,324% of Medicaid,268.94,,,268.94,Other,215% of Medicaid,268.94,,,268.94,Other,215% of Medicaid,156.36,,,156.36,Other,125% of Medicaid,104.53,405.29,
PSYTX PT&/FAM W/PSYCH 45 MIN,90836,CPT,,37190836,CDM,914,RC,,,both,,,175,129.5,,,129.5,Other,150% of Medicare + 9.63% HCRA Surcharge,78.75,45,,78.75,percent of total billed charges,Critical Access Hospital RCC factor,113.75,65,,113.75,percent of total billed charges,All Other,103.25,65,,103.25,percent of total billed charges,All Other,133.88,76.5,,133.88,percent of total billed charges,All Other,124.25,69,,124.25,percent of total billed charges,All Other,120.75,65,,120.75,percent of total billed charges,All Other,86.63,,,86.63,Other,110% of Medicare,126.78,,,126.78,Fee Schedule,Behavioral Health,233,,,233,Other,186% of Medicaid,126.78,,,126.78,Fee Schedule,Behavioral Health,126.78,,,126.78,Fee Schedule,Behavioral Health,126.78,,,126.78,Fee Schedule,Behavioral Health,126.78,,,126.78,Fee Schedule,Behavioral Health,126.78,,,126.78,Fee Schedule,Behavioral Health,140,80,,140,percent of total billed charges,All Other,122.5,70,,122.5,percent of total billed charges,All Other,100,,,100,Fee Schedule,Behavioral Health,85,,,85,Fee Schedule,Behavioral Health,79.55,,,79.55,Fee Schedule,Behavioral Health,79.55,,,79.55,Fee Schedule,Behavioral Health,79.55,,,79.55,Fee Schedule,Behavioral Health,79.55,,,79.55,Fee Schedule,Behavioral Health,125.09,,,125.09,Other,100% of Medicaid,125.09,,,125.09,Other,100% of Medicaid,125.09,,,125.09,Other,100% of Medicaid,125.09,,,125.09,Other,100% of Medicaid,281.45,,,281.45,Other,225% of Medicaid,191.39,,,191.39,Other,153% of Medicaid,281.45,,,281.45,Other,225% of Medicaid,175.13,,,175.13,Other,140% of Medicaid,281.45,,,281.45,Other,225% of Medicaid,325.23,,,325.23,Other,260% of Medicaid,405.29,,,405.29,Other,324% of Medicaid,268.94,,,268.94,Other,215% of Medicaid,268.94,,,268.94,Other,215% of Medicaid,156.36,,,156.36,Other,125% of Medicaid,78.75,405.29,
IOP PSYTX PT&/FAMILY 60 MIN,90837,CPT,,37190837,CDM,914,RC,,,both,,,399,295.26,,,295.26,Other,150% of Medicare + 9.63% HCRA Surcharge,179.55,45,,179.55,percent of total billed charges,Critical Access Hospital RCC factor,259.35,65,,259.35,percent of total billed charges,All Other,235.41,65,,235.41,percent of total billed charges,All Other,158,,,158,Fee Schedule,Behavioral Health,142,,,142,Fee Schedule,Behavioral Health,134,,,134,Fee Schedule,Behavioral Health,197.51,,,197.51,Other,110% of Medicare,207.78,,,207.78,Fee Schedule,Behavioral Health,233,,,233,Other,186% of Medicaid,207.78,,,207.78,Fee Schedule,Behavioral Health,207.78,,,207.78,Fee Schedule,Behavioral Health,207.78,,,207.78,Fee Schedule,Behavioral Health,207.78,,,207.78,Fee Schedule,Behavioral Health,207.78,,,207.78,Fee Schedule,Behavioral Health,319.2,80,,319.2,percent of total billed charges,All Other,279.3,70,,279.3,percent of total billed charges,All Other,154,,,154,Fee Schedule,Behavioral Health,131,,,131,Fee Schedule,Behavioral Health,110.87,,,110.87,Fee Schedule,Behavioral Health,110.87,,,110.87,Fee Schedule,Behavioral Health,110.87,,,110.87,Fee Schedule,Behavioral Health,110.87,,,110.87,Fee Schedule,Behavioral Health,125.09,,,125.09,Other,100% of Medicaid,125.09,,,125.09,Other,100% of Medicaid,125.09,,,125.09,Other,100% of Medicaid,125.09,,,125.09,Other,100% of Medicaid,281.45,,,281.45,Other,225% of Medicaid,191.39,,,191.39,Other,153% of Medicaid,281.45,,,281.45,Other,225% of Medicaid,175.13,,,175.13,Other,140% of Medicaid,281.45,,,281.45,Other,225% of Medicaid,325.23,,,325.23,Other,260% of Medicaid,405.29,,,405.29,Other,324% of Medicaid,268.94,,,268.94,Other,215% of Medicaid,268.94,,,268.94,Other,215% of Medicaid,156.36,,,156.36,Other,125% of Medicaid,110.87,405.29,
PSYTX PT&/FAM W/PSYCH 60 MIN,90838,CPT,,37190838,CDM,914,RC,,,both,,,282,208.68,,,208.68,Other,150% of Medicare + 9.63% HCRA Surcharge,126.9,45,,126.9,percent of total billed charges,Critical Access Hospital RCC factor,183.3,65,,183.3,percent of total billed charges,All Other,166.38,65,,166.38,percent of total billed charges,All Other,215.73,76.5,,215.73,percent of total billed charges,All Other,200.22,69,,200.22,percent of total billed charges,All Other,194.58,65,,194.58,percent of total billed charges,All Other,139.59,,,139.59,Other,110% of Medicare,168.08,,,168.08,Fee Schedule,Behavioral Health,233,,,233,Other,186% of Medicaid,168.08,,,168.08,Fee Schedule,Behavioral Health,168.08,,,168.08,Fee Schedule,Behavioral Health,168.08,,,168.08,Fee Schedule,Behavioral Health,168.08,,,168.08,Fee Schedule,Behavioral Health,168.08,,,168.08,Fee Schedule,Behavioral Health,225.6,80,,225.6,percent of total billed charges,All Other,197.4,70,,197.4,percent of total billed charges,All Other,121,,,121,Fee Schedule,Behavioral Health,103,,,103,Fee Schedule,Behavioral Health,106.31,,,106.31,Fee Schedule,Behavioral Health,106.31,,,106.31,Fee Schedule,Behavioral Health,106.31,,,106.31,Fee Schedule,Behavioral Health,106.31,,,106.31,Fee Schedule,Behavioral Health,125.09,,,125.09,Other,100% of Medicaid,125.09,,,125.09,Other,100% of Medicaid,125.09,,,125.09,Other,100% of Medicaid,125.09,,,125.09,Other,100% of Medicaid,281.45,,,281.45,Other,225% of Medicaid,191.39,,,191.39,Other,153% of Medicaid,281.45,,,281.45,Other,225% of Medicaid,175.13,,,175.13,Other,140% of Medicaid,281.45,,,281.45,Other,225% of Medicaid,325.23,,,325.23,Other,260% of Medicaid,405.29,,,405.29,Other,324% of Medicaid,268.94,,,268.94,Other,215% of Medicaid,268.94,,,268.94,Other,215% of Medicaid,156.36,,,156.36,Other,125% of Medicaid,103,405.29,
ATP PSYTX PT&/FAMILY 30 MIN,90832,CPT,,37290832,CDM,914,RC,,,both,,,329,243.46,,,243.46,Other,150% of Medicare + 9.63% HCRA Surcharge,148.05,45,,148.05,percent of total billed charges,Critical Access Hospital RCC factor,213.85,65,,213.85,percent of total billed charges,All Other,194.11,65,,194.11,percent of total billed charges,All Other,82,,,82,Fee Schedule,Behavioral Health,74,,,74,Fee Schedule,Behavioral Health,70,,,70,Fee Schedule,Behavioral Health,162.86,,,162.86,Other,110% of Medicare,106.52,,,106.52,Fee Schedule,Behavioral Health,174,,,174,Other,186% of Medicaid,106.52,,,106.52,Fee Schedule,Behavioral Health,106.52,,,106.52,Fee Schedule,Behavioral Health,106.52,,,106.52,Fee Schedule,Behavioral Health,106.52,,,106.52,Fee Schedule,Behavioral Health,106.52,,,106.52,Fee Schedule,Behavioral Health,263.2,80,,263.2,percent of total billed charges,All Other,230.3,70,,230.3,percent of total billed charges,All Other,99,,,99,Fee Schedule,Behavioral Health,84,,,84,Fee Schedule,Behavioral Health,69.32,,,69.32,Fee Schedule,Behavioral Health,69.32,,,69.32,Fee Schedule,Behavioral Health,69.32,,,69.32,Fee Schedule,Behavioral Health,69.32,,,69.32,Fee Schedule,Behavioral Health,93.82,,,93.82,Other,100% of Medicaid,93.82,,,93.82,Other,100% of Medicaid,93.82,,,93.82,Other,100% of Medicaid,93.82,,,93.82,Other,100% of Medicaid,211.09,,,211.09,Other,225% of Medicaid,143.54,,,143.54,Other,153% of Medicaid,211.09,,,211.09,Other,225% of Medicaid,131.34,,,131.34,Other,140% of Medicaid,211.09,,,211.09,Other,225% of Medicaid,243.92,,,243.92,Other,260% of Medicaid,303.97,,,303.97,Other,324% of Medicaid,201.71,,,201.71,Other,215% of Medicaid,201.71,,,201.71,Other,215% of Medicaid,117.27,,,117.27,Other,125% of Medicaid,69.32,303.97,
ATP PSYTX PT&/FAMILY 45 MIN,90834,CPT,,37290834,CDM,914,RC,,,both,,,399,295.26,,,295.26,Other,150% of Medicare + 9.63% HCRA Surcharge,179.55,45,,179.55,percent of total billed charges,Critical Access Hospital RCC factor,259.35,65,,259.35,percent of total billed charges,All Other,235.41,65,,235.41,percent of total billed charges,All Other,158,,,158,Fee Schedule,Behavioral Health,142,,,142,Fee Schedule,Behavioral Health,134,,,134,Fee Schedule,Behavioral Health,197.51,,,197.51,Other,110% of Medicare,140.78,,,140.78,Fee Schedule,Behavioral Health,233,,,233,Other,186% of Medicaid,140.78,,,140.78,Fee Schedule,Behavioral Health,140.78,,,140.78,Fee Schedule,Behavioral Health,140.78,,,140.78,Fee Schedule,Behavioral Health,140.78,,,140.78,Fee Schedule,Behavioral Health,140.78,,,140.78,Fee Schedule,Behavioral Health,319.2,80,,319.2,percent of total billed charges,All Other,279.3,70,,279.3,percent of total billed charges,All Other,154,,,154,Fee Schedule,Behavioral Health,131,,,131,Fee Schedule,Behavioral Health,104.53,,,104.53,Fee Schedule,Behavioral Health,104.53,,,104.53,Fee Schedule,Behavioral Health,104.53,,,104.53,Fee Schedule,Behavioral Health,104.53,,,104.53,Fee Schedule,Behavioral Health,125.09,,,125.09,Other,100% of Medicaid,125.09,,,125.09,Other,100% of Medicaid,125.09,,,125.09,Other,100% of Medicaid,125.09,,,125.09,Other,100% of Medicaid,281.45,,,281.45,Other,225% of Medicaid,191.39,,,191.39,Other,153% of Medicaid,281.45,,,281.45,Other,225% of Medicaid,175.13,,,175.13,Other,140% of Medicaid,281.45,,,281.45,Other,225% of Medicaid,325.23,,,325.23,Other,260% of Medicaid,405.29,,,405.29,Other,324% of Medicaid,268.94,,,268.94,Other,215% of Medicaid,268.94,,,268.94,Other,215% of Medicaid,156.36,,,156.36,Other,125% of Medicaid,104.53,405.29,
TH-ATP PSYTX PT&/FAMILY 30 MIN,90832,CPT,95,37490832,CDM,914,RC,,,both,,,329,243.46,,,243.46,Other,150% of Medicare + 9.63% HCRA Surcharge,148.05,45,,148.05,percent of total billed charges,Critical Access Hospital RCC factor,213.85,65,,213.85,percent of total billed charges,All Other,194.11,65,,194.11,percent of total billed charges,All Other,82,,,82,Fee Schedule,Behavioral Health,74,,,74,Fee Schedule,Behavioral Health,70,,,70,Fee Schedule,Behavioral Health,162.86,,,162.86,Other,110% of Medicare,106.52,,,106.52,Fee Schedule,Behavioral Health,174,,,174,Other,186% of Medicaid,106.52,,,106.52,Fee Schedule,Behavioral Health,106.52,,,106.52,Fee Schedule,Behavioral Health,106.52,,,106.52,Fee Schedule,Behavioral Health,106.52,,,106.52,Fee Schedule,Behavioral Health,106.52,,,106.52,Fee Schedule,Behavioral Health,263.2,80,,263.2,percent of total billed charges,All Other,230.3,70,,230.3,percent of total billed charges,All Other,99,,,99,Fee Schedule,Behavioral Health,84,,,84,Fee Schedule,Behavioral Health,69.32,,,69.32,Fee Schedule,Behavioral Health,69.32,,,69.32,Fee Schedule,Behavioral Health,69.32,,,69.32,Fee Schedule,Behavioral Health,69.32,,,69.32,Fee Schedule,Behavioral Health,93.82,,,93.82,Other,100% of Medicaid,93.82,,,93.82,Other,100% of Medicaid,93.82,,,93.82,Other,100% of Medicaid,93.82,,,93.82,Other,100% of Medicaid,211.09,,,211.09,Other,225% of Medicaid,143.54,,,143.54,Other,153% of Medicaid,211.09,,,211.09,Other,225% of Medicaid,131.34,,,131.34,Other,140% of Medicaid,211.09,,,211.09,Other,225% of Medicaid,243.92,,,243.92,Other,260% of Medicaid,303.97,,,303.97,Other,324% of Medicaid,201.71,,,201.71,Other,215% of Medicaid,201.71,,,201.71,Other,215% of Medicaid,117.27,,,117.27,Other,125% of Medicaid,69.32,303.97,
TH-PSYTX PT&/FAMILY 45 MIN,90834,CPT,95,37490834,CDM,914,RC,,,both,,,399,295.26,,,295.26,Other,150% of Medicare + 9.63% HCRA Surcharge,179.55,45,,179.55,percent of total billed charges,Critical Access Hospital RCC factor,259.35,65,,259.35,percent of total billed charges,All Other,235.41,65,,235.41,percent of total billed charges,All Other,158,,,158,Fee Schedule,Behavioral Health,142,,,142,Fee Schedule,Behavioral Health,134,,,134,Fee Schedule,Behavioral Health,197.51,,,197.51,Other,110% of Medicare,140.78,,,140.78,Fee Schedule,Behavioral Health,233,,,233,Other,186% of Medicaid,140.78,,,140.78,Fee Schedule,Behavioral Health,140.78,,,140.78,Fee Schedule,Behavioral Health,140.78,,,140.78,Fee Schedule,Behavioral Health,140.78,,,140.78,Fee Schedule,Behavioral Health,140.78,,,140.78,Fee Schedule,Behavioral Health,319.2,80,,319.2,percent of total billed charges,All Other,279.3,70,,279.3,percent of total billed charges,All Other,154,,,154,Fee Schedule,Behavioral Health,131,,,131,Fee Schedule,Behavioral Health,104.53,,,104.53,Fee Schedule,Behavioral Health,104.53,,,104.53,Fee Schedule,Behavioral Health,104.53,,,104.53,Fee Schedule,Behavioral Health,104.53,,,104.53,Fee Schedule,Behavioral Health,125.09,,,125.09,Other,100% of Medicaid,125.09,,,125.09,Other,100% of Medicaid,125.09,,,125.09,Other,100% of Medicaid,125.09,,,125.09,Other,100% of Medicaid,281.45,,,281.45,Other,225% of Medicaid,191.39,,,191.39,Other,153% of Medicaid,281.45,,,281.45,Other,225% of Medicaid,175.13,,,175.13,Other,140% of Medicaid,281.45,,,281.45,Other,225% of Medicaid,325.23,,,325.23,Other,260% of Medicaid,405.29,,,405.29,Other,324% of Medicaid,268.94,,,268.94,Other,215% of Medicaid,268.94,,,268.94,Other,215% of Medicaid,156.36,,,156.36,Other,125% of Medicaid,104.53,405.29,
TH- PSYTX PT&/FAMILY 60 MIN,90837,CPT,95,37490837,CDM,914,RC,,,both,,,399,295.26,,,295.26,Other,150% of Medicare + 9.63% HCRA Surcharge,179.55,45,,179.55,percent of total billed charges,Critical Access Hospital RCC factor,259.35,65,,259.35,percent of total billed charges,All Other,235.41,65,,235.41,percent of total billed charges,All Other,158,,,158,Fee Schedule,Behavioral Health,142,,,142,Fee Schedule,Behavioral Health,134,,,134,Fee Schedule,Behavioral Health,197.51,,,197.51,Other,110% of Medicare,207.78,,,207.78,Fee Schedule,Behavioral Health,233,,,233,Other,186% of Medicaid,207.78,,,207.78,Fee Schedule,Behavioral Health,207.78,,,207.78,Fee Schedule,Behavioral Health,207.78,,,207.78,Fee Schedule,Behavioral Health,207.78,,,207.78,Fee Schedule,Behavioral Health,207.78,,,207.78,Fee Schedule,Behavioral Health,319.2,80,,319.2,percent of total billed charges,All Other,279.3,70,,279.3,percent of total billed charges,All Other,154,,,154,Fee Schedule,Behavioral Health,131,,,131,Fee Schedule,Behavioral Health,110.87,,,110.87,Fee Schedule,Behavioral Health,110.87,,,110.87,Fee Schedule,Behavioral Health,110.87,,,110.87,Fee Schedule,Behavioral Health,110.87,,,110.87,Fee Schedule,Behavioral Health,125.09,,,125.09,Other,100% of Medicaid,125.09,,,125.09,Other,100% of Medicaid,125.09,,,125.09,Other,100% of Medicaid,125.09,,,125.09,Other,100% of Medicaid,281.45,,,281.45,Other,225% of Medicaid,191.39,,,191.39,Other,153% of Medicaid,281.45,,,281.45,Other,225% of Medicaid,175.13,,,175.13,Other,140% of Medicaid,281.45,,,281.45,Other,225% of Medicaid,325.23,,,325.23,Other,260% of Medicaid,405.29,,,405.29,Other,324% of Medicaid,268.94,,,268.94,Other,215% of Medicaid,268.94,,,268.94,Other,215% of Medicaid,156.36,,,156.36,Other,125% of Medicaid,110.87,405.29,
TH-PSYTX PT&/FAM W/MD 60 MIN,90838,CPT,95,37490838,CDM,914,RC,,,both,,,282,208.68,,,208.68,Other,150% of Medicare + 9.63% HCRA Surcharge,126.9,45,,126.9,percent of total billed charges,Critical Access Hospital RCC factor,183.3,65,,183.3,percent of total billed charges,All Other,166.38,65,,166.38,percent of total billed charges,All Other,215.73,76.5,,215.73,percent of total billed charges,All Other,200.22,69,,200.22,percent of total billed charges,All Other,194.58,65,,194.58,percent of total billed charges,All Other,139.59,,,139.59,Other,110% of Medicare,168.08,,,168.08,Fee Schedule,Behavioral Health,233,,,233,Other,186% of Medicaid,168.08,,,168.08,Fee Schedule,Behavioral Health,168.08,,,168.08,Fee Schedule,Behavioral Health,168.08,,,168.08,Fee Schedule,Behavioral Health,168.08,,,168.08,Fee Schedule,Behavioral Health,168.08,,,168.08,Fee Schedule,Behavioral Health,225.6,80,,225.6,percent of total billed charges,All Other,197.4,70,,197.4,percent of total billed charges,All Other,121,,,121,Fee Schedule,Behavioral Health,103,,,103,Fee Schedule,Behavioral Health,106.31,,,106.31,Fee Schedule,Behavioral Health,106.31,,,106.31,Fee Schedule,Behavioral Health,106.31,,,106.31,Fee Schedule,Behavioral Health,106.31,,,106.31,Fee Schedule,Behavioral Health,125.09,,,125.09,Other,100% of Medicaid,125.09,,,125.09,Other,100% of Medicaid,125.09,,,125.09,Other,100% of Medicaid,125.09,,,125.09,Other,100% of Medicaid,281.45,,,281.45,Other,225% of Medicaid,191.39,,,191.39,Other,153% of Medicaid,281.45,,,281.45,Other,225% of Medicaid,175.13,,,175.13,Other,140% of Medicaid,281.45,,,281.45,Other,225% of Medicaid,325.23,,,325.23,Other,260% of Medicaid,405.29,,,405.29,Other,324% of Medicaid,268.94,,,268.94,Other,215% of Medicaid,268.94,,,268.94,Other,215% of Medicaid,156.36,,,156.36,Other,125% of Medicaid,103,405.29,
TH-IOP PSYTX PT&/FAMILY 30 MIN,90832,CPT,95,37590832,CDM,914,RC,,,both,,,329,243.46,,,243.46,Other,150% of Medicare + 9.63% HCRA Surcharge,148.05,45,,148.05,percent of total billed charges,Critical Access Hospital RCC factor,213.85,65,,213.85,percent of total billed charges,All Other,194.11,65,,194.11,percent of total billed charges,All Other,82,,,82,Fee Schedule,Behavioral Health,74,,,74,Fee Schedule,Behavioral Health,70,,,70,Fee Schedule,Behavioral Health,162.86,,,162.86,Other,110% of Medicare,106.52,,,106.52,Fee Schedule,Behavioral Health,174,,,174,Other,186% of Medicaid,106.52,,,106.52,Fee Schedule,Behavioral Health,106.52,,,106.52,Fee Schedule,Behavioral Health,106.52,,,106.52,Fee Schedule,Behavioral Health,106.52,,,106.52,Fee Schedule,Behavioral Health,106.52,,,106.52,Fee Schedule,Behavioral Health,263.2,80,,263.2,percent of total billed charges,All Other,230.3,70,,230.3,percent of total billed charges,All Other,99,,,99,Fee Schedule,Behavioral Health,84,,,84,Fee Schedule,Behavioral Health,69.32,,,69.32,Fee Schedule,Behavioral Health,69.32,,,69.32,Fee Schedule,Behavioral Health,69.32,,,69.32,Fee Schedule,Behavioral Health,69.32,,,69.32,Fee Schedule,Behavioral Health,93.82,,,93.82,Other,100% of Medicaid,93.82,,,93.82,Other,100% of Medicaid,93.82,,,93.82,Other,100% of Medicaid,93.82,,,93.82,Other,100% of Medicaid,211.09,,,211.09,Other,225% of Medicaid,143.54,,,143.54,Other,153% of Medicaid,211.09,,,211.09,Other,225% of Medicaid,131.34,,,131.34,Other,140% of Medicaid,211.09,,,211.09,Other,225% of Medicaid,243.92,,,243.92,Other,260% of Medicaid,303.97,,,303.97,Other,324% of Medicaid,201.71,,,201.71,Other,215% of Medicaid,201.71,,,201.71,Other,215% of Medicaid,117.27,,,117.27,Other,125% of Medicaid,69.32,303.97,
TH-IOP PSYTX PT&/FAMILY 45 MIN,90834,CPT,95,37590834,CDM,914,RC,,,both,,,399,295.26,,,295.26,Other,150% of Medicare + 9.63% HCRA Surcharge,179.55,45,,179.55,percent of total billed charges,Critical Access Hospital RCC factor,259.35,65,,259.35,percent of total billed charges,All Other,235.41,65,,235.41,percent of total billed charges,All Other,158,,,158,Fee Schedule,Behavioral Health,142,,,142,Fee Schedule,Behavioral Health,134,,,134,Fee Schedule,Behavioral Health,197.51,,,197.51,Other,110% of Medicare,140.78,,,140.78,Fee Schedule,Behavioral Health,233,,,233,Other,186% of Medicaid,140.78,,,140.78,Fee Schedule,Behavioral Health,140.78,,,140.78,Fee Schedule,Behavioral Health,140.78,,,140.78,Fee Schedule,Behavioral Health,140.78,,,140.78,Fee Schedule,Behavioral Health,140.78,,,140.78,Fee Schedule,Behavioral Health,319.2,80,,319.2,percent of total billed charges,All Other,279.3,70,,279.3,percent of total billed charges,All Other,154,,,154,Fee Schedule,Behavioral Health,131,,,131,Fee Schedule,Behavioral Health,104.53,,,104.53,Fee Schedule,Behavioral Health,104.53,,,104.53,Fee Schedule,Behavioral Health,104.53,,,104.53,Fee Schedule,Behavioral Health,104.53,,,104.53,Fee Schedule,Behavioral Health,125.09,,,125.09,Other,100% of Medicaid,125.09,,,125.09,Other,100% of Medicaid,125.09,,,125.09,Other,100% of Medicaid,125.09,,,125.09,Other,100% of Medicaid,281.45,,,281.45,Other,225% of Medicaid,191.39,,,191.39,Other,153% of Medicaid,281.45,,,281.45,Other,225% of Medicaid,175.13,,,175.13,Other,140% of Medicaid,281.45,,,281.45,Other,225% of Medicaid,325.23,,,325.23,Other,260% of Medicaid,405.29,,,405.29,Other,324% of Medicaid,268.94,,,268.94,Other,215% of Medicaid,268.94,,,268.94,Other,215% of Medicaid,156.36,,,156.36,Other,125% of Medicaid,104.53,405.29,
TH -IOP PSYTX PT&/FAMILY 60 MIN,90837,CPT,95,37590837,CDM,914,RC,,,both,,,399,295.26,,,295.26,Other,150% of Medicare + 9.63% HCRA Surcharge,179.55,45,,179.55,percent of total billed charges,Critical Access Hospital RCC factor,259.35,65,,259.35,percent of total billed charges,All Other,235.41,65,,235.41,percent of total billed charges,All Other,158,,,158,Fee Schedule,Behavioral Health,142,,,142,Fee Schedule,Behavioral Health,134,,,134,Fee Schedule,Behavioral Health,197.51,,,197.51,Other,110% of Medicare,207.78,,,207.78,Fee Schedule,Behavioral Health,233,,,233,Other,186% of Medicaid,207.78,,,207.78,Fee Schedule,Behavioral Health,207.78,,,207.78,Fee Schedule,Behavioral Health,207.78,,,207.78,Fee Schedule,Behavioral Health,207.78,,,207.78,Fee Schedule,Behavioral Health,207.78,,,207.78,Fee Schedule,Behavioral Health,319.2,80,,319.2,percent of total billed charges,All Other,279.3,70,,279.3,percent of total billed charges,All Other,154,,,154,Fee Schedule,Behavioral Health,131,,,131,Fee Schedule,Behavioral Health,110.87,,,110.87,Fee Schedule,Behavioral Health,110.87,,,110.87,Fee Schedule,Behavioral Health,110.87,,,110.87,Fee Schedule,Behavioral Health,110.87,,,110.87,Fee Schedule,Behavioral Health,125.09,,,125.09,Other,100% of Medicaid,125.09,,,125.09,Other,100% of Medicaid,125.09,,,125.09,Other,100% of Medicaid,125.09,,,125.09,Other,100% of Medicaid,281.45,,,281.45,Other,225% of Medicaid,191.39,,,191.39,Other,153% of Medicaid,281.45,,,281.45,Other,225% of Medicaid,175.13,,,175.13,Other,140% of Medicaid,281.45,,,281.45,Other,225% of Medicaid,325.23,,,325.23,Other,260% of Medicaid,405.29,,,405.29,Other,324% of Medicaid,268.94,,,268.94,Other,215% of Medicaid,268.94,,,268.94,Other,215% of Medicaid,156.36,,,156.36,Other,125% of Medicaid,110.87,405.29,
TH-ATP PSYTX PT&/FAMILY 30 MIN,90832,CPT,95,37690832,CDM,914,RC,,,both,,,329,243.46,,,243.46,Other,150% of Medicare + 9.63% HCRA Surcharge,148.05,45,,148.05,percent of total billed charges,Critical Access Hospital RCC factor,213.85,65,,213.85,percent of total billed charges,All Other,194.11,65,,194.11,percent of total billed charges,All Other,82,,,82,Fee Schedule,Behavioral Health,74,,,74,Fee Schedule,Behavioral Health,70,,,70,Fee Schedule,Behavioral Health,162.86,,,162.86,Other,110% of Medicare,106.52,,,106.52,Fee Schedule,Behavioral Health,174,,,174,Other,186% of Medicaid,106.52,,,106.52,Fee Schedule,Behavioral Health,106.52,,,106.52,Fee Schedule,Behavioral Health,106.52,,,106.52,Fee Schedule,Behavioral Health,106.52,,,106.52,Fee Schedule,Behavioral Health,106.52,,,106.52,Fee Schedule,Behavioral Health,263.2,80,,263.2,percent of total billed charges,All Other,230.3,70,,230.3,percent of total billed charges,All Other,99,,,99,Fee Schedule,Behavioral Health,84,,,84,Fee Schedule,Behavioral Health,69.32,,,69.32,Fee Schedule,Behavioral Health,69.32,,,69.32,Fee Schedule,Behavioral Health,69.32,,,69.32,Fee Schedule,Behavioral Health,69.32,,,69.32,Fee Schedule,Behavioral Health,93.82,,,93.82,Other,100% of Medicaid,93.82,,,93.82,Other,100% of Medicaid,93.82,,,93.82,Other,100% of Medicaid,93.82,,,93.82,Other,100% of Medicaid,211.09,,,211.09,Other,225% of Medicaid,143.54,,,143.54,Other,153% of Medicaid,211.09,,,211.09,Other,225% of Medicaid,131.34,,,131.34,Other,140% of Medicaid,211.09,,,211.09,Other,225% of Medicaid,243.92,,,243.92,Other,260% of Medicaid,303.97,,,303.97,Other,324% of Medicaid,201.71,,,201.71,Other,215% of Medicaid,201.71,,,201.71,Other,215% of Medicaid,117.27,,,117.27,Other,125% of Medicaid,69.32,303.97,
TH-ATP PSYTX PT&/FAMILY 45 MIN,90834,CPT,95,37690834,CDM,914,RC,,,both,,,399,295.26,,,295.26,Other,150% of Medicare + 9.63% HCRA Surcharge,179.55,45,,179.55,percent of total billed charges,Critical Access Hospital RCC factor,259.35,65,,259.35,percent of total billed charges,All Other,235.41,65,,235.41,percent of total billed charges,All Other,158,,,158,Fee Schedule,Behavioral Health,142,,,142,Fee Schedule,Behavioral Health,134,,,134,Fee Schedule,Behavioral Health,197.51,,,197.51,Other,110% of Medicare,140.78,,,140.78,Fee Schedule,Behavioral Health,233,,,233,Other,186% of Medicaid,140.78,,,140.78,Fee Schedule,Behavioral Health,140.78,,,140.78,Fee Schedule,Behavioral Health,140.78,,,140.78,Fee Schedule,Behavioral Health,140.78,,,140.78,Fee Schedule,Behavioral Health,140.78,,,140.78,Fee Schedule,Behavioral Health,319.2,80,,319.2,percent of total billed charges,All Other,279.3,70,,279.3,percent of total billed charges,All Other,154,,,154,Fee Schedule,Behavioral Health,131,,,131,Fee Schedule,Behavioral Health,104.53,,,104.53,Fee Schedule,Behavioral Health,104.53,,,104.53,Fee Schedule,Behavioral Health,104.53,,,104.53,Fee Schedule,Behavioral Health,104.53,,,104.53,Fee Schedule,Behavioral Health,125.09,,,125.09,Other,100% of Medicaid,125.09,,,125.09,Other,100% of Medicaid,125.09,,,125.09,Other,100% of Medicaid,125.09,,,125.09,Other,100% of Medicaid,281.45,,,281.45,Other,225% of Medicaid,191.39,,,191.39,Other,153% of Medicaid,281.45,,,281.45,Other,225% of Medicaid,175.13,,,175.13,Other,140% of Medicaid,281.45,,,281.45,Other,225% of Medicaid,325.23,,,325.23,Other,260% of Medicaid,405.29,,,405.29,Other,324% of Medicaid,268.94,,,268.94,Other,215% of Medicaid,268.94,,,268.94,Other,215% of Medicaid,156.36,,,156.36,Other,125% of Medicaid,104.53,405.29,
ALCOHOL OR DRUG ASSESSMENT,H0001,HCPCS,,38000001,CDM,914,RC,,,both,,,203,150.22,,,150.22,Other,150% of Medicare + 9.63% HCRA Surcharge,91.35,45,,91.35,percent of total billed charges,Critical Access Hospital RCC factor,131.95,65,,131.95,percent of total billed charges,All Other,119.77,65,,119.77,percent of total billed charges,All Other,125.86,62,,125.86,percent of total billed charges,Behavioral Health,117.74,56,,117.74,percent of total billed charges,Behavioral Health,113.68,53,,113.68,percent of total billed charges,Behavioral Health,100.49,,,100.49,Other,110% of Medicare,101.5,50,,101.5,percent of total billed charges,Behavioral Health,291,,,291,Other,186% of Medicaid,101.5,50,,101.5,percent of total billed charges,Behavioral Health,101.5,50,,101.5,percent of total billed charges,Behavioral Health,101.5,50,,101.5,percent of total billed charges,Behavioral Health,101.5,50,,101.5,percent of total billed charges,Behavioral Health,101.5,50,,101.5,percent of total billed charges,Behavioral Health,162.4,80,,162.4,percent of total billed charges,All Other,142.1,70,,142.1,percent of total billed charges,All Other,131.95,65,,131.95,percent of total billed charges,Default if not in Fee Schedule,131.95,65,,131.95,percent of total billed charges,Default if not in Fee Schedule,0.01,,,0.01,Fee Schedule,Behavioral Health,0.01,,,0.01,Fee Schedule,Behavioral Health,0.01,,,0.01,Fee Schedule,Behavioral Health,0.01,,,0.01,Fee Schedule,Behavioral Health,156.36,,,156.36,Other,100% of Medicaid,156.36,,,156.36,Other,100% of Medicaid,156.36,,,156.36,Other,100% of Medicaid,156.36,,,156.36,Other,100% of Medicaid,351.81,,,351.81,Other,225% of Medicaid,239.23,,,239.23,Other,153% of Medicaid,351.81,,,351.81,Other,225% of Medicaid,218.91,,,218.91,Other,140% of Medicaid,351.81,,,351.81,Other,225% of Medicaid,406.54,,,406.54,Other,260% of Medicaid,506.61,,,506.61,Other,324% of Medicaid,336.18,,,336.18,Other,215% of Medicaid,336.18,,,336.18,Other,215% of Medicaid,195.45,,,195.45,Other,125% of Medicaid,0.01,506.61,
PROGRAM INTAKE ASSESSMENT,T1023,HCPCS,,38000003,CDM,914,RC,,,both,,,147,108.78,,,108.78,Other,150% of Medicare + 9.63% HCRA Surcharge,66.15,45,,66.15,percent of total billed charges,Critical Access Hospital RCC factor,95.55,65,,95.55,percent of total billed charges,All Other,86.73,65,,86.73,percent of total billed charges,All Other,29.45,,,29.45,Fee Schedule,Behavioral Health,29.45,,,29.45,Fee Schedule,Behavioral Health,29.45,,,29.45,Fee Schedule,Behavioral Health,72.77,,,72.77,Other,110% of Medicare,73.5,50,,73.5,percent of total billed charges,Behavioral Health,79,,,79,Other,186% of Medicaid,73.5,50,,73.5,percent of total billed charges,Behavioral Health,73.5,50,,73.5,percent of total billed charges,Behavioral Health,73.5,50,,73.5,percent of total billed charges,Behavioral Health,73.5,50,,73.5,percent of total billed charges,Behavioral Health,73.5,50,,73.5,percent of total billed charges,Behavioral Health,117.6,80,,117.6,percent of total billed charges,All Other,102.9,70,,102.9,percent of total billed charges,All Other,95.55,65,,95.55,percent of total billed charges,Default if not in Fee Schedule,95.55,65,,95.55,percent of total billed charges,Default if not in Fee Schedule,0.01,,,0.01,Fee Schedule,Behavioral Health,0.01,,,0.01,Fee Schedule,Behavioral Health,0.01,,,0.01,Fee Schedule,Behavioral Health,0.01,,,0.01,Fee Schedule,Behavioral Health,42.37,,,42.37,Other,100% of Medicaid,42.37,,,42.37,Other,100% of Medicaid,42.37,,,42.37,Other,100% of Medicaid,42.37,,,42.37,Other,100% of Medicaid,95.33,,,95.33,Other,225% of Medicaid,64.83,,,64.83,Other,153% of Medicaid,95.33,,,95.33,Other,225% of Medicaid,59.32,,,59.32,Other,140% of Medicaid,95.33,,,95.33,Other,225% of Medicaid,110.16,,,110.16,Other,260% of Medicaid,137.28,,,137.28,Other,324% of Medicaid,91.1,,,91.1,Other,215% of Medicaid,91.1,,,91.1,Other,215% of Medicaid,52.96,,,52.96,Other,125% of Medicaid,0.01,137.28,
ALCOHOL/DRUG SERVICES C&T PER 15 MINS,H0004,HCPCS,,38000008,CDM,914,RC,,,both,,,72,53.28,,,53.28,Other,150% of Medicare + 9.63% HCRA Surcharge,32.4,45,,32.4,percent of total billed charges,Critical Access Hospital RCC factor,46.8,65,,46.8,percent of total billed charges,All Other,42.48,65,,42.48,percent of total billed charges,All Other,44.64,62,,44.64,percent of total billed charges,Behavioral Health,41.76,56,,41.76,percent of total billed charges,Behavioral Health,40.32,53,,40.32,percent of total billed charges,Behavioral Health,35.64,,,35.64,Other,110% of Medicare,36,50,,36,percent of total billed charges,Behavioral Health,174,,,174,Other,186% of Medicaid,36,50,,36,percent of total billed charges,Behavioral Health,36,50,,36,percent of total billed charges,Behavioral Health,36,50,,36,percent of total billed charges,Behavioral Health,36,50,,36,percent of total billed charges,Behavioral Health,36,50,,36,percent of total billed charges,Behavioral Health,57.6,80,,57.6,percent of total billed charges,All Other,50.4,70,,50.4,percent of total billed charges,All Other,46.8,65,,46.8,percent of total billed charges,Default if not in Fee Schedule,46.8,65,,46.8,percent of total billed charges,Default if not in Fee Schedule,0.01,,,0.01,Fee Schedule,Behavioral Health,0.01,,,0.01,Fee Schedule,Behavioral Health,0.01,,,0.01,Fee Schedule,Behavioral Health,0.01,,,0.01,Fee Schedule,Behavioral Health,93.82,,,93.82,Other,100% of Medicaid,93.82,,,93.82,Other,100% of Medicaid,93.82,,,93.82,Other,100% of Medicaid,93.82,,,93.82,Other,100% of Medicaid,211.09,,,211.09,Other,225% of Medicaid,143.54,,,143.54,Other,153% of Medicaid,211.09,,,211.09,Other,225% of Medicaid,131.34,,,131.34,Other,140% of Medicaid,211.09,,,211.09,Other,225% of Medicaid,243.92,,,243.92,Other,260% of Medicaid,303.97,,,303.97,Other,324% of Medicaid,201.71,,,201.71,Other,215% of Medicaid,201.71,,,201.71,Other,215% of Medicaid,117.27,,,117.27,Other,125% of Medicaid,0.01,303.97,
TH-ALCOHOL/DRUG SERVICES C&T PER 15 MINS,H0004,HCPCS,GT,38000011,CDM,914,RC,,,both,,,72,53.28,,,53.28,Other,150% of Medicare + 9.63% HCRA Surcharge,32.4,45,,32.4,percent of total billed charges,Critical Access Hospital RCC factor,46.8,65,,46.8,percent of total billed charges,All Other,42.48,65,,42.48,percent of total billed charges,All Other,44.64,62,,44.64,percent of total billed charges,Behavioral Health,41.76,56,,41.76,percent of total billed charges,Behavioral Health,40.32,53,,40.32,percent of total billed charges,Behavioral Health,35.64,,,35.64,Other,110% of Medicare,36,50,,36,percent of total billed charges,Behavioral Health,174,,,174,Other,186% of Medicaid,36,50,,36,percent of total billed charges,Behavioral Health,36,50,,36,percent of total billed charges,Behavioral Health,36,50,,36,percent of total billed charges,Behavioral Health,36,50,,36,percent of total billed charges,Behavioral Health,36,50,,36,percent of total billed charges,Behavioral Health,57.6,80,,57.6,percent of total billed charges,All Other,50.4,70,,50.4,percent of total billed charges,All Other,46.8,65,,46.8,percent of total billed charges,Default if not in Fee Schedule,46.8,65,,46.8,percent of total billed charges,Default if not in Fee Schedule,0.01,,,0.01,Fee Schedule,Behavioral Health,0.01,,,0.01,Fee Schedule,Behavioral Health,0.01,,,0.01,Fee Schedule,Behavioral Health,0.01,,,0.01,Fee Schedule,Behavioral Health,93.82,,,93.82,Other,100% of Medicaid,93.82,,,93.82,Other,100% of Medicaid,93.82,,,93.82,Other,100% of Medicaid,93.82,,,93.82,Other,100% of Medicaid,211.09,,,211.09,Other,225% of Medicaid,143.54,,,143.54,Other,153% of Medicaid,211.09,,,211.09,Other,225% of Medicaid,131.34,,,131.34,Other,140% of Medicaid,211.09,,,211.09,Other,225% of Medicaid,243.92,,,243.92,Other,260% of Medicaid,303.97,,,303.97,Other,324% of Medicaid,201.71,,,201.71,Other,215% of Medicaid,201.71,,,201.71,Other,215% of Medicaid,117.27,,,117.27,Other,125% of Medicaid,0.01,303.97,
PSYTX PT&/FAMILY 30 MIN,90832,CPT,,38090832,CDM,914,RC,,,both,,,329,243.46,,,243.46,Other,150% of Medicare + 9.63% HCRA Surcharge,148.05,45,,148.05,percent of total billed charges,Critical Access Hospital RCC factor,213.85,65,,213.85,percent of total billed charges,All Other,194.11,65,,194.11,percent of total billed charges,All Other,82,,,82,Fee Schedule,Behavioral Health,74,,,74,Fee Schedule,Behavioral Health,70,,,70,Fee Schedule,Behavioral Health,162.86,,,162.86,Other,110% of Medicare,106.52,,,106.52,Fee Schedule,Behavioral Health,174,,,174,Other,186% of Medicaid,106.52,,,106.52,Fee Schedule,Behavioral Health,106.52,,,106.52,Fee Schedule,Behavioral Health,106.52,,,106.52,Fee Schedule,Behavioral Health,106.52,,,106.52,Fee Schedule,Behavioral Health,106.52,,,106.52,Fee Schedule,Behavioral Health,263.2,80,,263.2,percent of total billed charges,All Other,230.3,70,,230.3,percent of total billed charges,All Other,99,,,99,Fee Schedule,Behavioral Health,84,,,84,Fee Schedule,Behavioral Health,69.32,,,69.32,Fee Schedule,Behavioral Health,69.32,,,69.32,Fee Schedule,Behavioral Health,69.32,,,69.32,Fee Schedule,Behavioral Health,69.32,,,69.32,Fee Schedule,Behavioral Health,93.82,,,93.82,Other,100% of Medicaid,93.82,,,93.82,Other,100% of Medicaid,93.82,,,93.82,Other,100% of Medicaid,93.82,,,93.82,Other,100% of Medicaid,211.09,,,211.09,Other,225% of Medicaid,143.54,,,143.54,Other,153% of Medicaid,211.09,,,211.09,Other,225% of Medicaid,131.34,,,131.34,Other,140% of Medicaid,211.09,,,211.09,Other,225% of Medicaid,243.92,,,243.92,Other,260% of Medicaid,303.97,,,303.97,Other,324% of Medicaid,201.71,,,201.71,Other,215% of Medicaid,201.71,,,201.71,Other,215% of Medicaid,117.27,,,117.27,Other,125% of Medicaid,69.32,303.97,
PSYTX PT&/FAM W/MD 30 MIN,90833,CPT,,38090833,CDM,914,RC,,,both,,,108,79.92,,,79.92,Other,150% of Medicare + 9.63% HCRA Surcharge,48.6,45,,48.6,percent of total billed charges,Critical Access Hospital RCC factor,70.2,65,,70.2,percent of total billed charges,All Other,63.72,65,,63.72,percent of total billed charges,All Other,82.62,76.5,,82.62,percent of total billed charges,All Other,76.68,69,,76.68,percent of total billed charges,All Other,74.52,65,,74.52,percent of total billed charges,All Other,53.46,,,53.46,Other,110% of Medicare,100.23,,,100.23,Fee Schedule,Behavioral Health,174,,,174,Other,186% of Medicaid,100.23,,,100.23,Fee Schedule,Behavioral Health,100.23,,,100.23,Fee Schedule,Behavioral Health,100.23,,,100.23,Fee Schedule,Behavioral Health,100.23,,,100.23,Fee Schedule,Behavioral Health,100.23,,,100.23,Fee Schedule,Behavioral Health,86.4,80,,86.4,percent of total billed charges,All Other,75.6,70,,75.6,percent of total billed charges,All Other,28,,,28,Fee Schedule,Behavioral Health,24,,,24,Fee Schedule,Behavioral Health,52.8,,,52.8,Fee Schedule,Behavioral Health,52.8,,,52.8,Fee Schedule,Behavioral Health,52.8,,,52.8,Fee Schedule,Behavioral Health,52.8,,,52.8,Fee Schedule,Behavioral Health,93.82,,,93.82,Other,100% of Medicaid,93.82,,,93.82,Other,100% of Medicaid,93.82,,,93.82,Other,100% of Medicaid,93.82,,,93.82,Other,100% of Medicaid,211.09,,,211.09,Other,225% of Medicaid,143.54,,,143.54,Other,153% of Medicaid,211.09,,,211.09,Other,225% of Medicaid,131.34,,,131.34,Other,140% of Medicaid,211.09,,,211.09,Other,225% of Medicaid,243.92,,,243.92,Other,260% of Medicaid,303.97,,,303.97,Other,324% of Medicaid,201.71,,,201.71,Other,215% of Medicaid,201.71,,,201.71,Other,215% of Medicaid,117.27,,,117.27,Other,125% of Medicaid,24,303.97,
PSYTX PT&/FAMILY 45 MIN,90834,CPT,,38090834,CDM,914,RC,,,both,,,399,295.26,,,295.26,Other,150% of Medicare + 9.63% HCRA Surcharge,179.55,45,,179.55,percent of total billed charges,Critical Access Hospital RCC factor,259.35,65,,259.35,percent of total billed charges,All Other,235.41,65,,235.41,percent of total billed charges,All Other,158,,,158,Fee Schedule,Behavioral Health,142,,,142,Fee Schedule,Behavioral Health,134,,,134,Fee Schedule,Behavioral Health,197.51,,,197.51,Other,110% of Medicare,140.78,,,140.78,Fee Schedule,Behavioral Health,233,,,233,Other,186% of Medicaid,140.78,,,140.78,Fee Schedule,Behavioral Health,140.78,,,140.78,Fee Schedule,Behavioral Health,140.78,,,140.78,Fee Schedule,Behavioral Health,140.78,,,140.78,Fee Schedule,Behavioral Health,140.78,,,140.78,Fee Schedule,Behavioral Health,319.2,80,,319.2,percent of total billed charges,All Other,279.3,70,,279.3,percent of total billed charges,All Other,154,,,154,Fee Schedule,Behavioral Health,131,,,131,Fee Schedule,Behavioral Health,104.53,,,104.53,Fee Schedule,Behavioral Health,104.53,,,104.53,Fee Schedule,Behavioral Health,104.53,,,104.53,Fee Schedule,Behavioral Health,104.53,,,104.53,Fee Schedule,Behavioral Health,125.09,,,125.09,Other,100% of Medicaid,125.09,,,125.09,Other,100% of Medicaid,125.09,,,125.09,Other,100% of Medicaid,125.09,,,125.09,Other,100% of Medicaid,281.45,,,281.45,Other,225% of Medicaid,191.39,,,191.39,Other,153% of Medicaid,281.45,,,281.45,Other,225% of Medicaid,175.13,,,175.13,Other,140% of Medicaid,281.45,,,281.45,Other,225% of Medicaid,325.23,,,325.23,Other,260% of Medicaid,405.29,,,405.29,Other,324% of Medicaid,268.94,,,268.94,Other,215% of Medicaid,268.94,,,268.94,Other,215% of Medicaid,156.36,,,156.36,Other,125% of Medicaid,104.53,405.29,
PSYTX PT&/FAM W/MD 45 MIN,90836,CPT,,38090836,CDM,914,RC,,,both,,,175,129.5,,,129.5,Other,150% of Medicare + 9.63% HCRA Surcharge,78.75,45,,78.75,percent of total billed charges,Critical Access Hospital RCC factor,113.75,65,,113.75,percent of total billed charges,All Other,103.25,65,,103.25,percent of total billed charges,All Other,133.88,76.5,,133.88,percent of total billed charges,All Other,124.25,69,,124.25,percent of total billed charges,All Other,120.75,65,,120.75,percent of total billed charges,All Other,86.63,,,86.63,Other,110% of Medicare,126.78,,,126.78,Fee Schedule,Behavioral Health,233,,,233,Other,186% of Medicaid,126.78,,,126.78,Fee Schedule,Behavioral Health,126.78,,,126.78,Fee Schedule,Behavioral Health,126.78,,,126.78,Fee Schedule,Behavioral Health,126.78,,,126.78,Fee Schedule,Behavioral Health,126.78,,,126.78,Fee Schedule,Behavioral Health,140,80,,140,percent of total billed charges,All Other,122.5,70,,122.5,percent of total billed charges,All Other,100,,,100,Fee Schedule,Behavioral Health,85,,,85,Fee Schedule,Behavioral Health,79.55,,,79.55,Fee Schedule,Behavioral Health,79.55,,,79.55,Fee Schedule,Behavioral Health,79.55,,,79.55,Fee Schedule,Behavioral Health,79.55,,,79.55,Fee Schedule,Behavioral Health,125.09,,,125.09,Other,100% of Medicaid,125.09,,,125.09,Other,100% of Medicaid,125.09,,,125.09,Other,100% of Medicaid,125.09,,,125.09,Other,100% of Medicaid,281.45,,,281.45,Other,225% of Medicaid,191.39,,,191.39,Other,153% of Medicaid,281.45,,,281.45,Other,225% of Medicaid,175.13,,,175.13,Other,140% of Medicaid,281.45,,,281.45,Other,225% of Medicaid,325.23,,,325.23,Other,260% of Medicaid,405.29,,,405.29,Other,324% of Medicaid,268.94,,,268.94,Other,215% of Medicaid,268.94,,,268.94,Other,215% of Medicaid,156.36,,,156.36,Other,125% of Medicaid,78.75,405.29,
PSYTX PT&/FAMILY 60 MIN,90837,CPT,,38090837,CDM,914,RC,,,both,,,399,295.26,,,295.26,Other,150% of Medicare + 9.63% HCRA Surcharge,179.55,45,,179.55,percent of total billed charges,Critical Access Hospital RCC factor,259.35,65,,259.35,percent of total billed charges,All Other,235.41,65,,235.41,percent of total billed charges,All Other,158,,,158,Fee Schedule,Behavioral Health,142,,,142,Fee Schedule,Behavioral Health,134,,,134,Fee Schedule,Behavioral Health,197.51,,,197.51,Other,110% of Medicare,207.78,,,207.78,Fee Schedule,Behavioral Health,233,,,233,Other,186% of Medicaid,207.78,,,207.78,Fee Schedule,Behavioral Health,207.78,,,207.78,Fee Schedule,Behavioral Health,207.78,,,207.78,Fee Schedule,Behavioral Health,207.78,,,207.78,Fee Schedule,Behavioral Health,207.78,,,207.78,Fee Schedule,Behavioral Health,319.2,80,,319.2,percent of total billed charges,All Other,279.3,70,,279.3,percent of total billed charges,All Other,154,,,154,Fee Schedule,Behavioral Health,131,,,131,Fee Schedule,Behavioral Health,110.87,,,110.87,Fee Schedule,Behavioral Health,110.87,,,110.87,Fee Schedule,Behavioral Health,110.87,,,110.87,Fee Schedule,Behavioral Health,110.87,,,110.87,Fee Schedule,Behavioral Health,125.09,,,125.09,Other,100% of Medicaid,125.09,,,125.09,Other,100% of Medicaid,125.09,,,125.09,Other,100% of Medicaid,125.09,,,125.09,Other,100% of Medicaid,281.45,,,281.45,Other,225% of Medicaid,191.39,,,191.39,Other,153% of Medicaid,281.45,,,281.45,Other,225% of Medicaid,175.13,,,175.13,Other,140% of Medicaid,281.45,,,281.45,Other,225% of Medicaid,325.23,,,325.23,Other,260% of Medicaid,405.29,,,405.29,Other,324% of Medicaid,268.94,,,268.94,Other,215% of Medicaid,268.94,,,268.94,Other,215% of Medicaid,156.36,,,156.36,Other,125% of Medicaid,110.87,405.29,
PSYTX PT&/FAM W/MD 60 MIN,90838,CPT,,38090838,CDM,914,RC,,,both,,,282,208.68,,,208.68,Other,150% of Medicare + 9.63% HCRA Surcharge,126.9,45,,126.9,percent of total billed charges,Critical Access Hospital RCC factor,183.3,65,,183.3,percent of total billed charges,All Other,166.38,65,,166.38,percent of total billed charges,All Other,215.73,76.5,,215.73,percent of total billed charges,All Other,200.22,69,,200.22,percent of total billed charges,All Other,194.58,65,,194.58,percent of total billed charges,All Other,139.59,,,139.59,Other,110% of Medicare,168.08,,,168.08,Fee Schedule,Behavioral Health,233,,,233,Other,186% of Medicaid,168.08,,,168.08,Fee Schedule,Behavioral Health,168.08,,,168.08,Fee Schedule,Behavioral Health,168.08,,,168.08,Fee Schedule,Behavioral Health,168.08,,,168.08,Fee Schedule,Behavioral Health,168.08,,,168.08,Fee Schedule,Behavioral Health,225.6,80,,225.6,percent of total billed charges,All Other,197.4,70,,197.4,percent of total billed charges,All Other,121,,,121,Fee Schedule,Behavioral Health,103,,,103,Fee Schedule,Behavioral Health,106.31,,,106.31,Fee Schedule,Behavioral Health,106.31,,,106.31,Fee Schedule,Behavioral Health,106.31,,,106.31,Fee Schedule,Behavioral Health,106.31,,,106.31,Fee Schedule,Behavioral Health,125.09,,,125.09,Other,100% of Medicaid,125.09,,,125.09,Other,100% of Medicaid,125.09,,,125.09,Other,100% of Medicaid,125.09,,,125.09,Other,100% of Medicaid,281.45,,,281.45,Other,225% of Medicaid,191.39,,,191.39,Other,153% of Medicaid,281.45,,,281.45,Other,225% of Medicaid,175.13,,,175.13,Other,140% of Medicaid,281.45,,,281.45,Other,225% of Medicaid,325.23,,,325.23,Other,260% of Medicaid,405.29,,,405.29,Other,324% of Medicaid,268.94,,,268.94,Other,215% of Medicaid,268.94,,,268.94,Other,215% of Medicaid,156.36,,,156.36,Other,125% of Medicaid,103,405.29,
PHARMACOLOGIC MGMT W/PSYTX,90863,CPT,,38090863,CDM,914,RC,,,both,,,272,201.28,,,201.28,Other,150% of Medicare + 9.63% HCRA Surcharge,122.4,45,,122.4,percent of total billed charges,Critical Access Hospital RCC factor,176.8,65,,176.8,percent of total billed charges,All Other,160.48,65,,160.48,percent of total billed charges,All Other,208.08,76.5,,208.08,percent of total billed charges,All Other,193.12,69,,193.12,percent of total billed charges,All Other,187.68,65,,187.68,percent of total billed charges,All Other,134.64,,,134.64,Other,110% of Medicare,184.96,68,,184.96,percent of total billed charges,All Other,38,,,38,Other,186% of Medicaid,217.6,80,,217.6,percent of total billed charges,All Other,225.76,83,,225.76,percent of total billed charges,All Other,225.76,83,,225.76,percent of total billed charges,All Other,217.6,80,,217.6,percent of total billed charges,All Other,225.76,83,,225.76,percent of total billed charges,All Other,217.6,80,,217.6,percent of total billed charges,All Other,190.4,70,,190.4,percent of total billed charges,All Other,100,,,100,Fee Schedule,Behavioral Health,85,,,85,Fee Schedule,Behavioral Health,0.01,,,0.01,Fee Schedule,Behavioral Health,0.01,,,0.01,Fee Schedule,Behavioral Health,0.01,,,0.01,Fee Schedule,Behavioral Health,0.01,,,0.01,Fee Schedule,Behavioral Health,20.18,,,20.18,Other,100% of Medicaid,20.18,,,20.18,Other,100% of Medicaid,20.18,,,20.18,Other,100% of Medicaid,20.18,,,20.18,Other,100% of Medicaid,45.4,,,45.4,Other,225% of Medicaid,30.88,,,30.88,Other,153% of Medicaid,45.4,,,45.4,Other,225% of Medicaid,28.25,,,28.25,Other,140% of Medicaid,45.4,,,45.4,Other,225% of Medicaid,52.47,,,52.47,Other,260% of Medicaid,65.38,,,65.38,Other,324% of Medicaid,43.39,,,43.39,Other,215% of Medicaid,43.39,,,43.39,Other,215% of Medicaid,25.22,,,25.22,Other,125% of Medicaid,0.01,225.76,
PSYTX PT&/FAM W/PSYCH 30 MIN,90833,CPT,,38190833,CDM,914,RC,,,both,,,108,79.92,,,79.92,Other,150% of Medicare + 9.63% HCRA Surcharge,48.6,45,,48.6,percent of total billed charges,Critical Access Hospital RCC factor,70.2,65,,70.2,percent of total billed charges,All Other,63.72,65,,63.72,percent of total billed charges,All Other,82.62,76.5,,82.62,percent of total billed charges,All Other,76.68,69,,76.68,percent of total billed charges,All Other,74.52,65,,74.52,percent of total billed charges,All Other,53.46,,,53.46,Other,110% of Medicare,100.23,,,100.23,Fee Schedule,Behavioral Health,174,,,174,Other,186% of Medicaid,100.23,,,100.23,Fee Schedule,Behavioral Health,100.23,,,100.23,Fee Schedule,Behavioral Health,100.23,,,100.23,Fee Schedule,Behavioral Health,100.23,,,100.23,Fee Schedule,Behavioral Health,100.23,,,100.23,Fee Schedule,Behavioral Health,86.4,80,,86.4,percent of total billed charges,All Other,75.6,70,,75.6,percent of total billed charges,All Other,28,,,28,Fee Schedule,Behavioral Health,24,,,24,Fee Schedule,Behavioral Health,52.8,,,52.8,Fee Schedule,Behavioral Health,52.8,,,52.8,Fee Schedule,Behavioral Health,52.8,,,52.8,Fee Schedule,Behavioral Health,52.8,,,52.8,Fee Schedule,Behavioral Health,93.82,,,93.82,Other,100% of Medicaid,93.82,,,93.82,Other,100% of Medicaid,93.82,,,93.82,Other,100% of Medicaid,93.82,,,93.82,Other,100% of Medicaid,211.09,,,211.09,Other,225% of Medicaid,143.54,,,143.54,Other,153% of Medicaid,211.09,,,211.09,Other,225% of Medicaid,131.34,,,131.34,Other,140% of Medicaid,211.09,,,211.09,Other,225% of Medicaid,243.92,,,243.92,Other,260% of Medicaid,303.97,,,303.97,Other,324% of Medicaid,201.71,,,201.71,Other,215% of Medicaid,201.71,,,201.71,Other,215% of Medicaid,117.27,,,117.27,Other,125% of Medicaid,24,303.97,
PSYTX PT&/FAM W/PSYCH 45 MIN,90836,CPT,,38190836,CDM,914,RC,,,both,,,175,129.5,,,129.5,Other,150% of Medicare + 9.63% HCRA Surcharge,78.75,45,,78.75,percent of total billed charges,Critical Access Hospital RCC factor,113.75,65,,113.75,percent of total billed charges,All Other,103.25,65,,103.25,percent of total billed charges,All Other,133.88,76.5,,133.88,percent of total billed charges,All Other,124.25,69,,124.25,percent of total billed charges,All Other,120.75,65,,120.75,percent of total billed charges,All Other,86.63,,,86.63,Other,110% of Medicare,126.78,,,126.78,Fee Schedule,Behavioral Health,233,,,233,Other,186% of Medicaid,126.78,,,126.78,Fee Schedule,Behavioral Health,126.78,,,126.78,Fee Schedule,Behavioral Health,126.78,,,126.78,Fee Schedule,Behavioral Health,126.78,,,126.78,Fee Schedule,Behavioral Health,126.78,,,126.78,Fee Schedule,Behavioral Health,140,80,,140,percent of total billed charges,All Other,122.5,70,,122.5,percent of total billed charges,All Other,100,,,100,Fee Schedule,Behavioral Health,85,,,85,Fee Schedule,Behavioral Health,79.55,,,79.55,Fee Schedule,Behavioral Health,79.55,,,79.55,Fee Schedule,Behavioral Health,79.55,,,79.55,Fee Schedule,Behavioral Health,79.55,,,79.55,Fee Schedule,Behavioral Health,125.09,,,125.09,Other,100% of Medicaid,125.09,,,125.09,Other,100% of Medicaid,125.09,,,125.09,Other,100% of Medicaid,125.09,,,125.09,Other,100% of Medicaid,281.45,,,281.45,Other,225% of Medicaid,191.39,,,191.39,Other,153% of Medicaid,281.45,,,281.45,Other,225% of Medicaid,175.13,,,175.13,Other,140% of Medicaid,281.45,,,281.45,Other,225% of Medicaid,325.23,,,325.23,Other,260% of Medicaid,405.29,,,405.29,Other,324% of Medicaid,268.94,,,268.94,Other,215% of Medicaid,268.94,,,268.94,Other,215% of Medicaid,156.36,,,156.36,Other,125% of Medicaid,78.75,405.29,
PSYTX PT&/FAM W/PSYCH 60 MIN,90838,CPT,,38190838,CDM,914,RC,,,both,,,282,208.68,,,208.68,Other,150% of Medicare + 9.63% HCRA Surcharge,126.9,45,,126.9,percent of total billed charges,Critical Access Hospital RCC factor,183.3,65,,183.3,percent of total billed charges,All Other,166.38,65,,166.38,percent of total billed charges,All Other,215.73,76.5,,215.73,percent of total billed charges,All Other,200.22,69,,200.22,percent of total billed charges,All Other,194.58,65,,194.58,percent of total billed charges,All Other,139.59,,,139.59,Other,110% of Medicare,168.08,,,168.08,Fee Schedule,Behavioral Health,233,,,233,Other,186% of Medicaid,168.08,,,168.08,Fee Schedule,Behavioral Health,168.08,,,168.08,Fee Schedule,Behavioral Health,168.08,,,168.08,Fee Schedule,Behavioral Health,168.08,,,168.08,Fee Schedule,Behavioral Health,168.08,,,168.08,Fee Schedule,Behavioral Health,225.6,80,,225.6,percent of total billed charges,All Other,197.4,70,,197.4,percent of total billed charges,All Other,121,,,121,Fee Schedule,Behavioral Health,103,,,103,Fee Schedule,Behavioral Health,106.31,,,106.31,Fee Schedule,Behavioral Health,106.31,,,106.31,Fee Schedule,Behavioral Health,106.31,,,106.31,Fee Schedule,Behavioral Health,106.31,,,106.31,Fee Schedule,Behavioral Health,125.09,,,125.09,Other,100% of Medicaid,125.09,,,125.09,Other,100% of Medicaid,125.09,,,125.09,Other,100% of Medicaid,125.09,,,125.09,Other,100% of Medicaid,281.45,,,281.45,Other,225% of Medicaid,191.39,,,191.39,Other,153% of Medicaid,281.45,,,281.45,Other,225% of Medicaid,175.13,,,175.13,Other,140% of Medicaid,281.45,,,281.45,Other,225% of Medicaid,325.23,,,325.23,Other,260% of Medicaid,405.29,,,405.29,Other,324% of Medicaid,268.94,,,268.94,Other,215% of Medicaid,268.94,,,268.94,Other,215% of Medicaid,156.36,,,156.36,Other,125% of Medicaid,103,405.29,
PHARMACOLOGIC MGMT W/PSYTX ACUTE,90863,CPT,,38190863,CDM,914,RC,,,both,,,272,201.28,,,201.28,Other,150% of Medicare + 9.63% HCRA Surcharge,122.4,45,,122.4,percent of total billed charges,Critical Access Hospital RCC factor,176.8,65,,176.8,percent of total billed charges,All Other,160.48,65,,160.48,percent of total billed charges,All Other,208.08,76.5,,208.08,percent of total billed charges,All Other,193.12,69,,193.12,percent of total billed charges,All Other,187.68,65,,187.68,percent of total billed charges,All Other,134.64,,,134.64,Other,110% of Medicare,184.96,68,,184.96,percent of total billed charges,All Other,38,,,38,Other,186% of Medicaid,217.6,80,,217.6,percent of total billed charges,All Other,225.76,83,,225.76,percent of total billed charges,All Other,225.76,83,,225.76,percent of total billed charges,All Other,217.6,80,,217.6,percent of total billed charges,All Other,225.76,83,,225.76,percent of total billed charges,All Other,217.6,80,,217.6,percent of total billed charges,All Other,190.4,70,,190.4,percent of total billed charges,All Other,100,,,100,Fee Schedule,Behavioral Health,85,,,85,Fee Schedule,Behavioral Health,0.01,,,0.01,Fee Schedule,Behavioral Health,0.01,,,0.01,Fee Schedule,Behavioral Health,0.01,,,0.01,Fee Schedule,Behavioral Health,0.01,,,0.01,Fee Schedule,Behavioral Health,20.18,,,20.18,Other,100% of Medicaid,20.18,,,20.18,Other,100% of Medicaid,20.18,,,20.18,Other,100% of Medicaid,20.18,,,20.18,Other,100% of Medicaid,45.4,,,45.4,Other,225% of Medicaid,30.88,,,30.88,Other,153% of Medicaid,45.4,,,45.4,Other,225% of Medicaid,28.25,,,28.25,Other,140% of Medicaid,45.4,,,45.4,Other,225% of Medicaid,52.47,,,52.47,Other,260% of Medicaid,65.38,,,65.38,Other,324% of Medicaid,43.39,,,43.39,Other,215% of Medicaid,43.39,,,43.39,Other,215% of Medicaid,25.22,,,25.22,Other,125% of Medicaid,0.01,225.76,
TH-PSYTX PT&/FAM W/PSYCH 30 MIN,90833,CPT,,38290833,CDM,914,RC,,,both,,,108,79.92,,,79.92,Other,150% of Medicare + 9.63% HCRA Surcharge,48.6,45,,48.6,percent of total billed charges,Critical Access Hospital RCC factor,70.2,65,,70.2,percent of total billed charges,All Other,63.72,65,,63.72,percent of total billed charges,All Other,82.62,76.5,,82.62,percent of total billed charges,All Other,76.68,69,,76.68,percent of total billed charges,All Other,74.52,65,,74.52,percent of total billed charges,All Other,53.46,,,53.46,Other,110% of Medicare,100.23,,,100.23,Fee Schedule,Behavioral Health,174,,,174,Other,186% of Medicaid,100.23,,,100.23,Fee Schedule,Behavioral Health,100.23,,,100.23,Fee Schedule,Behavioral Health,100.23,,,100.23,Fee Schedule,Behavioral Health,100.23,,,100.23,Fee Schedule,Behavioral Health,100.23,,,100.23,Fee Schedule,Behavioral Health,86.4,80,,86.4,percent of total billed charges,All Other,75.6,70,,75.6,percent of total billed charges,All Other,28,,,28,Fee Schedule,Behavioral Health,24,,,24,Fee Schedule,Behavioral Health,52.8,,,52.8,Fee Schedule,Behavioral Health,52.8,,,52.8,Fee Schedule,Behavioral Health,52.8,,,52.8,Fee Schedule,Behavioral Health,52.8,,,52.8,Fee Schedule,Behavioral Health,93.82,,,93.82,Other,100% of Medicaid,93.82,,,93.82,Other,100% of Medicaid,93.82,,,93.82,Other,100% of Medicaid,93.82,,,93.82,Other,100% of Medicaid,211.09,,,211.09,Other,225% of Medicaid,143.54,,,143.54,Other,153% of Medicaid,211.09,,,211.09,Other,225% of Medicaid,131.34,,,131.34,Other,140% of Medicaid,211.09,,,211.09,Other,225% of Medicaid,243.92,,,243.92,Other,260% of Medicaid,303.97,,,303.97,Other,324% of Medicaid,201.71,,,201.71,Other,215% of Medicaid,201.71,,,201.71,Other,215% of Medicaid,117.27,,,117.27,Other,125% of Medicaid,24,303.97,
TH-PSYTX PT&/FAM W/PSYCH 45 MIN,90836,CPT,,38290836,CDM,914,RC,,,both,,,175,129.5,,,129.5,Other,150% of Medicare + 9.63% HCRA Surcharge,78.75,45,,78.75,percent of total billed charges,Critical Access Hospital RCC factor,113.75,65,,113.75,percent of total billed charges,All Other,103.25,65,,103.25,percent of total billed charges,All Other,133.88,76.5,,133.88,percent of total billed charges,All Other,124.25,69,,124.25,percent of total billed charges,All Other,120.75,65,,120.75,percent of total billed charges,All Other,86.63,,,86.63,Other,110% of Medicare,126.78,,,126.78,Fee Schedule,Behavioral Health,233,,,233,Other,186% of Medicaid,126.78,,,126.78,Fee Schedule,Behavioral Health,126.78,,,126.78,Fee Schedule,Behavioral Health,126.78,,,126.78,Fee Schedule,Behavioral Health,126.78,,,126.78,Fee Schedule,Behavioral Health,126.78,,,126.78,Fee Schedule,Behavioral Health,140,80,,140,percent of total billed charges,All Other,122.5,70,,122.5,percent of total billed charges,All Other,100,,,100,Fee Schedule,Behavioral Health,85,,,85,Fee Schedule,Behavioral Health,79.55,,,79.55,Fee Schedule,Behavioral Health,79.55,,,79.55,Fee Schedule,Behavioral Health,79.55,,,79.55,Fee Schedule,Behavioral Health,79.55,,,79.55,Fee Schedule,Behavioral Health,125.09,,,125.09,Other,100% of Medicaid,125.09,,,125.09,Other,100% of Medicaid,125.09,,,125.09,Other,100% of Medicaid,125.09,,,125.09,Other,100% of Medicaid,281.45,,,281.45,Other,225% of Medicaid,191.39,,,191.39,Other,153% of Medicaid,281.45,,,281.45,Other,225% of Medicaid,175.13,,,175.13,Other,140% of Medicaid,281.45,,,281.45,Other,225% of Medicaid,325.23,,,325.23,Other,260% of Medicaid,405.29,,,405.29,Other,324% of Medicaid,268.94,,,268.94,Other,215% of Medicaid,268.94,,,268.94,Other,215% of Medicaid,156.36,,,156.36,Other,125% of Medicaid,78.75,405.29,
TH-PSYTX PT&/FAM W/PSYCH 60 MIN,90838,CPT,,38290838,CDM,914,RC,,,both,,,282,208.68,,,208.68,Other,150% of Medicare + 9.63% HCRA Surcharge,126.9,45,,126.9,percent of total billed charges,Critical Access Hospital RCC factor,183.3,65,,183.3,percent of total billed charges,All Other,166.38,65,,166.38,percent of total billed charges,All Other,215.73,76.5,,215.73,percent of total billed charges,All Other,200.22,69,,200.22,percent of total billed charges,All Other,194.58,65,,194.58,percent of total billed charges,All Other,139.59,,,139.59,Other,110% of Medicare,168.08,,,168.08,Fee Schedule,Behavioral Health,233,,,233,Other,186% of Medicaid,168.08,,,168.08,Fee Schedule,Behavioral Health,168.08,,,168.08,Fee Schedule,Behavioral Health,168.08,,,168.08,Fee Schedule,Behavioral Health,168.08,,,168.08,Fee Schedule,Behavioral Health,168.08,,,168.08,Fee Schedule,Behavioral Health,225.6,80,,225.6,percent of total billed charges,All Other,197.4,70,,197.4,percent of total billed charges,All Other,121,,,121,Fee Schedule,Behavioral Health,103,,,103,Fee Schedule,Behavioral Health,106.31,,,106.31,Fee Schedule,Behavioral Health,106.31,,,106.31,Fee Schedule,Behavioral Health,106.31,,,106.31,Fee Schedule,Behavioral Health,106.31,,,106.31,Fee Schedule,Behavioral Health,125.09,,,125.09,Other,100% of Medicaid,125.09,,,125.09,Other,100% of Medicaid,125.09,,,125.09,Other,100% of Medicaid,125.09,,,125.09,Other,100% of Medicaid,281.45,,,281.45,Other,225% of Medicaid,191.39,,,191.39,Other,153% of Medicaid,281.45,,,281.45,Other,225% of Medicaid,175.13,,,175.13,Other,140% of Medicaid,281.45,,,281.45,Other,225% of Medicaid,325.23,,,325.23,Other,260% of Medicaid,405.29,,,405.29,Other,324% of Medicaid,268.94,,,268.94,Other,215% of Medicaid,268.94,,,268.94,Other,215% of Medicaid,156.36,,,156.36,Other,125% of Medicaid,103,405.29,
TH -PSYTX PT&/FAMILY 30 MIN,90832,CPT,95,38390832,CDM,914,RC,,,both,,,329,243.46,,,243.46,Other,150% of Medicare + 9.63% HCRA Surcharge,148.05,45,,148.05,percent of total billed charges,Critical Access Hospital RCC factor,213.85,65,,213.85,percent of total billed charges,All Other,194.11,65,,194.11,percent of total billed charges,All Other,82,,,82,Fee Schedule,Behavioral Health,74,,,74,Fee Schedule,Behavioral Health,70,,,70,Fee Schedule,Behavioral Health,162.86,,,162.86,Other,110% of Medicare,106.52,,,106.52,Fee Schedule,Behavioral Health,174,,,174,Other,186% of Medicaid,106.52,,,106.52,Fee Schedule,Behavioral Health,106.52,,,106.52,Fee Schedule,Behavioral Health,106.52,,,106.52,Fee Schedule,Behavioral Health,106.52,,,106.52,Fee Schedule,Behavioral Health,106.52,,,106.52,Fee Schedule,Behavioral Health,263.2,80,,263.2,percent of total billed charges,All Other,230.3,70,,230.3,percent of total billed charges,All Other,99,,,99,Fee Schedule,Behavioral Health,84,,,84,Fee Schedule,Behavioral Health,69.32,,,69.32,Fee Schedule,Behavioral Health,69.32,,,69.32,Fee Schedule,Behavioral Health,69.32,,,69.32,Fee Schedule,Behavioral Health,69.32,,,69.32,Fee Schedule,Behavioral Health,93.82,,,93.82,Other,100% of Medicaid,93.82,,,93.82,Other,100% of Medicaid,93.82,,,93.82,Other,100% of Medicaid,93.82,,,93.82,Other,100% of Medicaid,211.09,,,211.09,Other,225% of Medicaid,143.54,,,143.54,Other,153% of Medicaid,211.09,,,211.09,Other,225% of Medicaid,131.34,,,131.34,Other,140% of Medicaid,211.09,,,211.09,Other,225% of Medicaid,243.92,,,243.92,Other,260% of Medicaid,303.97,,,303.97,Other,324% of Medicaid,201.71,,,201.71,Other,215% of Medicaid,201.71,,,201.71,Other,215% of Medicaid,117.27,,,117.27,Other,125% of Medicaid,69.32,303.97,
TH -PSYTX PT&/FAMILY 45 MIN,90834,CPT,95,38390834,CDM,914,RC,,,both,,,399,295.26,,,295.26,Other,150% of Medicare + 9.63% HCRA Surcharge,179.55,45,,179.55,percent of total billed charges,Critical Access Hospital RCC factor,259.35,65,,259.35,percent of total billed charges,All Other,235.41,65,,235.41,percent of total billed charges,All Other,158,,,158,Fee Schedule,Behavioral Health,142,,,142,Fee Schedule,Behavioral Health,134,,,134,Fee Schedule,Behavioral Health,197.51,,,197.51,Other,110% of Medicare,140.78,,,140.78,Fee Schedule,Behavioral Health,233,,,233,Other,186% of Medicaid,140.78,,,140.78,Fee Schedule,Behavioral Health,140.78,,,140.78,Fee Schedule,Behavioral Health,140.78,,,140.78,Fee Schedule,Behavioral Health,140.78,,,140.78,Fee Schedule,Behavioral Health,140.78,,,140.78,Fee Schedule,Behavioral Health,319.2,80,,319.2,percent of total billed charges,All Other,279.3,70,,279.3,percent of total billed charges,All Other,154,,,154,Fee Schedule,Behavioral Health,131,,,131,Fee Schedule,Behavioral Health,104.53,,,104.53,Fee Schedule,Behavioral Health,104.53,,,104.53,Fee Schedule,Behavioral Health,104.53,,,104.53,Fee Schedule,Behavioral Health,104.53,,,104.53,Fee Schedule,Behavioral Health,125.09,,,125.09,Other,100% of Medicaid,125.09,,,125.09,Other,100% of Medicaid,125.09,,,125.09,Other,100% of Medicaid,125.09,,,125.09,Other,100% of Medicaid,281.45,,,281.45,Other,225% of Medicaid,191.39,,,191.39,Other,153% of Medicaid,281.45,,,281.45,Other,225% of Medicaid,175.13,,,175.13,Other,140% of Medicaid,281.45,,,281.45,Other,225% of Medicaid,325.23,,,325.23,Other,260% of Medicaid,405.29,,,405.29,Other,324% of Medicaid,268.94,,,268.94,Other,215% of Medicaid,268.94,,,268.94,Other,215% of Medicaid,156.36,,,156.36,Other,125% of Medicaid,104.53,405.29,
PSYTX PT&/FAMILY 60 MIN-TH,90837,CPT,95,38390837,CDM,914,RC,,,both,,,399,295.26,,,295.26,Other,150% of Medicare + 9.63% HCRA Surcharge,179.55,45,,179.55,percent of total billed charges,Critical Access Hospital RCC factor,259.35,65,,259.35,percent of total billed charges,All Other,235.41,65,,235.41,percent of total billed charges,All Other,158,,,158,Fee Schedule,Behavioral Health,142,,,142,Fee Schedule,Behavioral Health,134,,,134,Fee Schedule,Behavioral Health,197.51,,,197.51,Other,110% of Medicare,207.78,,,207.78,Fee Schedule,Behavioral Health,233,,,233,Other,186% of Medicaid,207.78,,,207.78,Fee Schedule,Behavioral Health,207.78,,,207.78,Fee Schedule,Behavioral Health,207.78,,,207.78,Fee Schedule,Behavioral Health,207.78,,,207.78,Fee Schedule,Behavioral Health,207.78,,,207.78,Fee Schedule,Behavioral Health,319.2,80,,319.2,percent of total billed charges,All Other,279.3,70,,279.3,percent of total billed charges,All Other,154,,,154,Fee Schedule,Behavioral Health,131,,,131,Fee Schedule,Behavioral Health,110.87,,,110.87,Fee Schedule,Behavioral Health,110.87,,,110.87,Fee Schedule,Behavioral Health,110.87,,,110.87,Fee Schedule,Behavioral Health,110.87,,,110.87,Fee Schedule,Behavioral Health,125.09,,,125.09,Other,100% of Medicaid,125.09,,,125.09,Other,100% of Medicaid,125.09,,,125.09,Other,100% of Medicaid,125.09,,,125.09,Other,100% of Medicaid,281.45,,,281.45,Other,225% of Medicaid,191.39,,,191.39,Other,153% of Medicaid,281.45,,,281.45,Other,225% of Medicaid,175.13,,,175.13,Other,140% of Medicaid,281.45,,,281.45,Other,225% of Medicaid,325.23,,,325.23,Other,260% of Medicaid,405.29,,,405.29,Other,324% of Medicaid,268.94,,,268.94,Other,215% of Medicaid,268.94,,,268.94,Other,215% of Medicaid,156.36,,,156.36,Other,125% of Medicaid,110.87,405.29,
PSYCH DIAG EVAL W/MD,90792,CPT,,39090792,CDM,914,RC,,,both,,,399,295.26,,,295.26,Other,150% of Medicare + 9.63% HCRA Surcharge,179.55,45,,179.55,percent of total billed charges,Critical Access Hospital RCC factor,259.35,65,,259.35,percent of total billed charges,All Other,235.41,65,,235.41,percent of total billed charges,All Other,190,,,190,Fee Schedule,Behavioral Health,171,,,171,Fee Schedule,Behavioral Health,162,,,162,Fee Schedule,Behavioral Health,197.51,,,197.51,Other,110% of Medicare,265.07,,,265.07,Fee Schedule,Behavioral Health,291,,,291,Other,186% of Medicaid,265.07,,,265.07,Fee Schedule,Behavioral Health,265.07,,,265.07,Fee Schedule,Behavioral Health,265.07,,,265.07,Fee Schedule,Behavioral Health,265.07,,,265.07,Fee Schedule,Behavioral Health,265.07,,,265.07,Fee Schedule,Behavioral Health,319.2,80,,319.2,percent of total billed charges,All Other,279.3,70,,279.3,percent of total billed charges,All Other,217,,,217,Fee Schedule,Behavioral Health,184,,,184,Fee Schedule,Behavioral Health,139.73,,,139.73,Fee Schedule,Behavioral Health,139.73,,,139.73,Fee Schedule,Behavioral Health,139.73,,,139.73,Fee Schedule,Behavioral Health,139.73,,,139.73,Fee Schedule,Behavioral Health,156.36,,,156.36,Other,100% of Medicaid,156.36,,,156.36,Other,100% of Medicaid,156.36,,,156.36,Other,100% of Medicaid,156.36,,,156.36,Other,100% of Medicaid,351.81,,,351.81,Other,225% of Medicaid,239.23,,,239.23,Other,153% of Medicaid,351.81,,,351.81,Other,225% of Medicaid,218.91,,,218.91,Other,140% of Medicaid,351.81,,,351.81,Other,225% of Medicaid,406.54,,,406.54,Other,260% of Medicaid,506.61,,,506.61,Other,324% of Medicaid,336.18,,,336.18,Other,215% of Medicaid,336.18,,,336.18,Other,215% of Medicaid,195.45,,,195.45,Other,125% of Medicaid,139.73,506.61,
PSYTX PT&/FAMILY 30 MINUTES,90832,CPT,,39090832,CDM,914,RC,,,both,,,329,243.46,,,243.46,Other,150% of Medicare + 9.63% HCRA Surcharge,148.05,45,,148.05,percent of total billed charges,Critical Access Hospital RCC factor,213.85,65,,213.85,percent of total billed charges,All Other,194.11,65,,194.11,percent of total billed charges,All Other,82,,,82,Fee Schedule,Behavioral Health,74,,,74,Fee Schedule,Behavioral Health,70,,,70,Fee Schedule,Behavioral Health,162.86,,,162.86,Other,110% of Medicare,106.52,,,106.52,Fee Schedule,Behavioral Health,174,,,174,Other,186% of Medicaid,106.52,,,106.52,Fee Schedule,Behavioral Health,106.52,,,106.52,Fee Schedule,Behavioral Health,106.52,,,106.52,Fee Schedule,Behavioral Health,106.52,,,106.52,Fee Schedule,Behavioral Health,106.52,,,106.52,Fee Schedule,Behavioral Health,263.2,80,,263.2,percent of total billed charges,All Other,230.3,70,,230.3,percent of total billed charges,All Other,99,,,99,Fee Schedule,Behavioral Health,84,,,84,Fee Schedule,Behavioral Health,69.32,,,69.32,Fee Schedule,Behavioral Health,69.32,,,69.32,Fee Schedule,Behavioral Health,69.32,,,69.32,Fee Schedule,Behavioral Health,69.32,,,69.32,Fee Schedule,Behavioral Health,93.82,,,93.82,Other,100% of Medicaid,93.82,,,93.82,Other,100% of Medicaid,93.82,,,93.82,Other,100% of Medicaid,93.82,,,93.82,Other,100% of Medicaid,211.09,,,211.09,Other,225% of Medicaid,143.54,,,143.54,Other,153% of Medicaid,211.09,,,211.09,Other,225% of Medicaid,131.34,,,131.34,Other,140% of Medicaid,211.09,,,211.09,Other,225% of Medicaid,243.92,,,243.92,Other,260% of Medicaid,303.97,,,303.97,Other,324% of Medicaid,201.71,,,201.71,Other,215% of Medicaid,201.71,,,201.71,Other,215% of Medicaid,117.27,,,117.27,Other,125% of Medicaid,69.32,303.97,
PSYTX PT&/FAM W/MD 30 MIN,90833,CPT,HE,39090833,CDM,914,RC,,,both,,,108,79.92,,,79.92,Other,150% of Medicare + 9.63% HCRA Surcharge,48.6,45,,48.6,percent of total billed charges,Critical Access Hospital RCC factor,70.2,65,,70.2,percent of total billed charges,All Other,63.72,65,,63.72,percent of total billed charges,All Other,82.62,76.5,,82.62,percent of total billed charges,All Other,76.68,69,,76.68,percent of total billed charges,All Other,74.52,65,,74.52,percent of total billed charges,All Other,53.46,,,53.46,Other,110% of Medicare,100.23,,,100.23,Fee Schedule,Behavioral Health,174,,,174,Other,186% of Medicaid,100.23,,,100.23,Fee Schedule,Behavioral Health,100.23,,,100.23,Fee Schedule,Behavioral Health,100.23,,,100.23,Fee Schedule,Behavioral Health,100.23,,,100.23,Fee Schedule,Behavioral Health,100.23,,,100.23,Fee Schedule,Behavioral Health,86.4,80,,86.4,percent of total billed charges,All Other,75.6,70,,75.6,percent of total billed charges,All Other,28,,,28,Fee Schedule,Behavioral Health,24,,,24,Fee Schedule,Behavioral Health,52.8,,,52.8,Fee Schedule,Behavioral Health,52.8,,,52.8,Fee Schedule,Behavioral Health,52.8,,,52.8,Fee Schedule,Behavioral Health,52.8,,,52.8,Fee Schedule,Behavioral Health,93.82,,,93.82,Other,100% of Medicaid,93.82,,,93.82,Other,100% of Medicaid,93.82,,,93.82,Other,100% of Medicaid,93.82,,,93.82,Other,100% of Medicaid,211.09,,,211.09,Other,225% of Medicaid,143.54,,,143.54,Other,153% of Medicaid,211.09,,,211.09,Other,225% of Medicaid,131.34,,,131.34,Other,140% of Medicaid,211.09,,,211.09,Other,225% of Medicaid,243.92,,,243.92,Other,260% of Medicaid,303.97,,,303.97,Other,324% of Medicaid,201.71,,,201.71,Other,215% of Medicaid,201.71,,,201.71,Other,215% of Medicaid,117.27,,,117.27,Other,125% of Medicaid,24,303.97,
PSYTX PT&/FAMILY 45 MIN,90834,CPT,,39090834,CDM,914,RC,,,both,,,399,295.26,,,295.26,Other,150% of Medicare + 9.63% HCRA Surcharge,179.55,45,,179.55,percent of total billed charges,Critical Access Hospital RCC factor,259.35,65,,259.35,percent of total billed charges,All Other,235.41,65,,235.41,percent of total billed charges,All Other,158,,,158,Fee Schedule,Behavioral Health,142,,,142,Fee Schedule,Behavioral Health,134,,,134,Fee Schedule,Behavioral Health,197.51,,,197.51,Other,110% of Medicare,140.78,,,140.78,Fee Schedule,Behavioral Health,233,,,233,Other,186% of Medicaid,140.78,,,140.78,Fee Schedule,Behavioral Health,140.78,,,140.78,Fee Schedule,Behavioral Health,140.78,,,140.78,Fee Schedule,Behavioral Health,140.78,,,140.78,Fee Schedule,Behavioral Health,140.78,,,140.78,Fee Schedule,Behavioral Health,319.2,80,,319.2,percent of total billed charges,All Other,279.3,70,,279.3,percent of total billed charges,All Other,154,,,154,Fee Schedule,Behavioral Health,131,,,131,Fee Schedule,Behavioral Health,104.53,,,104.53,Fee Schedule,Behavioral Health,104.53,,,104.53,Fee Schedule,Behavioral Health,104.53,,,104.53,Fee Schedule,Behavioral Health,104.53,,,104.53,Fee Schedule,Behavioral Health,125.09,,,125.09,Other,100% of Medicaid,125.09,,,125.09,Other,100% of Medicaid,125.09,,,125.09,Other,100% of Medicaid,125.09,,,125.09,Other,100% of Medicaid,281.45,,,281.45,Other,225% of Medicaid,191.39,,,191.39,Other,153% of Medicaid,281.45,,,281.45,Other,225% of Medicaid,175.13,,,175.13,Other,140% of Medicaid,281.45,,,281.45,Other,225% of Medicaid,325.23,,,325.23,Other,260% of Medicaid,405.29,,,405.29,Other,324% of Medicaid,268.94,,,268.94,Other,215% of Medicaid,268.94,,,268.94,Other,215% of Medicaid,156.36,,,156.36,Other,125% of Medicaid,104.53,405.29,
PSYTX PT&/FAM W/MD 45 MIN,90836,CPT,HE,39090836,CDM,914,RC,,,both,,,175,129.5,,,129.5,Other,150% of Medicare + 9.63% HCRA Surcharge,78.75,45,,78.75,percent of total billed charges,Critical Access Hospital RCC factor,113.75,65,,113.75,percent of total billed charges,All Other,103.25,65,,103.25,percent of total billed charges,All Other,133.88,76.5,,133.88,percent of total billed charges,All Other,124.25,69,,124.25,percent of total billed charges,All Other,120.75,65,,120.75,percent of total billed charges,All Other,86.63,,,86.63,Other,110% of Medicare,126.78,,,126.78,Fee Schedule,Behavioral Health,233,,,233,Other,186% of Medicaid,126.78,,,126.78,Fee Schedule,Behavioral Health,126.78,,,126.78,Fee Schedule,Behavioral Health,126.78,,,126.78,Fee Schedule,Behavioral Health,126.78,,,126.78,Fee Schedule,Behavioral Health,126.78,,,126.78,Fee Schedule,Behavioral Health,140,80,,140,percent of total billed charges,All Other,122.5,70,,122.5,percent of total billed charges,All Other,100,,,100,Fee Schedule,Behavioral Health,85,,,85,Fee Schedule,Behavioral Health,79.55,,,79.55,Fee Schedule,Behavioral Health,79.55,,,79.55,Fee Schedule,Behavioral Health,79.55,,,79.55,Fee Schedule,Behavioral Health,79.55,,,79.55,Fee Schedule,Behavioral Health,125.09,,,125.09,Other,100% of Medicaid,125.09,,,125.09,Other,100% of Medicaid,125.09,,,125.09,Other,100% of Medicaid,125.09,,,125.09,Other,100% of Medicaid,281.45,,,281.45,Other,225% of Medicaid,191.39,,,191.39,Other,153% of Medicaid,281.45,,,281.45,Other,225% of Medicaid,175.13,,,175.13,Other,140% of Medicaid,281.45,,,281.45,Other,225% of Medicaid,325.23,,,325.23,Other,260% of Medicaid,405.29,,,405.29,Other,324% of Medicaid,268.94,,,268.94,Other,215% of Medicaid,268.94,,,268.94,Other,215% of Medicaid,156.36,,,156.36,Other,125% of Medicaid,78.75,405.29,
PSYTX PT&/FAMILY 60 MIN,90837,CPT,,39090837,CDM,914,RC,,,both,,,399,295.26,,,295.26,Other,150% of Medicare + 9.63% HCRA Surcharge,179.55,45,,179.55,percent of total billed charges,Critical Access Hospital RCC factor,259.35,65,,259.35,percent of total billed charges,All Other,235.41,65,,235.41,percent of total billed charges,All Other,158,,,158,Fee Schedule,Behavioral Health,142,,,142,Fee Schedule,Behavioral Health,134,,,134,Fee Schedule,Behavioral Health,197.51,,,197.51,Other,110% of Medicare,207.78,,,207.78,Fee Schedule,Behavioral Health,233,,,233,Other,186% of Medicaid,207.78,,,207.78,Fee Schedule,Behavioral Health,207.78,,,207.78,Fee Schedule,Behavioral Health,207.78,,,207.78,Fee Schedule,Behavioral Health,207.78,,,207.78,Fee Schedule,Behavioral Health,207.78,,,207.78,Fee Schedule,Behavioral Health,319.2,80,,319.2,percent of total billed charges,All Other,279.3,70,,279.3,percent of total billed charges,All Other,154,,,154,Fee Schedule,Behavioral Health,131,,,131,Fee Schedule,Behavioral Health,110.87,,,110.87,Fee Schedule,Behavioral Health,110.87,,,110.87,Fee Schedule,Behavioral Health,110.87,,,110.87,Fee Schedule,Behavioral Health,110.87,,,110.87,Fee Schedule,Behavioral Health,125.09,,,125.09,Other,100% of Medicaid,125.09,,,125.09,Other,100% of Medicaid,125.09,,,125.09,Other,100% of Medicaid,125.09,,,125.09,Other,100% of Medicaid,281.45,,,281.45,Other,225% of Medicaid,191.39,,,191.39,Other,153% of Medicaid,281.45,,,281.45,Other,225% of Medicaid,175.13,,,175.13,Other,140% of Medicaid,281.45,,,281.45,Other,225% of Medicaid,325.23,,,325.23,Other,260% of Medicaid,405.29,,,405.29,Other,324% of Medicaid,268.94,,,268.94,Other,215% of Medicaid,268.94,,,268.94,Other,215% of Medicaid,156.36,,,156.36,Other,125% of Medicaid,110.87,405.29,
PSYTX PT&/FAM W/MD 60 MIN,90838,CPT,HE,39090838,CDM,914,RC,,,both,,,282,208.68,,,208.68,Other,150% of Medicare + 9.63% HCRA Surcharge,126.9,45,,126.9,percent of total billed charges,Critical Access Hospital RCC factor,183.3,65,,183.3,percent of total billed charges,All Other,166.38,65,,166.38,percent of total billed charges,All Other,215.73,76.5,,215.73,percent of total billed charges,All Other,200.22,69,,200.22,percent of total billed charges,All Other,194.58,65,,194.58,percent of total billed charges,All Other,139.59,,,139.59,Other,110% of Medicare,168.08,,,168.08,Fee Schedule,Behavioral Health,233,,,233,Other,186% of Medicaid,168.08,,,168.08,Fee Schedule,Behavioral Health,168.08,,,168.08,Fee Schedule,Behavioral Health,168.08,,,168.08,Fee Schedule,Behavioral Health,168.08,,,168.08,Fee Schedule,Behavioral Health,168.08,,,168.08,Fee Schedule,Behavioral Health,225.6,80,,225.6,percent of total billed charges,All Other,197.4,70,,197.4,percent of total billed charges,All Other,121,,,121,Fee Schedule,Behavioral Health,103,,,103,Fee Schedule,Behavioral Health,106.31,,,106.31,Fee Schedule,Behavioral Health,106.31,,,106.31,Fee Schedule,Behavioral Health,106.31,,,106.31,Fee Schedule,Behavioral Health,106.31,,,106.31,Fee Schedule,Behavioral Health,125.09,,,125.09,Other,100% of Medicaid,125.09,,,125.09,Other,100% of Medicaid,125.09,,,125.09,Other,100% of Medicaid,125.09,,,125.09,Other,100% of Medicaid,281.45,,,281.45,Other,225% of Medicaid,191.39,,,191.39,Other,153% of Medicaid,281.45,,,281.45,Other,225% of Medicaid,175.13,,,175.13,Other,140% of Medicaid,281.45,,,281.45,Other,225% of Medicaid,325.23,,,325.23,Other,260% of Medicaid,405.29,,,405.29,Other,324% of Medicaid,268.94,,,268.94,Other,215% of Medicaid,268.94,,,268.94,Other,215% of Medicaid,156.36,,,156.36,Other,125% of Medicaid,103,405.29,
PSYTX CRISIS INITIAL 60 MIN,90839,CPT,,39090839,CDM,914,RC,,,both,,,402,297.48,,,297.48,Other,150% of Medicare + 9.63% HCRA Surcharge,180.9,45,,180.9,percent of total billed charges,Critical Access Hospital RCC factor,261.3,65,,261.3,percent of total billed charges,All Other,237.18,65,,237.18,percent of total billed charges,All Other,307.53,76.5,,307.53,percent of total billed charges,All Other,285.42,69,,285.42,percent of total billed charges,All Other,277.38,65,,277.38,percent of total billed charges,All Other,198.99,,,198.99,Other,110% of Medicare,201.36,,,201.36,Fee Schedule,Behavioral Health,233,,,233,Other,186% of Medicaid,201.36,,,201.36,Fee Schedule,Behavioral Health,201.36,,,201.36,Fee Schedule,Behavioral Health,201.36,,,201.36,Fee Schedule,Behavioral Health,201.36,,,201.36,Fee Schedule,Behavioral Health,201.36,,,201.36,Fee Schedule,Behavioral Health,321.6,80,,321.6,percent of total billed charges,All Other,281.4,70,,281.4,percent of total billed charges,All Other,154,,,154,Fee Schedule,Behavioral Health,131,,,131,Fee Schedule,Behavioral Health,132.69,,,132.69,Fee Schedule,Behavioral Health,132.69,,,132.69,Fee Schedule,Behavioral Health,132.69,,,132.69,Fee Schedule,Behavioral Health,132.69,,,132.69,Fee Schedule,Behavioral Health,125.09,,,125.09,Other,100% of Medicaid,125.09,,,125.09,Other,100% of Medicaid,125.09,,,125.09,Other,100% of Medicaid,125.09,,,125.09,Other,100% of Medicaid,281.45,,,281.45,Other,225% of Medicaid,191.39,,,191.39,Other,153% of Medicaid,281.45,,,281.45,Other,225% of Medicaid,175.13,,,175.13,Other,140% of Medicaid,281.45,,,281.45,Other,225% of Medicaid,325.23,,,325.23,Other,260% of Medicaid,405.29,,,405.29,Other,324% of Medicaid,268.94,,,268.94,Other,215% of Medicaid,268.94,,,268.94,Other,215% of Medicaid,156.36,,,156.36,Other,125% of Medicaid,125.09,405.29,
PSYTX CRISIS EA ADDL 30 MIN,90840,CPT,,39090840,CDM,914,RC,,,both,,,140,103.6,,,103.6,Other,150% of Medicare + 9.63% HCRA Surcharge,63,45,,63,percent of total billed charges,Critical Access Hospital RCC factor,91,65,,91,percent of total billed charges,All Other,82.6,65,,82.6,percent of total billed charges,All Other,107.1,76.5,,107.1,percent of total billed charges,All Other,99.4,69,,99.4,percent of total billed charges,All Other,96.6,65,,96.6,percent of total billed charges,All Other,69.3,,,69.3,Other,110% of Medicare,101.4,,,101.4,Fee Schedule,Behavioral Health,233,,,233,Other,186% of Medicaid,101.4,,,101.4,Fee Schedule,Behavioral Health,101.4,,,101.4,Fee Schedule,Behavioral Health,101.4,,,101.4,Fee Schedule,Behavioral Health,101.4,,,101.4,Fee Schedule,Behavioral Health,101.4,,,101.4,Fee Schedule,Behavioral Health,112,80,,112,percent of total billed charges,All Other,98,70,,98,percent of total billed charges,All Other,99,,,99,Fee Schedule,Behavioral Health,84,,,84,Fee Schedule,Behavioral Health,6.69,,,6.69,Fee Schedule,Behavioral Health,6.69,,,6.69,Fee Schedule,Behavioral Health,6.69,,,6.69,Fee Schedule,Behavioral Health,6.69,,,6.69,Fee Schedule,Behavioral Health,125.09,,,125.09,Other,100% of Medicaid,125.09,,,125.09,Other,100% of Medicaid,125.09,,,125.09,Other,100% of Medicaid,125.09,,,125.09,Other,100% of Medicaid,281.45,,,281.45,Other,225% of Medicaid,191.39,,,191.39,Other,153% of Medicaid,281.45,,,281.45,Other,225% of Medicaid,175.13,,,175.13,Other,140% of Medicaid,281.45,,,281.45,Other,225% of Medicaid,325.23,,,325.23,Other,260% of Medicaid,405.29,,,405.29,Other,324% of Medicaid,268.94,,,268.94,Other,215% of Medicaid,268.94,,,268.94,Other,215% of Medicaid,156.36,,,156.36,Other,125% of Medicaid,6.69,405.29,
PSYCH DIAG EVAL W/MD TELEPSYCH,90792,CPT,95,39190792,CDM,914,RC,,,both,,,399,295.26,,,295.26,Other,150% of Medicare + 9.63% HCRA Surcharge,179.55,45,,179.55,percent of total billed charges,Critical Access Hospital RCC factor,259.35,65,,259.35,percent of total billed charges,All Other,235.41,65,,235.41,percent of total billed charges,All Other,190,,,190,Fee Schedule,Behavioral Health,171,,,171,Fee Schedule,Behavioral Health,162,,,162,Fee Schedule,Behavioral Health,197.51,,,197.51,Other,110% of Medicare,265.07,,,265.07,Fee Schedule,Behavioral Health,291,,,291,Other,186% of Medicaid,265.07,,,265.07,Fee Schedule,Behavioral Health,265.07,,,265.07,Fee Schedule,Behavioral Health,265.07,,,265.07,Fee Schedule,Behavioral Health,265.07,,,265.07,Fee Schedule,Behavioral Health,265.07,,,265.07,Fee Schedule,Behavioral Health,319.2,80,,319.2,percent of total billed charges,All Other,279.3,70,,279.3,percent of total billed charges,All Other,217,,,217,Fee Schedule,Behavioral Health,184,,,184,Fee Schedule,Behavioral Health,139.73,,,139.73,Fee Schedule,Behavioral Health,139.73,,,139.73,Fee Schedule,Behavioral Health,139.73,,,139.73,Fee Schedule,Behavioral Health,139.73,,,139.73,Fee Schedule,Behavioral Health,156.36,,,156.36,Other,100% of Medicaid,156.36,,,156.36,Other,100% of Medicaid,156.36,,,156.36,Other,100% of Medicaid,156.36,,,156.36,Other,100% of Medicaid,351.81,,,351.81,Other,225% of Medicaid,239.23,,,239.23,Other,153% of Medicaid,351.81,,,351.81,Other,225% of Medicaid,218.91,,,218.91,Other,140% of Medicaid,351.81,,,351.81,Other,225% of Medicaid,406.54,,,406.54,Other,260% of Medicaid,506.61,,,506.61,Other,324% of Medicaid,336.18,,,336.18,Other,215% of Medicaid,336.18,,,336.18,Other,215% of Medicaid,195.45,,,195.45,Other,125% of Medicaid,139.73,506.61,
PSYTX PT&/FAMILY 30 MINUTES-TH,90832,CPT,95,39190832,CDM,914,RC,,,both,,,329,243.46,,,243.46,Other,150% of Medicare + 9.63% HCRA Surcharge,148.05,45,,148.05,percent of total billed charges,Critical Access Hospital RCC factor,213.85,65,,213.85,percent of total billed charges,All Other,194.11,65,,194.11,percent of total billed charges,All Other,82,,,82,Fee Schedule,Behavioral Health,74,,,74,Fee Schedule,Behavioral Health,70,,,70,Fee Schedule,Behavioral Health,162.86,,,162.86,Other,110% of Medicare,106.52,,,106.52,Fee Schedule,Behavioral Health,174,,,174,Other,186% of Medicaid,106.52,,,106.52,Fee Schedule,Behavioral Health,106.52,,,106.52,Fee Schedule,Behavioral Health,106.52,,,106.52,Fee Schedule,Behavioral Health,106.52,,,106.52,Fee Schedule,Behavioral Health,106.52,,,106.52,Fee Schedule,Behavioral Health,263.2,80,,263.2,percent of total billed charges,All Other,230.3,70,,230.3,percent of total billed charges,All Other,99,,,99,Fee Schedule,Behavioral Health,84,,,84,Fee Schedule,Behavioral Health,69.32,,,69.32,Fee Schedule,Behavioral Health,69.32,,,69.32,Fee Schedule,Behavioral Health,69.32,,,69.32,Fee Schedule,Behavioral Health,69.32,,,69.32,Fee Schedule,Behavioral Health,93.82,,,93.82,Other,100% of Medicaid,93.82,,,93.82,Other,100% of Medicaid,93.82,,,93.82,Other,100% of Medicaid,93.82,,,93.82,Other,100% of Medicaid,211.09,,,211.09,Other,225% of Medicaid,143.54,,,143.54,Other,153% of Medicaid,211.09,,,211.09,Other,225% of Medicaid,131.34,,,131.34,Other,140% of Medicaid,211.09,,,211.09,Other,225% of Medicaid,243.92,,,243.92,Other,260% of Medicaid,303.97,,,303.97,Other,324% of Medicaid,201.71,,,201.71,Other,215% of Medicaid,201.71,,,201.71,Other,215% of Medicaid,117.27,,,117.27,Other,125% of Medicaid,69.32,303.97,
PSYTX PT&/FAM W/MD 30 MIN TELEPSYCH,90833,CPT,HE95,39190833,CDM,914,RC,,,both,,,108,79.92,,,79.92,Other,150% of Medicare + 9.63% HCRA Surcharge,48.6,45,,48.6,percent of total billed charges,Critical Access Hospital RCC factor,70.2,65,,70.2,percent of total billed charges,All Other,63.72,65,,63.72,percent of total billed charges,All Other,82.62,76.5,,82.62,percent of total billed charges,All Other,76.68,69,,76.68,percent of total billed charges,All Other,74.52,65,,74.52,percent of total billed charges,All Other,53.46,,,53.46,Other,110% of Medicare,100.23,,,100.23,Fee Schedule,Behavioral Health,174,,,174,Other,186% of Medicaid,100.23,,,100.23,Fee Schedule,Behavioral Health,100.23,,,100.23,Fee Schedule,Behavioral Health,100.23,,,100.23,Fee Schedule,Behavioral Health,100.23,,,100.23,Fee Schedule,Behavioral Health,100.23,,,100.23,Fee Schedule,Behavioral Health,86.4,80,,86.4,percent of total billed charges,All Other,75.6,70,,75.6,percent of total billed charges,All Other,28,,,28,Fee Schedule,Behavioral Health,24,,,24,Fee Schedule,Behavioral Health,52.8,,,52.8,Fee Schedule,Behavioral Health,52.8,,,52.8,Fee Schedule,Behavioral Health,52.8,,,52.8,Fee Schedule,Behavioral Health,52.8,,,52.8,Fee Schedule,Behavioral Health,93.82,,,93.82,Other,100% of Medicaid,93.82,,,93.82,Other,100% of Medicaid,93.82,,,93.82,Other,100% of Medicaid,93.82,,,93.82,Other,100% of Medicaid,211.09,,,211.09,Other,225% of Medicaid,143.54,,,143.54,Other,153% of Medicaid,211.09,,,211.09,Other,225% of Medicaid,131.34,,,131.34,Other,140% of Medicaid,211.09,,,211.09,Other,225% of Medicaid,243.92,,,243.92,Other,260% of Medicaid,303.97,,,303.97,Other,324% of Medicaid,201.71,,,201.71,Other,215% of Medicaid,201.71,,,201.71,Other,215% of Medicaid,117.27,,,117.27,Other,125% of Medicaid,24,303.97,
PSYTX PT&/FAMILY 45 MIN-TH,90834,CPT,HE95,39190834,CDM,914,RC,,,both,,,399,295.26,,,295.26,Other,150% of Medicare + 9.63% HCRA Surcharge,179.55,45,,179.55,percent of total billed charges,Critical Access Hospital RCC factor,259.35,65,,259.35,percent of total billed charges,All Other,235.41,65,,235.41,percent of total billed charges,All Other,158,,,158,Fee Schedule,Behavioral Health,142,,,142,Fee Schedule,Behavioral Health,134,,,134,Fee Schedule,Behavioral Health,197.51,,,197.51,Other,110% of Medicare,140.78,,,140.78,Fee Schedule,Behavioral Health,233,,,233,Other,186% of Medicaid,140.78,,,140.78,Fee Schedule,Behavioral Health,140.78,,,140.78,Fee Schedule,Behavioral Health,140.78,,,140.78,Fee Schedule,Behavioral Health,140.78,,,140.78,Fee Schedule,Behavioral Health,140.78,,,140.78,Fee Schedule,Behavioral Health,319.2,80,,319.2,percent of total billed charges,All Other,279.3,70,,279.3,percent of total billed charges,All Other,154,,,154,Fee Schedule,Behavioral Health,131,,,131,Fee Schedule,Behavioral Health,104.53,,,104.53,Fee Schedule,Behavioral Health,104.53,,,104.53,Fee Schedule,Behavioral Health,104.53,,,104.53,Fee Schedule,Behavioral Health,104.53,,,104.53,Fee Schedule,Behavioral Health,125.09,,,125.09,Other,100% of Medicaid,125.09,,,125.09,Other,100% of Medicaid,125.09,,,125.09,Other,100% of Medicaid,125.09,,,125.09,Other,100% of Medicaid,281.45,,,281.45,Other,225% of Medicaid,191.39,,,191.39,Other,153% of Medicaid,281.45,,,281.45,Other,225% of Medicaid,175.13,,,175.13,Other,140% of Medicaid,281.45,,,281.45,Other,225% of Medicaid,325.23,,,325.23,Other,260% of Medicaid,405.29,,,405.29,Other,324% of Medicaid,268.94,,,268.94,Other,215% of Medicaid,268.94,,,268.94,Other,215% of Medicaid,156.36,,,156.36,Other,125% of Medicaid,104.53,405.29,
PSYTX PT&/FAM W/MD 45 MIN TELEPSYCH,90836,CPT,HE95,39190836,CDM,914,RC,,,both,,,175,129.5,,,129.5,Other,150% of Medicare + 9.63% HCRA Surcharge,78.75,45,,78.75,percent of total billed charges,Critical Access Hospital RCC factor,113.75,65,,113.75,percent of total billed charges,All Other,103.25,65,,103.25,percent of total billed charges,All Other,133.88,76.5,,133.88,percent of total billed charges,All Other,124.25,69,,124.25,percent of total billed charges,All Other,120.75,65,,120.75,percent of total billed charges,All Other,86.63,,,86.63,Other,110% of Medicare,126.78,,,126.78,Fee Schedule,Behavioral Health,233,,,233,Other,186% of Medicaid,126.78,,,126.78,Fee Schedule,Behavioral Health,126.78,,,126.78,Fee Schedule,Behavioral Health,126.78,,,126.78,Fee Schedule,Behavioral Health,126.78,,,126.78,Fee Schedule,Behavioral Health,126.78,,,126.78,Fee Schedule,Behavioral Health,140,80,,140,percent of total billed charges,All Other,122.5,70,,122.5,percent of total billed charges,All Other,100,,,100,Fee Schedule,Behavioral Health,85,,,85,Fee Schedule,Behavioral Health,79.55,,,79.55,Fee Schedule,Behavioral Health,79.55,,,79.55,Fee Schedule,Behavioral Health,79.55,,,79.55,Fee Schedule,Behavioral Health,79.55,,,79.55,Fee Schedule,Behavioral Health,125.09,,,125.09,Other,100% of Medicaid,125.09,,,125.09,Other,100% of Medicaid,125.09,,,125.09,Other,100% of Medicaid,125.09,,,125.09,Other,100% of Medicaid,281.45,,,281.45,Other,225% of Medicaid,191.39,,,191.39,Other,153% of Medicaid,281.45,,,281.45,Other,225% of Medicaid,175.13,,,175.13,Other,140% of Medicaid,281.45,,,281.45,Other,225% of Medicaid,325.23,,,325.23,Other,260% of Medicaid,405.29,,,405.29,Other,324% of Medicaid,268.94,,,268.94,Other,215% of Medicaid,268.94,,,268.94,Other,215% of Medicaid,156.36,,,156.36,Other,125% of Medicaid,78.75,405.29,
PSYTX PT&/FAMILY 60 MIN-TH,90837,CPT,95,39190837,CDM,914,RC,,,both,,,399,295.26,,,295.26,Other,150% of Medicare + 9.63% HCRA Surcharge,179.55,45,,179.55,percent of total billed charges,Critical Access Hospital RCC factor,259.35,65,,259.35,percent of total billed charges,All Other,235.41,65,,235.41,percent of total billed charges,All Other,158,,,158,Fee Schedule,Behavioral Health,142,,,142,Fee Schedule,Behavioral Health,134,,,134,Fee Schedule,Behavioral Health,197.51,,,197.51,Other,110% of Medicare,207.78,,,207.78,Fee Schedule,Behavioral Health,233,,,233,Other,186% of Medicaid,207.78,,,207.78,Fee Schedule,Behavioral Health,207.78,,,207.78,Fee Schedule,Behavioral Health,207.78,,,207.78,Fee Schedule,Behavioral Health,207.78,,,207.78,Fee Schedule,Behavioral Health,207.78,,,207.78,Fee Schedule,Behavioral Health,319.2,80,,319.2,percent of total billed charges,All Other,279.3,70,,279.3,percent of total billed charges,All Other,154,,,154,Fee Schedule,Behavioral Health,131,,,131,Fee Schedule,Behavioral Health,110.87,,,110.87,Fee Schedule,Behavioral Health,110.87,,,110.87,Fee Schedule,Behavioral Health,110.87,,,110.87,Fee Schedule,Behavioral Health,110.87,,,110.87,Fee Schedule,Behavioral Health,125.09,,,125.09,Other,100% of Medicaid,125.09,,,125.09,Other,100% of Medicaid,125.09,,,125.09,Other,100% of Medicaid,125.09,,,125.09,Other,100% of Medicaid,281.45,,,281.45,Other,225% of Medicaid,191.39,,,191.39,Other,153% of Medicaid,281.45,,,281.45,Other,225% of Medicaid,175.13,,,175.13,Other,140% of Medicaid,281.45,,,281.45,Other,225% of Medicaid,325.23,,,325.23,Other,260% of Medicaid,405.29,,,405.29,Other,324% of Medicaid,268.94,,,268.94,Other,215% of Medicaid,268.94,,,268.94,Other,215% of Medicaid,156.36,,,156.36,Other,125% of Medicaid,110.87,405.29,
PSYTX PT&/FAM W/MD 60 MIN TELEPSYCH,90838,CPT,HE95,39190838,CDM,914,RC,,,both,,,282,208.68,,,208.68,Other,150% of Medicare + 9.63% HCRA Surcharge,126.9,45,,126.9,percent of total billed charges,Critical Access Hospital RCC factor,183.3,65,,183.3,percent of total billed charges,All Other,166.38,65,,166.38,percent of total billed charges,All Other,215.73,76.5,,215.73,percent of total billed charges,All Other,200.22,69,,200.22,percent of total billed charges,All Other,194.58,65,,194.58,percent of total billed charges,All Other,139.59,,,139.59,Other,110% of Medicare,168.08,,,168.08,Fee Schedule,Behavioral Health,233,,,233,Other,186% of Medicaid,168.08,,,168.08,Fee Schedule,Behavioral Health,168.08,,,168.08,Fee Schedule,Behavioral Health,168.08,,,168.08,Fee Schedule,Behavioral Health,168.08,,,168.08,Fee Schedule,Behavioral Health,168.08,,,168.08,Fee Schedule,Behavioral Health,225.6,80,,225.6,percent of total billed charges,All Other,197.4,70,,197.4,percent of total billed charges,All Other,121,,,121,Fee Schedule,Behavioral Health,103,,,103,Fee Schedule,Behavioral Health,106.31,,,106.31,Fee Schedule,Behavioral Health,106.31,,,106.31,Fee Schedule,Behavioral Health,106.31,,,106.31,Fee Schedule,Behavioral Health,106.31,,,106.31,Fee Schedule,Behavioral Health,125.09,,,125.09,Other,100% of Medicaid,125.09,,,125.09,Other,100% of Medicaid,125.09,,,125.09,Other,100% of Medicaid,125.09,,,125.09,Other,100% of Medicaid,281.45,,,281.45,Other,225% of Medicaid,191.39,,,191.39,Other,153% of Medicaid,281.45,,,281.45,Other,225% of Medicaid,175.13,,,175.13,Other,140% of Medicaid,281.45,,,281.45,Other,225% of Medicaid,325.23,,,325.23,Other,260% of Medicaid,405.29,,,405.29,Other,324% of Medicaid,268.94,,,268.94,Other,215% of Medicaid,268.94,,,268.94,Other,215% of Medicaid,156.36,,,156.36,Other,125% of Medicaid,103,405.29,
PSYTX CRISIS INITIAL 60 MIN-TH,90839,CPT,GT,39190839,CDM,914,RC,,,both,,,402,297.48,,,297.48,Other,150% of Medicare + 9.63% HCRA Surcharge,180.9,45,,180.9,percent of total billed charges,Critical Access Hospital RCC factor,261.3,65,,261.3,percent of total billed charges,All Other,237.18,65,,237.18,percent of total billed charges,All Other,307.53,76.5,,307.53,percent of total billed charges,All Other,285.42,69,,285.42,percent of total billed charges,All Other,277.38,65,,277.38,percent of total billed charges,All Other,198.99,,,198.99,Other,110% of Medicare,201.36,,,201.36,Fee Schedule,Behavioral Health,233,,,233,Other,186% of Medicaid,201.36,,,201.36,Fee Schedule,Behavioral Health,201.36,,,201.36,Fee Schedule,Behavioral Health,201.36,,,201.36,Fee Schedule,Behavioral Health,201.36,,,201.36,Fee Schedule,Behavioral Health,201.36,,,201.36,Fee Schedule,Behavioral Health,321.6,80,,321.6,percent of total billed charges,All Other,281.4,70,,281.4,percent of total billed charges,All Other,154,,,154,Fee Schedule,Behavioral Health,131,,,131,Fee Schedule,Behavioral Health,132.69,,,132.69,Fee Schedule,Behavioral Health,132.69,,,132.69,Fee Schedule,Behavioral Health,132.69,,,132.69,Fee Schedule,Behavioral Health,132.69,,,132.69,Fee Schedule,Behavioral Health,125.09,,,125.09,Other,100% of Medicaid,125.09,,,125.09,Other,100% of Medicaid,125.09,,,125.09,Other,100% of Medicaid,125.09,,,125.09,Other,100% of Medicaid,281.45,,,281.45,Other,225% of Medicaid,191.39,,,191.39,Other,153% of Medicaid,281.45,,,281.45,Other,225% of Medicaid,175.13,,,175.13,Other,140% of Medicaid,281.45,,,281.45,Other,225% of Medicaid,325.23,,,325.23,Other,260% of Medicaid,405.29,,,405.29,Other,324% of Medicaid,268.94,,,268.94,Other,215% of Medicaid,268.94,,,268.94,Other,215% of Medicaid,156.36,,,156.36,Other,125% of Medicaid,125.09,405.29,
PSYTX CRISIS EA ADDL 30 MIN-TH,90840,CPT,GT,39190840,CDM,914,RC,,,both,,,140,103.6,,,103.6,Other,150% of Medicare + 9.63% HCRA Surcharge,63,45,,63,percent of total billed charges,Critical Access Hospital RCC factor,91,65,,91,percent of total billed charges,All Other,82.6,65,,82.6,percent of total billed charges,All Other,107.1,76.5,,107.1,percent of total billed charges,All Other,99.4,69,,99.4,percent of total billed charges,All Other,96.6,65,,96.6,percent of total billed charges,All Other,69.3,,,69.3,Other,110% of Medicare,101.4,,,101.4,Fee Schedule,Behavioral Health,233,,,233,Other,186% of Medicaid,101.4,,,101.4,Fee Schedule,Behavioral Health,101.4,,,101.4,Fee Schedule,Behavioral Health,101.4,,,101.4,Fee Schedule,Behavioral Health,101.4,,,101.4,Fee Schedule,Behavioral Health,101.4,,,101.4,Fee Schedule,Behavioral Health,112,80,,112,percent of total billed charges,All Other,98,70,,98,percent of total billed charges,All Other,99,,,99,Fee Schedule,Behavioral Health,84,,,84,Fee Schedule,Behavioral Health,6.69,,,6.69,Fee Schedule,Behavioral Health,6.69,,,6.69,Fee Schedule,Behavioral Health,6.69,,,6.69,Fee Schedule,Behavioral Health,6.69,,,6.69,Fee Schedule,Behavioral Health,125.09,,,125.09,Other,100% of Medicaid,125.09,,,125.09,Other,100% of Medicaid,125.09,,,125.09,Other,100% of Medicaid,125.09,,,125.09,Other,100% of Medicaid,281.45,,,281.45,Other,225% of Medicaid,191.39,,,191.39,Other,153% of Medicaid,281.45,,,281.45,Other,225% of Medicaid,175.13,,,175.13,Other,140% of Medicaid,281.45,,,281.45,Other,225% of Medicaid,325.23,,,325.23,Other,260% of Medicaid,405.29,,,405.29,Other,324% of Medicaid,268.94,,,268.94,Other,215% of Medicaid,268.94,,,268.94,Other,215% of Medicaid,156.36,,,156.36,Other,125% of Medicaid,6.69,405.29,
PSYCH DIAG EVAL W/MD,90792,CPT,,40090792,CDM,914,RC,,,both,,,399,295.26,,,295.26,Other,150% of Medicare + 9.63% HCRA Surcharge,179.55,45,,179.55,percent of total billed charges,Critical Access Hospital RCC factor,259.35,65,,259.35,percent of total billed charges,All Other,235.41,65,,235.41,percent of total billed charges,All Other,190,,,190,Fee Schedule,Behavioral Health,171,,,171,Fee Schedule,Behavioral Health,162,,,162,Fee Schedule,Behavioral Health,197.51,,,197.51,Other,110% of Medicare,265.07,,,265.07,Fee Schedule,Behavioral Health,291,,,291,Other,186% of Medicaid,265.07,,,265.07,Fee Schedule,Behavioral Health,265.07,,,265.07,Fee Schedule,Behavioral Health,265.07,,,265.07,Fee Schedule,Behavioral Health,265.07,,,265.07,Fee Schedule,Behavioral Health,265.07,,,265.07,Fee Schedule,Behavioral Health,319.2,80,,319.2,percent of total billed charges,All Other,279.3,70,,279.3,percent of total billed charges,All Other,217,,,217,Fee Schedule,Behavioral Health,184,,,184,Fee Schedule,Behavioral Health,139.73,,,139.73,Fee Schedule,Behavioral Health,139.73,,,139.73,Fee Schedule,Behavioral Health,139.73,,,139.73,Fee Schedule,Behavioral Health,139.73,,,139.73,Fee Schedule,Behavioral Health,156.36,,,156.36,Other,100% of Medicaid,156.36,,,156.36,Other,100% of Medicaid,156.36,,,156.36,Other,100% of Medicaid,156.36,,,156.36,Other,100% of Medicaid,351.81,,,351.81,Other,225% of Medicaid,239.23,,,239.23,Other,153% of Medicaid,351.81,,,351.81,Other,225% of Medicaid,218.91,,,218.91,Other,140% of Medicaid,351.81,,,351.81,Other,225% of Medicaid,406.54,,,406.54,Other,260% of Medicaid,506.61,,,506.61,Other,324% of Medicaid,336.18,,,336.18,Other,215% of Medicaid,336.18,,,336.18,Other,215% of Medicaid,195.45,,,195.45,Other,125% of Medicaid,139.73,506.61,
PSYTX PT&/FAMILY 30 MINUTES,90832,CPT,,40090832,CDM,914,RC,,,both,,,329,243.46,,,243.46,Other,150% of Medicare + 9.63% HCRA Surcharge,148.05,45,,148.05,percent of total billed charges,Critical Access Hospital RCC factor,213.85,65,,213.85,percent of total billed charges,All Other,194.11,65,,194.11,percent of total billed charges,All Other,82,,,82,Fee Schedule,Behavioral Health,74,,,74,Fee Schedule,Behavioral Health,70,,,70,Fee Schedule,Behavioral Health,162.86,,,162.86,Other,110% of Medicare,106.52,,,106.52,Fee Schedule,Behavioral Health,174,,,174,Other,186% of Medicaid,106.52,,,106.52,Fee Schedule,Behavioral Health,106.52,,,106.52,Fee Schedule,Behavioral Health,106.52,,,106.52,Fee Schedule,Behavioral Health,106.52,,,106.52,Fee Schedule,Behavioral Health,106.52,,,106.52,Fee Schedule,Behavioral Health,263.2,80,,263.2,percent of total billed charges,All Other,230.3,70,,230.3,percent of total billed charges,All Other,99,,,99,Fee Schedule,Behavioral Health,84,,,84,Fee Schedule,Behavioral Health,69.32,,,69.32,Fee Schedule,Behavioral Health,69.32,,,69.32,Fee Schedule,Behavioral Health,69.32,,,69.32,Fee Schedule,Behavioral Health,69.32,,,69.32,Fee Schedule,Behavioral Health,93.82,,,93.82,Other,100% of Medicaid,93.82,,,93.82,Other,100% of Medicaid,93.82,,,93.82,Other,100% of Medicaid,93.82,,,93.82,Other,100% of Medicaid,211.09,,,211.09,Other,225% of Medicaid,143.54,,,143.54,Other,153% of Medicaid,211.09,,,211.09,Other,225% of Medicaid,131.34,,,131.34,Other,140% of Medicaid,211.09,,,211.09,Other,225% of Medicaid,243.92,,,243.92,Other,260% of Medicaid,303.97,,,303.97,Other,324% of Medicaid,201.71,,,201.71,Other,215% of Medicaid,201.71,,,201.71,Other,215% of Medicaid,117.27,,,117.27,Other,125% of Medicaid,69.32,303.97,
PSYTX PT&/FAM W/MD 30 MIN,90833,CPT,HE,40090833,CDM,914,RC,,,both,,,108,79.92,,,79.92,Other,150% of Medicare + 9.63% HCRA Surcharge,48.6,45,,48.6,percent of total billed charges,Critical Access Hospital RCC factor,70.2,65,,70.2,percent of total billed charges,All Other,63.72,65,,63.72,percent of total billed charges,All Other,82.62,76.5,,82.62,percent of total billed charges,All Other,76.68,69,,76.68,percent of total billed charges,All Other,74.52,65,,74.52,percent of total billed charges,All Other,53.46,,,53.46,Other,110% of Medicare,100.23,,,100.23,Fee Schedule,Behavioral Health,174,,,174,Other,186% of Medicaid,100.23,,,100.23,Fee Schedule,Behavioral Health,100.23,,,100.23,Fee Schedule,Behavioral Health,100.23,,,100.23,Fee Schedule,Behavioral Health,100.23,,,100.23,Fee Schedule,Behavioral Health,100.23,,,100.23,Fee Schedule,Behavioral Health,86.4,80,,86.4,percent of total billed charges,All Other,75.6,70,,75.6,percent of total billed charges,All Other,28,,,28,Fee Schedule,Behavioral Health,24,,,24,Fee Schedule,Behavioral Health,52.8,,,52.8,Fee Schedule,Behavioral Health,52.8,,,52.8,Fee Schedule,Behavioral Health,52.8,,,52.8,Fee Schedule,Behavioral Health,52.8,,,52.8,Fee Schedule,Behavioral Health,93.82,,,93.82,Other,100% of Medicaid,93.82,,,93.82,Other,100% of Medicaid,93.82,,,93.82,Other,100% of Medicaid,93.82,,,93.82,Other,100% of Medicaid,211.09,,,211.09,Other,225% of Medicaid,143.54,,,143.54,Other,153% of Medicaid,211.09,,,211.09,Other,225% of Medicaid,131.34,,,131.34,Other,140% of Medicaid,211.09,,,211.09,Other,225% of Medicaid,243.92,,,243.92,Other,260% of Medicaid,303.97,,,303.97,Other,324% of Medicaid,201.71,,,201.71,Other,215% of Medicaid,201.71,,,201.71,Other,215% of Medicaid,117.27,,,117.27,Other,125% of Medicaid,24,303.97,
PSYTX PT&/FAMILY 45 MIN,90834,CPT,,40090834,CDM,914,RC,,,both,,,399,295.26,,,295.26,Other,150% of Medicare + 9.63% HCRA Surcharge,179.55,45,,179.55,percent of total billed charges,Critical Access Hospital RCC factor,259.35,65,,259.35,percent of total billed charges,All Other,235.41,65,,235.41,percent of total billed charges,All Other,158,,,158,Fee Schedule,Behavioral Health,142,,,142,Fee Schedule,Behavioral Health,134,,,134,Fee Schedule,Behavioral Health,197.51,,,197.51,Other,110% of Medicare,140.78,,,140.78,Fee Schedule,Behavioral Health,233,,,233,Other,186% of Medicaid,140.78,,,140.78,Fee Schedule,Behavioral Health,140.78,,,140.78,Fee Schedule,Behavioral Health,140.78,,,140.78,Fee Schedule,Behavioral Health,140.78,,,140.78,Fee Schedule,Behavioral Health,140.78,,,140.78,Fee Schedule,Behavioral Health,319.2,80,,319.2,percent of total billed charges,All Other,279.3,70,,279.3,percent of total billed charges,All Other,154,,,154,Fee Schedule,Behavioral Health,131,,,131,Fee Schedule,Behavioral Health,104.53,,,104.53,Fee Schedule,Behavioral Health,104.53,,,104.53,Fee Schedule,Behavioral Health,104.53,,,104.53,Fee Schedule,Behavioral Health,104.53,,,104.53,Fee Schedule,Behavioral Health,125.09,,,125.09,Other,100% of Medicaid,125.09,,,125.09,Other,100% of Medicaid,125.09,,,125.09,Other,100% of Medicaid,125.09,,,125.09,Other,100% of Medicaid,281.45,,,281.45,Other,225% of Medicaid,191.39,,,191.39,Other,153% of Medicaid,281.45,,,281.45,Other,225% of Medicaid,175.13,,,175.13,Other,140% of Medicaid,281.45,,,281.45,Other,225% of Medicaid,325.23,,,325.23,Other,260% of Medicaid,405.29,,,405.29,Other,324% of Medicaid,268.94,,,268.94,Other,215% of Medicaid,268.94,,,268.94,Other,215% of Medicaid,156.36,,,156.36,Other,125% of Medicaid,104.53,405.29,
PSYTX PT&/FAM W/MD 45 MIN,90836,CPT,HE,40090836,CDM,914,RC,,,both,,,175,129.5,,,129.5,Other,150% of Medicare + 9.63% HCRA Surcharge,78.75,45,,78.75,percent of total billed charges,Critical Access Hospital RCC factor,113.75,65,,113.75,percent of total billed charges,All Other,103.25,65,,103.25,percent of total billed charges,All Other,133.88,76.5,,133.88,percent of total billed charges,All Other,124.25,69,,124.25,percent of total billed charges,All Other,120.75,65,,120.75,percent of total billed charges,All Other,86.63,,,86.63,Other,110% of Medicare,126.78,,,126.78,Fee Schedule,Behavioral Health,233,,,233,Other,186% of Medicaid,126.78,,,126.78,Fee Schedule,Behavioral Health,126.78,,,126.78,Fee Schedule,Behavioral Health,126.78,,,126.78,Fee Schedule,Behavioral Health,126.78,,,126.78,Fee Schedule,Behavioral Health,126.78,,,126.78,Fee Schedule,Behavioral Health,140,80,,140,percent of total billed charges,All Other,122.5,70,,122.5,percent of total billed charges,All Other,100,,,100,Fee Schedule,Behavioral Health,85,,,85,Fee Schedule,Behavioral Health,79.55,,,79.55,Fee Schedule,Behavioral Health,79.55,,,79.55,Fee Schedule,Behavioral Health,79.55,,,79.55,Fee Schedule,Behavioral Health,79.55,,,79.55,Fee Schedule,Behavioral Health,125.09,,,125.09,Other,100% of Medicaid,125.09,,,125.09,Other,100% of Medicaid,125.09,,,125.09,Other,100% of Medicaid,125.09,,,125.09,Other,100% of Medicaid,281.45,,,281.45,Other,225% of Medicaid,191.39,,,191.39,Other,153% of Medicaid,281.45,,,281.45,Other,225% of Medicaid,175.13,,,175.13,Other,140% of Medicaid,281.45,,,281.45,Other,225% of Medicaid,325.23,,,325.23,Other,260% of Medicaid,405.29,,,405.29,Other,324% of Medicaid,268.94,,,268.94,Other,215% of Medicaid,268.94,,,268.94,Other,215% of Medicaid,156.36,,,156.36,Other,125% of Medicaid,78.75,405.29,
PSYTX PT&/FAMILY 60 MIN,90837,CPT,,40090837,CDM,914,RC,,,both,,,399,295.26,,,295.26,Other,150% of Medicare + 9.63% HCRA Surcharge,179.55,45,,179.55,percent of total billed charges,Critical Access Hospital RCC factor,259.35,65,,259.35,percent of total billed charges,All Other,235.41,65,,235.41,percent of total billed charges,All Other,158,,,158,Fee Schedule,Behavioral Health,142,,,142,Fee Schedule,Behavioral Health,134,,,134,Fee Schedule,Behavioral Health,197.51,,,197.51,Other,110% of Medicare,207.78,,,207.78,Fee Schedule,Behavioral Health,233,,,233,Other,186% of Medicaid,207.78,,,207.78,Fee Schedule,Behavioral Health,207.78,,,207.78,Fee Schedule,Behavioral Health,207.78,,,207.78,Fee Schedule,Behavioral Health,207.78,,,207.78,Fee Schedule,Behavioral Health,207.78,,,207.78,Fee Schedule,Behavioral Health,319.2,80,,319.2,percent of total billed charges,All Other,279.3,70,,279.3,percent of total billed charges,All Other,154,,,154,Fee Schedule,Behavioral Health,131,,,131,Fee Schedule,Behavioral Health,110.87,,,110.87,Fee Schedule,Behavioral Health,110.87,,,110.87,Fee Schedule,Behavioral Health,110.87,,,110.87,Fee Schedule,Behavioral Health,110.87,,,110.87,Fee Schedule,Behavioral Health,125.09,,,125.09,Other,100% of Medicaid,125.09,,,125.09,Other,100% of Medicaid,125.09,,,125.09,Other,100% of Medicaid,125.09,,,125.09,Other,100% of Medicaid,281.45,,,281.45,Other,225% of Medicaid,191.39,,,191.39,Other,153% of Medicaid,281.45,,,281.45,Other,225% of Medicaid,175.13,,,175.13,Other,140% of Medicaid,281.45,,,281.45,Other,225% of Medicaid,325.23,,,325.23,Other,260% of Medicaid,405.29,,,405.29,Other,324% of Medicaid,268.94,,,268.94,Other,215% of Medicaid,268.94,,,268.94,Other,215% of Medicaid,156.36,,,156.36,Other,125% of Medicaid,110.87,405.29,
PSYTX PT&/FAM W/MD 60 MIN,90838,CPT,HE,40090838,CDM,914,RC,,,both,,,282,208.68,,,208.68,Other,150% of Medicare + 9.63% HCRA Surcharge,126.9,45,,126.9,percent of total billed charges,Critical Access Hospital RCC factor,183.3,65,,183.3,percent of total billed charges,All Other,166.38,65,,166.38,percent of total billed charges,All Other,215.73,76.5,,215.73,percent of total billed charges,All Other,200.22,69,,200.22,percent of total billed charges,All Other,194.58,65,,194.58,percent of total billed charges,All Other,139.59,,,139.59,Other,110% of Medicare,168.08,,,168.08,Fee Schedule,Behavioral Health,233,,,233,Other,186% of Medicaid,168.08,,,168.08,Fee Schedule,Behavioral Health,168.08,,,168.08,Fee Schedule,Behavioral Health,168.08,,,168.08,Fee Schedule,Behavioral Health,168.08,,,168.08,Fee Schedule,Behavioral Health,168.08,,,168.08,Fee Schedule,Behavioral Health,225.6,80,,225.6,percent of total billed charges,All Other,197.4,70,,197.4,percent of total billed charges,All Other,121,,,121,Fee Schedule,Behavioral Health,103,,,103,Fee Schedule,Behavioral Health,106.31,,,106.31,Fee Schedule,Behavioral Health,106.31,,,106.31,Fee Schedule,Behavioral Health,106.31,,,106.31,Fee Schedule,Behavioral Health,106.31,,,106.31,Fee Schedule,Behavioral Health,125.09,,,125.09,Other,100% of Medicaid,125.09,,,125.09,Other,100% of Medicaid,125.09,,,125.09,Other,100% of Medicaid,125.09,,,125.09,Other,100% of Medicaid,281.45,,,281.45,Other,225% of Medicaid,191.39,,,191.39,Other,153% of Medicaid,281.45,,,281.45,Other,225% of Medicaid,175.13,,,175.13,Other,140% of Medicaid,281.45,,,281.45,Other,225% of Medicaid,325.23,,,325.23,Other,260% of Medicaid,405.29,,,405.29,Other,324% of Medicaid,268.94,,,268.94,Other,215% of Medicaid,268.94,,,268.94,Other,215% of Medicaid,156.36,,,156.36,Other,125% of Medicaid,103,405.29,
PSYTX CRISIS INITIAL 60 MIN,90839,CPT,,40090839,CDM,914,RC,,,both,,,402,297.48,,,297.48,Other,150% of Medicare + 9.63% HCRA Surcharge,180.9,45,,180.9,percent of total billed charges,Critical Access Hospital RCC factor,261.3,65,,261.3,percent of total billed charges,All Other,237.18,65,,237.18,percent of total billed charges,All Other,307.53,76.5,,307.53,percent of total billed charges,All Other,285.42,69,,285.42,percent of total billed charges,All Other,277.38,65,,277.38,percent of total billed charges,All Other,198.99,,,198.99,Other,110% of Medicare,201.36,,,201.36,Fee Schedule,Behavioral Health,233,,,233,Other,186% of Medicaid,201.36,,,201.36,Fee Schedule,Behavioral Health,201.36,,,201.36,Fee Schedule,Behavioral Health,201.36,,,201.36,Fee Schedule,Behavioral Health,201.36,,,201.36,Fee Schedule,Behavioral Health,201.36,,,201.36,Fee Schedule,Behavioral Health,321.6,80,,321.6,percent of total billed charges,All Other,281.4,70,,281.4,percent of total billed charges,All Other,154,,,154,Fee Schedule,Behavioral Health,131,,,131,Fee Schedule,Behavioral Health,132.69,,,132.69,Fee Schedule,Behavioral Health,132.69,,,132.69,Fee Schedule,Behavioral Health,132.69,,,132.69,Fee Schedule,Behavioral Health,132.69,,,132.69,Fee Schedule,Behavioral Health,125.09,,,125.09,Other,100% of Medicaid,125.09,,,125.09,Other,100% of Medicaid,125.09,,,125.09,Other,100% of Medicaid,125.09,,,125.09,Other,100% of Medicaid,281.45,,,281.45,Other,225% of Medicaid,191.39,,,191.39,Other,153% of Medicaid,281.45,,,281.45,Other,225% of Medicaid,175.13,,,175.13,Other,140% of Medicaid,281.45,,,281.45,Other,225% of Medicaid,325.23,,,325.23,Other,260% of Medicaid,405.29,,,405.29,Other,324% of Medicaid,268.94,,,268.94,Other,215% of Medicaid,268.94,,,268.94,Other,215% of Medicaid,156.36,,,156.36,Other,125% of Medicaid,125.09,405.29,
PSYTX CRISIS EA ADDL 30 MIN,90840,CPT,,40090840,CDM,914,RC,,,both,,,140,103.6,,,103.6,Other,150% of Medicare + 9.63% HCRA Surcharge,63,45,,63,percent of total billed charges,Critical Access Hospital RCC factor,91,65,,91,percent of total billed charges,All Other,82.6,65,,82.6,percent of total billed charges,All Other,107.1,76.5,,107.1,percent of total billed charges,All Other,99.4,69,,99.4,percent of total billed charges,All Other,96.6,65,,96.6,percent of total billed charges,All Other,69.3,,,69.3,Other,110% of Medicare,101.4,,,101.4,Fee Schedule,Behavioral Health,233,,,233,Other,186% of Medicaid,101.4,,,101.4,Fee Schedule,Behavioral Health,101.4,,,101.4,Fee Schedule,Behavioral Health,101.4,,,101.4,Fee Schedule,Behavioral Health,101.4,,,101.4,Fee Schedule,Behavioral Health,101.4,,,101.4,Fee Schedule,Behavioral Health,112,80,,112,percent of total billed charges,All Other,98,70,,98,percent of total billed charges,All Other,99,,,99,Fee Schedule,Behavioral Health,84,,,84,Fee Schedule,Behavioral Health,6.69,,,6.69,Fee Schedule,Behavioral Health,6.69,,,6.69,Fee Schedule,Behavioral Health,6.69,,,6.69,Fee Schedule,Behavioral Health,6.69,,,6.69,Fee Schedule,Behavioral Health,125.09,,,125.09,Other,100% of Medicaid,125.09,,,125.09,Other,100% of Medicaid,125.09,,,125.09,Other,100% of Medicaid,125.09,,,125.09,Other,100% of Medicaid,281.45,,,281.45,Other,225% of Medicaid,191.39,,,191.39,Other,153% of Medicaid,281.45,,,281.45,Other,225% of Medicaid,175.13,,,175.13,Other,140% of Medicaid,281.45,,,281.45,Other,225% of Medicaid,325.23,,,325.23,Other,260% of Medicaid,405.29,,,405.29,Other,324% of Medicaid,268.94,,,268.94,Other,215% of Medicaid,268.94,,,268.94,Other,215% of Medicaid,156.36,,,156.36,Other,125% of Medicaid,6.69,405.29,
PSYCH DIAG EVAL W/MD TELEPSYCH,90792,CPT,95,40190792,CDM,914,RC,,,both,,,399,295.26,,,295.26,Other,150% of Medicare + 9.63% HCRA Surcharge,179.55,45,,179.55,percent of total billed charges,Critical Access Hospital RCC factor,259.35,65,,259.35,percent of total billed charges,All Other,235.41,65,,235.41,percent of total billed charges,All Other,190,,,190,Fee Schedule,Behavioral Health,171,,,171,Fee Schedule,Behavioral Health,162,,,162,Fee Schedule,Behavioral Health,197.51,,,197.51,Other,110% of Medicare,265.07,,,265.07,Fee Schedule,Behavioral Health,291,,,291,Other,186% of Medicaid,265.07,,,265.07,Fee Schedule,Behavioral Health,265.07,,,265.07,Fee Schedule,Behavioral Health,265.07,,,265.07,Fee Schedule,Behavioral Health,265.07,,,265.07,Fee Schedule,Behavioral Health,265.07,,,265.07,Fee Schedule,Behavioral Health,319.2,80,,319.2,percent of total billed charges,All Other,279.3,70,,279.3,percent of total billed charges,All Other,217,,,217,Fee Schedule,Behavioral Health,184,,,184,Fee Schedule,Behavioral Health,139.73,,,139.73,Fee Schedule,Behavioral Health,139.73,,,139.73,Fee Schedule,Behavioral Health,139.73,,,139.73,Fee Schedule,Behavioral Health,139.73,,,139.73,Fee Schedule,Behavioral Health,156.36,,,156.36,Other,100% of Medicaid,156.36,,,156.36,Other,100% of Medicaid,156.36,,,156.36,Other,100% of Medicaid,156.36,,,156.36,Other,100% of Medicaid,351.81,,,351.81,Other,225% of Medicaid,239.23,,,239.23,Other,153% of Medicaid,351.81,,,351.81,Other,225% of Medicaid,218.91,,,218.91,Other,140% of Medicaid,351.81,,,351.81,Other,225% of Medicaid,406.54,,,406.54,Other,260% of Medicaid,506.61,,,506.61,Other,324% of Medicaid,336.18,,,336.18,Other,215% of Medicaid,336.18,,,336.18,Other,215% of Medicaid,195.45,,,195.45,Other,125% of Medicaid,139.73,506.61,
PSYTX PT&/FAMILY 30 MINUTES-TH,90832,CPT,95,40190832,CDM,914,RC,,,both,,,329,243.46,,,243.46,Other,150% of Medicare + 9.63% HCRA Surcharge,148.05,45,,148.05,percent of total billed charges,Critical Access Hospital RCC factor,213.85,65,,213.85,percent of total billed charges,All Other,194.11,65,,194.11,percent of total billed charges,All Other,82,,,82,Fee Schedule,Behavioral Health,74,,,74,Fee Schedule,Behavioral Health,70,,,70,Fee Schedule,Behavioral Health,162.86,,,162.86,Other,110% of Medicare,106.52,,,106.52,Fee Schedule,Behavioral Health,174,,,174,Other,186% of Medicaid,106.52,,,106.52,Fee Schedule,Behavioral Health,106.52,,,106.52,Fee Schedule,Behavioral Health,106.52,,,106.52,Fee Schedule,Behavioral Health,106.52,,,106.52,Fee Schedule,Behavioral Health,106.52,,,106.52,Fee Schedule,Behavioral Health,263.2,80,,263.2,percent of total billed charges,All Other,230.3,70,,230.3,percent of total billed charges,All Other,99,,,99,Fee Schedule,Behavioral Health,84,,,84,Fee Schedule,Behavioral Health,69.32,,,69.32,Fee Schedule,Behavioral Health,69.32,,,69.32,Fee Schedule,Behavioral Health,69.32,,,69.32,Fee Schedule,Behavioral Health,69.32,,,69.32,Fee Schedule,Behavioral Health,93.82,,,93.82,Other,100% of Medicaid,93.82,,,93.82,Other,100% of Medicaid,93.82,,,93.82,Other,100% of Medicaid,93.82,,,93.82,Other,100% of Medicaid,211.09,,,211.09,Other,225% of Medicaid,143.54,,,143.54,Other,153% of Medicaid,211.09,,,211.09,Other,225% of Medicaid,131.34,,,131.34,Other,140% of Medicaid,211.09,,,211.09,Other,225% of Medicaid,243.92,,,243.92,Other,260% of Medicaid,303.97,,,303.97,Other,324% of Medicaid,201.71,,,201.71,Other,215% of Medicaid,201.71,,,201.71,Other,215% of Medicaid,117.27,,,117.27,Other,125% of Medicaid,69.32,303.97,
PSYTX PT&/FAM W/MD 30 MIN TELEPSYCH,90833,CPT,HE95,40190833,CDM,914,RC,,,both,,,108,79.92,,,79.92,Other,150% of Medicare + 9.63% HCRA Surcharge,48.6,45,,48.6,percent of total billed charges,Critical Access Hospital RCC factor,70.2,65,,70.2,percent of total billed charges,All Other,63.72,65,,63.72,percent of total billed charges,All Other,82.62,76.5,,82.62,percent of total billed charges,All Other,76.68,69,,76.68,percent of total billed charges,All Other,74.52,65,,74.52,percent of total billed charges,All Other,53.46,,,53.46,Other,110% of Medicare,100.23,,,100.23,Fee Schedule,Behavioral Health,174,,,174,Other,186% of Medicaid,100.23,,,100.23,Fee Schedule,Behavioral Health,100.23,,,100.23,Fee Schedule,Behavioral Health,100.23,,,100.23,Fee Schedule,Behavioral Health,100.23,,,100.23,Fee Schedule,Behavioral Health,100.23,,,100.23,Fee Schedule,Behavioral Health,86.4,80,,86.4,percent of total billed charges,All Other,75.6,70,,75.6,percent of total billed charges,All Other,28,,,28,Fee Schedule,Behavioral Health,24,,,24,Fee Schedule,Behavioral Health,52.8,,,52.8,Fee Schedule,Behavioral Health,52.8,,,52.8,Fee Schedule,Behavioral Health,52.8,,,52.8,Fee Schedule,Behavioral Health,52.8,,,52.8,Fee Schedule,Behavioral Health,93.82,,,93.82,Other,100% of Medicaid,93.82,,,93.82,Other,100% of Medicaid,93.82,,,93.82,Other,100% of Medicaid,93.82,,,93.82,Other,100% of Medicaid,211.09,,,211.09,Other,225% of Medicaid,143.54,,,143.54,Other,153% of Medicaid,211.09,,,211.09,Other,225% of Medicaid,131.34,,,131.34,Other,140% of Medicaid,211.09,,,211.09,Other,225% of Medicaid,243.92,,,243.92,Other,260% of Medicaid,303.97,,,303.97,Other,324% of Medicaid,201.71,,,201.71,Other,215% of Medicaid,201.71,,,201.71,Other,215% of Medicaid,117.27,,,117.27,Other,125% of Medicaid,24,303.97,
PSYTX PT&/FAMILY 45 MIN-TH,90834,CPT,95,40190834,CDM,914,RC,,,both,,,399,295.26,,,295.26,Other,150% of Medicare + 9.63% HCRA Surcharge,179.55,45,,179.55,percent of total billed charges,Critical Access Hospital RCC factor,259.35,65,,259.35,percent of total billed charges,All Other,235.41,65,,235.41,percent of total billed charges,All Other,158,,,158,Fee Schedule,Behavioral Health,142,,,142,Fee Schedule,Behavioral Health,134,,,134,Fee Schedule,Behavioral Health,197.51,,,197.51,Other,110% of Medicare,140.78,,,140.78,Fee Schedule,Behavioral Health,233,,,233,Other,186% of Medicaid,140.78,,,140.78,Fee Schedule,Behavioral Health,140.78,,,140.78,Fee Schedule,Behavioral Health,140.78,,,140.78,Fee Schedule,Behavioral Health,140.78,,,140.78,Fee Schedule,Behavioral Health,140.78,,,140.78,Fee Schedule,Behavioral Health,319.2,80,,319.2,percent of total billed charges,All Other,279.3,70,,279.3,percent of total billed charges,All Other,154,,,154,Fee Schedule,Behavioral Health,131,,,131,Fee Schedule,Behavioral Health,104.53,,,104.53,Fee Schedule,Behavioral Health,104.53,,,104.53,Fee Schedule,Behavioral Health,104.53,,,104.53,Fee Schedule,Behavioral Health,104.53,,,104.53,Fee Schedule,Behavioral Health,125.09,,,125.09,Other,100% of Medicaid,125.09,,,125.09,Other,100% of Medicaid,125.09,,,125.09,Other,100% of Medicaid,125.09,,,125.09,Other,100% of Medicaid,281.45,,,281.45,Other,225% of Medicaid,191.39,,,191.39,Other,153% of Medicaid,281.45,,,281.45,Other,225% of Medicaid,175.13,,,175.13,Other,140% of Medicaid,281.45,,,281.45,Other,225% of Medicaid,325.23,,,325.23,Other,260% of Medicaid,405.29,,,405.29,Other,324% of Medicaid,268.94,,,268.94,Other,215% of Medicaid,268.94,,,268.94,Other,215% of Medicaid,156.36,,,156.36,Other,125% of Medicaid,104.53,405.29,
PSYTX PT&/FAM W/MD 45 MIN TELEPSYCH,90836,CPT,HE95,40190836,CDM,914,RC,,,both,,,175,129.5,,,129.5,Other,150% of Medicare + 9.63% HCRA Surcharge,78.75,45,,78.75,percent of total billed charges,Critical Access Hospital RCC factor,113.75,65,,113.75,percent of total billed charges,All Other,103.25,65,,103.25,percent of total billed charges,All Other,133.88,76.5,,133.88,percent of total billed charges,All Other,124.25,69,,124.25,percent of total billed charges,All Other,120.75,65,,120.75,percent of total billed charges,All Other,86.63,,,86.63,Other,110% of Medicare,126.78,,,126.78,Fee Schedule,Behavioral Health,233,,,233,Other,186% of Medicaid,126.78,,,126.78,Fee Schedule,Behavioral Health,126.78,,,126.78,Fee Schedule,Behavioral Health,126.78,,,126.78,Fee Schedule,Behavioral Health,126.78,,,126.78,Fee Schedule,Behavioral Health,126.78,,,126.78,Fee Schedule,Behavioral Health,140,80,,140,percent of total billed charges,All Other,122.5,70,,122.5,percent of total billed charges,All Other,100,,,100,Fee Schedule,Behavioral Health,85,,,85,Fee Schedule,Behavioral Health,79.55,,,79.55,Fee Schedule,Behavioral Health,79.55,,,79.55,Fee Schedule,Behavioral Health,79.55,,,79.55,Fee Schedule,Behavioral Health,79.55,,,79.55,Fee Schedule,Behavioral Health,125.09,,,125.09,Other,100% of Medicaid,125.09,,,125.09,Other,100% of Medicaid,125.09,,,125.09,Other,100% of Medicaid,125.09,,,125.09,Other,100% of Medicaid,281.45,,,281.45,Other,225% of Medicaid,191.39,,,191.39,Other,153% of Medicaid,281.45,,,281.45,Other,225% of Medicaid,175.13,,,175.13,Other,140% of Medicaid,281.45,,,281.45,Other,225% of Medicaid,325.23,,,325.23,Other,260% of Medicaid,405.29,,,405.29,Other,324% of Medicaid,268.94,,,268.94,Other,215% of Medicaid,268.94,,,268.94,Other,215% of Medicaid,156.36,,,156.36,Other,125% of Medicaid,78.75,405.29,
PSYTX PT&/FAMILY 60 MIN-TH,90837,CPT,95,40190837,CDM,914,RC,,,both,,,399,295.26,,,295.26,Other,150% of Medicare + 9.63% HCRA Surcharge,179.55,45,,179.55,percent of total billed charges,Critical Access Hospital RCC factor,259.35,65,,259.35,percent of total billed charges,All Other,235.41,65,,235.41,percent of total billed charges,All Other,158,,,158,Fee Schedule,Behavioral Health,142,,,142,Fee Schedule,Behavioral Health,134,,,134,Fee Schedule,Behavioral Health,197.51,,,197.51,Other,110% of Medicare,207.78,,,207.78,Fee Schedule,Behavioral Health,233,,,233,Other,186% of Medicaid,207.78,,,207.78,Fee Schedule,Behavioral Health,207.78,,,207.78,Fee Schedule,Behavioral Health,207.78,,,207.78,Fee Schedule,Behavioral Health,207.78,,,207.78,Fee Schedule,Behavioral Health,207.78,,,207.78,Fee Schedule,Behavioral Health,319.2,80,,319.2,percent of total billed charges,All Other,279.3,70,,279.3,percent of total billed charges,All Other,154,,,154,Fee Schedule,Behavioral Health,131,,,131,Fee Schedule,Behavioral Health,110.87,,,110.87,Fee Schedule,Behavioral Health,110.87,,,110.87,Fee Schedule,Behavioral Health,110.87,,,110.87,Fee Schedule,Behavioral Health,110.87,,,110.87,Fee Schedule,Behavioral Health,125.09,,,125.09,Other,100% of Medicaid,125.09,,,125.09,Other,100% of Medicaid,125.09,,,125.09,Other,100% of Medicaid,125.09,,,125.09,Other,100% of Medicaid,281.45,,,281.45,Other,225% of Medicaid,191.39,,,191.39,Other,153% of Medicaid,281.45,,,281.45,Other,225% of Medicaid,175.13,,,175.13,Other,140% of Medicaid,281.45,,,281.45,Other,225% of Medicaid,325.23,,,325.23,Other,260% of Medicaid,405.29,,,405.29,Other,324% of Medicaid,268.94,,,268.94,Other,215% of Medicaid,268.94,,,268.94,Other,215% of Medicaid,156.36,,,156.36,Other,125% of Medicaid,110.87,405.29,
PSYTX PT&/FAM W/MD 60 MIN TELEPSYCH,90838,CPT,HE95,40190838,CDM,914,RC,,,both,,,282,208.68,,,208.68,Other,150% of Medicare + 9.63% HCRA Surcharge,126.9,45,,126.9,percent of total billed charges,Critical Access Hospital RCC factor,183.3,65,,183.3,percent of total billed charges,All Other,166.38,65,,166.38,percent of total billed charges,All Other,215.73,76.5,,215.73,percent of total billed charges,All Other,200.22,69,,200.22,percent of total billed charges,All Other,194.58,65,,194.58,percent of total billed charges,All Other,139.59,,,139.59,Other,110% of Medicare,168.08,,,168.08,Fee Schedule,Behavioral Health,233,,,233,Other,186% of Medicaid,168.08,,,168.08,Fee Schedule,Behavioral Health,168.08,,,168.08,Fee Schedule,Behavioral Health,168.08,,,168.08,Fee Schedule,Behavioral Health,168.08,,,168.08,Fee Schedule,Behavioral Health,168.08,,,168.08,Fee Schedule,Behavioral Health,225.6,80,,225.6,percent of total billed charges,All Other,197.4,70,,197.4,percent of total billed charges,All Other,121,,,121,Fee Schedule,Behavioral Health,103,,,103,Fee Schedule,Behavioral Health,106.31,,,106.31,Fee Schedule,Behavioral Health,106.31,,,106.31,Fee Schedule,Behavioral Health,106.31,,,106.31,Fee Schedule,Behavioral Health,106.31,,,106.31,Fee Schedule,Behavioral Health,125.09,,,125.09,Other,100% of Medicaid,125.09,,,125.09,Other,100% of Medicaid,125.09,,,125.09,Other,100% of Medicaid,125.09,,,125.09,Other,100% of Medicaid,281.45,,,281.45,Other,225% of Medicaid,191.39,,,191.39,Other,153% of Medicaid,281.45,,,281.45,Other,225% of Medicaid,175.13,,,175.13,Other,140% of Medicaid,281.45,,,281.45,Other,225% of Medicaid,325.23,,,325.23,Other,260% of Medicaid,405.29,,,405.29,Other,324% of Medicaid,268.94,,,268.94,Other,215% of Medicaid,268.94,,,268.94,Other,215% of Medicaid,156.36,,,156.36,Other,125% of Medicaid,103,405.29,
PSYTX CRISIS INITIAL 60 MIN-TH,90839,CPT,GT,40190839,CDM,914,RC,,,both,,,402,297.48,,,297.48,Other,150% of Medicare + 9.63% HCRA Surcharge,180.9,45,,180.9,percent of total billed charges,Critical Access Hospital RCC factor,261.3,65,,261.3,percent of total billed charges,All Other,237.18,65,,237.18,percent of total billed charges,All Other,307.53,76.5,,307.53,percent of total billed charges,All Other,285.42,69,,285.42,percent of total billed charges,All Other,277.38,65,,277.38,percent of total billed charges,All Other,198.99,,,198.99,Other,110% of Medicare,201.36,,,201.36,Fee Schedule,Behavioral Health,233,,,233,Other,186% of Medicaid,201.36,,,201.36,Fee Schedule,Behavioral Health,201.36,,,201.36,Fee Schedule,Behavioral Health,201.36,,,201.36,Fee Schedule,Behavioral Health,201.36,,,201.36,Fee Schedule,Behavioral Health,201.36,,,201.36,Fee Schedule,Behavioral Health,321.6,80,,321.6,percent of total billed charges,All Other,281.4,70,,281.4,percent of total billed charges,All Other,154,,,154,Fee Schedule,Behavioral Health,131,,,131,Fee Schedule,Behavioral Health,132.69,,,132.69,Fee Schedule,Behavioral Health,132.69,,,132.69,Fee Schedule,Behavioral Health,132.69,,,132.69,Fee Schedule,Behavioral Health,132.69,,,132.69,Fee Schedule,Behavioral Health,125.09,,,125.09,Other,100% of Medicaid,125.09,,,125.09,Other,100% of Medicaid,125.09,,,125.09,Other,100% of Medicaid,125.09,,,125.09,Other,100% of Medicaid,281.45,,,281.45,Other,225% of Medicaid,191.39,,,191.39,Other,153% of Medicaid,281.45,,,281.45,Other,225% of Medicaid,175.13,,,175.13,Other,140% of Medicaid,281.45,,,281.45,Other,225% of Medicaid,325.23,,,325.23,Other,260% of Medicaid,405.29,,,405.29,Other,324% of Medicaid,268.94,,,268.94,Other,215% of Medicaid,268.94,,,268.94,Other,215% of Medicaid,156.36,,,156.36,Other,125% of Medicaid,125.09,405.29,
PSYTX CRISIS EA ADDL 30 MIN-TH,90840,CPT,95,40190840,CDM,914,RC,,,both,,,140,103.6,,,103.6,Other,150% of Medicare + 9.63% HCRA Surcharge,63,45,,63,percent of total billed charges,Critical Access Hospital RCC factor,91,65,,91,percent of total billed charges,All Other,82.6,65,,82.6,percent of total billed charges,All Other,107.1,76.5,,107.1,percent of total billed charges,All Other,99.4,69,,99.4,percent of total billed charges,All Other,96.6,65,,96.6,percent of total billed charges,All Other,69.3,,,69.3,Other,110% of Medicare,101.4,,,101.4,Fee Schedule,Behavioral Health,233,,,233,Other,186% of Medicaid,101.4,,,101.4,Fee Schedule,Behavioral Health,101.4,,,101.4,Fee Schedule,Behavioral Health,101.4,,,101.4,Fee Schedule,Behavioral Health,101.4,,,101.4,Fee Schedule,Behavioral Health,101.4,,,101.4,Fee Schedule,Behavioral Health,112,80,,112,percent of total billed charges,All Other,98,70,,98,percent of total billed charges,All Other,99,,,99,Fee Schedule,Behavioral Health,84,,,84,Fee Schedule,Behavioral Health,6.69,,,6.69,Fee Schedule,Behavioral Health,6.69,,,6.69,Fee Schedule,Behavioral Health,6.69,,,6.69,Fee Schedule,Behavioral Health,6.69,,,6.69,Fee Schedule,Behavioral Health,125.09,,,125.09,Other,100% of Medicaid,125.09,,,125.09,Other,100% of Medicaid,125.09,,,125.09,Other,100% of Medicaid,125.09,,,125.09,Other,100% of Medicaid,281.45,,,281.45,Other,225% of Medicaid,191.39,,,191.39,Other,153% of Medicaid,281.45,,,281.45,Other,225% of Medicaid,175.13,,,175.13,Other,140% of Medicaid,281.45,,,281.45,Other,225% of Medicaid,325.23,,,325.23,Other,260% of Medicaid,405.29,,,405.29,Other,324% of Medicaid,268.94,,,268.94,Other,215% of Medicaid,268.94,,,268.94,Other,215% of Medicaid,156.36,,,156.36,Other,125% of Medicaid,6.69,405.29,
MULTI-FAMILY GROUP THERAPY,90849,CPT,,36090849,CDM,915,RC,,,both,,,329,243.46,,,243.46,Other,150% of Medicare + 9.63% HCRA Surcharge,148.05,45,,148.05,percent of total billed charges,Critical Access Hospital RCC factor,213.85,65,,213.85,percent of total billed charges,All Other,194.11,65,,194.11,percent of total billed charges,All Other,133,,,133,Fee Schedule,Behavioral Health,120,,,120,Fee Schedule,Behavioral Health,113,,,113,Fee Schedule,Behavioral Health,162.86,,,162.86,Other,110% of Medicare,46.14,,,46.14,Fee Schedule,Behavioral Health,90,,,90,Other,186% of Medicaid,46.14,,,46.14,Fee Schedule,Behavioral Health,46.14,,,46.14,Fee Schedule,Behavioral Health,46.14,,,46.14,Fee Schedule,Behavioral Health,46.14,,,46.14,Fee Schedule,Behavioral Health,46.14,,,46.14,Fee Schedule,Behavioral Health,263.2,80,,263.2,percent of total billed charges,All Other,230.3,70,,230.3,percent of total billed charges,All Other,39.99,,,39.99,Other,130% of Medicare,39.99,,,39.99,Other,130% of Medicare,62.67,,,62.67,Fee Schedule,Behavioral Health,62.67,,,62.67,Fee Schedule,Behavioral Health,62.67,,,62.67,Fee Schedule,Behavioral Health,62.67,,,62.67,Fee Schedule,Behavioral Health,48.47,,,48.47,Other,100% of Medicaid,48.47,,,48.47,Other,100% of Medicaid,48.47,,,48.47,Other,100% of Medicaid,48.47,,,48.47,Other,100% of Medicaid,109.06,,,109.06,Other,225% of Medicaid,74.16,,,74.16,Other,153% of Medicaid,109.06,,,109.06,Other,225% of Medicaid,67.86,,,67.86,Other,140% of Medicaid,109.06,,,109.06,Other,225% of Medicaid,126.03,,,126.03,Other,260% of Medicaid,157.05,,,157.05,Other,324% of Medicaid,104.22,,,104.22,Other,215% of Medicaid,104.22,,,104.22,Other,215% of Medicaid,60.59,,,60.59,Other,125% of Medicaid,39.99,263.2,
GROUP THERAPY NOT MULTI-FAMILY,90853,CPT,,36090853,CDM,915,RC,,,both,,,210,155.4,,,155.4,Other,150% of Medicare + 9.63% HCRA Surcharge,94.5,45,,94.5,percent of total billed charges,Critical Access Hospital RCC factor,136.5,65,,136.5,percent of total billed charges,All Other,123.9,65,,123.9,percent of total billed charges,All Other,133,,,133,Fee Schedule,Behavioral Health,120,,,120,Fee Schedule,Behavioral Health,113,,,113,Fee Schedule,Behavioral Health,103.95,,,103.95,Other,110% of Medicare,37.44,,,37.44,Fee Schedule,Behavioral Health,90,,,90,Other,186% of Medicaid,37.44,,,37.44,Fee Schedule,Behavioral Health,37.44,,,37.44,Fee Schedule,Behavioral Health,37.44,,,37.44,Fee Schedule,Behavioral Health,37.44,,,37.44,Fee Schedule,Behavioral Health,37.44,,,37.44,Fee Schedule,Behavioral Health,168,80,,168,percent of total billed charges,All Other,147,70,,147,percent of total billed charges,All Other,103,,,103,Fee Schedule,Behavioral Health,88,,,88,Fee Schedule,Behavioral Health,63.36,,,63.36,Fee Schedule,Behavioral Health,63.36,,,63.36,Fee Schedule,Behavioral Health,63.36,,,63.36,Fee Schedule,Behavioral Health,63.36,,,63.36,Fee Schedule,Behavioral Health,48.47,,,48.47,Other,100% of Medicaid,48.47,,,48.47,Other,100% of Medicaid,48.47,,,48.47,Other,100% of Medicaid,48.47,,,48.47,Other,100% of Medicaid,109.06,,,109.06,Other,225% of Medicaid,74.16,,,74.16,Other,153% of Medicaid,109.06,,,109.06,Other,225% of Medicaid,67.86,,,67.86,Other,140% of Medicaid,109.06,,,109.06,Other,225% of Medicaid,126.03,,,126.03,Other,260% of Medicaid,157.05,,,157.05,Other,324% of Medicaid,104.22,,,104.22,Other,215% of Medicaid,104.22,,,104.22,Other,215% of Medicaid,60.59,,,60.59,Other,125% of Medicaid,37.44,168,
IOP GROUP THERAPY NOT MULTI-FAMILY,90853,CPT,,36190853,CDM,915,RC,,,both,,,210,155.4,,,155.4,Other,150% of Medicare + 9.63% HCRA Surcharge,94.5,45,,94.5,percent of total billed charges,Critical Access Hospital RCC factor,136.5,65,,136.5,percent of total billed charges,All Other,123.9,65,,123.9,percent of total billed charges,All Other,133,,,133,Fee Schedule,Behavioral Health,120,,,120,Fee Schedule,Behavioral Health,113,,,113,Fee Schedule,Behavioral Health,103.95,,,103.95,Other,110% of Medicare,37.44,,,37.44,Fee Schedule,Behavioral Health,90,,,90,Other,186% of Medicaid,37.44,,,37.44,Fee Schedule,Behavioral Health,37.44,,,37.44,Fee Schedule,Behavioral Health,37.44,,,37.44,Fee Schedule,Behavioral Health,37.44,,,37.44,Fee Schedule,Behavioral Health,37.44,,,37.44,Fee Schedule,Behavioral Health,168,80,,168,percent of total billed charges,All Other,147,70,,147,percent of total billed charges,All Other,103,,,103,Fee Schedule,Behavioral Health,88,,,88,Fee Schedule,Behavioral Health,63.36,,,63.36,Fee Schedule,Behavioral Health,63.36,,,63.36,Fee Schedule,Behavioral Health,63.36,,,63.36,Fee Schedule,Behavioral Health,63.36,,,63.36,Fee Schedule,Behavioral Health,48.47,,,48.47,Other,100% of Medicaid,48.47,,,48.47,Other,100% of Medicaid,48.47,,,48.47,Other,100% of Medicaid,48.47,,,48.47,Other,100% of Medicaid,109.06,,,109.06,Other,225% of Medicaid,74.16,,,74.16,Other,153% of Medicaid,109.06,,,109.06,Other,225% of Medicaid,67.86,,,67.86,Other,140% of Medicaid,109.06,,,109.06,Other,225% of Medicaid,126.03,,,126.03,Other,260% of Medicaid,157.05,,,157.05,Other,324% of Medicaid,104.22,,,104.22,Other,215% of Medicaid,104.22,,,104.22,Other,215% of Medicaid,60.59,,,60.59,Other,125% of Medicaid,37.44,168,
ADR GROUP THERAPY NOT MF 120-240,90853,CPT,,36290853,CDM,915,RC,,,both,,,210,155.4,,,155.4,Other,150% of Medicare + 9.63% HCRA Surcharge,94.5,45,,94.5,percent of total billed charges,Critical Access Hospital RCC factor,136.5,65,,136.5,percent of total billed charges,All Other,123.9,65,,123.9,percent of total billed charges,All Other,133,,,133,Fee Schedule,Behavioral Health,120,,,120,Fee Schedule,Behavioral Health,113,,,113,Fee Schedule,Behavioral Health,103.95,,,103.95,Other,110% of Medicare,37.44,,,37.44,Fee Schedule,Behavioral Health,90,,,90,Other,186% of Medicaid,37.44,,,37.44,Fee Schedule,Behavioral Health,37.44,,,37.44,Fee Schedule,Behavioral Health,37.44,,,37.44,Fee Schedule,Behavioral Health,37.44,,,37.44,Fee Schedule,Behavioral Health,37.44,,,37.44,Fee Schedule,Behavioral Health,168,80,,168,percent of total billed charges,All Other,147,70,,147,percent of total billed charges,All Other,103,,,103,Fee Schedule,Behavioral Health,88,,,88,Fee Schedule,Behavioral Health,63.36,,,63.36,Fee Schedule,Behavioral Health,63.36,,,63.36,Fee Schedule,Behavioral Health,63.36,,,63.36,Fee Schedule,Behavioral Health,63.36,,,63.36,Fee Schedule,Behavioral Health,48.47,,,48.47,Other,100% of Medicaid,48.47,,,48.47,Other,100% of Medicaid,48.47,,,48.47,Other,100% of Medicaid,48.47,,,48.47,Other,100% of Medicaid,109.06,,,109.06,Other,225% of Medicaid,74.16,,,74.16,Other,153% of Medicaid,109.06,,,109.06,Other,225% of Medicaid,67.86,,,67.86,Other,140% of Medicaid,109.06,,,109.06,Other,225% of Medicaid,126.03,,,126.03,Other,260% of Medicaid,157.05,,,157.05,Other,324% of Medicaid,104.22,,,104.22,Other,215% of Medicaid,104.22,,,104.22,Other,215% of Medicaid,60.59,,,60.59,Other,125% of Medicaid,37.44,168,
ATP GROUP THERAPY NOT MF,90853,CPT,,36390853,CDM,915,RC,,,both,,,210,155.4,,,155.4,Other,150% of Medicare + 9.63% HCRA Surcharge,94.5,45,,94.5,percent of total billed charges,Critical Access Hospital RCC factor,136.5,65,,136.5,percent of total billed charges,All Other,123.9,65,,123.9,percent of total billed charges,All Other,133,,,133,Fee Schedule,Behavioral Health,120,,,120,Fee Schedule,Behavioral Health,113,,,113,Fee Schedule,Behavioral Health,103.95,,,103.95,Other,110% of Medicare,37.44,,,37.44,Fee Schedule,Behavioral Health,90,,,90,Other,186% of Medicaid,37.44,,,37.44,Fee Schedule,Behavioral Health,37.44,,,37.44,Fee Schedule,Behavioral Health,37.44,,,37.44,Fee Schedule,Behavioral Health,37.44,,,37.44,Fee Schedule,Behavioral Health,37.44,,,37.44,Fee Schedule,Behavioral Health,168,80,,168,percent of total billed charges,All Other,147,70,,147,percent of total billed charges,All Other,103,,,103,Fee Schedule,Behavioral Health,88,,,88,Fee Schedule,Behavioral Health,63.36,,,63.36,Fee Schedule,Behavioral Health,63.36,,,63.36,Fee Schedule,Behavioral Health,63.36,,,63.36,Fee Schedule,Behavioral Health,63.36,,,63.36,Fee Schedule,Behavioral Health,48.47,,,48.47,Other,100% of Medicaid,48.47,,,48.47,Other,100% of Medicaid,48.47,,,48.47,Other,100% of Medicaid,48.47,,,48.47,Other,100% of Medicaid,109.06,,,109.06,Other,225% of Medicaid,74.16,,,74.16,Other,153% of Medicaid,109.06,,,109.06,Other,225% of Medicaid,67.86,,,67.86,Other,140% of Medicaid,109.06,,,109.06,Other,225% of Medicaid,126.03,,,126.03,Other,260% of Medicaid,157.05,,,157.05,Other,324% of Medicaid,104.22,,,104.22,Other,215% of Medicaid,104.22,,,104.22,Other,215% of Medicaid,60.59,,,60.59,Other,125% of Medicaid,37.44,168,
TH -GROUP THERAPY NOT MULTI-FAMILY,90853,CPT,95,36490853,CDM,915,RC,,,both,,,210,155.4,,,155.4,Other,150% of Medicare + 9.63% HCRA Surcharge,94.5,45,,94.5,percent of total billed charges,Critical Access Hospital RCC factor,136.5,65,,136.5,percent of total billed charges,All Other,123.9,65,,123.9,percent of total billed charges,All Other,133,,,133,Fee Schedule,Behavioral Health,120,,,120,Fee Schedule,Behavioral Health,113,,,113,Fee Schedule,Behavioral Health,103.95,,,103.95,Other,110% of Medicare,37.44,,,37.44,Fee Schedule,Behavioral Health,90,,,90,Other,186% of Medicaid,37.44,,,37.44,Fee Schedule,Behavioral Health,37.44,,,37.44,Fee Schedule,Behavioral Health,37.44,,,37.44,Fee Schedule,Behavioral Health,37.44,,,37.44,Fee Schedule,Behavioral Health,37.44,,,37.44,Fee Schedule,Behavioral Health,168,80,,168,percent of total billed charges,All Other,147,70,,147,percent of total billed charges,All Other,103,,,103,Fee Schedule,Behavioral Health,88,,,88,Fee Schedule,Behavioral Health,63.36,,,63.36,Fee Schedule,Behavioral Health,63.36,,,63.36,Fee Schedule,Behavioral Health,63.36,,,63.36,Fee Schedule,Behavioral Health,63.36,,,63.36,Fee Schedule,Behavioral Health,48.47,,,48.47,Other,100% of Medicaid,48.47,,,48.47,Other,100% of Medicaid,48.47,,,48.47,Other,100% of Medicaid,48.47,,,48.47,Other,100% of Medicaid,109.06,,,109.06,Other,225% of Medicaid,74.16,,,74.16,Other,153% of Medicaid,109.06,,,109.06,Other,225% of Medicaid,67.86,,,67.86,Other,140% of Medicaid,109.06,,,109.06,Other,225% of Medicaid,126.03,,,126.03,Other,260% of Medicaid,157.05,,,157.05,Other,324% of Medicaid,104.22,,,104.22,Other,215% of Medicaid,104.22,,,104.22,Other,215% of Medicaid,60.59,,,60.59,Other,125% of Medicaid,37.44,168,
TH-IOP GROUP THERAPY NOT MULTI-FAMILY,90853,CPT,95,36590853,CDM,915,RC,,,both,,,210,155.4,,,155.4,Other,150% of Medicare + 9.63% HCRA Surcharge,94.5,45,,94.5,percent of total billed charges,Critical Access Hospital RCC factor,136.5,65,,136.5,percent of total billed charges,All Other,123.9,65,,123.9,percent of total billed charges,All Other,133,,,133,Fee Schedule,Behavioral Health,120,,,120,Fee Schedule,Behavioral Health,113,,,113,Fee Schedule,Behavioral Health,103.95,,,103.95,Other,110% of Medicare,37.44,,,37.44,Fee Schedule,Behavioral Health,90,,,90,Other,186% of Medicaid,37.44,,,37.44,Fee Schedule,Behavioral Health,37.44,,,37.44,Fee Schedule,Behavioral Health,37.44,,,37.44,Fee Schedule,Behavioral Health,37.44,,,37.44,Fee Schedule,Behavioral Health,37.44,,,37.44,Fee Schedule,Behavioral Health,168,80,,168,percent of total billed charges,All Other,147,70,,147,percent of total billed charges,All Other,103,,,103,Fee Schedule,Behavioral Health,88,,,88,Fee Schedule,Behavioral Health,63.36,,,63.36,Fee Schedule,Behavioral Health,63.36,,,63.36,Fee Schedule,Behavioral Health,63.36,,,63.36,Fee Schedule,Behavioral Health,63.36,,,63.36,Fee Schedule,Behavioral Health,48.47,,,48.47,Other,100% of Medicaid,48.47,,,48.47,Other,100% of Medicaid,48.47,,,48.47,Other,100% of Medicaid,48.47,,,48.47,Other,100% of Medicaid,109.06,,,109.06,Other,225% of Medicaid,74.16,,,74.16,Other,153% of Medicaid,109.06,,,109.06,Other,225% of Medicaid,67.86,,,67.86,Other,140% of Medicaid,109.06,,,109.06,Other,225% of Medicaid,126.03,,,126.03,Other,260% of Medicaid,157.05,,,157.05,Other,324% of Medicaid,104.22,,,104.22,Other,215% of Medicaid,104.22,,,104.22,Other,215% of Medicaid,60.59,,,60.59,Other,125% of Medicaid,37.44,168,
TH-ADR GROUP THERAPY NOT MF 120-240,90853,CPT,95,36690853,CDM,915,RC,,,both,,,210,155.4,,,155.4,Other,150% of Medicare + 9.63% HCRA Surcharge,94.5,45,,94.5,percent of total billed charges,Critical Access Hospital RCC factor,136.5,65,,136.5,percent of total billed charges,All Other,123.9,65,,123.9,percent of total billed charges,All Other,133,,,133,Fee Schedule,Behavioral Health,120,,,120,Fee Schedule,Behavioral Health,113,,,113,Fee Schedule,Behavioral Health,103.95,,,103.95,Other,110% of Medicare,37.44,,,37.44,Fee Schedule,Behavioral Health,90,,,90,Other,186% of Medicaid,37.44,,,37.44,Fee Schedule,Behavioral Health,37.44,,,37.44,Fee Schedule,Behavioral Health,37.44,,,37.44,Fee Schedule,Behavioral Health,37.44,,,37.44,Fee Schedule,Behavioral Health,37.44,,,37.44,Fee Schedule,Behavioral Health,168,80,,168,percent of total billed charges,All Other,147,70,,147,percent of total billed charges,All Other,103,,,103,Fee Schedule,Behavioral Health,88,,,88,Fee Schedule,Behavioral Health,63.36,,,63.36,Fee Schedule,Behavioral Health,63.36,,,63.36,Fee Schedule,Behavioral Health,63.36,,,63.36,Fee Schedule,Behavioral Health,63.36,,,63.36,Fee Schedule,Behavioral Health,48.47,,,48.47,Other,100% of Medicaid,48.47,,,48.47,Other,100% of Medicaid,48.47,,,48.47,Other,100% of Medicaid,48.47,,,48.47,Other,100% of Medicaid,109.06,,,109.06,Other,225% of Medicaid,74.16,,,74.16,Other,153% of Medicaid,109.06,,,109.06,Other,225% of Medicaid,67.86,,,67.86,Other,140% of Medicaid,109.06,,,109.06,Other,225% of Medicaid,126.03,,,126.03,Other,260% of Medicaid,157.05,,,157.05,Other,324% of Medicaid,104.22,,,104.22,Other,215% of Medicaid,104.22,,,104.22,Other,215% of Medicaid,60.59,,,60.59,Other,125% of Medicaid,37.44,168,
TH- ATP GROUP THERAPY NOT MF,90853,CPT,95,36790853,CDM,915,RC,,,both,,,210,155.4,,,155.4,Other,150% of Medicare + 9.63% HCRA Surcharge,94.5,45,,94.5,percent of total billed charges,Critical Access Hospital RCC factor,136.5,65,,136.5,percent of total billed charges,All Other,123.9,65,,123.9,percent of total billed charges,All Other,133,,,133,Fee Schedule,Behavioral Health,120,,,120,Fee Schedule,Behavioral Health,113,,,113,Fee Schedule,Behavioral Health,103.95,,,103.95,Other,110% of Medicare,37.44,,,37.44,Fee Schedule,Behavioral Health,90,,,90,Other,186% of Medicaid,37.44,,,37.44,Fee Schedule,Behavioral Health,37.44,,,37.44,Fee Schedule,Behavioral Health,37.44,,,37.44,Fee Schedule,Behavioral Health,37.44,,,37.44,Fee Schedule,Behavioral Health,37.44,,,37.44,Fee Schedule,Behavioral Health,168,80,,168,percent of total billed charges,All Other,147,70,,147,percent of total billed charges,All Other,103,,,103,Fee Schedule,Behavioral Health,88,,,88,Fee Schedule,Behavioral Health,63.36,,,63.36,Fee Schedule,Behavioral Health,63.36,,,63.36,Fee Schedule,Behavioral Health,63.36,,,63.36,Fee Schedule,Behavioral Health,63.36,,,63.36,Fee Schedule,Behavioral Health,48.47,,,48.47,Other,100% of Medicaid,48.47,,,48.47,Other,100% of Medicaid,48.47,,,48.47,Other,100% of Medicaid,48.47,,,48.47,Other,100% of Medicaid,109.06,,,109.06,Other,225% of Medicaid,74.16,,,74.16,Other,153% of Medicaid,109.06,,,109.06,Other,225% of Medicaid,67.86,,,67.86,Other,140% of Medicaid,109.06,,,109.06,Other,225% of Medicaid,126.03,,,126.03,Other,260% of Medicaid,157.05,,,157.05,Other,324% of Medicaid,104.22,,,104.22,Other,215% of Medicaid,104.22,,,104.22,Other,215% of Medicaid,60.59,,,60.59,Other,125% of Medicaid,37.44,168,
MULTI-FAMILY GROUP THERAPY,90849,CPT,,37090849,CDM,915,RC,,,both,,,329,243.46,,,243.46,Other,150% of Medicare + 9.63% HCRA Surcharge,148.05,45,,148.05,percent of total billed charges,Critical Access Hospital RCC factor,213.85,65,,213.85,percent of total billed charges,All Other,194.11,65,,194.11,percent of total billed charges,All Other,133,,,133,Fee Schedule,Behavioral Health,120,,,120,Fee Schedule,Behavioral Health,113,,,113,Fee Schedule,Behavioral Health,162.86,,,162.86,Other,110% of Medicare,46.14,,,46.14,Fee Schedule,Behavioral Health,90,,,90,Other,186% of Medicaid,46.14,,,46.14,Fee Schedule,Behavioral Health,46.14,,,46.14,Fee Schedule,Behavioral Health,46.14,,,46.14,Fee Schedule,Behavioral Health,46.14,,,46.14,Fee Schedule,Behavioral Health,46.14,,,46.14,Fee Schedule,Behavioral Health,263.2,80,,263.2,percent of total billed charges,All Other,230.3,70,,230.3,percent of total billed charges,All Other,39.99,,,39.99,Other,130% of Medicare,39.99,,,39.99,Other,130% of Medicare,62.67,,,62.67,Fee Schedule,Behavioral Health,62.67,,,62.67,Fee Schedule,Behavioral Health,62.67,,,62.67,Fee Schedule,Behavioral Health,62.67,,,62.67,Fee Schedule,Behavioral Health,48.47,,,48.47,Other,100% of Medicaid,48.47,,,48.47,Other,100% of Medicaid,48.47,,,48.47,Other,100% of Medicaid,48.47,,,48.47,Other,100% of Medicaid,109.06,,,109.06,Other,225% of Medicaid,74.16,,,74.16,Other,153% of Medicaid,109.06,,,109.06,Other,225% of Medicaid,67.86,,,67.86,Other,140% of Medicaid,109.06,,,109.06,Other,225% of Medicaid,126.03,,,126.03,Other,260% of Medicaid,157.05,,,157.05,Other,324% of Medicaid,104.22,,,104.22,Other,215% of Medicaid,104.22,,,104.22,Other,215% of Medicaid,60.59,,,60.59,Other,125% of Medicaid,39.99,263.2,
GROUP THERAPY NOT MULTI-FAMILY,90853,CPT,,37090853,CDM,915,RC,,,both,,,210,155.4,,,155.4,Other,150% of Medicare + 9.63% HCRA Surcharge,94.5,45,,94.5,percent of total billed charges,Critical Access Hospital RCC factor,136.5,65,,136.5,percent of total billed charges,All Other,123.9,65,,123.9,percent of total billed charges,All Other,133,,,133,Fee Schedule,Behavioral Health,120,,,120,Fee Schedule,Behavioral Health,113,,,113,Fee Schedule,Behavioral Health,103.95,,,103.95,Other,110% of Medicare,37.44,,,37.44,Fee Schedule,Behavioral Health,90,,,90,Other,186% of Medicaid,37.44,,,37.44,Fee Schedule,Behavioral Health,37.44,,,37.44,Fee Schedule,Behavioral Health,37.44,,,37.44,Fee Schedule,Behavioral Health,37.44,,,37.44,Fee Schedule,Behavioral Health,37.44,,,37.44,Fee Schedule,Behavioral Health,168,80,,168,percent of total billed charges,All Other,147,70,,147,percent of total billed charges,All Other,103,,,103,Fee Schedule,Behavioral Health,88,,,88,Fee Schedule,Behavioral Health,63.36,,,63.36,Fee Schedule,Behavioral Health,63.36,,,63.36,Fee Schedule,Behavioral Health,63.36,,,63.36,Fee Schedule,Behavioral Health,63.36,,,63.36,Fee Schedule,Behavioral Health,48.47,,,48.47,Other,100% of Medicaid,48.47,,,48.47,Other,100% of Medicaid,48.47,,,48.47,Other,100% of Medicaid,48.47,,,48.47,Other,100% of Medicaid,109.06,,,109.06,Other,225% of Medicaid,74.16,,,74.16,Other,153% of Medicaid,109.06,,,109.06,Other,225% of Medicaid,67.86,,,67.86,Other,140% of Medicaid,109.06,,,109.06,Other,225% of Medicaid,126.03,,,126.03,Other,260% of Medicaid,157.05,,,157.05,Other,324% of Medicaid,104.22,,,104.22,Other,215% of Medicaid,104.22,,,104.22,Other,215% of Medicaid,60.59,,,60.59,Other,125% of Medicaid,37.44,168,
IOP GROUP THERAPY NOT MULTI-FAMILY,90853,CPT,,37190853,CDM,915,RC,,,both,,,210,155.4,,,155.4,Other,150% of Medicare + 9.63% HCRA Surcharge,94.5,45,,94.5,percent of total billed charges,Critical Access Hospital RCC factor,136.5,65,,136.5,percent of total billed charges,All Other,123.9,65,,123.9,percent of total billed charges,All Other,133,,,133,Fee Schedule,Behavioral Health,120,,,120,Fee Schedule,Behavioral Health,113,,,113,Fee Schedule,Behavioral Health,103.95,,,103.95,Other,110% of Medicare,37.44,,,37.44,Fee Schedule,Behavioral Health,90,,,90,Other,186% of Medicaid,37.44,,,37.44,Fee Schedule,Behavioral Health,37.44,,,37.44,Fee Schedule,Behavioral Health,37.44,,,37.44,Fee Schedule,Behavioral Health,37.44,,,37.44,Fee Schedule,Behavioral Health,37.44,,,37.44,Fee Schedule,Behavioral Health,168,80,,168,percent of total billed charges,All Other,147,70,,147,percent of total billed charges,All Other,103,,,103,Fee Schedule,Behavioral Health,88,,,88,Fee Schedule,Behavioral Health,63.36,,,63.36,Fee Schedule,Behavioral Health,63.36,,,63.36,Fee Schedule,Behavioral Health,63.36,,,63.36,Fee Schedule,Behavioral Health,63.36,,,63.36,Fee Schedule,Behavioral Health,48.47,,,48.47,Other,100% of Medicaid,48.47,,,48.47,Other,100% of Medicaid,48.47,,,48.47,Other,100% of Medicaid,48.47,,,48.47,Other,100% of Medicaid,109.06,,,109.06,Other,225% of Medicaid,74.16,,,74.16,Other,153% of Medicaid,109.06,,,109.06,Other,225% of Medicaid,67.86,,,67.86,Other,140% of Medicaid,109.06,,,109.06,Other,225% of Medicaid,126.03,,,126.03,Other,260% of Medicaid,157.05,,,157.05,Other,324% of Medicaid,104.22,,,104.22,Other,215% of Medicaid,104.22,,,104.22,Other,215% of Medicaid,60.59,,,60.59,Other,125% of Medicaid,37.44,168,
ATP GROUP THERAPY NOT MF,90853,CPT,,37390853,CDM,915,RC,,,both,,,210,155.4,,,155.4,Other,150% of Medicare + 9.63% HCRA Surcharge,94.5,45,,94.5,percent of total billed charges,Critical Access Hospital RCC factor,136.5,65,,136.5,percent of total billed charges,All Other,123.9,65,,123.9,percent of total billed charges,All Other,133,,,133,Fee Schedule,Behavioral Health,120,,,120,Fee Schedule,Behavioral Health,113,,,113,Fee Schedule,Behavioral Health,103.95,,,103.95,Other,110% of Medicare,37.44,,,37.44,Fee Schedule,Behavioral Health,90,,,90,Other,186% of Medicaid,37.44,,,37.44,Fee Schedule,Behavioral Health,37.44,,,37.44,Fee Schedule,Behavioral Health,37.44,,,37.44,Fee Schedule,Behavioral Health,37.44,,,37.44,Fee Schedule,Behavioral Health,37.44,,,37.44,Fee Schedule,Behavioral Health,168,80,,168,percent of total billed charges,All Other,147,70,,147,percent of total billed charges,All Other,103,,,103,Fee Schedule,Behavioral Health,88,,,88,Fee Schedule,Behavioral Health,63.36,,,63.36,Fee Schedule,Behavioral Health,63.36,,,63.36,Fee Schedule,Behavioral Health,63.36,,,63.36,Fee Schedule,Behavioral Health,63.36,,,63.36,Fee Schedule,Behavioral Health,48.47,,,48.47,Other,100% of Medicaid,48.47,,,48.47,Other,100% of Medicaid,48.47,,,48.47,Other,100% of Medicaid,48.47,,,48.47,Other,100% of Medicaid,109.06,,,109.06,Other,225% of Medicaid,74.16,,,74.16,Other,153% of Medicaid,109.06,,,109.06,Other,225% of Medicaid,67.86,,,67.86,Other,140% of Medicaid,109.06,,,109.06,Other,225% of Medicaid,126.03,,,126.03,Other,260% of Medicaid,157.05,,,157.05,Other,324% of Medicaid,104.22,,,104.22,Other,215% of Medicaid,104.22,,,104.22,Other,215% of Medicaid,60.59,,,60.59,Other,125% of Medicaid,37.44,168,
TH -GROUP THERAPY NOT MULTI-FAMILY,90853,CPT,95,37490853,CDM,915,RC,,,both,,,210,155.4,,,155.4,Other,150% of Medicare + 9.63% HCRA Surcharge,94.5,45,,94.5,percent of total billed charges,Critical Access Hospital RCC factor,136.5,65,,136.5,percent of total billed charges,All Other,123.9,65,,123.9,percent of total billed charges,All Other,133,,,133,Fee Schedule,Behavioral Health,120,,,120,Fee Schedule,Behavioral Health,113,,,113,Fee Schedule,Behavioral Health,103.95,,,103.95,Other,110% of Medicare,37.44,,,37.44,Fee Schedule,Behavioral Health,90,,,90,Other,186% of Medicaid,37.44,,,37.44,Fee Schedule,Behavioral Health,37.44,,,37.44,Fee Schedule,Behavioral Health,37.44,,,37.44,Fee Schedule,Behavioral Health,37.44,,,37.44,Fee Schedule,Behavioral Health,37.44,,,37.44,Fee Schedule,Behavioral Health,168,80,,168,percent of total billed charges,All Other,147,70,,147,percent of total billed charges,All Other,103,,,103,Fee Schedule,Behavioral Health,88,,,88,Fee Schedule,Behavioral Health,63.36,,,63.36,Fee Schedule,Behavioral Health,63.36,,,63.36,Fee Schedule,Behavioral Health,63.36,,,63.36,Fee Schedule,Behavioral Health,63.36,,,63.36,Fee Schedule,Behavioral Health,48.47,,,48.47,Other,100% of Medicaid,48.47,,,48.47,Other,100% of Medicaid,48.47,,,48.47,Other,100% of Medicaid,48.47,,,48.47,Other,100% of Medicaid,109.06,,,109.06,Other,225% of Medicaid,74.16,,,74.16,Other,153% of Medicaid,109.06,,,109.06,Other,225% of Medicaid,67.86,,,67.86,Other,140% of Medicaid,109.06,,,109.06,Other,225% of Medicaid,126.03,,,126.03,Other,260% of Medicaid,157.05,,,157.05,Other,324% of Medicaid,104.22,,,104.22,Other,215% of Medicaid,104.22,,,104.22,Other,215% of Medicaid,60.59,,,60.59,Other,125% of Medicaid,37.44,168,
TH- IOP GROUP THERAPY NOT MULTI-FAMILY,90853,CPT,95,37590853,CDM,915,RC,,,both,,,210,155.4,,,155.4,Other,150% of Medicare + 9.63% HCRA Surcharge,94.5,45,,94.5,percent of total billed charges,Critical Access Hospital RCC factor,136.5,65,,136.5,percent of total billed charges,All Other,123.9,65,,123.9,percent of total billed charges,All Other,133,,,133,Fee Schedule,Behavioral Health,120,,,120,Fee Schedule,Behavioral Health,113,,,113,Fee Schedule,Behavioral Health,103.95,,,103.95,Other,110% of Medicare,37.44,,,37.44,Fee Schedule,Behavioral Health,90,,,90,Other,186% of Medicaid,37.44,,,37.44,Fee Schedule,Behavioral Health,37.44,,,37.44,Fee Schedule,Behavioral Health,37.44,,,37.44,Fee Schedule,Behavioral Health,37.44,,,37.44,Fee Schedule,Behavioral Health,37.44,,,37.44,Fee Schedule,Behavioral Health,168,80,,168,percent of total billed charges,All Other,147,70,,147,percent of total billed charges,All Other,103,,,103,Fee Schedule,Behavioral Health,88,,,88,Fee Schedule,Behavioral Health,63.36,,,63.36,Fee Schedule,Behavioral Health,63.36,,,63.36,Fee Schedule,Behavioral Health,63.36,,,63.36,Fee Schedule,Behavioral Health,63.36,,,63.36,Fee Schedule,Behavioral Health,48.47,,,48.47,Other,100% of Medicaid,48.47,,,48.47,Other,100% of Medicaid,48.47,,,48.47,Other,100% of Medicaid,48.47,,,48.47,Other,100% of Medicaid,109.06,,,109.06,Other,225% of Medicaid,74.16,,,74.16,Other,153% of Medicaid,109.06,,,109.06,Other,225% of Medicaid,67.86,,,67.86,Other,140% of Medicaid,109.06,,,109.06,Other,225% of Medicaid,126.03,,,126.03,Other,260% of Medicaid,157.05,,,157.05,Other,324% of Medicaid,104.22,,,104.22,Other,215% of Medicaid,104.22,,,104.22,Other,215% of Medicaid,60.59,,,60.59,Other,125% of Medicaid,37.44,168,
TH-ATP GROUP THERAPY NOT MF,90853,CPT,95,37690853,CDM,915,RC,,,both,,,210,155.4,,,155.4,Other,150% of Medicare + 9.63% HCRA Surcharge,94.5,45,,94.5,percent of total billed charges,Critical Access Hospital RCC factor,136.5,65,,136.5,percent of total billed charges,All Other,123.9,65,,123.9,percent of total billed charges,All Other,133,,,133,Fee Schedule,Behavioral Health,120,,,120,Fee Schedule,Behavioral Health,113,,,113,Fee Schedule,Behavioral Health,103.95,,,103.95,Other,110% of Medicare,37.44,,,37.44,Fee Schedule,Behavioral Health,90,,,90,Other,186% of Medicaid,37.44,,,37.44,Fee Schedule,Behavioral Health,37.44,,,37.44,Fee Schedule,Behavioral Health,37.44,,,37.44,Fee Schedule,Behavioral Health,37.44,,,37.44,Fee Schedule,Behavioral Health,37.44,,,37.44,Fee Schedule,Behavioral Health,168,80,,168,percent of total billed charges,All Other,147,70,,147,percent of total billed charges,All Other,103,,,103,Fee Schedule,Behavioral Health,88,,,88,Fee Schedule,Behavioral Health,63.36,,,63.36,Fee Schedule,Behavioral Health,63.36,,,63.36,Fee Schedule,Behavioral Health,63.36,,,63.36,Fee Schedule,Behavioral Health,63.36,,,63.36,Fee Schedule,Behavioral Health,48.47,,,48.47,Other,100% of Medicaid,48.47,,,48.47,Other,100% of Medicaid,48.47,,,48.47,Other,100% of Medicaid,48.47,,,48.47,Other,100% of Medicaid,109.06,,,109.06,Other,225% of Medicaid,74.16,,,74.16,Other,153% of Medicaid,109.06,,,109.06,Other,225% of Medicaid,67.86,,,67.86,Other,140% of Medicaid,109.06,,,109.06,Other,225% of Medicaid,126.03,,,126.03,Other,260% of Medicaid,157.05,,,157.05,Other,324% of Medicaid,104.22,,,104.22,Other,215% of Medicaid,104.22,,,104.22,Other,215% of Medicaid,60.59,,,60.59,Other,125% of Medicaid,37.44,168,
GROUP THERAPY NOT MULTI-FAMILY,90853,CPT,,38090853,CDM,915,RC,,,both,,,210,155.4,,,155.4,Other,150% of Medicare + 9.63% HCRA Surcharge,94.5,45,,94.5,percent of total billed charges,Critical Access Hospital RCC factor,136.5,65,,136.5,percent of total billed charges,All Other,123.9,65,,123.9,percent of total billed charges,All Other,133,,,133,Fee Schedule,Behavioral Health,120,,,120,Fee Schedule,Behavioral Health,113,,,113,Fee Schedule,Behavioral Health,103.95,,,103.95,Other,110% of Medicare,37.44,,,37.44,Fee Schedule,Behavioral Health,90,,,90,Other,186% of Medicaid,37.44,,,37.44,Fee Schedule,Behavioral Health,37.44,,,37.44,Fee Schedule,Behavioral Health,37.44,,,37.44,Fee Schedule,Behavioral Health,37.44,,,37.44,Fee Schedule,Behavioral Health,37.44,,,37.44,Fee Schedule,Behavioral Health,168,80,,168,percent of total billed charges,All Other,147,70,,147,percent of total billed charges,All Other,103,,,103,Fee Schedule,Behavioral Health,88,,,88,Fee Schedule,Behavioral Health,63.36,,,63.36,Fee Schedule,Behavioral Health,63.36,,,63.36,Fee Schedule,Behavioral Health,63.36,,,63.36,Fee Schedule,Behavioral Health,63.36,,,63.36,Fee Schedule,Behavioral Health,48.47,,,48.47,Other,100% of Medicaid,48.47,,,48.47,Other,100% of Medicaid,48.47,,,48.47,Other,100% of Medicaid,48.47,,,48.47,Other,100% of Medicaid,109.06,,,109.06,Other,225% of Medicaid,74.16,,,74.16,Other,153% of Medicaid,109.06,,,109.06,Other,225% of Medicaid,67.86,,,67.86,Other,140% of Medicaid,109.06,,,109.06,Other,225% of Medicaid,126.03,,,126.03,Other,260% of Medicaid,157.05,,,157.05,Other,324% of Medicaid,104.22,,,104.22,Other,215% of Medicaid,104.22,,,104.22,Other,215% of Medicaid,60.59,,,60.59,Other,125% of Medicaid,37.44,168,
TH - GROUP THERAPY NOT MULTI-FAMILY,90853,CPT,95,38390853,CDM,915,RC,,,both,,,210,155.4,,,155.4,Other,150% of Medicare + 9.63% HCRA Surcharge,94.5,45,,94.5,percent of total billed charges,Critical Access Hospital RCC factor,136.5,65,,136.5,percent of total billed charges,All Other,123.9,65,,123.9,percent of total billed charges,All Other,133,,,133,Fee Schedule,Behavioral Health,120,,,120,Fee Schedule,Behavioral Health,113,,,113,Fee Schedule,Behavioral Health,103.95,,,103.95,Other,110% of Medicare,37.44,,,37.44,Fee Schedule,Behavioral Health,90,,,90,Other,186% of Medicaid,37.44,,,37.44,Fee Schedule,Behavioral Health,37.44,,,37.44,Fee Schedule,Behavioral Health,37.44,,,37.44,Fee Schedule,Behavioral Health,37.44,,,37.44,Fee Schedule,Behavioral Health,37.44,,,37.44,Fee Schedule,Behavioral Health,168,80,,168,percent of total billed charges,All Other,147,70,,147,percent of total billed charges,All Other,103,,,103,Fee Schedule,Behavioral Health,88,,,88,Fee Schedule,Behavioral Health,63.36,,,63.36,Fee Schedule,Behavioral Health,63.36,,,63.36,Fee Schedule,Behavioral Health,63.36,,,63.36,Fee Schedule,Behavioral Health,63.36,,,63.36,Fee Schedule,Behavioral Health,48.47,,,48.47,Other,100% of Medicaid,48.47,,,48.47,Other,100% of Medicaid,48.47,,,48.47,Other,100% of Medicaid,48.47,,,48.47,Other,100% of Medicaid,109.06,,,109.06,Other,225% of Medicaid,74.16,,,74.16,Other,153% of Medicaid,109.06,,,109.06,Other,225% of Medicaid,67.86,,,67.86,Other,140% of Medicaid,109.06,,,109.06,Other,225% of Medicaid,126.03,,,126.03,Other,260% of Medicaid,157.05,,,157.05,Other,324% of Medicaid,104.22,,,104.22,Other,215% of Medicaid,104.22,,,104.22,Other,215% of Medicaid,60.59,,,60.59,Other,125% of Medicaid,37.44,168,
GROUP THRPY PARTIAL HOSP 45-50,G0410,HCPCS,,39000004,CDM,915,RC,,,both,,,194,143.56,,,143.56,Other,150% of Medicare + 9.63% HCRA Surcharge,87.3,45,,87.3,percent of total billed charges,Critical Access Hospital RCC factor,126.1,65,,126.1,percent of total billed charges,All Other,114.46,65,,114.46,percent of total billed charges,All Other,120.28,62,,120.28,percent of total billed charges,Behavioral Health,112.52,56,,112.52,percent of total billed charges,Behavioral Health,108.64,53,,108.64,percent of total billed charges,Behavioral Health,96.03,,,96.03,Other,110% of Medicare,97,50,,97,percent of total billed charges,Behavioral Health,90,,,90,Other,186% of Medicaid,97,50,,97,percent of total billed charges,Behavioral Health,97,50,,97,percent of total billed charges,Behavioral Health,97,50,,97,percent of total billed charges,Behavioral Health,97,50,,97,percent of total billed charges,Behavioral Health,97,50,,97,percent of total billed charges,Behavioral Health,155.2,80,,155.2,percent of total billed charges,All Other,135.8,70,,135.8,percent of total billed charges,All Other,126.1,65,,126.1,percent of total billed charges,Default if not in Fee Schedule,126.1,65,,126.1,percent of total billed charges,Default if not in Fee Schedule,0.01,,,0.01,Fee Schedule,Behavioral Health,0.01,,,0.01,Fee Schedule,Behavioral Health,0.01,,,0.01,Fee Schedule,Behavioral Health,0.01,,,0.01,Fee Schedule,Behavioral Health,48.47,,,48.47,Other,100% of Medicaid,48.47,,,48.47,Other,100% of Medicaid,48.47,,,48.47,Other,100% of Medicaid,48.47,,,48.47,Other,100% of Medicaid,109.06,,,109.06,Other,225% of Medicaid,74.16,,,74.16,Other,153% of Medicaid,109.06,,,109.06,Other,225% of Medicaid,67.86,,,67.86,Other,140% of Medicaid,109.06,,,109.06,Other,225% of Medicaid,126.03,,,126.03,Other,260% of Medicaid,157.05,,,157.05,Other,324% of Medicaid,104.22,,,104.22,Other,215% of Medicaid,104.22,,,104.22,Other,215% of Medicaid,60.59,,,60.59,Other,125% of Medicaid,0.01,157.05,
ADOL GROUP THERAPY,90853,CPT,,39090853,CDM,915,RC,,,both,,,210,155.4,,,155.4,Other,150% of Medicare + 9.63% HCRA Surcharge,94.5,45,,94.5,percent of total billed charges,Critical Access Hospital RCC factor,136.5,65,,136.5,percent of total billed charges,All Other,123.9,65,,123.9,percent of total billed charges,All Other,133,,,133,Fee Schedule,Behavioral Health,120,,,120,Fee Schedule,Behavioral Health,113,,,113,Fee Schedule,Behavioral Health,103.95,,,103.95,Other,110% of Medicare,37.44,,,37.44,Fee Schedule,Behavioral Health,90,,,90,Other,186% of Medicaid,37.44,,,37.44,Fee Schedule,Behavioral Health,37.44,,,37.44,Fee Schedule,Behavioral Health,37.44,,,37.44,Fee Schedule,Behavioral Health,37.44,,,37.44,Fee Schedule,Behavioral Health,37.44,,,37.44,Fee Schedule,Behavioral Health,168,80,,168,percent of total billed charges,All Other,147,70,,147,percent of total billed charges,All Other,103,,,103,Fee Schedule,Behavioral Health,88,,,88,Fee Schedule,Behavioral Health,63.36,,,63.36,Fee Schedule,Behavioral Health,63.36,,,63.36,Fee Schedule,Behavioral Health,63.36,,,63.36,Fee Schedule,Behavioral Health,63.36,,,63.36,Fee Schedule,Behavioral Health,48.47,,,48.47,Other,100% of Medicaid,48.47,,,48.47,Other,100% of Medicaid,48.47,,,48.47,Other,100% of Medicaid,48.47,,,48.47,Other,100% of Medicaid,109.06,,,109.06,Other,225% of Medicaid,74.16,,,74.16,Other,153% of Medicaid,109.06,,,109.06,Other,225% of Medicaid,67.86,,,67.86,Other,140% of Medicaid,109.06,,,109.06,Other,225% of Medicaid,126.03,,,126.03,Other,260% of Medicaid,157.05,,,157.05,Other,324% of Medicaid,104.22,,,104.22,Other,215% of Medicaid,104.22,,,104.22,Other,215% of Medicaid,60.59,,,60.59,Other,125% of Medicaid,37.44,168,
GROUP THRPY PARTIAL HOSP 45-50-TH,G0410,HCPCS,GT,39100003,CDM,915,RC,,,both,,,194,143.56,,,143.56,Other,150% of Medicare + 9.63% HCRA Surcharge,87.3,45,,87.3,percent of total billed charges,Critical Access Hospital RCC factor,126.1,65,,126.1,percent of total billed charges,All Other,114.46,65,,114.46,percent of total billed charges,All Other,120.28,62,,120.28,percent of total billed charges,Behavioral Health,112.52,56,,112.52,percent of total billed charges,Behavioral Health,108.64,53,,108.64,percent of total billed charges,Behavioral Health,96.03,,,96.03,Other,110% of Medicare,97,50,,97,percent of total billed charges,Behavioral Health,90,,,90,Other,186% of Medicaid,97,50,,97,percent of total billed charges,Behavioral Health,97,50,,97,percent of total billed charges,Behavioral Health,97,50,,97,percent of total billed charges,Behavioral Health,97,50,,97,percent of total billed charges,Behavioral Health,97,50,,97,percent of total billed charges,Behavioral Health,155.2,80,,155.2,percent of total billed charges,All Other,135.8,70,,135.8,percent of total billed charges,All Other,126.1,65,,126.1,percent of total billed charges,Default if not in Fee Schedule,126.1,65,,126.1,percent of total billed charges,Default if not in Fee Schedule,0.01,,,0.01,Fee Schedule,Behavioral Health,0.01,,,0.01,Fee Schedule,Behavioral Health,0.01,,,0.01,Fee Schedule,Behavioral Health,0.01,,,0.01,Fee Schedule,Behavioral Health,48.47,,,48.47,Other,100% of Medicaid,48.47,,,48.47,Other,100% of Medicaid,48.47,,,48.47,Other,100% of Medicaid,48.47,,,48.47,Other,100% of Medicaid,109.06,,,109.06,Other,225% of Medicaid,74.16,,,74.16,Other,153% of Medicaid,109.06,,,109.06,Other,225% of Medicaid,67.86,,,67.86,Other,140% of Medicaid,109.06,,,109.06,Other,225% of Medicaid,126.03,,,126.03,Other,260% of Medicaid,157.05,,,157.05,Other,324% of Medicaid,104.22,,,104.22,Other,215% of Medicaid,104.22,,,104.22,Other,215% of Medicaid,60.59,,,60.59,Other,125% of Medicaid,0.01,157.05,
GROUP THRPY PARTIAL HOSP 45-50,G0410,HCPCS,,40000004,CDM,915,RC,,,both,,,194,143.56,,,143.56,Other,150% of Medicare + 9.63% HCRA Surcharge,87.3,45,,87.3,percent of total billed charges,Critical Access Hospital RCC factor,126.1,65,,126.1,percent of total billed charges,All Other,114.46,65,,114.46,percent of total billed charges,All Other,120.28,62,,120.28,percent of total billed charges,Behavioral Health,112.52,56,,112.52,percent of total billed charges,Behavioral Health,108.64,53,,108.64,percent of total billed charges,Behavioral Health,96.03,,,96.03,Other,110% of Medicare,97,50,,97,percent of total billed charges,Behavioral Health,90,,,90,Other,186% of Medicaid,97,50,,97,percent of total billed charges,Behavioral Health,97,50,,97,percent of total billed charges,Behavioral Health,97,50,,97,percent of total billed charges,Behavioral Health,97,50,,97,percent of total billed charges,Behavioral Health,97,50,,97,percent of total billed charges,Behavioral Health,155.2,80,,155.2,percent of total billed charges,All Other,135.8,70,,135.8,percent of total billed charges,All Other,126.1,65,,126.1,percent of total billed charges,Default if not in Fee Schedule,126.1,65,,126.1,percent of total billed charges,Default if not in Fee Schedule,0.01,,,0.01,Fee Schedule,Behavioral Health,0.01,,,0.01,Fee Schedule,Behavioral Health,0.01,,,0.01,Fee Schedule,Behavioral Health,0.01,,,0.01,Fee Schedule,Behavioral Health,48.47,,,48.47,Other,100% of Medicaid,48.47,,,48.47,Other,100% of Medicaid,48.47,,,48.47,Other,100% of Medicaid,48.47,,,48.47,Other,100% of Medicaid,109.06,,,109.06,Other,225% of Medicaid,74.16,,,74.16,Other,153% of Medicaid,109.06,,,109.06,Other,225% of Medicaid,67.86,,,67.86,Other,140% of Medicaid,109.06,,,109.06,Other,225% of Medicaid,126.03,,,126.03,Other,260% of Medicaid,157.05,,,157.05,Other,324% of Medicaid,104.22,,,104.22,Other,215% of Medicaid,104.22,,,104.22,Other,215% of Medicaid,60.59,,,60.59,Other,125% of Medicaid,0.01,157.05,
GROUP THRPY PARTIAL HOSP 45-50-TH,G0410,HCPCS,GT,40100003,CDM,915,RC,,,both,,,194,143.56,,,143.56,Other,150% of Medicare + 9.63% HCRA Surcharge,87.3,45,,87.3,percent of total billed charges,Critical Access Hospital RCC factor,126.1,65,,126.1,percent of total billed charges,All Other,114.46,65,,114.46,percent of total billed charges,All Other,120.28,62,,120.28,percent of total billed charges,Behavioral Health,112.52,56,,112.52,percent of total billed charges,Behavioral Health,108.64,53,,108.64,percent of total billed charges,Behavioral Health,96.03,,,96.03,Other,110% of Medicare,97,50,,97,percent of total billed charges,Behavioral Health,90,,,90,Other,186% of Medicaid,97,50,,97,percent of total billed charges,Behavioral Health,97,50,,97,percent of total billed charges,Behavioral Health,97,50,,97,percent of total billed charges,Behavioral Health,97,50,,97,percent of total billed charges,Behavioral Health,97,50,,97,percent of total billed charges,Behavioral Health,155.2,80,,155.2,percent of total billed charges,All Other,135.8,70,,135.8,percent of total billed charges,All Other,126.1,65,,126.1,percent of total billed charges,Default if not in Fee Schedule,126.1,65,,126.1,percent of total billed charges,Default if not in Fee Schedule,0.01,,,0.01,Fee Schedule,Behavioral Health,0.01,,,0.01,Fee Schedule,Behavioral Health,0.01,,,0.01,Fee Schedule,Behavioral Health,0.01,,,0.01,Fee Schedule,Behavioral Health,48.47,,,48.47,Other,100% of Medicaid,48.47,,,48.47,Other,100% of Medicaid,48.47,,,48.47,Other,100% of Medicaid,48.47,,,48.47,Other,100% of Medicaid,109.06,,,109.06,Other,225% of Medicaid,74.16,,,74.16,Other,153% of Medicaid,109.06,,,109.06,Other,225% of Medicaid,67.86,,,67.86,Other,140% of Medicaid,109.06,,,109.06,Other,225% of Medicaid,126.03,,,126.03,Other,260% of Medicaid,157.05,,,157.05,Other,324% of Medicaid,104.22,,,104.22,Other,215% of Medicaid,104.22,,,104.22,Other,215% of Medicaid,60.59,,,60.59,Other,125% of Medicaid,0.01,157.05,
FAMILY THERAPY WO PT,90846,CPT,,36090846,CDM,916,RC,,,both,,,466,344.84,,,344.84,Other,150% of Medicare + 9.63% HCRA Surcharge,209.7,45,,209.7,percent of total billed charges,Critical Access Hospital RCC factor,302.9,65,,302.9,percent of total billed charges,All Other,274.94,65,,274.94,percent of total billed charges,All Other,158,,,158,Fee Schedule,Behavioral Health,142,,,142,Fee Schedule,Behavioral Health,134,,,134,Fee Schedule,Behavioral Health,230.67,,,230.67,Other,110% of Medicare,151.79,,,151.79,Fee Schedule,Behavioral Health,174,,,174,Other,186% of Medicaid,151.79,,,151.79,Fee Schedule,Behavioral Health,151.79,,,151.79,Fee Schedule,Behavioral Health,151.79,,,151.79,Fee Schedule,Behavioral Health,151.79,,,151.79,Fee Schedule,Behavioral Health,151.79,,,151.79,Fee Schedule,Behavioral Health,372.8,80,,372.8,percent of total billed charges,All Other,326.2,70,,326.2,percent of total billed charges,All Other,148,,,148,Fee Schedule,Behavioral Health,126,,,126,Fee Schedule,Behavioral Health,105.22,,,105.22,Fee Schedule,Behavioral Health,105.22,,,105.22,Fee Schedule,Behavioral Health,105.22,,,105.22,Fee Schedule,Behavioral Health,105.22,,,105.22,Fee Schedule,Behavioral Health,93.82,,,93.82,Other,100% of Medicaid,93.82,,,93.82,Other,100% of Medicaid,93.82,,,93.82,Other,100% of Medicaid,93.82,,,93.82,Other,100% of Medicaid,211.09,,,211.09,Other,225% of Medicaid,143.54,,,143.54,Other,153% of Medicaid,211.09,,,211.09,Other,225% of Medicaid,131.34,,,131.34,Other,140% of Medicaid,211.09,,,211.09,Other,225% of Medicaid,243.92,,,243.92,Other,260% of Medicaid,303.97,,,303.97,Other,324% of Medicaid,201.71,,,201.71,Other,215% of Medicaid,201.71,,,201.71,Other,215% of Medicaid,117.27,,,117.27,Other,125% of Medicaid,93.82,372.8,
FAMILY THERAPY W PT,90847,CPT,,36090847,CDM,916,RC,,,both,,,466,344.84,,,344.84,Other,150% of Medicare + 9.63% HCRA Surcharge,209.7,45,,209.7,percent of total billed charges,Critical Access Hospital RCC factor,302.9,65,,302.9,percent of total billed charges,All Other,274.94,65,,274.94,percent of total billed charges,All Other,158,,,158,Fee Schedule,Behavioral Health,142,,,142,Fee Schedule,Behavioral Health,134,,,134,Fee Schedule,Behavioral Health,230.67,,,230.67,Other,110% of Medicare,158.52,,,158.52,Fee Schedule,Behavioral Health,174,,,174,Other,186% of Medicaid,158.52,,,158.52,Fee Schedule,Behavioral Health,158.52,,,158.52,Fee Schedule,Behavioral Health,158.52,,,158.52,Fee Schedule,Behavioral Health,158.52,,,158.52,Fee Schedule,Behavioral Health,158.52,,,158.52,Fee Schedule,Behavioral Health,372.8,80,,372.8,percent of total billed charges,All Other,326.2,70,,326.2,percent of total billed charges,All Other,170,,,170,Fee Schedule,Behavioral Health,145,,,145,Fee Schedule,Behavioral Health,105.22,,,105.22,Fee Schedule,Behavioral Health,105.22,,,105.22,Fee Schedule,Behavioral Health,105.22,,,105.22,Fee Schedule,Behavioral Health,105.22,,,105.22,Fee Schedule,Behavioral Health,93.82,,,93.82,Other,100% of Medicaid,93.82,,,93.82,Other,100% of Medicaid,93.82,,,93.82,Other,100% of Medicaid,93.82,,,93.82,Other,100% of Medicaid,211.09,,,211.09,Other,225% of Medicaid,143.54,,,143.54,Other,153% of Medicaid,211.09,,,211.09,Other,225% of Medicaid,131.34,,,131.34,Other,140% of Medicaid,211.09,,,211.09,Other,225% of Medicaid,243.92,,,243.92,Other,260% of Medicaid,303.97,,,303.97,Other,324% of Medicaid,201.71,,,201.71,Other,215% of Medicaid,201.71,,,201.71,Other,215% of Medicaid,117.27,,,117.27,Other,125% of Medicaid,93.82,372.8,
IOP FAMILY THERAPY WO PT,90846,CPT,,36190846,CDM,916,RC,,,both,,,466,344.84,,,344.84,Other,150% of Medicare + 9.63% HCRA Surcharge,209.7,45,,209.7,percent of total billed charges,Critical Access Hospital RCC factor,302.9,65,,302.9,percent of total billed charges,All Other,274.94,65,,274.94,percent of total billed charges,All Other,158,,,158,Fee Schedule,Behavioral Health,142,,,142,Fee Schedule,Behavioral Health,134,,,134,Fee Schedule,Behavioral Health,230.67,,,230.67,Other,110% of Medicare,151.79,,,151.79,Fee Schedule,Behavioral Health,174,,,174,Other,186% of Medicaid,151.79,,,151.79,Fee Schedule,Behavioral Health,151.79,,,151.79,Fee Schedule,Behavioral Health,151.79,,,151.79,Fee Schedule,Behavioral Health,151.79,,,151.79,Fee Schedule,Behavioral Health,151.79,,,151.79,Fee Schedule,Behavioral Health,372.8,80,,372.8,percent of total billed charges,All Other,326.2,70,,326.2,percent of total billed charges,All Other,148,,,148,Fee Schedule,Behavioral Health,126,,,126,Fee Schedule,Behavioral Health,105.22,,,105.22,Fee Schedule,Behavioral Health,105.22,,,105.22,Fee Schedule,Behavioral Health,105.22,,,105.22,Fee Schedule,Behavioral Health,105.22,,,105.22,Fee Schedule,Behavioral Health,93.82,,,93.82,Other,100% of Medicaid,93.82,,,93.82,Other,100% of Medicaid,93.82,,,93.82,Other,100% of Medicaid,93.82,,,93.82,Other,100% of Medicaid,211.09,,,211.09,Other,225% of Medicaid,143.54,,,143.54,Other,153% of Medicaid,211.09,,,211.09,Other,225% of Medicaid,131.34,,,131.34,Other,140% of Medicaid,211.09,,,211.09,Other,225% of Medicaid,243.92,,,243.92,Other,260% of Medicaid,303.97,,,303.97,Other,324% of Medicaid,201.71,,,201.71,Other,215% of Medicaid,201.71,,,201.71,Other,215% of Medicaid,117.27,,,117.27,Other,125% of Medicaid,93.82,372.8,
IOP FAMILY THERAPY W PT,90847,CPT,,36190847,CDM,916,RC,,,both,,,466,344.84,,,344.84,Other,150% of Medicare + 9.63% HCRA Surcharge,209.7,45,,209.7,percent of total billed charges,Critical Access Hospital RCC factor,302.9,65,,302.9,percent of total billed charges,All Other,274.94,65,,274.94,percent of total billed charges,All Other,158,,,158,Fee Schedule,Behavioral Health,142,,,142,Fee Schedule,Behavioral Health,134,,,134,Fee Schedule,Behavioral Health,230.67,,,230.67,Other,110% of Medicare,158.52,,,158.52,Fee Schedule,Behavioral Health,174,,,174,Other,186% of Medicaid,158.52,,,158.52,Fee Schedule,Behavioral Health,158.52,,,158.52,Fee Schedule,Behavioral Health,158.52,,,158.52,Fee Schedule,Behavioral Health,158.52,,,158.52,Fee Schedule,Behavioral Health,158.52,,,158.52,Fee Schedule,Behavioral Health,372.8,80,,372.8,percent of total billed charges,All Other,326.2,70,,326.2,percent of total billed charges,All Other,170,,,170,Fee Schedule,Behavioral Health,145,,,145,Fee Schedule,Behavioral Health,105.22,,,105.22,Fee Schedule,Behavioral Health,105.22,,,105.22,Fee Schedule,Behavioral Health,105.22,,,105.22,Fee Schedule,Behavioral Health,105.22,,,105.22,Fee Schedule,Behavioral Health,93.82,,,93.82,Other,100% of Medicaid,93.82,,,93.82,Other,100% of Medicaid,93.82,,,93.82,Other,100% of Medicaid,93.82,,,93.82,Other,100% of Medicaid,211.09,,,211.09,Other,225% of Medicaid,143.54,,,143.54,Other,153% of Medicaid,211.09,,,211.09,Other,225% of Medicaid,131.34,,,131.34,Other,140% of Medicaid,211.09,,,211.09,Other,225% of Medicaid,243.92,,,243.92,Other,260% of Medicaid,303.97,,,303.97,Other,324% of Medicaid,201.71,,,201.71,Other,215% of Medicaid,201.71,,,201.71,Other,215% of Medicaid,117.27,,,117.27,Other,125% of Medicaid,93.82,372.8,
TH-IOP FAMILY THERAPY WO PT,90846,CPT,95,36490846,CDM,916,RC,,,both,,,466,344.84,,,344.84,Other,150% of Medicare + 9.63% HCRA Surcharge,209.7,45,,209.7,percent of total billed charges,Critical Access Hospital RCC factor,302.9,65,,302.9,percent of total billed charges,All Other,274.94,65,,274.94,percent of total billed charges,All Other,158,,,158,Fee Schedule,Behavioral Health,142,,,142,Fee Schedule,Behavioral Health,134,,,134,Fee Schedule,Behavioral Health,230.67,,,230.67,Other,110% of Medicare,151.79,,,151.79,Fee Schedule,Behavioral Health,174,,,174,Other,186% of Medicaid,151.79,,,151.79,Fee Schedule,Behavioral Health,151.79,,,151.79,Fee Schedule,Behavioral Health,151.79,,,151.79,Fee Schedule,Behavioral Health,151.79,,,151.79,Fee Schedule,Behavioral Health,151.79,,,151.79,Fee Schedule,Behavioral Health,372.8,80,,372.8,percent of total billed charges,All Other,326.2,70,,326.2,percent of total billed charges,All Other,148,,,148,Fee Schedule,Behavioral Health,126,,,126,Fee Schedule,Behavioral Health,105.22,,,105.22,Fee Schedule,Behavioral Health,105.22,,,105.22,Fee Schedule,Behavioral Health,105.22,,,105.22,Fee Schedule,Behavioral Health,105.22,,,105.22,Fee Schedule,Behavioral Health,93.82,,,93.82,Other,100% of Medicaid,93.82,,,93.82,Other,100% of Medicaid,93.82,,,93.82,Other,100% of Medicaid,93.82,,,93.82,Other,100% of Medicaid,211.09,,,211.09,Other,225% of Medicaid,143.54,,,143.54,Other,153% of Medicaid,211.09,,,211.09,Other,225% of Medicaid,131.34,,,131.34,Other,140% of Medicaid,211.09,,,211.09,Other,225% of Medicaid,243.92,,,243.92,Other,260% of Medicaid,303.97,,,303.97,Other,324% of Medicaid,201.71,,,201.71,Other,215% of Medicaid,201.71,,,201.71,Other,215% of Medicaid,117.27,,,117.27,Other,125% of Medicaid,93.82,372.8,
TH-IOP FAMILY THERAPY WO PT,90846,CPT,95,36590846,CDM,916,RC,,,both,,,466,344.84,,,344.84,Other,150% of Medicare + 9.63% HCRA Surcharge,209.7,45,,209.7,percent of total billed charges,Critical Access Hospital RCC factor,302.9,65,,302.9,percent of total billed charges,All Other,274.94,65,,274.94,percent of total billed charges,All Other,158,,,158,Fee Schedule,Behavioral Health,142,,,142,Fee Schedule,Behavioral Health,134,,,134,Fee Schedule,Behavioral Health,230.67,,,230.67,Other,110% of Medicare,151.79,,,151.79,Fee Schedule,Behavioral Health,174,,,174,Other,186% of Medicaid,151.79,,,151.79,Fee Schedule,Behavioral Health,151.79,,,151.79,Fee Schedule,Behavioral Health,151.79,,,151.79,Fee Schedule,Behavioral Health,151.79,,,151.79,Fee Schedule,Behavioral Health,151.79,,,151.79,Fee Schedule,Behavioral Health,372.8,80,,372.8,percent of total billed charges,All Other,326.2,70,,326.2,percent of total billed charges,All Other,148,,,148,Fee Schedule,Behavioral Health,126,,,126,Fee Schedule,Behavioral Health,105.22,,,105.22,Fee Schedule,Behavioral Health,105.22,,,105.22,Fee Schedule,Behavioral Health,105.22,,,105.22,Fee Schedule,Behavioral Health,105.22,,,105.22,Fee Schedule,Behavioral Health,93.82,,,93.82,Other,100% of Medicaid,93.82,,,93.82,Other,100% of Medicaid,93.82,,,93.82,Other,100% of Medicaid,93.82,,,93.82,Other,100% of Medicaid,211.09,,,211.09,Other,225% of Medicaid,143.54,,,143.54,Other,153% of Medicaid,211.09,,,211.09,Other,225% of Medicaid,131.34,,,131.34,Other,140% of Medicaid,211.09,,,211.09,Other,225% of Medicaid,243.92,,,243.92,Other,260% of Medicaid,303.97,,,303.97,Other,324% of Medicaid,201.71,,,201.71,Other,215% of Medicaid,201.71,,,201.71,Other,215% of Medicaid,117.27,,,117.27,Other,125% of Medicaid,93.82,372.8,
IOP FAMILY THERAPY W PT-TH,90847,CPT,95,36590847,CDM,916,RC,,,both,,,466,344.84,,,344.84,Other,150% of Medicare + 9.63% HCRA Surcharge,209.7,45,,209.7,percent of total billed charges,Critical Access Hospital RCC factor,302.9,65,,302.9,percent of total billed charges,All Other,274.94,65,,274.94,percent of total billed charges,All Other,158,,,158,Fee Schedule,Behavioral Health,142,,,142,Fee Schedule,Behavioral Health,134,,,134,Fee Schedule,Behavioral Health,230.67,,,230.67,Other,110% of Medicare,158.52,,,158.52,Fee Schedule,Behavioral Health,174,,,174,Other,186% of Medicaid,158.52,,,158.52,Fee Schedule,Behavioral Health,158.52,,,158.52,Fee Schedule,Behavioral Health,158.52,,,158.52,Fee Schedule,Behavioral Health,158.52,,,158.52,Fee Schedule,Behavioral Health,158.52,,,158.52,Fee Schedule,Behavioral Health,372.8,80,,372.8,percent of total billed charges,All Other,326.2,70,,326.2,percent of total billed charges,All Other,170,,,170,Fee Schedule,Behavioral Health,145,,,145,Fee Schedule,Behavioral Health,105.22,,,105.22,Fee Schedule,Behavioral Health,105.22,,,105.22,Fee Schedule,Behavioral Health,105.22,,,105.22,Fee Schedule,Behavioral Health,105.22,,,105.22,Fee Schedule,Behavioral Health,93.82,,,93.82,Other,100% of Medicaid,93.82,,,93.82,Other,100% of Medicaid,93.82,,,93.82,Other,100% of Medicaid,93.82,,,93.82,Other,100% of Medicaid,211.09,,,211.09,Other,225% of Medicaid,143.54,,,143.54,Other,153% of Medicaid,211.09,,,211.09,Other,225% of Medicaid,131.34,,,131.34,Other,140% of Medicaid,211.09,,,211.09,Other,225% of Medicaid,243.92,,,243.92,Other,260% of Medicaid,303.97,,,303.97,Other,324% of Medicaid,201.71,,,201.71,Other,215% of Medicaid,201.71,,,201.71,Other,215% of Medicaid,117.27,,,117.27,Other,125% of Medicaid,93.82,372.8,
FAMILY THERAPY WO PT,90846,CPT,,37090846,CDM,916,RC,,,both,,,466,344.84,,,344.84,Other,150% of Medicare + 9.63% HCRA Surcharge,209.7,45,,209.7,percent of total billed charges,Critical Access Hospital RCC factor,302.9,65,,302.9,percent of total billed charges,All Other,274.94,65,,274.94,percent of total billed charges,All Other,158,,,158,Fee Schedule,Behavioral Health,142,,,142,Fee Schedule,Behavioral Health,134,,,134,Fee Schedule,Behavioral Health,230.67,,,230.67,Other,110% of Medicare,151.79,,,151.79,Fee Schedule,Behavioral Health,174,,,174,Other,186% of Medicaid,151.79,,,151.79,Fee Schedule,Behavioral Health,151.79,,,151.79,Fee Schedule,Behavioral Health,151.79,,,151.79,Fee Schedule,Behavioral Health,151.79,,,151.79,Fee Schedule,Behavioral Health,151.79,,,151.79,Fee Schedule,Behavioral Health,372.8,80,,372.8,percent of total billed charges,All Other,326.2,70,,326.2,percent of total billed charges,All Other,148,,,148,Fee Schedule,Behavioral Health,126,,,126,Fee Schedule,Behavioral Health,105.22,,,105.22,Fee Schedule,Behavioral Health,105.22,,,105.22,Fee Schedule,Behavioral Health,105.22,,,105.22,Fee Schedule,Behavioral Health,105.22,,,105.22,Fee Schedule,Behavioral Health,93.82,,,93.82,Other,100% of Medicaid,93.82,,,93.82,Other,100% of Medicaid,93.82,,,93.82,Other,100% of Medicaid,93.82,,,93.82,Other,100% of Medicaid,211.09,,,211.09,Other,225% of Medicaid,143.54,,,143.54,Other,153% of Medicaid,211.09,,,211.09,Other,225% of Medicaid,131.34,,,131.34,Other,140% of Medicaid,211.09,,,211.09,Other,225% of Medicaid,243.92,,,243.92,Other,260% of Medicaid,303.97,,,303.97,Other,324% of Medicaid,201.71,,,201.71,Other,215% of Medicaid,201.71,,,201.71,Other,215% of Medicaid,117.27,,,117.27,Other,125% of Medicaid,93.82,372.8,
FAMILY THERAPY W PT,90847,CPT,,37090847,CDM,916,RC,,,both,,,466,344.84,,,344.84,Other,150% of Medicare + 9.63% HCRA Surcharge,209.7,45,,209.7,percent of total billed charges,Critical Access Hospital RCC factor,302.9,65,,302.9,percent of total billed charges,All Other,274.94,65,,274.94,percent of total billed charges,All Other,158,,,158,Fee Schedule,Behavioral Health,142,,,142,Fee Schedule,Behavioral Health,134,,,134,Fee Schedule,Behavioral Health,230.67,,,230.67,Other,110% of Medicare,158.52,,,158.52,Fee Schedule,Behavioral Health,174,,,174,Other,186% of Medicaid,158.52,,,158.52,Fee Schedule,Behavioral Health,158.52,,,158.52,Fee Schedule,Behavioral Health,158.52,,,158.52,Fee Schedule,Behavioral Health,158.52,,,158.52,Fee Schedule,Behavioral Health,158.52,,,158.52,Fee Schedule,Behavioral Health,372.8,80,,372.8,percent of total billed charges,All Other,326.2,70,,326.2,percent of total billed charges,All Other,170,,,170,Fee Schedule,Behavioral Health,145,,,145,Fee Schedule,Behavioral Health,105.22,,,105.22,Fee Schedule,Behavioral Health,105.22,,,105.22,Fee Schedule,Behavioral Health,105.22,,,105.22,Fee Schedule,Behavioral Health,105.22,,,105.22,Fee Schedule,Behavioral Health,93.82,,,93.82,Other,100% of Medicaid,93.82,,,93.82,Other,100% of Medicaid,93.82,,,93.82,Other,100% of Medicaid,93.82,,,93.82,Other,100% of Medicaid,211.09,,,211.09,Other,225% of Medicaid,143.54,,,143.54,Other,153% of Medicaid,211.09,,,211.09,Other,225% of Medicaid,131.34,,,131.34,Other,140% of Medicaid,211.09,,,211.09,Other,225% of Medicaid,243.92,,,243.92,Other,260% of Medicaid,303.97,,,303.97,Other,324% of Medicaid,201.71,,,201.71,Other,215% of Medicaid,201.71,,,201.71,Other,215% of Medicaid,117.27,,,117.27,Other,125% of Medicaid,93.82,372.8,
IOP FAMILY THERAPY WO PT,90846,CPT,,37190846,CDM,916,RC,,,both,,,466,344.84,,,344.84,Other,150% of Medicare + 9.63% HCRA Surcharge,209.7,45,,209.7,percent of total billed charges,Critical Access Hospital RCC factor,302.9,65,,302.9,percent of total billed charges,All Other,274.94,65,,274.94,percent of total billed charges,All Other,158,,,158,Fee Schedule,Behavioral Health,142,,,142,Fee Schedule,Behavioral Health,134,,,134,Fee Schedule,Behavioral Health,230.67,,,230.67,Other,110% of Medicare,151.79,,,151.79,Fee Schedule,Behavioral Health,174,,,174,Other,186% of Medicaid,151.79,,,151.79,Fee Schedule,Behavioral Health,151.79,,,151.79,Fee Schedule,Behavioral Health,151.79,,,151.79,Fee Schedule,Behavioral Health,151.79,,,151.79,Fee Schedule,Behavioral Health,151.79,,,151.79,Fee Schedule,Behavioral Health,372.8,80,,372.8,percent of total billed charges,All Other,326.2,70,,326.2,percent of total billed charges,All Other,148,,,148,Fee Schedule,Behavioral Health,126,,,126,Fee Schedule,Behavioral Health,105.22,,,105.22,Fee Schedule,Behavioral Health,105.22,,,105.22,Fee Schedule,Behavioral Health,105.22,,,105.22,Fee Schedule,Behavioral Health,105.22,,,105.22,Fee Schedule,Behavioral Health,93.82,,,93.82,Other,100% of Medicaid,93.82,,,93.82,Other,100% of Medicaid,93.82,,,93.82,Other,100% of Medicaid,93.82,,,93.82,Other,100% of Medicaid,211.09,,,211.09,Other,225% of Medicaid,143.54,,,143.54,Other,153% of Medicaid,211.09,,,211.09,Other,225% of Medicaid,131.34,,,131.34,Other,140% of Medicaid,211.09,,,211.09,Other,225% of Medicaid,243.92,,,243.92,Other,260% of Medicaid,303.97,,,303.97,Other,324% of Medicaid,201.71,,,201.71,Other,215% of Medicaid,201.71,,,201.71,Other,215% of Medicaid,117.27,,,117.27,Other,125% of Medicaid,93.82,372.8,
IOP FAMILY THERAPY W PT,90847,CPT,,37190847,CDM,916,RC,,,both,,,466,344.84,,,344.84,Other,150% of Medicare + 9.63% HCRA Surcharge,209.7,45,,209.7,percent of total billed charges,Critical Access Hospital RCC factor,302.9,65,,302.9,percent of total billed charges,All Other,274.94,65,,274.94,percent of total billed charges,All Other,158,,,158,Fee Schedule,Behavioral Health,142,,,142,Fee Schedule,Behavioral Health,134,,,134,Fee Schedule,Behavioral Health,230.67,,,230.67,Other,110% of Medicare,158.52,,,158.52,Fee Schedule,Behavioral Health,174,,,174,Other,186% of Medicaid,158.52,,,158.52,Fee Schedule,Behavioral Health,158.52,,,158.52,Fee Schedule,Behavioral Health,158.52,,,158.52,Fee Schedule,Behavioral Health,158.52,,,158.52,Fee Schedule,Behavioral Health,158.52,,,158.52,Fee Schedule,Behavioral Health,372.8,80,,372.8,percent of total billed charges,All Other,326.2,70,,326.2,percent of total billed charges,All Other,170,,,170,Fee Schedule,Behavioral Health,145,,,145,Fee Schedule,Behavioral Health,105.22,,,105.22,Fee Schedule,Behavioral Health,105.22,,,105.22,Fee Schedule,Behavioral Health,105.22,,,105.22,Fee Schedule,Behavioral Health,105.22,,,105.22,Fee Schedule,Behavioral Health,93.82,,,93.82,Other,100% of Medicaid,93.82,,,93.82,Other,100% of Medicaid,93.82,,,93.82,Other,100% of Medicaid,93.82,,,93.82,Other,100% of Medicaid,211.09,,,211.09,Other,225% of Medicaid,143.54,,,143.54,Other,153% of Medicaid,211.09,,,211.09,Other,225% of Medicaid,131.34,,,131.34,Other,140% of Medicaid,211.09,,,211.09,Other,225% of Medicaid,243.92,,,243.92,Other,260% of Medicaid,303.97,,,303.97,Other,324% of Medicaid,201.71,,,201.71,Other,215% of Medicaid,201.71,,,201.71,Other,215% of Medicaid,117.27,,,117.27,Other,125% of Medicaid,93.82,372.8,
TH-FAMILY THERAPY WO PT,90846,CPT,95,37490846,CDM,916,RC,,,both,,,466,344.84,,,344.84,Other,150% of Medicare + 9.63% HCRA Surcharge,209.7,45,,209.7,percent of total billed charges,Critical Access Hospital RCC factor,302.9,65,,302.9,percent of total billed charges,All Other,274.94,65,,274.94,percent of total billed charges,All Other,158,,,158,Fee Schedule,Behavioral Health,142,,,142,Fee Schedule,Behavioral Health,134,,,134,Fee Schedule,Behavioral Health,230.67,,,230.67,Other,110% of Medicare,151.79,,,151.79,Fee Schedule,Behavioral Health,174,,,174,Other,186% of Medicaid,151.79,,,151.79,Fee Schedule,Behavioral Health,151.79,,,151.79,Fee Schedule,Behavioral Health,151.79,,,151.79,Fee Schedule,Behavioral Health,151.79,,,151.79,Fee Schedule,Behavioral Health,151.79,,,151.79,Fee Schedule,Behavioral Health,372.8,80,,372.8,percent of total billed charges,All Other,326.2,70,,326.2,percent of total billed charges,All Other,148,,,148,Fee Schedule,Behavioral Health,126,,,126,Fee Schedule,Behavioral Health,105.22,,,105.22,Fee Schedule,Behavioral Health,105.22,,,105.22,Fee Schedule,Behavioral Health,105.22,,,105.22,Fee Schedule,Behavioral Health,105.22,,,105.22,Fee Schedule,Behavioral Health,93.82,,,93.82,Other,100% of Medicaid,93.82,,,93.82,Other,100% of Medicaid,93.82,,,93.82,Other,100% of Medicaid,93.82,,,93.82,Other,100% of Medicaid,211.09,,,211.09,Other,225% of Medicaid,143.54,,,143.54,Other,153% of Medicaid,211.09,,,211.09,Other,225% of Medicaid,131.34,,,131.34,Other,140% of Medicaid,211.09,,,211.09,Other,225% of Medicaid,243.92,,,243.92,Other,260% of Medicaid,303.97,,,303.97,Other,324% of Medicaid,201.71,,,201.71,Other,215% of Medicaid,201.71,,,201.71,Other,215% of Medicaid,117.27,,,117.27,Other,125% of Medicaid,93.82,372.8,
IOP FAMILY THERAPY WO PT- TH,90846,CPT,95,37590846,CDM,916,RC,,,both,,,466,344.84,,,344.84,Other,150% of Medicare + 9.63% HCRA Surcharge,209.7,45,,209.7,percent of total billed charges,Critical Access Hospital RCC factor,302.9,65,,302.9,percent of total billed charges,All Other,274.94,65,,274.94,percent of total billed charges,All Other,158,,,158,Fee Schedule,Behavioral Health,142,,,142,Fee Schedule,Behavioral Health,134,,,134,Fee Schedule,Behavioral Health,230.67,,,230.67,Other,110% of Medicare,151.79,,,151.79,Fee Schedule,Behavioral Health,174,,,174,Other,186% of Medicaid,151.79,,,151.79,Fee Schedule,Behavioral Health,151.79,,,151.79,Fee Schedule,Behavioral Health,151.79,,,151.79,Fee Schedule,Behavioral Health,151.79,,,151.79,Fee Schedule,Behavioral Health,151.79,,,151.79,Fee Schedule,Behavioral Health,372.8,80,,372.8,percent of total billed charges,All Other,326.2,70,,326.2,percent of total billed charges,All Other,148,,,148,Fee Schedule,Behavioral Health,126,,,126,Fee Schedule,Behavioral Health,105.22,,,105.22,Fee Schedule,Behavioral Health,105.22,,,105.22,Fee Schedule,Behavioral Health,105.22,,,105.22,Fee Schedule,Behavioral Health,105.22,,,105.22,Fee Schedule,Behavioral Health,93.82,,,93.82,Other,100% of Medicaid,93.82,,,93.82,Other,100% of Medicaid,93.82,,,93.82,Other,100% of Medicaid,93.82,,,93.82,Other,100% of Medicaid,211.09,,,211.09,Other,225% of Medicaid,143.54,,,143.54,Other,153% of Medicaid,211.09,,,211.09,Other,225% of Medicaid,131.34,,,131.34,Other,140% of Medicaid,211.09,,,211.09,Other,225% of Medicaid,243.92,,,243.92,Other,260% of Medicaid,303.97,,,303.97,Other,324% of Medicaid,201.71,,,201.71,Other,215% of Medicaid,201.71,,,201.71,Other,215% of Medicaid,117.27,,,117.27,Other,125% of Medicaid,93.82,372.8,
IOP FAMILY THERAPY W PT- TH,90847,CPT,95,37590847,CDM,916,RC,,,both,,,466,344.84,,,344.84,Other,150% of Medicare + 9.63% HCRA Surcharge,209.7,45,,209.7,percent of total billed charges,Critical Access Hospital RCC factor,302.9,65,,302.9,percent of total billed charges,All Other,274.94,65,,274.94,percent of total billed charges,All Other,158,,,158,Fee Schedule,Behavioral Health,142,,,142,Fee Schedule,Behavioral Health,134,,,134,Fee Schedule,Behavioral Health,230.67,,,230.67,Other,110% of Medicare,158.52,,,158.52,Fee Schedule,Behavioral Health,174,,,174,Other,186% of Medicaid,158.52,,,158.52,Fee Schedule,Behavioral Health,158.52,,,158.52,Fee Schedule,Behavioral Health,158.52,,,158.52,Fee Schedule,Behavioral Health,158.52,,,158.52,Fee Schedule,Behavioral Health,158.52,,,158.52,Fee Schedule,Behavioral Health,372.8,80,,372.8,percent of total billed charges,All Other,326.2,70,,326.2,percent of total billed charges,All Other,170,,,170,Fee Schedule,Behavioral Health,145,,,145,Fee Schedule,Behavioral Health,105.22,,,105.22,Fee Schedule,Behavioral Health,105.22,,,105.22,Fee Schedule,Behavioral Health,105.22,,,105.22,Fee Schedule,Behavioral Health,105.22,,,105.22,Fee Schedule,Behavioral Health,93.82,,,93.82,Other,100% of Medicaid,93.82,,,93.82,Other,100% of Medicaid,93.82,,,93.82,Other,100% of Medicaid,93.82,,,93.82,Other,100% of Medicaid,211.09,,,211.09,Other,225% of Medicaid,143.54,,,143.54,Other,153% of Medicaid,211.09,,,211.09,Other,225% of Medicaid,131.34,,,131.34,Other,140% of Medicaid,211.09,,,211.09,Other,225% of Medicaid,243.92,,,243.92,Other,260% of Medicaid,303.97,,,303.97,Other,324% of Medicaid,201.71,,,201.71,Other,215% of Medicaid,201.71,,,201.71,Other,215% of Medicaid,117.27,,,117.27,Other,125% of Medicaid,93.82,372.8,
FAMILY THERAPY W PT,90847,CPT,,38090847,CDM,916,RC,,,both,,,466,344.84,,,344.84,Other,150% of Medicare + 9.63% HCRA Surcharge,209.7,45,,209.7,percent of total billed charges,Critical Access Hospital RCC factor,302.9,65,,302.9,percent of total billed charges,All Other,274.94,65,,274.94,percent of total billed charges,All Other,158,,,158,Fee Schedule,Behavioral Health,142,,,142,Fee Schedule,Behavioral Health,134,,,134,Fee Schedule,Behavioral Health,230.67,,,230.67,Other,110% of Medicare,158.52,,,158.52,Fee Schedule,Behavioral Health,174,,,174,Other,186% of Medicaid,158.52,,,158.52,Fee Schedule,Behavioral Health,158.52,,,158.52,Fee Schedule,Behavioral Health,158.52,,,158.52,Fee Schedule,Behavioral Health,158.52,,,158.52,Fee Schedule,Behavioral Health,158.52,,,158.52,Fee Schedule,Behavioral Health,372.8,80,,372.8,percent of total billed charges,All Other,326.2,70,,326.2,percent of total billed charges,All Other,170,,,170,Fee Schedule,Behavioral Health,145,,,145,Fee Schedule,Behavioral Health,105.22,,,105.22,Fee Schedule,Behavioral Health,105.22,,,105.22,Fee Schedule,Behavioral Health,105.22,,,105.22,Fee Schedule,Behavioral Health,105.22,,,105.22,Fee Schedule,Behavioral Health,93.82,,,93.82,Other,100% of Medicaid,93.82,,,93.82,Other,100% of Medicaid,93.82,,,93.82,Other,100% of Medicaid,93.82,,,93.82,Other,100% of Medicaid,211.09,,,211.09,Other,225% of Medicaid,143.54,,,143.54,Other,153% of Medicaid,211.09,,,211.09,Other,225% of Medicaid,131.34,,,131.34,Other,140% of Medicaid,211.09,,,211.09,Other,225% of Medicaid,243.92,,,243.92,Other,260% of Medicaid,303.97,,,303.97,Other,324% of Medicaid,201.71,,,201.71,Other,215% of Medicaid,201.71,,,201.71,Other,215% of Medicaid,117.27,,,117.27,Other,125% of Medicaid,93.82,372.8,
ADOL FAMILY THERAPY WO PT,90846,CPT,,39090846,CDM,916,RC,,,both,,,466,344.84,,,344.84,Other,150% of Medicare + 9.63% HCRA Surcharge,209.7,45,,209.7,percent of total billed charges,Critical Access Hospital RCC factor,302.9,65,,302.9,percent of total billed charges,All Other,274.94,65,,274.94,percent of total billed charges,All Other,158,,,158,Fee Schedule,Behavioral Health,142,,,142,Fee Schedule,Behavioral Health,134,,,134,Fee Schedule,Behavioral Health,230.67,,,230.67,Other,110% of Medicare,151.79,,,151.79,Fee Schedule,Behavioral Health,174,,,174,Other,186% of Medicaid,151.79,,,151.79,Fee Schedule,Behavioral Health,151.79,,,151.79,Fee Schedule,Behavioral Health,151.79,,,151.79,Fee Schedule,Behavioral Health,151.79,,,151.79,Fee Schedule,Behavioral Health,151.79,,,151.79,Fee Schedule,Behavioral Health,372.8,80,,372.8,percent of total billed charges,All Other,326.2,70,,326.2,percent of total billed charges,All Other,148,,,148,Fee Schedule,Behavioral Health,126,,,126,Fee Schedule,Behavioral Health,105.22,,,105.22,Fee Schedule,Behavioral Health,105.22,,,105.22,Fee Schedule,Behavioral Health,105.22,,,105.22,Fee Schedule,Behavioral Health,105.22,,,105.22,Fee Schedule,Behavioral Health,93.82,,,93.82,Other,100% of Medicaid,93.82,,,93.82,Other,100% of Medicaid,93.82,,,93.82,Other,100% of Medicaid,93.82,,,93.82,Other,100% of Medicaid,211.09,,,211.09,Other,225% of Medicaid,143.54,,,143.54,Other,153% of Medicaid,211.09,,,211.09,Other,225% of Medicaid,131.34,,,131.34,Other,140% of Medicaid,211.09,,,211.09,Other,225% of Medicaid,243.92,,,243.92,Other,260% of Medicaid,303.97,,,303.97,Other,324% of Medicaid,201.71,,,201.71,Other,215% of Medicaid,201.71,,,201.71,Other,215% of Medicaid,117.27,,,117.27,Other,125% of Medicaid,93.82,372.8,
ADOL FAMILY THERAPY W PT,90847,CPT,,39090847,CDM,916,RC,,,both,,,466,344.84,,,344.84,Other,150% of Medicare + 9.63% HCRA Surcharge,209.7,45,,209.7,percent of total billed charges,Critical Access Hospital RCC factor,302.9,65,,302.9,percent of total billed charges,All Other,274.94,65,,274.94,percent of total billed charges,All Other,158,,,158,Fee Schedule,Behavioral Health,142,,,142,Fee Schedule,Behavioral Health,134,,,134,Fee Schedule,Behavioral Health,230.67,,,230.67,Other,110% of Medicare,158.52,,,158.52,Fee Schedule,Behavioral Health,174,,,174,Other,186% of Medicaid,158.52,,,158.52,Fee Schedule,Behavioral Health,158.52,,,158.52,Fee Schedule,Behavioral Health,158.52,,,158.52,Fee Schedule,Behavioral Health,158.52,,,158.52,Fee Schedule,Behavioral Health,158.52,,,158.52,Fee Schedule,Behavioral Health,372.8,80,,372.8,percent of total billed charges,All Other,326.2,70,,326.2,percent of total billed charges,All Other,170,,,170,Fee Schedule,Behavioral Health,145,,,145,Fee Schedule,Behavioral Health,105.22,,,105.22,Fee Schedule,Behavioral Health,105.22,,,105.22,Fee Schedule,Behavioral Health,105.22,,,105.22,Fee Schedule,Behavioral Health,105.22,,,105.22,Fee Schedule,Behavioral Health,93.82,,,93.82,Other,100% of Medicaid,93.82,,,93.82,Other,100% of Medicaid,93.82,,,93.82,Other,100% of Medicaid,93.82,,,93.82,Other,100% of Medicaid,211.09,,,211.09,Other,225% of Medicaid,143.54,,,143.54,Other,153% of Medicaid,211.09,,,211.09,Other,225% of Medicaid,131.34,,,131.34,Other,140% of Medicaid,211.09,,,211.09,Other,225% of Medicaid,243.92,,,243.92,Other,260% of Medicaid,303.97,,,303.97,Other,324% of Medicaid,201.71,,,201.71,Other,215% of Medicaid,201.71,,,201.71,Other,215% of Medicaid,117.27,,,117.27,Other,125% of Medicaid,93.82,372.8,
ADOL FAMILY THERAPY WO PT-TH,90846,CPT,95,39190846,CDM,916,RC,,,both,,,466,344.84,,,344.84,Other,150% of Medicare + 9.63% HCRA Surcharge,209.7,45,,209.7,percent of total billed charges,Critical Access Hospital RCC factor,302.9,65,,302.9,percent of total billed charges,All Other,274.94,65,,274.94,percent of total billed charges,All Other,158,,,158,Fee Schedule,Behavioral Health,142,,,142,Fee Schedule,Behavioral Health,134,,,134,Fee Schedule,Behavioral Health,230.67,,,230.67,Other,110% of Medicare,151.79,,,151.79,Fee Schedule,Behavioral Health,174,,,174,Other,186% of Medicaid,151.79,,,151.79,Fee Schedule,Behavioral Health,151.79,,,151.79,Fee Schedule,Behavioral Health,151.79,,,151.79,Fee Schedule,Behavioral Health,151.79,,,151.79,Fee Schedule,Behavioral Health,151.79,,,151.79,Fee Schedule,Behavioral Health,372.8,80,,372.8,percent of total billed charges,All Other,326.2,70,,326.2,percent of total billed charges,All Other,148,,,148,Fee Schedule,Behavioral Health,126,,,126,Fee Schedule,Behavioral Health,105.22,,,105.22,Fee Schedule,Behavioral Health,105.22,,,105.22,Fee Schedule,Behavioral Health,105.22,,,105.22,Fee Schedule,Behavioral Health,105.22,,,105.22,Fee Schedule,Behavioral Health,93.82,,,93.82,Other,100% of Medicaid,93.82,,,93.82,Other,100% of Medicaid,93.82,,,93.82,Other,100% of Medicaid,93.82,,,93.82,Other,100% of Medicaid,211.09,,,211.09,Other,225% of Medicaid,143.54,,,143.54,Other,153% of Medicaid,211.09,,,211.09,Other,225% of Medicaid,131.34,,,131.34,Other,140% of Medicaid,211.09,,,211.09,Other,225% of Medicaid,243.92,,,243.92,Other,260% of Medicaid,303.97,,,303.97,Other,324% of Medicaid,201.71,,,201.71,Other,215% of Medicaid,201.71,,,201.71,Other,215% of Medicaid,117.27,,,117.27,Other,125% of Medicaid,93.82,372.8,
ADOL FAMILY THERAPY W PT-TH,90847,CPT,95,39190847,CDM,916,RC,,,both,,,466,344.84,,,344.84,Other,150% of Medicare + 9.63% HCRA Surcharge,209.7,45,,209.7,percent of total billed charges,Critical Access Hospital RCC factor,302.9,65,,302.9,percent of total billed charges,All Other,274.94,65,,274.94,percent of total billed charges,All Other,158,,,158,Fee Schedule,Behavioral Health,142,,,142,Fee Schedule,Behavioral Health,134,,,134,Fee Schedule,Behavioral Health,230.67,,,230.67,Other,110% of Medicare,158.52,,,158.52,Fee Schedule,Behavioral Health,174,,,174,Other,186% of Medicaid,158.52,,,158.52,Fee Schedule,Behavioral Health,158.52,,,158.52,Fee Schedule,Behavioral Health,158.52,,,158.52,Fee Schedule,Behavioral Health,158.52,,,158.52,Fee Schedule,Behavioral Health,158.52,,,158.52,Fee Schedule,Behavioral Health,372.8,80,,372.8,percent of total billed charges,All Other,326.2,70,,326.2,percent of total billed charges,All Other,170,,,170,Fee Schedule,Behavioral Health,145,,,145,Fee Schedule,Behavioral Health,105.22,,,105.22,Fee Schedule,Behavioral Health,105.22,,,105.22,Fee Schedule,Behavioral Health,105.22,,,105.22,Fee Schedule,Behavioral Health,105.22,,,105.22,Fee Schedule,Behavioral Health,93.82,,,93.82,Other,100% of Medicaid,93.82,,,93.82,Other,100% of Medicaid,93.82,,,93.82,Other,100% of Medicaid,93.82,,,93.82,Other,100% of Medicaid,211.09,,,211.09,Other,225% of Medicaid,143.54,,,143.54,Other,153% of Medicaid,211.09,,,211.09,Other,225% of Medicaid,131.34,,,131.34,Other,140% of Medicaid,211.09,,,211.09,Other,225% of Medicaid,243.92,,,243.92,Other,260% of Medicaid,303.97,,,303.97,Other,324% of Medicaid,201.71,,,201.71,Other,215% of Medicaid,201.71,,,201.71,Other,215% of Medicaid,117.27,,,117.27,Other,125% of Medicaid,93.82,372.8,
ADOL GROUP THERAPY-TH,90853,CPT,GT,39190853,CDM,916,RC,,,both,,,210,155.4,,,155.4,Other,150% of Medicare + 9.63% HCRA Surcharge,94.5,45,,94.5,percent of total billed charges,Critical Access Hospital RCC factor,136.5,65,,136.5,percent of total billed charges,All Other,123.9,65,,123.9,percent of total billed charges,All Other,133,,,133,Fee Schedule,Behavioral Health,120,,,120,Fee Schedule,Behavioral Health,113,,,113,Fee Schedule,Behavioral Health,103.95,,,103.95,Other,110% of Medicare,37.44,,,37.44,Fee Schedule,Behavioral Health,90,,,90,Other,186% of Medicaid,37.44,,,37.44,Fee Schedule,Behavioral Health,37.44,,,37.44,Fee Schedule,Behavioral Health,37.44,,,37.44,Fee Schedule,Behavioral Health,37.44,,,37.44,Fee Schedule,Behavioral Health,37.44,,,37.44,Fee Schedule,Behavioral Health,168,80,,168,percent of total billed charges,All Other,147,70,,147,percent of total billed charges,All Other,103,,,103,Fee Schedule,Behavioral Health,88,,,88,Fee Schedule,Behavioral Health,63.36,,,63.36,Fee Schedule,Behavioral Health,63.36,,,63.36,Fee Schedule,Behavioral Health,63.36,,,63.36,Fee Schedule,Behavioral Health,63.36,,,63.36,Fee Schedule,Behavioral Health,48.47,,,48.47,Other,100% of Medicaid,48.47,,,48.47,Other,100% of Medicaid,48.47,,,48.47,Other,100% of Medicaid,48.47,,,48.47,Other,100% of Medicaid,109.06,,,109.06,Other,225% of Medicaid,74.16,,,74.16,Other,153% of Medicaid,109.06,,,109.06,Other,225% of Medicaid,67.86,,,67.86,Other,140% of Medicaid,109.06,,,109.06,Other,225% of Medicaid,126.03,,,126.03,Other,260% of Medicaid,157.05,,,157.05,Other,324% of Medicaid,104.22,,,104.22,Other,215% of Medicaid,104.22,,,104.22,Other,215% of Medicaid,60.59,,,60.59,Other,125% of Medicaid,37.44,168,
FAMILY THERAPY WO PT,90846,CPT,,40090846,CDM,916,RC,,,both,,,466,344.84,,,344.84,Other,150% of Medicare + 9.63% HCRA Surcharge,209.7,45,,209.7,percent of total billed charges,Critical Access Hospital RCC factor,302.9,65,,302.9,percent of total billed charges,All Other,274.94,65,,274.94,percent of total billed charges,All Other,158,,,158,Fee Schedule,Behavioral Health,142,,,142,Fee Schedule,Behavioral Health,134,,,134,Fee Schedule,Behavioral Health,230.67,,,230.67,Other,110% of Medicare,151.79,,,151.79,Fee Schedule,Behavioral Health,174,,,174,Other,186% of Medicaid,151.79,,,151.79,Fee Schedule,Behavioral Health,151.79,,,151.79,Fee Schedule,Behavioral Health,151.79,,,151.79,Fee Schedule,Behavioral Health,151.79,,,151.79,Fee Schedule,Behavioral Health,151.79,,,151.79,Fee Schedule,Behavioral Health,372.8,80,,372.8,percent of total billed charges,All Other,326.2,70,,326.2,percent of total billed charges,All Other,148,,,148,Fee Schedule,Behavioral Health,126,,,126,Fee Schedule,Behavioral Health,105.22,,,105.22,Fee Schedule,Behavioral Health,105.22,,,105.22,Fee Schedule,Behavioral Health,105.22,,,105.22,Fee Schedule,Behavioral Health,105.22,,,105.22,Fee Schedule,Behavioral Health,93.82,,,93.82,Other,100% of Medicaid,93.82,,,93.82,Other,100% of Medicaid,93.82,,,93.82,Other,100% of Medicaid,93.82,,,93.82,Other,100% of Medicaid,211.09,,,211.09,Other,225% of Medicaid,143.54,,,143.54,Other,153% of Medicaid,211.09,,,211.09,Other,225% of Medicaid,131.34,,,131.34,Other,140% of Medicaid,211.09,,,211.09,Other,225% of Medicaid,243.92,,,243.92,Other,260% of Medicaid,303.97,,,303.97,Other,324% of Medicaid,201.71,,,201.71,Other,215% of Medicaid,201.71,,,201.71,Other,215% of Medicaid,117.27,,,117.27,Other,125% of Medicaid,93.82,372.8,
FAMILY THERAPY W PT,90847,CPT,,40090847,CDM,916,RC,,,both,,,466,344.84,,,344.84,Other,150% of Medicare + 9.63% HCRA Surcharge,209.7,45,,209.7,percent of total billed charges,Critical Access Hospital RCC factor,302.9,65,,302.9,percent of total billed charges,All Other,274.94,65,,274.94,percent of total billed charges,All Other,158,,,158,Fee Schedule,Behavioral Health,142,,,142,Fee Schedule,Behavioral Health,134,,,134,Fee Schedule,Behavioral Health,230.67,,,230.67,Other,110% of Medicare,158.52,,,158.52,Fee Schedule,Behavioral Health,174,,,174,Other,186% of Medicaid,158.52,,,158.52,Fee Schedule,Behavioral Health,158.52,,,158.52,Fee Schedule,Behavioral Health,158.52,,,158.52,Fee Schedule,Behavioral Health,158.52,,,158.52,Fee Schedule,Behavioral Health,158.52,,,158.52,Fee Schedule,Behavioral Health,372.8,80,,372.8,percent of total billed charges,All Other,326.2,70,,326.2,percent of total billed charges,All Other,170,,,170,Fee Schedule,Behavioral Health,145,,,145,Fee Schedule,Behavioral Health,105.22,,,105.22,Fee Schedule,Behavioral Health,105.22,,,105.22,Fee Schedule,Behavioral Health,105.22,,,105.22,Fee Schedule,Behavioral Health,105.22,,,105.22,Fee Schedule,Behavioral Health,93.82,,,93.82,Other,100% of Medicaid,93.82,,,93.82,Other,100% of Medicaid,93.82,,,93.82,Other,100% of Medicaid,93.82,,,93.82,Other,100% of Medicaid,211.09,,,211.09,Other,225% of Medicaid,143.54,,,143.54,Other,153% of Medicaid,211.09,,,211.09,Other,225% of Medicaid,131.34,,,131.34,Other,140% of Medicaid,211.09,,,211.09,Other,225% of Medicaid,243.92,,,243.92,Other,260% of Medicaid,303.97,,,303.97,Other,324% of Medicaid,201.71,,,201.71,Other,215% of Medicaid,201.71,,,201.71,Other,215% of Medicaid,117.27,,,117.27,Other,125% of Medicaid,93.82,372.8,
MULTI FAMILY GROUP THERAPY,90849,CPT,,40090849,CDM,916,RC,,,both,,,329,243.46,,,243.46,Other,150% of Medicare + 9.63% HCRA Surcharge,148.05,45,,148.05,percent of total billed charges,Critical Access Hospital RCC factor,213.85,65,,213.85,percent of total billed charges,All Other,194.11,65,,194.11,percent of total billed charges,All Other,133,,,133,Fee Schedule,Behavioral Health,120,,,120,Fee Schedule,Behavioral Health,113,,,113,Fee Schedule,Behavioral Health,162.86,,,162.86,Other,110% of Medicare,46.14,,,46.14,Fee Schedule,Behavioral Health,90,,,90,Other,186% of Medicaid,46.14,,,46.14,Fee Schedule,Behavioral Health,46.14,,,46.14,Fee Schedule,Behavioral Health,46.14,,,46.14,Fee Schedule,Behavioral Health,46.14,,,46.14,Fee Schedule,Behavioral Health,46.14,,,46.14,Fee Schedule,Behavioral Health,263.2,80,,263.2,percent of total billed charges,All Other,230.3,70,,230.3,percent of total billed charges,All Other,39.99,,,39.99,Other,130% of Medicare,39.99,,,39.99,Other,130% of Medicare,62.67,,,62.67,Fee Schedule,Behavioral Health,62.67,,,62.67,Fee Schedule,Behavioral Health,62.67,,,62.67,Fee Schedule,Behavioral Health,62.67,,,62.67,Fee Schedule,Behavioral Health,48.47,,,48.47,Other,100% of Medicaid,48.47,,,48.47,Other,100% of Medicaid,48.47,,,48.47,Other,100% of Medicaid,48.47,,,48.47,Other,100% of Medicaid,109.06,,,109.06,Other,225% of Medicaid,74.16,,,74.16,Other,153% of Medicaid,109.06,,,109.06,Other,225% of Medicaid,67.86,,,67.86,Other,140% of Medicaid,109.06,,,109.06,Other,225% of Medicaid,126.03,,,126.03,Other,260% of Medicaid,157.05,,,157.05,Other,324% of Medicaid,104.22,,,104.22,Other,215% of Medicaid,104.22,,,104.22,Other,215% of Medicaid,60.59,,,60.59,Other,125% of Medicaid,39.99,263.2,
FAMILY THERAPY WO PT-TH,90846,CPT,95,40190846,CDM,916,RC,,,both,,,466,344.84,,,344.84,Other,150% of Medicare + 9.63% HCRA Surcharge,209.7,45,,209.7,percent of total billed charges,Critical Access Hospital RCC factor,302.9,65,,302.9,percent of total billed charges,All Other,274.94,65,,274.94,percent of total billed charges,All Other,158,,,158,Fee Schedule,Behavioral Health,142,,,142,Fee Schedule,Behavioral Health,134,,,134,Fee Schedule,Behavioral Health,230.67,,,230.67,Other,110% of Medicare,151.79,,,151.79,Fee Schedule,Behavioral Health,174,,,174,Other,186% of Medicaid,151.79,,,151.79,Fee Schedule,Behavioral Health,151.79,,,151.79,Fee Schedule,Behavioral Health,151.79,,,151.79,Fee Schedule,Behavioral Health,151.79,,,151.79,Fee Schedule,Behavioral Health,151.79,,,151.79,Fee Schedule,Behavioral Health,372.8,80,,372.8,percent of total billed charges,All Other,326.2,70,,326.2,percent of total billed charges,All Other,148,,,148,Fee Schedule,Behavioral Health,126,,,126,Fee Schedule,Behavioral Health,105.22,,,105.22,Fee Schedule,Behavioral Health,105.22,,,105.22,Fee Schedule,Behavioral Health,105.22,,,105.22,Fee Schedule,Behavioral Health,105.22,,,105.22,Fee Schedule,Behavioral Health,93.82,,,93.82,Other,100% of Medicaid,93.82,,,93.82,Other,100% of Medicaid,93.82,,,93.82,Other,100% of Medicaid,93.82,,,93.82,Other,100% of Medicaid,211.09,,,211.09,Other,225% of Medicaid,143.54,,,143.54,Other,153% of Medicaid,211.09,,,211.09,Other,225% of Medicaid,131.34,,,131.34,Other,140% of Medicaid,211.09,,,211.09,Other,225% of Medicaid,243.92,,,243.92,Other,260% of Medicaid,303.97,,,303.97,Other,324% of Medicaid,201.71,,,201.71,Other,215% of Medicaid,201.71,,,201.71,Other,215% of Medicaid,117.27,,,117.27,Other,125% of Medicaid,93.82,372.8,
FAMILY THERAPY W PT-TH,90847,CPT,95,40190847,CDM,916,RC,,,both,,,466,344.84,,,344.84,Other,150% of Medicare + 9.63% HCRA Surcharge,209.7,45,,209.7,percent of total billed charges,Critical Access Hospital RCC factor,302.9,65,,302.9,percent of total billed charges,All Other,274.94,65,,274.94,percent of total billed charges,All Other,158,,,158,Fee Schedule,Behavioral Health,142,,,142,Fee Schedule,Behavioral Health,134,,,134,Fee Schedule,Behavioral Health,230.67,,,230.67,Other,110% of Medicare,158.52,,,158.52,Fee Schedule,Behavioral Health,174,,,174,Other,186% of Medicaid,158.52,,,158.52,Fee Schedule,Behavioral Health,158.52,,,158.52,Fee Schedule,Behavioral Health,158.52,,,158.52,Fee Schedule,Behavioral Health,158.52,,,158.52,Fee Schedule,Behavioral Health,158.52,,,158.52,Fee Schedule,Behavioral Health,372.8,80,,372.8,percent of total billed charges,All Other,326.2,70,,326.2,percent of total billed charges,All Other,170,,,170,Fee Schedule,Behavioral Health,145,,,145,Fee Schedule,Behavioral Health,105.22,,,105.22,Fee Schedule,Behavioral Health,105.22,,,105.22,Fee Schedule,Behavioral Health,105.22,,,105.22,Fee Schedule,Behavioral Health,105.22,,,105.22,Fee Schedule,Behavioral Health,93.82,,,93.82,Other,100% of Medicaid,93.82,,,93.82,Other,100% of Medicaid,93.82,,,93.82,Other,100% of Medicaid,93.82,,,93.82,Other,100% of Medicaid,211.09,,,211.09,Other,225% of Medicaid,143.54,,,143.54,Other,153% of Medicaid,211.09,,,211.09,Other,225% of Medicaid,131.34,,,131.34,Other,140% of Medicaid,211.09,,,211.09,Other,225% of Medicaid,243.92,,,243.92,Other,260% of Medicaid,303.97,,,303.97,Other,324% of Medicaid,201.71,,,201.71,Other,215% of Medicaid,201.71,,,201.71,Other,215% of Medicaid,117.27,,,117.27,Other,125% of Medicaid,93.82,372.8,
FETAL CONTRACTION STRESS TEST,59020,CPT,,26059020,CDM,920,RC,,,both,,,667,493.58,,,493.58,Other,150% of Medicare + 9.63% HCRA Surcharge,300.15,45,,300.15,percent of total billed charges,Critical Access Hospital RCC factor,121.48,,,121.48,Fee Schedule,,109.29,,,109.29,Fee Schedule,,510.26,76.5,,510.26,percent of total billed charges,All Other,473.57,69,,473.57,percent of total billed charges,All Other,460.23,65,,460.23,percent of total billed charges,All Other,330.17,,,330.17,Other,110% of Medicare,144.32,,,144.32,Fee Schedule,,594,,,594,Other,186% of Medicaid,169.84,,,169.84,Fee Schedule,,413.54,,,413.54,Fee Schedule,,79.97,,,79.97,Fee Schedule,,169.84,,,169.84,Fee Schedule,,413.54,,,413.54,Fee Schedule,,533.6,80,,533.6,percent of total billed charges,All Other,466.9,70,,466.9,percent of total billed charges,All Other,162.36,,,162.36,Fee Schedule,,137.61,,,137.61,Fee Schedule,,333.5,,,333.5,Case Rate,,333.5,,,333.5,Case Rate,,333.5,,,333.5,Case Rate,,333.5,,,333.5,Case Rate,,319.45,,,319.45,Other,100% of Medicaid,319.45,,,319.45,Other,100% of Medicaid,319.45,,,319.45,Other,100% of Medicaid,319.45,,,319.45,Other,100% of Medicaid,718.76,,,718.76,Other,225% of Medicaid,488.76,,,488.76,Other,153% of Medicaid,718.76,,,718.76,Other,225% of Medicaid,447.23,,,447.23,Other,140% of Medicaid,718.76,,,718.76,Other,225% of Medicaid,830.57,,,830.57,Other,260% of Medicaid,1035.02,,,1035.02,Other,324% of Medicaid,686.82,,,686.82,Other,215% of Medicaid,686.82,,,686.82,Other,215% of Medicaid,399.31,,,399.31,Other,125% of Medicaid,79.97,1035.02,
FETAL NON-STRESS TEST,59025,CPT,,26059025,CDM,920,RC,,,both,,,408,301.92,,,301.92,Other,150% of Medicare + 9.63% HCRA Surcharge,183.6,45,,183.6,percent of total billed charges,Critical Access Hospital RCC factor,70.63,,,70.63,Fee Schedule,,63.54,,,63.54,Fee Schedule,,116.78,,,116.78,Fee Schedule,,105.04,,,105.04,Fee Schedule,,99.28,,,99.28,Fee Schedule,,201.96,,,201.96,Other,110% of Medicare,83.91,,,83.91,Fee Schedule,,594,,,594,Other,186% of Medicaid,98.74,,,98.74,Fee Schedule,,252.96,,,252.96,Fee Schedule,,46.49,,,46.49,Fee Schedule,,98.74,,,98.74,Fee Schedule,,252.96,,,252.96,Fee Schedule,,326.4,80,,326.4,percent of total billed charges,All Other,285.6,70,,285.6,percent of total billed charges,All Other,95.12,,,95.12,Fee Schedule,,80.62,,,80.62,Fee Schedule,,204,,,204,Case Rate,,204,,,204,Case Rate,,204,,,204,Case Rate,,204,,,204,Case Rate,,319.45,,,319.45,Other,100% of Medicaid,319.45,,,319.45,Other,100% of Medicaid,319.45,,,319.45,Other,100% of Medicaid,319.45,,,319.45,Other,100% of Medicaid,718.76,,,718.76,Other,225% of Medicaid,488.76,,,488.76,Other,153% of Medicaid,718.76,,,718.76,Other,225% of Medicaid,447.23,,,447.23,Other,140% of Medicaid,718.76,,,718.76,Other,225% of Medicaid,830.57,,,830.57,Other,260% of Medicaid,1035.02,,,1035.02,Other,324% of Medicaid,686.82,,,686.82,Other,215% of Medicaid,686.82,,,686.82,Other,215% of Medicaid,399.31,,,399.31,Other,125% of Medicaid,46.49,1035.02,
DUPLX VENOUS BILAT,93970,CPT,TC,44093970,CDM,920,RC,,,both,,,2036,1506.65,,,1506.65,Other,150% of Medicare + 9.63% HCRA Surcharge,916.2,45,,916.2,percent of total billed charges,Critical Access Hospital RCC factor,496.19,,,496.19,Fee Schedule,,447.41,,,447.41,Fee Schedule,,1032.13,,,1032.13,Fee Schedule,,928.33,,,928.33,Fee Schedule,,877.41,,,877.41,Fee Schedule,,1007.82,,,1007.82,Other,110% of Medicare,0.68,,,0.68,Fee Schedule,,982,,,982,Other,186% of Medicaid,0.8,,,0.8,Fee Schedule,,0.83,,,0.83,Fee Schedule,,0.83,,,0.83,Fee Schedule,,0.8,,,0.8,Fee Schedule,,0.83,,,0.83,Fee Schedule,,1628.8,80,,1628.8,percent of total billed charges,All Other,1425.2,70,,1425.2,percent of total billed charges,All Other,765.88,,,765.88,Fee Schedule,,649.13,,,649.13,Fee Schedule,,811,,,811,Case Rate,,730,,,730,Case Rate,,811,,,811,Case Rate,,689,,,689,Case Rate,,527.83,,,527.83,Other,100% of Medicaid,527.83,,,527.83,Other,100% of Medicaid,527.83,,,527.83,Other,100% of Medicaid,527.83,,,527.83,Other,100% of Medicaid,1187.61,,,1187.61,Other,225% of Medicaid,807.58,,,807.58,Other,153% of Medicaid,1187.61,,,1187.61,Other,225% of Medicaid,738.96,,,738.96,Other,140% of Medicaid,1187.61,,,1187.61,Other,225% of Medicaid,1372.35,,,1372.35,Other,260% of Medicaid,1710.16,,,1710.16,Other,324% of Medicaid,1134.83,,,1134.83,Other,215% of Medicaid,1134.83,,,1134.83,Other,215% of Medicaid,659.78,,,659.78,Other,125% of Medicaid,0.68,1710.16,
US AORTA DUPLEX COMPLETE,93978,CPT,TC,44093978,CDM,920,RC,,,both,,,1632,1207.68,,,1207.68,Other,150% of Medicare + 9.63% HCRA Surcharge,734.4,45,,734.4,percent of total billed charges,Critical Access Hospital RCC factor,458.78,,,458.78,Fee Schedule,,413.68,,,413.68,Fee Schedule,,1032.13,,,1032.13,Fee Schedule,,928.33,,,928.33,Fee Schedule,,877.41,,,877.41,Fee Schedule,,807.84,,,807.84,Other,110% of Medicare,0.68,,,0.68,Fee Schedule,,982,,,982,Other,186% of Medicaid,0.8,,,0.8,Fee Schedule,,0.83,,,0.83,Fee Schedule,,0.83,,,0.83,Fee Schedule,,0.8,,,0.8,Fee Schedule,,0.83,,,0.83,Fee Schedule,,1305.6,80,,1305.6,percent of total billed charges,All Other,1142.4,70,,1142.4,percent of total billed charges,All Other,708.48,,,708.48,Fee Schedule,,600.48,,,600.48,Fee Schedule,,811,,,811,Case Rate,,730,,,730,Case Rate,,811,,,811,Case Rate,,689,,,689,Case Rate,,527.83,,,527.83,Other,100% of Medicaid,527.83,,,527.83,Other,100% of Medicaid,527.83,,,527.83,Other,100% of Medicaid,527.83,,,527.83,Other,100% of Medicaid,1187.61,,,1187.61,Other,225% of Medicaid,807.58,,,807.58,Other,153% of Medicaid,1187.61,,,1187.61,Other,225% of Medicaid,738.96,,,738.96,Other,140% of Medicaid,1187.61,,,1187.61,Other,225% of Medicaid,1372.35,,,1372.35,Other,260% of Medicaid,1710.16,,,1710.16,Other,324% of Medicaid,1134.83,,,1134.83,Other,215% of Medicaid,1134.83,,,1134.83,Other,215% of Medicaid,659.78,,,659.78,Other,125% of Medicaid,0.68,1710.16,
US AORTA DUPLEX UNIL OR LTD,93979,CPT,TC,44093979,CDM,920,RC,,,both,,,746,552.04,,,552.04,Other,150% of Medicare + 9.63% HCRA Surcharge,335.7,45,,335.7,percent of total billed charges,Critical Access Hospital RCC factor,303.73,,,303.73,Fee Schedule,,273.87,,,273.87,Fee Schedule,,650,,,650,Fee Schedule,,584.63,,,584.63,Fee Schedule,,552.56,,,552.56,Fee Schedule,,369.27,,,369.27,Other,110% of Medicare,0.68,,,0.68,Fee Schedule,,226,,,226,Other,186% of Medicaid,0.8,,,0.8,Fee Schedule,,0.83,,,0.83,Fee Schedule,,0.83,,,0.83,Fee Schedule,,0.8,,,0.8,Fee Schedule,,0.83,,,0.83,Fee Schedule,,596.8,80,,596.8,percent of total billed charges,All Other,522.2,70,,522.2,percent of total billed charges,All Other,465.76,,,465.76,Fee Schedule,,394.76,,,394.76,Fee Schedule,,811,,,811,Case Rate,,730,,,730,Case Rate,,811,,,811,Case Rate,,689,,,689,Case Rate,,121.68,,,121.68,Other,100% of Medicaid,121.68,,,121.68,Other,100% of Medicaid,121.68,,,121.68,Other,100% of Medicaid,121.68,,,121.68,Other,100% of Medicaid,273.79,,,273.79,Other,225% of Medicaid,186.18,,,186.18,Other,153% of Medicaid,273.79,,,273.79,Other,225% of Medicaid,170.36,,,170.36,Other,140% of Medicaid,273.79,,,273.79,Other,225% of Medicaid,316.38,,,316.38,Other,260% of Medicaid,394.25,,,394.25,Other,324% of Medicaid,261.62,,,261.62,Other,215% of Medicaid,261.62,,,261.62,Other,215% of Medicaid,152.1,,,152.1,Other,125% of Medicaid,0.68,811,
VENOUS DOPPLER UNILATERAL LT,93971,CPT,TCLT,44193971,CDM,920,RC,,,both,,,1360,1006.4,,,1006.4,Other,150% of Medicare + 9.63% HCRA Surcharge,612,45,,612,percent of total billed charges,Critical Access Hospital RCC factor,315.47,,,315.47,Fee Schedule,,284.46,,,284.46,Fee Schedule,,650,,,650,Fee Schedule,,584.63,,,584.63,Fee Schedule,,552.56,,,552.56,Fee Schedule,,673.2,,,673.2,Other,110% of Medicare,0.68,,,0.68,Fee Schedule,,226,,,226,Other,186% of Medicaid,0.8,,,0.8,Fee Schedule,,0.83,,,0.83,Fee Schedule,,0.83,,,0.83,Fee Schedule,,0.8,,,0.8,Fee Schedule,,0.83,,,0.83,Fee Schedule,,1088,80,,1088,percent of total billed charges,All Other,952,70,,952,percent of total billed charges,All Other,485.44,,,485.44,Fee Schedule,,411.44,,,411.44,Fee Schedule,,811,,,811,Case Rate,,730,,,730,Case Rate,,811,,,811,Case Rate,,689,,,689,Case Rate,,121.68,,,121.68,Other,100% of Medicaid,121.68,,,121.68,Other,100% of Medicaid,121.68,,,121.68,Other,100% of Medicaid,121.68,,,121.68,Other,100% of Medicaid,273.79,,,273.79,Other,225% of Medicaid,186.18,,,186.18,Other,153% of Medicaid,273.79,,,273.79,Other,225% of Medicaid,170.36,,,170.36,Other,140% of Medicaid,273.79,,,273.79,Other,225% of Medicaid,316.38,,,316.38,Other,260% of Medicaid,394.25,,,394.25,Other,324% of Medicaid,261.62,,,261.62,Other,215% of Medicaid,261.62,,,261.62,Other,215% of Medicaid,152.1,,,152.1,Other,125% of Medicaid,0.68,1088,
VENOUS DOPPLER UNILATERAL RT,93971,CPT,TCRT,44293971,CDM,920,RC,,,both,,,1360,1006.4,,,1006.4,Other,150% of Medicare + 9.63% HCRA Surcharge,612,45,,612,percent of total billed charges,Critical Access Hospital RCC factor,315.47,,,315.47,Fee Schedule,,284.46,,,284.46,Fee Schedule,,650,,,650,Fee Schedule,,584.63,,,584.63,Fee Schedule,,552.56,,,552.56,Fee Schedule,,673.2,,,673.2,Other,110% of Medicare,0.68,,,0.68,Fee Schedule,,226,,,226,Other,186% of Medicaid,0.8,,,0.8,Fee Schedule,,0.83,,,0.83,Fee Schedule,,0.83,,,0.83,Fee Schedule,,0.8,,,0.8,Fee Schedule,,0.83,,,0.83,Fee Schedule,,1088,80,,1088,percent of total billed charges,All Other,952,70,,952,percent of total billed charges,All Other,485.44,,,485.44,Fee Schedule,,411.44,,,411.44,Fee Schedule,,811,,,811,Case Rate,,730,,,730,Case Rate,,811,,,811,Case Rate,,689,,,689,Case Rate,,121.68,,,121.68,Other,100% of Medicaid,121.68,,,121.68,Other,100% of Medicaid,121.68,,,121.68,Other,100% of Medicaid,121.68,,,121.68,Other,100% of Medicaid,273.79,,,273.79,Other,225% of Medicaid,186.18,,,186.18,Other,153% of Medicaid,273.79,,,273.79,Other,225% of Medicaid,170.36,,,170.36,Other,140% of Medicaid,273.79,,,273.79,Other,225% of Medicaid,316.38,,,316.38,Other,260% of Medicaid,394.25,,,394.25,Other,324% of Medicaid,261.62,,,261.62,Other,215% of Medicaid,261.62,,,261.62,Other,215% of Medicaid,152.1,,,152.1,Other,125% of Medicaid,0.68,1088,
ELECTRO-OCULOGRAPHY W INT & REP,92270,CPT,,66092270,CDM,920,RC,,,both,,,270,199.8,,,199.8,Other,150% of Medicare + 9.63% HCRA Surcharge,121.5,45,,121.5,percent of total billed charges,Critical Access Hospital RCC factor,243.91,,,243.91,Fee Schedule,,219.93,,,219.93,Fee Schedule,,310.05,,,310.05,Fee Schedule,,279.1,,,279.1,Fee Schedule,,263.63,,,263.63,Fee Schedule,,133.65,,,133.65,Other,110% of Medicare,313.36,,,313.36,Fee Schedule,,139,,,139,Other,186% of Medicaid,368.75,,,368.75,Fee Schedule,,167.4,,,167.4,Fee Schedule,,173.63,,,173.63,Fee Schedule,,368.75,,,368.75,Fee Schedule,,167.4,,,167.4,Fee Schedule,,326.59,,,326.59,Fee Schedule,,189,70,,189,percent of total billed charges,All Other,323.08,,,323.08,Fee Schedule,,273.83,,,273.83,Fee Schedule,,135,,,135,Case Rate,,135,,,135,Case Rate,,135,,,135,Case Rate,,135,,,135,Case Rate,,74.86,,,74.86,Other,100% of Medicaid,74.86,,,74.86,Other,100% of Medicaid,74.86,,,74.86,Other,100% of Medicaid,74.86,,,74.86,Other,100% of Medicaid,168.43,,,168.43,Other,225% of Medicaid,114.53,,,114.53,Other,153% of Medicaid,168.43,,,168.43,Other,225% of Medicaid,104.8,,,104.8,Other,140% of Medicaid,168.43,,,168.43,Other,225% of Medicaid,194.63,,,194.63,Other,260% of Medicaid,242.54,,,242.54,Other,324% of Medicaid,160.94,,,160.94,Other,215% of Medicaid,160.94,,,160.94,Other,215% of Medicaid,93.57,,,93.57,Other,125% of Medicaid,74.86,368.75,
CONT GLUC MNTR PT PROV EQP,95249,CPT,,70095249,CDM,920,RC,,,both,,,194,143.56,,,143.56,Other,150% of Medicare + 9.63% HCRA Surcharge,87.3,45,,87.3,percent of total billed charges,Critical Access Hospital RCC factor,227.13,,,227.13,Fee Schedule,,204.34,,,204.34,Fee Schedule,,148.41,76.5,,148.41,percent of total billed charges,All Other,137.74,69,,137.74,percent of total billed charges,All Other,133.86,65,,133.86,percent of total billed charges,All Other,96.03,,,96.03,Other,110% of Medicare,269.85,,,269.85,Fee Schedule,,0.01,,,0.01,Other,186% of Medicaid,317.55,,,317.55,Fee Schedule,,120.28,,,120.28,Fee Schedule,,149.52,,,149.52,Fee Schedule,,317.55,,,317.55,Fee Schedule,,120.28,,,120.28,Fee Schedule,,155.2,80,,155.2,percent of total billed charges,All Other,135.8,70,,135.8,percent of total billed charges,All Other,283.72,,,283.72,Fee Schedule,,240.47,,,240.47,Fee Schedule,,97,,,97,Case Rate,,97,,,97,Case Rate,,97,,,97,Case Rate,,97,,,97,Case Rate,,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,317.55,
GLUCOSE MONITORING CONT 72+ HRS,95250,CPT,,70095250,CDM,920,RC,,,both,,,1068,790.32,,,790.32,Other,150% of Medicare + 9.63% HCRA Surcharge,480.6,45,,480.6,percent of total billed charges,Critical Access Hospital RCC factor,512.47,,,512.47,Fee Schedule,,461.07,,,461.07,Fee Schedule,,997.82,,,997.82,Fee Schedule,,897.47,,,897.47,Fee Schedule,,848.24,,,848.24,Fee Schedule,,528.66,,,528.66,Other,110% of Medicare,608.86,,,608.86,Fee Schedule,,285,,,285,Other,186% of Medicaid,716.5,,,716.5,Fee Schedule,,662.16,,,662.16,Fee Schedule,,337.37,,,337.37,Fee Schedule,,716.5,,,716.5,Fee Schedule,,662.16,,,662.16,Fee Schedule,,854.4,80,,854.4,percent of total billed charges,All Other,747.6,70,,747.6,percent of total billed charges,All Other,718.32,,,718.32,Fee Schedule,,608.82,,,608.82,Fee Schedule,,534,,,534,Case Rate,,534,,,534,Case Rate,,534,,,534,Case Rate,,534,,,534,Case Rate,,153.11,,,153.11,Other,100% of Medicaid,153.11,,,153.11,Other,100% of Medicaid,153.11,,,153.11,Other,100% of Medicaid,153.11,,,153.11,Other,100% of Medicaid,344.49,,,344.49,Other,225% of Medicaid,234.25,,,234.25,Other,153% of Medicaid,344.49,,,344.49,Other,225% of Medicaid,214.35,,,214.35,Other,140% of Medicaid,344.49,,,344.49,Other,225% of Medicaid,398.08,,,398.08,Other,260% of Medicaid,496.07,,,496.07,Other,324% of Medicaid,329.18,,,329.18,Other,215% of Medicaid,329.18,,,329.18,Other,215% of Medicaid,191.38,,,191.38,Other,125% of Medicaid,153.11,997.82,
POLYSOM <6 YRS 4> PARAMTRS,95782,CPT,,72095782,CDM,920,RC,,,both,,,2304,1704.97,,,1704.97,Other,150% of Medicare + 9.63% HCRA Surcharge,1036.8,45,,1036.8,percent of total billed charges,Critical Access Hospital RCC factor,2882,,,2882,Case Rate,Sleep Study,2594,,,2594,Case Rate,Sleep Study,761.82,,,761.82,Fee Schedule,,761.82,,,761.82,Fee Schedule,,761.82,,,761.82,Fee Schedule,,1140.48,,,1140.48,Other,110% of Medicare,1566.72,68,,1566.72,percent of total billed charges,All Other,1316,,,1316,Other,186% of Medicaid,1843.2,80,,1843.2,percent of total billed charges,All Other,5645,,,5645,Case Rate,Sleep Study,5645,,,5645,Case Rate,Sleep Study,1843.2,80,,1843.2,percent of total billed charges,All Other,5645,,,5645,Case Rate,Sleep Study,1843.2,80,,1843.2,percent of total billed charges,All Other,1612.8,70,,1612.8,percent of total billed charges,All Other,3986.84,,,3986.84,Fee Schedule,,3379.09,,,3379.09,Fee Schedule,,3524,,,3524,Case Rate,Sleep Study,3171,,,3171,Case Rate,Sleep Study,3524,,,3524,Case Rate,Sleep Study,2995,,,2995,Case Rate,Sleep Study,707.27,,,707.27,Other,100% of Medicaid,707.27,,,707.27,Other,100% of Medicaid,707.27,,,707.27,Other,100% of Medicaid,707.27,,,707.27,Other,100% of Medicaid,1591.35,,,1591.35,Other,225% of Medicaid,1082.12,,,1082.12,Other,153% of Medicaid,1591.35,,,1591.35,Other,225% of Medicaid,990.17,,,990.17,Other,140% of Medicaid,1591.35,,,1591.35,Other,225% of Medicaid,1838.89,,,1838.89,Other,260% of Medicaid,2291.55,,,2291.55,Other,324% of Medicaid,1520.62,,,1520.62,Other,215% of Medicaid,1520.62,,,1520.62,Other,215% of Medicaid,884.08,,,884.08,Other,125% of Medicaid,707.27,5645,
POLYSOM <6 YRS CPAP/BILVL,95783,CPT,,72095783,CDM,920,RC,,,both,,,2466,1824.85,,,1824.85,Other,150% of Medicare + 9.63% HCRA Surcharge,1109.7,45,,1109.7,percent of total billed charges,Critical Access Hospital RCC factor,2882,,,2882,Case Rate,Sleep Study,2594,,,2594,Case Rate,Sleep Study,809.78,,,809.78,Fee Schedule,,809.78,,,809.78,Fee Schedule,,809.78,,,809.78,Fee Schedule,,1220.67,,,1220.67,Other,110% of Medicare,1676.88,68,,1676.88,percent of total billed charges,All Other,1316,,,1316,Other,186% of Medicaid,1972.8,80,,1972.8,percent of total billed charges,All Other,5645,,,5645,Case Rate,Sleep Study,5645,,,5645,Case Rate,Sleep Study,1972.8,80,,1972.8,percent of total billed charges,All Other,5645,,,5645,Case Rate,Sleep Study,1972.8,80,,1972.8,percent of total billed charges,All Other,1726.2,70,,1726.2,percent of total billed charges,All Other,4204.96,,,4204.96,Fee Schedule,,3563.96,,,3563.96,Fee Schedule,,3524,,,3524,Case Rate,Sleep Study,3171,,,3171,Case Rate,Sleep Study,3524,,,3524,Case Rate,Sleep Study,2995,,,2995,Case Rate,Sleep Study,707.27,,,707.27,Other,100% of Medicaid,707.27,,,707.27,Other,100% of Medicaid,707.27,,,707.27,Other,100% of Medicaid,707.27,,,707.27,Other,100% of Medicaid,1591.35,,,1591.35,Other,225% of Medicaid,1082.12,,,1082.12,Other,153% of Medicaid,1591.35,,,1591.35,Other,225% of Medicaid,990.17,,,990.17,Other,140% of Medicaid,1591.35,,,1591.35,Other,225% of Medicaid,1838.89,,,1838.89,Other,260% of Medicaid,2291.55,,,2291.55,Other,324% of Medicaid,1520.62,,,1520.62,Other,215% of Medicaid,1520.62,,,1520.62,Other,215% of Medicaid,884.08,,,884.08,Other,125% of Medicaid,707.27,5645,
MULTIPLE SLEEP LATENCY TEST,95805,CPT,,72095805,CDM,920,RC,,,both,,,4362,3227.89,,,3227.89,Other,150% of Medicare + 9.63% HCRA Surcharge,1962.9,45,,1962.9,percent of total billed charges,Critical Access Hospital RCC factor,2882,,,2882,Case Rate,Sleep Study,2594,,,2594,Case Rate,Sleep Study,2348.26,,,2348.26,Fee Schedule,,2112.1,,,2112.1,Fee Schedule,,1996.24,,,1996.24,Fee Schedule,,2159.19,,,2159.19,Other,110% of Medicare,2966.16,68,,2966.16,percent of total billed charges,All Other,1316,,,1316,Other,186% of Medicaid,3489.6,80,,3489.6,percent of total billed charges,All Other,5564,,,5564,Case Rate,Sleep Study,5564,,,5564,Case Rate,Sleep Study,3489.6,80,,3489.6,percent of total billed charges,All Other,5564,,,5564,Case Rate,Sleep Study,3489.6,80,,3489.6,percent of total billed charges,All Other,3053.4,70,,3053.4,percent of total billed charges,All Other,1748.24,,,1748.24,Fee Schedule,,1481.74,,,1481.74,Fee Schedule,,3524,,,3524,Case Rate,Sleep Study,3171,,,3171,Case Rate,Sleep Study,3524,,,3524,Case Rate,Sleep Study,2995,,,2995,Case Rate,Sleep Study,707.27,,,707.27,Other,100% of Medicaid,707.27,,,707.27,Other,100% of Medicaid,707.27,,,707.27,Other,100% of Medicaid,707.27,,,707.27,Other,100% of Medicaid,1591.35,,,1591.35,Other,225% of Medicaid,1082.12,,,1082.12,Other,153% of Medicaid,1591.35,,,1591.35,Other,225% of Medicaid,990.17,,,990.17,Other,140% of Medicaid,1591.35,,,1591.35,Other,225% of Medicaid,1838.89,,,1838.89,Other,260% of Medicaid,2291.55,,,2291.55,Other,324% of Medicaid,1520.62,,,1520.62,Other,215% of Medicaid,1520.62,,,1520.62,Other,215% of Medicaid,884.08,,,884.08,Other,125% of Medicaid,707.27,5564,
SLEEP STUDY UNATT&RESP EFFT(HOME),95806,CPT,,72095806,CDM,920,RC,,,both,,,1336,988.64,,,988.64,Other,150% of Medicare + 9.63% HCRA Surcharge,601.2,45,,601.2,percent of total billed charges,Critical Access Hospital RCC factor,2882,,,2882,Case Rate,Sleep Study,2594,,,2594,Case Rate,Sleep Study,803.52,,,803.52,Fee Schedule,,722.71,,,722.71,Fee Schedule,,683.07,,,683.07,Fee Schedule,,661.32,,,661.32,Other,110% of Medicare,908.48,68,,908.48,percent of total billed charges,All Other,741,,,741,Other,186% of Medicaid,1068.8,80,,1068.8,percent of total billed charges,All Other,5357,,,5357,Case Rate,Sleep Study,5357,,,5357,Case Rate,Sleep Study,1068.8,80,,1068.8,percent of total billed charges,All Other,5357,,,5357,Case Rate,Sleep Study,1068.8,80,,1068.8,percent of total billed charges,All Other,935.2,70,,935.2,percent of total billed charges,All Other,229.6,,,229.6,Fee Schedule,,194.6,,,194.6,Fee Schedule,,3524,,,3524,Case Rate,Sleep Study,3171,,,3171,Case Rate,Sleep Study,3524,,,3524,Case Rate,Sleep Study,2995,,,2995,Case Rate,Sleep Study,398.56,,,398.56,Other,100% of Medicaid,398.56,,,398.56,Other,100% of Medicaid,398.56,,,398.56,Other,100% of Medicaid,398.56,,,398.56,Other,100% of Medicaid,896.77,,,896.77,Other,225% of Medicaid,609.8,,,609.8,Other,153% of Medicaid,896.77,,,896.77,Other,225% of Medicaid,557.99,,,557.99,Other,140% of Medicaid,896.77,,,896.77,Other,225% of Medicaid,1036.27,,,1036.27,Other,260% of Medicaid,1291.35,,,1291.35,Other,324% of Medicaid,856.91,,,856.91,Other,215% of Medicaid,856.91,,,856.91,Other,215% of Medicaid,498.2,,,498.2,Other,125% of Medicaid,194.6,5357,
POLYSOMNOGRAPHY 4 OR MORE,95810,CPT,,72095810,CDM,920,RC,,,both,,,4362,3227.89,,,3227.89,Other,150% of Medicare + 9.63% HCRA Surcharge,1962.9,45,,1962.9,percent of total billed charges,Critical Access Hospital RCC factor,2882,,,2882,Case Rate,Sleep Study,2594,,,2594,Case Rate,Sleep Study,3831.76,,,3831.76,Fee Schedule,,3446.41,,,3446.41,Fee Schedule,,3257.36,,,3257.36,Fee Schedule,,2159.19,,,2159.19,Other,110% of Medicare,2966.16,68,,2966.16,percent of total billed charges,All Other,1316,,,1316,Other,186% of Medicaid,3489.6,80,,3489.6,percent of total billed charges,All Other,5645,,,5645,Case Rate,Sleep Study,5645,,,5645,Case Rate,Sleep Study,3489.6,80,,3489.6,percent of total billed charges,All Other,5645,,,5645,Case Rate,Sleep Study,3489.6,80,,3489.6,percent of total billed charges,All Other,3053.4,70,,3053.4,percent of total billed charges,All Other,2376.36,,,2376.36,Fee Schedule,,2014.11,,,2014.11,Fee Schedule,,3524,,,3524,Case Rate,Sleep Study,3171,,,3171,Case Rate,Sleep Study,3524,,,3524,Case Rate,Sleep Study,2995,,,2995,Case Rate,Sleep Study,707.27,,,707.27,Other,100% of Medicaid,707.27,,,707.27,Other,100% of Medicaid,707.27,,,707.27,Other,100% of Medicaid,707.27,,,707.27,Other,100% of Medicaid,1591.35,,,1591.35,Other,225% of Medicaid,1082.12,,,1082.12,Other,153% of Medicaid,1591.35,,,1591.35,Other,225% of Medicaid,990.17,,,990.17,Other,140% of Medicaid,1591.35,,,1591.35,Other,225% of Medicaid,1838.89,,,1838.89,Other,260% of Medicaid,2291.55,,,2291.55,Other,324% of Medicaid,1520.62,,,1520.62,Other,215% of Medicaid,1520.62,,,1520.62,Other,215% of Medicaid,884.08,,,884.08,Other,125% of Medicaid,707.27,5645,
POLYSOMNOGRAPHY WITH CPAP,95811,CPT,,72095811,CDM,920,RC,,,both,,,4362,3227.89,,,3227.89,Other,150% of Medicare + 9.63% HCRA Surcharge,1962.9,45,,1962.9,percent of total billed charges,Critical Access Hospital RCC factor,2882,,,2882,Case Rate,Sleep Study,2594,,,2594,Case Rate,Sleep Study,4163.72,,,4163.72,Fee Schedule,,3744.98,,,3744.98,Fee Schedule,,3539.56,,,3539.56,Fee Schedule,,2159.19,,,2159.19,Other,110% of Medicare,2966.16,68,,2966.16,percent of total billed charges,All Other,1316,,,1316,Other,186% of Medicaid,3489.6,80,,3489.6,percent of total billed charges,All Other,5645,,,5645,Case Rate,Sleep Study,5645,,,5645,Case Rate,Sleep Study,3489.6,80,,3489.6,percent of total billed charges,All Other,5645,,,5645,Case Rate,Sleep Study,3489.6,80,,3489.6,percent of total billed charges,All Other,3053.4,70,,3053.4,percent of total billed charges,All Other,2484.6,,,2484.6,Fee Schedule,,2105.85,,,2105.85,Fee Schedule,,3524,,,3524,Case Rate,Sleep Study,3171,,,3171,Case Rate,Sleep Study,3524,,,3524,Case Rate,Sleep Study,2995,,,2995,Case Rate,Sleep Study,707.27,,,707.27,Other,100% of Medicaid,707.27,,,707.27,Other,100% of Medicaid,707.27,,,707.27,Other,100% of Medicaid,707.27,,,707.27,Other,100% of Medicaid,1591.35,,,1591.35,Other,225% of Medicaid,1082.12,,,1082.12,Other,153% of Medicaid,1591.35,,,1591.35,Other,225% of Medicaid,990.17,,,990.17,Other,140% of Medicaid,1591.35,,,1591.35,Other,225% of Medicaid,1838.89,,,1838.89,Other,260% of Medicaid,2291.55,,,2291.55,Other,324% of Medicaid,1520.62,,,1520.62,Other,215% of Medicaid,1520.62,,,1520.62,Other,215% of Medicaid,884.08,,,884.08,Other,125% of Medicaid,707.27,5645,
POLYSOM <6 YRS 4> PARAMTRS <7 HOURS,95782,CPT,52,72195782,CDM,920,RC,,,both,,,1844,1364.56,,,1364.56,Other,150% of Medicare + 9.63% HCRA Surcharge,829.8,45,,829.8,percent of total billed charges,Critical Access Hospital RCC factor,2882,,,2882,Case Rate,Sleep Study,2594,,,2594,Case Rate,Sleep Study,761.82,,,761.82,Fee Schedule,,761.82,,,761.82,Fee Schedule,,761.82,,,761.82,Fee Schedule,,912.78,,,912.78,Other,110% of Medicare,1253.92,68,,1253.92,percent of total billed charges,All Other,1316,,,1316,Other,186% of Medicaid,1475.2,80,,1475.2,percent of total billed charges,All Other,5645,,,5645,Case Rate,Sleep Study,5645,,,5645,Case Rate,Sleep Study,1475.2,80,,1475.2,percent of total billed charges,All Other,5645,,,5645,Case Rate,Sleep Study,1475.2,80,,1475.2,percent of total billed charges,All Other,1290.8,70,,1290.8,percent of total billed charges,All Other,3986.84,,,3986.84,Fee Schedule,,3379.09,,,3379.09,Fee Schedule,,3524,,,3524,Case Rate,Sleep Study,3171,,,3171,Case Rate,Sleep Study,3524,,,3524,Case Rate,Sleep Study,2995,,,2995,Case Rate,Sleep Study,707.27,,,707.27,Other,100% of Medicaid,707.27,,,707.27,Other,100% of Medicaid,707.27,,,707.27,Other,100% of Medicaid,707.27,,,707.27,Other,100% of Medicaid,1591.35,,,1591.35,Other,225% of Medicaid,1082.12,,,1082.12,Other,153% of Medicaid,1591.35,,,1591.35,Other,225% of Medicaid,990.17,,,990.17,Other,140% of Medicaid,1591.35,,,1591.35,Other,225% of Medicaid,1838.89,,,1838.89,Other,260% of Medicaid,2291.55,,,2291.55,Other,324% of Medicaid,1520.62,,,1520.62,Other,215% of Medicaid,1520.62,,,1520.62,Other,215% of Medicaid,884.08,,,884.08,Other,125% of Medicaid,707.27,5645,
POLYSOM <6 YRS CPAP/BILVL <7 HOURS,95783,CPT,52,72195783,CDM,920,RC,,,both,,,1973,1460.02,,,1460.02,Other,150% of Medicare + 9.63% HCRA Surcharge,887.85,45,,887.85,percent of total billed charges,Critical Access Hospital RCC factor,2882,,,2882,Case Rate,Sleep Study,2594,,,2594,Case Rate,Sleep Study,809.78,,,809.78,Fee Schedule,,809.78,,,809.78,Fee Schedule,,809.78,,,809.78,Fee Schedule,,976.64,,,976.64,Other,110% of Medicare,1341.64,68,,1341.64,percent of total billed charges,All Other,1316,,,1316,Other,186% of Medicaid,1578.4,80,,1578.4,percent of total billed charges,All Other,5645,,,5645,Case Rate,Sleep Study,5645,,,5645,Case Rate,Sleep Study,1578.4,80,,1578.4,percent of total billed charges,All Other,5645,,,5645,Case Rate,Sleep Study,1578.4,80,,1578.4,percent of total billed charges,All Other,1381.1,70,,1381.1,percent of total billed charges,All Other,4204.96,,,4204.96,Fee Schedule,,3563.96,,,3563.96,Fee Schedule,,3524,,,3524,Case Rate,Sleep Study,3171,,,3171,Case Rate,Sleep Study,3524,,,3524,Case Rate,Sleep Study,2995,,,2995,Case Rate,Sleep Study,707.27,,,707.27,Other,100% of Medicaid,707.27,,,707.27,Other,100% of Medicaid,707.27,,,707.27,Other,100% of Medicaid,707.27,,,707.27,Other,100% of Medicaid,1591.35,,,1591.35,Other,225% of Medicaid,1082.12,,,1082.12,Other,153% of Medicaid,1591.35,,,1591.35,Other,225% of Medicaid,990.17,,,990.17,Other,140% of Medicaid,1591.35,,,1591.35,Other,225% of Medicaid,1838.89,,,1838.89,Other,260% of Medicaid,2291.55,,,2291.55,Other,324% of Medicaid,1520.62,,,1520.62,Other,215% of Medicaid,1520.62,,,1520.62,Other,215% of Medicaid,884.08,,,884.08,Other,125% of Medicaid,707.27,5645,
REDUCED POLYSOMOGRAPHY,95810,CPT,52,72195810,CDM,920,RC,,,both,,,3490,2582.61,,,2582.61,Other,150% of Medicare + 9.63% HCRA Surcharge,1570.5,45,,1570.5,percent of total billed charges,Critical Access Hospital RCC factor,2882,,,2882,Case Rate,Sleep Study,2594,,,2594,Case Rate,Sleep Study,3831.76,,,3831.76,Fee Schedule,,3446.41,,,3446.41,Fee Schedule,,3257.36,,,3257.36,Fee Schedule,,1727.55,,,1727.55,Other,110% of Medicare,2373.2,68,,2373.2,percent of total billed charges,All Other,1316,,,1316,Other,186% of Medicaid,2792,80,,2792,percent of total billed charges,All Other,5645,,,5645,Case Rate,Sleep Study,5645,,,5645,Case Rate,Sleep Study,2792,80,,2792,percent of total billed charges,All Other,5645,,,5645,Case Rate,Sleep Study,2792,80,,2792,percent of total billed charges,All Other,2443,70,,2443,percent of total billed charges,All Other,2376.36,,,2376.36,Fee Schedule,,2014.11,,,2014.11,Fee Schedule,,3524,,,3524,Case Rate,Sleep Study,3171,,,3171,Case Rate,Sleep Study,3524,,,3524,Case Rate,Sleep Study,2995,,,2995,Case Rate,Sleep Study,707.27,,,707.27,Other,100% of Medicaid,707.27,,,707.27,Other,100% of Medicaid,707.27,,,707.27,Other,100% of Medicaid,707.27,,,707.27,Other,100% of Medicaid,1591.35,,,1591.35,Other,225% of Medicaid,1082.12,,,1082.12,Other,153% of Medicaid,1591.35,,,1591.35,Other,225% of Medicaid,990.17,,,990.17,Other,140% of Medicaid,1591.35,,,1591.35,Other,225% of Medicaid,1838.89,,,1838.89,Other,260% of Medicaid,2291.55,,,2291.55,Other,324% of Medicaid,1520.62,,,1520.62,Other,215% of Medicaid,1520.62,,,1520.62,Other,215% of Medicaid,884.08,,,884.08,Other,125% of Medicaid,707.27,5645,
REDUCED POLYSOMNOGRAPHY WITH CPAP,95811,CPT,52,72195811,CDM,920,RC,,,both,,,3490,2582.61,,,2582.61,Other,150% of Medicare + 9.63% HCRA Surcharge,1570.5,45,,1570.5,percent of total billed charges,Critical Access Hospital RCC factor,2882,,,2882,Case Rate,Sleep Study,2594,,,2594,Case Rate,Sleep Study,4163.72,,,4163.72,Fee Schedule,,3744.98,,,3744.98,Fee Schedule,,3539.56,,,3539.56,Fee Schedule,,1727.55,,,1727.55,Other,110% of Medicare,2373.2,68,,2373.2,percent of total billed charges,All Other,1316,,,1316,Other,186% of Medicaid,2792,80,,2792,percent of total billed charges,All Other,5645,,,5645,Case Rate,Sleep Study,5645,,,5645,Case Rate,Sleep Study,2792,80,,2792,percent of total billed charges,All Other,5645,,,5645,Case Rate,Sleep Study,2792,80,,2792,percent of total billed charges,All Other,2443,70,,2443,percent of total billed charges,All Other,2484.6,,,2484.6,Fee Schedule,,2105.85,,,2105.85,Fee Schedule,,3524,,,3524,Case Rate,Sleep Study,3171,,,3171,Case Rate,Sleep Study,3524,,,3524,Case Rate,Sleep Study,2995,,,2995,Case Rate,Sleep Study,707.27,,,707.27,Other,100% of Medicaid,707.27,,,707.27,Other,100% of Medicaid,707.27,,,707.27,Other,100% of Medicaid,707.27,,,707.27,Other,100% of Medicaid,1591.35,,,1591.35,Other,225% of Medicaid,1082.12,,,1082.12,Other,153% of Medicaid,1591.35,,,1591.35,Other,225% of Medicaid,990.17,,,990.17,Other,140% of Medicaid,1591.35,,,1591.35,Other,225% of Medicaid,1838.89,,,1838.89,Other,260% of Medicaid,2291.55,,,2291.55,Other,324% of Medicaid,1520.62,,,1520.62,Other,215% of Medicaid,1520.62,,,1520.62,Other,215% of Medicaid,884.08,,,884.08,Other,125% of Medicaid,707.27,5645,
SAFE PASSAGE NEURO MONITORING PER 15 MIN,95955,CPT,,79006693,CDM,920,RC,,,both,,,728,538.72,,,538.72,Other,150% of Medicare + 9.63% HCRA Surcharge,327.6,45,,327.6,percent of total billed charges,Critical Access Hospital RCC factor,479.62,,,479.62,Fee Schedule,,431.5,,,431.5,Fee Schedule,,791.87,,,791.87,Fee Schedule,,712.23,,,712.23,Fee Schedule,,673.16,,,673.16,Fee Schedule,,360.36,,,360.36,Other,110% of Medicare,569.83,,,569.83,Fee Schedule,,273,,,273,Other,186% of Medicaid,670.56,,,670.56,Fee Schedule,,451.36,,,451.36,Fee Schedule,,315.74,,,315.74,Fee Schedule,,670.56,,,670.56,Fee Schedule,,451.36,,,451.36,Fee Schedule,,582.4,80,,582.4,percent of total billed charges,All Other,509.6,70,,509.6,percent of total billed charges,All Other,739.64,,,739.64,Fee Schedule,,626.89,,,626.89,Fee Schedule,,906,,,906,Case Rate,,816,,,816,Case Rate,,906,,,906,Case Rate,,770,,,770,Case Rate,,146.84,,,146.84,Other,100% of Medicaid,146.84,,,146.84,Other,100% of Medicaid,146.84,,,146.84,Other,100% of Medicaid,146.84,,,146.84,Other,100% of Medicaid,330.39,,,330.39,Other,225% of Medicaid,224.66,,,224.66,Other,153% of Medicaid,330.39,,,330.39,Other,225% of Medicaid,205.57,,,205.57,Other,140% of Medicaid,330.39,,,330.39,Other,225% of Medicaid,381.78,,,381.78,Other,260% of Medicaid,475.76,,,475.76,Other,324% of Medicaid,315.7,,,315.7,Other,215% of Medicaid,315.7,,,315.7,Other,215% of Medicaid,183.55,,,183.55,Other,125% of Medicaid,146.84,906,
UPR/L XTREMITY ART 2 LEVELS,93922,CPT,,34093922,CDM,921,RC,,,both,,,706,522.44,,,522.44,Other,150% of Medicare + 9.63% HCRA Surcharge,317.7,45,,317.7,percent of total billed charges,Critical Access Hospital RCC factor,226.8,,,226.8,Fee Schedule,,204.5,,,204.5,Fee Schedule,,661.44,,,661.44,Fee Schedule,,594.92,,,594.92,Fee Schedule,,562.28,,,562.28,Fee Schedule,,349.47,,,349.47,Other,110% of Medicare,0.68,,,0.68,Fee Schedule,,226,,,226,Other,186% of Medicaid,0.8,,,0.8,Fee Schedule,,0.83,,,0.83,Fee Schedule,,0.83,,,0.83,Fee Schedule,,0.8,,,0.8,Fee Schedule,,0.83,,,0.83,Fee Schedule,,564.8,80,,564.8,percent of total billed charges,All Other,494.2,70,,494.2,percent of total billed charges,All Other,342.76,,,342.76,Fee Schedule,,290.51,,,290.51,Fee Schedule,,353,,,353,Case Rate,,353,,,353,Case Rate,,353,,,353,Case Rate,,353,,,353,Case Rate,,121.68,,,121.68,Other,100% of Medicaid,121.68,,,121.68,Other,100% of Medicaid,121.68,,,121.68,Other,100% of Medicaid,121.68,,,121.68,Other,100% of Medicaid,273.79,,,273.79,Other,225% of Medicaid,186.18,,,186.18,Other,153% of Medicaid,273.79,,,273.79,Other,225% of Medicaid,170.36,,,170.36,Other,140% of Medicaid,273.79,,,273.79,Other,225% of Medicaid,316.38,,,316.38,Other,260% of Medicaid,394.25,,,394.25,Other,324% of Medicaid,261.62,,,261.62,Other,215% of Medicaid,261.62,,,261.62,Other,215% of Medicaid,152.1,,,152.1,Other,125% of Medicaid,0.68,661.44,
DUPLX EXTRACRANIAL  BILAT,93880,CPT,TC,44093880,CDM,921,RC,,,both,,,2002,1481.49,,,1481.49,Other,150% of Medicare + 9.63% HCRA Surcharge,900.9,45,,900.9,percent of total billed charges,Critical Access Hospital RCC factor,489.79,,,489.79,Fee Schedule,,441.64,,,441.64,Fee Schedule,,1032.13,,,1032.13,Fee Schedule,,928.33,,,928.33,Fee Schedule,,877.41,,,877.41,Fee Schedule,,990.99,,,990.99,Other,110% of Medicare,0.68,,,0.68,Fee Schedule,,982,,,982,Other,186% of Medicaid,0.8,,,0.8,Fee Schedule,,0.83,,,0.83,Fee Schedule,,0.83,,,0.83,Fee Schedule,,0.8,,,0.8,Fee Schedule,,0.83,,,0.83,Fee Schedule,,1601.6,80,,1601.6,percent of total billed charges,All Other,1401.4,70,,1401.4,percent of total billed charges,All Other,757.68,,,757.68,Fee Schedule,,642.18,,,642.18,Fee Schedule,,811,,,811,Case Rate,,730,,,730,Case Rate,,811,,,811,Case Rate,,689,,,689,Case Rate,,527.83,,,527.83,Other,100% of Medicaid,527.83,,,527.83,Other,100% of Medicaid,527.83,,,527.83,Other,100% of Medicaid,527.83,,,527.83,Other,100% of Medicaid,1187.61,,,1187.61,Other,225% of Medicaid,807.58,,,807.58,Other,153% of Medicaid,1187.61,,,1187.61,Other,225% of Medicaid,738.96,,,738.96,Other,140% of Medicaid,1187.61,,,1187.61,Other,225% of Medicaid,1372.35,,,1372.35,Other,260% of Medicaid,1710.16,,,1710.16,Other,324% of Medicaid,1134.83,,,1134.83,Other,215% of Medicaid,1134.83,,,1134.83,Other,215% of Medicaid,659.78,,,659.78,Other,125% of Medicaid,0.68,1710.16,
DUPLX EXTRACRANIAL UNILAT,93882,CPT,TC,44093882,CDM,921,RC,,,both,,,873,646.02,,,646.02,Other,150% of Medicare + 9.63% HCRA Surcharge,392.85,45,,392.85,percent of total billed charges,Critical Access Hospital RCC factor,325.09,,,325.09,Fee Schedule,,293.13,,,293.13,Fee Schedule,,1029.86,,,1029.86,Fee Schedule,,926.29,,,926.29,Fee Schedule,,875.48,,,875.48,Fee Schedule,,432.14,,,432.14,Other,110% of Medicare,0.68,,,0.68,Fee Schedule,,226,,,226,Other,186% of Medicaid,0.8,,,0.8,Fee Schedule,,0.83,,,0.83,Fee Schedule,,0.83,,,0.83,Fee Schedule,,0.8,,,0.8,Fee Schedule,,0.83,,,0.83,Fee Schedule,,698.4,80,,698.4,percent of total billed charges,All Other,611.1,70,,611.1,percent of total billed charges,All Other,500.2,,,500.2,Fee Schedule,,423.95,,,423.95,Fee Schedule,,811,,,811,Case Rate,,730,,,730,Case Rate,,811,,,811,Case Rate,,689,,,689,Case Rate,,121.68,,,121.68,Other,100% of Medicaid,121.68,,,121.68,Other,100% of Medicaid,121.68,,,121.68,Other,100% of Medicaid,121.68,,,121.68,Other,100% of Medicaid,273.79,,,273.79,Other,225% of Medicaid,186.18,,,186.18,Other,153% of Medicaid,273.79,,,273.79,Other,225% of Medicaid,170.36,,,170.36,Other,140% of Medicaid,273.79,,,273.79,Other,225% of Medicaid,316.38,,,316.38,Other,260% of Medicaid,394.25,,,394.25,Other,324% of Medicaid,261.62,,,261.62,Other,215% of Medicaid,261.62,,,261.62,Other,215% of Medicaid,152.1,,,152.1,Other,125% of Medicaid,0.68,1029.86,
UPR/L XTREMITY ART 2 LEVELS,93922,CPT,TC,44093922,CDM,921,RC,,,both,,,706,522.44,,,522.44,Other,150% of Medicare + 9.63% HCRA Surcharge,317.7,45,,317.7,percent of total billed charges,Critical Access Hospital RCC factor,226.8,,,226.8,Fee Schedule,,204.5,,,204.5,Fee Schedule,,661.44,,,661.44,Fee Schedule,,594.92,,,594.92,Fee Schedule,,562.28,,,562.28,Fee Schedule,,349.47,,,349.47,Other,110% of Medicare,0.68,,,0.68,Fee Schedule,,226,,,226,Other,186% of Medicaid,0.8,,,0.8,Fee Schedule,,0.83,,,0.83,Fee Schedule,,0.83,,,0.83,Fee Schedule,,0.8,,,0.8,Fee Schedule,,0.83,,,0.83,Fee Schedule,,564.8,80,,564.8,percent of total billed charges,All Other,494.2,70,,494.2,percent of total billed charges,All Other,342.76,,,342.76,Fee Schedule,,290.51,,,290.51,Fee Schedule,,353,,,353,Case Rate,,353,,,353,Case Rate,,353,,,353,Case Rate,,353,,,353,Case Rate,,121.68,,,121.68,Other,100% of Medicaid,121.68,,,121.68,Other,100% of Medicaid,121.68,,,121.68,Other,100% of Medicaid,121.68,,,121.68,Other,100% of Medicaid,273.79,,,273.79,Other,225% of Medicaid,186.18,,,186.18,Other,153% of Medicaid,273.79,,,273.79,Other,225% of Medicaid,170.36,,,170.36,Other,140% of Medicaid,273.79,,,273.79,Other,225% of Medicaid,316.38,,,316.38,Other,260% of Medicaid,394.25,,,394.25,Other,324% of Medicaid,261.62,,,261.62,Other,215% of Medicaid,261.62,,,261.62,Other,215% of Medicaid,152.1,,,152.1,Other,125% of Medicaid,0.68,661.44,
EXTREM PVR BILATERAL,93923,CPT,TC,44093923,CDM,921,RC,,,both,,,1054,779.96,,,779.96,Other,150% of Medicare + 9.63% HCRA Surcharge,474.3,45,,474.3,percent of total billed charges,Critical Access Hospital RCC factor,349.81,,,349.81,Fee Schedule,,315.42,,,315.42,Fee Schedule,,997.82,,,997.82,Fee Schedule,,897.47,,,897.47,Fee Schedule,,848.24,,,848.24,Fee Schedule,,521.73,,,521.73,Other,110% of Medicare,0.68,,,0.68,Fee Schedule,,255,,,255,Other,186% of Medicaid,0.8,,,0.8,Fee Schedule,,0.83,,,0.83,Fee Schedule,,0.83,,,0.83,Fee Schedule,,0.8,,,0.8,Fee Schedule,,0.83,,,0.83,Fee Schedule,,843.2,80,,843.2,percent of total billed charges,All Other,737.8,70,,737.8,percent of total billed charges,All Other,523.16,,,523.16,Fee Schedule,,443.41,,,443.41,Fee Schedule,,527,,,527,Case Rate,,527,,,527,Case Rate,,527,,,527,Case Rate,,527,,,527,Case Rate,,137.34,,,137.34,Other,100% of Medicaid,137.34,,,137.34,Other,100% of Medicaid,137.34,,,137.34,Other,100% of Medicaid,137.34,,,137.34,Other,100% of Medicaid,309.01,,,309.01,Other,225% of Medicaid,210.12,,,210.12,Other,153% of Medicaid,309.01,,,309.01,Other,225% of Medicaid,192.27,,,192.27,Other,140% of Medicaid,309.01,,,309.01,Other,225% of Medicaid,357.07,,,357.07,Other,260% of Medicaid,444.97,,,444.97,Other,324% of Medicaid,295.27,,,295.27,Other,215% of Medicaid,295.27,,,295.27,Other,215% of Medicaid,171.67,,,171.67,Other,125% of Medicaid,0.68,997.82,
PVR W STRESS BILAT COMPL,93924,CPT,TC,44093924,CDM,921,RC,,,both,,,1343,993.82,,,993.82,Other,150% of Medicare + 9.63% HCRA Surcharge,604.35,45,,604.35,percent of total billed charges,Critical Access Hospital RCC factor,438.49,,,438.49,Fee Schedule,,395.38,,,395.38,Fee Schedule,,1267.86,,,1267.86,Fee Schedule,,1140.35,,,1140.35,Fee Schedule,,1077.8,,,1077.8,Fee Schedule,,664.79,,,664.79,Other,110% of Medicare,0.68,,,0.68,Fee Schedule,,226,,,226,Other,186% of Medicaid,0.8,,,0.8,Fee Schedule,,0.83,,,0.83,Fee Schedule,,0.83,,,0.83,Fee Schedule,,0.8,,,0.8,Fee Schedule,,0.83,,,0.83,Fee Schedule,,1074.4,80,,1074.4,percent of total billed charges,All Other,940.1,70,,940.1,percent of total billed charges,All Other,659.28,,,659.28,Fee Schedule,,558.78,,,558.78,Fee Schedule,,811,,,811,Case Rate,,730,,,730,Case Rate,,811,,,811,Case Rate,,689,,,689,Case Rate,,121.68,,,121.68,Other,100% of Medicaid,121.68,,,121.68,Other,100% of Medicaid,121.68,,,121.68,Other,100% of Medicaid,121.68,,,121.68,Other,100% of Medicaid,273.79,,,273.79,Other,225% of Medicaid,186.18,,,186.18,Other,153% of Medicaid,273.79,,,273.79,Other,225% of Medicaid,170.36,,,170.36,Other,140% of Medicaid,273.79,,,273.79,Other,225% of Medicaid,316.38,,,316.38,Other,260% of Medicaid,394.25,,,394.25,Other,324% of Medicaid,261.62,,,261.62,Other,215% of Medicaid,261.62,,,261.62,Other,215% of Medicaid,152.1,,,152.1,Other,125% of Medicaid,0.68,1267.86,
DUPLEX LE ART/BPG; BILAT,93925,CPT,TC,44093925,CDM,921,RC,,,both,,,2012,1488.89,,,1488.89,Other,150% of Medicare + 9.63% HCRA Surcharge,905.4,45,,905.4,percent of total billed charges,Critical Access Hospital RCC factor,652.33,,,652.33,Fee Schedule,,588.21,,,588.21,Fee Schedule,,1032.23,,,1032.23,Fee Schedule,,928.42,,,928.42,Fee Schedule,,877.5,,,877.5,Fee Schedule,,995.94,,,995.94,Other,110% of Medicare,0.68,,,0.68,Fee Schedule,,982,,,982,Other,186% of Medicaid,0.8,,,0.8,Fee Schedule,,0.83,,,0.83,Fee Schedule,,0.83,,,0.83,Fee Schedule,,0.8,,,0.8,Fee Schedule,,0.83,,,0.83,Fee Schedule,,1609.6,80,,1609.6,percent of total billed charges,All Other,1408.4,70,,1408.4,percent of total billed charges,All Other,1011.88,,,1011.88,Fee Schedule,,857.63,,,857.63,Fee Schedule,,811,,,811,Case Rate,,730,,,730,Case Rate,,811,,,811,Case Rate,,689,,,689,Case Rate,,527.83,,,527.83,Other,100% of Medicaid,527.83,,,527.83,Other,100% of Medicaid,527.83,,,527.83,Other,100% of Medicaid,527.83,,,527.83,Other,100% of Medicaid,1187.61,,,1187.61,Other,225% of Medicaid,807.58,,,807.58,Other,153% of Medicaid,1187.61,,,1187.61,Other,225% of Medicaid,738.96,,,738.96,Other,140% of Medicaid,1187.61,,,1187.61,Other,225% of Medicaid,1372.35,,,1372.35,Other,260% of Medicaid,1710.16,,,1710.16,Other,324% of Medicaid,1134.83,,,1134.83,Other,215% of Medicaid,1134.83,,,1134.83,Other,215% of Medicaid,659.78,,,659.78,Other,125% of Medicaid,0.68,1710.16,
DUPLEX LE ART/BPG; UNIL/LIMIT,93926,CPT,TC,44093926,CDM,921,RC,,,both,,,1167,863.58,,,863.58,Other,150% of Medicare + 9.63% HCRA Surcharge,525.15,45,,525.15,percent of total billed charges,Critical Access Hospital RCC factor,342.35,,,342.35,Fee Schedule,,308.69,,,308.69,Fee Schedule,,650,,,650,Fee Schedule,,584.63,,,584.63,Fee Schedule,,552.56,,,552.56,Fee Schedule,,577.67,,,577.67,Other,110% of Medicare,0.68,,,0.68,Fee Schedule,,226,,,226,Other,186% of Medicaid,0.8,,,0.8,Fee Schedule,,0.83,,,0.83,Fee Schedule,,0.83,,,0.83,Fee Schedule,,0.8,,,0.8,Fee Schedule,,0.83,,,0.83,Fee Schedule,,933.6,80,,933.6,percent of total billed charges,All Other,816.9,70,,816.9,percent of total billed charges,All Other,595.32,,,595.32,Fee Schedule,,504.57,,,504.57,Fee Schedule,,811,,,811,Case Rate,,730,,,730,Case Rate,,811,,,811,Case Rate,,689,,,689,Case Rate,,121.68,,,121.68,Other,100% of Medicaid,121.68,,,121.68,Other,100% of Medicaid,121.68,,,121.68,Other,100% of Medicaid,121.68,,,121.68,Other,100% of Medicaid,273.79,,,273.79,Other,225% of Medicaid,186.18,,,186.18,Other,153% of Medicaid,273.79,,,273.79,Other,225% of Medicaid,170.36,,,170.36,Other,140% of Medicaid,273.79,,,273.79,Other,225% of Medicaid,316.38,,,316.38,Other,260% of Medicaid,394.25,,,394.25,Other,324% of Medicaid,261.62,,,261.62,Other,215% of Medicaid,261.62,,,261.62,Other,215% of Medicaid,152.1,,,152.1,Other,125% of Medicaid,0.68,933.6,
DUPLX UPPR EXTREM  ART BILAT,93930,CPT,TC,44093930,CDM,921,RC,,,both,,,1410,1043.4,,,1043.4,Other,150% of Medicare + 9.63% HCRA Surcharge,634.5,45,,634.5,percent of total billed charges,Critical Access Hospital RCC factor,515.42,,,515.42,Fee Schedule,,464.76,,,464.76,Fee Schedule,,1032.13,,,1032.13,Fee Schedule,,928.33,,,928.33,Fee Schedule,,877.41,,,877.41,Fee Schedule,,697.95,,,697.95,Other,110% of Medicare,0.68,,,0.68,Fee Schedule,,226,,,226,Other,186% of Medicaid,0.8,,,0.8,Fee Schedule,,0.83,,,0.83,Fee Schedule,,0.83,,,0.83,Fee Schedule,,0.8,,,0.8,Fee Schedule,,0.83,,,0.83,Fee Schedule,,1128,80,,1128,percent of total billed charges,All Other,987,70,,987,percent of total billed charges,All Other,783.92,,,783.92,Fee Schedule,,664.42,,,664.42,Fee Schedule,,811,,,811,Case Rate,,730,,,730,Case Rate,,811,,,811,Case Rate,,689,,,689,Case Rate,,121.68,,,121.68,Other,100% of Medicaid,121.68,,,121.68,Other,100% of Medicaid,121.68,,,121.68,Other,100% of Medicaid,121.68,,,121.68,Other,100% of Medicaid,273.79,,,273.79,Other,225% of Medicaid,186.18,,,186.18,Other,153% of Medicaid,273.79,,,273.79,Other,225% of Medicaid,170.36,,,170.36,Other,140% of Medicaid,273.79,,,273.79,Other,225% of Medicaid,316.38,,,316.38,Other,260% of Medicaid,394.25,,,394.25,Other,324% of Medicaid,261.62,,,261.62,Other,215% of Medicaid,261.62,,,261.62,Other,215% of Medicaid,152.1,,,152.1,Other,125% of Medicaid,0.68,1128,
DUPLEX UE ART/BPG; UNIL/LIMIT,93931,CPT,TC,44093931,CDM,921,RC,,,both,,,954,705.96,,,705.96,Other,150% of Medicare + 9.63% HCRA Surcharge,429.3,45,,429.3,percent of total billed charges,Critical Access Hospital RCC factor,322.97,,,322.97,Fee Schedule,,291.22,,,291.22,Fee Schedule,,650,,,650,Fee Schedule,,584.63,,,584.63,Fee Schedule,,552.56,,,552.56,Fee Schedule,,472.23,,,472.23,Other,110% of Medicare,0.68,,,0.68,Fee Schedule,,226,,,226,Other,186% of Medicaid,0.8,,,0.8,Fee Schedule,,0.83,,,0.83,Fee Schedule,,0.83,,,0.83,Fee Schedule,,0.8,,,0.8,Fee Schedule,,0.83,,,0.83,Fee Schedule,,763.2,80,,763.2,percent of total billed charges,All Other,667.8,70,,667.8,percent of total billed charges,All Other,498.56,,,498.56,Fee Schedule,,422.56,,,422.56,Fee Schedule,,811,,,811,Case Rate,,730,,,730,Case Rate,,811,,,811,Case Rate,,689,,,689,Case Rate,,121.68,,,121.68,Other,100% of Medicaid,121.68,,,121.68,Other,100% of Medicaid,121.68,,,121.68,Other,100% of Medicaid,121.68,,,121.68,Other,100% of Medicaid,273.79,,,273.79,Other,225% of Medicaid,186.18,,,186.18,Other,153% of Medicaid,273.79,,,273.79,Other,225% of Medicaid,170.36,,,170.36,Other,140% of Medicaid,273.79,,,273.79,Other,225% of Medicaid,316.38,,,316.38,Other,260% of Medicaid,394.25,,,394.25,Other,324% of Medicaid,261.62,,,261.62,Other,215% of Medicaid,261.62,,,261.62,Other,215% of Medicaid,152.1,,,152.1,Other,125% of Medicaid,0.68,811,
DUPLEX EXT VEINS; UNIL/LIMIT,93971,CPT,TC,44093971,CDM,921,RC,,,both,,,1360,1006.4,,,1006.4,Other,150% of Medicare + 9.63% HCRA Surcharge,612,45,,612,percent of total billed charges,Critical Access Hospital RCC factor,315.47,,,315.47,Fee Schedule,,284.46,,,284.46,Fee Schedule,,650,,,650,Fee Schedule,,584.63,,,584.63,Fee Schedule,,552.56,,,552.56,Fee Schedule,,673.2,,,673.2,Other,110% of Medicare,0.68,,,0.68,Fee Schedule,,226,,,226,Other,186% of Medicaid,0.8,,,0.8,Fee Schedule,,0.83,,,0.83,Fee Schedule,,0.83,,,0.83,Fee Schedule,,0.8,,,0.8,Fee Schedule,,0.83,,,0.83,Fee Schedule,,1088,80,,1088,percent of total billed charges,All Other,952,70,,952,percent of total billed charges,All Other,485.44,,,485.44,Fee Schedule,,411.44,,,411.44,Fee Schedule,,811,,,811,Case Rate,,730,,,730,Case Rate,,811,,,811,Case Rate,,689,,,689,Case Rate,,121.68,,,121.68,Other,100% of Medicaid,121.68,,,121.68,Other,100% of Medicaid,121.68,,,121.68,Other,100% of Medicaid,121.68,,,121.68,Other,100% of Medicaid,273.79,,,273.79,Other,225% of Medicaid,186.18,,,186.18,Other,153% of Medicaid,273.79,,,273.79,Other,225% of Medicaid,170.36,,,170.36,Other,140% of Medicaid,273.79,,,273.79,Other,225% of Medicaid,316.38,,,316.38,Other,260% of Medicaid,394.25,,,394.25,Other,324% of Medicaid,261.62,,,261.62,Other,215% of Medicaid,261.62,,,261.62,Other,215% of Medicaid,152.1,,,152.1,Other,125% of Medicaid,0.68,1088,
DUPLEX ARTERIAL FLOW; COMPL,93975,CPT,TC,44093975,CDM,921,RC,,,both,,,1880,1391.2,,,1391.2,Other,150% of Medicare + 9.63% HCRA Surcharge,846,45,,846,percent of total billed charges,Critical Access Hospital RCC factor,674.75,,,674.75,Fee Schedule,,608.42,,,608.42,Fee Schedule,,1032.23,,,1032.23,Fee Schedule,,928.42,,,928.42,Fee Schedule,,877.5,,,877.5,Fee Schedule,,930.6,,,930.6,Other,110% of Medicare,0.68,,,0.68,Fee Schedule,,982,,,982,Other,186% of Medicaid,0.8,,,0.8,Fee Schedule,,0.83,,,0.83,Fee Schedule,,0.83,,,0.83,Fee Schedule,,0.8,,,0.8,Fee Schedule,,0.83,,,0.83,Fee Schedule,,1504,80,,1504,percent of total billed charges,All Other,1316,70,,1316,percent of total billed charges,All Other,1044.68,,,1044.68,Fee Schedule,,885.43,,,885.43,Fee Schedule,,811,,,811,Case Rate,,730,,,730,Case Rate,,811,,,811,Case Rate,,689,,,689,Case Rate,,527.83,,,527.83,Other,100% of Medicaid,527.83,,,527.83,Other,100% of Medicaid,527.83,,,527.83,Other,100% of Medicaid,527.83,,,527.83,Other,100% of Medicaid,1187.61,,,1187.61,Other,225% of Medicaid,807.58,,,807.58,Other,153% of Medicaid,1187.61,,,1187.61,Other,225% of Medicaid,738.96,,,738.96,Other,140% of Medicaid,1187.61,,,1187.61,Other,225% of Medicaid,1372.35,,,1372.35,Other,260% of Medicaid,1710.16,,,1710.16,Other,324% of Medicaid,1134.83,,,1134.83,Other,215% of Medicaid,1134.83,,,1134.83,Other,215% of Medicaid,659.78,,,659.78,Other,125% of Medicaid,0.68,1710.16,
DUPLEX ARTERIAL FLOW; LIMITED,93976,CPT,TC,44093976,CDM,921,RC,,,both,,,1131,836.94,,,836.94,Other,150% of Medicare + 9.63% HCRA Surcharge,508.95,45,,508.95,percent of total billed charges,Critical Access Hospital RCC factor,342.2,,,342.2,Fee Schedule,,308.56,,,308.56,Fee Schedule,,1029.86,,,1029.86,Fee Schedule,,926.29,,,926.29,Fee Schedule,,875.48,,,875.48,Fee Schedule,,559.85,,,559.85,Other,110% of Medicare,0.68,,,0.68,Fee Schedule,,982,,,982,Other,186% of Medicaid,0.8,,,0.8,Fee Schedule,,0.83,,,0.83,Fee Schedule,,0.83,,,0.83,Fee Schedule,,0.8,,,0.8,Fee Schedule,,0.83,,,0.83,Fee Schedule,,904.8,80,,904.8,percent of total billed charges,All Other,791.7,70,,791.7,percent of total billed charges,All Other,595.32,,,595.32,Fee Schedule,,504.57,,,504.57,Fee Schedule,,811,,,811,Case Rate,,730,,,730,Case Rate,,811,,,811,Case Rate,,689,,,689,Case Rate,,527.83,,,527.83,Other,100% of Medicaid,527.83,,,527.83,Other,100% of Medicaid,527.83,,,527.83,Other,100% of Medicaid,527.83,,,527.83,Other,100% of Medicaid,1187.61,,,1187.61,Other,225% of Medicaid,807.58,,,807.58,Other,153% of Medicaid,1187.61,,,1187.61,Other,225% of Medicaid,738.96,,,738.96,Other,140% of Medicaid,1187.61,,,1187.61,Other,225% of Medicaid,1372.35,,,1372.35,Other,260% of Medicaid,1710.16,,,1710.16,Other,324% of Medicaid,1134.83,,,1134.83,Other,215% of Medicaid,1134.83,,,1134.83,Other,215% of Medicaid,659.78,,,659.78,Other,125% of Medicaid,0.68,1710.16,
DUPLEX HEMODIALYSIS ACCESS,93990,CPT,TC,44093990,CDM,921,RC,,,both,,,1261,933.14,,,933.14,Other,150% of Medicare + 9.63% HCRA Surcharge,567.45,45,,567.45,percent of total billed charges,Critical Access Hospital RCC factor,342.35,,,342.35,Fee Schedule,,308.69,,,308.69,Fee Schedule,,647.58,,,647.58,Fee Schedule,,582.45,,,582.45,Fee Schedule,,550.5,,,550.5,Fee Schedule,,624.2,,,624.2,Other,110% of Medicare,0.68,,,0.68,Fee Schedule,,226,,,226,Other,186% of Medicaid,0.8,,,0.8,Fee Schedule,,0.83,,,0.83,Fee Schedule,,0.83,,,0.83,Fee Schedule,,0.8,,,0.8,Fee Schedule,,0.83,,,0.83,Fee Schedule,,1008.8,80,,1008.8,percent of total billed charges,All Other,882.7,70,,882.7,percent of total billed charges,All Other,613.36,,,613.36,Fee Schedule,,519.86,,,519.86,Fee Schedule,,811,,,811,Case Rate,,730,,,730,Case Rate,,811,,,811,Case Rate,,689,,,689,Case Rate,,121.68,,,121.68,Other,100% of Medicaid,121.68,,,121.68,Other,100% of Medicaid,121.68,,,121.68,Other,100% of Medicaid,121.68,,,121.68,Other,100% of Medicaid,273.79,,,273.79,Other,225% of Medicaid,186.18,,,186.18,Other,153% of Medicaid,273.79,,,273.79,Other,225% of Medicaid,170.36,,,170.36,Other,140% of Medicaid,273.79,,,273.79,Other,225% of Medicaid,316.38,,,316.38,Other,260% of Medicaid,394.25,,,394.25,Other,324% of Medicaid,261.62,,,261.62,Other,215% of Medicaid,261.62,,,261.62,Other,215% of Medicaid,152.1,,,152.1,Other,125% of Medicaid,0.68,1008.8,
DUPLX LE ART UNILAT LT,93926,CPT,TCLT,44193926,CDM,921,RC,,,both,,,1167,863.58,,,863.58,Other,150% of Medicare + 9.63% HCRA Surcharge,525.15,45,,525.15,percent of total billed charges,Critical Access Hospital RCC factor,342.35,,,342.35,Fee Schedule,,308.69,,,308.69,Fee Schedule,,650,,,650,Fee Schedule,,584.63,,,584.63,Fee Schedule,,552.56,,,552.56,Fee Schedule,,577.67,,,577.67,Other,110% of Medicare,0.68,,,0.68,Fee Schedule,,226,,,226,Other,186% of Medicaid,0.8,,,0.8,Fee Schedule,,0.83,,,0.83,Fee Schedule,,0.83,,,0.83,Fee Schedule,,0.8,,,0.8,Fee Schedule,,0.83,,,0.83,Fee Schedule,,933.6,80,,933.6,percent of total billed charges,All Other,816.9,70,,816.9,percent of total billed charges,All Other,595.32,,,595.32,Fee Schedule,,504.57,,,504.57,Fee Schedule,,811,,,811,Case Rate,,730,,,730,Case Rate,,811,,,811,Case Rate,,689,,,689,Case Rate,,121.68,,,121.68,Other,100% of Medicaid,121.68,,,121.68,Other,100% of Medicaid,121.68,,,121.68,Other,100% of Medicaid,121.68,,,121.68,Other,100% of Medicaid,273.79,,,273.79,Other,225% of Medicaid,186.18,,,186.18,Other,153% of Medicaid,273.79,,,273.79,Other,225% of Medicaid,170.36,,,170.36,Other,140% of Medicaid,273.79,,,273.79,Other,225% of Medicaid,316.38,,,316.38,Other,260% of Medicaid,394.25,,,394.25,Other,324% of Medicaid,261.62,,,261.62,Other,215% of Medicaid,261.62,,,261.62,Other,215% of Medicaid,152.1,,,152.1,Other,125% of Medicaid,0.68,933.6,
DUPLX UE ART UNILAT LT,93931,CPT,TCLT,44193931,CDM,921,RC,,,both,,,954,705.96,,,705.96,Other,150% of Medicare + 9.63% HCRA Surcharge,429.3,45,,429.3,percent of total billed charges,Critical Access Hospital RCC factor,322.97,,,322.97,Fee Schedule,,291.22,,,291.22,Fee Schedule,,650,,,650,Fee Schedule,,584.63,,,584.63,Fee Schedule,,552.56,,,552.56,Fee Schedule,,472.23,,,472.23,Other,110% of Medicare,0.68,,,0.68,Fee Schedule,,226,,,226,Other,186% of Medicaid,0.8,,,0.8,Fee Schedule,,0.83,,,0.83,Fee Schedule,,0.83,,,0.83,Fee Schedule,,0.8,,,0.8,Fee Schedule,,0.83,,,0.83,Fee Schedule,,763.2,80,,763.2,percent of total billed charges,All Other,667.8,70,,667.8,percent of total billed charges,All Other,498.56,,,498.56,Fee Schedule,,422.56,,,422.56,Fee Schedule,,811,,,811,Case Rate,,730,,,730,Case Rate,,811,,,811,Case Rate,,689,,,689,Case Rate,,121.68,,,121.68,Other,100% of Medicaid,121.68,,,121.68,Other,100% of Medicaid,121.68,,,121.68,Other,100% of Medicaid,121.68,,,121.68,Other,100% of Medicaid,273.79,,,273.79,Other,225% of Medicaid,186.18,,,186.18,Other,153% of Medicaid,273.79,,,273.79,Other,225% of Medicaid,170.36,,,170.36,Other,140% of Medicaid,273.79,,,273.79,Other,225% of Medicaid,316.38,,,316.38,Other,260% of Medicaid,394.25,,,394.25,Other,324% of Medicaid,261.62,,,261.62,Other,215% of Medicaid,261.62,,,261.62,Other,215% of Medicaid,152.1,,,152.1,Other,125% of Medicaid,0.68,811,
DUPLX LE ART UNILAT RT,93926,CPT,TCRT,44293926,CDM,921,RC,,,both,,,1167,863.58,,,863.58,Other,150% of Medicare + 9.63% HCRA Surcharge,525.15,45,,525.15,percent of total billed charges,Critical Access Hospital RCC factor,342.35,,,342.35,Fee Schedule,,308.69,,,308.69,Fee Schedule,,650,,,650,Fee Schedule,,584.63,,,584.63,Fee Schedule,,552.56,,,552.56,Fee Schedule,,577.67,,,577.67,Other,110% of Medicare,0.68,,,0.68,Fee Schedule,,226,,,226,Other,186% of Medicaid,0.8,,,0.8,Fee Schedule,,0.83,,,0.83,Fee Schedule,,0.83,,,0.83,Fee Schedule,,0.8,,,0.8,Fee Schedule,,0.83,,,0.83,Fee Schedule,,933.6,80,,933.6,percent of total billed charges,All Other,816.9,70,,816.9,percent of total billed charges,All Other,595.32,,,595.32,Fee Schedule,,504.57,,,504.57,Fee Schedule,,811,,,811,Case Rate,,730,,,730,Case Rate,,811,,,811,Case Rate,,689,,,689,Case Rate,,121.68,,,121.68,Other,100% of Medicaid,121.68,,,121.68,Other,100% of Medicaid,121.68,,,121.68,Other,100% of Medicaid,121.68,,,121.68,Other,100% of Medicaid,273.79,,,273.79,Other,225% of Medicaid,186.18,,,186.18,Other,153% of Medicaid,273.79,,,273.79,Other,225% of Medicaid,170.36,,,170.36,Other,140% of Medicaid,273.79,,,273.79,Other,225% of Medicaid,316.38,,,316.38,Other,260% of Medicaid,394.25,,,394.25,Other,324% of Medicaid,261.62,,,261.62,Other,215% of Medicaid,261.62,,,261.62,Other,215% of Medicaid,152.1,,,152.1,Other,125% of Medicaid,0.68,933.6,
DUPLX UE ART UNILAT RT,93931,CPT,TCRT,44293931,CDM,921,RC,,,both,,,954,705.96,,,705.96,Other,150% of Medicare + 9.63% HCRA Surcharge,429.3,45,,429.3,percent of total billed charges,Critical Access Hospital RCC factor,322.97,,,322.97,Fee Schedule,,291.22,,,291.22,Fee Schedule,,650,,,650,Fee Schedule,,584.63,,,584.63,Fee Schedule,,552.56,,,552.56,Fee Schedule,,472.23,,,472.23,Other,110% of Medicare,0.68,,,0.68,Fee Schedule,,226,,,226,Other,186% of Medicaid,0.8,,,0.8,Fee Schedule,,0.83,,,0.83,Fee Schedule,,0.83,,,0.83,Fee Schedule,,0.8,,,0.8,Fee Schedule,,0.83,,,0.83,Fee Schedule,,763.2,80,,763.2,percent of total billed charges,All Other,667.8,70,,667.8,percent of total billed charges,All Other,498.56,,,498.56,Fee Schedule,,422.56,,,422.56,Fee Schedule,,811,,,811,Case Rate,,730,,,730,Case Rate,,811,,,811,Case Rate,,689,,,689,Case Rate,,121.68,,,121.68,Other,100% of Medicaid,121.68,,,121.68,Other,100% of Medicaid,121.68,,,121.68,Other,100% of Medicaid,121.68,,,121.68,Other,100% of Medicaid,273.79,,,273.79,Other,225% of Medicaid,186.18,,,186.18,Other,153% of Medicaid,273.79,,,273.79,Other,225% of Medicaid,170.36,,,170.36,Other,140% of Medicaid,273.79,,,273.79,Other,225% of Medicaid,316.38,,,316.38,Other,260% of Medicaid,394.25,,,394.25,Other,324% of Medicaid,261.62,,,261.62,Other,215% of Medicaid,261.62,,,261.62,Other,215% of Medicaid,152.1,,,152.1,Other,125% of Medicaid,0.68,811,
UPR/L XTREMITY ART 2 LEVELS,93922,CPT,,73093922,CDM,921,RC,,,both,,,706,522.44,,,522.44,Other,150% of Medicare + 9.63% HCRA Surcharge,317.7,45,,317.7,percent of total billed charges,Critical Access Hospital RCC factor,226.8,,,226.8,Fee Schedule,,204.5,,,204.5,Fee Schedule,,661.44,,,661.44,Fee Schedule,,594.92,,,594.92,Fee Schedule,,562.28,,,562.28,Fee Schedule,,349.47,,,349.47,Other,110% of Medicare,0.68,,,0.68,Fee Schedule,,226,,,226,Other,186% of Medicaid,0.8,,,0.8,Fee Schedule,,0.83,,,0.83,Fee Schedule,,0.83,,,0.83,Fee Schedule,,0.8,,,0.8,Fee Schedule,,0.83,,,0.83,Fee Schedule,,564.8,80,,564.8,percent of total billed charges,All Other,494.2,70,,494.2,percent of total billed charges,All Other,342.76,,,342.76,Fee Schedule,,290.51,,,290.51,Fee Schedule,,353,,,353,Case Rate,,353,,,353,Case Rate,,353,,,353,Case Rate,,353,,,353,Case Rate,,121.68,,,121.68,Other,100% of Medicaid,121.68,,,121.68,Other,100% of Medicaid,121.68,,,121.68,Other,100% of Medicaid,121.68,,,121.68,Other,100% of Medicaid,273.79,,,273.79,Other,225% of Medicaid,186.18,,,186.18,Other,153% of Medicaid,273.79,,,273.79,Other,225% of Medicaid,170.36,,,170.36,Other,140% of Medicaid,273.79,,,273.79,Other,225% of Medicaid,316.38,,,316.38,Other,260% of Medicaid,394.25,,,394.25,Other,324% of Medicaid,261.62,,,261.62,Other,215% of Medicaid,261.62,,,261.62,Other,215% of Medicaid,152.1,,,152.1,Other,125% of Medicaid,0.68,661.44,
UPR/L XTREMITY ART 2 LEVELS,93922,CPT,,74093922,CDM,921,RC,,,both,,,706,522.44,,,522.44,Other,150% of Medicare + 9.63% HCRA Surcharge,317.7,45,,317.7,percent of total billed charges,Critical Access Hospital RCC factor,226.8,,,226.8,Fee Schedule,,204.5,,,204.5,Fee Schedule,,661.44,,,661.44,Fee Schedule,,594.92,,,594.92,Fee Schedule,,562.28,,,562.28,Fee Schedule,,349.47,,,349.47,Other,110% of Medicare,0.68,,,0.68,Fee Schedule,,226,,,226,Other,186% of Medicaid,0.8,,,0.8,Fee Schedule,,0.83,,,0.83,Fee Schedule,,0.83,,,0.83,Fee Schedule,,0.8,,,0.8,Fee Schedule,,0.83,,,0.83,Fee Schedule,,564.8,80,,564.8,percent of total billed charges,All Other,494.2,70,,494.2,percent of total billed charges,All Other,342.76,,,342.76,Fee Schedule,,290.51,,,290.51,Fee Schedule,,353,,,353,Case Rate,,353,,,353,Case Rate,,353,,,353,Case Rate,,353,,,353,Case Rate,,121.68,,,121.68,Other,100% of Medicaid,121.68,,,121.68,Other,100% of Medicaid,121.68,,,121.68,Other,100% of Medicaid,121.68,,,121.68,Other,100% of Medicaid,273.79,,,273.79,Other,225% of Medicaid,186.18,,,186.18,Other,153% of Medicaid,273.79,,,273.79,Other,225% of Medicaid,170.36,,,170.36,Other,140% of Medicaid,273.79,,,273.79,Other,225% of Medicaid,316.38,,,316.38,Other,260% of Medicaid,394.25,,,394.25,Other,324% of Medicaid,261.62,,,261.62,Other,215% of Medicaid,261.62,,,261.62,Other,215% of Medicaid,152.1,,,152.1,Other,125% of Medicaid,0.68,661.44,
EMG-1 EXTREMITY,95860,CPT,TC,53095860,CDM,922,RC,,,both,,,441,326.34,,,326.34,Other,150% of Medicare + 9.63% HCRA Surcharge,198.45,45,,198.45,percent of total billed charges,Critical Access Hospital RCC factor,217.37,,,217.37,Fee Schedule,,195.56,,,195.56,Fee Schedule,,274.73,,,274.73,Fee Schedule,,247.1,,,247.1,Fee Schedule,,233.54,,,233.54,Fee Schedule,,218.3,,,218.3,Other,110% of Medicare,258.25,,,258.25,Fee Schedule,,210,,,210,Other,186% of Medicaid,303.9,,,303.9,Fee Schedule,,273.42,,,273.42,Fee Schedule,,143.09,,,143.09,Fee Schedule,,303.9,,,303.9,Fee Schedule,,273.42,,,273.42,Fee Schedule,,352.8,80,,352.8,percent of total billed charges,All Other,308.7,70,,308.7,percent of total billed charges,All Other,311.6,,,311.6,Fee Schedule,,264.1,,,264.1,Fee Schedule,,716,,,716,Case Rate,,644,,,644,Case Rate,,716,,,716,Case Rate,,609,,,609,Case Rate,,113.02,,,113.02,Other,100% of Medicaid,113.02,,,113.02,Other,100% of Medicaid,113.02,,,113.02,Other,100% of Medicaid,113.02,,,113.02,Other,100% of Medicaid,254.3,,,254.3,Other,225% of Medicaid,172.92,,,172.92,Other,153% of Medicaid,254.3,,,254.3,Other,225% of Medicaid,158.23,,,158.23,Other,140% of Medicaid,254.3,,,254.3,Other,225% of Medicaid,293.86,,,293.86,Other,260% of Medicaid,366.19,,,366.19,Other,324% of Medicaid,243,,,243,Other,215% of Medicaid,243,,,243,Other,215% of Medicaid,141.28,,,141.28,Other,125% of Medicaid,113.02,716,
EMG-2 EXTREMITIES,95861,CPT,TC,53095861,CDM,922,RC,,,both,,,705,521.7,,,521.7,Other,150% of Medicare + 9.63% HCRA Surcharge,317.25,45,,317.25,percent of total billed charges,Critical Access Hospital RCC factor,277.43,,,277.43,Fee Schedule,,249.6,,,249.6,Fee Schedule,,350.19,,,350.19,Fee Schedule,,314.97,,,314.97,Fee Schedule,,297.7,,,297.7,Fee Schedule,,348.98,,,348.98,Other,110% of Medicare,329.62,,,329.62,Fee Schedule,,210,,,210,Other,186% of Medicaid,387.89,,,387.89,Fee Schedule,,437.1,,,437.1,Fee Schedule,,182.64,,,182.64,Fee Schedule,,387.89,,,387.89,Fee Schedule,,437.1,,,437.1,Fee Schedule,,564,80,,564,percent of total billed charges,All Other,493.5,70,,493.5,percent of total billed charges,All Other,411.64,,,411.64,Fee Schedule,,348.89,,,348.89,Fee Schedule,,716,,,716,Case Rate,,644,,,644,Case Rate,,716,,,716,Case Rate,,609,,,609,Case Rate,,113.02,,,113.02,Other,100% of Medicaid,113.02,,,113.02,Other,100% of Medicaid,113.02,,,113.02,Other,100% of Medicaid,113.02,,,113.02,Other,100% of Medicaid,254.3,,,254.3,Other,225% of Medicaid,172.92,,,172.92,Other,153% of Medicaid,254.3,,,254.3,Other,225% of Medicaid,158.23,,,158.23,Other,140% of Medicaid,254.3,,,254.3,Other,225% of Medicaid,293.86,,,293.86,Other,260% of Medicaid,366.19,,,366.19,Other,324% of Medicaid,243,,,243,Other,215% of Medicaid,243,,,243,Other,215% of Medicaid,141.28,,,141.28,Other,125% of Medicaid,113.02,716,
NERVE CNDJ TEST 1-2 STUDIES,95907,CPT,TC,53095907,CDM,922,RC,,,both,,,329,243.46,,,243.46,Other,150% of Medicare + 9.63% HCRA Surcharge,148.05,45,,148.05,percent of total billed charges,Critical Access Hospital RCC factor,133.02,,,133.02,Fee Schedule,,119.68,,,119.68,Fee Schedule,,83.4,,,83.4,Fee Schedule,,83.4,,,83.4,Fee Schedule,,83.4,,,83.4,Fee Schedule,,162.86,,,162.86,Other,110% of Medicare,158.04,,,158.04,Fee Schedule,,210,,,210,Other,186% of Medicaid,185.98,,,185.98,Fee Schedule,,203.98,,,203.98,Fee Schedule,,87.57,,,87.57,Fee Schedule,,185.98,,,185.98,Fee Schedule,,203.98,,,203.98,Fee Schedule,,263.2,80,,263.2,percent of total billed charges,All Other,230.3,70,,230.3,percent of total billed charges,All Other,191.88,,,191.88,Fee Schedule,,162.63,,,162.63,Fee Schedule,,716,,,716,Case Rate,,644,,,644,Case Rate,,716,,,716,Case Rate,,609,,,609,Case Rate,,113.02,,,113.02,Other,100% of Medicaid,113.02,,,113.02,Other,100% of Medicaid,113.02,,,113.02,Other,100% of Medicaid,113.02,,,113.02,Other,100% of Medicaid,254.3,,,254.3,Other,225% of Medicaid,172.92,,,172.92,Other,153% of Medicaid,254.3,,,254.3,Other,225% of Medicaid,158.23,,,158.23,Other,140% of Medicaid,254.3,,,254.3,Other,225% of Medicaid,293.86,,,293.86,Other,260% of Medicaid,366.19,,,366.19,Other,324% of Medicaid,243,,,243,Other,215% of Medicaid,243,,,243,Other,215% of Medicaid,141.28,,,141.28,Other,125% of Medicaid,83.4,716,
NERVE CNDJ TEST 3-4 STUDIES,95908,CPT,TC,53095908,CDM,922,RC,,,both,,,632,467.68,,,467.68,Other,150% of Medicare + 9.63% HCRA Surcharge,284.4,45,,284.4,percent of total billed charges,Critical Access Hospital RCC factor,163.07,,,163.07,Fee Schedule,,146.71,,,146.71,Fee Schedule,,108,,,108,Fee Schedule,,108,,,108,Fee Schedule,,108,,,108,Fee Schedule,,312.84,,,312.84,Other,110% of Medicare,193.74,,,193.74,Fee Schedule,,210,,,210,Other,186% of Medicaid,228,,,228,Fee Schedule,,391.84,,,391.84,Fee Schedule,,107.35,,,107.35,Fee Schedule,,228,,,228,Fee Schedule,,391.84,,,391.84,Fee Schedule,,505.6,80,,505.6,percent of total billed charges,All Other,442.4,70,,442.4,percent of total billed charges,All Other,237.8,,,237.8,Fee Schedule,,201.55,,,201.55,Fee Schedule,,716,,,716,Case Rate,,644,,,644,Case Rate,,716,,,716,Case Rate,,609,,,609,Case Rate,,113.02,,,113.02,Other,100% of Medicaid,113.02,,,113.02,Other,100% of Medicaid,113.02,,,113.02,Other,100% of Medicaid,113.02,,,113.02,Other,100% of Medicaid,254.3,,,254.3,Other,225% of Medicaid,172.92,,,172.92,Other,153% of Medicaid,254.3,,,254.3,Other,225% of Medicaid,158.23,,,158.23,Other,140% of Medicaid,254.3,,,254.3,Other,225% of Medicaid,293.86,,,293.86,Other,260% of Medicaid,366.19,,,366.19,Other,324% of Medicaid,243,,,243,Other,215% of Medicaid,243,,,243,Other,215% of Medicaid,141.28,,,141.28,Other,125% of Medicaid,107.35,716,
NERVE CNDJ TEST 5-6 STUDIES,95909,CPT,TC,53095909,CDM,922,RC,,,both,,,632,467.68,,,467.68,Other,150% of Medicare + 9.63% HCRA Surcharge,284.4,45,,284.4,percent of total billed charges,Critical Access Hospital RCC factor,196.57,,,196.57,Fee Schedule,,176.85,,,176.85,Fee Schedule,,128.7,,,128.7,Fee Schedule,,128.7,,,128.7,Fee Schedule,,128.7,,,128.7,Fee Schedule,,312.84,,,312.84,Other,110% of Medicare,233.54,,,233.54,Fee Schedule,,210,,,210,Other,186% of Medicaid,274.83,,,274.83,Fee Schedule,,391.84,,,391.84,Fee Schedule,,129.4,,,129.4,Fee Schedule,,274.83,,,274.83,Fee Schedule,,391.84,,,391.84,Fee Schedule,,505.6,80,,505.6,percent of total billed charges,All Other,442.4,70,,442.4,percent of total billed charges,All Other,285.36,,,285.36,Fee Schedule,,241.86,,,241.86,Fee Schedule,,716,,,716,Case Rate,,644,,,644,Case Rate,,716,,,716,Case Rate,,609,,,609,Case Rate,,113.02,,,113.02,Other,100% of Medicaid,113.02,,,113.02,Other,100% of Medicaid,113.02,,,113.02,Other,100% of Medicaid,113.02,,,113.02,Other,100% of Medicaid,254.3,,,254.3,Other,225% of Medicaid,172.92,,,172.92,Other,153% of Medicaid,254.3,,,254.3,Other,225% of Medicaid,158.23,,,158.23,Other,140% of Medicaid,254.3,,,254.3,Other,225% of Medicaid,293.86,,,293.86,Other,260% of Medicaid,366.19,,,366.19,Other,324% of Medicaid,243,,,243,Other,215% of Medicaid,243,,,243,Other,215% of Medicaid,141.28,,,141.28,Other,125% of Medicaid,113.02,716,
NERVE CNDJ TEST 7-8 STUDIES,95910,CPT,TC,53095910,CDM,922,RC,,,both,,,632,467.68,,,467.68,Other,150% of Medicare + 9.63% HCRA Surcharge,284.4,45,,284.4,percent of total billed charges,Critical Access Hospital RCC factor,249.71,,,249.71,Fee Schedule,,224.66,,,224.66,Fee Schedule,,169.5,,,169.5,Fee Schedule,,169.5,,,169.5,Fee Schedule,,169.5,,,169.5,Fee Schedule,,312.84,,,312.84,Other,110% of Medicare,296.68,,,296.68,Fee Schedule,,210,,,210,Other,186% of Medicaid,349.13,,,349.13,Fee Schedule,,391.84,,,391.84,Fee Schedule,,164.39,,,164.39,Fee Schedule,,349.13,,,349.13,Fee Schedule,,391.84,,,391.84,Fee Schedule,,505.6,80,,505.6,percent of total billed charges,All Other,442.4,70,,442.4,percent of total billed charges,All Other,362.44,,,362.44,Fee Schedule,,307.19,,,307.19,Fee Schedule,,716,,,716,Case Rate,,644,,,644,Case Rate,,716,,,716,Case Rate,,609,,,609,Case Rate,,113.02,,,113.02,Other,100% of Medicaid,113.02,,,113.02,Other,100% of Medicaid,113.02,,,113.02,Other,100% of Medicaid,113.02,,,113.02,Other,100% of Medicaid,254.3,,,254.3,Other,225% of Medicaid,172.92,,,172.92,Other,153% of Medicaid,254.3,,,254.3,Other,225% of Medicaid,158.23,,,158.23,Other,140% of Medicaid,254.3,,,254.3,Other,225% of Medicaid,293.86,,,293.86,Other,260% of Medicaid,366.19,,,366.19,Other,324% of Medicaid,243,,,243,Other,215% of Medicaid,243,,,243,Other,215% of Medicaid,141.28,,,141.28,Other,125% of Medicaid,113.02,716,
NERVE CNDJ TEST 9-10 STUDIES,95911,CPT,TC,53095911,CDM,922,RC,,,both,,,1090,806.6,,,806.6,Other,150% of Medicare + 9.63% HCRA Surcharge,490.5,45,,490.5,percent of total billed charges,Critical Access Hospital RCC factor,285.51,,,285.51,Fee Schedule,,256.87,,,256.87,Fee Schedule,,202.2,,,202.2,Fee Schedule,,202.2,,,202.2,Fee Schedule,,202.2,,,202.2,Fee Schedule,,539.55,,,539.55,Other,110% of Medicare,339.21,,,339.21,Fee Schedule,,210,,,210,Other,186% of Medicaid,399.17,,,399.17,Fee Schedule,,675.8,,,675.8,Fee Schedule,,187.95,,,187.95,Fee Schedule,,399.17,,,399.17,Fee Schedule,,675.8,,,675.8,Fee Schedule,,872,80,,872,percent of total billed charges,All Other,763,70,,763,percent of total billed charges,All Other,416.56,,,416.56,Fee Schedule,,353.06,,,353.06,Fee Schedule,,716,,,716,Case Rate,,644,,,644,Case Rate,,716,,,716,Case Rate,,609,,,609,Case Rate,,113.02,,,113.02,Other,100% of Medicaid,113.02,,,113.02,Other,100% of Medicaid,113.02,,,113.02,Other,100% of Medicaid,113.02,,,113.02,Other,100% of Medicaid,254.3,,,254.3,Other,225% of Medicaid,172.92,,,172.92,Other,153% of Medicaid,254.3,,,254.3,Other,225% of Medicaid,158.23,,,158.23,Other,140% of Medicaid,254.3,,,254.3,Other,225% of Medicaid,293.86,,,293.86,Other,260% of Medicaid,366.19,,,366.19,Other,324% of Medicaid,243,,,243,Other,215% of Medicaid,243,,,243,Other,215% of Medicaid,141.28,,,141.28,Other,125% of Medicaid,113.02,872,
NERVE CNDJ TEST 11-12 STUDIES,95912,CPT,TC,53095912,CDM,922,RC,,,both,,,1090,806.6,,,806.6,Other,150% of Medicare + 9.63% HCRA Surcharge,490.5,45,,490.5,percent of total billed charges,Critical Access Hospital RCC factor,322.67,,,322.67,Fee Schedule,,290.3,,,290.3,Fee Schedule,,224.4,,,224.4,Fee Schedule,,224.4,,,224.4,Fee Schedule,,224.4,,,224.4,Fee Schedule,,539.55,,,539.55,Other,110% of Medicare,383.36,,,383.36,Fee Schedule,,210,,,210,Other,186% of Medicaid,451.13,,,451.13,Fee Schedule,,675.8,,,675.8,Fee Schedule,,212.42,,,212.42,Fee Schedule,,451.13,,,451.13,Fee Schedule,,675.8,,,675.8,Fee Schedule,,872,80,,872,percent of total billed charges,All Other,763,70,,763,percent of total billed charges,All Other,467.4,,,467.4,Fee Schedule,,396.15,,,396.15,Fee Schedule,,716,,,716,Case Rate,,644,,,644,Case Rate,,716,,,716,Case Rate,,609,,,609,Case Rate,,113.02,,,113.02,Other,100% of Medicaid,113.02,,,113.02,Other,100% of Medicaid,113.02,,,113.02,Other,100% of Medicaid,113.02,,,113.02,Other,100% of Medicaid,254.3,,,254.3,Other,225% of Medicaid,172.92,,,172.92,Other,153% of Medicaid,254.3,,,254.3,Other,225% of Medicaid,158.23,,,158.23,Other,140% of Medicaid,254.3,,,254.3,Other,225% of Medicaid,293.86,,,293.86,Other,260% of Medicaid,366.19,,,366.19,Other,324% of Medicaid,243,,,243,Other,215% of Medicaid,243,,,243,Other,215% of Medicaid,141.28,,,141.28,Other,125% of Medicaid,113.02,872,
NERVE CNDJ TEST 13/> STUDIES,95913,CPT,TC,53095913,CDM,922,RC,,,both,,,1090,806.6,,,806.6,Other,150% of Medicare + 9.63% HCRA Surcharge,490.5,45,,490.5,percent of total billed charges,Critical Access Hospital RCC factor,357.31,,,357.31,Fee Schedule,,321.47,,,321.47,Fee Schedule,,258.9,,,258.9,Fee Schedule,,258.9,,,258.9,Fee Schedule,,258.9,,,258.9,Fee Schedule,,539.55,,,539.55,Other,110% of Medicare,424.52,,,424.52,Fee Schedule,,210,,,210,Other,186% of Medicaid,499.56,,,499.56,Fee Schedule,,675.8,,,675.8,Fee Schedule,,235.22,,,235.22,Fee Schedule,,499.56,,,499.56,Fee Schedule,,675.8,,,675.8,Fee Schedule,,872,80,,872,percent of total billed charges,All Other,763,70,,763,percent of total billed charges,All Other,518.24,,,518.24,Fee Schedule,,439.24,,,439.24,Fee Schedule,,716,,,716,Case Rate,,644,,,644,Case Rate,,716,,,716,Case Rate,,609,,,609,Case Rate,,113.02,,,113.02,Other,100% of Medicaid,113.02,,,113.02,Other,100% of Medicaid,113.02,,,113.02,Other,100% of Medicaid,113.02,,,113.02,Other,100% of Medicaid,254.3,,,254.3,Other,225% of Medicaid,172.92,,,172.92,Other,153% of Medicaid,254.3,,,254.3,Other,225% of Medicaid,158.23,,,158.23,Other,140% of Medicaid,254.3,,,254.3,Other,225% of Medicaid,293.86,,,293.86,Other,260% of Medicaid,366.19,,,366.19,Other,324% of Medicaid,243,,,243,Other,215% of Medicaid,243,,,243,Other,215% of Medicaid,141.28,,,141.28,Other,125% of Medicaid,113.02,872,
SCR PAP SMER UP TO 3 TECH W/MD,P3000,HCPCS,,78000004,CDM,923,RC,,,both,,,81,59.94,,,59.94,Other,150% of Medicare + 9.63% HCRA Surcharge,36.45,45,,36.45,percent of total billed charges,Critical Access Hospital RCC factor,53.46,,,53.46,Fee Schedule,,48.13,,,48.13,Fee Schedule,,77.47,,,77.47,Fee Schedule,,69.74,,,69.74,Fee Schedule,,65.87,,,65.87,Fee Schedule,,40.1,,,40.1,Other,110% of Medicare,55.94,,,55.94,Fee Schedule,,51,,,51,Other,186% of Medicaid,65.89,,,65.89,Fee Schedule,,37.3,,,37.3,Fee Schedule,,37.3,,,37.3,Fee Schedule,,65.89,,,65.89,Fee Schedule,,37.3,,,37.3,Fee Schedule,,70.15,,,70.15,Fee Schedule,,56.7,70,,56.7,percent of total billed charges,All Other,75.45,,,75.45,Fee Schedule,,63.94,,,63.94,Fee Schedule,,22.68,,,22.68,Fee Schedule,,22.68,,,22.68,Fee Schedule,,22.68,,,22.68,Fee Schedule,,22.68,,,22.68,Fee Schedule,,27.32,,,27.32,Other,100% of Medicaid,27.32,,,27.32,Other,100% of Medicaid,27.32,,,27.32,Other,100% of Medicaid,27.32,,,27.32,Other,100% of Medicaid,61.48,,,61.48,Other,225% of Medicaid,41.8,,,41.8,Other,153% of Medicaid,61.48,,,61.48,Other,225% of Medicaid,38.25,,,38.25,Other,140% of Medicaid,61.48,,,61.48,Other,225% of Medicaid,71.04,,,71.04,Other,260% of Medicaid,88.53,,,88.53,Other,324% of Medicaid,58.74,,,58.74,Other,215% of Medicaid,58.74,,,58.74,Other,215% of Medicaid,34.15,,,34.15,Other,125% of Medicaid,22.68,88.53,
SCR PAP SMER UP TO 3 RQR INTER,P3001,HCPCS,,78000005,CDM,923,RC,,,both,,,89,65.86,,,65.86,Other,150% of Medicare + 9.63% HCRA Surcharge,40.05,45,,40.05,percent of total billed charges,Critical Access Hospital RCC factor,77.12,,,77.12,Fee Schedule,,69.43,,,69.43,Fee Schedule,,175.63,,,175.63,Fee Schedule,,158.1,,,158.1,Fee Schedule,,149.34,,,149.34,Fee Schedule,,44.06,,,44.06,Other,110% of Medicare,80.7,,,80.7,Fee Schedule,,51,,,51,Other,186% of Medicaid,95.05,,,95.05,Fee Schedule,,53.8,,,53.8,Fee Schedule,,53.8,,,53.8,Fee Schedule,,95.05,,,95.05,Fee Schedule,,53.8,,,53.8,Fee Schedule,,101.2,,,101.2,Fee Schedule,,62.3,70,,62.3,percent of total billed charges,All Other,106.6,,,106.6,Fee Schedule,,90.35,,,90.35,Fee Schedule,,39.53,,,39.53,Fee Schedule,,39.53,,,39.53,Fee Schedule,,39.53,,,39.53,Fee Schedule,,39.53,,,39.53,Fee Schedule,,27.32,,,27.32,Other,100% of Medicaid,27.32,,,27.32,Other,100% of Medicaid,27.32,,,27.32,Other,100% of Medicaid,27.32,,,27.32,Other,100% of Medicaid,61.48,,,61.48,Other,225% of Medicaid,41.8,,,41.8,Other,153% of Medicaid,61.48,,,61.48,Other,225% of Medicaid,38.25,,,38.25,Other,140% of Medicaid,61.48,,,61.48,Other,225% of Medicaid,71.04,,,71.04,Other,260% of Medicaid,88.53,,,88.53,Other,324% of Medicaid,58.74,,,58.74,Other,215% of Medicaid,58.74,,,58.74,Other,215% of Medicaid,34.15,,,34.15,Other,125% of Medicaid,27.32,175.63,
PHLEBOTOMY THERAPEUTIC,99195,CPT,,34099195,CDM,940,RC,,,both,,,263,194.62,,,194.62,Other,150% of Medicare + 9.63% HCRA Surcharge,118.35,45,,118.35,percent of total billed charges,Critical Access Hospital RCC factor,332.59,,,332.59,Fee Schedule,,299.23,,,299.23,Fee Schedule,,201.2,76.5,,201.2,percent of total billed charges,All Other,186.73,69,,186.73,percent of total billed charges,All Other,181.47,65,,181.47,percent of total billed charges,All Other,130.19,,,130.19,Other,110% of Medicare,178.84,68,,178.84,percent of total billed charges,All Other,49,,,49,Other,186% of Medicaid,210.4,80,,210.4,percent of total billed charges,All Other,218.29,83,,218.29,percent of total billed charges,All Other,218.29,83,,218.29,percent of total billed charges,All Other,210.4,80,,210.4,percent of total billed charges,All Other,218.29,83,,218.29,percent of total billed charges,All Other,210.4,80,,210.4,percent of total billed charges,All Other,184.1,70,,184.1,percent of total billed charges,All Other,493.64,,,493.64,Fee Schedule,,418.39,,,418.39,Fee Schedule,,131.5,,,131.5,Case Rate,,131.5,,,131.5,Case Rate,,131.5,,,131.5,Case Rate,,131.5,,,131.5,Case Rate,,26.36,,,26.36,Other,100% of Medicaid,26.36,,,26.36,Other,100% of Medicaid,26.36,,,26.36,Other,100% of Medicaid,26.36,,,26.36,Other,100% of Medicaid,59.32,,,59.32,Other,225% of Medicaid,40.33,,,40.33,Other,153% of Medicaid,59.32,,,59.32,Other,225% of Medicaid,36.91,,,36.91,Other,140% of Medicaid,59.32,,,59.32,Other,225% of Medicaid,68.54,,,68.54,Other,260% of Medicaid,85.41,,,85.41,Other,324% of Medicaid,56.68,,,56.68,Other,215% of Medicaid,56.68,,,56.68,Other,215% of Medicaid,32.95,,,32.95,Other,125% of Medicaid,26.36,493.64,
THER/PROPH/DIAG IV PUSH INITIA,96374,CPT,,48096374,CDM,940,RC,,,both,,,466,344.84,,,344.84,Other,150% of Medicare + 9.63% HCRA Surcharge,209.7,45,,209.7,percent of total billed charges,Critical Access Hospital RCC factor,126.29,,,126.29,Fee Schedule,,113.62,,,113.62,Fee Schedule,,356.49,76.5,,356.49,percent of total billed charges,All Other,330.86,69,,330.86,percent of total billed charges,All Other,321.54,65,,321.54,percent of total billed charges,All Other,230.67,,,230.67,Other,110% of Medicare,316.88,68,,316.88,percent of total billed charges,All Other,58,,,58,Other,186% of Medicaid,372.8,80,,372.8,percent of total billed charges,All Other,386.78,83,,386.78,percent of total billed charges,All Other,386.78,83,,386.78,percent of total billed charges,All Other,372.8,80,,372.8,percent of total billed charges,All Other,386.78,83,,386.78,percent of total billed charges,All Other,372.8,80,,372.8,percent of total billed charges,All Other,326.2,70,,326.2,percent of total billed charges,All Other,190.24,,,190.24,Fee Schedule,,161.24,,,161.24,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,31.2,,,31.2,Other,100% of Medicaid,31.2,,,31.2,Other,100% of Medicaid,31.2,,,31.2,Other,100% of Medicaid,31.2,,,31.2,Other,100% of Medicaid,70.2,,,70.2,Other,225% of Medicaid,47.74,,,47.74,Other,153% of Medicaid,70.2,,,70.2,Other,225% of Medicaid,43.68,,,43.68,Other,140% of Medicaid,70.2,,,70.2,Other,225% of Medicaid,81.12,,,81.12,Other,260% of Medicaid,101.09,,,101.09,Other,324% of Medicaid,67.08,,,67.08,Other,215% of Medicaid,67.08,,,67.08,Other,215% of Medicaid,39,,,39,Other,125% of Medicaid,0.01,386.78,
PULMONARY REHAB W EXER,G0424,HCPCS,,71000021,CDM,940,RC,,,both,,,221,163.54,,,163.54,Other,150% of Medicare + 9.63% HCRA Surcharge,99.45,45,,99.45,percent of total billed charges,Critical Access Hospital RCC factor,143.65,65,,143.65,percent of total billed charges,All Other,130.39,65,,130.39,percent of total billed charges,All Other,192.61,,,192.61,Fee Schedule,,173.39,,,173.39,Fee Schedule,,163.78,,,163.78,Fee Schedule,,109.4,,,109.4,Other,110% of Medicare,150.28,68,,150.28,percent of total billed charges,All Other,0.01,,,0.01,Other,186% of Medicaid,176.8,80,,176.8,percent of total billed charges,All Other,137.02,62,,137.02,percent of total billed charges,Lab and Radiology,121.55,83,,121.55,percent of total billed charges,All Other,176.8,80,,176.8,percent of total billed charges,All Other,137.02,62,,137.02,percent of total billed charges,Lab and Radiology,176.8,80,,176.8,percent of total billed charges,All Other,154.7,70,,154.7,percent of total billed charges,All Other,143.65,65,,143.65,percent of total billed charges,Default if not in Fee Schedule,143.65,65,,143.65,percent of total billed charges,Default if not in Fee Schedule,110.5,,,110.5,Case Rate,,110.5,,,110.5,Case Rate,,110.5,,,110.5,Case Rate,,110.5,,,110.5,Case Rate,,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,192.61,
PHLEBOTOMY THERAPEUTIC,99195,CPT,,75099195,CDM,940,RC,,,both,,,263,194.62,,,194.62,Other,150% of Medicare + 9.63% HCRA Surcharge,118.35,45,,118.35,percent of total billed charges,Critical Access Hospital RCC factor,332.59,,,332.59,Fee Schedule,,299.23,,,299.23,Fee Schedule,,201.2,76.5,,201.2,percent of total billed charges,All Other,186.73,69,,186.73,percent of total billed charges,All Other,181.47,65,,181.47,percent of total billed charges,All Other,130.19,,,130.19,Other,110% of Medicare,178.84,68,,178.84,percent of total billed charges,All Other,49,,,49,Other,186% of Medicaid,210.4,80,,210.4,percent of total billed charges,All Other,218.29,83,,218.29,percent of total billed charges,All Other,218.29,83,,218.29,percent of total billed charges,All Other,210.4,80,,210.4,percent of total billed charges,All Other,218.29,83,,218.29,percent of total billed charges,All Other,210.4,80,,210.4,percent of total billed charges,All Other,184.1,70,,184.1,percent of total billed charges,All Other,493.64,,,493.64,Fee Schedule,,418.39,,,418.39,Fee Schedule,,131.5,,,131.5,Case Rate,,131.5,,,131.5,Case Rate,,131.5,,,131.5,Case Rate,,131.5,,,131.5,Case Rate,,26.36,,,26.36,Other,100% of Medicaid,26.36,,,26.36,Other,100% of Medicaid,26.36,,,26.36,Other,100% of Medicaid,26.36,,,26.36,Other,100% of Medicaid,59.32,,,59.32,Other,225% of Medicaid,40.33,,,40.33,Other,153% of Medicaid,59.32,,,59.32,Other,225% of Medicaid,36.91,,,36.91,Other,140% of Medicaid,59.32,,,59.32,Other,225% of Medicaid,68.54,,,68.54,Other,260% of Medicaid,85.41,,,85.41,Other,324% of Medicaid,56.68,,,56.68,Other,215% of Medicaid,56.68,,,56.68,Other,215% of Medicaid,32.95,,,32.95,Other,125% of Medicaid,26.36,493.64,
PHLEBOTOMY THERAPEUTIC,99195,CPT,,82099195,CDM,940,RC,,,both,,,263,194.62,,,194.62,Other,150% of Medicare + 9.63% HCRA Surcharge,118.35,45,,118.35,percent of total billed charges,Critical Access Hospital RCC factor,332.59,,,332.59,Fee Schedule,,299.23,,,299.23,Fee Schedule,,201.2,76.5,,201.2,percent of total billed charges,All Other,186.73,69,,186.73,percent of total billed charges,All Other,181.47,65,,181.47,percent of total billed charges,All Other,130.19,,,130.19,Other,110% of Medicare,178.84,68,,178.84,percent of total billed charges,All Other,49,,,49,Other,186% of Medicaid,210.4,80,,210.4,percent of total billed charges,All Other,218.29,83,,218.29,percent of total billed charges,All Other,218.29,83,,218.29,percent of total billed charges,All Other,210.4,80,,210.4,percent of total billed charges,All Other,218.29,83,,218.29,percent of total billed charges,All Other,210.4,80,,210.4,percent of total billed charges,All Other,184.1,70,,184.1,percent of total billed charges,All Other,493.64,,,493.64,Fee Schedule,,418.39,,,418.39,Fee Schedule,,131.5,,,131.5,Case Rate,,131.5,,,131.5,Case Rate,,131.5,,,131.5,Case Rate,,131.5,,,131.5,Case Rate,,26.36,,,26.36,Other,100% of Medicaid,26.36,,,26.36,Other,100% of Medicaid,26.36,,,26.36,Other,100% of Medicaid,26.36,,,26.36,Other,100% of Medicaid,59.32,,,59.32,Other,225% of Medicaid,40.33,,,40.33,Other,153% of Medicaid,59.32,,,59.32,Other,225% of Medicaid,36.91,,,36.91,Other,140% of Medicaid,59.32,,,59.32,Other,225% of Medicaid,68.54,,,68.54,Other,260% of Medicaid,85.41,,,85.41,Other,324% of Medicaid,56.68,,,56.68,Other,215% of Medicaid,56.68,,,56.68,Other,215% of Medicaid,32.95,,,32.95,Other,125% of Medicaid,26.36,493.64,
PT EDUCATION NOC INDIVID LACTATION COUNS,S9445,HCPCS,,26000009,CDM,942,RC,,,both,,,217,160.58,,,160.58,Other,150% of Medicare + 9.63% HCRA Surcharge,97.65,45,,97.65,percent of total billed charges,Critical Access Hospital RCC factor,141.05,65,,141.05,percent of total billed charges,All Other,128.03,65,,128.03,percent of total billed charges,All Other,166.01,76.5,,166.01,percent of total billed charges,All Other,154.07,69,,154.07,percent of total billed charges,All Other,149.73,65,,149.73,percent of total billed charges,All Other,107.42,,,107.42,Other,110% of Medicare,147.56,68,,147.56,percent of total billed charges,All Other,0.01,,,0.01,Other,186% of Medicaid,173.6,80,,173.6,percent of total billed charges,All Other,134.54,62,,134.54,percent of total billed charges,Lab and Radiology,119.35,83,,119.35,percent of total billed charges,All Other,173.6,80,,173.6,percent of total billed charges,All Other,134.54,62,,134.54,percent of total billed charges,Lab and Radiology,173.6,80,,173.6,percent of total billed charges,All Other,151.9,70,,151.9,percent of total billed charges,All Other,141.05,65,,141.05,percent of total billed charges,Default if not in Fee Schedule,141.05,65,,141.05,percent of total billed charges,Default if not in Fee Schedule,0.01,,,0.01,Case Rate,,0.01,,,0.01,Case Rate,,0.01,,,0.01,Case Rate,,0.01,,,0.01,Case Rate,,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,173.6,
PT EDUCATION NOC GROUP LACTATION COUNS,S9446,HCPCS,,26000010,CDM,942,RC,,,both,,,63,46.62,,,46.62,Other,150% of Medicare + 9.63% HCRA Surcharge,28.35,45,,28.35,percent of total billed charges,Critical Access Hospital RCC factor,40.95,65,,40.95,percent of total billed charges,All Other,37.17,65,,37.17,percent of total billed charges,All Other,48.2,76.5,,48.2,percent of total billed charges,All Other,44.73,69,,44.73,percent of total billed charges,All Other,43.47,65,,43.47,percent of total billed charges,All Other,31.19,,,31.19,Other,110% of Medicare,42.84,68,,42.84,percent of total billed charges,All Other,0.01,,,0.01,Other,186% of Medicaid,50.4,80,,50.4,percent of total billed charges,All Other,39.06,62,,39.06,percent of total billed charges,Lab and Radiology,34.65,83,,34.65,percent of total billed charges,All Other,50.4,80,,50.4,percent of total billed charges,All Other,39.06,62,,39.06,percent of total billed charges,Lab and Radiology,50.4,80,,50.4,percent of total billed charges,All Other,44.1,70,,44.1,percent of total billed charges,All Other,40.95,65,,40.95,percent of total billed charges,Default if not in Fee Schedule,40.95,65,,40.95,percent of total billed charges,Default if not in Fee Schedule,0.01,,,0.01,Case Rate,,0.01,,,0.01,Case Rate,,0.01,,,0.01,Case Rate,,0.01,,,0.01,Case Rate,,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,50.4,
BEHAV CHNG SMOKING 3-10 MIN,99406,CPT,,30099406,CDM,942,RC,,,both,,,114,84.36,,,84.36,Other,150% of Medicare + 9.63% HCRA Surcharge,51.3,45,,51.3,percent of total billed charges,Critical Access Hospital RCC factor,74.1,65,,74.1,percent of total billed charges,All Other,67.26,65,,67.26,percent of total billed charges,All Other,87.21,76.5,,87.21,percent of total billed charges,All Other,80.94,69,,80.94,percent of total billed charges,All Other,78.66,65,,78.66,percent of total billed charges,All Other,56.43,,,56.43,Other,110% of Medicare,77.52,68,,77.52,percent of total billed charges,All Other,79,,,79,Other,186% of Medicaid,91.2,80,,91.2,percent of total billed charges,All Other,94.62,83,,94.62,percent of total billed charges,All Other,94.62,83,,94.62,percent of total billed charges,All Other,91.2,80,,91.2,percent of total billed charges,All Other,94.62,83,,94.62,percent of total billed charges,All Other,91.2,80,,91.2,percent of total billed charges,All Other,79.8,70,,79.8,percent of total billed charges,All Other,57.4,,,57.4,Fee Schedule,,48.65,,,48.65,Fee Schedule,,143,,,143,Case Rate,,131,,,131,Case Rate,,143,,,143,Case Rate,,122,,,122,Case Rate,,42.37,,,42.37,Other,100% of Medicaid,42.37,,,42.37,Other,100% of Medicaid,42.37,,,42.37,Other,100% of Medicaid,42.37,,,42.37,Other,100% of Medicaid,95.33,,,95.33,Other,225% of Medicaid,64.83,,,64.83,Other,153% of Medicaid,95.33,,,95.33,Other,225% of Medicaid,59.32,,,59.32,Other,140% of Medicaid,95.33,,,95.33,Other,225% of Medicaid,110.16,,,110.16,Other,260% of Medicaid,137.28,,,137.28,Other,324% of Medicaid,91.1,,,91.1,Other,215% of Medicaid,91.1,,,91.1,Other,215% of Medicaid,52.96,,,52.96,Other,125% of Medicaid,42.37,143,
BEHAV CHNG SMOKING > 10 MIN,99407,CPT,,30099407,CDM,942,RC,,,both,,,114,84.36,,,84.36,Other,150% of Medicare + 9.63% HCRA Surcharge,51.3,45,,51.3,percent of total billed charges,Critical Access Hospital RCC factor,74.1,65,,74.1,percent of total billed charges,All Other,67.26,65,,67.26,percent of total billed charges,All Other,87.21,76.5,,87.21,percent of total billed charges,All Other,80.94,69,,80.94,percent of total billed charges,All Other,78.66,65,,78.66,percent of total billed charges,All Other,56.43,,,56.43,Other,110% of Medicare,77.52,68,,77.52,percent of total billed charges,All Other,79,,,79,Other,186% of Medicaid,91.2,80,,91.2,percent of total billed charges,All Other,94.62,83,,94.62,percent of total billed charges,All Other,94.62,83,,94.62,percent of total billed charges,All Other,91.2,80,,91.2,percent of total billed charges,All Other,94.62,83,,94.62,percent of total billed charges,All Other,91.2,80,,91.2,percent of total billed charges,All Other,79.8,70,,79.8,percent of total billed charges,All Other,121.36,,,121.36,Fee Schedule,,102.86,,,102.86,Fee Schedule,,143,,,143,Case Rate,,131,,,131,Case Rate,,143,,,143,Case Rate,,122,,,122,Case Rate,,42.37,,,42.37,Other,100% of Medicaid,42.37,,,42.37,Other,100% of Medicaid,42.37,,,42.37,Other,100% of Medicaid,42.37,,,42.37,Other,100% of Medicaid,95.33,,,95.33,Other,225% of Medicaid,64.83,,,64.83,Other,153% of Medicaid,95.33,,,95.33,Other,225% of Medicaid,59.32,,,59.32,Other,140% of Medicaid,95.33,,,95.33,Other,225% of Medicaid,110.16,,,110.16,Other,260% of Medicaid,137.28,,,137.28,Other,324% of Medicaid,91.1,,,91.1,Other,215% of Medicaid,91.1,,,91.1,Other,215% of Medicaid,52.96,,,52.96,Other,125% of Medicaid,42.37,143,
ADOL TRAIN & EDUC PER SESS 45+ MINS,G0177,HCPCS,,39000002,CDM,942,RC,,,both,,,105,77.7,,,77.7,Other,150% of Medicare + 9.63% HCRA Surcharge,47.25,45,,47.25,percent of total billed charges,Critical Access Hospital RCC factor,68.25,65,,68.25,percent of total billed charges,All Other,61.95,65,,61.95,percent of total billed charges,All Other,80.33,76.5,,80.33,percent of total billed charges,All Other,74.55,69,,74.55,percent of total billed charges,All Other,72.45,65,,72.45,percent of total billed charges,All Other,51.98,,,51.98,Other,110% of Medicare,71.4,68,,71.4,percent of total billed charges,All Other,0.01,,,0.01,Other,186% of Medicaid,84,80,,84,percent of total billed charges,All Other,65.1,62,,65.1,percent of total billed charges,Lab and Radiology,57.75,83,,57.75,percent of total billed charges,All Other,84,80,,84,percent of total billed charges,All Other,65.1,62,,65.1,percent of total billed charges,Lab and Radiology,84,80,,84,percent of total billed charges,All Other,73.5,70,,73.5,percent of total billed charges,All Other,68.25,65,,68.25,percent of total billed charges,Default if not in Fee Schedule,68.25,65,,68.25,percent of total billed charges,Default if not in Fee Schedule,0.01,,,0.01,Case Rate,,0.01,,,0.01,Case Rate,,0.01,,,0.01,Case Rate,,0.01,,,0.01,Case Rate,,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,84,
ADOL TRAIN & EDUC PER SESS 45+ MINS-TH,G0177,HCPCS,GT,39100002,CDM,942,RC,,,both,,,105,77.7,,,77.7,Other,150% of Medicare + 9.63% HCRA Surcharge,47.25,45,,47.25,percent of total billed charges,Critical Access Hospital RCC factor,68.25,65,,68.25,percent of total billed charges,All Other,61.95,65,,61.95,percent of total billed charges,All Other,80.33,76.5,,80.33,percent of total billed charges,All Other,74.55,69,,74.55,percent of total billed charges,All Other,72.45,65,,72.45,percent of total billed charges,All Other,51.98,,,51.98,Other,110% of Medicare,71.4,68,,71.4,percent of total billed charges,All Other,0.01,,,0.01,Other,186% of Medicaid,84,80,,84,percent of total billed charges,All Other,65.1,62,,65.1,percent of total billed charges,Lab and Radiology,57.75,83,,57.75,percent of total billed charges,All Other,84,80,,84,percent of total billed charges,All Other,65.1,62,,65.1,percent of total billed charges,Lab and Radiology,84,80,,84,percent of total billed charges,All Other,73.5,70,,73.5,percent of total billed charges,All Other,68.25,65,,68.25,percent of total billed charges,Default if not in Fee Schedule,68.25,65,,68.25,percent of total billed charges,Default if not in Fee Schedule,0.01,,,0.01,Case Rate,,0.01,,,0.01,Case Rate,,0.01,,,0.01,Case Rate,,0.01,,,0.01,Case Rate,,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,84,
TRAIN & EDUC PER SESS 45+ MINS,G0177,HCPCS,,40000003,CDM,942,RC,,,both,,,105,77.7,,,77.7,Other,150% of Medicare + 9.63% HCRA Surcharge,47.25,45,,47.25,percent of total billed charges,Critical Access Hospital RCC factor,68.25,65,,68.25,percent of total billed charges,All Other,61.95,65,,61.95,percent of total billed charges,All Other,80.33,76.5,,80.33,percent of total billed charges,All Other,74.55,69,,74.55,percent of total billed charges,All Other,72.45,65,,72.45,percent of total billed charges,All Other,51.98,,,51.98,Other,110% of Medicare,71.4,68,,71.4,percent of total billed charges,All Other,0.01,,,0.01,Other,186% of Medicaid,84,80,,84,percent of total billed charges,All Other,65.1,62,,65.1,percent of total billed charges,Lab and Radiology,57.75,83,,57.75,percent of total billed charges,All Other,84,80,,84,percent of total billed charges,All Other,65.1,62,,65.1,percent of total billed charges,Lab and Radiology,84,80,,84,percent of total billed charges,All Other,73.5,70,,73.5,percent of total billed charges,All Other,68.25,65,,68.25,percent of total billed charges,Default if not in Fee Schedule,68.25,65,,68.25,percent of total billed charges,Default if not in Fee Schedule,0.01,,,0.01,Case Rate,,0.01,,,0.01,Case Rate,,0.01,,,0.01,Case Rate,,0.01,,,0.01,Case Rate,,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,84,
TRAIN & EDUC PER SESS 45+ MINS-TH,G0177,HCPCS,GT,40100002,CDM,942,RC,,,both,,,105,77.7,,,77.7,Other,150% of Medicare + 9.63% HCRA Surcharge,47.25,45,,47.25,percent of total billed charges,Critical Access Hospital RCC factor,68.25,65,,68.25,percent of total billed charges,All Other,61.95,65,,61.95,percent of total billed charges,All Other,80.33,76.5,,80.33,percent of total billed charges,All Other,74.55,69,,74.55,percent of total billed charges,All Other,72.45,65,,72.45,percent of total billed charges,All Other,51.98,,,51.98,Other,110% of Medicare,71.4,68,,71.4,percent of total billed charges,All Other,0.01,,,0.01,Other,186% of Medicaid,84,80,,84,percent of total billed charges,All Other,65.1,62,,65.1,percent of total billed charges,Lab and Radiology,57.75,83,,57.75,percent of total billed charges,All Other,84,80,,84,percent of total billed charges,All Other,65.1,62,,65.1,percent of total billed charges,Lab and Radiology,84,80,,84,percent of total billed charges,All Other,73.5,70,,73.5,percent of total billed charges,All Other,68.25,65,,68.25,percent of total billed charges,Default if not in Fee Schedule,68.25,65,,68.25,percent of total billed charges,Default if not in Fee Schedule,0.01,,,0.01,Case Rate,,0.01,,,0.01,Case Rate,,0.01,,,0.01,Case Rate,,0.01,,,0.01,Case Rate,,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,84,
DM OP SMT INDIV PER 30 MIN,G0108,HCPCS,,70000005,CDM,942,RC,,,both,,,237,175.38,,,175.38,Other,150% of Medicare + 9.63% HCRA Surcharge,106.65,45,,106.65,percent of total billed charges,Critical Access Hospital RCC factor,183.36,,,183.36,Fee Schedule,,164.97,,,164.97,Fee Schedule,,181.31,76.5,,181.31,percent of total billed charges,All Other,168.27,69,,168.27,percent of total billed charges,All Other,163.53,65,,163.53,percent of total billed charges,All Other,117.32,,,117.32,Other,110% of Medicare,217.85,,,217.85,Fee Schedule,,0.01,,,0.01,Other,186% of Medicaid,256.36,,,256.36,Fee Schedule,,120.71,,,120.71,Fee Schedule,,120.71,,,120.71,Fee Schedule,,256.36,,,256.36,Fee Schedule,,120.71,,,120.71,Fee Schedule,,189.6,80,,189.6,percent of total billed charges,All Other,165.9,70,,165.9,percent of total billed charges,All Other,265.68,,,265.68,Fee Schedule,,225.18,,,225.18,Fee Schedule,,0.01,,,0.01,Case Rate,,0.01,,,0.01,Case Rate,,0.01,,,0.01,Case Rate,,0.01,,,0.01,Case Rate,,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,265.68,
DM OP SMT GRP PER 30 MIN,G0109,HCPCS,,70000006,CDM,942,RC,,,both,,,72,53.28,,,53.28,Other,150% of Medicare + 9.63% HCRA Surcharge,32.4,45,,32.4,percent of total billed charges,Critical Access Hospital RCC factor,52.89,,,52.89,Fee Schedule,,47.58,,,47.58,Fee Schedule,,55.08,76.5,,55.08,percent of total billed charges,All Other,51.12,69,,51.12,percent of total billed charges,All Other,49.68,65,,49.68,percent of total billed charges,All Other,35.64,,,35.64,Other,110% of Medicare,62.84,,,62.84,Fee Schedule,,0.01,,,0.01,Other,186% of Medicaid,73.95,,,73.95,Fee Schedule,,34.82,,,34.82,Fee Schedule,,34.82,,,34.82,Fee Schedule,,73.95,,,73.95,Fee Schedule,,34.82,,,34.82,Fee Schedule,,57.6,80,,57.6,percent of total billed charges,All Other,50.4,70,,50.4,percent of total billed charges,All Other,75.44,,,75.44,Fee Schedule,,63.94,,,63.94,Fee Schedule,,0.01,,,0.01,Case Rate,,0.01,,,0.01,Case Rate,,0.01,,,0.01,Case Rate,,0.01,,,0.01,Case Rate,,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,75.44,
MNT EA 15 M AFTER 2ND REFRL,G0270,HCPCS,,70000007,CDM,942,RC,,,both,,,106,78.44,,,78.44,Other,150% of Medicare + 9.63% HCRA Surcharge,47.7,45,,47.7,percent of total billed charges,Critical Access Hospital RCC factor,90.92,,,90.92,Fee Schedule,,81.8,,,81.8,Fee Schedule,,81.09,76.5,,81.09,percent of total billed charges,All Other,75.26,69,,75.26,percent of total billed charges,All Other,73.14,65,,73.14,percent of total billed charges,All Other,52.47,,,52.47,Other,110% of Medicare,108.02,,,108.02,Fee Schedule,,0.01,,,0.01,Other,186% of Medicaid,127.11,,,127.11,Fee Schedule,,59.85,,,59.85,Fee Schedule,,59.85,,,59.85,Fee Schedule,,127.11,,,127.11,Fee Schedule,,59.85,,,59.85,Fee Schedule,,112.58,,,112.58,Fee Schedule,,74.2,70,,74.2,percent of total billed charges,All Other,132.84,,,132.84,Fee Schedule,,112.59,,,112.59,Fee Schedule,,0.01,,,0.01,Case Rate,,0.01,,,0.01,Case Rate,,0.01,,,0.01,Case Rate,,0.01,,,0.01,Case Rate,,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,132.84,
MNT GRP/30M AFTER 2ND RFERL,G0271,HCPCS,,70000008,CDM,942,RC,,,both,,,54,39.96,,,39.96,Other,150% of Medicare + 9.63% HCRA Surcharge,24.3,45,,24.3,percent of total billed charges,Critical Access Hospital RCC factor,51.74,,,51.74,Fee Schedule,,46.55,,,46.55,Fee Schedule,,41.31,76.5,,41.31,percent of total billed charges,All Other,38.34,69,,38.34,percent of total billed charges,All Other,37.26,65,,37.26,percent of total billed charges,All Other,26.73,,,26.73,Other,110% of Medicare,61.47,,,61.47,Fee Schedule,,0.01,,,0.01,Other,186% of Medicaid,72.34,,,72.34,Fee Schedule,,34.06,,,34.06,Fee Schedule,,34.06,,,34.06,Fee Schedule,,72.34,,,72.34,Fee Schedule,,34.06,,,34.06,Fee Schedule,,64.07,,,64.07,Fee Schedule,,37.8,70,,37.8,percent of total billed charges,All Other,73.8,,,73.8,Fee Schedule,,62.55,,,62.55,Fee Schedule,,0.01,,,0.01,Case Rate,,0.01,,,0.01,Case Rate,,0.01,,,0.01,Case Rate,,0.01,,,0.01,Case Rate,,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,73.8,
DM OP SMT INDIV PER 30 MIN-TH,G0108,HCPCS,GQ,70000011,CDM,942,RC,,,both,,,237,175.38,,,175.38,Other,150% of Medicare + 9.63% HCRA Surcharge,106.65,45,,106.65,percent of total billed charges,Critical Access Hospital RCC factor,183.36,,,183.36,Fee Schedule,,164.97,,,164.97,Fee Schedule,,181.31,76.5,,181.31,percent of total billed charges,All Other,168.27,69,,168.27,percent of total billed charges,All Other,163.53,65,,163.53,percent of total billed charges,All Other,117.32,,,117.32,Other,110% of Medicare,217.85,,,217.85,Fee Schedule,,0.01,,,0.01,Other,186% of Medicaid,256.36,,,256.36,Fee Schedule,,120.71,,,120.71,Fee Schedule,,120.71,,,120.71,Fee Schedule,,256.36,,,256.36,Fee Schedule,,120.71,,,120.71,Fee Schedule,,189.6,80,,189.6,percent of total billed charges,All Other,165.9,70,,165.9,percent of total billed charges,All Other,265.68,,,265.68,Fee Schedule,,225.18,,,225.18,Fee Schedule,,0.01,,,0.01,Case Rate,,0.01,,,0.01,Case Rate,,0.01,,,0.01,Case Rate,,0.01,,,0.01,Case Rate,,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,265.68,
INIT NUTRITION THERAPY EACH 15M-TH,97802,CPT,95,70000012,CDM,942,RC,,,both,,,141,104.34,,,104.34,Other,150% of Medicare + 9.63% HCRA Surcharge,63.45,45,,63.45,percent of total billed charges,Critical Access Hospital RCC factor,106.61,,,106.61,Fee Schedule,,95.92,,,95.92,Fee Schedule,,107.87,76.5,,107.87,percent of total billed charges,All Other,100.11,69,,100.11,percent of total billed charges,All Other,97.29,65,,97.29,percent of total billed charges,All Other,69.8,,,69.8,Other,110% of Medicare,95.88,68,,95.88,percent of total billed charges,All Other,0.01,,,0.01,Other,186% of Medicaid,112.8,80,,112.8,percent of total billed charges,All Other,117.03,83,,117.03,percent of total billed charges,All Other,117.03,83,,117.03,percent of total billed charges,All Other,112.8,80,,112.8,percent of total billed charges,All Other,117.03,83,,117.03,percent of total billed charges,All Other,112.8,80,,112.8,percent of total billed charges,All Other,98.7,70,,98.7,percent of total billed charges,All Other,155.8,,,155.8,Fee Schedule,,132.05,,,132.05,Fee Schedule,,143,,,143,Case Rate,,131,,,131,Case Rate,,143,,,143,Case Rate,,122,,,122,Case Rate,,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,155.8,
RE-ASSESS NUTRITION THER EA 15M-TH,97803,CPT,95,70000013,CDM,942,RC,,,both,,,118,87.32,,,87.32,Other,150% of Medicare + 9.63% HCRA Surcharge,53.1,45,,53.1,percent of total billed charges,Critical Access Hospital RCC factor,90.92,,,90.92,Fee Schedule,,81.8,,,81.8,Fee Schedule,,90.27,76.5,,90.27,percent of total billed charges,All Other,83.78,69,,83.78,percent of total billed charges,All Other,81.42,65,,81.42,percent of total billed charges,All Other,58.41,,,58.41,Other,110% of Medicare,80.24,68,,80.24,percent of total billed charges,All Other,0.01,,,0.01,Other,186% of Medicaid,94.4,80,,94.4,percent of total billed charges,All Other,97.94,83,,97.94,percent of total billed charges,All Other,97.94,83,,97.94,percent of total billed charges,All Other,94.4,80,,94.4,percent of total billed charges,All Other,97.94,83,,97.94,percent of total billed charges,All Other,94.4,80,,94.4,percent of total billed charges,All Other,82.6,70,,82.6,percent of total billed charges,All Other,132.84,,,132.84,Fee Schedule,,112.59,,,112.59,Fee Schedule,,143,,,143,Case Rate,,131,,,131,Case Rate,,143,,,143,Case Rate,,122,,,122,Case Rate,,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,143,
DM OP SMT GRP PER 30 MIN - TH,G0109,HCPCS,GQ,70000014,CDM,942,RC,,,both,,,72,53.28,,,53.28,Other,150% of Medicare + 9.63% HCRA Surcharge,32.4,45,,32.4,percent of total billed charges,Critical Access Hospital RCC factor,52.89,,,52.89,Fee Schedule,,47.58,,,47.58,Fee Schedule,,55.08,76.5,,55.08,percent of total billed charges,All Other,51.12,69,,51.12,percent of total billed charges,All Other,49.68,65,,49.68,percent of total billed charges,All Other,35.64,,,35.64,Other,110% of Medicare,62.84,,,62.84,Fee Schedule,,0.01,,,0.01,Other,186% of Medicaid,73.95,,,73.95,Fee Schedule,,34.82,,,34.82,Fee Schedule,,34.82,,,34.82,Fee Schedule,,73.95,,,73.95,Fee Schedule,,34.82,,,34.82,Fee Schedule,,57.6,80,,57.6,percent of total billed charges,All Other,50.4,70,,50.4,percent of total billed charges,All Other,75.44,,,75.44,Fee Schedule,,63.94,,,63.94,Fee Schedule,,0.01,,,0.01,Case Rate,,0.01,,,0.01,Case Rate,,0.01,,,0.01,Case Rate,,0.01,,,0.01,Case Rate,,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,75.44,
INIT NUTRITION THERAPY; EACH 15M,97802,CPT,,70097802,CDM,942,RC,,,both,,,141,104.34,,,104.34,Other,150% of Medicare + 9.63% HCRA Surcharge,63.45,45,,63.45,percent of total billed charges,Critical Access Hospital RCC factor,106.61,,,106.61,Fee Schedule,,95.92,,,95.92,Fee Schedule,,107.87,76.5,,107.87,percent of total billed charges,All Other,100.11,69,,100.11,percent of total billed charges,All Other,97.29,65,,97.29,percent of total billed charges,All Other,69.8,,,69.8,Other,110% of Medicare,95.88,68,,95.88,percent of total billed charges,All Other,0.01,,,0.01,Other,186% of Medicaid,112.8,80,,112.8,percent of total billed charges,All Other,117.03,83,,117.03,percent of total billed charges,All Other,117.03,83,,117.03,percent of total billed charges,All Other,112.8,80,,112.8,percent of total billed charges,All Other,117.03,83,,117.03,percent of total billed charges,All Other,112.8,80,,112.8,percent of total billed charges,All Other,98.7,70,,98.7,percent of total billed charges,All Other,155.8,,,155.8,Fee Schedule,,132.05,,,132.05,Fee Schedule,,143,,,143,Case Rate,,131,,,131,Case Rate,,143,,,143,Case Rate,,122,,,122,Case Rate,,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,155.8,
RE-ASSESS NUTRITION THER; EA 15M,97803,CPT,,70097803,CDM,942,RC,,,both,,,118,87.32,,,87.32,Other,150% of Medicare + 9.63% HCRA Surcharge,53.1,45,,53.1,percent of total billed charges,Critical Access Hospital RCC factor,90.92,,,90.92,Fee Schedule,,81.8,,,81.8,Fee Schedule,,90.27,76.5,,90.27,percent of total billed charges,All Other,83.78,69,,83.78,percent of total billed charges,All Other,81.42,65,,81.42,percent of total billed charges,All Other,58.41,,,58.41,Other,110% of Medicare,80.24,68,,80.24,percent of total billed charges,All Other,0.01,,,0.01,Other,186% of Medicaid,94.4,80,,94.4,percent of total billed charges,All Other,97.94,83,,97.94,percent of total billed charges,All Other,97.94,83,,97.94,percent of total billed charges,All Other,94.4,80,,94.4,percent of total billed charges,All Other,97.94,83,,97.94,percent of total billed charges,All Other,94.4,80,,94.4,percent of total billed charges,All Other,82.6,70,,82.6,percent of total billed charges,All Other,132.84,,,132.84,Fee Schedule,,112.59,,,112.59,Fee Schedule,,143,,,143,Case Rate,,131,,,131,Case Rate,,143,,,143,Case Rate,,122,,,122,Case Rate,,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,143,
GRP NUTRITION THERAPY; EA 30M,97804,CPT,,70097804,CDM,942,RC,,,both,,,68,50.32,,,50.32,Other,150% of Medicare + 9.63% HCRA Surcharge,30.6,45,,30.6,percent of total billed charges,Critical Access Hospital RCC factor,51.74,,,51.74,Fee Schedule,,46.55,,,46.55,Fee Schedule,,52.02,76.5,,52.02,percent of total billed charges,All Other,48.28,69,,48.28,percent of total billed charges,All Other,46.92,65,,46.92,percent of total billed charges,All Other,33.66,,,33.66,Other,110% of Medicare,46.24,68,,46.24,percent of total billed charges,All Other,0.01,,,0.01,Other,186% of Medicaid,54.4,80,,54.4,percent of total billed charges,All Other,56.44,83,,56.44,percent of total billed charges,All Other,56.44,83,,56.44,percent of total billed charges,All Other,54.4,80,,54.4,percent of total billed charges,All Other,56.44,83,,56.44,percent of total billed charges,All Other,54.4,80,,54.4,percent of total billed charges,All Other,47.6,70,,47.6,percent of total billed charges,All Other,73.8,,,73.8,Fee Schedule,,62.55,,,62.55,Fee Schedule,,143,,,143,Case Rate,,131,,,131,Case Rate,,143,,,143,Case Rate,,122,,,122,Case Rate,,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,143,
BEHAV CHNG SMOKING 3-10 MIN,99406,CPT,,71099406,CDM,942,RC,,,both,,,114,84.36,,,84.36,Other,150% of Medicare + 9.63% HCRA Surcharge,51.3,45,,51.3,percent of total billed charges,Critical Access Hospital RCC factor,74.1,65,,74.1,percent of total billed charges,All Other,67.26,65,,67.26,percent of total billed charges,All Other,87.21,76.5,,87.21,percent of total billed charges,All Other,80.94,69,,80.94,percent of total billed charges,All Other,78.66,65,,78.66,percent of total billed charges,All Other,56.43,,,56.43,Other,110% of Medicare,77.52,68,,77.52,percent of total billed charges,All Other,79,,,79,Other,186% of Medicaid,91.2,80,,91.2,percent of total billed charges,All Other,94.62,83,,94.62,percent of total billed charges,All Other,94.62,83,,94.62,percent of total billed charges,All Other,91.2,80,,91.2,percent of total billed charges,All Other,94.62,83,,94.62,percent of total billed charges,All Other,91.2,80,,91.2,percent of total billed charges,All Other,79.8,70,,79.8,percent of total billed charges,All Other,57.4,,,57.4,Fee Schedule,,48.65,,,48.65,Fee Schedule,,143,,,143,Case Rate,,131,,,131,Case Rate,,143,,,143,Case Rate,,122,,,122,Case Rate,,42.37,,,42.37,Other,100% of Medicaid,42.37,,,42.37,Other,100% of Medicaid,42.37,,,42.37,Other,100% of Medicaid,42.37,,,42.37,Other,100% of Medicaid,95.33,,,95.33,Other,225% of Medicaid,64.83,,,64.83,Other,153% of Medicaid,95.33,,,95.33,Other,225% of Medicaid,59.32,,,59.32,Other,140% of Medicaid,95.33,,,95.33,Other,225% of Medicaid,110.16,,,110.16,Other,260% of Medicaid,137.28,,,137.28,Other,324% of Medicaid,91.1,,,91.1,Other,215% of Medicaid,91.1,,,91.1,Other,215% of Medicaid,52.96,,,52.96,Other,125% of Medicaid,42.37,143,
BEHAV CHNG SMOKING > 10 MIN,99407,CPT,,71099407,CDM,942,RC,,,both,,,114,84.36,,,84.36,Other,150% of Medicare + 9.63% HCRA Surcharge,51.3,45,,51.3,percent of total billed charges,Critical Access Hospital RCC factor,74.1,65,,74.1,percent of total billed charges,All Other,67.26,65,,67.26,percent of total billed charges,All Other,87.21,76.5,,87.21,percent of total billed charges,All Other,80.94,69,,80.94,percent of total billed charges,All Other,78.66,65,,78.66,percent of total billed charges,All Other,56.43,,,56.43,Other,110% of Medicare,77.52,68,,77.52,percent of total billed charges,All Other,79,,,79,Other,186% of Medicaid,91.2,80,,91.2,percent of total billed charges,All Other,94.62,83,,94.62,percent of total billed charges,All Other,94.62,83,,94.62,percent of total billed charges,All Other,91.2,80,,91.2,percent of total billed charges,All Other,94.62,83,,94.62,percent of total billed charges,All Other,91.2,80,,91.2,percent of total billed charges,All Other,79.8,70,,79.8,percent of total billed charges,All Other,121.36,,,121.36,Fee Schedule,,102.86,,,102.86,Fee Schedule,,143,,,143,Case Rate,,131,,,131,Case Rate,,143,,,143,Case Rate,,122,,,122,Case Rate,,42.37,,,42.37,Other,100% of Medicaid,42.37,,,42.37,Other,100% of Medicaid,42.37,,,42.37,Other,100% of Medicaid,42.37,,,42.37,Other,100% of Medicaid,95.33,,,95.33,Other,225% of Medicaid,64.83,,,64.83,Other,153% of Medicaid,95.33,,,95.33,Other,225% of Medicaid,59.32,,,59.32,Other,140% of Medicaid,95.33,,,95.33,Other,225% of Medicaid,110.16,,,110.16,Other,260% of Medicaid,137.28,,,137.28,Other,324% of Medicaid,91.1,,,91.1,Other,215% of Medicaid,91.1,,,91.1,Other,215% of Medicaid,52.96,,,52.96,Other,125% of Medicaid,42.37,143,
NUTRITIONAL THERAPY FOLLOW UP 15 MIN,97803,CPT,,83097803,CDM,942,RC,,,both,,,118,87.32,,,87.32,Other,150% of Medicare + 9.63% HCRA Surcharge,53.1,45,,53.1,percent of total billed charges,Critical Access Hospital RCC factor,90.92,,,90.92,Fee Schedule,,81.8,,,81.8,Fee Schedule,,90.27,76.5,,90.27,percent of total billed charges,All Other,83.78,69,,83.78,percent of total billed charges,All Other,81.42,65,,81.42,percent of total billed charges,All Other,58.41,,,58.41,Other,110% of Medicare,80.24,68,,80.24,percent of total billed charges,All Other,0.01,,,0.01,Other,186% of Medicaid,94.4,,,94.4,percent of total billed charges,All Other,97.94,83,,97.94,percent of total billed charges,All Other,97.94,83,,97.94,percent of total billed charges,All Other,94.4,80,,94.4,percent of total billed charges,All Other,97.94,83,,97.94,percent of total billed charges,All Other,94.4,80,,94.4,percent of total billed charges,All Other,82.6,70,,82.6,percent of total billed charges,All Other,132.84,,,132.84,Fee Schedule,,112.59,,,112.59,Fee Schedule,,143,,,143,Case Rate,,131,,,131,Case Rate,,143,,,143,Case Rate,,122,,,122,Case Rate,,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,143,
DIET INSTRUCTION FOLLOW UP,99211,CPT,,83099211,CDM,942,RC,,,both,,,228,168.72,,,168.72,Other,150% of Medicare + 9.63% HCRA Surcharge,102.6,45,,102.6,percent of total billed charges,Critical Access Hospital RCC factor,148.2,65,,148.2,percent of total billed charges,All Other,134.52,65,,134.52,percent of total billed charges,All Other,174.42,76.5,,174.42,percent of total billed charges,All Other,161.88,69,,161.88,percent of total billed charges,All Other,157.32,65,,157.32,percent of total billed charges,All Other,112.86,,,112.86,Other,110% of Medicare,155.04,68,,155.04,percent of total billed charges,All Other,0.01,,,0.01,Other,186% of Medicaid,182.4,,,182.4,percent of total billed charges,All Other,189.24,83,,189.24,percent of total billed charges,All Other,189.24,83,,189.24,percent of total billed charges,All Other,182.4,80,,182.4,percent of total billed charges,All Other,189.24,83,,189.24,percent of total billed charges,All Other,182.4,80,,182.4,percent of total billed charges,All Other,159.6,70,,159.6,percent of total billed charges,All Other,42.64,,,42.64,Fee Schedule,,36.14,,,36.14,Fee Schedule,,143,,,143,Case Rate,,131,,,131,Case Rate,,143,,,143,Case Rate,,122,,,122,Case Rate,,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,100% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,153% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,140% of Medicaid,0.01,,,0.01,Other,225% of Medicaid,0.01,,,0.01,Other,260% of Medicaid,0.01,,,0.01,Other,324% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,215% of Medicaid,0.01,,,0.01,Other,125% of Medicaid,0.01,189.24,
PAD REHAB PER SESSION,93668,CPT,,52093668,CDM,943,RC,,,both,,,362,267.88,,,267.88,Other,150% of Medicare + 9.63% HCRA Surcharge,162.9,45,,162.9,percent of total billed charges,Critical Access Hospital RCC factor,47.17,,,47.17,Fee Schedule,,42.53,,,42.53,Fee Schedule,,18.33,,,18.33,Fee Schedule,,18.33,,,18.33,Fee Schedule,,18.33,,,18.33,Fee Schedule,,179.19,,,179.19,Other,110% of Medicare,60.6,,,60.6,Fee Schedule,,255,,,255,Other,186% of Medicaid,71.32,,,71.32,Fee Schedule,,224.44,,,224.44,Fee Schedule,,33.58,,,33.58,Fee Schedule,,71.32,,,71.32,Fee Schedule,,224.44,,,224.44,Fee Schedule,,63.16,,,63.16,Fee Schedule,,253.4,70,,253.4,percent of total billed charges,All Other,67.24,,,67.24,Fee Schedule,,56.99,,,56.99,Fee Schedule,,181,,,181,Case Rate,,181,,,181,Case Rate,,181,,,181,Case Rate,,181,,,181,Case Rate,,137.34,,,137.34,Other,100% of Medicaid,137.34,,,137.34,Other,100% of Medicaid,137.34,,,137.34,Other,100% of Medicaid,137.34,,,137.34,Other,100% of Medicaid,309.01,,,309.01,Other,225% of Medicaid,210.12,,,210.12,Other,153% of Medicaid,309.01,,,309.01,Other,225% of Medicaid,192.27,,,192.27,Other,140% of Medicaid,309.01,,,309.01,Other,225% of Medicaid,357.07,,,357.07,Other,260% of Medicaid,444.97,,,444.97,Other,324% of Medicaid,295.27,,,295.27,Other,215% of Medicaid,295.27,,,295.27,Other,215% of Medicaid,171.67,,,171.67,Other,125% of Medicaid,18.33,444.97,
CARDIAC REHAB; W CONT ECG,93798,CPT,,52093798,CDM,943,RC,,,both,,,295,218.3,,,218.3,Other,150% of Medicare + 9.63% HCRA Surcharge,132.75,45,,132.75,percent of total billed charges,Critical Access Hospital RCC factor,41.42,,,41.42,Fee Schedule,,37.35,,,37.35,Fee Schedule,,158.49,,,158.49,Fee Schedule,,142.67,,,142.67,Fee Schedule,,134.76,,,134.76,Fee Schedule,,146.03,,,146.03,Other,110% of Medicare,53.21,,,53.21,Fee Schedule,,58,,,58,Other,186% of Medicaid,62.62,,,62.62,Fee Schedule,,182.9,,,182.9,Fee Schedule,,29.48,,,29.48,Fee Schedule,,62.62,,,62.62,Fee Schedule,,182.9,,,182.9,Fee Schedule,,55.46,,,55.46,Fee Schedule,,206.5,70,,206.5,percent of total billed charges,All Other,65.6,,,65.6,Fee Schedule,,55.6,,,55.6,Fee Schedule,,147.5,,,147.5,Case Rate,,147.5,,,147.5,Case Rate,,147.5,,,147.5,Case Rate,,147.5,,,147.5,Case Rate,,31.37,,,31.37,Other,100% of Medicaid,31.37,,,31.37,Other,100% of Medicaid,31.37,,,31.37,Other,100% of Medicaid,31.37,,,31.37,Other,100% of Medicaid,70.58,,,70.58,Other,225% of Medicaid,47.99,,,47.99,Other,153% of Medicaid,70.58,,,70.58,Other,225% of Medicaid,43.92,,,43.92,Other,140% of Medicaid,70.58,,,70.58,Other,225% of Medicaid,81.56,,,81.56,Other,260% of Medicaid,101.63,,,101.63,Other,324% of Medicaid,67.44,,,67.44,Other,215% of Medicaid,67.44,,,67.44,Other,215% of Medicaid,39.21,,,39.21,Other,125% of Medicaid,29.48,218.3,
CARDIAC REHAB; W CONT ECG W KX MOD,93798,CPT,KX,52193798,CDM,943,RC,,,both,,,295,218.3,,,218.3,Other,150% of Medicare + 9.63% HCRA Surcharge,132.75,45,,132.75,percent of total billed charges,Critical Access Hospital RCC factor,41.42,,,41.42,Fee Schedule,,37.35,,,37.35,Fee Schedule,,158.49,,,158.49,Fee Schedule,,142.67,,,142.67,Fee Schedule,,134.76,,,134.76,Fee Schedule,,146.03,,,146.03,Other,110% of Medicare,53.21,,,53.21,Fee Schedule,,58,,,58,Other,186% of Medicaid,62.62,,,62.62,Fee Schedule,,182.9,,,182.9,Fee Schedule,,29.48,,,29.48,Fee Schedule,,62.62,,,62.62,Fee Schedule,,182.9,,,182.9,Fee Schedule,,55.46,,,55.46,Fee Schedule,,206.5,70,,206.5,percent of total billed charges,All Other,65.6,,,65.6,Fee Schedule,,55.6,,,55.6,Fee Schedule,,147.5,,,147.5,Case Rate,,147.5,,,147.5,Case Rate,,147.5,,,147.5,Case Rate,,147.5,,,147.5,Case Rate,,31.37,,,31.37,Other,100% of Medicaid,31.37,,,31.37,Other,100% of Medicaid,31.37,,,31.37,Other,100% of Medicaid,31.37,,,31.37,Other,100% of Medicaid,70.58,,,70.58,Other,225% of Medicaid,47.99,,,47.99,Other,153% of Medicaid,70.58,,,70.58,Other,225% of Medicaid,43.92,,,43.92,Other,140% of Medicaid,70.58,,,70.58,Other,225% of Medicaid,81.56,,,81.56,Other,260% of Medicaid,101.63,,,101.63,Other,324% of Medicaid,67.44,,,67.44,Other,215% of Medicaid,67.44,,,67.44,Other,215% of Medicaid,39.21,,,39.21,Other,125% of Medicaid,29.48,218.3,
TH-ALCOHOL/DRUG SERVICES C&T PER 15 MINS,H0004,HCPCS,GT,36000001,CDM,944,RC,,,both,,,72,53.28,,,53.28,Other,150% of Medicare + 9.63% HCRA Surcharge,32.4,45,,32.4,percent of total billed charges,Critical Access Hospital RCC factor,46.8,65,,46.8,percent of total billed charges,All Other,42.48,65,,42.48,percent of total billed charges,All Other,55.08,76.5,,55.08,percent of total billed charges,All Other,51.12,69,,51.12,percent of total billed charges,All Other,49.68,65,,49.68,percent of total billed charges,All Other,35.64,,,35.64,Other,110% of Medicare,48.96,68,,48.96,percent of total billed charges,All Other,174,,,174,Other,186% of Medicaid,57.6,,,57.6,percent of total billed charges,All Other,44.64,62,,44.64,percent of total billed charges,Lab and Radiology,39.6,83,,39.6,percent of total billed charges,All Other,57.6,80,,57.6,percent of total billed charges,All Other,44.64,62,,44.64,percent of total billed charges,Lab and Radiology,57.6,80,,57.6,percent of total billed charges,All Other,50.4,70,,50.4,percent of total billed charges,All Other,46.8,65,,46.8,percent of total billed charges,Default if not in Fee Schedule,46.8,65,,46.8,percent of total billed charges,Default if not in Fee Schedule,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,93.82,,,93.82,Other,100% of Medicaid,93.82,,,93.82,Other,100% of Medicaid,93.82,,,93.82,Other,100% of Medicaid,93.82,,,93.82,Other,100% of Medicaid,211.09,,,211.09,Other,225% of Medicaid,143.54,,,143.54,Other,153% of Medicaid,211.09,,,211.09,Other,225% of Medicaid,131.34,,,131.34,Other,140% of Medicaid,211.09,,,211.09,Other,225% of Medicaid,243.92,,,243.92,Other,260% of Medicaid,303.97,,,303.97,Other,324% of Medicaid,201.71,,,201.71,Other,215% of Medicaid,201.71,,,201.71,Other,215% of Medicaid,117.27,,,117.27,Other,125% of Medicaid,0.01,303.97,
CYTO/MOLECULAR REPORT,88291,CPT,,78088291,CDM,971,RC,,,both,,,682,504.68,,,504.68,Other,150% of Medicare + 9.63% HCRA Surcharge,306.9,45,,306.9,percent of total billed charges,Critical Access Hospital RCC factor,106.25,,,106.25,Fee Schedule,,95.66,,,95.66,Fee Schedule,,175.86,,,175.86,Fee Schedule,,158.17,,,158.17,Fee Schedule,,149.5,,,149.5,Fee Schedule,,337.59,,,337.59,Other,110% of Medicare,111.2,,,111.2,Fee Schedule,,103,,,103,Other,186% of Medicaid,130.96,,,130.96,Fee Schedule,,74.13,,,74.13,Fee Schedule,,74.13,,,74.13,Fee Schedule,,130.96,,,130.96,Fee Schedule,,74.13,,,74.13,Fee Schedule,,139.44,,,139.44,Fee Schedule,,477.4,70,,477.4,percent of total billed charges,All Other,159.08,,,159.08,Fee Schedule,,134.83,,,134.83,Fee Schedule,,51.98,,,51.98,Fee Schedule,,51.98,,,51.98,Fee Schedule,,51.98,,,51.98,Fee Schedule,,51.98,,,51.98,Fee Schedule,,55.61,,,55.61,Other,100% of Medicaid,55.61,,,55.61,Other,100% of Medicaid,55.61,,,55.61,Other,100% of Medicaid,55.61,,,55.61,Other,100% of Medicaid,125.13,,,125.13,Other,225% of Medicaid,85.09,,,85.09,Other,153% of Medicaid,125.13,,,125.13,Other,225% of Medicaid,77.86,,,77.86,Other,140% of Medicaid,125.13,,,125.13,Other,225% of Medicaid,144.59,,,144.59,Other,260% of Medicaid,180.18,,,180.18,Other,324% of Medicaid,119.57,,,119.57,Other,215% of Medicaid,119.57,,,119.57,Other,215% of Medicaid,69.51,,,69.51,Other,125% of Medicaid,51.98,504.68,
RHYTHM ECG REPORT,93042,CPT,,30093042,CDM,985,RC,,,both,,,41,30.34,,,30.34,Other,150% of Medicare + 9.63% HCRA Surcharge,18.45,45,,18.45,percent of total billed charges,Critical Access Hospital RCC factor,20.65,,,20.65,Fee Schedule,,18.62,,,18.62,Fee Schedule,,31.37,76.5,,31.37,percent of total billed charges,All Other,29.11,69,,29.11,percent of total billed charges,All Other,28.29,65,,28.29,percent of total billed charges,All Other,20.3,,,20.3,Other,110% of Medicare,0.68,,,0.68,Fee Schedule,,64,,,64,Other,186% of Medicaid,0.8,,,0.8,Fee Schedule,,0.83,,,0.83,Fee Schedule,,0.83,,,0.83,Fee Schedule,,0.8,,,0.8,Fee Schedule,,0.83,,,0.83,Fee Schedule,,27.65,,,27.65,Fee Schedule,,28.7,70,,28.7,percent of total billed charges,All Other,32.8,,,32.8,Fee Schedule,,27.8,,,27.8,Fee Schedule,,28.7,70,,28.7,percent of total billed charges,All Other,28.7,70,,28.7,percent of total billed charges,All Other,28.7,70,,28.7,percent of total billed charges,All Other,28.7,70,,28.7,percent of total billed charges,All Other,34.6,,,34.6,Other,100% of Medicaid,34.6,,,34.6,Other,100% of Medicaid,34.6,,,34.6,Other,100% of Medicaid,34.6,,,34.6,Other,100% of Medicaid,77.85,,,77.85,Other,225% of Medicaid,52.94,,,52.94,Other,153% of Medicaid,77.85,,,77.85,Other,225% of Medicaid,48.44,,,48.44,Other,140% of Medicaid,77.85,,,77.85,Other,225% of Medicaid,89.97,,,89.97,Other,260% of Medicaid,112.11,,,112.11,Other,324% of Medicaid,74.39,,,74.39,Other,215% of Medicaid,74.39,,,74.39,Other,215% of Medicaid,43.25,,,43.25,Other,125% of Medicaid,0.68,112.11,
"ECMO OR TRACHEOSTOMY WITH MV >96 HOURS OR PRINCIPAL DIAGNOSIS EXCEPT FACE, MOUTH AND NECK WITH MAJOR O.R. PROCEDURES",3,MS-DRG,,,,,,,,inpatient,,,2142512.18,216674,,,216674,Other,150% of Medicare + 9.63% HCRA Surcharge,131761,,"3,609.90 x patient days",131761,Per diem,,533988,,"25,046 x DRG weight",533988,Other,base rate x DRG weight,480581,,"22,541 x DRG weight",480581,Other,base rate x DRG weight,672080,,"31,523 x DRG weight",672080,Other,base rate x DRG weight,604878,,"28,371 x DRG weight",604878,Other,base rate x DRG weight,571277,,"26,795 x DRG weight",571277,Other,base rate x DRG weight,144937.1,,"3,970.89 x patient days",144937.1,Per diem,,478918,,"22,463 x DRG weight",478918,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,563410,,"26,426 x DRG weight",563410,Other,base rate x DRG weight,827420,,"38,809 x DRG weight",827420,Other,base rate x DRG weight,827420,,"38,809 x DRG weight",827420,Other,base rate x DRG weight,563410,,"26,426 x DRG weight",563410,Other,base rate x DRG weight,827420,,"38,809 x DRG weight",827420,Other,base rate x DRG weight,232250,,"6,363 x patient days",232250,Per diem,,1499759,70,,1499759,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,534223,,"25,057 x DRG weight",534223,Other,base rate x DRG weight,480815,,"22,552 x DRG weight",480815,Other,base rate x DRG weight,534223,,"25,057 x DRG weight",534223,Other,base rate x DRG weight,454080,,"21,298 x DRG weight",454080,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,1499759,
"TRACHEOSTOMY WITH MV >96 HOURS OR PRINCIPAL DIAGNOSIS EXCEPT FACE, MOUTH AND NECK WITHOUT MAJOR O.R. PROCEDURES",4,MS-DRG,,,,,,,,inpatient,,,2138389.4,189962,,,189962,Other,150% of Medicare + 9.63% HCRA Surcharge,115517,,"3,609.90 x patient days",115517,Per diem,,368176,,"25,046 x DRG weight",368176,Other,base rate x DRG weight,331353,,"22,541 x DRG weight",331353,Other,base rate x DRG weight,463388,,"31,523 x DRG weight",463388,Other,base rate x DRG weight,417054,,"28,371 x DRG weight",417054,Other,base rate x DRG weight,393887,,"26,795 x DRG weight",393887,Other,base rate x DRG weight,127068.7,,"3,970.89 x patient days",127068.7,Per diem,,330206,,"22,463 x DRG weight",330206,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,388462,,"26,426 x DRG weight",388462,Other,base rate x DRG weight,570492,,"38,809 x DRG weight",570492,Other,base rate x DRG weight,570492,,"38,809 x DRG weight",570492,Other,base rate x DRG weight,388462,,"26,426 x DRG weight",388462,Other,base rate x DRG weight,570492,,"38,809 x DRG weight",570492,Other,base rate x DRG weight,203616,,"6,363 x patient days",203616,Per diem,,1496873,70,,1496873,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,368338,,"25,057 x DRG weight",368338,Other,base rate x DRG weight,331514,,"22,552 x DRG weight",331514,Other,base rate x DRG weight,368338,,"25,057 x DRG weight",368338,Other,base rate x DRG weight,313081,,"21,298 x DRG weight",313081,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,1496873,
"TRACHEOSTOMY FOR FACE, MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITH MCC",11,MS-DRG,,,,,,,,inpatient,,,1018970.79,87858,,,87858,Other,150% of Medicare + 9.63% HCRA Surcharge,53427,,"3,609.90 x patient days",53427,Per diem,,129145,,"25,046 x DRG weight",129145,Other,base rate x DRG weight,116228,,"22,541 x DRG weight",116228,Other,base rate x DRG weight,162542,,"31,523 x DRG weight",162542,Other,base rate x DRG weight,146289,,"28,371 x DRG weight",146289,Other,base rate x DRG weight,138163,,"26,795 x DRG weight",138163,Other,base rate x DRG weight,58769.7,,"3,970.89 x patient days",58769.7,Per diem,,115826,,"22,463 x DRG weight",115826,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,136260,,"26,426 x DRG weight",136260,Other,base rate x DRG weight,200111,,"38,809 x DRG weight",200111,Other,base rate x DRG weight,200111,,"38,809 x DRG weight",200111,Other,base rate x DRG weight,136260,,"26,426 x DRG weight",136260,Other,base rate x DRG weight,200111,,"38,809 x DRG weight",200111,Other,base rate x DRG weight,94172,,"6,363 x patient days",94172,Per diem,,713280,70,,713280,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,129201,,"25,057 x DRG weight",129201,Other,base rate x DRG weight,116285,,"22,552 x DRG weight",116285,Other,base rate x DRG weight,129201,,"25,057 x DRG weight",129201,Other,base rate x DRG weight,109819,,"21,298 x DRG weight",109819,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,713280,
"TRACHEOSTOMY FOR FACE, MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITH CC",12,MS-DRG,,,,,,,,inpatient,,,746089.01,58176,,,58176,Other,150% of Medicare + 9.63% HCRA Surcharge,35377,,"3,609.90 x patient days",35377,Per diem,,100307,,"25,046 x DRG weight",100307,Other,base rate x DRG weight,90274,,"22,541 x DRG weight",90274,Other,base rate x DRG weight,126246,,"31,523 x DRG weight",126246,Other,base rate x DRG weight,113623,,"28,371 x DRG weight",113623,Other,base rate x DRG weight,107311,,"26,795 x DRG weight",107311,Other,base rate x DRG weight,38914.7,,"3,970.89 x patient days",38914.7,Per diem,,89962,,"22,463 x DRG weight",89962,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,105833,,"26,426 x DRG weight",105833,Other,base rate x DRG weight,155426,,"38,809 x DRG weight",155426,Other,base rate x DRG weight,155426,,"38,809 x DRG weight",155426,Other,base rate x DRG weight,105833,,"26,426 x DRG weight",105833,Other,base rate x DRG weight,155426,,"38,809 x DRG weight",155426,Other,base rate x DRG weight,62357,,"6,363 x patient days",62357,Per diem,,522262,70,,522262,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,100351,,"25,057 x DRG weight",100351,Other,base rate x DRG weight,90319,,"22,552 x DRG weight",90319,Other,base rate x DRG weight,100351,,"25,057 x DRG weight",100351,Other,base rate x DRG weight,85296,,"21,298 x DRG weight",85296,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,522262,
"TRACHEOSTOMY FOR FACE, MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITHOUT CC/MCC",13,MS-DRG,,,,,,,,inpatient,,,640772.94,41554,,,41554,Other,150% of Medicare + 9.63% HCRA Surcharge,25269,,"3,609.90 x patient days",25269,Per diem,,67266,,"25,046 x DRG weight",67266,Other,base rate x DRG weight,60538,,"22,541 x DRG weight",60538,Other,base rate x DRG weight,84661,,"31,523 x DRG weight",84661,Other,base rate x DRG weight,76196,,"28,371 x DRG weight",76196,Other,base rate x DRG weight,71963,,"26,795 x DRG weight",71963,Other,base rate x DRG weight,27795.9,,"3,970.89 x patient days",27795.9,Per diem,,60329,,"22,463 x DRG weight",60329,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,70972,,"26,426 x DRG weight",70972,Other,base rate x DRG weight,104229,,"38,809 x DRG weight",104229,Other,base rate x DRG weight,104229,,"38,809 x DRG weight",104229,Other,base rate x DRG weight,70972,,"26,426 x DRG weight",70972,Other,base rate x DRG weight,104229,,"38,809 x DRG weight",104229,Other,base rate x DRG weight,44541,,"6,363 x patient days",44541,Per diem,,448541,70,,448541,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,67296,,"25,057 x DRG weight",67296,Other,base rate x DRG weight,60568,,"22,552 x DRG weight",60568,Other,base rate x DRG weight,67296,,"25,057 x DRG weight",67296,Other,base rate x DRG weight,57200,,"21,298 x DRG weight",57200,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,448541,
CHIMERIC ANTIGEN RECEPTOR (CAR) T-CELL AND OTHER IMMUNOTHERAPIES,18,MS-DRG,,,,,,,,inpatient,,,2269653,89637,,,89637,Other,150% of Medicare + 9.63% HCRA Surcharge,54509,,"3,609.90 x patient days",54509,Per diem,,922762,,"25,046 x DRG weight",922762,Other,base rate x DRG weight,830471,,"22,541 x DRG weight",830471,Other,base rate x DRG weight,1161392,,"31,523 x DRG weight",1161392,Other,base rate x DRG weight,1045264,,"28,371 x DRG weight",1045264,Other,base rate x DRG weight,987200,,"26,795 x DRG weight",987200,Other,base rate x DRG weight,59959.9,,"3,970.89 x patient days",59959.9,Per diem,,827598,,"22,463 x DRG weight",827598,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,973605,,"26,426 x DRG weight",973605,Other,base rate x DRG weight,1429828,,"38,809 x DRG weight",1429828,Other,base rate x DRG weight,1429828,,"38,809 x DRG weight",1429828,Other,base rate x DRG weight,973605,,"26,426 x DRG weight",973605,Other,base rate x DRG weight,1429828,,"38,809 x DRG weight",1429828,Other,base rate x DRG weight,96081,,"6,363 x patient days",96081,Per diem,,1588757,70,,1588757,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,923168,,"25,057 x DRG weight",923168,Other,base rate x DRG weight,830877,,"22,552 x DRG weight",830877,Other,base rate x DRG weight,923168,,"25,057 x DRG weight",923168,Other,base rate x DRG weight,784676,,"21,298 x DRG weight",784676,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,1588757,
INTRACRANIAL VASCULAR PROCEDURES WITH PRINCIPAL DIAGNOSIS HEMORRHAGE WITH MCC,20,MS-DRG,,,,,,,,inpatient,,,843972.12,83703,,,83703,Other,150% of Medicare + 9.63% HCRA Surcharge,50900,,"3,609.90 x patient days",50900,Per diem,,211699,,"25,046 x DRG weight",211699,Other,base rate x DRG weight,190526,,"22,541 x DRG weight",190526,Other,base rate x DRG weight,266445,,"31,523 x DRG weight",266445,Other,base rate x DRG weight,239803,,"28,371 x DRG weight",239803,Other,base rate x DRG weight,226482,,"26,795 x DRG weight",226482,Other,base rate x DRG weight,55990,,"3,970.89 x patient days",55990,Per diem,,189866,,"22,463 x DRG weight",189866,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,223363,,"26,426 x DRG weight",223363,Other,base rate x DRG weight,328029,,"38,809 x DRG weight",328029,Other,base rate x DRG weight,328029,,"38,809 x DRG weight",328029,Other,base rate x DRG weight,223363,,"26,426 x DRG weight",223363,Other,base rate x DRG weight,328029,,"38,809 x DRG weight",328029,Other,base rate x DRG weight,89718,,"6,363 x patient days",89718,Per diem,,590780,70,,590780,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,211792,,"25,057 x DRG weight",211792,Other,base rate x DRG weight,190619,,"22,552 x DRG weight",190619,Other,base rate x DRG weight,211792,,"25,057 x DRG weight",211792,Other,base rate x DRG weight,180019,,"21,298 x DRG weight",180019,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,590780,
INTRACRANIAL VASCULAR PROCEDURES WITH PRINCIPAL DIAGNOSIS HEMORRHAGE WITH CC,21,MS-DRG,,,,,,,,inpatient,,,431596.61,53427,,,53427,Other,150% of Medicare + 9.63% HCRA Surcharge,32489,,"3,609.90 x patient days",32489,Per diem,,153818,,"25,046 x DRG weight",153818,Other,base rate x DRG weight,138433,,"22,541 x DRG weight",138433,Other,base rate x DRG weight,193595,,"31,523 x DRG weight",193595,Other,base rate x DRG weight,174238,,"28,371 x DRG weight",174238,Other,base rate x DRG weight,164559,,"26,795 x DRG weight",164559,Other,base rate x DRG weight,35737.9,,"3,970.89 x patient days",35737.9,Per diem,,137954,,"22,463 x DRG weight",137954,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,162293,,"26,426 x DRG weight",162293,Other,base rate x DRG weight,238342,,"38,809 x DRG weight",238342,Other,base rate x DRG weight,238342,,"38,809 x DRG weight",238342,Other,base rate x DRG weight,162293,,"26,426 x DRG weight",162293,Other,base rate x DRG weight,238342,,"38,809 x DRG weight",238342,Other,base rate x DRG weight,57267,,"6,363 x patient days",57267,Per diem,,302118,70,,302118,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,153885,,"25,057 x DRG weight",153885,Other,base rate x DRG weight,138501,,"22,552 x DRG weight",138501,Other,base rate x DRG weight,153885,,"25,057 x DRG weight",153885,Other,base rate x DRG weight,130800,,"21,298 x DRG weight",130800,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,302118,
INTRACRANIAL VASCULAR PROCEDURES WITH PRINCIPAL DIAGNOSIS HEMORRHAGE WITHOUT CC/MCC,22,MS-DRG,,,,,,,,inpatient,,,383655.44,23152,,,23152,Other,150% of Medicare + 9.63% HCRA Surcharge,14079,,"3,609.90 x patient days",14079,Per diem,,98248,,"25,046 x DRG weight",98248,Other,base rate x DRG weight,88422,,"22,541 x DRG weight",88422,Other,base rate x DRG weight,123655,,"31,523 x DRG weight",123655,Other,base rate x DRG weight,111291,,"28,371 x DRG weight",111291,Other,base rate x DRG weight,105109,,"26,795 x DRG weight",105109,Other,base rate x DRG weight,15486.9,,"3,970.89 x patient days",15486.9,Per diem,,88116,,"22,463 x DRG weight",88116,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,103661,,"26,426 x DRG weight",103661,Other,base rate x DRG weight,152236,,"38,809 x DRG weight",152236,Other,base rate x DRG weight,152236,,"38,809 x DRG weight",152236,Other,base rate x DRG weight,103661,,"26,426 x DRG weight",103661,Other,base rate x DRG weight,152236,,"38,809 x DRG weight",152236,Other,base rate x DRG weight,24816,,"6,363 x patient days",24816,Per diem,,268559,70,,268559,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,98291,,"25,057 x DRG weight",98291,Other,base rate x DRG weight,88465,,"22,552 x DRG weight",88465,Other,base rate x DRG weight,98291,,"25,057 x DRG weight",98291,Other,base rate x DRG weight,83546,,"21,298 x DRG weight",83546,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,268559,
CRANIOTOMY WITH MAJOR DEVICE IMPLANT OR ACUTE COMPLEX CNS PRINCIPAL DIAGNOSIS WITH MCC OR CHEMOTHERAPY IMPLANT OR EPILEPSY WITH NEUROSTIMULATOR,23,MS-DRG,,,,,,,,inpatient,,,464200.84,62331,,,62331,Other,150% of Medicare + 9.63% HCRA Surcharge,37904,,"3,609.90 x patient days",37904,Per diem,,141981,,"25,046 x DRG weight",141981,Other,base rate x DRG weight,127780,,"22,541 x DRG weight",127780,Other,base rate x DRG weight,178698,,"31,523 x DRG weight",178698,Other,base rate x DRG weight,160830,,"28,371 x DRG weight",160830,Other,base rate x DRG weight,151895,,"26,795 x DRG weight",151895,Other,base rate x DRG weight,41694.4,,"3,970.89 x patient days",41694.4,Per diem,,127338,,"22,463 x DRG weight",127338,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,149804,,"26,426 x DRG weight",149804,Other,base rate x DRG weight,220000,,"38,809 x DRG weight",220000,Other,base rate x DRG weight,220000,,"38,809 x DRG weight",220000,Other,base rate x DRG weight,149804,,"26,426 x DRG weight",149804,Other,base rate x DRG weight,220000,,"38,809 x DRG weight",220000,Other,base rate x DRG weight,66812,,"6,363 x patient days",66812,Per diem,,324941,70,,324941,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,142043,,"25,057 x DRG weight",142043,Other,base rate x DRG weight,127843,,"22,552 x DRG weight",127843,Other,base rate x DRG weight,142043,,"25,057 x DRG weight",142043,Other,base rate x DRG weight,120734,,"21,298 x DRG weight",120734,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,324941,
CRANIOTOMY WITH MAJOR DEVICE IMPLANT OR ACUTE COMPLEX CNS PRINCIPAL DIAGNOSIS WITHOUT MCC,24,MS-DRG,,,,,,,,inpatient,,,345432.72,30868,,,30868,Other,150% of Medicare + 9.63% HCRA Surcharge,18771,,"3,609.90 x patient days",18771,Per diem,,94894,,"25,046 x DRG weight",94894,Other,base rate x DRG weight,85403,,"22,541 x DRG weight",85403,Other,base rate x DRG weight,119434,,"31,523 x DRG weight",119434,Other,base rate x DRG weight,107492,,"28,371 x DRG weight",107492,Other,base rate x DRG weight,101521,,"26,795 x DRG weight",101521,Other,base rate x DRG weight,20648.1,,"3,970.89 x patient days",20648.1,Per diem,,85108,,"22,463 x DRG weight",85108,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,100123,,"26,426 x DRG weight",100123,Other,base rate x DRG weight,147040,,"38,809 x DRG weight",147040,Other,base rate x DRG weight,147040,,"38,809 x DRG weight",147040,Other,base rate x DRG weight,100123,,"26,426 x DRG weight",100123,Other,base rate x DRG weight,147040,,"38,809 x DRG weight",147040,Other,base rate x DRG weight,33088,,"6,363 x patient days",33088,Per diem,,241803,70,,241803,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,94936,,"25,057 x DRG weight",94936,Other,base rate x DRG weight,85445,,"22,552 x DRG weight",85445,Other,base rate x DRG weight,94936,,"25,057 x DRG weight",94936,Other,base rate x DRG weight,80694,,"21,298 x DRG weight",80694,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,241803,
CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITH MCC,25,MS-DRG,,,,,,,,inpatient,,,461817.62,54020,,,54020,Other,150% of Medicare + 9.63% HCRA Surcharge,32850,,"3,609.90 x patient days",32850,Per diem,,110603,,"25,046 x DRG weight",110603,Other,base rate x DRG weight,99541,,"22,541 x DRG weight",99541,Other,base rate x DRG weight,139206,,"31,523 x DRG weight",139206,Other,base rate x DRG weight,125286,,"28,371 x DRG weight",125286,Other,base rate x DRG weight,118327,,"26,795 x DRG weight",118327,Other,base rate x DRG weight,36135,,"3,970.89 x patient days",36135,Per diem,,99197,,"22,463 x DRG weight",99197,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,116697,,"26,426 x DRG weight",116697,Other,base rate x DRG weight,171381,,"38,809 x DRG weight",171381,Other,base rate x DRG weight,171381,,"38,809 x DRG weight",171381,Other,base rate x DRG weight,116697,,"26,426 x DRG weight",116697,Other,base rate x DRG weight,171381,,"38,809 x DRG weight",171381,Other,base rate x DRG weight,57903,,"6,363 x patient days",57903,Per diem,,323272,70,,323272,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,110652,,"25,057 x DRG weight",110652,Other,base rate x DRG weight,99590,,"22,552 x DRG weight",99590,Other,base rate x DRG weight,110652,,"25,057 x DRG weight",110652,Other,base rate x DRG weight,94052,,"21,298 x DRG weight",94052,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,323272,
CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITH CC,26,MS-DRG,,,,,,,,inpatient,,,336299.27,27901,,,27901,Other,150% of Medicare + 9.63% HCRA Surcharge,16967,,"3,609.90 x patient days",16967,Per diem,,73963,,"25,046 x DRG weight",73963,Other,base rate x DRG weight,66566,,"22,541 x DRG weight",66566,Other,base rate x DRG weight,93091,,"31,523 x DRG weight",93091,Other,base rate x DRG weight,83782,,"28,371 x DRG weight",83782,Other,base rate x DRG weight,79128,,"26,795 x DRG weight",79128,Other,base rate x DRG weight,18663.7,,"3,970.89 x patient days",18663.7,Per diem,,66335,,"22,463 x DRG weight",66335,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,78039,,"26,426 x DRG weight",78039,Other,base rate x DRG weight,114607,,"38,809 x DRG weight",114607,Other,base rate x DRG weight,114607,,"38,809 x DRG weight",114607,Other,base rate x DRG weight,78039,,"26,426 x DRG weight",78039,Other,base rate x DRG weight,114607,,"38,809 x DRG weight",114607,Other,base rate x DRG weight,29906,,"6,363 x patient days",29906,Per diem,,235409,70,,235409,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,73996,,"25,057 x DRG weight",73996,Other,base rate x DRG weight,66598,,"22,552 x DRG weight",66598,Other,base rate x DRG weight,73996,,"25,057 x DRG weight",73996,Other,base rate x DRG weight,62895,,"21,298 x DRG weight",62895,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,235409,
CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITHOUT CC/MCC,27,MS-DRG,,,,,,,,inpatient,,,206391.91,12467,,,12467,Other,150% of Medicare + 9.63% HCRA Surcharge,7581,,"3,609.90 x patient days",7581,Per diem,,60934,,"25,046 x DRG weight",60934,Other,base rate x DRG weight,54840,,"22,541 x DRG weight",54840,Other,base rate x DRG weight,76692,,"31,523 x DRG weight",76692,Other,base rate x DRG weight,69024,,"28,371 x DRG weight",69024,Other,base rate x DRG weight,65190,,"26,795 x DRG weight",65190,Other,base rate x DRG weight,8339.1,,"3,970.89 x patient days",8339.1,Per diem,,54650,,"22,463 x DRG weight",54650,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,64292,,"26,426 x DRG weight",64292,Other,base rate x DRG weight,94418,,"38,809 x DRG weight",94418,Other,base rate x DRG weight,94418,,"38,809 x DRG weight",94418,Other,base rate x DRG weight,64292,,"26,426 x DRG weight",64292,Other,base rate x DRG weight,94418,,"38,809 x DRG weight",94418,Other,base rate x DRG weight,13362,,"6,363 x patient days",13362,Per diem,,144474,70,,144474,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,60961,,"25,057 x DRG weight",60961,Other,base rate x DRG weight,54867,,"22,552 x DRG weight",54867,Other,base rate x DRG weight,60961,,"25,057 x DRG weight",60961,Other,base rate x DRG weight,51816,,"21,298 x DRG weight",51816,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,144474,
SPINAL PROCEDURES WITH MCC,28,MS-DRG,,,,,,,,inpatient,,,524282.81,78360,,,78360,Other,150% of Medicare + 9.63% HCRA Surcharge,47651,,"3,609.90 x patient days",47651,Per diem,,150930,,"25,046 x DRG weight",150930,Other,base rate x DRG weight,135834,,"22,541 x DRG weight",135834,Other,base rate x DRG weight,189961,,"31,523 x DRG weight",189961,Other,base rate x DRG weight,170966,,"28,371 x DRG weight",170966,Other,base rate x DRG weight,161469,,"26,795 x DRG weight",161469,Other,base rate x DRG weight,52416.1,,"3,970.89 x patient days",52416.1,Per diem,,135364,,"22,463 x DRG weight",135364,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,159246,,"26,426 x DRG weight",159246,Other,base rate x DRG weight,233867,,"38,809 x DRG weight",233867,Other,base rate x DRG weight,233867,,"38,809 x DRG weight",233867,Other,base rate x DRG weight,159246,,"26,426 x DRG weight",159246,Other,base rate x DRG weight,233867,,"38,809 x DRG weight",233867,Other,base rate x DRG weight,83992,,"6,363 x patient days",83992,Per diem,,366998,70,,366998,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,150996,,"25,057 x DRG weight",150996,Other,base rate x DRG weight,135901,,"22,552 x DRG weight",135901,Other,base rate x DRG weight,150996,,"25,057 x DRG weight",150996,Other,base rate x DRG weight,128344,,"21,298 x DRG weight",128344,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,366998,
SPINAL PROCEDURES WITH CC OR SPINAL NEUROSTIMULATORS,29,MS-DRG,,,,,,,,inpatient,,,391448.89,38585,,,38585,Other,150% of Medicare + 9.63% HCRA Surcharge,23464,,"3,609.90 x patient days",23464,Per diem,,85863,,"25,046 x DRG weight",85863,Other,base rate x DRG weight,77275,,"22,541 x DRG weight",77275,Other,base rate x DRG weight,108067,,"31,523 x DRG weight",108067,Other,base rate x DRG weight,97261,,"28,371 x DRG weight",97261,Other,base rate x DRG weight,91859,,"26,795 x DRG weight",91859,Other,base rate x DRG weight,25810.4,,"3,970.89 x patient days",25810.4,Per diem,,77008,,"22,463 x DRG weight",77008,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,90594,,"26,426 x DRG weight",90594,Other,base rate x DRG weight,133045,,"38,809 x DRG weight",133045,Other,base rate x DRG weight,133045,,"38,809 x DRG weight",133045,Other,base rate x DRG weight,90594,,"26,426 x DRG weight",90594,Other,base rate x DRG weight,133045,,"38,809 x DRG weight",133045,Other,base rate x DRG weight,41360,,"6,363 x patient days",41360,Per diem,,274014,70,,274014,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,85900,,"25,057 x DRG weight",85900,Other,base rate x DRG weight,77313,,"22,552 x DRG weight",77313,Other,base rate x DRG weight,85900,,"25,057 x DRG weight",85900,Other,base rate x DRG weight,73014,,"21,298 x DRG weight",73014,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,274014,
SPINAL PROCEDURES WITHOUT CC/MCC,30,MS-DRG,,,,,,,,inpatient,,,216991.21,21371,,,21371,Other,150% of Medicare + 9.63% HCRA Surcharge,12996,,"3,609.90 x patient days",12996,Per diem,,58082,,"25,046 x DRG weight",58082,Other,base rate x DRG weight,52273,,"22,541 x DRG weight",52273,Other,base rate x DRG weight,73102,,"31,523 x DRG weight",73102,Other,base rate x DRG weight,65792,,"28,371 x DRG weight",65792,Other,base rate x DRG weight,62138,,"26,795 x DRG weight",62138,Other,base rate x DRG weight,14295.6,,"3,970.89 x patient days",14295.6,Per diem,,52092,,"22,463 x DRG weight",52092,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,61282,,"26,426 x DRG weight",61282,Other,base rate x DRG weight,89998,,"38,809 x DRG weight",89998,Other,base rate x DRG weight,89998,,"38,809 x DRG weight",89998,Other,base rate x DRG weight,61282,,"26,426 x DRG weight",61282,Other,base rate x DRG weight,89998,,"38,809 x DRG weight",89998,Other,base rate x DRG weight,22907,,"6,363 x patient days",22907,Per diem,,151894,70,,151894,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,58107,,"25,057 x DRG weight",58107,Other,base rate x DRG weight,52298,,"22,552 x DRG weight",52298,Other,base rate x DRG weight,58107,,"25,057 x DRG weight",58107,Other,base rate x DRG weight,49390,,"21,298 x DRG weight",49390,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,151894,
VENTRICULAR SHUNT PROCEDURES WITH MCC,31,MS-DRG,,,,,,,,inpatient,,,307699.13,61738,,,61738,Other,150% of Medicare + 9.63% HCRA Surcharge,37543,,"3,609.90 x patient days",37543,Per diem,,103104,,"25,046 x DRG weight",103104,Other,base rate x DRG weight,92792,,"22,541 x DRG weight",92792,Other,base rate x DRG weight,129768,,"31,523 x DRG weight",129768,Other,base rate x DRG weight,116792,,"28,371 x DRG weight",116792,Other,base rate x DRG weight,110304,,"26,795 x DRG weight",110304,Other,base rate x DRG weight,41297.3,,"3,970.89 x patient days",41297.3,Per diem,,92471,,"22,463 x DRG weight",92471,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,108785,,"26,426 x DRG weight",108785,Other,base rate x DRG weight,159761,,"38,809 x DRG weight",159761,Other,base rate x DRG weight,159761,,"38,809 x DRG weight",159761,Other,base rate x DRG weight,108785,,"26,426 x DRG weight",108785,Other,base rate x DRG weight,159761,,"38,809 x DRG weight",159761,Other,base rate x DRG weight,66175,,"6,363 x patient days",66175,Per diem,,215389,70,,215389,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,103150,,"25,057 x DRG weight",103150,Other,base rate x DRG weight,92838,,"22,552 x DRG weight",92838,Other,base rate x DRG weight,103150,,"25,057 x DRG weight",103150,Other,base rate x DRG weight,87675,,"21,298 x DRG weight",87675,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,215389,
VENTRICULAR SHUNT PROCEDURES WITH CC,32,MS-DRG,,,,,,,,inpatient,,,206595.31,24340,,,24340,Other,150% of Medicare + 9.63% HCRA Surcharge,14801,,"3,609.90 x patient days",14801,Per diem,,53944,,"25,046 x DRG weight",53944,Other,base rate x DRG weight,48549,,"22,541 x DRG weight",48549,Other,base rate x DRG weight,67894,,"31,523 x DRG weight",67894,Other,base rate x DRG weight,61105,,"28,371 x DRG weight",61105,Other,base rate x DRG weight,57711,,"26,795 x DRG weight",57711,Other,base rate x DRG weight,16281.1,,"3,970.89 x patient days",16281.1,Per diem,,48381,,"22,463 x DRG weight",48381,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,56916,,"26,426 x DRG weight",56916,Other,base rate x DRG weight,83587,,"38,809 x DRG weight",83587,Other,base rate x DRG weight,83587,,"38,809 x DRG weight",83587,Other,base rate x DRG weight,56916,,"26,426 x DRG weight",56916,Other,base rate x DRG weight,83587,,"38,809 x DRG weight",83587,Other,base rate x DRG weight,26088,,"6,363 x patient days",26088,Per diem,,144617,70,,144617,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,53968,,"25,057 x DRG weight",53968,Other,base rate x DRG weight,48572,,"22,552 x DRG weight",48572,Other,base rate x DRG weight,53968,,"25,057 x DRG weight",53968,Other,base rate x DRG weight,45872,,"21,298 x DRG weight",45872,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,144617,
VENTRICULAR SHUNT PROCEDURES WITHOUT CC/MCC,33,MS-DRG,,,,,,,,inpatient,,,190809.61,11873,,,11873,Other,150% of Medicare + 9.63% HCRA Surcharge,7220,,"3,609.90 x patient days",7220,Per diem,,40647,,"25,046 x DRG weight",40647,Other,base rate x DRG weight,36582,,"22,541 x DRG weight",36582,Other,base rate x DRG weight,51159,,"31,523 x DRG weight",51159,Other,base rate x DRG weight,46043,,"28,371 x DRG weight",46043,Other,base rate x DRG weight,43486,,"26,795 x DRG weight",43486,Other,base rate x DRG weight,7942,,"3,970.89 x patient days",7942,Per diem,,36455,,"22,463 x DRG weight",36455,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,42887,,"26,426 x DRG weight",42887,Other,base rate x DRG weight,62983,,"38,809 x DRG weight",62983,Other,base rate x DRG weight,62983,,"38,809 x DRG weight",62983,Other,base rate x DRG weight,42887,,"26,426 x DRG weight",42887,Other,base rate x DRG weight,62983,,"38,809 x DRG weight",62983,Other,base rate x DRG weight,12726,,"6,363 x patient days",12726,Per diem,,133567,70,,133567,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,40665,,"25,057 x DRG weight",40665,Other,base rate x DRG weight,36600,,"22,552 x DRG weight",36600,Other,base rate x DRG weight,40665,,"25,057 x DRG weight",40665,Other,base rate x DRG weight,34565,,"21,298 x DRG weight",34565,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,133567,
CAROTID ARTERY STENT PROCEDURES WITH MCC,34,MS-DRG,,,,,,,,inpatient,,,474493.8,43928,,,43928,Other,150% of Medicare + 9.63% HCRA Surcharge,26713,,"3,609.90 x patient days",26713,Per diem,,97714,,"25,046 x DRG weight",97714,Other,base rate x DRG weight,87941,,"22,541 x DRG weight",87941,Other,base rate x DRG weight,122984,,"31,523 x DRG weight",122984,Other,base rate x DRG weight,110687,,"28,371 x DRG weight",110687,Other,base rate x DRG weight,104538,,"26,795 x DRG weight",104538,Other,base rate x DRG weight,29384.3,,"3,970.89 x patient days",29384.3,Per diem,,87637,,"22,463 x DRG weight",87637,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,103098,,"26,426 x DRG weight",103098,Other,base rate x DRG weight,151409,,"38,809 x DRG weight",151409,Other,base rate x DRG weight,151409,,"38,809 x DRG weight",151409,Other,base rate x DRG weight,103098,,"26,426 x DRG weight",103098,Other,base rate x DRG weight,151409,,"38,809 x DRG weight",151409,Other,base rate x DRG weight,47086,,"6,363 x patient days",47086,Per diem,,332146,70,,332146,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,97757,,"25,057 x DRG weight",97757,Other,base rate x DRG weight,87984,,"22,552 x DRG weight",87984,Other,base rate x DRG weight,97757,,"25,057 x DRG weight",97757,Other,base rate x DRG weight,83092,,"21,298 x DRG weight",83092,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,332146,
CAROTID ARTERY STENT PROCEDURES WITH CC,35,MS-DRG,,,,,,,,inpatient,,,159638.37,17216,,,17216,Other,150% of Medicare + 9.63% HCRA Surcharge,10469,,"3,609.90 x patient days",10469,Per diem,,57593,,"25,046 x DRG weight",57593,Other,base rate x DRG weight,51833,,"22,541 x DRG weight",51833,Other,base rate x DRG weight,72487,,"31,523 x DRG weight",72487,Other,base rate x DRG weight,65239,,"28,371 x DRG weight",65239,Other,base rate x DRG weight,61615,,"26,795 x DRG weight",61615,Other,base rate x DRG weight,11515.9,,"3,970.89 x patient days",11515.9,Per diem,,51654,,"22,463 x DRG weight",51654,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,60767,,"26,426 x DRG weight",60767,Other,base rate x DRG weight,89241,,"38,809 x DRG weight",89241,Other,base rate x DRG weight,89241,,"38,809 x DRG weight",89241,Other,base rate x DRG weight,60767,,"26,426 x DRG weight",60767,Other,base rate x DRG weight,89241,,"38,809 x DRG weight",89241,Other,base rate x DRG weight,18453,,"6,363 x patient days",18453,Per diem,,111747,70,,111747,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,57619,,"25,057 x DRG weight",57619,Other,base rate x DRG weight,51858,,"22,552 x DRG weight",51858,Other,base rate x DRG weight,57619,,"25,057 x DRG weight",57619,Other,base rate x DRG weight,48975,,"21,298 x DRG weight",48975,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,111747,
CAROTID ARTERY STENT PROCEDURES WITHOUT CC/MCC,36,MS-DRG,,,,,,,,inpatient,,,118825.49,8311,,,8311,Other,150% of Medicare + 9.63% HCRA Surcharge,5054,,"3,609.90 x patient days",5054,Per diem,,45288,,"25,046 x DRG weight",45288,Other,base rate x DRG weight,40759,,"22,541 x DRG weight",40759,Other,base rate x DRG weight,57000,,"31,523 x DRG weight",57000,Other,base rate x DRG weight,51300,,"28,371 x DRG weight",51300,Other,base rate x DRG weight,48451,,"26,795 x DRG weight",48451,Other,base rate x DRG weight,5559.4,,"3,970.89 x patient days",5559.4,Per diem,,40618,,"22,463 x DRG weight",40618,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,47783,,"26,426 x DRG weight",47783,Other,base rate x DRG weight,70174,,"38,809 x DRG weight",70174,Other,base rate x DRG weight,70174,,"38,809 x DRG weight",70174,Other,base rate x DRG weight,47783,,"26,426 x DRG weight",47783,Other,base rate x DRG weight,70174,,"38,809 x DRG weight",70174,Other,base rate x DRG weight,8908,,"6,363 x patient days",8908,Per diem,,83178,70,,83178,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,45308,,"25,057 x DRG weight",45308,Other,base rate x DRG weight,40779,,"22,552 x DRG weight",40779,Other,base rate x DRG weight,45308,,"25,057 x DRG weight",45308,Other,base rate x DRG weight,38511,,"21,298 x DRG weight",38511,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,83178,
EXTRACRANIAL PROCEDURES WITH MCC,37,MS-DRG,,,,,,,,inpatient,,,377407.72,48084,,,48084,Other,150% of Medicare + 9.63% HCRA Surcharge,29240,,"3,609.90 x patient days",29240,Per diem,,84545,,"25,046 x DRG weight",84545,Other,base rate x DRG weight,76089,,"22,541 x DRG weight",76089,Other,base rate x DRG weight,106409,,"31,523 x DRG weight",106409,Other,base rate x DRG weight,95769,,"28,371 x DRG weight",95769,Other,base rate x DRG weight,90449,,"26,795 x DRG weight",90449,Other,base rate x DRG weight,32164,,"3,970.89 x patient days",32164,Per diem,,75826,,"22,463 x DRG weight",75826,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,89204,,"26,426 x DRG weight",89204,Other,base rate x DRG weight,131004,,"38,809 x DRG weight",131004,Other,base rate x DRG weight,131004,,"38,809 x DRG weight",131004,Other,base rate x DRG weight,89204,,"26,426 x DRG weight",89204,Other,base rate x DRG weight,131004,,"38,809 x DRG weight",131004,Other,base rate x DRG weight,51540,,"6,363 x patient days",51540,Per diem,,264185,70,,264185,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,84582,,"25,057 x DRG weight",84582,Other,base rate x DRG weight,76127,,"22,552 x DRG weight",76127,Other,base rate x DRG weight,84582,,"25,057 x DRG weight",84582,Other,base rate x DRG weight,71894,,"21,298 x DRG weight",71894,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,264185,
EXTRACRANIAL PROCEDURES WITH CC,38,MS-DRG,,,,,,,,inpatient,,,218233.89,16622,,,16622,Other,150% of Medicare + 9.63% HCRA Surcharge,10108,,"3,609.90 x patient days",10108,Per diem,,40071,,"25,046 x DRG weight",40071,Other,base rate x DRG weight,36063,,"22,541 x DRG weight",36063,Other,base rate x DRG weight,50434,,"31,523 x DRG weight",50434,Other,base rate x DRG weight,45391,,"28,371 x DRG weight",45391,Other,base rate x DRG weight,42869,,"26,795 x DRG weight",42869,Other,base rate x DRG weight,11118.8,,"3,970.89 x patient days",11118.8,Per diem,,35939,,"22,463 x DRG weight",35939,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,42279,,"26,426 x DRG weight",42279,Other,base rate x DRG weight,62091,,"38,809 x DRG weight",62091,Other,base rate x DRG weight,62091,,"38,809 x DRG weight",62091,Other,base rate x DRG weight,42279,,"26,426 x DRG weight",42279,Other,base rate x DRG weight,62091,,"38,809 x DRG weight",62091,Other,base rate x DRG weight,17816,,"6,363 x patient days",17816,Per diem,,152764,70,,152764,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,40089,,"25,057 x DRG weight",40089,Other,base rate x DRG weight,36081,,"22,552 x DRG weight",36081,Other,base rate x DRG weight,40089,,"25,057 x DRG weight",40089,Other,base rate x DRG weight,34075,,"21,298 x DRG weight",34075,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,152764,
EXTRACRANIAL PROCEDURES WITHOUT CC/MCC,39,MS-DRG,,,,,,,,inpatient,,,158873.59,8311,,,8311,Other,150% of Medicare + 9.63% HCRA Surcharge,5054,,"3,609.90 x patient days",5054,Per diem,,28577,,"25,046 x DRG weight",28577,Other,base rate x DRG weight,25719,,"22,541 x DRG weight",25719,Other,base rate x DRG weight,35968,,"31,523 x DRG weight",35968,Other,base rate x DRG weight,32371,,"28,371 x DRG weight",32371,Other,base rate x DRG weight,30573,,"26,795 x DRG weight",30573,Other,base rate x DRG weight,5559.4,,"3,970.89 x patient days",5559.4,Per diem,,25630,,"22,463 x DRG weight",25630,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,30152,,"26,426 x DRG weight",30152,Other,base rate x DRG weight,44281,,"38,809 x DRG weight",44281,Other,base rate x DRG weight,44281,,"38,809 x DRG weight",44281,Other,base rate x DRG weight,30152,,"26,426 x DRG weight",30152,Other,base rate x DRG weight,44281,,"38,809 x DRG weight",44281,Other,base rate x DRG weight,8908,,"6,363 x patient days",8908,Per diem,,111212,70,,111212,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,28590,,"25,057 x DRG weight",28590,Other,base rate x DRG weight,25732,,"22,552 x DRG weight",25732,Other,base rate x DRG weight,28590,,"25,057 x DRG weight",28590,Other,base rate x DRG weight,24301,,"21,298 x DRG weight",24301,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,111212,
"PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITH MCC",40,MS-DRG,,,,,,,,inpatient,,,392203.02,64112,,,64112,Other,150% of Medicare + 9.63% HCRA Surcharge,38987,,"3,609.90 x patient days",38987,Per diem,,96440,,"25,046 x DRG weight",96440,Other,base rate x DRG weight,86794,,"22,541 x DRG weight",86794,Other,base rate x DRG weight,121379,,"31,523 x DRG weight",121379,Other,base rate x DRG weight,109243,,"28,371 x DRG weight",109243,Other,base rate x DRG weight,103174,,"26,795 x DRG weight",103174,Other,base rate x DRG weight,42885.7,,"3,970.89 x patient days",42885.7,Per diem,,86494,,"22,463 x DRG weight",86494,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,101753,,"26,426 x DRG weight",101753,Other,base rate x DRG weight,149434,,"38,809 x DRG weight",149434,Other,base rate x DRG weight,149434,,"38,809 x DRG weight",149434,Other,base rate x DRG weight,101753,,"26,426 x DRG weight",101753,Other,base rate x DRG weight,149434,,"38,809 x DRG weight",149434,Other,base rate x DRG weight,68720,,"6,363 x patient days",68720,Per diem,,274542,70,,274542,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,96482,,"25,057 x DRG weight",96482,Other,base rate x DRG weight,86836,,"22,552 x DRG weight",86836,Other,base rate x DRG weight,96482,,"25,057 x DRG weight",96482,Other,base rate x DRG weight,82008,,"21,298 x DRG weight",82008,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,274542,
"PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITH CC OR PERIPHERAL NEUROSTIMULATOR",41,MS-DRG,,,,,,,,inpatient,,,281707.97,29682,,,29682,Other,150% of Medicare + 9.63% HCRA Surcharge,18050,,"3,609.90 x patient days",18050,Per diem,,55870,,"25,046 x DRG weight",55870,Other,base rate x DRG weight,50282,,"22,541 x DRG weight",50282,Other,base rate x DRG weight,70318,,"31,523 x DRG weight",70318,Other,base rate x DRG weight,63287,,"28,371 x DRG weight",63287,Other,base rate x DRG weight,59772,,"26,795 x DRG weight",59772,Other,base rate x DRG weight,19855,,"3,970.89 x patient days",19855,Per diem,,50108,,"22,463 x DRG weight",50108,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,58948,,"26,426 x DRG weight",58948,Other,base rate x DRG weight,86571,,"38,809 x DRG weight",86571,Other,base rate x DRG weight,86571,,"38,809 x DRG weight",86571,Other,base rate x DRG weight,58948,,"26,426 x DRG weight",58948,Other,base rate x DRG weight,86571,,"38,809 x DRG weight",86571,Other,base rate x DRG weight,31815,,"6,363 x patient days",31815,Per diem,,197196,70,,197196,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,55895,,"25,057 x DRG weight",55895,Other,base rate x DRG weight,50307,,"22,552 x DRG weight",50307,Other,base rate x DRG weight,55895,,"25,057 x DRG weight",55895,Other,base rate x DRG weight,47509,,"21,298 x DRG weight",47509,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,197196,
"PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITHOUT CC/MCC",42,MS-DRG,,,,,,,,inpatient,,,196612.99,17809,,,17809,Other,150% of Medicare + 9.63% HCRA Surcharge,10830,,"3,609.90 x patient days",10830,Per diem,,43575,,"25,046 x DRG weight",43575,Other,base rate x DRG weight,39217,,"22,541 x DRG weight",39217,Other,base rate x DRG weight,54844,,"31,523 x DRG weight",54844,Other,base rate x DRG weight,49360,,"28,371 x DRG weight",49360,Other,base rate x DRG weight,46618,,"26,795 x DRG weight",46618,Other,base rate x DRG weight,11913,,"3,970.89 x patient days",11913,Per diem,,39081,,"22,463 x DRG weight",39081,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,45976,,"26,426 x DRG weight",45976,Other,base rate x DRG weight,67520,,"38,809 x DRG weight",67520,Other,base rate x DRG weight,67520,,"38,809 x DRG weight",67520,Other,base rate x DRG weight,45976,,"26,426 x DRG weight",45976,Other,base rate x DRG weight,67520,,"38,809 x DRG weight",67520,Other,base rate x DRG weight,19089,,"6,363 x patient days",19089,Per diem,,137629,70,,137629,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,43594,,"25,057 x DRG weight",43594,Other,base rate x DRG weight,39236,,"22,552 x DRG weight",39236,Other,base rate x DRG weight,43594,,"25,057 x DRG weight",43594,Other,base rate x DRG weight,37054,,"21,298 x DRG weight",37054,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,137629,
SPINAL DISORDERS AND INJURIES WITH CC/MCC,52,MS-DRG,,,,,,,,inpatient,,,241819.82,39179,,,39179,Other,150% of Medicare + 9.63% HCRA Surcharge,23825,,"3,609.90 x patient days",23825,Per diem,,48702,,"25,046 x DRG weight",48702,Other,base rate x DRG weight,43831,,"22,541 x DRG weight",43831,Other,base rate x DRG weight,61296,,"31,523 x DRG weight",61296,Other,base rate x DRG weight,55167,,"28,371 x DRG weight",55167,Other,base rate x DRG weight,52103,,"26,795 x DRG weight",52103,Other,base rate x DRG weight,26207.5,,"3,970.89 x patient days",26207.5,Per diem,,43679,,"22,463 x DRG weight",43679,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,51385,,"26,426 x DRG weight",51385,Other,base rate x DRG weight,75464,,"38,809 x DRG weight",75464,Other,base rate x DRG weight,75464,,"38,809 x DRG weight",75464,Other,base rate x DRG weight,51385,,"26,426 x DRG weight",51385,Other,base rate x DRG weight,75464,,"38,809 x DRG weight",75464,Other,base rate x DRG weight,41996,,"6,363 x patient days",41996,Per diem,,169274,70,,169274,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,48723,,"25,057 x DRG weight",48723,Other,base rate x DRG weight,43852,,"22,552 x DRG weight",43852,Other,base rate x DRG weight,48723,,"25,057 x DRG weight",48723,Other,base rate x DRG weight,41414,,"21,298 x DRG weight",41414,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,169274,
SPINAL DISORDERS AND INJURIES WITHOUT CC/MCC,53,MS-DRG,,,,,,,,inpatient,,,259436.94,21965,,,21965,Other,150% of Medicare + 9.63% HCRA Surcharge,13357,,"3,609.90 x patient days",13357,Per diem,,24640,,"25,046 x DRG weight",24640,Other,base rate x DRG weight,22176,,"22,541 x DRG weight",22176,Other,base rate x DRG weight,31012,,"31,523 x DRG weight",31012,Other,base rate x DRG weight,27911,,"28,371 x DRG weight",27911,Other,base rate x DRG weight,26361,,"26,795 x DRG weight",26361,Other,base rate x DRG weight,14692.7,,"3,970.89 x patient days",14692.7,Per diem,,22099,,"22,463 x DRG weight",22099,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,25998,,"26,426 x DRG weight",25998,Other,base rate x DRG weight,38180,,"38,809 x DRG weight",38180,Other,base rate x DRG weight,38180,,"38,809 x DRG weight",38180,Other,base rate x DRG weight,25998,,"26,426 x DRG weight",25998,Other,base rate x DRG weight,38180,,"38,809 x DRG weight",38180,Other,base rate x DRG weight,23543,,"6,363 x patient days",23543,Per diem,,181606,70,,181606,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,24651,,"25,057 x DRG weight",24651,Other,base rate x DRG weight,22187,,"22,552 x DRG weight",22187,Other,base rate x DRG weight,24651,,"25,057 x DRG weight",24651,Other,base rate x DRG weight,20953,,"21,298 x DRG weight",20953,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,181606,
NERVOUS SYSTEM NEOPLASMS WITH MCC,54,MS-DRG,,,,,,,,inpatient,,,232111.95,34430,,,34430,Other,150% of Medicare + 9.63% HCRA Surcharge,20937,,"3,609.90 x patient days",20937,Per diem,,36905,,"25,046 x DRG weight",36905,Other,base rate x DRG weight,33214,,"22,541 x DRG weight",33214,Other,base rate x DRG weight,46449,,"31,523 x DRG weight",46449,Other,base rate x DRG weight,41805,,"28,371 x DRG weight",41805,Other,base rate x DRG weight,39482,,"26,795 x DRG weight",39482,Other,base rate x DRG weight,23030.7,,"3,970.89 x patient days",23030.7,Per diem,,33099,,"22,463 x DRG weight",33099,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,38939,,"26,426 x DRG weight",38939,Other,base rate x DRG weight,57185,,"38,809 x DRG weight",57185,Other,base rate x DRG weight,57185,,"38,809 x DRG weight",57185,Other,base rate x DRG weight,38939,,"26,426 x DRG weight",38939,Other,base rate x DRG weight,57185,,"38,809 x DRG weight",57185,Other,base rate x DRG weight,36905,,"6,363 x patient days",36905,Per diem,,162478,70,,162478,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,36921,,"25,057 x DRG weight",36921,Other,base rate x DRG weight,33230,,"22,552 x DRG weight",33230,Other,base rate x DRG weight,36921,,"25,057 x DRG weight",36921,Other,base rate x DRG weight,31383,,"21,298 x DRG weight",31383,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,162478,
NERVOUS SYSTEM NEOPLASMS WITHOUT MCC,55,MS-DRG,,,,,,,,inpatient,,,191422.93,25527,,,25527,Other,150% of Medicare + 9.63% HCRA Surcharge,15523,,"3,609.90 x patient days",15523,Per diem,,26879,,"25,046 x DRG weight",26879,Other,base rate x DRG weight,24191,,"22,541 x DRG weight",24191,Other,base rate x DRG weight,33830,,"31,523 x DRG weight",33830,Other,base rate x DRG weight,30448,,"28,371 x DRG weight",30448,Other,base rate x DRG weight,28756,,"26,795 x DRG weight",28756,Other,base rate x DRG weight,17075.3,,"3,970.89 x patient days",17075.3,Per diem,,24107,,"22,463 x DRG weight",24107,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,28360,,"26,426 x DRG weight",28360,Other,base rate x DRG weight,41650,,"38,809 x DRG weight",41650,Other,base rate x DRG weight,41650,,"38,809 x DRG weight",41650,Other,base rate x DRG weight,28360,,"26,426 x DRG weight",28360,Other,base rate x DRG weight,41650,,"38,809 x DRG weight",41650,Other,base rate x DRG weight,27361,,"6,363 x patient days",27361,Per diem,,133996,70,,133996,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,26891,,"25,057 x DRG weight",26891,Other,base rate x DRG weight,24203,,"22,552 x DRG weight",24203,Other,base rate x DRG weight,26891,,"25,057 x DRG weight",26891,Other,base rate x DRG weight,22857,,"21,298 x DRG weight",22857,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,133996,
DEGENERATIVE NERVOUS SYSTEM DISORDERS WITH MCC,56,MS-DRG,,,,,,,,inpatient,,,328732.92,57582,,,57582,Other,150% of Medicare + 9.63% HCRA Surcharge,35016,,"3,609.90 x patient days",35016,Per diem,,59960,,"25,046 x DRG weight",59960,Other,base rate x DRG weight,53963,,"22,541 x DRG weight",53963,Other,base rate x DRG weight,75466,,"31,523 x DRG weight",75466,Other,base rate x DRG weight,67920,,"28,371 x DRG weight",67920,Other,base rate x DRG weight,64147,,"26,795 x DRG weight",64147,Other,base rate x DRG weight,38517.6,,"3,970.89 x patient days",38517.6,Per diem,,53776,,"22,463 x DRG weight",53776,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,63264,,"26,426 x DRG weight",63264,Other,base rate x DRG weight,92909,,"38,809 x DRG weight",92909,Other,base rate x DRG weight,92909,,"38,809 x DRG weight",92909,Other,base rate x DRG weight,63264,,"26,426 x DRG weight",63264,Other,base rate x DRG weight,92909,,"38,809 x DRG weight",92909,Other,base rate x DRG weight,61721,,"6,363 x patient days",61721,Per diem,,230113,70,,230113,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,59986,,"25,057 x DRG weight",59986,Other,base rate x DRG weight,53989,,"22,552 x DRG weight",53989,Other,base rate x DRG weight,59986,,"25,057 x DRG weight",59986,Other,base rate x DRG weight,50987,,"21,298 x DRG weight",50987,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,230113,
DEGENERATIVE NERVOUS SYSTEM DISORDERS WITHOUT MCC,57,MS-DRG,,,,,,,,inpatient,,,207796.84,37992,,,37992,Other,150% of Medicare + 9.63% HCRA Surcharge,23103,,"3,609.90 x patient days",23103,Per diem,,34143,,"25,046 x DRG weight",34143,Other,base rate x DRG weight,30728,,"22,541 x DRG weight",30728,Other,base rate x DRG weight,42972,,"31,523 x DRG weight",42972,Other,base rate x DRG weight,38675,,"28,371 x DRG weight",38675,Other,base rate x DRG weight,36527,,"26,795 x DRG weight",36527,Other,base rate x DRG weight,25413.3,,"3,970.89 x patient days",25413.3,Per diem,,30622,,"22,463 x DRG weight",30622,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,36024,,"26,426 x DRG weight",36024,Other,base rate x DRG weight,52904,,"38,809 x DRG weight",52904,Other,base rate x DRG weight,52904,,"38,809 x DRG weight",52904,Other,base rate x DRG weight,36024,,"26,426 x DRG weight",36024,Other,base rate x DRG weight,52904,,"38,809 x DRG weight",52904,Other,base rate x DRG weight,40723,,"6,363 x patient days",40723,Per diem,,145458,70,,145458,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,34158,,"25,057 x DRG weight",34158,Other,base rate x DRG weight,30743,,"22,552 x DRG weight",30743,Other,base rate x DRG weight,34158,,"25,057 x DRG weight",34158,Other,base rate x DRG weight,29033,,"21,298 x DRG weight",29033,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,145458,
MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITH MCC,58,MS-DRG,,,,,,,,inpatient,,,120609,42147,,,42147,Other,150% of Medicare + 9.63% HCRA Surcharge,25630,,"3,609.90 x patient days",25630,Per diem,,43277,,"25,046 x DRG weight",43277,Other,base rate x DRG weight,38949,,"22,541 x DRG weight",38949,Other,base rate x DRG weight,54469,,"31,523 x DRG weight",54469,Other,base rate x DRG weight,49022,,"28,371 x DRG weight",49022,Other,base rate x DRG weight,46299,,"26,795 x DRG weight",46299,Other,base rate x DRG weight,28193,,"3,970.89 x patient days",28193,Per diem,,38814,,"22,463 x DRG weight",38814,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,45661,,"26,426 x DRG weight",45661,Other,base rate x DRG weight,67058,,"38,809 x DRG weight",67058,Other,base rate x DRG weight,67058,,"38,809 x DRG weight",67058,Other,base rate x DRG weight,45661,,"26,426 x DRG weight",45661,Other,base rate x DRG weight,67058,,"38,809 x DRG weight",67058,Other,base rate x DRG weight,45177,,"6,363 x patient days",45177,Per diem,,84426,70,,84426,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,43296,,"25,057 x DRG weight",43296,Other,base rate x DRG weight,38968,,"22,552 x DRG weight",38968,Other,base rate x DRG weight,43296,,"25,057 x DRG weight",43296,Other,base rate x DRG weight,36801,,"21,298 x DRG weight",36801,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,84426,
MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITH CC,59,MS-DRG,,,,,,,,inpatient,,,173761,29682,,,29682,Other,150% of Medicare + 9.63% HCRA Surcharge,18050,,"3,609.90 x patient days",18050,Per diem,,29735,,"25,046 x DRG weight",29735,Other,base rate x DRG weight,26761,,"22,541 x DRG weight",26761,Other,base rate x DRG weight,37424,,"31,523 x DRG weight",37424,Other,base rate x DRG weight,33682,,"28,371 x DRG weight",33682,Other,base rate x DRG weight,31811,,"26,795 x DRG weight",31811,Other,base rate x DRG weight,19855,,"3,970.89 x patient days",19855,Per diem,,26668,,"22,463 x DRG weight",26668,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,31373,,"26,426 x DRG weight",31373,Other,base rate x DRG weight,46074,,"38,809 x DRG weight",46074,Other,base rate x DRG weight,46074,,"38,809 x DRG weight",46074,Other,base rate x DRG weight,31373,,"26,426 x DRG weight",31373,Other,base rate x DRG weight,46074,,"38,809 x DRG weight",46074,Other,base rate x DRG weight,31815,,"6,363 x patient days",31815,Per diem,,121633,70,,121633,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,29748,,"25,057 x DRG weight",29748,Other,base rate x DRG weight,26774,,"22,552 x DRG weight",26774,Other,base rate x DRG weight,29748,,"25,057 x DRG weight",29748,Other,base rate x DRG weight,25285,,"21,298 x DRG weight",25285,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,121633,
MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITHOUT CC/MCC,60,MS-DRG,,,,,,,,inpatient,,,96942.45,21371,,,21371,Other,150% of Medicare + 9.63% HCRA Surcharge,12996,,"3,609.90 x patient days",12996,Per diem,,22476,,"25,046 x DRG weight",22476,Other,base rate x DRG weight,20228,,"22,541 x DRG weight",20228,Other,base rate x DRG weight,28289,,"31,523 x DRG weight",28289,Other,base rate x DRG weight,25460,,"28,371 x DRG weight",25460,Other,base rate x DRG weight,24046,,"26,795 x DRG weight",24046,Other,base rate x DRG weight,14295.6,,"3,970.89 x patient days",14295.6,Per diem,,20158,,"22,463 x DRG weight",20158,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,23715,,"26,426 x DRG weight",23715,Other,base rate x DRG weight,34827,,"38,809 x DRG weight",34827,Other,base rate x DRG weight,34827,,"38,809 x DRG weight",34827,Other,base rate x DRG weight,23715,,"26,426 x DRG weight",23715,Other,base rate x DRG weight,34827,,"38,809 x DRG weight",34827,Other,base rate x DRG weight,22907,,"6,363 x patient days",22907,Per diem,,67860,70,,67860,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,22486,,"25,057 x DRG weight",22486,Other,base rate x DRG weight,20238,,"22,552 x DRG weight",20238,Other,base rate x DRG weight,22486,,"25,057 x DRG weight",22486,Other,base rate x DRG weight,19113,,"21,298 x DRG weight",19113,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,67860,
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITH MCC",61,MS-DRG,,,,,,,,inpatient,,,402567.78,39773,,,39773,Other,150% of Medicare + 9.63% HCRA Surcharge,24186,,"3,609.90 x patient days",24186,Per diem,,70199,,"25,046 x DRG weight",70199,Other,base rate x DRG weight,63178,,"22,541 x DRG weight",63178,Other,base rate x DRG weight,88353,,"31,523 x DRG weight",88353,Other,base rate x DRG weight,79518,,"28,371 x DRG weight",79518,Other,base rate x DRG weight,75101,,"26,795 x DRG weight",75101,Other,base rate x DRG weight,26604.6,,"3,970.89 x patient days",26604.6,Per diem,,62959,,"22,463 x DRG weight",62959,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,74067,,"26,426 x DRG weight",74067,Other,base rate x DRG weight,108774,,"38,809 x DRG weight",108774,Other,base rate x DRG weight,108774,,"38,809 x DRG weight",108774,Other,base rate x DRG weight,74067,,"26,426 x DRG weight",74067,Other,base rate x DRG weight,108774,,"38,809 x DRG weight",108774,Other,base rate x DRG weight,42632,,"6,363 x patient days",42632,Per diem,,281797,70,,281797,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,70230,,"25,057 x DRG weight",70230,Other,base rate x DRG weight,63209,,"22,552 x DRG weight",63209,Other,base rate x DRG weight,70230,,"25,057 x DRG weight",70230,Other,base rate x DRG weight,59694,,"21,298 x DRG weight",59694,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,281797,
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITH CC",62,MS-DRG,,,,,,,,inpatient,,,187858.06,22559,,,22559,Other,150% of Medicare + 9.63% HCRA Surcharge,13718,,"3,609.90 x patient days",13718,Per diem,,46879,,"25,046 x DRG weight",46879,Other,base rate x DRG weight,42190,,"22,541 x DRG weight",42190,Other,base rate x DRG weight,59002,,"31,523 x DRG weight",59002,Other,base rate x DRG weight,53102,,"28,371 x DRG weight",53102,Other,base rate x DRG weight,50152,,"26,795 x DRG weight",50152,Other,base rate x DRG weight,15089.8,,"3,970.89 x patient days",15089.8,Per diem,,42044,,"22,463 x DRG weight",42044,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,49462,,"26,426 x DRG weight",49462,Other,base rate x DRG weight,72639,,"38,809 x DRG weight",72639,Other,base rate x DRG weight,72639,,"38,809 x DRG weight",72639,Other,base rate x DRG weight,49462,,"26,426 x DRG weight",49462,Other,base rate x DRG weight,72639,,"38,809 x DRG weight",72639,Other,base rate x DRG weight,24179,,"6,363 x patient days",24179,Per diem,,131501,70,,131501,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,46899,,"25,057 x DRG weight",46899,Other,base rate x DRG weight,42211,,"22,552 x DRG weight",42211,Other,base rate x DRG weight,46899,,"25,057 x DRG weight",46899,Other,base rate x DRG weight,39863,,"21,298 x DRG weight",39863,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,131501,
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITHOUT CC/MCC",63,MS-DRG,,,,,,,,inpatient,,,146396.43,14841,,,14841,Other,150% of Medicare + 9.63% HCRA Surcharge,9025,,"3,609.90 x patient days",9025,Per diem,,37238,,"25,046 x DRG weight",37238,Other,base rate x DRG weight,33514,,"22,541 x DRG weight",33514,Other,base rate x DRG weight,46868,,"31,523 x DRG weight",46868,Other,base rate x DRG weight,42182,,"28,371 x DRG weight",42182,Other,base rate x DRG weight,39839,,"26,795 x DRG weight",39839,Other,base rate x DRG weight,9927.5,,"3,970.89 x patient days",9927.5,Per diem,,33398,,"22,463 x DRG weight",33398,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,39290,,"26,426 x DRG weight",39290,Other,base rate x DRG weight,57701,,"38,809 x DRG weight",57701,Other,base rate x DRG weight,57701,,"38,809 x DRG weight",57701,Other,base rate x DRG weight,39290,,"26,426 x DRG weight",39290,Other,base rate x DRG weight,57701,,"38,809 x DRG weight",57701,Other,base rate x DRG weight,15908,,"6,363 x patient days",15908,Per diem,,102477,70,,102477,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,37255,,"25,057 x DRG weight",37255,Other,base rate x DRG weight,33530,,"22,552 x DRG weight",33530,Other,base rate x DRG weight,37255,,"25,057 x DRG weight",37255,Other,base rate x DRG weight,31666,,"21,298 x DRG weight",31666,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,102477,
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH MCC,64,MS-DRG,,,,,,,,inpatient,,,276477.92,39773,,,39773,Other,150% of Medicare + 9.63% HCRA Surcharge,24186,,"3,609.90 x patient days",24186,Per diem,,50167,,"25,046 x DRG weight",50167,Other,base rate x DRG weight,45150,,"22,541 x DRG weight",45150,Other,base rate x DRG weight,63141,,"31,523 x DRG weight",63141,Other,base rate x DRG weight,56827,,"28,371 x DRG weight",56827,Other,base rate x DRG weight,53670,,"26,795 x DRG weight",53670,Other,base rate x DRG weight,26604.6,,"3,970.89 x patient days",26604.6,Per diem,,44993,,"22,463 x DRG weight",44993,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,52931,,"26,426 x DRG weight",52931,Other,base rate x DRG weight,77734,,"38,809 x DRG weight",77734,Other,base rate x DRG weight,77734,,"38,809 x DRG weight",77734,Other,base rate x DRG weight,52931,,"26,426 x DRG weight",52931,Other,base rate x DRG weight,77734,,"38,809 x DRG weight",77734,Other,base rate x DRG weight,42632,,"6,363 x patient days",42632,Per diem,,193535,70,,193535,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,50189,,"25,057 x DRG weight",50189,Other,base rate x DRG weight,45172,,"22,552 x DRG weight",45172,Other,base rate x DRG weight,50189,,"25,057 x DRG weight",50189,Other,base rate x DRG weight,42660,,"21,298 x DRG weight",42660,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,193535,
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH CC OR TPA IN 24 HOURS,65,MS-DRG,,,,,,,,inpatient,,,180198.81,21965,,,21965,Other,150% of Medicare + 9.63% HCRA Surcharge,13357,,"3,609.90 x patient days",13357,Per diem,,25457,,"25,046 x DRG weight",25457,Other,base rate x DRG weight,22911,,"22,541 x DRG weight",22911,Other,base rate x DRG weight,32040,,"31,523 x DRG weight",32040,Other,base rate x DRG weight,28836,,"28,371 x DRG weight",28836,Other,base rate x DRG weight,27234,,"26,795 x DRG weight",27234,Other,base rate x DRG weight,14692.7,,"3,970.89 x patient days",14692.7,Per diem,,22831,,"22,463 x DRG weight",22831,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,26859,,"26,426 x DRG weight",26859,Other,base rate x DRG weight,39445,,"38,809 x DRG weight",39445,Other,base rate x DRG weight,39445,,"38,809 x DRG weight",39445,Other,base rate x DRG weight,26859,,"26,426 x DRG weight",26859,Other,base rate x DRG weight,39445,,"38,809 x DRG weight",39445,Other,base rate x DRG weight,23543,,"6,363 x patient days",23543,Per diem,,126139,70,,126139,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,25468,,"25,057 x DRG weight",25468,Other,base rate x DRG weight,22922,,"22,552 x DRG weight",22922,Other,base rate x DRG weight,25468,,"25,057 x DRG weight",25468,Other,base rate x DRG weight,21647,,"21,298 x DRG weight",21647,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,126139,
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITHOUT CC/MCC,66,MS-DRG,,,,,,,,inpatient,,,140690.68,14248,,,14248,Other,150% of Medicare + 9.63% HCRA Surcharge,8664,,"3,609.90 x patient days",8664,Per diem,,17219,,"25,046 x DRG weight",17219,Other,base rate x DRG weight,15497,,"22,541 x DRG weight",15497,Other,base rate x DRG weight,21672,,"31,523 x DRG weight",21672,Other,base rate x DRG weight,19505,,"28,371 x DRG weight",19505,Other,base rate x DRG weight,18422,,"26,795 x DRG weight",18422,Other,base rate x DRG weight,9530.4,,"3,970.89 x patient days",9530.4,Per diem,,15443,,"22,463 x DRG weight",15443,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,18168,,"26,426 x DRG weight",18168,Other,base rate x DRG weight,26681,,"38,809 x DRG weight",26681,Other,base rate x DRG weight,26681,,"38,809 x DRG weight",26681,Other,base rate x DRG weight,18168,,"26,426 x DRG weight",18168,Other,base rate x DRG weight,26681,,"38,809 x DRG weight",26681,Other,base rate x DRG weight,15271,,"6,363 x patient days",15271,Per diem,,98483,70,,98483,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,17227,,"25,057 x DRG weight",17227,Other,base rate x DRG weight,15505,,"22,552 x DRG weight",15505,Other,base rate x DRG weight,17227,,"25,057 x DRG weight",17227,Other,base rate x DRG weight,14642,,"21,298 x DRG weight",14642,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,98483,
NONSPECIFIC CVA AND PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITH MCC,67,MS-DRG,,,,,,,,inpatient,,,288204.73,27901,,,27901,Other,150% of Medicare + 9.63% HCRA Surcharge,16967,,"3,609.90 x patient days",16967,Per diem,,35488,,"25,046 x DRG weight",35488,Other,base rate x DRG weight,31938,,"22,541 x DRG weight",31938,Other,base rate x DRG weight,44665,,"31,523 x DRG weight",44665,Other,base rate x DRG weight,40199,,"28,371 x DRG weight",40199,Other,base rate x DRG weight,37966,,"26,795 x DRG weight",37966,Other,base rate x DRG weight,18663.7,,"3,970.89 x patient days",18663.7,Per diem,,31828,,"22,463 x DRG weight",31828,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,37443,,"26,426 x DRG weight",37443,Other,base rate x DRG weight,54988,,"38,809 x DRG weight",54988,Other,base rate x DRG weight,54988,,"38,809 x DRG weight",54988,Other,base rate x DRG weight,37443,,"26,426 x DRG weight",37443,Other,base rate x DRG weight,54988,,"38,809 x DRG weight",54988,Other,base rate x DRG weight,29906,,"6,363 x patient days",29906,Per diem,,201743,70,,201743,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,35503,,"25,057 x DRG weight",35503,Other,base rate x DRG weight,31954,,"22,552 x DRG weight",31954,Other,base rate x DRG weight,35503,,"25,057 x DRG weight",35503,Other,base rate x DRG weight,30177,,"21,298 x DRG weight",30177,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,201743,
NONSPECIFIC CVA AND PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITHOUT MCC,68,MS-DRG,,,,,,,,inpatient,,,108189.13,15435,,,15435,Other,150% of Medicare + 9.63% HCRA Surcharge,9386,,"3,609.90 x patient days",9386,Per diem,,21815,,"25,046 x DRG weight",21815,Other,base rate x DRG weight,19633,,"22,541 x DRG weight",19633,Other,base rate x DRG weight,27457,,"31,523 x DRG weight",27457,Other,base rate x DRG weight,24711,,"28,371 x DRG weight",24711,Other,base rate x DRG weight,23338,,"26,795 x DRG weight",23338,Other,base rate x DRG weight,10324.6,,"3,970.89 x patient days",10324.6,Per diem,,19565,,"22,463 x DRG weight",19565,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,23017,,"26,426 x DRG weight",23017,Other,base rate x DRG weight,33803,,"38,809 x DRG weight",33803,Other,base rate x DRG weight,33803,,"38,809 x DRG weight",33803,Other,base rate x DRG weight,23017,,"26,426 x DRG weight",23017,Other,base rate x DRG weight,33803,,"38,809 x DRG weight",33803,Other,base rate x DRG weight,16544,,"6,363 x patient days",16544,Per diem,,75732,70,,75732,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,21825,,"25,057 x DRG weight",21825,Other,base rate x DRG weight,19643,,"22,552 x DRG weight",19643,Other,base rate x DRG weight,21825,,"25,057 x DRG weight",21825,Other,base rate x DRG weight,18551,,"21,298 x DRG weight",18551,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,75732,
TRANSIENT ISCHEMIA WITHOUT THROMBOLYTIC,69,MS-DRG,,,,,,,,inpatient,,,111705.66,15435,,,15435,Other,150% of Medicare + 9.63% HCRA Surcharge,9386,,"3,609.90 x patient days",9386,Per diem,,20004,,"25,046 x DRG weight",20004,Other,base rate x DRG weight,18003,,"22,541 x DRG weight",18003,Other,base rate x DRG weight,25177,,"31,523 x DRG weight",25177,Other,base rate x DRG weight,22660,,"28,371 x DRG weight",22660,Other,base rate x DRG weight,21401,,"26,795 x DRG weight",21401,Other,base rate x DRG weight,10324.6,,"3,970.89 x patient days",10324.6,Per diem,,17941,,"22,463 x DRG weight",17941,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,21106,,"26,426 x DRG weight",21106,Other,base rate x DRG weight,30997,,"38,809 x DRG weight",30997,Other,base rate x DRG weight,30997,,"38,809 x DRG weight",30997,Other,base rate x DRG weight,21106,,"26,426 x DRG weight",21106,Other,base rate x DRG weight,30997,,"38,809 x DRG weight",30997,Other,base rate x DRG weight,16544,,"6,363 x patient days",16544,Per diem,,78194,70,,78194,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,20013,,"25,057 x DRG weight",20013,Other,base rate x DRG weight,18012,,"22,552 x DRG weight",18012,Other,base rate x DRG weight,20013,,"25,057 x DRG weight",20013,Other,base rate x DRG weight,17011,,"21,298 x DRG weight",17011,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,78194,
NONSPECIFIC CEREBROVASCULAR DISORDERS WITH MCC,70,MS-DRG,,,,,,,,inpatient,,,190249.44,42147,,,42147,Other,150% of Medicare + 9.63% HCRA Surcharge,25630,,"3,609.90 x patient days",25630,Per diem,,44820,,"25,046 x DRG weight",44820,Other,base rate x DRG weight,40337,,"22,541 x DRG weight",40337,Other,base rate x DRG weight,56410,,"31,523 x DRG weight",56410,Other,base rate x DRG weight,50770,,"28,371 x DRG weight",50770,Other,base rate x DRG weight,47950,,"26,795 x DRG weight",47950,Other,base rate x DRG weight,28193,,"3,970.89 x patient days",28193,Per diem,,40198,,"22,463 x DRG weight",40198,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,47289,,"26,426 x DRG weight",47289,Other,base rate x DRG weight,69449,,"38,809 x DRG weight",69449,Other,base rate x DRG weight,69449,,"38,809 x DRG weight",69449,Other,base rate x DRG weight,47289,,"26,426 x DRG weight",47289,Other,base rate x DRG weight,69449,,"38,809 x DRG weight",69449,Other,base rate x DRG weight,45177,,"6,363 x patient days",45177,Per diem,,133175,70,,133175,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,44840,,"25,057 x DRG weight",44840,Other,base rate x DRG weight,40357,,"22,552 x DRG weight",40357,Other,base rate x DRG weight,44840,,"25,057 x DRG weight",44840,Other,base rate x DRG weight,38113,,"21,298 x DRG weight",38113,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,133175,
NONSPECIFIC CEREBROVASCULAR DISORDERS WITH CC,71,MS-DRG,,,,,,,,inpatient,,,184199.33,27901,,,27901,Other,150% of Medicare + 9.63% HCRA Surcharge,16967,,"3,609.90 x patient days",16967,Per diem,,26594,,"25,046 x DRG weight",26594,Other,base rate x DRG weight,23934,,"22,541 x DRG weight",23934,Other,base rate x DRG weight,33471,,"31,523 x DRG weight",33471,Other,base rate x DRG weight,30124,,"28,371 x DRG weight",30124,Other,base rate x DRG weight,28451,,"26,795 x DRG weight",28451,Other,base rate x DRG weight,18663.7,,"3,970.89 x patient days",18663.7,Per diem,,23851,,"22,463 x DRG weight",23851,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,28059,,"26,426 x DRG weight",28059,Other,base rate x DRG weight,41207,,"38,809 x DRG weight",41207,Other,base rate x DRG weight,41207,,"38,809 x DRG weight",41207,Other,base rate x DRG weight,28059,,"26,426 x DRG weight",28059,Other,base rate x DRG weight,41207,,"38,809 x DRG weight",41207,Other,base rate x DRG weight,29906,,"6,363 x patient days",29906,Per diem,,128940,70,,128940,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,26606,,"25,057 x DRG weight",26606,Other,base rate x DRG weight,23946,,"22,552 x DRG weight",23946,Other,base rate x DRG weight,26606,,"25,057 x DRG weight",26606,Other,base rate x DRG weight,22614,,"21,298 x DRG weight",22614,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,128940,
NONSPECIFIC CEREBROVASCULAR DISORDERS WITHOUT CC/MCC,72,MS-DRG,,,,,,,,inpatient,,,66397.16,18403,,,18403,Other,150% of Medicare + 9.63% HCRA Surcharge,11191,,"3,609.90 x patient days",11191,Per diem,,19611,,"25,046 x DRG weight",19611,Other,base rate x DRG weight,17650,,"22,541 x DRG weight",17650,Other,base rate x DRG weight,24683,,"31,523 x DRG weight",24683,Other,base rate x DRG weight,22214,,"28,371 x DRG weight",22214,Other,base rate x DRG weight,20980,,"26,795 x DRG weight",20980,Other,base rate x DRG weight,12310.1,,"3,970.89 x patient days",12310.1,Per diem,,17589,,"22,463 x DRG weight",17589,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,20692,,"26,426 x DRG weight",20692,Other,base rate x DRG weight,30387,,"38,809 x DRG weight",30387,Other,base rate x DRG weight,30387,,"38,809 x DRG weight",30387,Other,base rate x DRG weight,20692,,"26,426 x DRG weight",20692,Other,base rate x DRG weight,30387,,"38,809 x DRG weight",30387,Other,base rate x DRG weight,19725,,"6,363 x patient days",19725,Per diem,,46478,70,,46478,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,19620,,"25,057 x DRG weight",19620,Other,base rate x DRG weight,17658,,"22,552 x DRG weight",17658,Other,base rate x DRG weight,19620,,"25,057 x DRG weight",19620,Other,base rate x DRG weight,16676,,"21,298 x DRG weight",16676,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,46478,
CRANIAL AND PERIPHERAL NERVE DISORDERS WITH MCC,73,MS-DRG,,,,,,,,inpatient,,,195231.93,34430,,,34430,Other,150% of Medicare + 9.63% HCRA Surcharge,20937,,"3,609.90 x patient days",20937,Per diem,,37895,,"25,046 x DRG weight",37895,Other,base rate x DRG weight,34105,,"22,541 x DRG weight",34105,Other,base rate x DRG weight,47694,,"31,523 x DRG weight",47694,Other,base rate x DRG weight,42925,,"28,371 x DRG weight",42925,Other,base rate x DRG weight,40541,,"26,795 x DRG weight",40541,Other,base rate x DRG weight,23030.7,,"3,970.89 x patient days",23030.7,Per diem,,33987,,"22,463 x DRG weight",33987,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,39983,,"26,426 x DRG weight",39983,Other,base rate x DRG weight,58718,,"38,809 x DRG weight",58718,Other,base rate x DRG weight,58718,,"38,809 x DRG weight",58718,Other,base rate x DRG weight,39983,,"26,426 x DRG weight",39983,Other,base rate x DRG weight,58718,,"38,809 x DRG weight",58718,Other,base rate x DRG weight,36905,,"6,363 x patient days",36905,Per diem,,136662,70,,136662,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,37911,,"25,057 x DRG weight",37911,Other,base rate x DRG weight,34121,,"22,552 x DRG weight",34121,Other,base rate x DRG weight,37911,,"25,057 x DRG weight",37911,Other,base rate x DRG weight,32224,,"21,298 x DRG weight",32224,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,136662,
CRANIAL AND PERIPHERAL NERVE DISORDERS WITHOUT MCC,74,MS-DRG,,,,,,,,inpatient,,,176051.52,22559,,,22559,Other,150% of Medicare + 9.63% HCRA Surcharge,13718,,"3,609.90 x patient days",13718,Per diem,,25702,,"25,046 x DRG weight",25702,Other,base rate x DRG weight,23132,,"22,541 x DRG weight",23132,Other,base rate x DRG weight,32349,,"31,523 x DRG weight",32349,Other,base rate x DRG weight,29114,,"28,371 x DRG weight",29114,Other,base rate x DRG weight,27497,,"26,795 x DRG weight",27497,Other,base rate x DRG weight,15089.8,,"3,970.89 x patient days",15089.8,Per diem,,23052,,"22,463 x DRG weight",23052,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,27118,,"26,426 x DRG weight",27118,Other,base rate x DRG weight,39826,,"38,809 x DRG weight",39826,Other,base rate x DRG weight,39826,,"38,809 x DRG weight",39826,Other,base rate x DRG weight,27118,,"26,426 x DRG weight",27118,Other,base rate x DRG weight,39826,,"38,809 x DRG weight",39826,Other,base rate x DRG weight,24179,,"6,363 x patient days",24179,Per diem,,123236,70,,123236,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,25713,,"25,057 x DRG weight",25713,Other,base rate x DRG weight,23143,,"22,552 x DRG weight",23143,Other,base rate x DRG weight,25713,,"25,057 x DRG weight",25713,Other,base rate x DRG weight,21856,,"21,298 x DRG weight",21856,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,123236,
VIRAL MENINGITIS WITH CC/MCC,75,MS-DRG,,,,,,,,inpatient,,,166616.58,45709,,,45709,Other,150% of Medicare + 9.63% HCRA Surcharge,27796,,"3,609.90 x patient days",27796,Per diem,,47933,,"25,046 x DRG weight",47933,Other,base rate x DRG weight,43139,,"22,541 x DRG weight",43139,Other,base rate x DRG weight,60329,,"31,523 x DRG weight",60329,Other,base rate x DRG weight,54296,,"28,371 x DRG weight",54296,Other,base rate x DRG weight,51280,,"26,795 x DRG weight",51280,Other,base rate x DRG weight,30575.6,,"3,970.89 x patient days",30575.6,Per diem,,42990,,"22,463 x DRG weight",42990,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,50574,,"26,426 x DRG weight",50574,Other,base rate x DRG weight,74273,,"38,809 x DRG weight",74273,Other,base rate x DRG weight,74273,,"38,809 x DRG weight",74273,Other,base rate x DRG weight,50574,,"26,426 x DRG weight",50574,Other,base rate x DRG weight,74273,,"38,809 x DRG weight",74273,Other,base rate x DRG weight,48995,,"6,363 x patient days",48995,Per diem,,116632,70,,116632,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,47954,,"25,057 x DRG weight",47954,Other,base rate x DRG weight,43160,,"22,552 x DRG weight",43160,Other,base rate x DRG weight,47954,,"25,057 x DRG weight",47954,Other,base rate x DRG weight,40760,,"21,298 x DRG weight",40760,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,116632,
VIRAL MENINGITIS WITHOUT CC/MCC,76,MS-DRG,,,,,,,,inpatient,,,65979.44,23152,,,23152,Other,150% of Medicare + 9.63% HCRA Surcharge,14079,,"3,609.90 x patient days",14079,Per diem,,23105,,"25,046 x DRG weight",23105,Other,base rate x DRG weight,20794,,"22,541 x DRG weight",20794,Other,base rate x DRG weight,29080,,"31,523 x DRG weight",29080,Other,base rate x DRG weight,26172,,"28,371 x DRG weight",26172,Other,base rate x DRG weight,24718,,"26,795 x DRG weight",24718,Other,base rate x DRG weight,15486.9,,"3,970.89 x patient days",15486.9,Per diem,,20722,,"22,463 x DRG weight",20722,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,24378,,"26,426 x DRG weight",24378,Other,base rate x DRG weight,35801,,"38,809 x DRG weight",35801,Other,base rate x DRG weight,35801,,"38,809 x DRG weight",35801,Other,base rate x DRG weight,24378,,"26,426 x DRG weight",24378,Other,base rate x DRG weight,35801,,"38,809 x DRG weight",35801,Other,base rate x DRG weight,24816,,"6,363 x patient days",24816,Per diem,,46186,70,,46186,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,23115,,"25,057 x DRG weight",23115,Other,base rate x DRG weight,20804,,"22,552 x DRG weight",20804,Other,base rate x DRG weight,23115,,"25,057 x DRG weight",23115,Other,base rate x DRG weight,19647,,"21,298 x DRG weight",19647,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,46186,
HYPERTENSIVE ENCEPHALOPATHY WITH MCC,77,MS-DRG,,,,,,,,inpatient,,,88267,33243,,,33243,Other,150% of Medicare + 9.63% HCRA Surcharge,20215,,"3,609.90 x patient days",20215,Per diem,,37842,,"25,046 x DRG weight",37842,Other,base rate x DRG weight,34057,,"22,541 x DRG weight",34057,Other,base rate x DRG weight,47628,,"31,523 x DRG weight",47628,Other,base rate x DRG weight,42866,,"28,371 x DRG weight",42866,Other,base rate x DRG weight,40485,,"26,795 x DRG weight",40485,Other,base rate x DRG weight,22236.5,,"3,970.89 x patient days",22236.5,Per diem,,33939,,"22,463 x DRG weight",33939,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,39927,,"26,426 x DRG weight",39927,Other,base rate x DRG weight,58637,,"38,809 x DRG weight",58637,Other,base rate x DRG weight,58637,,"38,809 x DRG weight",58637,Other,base rate x DRG weight,39927,,"26,426 x DRG weight",39927,Other,base rate x DRG weight,58637,,"38,809 x DRG weight",58637,Other,base rate x DRG weight,35633,,"6,363 x patient days",35633,Per diem,,61787,70,,61787,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,37859,,"25,057 x DRG weight",37859,Other,base rate x DRG weight,34074,,"22,552 x DRG weight",34074,Other,base rate x DRG weight,37859,,"25,057 x DRG weight",37859,Other,base rate x DRG weight,32179,,"21,298 x DRG weight",32179,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,61787,
HYPERTENSIVE ENCEPHALOPATHY WITH CC,78,MS-DRG,,,,,,,,inpatient,,,181671,22559,,,22559,Other,150% of Medicare + 9.63% HCRA Surcharge,13718,,"3,609.90 x patient days",13718,Per diem,,25469,,"25,046 x DRG weight",25469,Other,base rate x DRG weight,22922,,"22,541 x DRG weight",22922,Other,base rate x DRG weight,32056,,"31,523 x DRG weight",32056,Other,base rate x DRG weight,28850,,"28,371 x DRG weight",28850,Other,base rate x DRG weight,27248,,"26,795 x DRG weight",27248,Other,base rate x DRG weight,15089.8,,"3,970.89 x patient days",15089.8,Per diem,,22843,,"22,463 x DRG weight",22843,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,26873,,"26,426 x DRG weight",26873,Other,base rate x DRG weight,39465,,"38,809 x DRG weight",39465,Other,base rate x DRG weight,39465,,"38,809 x DRG weight",39465,Other,base rate x DRG weight,26873,,"26,426 x DRG weight",26873,Other,base rate x DRG weight,39465,,"38,809 x DRG weight",39465,Other,base rate x DRG weight,24179,,"6,363 x patient days",24179,Per diem,,127170,70,,127170,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,25480,,"25,057 x DRG weight",25480,Other,base rate x DRG weight,22933,,"22,552 x DRG weight",22933,Other,base rate x DRG weight,25480,,"25,057 x DRG weight",25480,Other,base rate x DRG weight,21658,,"21,298 x DRG weight",21658,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,127170,
HYPERTENSIVE ENCEPHALOPATHY WITHOUT CC/MCC,79,MS-DRG,,,,,,,,inpatient,,,64503,15435,,,15435,Other,150% of Medicare + 9.63% HCRA Surcharge,9386,,"3,609.90 x patient days",9386,Per diem,,18554,,"25,046 x DRG weight",18554,Other,base rate x DRG weight,16698,,"22,541 x DRG weight",16698,Other,base rate x DRG weight,23352,,"31,523 x DRG weight",23352,Other,base rate x DRG weight,21017,,"28,371 x DRG weight",21017,Other,base rate x DRG weight,19850,,"26,795 x DRG weight",19850,Other,base rate x DRG weight,10324.6,,"3,970.89 x patient days",10324.6,Per diem,,16641,,"22,463 x DRG weight",16641,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,19576,,"26,426 x DRG weight",19576,Other,base rate x DRG weight,28750,,"38,809 x DRG weight",28750,Other,base rate x DRG weight,28750,,"38,809 x DRG weight",28750,Other,base rate x DRG weight,19576,,"26,426 x DRG weight",19576,Other,base rate x DRG weight,28750,,"38,809 x DRG weight",28750,Other,base rate x DRG weight,16544,,"6,363 x patient days",16544,Per diem,,45152,70,,45152,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,18562,,"25,057 x DRG weight",18562,Other,base rate x DRG weight,16707,,"22,552 x DRG weight",16707,Other,base rate x DRG weight,18562,,"25,057 x DRG weight",18562,Other,base rate x DRG weight,15778,,"21,298 x DRG weight",15778,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,45152,
NONTRAUMATIC STUPOR AND COMA WITH MCC,80,MS-DRG,,,,,,,,inpatient,,,255939.76,50458,,,50458,Other,150% of Medicare + 9.63% HCRA Surcharge,30684,,"3,609.90 x patient days",30684,Per diem,,55319,,"25,046 x DRG weight",55319,Other,base rate x DRG weight,49786,,"22,541 x DRG weight",49786,Other,base rate x DRG weight,69625,,"31,523 x DRG weight",69625,Other,base rate x DRG weight,62663,,"28,371 x DRG weight",62663,Other,base rate x DRG weight,59182,,"26,795 x DRG weight",59182,Other,base rate x DRG weight,33752.4,,"3,970.89 x patient days",33752.4,Per diem,,49614,,"22,463 x DRG weight",49614,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,58367,,"26,426 x DRG weight",58367,Other,base rate x DRG weight,85717,,"38,809 x DRG weight",85717,Other,base rate x DRG weight,85717,,"38,809 x DRG weight",85717,Other,base rate x DRG weight,58367,,"26,426 x DRG weight",58367,Other,base rate x DRG weight,85717,,"38,809 x DRG weight",85717,Other,base rate x DRG weight,54086,,"6,363 x patient days",54086,Per diem,,179158,70,,179158,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,55343,,"25,057 x DRG weight",55343,Other,base rate x DRG weight,49811,,"22,552 x DRG weight",49811,Other,base rate x DRG weight,55343,,"25,057 x DRG weight",55343,Other,base rate x DRG weight,47041,,"21,298 x DRG weight",47041,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,179158,
NONTRAUMATIC STUPOR AND COMA WITHOUT MCC,81,MS-DRG,,,,,,,,inpatient,,,121420.68,21965,,,21965,Other,150% of Medicare + 9.63% HCRA Surcharge,13357,,"3,609.90 x patient days",13357,Per diem,,22779,,"25,046 x DRG weight",22779,Other,base rate x DRG weight,20501,,"22,541 x DRG weight",20501,Other,base rate x DRG weight,28670,,"31,523 x DRG weight",28670,Other,base rate x DRG weight,25803,,"28,371 x DRG weight",25803,Other,base rate x DRG weight,24370,,"26,795 x DRG weight",24370,Other,base rate x DRG weight,14692.7,,"3,970.89 x patient days",14692.7,Per diem,,20430,,"22,463 x DRG weight",20430,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,24034,,"26,426 x DRG weight",24034,Other,base rate x DRG weight,35297,,"38,809 x DRG weight",35297,Other,base rate x DRG weight,35297,,"38,809 x DRG weight",35297,Other,base rate x DRG weight,24034,,"26,426 x DRG weight",24034,Other,base rate x DRG weight,35297,,"38,809 x DRG weight",35297,Other,base rate x DRG weight,23543,,"6,363 x patient days",23543,Per diem,,84994,70,,84994,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,22789,,"25,057 x DRG weight",22789,Other,base rate x DRG weight,20511,,"22,552 x DRG weight",20511,Other,base rate x DRG weight,22789,,"25,057 x DRG weight",22789,Other,base rate x DRG weight,19371,,"21,298 x DRG weight",19371,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,84994,
TRAUMATIC STUPOR AND COMA >1 HOUR WITH MCC,82,MS-DRG,,,,,,,,inpatient,,,283860.77,42147,,,42147,Other,150% of Medicare + 9.63% HCRA Surcharge,25630,,"3,609.90 x patient days",25630,Per diem,,57062,,"25,046 x DRG weight",57062,Other,base rate x DRG weight,51355,,"22,541 x DRG weight",51355,Other,base rate x DRG weight,71819,,"31,523 x DRG weight",71819,Other,base rate x DRG weight,64638,,"28,371 x DRG weight",64638,Other,base rate x DRG weight,61047,,"26,795 x DRG weight",61047,Other,base rate x DRG weight,28193,,"3,970.89 x patient days",28193,Per diem,,51177,,"22,463 x DRG weight",51177,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,60206,,"26,426 x DRG weight",60206,Other,base rate x DRG weight,88419,,"38,809 x DRG weight",88419,Other,base rate x DRG weight,88419,,"38,809 x DRG weight",88419,Other,base rate x DRG weight,60206,,"26,426 x DRG weight",60206,Other,base rate x DRG weight,88419,,"38,809 x DRG weight",88419,Other,base rate x DRG weight,45177,,"6,363 x patient days",45177,Per diem,,198703,70,,198703,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,57087,,"25,057 x DRG weight",57087,Other,base rate x DRG weight,51380,,"22,552 x DRG weight",51380,Other,base rate x DRG weight,57087,,"25,057 x DRG weight",57087,Other,base rate x DRG weight,48523,,"21,298 x DRG weight",48523,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,198703,
TRAUMATIC STUPOR AND COMA >1 HOUR WITH CC,83,MS-DRG,,,,,,,,inpatient,,,200124.21,26120,,,26120,Other,150% of Medicare + 9.63% HCRA Surcharge,15884,,"3,609.90 x patient days",15884,Per diem,,33972,,"25,046 x DRG weight",33972,Other,base rate x DRG weight,30575,,"22,541 x DRG weight",30575,Other,base rate x DRG weight,42758,,"31,523 x DRG weight",42758,Other,base rate x DRG weight,38482,,"28,371 x DRG weight",38482,Other,base rate x DRG weight,36345,,"26,795 x DRG weight",36345,Other,base rate x DRG weight,17472.4,,"3,970.89 x patient days",17472.4,Per diem,,30469,,"22,463 x DRG weight",30469,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,35844,,"26,426 x DRG weight",35844,Other,base rate x DRG weight,52641,,"38,809 x DRG weight",52641,Other,base rate x DRG weight,52641,,"38,809 x DRG weight",52641,Other,base rate x DRG weight,35844,,"26,426 x DRG weight",35844,Other,base rate x DRG weight,52641,,"38,809 x DRG weight",52641,Other,base rate x DRG weight,27997,,"6,363 x patient days",27997,Per diem,,140087,70,,140087,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,33987,,"25,057 x DRG weight",33987,Other,base rate x DRG weight,30590,,"22,552 x DRG weight",30590,Other,base rate x DRG weight,33987,,"25,057 x DRG weight",33987,Other,base rate x DRG weight,28889,,"21,298 x DRG weight",28889,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,140087,
TRAUMATIC STUPOR AND COMA >1 HOUR WITHOUT CC/MCC,84,MS-DRG,,,,,,,,inpatient,,,117757.53,15435,,,15435,Other,150% of Medicare + 9.63% HCRA Surcharge,9386,,"3,609.90 x patient days",9386,Per diem,,23035,,"25,046 x DRG weight",23035,Other,base rate x DRG weight,20731,,"22,541 x DRG weight",20731,Other,base rate x DRG weight,28992,,"31,523 x DRG weight",28992,Other,base rate x DRG weight,26093,,"28,371 x DRG weight",26093,Other,base rate x DRG weight,24643,,"26,795 x DRG weight",24643,Other,base rate x DRG weight,10324.6,,"3,970.89 x patient days",10324.6,Per diem,,20659,,"22,463 x DRG weight",20659,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,24304,,"26,426 x DRG weight",24304,Other,base rate x DRG weight,35693,,"38,809 x DRG weight",35693,Other,base rate x DRG weight,35693,,"38,809 x DRG weight",35693,Other,base rate x DRG weight,24304,,"26,426 x DRG weight",24304,Other,base rate x DRG weight,35693,,"38,809 x DRG weight",35693,Other,base rate x DRG weight,16544,,"6,363 x patient days",16544,Per diem,,82430,70,,82430,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,23045,,"25,057 x DRG weight",23045,Other,base rate x DRG weight,20741,,"22,552 x DRG weight",20741,Other,base rate x DRG weight,23045,,"25,057 x DRG weight",23045,Other,base rate x DRG weight,19588,,"21,298 x DRG weight",19588,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,82430,
TRAUMATIC STUPOR AND COMA <1 HOUR WITH MCC,85,MS-DRG,,,,,,,,inpatient,,,256151.69,39773,,,39773,Other,150% of Medicare + 9.63% HCRA Surcharge,24186,,"3,609.90 x patient days",24186,Per diem,,56925,,"25,046 x DRG weight",56925,Other,base rate x DRG weight,51231,,"22,541 x DRG weight",51231,Other,base rate x DRG weight,71645,,"31,523 x DRG weight",71645,Other,base rate x DRG weight,64482,,"28,371 x DRG weight",64482,Other,base rate x DRG weight,60900,,"26,795 x DRG weight",60900,Other,base rate x DRG weight,26604.6,,"3,970.89 x patient days",26604.6,Per diem,,51054,,"22,463 x DRG weight",51054,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,60061,,"26,426 x DRG weight",60061,Other,base rate x DRG weight,88205,,"38,809 x DRG weight",88205,Other,base rate x DRG weight,88205,,"38,809 x DRG weight",88205,Other,base rate x DRG weight,60061,,"26,426 x DRG weight",60061,Other,base rate x DRG weight,88205,,"38,809 x DRG weight",88205,Other,base rate x DRG weight,42632,,"6,363 x patient days",42632,Per diem,,179306,70,,179306,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,56950,,"25,057 x DRG weight",56950,Other,base rate x DRG weight,51256,,"22,552 x DRG weight",51256,Other,base rate x DRG weight,56950,,"25,057 x DRG weight",56950,Other,base rate x DRG weight,48406,,"21,298 x DRG weight",48406,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,179306,
TRAUMATIC STUPOR AND COMA <1 HOUR WITH CC,86,MS-DRG,,,,,,,,inpatient,,,177275.48,23152,,,23152,Other,150% of Medicare + 9.63% HCRA Surcharge,14079,,"3,609.90 x patient days",14079,Per diem,,32988,,"25,046 x DRG weight",32988,Other,base rate x DRG weight,29689,,"22,541 x DRG weight",29689,Other,base rate x DRG weight,41519,,"31,523 x DRG weight",41519,Other,base rate x DRG weight,37367,,"28,371 x DRG weight",37367,Other,base rate x DRG weight,35292,,"26,795 x DRG weight",35292,Other,base rate x DRG weight,15486.9,,"3,970.89 x patient days",15486.9,Per diem,,29586,,"22,463 x DRG weight",29586,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,34806,,"26,426 x DRG weight",34806,Other,base rate x DRG weight,51115,,"38,809 x DRG weight",51115,Other,base rate x DRG weight,51115,,"38,809 x DRG weight",51115,Other,base rate x DRG weight,34806,,"26,426 x DRG weight",34806,Other,base rate x DRG weight,51115,,"38,809 x DRG weight",51115,Other,base rate x DRG weight,24816,,"6,363 x patient days",24816,Per diem,,124093,70,,124093,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,33003,,"25,057 x DRG weight",33003,Other,base rate x DRG weight,29703,,"22,552 x DRG weight",29703,Other,base rate x DRG weight,33003,,"25,057 x DRG weight",33003,Other,base rate x DRG weight,28052,,"21,298 x DRG weight",28052,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,124093,
TRAUMATIC STUPOR AND COMA <1 HOUR WITHOUT CC/MCC,87,MS-DRG,,,,,,,,inpatient,,,80254.97,14248,,,14248,Other,150% of Medicare + 9.63% HCRA Surcharge,8664,,"3,609.90 x patient days",8664,Per diem,,22196,,"25,046 x DRG weight",22196,Other,base rate x DRG weight,19976,,"22,541 x DRG weight",19976,Other,base rate x DRG weight,27936,,"31,523 x DRG weight",27936,Other,base rate x DRG weight,25142,,"28,371 x DRG weight",25142,Other,base rate x DRG weight,23746,,"26,795 x DRG weight",23746,Other,base rate x DRG weight,9530.4,,"3,970.89 x patient days",9530.4,Per diem,,19907,,"22,463 x DRG weight",19907,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,23419,,"26,426 x DRG weight",23419,Other,base rate x DRG weight,34393,,"38,809 x DRG weight",34393,Other,base rate x DRG weight,34393,,"38,809 x DRG weight",34393,Other,base rate x DRG weight,23419,,"26,426 x DRG weight",23419,Other,base rate x DRG weight,34393,,"38,809 x DRG weight",34393,Other,base rate x DRG weight,15271,,"6,363 x patient days",15271,Per diem,,56178,70,,56178,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,22206,,"25,057 x DRG weight",22206,Other,base rate x DRG weight,19986,,"22,552 x DRG weight",19986,Other,base rate x DRG weight,22206,,"25,057 x DRG weight",22206,Other,base rate x DRG weight,18874,,"21,298 x DRG weight",18874,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,56178,
CONCUSSION WITH MCC,88,MS-DRG,,,,,,,,inpatient,,,131096.93,32055,,,32055,Other,150% of Medicare + 9.63% HCRA Surcharge,19493,,"3,609.90 x patient days",19493,Per diem,,38416,,"25,046 x DRG weight",38416,Other,base rate x DRG weight,34573,,"22,541 x DRG weight",34573,Other,base rate x DRG weight,48350,,"31,523 x DRG weight",48350,Other,base rate x DRG weight,43515,,"28,371 x DRG weight",43515,Other,base rate x DRG weight,41098,,"26,795 x DRG weight",41098,Other,base rate x DRG weight,21442.3,,"3,970.89 x patient days",21442.3,Per diem,,34454,,"22,463 x DRG weight",34454,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,40532,,"26,426 x DRG weight",40532,Other,base rate x DRG weight,59525,,"38,809 x DRG weight",59525,Other,base rate x DRG weight,59525,,"38,809 x DRG weight",59525,Other,base rate x DRG weight,40532,,"26,426 x DRG weight",40532,Other,base rate x DRG weight,59525,,"38,809 x DRG weight",59525,Other,base rate x DRG weight,34360,,"6,363 x patient days",34360,Per diem,,91768,70,,91768,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,38432,,"25,057 x DRG weight",38432,Other,base rate x DRG weight,34590,,"22,552 x DRG weight",34590,Other,base rate x DRG weight,38432,,"25,057 x DRG weight",38432,Other,base rate x DRG weight,32667,,"21,298 x DRG weight",32667,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,91768,
CONCUSSION WITH CC,89,MS-DRG,,,,,,,,inpatient,,,145574.28,20184,,,20184,Other,150% of Medicare + 9.63% HCRA Surcharge,12274,,"3,609.90 x patient days",12274,Per diem,,28800,,"25,046 x DRG weight",28800,Other,base rate x DRG weight,25920,,"22,541 x DRG weight",25920,Other,base rate x DRG weight,36248,,"31,523 x DRG weight",36248,Other,base rate x DRG weight,32624,,"28,371 x DRG weight",32624,Other,base rate x DRG weight,30812,,"26,795 x DRG weight",30812,Other,base rate x DRG weight,13501.4,,"3,970.89 x patient days",13501.4,Per diem,,25830,,"22,463 x DRG weight",25830,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,30387,,"26,426 x DRG weight",30387,Other,base rate x DRG weight,44626,,"38,809 x DRG weight",44626,Other,base rate x DRG weight,44626,,"38,809 x DRG weight",44626,Other,base rate x DRG weight,30387,,"26,426 x DRG weight",30387,Other,base rate x DRG weight,44626,,"38,809 x DRG weight",44626,Other,base rate x DRG weight,21634,,"6,363 x patient days",21634,Per diem,,101902,70,,101902,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,28813,,"25,057 x DRG weight",28813,Other,base rate x DRG weight,25933,,"22,552 x DRG weight",25933,Other,base rate x DRG weight,28813,,"25,057 x DRG weight",28813,Other,base rate x DRG weight,24491,,"21,298 x DRG weight",24491,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,101902,
CONCUSSION WITHOUT CC/MCC,90,MS-DRG,,,,,,,,inpatient,,,91120.84,14248,,,14248,Other,150% of Medicare + 9.63% HCRA Surcharge,8664,,"3,609.90 x patient days",8664,Per diem,,23413,,"25,046 x DRG weight",23413,Other,base rate x DRG weight,21071,,"22,541 x DRG weight",21071,Other,base rate x DRG weight,29468,,"31,523 x DRG weight",29468,Other,base rate x DRG weight,26521,,"28,371 x DRG weight",26521,Other,base rate x DRG weight,25048,,"26,795 x DRG weight",25048,Other,base rate x DRG weight,9530.4,,"3,970.89 x patient days",9530.4,Per diem,,20998,,"22,463 x DRG weight",20998,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,24703,,"26,426 x DRG weight",24703,Other,base rate x DRG weight,36279,,"38,809 x DRG weight",36279,Other,base rate x DRG weight,36279,,"38,809 x DRG weight",36279,Other,base rate x DRG weight,24703,,"26,426 x DRG weight",24703,Other,base rate x DRG weight,36279,,"38,809 x DRG weight",36279,Other,base rate x DRG weight,15271,,"6,363 x patient days",15271,Per diem,,63785,70,,63785,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,23423,,"25,057 x DRG weight",23423,Other,base rate x DRG weight,21082,,"22,552 x DRG weight",21082,Other,base rate x DRG weight,23423,,"25,057 x DRG weight",23423,Other,base rate x DRG weight,19909,,"21,298 x DRG weight",19909,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,63785,
OTHER DISORDERS OF NERVOUS SYSTEM WITH MCC,91,MS-DRG,,,,,,,,inpatient,,,247322.39,40366,,,40366,Other,150% of Medicare + 9.63% HCRA Surcharge,24547,,"3,609.90 x patient days",24547,Per diem,,44812,,"25,046 x DRG weight",44812,Other,base rate x DRG weight,40330,,"22,541 x DRG weight",40330,Other,base rate x DRG weight,56401,,"31,523 x DRG weight",56401,Other,base rate x DRG weight,50761,,"28,371 x DRG weight",50761,Other,base rate x DRG weight,47942,,"26,795 x DRG weight",47942,Other,base rate x DRG weight,27001.7,,"3,970.89 x patient days",27001.7,Per diem,,40191,,"22,463 x DRG weight",40191,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,47281,,"26,426 x DRG weight",47281,Other,base rate x DRG weight,69437,,"38,809 x DRG weight",69437,Other,base rate x DRG weight,69437,,"38,809 x DRG weight",69437,Other,base rate x DRG weight,47281,,"26,426 x DRG weight",47281,Other,base rate x DRG weight,69437,,"38,809 x DRG weight",69437,Other,base rate x DRG weight,43268,,"6,363 x patient days",43268,Per diem,,173126,70,,173126,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,44832,,"25,057 x DRG weight",44832,Other,base rate x DRG weight,40350,,"22,552 x DRG weight",40350,Other,base rate x DRG weight,44832,,"25,057 x DRG weight",44832,Other,base rate x DRG weight,38106,,"21,298 x DRG weight",38106,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,173126,
OTHER DISORDERS OF NERVOUS SYSTEM WITH CC,92,MS-DRG,,,,,,,,inpatient,,,163311.23,24933,,,24933,Other,150% of Medicare + 9.63% HCRA Surcharge,15162,,"3,609.90 x patient days",15162,Per diem,,25700,,"25,046 x DRG weight",25700,Other,base rate x DRG weight,23129,,"22,541 x DRG weight",23129,Other,base rate x DRG weight,32346,,"31,523 x DRG weight",32346,Other,base rate x DRG weight,29111,,"28,371 x DRG weight",29111,Other,base rate x DRG weight,27494,,"26,795 x DRG weight",27494,Other,base rate x DRG weight,16678.2,,"3,970.89 x patient days",16678.2,Per diem,,23049,,"22,463 x DRG weight",23049,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,27116,,"26,426 x DRG weight",27116,Other,base rate x DRG weight,39822,,"38,809 x DRG weight",39822,Other,base rate x DRG weight,39822,,"38,809 x DRG weight",39822,Other,base rate x DRG weight,27116,,"26,426 x DRG weight",27116,Other,base rate x DRG weight,39822,,"38,809 x DRG weight",39822,Other,base rate x DRG weight,26725,,"6,363 x patient days",26725,Per diem,,114318,70,,114318,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,25711,,"25,057 x DRG weight",25711,Other,base rate x DRG weight,23141,,"22,552 x DRG weight",23141,Other,base rate x DRG weight,25711,,"25,057 x DRG weight",25711,Other,base rate x DRG weight,21854,,"21,298 x DRG weight",21854,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,114318,
OTHER DISORDERS OF NERVOUS SYSTEM WITHOUT CC/MCC,93,MS-DRG,,,,,,,,inpatient,,,94602.58,16622,,,16622,Other,150% of Medicare + 9.63% HCRA Surcharge,10108,,"3,609.90 x patient days",10108,Per diem,,19396,,"25,046 x DRG weight",19396,Other,base rate x DRG weight,17456,,"22,541 x DRG weight",17456,Other,base rate x DRG weight,24411,,"31,523 x DRG weight",24411,Other,base rate x DRG weight,21971,,"28,371 x DRG weight",21971,Other,base rate x DRG weight,20750,,"26,795 x DRG weight",20750,Other,base rate x DRG weight,11118.8,,"3,970.89 x patient days",11118.8,Per diem,,17395,,"22,463 x DRG weight",17395,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,20464,,"26,426 x DRG weight",20464,Other,base rate x DRG weight,30054,,"38,809 x DRG weight",30054,Other,base rate x DRG weight,30054,,"38,809 x DRG weight",30054,Other,base rate x DRG weight,20464,,"26,426 x DRG weight",20464,Other,base rate x DRG weight,30054,,"38,809 x DRG weight",30054,Other,base rate x DRG weight,17816,,"6,363 x patient days",17816,Per diem,,66222,70,,66222,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,19404,,"25,057 x DRG weight",19404,Other,base rate x DRG weight,17464,,"22,552 x DRG weight",17464,Other,base rate x DRG weight,19404,,"25,057 x DRG weight",19404,Other,base rate x DRG weight,16493,,"21,298 x DRG weight",16493,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,66222,
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH MCC,94,MS-DRG,,,,,,,,inpatient,,,348015.49,68268,,,68268,Other,150% of Medicare + 9.63% HCRA Surcharge,41514,,"3,609.90 x patient days",41514,Per diem,,90734,,"25,046 x DRG weight",90734,Other,base rate x DRG weight,81659,,"22,541 x DRG weight",81659,Other,base rate x DRG weight,114198,,"31,523 x DRG weight",114198,Other,base rate x DRG weight,102780,,"28,371 x DRG weight",102780,Other,base rate x DRG weight,97070,,"26,795 x DRG weight",97070,Other,base rate x DRG weight,45665.4,,"3,970.89 x patient days",45665.4,Per diem,,81377,,"22,463 x DRG weight",81377,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,95733,,"26,426 x DRG weight",95733,Other,base rate x DRG weight,140593,,"38,809 x DRG weight",140593,Other,base rate x DRG weight,140593,,"38,809 x DRG weight",140593,Other,base rate x DRG weight,95733,,"26,426 x DRG weight",95733,Other,base rate x DRG weight,140593,,"38,809 x DRG weight",140593,Other,base rate x DRG weight,73175,,"6,363 x patient days",73175,Per diem,,243611,70,,243611,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,90774,,"25,057 x DRG weight",90774,Other,base rate x DRG weight,81699,,"22,552 x DRG weight",81699,Other,base rate x DRG weight,90774,,"25,057 x DRG weight",90774,Other,base rate x DRG weight,77156,,"21,298 x DRG weight",77156,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,243611,
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH CC,95,MS-DRG,,,,,,,,inpatient,,,251747.23,43335,,,43335,Other,150% of Medicare + 9.63% HCRA Surcharge,26352,,"3,609.90 x patient days",26352,Per diem,,59715,,"25,046 x DRG weight",59715,Other,base rate x DRG weight,53742,,"22,541 x DRG weight",53742,Other,base rate x DRG weight,75157,,"31,523 x DRG weight",75157,Other,base rate x DRG weight,67642,,"28,371 x DRG weight",67642,Other,base rate x DRG weight,63885,,"26,795 x DRG weight",63885,Other,base rate x DRG weight,28987.2,,"3,970.89 x patient days",28987.2,Per diem,,53556,,"22,463 x DRG weight",53556,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,63005,,"26,426 x DRG weight",63005,Other,base rate x DRG weight,92528,,"38,809 x DRG weight",92528,Other,base rate x DRG weight,92528,,"38,809 x DRG weight",92528,Other,base rate x DRG weight,63005,,"26,426 x DRG weight",63005,Other,base rate x DRG weight,92528,,"38,809 x DRG weight",92528,Other,base rate x DRG weight,46450,,"6,363 x patient days",46450,Per diem,,176223,70,,176223,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,59741,,"25,057 x DRG weight",59741,Other,base rate x DRG weight,53768,,"22,552 x DRG weight",53768,Other,base rate x DRG weight,59741,,"25,057 x DRG weight",59741,Other,base rate x DRG weight,50779,,"21,298 x DRG weight",50779,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,176223,
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITHOUT CC/MCC,96,MS-DRG,,,,,,,,inpatient,,,206916.67,31462,,,31462,Other,150% of Medicare + 9.63% HCRA Surcharge,19132,,"3,609.90 x patient days",19132,Per diem,,54593,,"25,046 x DRG weight",54593,Other,base rate x DRG weight,49133,,"22,541 x DRG weight",49133,Other,base rate x DRG weight,68711,,"31,523 x DRG weight",68711,Other,base rate x DRG weight,61840,,"28,371 x DRG weight",61840,Other,base rate x DRG weight,58405,,"26,795 x DRG weight",58405,Other,base rate x DRG weight,21045.2,,"3,970.89 x patient days",21045.2,Per diem,,48963,,"22,463 x DRG weight",48963,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,57601,,"26,426 x DRG weight",57601,Other,base rate x DRG weight,84592,,"38,809 x DRG weight",84592,Other,base rate x DRG weight,84592,,"38,809 x DRG weight",84592,Other,base rate x DRG weight,57601,,"26,426 x DRG weight",57601,Other,base rate x DRG weight,84592,,"38,809 x DRG weight",84592,Other,base rate x DRG weight,33724,,"6,363 x patient days",33724,Per diem,,144842,70,,144842,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,54617,,"25,057 x DRG weight",54617,Other,base rate x DRG weight,49157,,"22,552 x DRG weight",49157,Other,base rate x DRG weight,54617,,"25,057 x DRG weight",54617,Other,base rate x DRG weight,46423,,"21,298 x DRG weight",46423,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,144842,
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH MCC,97,MS-DRG,,,,,,,,inpatient,,,411465.66,74204,,,74204,Other,150% of Medicare + 9.63% HCRA Surcharge,45124,,"3,609.90 x patient days",45124,Per diem,,91090,,"25,046 x DRG weight",91090,Other,base rate x DRG weight,81979,,"22,541 x DRG weight",81979,Other,base rate x DRG weight,114646,,"31,523 x DRG weight",114646,Other,base rate x DRG weight,103182,,"28,371 x DRG weight",103182,Other,base rate x DRG weight,97451,,"26,795 x DRG weight",97451,Other,base rate x DRG weight,49636.4,,"3,970.89 x patient days",49636.4,Per diem,,81696,,"22,463 x DRG weight",81696,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,96109,,"26,426 x DRG weight",96109,Other,base rate x DRG weight,141144,,"38,809 x DRG weight",141144,Other,base rate x DRG weight,141144,,"38,809 x DRG weight",141144,Other,base rate x DRG weight,96109,,"26,426 x DRG weight",96109,Other,base rate x DRG weight,141144,,"38,809 x DRG weight",141144,Other,base rate x DRG weight,79538,,"6,363 x patient days",79538,Per diem,,288026,70,,288026,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,91130,,"25,057 x DRG weight",91130,Other,base rate x DRG weight,82019,,"22,552 x DRG weight",82019,Other,base rate x DRG weight,91130,,"25,057 x DRG weight",91130,Other,base rate x DRG weight,77459,,"21,298 x DRG weight",77459,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,288026,
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH CC,98,MS-DRG,,,,,,,,inpatient,,,305591.59,48677,,,48677,Other,150% of Medicare + 9.63% HCRA Surcharge,29601,,"3,609.90 x patient days",29601,Per diem,,53962,,"25,046 x DRG weight",53962,Other,base rate x DRG weight,48565,,"22,541 x DRG weight",48565,Other,base rate x DRG weight,67916,,"31,523 x DRG weight",67916,Other,base rate x DRG weight,61125,,"28,371 x DRG weight",61125,Other,base rate x DRG weight,57730,,"26,795 x DRG weight",57730,Other,base rate x DRG weight,32561.1,,"3,970.89 x patient days",32561.1,Per diem,,48397,,"22,463 x DRG weight",48397,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,56935,,"26,426 x DRG weight",56935,Other,base rate x DRG weight,83614,,"38,809 x DRG weight",83614,Other,base rate x DRG weight,83614,,"38,809 x DRG weight",83614,Other,base rate x DRG weight,56935,,"26,426 x DRG weight",56935,Other,base rate x DRG weight,83614,,"38,809 x DRG weight",83614,Other,base rate x DRG weight,52177,,"6,363 x patient days",52177,Per diem,,213914,70,,213914,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,53985,,"25,057 x DRG weight",53985,Other,base rate x DRG weight,48588,,"22,552 x DRG weight",48588,Other,base rate x DRG weight,53985,,"25,057 x DRG weight",53985,Other,base rate x DRG weight,45887,,"21,298 x DRG weight",45887,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,213914,
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITHOUT CC/MCC,99,MS-DRG,,,,,,,,inpatient,,,127994.65,28495,,,28495,Other,150% of Medicare + 9.63% HCRA Surcharge,17328,,"3,609.90 x patient days",17328,Per diem,,33066,,"25,046 x DRG weight",33066,Other,base rate x DRG weight,29759,,"22,541 x DRG weight",29759,Other,base rate x DRG weight,41617,,"31,523 x DRG weight",41617,Other,base rate x DRG weight,37455,,"28,371 x DRG weight",37455,Other,base rate x DRG weight,35375,,"26,795 x DRG weight",35375,Other,base rate x DRG weight,19060.8,,"3,970.89 x patient days",19060.8,Per diem,,29656,,"22,463 x DRG weight",29656,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,34888,,"26,426 x DRG weight",34888,Other,base rate x DRG weight,51236,,"38,809 x DRG weight",51236,Other,base rate x DRG weight,51236,,"38,809 x DRG weight",51236,Other,base rate x DRG weight,34888,,"26,426 x DRG weight",34888,Other,base rate x DRG weight,51236,,"38,809 x DRG weight",51236,Other,base rate x DRG weight,30542,,"6,363 x patient days",30542,Per diem,,89596,70,,89596,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,33080,,"25,057 x DRG weight",33080,Other,base rate x DRG weight,29773,,"22,552 x DRG weight",29773,Other,base rate x DRG weight,33080,,"25,057 x DRG weight",33080,Other,base rate x DRG weight,28118,,"21,298 x DRG weight",28118,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,89596,
SEIZURES WITH MCC,100,MS-DRG,,,,,,,,inpatient,,,212740.77,39773,,,39773,Other,150% of Medicare + 9.63% HCRA Surcharge,24186,,"3,609.90 x patient days",24186,Per diem,,49654,,"25,046 x DRG weight",49654,Other,base rate x DRG weight,44688,,"22,541 x DRG weight",44688,Other,base rate x DRG weight,62494,,"31,523 x DRG weight",62494,Other,base rate x DRG weight,56246,,"28,371 x DRG weight",56246,Other,base rate x DRG weight,53121,,"26,795 x DRG weight",53121,Other,base rate x DRG weight,26604.6,,"3,970.89 x patient days",26604.6,Per diem,,44533,,"22,463 x DRG weight",44533,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,52390,,"26,426 x DRG weight",52390,Other,base rate x DRG weight,76939,,"38,809 x DRG weight",76939,Other,base rate x DRG weight,76939,,"38,809 x DRG weight",76939,Other,base rate x DRG weight,52390,,"26,426 x DRG weight",52390,Other,base rate x DRG weight,76939,,"38,809 x DRG weight",76939,Other,base rate x DRG weight,42632,,"6,363 x patient days",42632,Per diem,,148919,70,,148919,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,49676,,"25,057 x DRG weight",49676,Other,base rate x DRG weight,44709,,"22,552 x DRG weight",44709,Other,base rate x DRG weight,49676,,"25,057 x DRG weight",49676,Other,base rate x DRG weight,42223,,"21,298 x DRG weight",42223,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,148919,
SEIZURES WITHOUT MCC,101,MS-DRG,,,,,,,,inpatient,,,89221.08,20778,,,20778,Other,150% of Medicare + 9.63% HCRA Surcharge,12635,,"3,609.90 x patient days",12635,Per diem,,22782,,"25,046 x DRG weight",22782,Other,base rate x DRG weight,20503,,"22,541 x DRG weight",20503,Other,base rate x DRG weight,28673,,"31,523 x DRG weight",28673,Other,base rate x DRG weight,25806,,"28,371 x DRG weight",25806,Other,base rate x DRG weight,24373,,"26,795 x DRG weight",24373,Other,base rate x DRG weight,13898.5,,"3,970.89 x patient days",13898.5,Per diem,,20432,,"22,463 x DRG weight",20432,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,24037,,"26,426 x DRG weight",24037,Other,base rate x DRG weight,35301,,"38,809 x DRG weight",35301,Other,base rate x DRG weight,35301,,"38,809 x DRG weight",35301,Other,base rate x DRG weight,24037,,"26,426 x DRG weight",24037,Other,base rate x DRG weight,35301,,"38,809 x DRG weight",35301,Other,base rate x DRG weight,22271,,"6,363 x patient days",22271,Per diem,,62455,70,,62455,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,22792,,"25,057 x DRG weight",22792,Other,base rate x DRG weight,20513,,"22,552 x DRG weight",20513,Other,base rate x DRG weight,22792,,"25,057 x DRG weight",22792,Other,base rate x DRG weight,19373,,"21,298 x DRG weight",19373,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,62455,
HEADACHES WITH MCC,102,MS-DRG,,,,,,,,inpatient,,,188017.58,26714,,,26714,Other,150% of Medicare + 9.63% HCRA Surcharge,16245,,"3,609.90 x patient days",16245,Per diem,,30221,,"25,046 x DRG weight",30221,Other,base rate x DRG weight,27198,,"22,541 x DRG weight",27198,Other,base rate x DRG weight,38036,,"31,523 x DRG weight",38036,Other,base rate x DRG weight,34232,,"28,371 x DRG weight",34232,Other,base rate x DRG weight,32331,,"26,795 x DRG weight",32331,Other,base rate x DRG weight,17869.5,,"3,970.89 x patient days",17869.5,Per diem,,27104,,"22,463 x DRG weight",27104,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,31886,,"26,426 x DRG weight",31886,Other,base rate x DRG weight,46827,,"38,809 x DRG weight",46827,Other,base rate x DRG weight,46827,,"38,809 x DRG weight",46827,Other,base rate x DRG weight,31886,,"26,426 x DRG weight",31886,Other,base rate x DRG weight,46827,,"38,809 x DRG weight",46827,Other,base rate x DRG weight,28634,,"6,363 x patient days",28634,Per diem,,131612,70,,131612,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,30234,,"25,057 x DRG weight",30234,Other,base rate x DRG weight,27211,,"22,552 x DRG weight",27211,Other,base rate x DRG weight,30234,,"25,057 x DRG weight",30234,Other,base rate x DRG weight,25698,,"21,298 x DRG weight",25698,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,131612,
HEADACHES WITHOUT MCC,103,MS-DRG,,,,,,,,inpatient,,,110728.85,18403,,,18403,Other,150% of Medicare + 9.63% HCRA Surcharge,11191,,"3,609.90 x patient days",11191,Per diem,,21099,,"25,046 x DRG weight",21099,Other,base rate x DRG weight,18989,,"22,541 x DRG weight",18989,Other,base rate x DRG weight,26555,,"31,523 x DRG weight",26555,Other,base rate x DRG weight,23900,,"28,371 x DRG weight",23900,Other,base rate x DRG weight,22572,,"26,795 x DRG weight",22572,Other,base rate x DRG weight,12310.1,,"3,970.89 x patient days",12310.1,Per diem,,18923,,"22,463 x DRG weight",18923,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,22261,,"26,426 x DRG weight",22261,Other,base rate x DRG weight,32693,,"38,809 x DRG weight",32693,Other,base rate x DRG weight,32693,,"38,809 x DRG weight",32693,Other,base rate x DRG weight,22261,,"26,426 x DRG weight",22261,Other,base rate x DRG weight,32693,,"38,809 x DRG weight",32693,Other,base rate x DRG weight,19725,,"6,363 x patient days",19725,Per diem,,77510,70,,77510,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,21108,,"25,057 x DRG weight",21108,Other,base rate x DRG weight,18998,,"22,552 x DRG weight",18998,Other,base rate x DRG weight,21108,,"25,057 x DRG weight",21108,Other,base rate x DRG weight,17941,,"21,298 x DRG weight",17941,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,77510,
ORBITAL PROCEDURES WITH CC/MCC,113,MS-DRG,,,,,,,,inpatient,,,464263.93,46896,,,46896,Other,150% of Medicare + 9.63% HCRA Surcharge,28518,,"3,609.90 x patient days",28518,Per diem,,62798,,"25,046 x DRG weight",62798,Other,base rate x DRG weight,56517,,"22,541 x DRG weight",56517,Other,base rate x DRG weight,79038,,"31,523 x DRG weight",79038,Other,base rate x DRG weight,71135,,"28,371 x DRG weight",71135,Other,base rate x DRG weight,67183,,"26,795 x DRG weight",67183,Other,base rate x DRG weight,31369.8,,"3,970.89 x patient days",31369.8,Per diem,,56321,,"22,463 x DRG weight",56321,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,66258,,"26,426 x DRG weight",66258,Other,base rate x DRG weight,97306,,"38,809 x DRG weight",97306,Other,base rate x DRG weight,97306,,"38,809 x DRG weight",97306,Other,base rate x DRG weight,66258,,"26,426 x DRG weight",66258,Other,base rate x DRG weight,97306,,"38,809 x DRG weight",97306,Other,base rate x DRG weight,50268,,"6,363 x patient days",50268,Per diem,,324985,70,,324985,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,62825,,"25,057 x DRG weight",62825,Other,base rate x DRG weight,56545,,"22,552 x DRG weight",56545,Other,base rate x DRG weight,62825,,"25,057 x DRG weight",62825,Other,base rate x DRG weight,53400,,"21,298 x DRG weight",53400,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,324985,
ORBITAL PROCEDURES WITHOUT CC/MCC,114,MS-DRG,,,,,,,,inpatient,,,92286.06,14841,,,14841,Other,150% of Medicare + 9.63% HCRA Surcharge,9025,,"3,609.90 x patient days",9025,Per diem,,30852,,"25,046 x DRG weight",30852,Other,base rate x DRG weight,27766,,"22,541 x DRG weight",27766,Other,base rate x DRG weight,38830,,"31,523 x DRG weight",38830,Other,base rate x DRG weight,34947,,"28,371 x DRG weight",34947,Other,base rate x DRG weight,33006,,"26,795 x DRG weight",33006,Other,base rate x DRG weight,9927.5,,"3,970.89 x patient days",9927.5,Per diem,,27670,,"22,463 x DRG weight",27670,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,32552,,"26,426 x DRG weight",32552,Other,base rate x DRG weight,47805,,"38,809 x DRG weight",47805,Other,base rate x DRG weight,47805,,"38,809 x DRG weight",47805,Other,base rate x DRG weight,32552,,"26,426 x DRG weight",32552,Other,base rate x DRG weight,47805,,"38,809 x DRG weight",47805,Other,base rate x DRG weight,15908,,"6,363 x patient days",15908,Per diem,,64600,70,,64600,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,30865,,"25,057 x DRG weight",30865,Other,base rate x DRG weight,27780,,"22,552 x DRG weight",27780,Other,base rate x DRG weight,30865,,"25,057 x DRG weight",30865,Other,base rate x DRG weight,26235,,"21,298 x DRG weight",26235,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,64600,
EXTRAOCULAR PROCEDURES EXCEPT ORBIT,115,MS-DRG,,,,,,,,inpatient,,,172972.87,29089,,,29089,Other,150% of Medicare + 9.63% HCRA Surcharge,17689,,"3,609.90 x patient days",17689,Per diem,,39182,,"25,046 x DRG weight",39182,Other,base rate x DRG weight,35263,,"22,541 x DRG weight",35263,Other,base rate x DRG weight,49315,,"31,523 x DRG weight",49315,Other,base rate x DRG weight,44384,,"28,371 x DRG weight",44384,Other,base rate x DRG weight,41918,,"26,795 x DRG weight",41918,Other,base rate x DRG weight,19457.9,,"3,970.89 x patient days",19457.9,Per diem,,35141,,"22,463 x DRG weight",35141,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,41341,,"26,426 x DRG weight",41341,Other,base rate x DRG weight,60713,,"38,809 x DRG weight",60713,Other,base rate x DRG weight,60713,,"38,809 x DRG weight",60713,Other,base rate x DRG weight,41341,,"26,426 x DRG weight",41341,Other,base rate x DRG weight,60713,,"38,809 x DRG weight",60713,Other,base rate x DRG weight,31179,,"6,363 x patient days",31179,Per diem,,121081,70,,121081,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,39199,,"25,057 x DRG weight",39199,Other,base rate x DRG weight,35280,,"22,552 x DRG weight",35280,Other,base rate x DRG weight,39199,,"25,057 x DRG weight",39199,Other,base rate x DRG weight,33319,,"21,298 x DRG weight",33319,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,121081,
INTRAOCULAR PROCEDURES WITH CC/MCC,116,MS-DRG,,,,,,,,inpatient,,,161700.79,36804,,,36804,Other,150% of Medicare + 9.63% HCRA Surcharge,22381,,"3,609.90 x patient days",22381,Per diem,,45854,,"25,046 x DRG weight",45854,Other,base rate x DRG weight,41268,,"22,541 x DRG weight",41268,Other,base rate x DRG weight,57712,,"31,523 x DRG weight",57712,Other,base rate x DRG weight,51942,,"28,371 x DRG weight",51942,Other,base rate x DRG weight,49056,,"26,795 x DRG weight",49056,Other,base rate x DRG weight,24619.1,,"3,970.89 x patient days",24619.1,Per diem,,41125,,"22,463 x DRG weight",41125,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,48381,,"26,426 x DRG weight",48381,Other,base rate x DRG weight,71052,,"38,809 x DRG weight",71052,Other,base rate x DRG weight,71052,,"38,809 x DRG weight",71052,Other,base rate x DRG weight,48381,,"26,426 x DRG weight",48381,Other,base rate x DRG weight,71052,,"38,809 x DRG weight",71052,Other,base rate x DRG weight,39451,,"6,363 x patient days",39451,Per diem,,113191,70,,113191,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,45874,,"25,057 x DRG weight",45874,Other,base rate x DRG weight,41288,,"22,552 x DRG weight",41288,Other,base rate x DRG weight,45874,,"25,057 x DRG weight",45874,Other,base rate x DRG weight,38992,,"21,298 x DRG weight",38992,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,113191,
INTRAOCULAR PROCEDURES WITHOUT CC/MCC,117,MS-DRG,,,,,,,,inpatient,,,87477.7,15435,,,15435,Other,150% of Medicare + 9.63% HCRA Surcharge,9386,,"3,609.90 x patient days",9386,Per diem,,30015,,"25,046 x DRG weight",30015,Other,base rate x DRG weight,27013,,"22,541 x DRG weight",27013,Other,base rate x DRG weight,37777,,"31,523 x DRG weight",37777,Other,base rate x DRG weight,34000,,"28,371 x DRG weight",34000,Other,base rate x DRG weight,32111,,"26,795 x DRG weight",32111,Other,base rate x DRG weight,10324.6,,"3,970.89 x patient days",10324.6,Per diem,,26920,,"22,463 x DRG weight",26920,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,31669,,"26,426 x DRG weight",31669,Other,base rate x DRG weight,46509,,"38,809 x DRG weight",46509,Other,base rate x DRG weight,46509,,"38,809 x DRG weight",46509,Other,base rate x DRG weight,31669,,"26,426 x DRG weight",31669,Other,base rate x DRG weight,46509,,"38,809 x DRG weight",46509,Other,base rate x DRG weight,16544,,"6,363 x patient days",16544,Per diem,,61234,70,,61234,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,30028,,"25,057 x DRG weight",30028,Other,base rate x DRG weight,27026,,"22,552 x DRG weight",27026,Other,base rate x DRG weight,30028,,"25,057 x DRG weight",30028,Other,base rate x DRG weight,25524,,"21,298 x DRG weight",25524,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,61234,
ACUTE MAJOR EYE INFECTIONS WITH CC/MCC,121,MS-DRG,,,,,,,,inpatient,,,101124.95,36804,,,36804,Other,150% of Medicare + 9.63% HCRA Surcharge,22381,,"3,609.90 x patient days",22381,Per diem,,32089,,"25,046 x DRG weight",32089,Other,base rate x DRG weight,28880,,"22,541 x DRG weight",28880,Other,base rate x DRG weight,40387,,"31,523 x DRG weight",40387,Other,base rate x DRG weight,36349,,"28,371 x DRG weight",36349,Other,base rate x DRG weight,34330,,"26,795 x DRG weight",34330,Other,base rate x DRG weight,24619.1,,"3,970.89 x patient days",24619.1,Per diem,,28780,,"22,463 x DRG weight",28780,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,33857,,"26,426 x DRG weight",33857,Other,base rate x DRG weight,49722,,"38,809 x DRG weight",49722,Other,base rate x DRG weight,49722,,"38,809 x DRG weight",49722,Other,base rate x DRG weight,33857,,"26,426 x DRG weight",33857,Other,base rate x DRG weight,49722,,"38,809 x DRG weight",49722,Other,base rate x DRG weight,39451,,"6,363 x patient days",39451,Per diem,,70787,70,,70787,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,32103,,"25,057 x DRG weight",32103,Other,base rate x DRG weight,28894,,"22,552 x DRG weight",28894,Other,base rate x DRG weight,32103,,"25,057 x DRG weight",32103,Other,base rate x DRG weight,27287,,"21,298 x DRG weight",27287,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,70787,
ACUTE MAJOR EYE INFECTIONS WITHOUT CC/MCC,122,MS-DRG,,,,,,,,inpatient,,,74313.11,21965,,,21965,Other,150% of Medicare + 9.63% HCRA Surcharge,13357,,"3,609.90 x patient days",13357,Per diem,,18647,,"25,046 x DRG weight",18647,Other,base rate x DRG weight,16782,,"22,541 x DRG weight",16782,Other,base rate x DRG weight,23469,,"31,523 x DRG weight",23469,Other,base rate x DRG weight,21122,,"28,371 x DRG weight",21122,Other,base rate x DRG weight,19949,,"26,795 x DRG weight",19949,Other,base rate x DRG weight,14692.7,,"3,970.89 x patient days",14692.7,Per diem,,16724,,"22,463 x DRG weight",16724,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,19674,,"26,426 x DRG weight",19674,Other,base rate x DRG weight,28893,,"38,809 x DRG weight",28893,Other,base rate x DRG weight,28893,,"38,809 x DRG weight",28893,Other,base rate x DRG weight,19674,,"26,426 x DRG weight",19674,Other,base rate x DRG weight,28893,,"38,809 x DRG weight",28893,Other,base rate x DRG weight,23543,,"6,363 x patient days",23543,Per diem,,52019,70,,52019,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,18655,,"25,057 x DRG weight",18655,Other,base rate x DRG weight,16790,,"22,552 x DRG weight",16790,Other,base rate x DRG weight,18655,,"25,057 x DRG weight",18655,Other,base rate x DRG weight,15856,,"21,298 x DRG weight",15856,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,52019,
NEUROLOGICAL EYE DISORDERS,123,MS-DRG,,,,,,,,inpatient,,,151775.32,16028,,,16028,Other,150% of Medicare + 9.63% HCRA Surcharge,9747,,"3,609.90 x patient days",9747,Per diem,,20137,,"25,046 x DRG weight",20137,Other,base rate x DRG weight,18123,,"22,541 x DRG weight",18123,Other,base rate x DRG weight,25344,,"31,523 x DRG weight",25344,Other,base rate x DRG weight,22810,,"28,371 x DRG weight",22810,Other,base rate x DRG weight,21543,,"26,795 x DRG weight",21543,Other,base rate x DRG weight,10721.7,,"3,970.89 x patient days",10721.7,Per diem,,18060,,"22,463 x DRG weight",18060,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,21247,,"26,426 x DRG weight",21247,Other,base rate x DRG weight,31202,,"38,809 x DRG weight",31202,Other,base rate x DRG weight,31202,,"38,809 x DRG weight",31202,Other,base rate x DRG weight,21247,,"26,426 x DRG weight",21247,Other,base rate x DRG weight,31202,,"38,809 x DRG weight",31202,Other,base rate x DRG weight,17180,,"6,363 x patient days",17180,Per diem,,106243,70,,106243,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,20146,,"25,057 x DRG weight",20146,Other,base rate x DRG weight,18132,,"22,552 x DRG weight",18132,Other,base rate x DRG weight,20146,,"25,057 x DRG weight",20146,Other,base rate x DRG weight,17124,,"21,298 x DRG weight",17124,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,106243,
OTHER DISORDERS OF THE EYE WITH MCC OR THROMBOLYTIC AGENT,124,MS-DRG,,,,,,,,inpatient,,,234515.92,29682,,,29682,Other,150% of Medicare + 9.63% HCRA Surcharge,18050,,"3,609.90 x patient days",18050,Per diem,,33108,,"25,046 x DRG weight",33108,Other,base rate x DRG weight,29797,,"22,541 x DRG weight",29797,Other,base rate x DRG weight,41670,,"31,523 x DRG weight",41670,Other,base rate x DRG weight,37504,,"28,371 x DRG weight",37504,Other,base rate x DRG weight,35420,,"26,795 x DRG weight",35420,Other,base rate x DRG weight,19855,,"3,970.89 x patient days",19855,Per diem,,29694,,"22,463 x DRG weight",29694,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,34933,,"26,426 x DRG weight",34933,Other,base rate x DRG weight,51302,,"38,809 x DRG weight",51302,Other,base rate x DRG weight,51302,,"38,809 x DRG weight",51302,Other,base rate x DRG weight,34933,,"26,426 x DRG weight",34933,Other,base rate x DRG weight,51302,,"38,809 x DRG weight",51302,Other,base rate x DRG weight,31815,,"6,363 x patient days",31815,Per diem,,164161,70,,164161,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,33123,,"25,057 x DRG weight",33123,Other,base rate x DRG weight,29811,,"22,552 x DRG weight",29811,Other,base rate x DRG weight,33123,,"25,057 x DRG weight",33123,Other,base rate x DRG weight,28154,,"21,298 x DRG weight",28154,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,164161,
OTHER DISORDERS OF THE EYE WITHOUT MCC,125,MS-DRG,,,,,,,,inpatient,,,148165.28,17809,,,17809,Other,150% of Medicare + 9.63% HCRA Surcharge,10830,,"3,609.90 x patient days",10830,Per diem,,19974,,"25,046 x DRG weight",19974,Other,base rate x DRG weight,17976,,"22,541 x DRG weight",17976,Other,base rate x DRG weight,25140,,"31,523 x DRG weight",25140,Other,base rate x DRG weight,22626,,"28,371 x DRG weight",22626,Other,base rate x DRG weight,21369,,"26,795 x DRG weight",21369,Other,base rate x DRG weight,11913,,"3,970.89 x patient days",11913,Per diem,,17914,,"22,463 x DRG weight",17914,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,21075,,"26,426 x DRG weight",21075,Other,base rate x DRG weight,30950,,"38,809 x DRG weight",30950,Other,base rate x DRG weight,30950,,"38,809 x DRG weight",30950,Other,base rate x DRG weight,21075,,"26,426 x DRG weight",21075,Other,base rate x DRG weight,30950,,"38,809 x DRG weight",30950,Other,base rate x DRG weight,19089,,"6,363 x patient days",19089,Per diem,,103716,70,,103716,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,19983,,"25,057 x DRG weight",19983,Other,base rate x DRG weight,17985,,"22,552 x DRG weight",17985,Other,base rate x DRG weight,19983,,"25,057 x DRG weight",19983,Other,base rate x DRG weight,16985,,"21,298 x DRG weight",16985,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,103716,
SINUS AND MASTOID PROCEDURES WITH CC/MCC,135,MS-DRG,,,,,,,,inpatient,,,263085.12,39773,,,39773,Other,150% of Medicare + 9.63% HCRA Surcharge,24186,,"3,609.90 x patient days",24186,Per diem,,66424,,"25,046 x DRG weight",66424,Other,base rate x DRG weight,59781,,"22,541 x DRG weight",59781,Other,base rate x DRG weight,83602,,"31,523 x DRG weight",83602,Other,base rate x DRG weight,75243,,"28,371 x DRG weight",75243,Other,base rate x DRG weight,71063,,"26,795 x DRG weight",71063,Other,base rate x DRG weight,26604.6,,"3,970.89 x patient days",26604.6,Per diem,,59574,,"22,463 x DRG weight",59574,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,70084,,"26,426 x DRG weight",70084,Other,base rate x DRG weight,102925,,"38,809 x DRG weight",102925,Other,base rate x DRG weight,102925,,"38,809 x DRG weight",102925,Other,base rate x DRG weight,70084,,"26,426 x DRG weight",70084,Other,base rate x DRG weight,102925,,"38,809 x DRG weight",102925,Other,base rate x DRG weight,42632,,"6,363 x patient days",42632,Per diem,,184160,70,,184160,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,66454,,"25,057 x DRG weight",66454,Other,base rate x DRG weight,59810,,"22,552 x DRG weight",59810,Other,base rate x DRG weight,66454,,"25,057 x DRG weight",66454,Other,base rate x DRG weight,56484,,"21,298 x DRG weight",56484,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,184160,
SINUS AND MASTOID PROCEDURES WITHOUT CC/MCC,136,MS-DRG,,,,,,,,inpatient,,,136004.4,8905,,,8905,Other,150% of Medicare + 9.63% HCRA Surcharge,5415,,"3,609.90 x patient days",5415,Per diem,,26156,,"25,046 x DRG weight",26156,Other,base rate x DRG weight,23540,,"22,541 x DRG weight",23540,Other,base rate x DRG weight,32919,,"31,523 x DRG weight",32919,Other,base rate x DRG weight,29628,,"28,371 x DRG weight",29628,Other,base rate x DRG weight,27982,,"26,795 x DRG weight",27982,Other,base rate x DRG weight,5956.5,,"3,970.89 x patient days",5956.5,Per diem,,23458,,"22,463 x DRG weight",23458,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,27597,,"26,426 x DRG weight",27597,Other,base rate x DRG weight,40528,,"38,809 x DRG weight",40528,Other,base rate x DRG weight,40528,,"38,809 x DRG weight",40528,Other,base rate x DRG weight,27597,,"26,426 x DRG weight",27597,Other,base rate x DRG weight,40528,,"38,809 x DRG weight",40528,Other,base rate x DRG weight,9545,,"6,363 x patient days",9545,Per diem,,95203,70,,95203,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,26167,,"25,057 x DRG weight",26167,Other,base rate x DRG weight,23551,,"22,552 x DRG weight",23551,Other,base rate x DRG weight,26167,,"25,057 x DRG weight",26167,Other,base rate x DRG weight,22242,,"21,298 x DRG weight",22242,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,95203,
MOUTH PROCEDURES WITH CC/MCC,137,MS-DRG,,,,,,,,inpatient,,,174872.07,30868,,,30868,Other,150% of Medicare + 9.63% HCRA Surcharge,18771,,"3,609.90 x patient days",18771,Per diem,,37687,,"25,046 x DRG weight",37687,Other,base rate x DRG weight,33917,,"22,541 x DRG weight",33917,Other,base rate x DRG weight,47433,,"31,523 x DRG weight",47433,Other,base rate x DRG weight,42690,,"28,371 x DRG weight",42690,Other,base rate x DRG weight,40318,,"26,795 x DRG weight",40318,Other,base rate x DRG weight,20648.1,,"3,970.89 x patient days",20648.1,Per diem,,33800,,"22,463 x DRG weight",33800,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,39763,,"26,426 x DRG weight",39763,Other,base rate x DRG weight,58396,,"38,809 x DRG weight",58396,Other,base rate x DRG weight,58396,,"38,809 x DRG weight",58396,Other,base rate x DRG weight,39763,,"26,426 x DRG weight",39763,Other,base rate x DRG weight,58396,,"38,809 x DRG weight",58396,Other,base rate x DRG weight,33088,,"6,363 x patient days",33088,Per diem,,122410,70,,122410,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,37703,,"25,057 x DRG weight",37703,Other,base rate x DRG weight,33934,,"22,552 x DRG weight",33934,Other,base rate x DRG weight,37703,,"25,057 x DRG weight",37703,Other,base rate x DRG weight,32047,,"21,298 x DRG weight",32047,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,122410,
MOUTH PROCEDURES WITHOUT CC/MCC,138,MS-DRG,,,,,,,,inpatient,,,222907.05,11873,,,11873,Other,150% of Medicare + 9.63% HCRA Surcharge,7220,,"3,609.90 x patient days",7220,Per diem,,21682,,"25,046 x DRG weight",21682,Other,base rate x DRG weight,19514,,"22,541 x DRG weight",19514,Other,base rate x DRG weight,27289,,"31,523 x DRG weight",27289,Other,base rate x DRG weight,24561,,"28,371 x DRG weight",24561,Other,base rate x DRG weight,23196,,"26,795 x DRG weight",23196,Other,base rate x DRG weight,7942,,"3,970.89 x patient days",7942,Per diem,,19446,,"22,463 x DRG weight",19446,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,22877,,"26,426 x DRG weight",22877,Other,base rate x DRG weight,33597,,"38,809 x DRG weight",33597,Other,base rate x DRG weight,33597,,"38,809 x DRG weight",33597,Other,base rate x DRG weight,22877,,"26,426 x DRG weight",22877,Other,base rate x DRG weight,33597,,"38,809 x DRG weight",33597,Other,base rate x DRG weight,12726,,"6,363 x patient days",12726,Per diem,,156035,70,,156035,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,21692,,"25,057 x DRG weight",21692,Other,base rate x DRG weight,19523,,"22,552 x DRG weight",19523,Other,base rate x DRG weight,21692,,"25,057 x DRG weight",21692,Other,base rate x DRG weight,18438,,"21,298 x DRG weight",18438,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,156035,
SALIVARY GLAND PROCEDURES,139,MS-DRG,,,,,,,,inpatient,,,185599.04,19590,,,19590,Other,150% of Medicare + 9.63% HCRA Surcharge,11913,,"3,609.90 x patient days",11913,Per diem,,29747,,"25,046 x DRG weight",29747,Other,base rate x DRG weight,26772,,"22,541 x DRG weight",26772,Other,base rate x DRG weight,37440,,"31,523 x DRG weight",37440,Other,base rate x DRG weight,33696,,"28,371 x DRG weight",33696,Other,base rate x DRG weight,31824,,"26,795 x DRG weight",31824,Other,base rate x DRG weight,13104.3,,"3,970.89 x patient days",13104.3,Per diem,,26679,,"22,463 x DRG weight",26679,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,31386,,"26,426 x DRG weight",31386,Other,base rate x DRG weight,46093,,"38,809 x DRG weight",46093,Other,base rate x DRG weight,46093,,"38,809 x DRG weight",46093,Other,base rate x DRG weight,31386,,"26,426 x DRG weight",31386,Other,base rate x DRG weight,46093,,"38,809 x DRG weight",46093,Other,base rate x DRG weight,20998,,"6,363 x patient days",20998,Per diem,,129919,70,,129919,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,29760,,"25,057 x DRG weight",29760,Other,base rate x DRG weight,26785,,"22,552 x DRG weight",26785,Other,base rate x DRG weight,29760,,"25,057 x DRG weight",29760,Other,base rate x DRG weight,25296,,"21,298 x DRG weight",25296,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,129919,
MAJOR HEAD AND NECK PROCEDURES WITH MCC,140,MS-DRG,,,,,,,,inpatient,,,540714.02,56988,,,56988,Other,150% of Medicare + 9.63% HCRA Surcharge,34655,,"3,609.90 x patient days",34655,Per diem,,94626,,"25,046 x DRG weight",94626,Other,base rate x DRG weight,85162,,"22,541 x DRG weight",85162,Other,base rate x DRG weight,119097,,"31,523 x DRG weight",119097,Other,base rate x DRG weight,107188,,"28,371 x DRG weight",107188,Other,base rate x DRG weight,101234,,"26,795 x DRG weight",101234,Other,base rate x DRG weight,38120.5,,"3,970.89 x patient days",38120.5,Per diem,,84867,,"22,463 x DRG weight",84867,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,99840,,"26,426 x DRG weight",99840,Other,base rate x DRG weight,146624,,"38,809 x DRG weight",146624,Other,base rate x DRG weight,146624,,"38,809 x DRG weight",146624,Other,base rate x DRG weight,99840,,"26,426 x DRG weight",99840,Other,base rate x DRG weight,146624,,"38,809 x DRG weight",146624,Other,base rate x DRG weight,61085,,"6,363 x patient days",61085,Per diem,,378500,70,,378500,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,94668,,"25,057 x DRG weight",94668,Other,base rate x DRG weight,85204,,"22,552 x DRG weight",85204,Other,base rate x DRG weight,94668,,"25,057 x DRG weight",94668,Other,base rate x DRG weight,80466,,"21,298 x DRG weight",80466,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,378500,
MAJOR HEAD AND NECK PROCEDURES WITH CC,141,MS-DRG,,,,,,,,inpatient,,,305703.48,25527,,,25527,Other,150% of Medicare + 9.63% HCRA Surcharge,15523,,"3,609.90 x patient days",15523,Per diem,,51888,,"25,046 x DRG weight",51888,Other,base rate x DRG weight,46698,,"22,541 x DRG weight",46698,Other,base rate x DRG weight,65306,,"31,523 x DRG weight",65306,Other,base rate x DRG weight,58776,,"28,371 x DRG weight",58776,Other,base rate x DRG weight,55511,,"26,795 x DRG weight",55511,Other,base rate x DRG weight,17075.3,,"3,970.89 x patient days",17075.3,Per diem,,46537,,"22,463 x DRG weight",46537,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,54747,,"26,426 x DRG weight",54747,Other,base rate x DRG weight,80401,,"38,809 x DRG weight",80401,Other,base rate x DRG weight,80401,,"38,809 x DRG weight",80401,Other,base rate x DRG weight,54747,,"26,426 x DRG weight",54747,Other,base rate x DRG weight,80401,,"38,809 x DRG weight",80401,Other,base rate x DRG weight,27361,,"6,363 x patient days",27361,Per diem,,213992,70,,213992,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,51911,,"25,057 x DRG weight",51911,Other,base rate x DRG weight,46721,,"22,552 x DRG weight",46721,Other,base rate x DRG weight,51911,,"25,057 x DRG weight",51911,Other,base rate x DRG weight,44123,,"21,298 x DRG weight",44123,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,213992,
MAJOR HEAD AND NECK PROCEDURES WITHOUT CC/MCC,142,MS-DRG,,,,,,,,inpatient,,,151922.26,14841,,,14841,Other,150% of Medicare + 9.63% HCRA Surcharge,9025,,"3,609.90 x patient days",9025,Per diem,,38696,,"25,046 x DRG weight",38696,Other,base rate x DRG weight,34826,,"22,541 x DRG weight",34826,Other,base rate x DRG weight,48703,,"31,523 x DRG weight",48703,Other,base rate x DRG weight,43833,,"28,371 x DRG weight",43833,Other,base rate x DRG weight,41398,,"26,795 x DRG weight",41398,Other,base rate x DRG weight,9927.5,,"3,970.89 x patient days",9927.5,Per diem,,34705,,"22,463 x DRG weight",34705,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,40828,,"26,426 x DRG weight",40828,Other,base rate x DRG weight,59960,,"38,809 x DRG weight",59960,Other,base rate x DRG weight,59960,,"38,809 x DRG weight",59960,Other,base rate x DRG weight,40828,,"26,426 x DRG weight",40828,Other,base rate x DRG weight,59960,,"38,809 x DRG weight",59960,Other,base rate x DRG weight,15908,,"6,363 x patient days",15908,Per diem,,106346,70,,106346,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,38713,,"25,057 x DRG weight",38713,Other,base rate x DRG weight,34843,,"22,552 x DRG weight",34843,Other,base rate x DRG weight,38713,,"25,057 x DRG weight",38713,Other,base rate x DRG weight,32905,,"21,298 x DRG weight",32905,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,106346,
"OTHER EAR, NOSE, MOUTH AND THROAT O.R. PROCEDURES WITH MCC",143,MS-DRG,,,,,,,,inpatient,,,298063.22,54020,,,54020,Other,150% of Medicare + 9.63% HCRA Surcharge,32850,,"3,609.90 x patient days",32850,Per diem,,83293,,"25,046 x DRG weight",83293,Other,base rate x DRG weight,74962,,"22,541 x DRG weight",74962,Other,base rate x DRG weight,104833,,"31,523 x DRG weight",104833,Other,base rate x DRG weight,94351,,"28,371 x DRG weight",94351,Other,base rate x DRG weight,89109,,"26,795 x DRG weight",89109,Other,base rate x DRG weight,36135,,"3,970.89 x patient days",36135,Per diem,,74703,,"22,463 x DRG weight",74703,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,87882,,"26,426 x DRG weight",87882,Other,base rate x DRG weight,129063,,"38,809 x DRG weight",129063,Other,base rate x DRG weight,129063,,"38,809 x DRG weight",129063,Other,base rate x DRG weight,87882,,"26,426 x DRG weight",87882,Other,base rate x DRG weight,129063,,"38,809 x DRG weight",129063,Other,base rate x DRG weight,57903,,"6,363 x patient days",57903,Per diem,,208644,70,,208644,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,83330,,"25,057 x DRG weight",83330,Other,base rate x DRG weight,74999,,"22,552 x DRG weight",74999,Other,base rate x DRG weight,83330,,"25,057 x DRG weight",83330,Other,base rate x DRG weight,70829,,"21,298 x DRG weight",70829,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,208644,
"OTHER EAR, NOSE, MOUTH AND THROAT O.R. PROCEDURES WITH CC",144,MS-DRG,,,,,,,,inpatient,,,116858.05,24340,,,24340,Other,150% of Medicare + 9.63% HCRA Surcharge,14801,,"3,609.90 x patient days",14801,Per diem,,43342,,"25,046 x DRG weight",43342,Other,base rate x DRG weight,39007,,"22,541 x DRG weight",39007,Other,base rate x DRG weight,54551,,"31,523 x DRG weight",54551,Other,base rate x DRG weight,49096,,"28,371 x DRG weight",49096,Other,base rate x DRG weight,46369,,"26,795 x DRG weight",46369,Other,base rate x DRG weight,16281.1,,"3,970.89 x patient days",16281.1,Per diem,,38872,,"22,463 x DRG weight",38872,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,45730,,"26,426 x DRG weight",45730,Other,base rate x DRG weight,67159,,"38,809 x DRG weight",67159,Other,base rate x DRG weight,67159,,"38,809 x DRG weight",67159,Other,base rate x DRG weight,45730,,"26,426 x DRG weight",45730,Other,base rate x DRG weight,67159,,"38,809 x DRG weight",67159,Other,base rate x DRG weight,26088,,"6,363 x patient days",26088,Per diem,,81801,70,,81801,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,43361,,"25,057 x DRG weight",43361,Other,base rate x DRG weight,39026,,"22,552 x DRG weight",39026,Other,base rate x DRG weight,43361,,"25,057 x DRG weight",43361,Other,base rate x DRG weight,36856,,"21,298 x DRG weight",36856,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,81801,
"OTHER EAR, NOSE, MOUTH AND THROAT O.R. PROCEDURES WITHOUT CC/MCC",145,MS-DRG,,,,,,,,inpatient,,,71466.59,12467,,,12467,Other,150% of Medicare + 9.63% HCRA Surcharge,7581,,"3,609.90 x patient days",7581,Per diem,,30584,,"25,046 x DRG weight",30584,Other,base rate x DRG weight,27525,,"22,541 x DRG weight",27525,Other,base rate x DRG weight,38493,,"31,523 x DRG weight",38493,Other,base rate x DRG weight,34644,,"28,371 x DRG weight",34644,Other,base rate x DRG weight,32719,,"26,795 x DRG weight",32719,Other,base rate x DRG weight,8339.1,,"3,970.89 x patient days",8339.1,Per diem,,27430,,"22,463 x DRG weight",27430,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,32269,,"26,426 x DRG weight",32269,Other,base rate x DRG weight,47390,,"38,809 x DRG weight",47390,Other,base rate x DRG weight,47390,,"38,809 x DRG weight",47390,Other,base rate x DRG weight,32269,,"26,426 x DRG weight",32269,Other,base rate x DRG weight,47390,,"38,809 x DRG weight",47390,Other,base rate x DRG weight,13362,,"6,363 x patient days",13362,Per diem,,50027,70,,50027,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,30597,,"25,057 x DRG weight",30597,Other,base rate x DRG weight,27538,,"22,552 x DRG weight",27538,Other,base rate x DRG weight,30597,,"25,057 x DRG weight",30597,Other,base rate x DRG weight,26007,,"21,298 x DRG weight",26007,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,50027,
"EAR, NOSE, MOUTH AND THROAT MALIGNANCY WITH MCC",146,MS-DRG,,,,,,,,inpatient,,,242841.51,49865,,,49865,Other,150% of Medicare + 9.63% HCRA Surcharge,30323,,"3,609.90 x patient days",30323,Per diem,,52872,,"25,046 x DRG weight",52872,Other,base rate x DRG weight,47584,,"22,541 x DRG weight",47584,Other,base rate x DRG weight,66545,,"31,523 x DRG weight",66545,Other,base rate x DRG weight,59891,,"28,371 x DRG weight",59891,Other,base rate x DRG weight,56564,,"26,795 x DRG weight",56564,Other,base rate x DRG weight,33355.3,,"3,970.89 x patient days",33355.3,Per diem,,47419,,"22,463 x DRG weight",47419,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,55785,,"26,426 x DRG weight",55785,Other,base rate x DRG weight,81926,,"38,809 x DRG weight",81926,Other,base rate x DRG weight,81926,,"38,809 x DRG weight",81926,Other,base rate x DRG weight,55785,,"26,426 x DRG weight",55785,Other,base rate x DRG weight,81926,,"38,809 x DRG weight",81926,Other,base rate x DRG weight,53449,,"6,363 x patient days",53449,Per diem,,169989,70,,169989,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,52895,,"25,057 x DRG weight",52895,Other,base rate x DRG weight,47607,,"22,552 x DRG weight",47607,Other,base rate x DRG weight,52895,,"25,057 x DRG weight",52895,Other,base rate x DRG weight,44960,,"21,298 x DRG weight",44960,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,169989,
"EAR, NOSE, MOUTH AND THROAT MALIGNANCY WITH CC",147,MS-DRG,,,,,,,,inpatient,,,195187.52,30274,,,30274,Other,150% of Medicare + 9.63% HCRA Surcharge,18410,,"3,609.90 x patient days",18410,Per diem,,30952,,"25,046 x DRG weight",30952,Other,base rate x DRG weight,27856,,"22,541 x DRG weight",27856,Other,base rate x DRG weight,38956,,"31,523 x DRG weight",38956,Other,base rate x DRG weight,35061,,"28,371 x DRG weight",35061,Other,base rate x DRG weight,33113,,"26,795 x DRG weight",33113,Other,base rate x DRG weight,20251,,"3,970.89 x patient days",20251,Per diem,,27760,,"22,463 x DRG weight",27760,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,32657,,"26,426 x DRG weight",32657,Other,base rate x DRG weight,47960,,"38,809 x DRG weight",47960,Other,base rate x DRG weight,47960,,"38,809 x DRG weight",47960,Other,base rate x DRG weight,32657,,"26,426 x DRG weight",32657,Other,base rate x DRG weight,47960,,"38,809 x DRG weight",47960,Other,base rate x DRG weight,32451,,"6,363 x patient days",32451,Per diem,,136631,70,,136631,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,30965,,"25,057 x DRG weight",30965,Other,base rate x DRG weight,27870,,"22,552 x DRG weight",27870,Other,base rate x DRG weight,30965,,"25,057 x DRG weight",30965,Other,base rate x DRG weight,26320,,"21,298 x DRG weight",26320,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,136631,
"EAR, NOSE, MOUTH AND THROAT MALIGNANCY WITHOUT CC/MCC",148,MS-DRG,,,,,,,,inpatient,,,106260,16622,,,16622,Other,150% of Medicare + 9.63% HCRA Surcharge,10108,,"3,609.90 x patient days",10108,Per diem,,22283,,"25,046 x DRG weight",22283,Other,base rate x DRG weight,20055,,"22,541 x DRG weight",20055,Other,base rate x DRG weight,28046,,"31,523 x DRG weight",28046,Other,base rate x DRG weight,25242,,"28,371 x DRG weight",25242,Other,base rate x DRG weight,23840,,"26,795 x DRG weight",23840,Other,base rate x DRG weight,11118.8,,"3,970.89 x patient days",11118.8,Per diem,,19985,,"22,463 x DRG weight",19985,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,23511,,"26,426 x DRG weight",23511,Other,base rate x DRG weight,34528,,"38,809 x DRG weight",34528,Other,base rate x DRG weight,34528,,"38,809 x DRG weight",34528,Other,base rate x DRG weight,23511,,"26,426 x DRG weight",23511,Other,base rate x DRG weight,34528,,"38,809 x DRG weight",34528,Other,base rate x DRG weight,17816,,"6,363 x patient days",17816,Per diem,,74382,70,,74382,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,22293,,"25,057 x DRG weight",22293,Other,base rate x DRG weight,20065,,"22,552 x DRG weight",20065,Other,base rate x DRG weight,22293,,"25,057 x DRG weight",22293,Other,base rate x DRG weight,18949,,"21,298 x DRG weight",18949,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,74382,
DYSEQUILIBRIUM,149,MS-DRG,,,,,,,,inpatient,,,119203.93,14248,,,14248,Other,150% of Medicare + 9.63% HCRA Surcharge,8664,,"3,609.90 x patient days",8664,Per diem,,18652,,"25,046 x DRG weight",18652,Other,base rate x DRG weight,16786,,"22,541 x DRG weight",16786,Other,base rate x DRG weight,23475,,"31,523 x DRG weight",23475,Other,base rate x DRG weight,21128,,"28,371 x DRG weight",21128,Other,base rate x DRG weight,19954,,"26,795 x DRG weight",19954,Other,base rate x DRG weight,9530.4,,"3,970.89 x patient days",9530.4,Per diem,,16728,,"22,463 x DRG weight",16728,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,19679,,"26,426 x DRG weight",19679,Other,base rate x DRG weight,28901,,"38,809 x DRG weight",28901,Other,base rate x DRG weight,28901,,"38,809 x DRG weight",28901,Other,base rate x DRG weight,19679,,"26,426 x DRG weight",19679,Other,base rate x DRG weight,28901,,"38,809 x DRG weight",28901,Other,base rate x DRG weight,15271,,"6,363 x patient days",15271,Per diem,,83443,70,,83443,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,18660,,"25,057 x DRG weight",18660,Other,base rate x DRG weight,16794,,"22,552 x DRG weight",16794,Other,base rate x DRG weight,18660,,"25,057 x DRG weight",18660,Other,base rate x DRG weight,15861,,"21,298 x DRG weight",15861,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,83443,
EPISTAXIS WITH MCC,150,MS-DRG,,,,,,,,inpatient,,,211777.46,26714,,,26714,Other,150% of Medicare + 9.63% HCRA Surcharge,16245,,"3,609.90 x patient days",16245,Per diem,,32923,,"25,046 x DRG weight",32923,Other,base rate x DRG weight,29630,,"22,541 x DRG weight",29630,Other,base rate x DRG weight,41437,,"31,523 x DRG weight",41437,Other,base rate x DRG weight,37294,,"28,371 x DRG weight",37294,Other,base rate x DRG weight,35222,,"26,795 x DRG weight",35222,Other,base rate x DRG weight,17869.5,,"3,970.89 x patient days",17869.5,Per diem,,29528,,"22,463 x DRG weight",29528,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,34737,,"26,426 x DRG weight",34737,Other,base rate x DRG weight,51014,,"38,809 x DRG weight",51014,Other,base rate x DRG weight,51014,,"38,809 x DRG weight",51014,Other,base rate x DRG weight,34737,,"26,426 x DRG weight",34737,Other,base rate x DRG weight,51014,,"38,809 x DRG weight",51014,Other,base rate x DRG weight,28634,,"6,363 x patient days",28634,Per diem,,148244,70,,148244,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,32937,,"25,057 x DRG weight",32937,Other,base rate x DRG weight,29645,,"22,552 x DRG weight",29645,Other,base rate x DRG weight,32937,,"25,057 x DRG weight",32937,Other,base rate x DRG weight,27996,,"21,298 x DRG weight",27996,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,148244,
EPISTAXIS WITHOUT MCC,151,MS-DRG,,,,,,,,inpatient,,,79887.08,16028,,,16028,Other,150% of Medicare + 9.63% HCRA Surcharge,9747,,"3,609.90 x patient days",9747,Per diem,,19303,,"25,046 x DRG weight",19303,Other,base rate x DRG weight,17372,,"22,541 x DRG weight",17372,Other,base rate x DRG weight,24295,,"31,523 x DRG weight",24295,Other,base rate x DRG weight,21866,,"28,371 x DRG weight",21866,Other,base rate x DRG weight,20651,,"26,795 x DRG weight",20651,Other,base rate x DRG weight,10721.7,,"3,970.89 x patient days",10721.7,Per diem,,17312,,"22,463 x DRG weight",17312,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,20367,,"26,426 x DRG weight",20367,Other,base rate x DRG weight,29910,,"38,809 x DRG weight",29910,Other,base rate x DRG weight,29910,,"38,809 x DRG weight",29910,Other,base rate x DRG weight,20367,,"26,426 x DRG weight",20367,Other,base rate x DRG weight,29910,,"38,809 x DRG weight",29910,Other,base rate x DRG weight,17180,,"6,363 x patient days",17180,Per diem,,55921,70,,55921,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,19311,,"25,057 x DRG weight",19311,Other,base rate x DRG weight,17381,,"22,552 x DRG weight",17381,Other,base rate x DRG weight,19311,,"25,057 x DRG weight",19311,Other,base rate x DRG weight,16414,,"21,298 x DRG weight",16414,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,55921,
OTITIS MEDIA AND URI WITH MCC,152,MS-DRG,,,,,,,,inpatient,,,79823.68,26120,,,26120,Other,150% of Medicare + 9.63% HCRA Surcharge,15884,,"3,609.90 x patient days",15884,Per diem,,29760,,"25,046 x DRG weight",29760,Other,base rate x DRG weight,26783,,"22,541 x DRG weight",26783,Other,base rate x DRG weight,37456,,"31,523 x DRG weight",37456,Other,base rate x DRG weight,33710,,"28,371 x DRG weight",33710,Other,base rate x DRG weight,31838,,"26,795 x DRG weight",31838,Other,base rate x DRG weight,17472.4,,"3,970.89 x patient days",17472.4,Per diem,,26691,,"22,463 x DRG weight",26691,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,31399,,"26,426 x DRG weight",31399,Other,base rate x DRG weight,46113,,"38,809 x DRG weight",46113,Other,base rate x DRG weight,46113,,"38,809 x DRG weight",46113,Other,base rate x DRG weight,31399,,"26,426 x DRG weight",31399,Other,base rate x DRG weight,46113,,"38,809 x DRG weight",46113,Other,base rate x DRG weight,27997,,"6,363 x patient days",27997,Per diem,,55877,70,,55877,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,29773,,"25,057 x DRG weight",29773,Other,base rate x DRG weight,26796,,"22,552 x DRG weight",26796,Other,base rate x DRG weight,29773,,"25,057 x DRG weight",29773,Other,base rate x DRG weight,25306,,"21,298 x DRG weight",25306,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,55877,
OTITIS MEDIA AND URI WITHOUT MCC,153,MS-DRG,,,,,,,,inpatient,,,64792.2,17216,,,17216,Other,150% of Medicare + 9.63% HCRA Surcharge,10469,,"3,609.90 x patient days",10469,Per diem,,18404,,"25,046 x DRG weight",18404,Other,base rate x DRG weight,16563,,"22,541 x DRG weight",16563,Other,base rate x DRG weight,23163,,"31,523 x DRG weight",23163,Other,base rate x DRG weight,20847,,"28,371 x DRG weight",20847,Other,base rate x DRG weight,19689,,"26,795 x DRG weight",19689,Other,base rate x DRG weight,11515.9,,"3,970.89 x patient days",11515.9,Per diem,,16506,,"22,463 x DRG weight",16506,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,19418,,"26,426 x DRG weight",19418,Other,base rate x DRG weight,28517,,"38,809 x DRG weight",28517,Other,base rate x DRG weight,28517,,"38,809 x DRG weight",28517,Other,base rate x DRG weight,19418,,"26,426 x DRG weight",19418,Other,base rate x DRG weight,28517,,"38,809 x DRG weight",28517,Other,base rate x DRG weight,18453,,"6,363 x patient days",18453,Per diem,,45355,70,,45355,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,18412,,"25,057 x DRG weight",18412,Other,base rate x DRG weight,16571,,"22,552 x DRG weight",16571,Other,base rate x DRG weight,18412,,"25,057 x DRG weight",18412,Other,base rate x DRG weight,15650,,"21,298 x DRG weight",15650,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,45355,
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITH MCC",154,MS-DRG,,,,,,,,inpatient,,,260488.17,34430,,,34430,Other,150% of Medicare + 9.63% HCRA Surcharge,20937,,"3,609.90 x patient days",20937,Per diem,,38526,,"25,046 x DRG weight",38526,Other,base rate x DRG weight,34673,,"22,541 x DRG weight",34673,Other,base rate x DRG weight,48489,,"31,523 x DRG weight",48489,Other,base rate x DRG weight,43640,,"28,371 x DRG weight",43640,Other,base rate x DRG weight,41216,,"26,795 x DRG weight",41216,Other,base rate x DRG weight,23030.7,,"3,970.89 x patient days",23030.7,Per diem,,34553,,"22,463 x DRG weight",34553,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,40648,,"26,426 x DRG weight",40648,Other,base rate x DRG weight,59696,,"38,809 x DRG weight",59696,Other,base rate x DRG weight,59696,,"38,809 x DRG weight",59696,Other,base rate x DRG weight,40648,,"26,426 x DRG weight",40648,Other,base rate x DRG weight,59696,,"38,809 x DRG weight",59696,Other,base rate x DRG weight,36905,,"6,363 x patient days",36905,Per diem,,182342,70,,182342,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,38543,,"25,057 x DRG weight",38543,Other,base rate x DRG weight,34689,,"22,552 x DRG weight",34689,Other,base rate x DRG weight,38543,,"25,057 x DRG weight",38543,Other,base rate x DRG weight,32761,,"21,298 x DRG weight",32761,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,182342,
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITH CC",155,MS-DRG,,,,,,,,inpatient,,,112500.78,21965,,,21965,Other,150% of Medicare + 9.63% HCRA Surcharge,13357,,"3,609.90 x patient days",13357,Per diem,,23709,,"25,046 x DRG weight",23709,Other,base rate x DRG weight,21337,,"22,541 x DRG weight",21337,Other,base rate x DRG weight,29840,,"31,523 x DRG weight",29840,Other,base rate x DRG weight,26856,,"28,371 x DRG weight",26856,Other,base rate x DRG weight,25364,,"26,795 x DRG weight",25364,Other,base rate x DRG weight,14692.7,,"3,970.89 x patient days",14692.7,Per diem,,21263,,"22,463 x DRG weight",21263,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,25015,,"26,426 x DRG weight",25015,Other,base rate x DRG weight,36737,,"38,809 x DRG weight",36737,Other,base rate x DRG weight,36737,,"38,809 x DRG weight",36737,Other,base rate x DRG weight,25015,,"26,426 x DRG weight",25015,Other,base rate x DRG weight,36737,,"38,809 x DRG weight",36737,Other,base rate x DRG weight,23543,,"6,363 x patient days",23543,Per diem,,78751,70,,78751,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,23719,,"25,057 x DRG weight",23719,Other,base rate x DRG weight,21348,,"22,552 x DRG weight",21348,Other,base rate x DRG weight,23719,,"25,057 x DRG weight",23719,Other,base rate x DRG weight,20161,,"21,298 x DRG weight",20161,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,78751,
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITHOUT CC/MCC",156,MS-DRG,,,,,,,,inpatient,,,72738.95,15435,,,15435,Other,150% of Medicare + 9.63% HCRA Surcharge,9386,,"3,609.90 x patient days",9386,Per diem,,16418,,"25,046 x DRG weight",16418,Other,base rate x DRG weight,14776,,"22,541 x DRG weight",14776,Other,base rate x DRG weight,20663,,"31,523 x DRG weight",20663,Other,base rate x DRG weight,18597,,"28,371 x DRG weight",18597,Other,base rate x DRG weight,17564,,"26,795 x DRG weight",17564,Other,base rate x DRG weight,10324.6,,"3,970.89 x patient days",10324.6,Per diem,,14724,,"22,463 x DRG weight",14724,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,17322,,"26,426 x DRG weight",17322,Other,base rate x DRG weight,25439,,"38,809 x DRG weight",25439,Other,base rate x DRG weight,25439,,"38,809 x DRG weight",25439,Other,base rate x DRG weight,17322,,"26,426 x DRG weight",17322,Other,base rate x DRG weight,25439,,"38,809 x DRG weight",25439,Other,base rate x DRG weight,16544,,"6,363 x patient days",16544,Per diem,,50917,70,,50917,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,16425,,"25,057 x DRG weight",16425,Other,base rate x DRG weight,14783,,"22,552 x DRG weight",14783,Other,base rate x DRG weight,16425,,"25,057 x DRG weight",16425,Other,base rate x DRG weight,13961,,"21,298 x DRG weight",13961,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,50917,
DENTAL AND ORAL DISEASES WITH MCC,157,MS-DRG,,,,,,,,inpatient,,,131007.38,39773,,,39773,Other,150% of Medicare + 9.63% HCRA Surcharge,24186,,"3,609.90 x patient days",24186,Per diem,,42754,,"25,046 x DRG weight",42754,Other,base rate x DRG weight,38477,,"22,541 x DRG weight",38477,Other,base rate x DRG weight,53810,,"31,523 x DRG weight",53810,Other,base rate x DRG weight,48429,,"28,371 x DRG weight",48429,Other,base rate x DRG weight,45739,,"26,795 x DRG weight",45739,Other,base rate x DRG weight,26604.6,,"3,970.89 x patient days",26604.6,Per diem,,38344,,"22,463 x DRG weight",38344,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,45109,,"26,426 x DRG weight",45109,Other,base rate x DRG weight,66247,,"38,809 x DRG weight",66247,Other,base rate x DRG weight,66247,,"38,809 x DRG weight",66247,Other,base rate x DRG weight,45109,,"26,426 x DRG weight",45109,Other,base rate x DRG weight,66247,,"38,809 x DRG weight",66247,Other,base rate x DRG weight,42632,,"6,363 x patient days",42632,Per diem,,91705,70,,91705,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,42772,,"25,057 x DRG weight",42772,Other,base rate x DRG weight,38496,,"22,552 x DRG weight",38496,Other,base rate x DRG weight,42772,,"25,057 x DRG weight",42772,Other,base rate x DRG weight,36356,,"21,298 x DRG weight",36356,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,91705,
DENTAL AND ORAL DISEASES WITH CC,158,MS-DRG,,,,,,,,inpatient,,,144648.14,21371,,,21371,Other,150% of Medicare + 9.63% HCRA Surcharge,12996,,"3,609.90 x patient days",12996,Per diem,,23506,,"25,046 x DRG weight",23506,Other,base rate x DRG weight,21155,,"22,541 x DRG weight",21155,Other,base rate x DRG weight,29584,,"31,523 x DRG weight",29584,Other,base rate x DRG weight,26626,,"28,371 x DRG weight",26626,Other,base rate x DRG weight,25147,,"26,795 x DRG weight",25147,Other,base rate x DRG weight,14295.6,,"3,970.89 x patient days",14295.6,Per diem,,21082,,"22,463 x DRG weight",21082,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,24801,,"26,426 x DRG weight",24801,Other,base rate x DRG weight,36422,,"38,809 x DRG weight",36422,Other,base rate x DRG weight,36422,,"38,809 x DRG weight",36422,Other,base rate x DRG weight,24801,,"26,426 x DRG weight",24801,Other,base rate x DRG weight,36422,,"38,809 x DRG weight",36422,Other,base rate x DRG weight,22907,,"6,363 x patient days",22907,Per diem,,101254,70,,101254,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,23516,,"25,057 x DRG weight",23516,Other,base rate x DRG weight,21165,,"22,552 x DRG weight",21165,Other,base rate x DRG weight,23516,,"25,057 x DRG weight",23516,Other,base rate x DRG weight,19988,,"21,298 x DRG weight",19988,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,101254,
DENTAL AND ORAL DISEASES WITHOUT CC/MCC,159,MS-DRG,,,,,,,,inpatient,,,79825.68,14841,,,14841,Other,150% of Medicare + 9.63% HCRA Surcharge,9025,,"3,609.90 x patient days",9025,Per diem,,16911,,"25,046 x DRG weight",16911,Other,base rate x DRG weight,15220,,"22,541 x DRG weight",15220,Other,base rate x DRG weight,21284,,"31,523 x DRG weight",21284,Other,base rate x DRG weight,19156,,"28,371 x DRG weight",19156,Other,base rate x DRG weight,18092,,"26,795 x DRG weight",18092,Other,base rate x DRG weight,9927.5,,"3,970.89 x patient days",9927.5,Per diem,,15167,,"22,463 x DRG weight",15167,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,17843,,"26,426 x DRG weight",17843,Other,base rate x DRG weight,26204,,"38,809 x DRG weight",26204,Other,base rate x DRG weight,26204,,"38,809 x DRG weight",26204,Other,base rate x DRG weight,17843,,"26,426 x DRG weight",17843,Other,base rate x DRG weight,26204,,"38,809 x DRG weight",26204,Other,base rate x DRG weight,15908,,"6,363 x patient days",15908,Per diem,,55878,70,,55878,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,16918,,"25,057 x DRG weight",16918,Other,base rate x DRG weight,15227,,"22,552 x DRG weight",15227,Other,base rate x DRG weight,16918,,"25,057 x DRG weight",16918,Other,base rate x DRG weight,14380,,"21,298 x DRG weight",14380,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,55878,
MAJOR CHEST PROCEDURES WITH MCC,163,MS-DRG,,,,,,,,inpatient,,,582271.14,61144,,,61144,Other,150% of Medicare + 9.63% HCRA Surcharge,37182,,"3,609.90 x patient days",37182,Per diem,,118057,,"25,046 x DRG weight",118057,Other,base rate x DRG weight,106249,,"22,541 x DRG weight",106249,Other,base rate x DRG weight,148587,,"31,523 x DRG weight",148587,Other,base rate x DRG weight,133730,,"28,371 x DRG weight",133730,Other,base rate x DRG weight,126301,,"26,795 x DRG weight",126301,Other,base rate x DRG weight,40900.2,,"3,970.89 x patient days",40900.2,Per diem,,105882,,"22,463 x DRG weight",105882,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,124562,,"26,426 x DRG weight",124562,Other,base rate x DRG weight,182930,,"38,809 x DRG weight",182930,Other,base rate x DRG weight,182930,,"38,809 x DRG weight",182930,Other,base rate x DRG weight,124562,,"26,426 x DRG weight",124562,Other,base rate x DRG weight,182930,,"38,809 x DRG weight",182930,Other,base rate x DRG weight,65539,,"6,363 x patient days",65539,Per diem,,407590,70,,407590,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,118109,,"25,057 x DRG weight",118109,Other,base rate x DRG weight,106301,,"22,552 x DRG weight",106301,Other,base rate x DRG weight,118109,,"25,057 x DRG weight",118109,Other,base rate x DRG weight,100390,,"21,298 x DRG weight",100390,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,407590,
MAJOR CHEST PROCEDURES WITH CC,164,MS-DRG,,,,,,,,inpatient,,,292149.29,27901,,,27901,Other,150% of Medicare + 9.63% HCRA Surcharge,16967,,"3,609.90 x patient days",16967,Per diem,,63877,,"25,046 x DRG weight",63877,Other,base rate x DRG weight,57489,,"22,541 x DRG weight",57489,Other,base rate x DRG weight,80396,,"31,523 x DRG weight",80396,Other,base rate x DRG weight,72357,,"28,371 x DRG weight",72357,Other,base rate x DRG weight,68338,,"26,795 x DRG weight",68338,Other,base rate x DRG weight,18663.7,,"3,970.89 x patient days",18663.7,Per diem,,57290,,"22,463 x DRG weight",57290,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,67397,,"26,426 x DRG weight",67397,Other,base rate x DRG weight,98978,,"38,809 x DRG weight",98978,Other,base rate x DRG weight,98978,,"38,809 x DRG weight",98978,Other,base rate x DRG weight,67397,,"26,426 x DRG weight",67397,Other,base rate x DRG weight,98978,,"38,809 x DRG weight",98978,Other,base rate x DRG weight,29906,,"6,363 x patient days",29906,Per diem,,204505,70,,204505,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,63905,,"25,057 x DRG weight",63905,Other,base rate x DRG weight,57517,,"22,552 x DRG weight",57517,Other,base rate x DRG weight,63905,,"25,057 x DRG weight",63905,Other,base rate x DRG weight,54318,,"21,298 x DRG weight",54318,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,204505,
MAJOR CHEST PROCEDURES WITHOUT CC/MCC,165,MS-DRG,,,,,,,,inpatient,,,176343.39,16028,,,16028,Other,150% of Medicare + 9.63% HCRA Surcharge,9747,,"3,609.90 x patient days",9747,Per diem,,46996,,"25,046 x DRG weight",46996,Other,base rate x DRG weight,42296,,"22,541 x DRG weight",42296,Other,base rate x DRG weight,59150,,"31,523 x DRG weight",59150,Other,base rate x DRG weight,53235,,"28,371 x DRG weight",53235,Other,base rate x DRG weight,50278,,"26,795 x DRG weight",50278,Other,base rate x DRG weight,10721.7,,"3,970.89 x patient days",10721.7,Per diem,,42150,,"22,463 x DRG weight",42150,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,49586,,"26,426 x DRG weight",49586,Other,base rate x DRG weight,72821,,"38,809 x DRG weight",72821,Other,base rate x DRG weight,72821,,"38,809 x DRG weight",72821,Other,base rate x DRG weight,49586,,"26,426 x DRG weight",49586,Other,base rate x DRG weight,72821,,"38,809 x DRG weight",72821,Other,base rate x DRG weight,17180,,"6,363 x patient days",17180,Per diem,,123440,70,,123440,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,47017,,"25,057 x DRG weight",47017,Other,base rate x DRG weight,42317,,"22,552 x DRG weight",42317,Other,base rate x DRG weight,47017,,"25,057 x DRG weight",47017,Other,base rate x DRG weight,39964,,"21,298 x DRG weight",39964,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,123440,
OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH MCC,166,MS-DRG,,,,,,,,inpatient,,,460006.21,70642,,,70642,Other,150% of Medicare + 9.63% HCRA Surcharge,42958,,"3,609.90 x patient days",42958,Per diem,,101632,,"25,046 x DRG weight",101632,Other,base rate x DRG weight,91467,,"22,541 x DRG weight",91467,Other,base rate x DRG weight,127914,,"31,523 x DRG weight",127914,Other,base rate x DRG weight,115124,,"28,371 x DRG weight",115124,Other,base rate x DRG weight,108729,,"26,795 x DRG weight",108729,Other,base rate x DRG weight,47253.8,,"3,970.89 x patient days",47253.8,Per diem,,91150,,"22,463 x DRG weight",91150,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,107231,,"26,426 x DRG weight",107231,Other,base rate x DRG weight,157479,,"38,809 x DRG weight",157479,Other,base rate x DRG weight,157479,,"38,809 x DRG weight",157479,Other,base rate x DRG weight,107231,,"26,426 x DRG weight",107231,Other,base rate x DRG weight,157479,,"38,809 x DRG weight",157479,Other,base rate x DRG weight,75720,,"6,363 x patient days",75720,Per diem,,322004,70,,322004,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,101676,,"25,057 x DRG weight",101676,Other,base rate x DRG weight,91512,,"22,552 x DRG weight",91512,Other,base rate x DRG weight,101676,,"25,057 x DRG weight",101676,Other,base rate x DRG weight,86423,,"21,298 x DRG weight",86423,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,322004,
OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH CC,167,MS-DRG,,,,,,,,inpatient,,,225094.23,28495,,,28495,Other,150% of Medicare + 9.63% HCRA Surcharge,17328,,"3,609.90 x patient days",17328,Per diem,,45579,,"25,046 x DRG weight",45579,Other,base rate x DRG weight,41020,,"22,541 x DRG weight",41020,Other,base rate x DRG weight,57366,,"31,523 x DRG weight",57366,Other,base rate x DRG weight,51630,,"28,371 x DRG weight",51630,Other,base rate x DRG weight,48762,,"26,795 x DRG weight",48762,Other,base rate x DRG weight,19060.8,,"3,970.89 x patient days",19060.8,Per diem,,40878,,"22,463 x DRG weight",40878,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,48090,,"26,426 x DRG weight",48090,Other,base rate x DRG weight,70625,,"38,809 x DRG weight",70625,Other,base rate x DRG weight,70625,,"38,809 x DRG weight",70625,Other,base rate x DRG weight,48090,,"26,426 x DRG weight",48090,Other,base rate x DRG weight,70625,,"38,809 x DRG weight",70625,Other,base rate x DRG weight,30542,,"6,363 x patient days",30542,Per diem,,157566,70,,157566,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,45599,,"25,057 x DRG weight",45599,Other,base rate x DRG weight,41040,,"22,552 x DRG weight",41040,Other,base rate x DRG weight,45599,,"25,057 x DRG weight",45599,Other,base rate x DRG weight,38758,,"21,298 x DRG weight",38758,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,157566,
OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITHOUT CC/MCC,168,MS-DRG,,,,,,,,inpatient,,,182152.28,13654,,,13654,Other,150% of Medicare + 9.63% HCRA Surcharge,8303,,"3,609.90 x patient days",8303,Per diem,,33955,,"25,046 x DRG weight",33955,Other,base rate x DRG weight,30559,,"22,541 x DRG weight",30559,Other,base rate x DRG weight,42736,,"31,523 x DRG weight",42736,Other,base rate x DRG weight,38463,,"28,371 x DRG weight",38463,Other,base rate x DRG weight,36326,,"26,795 x DRG weight",36326,Other,base rate x DRG weight,9133.3,,"3,970.89 x patient days",9133.3,Per diem,,30453,,"22,463 x DRG weight",30453,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,35826,,"26,426 x DRG weight",35826,Other,base rate x DRG weight,52613,,"38,809 x DRG weight",52613,Other,base rate x DRG weight,52613,,"38,809 x DRG weight",52613,Other,base rate x DRG weight,35826,,"26,426 x DRG weight",35826,Other,base rate x DRG weight,52613,,"38,809 x DRG weight",52613,Other,base rate x DRG weight,14635,,"6,363 x patient days",14635,Per diem,,127507,70,,127507,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,33970,,"25,057 x DRG weight",33970,Other,base rate x DRG weight,30574,,"22,552 x DRG weight",30574,Other,base rate x DRG weight,33970,,"25,057 x DRG weight",33970,Other,base rate x DRG weight,28874,,"21,298 x DRG weight",28874,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,127507,
ULTRASOUND ACCELERATED AND OTHER THROMBOLYSIS WITH PRINCIPAL DIAGNOSIS PULMONARY EMBOLISM,173,MS-DRG,,,,,,,,inpatient,,,244798.28,28495,,,28495,Other,150% of Medicare + 9.63% HCRA Surcharge,17328,,"3,609.90 x patient days",17328,Per diem,,77016,,"25,046 x DRG weight",77016,Other,base rate x DRG weight,69314,,"22,541 x DRG weight",69314,Other,base rate x DRG weight,96933,,"31,523 x DRG weight",96933,Other,base rate x DRG weight,87241,,"28,371 x DRG weight",87241,Other,base rate x DRG weight,82395,,"26,795 x DRG weight",82395,Other,base rate x DRG weight,19060.8,,"3,970.89 x patient days",19060.8,Per diem,,69074,,"22,463 x DRG weight",69074,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,81260,,"26,426 x DRG weight",81260,Other,base rate x DRG weight,119338,,"38,809 x DRG weight",119338,Other,base rate x DRG weight,119338,,"38,809 x DRG weight",119338,Other,base rate x DRG weight,81260,,"26,426 x DRG weight",81260,Other,base rate x DRG weight,119338,,"38,809 x DRG weight",119338,Other,base rate x DRG weight,30542,,"6,363 x patient days",30542,Per diem,,171359,70,,171359,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,77050,,"25,057 x DRG weight",77050,Other,base rate x DRG weight,69347,,"22,552 x DRG weight",69347,Other,base rate x DRG weight,77050,,"25,057 x DRG weight",77050,Other,base rate x DRG weight,65491,,"21,298 x DRG weight",65491,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,171359,
PULMONARY EMBOLISM WITH MCC OR ACUTE COR PULMONALE,175,MS-DRG,,,,,,,,inpatient,,,216094.4,30868,,,30868,Other,150% of Medicare + 9.63% HCRA Surcharge,18771,,"3,609.90 x patient days",18771,Per diem,,35140,,"25,046 x DRG weight",35140,Other,base rate x DRG weight,31625,,"22,541 x DRG weight",31625,Other,base rate x DRG weight,44227,,"31,523 x DRG weight",44227,Other,base rate x DRG weight,39805,,"28,371 x DRG weight",39805,Other,base rate x DRG weight,37593,,"26,795 x DRG weight",37593,Other,base rate x DRG weight,20648.1,,"3,970.89 x patient days",20648.1,Per diem,,31516,,"22,463 x DRG weight",31516,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,37076,,"26,426 x DRG weight",37076,Other,base rate x DRG weight,54449,,"38,809 x DRG weight",54449,Other,base rate x DRG weight,54449,,"38,809 x DRG weight",54449,Other,base rate x DRG weight,37076,,"26,426 x DRG weight",37076,Other,base rate x DRG weight,54449,,"38,809 x DRG weight",54449,Other,base rate x DRG weight,33088,,"6,363 x patient days",33088,Per diem,,151266,70,,151266,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,35155,,"25,057 x DRG weight",35155,Other,base rate x DRG weight,31640,,"22,552 x DRG weight",31640,Other,base rate x DRG weight,35155,,"25,057 x DRG weight",35155,Other,base rate x DRG weight,29881,,"21,298 x DRG weight",29881,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,151266,
PULMONARY EMBOLISM WITHOUT MCC,176,MS-DRG,,,,,,,,inpatient,,,136811.29,18403,,,18403,Other,150% of Medicare + 9.63% HCRA Surcharge,11191,,"3,609.90 x patient days",11191,Per diem,,20428,,"25,046 x DRG weight",20428,Other,base rate x DRG weight,18384,,"22,541 x DRG weight",18384,Other,base rate x DRG weight,25710,,"31,523 x DRG weight",25710,Other,base rate x DRG weight,23139,,"28,371 x DRG weight",23139,Other,base rate x DRG weight,21854,,"26,795 x DRG weight",21854,Other,base rate x DRG weight,12310.1,,"3,970.89 x patient days",12310.1,Per diem,,18321,,"22,463 x DRG weight",18321,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,21553,,"26,426 x DRG weight",21553,Other,base rate x DRG weight,31653,,"38,809 x DRG weight",31653,Other,base rate x DRG weight,31653,,"38,809 x DRG weight",31653,Other,base rate x DRG weight,21553,,"26,426 x DRG weight",21553,Other,base rate x DRG weight,31653,,"38,809 x DRG weight",31653,Other,base rate x DRG weight,19725,,"6,363 x patient days",19725,Per diem,,95768,70,,95768,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,20436,,"25,057 x DRG weight",20436,Other,base rate x DRG weight,18393,,"22,552 x DRG weight",18393,Other,base rate x DRG weight,20436,,"25,057 x DRG weight",20436,Other,base rate x DRG weight,17371,,"21,298 x DRG weight",17371,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,95768,
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH MCC,177,MS-DRG,,,,,,,,inpatient,,,205105.76,40366,,,40366,Other,150% of Medicare + 9.63% HCRA Surcharge,24547,,"3,609.90 x patient days",24547,Per diem,,42488,,"25,046 x DRG weight",42488,Other,base rate x DRG weight,38239,,"22,541 x DRG weight",38239,Other,base rate x DRG weight,53476,,"31,523 x DRG weight",53476,Other,base rate x DRG weight,48129,,"28,371 x DRG weight",48129,Other,base rate x DRG weight,45455,,"26,795 x DRG weight",45455,Other,base rate x DRG weight,27001.7,,"3,970.89 x patient days",27001.7,Per diem,,38106,,"22,463 x DRG weight",38106,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,44829,,"26,426 x DRG weight",44829,Other,base rate x DRG weight,65836,,"38,809 x DRG weight",65836,Other,base rate x DRG weight,65836,,"38,809 x DRG weight",65836,Other,base rate x DRG weight,44829,,"26,426 x DRG weight",44829,Other,base rate x DRG weight,65836,,"38,809 x DRG weight",65836,Other,base rate x DRG weight,43268,,"6,363 x patient days",43268,Per diem,,143574,70,,143574,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,42507,,"25,057 x DRG weight",42507,Other,base rate x DRG weight,38257,,"22,552 x DRG weight",38257,Other,base rate x DRG weight,42507,,"25,057 x DRG weight",42507,Other,base rate x DRG weight,36130,,"21,298 x DRG weight",36130,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,143574,
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH CC,178,MS-DRG,,,,,,,,inpatient,,,118142.66,25527,,,25527,Other,150% of Medicare + 9.63% HCRA Surcharge,15523,,"3,609.90 x patient days",15523,Per diem,,24713,,"25,046 x DRG weight",24713,Other,base rate x DRG weight,22241,,"22,541 x DRG weight",22241,Other,base rate x DRG weight,31104,,"31,523 x DRG weight",31104,Other,base rate x DRG weight,27994,,"28,371 x DRG weight",27994,Other,base rate x DRG weight,26439,,"26,795 x DRG weight",26439,Other,base rate x DRG weight,17075.3,,"3,970.89 x patient days",17075.3,Per diem,,22164,,"22,463 x DRG weight",22164,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,26075,,"26,426 x DRG weight",26075,Other,base rate x DRG weight,38293,,"38,809 x DRG weight",38293,Other,base rate x DRG weight,38293,,"38,809 x DRG weight",38293,Other,base rate x DRG weight,26075,,"26,426 x DRG weight",26075,Other,base rate x DRG weight,38293,,"38,809 x DRG weight",38293,Other,base rate x DRG weight,27361,,"6,363 x patient days",27361,Per diem,,82700,70,,82700,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,24724,,"25,057 x DRG weight",24724,Other,base rate x DRG weight,22252,,"22,552 x DRG weight",22252,Other,base rate x DRG weight,24724,,"25,057 x DRG weight",24724,Other,base rate x DRG weight,21015,,"21,298 x DRG weight",21015,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,82700,
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITHOUT CC/MCC,179,MS-DRG,,,,,,,,inpatient,,,78523.2,19590,,,19590,Other,150% of Medicare + 9.63% HCRA Surcharge,11913,,"3,609.90 x patient days",11913,Per diem,,19118,,"25,046 x DRG weight",19118,Other,base rate x DRG weight,17206,,"22,541 x DRG weight",17206,Other,base rate x DRG weight,24062,,"31,523 x DRG weight",24062,Other,base rate x DRG weight,21656,,"28,371 x DRG weight",21656,Other,base rate x DRG weight,20453,,"26,795 x DRG weight",20453,Other,base rate x DRG weight,13104.3,,"3,970.89 x patient days",13104.3,Per diem,,17146,,"22,463 x DRG weight",17146,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,20171,,"26,426 x DRG weight",20171,Other,base rate x DRG weight,29623,,"38,809 x DRG weight",29623,Other,base rate x DRG weight,29623,,"38,809 x DRG weight",29623,Other,base rate x DRG weight,20171,,"26,426 x DRG weight",20171,Other,base rate x DRG weight,29623,,"38,809 x DRG weight",29623,Other,base rate x DRG weight,20998,,"6,363 x patient days",20998,Per diem,,54966,70,,54966,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,19126,,"25,057 x DRG weight",19126,Other,base rate x DRG weight,17214,,"22,552 x DRG weight",17214,Other,base rate x DRG weight,19126,,"25,057 x DRG weight",19126,Other,base rate x DRG weight,16257,,"21,298 x DRG weight",16257,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,54966,
RESPIRATORY NEOPLASMS WITH MCC,180,MS-DRG,,,,,,,,inpatient,,,278728.13,39179,,,39179,Other,150% of Medicare + 9.63% HCRA Surcharge,23825,,"3,609.90 x patient days",23825,Per diem,,43535,,"25,046 x DRG weight",43535,Other,base rate x DRG weight,39181,,"22,541 x DRG weight",39181,Other,base rate x DRG weight,54793,,"31,523 x DRG weight",54793,Other,base rate x DRG weight,49314,,"28,371 x DRG weight",49314,Other,base rate x DRG weight,46575,,"26,795 x DRG weight",46575,Other,base rate x DRG weight,26207.5,,"3,970.89 x patient days",26207.5,Per diem,,39045,,"22,463 x DRG weight",39045,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,45934,,"26,426 x DRG weight",45934,Other,base rate x DRG weight,67458,,"38,809 x DRG weight",67458,Other,base rate x DRG weight,67458,,"38,809 x DRG weight",67458,Other,base rate x DRG weight,45934,,"26,426 x DRG weight",45934,Other,base rate x DRG weight,67458,,"38,809 x DRG weight",67458,Other,base rate x DRG weight,41996,,"6,363 x patient days",41996,Per diem,,195110,70,,195110,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,43554,,"25,057 x DRG weight",43554,Other,base rate x DRG weight,39200,,"22,552 x DRG weight",39200,Other,base rate x DRG weight,43554,,"25,057 x DRG weight",43554,Other,base rate x DRG weight,37020,,"21,298 x DRG weight",37020,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,195110,
RESPIRATORY NEOPLASMS WITH CC,181,MS-DRG,,,,,,,,inpatient,,,176490.82,24933,,,24933,Other,150% of Medicare + 9.63% HCRA Surcharge,15162,,"3,609.90 x patient days",15162,Per diem,,27578,,"25,046 x DRG weight",27578,Other,base rate x DRG weight,24820,,"22,541 x DRG weight",24820,Other,base rate x DRG weight,34710,,"31,523 x DRG weight",34710,Other,base rate x DRG weight,31239,,"28,371 x DRG weight",31239,Other,base rate x DRG weight,29504,,"26,795 x DRG weight",29504,Other,base rate x DRG weight,16678.2,,"3,970.89 x patient days",16678.2,Per diem,,24734,,"22,463 x DRG weight",24734,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,29098,,"26,426 x DRG weight",29098,Other,base rate x DRG weight,42733,,"38,809 x DRG weight",42733,Other,base rate x DRG weight,42733,,"38,809 x DRG weight",42733,Other,base rate x DRG weight,29098,,"26,426 x DRG weight",29098,Other,base rate x DRG weight,42733,,"38,809 x DRG weight",42733,Other,base rate x DRG weight,26725,,"6,363 x patient days",26725,Per diem,,123544,70,,123544,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,27590,,"25,057 x DRG weight",27590,Other,base rate x DRG weight,24832,,"22,552 x DRG weight",24832,Other,base rate x DRG weight,27590,,"25,057 x DRG weight",27590,Other,base rate x DRG weight,23451,,"21,298 x DRG weight",23451,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,123544,
RESPIRATORY NEOPLASMS WITHOUT CC/MCC,182,MS-DRG,,,,,,,,inpatient,,,107644.72,16622,,,16622,Other,150% of Medicare + 9.63% HCRA Surcharge,10108,,"3,609.90 x patient days",10108,Per diem,,20007,,"25,046 x DRG weight",20007,Other,base rate x DRG weight,18006,,"22,541 x DRG weight",18006,Other,base rate x DRG weight,25181,,"31,523 x DRG weight",25181,Other,base rate x DRG weight,22663,,"28,371 x DRG weight",22663,Other,base rate x DRG weight,21404,,"26,795 x DRG weight",21404,Other,base rate x DRG weight,11118.8,,"3,970.89 x patient days",11118.8,Per diem,,17943,,"22,463 x DRG weight",17943,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,21109,,"26,426 x DRG weight",21109,Other,base rate x DRG weight,31001,,"38,809 x DRG weight",31001,Other,base rate x DRG weight,31001,,"38,809 x DRG weight",31001,Other,base rate x DRG weight,21109,,"26,426 x DRG weight",21109,Other,base rate x DRG weight,31001,,"38,809 x DRG weight",31001,Other,base rate x DRG weight,17816,,"6,363 x patient days",17816,Per diem,,75351,70,,75351,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,20016,,"25,057 x DRG weight",20016,Other,base rate x DRG weight,18015,,"22,552 x DRG weight",18015,Other,base rate x DRG weight,20016,,"25,057 x DRG weight",20016,Other,base rate x DRG weight,17013,,"21,298 x DRG weight",17013,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,75351,
MAJOR CHEST TRAUMA WITH MCC,183,MS-DRG,,,,,,,,inpatient,,,189879.65,35617,,,35617,Other,150% of Medicare + 9.63% HCRA Surcharge,21659,,"3,609.90 x patient days",21659,Per diem,,39435,,"25,046 x DRG weight",39435,Other,base rate x DRG weight,35491,,"22,541 x DRG weight",35491,Other,base rate x DRG weight,49633,,"31,523 x DRG weight",49633,Other,base rate x DRG weight,44670,,"28,371 x DRG weight",44670,Other,base rate x DRG weight,42189,,"26,795 x DRG weight",42189,Other,base rate x DRG weight,23824.9,,"3,970.89 x patient days",23824.9,Per diem,,35368,,"22,463 x DRG weight",35368,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,41608,,"26,426 x DRG weight",41608,Other,base rate x DRG weight,61105,,"38,809 x DRG weight",61105,Other,base rate x DRG weight,61105,,"38,809 x DRG weight",61105,Other,base rate x DRG weight,41608,,"26,426 x DRG weight",41608,Other,base rate x DRG weight,61105,,"38,809 x DRG weight",61105,Other,base rate x DRG weight,38178,,"6,363 x patient days",38178,Per diem,,132916,70,,132916,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,39452,,"25,057 x DRG weight",39452,Other,base rate x DRG weight,35508,,"22,552 x DRG weight",35508,Other,base rate x DRG weight,39452,,"25,057 x DRG weight",39452,Other,base rate x DRG weight,33534,,"21,298 x DRG weight",33534,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,132916,
MAJOR CHEST TRAUMA WITH CC,184,MS-DRG,,,,,,,,inpatient,,,167982.92,22559,,,22559,Other,150% of Medicare + 9.63% HCRA Surcharge,13718,,"3,609.90 x patient days",13718,Per diem,,26346,,"25,046 x DRG weight",26346,Other,base rate x DRG weight,23711,,"22,541 x DRG weight",23711,Other,base rate x DRG weight,33159,,"31,523 x DRG weight",33159,Other,base rate x DRG weight,29843,,"28,371 x DRG weight",29843,Other,base rate x DRG weight,28186,,"26,795 x DRG weight",28186,Other,base rate x DRG weight,15089.8,,"3,970.89 x patient days",15089.8,Per diem,,23629,,"22,463 x DRG weight",23629,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,27798,,"26,426 x DRG weight",27798,Other,base rate x DRG weight,40823,,"38,809 x DRG weight",40823,Other,base rate x DRG weight,40823,,"38,809 x DRG weight",40823,Other,base rate x DRG weight,27798,,"26,426 x DRG weight",27798,Other,base rate x DRG weight,40823,,"38,809 x DRG weight",40823,Other,base rate x DRG weight,24179,,"6,363 x patient days",24179,Per diem,,117588,70,,117588,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,26357,,"25,057 x DRG weight",26357,Other,base rate x DRG weight,23722,,"22,552 x DRG weight",23722,Other,base rate x DRG weight,26357,,"25,057 x DRG weight",26357,Other,base rate x DRG weight,22403,,"21,298 x DRG weight",22403,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,117588,
MAJOR CHEST TRAUMA WITHOUT CC/MCC,185,MS-DRG,,,,,,,,inpatient,,,90469.83,15435,,,15435,Other,150% of Medicare + 9.63% HCRA Surcharge,9386,,"3,609.90 x patient days",9386,Per diem,,18927,,"25,046 x DRG weight",18927,Other,base rate x DRG weight,17034,,"22,541 x DRG weight",17034,Other,base rate x DRG weight,23822,,"31,523 x DRG weight",23822,Other,base rate x DRG weight,21440,,"28,371 x DRG weight",21440,Other,base rate x DRG weight,20249,,"26,795 x DRG weight",20249,Other,base rate x DRG weight,10324.6,,"3,970.89 x patient days",10324.6,Per diem,,16975,,"22,463 x DRG weight",16975,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,19970,,"26,426 x DRG weight",19970,Other,base rate x DRG weight,29328,,"38,809 x DRG weight",29328,Other,base rate x DRG weight,29328,,"38,809 x DRG weight",29328,Other,base rate x DRG weight,19970,,"26,426 x DRG weight",19970,Other,base rate x DRG weight,29328,,"38,809 x DRG weight",29328,Other,base rate x DRG weight,16544,,"6,363 x patient days",16544,Per diem,,63329,70,,63329,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,18936,,"25,057 x DRG weight",18936,Other,base rate x DRG weight,17043,,"22,552 x DRG weight",17043,Other,base rate x DRG weight,18936,,"25,057 x DRG weight",18936,Other,base rate x DRG weight,16095,,"21,298 x DRG weight",16095,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,63329,
PLEURAL EFFUSION WITH MCC,186,MS-DRG,,,,,,,,inpatient,,,180027.88,35023,,,35023,Other,150% of Medicare + 9.63% HCRA Surcharge,21298,,"3,609.90 x patient days",21298,Per diem,,38874,,"25,046 x DRG weight",38874,Other,base rate x DRG weight,34986,,"22,541 x DRG weight",34986,Other,base rate x DRG weight,48927,,"31,523 x DRG weight",48927,Other,base rate x DRG weight,44035,,"28,371 x DRG weight",44035,Other,base rate x DRG weight,41589,,"26,795 x DRG weight",41589,Other,base rate x DRG weight,23427.8,,"3,970.89 x patient days",23427.8,Per diem,,34865,,"22,463 x DRG weight",34865,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,41016,,"26,426 x DRG weight",41016,Other,base rate x DRG weight,60235,,"38,809 x DRG weight",60235,Other,base rate x DRG weight,60235,,"38,809 x DRG weight",60235,Other,base rate x DRG weight,41016,,"26,426 x DRG weight",41016,Other,base rate x DRG weight,60235,,"38,809 x DRG weight",60235,Other,base rate x DRG weight,37542,,"6,363 x patient days",37542,Per diem,,126020,70,,126020,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,38891,,"25,057 x DRG weight",38891,Other,base rate x DRG weight,35003,,"22,552 x DRG weight",35003,Other,base rate x DRG weight,38891,,"25,057 x DRG weight",38891,Other,base rate x DRG weight,33057,,"21,298 x DRG weight",33057,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,126020,
PLEURAL EFFUSION WITH CC,187,MS-DRG,,,,,,,,inpatient,,,131722.63,23152,,,23152,Other,150% of Medicare + 9.63% HCRA Surcharge,14079,,"3,609.90 x patient days",14079,Per diem,,24953,,"25,046 x DRG weight",24953,Other,base rate x DRG weight,22458,,"22,541 x DRG weight",22458,Other,base rate x DRG weight,31406,,"31,523 x DRG weight",31406,Other,base rate x DRG weight,28266,,"28,371 x DRG weight",28266,Other,base rate x DRG weight,26696,,"26,795 x DRG weight",26696,Other,base rate x DRG weight,15486.9,,"3,970.89 x patient days",15486.9,Per diem,,22380,,"22,463 x DRG weight",22380,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,26328,,"26,426 x DRG weight",26328,Other,base rate x DRG weight,38665,,"38,809 x DRG weight",38665,Other,base rate x DRG weight,38665,,"38,809 x DRG weight",38665,Other,base rate x DRG weight,26328,,"26,426 x DRG weight",26328,Other,base rate x DRG weight,38665,,"38,809 x DRG weight",38665,Other,base rate x DRG weight,24816,,"6,363 x patient days",24816,Per diem,,92206,70,,92206,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,24964,,"25,057 x DRG weight",24964,Other,base rate x DRG weight,22469,,"22,552 x DRG weight",22469,Other,base rate x DRG weight,24964,,"25,057 x DRG weight",24964,Other,base rate x DRG weight,21219,,"21,298 x DRG weight",21219,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,92206,
PLEURAL EFFUSION WITHOUT CC/MCC,188,MS-DRG,,,,,,,,inpatient,,,94434,17216,,,17216,Other,150% of Medicare + 9.63% HCRA Surcharge,10469,,"3,609.90 x patient days",10469,Per diem,,18697,,"25,046 x DRG weight",18697,Other,base rate x DRG weight,16827,,"22,541 x DRG weight",16827,Other,base rate x DRG weight,23532,,"31,523 x DRG weight",23532,Other,base rate x DRG weight,21179,,"28,371 x DRG weight",21179,Other,base rate x DRG weight,20002,,"26,795 x DRG weight",20002,Other,base rate x DRG weight,11515.9,,"3,970.89 x patient days",11515.9,Per diem,,16769,,"22,463 x DRG weight",16769,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,19727,,"26,426 x DRG weight",19727,Other,base rate x DRG weight,28971,,"38,809 x DRG weight",28971,Other,base rate x DRG weight,28971,,"38,809 x DRG weight",28971,Other,base rate x DRG weight,19727,,"26,426 x DRG weight",19727,Other,base rate x DRG weight,28971,,"38,809 x DRG weight",28971,Other,base rate x DRG weight,18453,,"6,363 x patient days",18453,Per diem,,66104,70,,66104,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,18705,,"25,057 x DRG weight",18705,Other,base rate x DRG weight,16835,,"22,552 x DRG weight",16835,Other,base rate x DRG weight,18705,,"25,057 x DRG weight",18705,Other,base rate x DRG weight,15899,,"21,298 x DRG weight",15899,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,66104,
PULMONARY EDEMA AND RESPIRATORY FAILURE,189,MS-DRG,,,,,,,,inpatient,,,131495.35,29089,,,29089,Other,150% of Medicare + 9.63% HCRA Surcharge,17689,,"3,609.90 x patient days",17689,Per diem,,30857,,"25,046 x DRG weight",30857,Other,base rate x DRG weight,27771,,"22,541 x DRG weight",27771,Other,base rate x DRG weight,38836,,"31,523 x DRG weight",38836,Other,base rate x DRG weight,34953,,"28,371 x DRG weight",34953,Other,base rate x DRG weight,33011,,"26,795 x DRG weight",33011,Other,base rate x DRG weight,19457.9,,"3,970.89 x patient days",19457.9,Per diem,,27674,,"22,463 x DRG weight",27674,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,32557,,"26,426 x DRG weight",32557,Other,base rate x DRG weight,47813,,"38,809 x DRG weight",47813,Other,base rate x DRG weight,47813,,"38,809 x DRG weight",47813,Other,base rate x DRG weight,32557,,"26,426 x DRG weight",32557,Other,base rate x DRG weight,47813,,"38,809 x DRG weight",47813,Other,base rate x DRG weight,31179,,"6,363 x patient days",31179,Per diem,,92047,70,,92047,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,30870,,"25,057 x DRG weight",30870,Other,base rate x DRG weight,27784,,"22,552 x DRG weight",27784,Other,base rate x DRG weight,30870,,"25,057 x DRG weight",30870,Other,base rate x DRG weight,26239,,"21,298 x DRG weight",26239,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,92047,
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH MCC,190,MS-DRG,,,,,,,,inpatient,,,141350.82,26120,,,26120,Other,150% of Medicare + 9.63% HCRA Surcharge,15884,,"3,609.90 x patient days",15884,Per diem,,27601,,"25,046 x DRG weight",27601,Other,base rate x DRG weight,24840,,"22,541 x DRG weight",24840,Other,base rate x DRG weight,34738,,"31,523 x DRG weight",34738,Other,base rate x DRG weight,31265,,"28,371 x DRG weight",31265,Other,base rate x DRG weight,29528,,"26,795 x DRG weight",29528,Other,base rate x DRG weight,17472.4,,"3,970.89 x patient days",17472.4,Per diem,,24754,,"22,463 x DRG weight",24754,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,29121,,"26,426 x DRG weight",29121,Other,base rate x DRG weight,42768,,"38,809 x DRG weight",42768,Other,base rate x DRG weight,42768,,"38,809 x DRG weight",42768,Other,base rate x DRG weight,29121,,"26,426 x DRG weight",29121,Other,base rate x DRG weight,42768,,"38,809 x DRG weight",42768,Other,base rate x DRG weight,27997,,"6,363 x patient days",27997,Per diem,,98946,70,,98946,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,27613,,"25,057 x DRG weight",27613,Other,base rate x DRG weight,24852,,"22,552 x DRG weight",24852,Other,base rate x DRG weight,27613,,"25,057 x DRG weight",27613,Other,base rate x DRG weight,23470,,"21,298 x DRG weight",23470,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,98946,
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH CC,191,MS-DRG,,,,,,,,inpatient,,,114478.28,20184,,,20184,Other,150% of Medicare + 9.63% HCRA Surcharge,12274,,"3,609.90 x patient days",12274,Per diem,,21264,,"25,046 x DRG weight",21264,Other,base rate x DRG weight,19137,,"22,541 x DRG weight",19137,Other,base rate x DRG weight,26763,,"31,523 x DRG weight",26763,Other,base rate x DRG weight,24087,,"28,371 x DRG weight",24087,Other,base rate x DRG weight,22749,,"26,795 x DRG weight",22749,Other,base rate x DRG weight,13501.4,,"3,970.89 x patient days",13501.4,Per diem,,19071,,"22,463 x DRG weight",19071,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,22436,,"26,426 x DRG weight",22436,Other,base rate x DRG weight,32949,,"38,809 x DRG weight",32949,Other,base rate x DRG weight,32949,,"38,809 x DRG weight",32949,Other,base rate x DRG weight,22436,,"26,426 x DRG weight",22436,Other,base rate x DRG weight,32949,,"38,809 x DRG weight",32949,Other,base rate x DRG weight,21634,,"6,363 x patient days",21634,Per diem,,80135,70,,80135,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,21273,,"25,057 x DRG weight",21273,Other,base rate x DRG weight,19147,,"22,552 x DRG weight",19147,Other,base rate x DRG weight,21273,,"25,057 x DRG weight",21273,Other,base rate x DRG weight,18082,,"21,298 x DRG weight",18082,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,80135,
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITHOUT CC/MCC,192,MS-DRG,,,,,,,,inpatient,,,68831.45,16028,,,16028,Other,150% of Medicare + 9.63% HCRA Surcharge,9747,,"3,609.90 x patient days",9747,Per diem,,16075,,"25,046 x DRG weight",16075,Other,base rate x DRG weight,14467,,"22,541 x DRG weight",14467,Other,base rate x DRG weight,20231,,"31,523 x DRG weight",20231,Other,base rate x DRG weight,18209,,"28,371 x DRG weight",18209,Other,base rate x DRG weight,17197,,"26,795 x DRG weight",17197,Other,base rate x DRG weight,10721.7,,"3,970.89 x patient days",10721.7,Per diem,,14417,,"22,463 x DRG weight",14417,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,16960,,"26,426 x DRG weight",16960,Other,base rate x DRG weight,24908,,"38,809 x DRG weight",24908,Other,base rate x DRG weight,24908,,"38,809 x DRG weight",24908,Other,base rate x DRG weight,16960,,"26,426 x DRG weight",16960,Other,base rate x DRG weight,24908,,"38,809 x DRG weight",24908,Other,base rate x DRG weight,17180,,"6,363 x patient days",17180,Per diem,,48182,70,,48182,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,16082,,"25,057 x DRG weight",16082,Other,base rate x DRG weight,14474,,"22,552 x DRG weight",14474,Other,base rate x DRG weight,16082,,"25,057 x DRG weight",16082,Other,base rate x DRG weight,13669,,"21,298 x DRG weight",13669,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,48182,
SIMPLE PNEUMONIA AND PLEURISY WITH MCC,193,MS-DRG,,,,,,,,inpatient,,,159275.83,30868,,,30868,Other,150% of Medicare + 9.63% HCRA Surcharge,18771,,"3,609.90 x patient days",18771,Per diem,,33226,,"25,046 x DRG weight",33226,Other,base rate x DRG weight,29903,,"22,541 x DRG weight",29903,Other,base rate x DRG weight,41818,,"31,523 x DRG weight",41818,Other,base rate x DRG weight,37637,,"28,371 x DRG weight",37637,Other,base rate x DRG weight,35546,,"26,795 x DRG weight",35546,Other,base rate x DRG weight,20648.1,,"3,970.89 x patient days",20648.1,Per diem,,29799,,"22,463 x DRG weight",29799,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,35057,,"26,426 x DRG weight",35057,Other,base rate x DRG weight,51484,,"38,809 x DRG weight",51484,Other,base rate x DRG weight,51484,,"38,809 x DRG weight",51484,Other,base rate x DRG weight,35057,,"26,426 x DRG weight",35057,Other,base rate x DRG weight,51484,,"38,809 x DRG weight",51484,Other,base rate x DRG weight,33088,,"6,363 x patient days",33088,Per diem,,111493,70,,111493,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,33241,,"25,057 x DRG weight",33241,Other,base rate x DRG weight,29917,,"22,552 x DRG weight",29917,Other,base rate x DRG weight,33241,,"25,057 x DRG weight",33241,Other,base rate x DRG weight,28254,,"21,298 x DRG weight",28254,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,111493,
SIMPLE PNEUMONIA AND PLEURISY WITH CC,194,MS-DRG,,,,,,,,inpatient,,,98405.59,21371,,,21371,Other,150% of Medicare + 9.63% HCRA Surcharge,12996,,"3,609.90 x patient days",12996,Per diem,,20593,,"25,046 x DRG weight",20593,Other,base rate x DRG weight,18533,,"22,541 x DRG weight",18533,Other,base rate x DRG weight,25918,,"31,523 x DRG weight",25918,Other,base rate x DRG weight,23327,,"28,371 x DRG weight",23327,Other,base rate x DRG weight,22031,,"26,795 x DRG weight",22031,Other,base rate x DRG weight,14295.6,,"3,970.89 x patient days",14295.6,Per diem,,18469,,"22,463 x DRG weight",18469,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,21727,,"26,426 x DRG weight",21727,Other,base rate x DRG weight,31909,,"38,809 x DRG weight",31909,Other,base rate x DRG weight,31909,,"38,809 x DRG weight",31909,Other,base rate x DRG weight,21727,,"26,426 x DRG weight",21727,Other,base rate x DRG weight,31909,,"38,809 x DRG weight",31909,Other,base rate x DRG weight,22907,,"6,363 x patient days",22907,Per diem,,68884,70,,68884,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,20602,,"25,057 x DRG weight",20602,Other,base rate x DRG weight,18542,,"22,552 x DRG weight",18542,Other,base rate x DRG weight,20602,,"25,057 x DRG weight",20602,Other,base rate x DRG weight,17511,,"21,298 x DRG weight",17511,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,68884,
SIMPLE PNEUMONIA AND PLEURISY WITHOUT CC/MCC,195,MS-DRG,,,,,,,,inpatient,,,64782.22,16622,,,16622,Other,150% of Medicare + 9.63% HCRA Surcharge,10108,,"3,609.90 x patient days",10108,Per diem,,15669,,"25,046 x DRG weight",15669,Other,base rate x DRG weight,14102,,"22,541 x DRG weight",14102,Other,base rate x DRG weight,19721,,"31,523 x DRG weight",19721,Other,base rate x DRG weight,17749,,"28,371 x DRG weight",17749,Other,base rate x DRG weight,16763,,"26,795 x DRG weight",16763,Other,base rate x DRG weight,11118.8,,"3,970.89 x patient days",11118.8,Per diem,,14053,,"22,463 x DRG weight",14053,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,16532,,"26,426 x DRG weight",16532,Other,base rate x DRG weight,24279,,"38,809 x DRG weight",24279,Other,base rate x DRG weight,24279,,"38,809 x DRG weight",24279,Other,base rate x DRG weight,16532,,"26,426 x DRG weight",16532,Other,base rate x DRG weight,24279,,"38,809 x DRG weight",24279,Other,base rate x DRG weight,17816,,"6,363 x patient days",17816,Per diem,,45348,70,,45348,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,15676,,"25,057 x DRG weight",15676,Other,base rate x DRG weight,14109,,"22,552 x DRG weight",14109,Other,base rate x DRG weight,15676,,"25,057 x DRG weight",15676,Other,base rate x DRG weight,13324,,"21,298 x DRG weight",13324,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,45348,
INTERSTITIAL LUNG DISEASE WITH MCC,196,MS-DRG,,,,,,,,inpatient,,,196429.88,41554,,,41554,Other,150% of Medicare + 9.63% HCRA Surcharge,25269,,"3,609.90 x patient days",25269,Per diem,,47472,,"25,046 x DRG weight",47472,Other,base rate x DRG weight,42724,,"22,541 x DRG weight",42724,Other,base rate x DRG weight,59749,,"31,523 x DRG weight",59749,Other,base rate x DRG weight,53774,,"28,371 x DRG weight",53774,Other,base rate x DRG weight,50787,,"26,795 x DRG weight",50787,Other,base rate x DRG weight,27795.9,,"3,970.89 x patient days",27795.9,Per diem,,42576,,"22,463 x DRG weight",42576,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,50088,,"26,426 x DRG weight",50088,Other,base rate x DRG weight,73559,,"38,809 x DRG weight",73559,Other,base rate x DRG weight,73559,,"38,809 x DRG weight",73559,Other,base rate x DRG weight,50088,,"26,426 x DRG weight",50088,Other,base rate x DRG weight,73559,,"38,809 x DRG weight",73559,Other,base rate x DRG weight,44541,,"6,363 x patient days",44541,Per diem,,137501,70,,137501,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,47493,,"25,057 x DRG weight",47493,Other,base rate x DRG weight,42745,,"22,552 x DRG weight",42745,Other,base rate x DRG weight,47493,,"25,057 x DRG weight",47493,Other,base rate x DRG weight,40368,,"21,298 x DRG weight",40368,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,137501,
INTERSTITIAL LUNG DISEASE WITH CC,197,MS-DRG,,,,,,,,inpatient,,,116692.32,23152,,,23152,Other,150% of Medicare + 9.63% HCRA Surcharge,14079,,"3,609.90 x patient days",14079,Per diem,,24983,,"25,046 x DRG weight",24983,Other,base rate x DRG weight,22485,,"22,541 x DRG weight",22485,Other,base rate x DRG weight,31444,,"31,523 x DRG weight",31444,Other,base rate x DRG weight,28300,,"28,371 x DRG weight",28300,Other,base rate x DRG weight,26728,,"26,795 x DRG weight",26728,Other,base rate x DRG weight,15486.9,,"3,970.89 x patient days",15486.9,Per diem,,22407,,"22,463 x DRG weight",22407,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,26360,,"26,426 x DRG weight",26360,Other,base rate x DRG weight,38712,,"38,809 x DRG weight",38712,Other,base rate x DRG weight,38712,,"38,809 x DRG weight",38712,Other,base rate x DRG weight,26360,,"26,426 x DRG weight",26360,Other,base rate x DRG weight,38712,,"38,809 x DRG weight",38712,Other,base rate x DRG weight,24816,,"6,363 x patient days",24816,Per diem,,81685,70,,81685,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,24994,,"25,057 x DRG weight",24994,Other,base rate x DRG weight,22496,,"22,552 x DRG weight",22496,Other,base rate x DRG weight,24994,,"25,057 x DRG weight",24994,Other,base rate x DRG weight,21245,,"21,298 x DRG weight",21245,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,81685,
INTERSTITIAL LUNG DISEASE WITHOUT CC/MCC,198,MS-DRG,,,,,,,,inpatient,,,53318,16622,,,16622,Other,150% of Medicare + 9.63% HCRA Surcharge,10108,,"3,609.90 x patient days",10108,Per diem,,19491,,"25,046 x DRG weight",19491,Other,base rate x DRG weight,17541,,"22,541 x DRG weight",17541,Other,base rate x DRG weight,24531,,"31,523 x DRG weight",24531,Other,base rate x DRG weight,22078,,"28,371 x DRG weight",22078,Other,base rate x DRG weight,20852,,"26,795 x DRG weight",20852,Other,base rate x DRG weight,11118.8,,"3,970.89 x patient days",11118.8,Per diem,,17481,,"22,463 x DRG weight",17481,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,20565,,"26,426 x DRG weight",20565,Other,base rate x DRG weight,30201,,"38,809 x DRG weight",30201,Other,base rate x DRG weight,30201,,"38,809 x DRG weight",30201,Other,base rate x DRG weight,20565,,"26,426 x DRG weight",20565,Other,base rate x DRG weight,30201,,"38,809 x DRG weight",30201,Other,base rate x DRG weight,17816,,"6,363 x patient days",17816,Per diem,,37323,70,,37323,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,19499,,"25,057 x DRG weight",19499,Other,base rate x DRG weight,17550,,"22,552 x DRG weight",17550,Other,base rate x DRG weight,19499,,"25,057 x DRG weight",19499,Other,base rate x DRG weight,16574,,"21,298 x DRG weight",16574,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,37323,
PNEUMOTHORAX WITH MCC,199,MS-DRG,,,,,,,,inpatient,,,183491.29,39773,,,39773,Other,150% of Medicare + 9.63% HCRA Surcharge,24186,,"3,609.90 x patient days",24186,Per diem,,44434,,"25,046 x DRG weight",44434,Other,base rate x DRG weight,39990,,"22,541 x DRG weight",39990,Other,base rate x DRG weight,55925,,"31,523 x DRG weight",55925,Other,base rate x DRG weight,50333,,"28,371 x DRG weight",50333,Other,base rate x DRG weight,47537,,"26,795 x DRG weight",47537,Other,base rate x DRG weight,26604.6,,"3,970.89 x patient days",26604.6,Per diem,,39852,,"22,463 x DRG weight",39852,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,46882,,"26,426 x DRG weight",46882,Other,base rate x DRG weight,68851,,"38,809 x DRG weight",68851,Other,base rate x DRG weight,68851,,"38,809 x DRG weight",68851,Other,base rate x DRG weight,46882,,"26,426 x DRG weight",46882,Other,base rate x DRG weight,68851,,"38,809 x DRG weight",68851,Other,base rate x DRG weight,42632,,"6,363 x patient days",42632,Per diem,,128444,70,,128444,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,44454,,"25,057 x DRG weight",44454,Other,base rate x DRG weight,40010,,"22,552 x DRG weight",40010,Other,base rate x DRG weight,44454,,"25,057 x DRG weight",44454,Other,base rate x DRG weight,37785,,"21,298 x DRG weight",37785,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,128444,
PNEUMOTHORAX WITH CC,200,MS-DRG,,,,,,,,inpatient,,,145711.42,24340,,,24340,Other,150% of Medicare + 9.63% HCRA Surcharge,14801,,"3,609.90 x patient days",14801,Per diem,,26975,,"25,046 x DRG weight",26975,Other,base rate x DRG weight,24277,,"22,541 x DRG weight",24277,Other,base rate x DRG weight,33950,,"31,523 x DRG weight",33950,Other,base rate x DRG weight,30556,,"28,371 x DRG weight",30556,Other,base rate x DRG weight,28858,,"26,795 x DRG weight",28858,Other,base rate x DRG weight,16281.1,,"3,970.89 x patient days",16281.1,Per diem,,24193,,"22,463 x DRG weight",24193,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,28461,,"26,426 x DRG weight",28461,Other,base rate x DRG weight,41797,,"38,809 x DRG weight",41797,Other,base rate x DRG weight,41797,,"38,809 x DRG weight",41797,Other,base rate x DRG weight,28461,,"26,426 x DRG weight",28461,Other,base rate x DRG weight,41797,,"38,809 x DRG weight",41797,Other,base rate x DRG weight,26088,,"6,363 x patient days",26088,Per diem,,101998,70,,101998,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,26986,,"25,057 x DRG weight",26986,Other,base rate x DRG weight,24289,,"22,552 x DRG weight",24289,Other,base rate x DRG weight,26986,,"25,057 x DRG weight",26986,Other,base rate x DRG weight,22938,,"21,298 x DRG weight",22938,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,101998,
PNEUMOTHORAX WITHOUT CC/MCC,201,MS-DRG,,,,,,,,inpatient,,,72268.8,17216,,,17216,Other,150% of Medicare + 9.63% HCRA Surcharge,10469,,"3,609.90 x patient days",10469,Per diem,,17685,,"25,046 x DRG weight",17685,Other,base rate x DRG weight,15916,,"22,541 x DRG weight",15916,Other,base rate x DRG weight,22258,,"31,523 x DRG weight",22258,Other,base rate x DRG weight,20033,,"28,371 x DRG weight",20033,Other,base rate x DRG weight,18920,,"26,795 x DRG weight",18920,Other,base rate x DRG weight,11515.9,,"3,970.89 x patient days",11515.9,Per diem,,15861,,"22,463 x DRG weight",15861,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,18659,,"26,426 x DRG weight",18659,Other,base rate x DRG weight,27403,,"38,809 x DRG weight",27403,Other,base rate x DRG weight,27403,,"38,809 x DRG weight",27403,Other,base rate x DRG weight,18659,,"26,426 x DRG weight",18659,Other,base rate x DRG weight,27403,,"38,809 x DRG weight",27403,Other,base rate x DRG weight,18453,,"6,363 x patient days",18453,Per diem,,50588,70,,50588,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,17693,,"25,057 x DRG weight",17693,Other,base rate x DRG weight,15924,,"22,552 x DRG weight",15924,Other,base rate x DRG weight,17693,,"25,057 x DRG weight",17693,Other,base rate x DRG weight,15039,,"21,298 x DRG weight",15039,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,50588,
BRONCHITIS AND ASTHMA WITH CC/MCC,202,MS-DRG,,,,,,,,inpatient,,,91494.19,21965,,,21965,Other,150% of Medicare + 9.63% HCRA Surcharge,13357,,"3,609.90 x patient days",13357,Per diem,,23982,,"25,046 x DRG weight",23982,Other,base rate x DRG weight,21583,,"22,541 x DRG weight",21583,Other,base rate x DRG weight,30183,,"31,523 x DRG weight",30183,Other,base rate x DRG weight,27165,,"28,371 x DRG weight",27165,Other,base rate x DRG weight,25656,,"26,795 x DRG weight",25656,Other,base rate x DRG weight,14692.7,,"3,970.89 x patient days",14692.7,Per diem,,21508,,"22,463 x DRG weight",21508,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,25303,,"26,426 x DRG weight",25303,Other,base rate x DRG weight,37160,,"38,809 x DRG weight",37160,Other,base rate x DRG weight,37160,,"38,809 x DRG weight",37160,Other,base rate x DRG weight,25303,,"26,426 x DRG weight",25303,Other,base rate x DRG weight,37160,,"38,809 x DRG weight",37160,Other,base rate x DRG weight,23543,,"6,363 x patient days",23543,Per diem,,64046,70,,64046,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,23992,,"25,057 x DRG weight",23992,Other,base rate x DRG weight,21594,,"22,552 x DRG weight",21594,Other,base rate x DRG weight,23992,,"25,057 x DRG weight",23992,Other,base rate x DRG weight,20393,,"21,298 x DRG weight",20393,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,64046,
BRONCHITIS AND ASTHMA WITHOUT CC/MCC,203,MS-DRG,,,,,,,,inpatient,,,58971.87,16028,,,16028,Other,150% of Medicare + 9.63% HCRA Surcharge,9747,,"3,609.90 x patient days",9747,Per diem,,17404,,"25,046 x DRG weight",17404,Other,base rate x DRG weight,15664,,"22,541 x DRG weight",15664,Other,base rate x DRG weight,21905,,"31,523 x DRG weight",21905,Other,base rate x DRG weight,19715,,"28,371 x DRG weight",19715,Other,base rate x DRG weight,18620,,"26,795 x DRG weight",18620,Other,base rate x DRG weight,10721.7,,"3,970.89 x patient days",10721.7,Per diem,,15610,,"22,463 x DRG weight",15610,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,18363,,"26,426 x DRG weight",18363,Other,base rate x DRG weight,26968,,"38,809 x DRG weight",26968,Other,base rate x DRG weight,26968,,"38,809 x DRG weight",26968,Other,base rate x DRG weight,18363,,"26,426 x DRG weight",18363,Other,base rate x DRG weight,26968,,"38,809 x DRG weight",26968,Other,base rate x DRG weight,17180,,"6,363 x patient days",17180,Per diem,,41280,70,,41280,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,17412,,"25,057 x DRG weight",17412,Other,base rate x DRG weight,15671,,"22,552 x DRG weight",15671,Other,base rate x DRG weight,17412,,"25,057 x DRG weight",17412,Other,base rate x DRG weight,14800,,"21,298 x DRG weight",14800,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,41280,
RESPIRATORY SIGNS AND SYMPTOMS,204,MS-DRG,,,,,,,,inpatient,,,144451.95,16622,,,16622,Other,150% of Medicare + 9.63% HCRA Surcharge,10108,,"3,609.90 x patient days",10108,Per diem,,20610,,"25,046 x DRG weight",20610,Other,base rate x DRG weight,18549,,"22,541 x DRG weight",18549,Other,base rate x DRG weight,25940,,"31,523 x DRG weight",25940,Other,base rate x DRG weight,23346,,"28,371 x DRG weight",23346,Other,base rate x DRG weight,22050,,"26,795 x DRG weight",22050,Other,base rate x DRG weight,11118.8,,"3,970.89 x patient days",11118.8,Per diem,,18485,,"22,463 x DRG weight",18485,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,21746,,"26,426 x DRG weight",21746,Other,base rate x DRG weight,31936,,"38,809 x DRG weight",31936,Other,base rate x DRG weight,31936,,"38,809 x DRG weight",31936,Other,base rate x DRG weight,21746,,"26,426 x DRG weight",21746,Other,base rate x DRG weight,31936,,"38,809 x DRG weight",31936,Other,base rate x DRG weight,17816,,"6,363 x patient days",17816,Per diem,,101116,70,,101116,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,20619,,"25,057 x DRG weight",20619,Other,base rate x DRG weight,18558,,"22,552 x DRG weight",18558,Other,base rate x DRG weight,20619,,"25,057 x DRG weight",20619,Other,base rate x DRG weight,17526,,"21,298 x DRG weight",17526,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,101116,
OTHER RESPIRATORY SYSTEM DIAGNOSES WITH MCC,205,MS-DRG,,,,,,,,inpatient,,,195278.34,37992,,,37992,Other,150% of Medicare + 9.63% HCRA Surcharge,23103,,"3,609.90 x patient days",23103,Per diem,,45341,,"25,046 x DRG weight",45341,Other,base rate x DRG weight,40806,,"22,541 x DRG weight",40806,Other,base rate x DRG weight,57066,,"31,523 x DRG weight",57066,Other,base rate x DRG weight,51360,,"28,371 x DRG weight",51360,Other,base rate x DRG weight,48507,,"26,795 x DRG weight",48507,Other,base rate x DRG weight,25413.3,,"3,970.89 x patient days",25413.3,Per diem,,40665,,"22,463 x DRG weight",40665,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,47839,,"26,426 x DRG weight",47839,Other,base rate x DRG weight,70256,,"38,809 x DRG weight",70256,Other,base rate x DRG weight,70256,,"38,809 x DRG weight",70256,Other,base rate x DRG weight,47839,,"26,426 x DRG weight",47839,Other,base rate x DRG weight,70256,,"38,809 x DRG weight",70256,Other,base rate x DRG weight,40723,,"6,363 x patient days",40723,Per diem,,136695,70,,136695,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,45361,,"25,057 x DRG weight",45361,Other,base rate x DRG weight,40826,,"22,552 x DRG weight",40826,Other,base rate x DRG weight,45361,,"25,057 x DRG weight",45361,Other,base rate x DRG weight,38556,,"21,298 x DRG weight",38556,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,136695,
OTHER RESPIRATORY SYSTEM DIAGNOSES WITHOUT MCC,206,MS-DRG,,,,,,,,inpatient,,,107739.98,18997,,,18997,Other,150% of Medicare + 9.63% HCRA Surcharge,11552,,"3,609.90 x patient days",11552,Per diem,,22880,,"25,046 x DRG weight",22880,Other,base rate x DRG weight,20591,,"22,541 x DRG weight",20591,Other,base rate x DRG weight,28796,,"31,523 x DRG weight",28796,Other,base rate x DRG weight,25917,,"28,371 x DRG weight",25917,Other,base rate x DRG weight,24477,,"26,795 x DRG weight",24477,Other,base rate x DRG weight,12707.2,,"3,970.89 x patient days",12707.2,Per diem,,20520,,"22,463 x DRG weight",20520,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,24140,,"26,426 x DRG weight",24140,Other,base rate x DRG weight,35452,,"38,809 x DRG weight",35452,Other,base rate x DRG weight,35452,,"38,809 x DRG weight",35452,Other,base rate x DRG weight,24140,,"26,426 x DRG weight",24140,Other,base rate x DRG weight,35452,,"38,809 x DRG weight",35452,Other,base rate x DRG weight,20362,,"6,363 x patient days",20362,Per diem,,75418,70,,75418,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,22890,,"25,057 x DRG weight",22890,Other,base rate x DRG weight,20601,,"22,552 x DRG weight",20601,Other,base rate x DRG weight,22890,,"25,057 x DRG weight",22890,Other,base rate x DRG weight,19456,,"21,298 x DRG weight",19456,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,75418,
RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT >96 HOURS,207,MS-DRG,,,,,,,,inpatient,,,585406.73,103291,,,103291,Other,150% of Medicare + 9.63% HCRA Surcharge,62812,,"3,609.90 x patient days",62812,Per diem,,173018,,"25,046 x DRG weight",173018,Other,base rate x DRG weight,155713,,"22,541 x DRG weight",155713,Other,base rate x DRG weight,217761,,"31,523 x DRG weight",217761,Other,base rate x DRG weight,195987,,"28,371 x DRG weight",195987,Other,base rate x DRG weight,185100,,"26,795 x DRG weight",185100,Other,base rate x DRG weight,69093.2,,"3,970.89 x patient days",69093.2,Per diem,,155174,,"22,463 x DRG weight",155174,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,182551,,"26,426 x DRG weight",182551,Other,base rate x DRG weight,268093,,"38,809 x DRG weight",268093,Other,base rate x DRG weight,268093,,"38,809 x DRG weight",268093,Other,base rate x DRG weight,182551,,"26,426 x DRG weight",182551,Other,base rate x DRG weight,268093,,"38,809 x DRG weight",268093,Other,base rate x DRG weight,110716,,"6,363 x patient days",110716,Per diem,,409785,70,,409785,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,173094,,"25,057 x DRG weight",173094,Other,base rate x DRG weight,155789,,"22,552 x DRG weight",155789,Other,base rate x DRG weight,173094,,"25,057 x DRG weight",173094,Other,base rate x DRG weight,147127,,"21,298 x DRG weight",147127,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,409785,
RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT <=96 HOURS,208,MS-DRG,,,,,,,,inpatient,,,244798.28,45709,,,45709,Other,150% of Medicare + 9.63% HCRA Surcharge,27796,,"3,609.90 x patient days",27796,Per diem,,67719,,"25,046 x DRG weight",67719,Other,base rate x DRG weight,60946,,"22,541 x DRG weight",60946,Other,base rate x DRG weight,85232,,"31,523 x DRG weight",85232,Other,base rate x DRG weight,76710,,"28,371 x DRG weight",76710,Other,base rate x DRG weight,72448,,"26,795 x DRG weight",72448,Other,base rate x DRG weight,30575.6,,"3,970.89 x patient days",30575.6,Per diem,,60735,,"22,463 x DRG weight",60735,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,71451,,"26,426 x DRG weight",71451,Other,base rate x DRG weight,104932,,"38,809 x DRG weight",104932,Other,base rate x DRG weight,104932,,"38,809 x DRG weight",104932,Other,base rate x DRG weight,71451,,"26,426 x DRG weight",71451,Other,base rate x DRG weight,104932,,"38,809 x DRG weight",104932,Other,base rate x DRG weight,48995,,"6,363 x patient days",48995,Per diem,,171359,70,,171359,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,67749,,"25,057 x DRG weight",67749,Other,base rate x DRG weight,60976,,"22,552 x DRG weight",60976,Other,base rate x DRG weight,67749,,"25,057 x DRG weight",67749,Other,base rate x DRG weight,57586,,"21,298 x DRG weight",57586,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,171359,
CONCOMITANT AORTIC AND MITRAL VALVE PROCEDURES,212,MS-DRG,,,,,,,,inpatient,,,1520385.15,93199,,,93199,Other,150% of Medicare + 9.63% HCRA Surcharge,56675,,"3,609.90 x patient days",56675,Per diem,,269763,,"25,046 x DRG weight",269763,Other,base rate x DRG weight,242782,,"22,541 x DRG weight",242782,Other,base rate x DRG weight,339525,,"31,523 x DRG weight",339525,Other,base rate x DRG weight,305576,,"28,371 x DRG weight",305576,Other,base rate x DRG weight,288601,,"26,795 x DRG weight",288601,Other,base rate x DRG weight,62342.5,,"3,970.89 x patient days",62342.5,Per diem,,241942,,"22,463 x DRG weight",241942,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,284627,,"26,426 x DRG weight",284627,Other,base rate x DRG weight,418000,,"38,809 x DRG weight",418000,Other,base rate x DRG weight,418000,,"38,809 x DRG weight",418000,Other,base rate x DRG weight,284627,,"26,426 x DRG weight",284627,Other,base rate x DRG weight,418000,,"38,809 x DRG weight",418000,Other,base rate x DRG weight,99899,,"6,363 x patient days",99899,Per diem,,1064270,70,,1064270,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,269881,,"25,057 x DRG weight",269881,Other,base rate x DRG weight,242901,,"22,552 x DRG weight",242901,Other,base rate x DRG weight,269881,,"25,057 x DRG weight",269881,Other,base rate x DRG weight,229394,,"21,298 x DRG weight",229394,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,1064270,
OTHER HEART ASSIST SYSTEM IMPLANT,215,MS-DRG,,,,,,,,inpatient,,,1281378.9,53427,,,53427,Other,150% of Medicare + 9.63% HCRA Surcharge,32489,,"3,609.90 x patient days",32489,Per diem,,255840,,"25,046 x DRG weight",255840,Other,base rate x DRG weight,230252,,"22,541 x DRG weight",230252,Other,base rate x DRG weight,322001,,"31,523 x DRG weight",322001,Other,base rate x DRG weight,289804,,"28,371 x DRG weight",289804,Other,base rate x DRG weight,273706,,"26,795 x DRG weight",273706,Other,base rate x DRG weight,35737.9,,"3,970.89 x patient days",35737.9,Per diem,,229455,,"22,463 x DRG weight",229455,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,269936,,"26,426 x DRG weight",269936,Other,base rate x DRG weight,396426,,"38,809 x DRG weight",396426,Other,base rate x DRG weight,396426,,"38,809 x DRG weight",396426,Other,base rate x DRG weight,269936,,"26,426 x DRG weight",269936,Other,base rate x DRG weight,396426,,"38,809 x DRG weight",396426,Other,base rate x DRG weight,57267,,"6,363 x patient days",57267,Per diem,,896965,70,,896965,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,255952,,"25,057 x DRG weight",255952,Other,base rate x DRG weight,230364,,"22,552 x DRG weight",230364,Other,base rate x DRG weight,255952,,"25,057 x DRG weight",255952,Other,base rate x DRG weight,217555,,"21,298 x DRG weight",217555,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,896965,
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITH MCC,216,MS-DRG,,,,,,,,inpatient,,,953897.27,86077,,,86077,Other,150% of Medicare + 9.63% HCRA Surcharge,52344,,"3,609.90 x patient days",52344,Per diem,,243079,,"25,046 x DRG weight",243079,Other,base rate x DRG weight,218767,,"22,541 x DRG weight",218767,Other,base rate x DRG weight,305940,,"31,523 x DRG weight",305940,Other,base rate x DRG weight,275349,,"28,371 x DRG weight",275349,Other,base rate x DRG weight,260054,,"26,795 x DRG weight",260054,Other,base rate x DRG weight,57578.4,,"3,970.89 x patient days",57578.4,Per diem,,218010,,"22,463 x DRG weight",218010,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,256472,,"26,426 x DRG weight",256472,Other,base rate x DRG weight,376653,,"38,809 x DRG weight",376653,Other,base rate x DRG weight,376653,,"38,809 x DRG weight",376653,Other,base rate x DRG weight,256472,,"26,426 x DRG weight",256472,Other,base rate x DRG weight,376653,,"38,809 x DRG weight",376653,Other,base rate x DRG weight,92264,,"6,363 x patient days",92264,Per diem,,667728,70,,667728,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,243186,,"25,057 x DRG weight",243186,Other,base rate x DRG weight,218874,,"22,552 x DRG weight",218874,Other,base rate x DRG weight,243186,,"25,057 x DRG weight",243186,Other,base rate x DRG weight,206703,,"21,298 x DRG weight",206703,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,667728,
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITH CC,217,MS-DRG,,,,,,,,inpatient,,,677974.07,42147,,,42147,Other,150% of Medicare + 9.63% HCRA Surcharge,25630,,"3,609.90 x patient days",25630,Per diem,,159425,,"25,046 x DRG weight",159425,Other,base rate x DRG weight,143480,,"22,541 x DRG weight",143480,Other,base rate x DRG weight,200653,,"31,523 x DRG weight",200653,Other,base rate x DRG weight,180590,,"28,371 x DRG weight",180590,Other,base rate x DRG weight,170558,,"26,795 x DRG weight",170558,Other,base rate x DRG weight,28193,,"3,970.89 x patient days",28193,Per diem,,142984,,"22,463 x DRG weight",142984,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,168209,,"26,426 x DRG weight",168209,Other,base rate x DRG weight,247031,,"38,809 x DRG weight",247031,Other,base rate x DRG weight,247031,,"38,809 x DRG weight",247031,Other,base rate x DRG weight,168209,,"26,426 x DRG weight",168209,Other,base rate x DRG weight,247031,,"38,809 x DRG weight",247031,Other,base rate x DRG weight,45177,,"6,363 x patient days",45177,Per diem,,474582,70,,474582,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,159495,,"25,057 x DRG weight",159495,Other,base rate x DRG weight,143550,,"22,552 x DRG weight",143550,Other,base rate x DRG weight,159495,,"25,057 x DRG weight",159495,Other,base rate x DRG weight,135568,,"21,298 x DRG weight",135568,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,474582,
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITHOUT CC/MCC,218,MS-DRG,,,,,,,,inpatient,,,568710.96,18403,,,18403,Other,150% of Medicare + 9.63% HCRA Surcharge,11191,,"3,609.90 x patient days",11191,Per diem,,142680,,"25,046 x DRG weight",142680,Other,base rate x DRG weight,128409,,"22,541 x DRG weight",128409,Other,base rate x DRG weight,179577,,"31,523 x DRG weight",179577,Other,base rate x DRG weight,161621,,"28,371 x DRG weight",161621,Other,base rate x DRG weight,152643,,"26,795 x DRG weight",152643,Other,base rate x DRG weight,12310.1,,"3,970.89 x patient days",12310.1,Per diem,,127965,,"22,463 x DRG weight",127965,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,150541,,"26,426 x DRG weight",150541,Other,base rate x DRG weight,221083,,"38,809 x DRG weight",221083,Other,base rate x DRG weight,221083,,"38,809 x DRG weight",221083,Other,base rate x DRG weight,150541,,"26,426 x DRG weight",150541,Other,base rate x DRG weight,221083,,"38,809 x DRG weight",221083,Other,base rate x DRG weight,19725,,"6,363 x patient days",19725,Per diem,,398098,70,,398098,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,142742,,"25,057 x DRG weight",142742,Other,base rate x DRG weight,128472,,"22,552 x DRG weight",128472,Other,base rate x DRG weight,142742,,"25,057 x DRG weight",142742,Other,base rate x DRG weight,121328,,"21,298 x DRG weight",121328,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,398098,
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITH MCC,219,MS-DRG,,,,,,,,inpatient,,,779264.3,63519,,,63519,Other,150% of Medicare + 9.63% HCRA Surcharge,38626,,"3,609.90 x patient days",38626,Per diem,,193135,,"25,046 x DRG weight",193135,Other,base rate x DRG weight,173818,,"22,541 x DRG weight",173818,Other,base rate x DRG weight,243080,,"31,523 x DRG weight",243080,Other,base rate x DRG weight,218774,,"28,371 x DRG weight",218774,Other,base rate x DRG weight,206622,,"26,795 x DRG weight",206622,Other,base rate x DRG weight,42488.6,,"3,970.89 x patient days",42488.6,Per diem,,173217,,"22,463 x DRG weight",173217,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,203776,,"26,426 x DRG weight",203776,Other,base rate x DRG weight,299264,,"38,809 x DRG weight",299264,Other,base rate x DRG weight,299264,,"38,809 x DRG weight",299264,Other,base rate x DRG weight,203776,,"26,426 x DRG weight",203776,Other,base rate x DRG weight,299264,,"38,809 x DRG weight",299264,Other,base rate x DRG weight,68084,,"6,363 x patient days",68084,Per diem,,545485,70,,545485,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,193220,,"25,057 x DRG weight",193220,Other,base rate x DRG weight,173903,,"22,552 x DRG weight",173903,Other,base rate x DRG weight,193220,,"25,057 x DRG weight",193220,Other,base rate x DRG weight,164233,,"21,298 x DRG weight",164233,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,545485,
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITH CC,220,MS-DRG,,,,,,,,inpatient,,,583822.96,37398,,,37398,Other,150% of Medicare + 9.63% HCRA Surcharge,22742,,"3,609.90 x patient days",22742,Per diem,,131356,,"25,046 x DRG weight",131356,Other,base rate x DRG weight,118219,,"22,541 x DRG weight",118219,Other,base rate x DRG weight,165326,,"31,523 x DRG weight",165326,Other,base rate x DRG weight,148795,,"28,371 x DRG weight",148795,Other,base rate x DRG weight,140529,,"26,795 x DRG weight",140529,Other,base rate x DRG weight,25016.2,,"3,970.89 x patient days",25016.2,Per diem,,117809,,"22,463 x DRG weight",117809,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,138594,,"26,426 x DRG weight",138594,Other,base rate x DRG weight,203538,,"38,809 x DRG weight",203538,Other,base rate x DRG weight,203538,,"38,809 x DRG weight",203538,Other,base rate x DRG weight,138594,,"26,426 x DRG weight",138594,Other,base rate x DRG weight,203538,,"38,809 x DRG weight",203538,Other,base rate x DRG weight,40087,,"6,363 x patient days",40087,Per diem,,408676,70,,408676,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,131414,,"25,057 x DRG weight",131414,Other,base rate x DRG weight,118276,,"22,552 x DRG weight",118276,Other,base rate x DRG weight,131414,,"25,057 x DRG weight",131414,Other,base rate x DRG weight,111699,,"21,298 x DRG weight",111699,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,408676,
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITHOUT CC/MCC,221,MS-DRG,,,,,,,,inpatient,,,416384.25,23746,,,23746,Other,150% of Medicare + 9.63% HCRA Surcharge,14440,,"3,609.90 x patient days",14440,Per diem,,116429,,"25,046 x DRG weight",116429,Other,base rate x DRG weight,104784,,"22,541 x DRG weight",104784,Other,base rate x DRG weight,146538,,"31,523 x DRG weight",146538,Other,base rate x DRG weight,131885,,"28,371 x DRG weight",131885,Other,base rate x DRG weight,124559,,"26,795 x DRG weight",124559,Other,base rate x DRG weight,15884,,"3,970.89 x patient days",15884,Per diem,,104422,,"22,463 x DRG weight",104422,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,122844,,"26,426 x DRG weight",122844,Other,base rate x DRG weight,180408,,"38,809 x DRG weight",180408,Other,base rate x DRG weight,180408,,"38,809 x DRG weight",180408,Other,base rate x DRG weight,122844,,"26,426 x DRG weight",122844,Other,base rate x DRG weight,180408,,"38,809 x DRG weight",180408,Other,base rate x DRG weight,25452,,"6,363 x patient days",25452,Per diem,,291469,70,,291469,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,116480,,"25,057 x DRG weight",116480,Other,base rate x DRG weight,104835,,"22,552 x DRG weight",104835,Other,base rate x DRG weight,116480,,"25,057 x DRG weight",116480,Other,base rate x DRG weight,99006,,"21,298 x DRG weight",99006,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,291469,
OTHER CARDIOTHORACIC PROCEDURES WITH MCC,228,MS-DRG,,,,,,,,inpatient,,,573616.59,54020,,,54020,Other,150% of Medicare + 9.63% HCRA Surcharge,32850,,"3,609.90 x patient days",32850,Per diem,,126199,,"25,046 x DRG weight",126199,Other,base rate x DRG weight,113577,,"22,541 x DRG weight",113577,Other,base rate x DRG weight,158835,,"31,523 x DRG weight",158835,Other,base rate x DRG weight,142953,,"28,371 x DRG weight",142953,Other,base rate x DRG weight,135012,,"26,795 x DRG weight",135012,Other,base rate x DRG weight,36135,,"3,970.89 x patient days",36135,Per diem,,113184,,"22,463 x DRG weight",113184,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,133153,,"26,426 x DRG weight",133153,Other,base rate x DRG weight,195547,,"38,809 x DRG weight",195547,Other,base rate x DRG weight,195547,,"38,809 x DRG weight",195547,Other,base rate x DRG weight,133153,,"26,426 x DRG weight",133153,Other,base rate x DRG weight,195547,,"38,809 x DRG weight",195547,Other,base rate x DRG weight,57903,,"6,363 x patient days",57903,Per diem,,401532,70,,401532,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,126255,,"25,057 x DRG weight",126255,Other,base rate x DRG weight,113633,,"22,552 x DRG weight",113633,Other,base rate x DRG weight,126255,,"25,057 x DRG weight",126255,Other,base rate x DRG weight,107314,,"21,298 x DRG weight",107314,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,401532,
OTHER CARDIOTHORACIC PROCEDURES WITHOUT MCC,229,MS-DRG,,,,,,,,inpatient,,,301670.68,20184,,,20184,Other,150% of Medicare + 9.63% HCRA Surcharge,12274,,"3,609.90 x patient days",12274,Per diem,,79636,,"25,046 x DRG weight",79636,Other,base rate x DRG weight,71671,,"22,541 x DRG weight",71671,Other,base rate x DRG weight,100231,,"31,523 x DRG weight",100231,Other,base rate x DRG weight,90208,,"28,371 x DRG weight",90208,Other,base rate x DRG weight,85197,,"26,795 x DRG weight",85197,Other,base rate x DRG weight,13501.4,,"3,970.89 x patient days",13501.4,Per diem,,71423,,"22,463 x DRG weight",71423,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,84024,,"26,426 x DRG weight",84024,Other,base rate x DRG weight,123397,,"38,809 x DRG weight",123397,Other,base rate x DRG weight,123397,,"38,809 x DRG weight",123397,Other,base rate x DRG weight,84024,,"26,426 x DRG weight",84024,Other,base rate x DRG weight,123397,,"38,809 x DRG weight",123397,Other,base rate x DRG weight,21634,,"6,363 x patient days",21634,Per diem,,211169,70,,211169,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,79671,,"25,057 x DRG weight",79671,Other,base rate x DRG weight,71706,,"22,552 x DRG weight",71706,Other,base rate x DRG weight,79671,,"25,057 x DRG weight",79671,Other,base rate x DRG weight,67719,,"21,298 x DRG weight",67719,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,211169,
CORONARY BYPASS WITH PTCA WITH MCC,231,MS-DRG,,,,,,,,inpatient,,,1154004.57,71236,,,71236,Other,150% of Medicare + 9.63% HCRA Surcharge,43319,,"3,609.90 x patient days",43319,Per diem,,203253,,"25,046 x DRG weight",203253,Other,base rate x DRG weight,182925,,"22,541 x DRG weight",182925,Other,base rate x DRG weight,255815,,"31,523 x DRG weight",255815,Other,base rate x DRG weight,230236,,"28,371 x DRG weight",230236,Other,base rate x DRG weight,217447,,"26,795 x DRG weight",217447,Other,base rate x DRG weight,47650.9,,"3,970.89 x patient days",47650.9,Per diem,,182292,,"22,463 x DRG weight",182292,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,214452,,"26,426 x DRG weight",214452,Other,base rate x DRG weight,314943,,"38,809 x DRG weight",314943,Other,base rate x DRG weight,314943,,"38,809 x DRG weight",314943,Other,base rate x DRG weight,214452,,"26,426 x DRG weight",214452,Other,base rate x DRG weight,314943,,"38,809 x DRG weight",314943,Other,base rate x DRG weight,76356,,"6,363 x patient days",76356,Per diem,,807803,70,,807803,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,203343,,"25,057 x DRG weight",203343,Other,base rate x DRG weight,183014,,"22,552 x DRG weight",183014,Other,base rate x DRG weight,203343,,"25,057 x DRG weight",203343,Other,base rate x DRG weight,172838,,"21,298 x DRG weight",172838,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,807803,
CORONARY BYPASS WITH PTCA WITHOUT MCC,232,MS-DRG,,,,,,,,inpatient,,,588002.47,49271,,,49271,Other,150% of Medicare + 9.63% HCRA Surcharge,29962,,"3,609.90 x patient days",29962,Per diem,,148989,,"25,046 x DRG weight",148989,Other,base rate x DRG weight,134087,,"22,541 x DRG weight",134087,Other,base rate x DRG weight,187518,,"31,523 x DRG weight",187518,Other,base rate x DRG weight,168768,,"28,371 x DRG weight",168768,Other,base rate x DRG weight,159393,,"26,795 x DRG weight",159393,Other,base rate x DRG weight,32958.2,,"3,970.89 x patient days",32958.2,Per diem,,133623,,"22,463 x DRG weight",133623,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,157198,,"26,426 x DRG weight",157198,Other,base rate x DRG weight,230859,,"38,809 x DRG weight",230859,Other,base rate x DRG weight,230859,,"38,809 x DRG weight",230859,Other,base rate x DRG weight,157198,,"26,426 x DRG weight",157198,Other,base rate x DRG weight,230859,,"38,809 x DRG weight",230859,Other,base rate x DRG weight,52813,,"6,363 x patient days",52813,Per diem,,411602,70,,411602,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,149054,,"25,057 x DRG weight",149054,Other,base rate x DRG weight,134153,,"22,552 x DRG weight",134153,Other,base rate x DRG weight,149054,,"25,057 x DRG weight",149054,Other,base rate x DRG weight,126693,,"21,298 x DRG weight",126693,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,411602,
CORONARY BYPASS WITH CARDIAC CATHETERIZATION OR OPEN ABLATION WITH MCC,233,MS-DRG,,,,,,,,inpatient,,,764165.03,75985,,,75985,Other,150% of Medicare + 9.63% HCRA Surcharge,46207,,"3,609.90 x patient days",46207,Per diem,,195349,,"25,046 x DRG weight",195349,Other,base rate x DRG weight,175811,,"22,541 x DRG weight",175811,Other,base rate x DRG weight,245867,,"31,523 x DRG weight",245867,Other,base rate x DRG weight,221282,,"28,371 x DRG weight",221282,Other,base rate x DRG weight,208990,,"26,795 x DRG weight",208990,Other,base rate x DRG weight,50827.7,,"3,970.89 x patient days",50827.7,Per diem,,175202,,"22,463 x DRG weight",175202,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,206112,,"26,426 x DRG weight",206112,Other,base rate x DRG weight,302695,,"38,809 x DRG weight",302695,Other,base rate x DRG weight,302695,,"38,809 x DRG weight",302695,Other,base rate x DRG weight,206112,,"26,426 x DRG weight",206112,Other,base rate x DRG weight,302695,,"38,809 x DRG weight",302695,Other,base rate x DRG weight,81446,,"6,363 x patient days",81446,Per diem,,534916,70,,534916,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,195435,,"25,057 x DRG weight",195435,Other,base rate x DRG weight,175897,,"22,552 x DRG weight",175897,Other,base rate x DRG weight,195435,,"25,057 x DRG weight",195435,Other,base rate x DRG weight,166116,,"21,298 x DRG weight",166116,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,534916,
CORONARY BYPASS WITH CARDIAC CATHETERIZATION OR OPEN ABLATION WITHOUT MCC,234,MS-DRG,,,,,,,,inpatient,,,578985.14,51052,,,51052,Other,150% of Medicare + 9.63% HCRA Surcharge,31045,,"3,609.90 x patient days",31045,Per diem,,130187,,"25,046 x DRG weight",130187,Other,base rate x DRG weight,117166,,"22,541 x DRG weight",117166,Other,base rate x DRG weight,163853,,"31,523 x DRG weight",163853,Other,base rate x DRG weight,147470,,"28,371 x DRG weight",147470,Other,base rate x DRG weight,139278,,"26,795 x DRG weight",139278,Other,base rate x DRG weight,34149.5,,"3,970.89 x patient days",34149.5,Per diem,,116760,,"22,463 x DRG weight",116760,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,137360,,"26,426 x DRG weight",137360,Other,base rate x DRG weight,201725,,"38,809 x DRG weight",201725,Other,base rate x DRG weight,201725,,"38,809 x DRG weight",201725,Other,base rate x DRG weight,137360,,"26,426 x DRG weight",137360,Other,base rate x DRG weight,201725,,"38,809 x DRG weight",201725,Other,base rate x DRG weight,54722,,"6,363 x patient days",54722,Per diem,,405290,70,,405290,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,130244,,"25,057 x DRG weight",130244,Other,base rate x DRG weight,117223,,"22,552 x DRG weight",117223,Other,base rate x DRG weight,130244,,"25,057 x DRG weight",130244,Other,base rate x DRG weight,110705,,"21,298 x DRG weight",110705,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,405290,
CORONARY BYPASS WITHOUT CARDIAC CATHETERIZATION WITH MCC,235,MS-DRG,,,,,,,,inpatient,,,616184.41,56395,,,56395,Other,150% of Medicare + 9.63% HCRA Surcharge,34294,,"3,609.90 x patient days",34294,Per diem,,147286,,"25,046 x DRG weight",147286,Other,base rate x DRG weight,132555,,"22,541 x DRG weight",132555,Other,base rate x DRG weight,185374,,"31,523 x DRG weight",185374,Other,base rate x DRG weight,166839,,"28,371 x DRG weight",166839,Other,base rate x DRG weight,157571,,"26,795 x DRG weight",157571,Other,base rate x DRG weight,37723.4,,"3,970.89 x patient days",37723.4,Per diem,,132096,,"22,463 x DRG weight",132096,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,155401,,"26,426 x DRG weight",155401,Other,base rate x DRG weight,228220,,"38,809 x DRG weight",228220,Other,base rate x DRG weight,228220,,"38,809 x DRG weight",228220,Other,base rate x DRG weight,155401,,"26,426 x DRG weight",155401,Other,base rate x DRG weight,228220,,"38,809 x DRG weight",228220,Other,base rate x DRG weight,60449,,"6,363 x patient days",60449,Per diem,,431329,70,,431329,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,147350,,"25,057 x DRG weight",147350,Other,base rate x DRG weight,132619,,"22,552 x DRG weight",132619,Other,base rate x DRG weight,147350,,"25,057 x DRG weight",147350,Other,base rate x DRG weight,125245,,"21,298 x DRG weight",125245,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,431329,
CORONARY BYPASS WITHOUT CARDIAC CATHETERIZATION WITHOUT MCC,236,MS-DRG,,,,,,,,inpatient,,,486448.72,37398,,,37398,Other,150% of Medicare + 9.63% HCRA Surcharge,22742,,"3,609.90 x patient days",22742,Per diem,,101216,,"25,046 x DRG weight",101216,Other,base rate x DRG weight,91093,,"22,541 x DRG weight",91093,Other,base rate x DRG weight,127391,,"31,523 x DRG weight",127391,Other,base rate x DRG weight,114653,,"28,371 x DRG weight",114653,Other,base rate x DRG weight,108284,,"26,795 x DRG weight",108284,Other,base rate x DRG weight,25016.2,,"3,970.89 x patient days",25016.2,Per diem,,90777,,"22,463 x DRG weight",90777,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,106793,,"26,426 x DRG weight",106793,Other,base rate x DRG weight,156835,,"38,809 x DRG weight",156835,Other,base rate x DRG weight,156835,,"38,809 x DRG weight",156835,Other,base rate x DRG weight,106793,,"26,426 x DRG weight",106793,Other,base rate x DRG weight,156835,,"38,809 x DRG weight",156835,Other,base rate x DRG weight,40087,,"6,363 x patient days",40087,Per diem,,340514,70,,340514,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,101260,,"25,057 x DRG weight",101260,Other,base rate x DRG weight,91137,,"22,552 x DRG weight",91137,Other,base rate x DRG weight,101260,,"25,057 x DRG weight",101260,Other,base rate x DRG weight,86069,,"21,298 x DRG weight",86069,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,340514,
AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH MCC,239,MS-DRG,,,,,,,,inpatient,,,922646.48,84296,,,84296,Other,150% of Medicare + 9.63% HCRA Surcharge,51261,,"3,609.90 x patient days",51261,Per diem,,120391,,"25,046 x DRG weight",120391,Other,base rate x DRG weight,108350,,"22,541 x DRG weight",108350,Other,base rate x DRG weight,151525,,"31,523 x DRG weight",151525,Other,base rate x DRG weight,136374,,"28,371 x DRG weight",136374,Other,base rate x DRG weight,128798,,"26,795 x DRG weight",128798,Other,base rate x DRG weight,56387.1,,"3,970.89 x patient days",56387.1,Per diem,,107975,,"22,463 x DRG weight",107975,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,127024,,"26,426 x DRG weight",127024,Other,base rate x DRG weight,186547,,"38,809 x DRG weight",186547,Other,base rate x DRG weight,186547,,"38,809 x DRG weight",186547,Other,base rate x DRG weight,127024,,"26,426 x DRG weight",127024,Other,base rate x DRG weight,186547,,"38,809 x DRG weight",186547,Other,base rate x DRG weight,90355,,"6,363 x patient days",90355,Per diem,,645853,70,,645853,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,120444,,"25,057 x DRG weight",120444,Other,base rate x DRG weight,108403,,"22,552 x DRG weight",108403,Other,base rate x DRG weight,120444,,"25,057 x DRG weight",120444,Other,base rate x DRG weight,102375,,"21,298 x DRG weight",102375,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,645853,
AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH CC,240,MS-DRG,,,,,,,,inpatient,,,628646.8,51646,,,51646,Other,150% of Medicare + 9.63% HCRA Surcharge,31406,,"3,609.90 x patient days",31406,Per diem,,70359,,"25,046 x DRG weight",70359,Other,base rate x DRG weight,63322,,"22,541 x DRG weight",63322,Other,base rate x DRG weight,88554,,"31,523 x DRG weight",88554,Other,base rate x DRG weight,79700,,"28,371 x DRG weight",79700,Other,base rate x DRG weight,75273,,"26,795 x DRG weight",75273,Other,base rate x DRG weight,34546.6,,"3,970.89 x patient days",34546.6,Per diem,,63103,,"22,463 x DRG weight",63103,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,74236,,"26,426 x DRG weight",74236,Other,base rate x DRG weight,109022,,"38,809 x DRG weight",109022,Other,base rate x DRG weight,109022,,"38,809 x DRG weight",109022,Other,base rate x DRG weight,74236,,"26,426 x DRG weight",74236,Other,base rate x DRG weight,109022,,"38,809 x DRG weight",109022,Other,base rate x DRG weight,55358,,"6,363 x patient days",55358,Per diem,,440053,70,,440053,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,70390,,"25,057 x DRG weight",70390,Other,base rate x DRG weight,63353,,"22,552 x DRG weight",63353,Other,base rate x DRG weight,70390,,"25,057 x DRG weight",70390,Other,base rate x DRG weight,59830,,"21,298 x DRG weight",59830,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,440053,
AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITHOUT CC/MCC,241,MS-DRG,,,,,,,,inpatient,,,278137.31,30274,,,30274,Other,150% of Medicare + 9.63% HCRA Surcharge,18410,,"3,609.90 x patient days",18410,Per diem,,34914,,"25,046 x DRG weight",34914,Other,base rate x DRG weight,31422,,"22,541 x DRG weight",31422,Other,base rate x DRG weight,43943,,"31,523 x DRG weight",43943,Other,base rate x DRG weight,39549,,"28,371 x DRG weight",39549,Other,base rate x DRG weight,37352,,"26,795 x DRG weight",37352,Other,base rate x DRG weight,20251,,"3,970.89 x patient days",20251,Per diem,,31313,,"22,463 x DRG weight",31313,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,36838,,"26,426 x DRG weight",36838,Other,base rate x DRG weight,54100,,"38,809 x DRG weight",54100,Other,base rate x DRG weight,54100,,"38,809 x DRG weight",54100,Other,base rate x DRG weight,36838,,"26,426 x DRG weight",36838,Other,base rate x DRG weight,54100,,"38,809 x DRG weight",54100,Other,base rate x DRG weight,32451,,"6,363 x patient days",32451,Per diem,,194696,70,,194696,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,34929,,"25,057 x DRG weight",34929,Other,base rate x DRG weight,31437,,"22,552 x DRG weight",31437,Other,base rate x DRG weight,34929,,"25,057 x DRG weight",34929,Other,base rate x DRG weight,29689,,"21,298 x DRG weight",29689,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,194696,
PERMANENT CARDIAC PACEMAKER IMPLANT WITH MCC,242,MS-DRG,,,,,,,,inpatient,,,517066.14,39773,,,39773,Other,150% of Medicare + 9.63% HCRA Surcharge,24186,,"3,609.90 x patient days",24186,Per diem,,86536,,"25,046 x DRG weight",86536,Other,base rate x DRG weight,77881,,"22,541 x DRG weight",77881,Other,base rate x DRG weight,108915,,"31,523 x DRG weight",108915,Other,base rate x DRG weight,98025,,"28,371 x DRG weight",98025,Other,base rate x DRG weight,92579,,"26,795 x DRG weight",92579,Other,base rate x DRG weight,26604.6,,"3,970.89 x patient days",26604.6,Per diem,,77612,,"22,463 x DRG weight",77612,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,91304,,"26,426 x DRG weight",91304,Other,base rate x DRG weight,134089,,"38,809 x DRG weight",134089,Other,base rate x DRG weight,134089,,"38,809 x DRG weight",134089,Other,base rate x DRG weight,91304,,"26,426 x DRG weight",91304,Other,base rate x DRG weight,134089,,"38,809 x DRG weight",134089,Other,base rate x DRG weight,42632,,"6,363 x patient days",42632,Per diem,,361946,70,,361946,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,86574,,"25,057 x DRG weight",86574,Other,base rate x DRG weight,77919,,"22,552 x DRG weight",77919,Other,base rate x DRG weight,86574,,"25,057 x DRG weight",86574,Other,base rate x DRG weight,73587,,"21,298 x DRG weight",73587,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,361946,
PERMANENT CARDIAC PACEMAKER IMPLANT WITH CC,243,MS-DRG,,,,,,,,inpatient,,,286481.93,21371,,,21371,Other,150% of Medicare + 9.63% HCRA Surcharge,12996,,"3,609.90 x patient days",12996,Per diem,,57045,,"25,046 x DRG weight",57045,Other,base rate x DRG weight,51339,,"22,541 x DRG weight",51339,Other,base rate x DRG weight,71797,,"31,523 x DRG weight",71797,Other,base rate x DRG weight,64618,,"28,371 x DRG weight",64618,Other,base rate x DRG weight,61028,,"26,795 x DRG weight",61028,Other,base rate x DRG weight,14295.6,,"3,970.89 x patient days",14295.6,Per diem,,51162,,"22,463 x DRG weight",51162,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,60188,,"26,426 x DRG weight",60188,Other,base rate x DRG weight,88391,,"38,809 x DRG weight",88391,Other,base rate x DRG weight,88391,,"38,809 x DRG weight",88391,Other,base rate x DRG weight,60188,,"26,426 x DRG weight",60188,Other,base rate x DRG weight,88391,,"38,809 x DRG weight",88391,Other,base rate x DRG weight,22907,,"6,363 x patient days",22907,Per diem,,200537,70,,200537,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,57070,,"25,057 x DRG weight",57070,Other,base rate x DRG weight,51364,,"22,552 x DRG weight",51364,Other,base rate x DRG weight,57070,,"25,057 x DRG weight",57070,Other,base rate x DRG weight,48508,,"21,298 x DRG weight",48508,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,200537,
PERMANENT CARDIAC PACEMAKER IMPLANT WITHOUT CC/MCC,244,MS-DRG,,,,,,,,inpatient,,,204054.44,14248,,,14248,Other,150% of Medicare + 9.63% HCRA Surcharge,8664,,"3,609.90 x patient days",8664,Per diem,,45822,,"25,046 x DRG weight",45822,Other,base rate x DRG weight,41239,,"22,541 x DRG weight",41239,Other,base rate x DRG weight,57671,,"31,523 x DRG weight",57671,Other,base rate x DRG weight,51905,,"28,371 x DRG weight",51905,Other,base rate x DRG weight,49021,,"26,795 x DRG weight",49021,Other,base rate x DRG weight,9530.4,,"3,970.89 x patient days",9530.4,Per diem,,41096,,"22,463 x DRG weight",41096,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,48346,,"26,426 x DRG weight",48346,Other,base rate x DRG weight,71001,,"38,809 x DRG weight",71001,Other,base rate x DRG weight,71001,,"38,809 x DRG weight",71001,Other,base rate x DRG weight,48346,,"26,426 x DRG weight",48346,Other,base rate x DRG weight,71001,,"38,809 x DRG weight",71001,Other,base rate x DRG weight,15271,,"6,363 x patient days",15271,Per diem,,142838,70,,142838,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,45842,,"25,057 x DRG weight",45842,Other,base rate x DRG weight,41259,,"22,552 x DRG weight",41259,Other,base rate x DRG weight,45842,,"25,057 x DRG weight",45842,Other,base rate x DRG weight,38965,,"21,298 x DRG weight",38965,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,142838,
AICD GENERATOR PROCEDURES,245,MS-DRG,,,,,,,,inpatient,,,449127.75,34430,,,34430,Other,150% of Medicare + 9.63% HCRA Surcharge,20937,,"3,609.90 x patient days",20937,Per diem,,113493,,"25,046 x DRG weight",113493,Other,base rate x DRG weight,102142,,"22,541 x DRG weight",102142,Other,base rate x DRG weight,142843,,"31,523 x DRG weight",142843,Other,base rate x DRG weight,128560,,"28,371 x DRG weight",128560,Other,base rate x DRG weight,121419,,"26,795 x DRG weight",121419,Other,base rate x DRG weight,23030.7,,"3,970.89 x patient days",23030.7,Per diem,,101789,,"22,463 x DRG weight",101789,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,119747,,"26,426 x DRG weight",119747,Other,base rate x DRG weight,175859,,"38,809 x DRG weight",175859,Other,base rate x DRG weight,175859,,"38,809 x DRG weight",175859,Other,base rate x DRG weight,119747,,"26,426 x DRG weight",119747,Other,base rate x DRG weight,175859,,"38,809 x DRG weight",175859,Other,base rate x DRG weight,36905,,"6,363 x patient days",36905,Per diem,,314389,70,,314389,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,113543,,"25,057 x DRG weight",113543,Other,base rate x DRG weight,102192,,"22,552 x DRG weight",102192,Other,base rate x DRG weight,113543,,"25,057 x DRG weight",113543,Other,base rate x DRG weight,96510,,"21,298 x DRG weight",96510,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,314389,
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITHOUT INTRALUMINAL DEVICE WITH MCC,250,MS-DRG,,,,,,,,inpatient,,,338735.7,28495,,,28495,Other,150% of Medicare + 9.63% HCRA Surcharge,17328,,"3,609.90 x patient days",17328,Per diem,,58878,,"25,046 x DRG weight",58878,Other,base rate x DRG weight,52989,,"22,541 x DRG weight",52989,Other,base rate x DRG weight,74104,,"31,523 x DRG weight",74104,Other,base rate x DRG weight,66695,,"28,371 x DRG weight",66695,Other,base rate x DRG weight,62990,,"26,795 x DRG weight",62990,Other,base rate x DRG weight,19060.8,,"3,970.89 x patient days",19060.8,Per diem,,52806,,"22,463 x DRG weight",52806,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,62122,,"26,426 x DRG weight",62122,Other,base rate x DRG weight,91232,,"38,809 x DRG weight",91232,Other,base rate x DRG weight,91232,,"38,809 x DRG weight",91232,Other,base rate x DRG weight,62122,,"26,426 x DRG weight",62122,Other,base rate x DRG weight,91232,,"38,809 x DRG weight",91232,Other,base rate x DRG weight,30542,,"6,363 x patient days",30542,Per diem,,237115,70,,237115,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,58904,,"25,057 x DRG weight",58904,Other,base rate x DRG weight,53015,,"22,552 x DRG weight",53015,Other,base rate x DRG weight,58904,,"25,057 x DRG weight",58904,Other,base rate x DRG weight,50067,,"21,298 x DRG weight",50067,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,237115,
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITHOUT INTRALUMINAL DEVICE WITHOUT MCC,251,MS-DRG,,,,,,,,inpatient,,,128369.42,14841,,,14841,Other,150% of Medicare + 9.63% HCRA Surcharge,9025,,"3,609.90 x patient days",9025,Per diem,,39745,,"25,046 x DRG weight",39745,Other,base rate x DRG weight,35770,,"22,541 x DRG weight",35770,Other,base rate x DRG weight,50024,,"31,523 x DRG weight",50024,Other,base rate x DRG weight,45022,,"28,371 x DRG weight",45022,Other,base rate x DRG weight,42521,,"26,795 x DRG weight",42521,Other,base rate x DRG weight,9927.5,,"3,970.89 x patient days",9927.5,Per diem,,35647,,"22,463 x DRG weight",35647,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,41935,,"26,426 x DRG weight",41935,Other,base rate x DRG weight,61586,,"38,809 x DRG weight",61586,Other,base rate x DRG weight,61586,,"38,809 x DRG weight",61586,Other,base rate x DRG weight,41935,,"26,426 x DRG weight",41935,Other,base rate x DRG weight,61586,,"38,809 x DRG weight",61586,Other,base rate x DRG weight,15908,,"6,363 x patient days",15908,Per diem,,89859,70,,89859,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,39763,,"25,057 x DRG weight",39763,Other,base rate x DRG weight,35788,,"22,552 x DRG weight",35788,Other,base rate x DRG weight,39763,,"25,057 x DRG weight",39763,Other,base rate x DRG weight,33798,,"21,298 x DRG weight",33798,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,89859,
OTHER VASCULAR PROCEDURES WITH MCC,252,MS-DRG,,,,,,,,inpatient,,,419441.03,47490,,,47490,Other,150% of Medicare + 9.63% HCRA Surcharge,28879,,"3,609.90 x patient days",28879,Per diem,,83999,,"25,046 x DRG weight",83999,Other,base rate x DRG weight,75598,,"22,541 x DRG weight",75598,Other,base rate x DRG weight,105722,,"31,523 x DRG weight",105722,Other,base rate x DRG weight,95151,,"28,371 x DRG weight",95151,Other,base rate x DRG weight,89865,,"26,795 x DRG weight",89865,Other,base rate x DRG weight,31766.9,,"3,970.89 x patient days",31766.9,Per diem,,75336,,"22,463 x DRG weight",75336,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,88628,,"26,426 x DRG weight",88628,Other,base rate x DRG weight,130158,,"38,809 x DRG weight",130158,Other,base rate x DRG weight,130158,,"38,809 x DRG weight",130158,Other,base rate x DRG weight,88628,,"26,426 x DRG weight",88628,Other,base rate x DRG weight,130158,,"38,809 x DRG weight",130158,Other,base rate x DRG weight,50904,,"6,363 x patient days",50904,Per diem,,293609,70,,293609,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,84036,,"25,057 x DRG weight",84036,Other,base rate x DRG weight,75635,,"22,552 x DRG weight",75635,Other,base rate x DRG weight,84036,,"25,057 x DRG weight",84036,Other,base rate x DRG weight,71429,,"21,298 x DRG weight",71429,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,293609,
OTHER VASCULAR PROCEDURES WITH CC,253,MS-DRG,,,,,,,,inpatient,,,373894.59,30868,,,30868,Other,150% of Medicare + 9.63% HCRA Surcharge,18771,,"3,609.90 x patient days",18771,Per diem,,63895,,"25,046 x DRG weight",63895,Other,base rate x DRG weight,57504,,"22,541 x DRG weight",57504,Other,base rate x DRG weight,80418,,"31,523 x DRG weight",80418,Other,base rate x DRG weight,72377,,"28,371 x DRG weight",72377,Other,base rate x DRG weight,68357,,"26,795 x DRG weight",68357,Other,base rate x DRG weight,20648.1,,"3,970.89 x patient days",20648.1,Per diem,,57305,,"22,463 x DRG weight",57305,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,67415,,"26,426 x DRG weight",67415,Other,base rate x DRG weight,99006,,"38,809 x DRG weight",99006,Other,base rate x DRG weight,99006,,"38,809 x DRG weight",99006,Other,base rate x DRG weight,67415,,"26,426 x DRG weight",67415,Other,base rate x DRG weight,99006,,"38,809 x DRG weight",99006,Other,base rate x DRG weight,33088,,"6,363 x patient days",33088,Per diem,,261726,70,,261726,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,63923,,"25,057 x DRG weight",63923,Other,base rate x DRG weight,57532,,"22,552 x DRG weight",57532,Other,base rate x DRG weight,63923,,"25,057 x DRG weight",63923,Other,base rate x DRG weight,54333,,"21,298 x DRG weight",54333,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,261726,
OTHER VASCULAR PROCEDURES WITHOUT CC/MCC,254,MS-DRG,,,,,,,,inpatient,,,167941.28,14248,,,14248,Other,150% of Medicare + 9.63% HCRA Surcharge,8664,,"3,609.90 x patient days",8664,Per diem,,43457,,"25,046 x DRG weight",43457,Other,base rate x DRG weight,39111,,"22,541 x DRG weight",39111,Other,base rate x DRG weight,54696,,"31,523 x DRG weight",54696,Other,base rate x DRG weight,49227,,"28,371 x DRG weight",49227,Other,base rate x DRG weight,46492,,"26,795 x DRG weight",46492,Other,base rate x DRG weight,9530.4,,"3,970.89 x patient days",9530.4,Per diem,,38976,,"22,463 x DRG weight",38976,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,45852,,"26,426 x DRG weight",45852,Other,base rate x DRG weight,67337,,"38,809 x DRG weight",67337,Other,base rate x DRG weight,67337,,"38,809 x DRG weight",67337,Other,base rate x DRG weight,45852,,"26,426 x DRG weight",45852,Other,base rate x DRG weight,67337,,"38,809 x DRG weight",67337,Other,base rate x DRG weight,15271,,"6,363 x patient days",15271,Per diem,,117559,70,,117559,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,43476,,"25,057 x DRG weight",43476,Other,base rate x DRG weight,39130,,"22,552 x DRG weight",39130,Other,base rate x DRG weight,43476,,"25,057 x DRG weight",43476,Other,base rate x DRG weight,36954,,"21,298 x DRG weight",36954,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,117559,
UPPER LIMB AND TOE AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS WITH MCC,255,MS-DRG,,,,,,,,inpatient,,,266996.59,54020,,,54020,Other,150% of Medicare + 9.63% HCRA Surcharge,32850,,"3,609.90 x patient days",32850,Per diem,,68811,,"25,046 x DRG weight",68811,Other,base rate x DRG weight,61929,,"22,541 x DRG weight",61929,Other,base rate x DRG weight,86606,,"31,523 x DRG weight",86606,Other,base rate x DRG weight,77946,,"28,371 x DRG weight",77946,Other,base rate x DRG weight,73617,,"26,795 x DRG weight",73617,Other,base rate x DRG weight,36135,,"3,970.89 x patient days",36135,Per diem,,61715,,"22,463 x DRG weight",61715,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,72603,,"26,426 x DRG weight",72603,Other,base rate x DRG weight,106624,,"38,809 x DRG weight",106624,Other,base rate x DRG weight,106624,,"38,809 x DRG weight",106624,Other,base rate x DRG weight,72603,,"26,426 x DRG weight",72603,Other,base rate x DRG weight,106624,,"38,809 x DRG weight",106624,Other,base rate x DRG weight,57903,,"6,363 x patient days",57903,Per diem,,186898,70,,186898,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,68842,,"25,057 x DRG weight",68842,Other,base rate x DRG weight,61959,,"22,552 x DRG weight",61959,Other,base rate x DRG weight,68842,,"25,057 x DRG weight",68842,Other,base rate x DRG weight,58514,,"21,298 x DRG weight",58514,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,186898,
UPPER LIMB AND TOE AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS WITH CC,256,MS-DRG,,,,,,,,inpatient,,,306098.74,35617,,,35617,Other,150% of Medicare + 9.63% HCRA Surcharge,21659,,"3,609.90 x patient days",21659,Per diem,,41068,,"25,046 x DRG weight",41068,Other,base rate x DRG weight,36960,,"22,541 x DRG weight",36960,Other,base rate x DRG weight,51688,,"31,523 x DRG weight",51688,Other,base rate x DRG weight,46520,,"28,371 x DRG weight",46520,Other,base rate x DRG weight,43936,,"26,795 x DRG weight",43936,Other,base rate x DRG weight,23824.9,,"3,970.89 x patient days",23824.9,Per diem,,36833,,"22,463 x DRG weight",36833,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,43331,,"26,426 x DRG weight",43331,Other,base rate x DRG weight,63635,,"38,809 x DRG weight",63635,Other,base rate x DRG weight,63635,,"38,809 x DRG weight",63635,Other,base rate x DRG weight,43331,,"26,426 x DRG weight",43331,Other,base rate x DRG weight,63635,,"38,809 x DRG weight",63635,Other,base rate x DRG weight,38178,,"6,363 x patient days",38178,Per diem,,214269,70,,214269,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,41086,,"25,057 x DRG weight",41086,Other,base rate x DRG weight,36979,,"22,552 x DRG weight",36979,Other,base rate x DRG weight,41086,,"25,057 x DRG weight",41086,Other,base rate x DRG weight,34922,,"21,298 x DRG weight",34922,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,214269,
UPPER LIMB AND TOE AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS WITHOUT CC/MCC,257,MS-DRG,,,,,,,,inpatient,,,131488.65,23746,,,23746,Other,150% of Medicare + 9.63% HCRA Surcharge,14440,,"3,609.90 x patient days",14440,Per diem,,24821,,"25,046 x DRG weight",24821,Other,base rate x DRG weight,22338,,"22,541 x DRG weight",22338,Other,base rate x DRG weight,31239,,"31,523 x DRG weight",31239,Other,base rate x DRG weight,28116,,"28,371 x DRG weight",28116,Other,base rate x DRG weight,26554,,"26,795 x DRG weight",26554,Other,base rate x DRG weight,15884,,"3,970.89 x patient days",15884,Per diem,,22261,,"22,463 x DRG weight",22261,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,26188,,"26,426 x DRG weight",26188,Other,base rate x DRG weight,38460,,"38,809 x DRG weight",38460,Other,base rate x DRG weight,38460,,"38,809 x DRG weight",38460,Other,base rate x DRG weight,26188,,"26,426 x DRG weight",26188,Other,base rate x DRG weight,38460,,"38,809 x DRG weight",38460,Other,base rate x DRG weight,25452,,"6,363 x patient days",25452,Per diem,,92042,70,,92042,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,24831,,"25,057 x DRG weight",24831,Other,base rate x DRG weight,22349,,"22,552 x DRG weight",22349,Other,base rate x DRG weight,24831,,"25,057 x DRG weight",24831,Other,base rate x DRG weight,21106,,"21,298 x DRG weight",21106,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,92042,
CARDIAC PACEMAKER DEVICE REPLACEMENT WITH MCC,258,MS-DRG,,,,,,,,inpatient,,,324936,37398,,,37398,Other,150% of Medicare + 9.63% HCRA Surcharge,22742,,"3,609.90 x patient days",22742,Per diem,,67840,,"25,046 x DRG weight",67840,Other,base rate x DRG weight,61055,,"22,541 x DRG weight",61055,Other,base rate x DRG weight,85383,,"31,523 x DRG weight",85383,Other,base rate x DRG weight,76846,,"28,371 x DRG weight",76846,Other,base rate x DRG weight,72577,,"26,795 x DRG weight",72577,Other,base rate x DRG weight,25016.2,,"3,970.89 x patient days",25016.2,Per diem,,60843,,"22,463 x DRG weight",60843,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,71577,,"26,426 x DRG weight",71577,Other,base rate x DRG weight,105118,,"38,809 x DRG weight",105118,Other,base rate x DRG weight,105118,,"38,809 x DRG weight",105118,Other,base rate x DRG weight,71577,,"26,426 x DRG weight",71577,Other,base rate x DRG weight,105118,,"38,809 x DRG weight",105118,Other,base rate x DRG weight,40087,,"6,363 x patient days",40087,Per diem,,227455,70,,227455,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,67869,,"25,057 x DRG weight",67869,Other,base rate x DRG weight,61084,,"22,552 x DRG weight",61084,Other,base rate x DRG weight,67869,,"25,057 x DRG weight",67869,Other,base rate x DRG weight,57688,,"21,298 x DRG weight",57688,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,227455,
CARDIAC PACEMAKER DEVICE REPLACEMENT WITHOUT MCC,259,MS-DRG,,,,,,,,inpatient,,,163347,17809,,,17809,Other,150% of Medicare + 9.63% HCRA Surcharge,10830,,"3,609.90 x patient days",10830,Per diem,,46751,,"25,046 x DRG weight",46751,Other,base rate x DRG weight,42075,,"22,541 x DRG weight",42075,Other,base rate x DRG weight,58841,,"31,523 x DRG weight",58841,Other,base rate x DRG weight,52957,,"28,371 x DRG weight",52957,Other,base rate x DRG weight,50016,,"26,795 x DRG weight",50016,Other,base rate x DRG weight,11913,,"3,970.89 x patient days",11913,Per diem,,41929,,"22,463 x DRG weight",41929,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,49327,,"26,426 x DRG weight",49327,Other,base rate x DRG weight,72441,,"38,809 x DRG weight",72441,Other,base rate x DRG weight,72441,,"38,809 x DRG weight",72441,Other,base rate x DRG weight,49327,,"26,426 x DRG weight",49327,Other,base rate x DRG weight,72441,,"38,809 x DRG weight",72441,Other,base rate x DRG weight,19089,,"6,363 x patient days",19089,Per diem,,114343,70,,114343,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,46771,,"25,057 x DRG weight",46771,Other,base rate x DRG weight,42096,,"22,552 x DRG weight",42096,Other,base rate x DRG weight,46771,,"25,057 x DRG weight",46771,Other,base rate x DRG weight,39755,,"21,298 x DRG weight",39755,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,114343,
CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITH MCC,260,MS-DRG,,,,,,,,inpatient,,,378802.63,49865,,,49865,Other,150% of Medicare + 9.63% HCRA Surcharge,30323,,"3,609.90 x patient days",30323,Per diem,,83032,,"25,046 x DRG weight",83032,Other,base rate x DRG weight,74728,,"22,541 x DRG weight",74728,Other,base rate x DRG weight,104505,,"31,523 x DRG weight",104505,Other,base rate x DRG weight,94056,,"28,371 x DRG weight",94056,Other,base rate x DRG weight,88831,,"26,795 x DRG weight",88831,Other,base rate x DRG weight,33355.3,,"3,970.89 x patient days",33355.3,Per diem,,74469,,"22,463 x DRG weight",74469,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,87607,,"26,426 x DRG weight",87607,Other,base rate x DRG weight,128660,,"38,809 x DRG weight",128660,Other,base rate x DRG weight,128660,,"38,809 x DRG weight",128660,Other,base rate x DRG weight,87607,,"26,426 x DRG weight",87607,Other,base rate x DRG weight,128660,,"38,809 x DRG weight",128660,Other,base rate x DRG weight,53449,,"6,363 x patient days",53449,Per diem,,265162,70,,265162,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,83069,,"25,057 x DRG weight",83069,Other,base rate x DRG weight,74764,,"22,552 x DRG weight",74764,Other,base rate x DRG weight,83069,,"25,057 x DRG weight",83069,Other,base rate x DRG weight,70607,,"21,298 x DRG weight",70607,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,265162,
CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITH CC,261,MS-DRG,,,,,,,,inpatient,,,247238.56,22559,,,22559,Other,150% of Medicare + 9.63% HCRA Surcharge,13718,,"3,609.90 x patient days",13718,Per diem,,47132,,"25,046 x DRG weight",47132,Other,base rate x DRG weight,42418,,"22,541 x DRG weight",42418,Other,base rate x DRG weight,59320,,"31,523 x DRG weight",59320,Other,base rate x DRG weight,53389,,"28,371 x DRG weight",53389,Other,base rate x DRG weight,50423,,"26,795 x DRG weight",50423,Other,base rate x DRG weight,15089.8,,"3,970.89 x patient days",15089.8,Per diem,,42271,,"22,463 x DRG weight",42271,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,49728,,"26,426 x DRG weight",49728,Other,base rate x DRG weight,73031,,"38,809 x DRG weight",73031,Other,base rate x DRG weight,73031,,"38,809 x DRG weight",73031,Other,base rate x DRG weight,49728,,"26,426 x DRG weight",49728,Other,base rate x DRG weight,73031,,"38,809 x DRG weight",73031,Other,base rate x DRG weight,24179,,"6,363 x patient days",24179,Per diem,,173067,70,,173067,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,47152,,"25,057 x DRG weight",47152,Other,base rate x DRG weight,42438,,"22,552 x DRG weight",42438,Other,base rate x DRG weight,47152,,"25,057 x DRG weight",47152,Other,base rate x DRG weight,40079,,"21,298 x DRG weight",40079,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,173067,
CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITHOUT CC/MCC,262,MS-DRG,,,,,,,,inpatient,,,184977.61,16028,,,16028,Other,150% of Medicare + 9.63% HCRA Surcharge,9747,,"3,609.90 x patient days",9747,Per diem,,41208,,"25,046 x DRG weight",41208,Other,base rate x DRG weight,37087,,"22,541 x DRG weight",37087,Other,base rate x DRG weight,51865,,"31,523 x DRG weight",51865,Other,base rate x DRG weight,46679,,"28,371 x DRG weight",46679,Other,base rate x DRG weight,44086,,"26,795 x DRG weight",44086,Other,base rate x DRG weight,10721.7,,"3,970.89 x patient days",10721.7,Per diem,,36958,,"22,463 x DRG weight",36958,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,43479,,"26,426 x DRG weight",43479,Other,base rate x DRG weight,63852,,"38,809 x DRG weight",63852,Other,base rate x DRG weight,63852,,"38,809 x DRG weight",63852,Other,base rate x DRG weight,43479,,"26,426 x DRG weight",43479,Other,base rate x DRG weight,63852,,"38,809 x DRG weight",63852,Other,base rate x DRG weight,17180,,"6,363 x patient days",17180,Per diem,,129484,70,,129484,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,41226,,"25,057 x DRG weight",41226,Other,base rate x DRG weight,37105,,"22,552 x DRG weight",37105,Other,base rate x DRG weight,41226,,"25,057 x DRG weight",41226,Other,base rate x DRG weight,35042,,"21,298 x DRG weight",35042,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,129484,
VEIN LIGATION AND STRIPPING,263,MS-DRG,,,,,,,,inpatient,,,720089.09,40366,,,40366,Other,150% of Medicare + 9.63% HCRA Surcharge,24547,,"3,609.90 x patient days",24547,Per diem,,70760,,"25,046 x DRG weight",70760,Other,base rate x DRG weight,63683,,"22,541 x DRG weight",63683,Other,base rate x DRG weight,89059,,"31,523 x DRG weight",89059,Other,base rate x DRG weight,80154,,"28,371 x DRG weight",80154,Other,base rate x DRG weight,75701,,"26,795 x DRG weight",75701,Other,base rate x DRG weight,27001.7,,"3,970.89 x patient days",27001.7,Per diem,,63462,,"22,463 x DRG weight",63462,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,74659,,"26,426 x DRG weight",74659,Other,base rate x DRG weight,109643,,"38,809 x DRG weight",109643,Other,base rate x DRG weight,109643,,"38,809 x DRG weight",109643,Other,base rate x DRG weight,74659,,"26,426 x DRG weight",74659,Other,base rate x DRG weight,109643,,"38,809 x DRG weight",109643,Other,base rate x DRG weight,43268,,"6,363 x patient days",43268,Per diem,,504062,70,,504062,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,70791,,"25,057 x DRG weight",70791,Other,base rate x DRG weight,63714,,"22,552 x DRG weight",63714,Other,base rate x DRG weight,70791,,"25,057 x DRG weight",70791,Other,base rate x DRG weight,60171,,"21,298 x DRG weight",60171,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,504062,
OTHER CIRCULATORY SYSTEM O.R. PROCEDURES,264,MS-DRG,,,,,,,,inpatient,,,500471.13,58769,,,58769,Other,150% of Medicare + 9.63% HCRA Surcharge,35738,,"3,609.90 x patient days",35738,Per diem,,81800,,"25,046 x DRG weight",81800,Other,base rate x DRG weight,73619,,"22,541 x DRG weight",73619,Other,base rate x DRG weight,102954,,"31,523 x DRG weight",102954,Other,base rate x DRG weight,92660,,"28,371 x DRG weight",92660,Other,base rate x DRG weight,87512,,"26,795 x DRG weight",87512,Other,base rate x DRG weight,39311.8,,"3,970.89 x patient days",39311.8,Per diem,,73364,,"22,463 x DRG weight",73364,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,86307,,"26,426 x DRG weight",86307,Other,base rate x DRG weight,126750,,"38,809 x DRG weight",126750,Other,base rate x DRG weight,126750,,"38,809 x DRG weight",126750,Other,base rate x DRG weight,86307,,"26,426 x DRG weight",86307,Other,base rate x DRG weight,126750,,"38,809 x DRG weight",126750,Other,base rate x DRG weight,62994,,"6,363 x patient days",62994,Per diem,,350330,70,,350330,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,81836,,"25,057 x DRG weight",81836,Other,base rate x DRG weight,73655,,"22,552 x DRG weight",73655,Other,base rate x DRG weight,81836,,"25,057 x DRG weight",81836,Other,base rate x DRG weight,69559,,"21,298 x DRG weight",69559,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,350330,
AICD LEAD PROCEDURES,265,MS-DRG,,,,,,,,inpatient,,,876391.52,33243,,,33243,Other,150% of Medicare + 9.63% HCRA Surcharge,20215,,"3,609.90 x patient days",20215,Per diem,,88515,,"25,046 x DRG weight",88515,Other,base rate x DRG weight,79662,,"22,541 x DRG weight",79662,Other,base rate x DRG weight,111405,,"31,523 x DRG weight",111405,Other,base rate x DRG weight,100266,,"28,371 x DRG weight",100266,Other,base rate x DRG weight,94696,,"26,795 x DRG weight",94696,Other,base rate x DRG weight,22236.5,,"3,970.89 x patient days",22236.5,Per diem,,79386,,"22,463 x DRG weight",79386,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,93392,,"26,426 x DRG weight",93392,Other,base rate x DRG weight,137155,,"38,809 x DRG weight",137155,Other,base rate x DRG weight,137155,,"38,809 x DRG weight",137155,Other,base rate x DRG weight,93392,,"26,426 x DRG weight",93392,Other,base rate x DRG weight,137155,,"38,809 x DRG weight",137155,Other,base rate x DRG weight,35633,,"6,363 x patient days",35633,Per diem,,613474,70,,613474,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,88554,,"25,057 x DRG weight",88554,Other,base rate x DRG weight,79701,,"22,552 x DRG weight",79701,Other,base rate x DRG weight,88554,,"25,057 x DRG weight",88554,Other,base rate x DRG weight,75269,,"21,298 x DRG weight",75269,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,613474,
ENDOVASCULAR CARDIAC VALVE REPLACEMENT AND SUPPLEMENT PROCEDURES WITH MCC,266,MS-DRG,,,,,,,,inpatient,,,567767.19,29089,,,29089,Other,150% of Medicare + 9.63% HCRA Surcharge,17689,,"3,609.90 x patient days",17689,Per diem,,156440,,"25,046 x DRG weight",156440,Other,base rate x DRG weight,140793,,"22,541 x DRG weight",140793,Other,base rate x DRG weight,196896,,"31,523 x DRG weight",196896,Other,base rate x DRG weight,177208,,"28,371 x DRG weight",177208,Other,base rate x DRG weight,167364,,"26,795 x DRG weight",167364,Other,base rate x DRG weight,19457.9,,"3,970.89 x patient days",19457.9,Per diem,,140306,,"22,463 x DRG weight",140306,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,165059,,"26,426 x DRG weight",165059,Other,base rate x DRG weight,242405,,"38,809 x DRG weight",242405,Other,base rate x DRG weight,242405,,"38,809 x DRG weight",242405,Other,base rate x DRG weight,165059,,"26,426 x DRG weight",165059,Other,base rate x DRG weight,242405,,"38,809 x DRG weight",242405,Other,base rate x DRG weight,31179,,"6,363 x patient days",31179,Per diem,,397437,70,,397437,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,156509,,"25,057 x DRG weight",156509,Other,base rate x DRG weight,140862,,"22,552 x DRG weight",140862,Other,base rate x DRG weight,156509,,"25,057 x DRG weight",156509,Other,base rate x DRG weight,133029,,"21,298 x DRG weight",133029,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,397437,
ENDOVASCULAR CARDIAC VALVE REPLACEMENT AND SUPPLEMENT PROCEDURES WITHOUT MCC,267,MS-DRG,,,,,,,,inpatient,,,351716.98,9498,,,9498,Other,150% of Medicare + 9.63% HCRA Surcharge,5776,,"3,609.90 x patient days",5776,Per diem,,122229,,"25,046 x DRG weight",122229,Other,base rate x DRG weight,110005,,"22,541 x DRG weight",110005,Other,base rate x DRG weight,153839,,"31,523 x DRG weight",153839,Other,base rate x DRG weight,138456,,"28,371 x DRG weight",138456,Other,base rate x DRG weight,130765,,"26,795 x DRG weight",130765,Other,base rate x DRG weight,6353.6,,"3,970.89 x patient days",6353.6,Per diem,,109624,,"22,463 x DRG weight",109624,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,128964,,"26,426 x DRG weight",128964,Other,base rate x DRG weight,189396,,"38,809 x DRG weight",189396,Other,base rate x DRG weight,189396,,"38,809 x DRG weight",189396,Other,base rate x DRG weight,128964,,"26,426 x DRG weight",128964,Other,base rate x DRG weight,189396,,"38,809 x DRG weight",189396,Other,base rate x DRG weight,10181,,"6,363 x patient days",10181,Per diem,,246202,70,,246202,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,122283,,"25,057 x DRG weight",122283,Other,base rate x DRG weight,110058,,"22,552 x DRG weight",110058,Other,base rate x DRG weight,122283,,"25,057 x DRG weight",122283,Other,base rate x DRG weight,103938,,"21,298 x DRG weight",103938,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,246202,
AORTIC AND HEART ASSIST PROCEDURES EXCEPT PULSATION BALLOON WITH MCC,268,MS-DRG,,,,,,,,inpatient,,,527800.13,56395,,,56395,Other,150% of Medicare + 9.63% HCRA Surcharge,34294,,"3,609.90 x patient days",34294,Per diem,,171683,,"25,046 x DRG weight",171683,Other,base rate x DRG weight,154512,,"22,541 x DRG weight",154512,Other,base rate x DRG weight,216081,,"31,523 x DRG weight",216081,Other,base rate x DRG weight,194475,,"28,371 x DRG weight",194475,Other,base rate x DRG weight,183672,,"26,795 x DRG weight",183672,Other,base rate x DRG weight,37723.4,,"3,970.89 x patient days",37723.4,Per diem,,153977,,"22,463 x DRG weight",153977,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,181142,,"26,426 x DRG weight",181142,Other,base rate x DRG weight,266024,,"38,809 x DRG weight",266024,Other,base rate x DRG weight,266024,,"38,809 x DRG weight",266024,Other,base rate x DRG weight,181142,,"26,426 x DRG weight",181142,Other,base rate x DRG weight,266024,,"38,809 x DRG weight",266024,Other,base rate x DRG weight,60449,,"6,363 x patient days",60449,Per diem,,369460,70,,369460,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,171758,,"25,057 x DRG weight",171758,Other,base rate x DRG weight,154587,,"22,552 x DRG weight",154587,Other,base rate x DRG weight,171758,,"25,057 x DRG weight",171758,Other,base rate x DRG weight,145991,,"21,298 x DRG weight",145991,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,369460,
AORTIC AND HEART ASSIST PROCEDURES EXCEPT PULSATION BALLOON WITHOUT MCC,269,MS-DRG,,,,,,,,inpatient,,,238295.27,12467,,,12467,Other,150% of Medicare + 9.63% HCRA Surcharge,7581,,"3,609.90 x patient days",7581,Per diem,,104156,,"25,046 x DRG weight",104156,Other,base rate x DRG weight,93739,,"22,541 x DRG weight",93739,Other,base rate x DRG weight,131092,,"31,523 x DRG weight",131092,Other,base rate x DRG weight,117984,,"28,371 x DRG weight",117984,Other,base rate x DRG weight,111430,,"26,795 x DRG weight",111430,Other,base rate x DRG weight,8339.1,,"3,970.89 x patient days",8339.1,Per diem,,93415,,"22,463 x DRG weight",93415,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,109895,,"26,426 x DRG weight",109895,Other,base rate x DRG weight,161391,,"38,809 x DRG weight",161391,Other,base rate x DRG weight,161391,,"38,809 x DRG weight",161391,Other,base rate x DRG weight,109895,,"26,426 x DRG weight",109895,Other,base rate x DRG weight,161391,,"38,809 x DRG weight",161391,Other,base rate x DRG weight,13362,,"6,363 x patient days",13362,Per diem,,166807,70,,166807,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,104202,,"25,057 x DRG weight",104202,Other,base rate x DRG weight,93785,,"22,552 x DRG weight",93785,Other,base rate x DRG weight,104202,,"25,057 x DRG weight",104202,Other,base rate x DRG weight,88570,,"21,298 x DRG weight",88570,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,166807,
OTHER MAJOR CARDIOVASCULAR PROCEDURES WITH MCC,270,MS-DRG,,,,,,,,inpatient,,,574901.75,56395,,,56395,Other,150% of Medicare + 9.63% HCRA Surcharge,34294,,"3,609.90 x patient days",34294,Per diem,,126655,,"25,046 x DRG weight",126655,Other,base rate x DRG weight,113988,,"22,541 x DRG weight",113988,Other,base rate x DRG weight,159409,,"31,523 x DRG weight",159409,Other,base rate x DRG weight,143469,,"28,371 x DRG weight",143469,Other,base rate x DRG weight,135500,,"26,795 x DRG weight",135500,Other,base rate x DRG weight,37723.4,,"3,970.89 x patient days",37723.4,Per diem,,113593,,"22,463 x DRG weight",113593,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,133634,,"26,426 x DRG weight",133634,Other,base rate x DRG weight,196253,,"38,809 x DRG weight",196253,Other,base rate x DRG weight,196253,,"38,809 x DRG weight",196253,Other,base rate x DRG weight,133634,,"26,426 x DRG weight",133634,Other,base rate x DRG weight,196253,,"38,809 x DRG weight",196253,Other,base rate x DRG weight,60449,,"6,363 x patient days",60449,Per diem,,402431,70,,402431,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,126711,,"25,057 x DRG weight",126711,Other,base rate x DRG weight,114043,,"22,552 x DRG weight",114043,Other,base rate x DRG weight,126711,,"25,057 x DRG weight",126711,Other,base rate x DRG weight,107702,,"21,298 x DRG weight",107702,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,402431,
OTHER MAJOR CARDIOVASCULAR PROCEDURES WITH CC,271,MS-DRG,,,,,,,,inpatient,,,365025.15,32055,,,32055,Other,150% of Medicare + 9.63% HCRA Surcharge,19493,,"3,609.90 x patient days",19493,Per diem,,86564,,"25,046 x DRG weight",86564,Other,base rate x DRG weight,77906,,"22,541 x DRG weight",77906,Other,base rate x DRG weight,108950,,"31,523 x DRG weight",108950,Other,base rate x DRG weight,98056,,"28,371 x DRG weight",98056,Other,base rate x DRG weight,92609,,"26,795 x DRG weight",92609,Other,base rate x DRG weight,21442.3,,"3,970.89 x patient days",21442.3,Per diem,,77637,,"22,463 x DRG weight",77637,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,91334,,"26,426 x DRG weight",91334,Other,base rate x DRG weight,134132,,"38,809 x DRG weight",134132,Other,base rate x DRG weight,134132,,"38,809 x DRG weight",134132,Other,base rate x DRG weight,91334,,"26,426 x DRG weight",91334,Other,base rate x DRG weight,134132,,"38,809 x DRG weight",134132,Other,base rate x DRG weight,34360,,"6,363 x patient days",34360,Per diem,,255518,70,,255518,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,86602,,"25,057 x DRG weight",86602,Other,base rate x DRG weight,77944,,"22,552 x DRG weight",77944,Other,base rate x DRG weight,86602,,"25,057 x DRG weight",86602,Other,base rate x DRG weight,73610,,"21,298 x DRG weight",73610,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,255518,
OTHER MAJOR CARDIOVASCULAR PROCEDURES WITHOUT CC/MCC,272,MS-DRG,,,,,,,,inpatient,,,234749.99,14248,,,14248,Other,150% of Medicare + 9.63% HCRA Surcharge,8664,,"3,609.90 x patient days",8664,Per diem,,61100,,"25,046 x DRG weight",61100,Other,base rate x DRG weight,54989,,"22,541 x DRG weight",54989,Other,base rate x DRG weight,76900,,"31,523 x DRG weight",76900,Other,base rate x DRG weight,69211,,"28,371 x DRG weight",69211,Other,base rate x DRG weight,65366,,"26,795 x DRG weight",65366,Other,base rate x DRG weight,9530.4,,"3,970.89 x patient days",9530.4,Per diem,,54798,,"22,463 x DRG weight",54798,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,64466,,"26,426 x DRG weight",64466,Other,base rate x DRG weight,94675,,"38,809 x DRG weight",94675,Other,base rate x DRG weight,94675,,"38,809 x DRG weight",94675,Other,base rate x DRG weight,64466,,"26,426 x DRG weight",64466,Other,base rate x DRG weight,94675,,"38,809 x DRG weight",94675,Other,base rate x DRG weight,15271,,"6,363 x patient days",15271,Per diem,,164325,70,,164325,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,61127,,"25,057 x DRG weight",61127,Other,base rate x DRG weight,55016,,"22,552 x DRG weight",55016,Other,base rate x DRG weight,61127,,"25,057 x DRG weight",61127,Other,base rate x DRG weight,51956,,"21,298 x DRG weight",51956,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,164325,
PERCUTANEOUS AND OTHER INTRACARDIAC PROCEDURES WITH MCC,273,MS-DRG,,,,,,,,inpatient,,,427760.46,32649,,,32649,Other,150% of Medicare + 9.63% HCRA Surcharge,19854,,"3,609.90 x patient days",19854,Per diem,,97604,,"25,046 x DRG weight",97604,Other,base rate x DRG weight,87842,,"22,541 x DRG weight",87842,Other,base rate x DRG weight,122845,,"31,523 x DRG weight",122845,Other,base rate x DRG weight,110562,,"28,371 x DRG weight",110562,Other,base rate x DRG weight,104420,,"26,795 x DRG weight",104420,Other,base rate x DRG weight,21839.4,,"3,970.89 x patient days",21839.4,Per diem,,87538,,"22,463 x DRG weight",87538,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,102982,,"26,426 x DRG weight",102982,Other,base rate x DRG weight,151239,,"38,809 x DRG weight",151239,Other,base rate x DRG weight,151239,,"38,809 x DRG weight",151239,Other,base rate x DRG weight,102982,,"26,426 x DRG weight",102982,Other,base rate x DRG weight,151239,,"38,809 x DRG weight",151239,Other,base rate x DRG weight,34997,,"6,363 x patient days",34997,Per diem,,299432,70,,299432,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,97647,,"25,057 x DRG weight",97647,Other,base rate x DRG weight,87885,,"22,552 x DRG weight",87885,Other,base rate x DRG weight,97647,,"25,057 x DRG weight",97647,Other,base rate x DRG weight,82998,,"21,298 x DRG weight",82998,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,299432,
PERCUTANEOUS AND OTHER INTRACARDIAC PROCEDURES WITHOUT MCC,274,MS-DRG,,,,,,,,inpatient,,,273708.33,8905,,,8905,Other,150% of Medicare + 9.63% HCRA Surcharge,5415,,"3,609.90 x patient days",5415,Per diem,,81169,,"25,046 x DRG weight",81169,Other,base rate x DRG weight,73051,,"22,541 x DRG weight",73051,Other,base rate x DRG weight,102160,,"31,523 x DRG weight",102160,Other,base rate x DRG weight,91945,,"28,371 x DRG weight",91945,Other,base rate x DRG weight,86837,,"26,795 x DRG weight",86837,Other,base rate x DRG weight,5956.5,,"3,970.89 x patient days",5956.5,Per diem,,72798,,"22,463 x DRG weight",72798,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,85641,,"26,426 x DRG weight",85641,Other,base rate x DRG weight,125772,,"38,809 x DRG weight",125772,Other,base rate x DRG weight,125772,,"38,809 x DRG weight",125772,Other,base rate x DRG weight,85641,,"26,426 x DRG weight",85641,Other,base rate x DRG weight,125772,,"38,809 x DRG weight",125772,Other,base rate x DRG weight,9545,,"6,363 x patient days",9545,Per diem,,191596,70,,191596,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,81205,,"25,057 x DRG weight",81205,Other,base rate x DRG weight,73087,,"22,552 x DRG weight",73087,Other,base rate x DRG weight,81205,,"25,057 x DRG weight",81205,Other,base rate x DRG weight,69023,,"21,298 x DRG weight",69023,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,191596,
CARDIAC DEFIBRILLATOR IMPLANT WITH CARDIAC CATHETERIZATION AND MCC,275,MS-DRG,,,,,,,,inpatient,,,679165.74,58769,,,58769,Other,150% of Medicare + 9.63% HCRA Surcharge,35738,,"3,609.90 x patient days",35738,Per diem,,176219,,"25,046 x DRG weight",176219,Other,base rate x DRG weight,158594,,"22,541 x DRG weight",158594,Other,base rate x DRG weight,221790,,"31,523 x DRG weight",221790,Other,base rate x DRG weight,199613,,"28,371 x DRG weight",199613,Other,base rate x DRG weight,188524,,"26,795 x DRG weight",188524,Other,base rate x DRG weight,39311.8,,"3,970.89 x patient days",39311.8,Per diem,,158045,,"22,463 x DRG weight",158045,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,185928,,"26,426 x DRG weight",185928,Other,base rate x DRG weight,273052,,"38,809 x DRG weight",273052,Other,base rate x DRG weight,273052,,"38,809 x DRG weight",273052,Other,base rate x DRG weight,185928,,"26,426 x DRG weight",185928,Other,base rate x DRG weight,273052,,"38,809 x DRG weight",273052,Other,base rate x DRG weight,62994,,"6,363 x patient days",62994,Per diem,,475416,70,,475416,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,176296,,"25,057 x DRG weight",176296,Other,base rate x DRG weight,158671,,"22,552 x DRG weight",158671,Other,base rate x DRG weight,176296,,"25,057 x DRG weight",176296,Other,base rate x DRG weight,149848,,"21,298 x DRG weight",149848,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,475416,
CARDIAC DEFIBRILLATOR IMPLANT WITH MCC,276,MS-DRG,,,,,,,,inpatient,,,527800.13,49271,,,49271,Other,150% of Medicare + 9.63% HCRA Surcharge,29962,,"3,609.90 x patient days",29962,Per diem,,155541,,"25,046 x DRG weight",155541,Other,base rate x DRG weight,139984,,"22,541 x DRG weight",139984,Other,base rate x DRG weight,195764,,"31,523 x DRG weight",195764,Other,base rate x DRG weight,176190,,"28,371 x DRG weight",176190,Other,base rate x DRG weight,166402,,"26,795 x DRG weight",166402,Other,base rate x DRG weight,32958.2,,"3,970.89 x patient days",32958.2,Per diem,,139500,,"22,463 x DRG weight",139500,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,164111,,"26,426 x DRG weight",164111,Other,base rate x DRG weight,241012,,"38,809 x DRG weight",241012,Other,base rate x DRG weight,241012,,"38,809 x DRG weight",241012,Other,base rate x DRG weight,164111,,"26,426 x DRG weight",164111,Other,base rate x DRG weight,241012,,"38,809 x DRG weight",241012,Other,base rate x DRG weight,52813,,"6,363 x patient days",52813,Per diem,,369460,70,,369460,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,155609,,"25,057 x DRG weight",155609,Other,base rate x DRG weight,140052,,"22,552 x DRG weight",140052,Other,base rate x DRG weight,155609,,"25,057 x DRG weight",155609,Other,base rate x DRG weight,132265,,"21,298 x DRG weight",132265,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,369460,
CARDIAC DEFIBRILLATOR IMPLANT WITHOUT MCC,277,MS-DRG,,,,,,,,inpatient,,,396793.25,24933,,,24933,Other,150% of Medicare + 9.63% HCRA Surcharge,15162,,"3,609.90 x patient days",15162,Per diem,,119780,,"25,046 x DRG weight",119780,Other,base rate x DRG weight,107800,,"22,541 x DRG weight",107800,Other,base rate x DRG weight,150756,,"31,523 x DRG weight",150756,Other,base rate x DRG weight,135681,,"28,371 x DRG weight",135681,Other,base rate x DRG weight,128144,,"26,795 x DRG weight",128144,Other,base rate x DRG weight,16678.2,,"3,970.89 x patient days",16678.2,Per diem,,107427,,"22,463 x DRG weight",107427,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,126380,,"26,426 x DRG weight",126380,Other,base rate x DRG weight,185600,,"38,809 x DRG weight",185600,Other,base rate x DRG weight,185600,,"38,809 x DRG weight",185600,Other,base rate x DRG weight,126380,,"26,426 x DRG weight",126380,Other,base rate x DRG weight,185600,,"38,809 x DRG weight",185600,Other,base rate x DRG weight,26725,,"6,363 x patient days",26725,Per diem,,277755,70,,277755,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,119833,,"25,057 x DRG weight",119833,Other,base rate x DRG weight,107853,,"22,552 x DRG weight",107853,Other,base rate x DRG weight,119833,,"25,057 x DRG weight",119833,Other,base rate x DRG weight,101856,,"21,298 x DRG weight",101856,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,277755,
ULTRASOUND ACCELERATED AND OTHER THROMBOLYSIS OF PERIPHERAL VASCULAR STRUCTURES WITH MCC,278,MS-DRG,,,,,,,,inpatient,,,624536.85,50458,,,50458,Other,150% of Medicare + 9.63% HCRA Surcharge,30684,,"3,609.90 x patient days",30684,Per diem,,111715,,"25,046 x DRG weight",111715,Other,base rate x DRG weight,100542,,"22,541 x DRG weight",100542,Other,base rate x DRG weight,140605,,"31,523 x DRG weight",140605,Other,base rate x DRG weight,126546,,"28,371 x DRG weight",126546,Other,base rate x DRG weight,119516,,"26,795 x DRG weight",119516,Other,base rate x DRG weight,33752.4,,"3,970.89 x patient days",33752.4,Per diem,,100194,,"22,463 x DRG weight",100194,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,117871,,"26,426 x DRG weight",117871,Other,base rate x DRG weight,173104,,"38,809 x DRG weight",173104,Other,base rate x DRG weight,173104,,"38,809 x DRG weight",173104,Other,base rate x DRG weight,117871,,"26,426 x DRG weight",117871,Other,base rate x DRG weight,173104,,"38,809 x DRG weight",173104,Other,base rate x DRG weight,54086,,"6,363 x patient days",54086,Per diem,,437176,70,,437176,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,111764,,"25,057 x DRG weight",111764,Other,base rate x DRG weight,100591,,"22,552 x DRG weight",100591,Other,base rate x DRG weight,111764,,"25,057 x DRG weight",111764,Other,base rate x DRG weight,94998,,"21,298 x DRG weight",94998,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,437176,
ULTRASOUND ACCELERATED AND OTHER THROMBOLYSIS OF PERIPHERAL VASCULAR STRUCTURES WITHOUT MCC,279,MS-DRG,,,,,,,,inpatient,,,503452,25527,,,25527,Other,150% of Medicare + 9.63% HCRA Surcharge,15523,,"3,609.90 x patient days",15523,Per diem,,80162,,"25,046 x DRG weight",80162,Other,base rate x DRG weight,72145,,"22,541 x DRG weight",72145,Other,base rate x DRG weight,100893,,"31,523 x DRG weight",100893,Other,base rate x DRG weight,90804,,"28,371 x DRG weight",90804,Other,base rate x DRG weight,85760,,"26,795 x DRG weight",85760,Other,base rate x DRG weight,17075.3,,"3,970.89 x patient days",17075.3,Per diem,,71895,,"22,463 x DRG weight",71895,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,84579,,"26,426 x DRG weight",84579,Other,base rate x DRG weight,124212,,"38,809 x DRG weight",124212,Other,base rate x DRG weight,124212,,"38,809 x DRG weight",124212,Other,base rate x DRG weight,84579,,"26,426 x DRG weight",84579,Other,base rate x DRG weight,124212,,"38,809 x DRG weight",124212,Other,base rate x DRG weight,27361,,"6,363 x patient days",27361,Per diem,,352416,70,,352416,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,80197,,"25,057 x DRG weight",80197,Other,base rate x DRG weight,72180,,"22,552 x DRG weight",72180,Other,base rate x DRG weight,80197,,"25,057 x DRG weight",80197,Other,base rate x DRG weight,68166,,"21,298 x DRG weight",68166,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,352416,
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH MCC",280,MS-DRG,,,,,,,,inpatient,,,187163.71,32649,,,32649,Other,150% of Medicare + 9.63% HCRA Surcharge,19854,,"3,609.90 x patient days",19854,Per diem,,39735,,"25,046 x DRG weight",39735,Other,base rate x DRG weight,35761,,"22,541 x DRG weight",35761,Other,base rate x DRG weight,50011,,"31,523 x DRG weight",50011,Other,base rate x DRG weight,45011,,"28,371 x DRG weight",45011,Other,base rate x DRG weight,42510,,"26,795 x DRG weight",42510,Other,base rate x DRG weight,21839.4,,"3,970.89 x patient days",21839.4,Per diem,,35638,,"22,463 x DRG weight",35638,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,41925,,"26,426 x DRG weight",41925,Other,base rate x DRG weight,61570,,"38,809 x DRG weight",61570,Other,base rate x DRG weight,61570,,"38,809 x DRG weight",61570,Other,base rate x DRG weight,41925,,"26,426 x DRG weight",41925,Other,base rate x DRG weight,61570,,"38,809 x DRG weight",61570,Other,base rate x DRG weight,34997,,"6,363 x patient days",34997,Per diem,,131015,70,,131015,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,39753,,"25,057 x DRG weight",39753,Other,base rate x DRG weight,35779,,"22,552 x DRG weight",35779,Other,base rate x DRG weight,39753,,"25,057 x DRG weight",39753,Other,base rate x DRG weight,33789,,"21,298 x DRG weight",33789,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,131015,
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH CC",281,MS-DRG,,,,,,,,inpatient,,,165079.79,17809,,,17809,Other,150% of Medicare + 9.63% HCRA Surcharge,10830,,"3,609.90 x patient days",10830,Per diem,,22867,,"25,046 x DRG weight",22867,Other,base rate x DRG weight,20580,,"22,541 x DRG weight",20580,Other,base rate x DRG weight,28780,,"31,523 x DRG weight",28780,Other,base rate x DRG weight,25903,,"28,371 x DRG weight",25903,Other,base rate x DRG weight,24464,,"26,795 x DRG weight",24464,Other,base rate x DRG weight,11913,,"3,970.89 x patient days",11913,Per diem,,20509,,"22,463 x DRG weight",20509,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,24127,,"26,426 x DRG weight",24127,Other,base rate x DRG weight,35433,,"38,809 x DRG weight",35433,Other,base rate x DRG weight,35433,,"38,809 x DRG weight",35433,Other,base rate x DRG weight,24127,,"26,426 x DRG weight",24127,Other,base rate x DRG weight,35433,,"38,809 x DRG weight",35433,Other,base rate x DRG weight,19089,,"6,363 x patient days",19089,Per diem,,115556,70,,115556,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,22877,,"25,057 x DRG weight",22877,Other,base rate x DRG weight,20590,,"22,552 x DRG weight",20590,Other,base rate x DRG weight,22877,,"25,057 x DRG weight",22877,Other,base rate x DRG weight,19445,,"21,298 x DRG weight",19445,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,115556,
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITHOUT CC/MCC",282,MS-DRG,,,,,,,,inpatient,,,125225.93,12467,,,12467,Other,150% of Medicare + 9.63% HCRA Surcharge,7581,,"3,609.90 x patient days",7581,Per diem,,17986,,"25,046 x DRG weight",17986,Other,base rate x DRG weight,16187,,"22,541 x DRG weight",16187,Other,base rate x DRG weight,22637,,"31,523 x DRG weight",22637,Other,base rate x DRG weight,20373,,"28,371 x DRG weight",20373,Other,base rate x DRG weight,19241,,"26,795 x DRG weight",19241,Other,base rate x DRG weight,8339.1,,"3,970.89 x patient days",8339.1,Per diem,,16131,,"22,463 x DRG weight",16131,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,18977,,"26,426 x DRG weight",18977,Other,base rate x DRG weight,27869,,"38,809 x DRG weight",27869,Other,base rate x DRG weight,27869,,"38,809 x DRG weight",27869,Other,base rate x DRG weight,18977,,"26,426 x DRG weight",18977,Other,base rate x DRG weight,27869,,"38,809 x DRG weight",27869,Other,base rate x DRG weight,13362,,"6,363 x patient days",13362,Per diem,,87658,70,,87658,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,17993,,"25,057 x DRG weight",17993,Other,base rate x DRG weight,16195,,"22,552 x DRG weight",16195,Other,base rate x DRG weight,17993,,"25,057 x DRG weight",17993,Other,base rate x DRG weight,15294,,"21,298 x DRG weight",15294,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,87658,
"ACUTE MYOCARDIAL INFARCTION, EXPIRED WITH MCC",283,MS-DRG,,,,,,,,inpatient,,,325734.2,32055,,,32055,Other,150% of Medicare + 9.63% HCRA Surcharge,19493,,"3,609.90 x patient days",19493,Per diem,,49376,,"25,046 x DRG weight",49376,Other,base rate x DRG weight,44437,,"22,541 x DRG weight",44437,Other,base rate x DRG weight,62144,,"31,523 x DRG weight",62144,Other,base rate x DRG weight,55931,,"28,371 x DRG weight",55931,Other,base rate x DRG weight,52824,,"26,795 x DRG weight",52824,Other,base rate x DRG weight,21442.3,,"3,970.89 x patient days",21442.3,Per diem,,44284,,"22,463 x DRG weight",44284,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,52096,,"26,426 x DRG weight",52096,Other,base rate x DRG weight,76508,,"38,809 x DRG weight",76508,Other,base rate x DRG weight,76508,,"38,809 x DRG weight",76508,Other,base rate x DRG weight,52096,,"26,426 x DRG weight",52096,Other,base rate x DRG weight,76508,,"38,809 x DRG weight",76508,Other,base rate x DRG weight,34360,,"6,363 x patient days",34360,Per diem,,228014,70,,228014,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,49397,,"25,057 x DRG weight",49397,Other,base rate x DRG weight,44459,,"22,552 x DRG weight",44459,Other,base rate x DRG weight,49397,,"25,057 x DRG weight",49397,Other,base rate x DRG weight,41987,,"21,298 x DRG weight",41987,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,228014,
"ACUTE MYOCARDIAL INFARCTION, EXPIRED WITH CC",284,MS-DRG,,,,,,,,inpatient,,,155313.68,14248,,,14248,Other,150% of Medicare + 9.63% HCRA Surcharge,8664,,"3,609.90 x patient days",8664,Per diem,,18527,,"25,046 x DRG weight",18527,Other,base rate x DRG weight,16674,,"22,541 x DRG weight",16674,Other,base rate x DRG weight,23318,,"31,523 x DRG weight",23318,Other,base rate x DRG weight,20986,,"28,371 x DRG weight",20986,Other,base rate x DRG weight,19820,,"26,795 x DRG weight",19820,Other,base rate x DRG weight,9530.4,,"3,970.89 x patient days",9530.4,Per diem,,16616,,"22,463 x DRG weight",16616,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,19547,,"26,426 x DRG weight",19547,Other,base rate x DRG weight,28707,,"38,809 x DRG weight",28707,Other,base rate x DRG weight,28707,,"38,809 x DRG weight",28707,Other,base rate x DRG weight,19547,,"26,426 x DRG weight",19547,Other,base rate x DRG weight,28707,,"38,809 x DRG weight",28707,Other,base rate x DRG weight,15271,,"6,363 x patient days",15271,Per diem,,108720,70,,108720,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,18535,,"25,057 x DRG weight",18535,Other,base rate x DRG weight,16682,,"22,552 x DRG weight",16682,Other,base rate x DRG weight,18535,,"25,057 x DRG weight",18535,Other,base rate x DRG weight,15754,,"21,298 x DRG weight",15754,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,108720,
"ACUTE MYOCARDIAL INFARCTION, EXPIRED WITHOUT CC/MCC",285,MS-DRG,,,,,,,,inpatient,,,62179.52,8311,,,8311,Other,150% of Medicare + 9.63% HCRA Surcharge,5054,,"3,609.90 x patient days",5054,Per diem,,12240,,"25,046 x DRG weight",12240,Other,base rate x DRG weight,11016,,"22,541 x DRG weight",11016,Other,base rate x DRG weight,15405,,"31,523 x DRG weight",15405,Other,base rate x DRG weight,13865,,"28,371 x DRG weight",13865,Other,base rate x DRG weight,13095,,"26,795 x DRG weight",13095,Other,base rate x DRG weight,5559.4,,"3,970.89 x patient days",5559.4,Per diem,,10978,,"22,463 x DRG weight",10978,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,12914,,"26,426 x DRG weight",12914,Other,base rate x DRG weight,18966,,"38,809 x DRG weight",18966,Other,base rate x DRG weight,18966,,"38,809 x DRG weight",18966,Other,base rate x DRG weight,12914,,"26,426 x DRG weight",12914,Other,base rate x DRG weight,18966,,"38,809 x DRG weight",18966,Other,base rate x DRG weight,8908,,"6,363 x patient days",8908,Per diem,,43526,70,,43526,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,12245,,"25,057 x DRG weight",12245,Other,base rate x DRG weight,11021,,"22,552 x DRG weight",11021,Other,base rate x DRG weight,12245,,"25,057 x DRG weight",12245,Other,base rate x DRG weight,10408,,"21,298 x DRG weight",10408,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,43526,
"CIRCULATORY DISORDERS EXCEPT AMI, WITH CARDIAC CATHETERIZATION WITH MCC",286,MS-DRG,,,,,,,,inpatient,,,320162.29,42741,,,42741,Other,150% of Medicare + 9.63% HCRA Surcharge,25991,,"3,609.90 x patient days",25991,Per diem,,53989,,"25,046 x DRG weight",53989,Other,base rate x DRG weight,48589,,"22,541 x DRG weight",48589,Other,base rate x DRG weight,67951,,"31,523 x DRG weight",67951,Other,base rate x DRG weight,61157,,"28,371 x DRG weight",61157,Other,base rate x DRG weight,57759,,"26,795 x DRG weight",57759,Other,base rate x DRG weight,28590.1,,"3,970.89 x patient days",28590.1,Per diem,,48421,,"22,463 x DRG weight",48421,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,56964,,"26,426 x DRG weight",56964,Other,base rate x DRG weight,83657,,"38,809 x DRG weight",83657,Other,base rate x DRG weight,83657,,"38,809 x DRG weight",83657,Other,base rate x DRG weight,56964,,"26,426 x DRG weight",56964,Other,base rate x DRG weight,83657,,"38,809 x DRG weight",83657,Other,base rate x DRG weight,45814,,"6,363 x patient days",45814,Per diem,,224114,70,,224114,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,54013,,"25,057 x DRG weight",54013,Other,base rate x DRG weight,48613,,"22,552 x DRG weight",48613,Other,base rate x DRG weight,54013,,"25,057 x DRG weight",54013,Other,base rate x DRG weight,45910,,"21,298 x DRG weight",45910,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,224114,
"CIRCULATORY DISORDERS EXCEPT AMI, WITH CARDIAC CATHETERIZATION WITHOUT MCC",287,MS-DRG,,,,,,,,inpatient,,,197727.89,16028,,,16028,Other,150% of Medicare + 9.63% HCRA Surcharge,9747,,"3,609.90 x patient days",9747,Per diem,,27090,,"25,046 x DRG weight",27090,Other,base rate x DRG weight,24380,,"22,541 x DRG weight",24380,Other,base rate x DRG weight,34095,,"31,523 x DRG weight",34095,Other,base rate x DRG weight,30686,,"28,371 x DRG weight",30686,Other,base rate x DRG weight,28981,,"26,795 x DRG weight",28981,Other,base rate x DRG weight,10721.7,,"3,970.89 x patient days",10721.7,Per diem,,24296,,"22,463 x DRG weight",24296,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,28582,,"26,426 x DRG weight",28582,Other,base rate x DRG weight,41976,,"38,809 x DRG weight",41976,Other,base rate x DRG weight,41976,,"38,809 x DRG weight",41976,Other,base rate x DRG weight,28582,,"26,426 x DRG weight",28582,Other,base rate x DRG weight,41976,,"38,809 x DRG weight",41976,Other,base rate x DRG weight,17180,,"6,363 x patient days",17180,Per diem,,138410,70,,138410,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,27102,,"25,057 x DRG weight",27102,Other,base rate x DRG weight,24392,,"22,552 x DRG weight",24392,Other,base rate x DRG weight,27102,,"25,057 x DRG weight",27102,Other,base rate x DRG weight,23036,,"21,298 x DRG weight",23036,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,138410,
ACUTE AND SUBACUTE ENDOCARDITIS WITH MCC,288,MS-DRG,,,,,,,,inpatient,,,234961.3,58769,,,58769,Other,150% of Medicare + 9.63% HCRA Surcharge,35738,,"3,609.90 x patient days",35738,Per diem,,64944,,"25,046 x DRG weight",64944,Other,base rate x DRG weight,58449,,"22,541 x DRG weight",58449,Other,base rate x DRG weight,81739,,"31,523 x DRG weight",81739,Other,base rate x DRG weight,73566,,"28,371 x DRG weight",73566,Other,base rate x DRG weight,69479,,"26,795 x DRG weight",69479,Other,base rate x DRG weight,39311.8,,"3,970.89 x patient days",39311.8,Per diem,,58247,,"22,463 x DRG weight",58247,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,68523,,"26,426 x DRG weight",68523,Other,base rate x DRG weight,100632,,"38,809 x DRG weight",100632,Other,base rate x DRG weight,100632,,"38,809 x DRG weight",100632,Other,base rate x DRG weight,68523,,"26,426 x DRG weight",68523,Other,base rate x DRG weight,100632,,"38,809 x DRG weight",100632,Other,base rate x DRG weight,62994,,"6,363 x patient days",62994,Per diem,,164473,70,,164473,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,64973,,"25,057 x DRG weight",64973,Other,base rate x DRG weight,58477,,"22,552 x DRG weight",58477,Other,base rate x DRG weight,64973,,"25,057 x DRG weight",64973,Other,base rate x DRG weight,55226,,"21,298 x DRG weight",55226,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,164473,
ACUTE AND SUBACUTE ENDOCARDITIS WITH CC,289,MS-DRG,,,,,,,,inpatient,,,75012,36804,,,36804,Other,150% of Medicare + 9.63% HCRA Surcharge,22381,,"3,609.90 x patient days",22381,Per diem,,37010,,"25,046 x DRG weight",37010,Other,base rate x DRG weight,33309,,"22,541 x DRG weight",33309,Other,base rate x DRG weight,46582,,"31,523 x DRG weight",46582,Other,base rate x DRG weight,41924,,"28,371 x DRG weight",41924,Other,base rate x DRG weight,39595,,"26,795 x DRG weight",39595,Other,base rate x DRG weight,24619.1,,"3,970.89 x patient days",24619.1,Per diem,,33194,,"22,463 x DRG weight",33194,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,39050,,"26,426 x DRG weight",39050,Other,base rate x DRG weight,57348,,"38,809 x DRG weight",57348,Other,base rate x DRG weight,57348,,"38,809 x DRG weight",57348,Other,base rate x DRG weight,39050,,"26,426 x DRG weight",39050,Other,base rate x DRG weight,57348,,"38,809 x DRG weight",57348,Other,base rate x DRG weight,39451,,"6,363 x patient days",39451,Per diem,,52508,70,,52508,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,37027,,"25,057 x DRG weight",37027,Other,base rate x DRG weight,33325,,"22,552 x DRG weight",33325,Other,base rate x DRG weight,37027,,"25,057 x DRG weight",37027,Other,base rate x DRG weight,31472,,"21,298 x DRG weight",31472,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,57348,
ACUTE AND SUBACUTE ENDOCARDITIS WITHOUT CC/MCC,290,MS-DRG,,,,,,,,inpatient,,,365016,25527,,,25527,Other,150% of Medicare + 9.63% HCRA Surcharge,15523,,"3,609.90 x patient days",15523,Per diem,,27177,,"25,046 x DRG weight",27177,Other,base rate x DRG weight,24459,,"22,541 x DRG weight",24459,Other,base rate x DRG weight,34206,,"31,523 x DRG weight",34206,Other,base rate x DRG weight,30785,,"28,371 x DRG weight",30785,Other,base rate x DRG weight,29075,,"26,795 x DRG weight",29075,Other,base rate x DRG weight,17075.3,,"3,970.89 x patient days",17075.3,Per diem,,24375,,"22,463 x DRG weight",24375,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,28675,,"26,426 x DRG weight",28675,Other,base rate x DRG weight,42112,,"38,809 x DRG weight",42112,Other,base rate x DRG weight,42112,,"38,809 x DRG weight",42112,Other,base rate x DRG weight,28675,,"26,426 x DRG weight",28675,Other,base rate x DRG weight,42112,,"38,809 x DRG weight",42112,Other,base rate x DRG weight,27361,,"6,363 x patient days",27361,Per diem,,255511,70,,255511,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,27189,,"25,057 x DRG weight",27189,Other,base rate x DRG weight,24471,,"22,552 x DRG weight",24471,Other,base rate x DRG weight,27189,,"25,057 x DRG weight",27189,Other,base rate x DRG weight,23110,,"21,298 x DRG weight",23110,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,255511,
HEART FAILURE AND SHOCK WITH MCC,291,MS-DRG,,,,,,,,inpatient,,,180437.03,30274,,,30274,Other,150% of Medicare + 9.63% HCRA Surcharge,18410,,"3,609.90 x patient days",18410,Per diem,,32157,,"25,046 x DRG weight",32157,Other,base rate x DRG weight,28940,,"22,541 x DRG weight",28940,Other,base rate x DRG weight,40472,,"31,523 x DRG weight",40472,Other,base rate x DRG weight,36426,,"28,371 x DRG weight",36426,Other,base rate x DRG weight,34402,,"26,795 x DRG weight",34402,Other,base rate x DRG weight,20251,,"3,970.89 x patient days",20251,Per diem,,28840,,"22,463 x DRG weight",28840,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,33928,,"26,426 x DRG weight",33928,Other,base rate x DRG weight,49827,,"38,809 x DRG weight",49827,Other,base rate x DRG weight,49827,,"38,809 x DRG weight",49827,Other,base rate x DRG weight,33928,,"26,426 x DRG weight",33928,Other,base rate x DRG weight,49827,,"38,809 x DRG weight",49827,Other,base rate x DRG weight,32451,,"6,363 x patient days",32451,Per diem,,126306,70,,126306,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,32171,,"25,057 x DRG weight",32171,Other,base rate x DRG weight,28955,,"22,552 x DRG weight",28955,Other,base rate x DRG weight,32171,,"25,057 x DRG weight",32171,Other,base rate x DRG weight,27345,,"21,298 x DRG weight",27345,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,126306,
HEART FAILURE AND SHOCK WITH CC,292,MS-DRG,,,,,,,,inpatient,,,140436.83,23152,,,23152,Other,150% of Medicare + 9.63% HCRA Surcharge,14079,,"3,609.90 x patient days",14079,Per diem,,21452,,"25,046 x DRG weight",21452,Other,base rate x DRG weight,19306,,"22,541 x DRG weight",19306,Other,base rate x DRG weight,26999,,"31,523 x DRG weight",26999,Other,base rate x DRG weight,24300,,"28,371 x DRG weight",24300,Other,base rate x DRG weight,22950,,"26,795 x DRG weight",22950,Other,base rate x DRG weight,15486.9,,"3,970.89 x patient days",15486.9,Per diem,,19240,,"22,463 x DRG weight",19240,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,22634,,"26,426 x DRG weight",22634,Other,base rate x DRG weight,33240,,"38,809 x DRG weight",33240,Other,base rate x DRG weight,33240,,"38,809 x DRG weight",33240,Other,base rate x DRG weight,22634,,"26,426 x DRG weight",22634,Other,base rate x DRG weight,33240,,"38,809 x DRG weight",33240,Other,base rate x DRG weight,24816,,"6,363 x patient days",24816,Per diem,,98306,70,,98306,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,21461,,"25,057 x DRG weight",21461,Other,base rate x DRG weight,19316,,"22,552 x DRG weight",19316,Other,base rate x DRG weight,21461,,"25,057 x DRG weight",21461,Other,base rate x DRG weight,18242,,"21,298 x DRG weight",18242,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,98306,
HEART FAILURE AND SHOCK WITHOUT CC/MCC,293,MS-DRG,,,,,,,,inpatient,,,158996.19,15435,,,15435,Other,150% of Medicare + 9.63% HCRA Surcharge,9386,,"3,609.90 x patient days",9386,Per diem,,14063,,"25,046 x DRG weight",14063,Other,base rate x DRG weight,12657,,"22,541 x DRG weight",12657,Other,base rate x DRG weight,17700,,"31,523 x DRG weight",17700,Other,base rate x DRG weight,15930,,"28,371 x DRG weight",15930,Other,base rate x DRG weight,15045,,"26,795 x DRG weight",15045,Other,base rate x DRG weight,10324.6,,"3,970.89 x patient days",10324.6,Per diem,,12613,,"22,463 x DRG weight",12613,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,14838,,"26,426 x DRG weight",14838,Other,base rate x DRG weight,21791,,"38,809 x DRG weight",21791,Other,base rate x DRG weight,21791,,"38,809 x DRG weight",21791,Other,base rate x DRG weight,14838,,"26,426 x DRG weight",14838,Other,base rate x DRG weight,21791,,"38,809 x DRG weight",21791,Other,base rate x DRG weight,16544,,"6,363 x patient days",16544,Per diem,,111297,70,,111297,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,14070,,"25,057 x DRG weight",14070,Other,base rate x DRG weight,12663,,"22,552 x DRG weight",12663,Other,base rate x DRG weight,14070,,"25,057 x DRG weight",14070,Other,base rate x DRG weight,11959,,"21,298 x DRG weight",11959,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,111297,
DEEP VEIN THROMBOPHLEBITIS WITH CC/MCC,294,MS-DRG,,,,,,,,inpatient,,,365016,27901,,,27901,Other,150% of Medicare + 9.63% HCRA Surcharge,16967,,"3,609.90 x patient days",16967,Per diem,,27393,,"25,046 x DRG weight",27393,Other,base rate x DRG weight,24653,,"22,541 x DRG weight",24653,Other,base rate x DRG weight,34477,,"31,523 x DRG weight",34477,Other,base rate x DRG weight,31029,,"28,371 x DRG weight",31029,Other,base rate x DRG weight,29306,,"26,795 x DRG weight",29306,Other,base rate x DRG weight,18663.7,,"3,970.89 x patient days",18663.7,Per diem,,24568,,"22,463 x DRG weight",24568,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,28902,,"26,426 x DRG weight",28902,Other,base rate x DRG weight,42445,,"38,809 x DRG weight",42445,Other,base rate x DRG weight,42445,,"38,809 x DRG weight",42445,Other,base rate x DRG weight,28902,,"26,426 x DRG weight",28902,Other,base rate x DRG weight,42445,,"38,809 x DRG weight",42445,Other,base rate x DRG weight,29906,,"6,363 x patient days",29906,Per diem,,255511,70,,255511,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,27405,,"25,057 x DRG weight",27405,Other,base rate x DRG weight,24665,,"22,552 x DRG weight",24665,Other,base rate x DRG weight,27405,,"25,057 x DRG weight",27405,Other,base rate x DRG weight,23294,,"21,298 x DRG weight",23294,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,255511,
DEEP VEIN THROMBOPHLEBITIS WITHOUT CC/MCC,295,MS-DRG,,,,,,,,inpatient,,,57778,16622,,,16622,Other,150% of Medicare + 9.63% HCRA Surcharge,10108,,"3,609.90 x patient days",10108,Per diem,,19964,,"25,046 x DRG weight",19964,Other,base rate x DRG weight,17967,,"22,541 x DRG weight",17967,Other,base rate x DRG weight,25127,,"31,523 x DRG weight",25127,Other,base rate x DRG weight,22615,,"28,371 x DRG weight",22615,Other,base rate x DRG weight,21358,,"26,795 x DRG weight",21358,Other,base rate x DRG weight,11118.8,,"3,970.89 x patient days",11118.8,Per diem,,17905,,"22,463 x DRG weight",17905,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,21064,,"26,426 x DRG weight",21064,Other,base rate x DRG weight,30935,,"38,809 x DRG weight",30935,Other,base rate x DRG weight,30935,,"38,809 x DRG weight",30935,Other,base rate x DRG weight,21064,,"26,426 x DRG weight",21064,Other,base rate x DRG weight,30935,,"38,809 x DRG weight",30935,Other,base rate x DRG weight,17816,,"6,363 x patient days",17816,Per diem,,40445,70,,40445,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,19973,,"25,057 x DRG weight",19973,Other,base rate x DRG weight,17976,,"22,552 x DRG weight",17976,Other,base rate x DRG weight,19973,,"25,057 x DRG weight",19973,Other,base rate x DRG weight,16977,,"21,298 x DRG weight",16977,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,40445,
"CARDIAC ARREST, UNEXPLAINED WITH MCC",296,MS-DRG,,,,,,,,inpatient,,,302456.76,19590,,,19590,Other,150% of Medicare + 9.63% HCRA Surcharge,11913,,"3,609.90 x patient days",11913,Per diem,,40154,,"25,046 x DRG weight",40154,Other,base rate x DRG weight,36138,,"22,541 x DRG weight",36138,Other,base rate x DRG weight,50538,,"31,523 x DRG weight",50538,Other,base rate x DRG weight,45484,,"28,371 x DRG weight",45484,Other,base rate x DRG weight,42958,,"26,795 x DRG weight",42958,Other,base rate x DRG weight,13104.3,,"3,970.89 x patient days",13104.3,Per diem,,36013,,"22,463 x DRG weight",36013,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,42366,,"26,426 x DRG weight",42366,Other,base rate x DRG weight,62219,,"38,809 x DRG weight",62219,Other,base rate x DRG weight,62219,,"38,809 x DRG weight",62219,Other,base rate x DRG weight,42366,,"26,426 x DRG weight",42366,Other,base rate x DRG weight,62219,,"38,809 x DRG weight",62219,Other,base rate x DRG weight,20998,,"6,363 x patient days",20998,Per diem,,211720,70,,211720,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,40171,,"25,057 x DRG weight",40171,Other,base rate x DRG weight,36155,,"22,552 x DRG weight",36155,Other,base rate x DRG weight,40171,,"25,057 x DRG weight",40171,Other,base rate x DRG weight,34145,,"21,298 x DRG weight",34145,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,211720,
"CARDIAC ARREST, UNEXPLAINED WITH CC",297,MS-DRG,,,,,,,,inpatient,,,57778,9498,,,9498,Other,150% of Medicare + 9.63% HCRA Surcharge,5776,,"3,609.90 x patient days",5776,Per diem,,18249,,"25,046 x DRG weight",18249,Other,base rate x DRG weight,16423,,"22,541 x DRG weight",16423,Other,base rate x DRG weight,22968,,"31,523 x DRG weight",22968,Other,base rate x DRG weight,20671,,"28,371 x DRG weight",20671,Other,base rate x DRG weight,19523,,"26,795 x DRG weight",19523,Other,base rate x DRG weight,6353.6,,"3,970.89 x patient days",6353.6,Per diem,,16367,,"22,463 x DRG weight",16367,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,19254,,"26,426 x DRG weight",19254,Other,base rate x DRG weight,28276,,"38,809 x DRG weight",28276,Other,base rate x DRG weight,28276,,"38,809 x DRG weight",28276,Other,base rate x DRG weight,19254,,"26,426 x DRG weight",19254,Other,base rate x DRG weight,28276,,"38,809 x DRG weight",28276,Other,base rate x DRG weight,10181,,"6,363 x patient days",10181,Per diem,,40445,70,,40445,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,18257,,"25,057 x DRG weight",18257,Other,base rate x DRG weight,16431,,"22,552 x DRG weight",16431,Other,base rate x DRG weight,18257,,"25,057 x DRG weight",18257,Other,base rate x DRG weight,15518,,"21,298 x DRG weight",15518,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,40445,
"CARDIAC ARREST, UNEXPLAINED WITHOUT CC/MCC",298,MS-DRG,,,,,,,,inpatient,,,39243,6530,,,6530,Other,150% of Medicare + 9.63% HCRA Surcharge,3971,,"3,609.90 x patient days",3971,Per diem,,11013,,"25,046 x DRG weight",11013,Other,base rate x DRG weight,9911,,"22,541 x DRG weight",9911,Other,base rate x DRG weight,13861,,"31,523 x DRG weight",13861,Other,base rate x DRG weight,12475,,"28,371 x DRG weight",12475,Other,base rate x DRG weight,11782,,"26,795 x DRG weight",11782,Other,base rate x DRG weight,4368.1,,"3,970.89 x patient days",4368.1,Per diem,,9877,,"22,463 x DRG weight",9877,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,11620,,"26,426 x DRG weight",11620,Other,base rate x DRG weight,17064,,"38,809 x DRG weight",17064,Other,base rate x DRG weight,17064,,"38,809 x DRG weight",17064,Other,base rate x DRG weight,11620,,"26,426 x DRG weight",11620,Other,base rate x DRG weight,17064,,"38,809 x DRG weight",17064,Other,base rate x DRG weight,6999,,"6,363 x patient days",6999,Per diem,,27470,70,,27470,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,11018,,"25,057 x DRG weight",11018,Other,base rate x DRG weight,9916,,"22,552 x DRG weight",9916,Other,base rate x DRG weight,11018,,"25,057 x DRG weight",11018,Other,base rate x DRG weight,9365,,"21,298 x DRG weight",9365,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,27470,
PERIPHERAL VASCULAR DISORDERS WITH MCC,299,MS-DRG,,,,,,,,inpatient,,,188166.23,33243,,,33243,Other,150% of Medicare + 9.63% HCRA Surcharge,20215,,"3,609.90 x patient days",20215,Per diem,,39478,,"25,046 x DRG weight",39478,Other,base rate x DRG weight,35529,,"22,541 x DRG weight",35529,Other,base rate x DRG weight,49687,,"31,523 x DRG weight",49687,Other,base rate x DRG weight,44718,,"28,371 x DRG weight",44718,Other,base rate x DRG weight,42234,,"26,795 x DRG weight",42234,Other,base rate x DRG weight,22236.5,,"3,970.89 x patient days",22236.5,Per diem,,35406,,"22,463 x DRG weight",35406,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,41653,,"26,426 x DRG weight",41653,Other,base rate x DRG weight,61171,,"38,809 x DRG weight",61171,Other,base rate x DRG weight,61171,,"38,809 x DRG weight",61171,Other,base rate x DRG weight,41653,,"26,426 x DRG weight",41653,Other,base rate x DRG weight,61171,,"38,809 x DRG weight",61171,Other,base rate x DRG weight,35633,,"6,363 x patient days",35633,Per diem,,131716,70,,131716,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,39495,,"25,057 x DRG weight",39495,Other,base rate x DRG weight,35546,,"22,552 x DRG weight",35546,Other,base rate x DRG weight,39495,,"25,057 x DRG weight",39495,Other,base rate x DRG weight,33570,,"21,298 x DRG weight",33570,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,131716,
PERIPHERAL VASCULAR DISORDERS WITH CC,300,MS-DRG,,,,,,,,inpatient,,,123909.19,23746,,,23746,Other,150% of Medicare + 9.63% HCRA Surcharge,14440,,"3,609.90 x patient days",14440,Per diem,,26724,,"25,046 x DRG weight",26724,Other,base rate x DRG weight,24051,,"22,541 x DRG weight",24051,Other,base rate x DRG weight,33635,,"31,523 x DRG weight",33635,Other,base rate x DRG weight,30272,,"28,371 x DRG weight",30272,Other,base rate x DRG weight,28590,,"26,795 x DRG weight",28590,Other,base rate x DRG weight,15884,,"3,970.89 x patient days",15884,Per diem,,23968,,"22,463 x DRG weight",23968,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,28197,,"26,426 x DRG weight",28197,Other,base rate x DRG weight,41409,,"38,809 x DRG weight",41409,Other,base rate x DRG weight,41409,,"38,809 x DRG weight",41409,Other,base rate x DRG weight,28197,,"26,426 x DRG weight",28197,Other,base rate x DRG weight,41409,,"38,809 x DRG weight",41409,Other,base rate x DRG weight,25452,,"6,363 x patient days",25452,Per diem,,86736,70,,86736,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,26736,,"25,057 x DRG weight",26736,Other,base rate x DRG weight,24063,,"22,552 x DRG weight",24063,Other,base rate x DRG weight,26736,,"25,057 x DRG weight",26736,Other,base rate x DRG weight,22725,,"21,298 x DRG weight",22725,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,86736,
PERIPHERAL VASCULAR DISORDERS WITHOUT CC/MCC,301,MS-DRG,,,,,,,,inpatient,,,108696.83,15435,,,15435,Other,150% of Medicare + 9.63% HCRA Surcharge,9386,,"3,609.90 x patient days",9386,Per diem,,17778,,"25,046 x DRG weight",17778,Other,base rate x DRG weight,16000,,"22,541 x DRG weight",16000,Other,base rate x DRG weight,22375,,"31,523 x DRG weight",22375,Other,base rate x DRG weight,20138,,"28,371 x DRG weight",20138,Other,base rate x DRG weight,19019,,"26,795 x DRG weight",19019,Other,base rate x DRG weight,10324.6,,"3,970.89 x patient days",10324.6,Per diem,,15944,,"22,463 x DRG weight",15944,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,18757,,"26,426 x DRG weight",18757,Other,base rate x DRG weight,27547,,"38,809 x DRG weight",27547,Other,base rate x DRG weight,27547,,"38,809 x DRG weight",27547,Other,base rate x DRG weight,18757,,"26,426 x DRG weight",18757,Other,base rate x DRG weight,27547,,"38,809 x DRG weight",27547,Other,base rate x DRG weight,16544,,"6,363 x patient days",16544,Per diem,,76088,70,,76088,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,17785,,"25,057 x DRG weight",17785,Other,base rate x DRG weight,16007,,"22,552 x DRG weight",16007,Other,base rate x DRG weight,17785,,"25,057 x DRG weight",17785,Other,base rate x DRG weight,15117,,"21,298 x DRG weight",15117,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,76088,
ATHEROSCLEROSIS WITH MCC,302,MS-DRG,,,,,,,,inpatient,,,118462.97,23152,,,23152,Other,150% of Medicare + 9.63% HCRA Surcharge,14079,,"3,609.90 x patient days",14079,Per diem,,28079,,"25,046 x DRG weight",28079,Other,base rate x DRG weight,25271,,"22,541 x DRG weight",25271,Other,base rate x DRG weight,35340,,"31,523 x DRG weight",35340,Other,base rate x DRG weight,31807,,"28,371 x DRG weight",31807,Other,base rate x DRG weight,30040,,"26,795 x DRG weight",30040,Other,base rate x DRG weight,15486.9,,"3,970.89 x patient days",15486.9,Per diem,,25183,,"22,463 x DRG weight",25183,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,29626,,"26,426 x DRG weight",29626,Other,base rate x DRG weight,43509,,"38,809 x DRG weight",43509,Other,base rate x DRG weight,43509,,"38,809 x DRG weight",43509,Other,base rate x DRG weight,29626,,"26,426 x DRG weight",29626,Other,base rate x DRG weight,43509,,"38,809 x DRG weight",43509,Other,base rate x DRG weight,24816,,"6,363 x patient days",24816,Per diem,,82924,70,,82924,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,28091,,"25,057 x DRG weight",28091,Other,base rate x DRG weight,25283,,"22,552 x DRG weight",25283,Other,base rate x DRG weight,28091,,"25,057 x DRG weight",28091,Other,base rate x DRG weight,23877,,"21,298 x DRG weight",23877,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,82924,
ATHEROSCLEROSIS WITHOUT MCC,303,MS-DRG,,,,,,,,inpatient,,,109760.62,13060,,,13060,Other,150% of Medicare + 9.63% HCRA Surcharge,7942,,"3,609.90 x patient days",7942,Per diem,,16483,,"25,046 x DRG weight",16483,Other,base rate x DRG weight,14834,,"22,541 x DRG weight",14834,Other,base rate x DRG weight,20745,,"31,523 x DRG weight",20745,Other,base rate x DRG weight,18671,,"28,371 x DRG weight",18671,Other,base rate x DRG weight,17634,,"26,795 x DRG weight",17634,Other,base rate x DRG weight,8736.2,,"3,970.89 x patient days",8736.2,Per diem,,14783,,"22,463 x DRG weight",14783,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,17391,,"26,426 x DRG weight",17391,Other,base rate x DRG weight,25540,,"38,809 x DRG weight",25540,Other,base rate x DRG weight,25540,,"38,809 x DRG weight",25540,Other,base rate x DRG weight,17391,,"26,426 x DRG weight",17391,Other,base rate x DRG weight,25540,,"38,809 x DRG weight",25540,Other,base rate x DRG weight,13999,,"6,363 x patient days",13999,Per diem,,76832,70,,76832,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,16490,,"25,057 x DRG weight",16490,Other,base rate x DRG weight,14841,,"22,552 x DRG weight",14841,Other,base rate x DRG weight,16490,,"25,057 x DRG weight",16490,Other,base rate x DRG weight,14016,,"21,298 x DRG weight",14016,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,76832,
HYPERTENSION WITH MCC,304,MS-DRG,,,,,,,,inpatient,,,164718.08,24933,,,24933,Other,150% of Medicare + 9.63% HCRA Surcharge,15162,,"3,609.90 x patient days",15162,Per diem,,28778,,"25,046 x DRG weight",28778,Other,base rate x DRG weight,25900,,"22,541 x DRG weight",25900,Other,base rate x DRG weight,36220,,"31,523 x DRG weight",36220,Other,base rate x DRG weight,32598,,"28,371 x DRG weight",32598,Other,base rate x DRG weight,30787,,"26,795 x DRG weight",30787,Other,base rate x DRG weight,16678.2,,"3,970.89 x patient days",16678.2,Per diem,,25810,,"22,463 x DRG weight",25810,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,30363,,"26,426 x DRG weight",30363,Other,base rate x DRG weight,44592,,"38,809 x DRG weight",44592,Other,base rate x DRG weight,44592,,"38,809 x DRG weight",44592,Other,base rate x DRG weight,30363,,"26,426 x DRG weight",30363,Other,base rate x DRG weight,44592,,"38,809 x DRG weight",44592,Other,base rate x DRG weight,26725,,"6,363 x patient days",26725,Per diem,,115303,70,,115303,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,28790,,"25,057 x DRG weight",28790,Other,base rate x DRG weight,25912,,"22,552 x DRG weight",25912,Other,base rate x DRG weight,28790,,"25,057 x DRG weight",28790,Other,base rate x DRG weight,24471,,"21,298 x DRG weight",24471,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,115303,
HYPERTENSION WITHOUT MCC,305,MS-DRG,,,,,,,,inpatient,,,116227.06,16028,,,16028,Other,150% of Medicare + 9.63% HCRA Surcharge,9747,,"3,609.90 x patient days",9747,Per diem,,18872,,"25,046 x DRG weight",18872,Other,base rate x DRG weight,16985,,"22,541 x DRG weight",16985,Other,base rate x DRG weight,23753,,"31,523 x DRG weight",23753,Other,base rate x DRG weight,21378,,"28,371 x DRG weight",21378,Other,base rate x DRG weight,20190,,"26,795 x DRG weight",20190,Other,base rate x DRG weight,10721.7,,"3,970.89 x patient days",10721.7,Per diem,,16926,,"22,463 x DRG weight",16926,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,19912,,"26,426 x DRG weight",19912,Other,base rate x DRG weight,29243,,"38,809 x DRG weight",29243,Other,base rate x DRG weight,29243,,"38,809 x DRG weight",29243,Other,base rate x DRG weight,19912,,"26,426 x DRG weight",19912,Other,base rate x DRG weight,29243,,"38,809 x DRG weight",29243,Other,base rate x DRG weight,17180,,"6,363 x patient days",17180,Per diem,,81359,70,,81359,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,18880,,"25,057 x DRG weight",18880,Other,base rate x DRG weight,16993,,"22,552 x DRG weight",16993,Other,base rate x DRG weight,18880,,"25,057 x DRG weight",18880,Other,base rate x DRG weight,16048,,"21,298 x DRG weight",16048,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,81359,
CARDIAC CONGENITAL AND VALVULAR DISORDERS WITH MCC,306,MS-DRG,,,,,,,,inpatient,,,546948.46,31462,,,31462,Other,150% of Medicare + 9.63% HCRA Surcharge,19132,,"3,609.90 x patient days",19132,Per diem,,38491,,"25,046 x DRG weight",38491,Other,base rate x DRG weight,34641,,"22,541 x DRG weight",34641,Other,base rate x DRG weight,48445,,"31,523 x DRG weight",48445,Other,base rate x DRG weight,43601,,"28,371 x DRG weight",43601,Other,base rate x DRG weight,41179,,"26,795 x DRG weight",41179,Other,base rate x DRG weight,21045.2,,"3,970.89 x patient days",21045.2,Per diem,,34521,,"22,463 x DRG weight",34521,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,40611,,"26,426 x DRG weight",40611,Other,base rate x DRG weight,59642,,"38,809 x DRG weight",59642,Other,base rate x DRG weight,59642,,"38,809 x DRG weight",59642,Other,base rate x DRG weight,40611,,"26,426 x DRG weight",40611,Other,base rate x DRG weight,59642,,"38,809 x DRG weight",59642,Other,base rate x DRG weight,33724,,"6,363 x patient days",33724,Per diem,,382864,70,,382864,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,38508,,"25,057 x DRG weight",38508,Other,base rate x DRG weight,34658,,"22,552 x DRG weight",34658,Other,base rate x DRG weight,38508,,"25,057 x DRG weight",38508,Other,base rate x DRG weight,32731,,"21,298 x DRG weight",32731,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,382864,
CARDIAC CONGENITAL AND VALVULAR DISORDERS WITHOUT MCC,307,MS-DRG,,,,,,,,inpatient,,,126821.63,17809,,,17809,Other,150% of Medicare + 9.63% HCRA Surcharge,10830,,"3,609.90 x patient days",10830,Per diem,,23608,,"25,046 x DRG weight",23608,Other,base rate x DRG weight,21247,,"22,541 x DRG weight",21247,Other,base rate x DRG weight,29714,,"31,523 x DRG weight",29714,Other,base rate x DRG weight,26743,,"28,371 x DRG weight",26743,Other,base rate x DRG weight,25257,,"26,795 x DRG weight",25257,Other,base rate x DRG weight,11913,,"3,970.89 x patient days",11913,Per diem,,21174,,"22,463 x DRG weight",21174,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,24909,,"26,426 x DRG weight",24909,Other,base rate x DRG weight,36581,,"38,809 x DRG weight",36581,Other,base rate x DRG weight,36581,,"38,809 x DRG weight",36581,Other,base rate x DRG weight,24909,,"26,426 x DRG weight",24909,Other,base rate x DRG weight,36581,,"38,809 x DRG weight",36581,Other,base rate x DRG weight,19089,,"6,363 x patient days",19089,Per diem,,88775,70,,88775,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,23619,,"25,057 x DRG weight",23619,Other,base rate x DRG weight,21258,,"22,552 x DRG weight",21258,Other,base rate x DRG weight,23619,,"25,057 x DRG weight",23619,Other,base rate x DRG weight,20075,,"21,298 x DRG weight",20075,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,88775,
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH MCC,308,MS-DRG,,,,,,,,inpatient,,,176568.14,27901,,,27901,Other,150% of Medicare + 9.63% HCRA Surcharge,16967,,"3,609.90 x patient days",16967,Per diem,,30110,,"25,046 x DRG weight",30110,Other,base rate x DRG weight,27099,,"22,541 x DRG weight",27099,Other,base rate x DRG weight,37897,,"31,523 x DRG weight",37897,Other,base rate x DRG weight,34108,,"28,371 x DRG weight",34108,Other,base rate x DRG weight,32213,,"26,795 x DRG weight",32213,Other,base rate x DRG weight,18663.7,,"3,970.89 x patient days",18663.7,Per diem,,27005,,"22,463 x DRG weight",27005,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,31769,,"26,426 x DRG weight",31769,Other,base rate x DRG weight,46656,,"38,809 x DRG weight",46656,Other,base rate x DRG weight,46656,,"38,809 x DRG weight",46656,Other,base rate x DRG weight,31769,,"26,426 x DRG weight",31769,Other,base rate x DRG weight,46656,,"38,809 x DRG weight",46656,Other,base rate x DRG weight,29906,,"6,363 x patient days",29906,Per diem,,123598,70,,123598,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,30124,,"25,057 x DRG weight",30124,Other,base rate x DRG weight,27112,,"22,552 x DRG weight",27112,Other,base rate x DRG weight,30124,,"25,057 x DRG weight",30124,Other,base rate x DRG weight,25604,,"21,298 x DRG weight",25604,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,123598,
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH CC,309,MS-DRG,,,,,,,,inpatient,,,122201.12,17216,,,17216,Other,150% of Medicare + 9.63% HCRA Surcharge,10469,,"3,609.90 x patient days",10469,Per diem,,18652,,"25,046 x DRG weight",18652,Other,base rate x DRG weight,16786,,"22,541 x DRG weight",16786,Other,base rate x DRG weight,23475,,"31,523 x DRG weight",23475,Other,base rate x DRG weight,21128,,"28,371 x DRG weight",21128,Other,base rate x DRG weight,19954,,"26,795 x DRG weight",19954,Other,base rate x DRG weight,11515.9,,"3,970.89 x patient days",11515.9,Per diem,,16728,,"22,463 x DRG weight",16728,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,19679,,"26,426 x DRG weight",19679,Other,base rate x DRG weight,28901,,"38,809 x DRG weight",28901,Other,base rate x DRG weight,28901,,"38,809 x DRG weight",28901,Other,base rate x DRG weight,19679,,"26,426 x DRG weight",19679,Other,base rate x DRG weight,28901,,"38,809 x DRG weight",28901,Other,base rate x DRG weight,18453,,"6,363 x patient days",18453,Per diem,,85541,70,,85541,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,18660,,"25,057 x DRG weight",18660,Other,base rate x DRG weight,16794,,"22,552 x DRG weight",16794,Other,base rate x DRG weight,18660,,"25,057 x DRG weight",18660,Other,base rate x DRG weight,15861,,"21,298 x DRG weight",15861,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,85541,
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITHOUT CC/MCC,310,MS-DRG,,,,,,,,inpatient,,,67364.96,12467,,,12467,Other,150% of Medicare + 9.63% HCRA Surcharge,7581,,"3,609.90 x patient days",7581,Per diem,,13850,,"25,046 x DRG weight",13850,Other,base rate x DRG weight,12465,,"22,541 x DRG weight",12465,Other,base rate x DRG weight,17432,,"31,523 x DRG weight",17432,Other,base rate x DRG weight,15689,,"28,371 x DRG weight",15689,Other,base rate x DRG weight,14818,,"26,795 x DRG weight",14818,Other,base rate x DRG weight,8339.1,,"3,970.89 x patient days",8339.1,Per diem,,12422,,"22,463 x DRG weight",12422,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,14614,,"26,426 x DRG weight",14614,Other,base rate x DRG weight,21461,,"38,809 x DRG weight",21461,Other,base rate x DRG weight,21461,,"38,809 x DRG weight",21461,Other,base rate x DRG weight,14614,,"26,426 x DRG weight",14614,Other,base rate x DRG weight,21461,,"38,809 x DRG weight",21461,Other,base rate x DRG weight,13362,,"6,363 x patient days",13362,Per diem,,47155,70,,47155,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,13857,,"25,057 x DRG weight",13857,Other,base rate x DRG weight,12471,,"22,552 x DRG weight",12471,Other,base rate x DRG weight,13857,,"25,057 x DRG weight",13857,Other,base rate x DRG weight,11778,,"21,298 x DRG weight",11778,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,47155,
ANGINA PECTORIS,311,MS-DRG,,,,,,,,inpatient,,,85151.04,14841,,,14841,Other,150% of Medicare + 9.63% HCRA Surcharge,9025,,"3,609.90 x patient days",9025,Per diem,,17485,,"25,046 x DRG weight",17485,Other,base rate x DRG weight,15736,,"22,541 x DRG weight",15736,Other,base rate x DRG weight,22006,,"31,523 x DRG weight",22006,Other,base rate x DRG weight,19806,,"28,371 x DRG weight",19806,Other,base rate x DRG weight,18706,,"26,795 x DRG weight",18706,Other,base rate x DRG weight,9927.5,,"3,970.89 x patient days",9927.5,Per diem,,15681,,"22,463 x DRG weight",15681,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,18448,,"26,426 x DRG weight",18448,Other,base rate x DRG weight,27093,,"38,809 x DRG weight",27093,Other,base rate x DRG weight,27093,,"38,809 x DRG weight",27093,Other,base rate x DRG weight,18448,,"26,426 x DRG weight",18448,Other,base rate x DRG weight,27093,,"38,809 x DRG weight",27093,Other,base rate x DRG weight,15908,,"6,363 x patient days",15908,Per diem,,59606,70,,59606,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,17492,,"25,057 x DRG weight",17492,Other,base rate x DRG weight,15744,,"22,552 x DRG weight",15744,Other,base rate x DRG weight,17492,,"25,057 x DRG weight",17492,Other,base rate x DRG weight,14868,,"21,298 x DRG weight",14868,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,59606,
SYNCOPE AND COLLAPSE,312,MS-DRG,,,,,,,,inpatient,,,135930.04,18403,,,18403,Other,150% of Medicare + 9.63% HCRA Surcharge,11191,,"3,609.90 x patient days",11191,Per diem,,21627,,"25,046 x DRG weight",21627,Other,base rate x DRG weight,19464,,"22,541 x DRG weight",19464,Other,base rate x DRG weight,27220,,"31,523 x DRG weight",27220,Other,base rate x DRG weight,24498,,"28,371 x DRG weight",24498,Other,base rate x DRG weight,23137,,"26,795 x DRG weight",23137,Other,base rate x DRG weight,12310.1,,"3,970.89 x patient days",12310.1,Per diem,,19397,,"22,463 x DRG weight",19397,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,22819,,"26,426 x DRG weight",22819,Other,base rate x DRG weight,33512,,"38,809 x DRG weight",33512,Other,base rate x DRG weight,33512,,"38,809 x DRG weight",33512,Other,base rate x DRG weight,22819,,"26,426 x DRG weight",22819,Other,base rate x DRG weight,33512,,"38,809 x DRG weight",33512,Other,base rate x DRG weight,19725,,"6,363 x patient days",19725,Per diem,,95151,70,,95151,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,21637,,"25,057 x DRG weight",21637,Other,base rate x DRG weight,19474,,"22,552 x DRG weight",19474,Other,base rate x DRG weight,21637,,"25,057 x DRG weight",21637,Other,base rate x DRG weight,18391,,"21,298 x DRG weight",18391,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,95151,
CHEST PAIN,313,MS-DRG,,,,,,,,inpatient,,,100121.91,13060,,,13060,Other,150% of Medicare + 9.63% HCRA Surcharge,7942,,"3,609.90 x patient days",7942,Per diem,,18123,,"25,046 x DRG weight",18123,Other,base rate x DRG weight,16311,,"22,541 x DRG weight",16311,Other,base rate x DRG weight,22810,,"31,523 x DRG weight",22810,Other,base rate x DRG weight,20529,,"28,371 x DRG weight",20529,Other,base rate x DRG weight,19389,,"26,795 x DRG weight",19389,Other,base rate x DRG weight,8736.2,,"3,970.89 x patient days",8736.2,Per diem,,16254,,"22,463 x DRG weight",16254,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,19122,,"26,426 x DRG weight",19122,Other,base rate x DRG weight,28082,,"38,809 x DRG weight",28082,Other,base rate x DRG weight,28082,,"38,809 x DRG weight",28082,Other,base rate x DRG weight,19122,,"26,426 x DRG weight",19122,Other,base rate x DRG weight,28082,,"38,809 x DRG weight",28082,Other,base rate x DRG weight,13999,,"6,363 x patient days",13999,Per diem,,70085,70,,70085,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,18131,,"25,057 x DRG weight",18131,Other,base rate x DRG weight,16319,,"22,552 x DRG weight",16319,Other,base rate x DRG weight,18131,,"25,057 x DRG weight",18131,Other,base rate x DRG weight,15411,,"21,298 x DRG weight",15411,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,70085,
OTHER CIRCULATORY SYSTEM DIAGNOSES WITH MCC,314,MS-DRG,,,,,,,,inpatient,,,310115.72,42147,,,42147,Other,150% of Medicare + 9.63% HCRA Surcharge,25630,,"3,609.90 x patient days",25630,Per diem,,52434,,"25,046 x DRG weight",52434,Other,base rate x DRG weight,47190,,"22,541 x DRG weight",47190,Other,base rate x DRG weight,65993,,"31,523 x DRG weight",65993,Other,base rate x DRG weight,59395,,"28,371 x DRG weight",59395,Other,base rate x DRG weight,56095,,"26,795 x DRG weight",56095,Other,base rate x DRG weight,28193,,"3,970.89 x patient days",28193,Per diem,,47026,,"22,463 x DRG weight",47026,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,55323,,"26,426 x DRG weight",55323,Other,base rate x DRG weight,81247,,"38,809 x DRG weight",81247,Other,base rate x DRG weight,81247,,"38,809 x DRG weight",81247,Other,base rate x DRG weight,55323,,"26,426 x DRG weight",55323,Other,base rate x DRG weight,81247,,"38,809 x DRG weight",81247,Other,base rate x DRG weight,45177,,"6,363 x patient days",45177,Per diem,,217081,70,,217081,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,52457,,"25,057 x DRG weight",52457,Other,base rate x DRG weight,47213,,"22,552 x DRG weight",47213,Other,base rate x DRG weight,52457,,"25,057 x DRG weight",52457,Other,base rate x DRG weight,44587,,"21,298 x DRG weight",44587,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,217081,
OTHER CIRCULATORY SYSTEM DIAGNOSES WITH CC,315,MS-DRG,,,,,,,,inpatient,,,143896.63,20778,,,20778,Other,150% of Medicare + 9.63% HCRA Surcharge,12635,,"3,609.90 x patient days",12635,Per diem,,24227,,"25,046 x DRG weight",24227,Other,base rate x DRG weight,21804,,"22,541 x DRG weight",21804,Other,base rate x DRG weight,30492,,"31,523 x DRG weight",30492,Other,base rate x DRG weight,27443,,"28,371 x DRG weight",27443,Other,base rate x DRG weight,25919,,"26,795 x DRG weight",25919,Other,base rate x DRG weight,13898.5,,"3,970.89 x patient days",13898.5,Per diem,,21728,,"22,463 x DRG weight",21728,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,25562,,"26,426 x DRG weight",25562,Other,base rate x DRG weight,37540,,"38,809 x DRG weight",37540,Other,base rate x DRG weight,37540,,"38,809 x DRG weight",37540,Other,base rate x DRG weight,25562,,"26,426 x DRG weight",25562,Other,base rate x DRG weight,37540,,"38,809 x DRG weight",37540,Other,base rate x DRG weight,22271,,"6,363 x patient days",22271,Per diem,,100728,70,,100728,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,24238,,"25,057 x DRG weight",24238,Other,base rate x DRG weight,21815,,"22,552 x DRG weight",21815,Other,base rate x DRG weight,24238,,"25,057 x DRG weight",24238,Other,base rate x DRG weight,20602,,"21,298 x DRG weight",20602,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,100728,
OTHER CIRCULATORY SYSTEM DIAGNOSES WITHOUT CC/MCC,316,MS-DRG,,,,,,,,inpatient,,,98929.04,13060,,,13060,Other,150% of Medicare + 9.63% HCRA Surcharge,7942,,"3,609.90 x patient days",7942,Per diem,,17349,,"25,046 x DRG weight",17349,Other,base rate x DRG weight,15614,,"22,541 x DRG weight",15614,Other,base rate x DRG weight,21836,,"31,523 x DRG weight",21836,Other,base rate x DRG weight,19653,,"28,371 x DRG weight",19653,Other,base rate x DRG weight,18561,,"26,795 x DRG weight",18561,Other,base rate x DRG weight,8736.2,,"3,970.89 x patient days",8736.2,Per diem,,15560,,"22,463 x DRG weight",15560,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,18305,,"26,426 x DRG weight",18305,Other,base rate x DRG weight,26883,,"38,809 x DRG weight",26883,Other,base rate x DRG weight,26883,,"38,809 x DRG weight",26883,Other,base rate x DRG weight,18305,,"26,426 x DRG weight",18305,Other,base rate x DRG weight,26883,,"38,809 x DRG weight",26883,Other,base rate x DRG weight,13999,,"6,363 x patient days",13999,Per diem,,69250,70,,69250,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,17357,,"25,057 x DRG weight",17357,Other,base rate x DRG weight,15622,,"22,552 x DRG weight",15622,Other,base rate x DRG weight,17357,,"25,057 x DRG weight",17357,Other,base rate x DRG weight,14753,,"21,298 x DRG weight",14753,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,69250,
OTHER ENDOVASCULAR CARDIAC VALVE PROCEDURES WITH MCC,319,MS-DRG,,,,,,,,inpatient,,,818007.19,61738,,,61738,Other,150% of Medicare + 9.63% HCRA Surcharge,37543,,"3,609.90 x patient days",37543,Per diem,,109248,,"25,046 x DRG weight",109248,Other,base rate x DRG weight,98322,,"22,541 x DRG weight",98322,Other,base rate x DRG weight,137500,,"31,523 x DRG weight",137500,Other,base rate x DRG weight,123751,,"28,371 x DRG weight",123751,Other,base rate x DRG weight,116877,,"26,795 x DRG weight",116877,Other,base rate x DRG weight,41297.3,,"3,970.89 x patient days",41297.3,Per diem,,97981,,"22,463 x DRG weight",97981,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,115268,,"26,426 x DRG weight",115268,Other,base rate x DRG weight,169281,,"38,809 x DRG weight",169281,Other,base rate x DRG weight,169281,,"38,809 x DRG weight",169281,Other,base rate x DRG weight,115268,,"26,426 x DRG weight",115268,Other,base rate x DRG weight,169281,,"38,809 x DRG weight",169281,Other,base rate x DRG weight,66175,,"6,363 x patient days",66175,Per diem,,572605,70,,572605,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,109296,,"25,057 x DRG weight",109296,Other,base rate x DRG weight,98370,,"22,552 x DRG weight",98370,Other,base rate x DRG weight,109296,,"25,057 x DRG weight",109296,Other,base rate x DRG weight,92900,,"21,298 x DRG weight",92900,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,572605,
OTHER ENDOVASCULAR CARDIAC VALVE PROCEDURES WITHOUT MCC,320,MS-DRG,,,,,,,,inpatient,,,421986.5,18403,,,18403,Other,150% of Medicare + 9.63% HCRA Surcharge,11191,,"3,609.90 x patient days",11191,Per diem,,55752,,"25,046 x DRG weight",55752,Other,base rate x DRG weight,50176,,"22,541 x DRG weight",50176,Other,base rate x DRG weight,70170,,"31,523 x DRG weight",70170,Other,base rate x DRG weight,63154,,"28,371 x DRG weight",63154,Other,base rate x DRG weight,59646,,"26,795 x DRG weight",59646,Other,base rate x DRG weight,12310.1,,"3,970.89 x patient days",12310.1,Per diem,,50003,,"22,463 x DRG weight",50003,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,58824,,"26,426 x DRG weight",58824,Other,base rate x DRG weight,86389,,"38,809 x DRG weight",86389,Other,base rate x DRG weight,86389,,"38,809 x DRG weight",86389,Other,base rate x DRG weight,58824,,"26,426 x DRG weight",58824,Other,base rate x DRG weight,86389,,"38,809 x DRG weight",86389,Other,base rate x DRG weight,19725,,"6,363 x patient days",19725,Per diem,,295391,70,,295391,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,55777,,"25,057 x DRG weight",55777,Other,base rate x DRG weight,50201,,"22,552 x DRG weight",50201,Other,base rate x DRG weight,55777,,"25,057 x DRG weight",55777,Other,base rate x DRG weight,47409,,"21,298 x DRG weight",47409,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,295391,
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH INTRALUMINAL DEVICE WITH MCC OR 4+ ARTERIES/INTRALUMINAL DEVICES,321,MS-DRG,,,,,,,,inpatient,,,345470.51,30868,,,30868,Other,150% of Medicare + 9.63% HCRA Surcharge,18771,,"3,609.90 x patient days",18771,Per diem,,72000,,"25,046 x DRG weight",72000,Other,base rate x DRG weight,64799,,"22,541 x DRG weight",64799,Other,base rate x DRG weight,90619,,"31,523 x DRG weight",90619,Other,base rate x DRG weight,81558,,"28,371 x DRG weight",81558,Other,base rate x DRG weight,77028,,"26,795 x DRG weight",77028,Other,base rate x DRG weight,20648.1,,"3,970.89 x patient days",20648.1,Per diem,,64574,,"22,463 x DRG weight",64574,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,75967,,"26,426 x DRG weight",75967,Other,base rate x DRG weight,111564,,"38,809 x DRG weight",111564,Other,base rate x DRG weight,111564,,"38,809 x DRG weight",111564,Other,base rate x DRG weight,75967,,"26,426 x DRG weight",75967,Other,base rate x DRG weight,111564,,"38,809 x DRG weight",111564,Other,base rate x DRG weight,33088,,"6,363 x patient days",33088,Per diem,,241829,70,,241829,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,72031,,"25,057 x DRG weight",72031,Other,base rate x DRG weight,64830,,"22,552 x DRG weight",64830,Other,base rate x DRG weight,72031,,"25,057 x DRG weight",72031,Other,base rate x DRG weight,61225,,"21,298 x DRG weight",61225,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,241829,
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH INTRALUMINAL DEVICE WITHOUT MCC,322,MS-DRG,,,,,,,,inpatient,,,204191.54,14248,,,14248,Other,150% of Medicare + 9.63% HCRA Surcharge,8664,,"3,609.90 x patient days",8664,Per diem,,45669,,"25,046 x DRG weight",45669,Other,base rate x DRG weight,41101,,"22,541 x DRG weight",41101,Other,base rate x DRG weight,57479,,"31,523 x DRG weight",57479,Other,base rate x DRG weight,51732,,"28,371 x DRG weight",51732,Other,base rate x DRG weight,48858,,"26,795 x DRG weight",48858,Other,base rate x DRG weight,9530.4,,"3,970.89 x patient days",9530.4,Per diem,,40959,,"22,463 x DRG weight",40959,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,48185,,"26,426 x DRG weight",48185,Other,base rate x DRG weight,70764,,"38,809 x DRG weight",70764,Other,base rate x DRG weight,70764,,"38,809 x DRG weight",70764,Other,base rate x DRG weight,48185,,"26,426 x DRG weight",48185,Other,base rate x DRG weight,70764,,"38,809 x DRG weight",70764,Other,base rate x DRG weight,15271,,"6,363 x patient days",15271,Per diem,,142934,70,,142934,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,45689,,"25,057 x DRG weight",45689,Other,base rate x DRG weight,41121,,"22,552 x DRG weight",41121,Other,base rate x DRG weight,45689,,"25,057 x DRG weight",45689,Other,base rate x DRG weight,38835,,"21,298 x DRG weight",38835,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,142934,
CORONARY INTRAVASCULAR LITHOTRIPSY WITH INTRALUMINAL DEVICE WITH MCC,323,MS-DRG,,,,,,,,inpatient,,,230036,37398,,,37398,Other,150% of Medicare + 9.63% HCRA Surcharge,22742,,"3,609.90 x patient days",22742,Per diem,,103690,,"25,046 x DRG weight",103690,Other,base rate x DRG weight,93320,,"22,541 x DRG weight",93320,Other,base rate x DRG weight,130505,,"31,523 x DRG weight",130505,Other,base rate x DRG weight,117456,,"28,371 x DRG weight",117456,Other,base rate x DRG weight,110931,,"26,795 x DRG weight",110931,Other,base rate x DRG weight,25016.2,,"3,970.89 x patient days",25016.2,Per diem,,92997,,"22,463 x DRG weight",92997,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,109404,,"26,426 x DRG weight",109404,Other,base rate x DRG weight,160669,,"38,809 x DRG weight",160669,Other,base rate x DRG weight,160669,,"38,809 x DRG weight",160669,Other,base rate x DRG weight,109404,,"26,426 x DRG weight",109404,Other,base rate x DRG weight,160669,,"38,809 x DRG weight",160669,Other,base rate x DRG weight,40087,,"6,363 x patient days",40087,Per diem,,161025,70,,161025,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,103736,,"25,057 x DRG weight",103736,Other,base rate x DRG weight,93365,,"22,552 x DRG weight",93365,Other,base rate x DRG weight,103736,,"25,057 x DRG weight",103736,Other,base rate x DRG weight,88174,,"21,298 x DRG weight",88174,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,161025,
CORONARY INTRAVASCULAR LITHOTRIPSY WITH INTRALUMINAL DEVICE WITHOUT MCC,324,MS-DRG,,,,,,,,inpatient,,,285419.08,17216,,,17216,Other,150% of Medicare + 9.63% HCRA Surcharge,10469,,"3,609.90 x patient days",10469,Per diem,,74352,,"25,046 x DRG weight",74352,Other,base rate x DRG weight,66915,,"22,541 x DRG weight",66915,Other,base rate x DRG weight,93579,,"31,523 x DRG weight",93579,Other,base rate x DRG weight,84222,,"28,371 x DRG weight",84222,Other,base rate x DRG weight,79544,,"26,795 x DRG weight",79544,Other,base rate x DRG weight,11515.9,,"3,970.89 x patient days",11515.9,Per diem,,66684,,"22,463 x DRG weight",66684,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,78448,,"26,426 x DRG weight",78448,Other,base rate x DRG weight,115208,,"38,809 x DRG weight",115208,Other,base rate x DRG weight,115208,,"38,809 x DRG weight",115208,Other,base rate x DRG weight,78448,,"26,426 x DRG weight",78448,Other,base rate x DRG weight,115208,,"38,809 x DRG weight",115208,Other,base rate x DRG weight,18453,,"6,363 x patient days",18453,Per diem,,199793,70,,199793,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,74384,,"25,057 x DRG weight",74384,Other,base rate x DRG weight,66948,,"22,552 x DRG weight",66948,Other,base rate x DRG weight,74384,,"25,057 x DRG weight",74384,Other,base rate x DRG weight,63225,,"21,298 x DRG weight",63225,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,199793,
CORONARY INTRAVASCULAR LITHOTRIPSY WITHOUT INTRALUMINAL DEVICE,325,MS-DRG,,,,,,,,inpatient,,,421986.5,20184,,,20184,Other,150% of Medicare + 9.63% HCRA Surcharge,12274,,"3,609.90 x patient days",12274,Per diem,,66229,,"25,046 x DRG weight",66229,Other,base rate x DRG weight,59605,,"22,541 x DRG weight",59605,Other,base rate x DRG weight,83356,,"31,523 x DRG weight",83356,Other,base rate x DRG weight,75021,,"28,371 x DRG weight",75021,Other,base rate x DRG weight,70854,,"26,795 x DRG weight",70854,Other,base rate x DRG weight,13501.4,,"3,970.89 x patient days",13501.4,Per diem,,59399,,"22,463 x DRG weight",59399,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,69878,,"26,426 x DRG weight",69878,Other,base rate x DRG weight,102623,,"38,809 x DRG weight",102623,Other,base rate x DRG weight,102623,,"38,809 x DRG weight",102623,Other,base rate x DRG weight,69878,,"26,426 x DRG weight",69878,Other,base rate x DRG weight,102623,,"38,809 x DRG weight",102623,Other,base rate x DRG weight,21634,,"6,363 x patient days",21634,Per diem,,295391,70,,295391,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,66258,,"25,057 x DRG weight",66258,Other,base rate x DRG weight,59634,,"22,552 x DRG weight",59634,Other,base rate x DRG weight,66258,,"25,057 x DRG weight",66258,Other,base rate x DRG weight,56318,,"21,298 x DRG weight",56318,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,295391,
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITH MCC",326,MS-DRG,,,,,,,,inpatient,,,510319.69,77172,,,77172,Other,150% of Medicare + 9.63% HCRA Surcharge,46929,,"3,609.90 x patient days",46929,Per diem,,127209,,"25,046 x DRG weight",127209,Other,base rate x DRG weight,114486,,"22,541 x DRG weight",114486,Other,base rate x DRG weight,160105,,"31,523 x DRG weight",160105,Other,base rate x DRG weight,144096,,"28,371 x DRG weight",144096,Other,base rate x DRG weight,136092,,"26,795 x DRG weight",136092,Other,base rate x DRG weight,51621.9,,"3,970.89 x patient days",51621.9,Per diem,,114090,,"22,463 x DRG weight",114090,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,134218,,"26,426 x DRG weight",134218,Other,base rate x DRG weight,197111,,"38,809 x DRG weight",197111,Other,base rate x DRG weight,197111,,"38,809 x DRG weight",197111,Other,base rate x DRG weight,134218,,"26,426 x DRG weight",134218,Other,base rate x DRG weight,197111,,"38,809 x DRG weight",197111,Other,base rate x DRG weight,82719,,"6,363 x patient days",82719,Per diem,,357224,70,,357224,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,127265,,"25,057 x DRG weight",127265,Other,base rate x DRG weight,114542,,"22,552 x DRG weight",114542,Other,base rate x DRG weight,127265,,"25,057 x DRG weight",127265,Other,base rate x DRG weight,108173,,"21,298 x DRG weight",108173,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,357224,
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITH CC",327,MS-DRG,,,,,,,,inpatient,,,210636.53,35617,,,35617,Other,150% of Medicare + 9.63% HCRA Surcharge,21659,,"3,609.90 x patient days",21659,Per diem,,62550,,"25,046 x DRG weight",62550,Other,base rate x DRG weight,56294,,"22,541 x DRG weight",56294,Other,base rate x DRG weight,78726,,"31,523 x DRG weight",78726,Other,base rate x DRG weight,70854,,"28,371 x DRG weight",70854,Other,base rate x DRG weight,66918,,"26,795 x DRG weight",66918,Other,base rate x DRG weight,23824.9,,"3,970.89 x patient days",23824.9,Per diem,,56099,,"22,463 x DRG weight",56099,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,65996,,"26,426 x DRG weight",65996,Other,base rate x DRG weight,96922,,"38,809 x DRG weight",96922,Other,base rate x DRG weight,96922,,"38,809 x DRG weight",96922,Other,base rate x DRG weight,65996,,"26,426 x DRG weight",65996,Other,base rate x DRG weight,96922,,"38,809 x DRG weight",96922,Other,base rate x DRG weight,38178,,"6,363 x patient days",38178,Per diem,,147446,70,,147446,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,62577,,"25,057 x DRG weight",62577,Other,base rate x DRG weight,56321,,"22,552 x DRG weight",56321,Other,base rate x DRG weight,62577,,"25,057 x DRG weight",62577,Other,base rate x DRG weight,53190,,"21,298 x DRG weight",53190,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,147446,
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITHOUT CC/MCC",328,MS-DRG,,,,,,,,inpatient,,,104022.57,16028,,,16028,Other,150% of Medicare + 9.63% HCRA Surcharge,9747,,"3,609.90 x patient days",9747,Per diem,,40006,,"25,046 x DRG weight",40006,Other,base rate x DRG weight,36005,,"22,541 x DRG weight",36005,Other,base rate x DRG weight,50352,,"31,523 x DRG weight",50352,Other,base rate x DRG weight,45317,,"28,371 x DRG weight",45317,Other,base rate x DRG weight,42800,,"26,795 x DRG weight",42800,Other,base rate x DRG weight,10721.7,,"3,970.89 x patient days",10721.7,Per diem,,35880,,"22,463 x DRG weight",35880,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,42210,,"26,426 x DRG weight",42210,Other,base rate x DRG weight,61990,,"38,809 x DRG weight",61990,Other,base rate x DRG weight,61990,,"38,809 x DRG weight",61990,Other,base rate x DRG weight,42210,,"26,426 x DRG weight",42210,Other,base rate x DRG weight,61990,,"38,809 x DRG weight",61990,Other,base rate x DRG weight,17180,,"6,363 x patient days",17180,Per diem,,72816,70,,72816,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,40024,,"25,057 x DRG weight",40024,Other,base rate x DRG weight,36022,,"22,552 x DRG weight",36022,Other,base rate x DRG weight,40024,,"25,057 x DRG weight",40024,Other,base rate x DRG weight,34019,,"21,298 x DRG weight",34019,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,72816,
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC,329,MS-DRG,,,,,,,,inpatient,,,541805.78,75391,,,75391,Other,150% of Medicare + 9.63% HCRA Surcharge,45846,,"3,609.90 x patient days",45846,Per diem,,113128,,"25,046 x DRG weight",113128,Other,base rate x DRG weight,101813,,"22,541 x DRG weight",101813,Other,base rate x DRG weight,142383,,"31,523 x DRG weight",142383,Other,base rate x DRG weight,128146,,"28,371 x DRG weight",128146,Other,base rate x DRG weight,121028,,"26,795 x DRG weight",121028,Other,base rate x DRG weight,50430.6,,"3,970.89 x patient days",50430.6,Per diem,,101461,,"22,463 x DRG weight",101461,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,119361,,"26,426 x DRG weight",119361,Other,base rate x DRG weight,175292,,"38,809 x DRG weight",175292,Other,base rate x DRG weight,175292,,"38,809 x DRG weight",175292,Other,base rate x DRG weight,119361,,"26,426 x DRG weight",119361,Other,base rate x DRG weight,175292,,"38,809 x DRG weight",175292,Other,base rate x DRG weight,80810,,"6,363 x patient days",80810,Per diem,,379264,70,,379264,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,113177,,"25,057 x DRG weight",113177,Other,base rate x DRG weight,101863,,"22,552 x DRG weight",101863,Other,base rate x DRG weight,113177,,"25,057 x DRG weight",113177,Other,base rate x DRG weight,96199,,"21,298 x DRG weight",96199,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,379264,
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH CC,330,MS-DRG,,,,,,,,inpatient,,,262953.11,37992,,,37992,Other,150% of Medicare + 9.63% HCRA Surcharge,23103,,"3,609.90 x patient days",23103,Per diem,,59412,,"25,046 x DRG weight",59412,Other,base rate x DRG weight,53470,,"22,541 x DRG weight",53470,Other,base rate x DRG weight,74776,,"31,523 x DRG weight",74776,Other,base rate x DRG weight,67299,,"28,371 x DRG weight",67299,Other,base rate x DRG weight,63560,,"26,795 x DRG weight",63560,Other,base rate x DRG weight,25413.3,,"3,970.89 x patient days",25413.3,Per diem,,53284,,"22,463 x DRG weight",53284,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,62685,,"26,426 x DRG weight",62685,Other,base rate x DRG weight,92059,,"38,809 x DRG weight",92059,Other,base rate x DRG weight,92059,,"38,809 x DRG weight",92059,Other,base rate x DRG weight,62685,,"26,426 x DRG weight",62685,Other,base rate x DRG weight,92059,,"38,809 x DRG weight",92059,Other,base rate x DRG weight,40723,,"6,363 x patient days",40723,Per diem,,184067,70,,184067,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,59438,,"25,057 x DRG weight",59438,Other,base rate x DRG weight,53496,,"22,552 x DRG weight",53496,Other,base rate x DRG weight,59438,,"25,057 x DRG weight",59438,Other,base rate x DRG weight,50521,,"21,298 x DRG weight",50521,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,184067,
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,331,MS-DRG,,,,,,,,inpatient,,,144011.03,20184,,,20184,Other,150% of Medicare + 9.63% HCRA Surcharge,12274,,"3,609.90 x patient days",12274,Per diem,,41877,,"25,046 x DRG weight",41877,Other,base rate x DRG weight,37689,,"22,541 x DRG weight",37689,Other,base rate x DRG weight,52706,,"31,523 x DRG weight",52706,Other,base rate x DRG weight,47436,,"28,371 x DRG weight",47436,Other,base rate x DRG weight,44801,,"26,795 x DRG weight",44801,Other,base rate x DRG weight,13501.4,,"3,970.89 x patient days",13501.4,Per diem,,37558,,"22,463 x DRG weight",37558,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,44184,,"26,426 x DRG weight",44184,Other,base rate x DRG weight,64889,,"38,809 x DRG weight",64889,Other,base rate x DRG weight,64889,,"38,809 x DRG weight",64889,Other,base rate x DRG weight,44184,,"26,426 x DRG weight",44184,Other,base rate x DRG weight,64889,,"38,809 x DRG weight",64889,Other,base rate x DRG weight,21634,,"6,363 x patient days",21634,Per diem,,100808,70,,100808,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,41895,,"25,057 x DRG weight",41895,Other,base rate x DRG weight,37707,,"22,552 x DRG weight",37707,Other,base rate x DRG weight,41895,,"25,057 x DRG weight",41895,Other,base rate x DRG weight,35610,,"21,298 x DRG weight",35610,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,100808,
RECTAL RESECTION WITH MCC,332,MS-DRG,,,,,,,,inpatient,,,511895.78,53427,,,53427,Other,150% of Medicare + 9.63% HCRA Surcharge,32489,,"3,609.90 x patient days",32489,Per diem,,91526,,"25,046 x DRG weight",91526,Other,base rate x DRG weight,82372,,"22,541 x DRG weight",82372,Other,base rate x DRG weight,115194,,"31,523 x DRG weight",115194,Other,base rate x DRG weight,103676,,"28,371 x DRG weight",103676,Other,base rate x DRG weight,97917,,"26,795 x DRG weight",97917,Other,base rate x DRG weight,35737.9,,"3,970.89 x patient days",35737.9,Per diem,,82087,,"22,463 x DRG weight",82087,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,96569,,"26,426 x DRG weight",96569,Other,base rate x DRG weight,141820,,"38,809 x DRG weight",141820,Other,base rate x DRG weight,141820,,"38,809 x DRG weight",141820,Other,base rate x DRG weight,96569,,"26,426 x DRG weight",96569,Other,base rate x DRG weight,141820,,"38,809 x DRG weight",141820,Other,base rate x DRG weight,57267,,"6,363 x patient days",57267,Per diem,,358327,70,,358327,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,91566,,"25,057 x DRG weight",91566,Other,base rate x DRG weight,82412,,"22,552 x DRG weight",82412,Other,base rate x DRG weight,91566,,"25,057 x DRG weight",91566,Other,base rate x DRG weight,77829,,"21,298 x DRG weight",77829,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,358327,
RECTAL RESECTION WITH CC,333,MS-DRG,,,,,,,,inpatient,,,86800.71,26120,,,26120,Other,150% of Medicare + 9.63% HCRA Surcharge,15884,,"3,609.90 x patient days",15884,Per diem,,52083,,"25,046 x DRG weight",52083,Other,base rate x DRG weight,46874,,"22,541 x DRG weight",46874,Other,base rate x DRG weight,65552,,"31,523 x DRG weight",65552,Other,base rate x DRG weight,58997,,"28,371 x DRG weight",58997,Other,base rate x DRG weight,55720,,"26,795 x DRG weight",55720,Other,base rate x DRG weight,17472.4,,"3,970.89 x patient days",17472.4,Per diem,,46712,,"22,463 x DRG weight",46712,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,54953,,"26,426 x DRG weight",54953,Other,base rate x DRG weight,80703,,"38,809 x DRG weight",80703,Other,base rate x DRG weight,80703,,"38,809 x DRG weight",80703,Other,base rate x DRG weight,54953,,"26,426 x DRG weight",54953,Other,base rate x DRG weight,80703,,"38,809 x DRG weight",80703,Other,base rate x DRG weight,27997,,"6,363 x patient days",27997,Per diem,,60760,70,,60760,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,52106,,"25,057 x DRG weight",52106,Other,base rate x DRG weight,46897,,"22,552 x DRG weight",46897,Other,base rate x DRG weight,52106,,"25,057 x DRG weight",52106,Other,base rate x DRG weight,44289,,"21,298 x DRG weight",44289,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,80703,
RECTAL RESECTION WITHOUT CC/MCC,334,MS-DRG,,,,,,,,inpatient,,,126740.94,16028,,,16028,Other,150% of Medicare + 9.63% HCRA Surcharge,9747,,"3,609.90 x patient days",9747,Per diem,,40201,,"25,046 x DRG weight",40201,Other,base rate x DRG weight,36181,,"22,541 x DRG weight",36181,Other,base rate x DRG weight,50598,,"31,523 x DRG weight",50598,Other,base rate x DRG weight,45538,,"28,371 x DRG weight",45538,Other,base rate x DRG weight,43009,,"26,795 x DRG weight",43009,Other,base rate x DRG weight,10721.7,,"3,970.89 x patient days",10721.7,Per diem,,36055,,"22,463 x DRG weight",36055,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,42416,,"26,426 x DRG weight",42416,Other,base rate x DRG weight,62292,,"38,809 x DRG weight",62292,Other,base rate x DRG weight,62292,,"38,809 x DRG weight",62292,Other,base rate x DRG weight,42416,,"26,426 x DRG weight",42416,Other,base rate x DRG weight,62292,,"38,809 x DRG weight",62292,Other,base rate x DRG weight,17180,,"6,363 x patient days",17180,Per diem,,88719,70,,88719,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,40219,,"25,057 x DRG weight",40219,Other,base rate x DRG weight,36198,,"22,552 x DRG weight",36198,Other,base rate x DRG weight,40219,,"25,057 x DRG weight",40219,Other,base rate x DRG weight,34185,,"21,298 x DRG weight",34185,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,88719,
PERITONEAL ADHESIOLYSIS WITH MCC,335,MS-DRG,,,,,,,,inpatient,,,353724.21,66487,,,66487,Other,150% of Medicare + 9.63% HCRA Surcharge,40431,,"3,609.90 x patient days",40431,Per diem,,89539,,"25,046 x DRG weight",89539,Other,base rate x DRG weight,80584,,"22,541 x DRG weight",80584,Other,base rate x DRG weight,112695,,"31,523 x DRG weight",112695,Other,base rate x DRG weight,101426,,"28,371 x DRG weight",101426,Other,base rate x DRG weight,95792,,"26,795 x DRG weight",95792,Other,base rate x DRG weight,44474.1,,"3,970.89 x patient days",44474.1,Per diem,,80305,,"22,463 x DRG weight",80305,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,94473,,"26,426 x DRG weight",94473,Other,base rate x DRG weight,138742,,"38,809 x DRG weight",138742,Other,base rate x DRG weight,138742,,"38,809 x DRG weight",138742,Other,base rate x DRG weight,94473,,"26,426 x DRG weight",94473,Other,base rate x DRG weight,138742,,"38,809 x DRG weight",138742,Other,base rate x DRG weight,71266,,"6,363 x patient days",71266,Per diem,,247607,70,,247607,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,89579,,"25,057 x DRG weight",89579,Other,base rate x DRG weight,80623,,"22,552 x DRG weight",80623,Other,base rate x DRG weight,89579,,"25,057 x DRG weight",89579,Other,base rate x DRG weight,76140,,"21,298 x DRG weight",76140,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,247607,
PERITONEAL ADHESIOLYSIS WITH CC,336,MS-DRG,,,,,,,,inpatient,,,240481.91,40366,,,40366,Other,150% of Medicare + 9.63% HCRA Surcharge,24547,,"3,609.90 x patient days",24547,Per diem,,52729,,"25,046 x DRG weight",52729,Other,base rate x DRG weight,47456,,"22,541 x DRG weight",47456,Other,base rate x DRG weight,66365,,"31,523 x DRG weight",66365,Other,base rate x DRG weight,59729,,"28,371 x DRG weight",59729,Other,base rate x DRG weight,56412,,"26,795 x DRG weight",56412,Other,base rate x DRG weight,27001.7,,"3,970.89 x patient days",27001.7,Per diem,,47291,,"22,463 x DRG weight",47291,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,55635,,"26,426 x DRG weight",55635,Other,base rate x DRG weight,81705,,"38,809 x DRG weight",81705,Other,base rate x DRG weight,81705,,"38,809 x DRG weight",81705,Other,base rate x DRG weight,55635,,"26,426 x DRG weight",55635,Other,base rate x DRG weight,81705,,"38,809 x DRG weight",81705,Other,base rate x DRG weight,43268,,"6,363 x patient days",43268,Per diem,,168337,70,,168337,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,52753,,"25,057 x DRG weight",52753,Other,base rate x DRG weight,47479,,"22,552 x DRG weight",47479,Other,base rate x DRG weight,52753,,"25,057 x DRG weight",52753,Other,base rate x DRG weight,44839,,"21,298 x DRG weight",44839,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,168337,
PERITONEAL ADHESIOLYSIS WITHOUT CC/MCC,337,MS-DRG,,,,,,,,inpatient,,,130269.51,24933,,,24933,Other,150% of Medicare + 9.63% HCRA Surcharge,15162,,"3,609.90 x patient days",15162,Per diem,,37479,,"25,046 x DRG weight",37479,Other,base rate x DRG weight,33730,,"22,541 x DRG weight",33730,Other,base rate x DRG weight,47171,,"31,523 x DRG weight",47171,Other,base rate x DRG weight,42454,,"28,371 x DRG weight",42454,Other,base rate x DRG weight,40096,,"26,795 x DRG weight",40096,Other,base rate x DRG weight,16678.2,,"3,970.89 x patient days",16678.2,Per diem,,33614,,"22,463 x DRG weight",33614,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,39544,,"26,426 x DRG weight",39544,Other,base rate x DRG weight,58074,,"38,809 x DRG weight",58074,Other,base rate x DRG weight,58074,,"38,809 x DRG weight",58074,Other,base rate x DRG weight,39544,,"26,426 x DRG weight",39544,Other,base rate x DRG weight,58074,,"38,809 x DRG weight",58074,Other,base rate x DRG weight,26725,,"6,363 x patient days",26725,Per diem,,91189,70,,91189,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,37495,,"25,057 x DRG weight",37495,Other,base rate x DRG weight,33747,,"22,552 x DRG weight",33747,Other,base rate x DRG weight,37495,,"25,057 x DRG weight",37495,Other,base rate x DRG weight,31870,,"21,298 x DRG weight",31870,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,91189,
MINOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC,344,MS-DRG,,,,,,,,inpatient,,,260881.91,58176,,,58176,Other,150% of Medicare + 9.63% HCRA Surcharge,35377,,"3,609.90 x patient days",35377,Per diem,,68636,,"25,046 x DRG weight",68636,Other,base rate x DRG weight,61771,,"22,541 x DRG weight",61771,Other,base rate x DRG weight,86386,,"31,523 x DRG weight",86386,Other,base rate x DRG weight,77748,,"28,371 x DRG weight",77748,Other,base rate x DRG weight,73429,,"26,795 x DRG weight",73429,Other,base rate x DRG weight,38914.7,,"3,970.89 x patient days",38914.7,Per diem,,61558,,"22,463 x DRG weight",61558,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,72418,,"26,426 x DRG weight",72418,Other,base rate x DRG weight,106352,,"38,809 x DRG weight",106352,Other,base rate x DRG weight,106352,,"38,809 x DRG weight",106352,Other,base rate x DRG weight,72418,,"26,426 x DRG weight",72418,Other,base rate x DRG weight,106352,,"38,809 x DRG weight",106352,Other,base rate x DRG weight,62357,,"6,363 x patient days",62357,Per diem,,182617,70,,182617,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,68666,,"25,057 x DRG weight",68666,Other,base rate x DRG weight,61802,,"22,552 x DRG weight",61802,Other,base rate x DRG weight,68666,,"25,057 x DRG weight",68666,Other,base rate x DRG weight,58365,,"21,298 x DRG weight",58365,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,182617,
MINOR SMALL AND LARGE BOWEL PROCEDURES WITH CC,345,MS-DRG,,,,,,,,inpatient,,,217741.13,31462,,,31462,Other,150% of Medicare + 9.63% HCRA Surcharge,19132,,"3,609.90 x patient days",19132,Per diem,,38586,,"25,046 x DRG weight",38586,Other,base rate x DRG weight,34727,,"22,541 x DRG weight",34727,Other,base rate x DRG weight,48564,,"31,523 x DRG weight",48564,Other,base rate x DRG weight,43708,,"28,371 x DRG weight",43708,Other,base rate x DRG weight,41280,,"26,795 x DRG weight",41280,Other,base rate x DRG weight,21045.2,,"3,970.89 x patient days",21045.2,Per diem,,34606,,"22,463 x DRG weight",34606,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,40712,,"26,426 x DRG weight",40712,Other,base rate x DRG weight,59789,,"38,809 x DRG weight",59789,Other,base rate x DRG weight,59789,,"38,809 x DRG weight",59789,Other,base rate x DRG weight,40712,,"26,426 x DRG weight",40712,Other,base rate x DRG weight,59789,,"38,809 x DRG weight",59789,Other,base rate x DRG weight,33724,,"6,363 x patient days",33724,Per diem,,152419,70,,152419,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,38603,,"25,057 x DRG weight",38603,Other,base rate x DRG weight,34744,,"22,552 x DRG weight",34744,Other,base rate x DRG weight,38603,,"25,057 x DRG weight",38603,Other,base rate x DRG weight,32812,,"21,298 x DRG weight",32812,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,152419,
MINOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,346,MS-DRG,,,,,,,,inpatient,,,124639,20184,,,20184,Other,150% of Medicare + 9.63% HCRA Surcharge,12274,,"3,609.90 x patient days",12274,Per diem,,32254,,"25,046 x DRG weight",32254,Other,base rate x DRG weight,29028,,"22,541 x DRG weight",29028,Other,base rate x DRG weight,40595,,"31,523 x DRG weight",40595,Other,base rate x DRG weight,36536,,"28,371 x DRG weight",36536,Other,base rate x DRG weight,34507,,"26,795 x DRG weight",34507,Other,base rate x DRG weight,13501.4,,"3,970.89 x patient days",13501.4,Per diem,,28928,,"22,463 x DRG weight",28928,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,34031,,"26,426 x DRG weight",34031,Other,base rate x DRG weight,49978,,"38,809 x DRG weight",49978,Other,base rate x DRG weight,49978,,"38,809 x DRG weight",49978,Other,base rate x DRG weight,34031,,"26,426 x DRG weight",34031,Other,base rate x DRG weight,49978,,"38,809 x DRG weight",49978,Other,base rate x DRG weight,21634,,"6,363 x patient days",21634,Per diem,,87247,70,,87247,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,32268,,"25,057 x DRG weight",32268,Other,base rate x DRG weight,29042,,"22,552 x DRG weight",29042,Other,base rate x DRG weight,32268,,"25,057 x DRG weight",32268,Other,base rate x DRG weight,27428,,"21,298 x DRG weight",27428,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,87247,
ANAL AND STOMAL PROCEDURES WITH MCC,347,MS-DRG,,,,,,,,inpatient,,,429562.31,46303,,,46303,Other,150% of Medicare + 9.63% HCRA Surcharge,28157,,"3,609.90 x patient days",28157,Per diem,,63845,,"25,046 x DRG weight",63845,Other,base rate x DRG weight,57459,,"22,541 x DRG weight",57459,Other,base rate x DRG weight,80355,,"31,523 x DRG weight",80355,Other,base rate x DRG weight,72321,,"28,371 x DRG weight",72321,Other,base rate x DRG weight,68303,,"26,795 x DRG weight",68303,Other,base rate x DRG weight,30972.7,,"3,970.89 x patient days",30972.7,Per diem,,57260,,"22,463 x DRG weight",57260,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,67363,,"26,426 x DRG weight",67363,Other,base rate x DRG weight,98928,,"38,809 x DRG weight",98928,Other,base rate x DRG weight,98928,,"38,809 x DRG weight",98928,Other,base rate x DRG weight,67363,,"26,426 x DRG weight",67363,Other,base rate x DRG weight,98928,,"38,809 x DRG weight",98928,Other,base rate x DRG weight,49631,,"6,363 x patient days",49631,Per diem,,300694,70,,300694,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,63873,,"25,057 x DRG weight",63873,Other,base rate x DRG weight,57487,,"22,552 x DRG weight",57487,Other,base rate x DRG weight,63873,,"25,057 x DRG weight",63873,Other,base rate x DRG weight,54291,,"21,298 x DRG weight",54291,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,300694,
ANAL AND STOMAL PROCEDURES WITH CC,348,MS-DRG,,,,,,,,inpatient,,,139982.84,24340,,,24340,Other,150% of Medicare + 9.63% HCRA Surcharge,14801,,"3,609.90 x patient days",14801,Per diem,,32595,,"25,046 x DRG weight",32595,Other,base rate x DRG weight,29335,,"22,541 x DRG weight",29335,Other,base rate x DRG weight,41024,,"31,523 x DRG weight",41024,Other,base rate x DRG weight,36922,,"28,371 x DRG weight",36922,Other,base rate x DRG weight,34871,,"26,795 x DRG weight",34871,Other,base rate x DRG weight,16281.1,,"3,970.89 x patient days",16281.1,Per diem,,29233,,"22,463 x DRG weight",29233,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,34391,,"26,426 x DRG weight",34391,Other,base rate x DRG weight,50506,,"38,809 x DRG weight",50506,Other,base rate x DRG weight,50506,,"38,809 x DRG weight",50506,Other,base rate x DRG weight,34391,,"26,426 x DRG weight",34391,Other,base rate x DRG weight,50506,,"38,809 x DRG weight",50506,Other,base rate x DRG weight,26088,,"6,363 x patient days",26088,Per diem,,97988,70,,97988,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,32609,,"25,057 x DRG weight",32609,Other,base rate x DRG weight,29349,,"22,552 x DRG weight",29349,Other,base rate x DRG weight,32609,,"25,057 x DRG weight",32609,Other,base rate x DRG weight,27717,,"21,298 x DRG weight",27717,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,97988,
ANAL AND STOMAL PROCEDURES WITHOUT CC/MCC,349,MS-DRG,,,,,,,,inpatient,,,58439.29,13060,,,13060,Other,150% of Medicare + 9.63% HCRA Surcharge,7942,,"3,609.90 x patient days",7942,Per diem,,24440,,"25,046 x DRG weight",24440,Other,base rate x DRG weight,21996,,"22,541 x DRG weight",21996,Other,base rate x DRG weight,30760,,"31,523 x DRG weight",30760,Other,base rate x DRG weight,27684,,"28,371 x DRG weight",27684,Other,base rate x DRG weight,26147,,"26,795 x DRG weight",26147,Other,base rate x DRG weight,8736.2,,"3,970.89 x patient days",8736.2,Per diem,,21919,,"22,463 x DRG weight",21919,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,25786,,"26,426 x DRG weight",25786,Other,base rate x DRG weight,37870,,"38,809 x DRG weight",37870,Other,base rate x DRG weight,37870,,"38,809 x DRG weight",37870,Other,base rate x DRG weight,25786,,"26,426 x DRG weight",25786,Other,base rate x DRG weight,37870,,"38,809 x DRG weight",37870,Other,base rate x DRG weight,13999,,"6,363 x patient days",13999,Per diem,,40908,70,,40908,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,24451,,"25,057 x DRG weight",24451,Other,base rate x DRG weight,22006,,"22,552 x DRG weight",22006,Other,base rate x DRG weight,24451,,"25,057 x DRG weight",24451,Other,base rate x DRG weight,20783,,"21,298 x DRG weight",20783,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,40908,
INGUINAL AND FEMORAL HERNIA PROCEDURES WITH MCC,350,MS-DRG,,,,,,,,inpatient,,,146612.33,38585,,,38585,Other,150% of Medicare + 9.63% HCRA Surcharge,23464,,"3,609.90 x patient days",23464,Per diem,,60110,,"25,046 x DRG weight",60110,Other,base rate x DRG weight,54098,,"22,541 x DRG weight",54098,Other,base rate x DRG weight,75655,,"31,523 x DRG weight",75655,Other,base rate x DRG weight,68090,,"28,371 x DRG weight",68090,Other,base rate x DRG weight,64308,,"26,795 x DRG weight",64308,Other,base rate x DRG weight,25810.4,,"3,970.89 x patient days",25810.4,Per diem,,53911,,"22,463 x DRG weight",53911,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,63422,,"26,426 x DRG weight",63422,Other,base rate x DRG weight,93142,,"38,809 x DRG weight",93142,Other,base rate x DRG weight,93142,,"38,809 x DRG weight",93142,Other,base rate x DRG weight,63422,,"26,426 x DRG weight",63422,Other,base rate x DRG weight,93142,,"38,809 x DRG weight",93142,Other,base rate x DRG weight,41360,,"6,363 x patient days",41360,Per diem,,102629,70,,102629,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,60137,,"25,057 x DRG weight",60137,Other,base rate x DRG weight,54125,,"22,552 x DRG weight",54125,Other,base rate x DRG weight,60137,,"25,057 x DRG weight",60137,Other,base rate x DRG weight,51115,,"21,298 x DRG weight",51115,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,102629,
INGUINAL AND FEMORAL HERNIA PROCEDURES WITH CC,351,MS-DRG,,,,,,,,inpatient,,,134953.04,22559,,,22559,Other,150% of Medicare + 9.63% HCRA Surcharge,13718,,"3,609.90 x patient days",13718,Per diem,,36457,,"25,046 x DRG weight",36457,Other,base rate x DRG weight,32811,,"22,541 x DRG weight",32811,Other,base rate x DRG weight,45885,,"31,523 x DRG weight",45885,Other,base rate x DRG weight,41297,,"28,371 x DRG weight",41297,Other,base rate x DRG weight,39003,,"26,795 x DRG weight",39003,Other,base rate x DRG weight,15089.8,,"3,970.89 x patient days",15089.8,Per diem,,32697,,"22,463 x DRG weight",32697,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,38466,,"26,426 x DRG weight",38466,Other,base rate x DRG weight,56490,,"38,809 x DRG weight",56490,Other,base rate x DRG weight,56490,,"38,809 x DRG weight",56490,Other,base rate x DRG weight,38466,,"26,426 x DRG weight",38466,Other,base rate x DRG weight,56490,,"38,809 x DRG weight",56490,Other,base rate x DRG weight,24179,,"6,363 x patient days",24179,Per diem,,94467,70,,94467,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,36473,,"25,057 x DRG weight",36473,Other,base rate x DRG weight,32827,,"22,552 x DRG weight",32827,Other,base rate x DRG weight,36473,,"25,057 x DRG weight",36473,Other,base rate x DRG weight,31001,,"21,298 x DRG weight",31001,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,94467,
INGUINAL AND FEMORAL HERNIA PROCEDURES WITHOUT CC/MCC,352,MS-DRG,,,,,,,,inpatient,,,111772.39,14248,,,14248,Other,150% of Medicare + 9.63% HCRA Surcharge,8664,,"3,609.90 x patient days",8664,Per diem,,27776,,"25,046 x DRG weight",27776,Other,base rate x DRG weight,24998,,"22,541 x DRG weight",24998,Other,base rate x DRG weight,34959,,"31,523 x DRG weight",34959,Other,base rate x DRG weight,31463,,"28,371 x DRG weight",31463,Other,base rate x DRG weight,29716,,"26,795 x DRG weight",29716,Other,base rate x DRG weight,9530.4,,"3,970.89 x patient days",9530.4,Per diem,,24911,,"22,463 x DRG weight",24911,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,29306,,"26,426 x DRG weight",29306,Other,base rate x DRG weight,43039,,"38,809 x DRG weight",43039,Other,base rate x DRG weight,43039,,"38,809 x DRG weight",43039,Other,base rate x DRG weight,29306,,"26,426 x DRG weight",29306,Other,base rate x DRG weight,43039,,"38,809 x DRG weight",43039,Other,base rate x DRG weight,15271,,"6,363 x patient days",15271,Per diem,,78241,70,,78241,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,27788,,"25,057 x DRG weight",27788,Other,base rate x DRG weight,25010,,"22,552 x DRG weight",25010,Other,base rate x DRG weight,27788,,"25,057 x DRG weight",27788,Other,base rate x DRG weight,23619,,"21,298 x DRG weight",23619,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,78241,
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITH MCC,353,MS-DRG,,,,,,,,inpatient,,,253158.37,48084,,,48084,Other,150% of Medicare + 9.63% HCRA Surcharge,29240,,"3,609.90 x patient days",29240,Per diem,,73242,,"25,046 x DRG weight",73242,Other,base rate x DRG weight,65917,,"22,541 x DRG weight",65917,Other,base rate x DRG weight,92183,,"31,523 x DRG weight",92183,Other,base rate x DRG weight,82965,,"28,371 x DRG weight",82965,Other,base rate x DRG weight,78357,,"26,795 x DRG weight",78357,Other,base rate x DRG weight,32164,,"3,970.89 x patient days",32164,Per diem,,65689,,"22,463 x DRG weight",65689,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,77278,,"26,426 x DRG weight",77278,Other,base rate x DRG weight,113489,,"38,809 x DRG weight",113489,Other,base rate x DRG weight,113489,,"38,809 x DRG weight",113489,Other,base rate x DRG weight,77278,,"26,426 x DRG weight",77278,Other,base rate x DRG weight,113489,,"38,809 x DRG weight",113489,Other,base rate x DRG weight,51540,,"6,363 x patient days",51540,Per diem,,177211,70,,177211,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,73274,,"25,057 x DRG weight",73274,Other,base rate x DRG weight,65949,,"22,552 x DRG weight",65949,Other,base rate x DRG weight,73274,,"25,057 x DRG weight",73274,Other,base rate x DRG weight,62282,,"21,298 x DRG weight",62282,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,177211,
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITH CC,354,MS-DRG,,,,,,,,inpatient,,,207376.47,26120,,,26120,Other,150% of Medicare + 9.63% HCRA Surcharge,15884,,"3,609.90 x patient days",15884,Per diem,,43024,,"25,046 x DRG weight",43024,Other,base rate x DRG weight,38721,,"22,541 x DRG weight",38721,Other,base rate x DRG weight,54150,,"31,523 x DRG weight",54150,Other,base rate x DRG weight,48736,,"28,371 x DRG weight",48736,Other,base rate x DRG weight,46028,,"26,795 x DRG weight",46028,Other,base rate x DRG weight,17472.4,,"3,970.89 x patient days",17472.4,Per diem,,38587,,"22,463 x DRG weight",38587,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,45395,,"26,426 x DRG weight",45395,Other,base rate x DRG weight,66666,,"38,809 x DRG weight",66666,Other,base rate x DRG weight,66666,,"38,809 x DRG weight",66666,Other,base rate x DRG weight,45395,,"26,426 x DRG weight",45395,Other,base rate x DRG weight,66666,,"38,809 x DRG weight",66666,Other,base rate x DRG weight,27997,,"6,363 x patient days",27997,Per diem,,145164,70,,145164,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,43043,,"25,057 x DRG weight",43043,Other,base rate x DRG weight,38740,,"22,552 x DRG weight",38740,Other,base rate x DRG weight,43043,,"25,057 x DRG weight",43043,Other,base rate x DRG weight,36586,,"21,298 x DRG weight",36586,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,145164,
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITHOUT CC/MCC,355,MS-DRG,,,,,,,,inpatient,,,96443.6,16028,,,16028,Other,150% of Medicare + 9.63% HCRA Surcharge,9747,,"3,609.90 x patient days",9747,Per diem,,34128,,"25,046 x DRG weight",34128,Other,base rate x DRG weight,30714,,"22,541 x DRG weight",30714,Other,base rate x DRG weight,42953,,"31,523 x DRG weight",42953,Other,base rate x DRG weight,38658,,"28,371 x DRG weight",38658,Other,base rate x DRG weight,36511,,"26,795 x DRG weight",36511,Other,base rate x DRG weight,10721.7,,"3,970.89 x patient days",10721.7,Per diem,,30608,,"22,463 x DRG weight",30608,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,36008,,"26,426 x DRG weight",36008,Other,base rate x DRG weight,52881,,"38,809 x DRG weight",52881,Other,base rate x DRG weight,52881,,"38,809 x DRG weight",52881,Other,base rate x DRG weight,36008,,"26,426 x DRG weight",36008,Other,base rate x DRG weight,52881,,"38,809 x DRG weight",52881,Other,base rate x DRG weight,17180,,"6,363 x patient days",17180,Per diem,,67511,70,,67511,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,34143,,"25,057 x DRG weight",34143,Other,base rate x DRG weight,30729,,"22,552 x DRG weight",30729,Other,base rate x DRG weight,34143,,"25,057 x DRG weight",34143,Other,base rate x DRG weight,29021,,"21,298 x DRG weight",29021,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,67511,
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH MCC,356,MS-DRG,,,,,,,,inpatient,,,610805.36,65299,,,65299,Other,150% of Medicare + 9.63% HCRA Surcharge,39709,,"3,609.90 x patient days",39709,Per diem,,107164,,"25,046 x DRG weight",107164,Other,base rate x DRG weight,96446,,"22,541 x DRG weight",96446,Other,base rate x DRG weight,134877,,"31,523 x DRG weight",134877,Other,base rate x DRG weight,121391,,"28,371 x DRG weight",121391,Other,base rate x DRG weight,114648,,"26,795 x DRG weight",114648,Other,base rate x DRG weight,43679.9,,"3,970.89 x patient days",43679.9,Per diem,,96112,,"22,463 x DRG weight",96112,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,113069,,"26,426 x DRG weight",113069,Other,base rate x DRG weight,166052,,"38,809 x DRG weight",166052,Other,base rate x DRG weight,166052,,"38,809 x DRG weight",166052,Other,base rate x DRG weight,113069,,"26,426 x DRG weight",113069,Other,base rate x DRG weight,166052,,"38,809 x DRG weight",166052,Other,base rate x DRG weight,69993,,"6,363 x patient days",69993,Per diem,,427564,70,,427564,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,107211,,"25,057 x DRG weight",107211,Other,base rate x DRG weight,96493,,"22,552 x DRG weight",96493,Other,base rate x DRG weight,107211,,"25,057 x DRG weight",107211,Other,base rate x DRG weight,91128,,"21,298 x DRG weight",91128,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,427564,
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH CC,357,MS-DRG,,,,,,,,inpatient,,,250970.93,33836,,,33836,Other,150% of Medicare + 9.63% HCRA Surcharge,20576,,"3,609.90 x patient days",20576,Per diem,,55021,,"25,046 x DRG weight",55021,Other,base rate x DRG weight,49518,,"22,541 x DRG weight",49518,Other,base rate x DRG weight,69250,,"31,523 x DRG weight",69250,Other,base rate x DRG weight,62325,,"28,371 x DRG weight",62325,Other,base rate x DRG weight,58863,,"26,795 x DRG weight",58863,Other,base rate x DRG weight,22633.6,,"3,970.89 x patient days",22633.6,Per diem,,49347,,"22,463 x DRG weight",49347,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,58053,,"26,426 x DRG weight",58053,Other,base rate x DRG weight,85256,,"38,809 x DRG weight",85256,Other,base rate x DRG weight,85256,,"38,809 x DRG weight",85256,Other,base rate x DRG weight,58053,,"26,426 x DRG weight",58053,Other,base rate x DRG weight,85256,,"38,809 x DRG weight",85256,Other,base rate x DRG weight,36269,,"6,363 x patient days",36269,Per diem,,175680,70,,175680,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,55045,,"25,057 x DRG weight",55045,Other,base rate x DRG weight,49542,,"22,552 x DRG weight",49542,Other,base rate x DRG weight,55045,,"25,057 x DRG weight",55045,Other,base rate x DRG weight,46787,,"21,298 x DRG weight",46787,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,175680,
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITHOUT CC/MCC,358,MS-DRG,,,,,,,,inpatient,,,147974.66,18997,,,18997,Other,150% of Medicare + 9.63% HCRA Surcharge,11552,,"3,609.90 x patient days",11552,Per diem,,32086,,"25,046 x DRG weight",32086,Other,base rate x DRG weight,28877,,"22,541 x DRG weight",28877,Other,base rate x DRG weight,40384,,"31,523 x DRG weight",40384,Other,base rate x DRG weight,36346,,"28,371 x DRG weight",36346,Other,base rate x DRG weight,34327,,"26,795 x DRG weight",34327,Other,base rate x DRG weight,12707.2,,"3,970.89 x patient days",12707.2,Per diem,,28777,,"22,463 x DRG weight",28777,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,33854,,"26,426 x DRG weight",33854,Other,base rate x DRG weight,49718,,"38,809 x DRG weight",49718,Other,base rate x DRG weight,49718,,"38,809 x DRG weight",49718,Other,base rate x DRG weight,33854,,"26,426 x DRG weight",33854,Other,base rate x DRG weight,49718,,"38,809 x DRG weight",49718,Other,base rate x DRG weight,20362,,"6,363 x patient days",20362,Per diem,,103582,70,,103582,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,32101,,"25,057 x DRG weight",32101,Other,base rate x DRG weight,28891,,"22,552 x DRG weight",28891,Other,base rate x DRG weight,32101,,"25,057 x DRG weight",32101,Other,base rate x DRG weight,27285,,"21,298 x DRG weight",27285,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,103582,
MAJOR ESOPHAGEAL DISORDERS WITH MCC,368,MS-DRG,,,,,,,,inpatient,,,125057.04,33243,,,33243,Other,150% of Medicare + 9.63% HCRA Surcharge,20215,,"3,609.90 x patient days",20215,Per diem,,41376,,"25,046 x DRG weight",41376,Other,base rate x DRG weight,37238,,"22,541 x DRG weight",37238,Other,base rate x DRG weight,52076,,"31,523 x DRG weight",52076,Other,base rate x DRG weight,46869,,"28,371 x DRG weight",46869,Other,base rate x DRG weight,44265,,"26,795 x DRG weight",44265,Other,base rate x DRG weight,22236.5,,"3,970.89 x patient days",22236.5,Per diem,,37109,,"22,463 x DRG weight",37109,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,43656,,"26,426 x DRG weight",43656,Other,base rate x DRG weight,64112,,"38,809 x DRG weight",64112,Other,base rate x DRG weight,64112,,"38,809 x DRG weight",64112,Other,base rate x DRG weight,43656,,"26,426 x DRG weight",43656,Other,base rate x DRG weight,64112,,"38,809 x DRG weight",64112,Other,base rate x DRG weight,35633,,"6,363 x patient days",35633,Per diem,,87540,70,,87540,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,41394,,"25,057 x DRG weight",41394,Other,base rate x DRG weight,37256,,"22,552 x DRG weight",37256,Other,base rate x DRG weight,41394,,"25,057 x DRG weight",41394,Other,base rate x DRG weight,35184,,"21,298 x DRG weight",35184,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,87540,
MAJOR ESOPHAGEAL DISORDERS WITH CC,369,MS-DRG,,,,,,,,inpatient,,,136788.2,21965,,,21965,Other,150% of Medicare + 9.63% HCRA Surcharge,13357,,"3,609.90 x patient days",13357,Per diem,,24753,,"25,046 x DRG weight",24753,Other,base rate x DRG weight,22277,,"22,541 x DRG weight",22277,Other,base rate x DRG weight,31154,,"31,523 x DRG weight",31154,Other,base rate x DRG weight,28039,,"28,371 x DRG weight",28039,Other,base rate x DRG weight,26481,,"26,795 x DRG weight",26481,Other,base rate x DRG weight,14692.7,,"3,970.89 x patient days",14692.7,Per diem,,22200,,"22,463 x DRG weight",22200,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,26117,,"26,426 x DRG weight",26117,Other,base rate x DRG weight,38355,,"38,809 x DRG weight",38355,Other,base rate x DRG weight,38355,,"38,809 x DRG weight",38355,Other,base rate x DRG weight,26117,,"26,426 x DRG weight",26117,Other,base rate x DRG weight,38355,,"38,809 x DRG weight",38355,Other,base rate x DRG weight,23543,,"6,363 x patient days",23543,Per diem,,95752,70,,95752,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,24764,,"25,057 x DRG weight",24764,Other,base rate x DRG weight,22288,,"22,552 x DRG weight",22288,Other,base rate x DRG weight,24764,,"25,057 x DRG weight",24764,Other,base rate x DRG weight,21049,,"21,298 x DRG weight",21049,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,95752,
MAJOR ESOPHAGEAL DISORDERS WITHOUT CC/MCC,370,MS-DRG,,,,,,,,inpatient,,,55938.84,15435,,,15435,Other,150% of Medicare + 9.63% HCRA Surcharge,9386,,"3,609.90 x patient days",9386,Per diem,,18627,,"25,046 x DRG weight",18627,Other,base rate x DRG weight,16764,,"22,541 x DRG weight",16764,Other,base rate x DRG weight,23444,,"31,523 x DRG weight",23444,Other,base rate x DRG weight,21100,,"28,371 x DRG weight",21100,Other,base rate x DRG weight,19927,,"26,795 x DRG weight",19927,Other,base rate x DRG weight,10324.6,,"3,970.89 x patient days",10324.6,Per diem,,16706,,"22,463 x DRG weight",16706,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,19653,,"26,426 x DRG weight",19653,Other,base rate x DRG weight,28862,,"38,809 x DRG weight",28862,Other,base rate x DRG weight,28862,,"38,809 x DRG weight",28862,Other,base rate x DRG weight,19653,,"26,426 x DRG weight",19653,Other,base rate x DRG weight,28862,,"38,809 x DRG weight",28862,Other,base rate x DRG weight,16544,,"6,363 x patient days",16544,Per diem,,39157,70,,39157,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,18635,,"25,057 x DRG weight",18635,Other,base rate x DRG weight,16772,,"22,552 x DRG weight",16772,Other,base rate x DRG weight,18635,,"25,057 x DRG weight",18635,Other,base rate x DRG weight,15839,,"21,298 x DRG weight",15839,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,39157,
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH MCC,371,MS-DRG,,,,,,,,inpatient,,,264384.74,42741,,,42741,Other,150% of Medicare + 9.63% HCRA Surcharge,25991,,"3,609.90 x patient days",25991,Per diem,,43773,,"25,046 x DRG weight",43773,Other,base rate x DRG weight,39395,,"22,541 x DRG weight",39395,Other,base rate x DRG weight,55093,,"31,523 x DRG weight",55093,Other,base rate x DRG weight,49584,,"28,371 x DRG weight",49584,Other,base rate x DRG weight,46830,,"26,795 x DRG weight",46830,Other,base rate x DRG weight,28590.1,,"3,970.89 x patient days",28590.1,Per diem,,39259,,"22,463 x DRG weight",39259,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,46185,,"26,426 x DRG weight",46185,Other,base rate x DRG weight,67826,,"38,809 x DRG weight",67826,Other,base rate x DRG weight,67826,,"38,809 x DRG weight",67826,Other,base rate x DRG weight,46185,,"26,426 x DRG weight",46185,Other,base rate x DRG weight,67826,,"38,809 x DRG weight",67826,Other,base rate x DRG weight,45814,,"6,363 x patient days",45814,Per diem,,185069,70,,185069,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,43792,,"25,057 x DRG weight",43792,Other,base rate x DRG weight,39414,,"22,552 x DRG weight",39414,Other,base rate x DRG weight,43792,,"25,057 x DRG weight",43792,Other,base rate x DRG weight,37223,,"21,298 x DRG weight",37223,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,185069,
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH CC,372,MS-DRG,,,,,,,,inpatient,,,140654.67,27901,,,27901,Other,150% of Medicare + 9.63% HCRA Surcharge,16967,,"3,609.90 x patient days",16967,Per diem,,26105,,"25,046 x DRG weight",26105,Other,base rate x DRG weight,23494,,"22,541 x DRG weight",23494,Other,base rate x DRG weight,32856,,"31,523 x DRG weight",32856,Other,base rate x DRG weight,29571,,"28,371 x DRG weight",29571,Other,base rate x DRG weight,27928,,"26,795 x DRG weight",27928,Other,base rate x DRG weight,18663.7,,"3,970.89 x patient days",18663.7,Per diem,,23413,,"22,463 x DRG weight",23413,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,27544,,"26,426 x DRG weight",27544,Other,base rate x DRG weight,40451,,"38,809 x DRG weight",40451,Other,base rate x DRG weight,40451,,"38,809 x DRG weight",40451,Other,base rate x DRG weight,27544,,"26,426 x DRG weight",27544,Other,base rate x DRG weight,40451,,"38,809 x DRG weight",40451,Other,base rate x DRG weight,29906,,"6,363 x patient days",29906,Per diem,,98458,70,,98458,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,26117,,"25,057 x DRG weight",26117,Other,base rate x DRG weight,23506,,"22,552 x DRG weight",23506,Other,base rate x DRG weight,26117,,"25,057 x DRG weight",26117,Other,base rate x DRG weight,22199,,"21,298 x DRG weight",22199,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,98458,
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITHOUT CC/MCC,373,MS-DRG,,,,,,,,inpatient,,,87175.27,20184,,,20184,Other,150% of Medicare + 9.63% HCRA Surcharge,12274,,"3,609.90 x patient days",12274,Per diem,,17945,,"25,046 x DRG weight",17945,Other,base rate x DRG weight,16151,,"22,541 x DRG weight",16151,Other,base rate x DRG weight,22586,,"31,523 x DRG weight",22586,Other,base rate x DRG weight,20328,,"28,371 x DRG weight",20328,Other,base rate x DRG weight,19199,,"26,795 x DRG weight",19199,Other,base rate x DRG weight,13501.4,,"3,970.89 x patient days",13501.4,Per diem,,16095,,"22,463 x DRG weight",16095,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,18934,,"26,426 x DRG weight",18934,Other,base rate x DRG weight,27807,,"38,809 x DRG weight",27807,Other,base rate x DRG weight,27807,,"38,809 x DRG weight",27807,Other,base rate x DRG weight,18934,,"26,426 x DRG weight",18934,Other,base rate x DRG weight,27807,,"38,809 x DRG weight",27807,Other,base rate x DRG weight,21634,,"6,363 x patient days",21634,Per diem,,61023,70,,61023,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,17953,,"25,057 x DRG weight",17953,Other,base rate x DRG weight,16159,,"22,552 x DRG weight",16159,Other,base rate x DRG weight,17953,,"25,057 x DRG weight",17953,Other,base rate x DRG weight,15260,,"21,298 x DRG weight",15260,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,61023,
DIGESTIVE MALIGNANCY WITH MCC,374,MS-DRG,,,,,,,,inpatient,,,334803.01,45709,,,45709,Other,150% of Medicare + 9.63% HCRA Surcharge,27796,,"3,609.90 x patient days",27796,Per diem,,52572,,"25,046 x DRG weight",52572,Other,base rate x DRG weight,47314,,"22,541 x DRG weight",47314,Other,base rate x DRG weight,66167,,"31,523 x DRG weight",66167,Other,base rate x DRG weight,59551,,"28,371 x DRG weight",59551,Other,base rate x DRG weight,56243,,"26,795 x DRG weight",56243,Other,base rate x DRG weight,30575.6,,"3,970.89 x patient days",30575.6,Per diem,,47150,,"22,463 x DRG weight",47150,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,55468,,"26,426 x DRG weight",55468,Other,base rate x DRG weight,81460,,"38,809 x DRG weight",81460,Other,base rate x DRG weight,81460,,"38,809 x DRG weight",81460,Other,base rate x DRG weight,55468,,"26,426 x DRG weight",55468,Other,base rate x DRG weight,81460,,"38,809 x DRG weight",81460,Other,base rate x DRG weight,48995,,"6,363 x patient days",48995,Per diem,,234362,70,,234362,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,52595,,"25,057 x DRG weight",52595,Other,base rate x DRG weight,47337,,"22,552 x DRG weight",47337,Other,base rate x DRG weight,52595,,"25,057 x DRG weight",52595,Other,base rate x DRG weight,44705,,"21,298 x DRG weight",44705,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,234362,
DIGESTIVE MALIGNANCY WITH CC,375,MS-DRG,,,,,,,,inpatient,,,290067.91,27901,,,27901,Other,150% of Medicare + 9.63% HCRA Surcharge,16967,,"3,609.90 x patient days",16967,Per diem,,30013,,"25,046 x DRG weight",30013,Other,base rate x DRG weight,27011,,"22,541 x DRG weight",27011,Other,base rate x DRG weight,37774,,"31,523 x DRG weight",37774,Other,base rate x DRG weight,33997,,"28,371 x DRG weight",33997,Other,base rate x DRG weight,32108,,"26,795 x DRG weight",32108,Other,base rate x DRG weight,18663.7,,"3,970.89 x patient days",18663.7,Per diem,,26917,,"22,463 x DRG weight",26917,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,31666,,"26,426 x DRG weight",31666,Other,base rate x DRG weight,46505,,"38,809 x DRG weight",46505,Other,base rate x DRG weight,46505,,"38,809 x DRG weight",46505,Other,base rate x DRG weight,31666,,"26,426 x DRG weight",31666,Other,base rate x DRG weight,46505,,"38,809 x DRG weight",46505,Other,base rate x DRG weight,29906,,"6,363 x patient days",29906,Per diem,,203048,70,,203048,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,30026,,"25,057 x DRG weight",30026,Other,base rate x DRG weight,27024,,"22,552 x DRG weight",27024,Other,base rate x DRG weight,30026,,"25,057 x DRG weight",30026,Other,base rate x DRG weight,25521,,"21,298 x DRG weight",25521,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,203048,
DIGESTIVE MALIGNANCY WITHOUT CC/MCC,376,MS-DRG,,,,,,,,inpatient,,,154497.32,17809,,,17809,Other,150% of Medicare + 9.63% HCRA Surcharge,10830,,"3,609.90 x patient days",10830,Per diem,,22326,,"25,046 x DRG weight",22326,Other,base rate x DRG weight,20093,,"22,541 x DRG weight",20093,Other,base rate x DRG weight,28100,,"31,523 x DRG weight",28100,Other,base rate x DRG weight,25290,,"28,371 x DRG weight",25290,Other,base rate x DRG weight,23885,,"26,795 x DRG weight",23885,Other,base rate x DRG weight,11913,,"3,970.89 x patient days",11913,Per diem,,20024,,"22,463 x DRG weight",20024,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,23556,,"26,426 x DRG weight",23556,Other,base rate x DRG weight,34594,,"38,809 x DRG weight",34594,Other,base rate x DRG weight,34594,,"38,809 x DRG weight",34594,Other,base rate x DRG weight,23556,,"26,426 x DRG weight",23556,Other,base rate x DRG weight,34594,,"38,809 x DRG weight",34594,Other,base rate x DRG weight,19089,,"6,363 x patient days",19089,Per diem,,108148,70,,108148,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,22336,,"25,057 x DRG weight",22336,Other,base rate x DRG weight,20103,,"22,552 x DRG weight",20103,Other,base rate x DRG weight,22336,,"25,057 x DRG weight",22336,Other,base rate x DRG weight,18985,,"21,298 x DRG weight",18985,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,108148,
GASTROINTESTINAL HEMORRHAGE WITH MCC,377,MS-DRG,,,,,,,,inpatient,,,267641.88,35617,,,35617,Other,150% of Medicare + 9.63% HCRA Surcharge,21659,,"3,609.90 x patient days",21659,Per diem,,44840,,"25,046 x DRG weight",44840,Other,base rate x DRG weight,40355,,"22,541 x DRG weight",40355,Other,base rate x DRG weight,56436,,"31,523 x DRG weight",56436,Other,base rate x DRG weight,50793,,"28,371 x DRG weight",50793,Other,base rate x DRG weight,47971,,"26,795 x DRG weight",47971,Other,base rate x DRG weight,23824.9,,"3,970.89 x patient days",23824.9,Per diem,,40216,,"22,463 x DRG weight",40216,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,47310,,"26,426 x DRG weight",47310,Other,base rate x DRG weight,69480,,"38,809 x DRG weight",69480,Other,base rate x DRG weight,69480,,"38,809 x DRG weight",69480,Other,base rate x DRG weight,47310,,"26,426 x DRG weight",47310,Other,base rate x DRG weight,69480,,"38,809 x DRG weight",69480,Other,base rate x DRG weight,38178,,"6,363 x patient days",38178,Per diem,,187349,70,,187349,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,44860,,"25,057 x DRG weight",44860,Other,base rate x DRG weight,40375,,"22,552 x DRG weight",40375,Other,base rate x DRG weight,44860,,"25,057 x DRG weight",44860,Other,base rate x DRG weight,38130,,"21,298 x DRG weight",38130,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,187349,
GASTROINTESTINAL HEMORRHAGE WITH CC,378,MS-DRG,,,,,,,,inpatient,,,137968.46,21371,,,21371,Other,150% of Medicare + 9.63% HCRA Surcharge,12996,,"3,609.90 x patient days",12996,Per diem,,24640,,"25,046 x DRG weight",24640,Other,base rate x DRG weight,22176,,"22,541 x DRG weight",22176,Other,base rate x DRG weight,31012,,"31,523 x DRG weight",31012,Other,base rate x DRG weight,27911,,"28,371 x DRG weight",27911,Other,base rate x DRG weight,26361,,"26,795 x DRG weight",26361,Other,base rate x DRG weight,14295.6,,"3,970.89 x patient days",14295.6,Per diem,,22099,,"22,463 x DRG weight",22099,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,25998,,"26,426 x DRG weight",25998,Other,base rate x DRG weight,38180,,"38,809 x DRG weight",38180,Other,base rate x DRG weight,38180,,"38,809 x DRG weight",38180,Other,base rate x DRG weight,25998,,"26,426 x DRG weight",25998,Other,base rate x DRG weight,38180,,"38,809 x DRG weight",38180,Other,base rate x DRG weight,22907,,"6,363 x patient days",22907,Per diem,,96578,70,,96578,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,24651,,"25,057 x DRG weight",24651,Other,base rate x DRG weight,22187,,"22,552 x DRG weight",22187,Other,base rate x DRG weight,24651,,"25,057 x DRG weight",24651,Other,base rate x DRG weight,20953,,"21,298 x DRG weight",20953,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,96578,
GASTROINTESTINAL HEMORRHAGE WITHOUT CC/MCC,379,MS-DRG,,,,,,,,inpatient,,,99890.04,14248,,,14248,Other,150% of Medicare + 9.63% HCRA Surcharge,8664,,"3,609.90 x patient days",8664,Per diem,,15859,,"25,046 x DRG weight",15859,Other,base rate x DRG weight,14273,,"22,541 x DRG weight",14273,Other,base rate x DRG weight,19960,,"31,523 x DRG weight",19960,Other,base rate x DRG weight,17965,,"28,371 x DRG weight",17965,Other,base rate x DRG weight,16967,,"26,795 x DRG weight",16967,Other,base rate x DRG weight,9530.4,,"3,970.89 x patient days",9530.4,Per diem,,14224,,"22,463 x DRG weight",14224,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,16733,,"26,426 x DRG weight",16733,Other,base rate x DRG weight,24574,,"38,809 x DRG weight",24574,Other,base rate x DRG weight,24574,,"38,809 x DRG weight",24574,Other,base rate x DRG weight,16733,,"26,426 x DRG weight",16733,Other,base rate x DRG weight,24574,,"38,809 x DRG weight",24574,Other,base rate x DRG weight,15271,,"6,363 x patient days",15271,Per diem,,69923,70,,69923,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,15866,,"25,057 x DRG weight",15866,Other,base rate x DRG weight,14280,,"22,552 x DRG weight",14280,Other,base rate x DRG weight,15866,,"25,057 x DRG weight",15866,Other,base rate x DRG weight,13486,,"21,298 x DRG weight",13486,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,69923,
COMPLICATED PEPTIC ULCER WITH MCC,380,MS-DRG,,,,,,,,inpatient,,,331567.02,39773,,,39773,Other,150% of Medicare + 9.63% HCRA Surcharge,24186,,"3,609.90 x patient days",24186,Per diem,,48802,,"25,046 x DRG weight",48802,Other,base rate x DRG weight,43921,,"22,541 x DRG weight",43921,Other,base rate x DRG weight,61423,,"31,523 x DRG weight",61423,Other,base rate x DRG weight,55281,,"28,371 x DRG weight",55281,Other,base rate x DRG weight,52210,,"26,795 x DRG weight",52210,Other,base rate x DRG weight,26604.6,,"3,970.89 x patient days",26604.6,Per diem,,43769,,"22,463 x DRG weight",43769,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,51491,,"26,426 x DRG weight",51491,Other,base rate x DRG weight,75619,,"38,809 x DRG weight",75619,Other,base rate x DRG weight,75619,,"38,809 x DRG weight",75619,Other,base rate x DRG weight,51491,,"26,426 x DRG weight",51491,Other,base rate x DRG weight,75619,,"38,809 x DRG weight",75619,Other,base rate x DRG weight,42632,,"6,363 x patient days",42632,Per diem,,232097,70,,232097,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,48824,,"25,057 x DRG weight",48824,Other,base rate x DRG weight,43943,,"22,552 x DRG weight",43943,Other,base rate x DRG weight,48824,,"25,057 x DRG weight",48824,Other,base rate x DRG weight,41499,,"21,298 x DRG weight",41499,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,232097,
COMPLICATED PEPTIC ULCER WITH CC,381,MS-DRG,,,,,,,,inpatient,,,259555.62,23152,,,23152,Other,150% of Medicare + 9.63% HCRA Surcharge,14079,,"3,609.90 x patient days",14079,Per diem,,26874,,"25,046 x DRG weight",26874,Other,base rate x DRG weight,24186,,"22,541 x DRG weight",24186,Other,base rate x DRG weight,33824,,"31,523 x DRG weight",33824,Other,base rate x DRG weight,30442,,"28,371 x DRG weight",30442,Other,base rate x DRG weight,28751,,"26,795 x DRG weight",28751,Other,base rate x DRG weight,15486.9,,"3,970.89 x patient days",15486.9,Per diem,,24103,,"22,463 x DRG weight",24103,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,28355,,"26,426 x DRG weight",28355,Other,base rate x DRG weight,41642,,"38,809 x DRG weight",41642,Other,base rate x DRG weight,41642,,"38,809 x DRG weight",41642,Other,base rate x DRG weight,28355,,"26,426 x DRG weight",28355,Other,base rate x DRG weight,41642,,"38,809 x DRG weight",41642,Other,base rate x DRG weight,24816,,"6,363 x patient days",24816,Per diem,,181689,70,,181689,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,26886,,"25,057 x DRG weight",26886,Other,base rate x DRG weight,24198,,"22,552 x DRG weight",24198,Other,base rate x DRG weight,26886,,"25,057 x DRG weight",26886,Other,base rate x DRG weight,22853,,"21,298 x DRG weight",22853,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,181689,
COMPLICATED PEPTIC ULCER WITHOUT CC/MCC,382,MS-DRG,,,,,,,,inpatient,,,172009,17216,,,17216,Other,150% of Medicare + 9.63% HCRA Surcharge,10469,,"3,609.90 x patient days",10469,Per diem,,18962,,"25,046 x DRG weight",18962,Other,base rate x DRG weight,17066,,"22,541 x DRG weight",17066,Other,base rate x DRG weight,23866,,"31,523 x DRG weight",23866,Other,base rate x DRG weight,21480,,"28,371 x DRG weight",21480,Other,base rate x DRG weight,20286,,"26,795 x DRG weight",20286,Other,base rate x DRG weight,11515.9,,"3,970.89 x patient days",11515.9,Per diem,,17007,,"22,463 x DRG weight",17007,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,20007,,"26,426 x DRG weight",20007,Other,base rate x DRG weight,29382,,"38,809 x DRG weight",29382,Other,base rate x DRG weight,29382,,"38,809 x DRG weight",29382,Other,base rate x DRG weight,20007,,"26,426 x DRG weight",20007,Other,base rate x DRG weight,29382,,"38,809 x DRG weight",29382,Other,base rate x DRG weight,18453,,"6,363 x patient days",18453,Per diem,,120406,70,,120406,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,18971,,"25,057 x DRG weight",18971,Other,base rate x DRG weight,17074,,"22,552 x DRG weight",17074,Other,base rate x DRG weight,18971,,"25,057 x DRG weight",18971,Other,base rate x DRG weight,16125,,"21,298 x DRG weight",16125,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,120406,
UNCOMPLICATED PEPTIC ULCER WITH MCC,383,MS-DRG,,,,,,,,inpatient,,,378280.8,29089,,,29089,Other,150% of Medicare + 9.63% HCRA Surcharge,17689,,"3,609.90 x patient days",17689,Per diem,,35019,,"25,046 x DRG weight",35019,Other,base rate x DRG weight,31517,,"22,541 x DRG weight",31517,Other,base rate x DRG weight,44075,,"31,523 x DRG weight",44075,Other,base rate x DRG weight,39668,,"28,371 x DRG weight",39668,Other,base rate x DRG weight,37465,,"26,795 x DRG weight",37465,Other,base rate x DRG weight,19457.9,,"3,970.89 x patient days",19457.9,Per diem,,31408,,"22,463 x DRG weight",31408,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,36949,,"26,426 x DRG weight",36949,Other,base rate x DRG weight,54263,,"38,809 x DRG weight",54263,Other,base rate x DRG weight,54263,,"38,809 x DRG weight",54263,Other,base rate x DRG weight,36949,,"26,426 x DRG weight",36949,Other,base rate x DRG weight,54263,,"38,809 x DRG weight",54263,Other,base rate x DRG weight,31179,,"6,363 x patient days",31179,Per diem,,264797,70,,264797,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,35035,,"25,057 x DRG weight",35035,Other,base rate x DRG weight,31532,,"22,552 x DRG weight",31532,Other,base rate x DRG weight,35035,,"25,057 x DRG weight",35035,Other,base rate x DRG weight,29779,,"21,298 x DRG weight",29779,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,264797,
UNCOMPLICATED PEPTIC ULCER WITHOUT MCC,384,MS-DRG,,,,,,,,inpatient,,,101786.77,18997,,,18997,Other,150% of Medicare + 9.63% HCRA Surcharge,11552,,"3,609.90 x patient days",11552,Per diem,,21933,,"25,046 x DRG weight",21933,Other,base rate x DRG weight,19739,,"22,541 x DRG weight",19739,Other,base rate x DRG weight,27605,,"31,523 x DRG weight",27605,Other,base rate x DRG weight,24844,,"28,371 x DRG weight",24844,Other,base rate x DRG weight,23464,,"26,795 x DRG weight",23464,Other,base rate x DRG weight,12707.2,,"3,970.89 x patient days",12707.2,Per diem,,19671,,"22,463 x DRG weight",19671,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,23141,,"26,426 x DRG weight",23141,Other,base rate x DRG weight,33985,,"38,809 x DRG weight",33985,Other,base rate x DRG weight,33985,,"38,809 x DRG weight",33985,Other,base rate x DRG weight,23141,,"26,426 x DRG weight",23141,Other,base rate x DRG weight,33985,,"38,809 x DRG weight",33985,Other,base rate x DRG weight,20362,,"6,363 x patient days",20362,Per diem,,71251,70,,71251,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,21942,,"25,057 x DRG weight",21942,Other,base rate x DRG weight,19749,,"22,552 x DRG weight",19749,Other,base rate x DRG weight,21942,,"25,057 x DRG weight",21942,Other,base rate x DRG weight,18651,,"21,298 x DRG weight",18651,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,71251,
INFLAMMATORY BOWEL DISEASE WITH MCC,385,MS-DRG,,,,,,,,inpatient,,,270251.77,39773,,,39773,Other,150% of Medicare + 9.63% HCRA Surcharge,24186,,"3,609.90 x patient days",24186,Per diem,,39245,,"25,046 x DRG weight",39245,Other,base rate x DRG weight,35319,,"22,541 x DRG weight",35319,Other,base rate x DRG weight,49393,,"31,523 x DRG weight",49393,Other,base rate x DRG weight,44455,,"28,371 x DRG weight",44455,Other,base rate x DRG weight,41985,,"26,795 x DRG weight",41985,Other,base rate x DRG weight,26604.6,,"3,970.89 x patient days",26604.6,Per diem,,35197,,"22,463 x DRG weight",35197,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,41407,,"26,426 x DRG weight",41407,Other,base rate x DRG weight,60810,,"38,809 x DRG weight",60810,Other,base rate x DRG weight,60810,,"38,809 x DRG weight",60810,Other,base rate x DRG weight,41407,,"26,426 x DRG weight",41407,Other,base rate x DRG weight,60810,,"38,809 x DRG weight",60810,Other,base rate x DRG weight,42632,,"6,363 x patient days",42632,Per diem,,189176,70,,189176,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,39262,,"25,057 x DRG weight",39262,Other,base rate x DRG weight,35337,,"22,552 x DRG weight",35337,Other,base rate x DRG weight,39262,,"25,057 x DRG weight",39262,Other,base rate x DRG weight,33372,,"21,298 x DRG weight",33372,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,189176,
INFLAMMATORY BOWEL DISEASE WITH CC,386,MS-DRG,,,,,,,,inpatient,,,176957.37,25527,,,25527,Other,150% of Medicare + 9.63% HCRA Surcharge,15523,,"3,609.90 x patient days",15523,Per diem,,24335,,"25,046 x DRG weight",24335,Other,base rate x DRG weight,21901,,"22,541 x DRG weight",21901,Other,base rate x DRG weight,30628,,"31,523 x DRG weight",30628,Other,base rate x DRG weight,27565,,"28,371 x DRG weight",27565,Other,base rate x DRG weight,26034,,"26,795 x DRG weight",26034,Other,base rate x DRG weight,17075.3,,"3,970.89 x patient days",17075.3,Per diem,,21825,,"22,463 x DRG weight",21825,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,25676,,"26,426 x DRG weight",25676,Other,base rate x DRG weight,37707,,"38,809 x DRG weight",37707,Other,base rate x DRG weight,37707,,"38,809 x DRG weight",37707,Other,base rate x DRG weight,25676,,"26,426 x DRG weight",25676,Other,base rate x DRG weight,37707,,"38,809 x DRG weight",37707,Other,base rate x DRG weight,27361,,"6,363 x patient days",27361,Per diem,,123870,70,,123870,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,24345,,"25,057 x DRG weight",24345,Other,base rate x DRG weight,21912,,"22,552 x DRG weight",21912,Other,base rate x DRG weight,24345,,"25,057 x DRG weight",24345,Other,base rate x DRG weight,20693,,"21,298 x DRG weight",20693,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,123870,
INFLAMMATORY BOWEL DISEASE WITHOUT CC/MCC,387,MS-DRG,,,,,,,,inpatient,,,123584.17,18997,,,18997,Other,150% of Medicare + 9.63% HCRA Surcharge,11552,,"3,609.90 x patient days",11552,Per diem,,17134,,"25,046 x DRG weight",17134,Other,base rate x DRG weight,15420,,"22,541 x DRG weight",15420,Other,base rate x DRG weight,21565,,"31,523 x DRG weight",21565,Other,base rate x DRG weight,19409,,"28,371 x DRG weight",19409,Other,base rate x DRG weight,18330,,"26,795 x DRG weight",18330,Other,base rate x DRG weight,12707.2,,"3,970.89 x patient days",12707.2,Per diem,,15367,,"22,463 x DRG weight",15367,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,18078,,"26,426 x DRG weight",18078,Other,base rate x DRG weight,26549,,"38,809 x DRG weight",26549,Other,base rate x DRG weight,26549,,"38,809 x DRG weight",26549,Other,base rate x DRG weight,18078,,"26,426 x DRG weight",18078,Other,base rate x DRG weight,26549,,"38,809 x DRG weight",26549,Other,base rate x DRG weight,20362,,"6,363 x patient days",20362,Per diem,,86509,70,,86509,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,17141,,"25,057 x DRG weight",17141,Other,base rate x DRG weight,15428,,"22,552 x DRG weight",15428,Other,base rate x DRG weight,17141,,"25,057 x DRG weight",17141,Other,base rate x DRG weight,14570,,"21,298 x DRG weight",14570,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,86509,
GASTROINTESTINAL OBSTRUCTION WITH MCC,388,MS-DRG,,,,,,,,inpatient,,,197166.6,36211,,,36211,Other,150% of Medicare + 9.63% HCRA Surcharge,22020,,"3,609.90 x patient days",22020,Per diem,,36404,,"25,046 x DRG weight",36404,Other,base rate x DRG weight,32763,,"22,541 x DRG weight",32763,Other,base rate x DRG weight,45819,,"31,523 x DRG weight",45819,Other,base rate x DRG weight,41237,,"28,371 x DRG weight",41237,Other,base rate x DRG weight,38947,,"26,795 x DRG weight",38947,Other,base rate x DRG weight,24222,,"3,970.89 x patient days",24222,Per diem,,32650,,"22,463 x DRG weight",32650,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,38410,,"26,426 x DRG weight",38410,Other,base rate x DRG weight,56409,,"38,809 x DRG weight",56409,Other,base rate x DRG weight,56409,,"38,809 x DRG weight",56409,Other,base rate x DRG weight,38410,,"26,426 x DRG weight",38410,Other,base rate x DRG weight,56409,,"38,809 x DRG weight",56409,Other,base rate x DRG weight,38814,,"6,363 x patient days",38814,Per diem,,138017,70,,138017,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,36420,,"25,057 x DRG weight",36420,Other,base rate x DRG weight,32779,,"22,552 x DRG weight",32779,Other,base rate x DRG weight,36420,,"25,057 x DRG weight",36420,Other,base rate x DRG weight,30957,,"21,298 x DRG weight",30957,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,138017,
GASTROINTESTINAL OBSTRUCTION WITH CC,389,MS-DRG,,,,,,,,inpatient,,,116946.79,22559,,,22559,Other,150% of Medicare + 9.63% HCRA Surcharge,13718,,"3,609.90 x patient days",13718,Per diem,,19947,,"25,046 x DRG weight",19947,Other,base rate x DRG weight,17952,,"22,541 x DRG weight",17952,Other,base rate x DRG weight,25105,,"31,523 x DRG weight",25105,Other,base rate x DRG weight,22595,,"28,371 x DRG weight",22595,Other,base rate x DRG weight,21340,,"26,795 x DRG weight",21340,Other,base rate x DRG weight,15089.8,,"3,970.89 x patient days",15089.8,Per diem,,17890,,"22,463 x DRG weight",17890,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,21046,,"26,426 x DRG weight",21046,Other,base rate x DRG weight,30907,,"38,809 x DRG weight",30907,Other,base rate x DRG weight,30907,,"38,809 x DRG weight",30907,Other,base rate x DRG weight,21046,,"26,426 x DRG weight",21046,Other,base rate x DRG weight,30907,,"38,809 x DRG weight",30907,Other,base rate x DRG weight,24179,,"6,363 x patient days",24179,Per diem,,81863,70,,81863,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,19955,,"25,057 x DRG weight",19955,Other,base rate x DRG weight,17960,,"22,552 x DRG weight",17960,Other,base rate x DRG weight,19955,,"25,057 x DRG weight",19955,Other,base rate x DRG weight,16962,,"21,298 x DRG weight",16962,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,81863,
GASTROINTESTINAL OBSTRUCTION WITHOUT CC/MCC,390,MS-DRG,,,,,,,,inpatient,,,84892.15,16028,,,16028,Other,150% of Medicare + 9.63% HCRA Surcharge,9747,,"3,609.90 x patient days",9747,Per diem,,14001,,"25,046 x DRG weight",14001,Other,base rate x DRG weight,12600,,"22,541 x DRG weight",12600,Other,base rate x DRG weight,17621,,"31,523 x DRG weight",17621,Other,base rate x DRG weight,15859,,"28,371 x DRG weight",15859,Other,base rate x DRG weight,14978,,"26,795 x DRG weight",14978,Other,base rate x DRG weight,10721.7,,"3,970.89 x patient days",10721.7,Per diem,,12557,,"22,463 x DRG weight",12557,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,14772,,"26,426 x DRG weight",14772,Other,base rate x DRG weight,21694,,"38,809 x DRG weight",21694,Other,base rate x DRG weight,21694,,"38,809 x DRG weight",21694,Other,base rate x DRG weight,14772,,"26,426 x DRG weight",14772,Other,base rate x DRG weight,21694,,"38,809 x DRG weight",21694,Other,base rate x DRG weight,17180,,"6,363 x patient days",17180,Per diem,,59425,70,,59425,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,14007,,"25,057 x DRG weight",14007,Other,base rate x DRG weight,12607,,"22,552 x DRG weight",12607,Other,base rate x DRG weight,14007,,"25,057 x DRG weight",14007,Other,base rate x DRG weight,11906,,"21,298 x DRG weight",11906,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,59425,
"ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITH MCC",391,MS-DRG,,,,,,,,inpatient,,,153223.48,31462,,,31462,Other,150% of Medicare + 9.63% HCRA Surcharge,19132,,"3,609.90 x patient days",19132,Per diem,,31951,,"25,046 x DRG weight",31951,Other,base rate x DRG weight,28756,,"22,541 x DRG weight",28756,Other,base rate x DRG weight,40214,,"31,523 x DRG weight",40214,Other,base rate x DRG weight,36193,,"28,371 x DRG weight",36193,Other,base rate x DRG weight,34182,,"26,795 x DRG weight",34182,Other,base rate x DRG weight,21045.2,,"3,970.89 x patient days",21045.2,Per diem,,28656,,"22,463 x DRG weight",28656,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,33712,,"26,426 x DRG weight",33712,Other,base rate x DRG weight,49509,,"38,809 x DRG weight",49509,Other,base rate x DRG weight,49509,,"38,809 x DRG weight",49509,Other,base rate x DRG weight,33712,,"26,426 x DRG weight",33712,Other,base rate x DRG weight,49509,,"38,809 x DRG weight",49509,Other,base rate x DRG weight,33724,,"6,363 x patient days",33724,Per diem,,107256,70,,107256,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,31965,,"25,057 x DRG weight",31965,Other,base rate x DRG weight,28770,,"22,552 x DRG weight",28770,Other,base rate x DRG weight,31965,,"25,057 x DRG weight",31965,Other,base rate x DRG weight,27170,,"21,298 x DRG weight",27170,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,107256,
"ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITHOUT MCC",392,MS-DRG,,,,,,,,inpatient,,,110388.6,19590,,,19590,Other,150% of Medicare + 9.63% HCRA Surcharge,11913,,"3,609.90 x patient days",11913,Per diem,,19676,,"25,046 x DRG weight",19676,Other,base rate x DRG weight,17708,,"22,541 x DRG weight",17708,Other,base rate x DRG weight,24764,,"31,523 x DRG weight",24764,Other,base rate x DRG weight,22288,,"28,371 x DRG weight",22288,Other,base rate x DRG weight,21050,,"26,795 x DRG weight",21050,Other,base rate x DRG weight,13104.3,,"3,970.89 x patient days",13104.3,Per diem,,17647,,"22,463 x DRG weight",17647,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,20760,,"26,426 x DRG weight",20760,Other,base rate x DRG weight,30488,,"38,809 x DRG weight",30488,Other,base rate x DRG weight,30488,,"38,809 x DRG weight",30488,Other,base rate x DRG weight,20760,,"26,426 x DRG weight",20760,Other,base rate x DRG weight,30488,,"38,809 x DRG weight",30488,Other,base rate x DRG weight,20998,,"6,363 x patient days",20998,Per diem,,77272,70,,77272,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,19685,,"25,057 x DRG weight",19685,Other,base rate x DRG weight,17717,,"22,552 x DRG weight",17717,Other,base rate x DRG weight,19685,,"25,057 x DRG weight",19685,Other,base rate x DRG weight,16732,,"21,298 x DRG weight",16732,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,77272,
OTHER DIGESTIVE SYSTEM DIAGNOSES WITH MCC,393,MS-DRG,,,,,,,,inpatient,,,233240.19,36804,,,36804,Other,150% of Medicare + 9.63% HCRA Surcharge,22381,,"3,609.90 x patient days",22381,Per diem,,40565,,"25,046 x DRG weight",40565,Other,base rate x DRG weight,36507,,"22,541 x DRG weight",36507,Other,base rate x DRG weight,51055,,"31,523 x DRG weight",51055,Other,base rate x DRG weight,45950,,"28,371 x DRG weight",45950,Other,base rate x DRG weight,43397,,"26,795 x DRG weight",43397,Other,base rate x DRG weight,24619.1,,"3,970.89 x patient days",24619.1,Per diem,,36381,,"22,463 x DRG weight",36381,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,42800,,"26,426 x DRG weight",42800,Other,base rate x DRG weight,62855,,"38,809 x DRG weight",62855,Other,base rate x DRG weight,62855,,"38,809 x DRG weight",62855,Other,base rate x DRG weight,42800,,"26,426 x DRG weight",42800,Other,base rate x DRG weight,62855,,"38,809 x DRG weight",62855,Other,base rate x DRG weight,39451,,"6,363 x patient days",39451,Per diem,,163268,70,,163268,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,40582,,"25,057 x DRG weight",40582,Other,base rate x DRG weight,36525,,"22,552 x DRG weight",36525,Other,base rate x DRG weight,40582,,"25,057 x DRG weight",40582,Other,base rate x DRG weight,34494,,"21,298 x DRG weight",34494,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,163268,
OTHER DIGESTIVE SYSTEM DIAGNOSES WITH CC,394,MS-DRG,,,,,,,,inpatient,,,140935.12,22559,,,22559,Other,150% of Medicare + 9.63% HCRA Surcharge,13718,,"3,609.90 x patient days",13718,Per diem,,23466,,"25,046 x DRG weight",23466,Other,base rate x DRG weight,21119,,"22,541 x DRG weight",21119,Other,base rate x DRG weight,29534,,"31,523 x DRG weight",29534,Other,base rate x DRG weight,26581,,"28,371 x DRG weight",26581,Other,base rate x DRG weight,25104,,"26,795 x DRG weight",25104,Other,base rate x DRG weight,15089.8,,"3,970.89 x patient days",15089.8,Per diem,,21046,,"22,463 x DRG weight",21046,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,24759,,"26,426 x DRG weight",24759,Other,base rate x DRG weight,36360,,"38,809 x DRG weight",36360,Other,base rate x DRG weight,36360,,"38,809 x DRG weight",36360,Other,base rate x DRG weight,24759,,"26,426 x DRG weight",24759,Other,base rate x DRG weight,36360,,"38,809 x DRG weight",36360,Other,base rate x DRG weight,24179,,"6,363 x patient days",24179,Per diem,,98655,70,,98655,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,23476,,"25,057 x DRG weight",23476,Other,base rate x DRG weight,21129,,"22,552 x DRG weight",21129,Other,base rate x DRG weight,23476,,"25,057 x DRG weight",23476,Other,base rate x DRG weight,19954,,"21,298 x DRG weight",19954,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,98655,
OTHER DIGESTIVE SYSTEM DIAGNOSES WITHOUT CC/MCC,395,MS-DRG,,,,,,,,inpatient,,,93151.05,15435,,,15435,Other,150% of Medicare + 9.63% HCRA Surcharge,9386,,"3,609.90 x patient days",9386,Per diem,,16217,,"25,046 x DRG weight",16217,Other,base rate x DRG weight,14595,,"22,541 x DRG weight",14595,Other,base rate x DRG weight,20411,,"31,523 x DRG weight",20411,Other,base rate x DRG weight,18370,,"28,371 x DRG weight",18370,Other,base rate x DRG weight,17350,,"26,795 x DRG weight",17350,Other,base rate x DRG weight,10324.6,,"3,970.89 x patient days",10324.6,Per diem,,14545,,"22,463 x DRG weight",14545,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,17111,,"26,426 x DRG weight",17111,Other,base rate x DRG weight,25129,,"38,809 x DRG weight",25129,Other,base rate x DRG weight,25129,,"38,809 x DRG weight",25129,Other,base rate x DRG weight,17111,,"26,426 x DRG weight",17111,Other,base rate x DRG weight,25129,,"38,809 x DRG weight",25129,Other,base rate x DRG weight,16544,,"6,363 x patient days",16544,Per diem,,65206,70,,65206,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,16224,,"25,057 x DRG weight",16224,Other,base rate x DRG weight,14602,,"22,552 x DRG weight",14602,Other,base rate x DRG weight,16224,,"25,057 x DRG weight",16224,Other,base rate x DRG weight,13790,,"21,298 x DRG weight",13790,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,65206,
APPENDIX PROCEDURES WITH MCC,397,MS-DRG,,,,,,,,inpatient,,,164873.11,37992,,,37992,Other,150% of Medicare + 9.63% HCRA Surcharge,23103,,"3,609.90 x patient days",23103,Per diem,,56268,,"25,046 x DRG weight",56268,Other,base rate x DRG weight,50641,,"22,541 x DRG weight",50641,Other,base rate x DRG weight,70820,,"31,523 x DRG weight",70820,Other,base rate x DRG weight,63738,,"28,371 x DRG weight",63738,Other,base rate x DRG weight,60198,,"26,795 x DRG weight",60198,Other,base rate x DRG weight,25413.3,,"3,970.89 x patient days",25413.3,Per diem,,50465,,"22,463 x DRG weight",50465,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,59369,,"26,426 x DRG weight",59369,Other,base rate x DRG weight,87188,,"38,809 x DRG weight",87188,Other,base rate x DRG weight,87188,,"38,809 x DRG weight",87188,Other,base rate x DRG weight,59369,,"26,426 x DRG weight",59369,Other,base rate x DRG weight,87188,,"38,809 x DRG weight",87188,Other,base rate x DRG weight,40723,,"6,363 x patient days",40723,Per diem,,115411,70,,115411,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,56293,,"25,057 x DRG weight",56293,Other,base rate x DRG weight,50665,,"22,552 x DRG weight",50665,Other,base rate x DRG weight,56293,,"25,057 x DRG weight",56293,Other,base rate x DRG weight,47848,,"21,298 x DRG weight",47848,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,115411,
APPENDIX PROCEDURES WITH CC,398,MS-DRG,,,,,,,,inpatient,,,103380.07,23746,,,23746,Other,150% of Medicare + 9.63% HCRA Surcharge,14440,,"3,609.90 x patient days",14440,Per diem,,37902,,"25,046 x DRG weight",37902,Other,base rate x DRG weight,34111,,"22,541 x DRG weight",34111,Other,base rate x DRG weight,47704,,"31,523 x DRG weight",47704,Other,base rate x DRG weight,42934,,"28,371 x DRG weight",42934,Other,base rate x DRG weight,40549,,"26,795 x DRG weight",40549,Other,base rate x DRG weight,15884,,"3,970.89 x patient days",15884,Per diem,,33993,,"22,463 x DRG weight",33993,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,39990,,"26,426 x DRG weight",39990,Other,base rate x DRG weight,58730,,"38,809 x DRG weight",58730,Other,base rate x DRG weight,58730,,"38,809 x DRG weight",58730,Other,base rate x DRG weight,39990,,"26,426 x DRG weight",39990,Other,base rate x DRG weight,58730,,"38,809 x DRG weight",58730,Other,base rate x DRG weight,25452,,"6,363 x patient days",25452,Per diem,,72366,70,,72366,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,37919,,"25,057 x DRG weight",37919,Other,base rate x DRG weight,34128,,"22,552 x DRG weight",34128,Other,base rate x DRG weight,37919,,"25,057 x DRG weight",37919,Other,base rate x DRG weight,32230,,"21,298 x DRG weight",32230,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,72366,
APPENDIX PROCEDURES WITHOUT CC/MCC,399,MS-DRG,,,,,,,,inpatient,,,89201.58,13654,,,13654,Other,150% of Medicare + 9.63% HCRA Surcharge,8303,,"3,609.90 x patient days",8303,Per diem,,27879,,"25,046 x DRG weight",27879,Other,base rate x DRG weight,25090,,"22,541 x DRG weight",25090,Other,base rate x DRG weight,35088,,"31,523 x DRG weight",35088,Other,base rate x DRG weight,31580,,"28,371 x DRG weight",31580,Other,base rate x DRG weight,29826,,"26,795 x DRG weight",29826,Other,base rate x DRG weight,9133.3,,"3,970.89 x patient days",9133.3,Per diem,,25004,,"22,463 x DRG weight",25004,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,29415,,"26,426 x DRG weight",29415,Other,base rate x DRG weight,43198,,"38,809 x DRG weight",43198,Other,base rate x DRG weight,43198,,"38,809 x DRG weight",43198,Other,base rate x DRG weight,29415,,"26,426 x DRG weight",29415,Other,base rate x DRG weight,43198,,"38,809 x DRG weight",43198,Other,base rate x DRG weight,14635,,"6,363 x patient days",14635,Per diem,,62441,70,,62441,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,27891,,"25,057 x DRG weight",27891,Other,base rate x DRG weight,25103,,"22,552 x DRG weight",25103,Other,base rate x DRG weight,27891,,"25,057 x DRG weight",27891,Other,base rate x DRG weight,23707,,"21,298 x DRG weight",23707,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,62441,
"PANCREAS, LIVER AND SHUNT PROCEDURES WITH MCC",405,MS-DRG,,,,,,,,inpatient,,,619797.78,74798,,,74798,Other,150% of Medicare + 9.63% HCRA Surcharge,45485,,"3,609.90 x patient days",45485,Per diem,,137883,,"25,046 x DRG weight",137883,Other,base rate x DRG weight,124093,,"22,541 x DRG weight",124093,Other,base rate x DRG weight,173540,,"31,523 x DRG weight",173540,Other,base rate x DRG weight,156188,,"28,371 x DRG weight",156188,Other,base rate x DRG weight,147512,,"26,795 x DRG weight",147512,Other,base rate x DRG weight,50033.5,,"3,970.89 x patient days",50033.5,Per diem,,123663,,"22,463 x DRG weight",123663,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,145480,,"26,426 x DRG weight",145480,Other,base rate x DRG weight,213651,,"38,809 x DRG weight",213651,Other,base rate x DRG weight,213651,,"38,809 x DRG weight",213651,Other,base rate x DRG weight,145480,,"26,426 x DRG weight",145480,Other,base rate x DRG weight,213651,,"38,809 x DRG weight",213651,Other,base rate x DRG weight,80174,,"6,363 x patient days",80174,Per diem,,433858,70,,433858,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,137944,,"25,057 x DRG weight",137944,Other,base rate x DRG weight,124153,,"22,552 x DRG weight",124153,Other,base rate x DRG weight,137944,,"25,057 x DRG weight",137944,Other,base rate x DRG weight,117250,,"21,298 x DRG weight",117250,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,433858,
"PANCREAS, LIVER AND SHUNT PROCEDURES WITH CC",406,MS-DRG,,,,,,,,inpatient,,,260950.29,36804,,,36804,Other,150% of Medicare + 9.63% HCRA Surcharge,22381,,"3,609.90 x patient days",22381,Per diem,,72318,,"25,046 x DRG weight",72318,Other,base rate x DRG weight,65085,,"22,541 x DRG weight",65085,Other,base rate x DRG weight,91020,,"31,523 x DRG weight",91020,Other,base rate x DRG weight,81918,,"28,371 x DRG weight",81918,Other,base rate x DRG weight,77368,,"26,795 x DRG weight",77368,Other,base rate x DRG weight,24619.1,,"3,970.89 x patient days",24619.1,Per diem,,64860,,"22,463 x DRG weight",64860,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,76302,,"26,426 x DRG weight",76302,Other,base rate x DRG weight,112057,,"38,809 x DRG weight",112057,Other,base rate x DRG weight,112057,,"38,809 x DRG weight",112057,Other,base rate x DRG weight,76302,,"26,426 x DRG weight",76302,Other,base rate x DRG weight,112057,,"38,809 x DRG weight",112057,Other,base rate x DRG weight,39451,,"6,363 x patient days",39451,Per diem,,182665,70,,182665,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,72350,,"25,057 x DRG weight",72350,Other,base rate x DRG weight,65117,,"22,552 x DRG weight",65117,Other,base rate x DRG weight,72350,,"25,057 x DRG weight",72350,Other,base rate x DRG weight,61496,,"21,298 x DRG weight",61496,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,182665,
"PANCREAS, LIVER AND SHUNT PROCEDURES WITHOUT CC/MCC",407,MS-DRG,,,,,,,,inpatient,,,225852.18,24933,,,24933,Other,150% of Medicare + 9.63% HCRA Surcharge,15162,,"3,609.90 x patient days",15162,Per diem,,53874,,"25,046 x DRG weight",53874,Other,base rate x DRG weight,48486,,"22,541 x DRG weight",48486,Other,base rate x DRG weight,67806,,"31,523 x DRG weight",67806,Other,base rate x DRG weight,61026,,"28,371 x DRG weight",61026,Other,base rate x DRG weight,57636,,"26,795 x DRG weight",57636,Other,base rate x DRG weight,16678.2,,"3,970.89 x patient days",16678.2,Per diem,,48318,,"22,463 x DRG weight",48318,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,56842,,"26,426 x DRG weight",56842,Other,base rate x DRG weight,83478,,"38,809 x DRG weight",83478,Other,base rate x DRG weight,83478,,"38,809 x DRG weight",83478,Other,base rate x DRG weight,56842,,"26,426 x DRG weight",56842,Other,base rate x DRG weight,83478,,"38,809 x DRG weight",83478,Other,base rate x DRG weight,26725,,"6,363 x patient days",26725,Per diem,,158097,70,,158097,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,53898,,"25,057 x DRG weight",53898,Other,base rate x DRG weight,48509,,"22,552 x DRG weight",48509,Other,base rate x DRG weight,53898,,"25,057 x DRG weight",53898,Other,base rate x DRG weight,45812,,"21,298 x DRG weight",45812,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,158097,
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH MCC,408,MS-DRG,,,,,,,,inpatient,,,636079.48,64706,,,64706,Other,150% of Medicare + 9.63% HCRA Surcharge,39348,,"3,609.90 x patient days",39348,Per diem,,93226,,"25,046 x DRG weight",93226,Other,base rate x DRG weight,83902,,"22,541 x DRG weight",83902,Other,base rate x DRG weight,117335,,"31,523 x DRG weight",117335,Other,base rate x DRG weight,105603,,"28,371 x DRG weight",105603,Other,base rate x DRG weight,99736,,"26,795 x DRG weight",99736,Other,base rate x DRG weight,43282.8,,"3,970.89 x patient days",43282.8,Per diem,,83612,,"22,463 x DRG weight",83612,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,98363,,"26,426 x DRG weight",98363,Other,base rate x DRG weight,144455,,"38,809 x DRG weight",144455,Other,base rate x DRG weight,144455,,"38,809 x DRG weight",144455,Other,base rate x DRG weight,98363,,"26,426 x DRG weight",98363,Other,base rate x DRG weight,144455,,"38,809 x DRG weight",144455,Other,base rate x DRG weight,69357,,"6,363 x patient days",69357,Per diem,,445256,70,,445256,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,93267,,"25,057 x DRG weight",93267,Other,base rate x DRG weight,83943,,"22,552 x DRG weight",83943,Other,base rate x DRG weight,93267,,"25,057 x DRG weight",93267,Other,base rate x DRG weight,79275,,"21,298 x DRG weight",79275,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,445256,
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH CC,409,MS-DRG,,,,,,,,inpatient,,,297030.96,33836,,,33836,Other,150% of Medicare + 9.63% HCRA Surcharge,20576,,"3,609.90 x patient days",20576,Per diem,,49023,,"25,046 x DRG weight",49023,Other,base rate x DRG weight,44119,,"22,541 x DRG weight",44119,Other,base rate x DRG weight,61700,,"31,523 x DRG weight",61700,Other,base rate x DRG weight,55531,,"28,371 x DRG weight",55531,Other,base rate x DRG weight,52446,,"26,795 x DRG weight",52446,Other,base rate x DRG weight,22633.6,,"3,970.89 x patient days",22633.6,Per diem,,43967,,"22,463 x DRG weight",43967,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,51724,,"26,426 x DRG weight",51724,Other,base rate x DRG weight,75961,,"38,809 x DRG weight",75961,Other,base rate x DRG weight,75961,,"38,809 x DRG weight",75961,Other,base rate x DRG weight,51724,,"26,426 x DRG weight",51724,Other,base rate x DRG weight,75961,,"38,809 x DRG weight",75961,Other,base rate x DRG weight,36269,,"6,363 x patient days",36269,Per diem,,207922,70,,207922,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,49044,,"25,057 x DRG weight",49044,Other,base rate x DRG weight,44141,,"22,552 x DRG weight",44141,Other,base rate x DRG weight,49044,,"25,057 x DRG weight",49044,Other,base rate x DRG weight,41687,,"21,298 x DRG weight",41687,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,207922,
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITHOUT CC/MCC,410,MS-DRG,,,,,,,,inpatient,,,122727.59,21371,,,21371,Other,150% of Medicare + 9.63% HCRA Surcharge,12996,,"3,609.90 x patient days",12996,Per diem,,39202,,"25,046 x DRG weight",39202,Other,base rate x DRG weight,35281,,"22,541 x DRG weight",35281,Other,base rate x DRG weight,49340,,"31,523 x DRG weight",49340,Other,base rate x DRG weight,44406,,"28,371 x DRG weight",44406,Other,base rate x DRG weight,41940,,"26,795 x DRG weight",41940,Other,base rate x DRG weight,14295.6,,"3,970.89 x patient days",14295.6,Per diem,,35159,,"22,463 x DRG weight",35159,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,41362,,"26,426 x DRG weight",41362,Other,base rate x DRG weight,60744,,"38,809 x DRG weight",60744,Other,base rate x DRG weight,60744,,"38,809 x DRG weight",60744,Other,base rate x DRG weight,41362,,"26,426 x DRG weight",41362,Other,base rate x DRG weight,60744,,"38,809 x DRG weight",60744,Other,base rate x DRG weight,22907,,"6,363 x patient days",22907,Per diem,,85909,70,,85909,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,39219,,"25,057 x DRG weight",39219,Other,base rate x DRG weight,35298,,"22,552 x DRG weight",35298,Other,base rate x DRG weight,39219,,"25,057 x DRG weight",39219,Other,base rate x DRG weight,33336,,"21,298 x DRG weight",33336,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,85909,
CHOLECYSTECTOMY WITH C.D.E. WITH MCC,411,MS-DRG,,,,,,,,inpatient,,,636079.48,48084,,,48084,Other,150% of Medicare + 9.63% HCRA Surcharge,29240,,"3,609.90 x patient days",29240,Per diem,,76150,,"25,046 x DRG weight",76150,Other,base rate x DRG weight,68534,,"22,541 x DRG weight",68534,Other,base rate x DRG weight,95843,,"31,523 x DRG weight",95843,Other,base rate x DRG weight,86259,,"28,371 x DRG weight",86259,Other,base rate x DRG weight,81468,,"26,795 x DRG weight",81468,Other,base rate x DRG weight,32164,,"3,970.89 x patient days",32164,Per diem,,68297,,"22,463 x DRG weight",68297,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,80346,,"26,426 x DRG weight",80346,Other,base rate x DRG weight,117995,,"38,809 x DRG weight",117995,Other,base rate x DRG weight,117995,,"38,809 x DRG weight",117995,Other,base rate x DRG weight,80346,,"26,426 x DRG weight",80346,Other,base rate x DRG weight,117995,,"38,809 x DRG weight",117995,Other,base rate x DRG weight,51540,,"6,363 x patient days",51540,Per diem,,445256,70,,445256,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,76183,,"25,057 x DRG weight",76183,Other,base rate x DRG weight,68567,,"22,552 x DRG weight",68567,Other,base rate x DRG weight,76183,,"25,057 x DRG weight",76183,Other,base rate x DRG weight,64754,,"21,298 x DRG weight",64754,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,445256,
CHOLECYSTECTOMY WITH C.D.E. WITH CC,412,MS-DRG,,,,,,,,inpatient,,,142251.57,29682,,,29682,Other,150% of Medicare + 9.63% HCRA Surcharge,18050,,"3,609.90 x patient days",18050,Per diem,,51748,,"25,046 x DRG weight",51748,Other,base rate x DRG weight,46572,,"22,541 x DRG weight",46572,Other,base rate x DRG weight,65130,,"31,523 x DRG weight",65130,Other,base rate x DRG weight,58617,,"28,371 x DRG weight",58617,Other,base rate x DRG weight,55361,,"26,795 x DRG weight",55361,Other,base rate x DRG weight,19855,,"3,970.89 x patient days",19855,Per diem,,46411,,"22,463 x DRG weight",46411,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,54599,,"26,426 x DRG weight",54599,Other,base rate x DRG weight,80183,,"38,809 x DRG weight",80183,Other,base rate x DRG weight,80183,,"38,809 x DRG weight",80183,Other,base rate x DRG weight,54599,,"26,426 x DRG weight",54599,Other,base rate x DRG weight,80183,,"38,809 x DRG weight",80183,Other,base rate x DRG weight,31815,,"6,363 x patient days",31815,Per diem,,99576,70,,99576,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,51770,,"25,057 x DRG weight",51770,Other,base rate x DRG weight,46595,,"22,552 x DRG weight",46595,Other,base rate x DRG weight,51770,,"25,057 x DRG weight",51770,Other,base rate x DRG weight,44004,,"21,298 x DRG weight",44004,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,99576,
CHOLECYSTECTOMY WITH C.D.E. WITHOUT CC/MCC,413,MS-DRG,,,,,,,,inpatient,,,336831.31,17216,,,17216,Other,150% of Medicare + 9.63% HCRA Surcharge,10469,,"3,609.90 x patient days",10469,Per diem,,37809,,"25,046 x DRG weight",37809,Other,base rate x DRG weight,34028,,"22,541 x DRG weight",34028,Other,base rate x DRG weight,47587,,"31,523 x DRG weight",47587,Other,base rate x DRG weight,42829,,"28,371 x DRG weight",42829,Other,base rate x DRG weight,40450,,"26,795 x DRG weight",40450,Other,base rate x DRG weight,11515.9,,"3,970.89 x patient days",11515.9,Per diem,,33910,,"22,463 x DRG weight",33910,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,39893,,"26,426 x DRG weight",39893,Other,base rate x DRG weight,58586,,"38,809 x DRG weight",58586,Other,base rate x DRG weight,58586,,"38,809 x DRG weight",58586,Other,base rate x DRG weight,39893,,"26,426 x DRG weight",39893,Other,base rate x DRG weight,58586,,"38,809 x DRG weight",58586,Other,base rate x DRG weight,18453,,"6,363 x patient days",18453,Per diem,,235782,70,,235782,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,37826,,"25,057 x DRG weight",37826,Other,base rate x DRG weight,34044,,"22,552 x DRG weight",34044,Other,base rate x DRG weight,37826,,"25,057 x DRG weight",37826,Other,base rate x DRG weight,32151,,"21,298 x DRG weight",32151,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,235782,
CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH MCC,414,MS-DRG,,,,,,,,inpatient,,,411884.91,58769,,,58769,Other,150% of Medicare + 9.63% HCRA Surcharge,35738,,"3,609.90 x patient days",35738,Per diem,,88292,,"25,046 x DRG weight",88292,Other,base rate x DRG weight,79462,,"22,541 x DRG weight",79462,Other,base rate x DRG weight,111125,,"31,523 x DRG weight",111125,Other,base rate x DRG weight,100013,,"28,371 x DRG weight",100013,Other,base rate x DRG weight,94458,,"26,795 x DRG weight",94458,Other,base rate x DRG weight,39311.8,,"3,970.89 x patient days",39311.8,Per diem,,79187,,"22,463 x DRG weight",79187,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,93157,,"26,426 x DRG weight",93157,Other,base rate x DRG weight,136809,,"38,809 x DRG weight",136809,Other,base rate x DRG weight,136809,,"38,809 x DRG weight",136809,Other,base rate x DRG weight,93157,,"26,426 x DRG weight",93157,Other,base rate x DRG weight,136809,,"38,809 x DRG weight",136809,Other,base rate x DRG weight,62994,,"6,363 x patient days",62994,Per diem,,288319,70,,288319,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,88331,,"25,057 x DRG weight",88331,Other,base rate x DRG weight,79500,,"22,552 x DRG weight",79500,Other,base rate x DRG weight,88331,,"25,057 x DRG weight",88331,Other,base rate x DRG weight,75080,,"21,298 x DRG weight",75080,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,288319,
CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH CC,415,MS-DRG,,,,,,,,inpatient,,,214840.92,33836,,,33836,Other,150% of Medicare + 9.63% HCRA Surcharge,20576,,"3,609.90 x patient days",20576,Per diem,,49486,,"25,046 x DRG weight",49486,Other,base rate x DRG weight,44537,,"22,541 x DRG weight",44537,Other,base rate x DRG weight,62283,,"31,523 x DRG weight",62283,Other,base rate x DRG weight,56055,,"28,371 x DRG weight",56055,Other,base rate x DRG weight,52942,,"26,795 x DRG weight",52942,Other,base rate x DRG weight,22633.6,,"3,970.89 x patient days",22633.6,Per diem,,44382,,"22,463 x DRG weight",44382,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,52212,,"26,426 x DRG weight",52212,Other,base rate x DRG weight,76679,,"38,809 x DRG weight",76679,Other,base rate x DRG weight,76679,,"38,809 x DRG weight",76679,Other,base rate x DRG weight,52212,,"26,426 x DRG weight",52212,Other,base rate x DRG weight,76679,,"38,809 x DRG weight",76679,Other,base rate x DRG weight,36269,,"6,363 x patient days",36269,Per diem,,150389,70,,150389,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,49508,,"25,057 x DRG weight",49508,Other,base rate x DRG weight,44558,,"22,552 x DRG weight",44558,Other,base rate x DRG weight,49508,,"25,057 x DRG weight",49508,Other,base rate x DRG weight,42081,,"21,298 x DRG weight",42081,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,150389,
CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITHOUT CC/MCC,416,MS-DRG,,,,,,,,inpatient,,,179180.51,20184,,,20184,Other,150% of Medicare + 9.63% HCRA Surcharge,12274,,"3,609.90 x patient days",12274,Per diem,,33542,,"25,046 x DRG weight",33542,Other,base rate x DRG weight,30187,,"22,541 x DRG weight",30187,Other,base rate x DRG weight,42216,,"31,523 x DRG weight",42216,Other,base rate x DRG weight,37994,,"28,371 x DRG weight",37994,Other,base rate x DRG weight,35884,,"26,795 x DRG weight",35884,Other,base rate x DRG weight,13501.4,,"3,970.89 x patient days",13501.4,Per diem,,30082,,"22,463 x DRG weight",30082,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,35390,,"26,426 x DRG weight",35390,Other,base rate x DRG weight,51973,,"38,809 x DRG weight",51973,Other,base rate x DRG weight,51973,,"38,809 x DRG weight",51973,Other,base rate x DRG weight,35390,,"26,426 x DRG weight",35390,Other,base rate x DRG weight,51973,,"38,809 x DRG weight",51973,Other,base rate x DRG weight,21634,,"6,363 x patient days",21634,Per diem,,125426,70,,125426,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,33556,,"25,057 x DRG weight",33556,Other,base rate x DRG weight,30202,,"22,552 x DRG weight",30202,Other,base rate x DRG weight,33556,,"25,057 x DRG weight",33556,Other,base rate x DRG weight,28522,,"21,298 x DRG weight",28522,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,125426,
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH MCC,417,MS-DRG,,,,,,,,inpatient,,,212879.52,37398,,,37398,Other,150% of Medicare + 9.63% HCRA Surcharge,22742,,"3,609.90 x patient days",22742,Per diem,,58052,,"25,046 x DRG weight",58052,Other,base rate x DRG weight,52246,,"22,541 x DRG weight",52246,Other,base rate x DRG weight,73064,,"31,523 x DRG weight",73064,Other,base rate x DRG weight,65758,,"28,371 x DRG weight",65758,Other,base rate x DRG weight,62105,,"26,795 x DRG weight",62105,Other,base rate x DRG weight,25016.2,,"3,970.89 x patient days",25016.2,Per diem,,52065,,"22,463 x DRG weight",52065,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,61250,,"26,426 x DRG weight",61250,Other,base rate x DRG weight,89952,,"38,809 x DRG weight",89952,Other,base rate x DRG weight,89952,,"38,809 x DRG weight",89952,Other,base rate x DRG weight,61250,,"26,426 x DRG weight",61250,Other,base rate x DRG weight,89952,,"38,809 x DRG weight",89952,Other,base rate x DRG weight,40087,,"6,363 x patient days",40087,Per diem,,149016,70,,149016,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,58077,,"25,057 x DRG weight",58077,Other,base rate x DRG weight,52271,,"22,552 x DRG weight",52271,Other,base rate x DRG weight,58077,,"25,057 x DRG weight",58077,Other,base rate x DRG weight,49365,,"21,298 x DRG weight",49365,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,149016,
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH CC,418,MS-DRG,,,,,,,,inpatient,,,182591.62,24340,,,24340,Other,150% of Medicare + 9.63% HCRA Surcharge,14801,,"3,609.90 x patient days",14801,Per diem,,40943,,"25,046 x DRG weight",40943,Other,base rate x DRG weight,36848,,"22,541 x DRG weight",36848,Other,base rate x DRG weight,51531,,"31,523 x DRG weight",51531,Other,base rate x DRG weight,46378,,"28,371 x DRG weight",46378,Other,base rate x DRG weight,43802,,"26,795 x DRG weight",43802,Other,base rate x DRG weight,16281.1,,"3,970.89 x patient days",16281.1,Per diem,,36720,,"22,463 x DRG weight",36720,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,43199,,"26,426 x DRG weight",43199,Other,base rate x DRG weight,63441,,"38,809 x DRG weight",63441,Other,base rate x DRG weight,63441,,"38,809 x DRG weight",63441,Other,base rate x DRG weight,43199,,"26,426 x DRG weight",43199,Other,base rate x DRG weight,63441,,"38,809 x DRG weight",63441,Other,base rate x DRG weight,26088,,"6,363 x patient days",26088,Per diem,,127814,70,,127814,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,40961,,"25,057 x DRG weight",40961,Other,base rate x DRG weight,36866,,"22,552 x DRG weight",36866,Other,base rate x DRG weight,40961,,"25,057 x DRG weight",40961,Other,base rate x DRG weight,34816,,"21,298 x DRG weight",34816,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,127814,
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITHOUT CC/MCC,419,MS-DRG,,,,,,,,inpatient,,,128377.27,16028,,,16028,Other,150% of Medicare + 9.63% HCRA Surcharge,9747,,"3,609.90 x patient days",9747,Per diem,,32890,,"25,046 x DRG weight",32890,Other,base rate x DRG weight,29601,,"22,541 x DRG weight",29601,Other,base rate x DRG weight,41396,,"31,523 x DRG weight",41396,Other,base rate x DRG weight,37257,,"28,371 x DRG weight",37257,Other,base rate x DRG weight,35187,,"26,795 x DRG weight",35187,Other,base rate x DRG weight,10721.7,,"3,970.89 x patient days",10721.7,Per diem,,29498,,"22,463 x DRG weight",29498,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,34703,,"26,426 x DRG weight",34703,Other,base rate x DRG weight,50964,,"38,809 x DRG weight",50964,Other,base rate x DRG weight,50964,,"38,809 x DRG weight",50964,Other,base rate x DRG weight,34703,,"26,426 x DRG weight",34703,Other,base rate x DRG weight,50964,,"38,809 x DRG weight",50964,Other,base rate x DRG weight,17180,,"6,363 x patient days",17180,Per diem,,89864,70,,89864,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,32905,,"25,057 x DRG weight",32905,Other,base rate x DRG weight,29615,,"22,552 x DRG weight",29615,Other,base rate x DRG weight,32905,,"25,057 x DRG weight",32905,Other,base rate x DRG weight,27969,,"21,298 x DRG weight",27969,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,89864,
HEPATOBILIARY DIAGNOSTIC PROCEDURES WITH MCC,420,MS-DRG,,,,,,,,inpatient,,,341777.81,58769,,,58769,Other,150% of Medicare + 9.63% HCRA Surcharge,35738,,"3,609.90 x patient days",35738,Per diem,,80167,,"25,046 x DRG weight",80167,Other,base rate x DRG weight,72149,,"22,541 x DRG weight",72149,Other,base rate x DRG weight,100899,,"31,523 x DRG weight",100899,Other,base rate x DRG weight,90810,,"28,371 x DRG weight",90810,Other,base rate x DRG weight,85765,,"26,795 x DRG weight",85765,Other,base rate x DRG weight,39311.8,,"3,970.89 x patient days",39311.8,Per diem,,71900,,"22,463 x DRG weight",71900,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,84584,,"26,426 x DRG weight",84584,Other,base rate x DRG weight,124220,,"38,809 x DRG weight",124220,Other,base rate x DRG weight,124220,,"38,809 x DRG weight",124220,Other,base rate x DRG weight,84584,,"26,426 x DRG weight",84584,Other,base rate x DRG weight,124220,,"38,809 x DRG weight",124220,Other,base rate x DRG weight,62994,,"6,363 x patient days",62994,Per diem,,239244,70,,239244,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,80202,,"25,057 x DRG weight",80202,Other,base rate x DRG weight,72184,,"22,552 x DRG weight",72184,Other,base rate x DRG weight,80202,,"25,057 x DRG weight",80202,Other,base rate x DRG weight,68171,,"21,298 x DRG weight",68171,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,239244,
HEPATOBILIARY DIAGNOSTIC PROCEDURES WITH CC,421,MS-DRG,,,,,,,,inpatient,,,105017.04,28495,,,28495,Other,150% of Medicare + 9.63% HCRA Surcharge,17328,,"3,609.90 x patient days",17328,Per diem,,42819,,"25,046 x DRG weight",42819,Other,base rate x DRG weight,38536,,"22,541 x DRG weight",38536,Other,base rate x DRG weight,53892,,"31,523 x DRG weight",53892,Other,base rate x DRG weight,48503,,"28,371 x DRG weight",48503,Other,base rate x DRG weight,45809,,"26,795 x DRG weight",45809,Other,base rate x DRG weight,19060.8,,"3,970.89 x patient days",19060.8,Per diem,,38403,,"22,463 x DRG weight",38403,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,45178,,"26,426 x DRG weight",45178,Other,base rate x DRG weight,66348,,"38,809 x DRG weight",66348,Other,base rate x DRG weight,66348,,"38,809 x DRG weight",66348,Other,base rate x DRG weight,45178,,"26,426 x DRG weight",45178,Other,base rate x DRG weight,66348,,"38,809 x DRG weight",66348,Other,base rate x DRG weight,30542,,"6,363 x patient days",30542,Per diem,,73512,70,,73512,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,42837,,"25,057 x DRG weight",42837,Other,base rate x DRG weight,38555,,"22,552 x DRG weight",38555,Other,base rate x DRG weight,42837,,"25,057 x DRG weight",42837,Other,base rate x DRG weight,36411,,"21,298 x DRG weight",36411,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,73512,
HEPATOBILIARY DIAGNOSTIC PROCEDURES WITHOUT CC/MCC,422,MS-DRG,,,,,,,,inpatient,,,107453.52,18403,,,18403,Other,150% of Medicare + 9.63% HCRA Surcharge,11191,,"3,609.90 x patient days",11191,Per diem,,35340,,"25,046 x DRG weight",35340,Other,base rate x DRG weight,31805,,"22,541 x DRG weight",31805,Other,base rate x DRG weight,44479,,"31,523 x DRG weight",44479,Other,base rate x DRG weight,40031,,"28,371 x DRG weight",40031,Other,base rate x DRG weight,37808,,"26,795 x DRG weight",37808,Other,base rate x DRG weight,12310.1,,"3,970.89 x patient days",12310.1,Per diem,,31695,,"22,463 x DRG weight",31695,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,37287,,"26,426 x DRG weight",37287,Other,base rate x DRG weight,54759,,"38,809 x DRG weight",54759,Other,base rate x DRG weight,54759,,"38,809 x DRG weight",54759,Other,base rate x DRG weight,37287,,"26,426 x DRG weight",37287,Other,base rate x DRG weight,54759,,"38,809 x DRG weight",54759,Other,base rate x DRG weight,19725,,"6,363 x patient days",19725,Per diem,,75217,70,,75217,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,35355,,"25,057 x DRG weight",35355,Other,base rate x DRG weight,31821,,"22,552 x DRG weight",31821,Other,base rate x DRG weight,35355,,"25,057 x DRG weight",35355,Other,base rate x DRG weight,30051,,"21,298 x DRG weight",30051,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,75217,
OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITH MCC,423,MS-DRG,,,,,,,,inpatient,,,1102167.42,65299,,,65299,Other,150% of Medicare + 9.63% HCRA Surcharge,39709,,"3,609.90 x patient days",39709,Per diem,,97952,,"25,046 x DRG weight",97952,Other,base rate x DRG weight,88156,,"22,541 x DRG weight",88156,Other,base rate x DRG weight,123283,,"31,523 x DRG weight",123283,Other,base rate x DRG weight,110956,,"28,371 x DRG weight",110956,Other,base rate x DRG weight,104793,,"26,795 x DRG weight",104793,Other,base rate x DRG weight,43679.9,,"3,970.89 x patient days",43679.9,Per diem,,87851,,"22,463 x DRG weight",87851,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,103349,,"26,426 x DRG weight",103349,Other,base rate x DRG weight,151778,,"38,809 x DRG weight",151778,Other,base rate x DRG weight,151778,,"38,809 x DRG weight",151778,Other,base rate x DRG weight,103349,,"26,426 x DRG weight",103349,Other,base rate x DRG weight,151778,,"38,809 x DRG weight",151778,Other,base rate x DRG weight,69993,,"6,363 x patient days",69993,Per diem,,771517,70,,771517,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,97995,,"25,057 x DRG weight",97995,Other,base rate x DRG weight,88199,,"22,552 x DRG weight",88199,Other,base rate x DRG weight,97995,,"25,057 x DRG weight",97995,Other,base rate x DRG weight,83294,,"21,298 x DRG weight",83294,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,771517,
OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITH CC,424,MS-DRG,,,,,,,,inpatient,,,233759.2,35617,,,35617,Other,150% of Medicare + 9.63% HCRA Surcharge,21659,,"3,609.90 x patient days",21659,Per diem,,53391,,"25,046 x DRG weight",53391,Other,base rate x DRG weight,48051,,"22,541 x DRG weight",48051,Other,base rate x DRG weight,67198,,"31,523 x DRG weight",67198,Other,base rate x DRG weight,60478,,"28,371 x DRG weight",60478,Other,base rate x DRG weight,57119,,"26,795 x DRG weight",57119,Other,base rate x DRG weight,23824.9,,"3,970.89 x patient days",23824.9,Per diem,,47884,,"22,463 x DRG weight",47884,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,56332,,"26,426 x DRG weight",56332,Other,base rate x DRG weight,82729,,"38,809 x DRG weight",82729,Other,base rate x DRG weight,82729,,"38,809 x DRG weight",82729,Other,base rate x DRG weight,56332,,"26,426 x DRG weight",56332,Other,base rate x DRG weight,82729,,"38,809 x DRG weight",82729,Other,base rate x DRG weight,38178,,"6,363 x patient days",38178,Per diem,,163631,70,,163631,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,53414,,"25,057 x DRG weight",53414,Other,base rate x DRG weight,48074,,"22,552 x DRG weight",48074,Other,base rate x DRG weight,53414,,"25,057 x DRG weight",53414,Other,base rate x DRG weight,45401,,"21,298 x DRG weight",45401,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,163631,
OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITHOUT CC/MCC,425,MS-DRG,,,,,,,,inpatient,,,224128.8,19590,,,19590,Other,150% of Medicare + 9.63% HCRA Surcharge,11913,,"3,609.90 x patient days",11913,Per diem,,40121,,"25,046 x DRG weight",40121,Other,base rate x DRG weight,36108,,"22,541 x DRG weight",36108,Other,base rate x DRG weight,50497,,"31,523 x DRG weight",50497,Other,base rate x DRG weight,45448,,"28,371 x DRG weight",45448,Other,base rate x DRG weight,42923,,"26,795 x DRG weight",42923,Other,base rate x DRG weight,13104.3,,"3,970.89 x patient days",13104.3,Per diem,,35983,,"22,463 x DRG weight",35983,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,42332,,"26,426 x DRG weight",42332,Other,base rate x DRG weight,62168,,"38,809 x DRG weight",62168,Other,base rate x DRG weight,62168,,"38,809 x DRG weight",62168,Other,base rate x DRG weight,42332,,"26,426 x DRG weight",42332,Other,base rate x DRG weight,62168,,"38,809 x DRG weight",62168,Other,base rate x DRG weight,20998,,"6,363 x patient days",20998,Per diem,,156890,70,,156890,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,40139,,"25,057 x DRG weight",40139,Other,base rate x DRG weight,36126,,"22,552 x DRG weight",36126,Other,base rate x DRG weight,40139,,"25,057 x DRG weight",40139,Other,base rate x DRG weight,34117,,"21,298 x DRG weight",34117,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,156890,
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH MCC,432,MS-DRG,,,,,,,,inpatient,,,338325.67,40366,,,40366,Other,150% of Medicare + 9.63% HCRA Surcharge,24547,,"3,609.90 x patient days",24547,Per diem,,47988,,"25,046 x DRG weight",47988,Other,base rate x DRG weight,43189,,"22,541 x DRG weight",43189,Other,base rate x DRG weight,60398,,"31,523 x DRG weight",60398,Other,base rate x DRG weight,54359,,"28,371 x DRG weight",54359,Other,base rate x DRG weight,51339,,"26,795 x DRG weight",51339,Other,base rate x DRG weight,27001.7,,"3,970.89 x patient days",27001.7,Per diem,,43039,,"22,463 x DRG weight",43039,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,50632,,"26,426 x DRG weight",50632,Other,base rate x DRG weight,74358,,"38,809 x DRG weight",74358,Other,base rate x DRG weight,74358,,"38,809 x DRG weight",74358,Other,base rate x DRG weight,50632,,"26,426 x DRG weight",50632,Other,base rate x DRG weight,74358,,"38,809 x DRG weight",74358,Other,base rate x DRG weight,43268,,"6,363 x patient days",43268,Per diem,,236828,70,,236828,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,48009,,"25,057 x DRG weight",48009,Other,base rate x DRG weight,43210,,"22,552 x DRG weight",43210,Other,base rate x DRG weight,48009,,"25,057 x DRG weight",48009,Other,base rate x DRG weight,40807,,"21,298 x DRG weight",40807,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,236828,
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH CC,433,MS-DRG,,,,,,,,inpatient,,,160499.33,25527,,,25527,Other,150% of Medicare + 9.63% HCRA Surcharge,15523,,"3,609.90 x patient days",15523,Per diem,,25822,,"25,046 x DRG weight",25822,Other,base rate x DRG weight,23240,,"22,541 x DRG weight",23240,Other,base rate x DRG weight,32500,,"31,523 x DRG weight",32500,Other,base rate x DRG weight,29251,,"28,371 x DRG weight",29251,Other,base rate x DRG weight,27626,,"26,795 x DRG weight",27626,Other,base rate x DRG weight,17075.3,,"3,970.89 x patient days",17075.3,Per diem,,23159,,"22,463 x DRG weight",23159,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,27245,,"26,426 x DRG weight",27245,Other,base rate x DRG weight,40012,,"38,809 x DRG weight",40012,Other,base rate x DRG weight,40012,,"38,809 x DRG weight",40012,Other,base rate x DRG weight,27245,,"26,426 x DRG weight",27245,Other,base rate x DRG weight,40012,,"38,809 x DRG weight",40012,Other,base rate x DRG weight,27361,,"6,363 x patient days",27361,Per diem,,112350,70,,112350,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,25834,,"25,057 x DRG weight",25834,Other,base rate x DRG weight,23251,,"22,552 x DRG weight",23251,Other,base rate x DRG weight,25834,,"25,057 x DRG weight",25834,Other,base rate x DRG weight,21958,,"21,298 x DRG weight",21958,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,112350,
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITHOUT CC/MCC,434,MS-DRG,,,,,,,,inpatient,,,136029.08,16622,,,16622,Other,150% of Medicare + 9.63% HCRA Surcharge,10108,,"3,609.90 x patient days",10108,Per diem,,16768,,"25,046 x DRG weight",16768,Other,base rate x DRG weight,15091,,"22,541 x DRG weight",15091,Other,base rate x DRG weight,21105,,"31,523 x DRG weight",21105,Other,base rate x DRG weight,18994,,"28,371 x DRG weight",18994,Other,base rate x DRG weight,17939,,"26,795 x DRG weight",17939,Other,base rate x DRG weight,11118.8,,"3,970.89 x patient days",11118.8,Per diem,,15039,,"22,463 x DRG weight",15039,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,17692,,"26,426 x DRG weight",17692,Other,base rate x DRG weight,25983,,"38,809 x DRG weight",25983,Other,base rate x DRG weight,25983,,"38,809 x DRG weight",25983,Other,base rate x DRG weight,17692,,"26,426 x DRG weight",17692,Other,base rate x DRG weight,25983,,"38,809 x DRG weight",25983,Other,base rate x DRG weight,17816,,"6,363 x patient days",17816,Per diem,,95220,70,,95220,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,16776,,"25,057 x DRG weight",16776,Other,base rate x DRG weight,15099,,"22,552 x DRG weight",15099,Other,base rate x DRG weight,16776,,"25,057 x DRG weight",16776,Other,base rate x DRG weight,14259,,"21,298 x DRG weight",14259,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,95220,
MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH MCC,435,MS-DRG,,,,,,,,inpatient,,,260130.32,37992,,,37992,Other,150% of Medicare + 9.63% HCRA Surcharge,23103,,"3,609.90 x patient days",23103,Per diem,,44078,,"25,046 x DRG weight",44078,Other,base rate x DRG weight,39670,,"22,541 x DRG weight",39670,Other,base rate x DRG weight,55477,,"31,523 x DRG weight",55477,Other,base rate x DRG weight,49930,,"28,371 x DRG weight",49930,Other,base rate x DRG weight,47157,,"26,795 x DRG weight",47157,Other,base rate x DRG weight,25413.3,,"3,970.89 x patient days",25413.3,Per diem,,39533,,"22,463 x DRG weight",39533,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,46507,,"26,426 x DRG weight",46507,Other,base rate x DRG weight,68300,,"38,809 x DRG weight",68300,Other,base rate x DRG weight,68300,,"38,809 x DRG weight",68300,Other,base rate x DRG weight,46507,,"26,426 x DRG weight",46507,Other,base rate x DRG weight,68300,,"38,809 x DRG weight",68300,Other,base rate x DRG weight,40723,,"6,363 x patient days",40723,Per diem,,182091,70,,182091,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,44098,,"25,057 x DRG weight",44098,Other,base rate x DRG weight,39689,,"22,552 x DRG weight",39689,Other,base rate x DRG weight,44098,,"25,057 x DRG weight",44098,Other,base rate x DRG weight,37482,,"21,298 x DRG weight",37482,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,182091,
MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH CC,436,MS-DRG,,,,,,,,inpatient,,,165540.76,26120,,,26120,Other,150% of Medicare + 9.63% HCRA Surcharge,15884,,"3,609.90 x patient days",15884,Per diem,,27568,,"25,046 x DRG weight",27568,Other,base rate x DRG weight,24811,,"22,541 x DRG weight",24811,Other,base rate x DRG weight,34697,,"31,523 x DRG weight",34697,Other,base rate x DRG weight,31228,,"28,371 x DRG weight",31228,Other,base rate x DRG weight,29493,,"26,795 x DRG weight",29493,Other,base rate x DRG weight,17472.4,,"3,970.89 x patient days",17472.4,Per diem,,24725,,"22,463 x DRG weight",24725,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,29087,,"26,426 x DRG weight",29087,Other,base rate x DRG weight,42717,,"38,809 x DRG weight",42717,Other,base rate x DRG weight,42717,,"38,809 x DRG weight",42717,Other,base rate x DRG weight,29087,,"26,426 x DRG weight",29087,Other,base rate x DRG weight,42717,,"38,809 x DRG weight",42717,Other,base rate x DRG weight,27997,,"6,363 x patient days",27997,Per diem,,115879,70,,115879,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,27580,,"25,057 x DRG weight",27580,Other,base rate x DRG weight,24823,,"22,552 x DRG weight",24823,Other,base rate x DRG weight,27580,,"25,057 x DRG weight",27580,Other,base rate x DRG weight,23443,,"21,298 x DRG weight",23443,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,115879,
MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITHOUT CC/MCC,437,MS-DRG,,,,,,,,inpatient,,,139705.79,17216,,,17216,Other,150% of Medicare + 9.63% HCRA Surcharge,10469,,"3,609.90 x patient days",10469,Per diem,,20816,,"25,046 x DRG weight",20816,Other,base rate x DRG weight,18734,,"22,541 x DRG weight",18734,Other,base rate x DRG weight,26199,,"31,523 x DRG weight",26199,Other,base rate x DRG weight,23579,,"28,371 x DRG weight",23579,Other,base rate x DRG weight,22269,,"26,795 x DRG weight",22269,Other,base rate x DRG weight,11515.9,,"3,970.89 x patient days",11515.9,Per diem,,18669,,"22,463 x DRG weight",18669,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,21963,,"26,426 x DRG weight",21963,Other,base rate x DRG weight,32254,,"38,809 x DRG weight",32254,Other,base rate x DRG weight,32254,,"38,809 x DRG weight",32254,Other,base rate x DRG weight,21963,,"26,426 x DRG weight",21963,Other,base rate x DRG weight,32254,,"38,809 x DRG weight",32254,Other,base rate x DRG weight,18453,,"6,363 x patient days",18453,Per diem,,97794,70,,97794,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,20825,,"25,057 x DRG weight",20825,Other,base rate x DRG weight,18743,,"22,552 x DRG weight",18743,Other,base rate x DRG weight,20825,,"25,057 x DRG weight",20825,Other,base rate x DRG weight,17701,,"21,298 x DRG weight",17701,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,97794,
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH MCC,438,MS-DRG,,,,,,,,inpatient,,,231225.22,39179,,,39179,Other,150% of Medicare + 9.63% HCRA Surcharge,23825,,"3,609.90 x patient days",23825,Per diem,,41797,,"25,046 x DRG weight",41797,Other,base rate x DRG weight,37616,,"22,541 x DRG weight",37616,Other,base rate x DRG weight,52606,,"31,523 x DRG weight",52606,Other,base rate x DRG weight,47346,,"28,371 x DRG weight",47346,Other,base rate x DRG weight,44715,,"26,795 x DRG weight",44715,Other,base rate x DRG weight,26207.5,,"3,970.89 x patient days",26207.5,Per diem,,37486,,"22,463 x DRG weight",37486,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,44100,,"26,426 x DRG weight",44100,Other,base rate x DRG weight,64764,,"38,809 x DRG weight",64764,Other,base rate x DRG weight,64764,,"38,809 x DRG weight",64764,Other,base rate x DRG weight,44100,,"26,426 x DRG weight",44100,Other,base rate x DRG weight,64764,,"38,809 x DRG weight",64764,Other,base rate x DRG weight,41996,,"6,363 x patient days",41996,Per diem,,161858,70,,161858,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,41815,,"25,057 x DRG weight",41815,Other,base rate x DRG weight,37635,,"22,552 x DRG weight",37635,Other,base rate x DRG weight,41815,,"25,057 x DRG weight",41815,Other,base rate x DRG weight,35542,,"21,298 x DRG weight",35542,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,161858,
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH CC,439,MS-DRG,,,,,,,,inpatient,,,154774.29,22559,,,22559,Other,150% of Medicare + 9.63% HCRA Surcharge,13718,,"3,609.90 x patient days",13718,Per diem,,21419,,"25,046 x DRG weight",21419,Other,base rate x DRG weight,19277,,"22,541 x DRG weight",19277,Other,base rate x DRG weight,26958,,"31,523 x DRG weight",26958,Other,base rate x DRG weight,24263,,"28,371 x DRG weight",24263,Other,base rate x DRG weight,22915,,"26,795 x DRG weight",22915,Other,base rate x DRG weight,15089.8,,"3,970.89 x patient days",15089.8,Per diem,,19210,,"22,463 x DRG weight",19210,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,22600,,"26,426 x DRG weight",22600,Other,base rate x DRG weight,33189,,"38,809 x DRG weight",33189,Other,base rate x DRG weight,33189,,"38,809 x DRG weight",33189,Other,base rate x DRG weight,22600,,"26,426 x DRG weight",22600,Other,base rate x DRG weight,33189,,"38,809 x DRG weight",33189,Other,base rate x DRG weight,24179,,"6,363 x patient days",24179,Per diem,,108342,70,,108342,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,21429,,"25,057 x DRG weight",21429,Other,base rate x DRG weight,19286,,"22,552 x DRG weight",19286,Other,base rate x DRG weight,21429,,"25,057 x DRG weight",21429,Other,base rate x DRG weight,18214,,"21,298 x DRG weight",18214,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,108342,
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITHOUT CC/MCC,440,MS-DRG,,,,,,,,inpatient,,,93885.21,16622,,,16622,Other,150% of Medicare + 9.63% HCRA Surcharge,10108,,"3,609.90 x patient days",10108,Per diem,,15418,,"25,046 x DRG weight",15418,Other,base rate x DRG weight,13876,,"22,541 x DRG weight",13876,Other,base rate x DRG weight,19406,,"31,523 x DRG weight",19406,Other,base rate x DRG weight,17465,,"28,371 x DRG weight",17465,Other,base rate x DRG weight,16495,,"26,795 x DRG weight",16495,Other,base rate x DRG weight,11118.8,,"3,970.89 x patient days",11118.8,Per diem,,13828,,"22,463 x DRG weight",13828,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,16268,,"26,426 x DRG weight",16268,Other,base rate x DRG weight,23891,,"38,809 x DRG weight",23891,Other,base rate x DRG weight,23891,,"38,809 x DRG weight",23891,Other,base rate x DRG weight,16268,,"26,426 x DRG weight",16268,Other,base rate x DRG weight,23891,,"38,809 x DRG weight",23891,Other,base rate x DRG weight,17816,,"6,363 x patient days",17816,Per diem,,65720,70,,65720,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,15425,,"25,057 x DRG weight",15425,Other,base rate x DRG weight,13883,,"22,552 x DRG weight",13883,Other,base rate x DRG weight,15425,,"25,057 x DRG weight",15425,Other,base rate x DRG weight,13111,,"21,298 x DRG weight",13111,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,65720,
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH MCC",441,MS-DRG,,,,,,,,inpatient,,,292904.11,39773,,,39773,Other,150% of Medicare + 9.63% HCRA Surcharge,24186,,"3,609.90 x patient days",24186,Per diem,,45789,,"25,046 x DRG weight",45789,Other,base rate x DRG weight,41209,,"22,541 x DRG weight",41209,Other,base rate x DRG weight,57630,,"31,523 x DRG weight",57630,Other,base rate x DRG weight,51868,,"28,371 x DRG weight",51868,Other,base rate x DRG weight,48987,,"26,795 x DRG weight",48987,Other,base rate x DRG weight,26604.6,,"3,970.89 x patient days",26604.6,Per diem,,41067,,"22,463 x DRG weight",41067,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,48312,,"26,426 x DRG weight",48312,Other,base rate x DRG weight,70951,,"38,809 x DRG weight",70951,Other,base rate x DRG weight,70951,,"38,809 x DRG weight",70951,Other,base rate x DRG weight,48312,,"26,426 x DRG weight",48312,Other,base rate x DRG weight,70951,,"38,809 x DRG weight",70951,Other,base rate x DRG weight,42632,,"6,363 x patient days",42632,Per diem,,205033,70,,205033,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,45809,,"25,057 x DRG weight",45809,Other,base rate x DRG weight,41230,,"22,552 x DRG weight",41230,Other,base rate x DRG weight,45809,,"25,057 x DRG weight",45809,Other,base rate x DRG weight,38937,,"21,298 x DRG weight",38937,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,205033,
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH CC",442,MS-DRG,,,,,,,,inpatient,,,154877.1,24340,,,24340,Other,150% of Medicare + 9.63% HCRA Surcharge,14801,,"3,609.90 x patient days",14801,Per diem,,23831,,"25,046 x DRG weight",23831,Other,base rate x DRG weight,21448,,"22,541 x DRG weight",21448,Other,base rate x DRG weight,29994,,"31,523 x DRG weight",29994,Other,base rate x DRG weight,26995,,"28,371 x DRG weight",26995,Other,base rate x DRG weight,25495,,"26,795 x DRG weight",25495,Other,base rate x DRG weight,16281.1,,"3,970.89 x patient days",16281.1,Per diem,,21374,,"22,463 x DRG weight",21374,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,25144,,"26,426 x DRG weight",25144,Other,base rate x DRG weight,36927,,"38,809 x DRG weight",36927,Other,base rate x DRG weight,36927,,"38,809 x DRG weight",36927,Other,base rate x DRG weight,25144,,"26,426 x DRG weight",25144,Other,base rate x DRG weight,36927,,"38,809 x DRG weight",36927,Other,base rate x DRG weight,26088,,"6,363 x patient days",26088,Per diem,,108414,70,,108414,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,23842,,"25,057 x DRG weight",23842,Other,base rate x DRG weight,21458,,"22,552 x DRG weight",21458,Other,base rate x DRG weight,23842,,"25,057 x DRG weight",23842,Other,base rate x DRG weight,20265,,"21,298 x DRG weight",20265,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,108414,
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITHOUT CC/MCC",443,MS-DRG,,,,,,,,inpatient,,,124494.32,18403,,,18403,Other,150% of Medicare + 9.63% HCRA Surcharge,11191,,"3,609.90 x patient days",11191,Per diem,,17900,,"25,046 x DRG weight",17900,Other,base rate x DRG weight,16110,,"22,541 x DRG weight",16110,Other,base rate x DRG weight,22529,,"31,523 x DRG weight",22529,Other,base rate x DRG weight,20277,,"28,371 x DRG weight",20277,Other,base rate x DRG weight,19150,,"26,795 x DRG weight",19150,Other,base rate x DRG weight,12310.1,,"3,970.89 x patient days",12310.1,Per diem,,16054,,"22,463 x DRG weight",16054,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,18887,,"26,426 x DRG weight",18887,Other,base rate x DRG weight,27737,,"38,809 x DRG weight",27737,Other,base rate x DRG weight,27737,,"38,809 x DRG weight",27737,Other,base rate x DRG weight,18887,,"26,426 x DRG weight",18887,Other,base rate x DRG weight,27737,,"38,809 x DRG weight",27737,Other,base rate x DRG weight,19725,,"6,363 x patient days",19725,Per diem,,87146,70,,87146,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,17908,,"25,057 x DRG weight",17908,Other,base rate x DRG weight,16118,,"22,552 x DRG weight",16118,Other,base rate x DRG weight,17908,,"25,057 x DRG weight",17908,Other,base rate x DRG weight,15222,,"21,298 x DRG weight",15222,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,87146,
DISORDERS OF THE BILIARY TRACT WITH MCC,444,MS-DRG,,,,,,,,inpatient,,,229395.79,35023,,,35023,Other,150% of Medicare + 9.63% HCRA Surcharge,21298,,"3,609.90 x patient days",21298,Per diem,,40905,,"25,046 x DRG weight",40905,Other,base rate x DRG weight,36814,,"22,541 x DRG weight",36814,Other,base rate x DRG weight,51483,,"31,523 x DRG weight",51483,Other,base rate x DRG weight,46336,,"28,371 x DRG weight",46336,Other,base rate x DRG weight,43762,,"26,795 x DRG weight",43762,Other,base rate x DRG weight,23427.8,,"3,970.89 x patient days",23427.8,Per diem,,36687,,"22,463 x DRG weight",36687,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,43159,,"26,426 x DRG weight",43159,Other,base rate x DRG weight,63383,,"38,809 x DRG weight",63383,Other,base rate x DRG weight,63383,,"38,809 x DRG weight",63383,Other,base rate x DRG weight,43159,,"26,426 x DRG weight",43159,Other,base rate x DRG weight,63383,,"38,809 x DRG weight",63383,Other,base rate x DRG weight,37542,,"6,363 x patient days",37542,Per diem,,160577,70,,160577,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,40923,,"25,057 x DRG weight",40923,Other,base rate x DRG weight,36832,,"22,552 x DRG weight",36832,Other,base rate x DRG weight,40923,,"25,057 x DRG weight",40923,Other,base rate x DRG weight,34784,,"21,298 x DRG weight",34784,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,160577,
DISORDERS OF THE BILIARY TRACT WITH CC,445,MS-DRG,,,,,,,,inpatient,,,155190.87,22559,,,22559,Other,150% of Medicare + 9.63% HCRA Surcharge,13718,,"3,609.90 x patient days",13718,Per diem,,27220,,"25,046 x DRG weight",27220,Other,base rate x DRG weight,24498,,"22,541 x DRG weight",24498,Other,base rate x DRG weight,34259,,"31,523 x DRG weight",34259,Other,base rate x DRG weight,30834,,"28,371 x DRG weight",30834,Other,base rate x DRG weight,29121,,"26,795 x DRG weight",29121,Other,base rate x DRG weight,15089.8,,"3,970.89 x patient days",15089.8,Per diem,,24413,,"22,463 x DRG weight",24413,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,28720,,"26,426 x DRG weight",28720,Other,base rate x DRG weight,42178,,"38,809 x DRG weight",42178,Other,base rate x DRG weight,42178,,"38,809 x DRG weight",42178,Other,base rate x DRG weight,28720,,"26,426 x DRG weight",28720,Other,base rate x DRG weight,42178,,"38,809 x DRG weight",42178,Other,base rate x DRG weight,24179,,"6,363 x patient days",24179,Per diem,,108634,70,,108634,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,27232,,"25,057 x DRG weight",27232,Other,base rate x DRG weight,24510,,"22,552 x DRG weight",24510,Other,base rate x DRG weight,27232,,"25,057 x DRG weight",27232,Other,base rate x DRG weight,23147,,"21,298 x DRG weight",23147,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,108634,
DISORDERS OF THE BILIARY TRACT WITHOUT CC/MCC,446,MS-DRG,,,,,,,,inpatient,,,90748.1,15435,,,15435,Other,150% of Medicare + 9.63% HCRA Surcharge,9386,,"3,609.90 x patient days",9386,Per diem,,20074,,"25,046 x DRG weight",20074,Other,base rate x DRG weight,18067,,"22,541 x DRG weight",18067,Other,base rate x DRG weight,25266,,"31,523 x DRG weight",25266,Other,base rate x DRG weight,22739,,"28,371 x DRG weight",22739,Other,base rate x DRG weight,21476,,"26,795 x DRG weight",21476,Other,base rate x DRG weight,10324.6,,"3,970.89 x patient days",10324.6,Per diem,,18004,,"22,463 x DRG weight",18004,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,21180,,"26,426 x DRG weight",21180,Other,base rate x DRG weight,31105,,"38,809 x DRG weight",31105,Other,base rate x DRG weight,31105,,"38,809 x DRG weight",31105,Other,base rate x DRG weight,21180,,"26,426 x DRG weight",21180,Other,base rate x DRG weight,31105,,"38,809 x DRG weight",31105,Other,base rate x DRG weight,16544,,"6,363 x patient days",16544,Per diem,,63524,70,,63524,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,20083,,"25,057 x DRG weight",20083,Other,base rate x DRG weight,18075,,"22,552 x DRG weight",18075,Other,base rate x DRG weight,20083,,"25,057 x DRG weight",20083,Other,base rate x DRG weight,17070,,"21,298 x DRG weight",17070,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,63524,
COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION WITH MCC,453,MS-DRG,,,,,,,,inpatient,,,633098.44,55801,,,55801,Other,150% of Medicare + 9.63% HCRA Surcharge,33933,,"3,609.90 x patient days",33933,Per diem,,221943,,"25,046 x DRG weight",221943,Other,base rate x DRG weight,199745,,"22,541 x DRG weight",199745,Other,base rate x DRG weight,279338,,"31,523 x DRG weight",279338,Other,base rate x DRG weight,251407,,"28,371 x DRG weight",251407,Other,base rate x DRG weight,237441,,"26,795 x DRG weight",237441,Other,base rate x DRG weight,37326.3,,"3,970.89 x patient days",37326.3,Per diem,,199054,,"22,463 x DRG weight",199054,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,234171,,"26,426 x DRG weight",234171,Other,base rate x DRG weight,343902,,"38,809 x DRG weight",343902,Other,base rate x DRG weight,343902,,"38,809 x DRG weight",343902,Other,base rate x DRG weight,234171,,"26,426 x DRG weight",234171,Other,base rate x DRG weight,343902,,"38,809 x DRG weight",343902,Other,base rate x DRG weight,59812,,"6,363 x patient days",59812,Per diem,,443169,70,,443169,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,222040,,"25,057 x DRG weight",222040,Other,base rate x DRG weight,199842,,"22,552 x DRG weight",199842,Other,base rate x DRG weight,222040,,"25,057 x DRG weight",222040,Other,base rate x DRG weight,188730,,"21,298 x DRG weight",188730,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,443169,
COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION WITH CC,454,MS-DRG,,,,,,,,inpatient,,,567022.09,26120,,,26120,Other,150% of Medicare + 9.63% HCRA Surcharge,15884,,"3,609.90 x patient days",15884,Per diem,,153189,,"25,046 x DRG weight",153189,Other,base rate x DRG weight,137868,,"22,541 x DRG weight",137868,Other,base rate x DRG weight,192804,,"31,523 x DRG weight",192804,Other,base rate x DRG weight,173526,,"28,371 x DRG weight",173526,Other,base rate x DRG weight,163886,,"26,795 x DRG weight",163886,Other,base rate x DRG weight,17472.4,,"3,970.89 x patient days",17472.4,Per diem,,137390,,"22,463 x DRG weight",137390,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,161629,,"26,426 x DRG weight",161629,Other,base rate x DRG weight,237367,,"38,809 x DRG weight",237367,Other,base rate x DRG weight,237367,,"38,809 x DRG weight",237367,Other,base rate x DRG weight,161629,,"26,426 x DRG weight",161629,Other,base rate x DRG weight,237367,,"38,809 x DRG weight",237367,Other,base rate x DRG weight,27997,,"6,363 x patient days",27997,Per diem,,396915,70,,396915,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,153256,,"25,057 x DRG weight",153256,Other,base rate x DRG weight,137935,,"22,552 x DRG weight",137935,Other,base rate x DRG weight,153256,,"25,057 x DRG weight",153256,Other,base rate x DRG weight,130265,,"21,298 x DRG weight",130265,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,396915,
COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION WITHOUT CC/MCC,455,MS-DRG,,,,,,,,inpatient,,,369111.85,16028,,,16028,Other,150% of Medicare + 9.63% HCRA Surcharge,9747,,"3,609.90 x patient days",9747,Per diem,,115352,,"25,046 x DRG weight",115352,Other,base rate x DRG weight,103815,,"22,541 x DRG weight",103815,Other,base rate x DRG weight,145182,,"31,523 x DRG weight",145182,Other,base rate x DRG weight,130665,,"28,371 x DRG weight",130665,Other,base rate x DRG weight,123407,,"26,795 x DRG weight",123407,Other,base rate x DRG weight,10721.7,,"3,970.89 x patient days",10721.7,Per diem,,103456,,"22,463 x DRG weight",103456,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,121708,,"26,426 x DRG weight",121708,Other,base rate x DRG weight,178739,,"38,809 x DRG weight",178739,Other,base rate x DRG weight,178739,,"38,809 x DRG weight",178739,Other,base rate x DRG weight,121708,,"26,426 x DRG weight",121708,Other,base rate x DRG weight,178739,,"38,809 x DRG weight",178739,Other,base rate x DRG weight,17180,,"6,363 x patient days",17180,Per diem,,258378,70,,258378,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,115403,,"25,057 x DRG weight",115403,Other,base rate x DRG weight,103865,,"22,552 x DRG weight",103865,Other,base rate x DRG weight,115403,,"25,057 x DRG weight",115403,Other,base rate x DRG weight,98090,,"21,298 x DRG weight",98090,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,258378,
"SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE, MALIGNANCY, INFECTION OR EXTENSIVE FUSIONS WITH MCC",456,MS-DRG,,,,,,,,inpatient,,,843561.74,78953,,,78953,Other,150% of Medicare + 9.63% HCRA Surcharge,48012,,"3,609.90 x patient days",48012,Per diem,,211123,,"25,046 x DRG weight",211123,Other,base rate x DRG weight,190007,,"22,541 x DRG weight",190007,Other,base rate x DRG weight,265720,,"31,523 x DRG weight",265720,Other,base rate x DRG weight,239151,,"28,371 x DRG weight",239151,Other,base rate x DRG weight,225866,,"26,795 x DRG weight",225866,Other,base rate x DRG weight,52813.2,,"3,970.89 x patient days",52813.2,Per diem,,189350,,"22,463 x DRG weight",189350,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,222755,,"26,426 x DRG weight",222755,Other,base rate x DRG weight,327137,,"38,809 x DRG weight",327137,Other,base rate x DRG weight,327137,,"38,809 x DRG weight",327137,Other,base rate x DRG weight,222755,,"26,426 x DRG weight",222755,Other,base rate x DRG weight,327137,,"38,809 x DRG weight",327137,Other,base rate x DRG weight,84628,,"6,363 x patient days",84628,Per diem,,590493,70,,590493,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,211215,,"25,057 x DRG weight",211215,Other,base rate x DRG weight,190100,,"22,552 x DRG weight",190100,Other,base rate x DRG weight,211215,,"25,057 x DRG weight",211215,Other,base rate x DRG weight,179529,,"21,298 x DRG weight",179529,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,590493,
"SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE, MALIGNANCY, INFECTION OR EXTENSIVE FUSIONS WITH CC",457,MS-DRG,,,,,,,,inpatient,,,595047.79,37992,,,37992,Other,150% of Medicare + 9.63% HCRA Surcharge,23103,,"3,609.90 x patient days",23103,Per diem,,152162,,"25,046 x DRG weight",152162,Other,base rate x DRG weight,136943,,"22,541 x DRG weight",136943,Other,base rate x DRG weight,191512,,"31,523 x DRG weight",191512,Other,base rate x DRG weight,172362,,"28,371 x DRG weight",172362,Other,base rate x DRG weight,162788,,"26,795 x DRG weight",162788,Other,base rate x DRG weight,25413.3,,"3,970.89 x patient days",25413.3,Per diem,,136469,,"22,463 x DRG weight",136469,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,160546,,"26,426 x DRG weight",160546,Other,base rate x DRG weight,235776,,"38,809 x DRG weight",235776,Other,base rate x DRG weight,235776,,"38,809 x DRG weight",235776,Other,base rate x DRG weight,160546,,"26,426 x DRG weight",160546,Other,base rate x DRG weight,235776,,"38,809 x DRG weight",235776,Other,base rate x DRG weight,40723,,"6,363 x patient days",40723,Per diem,,416533,70,,416533,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,152229,,"25,057 x DRG weight",152229,Other,base rate x DRG weight,137010,,"22,552 x DRG weight",137010,Other,base rate x DRG weight,152229,,"25,057 x DRG weight",152229,Other,base rate x DRG weight,129392,,"21,298 x DRG weight",129392,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,416533,
"SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE, MALIGNANCY, INFECTION OR EXTENSIVE FUSIONS WITHOUT CC/MCC",458,MS-DRG,,,,,,,,inpatient,,,361625.58,20778,,,20778,Other,150% of Medicare + 9.63% HCRA Surcharge,12635,,"3,609.90 x patient days",12635,Per diem,,113483,,"25,046 x DRG weight",113483,Other,base rate x DRG weight,102133,,"22,541 x DRG weight",102133,Other,base rate x DRG weight,142831,,"31,523 x DRG weight",142831,Other,base rate x DRG weight,128549,,"28,371 x DRG weight",128549,Other,base rate x DRG weight,121408,,"26,795 x DRG weight",121408,Other,base rate x DRG weight,13898.5,,"3,970.89 x patient days",13898.5,Per diem,,101780,,"22,463 x DRG weight",101780,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,119736,,"26,426 x DRG weight",119736,Other,base rate x DRG weight,175844,,"38,809 x DRG weight",175844,Other,base rate x DRG weight,175844,,"38,809 x DRG weight",175844,Other,base rate x DRG weight,119736,,"26,426 x DRG weight",119736,Other,base rate x DRG weight,175844,,"38,809 x DRG weight",175844,Other,base rate x DRG weight,22271,,"6,363 x patient days",22271,Per diem,,253138,70,,253138,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,113533,,"25,057 x DRG weight",113533,Other,base rate x DRG weight,102183,,"22,552 x DRG weight",102183,Other,base rate x DRG weight,113533,,"25,057 x DRG weight",113533,Other,base rate x DRG weight,96501,,"21,298 x DRG weight",96501,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,253138,
SPINAL FUSION EXCEPT CERVICAL WITH MCC,459,MS-DRG,,,,,,,,inpatient,,,571947.85,58176,,,58176,Other,150% of Medicare + 9.63% HCRA Surcharge,35377,,"3,609.90 x patient days",35377,Per diem,,166113,,"25,046 x DRG weight",166113,Other,base rate x DRG weight,149499,,"22,541 x DRG weight",149499,Other,base rate x DRG weight,209070,,"31,523 x DRG weight",209070,Other,base rate x DRG weight,188165,,"28,371 x DRG weight",188165,Other,base rate x DRG weight,177712,,"26,795 x DRG weight",177712,Other,base rate x DRG weight,38914.7,,"3,970.89 x patient days",38914.7,Per diem,,148981,,"22,463 x DRG weight",148981,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,175265,,"26,426 x DRG weight",175265,Other,base rate x DRG weight,257393,,"38,809 x DRG weight",257393,Other,base rate x DRG weight,257393,,"38,809 x DRG weight",257393,Other,base rate x DRG weight,175265,,"26,426 x DRG weight",175265,Other,base rate x DRG weight,257393,,"38,809 x DRG weight",257393,Other,base rate x DRG weight,62357,,"6,363 x patient days",62357,Per diem,,400363,70,,400363,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,166186,,"25,057 x DRG weight",166186,Other,base rate x DRG weight,149572,,"22,552 x DRG weight",149572,Other,base rate x DRG weight,166186,,"25,057 x DRG weight",166186,Other,base rate x DRG weight,141255,,"21,298 x DRG weight",141255,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,400363,
SPINAL FUSION EXCEPT CERVICAL WITHOUT MCC,460,MS-DRG,,,,,,,,inpatient,,,412534.11,20778,,,20778,Other,150% of Medicare + 9.63% HCRA Surcharge,12635,,"3,609.90 x patient days",12635,Per diem,,91616,,"25,046 x DRG weight",91616,Other,base rate x DRG weight,82453,,"22,541 x DRG weight",82453,Other,base rate x DRG weight,115308,,"31,523 x DRG weight",115308,Other,base rate x DRG weight,103778,,"28,371 x DRG weight",103778,Other,base rate x DRG weight,98013,,"26,795 x DRG weight",98013,Other,base rate x DRG weight,13898.5,,"3,970.89 x patient days",13898.5,Per diem,,82167,,"22,463 x DRG weight",82167,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,96664,,"26,426 x DRG weight",96664,Other,base rate x DRG weight,141959,,"38,809 x DRG weight",141959,Other,base rate x DRG weight,141959,,"38,809 x DRG weight",141959,Other,base rate x DRG weight,96664,,"26,426 x DRG weight",96664,Other,base rate x DRG weight,141959,,"38,809 x DRG weight",141959,Other,base rate x DRG weight,22271,,"6,363 x patient days",22271,Per diem,,288774,70,,288774,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,91656,,"25,057 x DRG weight",91656,Other,base rate x DRG weight,82493,,"22,552 x DRG weight",82493,Other,base rate x DRG weight,91656,,"25,057 x DRG weight",91656,Other,base rate x DRG weight,77906,,"21,298 x DRG weight",77906,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,288774,
BILATERAL OR MULTIPLE MAJOR JOINT PROCEDURES OF LOWER EXTREMITY WITH MCC,461,MS-DRG,,,,,,,,inpatient,,,375453.95,62925,,,62925,Other,150% of Medicare + 9.63% HCRA Surcharge,38265,,"3,609.90 x patient days",38265,Per diem,,170776,,"25,046 x DRG weight",170776,Other,base rate x DRG weight,153696,,"22,541 x DRG weight",153696,Other,base rate x DRG weight,214940,,"31,523 x DRG weight",214940,Other,base rate x DRG weight,193448,,"28,371 x DRG weight",193448,Other,base rate x DRG weight,182702,,"26,795 x DRG weight",182702,Other,base rate x DRG weight,42091.5,,"3,970.89 x patient days",42091.5,Per diem,,153164,,"22,463 x DRG weight",153164,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,180186,,"26,426 x DRG weight",180186,Other,base rate x DRG weight,264619,,"38,809 x DRG weight",264619,Other,base rate x DRG weight,264619,,"38,809 x DRG weight",264619,Other,base rate x DRG weight,180186,,"26,426 x DRG weight",180186,Other,base rate x DRG weight,264619,,"38,809 x DRG weight",264619,Other,base rate x DRG weight,67448,,"6,363 x patient days",67448,Per diem,,262818,70,,262818,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,170851,,"25,057 x DRG weight",170851,Other,base rate x DRG weight,153771,,"22,552 x DRG weight",153771,Other,base rate x DRG weight,170851,,"25,057 x DRG weight",170851,Other,base rate x DRG weight,145220,,"21,298 x DRG weight",145220,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,264619,
BILATERAL OR MULTIPLE MAJOR JOINT PROCEDURES OF LOWER EXTREMITY WITHOUT MCC,462,MS-DRG,,,,,,,,inpatient,,,213954.99,17216,,,17216,Other,150% of Medicare + 9.63% HCRA Surcharge,10469,,"3,609.90 x patient days",10469,Per diem,,71288,,"25,046 x DRG weight",71288,Other,base rate x DRG weight,64158,,"22,541 x DRG weight",64158,Other,base rate x DRG weight,89724,,"31,523 x DRG weight",89724,Other,base rate x DRG weight,80752,,"28,371 x DRG weight",80752,Other,base rate x DRG weight,76267,,"26,795 x DRG weight",76267,Other,base rate x DRG weight,11515.9,,"3,970.89 x patient days",11515.9,Per diem,,63936,,"22,463 x DRG weight",63936,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,75216,,"26,426 x DRG weight",75216,Other,base rate x DRG weight,110462,,"38,809 x DRG weight",110462,Other,base rate x DRG weight,110462,,"38,809 x DRG weight",110462,Other,base rate x DRG weight,75216,,"26,426 x DRG weight",75216,Other,base rate x DRG weight,110462,,"38,809 x DRG weight",110462,Other,base rate x DRG weight,18453,,"6,363 x patient days",18453,Per diem,,149768,70,,149768,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,71320,,"25,057 x DRG weight",71320,Other,base rate x DRG weight,64190,,"22,552 x DRG weight",64190,Other,base rate x DRG weight,71320,,"25,057 x DRG weight",71320,Other,base rate x DRG weight,60620,,"21,298 x DRG weight",60620,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,149768,
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH MCC,463,MS-DRG,,,,,,,,inpatient,,,848239.31,91418,,,91418,Other,150% of Medicare + 9.63% HCRA Surcharge,55592,,"3,609.90 x patient days",55592,Per diem,,141853,,"25,046 x DRG weight",141853,Other,base rate x DRG weight,127665,,"22,541 x DRG weight",127665,Other,base rate x DRG weight,178537,,"31,523 x DRG weight",178537,Other,base rate x DRG weight,160685,,"28,371 x DRG weight",160685,Other,base rate x DRG weight,151759,,"26,795 x DRG weight",151759,Other,base rate x DRG weight,61151.2,,"3,970.89 x patient days",61151.2,Per diem,,127224,,"22,463 x DRG weight",127224,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,149669,,"26,426 x DRG weight",149669,Other,base rate x DRG weight,219803,,"38,809 x DRG weight",219803,Other,base rate x DRG weight,219803,,"38,809 x DRG weight",219803,Other,base rate x DRG weight,149669,,"26,426 x DRG weight",149669,Other,base rate x DRG weight,219803,,"38,809 x DRG weight",219803,Other,base rate x DRG weight,97990,,"6,363 x patient days",97990,Per diem,,593768,70,,593768,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,141915,,"25,057 x DRG weight",141915,Other,base rate x DRG weight,127728,,"22,552 x DRG weight",127728,Other,base rate x DRG weight,141915,,"25,057 x DRG weight",141915,Other,base rate x DRG weight,120625,,"21,298 x DRG weight",120625,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,593768,
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH CC,464,MS-DRG,,,,,,,,inpatient,,,544659.96,43928,,,43928,Other,150% of Medicare + 9.63% HCRA Surcharge,26713,,"3,609.90 x patient days",26713,Per diem,,75173,,"25,046 x DRG weight",75173,Other,base rate x DRG weight,67655,,"22,541 x DRG weight",67655,Other,base rate x DRG weight,94613,,"31,523 x DRG weight",94613,Other,base rate x DRG weight,85153,,"28,371 x DRG weight",85153,Other,base rate x DRG weight,80423,,"26,795 x DRG weight",80423,Other,base rate x DRG weight,29384.3,,"3,970.89 x patient days",29384.3,Per diem,,67420,,"22,463 x DRG weight",67420,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,79315,,"26,426 x DRG weight",79315,Other,base rate x DRG weight,116481,,"38,809 x DRG weight",116481,Other,base rate x DRG weight,116481,,"38,809 x DRG weight",116481,Other,base rate x DRG weight,79315,,"26,426 x DRG weight",79315,Other,base rate x DRG weight,116481,,"38,809 x DRG weight",116481,Other,base rate x DRG weight,47086,,"6,363 x patient days",47086,Per diem,,381262,70,,381262,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,75206,,"25,057 x DRG weight",75206,Other,base rate x DRG weight,67688,,"22,552 x DRG weight",67688,Other,base rate x DRG weight,75206,,"25,057 x DRG weight",75206,Other,base rate x DRG weight,63924,,"21,298 x DRG weight",63924,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,381262,
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC,465,MS-DRG,,,,,,,,inpatient,,,300547.76,19590,,,19590,Other,150% of Medicare + 9.63% HCRA Surcharge,11913,,"3,609.90 x patient days",11913,Per diem,,46856,,"25,046 x DRG weight",46856,Other,base rate x DRG weight,42170,,"22,541 x DRG weight",42170,Other,base rate x DRG weight,58973,,"31,523 x DRG weight",58973,Other,base rate x DRG weight,53076,,"28,371 x DRG weight",53076,Other,base rate x DRG weight,50128,,"26,795 x DRG weight",50128,Other,base rate x DRG weight,13104.3,,"3,970.89 x patient days",13104.3,Per diem,,42024,,"22,463 x DRG weight",42024,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,49438,,"26,426 x DRG weight",49438,Other,base rate x DRG weight,72604,,"38,809 x DRG weight",72604,Other,base rate x DRG weight,72604,,"38,809 x DRG weight",72604,Other,base rate x DRG weight,49438,,"26,426 x DRG weight",49438,Other,base rate x DRG weight,72604,,"38,809 x DRG weight",72604,Other,base rate x DRG weight,20998,,"6,363 x patient days",20998,Per diem,,210383,70,,210383,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,46877,,"25,057 x DRG weight",46877,Other,base rate x DRG weight,42190,,"22,552 x DRG weight",42190,Other,base rate x DRG weight,46877,,"25,057 x DRG weight",46877,Other,base rate x DRG weight,39844,,"21,298 x DRG weight",39844,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,210383,
REVISION OF HIP OR KNEE REPLACEMENT WITH MCC,466,MS-DRG,,,,,,,,inpatient,,,415619.59,55801,,,55801,Other,150% of Medicare + 9.63% HCRA Surcharge,33933,,"3,609.90 x patient days",33933,Per diem,,129904,,"25,046 x DRG weight",129904,Other,base rate x DRG weight,116911,,"22,541 x DRG weight",116911,Other,base rate x DRG weight,163497,,"31,523 x DRG weight",163497,Other,base rate x DRG weight,147149,,"28,371 x DRG weight",147149,Other,base rate x DRG weight,138975,,"26,795 x DRG weight",138975,Other,base rate x DRG weight,37326.3,,"3,970.89 x patient days",37326.3,Per diem,,116507,,"22,463 x DRG weight",116507,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,137061,,"26,426 x DRG weight",137061,Other,base rate x DRG weight,201287,,"38,809 x DRG weight",201287,Other,base rate x DRG weight,201287,,"38,809 x DRG weight",201287,Other,base rate x DRG weight,137061,,"26,426 x DRG weight",137061,Other,base rate x DRG weight,201287,,"38,809 x DRG weight",201287,Other,base rate x DRG weight,59812,,"6,363 x patient days",59812,Per diem,,290934,70,,290934,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,129961,,"25,057 x DRG weight",129961,Other,base rate x DRG weight,116968,,"22,552 x DRG weight",116968,Other,base rate x DRG weight,129961,,"25,057 x DRG weight",129961,Other,base rate x DRG weight,110464,,"21,298 x DRG weight",110464,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,290934,
REVISION OF HIP OR KNEE REPLACEMENT WITH CC,467,MS-DRG,,,,,,,,inpatient,,,301348.69,25527,,,25527,Other,150% of Medicare + 9.63% HCRA Surcharge,15523,,"3,609.90 x patient days",15523,Per diem,,87318,,"25,046 x DRG weight",87318,Other,base rate x DRG weight,78585,,"22,541 x DRG weight",78585,Other,base rate x DRG weight,109899,,"31,523 x DRG weight",109899,Other,base rate x DRG weight,98910,,"28,371 x DRG weight",98910,Other,base rate x DRG weight,93415,,"26,795 x DRG weight",93415,Other,base rate x DRG weight,17075.3,,"3,970.89 x patient days",17075.3,Per diem,,78313,,"22,463 x DRG weight",78313,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,92129,,"26,426 x DRG weight",92129,Other,base rate x DRG weight,135300,,"38,809 x DRG weight",135300,Other,base rate x DRG weight,135300,,"38,809 x DRG weight",135300,Other,base rate x DRG weight,92129,,"26,426 x DRG weight",92129,Other,base rate x DRG weight,135300,,"38,809 x DRG weight",135300,Other,base rate x DRG weight,27361,,"6,363 x patient days",27361,Per diem,,210944,70,,210944,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,87356,,"25,057 x DRG weight",87356,Other,base rate x DRG weight,78623,,"22,552 x DRG weight",78623,Other,base rate x DRG weight,87356,,"25,057 x DRG weight",87356,Other,base rate x DRG weight,74251,,"21,298 x DRG weight",74251,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,210944,
REVISION OF HIP OR KNEE REPLACEMENT WITHOUT CC/MCC,468,MS-DRG,,,,,,,,inpatient,,,176455.89,11873,,,11873,Other,150% of Medicare + 9.63% HCRA Surcharge,7220,,"3,609.90 x patient days",7220,Per diem,,66863,,"25,046 x DRG weight",66863,Other,base rate x DRG weight,60175,,"22,541 x DRG weight",60175,Other,base rate x DRG weight,84154,,"31,523 x DRG weight",84154,Other,base rate x DRG weight,75739,,"28,371 x DRG weight",75739,Other,base rate x DRG weight,71532,,"26,795 x DRG weight",71532,Other,base rate x DRG weight,7942,,"3,970.89 x patient days",7942,Per diem,,59967,,"22,463 x DRG weight",59967,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,70547,,"26,426 x DRG weight",70547,Other,base rate x DRG weight,103605,,"38,809 x DRG weight",103605,Other,base rate x DRG weight,103605,,"38,809 x DRG weight",103605,Other,base rate x DRG weight,70547,,"26,426 x DRG weight",70547,Other,base rate x DRG weight,103605,,"38,809 x DRG weight",103605,Other,base rate x DRG weight,12726,,"6,363 x patient days",12726,Per diem,,123519,70,,123519,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,66892,,"25,057 x DRG weight",66892,Other,base rate x DRG weight,60205,,"22,552 x DRG weight",60205,Other,base rate x DRG weight,66892,,"25,057 x DRG weight",66892,Other,base rate x DRG weight,56857,,"21,298 x DRG weight",56857,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,123519,
MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY WITH MCC OR TOTAL ANKLE REPLACEMENT,469,MS-DRG,,,,,,,,inpatient,,,267132.55,29682,,,29682,Other,150% of Medicare + 9.63% HCRA Surcharge,18050,,"3,609.90 x patient days",18050,Per diem,,83398,,"25,046 x DRG weight",83398,Other,base rate x DRG weight,75057,,"22,541 x DRG weight",75057,Other,base rate x DRG weight,104965,,"31,523 x DRG weight",104965,Other,base rate x DRG weight,94470,,"28,371 x DRG weight",94470,Other,base rate x DRG weight,89222,,"26,795 x DRG weight",89222,Other,base rate x DRG weight,19855,,"3,970.89 x patient days",19855,Per diem,,74797,,"22,463 x DRG weight",74797,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,87993,,"26,426 x DRG weight",87993,Other,base rate x DRG weight,129226,,"38,809 x DRG weight",129226,Other,base rate x DRG weight,129226,,"38,809 x DRG weight",129226,Other,base rate x DRG weight,87993,,"26,426 x DRG weight",87993,Other,base rate x DRG weight,129226,,"38,809 x DRG weight",129226,Other,base rate x DRG weight,31815,,"6,363 x patient days",31815,Per diem,,186993,70,,186993,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,83435,,"25,057 x DRG weight",83435,Other,base rate x DRG weight,75094,,"22,552 x DRG weight",75094,Other,base rate x DRG weight,83435,,"25,057 x DRG weight",83435,Other,base rate x DRG weight,70918,,"21,298 x DRG weight",70918,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,186993,
MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY WITHOUT MCC,470,MS-DRG,,,,,,,,inpatient,,,151090.61,11873,,,11873,Other,150% of Medicare + 9.63% HCRA Surcharge,7220,,"3,609.90 x patient days",7220,Per diem,,47129,,"25,046 x DRG weight",47129,Other,base rate x DRG weight,42415,,"22,541 x DRG weight",42415,Other,base rate x DRG weight,59317,,"31,523 x DRG weight",59317,Other,base rate x DRG weight,53386,,"28,371 x DRG weight",53386,Other,base rate x DRG weight,50420,,"26,795 x DRG weight",50420,Other,base rate x DRG weight,7942,,"3,970.89 x patient days",7942,Per diem,,42269,,"22,463 x DRG weight",42269,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,49726,,"26,426 x DRG weight",49726,Other,base rate x DRG weight,73027,,"38,809 x DRG weight",73027,Other,base rate x DRG weight,73027,,"38,809 x DRG weight",73027,Other,base rate x DRG weight,49726,,"26,426 x DRG weight",49726,Other,base rate x DRG weight,73027,,"38,809 x DRG weight",73027,Other,base rate x DRG weight,12726,,"6,363 x patient days",12726,Per diem,,105763,70,,105763,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,47150,,"25,057 x DRG weight",47150,Other,base rate x DRG weight,42436,,"22,552 x DRG weight",42436,Other,base rate x DRG weight,47150,,"25,057 x DRG weight",47150,Other,base rate x DRG weight,40076,,"21,298 x DRG weight",40076,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,105763,
CERVICAL SPINAL FUSION WITH MCC,471,MS-DRG,,,,,,,,inpatient,,,489370.33,57582,,,57582,Other,150% of Medicare + 9.63% HCRA Surcharge,35016,,"3,609.90 x patient days",35016,Per diem,,123201,,"25,046 x DRG weight",123201,Other,base rate x DRG weight,110879,,"22,541 x DRG weight",110879,Other,base rate x DRG weight,155062,,"31,523 x DRG weight",155062,Other,base rate x DRG weight,139557,,"28,371 x DRG weight",139557,Other,base rate x DRG weight,131805,,"26,795 x DRG weight",131805,Other,base rate x DRG weight,38517.6,,"3,970.89 x patient days",38517.6,Per diem,,110495,,"22,463 x DRG weight",110495,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,129989,,"26,426 x DRG weight",129989,Other,base rate x DRG weight,190901,,"38,809 x DRG weight",190901,Other,base rate x DRG weight,190901,,"38,809 x DRG weight",190901,Other,base rate x DRG weight,129989,,"26,426 x DRG weight",129989,Other,base rate x DRG weight,190901,,"38,809 x DRG weight",190901,Other,base rate x DRG weight,61721,,"6,363 x patient days",61721,Per diem,,342559,70,,342559,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,123255,,"25,057 x DRG weight",123255,Other,base rate x DRG weight,110933,,"22,552 x DRG weight",110933,Other,base rate x DRG weight,123255,,"25,057 x DRG weight",123255,Other,base rate x DRG weight,104765,,"21,298 x DRG weight",104765,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,342559,
CERVICAL SPINAL FUSION WITH CC,472,MS-DRG,,,,,,,,inpatient,,,288821.42,21371,,,21371,Other,150% of Medicare + 9.63% HCRA Surcharge,12996,,"3,609.90 x patient days",12996,Per diem,,74021,,"25,046 x DRG weight",74021,Other,base rate x DRG weight,66618,,"22,541 x DRG weight",66618,Other,base rate x DRG weight,93163,,"31,523 x DRG weight",93163,Other,base rate x DRG weight,83848,,"28,371 x DRG weight",83848,Other,base rate x DRG weight,79190,,"26,795 x DRG weight",79190,Other,base rate x DRG weight,14295.6,,"3,970.89 x patient days",14295.6,Per diem,,66387,,"22,463 x DRG weight",66387,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,78099,,"26,426 x DRG weight",78099,Other,base rate x DRG weight,114696,,"38,809 x DRG weight",114696,Other,base rate x DRG weight,114696,,"38,809 x DRG weight",114696,Other,base rate x DRG weight,78099,,"26,426 x DRG weight",78099,Other,base rate x DRG weight,114696,,"38,809 x DRG weight",114696,Other,base rate x DRG weight,22907,,"6,363 x patient days",22907,Per diem,,202175,70,,202175,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,74053,,"25,057 x DRG weight",74053,Other,base rate x DRG weight,66650,,"22,552 x DRG weight",66650,Other,base rate x DRG weight,74053,,"25,057 x DRG weight",74053,Other,base rate x DRG weight,62944,,"21,298 x DRG weight",62944,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,202175,
CERVICAL SPINAL FUSION WITHOUT CC/MCC,473,MS-DRG,,,,,,,,inpatient,,,189159.65,11873,,,11873,Other,150% of Medicare + 9.63% HCRA Surcharge,7220,,"3,609.90 x patient days",7220,Per diem,,61628,,"25,046 x DRG weight",61628,Other,base rate x DRG weight,55464,,"22,541 x DRG weight",55464,Other,base rate x DRG weight,77565,,"31,523 x DRG weight",77565,Other,base rate x DRG weight,69810,,"28,371 x DRG weight",69810,Other,base rate x DRG weight,65932,,"26,795 x DRG weight",65932,Other,base rate x DRG weight,7942,,"3,970.89 x patient days",7942,Per diem,,55272,,"22,463 x DRG weight",55272,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,65024,,"26,426 x DRG weight",65024,Other,base rate x DRG weight,95493,,"38,809 x DRG weight",95493,Other,base rate x DRG weight,95493,,"38,809 x DRG weight",95493,Other,base rate x DRG weight,65024,,"26,426 x DRG weight",65024,Other,base rate x DRG weight,95493,,"38,809 x DRG weight",95493,Other,base rate x DRG weight,12726,,"6,363 x patient days",12726,Per diem,,132412,70,,132412,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,61655,,"25,057 x DRG weight",61655,Other,base rate x DRG weight,55491,,"22,552 x DRG weight",55491,Other,base rate x DRG weight,61655,,"25,057 x DRG weight",61655,Other,base rate x DRG weight,52406,,"21,298 x DRG weight",52406,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,132412,
AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH MCC,474,MS-DRG,,,,,,,,inpatient,,,544842.37,77766,,,77766,Other,150% of Medicare + 9.63% HCRA Surcharge,47290,,"3,609.90 x patient days",47290,Per diem,,107768,,"25,046 x DRG weight",107768,Other,base rate x DRG weight,96989,,"22,541 x DRG weight",96989,Other,base rate x DRG weight,135637,,"31,523 x DRG weight",135637,Other,base rate x DRG weight,122075,,"28,371 x DRG weight",122075,Other,base rate x DRG weight,115294,,"26,795 x DRG weight",115294,Other,base rate x DRG weight,52019,,"3,970.89 x patient days",52019,Per diem,,96654,,"22,463 x DRG weight",96654,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,113706,,"26,426 x DRG weight",113706,Other,base rate x DRG weight,166987,,"38,809 x DRG weight",166987,Other,base rate x DRG weight,166987,,"38,809 x DRG weight",166987,Other,base rate x DRG weight,113706,,"26,426 x DRG weight",113706,Other,base rate x DRG weight,166987,,"38,809 x DRG weight",166987,Other,base rate x DRG weight,83355,,"6,363 x patient days",83355,Per diem,,381390,70,,381390,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,107815,,"25,057 x DRG weight",107815,Other,base rate x DRG weight,97037,,"22,552 x DRG weight",97037,Other,base rate x DRG weight,107815,,"25,057 x DRG weight",107815,Other,base rate x DRG weight,91641,,"21,298 x DRG weight",91641,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,381390,
AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH CC,475,MS-DRG,,,,,,,,inpatient,,,263729.03,43335,,,43335,Other,150% of Medicare + 9.63% HCRA Surcharge,26352,,"3,609.90 x patient days",26352,Per diem,,53716,,"25,046 x DRG weight",53716,Other,base rate x DRG weight,48344,,"22,541 x DRG weight",48344,Other,base rate x DRG weight,67607,,"31,523 x DRG weight",67607,Other,base rate x DRG weight,60847,,"28,371 x DRG weight",60847,Other,base rate x DRG weight,57467,,"26,795 x DRG weight",57467,Other,base rate x DRG weight,28987.2,,"3,970.89 x patient days",28987.2,Per diem,,48176,,"22,463 x DRG weight",48176,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,56676,,"26,426 x DRG weight",56676,Other,base rate x DRG weight,83234,,"38,809 x DRG weight",83234,Other,base rate x DRG weight,83234,,"38,809 x DRG weight",83234,Other,base rate x DRG weight,56676,,"26,426 x DRG weight",56676,Other,base rate x DRG weight,83234,,"38,809 x DRG weight",83234,Other,base rate x DRG weight,46450,,"6,363 x patient days",46450,Per diem,,184610,70,,184610,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,53740,,"25,057 x DRG weight",53740,Other,base rate x DRG weight,48367,,"22,552 x DRG weight",48367,Other,base rate x DRG weight,53740,,"25,057 x DRG weight",53740,Other,base rate x DRG weight,45678,,"21,298 x DRG weight",45678,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,184610,
AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC,476,MS-DRG,,,,,,,,inpatient,,,139055.76,20184,,,20184,Other,150% of Medicare + 9.63% HCRA Surcharge,12274,,"3,609.90 x patient days",12274,Per diem,,29477,,"25,046 x DRG weight",29477,Other,base rate x DRG weight,26529,,"22,541 x DRG weight",26529,Other,base rate x DRG weight,37099,,"31,523 x DRG weight",37099,Other,base rate x DRG weight,33390,,"28,371 x DRG weight",33390,Other,base rate x DRG weight,31535,,"26,795 x DRG weight",31535,Other,base rate x DRG weight,13501.4,,"3,970.89 x patient days",13501.4,Per diem,,26437,,"22,463 x DRG weight",26437,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,31101,,"26,426 x DRG weight",31101,Other,base rate x DRG weight,45674,,"38,809 x DRG weight",45674,Other,base rate x DRG weight,45674,,"38,809 x DRG weight",45674,Other,base rate x DRG weight,31101,,"26,426 x DRG weight",31101,Other,base rate x DRG weight,45674,,"38,809 x DRG weight",45674,Other,base rate x DRG weight,21634,,"6,363 x patient days",21634,Per diem,,97339,70,,97339,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,29490,,"25,057 x DRG weight",29490,Other,base rate x DRG weight,26541,,"22,552 x DRG weight",26541,Other,base rate x DRG weight,29490,,"25,057 x DRG weight",29490,Other,base rate x DRG weight,25066,,"21,298 x DRG weight",25066,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,97339,
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC,477,MS-DRG,,,,,,,,inpatient,,,534816.66,65299,,,65299,Other,150% of Medicare + 9.63% HCRA Surcharge,39709,,"3,609.90 x patient days",39709,Per diem,,84380,,"25,046 x DRG weight",84380,Other,base rate x DRG weight,75941,,"22,541 x DRG weight",75941,Other,base rate x DRG weight,106201,,"31,523 x DRG weight",106201,Other,base rate x DRG weight,95582,,"28,371 x DRG weight",95582,Other,base rate x DRG weight,90272,,"26,795 x DRG weight",90272,Other,base rate x DRG weight,43679.9,,"3,970.89 x patient days",43679.9,Per diem,,75678,,"22,463 x DRG weight",75678,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,89029,,"26,426 x DRG weight",89029,Other,base rate x DRG weight,130748,,"38,809 x DRG weight",130748,Other,base rate x DRG weight,130748,,"38,809 x DRG weight",130748,Other,base rate x DRG weight,89029,,"26,426 x DRG weight",89029,Other,base rate x DRG weight,130748,,"38,809 x DRG weight",130748,Other,base rate x DRG weight,69993,,"6,363 x patient days",69993,Per diem,,374372,70,,374372,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,84417,,"25,057 x DRG weight",84417,Other,base rate x DRG weight,75978,,"22,552 x DRG weight",75978,Other,base rate x DRG weight,84417,,"25,057 x DRG weight",84417,Other,base rate x DRG weight,71753,,"21,298 x DRG weight",71753,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,374372,
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC,478,MS-DRG,,,,,,,,inpatient,,,300553.25,40366,,,40366,Other,150% of Medicare + 9.63% HCRA Surcharge,24547,,"3,609.90 x patient days",24547,Per diem,,59702,,"25,046 x DRG weight",59702,Other,base rate x DRG weight,53731,,"22,541 x DRG weight",53731,Other,base rate x DRG weight,75141,,"31,523 x DRG weight",75141,Other,base rate x DRG weight,67628,,"28,371 x DRG weight",67628,Other,base rate x DRG weight,63871,,"26,795 x DRG weight",63871,Other,base rate x DRG weight,27001.7,,"3,970.89 x patient days",27001.7,Per diem,,53545,,"22,463 x DRG weight",53545,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,62992,,"26,426 x DRG weight",62992,Other,base rate x DRG weight,92509,,"38,809 x DRG weight",92509,Other,base rate x DRG weight,92509,,"38,809 x DRG weight",92509,Other,base rate x DRG weight,62992,,"26,426 x DRG weight",62992,Other,base rate x DRG weight,92509,,"38,809 x DRG weight",92509,Other,base rate x DRG weight,43268,,"6,363 x patient days",43268,Per diem,,210387,70,,210387,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,59728,,"25,057 x DRG weight",59728,Other,base rate x DRG weight,53757,,"22,552 x DRG weight",53757,Other,base rate x DRG weight,59728,,"25,057 x DRG weight",59728,Other,base rate x DRG weight,50768,,"21,298 x DRG weight",50768,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,210387,
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT CC/MCC,479,MS-DRG,,,,,,,,inpatient,,,252720.48,24933,,,24933,Other,150% of Medicare + 9.63% HCRA Surcharge,15162,,"3,609.90 x patient days",15162,Per diem,,46686,,"25,046 x DRG weight",46686,Other,base rate x DRG weight,42016,,"22,541 x DRG weight",42016,Other,base rate x DRG weight,58759,,"31,523 x DRG weight",58759,Other,base rate x DRG weight,52884,,"28,371 x DRG weight",52884,Other,base rate x DRG weight,49946,,"26,795 x DRG weight",49946,Other,base rate x DRG weight,16678.2,,"3,970.89 x patient days",16678.2,Per diem,,41871,,"22,463 x DRG weight",41871,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,49258,,"26,426 x DRG weight",49258,Other,base rate x DRG weight,72340,,"38,809 x DRG weight",72340,Other,base rate x DRG weight,72340,,"38,809 x DRG weight",72340,Other,base rate x DRG weight,49258,,"26,426 x DRG weight",49258,Other,base rate x DRG weight,72340,,"38,809 x DRG weight",72340,Other,base rate x DRG weight,26725,,"6,363 x patient days",26725,Per diem,,176904,70,,176904,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,46706,,"25,057 x DRG weight",46706,Other,base rate x DRG weight,42037,,"22,552 x DRG weight",42037,Other,base rate x DRG weight,46706,,"25,057 x DRG weight",46706,Other,base rate x DRG weight,39699,,"21,298 x DRG weight",39699,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,176904,
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH MCC,480,MS-DRG,,,,,,,,inpatient,,,332195.9,46896,,,46896,Other,150% of Medicare + 9.63% HCRA Surcharge,28518,,"3,609.90 x patient days",28518,Per diem,,73858,,"25,046 x DRG weight",73858,Other,base rate x DRG weight,66471,,"22,541 x DRG weight",66471,Other,base rate x DRG weight,92958,,"31,523 x DRG weight",92958,Other,base rate x DRG weight,83663,,"28,371 x DRG weight",83663,Other,base rate x DRG weight,79016,,"26,795 x DRG weight",79016,Other,base rate x DRG weight,31369.8,,"3,970.89 x patient days",31369.8,Per diem,,66241,,"22,463 x DRG weight",66241,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,77928,,"26,426 x DRG weight",77928,Other,base rate x DRG weight,114444,,"38,809 x DRG weight",114444,Other,base rate x DRG weight,114444,,"38,809 x DRG weight",114444,Other,base rate x DRG weight,77928,,"26,426 x DRG weight",77928,Other,base rate x DRG weight,114444,,"38,809 x DRG weight",114444,Other,base rate x DRG weight,50268,,"6,363 x patient days",50268,Per diem,,232537,70,,232537,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,73891,,"25,057 x DRG weight",73891,Other,base rate x DRG weight,66504,,"22,552 x DRG weight",66504,Other,base rate x DRG weight,73891,,"25,057 x DRG weight",73891,Other,base rate x DRG weight,62806,,"21,298 x DRG weight",62806,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,232537,
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH CC,481,MS-DRG,,,,,,,,inpatient,,,253655.8,29682,,,29682,Other,150% of Medicare + 9.63% HCRA Surcharge,18050,,"3,609.90 x patient days",18050,Per diem,,51968,,"25,046 x DRG weight",51968,Other,base rate x DRG weight,46770,,"22,541 x DRG weight",46770,Other,base rate x DRG weight,65407,,"31,523 x DRG weight",65407,Other,base rate x DRG weight,58867,,"28,371 x DRG weight",58867,Other,base rate x DRG weight,55597,,"26,795 x DRG weight",55597,Other,base rate x DRG weight,19855,,"3,970.89 x patient days",19855,Per diem,,46608,,"22,463 x DRG weight",46608,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,54831,,"26,426 x DRG weight",54831,Other,base rate x DRG weight,80525,,"38,809 x DRG weight",80525,Other,base rate x DRG weight,80525,,"38,809 x DRG weight",80525,Other,base rate x DRG weight,54831,,"26,426 x DRG weight",54831,Other,base rate x DRG weight,80525,,"38,809 x DRG weight",80525,Other,base rate x DRG weight,31815,,"6,363 x patient days",31815,Per diem,,177559,70,,177559,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,51991,,"25,057 x DRG weight",51991,Other,base rate x DRG weight,46793,,"22,552 x DRG weight",46793,Other,base rate x DRG weight,51991,,"25,057 x DRG weight",51991,Other,base rate x DRG weight,44191,,"21,298 x DRG weight",44191,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,177559,
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITHOUT CC/MCC,482,MS-DRG,,,,,,,,inpatient,,,183953.55,21371,,,21371,Other,150% of Medicare + 9.63% HCRA Surcharge,12996,,"3,609.90 x patient days",12996,Per diem,,39783,,"25,046 x DRG weight",39783,Other,base rate x DRG weight,35804,,"22,541 x DRG weight",35804,Other,base rate x DRG weight,50071,,"31,523 x DRG weight",50071,Other,base rate x DRG weight,45064,,"28,371 x DRG weight",45064,Other,base rate x DRG weight,42561,,"26,795 x DRG weight",42561,Other,base rate x DRG weight,14295.6,,"3,970.89 x patient days",14295.6,Per diem,,35680,,"22,463 x DRG weight",35680,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,41975,,"26,426 x DRG weight",41975,Other,base rate x DRG weight,61644,,"38,809 x DRG weight",61644,Other,base rate x DRG weight,61644,,"38,809 x DRG weight",61644,Other,base rate x DRG weight,41975,,"26,426 x DRG weight",41975,Other,base rate x DRG weight,61644,,"38,809 x DRG weight",61644,Other,base rate x DRG weight,22907,,"6,363 x patient days",22907,Per diem,,128767,70,,128767,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,39801,,"25,057 x DRG weight",39801,Other,base rate x DRG weight,35822,,"22,552 x DRG weight",35822,Other,base rate x DRG weight,39801,,"25,057 x DRG weight",39801,Other,base rate x DRG weight,33830,,"21,298 x DRG weight",33830,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,128767,
MAJOR JOINT OR LIMB REATTACHMENT PROCEDURES OF UPPER EXTREMITIES,483,MS-DRG,,,,,,,,inpatient,,,271272.5,13654,,,13654,Other,150% of Medicare + 9.63% HCRA Surcharge,8303,,"3,609.90 x patient days",8303,Per diem,,62219,,"25,046 x DRG weight",62219,Other,base rate x DRG weight,55996,,"22,541 x DRG weight",55996,Other,base rate x DRG weight,78309,,"31,523 x DRG weight",78309,Other,base rate x DRG weight,70479,,"28,371 x DRG weight",70479,Other,base rate x DRG weight,66564,,"26,795 x DRG weight",66564,Other,base rate x DRG weight,9133.3,,"3,970.89 x patient days",9133.3,Per diem,,55803,,"22,463 x DRG weight",55803,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,65647,,"26,426 x DRG weight",65647,Other,base rate x DRG weight,96409,,"38,809 x DRG weight",96409,Other,base rate x DRG weight,96409,,"38,809 x DRG weight",96409,Other,base rate x DRG weight,65647,,"26,426 x DRG weight",65647,Other,base rate x DRG weight,96409,,"38,809 x DRG weight",96409,Other,base rate x DRG weight,14635,,"6,363 x patient days",14635,Per diem,,189891,70,,189891,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,62247,,"25,057 x DRG weight",62247,Other,base rate x DRG weight,56024,,"22,552 x DRG weight",56024,Other,base rate x DRG weight,62247,,"25,057 x DRG weight",62247,Other,base rate x DRG weight,52908,,"21,298 x DRG weight",52908,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,189891,
KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITH MCC,485,MS-DRG,,,,,,,,inpatient,,,502414.13,59957,,,59957,Other,150% of Medicare + 9.63% HCRA Surcharge,36460,,"3,609.90 x patient days",36460,Per diem,,82502,,"25,046 x DRG weight",82502,Other,base rate x DRG weight,74250,,"22,541 x DRG weight",74250,Other,base rate x DRG weight,103837,,"31,523 x DRG weight",103837,Other,base rate x DRG weight,93454,,"28,371 x DRG weight",93454,Other,base rate x DRG weight,88263,,"26,795 x DRG weight",88263,Other,base rate x DRG weight,40106,,"3,970.89 x patient days",40106,Per diem,,73993,,"22,463 x DRG weight",73993,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,87047,,"26,426 x DRG weight",87047,Other,base rate x DRG weight,127837,,"38,809 x DRG weight",127837,Other,base rate x DRG weight,127837,,"38,809 x DRG weight",127837,Other,base rate x DRG weight,87047,,"26,426 x DRG weight",87047,Other,base rate x DRG weight,127837,,"38,809 x DRG weight",127837,Other,base rate x DRG weight,64266,,"6,363 x patient days",64266,Per diem,,351690,70,,351690,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,82538,,"25,057 x DRG weight",82538,Other,base rate x DRG weight,74286,,"22,552 x DRG weight",74286,Other,base rate x DRG weight,82538,,"25,057 x DRG weight",82538,Other,base rate x DRG weight,70156,,"21,298 x DRG weight",70156,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,351690,
KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITH CC,486,MS-DRG,,,,,,,,inpatient,,,261162.63,35023,,,35023,Other,150% of Medicare + 9.63% HCRA Surcharge,21298,,"3,609.90 x patient days",21298,Per diem,,50300,,"25,046 x DRG weight",50300,Other,base rate x DRG weight,45269,,"22,541 x DRG weight",45269,Other,base rate x DRG weight,63308,,"31,523 x DRG weight",63308,Other,base rate x DRG weight,56977,,"28,371 x DRG weight",56977,Other,base rate x DRG weight,53812,,"26,795 x DRG weight",53812,Other,base rate x DRG weight,23427.8,,"3,970.89 x patient days",23427.8,Per diem,,45112,,"22,463 x DRG weight",45112,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,53071,,"26,426 x DRG weight",53071,Other,base rate x DRG weight,77940,,"38,809 x DRG weight",77940,Other,base rate x DRG weight,77940,,"38,809 x DRG weight",77940,Other,base rate x DRG weight,53071,,"26,426 x DRG weight",53071,Other,base rate x DRG weight,77940,,"38,809 x DRG weight",77940,Other,base rate x DRG weight,37542,,"6,363 x patient days",37542,Per diem,,182814,70,,182814,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,50322,,"25,057 x DRG weight",50322,Other,base rate x DRG weight,45291,,"22,552 x DRG weight",45291,Other,base rate x DRG weight,50322,,"25,057 x DRG weight",50322,Other,base rate x DRG weight,42773,,"21,298 x DRG weight",42773,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,182814,
KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITHOUT CC/MCC,487,MS-DRG,,,,,,,,inpatient,,,164039.72,24340,,,24340,Other,150% of Medicare + 9.63% HCRA Surcharge,14801,,"3,609.90 x patient days",14801,Per diem,,38694,,"25,046 x DRG weight",38694,Other,base rate x DRG weight,34824,,"22,541 x DRG weight",34824,Other,base rate x DRG weight,48700,,"31,523 x DRG weight",48700,Other,base rate x DRG weight,43830,,"28,371 x DRG weight",43830,Other,base rate x DRG weight,41396,,"26,795 x DRG weight",41396,Other,base rate x DRG weight,16281.1,,"3,970.89 x patient days",16281.1,Per diem,,34703,,"22,463 x DRG weight",34703,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,40826,,"26,426 x DRG weight",40826,Other,base rate x DRG weight,59956,,"38,809 x DRG weight",59956,Other,base rate x DRG weight,59956,,"38,809 x DRG weight",59956,Other,base rate x DRG weight,40826,,"26,426 x DRG weight",40826,Other,base rate x DRG weight,59956,,"38,809 x DRG weight",59956,Other,base rate x DRG weight,26088,,"6,363 x patient days",26088,Per diem,,114828,70,,114828,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,38711,,"25,057 x DRG weight",38711,Other,base rate x DRG weight,34841,,"22,552 x DRG weight",34841,Other,base rate x DRG weight,38711,,"25,057 x DRG weight",38711,Other,base rate x DRG weight,32903,,"21,298 x DRG weight",32903,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,114828,
KNEE PROCEDURES WITHOUT PRINCIPAL DIAGNOSIS OF INFECTION WITH CC/MCC,488,MS-DRG,,,,,,,,inpatient,,,322882.32,26714,,,26714,Other,150% of Medicare + 9.63% HCRA Surcharge,16245,,"3,609.90 x patient days",16245,Per diem,,52762,,"25,046 x DRG weight",52762,Other,base rate x DRG weight,47485,,"22,541 x DRG weight",47485,Other,base rate x DRG weight,66406,,"31,523 x DRG weight",66406,Other,base rate x DRG weight,59766,,"28,371 x DRG weight",59766,Other,base rate x DRG weight,56446,,"26,795 x DRG weight",56446,Other,base rate x DRG weight,17869.5,,"3,970.89 x patient days",17869.5,Per diem,,47321,,"22,463 x DRG weight",47321,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,55669,,"26,426 x DRG weight",55669,Other,base rate x DRG weight,81755,,"38,809 x DRG weight",81755,Other,base rate x DRG weight,81755,,"38,809 x DRG weight",81755,Other,base rate x DRG weight,55669,,"26,426 x DRG weight",55669,Other,base rate x DRG weight,81755,,"38,809 x DRG weight",81755,Other,base rate x DRG weight,28634,,"6,363 x patient days",28634,Per diem,,226018,70,,226018,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,52785,,"25,057 x DRG weight",52785,Other,base rate x DRG weight,47508,,"22,552 x DRG weight",47508,Other,base rate x DRG weight,52785,,"25,057 x DRG weight",52785,Other,base rate x DRG weight,44866,,"21,298 x DRG weight",44866,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,226018,
KNEE PROCEDURES WITHOUT PRINCIPAL DIAGNOSIS OF INFECTION WITHOUT CC/MCC,489,MS-DRG,,,,,,,,inpatient,,,190126.09,11279,,,11279,Other,150% of Medicare + 9.63% HCRA Surcharge,6859,,"3,609.90 x patient days",6859,Per diem,,30999,,"25,046 x DRG weight",30999,Other,base rate x DRG weight,27899,,"22,541 x DRG weight",27899,Other,base rate x DRG weight,39016,,"31,523 x DRG weight",39016,Other,base rate x DRG weight,35115,,"28,371 x DRG weight",35115,Other,base rate x DRG weight,33164,,"26,795 x DRG weight",33164,Other,base rate x DRG weight,7544.9,,"3,970.89 x patient days",7544.9,Per diem,,27802,,"22,463 x DRG weight",27802,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,32707,,"26,426 x DRG weight",32707,Other,base rate x DRG weight,48034,,"38,809 x DRG weight",48034,Other,base rate x DRG weight,48034,,"38,809 x DRG weight",48034,Other,base rate x DRG weight,32707,,"26,426 x DRG weight",32707,Other,base rate x DRG weight,48034,,"38,809 x DRG weight",48034,Other,base rate x DRG weight,12090,,"6,363 x patient days",12090,Per diem,,133088,70,,133088,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,31013,,"25,057 x DRG weight",31013,Other,base rate x DRG weight,27913,,"22,552 x DRG weight",27913,Other,base rate x DRG weight,31013,,"25,057 x DRG weight",31013,Other,base rate x DRG weight,26361,,"21,298 x DRG weight",26361,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,133088,
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH MCC",492,MS-DRG,,,,,,,,inpatient,,,407050.77,51052,,,51052,Other,150% of Medicare + 9.63% HCRA Surcharge,31045,,"3,609.90 x patient days",31045,Per diem,,86712,,"25,046 x DRG weight",86712,Other,base rate x DRG weight,78039,,"22,541 x DRG weight",78039,Other,base rate x DRG weight,109136,,"31,523 x DRG weight",109136,Other,base rate x DRG weight,98223,,"28,371 x DRG weight",98223,Other,base rate x DRG weight,92767,,"26,795 x DRG weight",92767,Other,base rate x DRG weight,34149.5,,"3,970.89 x patient days",34149.5,Per diem,,77769,,"22,463 x DRG weight",77769,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,91489,,"26,426 x DRG weight",91489,Other,base rate x DRG weight,134361,,"38,809 x DRG weight",134361,Other,base rate x DRG weight,134361,,"38,809 x DRG weight",134361,Other,base rate x DRG weight,91489,,"26,426 x DRG weight",91489,Other,base rate x DRG weight,134361,,"38,809 x DRG weight",134361,Other,base rate x DRG weight,54722,,"6,363 x patient days",54722,Per diem,,284936,70,,284936,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,86750,,"25,057 x DRG weight",86750,Other,base rate x DRG weight,78077,,"22,552 x DRG weight",78077,Other,base rate x DRG weight,86750,,"25,057 x DRG weight",86750,Other,base rate x DRG weight,73736,,"21,298 x DRG weight",73736,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,284936,
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH CC",493,MS-DRG,,,,,,,,inpatient,,,277949.72,30868,,,30868,Other,150% of Medicare + 9.63% HCRA Surcharge,18771,,"3,609.90 x patient days",18771,Per diem,,60153,,"25,046 x DRG weight",60153,Other,base rate x DRG weight,54137,,"22,541 x DRG weight",54137,Other,base rate x DRG weight,75709,,"31,523 x DRG weight",75709,Other,base rate x DRG weight,68139,,"28,371 x DRG weight",68139,Other,base rate x DRG weight,64354,,"26,795 x DRG weight",64354,Other,base rate x DRG weight,20648.1,,"3,970.89 x patient days",20648.1,Per diem,,53949,,"22,463 x DRG weight",53949,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,63467,,"26,426 x DRG weight",63467,Other,base rate x DRG weight,93208,,"38,809 x DRG weight",93208,Other,base rate x DRG weight,93208,,"38,809 x DRG weight",93208,Other,base rate x DRG weight,63467,,"26,426 x DRG weight",63467,Other,base rate x DRG weight,93208,,"38,809 x DRG weight",93208,Other,base rate x DRG weight,33088,,"6,363 x patient days",33088,Per diem,,194565,70,,194565,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,60179,,"25,057 x DRG weight",60179,Other,base rate x DRG weight,54163,,"22,552 x DRG weight",54163,Other,base rate x DRG weight,60179,,"25,057 x DRG weight",60179,Other,base rate x DRG weight,51151,,"21,298 x DRG weight",51151,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,194565,
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITHOUT CC/MCC",494,MS-DRG,,,,,,,,inpatient,,,207862.3,20184,,,20184,Other,150% of Medicare + 9.63% HCRA Surcharge,12274,,"3,609.90 x patient days",12274,Per diem,,46816,,"25,046 x DRG weight",46816,Other,base rate x DRG weight,42134,,"22,541 x DRG weight",42134,Other,base rate x DRG weight,58923,,"31,523 x DRG weight",58923,Other,base rate x DRG weight,53031,,"28,371 x DRG weight",53031,Other,base rate x DRG weight,50085,,"26,795 x DRG weight",50085,Other,base rate x DRG weight,13501.4,,"3,970.89 x patient days",13501.4,Per diem,,41988,,"22,463 x DRG weight",41988,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,49395,,"26,426 x DRG weight",49395,Other,base rate x DRG weight,72542,,"38,809 x DRG weight",72542,Other,base rate x DRG weight,72542,,"38,809 x DRG weight",72542,Other,base rate x DRG weight,49395,,"26,426 x DRG weight",49395,Other,base rate x DRG weight,72542,,"38,809 x DRG weight",72542,Other,base rate x DRG weight,21634,,"6,363 x patient days",21634,Per diem,,145504,70,,145504,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,46837,,"25,057 x DRG weight",46837,Other,base rate x DRG weight,42154,,"22,552 x DRG weight",42154,Other,base rate x DRG weight,46837,,"25,057 x DRG weight",46837,Other,base rate x DRG weight,39810,,"21,298 x DRG weight",39810,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,145504,
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITH MCC,495,MS-DRG,,,,,,,,inpatient,,,1130144.9,62331,,,62331,Other,150% of Medicare + 9.63% HCRA Surcharge,37904,,"3,609.90 x patient days",37904,Per diem,,89695,,"25,046 x DRG weight",89695,Other,base rate x DRG weight,80724,,"22,541 x DRG weight",80724,Other,base rate x DRG weight,112890,,"31,523 x DRG weight",112890,Other,base rate x DRG weight,101602,,"28,371 x DRG weight",101602,Other,base rate x DRG weight,95958,,"26,795 x DRG weight",95958,Other,base rate x DRG weight,41694.4,,"3,970.89 x patient days",41694.4,Per diem,,80444,,"22,463 x DRG weight",80444,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,94637,,"26,426 x DRG weight",94637,Other,base rate x DRG weight,138983,,"38,809 x DRG weight",138983,Other,base rate x DRG weight,138983,,"38,809 x DRG weight",138983,Other,base rate x DRG weight,94637,,"26,426 x DRG weight",94637,Other,base rate x DRG weight,138983,,"38,809 x DRG weight",138983,Other,base rate x DRG weight,66812,,"6,363 x patient days",66812,Per diem,,791101,70,,791101,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,89734,,"25,057 x DRG weight",89734,Other,base rate x DRG weight,80763,,"22,552 x DRG weight",80763,Other,base rate x DRG weight,89734,,"25,057 x DRG weight",89734,Other,base rate x DRG weight,76272,,"21,298 x DRG weight",76272,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,791101,
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITH CC,496,MS-DRG,,,,,,,,inpatient,,,239548.84,27308,,,27308,Other,150% of Medicare + 9.63% HCRA Surcharge,16606,,"3,609.90 x patient days",16606,Per diem,,49779,,"25,046 x DRG weight",49779,Other,base rate x DRG weight,44800,,"22,541 x DRG weight",44800,Other,base rate x DRG weight,62652,,"31,523 x DRG weight",62652,Other,base rate x DRG weight,56387,,"28,371 x DRG weight",56387,Other,base rate x DRG weight,53255,,"26,795 x DRG weight",53255,Other,base rate x DRG weight,18266.6,,"3,970.89 x patient days",18266.6,Per diem,,44645,,"22,463 x DRG weight",44645,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,52522,,"26,426 x DRG weight",52522,Other,base rate x DRG weight,77133,,"38,809 x DRG weight",77133,Other,base rate x DRG weight,77133,,"38,809 x DRG weight",77133,Other,base rate x DRG weight,52522,,"26,426 x DRG weight",52522,Other,base rate x DRG weight,77133,,"38,809 x DRG weight",77133,Other,base rate x DRG weight,29270,,"6,363 x patient days",29270,Per diem,,167684,70,,167684,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,49801,,"25,057 x DRG weight",49801,Other,base rate x DRG weight,44822,,"22,552 x DRG weight",44822,Other,base rate x DRG weight,49801,,"25,057 x DRG weight",49801,Other,base rate x DRG weight,42330,,"21,298 x DRG weight",42330,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,167684,
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITHOUT CC/MCC,497,MS-DRG,,,,,,,,inpatient,,,111107.51,13654,,,13654,Other,150% of Medicare + 9.63% HCRA Surcharge,8303,,"3,609.90 x patient days",8303,Per diem,,35751,,"25,046 x DRG weight",35751,Other,base rate x DRG weight,32175,,"22,541 x DRG weight",32175,Other,base rate x DRG weight,44996,,"31,523 x DRG weight",44996,Other,base rate x DRG weight,40497,,"28,371 x DRG weight",40497,Other,base rate x DRG weight,38247,,"26,795 x DRG weight",38247,Other,base rate x DRG weight,9133.3,,"3,970.89 x patient days",9133.3,Per diem,,32064,,"22,463 x DRG weight",32064,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,37720,,"26,426 x DRG weight",37720,Other,base rate x DRG weight,55396,,"38,809 x DRG weight",55396,Other,base rate x DRG weight,55396,,"38,809 x DRG weight",55396,Other,base rate x DRG weight,37720,,"26,426 x DRG weight",37720,Other,base rate x DRG weight,55396,,"38,809 x DRG weight",55396,Other,base rate x DRG weight,14635,,"6,363 x patient days",14635,Per diem,,77775,70,,77775,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,35766,,"25,057 x DRG weight",35766,Other,base rate x DRG weight,32191,,"22,552 x DRG weight",32191,Other,base rate x DRG weight,35766,,"25,057 x DRG weight",35766,Other,base rate x DRG weight,30401,,"21,298 x DRG weight",30401,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,77775,
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES OF HIP AND FEMUR WITH CC/MCC,498,MS-DRG,,,,,,,,inpatient,,,433070.13,49865,,,49865,Other,150% of Medicare + 9.63% HCRA Surcharge,30323,,"3,609.90 x patient days",30323,Per diem,,65395,,"25,046 x DRG weight",65395,Other,base rate x DRG weight,58855,,"22,541 x DRG weight",58855,Other,base rate x DRG weight,82307,,"31,523 x DRG weight",82307,Other,base rate x DRG weight,74077,,"28,371 x DRG weight",74077,Other,base rate x DRG weight,69962,,"26,795 x DRG weight",69962,Other,base rate x DRG weight,33355.3,,"3,970.89 x patient days",33355.3,Per diem,,58651,,"22,463 x DRG weight",58651,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,68998,,"26,426 x DRG weight",68998,Other,base rate x DRG weight,101330,,"38,809 x DRG weight",101330,Other,base rate x DRG weight,101330,,"38,809 x DRG weight",101330,Other,base rate x DRG weight,68998,,"26,426 x DRG weight",68998,Other,base rate x DRG weight,101330,,"38,809 x DRG weight",101330,Other,base rate x DRG weight,53449,,"6,363 x patient days",53449,Per diem,,303149,70,,303149,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,65424,,"25,057 x DRG weight",65424,Other,base rate x DRG weight,58883,,"22,552 x DRG weight",58883,Other,base rate x DRG weight,65424,,"25,057 x DRG weight",65424,Other,base rate x DRG weight,55609,,"21,298 x DRG weight",55609,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,303149,
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES OF HIP AND FEMUR WITHOUT CC/MCC,499,MS-DRG,,,,,,,,inpatient,,,175437.85,15435,,,15435,Other,150% of Medicare + 9.63% HCRA Surcharge,9386,,"3,609.90 x patient days",9386,Per diem,,32304,,"25,046 x DRG weight",32304,Other,base rate x DRG weight,29073,,"22,541 x DRG weight",29073,Other,base rate x DRG weight,40658,,"31,523 x DRG weight",40658,Other,base rate x DRG weight,36593,,"28,371 x DRG weight",36593,Other,base rate x DRG weight,34560,,"26,795 x DRG weight",34560,Other,base rate x DRG weight,10324.6,,"3,970.89 x patient days",10324.6,Per diem,,28973,,"22,463 x DRG weight",28973,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,34084,,"26,426 x DRG weight",34084,Other,base rate x DRG weight,50056,,"38,809 x DRG weight",50056,Other,base rate x DRG weight,50056,,"38,809 x DRG weight",50056,Other,base rate x DRG weight,34084,,"26,426 x DRG weight",34084,Other,base rate x DRG weight,50056,,"38,809 x DRG weight",50056,Other,base rate x DRG weight,16544,,"6,363 x patient days",16544,Per diem,,122806,70,,122806,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,32319,,"25,057 x DRG weight",32319,Other,base rate x DRG weight,29088,,"22,552 x DRG weight",29088,Other,base rate x DRG weight,32319,,"25,057 x DRG weight",32319,Other,base rate x DRG weight,27470,,"21,298 x DRG weight",27470,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,122806,
SOFT TISSUE PROCEDURES WITH MCC,500,MS-DRG,,,,,,,,inpatient,,,262912.23,62925,,,62925,Other,150% of Medicare + 9.63% HCRA Surcharge,38265,,"3,609.90 x patient days",38265,Per diem,,81219,,"25,046 x DRG weight",81219,Other,base rate x DRG weight,73096,,"22,541 x DRG weight",73096,Other,base rate x DRG weight,102223,,"31,523 x DRG weight",102223,Other,base rate x DRG weight,92001,,"28,371 x DRG weight",92001,Other,base rate x DRG weight,86891,,"26,795 x DRG weight",86891,Other,base rate x DRG weight,42091.5,,"3,970.89 x patient days",42091.5,Per diem,,72843,,"22,463 x DRG weight",72843,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,85694,,"26,426 x DRG weight",85694,Other,base rate x DRG weight,125850,,"38,809 x DRG weight",125850,Other,base rate x DRG weight,125850,,"38,809 x DRG weight",125850,Other,base rate x DRG weight,85694,,"26,426 x DRG weight",85694,Other,base rate x DRG weight,125850,,"38,809 x DRG weight",125850,Other,base rate x DRG weight,67448,,"6,363 x patient days",67448,Per diem,,184039,70,,184039,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,81255,,"25,057 x DRG weight",81255,Other,base rate x DRG weight,73132,,"22,552 x DRG weight",73132,Other,base rate x DRG weight,81255,,"25,057 x DRG weight",81255,Other,base rate x DRG weight,69065,,"21,298 x DRG weight",69065,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,184039,
SOFT TISSUE PROCEDURES WITH CC,501,MS-DRG,,,,,,,,inpatient,,,275120.97,31462,,,31462,Other,150% of Medicare + 9.63% HCRA Surcharge,19132,,"3,609.90 x patient days",19132,Per diem,,43472,,"25,046 x DRG weight",43472,Other,base rate x DRG weight,39124,,"22,541 x DRG weight",39124,Other,base rate x DRG weight,54714,,"31,523 x DRG weight",54714,Other,base rate x DRG weight,49244,,"28,371 x DRG weight",49244,Other,base rate x DRG weight,46508,,"26,795 x DRG weight",46508,Other,base rate x DRG weight,21045.2,,"3,970.89 x patient days",21045.2,Per diem,,38989,,"22,463 x DRG weight",38989,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,45868,,"26,426 x DRG weight",45868,Other,base rate x DRG weight,67361,,"38,809 x DRG weight",67361,Other,base rate x DRG weight,67361,,"38,809 x DRG weight",67361,Other,base rate x DRG weight,45868,,"26,426 x DRG weight",45868,Other,base rate x DRG weight,67361,,"38,809 x DRG weight",67361,Other,base rate x DRG weight,33724,,"6,363 x patient days",33724,Per diem,,192585,70,,192585,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,43491,,"25,057 x DRG weight",43491,Other,base rate x DRG weight,39144,,"22,552 x DRG weight",39144,Other,base rate x DRG weight,43491,,"25,057 x DRG weight",43491,Other,base rate x DRG weight,36967,,"21,298 x DRG weight",36967,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,192585,
SOFT TISSUE PROCEDURES WITHOUT CC/MCC,502,MS-DRG,,,,,,,,inpatient,,,174345.25,17216,,,17216,Other,150% of Medicare + 9.63% HCRA Surcharge,10469,,"3,609.90 x patient days",10469,Per diem,,34631,,"25,046 x DRG weight",34631,Other,base rate x DRG weight,31167,,"22,541 x DRG weight",31167,Other,base rate x DRG weight,43587,,"31,523 x DRG weight",43587,Other,base rate x DRG weight,39229,,"28,371 x DRG weight",39229,Other,base rate x DRG weight,37049,,"26,795 x DRG weight",37049,Other,base rate x DRG weight,11515.9,,"3,970.89 x patient days",11515.9,Per diem,,31060,,"22,463 x DRG weight",31060,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,36539,,"26,426 x DRG weight",36539,Other,base rate x DRG weight,53661,,"38,809 x DRG weight",53661,Other,base rate x DRG weight,53661,,"38,809 x DRG weight",53661,Other,base rate x DRG weight,36539,,"26,426 x DRG weight",36539,Other,base rate x DRG weight,53661,,"38,809 x DRG weight",53661,Other,base rate x DRG weight,18453,,"6,363 x patient days",18453,Per diem,,122042,70,,122042,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,34646,,"25,057 x DRG weight",34646,Other,base rate x DRG weight,31183,,"22,552 x DRG weight",31183,Other,base rate x DRG weight,34646,,"25,057 x DRG weight",34646,Other,base rate x DRG weight,29449,,"21,298 x DRG weight",29449,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,122042,
FOOT PROCEDURES WITH MCC,503,MS-DRG,,,,,,,,inpatient,,,335847.49,54020,,,54020,Other,150% of Medicare + 9.63% HCRA Surcharge,32850,,"3,609.90 x patient days",32850,Per diem,,67171,,"25,046 x DRG weight",67171,Other,base rate x DRG weight,60453,,"22,541 x DRG weight",60453,Other,base rate x DRG weight,84542,,"31,523 x DRG weight",84542,Other,base rate x DRG weight,76088,,"28,371 x DRG weight",76088,Other,base rate x DRG weight,71862,,"26,795 x DRG weight",71862,Other,base rate x DRG weight,36135,,"3,970.89 x patient days",36135,Per diem,,60244,,"22,463 x DRG weight",60244,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,70872,,"26,426 x DRG weight",70872,Other,base rate x DRG weight,104082,,"38,809 x DRG weight",104082,Other,base rate x DRG weight,104082,,"38,809 x DRG weight",104082,Other,base rate x DRG weight,70872,,"26,426 x DRG weight",70872,Other,base rate x DRG weight,104082,,"38,809 x DRG weight",104082,Other,base rate x DRG weight,57903,,"6,363 x patient days",57903,Per diem,,235093,70,,235093,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,67200,,"25,057 x DRG weight",67200,Other,base rate x DRG weight,60482,,"22,552 x DRG weight",60482,Other,base rate x DRG weight,67200,,"25,057 x DRG weight",67200,Other,base rate x DRG weight,57119,,"21,298 x DRG weight",57119,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,235093,
FOOT PROCEDURES WITH CC,504,MS-DRG,,,,,,,,inpatient,,,217277.38,33243,,,33243,Other,150% of Medicare + 9.63% HCRA Surcharge,20215,,"3,609.90 x patient days",20215,Per diem,,43257,,"25,046 x DRG weight",43257,Other,base rate x DRG weight,38931,,"22,541 x DRG weight",38931,Other,base rate x DRG weight,54443,,"31,523 x DRG weight",54443,Other,base rate x DRG weight,49000,,"28,371 x DRG weight",49000,Other,base rate x DRG weight,46278,,"26,795 x DRG weight",46278,Other,base rate x DRG weight,22236.5,,"3,970.89 x patient days",22236.5,Per diem,,38796,,"22,463 x DRG weight",38796,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,45640,,"26,426 x DRG weight",45640,Other,base rate x DRG weight,67027,,"38,809 x DRG weight",67027,Other,base rate x DRG weight,67027,,"38,809 x DRG weight",67027,Other,base rate x DRG weight,45640,,"26,426 x DRG weight",45640,Other,base rate x DRG weight,67027,,"38,809 x DRG weight",67027,Other,base rate x DRG weight,35633,,"6,363 x patient days",35633,Per diem,,152094,70,,152094,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,43276,,"25,057 x DRG weight",43276,Other,base rate x DRG weight,38950,,"22,552 x DRG weight",38950,Other,base rate x DRG weight,43276,,"25,057 x DRG weight",43276,Other,base rate x DRG weight,36784,,"21,298 x DRG weight",36784,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,152094,
FOOT PROCEDURES WITHOUT CC/MCC,505,MS-DRG,,,,,,,,inpatient,,,226961.08,18997,,,18997,Other,150% of Medicare + 9.63% HCRA Surcharge,11552,,"3,609.90 x patient days",11552,Per diem,,42721,,"25,046 x DRG weight",42721,Other,base rate x DRG weight,38448,,"22,541 x DRG weight",38448,Other,base rate x DRG weight,53769,,"31,523 x DRG weight",53769,Other,base rate x DRG weight,48392,,"28,371 x DRG weight",48392,Other,base rate x DRG weight,45704,,"26,795 x DRG weight",45704,Other,base rate x DRG weight,12707.2,,"3,970.89 x patient days",12707.2,Per diem,,38315,,"22,463 x DRG weight",38315,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,45075,,"26,426 x DRG weight",45075,Other,base rate x DRG weight,66197,,"38,809 x DRG weight",66197,Other,base rate x DRG weight,66197,,"38,809 x DRG weight",66197,Other,base rate x DRG weight,45075,,"26,426 x DRG weight",45075,Other,base rate x DRG weight,66197,,"38,809 x DRG weight",66197,Other,base rate x DRG weight,20362,,"6,363 x patient days",20362,Per diem,,158873,70,,158873,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,42740,,"25,057 x DRG weight",42740,Other,base rate x DRG weight,38467,,"22,552 x DRG weight",38467,Other,base rate x DRG weight,42740,,"25,057 x DRG weight",42740,Other,base rate x DRG weight,36328,,"21,298 x DRG weight",36328,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,158873,
MAJOR THUMB OR JOINT PROCEDURES,506,MS-DRG,,,,,,,,inpatient,,,342220.88,30274,,,30274,Other,150% of Medicare + 9.63% HCRA Surcharge,18410,,"3,609.90 x patient days",18410,Per diem,,36632,,"25,046 x DRG weight",36632,Other,base rate x DRG weight,32968,,"22,541 x DRG weight",32968,Other,base rate x DRG weight,46106,,"31,523 x DRG weight",46106,Other,base rate x DRG weight,41495,,"28,371 x DRG weight",41495,Other,base rate x DRG weight,39190,,"26,795 x DRG weight",39190,Other,base rate x DRG weight,20251,,"3,970.89 x patient days",20251,Per diem,,32854,,"22,463 x DRG weight",32854,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,38651,,"26,426 x DRG weight",38651,Other,base rate x DRG weight,56762,,"38,809 x DRG weight",56762,Other,base rate x DRG weight,56762,,"38,809 x DRG weight",56762,Other,base rate x DRG weight,38651,,"26,426 x DRG weight",38651,Other,base rate x DRG weight,56762,,"38,809 x DRG weight",56762,Other,base rate x DRG weight,32451,,"6,363 x patient days",32451,Per diem,,239555,70,,239555,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,36648,,"25,057 x DRG weight",36648,Other,base rate x DRG weight,32985,,"22,552 x DRG weight",32985,Other,base rate x DRG weight,36648,,"25,057 x DRG weight",36648,Other,base rate x DRG weight,31150,,"21,298 x DRG weight",31150,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,239555,
MAJOR SHOULDER OR ELBOW JOINT PROCEDURES WITH CC/MCC,507,MS-DRG,,,,,,,,inpatient,,,398980.37,42147,,,42147,Other,150% of Medicare + 9.63% HCRA Surcharge,25630,,"3,609.90 x patient days",25630,Per diem,,53391,,"25,046 x DRG weight",53391,Other,base rate x DRG weight,48051,,"22,541 x DRG weight",48051,Other,base rate x DRG weight,67198,,"31,523 x DRG weight",67198,Other,base rate x DRG weight,60478,,"28,371 x DRG weight",60478,Other,base rate x DRG weight,57119,,"26,795 x DRG weight",57119,Other,base rate x DRG weight,28193,,"3,970.89 x patient days",28193,Per diem,,47884,,"22,463 x DRG weight",47884,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,56332,,"26,426 x DRG weight",56332,Other,base rate x DRG weight,82729,,"38,809 x DRG weight",82729,Other,base rate x DRG weight,82729,,"38,809 x DRG weight",82729,Other,base rate x DRG weight,56332,,"26,426 x DRG weight",56332,Other,base rate x DRG weight,82729,,"38,809 x DRG weight",82729,Other,base rate x DRG weight,45177,,"6,363 x patient days",45177,Per diem,,279286,70,,279286,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,53414,,"25,057 x DRG weight",53414,Other,base rate x DRG weight,48074,,"22,552 x DRG weight",48074,Other,base rate x DRG weight,53414,,"25,057 x DRG weight",53414,Other,base rate x DRG weight,45401,,"21,298 x DRG weight",45401,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,279286,
MAJOR SHOULDER OR ELBOW JOINT PROCEDURES WITHOUT CC/MCC,508,MS-DRG,,,,,,,,inpatient,,,173438.38,17216,,,17216,Other,150% of Medicare + 9.63% HCRA Surcharge,10469,,"3,609.90 x patient days",10469,Per diem,,35916,,"25,046 x DRG weight",35916,Other,base rate x DRG weight,32324,,"22,541 x DRG weight",32324,Other,base rate x DRG weight,45204,,"31,523 x DRG weight",45204,Other,base rate x DRG weight,40684,,"28,371 x DRG weight",40684,Other,base rate x DRG weight,38424,,"26,795 x DRG weight",38424,Other,base rate x DRG weight,11515.9,,"3,970.89 x patient days",11515.9,Per diem,,32212,,"22,463 x DRG weight",32212,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,37895,,"26,426 x DRG weight",37895,Other,base rate x DRG weight,55652,,"38,809 x DRG weight",55652,Other,base rate x DRG weight,55652,,"38,809 x DRG weight",55652,Other,base rate x DRG weight,37895,,"26,426 x DRG weight",37895,Other,base rate x DRG weight,55652,,"38,809 x DRG weight",55652,Other,base rate x DRG weight,18453,,"6,363 x patient days",18453,Per diem,,121407,70,,121407,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,35932,,"25,057 x DRG weight",35932,Other,base rate x DRG weight,32340,,"22,552 x DRG weight",32340,Other,base rate x DRG weight,35932,,"25,057 x DRG weight",35932,Other,base rate x DRG weight,30541,,"21,298 x DRG weight",30541,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,121407,
ARTHROSCOPY,509,MS-DRG,,,,,,,,inpatient,,,173438.38,24933,,,24933,Other,150% of Medicare + 9.63% HCRA Surcharge,15162,,"3,609.90 x patient days",15162,Per diem,,34215,,"25,046 x DRG weight",34215,Other,base rate x DRG weight,30793,,"22,541 x DRG weight",30793,Other,base rate x DRG weight,43064,,"31,523 x DRG weight",43064,Other,base rate x DRG weight,38758,,"28,371 x DRG weight",38758,Other,base rate x DRG weight,36605,,"26,795 x DRG weight",36605,Other,base rate x DRG weight,16678.2,,"3,970.89 x patient days",16678.2,Per diem,,30687,,"22,463 x DRG weight",30687,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,36101,,"26,426 x DRG weight",36101,Other,base rate x DRG weight,53017,,"38,809 x DRG weight",53017,Other,base rate x DRG weight,53017,,"38,809 x DRG weight",53017,Other,base rate x DRG weight,36101,,"26,426 x DRG weight",36101,Other,base rate x DRG weight,53017,,"38,809 x DRG weight",53017,Other,base rate x DRG weight,26725,,"6,363 x patient days",26725,Per diem,,121407,70,,121407,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,34230,,"25,057 x DRG weight",34230,Other,base rate x DRG weight,30808,,"22,552 x DRG weight",30808,Other,base rate x DRG weight,34230,,"25,057 x DRG weight",34230,Other,base rate x DRG weight,29095,,"21,298 x DRG weight",29095,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,121407,
"SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITH MCC",510,MS-DRG,,,,,,,,inpatient,,,318283.56,37992,,,37992,Other,150% of Medicare + 9.63% HCRA Surcharge,23103,,"3,609.90 x patient days",23103,Per diem,,68140,,"25,046 x DRG weight",68140,Other,base rate x DRG weight,61325,,"22,541 x DRG weight",61325,Other,base rate x DRG weight,85761,,"31,523 x DRG weight",85761,Other,base rate x DRG weight,77186,,"28,371 x DRG weight",77186,Other,base rate x DRG weight,72898,,"26,795 x DRG weight",72898,Other,base rate x DRG weight,25413.3,,"3,970.89 x patient days",25413.3,Per diem,,61113,,"22,463 x DRG weight",61113,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,71895,,"26,426 x DRG weight",71895,Other,base rate x DRG weight,105584,,"38,809 x DRG weight",105584,Other,base rate x DRG weight,105584,,"38,809 x DRG weight",105584,Other,base rate x DRG weight,71895,,"26,426 x DRG weight",71895,Other,base rate x DRG weight,105584,,"38,809 x DRG weight",105584,Other,base rate x DRG weight,40723,,"6,363 x patient days",40723,Per diem,,222798,70,,222798,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,68170,,"25,057 x DRG weight",68170,Other,base rate x DRG weight,61355,,"22,552 x DRG weight",61355,Other,base rate x DRG weight,68170,,"25,057 x DRG weight",68170,Other,base rate x DRG weight,57943,,"21,298 x DRG weight",57943,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,222798,
"SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITH CC",511,MS-DRG,,,,,,,,inpatient,,,247003.25,24933,,,24933,Other,150% of Medicare + 9.63% HCRA Surcharge,15162,,"3,609.90 x patient days",15162,Per diem,,49937,,"25,046 x DRG weight",49937,Other,base rate x DRG weight,44942,,"22,541 x DRG weight",44942,Other,base rate x DRG weight,62851,,"31,523 x DRG weight",62851,Other,base rate x DRG weight,56566,,"28,371 x DRG weight",56566,Other,base rate x DRG weight,53424,,"26,795 x DRG weight",53424,Other,base rate x DRG weight,16678.2,,"3,970.89 x patient days",16678.2,Per diem,,44787,,"22,463 x DRG weight",44787,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,52688,,"26,426 x DRG weight",52688,Other,base rate x DRG weight,77377,,"38,809 x DRG weight",77377,Other,base rate x DRG weight,77377,,"38,809 x DRG weight",77377,Other,base rate x DRG weight,52688,,"26,426 x DRG weight",52688,Other,base rate x DRG weight,77377,,"38,809 x DRG weight",77377,Other,base rate x DRG weight,26725,,"6,363 x patient days",26725,Per diem,,172902,70,,172902,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,49959,,"25,057 x DRG weight",49959,Other,base rate x DRG weight,44964,,"22,552 x DRG weight",44964,Other,base rate x DRG weight,49959,,"25,057 x DRG weight",49959,Other,base rate x DRG weight,42464,,"21,298 x DRG weight",42464,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,172902,
"SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITHOUT CC/MCC",512,MS-DRG,,,,,,,,inpatient,,,160689.07,15435,,,15435,Other,150% of Medicare + 9.63% HCRA Surcharge,9386,,"3,609.90 x patient days",9386,Per diem,,40419,,"25,046 x DRG weight",40419,Other,base rate x DRG weight,36377,,"22,541 x DRG weight",36377,Other,base rate x DRG weight,50872,,"31,523 x DRG weight",50872,Other,base rate x DRG weight,45785,,"28,371 x DRG weight",45785,Other,base rate x DRG weight,43242,,"26,795 x DRG weight",43242,Other,base rate x DRG weight,10324.6,,"3,970.89 x patient days",10324.6,Per diem,,36251,,"22,463 x DRG weight",36251,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,42646,,"26,426 x DRG weight",42646,Other,base rate x DRG weight,62630,,"38,809 x DRG weight",62630,Other,base rate x DRG weight,62630,,"38,809 x DRG weight",62630,Other,base rate x DRG weight,42646,,"26,426 x DRG weight",42646,Other,base rate x DRG weight,62630,,"38,809 x DRG weight",62630,Other,base rate x DRG weight,16544,,"6,363 x patient days",16544,Per diem,,112482,70,,112482,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,40437,,"25,057 x DRG weight",40437,Other,base rate x DRG weight,36394,,"22,552 x DRG weight",36394,Other,base rate x DRG weight,40437,,"25,057 x DRG weight",40437,Other,base rate x DRG weight,34371,,"21,298 x DRG weight",34371,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,112482,
"HAND OR WRIST PROCEDURES, EXCEPT MAJOR THUMB OR JOINT PROCEDURES WITH CC/MCC",513,MS-DRG,,,,,,,,inpatient,,,192311.1,32649,,,32649,Other,150% of Medicare + 9.63% HCRA Surcharge,19854,,"3,609.90 x patient days",19854,Per diem,,40600,,"25,046 x DRG weight",40600,Other,base rate x DRG weight,36539,,"22,541 x DRG weight",36539,Other,base rate x DRG weight,51099,,"31,523 x DRG weight",51099,Other,base rate x DRG weight,45989,,"28,371 x DRG weight",45989,Other,base rate x DRG weight,43435,,"26,795 x DRG weight",43435,Other,base rate x DRG weight,21839.4,,"3,970.89 x patient days",21839.4,Per diem,,36413,,"22,463 x DRG weight",36413,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,42837,,"26,426 x DRG weight",42837,Other,base rate x DRG weight,62909,,"38,809 x DRG weight",62909,Other,base rate x DRG weight,62909,,"38,809 x DRG weight",62909,Other,base rate x DRG weight,42837,,"26,426 x DRG weight",42837,Other,base rate x DRG weight,62909,,"38,809 x DRG weight",62909,Other,base rate x DRG weight,34997,,"6,363 x patient days",34997,Per diem,,134618,70,,134618,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,40617,,"25,057 x DRG weight",40617,Other,base rate x DRG weight,36557,,"22,552 x DRG weight",36557,Other,base rate x DRG weight,40617,,"25,057 x DRG weight",40617,Other,base rate x DRG weight,34524,,"21,298 x DRG weight",34524,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,134618,
"HAND OR WRIST PROCEDURES, EXCEPT MAJOR THUMB OR JOINT PROCEDURES WITHOUT CC/MCC",514,MS-DRG,,,,,,,,inpatient,,,129155.97,16622,,,16622,Other,150% of Medicare + 9.63% HCRA Surcharge,10108,,"3,609.90 x patient days",10108,Per diem,,26085,,"25,046 x DRG weight",26085,Other,base rate x DRG weight,23476,,"22,541 x DRG weight",23476,Other,base rate x DRG weight,32831,,"31,523 x DRG weight",32831,Other,base rate x DRG weight,29548,,"28,371 x DRG weight",29548,Other,base rate x DRG weight,27907,,"26,795 x DRG weight",27907,Other,base rate x DRG weight,11118.8,,"3,970.89 x patient days",11118.8,Per diem,,23395,,"22,463 x DRG weight",23395,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,27523,,"26,426 x DRG weight",27523,Other,base rate x DRG weight,40420,,"38,809 x DRG weight",40420,Other,base rate x DRG weight,40420,,"38,809 x DRG weight",40420,Other,base rate x DRG weight,27523,,"26,426 x DRG weight",27523,Other,base rate x DRG weight,40420,,"38,809 x DRG weight",40420,Other,base rate x DRG weight,17816,,"6,363 x patient days",17816,Per diem,,90409,70,,90409,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,26097,,"25,057 x DRG weight",26097,Other,base rate x DRG weight,23488,,"22,552 x DRG weight",23488,Other,base rate x DRG weight,26097,,"25,057 x DRG weight",26097,Other,base rate x DRG weight,22182,,"21,298 x DRG weight",22182,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,90409,
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH MCC,515,MS-DRG,,,,,,,,inpatient,,,390024.67,53427,,,53427,Other,150% of Medicare + 9.63% HCRA Surcharge,32489,,"3,609.90 x patient days",32489,Per diem,,79183,,"25,046 x DRG weight",79183,Other,base rate x DRG weight,71263,,"22,541 x DRG weight",71263,Other,base rate x DRG weight,99660,,"31,523 x DRG weight",99660,Other,base rate x DRG weight,89695,,"28,371 x DRG weight",89695,Other,base rate x DRG weight,84712,,"26,795 x DRG weight",84712,Other,base rate x DRG weight,35737.9,,"3,970.89 x patient days",35737.9,Per diem,,71017,,"22,463 x DRG weight",71017,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,83546,,"26,426 x DRG weight",83546,Other,base rate x DRG weight,122695,,"38,809 x DRG weight",122695,Other,base rate x DRG weight,122695,,"38,809 x DRG weight",122695,Other,base rate x DRG weight,83546,,"26,426 x DRG weight",83546,Other,base rate x DRG weight,122695,,"38,809 x DRG weight",122695,Other,base rate x DRG weight,57267,,"6,363 x patient days",57267,Per diem,,273017,70,,273017,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,79218,,"25,057 x DRG weight",79218,Other,base rate x DRG weight,71298,,"22,552 x DRG weight",71298,Other,base rate x DRG weight,79218,,"25,057 x DRG weight",79218,Other,base rate x DRG weight,67334,,"21,298 x DRG weight",67334,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,273017,
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH CC,516,MS-DRG,,,,,,,,inpatient,,,265776.1,29682,,,29682,Other,150% of Medicare + 9.63% HCRA Surcharge,18050,,"3,609.90 x patient days",18050,Per diem,,51114,,"25,046 x DRG weight",51114,Other,base rate x DRG weight,46002,,"22,541 x DRG weight",46002,Other,base rate x DRG weight,64332,,"31,523 x DRG weight",64332,Other,base rate x DRG weight,57900,,"28,371 x DRG weight",57900,Other,base rate x DRG weight,54683,,"26,795 x DRG weight",54683,Other,base rate x DRG weight,19855,,"3,970.89 x patient days",19855,Per diem,,45842,,"22,463 x DRG weight",45842,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,53930,,"26,426 x DRG weight",53930,Other,base rate x DRG weight,79201,,"38,809 x DRG weight",79201,Other,base rate x DRG weight,79201,,"38,809 x DRG weight",79201,Other,base rate x DRG weight,53930,,"26,426 x DRG weight",53930,Other,base rate x DRG weight,79201,,"38,809 x DRG weight",79201,Other,base rate x DRG weight,31815,,"6,363 x patient days",31815,Per diem,,186043,70,,186043,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,51136,,"25,057 x DRG weight",51136,Other,base rate x DRG weight,46024,,"22,552 x DRG weight",46024,Other,base rate x DRG weight,51136,,"25,057 x DRG weight",51136,Other,base rate x DRG weight,43465,,"21,298 x DRG weight",43465,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,186043,
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITHOUT CC/MCC,517,MS-DRG,,,,,,,,inpatient,,,202936.2,17216,,,17216,Other,150% of Medicare + 9.63% HCRA Surcharge,10469,,"3,609.90 x patient days",10469,Per diem,,37429,,"25,046 x DRG weight",37429,Other,base rate x DRG weight,33685,,"22,541 x DRG weight",33685,Other,base rate x DRG weight,47108,,"31,523 x DRG weight",47108,Other,base rate x DRG weight,42398,,"28,371 x DRG weight",42398,Other,base rate x DRG weight,40042,,"26,795 x DRG weight",40042,Other,base rate x DRG weight,11515.9,,"3,970.89 x patient days",11515.9,Per diem,,33569,,"22,463 x DRG weight",33569,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,39491,,"26,426 x DRG weight",39491,Other,base rate x DRG weight,57996,,"38,809 x DRG weight",57996,Other,base rate x DRG weight,57996,,"38,809 x DRG weight",57996,Other,base rate x DRG weight,39491,,"26,426 x DRG weight",39491,Other,base rate x DRG weight,57996,,"38,809 x DRG weight",57996,Other,base rate x DRG weight,18453,,"6,363 x patient days",18453,Per diem,,142055,70,,142055,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,37445,,"25,057 x DRG weight",37445,Other,base rate x DRG weight,33702,,"22,552 x DRG weight",33702,Other,base rate x DRG weight,37445,,"25,057 x DRG weight",37445,Other,base rate x DRG weight,31828,,"21,298 x DRG weight",31828,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,142055,
BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITH MCC OR DISC DEVICE OR NEUROSTIMULATOR,518,MS-DRG,,,,,,,,inpatient,,,405596.54,47490,,,47490,Other,150% of Medicare + 9.63% HCRA Surcharge,28879,,"3,609.90 x patient days",28879,Per diem,,91463,,"25,046 x DRG weight",91463,Other,base rate x DRG weight,82315,,"22,541 x DRG weight",82315,Other,base rate x DRG weight,115116,,"31,523 x DRG weight",115116,Other,base rate x DRG weight,103605,,"28,371 x DRG weight",103605,Other,base rate x DRG weight,97850,,"26,795 x DRG weight",97850,Other,base rate x DRG weight,31766.9,,"3,970.89 x patient days",31766.9,Per diem,,82030,,"22,463 x DRG weight",82030,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,96502,,"26,426 x DRG weight",96502,Other,base rate x DRG weight,141723,,"38,809 x DRG weight",141723,Other,base rate x DRG weight,141723,,"38,809 x DRG weight",141723,Other,base rate x DRG weight,96502,,"26,426 x DRG weight",96502,Other,base rate x DRG weight,141723,,"38,809 x DRG weight",141723,Other,base rate x DRG weight,50904,,"6,363 x patient days",50904,Per diem,,283918,70,,283918,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,91503,,"25,057 x DRG weight",91503,Other,base rate x DRG weight,82355,,"22,552 x DRG weight",82355,Other,base rate x DRG weight,91503,,"25,057 x DRG weight",91503,Other,base rate x DRG weight,77776,,"21,298 x DRG weight",77776,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,283918,
BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITH CC,519,MS-DRG,,,,,,,,inpatient,,,306057.09,24933,,,24933,Other,150% of Medicare + 9.63% HCRA Surcharge,15162,,"3,609.90 x patient days",15162,Per diem,,49306,,"25,046 x DRG weight",49306,Other,base rate x DRG weight,44374,,"22,541 x DRG weight",44374,Other,base rate x DRG weight,62056,,"31,523 x DRG weight",62056,Other,base rate x DRG weight,55851,,"28,371 x DRG weight",55851,Other,base rate x DRG weight,52749,,"26,795 x DRG weight",52749,Other,base rate x DRG weight,16678.2,,"3,970.89 x patient days",16678.2,Per diem,,44221,,"22,463 x DRG weight",44221,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,52022,,"26,426 x DRG weight",52022,Other,base rate x DRG weight,76399,,"38,809 x DRG weight",76399,Other,base rate x DRG weight,76399,,"38,809 x DRG weight",76399,Other,base rate x DRG weight,52022,,"26,426 x DRG weight",52022,Other,base rate x DRG weight,76399,,"38,809 x DRG weight",76399,Other,base rate x DRG weight,26725,,"6,363 x patient days",26725,Per diem,,214240,70,,214240,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,49327,,"25,057 x DRG weight",49327,Other,base rate x DRG weight,44396,,"22,552 x DRG weight",44396,Other,base rate x DRG weight,49327,,"25,057 x DRG weight",49327,Other,base rate x DRG weight,41927,,"21,298 x DRG weight",41927,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,214240,
BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITHOUT CC/MCC,520,MS-DRG,,,,,,,,inpatient,,,189873.17,14841,,,14841,Other,150% of Medicare + 9.63% HCRA Surcharge,9025,,"3,609.90 x patient days",9025,Per diem,,35853,,"25,046 x DRG weight",35853,Other,base rate x DRG weight,32267,,"22,541 x DRG weight",32267,Other,base rate x DRG weight,45125,,"31,523 x DRG weight",45125,Other,base rate x DRG weight,40613,,"28,371 x DRG weight",40613,Other,base rate x DRG weight,38357,,"26,795 x DRG weight",38357,Other,base rate x DRG weight,9927.5,,"3,970.89 x patient days",9927.5,Per diem,,32156,,"22,463 x DRG weight",32156,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,37829,,"26,426 x DRG weight",37829,Other,base rate x DRG weight,55555,,"38,809 x DRG weight",55555,Other,base rate x DRG weight,55555,,"38,809 x DRG weight",55555,Other,base rate x DRG weight,37829,,"26,426 x DRG weight",37829,Other,base rate x DRG weight,55555,,"38,809 x DRG weight",55555,Other,base rate x DRG weight,15908,,"6,363 x patient days",15908,Per diem,,132911,70,,132911,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,35869,,"25,057 x DRG weight",35869,Other,base rate x DRG weight,32283,,"22,552 x DRG weight",32283,Other,base rate x DRG weight,35869,,"25,057 x DRG weight",35869,Other,base rate x DRG weight,30488,,"21,298 x DRG weight",30488,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,132911,
HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITH MCC,521,MS-DRG,,,,,,,,inpatient,,,352051.27,45709,,,45709,Other,150% of Medicare + 9.63% HCRA Surcharge,27796,,"3,609.90 x patient days",27796,Per diem,,74993,,"25,046 x DRG weight",74993,Other,base rate x DRG weight,67492,,"22,541 x DRG weight",67492,Other,base rate x DRG weight,94386,,"31,523 x DRG weight",94386,Other,base rate x DRG weight,84948,,"28,371 x DRG weight",84948,Other,base rate x DRG weight,80230,,"26,795 x DRG weight",80230,Other,base rate x DRG weight,30575.6,,"3,970.89 x patient days",30575.6,Per diem,,67259,,"22,463 x DRG weight",67259,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,79125,,"26,426 x DRG weight",79125,Other,base rate x DRG weight,116202,,"38,809 x DRG weight",116202,Other,base rate x DRG weight,116202,,"38,809 x DRG weight",116202,Other,base rate x DRG weight,79125,,"26,426 x DRG weight",79125,Other,base rate x DRG weight,116202,,"38,809 x DRG weight",116202,Other,base rate x DRG weight,48995,,"6,363 x patient days",48995,Per diem,,246436,70,,246436,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,75026,,"25,057 x DRG weight",75026,Other,base rate x DRG weight,67525,,"22,552 x DRG weight",67525,Other,base rate x DRG weight,75026,,"25,057 x DRG weight",75026,Other,base rate x DRG weight,63770,,"21,298 x DRG weight",63770,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,246436,
HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITHOUT MCC,522,MS-DRG,,,,,,,,inpatient,,,229904.83,27308,,,27308,Other,150% of Medicare + 9.63% HCRA Surcharge,16606,,"3,609.90 x patient days",16606,Per diem,,52902,,"25,046 x DRG weight",52902,Other,base rate x DRG weight,47611,,"22,541 x DRG weight",47611,Other,base rate x DRG weight,66583,,"31,523 x DRG weight",66583,Other,base rate x DRG weight,59925,,"28,371 x DRG weight",59925,Other,base rate x DRG weight,56596,,"26,795 x DRG weight",56596,Other,base rate x DRG weight,18266.6,,"3,970.89 x patient days",18266.6,Per diem,,47446,,"22,463 x DRG weight",47446,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,55817,,"26,426 x DRG weight",55817,Other,base rate x DRG weight,81972,,"38,809 x DRG weight",81972,Other,base rate x DRG weight,81972,,"38,809 x DRG weight",81972,Other,base rate x DRG weight,55817,,"26,426 x DRG weight",55817,Other,base rate x DRG weight,81972,,"38,809 x DRG weight",81972,Other,base rate x DRG weight,29270,,"6,363 x patient days",29270,Per diem,,160933,70,,160933,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,52925,,"25,057 x DRG weight",52925,Other,base rate x DRG weight,47634,,"22,552 x DRG weight",47634,Other,base rate x DRG weight,52925,,"25,057 x DRG weight",52925,Other,base rate x DRG weight,44986,,"21,298 x DRG weight",44986,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,160933,
FRACTURES OF FEMUR WITH MCC,533,MS-DRG,,,,,,,,inpatient,,,247711.73,38585,,,38585,Other,150% of Medicare + 9.63% HCRA Surcharge,23464,,"3,609.90 x patient days",23464,Per diem,,40860,,"25,046 x DRG weight",40860,Other,base rate x DRG weight,36773,,"22,541 x DRG weight",36773,Other,base rate x DRG weight,51427,,"31,523 x DRG weight",51427,Other,base rate x DRG weight,46284,,"28,371 x DRG weight",46284,Other,base rate x DRG weight,43713,,"26,795 x DRG weight",43713,Other,base rate x DRG weight,25810.4,,"3,970.89 x patient days",25810.4,Per diem,,36646,,"22,463 x DRG weight",36646,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,43111,,"26,426 x DRG weight",43111,Other,base rate x DRG weight,63313,,"38,809 x DRG weight",63313,Other,base rate x DRG weight,63313,,"38,809 x DRG weight",63313,Other,base rate x DRG weight,43111,,"26,426 x DRG weight",43111,Other,base rate x DRG weight,63313,,"38,809 x DRG weight",63313,Other,base rate x DRG weight,41360,,"6,363 x patient days",41360,Per diem,,173398,70,,173398,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,40878,,"25,057 x DRG weight",40878,Other,base rate x DRG weight,36791,,"22,552 x DRG weight",36791,Other,base rate x DRG weight,40878,,"25,057 x DRG weight",40878,Other,base rate x DRG weight,34746,,"21,298 x DRG weight",34746,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,173398,
FRACTURES OF FEMUR WITHOUT MCC,534,MS-DRG,,,,,,,,inpatient,,,99141.01,21965,,,21965,Other,150% of Medicare + 9.63% HCRA Surcharge,13357,,"3,609.90 x patient days",13357,Per diem,,20287,,"25,046 x DRG weight",20287,Other,base rate x DRG weight,18258,,"22,541 x DRG weight",18258,Other,base rate x DRG weight,25534,,"31,523 x DRG weight",25534,Other,base rate x DRG weight,22981,,"28,371 x DRG weight",22981,Other,base rate x DRG weight,21704,,"26,795 x DRG weight",21704,Other,base rate x DRG weight,14692.7,,"3,970.89 x patient days",14692.7,Per diem,,18195,,"22,463 x DRG weight",18195,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,21405,,"26,426 x DRG weight",21405,Other,base rate x DRG weight,31435,,"38,809 x DRG weight",31435,Other,base rate x DRG weight,31435,,"38,809 x DRG weight",31435,Other,base rate x DRG weight,21405,,"26,426 x DRG weight",21405,Other,base rate x DRG weight,31435,,"38,809 x DRG weight",31435,Other,base rate x DRG weight,23543,,"6,363 x patient days",23543,Per diem,,69399,70,,69399,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,20296,,"25,057 x DRG weight",20296,Other,base rate x DRG weight,18267,,"22,552 x DRG weight",18267,Other,base rate x DRG weight,20296,,"25,057 x DRG weight",20296,Other,base rate x DRG weight,17251,,"21,298 x DRG weight",17251,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,69399,
FRACTURES OF HIP AND PELVIS WITH MCC,535,MS-DRG,,,,,,,,inpatient,,,210494.22,30868,,,30868,Other,150% of Medicare + 9.63% HCRA Surcharge,18771,,"3,609.90 x patient days",18771,Per diem,,32477,,"25,046 x DRG weight",32477,Other,base rate x DRG weight,29229,,"22,541 x DRG weight",29229,Other,base rate x DRG weight,40876,,"31,523 x DRG weight",40876,Other,base rate x DRG weight,36789,,"28,371 x DRG weight",36789,Other,base rate x DRG weight,34745,,"26,795 x DRG weight",34745,Other,base rate x DRG weight,20648.1,,"3,970.89 x patient days",20648.1,Per diem,,29128,,"22,463 x DRG weight",29128,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,34267,,"26,426 x DRG weight",34267,Other,base rate x DRG weight,50324,,"38,809 x DRG weight",50324,Other,base rate x DRG weight,50324,,"38,809 x DRG weight",50324,Other,base rate x DRG weight,34267,,"26,426 x DRG weight",34267,Other,base rate x DRG weight,50324,,"38,809 x DRG weight",50324,Other,base rate x DRG weight,33088,,"6,363 x patient days",33088,Per diem,,147346,70,,147346,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,32491,,"25,057 x DRG weight",32491,Other,base rate x DRG weight,29243,,"22,552 x DRG weight",29243,Other,base rate x DRG weight,32491,,"25,057 x DRG weight",32491,Other,base rate x DRG weight,27617,,"21,298 x DRG weight",27617,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,147346,
FRACTURES OF HIP AND PELVIS WITHOUT MCC,536,MS-DRG,,,,,,,,inpatient,,,125096.21,20184,,,20184,Other,150% of Medicare + 9.63% HCRA Surcharge,12274,,"3,609.90 x patient days",12274,Per diem,,19714,,"25,046 x DRG weight",19714,Other,base rate x DRG weight,17742,,"22,541 x DRG weight",17742,Other,base rate x DRG weight,24812,,"31,523 x DRG weight",24812,Other,base rate x DRG weight,22331,,"28,371 x DRG weight",22331,Other,base rate x DRG weight,21090,,"26,795 x DRG weight",21090,Other,base rate x DRG weight,13501.4,,"3,970.89 x patient days",13501.4,Per diem,,17681,,"22,463 x DRG weight",17681,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,20800,,"26,426 x DRG weight",20800,Other,base rate x DRG weight,30547,,"38,809 x DRG weight",30547,Other,base rate x DRG weight,30547,,"38,809 x DRG weight",30547,Other,base rate x DRG weight,20800,,"26,426 x DRG weight",20800,Other,base rate x DRG weight,30547,,"38,809 x DRG weight",30547,Other,base rate x DRG weight,21634,,"6,363 x patient days",21634,Per diem,,87567,70,,87567,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,19722,,"25,057 x DRG weight",19722,Other,base rate x DRG weight,17751,,"22,552 x DRG weight",17751,Other,base rate x DRG weight,19722,,"25,057 x DRG weight",19722,Other,base rate x DRG weight,16764,,"21,298 x DRG weight",16764,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,87567,
"SPRAINS, STRAINS, AND DISLOCATIONS OF HIP, PELVIS AND THIGH WITH CC/MCC",537,MS-DRG,,,,,,,,inpatient,,,413970,23746,,,23746,Other,150% of Medicare + 9.63% HCRA Surcharge,14440,,"3,609.90 x patient days",14440,Per diem,,24219,,"25,046 x DRG weight",24219,Other,base rate x DRG weight,21797,,"22,541 x DRG weight",21797,Other,base rate x DRG weight,30483,,"31,523 x DRG weight",30483,Other,base rate x DRG weight,27435,,"28,371 x DRG weight",27435,Other,base rate x DRG weight,25911,,"26,795 x DRG weight",25911,Other,base rate x DRG weight,15884,,"3,970.89 x patient days",15884,Per diem,,21722,,"22,463 x DRG weight",21722,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,25554,,"26,426 x DRG weight",25554,Other,base rate x DRG weight,37528,,"38,809 x DRG weight",37528,Other,base rate x DRG weight,37528,,"38,809 x DRG weight",37528,Other,base rate x DRG weight,25554,,"26,426 x DRG weight",25554,Other,base rate x DRG weight,37528,,"38,809 x DRG weight",37528,Other,base rate x DRG weight,25452,,"6,363 x patient days",25452,Per diem,,289779,70,,289779,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,24230,,"25,057 x DRG weight",24230,Other,base rate x DRG weight,21808,,"22,552 x DRG weight",21808,Other,base rate x DRG weight,24230,,"25,057 x DRG weight",24230,Other,base rate x DRG weight,20595,,"21,298 x DRG weight",20595,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,289779,
"SPRAINS, STRAINS, AND DISLOCATIONS OF HIP, PELVIS AND THIGH WITHOUT CC/MCC",538,MS-DRG,,,,,,,,inpatient,,,30498,16028,,,16028,Other,150% of Medicare + 9.63% HCRA Surcharge,9747,,"3,609.90 x patient days",9747,Per diem,,17760,,"25,046 x DRG weight",17760,Other,base rate x DRG weight,15984,,"22,541 x DRG weight",15984,Other,base rate x DRG weight,22353,,"31,523 x DRG weight",22353,Other,base rate x DRG weight,20118,,"28,371 x DRG weight",20118,Other,base rate x DRG weight,19000,,"26,795 x DRG weight",19000,Other,base rate x DRG weight,10721.7,,"3,970.89 x patient days",10721.7,Per diem,,15929,,"22,463 x DRG weight",15929,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,18739,,"26,426 x DRG weight",18739,Other,base rate x DRG weight,27519,,"38,809 x DRG weight",27519,Other,base rate x DRG weight,27519,,"38,809 x DRG weight",27519,Other,base rate x DRG weight,18739,,"26,426 x DRG weight",18739,Other,base rate x DRG weight,27519,,"38,809 x DRG weight",27519,Other,base rate x DRG weight,17180,,"6,363 x patient days",17180,Per diem,,21349,70,,21349,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,17768,,"25,057 x DRG weight",17768,Other,base rate x DRG weight,15992,,"22,552 x DRG weight",15992,Other,base rate x DRG weight,17768,,"25,057 x DRG weight",17768,Other,base rate x DRG weight,15102,,"21,298 x DRG weight",15102,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,27519,
OSTEOMYELITIS WITH MCC,539,MS-DRG,,,,,,,,inpatient,,,445794.23,51052,,,51052,Other,150% of Medicare + 9.63% HCRA Surcharge,31045,,"3,609.90 x patient days",31045,Per diem,,49701,,"25,046 x DRG weight",49701,Other,base rate x DRG weight,44730,,"22,541 x DRG weight",44730,Other,base rate x DRG weight,62554,,"31,523 x DRG weight",62554,Other,base rate x DRG weight,56299,,"28,371 x DRG weight",56299,Other,base rate x DRG weight,53172,,"26,795 x DRG weight",53172,Other,base rate x DRG weight,34149.5,,"3,970.89 x patient days",34149.5,Per diem,,44576,,"22,463 x DRG weight",44576,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,52440,,"26,426 x DRG weight",52440,Other,base rate x DRG weight,77013,,"38,809 x DRG weight",77013,Other,base rate x DRG weight,77013,,"38,809 x DRG weight",77013,Other,base rate x DRG weight,52440,,"26,426 x DRG weight",52440,Other,base rate x DRG weight,77013,,"38,809 x DRG weight",77013,Other,base rate x DRG weight,54722,,"6,363 x patient days",54722,Per diem,,312056,70,,312056,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,49723,,"25,057 x DRG weight",49723,Other,base rate x DRG weight,44752,,"22,552 x DRG weight",44752,Other,base rate x DRG weight,49723,,"25,057 x DRG weight",49723,Other,base rate x DRG weight,42264,,"21,298 x DRG weight",42264,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,312056,
OSTEOMYELITIS WITH CC,540,MS-DRG,,,,,,,,inpatient,,,161586.34,33836,,,33836,Other,150% of Medicare + 9.63% HCRA Surcharge,20576,,"3,609.90 x patient days",20576,Per diem,,32515,,"25,046 x DRG weight",32515,Other,base rate x DRG weight,29263,,"22,541 x DRG weight",29263,Other,base rate x DRG weight,40923,,"31,523 x DRG weight",40923,Other,base rate x DRG weight,36831,,"28,371 x DRG weight",36831,Other,base rate x DRG weight,34785,,"26,795 x DRG weight",34785,Other,base rate x DRG weight,22633.6,,"3,970.89 x patient days",22633.6,Per diem,,29161,,"22,463 x DRG weight",29161,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,34306,,"26,426 x DRG weight",34306,Other,base rate x DRG weight,50382,,"38,809 x DRG weight",50382,Other,base rate x DRG weight,50382,,"38,809 x DRG weight",50382,Other,base rate x DRG weight,34306,,"26,426 x DRG weight",34306,Other,base rate x DRG weight,50382,,"38,809 x DRG weight",50382,Other,base rate x DRG weight,36269,,"6,363 x patient days",36269,Per diem,,113110,70,,113110,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,32529,,"25,057 x DRG weight",32529,Other,base rate x DRG weight,29277,,"22,552 x DRG weight",29277,Other,base rate x DRG weight,32529,,"25,057 x DRG weight",32529,Other,base rate x DRG weight,27649,,"21,298 x DRG weight",27649,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,113110,
OSTEOMYELITIS WITHOUT CC/MCC,541,MS-DRG,,,,,,,,inpatient,,,95377.2,23152,,,23152,Other,150% of Medicare + 9.63% HCRA Surcharge,14079,,"3,609.90 x patient days",14079,Per diem,,21487,,"25,046 x DRG weight",21487,Other,base rate x DRG weight,19338,,"22,541 x DRG weight",19338,Other,base rate x DRG weight,27044,,"31,523 x DRG weight",27044,Other,base rate x DRG weight,24339,,"28,371 x DRG weight",24339,Other,base rate x DRG weight,22987,,"26,795 x DRG weight",22987,Other,base rate x DRG weight,15486.9,,"3,970.89 x patient days",15486.9,Per diem,,19271,,"22,463 x DRG weight",19271,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,22671,,"26,426 x DRG weight",22671,Other,base rate x DRG weight,33294,,"38,809 x DRG weight",33294,Other,base rate x DRG weight,33294,,"38,809 x DRG weight",33294,Other,base rate x DRG weight,22671,,"26,426 x DRG weight",22671,Other,base rate x DRG weight,33294,,"38,809 x DRG weight",33294,Other,base rate x DRG weight,24816,,"6,363 x patient days",24816,Per diem,,66764,70,,66764,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,21496,,"25,057 x DRG weight",21496,Other,base rate x DRG weight,19347,,"22,552 x DRG weight",19347,Other,base rate x DRG weight,21496,,"25,057 x DRG weight",21496,Other,base rate x DRG weight,18272,,"21,298 x DRG weight",18272,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,66764,
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH MCC,542,MS-DRG,,,,,,,,inpatient,,,295335.51,42147,,,42147,Other,150% of Medicare + 9.63% HCRA Surcharge,25630,,"3,609.90 x patient days",25630,Per diem,,45676,,"25,046 x DRG weight",45676,Other,base rate x DRG weight,41108,,"22,541 x DRG weight",41108,Other,base rate x DRG weight,57488,,"31,523 x DRG weight",57488,Other,base rate x DRG weight,51740,,"28,371 x DRG weight",51740,Other,base rate x DRG weight,48866,,"26,795 x DRG weight",48866,Other,base rate x DRG weight,28193,,"3,970.89 x patient days",28193,Per diem,,40966,,"22,463 x DRG weight",40966,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,48193,,"26,426 x DRG weight",48193,Other,base rate x DRG weight,70776,,"38,809 x DRG weight",70776,Other,base rate x DRG weight,70776,,"38,809 x DRG weight",70776,Other,base rate x DRG weight,48193,,"26,426 x DRG weight",48193,Other,base rate x DRG weight,70776,,"38,809 x DRG weight",70776,Other,base rate x DRG weight,45177,,"6,363 x patient days",45177,Per diem,,206735,70,,206735,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,45696,,"25,057 x DRG weight",45696,Other,base rate x DRG weight,41128,,"22,552 x DRG weight",41128,Other,base rate x DRG weight,45696,,"25,057 x DRG weight",45696,Other,base rate x DRG weight,38841,,"21,298 x DRG weight",38841,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,206735,
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH CC,543,MS-DRG,,,,,,,,inpatient,,,305965.02,26714,,,26714,Other,150% of Medicare + 9.63% HCRA Surcharge,16245,,"3,609.90 x patient days",16245,Per diem,,27318,,"25,046 x DRG weight",27318,Other,base rate x DRG weight,24585,,"22,541 x DRG weight",24585,Other,base rate x DRG weight,34382,,"31,523 x DRG weight",34382,Other,base rate x DRG weight,30944,,"28,371 x DRG weight",30944,Other,base rate x DRG weight,29225,,"26,795 x DRG weight",29225,Other,base rate x DRG weight,17869.5,,"3,970.89 x patient days",17869.5,Per diem,,24500,,"22,463 x DRG weight",24500,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,28823,,"26,426 x DRG weight",28823,Other,base rate x DRG weight,42329,,"38,809 x DRG weight",42329,Other,base rate x DRG weight,42329,,"38,809 x DRG weight",42329,Other,base rate x DRG weight,28823,,"26,426 x DRG weight",28823,Other,base rate x DRG weight,42329,,"38,809 x DRG weight",42329,Other,base rate x DRG weight,28634,,"6,363 x patient days",28634,Per diem,,214176,70,,214176,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,27330,,"25,057 x DRG weight",27330,Other,base rate x DRG weight,24597,,"22,552 x DRG weight",24597,Other,base rate x DRG weight,27330,,"25,057 x DRG weight",27330,Other,base rate x DRG weight,23230,,"21,298 x DRG weight",23230,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,214176,
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITHOUT CC/MCC,544,MS-DRG,,,,,,,,inpatient,,,137580.85,18997,,,18997,Other,150% of Medicare + 9.63% HCRA Surcharge,11552,,"3,609.90 x patient days",11552,Per diem,,19223,,"25,046 x DRG weight",19223,Other,base rate x DRG weight,17300,,"22,541 x DRG weight",17300,Other,base rate x DRG weight,24194,,"31,523 x DRG weight",24194,Other,base rate x DRG weight,21775,,"28,371 x DRG weight",21775,Other,base rate x DRG weight,20565,,"26,795 x DRG weight",20565,Other,base rate x DRG weight,12707.2,,"3,970.89 x patient days",12707.2,Per diem,,17240,,"22,463 x DRG weight",17240,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,20282,,"26,426 x DRG weight",20282,Other,base rate x DRG weight,29786,,"38,809 x DRG weight",29786,Other,base rate x DRG weight,29786,,"38,809 x DRG weight",29786,Other,base rate x DRG weight,20282,,"26,426 x DRG weight",20282,Other,base rate x DRG weight,29786,,"38,809 x DRG weight",29786,Other,base rate x DRG weight,20362,,"6,363 x patient days",20362,Per diem,,96307,70,,96307,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,19231,,"25,057 x DRG weight",19231,Other,base rate x DRG weight,17309,,"22,552 x DRG weight",17309,Other,base rate x DRG weight,19231,,"25,057 x DRG weight",19231,Other,base rate x DRG weight,16346,,"21,298 x DRG weight",16346,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,96307,
CONNECTIVE TISSUE DISORDERS WITH MCC,545,MS-DRG,,,,,,,,inpatient,,,402996.07,51052,,,51052,Other,150% of Medicare + 9.63% HCRA Surcharge,31045,,"3,609.90 x patient days",31045,Per diem,,62445,,"25,046 x DRG weight",62445,Other,base rate x DRG weight,56199,,"22,541 x DRG weight",56199,Other,base rate x DRG weight,78593,,"31,523 x DRG weight",78593,Other,base rate x DRG weight,70735,,"28,371 x DRG weight",70735,Other,base rate x DRG weight,66805,,"26,795 x DRG weight",66805,Other,base rate x DRG weight,34149.5,,"3,970.89 x patient days",34149.5,Per diem,,56005,,"22,463 x DRG weight",56005,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,65885,,"26,426 x DRG weight",65885,Other,base rate x DRG weight,96759,,"38,809 x DRG weight",96759,Other,base rate x DRG weight,96759,,"38,809 x DRG weight",96759,Other,base rate x DRG weight,65885,,"26,426 x DRG weight",65885,Other,base rate x DRG weight,96759,,"38,809 x DRG weight",96759,Other,base rate x DRG weight,54722,,"6,363 x patient days",54722,Per diem,,282097,70,,282097,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,62472,,"25,057 x DRG weight",62472,Other,base rate x DRG weight,56227,,"22,552 x DRG weight",56227,Other,base rate x DRG weight,62472,,"25,057 x DRG weight",62472,Other,base rate x DRG weight,53100,,"21,298 x DRG weight",53100,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,282097,
CONNECTIVE TISSUE DISORDERS WITH CC,546,MS-DRG,,,,,,,,inpatient,,,171715.72,27308,,,27308,Other,150% of Medicare + 9.63% HCRA Surcharge,16606,,"3,609.90 x patient days",16606,Per diem,,30038,,"25,046 x DRG weight",30038,Other,base rate x DRG weight,27033,,"22,541 x DRG weight",27033,Other,base rate x DRG weight,37806,,"31,523 x DRG weight",37806,Other,base rate x DRG weight,34025,,"28,371 x DRG weight",34025,Other,base rate x DRG weight,32135,,"26,795 x DRG weight",32135,Other,base rate x DRG weight,18266.6,,"3,970.89 x patient days",18266.6,Per diem,,26940,,"22,463 x DRG weight",26940,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,31693,,"26,426 x DRG weight",31693,Other,base rate x DRG weight,46544,,"38,809 x DRG weight",46544,Other,base rate x DRG weight,46544,,"38,809 x DRG weight",46544,Other,base rate x DRG weight,31693,,"26,426 x DRG weight",31693,Other,base rate x DRG weight,46544,,"38,809 x DRG weight",46544,Other,base rate x DRG weight,29270,,"6,363 x patient days",29270,Per diem,,120201,70,,120201,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,30051,,"25,057 x DRG weight",30051,Other,base rate x DRG weight,27047,,"22,552 x DRG weight",27047,Other,base rate x DRG weight,30051,,"25,057 x DRG weight",30051,Other,base rate x DRG weight,25543,,"21,298 x DRG weight",25543,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,120201,
CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC,547,MS-DRG,,,,,,,,inpatient,,,119033.23,17809,,,17809,Other,150% of Medicare + 9.63% HCRA Surcharge,10830,,"3,609.90 x patient days",10830,Per diem,,20620,,"25,046 x DRG weight",20620,Other,base rate x DRG weight,18558,,"22,541 x DRG weight",18558,Other,base rate x DRG weight,25953,,"31,523 x DRG weight",25953,Other,base rate x DRG weight,23358,,"28,371 x DRG weight",23358,Other,base rate x DRG weight,22060,,"26,795 x DRG weight",22060,Other,base rate x DRG weight,11913,,"3,970.89 x patient days",11913,Per diem,,18494,,"22,463 x DRG weight",18494,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,21757,,"26,426 x DRG weight",21757,Other,base rate x DRG weight,31951,,"38,809 x DRG weight",31951,Other,base rate x DRG weight,31951,,"38,809 x DRG weight",31951,Other,base rate x DRG weight,21757,,"26,426 x DRG weight",21757,Other,base rate x DRG weight,31951,,"38,809 x DRG weight",31951,Other,base rate x DRG weight,19089,,"6,363 x patient days",19089,Per diem,,83323,70,,83323,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,20629,,"25,057 x DRG weight",20629,Other,base rate x DRG weight,18567,,"22,552 x DRG weight",18567,Other,base rate x DRG weight,20629,,"25,057 x DRG weight",20629,Other,base rate x DRG weight,17535,,"21,298 x DRG weight",17535,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,83323,
SEPTIC ARTHRITIS WITH MCC,548,MS-DRG,,,,,,,,inpatient,,,145414.91,49865,,,49865,Other,150% of Medicare + 9.63% HCRA Surcharge,30323,,"3,609.90 x patient days",30323,Per diem,,48835,,"25,046 x DRG weight",48835,Other,base rate x DRG weight,43950,,"22,541 x DRG weight",43950,Other,base rate x DRG weight,61464,,"31,523 x DRG weight",61464,Other,base rate x DRG weight,55318,,"28,371 x DRG weight",55318,Other,base rate x DRG weight,52245,,"26,795 x DRG weight",52245,Other,base rate x DRG weight,33355.3,,"3,970.89 x patient days",33355.3,Per diem,,43798,,"22,463 x DRG weight",43798,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,51525,,"26,426 x DRG weight",51525,Other,base rate x DRG weight,75670,,"38,809 x DRG weight",75670,Other,base rate x DRG weight,75670,,"38,809 x DRG weight",75670,Other,base rate x DRG weight,51525,,"26,426 x DRG weight",51525,Other,base rate x DRG weight,75670,,"38,809 x DRG weight",75670,Other,base rate x DRG weight,53449,,"6,363 x patient days",53449,Per diem,,101790,70,,101790,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,48856,,"25,057 x DRG weight",48856,Other,base rate x DRG weight,43972,,"22,552 x DRG weight",43972,Other,base rate x DRG weight,48856,,"25,057 x DRG weight",48856,Other,base rate x DRG weight,41527,,"21,298 x DRG weight",41527,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,101790,
SEPTIC ARTHRITIS WITH CC,549,MS-DRG,,,,,,,,inpatient,,,153496.95,31462,,,31462,Other,150% of Medicare + 9.63% HCRA Surcharge,19132,,"3,609.90 x patient days",19132,Per diem,,30210,,"25,046 x DRG weight",30210,Other,base rate x DRG weight,27189,,"22,541 x DRG weight",27189,Other,base rate x DRG weight,38023,,"31,523 x DRG weight",38023,Other,base rate x DRG weight,34221,,"28,371 x DRG weight",34221,Other,base rate x DRG weight,32320,,"26,795 x DRG weight",32320,Other,base rate x DRG weight,21045.2,,"3,970.89 x patient days",21045.2,Per diem,,27095,,"22,463 x DRG weight",27095,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,31875,,"26,426 x DRG weight",31875,Other,base rate x DRG weight,46811,,"38,809 x DRG weight",46811,Other,base rate x DRG weight,46811,,"38,809 x DRG weight",46811,Other,base rate x DRG weight,31875,,"26,426 x DRG weight",31875,Other,base rate x DRG weight,46811,,"38,809 x DRG weight",46811,Other,base rate x DRG weight,33724,,"6,363 x patient days",33724,Per diem,,107448,70,,107448,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,30224,,"25,057 x DRG weight",30224,Other,base rate x DRG weight,27202,,"22,552 x DRG weight",27202,Other,base rate x DRG weight,30224,,"25,057 x DRG weight",30224,Other,base rate x DRG weight,25690,,"21,298 x DRG weight",25690,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,107448,
SEPTIC ARTHRITIS WITHOUT CC/MCC,550,MS-DRG,,,,,,,,inpatient,,,71104.5,21965,,,21965,Other,150% of Medicare + 9.63% HCRA Surcharge,13357,,"3,609.90 x patient days",13357,Per diem,,23631,,"25,046 x DRG weight",23631,Other,base rate x DRG weight,21267,,"22,541 x DRG weight",21267,Other,base rate x DRG weight,29742,,"31,523 x DRG weight",29742,Other,base rate x DRG weight,26768,,"28,371 x DRG weight",26768,Other,base rate x DRG weight,25281,,"26,795 x DRG weight",25281,Other,base rate x DRG weight,14692.7,,"3,970.89 x patient days",14692.7,Per diem,,21194,,"22,463 x DRG weight",21194,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,24933,,"26,426 x DRG weight",24933,Other,base rate x DRG weight,36616,,"38,809 x DRG weight",36616,Other,base rate x DRG weight,36616,,"38,809 x DRG weight",36616,Other,base rate x DRG weight,24933,,"26,426 x DRG weight",24933,Other,base rate x DRG weight,36616,,"38,809 x DRG weight",36616,Other,base rate x DRG weight,23543,,"6,363 x patient days",23543,Per diem,,49773,70,,49773,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,23641,,"25,057 x DRG weight",23641,Other,base rate x DRG weight,21278,,"22,552 x DRG weight",21278,Other,base rate x DRG weight,23641,,"25,057 x DRG weight",23641,Other,base rate x DRG weight,20095,,"21,298 x DRG weight",20095,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,49773,
MEDICAL BACK PROBLEMS WITH MCC,551,MS-DRG,,,,,,,,inpatient,,,222008.27,36804,,,36804,Other,150% of Medicare + 9.63% HCRA Surcharge,22381,,"3,609.90 x patient days",22381,Per diem,,42626,,"25,046 x DRG weight",42626,Other,base rate x DRG weight,38363,,"22,541 x DRG weight",38363,Other,base rate x DRG weight,53649,,"31,523 x DRG weight",53649,Other,base rate x DRG weight,48285,,"28,371 x DRG weight",48285,Other,base rate x DRG weight,45602,,"26,795 x DRG weight",45602,Other,base rate x DRG weight,24619.1,,"3,970.89 x patient days",24619.1,Per diem,,38230,,"22,463 x DRG weight",38230,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,44974,,"26,426 x DRG weight",44974,Other,base rate x DRG weight,66049,,"38,809 x DRG weight",66049,Other,base rate x DRG weight,66049,,"38,809 x DRG weight",66049,Other,base rate x DRG weight,44974,,"26,426 x DRG weight",44974,Other,base rate x DRG weight,66049,,"38,809 x DRG weight",66049,Other,base rate x DRG weight,39451,,"6,363 x patient days",39451,Per diem,,155406,70,,155406,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,42645,,"25,057 x DRG weight",42645,Other,base rate x DRG weight,38381,,"22,552 x DRG weight",38381,Other,base rate x DRG weight,42645,,"25,057 x DRG weight",42645,Other,base rate x DRG weight,36247,,"21,298 x DRG weight",36247,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,155406,
MEDICAL BACK PROBLEMS WITHOUT MCC,552,MS-DRG,,,,,,,,inpatient,,,149351.04,21965,,,21965,Other,150% of Medicare + 9.63% HCRA Surcharge,13357,,"3,609.90 x patient days",13357,Per diem,,24202,,"25,046 x DRG weight",24202,Other,base rate x DRG weight,21781,,"22,541 x DRG weight",21781,Other,base rate x DRG weight,30461,,"31,523 x DRG weight",30461,Other,base rate x DRG weight,27415,,"28,371 x DRG weight",27415,Other,base rate x DRG weight,25892,,"26,795 x DRG weight",25892,Other,base rate x DRG weight,14692.7,,"3,970.89 x patient days",14692.7,Per diem,,21706,,"22,463 x DRG weight",21706,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,25535,,"26,426 x DRG weight",25535,Other,base rate x DRG weight,37501,,"38,809 x DRG weight",37501,Other,base rate x DRG weight,37501,,"38,809 x DRG weight",37501,Other,base rate x DRG weight,25535,,"26,426 x DRG weight",25535,Other,base rate x DRG weight,37501,,"38,809 x DRG weight",37501,Other,base rate x DRG weight,23543,,"6,363 x patient days",23543,Per diem,,104546,70,,104546,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,24213,,"25,057 x DRG weight",24213,Other,base rate x DRG weight,21792,,"22,552 x DRG weight",21792,Other,base rate x DRG weight,24213,,"25,057 x DRG weight",24213,Other,base rate x DRG weight,20580,,"21,298 x DRG weight",20580,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,104546,
BONE DISEASES AND ARTHROPATHIES WITH MCC,553,MS-DRG,,,,,,,,inpatient,,,154011.39,33836,,,33836,Other,150% of Medicare + 9.63% HCRA Surcharge,20576,,"3,609.90 x patient days",20576,Per diem,,33850,,"25,046 x DRG weight",33850,Other,base rate x DRG weight,30464,,"22,541 x DRG weight",30464,Other,base rate x DRG weight,42603,,"31,523 x DRG weight",42603,Other,base rate x DRG weight,38343,,"28,371 x DRG weight",38343,Other,base rate x DRG weight,36213,,"26,795 x DRG weight",36213,Other,base rate x DRG weight,22633.6,,"3,970.89 x patient days",22633.6,Per diem,,30359,,"22,463 x DRG weight",30359,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,35715,,"26,426 x DRG weight",35715,Other,base rate x DRG weight,52450,,"38,809 x DRG weight",52450,Other,base rate x DRG weight,52450,,"38,809 x DRG weight",52450,Other,base rate x DRG weight,35715,,"26,426 x DRG weight",35715,Other,base rate x DRG weight,52450,,"38,809 x DRG weight",52450,Other,base rate x DRG weight,36269,,"6,363 x patient days",36269,Per diem,,107808,70,,107808,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,33865,,"25,057 x DRG weight",33865,Other,base rate x DRG weight,30479,,"22,552 x DRG weight",30479,Other,base rate x DRG weight,33865,,"25,057 x DRG weight",33865,Other,base rate x DRG weight,28784,,"21,298 x DRG weight",28784,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,107808,
BONE DISEASES AND ARTHROPATHIES WITHOUT MCC,554,MS-DRG,,,,,,,,inpatient,,,135978.72,20778,,,20778,Other,150% of Medicare + 9.63% HCRA Surcharge,12635,,"3,609.90 x patient days",12635,Per diem,,20583,,"25,046 x DRG weight",20583,Other,base rate x DRG weight,18524,,"22,541 x DRG weight",18524,Other,base rate x DRG weight,25906,,"31,523 x DRG weight",25906,Other,base rate x DRG weight,23315,,"28,371 x DRG weight",23315,Other,base rate x DRG weight,22020,,"26,795 x DRG weight",22020,Other,base rate x DRG weight,13898.5,,"3,970.89 x patient days",13898.5,Per diem,,18460,,"22,463 x DRG weight",18460,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,21717,,"26,426 x DRG weight",21717,Other,base rate x DRG weight,31893,,"38,809 x DRG weight",31893,Other,base rate x DRG weight,31893,,"38,809 x DRG weight",31893,Other,base rate x DRG weight,21717,,"26,426 x DRG weight",21717,Other,base rate x DRG weight,31893,,"38,809 x DRG weight",31893,Other,base rate x DRG weight,22271,,"6,363 x patient days",22271,Per diem,,95185,70,,95185,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,20592,,"25,057 x DRG weight",20592,Other,base rate x DRG weight,18533,,"22,552 x DRG weight",18533,Other,base rate x DRG weight,20592,,"25,057 x DRG weight",20592,Other,base rate x DRG weight,17503,,"21,298 x DRG weight",17503,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,95185,
SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC,555,MS-DRG,,,,,,,,inpatient,,,111419.12,33243,,,33243,Other,150% of Medicare + 9.63% HCRA Surcharge,20215,,"3,609.90 x patient days",20215,Per diem,,35039,,"25,046 x DRG weight",35039,Other,base rate x DRG weight,31535,,"22,541 x DRG weight",31535,Other,base rate x DRG weight,44101,,"31,523 x DRG weight",44101,Other,base rate x DRG weight,39691,,"28,371 x DRG weight",39691,Other,base rate x DRG weight,37486,,"26,795 x DRG weight",37486,Other,base rate x DRG weight,22236.5,,"3,970.89 x patient days",22236.5,Per diem,,31426,,"22,463 x DRG weight",31426,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,36970,,"26,426 x DRG weight",36970,Other,base rate x DRG weight,54294,,"38,809 x DRG weight",54294,Other,base rate x DRG weight,54294,,"38,809 x DRG weight",54294,Other,base rate x DRG weight,36970,,"26,426 x DRG weight",36970,Other,base rate x DRG weight,54294,,"38,809 x DRG weight",54294,Other,base rate x DRG weight,35633,,"6,363 x patient days",35633,Per diem,,77993,70,,77993,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,35055,,"25,057 x DRG weight",35055,Other,base rate x DRG weight,31550,,"22,552 x DRG weight",31550,Other,base rate x DRG weight,35055,,"25,057 x DRG weight",35055,Other,base rate x DRG weight,29796,,"21,298 x DRG weight",29796,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,77993,
SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT MCC,556,MS-DRG,,,,,,,,inpatient,,,114607.91,19590,,,19590,Other,150% of Medicare + 9.63% HCRA Surcharge,11913,,"3,609.90 x patient days",11913,Per diem,,20648,,"25,046 x DRG weight",20648,Other,base rate x DRG weight,18583,,"22,541 x DRG weight",18583,Other,base rate x DRG weight,25988,,"31,523 x DRG weight",25988,Other,base rate x DRG weight,23389,,"28,371 x DRG weight",23389,Other,base rate x DRG weight,22090,,"26,795 x DRG weight",22090,Other,base rate x DRG weight,13104.3,,"3,970.89 x patient days",13104.3,Per diem,,18518,,"22,463 x DRG weight",18518,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,21786,,"26,426 x DRG weight",21786,Other,base rate x DRG weight,31994,,"38,809 x DRG weight",31994,Other,base rate x DRG weight,31994,,"38,809 x DRG weight",31994,Other,base rate x DRG weight,21786,,"26,426 x DRG weight",21786,Other,base rate x DRG weight,31994,,"38,809 x DRG weight",31994,Other,base rate x DRG weight,20998,,"6,363 x patient days",20998,Per diem,,80226,70,,80226,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,20657,,"25,057 x DRG weight",20657,Other,base rate x DRG weight,18592,,"22,552 x DRG weight",18592,Other,base rate x DRG weight,20657,,"25,057 x DRG weight",20657,Other,base rate x DRG weight,17558,,"21,298 x DRG weight",17558,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,80226,
"TENDONITIS, MYOSITIS AND BURSITIS WITH MCC",557,MS-DRG,,,,,,,,inpatient,,,219778.64,41554,,,41554,Other,150% of Medicare + 9.63% HCRA Surcharge,25269,,"3,609.90 x patient days",25269,Per diem,,38992,,"25,046 x DRG weight",38992,Other,base rate x DRG weight,35092,,"22,541 x DRG weight",35092,Other,base rate x DRG weight,49075,,"31,523 x DRG weight",49075,Other,base rate x DRG weight,44168,,"28,371 x DRG weight",44168,Other,base rate x DRG weight,41714,,"26,795 x DRG weight",41714,Other,base rate x DRG weight,27795.9,,"3,970.89 x patient days",27795.9,Per diem,,34970,,"22,463 x DRG weight",34970,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,41140,,"26,426 x DRG weight",41140,Other,base rate x DRG weight,60418,,"38,809 x DRG weight",60418,Other,base rate x DRG weight,60418,,"38,809 x DRG weight",60418,Other,base rate x DRG weight,41140,,"26,426 x DRG weight",41140,Other,base rate x DRG weight,60418,,"38,809 x DRG weight",60418,Other,base rate x DRG weight,44541,,"6,363 x patient days",44541,Per diem,,153845,70,,153845,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,39009,,"25,057 x DRG weight",39009,Other,base rate x DRG weight,35109,,"22,552 x DRG weight",35109,Other,base rate x DRG weight,39009,,"25,057 x DRG weight",39009,Other,base rate x DRG weight,33157,,"21,298 x DRG weight",33157,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,153845,
"TENDONITIS, MYOSITIS AND BURSITIS WITHOUT MCC",558,MS-DRG,,,,,,,,inpatient,,,88055.18,23152,,,23152,Other,150% of Medicare + 9.63% HCRA Surcharge,14079,,"3,609.90 x patient days",14079,Per diem,,22000,,"25,046 x DRG weight",22000,Other,base rate x DRG weight,19800,,"22,541 x DRG weight",19800,Other,base rate x DRG weight,27690,,"31,523 x DRG weight",27690,Other,base rate x DRG weight,24921,,"28,371 x DRG weight",24921,Other,base rate x DRG weight,23537,,"26,795 x DRG weight",23537,Other,base rate x DRG weight,15486.9,,"3,970.89 x patient days",15486.9,Per diem,,19731,,"22,463 x DRG weight",19731,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,23213,,"26,426 x DRG weight",23213,Other,base rate x DRG weight,34090,,"38,809 x DRG weight",34090,Other,base rate x DRG weight,34090,,"38,809 x DRG weight",34090,Other,base rate x DRG weight,23213,,"26,426 x DRG weight",23213,Other,base rate x DRG weight,34090,,"38,809 x DRG weight",34090,Other,base rate x DRG weight,24816,,"6,363 x patient days",24816,Per diem,,61639,70,,61639,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,22010,,"25,057 x DRG weight",22010,Other,base rate x DRG weight,19810,,"22,552 x DRG weight",19810,Other,base rate x DRG weight,22010,,"25,057 x DRG weight",22010,Other,base rate x DRG weight,18708,,"21,298 x DRG weight",18708,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,61639,
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC",559,MS-DRG,,,,,,,,inpatient,,,185727.45,43335,,,43335,Other,150% of Medicare + 9.63% HCRA Surcharge,26352,,"3,609.90 x patient days",26352,Per diem,,46348,,"25,046 x DRG weight",46348,Other,base rate x DRG weight,41712,,"22,541 x DRG weight",41712,Other,base rate x DRG weight,58333,,"31,523 x DRG weight",58333,Other,base rate x DRG weight,52501,,"28,371 x DRG weight",52501,Other,base rate x DRG weight,49584,,"26,795 x DRG weight",49584,Other,base rate x DRG weight,28987.2,,"3,970.89 x patient days",28987.2,Per diem,,41568,,"22,463 x DRG weight",41568,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,48901,,"26,426 x DRG weight",48901,Other,base rate x DRG weight,71816,,"38,809 x DRG weight",71816,Other,base rate x DRG weight,71816,,"38,809 x DRG weight",71816,Other,base rate x DRG weight,48901,,"26,426 x DRG weight",48901,Other,base rate x DRG weight,71816,,"38,809 x DRG weight",71816,Other,base rate x DRG weight,46450,,"6,363 x patient days",46450,Per diem,,130009,70,,130009,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,46368,,"25,057 x DRG weight",46368,Other,base rate x DRG weight,41732,,"22,552 x DRG weight",41732,Other,base rate x DRG weight,46368,,"25,057 x DRG weight",46368,Other,base rate x DRG weight,39412,,"21,298 x DRG weight",39412,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,130009,
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC",560,MS-DRG,,,,,,,,inpatient,,,150931.77,31462,,,31462,Other,150% of Medicare + 9.63% HCRA Surcharge,19132,,"3,609.90 x patient days",19132,Per diem,,28355,,"25,046 x DRG weight",28355,Other,base rate x DRG weight,25519,,"22,541 x DRG weight",25519,Other,base rate x DRG weight,35687,,"31,523 x DRG weight",35687,Other,base rate x DRG weight,32119,,"28,371 x DRG weight",32119,Other,base rate x DRG weight,30335,,"26,795 x DRG weight",30335,Other,base rate x DRG weight,21045.2,,"3,970.89 x patient days",21045.2,Per diem,,25430,,"22,463 x DRG weight",25430,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,29917,,"26,426 x DRG weight",29917,Other,base rate x DRG weight,43936,,"38,809 x DRG weight",43936,Other,base rate x DRG weight,43936,,"38,809 x DRG weight",43936,Other,base rate x DRG weight,29917,,"26,426 x DRG weight",29917,Other,base rate x DRG weight,43936,,"38,809 x DRG weight",43936,Other,base rate x DRG weight,33724,,"6,363 x patient days",33724,Per diem,,105652,70,,105652,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,28367,,"25,057 x DRG weight",28367,Other,base rate x DRG weight,25531,,"22,552 x DRG weight",25531,Other,base rate x DRG weight,28367,,"25,057 x DRG weight",28367,Other,base rate x DRG weight,24111,,"21,298 x DRG weight",24111,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,105652,
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT CC/MCC",561,MS-DRG,,,,,,,,inpatient,,,125772.49,23152,,,23152,Other,150% of Medicare + 9.63% HCRA Surcharge,14079,,"3,609.90 x patient days",14079,Per diem,,19541,,"25,046 x DRG weight",19541,Other,base rate x DRG weight,17586,,"22,541 x DRG weight",17586,Other,base rate x DRG weight,24594,,"31,523 x DRG weight",24594,Other,base rate x DRG weight,22135,,"28,371 x DRG weight",22135,Other,base rate x DRG weight,20905,,"26,795 x DRG weight",20905,Other,base rate x DRG weight,15486.9,,"3,970.89 x patient days",15486.9,Per diem,,17526,,"22,463 x DRG weight",17526,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,20618,,"26,426 x DRG weight",20618,Other,base rate x DRG weight,30279,,"38,809 x DRG weight",30279,Other,base rate x DRG weight,30279,,"38,809 x DRG weight",30279,Other,base rate x DRG weight,20618,,"26,426 x DRG weight",20618,Other,base rate x DRG weight,30279,,"38,809 x DRG weight",30279,Other,base rate x DRG weight,24816,,"6,363 x patient days",24816,Per diem,,88041,70,,88041,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,19549,,"25,057 x DRG weight",19549,Other,base rate x DRG weight,17595,,"22,552 x DRG weight",17595,Other,base rate x DRG weight,19549,,"25,057 x DRG weight",19549,Other,base rate x DRG weight,16617,,"21,298 x DRG weight",16617,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,88041,
"FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITH MCC",562,MS-DRG,,,,,,,,inpatient,,,209266.75,34430,,,34430,Other,150% of Medicare + 9.63% HCRA Surcharge,20937,,"3,609.90 x patient days",20937,Per diem,,38087,,"25,046 x DRG weight",38087,Other,base rate x DRG weight,34278,,"22,541 x DRG weight",34278,Other,base rate x DRG weight,47937,,"31,523 x DRG weight",47937,Other,base rate x DRG weight,43144,,"28,371 x DRG weight",43144,Other,base rate x DRG weight,40747,,"26,795 x DRG weight",40747,Other,base rate x DRG weight,23030.7,,"3,970.89 x patient days",23030.7,Per diem,,34159,,"22,463 x DRG weight",34159,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,40186,,"26,426 x DRG weight",40186,Other,base rate x DRG weight,59017,,"38,809 x DRG weight",59017,Other,base rate x DRG weight,59017,,"38,809 x DRG weight",59017,Other,base rate x DRG weight,40186,,"26,426 x DRG weight",40186,Other,base rate x DRG weight,59017,,"38,809 x DRG weight",59017,Other,base rate x DRG weight,36905,,"6,363 x patient days",36905,Per diem,,146487,70,,146487,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,38104,,"25,057 x DRG weight",38104,Other,base rate x DRG weight,34295,,"22,552 x DRG weight",34295,Other,base rate x DRG weight,38104,,"25,057 x DRG weight",38104,Other,base rate x DRG weight,32388,,"21,298 x DRG weight",32388,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,146487,
"FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITHOUT MCC",563,MS-DRG,,,,,,,,inpatient,,,116010.17,20778,,,20778,Other,150% of Medicare + 9.63% HCRA Surcharge,12635,,"3,609.90 x patient days",12635,Per diem,,22431,,"25,046 x DRG weight",22431,Other,base rate x DRG weight,20188,,"22,541 x DRG weight",20188,Other,base rate x DRG weight,28232,,"31,523 x DRG weight",28232,Other,base rate x DRG weight,25409,,"28,371 x DRG weight",25409,Other,base rate x DRG weight,23998,,"26,795 x DRG weight",23998,Other,base rate x DRG weight,13898.5,,"3,970.89 x patient days",13898.5,Per diem,,20118,,"22,463 x DRG weight",20118,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,23667,,"26,426 x DRG weight",23667,Other,base rate x DRG weight,34757,,"38,809 x DRG weight",34757,Other,base rate x DRG weight,34757,,"38,809 x DRG weight",34757,Other,base rate x DRG weight,23667,,"26,426 x DRG weight",23667,Other,base rate x DRG weight,34757,,"38,809 x DRG weight",34757,Other,base rate x DRG weight,22271,,"6,363 x patient days",22271,Per diem,,81207,70,,81207,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,22441,,"25,057 x DRG weight",22441,Other,base rate x DRG weight,20198,,"22,552 x DRG weight",20198,Other,base rate x DRG weight,22441,,"25,057 x DRG weight",22441,Other,base rate x DRG weight,19074,,"21,298 x DRG weight",19074,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,81207,
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITH MCC,564,MS-DRG,,,,,,,,inpatient,,,286985.36,38585,,,38585,Other,150% of Medicare + 9.63% HCRA Surcharge,23464,,"3,609.90 x patient days",23464,Per diem,,39119,,"25,046 x DRG weight",39119,Other,base rate x DRG weight,35207,,"22,541 x DRG weight",35207,Other,base rate x DRG weight,49236,,"31,523 x DRG weight",49236,Other,base rate x DRG weight,44313,,"28,371 x DRG weight",44313,Other,base rate x DRG weight,41851,,"26,795 x DRG weight",41851,Other,base rate x DRG weight,25810.4,,"3,970.89 x patient days",25810.4,Per diem,,35085,,"22,463 x DRG weight",35085,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,41275,,"26,426 x DRG weight",41275,Other,base rate x DRG weight,60616,,"38,809 x DRG weight",60616,Other,base rate x DRG weight,60616,,"38,809 x DRG weight",60616,Other,base rate x DRG weight,41275,,"26,426 x DRG weight",41275,Other,base rate x DRG weight,60616,,"38,809 x DRG weight",60616,Other,base rate x DRG weight,41360,,"6,363 x patient days",41360,Per diem,,200890,70,,200890,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,39137,,"25,057 x DRG weight",39137,Other,base rate x DRG weight,35224,,"22,552 x DRG weight",35224,Other,base rate x DRG weight,39137,,"25,057 x DRG weight",39137,Other,base rate x DRG weight,33265,,"21,298 x DRG weight",33265,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,200890,
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITH CC,565,MS-DRG,,,,,,,,inpatient,,,146472.21,24933,,,24933,Other,150% of Medicare + 9.63% HCRA Surcharge,15162,,"3,609.90 x patient days",15162,Per diem,,25031,,"25,046 x DRG weight",25031,Other,base rate x DRG weight,22527,,"22,541 x DRG weight",22527,Other,base rate x DRG weight,31504,,"31,523 x DRG weight",31504,Other,base rate x DRG weight,28354,,"28,371 x DRG weight",28354,Other,base rate x DRG weight,26779,,"26,795 x DRG weight",26779,Other,base rate x DRG weight,16678.2,,"3,970.89 x patient days",16678.2,Per diem,,22450,,"22,463 x DRG weight",22450,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,26410,,"26,426 x DRG weight",26410,Other,base rate x DRG weight,38786,,"38,809 x DRG weight",38786,Other,base rate x DRG weight,38786,,"38,809 x DRG weight",38786,Other,base rate x DRG weight,26410,,"26,426 x DRG weight",26410,Other,base rate x DRG weight,38786,,"38,809 x DRG weight",38786,Other,base rate x DRG weight,26725,,"6,363 x patient days",26725,Per diem,,102531,70,,102531,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,25042,,"25,057 x DRG weight",25042,Other,base rate x DRG weight,22538,,"22,552 x DRG weight",22538,Other,base rate x DRG weight,25042,,"25,057 x DRG weight",25042,Other,base rate x DRG weight,21285,,"21,298 x DRG weight",21285,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,102531,
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITHOUT CC/MCC,566,MS-DRG,,,,,,,,inpatient,,,77997.2,17809,,,17809,Other,150% of Medicare + 9.63% HCRA Surcharge,10830,,"3,609.90 x patient days",10830,Per diem,,18797,,"25,046 x DRG weight",18797,Other,base rate x DRG weight,16917,,"22,541 x DRG weight",16917,Other,base rate x DRG weight,23658,,"31,523 x DRG weight",23658,Other,base rate x DRG weight,21292,,"28,371 x DRG weight",21292,Other,base rate x DRG weight,20110,,"26,795 x DRG weight",20110,Other,base rate x DRG weight,11913,,"3,970.89 x patient days",11913,Per diem,,16858,,"22,463 x DRG weight",16858,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,19833,,"26,426 x DRG weight",19833,Other,base rate x DRG weight,29126,,"38,809 x DRG weight",29126,Other,base rate x DRG weight,29126,,"38,809 x DRG weight",29126,Other,base rate x DRG weight,19833,,"26,426 x DRG weight",19833,Other,base rate x DRG weight,29126,,"38,809 x DRG weight",29126,Other,base rate x DRG weight,19089,,"6,363 x patient days",19089,Per diem,,54598,70,,54598,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,18805,,"25,057 x DRG weight",18805,Other,base rate x DRG weight,16925,,"22,552 x DRG weight",16925,Other,base rate x DRG weight,18805,,"25,057 x DRG weight",18805,Other,base rate x DRG weight,15984,,"21,298 x DRG weight",15984,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,54598,
SKIN DEBRIDEMENT WITH MCC,570,MS-DRG,,,,,,,,inpatient,,,296566.47,63519,,,63519,Other,150% of Medicare + 9.63% HCRA Surcharge,38626,,"3,609.90 x patient days",38626,Per diem,,73189,,"25,046 x DRG weight",73189,Other,base rate x DRG weight,65869,,"22,541 x DRG weight",65869,Other,base rate x DRG weight,92117,,"31,523 x DRG weight",92117,Other,base rate x DRG weight,82906,,"28,371 x DRG weight",82906,Other,base rate x DRG weight,78300,,"26,795 x DRG weight",78300,Other,base rate x DRG weight,42488.6,,"3,970.89 x patient days",42488.6,Per diem,,65641,,"22,463 x DRG weight",65641,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,77222,,"26,426 x DRG weight",77222,Other,base rate x DRG weight,113408,,"38,809 x DRG weight",113408,Other,base rate x DRG weight,113408,,"38,809 x DRG weight",113408,Other,base rate x DRG weight,77222,,"26,426 x DRG weight",77222,Other,base rate x DRG weight,113408,,"38,809 x DRG weight",113408,Other,base rate x DRG weight,68084,,"6,363 x patient days",68084,Per diem,,207597,70,,207597,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,73222,,"25,057 x DRG weight",73222,Other,base rate x DRG weight,65901,,"22,552 x DRG weight",65901,Other,base rate x DRG weight,73222,,"25,057 x DRG weight",73222,Other,base rate x DRG weight,62237,,"21,298 x DRG weight",62237,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,207597,
SKIN DEBRIDEMENT WITH CC,571,MS-DRG,,,,,,,,inpatient,,,230034.64,38585,,,38585,Other,150% of Medicare + 9.63% HCRA Surcharge,23464,,"3,609.90 x patient days",23464,Per diem,,42375,,"25,046 x DRG weight",42375,Other,base rate x DRG weight,38137,,"22,541 x DRG weight",38137,Other,base rate x DRG weight,53334,,"31,523 x DRG weight",53334,Other,base rate x DRG weight,48001,,"28,371 x DRG weight",48001,Other,base rate x DRG weight,45334,,"26,795 x DRG weight",45334,Other,base rate x DRG weight,25810.4,,"3,970.89 x patient days",25810.4,Per diem,,38005,,"22,463 x DRG weight",38005,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,44710,,"26,426 x DRG weight",44710,Other,base rate x DRG weight,65661,,"38,809 x DRG weight",65661,Other,base rate x DRG weight,65661,,"38,809 x DRG weight",65661,Other,base rate x DRG weight,44710,,"26,426 x DRG weight",44710,Other,base rate x DRG weight,65661,,"38,809 x DRG weight",65661,Other,base rate x DRG weight,41360,,"6,363 x patient days",41360,Per diem,,161024,70,,161024,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,42394,,"25,057 x DRG weight",42394,Other,base rate x DRG weight,38156,,"22,552 x DRG weight",38156,Other,base rate x DRG weight,42394,,"25,057 x DRG weight",42394,Other,base rate x DRG weight,36034,,"21,298 x DRG weight",36034,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,161024,
SKIN DEBRIDEMENT WITHOUT CC/MCC,572,MS-DRG,,,,,,,,inpatient,,,116935.28,22559,,,22559,Other,150% of Medicare + 9.63% HCRA Surcharge,13718,,"3,609.90 x patient days",13718,Per diem,,28542,,"25,046 x DRG weight",28542,Other,base rate x DRG weight,25688,,"22,541 x DRG weight",25688,Other,base rate x DRG weight,35924,,"31,523 x DRG weight",35924,Other,base rate x DRG weight,32332,,"28,371 x DRG weight",32332,Other,base rate x DRG weight,30536,,"26,795 x DRG weight",30536,Other,base rate x DRG weight,15089.8,,"3,970.89 x patient days",15089.8,Per diem,,25599,,"22,463 x DRG weight",25599,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,30115,,"26,426 x DRG weight",30115,Other,base rate x DRG weight,44227,,"38,809 x DRG weight",44227,Other,base rate x DRG weight,44227,,"38,809 x DRG weight",44227,Other,base rate x DRG weight,30115,,"26,426 x DRG weight",30115,Other,base rate x DRG weight,44227,,"38,809 x DRG weight",44227,Other,base rate x DRG weight,24179,,"6,363 x patient days",24179,Per diem,,81855,70,,81855,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,28555,,"25,057 x DRG weight",28555,Other,base rate x DRG weight,25700,,"22,552 x DRG weight",25700,Other,base rate x DRG weight,28555,,"25,057 x DRG weight",28555,Other,base rate x DRG weight,24271,,"21,298 x DRG weight",24271,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,81855,
SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITH MCC,573,MS-DRG,,,,,,,,inpatient,,,990952.69,104478,,,104478,Other,150% of Medicare + 9.63% HCRA Surcharge,63534,,"3,609.90 x patient days",63534,Per diem,,155739,,"25,046 x DRG weight",155739,Other,base rate x DRG weight,140162,,"22,541 x DRG weight",140162,Other,base rate x DRG weight,196013,,"31,523 x DRG weight",196013,Other,base rate x DRG weight,176414,,"28,371 x DRG weight",176414,Other,base rate x DRG weight,166614,,"26,795 x DRG weight",166614,Other,base rate x DRG weight,69887.4,,"3,970.89 x patient days",69887.4,Per diem,,139677,,"22,463 x DRG weight",139677,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,164320,,"26,426 x DRG weight",164320,Other,base rate x DRG weight,241318,,"38,809 x DRG weight",241318,Other,base rate x DRG weight,241318,,"38,809 x DRG weight",241318,Other,base rate x DRG weight,164320,,"26,426 x DRG weight",164320,Other,base rate x DRG weight,241318,,"38,809 x DRG weight",241318,Other,base rate x DRG weight,111989,,"6,363 x patient days",111989,Per diem,,693667,70,,693667,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,155807,,"25,057 x DRG weight",155807,Other,base rate x DRG weight,140231,,"22,552 x DRG weight",140231,Other,base rate x DRG weight,155807,,"25,057 x DRG weight",155807,Other,base rate x DRG weight,132433,,"21,298 x DRG weight",132433,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,693667,
SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITH CC,574,MS-DRG,,,,,,,,inpatient,,,415535.65,67080,,,67080,Other,150% of Medicare + 9.63% HCRA Surcharge,40792,,"3,609.90 x patient days",40792,Per diem,,85302,,"25,046 x DRG weight",85302,Other,base rate x DRG weight,76770,,"22,541 x DRG weight",76770,Other,base rate x DRG weight,107361,,"31,523 x DRG weight",107361,Other,base rate x DRG weight,96626,,"28,371 x DRG weight",96626,Other,base rate x DRG weight,91258,,"26,795 x DRG weight",91258,Other,base rate x DRG weight,44871.2,,"3,970.89 x patient days",44871.2,Per diem,,76504,,"22,463 x DRG weight",76504,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,90002,,"26,426 x DRG weight",90002,Other,base rate x DRG weight,132176,,"38,809 x DRG weight",132176,Other,base rate x DRG weight,132176,,"38,809 x DRG weight",132176,Other,base rate x DRG weight,90002,,"26,426 x DRG weight",90002,Other,base rate x DRG weight,132176,,"38,809 x DRG weight",132176,Other,base rate x DRG weight,71902,,"6,363 x patient days",71902,Per diem,,290875,70,,290875,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,85339,,"25,057 x DRG weight",85339,Other,base rate x DRG weight,76808,,"22,552 x DRG weight",76808,Other,base rate x DRG weight,85339,,"25,057 x DRG weight",85339,Other,base rate x DRG weight,72537,,"21,298 x DRG weight",72537,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,290875,
SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITHOUT CC/MCC,575,MS-DRG,,,,,,,,inpatient,,,126628.96,33836,,,33836,Other,150% of Medicare + 9.63% HCRA Surcharge,20576,,"3,609.90 x patient days",20576,Per diem,,51244,,"25,046 x DRG weight",51244,Other,base rate x DRG weight,46119,,"22,541 x DRG weight",46119,Other,base rate x DRG weight,64496,,"31,523 x DRG weight",64496,Other,base rate x DRG weight,58047,,"28,371 x DRG weight",58047,Other,base rate x DRG weight,54823,,"26,795 x DRG weight",54823,Other,base rate x DRG weight,22633.6,,"3,970.89 x patient days",22633.6,Per diem,,45959,,"22,463 x DRG weight",45959,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,54068,,"26,426 x DRG weight",54068,Other,base rate x DRG weight,79403,,"38,809 x DRG weight",79403,Other,base rate x DRG weight,79403,,"38,809 x DRG weight",79403,Other,base rate x DRG weight,54068,,"26,426 x DRG weight",54068,Other,base rate x DRG weight,79403,,"38,809 x DRG weight",79403,Other,base rate x DRG weight,36269,,"6,363 x patient days",36269,Per diem,,88640,70,,88640,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,51267,,"25,057 x DRG weight",51267,Other,base rate x DRG weight,46141,,"22,552 x DRG weight",46141,Other,base rate x DRG weight,51267,,"25,057 x DRG weight",51267,Other,base rate x DRG weight,43576,,"21,298 x DRG weight",43576,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,88640,
SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITH MCC,576,MS-DRG,,,,,,,,inpatient,,,1204252.37,87264,,,87264,Other,150% of Medicare + 9.63% HCRA Surcharge,53066,,"3,609.90 x patient days",53066,Per diem,,142339,,"25,046 x DRG weight",142339,Other,base rate x DRG weight,128103,,"22,541 x DRG weight",128103,Other,base rate x DRG weight,179148,,"31,523 x DRG weight",179148,Other,base rate x DRG weight,161235,,"28,371 x DRG weight",161235,Other,base rate x DRG weight,152279,,"26,795 x DRG weight",152279,Other,base rate x DRG weight,58372.6,,"3,970.89 x patient days",58372.6,Per diem,,127659,,"22,463 x DRG weight",127659,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,150182,,"26,426 x DRG weight",150182,Other,base rate x DRG weight,220555,,"38,809 x DRG weight",220555,Other,base rate x DRG weight,220555,,"38,809 x DRG weight",220555,Other,base rate x DRG weight,150182,,"26,426 x DRG weight",150182,Other,base rate x DRG weight,220555,,"38,809 x DRG weight",220555,Other,base rate x DRG weight,93536,,"6,363 x patient days",93536,Per diem,,842977,70,,842977,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,142401,,"25,057 x DRG weight",142401,Other,base rate x DRG weight,128165,,"22,552 x DRG weight",128165,Other,base rate x DRG weight,142401,,"25,057 x DRG weight",142401,Other,base rate x DRG weight,121039,,"21,298 x DRG weight",121039,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,842977,
SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITH CC,577,MS-DRG,,,,,,,,inpatient,,,447661.57,40960,,,40960,Other,150% of Medicare + 9.63% HCRA Surcharge,24908,,"3,609.90 x patient days",24908,Per diem,,66349,,"25,046 x DRG weight",66349,Other,base rate x DRG weight,59713,,"22,541 x DRG weight",59713,Other,base rate x DRG weight,83508,,"31,523 x DRG weight",83508,Other,base rate x DRG weight,75158,,"28,371 x DRG weight",75158,Other,base rate x DRG weight,70983,,"26,795 x DRG weight",70983,Other,base rate x DRG weight,27398.8,,"3,970.89 x patient days",27398.8,Per diem,,59507,,"22,463 x DRG weight",59507,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,70005,,"26,426 x DRG weight",70005,Other,base rate x DRG weight,102809,,"38,809 x DRG weight",102809,Other,base rate x DRG weight,102809,,"38,809 x DRG weight",102809,Other,base rate x DRG weight,70005,,"26,426 x DRG weight",70005,Other,base rate x DRG weight,102809,,"38,809 x DRG weight",102809,Other,base rate x DRG weight,43905,,"6,363 x patient days",43905,Per diem,,313363,70,,313363,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,66378,,"25,057 x DRG weight",66378,Other,base rate x DRG weight,59743,,"22,552 x DRG weight",59743,Other,base rate x DRG weight,66378,,"25,057 x DRG weight",66378,Other,base rate x DRG weight,56421,,"21,298 x DRG weight",56421,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,313363,
SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITHOUT CC/MCC,578,MS-DRG,,,,,,,,inpatient,,,107260.28,21371,,,21371,Other,150% of Medicare + 9.63% HCRA Surcharge,12996,,"3,609.90 x patient days",12996,Per diem,,40337,,"25,046 x DRG weight",40337,Other,base rate x DRG weight,36302,,"22,541 x DRG weight",36302,Other,base rate x DRG weight,50768,,"31,523 x DRG weight",50768,Other,base rate x DRG weight,45691,,"28,371 x DRG weight",45691,Other,base rate x DRG weight,43153,,"26,795 x DRG weight",43153,Other,base rate x DRG weight,14295.6,,"3,970.89 x patient days",14295.6,Per diem,,36177,,"22,463 x DRG weight",36177,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,42559,,"26,426 x DRG weight",42559,Other,base rate x DRG weight,62502,,"38,809 x DRG weight",62502,Other,base rate x DRG weight,62502,,"38,809 x DRG weight",62502,Other,base rate x DRG weight,42559,,"26,426 x DRG weight",42559,Other,base rate x DRG weight,62502,,"38,809 x DRG weight",62502,Other,base rate x DRG weight,22907,,"6,363 x patient days",22907,Per diem,,75082,70,,75082,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,40354,,"25,057 x DRG weight",40354,Other,base rate x DRG weight,36320,,"22,552 x DRG weight",36320,Other,base rate x DRG weight,40354,,"25,057 x DRG weight",40354,Other,base rate x DRG weight,34300,,"21,298 x DRG weight",34300,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,75082,
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITH MCC",579,MS-DRG,,,,,,,,inpatient,,,290583.64,65893,,,65893,Other,150% of Medicare + 9.63% HCRA Surcharge,40070,,"3,609.90 x patient days",40070,Per diem,,83709,,"25,046 x DRG weight",83709,Other,base rate x DRG weight,75337,,"22,541 x DRG weight",75337,Other,base rate x DRG weight,105356,,"31,523 x DRG weight",105356,Other,base rate x DRG weight,94822,,"28,371 x DRG weight",94822,Other,base rate x DRG weight,89554,,"26,795 x DRG weight",89554,Other,base rate x DRG weight,44077,,"3,970.89 x patient days",44077,Per diem,,75076,,"22,463 x DRG weight",75076,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,88321,,"26,426 x DRG weight",88321,Other,base rate x DRG weight,129707,,"38,809 x DRG weight",129707,Other,base rate x DRG weight,129707,,"38,809 x DRG weight",129707,Other,base rate x DRG weight,88321,,"26,426 x DRG weight",88321,Other,base rate x DRG weight,129707,,"38,809 x DRG weight",129707,Other,base rate x DRG weight,70629,,"6,363 x patient days",70629,Per diem,,203409,70,,203409,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,83746,,"25,057 x DRG weight",83746,Other,base rate x DRG weight,75373,,"22,552 x DRG weight",75373,Other,base rate x DRG weight,83746,,"25,057 x DRG weight",83746,Other,base rate x DRG weight,71182,,"21,298 x DRG weight",71182,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,203409,
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITH CC",580,MS-DRG,,,,,,,,inpatient,,,208980.23,33243,,,33243,Other,150% of Medicare + 9.63% HCRA Surcharge,20215,,"3,609.90 x patient days",20215,Per diem,,43745,,"25,046 x DRG weight",43745,Other,base rate x DRG weight,39370,,"22,541 x DRG weight",39370,Other,base rate x DRG weight,55058,,"31,523 x DRG weight",55058,Other,base rate x DRG weight,49553,,"28,371 x DRG weight",49553,Other,base rate x DRG weight,46800,,"26,795 x DRG weight",46800,Other,base rate x DRG weight,22236.5,,"3,970.89 x patient days",22236.5,Per diem,,39234,,"22,463 x DRG weight",39234,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,46156,,"26,426 x DRG weight",46156,Other,base rate x DRG weight,67784,,"38,809 x DRG weight",67784,Other,base rate x DRG weight,67784,,"38,809 x DRG weight",67784,Other,base rate x DRG weight,46156,,"26,426 x DRG weight",46156,Other,base rate x DRG weight,67784,,"38,809 x DRG weight",67784,Other,base rate x DRG weight,35633,,"6,363 x patient days",35633,Per diem,,146286,70,,146286,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,43765,,"25,057 x DRG weight",43765,Other,base rate x DRG weight,39389,,"22,552 x DRG weight",39389,Other,base rate x DRG weight,43765,,"25,057 x DRG weight",43765,Other,base rate x DRG weight,37199,,"21,298 x DRG weight",37199,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,146286,
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITHOUT CC/MCC",581,MS-DRG,,,,,,,,inpatient,,,140192.28,15435,,,15435,Other,150% of Medicare + 9.63% HCRA Surcharge,9386,,"3,609.90 x patient days",9386,Per diem,,33729,,"25,046 x DRG weight",33729,Other,base rate x DRG weight,30356,,"22,541 x DRG weight",30356,Other,base rate x DRG weight,42452,,"31,523 x DRG weight",42452,Other,base rate x DRG weight,38207,,"28,371 x DRG weight",38207,Other,base rate x DRG weight,36085,,"26,795 x DRG weight",36085,Other,base rate x DRG weight,10324.6,,"3,970.89 x patient days",10324.6,Per diem,,30251,,"22,463 x DRG weight",30251,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,35588,,"26,426 x DRG weight",35588,Other,base rate x DRG weight,52264,,"38,809 x DRG weight",52264,Other,base rate x DRG weight,52264,,"38,809 x DRG weight",52264,Other,base rate x DRG weight,35588,,"26,426 x DRG weight",35588,Other,base rate x DRG weight,52264,,"38,809 x DRG weight",52264,Other,base rate x DRG weight,16544,,"6,363 x patient days",16544,Per diem,,98135,70,,98135,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,33744,,"25,057 x DRG weight",33744,Other,base rate x DRG weight,30371,,"22,552 x DRG weight",30371,Other,base rate x DRG weight,33744,,"25,057 x DRG weight",33744,Other,base rate x DRG weight,28682,,"21,298 x DRG weight",28682,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,98135,
MASTECTOMY FOR MALIGNANCY WITH CC/MCC,582,MS-DRG,,,,,,,,inpatient,,,452655.36,20778,,,20778,Other,150% of Medicare + 9.63% HCRA Surcharge,12635,,"3,609.90 x patient days",12635,Per diem,,43613,,"25,046 x DRG weight",43613,Other,base rate x DRG weight,39251,,"22,541 x DRG weight",39251,Other,base rate x DRG weight,54891,,"31,523 x DRG weight",54891,Other,base rate x DRG weight,49402,,"28,371 x DRG weight",49402,Other,base rate x DRG weight,46658,,"26,795 x DRG weight",46658,Other,base rate x DRG weight,13898.5,,"3,970.89 x patient days",13898.5,Per diem,,39115,,"22,463 x DRG weight",39115,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,46016,,"26,426 x DRG weight",46016,Other,base rate x DRG weight,67578,,"38,809 x DRG weight",67578,Other,base rate x DRG weight,67578,,"38,809 x DRG weight",67578,Other,base rate x DRG weight,46016,,"26,426 x DRG weight",46016,Other,base rate x DRG weight,67578,,"38,809 x DRG weight",67578,Other,base rate x DRG weight,22271,,"6,363 x patient days",22271,Per diem,,316859,70,,316859,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,43632,,"25,057 x DRG weight",43632,Other,base rate x DRG weight,39270,,"22,552 x DRG weight",39270,Other,base rate x DRG weight,43632,,"25,057 x DRG weight",43632,Other,base rate x DRG weight,37086,,"21,298 x DRG weight",37086,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,316859,
MASTECTOMY FOR MALIGNANCY WITHOUT CC/MCC,583,MS-DRG,,,,,,,,inpatient,,,262765.06,11873,,,11873,Other,150% of Medicare + 9.63% HCRA Surcharge,7220,,"3,609.90 x patient days",7220,Per diem,,38118,,"25,046 x DRG weight",38118,Other,base rate x DRG weight,34305,,"22,541 x DRG weight",34305,Other,base rate x DRG weight,47975,,"31,523 x DRG weight",47975,Other,base rate x DRG weight,43178,,"28,371 x DRG weight",43178,Other,base rate x DRG weight,40779,,"26,795 x DRG weight",40779,Other,base rate x DRG weight,7942,,"3,970.89 x patient days",7942,Per diem,,34186,,"22,463 x DRG weight",34186,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,40218,,"26,426 x DRG weight",40218,Other,base rate x DRG weight,59063,,"38,809 x DRG weight",59063,Other,base rate x DRG weight,59063,,"38,809 x DRG weight",59063,Other,base rate x DRG weight,40218,,"26,426 x DRG weight",40218,Other,base rate x DRG weight,59063,,"38,809 x DRG weight",59063,Other,base rate x DRG weight,12726,,"6,363 x patient days",12726,Per diem,,183936,70,,183936,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,38134,,"25,057 x DRG weight",38134,Other,base rate x DRG weight,34322,,"22,552 x DRG weight",34322,Other,base rate x DRG weight,38134,,"25,057 x DRG weight",38134,Other,base rate x DRG weight,32413,,"21,298 x DRG weight",32413,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,183936,
"BREAST BIOPSY, LOCAL EXCISION AND OTHER BREAST PROCEDURES WITH CC/MCC",584,MS-DRG,,,,,,,,inpatient,,,281117.77,26714,,,26714,Other,150% of Medicare + 9.63% HCRA Surcharge,16245,,"3,609.90 x patient days",16245,Per diem,,49055,,"25,046 x DRG weight",49055,Other,base rate x DRG weight,44149,,"22,541 x DRG weight",44149,Other,base rate x DRG weight,61741,,"31,523 x DRG weight",61741,Other,base rate x DRG weight,55567,,"28,371 x DRG weight",55567,Other,base rate x DRG weight,52481,,"26,795 x DRG weight",52481,Other,base rate x DRG weight,17869.5,,"3,970.89 x patient days",17869.5,Per diem,,43996,,"22,463 x DRG weight",43996,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,51758,,"26,426 x DRG weight",51758,Other,base rate x DRG weight,76011,,"38,809 x DRG weight",76011,Other,base rate x DRG weight,76011,,"38,809 x DRG weight",76011,Other,base rate x DRG weight,51758,,"26,426 x DRG weight",51758,Other,base rate x DRG weight,76011,,"38,809 x DRG weight",76011,Other,base rate x DRG weight,28634,,"6,363 x patient days",28634,Per diem,,196782,70,,196782,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,49077,,"25,057 x DRG weight",49077,Other,base rate x DRG weight,44170,,"22,552 x DRG weight",44170,Other,base rate x DRG weight,49077,,"25,057 x DRG weight",49077,Other,base rate x DRG weight,41714,,"21,298 x DRG weight",41714,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,196782,
"BREAST BIOPSY, LOCAL EXCISION AND OTHER BREAST PROCEDURES WITHOUT CC/MCC",585,MS-DRG,,,,,,,,inpatient,,,166960.29,14248,,,14248,Other,150% of Medicare + 9.63% HCRA Surcharge,8664,,"3,609.90 x patient days",8664,Per diem,,42177,,"25,046 x DRG weight",42177,Other,base rate x DRG weight,37959,,"22,541 x DRG weight",37959,Other,base rate x DRG weight,53085,,"31,523 x DRG weight",53085,Other,base rate x DRG weight,47777,,"28,371 x DRG weight",47777,Other,base rate x DRG weight,45123,,"26,795 x DRG weight",45123,Other,base rate x DRG weight,9530.4,,"3,970.89 x patient days",9530.4,Per diem,,37828,,"22,463 x DRG weight",37828,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,44501,,"26,426 x DRG weight",44501,Other,base rate x DRG weight,65354,,"38,809 x DRG weight",65354,Other,base rate x DRG weight,65354,,"38,809 x DRG weight",65354,Other,base rate x DRG weight,44501,,"26,426 x DRG weight",44501,Other,base rate x DRG weight,65354,,"38,809 x DRG weight",65354,Other,base rate x DRG weight,15271,,"6,363 x patient days",15271,Per diem,,116872,70,,116872,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,42196,,"25,057 x DRG weight",42196,Other,base rate x DRG weight,37978,,"22,552 x DRG weight",37978,Other,base rate x DRG weight,42196,,"25,057 x DRG weight",42196,Other,base rate x DRG weight,35866,,"21,298 x DRG weight",35866,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,116872,
SKIN ULCERS WITH MCC,592,MS-DRG,,,,,,,,inpatient,,,154357.17,51646,,,51646,Other,150% of Medicare + 9.63% HCRA Surcharge,31406,,"3,609.90 x patient days",31406,Per diem,,52349,,"25,046 x DRG weight",52349,Other,base rate x DRG weight,47113,,"22,541 x DRG weight",47113,Other,base rate x DRG weight,65886,,"31,523 x DRG weight",65886,Other,base rate x DRG weight,59298,,"28,371 x DRG weight",59298,Other,base rate x DRG weight,56004,,"26,795 x DRG weight",56004,Other,base rate x DRG weight,34546.6,,"3,970.89 x patient days",34546.6,Per diem,,46950,,"22,463 x DRG weight",46950,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,55233,,"26,426 x DRG weight",55233,Other,base rate x DRG weight,81115,,"38,809 x DRG weight",81115,Other,base rate x DRG weight,81115,,"38,809 x DRG weight",81115,Other,base rate x DRG weight,55233,,"26,426 x DRG weight",55233,Other,base rate x DRG weight,81115,,"38,809 x DRG weight",81115,Other,base rate x DRG weight,55358,,"6,363 x patient days",55358,Per diem,,108050,70,,108050,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,52372,,"25,057 x DRG weight",52372,Other,base rate x DRG weight,47136,,"22,552 x DRG weight",47136,Other,base rate x DRG weight,52372,,"25,057 x DRG weight",52372,Other,base rate x DRG weight,44515,,"21,298 x DRG weight",44515,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,108050,
SKIN ULCERS WITH CC,593,MS-DRG,,,,,,,,inpatient,,,75200.5,33836,,,33836,Other,150% of Medicare + 9.63% HCRA Surcharge,20576,,"3,609.90 x patient days",20576,Per diem,,30303,,"25,046 x DRG weight",30303,Other,base rate x DRG weight,27272,,"22,541 x DRG weight",27272,Other,base rate x DRG weight,38140,,"31,523 x DRG weight",38140,Other,base rate x DRG weight,34326,,"28,371 x DRG weight",34326,Other,base rate x DRG weight,32419,,"26,795 x DRG weight",32419,Other,base rate x DRG weight,22633.6,,"3,970.89 x patient days",22633.6,Per diem,,27178,,"22,463 x DRG weight",27178,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,31973,,"26,426 x DRG weight",31973,Other,base rate x DRG weight,46955,,"38,809 x DRG weight",46955,Other,base rate x DRG weight,46955,,"38,809 x DRG weight",46955,Other,base rate x DRG weight,31973,,"26,426 x DRG weight",31973,Other,base rate x DRG weight,46955,,"38,809 x DRG weight",46955,Other,base rate x DRG weight,36269,,"6,363 x patient days",36269,Per diem,,52640,70,,52640,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,30316,,"25,057 x DRG weight",30316,Other,base rate x DRG weight,27286,,"22,552 x DRG weight",27286,Other,base rate x DRG weight,30316,,"25,057 x DRG weight",30316,Other,base rate x DRG weight,25768,,"21,298 x DRG weight",25768,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,52640,
SKIN ULCERS WITHOUT CC/MCC,594,MS-DRG,,,,,,,,inpatient,,,41415,23152,,,23152,Other,150% of Medicare + 9.63% HCRA Surcharge,14079,,"3,609.90 x patient days",14079,Per diem,,19721,,"25,046 x DRG weight",19721,Other,base rate x DRG weight,17749,,"22,541 x DRG weight",17749,Other,base rate x DRG weight,24821,,"31,523 x DRG weight",24821,Other,base rate x DRG weight,22339,,"28,371 x DRG weight",22339,Other,base rate x DRG weight,21098,,"26,795 x DRG weight",21098,Other,base rate x DRG weight,15486.9,,"3,970.89 x patient days",15486.9,Per diem,,17687,,"22,463 x DRG weight",17687,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,20808,,"26,426 x DRG weight",20808,Other,base rate x DRG weight,30558,,"38,809 x DRG weight",30558,Other,base rate x DRG weight,30558,,"38,809 x DRG weight",30558,Other,base rate x DRG weight,20808,,"26,426 x DRG weight",20808,Other,base rate x DRG weight,30558,,"38,809 x DRG weight",30558,Other,base rate x DRG weight,24816,,"6,363 x patient days",24816,Per diem,,28991,70,,28991,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,19730,,"25,057 x DRG weight",19730,Other,base rate x DRG weight,17757,,"22,552 x DRG weight",17757,Other,base rate x DRG weight,19730,,"25,057 x DRG weight",19730,Other,base rate x DRG weight,16770,,"21,298 x DRG weight",16770,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,30558,
MAJOR SKIN DISORDERS WITH MCC,595,MS-DRG,,,,,,,,inpatient,,,357838.87,47490,,,47490,Other,150% of Medicare + 9.63% HCRA Surcharge,28879,,"3,609.90 x patient days",28879,Per diem,,54475,,"25,046 x DRG weight",54475,Other,base rate x DRG weight,49027,,"22,541 x DRG weight",49027,Other,base rate x DRG weight,68563,,"31,523 x DRG weight",68563,Other,base rate x DRG weight,61707,,"28,371 x DRG weight",61707,Other,base rate x DRG weight,58279,,"26,795 x DRG weight",58279,Other,base rate x DRG weight,31766.9,,"3,970.89 x patient days",31766.9,Per diem,,48857,,"22,463 x DRG weight",48857,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,57477,,"26,426 x DRG weight",57477,Other,base rate x DRG weight,84410,,"38,809 x DRG weight",84410,Other,base rate x DRG weight,84410,,"38,809 x DRG weight",84410,Other,base rate x DRG weight,57477,,"26,426 x DRG weight",57477,Other,base rate x DRG weight,84410,,"38,809 x DRG weight",84410,Other,base rate x DRG weight,50904,,"6,363 x patient days",50904,Per diem,,250487,70,,250487,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,54499,,"25,057 x DRG weight",54499,Other,base rate x DRG weight,49051,,"22,552 x DRG weight",49051,Other,base rate x DRG weight,54499,,"25,057 x DRG weight",54499,Other,base rate x DRG weight,46323,,"21,298 x DRG weight",46323,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,250487,
MAJOR SKIN DISORDERS WITHOUT MCC,596,MS-DRG,,,,,,,,inpatient,,,121904.89,27308,,,27308,Other,150% of Medicare + 9.63% HCRA Surcharge,16606,,"3,609.90 x patient days",16606,Per diem,,25271,,"25,046 x DRG weight",25271,Other,base rate x DRG weight,22744,,"22,541 x DRG weight",22744,Other,base rate x DRG weight,31807,,"31,523 x DRG weight",31807,Other,base rate x DRG weight,28626,,"28,371 x DRG weight",28626,Other,base rate x DRG weight,27036,,"26,795 x DRG weight",27036,Other,base rate x DRG weight,18266.6,,"3,970.89 x patient days",18266.6,Per diem,,22665,,"22,463 x DRG weight",22665,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,26664,,"26,426 x DRG weight",26664,Other,base rate x DRG weight,39158,,"38,809 x DRG weight",39158,Other,base rate x DRG weight,39158,,"38,809 x DRG weight",39158,Other,base rate x DRG weight,26664,,"26,426 x DRG weight",26664,Other,base rate x DRG weight,39158,,"38,809 x DRG weight",39158,Other,base rate x DRG weight,29270,,"6,363 x patient days",29270,Per diem,,85333,70,,85333,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,25283,,"25,057 x DRG weight",25283,Other,base rate x DRG weight,22755,,"22,552 x DRG weight",22755,Other,base rate x DRG weight,25283,,"25,057 x DRG weight",25283,Other,base rate x DRG weight,21490,,"21,298 x DRG weight",21490,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,85333,
MALIGNANT BREAST DISORDERS WITH MCC,597,MS-DRG,,,,,,,,inpatient,,,231290.93,37992,,,37992,Other,150% of Medicare + 9.63% HCRA Surcharge,23103,,"3,609.90 x patient days",23103,Per diem,,40086,,"25,046 x DRG weight",40086,Other,base rate x DRG weight,36077,,"22,541 x DRG weight",36077,Other,base rate x DRG weight,50453,,"31,523 x DRG weight",50453,Other,base rate x DRG weight,45408,,"28,371 x DRG weight",45408,Other,base rate x DRG weight,42885,,"26,795 x DRG weight",42885,Other,base rate x DRG weight,25413.3,,"3,970.89 x patient days",25413.3,Per diem,,35952,,"22,463 x DRG weight",35952,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,42295,,"26,426 x DRG weight",42295,Other,base rate x DRG weight,62114,,"38,809 x DRG weight",62114,Other,base rate x DRG weight,62114,,"38,809 x DRG weight",62114,Other,base rate x DRG weight,42295,,"26,426 x DRG weight",42295,Other,base rate x DRG weight,62114,,"38,809 x DRG weight",62114,Other,base rate x DRG weight,40723,,"6,363 x patient days",40723,Per diem,,161904,70,,161904,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,40104,,"25,057 x DRG weight",40104,Other,base rate x DRG weight,36094,,"22,552 x DRG weight",36094,Other,base rate x DRG weight,40104,,"25,057 x DRG weight",40104,Other,base rate x DRG weight,34087,,"21,298 x DRG weight",34087,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,161904,
MALIGNANT BREAST DISORDERS WITH CC,598,MS-DRG,,,,,,,,inpatient,,,134604.21,29089,,,29089,Other,150% of Medicare + 9.63% HCRA Surcharge,17689,,"3,609.90 x patient days",17689,Per diem,,30025,,"25,046 x DRG weight",30025,Other,base rate x DRG weight,27022,,"22,541 x DRG weight",27022,Other,base rate x DRG weight,37790,,"31,523 x DRG weight",37790,Other,base rate x DRG weight,34011,,"28,371 x DRG weight",34011,Other,base rate x DRG weight,32122,,"26,795 x DRG weight",32122,Other,base rate x DRG weight,19457.9,,"3,970.89 x patient days",19457.9,Per diem,,26929,,"22,463 x DRG weight",26929,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,31679,,"26,426 x DRG weight",31679,Other,base rate x DRG weight,46524,,"38,809 x DRG weight",46524,Other,base rate x DRG weight,46524,,"38,809 x DRG weight",46524,Other,base rate x DRG weight,31679,,"26,426 x DRG weight",31679,Other,base rate x DRG weight,46524,,"38,809 x DRG weight",46524,Other,base rate x DRG weight,31179,,"6,363 x patient days",31179,Per diem,,94223,70,,94223,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,30038,,"25,057 x DRG weight",30038,Other,base rate x DRG weight,27035,,"22,552 x DRG weight",27035,Other,base rate x DRG weight,30038,,"25,057 x DRG weight",30038,Other,base rate x DRG weight,25532,,"21,298 x DRG weight",25532,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,94223,
MALIGNANT BREAST DISORDERS WITHOUT CC/MCC,599,MS-DRG,,,,,,,,inpatient,,,121904.89,13060,,,13060,Other,150% of Medicare + 9.63% HCRA Surcharge,7942,,"3,609.90 x patient days",7942,Per diem,,16851,,"25,046 x DRG weight",16851,Other,base rate x DRG weight,15166,,"22,541 x DRG weight",15166,Other,base rate x DRG weight,21209,,"31,523 x DRG weight",21209,Other,base rate x DRG weight,19088,,"28,371 x DRG weight",19088,Other,base rate x DRG weight,18028,,"26,795 x DRG weight",18028,Other,base rate x DRG weight,8736.2,,"3,970.89 x patient days",8736.2,Per diem,,15113,,"22,463 x DRG weight",15113,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,17779,,"26,426 x DRG weight",17779,Other,base rate x DRG weight,26111,,"38,809 x DRG weight",26111,Other,base rate x DRG weight,26111,,"38,809 x DRG weight",26111,Other,base rate x DRG weight,17779,,"26,426 x DRG weight",17779,Other,base rate x DRG weight,26111,,"38,809 x DRG weight",26111,Other,base rate x DRG weight,13999,,"6,363 x patient days",13999,Per diem,,85333,70,,85333,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,16858,,"25,057 x DRG weight",16858,Other,base rate x DRG weight,15173,,"22,552 x DRG weight",15173,Other,base rate x DRG weight,16858,,"25,057 x DRG weight",16858,Other,base rate x DRG weight,14329,,"21,298 x DRG weight",14329,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,85333,
NON-MALIGNANT BREAST DISORDERS WITH CC/MCC,600,MS-DRG,,,,,,,,inpatient,,,307554.34,26120,,,26120,Other,150% of Medicare + 9.63% HCRA Surcharge,15884,,"3,609.90 x patient days",15884,Per diem,,25685,,"25,046 x DRG weight",25685,Other,base rate x DRG weight,23116,,"22,541 x DRG weight",23116,Other,base rate x DRG weight,32327,,"31,523 x DRG weight",32327,Other,base rate x DRG weight,29094,,"28,371 x DRG weight",29094,Other,base rate x DRG weight,27478,,"26,795 x DRG weight",27478,Other,base rate x DRG weight,17472.4,,"3,970.89 x patient days",17472.4,Per diem,,23036,,"22,463 x DRG weight",23036,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,27100,,"26,426 x DRG weight",27100,Other,base rate x DRG weight,39799,,"38,809 x DRG weight",39799,Other,base rate x DRG weight,39799,,"38,809 x DRG weight",39799,Other,base rate x DRG weight,27100,,"26,426 x DRG weight",27100,Other,base rate x DRG weight,39799,,"38,809 x DRG weight",39799,Other,base rate x DRG weight,27997,,"6,363 x patient days",27997,Per diem,,215288,70,,215288,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,25696,,"25,057 x DRG weight",25696,Other,base rate x DRG weight,23127,,"22,552 x DRG weight",23127,Other,base rate x DRG weight,25696,,"25,057 x DRG weight",25696,Other,base rate x DRG weight,21841,,"21,298 x DRG weight",21841,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,215288,
NON-MALIGNANT BREAST DISORDERS WITHOUT CC/MCC,601,MS-DRG,,,,,,,,inpatient,,,54660.52,16622,,,16622,Other,150% of Medicare + 9.63% HCRA Surcharge,10108,,"3,609.90 x patient days",10108,Per diem,,15867,,"25,046 x DRG weight",15867,Other,base rate x DRG weight,14280,,"22,541 x DRG weight",14280,Other,base rate x DRG weight,19970,,"31,523 x DRG weight",19970,Other,base rate x DRG weight,17973,,"28,371 x DRG weight",17973,Other,base rate x DRG weight,16975,,"26,795 x DRG weight",16975,Other,base rate x DRG weight,11118.8,,"3,970.89 x patient days",11118.8,Per diem,,14230,,"22,463 x DRG weight",14230,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,16741,,"26,426 x DRG weight",16741,Other,base rate x DRG weight,24586,,"38,809 x DRG weight",24586,Other,base rate x DRG weight,24586,,"38,809 x DRG weight",24586,Other,base rate x DRG weight,16741,,"26,426 x DRG weight",16741,Other,base rate x DRG weight,24586,,"38,809 x DRG weight",24586,Other,base rate x DRG weight,17816,,"6,363 x patient days",17816,Per diem,,38262,70,,38262,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,15874,,"25,057 x DRG weight",15874,Other,base rate x DRG weight,14287,,"22,552 x DRG weight",14287,Other,base rate x DRG weight,15874,,"25,057 x DRG weight",15874,Other,base rate x DRG weight,13492,,"21,298 x DRG weight",13492,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,38262,
CELLULITIS WITH MCC,602,MS-DRG,,,,,,,,inpatient,,,167772.02,36804,,,36804,Other,150% of Medicare + 9.63% HCRA Surcharge,22381,,"3,609.90 x patient days",22381,Per diem,,37256,,"25,046 x DRG weight",37256,Other,base rate x DRG weight,33530,,"22,541 x DRG weight",33530,Other,base rate x DRG weight,46890,,"31,523 x DRG weight",46890,Other,base rate x DRG weight,42202,,"28,371 x DRG weight",42202,Other,base rate x DRG weight,39858,,"26,795 x DRG weight",39858,Other,base rate x DRG weight,24619.1,,"3,970.89 x patient days",24619.1,Per diem,,33414,,"22,463 x DRG weight",33414,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,39309,,"26,426 x DRG weight",39309,Other,base rate x DRG weight,57728,,"38,809 x DRG weight",57728,Other,base rate x DRG weight,57728,,"38,809 x DRG weight",57728,Other,base rate x DRG weight,39309,,"26,426 x DRG weight",39309,Other,base rate x DRG weight,57728,,"38,809 x DRG weight",57728,Other,base rate x DRG weight,39451,,"6,363 x patient days",39451,Per diem,,117440,70,,117440,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,37272,,"25,057 x DRG weight",37272,Other,base rate x DRG weight,33546,,"22,552 x DRG weight",33546,Other,base rate x DRG weight,37272,,"25,057 x DRG weight",37272,Other,base rate x DRG weight,31681,,"21,298 x DRG weight",31681,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,117440,
CELLULITIS WITHOUT MCC,603,MS-DRG,,,,,,,,inpatient,,,93896.51,23152,,,23152,Other,150% of Medicare + 9.63% HCRA Surcharge,14079,,"3,609.90 x patient days",14079,Per diem,,22158,,"25,046 x DRG weight",22158,Other,base rate x DRG weight,19942,,"22,541 x DRG weight",19942,Other,base rate x DRG weight,27888,,"31,523 x DRG weight",27888,Other,base rate x DRG weight,25100,,"28,371 x DRG weight",25100,Other,base rate x DRG weight,23706,,"26,795 x DRG weight",23706,Other,base rate x DRG weight,15486.9,,"3,970.89 x patient days",15486.9,Per diem,,19873,,"22,463 x DRG weight",19873,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,23379,,"26,426 x DRG weight",23379,Other,base rate x DRG weight,34334,,"38,809 x DRG weight",34334,Other,base rate x DRG weight,34334,,"38,809 x DRG weight",34334,Other,base rate x DRG weight,23379,,"26,426 x DRG weight",23379,Other,base rate x DRG weight,34334,,"38,809 x DRG weight",34334,Other,base rate x DRG weight,24816,,"6,363 x patient days",24816,Per diem,,65728,70,,65728,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,22168,,"25,057 x DRG weight",22168,Other,base rate x DRG weight,19952,,"22,552 x DRG weight",19952,Other,base rate x DRG weight,22168,,"25,057 x DRG weight",22168,Other,base rate x DRG weight,18842,,"21,298 x DRG weight",18842,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,65728,
"TRAUMA TO THE SKIN, SUBCUTANEOUS TISSUE AND BREAST WITH MCC",604,MS-DRG,,,,,,,,inpatient,,,201464.97,32649,,,32649,Other,150% of Medicare + 9.63% HCRA Surcharge,19854,,"3,609.90 x patient days",19854,Per diem,,37724,,"25,046 x DRG weight",37724,Other,base rate x DRG weight,33951,,"22,541 x DRG weight",33951,Other,base rate x DRG weight,47480,,"31,523 x DRG weight",47480,Other,base rate x DRG weight,42732,,"28,371 x DRG weight",42732,Other,base rate x DRG weight,40359,,"26,795 x DRG weight",40359,Other,base rate x DRG weight,21839.4,,"3,970.89 x patient days",21839.4,Per diem,,33834,,"22,463 x DRG weight",33834,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,39803,,"26,426 x DRG weight",39803,Other,base rate x DRG weight,58454,,"38,809 x DRG weight",58454,Other,base rate x DRG weight,58454,,"38,809 x DRG weight",58454,Other,base rate x DRG weight,39803,,"26,426 x DRG weight",39803,Other,base rate x DRG weight,58454,,"38,809 x DRG weight",58454,Other,base rate x DRG weight,34997,,"6,363 x patient days",34997,Per diem,,141025,70,,141025,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,37741,,"25,057 x DRG weight",37741,Other,base rate x DRG weight,33968,,"22,552 x DRG weight",33968,Other,base rate x DRG weight,37741,,"25,057 x DRG weight",37741,Other,base rate x DRG weight,32079,,"21,298 x DRG weight",32079,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,141025,
"TRAUMA TO THE SKIN, SUBCUTANEOUS TISSUE AND BREAST WITHOUT MCC",605,MS-DRG,,,,,,,,inpatient,,,101598.7,20184,,,20184,Other,150% of Medicare + 9.63% HCRA Surcharge,12274,,"3,609.90 x patient days",12274,Per diem,,22762,,"25,046 x DRG weight",22762,Other,base rate x DRG weight,20485,,"22,541 x DRG weight",20485,Other,base rate x DRG weight,28648,,"31,523 x DRG weight",28648,Other,base rate x DRG weight,25784,,"28,371 x DRG weight",25784,Other,base rate x DRG weight,24351,,"26,795 x DRG weight",24351,Other,base rate x DRG weight,13501.4,,"3,970.89 x patient days",13501.4,Per diem,,20414,,"22,463 x DRG weight",20414,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,24016,,"26,426 x DRG weight",24016,Other,base rate x DRG weight,35270,,"38,809 x DRG weight",35270,Other,base rate x DRG weight,35270,,"38,809 x DRG weight",35270,Other,base rate x DRG weight,24016,,"26,426 x DRG weight",24016,Other,base rate x DRG weight,35270,,"38,809 x DRG weight",35270,Other,base rate x DRG weight,21634,,"6,363 x patient days",21634,Per diem,,71119,70,,71119,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,22772,,"25,057 x DRG weight",22772,Other,base rate x DRG weight,20495,,"22,552 x DRG weight",20495,Other,base rate x DRG weight,22772,,"25,057 x DRG weight",22772,Other,base rate x DRG weight,19356,,"21,298 x DRG weight",19356,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,71119,
MINOR SKIN DISORDERS WITH MCC,606,MS-DRG,,,,,,,,inpatient,,,288867.89,40366,,,40366,Other,150% of Medicare + 9.63% HCRA Surcharge,24547,,"3,609.90 x patient days",24547,Per diem,,39718,,"25,046 x DRG weight",39718,Other,base rate x DRG weight,35746,,"22,541 x DRG weight",35746,Other,base rate x DRG weight,49989,,"31,523 x DRG weight",49989,Other,base rate x DRG weight,44991,,"28,371 x DRG weight",44991,Other,base rate x DRG weight,42492,,"26,795 x DRG weight",42492,Other,base rate x DRG weight,27001.7,,"3,970.89 x patient days",27001.7,Per diem,,35622,,"22,463 x DRG weight",35622,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,41906,,"26,426 x DRG weight",41906,Other,base rate x DRG weight,61543,,"38,809 x DRG weight",61543,Other,base rate x DRG weight,61543,,"38,809 x DRG weight",61543,Other,base rate x DRG weight,41906,,"26,426 x DRG weight",41906,Other,base rate x DRG weight,61543,,"38,809 x DRG weight",61543,Other,base rate x DRG weight,43268,,"6,363 x patient days",43268,Per diem,,202208,70,,202208,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,39735,,"25,057 x DRG weight",39735,Other,base rate x DRG weight,35763,,"22,552 x DRG weight",35763,Other,base rate x DRG weight,39735,,"25,057 x DRG weight",39735,Other,base rate x DRG weight,33774,,"21,298 x DRG weight",33774,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,202208,
MINOR SKIN DISORDERS WITHOUT MCC,607,MS-DRG,,,,,,,,inpatient,,,124704.26,23152,,,23152,Other,150% of Medicare + 9.63% HCRA Surcharge,14079,,"3,609.90 x patient days",14079,Per diem,,22379,,"25,046 x DRG weight",22379,Other,base rate x DRG weight,20140,,"22,541 x DRG weight",20140,Other,base rate x DRG weight,28166,,"31,523 x DRG weight",28166,Other,base rate x DRG weight,25349,,"28,371 x DRG weight",25349,Other,base rate x DRG weight,23941,,"26,795 x DRG weight",23941,Other,base rate x DRG weight,15486.9,,"3,970.89 x patient days",15486.9,Per diem,,20071,,"22,463 x DRG weight",20071,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,23612,,"26,426 x DRG weight",23612,Other,base rate x DRG weight,34676,,"38,809 x DRG weight",34676,Other,base rate x DRG weight,34676,,"38,809 x DRG weight",34676,Other,base rate x DRG weight,23612,,"26,426 x DRG weight",23612,Other,base rate x DRG weight,34676,,"38,809 x DRG weight",34676,Other,base rate x DRG weight,24816,,"6,363 x patient days",24816,Per diem,,87293,70,,87293,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,22388,,"25,057 x DRG weight",22388,Other,base rate x DRG weight,20150,,"22,552 x DRG weight",20150,Other,base rate x DRG weight,22388,,"25,057 x DRG weight",22388,Other,base rate x DRG weight,19030,,"21,298 x DRG weight",19030,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,87293,
ADRENAL AND PITUITARY PROCEDURES WITH CC/MCC,614,MS-DRG,,,,,,,,inpatient,,,290925.87,24340,,,24340,Other,150% of Medicare + 9.63% HCRA Surcharge,14801,,"3,609.90 x patient days",14801,Per diem,,56414,,"25,046 x DRG weight",56414,Other,base rate x DRG weight,50771,,"22,541 x DRG weight",50771,Other,base rate x DRG weight,71002,,"31,523 x DRG weight",71002,Other,base rate x DRG weight,63903,,"28,371 x DRG weight",63903,Other,base rate x DRG weight,60353,,"26,795 x DRG weight",60353,Other,base rate x DRG weight,16281.1,,"3,970.89 x patient days",16281.1,Per diem,,50596,,"22,463 x DRG weight",50596,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,59522,,"26,426 x DRG weight",59522,Other,base rate x DRG weight,87413,,"38,809 x DRG weight",87413,Other,base rate x DRG weight,87413,,"38,809 x DRG weight",87413,Other,base rate x DRG weight,59522,,"26,426 x DRG weight",59522,Other,base rate x DRG weight,87413,,"38,809 x DRG weight",87413,Other,base rate x DRG weight,26088,,"6,363 x patient days",26088,Per diem,,203648,70,,203648,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,56438,,"25,057 x DRG weight",56438,Other,base rate x DRG weight,50796,,"22,552 x DRG weight",50796,Other,base rate x DRG weight,56438,,"25,057 x DRG weight",56438,Other,base rate x DRG weight,47972,,"21,298 x DRG weight",47972,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,203648,
ADRENAL AND PITUITARY PROCEDURES WITHOUT CC/MCC,615,MS-DRG,,,,,,,,inpatient,,,252737.71,10686,,,10686,Other,150% of Medicare + 9.63% HCRA Surcharge,6498,,"3,609.90 x patient days",6498,Per diem,,36845,,"25,046 x DRG weight",36845,Other,base rate x DRG weight,33160,,"22,541 x DRG weight",33160,Other,base rate x DRG weight,46373,,"31,523 x DRG weight",46373,Other,base rate x DRG weight,41737,,"28,371 x DRG weight",41737,Other,base rate x DRG weight,39418,,"26,795 x DRG weight",39418,Other,base rate x DRG weight,7147.8,,"3,970.89 x patient days",7147.8,Per diem,,33045,,"22,463 x DRG weight",33045,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,38875,,"26,426 x DRG weight",38875,Other,base rate x DRG weight,57092,,"38,809 x DRG weight",57092,Other,base rate x DRG weight,57092,,"38,809 x DRG weight",57092,Other,base rate x DRG weight,38875,,"26,426 x DRG weight",38875,Other,base rate x DRG weight,57092,,"38,809 x DRG weight",57092,Other,base rate x DRG weight,11453,,"6,363 x patient days",11453,Per diem,,176916,70,,176916,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,36861,,"25,057 x DRG weight",36861,Other,base rate x DRG weight,33176,,"22,552 x DRG weight",33176,Other,base rate x DRG weight,36861,,"25,057 x DRG weight",36861,Other,base rate x DRG weight,31331,,"21,298 x DRG weight",31331,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,176916,
"AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH MCC",616,MS-DRG,,,,,,,,inpatient,,,496608.26,77172,,,77172,Other,150% of Medicare + 9.63% HCRA Surcharge,46929,,"3,609.90 x patient days",46929,Per diem,,99125,,"25,046 x DRG weight",99125,Other,base rate x DRG weight,89211,,"22,541 x DRG weight",89211,Other,base rate x DRG weight,124759,,"31,523 x DRG weight",124759,Other,base rate x DRG weight,112284,,"28,371 x DRG weight",112284,Other,base rate x DRG weight,106047,,"26,795 x DRG weight",106047,Other,base rate x DRG weight,51621.9,,"3,970.89 x patient days",51621.9,Per diem,,88902,,"22,463 x DRG weight",88902,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,104586,,"26,426 x DRG weight",104586,Other,base rate x DRG weight,153594,,"38,809 x DRG weight",153594,Other,base rate x DRG weight,153594,,"38,809 x DRG weight",153594,Other,base rate x DRG weight,104586,,"26,426 x DRG weight",104586,Other,base rate x DRG weight,153594,,"38,809 x DRG weight",153594,Other,base rate x DRG weight,82719,,"6,363 x patient days",82719,Per diem,,347626,70,,347626,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,99168,,"25,057 x DRG weight",99168,Other,base rate x DRG weight,89254,,"22,552 x DRG weight",89254,Other,base rate x DRG weight,99168,,"25,057 x DRG weight",99168,Other,base rate x DRG weight,84291,,"21,298 x DRG weight",84291,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,347626,
"AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC",617,MS-DRG,,,,,,,,inpatient,,,211436.08,41554,,,41554,Other,150% of Medicare + 9.63% HCRA Surcharge,25269,,"3,609.90 x patient days",25269,Per diem,,49704,,"25,046 x DRG weight",49704,Other,base rate x DRG weight,44733,,"22,541 x DRG weight",44733,Other,base rate x DRG weight,62557,,"31,523 x DRG weight",62557,Other,base rate x DRG weight,56302,,"28,371 x DRG weight",56302,Other,base rate x DRG weight,53175,,"26,795 x DRG weight",53175,Other,base rate x DRG weight,27795.9,,"3,970.89 x patient days",27795.9,Per diem,,44578,,"22,463 x DRG weight",44578,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,52442,,"26,426 x DRG weight",52442,Other,base rate x DRG weight,77016,,"38,809 x DRG weight",77016,Other,base rate x DRG weight,77016,,"38,809 x DRG weight",77016,Other,base rate x DRG weight,52442,,"26,426 x DRG weight",52442,Other,base rate x DRG weight,77016,,"38,809 x DRG weight",77016,Other,base rate x DRG weight,44541,,"6,363 x patient days",44541,Per diem,,148005,70,,148005,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,49726,,"25,057 x DRG weight",49726,Other,base rate x DRG weight,44754,,"22,552 x DRG weight",44754,Other,base rate x DRG weight,49726,,"25,057 x DRG weight",49726,Other,base rate x DRG weight,42266,,"21,298 x DRG weight",42266,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,148005,
"AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITHOUT CC/MCC",618,MS-DRG,,,,,,,,inpatient,,,82460.9,23152,,,23152,Other,150% of Medicare + 9.63% HCRA Surcharge,14079,,"3,609.90 x patient days",14079,Per diem,,29091,,"25,046 x DRG weight",29091,Other,base rate x DRG weight,26181,,"22,541 x DRG weight",26181,Other,base rate x DRG weight,36614,,"31,523 x DRG weight",36614,Other,base rate x DRG weight,32953,,"28,371 x DRG weight",32953,Other,base rate x DRG weight,31122,,"26,795 x DRG weight",31122,Other,base rate x DRG weight,15486.9,,"3,970.89 x patient days",15486.9,Per diem,,26091,,"22,463 x DRG weight",26091,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,30694,,"26,426 x DRG weight",30694,Other,base rate x DRG weight,45077,,"38,809 x DRG weight",45077,Other,base rate x DRG weight,45077,,"38,809 x DRG weight",45077,Other,base rate x DRG weight,30694,,"26,426 x DRG weight",30694,Other,base rate x DRG weight,45077,,"38,809 x DRG weight",45077,Other,base rate x DRG weight,24816,,"6,363 x patient days",24816,Per diem,,57723,70,,57723,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,29104,,"25,057 x DRG weight",29104,Other,base rate x DRG weight,26194,,"22,552 x DRG weight",26194,Other,base rate x DRG weight,29104,,"25,057 x DRG weight",29104,Other,base rate x DRG weight,24738,,"21,298 x DRG weight",24738,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,57723,
O.R. PROCEDURES FOR OBESITY WITH MCC,619,MS-DRG,,,,,,,,inpatient,,,65001.95,24933,,,24933,Other,150% of Medicare + 9.63% HCRA Surcharge,15162,,"3,609.90 x patient days",15162,Per diem,,65182,,"25,046 x DRG weight",65182,Other,base rate x DRG weight,58663,,"22,541 x DRG weight",58663,Other,base rate x DRG weight,82039,,"31,523 x DRG weight",82039,Other,base rate x DRG weight,73836,,"28,371 x DRG weight",73836,Other,base rate x DRG weight,69734,,"26,795 x DRG weight",69734,Other,base rate x DRG weight,16678.2,,"3,970.89 x patient days",16678.2,Per diem,,58460,,"22,463 x DRG weight",58460,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,68774,,"26,426 x DRG weight",68774,Other,base rate x DRG weight,101000,,"38,809 x DRG weight",101000,Other,base rate x DRG weight,101000,,"38,809 x DRG weight",101000,Other,base rate x DRG weight,68774,,"26,426 x DRG weight",68774,Other,base rate x DRG weight,101000,,"38,809 x DRG weight",101000,Other,base rate x DRG weight,26725,,"6,363 x patient days",26725,Per diem,,45501,70,,45501,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,65211,,"25,057 x DRG weight",65211,Other,base rate x DRG weight,58692,,"22,552 x DRG weight",58692,Other,base rate x DRG weight,65211,,"25,057 x DRG weight",65211,Other,base rate x DRG weight,55428,,"21,298 x DRG weight",55428,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,101000,
O.R. PROCEDURES FOR OBESITY WITH CC,620,MS-DRG,,,,,,,,inpatient,,,76851.85,11279,,,11279,Other,150% of Medicare + 9.63% HCRA Surcharge,6859,,"3,609.90 x patient days",6859,Per diem,,40630,,"25,046 x DRG weight",40630,Other,base rate x DRG weight,36566,,"22,541 x DRG weight",36566,Other,base rate x DRG weight,51137,,"31,523 x DRG weight",51137,Other,base rate x DRG weight,46023,,"28,371 x DRG weight",46023,Other,base rate x DRG weight,43467,,"26,795 x DRG weight",43467,Other,base rate x DRG weight,7544.9,,"3,970.89 x patient days",7544.9,Per diem,,36439,,"22,463 x DRG weight",36439,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,42868,,"26,426 x DRG weight",42868,Other,base rate x DRG weight,62956,,"38,809 x DRG weight",62956,Other,base rate x DRG weight,62956,,"38,809 x DRG weight",62956,Other,base rate x DRG weight,42868,,"26,426 x DRG weight",42868,Other,base rate x DRG weight,62956,,"38,809 x DRG weight",62956,Other,base rate x DRG weight,12090,,"6,363 x patient days",12090,Per diem,,53796,70,,53796,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,40647,,"25,057 x DRG weight",40647,Other,base rate x DRG weight,36584,,"22,552 x DRG weight",36584,Other,base rate x DRG weight,40647,,"25,057 x DRG weight",40647,Other,base rate x DRG weight,34550,,"21,298 x DRG weight",34550,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,62956,
"SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH MCC",622,MS-DRG,,,,,,,,inpatient,,,1025121.9,75985,,,75985,Other,150% of Medicare + 9.63% HCRA Surcharge,46207,,"3,609.90 x patient days",46207,Per diem,,95816,,"25,046 x DRG weight",95816,Other,base rate x DRG weight,86233,,"22,541 x DRG weight",86233,Other,base rate x DRG weight,120594,,"31,523 x DRG weight",120594,Other,base rate x DRG weight,108536,,"28,371 x DRG weight",108536,Other,base rate x DRG weight,102507,,"26,795 x DRG weight",102507,Other,base rate x DRG weight,50827.7,,"3,970.89 x patient days",50827.7,Per diem,,85934,,"22,463 x DRG weight",85934,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,101095,,"26,426 x DRG weight",101095,Other,base rate x DRG weight,148468,,"38,809 x DRG weight",148468,Other,base rate x DRG weight,148468,,"38,809 x DRG weight",148468,Other,base rate x DRG weight,101095,,"26,426 x DRG weight",101095,Other,base rate x DRG weight,148468,,"38,809 x DRG weight",148468,Other,base rate x DRG weight,81446,,"6,363 x patient days",81446,Per diem,,717585,70,,717585,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,95858,,"25,057 x DRG weight",95858,Other,base rate x DRG weight,86275,,"22,552 x DRG weight",86275,Other,base rate x DRG weight,95858,,"25,057 x DRG weight",95858,Other,base rate x DRG weight,81478,,"21,298 x DRG weight",81478,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,717585,
"SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC",623,MS-DRG,,,,,,,,inpatient,,,335410.92,39773,,,39773,Other,150% of Medicare + 9.63% HCRA Surcharge,24186,,"3,609.90 x patient days",24186,Per diem,,46621,,"25,046 x DRG weight",46621,Other,base rate x DRG weight,41958,,"22,541 x DRG weight",41958,Other,base rate x DRG weight,58677,,"31,523 x DRG weight",58677,Other,base rate x DRG weight,52810,,"28,371 x DRG weight",52810,Other,base rate x DRG weight,49876,,"26,795 x DRG weight",49876,Other,base rate x DRG weight,26604.6,,"3,970.89 x patient days",26604.6,Per diem,,41813,,"22,463 x DRG weight",41813,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,49189,,"26,426 x DRG weight",49189,Other,base rate x DRG weight,72239,,"38,809 x DRG weight",72239,Other,base rate x DRG weight,72239,,"38,809 x DRG weight",72239,Other,base rate x DRG weight,49189,,"26,426 x DRG weight",49189,Other,base rate x DRG weight,72239,,"38,809 x DRG weight",72239,Other,base rate x DRG weight,42632,,"6,363 x patient days",42632,Per diem,,234788,70,,234788,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,46641,,"25,057 x DRG weight",46641,Other,base rate x DRG weight,41978,,"22,552 x DRG weight",41978,Other,base rate x DRG weight,46641,,"25,057 x DRG weight",46641,Other,base rate x DRG weight,39644,,"21,298 x DRG weight",39644,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,234788,
"SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITHOUT CC/MCC",624,MS-DRG,,,,,,,,inpatient,,,82460.9,21965,,,21965,Other,150% of Medicare + 9.63% HCRA Surcharge,13357,,"3,609.90 x patient days",13357,Per diem,,27914,,"25,046 x DRG weight",27914,Other,base rate x DRG weight,25122,,"22,541 x DRG weight",25122,Other,base rate x DRG weight,35132,,"31,523 x DRG weight",35132,Other,base rate x DRG weight,31619,,"28,371 x DRG weight",31619,Other,base rate x DRG weight,29863,,"26,795 x DRG weight",29863,Other,base rate x DRG weight,14692.7,,"3,970.89 x patient days",14692.7,Per diem,,25035,,"22,463 x DRG weight",25035,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,29452,,"26,426 x DRG weight",29452,Other,base rate x DRG weight,43253,,"38,809 x DRG weight",43253,Other,base rate x DRG weight,43253,,"38,809 x DRG weight",43253,Other,base rate x DRG weight,29452,,"26,426 x DRG weight",29452,Other,base rate x DRG weight,43253,,"38,809 x DRG weight",43253,Other,base rate x DRG weight,23543,,"6,363 x patient days",23543,Per diem,,57723,70,,57723,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,27926,,"25,057 x DRG weight",27926,Other,base rate x DRG weight,25134,,"22,552 x DRG weight",25134,Other,base rate x DRG weight,27926,,"25,057 x DRG weight",27926,Other,base rate x DRG weight,23737,,"21,298 x DRG weight",23737,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,57723,
"THYROID, PARATHYROID AND THYROGLOSSAL PROCEDURES WITH MCC",625,MS-DRG,,,,,,,,inpatient,,,458181.8,48084,,,48084,Other,150% of Medicare + 9.63% HCRA Surcharge,29240,,"3,609.90 x patient days",29240,Per diem,,73164,,"25,046 x DRG weight",73164,Other,base rate x DRG weight,65847,,"22,541 x DRG weight",65847,Other,base rate x DRG weight,92085,,"31,523 x DRG weight",92085,Other,base rate x DRG weight,82877,,"28,371 x DRG weight",82877,Other,base rate x DRG weight,78274,,"26,795 x DRG weight",78274,Other,base rate x DRG weight,32164,,"3,970.89 x patient days",32164,Per diem,,65619,,"22,463 x DRG weight",65619,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,77196,,"26,426 x DRG weight",77196,Other,base rate x DRG weight,113369,,"38,809 x DRG weight",113369,Other,base rate x DRG weight,113369,,"38,809 x DRG weight",113369,Other,base rate x DRG weight,77196,,"26,426 x DRG weight",77196,Other,base rate x DRG weight,113369,,"38,809 x DRG weight",113369,Other,base rate x DRG weight,51540,,"6,363 x patient days",51540,Per diem,,320727,70,,320727,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,73197,,"25,057 x DRG weight",73197,Other,base rate x DRG weight,65879,,"22,552 x DRG weight",65879,Other,base rate x DRG weight,73197,,"25,057 x DRG weight",73197,Other,base rate x DRG weight,62216,,"21,298 x DRG weight",62216,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,320727,
"THYROID, PARATHYROID AND THYROGLOSSAL PROCEDURES WITH CC",626,MS-DRG,,,,,,,,inpatient,,,205070.14,16622,,,16622,Other,150% of Medicare + 9.63% HCRA Surcharge,10108,,"3,609.90 x patient days",10108,Per diem,,37366,,"25,046 x DRG weight",37366,Other,base rate x DRG weight,33629,,"22,541 x DRG weight",33629,Other,base rate x DRG weight,47029,,"31,523 x DRG weight",47029,Other,base rate x DRG weight,42327,,"28,371 x DRG weight",42327,Other,base rate x DRG weight,39975,,"26,795 x DRG weight",39975,Other,base rate x DRG weight,11118.8,,"3,970.89 x patient days",11118.8,Per diem,,33513,,"22,463 x DRG weight",33513,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,39425,,"26,426 x DRG weight",39425,Other,base rate x DRG weight,57899,,"38,809 x DRG weight",57899,Other,base rate x DRG weight,57899,,"38,809 x DRG weight",57899,Other,base rate x DRG weight,39425,,"26,426 x DRG weight",39425,Other,base rate x DRG weight,57899,,"38,809 x DRG weight",57899,Other,base rate x DRG weight,17816,,"6,363 x patient days",17816,Per diem,,143549,70,,143549,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,37383,,"25,057 x DRG weight",37383,Other,base rate x DRG weight,33645,,"22,552 x DRG weight",33645,Other,base rate x DRG weight,37383,,"25,057 x DRG weight",37383,Other,base rate x DRG weight,31774,,"21,298 x DRG weight",31774,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,143549,
"THYROID, PARATHYROID AND THYROGLOSSAL PROCEDURES WITHOUT CC/MCC",627,MS-DRG,,,,,,,,inpatient,,,115715.03,8905,,,8905,Other,150% of Medicare + 9.63% HCRA Surcharge,5415,,"3,609.90 x patient days",5415,Per diem,,30957,,"25,046 x DRG weight",30957,Other,base rate x DRG weight,27861,,"22,541 x DRG weight",27861,Other,base rate x DRG weight,38962,,"31,523 x DRG weight",38962,Other,base rate x DRG weight,35067,,"28,371 x DRG weight",35067,Other,base rate x DRG weight,33119,,"26,795 x DRG weight",33119,Other,base rate x DRG weight,5956.5,,"3,970.89 x patient days",5956.5,Per diem,,27764,,"22,463 x DRG weight",27764,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,32663,,"26,426 x DRG weight",32663,Other,base rate x DRG weight,47968,,"38,809 x DRG weight",47968,Other,base rate x DRG weight,47968,,"38,809 x DRG weight",47968,Other,base rate x DRG weight,32663,,"26,426 x DRG weight",32663,Other,base rate x DRG weight,47968,,"38,809 x DRG weight",47968,Other,base rate x DRG weight,9545,,"6,363 x patient days",9545,Per diem,,81001,70,,81001,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,30970,,"25,057 x DRG weight",30970,Other,base rate x DRG weight,27874,,"22,552 x DRG weight",27874,Other,base rate x DRG weight,30970,,"25,057 x DRG weight",30970,Other,base rate x DRG weight,26324,,"21,298 x DRG weight",26324,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,81001,
"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITH MCC",628,MS-DRG,,,,,,,,inpatient,,,493924.97,71830,,,71830,Other,150% of Medicare + 9.63% HCRA Surcharge,43680,,"3,609.90 x patient days",43680,Per diem,,100547,,"25,046 x DRG weight",100547,Other,base rate x DRG weight,90491,,"22,541 x DRG weight",90491,Other,base rate x DRG weight,126549,,"31,523 x DRG weight",126549,Other,base rate x DRG weight,113895,,"28,371 x DRG weight",113895,Other,base rate x DRG weight,107569,,"26,795 x DRG weight",107569,Other,base rate x DRG weight,48048,,"3,970.89 x patient days",48048,Per diem,,90178,,"22,463 x DRG weight",90178,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,106087,,"26,426 x DRG weight",106087,Other,base rate x DRG weight,155799,,"38,809 x DRG weight",155799,Other,base rate x DRG weight,155799,,"38,809 x DRG weight",155799,Other,base rate x DRG weight,106087,,"26,426 x DRG weight",106087,Other,base rate x DRG weight,155799,,"38,809 x DRG weight",155799,Other,base rate x DRG weight,76992,,"6,363 x patient days",76992,Per diem,,345747,70,,345747,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,100591,,"25,057 x DRG weight",100591,Other,base rate x DRG weight,90535,,"22,552 x DRG weight",90535,Other,base rate x DRG weight,100591,,"25,057 x DRG weight",100591,Other,base rate x DRG weight,85501,,"21,298 x DRG weight",85501,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,345747,
"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITH CC",629,MS-DRG,,,,,,,,inpatient,,,254257.07,43928,,,43928,Other,150% of Medicare + 9.63% HCRA Surcharge,26713,,"3,609.90 x patient days",26713,Per diem,,56674,,"25,046 x DRG weight",56674,Other,base rate x DRG weight,51006,,"22,541 x DRG weight",51006,Other,base rate x DRG weight,71330,,"31,523 x DRG weight",71330,Other,base rate x DRG weight,64198,,"28,371 x DRG weight",64198,Other,base rate x DRG weight,60632,,"26,795 x DRG weight",60632,Other,base rate x DRG weight,29384.3,,"3,970.89 x patient days",29384.3,Per diem,,50829,,"22,463 x DRG weight",50829,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,59797,,"26,426 x DRG weight",59797,Other,base rate x DRG weight,87817,,"38,809 x DRG weight",87817,Other,base rate x DRG weight,87817,,"38,809 x DRG weight",87817,Other,base rate x DRG weight,59797,,"26,426 x DRG weight",59797,Other,base rate x DRG weight,87817,,"38,809 x DRG weight",87817,Other,base rate x DRG weight,47086,,"6,363 x patient days",47086,Per diem,,177980,70,,177980,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,56699,,"25,057 x DRG weight",56699,Other,base rate x DRG weight,51031,,"22,552 x DRG weight",51031,Other,base rate x DRG weight,56699,,"25,057 x DRG weight",56699,Other,base rate x DRG weight,48193,,"21,298 x DRG weight",48193,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,177980,
"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITHOUT CC/MCC",630,MS-DRG,,,,,,,,inpatient,,,255914.82,16622,,,16622,Other,150% of Medicare + 9.63% HCRA Surcharge,10108,,"3,609.90 x patient days",10108,Per diem,,34972,,"25,046 x DRG weight",34972,Other,base rate x DRG weight,31474,,"22,541 x DRG weight",31474,Other,base rate x DRG weight,44016,,"31,523 x DRG weight",44016,Other,base rate x DRG weight,39614,,"28,371 x DRG weight",39614,Other,base rate x DRG weight,37414,,"26,795 x DRG weight",37414,Other,base rate x DRG weight,11118.8,,"3,970.89 x patient days",11118.8,Per diem,,31365,,"22,463 x DRG weight",31365,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,36899,,"26,426 x DRG weight",36899,Other,base rate x DRG weight,54189,,"38,809 x DRG weight",54189,Other,base rate x DRG weight,54189,,"38,809 x DRG weight",54189,Other,base rate x DRG weight,36899,,"26,426 x DRG weight",36899,Other,base rate x DRG weight,54189,,"38,809 x DRG weight",54189,Other,base rate x DRG weight,17816,,"6,363 x patient days",17816,Per diem,,179140,70,,179140,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,34987,,"25,057 x DRG weight",34987,Other,base rate x DRG weight,31489,,"22,552 x DRG weight",31489,Other,base rate x DRG weight,34987,,"25,057 x DRG weight",34987,Other,base rate x DRG weight,29738,,"21,298 x DRG weight",29738,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,179140,
DIABETES WITH MCC,637,MS-DRG,,,,,,,,inpatient,,,159288.06,33243,,,33243,Other,150% of Medicare + 9.63% HCRA Surcharge,20215,,"3,609.90 x patient days",20215,Per diem,,36299,,"25,046 x DRG weight",36299,Other,base rate x DRG weight,32669,,"22,541 x DRG weight",32669,Other,base rate x DRG weight,45686,,"31,523 x DRG weight",45686,Other,base rate x DRG weight,41118,,"28,371 x DRG weight",41118,Other,base rate x DRG weight,38834,,"26,795 x DRG weight",38834,Other,base rate x DRG weight,22236.5,,"3,970.89 x patient days",22236.5,Per diem,,32556,,"22,463 x DRG weight",32556,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,38299,,"26,426 x DRG weight",38299,Other,base rate x DRG weight,56246,,"38,809 x DRG weight",56246,Other,base rate x DRG weight,56246,,"38,809 x DRG weight",56246,Other,base rate x DRG weight,38299,,"26,426 x DRG weight",38299,Other,base rate x DRG weight,56246,,"38,809 x DRG weight",56246,Other,base rate x DRG weight,35633,,"6,363 x patient days",35633,Per diem,,111502,70,,111502,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,36315,,"25,057 x DRG weight",36315,Other,base rate x DRG weight,32685,,"22,552 x DRG weight",32685,Other,base rate x DRG weight,36315,,"25,057 x DRG weight",36315,Other,base rate x DRG weight,30867,,"21,298 x DRG weight",30867,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,111502,
DIABETES WITH CC,638,MS-DRG,,,,,,,,inpatient,,,110017.24,22559,,,22559,Other,150% of Medicare + 9.63% HCRA Surcharge,13718,,"3,609.90 x patient days",13718,Per diem,,22526,,"25,046 x DRG weight",22526,Other,base rate x DRG weight,20273,,"22,541 x DRG weight",20273,Other,base rate x DRG weight,28352,,"31,523 x DRG weight",28352,Other,base rate x DRG weight,25517,,"28,371 x DRG weight",25517,Other,base rate x DRG weight,24099,,"26,795 x DRG weight",24099,Other,base rate x DRG weight,15089.8,,"3,970.89 x patient days",15089.8,Per diem,,20203,,"22,463 x DRG weight",20203,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,23768,,"26,426 x DRG weight",23768,Other,base rate x DRG weight,34905,,"38,809 x DRG weight",34905,Other,base rate x DRG weight,34905,,"38,809 x DRG weight",34905,Other,base rate x DRG weight,23768,,"26,426 x DRG weight",23768,Other,base rate x DRG weight,34905,,"38,809 x DRG weight",34905,Other,base rate x DRG weight,24179,,"6,363 x patient days",24179,Per diem,,77012,70,,77012,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,22536,,"25,057 x DRG weight",22536,Other,base rate x DRG weight,20283,,"22,552 x DRG weight",20283,Other,base rate x DRG weight,22536,,"25,057 x DRG weight",22536,Other,base rate x DRG weight,19155,,"21,298 x DRG weight",19155,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,77012,
DIABETES WITHOUT CC/MCC,639,MS-DRG,,,,,,,,inpatient,,,69968.93,14841,,,14841,Other,150% of Medicare + 9.63% HCRA Surcharge,9025,,"3,609.90 x patient days",9025,Per diem,,15591,,"25,046 x DRG weight",15591,Other,base rate x DRG weight,14032,,"22,541 x DRG weight",14032,Other,base rate x DRG weight,19623,,"31,523 x DRG weight",19623,Other,base rate x DRG weight,17661,,"28,371 x DRG weight",17661,Other,base rate x DRG weight,16680,,"26,795 x DRG weight",16680,Other,base rate x DRG weight,9927.5,,"3,970.89 x patient days",9927.5,Per diem,,13983,,"22,463 x DRG weight",13983,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,16450,,"26,426 x DRG weight",16450,Other,base rate x DRG weight,24159,,"38,809 x DRG weight",24159,Other,base rate x DRG weight,24159,,"38,809 x DRG weight",24159,Other,base rate x DRG weight,16450,,"26,426 x DRG weight",16450,Other,base rate x DRG weight,24159,,"38,809 x DRG weight",24159,Other,base rate x DRG weight,15908,,"6,363 x patient days",15908,Per diem,,48978,70,,48978,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,15598,,"25,057 x DRG weight",15598,Other,base rate x DRG weight,14039,,"22,552 x DRG weight",14039,Other,base rate x DRG weight,15598,,"25,057 x DRG weight",15598,Other,base rate x DRG weight,13258,,"21,298 x DRG weight",13258,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,48978,
"MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITH MCC",640,MS-DRG,,,,,,,,inpatient,,,195858.9,30868,,,30868,Other,150% of Medicare + 9.63% HCRA Surcharge,18771,,"3,609.90 x patient days",18771,Per diem,,32940,,"25,046 x DRG weight",32940,Other,base rate x DRG weight,29646,,"22,541 x DRG weight",29646,Other,base rate x DRG weight,41459,,"31,523 x DRG weight",41459,Other,base rate x DRG weight,37314,,"28,371 x DRG weight",37314,Other,base rate x DRG weight,35241,,"26,795 x DRG weight",35241,Other,base rate x DRG weight,20648.1,,"3,970.89 x patient days",20648.1,Per diem,,29543,,"22,463 x DRG weight",29543,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,34755,,"26,426 x DRG weight",34755,Other,base rate x DRG weight,51042,,"38,809 x DRG weight",51042,Other,base rate x DRG weight,51042,,"38,809 x DRG weight",51042,Other,base rate x DRG weight,34755,,"26,426 x DRG weight",34755,Other,base rate x DRG weight,51042,,"38,809 x DRG weight",51042,Other,base rate x DRG weight,33088,,"6,363 x patient days",33088,Per diem,,137101,70,,137101,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,32955,,"25,057 x DRG weight",32955,Other,base rate x DRG weight,29660,,"22,552 x DRG weight",29660,Other,base rate x DRG weight,32955,,"25,057 x DRG weight",32955,Other,base rate x DRG weight,28011,,"21,298 x DRG weight",28011,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,137101,
"MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITHOUT MCC",641,MS-DRG,,,,,,,,inpatient,,,132454.53,20184,,,20184,Other,150% of Medicare + 9.63% HCRA Surcharge,12274,,"3,609.90 x patient days",12274,Per diem,,19571,,"25,046 x DRG weight",19571,Other,base rate x DRG weight,17614,,"22,541 x DRG weight",17614,Other,base rate x DRG weight,24632,,"31,523 x DRG weight",24632,Other,base rate x DRG weight,22169,,"28,371 x DRG weight",22169,Other,base rate x DRG weight,20938,,"26,795 x DRG weight",20938,Other,base rate x DRG weight,13501.4,,"3,970.89 x patient days",13501.4,Per diem,,17553,,"22,463 x DRG weight",17553,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,20649,,"26,426 x DRG weight",20649,Other,base rate x DRG weight,30325,,"38,809 x DRG weight",30325,Other,base rate x DRG weight,30325,,"38,809 x DRG weight",30325,Other,base rate x DRG weight,20649,,"26,426 x DRG weight",20649,Other,base rate x DRG weight,30325,,"38,809 x DRG weight",30325,Other,base rate x DRG weight,21634,,"6,363 x patient days",21634,Per diem,,92718,70,,92718,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,19580,,"25,057 x DRG weight",19580,Other,base rate x DRG weight,17622,,"22,552 x DRG weight",17622,Other,base rate x DRG weight,19580,,"25,057 x DRG weight",19580,Other,base rate x DRG weight,16642,,"21,298 x DRG weight",16642,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,92718,
INBORN AND OTHER DISORDERS OF METABOLISM,642,MS-DRG,,,,,,,,inpatient,,,93890.09,27901,,,27901,Other,150% of Medicare + 9.63% HCRA Surcharge,16967,,"3,609.90 x patient days",16967,Per diem,,32642,,"25,046 x DRG weight",32642,Other,base rate x DRG weight,29378,,"22,541 x DRG weight",29378,Other,base rate x DRG weight,41084,,"31,523 x DRG weight",41084,Other,base rate x DRG weight,36976,,"28,371 x DRG weight",36976,Other,base rate x DRG weight,34922,,"26,795 x DRG weight",34922,Other,base rate x DRG weight,18663.7,,"3,970.89 x patient days",18663.7,Per diem,,29276,,"22,463 x DRG weight",29276,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,34441,,"26,426 x DRG weight",34441,Other,base rate x DRG weight,50580,,"38,809 x DRG weight",50580,Other,base rate x DRG weight,50580,,"38,809 x DRG weight",50580,Other,base rate x DRG weight,34441,,"26,426 x DRG weight",34441,Other,base rate x DRG weight,50580,,"38,809 x DRG weight",50580,Other,base rate x DRG weight,29906,,"6,363 x patient days",29906,Per diem,,65723,70,,65723,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,32657,,"25,057 x DRG weight",32657,Other,base rate x DRG weight,29392,,"22,552 x DRG weight",29392,Other,base rate x DRG weight,32657,,"25,057 x DRG weight",32657,Other,base rate x DRG weight,27758,,"21,298 x DRG weight",27758,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,65723,
ENDOCRINE DISORDERS WITH MCC,643,MS-DRG,,,,,,,,inpatient,,,190340.66,39179,,,39179,Other,150% of Medicare + 9.63% HCRA Surcharge,23825,,"3,609.90 x patient days",23825,Per diem,,41203,,"25,046 x DRG weight",41203,Other,base rate x DRG weight,37082,,"22,541 x DRG weight",37082,Other,base rate x DRG weight,51858,,"31,523 x DRG weight",51858,Other,base rate x DRG weight,46673,,"28,371 x DRG weight",46673,Other,base rate x DRG weight,44080,,"26,795 x DRG weight",44080,Other,base rate x DRG weight,26207.5,,"3,970.89 x patient days",26207.5,Per diem,,36954,,"22,463 x DRG weight",36954,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,43473,,"26,426 x DRG weight",43473,Other,base rate x DRG weight,63845,,"38,809 x DRG weight",63845,Other,base rate x DRG weight,63845,,"38,809 x DRG weight",63845,Other,base rate x DRG weight,43473,,"26,426 x DRG weight",43473,Other,base rate x DRG weight,63845,,"38,809 x DRG weight",63845,Other,base rate x DRG weight,41996,,"6,363 x patient days",41996,Per diem,,133238,70,,133238,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,41221,,"25,057 x DRG weight",41221,Other,base rate x DRG weight,37100,,"22,552 x DRG weight",37100,Other,base rate x DRG weight,41221,,"25,057 x DRG weight",41221,Other,base rate x DRG weight,35037,,"21,298 x DRG weight",35037,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,133238,
ENDOCRINE DISORDERS WITH CC,644,MS-DRG,,,,,,,,inpatient,,,153940.75,26714,,,26714,Other,150% of Medicare + 9.63% HCRA Surcharge,16245,,"3,609.90 x patient days",16245,Per diem,,26591,,"25,046 x DRG weight",26591,Other,base rate x DRG weight,23932,,"22,541 x DRG weight",23932,Other,base rate x DRG weight,33468,,"31,523 x DRG weight",33468,Other,base rate x DRG weight,30121,,"28,371 x DRG weight",30121,Other,base rate x DRG weight,28448,,"26,795 x DRG weight",28448,Other,base rate x DRG weight,17869.5,,"3,970.89 x patient days",17869.5,Per diem,,23849,,"22,463 x DRG weight",23849,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,28056,,"26,426 x DRG weight",28056,Other,base rate x DRG weight,41204,,"38,809 x DRG weight",41204,Other,base rate x DRG weight,41204,,"38,809 x DRG weight",41204,Other,base rate x DRG weight,28056,,"26,426 x DRG weight",28056,Other,base rate x DRG weight,41204,,"38,809 x DRG weight",41204,Other,base rate x DRG weight,28634,,"6,363 x patient days",28634,Per diem,,107759,70,,107759,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,26603,,"25,057 x DRG weight",26603,Other,base rate x DRG weight,23943,,"22,552 x DRG weight",23943,Other,base rate x DRG weight,26603,,"25,057 x DRG weight",26603,Other,base rate x DRG weight,22612,,"21,298 x DRG weight",22612,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,107759,
ENDOCRINE DISORDERS WITHOUT CC/MCC,645,MS-DRG,,,,,,,,inpatient,,,82997.27,18997,,,18997,Other,150% of Medicare + 9.63% HCRA Surcharge,11552,,"3,609.90 x patient days",11552,Per diem,,19058,,"25,046 x DRG weight",19058,Other,base rate x DRG weight,17151,,"22,541 x DRG weight",17151,Other,base rate x DRG weight,23986,,"31,523 x DRG weight",23986,Other,base rate x DRG weight,21587,,"28,371 x DRG weight",21587,Other,base rate x DRG weight,20388,,"26,795 x DRG weight",20388,Other,base rate x DRG weight,12707.2,,"3,970.89 x patient days",12707.2,Per diem,,17092,,"22,463 x DRG weight",17092,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,20108,,"26,426 x DRG weight",20108,Other,base rate x DRG weight,29530,,"38,809 x DRG weight",29530,Other,base rate x DRG weight,29530,,"38,809 x DRG weight",29530,Other,base rate x DRG weight,20108,,"26,426 x DRG weight",20108,Other,base rate x DRG weight,29530,,"38,809 x DRG weight",29530,Other,base rate x DRG weight,20362,,"6,363 x patient days",20362,Per diem,,58098,70,,58098,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,19066,,"25,057 x DRG weight",19066,Other,base rate x DRG weight,17160,,"22,552 x DRG weight",17160,Other,base rate x DRG weight,19066,,"25,057 x DRG weight",19066,Other,base rate x DRG weight,16206,,"21,298 x DRG weight",16206,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,58098,
MAJOR BLADDER PROCEDURES WITH MCC,653,MS-DRG,,,,,,,,inpatient,,,995537.36,78953,,,78953,Other,150% of Medicare + 9.63% HCRA Surcharge,48012,,"3,609.90 x patient days",48012,Per diem,,135589,,"25,046 x DRG weight",135589,Other,base rate x DRG weight,122028,,"22,541 x DRG weight",122028,Other,base rate x DRG weight,170653,,"31,523 x DRG weight",170653,Other,base rate x DRG weight,153589,,"28,371 x DRG weight",153589,Other,base rate x DRG weight,145057,,"26,795 x DRG weight",145057,Other,base rate x DRG weight,52813.2,,"3,970.89 x patient days",52813.2,Per diem,,121606,,"22,463 x DRG weight",121606,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,143060,,"26,426 x DRG weight",143060,Other,base rate x DRG weight,210096,,"38,809 x DRG weight",210096,Other,base rate x DRG weight,210096,,"38,809 x DRG weight",210096,Other,base rate x DRG weight,143060,,"26,426 x DRG weight",143060,Other,base rate x DRG weight,210096,,"38,809 x DRG weight",210096,Other,base rate x DRG weight,84628,,"6,363 x patient days",84628,Per diem,,696876,70,,696876,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,135649,,"25,057 x DRG weight",135649,Other,base rate x DRG weight,122088,,"22,552 x DRG weight",122088,Other,base rate x DRG weight,135649,,"25,057 x DRG weight",135649,Other,base rate x DRG weight,115299,,"21,298 x DRG weight",115299,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,696876,
MAJOR BLADDER PROCEDURES WITH CC,654,MS-DRG,,,,,,,,inpatient,,,341123.2,37992,,,37992,Other,150% of Medicare + 9.63% HCRA Surcharge,23103,,"3,609.90 x patient days",23103,Per diem,,68563,,"25,046 x DRG weight",68563,Other,base rate x DRG weight,61706,,"22,541 x DRG weight",61706,Other,base rate x DRG weight,86294,,"31,523 x DRG weight",86294,Other,base rate x DRG weight,77666,,"28,371 x DRG weight",77666,Other,base rate x DRG weight,73351,,"26,795 x DRG weight",73351,Other,base rate x DRG weight,25413.3,,"3,970.89 x patient days",25413.3,Per diem,,61492,,"22,463 x DRG weight",61492,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,72341,,"26,426 x DRG weight",72341,Other,base rate x DRG weight,106240,,"38,809 x DRG weight",106240,Other,base rate x DRG weight,106240,,"38,809 x DRG weight",106240,Other,base rate x DRG weight,72341,,"26,426 x DRG weight",72341,Other,base rate x DRG weight,106240,,"38,809 x DRG weight",106240,Other,base rate x DRG weight,40723,,"6,363 x patient days",40723,Per diem,,238786,70,,238786,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,68594,,"25,057 x DRG weight",68594,Other,base rate x DRG weight,61736,,"22,552 x DRG weight",61736,Other,base rate x DRG weight,68594,,"25,057 x DRG weight",68594,Other,base rate x DRG weight,58303,,"21,298 x DRG weight",58303,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,238786,
MAJOR BLADDER PROCEDURES WITHOUT CC/MCC,655,MS-DRG,,,,,,,,inpatient,,,232323.22,23746,,,23746,Other,150% of Medicare + 9.63% HCRA Surcharge,14440,,"3,609.90 x patient days",14440,Per diem,,52792,,"25,046 x DRG weight",52792,Other,base rate x DRG weight,47512,,"22,541 x DRG weight",47512,Other,base rate x DRG weight,66444,,"31,523 x DRG weight",66444,Other,base rate x DRG weight,59800,,"28,371 x DRG weight",59800,Other,base rate x DRG weight,56479,,"26,795 x DRG weight",56479,Other,base rate x DRG weight,15884,,"3,970.89 x patient days",15884,Per diem,,47348,,"22,463 x DRG weight",47348,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,55701,,"26,426 x DRG weight",55701,Other,base rate x DRG weight,81802,,"38,809 x DRG weight",81802,Other,base rate x DRG weight,81802,,"38,809 x DRG weight",81802,Other,base rate x DRG weight,55701,,"26,426 x DRG weight",55701,Other,base rate x DRG weight,81802,,"38,809 x DRG weight",81802,Other,base rate x DRG weight,25452,,"6,363 x patient days",25452,Per diem,,162626,70,,162626,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,52815,,"25,057 x DRG weight",52815,Other,base rate x DRG weight,47535,,"22,552 x DRG weight",47535,Other,base rate x DRG weight,52815,,"25,057 x DRG weight",52815,Other,base rate x DRG weight,44892,,"21,298 x DRG weight",44892,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,162626,
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH MCC,656,MS-DRG,,,,,,,,inpatient,,,427366.57,43928,,,43928,Other,150% of Medicare + 9.63% HCRA Surcharge,26713,,"3,609.90 x patient days",26713,Per diem,,78584,,"25,046 x DRG weight",78584,Other,base rate x DRG weight,70725,,"22,541 x DRG weight",70725,Other,base rate x DRG weight,98907,,"31,523 x DRG weight",98907,Other,base rate x DRG weight,89017,,"28,371 x DRG weight",89017,Other,base rate x DRG weight,84072,,"26,795 x DRG weight",84072,Other,base rate x DRG weight,29384.3,,"3,970.89 x patient days",29384.3,Per diem,,70480,,"22,463 x DRG weight",70480,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,82914,,"26,426 x DRG weight",82914,Other,base rate x DRG weight,121767,,"38,809 x DRG weight",121767,Other,base rate x DRG weight,121767,,"38,809 x DRG weight",121767,Other,base rate x DRG weight,82914,,"26,426 x DRG weight",82914,Other,base rate x DRG weight,121767,,"38,809 x DRG weight",121767,Other,base rate x DRG weight,47086,,"6,363 x patient days",47086,Per diem,,299157,70,,299157,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,78619,,"25,057 x DRG weight",78619,Other,base rate x DRG weight,70759,,"22,552 x DRG weight",70759,Other,base rate x DRG weight,78619,,"25,057 x DRG weight",78619,Other,base rate x DRG weight,66825,,"21,298 x DRG weight",66825,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,299157,
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH CC,657,MS-DRG,,,,,,,,inpatient,,,168435.95,20778,,,20778,Other,150% of Medicare + 9.63% HCRA Surcharge,12635,,"3,609.90 x patient days",12635,Per diem,,46190,,"25,046 x DRG weight",46190,Other,base rate x DRG weight,41570,,"22,541 x DRG weight",41570,Other,base rate x DRG weight,58135,,"31,523 x DRG weight",58135,Other,base rate x DRG weight,52322,,"28,371 x DRG weight",52322,Other,base rate x DRG weight,49415,,"26,795 x DRG weight",49415,Other,base rate x DRG weight,13898.5,,"3,970.89 x patient days",13898.5,Per diem,,41426,,"22,463 x DRG weight",41426,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,48735,,"26,426 x DRG weight",48735,Other,base rate x DRG weight,71572,,"38,809 x DRG weight",71572,Other,base rate x DRG weight,71572,,"38,809 x DRG weight",71572,Other,base rate x DRG weight,48735,,"26,426 x DRG weight",48735,Other,base rate x DRG weight,71572,,"38,809 x DRG weight",71572,Other,base rate x DRG weight,22271,,"6,363 x patient days",22271,Per diem,,117905,70,,117905,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,46210,,"25,057 x DRG weight",46210,Other,base rate x DRG weight,41590,,"22,552 x DRG weight",41590,Other,base rate x DRG weight,46210,,"25,057 x DRG weight",46210,Other,base rate x DRG weight,39278,,"21,298 x DRG weight",39278,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,117905,
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITHOUT CC/MCC,658,MS-DRG,,,,,,,,inpatient,,,79976.07,11873,,,11873,Other,150% of Medicare + 9.63% HCRA Surcharge,7220,,"3,609.90 x patient days",7220,Per diem,,37078,,"25,046 x DRG weight",37078,Other,base rate x DRG weight,33370,,"22,541 x DRG weight",33370,Other,base rate x DRG weight,46667,,"31,523 x DRG weight",46667,Other,base rate x DRG weight,42000,,"28,371 x DRG weight",42000,Other,base rate x DRG weight,39667,,"26,795 x DRG weight",39667,Other,base rate x DRG weight,7942,,"3,970.89 x patient days",7942,Per diem,,33254,,"22,463 x DRG weight",33254,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,39121,,"26,426 x DRG weight",39121,Other,base rate x DRG weight,57453,,"38,809 x DRG weight",57453,Other,base rate x DRG weight,57453,,"38,809 x DRG weight",57453,Other,base rate x DRG weight,39121,,"26,426 x DRG weight",39121,Other,base rate x DRG weight,57453,,"38,809 x DRG weight",57453,Other,base rate x DRG weight,12726,,"6,363 x patient days",12726,Per diem,,55983,70,,55983,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,37094,,"25,057 x DRG weight",37094,Other,base rate x DRG weight,33386,,"22,552 x DRG weight",33386,Other,base rate x DRG weight,37094,,"25,057 x DRG weight",37094,Other,base rate x DRG weight,31530,,"21,298 x DRG weight",31530,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,57453,
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH MCC,659,MS-DRG,,,,,,,,inpatient,,,388139.55,48677,,,48677,Other,150% of Medicare + 9.63% HCRA Surcharge,29601,,"3,609.90 x patient days",29601,Per diem,,64842,,"25,046 x DRG weight",64842,Other,base rate x DRG weight,58356,,"22,541 x DRG weight",58356,Other,base rate x DRG weight,81610,,"31,523 x DRG weight",81610,Other,base rate x DRG weight,73450,,"28,371 x DRG weight",73450,Other,base rate x DRG weight,69370,,"26,795 x DRG weight",69370,Other,base rate x DRG weight,32561.1,,"3,970.89 x patient days",32561.1,Per diem,,58154,,"22,463 x DRG weight",58154,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,68414,,"26,426 x DRG weight",68414,Other,base rate x DRG weight,100473,,"38,809 x DRG weight",100473,Other,base rate x DRG weight,100473,,"38,809 x DRG weight",100473,Other,base rate x DRG weight,68414,,"26,426 x DRG weight",68414,Other,base rate x DRG weight,100473,,"38,809 x DRG weight",100473,Other,base rate x DRG weight,52177,,"6,363 x patient days",52177,Per diem,,271698,70,,271698,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,64870,,"25,057 x DRG weight",64870,Other,base rate x DRG weight,58385,,"22,552 x DRG weight",58385,Other,base rate x DRG weight,64870,,"25,057 x DRG weight",64870,Other,base rate x DRG weight,55138,,"21,298 x DRG weight",55138,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,271698,
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH CC,660,MS-DRG,,,,,,,,inpatient,,,183635.31,22559,,,22559,Other,150% of Medicare + 9.63% HCRA Surcharge,13718,,"3,609.90 x patient days",13718,Per diem,,33709,,"25,046 x DRG weight",33709,Other,base rate x DRG weight,30338,,"22,541 x DRG weight",30338,Other,base rate x DRG weight,42427,,"31,523 x DRG weight",42427,Other,base rate x DRG weight,38185,,"28,371 x DRG weight",38185,Other,base rate x DRG weight,36063,,"26,795 x DRG weight",36063,Other,base rate x DRG weight,15089.8,,"3,970.89 x patient days",15089.8,Per diem,,30233,,"22,463 x DRG weight",30233,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,35567,,"26,426 x DRG weight",35567,Other,base rate x DRG weight,52233,,"38,809 x DRG weight",52233,Other,base rate x DRG weight,52233,,"38,809 x DRG weight",52233,Other,base rate x DRG weight,35567,,"26,426 x DRG weight",35567,Other,base rate x DRG weight,52233,,"38,809 x DRG weight",52233,Other,base rate x DRG weight,24179,,"6,363 x patient days",24179,Per diem,,128545,70,,128545,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,33724,,"25,057 x DRG weight",33724,Other,base rate x DRG weight,30353,,"22,552 x DRG weight",30353,Other,base rate x DRG weight,33724,,"25,057 x DRG weight",33724,Other,base rate x DRG weight,28665,,"21,298 x DRG weight",28665,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,128545,
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITHOUT CC/MCC,661,MS-DRG,,,,,,,,inpatient,,,97671.39,13060,,,13060,Other,150% of Medicare + 9.63% HCRA Surcharge,7942,,"3,609.90 x patient days",7942,Per diem,,26258,,"25,046 x DRG weight",26258,Other,base rate x DRG weight,23632,,"22,541 x DRG weight",23632,Other,base rate x DRG weight,33049,,"31,523 x DRG weight",33049,Other,base rate x DRG weight,29744,,"28,371 x DRG weight",29744,Other,base rate x DRG weight,28092,,"26,795 x DRG weight",28092,Other,base rate x DRG weight,8736.2,,"3,970.89 x patient days",8736.2,Per diem,,23550,,"22,463 x DRG weight",23550,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,27705,,"26,426 x DRG weight",27705,Other,base rate x DRG weight,40687,,"38,809 x DRG weight",40687,Other,base rate x DRG weight,40687,,"38,809 x DRG weight",40687,Other,base rate x DRG weight,27705,,"26,426 x DRG weight",27705,Other,base rate x DRG weight,40687,,"38,809 x DRG weight",40687,Other,base rate x DRG weight,13999,,"6,363 x patient days",13999,Per diem,,68370,70,,68370,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,26270,,"25,057 x DRG weight",26270,Other,base rate x DRG weight,23644,,"22,552 x DRG weight",23644,Other,base rate x DRG weight,26270,,"25,057 x DRG weight",26270,Other,base rate x DRG weight,22329,,"21,298 x DRG weight",22329,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,68370,
MINOR BLADDER PROCEDURES WITH MCC,662,MS-DRG,,,,,,,,inpatient,,,275160.83,59363,,,59363,Other,150% of Medicare + 9.63% HCRA Surcharge,36099,,"3,609.90 x patient days",36099,Per diem,,75055,,"25,046 x DRG weight",75055,Other,base rate x DRG weight,67549,,"22,541 x DRG weight",67549,Other,base rate x DRG weight,94465,,"31,523 x DRG weight",94465,Other,base rate x DRG weight,85019,,"28,371 x DRG weight",85019,Other,base rate x DRG weight,80297,,"26,795 x DRG weight",80297,Other,base rate x DRG weight,39708.9,,"3,970.89 x patient days",39708.9,Per diem,,67315,,"22,463 x DRG weight",67315,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,79191,,"26,426 x DRG weight",79191,Other,base rate x DRG weight,116299,,"38,809 x DRG weight",116299,Other,base rate x DRG weight,116299,,"38,809 x DRG weight",116299,Other,base rate x DRG weight,79191,,"26,426 x DRG weight",79191,Other,base rate x DRG weight,116299,,"38,809 x DRG weight",116299,Other,base rate x DRG weight,63630,,"6,363 x patient days",63630,Per diem,,192613,70,,192613,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,75088,,"25,057 x DRG weight",75088,Other,base rate x DRG weight,67582,,"22,552 x DRG weight",67582,Other,base rate x DRG weight,75088,,"25,057 x DRG weight",75088,Other,base rate x DRG weight,63824,,"21,298 x DRG weight",63824,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,192613,
MINOR BLADDER PROCEDURES WITH CC,663,MS-DRG,,,,,,,,inpatient,,,169235.84,27901,,,27901,Other,150% of Medicare + 9.63% HCRA Surcharge,16967,,"3,609.90 x patient days",16967,Per diem,,36542,,"25,046 x DRG weight",36542,Other,base rate x DRG weight,32887,,"22,541 x DRG weight",32887,Other,base rate x DRG weight,45992,,"31,523 x DRG weight",45992,Other,base rate x DRG weight,41393,,"28,371 x DRG weight",41393,Other,base rate x DRG weight,39094,,"26,795 x DRG weight",39094,Other,base rate x DRG weight,18663.7,,"3,970.89 x patient days",18663.7,Per diem,,32774,,"22,463 x DRG weight",32774,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,38556,,"26,426 x DRG weight",38556,Other,base rate x DRG weight,56622,,"38,809 x DRG weight",56622,Other,base rate x DRG weight,56622,,"38,809 x DRG weight",56622,Other,base rate x DRG weight,38556,,"26,426 x DRG weight",38556,Other,base rate x DRG weight,56622,,"38,809 x DRG weight",56622,Other,base rate x DRG weight,29906,,"6,363 x patient days",29906,Per diem,,118465,70,,118465,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,36558,,"25,057 x DRG weight",36558,Other,base rate x DRG weight,32903,,"22,552 x DRG weight",32903,Other,base rate x DRG weight,36558,,"25,057 x DRG weight",36558,Other,base rate x DRG weight,31074,,"21,298 x DRG weight",31074,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,118465,
MINOR BLADDER PROCEDURES WITHOUT CC/MCC,664,MS-DRG,,,,,,,,inpatient,,,136684.75,13060,,,13060,Other,150% of Medicare + 9.63% HCRA Surcharge,7942,,"3,609.90 x patient days",7942,Per diem,,26589,,"25,046 x DRG weight",26589,Other,base rate x DRG weight,23930,,"22,541 x DRG weight",23930,Other,base rate x DRG weight,33465,,"31,523 x DRG weight",33465,Other,base rate x DRG weight,30119,,"28,371 x DRG weight",30119,Other,base rate x DRG weight,28446,,"26,795 x DRG weight",28446,Other,base rate x DRG weight,8736.2,,"3,970.89 x patient days",8736.2,Per diem,,23847,,"22,463 x DRG weight",23847,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,28054,,"26,426 x DRG weight",28054,Other,base rate x DRG weight,41200,,"38,809 x DRG weight",41200,Other,base rate x DRG weight,41200,,"38,809 x DRG weight",41200,Other,base rate x DRG weight,28054,,"26,426 x DRG weight",28054,Other,base rate x DRG weight,41200,,"38,809 x DRG weight",41200,Other,base rate x DRG weight,13999,,"6,363 x patient days",13999,Per diem,,95679,70,,95679,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,26601,,"25,057 x DRG weight",26601,Other,base rate x DRG weight,23941,,"22,552 x DRG weight",23941,Other,base rate x DRG weight,26601,,"25,057 x DRG weight",26601,Other,base rate x DRG weight,22610,,"21,298 x DRG weight",22610,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,95679,
PROSTATECTOMY WITH MCC,665,MS-DRG,,,,,,,,inpatient,,,166503.8,62925,,,62925,Other,150% of Medicare + 9.63% HCRA Surcharge,38265,,"3,609.90 x patient days",38265,Per diem,,77370,,"25,046 x DRG weight",77370,Other,base rate x DRG weight,69631,,"22,541 x DRG weight",69631,Other,base rate x DRG weight,97378,,"31,523 x DRG weight",97378,Other,base rate x DRG weight,87641,,"28,371 x DRG weight",87641,Other,base rate x DRG weight,82772,,"26,795 x DRG weight",82772,Other,base rate x DRG weight,42091.5,,"3,970.89 x patient days",42091.5,Per diem,,69390,,"22,463 x DRG weight",69390,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,81633,,"26,426 x DRG weight",81633,Other,base rate x DRG weight,119885,,"38,809 x DRG weight",119885,Other,base rate x DRG weight,119885,,"38,809 x DRG weight",119885,Other,base rate x DRG weight,81633,,"26,426 x DRG weight",81633,Other,base rate x DRG weight,119885,,"38,809 x DRG weight",119885,Other,base rate x DRG weight,67448,,"6,363 x patient days",67448,Per diem,,116553,70,,116553,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,77404,,"25,057 x DRG weight",77404,Other,base rate x DRG weight,69665,,"22,552 x DRG weight",69665,Other,base rate x DRG weight,77404,,"25,057 x DRG weight",77404,Other,base rate x DRG weight,65792,,"21,298 x DRG weight",65792,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,119885,
PROSTATECTOMY WITH CC,666,MS-DRG,,,,,,,,inpatient,,,199155.01,29682,,,29682,Other,150% of Medicare + 9.63% HCRA Surcharge,18050,,"3,609.90 x patient days",18050,Per diem,,43014,,"25,046 x DRG weight",43014,Other,base rate x DRG weight,38712,,"22,541 x DRG weight",38712,Other,base rate x DRG weight,54138,,"31,523 x DRG weight",54138,Other,base rate x DRG weight,48724,,"28,371 x DRG weight",48724,Other,base rate x DRG weight,46018,,"26,795 x DRG weight",46018,Other,base rate x DRG weight,19855,,"3,970.89 x patient days",19855,Per diem,,38578,,"22,463 x DRG weight",38578,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,45384,,"26,426 x DRG weight",45384,Other,base rate x DRG weight,66651,,"38,809 x DRG weight",66651,Other,base rate x DRG weight,66651,,"38,809 x DRG weight",66651,Other,base rate x DRG weight,45384,,"26,426 x DRG weight",45384,Other,base rate x DRG weight,66651,,"38,809 x DRG weight",66651,Other,base rate x DRG weight,31815,,"6,363 x patient days",31815,Per diem,,139409,70,,139409,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,43033,,"25,057 x DRG weight",43033,Other,base rate x DRG weight,38731,,"22,552 x DRG weight",38731,Other,base rate x DRG weight,43033,,"25,057 x DRG weight",43033,Other,base rate x DRG weight,36577,,"21,298 x DRG weight",36577,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,139409,
PROSTATECTOMY WITHOUT CC/MCC,667,MS-DRG,,,,,,,,inpatient,,,67691.82,15435,,,15435,Other,150% of Medicare + 9.63% HCRA Surcharge,9386,,"3,609.90 x patient days",9386,Per diem,,26288,,"25,046 x DRG weight",26288,Other,base rate x DRG weight,23659,,"22,541 x DRG weight",23659,Other,base rate x DRG weight,33087,,"31,523 x DRG weight",33087,Other,base rate x DRG weight,29778,,"28,371 x DRG weight",29778,Other,base rate x DRG weight,28124,,"26,795 x DRG weight",28124,Other,base rate x DRG weight,10324.6,,"3,970.89 x patient days",10324.6,Per diem,,23577,,"22,463 x DRG weight",23577,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,27737,,"26,426 x DRG weight",27737,Other,base rate x DRG weight,40734,,"38,809 x DRG weight",40734,Other,base rate x DRG weight,40734,,"38,809 x DRG weight",40734,Other,base rate x DRG weight,27737,,"26,426 x DRG weight",27737,Other,base rate x DRG weight,40734,,"38,809 x DRG weight",40734,Other,base rate x DRG weight,16544,,"6,363 x patient days",16544,Per diem,,47384,70,,47384,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,26300,,"25,057 x DRG weight",26300,Other,base rate x DRG weight,23671,,"22,552 x DRG weight",23671,Other,base rate x DRG weight,26300,,"25,057 x DRG weight",26300,Other,base rate x DRG weight,22354,,"21,298 x DRG weight",22354,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,47384,
TRANSURETHRAL PROCEDURES WITH MCC,668,MS-DRG,,,,,,,,inpatient,,,152868.85,58176,,,58176,Other,150% of Medicare + 9.63% HCRA Surcharge,35377,,"3,609.90 x patient days",35377,Per diem,,70580,,"25,046 x DRG weight",70580,Other,base rate x DRG weight,63521,,"22,541 x DRG weight",63521,Other,base rate x DRG weight,88832,,"31,523 x DRG weight",88832,Other,base rate x DRG weight,79949,,"28,371 x DRG weight",79949,Other,base rate x DRG weight,75508,,"26,795 x DRG weight",75508,Other,base rate x DRG weight,38914.7,,"3,970.89 x patient days",38914.7,Per diem,,63301,,"22,463 x DRG weight",63301,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,74468,,"26,426 x DRG weight",74468,Other,base rate x DRG weight,109364,,"38,809 x DRG weight",109364,Other,base rate x DRG weight,109364,,"38,809 x DRG weight",109364,Other,base rate x DRG weight,74468,,"26,426 x DRG weight",74468,Other,base rate x DRG weight,109364,,"38,809 x DRG weight",109364,Other,base rate x DRG weight,62357,,"6,363 x patient days",62357,Per diem,,107008,70,,107008,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,70611,,"25,057 x DRG weight",70611,Other,base rate x DRG weight,63552,,"22,552 x DRG weight",63552,Other,base rate x DRG weight,70611,,"25,057 x DRG weight",70611,Other,base rate x DRG weight,60018,,"21,298 x DRG weight",60018,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,109364,
TRANSURETHRAL PROCEDURES WITH CC,669,MS-DRG,,,,,,,,inpatient,,,213964.49,29682,,,29682,Other,150% of Medicare + 9.63% HCRA Surcharge,18050,,"3,609.90 x patient days",18050,Per diem,,38436,,"25,046 x DRG weight",38436,Other,base rate x DRG weight,34591,,"22,541 x DRG weight",34591,Other,base rate x DRG weight,48375,,"31,523 x DRG weight",48375,Other,base rate x DRG weight,43538,,"28,371 x DRG weight",43538,Other,base rate x DRG weight,41120,,"26,795 x DRG weight",41120,Other,base rate x DRG weight,19855,,"3,970.89 x patient days",19855,Per diem,,34472,,"22,463 x DRG weight",34472,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,40553,,"26,426 x DRG weight",40553,Other,base rate x DRG weight,59556,,"38,809 x DRG weight",59556,Other,base rate x DRG weight,59556,,"38,809 x DRG weight",59556,Other,base rate x DRG weight,40553,,"26,426 x DRG weight",40553,Other,base rate x DRG weight,59556,,"38,809 x DRG weight",59556,Other,base rate x DRG weight,31815,,"6,363 x patient days",31815,Per diem,,149775,70,,149775,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,38452,,"25,057 x DRG weight",38452,Other,base rate x DRG weight,34608,,"22,552 x DRG weight",34608,Other,base rate x DRG weight,38452,,"25,057 x DRG weight",38452,Other,base rate x DRG weight,32684,,"21,298 x DRG weight",32684,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,149775,
TRANSURETHRAL PROCEDURES WITHOUT CC/MCC,670,MS-DRG,,,,,,,,inpatient,,,111634.82,14841,,,14841,Other,150% of Medicare + 9.63% HCRA Surcharge,9025,,"3,609.90 x patient days",9025,Per diem,,24109,,"25,046 x DRG weight",24109,Other,base rate x DRG weight,21698,,"22,541 x DRG weight",21698,Other,base rate x DRG weight,30344,,"31,523 x DRG weight",30344,Other,base rate x DRG weight,27310,,"28,371 x DRG weight",27310,Other,base rate x DRG weight,25793,,"26,795 x DRG weight",25793,Other,base rate x DRG weight,9927.5,,"3,970.89 x patient days",9927.5,Per diem,,21623,,"22,463 x DRG weight",21623,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,25438,,"26,426 x DRG weight",25438,Other,base rate x DRG weight,37358,,"38,809 x DRG weight",37358,Other,base rate x DRG weight,37358,,"38,809 x DRG weight",37358,Other,base rate x DRG weight,25438,,"26,426 x DRG weight",25438,Other,base rate x DRG weight,37358,,"38,809 x DRG weight",37358,Other,base rate x DRG weight,15908,,"6,363 x patient days",15908,Per diem,,78144,70,,78144,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,24120,,"25,057 x DRG weight",24120,Other,base rate x DRG weight,21709,,"22,552 x DRG weight",21709,Other,base rate x DRG weight,24120,,"25,057 x DRG weight",24120,Other,base rate x DRG weight,20501,,"21,298 x DRG weight",20501,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,78144,
URETHRAL PROCEDURES WITH CC/MCC,671,MS-DRG,,,,,,,,inpatient,,,1092892.95,33243,,,33243,Other,150% of Medicare + 9.63% HCRA Surcharge,20215,,"3,609.90 x patient days",20215,Per diem,,42876,,"25,046 x DRG weight",42876,Other,base rate x DRG weight,38588,,"22,541 x DRG weight",38588,Other,base rate x DRG weight,53964,,"31,523 x DRG weight",53964,Other,base rate x DRG weight,48568,,"28,371 x DRG weight",48568,Other,base rate x DRG weight,45870,,"26,795 x DRG weight",45870,Other,base rate x DRG weight,22236.5,,"3,970.89 x patient days",22236.5,Per diem,,38454,,"22,463 x DRG weight",38454,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,45239,,"26,426 x DRG weight",45239,Other,base rate x DRG weight,66437,,"38,809 x DRG weight",66437,Other,base rate x DRG weight,66437,,"38,809 x DRG weight",66437,Other,base rate x DRG weight,45239,,"26,426 x DRG weight",45239,Other,base rate x DRG weight,66437,,"38,809 x DRG weight",66437,Other,base rate x DRG weight,35633,,"6,363 x patient days",35633,Per diem,,765025,70,,765025,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,42895,,"25,057 x DRG weight",42895,Other,base rate x DRG weight,38607,,"22,552 x DRG weight",38607,Other,base rate x DRG weight,42895,,"25,057 x DRG weight",42895,Other,base rate x DRG weight,36460,,"21,298 x DRG weight",36460,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,765025,
URETHRAL PROCEDURES WITHOUT CC/MCC,672,MS-DRG,,,,,,,,inpatient,,,122264.34,10686,,,10686,Other,150% of Medicare + 9.63% HCRA Surcharge,6498,,"3,609.90 x patient days",6498,Per diem,,23481,,"25,046 x DRG weight",23481,Other,base rate x DRG weight,21132,,"22,541 x DRG weight",21132,Other,base rate x DRG weight,29553,,"31,523 x DRG weight",29553,Other,base rate x DRG weight,26598,,"28,371 x DRG weight",26598,Other,base rate x DRG weight,25120,,"26,795 x DRG weight",25120,Other,base rate x DRG weight,7147.8,,"3,970.89 x patient days",7147.8,Per diem,,21059,,"22,463 x DRG weight",21059,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,24774,,"26,426 x DRG weight",24774,Other,base rate x DRG weight,36383,,"38,809 x DRG weight",36383,Other,base rate x DRG weight,36383,,"38,809 x DRG weight",36383,Other,base rate x DRG weight,24774,,"26,426 x DRG weight",24774,Other,base rate x DRG weight,36383,,"38,809 x DRG weight",36383,Other,base rate x DRG weight,11453,,"6,363 x patient days",11453,Per diem,,85585,70,,85585,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,23491,,"25,057 x DRG weight",23491,Other,base rate x DRG weight,21143,,"22,552 x DRG weight",21143,Other,base rate x DRG weight,23491,,"25,057 x DRG weight",23491,Other,base rate x DRG weight,19967,,"21,298 x DRG weight",19967,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,85585,
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH MCC,673,MS-DRG,,,,,,,,inpatient,,,547788.05,72423,,,72423,Other,150% of Medicare + 9.63% HCRA Surcharge,44041,,"3,609.90 x patient days",44041,Per diem,,92620,,"25,046 x DRG weight",92620,Other,base rate x DRG weight,83357,,"22,541 x DRG weight",83357,Other,base rate x DRG weight,116572,,"31,523 x DRG weight",116572,Other,base rate x DRG weight,104916,,"28,371 x DRG weight",104916,Other,base rate x DRG weight,99088,,"26,795 x DRG weight",99088,Other,base rate x DRG weight,48445.1,,"3,970.89 x patient days",48445.1,Per diem,,83068,,"22,463 x DRG weight",83068,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,97723,,"26,426 x DRG weight",97723,Other,base rate x DRG weight,143516,,"38,809 x DRG weight",143516,Other,base rate x DRG weight,143516,,"38,809 x DRG weight",143516,Other,base rate x DRG weight,97723,,"26,426 x DRG weight",97723,Other,base rate x DRG weight,143516,,"38,809 x DRG weight",143516,Other,base rate x DRG weight,77629,,"6,363 x patient days",77629,Per diem,,383452,70,,383452,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,92661,,"25,057 x DRG weight",92661,Other,base rate x DRG weight,83397,,"22,552 x DRG weight",83397,Other,base rate x DRG weight,92661,,"25,057 x DRG weight",92661,Other,base rate x DRG weight,78760,,"21,298 x DRG weight",78760,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,383452,
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH CC,674,MS-DRG,,,,,,,,inpatient,,,385911.79,46303,,,46303,Other,150% of Medicare + 9.63% HCRA Surcharge,28157,,"3,609.90 x patient days",28157,Per diem,,59665,,"25,046 x DRG weight",59665,Other,base rate x DRG weight,53697,,"22,541 x DRG weight",53697,Other,base rate x DRG weight,75094,,"31,523 x DRG weight",75094,Other,base rate x DRG weight,67585,,"28,371 x DRG weight",67585,Other,base rate x DRG weight,63831,,"26,795 x DRG weight",63831,Other,base rate x DRG weight,30972.7,,"3,970.89 x patient days",30972.7,Per diem,,53511,,"22,463 x DRG weight",53511,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,62952,,"26,426 x DRG weight",62952,Other,base rate x DRG weight,92451,,"38,809 x DRG weight",92451,Other,base rate x DRG weight,92451,,"38,809 x DRG weight",92451,Other,base rate x DRG weight,62952,,"26,426 x DRG weight",62952,Other,base rate x DRG weight,92451,,"38,809 x DRG weight",92451,Other,base rate x DRG weight,49631,,"6,363 x patient days",49631,Per diem,,270138,70,,270138,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,59691,,"25,057 x DRG weight",59691,Other,base rate x DRG weight,53723,,"22,552 x DRG weight",53723,Other,base rate x DRG weight,59691,,"25,057 x DRG weight",59691,Other,base rate x DRG weight,50736,,"21,298 x DRG weight",50736,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,270138,
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITHOUT CC/MCC,675,MS-DRG,,,,,,,,inpatient,,,107041,21371,,,21371,Other,150% of Medicare + 9.63% HCRA Surcharge,12996,,"3,609.90 x patient days",12996,Per diem,,39735,,"25,046 x DRG weight",39735,Other,base rate x DRG weight,35761,,"22,541 x DRG weight",35761,Other,base rate x DRG weight,50011,,"31,523 x DRG weight",50011,Other,base rate x DRG weight,45011,,"28,371 x DRG weight",45011,Other,base rate x DRG weight,42510,,"26,795 x DRG weight",42510,Other,base rate x DRG weight,14295.6,,"3,970.89 x patient days",14295.6,Per diem,,35638,,"22,463 x DRG weight",35638,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,41925,,"26,426 x DRG weight",41925,Other,base rate x DRG weight,61570,,"38,809 x DRG weight",61570,Other,base rate x DRG weight,61570,,"38,809 x DRG weight",61570,Other,base rate x DRG weight,41925,,"26,426 x DRG weight",41925,Other,base rate x DRG weight,61570,,"38,809 x DRG weight",61570,Other,base rate x DRG weight,22907,,"6,363 x patient days",22907,Per diem,,74929,70,,74929,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,39753,,"25,057 x DRG weight",39753,Other,base rate x DRG weight,35779,,"22,552 x DRG weight",35779,Other,base rate x DRG weight,39753,,"25,057 x DRG weight",39753,Other,base rate x DRG weight,33789,,"21,298 x DRG weight",33789,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,74929,
RENAL FAILURE WITH MCC,682,MS-DRG,,,,,,,,inpatient,,,237883.59,35617,,,35617,Other,150% of Medicare + 9.63% HCRA Surcharge,21659,,"3,609.90 x patient days",21659,Per diem,,37589,,"25,046 x DRG weight",37589,Other,base rate x DRG weight,33830,,"22,541 x DRG weight",33830,Other,base rate x DRG weight,47310,,"31,523 x DRG weight",47310,Other,base rate x DRG weight,42579,,"28,371 x DRG weight",42579,Other,base rate x DRG weight,40214,,"26,795 x DRG weight",40214,Other,base rate x DRG weight,23824.9,,"3,970.89 x patient days",23824.9,Per diem,,33712,,"22,463 x DRG weight",33712,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,39660,,"26,426 x DRG weight",39660,Other,base rate x DRG weight,58245,,"38,809 x DRG weight",58245,Other,base rate x DRG weight,58245,,"38,809 x DRG weight",58245,Other,base rate x DRG weight,39660,,"26,426 x DRG weight",39660,Other,base rate x DRG weight,58245,,"38,809 x DRG weight",58245,Other,base rate x DRG weight,38178,,"6,363 x patient days",38178,Per diem,,166519,70,,166519,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,37606,,"25,057 x DRG weight",37606,Other,base rate x DRG weight,33846,,"22,552 x DRG weight",33846,Other,base rate x DRG weight,37606,,"25,057 x DRG weight",37606,Other,base rate x DRG weight,31964,,"21,298 x DRG weight",31964,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,166519,
RENAL FAILURE WITH CC,683,MS-DRG,,,,,,,,inpatient,,,135915.06,23152,,,23152,Other,150% of Medicare + 9.63% HCRA Surcharge,14079,,"3,609.90 x patient days",14079,Per diem,,22561,,"25,046 x DRG weight",22561,Other,base rate x DRG weight,20305,,"22,541 x DRG weight",20305,Other,base rate x DRG weight,28396,,"31,523 x DRG weight",28396,Other,base rate x DRG weight,25557,,"28,371 x DRG weight",25557,Other,base rate x DRG weight,24137,,"26,795 x DRG weight",24137,Other,base rate x DRG weight,15486.9,,"3,970.89 x patient days",15486.9,Per diem,,20235,,"22,463 x DRG weight",20235,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,23805,,"26,426 x DRG weight",23805,Other,base rate x DRG weight,34959,,"38,809 x DRG weight",34959,Other,base rate x DRG weight,34959,,"38,809 x DRG weight",34959,Other,base rate x DRG weight,23805,,"26,426 x DRG weight",23805,Other,base rate x DRG weight,34959,,"38,809 x DRG weight",34959,Other,base rate x DRG weight,24816,,"6,363 x patient days",24816,Per diem,,95141,70,,95141,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,22571,,"25,057 x DRG weight",22571,Other,base rate x DRG weight,20315,,"22,552 x DRG weight",20315,Other,base rate x DRG weight,22571,,"25,057 x DRG weight",22571,Other,base rate x DRG weight,19185,,"21,298 x DRG weight",19185,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,95141,
RENAL FAILURE WITHOUT CC/MCC,684,MS-DRG,,,,,,,,inpatient,,,87987.72,16028,,,16028,Other,150% of Medicare + 9.63% HCRA Surcharge,9747,,"3,609.90 x patient days",9747,Per diem,,15240,,"25,046 x DRG weight",15240,Other,base rate x DRG weight,13716,,"22,541 x DRG weight",13716,Other,base rate x DRG weight,19182,,"31,523 x DRG weight",19182,Other,base rate x DRG weight,17264,,"28,371 x DRG weight",17264,Other,base rate x DRG weight,16305,,"26,795 x DRG weight",16305,Other,base rate x DRG weight,10721.7,,"3,970.89 x patient days",10721.7,Per diem,,13669,,"22,463 x DRG weight",13669,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,16080,,"26,426 x DRG weight",16080,Other,base rate x DRG weight,23615,,"38,809 x DRG weight",23615,Other,base rate x DRG weight,23615,,"38,809 x DRG weight",23615,Other,base rate x DRG weight,16080,,"26,426 x DRG weight",16080,Other,base rate x DRG weight,23615,,"38,809 x DRG weight",23615,Other,base rate x DRG weight,17180,,"6,363 x patient days",17180,Per diem,,61591,70,,61591,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,15247,,"25,057 x DRG weight",15247,Other,base rate x DRG weight,13723,,"22,552 x DRG weight",13723,Other,base rate x DRG weight,15247,,"25,057 x DRG weight",15247,Other,base rate x DRG weight,12960,,"21,298 x DRG weight",12960,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,61591,
KIDNEY AND URINARY TRACT NEOPLASMS WITH MCC,686,MS-DRG,,,,,,,,inpatient,,,155268.42,43335,,,43335,Other,150% of Medicare + 9.63% HCRA Surcharge,26352,,"3,609.90 x patient days",26352,Per diem,,46070,,"25,046 x DRG weight",46070,Other,base rate x DRG weight,41462,,"22,541 x DRG weight",41462,Other,base rate x DRG weight,57983,,"31,523 x DRG weight",57983,Other,base rate x DRG weight,52186,,"28,371 x DRG weight",52186,Other,base rate x DRG weight,49287,,"26,795 x DRG weight",49287,Other,base rate x DRG weight,28987.2,,"3,970.89 x patient days",28987.2,Per diem,,41318,,"22,463 x DRG weight",41318,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,48608,,"26,426 x DRG weight",48608,Other,base rate x DRG weight,71385,,"38,809 x DRG weight",71385,Other,base rate x DRG weight,71385,,"38,809 x DRG weight",71385,Other,base rate x DRG weight,48608,,"26,426 x DRG weight",48608,Other,base rate x DRG weight,71385,,"38,809 x DRG weight",71385,Other,base rate x DRG weight,46450,,"6,363 x patient days",46450,Per diem,,108688,70,,108688,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,46090,,"25,057 x DRG weight",46090,Other,base rate x DRG weight,41482,,"22,552 x DRG weight",41482,Other,base rate x DRG weight,46090,,"25,057 x DRG weight",46090,Other,base rate x DRG weight,39176,,"21,298 x DRG weight",39176,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,108688,
KIDNEY AND URINARY TRACT NEOPLASMS WITH CC,687,MS-DRG,,,,,,,,inpatient,,,263020.16,25527,,,25527,Other,150% of Medicare + 9.63% HCRA Surcharge,15523,,"3,609.90 x patient days",15523,Per diem,,26181,,"25,046 x DRG weight",26181,Other,base rate x DRG weight,23562,,"22,541 x DRG weight",23562,Other,base rate x DRG weight,32951,,"31,523 x DRG weight",32951,Other,base rate x DRG weight,29656,,"28,371 x DRG weight",29656,Other,base rate x DRG weight,28009,,"26,795 x DRG weight",28009,Other,base rate x DRG weight,17075.3,,"3,970.89 x patient days",17075.3,Per diem,,23481,,"22,463 x DRG weight",23481,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,27623,,"26,426 x DRG weight",27623,Other,base rate x DRG weight,40567,,"38,809 x DRG weight",40567,Other,base rate x DRG weight,40567,,"38,809 x DRG weight",40567,Other,base rate x DRG weight,27623,,"26,426 x DRG weight",27623,Other,base rate x DRG weight,40567,,"38,809 x DRG weight",40567,Other,base rate x DRG weight,27361,,"6,363 x patient days",27361,Per diem,,184114,70,,184114,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,26192,,"25,057 x DRG weight",26192,Other,base rate x DRG weight,23574,,"22,552 x DRG weight",23574,Other,base rate x DRG weight,26192,,"25,057 x DRG weight",26192,Other,base rate x DRG weight,22263,,"21,298 x DRG weight",22263,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,184114,
KIDNEY AND URINARY TRACT NEOPLASMS WITHOUT CC/MCC,688,MS-DRG,,,,,,,,inpatient,,,96103.05,14248,,,14248,Other,150% of Medicare + 9.63% HCRA Surcharge,8664,,"3,609.90 x patient days",8664,Per diem,,19558,,"25,046 x DRG weight",19558,Other,base rate x DRG weight,17602,,"22,541 x DRG weight",17602,Other,base rate x DRG weight,24616,,"31,523 x DRG weight",24616,Other,base rate x DRG weight,22155,,"28,371 x DRG weight",22155,Other,base rate x DRG weight,20924,,"26,795 x DRG weight",20924,Other,base rate x DRG weight,9530.4,,"3,970.89 x patient days",9530.4,Per diem,,17541,,"22,463 x DRG weight",17541,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,20636,,"26,426 x DRG weight",20636,Other,base rate x DRG weight,30306,,"38,809 x DRG weight",30306,Other,base rate x DRG weight,30306,,"38,809 x DRG weight",30306,Other,base rate x DRG weight,20636,,"26,426 x DRG weight",20636,Other,base rate x DRG weight,30306,,"38,809 x DRG weight",30306,Other,base rate x DRG weight,15271,,"6,363 x patient days",15271,Per diem,,67272,70,,67272,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,19567,,"25,057 x DRG weight",19567,Other,base rate x DRG weight,17611,,"22,552 x DRG weight",17611,Other,base rate x DRG weight,19567,,"25,057 x DRG weight",19567,Other,base rate x DRG weight,16632,,"21,298 x DRG weight",16632,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,67272,
KIDNEY AND URINARY TRACT INFECTIONS WITH MCC,689,MS-DRG,,,,,,,,inpatient,,,214037.92,30868,,,30868,Other,150% of Medicare + 9.63% HCRA Surcharge,18771,,"3,609.90 x patient days",18771,Per diem,,29414,,"25,046 x DRG weight",29414,Other,base rate x DRG weight,26472,,"22,541 x DRG weight",26472,Other,base rate x DRG weight,37021,,"31,523 x DRG weight",37021,Other,base rate x DRG weight,33319,,"28,371 x DRG weight",33319,Other,base rate x DRG weight,31468,,"26,795 x DRG weight",31468,Other,base rate x DRG weight,20648.1,,"3,970.89 x patient days",20648.1,Per diem,,26381,,"22,463 x DRG weight",26381,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,31035,,"26,426 x DRG weight",31035,Other,base rate x DRG weight,45577,,"38,809 x DRG weight",45577,Other,base rate x DRG weight,45577,,"38,809 x DRG weight",45577,Other,base rate x DRG weight,31035,,"26,426 x DRG weight",31035,Other,base rate x DRG weight,45577,,"38,809 x DRG weight",45577,Other,base rate x DRG weight,33088,,"6,363 x patient days",33088,Per diem,,149827,70,,149827,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,29427,,"25,057 x DRG weight",29427,Other,base rate x DRG weight,26485,,"22,552 x DRG weight",26485,Other,base rate x DRG weight,29427,,"25,057 x DRG weight",29427,Other,base rate x DRG weight,25012,,"21,298 x DRG weight",25012,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,149827,
KIDNEY AND URINARY TRACT INFECTIONS WITHOUT MCC,690,MS-DRG,,,,,,,,inpatient,,,109233.76,21371,,,21371,Other,150% of Medicare + 9.63% HCRA Surcharge,12996,,"3,609.90 x patient days",12996,Per diem,,20210,,"25,046 x DRG weight",20210,Other,base rate x DRG weight,18188,,"22,541 x DRG weight",18188,Other,base rate x DRG weight,25436,,"31,523 x DRG weight",25436,Other,base rate x DRG weight,22893,,"28,371 x DRG weight",22893,Other,base rate x DRG weight,21621,,"26,795 x DRG weight",21621,Other,base rate x DRG weight,14295.6,,"3,970.89 x patient days",14295.6,Per diem,,18125,,"22,463 x DRG weight",18125,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,21323,,"26,426 x DRG weight",21323,Other,base rate x DRG weight,31315,,"38,809 x DRG weight",31315,Other,base rate x DRG weight,31315,,"38,809 x DRG weight",31315,Other,base rate x DRG weight,21323,,"26,426 x DRG weight",21323,Other,base rate x DRG weight,31315,,"38,809 x DRG weight",31315,Other,base rate x DRG weight,22907,,"6,363 x patient days",22907,Per diem,,76464,70,,76464,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,20218,,"25,057 x DRG weight",20218,Other,base rate x DRG weight,18197,,"22,552 x DRG weight",18197,Other,base rate x DRG weight,20218,,"25,057 x DRG weight",20218,Other,base rate x DRG weight,17185,,"21,298 x DRG weight",17185,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,76464,
URINARY STONES WITH MCC,693,MS-DRG,,,,,,,,inpatient,,,188718.89,32055,,,32055,Other,150% of Medicare + 9.63% HCRA Surcharge,19493,,"3,609.90 x patient days",19493,Per diem,,35473,,"25,046 x DRG weight",35473,Other,base rate x DRG weight,31925,,"22,541 x DRG weight",31925,Other,base rate x DRG weight,44646,,"31,523 x DRG weight",44646,Other,base rate x DRG weight,40182,,"28,371 x DRG weight",40182,Other,base rate x DRG weight,37950,,"26,795 x DRG weight",37950,Other,base rate x DRG weight,21442.3,,"3,970.89 x patient days",21442.3,Per diem,,31814,,"22,463 x DRG weight",31814,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,37427,,"26,426 x DRG weight",37427,Other,base rate x DRG weight,54965,,"38,809 x DRG weight",54965,Other,base rate x DRG weight,54965,,"38,809 x DRG weight",54965,Other,base rate x DRG weight,37427,,"26,426 x DRG weight",37427,Other,base rate x DRG weight,54965,,"38,809 x DRG weight",54965,Other,base rate x DRG weight,34360,,"6,363 x patient days",34360,Per diem,,132103,70,,132103,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,35488,,"25,057 x DRG weight",35488,Other,base rate x DRG weight,31940,,"22,552 x DRG weight",31940,Other,base rate x DRG weight,35488,,"25,057 x DRG weight",35488,Other,base rate x DRG weight,30164,,"21,298 x DRG weight",30164,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,132103,
URINARY STONES WITHOUT MCC,694,MS-DRG,,,,,,,,inpatient,,,71696.51,16028,,,16028,Other,150% of Medicare + 9.63% HCRA Surcharge,9747,,"3,609.90 x patient days",9747,Per diem,,19604,,"25,046 x DRG weight",19604,Other,base rate x DRG weight,17643,,"22,541 x DRG weight",17643,Other,base rate x DRG weight,24673,,"31,523 x DRG weight",24673,Other,base rate x DRG weight,22206,,"28,371 x DRG weight",22206,Other,base rate x DRG weight,20972,,"26,795 x DRG weight",20972,Other,base rate x DRG weight,10721.7,,"3,970.89 x patient days",10721.7,Per diem,,17582,,"22,463 x DRG weight",17582,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,20684,,"26,426 x DRG weight",20684,Other,base rate x DRG weight,30376,,"38,809 x DRG weight",30376,Other,base rate x DRG weight,30376,,"38,809 x DRG weight",30376,Other,base rate x DRG weight,20684,,"26,426 x DRG weight",20684,Other,base rate x DRG weight,30376,,"38,809 x DRG weight",30376,Other,base rate x DRG weight,17180,,"6,363 x patient days",17180,Per diem,,50188,70,,50188,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,19612,,"25,057 x DRG weight",19612,Other,base rate x DRG weight,17651,,"22,552 x DRG weight",17651,Other,base rate x DRG weight,19612,,"25,057 x DRG weight",19612,Other,base rate x DRG weight,16670,,"21,298 x DRG weight",16670,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,50188,
KIDNEY AND URINARY TRACT SIGNS AND SYMPTOMS WITH MCC,695,MS-DRG,,,,,,,,inpatient,,,171132,29089,,,29089,Other,150% of Medicare + 9.63% HCRA Surcharge,17689,,"3,609.90 x patient days",17689,Per diem,,29955,,"25,046 x DRG weight",29955,Other,base rate x DRG weight,26959,,"22,541 x DRG weight",26959,Other,base rate x DRG weight,37702,,"31,523 x DRG weight",37702,Other,base rate x DRG weight,33932,,"28,371 x DRG weight",33932,Other,base rate x DRG weight,32047,,"26,795 x DRG weight",32047,Other,base rate x DRG weight,19457.9,,"3,970.89 x patient days",19457.9,Per diem,,26866,,"22,463 x DRG weight",26866,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,31605,,"26,426 x DRG weight",31605,Other,base rate x DRG weight,46416,,"38,809 x DRG weight",46416,Other,base rate x DRG weight,46416,,"38,809 x DRG weight",46416,Other,base rate x DRG weight,31605,,"26,426 x DRG weight",31605,Other,base rate x DRG weight,46416,,"38,809 x DRG weight",46416,Other,base rate x DRG weight,31179,,"6,363 x patient days",31179,Per diem,,119792,70,,119792,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,29968,,"25,057 x DRG weight",29968,Other,base rate x DRG weight,26972,,"22,552 x DRG weight",26972,Other,base rate x DRG weight,29968,,"25,057 x DRG weight",29968,Other,base rate x DRG weight,25472,,"21,298 x DRG weight",25472,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,119792,
KIDNEY AND URINARY TRACT SIGNS AND SYMPTOMS WITHOUT MCC,696,MS-DRG,,,,,,,,inpatient,,,100621.85,17216,,,17216,Other,150% of Medicare + 9.63% HCRA Surcharge,10469,,"3,609.90 x patient days",10469,Per diem,,17334,,"25,046 x DRG weight",17334,Other,base rate x DRG weight,15601,,"22,541 x DRG weight",15601,Other,base rate x DRG weight,21817,,"31,523 x DRG weight",21817,Other,base rate x DRG weight,19636,,"28,371 x DRG weight",19636,Other,base rate x DRG weight,18545,,"26,795 x DRG weight",18545,Other,base rate x DRG weight,11515.9,,"3,970.89 x patient days",11515.9,Per diem,,15547,,"22,463 x DRG weight",15547,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,18289,,"26,426 x DRG weight",18289,Other,base rate x DRG weight,26860,,"38,809 x DRG weight",26860,Other,base rate x DRG weight,26860,,"38,809 x DRG weight",26860,Other,base rate x DRG weight,18289,,"26,426 x DRG weight",18289,Other,base rate x DRG weight,26860,,"38,809 x DRG weight",26860,Other,base rate x DRG weight,18453,,"6,363 x patient days",18453,Per diem,,70435,70,,70435,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,17342,,"25,057 x DRG weight",17342,Other,base rate x DRG weight,15608,,"22,552 x DRG weight",15608,Other,base rate x DRG weight,17342,,"25,057 x DRG weight",17342,Other,base rate x DRG weight,14740,,"21,298 x DRG weight",14740,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,70435,
URETHRAL STRICTURE,697,MS-DRG,,,,,,,,inpatient,,,94621.51,21965,,,21965,Other,150% of Medicare + 9.63% HCRA Surcharge,13357,,"3,609.90 x patient days",13357,Per diem,,27879,,"25,046 x DRG weight",27879,Other,base rate x DRG weight,25090,,"22,541 x DRG weight",25090,Other,base rate x DRG weight,35088,,"31,523 x DRG weight",35088,Other,base rate x DRG weight,31580,,"28,371 x DRG weight",31580,Other,base rate x DRG weight,29826,,"26,795 x DRG weight",29826,Other,base rate x DRG weight,14692.7,,"3,970.89 x patient days",14692.7,Per diem,,25004,,"22,463 x DRG weight",25004,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,29415,,"26,426 x DRG weight",29415,Other,base rate x DRG weight,43198,,"38,809 x DRG weight",43198,Other,base rate x DRG weight,43198,,"38,809 x DRG weight",43198,Other,base rate x DRG weight,29415,,"26,426 x DRG weight",29415,Other,base rate x DRG weight,43198,,"38,809 x DRG weight",43198,Other,base rate x DRG weight,23543,,"6,363 x patient days",23543,Per diem,,66235,70,,66235,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,27891,,"25,057 x DRG weight",27891,Other,base rate x DRG weight,25103,,"22,552 x DRG weight",25103,Other,base rate x DRG weight,27891,,"25,057 x DRG weight",27891,Other,base rate x DRG weight,23707,,"21,298 x DRG weight",23707,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,66235,
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH MCC,698,MS-DRG,,,,,,,,inpatient,,,184205.46,37992,,,37992,Other,150% of Medicare + 9.63% HCRA Surcharge,23103,,"3,609.90 x patient days",23103,Per diem,,41436,,"25,046 x DRG weight",41436,Other,base rate x DRG weight,37292,,"22,541 x DRG weight",37292,Other,base rate x DRG weight,52152,,"31,523 x DRG weight",52152,Other,base rate x DRG weight,46937,,"28,371 x DRG weight",46937,Other,base rate x DRG weight,44330,,"26,795 x DRG weight",44330,Other,base rate x DRG weight,25413.3,,"3,970.89 x patient days",25413.3,Per diem,,37163,,"22,463 x DRG weight",37163,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,43719,,"26,426 x DRG weight",43719,Other,base rate x DRG weight,64206,,"38,809 x DRG weight",64206,Other,base rate x DRG weight,64206,,"38,809 x DRG weight",64206,Other,base rate x DRG weight,43719,,"26,426 x DRG weight",43719,Other,base rate x DRG weight,64206,,"38,809 x DRG weight",64206,Other,base rate x DRG weight,40723,,"6,363 x patient days",40723,Per diem,,128944,70,,128944,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,41454,,"25,057 x DRG weight",41454,Other,base rate x DRG weight,37310,,"22,552 x DRG weight",37310,Other,base rate x DRG weight,41454,,"25,057 x DRG weight",41454,Other,base rate x DRG weight,35235,,"21,298 x DRG weight",35235,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,128944,
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH CC,699,MS-DRG,,,,,,,,inpatient,,,140422.98,24933,,,24933,Other,150% of Medicare + 9.63% HCRA Surcharge,15162,,"3,609.90 x patient days",15162,Per diem,,25567,,"25,046 x DRG weight",25567,Other,base rate x DRG weight,23010,,"22,541 x DRG weight",23010,Other,base rate x DRG weight,32179,,"31,523 x DRG weight",32179,Other,base rate x DRG weight,28961,,"28,371 x DRG weight",28961,Other,base rate x DRG weight,27352,,"26,795 x DRG weight",27352,Other,base rate x DRG weight,16678.2,,"3,970.89 x patient days",16678.2,Per diem,,22930,,"22,463 x DRG weight",22930,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,26976,,"26,426 x DRG weight",26976,Other,base rate x DRG weight,39616,,"38,809 x DRG weight",39616,Other,base rate x DRG weight,39616,,"38,809 x DRG weight",39616,Other,base rate x DRG weight,26976,,"26,426 x DRG weight",26976,Other,base rate x DRG weight,39616,,"38,809 x DRG weight",39616,Other,base rate x DRG weight,26725,,"6,363 x patient days",26725,Per diem,,98296,70,,98296,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,25578,,"25,057 x DRG weight",25578,Other,base rate x DRG weight,23021,,"22,552 x DRG weight",23021,Other,base rate x DRG weight,25578,,"25,057 x DRG weight",25578,Other,base rate x DRG weight,21741,,"21,298 x DRG weight",21741,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,98296,
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITHOUT CC/MCC,700,MS-DRG,,,,,,,,inpatient,,,93081.62,16622,,,16622,Other,150% of Medicare + 9.63% HCRA Surcharge,10108,,"3,609.90 x patient days",10108,Per diem,,17740,,"25,046 x DRG weight",17740,Other,base rate x DRG weight,15966,,"22,541 x DRG weight",15966,Other,base rate x DRG weight,22328,,"31,523 x DRG weight",22328,Other,base rate x DRG weight,20095,,"28,371 x DRG weight",20095,Other,base rate x DRG weight,18979,,"26,795 x DRG weight",18979,Other,base rate x DRG weight,11118.8,,"3,970.89 x patient days",11118.8,Per diem,,15911,,"22,463 x DRG weight",15911,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,18718,,"26,426 x DRG weight",18718,Other,base rate x DRG weight,27488,,"38,809 x DRG weight",27488,Other,base rate x DRG weight,27488,,"38,809 x DRG weight",27488,Other,base rate x DRG weight,18718,,"26,426 x DRG weight",18718,Other,base rate x DRG weight,27488,,"38,809 x DRG weight",27488,Other,base rate x DRG weight,17816,,"6,363 x patient days",17816,Per diem,,65157,70,,65157,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,17748,,"25,057 x DRG weight",17748,Other,base rate x DRG weight,15974,,"22,552 x DRG weight",15974,Other,base rate x DRG weight,17748,,"25,057 x DRG weight",17748,Other,base rate x DRG weight,15085,,"21,298 x DRG weight",15085,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,65157,
MAJOR MALE PELVIC PROCEDURES WITH CC/MCC,707,MS-DRG,,,,,,,,inpatient,,,165828.54,18997,,,18997,Other,150% of Medicare + 9.63% HCRA Surcharge,11552,,"3,609.90 x patient days",11552,Per diem,,49138,,"25,046 x DRG weight",49138,Other,base rate x DRG weight,44223,,"22,541 x DRG weight",44223,Other,base rate x DRG weight,61845,,"31,523 x DRG weight",61845,Other,base rate x DRG weight,55661,,"28,371 x DRG weight",55661,Other,base rate x DRG weight,52569,,"26,795 x DRG weight",52569,Other,base rate x DRG weight,12707.2,,"3,970.89 x patient days",12707.2,Per diem,,44070,,"22,463 x DRG weight",44070,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,51845,,"26,426 x DRG weight",51845,Other,base rate x DRG weight,76139,,"38,809 x DRG weight",76139,Other,base rate x DRG weight,76139,,"38,809 x DRG weight",76139,Other,base rate x DRG weight,51845,,"26,426 x DRG weight",51845,Other,base rate x DRG weight,76139,,"38,809 x DRG weight",76139,Other,base rate x DRG weight,20362,,"6,363 x patient days",20362,Per diem,,116080,70,,116080,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,49159,,"25,057 x DRG weight",49159,Other,base rate x DRG weight,44245,,"22,552 x DRG weight",44245,Other,base rate x DRG weight,49159,,"25,057 x DRG weight",49159,Other,base rate x DRG weight,41785,,"21,298 x DRG weight",41785,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,116080,
MAJOR MALE PELVIC PROCEDURES WITHOUT CC/MCC,708,MS-DRG,,,,,,,,inpatient,,,89728.12,9498,,,9498,Other,150% of Medicare + 9.63% HCRA Surcharge,5776,,"3,609.90 x patient days",5776,Per diem,,36530,,"25,046 x DRG weight",36530,Other,base rate x DRG weight,32876,,"22,541 x DRG weight",32876,Other,base rate x DRG weight,45976,,"31,523 x DRG weight",45976,Other,base rate x DRG weight,41379,,"28,371 x DRG weight",41379,Other,base rate x DRG weight,39081,,"26,795 x DRG weight",39081,Other,base rate x DRG weight,6353.6,,"3,970.89 x patient days",6353.6,Per diem,,32762,,"22,463 x DRG weight",32762,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,38542,,"26,426 x DRG weight",38542,Other,base rate x DRG weight,56603,,"38,809 x DRG weight",56603,Other,base rate x DRG weight,56603,,"38,809 x DRG weight",56603,Other,base rate x DRG weight,38542,,"26,426 x DRG weight",38542,Other,base rate x DRG weight,56603,,"38,809 x DRG weight",56603,Other,base rate x DRG weight,10181,,"6,363 x patient days",10181,Per diem,,62810,70,,62810,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,36546,,"25,057 x DRG weight",36546,Other,base rate x DRG weight,32892,,"22,552 x DRG weight",32892,Other,base rate x DRG weight,36546,,"25,057 x DRG weight",36546,Other,base rate x DRG weight,31063,,"21,298 x DRG weight",31063,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,62810,
PENIS PROCEDURES WITH CC/MCC,709,MS-DRG,,,,,,,,inpatient,,,153367.65,40366,,,40366,Other,150% of Medicare + 9.63% HCRA Surcharge,24547,,"3,609.90 x patient days",24547,Per diem,,54370,,"25,046 x DRG weight",54370,Other,base rate x DRG weight,48932,,"22,541 x DRG weight",48932,Other,base rate x DRG weight,68430,,"31,523 x DRG weight",68430,Other,base rate x DRG weight,61588,,"28,371 x DRG weight",61588,Other,base rate x DRG weight,58167,,"26,795 x DRG weight",58167,Other,base rate x DRG weight,27001.7,,"3,970.89 x patient days",27001.7,Per diem,,48763,,"22,463 x DRG weight",48763,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,57366,,"26,426 x DRG weight",57366,Other,base rate x DRG weight,84247,,"38,809 x DRG weight",84247,Other,base rate x DRG weight,84247,,"38,809 x DRG weight",84247,Other,base rate x DRG weight,57366,,"26,426 x DRG weight",57366,Other,base rate x DRG weight,84247,,"38,809 x DRG weight",84247,Other,base rate x DRG weight,43268,,"6,363 x patient days",43268,Per diem,,107357,70,,107357,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,54394,,"25,057 x DRG weight",54394,Other,base rate x DRG weight,48956,,"22,552 x DRG weight",48956,Other,base rate x DRG weight,54394,,"25,057 x DRG weight",54394,Other,base rate x DRG weight,46234,,"21,298 x DRG weight",46234,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,107357,
PENIS PROCEDURES WITHOUT CC/MCC,710,MS-DRG,,,,,,,,inpatient,,,85369.11,13654,,,13654,Other,150% of Medicare + 9.63% HCRA Surcharge,8303,,"3,609.90 x patient days",8303,Per diem,,32492,,"25,046 x DRG weight",32492,Other,base rate x DRG weight,29242,,"22,541 x DRG weight",29242,Other,base rate x DRG weight,40895,,"31,523 x DRG weight",40895,Other,base rate x DRG weight,36806,,"28,371 x DRG weight",36806,Other,base rate x DRG weight,34761,,"26,795 x DRG weight",34761,Other,base rate x DRG weight,9133.3,,"3,970.89 x patient days",9133.3,Per diem,,29141,,"22,463 x DRG weight",29141,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,34282,,"26,426 x DRG weight",34282,Other,base rate x DRG weight,50347,,"38,809 x DRG weight",50347,Other,base rate x DRG weight,50347,,"38,809 x DRG weight",50347,Other,base rate x DRG weight,34282,,"26,426 x DRG weight",34282,Other,base rate x DRG weight,50347,,"38,809 x DRG weight",50347,Other,base rate x DRG weight,14635,,"6,363 x patient days",14635,Per diem,,59758,70,,59758,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,32506,,"25,057 x DRG weight",32506,Other,base rate x DRG weight,29257,,"22,552 x DRG weight",29257,Other,base rate x DRG weight,32506,,"25,057 x DRG weight",32506,Other,base rate x DRG weight,27630,,"21,298 x DRG weight",27630,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,59758,
TESTES PROCEDURES WITH CC/MCC,711,MS-DRG,,,,,,,,inpatient,,,73437.13,42147,,,42147,Other,150% of Medicare + 9.63% HCRA Surcharge,25630,,"3,609.90 x patient days",25630,Per diem,,53170,,"25,046 x DRG weight",53170,Other,base rate x DRG weight,47852,,"22,541 x DRG weight",47852,Other,base rate x DRG weight,66920,,"31,523 x DRG weight",66920,Other,base rate x DRG weight,60229,,"28,371 x DRG weight",60229,Other,base rate x DRG weight,56883,,"26,795 x DRG weight",56883,Other,base rate x DRG weight,28193,,"3,970.89 x patient days",28193,Per diem,,47687,,"22,463 x DRG weight",47687,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,56100,,"26,426 x DRG weight",56100,Other,base rate x DRG weight,82388,,"38,809 x DRG weight",82388,Other,base rate x DRG weight,82388,,"38,809 x DRG weight",82388,Other,base rate x DRG weight,56100,,"26,426 x DRG weight",56100,Other,base rate x DRG weight,82388,,"38,809 x DRG weight",82388,Other,base rate x DRG weight,45177,,"6,363 x patient days",45177,Per diem,,51406,70,,51406,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,53194,,"25,057 x DRG weight",53194,Other,base rate x DRG weight,47876,,"22,552 x DRG weight",47876,Other,base rate x DRG weight,53194,,"25,057 x DRG weight",53194,Other,base rate x DRG weight,45214,,"21,298 x DRG weight",45214,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,82388,
TESTES PROCEDURES WITHOUT CC/MCC,712,MS-DRG,,,,,,,,inpatient,,,73198,21371,,,21371,Other,150% of Medicare + 9.63% HCRA Surcharge,12996,,"3,609.90 x patient days",12996,Per diem,,29765,,"25,046 x DRG weight",29765,Other,base rate x DRG weight,26788,,"22,541 x DRG weight",26788,Other,base rate x DRG weight,37462,,"31,523 x DRG weight",37462,Other,base rate x DRG weight,33716,,"28,371 x DRG weight",33716,Other,base rate x DRG weight,31843,,"26,795 x DRG weight",31843,Other,base rate x DRG weight,14295.6,,"3,970.89 x patient days",14295.6,Per diem,,26695,,"22,463 x DRG weight",26695,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,31405,,"26,426 x DRG weight",31405,Other,base rate x DRG weight,46121,,"38,809 x DRG weight",46121,Other,base rate x DRG weight,46121,,"38,809 x DRG weight",46121,Other,base rate x DRG weight,31405,,"26,426 x DRG weight",31405,Other,base rate x DRG weight,46121,,"38,809 x DRG weight",46121,Other,base rate x DRG weight,22907,,"6,363 x patient days",22907,Per diem,,51239,70,,51239,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,29778,,"25,057 x DRG weight",29778,Other,base rate x DRG weight,26801,,"22,552 x DRG weight",26801,Other,base rate x DRG weight,29778,,"25,057 x DRG weight",29778,Other,base rate x DRG weight,25311,,"21,298 x DRG weight",25311,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,51239,
TRANSURETHRAL PROSTATECTOMY WITH CC/MCC,713,MS-DRG,,,,,,,,inpatient,,,82123.62,23152,,,23152,Other,150% of Medicare + 9.63% HCRA Surcharge,14079,,"3,609.90 x patient days",14079,Per diem,,36334,,"25,046 x DRG weight",36334,Other,base rate x DRG weight,32700,,"22,541 x DRG weight",32700,Other,base rate x DRG weight,45730,,"31,523 x DRG weight",45730,Other,base rate x DRG weight,41158,,"28,371 x DRG weight",41158,Other,base rate x DRG weight,38872,,"26,795 x DRG weight",38872,Other,base rate x DRG weight,15486.9,,"3,970.89 x patient days",15486.9,Per diem,,32587,,"22,463 x DRG weight",32587,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,38336,,"26,426 x DRG weight",38336,Other,base rate x DRG weight,56300,,"38,809 x DRG weight",56300,Other,base rate x DRG weight,56300,,"38,809 x DRG weight",56300,Other,base rate x DRG weight,38336,,"26,426 x DRG weight",38336,Other,base rate x DRG weight,56300,,"38,809 x DRG weight",56300,Other,base rate x DRG weight,24816,,"6,363 x patient days",24816,Per diem,,57487,70,,57487,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,36350,,"25,057 x DRG weight",36350,Other,base rate x DRG weight,32716,,"22,552 x DRG weight",32716,Other,base rate x DRG weight,36350,,"25,057 x DRG weight",36350,Other,base rate x DRG weight,30897,,"21,298 x DRG weight",30897,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,57487,
TRANSURETHRAL PROSTATECTOMY WITHOUT CC/MCC,714,MS-DRG,,,,,,,,inpatient,,,72648.49,10092,,,10092,Other,150% of Medicare + 9.63% HCRA Surcharge,6137,,"3,609.90 x patient days",6137,Per diem,,24007,,"25,046 x DRG weight",24007,Other,base rate x DRG weight,21606,,"22,541 x DRG weight",21606,Other,base rate x DRG weight,30215,,"31,523 x DRG weight",30215,Other,base rate x DRG weight,27194,,"28,371 x DRG weight",27194,Other,base rate x DRG weight,25683,,"26,795 x DRG weight",25683,Other,base rate x DRG weight,6750.7,,"3,970.89 x patient days",6750.7,Per diem,,21531,,"22,463 x DRG weight",21531,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,25329,,"26,426 x DRG weight",25329,Other,base rate x DRG weight,37198,,"38,809 x DRG weight",37198,Other,base rate x DRG weight,37198,,"38,809 x DRG weight",37198,Other,base rate x DRG weight,25329,,"26,426 x DRG weight",25329,Other,base rate x DRG weight,37198,,"38,809 x DRG weight",37198,Other,base rate x DRG weight,10817,,"6,363 x patient days",10817,Per diem,,50854,70,,50854,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,24017,,"25,057 x DRG weight",24017,Other,base rate x DRG weight,21616,,"22,552 x DRG weight",21616,Other,base rate x DRG weight,24017,,"25,057 x DRG weight",24017,Other,base rate x DRG weight,20414,,"21,298 x DRG weight",20414,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,50854,
OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES FOR MALIGNANCY WITH CC/MCC,715,MS-DRG,,,,,,,,inpatient,,,672810.72,45709,,,45709,Other,150% of Medicare + 9.63% HCRA Surcharge,27796,,"3,609.90 x patient days",27796,Per diem,,55289,,"25,046 x DRG weight",55289,Other,base rate x DRG weight,49759,,"22,541 x DRG weight",49759,Other,base rate x DRG weight,69587,,"31,523 x DRG weight",69587,Other,base rate x DRG weight,62629,,"28,371 x DRG weight",62629,Other,base rate x DRG weight,59150,,"26,795 x DRG weight",59150,Other,base rate x DRG weight,30575.6,,"3,970.89 x patient days",30575.6,Per diem,,49587,,"22,463 x DRG weight",49587,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,58335,,"26,426 x DRG weight",58335,Other,base rate x DRG weight,85671,,"38,809 x DRG weight",85671,Other,base rate x DRG weight,85671,,"38,809 x DRG weight",85671,Other,base rate x DRG weight,58335,,"26,426 x DRG weight",58335,Other,base rate x DRG weight,85671,,"38,809 x DRG weight",85671,Other,base rate x DRG weight,48995,,"6,363 x patient days",48995,Per diem,,470968,70,,470968,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,55313,,"25,057 x DRG weight",55313,Other,base rate x DRG weight,49784,,"22,552 x DRG weight",49784,Other,base rate x DRG weight,55313,,"25,057 x DRG weight",55313,Other,base rate x DRG weight,47015,,"21,298 x DRG weight",47015,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,470968,
OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES FOR MALIGNANCY WITHOUT CC/MCC,716,MS-DRG,,,,,,,,inpatient,,,85878.08,11279,,,11279,Other,150% of Medicare + 9.63% HCRA Surcharge,6859,,"3,609.90 x patient days",6859,Per diem,,35620,,"25,046 x DRG weight",35620,Other,base rate x DRG weight,32058,,"22,541 x DRG weight",32058,Other,base rate x DRG weight,44832,,"31,523 x DRG weight",44832,Other,base rate x DRG weight,40349,,"28,371 x DRG weight",40349,Other,base rate x DRG weight,38108,,"26,795 x DRG weight",38108,Other,base rate x DRG weight,7544.9,,"3,970.89 x patient days",7544.9,Per diem,,31947,,"22,463 x DRG weight",31947,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,37583,,"26,426 x DRG weight",37583,Other,base rate x DRG weight,55194,,"38,809 x DRG weight",55194,Other,base rate x DRG weight,55194,,"38,809 x DRG weight",55194,Other,base rate x DRG weight,37583,,"26,426 x DRG weight",37583,Other,base rate x DRG weight,55194,,"38,809 x DRG weight",55194,Other,base rate x DRG weight,12090,,"6,363 x patient days",12090,Per diem,,60115,70,,60115,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,35636,,"25,057 x DRG weight",35636,Other,base rate x DRG weight,32073,,"22,552 x DRG weight",32073,Other,base rate x DRG weight,35636,,"25,057 x DRG weight",35636,Other,base rate x DRG weight,30290,,"21,298 x DRG weight",30290,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,60115,
OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES EXCEPT MALIGNANCY WITH CC/MCC,717,MS-DRG,,,,,,,,inpatient,,,193611.43,31462,,,31462,Other,150% of Medicare + 9.63% HCRA Surcharge,19132,,"3,609.90 x patient days",19132,Per diem,,45426,,"25,046 x DRG weight",45426,Other,base rate x DRG weight,40883,,"22,541 x DRG weight",40883,Other,base rate x DRG weight,57173,,"31,523 x DRG weight",57173,Other,base rate x DRG weight,51456,,"28,371 x DRG weight",51456,Other,base rate x DRG weight,48598,,"26,795 x DRG weight",48598,Other,base rate x DRG weight,21045.2,,"3,970.89 x patient days",21045.2,Per diem,,40741,,"22,463 x DRG weight",40741,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,47929,,"26,426 x DRG weight",47929,Other,base rate x DRG weight,70388,,"38,809 x DRG weight",70388,Other,base rate x DRG weight,70388,,"38,809 x DRG weight",70388,Other,base rate x DRG weight,47929,,"26,426 x DRG weight",47929,Other,base rate x DRG weight,70388,,"38,809 x DRG weight",70388,Other,base rate x DRG weight,33724,,"6,363 x patient days",33724,Per diem,,135528,70,,135528,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,45446,,"25,057 x DRG weight",45446,Other,base rate x DRG weight,40903,,"22,552 x DRG weight",40903,Other,base rate x DRG weight,45446,,"25,057 x DRG weight",45446,Other,base rate x DRG weight,38628,,"21,298 x DRG weight",38628,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,135528,
OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES EXCEPT MALIGNANCY WITHOUT CC/MCC,718,MS-DRG,,,,,,,,inpatient,,,86665.45,13654,,,13654,Other,150% of Medicare + 9.63% HCRA Surcharge,8303,,"3,609.90 x patient days",8303,Per diem,,29449,,"25,046 x DRG weight",29449,Other,base rate x DRG weight,26504,,"22,541 x DRG weight",26504,Other,base rate x DRG weight,37065,,"31,523 x DRG weight",37065,Other,base rate x DRG weight,33359,,"28,371 x DRG weight",33359,Other,base rate x DRG weight,31506,,"26,795 x DRG weight",31506,Other,base rate x DRG weight,9133.3,,"3,970.89 x patient days",9133.3,Per diem,,26412,,"22,463 x DRG weight",26412,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,31072,,"26,426 x DRG weight",31072,Other,base rate x DRG weight,45632,,"38,809 x DRG weight",45632,Other,base rate x DRG weight,45632,,"38,809 x DRG weight",45632,Other,base rate x DRG weight,31072,,"26,426 x DRG weight",31072,Other,base rate x DRG weight,45632,,"38,809 x DRG weight",45632,Other,base rate x DRG weight,14635,,"6,363 x patient days",14635,Per diem,,60666,70,,60666,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,29462,,"25,057 x DRG weight",29462,Other,base rate x DRG weight,26517,,"22,552 x DRG weight",26517,Other,base rate x DRG weight,29462,,"25,057 x DRG weight",29462,Other,base rate x DRG weight,25042,,"21,298 x DRG weight",25042,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,60666,
"MALIGNANCY, MALE REPRODUCTIVE SYSTEM WITH MCC",722,MS-DRG,,,,,,,,inpatient,,,66917,46303,,,46303,Other,150% of Medicare + 9.63% HCRA Surcharge,28157,,"3,609.90 x patient days",28157,Per diem,,46956,,"25,046 x DRG weight",46956,Other,base rate x DRG weight,42260,,"22,541 x DRG weight",42260,Other,base rate x DRG weight,59099,,"31,523 x DRG weight",59099,Other,base rate x DRG weight,53190,,"28,371 x DRG weight",53190,Other,base rate x DRG weight,50235,,"26,795 x DRG weight",50235,Other,base rate x DRG weight,30972.7,,"3,970.89 x patient days",30972.7,Per diem,,42114,,"22,463 x DRG weight",42114,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,49543,,"26,426 x DRG weight",49543,Other,base rate x DRG weight,72759,,"38,809 x DRG weight",72759,Other,base rate x DRG weight,72759,,"38,809 x DRG weight",72759,Other,base rate x DRG weight,49543,,"26,426 x DRG weight",49543,Other,base rate x DRG weight,72759,,"38,809 x DRG weight",72759,Other,base rate x DRG weight,49631,,"6,363 x patient days",49631,Per diem,,46842,70,,46842,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,46977,,"25,057 x DRG weight",46977,Other,base rate x DRG weight,42280,,"22,552 x DRG weight",42280,Other,base rate x DRG weight,46977,,"25,057 x DRG weight",46977,Other,base rate x DRG weight,39929,,"21,298 x DRG weight",39929,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,72759,
"MALIGNANCY, MALE REPRODUCTIVE SYSTEM WITH CC",723,MS-DRG,,,,,,,,inpatient,,,173080.84,27901,,,27901,Other,150% of Medicare + 9.63% HCRA Surcharge,16967,,"3,609.90 x patient days",16967,Per diem,,27909,,"25,046 x DRG weight",27909,Other,base rate x DRG weight,25117,,"22,541 x DRG weight",25117,Other,base rate x DRG weight,35126,,"31,523 x DRG weight",35126,Other,base rate x DRG weight,31614,,"28,371 x DRG weight",31614,Other,base rate x DRG weight,29858,,"26,795 x DRG weight",29858,Other,base rate x DRG weight,18663.7,,"3,970.89 x patient days",18663.7,Per diem,,25031,,"22,463 x DRG weight",25031,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,29446,,"26,426 x DRG weight",29446,Other,base rate x DRG weight,43245,,"38,809 x DRG weight",43245,Other,base rate x DRG weight,43245,,"38,809 x DRG weight",43245,Other,base rate x DRG weight,29446,,"26,426 x DRG weight",29446,Other,base rate x DRG weight,43245,,"38,809 x DRG weight",43245,Other,base rate x DRG weight,29906,,"6,363 x patient days",29906,Per diem,,121157,70,,121157,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,27921,,"25,057 x DRG weight",27921,Other,base rate x DRG weight,25130,,"22,552 x DRG weight",25130,Other,base rate x DRG weight,27921,,"25,057 x DRG weight",27921,Other,base rate x DRG weight,23732,,"21,298 x DRG weight",23732,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,121157,
"MALIGNANCY, MALE REPRODUCTIVE SYSTEM WITHOUT CC/MCC",724,MS-DRG,,,,,,,,inpatient,,,19635,20184,,,20184,Other,150% of Medicare + 9.63% HCRA Surcharge,12274,,"3,609.90 x patient days",12274,Per diem,,20275,,"25,046 x DRG weight",20275,Other,base rate x DRG weight,18247,,"22,541 x DRG weight",18247,Other,base rate x DRG weight,25518,,"31,523 x DRG weight",25518,Other,base rate x DRG weight,22966,,"28,371 x DRG weight",22966,Other,base rate x DRG weight,21691,,"26,795 x DRG weight",21691,Other,base rate x DRG weight,13501.4,,"3,970.89 x patient days",13501.4,Per diem,,18184,,"22,463 x DRG weight",18184,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,21392,,"26,426 x DRG weight",21392,Other,base rate x DRG weight,31416,,"38,809 x DRG weight",31416,Other,base rate x DRG weight,31416,,"38,809 x DRG weight",31416,Other,base rate x DRG weight,21392,,"26,426 x DRG weight",21392,Other,base rate x DRG weight,31416,,"38,809 x DRG weight",31416,Other,base rate x DRG weight,21634,,"6,363 x patient days",21634,Per diem,,13745,70,,13745,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,20284,,"25,057 x DRG weight",20284,Other,base rate x DRG weight,18256,,"22,552 x DRG weight",18256,Other,base rate x DRG weight,20284,,"25,057 x DRG weight",20284,Other,base rate x DRG weight,17241,,"21,298 x DRG weight",17241,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,31416,
BENIGN PROSTATIC HYPERTROPHY WITH MCC,725,MS-DRG,,,,,,,,inpatient,,,105831,33243,,,33243,Other,150% of Medicare + 9.63% HCRA Surcharge,20215,,"3,609.90 x patient days",20215,Per diem,,31080,,"25,046 x DRG weight",31080,Other,base rate x DRG weight,27971,,"22,541 x DRG weight",27971,Other,base rate x DRG weight,39117,,"31,523 x DRG weight",39117,Other,base rate x DRG weight,35206,,"28,371 x DRG weight",35206,Other,base rate x DRG weight,33250,,"26,795 x DRG weight",33250,Other,base rate x DRG weight,22236.5,,"3,970.89 x patient days",22236.5,Per diem,,27874,,"22,463 x DRG weight",27874,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,32792,,"26,426 x DRG weight",32792,Other,base rate x DRG weight,48158,,"38,809 x DRG weight",48158,Other,base rate x DRG weight,48158,,"38,809 x DRG weight",48158,Other,base rate x DRG weight,32792,,"26,426 x DRG weight",32792,Other,base rate x DRG weight,48158,,"38,809 x DRG weight",48158,Other,base rate x DRG weight,35633,,"6,363 x patient days",35633,Per diem,,74082,70,,74082,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,31093,,"25,057 x DRG weight",31093,Other,base rate x DRG weight,27985,,"22,552 x DRG weight",27985,Other,base rate x DRG weight,31093,,"25,057 x DRG weight",31093,Other,base rate x DRG weight,26429,,"21,298 x DRG weight",26429,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,74082,
BENIGN PROSTATIC HYPERTROPHY WITHOUT MCC,726,MS-DRG,,,,,,,,inpatient,,,135159.5,18403,,,18403,Other,150% of Medicare + 9.63% HCRA Surcharge,11191,,"3,609.90 x patient days",11191,Per diem,,18306,,"25,046 x DRG weight",18306,Other,base rate x DRG weight,16475,,"22,541 x DRG weight",16475,Other,base rate x DRG weight,23040,,"31,523 x DRG weight",23040,Other,base rate x DRG weight,20736,,"28,371 x DRG weight",20736,Other,base rate x DRG weight,19584,,"26,795 x DRG weight",19584,Other,base rate x DRG weight,12310.1,,"3,970.89 x patient days",12310.1,Per diem,,16418,,"22,463 x DRG weight",16418,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,19315,,"26,426 x DRG weight",19315,Other,base rate x DRG weight,28365,,"38,809 x DRG weight",28365,Other,base rate x DRG weight,28365,,"38,809 x DRG weight",28365,Other,base rate x DRG weight,19315,,"26,426 x DRG weight",19315,Other,base rate x DRG weight,28365,,"38,809 x DRG weight",28365,Other,base rate x DRG weight,19725,,"6,363 x patient days",19725,Per diem,,94612,70,,94612,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,18314,,"25,057 x DRG weight",18314,Other,base rate x DRG weight,16483,,"22,552 x DRG weight",16483,Other,base rate x DRG weight,18314,,"25,057 x DRG weight",18314,Other,base rate x DRG weight,15567,,"21,298 x DRG weight",15567,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,94612,
INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITH MCC,727,MS-DRG,,,,,,,,inpatient,,,121672.4,40366,,,40366,Other,150% of Medicare + 9.63% HCRA Surcharge,24547,,"3,609.90 x patient days",24547,Per diem,,40600,,"25,046 x DRG weight",40600,Other,base rate x DRG weight,36539,,"22,541 x DRG weight",36539,Other,base rate x DRG weight,51099,,"31,523 x DRG weight",51099,Other,base rate x DRG weight,45989,,"28,371 x DRG weight",45989,Other,base rate x DRG weight,43435,,"26,795 x DRG weight",43435,Other,base rate x DRG weight,27001.7,,"3,970.89 x patient days",27001.7,Per diem,,36413,,"22,463 x DRG weight",36413,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,42837,,"26,426 x DRG weight",42837,Other,base rate x DRG weight,62909,,"38,809 x DRG weight",62909,Other,base rate x DRG weight,62909,,"38,809 x DRG weight",62909,Other,base rate x DRG weight,42837,,"26,426 x DRG weight",42837,Other,base rate x DRG weight,62909,,"38,809 x DRG weight",62909,Other,base rate x DRG weight,43268,,"6,363 x patient days",43268,Per diem,,85171,70,,85171,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,40617,,"25,057 x DRG weight",40617,Other,base rate x DRG weight,36557,,"22,552 x DRG weight",36557,Other,base rate x DRG weight,40617,,"25,057 x DRG weight",40617,Other,base rate x DRG weight,34524,,"21,298 x DRG weight",34524,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,85171,
INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITHOUT MCC,728,MS-DRG,,,,,,,,inpatient,,,107991.3,21371,,,21371,Other,150% of Medicare + 9.63% HCRA Surcharge,12996,,"3,609.90 x patient days",12996,Per diem,,20039,,"25,046 x DRG weight",20039,Other,base rate x DRG weight,18035,,"22,541 x DRG weight",18035,Other,base rate x DRG weight,25222,,"31,523 x DRG weight",25222,Other,base rate x DRG weight,22700,,"28,371 x DRG weight",22700,Other,base rate x DRG weight,21439,,"26,795 x DRG weight",21439,Other,base rate x DRG weight,14295.6,,"3,970.89 x patient days",14295.6,Per diem,,17973,,"22,463 x DRG weight",17973,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,21143,,"26,426 x DRG weight",21143,Other,base rate x DRG weight,31051,,"38,809 x DRG weight",31051,Other,base rate x DRG weight,31051,,"38,809 x DRG weight",31051,Other,base rate x DRG weight,21143,,"26,426 x DRG weight",21143,Other,base rate x DRG weight,31051,,"38,809 x DRG weight",31051,Other,base rate x DRG weight,22907,,"6,363 x patient days",22907,Per diem,,75594,70,,75594,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,20048,,"25,057 x DRG weight",20048,Other,base rate x DRG weight,18044,,"22,552 x DRG weight",18044,Other,base rate x DRG weight,20048,,"25,057 x DRG weight",20048,Other,base rate x DRG weight,17041,,"21,298 x DRG weight",17041,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,75594,
OTHER MALE REPRODUCTIVE SYSTEM DIAGNOSES WITH CC/MCC,729,MS-DRG,,,,,,,,inpatient,,,150200.13,23152,,,23152,Other,150% of Medicare + 9.63% HCRA Surcharge,14079,,"3,609.90 x patient days",14079,Per diem,,25144,,"25,046 x DRG weight",25144,Other,base rate x DRG weight,22629,,"22,541 x DRG weight",22629,Other,base rate x DRG weight,31646,,"31,523 x DRG weight",31646,Other,base rate x DRG weight,28482,,"28,371 x DRG weight",28482,Other,base rate x DRG weight,26900,,"26,795 x DRG weight",26900,Other,base rate x DRG weight,15486.9,,"3,970.89 x patient days",15486.9,Per diem,,22551,,"22,463 x DRG weight",22551,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,26529,,"26,426 x DRG weight",26529,Other,base rate x DRG weight,38960,,"38,809 x DRG weight",38960,Other,base rate x DRG weight,38960,,"38,809 x DRG weight",38960,Other,base rate x DRG weight,26529,,"26,426 x DRG weight",26529,Other,base rate x DRG weight,38960,,"38,809 x DRG weight",38960,Other,base rate x DRG weight,24816,,"6,363 x patient days",24816,Per diem,,105140,70,,105140,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,25155,,"25,057 x DRG weight",25155,Other,base rate x DRG weight,22640,,"22,552 x DRG weight",22640,Other,base rate x DRG weight,25155,,"25,057 x DRG weight",25155,Other,base rate x DRG weight,21381,,"21,298 x DRG weight",21381,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,105140,
OTHER MALE REPRODUCTIVE SYSTEM DIAGNOSES WITHOUT CC/MCC,730,MS-DRG,,,,,,,,inpatient,,,45266,13654,,,13654,Other,150% of Medicare + 9.63% HCRA Surcharge,8303,,"3,609.90 x patient days",8303,Per diem,,15569,,"25,046 x DRG weight",15569,Other,base rate x DRG weight,14011,,"22,541 x DRG weight",14011,Other,base rate x DRG weight,19595,,"31,523 x DRG weight",19595,Other,base rate x DRG weight,17635,,"28,371 x DRG weight",17635,Other,base rate x DRG weight,16656,,"26,795 x DRG weight",16656,Other,base rate x DRG weight,9133.3,,"3,970.89 x patient days",9133.3,Per diem,,13963,,"22,463 x DRG weight",13963,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,16426,,"26,426 x DRG weight",16426,Other,base rate x DRG weight,24124,,"38,809 x DRG weight",24124,Other,base rate x DRG weight,24124,,"38,809 x DRG weight",24124,Other,base rate x DRG weight,16426,,"26,426 x DRG weight",16426,Other,base rate x DRG weight,24124,,"38,809 x DRG weight",24124,Other,base rate x DRG weight,14635,,"6,363 x patient days",14635,Per diem,,31686,70,,31686,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,15575,,"25,057 x DRG weight",15575,Other,base rate x DRG weight,14018,,"22,552 x DRG weight",14018,Other,base rate x DRG weight,15575,,"25,057 x DRG weight",15575,Other,base rate x DRG weight,13239,,"21,298 x DRG weight",13239,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,31686,
"PELVIC EVISCERATION, RADICAL HYSTERECTOMY AND RADICAL VULVECTOMY WITH CC/MCC",734,MS-DRG,,,,,,,,inpatient,,,266811.89,28495,,,28495,Other,150% of Medicare + 9.63% HCRA Surcharge,17328,,"3,609.90 x patient days",17328,Per diem,,54440,,"25,046 x DRG weight",54440,Other,base rate x DRG weight,48995,,"22,541 x DRG weight",48995,Other,base rate x DRG weight,68518,,"31,523 x DRG weight",68518,Other,base rate x DRG weight,61667,,"28,371 x DRG weight",61667,Other,base rate x DRG weight,58242,,"26,795 x DRG weight",58242,Other,base rate x DRG weight,19060.8,,"3,970.89 x patient days",19060.8,Per diem,,48826,,"22,463 x DRG weight",48826,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,57440,,"26,426 x DRG weight",57440,Other,base rate x DRG weight,84355,,"38,809 x DRG weight",84355,Other,base rate x DRG weight,84355,,"38,809 x DRG weight",84355,Other,base rate x DRG weight,57440,,"26,426 x DRG weight",57440,Other,base rate x DRG weight,84355,,"38,809 x DRG weight",84355,Other,base rate x DRG weight,30542,,"6,363 x patient days",30542,Per diem,,186768,70,,186768,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,54464,,"25,057 x DRG weight",54464,Other,base rate x DRG weight,49019,,"22,552 x DRG weight",49019,Other,base rate x DRG weight,54464,,"25,057 x DRG weight",54464,Other,base rate x DRG weight,46293,,"21,298 x DRG weight",46293,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,186768,
"PELVIC EVISCERATION, RADICAL HYSTERECTOMY AND RADICAL VULVECTOMY WITHOUT CC/MCC",735,MS-DRG,,,,,,,,inpatient,,,138118.19,11279,,,11279,Other,150% of Medicare + 9.63% HCRA Surcharge,6859,,"3,609.90 x patient days",6859,Per diem,,31563,,"25,046 x DRG weight",31563,Other,base rate x DRG weight,28406,,"22,541 x DRG weight",28406,Other,base rate x DRG weight,39725,,"31,523 x DRG weight",39725,Other,base rate x DRG weight,35753,,"28,371 x DRG weight",35753,Other,base rate x DRG weight,33767,,"26,795 x DRG weight",33767,Other,base rate x DRG weight,7544.9,,"3,970.89 x patient days",7544.9,Per diem,,28308,,"22,463 x DRG weight",28308,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,33302,,"26,426 x DRG weight",33302,Other,base rate x DRG weight,48907,,"38,809 x DRG weight",48907,Other,base rate x DRG weight,48907,,"38,809 x DRG weight",48907,Other,base rate x DRG weight,33302,,"26,426 x DRG weight",33302,Other,base rate x DRG weight,48907,,"38,809 x DRG weight",48907,Other,base rate x DRG weight,12090,,"6,363 x patient days",12090,Per diem,,96683,70,,96683,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,31577,,"25,057 x DRG weight",31577,Other,base rate x DRG weight,28420,,"22,552 x DRG weight",28420,Other,base rate x DRG weight,31577,,"25,057 x DRG weight",31577,Other,base rate x DRG weight,26840,,"21,298 x DRG weight",26840,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,96683,
UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITH MCC,736,MS-DRG,,,,,,,,inpatient,,,395451.85,61144,,,61144,Other,150% of Medicare + 9.63% HCRA Surcharge,37182,,"3,609.90 x patient days",37182,Per diem,,97359,,"25,046 x DRG weight",97359,Other,base rate x DRG weight,87621,,"22,541 x DRG weight",87621,Other,base rate x DRG weight,122536,,"31,523 x DRG weight",122536,Other,base rate x DRG weight,110284,,"28,371 x DRG weight",110284,Other,base rate x DRG weight,104158,,"26,795 x DRG weight",104158,Other,base rate x DRG weight,40900.2,,"3,970.89 x patient days",40900.2,Per diem,,87318,,"22,463 x DRG weight",87318,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,102723,,"26,426 x DRG weight",102723,Other,base rate x DRG weight,150858,,"38,809 x DRG weight",150858,Other,base rate x DRG weight,150858,,"38,809 x DRG weight",150858,Other,base rate x DRG weight,102723,,"26,426 x DRG weight",102723,Other,base rate x DRG weight,150858,,"38,809 x DRG weight",150858,Other,base rate x DRG weight,65539,,"6,363 x patient days",65539,Per diem,,276816,70,,276816,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,97402,,"25,057 x DRG weight",97402,Other,base rate x DRG weight,87664,,"22,552 x DRG weight",87664,Other,base rate x DRG weight,97402,,"25,057 x DRG weight",97402,Other,base rate x DRG weight,82790,,"21,298 x DRG weight",82790,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,276816,
UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITH CC,737,MS-DRG,,,,,,,,inpatient,,,230661.41,27901,,,27901,Other,150% of Medicare + 9.63% HCRA Surcharge,16967,,"3,609.90 x patient days",16967,Per diem,,49436,,"25,046 x DRG weight",49436,Other,base rate x DRG weight,44491,,"22,541 x DRG weight",44491,Other,base rate x DRG weight,62220,,"31,523 x DRG weight",62220,Other,base rate x DRG weight,55999,,"28,371 x DRG weight",55999,Other,base rate x DRG weight,52888,,"26,795 x DRG weight",52888,Other,base rate x DRG weight,18663.7,,"3,970.89 x patient days",18663.7,Per diem,,44337,,"22,463 x DRG weight",44337,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,52160,,"26,426 x DRG weight",52160,Other,base rate x DRG weight,76601,,"38,809 x DRG weight",76601,Other,base rate x DRG weight,76601,,"38,809 x DRG weight",76601,Other,base rate x DRG weight,52160,,"26,426 x DRG weight",52160,Other,base rate x DRG weight,76601,,"38,809 x DRG weight",76601,Other,base rate x DRG weight,29906,,"6,363 x patient days",29906,Per diem,,161463,70,,161463,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,49458,,"25,057 x DRG weight",49458,Other,base rate x DRG weight,44513,,"22,552 x DRG weight",44513,Other,base rate x DRG weight,49458,,"25,057 x DRG weight",49458,Other,base rate x DRG weight,42038,,"21,298 x DRG weight",42038,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,161463,
UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITHOUT CC/MCC,738,MS-DRG,,,,,,,,inpatient,,,154592.47,15435,,,15435,Other,150% of Medicare + 9.63% HCRA Surcharge,9386,,"3,609.90 x patient days",9386,Per diem,,34178,,"25,046 x DRG weight",34178,Other,base rate x DRG weight,30759,,"22,541 x DRG weight",30759,Other,base rate x DRG weight,43016,,"31,523 x DRG weight",43016,Other,base rate x DRG weight,38715,,"28,371 x DRG weight",38715,Other,base rate x DRG weight,36564,,"26,795 x DRG weight",36564,Other,base rate x DRG weight,10324.6,,"3,970.89 x patient days",10324.6,Per diem,,30653,,"22,463 x DRG weight",30653,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,36061,,"26,426 x DRG weight",36061,Other,base rate x DRG weight,52959,,"38,809 x DRG weight",52959,Other,base rate x DRG weight,52959,,"38,809 x DRG weight",52959,Other,base rate x DRG weight,36061,,"26,426 x DRG weight",36061,Other,base rate x DRG weight,52959,,"38,809 x DRG weight",52959,Other,base rate x DRG weight,16544,,"6,363 x patient days",16544,Per diem,,108215,70,,108215,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,34193,,"25,057 x DRG weight",34193,Other,base rate x DRG weight,30774,,"22,552 x DRG weight",30774,Other,base rate x DRG weight,34193,,"25,057 x DRG weight",34193,Other,base rate x DRG weight,29063,,"21,298 x DRG weight",29063,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,108215,
UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITH MCC,739,MS-DRG,,,,,,,,inpatient,,,394301.66,53427,,,53427,Other,150% of Medicare + 9.63% HCRA Surcharge,32489,,"3,609.90 x patient days",32489,Per diem,,90574,,"25,046 x DRG weight",90574,Other,base rate x DRG weight,81515,,"22,541 x DRG weight",81515,Other,base rate x DRG weight,113997,,"31,523 x DRG weight",113997,Other,base rate x DRG weight,102598,,"28,371 x DRG weight",102598,Other,base rate x DRG weight,96899,,"26,795 x DRG weight",96899,Other,base rate x DRG weight,35737.9,,"3,970.89 x patient days",35737.9,Per diem,,81233,,"22,463 x DRG weight",81233,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,95564,,"26,426 x DRG weight",95564,Other,base rate x DRG weight,140345,,"38,809 x DRG weight",140345,Other,base rate x DRG weight,140345,,"38,809 x DRG weight",140345,Other,base rate x DRG weight,95564,,"26,426 x DRG weight",95564,Other,base rate x DRG weight,140345,,"38,809 x DRG weight",140345,Other,base rate x DRG weight,57267,,"6,363 x patient days",57267,Per diem,,276011,70,,276011,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,90614,,"25,057 x DRG weight",90614,Other,base rate x DRG weight,81555,,"22,552 x DRG weight",81555,Other,base rate x DRG weight,90614,,"25,057 x DRG weight",90614,Other,base rate x DRG weight,77020,,"21,298 x DRG weight",77020,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,276011,
UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITH CC,740,MS-DRG,,,,,,,,inpatient,,,224338.12,21371,,,21371,Other,150% of Medicare + 9.63% HCRA Surcharge,12996,,"3,609.90 x patient days",12996,Per diem,,44757,,"25,046 x DRG weight",44757,Other,base rate x DRG weight,40281,,"22,541 x DRG weight",40281,Other,base rate x DRG weight,56332,,"31,523 x DRG weight",56332,Other,base rate x DRG weight,50699,,"28,371 x DRG weight",50699,Other,base rate x DRG weight,47883,,"26,795 x DRG weight",47883,Other,base rate x DRG weight,14295.6,,"3,970.89 x patient days",14295.6,Per diem,,40141,,"22,463 x DRG weight",40141,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,47223,,"26,426 x DRG weight",47223,Other,base rate x DRG weight,69352,,"38,809 x DRG weight",69352,Other,base rate x DRG weight,69352,,"38,809 x DRG weight",69352,Other,base rate x DRG weight,47223,,"26,426 x DRG weight",47223,Other,base rate x DRG weight,69352,,"38,809 x DRG weight",69352,Other,base rate x DRG weight,22907,,"6,363 x patient days",22907,Per diem,,157037,70,,157037,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,44777,,"25,057 x DRG weight",44777,Other,base rate x DRG weight,40300,,"22,552 x DRG weight",40300,Other,base rate x DRG weight,44777,,"25,057 x DRG weight",44777,Other,base rate x DRG weight,38060,,"21,298 x DRG weight",38060,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,157037,
UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITHOUT CC/MCC,741,MS-DRG,,,,,,,,inpatient,,,119467.87,11279,,,11279,Other,150% of Medicare + 9.63% HCRA Surcharge,6859,,"3,609.90 x patient days",6859,Per diem,,32542,,"25,046 x DRG weight",32542,Other,base rate x DRG weight,29288,,"22,541 x DRG weight",29288,Other,base rate x DRG weight,40958,,"31,523 x DRG weight",40958,Other,base rate x DRG weight,36862,,"28,371 x DRG weight",36862,Other,base rate x DRG weight,34815,,"26,795 x DRG weight",34815,Other,base rate x DRG weight,7544.9,,"3,970.89 x patient days",7544.9,Per diem,,29186,,"22,463 x DRG weight",29186,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,34335,,"26,426 x DRG weight",34335,Other,base rate x DRG weight,50425,,"38,809 x DRG weight",50425,Other,base rate x DRG weight,50425,,"38,809 x DRG weight",50425,Other,base rate x DRG weight,34335,,"26,426 x DRG weight",34335,Other,base rate x DRG weight,50425,,"38,809 x DRG weight",50425,Other,base rate x DRG weight,12090,,"6,363 x patient days",12090,Per diem,,83628,70,,83628,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,32557,,"25,057 x DRG weight",32557,Other,base rate x DRG weight,29302,,"22,552 x DRG weight",29302,Other,base rate x DRG weight,32557,,"25,057 x DRG weight",32557,Other,base rate x DRG weight,27672,,"21,298 x DRG weight",27672,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,83628,
UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITH CC/MCC,742,MS-DRG,,,,,,,,inpatient,,,143911.13,22559,,,22559,Other,150% of Medicare + 9.63% HCRA Surcharge,13718,,"3,609.90 x patient days",13718,Per diem,,44629,,"25,046 x DRG weight",44629,Other,base rate x DRG weight,40166,,"22,541 x DRG weight",40166,Other,base rate x DRG weight,56171,,"31,523 x DRG weight",56171,Other,base rate x DRG weight,50554,,"28,371 x DRG weight",50554,Other,base rate x DRG weight,47746,,"26,795 x DRG weight",47746,Other,base rate x DRG weight,15089.8,,"3,970.89 x patient days",15089.8,Per diem,,40027,,"22,463 x DRG weight",40027,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,47088,,"26,426 x DRG weight",47088,Other,base rate x DRG weight,69154,,"38,809 x DRG weight",69154,Other,base rate x DRG weight,69154,,"38,809 x DRG weight",69154,Other,base rate x DRG weight,47088,,"26,426 x DRG weight",47088,Other,base rate x DRG weight,69154,,"38,809 x DRG weight",69154,Other,base rate x DRG weight,24179,,"6,363 x patient days",24179,Per diem,,100738,70,,100738,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,44649,,"25,057 x DRG weight",44649,Other,base rate x DRG weight,40185,,"22,552 x DRG weight",40185,Other,base rate x DRG weight,44649,,"25,057 x DRG weight",44649,Other,base rate x DRG weight,37951,,"21,298 x DRG weight",37951,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,100738,
UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITHOUT CC/MCC,743,MS-DRG,,,,,,,,inpatient,,,119614.78,10686,,,10686,Other,150% of Medicare + 9.63% HCRA Surcharge,6498,,"3,609.90 x patient days",6498,Per diem,,29103,,"25,046 x DRG weight",29103,Other,base rate x DRG weight,26193,,"22,541 x DRG weight",26193,Other,base rate x DRG weight,36630,,"31,523 x DRG weight",36630,Other,base rate x DRG weight,32967,,"28,371 x DRG weight",32967,Other,base rate x DRG weight,31136,,"26,795 x DRG weight",31136,Other,base rate x DRG weight,7147.8,,"3,970.89 x patient days",7147.8,Per diem,,26102,,"22,463 x DRG weight",26102,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,30707,,"26,426 x DRG weight",30707,Other,base rate x DRG weight,45096,,"38,809 x DRG weight",45096,Other,base rate x DRG weight,45096,,"38,809 x DRG weight",45096,Other,base rate x DRG weight,30707,,"26,426 x DRG weight",30707,Other,base rate x DRG weight,45096,,"38,809 x DRG weight",45096,Other,base rate x DRG weight,11453,,"6,363 x patient days",11453,Per diem,,83730,70,,83730,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,29116,,"25,057 x DRG weight",29116,Other,base rate x DRG weight,26205,,"22,552 x DRG weight",26205,Other,base rate x DRG weight,29116,,"25,057 x DRG weight",29116,Other,base rate x DRG weight,24748,,"21,298 x DRG weight",24748,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,83730,
"D&C, CONIZATION, LAPAROSCOPY AND TUBAL INTERRUPTION WITH CC/MCC",744,MS-DRG,,,,,,,,inpatient,,,188345.52,37992,,,37992,Other,150% of Medicare + 9.63% HCRA Surcharge,23103,,"3,609.90 x patient days",23103,Per diem,,47147,,"25,046 x DRG weight",47147,Other,base rate x DRG weight,42431,,"22,541 x DRG weight",42431,Other,base rate x DRG weight,59339,,"31,523 x DRG weight",59339,Other,base rate x DRG weight,53406,,"28,371 x DRG weight",53406,Other,base rate x DRG weight,50439,,"26,795 x DRG weight",50439,Other,base rate x DRG weight,25413.3,,"3,970.89 x patient days",25413.3,Per diem,,42284,,"22,463 x DRG weight",42284,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,49744,,"26,426 x DRG weight",49744,Other,base rate x DRG weight,73054,,"38,809 x DRG weight",73054,Other,base rate x DRG weight,73054,,"38,809 x DRG weight",73054,Other,base rate x DRG weight,49744,,"26,426 x DRG weight",49744,Other,base rate x DRG weight,73054,,"38,809 x DRG weight",73054,Other,base rate x DRG weight,40723,,"6,363 x patient days",40723,Per diem,,131842,70,,131842,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,47167,,"25,057 x DRG weight",47167,Other,base rate x DRG weight,42452,,"22,552 x DRG weight",42452,Other,base rate x DRG weight,47167,,"25,057 x DRG weight",47167,Other,base rate x DRG weight,40091,,"21,298 x DRG weight",40091,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,131842,
"D&C, CONIZATION, LAPAROSCOPY AND TUBAL INTERRUPTION WITHOUT CC/MCC",745,MS-DRG,,,,,,,,inpatient,,,105015.35,13654,,,13654,Other,150% of Medicare + 9.63% HCRA Surcharge,8303,,"3,609.90 x patient days",8303,Per diem,,25945,,"25,046 x DRG weight",25945,Other,base rate x DRG weight,23350,,"22,541 x DRG weight",23350,Other,base rate x DRG weight,32655,,"31,523 x DRG weight",32655,Other,base rate x DRG weight,29390,,"28,371 x DRG weight",29390,Other,base rate x DRG weight,27757,,"26,795 x DRG weight",27757,Other,base rate x DRG weight,9133.3,,"3,970.89 x patient days",9133.3,Per diem,,23269,,"22,463 x DRG weight",23269,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,27375,,"26,426 x DRG weight",27375,Other,base rate x DRG weight,40202,,"38,809 x DRG weight",40202,Other,base rate x DRG weight,40202,,"38,809 x DRG weight",40202,Other,base rate x DRG weight,27375,,"26,426 x DRG weight",27375,Other,base rate x DRG weight,40202,,"38,809 x DRG weight",40202,Other,base rate x DRG weight,14635,,"6,363 x patient days",14635,Per diem,,73511,70,,73511,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,25957,,"25,057 x DRG weight",25957,Other,base rate x DRG weight,23362,,"22,552 x DRG weight",23362,Other,base rate x DRG weight,25957,,"25,057 x DRG weight",25957,Other,base rate x DRG weight,22063,,"21,298 x DRG weight",22063,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,73511,
"VAGINA, CERVIX AND VULVA PROCEDURES WITH CC/MCC",746,MS-DRG,,,,,,,,inpatient,,,318480.73,32649,,,32649,Other,150% of Medicare + 9.63% HCRA Surcharge,19854,,"3,609.90 x patient days",19854,Per diem,,41980,,"25,046 x DRG weight",41980,Other,base rate x DRG weight,37781,,"22,541 x DRG weight",37781,Other,base rate x DRG weight,52836,,"31,523 x DRG weight",52836,Other,base rate x DRG weight,47553,,"28,371 x DRG weight",47553,Other,base rate x DRG weight,44911,,"26,795 x DRG weight",44911,Other,base rate x DRG weight,21839.4,,"3,970.89 x patient days",21839.4,Per diem,,37650,,"22,463 x DRG weight",37650,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,44293,,"26,426 x DRG weight",44293,Other,base rate x DRG weight,65048,,"38,809 x DRG weight",65048,Other,base rate x DRG weight,65048,,"38,809 x DRG weight",65048,Other,base rate x DRG weight,44293,,"26,426 x DRG weight",44293,Other,base rate x DRG weight,65048,,"38,809 x DRG weight",65048,Other,base rate x DRG weight,34997,,"6,363 x patient days",34997,Per diem,,222937,70,,222937,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,41998,,"25,057 x DRG weight",41998,Other,base rate x DRG weight,37799,,"22,552 x DRG weight",37799,Other,base rate x DRG weight,41998,,"25,057 x DRG weight",41998,Other,base rate x DRG weight,35698,,"21,298 x DRG weight",35698,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,222937,
"VAGINA, CERVIX AND VULVA PROCEDURES WITHOUT CC/MCC",747,MS-DRG,,,,,,,,inpatient,,,120820.28,9498,,,9498,Other,150% of Medicare + 9.63% HCRA Surcharge,5776,,"3,609.90 x patient days",5776,Per diem,,22221,,"25,046 x DRG weight",22221,Other,base rate x DRG weight,19998,,"22,541 x DRG weight",19998,Other,base rate x DRG weight,27967,,"31,523 x DRG weight",27967,Other,base rate x DRG weight,25171,,"28,371 x DRG weight",25171,Other,base rate x DRG weight,23773,,"26,795 x DRG weight",23773,Other,base rate x DRG weight,6353.6,,"3,970.89 x patient days",6353.6,Per diem,,19929,,"22,463 x DRG weight",19929,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,23445,,"26,426 x DRG weight",23445,Other,base rate x DRG weight,34431,,"38,809 x DRG weight",34431,Other,base rate x DRG weight,34431,,"38,809 x DRG weight",34431,Other,base rate x DRG weight,23445,,"26,426 x DRG weight",23445,Other,base rate x DRG weight,34431,,"38,809 x DRG weight",34431,Other,base rate x DRG weight,10181,,"6,363 x patient days",10181,Per diem,,84574,70,,84574,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,22231,,"25,057 x DRG weight",22231,Other,base rate x DRG weight,20008,,"22,552 x DRG weight",20008,Other,base rate x DRG weight,22231,,"25,057 x DRG weight",22231,Other,base rate x DRG weight,18896,,"21,298 x DRG weight",18896,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,84574,
FEMALE REPRODUCTIVE SYSTEM RECONSTRUCTIVE PROCEDURES,748,MS-DRG,,,,,,,,inpatient,,,117580.68,10686,,,10686,Other,150% of Medicare + 9.63% HCRA Surcharge,6498,,"3,609.90 x patient days",6498,Per diem,,35187,,"25,046 x DRG weight",35187,Other,base rate x DRG weight,31668,,"22,541 x DRG weight",31668,Other,base rate x DRG weight,44287,,"31,523 x DRG weight",44287,Other,base rate x DRG weight,39858,,"28,371 x DRG weight",39858,Other,base rate x DRG weight,37644,,"26,795 x DRG weight",37644,Other,base rate x DRG weight,7147.8,,"3,970.89 x patient days",7147.8,Per diem,,31558,,"22,463 x DRG weight",31558,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,37126,,"26,426 x DRG weight",37126,Other,base rate x DRG weight,54523,,"38,809 x DRG weight",54523,Other,base rate x DRG weight,54523,,"38,809 x DRG weight",54523,Other,base rate x DRG weight,37126,,"26,426 x DRG weight",37126,Other,base rate x DRG weight,54523,,"38,809 x DRG weight",54523,Other,base rate x DRG weight,11453,,"6,363 x patient days",11453,Per diem,,82306,70,,82306,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,35203,,"25,057 x DRG weight",35203,Other,base rate x DRG weight,31683,,"22,552 x DRG weight",31683,Other,base rate x DRG weight,35203,,"25,057 x DRG weight",35203,Other,base rate x DRG weight,29922,,"21,298 x DRG weight",29922,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,82306,
OTHER FEMALE REPRODUCTIVE SYSTEM O.R. PROCEDURES WITH CC/MCC,749,MS-DRG,,,,,,,,inpatient,,,154320.11,45115,,,45115,Other,150% of Medicare + 9.63% HCRA Surcharge,27435,,"3,609.90 x patient days",27435,Per diem,,63046,,"25,046 x DRG weight",63046,Other,base rate x DRG weight,56740,,"22,541 x DRG weight",56740,Other,base rate x DRG weight,79350,,"31,523 x DRG weight",79350,Other,base rate x DRG weight,71415,,"28,371 x DRG weight",71415,Other,base rate x DRG weight,67448,,"26,795 x DRG weight",67448,Other,base rate x DRG weight,30178.5,,"3,970.89 x patient days",30178.5,Per diem,,56544,,"22,463 x DRG weight",56544,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,66520,,"26,426 x DRG weight",66520,Other,base rate x DRG weight,97690,,"38,809 x DRG weight",97690,Other,base rate x DRG weight,97690,,"38,809 x DRG weight",97690,Other,base rate x DRG weight,66520,,"26,426 x DRG weight",66520,Other,base rate x DRG weight,97690,,"38,809 x DRG weight",97690,Other,base rate x DRG weight,48359,,"6,363 x patient days",48359,Per diem,,108024,70,,108024,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,63073,,"25,057 x DRG weight",63073,Other,base rate x DRG weight,56768,,"22,552 x DRG weight",56768,Other,base rate x DRG weight,63073,,"25,057 x DRG weight",63073,Other,base rate x DRG weight,53611,,"21,298 x DRG weight",53611,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,108024,
OTHER FEMALE REPRODUCTIVE SYSTEM O.R. PROCEDURES WITHOUT CC/MCC,750,MS-DRG,,,,,,,,inpatient,,,77672.49,14841,,,14841,Other,150% of Medicare + 9.63% HCRA Surcharge,9025,,"3,609.90 x patient days",9025,Per diem,,34063,,"25,046 x DRG weight",34063,Other,base rate x DRG weight,30656,,"22,541 x DRG weight",30656,Other,base rate x DRG weight,42871,,"31,523 x DRG weight",42871,Other,base rate x DRG weight,38585,,"28,371 x DRG weight",38585,Other,base rate x DRG weight,36441,,"26,795 x DRG weight",36441,Other,base rate x DRG weight,9927.5,,"3,970.89 x patient days",9927.5,Per diem,,30550,,"22,463 x DRG weight",30550,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,35939,,"26,426 x DRG weight",35939,Other,base rate x DRG weight,52780,,"38,809 x DRG weight",52780,Other,base rate x DRG weight,52780,,"38,809 x DRG weight",52780,Other,base rate x DRG weight,35939,,"26,426 x DRG weight",35939,Other,base rate x DRG weight,52780,,"38,809 x DRG weight",52780,Other,base rate x DRG weight,15908,,"6,363 x patient days",15908,Per diem,,54371,70,,54371,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,34078,,"25,057 x DRG weight",34078,Other,base rate x DRG weight,30671,,"22,552 x DRG weight",30671,Other,base rate x DRG weight,34078,,"25,057 x DRG weight",34078,Other,base rate x DRG weight,28965,,"21,298 x DRG weight",28965,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,54371,
"MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM WITH MCC",754,MS-DRG,,,,,,,,inpatient,,,223184.5,43928,,,43928,Other,150% of Medicare + 9.63% HCRA Surcharge,26713,,"3,609.90 x patient days",26713,Per diem,,46398,,"25,046 x DRG weight",46398,Other,base rate x DRG weight,41757,,"22,541 x DRG weight",41757,Other,base rate x DRG weight,58396,,"31,523 x DRG weight",58396,Other,base rate x DRG weight,52557,,"28,371 x DRG weight",52557,Other,base rate x DRG weight,49638,,"26,795 x DRG weight",49638,Other,base rate x DRG weight,29384.3,,"3,970.89 x patient days",29384.3,Per diem,,41613,,"22,463 x DRG weight",41613,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,48954,,"26,426 x DRG weight",48954,Other,base rate x DRG weight,71894,,"38,809 x DRG weight",71894,Other,base rate x DRG weight,71894,,"38,809 x DRG weight",71894,Other,base rate x DRG weight,48954,,"26,426 x DRG weight",48954,Other,base rate x DRG weight,71894,,"38,809 x DRG weight",71894,Other,base rate x DRG weight,47086,,"6,363 x patient days",47086,Per diem,,156229,70,,156229,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,46418,,"25,057 x DRG weight",46418,Other,base rate x DRG weight,41778,,"22,552 x DRG weight",41778,Other,base rate x DRG weight,46418,,"25,057 x DRG weight",46418,Other,base rate x DRG weight,39455,,"21,298 x DRG weight",39455,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,156229,
"MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM WITH CC",755,MS-DRG,,,,,,,,inpatient,,,225371.75,26120,,,26120,Other,150% of Medicare + 9.63% HCRA Surcharge,15884,,"3,609.90 x patient days",15884,Per diem,,27167,,"25,046 x DRG weight",27167,Other,base rate x DRG weight,24450,,"22,541 x DRG weight",24450,Other,base rate x DRG weight,34193,,"31,523 x DRG weight",34193,Other,base rate x DRG weight,30774,,"28,371 x DRG weight",30774,Other,base rate x DRG weight,29065,,"26,795 x DRG weight",29065,Other,base rate x DRG weight,17472.4,,"3,970.89 x patient days",17472.4,Per diem,,24366,,"22,463 x DRG weight",24366,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,28664,,"26,426 x DRG weight",28664,Other,base rate x DRG weight,42096,,"38,809 x DRG weight",42096,Other,base rate x DRG weight,42096,,"38,809 x DRG weight",42096,Other,base rate x DRG weight,28664,,"26,426 x DRG weight",28664,Other,base rate x DRG weight,42096,,"38,809 x DRG weight",42096,Other,base rate x DRG weight,27997,,"6,363 x patient days",27997,Per diem,,157760,70,,157760,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,27179,,"25,057 x DRG weight",27179,Other,base rate x DRG weight,24462,,"22,552 x DRG weight",24462,Other,base rate x DRG weight,27179,,"25,057 x DRG weight",27179,Other,base rate x DRG weight,23102,,"21,298 x DRG weight",23102,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,157760,
"MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM WITHOUT CC/MCC",756,MS-DRG,,,,,,,,inpatient,,,94960,14841,,,14841,Other,150% of Medicare + 9.63% HCRA Surcharge,9025,,"3,609.90 x patient days",9025,Per diem,,24788,,"25,046 x DRG weight",24788,Other,base rate x DRG weight,22309,,"22,541 x DRG weight",22309,Other,base rate x DRG weight,31198,,"31,523 x DRG weight",31198,Other,base rate x DRG weight,28079,,"28,371 x DRG weight",28079,Other,base rate x DRG weight,26519,,"26,795 x DRG weight",26519,Other,base rate x DRG weight,9927.5,,"3,970.89 x patient days",9927.5,Per diem,,22232,,"22,463 x DRG weight",22232,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,26154,,"26,426 x DRG weight",26154,Other,base rate x DRG weight,38409,,"38,809 x DRG weight",38409,Other,base rate x DRG weight,38409,,"38,809 x DRG weight",38409,Other,base rate x DRG weight,26154,,"26,426 x DRG weight",26154,Other,base rate x DRG weight,38409,,"38,809 x DRG weight",38409,Other,base rate x DRG weight,15908,,"6,363 x patient days",15908,Per diem,,66472,70,,66472,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,24799,,"25,057 x DRG weight",24799,Other,base rate x DRG weight,22320,,"22,552 x DRG weight",22320,Other,base rate x DRG weight,24799,,"25,057 x DRG weight",24799,Other,base rate x DRG weight,21079,,"21,298 x DRG weight",21079,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,66472,
"INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITH MCC",757,MS-DRG,,,,,,,,inpatient,,,109570.47,39179,,,39179,Other,150% of Medicare + 9.63% HCRA Surcharge,23825,,"3,609.90 x patient days",23825,Per diem,,37359,,"25,046 x DRG weight",37359,Other,base rate x DRG weight,33622,,"22,541 x DRG weight",33622,Other,base rate x DRG weight,47020,,"31,523 x DRG weight",47020,Other,base rate x DRG weight,42318,,"28,371 x DRG weight",42318,Other,base rate x DRG weight,39967,,"26,795 x DRG weight",39967,Other,base rate x DRG weight,26207.5,,"3,970.89 x patient days",26207.5,Per diem,,33506,,"22,463 x DRG weight",33506,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,39417,,"26,426 x DRG weight",39417,Other,base rate x DRG weight,57888,,"38,809 x DRG weight",57888,Other,base rate x DRG weight,57888,,"38,809 x DRG weight",57888,Other,base rate x DRG weight,39417,,"26,426 x DRG weight",39417,Other,base rate x DRG weight,57888,,"38,809 x DRG weight",57888,Other,base rate x DRG weight,41996,,"6,363 x patient days",41996,Per diem,,76699,70,,76699,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,37375,,"25,057 x DRG weight",37375,Other,base rate x DRG weight,33639,,"22,552 x DRG weight",33639,Other,base rate x DRG weight,37375,,"25,057 x DRG weight",37375,Other,base rate x DRG weight,31768,,"21,298 x DRG weight",31768,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,76699,
"INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITH CC",758,MS-DRG,,,,,,,,inpatient,,,140774.2,27308,,,27308,Other,150% of Medicare + 9.63% HCRA Surcharge,16606,,"3,609.90 x patient days",16606,Per diem,,24861,,"25,046 x DRG weight",24861,Other,base rate x DRG weight,22374,,"22,541 x DRG weight",22374,Other,base rate x DRG weight,31290,,"31,523 x DRG weight",31290,Other,base rate x DRG weight,28161,,"28,371 x DRG weight",28161,Other,base rate x DRG weight,26597,,"26,795 x DRG weight",26597,Other,base rate x DRG weight,18266.6,,"3,970.89 x patient days",18266.6,Per diem,,22297,,"22,463 x DRG weight",22297,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,26230,,"26,426 x DRG weight",26230,Other,base rate x DRG weight,38522,,"38,809 x DRG weight",38522,Other,base rate x DRG weight,38522,,"38,809 x DRG weight",38522,Other,base rate x DRG weight,26230,,"26,426 x DRG weight",26230,Other,base rate x DRG weight,38522,,"38,809 x DRG weight",38522,Other,base rate x DRG weight,29270,,"6,363 x patient days",29270,Per diem,,98542,70,,98542,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,24872,,"25,057 x DRG weight",24872,Other,base rate x DRG weight,22385,,"22,552 x DRG weight",22385,Other,base rate x DRG weight,24872,,"25,057 x DRG weight",24872,Other,base rate x DRG weight,21140,,"21,298 x DRG weight",21140,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,98542,
"INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITHOUT CC/MCC",759,MS-DRG,,,,,,,,inpatient,,,80688.03,18997,,,18997,Other,150% of Medicare + 9.63% HCRA Surcharge,11552,,"3,609.90 x patient days",11552,Per diem,,16185,,"25,046 x DRG weight",16185,Other,base rate x DRG weight,14566,,"22,541 x DRG weight",14566,Other,base rate x DRG weight,20370,,"31,523 x DRG weight",20370,Other,base rate x DRG weight,18333,,"28,371 x DRG weight",18333,Other,base rate x DRG weight,17315,,"26,795 x DRG weight",17315,Other,base rate x DRG weight,12707.2,,"3,970.89 x patient days",12707.2,Per diem,,14516,,"22,463 x DRG weight",14516,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,17076,,"26,426 x DRG weight",17076,Other,base rate x DRG weight,25078,,"38,809 x DRG weight",25078,Other,base rate x DRG weight,25078,,"38,809 x DRG weight",25078,Other,base rate x DRG weight,17076,,"26,426 x DRG weight",17076,Other,base rate x DRG weight,25078,,"38,809 x DRG weight",25078,Other,base rate x DRG weight,20362,,"6,363 x patient days",20362,Per diem,,56482,70,,56482,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,16192,,"25,057 x DRG weight",16192,Other,base rate x DRG weight,14573,,"22,552 x DRG weight",14573,Other,base rate x DRG weight,16192,,"25,057 x DRG weight",16192,Other,base rate x DRG weight,13763,,"21,298 x DRG weight",13763,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,56482,
MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITH CC/MCC,760,MS-DRG,,,,,,,,inpatient,,,75978.04,23152,,,23152,Other,150% of Medicare + 9.63% HCRA Surcharge,14079,,"3,609.90 x patient days",14079,Per diem,,24931,,"25,046 x DRG weight",24931,Other,base rate x DRG weight,22437,,"22,541 x DRG weight",22437,Other,base rate x DRG weight,31378,,"31,523 x DRG weight",31378,Other,base rate x DRG weight,28240,,"28,371 x DRG weight",28240,Other,base rate x DRG weight,26672,,"26,795 x DRG weight",26672,Other,base rate x DRG weight,15486.9,,"3,970.89 x patient days",15486.9,Per diem,,22360,,"22,463 x DRG weight",22360,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,26304,,"26,426 x DRG weight",26304,Other,base rate x DRG weight,38630,,"38,809 x DRG weight",38630,Other,base rate x DRG weight,38630,,"38,809 x DRG weight",38630,Other,base rate x DRG weight,26304,,"26,426 x DRG weight",26304,Other,base rate x DRG weight,38630,,"38,809 x DRG weight",38630,Other,base rate x DRG weight,24816,,"6,363 x patient days",24816,Per diem,,53185,70,,53185,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,24942,,"25,057 x DRG weight",24942,Other,base rate x DRG weight,22448,,"22,552 x DRG weight",22448,Other,base rate x DRG weight,24942,,"25,057 x DRG weight",24942,Other,base rate x DRG weight,21200,,"21,298 x DRG weight",21200,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,53185,
MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITHOUT CC/MCC,761,MS-DRG,,,,,,,,inpatient,,,72379.63,12467,,,12467,Other,150% of Medicare + 9.63% HCRA Surcharge,7581,,"3,609.90 x patient days",7581,Per diem,,15168,,"25,046 x DRG weight",15168,Other,base rate x DRG weight,13651,,"22,541 x DRG weight",13651,Other,base rate x DRG weight,19090,,"31,523 x DRG weight",19090,Other,base rate x DRG weight,17181,,"28,371 x DRG weight",17181,Other,base rate x DRG weight,16227,,"26,795 x DRG weight",16227,Other,base rate x DRG weight,8339.1,,"3,970.89 x patient days",8339.1,Per diem,,13604,,"22,463 x DRG weight",13604,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,16004,,"26,426 x DRG weight",16004,Other,base rate x DRG weight,23503,,"38,809 x DRG weight",23503,Other,base rate x DRG weight,23503,,"38,809 x DRG weight",23503,Other,base rate x DRG weight,16004,,"26,426 x DRG weight",16004,Other,base rate x DRG weight,23503,,"38,809 x DRG weight",23503,Other,base rate x DRG weight,13362,,"6,363 x patient days",13362,Per diem,,50666,70,,50666,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,15175,,"25,057 x DRG weight",15175,Other,base rate x DRG weight,13657,,"22,552 x DRG weight",13657,Other,base rate x DRG weight,15175,,"25,057 x DRG weight",15175,Other,base rate x DRG weight,12898,,"21,298 x DRG weight",12898,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,50666,
POSTPARTUM AND POST ABORTION DIAGNOSES WITH O.R. PROCEDURES,769,MS-DRG,,,,,,,,inpatient,,,204856.68,29682,,,29682,Other,150% of Medicare + 9.63% HCRA Surcharge,18050,,"3,609.90 x patient days",18050,Per diem,,38669,,"25,046 x DRG weight",38669,Other,base rate x DRG weight,34801,,"22,541 x DRG weight",34801,Other,base rate x DRG weight,48668,,"31,523 x DRG weight",48668,Other,base rate x DRG weight,43802,,"28,371 x DRG weight",43802,Other,base rate x DRG weight,41369,,"26,795 x DRG weight",41369,Other,base rate x DRG weight,19855,,"3,970.89 x patient days",19855,Per diem,,34681,,"22,463 x DRG weight",34681,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,40799,,"26,426 x DRG weight",40799,Other,base rate x DRG weight,59917,,"38,809 x DRG weight",59917,Other,base rate x DRG weight,59917,,"38,809 x DRG weight",59917,Other,base rate x DRG weight,40799,,"26,426 x DRG weight",40799,Other,base rate x DRG weight,59917,,"38,809 x DRG weight",59917,Other,base rate x DRG weight,31815,,"6,363 x patient days",31815,Per diem,,143400,70,,143400,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,38686,,"25,057 x DRG weight",38686,Other,base rate x DRG weight,34818,,"22,552 x DRG weight",34818,Other,base rate x DRG weight,38686,,"25,057 x DRG weight",38686,Other,base rate x DRG weight,32882,,"21,298 x DRG weight",32882,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,143400,
"ABORTION WITH D&C, ASPIRATION CURETTAGE OR HYSTEROTOMY",770,MS-DRG,,,,,,,,inpatient,,,121738.67,11873,,,11873,Other,150% of Medicare + 9.63% HCRA Surcharge,7220,,"3,609.90 x patient days",7220,Per diem,,20004,,"25,046 x DRG weight",20004,Other,base rate x DRG weight,18003,,"22,541 x DRG weight",18003,Other,base rate x DRG weight,25177,,"31,523 x DRG weight",25177,Other,base rate x DRG weight,22660,,"28,371 x DRG weight",22660,Other,base rate x DRG weight,21401,,"26,795 x DRG weight",21401,Other,base rate x DRG weight,7942,,"3,970.89 x patient days",7942,Per diem,,17941,,"22,463 x DRG weight",17941,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,21106,,"26,426 x DRG weight",21106,Other,base rate x DRG weight,30997,,"38,809 x DRG weight",30997,Other,base rate x DRG weight,30997,,"38,809 x DRG weight",30997,Other,base rate x DRG weight,21106,,"26,426 x DRG weight",21106,Other,base rate x DRG weight,30997,,"38,809 x DRG weight",30997,Other,base rate x DRG weight,12726,,"6,363 x patient days",12726,Per diem,,85217,70,,85217,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,20013,,"25,057 x DRG weight",20013,Other,base rate x DRG weight,18012,,"22,552 x DRG weight",18012,Other,base rate x DRG weight,20013,,"25,057 x DRG weight",20013,Other,base rate x DRG weight,17011,,"21,298 x DRG weight",17011,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,85217,
POSTPARTUM AND POST ABORTION DIAGNOSES WITHOUT O.R. PROCEDURES,776,MS-DRG,,,,,,,,inpatient,,,80412.78,18997,,,18997,Other,150% of Medicare + 9.63% HCRA Surcharge,11552,,"3,609.90 x patient days",11552,Per diem,,17950,,"25,046 x DRG weight",17950,Other,base rate x DRG weight,16155,,"22,541 x DRG weight",16155,Other,base rate x DRG weight,22593,,"31,523 x DRG weight",22593,Other,base rate x DRG weight,20333,,"28,371 x DRG weight",20333,Other,base rate x DRG weight,19204,,"26,795 x DRG weight",19204,Other,base rate x DRG weight,12707.2,,"3,970.89 x patient days",12707.2,Per diem,,16099,,"22,463 x DRG weight",16099,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,18940,,"26,426 x DRG weight",18940,Other,base rate x DRG weight,27814,,"38,809 x DRG weight",27814,Other,base rate x DRG weight,27814,,"38,809 x DRG weight",27814,Other,base rate x DRG weight,18940,,"26,426 x DRG weight",18940,Other,base rate x DRG weight,27814,,"38,809 x DRG weight",27814,Other,base rate x DRG weight,20362,,"6,363 x patient days",20362,Per diem,,56289,70,,56289,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,17958,,"25,057 x DRG weight",17958,Other,base rate x DRG weight,16163,,"22,552 x DRG weight",16163,Other,base rate x DRG weight,17958,,"25,057 x DRG weight",17958,Other,base rate x DRG weight,15264,,"21,298 x DRG weight",15264,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,56289,
ABORTION WITHOUT D&C,779,MS-DRG,,,,,,,,inpatient,,,161268.53,16622,,,16622,Other,150% of Medicare + 9.63% HCRA Surcharge,10108,,"3,609.90 x patient days",10108,Per diem,,24776,,"25,046 x DRG weight",24776,Other,base rate x DRG weight,22298,,"22,541 x DRG weight",22298,Other,base rate x DRG weight,31183,,"31,523 x DRG weight",31183,Other,base rate x DRG weight,28065,,"28,371 x DRG weight",28065,Other,base rate x DRG weight,26506,,"26,795 x DRG weight",26506,Other,base rate x DRG weight,11118.8,,"3,970.89 x patient days",11118.8,Per diem,,22220,,"22,463 x DRG weight",22220,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,26141,,"26,426 x DRG weight",26141,Other,base rate x DRG weight,38390,,"38,809 x DRG weight",38390,Other,base rate x DRG weight,38390,,"38,809 x DRG weight",38390,Other,base rate x DRG weight,26141,,"26,426 x DRG weight",26141,Other,base rate x DRG weight,38390,,"38,809 x DRG weight",38390,Other,base rate x DRG weight,17816,,"6,363 x patient days",17816,Per diem,,112888,70,,112888,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,24786,,"25,057 x DRG weight",24786,Other,base rate x DRG weight,22308,,"22,552 x DRG weight",22308,Other,base rate x DRG weight,24786,,"25,057 x DRG weight",24786,Other,base rate x DRG weight,21068,,"21,298 x DRG weight",21068,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,112888,
SPLENIC PROCEDURES WITH MCC,799,MS-DRG,,,,,,,,inpatient,,,201209,60550,,,60550,Other,150% of Medicare + 9.63% HCRA Surcharge,36821,,"3,609.90 x patient days",36821,Per diem,,124093,,"25,046 x DRG weight",124093,Other,base rate x DRG weight,111682,,"22,541 x DRG weight",111682,Other,base rate x DRG weight,156184,,"31,523 x DRG weight",156184,Other,base rate x DRG weight,140567,,"28,371 x DRG weight",140567,Other,base rate x DRG weight,132759,,"26,795 x DRG weight",132759,Other,base rate x DRG weight,40503.1,,"3,970.89 x patient days",40503.1,Per diem,,111295,,"22,463 x DRG weight",111295,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,130930,,"26,426 x DRG weight",130930,Other,base rate x DRG weight,192283,,"38,809 x DRG weight",192283,Other,base rate x DRG weight,192283,,"38,809 x DRG weight",192283,Other,base rate x DRG weight,130930,,"26,426 x DRG weight",130930,Other,base rate x DRG weight,192283,,"38,809 x DRG weight",192283,Other,base rate x DRG weight,64903,,"6,363 x patient days",64903,Per diem,,140846,70,,140846,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,124147,,"25,057 x DRG weight",124147,Other,base rate x DRG weight,111736,,"22,552 x DRG weight",111736,Other,base rate x DRG weight,124147,,"25,057 x DRG weight",124147,Other,base rate x DRG weight,105523,,"21,298 x DRG weight",105523,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,192283,
SPLENIC PROCEDURES WITH CC,800,MS-DRG,,,,,,,,inpatient,,,134326.23,33836,,,33836,Other,150% of Medicare + 9.63% HCRA Surcharge,20576,,"3,609.90 x patient days",20576,Per diem,,70572,,"25,046 x DRG weight",70572,Other,base rate x DRG weight,63514,,"22,541 x DRG weight",63514,Other,base rate x DRG weight,88822,,"31,523 x DRG weight",88822,Other,base rate x DRG weight,79941,,"28,371 x DRG weight",79941,Other,base rate x DRG weight,75500,,"26,795 x DRG weight",75500,Other,base rate x DRG weight,22633.6,,"3,970.89 x patient days",22633.6,Per diem,,63294,,"22,463 x DRG weight",63294,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,74461,,"26,426 x DRG weight",74461,Other,base rate x DRG weight,109352,,"38,809 x DRG weight",109352,Other,base rate x DRG weight,109352,,"38,809 x DRG weight",109352,Other,base rate x DRG weight,74461,,"26,426 x DRG weight",74461,Other,base rate x DRG weight,109352,,"38,809 x DRG weight",109352,Other,base rate x DRG weight,36269,,"6,363 x patient days",36269,Per diem,,94028,70,,94028,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,70603,,"25,057 x DRG weight",70603,Other,base rate x DRG weight,63545,,"22,552 x DRG weight",63545,Other,base rate x DRG weight,70603,,"25,057 x DRG weight",70603,Other,base rate x DRG weight,60011,,"21,298 x DRG weight",60011,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,109352,
SPLENIC PROCEDURES WITHOUT CC/MCC,801,MS-DRG,,,,,,,,inpatient,,,81755.94,16028,,,16028,Other,150% of Medicare + 9.63% HCRA Surcharge,9747,,"3,609.90 x patient days",9747,Per diem,,44825,,"25,046 x DRG weight",44825,Other,base rate x DRG weight,40342,,"22,541 x DRG weight",40342,Other,base rate x DRG weight,56417,,"31,523 x DRG weight",56417,Other,base rate x DRG weight,50776,,"28,371 x DRG weight",50776,Other,base rate x DRG weight,47955,,"26,795 x DRG weight",47955,Other,base rate x DRG weight,10721.7,,"3,970.89 x patient days",10721.7,Per diem,,40202,,"22,463 x DRG weight",40202,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,47295,,"26,426 x DRG weight",47295,Other,base rate x DRG weight,69456,,"38,809 x DRG weight",69456,Other,base rate x DRG weight,69456,,"38,809 x DRG weight",69456,Other,base rate x DRG weight,47295,,"26,426 x DRG weight",47295,Other,base rate x DRG weight,69456,,"38,809 x DRG weight",69456,Other,base rate x DRG weight,17180,,"6,363 x patient days",17180,Per diem,,57229,70,,57229,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,44845,,"25,057 x DRG weight",44845,Other,base rate x DRG weight,40361,,"22,552 x DRG weight",40361,Other,base rate x DRG weight,44845,,"25,057 x DRG weight",44845,Other,base rate x DRG weight,38117,,"21,298 x DRG weight",38117,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,69456,
OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITH MCC,802,MS-DRG,,,,,,,,inpatient,,,285425.59,64112,,,64112,Other,150% of Medicare + 9.63% HCRA Surcharge,38987,,"3,609.90 x patient days",38987,Per diem,,85928,,"25,046 x DRG weight",85928,Other,base rate x DRG weight,77334,,"22,541 x DRG weight",77334,Other,base rate x DRG weight,108149,,"31,523 x DRG weight",108149,Other,base rate x DRG weight,97335,,"28,371 x DRG weight",97335,Other,base rate x DRG weight,91928,,"26,795 x DRG weight",91928,Other,base rate x DRG weight,42885.7,,"3,970.89 x patient days",42885.7,Per diem,,77066,,"22,463 x DRG weight",77066,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,90662,,"26,426 x DRG weight",90662,Other,base rate x DRG weight,133146,,"38,809 x DRG weight",133146,Other,base rate x DRG weight,133146,,"38,809 x DRG weight",133146,Other,base rate x DRG weight,90662,,"26,426 x DRG weight",90662,Other,base rate x DRG weight,133146,,"38,809 x DRG weight",133146,Other,base rate x DRG weight,68720,,"6,363 x patient days",68720,Per diem,,199798,70,,199798,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,85966,,"25,057 x DRG weight",85966,Other,base rate x DRG weight,77371,,"22,552 x DRG weight",77371,Other,base rate x DRG weight,85966,,"25,057 x DRG weight",85966,Other,base rate x DRG weight,73069,,"21,298 x DRG weight",73069,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,199798,
OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITH CC,803,MS-DRG,,,,,,,,inpatient,,,157504.65,31462,,,31462,Other,150% of Medicare + 9.63% HCRA Surcharge,19132,,"3,609.90 x patient days",19132,Per diem,,46540,,"25,046 x DRG weight",46540,Other,base rate x DRG weight,41886,,"22,541 x DRG weight",41886,Other,base rate x DRG weight,58576,,"31,523 x DRG weight",58576,Other,base rate x DRG weight,52719,,"28,371 x DRG weight",52719,Other,base rate x DRG weight,49790,,"26,795 x DRG weight",49790,Other,base rate x DRG weight,21045.2,,"3,970.89 x patient days",21045.2,Per diem,,41741,,"22,463 x DRG weight",41741,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,49105,,"26,426 x DRG weight",49105,Other,base rate x DRG weight,72115,,"38,809 x DRG weight",72115,Other,base rate x DRG weight,72115,,"38,809 x DRG weight",72115,Other,base rate x DRG weight,49105,,"26,426 x DRG weight",49105,Other,base rate x DRG weight,72115,,"38,809 x DRG weight",72115,Other,base rate x DRG weight,33724,,"6,363 x patient days",33724,Per diem,,110253,70,,110253,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,46561,,"25,057 x DRG weight",46561,Other,base rate x DRG weight,41906,,"22,552 x DRG weight",41906,Other,base rate x DRG weight,46561,,"25,057 x DRG weight",46561,Other,base rate x DRG weight,39576,,"21,298 x DRG weight",39576,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,110253,
OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITHOUT CC/MCC,804,MS-DRG,,,,,,,,inpatient,,,172279.15,13654,,,13654,Other,150% of Medicare + 9.63% HCRA Surcharge,8303,,"3,609.90 x patient days",8303,Per diem,,30316,,"25,046 x DRG weight",30316,Other,base rate x DRG weight,27284,,"22,541 x DRG weight",27284,Other,base rate x DRG weight,38155,,"31,523 x DRG weight",38155,Other,base rate x DRG weight,34340,,"28,371 x DRG weight",34340,Other,base rate x DRG weight,32433,,"26,795 x DRG weight",32433,Other,base rate x DRG weight,9133.3,,"3,970.89 x patient days",9133.3,Per diem,,27189,,"22,463 x DRG weight",27189,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,31986,,"26,426 x DRG weight",31986,Other,base rate x DRG weight,46974,,"38,809 x DRG weight",46974,Other,base rate x DRG weight,46974,,"38,809 x DRG weight",46974,Other,base rate x DRG weight,31986,,"26,426 x DRG weight",31986,Other,base rate x DRG weight,46974,,"38,809 x DRG weight",46974,Other,base rate x DRG weight,14635,,"6,363 x patient days",14635,Per diem,,120595,70,,120595,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,30329,,"25,057 x DRG weight",30329,Other,base rate x DRG weight,27297,,"22,552 x DRG weight",27297,Other,base rate x DRG weight,30329,,"25,057 x DRG weight",30329,Other,base rate x DRG weight,25779,,"21,298 x DRG weight",25779,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,120595,
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH MCC,808,MS-DRG,,,,,,,,inpatient,,,320861.91,43928,,,43928,Other,150% of Medicare + 9.63% HCRA Surcharge,26713,,"3,609.90 x patient days",26713,Per diem,,54853,,"25,046 x DRG weight",54853,Other,base rate x DRG weight,49367,,"22,541 x DRG weight",49367,Other,base rate x DRG weight,69039,,"31,523 x DRG weight",69039,Other,base rate x DRG weight,62135,,"28,371 x DRG weight",62135,Other,base rate x DRG weight,58684,,"26,795 x DRG weight",58684,Other,base rate x DRG weight,29384.3,,"3,970.89 x patient days",29384.3,Per diem,,49196,,"22,463 x DRG weight",49196,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,57876,,"26,426 x DRG weight",57876,Other,base rate x DRG weight,84996,,"38,809 x DRG weight",84996,Other,base rate x DRG weight,84996,,"38,809 x DRG weight",84996,Other,base rate x DRG weight,57876,,"26,426 x DRG weight",57876,Other,base rate x DRG weight,84996,,"38,809 x DRG weight",84996,Other,base rate x DRG weight,47086,,"6,363 x patient days",47086,Per diem,,224603,70,,224603,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,54877,,"25,057 x DRG weight",54877,Other,base rate x DRG weight,49391,,"22,552 x DRG weight",49391,Other,base rate x DRG weight,54877,,"25,057 x DRG weight",54877,Other,base rate x DRG weight,46645,,"21,298 x DRG weight",46645,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,224603,
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH CC,809,MS-DRG,,,,,,,,inpatient,,,155465.23,26120,,,26120,Other,150% of Medicare + 9.63% HCRA Surcharge,15884,,"3,609.90 x patient days",15884,Per diem,,30165,,"25,046 x DRG weight",30165,Other,base rate x DRG weight,27148,,"22,541 x DRG weight",27148,Other,base rate x DRG weight,37966,,"31,523 x DRG weight",37966,Other,base rate x DRG weight,34170,,"28,371 x DRG weight",34170,Other,base rate x DRG weight,32272,,"26,795 x DRG weight",32272,Other,base rate x DRG weight,17472.4,,"3,970.89 x patient days",17472.4,Per diem,,27054,,"22,463 x DRG weight",27054,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,31827,,"26,426 x DRG weight",31827,Other,base rate x DRG weight,46742,,"38,809 x DRG weight",46742,Other,base rate x DRG weight,46742,,"38,809 x DRG weight",46742,Other,base rate x DRG weight,31827,,"26,426 x DRG weight",31827,Other,base rate x DRG weight,46742,,"38,809 x DRG weight",46742,Other,base rate x DRG weight,27997,,"6,363 x patient days",27997,Per diem,,108826,70,,108826,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,30179,,"25,057 x DRG weight",30179,Other,base rate x DRG weight,27162,,"22,552 x DRG weight",27162,Other,base rate x DRG weight,30179,,"25,057 x DRG weight",30179,Other,base rate x DRG weight,25651,,"21,298 x DRG weight",25651,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,108826,
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITHOUT CC/MCC,810,MS-DRG,,,,,,,,inpatient,,,148218.26,18997,,,18997,Other,150% of Medicare + 9.63% HCRA Surcharge,11552,,"3,609.90 x patient days",11552,Per diem,,25159,,"25,046 x DRG weight",25159,Other,base rate x DRG weight,22642,,"22,541 x DRG weight",22642,Other,base rate x DRG weight,31665,,"31,523 x DRG weight",31665,Other,base rate x DRG weight,28499,,"28,371 x DRG weight",28499,Other,base rate x DRG weight,26916,,"26,795 x DRG weight",26916,Other,base rate x DRG weight,12707.2,,"3,970.89 x patient days",12707.2,Per diem,,22564,,"22,463 x DRG weight",22564,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,26545,,"26,426 x DRG weight",26545,Other,base rate x DRG weight,38984,,"38,809 x DRG weight",38984,Other,base rate x DRG weight,38984,,"38,809 x DRG weight",38984,Other,base rate x DRG weight,26545,,"26,426 x DRG weight",26545,Other,base rate x DRG weight,38984,,"38,809 x DRG weight",38984,Other,base rate x DRG weight,20362,,"6,363 x patient days",20362,Per diem,,103753,70,,103753,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,25170,,"25,057 x DRG weight",25170,Other,base rate x DRG weight,22653,,"22,552 x DRG weight",22653,Other,base rate x DRG weight,25170,,"25,057 x DRG weight",25170,Other,base rate x DRG weight,21394,,"21,298 x DRG weight",21394,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,103753,
RED BLOOD CELL DISORDERS WITH MCC,811,MS-DRG,,,,,,,,inpatient,,,193444.49,30274,,,30274,Other,150% of Medicare + 9.63% HCRA Surcharge,18410,,"3,609.90 x patient days",18410,Per diem,,35155,,"25,046 x DRG weight",35155,Other,base rate x DRG weight,31639,,"22,541 x DRG weight",31639,Other,base rate x DRG weight,44246,,"31,523 x DRG weight",44246,Other,base rate x DRG weight,39822,,"28,371 x DRG weight",39822,Other,base rate x DRG weight,37609,,"26,795 x DRG weight",37609,Other,base rate x DRG weight,20251,,"3,970.89 x patient days",20251,Per diem,,31529,,"22,463 x DRG weight",31529,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,37092,,"26,426 x DRG weight",37092,Other,base rate x DRG weight,54472,,"38,809 x DRG weight",54472,Other,base rate x DRG weight,54472,,"38,809 x DRG weight",54472,Other,base rate x DRG weight,37092,,"26,426 x DRG weight",37092,Other,base rate x DRG weight,54472,,"38,809 x DRG weight",54472,Other,base rate x DRG weight,32451,,"6,363 x patient days",32451,Per diem,,135411,70,,135411,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,35170,,"25,057 x DRG weight",35170,Other,base rate x DRG weight,31654,,"22,552 x DRG weight",31654,Other,base rate x DRG weight,35170,,"25,057 x DRG weight",35170,Other,base rate x DRG weight,29894,,"21,298 x DRG weight",29894,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,135411,
RED BLOOD CELL DISORDERS WITHOUT MCC,812,MS-DRG,,,,,,,,inpatient,,,136529.49,21371,,,21371,Other,150% of Medicare + 9.63% HCRA Surcharge,12996,,"3,609.90 x patient days",12996,Per diem,,22559,,"25,046 x DRG weight",22559,Other,base rate x DRG weight,20303,,"22,541 x DRG weight",20303,Other,base rate x DRG weight,28393,,"31,523 x DRG weight",28393,Other,base rate x DRG weight,25554,,"28,371 x DRG weight",25554,Other,base rate x DRG weight,24134,,"26,795 x DRG weight",24134,Other,base rate x DRG weight,14295.6,,"3,970.89 x patient days",14295.6,Per diem,,20232,,"22,463 x DRG weight",20232,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,23802,,"26,426 x DRG weight",23802,Other,base rate x DRG weight,34955,,"38,809 x DRG weight",34955,Other,base rate x DRG weight,34955,,"38,809 x DRG weight",34955,Other,base rate x DRG weight,23802,,"26,426 x DRG weight",23802,Other,base rate x DRG weight,34955,,"38,809 x DRG weight",34955,Other,base rate x DRG weight,22907,,"6,363 x patient days",22907,Per diem,,95571,70,,95571,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,22569,,"25,057 x DRG weight",22569,Other,base rate x DRG weight,20313,,"22,552 x DRG weight",20313,Other,base rate x DRG weight,22569,,"25,057 x DRG weight",22569,Other,base rate x DRG weight,19183,,"21,298 x DRG weight",19183,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,95571,
COAGULATION DISORDERS,813,MS-DRG,,,,,,,,inpatient,,,150549.26,29089,,,29089,Other,150% of Medicare + 9.63% HCRA Surcharge,17689,,"3,609.90 x patient days",17689,Per diem,,39072,,"25,046 x DRG weight",39072,Other,base rate x DRG weight,35164,,"22,541 x DRG weight",35164,Other,base rate x DRG weight,49176,,"31,523 x DRG weight",49176,Other,base rate x DRG weight,44259,,"28,371 x DRG weight",44259,Other,base rate x DRG weight,41800,,"26,795 x DRG weight",41800,Other,base rate x DRG weight,19457.9,,"3,970.89 x patient days",19457.9,Per diem,,35042,,"22,463 x DRG weight",35042,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,41225,,"26,426 x DRG weight",41225,Other,base rate x DRG weight,60542,,"38,809 x DRG weight",60542,Other,base rate x DRG weight,60542,,"38,809 x DRG weight",60542,Other,base rate x DRG weight,41225,,"26,426 x DRG weight",41225,Other,base rate x DRG weight,60542,,"38,809 x DRG weight",60542,Other,base rate x DRG weight,31179,,"6,363 x patient days",31179,Per diem,,105384,70,,105384,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,39089,,"25,057 x DRG weight",39089,Other,base rate x DRG weight,35181,,"22,552 x DRG weight",35181,Other,base rate x DRG weight,39089,,"25,057 x DRG weight",39089,Other,base rate x DRG weight,33225,,"21,298 x DRG weight",33225,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,105384,
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH MCC,814,MS-DRG,,,,,,,,inpatient,,,442077.65,42741,,,42741,Other,150% of Medicare + 9.63% HCRA Surcharge,25991,,"3,609.90 x patient days",25991,Per diem,,53300,,"25,046 x DRG weight",53300,Other,base rate x DRG weight,47970,,"22,541 x DRG weight",47970,Other,base rate x DRG weight,67084,,"31,523 x DRG weight",67084,Other,base rate x DRG weight,60376,,"28,371 x DRG weight",60376,Other,base rate x DRG weight,57022,,"26,795 x DRG weight",57022,Other,base rate x DRG weight,28590.1,,"3,970.89 x patient days",28590.1,Per diem,,47804,,"22,463 x DRG weight",47804,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,56237,,"26,426 x DRG weight",56237,Other,base rate x DRG weight,82589,,"38,809 x DRG weight",82589,Other,base rate x DRG weight,82589,,"38,809 x DRG weight",82589,Other,base rate x DRG weight,56237,,"26,426 x DRG weight",56237,Other,base rate x DRG weight,82589,,"38,809 x DRG weight",82589,Other,base rate x DRG weight,45814,,"6,363 x patient days",45814,Per diem,,309454,70,,309454,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,53324,,"25,057 x DRG weight",53324,Other,base rate x DRG weight,47993,,"22,552 x DRG weight",47993,Other,base rate x DRG weight,53324,,"25,057 x DRG weight",53324,Other,base rate x DRG weight,45324,,"21,298 x DRG weight",45324,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,309454,
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH CC,815,MS-DRG,,,,,,,,inpatient,,,124895.14,23152,,,23152,Other,150% of Medicare + 9.63% HCRA Surcharge,14079,,"3,609.90 x patient days",14079,Per diem,,24901,,"25,046 x DRG weight",24901,Other,base rate x DRG weight,22410,,"22,541 x DRG weight",22410,Other,base rate x DRG weight,31340,,"31,523 x DRG weight",31340,Other,base rate x DRG weight,28206,,"28,371 x DRG weight",28206,Other,base rate x DRG weight,26640,,"26,795 x DRG weight",26640,Other,base rate x DRG weight,15486.9,,"3,970.89 x patient days",15486.9,Per diem,,22333,,"22,463 x DRG weight",22333,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,26273,,"26,426 x DRG weight",26273,Other,base rate x DRG weight,38584,,"38,809 x DRG weight",38584,Other,base rate x DRG weight,38584,,"38,809 x DRG weight",38584,Other,base rate x DRG weight,26273,,"26,426 x DRG weight",26273,Other,base rate x DRG weight,38584,,"38,809 x DRG weight",38584,Other,base rate x DRG weight,24816,,"6,363 x patient days",24816,Per diem,,87427,70,,87427,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,24912,,"25,057 x DRG weight",24912,Other,base rate x DRG weight,22421,,"22,552 x DRG weight",22421,Other,base rate x DRG weight,24912,,"25,057 x DRG weight",24912,Other,base rate x DRG weight,21174,,"21,298 x DRG weight",21174,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,87427,
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITHOUT CC/MCC,816,MS-DRG,,,,,,,,inpatient,,,82618.99,17216,,,17216,Other,150% of Medicare + 9.63% HCRA Surcharge,10469,,"3,609.90 x patient days",10469,Per diem,,17788,,"25,046 x DRG weight",17788,Other,base rate x DRG weight,16009,,"22,541 x DRG weight",16009,Other,base rate x DRG weight,22388,,"31,523 x DRG weight",22388,Other,base rate x DRG weight,20149,,"28,371 x DRG weight",20149,Other,base rate x DRG weight,19030,,"26,795 x DRG weight",19030,Other,base rate x DRG weight,11515.9,,"3,970.89 x patient days",11515.9,Per diem,,15953,,"22,463 x DRG weight",15953,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,18768,,"26,426 x DRG weight",18768,Other,base rate x DRG weight,27562,,"38,809 x DRG weight",27562,Other,base rate x DRG weight,27562,,"38,809 x DRG weight",27562,Other,base rate x DRG weight,18768,,"26,426 x DRG weight",18768,Other,base rate x DRG weight,27562,,"38,809 x DRG weight",27562,Other,base rate x DRG weight,18453,,"6,363 x patient days",18453,Per diem,,57833,70,,57833,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,17795,,"25,057 x DRG weight",17795,Other,base rate x DRG weight,16016,,"22,552 x DRG weight",16016,Other,base rate x DRG weight,17795,,"25,057 x DRG weight",17795,Other,base rate x DRG weight,15126,,"21,298 x DRG weight",15126,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,57833,
OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITH MCC,817,MS-DRG,,,,,,,,inpatient,,,203739,40366,,,40366,Other,150% of Medicare + 9.63% HCRA Surcharge,24547,,"3,609.90 x patient days",24547,Per diem,,70550,,"25,046 x DRG weight",70550,Other,base rate x DRG weight,63493,,"22,541 x DRG weight",63493,Other,base rate x DRG weight,88794,,"31,523 x DRG weight",88794,Other,base rate x DRG weight,79915,,"28,371 x DRG weight",79915,Other,base rate x DRG weight,75476,,"26,795 x DRG weight",75476,Other,base rate x DRG weight,27001.7,,"3,970.89 x patient days",27001.7,Per diem,,63274,,"22,463 x DRG weight",63274,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,74437,,"26,426 x DRG weight",74437,Other,base rate x DRG weight,109317,,"38,809 x DRG weight",109317,Other,base rate x DRG weight,109317,,"38,809 x DRG weight",109317,Other,base rate x DRG weight,74437,,"26,426 x DRG weight",74437,Other,base rate x DRG weight,109317,,"38,809 x DRG weight",109317,Other,base rate x DRG weight,43268,,"6,363 x patient days",43268,Per diem,,142617,70,,142617,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,70581,,"25,057 x DRG weight",70581,Other,base rate x DRG weight,63524,,"22,552 x DRG weight",63524,Other,base rate x DRG weight,70581,,"25,057 x DRG weight",70581,Other,base rate x DRG weight,59992,,"21,298 x DRG weight",59992,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,142617,
OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITH CC,818,MS-DRG,,,,,,,,inpatient,,,171139.33,17809,,,17809,Other,150% of Medicare + 9.63% HCRA Surcharge,10830,,"3,609.90 x patient days",10830,Per diem,,35843,,"25,046 x DRG weight",35843,Other,base rate x DRG weight,32258,,"22,541 x DRG weight",32258,Other,base rate x DRG weight,45113,,"31,523 x DRG weight",45113,Other,base rate x DRG weight,40602,,"28,371 x DRG weight",40602,Other,base rate x DRG weight,38346,,"26,795 x DRG weight",38346,Other,base rate x DRG weight,11913,,"3,970.89 x patient days",11913,Per diem,,32147,,"22,463 x DRG weight",32147,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,37818,,"26,426 x DRG weight",37818,Other,base rate x DRG weight,55540,,"38,809 x DRG weight",55540,Other,base rate x DRG weight,55540,,"38,809 x DRG weight",55540,Other,base rate x DRG weight,37818,,"26,426 x DRG weight",37818,Other,base rate x DRG weight,55540,,"38,809 x DRG weight",55540,Other,base rate x DRG weight,19089,,"6,363 x patient days",19089,Per diem,,119798,70,,119798,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,35859,,"25,057 x DRG weight",35859,Other,base rate x DRG weight,32274,,"22,552 x DRG weight",32274,Other,base rate x DRG weight,35859,,"25,057 x DRG weight",35859,Other,base rate x DRG weight,30480,,"21,298 x DRG weight",30480,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,119798,
OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITHOUT CC/MCC,819,MS-DRG,,,,,,,,inpatient,,,88619.17,14248,,,14248,Other,150% of Medicare + 9.63% HCRA Surcharge,8664,,"3,609.90 x patient days",8664,Per diem,,22722,,"25,046 x DRG weight",22722,Other,base rate x DRG weight,20449,,"22,541 x DRG weight",20449,Other,base rate x DRG weight,28598,,"31,523 x DRG weight",28598,Other,base rate x DRG weight,25738,,"28,371 x DRG weight",25738,Other,base rate x DRG weight,24308,,"26,795 x DRG weight",24308,Other,base rate x DRG weight,9530.4,,"3,970.89 x patient days",9530.4,Per diem,,20378,,"22,463 x DRG weight",20378,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,23974,,"26,426 x DRG weight",23974,Other,base rate x DRG weight,35208,,"38,809 x DRG weight",35208,Other,base rate x DRG weight,35208,,"38,809 x DRG weight",35208,Other,base rate x DRG weight,23974,,"26,426 x DRG weight",23974,Other,base rate x DRG weight,35208,,"38,809 x DRG weight",35208,Other,base rate x DRG weight,15271,,"6,363 x patient days",15271,Per diem,,62033,70,,62033,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,22732,,"25,057 x DRG weight",22732,Other,base rate x DRG weight,20459,,"22,552 x DRG weight",20459,Other,base rate x DRG weight,22732,,"25,057 x DRG weight",22732,Other,base rate x DRG weight,19322,,"21,298 x DRG weight",19322,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,62033,
LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITH MCC,820,MS-DRG,,,,,,,,inpatient,,,1390777.53,102104,,,102104,Other,150% of Medicare + 9.63% HCRA Surcharge,62090,,"3,609.90 x patient days",62090,Per diem,,151446,,"25,046 x DRG weight",151446,Other,base rate x DRG weight,136299,,"22,541 x DRG weight",136299,Other,base rate x DRG weight,190610,,"31,523 x DRG weight",190610,Other,base rate x DRG weight,171551,,"28,371 x DRG weight",171551,Other,base rate x DRG weight,162021,,"26,795 x DRG weight",162021,Other,base rate x DRG weight,68299,,"3,970.89 x patient days",68299,Per diem,,135827,,"22,463 x DRG weight",135827,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,159790,,"26,426 x DRG weight",159790,Other,base rate x DRG weight,234666,,"38,809 x DRG weight",234666,Other,base rate x DRG weight,234666,,"38,809 x DRG weight",234666,Other,base rate x DRG weight,159790,,"26,426 x DRG weight",159790,Other,base rate x DRG weight,234666,,"38,809 x DRG weight",234666,Other,base rate x DRG weight,109444,,"6,363 x patient days",109444,Per diem,,973544,70,,973544,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,151512,,"25,057 x DRG weight",151512,Other,base rate x DRG weight,136365,,"22,552 x DRG weight",136365,Other,base rate x DRG weight,151512,,"25,057 x DRG weight",151512,Other,base rate x DRG weight,128783,,"21,298 x DRG weight",128783,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,973544,
LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITH CC,821,MS-DRG,,,,,,,,inpatient,,,699365.59,32649,,,32649,Other,150% of Medicare + 9.63% HCRA Surcharge,19854,,"3,609.90 x patient days",19854,Per diem,,55905,,"25,046 x DRG weight",55905,Other,base rate x DRG weight,50314,,"22,541 x DRG weight",50314,Other,base rate x DRG weight,70362,,"31,523 x DRG weight",70362,Other,base rate x DRG weight,63327,,"28,371 x DRG weight",63327,Other,base rate x DRG weight,59809,,"26,795 x DRG weight",59809,Other,base rate x DRG weight,21839.4,,"3,970.89 x patient days",21839.4,Per diem,,50140,,"22,463 x DRG weight",50140,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,58985,,"26,426 x DRG weight",58985,Other,base rate x DRG weight,86626,,"38,809 x DRG weight",86626,Other,base rate x DRG weight,86626,,"38,809 x DRG weight",86626,Other,base rate x DRG weight,58985,,"26,426 x DRG weight",58985,Other,base rate x DRG weight,86626,,"38,809 x DRG weight",86626,Other,base rate x DRG weight,34997,,"6,363 x patient days",34997,Per diem,,489556,70,,489556,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,55930,,"25,057 x DRG weight",55930,Other,base rate x DRG weight,50338,,"22,552 x DRG weight",50338,Other,base rate x DRG weight,55930,,"25,057 x DRG weight",55930,Other,base rate x DRG weight,47539,,"21,298 x DRG weight",47539,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,489556,
LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITHOUT CC/MCC,822,MS-DRG,,,,,,,,inpatient,,,410703.18,11873,,,11873,Other,150% of Medicare + 9.63% HCRA Surcharge,7220,,"3,609.90 x patient days",7220,Per diem,,31027,,"25,046 x DRG weight",31027,Other,base rate x DRG weight,27924,,"22,541 x DRG weight",27924,Other,base rate x DRG weight,39051,,"31,523 x DRG weight",39051,Other,base rate x DRG weight,35146,,"28,371 x DRG weight",35146,Other,base rate x DRG weight,33194,,"26,795 x DRG weight",33194,Other,base rate x DRG weight,7942,,"3,970.89 x patient days",7942,Per diem,,27827,,"22,463 x DRG weight",27827,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,32737,,"26,426 x DRG weight",32737,Other,base rate x DRG weight,48077,,"38,809 x DRG weight",48077,Other,base rate x DRG weight,48077,,"38,809 x DRG weight",48077,Other,base rate x DRG weight,32737,,"26,426 x DRG weight",32737,Other,base rate x DRG weight,48077,,"38,809 x DRG weight",48077,Other,base rate x DRG weight,12726,,"6,363 x patient days",12726,Per diem,,287492,70,,287492,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,31041,,"25,057 x DRG weight",31041,Other,base rate x DRG weight,27937,,"22,552 x DRG weight",27937,Other,base rate x DRG weight,31041,,"25,057 x DRG weight",31041,Other,base rate x DRG weight,26384,,"21,298 x DRG weight",26384,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,287492,
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITH MCC,823,MS-DRG,,,,,,,,inpatient,,,637850.16,83109,,,83109,Other,150% of Medicare + 9.63% HCRA Surcharge,50539,,"3,609.90 x patient days",50539,Per diem,,112755,,"25,046 x DRG weight",112755,Other,base rate x DRG weight,101477,,"22,541 x DRG weight",101477,Other,base rate x DRG weight,141913,,"31,523 x DRG weight",141913,Other,base rate x DRG weight,127723,,"28,371 x DRG weight",127723,Other,base rate x DRG weight,120628,,"26,795 x DRG weight",120628,Other,base rate x DRG weight,55592.9,,"3,970.89 x patient days",55592.9,Per diem,,101126,,"22,463 x DRG weight",101126,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,118967,,"26,426 x DRG weight",118967,Other,base rate x DRG weight,174714,,"38,809 x DRG weight",174714,Other,base rate x DRG weight,174714,,"38,809 x DRG weight",174714,Other,base rate x DRG weight,118967,,"26,426 x DRG weight",118967,Other,base rate x DRG weight,174714,,"38,809 x DRG weight",174714,Other,base rate x DRG weight,89082,,"6,363 x patient days",89082,Per diem,,446495,70,,446495,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,112804,,"25,057 x DRG weight",112804,Other,base rate x DRG weight,101527,,"22,552 x DRG weight",101527,Other,base rate x DRG weight,112804,,"25,057 x DRG weight",112804,Other,base rate x DRG weight,95881,,"21,298 x DRG weight",95881,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,446495,
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITH CC,824,MS-DRG,,,,,,,,inpatient,,,416247.07,41554,,,41554,Other,150% of Medicare + 9.63% HCRA Surcharge,25269,,"3,609.90 x patient days",25269,Per diem,,55925,,"25,046 x DRG weight",55925,Other,base rate x DRG weight,50332,,"22,541 x DRG weight",50332,Other,base rate x DRG weight,70388,,"31,523 x DRG weight",70388,Other,base rate x DRG weight,63350,,"28,371 x DRG weight",63350,Other,base rate x DRG weight,59831,,"26,795 x DRG weight",59831,Other,base rate x DRG weight,27795.9,,"3,970.89 x patient days",27795.9,Per diem,,50158,,"22,463 x DRG weight",50158,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,59007,,"26,426 x DRG weight",59007,Other,base rate x DRG weight,86657,,"38,809 x DRG weight",86657,Other,base rate x DRG weight,86657,,"38,809 x DRG weight",86657,Other,base rate x DRG weight,59007,,"26,426 x DRG weight",59007,Other,base rate x DRG weight,86657,,"38,809 x DRG weight",86657,Other,base rate x DRG weight,44541,,"6,363 x patient days",44541,Per diem,,291373,70,,291373,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,55950,,"25,057 x DRG weight",55950,Other,base rate x DRG weight,50356,,"22,552 x DRG weight",50356,Other,base rate x DRG weight,55950,,"25,057 x DRG weight",55950,Other,base rate x DRG weight,47556,,"21,298 x DRG weight",47556,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,291373,
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITHOUT CC/MCC,825,MS-DRG,,,,,,,,inpatient,,,181929.93,18403,,,18403,Other,150% of Medicare + 9.63% HCRA Surcharge,11191,,"3,609.90 x patient days",11191,Per diem,,32344,,"25,046 x DRG weight",32344,Other,base rate x DRG weight,29109,,"22,541 x DRG weight",29109,Other,base rate x DRG weight,40709,,"31,523 x DRG weight",40709,Other,base rate x DRG weight,36638,,"28,371 x DRG weight",36638,Other,base rate x DRG weight,34603,,"26,795 x DRG weight",34603,Other,base rate x DRG weight,12310.1,,"3,970.89 x patient days",12310.1,Per diem,,29009,,"22,463 x DRG weight",29009,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,34127,,"26,426 x DRG weight",34127,Other,base rate x DRG weight,50118,,"38,809 x DRG weight",50118,Other,base rate x DRG weight,50118,,"38,809 x DRG weight",50118,Other,base rate x DRG weight,34127,,"26,426 x DRG weight",34127,Other,base rate x DRG weight,50118,,"38,809 x DRG weight",50118,Other,base rate x DRG weight,19725,,"6,363 x patient days",19725,Per diem,,127351,70,,127351,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,32359,,"25,057 x DRG weight",32359,Other,base rate x DRG weight,29124,,"22,552 x DRG weight",29124,Other,base rate x DRG weight,32359,,"25,057 x DRG weight",32359,Other,base rate x DRG weight,27504,,"21,298 x DRG weight",27504,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,127351,
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITH MCC,826,MS-DRG,,,,,,,,inpatient,,,949759.67,70049,,,70049,Other,150% of Medicare + 9.63% HCRA Surcharge,42597,,"3,609.90 x patient days",42597,Per diem,,115905,,"25,046 x DRG weight",115905,Other,base rate x DRG weight,104313,,"22,541 x DRG weight",104313,Other,base rate x DRG weight,145879,,"31,523 x DRG weight",145879,Other,base rate x DRG weight,131292,,"28,371 x DRG weight",131292,Other,base rate x DRG weight,123999,,"26,795 x DRG weight",123999,Other,base rate x DRG weight,46856.7,,"3,970.89 x patient days",46856.7,Per diem,,103952,,"22,463 x DRG weight",103952,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,122292,,"26,426 x DRG weight",122292,Other,base rate x DRG weight,179596,,"38,809 x DRG weight",179596,Other,base rate x DRG weight,179596,,"38,809 x DRG weight",179596,Other,base rate x DRG weight,122292,,"26,426 x DRG weight",122292,Other,base rate x DRG weight,179596,,"38,809 x DRG weight",179596,Other,base rate x DRG weight,75083,,"6,363 x patient days",75083,Per diem,,664832,70,,664832,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,115956,,"25,057 x DRG weight",115956,Other,base rate x DRG weight,104364,,"22,552 x DRG weight",104364,Other,base rate x DRG weight,115956,,"25,057 x DRG weight",115956,Other,base rate x DRG weight,98561,,"21,298 x DRG weight",98561,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,664832,
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITH CC,827,MS-DRG,,,,,,,,inpatient,,,244097.37,32649,,,32649,Other,150% of Medicare + 9.63% HCRA Surcharge,19854,,"3,609.90 x patient days",19854,Per diem,,58037,,"25,046 x DRG weight",58037,Other,base rate x DRG weight,52232,,"22,541 x DRG weight",52232,Other,base rate x DRG weight,73045,,"31,523 x DRG weight",73045,Other,base rate x DRG weight,65741,,"28,371 x DRG weight",65741,Other,base rate x DRG weight,62089,,"26,795 x DRG weight",62089,Other,base rate x DRG weight,21839.4,,"3,970.89 x patient days",21839.4,Per diem,,52051,,"22,463 x DRG weight",52051,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,61234,,"26,426 x DRG weight",61234,Other,base rate x DRG weight,89928,,"38,809 x DRG weight",89928,Other,base rate x DRG weight,89928,,"38,809 x DRG weight",89928,Other,base rate x DRG weight,61234,,"26,426 x DRG weight",61234,Other,base rate x DRG weight,89928,,"38,809 x DRG weight",89928,Other,base rate x DRG weight,34997,,"6,363 x patient days",34997,Per diem,,170868,70,,170868,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,58062,,"25,057 x DRG weight",58062,Other,base rate x DRG weight,52257,,"22,552 x DRG weight",52257,Other,base rate x DRG weight,58062,,"25,057 x DRG weight",58062,Other,base rate x DRG weight,49352,,"21,298 x DRG weight",49352,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,170868,
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITHOUT CC/MCC,828,MS-DRG,,,,,,,,inpatient,,,218325.59,18403,,,18403,Other,150% of Medicare + 9.63% HCRA Surcharge,11191,,"3,609.90 x patient days",11191,Per diem,,41085,,"25,046 x DRG weight",41085,Other,base rate x DRG weight,36976,,"22,541 x DRG weight",36976,Other,base rate x DRG weight,51710,,"31,523 x DRG weight",51710,Other,base rate x DRG weight,46540,,"28,371 x DRG weight",46540,Other,base rate x DRG weight,43955,,"26,795 x DRG weight",43955,Other,base rate x DRG weight,12310.1,,"3,970.89 x patient days",12310.1,Per diem,,36848,,"22,463 x DRG weight",36848,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,43349,,"26,426 x DRG weight",43349,Other,base rate x DRG weight,63662,,"38,809 x DRG weight",63662,Other,base rate x DRG weight,63662,,"38,809 x DRG weight",63662,Other,base rate x DRG weight,43349,,"26,426 x DRG weight",43349,Other,base rate x DRG weight,63662,,"38,809 x DRG weight",63662,Other,base rate x DRG weight,19725,,"6,363 x patient days",19725,Per diem,,152828,70,,152828,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,41104,,"25,057 x DRG weight",41104,Other,base rate x DRG weight,36994,,"22,552 x DRG weight",36994,Other,base rate x DRG weight,41104,,"25,057 x DRG weight",41104,Other,base rate x DRG weight,34937,,"21,298 x DRG weight",34937,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,152828,
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH OTHER PROCEDURES WITH CC/MCC,829,MS-DRG,,,,,,,,inpatient,,,430007.92,54614,,,54614,Other,150% of Medicare + 9.63% HCRA Surcharge,33211,,"3,609.90 x patient days",33211,Per diem,,78990,,"25,046 x DRG weight",78990,Other,base rate x DRG weight,71090,,"22,541 x DRG weight",71090,Other,base rate x DRG weight,99417,,"31,523 x DRG weight",99417,Other,base rate x DRG weight,89476,,"28,371 x DRG weight",89476,Other,base rate x DRG weight,84506,,"26,795 x DRG weight",84506,Other,base rate x DRG weight,36532.1,,"3,970.89 x patient days",36532.1,Per diem,,70844,,"22,463 x DRG weight",70844,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,83342,,"26,426 x DRG weight",83342,Other,base rate x DRG weight,122396,,"38,809 x DRG weight",122396,Other,base rate x DRG weight,122396,,"38,809 x DRG weight",122396,Other,base rate x DRG weight,83342,,"26,426 x DRG weight",83342,Other,base rate x DRG weight,122396,,"38,809 x DRG weight",122396,Other,base rate x DRG weight,58540,,"6,363 x patient days",58540,Per diem,,301006,70,,301006,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,79025,,"25,057 x DRG weight",79025,Other,base rate x DRG weight,71124,,"22,552 x DRG weight",71124,Other,base rate x DRG weight,79025,,"25,057 x DRG weight",79025,Other,base rate x DRG weight,67170,,"21,298 x DRG weight",67170,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,301006,
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH OTHER PROCEDURES WITHOUT CC/MCC,830,MS-DRG,,,,,,,,inpatient,,,123797.2,18403,,,18403,Other,150% of Medicare + 9.63% HCRA Surcharge,11191,,"3,609.90 x patient days",11191,Per diem,,39603,,"25,046 x DRG weight",39603,Other,base rate x DRG weight,35642,,"22,541 x DRG weight",35642,Other,base rate x DRG weight,49844,,"31,523 x DRG weight",49844,Other,base rate x DRG weight,44860,,"28,371 x DRG weight",44860,Other,base rate x DRG weight,42368,,"26,795 x DRG weight",42368,Other,base rate x DRG weight,12310.1,,"3,970.89 x patient days",12310.1,Per diem,,35518,,"22,463 x DRG weight",35518,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,41785,,"26,426 x DRG weight",41785,Other,base rate x DRG weight,61365,,"38,809 x DRG weight",61365,Other,base rate x DRG weight,61365,,"38,809 x DRG weight",61365,Other,base rate x DRG weight,41785,,"26,426 x DRG weight",41785,Other,base rate x DRG weight,61365,,"38,809 x DRG weight",61365,Other,base rate x DRG weight,19725,,"6,363 x patient days",19725,Per diem,,86658,70,,86658,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,39620,,"25,057 x DRG weight",39620,Other,base rate x DRG weight,35659,,"22,552 x DRG weight",35659,Other,base rate x DRG weight,39620,,"25,057 x DRG weight",39620,Other,base rate x DRG weight,33676,,"21,298 x DRG weight",33676,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,86658,
OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITH MCC,831,MS-DRG,,,,,,,,inpatient,,,111509.39,27901,,,27901,Other,150% of Medicare + 9.63% HCRA Surcharge,16967,,"3,609.90 x patient days",16967,Per diem,,26932,,"25,046 x DRG weight",26932,Other,base rate x DRG weight,24238,,"22,541 x DRG weight",24238,Other,base rate x DRG weight,33897,,"31,523 x DRG weight",33897,Other,base rate x DRG weight,30507,,"28,371 x DRG weight",30507,Other,base rate x DRG weight,28813,,"26,795 x DRG weight",28813,Other,base rate x DRG weight,18663.7,,"3,970.89 x patient days",18663.7,Per diem,,24154,,"22,463 x DRG weight",24154,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,28416,,"26,426 x DRG weight",28416,Other,base rate x DRG weight,41731,,"38,809 x DRG weight",41731,Other,base rate x DRG weight,41731,,"38,809 x DRG weight",41731,Other,base rate x DRG weight,28416,,"26,426 x DRG weight",28416,Other,base rate x DRG weight,41731,,"38,809 x DRG weight",41731,Other,base rate x DRG weight,29906,,"6,363 x patient days",29906,Per diem,,78057,70,,78057,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,26944,,"25,057 x DRG weight",26944,Other,base rate x DRG weight,24250,,"22,552 x DRG weight",24250,Other,base rate x DRG weight,26944,,"25,057 x DRG weight",26944,Other,base rate x DRG weight,22902,,"21,298 x DRG weight",22902,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,78057,
OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITH CC,832,MS-DRG,,,,,,,,inpatient,,,106476.69,23152,,,23152,Other,150% of Medicare + 9.63% HCRA Surcharge,14079,,"3,609.90 x patient days",14079,Per diem,,18476,,"25,046 x DRG weight",18476,Other,base rate x DRG weight,16628,,"22,541 x DRG weight",16628,Other,base rate x DRG weight,23255,,"31,523 x DRG weight",23255,Other,base rate x DRG weight,20929,,"28,371 x DRG weight",20929,Other,base rate x DRG weight,19767,,"26,795 x DRG weight",19767,Other,base rate x DRG weight,15486.9,,"3,970.89 x patient days",15486.9,Per diem,,16571,,"22,463 x DRG weight",16571,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,19494,,"26,426 x DRG weight",19494,Other,base rate x DRG weight,28629,,"38,809 x DRG weight",28629,Other,base rate x DRG weight,28629,,"38,809 x DRG weight",28629,Other,base rate x DRG weight,19494,,"26,426 x DRG weight",19494,Other,base rate x DRG weight,28629,,"38,809 x DRG weight",28629,Other,base rate x DRG weight,24816,,"6,363 x patient days",24816,Per diem,,74534,70,,74534,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,18485,,"25,057 x DRG weight",18485,Other,base rate x DRG weight,16637,,"22,552 x DRG weight",16637,Other,base rate x DRG weight,18485,,"25,057 x DRG weight",18485,Other,base rate x DRG weight,15712,,"21,298 x DRG weight",15712,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,74534,
OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITHOUT CC/MCC,833,MS-DRG,,,,,,,,inpatient,,,79106,16028,,,16028,Other,150% of Medicare + 9.63% HCRA Surcharge,9747,,"3,609.90 x patient days",9747,Per diem,,12819,,"25,046 x DRG weight",12819,Other,base rate x DRG weight,11536,,"22,541 x DRG weight",11536,Other,base rate x DRG weight,16133,,"31,523 x DRG weight",16133,Other,base rate x DRG weight,14520,,"28,371 x DRG weight",14520,Other,base rate x DRG weight,13714,,"26,795 x DRG weight",13714,Other,base rate x DRG weight,10721.7,,"3,970.89 x patient days",10721.7,Per diem,,11497,,"22,463 x DRG weight",11497,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,13525,,"26,426 x DRG weight",13525,Other,base rate x DRG weight,19862,,"38,809 x DRG weight",19862,Other,base rate x DRG weight,19862,,"38,809 x DRG weight",19862,Other,base rate x DRG weight,13525,,"26,426 x DRG weight",13525,Other,base rate x DRG weight,19862,,"38,809 x DRG weight",19862,Other,base rate x DRG weight,17180,,"6,363 x patient days",17180,Per diem,,55374,70,,55374,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,12824,,"25,057 x DRG weight",12824,Other,base rate x DRG weight,11542,,"22,552 x DRG weight",11542,Other,base rate x DRG weight,12824,,"25,057 x DRG weight",12824,Other,base rate x DRG weight,10900,,"21,298 x DRG weight",10900,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,55374,
ACUTE LEUKEMIA WITHOUT MAJOR O.R. PROCEDURES WITH MCC,834,MS-DRG,,,,,,,,inpatient,,,796579.88,96761,,,96761,Other,150% of Medicare + 9.63% HCRA Surcharge,58841,,"3,609.90 x patient days",58841,Per diem,,140233,,"25,046 x DRG weight",140233,Other,base rate x DRG weight,126207,,"22,541 x DRG weight",126207,Other,base rate x DRG weight,176497,,"31,523 x DRG weight",176497,Other,base rate x DRG weight,158849,,"28,371 x DRG weight",158849,Other,base rate x DRG weight,150025,,"26,795 x DRG weight",150025,Other,base rate x DRG weight,64725.1,,"3,970.89 x patient days",64725.1,Per diem,,125770,,"22,463 x DRG weight",125770,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,147959,,"26,426 x DRG weight",147959,Other,base rate x DRG weight,217292,,"38,809 x DRG weight",217292,Other,base rate x DRG weight,217292,,"38,809 x DRG weight",217292,Other,base rate x DRG weight,147959,,"26,426 x DRG weight",147959,Other,base rate x DRG weight,217292,,"38,809 x DRG weight",217292,Other,base rate x DRG weight,103717,,"6,363 x patient days",103717,Per diem,,557606,70,,557606,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,140294,,"25,057 x DRG weight",140294,Other,base rate x DRG weight,126269,,"22,552 x DRG weight",126269,Other,base rate x DRG weight,140294,,"25,057 x DRG weight",140294,Other,base rate x DRG weight,119248,,"21,298 x DRG weight",119248,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,557606,
ACUTE LEUKEMIA WITHOUT MAJOR O.R. PROCEDURES WITH CC,835,MS-DRG,,,,,,,,inpatient,,,623373.46,42741,,,42741,Other,150% of Medicare + 9.63% HCRA Surcharge,25991,,"3,609.90 x patient days",25991,Per diem,,55990,,"25,046 x DRG weight",55990,Other,base rate x DRG weight,50390,,"22,541 x DRG weight",50390,Other,base rate x DRG weight,70470,,"31,523 x DRG weight",70470,Other,base rate x DRG weight,63423,,"28,371 x DRG weight",63423,Other,base rate x DRG weight,59900,,"26,795 x DRG weight",59900,Other,base rate x DRG weight,28590.1,,"3,970.89 x patient days",28590.1,Per diem,,50216,,"22,463 x DRG weight",50216,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,59075,,"26,426 x DRG weight",59075,Other,base rate x DRG weight,86758,,"38,809 x DRG weight",86758,Other,base rate x DRG weight,86758,,"38,809 x DRG weight",86758,Other,base rate x DRG weight,59075,,"26,426 x DRG weight",59075,Other,base rate x DRG weight,86758,,"38,809 x DRG weight",86758,Other,base rate x DRG weight,45814,,"6,363 x patient days",45814,Per diem,,436361,70,,436361,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,56015,,"25,057 x DRG weight",56015,Other,base rate x DRG weight,50415,,"22,552 x DRG weight",50415,Other,base rate x DRG weight,56015,,"25,057 x DRG weight",56015,Other,base rate x DRG weight,47612,,"21,298 x DRG weight",47612,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,436361,
ACUTE LEUKEMIA WITHOUT MAJOR O.R. PROCEDURES WITHOUT CC/MCC,836,MS-DRG,,,,,,,,inpatient,,,216729.11,23152,,,23152,Other,150% of Medicare + 9.63% HCRA Surcharge,14079,,"3,609.90 x patient days",14079,Per diem,,35362,,"25,046 x DRG weight",35362,Other,base rate x DRG weight,31826,,"22,541 x DRG weight",31826,Other,base rate x DRG weight,44507,,"31,523 x DRG weight",44507,Other,base rate x DRG weight,40057,,"28,371 x DRG weight",40057,Other,base rate x DRG weight,37832,,"26,795 x DRG weight",37832,Other,base rate x DRG weight,15486.9,,"3,970.89 x patient days",15486.9,Per diem,,31716,,"22,463 x DRG weight",31716,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,37311,,"26,426 x DRG weight",37311,Other,base rate x DRG weight,54794,,"38,809 x DRG weight",54794,Other,base rate x DRG weight,54794,,"38,809 x DRG weight",54794,Other,base rate x DRG weight,37311,,"26,426 x DRG weight",37311,Other,base rate x DRG weight,54794,,"38,809 x DRG weight",54794,Other,base rate x DRG weight,24816,,"6,363 x patient days",24816,Per diem,,151710,70,,151710,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,35378,,"25,057 x DRG weight",35378,Other,base rate x DRG weight,31841,,"22,552 x DRG weight",31841,Other,base rate x DRG weight,35378,,"25,057 x DRG weight",35378,Other,base rate x DRG weight,30071,,"21,298 x DRG weight",30071,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,151710,
CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS OR WITH HIGH DOSE CHEMOTHERAPY AGENT WITH MCC,837,MS-DRG,,,,,,,,inpatient,,,621914.21,94980,,,94980,Other,150% of Medicare + 9.63% HCRA Surcharge,57758,,"3,609.90 x patient days",57758,Per diem,,121323,,"25,046 x DRG weight",121323,Other,base rate x DRG weight,109189,,"22,541 x DRG weight",109189,Other,base rate x DRG weight,152697,,"31,523 x DRG weight",152697,Other,base rate x DRG weight,137429,,"28,371 x DRG weight",137429,Other,base rate x DRG weight,129795,,"26,795 x DRG weight",129795,Other,base rate x DRG weight,63533.8,,"3,970.89 x patient days",63533.8,Per diem,,108811,,"22,463 x DRG weight",108811,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,128008,,"26,426 x DRG weight",128008,Other,base rate x DRG weight,187991,,"38,809 x DRG weight",187991,Other,base rate x DRG weight,187991,,"38,809 x DRG weight",187991,Other,base rate x DRG weight,128008,,"26,426 x DRG weight",128008,Other,base rate x DRG weight,187991,,"38,809 x DRG weight",187991,Other,base rate x DRG weight,101808,,"6,363 x patient days",101808,Per diem,,435340,70,,435340,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,121376,,"25,057 x DRG weight",121376,Other,base rate x DRG weight,109242,,"22,552 x DRG weight",109242,Other,base rate x DRG weight,121376,,"25,057 x DRG weight",121376,Other,base rate x DRG weight,103168,,"21,298 x DRG weight",103168,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,435340,
CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH CC OR HIGH DOSE CHEMOTHERAPY AGENT,838,MS-DRG,,,,,,,,inpatient,,,283819.16,39179,,,39179,Other,150% of Medicare + 9.63% HCRA Surcharge,23825,,"3,609.90 x patient days",23825,Per diem,,50135,,"25,046 x DRG weight",50135,Other,base rate x DRG weight,45120,,"22,541 x DRG weight",45120,Other,base rate x DRG weight,63100,,"31,523 x DRG weight",63100,Other,base rate x DRG weight,56790,,"28,371 x DRG weight",56790,Other,base rate x DRG weight,53636,,"26,795 x DRG weight",53636,Other,base rate x DRG weight,26207.5,,"3,970.89 x patient days",26207.5,Per diem,,44964,,"22,463 x DRG weight",44964,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,52897,,"26,426 x DRG weight",52897,Other,base rate x DRG weight,77684,,"38,809 x DRG weight",77684,Other,base rate x DRG weight,77684,,"38,809 x DRG weight",77684,Other,base rate x DRG weight,52897,,"26,426 x DRG weight",52897,Other,base rate x DRG weight,77684,,"38,809 x DRG weight",77684,Other,base rate x DRG weight,41996,,"6,363 x patient days",41996,Per diem,,198673,70,,198673,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,50157,,"25,057 x DRG weight",50157,Other,base rate x DRG weight,45142,,"22,552 x DRG weight",45142,Other,base rate x DRG weight,50157,,"25,057 x DRG weight",50157,Other,base rate x DRG weight,42632,,"21,298 x DRG weight",42632,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,198673,
CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITHOUT CC/MCC,839,MS-DRG,,,,,,,,inpatient,,,164472.38,26714,,,26714,Other,150% of Medicare + 9.63% HCRA Surcharge,16245,,"3,609.90 x patient days",16245,Per diem,,32637,,"25,046 x DRG weight",32637,Other,base rate x DRG weight,29373,,"22,541 x DRG weight",29373,Other,base rate x DRG weight,41078,,"31,523 x DRG weight",41078,Other,base rate x DRG weight,36970,,"28,371 x DRG weight",36970,Other,base rate x DRG weight,34917,,"26,795 x DRG weight",34917,Other,base rate x DRG weight,17869.5,,"3,970.89 x patient days",17869.5,Per diem,,29272,,"22,463 x DRG weight",29272,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,34436,,"26,426 x DRG weight",34436,Other,base rate x DRG weight,50572,,"38,809 x DRG weight",50572,Other,base rate x DRG weight,50572,,"38,809 x DRG weight",50572,Other,base rate x DRG weight,34436,,"26,426 x DRG weight",34436,Other,base rate x DRG weight,50572,,"38,809 x DRG weight",50572,Other,base rate x DRG weight,28634,,"6,363 x patient days",28634,Per diem,,115131,70,,115131,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,32652,,"25,057 x DRG weight",32652,Other,base rate x DRG weight,29388,,"22,552 x DRG weight",29388,Other,base rate x DRG weight,32652,,"25,057 x DRG weight",32652,Other,base rate x DRG weight,27753,,"21,298 x DRG weight",27753,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,115131,
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH MCC,840,MS-DRG,,,,,,,,inpatient,,,435632.41,58769,,,58769,Other,150% of Medicare + 9.63% HCRA Surcharge,35738,,"3,609.90 x patient days",35738,Per diem,,78274,,"25,046 x DRG weight",78274,Other,base rate x DRG weight,70445,,"22,541 x DRG weight",70445,Other,base rate x DRG weight,98516,,"31,523 x DRG weight",98516,Other,base rate x DRG weight,88665,,"28,371 x DRG weight",88665,Other,base rate x DRG weight,83740,,"26,795 x DRG weight",83740,Other,base rate x DRG weight,39311.8,,"3,970.89 x patient days",39311.8,Per diem,,70201,,"22,463 x DRG weight",70201,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,82587,,"26,426 x DRG weight",82587,Other,base rate x DRG weight,121286,,"38,809 x DRG weight",121286,Other,base rate x DRG weight,121286,,"38,809 x DRG weight",121286,Other,base rate x DRG weight,82587,,"26,426 x DRG weight",82587,Other,base rate x DRG weight,121286,,"38,809 x DRG weight",121286,Other,base rate x DRG weight,62994,,"6,363 x patient days",62994,Per diem,,304943,70,,304943,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,78308,,"25,057 x DRG weight",78308,Other,base rate x DRG weight,70480,,"22,552 x DRG weight",70480,Other,base rate x DRG weight,78308,,"25,057 x DRG weight",78308,Other,base rate x DRG weight,66561,,"21,298 x DRG weight",66561,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,304943,
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH CC,841,MS-DRG,,,,,,,,inpatient,,,330332.43,32649,,,32649,Other,150% of Medicare + 9.63% HCRA Surcharge,19854,,"3,609.90 x patient days",19854,Per diem,,39410,,"25,046 x DRG weight",39410,Other,base rate x DRG weight,35468,,"22,541 x DRG weight",35468,Other,base rate x DRG weight,49601,,"31,523 x DRG weight",49601,Other,base rate x DRG weight,44642,,"28,371 x DRG weight",44642,Other,base rate x DRG weight,42162,,"26,795 x DRG weight",42162,Other,base rate x DRG weight,21839.4,,"3,970.89 x patient days",21839.4,Per diem,,35346,,"22,463 x DRG weight",35346,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,41581,,"26,426 x DRG weight",41581,Other,base rate x DRG weight,61066,,"38,809 x DRG weight",61066,Other,base rate x DRG weight,61066,,"38,809 x DRG weight",61066,Other,base rate x DRG weight,41581,,"26,426 x DRG weight",41581,Other,base rate x DRG weight,61066,,"38,809 x DRG weight",61066,Other,base rate x DRG weight,34997,,"6,363 x patient days",34997,Per diem,,231233,70,,231233,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,39427,,"25,057 x DRG weight",39427,Other,base rate x DRG weight,35486,,"22,552 x DRG weight",35486,Other,base rate x DRG weight,39427,,"25,057 x DRG weight",39427,Other,base rate x DRG weight,33512,,"21,298 x DRG weight",33512,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,231233,
LYMPHOMA AND NON-ACUTE LEUKEMIA WITHOUT CC/MCC,842,MS-DRG,,,,,,,,inpatient,,,208498.44,20778,,,20778,Other,150% of Medicare + 9.63% HCRA Surcharge,12635,,"3,609.90 x patient days",12635,Per diem,,26709,,"25,046 x DRG weight",26709,Other,base rate x DRG weight,24038,,"22,541 x DRG weight",24038,Other,base rate x DRG weight,33616,,"31,523 x DRG weight",33616,Other,base rate x DRG weight,30255,,"28,371 x DRG weight",30255,Other,base rate x DRG weight,28574,,"26,795 x DRG weight",28574,Other,base rate x DRG weight,13898.5,,"3,970.89 x patient days",13898.5,Per diem,,23955,,"22,463 x DRG weight",23955,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,28181,,"26,426 x DRG weight",28181,Other,base rate x DRG weight,41386,,"38,809 x DRG weight",41386,Other,base rate x DRG weight,41386,,"38,809 x DRG weight",41386,Other,base rate x DRG weight,28181,,"26,426 x DRG weight",28181,Other,base rate x DRG weight,41386,,"38,809 x DRG weight",41386,Other,base rate x DRG weight,22271,,"6,363 x patient days",22271,Per diem,,145949,70,,145949,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,26721,,"25,057 x DRG weight",26721,Other,base rate x DRG weight,24049,,"22,552 x DRG weight",24049,Other,base rate x DRG weight,26721,,"25,057 x DRG weight",26721,Other,base rate x DRG weight,22712,,"21,298 x DRG weight",22712,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,145949,
OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITH MCC,843,MS-DRG,,,,,,,,inpatient,,,524795.41,43928,,,43928,Other,150% of Medicare + 9.63% HCRA Surcharge,26713,,"3,609.90 x patient days",26713,Per diem,,46601,,"25,046 x DRG weight",46601,Other,base rate x DRG weight,41940,,"22,541 x DRG weight",41940,Other,base rate x DRG weight,58652,,"31,523 x DRG weight",58652,Other,base rate x DRG weight,52787,,"28,371 x DRG weight",52787,Other,base rate x DRG weight,49855,,"26,795 x DRG weight",49855,Other,base rate x DRG weight,29384.3,,"3,970.89 x patient days",29384.3,Per diem,,41795,,"22,463 x DRG weight",41795,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,49168,,"26,426 x DRG weight",49168,Other,base rate x DRG weight,72208,,"38,809 x DRG weight",72208,Other,base rate x DRG weight,72208,,"38,809 x DRG weight",72208,Other,base rate x DRG weight,49168,,"26,426 x DRG weight",49168,Other,base rate x DRG weight,72208,,"38,809 x DRG weight",72208,Other,base rate x DRG weight,47086,,"6,363 x patient days",47086,Per diem,,367357,70,,367357,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,46621,,"25,057 x DRG weight",46621,Other,base rate x DRG weight,41960,,"22,552 x DRG weight",41960,Other,base rate x DRG weight,46621,,"25,057 x DRG weight",46621,Other,base rate x DRG weight,39627,,"21,298 x DRG weight",39627,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,367357,
OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITH CC,844,MS-DRG,,,,,,,,inpatient,,,423023.75,29682,,,29682,Other,150% of Medicare + 9.63% HCRA Surcharge,18050,,"3,609.90 x patient days",18050,Per diem,,28983,,"25,046 x DRG weight",28983,Other,base rate x DRG weight,26084,,"22,541 x DRG weight",26084,Other,base rate x DRG weight,36478,,"31,523 x DRG weight",36478,Other,base rate x DRG weight,32831,,"28,371 x DRG weight",32831,Other,base rate x DRG weight,31007,,"26,795 x DRG weight",31007,Other,base rate x DRG weight,19855,,"3,970.89 x patient days",19855,Per diem,,25994,,"22,463 x DRG weight",25994,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,30580,,"26,426 x DRG weight",30580,Other,base rate x DRG weight,44910,,"38,809 x DRG weight",44910,Other,base rate x DRG weight,44910,,"38,809 x DRG weight",44910,Other,base rate x DRG weight,30580,,"26,426 x DRG weight",30580,Other,base rate x DRG weight,44910,,"38,809 x DRG weight",44910,Other,base rate x DRG weight,31815,,"6,363 x patient days",31815,Per diem,,296117,70,,296117,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,28996,,"25,057 x DRG weight",28996,Other,base rate x DRG weight,26097,,"22,552 x DRG weight",26097,Other,base rate x DRG weight,28996,,"25,057 x DRG weight",28996,Other,base rate x DRG weight,24646,,"21,298 x DRG weight",24646,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,296117,
OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITHOUT CC/MCC,845,MS-DRG,,,,,,,,inpatient,,,80786,21371,,,21371,Other,150% of Medicare + 9.63% HCRA Surcharge,12996,,"3,609.90 x patient days",12996,Per diem,,21662,,"25,046 x DRG weight",21662,Other,base rate x DRG weight,19496,,"22,541 x DRG weight",19496,Other,base rate x DRG weight,27264,,"31,523 x DRG weight",27264,Other,base rate x DRG weight,24538,,"28,371 x DRG weight",24538,Other,base rate x DRG weight,23175,,"26,795 x DRG weight",23175,Other,base rate x DRG weight,14295.6,,"3,970.89 x patient days",14295.6,Per diem,,19428,,"22,463 x DRG weight",19428,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,22856,,"26,426 x DRG weight",22856,Other,base rate x DRG weight,33566,,"38,809 x DRG weight",33566,Other,base rate x DRG weight,33566,,"38,809 x DRG weight",33566,Other,base rate x DRG weight,22856,,"26,426 x DRG weight",22856,Other,base rate x DRG weight,33566,,"38,809 x DRG weight",33566,Other,base rate x DRG weight,22907,,"6,363 x patient days",22907,Per diem,,56550,70,,56550,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,21672,,"25,057 x DRG weight",21672,Other,base rate x DRG weight,19505,,"22,552 x DRG weight",19505,Other,base rate x DRG weight,21672,,"25,057 x DRG weight",21672,Other,base rate x DRG weight,18421,,"21,298 x DRG weight",18421,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,56550,
CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH MCC,846,MS-DRG,,,,,,,,inpatient,,,271697,46896,,,46896,Other,150% of Medicare + 9.63% HCRA Surcharge,28518,,"3,609.90 x patient days",28518,Per diem,,61212,,"25,046 x DRG weight",61212,Other,base rate x DRG weight,55090,,"22,541 x DRG weight",55090,Other,base rate x DRG weight,77042,,"31,523 x DRG weight",77042,Other,base rate x DRG weight,69339,,"28,371 x DRG weight",69339,Other,base rate x DRG weight,65487,,"26,795 x DRG weight",65487,Other,base rate x DRG weight,31369.8,,"3,970.89 x patient days",31369.8,Per diem,,54900,,"22,463 x DRG weight",54900,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,64585,,"26,426 x DRG weight",64585,Other,base rate x DRG weight,94849,,"38,809 x DRG weight",94849,Other,base rate x DRG weight,94849,,"38,809 x DRG weight",94849,Other,base rate x DRG weight,64585,,"26,426 x DRG weight",64585,Other,base rate x DRG weight,94849,,"38,809 x DRG weight",94849,Other,base rate x DRG weight,50268,,"6,363 x patient days",50268,Per diem,,190188,70,,190188,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,61239,,"25,057 x DRG weight",61239,Other,base rate x DRG weight,55117,,"22,552 x DRG weight",55117,Other,base rate x DRG weight,61239,,"25,057 x DRG weight",61239,Other,base rate x DRG weight,52052,,"21,298 x DRG weight",52052,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,190188,
CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH CC,847,MS-DRG,,,,,,,,inpatient,,,110806.33,24933,,,24933,Other,150% of Medicare + 9.63% HCRA Surcharge,15162,,"3,609.90 x patient days",15162,Per diem,,30371,,"25,046 x DRG weight",30371,Other,base rate x DRG weight,27333,,"22,541 x DRG weight",27333,Other,base rate x DRG weight,38225,,"31,523 x DRG weight",38225,Other,base rate x DRG weight,34403,,"28,371 x DRG weight",34403,Other,base rate x DRG weight,32492,,"26,795 x DRG weight",32492,Other,base rate x DRG weight,16678.2,,"3,970.89 x patient days",16678.2,Per diem,,27239,,"22,463 x DRG weight",27239,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,32044,,"26,426 x DRG weight",32044,Other,base rate x DRG weight,47060,,"38,809 x DRG weight",47060,Other,base rate x DRG weight,47060,,"38,809 x DRG weight",47060,Other,base rate x DRG weight,32044,,"26,426 x DRG weight",32044,Other,base rate x DRG weight,47060,,"38,809 x DRG weight",47060,Other,base rate x DRG weight,26725,,"6,363 x patient days",26725,Per diem,,77564,70,,77564,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,30384,,"25,057 x DRG weight",30384,Other,base rate x DRG weight,27347,,"22,552 x DRG weight",27347,Other,base rate x DRG weight,30384,,"25,057 x DRG weight",30384,Other,base rate x DRG weight,25826,,"21,298 x DRG weight",25826,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,77564,
CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITHOUT CC/MCC,848,MS-DRG,,,,,,,,inpatient,,,75000.87,18997,,,18997,Other,150% of Medicare + 9.63% HCRA Surcharge,11552,,"3,609.90 x patient days",11552,Per diem,,20943,,"25,046 x DRG weight",20943,Other,base rate x DRG weight,18849,,"22,541 x DRG weight",18849,Other,base rate x DRG weight,26360,,"31,523 x DRG weight",26360,Other,base rate x DRG weight,23724,,"28,371 x DRG weight",23724,Other,base rate x DRG weight,22406,,"26,795 x DRG weight",22406,Other,base rate x DRG weight,12707.2,,"3,970.89 x patient days",12707.2,Per diem,,18784,,"22,463 x DRG weight",18784,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,22097,,"26,426 x DRG weight",22097,Other,base rate x DRG weight,32452,,"38,809 x DRG weight",32452,Other,base rate x DRG weight,32452,,"38,809 x DRG weight",32452,Other,base rate x DRG weight,22097,,"26,426 x DRG weight",22097,Other,base rate x DRG weight,32452,,"38,809 x DRG weight",32452,Other,base rate x DRG weight,20362,,"6,363 x patient days",20362,Per diem,,52501,70,,52501,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,20953,,"25,057 x DRG weight",20953,Other,base rate x DRG weight,18858,,"22,552 x DRG weight",18858,Other,base rate x DRG weight,20953,,"25,057 x DRG weight",20953,Other,base rate x DRG weight,17809,,"21,298 x DRG weight",17809,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,52501,
RADIOTHERAPY,849,MS-DRG,,,,,,,,inpatient,,,177682.96,61738,,,61738,Other,150% of Medicare + 9.63% HCRA Surcharge,37543,,"3,609.90 x patient days",37543,Per diem,,67409,,"25,046 x DRG weight",67409,Other,base rate x DRG weight,60667,,"22,541 x DRG weight",60667,Other,base rate x DRG weight,84841,,"31,523 x DRG weight",84841,Other,base rate x DRG weight,76358,,"28,371 x DRG weight",76358,Other,base rate x DRG weight,72116,,"26,795 x DRG weight",72116,Other,base rate x DRG weight,41297.3,,"3,970.89 x patient days",41297.3,Per diem,,60457,,"22,463 x DRG weight",60457,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,71123,,"26,426 x DRG weight",71123,Other,base rate x DRG weight,104451,,"38,809 x DRG weight",104451,Other,base rate x DRG weight,104451,,"38,809 x DRG weight",104451,Other,base rate x DRG weight,71123,,"26,426 x DRG weight",71123,Other,base rate x DRG weight,104451,,"38,809 x DRG weight",104451,Other,base rate x DRG weight,66175,,"6,363 x patient days",66175,Per diem,,124378,70,,124378,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,67438,,"25,057 x DRG weight",67438,Other,base rate x DRG weight,60696,,"22,552 x DRG weight",60696,Other,base rate x DRG weight,67438,,"25,057 x DRG weight",67438,Other,base rate x DRG weight,57321,,"21,298 x DRG weight",57321,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,124378,
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH MCC,853,MS-DRG,,,,,,,,inpatient,,,645394.83,78953,,,78953,Other,150% of Medicare + 9.63% HCRA Surcharge,48012,,"3,609.90 x patient days",48012,Per diem,,125212,,"25,046 x DRG weight",125212,Other,base rate x DRG weight,112689,,"22,541 x DRG weight",112689,Other,base rate x DRG weight,157593,,"31,523 x DRG weight",157593,Other,base rate x DRG weight,141835,,"28,371 x DRG weight",141835,Other,base rate x DRG weight,133956,,"26,795 x DRG weight",133956,Other,base rate x DRG weight,52813.2,,"3,970.89 x patient days",52813.2,Per diem,,112299,,"22,463 x DRG weight",112299,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,132112,,"26,426 x DRG weight",132112,Other,base rate x DRG weight,194018,,"38,809 x DRG weight",194018,Other,base rate x DRG weight,194018,,"38,809 x DRG weight",194018,Other,base rate x DRG weight,132112,,"26,426 x DRG weight",132112,Other,base rate x DRG weight,194018,,"38,809 x DRG weight",194018,Other,base rate x DRG weight,84628,,"6,363 x patient days",84628,Per diem,,451776,70,,451776,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,125267,,"25,057 x DRG weight",125267,Other,base rate x DRG weight,112744,,"22,552 x DRG weight",112744,Other,base rate x DRG weight,125267,,"25,057 x DRG weight",125267,Other,base rate x DRG weight,106475,,"21,298 x DRG weight",106475,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,451776,
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH CC,854,MS-DRG,,,,,,,,inpatient,,,221748.51,39179,,,39179,Other,150% of Medicare + 9.63% HCRA Surcharge,23825,,"3,609.90 x patient days",23825,Per diem,,51049,,"25,046 x DRG weight",51049,Other,base rate x DRG weight,45943,,"22,541 x DRG weight",45943,Other,base rate x DRG weight,64250,,"31,523 x DRG weight",64250,Other,base rate x DRG weight,57826,,"28,371 x DRG weight",57826,Other,base rate x DRG weight,54614,,"26,795 x DRG weight",54614,Other,base rate x DRG weight,26207.5,,"3,970.89 x patient days",26207.5,Per diem,,45784,,"22,463 x DRG weight",45784,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,53861,,"26,426 x DRG weight",53861,Other,base rate x DRG weight,79101,,"38,809 x DRG weight",79101,Other,base rate x DRG weight,79101,,"38,809 x DRG weight",79101,Other,base rate x DRG weight,53861,,"26,426 x DRG weight",53861,Other,base rate x DRG weight,79101,,"38,809 x DRG weight",79101,Other,base rate x DRG weight,41996,,"6,363 x patient days",41996,Per diem,,155224,70,,155224,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,51071,,"25,057 x DRG weight",51071,Other,base rate x DRG weight,45965,,"22,552 x DRG weight",45965,Other,base rate x DRG weight,51071,,"25,057 x DRG weight",51071,Other,base rate x DRG weight,43410,,"21,298 x DRG weight",43410,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,155224,
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITHOUT CC/MCC,855,MS-DRG,,,,,,,,inpatient,,,246890.84,26714,,,26714,Other,150% of Medicare + 9.63% HCRA Surcharge,16245,,"3,609.90 x patient days",16245,Per diem,,42623,,"25,046 x DRG weight",42623,Other,base rate x DRG weight,38360,,"22,541 x DRG weight",38360,Other,base rate x DRG weight,53646,,"31,523 x DRG weight",53646,Other,base rate x DRG weight,48282,,"28,371 x DRG weight",48282,Other,base rate x DRG weight,45600,,"26,795 x DRG weight",45600,Other,base rate x DRG weight,17869.5,,"3,970.89 x patient days",17869.5,Per diem,,38228,,"22,463 x DRG weight",38228,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,44972,,"26,426 x DRG weight",44972,Other,base rate x DRG weight,66045,,"38,809 x DRG weight",66045,Other,base rate x DRG weight,66045,,"38,809 x DRG weight",66045,Other,base rate x DRG weight,44972,,"26,426 x DRG weight",44972,Other,base rate x DRG weight,66045,,"38,809 x DRG weight",66045,Other,base rate x DRG weight,28634,,"6,363 x patient days",28634,Per diem,,172824,70,,172824,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,42642,,"25,057 x DRG weight",42642,Other,base rate x DRG weight,38379,,"22,552 x DRG weight",38379,Other,base rate x DRG weight,42642,,"25,057 x DRG weight",42642,Other,base rate x DRG weight,36245,,"21,298 x DRG weight",36245,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,172824,
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH MCC,856,MS-DRG,,,,,,,,inpatient,,,744269.96,74204,,,74204,Other,150% of Medicare + 9.63% HCRA Surcharge,45124,,"3,609.90 x patient days",45124,Per diem,,110914,,"25,046 x DRG weight",110914,Other,base rate x DRG weight,99821,,"22,541 x DRG weight",99821,Other,base rate x DRG weight,139596,,"31,523 x DRG weight",139596,Other,base rate x DRG weight,125638,,"28,371 x DRG weight",125638,Other,base rate x DRG weight,118659,,"26,795 x DRG weight",118659,Other,base rate x DRG weight,49636.4,,"3,970.89 x patient days",49636.4,Per diem,,99475,,"22,463 x DRG weight",99475,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,117025,,"26,426 x DRG weight",117025,Other,base rate x DRG weight,171862,,"38,809 x DRG weight",171862,Other,base rate x DRG weight,171862,,"38,809 x DRG weight",171862,Other,base rate x DRG weight,117025,,"26,426 x DRG weight",117025,Other,base rate x DRG weight,171862,,"38,809 x DRG weight",171862,Other,base rate x DRG weight,79538,,"6,363 x patient days",79538,Per diem,,520989,70,,520989,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,110962,,"25,057 x DRG weight",110962,Other,base rate x DRG weight,99869,,"22,552 x DRG weight",99869,Other,base rate x DRG weight,110962,,"25,057 x DRG weight",110962,Other,base rate x DRG weight,94316,,"21,298 x DRG weight",94316,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,520989,
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH CC,857,MS-DRG,,,,,,,,inpatient,,,276880.94,40960,,,40960,Other,150% of Medicare + 9.63% HCRA Surcharge,24908,,"3,609.90 x patient days",24908,Per diem,,53491,,"25,046 x DRG weight",53491,Other,base rate x DRG weight,48141,,"22,541 x DRG weight",48141,Other,base rate x DRG weight,67324,,"31,523 x DRG weight",67324,Other,base rate x DRG weight,60592,,"28,371 x DRG weight",60592,Other,base rate x DRG weight,57226,,"26,795 x DRG weight",57226,Other,base rate x DRG weight,27398.8,,"3,970.89 x patient days",27398.8,Per diem,,47974,,"22,463 x DRG weight",47974,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,56438,,"26,426 x DRG weight",56438,Other,base rate x DRG weight,82884,,"38,809 x DRG weight",82884,Other,base rate x DRG weight,82884,,"38,809 x DRG weight",82884,Other,base rate x DRG weight,56438,,"26,426 x DRG weight",56438,Other,base rate x DRG weight,82884,,"38,809 x DRG weight",82884,Other,base rate x DRG weight,43905,,"6,363 x patient days",43905,Per diem,,193817,70,,193817,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,53514,,"25,057 x DRG weight",53514,Other,base rate x DRG weight,48164,,"22,552 x DRG weight",48164,Other,base rate x DRG weight,53514,,"25,057 x DRG weight",53514,Other,base rate x DRG weight,45486,,"21,298 x DRG weight",45486,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,193817,
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITHOUT CC/MCC,858,MS-DRG,,,,,,,,inpatient,,,68959.4,24340,,,24340,Other,150% of Medicare + 9.63% HCRA Surcharge,14801,,"3,609.90 x patient days",14801,Per diem,,32144,,"25,046 x DRG weight",32144,Other,base rate x DRG weight,28929,,"22,541 x DRG weight",28929,Other,base rate x DRG weight,40457,,"31,523 x DRG weight",40457,Other,base rate x DRG weight,36411,,"28,371 x DRG weight",36411,Other,base rate x DRG weight,34389,,"26,795 x DRG weight",34389,Other,base rate x DRG weight,16281.1,,"3,970.89 x patient days",16281.1,Per diem,,28829,,"22,463 x DRG weight",28829,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,33915,,"26,426 x DRG weight",33915,Other,base rate x DRG weight,49807,,"38,809 x DRG weight",49807,Other,base rate x DRG weight,49807,,"38,809 x DRG weight",49807,Other,base rate x DRG weight,33915,,"26,426 x DRG weight",33915,Other,base rate x DRG weight,49807,,"38,809 x DRG weight",49807,Other,base rate x DRG weight,26088,,"6,363 x patient days",26088,Per diem,,48272,70,,48272,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,32158,,"25,057 x DRG weight",32158,Other,base rate x DRG weight,28943,,"22,552 x DRG weight",28943,Other,base rate x DRG weight,32158,,"25,057 x DRG weight",32158,Other,base rate x DRG weight,27334,,"21,298 x DRG weight",27334,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,49807,
POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITH MCC,862,MS-DRG,,,,,,,,inpatient,,,234292.57,40366,,,40366,Other,150% of Medicare + 9.63% HCRA Surcharge,24547,,"3,609.90 x patient days",24547,Per diem,,46135,,"25,046 x DRG weight",46135,Other,base rate x DRG weight,41521,,"22,541 x DRG weight",41521,Other,base rate x DRG weight,58065,,"31,523 x DRG weight",58065,Other,base rate x DRG weight,52259,,"28,371 x DRG weight",52259,Other,base rate x DRG weight,49356,,"26,795 x DRG weight",49356,Other,base rate x DRG weight,27001.7,,"3,970.89 x patient days",27001.7,Per diem,,41377,,"22,463 x DRG weight",41377,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,48677,,"26,426 x DRG weight",48677,Other,base rate x DRG weight,71486,,"38,809 x DRG weight",71486,Other,base rate x DRG weight,71486,,"38,809 x DRG weight",71486,Other,base rate x DRG weight,48677,,"26,426 x DRG weight",48677,Other,base rate x DRG weight,71486,,"38,809 x DRG weight",71486,Other,base rate x DRG weight,43268,,"6,363 x patient days",43268,Per diem,,164005,70,,164005,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,46155,,"25,057 x DRG weight",46155,Other,base rate x DRG weight,41541,,"22,552 x DRG weight",41541,Other,base rate x DRG weight,46155,,"25,057 x DRG weight",46155,Other,base rate x DRG weight,39231,,"21,298 x DRG weight",39231,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,164005,
POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITHOUT MCC,863,MS-DRG,,,,,,,,inpatient,,,126665.38,25527,,,25527,Other,150% of Medicare + 9.63% HCRA Surcharge,15523,,"3,609.90 x patient days",15523,Per diem,,25184,,"25,046 x DRG weight",25184,Other,base rate x DRG weight,22665,,"22,541 x DRG weight",22665,Other,base rate x DRG weight,31696,,"31,523 x DRG weight",31696,Other,base rate x DRG weight,28527,,"28,371 x DRG weight",28527,Other,base rate x DRG weight,26942,,"26,795 x DRG weight",26942,Other,base rate x DRG weight,17075.3,,"3,970.89 x patient days",17075.3,Per diem,,22587,,"22,463 x DRG weight",22587,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,26571,,"26,426 x DRG weight",26571,Other,base rate x DRG weight,39022,,"38,809 x DRG weight",39022,Other,base rate x DRG weight,39022,,"38,809 x DRG weight",39022,Other,base rate x DRG weight,26571,,"26,426 x DRG weight",26571,Other,base rate x DRG weight,39022,,"38,809 x DRG weight",39022,Other,base rate x DRG weight,27361,,"6,363 x patient days",27361,Per diem,,88666,70,,88666,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,25195,,"25,057 x DRG weight",25195,Other,base rate x DRG weight,22676,,"22,552 x DRG weight",22676,Other,base rate x DRG weight,25195,,"25,057 x DRG weight",25195,Other,base rate x DRG weight,21415,,"21,298 x DRG weight",21415,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,88666,
FEVER AND INFLAMMATORY CONDITIONS,864,MS-DRG,,,,,,,,inpatient,,,89742.06,20184,,,20184,Other,150% of Medicare + 9.63% HCRA Surcharge,12274,,"3,609.90 x patient days",12274,Per diem,,22111,,"25,046 x DRG weight",22111,Other,base rate x DRG weight,19899,,"22,541 x DRG weight",19899,Other,base rate x DRG weight,27829,,"31,523 x DRG weight",27829,Other,base rate x DRG weight,25046,,"28,371 x DRG weight",25046,Other,base rate x DRG weight,23655,,"26,795 x DRG weight",23655,Other,base rate x DRG weight,13501.4,,"3,970.89 x patient days",13501.4,Per diem,,19830,,"22,463 x DRG weight",19830,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,23329,,"26,426 x DRG weight",23329,Other,base rate x DRG weight,34261,,"38,809 x DRG weight",34261,Other,base rate x DRG weight,34261,,"38,809 x DRG weight",34261,Other,base rate x DRG weight,23329,,"26,426 x DRG weight",23329,Other,base rate x DRG weight,34261,,"38,809 x DRG weight",34261,Other,base rate x DRG weight,21634,,"6,363 x patient days",21634,Per diem,,62819,70,,62819,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,22120,,"25,057 x DRG weight",22120,Other,base rate x DRG weight,19909,,"22,552 x DRG weight",19909,Other,base rate x DRG weight,22120,,"25,057 x DRG weight",22120,Other,base rate x DRG weight,18802,,"21,298 x DRG weight",18802,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,62819,
VIRAL ILLNESS WITH MCC,865,MS-DRG,,,,,,,,inpatient,,,116548.9,37398,,,37398,Other,150% of Medicare + 9.63% HCRA Surcharge,22742,,"3,609.90 x patient days",22742,Per diem,,41073,,"25,046 x DRG weight",41073,Other,base rate x DRG weight,36965,,"22,541 x DRG weight",36965,Other,base rate x DRG weight,51695,,"31,523 x DRG weight",51695,Other,base rate x DRG weight,46526,,"28,371 x DRG weight",46526,Other,base rate x DRG weight,43941,,"26,795 x DRG weight",43941,Other,base rate x DRG weight,25016.2,,"3,970.89 x patient days",25016.2,Per diem,,36837,,"22,463 x DRG weight",36837,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,43336,,"26,426 x DRG weight",43336,Other,base rate x DRG weight,63643,,"38,809 x DRG weight",63643,Other,base rate x DRG weight,63643,,"38,809 x DRG weight",63643,Other,base rate x DRG weight,43336,,"26,426 x DRG weight",43336,Other,base rate x DRG weight,63643,,"38,809 x DRG weight",63643,Other,base rate x DRG weight,40087,,"6,363 x patient days",40087,Per diem,,81584,70,,81584,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,41091,,"25,057 x DRG weight",41091,Other,base rate x DRG weight,36983,,"22,552 x DRG weight",36983,Other,base rate x DRG weight,41091,,"25,057 x DRG weight",41091,Other,base rate x DRG weight,34927,,"21,298 x DRG weight",34927,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,81584,
VIRAL ILLNESS WITHOUT MCC,866,MS-DRG,,,,,,,,inpatient,,,103943.58,22559,,,22559,Other,150% of Medicare + 9.63% HCRA Surcharge,13718,,"3,609.90 x patient days",13718,Per diem,,22985,,"25,046 x DRG weight",22985,Other,base rate x DRG weight,20686,,"22,541 x DRG weight",20686,Other,base rate x DRG weight,28929,,"31,523 x DRG weight",28929,Other,base rate x DRG weight,26036,,"28,371 x DRG weight",26036,Other,base rate x DRG weight,24590,,"26,795 x DRG weight",24590,Other,base rate x DRG weight,15089.8,,"3,970.89 x patient days",15089.8,Per diem,,20614,,"22,463 x DRG weight",20614,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,24251,,"26,426 x DRG weight",24251,Other,base rate x DRG weight,35615,,"38,809 x DRG weight",35615,Other,base rate x DRG weight,35615,,"38,809 x DRG weight",35615,Other,base rate x DRG weight,24251,,"26,426 x DRG weight",24251,Other,base rate x DRG weight,35615,,"38,809 x DRG weight",35615,Other,base rate x DRG weight,24179,,"6,363 x patient days",24179,Per diem,,72761,70,,72761,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,22995,,"25,057 x DRG weight",22995,Other,base rate x DRG weight,20696,,"22,552 x DRG weight",20696,Other,base rate x DRG weight,22995,,"25,057 x DRG weight",22995,Other,base rate x DRG weight,19545,,"21,298 x DRG weight",19545,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,72761,
OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITH MCC,867,MS-DRG,,,,,,,,inpatient,,,194621.4,46303,,,46303,Other,150% of Medicare + 9.63% HCRA Surcharge,28157,,"3,609.90 x patient days",28157,Per diem,,52404,,"25,046 x DRG weight",52404,Other,base rate x DRG weight,47163,,"22,541 x DRG weight",47163,Other,base rate x DRG weight,65956,,"31,523 x DRG weight",65956,Other,base rate x DRG weight,59361,,"28,371 x DRG weight",59361,Other,base rate x DRG weight,56063,,"26,795 x DRG weight",56063,Other,base rate x DRG weight,30972.7,,"3,970.89 x patient days",30972.7,Per diem,,46999,,"22,463 x DRG weight",46999,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,55291,,"26,426 x DRG weight",55291,Other,base rate x DRG weight,81200,,"38,809 x DRG weight",81200,Other,base rate x DRG weight,81200,,"38,809 x DRG weight",81200,Other,base rate x DRG weight,55291,,"26,426 x DRG weight",55291,Other,base rate x DRG weight,81200,,"38,809 x DRG weight",81200,Other,base rate x DRG weight,49631,,"6,363 x patient days",49631,Per diem,,136235,70,,136235,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,52427,,"25,057 x DRG weight",52427,Other,base rate x DRG weight,47186,,"22,552 x DRG weight",47186,Other,base rate x DRG weight,52427,,"25,057 x DRG weight",52427,Other,base rate x DRG weight,44562,,"21,298 x DRG weight",44562,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,136235,
OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITH CC,868,MS-DRG,,,,,,,,inpatient,,,101550.82,28495,,,28495,Other,150% of Medicare + 9.63% HCRA Surcharge,17328,,"3,609.90 x patient days",17328,Per diem,,27187,,"25,046 x DRG weight",27187,Other,base rate x DRG weight,24468,,"22,541 x DRG weight",24468,Other,base rate x DRG weight,34218,,"31,523 x DRG weight",34218,Other,base rate x DRG weight,30797,,"28,371 x DRG weight",30797,Other,base rate x DRG weight,29086,,"26,795 x DRG weight",29086,Other,base rate x DRG weight,19060.8,,"3,970.89 x patient days",19060.8,Per diem,,24384,,"22,463 x DRG weight",24384,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,28685,,"26,426 x DRG weight",28685,Other,base rate x DRG weight,42127,,"38,809 x DRG weight",42127,Other,base rate x DRG weight,42127,,"38,809 x DRG weight",42127,Other,base rate x DRG weight,28685,,"26,426 x DRG weight",28685,Other,base rate x DRG weight,42127,,"38,809 x DRG weight",42127,Other,base rate x DRG weight,30542,,"6,363 x patient days",30542,Per diem,,71086,70,,71086,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,27199,,"25,057 x DRG weight",27199,Other,base rate x DRG weight,24480,,"22,552 x DRG weight",24480,Other,base rate x DRG weight,27199,,"25,057 x DRG weight",27199,Other,base rate x DRG weight,23119,,"21,298 x DRG weight",23119,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,71086,
OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITHOUT CC/MCC,869,MS-DRG,,,,,,,,inpatient,,,91651.41,18403,,,18403,Other,150% of Medicare + 9.63% HCRA Surcharge,11191,,"3,609.90 x patient days",11191,Per diem,,17299,,"25,046 x DRG weight",17299,Other,base rate x DRG weight,15569,,"22,541 x DRG weight",15569,Other,base rate x DRG weight,21773,,"31,523 x DRG weight",21773,Other,base rate x DRG weight,19596,,"28,371 x DRG weight",19596,Other,base rate x DRG weight,18507,,"26,795 x DRG weight",18507,Other,base rate x DRG weight,12310.1,,"3,970.89 x patient days",12310.1,Per diem,,15515,,"22,463 x DRG weight",15515,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,18252,,"26,426 x DRG weight",18252,Other,base rate x DRG weight,26805,,"38,809 x DRG weight",26805,Other,base rate x DRG weight,26805,,"38,809 x DRG weight",26805,Other,base rate x DRG weight,18252,,"26,426 x DRG weight",18252,Other,base rate x DRG weight,26805,,"38,809 x DRG weight",26805,Other,base rate x DRG weight,19725,,"6,363 x patient days",19725,Per diem,,64156,70,,64156,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,17307,,"25,057 x DRG weight",17307,Other,base rate x DRG weight,15577,,"22,552 x DRG weight",15577,Other,base rate x DRG weight,17307,,"25,057 x DRG weight",17307,Other,base rate x DRG weight,14711,,"21,298 x DRG weight",14711,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,64156,
SEPTICEMIA OR SEVERE SEPSIS WITH MV >96 HOURS,870,MS-DRG,,,,,,,,inpatient,,,800008.95,95574,,,95574,Other,150% of Medicare + 9.63% HCRA Surcharge,58119,,"3,609.90 x patient days",58119,Per diem,,174443,,"25,046 x DRG weight",174443,Other,base rate x DRG weight,156996,,"22,541 x DRG weight",156996,Other,base rate x DRG weight,219555,,"31,523 x DRG weight",219555,Other,base rate x DRG weight,197601,,"28,371 x DRG weight",197601,Other,base rate x DRG weight,186624,,"26,795 x DRG weight",186624,Other,base rate x DRG weight,63930.9,,"3,970.89 x patient days",63930.9,Per diem,,156453,,"22,463 x DRG weight",156453,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,184054,,"26,426 x DRG weight",184054,Other,base rate x DRG weight,270301,,"38,809 x DRG weight",270301,Other,base rate x DRG weight,270301,,"38,809 x DRG weight",270301,Other,base rate x DRG weight,184054,,"26,426 x DRG weight",184054,Other,base rate x DRG weight,270301,,"38,809 x DRG weight",270301,Other,base rate x DRG weight,102444,,"6,363 x patient days",102444,Per diem,,560006,70,,560006,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,174519,,"25,057 x DRG weight",174519,Other,base rate x DRG weight,157072,,"22,552 x DRG weight",157072,Other,base rate x DRG weight,174519,,"25,057 x DRG weight",174519,Other,base rate x DRG weight,148338,,"21,298 x DRG weight",148338,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,560006,
SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITH MCC,871,MS-DRG,,,,,,,,inpatient,,,229554.05,40960,,,40960,Other,150% of Medicare + 9.63% HCRA Surcharge,24908,,"3,609.90 x patient days",24908,Per diem,,49656,,"25,046 x DRG weight",49656,Other,base rate x DRG weight,44690,,"22,541 x DRG weight",44690,Other,base rate x DRG weight,62497,,"31,523 x DRG weight",62497,Other,base rate x DRG weight,56248,,"28,371 x DRG weight",56248,Other,base rate x DRG weight,53124,,"26,795 x DRG weight",53124,Other,base rate x DRG weight,27398.8,,"3,970.89 x patient days",27398.8,Per diem,,44535,,"22,463 x DRG weight",44535,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,52392,,"26,426 x DRG weight",52392,Other,base rate x DRG weight,76943,,"38,809 x DRG weight",76943,Other,base rate x DRG weight,76943,,"38,809 x DRG weight",76943,Other,base rate x DRG weight,52392,,"26,426 x DRG weight",52392,Other,base rate x DRG weight,76943,,"38,809 x DRG weight",76943,Other,base rate x DRG weight,43905,,"6,363 x patient days",43905,Per diem,,160688,70,,160688,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,49678,,"25,057 x DRG weight",49678,Other,base rate x DRG weight,44712,,"22,552 x DRG weight",44712,Other,base rate x DRG weight,49678,,"25,057 x DRG weight",49678,Other,base rate x DRG weight,42225,,"21,298 x DRG weight",42225,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,160688,
SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITHOUT MCC,872,MS-DRG,,,,,,,,inpatient,,,131995.42,25527,,,25527,Other,150% of Medicare + 9.63% HCRA Surcharge,15523,,"3,609.90 x patient days",15523,Per diem,,25795,,"25,046 x DRG weight",25795,Other,base rate x DRG weight,23215,,"22,541 x DRG weight",23215,Other,base rate x DRG weight,32466,,"31,523 x DRG weight",32466,Other,base rate x DRG weight,29219,,"28,371 x DRG weight",29219,Other,base rate x DRG weight,27596,,"26,795 x DRG weight",27596,Other,base rate x DRG weight,17075.3,,"3,970.89 x patient days",17075.3,Per diem,,23135,,"22,463 x DRG weight",23135,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,27216,,"26,426 x DRG weight",27216,Other,base rate x DRG weight,39969,,"38,809 x DRG weight",39969,Other,base rate x DRG weight,39969,,"38,809 x DRG weight",39969,Other,base rate x DRG weight,27216,,"26,426 x DRG weight",27216,Other,base rate x DRG weight,39969,,"38,809 x DRG weight",39969,Other,base rate x DRG weight,27361,,"6,363 x patient days",27361,Per diem,,92397,70,,92397,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,25806,,"25,057 x DRG weight",25806,Other,base rate x DRG weight,23226,,"22,552 x DRG weight",23226,Other,base rate x DRG weight,25806,,"25,057 x DRG weight",25806,Other,base rate x DRG weight,21935,,"21,298 x DRG weight",21935,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,92397,
O.R. PROCEDURES WITH PRINCIPAL DIAGNOSIS OF MENTAL ILLNESS,876,MS-DRG,,,,,,,,inpatient,,,333359.01,105072,,,105072,Other,150% of Medicare + 9.63% HCRA Surcharge,63895,,"3,609.90 x patient days",63895,Per diem,,93459,,"25,046 x DRG weight",93459,Other,base rate x DRG weight,84112,,"22,541 x DRG weight",84112,Other,base rate x DRG weight,117628,,"31,523 x DRG weight",117628,Other,base rate x DRG weight,105866,,"28,371 x DRG weight",105866,Other,base rate x DRG weight,99986,,"26,795 x DRG weight",99986,Other,base rate x DRG weight,70284.5,,"3,970.89 x patient days",70284.5,Per diem,,83821,,"22,463 x DRG weight",83821,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,98609,,"26,426 x DRG weight",98609,Other,base rate x DRG weight,144816,,"38,809 x DRG weight",144816,Other,base rate x DRG weight,144816,,"38,809 x DRG weight",144816,Other,base rate x DRG weight,98609,,"26,426 x DRG weight",98609,Other,base rate x DRG weight,144816,,"38,809 x DRG weight",144816,Other,base rate x DRG weight,112625,,"6,363 x patient days",112625,Per diem,,233351,70,,233351,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,93500,,"25,057 x DRG weight",93500,Other,base rate x DRG weight,84153,,"22,552 x DRG weight",84153,Other,base rate x DRG weight,93500,,"25,057 x DRG weight",93500,Other,base rate x DRG weight,79473,,"21,298 x DRG weight",79473,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,233351,
WOUND DEBRIDEMENTS FOR INJURIES WITH MCC,901,MS-DRG,,,,,,,,inpatient,,,1190531.27,87264,,,87264,Other,150% of Medicare + 9.63% HCRA Surcharge,53066,,"3,609.90 x patient days",53066,Per diem,,108394,,"25,046 x DRG weight",108394,Other,base rate x DRG weight,97553,,"22,541 x DRG weight",97553,Other,base rate x DRG weight,136425,,"31,523 x DRG weight",136425,Other,base rate x DRG weight,122784,,"28,371 x DRG weight",122784,Other,base rate x DRG weight,115963,,"26,795 x DRG weight",115963,Other,base rate x DRG weight,58372.6,,"3,970.89 x patient days",58372.6,Per diem,,97215,,"22,463 x DRG weight",97215,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,114366,,"26,426 x DRG weight",114366,Other,base rate x DRG weight,167958,,"38,809 x DRG weight",167958,Other,base rate x DRG weight,167958,,"38,809 x DRG weight",167958,Other,base rate x DRG weight,114366,,"26,426 x DRG weight",114366,Other,base rate x DRG weight,167958,,"38,809 x DRG weight",167958,Other,base rate x DRG weight,93536,,"6,363 x patient days",93536,Per diem,,833372,70,,833372,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,108442,,"25,057 x DRG weight",108442,Other,base rate x DRG weight,97601,,"22,552 x DRG weight",97601,Other,base rate x DRG weight,108442,,"25,057 x DRG weight",108442,Other,base rate x DRG weight,92173,,"21,298 x DRG weight",92173,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,833372,
WOUND DEBRIDEMENTS FOR INJURIES WITH CC,902,MS-DRG,,,,,,,,inpatient,,,101203.96,39179,,,39179,Other,150% of Medicare + 9.63% HCRA Surcharge,23825,,"3,609.90 x patient days",23825,Per diem,,47204,,"25,046 x DRG weight",47204,Other,base rate x DRG weight,42483,,"22,541 x DRG weight",42483,Other,base rate x DRG weight,59411,,"31,523 x DRG weight",59411,Other,base rate x DRG weight,53471,,"28,371 x DRG weight",53471,Other,base rate x DRG weight,50501,,"26,795 x DRG weight",50501,Other,base rate x DRG weight,26207.5,,"3,970.89 x patient days",26207.5,Per diem,,42336,,"22,463 x DRG weight",42336,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,49805,,"26,426 x DRG weight",49805,Other,base rate x DRG weight,73143,,"38,809 x DRG weight",73143,Other,base rate x DRG weight,73143,,"38,809 x DRG weight",73143,Other,base rate x DRG weight,49805,,"26,426 x DRG weight",49805,Other,base rate x DRG weight,73143,,"38,809 x DRG weight",73143,Other,base rate x DRG weight,41996,,"6,363 x patient days",41996,Per diem,,70843,70,,70843,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,47225,,"25,057 x DRG weight",47225,Other,base rate x DRG weight,42504,,"22,552 x DRG weight",42504,Other,base rate x DRG weight,47225,,"25,057 x DRG weight",47225,Other,base rate x DRG weight,40140,,"21,298 x DRG weight",40140,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,73143,
WOUND DEBRIDEMENTS FOR INJURIES WITHOUT CC/MCC,903,MS-DRG,,,,,,,,inpatient,,,129098.3,20778,,,20778,Other,150% of Medicare + 9.63% HCRA Surcharge,12635,,"3,609.90 x patient days",12635,Per diem,,31095,,"25,046 x DRG weight",31095,Other,base rate x DRG weight,27985,,"22,541 x DRG weight",27985,Other,base rate x DRG weight,39136,,"31,523 x DRG weight",39136,Other,base rate x DRG weight,35223,,"28,371 x DRG weight",35223,Other,base rate x DRG weight,33266,,"26,795 x DRG weight",33266,Other,base rate x DRG weight,13898.5,,"3,970.89 x patient days",13898.5,Per diem,,27888,,"22,463 x DRG weight",27888,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,32808,,"26,426 x DRG weight",32808,Other,base rate x DRG weight,48181,,"38,809 x DRG weight",48181,Other,base rate x DRG weight,48181,,"38,809 x DRG weight",48181,Other,base rate x DRG weight,32808,,"26,426 x DRG weight",32808,Other,base rate x DRG weight,48181,,"38,809 x DRG weight",48181,Other,base rate x DRG weight,22271,,"6,363 x patient days",22271,Per diem,,90369,70,,90369,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,31108,,"25,057 x DRG weight",31108,Other,base rate x DRG weight,27998,,"22,552 x DRG weight",27998,Other,base rate x DRG weight,31108,,"25,057 x DRG weight",31108,Other,base rate x DRG weight,26441,,"21,298 x DRG weight",26441,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,90369,
SKIN GRAFTS FOR INJURIES WITH CC/MCC,904,MS-DRG,,,,,,,,inpatient,,,725620.05,59363,,,59363,Other,150% of Medicare + 9.63% HCRA Surcharge,36099,,"3,609.90 x patient days",36099,Per diem,,81555,,"25,046 x DRG weight",81555,Other,base rate x DRG weight,73398,,"22,541 x DRG weight",73398,Other,base rate x DRG weight,102645,,"31,523 x DRG weight",102645,Other,base rate x DRG weight,92382,,"28,371 x DRG weight",92382,Other,base rate x DRG weight,87250,,"26,795 x DRG weight",87250,Other,base rate x DRG weight,39708.9,,"3,970.89 x patient days",39708.9,Per diem,,73144,,"22,463 x DRG weight",73144,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,86048,,"26,426 x DRG weight",86048,Other,base rate x DRG weight,126370,,"38,809 x DRG weight",126370,Other,base rate x DRG weight,126370,,"38,809 x DRG weight",126370,Other,base rate x DRG weight,86048,,"26,426 x DRG weight",86048,Other,base rate x DRG weight,126370,,"38,809 x DRG weight",126370,Other,base rate x DRG weight,63630,,"6,363 x patient days",63630,Per diem,,507934,70,,507934,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,81591,,"25,057 x DRG weight",81591,Other,base rate x DRG weight,73434,,"22,552 x DRG weight",73434,Other,base rate x DRG weight,81591,,"25,057 x DRG weight",81591,Other,base rate x DRG weight,69351,,"21,298 x DRG weight",69351,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,507934,
SKIN GRAFTS FOR INJURIES WITHOUT CC/MCC,905,MS-DRG,,,,,,,,inpatient,,,143321.31,27901,,,27901,Other,150% of Medicare + 9.63% HCRA Surcharge,16967,,"3,609.90 x patient days",16967,Per diem,,39665,,"25,046 x DRG weight",39665,Other,base rate x DRG weight,35698,,"22,541 x DRG weight",35698,Other,base rate x DRG weight,49923,,"31,523 x DRG weight",49923,Other,base rate x DRG weight,44931,,"28,371 x DRG weight",44931,Other,base rate x DRG weight,42435,,"26,795 x DRG weight",42435,Other,base rate x DRG weight,18663.7,,"3,970.89 x patient days",18663.7,Per diem,,35575,,"22,463 x DRG weight",35575,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,41851,,"26,426 x DRG weight",41851,Other,base rate x DRG weight,61462,,"38,809 x DRG weight",61462,Other,base rate x DRG weight,61462,,"38,809 x DRG weight",61462,Other,base rate x DRG weight,41851,,"26,426 x DRG weight",41851,Other,base rate x DRG weight,61462,,"38,809 x DRG weight",61462,Other,base rate x DRG weight,29906,,"6,363 x patient days",29906,Per diem,,100325,70,,100325,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,39683,,"25,057 x DRG weight",39683,Other,base rate x DRG weight,35716,,"22,552 x DRG weight",35716,Other,base rate x DRG weight,39683,,"25,057 x DRG weight",39683,Other,base rate x DRG weight,33730,,"21,298 x DRG weight",33730,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,100325,
HAND PROCEDURES FOR INJURIES,906,MS-DRG,,,,,,,,inpatient,,,145480.88,30274,,,30274,Other,150% of Medicare + 9.63% HCRA Surcharge,18410,,"3,609.90 x patient days",18410,Per diem,,47127,,"25,046 x DRG weight",47127,Other,base rate x DRG weight,42413,,"22,541 x DRG weight",42413,Other,base rate x DRG weight,59314,,"31,523 x DRG weight",59314,Other,base rate x DRG weight,53383,,"28,371 x DRG weight",53383,Other,base rate x DRG weight,50417,,"26,795 x DRG weight",50417,Other,base rate x DRG weight,20251,,"3,970.89 x patient days",20251,Per diem,,42266,,"22,463 x DRG weight",42266,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,49723,,"26,426 x DRG weight",49723,Other,base rate x DRG weight,73023,,"38,809 x DRG weight",73023,Other,base rate x DRG weight,73023,,"38,809 x DRG weight",73023,Other,base rate x DRG weight,49723,,"26,426 x DRG weight",49723,Other,base rate x DRG weight,73023,,"38,809 x DRG weight",73023,Other,base rate x DRG weight,32451,,"6,363 x patient days",32451,Per diem,,101837,70,,101837,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,47147,,"25,057 x DRG weight",47147,Other,base rate x DRG weight,42434,,"22,552 x DRG weight",42434,Other,base rate x DRG weight,47147,,"25,057 x DRG weight",47147,Other,base rate x DRG weight,40074,,"21,298 x DRG weight",40074,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,101837,
OTHER O.R. PROCEDURES FOR INJURIES WITH MCC,907,MS-DRG,,,,,,,,inpatient,,,404436.95,57582,,,57582,Other,150% of Medicare + 9.63% HCRA Surcharge,35016,,"3,609.90 x patient days",35016,Per diem,,93159,,"25,046 x DRG weight",93159,Other,base rate x DRG weight,83841,,"22,541 x DRG weight",83841,Other,base rate x DRG weight,117250,,"31,523 x DRG weight",117250,Other,base rate x DRG weight,105526,,"28,371 x DRG weight",105526,Other,base rate x DRG weight,99664,,"26,795 x DRG weight",99664,Other,base rate x DRG weight,38517.6,,"3,970.89 x patient days",38517.6,Per diem,,83551,,"22,463 x DRG weight",83551,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,98292,,"26,426 x DRG weight",98292,Other,base rate x DRG weight,144350,,"38,809 x DRG weight",144350,Other,base rate x DRG weight,144350,,"38,809 x DRG weight",144350,Other,base rate x DRG weight,98292,,"26,426 x DRG weight",98292,Other,base rate x DRG weight,144350,,"38,809 x DRG weight",144350,Other,base rate x DRG weight,61721,,"6,363 x patient days",61721,Per diem,,283106,70,,283106,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,93200,,"25,057 x DRG weight",93200,Other,base rate x DRG weight,83882,,"22,552 x DRG weight",83882,Other,base rate x DRG weight,93200,,"25,057 x DRG weight",93200,Other,base rate x DRG weight,79218,,"21,298 x DRG weight",79218,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,283106,
OTHER O.R. PROCEDURES FOR INJURIES WITH CC,908,MS-DRG,,,,,,,,inpatient,,,280457.16,30274,,,30274,Other,150% of Medicare + 9.63% HCRA Surcharge,18410,,"3,609.90 x patient days",18410,Per diem,,50195,,"25,046 x DRG weight",50195,Other,base rate x DRG weight,45174,,"22,541 x DRG weight",45174,Other,base rate x DRG weight,63175,,"31,523 x DRG weight",63175,Other,base rate x DRG weight,56858,,"28,371 x DRG weight",56858,Other,base rate x DRG weight,53700,,"26,795 x DRG weight",53700,Other,base rate x DRG weight,20251,,"3,970.89 x patient days",20251,Per diem,,45018,,"22,463 x DRG weight",45018,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,52960,,"26,426 x DRG weight",52960,Other,base rate x DRG weight,77777,,"38,809 x DRG weight",77777,Other,base rate x DRG weight,77777,,"38,809 x DRG weight",77777,Other,base rate x DRG weight,52960,,"26,426 x DRG weight",52960,Other,base rate x DRG weight,77777,,"38,809 x DRG weight",77777,Other,base rate x DRG weight,32451,,"6,363 x patient days",32451,Per diem,,196320,70,,196320,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,50217,,"25,057 x DRG weight",50217,Other,base rate x DRG weight,45196,,"22,552 x DRG weight",45196,Other,base rate x DRG weight,50217,,"25,057 x DRG weight",50217,Other,base rate x DRG weight,42683,,"21,298 x DRG weight",42683,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,196320,
OTHER O.R. PROCEDURES FOR INJURIES WITHOUT CC/MCC,909,MS-DRG,,,,,,,,inpatient,,,151285.75,16622,,,16622,Other,150% of Medicare + 9.63% HCRA Surcharge,10108,,"3,609.90 x patient days",10108,Per diem,,33970,,"25,046 x DRG weight",33970,Other,base rate x DRG weight,30572,,"22,541 x DRG weight",30572,Other,base rate x DRG weight,42755,,"31,523 x DRG weight",42755,Other,base rate x DRG weight,38480,,"28,371 x DRG weight",38480,Other,base rate x DRG weight,36342,,"26,795 x DRG weight",36342,Other,base rate x DRG weight,11118.8,,"3,970.89 x patient days",11118.8,Per diem,,30467,,"22,463 x DRG weight",30467,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,35842,,"26,426 x DRG weight",35842,Other,base rate x DRG weight,52637,,"38,809 x DRG weight",52637,Other,base rate x DRG weight,52637,,"38,809 x DRG weight",52637,Other,base rate x DRG weight,35842,,"26,426 x DRG weight",35842,Other,base rate x DRG weight,52637,,"38,809 x DRG weight",52637,Other,base rate x DRG weight,17816,,"6,363 x patient days",17816,Per diem,,105900,70,,105900,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,33985,,"25,057 x DRG weight",33985,Other,base rate x DRG weight,30587,,"22,552 x DRG weight",30587,Other,base rate x DRG weight,33985,,"25,057 x DRG weight",33985,Other,base rate x DRG weight,28886,,"21,298 x DRG weight",28886,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,105900,
TRAUMATIC INJURY WITH MCC,913,MS-DRG,,,,,,,,inpatient,,,300873.47,33836,,,33836,Other,150% of Medicare + 9.63% HCRA Surcharge,20576,,"3,609.90 x patient days",20576,Per diem,,37431,,"25,046 x DRG weight",37431,Other,base rate x DRG weight,33688,,"22,541 x DRG weight",33688,Other,base rate x DRG weight,47111,,"31,523 x DRG weight",47111,Other,base rate x DRG weight,42400,,"28,371 x DRG weight",42400,Other,base rate x DRG weight,40045,,"26,795 x DRG weight",40045,Other,base rate x DRG weight,22633.6,,"3,970.89 x patient days",22633.6,Per diem,,33571,,"22,463 x DRG weight",33571,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,39494,,"26,426 x DRG weight",39494,Other,base rate x DRG weight,58000,,"38,809 x DRG weight",58000,Other,base rate x DRG weight,58000,,"38,809 x DRG weight",58000,Other,base rate x DRG weight,39494,,"26,426 x DRG weight",39494,Other,base rate x DRG weight,58000,,"38,809 x DRG weight",58000,Other,base rate x DRG weight,36269,,"6,363 x patient days",36269,Per diem,,210611,70,,210611,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,37448,,"25,057 x DRG weight",37448,Other,base rate x DRG weight,33704,,"22,552 x DRG weight",33704,Other,base rate x DRG weight,37448,,"25,057 x DRG weight",37448,Other,base rate x DRG weight,31830,,"21,298 x DRG weight",31830,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,210611,
TRAUMATIC INJURY WITHOUT MCC,914,MS-DRG,,,,,,,,inpatient,,,86778.14,18997,,,18997,Other,150% of Medicare + 9.63% HCRA Surcharge,11552,,"3,609.90 x patient days",11552,Per diem,,22734,,"25,046 x DRG weight",22734,Other,base rate x DRG weight,20460,,"22,541 x DRG weight",20460,Other,base rate x DRG weight,28613,,"31,523 x DRG weight",28613,Other,base rate x DRG weight,25752,,"28,371 x DRG weight",25752,Other,base rate x DRG weight,24322,,"26,795 x DRG weight",24322,Other,base rate x DRG weight,12707.2,,"3,970.89 x patient days",12707.2,Per diem,,20390,,"22,463 x DRG weight",20390,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,23987,,"26,426 x DRG weight",23987,Other,base rate x DRG weight,35227,,"38,809 x DRG weight",35227,Other,base rate x DRG weight,35227,,"38,809 x DRG weight",35227,Other,base rate x DRG weight,23987,,"26,426 x DRG weight",23987,Other,base rate x DRG weight,35227,,"38,809 x DRG weight",35227,Other,base rate x DRG weight,20362,,"6,363 x patient days",20362,Per diem,,60745,70,,60745,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,22744,,"25,057 x DRG weight",22744,Other,base rate x DRG weight,20470,,"22,552 x DRG weight",20470,Other,base rate x DRG weight,22744,,"25,057 x DRG weight",22744,Other,base rate x DRG weight,19332,,"21,298 x DRG weight",19332,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,60745,
ALLERGIC REACTIONS WITH MCC,915,MS-DRG,,,,,,,,inpatient,,,202183.18,32055,,,32055,Other,150% of Medicare + 9.63% HCRA Surcharge,19493,,"3,609.90 x patient days",19493,Per diem,,44432,,"25,046 x DRG weight",44432,Other,base rate x DRG weight,39988,,"22,541 x DRG weight",39988,Other,base rate x DRG weight,55922,,"31,523 x DRG weight",55922,Other,base rate x DRG weight,50330,,"28,371 x DRG weight",50330,Other,base rate x DRG weight,47534,,"26,795 x DRG weight",47534,Other,base rate x DRG weight,21442.3,,"3,970.89 x patient days",21442.3,Per diem,,39849,,"22,463 x DRG weight",39849,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,46880,,"26,426 x DRG weight",46880,Other,base rate x DRG weight,68847,,"38,809 x DRG weight",68847,Other,base rate x DRG weight,68847,,"38,809 x DRG weight",68847,Other,base rate x DRG weight,46880,,"26,426 x DRG weight",46880,Other,base rate x DRG weight,68847,,"38,809 x DRG weight",68847,Other,base rate x DRG weight,34360,,"6,363 x patient days",34360,Per diem,,141528,70,,141528,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,44451,,"25,057 x DRG weight",44451,Other,base rate x DRG weight,40007,,"22,552 x DRG weight",40007,Other,base rate x DRG weight,44451,,"25,057 x DRG weight",44451,Other,base rate x DRG weight,37783,,"21,298 x DRG weight",37783,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,141528,
ALLERGIC REACTIONS WITHOUT MCC,916,MS-DRG,,,,,,,,inpatient,,,84150.39,13654,,,13654,Other,150% of Medicare + 9.63% HCRA Surcharge,8303,,"3,609.90 x patient days",8303,Per diem,,16500,,"25,046 x DRG weight",16500,Other,base rate x DRG weight,14850,,"22,541 x DRG weight",14850,Other,base rate x DRG weight,20767,,"31,523 x DRG weight",20767,Other,base rate x DRG weight,18691,,"28,371 x DRG weight",18691,Other,base rate x DRG weight,17653,,"26,795 x DRG weight",17653,Other,base rate x DRG weight,9133.3,,"3,970.89 x patient days",9133.3,Per diem,,14799,,"22,463 x DRG weight",14799,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,17409,,"26,426 x DRG weight",17409,Other,base rate x DRG weight,25567,,"38,809 x DRG weight",25567,Other,base rate x DRG weight,25567,,"38,809 x DRG weight",25567,Other,base rate x DRG weight,17409,,"26,426 x DRG weight",17409,Other,base rate x DRG weight,25567,,"38,809 x DRG weight",25567,Other,base rate x DRG weight,14635,,"6,363 x patient days",14635,Per diem,,58905,70,,58905,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,16508,,"25,057 x DRG weight",16508,Other,base rate x DRG weight,14857,,"22,552 x DRG weight",14857,Other,base rate x DRG weight,16508,,"25,057 x DRG weight",16508,Other,base rate x DRG weight,14031,,"21,298 x DRG weight",14031,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,58905,
POISONING AND TOXIC EFFECTS OF DRUGS WITH MCC,917,MS-DRG,,,,,,,,inpatient,,,189693.48,33836,,,33836,Other,150% of Medicare + 9.63% HCRA Surcharge,20576,,"3,609.90 x patient days",20576,Per diem,,39971,,"25,046 x DRG weight",39971,Other,base rate x DRG weight,35973,,"22,541 x DRG weight",35973,Other,base rate x DRG weight,50308,,"31,523 x DRG weight",50308,Other,base rate x DRG weight,45277,,"28,371 x DRG weight",45277,Other,base rate x DRG weight,42762,,"26,795 x DRG weight",42762,Other,base rate x DRG weight,22633.6,,"3,970.89 x patient days",22633.6,Per diem,,35849,,"22,463 x DRG weight",35849,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,42173,,"26,426 x DRG weight",42173,Other,base rate x DRG weight,61935,,"38,809 x DRG weight",61935,Other,base rate x DRG weight,61935,,"38,809 x DRG weight",61935,Other,base rate x DRG weight,42173,,"26,426 x DRG weight",42173,Other,base rate x DRG weight,61935,,"38,809 x DRG weight",61935,Other,base rate x DRG weight,36269,,"6,363 x patient days",36269,Per diem,,132785,70,,132785,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,39988,,"25,057 x DRG weight",39988,Other,base rate x DRG weight,35991,,"22,552 x DRG weight",35991,Other,base rate x DRG weight,39988,,"25,057 x DRG weight",39988,Other,base rate x DRG weight,33989,,"21,298 x DRG weight",33989,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,132785,
POISONING AND TOXIC EFFECTS OF DRUGS WITHOUT MCC,918,MS-DRG,,,,,,,,inpatient,,,90526.71,20778,,,20778,Other,150% of Medicare + 9.63% HCRA Surcharge,12635,,"3,609.90 x patient days",12635,Per diem,,21562,,"25,046 x DRG weight",21562,Other,base rate x DRG weight,19406,,"22,541 x DRG weight",19406,Other,base rate x DRG weight,27138,,"31,523 x DRG weight",27138,Other,base rate x DRG weight,24425,,"28,371 x DRG weight",24425,Other,base rate x DRG weight,23068,,"26,795 x DRG weight",23068,Other,base rate x DRG weight,13898.5,,"3,970.89 x patient days",13898.5,Per diem,,19338,,"22,463 x DRG weight",19338,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,22750,,"26,426 x DRG weight",22750,Other,base rate x DRG weight,33411,,"38,809 x DRG weight",33411,Other,base rate x DRG weight,33411,,"38,809 x DRG weight",33411,Other,base rate x DRG weight,22750,,"26,426 x DRG weight",22750,Other,base rate x DRG weight,33411,,"38,809 x DRG weight",33411,Other,base rate x DRG weight,22271,,"6,363 x patient days",22271,Per diem,,63369,70,,63369,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,21572,,"25,057 x DRG weight",21572,Other,base rate x DRG weight,19415,,"22,552 x DRG weight",19415,Other,base rate x DRG weight,21572,,"25,057 x DRG weight",21572,Other,base rate x DRG weight,18335,,"21,298 x DRG weight",18335,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,63369,
COMPLICATIONS OF TREATMENT WITH MCC,919,MS-DRG,,,,,,,,inpatient,,,198006.82,36804,,,36804,Other,150% of Medicare + 9.63% HCRA Surcharge,22381,,"3,609.90 x patient days",22381,Per diem,,45701,,"25,046 x DRG weight",45701,Other,base rate x DRG weight,41131,,"22,541 x DRG weight",41131,Other,base rate x DRG weight,57520,,"31,523 x DRG weight",57520,Other,base rate x DRG weight,51769,,"28,371 x DRG weight",51769,Other,base rate x DRG weight,48893,,"26,795 x DRG weight",48893,Other,base rate x DRG weight,24619.1,,"3,970.89 x patient days",24619.1,Per diem,,40988,,"22,463 x DRG weight",40988,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,48220,,"26,426 x DRG weight",48220,Other,base rate x DRG weight,70815,,"38,809 x DRG weight",70815,Other,base rate x DRG weight,70815,,"38,809 x DRG weight",70815,Other,base rate x DRG weight,48220,,"26,426 x DRG weight",48220,Other,base rate x DRG weight,70815,,"38,809 x DRG weight",70815,Other,base rate x DRG weight,39451,,"6,363 x patient days",39451,Per diem,,138605,70,,138605,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,45722,,"25,057 x DRG weight",45722,Other,base rate x DRG weight,41151,,"22,552 x DRG weight",41151,Other,base rate x DRG weight,45722,,"25,057 x DRG weight",45722,Other,base rate x DRG weight,38862,,"21,298 x DRG weight",38862,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,138605,
COMPLICATIONS OF TREATMENT WITH CC,920,MS-DRG,,,,,,,,inpatient,,,161505.57,23152,,,23152,Other,150% of Medicare + 9.63% HCRA Surcharge,14079,,"3,609.90 x patient days",14079,Per diem,,25893,,"25,046 x DRG weight",25893,Other,base rate x DRG weight,23303,,"22,541 x DRG weight",23303,Other,base rate x DRG weight,32588,,"31,523 x DRG weight",32588,Other,base rate x DRG weight,29330,,"28,371 x DRG weight",29330,Other,base rate x DRG weight,27701,,"26,795 x DRG weight",27701,Other,base rate x DRG weight,15486.9,,"3,970.89 x patient days",15486.9,Per diem,,23222,,"22,463 x DRG weight",23222,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,27319,,"26,426 x DRG weight",27319,Other,base rate x DRG weight,40121,,"38,809 x DRG weight",40121,Other,base rate x DRG weight,40121,,"38,809 x DRG weight",40121,Other,base rate x DRG weight,27319,,"26,426 x DRG weight",27319,Other,base rate x DRG weight,40121,,"38,809 x DRG weight",40121,Other,base rate x DRG weight,24816,,"6,363 x patient days",24816,Per diem,,113054,70,,113054,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,25904,,"25,057 x DRG weight",25904,Other,base rate x DRG weight,23314,,"22,552 x DRG weight",23314,Other,base rate x DRG weight,25904,,"25,057 x DRG weight",25904,Other,base rate x DRG weight,22018,,"21,298 x DRG weight",22018,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,113054,
COMPLICATIONS OF TREATMENT WITHOUT CC/MCC,921,MS-DRG,,,,,,,,inpatient,,,90123.85,16028,,,16028,Other,150% of Medicare + 9.63% HCRA Surcharge,9747,,"3,609.90 x patient days",9747,Per diem,,17477,,"25,046 x DRG weight",17477,Other,base rate x DRG weight,15729,,"22,541 x DRG weight",15729,Other,base rate x DRG weight,21997,,"31,523 x DRG weight",21997,Other,base rate x DRG weight,19797,,"28,371 x DRG weight",19797,Other,base rate x DRG weight,18698,,"26,795 x DRG weight",18698,Other,base rate x DRG weight,10721.7,,"3,970.89 x patient days",10721.7,Per diem,,15675,,"22,463 x DRG weight",15675,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,18440,,"26,426 x DRG weight",18440,Other,base rate x DRG weight,27081,,"38,809 x DRG weight",27081,Other,base rate x DRG weight,27081,,"38,809 x DRG weight",27081,Other,base rate x DRG weight,18440,,"26,426 x DRG weight",18440,Other,base rate x DRG weight,27081,,"38,809 x DRG weight",27081,Other,base rate x DRG weight,17180,,"6,363 x patient days",17180,Per diem,,63087,70,,63087,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,17485,,"25,057 x DRG weight",17485,Other,base rate x DRG weight,15737,,"22,552 x DRG weight",15737,Other,base rate x DRG weight,17485,,"25,057 x DRG weight",17485,Other,base rate x DRG weight,14862,,"21,298 x DRG weight",14862,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,63087,
"OTHER INJURY, POISONING AND TOXIC EFFECT DIAGNOSES WITH MCC",922,MS-DRG,,,,,,,,inpatient,,,353327.55,45709,,,45709,Other,150% of Medicare + 9.63% HCRA Surcharge,27796,,"3,609.90 x patient days",27796,Per diem,,43703,,"25,046 x DRG weight",43703,Other,base rate x DRG weight,39332,,"22,541 x DRG weight",39332,Other,base rate x DRG weight,55004,,"31,523 x DRG weight",55004,Other,base rate x DRG weight,49505,,"28,371 x DRG weight",49505,Other,base rate x DRG weight,46755,,"26,795 x DRG weight",46755,Other,base rate x DRG weight,30575.6,,"3,970.89 x patient days",30575.6,Per diem,,39196,,"22,463 x DRG weight",39196,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,46111,,"26,426 x DRG weight",46111,Other,base rate x DRG weight,67718,,"38,809 x DRG weight",67718,Other,base rate x DRG weight,67718,,"38,809 x DRG weight",67718,Other,base rate x DRG weight,46111,,"26,426 x DRG weight",46111,Other,base rate x DRG weight,67718,,"38,809 x DRG weight",67718,Other,base rate x DRG weight,48995,,"6,363 x patient days",48995,Per diem,,247329,70,,247329,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,43722,,"25,057 x DRG weight",43722,Other,base rate x DRG weight,39351,,"22,552 x DRG weight",39351,Other,base rate x DRG weight,43722,,"25,057 x DRG weight",43722,Other,base rate x DRG weight,37163,,"21,298 x DRG weight",37163,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,247329,
"OTHER INJURY, POISONING AND TOXIC EFFECT DIAGNOSES WITHOUT MCC",923,MS-DRG,,,,,,,,inpatient,,,232553.09,28495,,,28495,Other,150% of Medicare + 9.63% HCRA Surcharge,17328,,"3,609.90 x patient days",17328,Per diem,,25332,,"25,046 x DRG weight",25332,Other,base rate x DRG weight,22798,,"22,541 x DRG weight",22798,Other,base rate x DRG weight,31882,,"31,523 x DRG weight",31882,Other,base rate x DRG weight,28694,,"28,371 x DRG weight",28694,Other,base rate x DRG weight,27100,,"26,795 x DRG weight",27100,Other,base rate x DRG weight,19060.8,,"3,970.89 x patient days",19060.8,Per diem,,22719,,"22,463 x DRG weight",22719,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,26727,,"26,426 x DRG weight",26727,Other,base rate x DRG weight,39251,,"38,809 x DRG weight",39251,Other,base rate x DRG weight,39251,,"38,809 x DRG weight",39251,Other,base rate x DRG weight,26727,,"26,426 x DRG weight",26727,Other,base rate x DRG weight,39251,,"38,809 x DRG weight",39251,Other,base rate x DRG weight,30542,,"6,363 x patient days",30542,Per diem,,162787,70,,162787,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,25343,,"25,057 x DRG weight",25343,Other,base rate x DRG weight,22809,,"22,552 x DRG weight",22809,Other,base rate x DRG weight,25343,,"25,057 x DRG weight",25343,Other,base rate x DRG weight,21541,,"21,298 x DRG weight",21541,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,162787,
EXTENSIVE BURNS OR FULL THICKNESS BURNS WITH MV >96 HOURS WITH SKIN GRAFT,927,MS-DRG,,,,,,,,inpatient,,,1868428.79,213706,,,213706,Other,150% of Medicare + 9.63% HCRA Surcharge,129956,,"3,609.90 x patient days",129956,Per diem,,660180,,"25,046 x DRG weight",660180,Other,base rate x DRG weight,594151,,"22,541 x DRG weight",594151,Other,base rate x DRG weight,830905,,"31,523 x DRG weight",830905,Other,base rate x DRG weight,747823,,"28,371 x DRG weight",747823,Other,base rate x DRG weight,706281,,"26,795 x DRG weight",706281,Other,base rate x DRG weight,142951.6,,"3,970.89 x patient days",142951.6,Per diem,,592095,,"22,463 x DRG weight",592095,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,696555,,"26,426 x DRG weight",696555,Other,base rate x DRG weight,1022955,,"38,809 x DRG weight",1022955,Other,base rate x DRG weight,1022955,,"38,809 x DRG weight",1022955,Other,base rate x DRG weight,696555,,"26,426 x DRG weight",696555,Other,base rate x DRG weight,1022955,,"38,809 x DRG weight",1022955,Other,base rate x DRG weight,229068,,"6,363 x patient days",229068,Per diem,,1307900,70,,1307900,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,660470,,"25,057 x DRG weight",660470,Other,base rate x DRG weight,594441,,"22,552 x DRG weight",594441,Other,base rate x DRG weight,660470,,"25,057 x DRG weight",660470,Other,base rate x DRG weight,561388,,"21,298 x DRG weight",561388,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,1307900,
FULL THICKNESS BURN WITH SKIN GRAFT OR INHALATION INJURY WITH CC/MCC,928,MS-DRG,,,,,,,,inpatient,,,699323.95,101510,,,101510,Other,150% of Medicare + 9.63% HCRA Surcharge,61729,,"3,609.90 x patient days",61729,Per diem,,173311,,"25,046 x DRG weight",173311,Other,base rate x DRG weight,155977,,"22,541 x DRG weight",155977,Other,base rate x DRG weight,218130,,"31,523 x DRG weight",218130,Other,base rate x DRG weight,196319,,"28,371 x DRG weight",196319,Other,base rate x DRG weight,185413,,"26,795 x DRG weight",185413,Other,base rate x DRG weight,67901.9,,"3,970.89 x patient days",67901.9,Per diem,,155437,,"22,463 x DRG weight",155437,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,182860,,"26,426 x DRG weight",182860,Other,base rate x DRG weight,268547,,"38,809 x DRG weight",268547,Other,base rate x DRG weight,268547,,"38,809 x DRG weight",268547,Other,base rate x DRG weight,182860,,"26,426 x DRG weight",182860,Other,base rate x DRG weight,268547,,"38,809 x DRG weight",268547,Other,base rate x DRG weight,108807,,"6,363 x patient days",108807,Per diem,,489527,70,,489527,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,173387,,"25,057 x DRG weight",173387,Other,base rate x DRG weight,156053,,"22,552 x DRG weight",156053,Other,base rate x DRG weight,173387,,"25,057 x DRG weight",173387,Other,base rate x DRG weight,147376,,"21,298 x DRG weight",147376,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,489527,
FULL THICKNESS BURN WITH SKIN GRAFT OR INHALATION INJURY WITHOUT CC/MCC,929,MS-DRG,,,,,,,,inpatient,,,487625.04,49271,,,49271,Other,150% of Medicare + 9.63% HCRA Surcharge,29962,,"3,609.90 x patient days",29962,Per diem,,80535,,"25,046 x DRG weight",80535,Other,base rate x DRG weight,72481,,"22,541 x DRG weight",72481,Other,base rate x DRG weight,101362,,"31,523 x DRG weight",101362,Other,base rate x DRG weight,91227,,"28,371 x DRG weight",91227,Other,base rate x DRG weight,86159,,"26,795 x DRG weight",86159,Other,base rate x DRG weight,32958.2,,"3,970.89 x patient days",32958.2,Per diem,,72230,,"22,463 x DRG weight",72230,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,84973,,"26,426 x DRG weight",84973,Other,base rate x DRG weight,124790,,"38,809 x DRG weight",124790,Other,base rate x DRG weight,124790,,"38,809 x DRG weight",124790,Other,base rate x DRG weight,84973,,"26,426 x DRG weight",84973,Other,base rate x DRG weight,124790,,"38,809 x DRG weight",124790,Other,base rate x DRG weight,52813,,"6,363 x patient days",52813,Per diem,,341338,70,,341338,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,80571,,"25,057 x DRG weight",80571,Other,base rate x DRG weight,72516,,"22,552 x DRG weight",72516,Other,base rate x DRG weight,80571,,"25,057 x DRG weight",80571,Other,base rate x DRG weight,68484,,"21,298 x DRG weight",68484,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,341338,
EXTENSIVE BURNS OR FULL THICKNESS BURNS WITH MV >96 HOURS WITHOUT SKIN GRAFT,933,MS-DRG,,,,,,,,inpatient,,,250045.33,29682,,,29682,Other,150% of Medicare + 9.63% HCRA Surcharge,18050,,"3,609.90 x patient days",18050,Per diem,,75939,,"25,046 x DRG weight",75939,Other,base rate x DRG weight,68344,,"22,541 x DRG weight",68344,Other,base rate x DRG weight,95578,,"31,523 x DRG weight",95578,Other,base rate x DRG weight,86021,,"28,371 x DRG weight",86021,Other,base rate x DRG weight,81242,,"26,795 x DRG weight",81242,Other,base rate x DRG weight,19855,,"3,970.89 x patient days",19855,Per diem,,68108,,"22,463 x DRG weight",68108,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,80124,,"26,426 x DRG weight",80124,Other,base rate x DRG weight,117669,,"38,809 x DRG weight",117669,Other,base rate x DRG weight,117669,,"38,809 x DRG weight",117669,Other,base rate x DRG weight,80124,,"26,426 x DRG weight",80124,Other,base rate x DRG weight,117669,,"38,809 x DRG weight",117669,Other,base rate x DRG weight,31815,,"6,363 x patient days",31815,Per diem,,175032,70,,175032,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,75973,,"25,057 x DRG weight",75973,Other,base rate x DRG weight,68378,,"22,552 x DRG weight",68378,Other,base rate x DRG weight,75973,,"25,057 x DRG weight",75973,Other,base rate x DRG weight,64576,,"21,298 x DRG weight",64576,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,175032,
FULL THICKNESS BURN WITHOUT SKIN GRAFT OR INHALATION INJURY,934,MS-DRG,,,,,,,,inpatient,,,402958.87,43335,,,43335,Other,150% of Medicare + 9.63% HCRA Surcharge,26352,,"3,609.90 x patient days",26352,Per diem,,52409,,"25,046 x DRG weight",52409,Other,base rate x DRG weight,47167,,"22,541 x DRG weight",47167,Other,base rate x DRG weight,65962,,"31,523 x DRG weight",65962,Other,base rate x DRG weight,59366,,"28,371 x DRG weight",59366,Other,base rate x DRG weight,56069,,"26,795 x DRG weight",56069,Other,base rate x DRG weight,28987.2,,"3,970.89 x patient days",28987.2,Per diem,,47004,,"22,463 x DRG weight",47004,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,55296,,"26,426 x DRG weight",55296,Other,base rate x DRG weight,81208,,"38,809 x DRG weight",81208,Other,base rate x DRG weight,81208,,"38,809 x DRG weight",81208,Other,base rate x DRG weight,55296,,"26,426 x DRG weight",55296,Other,base rate x DRG weight,81208,,"38,809 x DRG weight",81208,Other,base rate x DRG weight,46450,,"6,363 x patient days",46450,Per diem,,282071,70,,282071,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,52432,,"25,057 x DRG weight",52432,Other,base rate x DRG weight,47190,,"22,552 x DRG weight",47190,Other,base rate x DRG weight,52432,,"25,057 x DRG weight",52432,Other,base rate x DRG weight,44566,,"21,298 x DRG weight",44566,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,282071,
NON-EXTENSIVE BURNS,935,MS-DRG,,,,,,,,inpatient,,,270505.91,32649,,,32649,Other,150% of Medicare + 9.63% HCRA Surcharge,19854,,"3,609.90 x patient days",19854,Per diem,,51121,,"25,046 x DRG weight",51121,Other,base rate x DRG weight,46008,,"22,541 x DRG weight",46008,Other,base rate x DRG weight,64342,,"31,523 x DRG weight",64342,Other,base rate x DRG weight,57908,,"28,371 x DRG weight",57908,Other,base rate x DRG weight,54691,,"26,795 x DRG weight",54691,Other,base rate x DRG weight,21839.4,,"3,970.89 x patient days",21839.4,Per diem,,45849,,"22,463 x DRG weight",45849,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,53938,,"26,426 x DRG weight",53938,Other,base rate x DRG weight,79213,,"38,809 x DRG weight",79213,Other,base rate x DRG weight,79213,,"38,809 x DRG weight",79213,Other,base rate x DRG weight,53938,,"26,426 x DRG weight",53938,Other,base rate x DRG weight,79213,,"38,809 x DRG weight",79213,Other,base rate x DRG weight,34997,,"6,363 x patient days",34997,Per diem,,189354,70,,189354,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,51144,,"25,057 x DRG weight",51144,Other,base rate x DRG weight,46031,,"22,552 x DRG weight",46031,Other,base rate x DRG weight,51144,,"25,057 x DRG weight",51144,Other,base rate x DRG weight,43471,,"21,298 x DRG weight",43471,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,189354,
O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITH MCC,939,MS-DRG,,,,,,,,inpatient,,,254493.41,55801,,,55801,Other,150% of Medicare + 9.63% HCRA Surcharge,33933,,"3,609.90 x patient days",33933,Per diem,,80530,,"25,046 x DRG weight",80530,Other,base rate x DRG weight,72476,,"22,541 x DRG weight",72476,Other,base rate x DRG weight,101356,,"31,523 x DRG weight",101356,Other,base rate x DRG weight,91221,,"28,371 x DRG weight",91221,Other,base rate x DRG weight,86154,,"26,795 x DRG weight",86154,Other,base rate x DRG weight,37326.3,,"3,970.89 x patient days",37326.3,Per diem,,72225,,"22,463 x DRG weight",72225,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,84968,,"26,426 x DRG weight",84968,Other,base rate x DRG weight,124783,,"38,809 x DRG weight",124783,Other,base rate x DRG weight,124783,,"38,809 x DRG weight",124783,Other,base rate x DRG weight,84968,,"26,426 x DRG weight",84968,Other,base rate x DRG weight,124783,,"38,809 x DRG weight",124783,Other,base rate x DRG weight,59812,,"6,363 x patient days",59812,Per diem,,178145,70,,178145,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,80566,,"25,057 x DRG weight",80566,Other,base rate x DRG weight,72511,,"22,552 x DRG weight",72511,Other,base rate x DRG weight,80566,,"25,057 x DRG weight",80566,Other,base rate x DRG weight,68479,,"21,298 x DRG weight",68479,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,178145,
O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITH CC,940,MS-DRG,,,,,,,,inpatient,,,250994.14,27308,,,27308,Other,150% of Medicare + 9.63% HCRA Surcharge,16606,,"3,609.90 x patient days",16606,Per diem,,54265,,"25,046 x DRG weight",54265,Other,base rate x DRG weight,48837,,"22,541 x DRG weight",48837,Other,base rate x DRG weight,68298,,"31,523 x DRG weight",68298,Other,base rate x DRG weight,61469,,"28,371 x DRG weight",61469,Other,base rate x DRG weight,58054,,"26,795 x DRG weight",58054,Other,base rate x DRG weight,18266.6,,"3,970.89 x patient days",18266.6,Per diem,,48668,,"22,463 x DRG weight",48668,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,57255,,"26,426 x DRG weight",57255,Other,base rate x DRG weight,84084,,"38,809 x DRG weight",84084,Other,base rate x DRG weight,84084,,"38,809 x DRG weight",84084,Other,base rate x DRG weight,57255,,"26,426 x DRG weight",57255,Other,base rate x DRG weight,84084,,"38,809 x DRG weight",84084,Other,base rate x DRG weight,29270,,"6,363 x patient days",29270,Per diem,,175696,70,,175696,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,54288,,"25,057 x DRG weight",54288,Other,base rate x DRG weight,48861,,"22,552 x DRG weight",48861,Other,base rate x DRG weight,54288,,"25,057 x DRG weight",54288,Other,base rate x DRG weight,46144,,"21,298 x DRG weight",46144,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,175696,
O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITHOUT CC/MCC,941,MS-DRG,,,,,,,,inpatient,,,117589.06,13654,,,13654,Other,150% of Medicare + 9.63% HCRA Surcharge,8303,,"3,609.90 x patient days",8303,Per diem,,46485,,"25,046 x DRG weight",46485,Other,base rate x DRG weight,41836,,"22,541 x DRG weight",41836,Other,base rate x DRG weight,58507,,"31,523 x DRG weight",58507,Other,base rate x DRG weight,52657,,"28,371 x DRG weight",52657,Other,base rate x DRG weight,49732,,"26,795 x DRG weight",49732,Other,base rate x DRG weight,9133.3,,"3,970.89 x patient days",9133.3,Per diem,,41691,,"22,463 x DRG weight",41691,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,49047,,"26,426 x DRG weight",49047,Other,base rate x DRG weight,72030,,"38,809 x DRG weight",72030,Other,base rate x DRG weight,72030,,"38,809 x DRG weight",72030,Other,base rate x DRG weight,49047,,"26,426 x DRG weight",49047,Other,base rate x DRG weight,72030,,"38,809 x DRG weight",72030,Other,base rate x DRG weight,14635,,"6,363 x patient days",14635,Per diem,,82312,70,,82312,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,46506,,"25,057 x DRG weight",46506,Other,base rate x DRG weight,41857,,"22,552 x DRG weight",41857,Other,base rate x DRG weight,46506,,"25,057 x DRG weight",46506,Other,base rate x DRG weight,39529,,"21,298 x DRG weight",39529,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,82312,
SIGNS AND SYMPTOMS WITH MCC,947,MS-DRG,,,,,,,,inpatient,,,315077.54,31462,,,31462,Other,150% of Medicare + 9.63% HCRA Surcharge,19132,,"3,609.90 x patient days",19132,Per diem,,31348,,"25,046 x DRG weight",31348,Other,base rate x DRG weight,28212,,"22,541 x DRG weight",28212,Other,base rate x DRG weight,39454,,"31,523 x DRG weight",39454,Other,base rate x DRG weight,35509,,"28,371 x DRG weight",35509,Other,base rate x DRG weight,33537,,"26,795 x DRG weight",33537,Other,base rate x DRG weight,21045.2,,"3,970.89 x patient days",21045.2,Per diem,,28115,,"22,463 x DRG weight",28115,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,33075,,"26,426 x DRG weight",33075,Other,base rate x DRG weight,48573,,"38,809 x DRG weight",48573,Other,base rate x DRG weight,48573,,"38,809 x DRG weight",48573,Other,base rate x DRG weight,33075,,"26,426 x DRG weight",33075,Other,base rate x DRG weight,48573,,"38,809 x DRG weight",48573,Other,base rate x DRG weight,33724,,"6,363 x patient days",33724,Per diem,,220554,70,,220554,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,31361,,"25,057 x DRG weight",31361,Other,base rate x DRG weight,28226,,"22,552 x DRG weight",28226,Other,base rate x DRG weight,31361,,"25,057 x DRG weight",31361,Other,base rate x DRG weight,26657,,"21,298 x DRG weight",26657,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,220554,
SIGNS AND SYMPTOMS WITHOUT MCC,948,MS-DRG,,,,,,,,inpatient,,,107235.24,20778,,,20778,Other,150% of Medicare + 9.63% HCRA Surcharge,12635,,"3,609.90 x patient days",12635,Per diem,,20062,,"25,046 x DRG weight",20062,Other,base rate x DRG weight,18055,,"22,541 x DRG weight",18055,Other,base rate x DRG weight,25250,,"31,523 x DRG weight",25250,Other,base rate x DRG weight,22725,,"28,371 x DRG weight",22725,Other,base rate x DRG weight,21463,,"26,795 x DRG weight",21463,Other,base rate x DRG weight,13898.5,,"3,970.89 x patient days",13898.5,Per diem,,17993,,"22,463 x DRG weight",17993,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,21167,,"26,426 x DRG weight",21167,Other,base rate x DRG weight,31086,,"38,809 x DRG weight",31086,Other,base rate x DRG weight,31086,,"38,809 x DRG weight",31086,Other,base rate x DRG weight,21167,,"26,426 x DRG weight",21167,Other,base rate x DRG weight,31086,,"38,809 x DRG weight",31086,Other,base rate x DRG weight,22271,,"6,363 x patient days",22271,Per diem,,75065,70,,75065,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,20071,,"25,057 x DRG weight",20071,Other,base rate x DRG weight,18064,,"22,552 x DRG weight",18064,Other,base rate x DRG weight,20071,,"25,057 x DRG weight",20071,Other,base rate x DRG weight,17060,,"21,298 x DRG weight",17060,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,75065,
AFTERCARE WITH CC/MCC,949,MS-DRG,,,,,,,,inpatient,,,152010.9,37992,,,37992,Other,150% of Medicare + 9.63% HCRA Surcharge,23103,,"3,609.90 x patient days",23103,Per diem,,26869,,"25,046 x DRG weight",26869,Other,base rate x DRG weight,24182,,"22,541 x DRG weight",24182,Other,base rate x DRG weight,33818,,"31,523 x DRG weight",33818,Other,base rate x DRG weight,30436,,"28,371 x DRG weight",30436,Other,base rate x DRG weight,28746,,"26,795 x DRG weight",28746,Other,base rate x DRG weight,25413.3,,"3,970.89 x patient days",25413.3,Per diem,,24098,,"22,463 x DRG weight",24098,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,28350,,"26,426 x DRG weight",28350,Other,base rate x DRG weight,41634,,"38,809 x DRG weight",41634,Other,base rate x DRG weight,41634,,"38,809 x DRG weight",41634,Other,base rate x DRG weight,28350,,"26,426 x DRG weight",28350,Other,base rate x DRG weight,41634,,"38,809 x DRG weight",41634,Other,base rate x DRG weight,40723,,"6,363 x patient days",40723,Per diem,,106408,70,,106408,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,26881,,"25,057 x DRG weight",26881,Other,base rate x DRG weight,24194,,"22,552 x DRG weight",24194,Other,base rate x DRG weight,26881,,"25,057 x DRG weight",26881,Other,base rate x DRG weight,22848,,"21,298 x DRG weight",22848,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,106408,
AFTERCARE WITHOUT CC/MCC,950,MS-DRG,,,,,,,,inpatient,,,91528.2,23746,,,23746,Other,150% of Medicare + 9.63% HCRA Surcharge,14440,,"3,609.90 x patient days",14440,Per diem,,15994,,"25,046 x DRG weight",15994,Other,base rate x DRG weight,14395,,"22,541 x DRG weight",14395,Other,base rate x DRG weight,20131,,"31,523 x DRG weight",20131,Other,base rate x DRG weight,18118,,"28,371 x DRG weight",18118,Other,base rate x DRG weight,17111,,"26,795 x DRG weight",17111,Other,base rate x DRG weight,15884,,"3,970.89 x patient days",15884,Per diem,,14345,,"22,463 x DRG weight",14345,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,16876,,"26,426 x DRG weight",16876,Other,base rate x DRG weight,24783,,"38,809 x DRG weight",24783,Other,base rate x DRG weight,24783,,"38,809 x DRG weight",24783,Other,base rate x DRG weight,16876,,"26,426 x DRG weight",16876,Other,base rate x DRG weight,24783,,"38,809 x DRG weight",24783,Other,base rate x DRG weight,25452,,"6,363 x patient days",25452,Per diem,,64070,70,,64070,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,16001,,"25,057 x DRG weight",16001,Other,base rate x DRG weight,14402,,"22,552 x DRG weight",14402,Other,base rate x DRG weight,16001,,"25,057 x DRG weight",16001,Other,base rate x DRG weight,13601,,"21,298 x DRG weight",13601,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,64070,
OTHER FACTORS INFLUENCING HEALTH STATUS,951,MS-DRG,,,,,,,,inpatient,,,103021.31,16622,,,16622,Other,150% of Medicare + 9.63% HCRA Surcharge,10108,,"3,609.90 x patient days",10108,Per diem,,14777,,"25,046 x DRG weight",14777,Other,base rate x DRG weight,13299,,"22,541 x DRG weight",13299,Other,base rate x DRG weight,18599,,"31,523 x DRG weight",18599,Other,base rate x DRG weight,16739,,"28,371 x DRG weight",16739,Other,base rate x DRG weight,15809,,"26,795 x DRG weight",15809,Other,base rate x DRG weight,11118.8,,"3,970.89 x patient days",11118.8,Per diem,,13253,,"22,463 x DRG weight",13253,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,15591,,"26,426 x DRG weight",15591,Other,base rate x DRG weight,22897,,"38,809 x DRG weight",22897,Other,base rate x DRG weight,22897,,"38,809 x DRG weight",22897,Other,base rate x DRG weight,15591,,"26,426 x DRG weight",15591,Other,base rate x DRG weight,22897,,"38,809 x DRG weight",22897,Other,base rate x DRG weight,17816,,"6,363 x patient days",17816,Per diem,,72115,70,,72115,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,14784,,"25,057 x DRG weight",14784,Other,base rate x DRG weight,13306,,"22,552 x DRG weight",13306,Other,base rate x DRG weight,14784,,"25,057 x DRG weight",14784,Other,base rate x DRG weight,12566,,"21,298 x DRG weight",12566,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,72115,
CRANIOTOMY FOR MULTIPLE SIGNIFICANT TRAUMA,955,MS-DRG,,,,,,,,inpatient,,,666307.7,72423,,,72423,Other,150% of Medicare + 9.63% HCRA Surcharge,44041,,"3,609.90 x patient days",44041,Per diem,,152535,,"25,046 x DRG weight",152535,Other,base rate x DRG weight,137279,,"22,541 x DRG weight",137279,Other,base rate x DRG weight,191981,,"31,523 x DRG weight",191981,Other,base rate x DRG weight,172785,,"28,371 x DRG weight",172785,Other,base rate x DRG weight,163187,,"26,795 x DRG weight",163187,Other,base rate x DRG weight,48445.1,,"3,970.89 x patient days",48445.1,Per diem,,136804,,"22,463 x DRG weight",136804,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,160940,,"26,426 x DRG weight",160940,Other,base rate x DRG weight,236355,,"38,809 x DRG weight",236355,Other,base rate x DRG weight,236355,,"38,809 x DRG weight",236355,Other,base rate x DRG weight,160940,,"26,426 x DRG weight",160940,Other,base rate x DRG weight,236355,,"38,809 x DRG weight",236355,Other,base rate x DRG weight,77629,,"6,363 x patient days",77629,Per diem,,466415,70,,466415,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,152602,,"25,057 x DRG weight",152602,Other,base rate x DRG weight,137346,,"22,552 x DRG weight",137346,Other,base rate x DRG weight,152602,,"25,057 x DRG weight",152602,Other,base rate x DRG weight,129709,,"21,298 x DRG weight",129709,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,466415,
"LIMB REATTACHMENT, HIP AND FEMUR PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA",956,MS-DRG,,,,,,,,inpatient,,,651853.98,47490,,,47490,Other,150% of Medicare + 9.63% HCRA Surcharge,28879,,"3,609.90 x patient days",28879,Per diem,,97133,,"25,046 x DRG weight",97133,Other,base rate x DRG weight,87419,,"22,541 x DRG weight",87419,Other,base rate x DRG weight,122252,,"31,523 x DRG weight",122252,Other,base rate x DRG weight,110028,,"28,371 x DRG weight",110028,Other,base rate x DRG weight,103916,,"26,795 x DRG weight",103916,Other,base rate x DRG weight,31766.9,,"3,970.89 x patient days",31766.9,Per diem,,87116,,"22,463 x DRG weight",87116,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,102485,,"26,426 x DRG weight",102485,Other,base rate x DRG weight,150509,,"38,809 x DRG weight",150509,Other,base rate x DRG weight,150509,,"38,809 x DRG weight",150509,Other,base rate x DRG weight,102485,,"26,426 x DRG weight",102485,Other,base rate x DRG weight,150509,,"38,809 x DRG weight",150509,Other,base rate x DRG weight,50904,,"6,363 x patient days",50904,Per diem,,456298,70,,456298,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,97176,,"25,057 x DRG weight",97176,Other,base rate x DRG weight,87461,,"22,552 x DRG weight",87461,Other,base rate x DRG weight,97176,,"25,057 x DRG weight",97176,Other,base rate x DRG weight,82598,,"21,298 x DRG weight",82598,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,456298,
OTHER O.R. PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA WITH MCC,957,MS-DRG,,,,,,,,inpatient,,,644915.06,86077,,,86077,Other,150% of Medicare + 9.63% HCRA Surcharge,52344,,"3,609.90 x patient days",52344,Per diem,,181145,,"25,046 x DRG weight",181145,Other,base rate x DRG weight,163028,,"22,541 x DRG weight",163028,Other,base rate x DRG weight,227990,,"31,523 x DRG weight",227990,Other,base rate x DRG weight,205193,,"28,371 x DRG weight",205193,Other,base rate x DRG weight,193795,,"26,795 x DRG weight",193795,Other,base rate x DRG weight,57578.4,,"3,970.89 x patient days",57578.4,Per diem,,162464,,"22,463 x DRG weight",162464,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,191126,,"26,426 x DRG weight",191126,Other,base rate x DRG weight,280686,,"38,809 x DRG weight",280686,Other,base rate x DRG weight,280686,,"38,809 x DRG weight",280686,Other,base rate x DRG weight,191126,,"26,426 x DRG weight",191126,Other,base rate x DRG weight,280686,,"38,809 x DRG weight",280686,Other,base rate x DRG weight,92264,,"6,363 x patient days",92264,Per diem,,451441,70,,451441,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,181225,,"25,057 x DRG weight",181225,Other,base rate x DRG weight,163107,,"22,552 x DRG weight",163107,Other,base rate x DRG weight,181225,,"25,057 x DRG weight",181225,Other,base rate x DRG weight,154038,,"21,298 x DRG weight",154038,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,451441,
OTHER O.R. PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA WITH CC,958,MS-DRG,,,,,,,,inpatient,,,450638.53,48677,,,48677,Other,150% of Medicare + 9.63% HCRA Surcharge,29601,,"3,609.90 x patient days",29601,Per diem,,101306,,"25,046 x DRG weight",101306,Other,base rate x DRG weight,91174,,"22,541 x DRG weight",91174,Other,base rate x DRG weight,127504,,"31,523 x DRG weight",127504,Other,base rate x DRG weight,114755,,"28,371 x DRG weight",114755,Other,base rate x DRG weight,108380,,"26,795 x DRG weight",108380,Other,base rate x DRG weight,32561.1,,"3,970.89 x patient days",32561.1,Per diem,,90858,,"22,463 x DRG weight",90858,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,106888,,"26,426 x DRG weight",106888,Other,base rate x DRG weight,156975,,"38,809 x DRG weight",156975,Other,base rate x DRG weight,156975,,"38,809 x DRG weight",156975,Other,base rate x DRG weight,106888,,"26,426 x DRG weight",106888,Other,base rate x DRG weight,156975,,"38,809 x DRG weight",156975,Other,base rate x DRG weight,52177,,"6,363 x patient days",52177,Per diem,,315447,70,,315447,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,101351,,"25,057 x DRG weight",101351,Other,base rate x DRG weight,91218,,"22,552 x DRG weight",91218,Other,base rate x DRG weight,101351,,"25,057 x DRG weight",101351,Other,base rate x DRG weight,86146,,"21,298 x DRG weight",86146,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,315447,
OTHER O.R. PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA WITHOUT CC/MCC,959,MS-DRG,,,,,,,,inpatient,,,429728.36,29682,,,29682,Other,150% of Medicare + 9.63% HCRA Surcharge,18050,,"3,609.90 x patient days",18050,Per diem,,63426,,"25,046 x DRG weight",63426,Other,base rate x DRG weight,57083,,"22,541 x DRG weight",57083,Other,base rate x DRG weight,79829,,"31,523 x DRG weight",79829,Other,base rate x DRG weight,71847,,"28,371 x DRG weight",71847,Other,base rate x DRG weight,67856,,"26,795 x DRG weight",67856,Other,base rate x DRG weight,19855,,"3,970.89 x patient days",19855,Per diem,,56885,,"22,463 x DRG weight",56885,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,66921,,"26,426 x DRG weight",66921,Other,base rate x DRG weight,98280,,"38,809 x DRG weight",98280,Other,base rate x DRG weight,98280,,"38,809 x DRG weight",98280,Other,base rate x DRG weight,66921,,"26,426 x DRG weight",66921,Other,base rate x DRG weight,98280,,"38,809 x DRG weight",98280,Other,base rate x DRG weight,31815,,"6,363 x patient days",31815,Per diem,,300810,70,,300810,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,63454,,"25,057 x DRG weight",63454,Other,base rate x DRG weight,57111,,"22,552 x DRG weight",57111,Other,base rate x DRG weight,63454,,"25,057 x DRG weight",63454,Other,base rate x DRG weight,53935,,"21,298 x DRG weight",53935,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,300810,
OTHER MULTIPLE SIGNIFICANT TRAUMA WITH MCC,963,MS-DRG,,,,,,,,inpatient,,,288738.68,48677,,,48677,Other,150% of Medicare + 9.63% HCRA Surcharge,29601,,"3,609.90 x patient days",29601,Per diem,,68483,,"25,046 x DRG weight",68483,Other,base rate x DRG weight,61634,,"22,541 x DRG weight",61634,Other,base rate x DRG weight,86193,,"31,523 x DRG weight",86193,Other,base rate x DRG weight,77575,,"28,371 x DRG weight",77575,Other,base rate x DRG weight,73266,,"26,795 x DRG weight",73266,Other,base rate x DRG weight,32561.1,,"3,970.89 x patient days",32561.1,Per diem,,61421,,"22,463 x DRG weight",61421,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,72257,,"26,426 x DRG weight",72257,Other,base rate x DRG weight,106115,,"38,809 x DRG weight",106115,Other,base rate x DRG weight,106115,,"38,809 x DRG weight",106115,Other,base rate x DRG weight,72257,,"26,426 x DRG weight",72257,Other,base rate x DRG weight,106115,,"38,809 x DRG weight",106115,Other,base rate x DRG weight,52177,,"6,363 x patient days",52177,Per diem,,202117,70,,202117,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,68513,,"25,057 x DRG weight",68513,Other,base rate x DRG weight,61664,,"22,552 x DRG weight",61664,Other,base rate x DRG weight,68513,,"25,057 x DRG weight",68513,Other,base rate x DRG weight,58235,,"21,298 x DRG weight",58235,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,202117,
OTHER MULTIPLE SIGNIFICANT TRAUMA WITH CC,964,MS-DRG,,,,,,,,inpatient,,,177696.36,29682,,,29682,Other,150% of Medicare + 9.63% HCRA Surcharge,18050,,"3,609.90 x patient days",18050,Per diem,,37594,,"25,046 x DRG weight",37594,Other,base rate x DRG weight,33834,,"22,541 x DRG weight",33834,Other,base rate x DRG weight,47316,,"31,523 x DRG weight",47316,Other,base rate x DRG weight,42585,,"28,371 x DRG weight",42585,Other,base rate x DRG weight,40219,,"26,795 x DRG weight",40219,Other,base rate x DRG weight,19855,,"3,970.89 x patient days",19855,Per diem,,33717,,"22,463 x DRG weight",33717,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,39665,,"26,426 x DRG weight",39665,Other,base rate x DRG weight,58252,,"38,809 x DRG weight",58252,Other,base rate x DRG weight,58252,,"38,809 x DRG weight",58252,Other,base rate x DRG weight,39665,,"26,426 x DRG weight",39665,Other,base rate x DRG weight,58252,,"38,809 x DRG weight",58252,Other,base rate x DRG weight,31815,,"6,363 x patient days",31815,Per diem,,124387,70,,124387,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,37611,,"25,057 x DRG weight",37611,Other,base rate x DRG weight,33851,,"22,552 x DRG weight",33851,Other,base rate x DRG weight,37611,,"25,057 x DRG weight",37611,Other,base rate x DRG weight,31968,,"21,298 x DRG weight",31968,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,124387,
OTHER MULTIPLE SIGNIFICANT TRAUMA WITHOUT CC/MCC,965,MS-DRG,,,,,,,,inpatient,,,136727.25,18997,,,18997,Other,150% of Medicare + 9.63% HCRA Surcharge,11552,,"3,609.90 x patient days",11552,Per diem,,23941,,"25,046 x DRG weight",23941,Other,base rate x DRG weight,21547,,"22,541 x DRG weight",21547,Other,base rate x DRG weight,30133,,"31,523 x DRG weight",30133,Other,base rate x DRG weight,27120,,"28,371 x DRG weight",27120,Other,base rate x DRG weight,25613,,"26,795 x DRG weight",25613,Other,base rate x DRG weight,12707.2,,"3,970.89 x patient days",12707.2,Per diem,,21472,,"22,463 x DRG weight",21472,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,25261,,"26,426 x DRG weight",25261,Other,base rate x DRG weight,37098,,"38,809 x DRG weight",37098,Other,base rate x DRG weight,37098,,"38,809 x DRG weight",37098,Other,base rate x DRG weight,25261,,"26,426 x DRG weight",25261,Other,base rate x DRG weight,37098,,"38,809 x DRG weight",37098,Other,base rate x DRG weight,20362,,"6,363 x patient days",20362,Per diem,,95709,70,,95709,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,23952,,"25,057 x DRG weight",23952,Other,base rate x DRG weight,21557,,"22,552 x DRG weight",21557,Other,base rate x DRG weight,23952,,"25,057 x DRG weight",23952,Other,base rate x DRG weight,20359,,"21,298 x DRG weight",20359,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,95709,
HIV WITH EXTENSIVE O.R. PROCEDURES WITH MCC,969,MS-DRG,,,,,,,,inpatient,,,2067235,119913,,,119913,Other,150% of Medicare + 9.63% HCRA Surcharge,72920,,"3,609.90 x patient days",72920,Per diem,,172131,,"25,046 x DRG weight",172131,Other,base rate x DRG weight,154915,,"22,541 x DRG weight",154915,Other,base rate x DRG weight,216645,,"31,523 x DRG weight",216645,Other,base rate x DRG weight,194983,,"28,371 x DRG weight",194983,Other,base rate x DRG weight,184151,,"26,795 x DRG weight",184151,Other,base rate x DRG weight,80212,,"3,970.89 x patient days",80212,Per diem,,154379,,"22,463 x DRG weight",154379,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,181615,,"26,426 x DRG weight",181615,Other,base rate x DRG weight,266719,,"38,809 x DRG weight",266719,Other,base rate x DRG weight,266719,,"38,809 x DRG weight",266719,Other,base rate x DRG weight,181615,,"26,426 x DRG weight",181615,Other,base rate x DRG weight,266719,,"38,809 x DRG weight",266719,Other,base rate x DRG weight,128533,,"6,363 x patient days",128533,Per diem,,1447065,70,,1447065,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,172207,,"25,057 x DRG weight",172207,Other,base rate x DRG weight,154991,,"22,552 x DRG weight",154991,Other,base rate x DRG weight,172207,,"25,057 x DRG weight",172207,Other,base rate x DRG weight,146373,,"21,298 x DRG weight",146373,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,1447065,
HIV WITH EXTENSIVE O.R. PROCEDURES WITHOUT MCC,970,MS-DRG,,,,,,,,inpatient,,,2067235,48084,,,48084,Other,150% of Medicare + 9.63% HCRA Surcharge,29240,,"3,609.90 x patient days",29240,Per diem,,69618,,"25,046 x DRG weight",69618,Other,base rate x DRG weight,62655,,"22,541 x DRG weight",62655,Other,base rate x DRG weight,87621,,"31,523 x DRG weight",87621,Other,base rate x DRG weight,78860,,"28,371 x DRG weight",78860,Other,base rate x DRG weight,74479,,"26,795 x DRG weight",74479,Other,base rate x DRG weight,32164,,"3,970.89 x patient days",32164,Per diem,,62438,,"22,463 x DRG weight",62438,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,73454,,"26,426 x DRG weight",73454,Other,base rate x DRG weight,107873,,"38,809 x DRG weight",107873,Other,base rate x DRG weight,107873,,"38,809 x DRG weight",107873,Other,base rate x DRG weight,73454,,"26,426 x DRG weight",73454,Other,base rate x DRG weight,107873,,"38,809 x DRG weight",107873,Other,base rate x DRG weight,51540,,"6,363 x patient days",51540,Per diem,,1447065,70,,1447065,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,69648,,"25,057 x DRG weight",69648,Other,base rate x DRG weight,62686,,"22,552 x DRG weight",62686,Other,base rate x DRG weight,69648,,"25,057 x DRG weight",69648,Other,base rate x DRG weight,59200,,"21,298 x DRG weight",59200,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,1447065,
HIV WITH MAJOR RELATED CONDITION WITH MCC,974,MS-DRG,,,,,,,,inpatient,,,720980.75,62331,,,62331,Other,150% of Medicare + 9.63% HCRA Surcharge,37904,,"3,609.90 x patient days",37904,Per diem,,73047,,"25,046 x DRG weight",73047,Other,base rate x DRG weight,65741,,"22,541 x DRG weight",65741,Other,base rate x DRG weight,91937,,"31,523 x DRG weight",91937,Other,base rate x DRG weight,82744,,"28,371 x DRG weight",82744,Other,base rate x DRG weight,78148,,"26,795 x DRG weight",78148,Other,base rate x DRG weight,41694.4,,"3,970.89 x patient days",41694.4,Per diem,,65513,,"22,463 x DRG weight",65513,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,77071,,"26,426 x DRG weight",77071,Other,base rate x DRG weight,113186,,"38,809 x DRG weight",113186,Other,base rate x DRG weight,113186,,"38,809 x DRG weight",113186,Other,base rate x DRG weight,77071,,"26,426 x DRG weight",77071,Other,base rate x DRG weight,113186,,"38,809 x DRG weight",113186,Other,base rate x DRG weight,66812,,"6,363 x patient days",66812,Per diem,,504687,70,,504687,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,73079,,"25,057 x DRG weight",73079,Other,base rate x DRG weight,65773,,"22,552 x DRG weight",65773,Other,base rate x DRG weight,73079,,"25,057 x DRG weight",73079,Other,base rate x DRG weight,62116,,"21,298 x DRG weight",62116,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,504687,
HIV WITH MAJOR RELATED CONDITION WITH CC,975,MS-DRG,,,,,,,,inpatient,,,197222.56,35023,,,35023,Other,150% of Medicare + 9.63% HCRA Surcharge,21298,,"3,609.90 x patient days",21298,Per diem,,34145,,"25,046 x DRG weight",34145,Other,base rate x DRG weight,30730,,"22,541 x DRG weight",30730,Other,base rate x DRG weight,42975,,"31,523 x DRG weight",42975,Other,base rate x DRG weight,38678,,"28,371 x DRG weight",38678,Other,base rate x DRG weight,36530,,"26,795 x DRG weight",36530,Other,base rate x DRG weight,23427.8,,"3,970.89 x patient days",23427.8,Per diem,,30624,,"22,463 x DRG weight",30624,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,36027,,"26,426 x DRG weight",36027,Other,base rate x DRG weight,52908,,"38,809 x DRG weight",52908,Other,base rate x DRG weight,52908,,"38,809 x DRG weight",52908,Other,base rate x DRG weight,36027,,"26,426 x DRG weight",36027,Other,base rate x DRG weight,52908,,"38,809 x DRG weight",52908,Other,base rate x DRG weight,37542,,"6,363 x patient days",37542,Per diem,,138056,70,,138056,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,34160,,"25,057 x DRG weight",34160,Other,base rate x DRG weight,30745,,"22,552 x DRG weight",30745,Other,base rate x DRG weight,34160,,"25,057 x DRG weight",34160,Other,base rate x DRG weight,29036,,"21,298 x DRG weight",29036,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,138056,
HIV WITH MAJOR RELATED CONDITION WITHOUT CC/MCC,976,MS-DRG,,,,,,,,inpatient,,,122280.7,21371,,,21371,Other,150% of Medicare + 9.63% HCRA Surcharge,12996,,"3,609.90 x patient days",12996,Per diem,,21171,,"25,046 x DRG weight",21171,Other,base rate x DRG weight,19054,,"22,541 x DRG weight",19054,Other,base rate x DRG weight,26646,,"31,523 x DRG weight",26646,Other,base rate x DRG weight,23982,,"28,371 x DRG weight",23982,Other,base rate x DRG weight,22650,,"26,795 x DRG weight",22650,Other,base rate x DRG weight,14295.6,,"3,970.89 x patient days",14295.6,Per diem,,18988,,"22,463 x DRG weight",18988,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,22338,,"26,426 x DRG weight",22338,Other,base rate x DRG weight,32805,,"38,809 x DRG weight",32805,Other,base rate x DRG weight,32805,,"38,809 x DRG weight",32805,Other,base rate x DRG weight,22338,,"26,426 x DRG weight",22338,Other,base rate x DRG weight,32805,,"38,809 x DRG weight",32805,Other,base rate x DRG weight,22907,,"6,363 x patient days",22907,Per diem,,85596,70,,85596,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,21181,,"25,057 x DRG weight",21181,Other,base rate x DRG weight,19063,,"22,552 x DRG weight",19063,Other,base rate x DRG weight,21181,,"25,057 x DRG weight",21181,Other,base rate x DRG weight,18003,,"21,298 x DRG weight",18003,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,85596,
HIV WITH OR WITHOUT OTHER RELATED CONDITION,977,MS-DRG,,,,,,,,inpatient,,,338221.04,36804,,,36804,Other,150% of Medicare + 9.63% HCRA Surcharge,22381,,"3,609.90 x patient days",22381,Per diem,,35468,,"25,046 x DRG weight",35468,Other,base rate x DRG weight,31920,,"22,541 x DRG weight",31920,Other,base rate x DRG weight,44640,,"31,523 x DRG weight",44640,Other,base rate x DRG weight,40176,,"28,371 x DRG weight",40176,Other,base rate x DRG weight,37944,,"26,795 x DRG weight",37944,Other,base rate x DRG weight,24619.1,,"3,970.89 x patient days",24619.1,Per diem,,31810,,"22,463 x DRG weight",31810,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,37422,,"26,426 x DRG weight",37422,Other,base rate x DRG weight,54957,,"38,809 x DRG weight",54957,Other,base rate x DRG weight,54957,,"38,809 x DRG weight",54957,Other,base rate x DRG weight,37422,,"26,426 x DRG weight",37422,Other,base rate x DRG weight,54957,,"38,809 x DRG weight",54957,Other,base rate x DRG weight,39451,,"6,363 x patient days",39451,Per diem,,236755,70,,236755,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,35483,,"25,057 x DRG weight",35483,Other,base rate x DRG weight,31936,,"22,552 x DRG weight",31936,Other,base rate x DRG weight,35483,,"25,057 x DRG weight",35483,Other,base rate x DRG weight,30160,,"21,298 x DRG weight",30160,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,236755,
EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC,981,MS-DRG,,,,,,,,inpatient,,,796330.3,75985,,,75985,Other,150% of Medicare + 9.63% HCRA Surcharge,46207,,"3,609.90 x patient days",46207,Per diem,,118728,,"25,046 x DRG weight",118728,Other,base rate x DRG weight,106853,,"22,541 x DRG weight",106853,Other,base rate x DRG weight,149432,,"31,523 x DRG weight",149432,Other,base rate x DRG weight,134490,,"28,371 x DRG weight",134490,Other,base rate x DRG weight,127019,,"26,795 x DRG weight",127019,Other,base rate x DRG weight,50827.7,,"3,970.89 x patient days",50827.7,Per diem,,106484,,"22,463 x DRG weight",106484,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,125270,,"26,426 x DRG weight",125270,Other,base rate x DRG weight,183970,,"38,809 x DRG weight",183970,Other,base rate x DRG weight,183970,,"38,809 x DRG weight",183970,Other,base rate x DRG weight,125270,,"26,426 x DRG weight",125270,Other,base rate x DRG weight,183970,,"38,809 x DRG weight",183970,Other,base rate x DRG weight,81446,,"6,363 x patient days",81446,Per diem,,557431,70,,557431,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,118780,,"25,057 x DRG weight",118780,Other,base rate x DRG weight,106906,,"22,552 x DRG weight",106906,Other,base rate x DRG weight,118780,,"25,057 x DRG weight",118780,Other,base rate x DRG weight,100961,,"21,298 x DRG weight",100961,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,557431,
EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC,982,MS-DRG,,,,,,,,inpatient,,,273227.72,35023,,,35023,Other,150% of Medicare + 9.63% HCRA Surcharge,21298,,"3,609.90 x patient days",21298,Per diem,,62264,,"25,046 x DRG weight",62264,Other,base rate x DRG weight,56037,,"22,541 x DRG weight",56037,Other,base rate x DRG weight,78366,,"31,523 x DRG weight",78366,Other,base rate x DRG weight,70530,,"28,371 x DRG weight",70530,Other,base rate x DRG weight,66612,,"26,795 x DRG weight",66612,Other,base rate x DRG weight,23427.8,,"3,970.89 x patient days",23427.8,Per diem,,55843,,"22,463 x DRG weight",55843,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,65695,,"26,426 x DRG weight",65695,Other,base rate x DRG weight,96479,,"38,809 x DRG weight",96479,Other,base rate x DRG weight,96479,,"38,809 x DRG weight",96479,Other,base rate x DRG weight,65695,,"26,426 x DRG weight",65695,Other,base rate x DRG weight,96479,,"38,809 x DRG weight",96479,Other,base rate x DRG weight,37542,,"6,363 x patient days",37542,Per diem,,191259,70,,191259,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,62292,,"25,057 x DRG weight",62292,Other,base rate x DRG weight,56064,,"22,552 x DRG weight",56064,Other,base rate x DRG weight,62292,,"25,057 x DRG weight",62292,Other,base rate x DRG weight,52947,,"21,298 x DRG weight",52947,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,191259,
EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITHOUT CC/MCC,983,MS-DRG,,,,,,,,inpatient,,,111288.85,14841,,,14841,Other,150% of Medicare + 9.63% HCRA Surcharge,9025,,"3,609.90 x patient days",9025,Per diem,,40955,,"25,046 x DRG weight",40955,Other,base rate x DRG weight,36859,,"22,541 x DRG weight",36859,Other,base rate x DRG weight,51546,,"31,523 x DRG weight",51546,Other,base rate x DRG weight,46392,,"28,371 x DRG weight",46392,Other,base rate x DRG weight,43815,,"26,795 x DRG weight",43815,Other,base rate x DRG weight,9927.5,,"3,970.89 x patient days",9927.5,Per diem,,36731,,"22,463 x DRG weight",36731,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,43212,,"26,426 x DRG weight",43212,Other,base rate x DRG weight,63460,,"38,809 x DRG weight",63460,Other,base rate x DRG weight,63460,,"38,809 x DRG weight",63460,Other,base rate x DRG weight,43212,,"26,426 x DRG weight",43212,Other,base rate x DRG weight,63460,,"38,809 x DRG weight",63460,Other,base rate x DRG weight,15908,,"6,363 x patient days",15908,Per diem,,77902,70,,77902,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,40973,,"25,057 x DRG weight",40973,Other,base rate x DRG weight,36877,,"22,552 x DRG weight",36877,Other,base rate x DRG weight,40973,,"25,057 x DRG weight",40973,Other,base rate x DRG weight,34826,,"21,298 x DRG weight",34826,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,77902,
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC,987,MS-DRG,,,,,,,,inpatient,,,493854.01,67674,,,67674,Other,150% of Medicare + 9.63% HCRA Surcharge,41153,,"3,609.90 x patient days",41153,Per diem,,84573,,"25,046 x DRG weight",84573,Other,base rate x DRG weight,76114,,"22,541 x DRG weight",76114,Other,base rate x DRG weight,106444,,"31,523 x DRG weight",106444,Other,base rate x DRG weight,95800,,"28,371 x DRG weight",95800,Other,base rate x DRG weight,90479,,"26,795 x DRG weight",90479,Other,base rate x DRG weight,45268.3,,"3,970.89 x patient days",45268.3,Per diem,,75851,,"22,463 x DRG weight",75851,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,89233,,"26,426 x DRG weight",89233,Other,base rate x DRG weight,131046,,"38,809 x DRG weight",131046,Other,base rate x DRG weight,131046,,"38,809 x DRG weight",131046,Other,base rate x DRG weight,89233,,"26,426 x DRG weight",89233,Other,base rate x DRG weight,131046,,"38,809 x DRG weight",131046,Other,base rate x DRG weight,72538,,"6,363 x patient days",72538,Per diem,,345698,70,,345698,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,84610,,"25,057 x DRG weight",84610,Other,base rate x DRG weight,76151,,"22,552 x DRG weight",76151,Other,base rate x DRG weight,84610,,"25,057 x DRG weight",84610,Other,base rate x DRG weight,71917,,"21,298 x DRG weight",71917,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,345698,
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC,988,MS-DRG,,,,,,,,inpatient,,,272581.15,35023,,,35023,Other,150% of Medicare + 9.63% HCRA Surcharge,21298,,"3,609.90 x patient days",21298,Per diem,,42503,,"25,046 x DRG weight",42503,Other,base rate x DRG weight,38252,,"22,541 x DRG weight",38252,Other,base rate x DRG weight,53495,,"31,523 x DRG weight",53495,Other,base rate x DRG weight,48146,,"28,371 x DRG weight",48146,Other,base rate x DRG weight,45471,,"26,795 x DRG weight",45471,Other,base rate x DRG weight,23427.8,,"3,970.89 x patient days",23427.8,Per diem,,38120,,"22,463 x DRG weight",38120,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,44845,,"26,426 x DRG weight",44845,Other,base rate x DRG weight,65859,,"38,809 x DRG weight",65859,Other,base rate x DRG weight,65859,,"38,809 x DRG weight",65859,Other,base rate x DRG weight,44845,,"26,426 x DRG weight",44845,Other,base rate x DRG weight,65859,,"38,809 x DRG weight",65859,Other,base rate x DRG weight,37542,,"6,363 x patient days",37542,Per diem,,190807,70,,190807,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,42522,,"25,057 x DRG weight",42522,Other,base rate x DRG weight,38271,,"22,552 x DRG weight",38271,Other,base rate x DRG weight,42522,,"25,057 x DRG weight",42522,Other,base rate x DRG weight,36143,,"21,298 x DRG weight",36143,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,190807,
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITHOUT CC/MCC,989,MS-DRG,,,,,,,,inpatient,,,110395.47,17809,,,17809,Other,150% of Medicare + 9.63% HCRA Surcharge,10830,,"3,609.90 x patient days",10830,Per diem,,27057,,"25,046 x DRG weight",27057,Other,base rate x DRG weight,24351,,"22,541 x DRG weight",24351,Other,base rate x DRG weight,34054,,"31,523 x DRG weight",34054,Other,base rate x DRG weight,30649,,"28,371 x DRG weight",30649,Other,base rate x DRG weight,28947,,"26,795 x DRG weight",28947,Other,base rate x DRG weight,11913,,"3,970.89 x patient days",11913,Per diem,,24267,,"22,463 x DRG weight",24267,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,28548,,"26,426 x DRG weight",28548,Other,base rate x DRG weight,41925,,"38,809 x DRG weight",41925,Other,base rate x DRG weight,41925,,"38,809 x DRG weight",41925,Other,base rate x DRG weight,28548,,"26,426 x DRG weight",28548,Other,base rate x DRG weight,41925,,"38,809 x DRG weight",41925,Other,base rate x DRG weight,19089,,"6,363 x patient days",19089,Per diem,,77277,70,,77277,percent of total billed charges,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,27069,,"25,057 x DRG weight",27069,Other,base rate x DRG weight,24363,,"22,552 x DRG weight",24363,Other,base rate x DRG weight,27069,,"25,057 x DRG weight",27069,Other,base rate x DRG weight,23008,,"21,298 x DRG weight",23008,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,77277,
Tracheostomy w MV 96+ hours w extensive procedure or ECMO,004-1,APR-DRG,,,,,,,,inpatient,,,578945.06,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,190109,,"4,044.85 x patient days",190109,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,198650,,"27,634 x DRG weight",198650,Other,base rate x DRG weight,168846,,"23,488 x DRG weight",168846,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,102209,,"2,174.65 x patient days",102209,Per diem,,102209,,"2,174.65 x patient days",102209,Per diem,,102209,,"2,174.65 x patient days",102209,Per diem,,102209,,"2,174.65 x patient days",102209,Per diem,,229970,,"4,892.96 x patient days",229970,Per diem,,156380,,"3,327.21 x patient days",156380,Per diem,,229970,,"4,892.96 x patient days",229970,Per diem,,143093,,"3,044.51 x patient days",143093,Per diem,,229970,,"4,892.96 x patient days",229970,Per diem,,281075,,"5,980.29 x patient days",281075,Per diem,,331157,,"7,045.87 x patient days",331157,Per diem,,219749,,"4,675.50 x patient days",219749,Per diem,,219749,,"4,675.50 x patient days",219749,Per diem,,127761,,"2,718.31 x patient days",127761,Per diem,,0.01,331157,
Tracheostomy w MV 96+ hours w extensive procedure or ECMO,004-2,APR-DRG,,,,,,,,inpatient,,,578945.06,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,190109,,"4,044.85 x patient days",190109,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,198650,,"27,634 x DRG weight",198650,Other,base rate x DRG weight,168846,,"23,488 x DRG weight",168846,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,102209,,"2,174.65 x patient days",102209,Per diem,,102209,,"2,174.65 x patient days",102209,Per diem,,102209,,"2,174.65 x patient days",102209,Per diem,,102209,,"2,174.65 x patient days",102209,Per diem,,229970,,"4,892.96 x patient days",229970,Per diem,,156380,,"3,327.21 x patient days",156380,Per diem,,229970,,"4,892.96 x patient days",229970,Per diem,,143093,,"3,044.51 x patient days",143093,Per diem,,229970,,"4,892.96 x patient days",229970,Per diem,,281075,,"5,980.29 x patient days",281075,Per diem,,331157,,"7,045.87 x patient days",331157,Per diem,,219749,,"4,675.50 x patient days",219749,Per diem,,219749,,"4,675.50 x patient days",219749,Per diem,,127761,,"2,718.31 x patient days",127761,Per diem,,0.01,331157,
Tracheostomy w MV 96+ hours w extensive procedure or ECMO,004-3,APR-DRG,,,,,,,,inpatient,,,1276065.57,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,190109,,"4,044.85 x patient days",190109,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,278291,,"27,634 x DRG weight",278291,Other,base rate x DRG weight,236538,,"23,488 x DRG weight",236538,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,102209,,"2,174.65 x patient days",102209,Per diem,,102209,,"2,174.65 x patient days",102209,Per diem,,102209,,"2,174.65 x patient days",102209,Per diem,,102209,,"2,174.65 x patient days",102209,Per diem,,229970,,"4,892.96 x patient days",229970,Per diem,,156380,,"3,327.21 x patient days",156380,Per diem,,229970,,"4,892.96 x patient days",229970,Per diem,,143093,,"3,044.51 x patient days",143093,Per diem,,229970,,"4,892.96 x patient days",229970,Per diem,,281075,,"5,980.29 x patient days",281075,Per diem,,331157,,"7,045.87 x patient days",331157,Per diem,,219749,,"4,675.50 x patient days",219749,Per diem,,219749,,"4,675.50 x patient days",219749,Per diem,,127761,,"2,718.31 x patient days",127761,Per diem,,0.01,331157,
Tracheostomy w MV 96+ hours w extensive procedure or ECMO,004-4,APR-DRG,,,,,,,,inpatient,,,2232524.79,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,190109,,"4,044.85 x patient days",190109,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,499404,,"27,634 x DRG weight",499404,Other,base rate x DRG weight,424477,,"23,488 x DRG weight",424477,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,102209,,"2,174.65 x patient days",102209,Per diem,,102209,,"2,174.65 x patient days",102209,Per diem,,102209,,"2,174.65 x patient days",102209,Per diem,,102209,,"2,174.65 x patient days",102209,Per diem,,229970,,"4,892.96 x patient days",229970,Per diem,,156380,,"3,327.21 x patient days",156380,Per diem,,229970,,"4,892.96 x patient days",229970,Per diem,,143093,,"3,044.51 x patient days",143093,Per diem,,229970,,"4,892.96 x patient days",229970,Per diem,,281075,,"5,980.29 x patient days",281075,Per diem,,331157,,"7,045.87 x patient days",331157,Per diem,,219749,,"4,675.50 x patient days",219749,Per diem,,219749,,"4,675.50 x patient days",219749,Per diem,,127761,,"2,718.31 x patient days",127761,Per diem,,0.01,499404,
Tracheostomy w MV 96+ hours w/o extensive procedure,005-1,APR-DRG,,,,,,,,inpatient,,,843405.03,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,177974,,"4,044.85 x patient days",177974,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,157406,,"27,634 x DRG weight",157406,Other,base rate x DRG weight,133790,,"23,488 x DRG weight",133790,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,95685,,"2,174.65 x patient days",95685,Per diem,,95685,,"2,174.65 x patient days",95685,Per diem,,95685,,"2,174.65 x patient days",95685,Per diem,,95685,,"2,174.65 x patient days",95685,Per diem,,215291,,"4,892.96 x patient days",215291,Per diem,,146398,,"3,327.21 x patient days",146398,Per diem,,215291,,"4,892.96 x patient days",215291,Per diem,,133959,,"3,044.51 x patient days",133959,Per diem,,215291,,"4,892.96 x patient days",215291,Per diem,,263134,,"5,980.29 x patient days",263134,Per diem,,310019,,"7,045.87 x patient days",310019,Per diem,,205723,,"4,675.50 x patient days",205723,Per diem,,205723,,"4,675.50 x patient days",205723,Per diem,,119606,,"2,718.31 x patient days",119606,Per diem,,0.01,310019,
Tracheostomy w MV 96+ hours w/o extensive procedure,005-2,APR-DRG,,,,,,,,inpatient,,,843405.03,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,177974,,"4,044.85 x patient days",177974,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,161482,,"27,634 x DRG weight",161482,Other,base rate x DRG weight,137254,,"23,488 x DRG weight",137254,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,95685,,"2,174.65 x patient days",95685,Per diem,,95685,,"2,174.65 x patient days",95685,Per diem,,95685,,"2,174.65 x patient days",95685,Per diem,,95685,,"2,174.65 x patient days",95685,Per diem,,215291,,"4,892.96 x patient days",215291,Per diem,,146398,,"3,327.21 x patient days",146398,Per diem,,215291,,"4,892.96 x patient days",215291,Per diem,,133959,,"3,044.51 x patient days",133959,Per diem,,215291,,"4,892.96 x patient days",215291,Per diem,,263134,,"5,980.29 x patient days",263134,Per diem,,310019,,"7,045.87 x patient days",310019,Per diem,,205723,,"4,675.50 x patient days",205723,Per diem,,205723,,"4,675.50 x patient days",205723,Per diem,,119606,,"2,718.31 x patient days",119606,Per diem,,0.01,310019,
Tracheostomy w MV 96+ hours w/o extensive procedure,005-3,APR-DRG,,,,,,,,inpatient,,,1220871.77,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,177974,,"4,044.85 x patient days",177974,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,255136,,"27,634 x DRG weight",255136,Other,base rate x DRG weight,216858,,"23,488 x DRG weight",216858,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,95685,,"2,174.65 x patient days",95685,Per diem,,95685,,"2,174.65 x patient days",95685,Per diem,,95685,,"2,174.65 x patient days",95685,Per diem,,95685,,"2,174.65 x patient days",95685,Per diem,,215291,,"4,892.96 x patient days",215291,Per diem,,146398,,"3,327.21 x patient days",146398,Per diem,,215291,,"4,892.96 x patient days",215291,Per diem,,133959,,"3,044.51 x patient days",133959,Per diem,,215291,,"4,892.96 x patient days",215291,Per diem,,263134,,"5,980.29 x patient days",263134,Per diem,,310019,,"7,045.87 x patient days",310019,Per diem,,205723,,"4,675.50 x patient days",205723,Per diem,,205723,,"4,675.50 x patient days",205723,Per diem,,119606,,"2,718.31 x patient days",119606,Per diem,,0.01,310019,
Tracheostomy w MV 96+ hours w/o extensive procedure,005-4,APR-DRG,,,,,,,,inpatient,,,1735098.49,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,177974,,"4,044.85 x patient days",177974,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,381059,,"27,634 x DRG weight",381059,Other,base rate x DRG weight,323888,,"23,488 x DRG weight",323888,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,95685,,"2,174.65 x patient days",95685,Per diem,,95685,,"2,174.65 x patient days",95685,Per diem,,95685,,"2,174.65 x patient days",95685,Per diem,,95685,,"2,174.65 x patient days",95685,Per diem,,215291,,"4,892.96 x patient days",215291,Per diem,,146398,,"3,327.21 x patient days",146398,Per diem,,215291,,"4,892.96 x patient days",215291,Per diem,,133959,,"3,044.51 x patient days",133959,Per diem,,215291,,"4,892.96 x patient days",215291,Per diem,,263134,,"5,980.29 x patient days",263134,Per diem,,310019,,"7,045.87 x patient days",310019,Per diem,,205723,,"4,675.50 x patient days",205723,Per diem,,205723,,"4,675.50 x patient days",205723,Per diem,,119606,,"2,718.31 x patient days",119606,Per diem,,0.01,381059,
Craniotomy for trauma,020-1,APR-DRG,,,,,,,,inpatient,,,172052.26,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,36404,,"4,044.85 x patient days",36404,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,49343,,"27,634 x DRG weight",49343,Other,base rate x DRG weight,41940,,"23,488 x DRG weight",41940,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,19572,,"2,174.65 x patient days",19572,Per diem,,19572,,"2,174.65 x patient days",19572,Per diem,,19572,,"2,174.65 x patient days",19572,Per diem,,19572,,"2,174.65 x patient days",19572,Per diem,,44037,,"4,892.96 x patient days",44037,Per diem,,29945,,"3,327.21 x patient days",29945,Per diem,,44037,,"4,892.96 x patient days",44037,Per diem,,27401,,"3,044.51 x patient days",27401,Per diem,,44037,,"4,892.96 x patient days",44037,Per diem,,53823,,"5,980.29 x patient days",53823,Per diem,,63413,,"7,045.87 x patient days",63413,Per diem,,42080,,"4,675.50 x patient days",42080,Per diem,,42080,,"4,675.50 x patient days",42080,Per diem,,24465,,"2,718.31 x patient days",24465,Per diem,,0.01,63413,
Craniotomy for trauma,020-2,APR-DRG,,,,,,,,inpatient,,,193932.31,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,36404,,"4,044.85 x patient days",36404,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,62326,,"27,634 x DRG weight",62326,Other,base rate x DRG weight,52975,,"23,488 x DRG weight",52975,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,19572,,"2,174.65 x patient days",19572,Per diem,,19572,,"2,174.65 x patient days",19572,Per diem,,19572,,"2,174.65 x patient days",19572,Per diem,,19572,,"2,174.65 x patient days",19572,Per diem,,44037,,"4,892.96 x patient days",44037,Per diem,,29945,,"3,327.21 x patient days",29945,Per diem,,44037,,"4,892.96 x patient days",44037,Per diem,,27401,,"3,044.51 x patient days",27401,Per diem,,44037,,"4,892.96 x patient days",44037,Per diem,,53823,,"5,980.29 x patient days",53823,Per diem,,63413,,"7,045.87 x patient days",63413,Per diem,,42080,,"4,675.50 x patient days",42080,Per diem,,42080,,"4,675.50 x patient days",42080,Per diem,,24465,,"2,718.31 x patient days",24465,Per diem,,0.01,63413,
Craniotomy for trauma,020-3,APR-DRG,,,,,,,,inpatient,,,496264.4,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,36404,,"4,044.85 x patient days",36404,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,97891,,"27,634 x DRG weight",97891,Other,base rate x DRG weight,83204,,"23,488 x DRG weight",83204,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,19572,,"2,174.65 x patient days",19572,Per diem,,19572,,"2,174.65 x patient days",19572,Per diem,,19572,,"2,174.65 x patient days",19572,Per diem,,19572,,"2,174.65 x patient days",19572,Per diem,,44037,,"4,892.96 x patient days",44037,Per diem,,29945,,"3,327.21 x patient days",29945,Per diem,,44037,,"4,892.96 x patient days",44037,Per diem,,27401,,"3,044.51 x patient days",27401,Per diem,,44037,,"4,892.96 x patient days",44037,Per diem,,53823,,"5,980.29 x patient days",53823,Per diem,,63413,,"7,045.87 x patient days",63413,Per diem,,42080,,"4,675.50 x patient days",42080,Per diem,,42080,,"4,675.50 x patient days",42080,Per diem,,24465,,"2,718.31 x patient days",24465,Per diem,,0.01,97891,
Craniotomy for trauma,020-4,APR-DRG,,,,,,,,inpatient,,,914478.38,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,36404,,"4,044.85 x patient days",36404,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,184871,,"27,634 x DRG weight",184871,Other,base rate x DRG weight,157135,,"23,488 x DRG weight",157135,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,19572,,"2,174.65 x patient days",19572,Per diem,,19572,,"2,174.65 x patient days",19572,Per diem,,19572,,"2,174.65 x patient days",19572,Per diem,,19572,,"2,174.65 x patient days",19572,Per diem,,44037,,"4,892.96 x patient days",44037,Per diem,,29945,,"3,327.21 x patient days",29945,Per diem,,44037,,"4,892.96 x patient days",44037,Per diem,,27401,,"3,044.51 x patient days",27401,Per diem,,44037,,"4,892.96 x patient days",44037,Per diem,,53823,,"5,980.29 x patient days",53823,Per diem,,63413,,"7,045.87 x patient days",63413,Per diem,,42080,,"4,675.50 x patient days",42080,Per diem,,42080,,"4,675.50 x patient days",42080,Per diem,,24465,,"2,718.31 x patient days",24465,Per diem,,0.01,184871,
Craniotomy except for trauma,021-1,APR-DRG,,,,,,,,inpatient,,,289033.37,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,32358,,"4,044.85 x patient days",32358,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,52342,,"27,634 x DRG weight",52342,Other,base rate x DRG weight,44489,,"23,488 x DRG weight",44489,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,17397,,"2,174.65 x patient days",17397,Per diem,,17397,,"2,174.65 x patient days",17397,Per diem,,17397,,"2,174.65 x patient days",17397,Per diem,,17397,,"2,174.65 x patient days",17397,Per diem,,39143,,"4,892.96 x patient days",39143,Per diem,,26617,,"3,327.21 x patient days",26617,Per diem,,39143,,"4,892.96 x patient days",39143,Per diem,,24356,,"3,044.51 x patient days",24356,Per diem,,39143,,"4,892.96 x patient days",39143,Per diem,,47842,,"5,980.29 x patient days",47842,Per diem,,56366,,"7,045.87 x patient days",56366,Per diem,,37404,,"4,675.50 x patient days",37404,Per diem,,37404,,"4,675.50 x patient days",37404,Per diem,,21746,,"2,718.31 x patient days",21746,Per diem,,0.01,56366,
Craniotomy except for trauma,021-2,APR-DRG,,,,,,,,inpatient,,,292310.31,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,32358,,"4,044.85 x patient days",32358,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,73982,,"27,634 x DRG weight",73982,Other,base rate x DRG weight,62882,,"23,488 x DRG weight",62882,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,17397,,"2,174.65 x patient days",17397,Per diem,,17397,,"2,174.65 x patient days",17397,Per diem,,17397,,"2,174.65 x patient days",17397,Per diem,,17397,,"2,174.65 x patient days",17397,Per diem,,39143,,"4,892.96 x patient days",39143,Per diem,,26617,,"3,327.21 x patient days",26617,Per diem,,39143,,"4,892.96 x patient days",39143,Per diem,,24356,,"3,044.51 x patient days",24356,Per diem,,39143,,"4,892.96 x patient days",39143,Per diem,,47842,,"5,980.29 x patient days",47842,Per diem,,56366,,"7,045.87 x patient days",56366,Per diem,,37404,,"4,675.50 x patient days",37404,Per diem,,37404,,"4,675.50 x patient days",37404,Per diem,,21746,,"2,718.31 x patient days",21746,Per diem,,0.01,73982,
Craniotomy except for trauma,021-3,APR-DRG,,,,,,,,inpatient,,,429083.55,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,32358,,"4,044.85 x patient days",32358,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,119708,,"27,634 x DRG weight",119708,Other,base rate x DRG weight,101748,,"23,488 x DRG weight",101748,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,17397,,"2,174.65 x patient days",17397,Per diem,,17397,,"2,174.65 x patient days",17397,Per diem,,17397,,"2,174.65 x patient days",17397,Per diem,,17397,,"2,174.65 x patient days",17397,Per diem,,39143,,"4,892.96 x patient days",39143,Per diem,,26617,,"3,327.21 x patient days",26617,Per diem,,39143,,"4,892.96 x patient days",39143,Per diem,,24356,,"3,044.51 x patient days",24356,Per diem,,39143,,"4,892.96 x patient days",39143,Per diem,,47842,,"5,980.29 x patient days",47842,Per diem,,56366,,"7,045.87 x patient days",56366,Per diem,,37404,,"4,675.50 x patient days",37404,Per diem,,37404,,"4,675.50 x patient days",37404,Per diem,,21746,,"2,718.31 x patient days",21746,Per diem,,0.01,119708,
Craniotomy except for trauma,021-4,APR-DRG,,,,,,,,inpatient,,,747089.04,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,32358,,"4,044.85 x patient days",32358,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,200109,,"27,634 x DRG weight",200109,Other,base rate x DRG weight,170086,,"23,488 x DRG weight",170086,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,17397,,"2,174.65 x patient days",17397,Per diem,,17397,,"2,174.65 x patient days",17397,Per diem,,17397,,"2,174.65 x patient days",17397,Per diem,,17397,,"2,174.65 x patient days",17397,Per diem,,39143,,"4,892.96 x patient days",39143,Per diem,,26617,,"3,327.21 x patient days",26617,Per diem,,39143,,"4,892.96 x patient days",39143,Per diem,,24356,,"3,044.51 x patient days",24356,Per diem,,39143,,"4,892.96 x patient days",39143,Per diem,,47842,,"5,980.29 x patient days",47842,Per diem,,56366,,"7,045.87 x patient days",56366,Per diem,,37404,,"4,675.50 x patient days",37404,Per diem,,37404,,"4,675.50 x patient days",37404,Per diem,,21746,,"2,718.31 x patient days",21746,Per diem,,0.01,200109,
Ventricular shunt procedures,022-1,APR-DRG,,,,,,,,inpatient,,,202387.4,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,20224,,"4,044.85 x patient days",20224,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,35228,,"27,634 x DRG weight",35228,Other,base rate x DRG weight,29943,,"23,488 x DRG weight",29943,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,16636,,"3,327.21 x patient days",16636,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,15222,,"3,044.51 x patient days",15222,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,29901,,"5,980.29 x patient days",29901,Per diem,,35229,,"7,045.87 x patient days",35229,Per diem,,23377,,"4,675.50 x patient days",23377,Per diem,,23377,,"4,675.50 x patient days",23377,Per diem,,13591,,"2,718.31 x patient days",13591,Per diem,,0.01,35229,
Ventricular shunt procedures,022-2,APR-DRG,,,,,,,,inpatient,,,268233.96,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,20224,,"4,044.85 x patient days",20224,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,45043,,"27,634 x DRG weight",45043,Other,base rate x DRG weight,38285,,"23,488 x DRG weight",38285,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,16636,,"3,327.21 x patient days",16636,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,15222,,"3,044.51 x patient days",15222,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,29901,,"5,980.29 x patient days",29901,Per diem,,35229,,"7,045.87 x patient days",35229,Per diem,,23377,,"4,675.50 x patient days",23377,Per diem,,23377,,"4,675.50 x patient days",23377,Per diem,,13591,,"2,718.31 x patient days",13591,Per diem,,0.01,45043,
Ventricular shunt procedures,022-3,APR-DRG,,,,,,,,inpatient,,,234390.75,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,20224,,"4,044.85 x patient days",20224,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,73838,,"27,634 x DRG weight",73838,Other,base rate x DRG weight,62760,,"23,488 x DRG weight",62760,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,16636,,"3,327.21 x patient days",16636,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,15222,,"3,044.51 x patient days",15222,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,29901,,"5,980.29 x patient days",29901,Per diem,,35229,,"7,045.87 x patient days",35229,Per diem,,23377,,"4,675.50 x patient days",23377,Per diem,,23377,,"4,675.50 x patient days",23377,Per diem,,13591,,"2,718.31 x patient days",13591,Per diem,,0.01,73838,
Ventricular shunt procedures,022-4,APR-DRG,,,,,,,,inpatient,,,1031318.43,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,20224,,"4,044.85 x patient days",20224,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,148878,,"27,634 x DRG weight",148878,Other,base rate x DRG weight,126542,,"23,488 x DRG weight",126542,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,16636,,"3,327.21 x patient days",16636,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,15222,,"3,044.51 x patient days",15222,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,29901,,"5,980.29 x patient days",29901,Per diem,,35229,,"7,045.87 x patient days",35229,Per diem,,23377,,"4,675.50 x patient days",23377,Per diem,,23377,,"4,675.50 x patient days",23377,Per diem,,13591,,"2,718.31 x patient days",13591,Per diem,,0.01,148878,
Spinal procedures,023-1,APR-DRG,,,,,,,,inpatient,,,164749.12,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,24269,,"4,044.85 x patient days",24269,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,45347,,"27,634 x DRG weight",45347,Other,base rate x DRG weight,38544,,"23,488 x DRG weight",38544,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,13048,,"2,174.65 x patient days",13048,Per diem,,13048,,"2,174.65 x patient days",13048,Per diem,,13048,,"2,174.65 x patient days",13048,Per diem,,13048,,"2,174.65 x patient days",13048,Per diem,,29358,,"4,892.96 x patient days",29358,Per diem,,19963,,"3,327.21 x patient days",19963,Per diem,,29358,,"4,892.96 x patient days",29358,Per diem,,18267,,"3,044.51 x patient days",18267,Per diem,,29358,,"4,892.96 x patient days",29358,Per diem,,35882,,"5,980.29 x patient days",35882,Per diem,,42276,,"7,045.87 x patient days",42276,Per diem,,28053,,"4,675.50 x patient days",28053,Per diem,,28053,,"4,675.50 x patient days",28053,Per diem,,16310,,"2,718.31 x patient days",16310,Per diem,,0.01,45347,
Spinal procedures,023-2,APR-DRG,,,,,,,,inpatient,,,294874.08,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,24269,,"4,044.85 x patient days",24269,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,60961,,"27,634 x DRG weight",60961,Other,base rate x DRG weight,51815,,"23,488 x DRG weight",51815,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,13048,,"2,174.65 x patient days",13048,Per diem,,13048,,"2,174.65 x patient days",13048,Per diem,,13048,,"2,174.65 x patient days",13048,Per diem,,13048,,"2,174.65 x patient days",13048,Per diem,,29358,,"4,892.96 x patient days",29358,Per diem,,19963,,"3,327.21 x patient days",19963,Per diem,,29358,,"4,892.96 x patient days",29358,Per diem,,18267,,"3,044.51 x patient days",18267,Per diem,,29358,,"4,892.96 x patient days",29358,Per diem,,35882,,"5,980.29 x patient days",35882,Per diem,,42276,,"7,045.87 x patient days",42276,Per diem,,28053,,"4,675.50 x patient days",28053,Per diem,,28053,,"4,675.50 x patient days",28053,Per diem,,16310,,"2,718.31 x patient days",16310,Per diem,,0.01,60961,
Spinal procedures,023-3,APR-DRG,,,,,,,,inpatient,,,550176.99,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,24269,,"4,044.85 x patient days",24269,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,118727,,"27,634 x DRG weight",118727,Other,base rate x DRG weight,100914,,"23,488 x DRG weight",100914,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,13048,,"2,174.65 x patient days",13048,Per diem,,13048,,"2,174.65 x patient days",13048,Per diem,,13048,,"2,174.65 x patient days",13048,Per diem,,13048,,"2,174.65 x patient days",13048,Per diem,,29358,,"4,892.96 x patient days",29358,Per diem,,19963,,"3,327.21 x patient days",19963,Per diem,,29358,,"4,892.96 x patient days",29358,Per diem,,18267,,"3,044.51 x patient days",18267,Per diem,,29358,,"4,892.96 x patient days",29358,Per diem,,35882,,"5,980.29 x patient days",35882,Per diem,,42276,,"7,045.87 x patient days",42276,Per diem,,28053,,"4,675.50 x patient days",28053,Per diem,,28053,,"4,675.50 x patient days",28053,Per diem,,16310,,"2,718.31 x patient days",16310,Per diem,,0.01,118727,
Spinal procedures,023-4,APR-DRG,,,,,,,,inpatient,,,309827.1,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,24269,,"4,044.85 x patient days",24269,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,223341,,"27,634 x DRG weight",223341,Other,base rate x DRG weight,189832,,"23,488 x DRG weight",189832,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,13048,,"2,174.65 x patient days",13048,Per diem,,13048,,"2,174.65 x patient days",13048,Per diem,,13048,,"2,174.65 x patient days",13048,Per diem,,13048,,"2,174.65 x patient days",13048,Per diem,,29358,,"4,892.96 x patient days",29358,Per diem,,19963,,"3,327.21 x patient days",19963,Per diem,,29358,,"4,892.96 x patient days",29358,Per diem,,18267,,"3,044.51 x patient days",18267,Per diem,,29358,,"4,892.96 x patient days",29358,Per diem,,35882,,"5,980.29 x patient days",35882,Per diem,,42276,,"7,045.87 x patient days",42276,Per diem,,28053,,"4,675.50 x patient days",28053,Per diem,,28053,,"4,675.50 x patient days",28053,Per diem,,16310,,"2,718.31 x patient days",16310,Per diem,,0.01,223341,
Extracranial vascular procedures,024-1,APR-DRG,,,,,,,,inpatient,,,162208.3,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,16180,,"4,044.85 x patient days",16180,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,41498,,"27,634 x DRG weight",41498,Other,base rate x DRG weight,35272,,"23,488 x DRG weight",35272,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,13309,,"3,327.21 x patient days",13309,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,12179,,"3,044.51 x patient days",12179,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,23922,,"5,980.29 x patient days",23922,Per diem,,28185,,"7,045.87 x patient days",28185,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,10874,,"2,718.31 x patient days",10874,Per diem,,0.01,41498,
Extracranial vascular procedures,024-2,APR-DRG,,,,,,,,inpatient,,,330447.13,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,16180,,"4,044.85 x patient days",16180,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,58874,,"27,634 x DRG weight",58874,Other,base rate x DRG weight,50041,,"23,488 x DRG weight",50041,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,13309,,"3,327.21 x patient days",13309,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,12179,,"3,044.51 x patient days",12179,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,23922,,"5,980.29 x patient days",23922,Per diem,,28185,,"7,045.87 x patient days",28185,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,10874,,"2,718.31 x patient days",10874,Per diem,,0.01,58874,
Extracranial vascular procedures,024-3,APR-DRG,,,,,,,,inpatient,,,524773.59,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,16180,,"4,044.85 x patient days",16180,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,101978,,"27,634 x DRG weight",101978,Other,base rate x DRG weight,86678,,"23,488 x DRG weight",86678,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,13309,,"3,327.21 x patient days",13309,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,12179,,"3,044.51 x patient days",12179,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,23922,,"5,980.29 x patient days",23922,Per diem,,28185,,"7,045.87 x patient days",28185,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,10874,,"2,718.31 x patient days",10874,Per diem,,0.01,101978,
Extracranial vascular procedures,024-4,APR-DRG,,,,,,,,inpatient,,,516288.78,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,16180,,"4,044.85 x patient days",16180,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,187734,,"27,634 x DRG weight",187734,Other,base rate x DRG weight,159568,,"23,488 x DRG weight",159568,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,13309,,"3,327.21 x patient days",13309,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,12179,,"3,044.51 x patient days",12179,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,23922,,"5,980.29 x patient days",23922,Per diem,,28185,,"7,045.87 x patient days",28185,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,10874,,"2,718.31 x patient days",10874,Per diem,,0.01,187734,
Other nervous system & related procedures,026-1,APR-DRG,,,,,,,,inpatient,,,159967.32,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,20224,,"4,044.85 x patient days",20224,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,33899,,"27,634 x DRG weight",33899,Other,base rate x DRG weight,28813,,"23,488 x DRG weight",28813,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,16636,,"3,327.21 x patient days",16636,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,15222,,"3,044.51 x patient days",15222,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,29901,,"5,980.29 x patient days",29901,Per diem,,35229,,"7,045.87 x patient days",35229,Per diem,,23377,,"4,675.50 x patient days",23377,Per diem,,23377,,"4,675.50 x patient days",23377,Per diem,,13591,,"2,718.31 x patient days",13591,Per diem,,0.01,35229,
Other nervous system & related procedures,026-2,APR-DRG,,,,,,,,inpatient,,,273933.25,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,20224,,"4,044.85 x patient days",20224,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,49631,,"27,634 x DRG weight",49631,Other,base rate x DRG weight,42184,,"23,488 x DRG weight",42184,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,16636,,"3,327.21 x patient days",16636,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,15222,,"3,044.51 x patient days",15222,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,29901,,"5,980.29 x patient days",29901,Per diem,,35229,,"7,045.87 x patient days",35229,Per diem,,23377,,"4,675.50 x patient days",23377,Per diem,,23377,,"4,675.50 x patient days",23377,Per diem,,13591,,"2,718.31 x patient days",13591,Per diem,,0.01,49631,
Other nervous system & related procedures,026-3,APR-DRG,,,,,,,,inpatient,,,252795.91,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,20224,,"4,044.85 x patient days",20224,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,73739,,"27,634 x DRG weight",73739,Other,base rate x DRG weight,62675,,"23,488 x DRG weight",62675,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,16636,,"3,327.21 x patient days",16636,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,15222,,"3,044.51 x patient days",15222,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,29901,,"5,980.29 x patient days",29901,Per diem,,35229,,"7,045.87 x patient days",35229,Per diem,,23377,,"4,675.50 x patient days",23377,Per diem,,23377,,"4,675.50 x patient days",23377,Per diem,,13591,,"2,718.31 x patient days",13591,Per diem,,0.01,73739,
Other nervous system & related procedures,026-4,APR-DRG,,,,,,,,inpatient,,,1599828.5,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,20224,,"4,044.85 x patient days",20224,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,173428,,"27,634 x DRG weight",173428,Other,base rate x DRG weight,147408,,"23,488 x DRG weight",147408,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,16636,,"3,327.21 x patient days",16636,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,15222,,"3,044.51 x patient days",15222,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,29901,,"5,980.29 x patient days",29901,Per diem,,35229,,"7,045.87 x patient days",35229,Per diem,,23377,,"4,675.50 x patient days",23377,Per diem,,23377,,"4,675.50 x patient days",23377,Per diem,,13591,,"2,718.31 x patient days",13591,Per diem,,0.01,173428,
Spinal disorders & injuries,040-1,APR-DRG,,,,,,,,inpatient,,,87432.5,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,24269,,"4,044.85 x patient days",24269,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,22547,,"27,634 x DRG weight",22547,Other,base rate x DRG weight,19164,,"23,488 x DRG weight",19164,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,13048,,"2,174.65 x patient days",13048,Per diem,,13048,,"2,174.65 x patient days",13048,Per diem,,13048,,"2,174.65 x patient days",13048,Per diem,,13048,,"2,174.65 x patient days",13048,Per diem,,29358,,"4,892.96 x patient days",29358,Per diem,,19963,,"3,327.21 x patient days",19963,Per diem,,29358,,"4,892.96 x patient days",29358,Per diem,,18267,,"3,044.51 x patient days",18267,Per diem,,29358,,"4,892.96 x patient days",29358,Per diem,,35882,,"5,980.29 x patient days",35882,Per diem,,42276,,"7,045.87 x patient days",42276,Per diem,,28053,,"4,675.50 x patient days",28053,Per diem,,28053,,"4,675.50 x patient days",28053,Per diem,,16310,,"2,718.31 x patient days",16310,Per diem,,0.01,42276,
Spinal disorders & injuries,040-2,APR-DRG,,,,,,,,inpatient,,,153585.67,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,24269,,"4,044.85 x patient days",24269,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,35490,,"27,634 x DRG weight",35490,Other,base rate x DRG weight,30166,,"23,488 x DRG weight",30166,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,13048,,"2,174.65 x patient days",13048,Per diem,,13048,,"2,174.65 x patient days",13048,Per diem,,13048,,"2,174.65 x patient days",13048,Per diem,,13048,,"2,174.65 x patient days",13048,Per diem,,29358,,"4,892.96 x patient days",29358,Per diem,,19963,,"3,327.21 x patient days",19963,Per diem,,29358,,"4,892.96 x patient days",29358,Per diem,,18267,,"3,044.51 x patient days",18267,Per diem,,29358,,"4,892.96 x patient days",29358,Per diem,,35882,,"5,980.29 x patient days",35882,Per diem,,42276,,"7,045.87 x patient days",42276,Per diem,,28053,,"4,675.50 x patient days",28053,Per diem,,28053,,"4,675.50 x patient days",28053,Per diem,,16310,,"2,718.31 x patient days",16310,Per diem,,0.01,42276,
Spinal disorders & injuries,040-3,APR-DRG,,,,,,,,inpatient,,,350638.29,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,24269,,"4,044.85 x patient days",24269,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,63461,,"27,634 x DRG weight",63461,Other,base rate x DRG weight,53940,,"23,488 x DRG weight",53940,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,13048,,"2,174.65 x patient days",13048,Per diem,,13048,,"2,174.65 x patient days",13048,Per diem,,13048,,"2,174.65 x patient days",13048,Per diem,,13048,,"2,174.65 x patient days",13048,Per diem,,29358,,"4,892.96 x patient days",29358,Per diem,,19963,,"3,327.21 x patient days",19963,Per diem,,29358,,"4,892.96 x patient days",29358,Per diem,,18267,,"3,044.51 x patient days",18267,Per diem,,29358,,"4,892.96 x patient days",29358,Per diem,,35882,,"5,980.29 x patient days",35882,Per diem,,42276,,"7,045.87 x patient days",42276,Per diem,,28053,,"4,675.50 x patient days",28053,Per diem,,28053,,"4,675.50 x patient days",28053,Per diem,,16310,,"2,718.31 x patient days",16310,Per diem,,0.01,63461,
Spinal disorders & injuries,040-4,APR-DRG,,,,,,,,inpatient,,,350638.29,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,24269,,"4,044.85 x patient days",24269,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,75054,,"27,634 x DRG weight",75054,Other,base rate x DRG weight,63793,,"23,488 x DRG weight",63793,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,13048,,"2,174.65 x patient days",13048,Per diem,,13048,,"2,174.65 x patient days",13048,Per diem,,13048,,"2,174.65 x patient days",13048,Per diem,,13048,,"2,174.65 x patient days",13048,Per diem,,29358,,"4,892.96 x patient days",29358,Per diem,,19963,,"3,327.21 x patient days",19963,Per diem,,29358,,"4,892.96 x patient days",29358,Per diem,,18267,,"3,044.51 x patient days",18267,Per diem,,29358,,"4,892.96 x patient days",29358,Per diem,,35882,,"5,980.29 x patient days",35882,Per diem,,42276,,"7,045.87 x patient days",42276,Per diem,,28053,,"4,675.50 x patient days",28053,Per diem,,28053,,"4,675.50 x patient days",28053,Per diem,,16310,,"2,718.31 x patient days",16310,Per diem,,0.01,75054,
Nervous system malignancy,041-1,APR-DRG,,,,,,,,inpatient,,,60218.14,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,24269,,"4,044.85 x patient days",24269,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,20748,,"27,634 x DRG weight",20748,Other,base rate x DRG weight,17635,,"23,488 x DRG weight",17635,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,13048,,"2,174.65 x patient days",13048,Per diem,,13048,,"2,174.65 x patient days",13048,Per diem,,13048,,"2,174.65 x patient days",13048,Per diem,,13048,,"2,174.65 x patient days",13048,Per diem,,29358,,"4,892.96 x patient days",29358,Per diem,,19963,,"3,327.21 x patient days",19963,Per diem,,29358,,"4,892.96 x patient days",29358,Per diem,,18267,,"3,044.51 x patient days",18267,Per diem,,29358,,"4,892.96 x patient days",29358,Per diem,,35882,,"5,980.29 x patient days",35882,Per diem,,42276,,"7,045.87 x patient days",42276,Per diem,,28053,,"4,675.50 x patient days",28053,Per diem,,28053,,"4,675.50 x patient days",28053,Per diem,,16310,,"2,718.31 x patient days",16310,Per diem,,0.01,42276,
Nervous system malignancy,041-2,APR-DRG,,,,,,,,inpatient,,,70598.89,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,24269,,"4,044.85 x patient days",24269,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,23942,,"27,634 x DRG weight",23942,Other,base rate x DRG weight,20350,,"23,488 x DRG weight",20350,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,13048,,"2,174.65 x patient days",13048,Per diem,,13048,,"2,174.65 x patient days",13048,Per diem,,13048,,"2,174.65 x patient days",13048,Per diem,,13048,,"2,174.65 x patient days",13048,Per diem,,29358,,"4,892.96 x patient days",29358,Per diem,,19963,,"3,327.21 x patient days",19963,Per diem,,29358,,"4,892.96 x patient days",29358,Per diem,,18267,,"3,044.51 x patient days",18267,Per diem,,29358,,"4,892.96 x patient days",29358,Per diem,,35882,,"5,980.29 x patient days",35882,Per diem,,42276,,"7,045.87 x patient days",42276,Per diem,,28053,,"4,675.50 x patient days",28053,Per diem,,28053,,"4,675.50 x patient days",28053,Per diem,,16310,,"2,718.31 x patient days",16310,Per diem,,0.01,42276,
Nervous system malignancy,041-3,APR-DRG,,,,,,,,inpatient,,,263831.69,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,24269,,"4,044.85 x patient days",24269,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,40730,,"27,634 x DRG weight",40730,Other,base rate x DRG weight,34619,,"23,488 x DRG weight",34619,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,13048,,"2,174.65 x patient days",13048,Per diem,,13048,,"2,174.65 x patient days",13048,Per diem,,13048,,"2,174.65 x patient days",13048,Per diem,,13048,,"2,174.65 x patient days",13048,Per diem,,29358,,"4,892.96 x patient days",29358,Per diem,,19963,,"3,327.21 x patient days",19963,Per diem,,29358,,"4,892.96 x patient days",29358,Per diem,,18267,,"3,044.51 x patient days",18267,Per diem,,29358,,"4,892.96 x patient days",29358,Per diem,,35882,,"5,980.29 x patient days",35882,Per diem,,42276,,"7,045.87 x patient days",42276,Per diem,,28053,,"4,675.50 x patient days",28053,Per diem,,28053,,"4,675.50 x patient days",28053,Per diem,,16310,,"2,718.31 x patient days",16310,Per diem,,0.01,42276,
Nervous system malignancy,041-4,APR-DRG,,,,,,,,inpatient,,,133503.72,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,24269,,"4,044.85 x patient days",24269,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,75477,,"27,634 x DRG weight",75477,Other,base rate x DRG weight,64153,,"23,488 x DRG weight",64153,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,13048,,"2,174.65 x patient days",13048,Per diem,,13048,,"2,174.65 x patient days",13048,Per diem,,13048,,"2,174.65 x patient days",13048,Per diem,,13048,,"2,174.65 x patient days",13048,Per diem,,29358,,"4,892.96 x patient days",29358,Per diem,,19963,,"3,327.21 x patient days",19963,Per diem,,29358,,"4,892.96 x patient days",29358,Per diem,,18267,,"3,044.51 x patient days",18267,Per diem,,29358,,"4,892.96 x patient days",29358,Per diem,,35882,,"5,980.29 x patient days",35882,Per diem,,42276,,"7,045.87 x patient days",42276,Per diem,,28053,,"4,675.50 x patient days",28053,Per diem,,28053,,"4,675.50 x patient days",28053,Per diem,,16310,,"2,718.31 x patient days",16310,Per diem,,0.01,75477,
Degenerative nervous system disorders exc mult sclerosis,042-1,APR-DRG,,,,,,,,inpatient,,,106754.16,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,24269,,"4,044.85 x patient days",24269,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,17608,,"27,634 x DRG weight",17608,Other,base rate x DRG weight,14967,,"23,488 x DRG weight",14967,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,13048,,"2,174.65 x patient days",13048,Per diem,,13048,,"2,174.65 x patient days",13048,Per diem,,13048,,"2,174.65 x patient days",13048,Per diem,,13048,,"2,174.65 x patient days",13048,Per diem,,29358,,"4,892.96 x patient days",29358,Per diem,,19963,,"3,327.21 x patient days",19963,Per diem,,29358,,"4,892.96 x patient days",29358,Per diem,,18267,,"3,044.51 x patient days",18267,Per diem,,29358,,"4,892.96 x patient days",29358,Per diem,,35882,,"5,980.29 x patient days",35882,Per diem,,42276,,"7,045.87 x patient days",42276,Per diem,,28053,,"4,675.50 x patient days",28053,Per diem,,28053,,"4,675.50 x patient days",28053,Per diem,,16310,,"2,718.31 x patient days",16310,Per diem,,0.01,42276,
Degenerative nervous system disorders exc mult sclerosis,042-2,APR-DRG,,,,,,,,inpatient,,,173922.63,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,24269,,"4,044.85 x patient days",24269,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,24393,,"27,634 x DRG weight",24393,Other,base rate x DRG weight,20733,,"23,488 x DRG weight",20733,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,13048,,"2,174.65 x patient days",13048,Per diem,,13048,,"2,174.65 x patient days",13048,Per diem,,13048,,"2,174.65 x patient days",13048,Per diem,,13048,,"2,174.65 x patient days",13048,Per diem,,29358,,"4,892.96 x patient days",29358,Per diem,,19963,,"3,327.21 x patient days",19963,Per diem,,29358,,"4,892.96 x patient days",29358,Per diem,,18267,,"3,044.51 x patient days",18267,Per diem,,29358,,"4,892.96 x patient days",29358,Per diem,,35882,,"5,980.29 x patient days",35882,Per diem,,42276,,"7,045.87 x patient days",42276,Per diem,,28053,,"4,675.50 x patient days",28053,Per diem,,28053,,"4,675.50 x patient days",28053,Per diem,,16310,,"2,718.31 x patient days",16310,Per diem,,0.01,42276,
Degenerative nervous system disorders exc mult sclerosis,042-3,APR-DRG,,,,,,,,inpatient,,,130034.5,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,24269,,"4,044.85 x patient days",24269,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,50451,,"27,634 x DRG weight",50451,Other,base rate x DRG weight,42882,,"23,488 x DRG weight",42882,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,13048,,"2,174.65 x patient days",13048,Per diem,,13048,,"2,174.65 x patient days",13048,Per diem,,13048,,"2,174.65 x patient days",13048,Per diem,,13048,,"2,174.65 x patient days",13048,Per diem,,29358,,"4,892.96 x patient days",29358,Per diem,,19963,,"3,327.21 x patient days",19963,Per diem,,29358,,"4,892.96 x patient days",29358,Per diem,,18267,,"3,044.51 x patient days",18267,Per diem,,29358,,"4,892.96 x patient days",29358,Per diem,,35882,,"5,980.29 x patient days",35882,Per diem,,42276,,"7,045.87 x patient days",42276,Per diem,,28053,,"4,675.50 x patient days",28053,Per diem,,28053,,"4,675.50 x patient days",28053,Per diem,,16310,,"2,718.31 x patient days",16310,Per diem,,0.01,50451,
Degenerative nervous system disorders exc mult sclerosis,042-4,APR-DRG,,,,,,,,inpatient,,,411649.05,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,24269,,"4,044.85 x patient days",24269,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,53704,,"27,634 x DRG weight",53704,Other,base rate x DRG weight,45647,,"23,488 x DRG weight",45647,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,13048,,"2,174.65 x patient days",13048,Per diem,,13048,,"2,174.65 x patient days",13048,Per diem,,13048,,"2,174.65 x patient days",13048,Per diem,,13048,,"2,174.65 x patient days",13048,Per diem,,29358,,"4,892.96 x patient days",29358,Per diem,,19963,,"3,327.21 x patient days",19963,Per diem,,29358,,"4,892.96 x patient days",29358,Per diem,,18267,,"3,044.51 x patient days",18267,Per diem,,29358,,"4,892.96 x patient days",29358,Per diem,,35882,,"5,980.29 x patient days",35882,Per diem,,42276,,"7,045.87 x patient days",42276,Per diem,,28053,,"4,675.50 x patient days",28053,Per diem,,28053,,"4,675.50 x patient days",28053,Per diem,,16310,,"2,718.31 x patient days",16310,Per diem,,0.01,53704,
Multiple sclerosis & other demyelinating diseases,043-1,APR-DRG,,,,,,,,inpatient,,,63962,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,20224,,"4,044.85 x patient days",20224,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,21662,,"27,634 x DRG weight",21662,Other,base rate x DRG weight,18412,,"23,488 x DRG weight",18412,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,16636,,"3,327.21 x patient days",16636,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,15222,,"3,044.51 x patient days",15222,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,29901,,"5,980.29 x patient days",29901,Per diem,,35229,,"7,045.87 x patient days",35229,Per diem,,23377,,"4,675.50 x patient days",23377,Per diem,,23377,,"4,675.50 x patient days",23377,Per diem,,13591,,"2,718.31 x patient days",13591,Per diem,,0.01,35229,
Multiple sclerosis & other demyelinating diseases,043-2,APR-DRG,,,,,,,,inpatient,,,100947.22,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,20224,,"4,044.85 x patient days",20224,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,29701,,"27,634 x DRG weight",29701,Other,base rate x DRG weight,25245,,"23,488 x DRG weight",25245,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,16636,,"3,327.21 x patient days",16636,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,15222,,"3,044.51 x patient days",15222,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,29901,,"5,980.29 x patient days",29901,Per diem,,35229,,"7,045.87 x patient days",35229,Per diem,,23377,,"4,675.50 x patient days",23377,Per diem,,23377,,"4,675.50 x patient days",23377,Per diem,,13591,,"2,718.31 x patient days",13591,Per diem,,0.01,35229,
Multiple sclerosis & other demyelinating diseases,043-3,APR-DRG,,,,,,,,inpatient,,,138710.01,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,20224,,"4,044.85 x patient days",20224,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,62400,,"27,634 x DRG weight",62400,Other,base rate x DRG weight,53038,,"23,488 x DRG weight",53038,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,16636,,"3,327.21 x patient days",16636,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,15222,,"3,044.51 x patient days",15222,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,29901,,"5,980.29 x patient days",29901,Per diem,,35229,,"7,045.87 x patient days",35229,Per diem,,23377,,"4,675.50 x patient days",23377,Per diem,,23377,,"4,675.50 x patient days",23377,Per diem,,13591,,"2,718.31 x patient days",13591,Per diem,,0.01,62400,
Multiple sclerosis & other demyelinating diseases,043-4,APR-DRG,,,,,,,,inpatient,,,366821.02,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,20224,,"4,044.85 x patient days",20224,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,163530,,"27,634 x DRG weight",163530,Other,base rate x DRG weight,138995,,"23,488 x DRG weight",138995,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,16636,,"3,327.21 x patient days",16636,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,15222,,"3,044.51 x patient days",15222,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,29901,,"5,980.29 x patient days",29901,Per diem,,35229,,"7,045.87 x patient days",35229,Per diem,,23377,,"4,675.50 x patient days",23377,Per diem,,23377,,"4,675.50 x patient days",23377,Per diem,,13591,,"2,718.31 x patient days",13591,Per diem,,0.01,163530,
Intracranial hemorrhage,044-1,APR-DRG,,,,,,,,inpatient,,,143706.99,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,28315,,"4,044.85 x patient days",28315,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,27637,,"27,634 x DRG weight",27637,Other,base rate x DRG weight,23490,,"23,488 x DRG weight",23490,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,15223,,"2,174.65 x patient days",15223,Per diem,,15223,,"2,174.65 x patient days",15223,Per diem,,15223,,"2,174.65 x patient days",15223,Per diem,,15223,,"2,174.65 x patient days",15223,Per diem,,34252,,"4,892.96 x patient days",34252,Per diem,,23291,,"3,327.21 x patient days",23291,Per diem,,34252,,"4,892.96 x patient days",34252,Per diem,,21312,,"3,044.51 x patient days",21312,Per diem,,34252,,"4,892.96 x patient days",34252,Per diem,,41863,,"5,980.29 x patient days",41863,Per diem,,49323,,"7,045.87 x patient days",49323,Per diem,,32729,,"4,675.50 x patient days",32729,Per diem,,32729,,"4,675.50 x patient days",32729,Per diem,,19029,,"2,718.31 x patient days",19029,Per diem,,0.01,49323,
Intracranial hemorrhage,044-2,APR-DRG,,,,,,,,inpatient,,,134232.85,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,28315,,"4,044.85 x patient days",28315,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,40431,,"27,634 x DRG weight",40431,Other,base rate x DRG weight,34365,,"23,488 x DRG weight",34365,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,15223,,"2,174.65 x patient days",15223,Per diem,,15223,,"2,174.65 x patient days",15223,Per diem,,15223,,"2,174.65 x patient days",15223,Per diem,,15223,,"2,174.65 x patient days",15223,Per diem,,34252,,"4,892.96 x patient days",34252,Per diem,,23291,,"3,327.21 x patient days",23291,Per diem,,34252,,"4,892.96 x patient days",34252,Per diem,,21312,,"3,044.51 x patient days",21312,Per diem,,34252,,"4,892.96 x patient days",34252,Per diem,,41863,,"5,980.29 x patient days",41863,Per diem,,49323,,"7,045.87 x patient days",49323,Per diem,,32729,,"4,675.50 x patient days",32729,Per diem,,32729,,"4,675.50 x patient days",32729,Per diem,,19029,,"2,718.31 x patient days",19029,Per diem,,0.01,49323,
Intracranial hemorrhage,044-3,APR-DRG,,,,,,,,inpatient,,,275985.91,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,28315,,"4,044.85 x patient days",28315,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,58460,,"27,634 x DRG weight",58460,Other,base rate x DRG weight,49689,,"23,488 x DRG weight",49689,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,15223,,"2,174.65 x patient days",15223,Per diem,,15223,,"2,174.65 x patient days",15223,Per diem,,15223,,"2,174.65 x patient days",15223,Per diem,,15223,,"2,174.65 x patient days",15223,Per diem,,34252,,"4,892.96 x patient days",34252,Per diem,,23291,,"3,327.21 x patient days",23291,Per diem,,34252,,"4,892.96 x patient days",34252,Per diem,,21312,,"3,044.51 x patient days",21312,Per diem,,34252,,"4,892.96 x patient days",34252,Per diem,,41863,,"5,980.29 x patient days",41863,Per diem,,49323,,"7,045.87 x patient days",49323,Per diem,,32729,,"4,675.50 x patient days",32729,Per diem,,32729,,"4,675.50 x patient days",32729,Per diem,,19029,,"2,718.31 x patient days",19029,Per diem,,0.01,58460,
Intracranial hemorrhage,044-4,APR-DRG,,,,,,,,inpatient,,,479134.32,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,28315,,"4,044.85 x patient days",28315,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,76787,,"27,634 x DRG weight",76787,Other,base rate x DRG weight,65266,,"23,488 x DRG weight",65266,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,15223,,"2,174.65 x patient days",15223,Per diem,,15223,,"2,174.65 x patient days",15223,Per diem,,15223,,"2,174.65 x patient days",15223,Per diem,,15223,,"2,174.65 x patient days",15223,Per diem,,34252,,"4,892.96 x patient days",34252,Per diem,,23291,,"3,327.21 x patient days",23291,Per diem,,34252,,"4,892.96 x patient days",34252,Per diem,,21312,,"3,044.51 x patient days",21312,Per diem,,34252,,"4,892.96 x patient days",34252,Per diem,,41863,,"5,980.29 x patient days",41863,Per diem,,49323,,"7,045.87 x patient days",49323,Per diem,,32729,,"4,675.50 x patient days",32729,Per diem,,32729,,"4,675.50 x patient days",32729,Per diem,,19029,,"2,718.31 x patient days",19029,Per diem,,0.01,76787,
CVA & precerebral occlusion w infarct,045-1,APR-DRG,,,,,,,,inpatient,,,109772.6,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,20224,,"4,044.85 x patient days",20224,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,22033,,"27,634 x DRG weight",22033,Other,base rate x DRG weight,18727,,"23,488 x DRG weight",18727,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,16636,,"3,327.21 x patient days",16636,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,15222,,"3,044.51 x patient days",15222,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,29901,,"5,980.29 x patient days",29901,Per diem,,35229,,"7,045.87 x patient days",35229,Per diem,,23377,,"4,675.50 x patient days",23377,Per diem,,23377,,"4,675.50 x patient days",23377,Per diem,,13591,,"2,718.31 x patient days",13591,Per diem,,0.01,35229,
CVA & precerebral occlusion w infarct,045-2,APR-DRG,,,,,,,,inpatient,,,210289.76,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,20224,,"4,044.85 x patient days",20224,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,30710,,"27,634 x DRG weight",30710,Other,base rate x DRG weight,26102,,"23,488 x DRG weight",26102,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,16636,,"3,327.21 x patient days",16636,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,15222,,"3,044.51 x patient days",15222,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,29901,,"5,980.29 x patient days",29901,Per diem,,35229,,"7,045.87 x patient days",35229,Per diem,,23377,,"4,675.50 x patient days",23377,Per diem,,23377,,"4,675.50 x patient days",23377,Per diem,,13591,,"2,718.31 x patient days",13591,Per diem,,0.01,35229,
CVA & precerebral occlusion w infarct,045-3,APR-DRG,,,,,,,,inpatient,,,205432.59,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,20224,,"4,044.85 x patient days",20224,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,47566,,"27,634 x DRG weight",47566,Other,base rate x DRG weight,40430,,"23,488 x DRG weight",40430,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,16636,,"3,327.21 x patient days",16636,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,15222,,"3,044.51 x patient days",15222,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,29901,,"5,980.29 x patient days",29901,Per diem,,35229,,"7,045.87 x patient days",35229,Per diem,,23377,,"4,675.50 x patient days",23377,Per diem,,23377,,"4,675.50 x patient days",23377,Per diem,,13591,,"2,718.31 x patient days",13591,Per diem,,0.01,47566,
CVA & precerebral occlusion w infarct,045-4,APR-DRG,,,,,,,,inpatient,,,592370.68,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,20224,,"4,044.85 x patient days",20224,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,94514,,"27,634 x DRG weight",94514,Other,base rate x DRG weight,80334,,"23,488 x DRG weight",80334,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,16636,,"3,327.21 x patient days",16636,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,15222,,"3,044.51 x patient days",15222,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,29901,,"5,980.29 x patient days",29901,Per diem,,35229,,"7,045.87 x patient days",35229,Per diem,,23377,,"4,675.50 x patient days",23377,Per diem,,23377,,"4,675.50 x patient days",23377,Per diem,,13591,,"2,718.31 x patient days",13591,Per diem,,0.01,94514,
Nonspecific CVA & precerebral occlusion w/o infarct,046-1,APR-DRG,,,,,,,,inpatient,,,63313.52,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,16180,,"4,044.85 x patient days",16180,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,17451,,"27,634 x DRG weight",17451,Other,base rate x DRG weight,14833,,"23,488 x DRG weight",14833,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,13309,,"3,327.21 x patient days",13309,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,12179,,"3,044.51 x patient days",12179,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,23922,,"5,980.29 x patient days",23922,Per diem,,28185,,"7,045.87 x patient days",28185,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,10874,,"2,718.31 x patient days",10874,Per diem,,0.01,28185,
Nonspecific CVA & precerebral occlusion w/o infarct,046-2,APR-DRG,,,,,,,,inpatient,,,125107.23,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,16180,,"4,044.85 x patient days",16180,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,23445,,"27,634 x DRG weight",23445,Other,base rate x DRG weight,19927,,"23,488 x DRG weight",19927,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,13309,,"3,327.21 x patient days",13309,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,12179,,"3,044.51 x patient days",12179,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,23922,,"5,980.29 x patient days",23922,Per diem,,28185,,"7,045.87 x patient days",28185,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,10874,,"2,718.31 x patient days",10874,Per diem,,0.01,28185,
Nonspecific CVA & precerebral occlusion w/o infarct,046-3,APR-DRG,,,,,,,,inpatient,,,91913.6,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,16180,,"4,044.85 x patient days",16180,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,30558,,"27,634 x DRG weight",30558,Other,base rate x DRG weight,25973,,"23,488 x DRG weight",25973,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,13309,,"3,327.21 x patient days",13309,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,12179,,"3,044.51 x patient days",12179,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,23922,,"5,980.29 x patient days",23922,Per diem,,28185,,"7,045.87 x patient days",28185,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,10874,,"2,718.31 x patient days",10874,Per diem,,0.01,30558,
Nonspecific CVA & precerebral occlusion w/o infarct,046-4,APR-DRG,,,,,,,,inpatient,,,170256,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,16180,,"4,044.85 x patient days",16180,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,31931,,"27,634 x DRG weight",31931,Other,base rate x DRG weight,27140,,"23,488 x DRG weight",27140,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,13309,,"3,327.21 x patient days",13309,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,12179,,"3,044.51 x patient days",12179,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,23922,,"5,980.29 x patient days",23922,Per diem,,28185,,"7,045.87 x patient days",28185,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,10874,,"2,718.31 x patient days",10874,Per diem,,0.01,31931,
Transient ischemia,047-1,APR-DRG,,,,,,,,inpatient,,,92888.52,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8089,,"4,044.85 x patient days",8089,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,14187,,"27,634 x DRG weight",14187,Other,base rate x DRG weight,12059,,"23,488 x DRG weight",12059,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6654,,"3,327.21 x patient days",6654,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6089,,"3,044.51 x patient days",6089,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,11960,,"5,980.29 x patient days",11960,Per diem,,14091,,"7,045.87 x patient days",14091,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,5436,,"2,718.31 x patient days",5436,Per diem,,0.01,14187,
Transient ischemia,047-2,APR-DRG,,,,,,,,inpatient,,,114868.04,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8089,,"4,044.85 x patient days",8089,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,17490,,"27,634 x DRG weight",17490,Other,base rate x DRG weight,14866,,"23,488 x DRG weight",14866,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6654,,"3,327.21 x patient days",6654,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6089,,"3,044.51 x patient days",6089,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,11960,,"5,980.29 x patient days",11960,Per diem,,14091,,"7,045.87 x patient days",14091,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,5436,,"2,718.31 x patient days",5436,Per diem,,0.01,17490,
Transient ischemia,047-3,APR-DRG,,,,,,,,inpatient,,,86204.75,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8089,,"4,044.85 x patient days",8089,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,24196,,"27,634 x DRG weight",24196,Other,base rate x DRG weight,20566,,"23,488 x DRG weight",20566,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6654,,"3,327.21 x patient days",6654,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6089,,"3,044.51 x patient days",6089,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,11960,,"5,980.29 x patient days",11960,Per diem,,14091,,"7,045.87 x patient days",14091,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,5436,,"2,718.31 x patient days",5436,Per diem,,0.01,24196,
Transient ischemia,047-4,APR-DRG,,,,,,,,inpatient,,,114868.04,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8089,,"4,044.85 x patient days",8089,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,24774,,"27,634 x DRG weight",24774,Other,base rate x DRG weight,21057,,"23,488 x DRG weight",21057,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6654,,"3,327.21 x patient days",6654,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6089,,"3,044.51 x patient days",6089,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,11960,,"5,980.29 x patient days",11960,Per diem,,14091,,"7,045.87 x patient days",14091,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,5436,,"2,718.31 x patient days",5436,Per diem,,0.01,24774,
"Peripheral, cranial & autonomic nerve disorders",048-1,APR-DRG,,,,,,,,inpatient,,,146144.94,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,16180,,"4,044.85 x patient days",16180,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,15304,,"27,634 x DRG weight",15304,Other,base rate x DRG weight,13008,,"23,488 x DRG weight",13008,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,13309,,"3,327.21 x patient days",13309,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,12179,,"3,044.51 x patient days",12179,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,23922,,"5,980.29 x patient days",23922,Per diem,,28185,,"7,045.87 x patient days",28185,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,10874,,"2,718.31 x patient days",10874,Per diem,,0.01,28185,
"Peripheral, cranial & autonomic nerve disorders",048-2,APR-DRG,,,,,,,,inpatient,,,250051.21,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,16180,,"4,044.85 x patient days",16180,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,20430,,"27,634 x DRG weight",20430,Other,base rate x DRG weight,17365,,"23,488 x DRG weight",17365,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,13309,,"3,327.21 x patient days",13309,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,12179,,"3,044.51 x patient days",12179,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,23922,,"5,980.29 x patient days",23922,Per diem,,28185,,"7,045.87 x patient days",28185,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,10874,,"2,718.31 x patient days",10874,Per diem,,0.01,28185,
"Peripheral, cranial & autonomic nerve disorders",048-3,APR-DRG,,,,,,,,inpatient,,,137867.03,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,16180,,"4,044.85 x patient days",16180,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,30566,,"27,634 x DRG weight",30566,Other,base rate x DRG weight,25980,,"23,488 x DRG weight",25980,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,13309,,"3,327.21 x patient days",13309,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,12179,,"3,044.51 x patient days",12179,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,23922,,"5,980.29 x patient days",23922,Per diem,,28185,,"7,045.87 x patient days",28185,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,10874,,"2,718.31 x patient days",10874,Per diem,,0.01,30566,
"Peripheral, cranial & autonomic nerve disorders",048-4,APR-DRG,,,,,,,,inpatient,,,240670.21,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,16180,,"4,044.85 x patient days",16180,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,96285,,"27,634 x DRG weight",96285,Other,base rate x DRG weight,81839,,"23,488 x DRG weight",81839,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,13309,,"3,327.21 x patient days",13309,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,12179,,"3,044.51 x patient days",12179,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,23922,,"5,980.29 x patient days",23922,Per diem,,28185,,"7,045.87 x patient days",28185,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,10874,,"2,718.31 x patient days",10874,Per diem,,0.01,96285,
Bacterial & tuberculous infections of nervous system,049-1,APR-DRG,,,,,,,,inpatient,,,238126.44,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,36404,,"4,044.85 x patient days",36404,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,32188,,"27,634 x DRG weight",32188,Other,base rate x DRG weight,27359,,"23,488 x DRG weight",27359,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,19572,,"2,174.65 x patient days",19572,Per diem,,19572,,"2,174.65 x patient days",19572,Per diem,,19572,,"2,174.65 x patient days",19572,Per diem,,19572,,"2,174.65 x patient days",19572,Per diem,,44037,,"4,892.96 x patient days",44037,Per diem,,29945,,"3,327.21 x patient days",29945,Per diem,,44037,,"4,892.96 x patient days",44037,Per diem,,27401,,"3,044.51 x patient days",27401,Per diem,,44037,,"4,892.96 x patient days",44037,Per diem,,53823,,"5,980.29 x patient days",53823,Per diem,,63413,,"7,045.87 x patient days",63413,Per diem,,42080,,"4,675.50 x patient days",42080,Per diem,,42080,,"4,675.50 x patient days",42080,Per diem,,24465,,"2,718.31 x patient days",24465,Per diem,,0.01,63413,
Bacterial & tuberculous infections of nervous system,049-2,APR-DRG,,,,,,,,inpatient,,,201766.55,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,36404,,"4,044.85 x patient days",36404,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,68784,,"27,634 x DRG weight",68784,Other,base rate x DRG weight,58464,,"23,488 x DRG weight",58464,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,19572,,"2,174.65 x patient days",19572,Per diem,,19572,,"2,174.65 x patient days",19572,Per diem,,19572,,"2,174.65 x patient days",19572,Per diem,,19572,,"2,174.65 x patient days",19572,Per diem,,44037,,"4,892.96 x patient days",44037,Per diem,,29945,,"3,327.21 x patient days",29945,Per diem,,44037,,"4,892.96 x patient days",44037,Per diem,,27401,,"3,044.51 x patient days",27401,Per diem,,44037,,"4,892.96 x patient days",44037,Per diem,,53823,,"5,980.29 x patient days",53823,Per diem,,63413,,"7,045.87 x patient days",63413,Per diem,,42080,,"4,675.50 x patient days",42080,Per diem,,42080,,"4,675.50 x patient days",42080,Per diem,,24465,,"2,718.31 x patient days",24465,Per diem,,0.01,68784,
Bacterial & tuberculous infections of nervous system,049-3,APR-DRG,,,,,,,,inpatient,,,393665.33,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,36404,,"4,044.85 x patient days",36404,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,88443,,"27,634 x DRG weight",88443,Other,base rate x DRG weight,75173,,"23,488 x DRG weight",75173,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,19572,,"2,174.65 x patient days",19572,Per diem,,19572,,"2,174.65 x patient days",19572,Per diem,,19572,,"2,174.65 x patient days",19572,Per diem,,19572,,"2,174.65 x patient days",19572,Per diem,,44037,,"4,892.96 x patient days",44037,Per diem,,29945,,"3,327.21 x patient days",29945,Per diem,,44037,,"4,892.96 x patient days",44037,Per diem,,27401,,"3,044.51 x patient days",27401,Per diem,,44037,,"4,892.96 x patient days",44037,Per diem,,53823,,"5,980.29 x patient days",53823,Per diem,,63413,,"7,045.87 x patient days",63413,Per diem,,42080,,"4,675.50 x patient days",42080,Per diem,,42080,,"4,675.50 x patient days",42080,Per diem,,24465,,"2,718.31 x patient days",24465,Per diem,,0.01,88443,
Bacterial & tuberculous infections of nervous system,049-4,APR-DRG,,,,,,,,inpatient,,,401539.38,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,36404,,"4,044.85 x patient days",36404,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,164906,,"27,634 x DRG weight",164906,Other,base rate x DRG weight,140165,,"23,488 x DRG weight",140165,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,19572,,"2,174.65 x patient days",19572,Per diem,,19572,,"2,174.65 x patient days",19572,Per diem,,19572,,"2,174.65 x patient days",19572,Per diem,,19572,,"2,174.65 x patient days",19572,Per diem,,44037,,"4,892.96 x patient days",44037,Per diem,,29945,,"3,327.21 x patient days",29945,Per diem,,44037,,"4,892.96 x patient days",44037,Per diem,,27401,,"3,044.51 x patient days",27401,Per diem,,44037,,"4,892.96 x patient days",44037,Per diem,,53823,,"5,980.29 x patient days",53823,Per diem,,63413,,"7,045.87 x patient days",63413,Per diem,,42080,,"4,675.50 x patient days",42080,Per diem,,42080,,"4,675.50 x patient days",42080,Per diem,,24465,,"2,718.31 x patient days",24465,Per diem,,0.01,164906,
Non-bacterial infections of nervous system exc viral meningitis,050-1,APR-DRG,,,,,,,,inpatient,,,135796,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,28315,,"4,044.85 x patient days",28315,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,20739,,"27,634 x DRG weight",20739,Other,base rate x DRG weight,17628,,"23,488 x DRG weight",17628,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,15223,,"2,174.65 x patient days",15223,Per diem,,15223,,"2,174.65 x patient days",15223,Per diem,,15223,,"2,174.65 x patient days",15223,Per diem,,15223,,"2,174.65 x patient days",15223,Per diem,,34252,,"4,892.96 x patient days",34252,Per diem,,23291,,"3,327.21 x patient days",23291,Per diem,,34252,,"4,892.96 x patient days",34252,Per diem,,21312,,"3,044.51 x patient days",21312,Per diem,,34252,,"4,892.96 x patient days",34252,Per diem,,41863,,"5,980.29 x patient days",41863,Per diem,,49323,,"7,045.87 x patient days",49323,Per diem,,32729,,"4,675.50 x patient days",32729,Per diem,,32729,,"4,675.50 x patient days",32729,Per diem,,19029,,"2,718.31 x patient days",19029,Per diem,,0.01,49323,
Non-bacterial infections of nervous system exc viral meningitis,050-2,APR-DRG,,,,,,,,inpatient,,,287236.16,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,28315,,"4,044.85 x patient days",28315,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,37375,,"27,634 x DRG weight",37375,Other,base rate x DRG weight,31768,,"23,488 x DRG weight",31768,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,15223,,"2,174.65 x patient days",15223,Per diem,,15223,,"2,174.65 x patient days",15223,Per diem,,15223,,"2,174.65 x patient days",15223,Per diem,,15223,,"2,174.65 x patient days",15223,Per diem,,34252,,"4,892.96 x patient days",34252,Per diem,,23291,,"3,327.21 x patient days",23291,Per diem,,34252,,"4,892.96 x patient days",34252,Per diem,,21312,,"3,044.51 x patient days",21312,Per diem,,34252,,"4,892.96 x patient days",34252,Per diem,,41863,,"5,980.29 x patient days",41863,Per diem,,49323,,"7,045.87 x patient days",49323,Per diem,,32729,,"4,675.50 x patient days",32729,Per diem,,32729,,"4,675.50 x patient days",32729,Per diem,,19029,,"2,718.31 x patient days",19029,Per diem,,0.01,49323,
Non-bacterial infections of nervous system exc viral meningitis,050-3,APR-DRG,,,,,,,,inpatient,,,289045.29,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,28315,,"4,044.85 x patient days",28315,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,60922,,"27,634 x DRG weight",60922,Other,base rate x DRG weight,51782,,"23,488 x DRG weight",51782,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,15223,,"2,174.65 x patient days",15223,Per diem,,15223,,"2,174.65 x patient days",15223,Per diem,,15223,,"2,174.65 x patient days",15223,Per diem,,15223,,"2,174.65 x patient days",15223,Per diem,,34252,,"4,892.96 x patient days",34252,Per diem,,23291,,"3,327.21 x patient days",23291,Per diem,,34252,,"4,892.96 x patient days",34252,Per diem,,21312,,"3,044.51 x patient days",21312,Per diem,,34252,,"4,892.96 x patient days",34252,Per diem,,41863,,"5,980.29 x patient days",41863,Per diem,,49323,,"7,045.87 x patient days",49323,Per diem,,32729,,"4,675.50 x patient days",32729,Per diem,,32729,,"4,675.50 x patient days",32729,Per diem,,19029,,"2,718.31 x patient days",19029,Per diem,,0.01,60922,
Non-bacterial infections of nervous system exc viral meningitis,050-4,APR-DRG,,,,,,,,inpatient,,,785355.87,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,28315,,"4,044.85 x patient days",28315,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,147745,,"27,634 x DRG weight",147745,Other,base rate x DRG weight,125579,,"23,488 x DRG weight",125579,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,15223,,"2,174.65 x patient days",15223,Per diem,,15223,,"2,174.65 x patient days",15223,Per diem,,15223,,"2,174.65 x patient days",15223,Per diem,,15223,,"2,174.65 x patient days",15223,Per diem,,34252,,"4,892.96 x patient days",34252,Per diem,,23291,,"3,327.21 x patient days",23291,Per diem,,34252,,"4,892.96 x patient days",34252,Per diem,,21312,,"3,044.51 x patient days",21312,Per diem,,34252,,"4,892.96 x patient days",34252,Per diem,,41863,,"5,980.29 x patient days",41863,Per diem,,49323,,"7,045.87 x patient days",49323,Per diem,,32729,,"4,675.50 x patient days",32729,Per diem,,32729,,"4,675.50 x patient days",32729,Per diem,,19029,,"2,718.31 x patient days",19029,Per diem,,0.01,147745,
Viral meningitis,051-1,APR-DRG,,,,,,,,inpatient,,,99340.16,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,16180,,"4,044.85 x patient days",16180,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,17056,,"27,634 x DRG weight",17056,Other,base rate x DRG weight,14497,,"23,488 x DRG weight",14497,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,13309,,"3,327.21 x patient days",13309,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,12179,,"3,044.51 x patient days",12179,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,23922,,"5,980.29 x patient days",23922,Per diem,,28185,,"7,045.87 x patient days",28185,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,10874,,"2,718.31 x patient days",10874,Per diem,,0.01,28185,
Viral meningitis,051-2,APR-DRG,,,,,,,,inpatient,,,68612.95,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,16180,,"4,044.85 x patient days",16180,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,21643,,"27,634 x DRG weight",21643,Other,base rate x DRG weight,18396,,"23,488 x DRG weight",18396,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,13309,,"3,327.21 x patient days",13309,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,12179,,"3,044.51 x patient days",12179,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,23922,,"5,980.29 x patient days",23922,Per diem,,28185,,"7,045.87 x patient days",28185,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,10874,,"2,718.31 x patient days",10874,Per diem,,0.01,28185,
Viral meningitis,051-3,APR-DRG,,,,,,,,inpatient,,,110348.54,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,16180,,"4,044.85 x patient days",16180,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,41915,,"27,634 x DRG weight",41915,Other,base rate x DRG weight,35627,,"23,488 x DRG weight",35627,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,13309,,"3,327.21 x patient days",13309,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,12179,,"3,044.51 x patient days",12179,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,23922,,"5,980.29 x patient days",23922,Per diem,,28185,,"7,045.87 x patient days",28185,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,10874,,"2,718.31 x patient days",10874,Per diem,,0.01,41915,
Viral meningitis,051-4,APR-DRG,,,,,,,,inpatient,,,356085.28,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,16180,,"4,044.85 x patient days",16180,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,47832,,"27,634 x DRG weight",47832,Other,base rate x DRG weight,40655,,"23,488 x DRG weight",40655,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,13309,,"3,327.21 x patient days",13309,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,12179,,"3,044.51 x patient days",12179,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,23922,,"5,980.29 x patient days",23922,Per diem,,28185,,"7,045.87 x patient days",28185,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,10874,,"2,718.31 x patient days",10874,Per diem,,0.01,47832,
Nontraumatic stupor & coma,052-1,APR-DRG,,,,,,,,inpatient,,,102492.98,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,16180,,"4,044.85 x patient days",16180,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,15345,,"27,634 x DRG weight",15345,Other,base rate x DRG weight,13043,,"23,488 x DRG weight",13043,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,13309,,"3,327.21 x patient days",13309,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,12179,,"3,044.51 x patient days",12179,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,23922,,"5,980.29 x patient days",23922,Per diem,,28185,,"7,045.87 x patient days",28185,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,10874,,"2,718.31 x patient days",10874,Per diem,,0.01,28185,
Nontraumatic stupor & coma,052-2,APR-DRG,,,,,,,,inpatient,,,92078.95,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,16180,,"4,044.85 x patient days",16180,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,20084,,"27,634 x DRG weight",20084,Other,base rate x DRG weight,17071,,"23,488 x DRG weight",17071,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,13309,,"3,327.21 x patient days",13309,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,12179,,"3,044.51 x patient days",12179,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,23922,,"5,980.29 x patient days",23922,Per diem,,28185,,"7,045.87 x patient days",28185,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,10874,,"2,718.31 x patient days",10874,Per diem,,0.01,28185,
Nontraumatic stupor & coma,052-3,APR-DRG,,,,,,,,inpatient,,,133418.37,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,16180,,"4,044.85 x patient days",16180,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,27698,,"27,634 x DRG weight",27698,Other,base rate x DRG weight,23542,,"23,488 x DRG weight",23542,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,13309,,"3,327.21 x patient days",13309,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,12179,,"3,044.51 x patient days",12179,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,23922,,"5,980.29 x patient days",23922,Per diem,,28185,,"7,045.87 x patient days",28185,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,10874,,"2,718.31 x patient days",10874,Per diem,,0.01,28185,
Nontraumatic stupor & coma,052-4,APR-DRG,,,,,,,,inpatient,,,393684.57,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,16180,,"4,044.85 x patient days",16180,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,62928,,"27,634 x DRG weight",62928,Other,base rate x DRG weight,53487,,"23,488 x DRG weight",53487,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,13309,,"3,327.21 x patient days",13309,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,12179,,"3,044.51 x patient days",12179,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,23922,,"5,980.29 x patient days",23922,Per diem,,28185,,"7,045.87 x patient days",28185,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,10874,,"2,718.31 x patient days",10874,Per diem,,0.01,62928,
Seizure,053-1,APR-DRG,,,,,,,,inpatient,,,72041.55,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12135,,"4,044.85 x patient days",12135,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,13485,,"27,634 x DRG weight",13485,Other,base rate x DRG weight,11462,,"23,488 x DRG weight",11462,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9982,,"3,327.21 x patient days",9982,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9134,,"3,044.51 x patient days",9134,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,17941,,"5,980.29 x patient days",17941,Per diem,,21138,,"7,045.87 x patient days",21138,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,8155,,"2,718.31 x patient days",8155,Per diem,,0.01,21138,
Seizure,053-2,APR-DRG,,,,,,,,inpatient,,,83092.5,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12135,,"4,044.85 x patient days",12135,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,16086,,"27,634 x DRG weight",16086,Other,base rate x DRG weight,13672,,"23,488 x DRG weight",13672,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9982,,"3,327.21 x patient days",9982,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9134,,"3,044.51 x patient days",9134,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,17941,,"5,980.29 x patient days",17941,Per diem,,21138,,"7,045.87 x patient days",21138,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,8155,,"2,718.31 x patient days",8155,Per diem,,0.01,21138,
Seizure,053-3,APR-DRG,,,,,,,,inpatient,,,116588.04,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12135,,"4,044.85 x patient days",12135,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,22657,,"27,634 x DRG weight",22657,Other,base rate x DRG weight,19258,,"23,488 x DRG weight",19258,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9982,,"3,327.21 x patient days",9982,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9134,,"3,044.51 x patient days",9134,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,17941,,"5,980.29 x patient days",17941,Per diem,,21138,,"7,045.87 x patient days",21138,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,8155,,"2,718.31 x patient days",8155,Per diem,,0.01,22657,
Seizure,053-4,APR-DRG,,,,,,,,inpatient,,,293200.96,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12135,,"4,044.85 x patient days",12135,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,73973,,"27,634 x DRG weight",73973,Other,base rate x DRG weight,62875,,"23,488 x DRG weight",62875,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9982,,"3,327.21 x patient days",9982,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9134,,"3,044.51 x patient days",9134,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,17941,,"5,980.29 x patient days",17941,Per diem,,21138,,"7,045.87 x patient days",21138,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,8155,,"2,718.31 x patient days",8155,Per diem,,0.01,73973,
Migraine & other headaches,054-1,APR-DRG,,,,,,,,inpatient,,,83169.75,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8089,,"4,044.85 x patient days",8089,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,13599,,"27,634 x DRG weight",13599,Other,base rate x DRG weight,11558,,"23,488 x DRG weight",11558,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6654,,"3,327.21 x patient days",6654,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6089,,"3,044.51 x patient days",6089,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,11960,,"5,980.29 x patient days",11960,Per diem,,14091,,"7,045.87 x patient days",14091,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,5436,,"2,718.31 x patient days",5436,Per diem,,0.01,14091,
Migraine & other headaches,054-2,APR-DRG,,,,,,,,inpatient,,,106107.34,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8089,,"4,044.85 x patient days",8089,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,16918,,"27,634 x DRG weight",16918,Other,base rate x DRG weight,14379,,"23,488 x DRG weight",14379,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6654,,"3,327.21 x patient days",6654,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6089,,"3,044.51 x patient days",6089,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,11960,,"5,980.29 x patient days",11960,Per diem,,14091,,"7,045.87 x patient days",14091,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,5436,,"2,718.31 x patient days",5436,Per diem,,0.01,16918,
Migraine & other headaches,054-3,APR-DRG,,,,,,,,inpatient,,,106098.11,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8089,,"4,044.85 x patient days",8089,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,21828,,"27,634 x DRG weight",21828,Other,base rate x DRG weight,18553,,"23,488 x DRG weight",18553,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6654,,"3,327.21 x patient days",6654,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6089,,"3,044.51 x patient days",6089,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,11960,,"5,980.29 x patient days",11960,Per diem,,14091,,"7,045.87 x patient days",14091,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,5436,,"2,718.31 x patient days",5436,Per diem,,0.01,21828,
Migraine & other headaches,054-4,APR-DRG,,,,,,,,inpatient,,,137275.75,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8089,,"4,044.85 x patient days",8089,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,22229,,"27,634 x DRG weight",22229,Other,base rate x DRG weight,18894,,"23,488 x DRG weight",18894,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6654,,"3,327.21 x patient days",6654,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6089,,"3,044.51 x patient days",6089,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,11960,,"5,980.29 x patient days",11960,Per diem,,14091,,"7,045.87 x patient days",14091,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,5436,,"2,718.31 x patient days",5436,Per diem,,0.01,22229,
Head trauma w coma >1 hr or hemorrhage,055-1,APR-DRG,,,,,,,,inpatient,,,77715.73,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,16180,,"4,044.85 x patient days",16180,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,15389,,"27,634 x DRG weight",15389,Other,base rate x DRG weight,13080,,"23,488 x DRG weight",13080,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,13309,,"3,327.21 x patient days",13309,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,12179,,"3,044.51 x patient days",12179,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,23922,,"5,980.29 x patient days",23922,Per diem,,28185,,"7,045.87 x patient days",28185,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,10874,,"2,718.31 x patient days",10874,Per diem,,0.01,28185,
Head trauma w coma >1 hr or hemorrhage,055-2,APR-DRG,,,,,,,,inpatient,,,141938.68,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,16180,,"4,044.85 x patient days",16180,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,24249,,"27,634 x DRG weight",24249,Other,base rate x DRG weight,20611,,"23,488 x DRG weight",20611,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,13309,,"3,327.21 x patient days",13309,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,12179,,"3,044.51 x patient days",12179,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,23922,,"5,980.29 x patient days",23922,Per diem,,28185,,"7,045.87 x patient days",28185,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,10874,,"2,718.31 x patient days",10874,Per diem,,0.01,28185,
Head trauma w coma >1 hr or hemorrhage,055-3,APR-DRG,,,,,,,,inpatient,,,224219.58,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,16180,,"4,044.85 x patient days",16180,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,41473,,"27,634 x DRG weight",41473,Other,base rate x DRG weight,35251,,"23,488 x DRG weight",35251,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,13309,,"3,327.21 x patient days",13309,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,12179,,"3,044.51 x patient days",12179,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,23922,,"5,980.29 x patient days",23922,Per diem,,28185,,"7,045.87 x patient days",28185,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,10874,,"2,718.31 x patient days",10874,Per diem,,0.01,41473,
Head trauma w coma >1 hr or hemorrhage,055-4,APR-DRG,,,,,,,,inpatient,,,556386.4,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,16180,,"4,044.85 x patient days",16180,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,93491,,"27,634 x DRG weight",93491,Other,base rate x DRG weight,79465,,"23,488 x DRG weight",79465,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,13309,,"3,327.21 x patient days",13309,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,12179,,"3,044.51 x patient days",12179,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,23922,,"5,980.29 x patient days",23922,Per diem,,28185,,"7,045.87 x patient days",28185,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,10874,,"2,718.31 x patient days",10874,Per diem,,0.01,93491,
"Brain contusion/laceration & complicated skull Fx, coma < 1 hr or no coma",056-1,APR-DRG,,,,,,,,inpatient,,,77715.73,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,16180,,"4,044.85 x patient days",16180,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,14350,,"27,634 x DRG weight",14350,Other,base rate x DRG weight,12197,,"23,488 x DRG weight",12197,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,13309,,"3,327.21 x patient days",13309,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,12179,,"3,044.51 x patient days",12179,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,23922,,"5,980.29 x patient days",23922,Per diem,,28185,,"7,045.87 x patient days",28185,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,10874,,"2,718.31 x patient days",10874,Per diem,,0.01,28185,
"Brain contusion/laceration & complicated skull Fx, coma < 1 hr or no coma",056-2,APR-DRG,,,,,,,,inpatient,,,129437.02,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,16180,,"4,044.85 x patient days",16180,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,22151,,"27,634 x DRG weight",22151,Other,base rate x DRG weight,18828,,"23,488 x DRG weight",18828,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,13309,,"3,327.21 x patient days",13309,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,12179,,"3,044.51 x patient days",12179,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,23922,,"5,980.29 x patient days",23922,Per diem,,28185,,"7,045.87 x patient days",28185,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,10874,,"2,718.31 x patient days",10874,Per diem,,0.01,28185,
"Brain contusion/laceration & complicated skull Fx, coma < 1 hr or no coma",056-3,APR-DRG,,,,,,,,inpatient,,,33187.55,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,16180,,"4,044.85 x patient days",16180,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,39425,,"27,634 x DRG weight",39425,Other,base rate x DRG weight,33510,,"23,488 x DRG weight",33510,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,13309,,"3,327.21 x patient days",13309,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,12179,,"3,044.51 x patient days",12179,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,23922,,"5,980.29 x patient days",23922,Per diem,,28185,,"7,045.87 x patient days",28185,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,10874,,"2,718.31 x patient days",10874,Per diem,,0.01,39425,
"Brain contusion/laceration & complicated skull Fx, coma < 1 hr or no coma",056-4,APR-DRG,,,,,,,,inpatient,,,296222.6,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,16180,,"4,044.85 x patient days",16180,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,105120,,"27,634 x DRG weight",105120,Other,base rate x DRG weight,89348,,"23,488 x DRG weight",89348,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,13309,,"3,327.21 x patient days",13309,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,12179,,"3,044.51 x patient days",12179,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,23922,,"5,980.29 x patient days",23922,Per diem,,28185,,"7,045.87 x patient days",28185,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,10874,,"2,718.31 x patient days",10874,Per diem,,0.01,105120,
"Concussion, closed skull Fx nos,uncomplicated intracranial injury, coma < 1 hr or no coma",057-1,APR-DRG,,,,,,,,inpatient,,,87457.34,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8089,,"4,044.85 x patient days",8089,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,10968,,"27,634 x DRG weight",10968,Other,base rate x DRG weight,9322,,"23,488 x DRG weight",9322,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6654,,"3,327.21 x patient days",6654,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6089,,"3,044.51 x patient days",6089,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,11960,,"5,980.29 x patient days",11960,Per diem,,14091,,"7,045.87 x patient days",14091,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,5436,,"2,718.31 x patient days",5436,Per diem,,0.01,14091,
"Concussion, closed skull Fx nos,uncomplicated intracranial injury, coma < 1 hr or no coma",057-2,APR-DRG,,,,,,,,inpatient,,,82004.88,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8089,,"4,044.85 x patient days",8089,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,14920,,"27,634 x DRG weight",14920,Other,base rate x DRG weight,12681,,"23,488 x DRG weight",12681,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6654,,"3,327.21 x patient days",6654,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6089,,"3,044.51 x patient days",6089,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,11960,,"5,980.29 x patient days",11960,Per diem,,14091,,"7,045.87 x patient days",14091,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,5436,,"2,718.31 x patient days",5436,Per diem,,0.01,14920,
"Concussion, closed skull Fx nos,uncomplicated intracranial injury, coma < 1 hr or no coma",057-3,APR-DRG,,,,,,,,inpatient,,,109547.25,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8089,,"4,044.85 x patient days",8089,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,26761,,"27,634 x DRG weight",26761,Other,base rate x DRG weight,22746,,"23,488 x DRG weight",22746,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6654,,"3,327.21 x patient days",6654,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6089,,"3,044.51 x patient days",6089,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,11960,,"5,980.29 x patient days",11960,Per diem,,14091,,"7,045.87 x patient days",14091,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,5436,,"2,718.31 x patient days",5436,Per diem,,0.01,26761,
"Concussion, closed skull Fx nos,uncomplicated intracranial injury, coma < 1 hr or no coma",057-4,APR-DRG,,,,,,,,inpatient,,,160983.2,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8089,,"4,044.85 x patient days",8089,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,81625,,"27,634 x DRG weight",81625,Other,base rate x DRG weight,69379,,"23,488 x DRG weight",69379,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6654,,"3,327.21 x patient days",6654,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6089,,"3,044.51 x patient days",6089,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,11960,,"5,980.29 x patient days",11960,Per diem,,14091,,"7,045.87 x patient days",14091,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,5436,,"2,718.31 x patient days",5436,Per diem,,0.01,81625,
Other disorders of nervous system,058-1,APR-DRG,,,,,,,,inpatient,,,101846.62,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12135,,"4,044.85 x patient days",12135,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,14881,,"27,634 x DRG weight",14881,Other,base rate x DRG weight,12648,,"23,488 x DRG weight",12648,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9982,,"3,327.21 x patient days",9982,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9134,,"3,044.51 x patient days",9134,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,17941,,"5,980.29 x patient days",17941,Per diem,,21138,,"7,045.87 x patient days",21138,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,8155,,"2,718.31 x patient days",8155,Per diem,,0.01,21138,
Other disorders of nervous system,058-2,APR-DRG,,,,,,,,inpatient,,,137387.77,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12135,,"4,044.85 x patient days",12135,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,21635,,"27,634 x DRG weight",21635,Other,base rate x DRG weight,18389,,"23,488 x DRG weight",18389,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9982,,"3,327.21 x patient days",9982,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9134,,"3,044.51 x patient days",9134,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,17941,,"5,980.29 x patient days",17941,Per diem,,21138,,"7,045.87 x patient days",21138,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,8155,,"2,718.31 x patient days",8155,Per diem,,0.01,21635,
Other disorders of nervous system,058-3,APR-DRG,,,,,,,,inpatient,,,232142.62,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12135,,"4,044.85 x patient days",12135,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,34938,,"27,634 x DRG weight",34938,Other,base rate x DRG weight,29696,,"23,488 x DRG weight",29696,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9982,,"3,327.21 x patient days",9982,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9134,,"3,044.51 x patient days",9134,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,17941,,"5,980.29 x patient days",17941,Per diem,,21138,,"7,045.87 x patient days",21138,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,8155,,"2,718.31 x patient days",8155,Per diem,,0.01,34938,
Other disorders of nervous system,058-4,APR-DRG,,,,,,,,inpatient,,,214088.32,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12135,,"4,044.85 x patient days",12135,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,93632,,"27,634 x DRG weight",93632,Other,base rate x DRG weight,79584,,"23,488 x DRG weight",79584,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9982,,"3,327.21 x patient days",9982,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9134,,"3,044.51 x patient days",9134,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,17941,,"5,980.29 x patient days",17941,Per diem,,21138,,"7,045.87 x patient days",21138,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,8155,,"2,718.31 x patient days",8155,Per diem,,0.01,93632,
Orbital procedures,070-1,APR-DRG,,,,,,,,inpatient,,,86402.55,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12135,,"4,044.85 x patient days",12135,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,22223,,"27,634 x DRG weight",22223,Other,base rate x DRG weight,18889,,"23,488 x DRG weight",18889,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9982,,"3,327.21 x patient days",9982,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9134,,"3,044.51 x patient days",9134,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,17941,,"5,980.29 x patient days",17941,Per diem,,21138,,"7,045.87 x patient days",21138,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,8155,,"2,718.31 x patient days",8155,Per diem,,0.01,22223,
Orbital procedures,070-2,APR-DRG,,,,,,,,inpatient,,,134182.94,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12135,,"4,044.85 x patient days",12135,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,34095,,"27,634 x DRG weight",34095,Other,base rate x DRG weight,28979,,"23,488 x DRG weight",28979,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9982,,"3,327.21 x patient days",9982,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9134,,"3,044.51 x patient days",9134,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,17941,,"5,980.29 x patient days",17941,Per diem,,21138,,"7,045.87 x patient days",21138,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,8155,,"2,718.31 x patient days",8155,Per diem,,0.01,34095,
Orbital procedures,070-3,APR-DRG,,,,,,,,inpatient,,,541419.85,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12135,,"4,044.85 x patient days",12135,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,56343,,"27,634 x DRG weight",56343,Other,base rate x DRG weight,47890,,"23,488 x DRG weight",47890,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9982,,"3,327.21 x patient days",9982,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9134,,"3,044.51 x patient days",9134,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,17941,,"5,980.29 x patient days",17941,Per diem,,21138,,"7,045.87 x patient days",21138,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,8155,,"2,718.31 x patient days",8155,Per diem,,0.01,56343,
Orbital procedures,070-4,APR-DRG,,,,,,,,inpatient,,,541419.85,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12135,,"4,044.85 x patient days",12135,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,64130,,"27,634 x DRG weight",64130,Other,base rate x DRG weight,54509,,"23,488 x DRG weight",54509,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9982,,"3,327.21 x patient days",9982,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9134,,"3,044.51 x patient days",9134,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,17941,,"5,980.29 x patient days",17941,Per diem,,21138,,"7,045.87 x patient days",21138,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,8155,,"2,718.31 x patient days",8155,Per diem,,0.01,64130,
Eye procedures except orbit,073-1,APR-DRG,,,,,,,,inpatient,,,120793.18,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12135,,"4,044.85 x patient days",12135,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,18211,,"27,634 x DRG weight",18211,Other,base rate x DRG weight,15479,,"23,488 x DRG weight",15479,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9982,,"3,327.21 x patient days",9982,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9134,,"3,044.51 x patient days",9134,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,17941,,"5,980.29 x patient days",17941,Per diem,,21138,,"7,045.87 x patient days",21138,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,8155,,"2,718.31 x patient days",8155,Per diem,,0.01,21138,
Eye procedures except orbit,073-2,APR-DRG,,,,,,,,inpatient,,,129700.15,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12135,,"4,044.85 x patient days",12135,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,23378,,"27,634 x DRG weight",23378,Other,base rate x DRG weight,19871,,"23,488 x DRG weight",19871,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9982,,"3,327.21 x patient days",9982,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9134,,"3,044.51 x patient days",9134,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,17941,,"5,980.29 x patient days",17941,Per diem,,21138,,"7,045.87 x patient days",21138,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,8155,,"2,718.31 x patient days",8155,Per diem,,0.01,23378,
Eye procedures except orbit,073-3,APR-DRG,,,,,,,,inpatient,,,721787.24,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12135,,"4,044.85 x patient days",12135,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,68112,,"27,634 x DRG weight",68112,Other,base rate x DRG weight,57893,,"23,488 x DRG weight",57893,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9982,,"3,327.21 x patient days",9982,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9134,,"3,044.51 x patient days",9134,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,17941,,"5,980.29 x patient days",17941,Per diem,,21138,,"7,045.87 x patient days",21138,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,8155,,"2,718.31 x patient days",8155,Per diem,,0.01,68112,
Eye procedures except orbit,073-4,APR-DRG,,,,,,,,inpatient,,,285207.06,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12135,,"4,044.85 x patient days",12135,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,71202,,"27,634 x DRG weight",71202,Other,base rate x DRG weight,60519,,"23,488 x DRG weight",60519,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9982,,"3,327.21 x patient days",9982,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9134,,"3,044.51 x patient days",9134,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,17941,,"5,980.29 x patient days",17941,Per diem,,21138,,"7,045.87 x patient days",21138,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,8155,,"2,718.31 x patient days",8155,Per diem,,0.01,71202,
Acute major eye infections,080-1,APR-DRG,,,,,,,,inpatient,,,62248.42,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,16180,,"4,044.85 x patient days",16180,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,15190,,"27,634 x DRG weight",15190,Other,base rate x DRG weight,12911,,"23,488 x DRG weight",12911,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,13309,,"3,327.21 x patient days",13309,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,12179,,"3,044.51 x patient days",12179,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,23922,,"5,980.29 x patient days",23922,Per diem,,28185,,"7,045.87 x patient days",28185,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,10874,,"2,718.31 x patient days",10874,Per diem,,0.01,28185,
Acute major eye infections,080-2,APR-DRG,,,,,,,,inpatient,,,75862.99,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,16180,,"4,044.85 x patient days",16180,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,19407,,"27,634 x DRG weight",19407,Other,base rate x DRG weight,16496,,"23,488 x DRG weight",16496,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,13309,,"3,327.21 x patient days",13309,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,12179,,"3,044.51 x patient days",12179,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,23922,,"5,980.29 x patient days",23922,Per diem,,28185,,"7,045.87 x patient days",28185,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,10874,,"2,718.31 x patient days",10874,Per diem,,0.01,28185,
Acute major eye infections,080-3,APR-DRG,,,,,,,,inpatient,,,189423,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,16180,,"4,044.85 x patient days",16180,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,33470,,"27,634 x DRG weight",33470,Other,base rate x DRG weight,28449,,"23,488 x DRG weight",28449,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,13309,,"3,327.21 x patient days",13309,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,12179,,"3,044.51 x patient days",12179,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,23922,,"5,980.29 x patient days",23922,Per diem,,28185,,"7,045.87 x patient days",28185,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,10874,,"2,718.31 x patient days",10874,Per diem,,0.01,33470,
Acute major eye infections,080-4,APR-DRG,,,,,,,,inpatient,,,189423,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,16180,,"4,044.85 x patient days",16180,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,37361,,"27,634 x DRG weight",37361,Other,base rate x DRG weight,31756,,"23,488 x DRG weight",31756,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,13309,,"3,327.21 x patient days",13309,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,12179,,"3,044.51 x patient days",12179,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,23922,,"5,980.29 x patient days",23922,Per diem,,28185,,"7,045.87 x patient days",28185,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,10874,,"2,718.31 x patient days",10874,Per diem,,0.01,37361,
Eye disorders except major infections,082-1,APR-DRG,,,,,,,,inpatient,,,92331.8,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12135,,"4,044.85 x patient days",12135,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,13527,,"27,634 x DRG weight",13527,Other,base rate x DRG weight,11497,,"23,488 x DRG weight",11497,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9982,,"3,327.21 x patient days",9982,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9134,,"3,044.51 x patient days",9134,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,17941,,"5,980.29 x patient days",17941,Per diem,,21138,,"7,045.87 x patient days",21138,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,8155,,"2,718.31 x patient days",8155,Per diem,,0.01,21138,
Eye disorders except major infections,082-2,APR-DRG,,,,,,,,inpatient,,,117692.58,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12135,,"4,044.85 x patient days",12135,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,16401,,"27,634 x DRG weight",16401,Other,base rate x DRG weight,13940,,"23,488 x DRG weight",13940,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9982,,"3,327.21 x patient days",9982,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9134,,"3,044.51 x patient days",9134,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,17941,,"5,980.29 x patient days",17941,Per diem,,21138,,"7,045.87 x patient days",21138,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,8155,,"2,718.31 x patient days",8155,Per diem,,0.01,21138,
Eye disorders except major infections,082-3,APR-DRG,,,,,,,,inpatient,,,271037.25,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12135,,"4,044.85 x patient days",12135,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,28355,,"27,634 x DRG weight",28355,Other,base rate x DRG weight,24101,,"23,488 x DRG weight",24101,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9982,,"3,327.21 x patient days",9982,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9134,,"3,044.51 x patient days",9134,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,17941,,"5,980.29 x patient days",17941,Per diem,,21138,,"7,045.87 x patient days",21138,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,8155,,"2,718.31 x patient days",8155,Per diem,,0.01,28355,
Eye disorders except major infections,082-4,APR-DRG,,,,,,,,inpatient,,,271037.25,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12135,,"4,044.85 x patient days",12135,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,29151,,"27,634 x DRG weight",29151,Other,base rate x DRG weight,24777,,"23,488 x DRG weight",24777,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9982,,"3,327.21 x patient days",9982,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9134,,"3,044.51 x patient days",9134,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,17941,,"5,980.29 x patient days",17941,Per diem,,21138,,"7,045.87 x patient days",21138,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,8155,,"2,718.31 x patient days",8155,Per diem,,0.01,29151,
Major cranial/facial bone procedures,089-1,APR-DRG,,,,,,,,inpatient,,,163032.31,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,20224,,"4,044.85 x patient days",20224,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,37676,,"27,634 x DRG weight",37676,Other,base rate x DRG weight,32024,,"23,488 x DRG weight",32024,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,16636,,"3,327.21 x patient days",16636,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,15222,,"3,044.51 x patient days",15222,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,29901,,"5,980.29 x patient days",29901,Per diem,,35229,,"7,045.87 x patient days",35229,Per diem,,23377,,"4,675.50 x patient days",23377,Per diem,,23377,,"4,675.50 x patient days",23377,Per diem,,13591,,"2,718.31 x patient days",13591,Per diem,,0.01,37676,
Major cranial/facial bone procedures,089-2,APR-DRG,,,,,,,,inpatient,,,248871.79,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,20224,,"4,044.85 x patient days",20224,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,59750,,"27,634 x DRG weight",59750,Other,base rate x DRG weight,50786,,"23,488 x DRG weight",50786,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,16636,,"3,327.21 x patient days",16636,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,15222,,"3,044.51 x patient days",15222,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,29901,,"5,980.29 x patient days",29901,Per diem,,35229,,"7,045.87 x patient days",35229,Per diem,,23377,,"4,675.50 x patient days",23377,Per diem,,23377,,"4,675.50 x patient days",23377,Per diem,,13591,,"2,718.31 x patient days",13591,Per diem,,0.01,59750,
Major cranial/facial bone procedures,089-3,APR-DRG,,,,,,,,inpatient,,,509390.85,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,20224,,"4,044.85 x patient days",20224,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,105286,,"27,634 x DRG weight",105286,Other,base rate x DRG weight,89489,,"23,488 x DRG weight",89489,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,16636,,"3,327.21 x patient days",16636,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,15222,,"3,044.51 x patient days",15222,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,29901,,"5,980.29 x patient days",29901,Per diem,,35229,,"7,045.87 x patient days",35229,Per diem,,23377,,"4,675.50 x patient days",23377,Per diem,,23377,,"4,675.50 x patient days",23377,Per diem,,13591,,"2,718.31 x patient days",13591,Per diem,,0.01,105286,
Major cranial/facial bone procedures,089-4,APR-DRG,,,,,,,,inpatient,,,1100723.23,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,20224,,"4,044.85 x patient days",20224,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,188425,,"27,634 x DRG weight",188425,Other,base rate x DRG weight,160155,,"23,488 x DRG weight",160155,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,16636,,"3,327.21 x patient days",16636,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,15222,,"3,044.51 x patient days",15222,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,29901,,"5,980.29 x patient days",29901,Per diem,,35229,,"7,045.87 x patient days",35229,Per diem,,23377,,"4,675.50 x patient days",23377,Per diem,,23377,,"4,675.50 x patient days",23377,Per diem,,13591,,"2,718.31 x patient days",13591,Per diem,,0.01,188425,
Major larynx & trachea procedures,090-1,APR-DRG,,,,,,,,inpatient,,,111215.31,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,44493,,"4,044.85 x patient days",44493,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,20963,,"27,634 x DRG weight",20963,Other,base rate x DRG weight,17818,,"23,488 x DRG weight",17818,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,23921,,"2,174.65 x patient days",23921,Per diem,,23921,,"2,174.65 x patient days",23921,Per diem,,23921,,"2,174.65 x patient days",23921,Per diem,,23921,,"2,174.65 x patient days",23921,Per diem,,53822,,"4,892.96 x patient days",53822,Per diem,,36599,,"3,327.21 x patient days",36599,Per diem,,53822,,"4,892.96 x patient days",53822,Per diem,,33489,,"3,044.51 x patient days",33489,Per diem,,53822,,"4,892.96 x patient days",53822,Per diem,,65783,,"5,980.29 x patient days",65783,Per diem,,77504,,"7,045.87 x patient days",77504,Per diem,,51430,,"4,675.50 x patient days",51430,Per diem,,51430,,"4,675.50 x patient days",51430,Per diem,,29901,,"2,718.31 x patient days",29901,Per diem,,0.01,77504,
Major larynx & trachea procedures,090-2,APR-DRG,,,,,,,,inpatient,,,357205.01,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,44493,,"4,044.85 x patient days",44493,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,62787,,"27,634 x DRG weight",62787,Other,base rate x DRG weight,53367,,"23,488 x DRG weight",53367,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,23921,,"2,174.65 x patient days",23921,Per diem,,23921,,"2,174.65 x patient days",23921,Per diem,,23921,,"2,174.65 x patient days",23921,Per diem,,23921,,"2,174.65 x patient days",23921,Per diem,,53822,,"4,892.96 x patient days",53822,Per diem,,36599,,"3,327.21 x patient days",36599,Per diem,,53822,,"4,892.96 x patient days",53822,Per diem,,33489,,"3,044.51 x patient days",33489,Per diem,,53822,,"4,892.96 x patient days",53822,Per diem,,65783,,"5,980.29 x patient days",65783,Per diem,,77504,,"7,045.87 x patient days",77504,Per diem,,51430,,"4,675.50 x patient days",51430,Per diem,,51430,,"4,675.50 x patient days",51430,Per diem,,29901,,"2,718.31 x patient days",29901,Per diem,,0.01,77504,
Major larynx & trachea procedures,090-3,APR-DRG,,,,,,,,inpatient,,,300761.19,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,44493,,"4,044.85 x patient days",44493,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,112929,,"27,634 x DRG weight",112929,Other,base rate x DRG weight,95986,,"23,488 x DRG weight",95986,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,23921,,"2,174.65 x patient days",23921,Per diem,,23921,,"2,174.65 x patient days",23921,Per diem,,23921,,"2,174.65 x patient days",23921,Per diem,,23921,,"2,174.65 x patient days",23921,Per diem,,53822,,"4,892.96 x patient days",53822,Per diem,,36599,,"3,327.21 x patient days",36599,Per diem,,53822,,"4,892.96 x patient days",53822,Per diem,,33489,,"3,044.51 x patient days",33489,Per diem,,53822,,"4,892.96 x patient days",53822,Per diem,,65783,,"5,980.29 x patient days",65783,Per diem,,77504,,"7,045.87 x patient days",77504,Per diem,,51430,,"4,675.50 x patient days",51430,Per diem,,51430,,"4,675.50 x patient days",51430,Per diem,,29901,,"2,718.31 x patient days",29901,Per diem,,0.01,112929,
Major larynx & trachea procedures,090-4,APR-DRG,,,,,,,,inpatient,,,1517996.77,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,44493,,"4,044.85 x patient days",44493,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,310341,,"27,634 x DRG weight",310341,Other,base rate x DRG weight,263780,,"23,488 x DRG weight",263780,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,23921,,"2,174.65 x patient days",23921,Per diem,,23921,,"2,174.65 x patient days",23921,Per diem,,23921,,"2,174.65 x patient days",23921,Per diem,,23921,,"2,174.65 x patient days",23921,Per diem,,53822,,"4,892.96 x patient days",53822,Per diem,,36599,,"3,327.21 x patient days",36599,Per diem,,53822,,"4,892.96 x patient days",53822,Per diem,,33489,,"3,044.51 x patient days",33489,Per diem,,53822,,"4,892.96 x patient days",53822,Per diem,,65783,,"5,980.29 x patient days",65783,Per diem,,77504,,"7,045.87 x patient days",77504,Per diem,,51430,,"4,675.50 x patient days",51430,Per diem,,51430,,"4,675.50 x patient days",51430,Per diem,,29901,,"2,718.31 x patient days",29901,Per diem,,0.01,310341,
Other major head & neck procedures,091-1,APR-DRG,,,,,,,,inpatient,,,591656.53,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,16180,,"4,044.85 x patient days",16180,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,36880,,"27,634 x DRG weight",36880,Other,base rate x DRG weight,31347,,"23,488 x DRG weight",31347,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,13309,,"3,327.21 x patient days",13309,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,12179,,"3,044.51 x patient days",12179,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,23922,,"5,980.29 x patient days",23922,Per diem,,28185,,"7,045.87 x patient days",28185,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,10874,,"2,718.31 x patient days",10874,Per diem,,0.01,36880,
Other major head & neck procedures,091-2,APR-DRG,,,,,,,,inpatient,,,591656.53,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,16180,,"4,044.85 x patient days",16180,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,78729,,"27,634 x DRG weight",78729,Other,base rate x DRG weight,66917,,"23,488 x DRG weight",66917,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,13309,,"3,327.21 x patient days",13309,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,12179,,"3,044.51 x patient days",12179,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,23922,,"5,980.29 x patient days",23922,Per diem,,28185,,"7,045.87 x patient days",28185,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,10874,,"2,718.31 x patient days",10874,Per diem,,0.01,78729,
Other major head & neck procedures,091-3,APR-DRG,,,,,,,,inpatient,,,553354.16,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,16180,,"4,044.85 x patient days",16180,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,101820,,"27,634 x DRG weight",101820,Other,base rate x DRG weight,86544,,"23,488 x DRG weight",86544,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,13309,,"3,327.21 x patient days",13309,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,12179,,"3,044.51 x patient days",12179,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,23922,,"5,980.29 x patient days",23922,Per diem,,28185,,"7,045.87 x patient days",28185,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,10874,,"2,718.31 x patient days",10874,Per diem,,0.01,101820,
Other major head & neck procedures,091-4,APR-DRG,,,,,,,,inpatient,,,591656.53,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,16180,,"4,044.85 x patient days",16180,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,114479,,"27,634 x DRG weight",114479,Other,base rate x DRG weight,97304,,"23,488 x DRG weight",97304,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,13309,,"3,327.21 x patient days",13309,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,12179,,"3,044.51 x patient days",12179,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,23922,,"5,980.29 x patient days",23922,Per diem,,28185,,"7,045.87 x patient days",28185,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,10874,,"2,718.31 x patient days",10874,Per diem,,0.01,114479,
Facial bone procedures except major cranial/facial bone procedures,092-1,APR-DRG,,,,,,,,inpatient,,,144089.34,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12135,,"4,044.85 x patient days",12135,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,29060,,"27,634 x DRG weight",29060,Other,base rate x DRG weight,24700,,"23,488 x DRG weight",24700,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9982,,"3,327.21 x patient days",9982,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9134,,"3,044.51 x patient days",9134,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,17941,,"5,980.29 x patient days",17941,Per diem,,21138,,"7,045.87 x patient days",21138,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,8155,,"2,718.31 x patient days",8155,Per diem,,0.01,29060,
Facial bone procedures except major cranial/facial bone procedures,092-2,APR-DRG,,,,,,,,inpatient,,,228573.82,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12135,,"4,044.85 x patient days",12135,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,37707,,"27,634 x DRG weight",37707,Other,base rate x DRG weight,32049,,"23,488 x DRG weight",32049,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9982,,"3,327.21 x patient days",9982,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9134,,"3,044.51 x patient days",9134,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,17941,,"5,980.29 x patient days",17941,Per diem,,21138,,"7,045.87 x patient days",21138,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,8155,,"2,718.31 x patient days",8155,Per diem,,0.01,37707,
Facial bone procedures except major cranial/facial bone procedures,092-3,APR-DRG,,,,,,,,inpatient,,,358636.71,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12135,,"4,044.85 x patient days",12135,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,60220,,"27,634 x DRG weight",60220,Other,base rate x DRG weight,51185,,"23,488 x DRG weight",51185,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9982,,"3,327.21 x patient days",9982,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9134,,"3,044.51 x patient days",9134,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,17941,,"5,980.29 x patient days",17941,Per diem,,21138,,"7,045.87 x patient days",21138,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,8155,,"2,718.31 x patient days",8155,Per diem,,0.01,60220,
Facial bone procedures except major cranial/facial bone procedures,092-4,APR-DRG,,,,,,,,inpatient,,,957722.22,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12135,,"4,044.85 x patient days",12135,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,203204,,"27,634 x DRG weight",203204,Other,base rate x DRG weight,172717,,"23,488 x DRG weight",172717,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9982,,"3,327.21 x patient days",9982,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9134,,"3,044.51 x patient days",9134,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,17941,,"5,980.29 x patient days",17941,Per diem,,21138,,"7,045.87 x patient days",21138,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,8155,,"2,718.31 x patient days",8155,Per diem,,0.01,203204,
Sinus & mastoid procedures,093-1,APR-DRG,,,,,,,,inpatient,,,92659.22,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12135,,"4,044.85 x patient days",12135,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,24788,,"27,634 x DRG weight",24788,Other,base rate x DRG weight,21069,,"23,488 x DRG weight",21069,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9982,,"3,327.21 x patient days",9982,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9134,,"3,044.51 x patient days",9134,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,17941,,"5,980.29 x patient days",17941,Per diem,,21138,,"7,045.87 x patient days",21138,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,8155,,"2,718.31 x patient days",8155,Per diem,,0.01,24788,
Sinus & mastoid procedures,093-2,APR-DRG,,,,,,,,inpatient,,,168159.59,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12135,,"4,044.85 x patient days",12135,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,34095,,"27,634 x DRG weight",34095,Other,base rate x DRG weight,28979,,"23,488 x DRG weight",28979,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9982,,"3,327.21 x patient days",9982,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9134,,"3,044.51 x patient days",9134,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,17941,,"5,980.29 x patient days",17941,Per diem,,21138,,"7,045.87 x patient days",21138,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,8155,,"2,718.31 x patient days",8155,Per diem,,0.01,34095,
Sinus & mastoid procedures,093-3,APR-DRG,,,,,,,,inpatient,,,320080.1,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12135,,"4,044.85 x patient days",12135,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,65440,,"27,634 x DRG weight",65440,Other,base rate x DRG weight,55622,,"23,488 x DRG weight",55622,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9982,,"3,327.21 x patient days",9982,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9134,,"3,044.51 x patient days",9134,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,17941,,"5,980.29 x patient days",17941,Per diem,,21138,,"7,045.87 x patient days",21138,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,8155,,"2,718.31 x patient days",8155,Per diem,,0.01,65440,
Sinus & mastoid procedures,093-4,APR-DRG,,,,,,,,inpatient,,,350155.65,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12135,,"4,044.85 x patient days",12135,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,76850,,"27,634 x DRG weight",76850,Other,base rate x DRG weight,65320,,"23,488 x DRG weight",65320,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9982,,"3,327.21 x patient days",9982,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9134,,"3,044.51 x patient days",9134,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,17941,,"5,980.29 x patient days",17941,Per diem,,21138,,"7,045.87 x patient days",21138,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,8155,,"2,718.31 x patient days",8155,Per diem,,0.01,76850,
Cleft lip & palate repair,095-1,APR-DRG,,,,,,,,inpatient,,,93293.69,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8089,,"4,044.85 x patient days",8089,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,19811,,"27,634 x DRG weight",19811,Other,base rate x DRG weight,16839,,"23,488 x DRG weight",16839,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6654,,"3,327.21 x patient days",6654,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6089,,"3,044.51 x patient days",6089,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,11960,,"5,980.29 x patient days",11960,Per diem,,14091,,"7,045.87 x patient days",14091,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,5436,,"2,718.31 x patient days",5436,Per diem,,0.01,19811,
Cleft lip & palate repair,095-2,APR-DRG,,,,,,,,inpatient,,,70312.7,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8089,,"4,044.85 x patient days",8089,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,25064,,"27,634 x DRG weight",25064,Other,base rate x DRG weight,21304,,"23,488 x DRG weight",21304,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6654,,"3,327.21 x patient days",6654,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6089,,"3,044.51 x patient days",6089,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,11960,,"5,980.29 x patient days",11960,Per diem,,14091,,"7,045.87 x patient days",14091,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,5436,,"2,718.31 x patient days",5436,Per diem,,0.01,25064,
Cleft lip & palate repair,095-3,APR-DRG,,,,,,,,inpatient,,,93293.69,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8089,,"4,044.85 x patient days",8089,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,38312,,"27,634 x DRG weight",38312,Other,base rate x DRG weight,32564,,"23,488 x DRG weight",32564,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6654,,"3,327.21 x patient days",6654,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6089,,"3,044.51 x patient days",6089,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,11960,,"5,980.29 x patient days",11960,Per diem,,14091,,"7,045.87 x patient days",14091,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,5436,,"2,718.31 x patient days",5436,Per diem,,0.01,38312,
Cleft lip & palate repair,095-4,APR-DRG,,,,,,,,inpatient,,,93293.69,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8089,,"4,044.85 x patient days",8089,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,70287,,"27,634 x DRG weight",70287,Other,base rate x DRG weight,59742,,"23,488 x DRG weight",59742,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6654,,"3,327.21 x patient days",6654,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6089,,"3,044.51 x patient days",6089,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,11960,,"5,980.29 x patient days",11960,Per diem,,14091,,"7,045.87 x patient days",14091,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,5436,,"2,718.31 x patient days",5436,Per diem,,0.01,70287,
Tonsil & adenoid procedures,097-1,APR-DRG,,,,,,,,inpatient,,,59099.59,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8089,,"4,044.85 x patient days",8089,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,13380,,"27,634 x DRG weight",13380,Other,base rate x DRG weight,11373,,"23,488 x DRG weight",11373,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6654,,"3,327.21 x patient days",6654,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6089,,"3,044.51 x patient days",6089,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,11960,,"5,980.29 x patient days",11960,Per diem,,14091,,"7,045.87 x patient days",14091,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,5436,,"2,718.31 x patient days",5436,Per diem,,0.01,14091,
Tonsil & adenoid procedures,097-2,APR-DRG,,,,,,,,inpatient,,,85499.55,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8089,,"4,044.85 x patient days",8089,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,19084,,"27,634 x DRG weight",19084,Other,base rate x DRG weight,16221,,"23,488 x DRG weight",16221,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6654,,"3,327.21 x patient days",6654,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6089,,"3,044.51 x patient days",6089,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,11960,,"5,980.29 x patient days",11960,Per diem,,14091,,"7,045.87 x patient days",14091,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,5436,,"2,718.31 x patient days",5436,Per diem,,0.01,19084,
Tonsil & adenoid procedures,097-3,APR-DRG,,,,,,,,inpatient,,,121239.26,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8089,,"4,044.85 x patient days",8089,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,40873,,"27,634 x DRG weight",40873,Other,base rate x DRG weight,34741,,"23,488 x DRG weight",34741,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6654,,"3,327.21 x patient days",6654,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6089,,"3,044.51 x patient days",6089,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,11960,,"5,980.29 x patient days",11960,Per diem,,14091,,"7,045.87 x patient days",14091,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,5436,,"2,718.31 x patient days",5436,Per diem,,0.01,40873,
Tonsil & adenoid procedures,097-4,APR-DRG,,,,,,,,inpatient,,,200632.02,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8089,,"4,044.85 x patient days",8089,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,109823,,"27,634 x DRG weight",109823,Other,base rate x DRG weight,93346,,"23,488 x DRG weight",93346,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6654,,"3,327.21 x patient days",6654,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6089,,"3,044.51 x patient days",6089,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,11960,,"5,980.29 x patient days",11960,Per diem,,14091,,"7,045.87 x patient days",14091,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,5436,,"2,718.31 x patient days",5436,Per diem,,0.01,109823,
"Other ear, nose, mouth & throat procedures",098-1,APR-DRG,,,,,,,,inpatient,,,92389.93,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12135,,"4,044.85 x patient days",12135,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,18921,,"27,634 x DRG weight",18921,Other,base rate x DRG weight,16082,,"23,488 x DRG weight",16082,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9982,,"3,327.21 x patient days",9982,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9134,,"3,044.51 x patient days",9134,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,17941,,"5,980.29 x patient days",17941,Per diem,,21138,,"7,045.87 x patient days",21138,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,8155,,"2,718.31 x patient days",8155,Per diem,,0.01,21138,
"Other ear, nose, mouth & throat procedures",098-2,APR-DRG,,,,,,,,inpatient,,,124969.05,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12135,,"4,044.85 x patient days",12135,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,26951,,"27,634 x DRG weight",26951,Other,base rate x DRG weight,22908,,"23,488 x DRG weight",22908,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9982,,"3,327.21 x patient days",9982,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9134,,"3,044.51 x patient days",9134,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,17941,,"5,980.29 x patient days",17941,Per diem,,21138,,"7,045.87 x patient days",21138,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,8155,,"2,718.31 x patient days",8155,Per diem,,0.01,26951,
"Other ear, nose, mouth & throat procedures",098-3,APR-DRG,,,,,,,,inpatient,,,273103.8,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12135,,"4,044.85 x patient days",12135,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,51490,,"27,634 x DRG weight",51490,Other,base rate x DRG weight,43765,,"23,488 x DRG weight",43765,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9982,,"3,327.21 x patient days",9982,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9134,,"3,044.51 x patient days",9134,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,17941,,"5,980.29 x patient days",17941,Per diem,,21138,,"7,045.87 x patient days",21138,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,8155,,"2,718.31 x patient days",8155,Per diem,,0.01,51490,
"Other ear, nose, mouth & throat procedures",098-4,APR-DRG,,,,,,,,inpatient,,,813558.95,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12135,,"4,044.85 x patient days",12135,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,114999,,"27,634 x DRG weight",114999,Other,base rate x DRG weight,97745,,"23,488 x DRG weight",97745,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9982,,"3,327.21 x patient days",9982,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9134,,"3,044.51 x patient days",9134,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,17941,,"5,980.29 x patient days",17941,Per diem,,21138,,"7,045.87 x patient days",21138,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,8155,,"2,718.31 x patient days",8155,Per diem,,0.01,114999,
"Ear, nose, mouth, throat, cranial/facial malignancies",110-1,APR-DRG,,,,,,,,inpatient,,,106260,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,32358,,"4,044.85 x patient days",32358,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,19819,,"27,634 x DRG weight",19819,Other,base rate x DRG weight,16846,,"23,488 x DRG weight",16846,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,17397,,"2,174.65 x patient days",17397,Per diem,,17397,,"2,174.65 x patient days",17397,Per diem,,17397,,"2,174.65 x patient days",17397,Per diem,,17397,,"2,174.65 x patient days",17397,Per diem,,39143,,"4,892.96 x patient days",39143,Per diem,,26617,,"3,327.21 x patient days",26617,Per diem,,39143,,"4,892.96 x patient days",39143,Per diem,,24356,,"3,044.51 x patient days",24356,Per diem,,39143,,"4,892.96 x patient days",39143,Per diem,,47842,,"5,980.29 x patient days",47842,Per diem,,56366,,"7,045.87 x patient days",56366,Per diem,,37404,,"4,675.50 x patient days",37404,Per diem,,37404,,"4,675.50 x patient days",37404,Per diem,,21746,,"2,718.31 x patient days",21746,Per diem,,0.01,56366,
"Ear, nose, mouth, throat, cranial/facial malignancies",110-2,APR-DRG,,,,,,,,inpatient,,,79162,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,32358,,"4,044.85 x patient days",32358,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,24940,,"27,634 x DRG weight",24940,Other,base rate x DRG weight,21198,,"23,488 x DRG weight",21198,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,17397,,"2,174.65 x patient days",17397,Per diem,,17397,,"2,174.65 x patient days",17397,Per diem,,17397,,"2,174.65 x patient days",17397,Per diem,,17397,,"2,174.65 x patient days",17397,Per diem,,39143,,"4,892.96 x patient days",39143,Per diem,,26617,,"3,327.21 x patient days",26617,Per diem,,39143,,"4,892.96 x patient days",39143,Per diem,,24356,,"3,044.51 x patient days",24356,Per diem,,39143,,"4,892.96 x patient days",39143,Per diem,,47842,,"5,980.29 x patient days",47842,Per diem,,56366,,"7,045.87 x patient days",56366,Per diem,,37404,,"4,675.50 x patient days",37404,Per diem,,37404,,"4,675.50 x patient days",37404,Per diem,,21746,,"2,718.31 x patient days",21746,Per diem,,0.01,56366,
"Ear, nose, mouth, throat, cranial/facial malignancies",110-3,APR-DRG,,,,,,,,inpatient,,,175765.11,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,32358,,"4,044.85 x patient days",32358,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,49009,,"27,634 x DRG weight",49009,Other,base rate x DRG weight,41656,,"23,488 x DRG weight",41656,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,17397,,"2,174.65 x patient days",17397,Per diem,,17397,,"2,174.65 x patient days",17397,Per diem,,17397,,"2,174.65 x patient days",17397,Per diem,,17397,,"2,174.65 x patient days",17397,Per diem,,39143,,"4,892.96 x patient days",39143,Per diem,,26617,,"3,327.21 x patient days",26617,Per diem,,39143,,"4,892.96 x patient days",39143,Per diem,,24356,,"3,044.51 x patient days",24356,Per diem,,39143,,"4,892.96 x patient days",39143,Per diem,,47842,,"5,980.29 x patient days",47842,Per diem,,56366,,"7,045.87 x patient days",56366,Per diem,,37404,,"4,675.50 x patient days",37404,Per diem,,37404,,"4,675.50 x patient days",37404,Per diem,,21746,,"2,718.31 x patient days",21746,Per diem,,0.01,56366,
"Ear, nose, mouth, throat, cranial/facial malignancies",110-4,APR-DRG,,,,,,,,inpatient,,,609618.43,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,32358,,"4,044.85 x patient days",32358,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,100248,,"27,634 x DRG weight",100248,Other,base rate x DRG weight,85207,,"23,488 x DRG weight",85207,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,17397,,"2,174.65 x patient days",17397,Per diem,,17397,,"2,174.65 x patient days",17397,Per diem,,17397,,"2,174.65 x patient days",17397,Per diem,,17397,,"2,174.65 x patient days",17397,Per diem,,39143,,"4,892.96 x patient days",39143,Per diem,,26617,,"3,327.21 x patient days",26617,Per diem,,39143,,"4,892.96 x patient days",39143,Per diem,,24356,,"3,044.51 x patient days",24356,Per diem,,39143,,"4,892.96 x patient days",39143,Per diem,,47842,,"5,980.29 x patient days",47842,Per diem,,56366,,"7,045.87 x patient days",56366,Per diem,,37404,,"4,675.50 x patient days",37404,Per diem,,37404,,"4,675.50 x patient days",37404,Per diem,,21746,,"2,718.31 x patient days",21746,Per diem,,0.01,100248,
Vertigo & other labyrinth disorders,111-1,APR-DRG,,,,,,,,inpatient,,,94223.81,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8089,,"4,044.85 x patient days",8089,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12098,,"27,634 x DRG weight",12098,Other,base rate x DRG weight,10283,,"23,488 x DRG weight",10283,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6654,,"3,327.21 x patient days",6654,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6089,,"3,044.51 x patient days",6089,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,11960,,"5,980.29 x patient days",11960,Per diem,,14091,,"7,045.87 x patient days",14091,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,5436,,"2,718.31 x patient days",5436,Per diem,,0.01,14091,
Vertigo & other labyrinth disorders,111-2,APR-DRG,,,,,,,,inpatient,,,130338.67,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8089,,"4,044.85 x patient days",8089,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,14969,,"27,634 x DRG weight",14969,Other,base rate x DRG weight,12723,,"23,488 x DRG weight",12723,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6654,,"3,327.21 x patient days",6654,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6089,,"3,044.51 x patient days",6089,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,11960,,"5,980.29 x patient days",11960,Per diem,,14091,,"7,045.87 x patient days",14091,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,5436,,"2,718.31 x patient days",5436,Per diem,,0.01,14969,
Vertigo & other labyrinth disorders,111-3,APR-DRG,,,,,,,,inpatient,,,121320.4,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8089,,"4,044.85 x patient days",8089,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,21074,,"27,634 x DRG weight",21074,Other,base rate x DRG weight,17912,,"23,488 x DRG weight",17912,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6654,,"3,327.21 x patient days",6654,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6089,,"3,044.51 x patient days",6089,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,11960,,"5,980.29 x patient days",11960,Per diem,,14091,,"7,045.87 x patient days",14091,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,5436,,"2,718.31 x patient days",5436,Per diem,,0.01,21074,
Vertigo & other labyrinth disorders,111-4,APR-DRG,,,,,,,,inpatient,,,130338.67,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8089,,"4,044.85 x patient days",8089,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,21458,,"27,634 x DRG weight",21458,Other,base rate x DRG weight,18238,,"23,488 x DRG weight",18238,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6654,,"3,327.21 x patient days",6654,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6089,,"3,044.51 x patient days",6089,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,11960,,"5,980.29 x patient days",11960,Per diem,,14091,,"7,045.87 x patient days",14091,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,5436,,"2,718.31 x patient days",5436,Per diem,,0.01,21458,
Infections of upper respiratory tract,113-1,APR-DRG,,,,,,,,inpatient,,,47537.13,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8089,,"4,044.85 x patient days",8089,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,10725,,"27,634 x DRG weight",10725,Other,base rate x DRG weight,9116,,"23,488 x DRG weight",9116,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6654,,"3,327.21 x patient days",6654,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6089,,"3,044.51 x patient days",6089,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,11960,,"5,980.29 x patient days",11960,Per diem,,14091,,"7,045.87 x patient days",14091,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,5436,,"2,718.31 x patient days",5436,Per diem,,0.01,14091,
Infections of upper respiratory tract,113-2,APR-DRG,,,,,,,,inpatient,,,65903.7,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8089,,"4,044.85 x patient days",8089,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,13745,,"27,634 x DRG weight",13745,Other,base rate x DRG weight,11683,,"23,488 x DRG weight",11683,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6654,,"3,327.21 x patient days",6654,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6089,,"3,044.51 x patient days",6089,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,11960,,"5,980.29 x patient days",11960,Per diem,,14091,,"7,045.87 x patient days",14091,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,5436,,"2,718.31 x patient days",5436,Per diem,,0.01,14091,
Infections of upper respiratory tract,113-3,APR-DRG,,,,,,,,inpatient,,,98363.09,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8089,,"4,044.85 x patient days",8089,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,21516,,"27,634 x DRG weight",21516,Other,base rate x DRG weight,18288,,"23,488 x DRG weight",18288,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6654,,"3,327.21 x patient days",6654,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6089,,"3,044.51 x patient days",6089,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,11960,,"5,980.29 x patient days",11960,Per diem,,14091,,"7,045.87 x patient days",14091,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,5436,,"2,718.31 x patient days",5436,Per diem,,0.01,21516,
Infections of upper respiratory tract,113-4,APR-DRG,,,,,,,,inpatient,,,131847,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8089,,"4,044.85 x patient days",8089,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,57656,,"27,634 x DRG weight",57656,Other,base rate x DRG weight,49005,,"23,488 x DRG weight",49005,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6654,,"3,327.21 x patient days",6654,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6089,,"3,044.51 x patient days",6089,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,11960,,"5,980.29 x patient days",11960,Per diem,,14091,,"7,045.87 x patient days",14091,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,5436,,"2,718.31 x patient days",5436,Per diem,,0.01,57656,
Dental & oral diseases & injuries,114-1,APR-DRG,,,,,,,,inpatient,,,57194.42,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12135,,"4,044.85 x patient days",12135,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,13228,,"27,634 x DRG weight",13228,Other,base rate x DRG weight,11244,,"23,488 x DRG weight",11244,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9982,,"3,327.21 x patient days",9982,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9134,,"3,044.51 x patient days",9134,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,17941,,"5,980.29 x patient days",17941,Per diem,,21138,,"7,045.87 x patient days",21138,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,8155,,"2,718.31 x patient days",8155,Per diem,,0.01,21138,
Dental & oral diseases & injuries,114-2,APR-DRG,,,,,,,,inpatient,,,94020.35,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12135,,"4,044.85 x patient days",12135,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,16730,,"27,634 x DRG weight",16730,Other,base rate x DRG weight,14220,,"23,488 x DRG weight",14220,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9982,,"3,327.21 x patient days",9982,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9134,,"3,044.51 x patient days",9134,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,17941,,"5,980.29 x patient days",17941,Per diem,,21138,,"7,045.87 x patient days",21138,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,8155,,"2,718.31 x patient days",8155,Per diem,,0.01,21138,
Dental & oral diseases & injuries,114-3,APR-DRG,,,,,,,,inpatient,,,237822.49,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12135,,"4,044.85 x patient days",12135,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,33155,,"27,634 x DRG weight",33155,Other,base rate x DRG weight,28181,,"23,488 x DRG weight",28181,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9982,,"3,327.21 x patient days",9982,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9134,,"3,044.51 x patient days",9134,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,17941,,"5,980.29 x patient days",17941,Per diem,,21138,,"7,045.87 x patient days",21138,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,8155,,"2,718.31 x patient days",8155,Per diem,,0.01,33155,
Dental & oral diseases & injuries,114-4,APR-DRG,,,,,,,,inpatient,,,32501,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12135,,"4,044.85 x patient days",12135,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,68190,,"27,634 x DRG weight",68190,Other,base rate x DRG weight,57959,,"23,488 x DRG weight",57959,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9982,,"3,327.21 x patient days",9982,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9134,,"3,044.51 x patient days",9134,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,17941,,"5,980.29 x patient days",17941,Per diem,,21138,,"7,045.87 x patient days",21138,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,8155,,"2,718.31 x patient days",8155,Per diem,,0.01,68190,
"Other ear, nose, mouth,throat & cranial/facial diagnoses",115-1,APR-DRG,,,,,,,,inpatient,,,62696.36,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12135,,"4,044.85 x patient days",12135,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12203,,"27,634 x DRG weight",12203,Other,base rate x DRG weight,10372,,"23,488 x DRG weight",10372,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9982,,"3,327.21 x patient days",9982,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9134,,"3,044.51 x patient days",9134,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,17941,,"5,980.29 x patient days",17941,Per diem,,21138,,"7,045.87 x patient days",21138,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,8155,,"2,718.31 x patient days",8155,Per diem,,0.01,21138,
"Other ear, nose, mouth,throat & cranial/facial diagnoses",115-2,APR-DRG,,,,,,,,inpatient,,,109849.93,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12135,,"4,044.85 x patient days",12135,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,16619,,"27,634 x DRG weight",16619,Other,base rate x DRG weight,14126,,"23,488 x DRG weight",14126,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9982,,"3,327.21 x patient days",9982,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9134,,"3,044.51 x patient days",9134,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,17941,,"5,980.29 x patient days",17941,Per diem,,21138,,"7,045.87 x patient days",21138,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,8155,,"2,718.31 x patient days",8155,Per diem,,0.01,21138,
"Other ear, nose, mouth,throat & cranial/facial diagnoses",115-3,APR-DRG,,,,,,,,inpatient,,,97821.52,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12135,,"4,044.85 x patient days",12135,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,27441,,"27,634 x DRG weight",27441,Other,base rate x DRG weight,23324,,"23,488 x DRG weight",23324,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9982,,"3,327.21 x patient days",9982,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9134,,"3,044.51 x patient days",9134,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,17941,,"5,980.29 x patient days",17941,Per diem,,21138,,"7,045.87 x patient days",21138,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,8155,,"2,718.31 x patient days",8155,Per diem,,0.01,27441,
"Other ear, nose, mouth,throat & cranial/facial diagnoses",115-4,APR-DRG,,,,,,,,inpatient,,,341570.76,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12135,,"4,044.85 x patient days",12135,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,72451,,"27,634 x DRG weight",72451,Other,base rate x DRG weight,61581,,"23,488 x DRG weight",61581,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9982,,"3,327.21 x patient days",9982,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9134,,"3,044.51 x patient days",9134,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,17941,,"5,980.29 x patient days",17941,Per diem,,21138,,"7,045.87 x patient days",21138,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,8155,,"2,718.31 x patient days",8155,Per diem,,0.01,72451,
Major respiratory & chest procedures,120-1,APR-DRG,,,,,,,,inpatient,,,176767.21,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,32358,,"4,044.85 x patient days",32358,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,47881,,"27,634 x DRG weight",47881,Other,base rate x DRG weight,40698,,"23,488 x DRG weight",40698,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,17397,,"2,174.65 x patient days",17397,Per diem,,17397,,"2,174.65 x patient days",17397,Per diem,,17397,,"2,174.65 x patient days",17397,Per diem,,17397,,"2,174.65 x patient days",17397,Per diem,,39143,,"4,892.96 x patient days",39143,Per diem,,26617,,"3,327.21 x patient days",26617,Per diem,,39143,,"4,892.96 x patient days",39143,Per diem,,24356,,"3,044.51 x patient days",24356,Per diem,,39143,,"4,892.96 x patient days",39143,Per diem,,47842,,"5,980.29 x patient days",47842,Per diem,,56366,,"7,045.87 x patient days",56366,Per diem,,37404,,"4,675.50 x patient days",37404,Per diem,,37404,,"4,675.50 x patient days",37404,Per diem,,21746,,"2,718.31 x patient days",21746,Per diem,,0.01,56366,
Major respiratory & chest procedures,120-2,APR-DRG,,,,,,,,inpatient,,,209877.51,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,32358,,"4,044.85 x patient days",32358,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,58338,,"27,634 x DRG weight",58338,Other,base rate x DRG weight,49586,,"23,488 x DRG weight",49586,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,17397,,"2,174.65 x patient days",17397,Per diem,,17397,,"2,174.65 x patient days",17397,Per diem,,17397,,"2,174.65 x patient days",17397,Per diem,,17397,,"2,174.65 x patient days",17397,Per diem,,39143,,"4,892.96 x patient days",39143,Per diem,,26617,,"3,327.21 x patient days",26617,Per diem,,39143,,"4,892.96 x patient days",39143,Per diem,,24356,,"3,044.51 x patient days",24356,Per diem,,39143,,"4,892.96 x patient days",39143,Per diem,,47842,,"5,980.29 x patient days",47842,Per diem,,56366,,"7,045.87 x patient days",56366,Per diem,,37404,,"4,675.50 x patient days",37404,Per diem,,37404,,"4,675.50 x patient days",37404,Per diem,,21746,,"2,718.31 x patient days",21746,Per diem,,0.01,58338,
Major respiratory & chest procedures,120-3,APR-DRG,,,,,,,,inpatient,,,513444.58,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,32358,,"4,044.85 x patient days",32358,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,92969,,"27,634 x DRG weight",92969,Other,base rate x DRG weight,79021,,"23,488 x DRG weight",79021,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,17397,,"2,174.65 x patient days",17397,Per diem,,17397,,"2,174.65 x patient days",17397,Per diem,,17397,,"2,174.65 x patient days",17397,Per diem,,17397,,"2,174.65 x patient days",17397,Per diem,,39143,,"4,892.96 x patient days",39143,Per diem,,26617,,"3,327.21 x patient days",26617,Per diem,,39143,,"4,892.96 x patient days",39143,Per diem,,24356,,"3,044.51 x patient days",24356,Per diem,,39143,,"4,892.96 x patient days",39143,Per diem,,47842,,"5,980.29 x patient days",47842,Per diem,,56366,,"7,045.87 x patient days",56366,Per diem,,37404,,"4,675.50 x patient days",37404,Per diem,,37404,,"4,675.50 x patient days",37404,Per diem,,21746,,"2,718.31 x patient days",21746,Per diem,,0.01,92969,
Major respiratory & chest procedures,120-4,APR-DRG,,,,,,,,inpatient,,,618420.87,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,32358,,"4,044.85 x patient days",32358,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,168313,,"27,634 x DRG weight",168313,Other,base rate x DRG weight,143061,,"23,488 x DRG weight",143061,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,17397,,"2,174.65 x patient days",17397,Per diem,,17397,,"2,174.65 x patient days",17397,Per diem,,17397,,"2,174.65 x patient days",17397,Per diem,,17397,,"2,174.65 x patient days",17397,Per diem,,39143,,"4,892.96 x patient days",39143,Per diem,,26617,,"3,327.21 x patient days",26617,Per diem,,39143,,"4,892.96 x patient days",39143,Per diem,,24356,,"3,044.51 x patient days",24356,Per diem,,39143,,"4,892.96 x patient days",39143,Per diem,,47842,,"5,980.29 x patient days",47842,Per diem,,56366,,"7,045.87 x patient days",56366,Per diem,,37404,,"4,675.50 x patient days",37404,Per diem,,37404,,"4,675.50 x patient days",37404,Per diem,,21746,,"2,718.31 x patient days",21746,Per diem,,0.01,168313,
Other respiratory & chest procedures,121-1,APR-DRG,,,,,,,,inpatient,,,105207.12,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,28315,,"4,044.85 x patient days",28315,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,33401,,"27,634 x DRG weight",33401,Other,base rate x DRG weight,28390,,"23,488 x DRG weight",28390,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,15223,,"2,174.65 x patient days",15223,Per diem,,15223,,"2,174.65 x patient days",15223,Per diem,,15223,,"2,174.65 x patient days",15223,Per diem,,15223,,"2,174.65 x patient days",15223,Per diem,,34252,,"4,892.96 x patient days",34252,Per diem,,23291,,"3,327.21 x patient days",23291,Per diem,,34252,,"4,892.96 x patient days",34252,Per diem,,21312,,"3,044.51 x patient days",21312,Per diem,,34252,,"4,892.96 x patient days",34252,Per diem,,41863,,"5,980.29 x patient days",41863,Per diem,,49323,,"7,045.87 x patient days",49323,Per diem,,32729,,"4,675.50 x patient days",32729,Per diem,,32729,,"4,675.50 x patient days",32729,Per diem,,19029,,"2,718.31 x patient days",19029,Per diem,,0.01,49323,
Other respiratory & chest procedures,121-2,APR-DRG,,,,,,,,inpatient,,,325454.56,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,28315,,"4,044.85 x patient days",28315,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,44972,,"27,634 x DRG weight",44972,Other,base rate x DRG weight,38224,,"23,488 x DRG weight",38224,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,15223,,"2,174.65 x patient days",15223,Per diem,,15223,,"2,174.65 x patient days",15223,Per diem,,15223,,"2,174.65 x patient days",15223,Per diem,,15223,,"2,174.65 x patient days",15223,Per diem,,34252,,"4,892.96 x patient days",34252,Per diem,,23291,,"3,327.21 x patient days",23291,Per diem,,34252,,"4,892.96 x patient days",34252,Per diem,,21312,,"3,044.51 x patient days",21312,Per diem,,34252,,"4,892.96 x patient days",34252,Per diem,,41863,,"5,980.29 x patient days",41863,Per diem,,49323,,"7,045.87 x patient days",49323,Per diem,,32729,,"4,675.50 x patient days",32729,Per diem,,32729,,"4,675.50 x patient days",32729,Per diem,,19029,,"2,718.31 x patient days",19029,Per diem,,0.01,49323,
Other respiratory & chest procedures,121-3,APR-DRG,,,,,,,,inpatient,,,560210.09,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,28315,,"4,044.85 x patient days",28315,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,78580,,"27,634 x DRG weight",78580,Other,base rate x DRG weight,66790,,"23,488 x DRG weight",66790,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,15223,,"2,174.65 x patient days",15223,Per diem,,15223,,"2,174.65 x patient days",15223,Per diem,,15223,,"2,174.65 x patient days",15223,Per diem,,15223,,"2,174.65 x patient days",15223,Per diem,,34252,,"4,892.96 x patient days",34252,Per diem,,23291,,"3,327.21 x patient days",23291,Per diem,,34252,,"4,892.96 x patient days",34252,Per diem,,21312,,"3,044.51 x patient days",21312,Per diem,,34252,,"4,892.96 x patient days",34252,Per diem,,41863,,"5,980.29 x patient days",41863,Per diem,,49323,,"7,045.87 x patient days",49323,Per diem,,32729,,"4,675.50 x patient days",32729,Per diem,,32729,,"4,675.50 x patient days",32729,Per diem,,19029,,"2,718.31 x patient days",19029,Per diem,,0.01,78580,
Other respiratory & chest procedures,121-4,APR-DRG,,,,,,,,inpatient,,,933405.05,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,28315,,"4,044.85 x patient days",28315,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,167382,,"27,634 x DRG weight",167382,Other,base rate x DRG weight,142269,,"23,488 x DRG weight",142269,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,15223,,"2,174.65 x patient days",15223,Per diem,,15223,,"2,174.65 x patient days",15223,Per diem,,15223,,"2,174.65 x patient days",15223,Per diem,,15223,,"2,174.65 x patient days",15223,Per diem,,34252,,"4,892.96 x patient days",34252,Per diem,,23291,,"3,327.21 x patient days",23291,Per diem,,34252,,"4,892.96 x patient days",34252,Per diem,,21312,,"3,044.51 x patient days",21312,Per diem,,34252,,"4,892.96 x patient days",34252,Per diem,,41863,,"5,980.29 x patient days",41863,Per diem,,49323,,"7,045.87 x patient days",49323,Per diem,,32729,,"4,675.50 x patient days",32729,Per diem,,32729,,"4,675.50 x patient days",32729,Per diem,,19029,,"2,718.31 x patient days",19029,Per diem,,0.01,167382,
Respiratory system diagnosis w ventilator support 96+ hours,130-1,APR-DRG,,,,,,,,inpatient,,,116711,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,64717,,"4,044.85 x patient days",64717,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,94790,,"27,634 x DRG weight",94790,Other,base rate x DRG weight,80569,,"23,488 x DRG weight",80569,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,34794,,"2,174.65 x patient days",34794,Per diem,,34794,,"2,174.65 x patient days",34794,Per diem,,34794,,"2,174.65 x patient days",34794,Per diem,,34794,,"2,174.65 x patient days",34794,Per diem,,78287,,"4,892.96 x patient days",78287,Per diem,,53235,,"3,327.21 x patient days",53235,Per diem,,78287,,"4,892.96 x patient days",78287,Per diem,,48712,,"3,044.51 x patient days",48712,Per diem,,78287,,"4,892.96 x patient days",78287,Per diem,,95684,,"5,980.29 x patient days",95684,Per diem,,112733,,"7,045.87 x patient days",112733,Per diem,,74807,,"4,675.50 x patient days",74807,Per diem,,74807,,"4,675.50 x patient days",74807,Per diem,,43493,,"2,718.31 x patient days",43493,Per diem,,0.01,112733,
Respiratory system diagnosis w ventilator support 96+ hours,130-2,APR-DRG,,,,,,,,inpatient,,,296886,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,64717,,"4,044.85 x patient days",64717,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,94790,,"27,634 x DRG weight",94790,Other,base rate x DRG weight,80569,,"23,488 x DRG weight",80569,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,34794,,"2,174.65 x patient days",34794,Per diem,,34794,,"2,174.65 x patient days",34794,Per diem,,34794,,"2,174.65 x patient days",34794,Per diem,,34794,,"2,174.65 x patient days",34794,Per diem,,78287,,"4,892.96 x patient days",78287,Per diem,,53235,,"3,327.21 x patient days",53235,Per diem,,78287,,"4,892.96 x patient days",78287,Per diem,,48712,,"3,044.51 x patient days",48712,Per diem,,78287,,"4,892.96 x patient days",78287,Per diem,,95684,,"5,980.29 x patient days",95684,Per diem,,112733,,"7,045.87 x patient days",112733,Per diem,,74807,,"4,675.50 x patient days",74807,Per diem,,74807,,"4,675.50 x patient days",74807,Per diem,,43493,,"2,718.31 x patient days",43493,Per diem,,0.01,112733,
Respiratory system diagnosis w ventilator support 96+ hours,130-3,APR-DRG,,,,,,,,inpatient,,,481963.13,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,64717,,"4,044.85 x patient days",64717,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,118257,,"27,634 x DRG weight",118257,Other,base rate x DRG weight,100515,,"23,488 x DRG weight",100515,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,34794,,"2,174.65 x patient days",34794,Per diem,,34794,,"2,174.65 x patient days",34794,Per diem,,34794,,"2,174.65 x patient days",34794,Per diem,,34794,,"2,174.65 x patient days",34794,Per diem,,78287,,"4,892.96 x patient days",78287,Per diem,,53235,,"3,327.21 x patient days",53235,Per diem,,78287,,"4,892.96 x patient days",78287,Per diem,,48712,,"3,044.51 x patient days",48712,Per diem,,78287,,"4,892.96 x patient days",78287,Per diem,,95684,,"5,980.29 x patient days",95684,Per diem,,112733,,"7,045.87 x patient days",112733,Per diem,,74807,,"4,675.50 x patient days",74807,Per diem,,74807,,"4,675.50 x patient days",74807,Per diem,,43493,,"2,718.31 x patient days",43493,Per diem,,0.01,118257,
Respiratory system diagnosis w ventilator support 96+ hours,130-4,APR-DRG,,,,,,,,inpatient,,,1565318.9,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,64717,,"4,044.85 x patient days",64717,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,167816,,"27,634 x DRG weight",167816,Other,base rate x DRG weight,142638,,"23,488 x DRG weight",142638,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,34794,,"2,174.65 x patient days",34794,Per diem,,34794,,"2,174.65 x patient days",34794,Per diem,,34794,,"2,174.65 x patient days",34794,Per diem,,34794,,"2,174.65 x patient days",34794,Per diem,,78287,,"4,892.96 x patient days",78287,Per diem,,53235,,"3,327.21 x patient days",53235,Per diem,,78287,,"4,892.96 x patient days",78287,Per diem,,48712,,"3,044.51 x patient days",48712,Per diem,,78287,,"4,892.96 x patient days",78287,Per diem,,95684,,"5,980.29 x patient days",95684,Per diem,,112733,,"7,045.87 x patient days",112733,Per diem,,74807,,"4,675.50 x patient days",74807,Per diem,,74807,,"4,675.50 x patient days",74807,Per diem,,43493,,"2,718.31 x patient days",43493,Per diem,,0.01,167816,
Cystic fibrosis - pulmonary disease,131-1,APR-DRG,,,,,,,,inpatient,,,101263.02,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,36404,,"4,044.85 x patient days",36404,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,38135,,"27,634 x DRG weight",38135,Other,base rate x DRG weight,32413,,"23,488 x DRG weight",32413,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,19572,,"2,174.65 x patient days",19572,Per diem,,19572,,"2,174.65 x patient days",19572,Per diem,,19572,,"2,174.65 x patient days",19572,Per diem,,19572,,"2,174.65 x patient days",19572,Per diem,,44037,,"4,892.96 x patient days",44037,Per diem,,29945,,"3,327.21 x patient days",29945,Per diem,,44037,,"4,892.96 x patient days",44037,Per diem,,27401,,"3,044.51 x patient days",27401,Per diem,,44037,,"4,892.96 x patient days",44037,Per diem,,53823,,"5,980.29 x patient days",53823,Per diem,,63413,,"7,045.87 x patient days",63413,Per diem,,42080,,"4,675.50 x patient days",42080,Per diem,,42080,,"4,675.50 x patient days",42080,Per diem,,24465,,"2,718.31 x patient days",24465,Per diem,,0.01,63413,
Cystic fibrosis - pulmonary disease,131-2,APR-DRG,,,,,,,,inpatient,,,115061.18,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,36404,,"4,044.85 x patient days",36404,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,47801,,"27,634 x DRG weight",47801,Other,base rate x DRG weight,40630,,"23,488 x DRG weight",40630,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,19572,,"2,174.65 x patient days",19572,Per diem,,19572,,"2,174.65 x patient days",19572,Per diem,,19572,,"2,174.65 x patient days",19572,Per diem,,19572,,"2,174.65 x patient days",19572,Per diem,,44037,,"4,892.96 x patient days",44037,Per diem,,29945,,"3,327.21 x patient days",29945,Per diem,,44037,,"4,892.96 x patient days",44037,Per diem,,27401,,"3,044.51 x patient days",27401,Per diem,,44037,,"4,892.96 x patient days",44037,Per diem,,53823,,"5,980.29 x patient days",53823,Per diem,,63413,,"7,045.87 x patient days",63413,Per diem,,42080,,"4,675.50 x patient days",42080,Per diem,,42080,,"4,675.50 x patient days",42080,Per diem,,24465,,"2,718.31 x patient days",24465,Per diem,,0.01,63413,
Cystic fibrosis - pulmonary disease,131-3,APR-DRG,,,,,,,,inpatient,,,173087.03,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,36404,,"4,044.85 x patient days",36404,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,70561,,"27,634 x DRG weight",70561,Other,base rate x DRG weight,59974,,"23,488 x DRG weight",59974,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,19572,,"2,174.65 x patient days",19572,Per diem,,19572,,"2,174.65 x patient days",19572,Per diem,,19572,,"2,174.65 x patient days",19572,Per diem,,19572,,"2,174.65 x patient days",19572,Per diem,,44037,,"4,892.96 x patient days",44037,Per diem,,29945,,"3,327.21 x patient days",29945,Per diem,,44037,,"4,892.96 x patient days",44037,Per diem,,27401,,"3,044.51 x patient days",27401,Per diem,,44037,,"4,892.96 x patient days",44037,Per diem,,53823,,"5,980.29 x patient days",53823,Per diem,,63413,,"7,045.87 x patient days",63413,Per diem,,42080,,"4,675.50 x patient days",42080,Per diem,,42080,,"4,675.50 x patient days",42080,Per diem,,24465,,"2,718.31 x patient days",24465,Per diem,,0.01,70561,
Cystic fibrosis - pulmonary disease,131-4,APR-DRG,,,,,,,,inpatient,,,259723.18,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,36404,,"4,044.85 x patient days",36404,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,75538,,"27,634 x DRG weight",75538,Other,base rate x DRG weight,64204,,"23,488 x DRG weight",64204,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,19572,,"2,174.65 x patient days",19572,Per diem,,19572,,"2,174.65 x patient days",19572,Per diem,,19572,,"2,174.65 x patient days",19572,Per diem,,19572,,"2,174.65 x patient days",19572,Per diem,,44037,,"4,892.96 x patient days",44037,Per diem,,29945,,"3,327.21 x patient days",29945,Per diem,,44037,,"4,892.96 x patient days",44037,Per diem,,27401,,"3,044.51 x patient days",27401,Per diem,,44037,,"4,892.96 x patient days",44037,Per diem,,53823,,"5,980.29 x patient days",53823,Per diem,,63413,,"7,045.87 x patient days",63413,Per diem,,42080,,"4,675.50 x patient days",42080,Per diem,,42080,,"4,675.50 x patient days",42080,Per diem,,24465,,"2,718.31 x patient days",24465,Per diem,,0.01,75538,
BPD & oth chronic respiratory diseases arising in perinatal period,132-1,APR-DRG,,,,,,,,inpatient,,,134363.12,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,20224,,"4,044.85 x patient days",20224,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,16310,,"27,634 x DRG weight",16310,Other,base rate x DRG weight,13863,,"23,488 x DRG weight",13863,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,16636,,"3,327.21 x patient days",16636,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,15222,,"3,044.51 x patient days",15222,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,29901,,"5,980.29 x patient days",29901,Per diem,,35229,,"7,045.87 x patient days",35229,Per diem,,23377,,"4,675.50 x patient days",23377,Per diem,,23377,,"4,675.50 x patient days",23377,Per diem,,13591,,"2,718.31 x patient days",13591,Per diem,,0.01,35229,
BPD & oth chronic respiratory diseases arising in perinatal period,132-2,APR-DRG,,,,,,,,inpatient,,,130750.55,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,20224,,"4,044.85 x patient days",20224,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,21673,,"27,634 x DRG weight",21673,Other,base rate x DRG weight,18422,,"23,488 x DRG weight",18422,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,16636,,"3,327.21 x patient days",16636,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,15222,,"3,044.51 x patient days",15222,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,29901,,"5,980.29 x patient days",29901,Per diem,,35229,,"7,045.87 x patient days",35229,Per diem,,23377,,"4,675.50 x patient days",23377,Per diem,,23377,,"4,675.50 x patient days",23377,Per diem,,13591,,"2,718.31 x patient days",13591,Per diem,,0.01,35229,
BPD & oth chronic respiratory diseases arising in perinatal period,132-3,APR-DRG,,,,,,,,inpatient,,,99357.25,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,20224,,"4,044.85 x patient days",20224,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,36413,,"27,634 x DRG weight",36413,Other,base rate x DRG weight,30950,,"23,488 x DRG weight",30950,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,16636,,"3,327.21 x patient days",16636,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,15222,,"3,044.51 x patient days",15222,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,29901,,"5,980.29 x patient days",29901,Per diem,,35229,,"7,045.87 x patient days",35229,Per diem,,23377,,"4,675.50 x patient days",23377,Per diem,,23377,,"4,675.50 x patient days",23377,Per diem,,13591,,"2,718.31 x patient days",13591,Per diem,,0.01,36413,
BPD & oth chronic respiratory diseases arising in perinatal period,132-4,APR-DRG,,,,,,,,inpatient,,,222809.96,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,20224,,"4,044.85 x patient days",20224,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,66344,,"27,634 x DRG weight",66344,Other,base rate x DRG weight,56390,,"23,488 x DRG weight",56390,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,16636,,"3,327.21 x patient days",16636,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,15222,,"3,044.51 x patient days",15222,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,29901,,"5,980.29 x patient days",29901,Per diem,,35229,,"7,045.87 x patient days",35229,Per diem,,23377,,"4,675.50 x patient days",23377,Per diem,,23377,,"4,675.50 x patient days",23377,Per diem,,13591,,"2,718.31 x patient days",13591,Per diem,,0.01,66344,
Respiratory Failure,133-1,APR-DRG,,,,,,,,inpatient,,,93911,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,20224,,"4,044.85 x patient days",20224,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,25465,,"27,634 x DRG weight",25465,Other,base rate x DRG weight,21644,,"23,488 x DRG weight",21644,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,16636,,"3,327.21 x patient days",16636,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,15222,,"3,044.51 x patient days",15222,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,29901,,"5,980.29 x patient days",29901,Per diem,,35229,,"7,045.87 x patient days",35229,Per diem,,23377,,"4,675.50 x patient days",23377,Per diem,,23377,,"4,675.50 x patient days",23377,Per diem,,13591,,"2,718.31 x patient days",13591,Per diem,,0.01,35229,
Respiratory Failure,133-2,APR-DRG,,,,,,,,inpatient,,,93911,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,20224,,"4,044.85 x patient days",20224,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,25517,,"27,634 x DRG weight",25517,Other,base rate x DRG weight,21689,,"23,488 x DRG weight",21689,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,16636,,"3,327.21 x patient days",16636,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,15222,,"3,044.51 x patient days",15222,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,29901,,"5,980.29 x patient days",29901,Per diem,,35229,,"7,045.87 x patient days",35229,Per diem,,23377,,"4,675.50 x patient days",23377,Per diem,,23377,,"4,675.50 x patient days",23377,Per diem,,13591,,"2,718.31 x patient days",13591,Per diem,,0.01,35229,
Respiratory Failure,133-3,APR-DRG,,,,,,,,inpatient,,,121549.43,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,20224,,"4,044.85 x patient days",20224,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,37770,,"27,634 x DRG weight",37770,Other,base rate x DRG weight,32103,,"23,488 x DRG weight",32103,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,16636,,"3,327.21 x patient days",16636,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,15222,,"3,044.51 x patient days",15222,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,29901,,"5,980.29 x patient days",29901,Per diem,,35229,,"7,045.87 x patient days",35229,Per diem,,23377,,"4,675.50 x patient days",23377,Per diem,,23377,,"4,675.50 x patient days",23377,Per diem,,13591,,"2,718.31 x patient days",13591,Per diem,,0.01,37770,
Respiratory Failure,133-4,APR-DRG,,,,,,,,inpatient,,,153146.39,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,20224,,"4,044.85 x patient days",20224,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,55741,,"27,634 x DRG weight",55741,Other,base rate x DRG weight,47378,,"23,488 x DRG weight",47378,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,16636,,"3,327.21 x patient days",16636,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,15222,,"3,044.51 x patient days",15222,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,29901,,"5,980.29 x patient days",29901,Per diem,,35229,,"7,045.87 x patient days",35229,Per diem,,23377,,"4,675.50 x patient days",23377,Per diem,,23377,,"4,675.50 x patient days",23377,Per diem,,13591,,"2,718.31 x patient days",13591,Per diem,,0.01,55741,
Pulmonary embolism,134-1,APR-DRG,,,,,,,,inpatient,,,83186.91,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,20224,,"4,044.85 x patient days",20224,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,19474,,"27,634 x DRG weight",19474,Other,base rate x DRG weight,16552,,"23,488 x DRG weight",16552,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,16636,,"3,327.21 x patient days",16636,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,15222,,"3,044.51 x patient days",15222,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,29901,,"5,980.29 x patient days",29901,Per diem,,35229,,"7,045.87 x patient days",35229,Per diem,,23377,,"4,675.50 x patient days",23377,Per diem,,23377,,"4,675.50 x patient days",23377,Per diem,,13591,,"2,718.31 x patient days",13591,Per diem,,0.01,35229,
Pulmonary embolism,134-2,APR-DRG,,,,,,,,inpatient,,,141942.08,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,20224,,"4,044.85 x patient days",20224,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,25841,,"27,634 x DRG weight",25841,Other,base rate x DRG weight,21964,,"23,488 x DRG weight",21964,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,16636,,"3,327.21 x patient days",16636,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,15222,,"3,044.51 x patient days",15222,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,29901,,"5,980.29 x patient days",29901,Per diem,,35229,,"7,045.87 x patient days",35229,Per diem,,23377,,"4,675.50 x patient days",23377,Per diem,,23377,,"4,675.50 x patient days",23377,Per diem,,13591,,"2,718.31 x patient days",13591,Per diem,,0.01,35229,
Pulmonary embolism,134-3,APR-DRG,,,,,,,,inpatient,,,218830.2,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,20224,,"4,044.85 x patient days",20224,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,41711,,"27,634 x DRG weight",41711,Other,base rate x DRG weight,35453,,"23,488 x DRG weight",35453,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,16636,,"3,327.21 x patient days",16636,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,15222,,"3,044.51 x patient days",15222,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,29901,,"5,980.29 x patient days",29901,Per diem,,35229,,"7,045.87 x patient days",35229,Per diem,,23377,,"4,675.50 x patient days",23377,Per diem,,23377,,"4,675.50 x patient days",23377,Per diem,,13591,,"2,718.31 x patient days",13591,Per diem,,0.01,41711,
Pulmonary embolism,134-4,APR-DRG,,,,,,,,inpatient,,,673798.06,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,20224,,"4,044.85 x patient days",20224,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,70644,,"27,634 x DRG weight",70644,Other,base rate x DRG weight,60045,,"23,488 x DRG weight",60045,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,16636,,"3,327.21 x patient days",16636,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,15222,,"3,044.51 x patient days",15222,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,29901,,"5,980.29 x patient days",29901,Per diem,,35229,,"7,045.87 x patient days",35229,Per diem,,23377,,"4,675.50 x patient days",23377,Per diem,,23377,,"4,675.50 x patient days",23377,Per diem,,13591,,"2,718.31 x patient days",13591,Per diem,,0.01,70644,
Major chest & respiratory trauma,135-1,APR-DRG,,,,,,,,inpatient,,,112165.56,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12135,,"4,044.85 x patient days",12135,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,14303,,"27,634 x DRG weight",14303,Other,base rate x DRG weight,12157,,"23,488 x DRG weight",12157,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9982,,"3,327.21 x patient days",9982,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9134,,"3,044.51 x patient days",9134,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,17941,,"5,980.29 x patient days",17941,Per diem,,21138,,"7,045.87 x patient days",21138,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,8155,,"2,718.31 x patient days",8155,Per diem,,0.01,21138,
Major chest & respiratory trauma,135-2,APR-DRG,,,,,,,,inpatient,,,152828.66,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12135,,"4,044.85 x patient days",12135,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,19921,,"27,634 x DRG weight",19921,Other,base rate x DRG weight,16932,,"23,488 x DRG weight",16932,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9982,,"3,327.21 x patient days",9982,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9134,,"3,044.51 x patient days",9134,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,17941,,"5,980.29 x patient days",17941,Per diem,,21138,,"7,045.87 x patient days",21138,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,8155,,"2,718.31 x patient days",8155,Per diem,,0.01,21138,
Major chest & respiratory trauma,135-3,APR-DRG,,,,,,,,inpatient,,,198307.37,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12135,,"4,044.85 x patient days",12135,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,33899,,"27,634 x DRG weight",33899,Other,base rate x DRG weight,28813,,"23,488 x DRG weight",28813,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9982,,"3,327.21 x patient days",9982,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9134,,"3,044.51 x patient days",9134,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,17941,,"5,980.29 x patient days",17941,Per diem,,21138,,"7,045.87 x patient days",21138,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,8155,,"2,718.31 x patient days",8155,Per diem,,0.01,33899,
Major chest & respiratory trauma,135-4,APR-DRG,,,,,,,,inpatient,,,181349.84,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12135,,"4,044.85 x patient days",12135,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,50175,,"27,634 x DRG weight",50175,Other,base rate x DRG weight,42647,,"23,488 x DRG weight",42647,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9982,,"3,327.21 x patient days",9982,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9134,,"3,044.51 x patient days",9134,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,17941,,"5,980.29 x patient days",17941,Per diem,,21138,,"7,045.87 x patient days",21138,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,8155,,"2,718.31 x patient days",8155,Per diem,,0.01,50175,
Respiratory malignancy,136-1,APR-DRG,,,,,,,,inpatient,,,140050,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,28315,,"4,044.85 x patient days",28315,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,15724,,"27,634 x DRG weight",15724,Other,base rate x DRG weight,13365,,"23,488 x DRG weight",13365,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,15223,,"2,174.65 x patient days",15223,Per diem,,15223,,"2,174.65 x patient days",15223,Per diem,,15223,,"2,174.65 x patient days",15223,Per diem,,15223,,"2,174.65 x patient days",15223,Per diem,,34252,,"4,892.96 x patient days",34252,Per diem,,23291,,"3,327.21 x patient days",23291,Per diem,,34252,,"4,892.96 x patient days",34252,Per diem,,21312,,"3,044.51 x patient days",21312,Per diem,,34252,,"4,892.96 x patient days",34252,Per diem,,41863,,"5,980.29 x patient days",41863,Per diem,,49323,,"7,045.87 x patient days",49323,Per diem,,32729,,"4,675.50 x patient days",32729,Per diem,,32729,,"4,675.50 x patient days",32729,Per diem,,19029,,"2,718.31 x patient days",19029,Per diem,,0.01,49323,
Respiratory malignancy,136-2,APR-DRG,,,,,,,,inpatient,,,193028.83,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,28315,,"4,044.85 x patient days",28315,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,24978,,"27,634 x DRG weight",24978,Other,base rate x DRG weight,21231,,"23,488 x DRG weight",21231,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,15223,,"2,174.65 x patient days",15223,Per diem,,15223,,"2,174.65 x patient days",15223,Per diem,,15223,,"2,174.65 x patient days",15223,Per diem,,15223,,"2,174.65 x patient days",15223,Per diem,,34252,,"4,892.96 x patient days",34252,Per diem,,23291,,"3,327.21 x patient days",23291,Per diem,,34252,,"4,892.96 x patient days",34252,Per diem,,21312,,"3,044.51 x patient days",21312,Per diem,,34252,,"4,892.96 x patient days",34252,Per diem,,41863,,"5,980.29 x patient days",41863,Per diem,,49323,,"7,045.87 x patient days",49323,Per diem,,32729,,"4,675.50 x patient days",32729,Per diem,,32729,,"4,675.50 x patient days",32729,Per diem,,19029,,"2,718.31 x patient days",19029,Per diem,,0.01,49323,
Respiratory malignancy,136-3,APR-DRG,,,,,,,,inpatient,,,278808.17,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,28315,,"4,044.85 x patient days",28315,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,43101,,"27,634 x DRG weight",43101,Other,base rate x DRG weight,36634,,"23,488 x DRG weight",36634,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,15223,,"2,174.65 x patient days",15223,Per diem,,15223,,"2,174.65 x patient days",15223,Per diem,,15223,,"2,174.65 x patient days",15223,Per diem,,15223,,"2,174.65 x patient days",15223,Per diem,,34252,,"4,892.96 x patient days",34252,Per diem,,23291,,"3,327.21 x patient days",23291,Per diem,,34252,,"4,892.96 x patient days",34252,Per diem,,21312,,"3,044.51 x patient days",21312,Per diem,,34252,,"4,892.96 x patient days",34252,Per diem,,41863,,"5,980.29 x patient days",41863,Per diem,,49323,,"7,045.87 x patient days",49323,Per diem,,32729,,"4,675.50 x patient days",32729,Per diem,,32729,,"4,675.50 x patient days",32729,Per diem,,19029,,"2,718.31 x patient days",19029,Per diem,,0.01,49323,
Respiratory malignancy,136-4,APR-DRG,,,,,,,,inpatient,,,278808.17,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,28315,,"4,044.85 x patient days",28315,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,63381,,"27,634 x DRG weight",63381,Other,base rate x DRG weight,53872,,"23,488 x DRG weight",53872,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,15223,,"2,174.65 x patient days",15223,Per diem,,15223,,"2,174.65 x patient days",15223,Per diem,,15223,,"2,174.65 x patient days",15223,Per diem,,15223,,"2,174.65 x patient days",15223,Per diem,,34252,,"4,892.96 x patient days",34252,Per diem,,23291,,"3,327.21 x patient days",23291,Per diem,,34252,,"4,892.96 x patient days",34252,Per diem,,21312,,"3,044.51 x patient days",21312,Per diem,,34252,,"4,892.96 x patient days",34252,Per diem,,41863,,"5,980.29 x patient days",41863,Per diem,,49323,,"7,045.87 x patient days",49323,Per diem,,32729,,"4,675.50 x patient days",32729,Per diem,,32729,,"4,675.50 x patient days",32729,Per diem,,19029,,"2,718.31 x patient days",19029,Per diem,,0.01,63381,
Major respiratory infections & inflammations,137-1,APR-DRG,,,,,,,,inpatient,,,58081,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,28315,,"4,044.85 x patient days",28315,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,19228,,"27,634 x DRG weight",19228,Other,base rate x DRG weight,16343,,"23,488 x DRG weight",16343,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,15223,,"2,174.65 x patient days",15223,Per diem,,15223,,"2,174.65 x patient days",15223,Per diem,,15223,,"2,174.65 x patient days",15223,Per diem,,15223,,"2,174.65 x patient days",15223,Per diem,,34252,,"4,892.96 x patient days",34252,Per diem,,23291,,"3,327.21 x patient days",23291,Per diem,,34252,,"4,892.96 x patient days",34252,Per diem,,21312,,"3,044.51 x patient days",21312,Per diem,,34252,,"4,892.96 x patient days",34252,Per diem,,41863,,"5,980.29 x patient days",41863,Per diem,,49323,,"7,045.87 x patient days",49323,Per diem,,32729,,"4,675.50 x patient days",32729,Per diem,,32729,,"4,675.50 x patient days",32729,Per diem,,19029,,"2,718.31 x patient days",19029,Per diem,,0.01,49323,
Major respiratory infections & inflammations,137-2,APR-DRG,,,,,,,,inpatient,,,97455.91,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,28315,,"4,044.85 x patient days",28315,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,28485,,"27,634 x DRG weight",28485,Other,base rate x DRG weight,24211,,"23,488 x DRG weight",24211,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,15223,,"2,174.65 x patient days",15223,Per diem,,15223,,"2,174.65 x patient days",15223,Per diem,,15223,,"2,174.65 x patient days",15223,Per diem,,15223,,"2,174.65 x patient days",15223,Per diem,,34252,,"4,892.96 x patient days",34252,Per diem,,23291,,"3,327.21 x patient days",23291,Per diem,,34252,,"4,892.96 x patient days",34252,Per diem,,21312,,"3,044.51 x patient days",21312,Per diem,,34252,,"4,892.96 x patient days",34252,Per diem,,41863,,"5,980.29 x patient days",41863,Per diem,,49323,,"7,045.87 x patient days",49323,Per diem,,32729,,"4,675.50 x patient days",32729,Per diem,,32729,,"4,675.50 x patient days",32729,Per diem,,19029,,"2,718.31 x patient days",19029,Per diem,,0.01,49323,
Major respiratory infections & inflammations,137-3,APR-DRG,,,,,,,,inpatient,,,138466.37,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,28315,,"4,044.85 x patient days",28315,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,46337,,"27,634 x DRG weight",46337,Other,base rate x DRG weight,39385,,"23,488 x DRG weight",39385,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,15223,,"2,174.65 x patient days",15223,Per diem,,15223,,"2,174.65 x patient days",15223,Per diem,,15223,,"2,174.65 x patient days",15223,Per diem,,15223,,"2,174.65 x patient days",15223,Per diem,,34252,,"4,892.96 x patient days",34252,Per diem,,23291,,"3,327.21 x patient days",23291,Per diem,,34252,,"4,892.96 x patient days",34252,Per diem,,21312,,"3,044.51 x patient days",21312,Per diem,,34252,,"4,892.96 x patient days",34252,Per diem,,41863,,"5,980.29 x patient days",41863,Per diem,,49323,,"7,045.87 x patient days",49323,Per diem,,32729,,"4,675.50 x patient days",32729,Per diem,,32729,,"4,675.50 x patient days",32729,Per diem,,19029,,"2,718.31 x patient days",19029,Per diem,,0.01,49323,
Major respiratory infections & inflammations,137-4,APR-DRG,,,,,,,,inpatient,,,439858.31,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,28315,,"4,044.85 x patient days",28315,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,72183,,"27,634 x DRG weight",72183,Other,base rate x DRG weight,61353,,"23,488 x DRG weight",61353,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,15223,,"2,174.65 x patient days",15223,Per diem,,15223,,"2,174.65 x patient days",15223,Per diem,,15223,,"2,174.65 x patient days",15223,Per diem,,15223,,"2,174.65 x patient days",15223,Per diem,,34252,,"4,892.96 x patient days",34252,Per diem,,23291,,"3,327.21 x patient days",23291,Per diem,,34252,,"4,892.96 x patient days",34252,Per diem,,21312,,"3,044.51 x patient days",21312,Per diem,,34252,,"4,892.96 x patient days",34252,Per diem,,41863,,"5,980.29 x patient days",41863,Per diem,,49323,,"7,045.87 x patient days",49323,Per diem,,32729,,"4,675.50 x patient days",32729,Per diem,,32729,,"4,675.50 x patient days",32729,Per diem,,19029,,"2,718.31 x patient days",19029,Per diem,,0.01,72183,
Bronchiolitis & RSV pneumonia,138-1,APR-DRG,,,,,,,,inpatient,,,49164.88,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12135,,"4,044.85 x patient days",12135,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,13477,,"27,634 x DRG weight",13477,Other,base rate x DRG weight,11455,,"23,488 x DRG weight",11455,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9982,,"3,327.21 x patient days",9982,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9134,,"3,044.51 x patient days",9134,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,17941,,"5,980.29 x patient days",17941,Per diem,,21138,,"7,045.87 x patient days",21138,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,8155,,"2,718.31 x patient days",8155,Per diem,,0.01,21138,
Bronchiolitis & RSV pneumonia,138-2,APR-DRG,,,,,,,,inpatient,,,75374.07,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12135,,"4,044.85 x patient days",12135,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,17418,,"27,634 x DRG weight",17418,Other,base rate x DRG weight,14804,,"23,488 x DRG weight",14804,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9982,,"3,327.21 x patient days",9982,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9134,,"3,044.51 x patient days",9134,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,17941,,"5,980.29 x patient days",17941,Per diem,,21138,,"7,045.87 x patient days",21138,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,8155,,"2,718.31 x patient days",8155,Per diem,,0.01,21138,
Bronchiolitis & RSV pneumonia,138-3,APR-DRG,,,,,,,,inpatient,,,121433.97,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12135,,"4,044.85 x patient days",12135,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,37715,,"27,634 x DRG weight",37715,Other,base rate x DRG weight,32056,,"23,488 x DRG weight",32056,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9982,,"3,327.21 x patient days",9982,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9134,,"3,044.51 x patient days",9134,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,17941,,"5,980.29 x patient days",17941,Per diem,,21138,,"7,045.87 x patient days",21138,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,8155,,"2,718.31 x patient days",8155,Per diem,,0.01,37715,
Bronchiolitis & RSV pneumonia,138-4,APR-DRG,,,,,,,,inpatient,,,114746.81,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12135,,"4,044.85 x patient days",12135,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,83557,,"27,634 x DRG weight",83557,Other,base rate x DRG weight,71021,,"23,488 x DRG weight",71021,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9982,,"3,327.21 x patient days",9982,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9134,,"3,044.51 x patient days",9134,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,17941,,"5,980.29 x patient days",17941,Per diem,,21138,,"7,045.87 x patient days",21138,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,8155,,"2,718.31 x patient days",8155,Per diem,,0.01,83557,
Other pneumonia,139-1,APR-DRG,,,,,,,,inpatient,,,65208.31,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,16180,,"4,044.85 x patient days",16180,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,14196,,"27,634 x DRG weight",14196,Other,base rate x DRG weight,12066,,"23,488 x DRG weight",12066,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,13309,,"3,327.21 x patient days",13309,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,12179,,"3,044.51 x patient days",12179,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,23922,,"5,980.29 x patient days",23922,Per diem,,28185,,"7,045.87 x patient days",28185,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,10874,,"2,718.31 x patient days",10874,Per diem,,0.01,28185,
Other pneumonia,139-2,APR-DRG,,,,,,,,inpatient,,,78521.38,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,16180,,"4,044.85 x patient days",16180,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,18744,,"27,634 x DRG weight",18744,Other,base rate x DRG weight,15932,,"23,488 x DRG weight",15932,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,13309,,"3,327.21 x patient days",13309,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,12179,,"3,044.51 x patient days",12179,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,23922,,"5,980.29 x patient days",23922,Per diem,,28185,,"7,045.87 x patient days",28185,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,10874,,"2,718.31 x patient days",10874,Per diem,,0.01,28185,
Other pneumonia,139-3,APR-DRG,,,,,,,,inpatient,,,157119.86,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,16180,,"4,044.85 x patient days",16180,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,31450,,"27,634 x DRG weight",31450,Other,base rate x DRG weight,26732,,"23,488 x DRG weight",26732,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,13309,,"3,327.21 x patient days",13309,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,12179,,"3,044.51 x patient days",12179,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,23922,,"5,980.29 x patient days",23922,Per diem,,28185,,"7,045.87 x patient days",28185,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,10874,,"2,718.31 x patient days",10874,Per diem,,0.01,31450,
Other pneumonia,139-4,APR-DRG,,,,,,,,inpatient,,,257249.45,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,16180,,"4,044.85 x patient days",16180,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,59960,,"27,634 x DRG weight",59960,Other,base rate x DRG weight,50964,,"23,488 x DRG weight",50964,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,13309,,"3,327.21 x patient days",13309,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,12179,,"3,044.51 x patient days",12179,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,23922,,"5,980.29 x patient days",23922,Per diem,,28185,,"7,045.87 x patient days",28185,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,10874,,"2,718.31 x patient days",10874,Per diem,,0.01,59960,
Chronic obstructive pulmonary disease,140-1,APR-DRG,,,,,,,,inpatient,,,70974.51,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,16180,,"4,044.85 x patient days",16180,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,15892,,"27,634 x DRG weight",15892,Other,base rate x DRG weight,13508,,"23,488 x DRG weight",13508,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,13309,,"3,327.21 x patient days",13309,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,12179,,"3,044.51 x patient days",12179,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,23922,,"5,980.29 x patient days",23922,Per diem,,28185,,"7,045.87 x patient days",28185,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,10874,,"2,718.31 x patient days",10874,Per diem,,0.01,28185,
Chronic obstructive pulmonary disease,140-2,APR-DRG,,,,,,,,inpatient,,,80328.69,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,16180,,"4,044.85 x patient days",16180,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,19952,,"27,634 x DRG weight",19952,Other,base rate x DRG weight,16958,,"23,488 x DRG weight",16958,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,13309,,"3,327.21 x patient days",13309,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,12179,,"3,044.51 x patient days",12179,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,23922,,"5,980.29 x patient days",23922,Per diem,,28185,,"7,045.87 x patient days",28185,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,10874,,"2,718.31 x patient days",10874,Per diem,,0.01,28185,
Chronic obstructive pulmonary disease,140-3,APR-DRG,,,,,,,,inpatient,,,105230.1,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,16180,,"4,044.85 x patient days",16180,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,27974,,"27,634 x DRG weight",27974,Other,base rate x DRG weight,23777,,"23,488 x DRG weight",23777,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,13309,,"3,327.21 x patient days",13309,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,12179,,"3,044.51 x patient days",12179,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,23922,,"5,980.29 x patient days",23922,Per diem,,28185,,"7,045.87 x patient days",28185,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,10874,,"2,718.31 x patient days",10874,Per diem,,0.01,28185,
Chronic obstructive pulmonary disease,140-4,APR-DRG,,,,,,,,inpatient,,,212102.07,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,16180,,"4,044.85 x patient days",16180,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,54450,,"27,634 x DRG weight",54450,Other,base rate x DRG weight,46281,,"23,488 x DRG weight",46281,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,13309,,"3,327.21 x patient days",13309,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,12179,,"3,044.51 x patient days",12179,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,23922,,"5,980.29 x patient days",23922,Per diem,,28185,,"7,045.87 x patient days",28185,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,10874,,"2,718.31 x patient days",10874,Per diem,,0.01,54450,
Asthma,141-1,APR-DRG,,,,,,,,inpatient,,,60338.58,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12135,,"4,044.85 x patient days",12135,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,13087,,"27,634 x DRG weight",13087,Other,base rate x DRG weight,11124,,"23,488 x DRG weight",11124,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9982,,"3,327.21 x patient days",9982,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9134,,"3,044.51 x patient days",9134,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,17941,,"5,980.29 x patient days",17941,Per diem,,21138,,"7,045.87 x patient days",21138,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,8155,,"2,718.31 x patient days",8155,Per diem,,0.01,21138,
Asthma,141-2,APR-DRG,,,,,,,,inpatient,,,70052.89,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12135,,"4,044.85 x patient days",12135,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,17058,,"27,634 x DRG weight",17058,Other,base rate x DRG weight,14499,,"23,488 x DRG weight",14499,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9982,,"3,327.21 x patient days",9982,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9134,,"3,044.51 x patient days",9134,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,17941,,"5,980.29 x patient days",17941,Per diem,,21138,,"7,045.87 x patient days",21138,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,8155,,"2,718.31 x patient days",8155,Per diem,,0.01,21138,
Asthma,141-3,APR-DRG,,,,,,,,inpatient,,,92648.53,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12135,,"4,044.85 x patient days",12135,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,25912,,"27,634 x DRG weight",25912,Other,base rate x DRG weight,22025,,"23,488 x DRG weight",22025,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9982,,"3,327.21 x patient days",9982,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9134,,"3,044.51 x patient days",9134,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,17941,,"5,980.29 x patient days",17941,Per diem,,21138,,"7,045.87 x patient days",21138,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,8155,,"2,718.31 x patient days",8155,Per diem,,0.01,25912,
Asthma,141-4,APR-DRG,,,,,,,,inpatient,,,123003.7,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12135,,"4,044.85 x patient days",12135,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,45649,,"27,634 x DRG weight",45649,Other,base rate x DRG weight,38800,,"23,488 x DRG weight",38800,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9982,,"3,327.21 x patient days",9982,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9134,,"3,044.51 x patient days",9134,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,17941,,"5,980.29 x patient days",17941,Per diem,,21138,,"7,045.87 x patient days",21138,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,8155,,"2,718.31 x patient days",8155,Per diem,,0.01,45649,
Interstitial & alveolar lung diseases,142-1,APR-DRG,,,,,,,,inpatient,,,320544.88,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,20224,,"4,044.85 x patient days",20224,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,18435,,"27,634 x DRG weight",18435,Other,base rate x DRG weight,15669,,"23,488 x DRG weight",15669,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,16636,,"3,327.21 x patient days",16636,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,15222,,"3,044.51 x patient days",15222,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,29901,,"5,980.29 x patient days",29901,Per diem,,35229,,"7,045.87 x patient days",35229,Per diem,,23377,,"4,675.50 x patient days",23377,Per diem,,23377,,"4,675.50 x patient days",23377,Per diem,,13591,,"2,718.31 x patient days",13591,Per diem,,0.01,35229,
Interstitial & alveolar lung diseases,142-2,APR-DRG,,,,,,,,inpatient,,,167842.71,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,20224,,"4,044.85 x patient days",20224,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,23740,,"27,634 x DRG weight",23740,Other,base rate x DRG weight,20179,,"23,488 x DRG weight",20179,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,16636,,"3,327.21 x patient days",16636,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,15222,,"3,044.51 x patient days",15222,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,29901,,"5,980.29 x patient days",29901,Per diem,,35229,,"7,045.87 x patient days",35229,Per diem,,23377,,"4,675.50 x patient days",23377,Per diem,,23377,,"4,675.50 x patient days",23377,Per diem,,13591,,"2,718.31 x patient days",13591,Per diem,,0.01,35229,
Interstitial & alveolar lung diseases,142-3,APR-DRG,,,,,,,,inpatient,,,212654.14,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,20224,,"4,044.85 x patient days",20224,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,36775,,"27,634 x DRG weight",36775,Other,base rate x DRG weight,31258,,"23,488 x DRG weight",31258,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,16636,,"3,327.21 x patient days",16636,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,15222,,"3,044.51 x patient days",15222,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,29901,,"5,980.29 x patient days",29901,Per diem,,35229,,"7,045.87 x patient days",35229,Per diem,,23377,,"4,675.50 x patient days",23377,Per diem,,23377,,"4,675.50 x patient days",23377,Per diem,,13591,,"2,718.31 x patient days",13591,Per diem,,0.01,36775,
Interstitial & alveolar lung diseases,142-4,APR-DRG,,,,,,,,inpatient,,,415838,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,20224,,"4,044.85 x patient days",20224,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,76867,,"27,634 x DRG weight",76867,Other,base rate x DRG weight,65334,,"23,488 x DRG weight",65334,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,16636,,"3,327.21 x patient days",16636,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,15222,,"3,044.51 x patient days",15222,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,29901,,"5,980.29 x patient days",29901,Per diem,,35229,,"7,045.87 x patient days",35229,Per diem,,23377,,"4,675.50 x patient days",23377,Per diem,,23377,,"4,675.50 x patient days",23377,Per diem,,13591,,"2,718.31 x patient days",13591,Per diem,,0.01,76867,
"Other respiratory diagnoses except signs, symptoms & minor diagnoses",143-1,APR-DRG,,,,,,,,inpatient,,,64108.13,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,16180,,"4,044.85 x patient days",16180,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,14676,,"27,634 x DRG weight",14676,Other,base rate x DRG weight,12474,,"23,488 x DRG weight",12474,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,13309,,"3,327.21 x patient days",13309,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,12179,,"3,044.51 x patient days",12179,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,23922,,"5,980.29 x patient days",23922,Per diem,,28185,,"7,045.87 x patient days",28185,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,10874,,"2,718.31 x patient days",10874,Per diem,,0.01,28185,
"Other respiratory diagnoses except signs, symptoms & minor diagnoses",143-2,APR-DRG,,,,,,,,inpatient,,,110654.41,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,16180,,"4,044.85 x patient days",16180,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,20974,,"27,634 x DRG weight",20974,Other,base rate x DRG weight,17827,,"23,488 x DRG weight",17827,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,13309,,"3,327.21 x patient days",13309,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,12179,,"3,044.51 x patient days",12179,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,23922,,"5,980.29 x patient days",23922,Per diem,,28185,,"7,045.87 x patient days",28185,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,10874,,"2,718.31 x patient days",10874,Per diem,,0.01,28185,
"Other respiratory diagnoses except signs, symptoms & minor diagnoses",143-3,APR-DRG,,,,,,,,inpatient,,,155647.11,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,16180,,"4,044.85 x patient days",16180,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,35449,,"27,634 x DRG weight",35449,Other,base rate x DRG weight,30130,,"23,488 x DRG weight",30130,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,13309,,"3,327.21 x patient days",13309,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,12179,,"3,044.51 x patient days",12179,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,23922,,"5,980.29 x patient days",23922,Per diem,,28185,,"7,045.87 x patient days",28185,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,10874,,"2,718.31 x patient days",10874,Per diem,,0.01,35449,
"Other respiratory diagnoses except signs, symptoms & minor diagnoses",143-4,APR-DRG,,,,,,,,inpatient,,,136025.18,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,16180,,"4,044.85 x patient days",16180,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,56862,,"27,634 x DRG weight",56862,Other,base rate x DRG weight,48331,,"23,488 x DRG weight",48331,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,13309,,"3,327.21 x patient days",13309,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,12179,,"3,044.51 x patient days",12179,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,23922,,"5,980.29 x patient days",23922,Per diem,,28185,,"7,045.87 x patient days",28185,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,10874,,"2,718.31 x patient days",10874,Per diem,,0.01,56862,
"Respiratory signs, symptoms & minor diagnoses",144-1,APR-DRG,,,,,,,,inpatient,,,73692.76,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12135,,"4,044.85 x patient days",12135,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12510,,"27,634 x DRG weight",12510,Other,base rate x DRG weight,10633,,"23,488 x DRG weight",10633,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9982,,"3,327.21 x patient days",9982,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9134,,"3,044.51 x patient days",9134,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,17941,,"5,980.29 x patient days",17941,Per diem,,21138,,"7,045.87 x patient days",21138,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,8155,,"2,718.31 x patient days",8155,Per diem,,0.01,21138,
"Respiratory signs, symptoms & minor diagnoses",144-2,APR-DRG,,,,,,,,inpatient,,,94240.84,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12135,,"4,044.85 x patient days",12135,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,15721,,"27,634 x DRG weight",15721,Other,base rate x DRG weight,13362,,"23,488 x DRG weight",13362,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9982,,"3,327.21 x patient days",9982,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9134,,"3,044.51 x patient days",9134,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,17941,,"5,980.29 x patient days",17941,Per diem,,21138,,"7,045.87 x patient days",21138,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,8155,,"2,718.31 x patient days",8155,Per diem,,0.01,21138,
"Respiratory signs, symptoms & minor diagnoses",144-3,APR-DRG,,,,,,,,inpatient,,,120079.79,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12135,,"4,044.85 x patient days",12135,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,23881,,"27,634 x DRG weight",23881,Other,base rate x DRG weight,20298,,"23,488 x DRG weight",20298,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9982,,"3,327.21 x patient days",9982,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9134,,"3,044.51 x patient days",9134,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,17941,,"5,980.29 x patient days",17941,Per diem,,21138,,"7,045.87 x patient days",21138,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,8155,,"2,718.31 x patient days",8155,Per diem,,0.01,23881,
"Respiratory signs, symptoms & minor diagnoses",144-4,APR-DRG,,,,,,,,inpatient,,,169840.16,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12135,,"4,044.85 x patient days",12135,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,46947,,"27,634 x DRG weight",46947,Other,base rate x DRG weight,39904,,"23,488 x DRG weight",39904,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9982,,"3,327.21 x patient days",9982,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9134,,"3,044.51 x patient days",9134,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,17941,,"5,980.29 x patient days",17941,Per diem,,21138,,"7,045.87 x patient days",21138,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,8155,,"2,718.31 x patient days",8155,Per diem,,0.01,46947,
Major cardiothoracic repair of heart anomaly,160-1,APR-DRG,,,,,,,,inpatient,,,586096.75,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,40449,,"4,044.85 x patient days",40449,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,86942,,"27,634 x DRG weight",86942,Other,base rate x DRG weight,73898,,"23,488 x DRG weight",73898,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,21747,,"2,174.65 x patient days",21747,Per diem,,21747,,"2,174.65 x patient days",21747,Per diem,,21747,,"2,174.65 x patient days",21747,Per diem,,21747,,"2,174.65 x patient days",21747,Per diem,,48931,,"4,892.96 x patient days",48931,Per diem,,33273,,"3,327.21 x patient days",33273,Per diem,,48931,,"4,892.96 x patient days",48931,Per diem,,30446,,"3,044.51 x patient days",30446,Per diem,,48931,,"4,892.96 x patient days",48931,Per diem,,59804,,"5,980.29 x patient days",59804,Per diem,,70460,,"7,045.87 x patient days",70460,Per diem,,46756,,"4,675.50 x patient days",46756,Per diem,,46756,,"4,675.50 x patient days",46756,Per diem,,27184,,"2,718.31 x patient days",27184,Per diem,,0.01,86942,
Major cardiothoracic repair of heart anomaly,160-2,APR-DRG,,,,,,,,inpatient,,,586096.75,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,40449,,"4,044.85 x patient days",40449,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,93895,,"27,634 x DRG weight",93895,Other,base rate x DRG weight,79808,,"23,488 x DRG weight",79808,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,21747,,"2,174.65 x patient days",21747,Per diem,,21747,,"2,174.65 x patient days",21747,Per diem,,21747,,"2,174.65 x patient days",21747,Per diem,,21747,,"2,174.65 x patient days",21747,Per diem,,48931,,"4,892.96 x patient days",48931,Per diem,,33273,,"3,327.21 x patient days",33273,Per diem,,48931,,"4,892.96 x patient days",48931,Per diem,,30446,,"3,044.51 x patient days",30446,Per diem,,48931,,"4,892.96 x patient days",48931,Per diem,,59804,,"5,980.29 x patient days",59804,Per diem,,70460,,"7,045.87 x patient days",70460,Per diem,,46756,,"4,675.50 x patient days",46756,Per diem,,46756,,"4,675.50 x patient days",46756,Per diem,,27184,,"2,718.31 x patient days",27184,Per diem,,0.01,93895,
Major cardiothoracic repair of heart anomaly,160-3,APR-DRG,,,,,,,,inpatient,,,843071.64,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,40449,,"4,044.85 x patient days",40449,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,132093,,"27,634 x DRG weight",132093,Other,base rate x DRG weight,112275,,"23,488 x DRG weight",112275,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,21747,,"2,174.65 x patient days",21747,Per diem,,21747,,"2,174.65 x patient days",21747,Per diem,,21747,,"2,174.65 x patient days",21747,Per diem,,21747,,"2,174.65 x patient days",21747,Per diem,,48931,,"4,892.96 x patient days",48931,Per diem,,33273,,"3,327.21 x patient days",33273,Per diem,,48931,,"4,892.96 x patient days",48931,Per diem,,30446,,"3,044.51 x patient days",30446,Per diem,,48931,,"4,892.96 x patient days",48931,Per diem,,59804,,"5,980.29 x patient days",59804,Per diem,,70460,,"7,045.87 x patient days",70460,Per diem,,46756,,"4,675.50 x patient days",46756,Per diem,,46756,,"4,675.50 x patient days",46756,Per diem,,27184,,"2,718.31 x patient days",27184,Per diem,,0.01,132093,
Major cardiothoracic repair of heart anomaly,160-4,APR-DRG,,,,,,,,inpatient,,,586096.75,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,40449,,"4,044.85 x patient days",40449,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,274790,,"27,634 x DRG weight",274790,Other,base rate x DRG weight,233562,,"23,488 x DRG weight",233562,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,21747,,"2,174.65 x patient days",21747,Per diem,,21747,,"2,174.65 x patient days",21747,Per diem,,21747,,"2,174.65 x patient days",21747,Per diem,,21747,,"2,174.65 x patient days",21747,Per diem,,48931,,"4,892.96 x patient days",48931,Per diem,,33273,,"3,327.21 x patient days",33273,Per diem,,48931,,"4,892.96 x patient days",48931,Per diem,,30446,,"3,044.51 x patient days",30446,Per diem,,48931,,"4,892.96 x patient days",48931,Per diem,,59804,,"5,980.29 x patient days",59804,Per diem,,70460,,"7,045.87 x patient days",70460,Per diem,,46756,,"4,675.50 x patient days",46756,Per diem,,46756,,"4,675.50 x patient days",46756,Per diem,,27184,,"2,718.31 x patient days",27184,Per diem,,0.01,274790,
Cardiac defibrillator & heart assist implant,161-1,APR-DRG,,,,,,,,inpatient,,,284329.4,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,28315,,"4,044.85 x patient days",28315,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,110931,,"27,634 x DRG weight",110931,Other,base rate x DRG weight,94288,,"23,488 x DRG weight",94288,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,15223,,"2,174.65 x patient days",15223,Per diem,,15223,,"2,174.65 x patient days",15223,Per diem,,15223,,"2,174.65 x patient days",15223,Per diem,,15223,,"2,174.65 x patient days",15223,Per diem,,34252,,"4,892.96 x patient days",34252,Per diem,,23291,,"3,327.21 x patient days",23291,Per diem,,34252,,"4,892.96 x patient days",34252,Per diem,,21312,,"3,044.51 x patient days",21312,Per diem,,34252,,"4,892.96 x patient days",34252,Per diem,,41863,,"5,980.29 x patient days",41863,Per diem,,49323,,"7,045.87 x patient days",49323,Per diem,,32729,,"4,675.50 x patient days",32729,Per diem,,32729,,"4,675.50 x patient days",32729,Per diem,,19029,,"2,718.31 x patient days",19029,Per diem,,0.01,110931,
Cardiac defibrillator & heart assist implant,161-2,APR-DRG,,,,,,,,inpatient,,,538737.24,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,28315,,"4,044.85 x patient days",28315,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,169330,,"27,634 x DRG weight",169330,Other,base rate x DRG weight,143925,,"23,488 x DRG weight",143925,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,15223,,"2,174.65 x patient days",15223,Per diem,,15223,,"2,174.65 x patient days",15223,Per diem,,15223,,"2,174.65 x patient days",15223,Per diem,,15223,,"2,174.65 x patient days",15223,Per diem,,34252,,"4,892.96 x patient days",34252,Per diem,,23291,,"3,327.21 x patient days",23291,Per diem,,34252,,"4,892.96 x patient days",34252,Per diem,,21312,,"3,044.51 x patient days",21312,Per diem,,34252,,"4,892.96 x patient days",34252,Per diem,,41863,,"5,980.29 x patient days",41863,Per diem,,49323,,"7,045.87 x patient days",49323,Per diem,,32729,,"4,675.50 x patient days",32729,Per diem,,32729,,"4,675.50 x patient days",32729,Per diem,,19029,,"2,718.31 x patient days",19029,Per diem,,0.01,169330,
Cardiac defibrillator & heart assist implant,161-3,APR-DRG,,,,,,,,inpatient,,,494301.5,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,28315,,"4,044.85 x patient days",28315,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,271908,,"27,634 x DRG weight",271908,Other,base rate x DRG weight,231113,,"23,488 x DRG weight",231113,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,15223,,"2,174.65 x patient days",15223,Per diem,,15223,,"2,174.65 x patient days",15223,Per diem,,15223,,"2,174.65 x patient days",15223,Per diem,,15223,,"2,174.65 x patient days",15223,Per diem,,34252,,"4,892.96 x patient days",34252,Per diem,,23291,,"3,327.21 x patient days",23291,Per diem,,34252,,"4,892.96 x patient days",34252,Per diem,,21312,,"3,044.51 x patient days",21312,Per diem,,34252,,"4,892.96 x patient days",34252,Per diem,,41863,,"5,980.29 x patient days",41863,Per diem,,49323,,"7,045.87 x patient days",49323,Per diem,,32729,,"4,675.50 x patient days",32729,Per diem,,32729,,"4,675.50 x patient days",32729,Per diem,,19029,,"2,718.31 x patient days",19029,Per diem,,0.01,271908,
Cardiac defibrillator & heart assist implant,161-4,APR-DRG,,,,,,,,inpatient,,,1641477.14,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,28315,,"4,044.85 x patient days",28315,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,637815,,"27,634 x DRG weight",637815,Other,base rate x DRG weight,542122,,"23,488 x DRG weight",542122,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,15223,,"2,174.65 x patient days",15223,Per diem,,15223,,"2,174.65 x patient days",15223,Per diem,,15223,,"2,174.65 x patient days",15223,Per diem,,15223,,"2,174.65 x patient days",15223,Per diem,,34252,,"4,892.96 x patient days",34252,Per diem,,23291,,"3,327.21 x patient days",23291,Per diem,,34252,,"4,892.96 x patient days",34252,Per diem,,21312,,"3,044.51 x patient days",21312,Per diem,,34252,,"4,892.96 x patient days",34252,Per diem,,41863,,"5,980.29 x patient days",41863,Per diem,,49323,,"7,045.87 x patient days",49323,Per diem,,32729,,"4,675.50 x patient days",32729,Per diem,,32729,,"4,675.50 x patient days",32729,Per diem,,19029,,"2,718.31 x patient days",19029,Per diem,,0.01,637815,
Cardiac valve procedures w AMI or complex PDX,162-1,APR-DRG,,,,,,,,inpatient,,,497337.94,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,52582,,"4,044.85 x patient days",52582,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,95672,,"27,634 x DRG weight",95672,Other,base rate x DRG weight,81318,,"23,488 x DRG weight",81318,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,28270,,"2,174.65 x patient days",28270,Per diem,,28270,,"2,174.65 x patient days",28270,Per diem,,28270,,"2,174.65 x patient days",28270,Per diem,,28270,,"2,174.65 x patient days",28270,Per diem,,63608,,"4,892.96 x patient days",63608,Per diem,,43253,,"3,327.21 x patient days",43253,Per diem,,63608,,"4,892.96 x patient days",63608,Per diem,,39578,,"3,044.51 x patient days",39578,Per diem,,63608,,"4,892.96 x patient days",63608,Per diem,,77743,,"5,980.29 x patient days",77743,Per diem,,91595,,"7,045.87 x patient days",91595,Per diem,,60781,,"4,675.50 x patient days",60781,Per diem,,60781,,"4,675.50 x patient days",60781,Per diem,,35338,,"2,718.31 x patient days",35338,Per diem,,0.01,95672,
Cardiac valve procedures w AMI or complex PDX,162-2,APR-DRG,,,,,,,,inpatient,,,446594.87,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,52582,,"4,044.85 x patient days",52582,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,123858,,"27,634 x DRG weight",123858,Other,base rate x DRG weight,105276,,"23,488 x DRG weight",105276,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,28270,,"2,174.65 x patient days",28270,Per diem,,28270,,"2,174.65 x patient days",28270,Per diem,,28270,,"2,174.65 x patient days",28270,Per diem,,28270,,"2,174.65 x patient days",28270,Per diem,,63608,,"4,892.96 x patient days",63608,Per diem,,43253,,"3,327.21 x patient days",43253,Per diem,,63608,,"4,892.96 x patient days",63608,Per diem,,39578,,"3,044.51 x patient days",39578,Per diem,,63608,,"4,892.96 x patient days",63608,Per diem,,77743,,"5,980.29 x patient days",77743,Per diem,,91595,,"7,045.87 x patient days",91595,Per diem,,60781,,"4,675.50 x patient days",60781,Per diem,,60781,,"4,675.50 x patient days",60781,Per diem,,35338,,"2,718.31 x patient days",35338,Per diem,,0.01,123858,
Cardiac valve procedures w AMI or complex PDX,162-3,APR-DRG,,,,,,,,inpatient,,,666539.54,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,52582,,"4,044.85 x patient days",52582,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,158528,,"27,634 x DRG weight",158528,Other,base rate x DRG weight,134744,,"23,488 x DRG weight",134744,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,28270,,"2,174.65 x patient days",28270,Per diem,,28270,,"2,174.65 x patient days",28270,Per diem,,28270,,"2,174.65 x patient days",28270,Per diem,,28270,,"2,174.65 x patient days",28270,Per diem,,63608,,"4,892.96 x patient days",63608,Per diem,,43253,,"3,327.21 x patient days",43253,Per diem,,63608,,"4,892.96 x patient days",63608,Per diem,,39578,,"3,044.51 x patient days",39578,Per diem,,63608,,"4,892.96 x patient days",63608,Per diem,,77743,,"5,980.29 x patient days",77743,Per diem,,91595,,"7,045.87 x patient days",91595,Per diem,,60781,,"4,675.50 x patient days",60781,Per diem,,60781,,"4,675.50 x patient days",60781,Per diem,,35338,,"2,718.31 x patient days",35338,Per diem,,0.01,158528,
Cardiac valve procedures w AMI or complex PDX,162-4,APR-DRG,,,,,,,,inpatient,,,1293079.92,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,52582,,"4,044.85 x patient days",52582,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,259337,,"27,634 x DRG weight",259337,Other,base rate x DRG weight,220428,,"23,488 x DRG weight",220428,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,28270,,"2,174.65 x patient days",28270,Per diem,,28270,,"2,174.65 x patient days",28270,Per diem,,28270,,"2,174.65 x patient days",28270,Per diem,,28270,,"2,174.65 x patient days",28270,Per diem,,63608,,"4,892.96 x patient days",63608,Per diem,,43253,,"3,327.21 x patient days",43253,Per diem,,63608,,"4,892.96 x patient days",63608,Per diem,,39578,,"3,044.51 x patient days",39578,Per diem,,63608,,"4,892.96 x patient days",63608,Per diem,,77743,,"5,980.29 x patient days",77743,Per diem,,91595,,"7,045.87 x patient days",91595,Per diem,,60781,,"4,675.50 x patient days",60781,Per diem,,60781,,"4,675.50 x patient days",60781,Per diem,,35338,,"2,718.31 x patient days",35338,Per diem,,0.01,259337,
Cardiac valve procedures w/o AMI or complex PDX,163-1,APR-DRG,,,,,,,,inpatient,,,368680.69,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,32358,,"4,044.85 x patient days",32358,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,83585,,"27,634 x DRG weight",83585,Other,base rate x DRG weight,71044,,"23,488 x DRG weight",71044,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,17397,,"2,174.65 x patient days",17397,Per diem,,17397,,"2,174.65 x patient days",17397,Per diem,,17397,,"2,174.65 x patient days",17397,Per diem,,17397,,"2,174.65 x patient days",17397,Per diem,,39143,,"4,892.96 x patient days",39143,Per diem,,26617,,"3,327.21 x patient days",26617,Per diem,,39143,,"4,892.96 x patient days",39143,Per diem,,24356,,"3,044.51 x patient days",24356,Per diem,,39143,,"4,892.96 x patient days",39143,Per diem,,47842,,"5,980.29 x patient days",47842,Per diem,,56366,,"7,045.87 x patient days",56366,Per diem,,37404,,"4,675.50 x patient days",37404,Per diem,,37404,,"4,675.50 x patient days",37404,Per diem,,21746,,"2,718.31 x patient days",21746,Per diem,,0.01,83585,
Cardiac valve procedures w/o AMI or complex PDX,163-2,APR-DRG,,,,,,,,inpatient,,,426385.75,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,32358,,"4,044.85 x patient days",32358,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,102249,,"27,634 x DRG weight",102249,Other,base rate x DRG weight,86908,,"23,488 x DRG weight",86908,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,17397,,"2,174.65 x patient days",17397,Per diem,,17397,,"2,174.65 x patient days",17397,Per diem,,17397,,"2,174.65 x patient days",17397,Per diem,,17397,,"2,174.65 x patient days",17397,Per diem,,39143,,"4,892.96 x patient days",39143,Per diem,,26617,,"3,327.21 x patient days",26617,Per diem,,39143,,"4,892.96 x patient days",39143,Per diem,,24356,,"3,044.51 x patient days",24356,Per diem,,39143,,"4,892.96 x patient days",39143,Per diem,,47842,,"5,980.29 x patient days",47842,Per diem,,56366,,"7,045.87 x patient days",56366,Per diem,,37404,,"4,675.50 x patient days",37404,Per diem,,37404,,"4,675.50 x patient days",37404,Per diem,,21746,,"2,718.31 x patient days",21746,Per diem,,0.01,102249,
Cardiac valve procedures w/o AMI or complex PDX,163-3,APR-DRG,,,,,,,,inpatient,,,770325.98,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,32358,,"4,044.85 x patient days",32358,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,125613,,"27,634 x DRG weight",125613,Other,base rate x DRG weight,106767,,"23,488 x DRG weight",106767,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,17397,,"2,174.65 x patient days",17397,Per diem,,17397,,"2,174.65 x patient days",17397,Per diem,,17397,,"2,174.65 x patient days",17397,Per diem,,17397,,"2,174.65 x patient days",17397,Per diem,,39143,,"4,892.96 x patient days",39143,Per diem,,26617,,"3,327.21 x patient days",26617,Per diem,,39143,,"4,892.96 x patient days",39143,Per diem,,24356,,"3,044.51 x patient days",24356,Per diem,,39143,,"4,892.96 x patient days",39143,Per diem,,47842,,"5,980.29 x patient days",47842,Per diem,,56366,,"7,045.87 x patient days",56366,Per diem,,37404,,"4,675.50 x patient days",37404,Per diem,,37404,,"4,675.50 x patient days",37404,Per diem,,21746,,"2,718.31 x patient days",21746,Per diem,,0.01,125613,
Cardiac valve procedures w/o AMI or complex PDX,163-4,APR-DRG,,,,,,,,inpatient,,,922959.67,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,32358,,"4,044.85 x patient days",32358,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,194737,,"27,634 x DRG weight",194737,Other,base rate x DRG weight,165520,,"23,488 x DRG weight",165520,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,17397,,"2,174.65 x patient days",17397,Per diem,,17397,,"2,174.65 x patient days",17397,Per diem,,17397,,"2,174.65 x patient days",17397,Per diem,,17397,,"2,174.65 x patient days",17397,Per diem,,39143,,"4,892.96 x patient days",39143,Per diem,,26617,,"3,327.21 x patient days",26617,Per diem,,39143,,"4,892.96 x patient days",39143,Per diem,,24356,,"3,044.51 x patient days",24356,Per diem,,39143,,"4,892.96 x patient days",39143,Per diem,,47842,,"5,980.29 x patient days",47842,Per diem,,56366,,"7,045.87 x patient days",56366,Per diem,,37404,,"4,675.50 x patient days",37404,Per diem,,37404,,"4,675.50 x patient days",37404,Per diem,,21746,,"2,718.31 x patient days",21746,Per diem,,0.01,194737,
Coronary bypass w AMI or complex PDX,165-1,APR-DRG,,,,,,,,inpatient,,,498912.47,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,44493,,"4,044.85 x patient days",44493,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,108698,,"27,634 x DRG weight",108698,Other,base rate x DRG weight,92390,,"23,488 x DRG weight",92390,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,23921,,"2,174.65 x patient days",23921,Per diem,,23921,,"2,174.65 x patient days",23921,Per diem,,23921,,"2,174.65 x patient days",23921,Per diem,,23921,,"2,174.65 x patient days",23921,Per diem,,53822,,"4,892.96 x patient days",53822,Per diem,,36599,,"3,327.21 x patient days",36599,Per diem,,53822,,"4,892.96 x patient days",53822,Per diem,,33489,,"3,044.51 x patient days",33489,Per diem,,53822,,"4,892.96 x patient days",53822,Per diem,,65783,,"5,980.29 x patient days",65783,Per diem,,77504,,"7,045.87 x patient days",77504,Per diem,,51430,,"4,675.50 x patient days",51430,Per diem,,51430,,"4,675.50 x patient days",51430,Per diem,,29901,,"2,718.31 x patient days",29901,Per diem,,0.01,108698,
Coronary bypass w AMI or complex PDX,165-2,APR-DRG,,,,,,,,inpatient,,,498912.47,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,44493,,"4,044.85 x patient days",44493,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,109071,,"27,634 x DRG weight",109071,Other,base rate x DRG weight,92707,,"23,488 x DRG weight",92707,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,23921,,"2,174.65 x patient days",23921,Per diem,,23921,,"2,174.65 x patient days",23921,Per diem,,23921,,"2,174.65 x patient days",23921,Per diem,,23921,,"2,174.65 x patient days",23921,Per diem,,53822,,"4,892.96 x patient days",53822,Per diem,,36599,,"3,327.21 x patient days",36599,Per diem,,53822,,"4,892.96 x patient days",53822,Per diem,,33489,,"3,044.51 x patient days",33489,Per diem,,53822,,"4,892.96 x patient days",53822,Per diem,,65783,,"5,980.29 x patient days",65783,Per diem,,77504,,"7,045.87 x patient days",77504,Per diem,,51430,,"4,675.50 x patient days",51430,Per diem,,51430,,"4,675.50 x patient days",51430,Per diem,,29901,,"2,718.31 x patient days",29901,Per diem,,0.01,109071,
Coronary bypass w AMI or complex PDX,165-3,APR-DRG,,,,,,,,inpatient,,,722596.53,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,44493,,"4,044.85 x patient days",44493,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,134340,,"27,634 x DRG weight",134340,Other,base rate x DRG weight,114185,,"23,488 x DRG weight",114185,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,23921,,"2,174.65 x patient days",23921,Per diem,,23921,,"2,174.65 x patient days",23921,Per diem,,23921,,"2,174.65 x patient days",23921,Per diem,,23921,,"2,174.65 x patient days",23921,Per diem,,53822,,"4,892.96 x patient days",53822,Per diem,,36599,,"3,327.21 x patient days",36599,Per diem,,53822,,"4,892.96 x patient days",53822,Per diem,,33489,,"3,044.51 x patient days",33489,Per diem,,53822,,"4,892.96 x patient days",53822,Per diem,,65783,,"5,980.29 x patient days",65783,Per diem,,77504,,"7,045.87 x patient days",77504,Per diem,,51430,,"4,675.50 x patient days",51430,Per diem,,51430,,"4,675.50 x patient days",51430,Per diem,,29901,,"2,718.31 x patient days",29901,Per diem,,0.01,134340,
Coronary bypass w AMI or complex PDX,165-4,APR-DRG,,,,,,,,inpatient,,,1510877.43,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,44493,,"4,044.85 x patient days",44493,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,195555,,"27,634 x DRG weight",195555,Other,base rate x DRG weight,166215,,"23,488 x DRG weight",166215,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,23921,,"2,174.65 x patient days",23921,Per diem,,23921,,"2,174.65 x patient days",23921,Per diem,,23921,,"2,174.65 x patient days",23921,Per diem,,23921,,"2,174.65 x patient days",23921,Per diem,,53822,,"4,892.96 x patient days",53822,Per diem,,36599,,"3,327.21 x patient days",36599,Per diem,,53822,,"4,892.96 x patient days",53822,Per diem,,33489,,"3,044.51 x patient days",33489,Per diem,,53822,,"4,892.96 x patient days",53822,Per diem,,65783,,"5,980.29 x patient days",65783,Per diem,,77504,,"7,045.87 x patient days",77504,Per diem,,51430,,"4,675.50 x patient days",51430,Per diem,,51430,,"4,675.50 x patient days",51430,Per diem,,29901,,"2,718.31 x patient days",29901,Per diem,,0.01,195555,
Coronary bypass w/o AMI or complex PDX,166-1,APR-DRG,,,,,,,,inpatient,,,355089.76,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,32358,,"4,044.85 x patient days",32358,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,83004,,"27,634 x DRG weight",83004,Other,base rate x DRG weight,70551,,"23,488 x DRG weight",70551,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,17397,,"2,174.65 x patient days",17397,Per diem,,17397,,"2,174.65 x patient days",17397,Per diem,,17397,,"2,174.65 x patient days",17397,Per diem,,17397,,"2,174.65 x patient days",17397,Per diem,,39143,,"4,892.96 x patient days",39143,Per diem,,26617,,"3,327.21 x patient days",26617,Per diem,,39143,,"4,892.96 x patient days",39143,Per diem,,24356,,"3,044.51 x patient days",24356,Per diem,,39143,,"4,892.96 x patient days",39143,Per diem,,47842,,"5,980.29 x patient days",47842,Per diem,,56366,,"7,045.87 x patient days",56366,Per diem,,37404,,"4,675.50 x patient days",37404,Per diem,,37404,,"4,675.50 x patient days",37404,Per diem,,21746,,"2,718.31 x patient days",21746,Per diem,,0.01,83004,
Coronary bypass w/o AMI or complex PDX,166-2,APR-DRG,,,,,,,,inpatient,,,541172.91,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,32358,,"4,044.85 x patient days",32358,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,90131,,"27,634 x DRG weight",90131,Other,base rate x DRG weight,76608,,"23,488 x DRG weight",76608,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,17397,,"2,174.65 x patient days",17397,Per diem,,17397,,"2,174.65 x patient days",17397,Per diem,,17397,,"2,174.65 x patient days",17397,Per diem,,17397,,"2,174.65 x patient days",17397,Per diem,,39143,,"4,892.96 x patient days",39143,Per diem,,26617,,"3,327.21 x patient days",26617,Per diem,,39143,,"4,892.96 x patient days",39143,Per diem,,24356,,"3,044.51 x patient days",24356,Per diem,,39143,,"4,892.96 x patient days",39143,Per diem,,47842,,"5,980.29 x patient days",47842,Per diem,,56366,,"7,045.87 x patient days",56366,Per diem,,37404,,"4,675.50 x patient days",37404,Per diem,,37404,,"4,675.50 x patient days",37404,Per diem,,21746,,"2,718.31 x patient days",21746,Per diem,,0.01,90131,
Coronary bypass w/o AMI or complex PDX,166-3,APR-DRG,,,,,,,,inpatient,,,482321.88,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,32358,,"4,044.85 x patient days",32358,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,110973,,"27,634 x DRG weight",110973,Other,base rate x DRG weight,94323,,"23,488 x DRG weight",94323,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,17397,,"2,174.65 x patient days",17397,Per diem,,17397,,"2,174.65 x patient days",17397,Per diem,,17397,,"2,174.65 x patient days",17397,Per diem,,17397,,"2,174.65 x patient days",17397,Per diem,,39143,,"4,892.96 x patient days",39143,Per diem,,26617,,"3,327.21 x patient days",26617,Per diem,,39143,,"4,892.96 x patient days",39143,Per diem,,24356,,"3,044.51 x patient days",24356,Per diem,,39143,,"4,892.96 x patient days",39143,Per diem,,47842,,"5,980.29 x patient days",47842,Per diem,,56366,,"7,045.87 x patient days",56366,Per diem,,37404,,"4,675.50 x patient days",37404,Per diem,,37404,,"4,675.50 x patient days",37404,Per diem,,21746,,"2,718.31 x patient days",21746,Per diem,,0.01,110973,
Coronary bypass w/o AMI or complex PDX,166-4,APR-DRG,,,,,,,,inpatient,,,614887.93,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,32358,,"4,044.85 x patient days",32358,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,172193,,"27,634 x DRG weight",172193,Other,base rate x DRG weight,146358,,"23,488 x DRG weight",146358,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,17397,,"2,174.65 x patient days",17397,Per diem,,17397,,"2,174.65 x patient days",17397,Per diem,,17397,,"2,174.65 x patient days",17397,Per diem,,17397,,"2,174.65 x patient days",17397,Per diem,,39143,,"4,892.96 x patient days",39143,Per diem,,26617,,"3,327.21 x patient days",26617,Per diem,,39143,,"4,892.96 x patient days",39143,Per diem,,24356,,"3,044.51 x patient days",24356,Per diem,,39143,,"4,892.96 x patient days",39143,Per diem,,47842,,"5,980.29 x patient days",47842,Per diem,,56366,,"7,045.87 x patient days",56366,Per diem,,37404,,"4,675.50 x patient days",37404,Per diem,,37404,,"4,675.50 x patient days",37404,Per diem,,21746,,"2,718.31 x patient days",21746,Per diem,,0.01,172193,
Other cardiothoracic & thoracic vascular procedures,167-1,APR-DRG,,,,,,,,inpatient,,,196915.88,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,32358,,"4,044.85 x patient days",32358,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,67032,,"27,634 x DRG weight",67032,Other,base rate x DRG weight,56975,,"23,488 x DRG weight",56975,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,17397,,"2,174.65 x patient days",17397,Per diem,,17397,,"2,174.65 x patient days",17397,Per diem,,17397,,"2,174.65 x patient days",17397,Per diem,,17397,,"2,174.65 x patient days",17397,Per diem,,39143,,"4,892.96 x patient days",39143,Per diem,,26617,,"3,327.21 x patient days",26617,Per diem,,39143,,"4,892.96 x patient days",39143,Per diem,,24356,,"3,044.51 x patient days",24356,Per diem,,39143,,"4,892.96 x patient days",39143,Per diem,,47842,,"5,980.29 x patient days",47842,Per diem,,56366,,"7,045.87 x patient days",56366,Per diem,,37404,,"4,675.50 x patient days",37404,Per diem,,37404,,"4,675.50 x patient days",37404,Per diem,,21746,,"2,718.31 x patient days",21746,Per diem,,0.01,67032,
Other cardiothoracic & thoracic vascular procedures,167-2,APR-DRG,,,,,,,,inpatient,,,369975.64,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,32358,,"4,044.85 x patient days",32358,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,78472,,"27,634 x DRG weight",78472,Other,base rate x DRG weight,66699,,"23,488 x DRG weight",66699,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,17397,,"2,174.65 x patient days",17397,Per diem,,17397,,"2,174.65 x patient days",17397,Per diem,,17397,,"2,174.65 x patient days",17397,Per diem,,17397,,"2,174.65 x patient days",17397,Per diem,,39143,,"4,892.96 x patient days",39143,Per diem,,26617,,"3,327.21 x patient days",26617,Per diem,,39143,,"4,892.96 x patient days",39143,Per diem,,24356,,"3,044.51 x patient days",24356,Per diem,,39143,,"4,892.96 x patient days",39143,Per diem,,47842,,"5,980.29 x patient days",47842,Per diem,,56366,,"7,045.87 x patient days",56366,Per diem,,37404,,"4,675.50 x patient days",37404,Per diem,,37404,,"4,675.50 x patient days",37404,Per diem,,21746,,"2,718.31 x patient days",21746,Per diem,,0.01,78472,
Other cardiothoracic & thoracic vascular procedures,167-3,APR-DRG,,,,,,,,inpatient,,,565606.14,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,32358,,"4,044.85 x patient days",32358,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,101726,,"27,634 x DRG weight",101726,Other,base rate x DRG weight,86464,,"23,488 x DRG weight",86464,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,17397,,"2,174.65 x patient days",17397,Per diem,,17397,,"2,174.65 x patient days",17397,Per diem,,17397,,"2,174.65 x patient days",17397,Per diem,,17397,,"2,174.65 x patient days",17397,Per diem,,39143,,"4,892.96 x patient days",39143,Per diem,,26617,,"3,327.21 x patient days",26617,Per diem,,39143,,"4,892.96 x patient days",39143,Per diem,,24356,,"3,044.51 x patient days",24356,Per diem,,39143,,"4,892.96 x patient days",39143,Per diem,,47842,,"5,980.29 x patient days",47842,Per diem,,56366,,"7,045.87 x patient days",56366,Per diem,,37404,,"4,675.50 x patient days",37404,Per diem,,37404,,"4,675.50 x patient days",37404,Per diem,,21746,,"2,718.31 x patient days",21746,Per diem,,0.01,101726,
Other cardiothoracic & thoracic vascular procedures,167-4,APR-DRG,,,,,,,,inpatient,,,1019180.67,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,32358,,"4,044.85 x patient days",32358,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,183247,,"27,634 x DRG weight",183247,Other,base rate x DRG weight,155754,,"23,488 x DRG weight",155754,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,17397,,"2,174.65 x patient days",17397,Per diem,,17397,,"2,174.65 x patient days",17397,Per diem,,17397,,"2,174.65 x patient days",17397,Per diem,,17397,,"2,174.65 x patient days",17397,Per diem,,39143,,"4,892.96 x patient days",39143,Per diem,,26617,,"3,327.21 x patient days",26617,Per diem,,39143,,"4,892.96 x patient days",39143,Per diem,,24356,,"3,044.51 x patient days",24356,Per diem,,39143,,"4,892.96 x patient days",39143,Per diem,,47842,,"5,980.29 x patient days",47842,Per diem,,56366,,"7,045.87 x patient days",56366,Per diem,,37404,,"4,675.50 x patient days",37404,Per diem,,37404,,"4,675.50 x patient days",37404,Per diem,,21746,,"2,718.31 x patient days",21746,Per diem,,0.01,183247,
Major abdominal vascular procedures,169-1,APR-DRG,,,,,,,,inpatient,,,224037.16,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,32358,,"4,044.85 x patient days",32358,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,49280,,"27,634 x DRG weight",49280,Other,base rate x DRG weight,41886,,"23,488 x DRG weight",41886,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,17397,,"2,174.65 x patient days",17397,Per diem,,17397,,"2,174.65 x patient days",17397,Per diem,,17397,,"2,174.65 x patient days",17397,Per diem,,17397,,"2,174.65 x patient days",17397,Per diem,,39143,,"4,892.96 x patient days",39143,Per diem,,26617,,"3,327.21 x patient days",26617,Per diem,,39143,,"4,892.96 x patient days",39143,Per diem,,24356,,"3,044.51 x patient days",24356,Per diem,,39143,,"4,892.96 x patient days",39143,Per diem,,47842,,"5,980.29 x patient days",47842,Per diem,,56366,,"7,045.87 x patient days",56366,Per diem,,37404,,"4,675.50 x patient days",37404,Per diem,,37404,,"4,675.50 x patient days",37404,Per diem,,21746,,"2,718.31 x patient days",21746,Per diem,,0.01,56366,
Major abdominal vascular procedures,169-2,APR-DRG,,,,,,,,inpatient,,,320855.16,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,32358,,"4,044.85 x patient days",32358,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,63238,,"27,634 x DRG weight",63238,Other,base rate x DRG weight,53750,,"23,488 x DRG weight",53750,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,17397,,"2,174.65 x patient days",17397,Per diem,,17397,,"2,174.65 x patient days",17397,Per diem,,17397,,"2,174.65 x patient days",17397,Per diem,,17397,,"2,174.65 x patient days",17397,Per diem,,39143,,"4,892.96 x patient days",39143,Per diem,,26617,,"3,327.21 x patient days",26617,Per diem,,39143,,"4,892.96 x patient days",39143,Per diem,,24356,,"3,044.51 x patient days",24356,Per diem,,39143,,"4,892.96 x patient days",39143,Per diem,,47842,,"5,980.29 x patient days",47842,Per diem,,56366,,"7,045.87 x patient days",56366,Per diem,,37404,,"4,675.50 x patient days",37404,Per diem,,37404,,"4,675.50 x patient days",37404,Per diem,,21746,,"2,718.31 x patient days",21746,Per diem,,0.01,63238,
Major abdominal vascular procedures,169-3,APR-DRG,,,,,,,,inpatient,,,471431.61,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,32358,,"4,044.85 x patient days",32358,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,102671,,"27,634 x DRG weight",102671,Other,base rate x DRG weight,87267,,"23,488 x DRG weight",87267,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,17397,,"2,174.65 x patient days",17397,Per diem,,17397,,"2,174.65 x patient days",17397,Per diem,,17397,,"2,174.65 x patient days",17397,Per diem,,17397,,"2,174.65 x patient days",17397,Per diem,,39143,,"4,892.96 x patient days",39143,Per diem,,26617,,"3,327.21 x patient days",26617,Per diem,,39143,,"4,892.96 x patient days",39143,Per diem,,24356,,"3,044.51 x patient days",24356,Per diem,,39143,,"4,892.96 x patient days",39143,Per diem,,47842,,"5,980.29 x patient days",47842,Per diem,,56366,,"7,045.87 x patient days",56366,Per diem,,37404,,"4,675.50 x patient days",37404,Per diem,,37404,,"4,675.50 x patient days",37404,Per diem,,21746,,"2,718.31 x patient days",21746,Per diem,,0.01,102671,
Major abdominal vascular procedures,169-4,APR-DRG,,,,,,,,inpatient,,,1233181.37,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,32358,,"4,044.85 x patient days",32358,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,198492,,"27,634 x DRG weight",198492,Other,base rate x DRG weight,168712,,"23,488 x DRG weight",168712,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,17397,,"2,174.65 x patient days",17397,Per diem,,17397,,"2,174.65 x patient days",17397,Per diem,,17397,,"2,174.65 x patient days",17397,Per diem,,17397,,"2,174.65 x patient days",17397,Per diem,,39143,,"4,892.96 x patient days",39143,Per diem,,26617,,"3,327.21 x patient days",26617,Per diem,,39143,,"4,892.96 x patient days",39143,Per diem,,24356,,"3,044.51 x patient days",24356,Per diem,,39143,,"4,892.96 x patient days",39143,Per diem,,47842,,"5,980.29 x patient days",47842,Per diem,,56366,,"7,045.87 x patient days",56366,Per diem,,37404,,"4,675.50 x patient days",37404,Per diem,,37404,,"4,675.50 x patient days",37404,Per diem,,21746,,"2,718.31 x patient days",21746,Per diem,,0.01,198492,
"Permanent cardiac pacemaker implant w AMI, heart failure or shock",170-1,APR-DRG,,,,,,,,inpatient,,,272579,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,40449,,"4,044.85 x patient days",40449,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,74767,,"27,634 x DRG weight",74767,Other,base rate x DRG weight,63549,,"23,488 x DRG weight",63549,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,21747,,"2,174.65 x patient days",21747,Per diem,,21747,,"2,174.65 x patient days",21747,Per diem,,21747,,"2,174.65 x patient days",21747,Per diem,,21747,,"2,174.65 x patient days",21747,Per diem,,48931,,"4,892.96 x patient days",48931,Per diem,,33273,,"3,327.21 x patient days",33273,Per diem,,48931,,"4,892.96 x patient days",48931,Per diem,,30446,,"3,044.51 x patient days",30446,Per diem,,48931,,"4,892.96 x patient days",48931,Per diem,,59804,,"5,980.29 x patient days",59804,Per diem,,70460,,"7,045.87 x patient days",70460,Per diem,,46756,,"4,675.50 x patient days",46756,Per diem,,46756,,"4,675.50 x patient days",46756,Per diem,,27184,,"2,718.31 x patient days",27184,Per diem,,0.01,74767,
"Permanent cardiac pacemaker implant w AMI, heart failure or shock",170-2,APR-DRG,,,,,,,,inpatient,,,256944.8,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,40449,,"4,044.85 x patient days",40449,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,75590,,"27,634 x DRG weight",75590,Other,base rate x DRG weight,64249,,"23,488 x DRG weight",64249,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,21747,,"2,174.65 x patient days",21747,Per diem,,21747,,"2,174.65 x patient days",21747,Per diem,,21747,,"2,174.65 x patient days",21747,Per diem,,21747,,"2,174.65 x patient days",21747,Per diem,,48931,,"4,892.96 x patient days",48931,Per diem,,33273,,"3,327.21 x patient days",33273,Per diem,,48931,,"4,892.96 x patient days",48931,Per diem,,30446,,"3,044.51 x patient days",30446,Per diem,,48931,,"4,892.96 x patient days",48931,Per diem,,59804,,"5,980.29 x patient days",59804,Per diem,,70460,,"7,045.87 x patient days",70460,Per diem,,46756,,"4,675.50 x patient days",46756,Per diem,,46756,,"4,675.50 x patient days",46756,Per diem,,27184,,"2,718.31 x patient days",27184,Per diem,,0.01,75590,
"Permanent cardiac pacemaker implant w AMI, heart failure or shock",170-3,APR-DRG,,,,,,,,inpatient,,,406911.67,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,40449,,"4,044.85 x patient days",40449,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,99565,,"27,634 x DRG weight",99565,Other,base rate x DRG weight,84627,,"23,488 x DRG weight",84627,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,21747,,"2,174.65 x patient days",21747,Per diem,,21747,,"2,174.65 x patient days",21747,Per diem,,21747,,"2,174.65 x patient days",21747,Per diem,,21747,,"2,174.65 x patient days",21747,Per diem,,48931,,"4,892.96 x patient days",48931,Per diem,,33273,,"3,327.21 x patient days",33273,Per diem,,48931,,"4,892.96 x patient days",48931,Per diem,,30446,,"3,044.51 x patient days",30446,Per diem,,48931,,"4,892.96 x patient days",48931,Per diem,,59804,,"5,980.29 x patient days",59804,Per diem,,70460,,"7,045.87 x patient days",70460,Per diem,,46756,,"4,675.50 x patient days",46756,Per diem,,46756,,"4,675.50 x patient days",46756,Per diem,,27184,,"2,718.31 x patient days",27184,Per diem,,0.01,99565,
"Permanent cardiac pacemaker implant w AMI, heart failure or shock",170-4,APR-DRG,,,,,,,,inpatient,,,406911.67,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,40449,,"4,044.85 x patient days",40449,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,132989,,"27,634 x DRG weight",132989,Other,base rate x DRG weight,113036,,"23,488 x DRG weight",113036,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,21747,,"2,174.65 x patient days",21747,Per diem,,21747,,"2,174.65 x patient days",21747,Per diem,,21747,,"2,174.65 x patient days",21747,Per diem,,21747,,"2,174.65 x patient days",21747,Per diem,,48931,,"4,892.96 x patient days",48931,Per diem,,33273,,"3,327.21 x patient days",33273,Per diem,,48931,,"4,892.96 x patient days",48931,Per diem,,30446,,"3,044.51 x patient days",30446,Per diem,,48931,,"4,892.96 x patient days",48931,Per diem,,59804,,"5,980.29 x patient days",59804,Per diem,,70460,,"7,045.87 x patient days",70460,Per diem,,46756,,"4,675.50 x patient days",46756,Per diem,,46756,,"4,675.50 x patient days",46756,Per diem,,27184,,"2,718.31 x patient days",27184,Per diem,,0.01,132989,
"Perm cardiac pacemaker implant w/o AMI, heart failure or shock",171-1,APR-DRG,,,,,,,,inpatient,,,272579,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,16180,,"4,044.85 x patient days",16180,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,48078,,"27,634 x DRG weight",48078,Other,base rate x DRG weight,40864,,"23,488 x DRG weight",40864,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,13309,,"3,327.21 x patient days",13309,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,12179,,"3,044.51 x patient days",12179,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,23922,,"5,980.29 x patient days",23922,Per diem,,28185,,"7,045.87 x patient days",28185,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,10874,,"2,718.31 x patient days",10874,Per diem,,0.01,48078,
"Perm cardiac pacemaker implant w/o AMI, heart failure or shock",171-2,APR-DRG,,,,,,,,inpatient,,,256944.8,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,16180,,"4,044.85 x patient days",16180,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,59247,,"27,634 x DRG weight",59247,Other,base rate x DRG weight,50358,,"23,488 x DRG weight",50358,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,13309,,"3,327.21 x patient days",13309,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,12179,,"3,044.51 x patient days",12179,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,23922,,"5,980.29 x patient days",23922,Per diem,,28185,,"7,045.87 x patient days",28185,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,10874,,"2,718.31 x patient days",10874,Per diem,,0.01,59247,
"Perm cardiac pacemaker implant w/o AMI, heart failure or shock",171-3,APR-DRG,,,,,,,,inpatient,,,406911.67,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,16180,,"4,044.85 x patient days",16180,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,82568,,"27,634 x DRG weight",82568,Other,base rate x DRG weight,70180,,"23,488 x DRG weight",70180,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,13309,,"3,327.21 x patient days",13309,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,12179,,"3,044.51 x patient days",12179,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,23922,,"5,980.29 x patient days",23922,Per diem,,28185,,"7,045.87 x patient days",28185,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,10874,,"2,718.31 x patient days",10874,Per diem,,0.01,82568,
"Perm cardiac pacemaker implant w/o AMI, heart failure or shock",171-4,APR-DRG,,,,,,,,inpatient,,,406911.67,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,16180,,"4,044.85 x patient days",16180,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,164804,,"27,634 x DRG weight",164804,Other,base rate x DRG weight,140078,,"23,488 x DRG weight",140078,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,13309,,"3,327.21 x patient days",13309,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,12179,,"3,044.51 x patient days",12179,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,23922,,"5,980.29 x patient days",23922,Per diem,,28185,,"7,045.87 x patient days",28185,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,10874,,"2,718.31 x patient days",10874,Per diem,,0.01,164804,
Percutaneous coronary intervention w AMI,174-1,APR-DRG,,,,,,,,inpatient,,,179858.95,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12135,,"4,044.85 x patient days",12135,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,48774,,"27,634 x DRG weight",48774,Other,base rate x DRG weight,41456,,"23,488 x DRG weight",41456,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9982,,"3,327.21 x patient days",9982,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9134,,"3,044.51 x patient days",9134,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,17941,,"5,980.29 x patient days",17941,Per diem,,21138,,"7,045.87 x patient days",21138,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,8155,,"2,718.31 x patient days",8155,Per diem,,0.01,48774,
Percutaneous coronary intervention w AMI,174-2,APR-DRG,,,,,,,,inpatient,,,212603.48,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12135,,"4,044.85 x patient days",12135,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,53674,,"27,634 x DRG weight",53674,Other,base rate x DRG weight,45621,,"23,488 x DRG weight",45621,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9982,,"3,327.21 x patient days",9982,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9134,,"3,044.51 x patient days",9134,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,17941,,"5,980.29 x patient days",17941,Per diem,,21138,,"7,045.87 x patient days",21138,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,8155,,"2,718.31 x patient days",8155,Per diem,,0.01,53674,
Percutaneous coronary intervention w AMI,174-3,APR-DRG,,,,,,,,inpatient,,,313907.53,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12135,,"4,044.85 x patient days",12135,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,69262,,"27,634 x DRG weight",69262,Other,base rate x DRG weight,58870,,"23,488 x DRG weight",58870,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9982,,"3,327.21 x patient days",9982,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9134,,"3,044.51 x patient days",9134,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,17941,,"5,980.29 x patient days",17941,Per diem,,21138,,"7,045.87 x patient days",21138,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,8155,,"2,718.31 x patient days",8155,Per diem,,0.01,69262,
Percutaneous coronary intervention w AMI,174-4,APR-DRG,,,,,,,,inpatient,,,632784.5,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12135,,"4,044.85 x patient days",12135,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,105805,,"27,634 x DRG weight",105805,Other,base rate x DRG weight,89931,,"23,488 x DRG weight",89931,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9982,,"3,327.21 x patient days",9982,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9134,,"3,044.51 x patient days",9134,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,17941,,"5,980.29 x patient days",17941,Per diem,,21138,,"7,045.87 x patient days",21138,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,8155,,"2,718.31 x patient days",8155,Per diem,,0.01,105805,
Percutaneous coronary intervention w/o AMI,175-1,APR-DRG,,,,,,,,inpatient,,,201004.5,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8089,,"4,044.85 x patient days",8089,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,40771,,"27,634 x DRG weight",40771,Other,base rate x DRG weight,34654,,"23,488 x DRG weight",34654,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6654,,"3,327.21 x patient days",6654,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6089,,"3,044.51 x patient days",6089,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,11960,,"5,980.29 x patient days",11960,Per diem,,14091,,"7,045.87 x patient days",14091,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,5436,,"2,718.31 x patient days",5436,Per diem,,0.01,40771,
Percutaneous coronary intervention w/o AMI,175-2,APR-DRG,,,,,,,,inpatient,,,455540.26,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8089,,"4,044.85 x patient days",8089,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,46262,,"27,634 x DRG weight",46262,Other,base rate x DRG weight,39321,,"23,488 x DRG weight",39321,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6654,,"3,327.21 x patient days",6654,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6089,,"3,044.51 x patient days",6089,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,11960,,"5,980.29 x patient days",11960,Per diem,,14091,,"7,045.87 x patient days",14091,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,5436,,"2,718.31 x patient days",5436,Per diem,,0.01,46262,
Percutaneous coronary intervention w/o AMI,175-3,APR-DRG,,,,,,,,inpatient,,,339435.21,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8089,,"4,044.85 x patient days",8089,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,66830,,"27,634 x DRG weight",66830,Other,base rate x DRG weight,56803,,"23,488 x DRG weight",56803,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6654,,"3,327.21 x patient days",6654,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6089,,"3,044.51 x patient days",6089,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,11960,,"5,980.29 x patient days",11960,Per diem,,14091,,"7,045.87 x patient days",14091,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,5436,,"2,718.31 x patient days",5436,Per diem,,0.01,66830,
Percutaneous coronary intervention w/o AMI,175-4,APR-DRG,,,,,,,,inpatient,,,658090.41,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8089,,"4,044.85 x patient days",8089,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,135702,,"27,634 x DRG weight",135702,Other,base rate x DRG weight,115343,,"23,488 x DRG weight",115343,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6654,,"3,327.21 x patient days",6654,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6089,,"3,044.51 x patient days",6089,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,11960,,"5,980.29 x patient days",11960,Per diem,,14091,,"7,045.87 x patient days",14091,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,5436,,"2,718.31 x patient days",5436,Per diem,,0.01,135702,
Cardiac pacemaker & defibrillator device replacement,176-1,APR-DRG,,,,,,,,inpatient,,,449127.75,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12135,,"4,044.85 x patient days",12135,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,39597,,"27,634 x DRG weight",39597,Other,base rate x DRG weight,33656,,"23,488 x DRG weight",33656,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9982,,"3,327.21 x patient days",9982,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9134,,"3,044.51 x patient days",9134,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,17941,,"5,980.29 x patient days",17941,Per diem,,21138,,"7,045.87 x patient days",21138,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,8155,,"2,718.31 x patient days",8155,Per diem,,0.01,39597,
Cardiac pacemaker & defibrillator device replacement,176-2,APR-DRG,,,,,,,,inpatient,,,449127.75,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12135,,"4,044.85 x patient days",12135,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,72965,,"27,634 x DRG weight",72965,Other,base rate x DRG weight,62018,,"23,488 x DRG weight",62018,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9982,,"3,327.21 x patient days",9982,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9134,,"3,044.51 x patient days",9134,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,17941,,"5,980.29 x patient days",17941,Per diem,,21138,,"7,045.87 x patient days",21138,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,8155,,"2,718.31 x patient days",8155,Per diem,,0.01,72965,
Cardiac pacemaker & defibrillator device replacement,176-3,APR-DRG,,,,,,,,inpatient,,,500234,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12135,,"4,044.85 x patient days",12135,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,92977,,"27,634 x DRG weight",92977,Other,base rate x DRG weight,79028,,"23,488 x DRG weight",79028,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9982,,"3,327.21 x patient days",9982,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9134,,"3,044.51 x patient days",9134,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,17941,,"5,980.29 x patient days",17941,Per diem,,21138,,"7,045.87 x patient days",21138,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,8155,,"2,718.31 x patient days",8155,Per diem,,0.01,92977,
Cardiac pacemaker & defibrillator device replacement,176-4,APR-DRG,,,,,,,,inpatient,,,901458.74,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12135,,"4,044.85 x patient days",12135,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,98131,,"27,634 x DRG weight",98131,Other,base rate x DRG weight,83408,,"23,488 x DRG weight",83408,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9982,,"3,327.21 x patient days",9982,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9134,,"3,044.51 x patient days",9134,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,17941,,"5,980.29 x patient days",17941,Per diem,,21138,,"7,045.87 x patient days",21138,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,8155,,"2,718.31 x patient days",8155,Per diem,,0.01,98131,
Cardiac pacemaker & defibrillator revision except device replacement,177-1,APR-DRG,,,,,,,,inpatient,,,157007,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,20224,,"4,044.85 x patient days",20224,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,38527,,"27,634 x DRG weight",38527,Other,base rate x DRG weight,32747,,"23,488 x DRG weight",32747,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,16636,,"3,327.21 x patient days",16636,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,15222,,"3,044.51 x patient days",15222,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,29901,,"5,980.29 x patient days",29901,Per diem,,35229,,"7,045.87 x patient days",35229,Per diem,,23377,,"4,675.50 x patient days",23377,Per diem,,23377,,"4,675.50 x patient days",23377,Per diem,,13591,,"2,718.31 x patient days",13591,Per diem,,0.01,38527,
Cardiac pacemaker & defibrillator revision except device replacement,177-2,APR-DRG,,,,,,,,inpatient,,,157007,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,20224,,"4,044.85 x patient days",20224,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,48282,,"27,634 x DRG weight",48282,Other,base rate x DRG weight,41038,,"23,488 x DRG weight",41038,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,16636,,"3,327.21 x patient days",16636,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,15222,,"3,044.51 x patient days",15222,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,29901,,"5,980.29 x patient days",29901,Per diem,,35229,,"7,045.87 x patient days",35229,Per diem,,23377,,"4,675.50 x patient days",23377,Per diem,,23377,,"4,675.50 x patient days",23377,Per diem,,13591,,"2,718.31 x patient days",13591,Per diem,,0.01,48282,
Cardiac pacemaker & defibrillator revision except device replacement,177-3,APR-DRG,,,,,,,,inpatient,,,348888.27,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,20224,,"4,044.85 x patient days",20224,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,74076,,"27,634 x DRG weight",74076,Other,base rate x DRG weight,62962,,"23,488 x DRG weight",62962,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,16636,,"3,327.21 x patient days",16636,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,15222,,"3,044.51 x patient days",15222,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,29901,,"5,980.29 x patient days",29901,Per diem,,35229,,"7,045.87 x patient days",35229,Per diem,,23377,,"4,675.50 x patient days",23377,Per diem,,23377,,"4,675.50 x patient days",23377,Per diem,,13591,,"2,718.31 x patient days",13591,Per diem,,0.01,74076,
Cardiac pacemaker & defibrillator revision except device replacement,177-4,APR-DRG,,,,,,,,inpatient,,,170896,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,20224,,"4,044.85 x patient days",20224,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,175050,,"27,634 x DRG weight",175050,Other,base rate x DRG weight,148787,,"23,488 x DRG weight",148787,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,16636,,"3,327.21 x patient days",16636,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,15222,,"3,044.51 x patient days",15222,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,29901,,"5,980.29 x patient days",29901,Per diem,,35229,,"7,045.87 x patient days",35229,Per diem,,23377,,"4,675.50 x patient days",23377,Per diem,,23377,,"4,675.50 x patient days",23377,Per diem,,13591,,"2,718.31 x patient days",13591,Per diem,,0.01,175050,
Other circulatory system procedures,180-1,APR-DRG,,,,,,,,inpatient,,,333865.32,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,36404,,"4,044.85 x patient days",36404,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,31475,,"27,634 x DRG weight",31475,Other,base rate x DRG weight,26753,,"23,488 x DRG weight",26753,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,19572,,"2,174.65 x patient days",19572,Per diem,,19572,,"2,174.65 x patient days",19572,Per diem,,19572,,"2,174.65 x patient days",19572,Per diem,,19572,,"2,174.65 x patient days",19572,Per diem,,44037,,"4,892.96 x patient days",44037,Per diem,,29945,,"3,327.21 x patient days",29945,Per diem,,44037,,"4,892.96 x patient days",44037,Per diem,,27401,,"3,044.51 x patient days",27401,Per diem,,44037,,"4,892.96 x patient days",44037,Per diem,,53823,,"5,980.29 x patient days",53823,Per diem,,63413,,"7,045.87 x patient days",63413,Per diem,,42080,,"4,675.50 x patient days",42080,Per diem,,42080,,"4,675.50 x patient days",42080,Per diem,,24465,,"2,718.31 x patient days",24465,Per diem,,0.01,63413,
Other circulatory system procedures,180-2,APR-DRG,,,,,,,,inpatient,,,333865.32,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,36404,,"4,044.85 x patient days",36404,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,45491,,"27,634 x DRG weight",45491,Other,base rate x DRG weight,38666,,"23,488 x DRG weight",38666,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,19572,,"2,174.65 x patient days",19572,Per diem,,19572,,"2,174.65 x patient days",19572,Per diem,,19572,,"2,174.65 x patient days",19572,Per diem,,19572,,"2,174.65 x patient days",19572,Per diem,,44037,,"4,892.96 x patient days",44037,Per diem,,29945,,"3,327.21 x patient days",29945,Per diem,,44037,,"4,892.96 x patient days",44037,Per diem,,27401,,"3,044.51 x patient days",27401,Per diem,,44037,,"4,892.96 x patient days",44037,Per diem,,53823,,"5,980.29 x patient days",53823,Per diem,,63413,,"7,045.87 x patient days",63413,Per diem,,42080,,"4,675.50 x patient days",42080,Per diem,,42080,,"4,675.50 x patient days",42080,Per diem,,24465,,"2,718.31 x patient days",24465,Per diem,,0.01,63413,
Other circulatory system procedures,180-3,APR-DRG,,,,,,,,inpatient,,,305442.72,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,36404,,"4,044.85 x patient days",36404,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,66860,,"27,634 x DRG weight",66860,Other,base rate x DRG weight,56829,,"23,488 x DRG weight",56829,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,19572,,"2,174.65 x patient days",19572,Per diem,,19572,,"2,174.65 x patient days",19572,Per diem,,19572,,"2,174.65 x patient days",19572,Per diem,,19572,,"2,174.65 x patient days",19572,Per diem,,44037,,"4,892.96 x patient days",44037,Per diem,,29945,,"3,327.21 x patient days",29945,Per diem,,44037,,"4,892.96 x patient days",44037,Per diem,,27401,,"3,044.51 x patient days",27401,Per diem,,44037,,"4,892.96 x patient days",44037,Per diem,,53823,,"5,980.29 x patient days",53823,Per diem,,63413,,"7,045.87 x patient days",63413,Per diem,,42080,,"4,675.50 x patient days",42080,Per diem,,42080,,"4,675.50 x patient days",42080,Per diem,,24465,,"2,718.31 x patient days",24465,Per diem,,0.01,66860,
Other circulatory system procedures,180-4,APR-DRG,,,,,,,,inpatient,,,617103.78,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,36404,,"4,044.85 x patient days",36404,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,133171,,"27,634 x DRG weight",133171,Other,base rate x DRG weight,113191,,"23,488 x DRG weight",113191,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,19572,,"2,174.65 x patient days",19572,Per diem,,19572,,"2,174.65 x patient days",19572,Per diem,,19572,,"2,174.65 x patient days",19572,Per diem,,19572,,"2,174.65 x patient days",19572,Per diem,,44037,,"4,892.96 x patient days",44037,Per diem,,29945,,"3,327.21 x patient days",29945,Per diem,,44037,,"4,892.96 x patient days",44037,Per diem,,27401,,"3,044.51 x patient days",27401,Per diem,,44037,,"4,892.96 x patient days",44037,Per diem,,53823,,"5,980.29 x patient days",53823,Per diem,,63413,,"7,045.87 x patient days",63413,Per diem,,42080,,"4,675.50 x patient days",42080,Per diem,,42080,,"4,675.50 x patient days",42080,Per diem,,24465,,"2,718.31 x patient days",24465,Per diem,,0.01,133171,
Lower extremity arterial procedures #,181-1,APR-DRG,,,,,,,,inpatient,,,274129.69,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,28315,,"4,044.85 x patient days",28315,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,39655,,"27,634 x DRG weight",39655,Other,base rate x DRG weight,33705,,"23,488 x DRG weight",33705,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,15223,,"2,174.65 x patient days",15223,Per diem,,15223,,"2,174.65 x patient days",15223,Per diem,,15223,,"2,174.65 x patient days",15223,Per diem,,15223,,"2,174.65 x patient days",15223,Per diem,,34252,,"4,892.96 x patient days",34252,Per diem,,23291,,"3,327.21 x patient days",23291,Per diem,,34252,,"4,892.96 x patient days",34252,Per diem,,21312,,"3,044.51 x patient days",21312,Per diem,,34252,,"4,892.96 x patient days",34252,Per diem,,41863,,"5,980.29 x patient days",41863,Per diem,,49323,,"7,045.87 x patient days",49323,Per diem,,32729,,"4,675.50 x patient days",32729,Per diem,,32729,,"4,675.50 x patient days",32729,Per diem,,19029,,"2,718.31 x patient days",19029,Per diem,,0.01,49323,
Lower extremity arterial procedures #,181-2,APR-DRG,,,,,,,,inpatient,,,245632.8,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,28315,,"4,044.85 x patient days",28315,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,62942,,"27,634 x DRG weight",62942,Other,base rate x DRG weight,53499,,"23,488 x DRG weight",53499,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,15223,,"2,174.65 x patient days",15223,Per diem,,15223,,"2,174.65 x patient days",15223,Per diem,,15223,,"2,174.65 x patient days",15223,Per diem,,15223,,"2,174.65 x patient days",15223,Per diem,,34252,,"4,892.96 x patient days",34252,Per diem,,23291,,"3,327.21 x patient days",23291,Per diem,,34252,,"4,892.96 x patient days",34252,Per diem,,21312,,"3,044.51 x patient days",21312,Per diem,,34252,,"4,892.96 x patient days",34252,Per diem,,41863,,"5,980.29 x patient days",41863,Per diem,,49323,,"7,045.87 x patient days",49323,Per diem,,32729,,"4,675.50 x patient days",32729,Per diem,,32729,,"4,675.50 x patient days",32729,Per diem,,19029,,"2,718.31 x patient days",19029,Per diem,,0.01,62942,
Lower extremity arterial procedures #,181-3,APR-DRG,,,,,,,,inpatient,,,733088.12,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,28315,,"4,044.85 x patient days",28315,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,113031,,"27,634 x DRG weight",113031,Other,base rate x DRG weight,96073,,"23,488 x DRG weight",96073,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,15223,,"2,174.65 x patient days",15223,Per diem,,15223,,"2,174.65 x patient days",15223,Per diem,,15223,,"2,174.65 x patient days",15223,Per diem,,15223,,"2,174.65 x patient days",15223,Per diem,,34252,,"4,892.96 x patient days",34252,Per diem,,23291,,"3,327.21 x patient days",23291,Per diem,,34252,,"4,892.96 x patient days",34252,Per diem,,21312,,"3,044.51 x patient days",21312,Per diem,,34252,,"4,892.96 x patient days",34252,Per diem,,41863,,"5,980.29 x patient days",41863,Per diem,,49323,,"7,045.87 x patient days",49323,Per diem,,32729,,"4,675.50 x patient days",32729,Per diem,,32729,,"4,675.50 x patient days",32729,Per diem,,19029,,"2,718.31 x patient days",19029,Per diem,,0.01,113031,
Lower extremity arterial procedures #,181-4,APR-DRG,,,,,,,,inpatient,,,854967.03,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,28315,,"4,044.85 x patient days",28315,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,182840,,"27,634 x DRG weight",182840,Other,base rate x DRG weight,155408,,"23,488 x DRG weight",155408,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,15223,,"2,174.65 x patient days",15223,Per diem,,15223,,"2,174.65 x patient days",15223,Per diem,,15223,,"2,174.65 x patient days",15223,Per diem,,15223,,"2,174.65 x patient days",15223,Per diem,,34252,,"4,892.96 x patient days",34252,Per diem,,23291,,"3,327.21 x patient days",23291,Per diem,,34252,,"4,892.96 x patient days",34252,Per diem,,21312,,"3,044.51 x patient days",21312,Per diem,,34252,,"4,892.96 x patient days",34252,Per diem,,41863,,"5,980.29 x patient days",41863,Per diem,,49323,,"7,045.87 x patient days",49323,Per diem,,32729,,"4,675.50 x patient days",32729,Per diem,,32729,,"4,675.50 x patient days",32729,Per diem,,19029,,"2,718.31 x patient days",19029,Per diem,,0.01,182840,
Other peripheral vascular procedures #,182-1,APR-DRG,,,,,,,,inpatient,,,119359.66,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,20224,,"4,044.85 x patient days",20224,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,41462,,"27,634 x DRG weight",41462,Other,base rate x DRG weight,35241,,"23,488 x DRG weight",35241,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,16636,,"3,327.21 x patient days",16636,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,15222,,"3,044.51 x patient days",15222,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,29901,,"5,980.29 x patient days",29901,Per diem,,35229,,"7,045.87 x patient days",35229,Per diem,,23377,,"4,675.50 x patient days",23377,Per diem,,23377,,"4,675.50 x patient days",23377,Per diem,,13591,,"2,718.31 x patient days",13591,Per diem,,0.01,41462,
Other peripheral vascular procedures #,182-2,APR-DRG,,,,,,,,inpatient,,,401770.41,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,20224,,"4,044.85 x patient days",20224,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,58529,,"27,634 x DRG weight",58529,Other,base rate x DRG weight,49748,,"23,488 x DRG weight",49748,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,16636,,"3,327.21 x patient days",16636,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,15222,,"3,044.51 x patient days",15222,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,29901,,"5,980.29 x patient days",29901,Per diem,,35229,,"7,045.87 x patient days",35229,Per diem,,23377,,"4,675.50 x patient days",23377,Per diem,,23377,,"4,675.50 x patient days",23377,Per diem,,13591,,"2,718.31 x patient days",13591,Per diem,,0.01,58529,
Other peripheral vascular procedures #,182-3,APR-DRG,,,,,,,,inpatient,,,658418.75,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,20224,,"4,044.85 x patient days",20224,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,89092,,"27,634 x DRG weight",89092,Other,base rate x DRG weight,75725,,"23,488 x DRG weight",75725,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,16636,,"3,327.21 x patient days",16636,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,15222,,"3,044.51 x patient days",15222,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,29901,,"5,980.29 x patient days",29901,Per diem,,35229,,"7,045.87 x patient days",35229,Per diem,,23377,,"4,675.50 x patient days",23377,Per diem,,23377,,"4,675.50 x patient days",23377,Per diem,,13591,,"2,718.31 x patient days",13591,Per diem,,0.01,89092,
Other peripheral vascular procedures #,182-4,APR-DRG,,,,,,,,inpatient,,,611609.16,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,20224,,"4,044.85 x patient days",20224,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,173320,,"27,634 x DRG weight",173320,Other,base rate x DRG weight,147317,,"23,488 x DRG weight",147317,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,16636,,"3,327.21 x patient days",16636,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,15222,,"3,044.51 x patient days",15222,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,29901,,"5,980.29 x patient days",29901,Per diem,,35229,,"7,045.87 x patient days",35229,Per diem,,23377,,"4,675.50 x patient days",23377,Per diem,,23377,,"4,675.50 x patient days",23377,Per diem,,13591,,"2,718.31 x patient days",13591,Per diem,,0.01,173320,
Acute myocardial infarction,190-1,APR-DRG,,,,,,,,inpatient,,,121278.26,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,16180,,"4,044.85 x patient days",16180,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,20330,,"27,634 x DRG weight",20330,Other,base rate x DRG weight,17280,,"23,488 x DRG weight",17280,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,13309,,"3,327.21 x patient days",13309,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,12179,,"3,044.51 x patient days",12179,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,23922,,"5,980.29 x patient days",23922,Per diem,,28185,,"7,045.87 x patient days",28185,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,10874,,"2,718.31 x patient days",10874,Per diem,,0.01,28185,
Acute myocardial infarction,190-2,APR-DRG,,,,,,,,inpatient,,,113366.49,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,16180,,"4,044.85 x patient days",16180,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,26482,,"27,634 x DRG weight",26482,Other,base rate x DRG weight,22509,,"23,488 x DRG weight",22509,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,13309,,"3,327.21 x patient days",13309,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,12179,,"3,044.51 x patient days",12179,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,23922,,"5,980.29 x patient days",23922,Per diem,,28185,,"7,045.87 x patient days",28185,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,10874,,"2,718.31 x patient days",10874,Per diem,,0.01,28185,
Acute myocardial infarction,190-3,APR-DRG,,,,,,,,inpatient,,,161463.7,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,16180,,"4,044.85 x patient days",16180,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,40091,,"27,634 x DRG weight",40091,Other,base rate x DRG weight,34076,,"23,488 x DRG weight",34076,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,13309,,"3,327.21 x patient days",13309,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,12179,,"3,044.51 x patient days",12179,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,23922,,"5,980.29 x patient days",23922,Per diem,,28185,,"7,045.87 x patient days",28185,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,10874,,"2,718.31 x patient days",10874,Per diem,,0.01,40091,
Acute myocardial infarction,190-4,APR-DRG,,,,,,,,inpatient,,,350968.47,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,16180,,"4,044.85 x patient days",16180,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,77740,,"27,634 x DRG weight",77740,Other,base rate x DRG weight,66076,,"23,488 x DRG weight",66076,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,13309,,"3,327.21 x patient days",13309,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,12179,,"3,044.51 x patient days",12179,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,23922,,"5,980.29 x patient days",23922,Per diem,,28185,,"7,045.87 x patient days",28185,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,10874,,"2,718.31 x patient days",10874,Per diem,,0.01,77740,
Cardiac catheterization for coronary artery disease,191-1,APR-DRG,,,,,,,,inpatient,,,161517.61,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8089,,"4,044.85 x patient days",8089,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,19814,,"27,634 x DRG weight",19814,Other,base rate x DRG weight,16841,,"23,488 x DRG weight",16841,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6654,,"3,327.21 x patient days",6654,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6089,,"3,044.51 x patient days",6089,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,11960,,"5,980.29 x patient days",11960,Per diem,,14091,,"7,045.87 x patient days",14091,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,5436,,"2,718.31 x patient days",5436,Per diem,,0.01,19814,
Cardiac catheterization for coronary artery disease,191-2,APR-DRG,,,,,,,,inpatient,,,285660.87,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8089,,"4,044.85 x patient days",8089,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,24213,,"27,634 x DRG weight",24213,Other,base rate x DRG weight,20580,,"23,488 x DRG weight",20580,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6654,,"3,327.21 x patient days",6654,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6089,,"3,044.51 x patient days",6089,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,11960,,"5,980.29 x patient days",11960,Per diem,,14091,,"7,045.87 x patient days",14091,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,5436,,"2,718.31 x patient days",5436,Per diem,,0.01,24213,
Cardiac catheterization for coronary artery disease,191-3,APR-DRG,,,,,,,,inpatient,,,378281.5,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8089,,"4,044.85 x patient days",8089,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,39425,,"27,634 x DRG weight",39425,Other,base rate x DRG weight,33510,,"23,488 x DRG weight",33510,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6654,,"3,327.21 x patient days",6654,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6089,,"3,044.51 x patient days",6089,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,11960,,"5,980.29 x patient days",11960,Per diem,,14091,,"7,045.87 x patient days",14091,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,5436,,"2,718.31 x patient days",5436,Per diem,,0.01,39425,
Cardiac catheterization for coronary artery disease,191-4,APR-DRG,,,,,,,,inpatient,,,378281.5,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8089,,"4,044.85 x patient days",8089,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,73161,,"27,634 x DRG weight",73161,Other,base rate x DRG weight,62184,,"23,488 x DRG weight",62184,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6654,,"3,327.21 x patient days",6654,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6089,,"3,044.51 x patient days",6089,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,11960,,"5,980.29 x patient days",11960,Per diem,,14091,,"7,045.87 x patient days",14091,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,5436,,"2,718.31 x patient days",5436,Per diem,,0.01,73161,
Cardiac catheterization for other non-coronary conditions,192-1,APR-DRG,,,,,,,,inpatient,,,161036.98,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,16180,,"4,044.85 x patient days",16180,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,19844,,"27,634 x DRG weight",19844,Other,base rate x DRG weight,16867,,"23,488 x DRG weight",16867,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,13309,,"3,327.21 x patient days",13309,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,12179,,"3,044.51 x patient days",12179,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,23922,,"5,980.29 x patient days",23922,Per diem,,28185,,"7,045.87 x patient days",28185,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,10874,,"2,718.31 x patient days",10874,Per diem,,0.01,28185,
Cardiac catheterization for other non-coronary conditions,192-2,APR-DRG,,,,,,,,inpatient,,,226320.14,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,16180,,"4,044.85 x patient days",16180,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,28170,,"27,634 x DRG weight",28170,Other,base rate x DRG weight,23944,,"23,488 x DRG weight",23944,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,13309,,"3,327.21 x patient days",13309,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,12179,,"3,044.51 x patient days",12179,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,23922,,"5,980.29 x patient days",23922,Per diem,,28185,,"7,045.87 x patient days",28185,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,10874,,"2,718.31 x patient days",10874,Per diem,,0.01,28185,
Cardiac catheterization for other non-coronary conditions,192-3,APR-DRG,,,,,,,,inpatient,,,270443.38,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,16180,,"4,044.85 x patient days",16180,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,50291,,"27,634 x DRG weight",50291,Other,base rate x DRG weight,42746,,"23,488 x DRG weight",42746,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,13309,,"3,327.21 x patient days",13309,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,12179,,"3,044.51 x patient days",12179,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,23922,,"5,980.29 x patient days",23922,Per diem,,28185,,"7,045.87 x patient days",28185,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,10874,,"2,718.31 x patient days",10874,Per diem,,0.01,50291,
Cardiac catheterization for other non-coronary conditions,192-4,APR-DRG,,,,,,,,inpatient,,,566014.56,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,16180,,"4,044.85 x patient days",16180,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,113777,,"27,634 x DRG weight",113777,Other,base rate x DRG weight,96707,,"23,488 x DRG weight",96707,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,13309,,"3,327.21 x patient days",13309,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,12179,,"3,044.51 x patient days",12179,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,23922,,"5,980.29 x patient days",23922,Per diem,,28185,,"7,045.87 x patient days",28185,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,10874,,"2,718.31 x patient days",10874,Per diem,,0.01,113777,
Acute & subacute endocarditis,193-1,APR-DRG,,,,,,,,inpatient,,,75012,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,44493,,"4,044.85 x patient days",44493,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,28513,,"27,634 x DRG weight",28513,Other,base rate x DRG weight,24235,,"23,488 x DRG weight",24235,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,23921,,"2,174.65 x patient days",23921,Per diem,,23921,,"2,174.65 x patient days",23921,Per diem,,23921,,"2,174.65 x patient days",23921,Per diem,,23921,,"2,174.65 x patient days",23921,Per diem,,53822,,"4,892.96 x patient days",53822,Per diem,,36599,,"3,327.21 x patient days",36599,Per diem,,53822,,"4,892.96 x patient days",53822,Per diem,,33489,,"3,044.51 x patient days",33489,Per diem,,53822,,"4,892.96 x patient days",53822,Per diem,,65783,,"5,980.29 x patient days",65783,Per diem,,77504,,"7,045.87 x patient days",77504,Per diem,,51430,,"4,675.50 x patient days",51430,Per diem,,51430,,"4,675.50 x patient days",51430,Per diem,,29901,,"2,718.31 x patient days",29901,Per diem,,0.01,77504,
Acute & subacute endocarditis,193-2,APR-DRG,,,,,,,,inpatient,,,75012,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,44493,,"4,044.85 x patient days",44493,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,38082,,"27,634 x DRG weight",38082,Other,base rate x DRG weight,32369,,"23,488 x DRG weight",32369,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,23921,,"2,174.65 x patient days",23921,Per diem,,23921,,"2,174.65 x patient days",23921,Per diem,,23921,,"2,174.65 x patient days",23921,Per diem,,23921,,"2,174.65 x patient days",23921,Per diem,,53822,,"4,892.96 x patient days",53822,Per diem,,36599,,"3,327.21 x patient days",36599,Per diem,,53822,,"4,892.96 x patient days",53822,Per diem,,33489,,"3,044.51 x patient days",33489,Per diem,,53822,,"4,892.96 x patient days",53822,Per diem,,65783,,"5,980.29 x patient days",65783,Per diem,,77504,,"7,045.87 x patient days",77504,Per diem,,51430,,"4,675.50 x patient days",51430,Per diem,,51430,,"4,675.50 x patient days",51430,Per diem,,29901,,"2,718.31 x patient days",29901,Per diem,,0.01,77504,
Acute & subacute endocarditis,193-3,APR-DRG,,,,,,,,inpatient,,,75012,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,44493,,"4,044.85 x patient days",44493,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,59502,,"27,634 x DRG weight",59502,Other,base rate x DRG weight,50574,,"23,488 x DRG weight",50574,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,23921,,"2,174.65 x patient days",23921,Per diem,,23921,,"2,174.65 x patient days",23921,Per diem,,23921,,"2,174.65 x patient days",23921,Per diem,,23921,,"2,174.65 x patient days",23921,Per diem,,53822,,"4,892.96 x patient days",53822,Per diem,,36599,,"3,327.21 x patient days",36599,Per diem,,53822,,"4,892.96 x patient days",53822,Per diem,,33489,,"3,044.51 x patient days",33489,Per diem,,53822,,"4,892.96 x patient days",53822,Per diem,,65783,,"5,980.29 x patient days",65783,Per diem,,77504,,"7,045.87 x patient days",77504,Per diem,,51430,,"4,675.50 x patient days",51430,Per diem,,51430,,"4,675.50 x patient days",51430,Per diem,,29901,,"2,718.31 x patient days",29901,Per diem,,0.01,77504,
Acute & subacute endocarditis,193-4,APR-DRG,,,,,,,,inpatient,,,836588.15,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,44493,,"4,044.85 x patient days",44493,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,123364,,"27,634 x DRG weight",123364,Other,base rate x DRG weight,104855,,"23,488 x DRG weight",104855,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,23921,,"2,174.65 x patient days",23921,Per diem,,23921,,"2,174.65 x patient days",23921,Per diem,,23921,,"2,174.65 x patient days",23921,Per diem,,23921,,"2,174.65 x patient days",23921,Per diem,,53822,,"4,892.96 x patient days",53822,Per diem,,36599,,"3,327.21 x patient days",36599,Per diem,,53822,,"4,892.96 x patient days",53822,Per diem,,33489,,"3,044.51 x patient days",33489,Per diem,,53822,,"4,892.96 x patient days",53822,Per diem,,65783,,"5,980.29 x patient days",65783,Per diem,,77504,,"7,045.87 x patient days",77504,Per diem,,51430,,"4,675.50 x patient days",51430,Per diem,,51430,,"4,675.50 x patient days",51430,Per diem,,29901,,"2,718.31 x patient days",29901,Per diem,,0.01,123364,
Heart failure,194-1,APR-DRG,,,,,,,,inpatient,,,98706.13,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,20224,,"4,044.85 x patient days",20224,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,15746,,"27,634 x DRG weight",15746,Other,base rate x DRG weight,13383,,"23,488 x DRG weight",13383,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,16636,,"3,327.21 x patient days",16636,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,15222,,"3,044.51 x patient days",15222,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,29901,,"5,980.29 x patient days",29901,Per diem,,35229,,"7,045.87 x patient days",35229,Per diem,,23377,,"4,675.50 x patient days",23377,Per diem,,23377,,"4,675.50 x patient days",23377,Per diem,,13591,,"2,718.31 x patient days",13591,Per diem,,0.01,35229,
Heart failure,194-2,APR-DRG,,,,,,,,inpatient,,,140073.61,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,20224,,"4,044.85 x patient days",20224,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,21864,,"27,634 x DRG weight",21864,Other,base rate x DRG weight,18584,,"23,488 x DRG weight",18584,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,16636,,"3,327.21 x patient days",16636,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,15222,,"3,044.51 x patient days",15222,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,29901,,"5,980.29 x patient days",29901,Per diem,,35229,,"7,045.87 x patient days",35229,Per diem,,23377,,"4,675.50 x patient days",23377,Per diem,,23377,,"4,675.50 x patient days",23377,Per diem,,13591,,"2,718.31 x patient days",13591,Per diem,,0.01,35229,
Heart failure,194-3,APR-DRG,,,,,,,,inpatient,,,160572.79,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,20224,,"4,044.85 x patient days",20224,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,35750,,"27,634 x DRG weight",35750,Other,base rate x DRG weight,30386,,"23,488 x DRG weight",30386,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,16636,,"3,327.21 x patient days",16636,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,15222,,"3,044.51 x patient days",15222,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,29901,,"5,980.29 x patient days",29901,Per diem,,35229,,"7,045.87 x patient days",35229,Per diem,,23377,,"4,675.50 x patient days",23377,Per diem,,23377,,"4,675.50 x patient days",23377,Per diem,,13591,,"2,718.31 x patient days",13591,Per diem,,0.01,35750,
Heart failure,194-4,APR-DRG,,,,,,,,inpatient,,,310713.52,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,20224,,"4,044.85 x patient days",20224,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,79818,,"27,634 x DRG weight",79818,Other,base rate x DRG weight,67843,,"23,488 x DRG weight",67843,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,16636,,"3,327.21 x patient days",16636,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,15222,,"3,044.51 x patient days",15222,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,29901,,"5,980.29 x patient days",29901,Per diem,,35229,,"7,045.87 x patient days",35229,Per diem,,23377,,"4,675.50 x patient days",23377,Per diem,,23377,,"4,675.50 x patient days",23377,Per diem,,13591,,"2,718.31 x patient days",13591,Per diem,,0.01,79818,
Cardiac arrest and shock,196-1,APR-DRG,,,,,,,,inpatient,,,39243,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,16180,,"4,044.85 x patient days",16180,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,16185,,"27,634 x DRG weight",16185,Other,base rate x DRG weight,13757,,"23,488 x DRG weight",13757,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,13309,,"3,327.21 x patient days",13309,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,12179,,"3,044.51 x patient days",12179,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,23922,,"5,980.29 x patient days",23922,Per diem,,28185,,"7,045.87 x patient days",28185,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,10874,,"2,718.31 x patient days",10874,Per diem,,0.01,28185,
Cardiac arrest and shock,196-2,APR-DRG,,,,,,,,inpatient,,,39243,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,16180,,"4,044.85 x patient days",16180,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,17465,,"27,634 x DRG weight",17465,Other,base rate x DRG weight,14844,,"23,488 x DRG weight",14844,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,13309,,"3,327.21 x patient days",13309,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,12179,,"3,044.51 x patient days",12179,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,23922,,"5,980.29 x patient days",23922,Per diem,,28185,,"7,045.87 x patient days",28185,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,10874,,"2,718.31 x patient days",10874,Per diem,,0.01,28185,
Cardiac arrest and shock,196-3,APR-DRG,,,,,,,,inpatient,,,58926,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,16180,,"4,044.85 x patient days",16180,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,19385,,"27,634 x DRG weight",19385,Other,base rate x DRG weight,16477,,"23,488 x DRG weight",16477,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,13309,,"3,327.21 x patient days",13309,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,12179,,"3,044.51 x patient days",12179,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,23922,,"5,980.29 x patient days",23922,Per diem,,28185,,"7,045.87 x patient days",28185,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,10874,,"2,718.31 x patient days",10874,Per diem,,0.01,28185,
Cardiac arrest and shock,196-4,APR-DRG,,,,,,,,inpatient,,,436026.47,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,16180,,"4,044.85 x patient days",16180,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,57777,,"27,634 x DRG weight",57777,Other,base rate x DRG weight,49109,,"23,488 x DRG weight",49109,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,13309,,"3,327.21 x patient days",13309,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,12179,,"3,044.51 x patient days",12179,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,23922,,"5,980.29 x patient days",23922,Per diem,,28185,,"7,045.87 x patient days",28185,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,10874,,"2,718.31 x patient days",10874,Per diem,,0.01,57777,
Peripheral & other vascular disorders,197-1,APR-DRG,,,,,,,,inpatient,,,67963.56,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,16180,,"4,044.85 x patient days",16180,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,16194,,"27,634 x DRG weight",16194,Other,base rate x DRG weight,13764,,"23,488 x DRG weight",13764,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,13309,,"3,327.21 x patient days",13309,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,12179,,"3,044.51 x patient days",12179,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,23922,,"5,980.29 x patient days",23922,Per diem,,28185,,"7,045.87 x patient days",28185,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,10874,,"2,718.31 x patient days",10874,Per diem,,0.01,28185,
Peripheral & other vascular disorders,197-2,APR-DRG,,,,,,,,inpatient,,,188289.28,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,16180,,"4,044.85 x patient days",16180,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,21894,,"27,634 x DRG weight",21894,Other,base rate x DRG weight,18610,,"23,488 x DRG weight",18610,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,13309,,"3,327.21 x patient days",13309,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,12179,,"3,044.51 x patient days",12179,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,23922,,"5,980.29 x patient days",23922,Per diem,,28185,,"7,045.87 x patient days",28185,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,10874,,"2,718.31 x patient days",10874,Per diem,,0.01,28185,
Peripheral & other vascular disorders,197-3,APR-DRG,,,,,,,,inpatient,,,141771.2,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,16180,,"4,044.85 x patient days",16180,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,32633,,"27,634 x DRG weight",32633,Other,base rate x DRG weight,27737,,"23,488 x DRG weight",27737,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,13309,,"3,327.21 x patient days",13309,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,12179,,"3,044.51 x patient days",12179,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,23922,,"5,980.29 x patient days",23922,Per diem,,28185,,"7,045.87 x patient days",28185,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,10874,,"2,718.31 x patient days",10874,Per diem,,0.01,32633,
Peripheral & other vascular disorders,197-4,APR-DRG,,,,,,,,inpatient,,,249807.56,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,16180,,"4,044.85 x patient days",16180,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,79141,,"27,634 x DRG weight",79141,Other,base rate x DRG weight,67267,,"23,488 x DRG weight",67267,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,13309,,"3,327.21 x patient days",13309,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,12179,,"3,044.51 x patient days",12179,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,23922,,"5,980.29 x patient days",23922,Per diem,,28185,,"7,045.87 x patient days",28185,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,10874,,"2,718.31 x patient days",10874,Per diem,,0.01,79141,
Angina pectoris & coronary atherosclerosis,198-1,APR-DRG,,,,,,,,inpatient,,,102325.47,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8089,,"4,044.85 x patient days",8089,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,11283,,"27,634 x DRG weight",11283,Other,base rate x DRG weight,9590,,"23,488 x DRG weight",9590,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6654,,"3,327.21 x patient days",6654,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6089,,"3,044.51 x patient days",6089,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,11960,,"5,980.29 x patient days",11960,Per diem,,14091,,"7,045.87 x patient days",14091,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,5436,,"2,718.31 x patient days",5436,Per diem,,0.01,14091,
Angina pectoris & coronary atherosclerosis,198-2,APR-DRG,,,,,,,,inpatient,,,85033.92,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8089,,"4,044.85 x patient days",8089,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,14765,,"27,634 x DRG weight",14765,Other,base rate x DRG weight,12550,,"23,488 x DRG weight",12550,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6654,,"3,327.21 x patient days",6654,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6089,,"3,044.51 x patient days",6089,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,11960,,"5,980.29 x patient days",11960,Per diem,,14091,,"7,045.87 x patient days",14091,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,5436,,"2,718.31 x patient days",5436,Per diem,,0.01,14765,
Angina pectoris & coronary atherosclerosis,198-3,APR-DRG,,,,,,,,inpatient,,,81012.79,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8089,,"4,044.85 x patient days",8089,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,22596,,"27,634 x DRG weight",22596,Other,base rate x DRG weight,19206,,"23,488 x DRG weight",19206,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6654,,"3,327.21 x patient days",6654,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6089,,"3,044.51 x patient days",6089,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,11960,,"5,980.29 x patient days",11960,Per diem,,14091,,"7,045.87 x patient days",14091,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,5436,,"2,718.31 x patient days",5436,Per diem,,0.01,22596,
Angina pectoris & coronary atherosclerosis,198-4,APR-DRG,,,,,,,,inpatient,,,90536,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8089,,"4,044.85 x patient days",8089,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,66894,,"27,634 x DRG weight",66894,Other,base rate x DRG weight,56857,,"23,488 x DRG weight",56857,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6654,,"3,327.21 x patient days",6654,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6089,,"3,044.51 x patient days",6089,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,11960,,"5,980.29 x patient days",11960,Per diem,,14091,,"7,045.87 x patient days",14091,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,5436,,"2,718.31 x patient days",5436,Per diem,,0.01,66894,
Hypertension,199-1,APR-DRG,,,,,,,,inpatient,,,92242.65,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8089,,"4,044.85 x patient days",8089,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12504,,"27,634 x DRG weight",12504,Other,base rate x DRG weight,10628,,"23,488 x DRG weight",10628,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6654,,"3,327.21 x patient days",6654,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6089,,"3,044.51 x patient days",6089,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,11960,,"5,980.29 x patient days",11960,Per diem,,14091,,"7,045.87 x patient days",14091,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,5436,,"2,718.31 x patient days",5436,Per diem,,0.01,14091,
Hypertension,199-2,APR-DRG,,,,,,,,inpatient,,,80019.84,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8089,,"4,044.85 x patient days",8089,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,16370,,"27,634 x DRG weight",16370,Other,base rate x DRG weight,13914,,"23,488 x DRG weight",13914,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6654,,"3,327.21 x patient days",6654,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6089,,"3,044.51 x patient days",6089,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,11960,,"5,980.29 x patient days",11960,Per diem,,14091,,"7,045.87 x patient days",14091,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,5436,,"2,718.31 x patient days",5436,Per diem,,0.01,16370,
Hypertension,199-3,APR-DRG,,,,,,,,inpatient,,,143572.32,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8089,,"4,044.85 x patient days",8089,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,25752,,"27,634 x DRG weight",25752,Other,base rate x DRG weight,21888,,"23,488 x DRG weight",21888,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6654,,"3,327.21 x patient days",6654,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6089,,"3,044.51 x patient days",6089,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,11960,,"5,980.29 x patient days",11960,Per diem,,14091,,"7,045.87 x patient days",14091,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,5436,,"2,718.31 x patient days",5436,Per diem,,0.01,25752,
Hypertension,199-4,APR-DRG,,,,,,,,inpatient,,,229473.45,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8089,,"4,044.85 x patient days",8089,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,67877,,"27,634 x DRG weight",67877,Other,base rate x DRG weight,57694,,"23,488 x DRG weight",57694,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6654,,"3,327.21 x patient days",6654,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6089,,"3,044.51 x patient days",6089,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,11960,,"5,980.29 x patient days",11960,Per diem,,14091,,"7,045.87 x patient days",14091,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,5436,,"2,718.31 x patient days",5436,Per diem,,0.01,67877,
Cardiac structural & valvular disorders,200-1,APR-DRG,,,,,,,,inpatient,,,47277.5,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,16180,,"4,044.85 x patient days",16180,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,14019,,"27,634 x DRG weight",14019,Other,base rate x DRG weight,11915,,"23,488 x DRG weight",11915,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,13309,,"3,327.21 x patient days",13309,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,12179,,"3,044.51 x patient days",12179,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,23922,,"5,980.29 x patient days",23922,Per diem,,28185,,"7,045.87 x patient days",28185,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,10874,,"2,718.31 x patient days",10874,Per diem,,0.01,28185,
Cardiac structural & valvular disorders,200-2,APR-DRG,,,,,,,,inpatient,,,85847.83,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,16180,,"4,044.85 x patient days",16180,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,19233,,"27,634 x DRG weight",19233,Other,base rate x DRG weight,16348,,"23,488 x DRG weight",16348,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,13309,,"3,327.21 x patient days",13309,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,12179,,"3,044.51 x patient days",12179,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,23922,,"5,980.29 x patient days",23922,Per diem,,28185,,"7,045.87 x patient days",28185,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,10874,,"2,718.31 x patient days",10874,Per diem,,0.01,28185,
Cardiac structural & valvular disorders,200-3,APR-DRG,,,,,,,,inpatient,,,219955.13,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,16180,,"4,044.85 x patient days",16180,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,34587,,"27,634 x DRG weight",34587,Other,base rate x DRG weight,29398,,"23,488 x DRG weight",29398,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,13309,,"3,327.21 x patient days",13309,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,12179,,"3,044.51 x patient days",12179,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,23922,,"5,980.29 x patient days",23922,Per diem,,28185,,"7,045.87 x patient days",28185,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,10874,,"2,718.31 x patient days",10874,Per diem,,0.01,34587,
Cardiac structural & valvular disorders,200-4,APR-DRG,,,,,,,,inpatient,,,36093,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,16180,,"4,044.85 x patient days",16180,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,108864,,"27,634 x DRG weight",108864,Other,base rate x DRG weight,92531,,"23,488 x DRG weight",92531,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,13309,,"3,327.21 x patient days",13309,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,12179,,"3,044.51 x patient days",12179,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,23922,,"5,980.29 x patient days",23922,Per diem,,28185,,"7,045.87 x patient days",28185,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,10874,,"2,718.31 x patient days",10874,Per diem,,0.01,108864,
Cardiac arrhythmia & conduction disorders,201-1,APR-DRG,,,,,,,,inpatient,,,116319.68,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12135,,"4,044.85 x patient days",12135,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,11952,,"27,634 x DRG weight",11952,Other,base rate x DRG weight,10159,,"23,488 x DRG weight",10159,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9982,,"3,327.21 x patient days",9982,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9134,,"3,044.51 x patient days",9134,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,17941,,"5,980.29 x patient days",17941,Per diem,,21138,,"7,045.87 x patient days",21138,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,8155,,"2,718.31 x patient days",8155,Per diem,,0.01,21138,
Cardiac arrhythmia & conduction disorders,201-2,APR-DRG,,,,,,,,inpatient,,,107906.78,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12135,,"4,044.85 x patient days",12135,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,17263,,"27,634 x DRG weight",17263,Other,base rate x DRG weight,14673,,"23,488 x DRG weight",14673,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9982,,"3,327.21 x patient days",9982,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9134,,"3,044.51 x patient days",9134,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,17941,,"5,980.29 x patient days",17941,Per diem,,21138,,"7,045.87 x patient days",21138,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,8155,,"2,718.31 x patient days",8155,Per diem,,0.01,21138,
Cardiac arrhythmia & conduction disorders,201-3,APR-DRG,,,,,,,,inpatient,,,113020.64,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12135,,"4,044.85 x patient days",12135,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,29980,,"27,634 x DRG weight",29980,Other,base rate x DRG weight,25482,,"23,488 x DRG weight",25482,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9982,,"3,327.21 x patient days",9982,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9134,,"3,044.51 x patient days",9134,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,17941,,"5,980.29 x patient days",17941,Per diem,,21138,,"7,045.87 x patient days",21138,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,8155,,"2,718.31 x patient days",8155,Per diem,,0.01,29980,
Cardiac arrhythmia & conduction disorders,201-4,APR-DRG,,,,,,,,inpatient,,,158033,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12135,,"4,044.85 x patient days",12135,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,70190,,"27,634 x DRG weight",70190,Other,base rate x DRG weight,59660,,"23,488 x DRG weight",59660,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9982,,"3,327.21 x patient days",9982,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9134,,"3,044.51 x patient days",9134,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,17941,,"5,980.29 x patient days",17941,Per diem,,21138,,"7,045.87 x patient days",21138,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,8155,,"2,718.31 x patient days",8155,Per diem,,0.01,70190,
Chest pain,203-1,APR-DRG,,,,,,,,inpatient,,,115321.97,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8089,,"4,044.85 x patient days",8089,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,10882,,"27,634 x DRG weight",10882,Other,base rate x DRG weight,9250,,"23,488 x DRG weight",9250,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6654,,"3,327.21 x patient days",6654,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6089,,"3,044.51 x patient days",6089,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,11960,,"5,980.29 x patient days",11960,Per diem,,14091,,"7,045.87 x patient days",14091,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,5436,,"2,718.31 x patient days",5436,Per diem,,0.01,14091,
Chest pain,203-2,APR-DRG,,,,,,,,inpatient,,,102165.3,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8089,,"4,044.85 x patient days",8089,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,13577,,"27,634 x DRG weight",13577,Other,base rate x DRG weight,11540,,"23,488 x DRG weight",11540,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6654,,"3,327.21 x patient days",6654,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6089,,"3,044.51 x patient days",6089,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,11960,,"5,980.29 x patient days",11960,Per diem,,14091,,"7,045.87 x patient days",14091,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,5436,,"2,718.31 x patient days",5436,Per diem,,0.01,14091,
Chest pain,203-3,APR-DRG,,,,,,,,inpatient,,,123261,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8089,,"4,044.85 x patient days",8089,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,19507,,"27,634 x DRG weight",19507,Other,base rate x DRG weight,16580,,"23,488 x DRG weight",16580,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6654,,"3,327.21 x patient days",6654,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6089,,"3,044.51 x patient days",6089,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,11960,,"5,980.29 x patient days",11960,Per diem,,14091,,"7,045.87 x patient days",14091,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,5436,,"2,718.31 x patient days",5436,Per diem,,0.01,19507,
Chest pain,203-4,APR-DRG,,,,,,,,inpatient,,,123261,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8089,,"4,044.85 x patient days",8089,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,65084,,"27,634 x DRG weight",65084,Other,base rate x DRG weight,55319,,"23,488 x DRG weight",55319,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6654,,"3,327.21 x patient days",6654,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6089,,"3,044.51 x patient days",6089,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,11960,,"5,980.29 x patient days",11960,Per diem,,14091,,"7,045.87 x patient days",14091,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,5436,,"2,718.31 x patient days",5436,Per diem,,0.01,65084,
Syncope & collapse,204-1,APR-DRG,,,,,,,,inpatient,,,92229.29,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8089,,"4,044.85 x patient days",8089,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12720,,"27,634 x DRG weight",12720,Other,base rate x DRG weight,10812,,"23,488 x DRG weight",10812,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6654,,"3,327.21 x patient days",6654,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6089,,"3,044.51 x patient days",6089,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,11960,,"5,980.29 x patient days",11960,Per diem,,14091,,"7,045.87 x patient days",14091,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,5436,,"2,718.31 x patient days",5436,Per diem,,0.01,14091,
Syncope & collapse,204-2,APR-DRG,,,,,,,,inpatient,,,150563.03,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8089,,"4,044.85 x patient days",8089,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,15890,,"27,634 x DRG weight",15890,Other,base rate x DRG weight,13506,,"23,488 x DRG weight",13506,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6654,,"3,327.21 x patient days",6654,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6089,,"3,044.51 x patient days",6089,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,11960,,"5,980.29 x patient days",11960,Per diem,,14091,,"7,045.87 x patient days",14091,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,5436,,"2,718.31 x patient days",5436,Per diem,,0.01,15890,
Syncope & collapse,204-3,APR-DRG,,,,,,,,inpatient,,,189869.65,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8089,,"4,044.85 x patient days",8089,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,23749,,"27,634 x DRG weight",23749,Other,base rate x DRG weight,20186,,"23,488 x DRG weight",20186,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6654,,"3,327.21 x patient days",6654,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6089,,"3,044.51 x patient days",6089,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,11960,,"5,980.29 x patient days",11960,Per diem,,14091,,"7,045.87 x patient days",14091,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,5436,,"2,718.31 x patient days",5436,Per diem,,0.01,23749,
Syncope & collapse,204-4,APR-DRG,,,,,,,,inpatient,,,118084.71,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8089,,"4,044.85 x patient days",8089,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,58603,,"27,634 x DRG weight",58603,Other,base rate x DRG weight,49811,,"23,488 x DRG weight",49811,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6654,,"3,327.21 x patient days",6654,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6089,,"3,044.51 x patient days",6089,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,11960,,"5,980.29 x patient days",11960,Per diem,,14091,,"7,045.87 x patient days",14091,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,5436,,"2,718.31 x patient days",5436,Per diem,,0.01,58603,
Cardiomyopathy,205-1,APR-DRG,,,,,,,,inpatient,,,36299.23,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,16180,,"4,044.85 x patient days",16180,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,16238,,"27,634 x DRG weight",16238,Other,base rate x DRG weight,13802,,"23,488 x DRG weight",13802,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,13309,,"3,327.21 x patient days",13309,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,12179,,"3,044.51 x patient days",12179,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,23922,,"5,980.29 x patient days",23922,Per diem,,28185,,"7,045.87 x patient days",28185,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,10874,,"2,718.31 x patient days",10874,Per diem,,0.01,28185,
Cardiomyopathy,205-2,APR-DRG,,,,,,,,inpatient,,,133924.12,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,16180,,"4,044.85 x patient days",16180,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,20623,,"27,634 x DRG weight",20623,Other,base rate x DRG weight,17529,,"23,488 x DRG weight",17529,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,13309,,"3,327.21 x patient days",13309,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,12179,,"3,044.51 x patient days",12179,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,23922,,"5,980.29 x patient days",23922,Per diem,,28185,,"7,045.87 x patient days",28185,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,10874,,"2,718.31 x patient days",10874,Per diem,,0.01,28185,
Cardiomyopathy,205-3,APR-DRG,,,,,,,,inpatient,,,121963.73,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,16180,,"4,044.85 x patient days",16180,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,40163,,"27,634 x DRG weight",40163,Other,base rate x DRG weight,34137,,"23,488 x DRG weight",34137,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,13309,,"3,327.21 x patient days",13309,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,12179,,"3,044.51 x patient days",12179,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,23922,,"5,980.29 x patient days",23922,Per diem,,28185,,"7,045.87 x patient days",28185,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,10874,,"2,718.31 x patient days",10874,Per diem,,0.01,40163,
Cardiomyopathy,205-4,APR-DRG,,,,,,,,inpatient,,,133924.12,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,16180,,"4,044.85 x patient days",16180,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,48970,,"27,634 x DRG weight",48970,Other,base rate x DRG weight,41623,,"23,488 x DRG weight",41623,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,13309,,"3,327.21 x patient days",13309,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,12179,,"3,044.51 x patient days",12179,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,23922,,"5,980.29 x patient days",23922,Per diem,,28185,,"7,045.87 x patient days",28185,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,10874,,"2,718.31 x patient days",10874,Per diem,,0.01,48970,
"Malfunction,reaction,complication of cardiac/vasc device or procedure",206-1,APR-DRG,,,,,,,,inpatient,,,135654.44,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,20224,,"4,044.85 x patient days",20224,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,15193,,"27,634 x DRG weight",15193,Other,base rate x DRG weight,12914,,"23,488 x DRG weight",12914,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,16636,,"3,327.21 x patient days",16636,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,15222,,"3,044.51 x patient days",15222,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,29901,,"5,980.29 x patient days",29901,Per diem,,35229,,"7,045.87 x patient days",35229,Per diem,,23377,,"4,675.50 x patient days",23377,Per diem,,23377,,"4,675.50 x patient days",23377,Per diem,,13591,,"2,718.31 x patient days",13591,Per diem,,0.01,35229,
"Malfunction,reaction,complication of cardiac/vasc device or procedure",206-2,APR-DRG,,,,,,,,inpatient,,,76262.3,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,20224,,"4,044.85 x patient days",20224,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,20109,,"27,634 x DRG weight",20109,Other,base rate x DRG weight,17092,,"23,488 x DRG weight",17092,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,16636,,"3,327.21 x patient days",16636,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,15222,,"3,044.51 x patient days",15222,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,29901,,"5,980.29 x patient days",29901,Per diem,,35229,,"7,045.87 x patient days",35229,Per diem,,23377,,"4,675.50 x patient days",23377,Per diem,,23377,,"4,675.50 x patient days",23377,Per diem,,13591,,"2,718.31 x patient days",13591,Per diem,,0.01,35229,
"Malfunction,reaction,complication of cardiac/vasc device or procedure",206-3,APR-DRG,,,,,,,,inpatient,,,213020.68,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,20224,,"4,044.85 x patient days",20224,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,34382,,"27,634 x DRG weight",34382,Other,base rate x DRG weight,29224,,"23,488 x DRG weight",29224,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,16636,,"3,327.21 x patient days",16636,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,15222,,"3,044.51 x patient days",15222,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,29901,,"5,980.29 x patient days",29901,Per diem,,35229,,"7,045.87 x patient days",35229,Per diem,,23377,,"4,675.50 x patient days",23377,Per diem,,23377,,"4,675.50 x patient days",23377,Per diem,,13591,,"2,718.31 x patient days",13591,Per diem,,0.01,35229,
"Malfunction,reaction,complication of cardiac/vasc device or procedure",206-4,APR-DRG,,,,,,,,inpatient,,,264277.07,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,20224,,"4,044.85 x patient days",20224,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,94080,,"27,634 x DRG weight",94080,Other,base rate x DRG weight,79965,,"23,488 x DRG weight",79965,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,16636,,"3,327.21 x patient days",16636,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,15222,,"3,044.51 x patient days",15222,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,29901,,"5,980.29 x patient days",29901,Per diem,,35229,,"7,045.87 x patient days",35229,Per diem,,23377,,"4,675.50 x patient days",23377,Per diem,,23377,,"4,675.50 x patient days",23377,Per diem,,13591,,"2,718.31 x patient days",13591,Per diem,,0.01,94080,
Other circulatory system diagnoses,207-1,APR-DRG,,,,,,,,inpatient,,,64898.43,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12135,,"4,044.85 x patient days",12135,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,13510,,"27,634 x DRG weight",13510,Other,base rate x DRG weight,11483,,"23,488 x DRG weight",11483,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9982,,"3,327.21 x patient days",9982,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9134,,"3,044.51 x patient days",9134,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,17941,,"5,980.29 x patient days",17941,Per diem,,21138,,"7,045.87 x patient days",21138,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,8155,,"2,718.31 x patient days",8155,Per diem,,0.01,21138,
Other circulatory system diagnoses,207-2,APR-DRG,,,,,,,,inpatient,,,137783.15,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12135,,"4,044.85 x patient days",12135,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,19816,,"27,634 x DRG weight",19816,Other,base rate x DRG weight,16843,,"23,488 x DRG weight",16843,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9982,,"3,327.21 x patient days",9982,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9134,,"3,044.51 x patient days",9134,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,17941,,"5,980.29 x patient days",17941,Per diem,,21138,,"7,045.87 x patient days",21138,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,8155,,"2,718.31 x patient days",8155,Per diem,,0.01,21138,
Other circulatory system diagnoses,207-3,APR-DRG,,,,,,,,inpatient,,,190779.16,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12135,,"4,044.85 x patient days",12135,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,33241,,"27,634 x DRG weight",33241,Other,base rate x DRG weight,28254,,"23,488 x DRG weight",28254,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9982,,"3,327.21 x patient days",9982,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9134,,"3,044.51 x patient days",9134,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,17941,,"5,980.29 x patient days",17941,Per diem,,21138,,"7,045.87 x patient days",21138,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,8155,,"2,718.31 x patient days",8155,Per diem,,0.01,33241,
Other circulatory system diagnoses,207-4,APR-DRG,,,,,,,,inpatient,,,350200.53,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12135,,"4,044.85 x patient days",12135,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,69831,,"27,634 x DRG weight",69831,Other,base rate x DRG weight,59354,,"23,488 x DRG weight",59354,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9982,,"3,327.21 x patient days",9982,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9134,,"3,044.51 x patient days",9134,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,17941,,"5,980.29 x patient days",17941,Per diem,,21138,,"7,045.87 x patient days",21138,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,8155,,"2,718.31 x patient days",8155,Per diem,,0.01,69831,
"Major stomach, esophageal & duodenal procedures",220-1,APR-DRG,,,,,,,,inpatient,,,126137.5,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,32358,,"4,044.85 x patient days",32358,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,32017,,"27,634 x DRG weight",32017,Other,base rate x DRG weight,27213,,"23,488 x DRG weight",27213,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,17397,,"2,174.65 x patient days",17397,Per diem,,17397,,"2,174.65 x patient days",17397,Per diem,,17397,,"2,174.65 x patient days",17397,Per diem,,17397,,"2,174.65 x patient days",17397,Per diem,,39143,,"4,892.96 x patient days",39143,Per diem,,26617,,"3,327.21 x patient days",26617,Per diem,,39143,,"4,892.96 x patient days",39143,Per diem,,24356,,"3,044.51 x patient days",24356,Per diem,,39143,,"4,892.96 x patient days",39143,Per diem,,47842,,"5,980.29 x patient days",47842,Per diem,,56366,,"7,045.87 x patient days",56366,Per diem,,37404,,"4,675.50 x patient days",37404,Per diem,,37404,,"4,675.50 x patient days",37404,Per diem,,21746,,"2,718.31 x patient days",21746,Per diem,,0.01,56366,
"Major stomach, esophageal & duodenal procedures",220-2,APR-DRG,,,,,,,,inpatient,,,83452.34,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,32358,,"4,044.85 x patient days",32358,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,50990,,"27,634 x DRG weight",50990,Other,base rate x DRG weight,43340,,"23,488 x DRG weight",43340,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,17397,,"2,174.65 x patient days",17397,Per diem,,17397,,"2,174.65 x patient days",17397,Per diem,,17397,,"2,174.65 x patient days",17397,Per diem,,17397,,"2,174.65 x patient days",17397,Per diem,,39143,,"4,892.96 x patient days",39143,Per diem,,26617,,"3,327.21 x patient days",26617,Per diem,,39143,,"4,892.96 x patient days",39143,Per diem,,24356,,"3,044.51 x patient days",24356,Per diem,,39143,,"4,892.96 x patient days",39143,Per diem,,47842,,"5,980.29 x patient days",47842,Per diem,,56366,,"7,045.87 x patient days",56366,Per diem,,37404,,"4,675.50 x patient days",37404,Per diem,,37404,,"4,675.50 x patient days",37404,Per diem,,21746,,"2,718.31 x patient days",21746,Per diem,,0.01,56366,
"Major stomach, esophageal & duodenal procedures",220-3,APR-DRG,,,,,,,,inpatient,,,232708.83,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,32358,,"4,044.85 x patient days",32358,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,94033,,"27,634 x DRG weight",94033,Other,base rate x DRG weight,79925,,"23,488 x DRG weight",79925,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,17397,,"2,174.65 x patient days",17397,Per diem,,17397,,"2,174.65 x patient days",17397,Per diem,,17397,,"2,174.65 x patient days",17397,Per diem,,17397,,"2,174.65 x patient days",17397,Per diem,,39143,,"4,892.96 x patient days",39143,Per diem,,26617,,"3,327.21 x patient days",26617,Per diem,,39143,,"4,892.96 x patient days",39143,Per diem,,24356,,"3,044.51 x patient days",24356,Per diem,,39143,,"4,892.96 x patient days",39143,Per diem,,47842,,"5,980.29 x patient days",47842,Per diem,,56366,,"7,045.87 x patient days",56366,Per diem,,37404,,"4,675.50 x patient days",37404,Per diem,,37404,,"4,675.50 x patient days",37404,Per diem,,21746,,"2,718.31 x patient days",21746,Per diem,,0.01,94033,
"Major stomach, esophageal & duodenal procedures",220-4,APR-DRG,,,,,,,,inpatient,,,1103905.49,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,32358,,"4,044.85 x patient days",32358,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,195862,,"27,634 x DRG weight",195862,Other,base rate x DRG weight,166476,,"23,488 x DRG weight",166476,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,17397,,"2,174.65 x patient days",17397,Per diem,,17397,,"2,174.65 x patient days",17397,Per diem,,17397,,"2,174.65 x patient days",17397,Per diem,,17397,,"2,174.65 x patient days",17397,Per diem,,39143,,"4,892.96 x patient days",39143,Per diem,,26617,,"3,327.21 x patient days",26617,Per diem,,39143,,"4,892.96 x patient days",39143,Per diem,,24356,,"3,044.51 x patient days",24356,Per diem,,39143,,"4,892.96 x patient days",39143,Per diem,,47842,,"5,980.29 x patient days",47842,Per diem,,56366,,"7,045.87 x patient days",56366,Per diem,,37404,,"4,675.50 x patient days",37404,Per diem,,37404,,"4,675.50 x patient days",37404,Per diem,,21746,,"2,718.31 x patient days",21746,Per diem,,0.01,195862,
Major small & large bowel procedures,221-1,APR-DRG,,,,,,,,inpatient,,,161782.59,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,32358,,"4,044.85 x patient days",32358,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,41081,,"27,634 x DRG weight",41081,Other,base rate x DRG weight,34917,,"23,488 x DRG weight",34917,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,17397,,"2,174.65 x patient days",17397,Per diem,,17397,,"2,174.65 x patient days",17397,Per diem,,17397,,"2,174.65 x patient days",17397,Per diem,,17397,,"2,174.65 x patient days",17397,Per diem,,39143,,"4,892.96 x patient days",39143,Per diem,,26617,,"3,327.21 x patient days",26617,Per diem,,39143,,"4,892.96 x patient days",39143,Per diem,,24356,,"3,044.51 x patient days",24356,Per diem,,39143,,"4,892.96 x patient days",39143,Per diem,,47842,,"5,980.29 x patient days",47842,Per diem,,56366,,"7,045.87 x patient days",56366,Per diem,,37404,,"4,675.50 x patient days",37404,Per diem,,37404,,"4,675.50 x patient days",37404,Per diem,,21746,,"2,718.31 x patient days",21746,Per diem,,0.01,56366,
Major small & large bowel procedures,221-2,APR-DRG,,,,,,,,inpatient,,,207501.99,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,32358,,"4,044.85 x patient days",32358,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,52027,,"27,634 x DRG weight",52027,Other,base rate x DRG weight,44221,,"23,488 x DRG weight",44221,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,17397,,"2,174.65 x patient days",17397,Per diem,,17397,,"2,174.65 x patient days",17397,Per diem,,17397,,"2,174.65 x patient days",17397,Per diem,,17397,,"2,174.65 x patient days",17397,Per diem,,39143,,"4,892.96 x patient days",39143,Per diem,,26617,,"3,327.21 x patient days",26617,Per diem,,39143,,"4,892.96 x patient days",39143,Per diem,,24356,,"3,044.51 x patient days",24356,Per diem,,39143,,"4,892.96 x patient days",39143,Per diem,,47842,,"5,980.29 x patient days",47842,Per diem,,56366,,"7,045.87 x patient days",56366,Per diem,,37404,,"4,675.50 x patient days",37404,Per diem,,37404,,"4,675.50 x patient days",37404,Per diem,,21746,,"2,718.31 x patient days",21746,Per diem,,0.01,56366,
Major small & large bowel procedures,221-3,APR-DRG,,,,,,,,inpatient,,,414882.92,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,32358,,"4,044.85 x patient days",32358,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,85704,,"27,634 x DRG weight",85704,Other,base rate x DRG weight,72846,,"23,488 x DRG weight",72846,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,17397,,"2,174.65 x patient days",17397,Per diem,,17397,,"2,174.65 x patient days",17397,Per diem,,17397,,"2,174.65 x patient days",17397,Per diem,,17397,,"2,174.65 x patient days",17397,Per diem,,39143,,"4,892.96 x patient days",39143,Per diem,,26617,,"3,327.21 x patient days",26617,Per diem,,39143,,"4,892.96 x patient days",39143,Per diem,,24356,,"3,044.51 x patient days",24356,Per diem,,39143,,"4,892.96 x patient days",39143,Per diem,,47842,,"5,980.29 x patient days",47842,Per diem,,56366,,"7,045.87 x patient days",56366,Per diem,,37404,,"4,675.50 x patient days",37404,Per diem,,37404,,"4,675.50 x patient days",37404,Per diem,,21746,,"2,718.31 x patient days",21746,Per diem,,0.01,85704,
Major small & large bowel procedures,221-4,APR-DRG,,,,,,,,inpatient,,,605283.98,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,32358,,"4,044.85 x patient days",32358,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,182614,,"27,634 x DRG weight",182614,Other,base rate x DRG weight,155216,,"23,488 x DRG weight",155216,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,17397,,"2,174.65 x patient days",17397,Per diem,,17397,,"2,174.65 x patient days",17397,Per diem,,17397,,"2,174.65 x patient days",17397,Per diem,,17397,,"2,174.65 x patient days",17397,Per diem,,39143,,"4,892.96 x patient days",39143,Per diem,,26617,,"3,327.21 x patient days",26617,Per diem,,39143,,"4,892.96 x patient days",39143,Per diem,,24356,,"3,044.51 x patient days",24356,Per diem,,39143,,"4,892.96 x patient days",39143,Per diem,,47842,,"5,980.29 x patient days",47842,Per diem,,56366,,"7,045.87 x patient days",56366,Per diem,,37404,,"4,675.50 x patient days",37404,Per diem,,37404,,"4,675.50 x patient days",37404,Per diem,,21746,,"2,718.31 x patient days",21746,Per diem,,0.01,182614,
"Other stomach, esophageal & duodenal procedures",222-1,APR-DRG,,,,,,,,inpatient,,,106756.77,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12135,,"4,044.85 x patient days",12135,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,22740,,"27,634 x DRG weight",22740,Other,base rate x DRG weight,19328,,"23,488 x DRG weight",19328,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9982,,"3,327.21 x patient days",9982,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9134,,"3,044.51 x patient days",9134,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,17941,,"5,980.29 x patient days",17941,Per diem,,21138,,"7,045.87 x patient days",21138,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,8155,,"2,718.31 x patient days",8155,Per diem,,0.01,22740,
"Other stomach, esophageal & duodenal procedures",222-2,APR-DRG,,,,,,,,inpatient,,,185488.46,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12135,,"4,044.85 x patient days",12135,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,31334,,"27,634 x DRG weight",31334,Other,base rate x DRG weight,26633,,"23,488 x DRG weight",26633,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9982,,"3,327.21 x patient days",9982,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9134,,"3,044.51 x patient days",9134,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,17941,,"5,980.29 x patient days",17941,Per diem,,21138,,"7,045.87 x patient days",21138,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,8155,,"2,718.31 x patient days",8155,Per diem,,0.01,31334,
"Other stomach, esophageal & duodenal procedures",222-3,APR-DRG,,,,,,,,inpatient,,,188404.29,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12135,,"4,044.85 x patient days",12135,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,56586,,"27,634 x DRG weight",56586,Other,base rate x DRG weight,48096,,"23,488 x DRG weight",48096,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9982,,"3,327.21 x patient days",9982,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9134,,"3,044.51 x patient days",9134,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,17941,,"5,980.29 x patient days",17941,Per diem,,21138,,"7,045.87 x patient days",21138,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,8155,,"2,718.31 x patient days",8155,Per diem,,0.01,56586,
"Other stomach, esophageal & duodenal procedures",222-4,APR-DRG,,,,,,,,inpatient,,,249880.41,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12135,,"4,044.85 x patient days",12135,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,152927,,"27,634 x DRG weight",152927,Other,base rate x DRG weight,129983,,"23,488 x DRG weight",129983,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9982,,"3,327.21 x patient days",9982,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9134,,"3,044.51 x patient days",9134,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,17941,,"5,980.29 x patient days",17941,Per diem,,21138,,"7,045.87 x patient days",21138,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,8155,,"2,718.31 x patient days",8155,Per diem,,0.01,152927,
Other small & large bowel procedures,223-1,APR-DRG,,,,,,,,inpatient,,,116815.9,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,24269,,"4,044.85 x patient days",24269,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,32522,,"27,634 x DRG weight",32522,Other,base rate x DRG weight,27643,,"23,488 x DRG weight",27643,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,13048,,"2,174.65 x patient days",13048,Per diem,,13048,,"2,174.65 x patient days",13048,Per diem,,13048,,"2,174.65 x patient days",13048,Per diem,,13048,,"2,174.65 x patient days",13048,Per diem,,29358,,"4,892.96 x patient days",29358,Per diem,,19963,,"3,327.21 x patient days",19963,Per diem,,29358,,"4,892.96 x patient days",29358,Per diem,,18267,,"3,044.51 x patient days",18267,Per diem,,29358,,"4,892.96 x patient days",29358,Per diem,,35882,,"5,980.29 x patient days",35882,Per diem,,42276,,"7,045.87 x patient days",42276,Per diem,,28053,,"4,675.50 x patient days",28053,Per diem,,28053,,"4,675.50 x patient days",28053,Per diem,,16310,,"2,718.31 x patient days",16310,Per diem,,0.01,42276,
Other small & large bowel procedures,223-2,APR-DRG,,,,,,,,inpatient,,,192783.69,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,24269,,"4,044.85 x patient days",24269,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,43512,,"27,634 x DRG weight",43512,Other,base rate x DRG weight,36984,,"23,488 x DRG weight",36984,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,13048,,"2,174.65 x patient days",13048,Per diem,,13048,,"2,174.65 x patient days",13048,Per diem,,13048,,"2,174.65 x patient days",13048,Per diem,,13048,,"2,174.65 x patient days",13048,Per diem,,29358,,"4,892.96 x patient days",29358,Per diem,,19963,,"3,327.21 x patient days",19963,Per diem,,29358,,"4,892.96 x patient days",29358,Per diem,,18267,,"3,044.51 x patient days",18267,Per diem,,29358,,"4,892.96 x patient days",29358,Per diem,,35882,,"5,980.29 x patient days",35882,Per diem,,42276,,"7,045.87 x patient days",42276,Per diem,,28053,,"4,675.50 x patient days",28053,Per diem,,28053,,"4,675.50 x patient days",28053,Per diem,,16310,,"2,718.31 x patient days",16310,Per diem,,0.01,43512,
Other small & large bowel procedures,223-3,APR-DRG,,,,,,,,inpatient,,,334628.89,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,24269,,"4,044.85 x patient days",24269,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,73515,,"27,634 x DRG weight",73515,Other,base rate x DRG weight,62485,,"23,488 x DRG weight",62485,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,13048,,"2,174.65 x patient days",13048,Per diem,,13048,,"2,174.65 x patient days",13048,Per diem,,13048,,"2,174.65 x patient days",13048,Per diem,,13048,,"2,174.65 x patient days",13048,Per diem,,29358,,"4,892.96 x patient days",29358,Per diem,,19963,,"3,327.21 x patient days",19963,Per diem,,29358,,"4,892.96 x patient days",29358,Per diem,,18267,,"3,044.51 x patient days",18267,Per diem,,29358,,"4,892.96 x patient days",29358,Per diem,,35882,,"5,980.29 x patient days",35882,Per diem,,42276,,"7,045.87 x patient days",42276,Per diem,,28053,,"4,675.50 x patient days",28053,Per diem,,28053,,"4,675.50 x patient days",28053,Per diem,,16310,,"2,718.31 x patient days",16310,Per diem,,0.01,73515,
Other small & large bowel procedures,223-4,APR-DRG,,,,,,,,inpatient,,,283345.2,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,24269,,"4,044.85 x patient days",24269,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,154156,,"27,634 x DRG weight",154156,Other,base rate x DRG weight,131028,,"23,488 x DRG weight",131028,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,13048,,"2,174.65 x patient days",13048,Per diem,,13048,,"2,174.65 x patient days",13048,Per diem,,13048,,"2,174.65 x patient days",13048,Per diem,,13048,,"2,174.65 x patient days",13048,Per diem,,29358,,"4,892.96 x patient days",29358,Per diem,,19963,,"3,327.21 x patient days",19963,Per diem,,29358,,"4,892.96 x patient days",29358,Per diem,,18267,,"3,044.51 x patient days",18267,Per diem,,29358,,"4,892.96 x patient days",29358,Per diem,,35882,,"5,980.29 x patient days",35882,Per diem,,42276,,"7,045.87 x patient days",42276,Per diem,,28053,,"4,675.50 x patient days",28053,Per diem,,28053,,"4,675.50 x patient days",28053,Per diem,,16310,,"2,718.31 x patient days",16310,Per diem,,0.01,154156,
Peritoneal adhesiolysis,224-1,APR-DRG,,,,,,,,inpatient,,,124158.25,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,28315,,"4,044.85 x patient days",28315,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,33211,,"27,634 x DRG weight",33211,Other,base rate x DRG weight,28228,,"23,488 x DRG weight",28228,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,15223,,"2,174.65 x patient days",15223,Per diem,,15223,,"2,174.65 x patient days",15223,Per diem,,15223,,"2,174.65 x patient days",15223,Per diem,,15223,,"2,174.65 x patient days",15223,Per diem,,34252,,"4,892.96 x patient days",34252,Per diem,,23291,,"3,327.21 x patient days",23291,Per diem,,34252,,"4,892.96 x patient days",34252,Per diem,,21312,,"3,044.51 x patient days",21312,Per diem,,34252,,"4,892.96 x patient days",34252,Per diem,,41863,,"5,980.29 x patient days",41863,Per diem,,49323,,"7,045.87 x patient days",49323,Per diem,,32729,,"4,675.50 x patient days",32729,Per diem,,32729,,"4,675.50 x patient days",32729,Per diem,,19029,,"2,718.31 x patient days",19029,Per diem,,0.01,49323,
Peritoneal adhesiolysis,224-2,APR-DRG,,,,,,,,inpatient,,,177502.78,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,28315,,"4,044.85 x patient days",28315,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,44250,,"27,634 x DRG weight",44250,Other,base rate x DRG weight,37611,,"23,488 x DRG weight",37611,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,15223,,"2,174.65 x patient days",15223,Per diem,,15223,,"2,174.65 x patient days",15223,Per diem,,15223,,"2,174.65 x patient days",15223,Per diem,,15223,,"2,174.65 x patient days",15223,Per diem,,34252,,"4,892.96 x patient days",34252,Per diem,,23291,,"3,327.21 x patient days",23291,Per diem,,34252,,"4,892.96 x patient days",34252,Per diem,,21312,,"3,044.51 x patient days",21312,Per diem,,34252,,"4,892.96 x patient days",34252,Per diem,,41863,,"5,980.29 x patient days",41863,Per diem,,49323,,"7,045.87 x patient days",49323,Per diem,,32729,,"4,675.50 x patient days",32729,Per diem,,32729,,"4,675.50 x patient days",32729,Per diem,,19029,,"2,718.31 x patient days",19029,Per diem,,0.01,49323,
Peritoneal adhesiolysis,224-3,APR-DRG,,,,,,,,inpatient,,,605898.02,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,28315,,"4,044.85 x patient days",28315,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,73335,,"27,634 x DRG weight",73335,Other,base rate x DRG weight,62332,,"23,488 x DRG weight",62332,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,15223,,"2,174.65 x patient days",15223,Per diem,,15223,,"2,174.65 x patient days",15223,Per diem,,15223,,"2,174.65 x patient days",15223,Per diem,,15223,,"2,174.65 x patient days",15223,Per diem,,34252,,"4,892.96 x patient days",34252,Per diem,,23291,,"3,327.21 x patient days",23291,Per diem,,34252,,"4,892.96 x patient days",34252,Per diem,,21312,,"3,044.51 x patient days",21312,Per diem,,34252,,"4,892.96 x patient days",34252,Per diem,,41863,,"5,980.29 x patient days",41863,Per diem,,49323,,"7,045.87 x patient days",49323,Per diem,,32729,,"4,675.50 x patient days",32729,Per diem,,32729,,"4,675.50 x patient days",32729,Per diem,,19029,,"2,718.31 x patient days",19029,Per diem,,0.01,73335,
Peritoneal adhesiolysis,224-4,APR-DRG,,,,,,,,inpatient,,,631151.13,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,28315,,"4,044.85 x patient days",28315,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,153883,,"27,634 x DRG weight",153883,Other,base rate x DRG weight,130795,,"23,488 x DRG weight",130795,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,15223,,"2,174.65 x patient days",15223,Per diem,,15223,,"2,174.65 x patient days",15223,Per diem,,15223,,"2,174.65 x patient days",15223,Per diem,,15223,,"2,174.65 x patient days",15223,Per diem,,34252,,"4,892.96 x patient days",34252,Per diem,,23291,,"3,327.21 x patient days",23291,Per diem,,34252,,"4,892.96 x patient days",34252,Per diem,,21312,,"3,044.51 x patient days",21312,Per diem,,34252,,"4,892.96 x patient days",34252,Per diem,,41863,,"5,980.29 x patient days",41863,Per diem,,49323,,"7,045.87 x patient days",49323,Per diem,,32729,,"4,675.50 x patient days",32729,Per diem,,32729,,"4,675.50 x patient days",32729,Per diem,,19029,,"2,718.31 x patient days",19029,Per diem,,0.01,153883,
Appendectomy,225-1,APR-DRG,,,,,,,,inpatient,,,74424.07,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8089,,"4,044.85 x patient days",8089,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,19896,,"27,634 x DRG weight",19896,Other,base rate x DRG weight,16911,,"23,488 x DRG weight",16911,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6654,,"3,327.21 x patient days",6654,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6089,,"3,044.51 x patient days",6089,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,11960,,"5,980.29 x patient days",11960,Per diem,,14091,,"7,045.87 x patient days",14091,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,5436,,"2,718.31 x patient days",5436,Per diem,,0.01,19896,
Appendectomy,225-2,APR-DRG,,,,,,,,inpatient,,,121347.09,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8089,,"4,044.85 x patient days",8089,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,30519,,"27,634 x DRG weight",30519,Other,base rate x DRG weight,25940,,"23,488 x DRG weight",25940,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6654,,"3,327.21 x patient days",6654,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6089,,"3,044.51 x patient days",6089,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,11960,,"5,980.29 x patient days",11960,Per diem,,14091,,"7,045.87 x patient days",14091,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,5436,,"2,718.31 x patient days",5436,Per diem,,0.01,30519,
Appendectomy,225-3,APR-DRG,,,,,,,,inpatient,,,241930.68,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8089,,"4,044.85 x patient days",8089,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,56064,,"27,634 x DRG weight",56064,Other,base rate x DRG weight,47652,,"23,488 x DRG weight",47652,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6654,,"3,327.21 x patient days",6654,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6089,,"3,044.51 x patient days",6089,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,11960,,"5,980.29 x patient days",11960,Per diem,,14091,,"7,045.87 x patient days",14091,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,5436,,"2,718.31 x patient days",5436,Per diem,,0.01,56064,
Appendectomy,225-4,APR-DRG,,,,,,,,inpatient,,,285684.07,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8089,,"4,044.85 x patient days",8089,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,112255,,"27,634 x DRG weight",112255,Other,base rate x DRG weight,95413,,"23,488 x DRG weight",95413,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6654,,"3,327.21 x patient days",6654,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6089,,"3,044.51 x patient days",6089,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,11960,,"5,980.29 x patient days",11960,Per diem,,14091,,"7,045.87 x patient days",14091,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,5436,,"2,718.31 x patient days",5436,Per diem,,0.01,112255,
Anal procedures,226-1,APR-DRG,,,,,,,,inpatient,,,81392.18,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12135,,"4,044.85 x patient days",12135,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,17103,,"27,634 x DRG weight",17103,Other,base rate x DRG weight,14537,,"23,488 x DRG weight",14537,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9982,,"3,327.21 x patient days",9982,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9134,,"3,044.51 x patient days",9134,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,17941,,"5,980.29 x patient days",17941,Per diem,,21138,,"7,045.87 x patient days",21138,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,8155,,"2,718.31 x patient days",8155,Per diem,,0.01,21138,
Anal procedures,226-2,APR-DRG,,,,,,,,inpatient,,,126614.67,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12135,,"4,044.85 x patient days",12135,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,24401,,"27,634 x DRG weight",24401,Other,base rate x DRG weight,20740,,"23,488 x DRG weight",20740,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9982,,"3,327.21 x patient days",9982,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9134,,"3,044.51 x patient days",9134,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,17941,,"5,980.29 x patient days",17941,Per diem,,21138,,"7,045.87 x patient days",21138,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,8155,,"2,718.31 x patient days",8155,Per diem,,0.01,24401,
Anal procedures,226-3,APR-DRG,,,,,,,,inpatient,,,356419.86,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12135,,"4,044.85 x patient days",12135,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,41407,,"27,634 x DRG weight",41407,Other,base rate x DRG weight,35194,,"23,488 x DRG weight",35194,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9982,,"3,327.21 x patient days",9982,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9134,,"3,044.51 x patient days",9134,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,17941,,"5,980.29 x patient days",17941,Per diem,,21138,,"7,045.87 x patient days",21138,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,8155,,"2,718.31 x patient days",8155,Per diem,,0.01,41407,
Anal procedures,226-4,APR-DRG,,,,,,,,inpatient,,,1092437.37,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12135,,"4,044.85 x patient days",12135,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,100281,,"27,634 x DRG weight",100281,Other,base rate x DRG weight,85236,,"23,488 x DRG weight",85236,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9982,,"3,327.21 x patient days",9982,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9134,,"3,044.51 x patient days",9134,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,17941,,"5,980.29 x patient days",17941,Per diem,,21138,,"7,045.87 x patient days",21138,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,8155,,"2,718.31 x patient days",8155,Per diem,,0.01,100281,
"Hernia procedures except inguinal, femoral & umbilical",227-1,APR-DRG,,,,,,,,inpatient,,,161537.48,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,16180,,"4,044.85 x patient days",16180,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,28723,,"27,634 x DRG weight",28723,Other,base rate x DRG weight,24413,,"23,488 x DRG weight",24413,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,13309,,"3,327.21 x patient days",13309,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,12179,,"3,044.51 x patient days",12179,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,23922,,"5,980.29 x patient days",23922,Per diem,,28185,,"7,045.87 x patient days",28185,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,10874,,"2,718.31 x patient days",10874,Per diem,,0.01,28723,
"Hernia procedures except inguinal, femoral & umbilical",227-2,APR-DRG,,,,,,,,inpatient,,,233346.75,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,16180,,"4,044.85 x patient days",16180,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,37317,,"27,634 x DRG weight",37317,Other,base rate x DRG weight,31718,,"23,488 x DRG weight",31718,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,13309,,"3,327.21 x patient days",13309,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,12179,,"3,044.51 x patient days",12179,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,23922,,"5,980.29 x patient days",23922,Per diem,,28185,,"7,045.87 x patient days",28185,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,10874,,"2,718.31 x patient days",10874,Per diem,,0.01,37317,
"Hernia procedures except inguinal, femoral & umbilical",227-3,APR-DRG,,,,,,,,inpatient,,,242045.54,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,16180,,"4,044.85 x patient days",16180,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,64067,,"27,634 x DRG weight",64067,Other,base rate x DRG weight,54455,,"23,488 x DRG weight",54455,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,13309,,"3,327.21 x patient days",13309,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,12179,,"3,044.51 x patient days",12179,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,23922,,"5,980.29 x patient days",23922,Per diem,,28185,,"7,045.87 x patient days",28185,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,10874,,"2,718.31 x patient days",10874,Per diem,,0.01,64067,
"Hernia procedures except inguinal, femoral & umbilical",227-4,APR-DRG,,,,,,,,inpatient,,,95511.63,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,16180,,"4,044.85 x patient days",16180,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,145733,,"27,634 x DRG weight",145733,Other,base rate x DRG weight,123869,,"23,488 x DRG weight",123869,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,13309,,"3,327.21 x patient days",13309,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,12179,,"3,044.51 x patient days",12179,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,23922,,"5,980.29 x patient days",23922,Per diem,,28185,,"7,045.87 x patient days",28185,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,10874,,"2,718.31 x patient days",10874,Per diem,,0.01,145733,
"Inguinal, femoral & umbilical hernia procedures",228-1,APR-DRG,,,,,,,,inpatient,,,81869.87,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8089,,"4,044.85 x patient days",8089,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,19266,,"27,634 x DRG weight",19266,Other,base rate x DRG weight,16376,,"23,488 x DRG weight",16376,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6654,,"3,327.21 x patient days",6654,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6089,,"3,044.51 x patient days",6089,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,11960,,"5,980.29 x patient days",11960,Per diem,,14091,,"7,045.87 x patient days",14091,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,5436,,"2,718.31 x patient days",5436,Per diem,,0.01,19266,
"Inguinal, femoral & umbilical hernia procedures",228-2,APR-DRG,,,,,,,,inpatient,,,161105.35,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8089,,"4,044.85 x patient days",8089,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,26343,,"27,634 x DRG weight",26343,Other,base rate x DRG weight,22391,,"23,488 x DRG weight",22391,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6654,,"3,327.21 x patient days",6654,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6089,,"3,044.51 x patient days",6089,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,11960,,"5,980.29 x patient days",11960,Per diem,,14091,,"7,045.87 x patient days",14091,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,5436,,"2,718.31 x patient days",5436,Per diem,,0.01,26343,
"Inguinal, femoral & umbilical hernia procedures",228-3,APR-DRG,,,,,,,,inpatient,,,78257.78,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8089,,"4,044.85 x patient days",8089,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,44590,,"27,634 x DRG weight",44590,Other,base rate x DRG weight,37900,,"23,488 x DRG weight",37900,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6654,,"3,327.21 x patient days",6654,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6089,,"3,044.51 x patient days",6089,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,11960,,"5,980.29 x patient days",11960,Per diem,,14091,,"7,045.87 x patient days",14091,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,5436,,"2,718.31 x patient days",5436,Per diem,,0.01,44590,
"Inguinal, femoral & umbilical hernia procedures",228-4,APR-DRG,,,,,,,,inpatient,,,454616.93,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8089,,"4,044.85 x patient days",8089,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,123132,,"27,634 x DRG weight",123132,Other,base rate x DRG weight,104658,,"23,488 x DRG weight",104658,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6654,,"3,327.21 x patient days",6654,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6089,,"3,044.51 x patient days",6089,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,11960,,"5,980.29 x patient days",11960,Per diem,,14091,,"7,045.87 x patient days",14091,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,5436,,"2,718.31 x patient days",5436,Per diem,,0.01,123132,
Other digestive system & abdominal procedures,229-1,APR-DRG,,,,,,,,inpatient,,,209990.27,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,28315,,"4,044.85 x patient days",28315,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,28223,,"27,634 x DRG weight",28223,Other,base rate x DRG weight,23988,,"23,488 x DRG weight",23988,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,15223,,"2,174.65 x patient days",15223,Per diem,,15223,,"2,174.65 x patient days",15223,Per diem,,15223,,"2,174.65 x patient days",15223,Per diem,,15223,,"2,174.65 x patient days",15223,Per diem,,34252,,"4,892.96 x patient days",34252,Per diem,,23291,,"3,327.21 x patient days",23291,Per diem,,34252,,"4,892.96 x patient days",34252,Per diem,,21312,,"3,044.51 x patient days",21312,Per diem,,34252,,"4,892.96 x patient days",34252,Per diem,,41863,,"5,980.29 x patient days",41863,Per diem,,49323,,"7,045.87 x patient days",49323,Per diem,,32729,,"4,675.50 x patient days",32729,Per diem,,32729,,"4,675.50 x patient days",32729,Per diem,,19029,,"2,718.31 x patient days",19029,Per diem,,0.01,49323,
Other digestive system & abdominal procedures,229-2,APR-DRG,,,,,,,,inpatient,,,158747.34,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,28315,,"4,044.85 x patient days",28315,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,40904,,"27,634 x DRG weight",40904,Other,base rate x DRG weight,34767,,"23,488 x DRG weight",34767,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,15223,,"2,174.65 x patient days",15223,Per diem,,15223,,"2,174.65 x patient days",15223,Per diem,,15223,,"2,174.65 x patient days",15223,Per diem,,15223,,"2,174.65 x patient days",15223,Per diem,,34252,,"4,892.96 x patient days",34252,Per diem,,23291,,"3,327.21 x patient days",23291,Per diem,,34252,,"4,892.96 x patient days",34252,Per diem,,21312,,"3,044.51 x patient days",21312,Per diem,,34252,,"4,892.96 x patient days",34252,Per diem,,41863,,"5,980.29 x patient days",41863,Per diem,,49323,,"7,045.87 x patient days",49323,Per diem,,32729,,"4,675.50 x patient days",32729,Per diem,,32729,,"4,675.50 x patient days",32729,Per diem,,19029,,"2,718.31 x patient days",19029,Per diem,,0.01,49323,
Other digestive system & abdominal procedures,229-3,APR-DRG,,,,,,,,inpatient,,,364897.14,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,28315,,"4,044.85 x patient days",28315,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,72006,,"27,634 x DRG weight",72006,Other,base rate x DRG weight,61203,,"23,488 x DRG weight",61203,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,15223,,"2,174.65 x patient days",15223,Per diem,,15223,,"2,174.65 x patient days",15223,Per diem,,15223,,"2,174.65 x patient days",15223,Per diem,,15223,,"2,174.65 x patient days",15223,Per diem,,34252,,"4,892.96 x patient days",34252,Per diem,,23291,,"3,327.21 x patient days",23291,Per diem,,34252,,"4,892.96 x patient days",34252,Per diem,,21312,,"3,044.51 x patient days",21312,Per diem,,34252,,"4,892.96 x patient days",34252,Per diem,,41863,,"5,980.29 x patient days",41863,Per diem,,49323,,"7,045.87 x patient days",49323,Per diem,,32729,,"4,675.50 x patient days",32729,Per diem,,32729,,"4,675.50 x patient days",32729,Per diem,,19029,,"2,718.31 x patient days",19029,Per diem,,0.01,72006,
Other digestive system & abdominal procedures,229-4,APR-DRG,,,,,,,,inpatient,,,723373.83,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,28315,,"4,044.85 x patient days",28315,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,159912,,"27,634 x DRG weight",159912,Other,base rate x DRG weight,135920,,"23,488 x DRG weight",135920,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,15223,,"2,174.65 x patient days",15223,Per diem,,15223,,"2,174.65 x patient days",15223,Per diem,,15223,,"2,174.65 x patient days",15223,Per diem,,15223,,"2,174.65 x patient days",15223,Per diem,,34252,,"4,892.96 x patient days",34252,Per diem,,23291,,"3,327.21 x patient days",23291,Per diem,,34252,,"4,892.96 x patient days",34252,Per diem,,21312,,"3,044.51 x patient days",21312,Per diem,,34252,,"4,892.96 x patient days",34252,Per diem,,41863,,"5,980.29 x patient days",41863,Per diem,,49323,,"7,045.87 x patient days",49323,Per diem,,32729,,"4,675.50 x patient days",32729,Per diem,,32729,,"4,675.50 x patient days",32729,Per diem,,19029,,"2,718.31 x patient days",19029,Per diem,,0.01,159912,
Digestive malignancy,240-1,APR-DRG,,,,,,,,inpatient,,,175015.63,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,28315,,"4,044.85 x patient days",28315,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,19338,,"27,634 x DRG weight",19338,Other,base rate x DRG weight,16437,,"23,488 x DRG weight",16437,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,15223,,"2,174.65 x patient days",15223,Per diem,,15223,,"2,174.65 x patient days",15223,Per diem,,15223,,"2,174.65 x patient days",15223,Per diem,,15223,,"2,174.65 x patient days",15223,Per diem,,34252,,"4,892.96 x patient days",34252,Per diem,,23291,,"3,327.21 x patient days",23291,Per diem,,34252,,"4,892.96 x patient days",34252,Per diem,,21312,,"3,044.51 x patient days",21312,Per diem,,34252,,"4,892.96 x patient days",34252,Per diem,,41863,,"5,980.29 x patient days",41863,Per diem,,49323,,"7,045.87 x patient days",49323,Per diem,,32729,,"4,675.50 x patient days",32729,Per diem,,32729,,"4,675.50 x patient days",32729,Per diem,,19029,,"2,718.31 x patient days",19029,Per diem,,0.01,49323,
Digestive malignancy,240-2,APR-DRG,,,,,,,,inpatient,,,363554.48,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,28315,,"4,044.85 x patient days",28315,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,26233,,"27,634 x DRG weight",26233,Other,base rate x DRG weight,22297,,"23,488 x DRG weight",22297,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,15223,,"2,174.65 x patient days",15223,Per diem,,15223,,"2,174.65 x patient days",15223,Per diem,,15223,,"2,174.65 x patient days",15223,Per diem,,15223,,"2,174.65 x patient days",15223,Per diem,,34252,,"4,892.96 x patient days",34252,Per diem,,23291,,"3,327.21 x patient days",23291,Per diem,,34252,,"4,892.96 x patient days",34252,Per diem,,21312,,"3,044.51 x patient days",21312,Per diem,,34252,,"4,892.96 x patient days",34252,Per diem,,41863,,"5,980.29 x patient days",41863,Per diem,,49323,,"7,045.87 x patient days",49323,Per diem,,32729,,"4,675.50 x patient days",32729,Per diem,,32729,,"4,675.50 x patient days",32729,Per diem,,19029,,"2,718.31 x patient days",19029,Per diem,,0.01,49323,
Digestive malignancy,240-3,APR-DRG,,,,,,,,inpatient,,,394722.98,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,28315,,"4,044.85 x patient days",28315,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,43756,,"27,634 x DRG weight",43756,Other,base rate x DRG weight,37191,,"23,488 x DRG weight",37191,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,15223,,"2,174.65 x patient days",15223,Per diem,,15223,,"2,174.65 x patient days",15223,Per diem,,15223,,"2,174.65 x patient days",15223,Per diem,,15223,,"2,174.65 x patient days",15223,Per diem,,34252,,"4,892.96 x patient days",34252,Per diem,,23291,,"3,327.21 x patient days",23291,Per diem,,34252,,"4,892.96 x patient days",34252,Per diem,,21312,,"3,044.51 x patient days",21312,Per diem,,34252,,"4,892.96 x patient days",34252,Per diem,,41863,,"5,980.29 x patient days",41863,Per diem,,49323,,"7,045.87 x patient days",49323,Per diem,,32729,,"4,675.50 x patient days",32729,Per diem,,32729,,"4,675.50 x patient days",32729,Per diem,,19029,,"2,718.31 x patient days",19029,Per diem,,0.01,49323,
Digestive malignancy,240-4,APR-DRG,,,,,,,,inpatient,,,508662.69,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,28315,,"4,044.85 x patient days",28315,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,82181,,"27,634 x DRG weight",82181,Other,base rate x DRG weight,69851,,"23,488 x DRG weight",69851,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,15223,,"2,174.65 x patient days",15223,Per diem,,15223,,"2,174.65 x patient days",15223,Per diem,,15223,,"2,174.65 x patient days",15223,Per diem,,15223,,"2,174.65 x patient days",15223,Per diem,,34252,,"4,892.96 x patient days",34252,Per diem,,23291,,"3,327.21 x patient days",23291,Per diem,,34252,,"4,892.96 x patient days",34252,Per diem,,21312,,"3,044.51 x patient days",21312,Per diem,,34252,,"4,892.96 x patient days",34252,Per diem,,41863,,"5,980.29 x patient days",41863,Per diem,,49323,,"7,045.87 x patient days",49323,Per diem,,32729,,"4,675.50 x patient days",32729,Per diem,,32729,,"4,675.50 x patient days",32729,Per diem,,19029,,"2,718.31 x patient days",19029,Per diem,,0.01,82181,
Peptic ulcer & gastritis,241-1,APR-DRG,,,,,,,,inpatient,,,98652.05,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12135,,"4,044.85 x patient days",12135,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,14936,,"27,634 x DRG weight",14936,Other,base rate x DRG weight,12695,,"23,488 x DRG weight",12695,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9982,,"3,327.21 x patient days",9982,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9134,,"3,044.51 x patient days",9134,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,17941,,"5,980.29 x patient days",17941,Per diem,,21138,,"7,045.87 x patient days",21138,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,8155,,"2,718.31 x patient days",8155,Per diem,,0.01,21138,
Peptic ulcer & gastritis,241-2,APR-DRG,,,,,,,,inpatient,,,130688.37,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12135,,"4,044.85 x patient days",12135,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,21436,,"27,634 x DRG weight",21436,Other,base rate x DRG weight,18220,,"23,488 x DRG weight",18220,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9982,,"3,327.21 x patient days",9982,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9134,,"3,044.51 x patient days",9134,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,17941,,"5,980.29 x patient days",17941,Per diem,,21138,,"7,045.87 x patient days",21138,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,8155,,"2,718.31 x patient days",8155,Per diem,,0.01,21436,
Peptic ulcer & gastritis,241-3,APR-DRG,,,,,,,,inpatient,,,152371.82,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12135,,"4,044.85 x patient days",12135,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,34341,,"27,634 x DRG weight",34341,Other,base rate x DRG weight,29189,,"23,488 x DRG weight",29189,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9982,,"3,327.21 x patient days",9982,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9134,,"3,044.51 x patient days",9134,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,17941,,"5,980.29 x patient days",17941,Per diem,,21138,,"7,045.87 x patient days",21138,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,8155,,"2,718.31 x patient days",8155,Per diem,,0.01,34341,
Peptic ulcer & gastritis,241-4,APR-DRG,,,,,,,,inpatient,,,346158.03,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12135,,"4,044.85 x patient days",12135,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,86486,,"27,634 x DRG weight",86486,Other,base rate x DRG weight,73510,,"23,488 x DRG weight",73510,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9982,,"3,327.21 x patient days",9982,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9134,,"3,044.51 x patient days",9134,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,17941,,"5,980.29 x patient days",17941,Per diem,,21138,,"7,045.87 x patient days",21138,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,8155,,"2,718.31 x patient days",8155,Per diem,,0.01,86486,
Major esophageal disorders,242-1,APR-DRG,,,,,,,,inpatient,,,49854,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,16180,,"4,044.85 x patient days",16180,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,15268,,"27,634 x DRG weight",15268,Other,base rate x DRG weight,12977,,"23,488 x DRG weight",12977,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,13309,,"3,327.21 x patient days",13309,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,12179,,"3,044.51 x patient days",12179,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,23922,,"5,980.29 x patient days",23922,Per diem,,28185,,"7,045.87 x patient days",28185,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,10874,,"2,718.31 x patient days",10874,Per diem,,0.01,28185,
Major esophageal disorders,242-2,APR-DRG,,,,,,,,inpatient,,,57789.91,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,16180,,"4,044.85 x patient days",16180,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,21952,,"27,634 x DRG weight",21952,Other,base rate x DRG weight,18659,,"23,488 x DRG weight",18659,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,13309,,"3,327.21 x patient days",13309,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,12179,,"3,044.51 x patient days",12179,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,23922,,"5,980.29 x patient days",23922,Per diem,,28185,,"7,045.87 x patient days",28185,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,10874,,"2,718.31 x patient days",10874,Per diem,,0.01,28185,
Major esophageal disorders,242-3,APR-DRG,,,,,,,,inpatient,,,95020.06,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,16180,,"4,044.85 x patient days",16180,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,34496,,"27,634 x DRG weight",34496,Other,base rate x DRG weight,29320,,"23,488 x DRG weight",29320,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,13309,,"3,327.21 x patient days",13309,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,12179,,"3,044.51 x patient days",12179,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,23922,,"5,980.29 x patient days",23922,Per diem,,28185,,"7,045.87 x patient days",28185,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,10874,,"2,718.31 x patient days",10874,Per diem,,0.01,34496,
Major esophageal disorders,242-4,APR-DRG,,,,,,,,inpatient,,,152089.88,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,16180,,"4,044.85 x patient days",16180,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,87191,,"27,634 x DRG weight",87191,Other,base rate x DRG weight,74109,,"23,488 x DRG weight",74109,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,13309,,"3,327.21 x patient days",13309,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,12179,,"3,044.51 x patient days",12179,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,23922,,"5,980.29 x patient days",23922,Per diem,,28185,,"7,045.87 x patient days",28185,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,10874,,"2,718.31 x patient days",10874,Per diem,,0.01,87191,
Other esophageal disorders,243-1,APR-DRG,,,,,,,,inpatient,,,70883.52,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12135,,"4,044.85 x patient days",12135,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12010,,"27,634 x DRG weight",12010,Other,base rate x DRG weight,10208,,"23,488 x DRG weight",10208,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9982,,"3,327.21 x patient days",9982,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9134,,"3,044.51 x patient days",9134,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,17941,,"5,980.29 x patient days",17941,Per diem,,21138,,"7,045.87 x patient days",21138,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,8155,,"2,718.31 x patient days",8155,Per diem,,0.01,21138,
Other esophageal disorders,243-2,APR-DRG,,,,,,,,inpatient,,,138448.13,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12135,,"4,044.85 x patient days",12135,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,17382,,"27,634 x DRG weight",17382,Other,base rate x DRG weight,14774,,"23,488 x DRG weight",14774,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9982,,"3,327.21 x patient days",9982,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9134,,"3,044.51 x patient days",9134,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,17941,,"5,980.29 x patient days",17941,Per diem,,21138,,"7,045.87 x patient days",21138,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,8155,,"2,718.31 x patient days",8155,Per diem,,0.01,21138,
Other esophageal disorders,243-3,APR-DRG,,,,,,,,inpatient,,,157721.23,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12135,,"4,044.85 x patient days",12135,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,29157,,"27,634 x DRG weight",29157,Other,base rate x DRG weight,24782,,"23,488 x DRG weight",24782,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9982,,"3,327.21 x patient days",9982,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9134,,"3,044.51 x patient days",9134,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,17941,,"5,980.29 x patient days",17941,Per diem,,21138,,"7,045.87 x patient days",21138,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,8155,,"2,718.31 x patient days",8155,Per diem,,0.01,29157,
Other esophageal disorders,243-4,APR-DRG,,,,,,,,inpatient,,,580126.69,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12135,,"4,044.85 x patient days",12135,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,63522,,"27,634 x DRG weight",63522,Other,base rate x DRG weight,53992,,"23,488 x DRG weight",53992,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9982,,"3,327.21 x patient days",9982,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9134,,"3,044.51 x patient days",9134,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,17941,,"5,980.29 x patient days",17941,Per diem,,21138,,"7,045.87 x patient days",21138,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,8155,,"2,718.31 x patient days",8155,Per diem,,0.01,63522,
Diverticulitis & diverticulosis,244-1,APR-DRG,,,,,,,,inpatient,,,75251.49,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,16180,,"4,044.85 x patient days",16180,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,14375,,"27,634 x DRG weight",14375,Other,base rate x DRG weight,12218,,"23,488 x DRG weight",12218,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,13309,,"3,327.21 x patient days",13309,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,12179,,"3,044.51 x patient days",12179,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,23922,,"5,980.29 x patient days",23922,Per diem,,28185,,"7,045.87 x patient days",28185,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,10874,,"2,718.31 x patient days",10874,Per diem,,0.01,28185,
Diverticulitis & diverticulosis,244-2,APR-DRG,,,,,,,,inpatient,,,66037.3,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,16180,,"4,044.85 x patient days",16180,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,19164,,"27,634 x DRG weight",19164,Other,base rate x DRG weight,16289,,"23,488 x DRG weight",16289,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,13309,,"3,327.21 x patient days",13309,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,12179,,"3,044.51 x patient days",12179,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,23922,,"5,980.29 x patient days",23922,Per diem,,28185,,"7,045.87 x patient days",28185,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,10874,,"2,718.31 x patient days",10874,Per diem,,0.01,28185,
Diverticulitis & diverticulosis,244-3,APR-DRG,,,,,,,,inpatient,,,141395.87,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,16180,,"4,044.85 x patient days",16180,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,32102,,"27,634 x DRG weight",32102,Other,base rate x DRG weight,27286,,"23,488 x DRG weight",27286,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,13309,,"3,327.21 x patient days",13309,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,12179,,"3,044.51 x patient days",12179,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,23922,,"5,980.29 x patient days",23922,Per diem,,28185,,"7,045.87 x patient days",28185,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,10874,,"2,718.31 x patient days",10874,Per diem,,0.01,32102,
Diverticulitis & diverticulosis,244-4,APR-DRG,,,,,,,,inpatient,,,141395.87,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,16180,,"4,044.85 x patient days",16180,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,84917,,"27,634 x DRG weight",84917,Other,base rate x DRG weight,72176,,"23,488 x DRG weight",72176,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,13309,,"3,327.21 x patient days",13309,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,12179,,"3,044.51 x patient days",12179,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,23922,,"5,980.29 x patient days",23922,Per diem,,28185,,"7,045.87 x patient days",28185,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,10874,,"2,718.31 x patient days",10874,Per diem,,0.01,84917,
Inflammatory bowel disease,245-1,APR-DRG,,,,,,,,inpatient,,,108866.14,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,16180,,"4,044.85 x patient days",16180,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,17263,,"27,634 x DRG weight",17263,Other,base rate x DRG weight,14673,,"23,488 x DRG weight",14673,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,13309,,"3,327.21 x patient days",13309,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,12179,,"3,044.51 x patient days",12179,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,23922,,"5,980.29 x patient days",23922,Per diem,,28185,,"7,045.87 x patient days",28185,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,10874,,"2,718.31 x patient days",10874,Per diem,,0.01,28185,
Inflammatory bowel disease,245-2,APR-DRG,,,,,,,,inpatient,,,153893.34,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,16180,,"4,044.85 x patient days",16180,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,21430,,"27,634 x DRG weight",21430,Other,base rate x DRG weight,18215,,"23,488 x DRG weight",18215,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,13309,,"3,327.21 x patient days",13309,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,12179,,"3,044.51 x patient days",12179,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,23922,,"5,980.29 x patient days",23922,Per diem,,28185,,"7,045.87 x patient days",28185,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,10874,,"2,718.31 x patient days",10874,Per diem,,0.01,28185,
Inflammatory bowel disease,245-3,APR-DRG,,,,,,,,inpatient,,,172569.03,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,16180,,"4,044.85 x patient days",16180,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,33661,,"27,634 x DRG weight",33661,Other,base rate x DRG weight,28611,,"23,488 x DRG weight",28611,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,13309,,"3,327.21 x patient days",13309,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,12179,,"3,044.51 x patient days",12179,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,23922,,"5,980.29 x patient days",23922,Per diem,,28185,,"7,045.87 x patient days",28185,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,10874,,"2,718.31 x patient days",10874,Per diem,,0.01,33661,
Inflammatory bowel disease,245-4,APR-DRG,,,,,,,,inpatient,,,198353.06,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,16180,,"4,044.85 x patient days",16180,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,59562,,"27,634 x DRG weight",59562,Other,base rate x DRG weight,50626,,"23,488 x DRG weight",50626,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,13309,,"3,327.21 x patient days",13309,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,12179,,"3,044.51 x patient days",12179,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,23922,,"5,980.29 x patient days",23922,Per diem,,28185,,"7,045.87 x patient days",28185,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,10874,,"2,718.31 x patient days",10874,Per diem,,0.01,59562,
Gastrointestinal vascular insufficiency,246-1,APR-DRG,,,,,,,,inpatient,,,124504.2,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,16180,,"4,044.85 x patient days",16180,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,17219,,"27,634 x DRG weight",17219,Other,base rate x DRG weight,14635,,"23,488 x DRG weight",14635,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,13309,,"3,327.21 x patient days",13309,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,12179,,"3,044.51 x patient days",12179,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,23922,,"5,980.29 x patient days",23922,Per diem,,28185,,"7,045.87 x patient days",28185,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,10874,,"2,718.31 x patient days",10874,Per diem,,0.01,28185,
Gastrointestinal vascular insufficiency,246-2,APR-DRG,,,,,,,,inpatient,,,148396.93,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,16180,,"4,044.85 x patient days",16180,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,21682,,"27,634 x DRG weight",21682,Other,base rate x DRG weight,18429,,"23,488 x DRG weight",18429,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,13309,,"3,327.21 x patient days",13309,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,12179,,"3,044.51 x patient days",12179,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,23922,,"5,980.29 x patient days",23922,Per diem,,28185,,"7,045.87 x patient days",28185,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,10874,,"2,718.31 x patient days",10874,Per diem,,0.01,28185,
Gastrointestinal vascular insufficiency,246-3,APR-DRG,,,,,,,,inpatient,,,226363.48,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,16180,,"4,044.85 x patient days",16180,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,35722,,"27,634 x DRG weight",35722,Other,base rate x DRG weight,30363,,"23,488 x DRG weight",30363,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,13309,,"3,327.21 x patient days",13309,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,12179,,"3,044.51 x patient days",12179,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,23922,,"5,980.29 x patient days",23922,Per diem,,28185,,"7,045.87 x patient days",28185,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,10874,,"2,718.31 x patient days",10874,Per diem,,0.01,35722,
Gastrointestinal vascular insufficiency,246-4,APR-DRG,,,,,,,,inpatient,,,189923.74,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,16180,,"4,044.85 x patient days",16180,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,78798,,"27,634 x DRG weight",78798,Other,base rate x DRG weight,66976,,"23,488 x DRG weight",66976,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,13309,,"3,327.21 x patient days",13309,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,12179,,"3,044.51 x patient days",12179,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,23922,,"5,980.29 x patient days",23922,Per diem,,28185,,"7,045.87 x patient days",28185,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,10874,,"2,718.31 x patient days",10874,Per diem,,0.01,78798,
Intestinal obstruction,247-1,APR-DRG,,,,,,,,inpatient,,,137358.07,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12135,,"4,044.85 x patient days",12135,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,13554,,"27,634 x DRG weight",13554,Other,base rate x DRG weight,11521,,"23,488 x DRG weight",11521,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9982,,"3,327.21 x patient days",9982,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9134,,"3,044.51 x patient days",9134,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,17941,,"5,980.29 x patient days",17941,Per diem,,21138,,"7,045.87 x patient days",21138,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,8155,,"2,718.31 x patient days",8155,Per diem,,0.01,21138,
Intestinal obstruction,247-2,APR-DRG,,,,,,,,inpatient,,,86834.82,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12135,,"4,044.85 x patient days",12135,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,18598,,"27,634 x DRG weight",18598,Other,base rate x DRG weight,15807,,"23,488 x DRG weight",15807,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9982,,"3,327.21 x patient days",9982,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9134,,"3,044.51 x patient days",9134,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,17941,,"5,980.29 x patient days",17941,Per diem,,21138,,"7,045.87 x patient days",21138,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,8155,,"2,718.31 x patient days",8155,Per diem,,0.01,21138,
Intestinal obstruction,247-3,APR-DRG,,,,,,,,inpatient,,,205820.56,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12135,,"4,044.85 x patient days",12135,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,33280,,"27,634 x DRG weight",33280,Other,base rate x DRG weight,28287,,"23,488 x DRG weight",28287,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9982,,"3,327.21 x patient days",9982,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9134,,"3,044.51 x patient days",9134,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,17941,,"5,980.29 x patient days",17941,Per diem,,21138,,"7,045.87 x patient days",21138,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,8155,,"2,718.31 x patient days",8155,Per diem,,0.01,33280,
Intestinal obstruction,247-4,APR-DRG,,,,,,,,inpatient,,,138423.16,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12135,,"4,044.85 x patient days",12135,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,70624,,"27,634 x DRG weight",70624,Other,base rate x DRG weight,60028,,"23,488 x DRG weight",60028,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9982,,"3,327.21 x patient days",9982,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9134,,"3,044.51 x patient days",9134,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,17941,,"5,980.29 x patient days",17941,Per diem,,21138,,"7,045.87 x patient days",21138,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,8155,,"2,718.31 x patient days",8155,Per diem,,0.01,70624,
Major gastrointestinal & peritoneal infections,248-1,APR-DRG,,,,,,,,inpatient,,,69893.42,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,20224,,"4,044.85 x patient days",20224,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,16445,,"27,634 x DRG weight",16445,Other,base rate x DRG weight,13978,,"23,488 x DRG weight",13978,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,16636,,"3,327.21 x patient days",16636,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,15222,,"3,044.51 x patient days",15222,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,29901,,"5,980.29 x patient days",29901,Per diem,,35229,,"7,045.87 x patient days",35229,Per diem,,23377,,"4,675.50 x patient days",23377,Per diem,,23377,,"4,675.50 x patient days",23377,Per diem,,13591,,"2,718.31 x patient days",13591,Per diem,,0.01,35229,
Major gastrointestinal & peritoneal infections,248-2,APR-DRG,,,,,,,,inpatient,,,125491.92,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,20224,,"4,044.85 x patient days",20224,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,23389,,"27,634 x DRG weight",23389,Other,base rate x DRG weight,19880,,"23,488 x DRG weight",19880,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,16636,,"3,327.21 x patient days",16636,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,15222,,"3,044.51 x patient days",15222,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,29901,,"5,980.29 x patient days",29901,Per diem,,35229,,"7,045.87 x patient days",35229,Per diem,,23377,,"4,675.50 x patient days",23377,Per diem,,23377,,"4,675.50 x patient days",23377,Per diem,,13591,,"2,718.31 x patient days",13591,Per diem,,0.01,35229,
Major gastrointestinal & peritoneal infections,248-3,APR-DRG,,,,,,,,inpatient,,,160443.75,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,20224,,"4,044.85 x patient days",20224,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,36446,,"27,634 x DRG weight",36446,Other,base rate x DRG weight,30978,,"23,488 x DRG weight",30978,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,16636,,"3,327.21 x patient days",16636,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,15222,,"3,044.51 x patient days",15222,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,29901,,"5,980.29 x patient days",29901,Per diem,,35229,,"7,045.87 x patient days",35229,Per diem,,23377,,"4,675.50 x patient days",23377,Per diem,,23377,,"4,675.50 x patient days",23377,Per diem,,13591,,"2,718.31 x patient days",13591,Per diem,,0.01,36446,
Major gastrointestinal & peritoneal infections,248-4,APR-DRG,,,,,,,,inpatient,,,526142.31,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,20224,,"4,044.85 x patient days",20224,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,89437,,"27,634 x DRG weight",89437,Other,base rate x DRG weight,76019,,"23,488 x DRG weight",76019,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,16636,,"3,327.21 x patient days",16636,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,15222,,"3,044.51 x patient days",15222,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,29901,,"5,980.29 x patient days",29901,Per diem,,35229,,"7,045.87 x patient days",35229,Per diem,,23377,,"4,675.50 x patient days",23377,Per diem,,23377,,"4,675.50 x patient days",23377,Per diem,,13591,,"2,718.31 x patient days",13591,Per diem,,0.01,89437,
"Other gastroenteritis, nausa & vomiting",249-1,APR-DRG,,,,,,,,inpatient,,,69371.71,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12135,,"4,044.85 x patient days",12135,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,11747,,"27,634 x DRG weight",11747,Other,base rate x DRG weight,9985,,"23,488 x DRG weight",9985,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9982,,"3,327.21 x patient days",9982,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9134,,"3,044.51 x patient days",9134,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,17941,,"5,980.29 x patient days",17941,Per diem,,21138,,"7,045.87 x patient days",21138,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,8155,,"2,718.31 x patient days",8155,Per diem,,0.01,21138,
"Other gastroenteritis, nausa & vomiting",249-2,APR-DRG,,,,,,,,inpatient,,,87768.62,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12135,,"4,044.85 x patient days",12135,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,14765,,"27,634 x DRG weight",14765,Other,base rate x DRG weight,12550,,"23,488 x DRG weight",12550,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9982,,"3,327.21 x patient days",9982,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9134,,"3,044.51 x patient days",9134,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,17941,,"5,980.29 x patient days",17941,Per diem,,21138,,"7,045.87 x patient days",21138,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,8155,,"2,718.31 x patient days",8155,Per diem,,0.01,21138,
"Other gastroenteritis, nausa & vomiting",249-3,APR-DRG,,,,,,,,inpatient,,,99367.64,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12135,,"4,044.85 x patient days",12135,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,23085,,"27,634 x DRG weight",23085,Other,base rate x DRG weight,19622,,"23,488 x DRG weight",19622,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9982,,"3,327.21 x patient days",9982,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9134,,"3,044.51 x patient days",9134,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,17941,,"5,980.29 x patient days",17941,Per diem,,21138,,"7,045.87 x patient days",21138,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,8155,,"2,718.31 x patient days",8155,Per diem,,0.01,23085,
"Other gastroenteritis, nausa & vomiting",249-4,APR-DRG,,,,,,,,inpatient,,,338050.61,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12135,,"4,044.85 x patient days",12135,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,55895,,"27,634 x DRG weight",55895,Other,base rate x DRG weight,47509,,"23,488 x DRG weight",47509,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9982,,"3,327.21 x patient days",9982,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9134,,"3,044.51 x patient days",9134,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,17941,,"5,980.29 x patient days",17941,Per diem,,21138,,"7,045.87 x patient days",21138,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,8155,,"2,718.31 x patient days",8155,Per diem,,0.01,55895,
Abdominal pain,251-1,APR-DRG,,,,,,,,inpatient,,,109406.27,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8089,,"4,044.85 x patient days",8089,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,11836,,"27,634 x DRG weight",11836,Other,base rate x DRG weight,10060,,"23,488 x DRG weight",10060,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6654,,"3,327.21 x patient days",6654,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6089,,"3,044.51 x patient days",6089,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,11960,,"5,980.29 x patient days",11960,Per diem,,14091,,"7,045.87 x patient days",14091,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,5436,,"2,718.31 x patient days",5436,Per diem,,0.01,14091,
Abdominal pain,251-2,APR-DRG,,,,,,,,inpatient,,,114457.78,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8089,,"4,044.85 x patient days",8089,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,15666,,"27,634 x DRG weight",15666,Other,base rate x DRG weight,13315,,"23,488 x DRG weight",13315,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6654,,"3,327.21 x patient days",6654,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6089,,"3,044.51 x patient days",6089,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,11960,,"5,980.29 x patient days",11960,Per diem,,14091,,"7,045.87 x patient days",14091,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,5436,,"2,718.31 x patient days",5436,Per diem,,0.01,15666,
Abdominal pain,251-3,APR-DRG,,,,,,,,inpatient,,,199796.19,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8089,,"4,044.85 x patient days",8089,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,23417,,"27,634 x DRG weight",23417,Other,base rate x DRG weight,19904,,"23,488 x DRG weight",19904,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6654,,"3,327.21 x patient days",6654,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6089,,"3,044.51 x patient days",6089,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,11960,,"5,980.29 x patient days",11960,Per diem,,14091,,"7,045.87 x patient days",14091,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,5436,,"2,718.31 x patient days",5436,Per diem,,0.01,23417,
Abdominal pain,251-4,APR-DRG,,,,,,,,inpatient,,,234267.8,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8089,,"4,044.85 x patient days",8089,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,53508,,"27,634 x DRG weight",53508,Other,base rate x DRG weight,45480,,"23,488 x DRG weight",45480,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6654,,"3,327.21 x patient days",6654,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6089,,"3,044.51 x patient days",6089,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,11960,,"5,980.29 x patient days",11960,Per diem,,14091,,"7,045.87 x patient days",14091,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,5436,,"2,718.31 x patient days",5436,Per diem,,0.01,53508,
"Malfunction, reaction & complication of GI device or procedure",252-1,APR-DRG,,,,,,,,inpatient,,,54933.73,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,20224,,"4,044.85 x patient days",20224,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,16837,,"27,634 x DRG weight",16837,Other,base rate x DRG weight,14311,,"23,488 x DRG weight",14311,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,16636,,"3,327.21 x patient days",16636,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,15222,,"3,044.51 x patient days",15222,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,29901,,"5,980.29 x patient days",29901,Per diem,,35229,,"7,045.87 x patient days",35229,Per diem,,23377,,"4,675.50 x patient days",23377,Per diem,,23377,,"4,675.50 x patient days",23377,Per diem,,13591,,"2,718.31 x patient days",13591,Per diem,,0.01,35229,
"Malfunction, reaction & complication of GI device or procedure",252-2,APR-DRG,,,,,,,,inpatient,,,111395.84,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,20224,,"4,044.85 x patient days",20224,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,21577,,"27,634 x DRG weight",21577,Other,base rate x DRG weight,18339,,"23,488 x DRG weight",18339,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,16636,,"3,327.21 x patient days",16636,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,15222,,"3,044.51 x patient days",15222,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,29901,,"5,980.29 x patient days",29901,Per diem,,35229,,"7,045.87 x patient days",35229,Per diem,,23377,,"4,675.50 x patient days",23377,Per diem,,23377,,"4,675.50 x patient days",23377,Per diem,,13591,,"2,718.31 x patient days",13591,Per diem,,0.01,35229,
"Malfunction, reaction & complication of GI device or procedure",252-3,APR-DRG,,,,,,,,inpatient,,,156639.95,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,20224,,"4,044.85 x patient days",20224,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,34321,,"27,634 x DRG weight",34321,Other,base rate x DRG weight,29172,,"23,488 x DRG weight",29172,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,16636,,"3,327.21 x patient days",16636,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,15222,,"3,044.51 x patient days",15222,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,29901,,"5,980.29 x patient days",29901,Per diem,,35229,,"7,045.87 x patient days",35229,Per diem,,23377,,"4,675.50 x patient days",23377,Per diem,,23377,,"4,675.50 x patient days",23377,Per diem,,13591,,"2,718.31 x patient days",13591,Per diem,,0.01,35229,
"Malfunction, reaction & complication of GI device or procedure",252-4,APR-DRG,,,,,,,,inpatient,,,817997.36,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,20224,,"4,044.85 x patient days",20224,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,78320,,"27,634 x DRG weight",78320,Other,base rate x DRG weight,66570,,"23,488 x DRG weight",66570,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,16636,,"3,327.21 x patient days",16636,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,15222,,"3,044.51 x patient days",15222,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,29901,,"5,980.29 x patient days",29901,Per diem,,35229,,"7,045.87 x patient days",35229,Per diem,,23377,,"4,675.50 x patient days",23377,Per diem,,23377,,"4,675.50 x patient days",23377,Per diem,,13591,,"2,718.31 x patient days",13591,Per diem,,0.01,78320,
Other & unspecified gastrointestinal hemorrhage,253-1,APR-DRG,,,,,,,,inpatient,,,93809.8,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,16180,,"4,044.85 x patient days",16180,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,16868,,"27,634 x DRG weight",16868,Other,base rate x DRG weight,14337,,"23,488 x DRG weight",14337,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,13309,,"3,327.21 x patient days",13309,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,12179,,"3,044.51 x patient days",12179,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,23922,,"5,980.29 x patient days",23922,Per diem,,28185,,"7,045.87 x patient days",28185,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,10874,,"2,718.31 x patient days",10874,Per diem,,0.01,28185,
Other & unspecified gastrointestinal hemorrhage,253-2,APR-DRG,,,,,,,,inpatient,,,101111.68,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,16180,,"4,044.85 x patient days",16180,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,22530,,"27,634 x DRG weight",22530,Other,base rate x DRG weight,19150,,"23,488 x DRG weight",19150,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,13309,,"3,327.21 x patient days",13309,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,12179,,"3,044.51 x patient days",12179,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,23922,,"5,980.29 x patient days",23922,Per diem,,28185,,"7,045.87 x patient days",28185,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,10874,,"2,718.31 x patient days",10874,Per diem,,0.01,28185,
Other & unspecified gastrointestinal hemorrhage,253-3,APR-DRG,,,,,,,,inpatient,,,231917.58,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,16180,,"4,044.85 x patient days",16180,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,36938,,"27,634 x DRG weight",36938,Other,base rate x DRG weight,31396,,"23,488 x DRG weight",31396,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,13309,,"3,327.21 x patient days",13309,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,12179,,"3,044.51 x patient days",12179,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,23922,,"5,980.29 x patient days",23922,Per diem,,28185,,"7,045.87 x patient days",28185,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,10874,,"2,718.31 x patient days",10874,Per diem,,0.01,36938,
Other & unspecified gastrointestinal hemorrhage,253-4,APR-DRG,,,,,,,,inpatient,,,242914.42,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,16180,,"4,044.85 x patient days",16180,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,65379,,"27,634 x DRG weight",65379,Other,base rate x DRG weight,55570,,"23,488 x DRG weight",55570,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,13309,,"3,327.21 x patient days",13309,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,12179,,"3,044.51 x patient days",12179,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,23922,,"5,980.29 x patient days",23922,Per diem,,28185,,"7,045.87 x patient days",28185,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,10874,,"2,718.31 x patient days",10874,Per diem,,0.01,65379,
Other digestive system diagnoses,254-1,APR-DRG,,,,,,,,inpatient,,,93265.41,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12135,,"4,044.85 x patient days",12135,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,13800,,"27,634 x DRG weight",13800,Other,base rate x DRG weight,11730,,"23,488 x DRG weight",11730,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9982,,"3,327.21 x patient days",9982,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9134,,"3,044.51 x patient days",9134,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,17941,,"5,980.29 x patient days",17941,Per diem,,21138,,"7,045.87 x patient days",21138,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,8155,,"2,718.31 x patient days",8155,Per diem,,0.01,21138,
Other digestive system diagnoses,254-2,APR-DRG,,,,,,,,inpatient,,,139161.81,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12135,,"4,044.85 x patient days",12135,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,19943,,"27,634 x DRG weight",19943,Other,base rate x DRG weight,16951,,"23,488 x DRG weight",16951,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9982,,"3,327.21 x patient days",9982,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9134,,"3,044.51 x patient days",9134,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,17941,,"5,980.29 x patient days",17941,Per diem,,21138,,"7,045.87 x patient days",21138,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,8155,,"2,718.31 x patient days",8155,Per diem,,0.01,21138,
Other digestive system diagnoses,254-3,APR-DRG,,,,,,,,inpatient,,,175379.31,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12135,,"4,044.85 x patient days",12135,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,33509,,"27,634 x DRG weight",33509,Other,base rate x DRG weight,28482,,"23,488 x DRG weight",28482,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9982,,"3,327.21 x patient days",9982,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9134,,"3,044.51 x patient days",9134,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,17941,,"5,980.29 x patient days",17941,Per diem,,21138,,"7,045.87 x patient days",21138,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,8155,,"2,718.31 x patient days",8155,Per diem,,0.01,33509,
Other digestive system diagnoses,254-4,APR-DRG,,,,,,,,inpatient,,,168762.38,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12135,,"4,044.85 x patient days",12135,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,72072,,"27,634 x DRG weight",72072,Other,base rate x DRG weight,61259,,"23,488 x DRG weight",61259,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9982,,"3,327.21 x patient days",9982,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9134,,"3,044.51 x patient days",9134,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,17941,,"5,980.29 x patient days",17941,Per diem,,21138,,"7,045.87 x patient days",21138,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,8155,,"2,718.31 x patient days",8155,Per diem,,0.01,72072,
"Major pancreas, liver & shunt procedures",260-1,APR-DRG,,,,,,,,inpatient,,,269874.03,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,36404,,"4,044.85 x patient days",36404,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,40340,,"27,634 x DRG weight",40340,Other,base rate x DRG weight,34288,,"23,488 x DRG weight",34288,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,19572,,"2,174.65 x patient days",19572,Per diem,,19572,,"2,174.65 x patient days",19572,Per diem,,19572,,"2,174.65 x patient days",19572,Per diem,,19572,,"2,174.65 x patient days",19572,Per diem,,44037,,"4,892.96 x patient days",44037,Per diem,,29945,,"3,327.21 x patient days",29945,Per diem,,44037,,"4,892.96 x patient days",44037,Per diem,,27401,,"3,044.51 x patient days",27401,Per diem,,44037,,"4,892.96 x patient days",44037,Per diem,,53823,,"5,980.29 x patient days",53823,Per diem,,63413,,"7,045.87 x patient days",63413,Per diem,,42080,,"4,675.50 x patient days",42080,Per diem,,42080,,"4,675.50 x patient days",42080,Per diem,,24465,,"2,718.31 x patient days",24465,Per diem,,0.01,63413,
"Major pancreas, liver & shunt procedures",260-2,APR-DRG,,,,,,,,inpatient,,,234321.88,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,36404,,"4,044.85 x patient days",36404,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,55055,,"27,634 x DRG weight",55055,Other,base rate x DRG weight,46795,,"23,488 x DRG weight",46795,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,19572,,"2,174.65 x patient days",19572,Per diem,,19572,,"2,174.65 x patient days",19572,Per diem,,19572,,"2,174.65 x patient days",19572,Per diem,,19572,,"2,174.65 x patient days",19572,Per diem,,44037,,"4,892.96 x patient days",44037,Per diem,,29945,,"3,327.21 x patient days",29945,Per diem,,44037,,"4,892.96 x patient days",44037,Per diem,,27401,,"3,044.51 x patient days",27401,Per diem,,44037,,"4,892.96 x patient days",44037,Per diem,,53823,,"5,980.29 x patient days",53823,Per diem,,63413,,"7,045.87 x patient days",63413,Per diem,,42080,,"4,675.50 x patient days",42080,Per diem,,42080,,"4,675.50 x patient days",42080,Per diem,,24465,,"2,718.31 x patient days",24465,Per diem,,0.01,63413,
"Major pancreas, liver & shunt procedures",260-3,APR-DRG,,,,,,,,inpatient,,,272459.86,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,36404,,"4,044.85 x patient days",36404,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,86914,,"27,634 x DRG weight",86914,Other,base rate x DRG weight,73874,,"23,488 x DRG weight",73874,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,19572,,"2,174.65 x patient days",19572,Per diem,,19572,,"2,174.65 x patient days",19572,Per diem,,19572,,"2,174.65 x patient days",19572,Per diem,,19572,,"2,174.65 x patient days",19572,Per diem,,44037,,"4,892.96 x patient days",44037,Per diem,,29945,,"3,327.21 x patient days",29945,Per diem,,44037,,"4,892.96 x patient days",44037,Per diem,,27401,,"3,044.51 x patient days",27401,Per diem,,44037,,"4,892.96 x patient days",44037,Per diem,,53823,,"5,980.29 x patient days",53823,Per diem,,63413,,"7,045.87 x patient days",63413,Per diem,,42080,,"4,675.50 x patient days",42080,Per diem,,42080,,"4,675.50 x patient days",42080,Per diem,,24465,,"2,718.31 x patient days",24465,Per diem,,0.01,86914,
"Major pancreas, liver & shunt procedures",260-4,APR-DRG,,,,,,,,inpatient,,,791173,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,36404,,"4,044.85 x patient days",36404,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,205224,,"27,634 x DRG weight",205224,Other,base rate x DRG weight,174434,,"23,488 x DRG weight",174434,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,19572,,"2,174.65 x patient days",19572,Per diem,,19572,,"2,174.65 x patient days",19572,Per diem,,19572,,"2,174.65 x patient days",19572,Per diem,,19572,,"2,174.65 x patient days",19572,Per diem,,44037,,"4,892.96 x patient days",44037,Per diem,,29945,,"3,327.21 x patient days",29945,Per diem,,44037,,"4,892.96 x patient days",44037,Per diem,,27401,,"3,044.51 x patient days",27401,Per diem,,44037,,"4,892.96 x patient days",44037,Per diem,,53823,,"5,980.29 x patient days",53823,Per diem,,63413,,"7,045.87 x patient days",63413,Per diem,,42080,,"4,675.50 x patient days",42080,Per diem,,42080,,"4,675.50 x patient days",42080,Per diem,,24465,,"2,718.31 x patient days",24465,Per diem,,0.01,205224,
Major biliary tract procedures,261-1,APR-DRG,,,,,,,,inpatient,,,102145.51,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,36404,,"4,044.85 x patient days",36404,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,38641,,"27,634 x DRG weight",38641,Other,base rate x DRG weight,32843,,"23,488 x DRG weight",32843,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,19572,,"2,174.65 x patient days",19572,Per diem,,19572,,"2,174.65 x patient days",19572,Per diem,,19572,,"2,174.65 x patient days",19572,Per diem,,19572,,"2,174.65 x patient days",19572,Per diem,,44037,,"4,892.96 x patient days",44037,Per diem,,29945,,"3,327.21 x patient days",29945,Per diem,,44037,,"4,892.96 x patient days",44037,Per diem,,27401,,"3,044.51 x patient days",27401,Per diem,,44037,,"4,892.96 x patient days",44037,Per diem,,53823,,"5,980.29 x patient days",53823,Per diem,,63413,,"7,045.87 x patient days",63413,Per diem,,42080,,"4,675.50 x patient days",42080,Per diem,,42080,,"4,675.50 x patient days",42080,Per diem,,24465,,"2,718.31 x patient days",24465,Per diem,,0.01,63413,
Major biliary tract procedures,261-2,APR-DRG,,,,,,,,inpatient,,,184103.12,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,36404,,"4,044.85 x patient days",36404,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,55323,,"27,634 x DRG weight",55323,Other,base rate x DRG weight,47023,,"23,488 x DRG weight",47023,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,19572,,"2,174.65 x patient days",19572,Per diem,,19572,,"2,174.65 x patient days",19572,Per diem,,19572,,"2,174.65 x patient days",19572,Per diem,,19572,,"2,174.65 x patient days",19572,Per diem,,44037,,"4,892.96 x patient days",44037,Per diem,,29945,,"3,327.21 x patient days",29945,Per diem,,44037,,"4,892.96 x patient days",44037,Per diem,,27401,,"3,044.51 x patient days",27401,Per diem,,44037,,"4,892.96 x patient days",44037,Per diem,,53823,,"5,980.29 x patient days",53823,Per diem,,63413,,"7,045.87 x patient days",63413,Per diem,,42080,,"4,675.50 x patient days",42080,Per diem,,42080,,"4,675.50 x patient days",42080,Per diem,,24465,,"2,718.31 x patient days",24465,Per diem,,0.01,63413,
Major biliary tract procedures,261-3,APR-DRG,,,,,,,,inpatient,,,300116.27,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,36404,,"4,044.85 x patient days",36404,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,85342,,"27,634 x DRG weight",85342,Other,base rate x DRG weight,72538,,"23,488 x DRG weight",72538,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,19572,,"2,174.65 x patient days",19572,Per diem,,19572,,"2,174.65 x patient days",19572,Per diem,,19572,,"2,174.65 x patient days",19572,Per diem,,19572,,"2,174.65 x patient days",19572,Per diem,,44037,,"4,892.96 x patient days",44037,Per diem,,29945,,"3,327.21 x patient days",29945,Per diem,,44037,,"4,892.96 x patient days",44037,Per diem,,27401,,"3,044.51 x patient days",27401,Per diem,,44037,,"4,892.96 x patient days",44037,Per diem,,53823,,"5,980.29 x patient days",53823,Per diem,,63413,,"7,045.87 x patient days",63413,Per diem,,42080,,"4,675.50 x patient days",42080,Per diem,,42080,,"4,675.50 x patient days",42080,Per diem,,24465,,"2,718.31 x patient days",24465,Per diem,,0.01,85342,
Major biliary tract procedures,261-4,APR-DRG,,,,,,,,inpatient,,,832933.17,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,36404,,"4,044.85 x patient days",36404,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,169689,,"27,634 x DRG weight",169689,Other,base rate x DRG weight,144230,,"23,488 x DRG weight",144230,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,19572,,"2,174.65 x patient days",19572,Per diem,,19572,,"2,174.65 x patient days",19572,Per diem,,19572,,"2,174.65 x patient days",19572,Per diem,,19572,,"2,174.65 x patient days",19572,Per diem,,44037,,"4,892.96 x patient days",44037,Per diem,,29945,,"3,327.21 x patient days",29945,Per diem,,44037,,"4,892.96 x patient days",44037,Per diem,,27401,,"3,044.51 x patient days",27401,Per diem,,44037,,"4,892.96 x patient days",44037,Per diem,,53823,,"5,980.29 x patient days",53823,Per diem,,63413,,"7,045.87 x patient days",63413,Per diem,,42080,,"4,675.50 x patient days",42080,Per diem,,42080,,"4,675.50 x patient days",42080,Per diem,,24465,,"2,718.31 x patient days",24465,Per diem,,0.01,169689,
Cholecystectomy except laparoscopic,262-1,APR-DRG,,,,,,,,inpatient,,,133070.01,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,24269,,"4,044.85 x patient days",24269,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,36303,,"27,634 x DRG weight",36303,Other,base rate x DRG weight,30856,,"23,488 x DRG weight",30856,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,13048,,"2,174.65 x patient days",13048,Per diem,,13048,,"2,174.65 x patient days",13048,Per diem,,13048,,"2,174.65 x patient days",13048,Per diem,,13048,,"2,174.65 x patient days",13048,Per diem,,29358,,"4,892.96 x patient days",29358,Per diem,,19963,,"3,327.21 x patient days",19963,Per diem,,29358,,"4,892.96 x patient days",29358,Per diem,,18267,,"3,044.51 x patient days",18267,Per diem,,29358,,"4,892.96 x patient days",29358,Per diem,,35882,,"5,980.29 x patient days",35882,Per diem,,42276,,"7,045.87 x patient days",42276,Per diem,,28053,,"4,675.50 x patient days",28053,Per diem,,28053,,"4,675.50 x patient days",28053,Per diem,,16310,,"2,718.31 x patient days",16310,Per diem,,0.01,42276,
Cholecystectomy except laparoscopic,262-2,APR-DRG,,,,,,,,inpatient,,,177590.92,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,24269,,"4,044.85 x patient days",24269,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,44366,,"27,634 x DRG weight",44366,Other,base rate x DRG weight,37710,,"23,488 x DRG weight",37710,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,13048,,"2,174.65 x patient days",13048,Per diem,,13048,,"2,174.65 x patient days",13048,Per diem,,13048,,"2,174.65 x patient days",13048,Per diem,,13048,,"2,174.65 x patient days",13048,Per diem,,29358,,"4,892.96 x patient days",29358,Per diem,,19963,,"3,327.21 x patient days",19963,Per diem,,29358,,"4,892.96 x patient days",29358,Per diem,,18267,,"3,044.51 x patient days",18267,Per diem,,29358,,"4,892.96 x patient days",29358,Per diem,,35882,,"5,980.29 x patient days",35882,Per diem,,42276,,"7,045.87 x patient days",42276,Per diem,,28053,,"4,675.50 x patient days",28053,Per diem,,28053,,"4,675.50 x patient days",28053,Per diem,,16310,,"2,718.31 x patient days",16310,Per diem,,0.01,44366,
Cholecystectomy except laparoscopic,262-3,APR-DRG,,,,,,,,inpatient,,,334695.61,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,24269,,"4,044.85 x patient days",24269,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,75634,,"27,634 x DRG weight",75634,Other,base rate x DRG weight,64287,,"23,488 x DRG weight",64287,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,13048,,"2,174.65 x patient days",13048,Per diem,,13048,,"2,174.65 x patient days",13048,Per diem,,13048,,"2,174.65 x patient days",13048,Per diem,,13048,,"2,174.65 x patient days",13048,Per diem,,29358,,"4,892.96 x patient days",29358,Per diem,,19963,,"3,327.21 x patient days",19963,Per diem,,29358,,"4,892.96 x patient days",29358,Per diem,,18267,,"3,044.51 x patient days",18267,Per diem,,29358,,"4,892.96 x patient days",29358,Per diem,,35882,,"5,980.29 x patient days",35882,Per diem,,42276,,"7,045.87 x patient days",42276,Per diem,,28053,,"4,675.50 x patient days",28053,Per diem,,28053,,"4,675.50 x patient days",28053,Per diem,,16310,,"2,718.31 x patient days",16310,Per diem,,0.01,75634,
Cholecystectomy except laparoscopic,262-4,APR-DRG,,,,,,,,inpatient,,,334695.61,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,24269,,"4,044.85 x patient days",24269,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,167285,,"27,634 x DRG weight",167285,Other,base rate x DRG weight,142187,,"23,488 x DRG weight",142187,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,13048,,"2,174.65 x patient days",13048,Per diem,,13048,,"2,174.65 x patient days",13048,Per diem,,13048,,"2,174.65 x patient days",13048,Per diem,,13048,,"2,174.65 x patient days",13048,Per diem,,29358,,"4,892.96 x patient days",29358,Per diem,,19963,,"3,327.21 x patient days",19963,Per diem,,29358,,"4,892.96 x patient days",29358,Per diem,,18267,,"3,044.51 x patient days",18267,Per diem,,29358,,"4,892.96 x patient days",29358,Per diem,,35882,,"5,980.29 x patient days",35882,Per diem,,42276,,"7,045.87 x patient days",42276,Per diem,,28053,,"4,675.50 x patient days",28053,Per diem,,28053,,"4,675.50 x patient days",28053,Per diem,,16310,,"2,718.31 x patient days",16310,Per diem,,0.01,167285,
Laparoscopic cholecystectomy,263-1,APR-DRG,,,,,,,,inpatient,,,125328.27,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12135,,"4,044.85 x patient days",12135,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,24445,,"27,634 x DRG weight",24445,Other,base rate x DRG weight,20777,,"23,488 x DRG weight",20777,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9982,,"3,327.21 x patient days",9982,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9134,,"3,044.51 x patient days",9134,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,17941,,"5,980.29 x patient days",17941,Per diem,,21138,,"7,045.87 x patient days",21138,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,8155,,"2,718.31 x patient days",8155,Per diem,,0.01,24445,
Laparoscopic cholecystectomy,263-2,APR-DRG,,,,,,,,inpatient,,,151224.13,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12135,,"4,044.85 x patient days",12135,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,32379,,"27,634 x DRG weight",32379,Other,base rate x DRG weight,27521,,"23,488 x DRG weight",27521,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9982,,"3,327.21 x patient days",9982,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9134,,"3,044.51 x patient days",9134,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,17941,,"5,980.29 x patient days",17941,Per diem,,21138,,"7,045.87 x patient days",21138,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,8155,,"2,718.31 x patient days",8155,Per diem,,0.01,32379,
Laparoscopic cholecystectomy,263-3,APR-DRG,,,,,,,,inpatient,,,183923.21,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12135,,"4,044.85 x patient days",12135,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,44640,,"27,634 x DRG weight",44640,Other,base rate x DRG weight,37943,,"23,488 x DRG weight",37943,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9982,,"3,327.21 x patient days",9982,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9134,,"3,044.51 x patient days",9134,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,17941,,"5,980.29 x patient days",17941,Per diem,,21138,,"7,045.87 x patient days",21138,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,8155,,"2,718.31 x patient days",8155,Per diem,,0.01,44640,
Laparoscopic cholecystectomy,263-4,APR-DRG,,,,,,,,inpatient,,,386814.04,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12135,,"4,044.85 x patient days",12135,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,101408,,"27,634 x DRG weight",101408,Other,base rate x DRG weight,86194,,"23,488 x DRG weight",86194,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9982,,"3,327.21 x patient days",9982,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9134,,"3,044.51 x patient days",9134,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,17941,,"5,980.29 x patient days",17941,Per diem,,21138,,"7,045.87 x patient days",21138,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,8155,,"2,718.31 x patient days",8155,Per diem,,0.01,101408,
"Other hepatobiliary, pancreas & abdominal procedures",264-1,APR-DRG,,,,,,,,inpatient,,,116577.44,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,40449,,"4,044.85 x patient days",40449,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,36861,,"27,634 x DRG weight",36861,Other,base rate x DRG weight,31331,,"23,488 x DRG weight",31331,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,21747,,"2,174.65 x patient days",21747,Per diem,,21747,,"2,174.65 x patient days",21747,Per diem,,21747,,"2,174.65 x patient days",21747,Per diem,,21747,,"2,174.65 x patient days",21747,Per diem,,48931,,"4,892.96 x patient days",48931,Per diem,,33273,,"3,327.21 x patient days",33273,Per diem,,48931,,"4,892.96 x patient days",48931,Per diem,,30446,,"3,044.51 x patient days",30446,Per diem,,48931,,"4,892.96 x patient days",48931,Per diem,,59804,,"5,980.29 x patient days",59804,Per diem,,70460,,"7,045.87 x patient days",70460,Per diem,,46756,,"4,675.50 x patient days",46756,Per diem,,46756,,"4,675.50 x patient days",46756,Per diem,,27184,,"2,718.31 x patient days",27184,Per diem,,0.01,70460,
"Other hepatobiliary, pancreas & abdominal procedures",264-2,APR-DRG,,,,,,,,inpatient,,,248042.73,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,40449,,"4,044.85 x patient days",40449,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,41785,,"27,634 x DRG weight",41785,Other,base rate x DRG weight,35516,,"23,488 x DRG weight",35516,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,21747,,"2,174.65 x patient days",21747,Per diem,,21747,,"2,174.65 x patient days",21747,Per diem,,21747,,"2,174.65 x patient days",21747,Per diem,,21747,,"2,174.65 x patient days",21747,Per diem,,48931,,"4,892.96 x patient days",48931,Per diem,,33273,,"3,327.21 x patient days",33273,Per diem,,48931,,"4,892.96 x patient days",48931,Per diem,,30446,,"3,044.51 x patient days",30446,Per diem,,48931,,"4,892.96 x patient days",48931,Per diem,,59804,,"5,980.29 x patient days",59804,Per diem,,70460,,"7,045.87 x patient days",70460,Per diem,,46756,,"4,675.50 x patient days",46756,Per diem,,46756,,"4,675.50 x patient days",46756,Per diem,,27184,,"2,718.31 x patient days",27184,Per diem,,0.01,70460,
"Other hepatobiliary, pancreas & abdominal procedures",264-3,APR-DRG,,,,,,,,inpatient,,,193423.85,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,40449,,"4,044.85 x patient days",40449,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,78937,,"27,634 x DRG weight",78937,Other,base rate x DRG weight,67093,,"23,488 x DRG weight",67093,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,21747,,"2,174.65 x patient days",21747,Per diem,,21747,,"2,174.65 x patient days",21747,Per diem,,21747,,"2,174.65 x patient days",21747,Per diem,,21747,,"2,174.65 x patient days",21747,Per diem,,48931,,"4,892.96 x patient days",48931,Per diem,,33273,,"3,327.21 x patient days",33273,Per diem,,48931,,"4,892.96 x patient days",48931,Per diem,,30446,,"3,044.51 x patient days",30446,Per diem,,48931,,"4,892.96 x patient days",48931,Per diem,,59804,,"5,980.29 x patient days",59804,Per diem,,70460,,"7,045.87 x patient days",70460,Per diem,,46756,,"4,675.50 x patient days",46756,Per diem,,46756,,"4,675.50 x patient days",46756,Per diem,,27184,,"2,718.31 x patient days",27184,Per diem,,0.01,78937,
"Other hepatobiliary, pancreas & abdominal procedures",264-4,APR-DRG,,,,,,,,inpatient,,,753257.14,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,40449,,"4,044.85 x patient days",40449,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,170076,,"27,634 x DRG weight",170076,Other,base rate x DRG weight,144559,,"23,488 x DRG weight",144559,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,21747,,"2,174.65 x patient days",21747,Per diem,,21747,,"2,174.65 x patient days",21747,Per diem,,21747,,"2,174.65 x patient days",21747,Per diem,,21747,,"2,174.65 x patient days",21747,Per diem,,48931,,"4,892.96 x patient days",48931,Per diem,,33273,,"3,327.21 x patient days",33273,Per diem,,48931,,"4,892.96 x patient days",48931,Per diem,,30446,,"3,044.51 x patient days",30446,Per diem,,48931,,"4,892.96 x patient days",48931,Per diem,,59804,,"5,980.29 x patient days",59804,Per diem,,70460,,"7,045.87 x patient days",70460,Per diem,,46756,,"4,675.50 x patient days",46756,Per diem,,46756,,"4,675.50 x patient days",46756,Per diem,,27184,,"2,718.31 x patient days",27184,Per diem,,0.01,170076,
Hepatic coma & other major acute liver disorders,279-1,APR-DRG,,,,,,,,inpatient,,,104262,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,28315,,"4,044.85 x patient days",28315,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,15188,,"27,634 x DRG weight",15188,Other,base rate x DRG weight,12909,,"23,488 x DRG weight",12909,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,15223,,"2,174.65 x patient days",15223,Per diem,,15223,,"2,174.65 x patient days",15223,Per diem,,15223,,"2,174.65 x patient days",15223,Per diem,,15223,,"2,174.65 x patient days",15223,Per diem,,34252,,"4,892.96 x patient days",34252,Per diem,,23291,,"3,327.21 x patient days",23291,Per diem,,34252,,"4,892.96 x patient days",34252,Per diem,,21312,,"3,044.51 x patient days",21312,Per diem,,34252,,"4,892.96 x patient days",34252,Per diem,,41863,,"5,980.29 x patient days",41863,Per diem,,49323,,"7,045.87 x patient days",49323,Per diem,,32729,,"4,675.50 x patient days",32729,Per diem,,32729,,"4,675.50 x patient days",32729,Per diem,,19029,,"2,718.31 x patient days",19029,Per diem,,0.01,49323,
Hepatic coma & other major acute liver disorders,279-2,APR-DRG,,,,,,,,inpatient,,,136931.56,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,28315,,"4,044.85 x patient days",28315,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,21618,,"27,634 x DRG weight",21618,Other,base rate x DRG weight,18375,,"23,488 x DRG weight",18375,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,15223,,"2,174.65 x patient days",15223,Per diem,,15223,,"2,174.65 x patient days",15223,Per diem,,15223,,"2,174.65 x patient days",15223,Per diem,,15223,,"2,174.65 x patient days",15223,Per diem,,34252,,"4,892.96 x patient days",34252,Per diem,,23291,,"3,327.21 x patient days",23291,Per diem,,34252,,"4,892.96 x patient days",34252,Per diem,,21312,,"3,044.51 x patient days",21312,Per diem,,34252,,"4,892.96 x patient days",34252,Per diem,,41863,,"5,980.29 x patient days",41863,Per diem,,49323,,"7,045.87 x patient days",49323,Per diem,,32729,,"4,675.50 x patient days",32729,Per diem,,32729,,"4,675.50 x patient days",32729,Per diem,,19029,,"2,718.31 x patient days",19029,Per diem,,0.01,49323,
Hepatic coma & other major acute liver disorders,279-3,APR-DRG,,,,,,,,inpatient,,,281532.38,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,28315,,"4,044.85 x patient days",28315,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,37519,,"27,634 x DRG weight",37519,Other,base rate x DRG weight,31890,,"23,488 x DRG weight",31890,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,15223,,"2,174.65 x patient days",15223,Per diem,,15223,,"2,174.65 x patient days",15223,Per diem,,15223,,"2,174.65 x patient days",15223,Per diem,,15223,,"2,174.65 x patient days",15223,Per diem,,34252,,"4,892.96 x patient days",34252,Per diem,,23291,,"3,327.21 x patient days",23291,Per diem,,34252,,"4,892.96 x patient days",34252,Per diem,,21312,,"3,044.51 x patient days",21312,Per diem,,34252,,"4,892.96 x patient days",34252,Per diem,,41863,,"5,980.29 x patient days",41863,Per diem,,49323,,"7,045.87 x patient days",49323,Per diem,,32729,,"4,675.50 x patient days",32729,Per diem,,32729,,"4,675.50 x patient days",32729,Per diem,,19029,,"2,718.31 x patient days",19029,Per diem,,0.01,49323,
Hepatic coma & other major acute liver disorders,279-4,APR-DRG,,,,,,,,inpatient,,,269612.32,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,28315,,"4,044.85 x patient days",28315,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,102384,,"27,634 x DRG weight",102384,Other,base rate x DRG weight,87023,,"23,488 x DRG weight",87023,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,15223,,"2,174.65 x patient days",15223,Per diem,,15223,,"2,174.65 x patient days",15223,Per diem,,15223,,"2,174.65 x patient days",15223,Per diem,,15223,,"2,174.65 x patient days",15223,Per diem,,34252,,"4,892.96 x patient days",34252,Per diem,,23291,,"3,327.21 x patient days",23291,Per diem,,34252,,"4,892.96 x patient days",34252,Per diem,,21312,,"3,044.51 x patient days",21312,Per diem,,34252,,"4,892.96 x patient days",34252,Per diem,,41863,,"5,980.29 x patient days",41863,Per diem,,49323,,"7,045.87 x patient days",49323,Per diem,,32729,,"4,675.50 x patient days",32729,Per diem,,32729,,"4,675.50 x patient days",32729,Per diem,,19029,,"2,718.31 x patient days",19029,Per diem,,0.01,102384,
Alcoholic liver disease,280-1,APR-DRG,,,,,,,,inpatient,,,112061.4,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,24269,,"4,044.85 x patient days",24269,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,14809,,"27,634 x DRG weight",14809,Other,base rate x DRG weight,12587,,"23,488 x DRG weight",12587,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,13048,,"2,174.65 x patient days",13048,Per diem,,13048,,"2,174.65 x patient days",13048,Per diem,,13048,,"2,174.65 x patient days",13048,Per diem,,13048,,"2,174.65 x patient days",13048,Per diem,,29358,,"4,892.96 x patient days",29358,Per diem,,19963,,"3,327.21 x patient days",19963,Per diem,,29358,,"4,892.96 x patient days",29358,Per diem,,18267,,"3,044.51 x patient days",18267,Per diem,,29358,,"4,892.96 x patient days",29358,Per diem,,35882,,"5,980.29 x patient days",35882,Per diem,,42276,,"7,045.87 x patient days",42276,Per diem,,28053,,"4,675.50 x patient days",28053,Per diem,,28053,,"4,675.50 x patient days",28053,Per diem,,16310,,"2,718.31 x patient days",16310,Per diem,,0.01,42276,
Alcoholic liver disease,280-2,APR-DRG,,,,,,,,inpatient,,,131466.98,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,24269,,"4,044.85 x patient days",24269,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,20808,,"27,634 x DRG weight",20808,Other,base rate x DRG weight,17686,,"23,488 x DRG weight",17686,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,13048,,"2,174.65 x patient days",13048,Per diem,,13048,,"2,174.65 x patient days",13048,Per diem,,13048,,"2,174.65 x patient days",13048,Per diem,,13048,,"2,174.65 x patient days",13048,Per diem,,29358,,"4,892.96 x patient days",29358,Per diem,,19963,,"3,327.21 x patient days",19963,Per diem,,29358,,"4,892.96 x patient days",29358,Per diem,,18267,,"3,044.51 x patient days",18267,Per diem,,29358,,"4,892.96 x patient days",29358,Per diem,,35882,,"5,980.29 x patient days",35882,Per diem,,42276,,"7,045.87 x patient days",42276,Per diem,,28053,,"4,675.50 x patient days",28053,Per diem,,28053,,"4,675.50 x patient days",28053,Per diem,,16310,,"2,718.31 x patient days",16310,Per diem,,0.01,42276,
Alcoholic liver disease,280-3,APR-DRG,,,,,,,,inpatient,,,176449.92,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,24269,,"4,044.85 x patient days",24269,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,35018,,"27,634 x DRG weight",35018,Other,base rate x DRG weight,29764,,"23,488 x DRG weight",29764,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,13048,,"2,174.65 x patient days",13048,Per diem,,13048,,"2,174.65 x patient days",13048,Per diem,,13048,,"2,174.65 x patient days",13048,Per diem,,13048,,"2,174.65 x patient days",13048,Per diem,,29358,,"4,892.96 x patient days",29358,Per diem,,19963,,"3,327.21 x patient days",19963,Per diem,,29358,,"4,892.96 x patient days",29358,Per diem,,18267,,"3,044.51 x patient days",18267,Per diem,,29358,,"4,892.96 x patient days",29358,Per diem,,35882,,"5,980.29 x patient days",35882,Per diem,,42276,,"7,045.87 x patient days",42276,Per diem,,28053,,"4,675.50 x patient days",28053,Per diem,,28053,,"4,675.50 x patient days",28053,Per diem,,16310,,"2,718.31 x patient days",16310,Per diem,,0.01,42276,
Alcoholic liver disease,280-4,APR-DRG,,,,,,,,inpatient,,,394717.61,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,24269,,"4,044.85 x patient days",24269,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,94295,,"27,634 x DRG weight",94295,Other,base rate x DRG weight,80148,,"23,488 x DRG weight",80148,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,13048,,"2,174.65 x patient days",13048,Per diem,,13048,,"2,174.65 x patient days",13048,Per diem,,13048,,"2,174.65 x patient days",13048,Per diem,,13048,,"2,174.65 x patient days",13048,Per diem,,29358,,"4,892.96 x patient days",29358,Per diem,,19963,,"3,327.21 x patient days",19963,Per diem,,29358,,"4,892.96 x patient days",29358,Per diem,,18267,,"3,044.51 x patient days",18267,Per diem,,29358,,"4,892.96 x patient days",29358,Per diem,,35882,,"5,980.29 x patient days",35882,Per diem,,42276,,"7,045.87 x patient days",42276,Per diem,,28053,,"4,675.50 x patient days",28053,Per diem,,28053,,"4,675.50 x patient days",28053,Per diem,,16310,,"2,718.31 x patient days",16310,Per diem,,0.01,94295,
Malignancy of hepatobiliary system & pancreas,281-1,APR-DRG,,,,,,,,inpatient,,,140808.99,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,28315,,"4,044.85 x patient days",28315,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,18435,,"27,634 x DRG weight",18435,Other,base rate x DRG weight,15669,,"23,488 x DRG weight",15669,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,15223,,"2,174.65 x patient days",15223,Per diem,,15223,,"2,174.65 x patient days",15223,Per diem,,15223,,"2,174.65 x patient days",15223,Per diem,,15223,,"2,174.65 x patient days",15223,Per diem,,34252,,"4,892.96 x patient days",34252,Per diem,,23291,,"3,327.21 x patient days",23291,Per diem,,34252,,"4,892.96 x patient days",34252,Per diem,,21312,,"3,044.51 x patient days",21312,Per diem,,34252,,"4,892.96 x patient days",34252,Per diem,,41863,,"5,980.29 x patient days",41863,Per diem,,49323,,"7,045.87 x patient days",49323,Per diem,,32729,,"4,675.50 x patient days",32729,Per diem,,32729,,"4,675.50 x patient days",32729,Per diem,,19029,,"2,718.31 x patient days",19029,Per diem,,0.01,49323,
Malignancy of hepatobiliary system & pancreas,281-2,APR-DRG,,,,,,,,inpatient,,,140808.99,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,28315,,"4,044.85 x patient days",28315,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,25981,,"27,634 x DRG weight",25981,Other,base rate x DRG weight,22083,,"23,488 x DRG weight",22083,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,15223,,"2,174.65 x patient days",15223,Per diem,,15223,,"2,174.65 x patient days",15223,Per diem,,15223,,"2,174.65 x patient days",15223,Per diem,,15223,,"2,174.65 x patient days",15223,Per diem,,34252,,"4,892.96 x patient days",34252,Per diem,,23291,,"3,327.21 x patient days",23291,Per diem,,34252,,"4,892.96 x patient days",34252,Per diem,,21312,,"3,044.51 x patient days",21312,Per diem,,34252,,"4,892.96 x patient days",34252,Per diem,,41863,,"5,980.29 x patient days",41863,Per diem,,49323,,"7,045.87 x patient days",49323,Per diem,,32729,,"4,675.50 x patient days",32729,Per diem,,32729,,"4,675.50 x patient days",32729,Per diem,,19029,,"2,718.31 x patient days",19029,Per diem,,0.01,49323,
Malignancy of hepatobiliary system & pancreas,281-3,APR-DRG,,,,,,,,inpatient,,,144959.85,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,28315,,"4,044.85 x patient days",28315,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,38082,,"27,634 x DRG weight",38082,Other,base rate x DRG weight,32369,,"23,488 x DRG weight",32369,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,15223,,"2,174.65 x patient days",15223,Per diem,,15223,,"2,174.65 x patient days",15223,Per diem,,15223,,"2,174.65 x patient days",15223,Per diem,,15223,,"2,174.65 x patient days",15223,Per diem,,34252,,"4,892.96 x patient days",34252,Per diem,,23291,,"3,327.21 x patient days",23291,Per diem,,34252,,"4,892.96 x patient days",34252,Per diem,,21312,,"3,044.51 x patient days",21312,Per diem,,34252,,"4,892.96 x patient days",34252,Per diem,,41863,,"5,980.29 x patient days",41863,Per diem,,49323,,"7,045.87 x patient days",49323,Per diem,,32729,,"4,675.50 x patient days",32729,Per diem,,32729,,"4,675.50 x patient days",32729,Per diem,,19029,,"2,718.31 x patient days",19029,Per diem,,0.01,49323,
Malignancy of hepatobiliary system & pancreas,281-4,APR-DRG,,,,,,,,inpatient,,,394655.48,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,28315,,"4,044.85 x patient days",28315,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,66833,,"27,634 x DRG weight",66833,Other,base rate x DRG weight,56806,,"23,488 x DRG weight",56806,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,15223,,"2,174.65 x patient days",15223,Per diem,,15223,,"2,174.65 x patient days",15223,Per diem,,15223,,"2,174.65 x patient days",15223,Per diem,,15223,,"2,174.65 x patient days",15223,Per diem,,34252,,"4,892.96 x patient days",34252,Per diem,,23291,,"3,327.21 x patient days",23291,Per diem,,34252,,"4,892.96 x patient days",34252,Per diem,,21312,,"3,044.51 x patient days",21312,Per diem,,34252,,"4,892.96 x patient days",34252,Per diem,,41863,,"5,980.29 x patient days",41863,Per diem,,49323,,"7,045.87 x patient days",49323,Per diem,,32729,,"4,675.50 x patient days",32729,Per diem,,32729,,"4,675.50 x patient days",32729,Per diem,,19029,,"2,718.31 x patient days",19029,Per diem,,0.01,66833,
Disorders of pancreas except malignancy,282-1,APR-DRG,,,,,,,,inpatient,,,72804.21,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,16180,,"4,044.85 x patient days",16180,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,15254,,"27,634 x DRG weight",15254,Other,base rate x DRG weight,12965,,"23,488 x DRG weight",12965,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,13309,,"3,327.21 x patient days",13309,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,12179,,"3,044.51 x patient days",12179,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,23922,,"5,980.29 x patient days",23922,Per diem,,28185,,"7,045.87 x patient days",28185,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,10874,,"2,718.31 x patient days",10874,Per diem,,0.01,28185,
Disorders of pancreas except malignancy,282-2,APR-DRG,,,,,,,,inpatient,,,106860.64,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,16180,,"4,044.85 x patient days",16180,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,20640,,"27,634 x DRG weight",20640,Other,base rate x DRG weight,17543,,"23,488 x DRG weight",17543,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,13309,,"3,327.21 x patient days",13309,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,12179,,"3,044.51 x patient days",12179,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,23922,,"5,980.29 x patient days",23922,Per diem,,28185,,"7,045.87 x patient days",28185,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,10874,,"2,718.31 x patient days",10874,Per diem,,0.01,28185,
Disorders of pancreas except malignancy,282-3,APR-DRG,,,,,,,,inpatient,,,161341.38,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,16180,,"4,044.85 x patient days",16180,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,37635,,"27,634 x DRG weight",37635,Other,base rate x DRG weight,31988,,"23,488 x DRG weight",31988,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,13309,,"3,327.21 x patient days",13309,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,12179,,"3,044.51 x patient days",12179,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,23922,,"5,980.29 x patient days",23922,Per diem,,28185,,"7,045.87 x patient days",28185,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,10874,,"2,718.31 x patient days",10874,Per diem,,0.01,37635,
Disorders of pancreas except malignancy,282-4,APR-DRG,,,,,,,,inpatient,,,386058.29,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,16180,,"4,044.85 x patient days",16180,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,95525,,"27,634 x DRG weight",95525,Other,base rate x DRG weight,81193,,"23,488 x DRG weight",81193,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,13309,,"3,327.21 x patient days",13309,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,12179,,"3,044.51 x patient days",12179,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,23922,,"5,980.29 x patient days",23922,Per diem,,28185,,"7,045.87 x patient days",28185,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,10874,,"2,718.31 x patient days",10874,Per diem,,0.01,95525,
Other disorders of the liver,283-1,APR-DRG,,,,,,,,inpatient,,,52012.6,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,20224,,"4,044.85 x patient days",20224,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,15575,,"27,634 x DRG weight",15575,Other,base rate x DRG weight,13238,,"23,488 x DRG weight",13238,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,16636,,"3,327.21 x patient days",16636,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,15222,,"3,044.51 x patient days",15222,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,29901,,"5,980.29 x patient days",29901,Per diem,,35229,,"7,045.87 x patient days",35229,Per diem,,23377,,"4,675.50 x patient days",23377,Per diem,,23377,,"4,675.50 x patient days",23377,Per diem,,13591,,"2,718.31 x patient days",13591,Per diem,,0.01,35229,
Other disorders of the liver,283-2,APR-DRG,,,,,,,,inpatient,,,147359.35,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,20224,,"4,044.85 x patient days",20224,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,20651,,"27,634 x DRG weight",20651,Other,base rate x DRG weight,17553,,"23,488 x DRG weight",17553,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,16636,,"3,327.21 x patient days",16636,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,15222,,"3,044.51 x patient days",15222,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,29901,,"5,980.29 x patient days",29901,Per diem,,35229,,"7,045.87 x patient days",35229,Per diem,,23377,,"4,675.50 x patient days",23377,Per diem,,23377,,"4,675.50 x patient days",23377,Per diem,,13591,,"2,718.31 x patient days",13591,Per diem,,0.01,35229,
Other disorders of the liver,283-3,APR-DRG,,,,,,,,inpatient,,,170913.92,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,20224,,"4,044.85 x patient days",20224,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,33285,,"27,634 x DRG weight",33285,Other,base rate x DRG weight,28291,,"23,488 x DRG weight",28291,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,16636,,"3,327.21 x patient days",16636,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,15222,,"3,044.51 x patient days",15222,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,29901,,"5,980.29 x patient days",29901,Per diem,,35229,,"7,045.87 x patient days",35229,Per diem,,23377,,"4,675.50 x patient days",23377,Per diem,,23377,,"4,675.50 x patient days",23377,Per diem,,13591,,"2,718.31 x patient days",13591,Per diem,,0.01,35229,
Other disorders of the liver,283-4,APR-DRG,,,,,,,,inpatient,,,287184.28,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,20224,,"4,044.85 x patient days",20224,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,71564,,"27,634 x DRG weight",71564,Other,base rate x DRG weight,60827,,"23,488 x DRG weight",60827,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,16636,,"3,327.21 x patient days",16636,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,15222,,"3,044.51 x patient days",15222,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,29901,,"5,980.29 x patient days",29901,Per diem,,35229,,"7,045.87 x patient days",35229,Per diem,,23377,,"4,675.50 x patient days",23377,Per diem,,23377,,"4,675.50 x patient days",23377,Per diem,,13591,,"2,718.31 x patient days",13591,Per diem,,0.01,71564,
Disorders of gallbladder & biliary tract,284-1,APR-DRG,,,,,,,,inpatient,,,104250.23,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,16180,,"4,044.85 x patient days",16180,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,15961,,"27,634 x DRG weight",15961,Other,base rate x DRG weight,13567,,"23,488 x DRG weight",13567,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,13309,,"3,327.21 x patient days",13309,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,12179,,"3,044.51 x patient days",12179,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,23922,,"5,980.29 x patient days",23922,Per diem,,28185,,"7,045.87 x patient days",28185,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,10874,,"2,718.31 x patient days",10874,Per diem,,0.01,28185,
Disorders of gallbladder & biliary tract,284-2,APR-DRG,,,,,,,,inpatient,,,119435.12,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,16180,,"4,044.85 x patient days",16180,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,22870,,"27,634 x DRG weight",22870,Other,base rate x DRG weight,19439,,"23,488 x DRG weight",19439,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,13309,,"3,327.21 x patient days",13309,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,12179,,"3,044.51 x patient days",12179,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,23922,,"5,980.29 x patient days",23922,Per diem,,28185,,"7,045.87 x patient days",28185,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,10874,,"2,718.31 x patient days",10874,Per diem,,0.01,28185,
Disorders of gallbladder & biliary tract,284-3,APR-DRG,,,,,,,,inpatient,,,161164.14,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,16180,,"4,044.85 x patient days",16180,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,36419,,"27,634 x DRG weight",36419,Other,base rate x DRG weight,30955,,"23,488 x DRG weight",30955,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,13309,,"3,327.21 x patient days",13309,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,12179,,"3,044.51 x patient days",12179,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,23922,,"5,980.29 x patient days",23922,Per diem,,28185,,"7,045.87 x patient days",28185,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,10874,,"2,718.31 x patient days",10874,Per diem,,0.01,36419,
Disorders of gallbladder & biliary tract,284-4,APR-DRG,,,,,,,,inpatient,,,138819.13,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,16180,,"4,044.85 x patient days",16180,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,81913,,"27,634 x DRG weight",81913,Other,base rate x DRG weight,69623,,"23,488 x DRG weight",69623,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,13309,,"3,327.21 x patient days",13309,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,12179,,"3,044.51 x patient days",12179,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,23922,,"5,980.29 x patient days",23922,Per diem,,28185,,"7,045.87 x patient days",28185,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,10874,,"2,718.31 x patient days",10874,Per diem,,0.01,81913,
Hip joint replacement,301-1,APR-DRG,,,,,,,,inpatient,,,205313.51,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12135,,"4,044.85 x patient days",12135,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,50996,,"27,634 x DRG weight",50996,Other,base rate x DRG weight,43345,,"23,488 x DRG weight",43345,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9982,,"3,327.21 x patient days",9982,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9134,,"3,044.51 x patient days",9134,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,17941,,"5,980.29 x patient days",17941,Per diem,,21138,,"7,045.87 x patient days",21138,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,8155,,"2,718.31 x patient days",8155,Per diem,,0.01,50996,
Hip joint replacement,301-2,APR-DRG,,,,,,,,inpatient,,,206062.91,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12135,,"4,044.85 x patient days",12135,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,52999,,"27,634 x DRG weight",52999,Other,base rate x DRG weight,45048,,"23,488 x DRG weight",45048,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9982,,"3,327.21 x patient days",9982,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9134,,"3,044.51 x patient days",9134,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,17941,,"5,980.29 x patient days",17941,Per diem,,21138,,"7,045.87 x patient days",21138,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,8155,,"2,718.31 x patient days",8155,Per diem,,0.01,52999,
Hip joint replacement,301-3,APR-DRG,,,,,,,,inpatient,,,534583.85,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12135,,"4,044.85 x patient days",12135,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,70099,,"27,634 x DRG weight",70099,Other,base rate x DRG weight,59582,,"23,488 x DRG weight",59582,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9982,,"3,327.21 x patient days",9982,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9134,,"3,044.51 x patient days",9134,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,17941,,"5,980.29 x patient days",17941,Per diem,,21138,,"7,045.87 x patient days",21138,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,8155,,"2,718.31 x patient days",8155,Per diem,,0.01,70099,
Hip joint replacement,301-4,APR-DRG,,,,,,,,inpatient,,,1017525.91,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12135,,"4,044.85 x patient days",12135,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,167288,,"27,634 x DRG weight",167288,Other,base rate x DRG weight,142189,,"23,488 x DRG weight",142189,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9982,,"3,327.21 x patient days",9982,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9134,,"3,044.51 x patient days",9134,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,17941,,"5,980.29 x patient days",17941,Per diem,,21138,,"7,045.87 x patient days",21138,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,8155,,"2,718.31 x patient days",8155,Per diem,,0.01,167288,
Knee joint replacement,302-1,APR-DRG,,,,,,,,inpatient,,,156533.17,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12135,,"4,044.85 x patient days",12135,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,48998,,"27,634 x DRG weight",48998,Other,base rate x DRG weight,41647,,"23,488 x DRG weight",41647,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9982,,"3,327.21 x patient days",9982,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9134,,"3,044.51 x patient days",9134,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,17941,,"5,980.29 x patient days",17941,Per diem,,21138,,"7,045.87 x patient days",21138,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,8155,,"2,718.31 x patient days",8155,Per diem,,0.01,48998,
Knee joint replacement,302-2,APR-DRG,,,,,,,,inpatient,,,205346.99,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12135,,"4,044.85 x patient days",12135,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,55285,,"27,634 x DRG weight",55285,Other,base rate x DRG weight,46990,,"23,488 x DRG weight",46990,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9982,,"3,327.21 x patient days",9982,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9134,,"3,044.51 x patient days",9134,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,17941,,"5,980.29 x patient days",17941,Per diem,,21138,,"7,045.87 x patient days",21138,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,8155,,"2,718.31 x patient days",8155,Per diem,,0.01,55285,
Knee joint replacement,302-3,APR-DRG,,,,,,,,inpatient,,,326053.32,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12135,,"4,044.85 x patient days",12135,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,74435,,"27,634 x DRG weight",74435,Other,base rate x DRG weight,63267,,"23,488 x DRG weight",63267,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9982,,"3,327.21 x patient days",9982,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9134,,"3,044.51 x patient days",9134,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,17941,,"5,980.29 x patient days",17941,Per diem,,21138,,"7,045.87 x patient days",21138,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,8155,,"2,718.31 x patient days",8155,Per diem,,0.01,74435,
Knee joint replacement,302-4,APR-DRG,,,,,,,,inpatient,,,326053.32,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12135,,"4,044.85 x patient days",12135,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,150406,,"27,634 x DRG weight",150406,Other,base rate x DRG weight,127840,,"23,488 x DRG weight",127840,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9982,,"3,327.21 x patient days",9982,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9134,,"3,044.51 x patient days",9134,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,17941,,"5,980.29 x patient days",17941,Per diem,,21138,,"7,045.87 x patient days",21138,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,8155,,"2,718.31 x patient days",8155,Per diem,,0.01,150406,
Dorsal & lumbar fusion proc for curvature of back,303-1,APR-DRG,,,,,,,,inpatient,,,381245.87,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,24269,,"4,044.85 x patient days",24269,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,122137,,"27,634 x DRG weight",122137,Other,base rate x DRG weight,103812,,"23,488 x DRG weight",103812,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,13048,,"2,174.65 x patient days",13048,Per diem,,13048,,"2,174.65 x patient days",13048,Per diem,,13048,,"2,174.65 x patient days",13048,Per diem,,13048,,"2,174.65 x patient days",13048,Per diem,,29358,,"4,892.96 x patient days",29358,Per diem,,19963,,"3,327.21 x patient days",19963,Per diem,,29358,,"4,892.96 x patient days",29358,Per diem,,18267,,"3,044.51 x patient days",18267,Per diem,,29358,,"4,892.96 x patient days",29358,Per diem,,35882,,"5,980.29 x patient days",35882,Per diem,,42276,,"7,045.87 x patient days",42276,Per diem,,28053,,"4,675.50 x patient days",28053,Per diem,,28053,,"4,675.50 x patient days",28053,Per diem,,16310,,"2,718.31 x patient days",16310,Per diem,,0.01,122137,
Dorsal & lumbar fusion proc for curvature of back,303-2,APR-DRG,,,,,,,,inpatient,,,475680.86,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,24269,,"4,044.85 x patient days",24269,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,146140,,"27,634 x DRG weight",146140,Other,base rate x DRG weight,124214,,"23,488 x DRG weight",124214,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,13048,,"2,174.65 x patient days",13048,Per diem,,13048,,"2,174.65 x patient days",13048,Per diem,,13048,,"2,174.65 x patient days",13048,Per diem,,13048,,"2,174.65 x patient days",13048,Per diem,,29358,,"4,892.96 x patient days",29358,Per diem,,19963,,"3,327.21 x patient days",19963,Per diem,,29358,,"4,892.96 x patient days",29358,Per diem,,18267,,"3,044.51 x patient days",18267,Per diem,,29358,,"4,892.96 x patient days",29358,Per diem,,35882,,"5,980.29 x patient days",35882,Per diem,,42276,,"7,045.87 x patient days",42276,Per diem,,28053,,"4,675.50 x patient days",28053,Per diem,,28053,,"4,675.50 x patient days",28053,Per diem,,16310,,"2,718.31 x patient days",16310,Per diem,,0.01,146140,
Dorsal & lumbar fusion proc for curvature of back,303-3,APR-DRG,,,,,,,,inpatient,,,920228.23,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,24269,,"4,044.85 x patient days",24269,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,193106,,"27,634 x DRG weight",193106,Other,base rate x DRG weight,164134,,"23,488 x DRG weight",164134,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,13048,,"2,174.65 x patient days",13048,Per diem,,13048,,"2,174.65 x patient days",13048,Per diem,,13048,,"2,174.65 x patient days",13048,Per diem,,13048,,"2,174.65 x patient days",13048,Per diem,,29358,,"4,892.96 x patient days",29358,Per diem,,19963,,"3,327.21 x patient days",19963,Per diem,,29358,,"4,892.96 x patient days",29358,Per diem,,18267,,"3,044.51 x patient days",18267,Per diem,,29358,,"4,892.96 x patient days",29358,Per diem,,35882,,"5,980.29 x patient days",35882,Per diem,,42276,,"7,045.87 x patient days",42276,Per diem,,28053,,"4,675.50 x patient days",28053,Per diem,,28053,,"4,675.50 x patient days",28053,Per diem,,16310,,"2,718.31 x patient days",16310,Per diem,,0.01,193106,
Dorsal & lumbar fusion proc for curvature of back,303-4,APR-DRG,,,,,,,,inpatient,,,720917.41,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,24269,,"4,044.85 x patient days",24269,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,301059,,"27,634 x DRG weight",301059,Other,base rate x DRG weight,255890,,"23,488 x DRG weight",255890,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,13048,,"2,174.65 x patient days",13048,Per diem,,13048,,"2,174.65 x patient days",13048,Per diem,,13048,,"2,174.65 x patient days",13048,Per diem,,13048,,"2,174.65 x patient days",13048,Per diem,,29358,,"4,892.96 x patient days",29358,Per diem,,19963,,"3,327.21 x patient days",19963,Per diem,,29358,,"4,892.96 x patient days",29358,Per diem,,18267,,"3,044.51 x patient days",18267,Per diem,,29358,,"4,892.96 x patient days",29358,Per diem,,35882,,"5,980.29 x patient days",35882,Per diem,,42276,,"7,045.87 x patient days",42276,Per diem,,28053,,"4,675.50 x patient days",28053,Per diem,,28053,,"4,675.50 x patient days",28053,Per diem,,16310,,"2,718.31 x patient days",16310,Per diem,,0.01,301059,
Dorsal & lumbar fusion proc except for curvature of back,304-1,APR-DRG,,,,,,,,inpatient,,,370295.15,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,16180,,"4,044.85 x patient days",16180,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,84729,,"27,634 x DRG weight",84729,Other,base rate x DRG weight,72017,,"23,488 x DRG weight",72017,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,13309,,"3,327.21 x patient days",13309,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,12179,,"3,044.51 x patient days",12179,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,23922,,"5,980.29 x patient days",23922,Per diem,,28185,,"7,045.87 x patient days",28185,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,10874,,"2,718.31 x patient days",10874,Per diem,,0.01,84729,
Dorsal & lumbar fusion proc except for curvature of back,304-2,APR-DRG,,,,,,,,inpatient,,,431640.21,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,16180,,"4,044.85 x patient days",16180,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,103207,,"27,634 x DRG weight",103207,Other,base rate x DRG weight,87723,,"23,488 x DRG weight",87723,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,13309,,"3,327.21 x patient days",13309,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,12179,,"3,044.51 x patient days",12179,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,23922,,"5,980.29 x patient days",23922,Per diem,,28185,,"7,045.87 x patient days",28185,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,10874,,"2,718.31 x patient days",10874,Per diem,,0.01,103207,
Dorsal & lumbar fusion proc except for curvature of back,304-3,APR-DRG,,,,,,,,inpatient,,,556856,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,16180,,"4,044.85 x patient days",16180,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,147223,,"27,634 x DRG weight",147223,Other,base rate x DRG weight,125135,,"23,488 x DRG weight",125135,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,13309,,"3,327.21 x patient days",13309,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,12179,,"3,044.51 x patient days",12179,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,23922,,"5,980.29 x patient days",23922,Per diem,,28185,,"7,045.87 x patient days",28185,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,10874,,"2,718.31 x patient days",10874,Per diem,,0.01,147223,
Dorsal & lumbar fusion proc except for curvature of back,304-4,APR-DRG,,,,,,,,inpatient,,,853371.29,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,16180,,"4,044.85 x patient days",16180,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,253741,,"27,634 x DRG weight",253741,Other,base rate x DRG weight,215672,,"23,488 x DRG weight",215672,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,13309,,"3,327.21 x patient days",13309,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,12179,,"3,044.51 x patient days",12179,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,23922,,"5,980.29 x patient days",23922,Per diem,,28185,,"7,045.87 x patient days",28185,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,10874,,"2,718.31 x patient days",10874,Per diem,,0.01,253741,
Amputation of lower limb except toes,305-1,APR-DRG,,,,,,,,inpatient,,,201582.53,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,56628,,"4,044.85 x patient days",56628,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,37615,,"27,634 x DRG weight",37615,Other,base rate x DRG weight,31972,,"23,488 x DRG weight",31972,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,30445,,"2,174.65 x patient days",30445,Per diem,,30445,,"2,174.65 x patient days",30445,Per diem,,30445,,"2,174.65 x patient days",30445,Per diem,,30445,,"2,174.65 x patient days",30445,Per diem,,68501,,"4,892.96 x patient days",68501,Per diem,,46581,,"3,327.21 x patient days",46581,Per diem,,68501,,"4,892.96 x patient days",68501,Per diem,,42623,,"3,044.51 x patient days",42623,Per diem,,68501,,"4,892.96 x patient days",68501,Per diem,,83724,,"5,980.29 x patient days",83724,Per diem,,98642,,"7,045.87 x patient days",98642,Per diem,,65457,,"4,675.50 x patient days",65457,Per diem,,65457,,"4,675.50 x patient days",65457,Per diem,,38056,,"2,718.31 x patient days",38056,Per diem,,0.01,98642,
Amputation of lower limb except toes,305-2,APR-DRG,,,,,,,,inpatient,,,503908.58,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,56628,,"4,044.85 x patient days",56628,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,52977,,"27,634 x DRG weight",52977,Other,base rate x DRG weight,45029,,"23,488 x DRG weight",45029,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,30445,,"2,174.65 x patient days",30445,Per diem,,30445,,"2,174.65 x patient days",30445,Per diem,,30445,,"2,174.65 x patient days",30445,Per diem,,30445,,"2,174.65 x patient days",30445,Per diem,,68501,,"4,892.96 x patient days",68501,Per diem,,46581,,"3,327.21 x patient days",46581,Per diem,,68501,,"4,892.96 x patient days",68501,Per diem,,42623,,"3,044.51 x patient days",42623,Per diem,,68501,,"4,892.96 x patient days",68501,Per diem,,83724,,"5,980.29 x patient days",83724,Per diem,,98642,,"7,045.87 x patient days",98642,Per diem,,65457,,"4,675.50 x patient days",65457,Per diem,,65457,,"4,675.50 x patient days",65457,Per diem,,38056,,"2,718.31 x patient days",38056,Per diem,,0.01,98642,
Amputation of lower limb except toes,305-3,APR-DRG,,,,,,,,inpatient,,,482034.2,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,56628,,"4,044.85 x patient days",56628,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,93455,,"27,634 x DRG weight",93455,Other,base rate x DRG weight,79434,,"23,488 x DRG weight",79434,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,30445,,"2,174.65 x patient days",30445,Per diem,,30445,,"2,174.65 x patient days",30445,Per diem,,30445,,"2,174.65 x patient days",30445,Per diem,,30445,,"2,174.65 x patient days",30445,Per diem,,68501,,"4,892.96 x patient days",68501,Per diem,,46581,,"3,327.21 x patient days",46581,Per diem,,68501,,"4,892.96 x patient days",68501,Per diem,,42623,,"3,044.51 x patient days",42623,Per diem,,68501,,"4,892.96 x patient days",68501,Per diem,,83724,,"5,980.29 x patient days",83724,Per diem,,98642,,"7,045.87 x patient days",98642,Per diem,,65457,,"4,675.50 x patient days",65457,Per diem,,65457,,"4,675.50 x patient days",65457,Per diem,,38056,,"2,718.31 x patient days",38056,Per diem,,0.01,98642,
Amputation of lower limb except toes,305-4,APR-DRG,,,,,,,,inpatient,,,684953.3,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,56628,,"4,044.85 x patient days",56628,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,174144,,"27,634 x DRG weight",174144,Other,base rate x DRG weight,148017,,"23,488 x DRG weight",148017,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,30445,,"2,174.65 x patient days",30445,Per diem,,30445,,"2,174.65 x patient days",30445,Per diem,,30445,,"2,174.65 x patient days",30445,Per diem,,30445,,"2,174.65 x patient days",30445,Per diem,,68501,,"4,892.96 x patient days",68501,Per diem,,46581,,"3,327.21 x patient days",46581,Per diem,,68501,,"4,892.96 x patient days",68501,Per diem,,42623,,"3,044.51 x patient days",42623,Per diem,,68501,,"4,892.96 x patient days",68501,Per diem,,83724,,"5,980.29 x patient days",83724,Per diem,,98642,,"7,045.87 x patient days",98642,Per diem,,65457,,"4,675.50 x patient days",65457,Per diem,,65457,,"4,675.50 x patient days",65457,Per diem,,38056,,"2,718.31 x patient days",38056,Per diem,,0.01,174144,
Hip and femur fracture repair,308-1,APR-DRG,,,,,,,,inpatient,,,178777.39,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,24269,,"4,044.85 x patient days",24269,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,36908,,"27,634 x DRG weight",36908,Other,base rate x DRG weight,31371,,"23,488 x DRG weight",31371,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,13048,,"2,174.65 x patient days",13048,Per diem,,13048,,"2,174.65 x patient days",13048,Per diem,,13048,,"2,174.65 x patient days",13048,Per diem,,13048,,"2,174.65 x patient days",13048,Per diem,,29358,,"4,892.96 x patient days",29358,Per diem,,19963,,"3,327.21 x patient days",19963,Per diem,,29358,,"4,892.96 x patient days",29358,Per diem,,18267,,"3,044.51 x patient days",18267,Per diem,,29358,,"4,892.96 x patient days",29358,Per diem,,35882,,"5,980.29 x patient days",35882,Per diem,,42276,,"7,045.87 x patient days",42276,Per diem,,28053,,"4,675.50 x patient days",28053,Per diem,,28053,,"4,675.50 x patient days",28053,Per diem,,16310,,"2,718.31 x patient days",16310,Per diem,,0.01,42276,
Hip and femur fracture repair,308-2,APR-DRG,,,,,,,,inpatient,,,202004.06,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,24269,,"4,044.85 x patient days",24269,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,50813,,"27,634 x DRG weight",50813,Other,base rate x DRG weight,43190,,"23,488 x DRG weight",43190,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,13048,,"2,174.65 x patient days",13048,Per diem,,13048,,"2,174.65 x patient days",13048,Per diem,,13048,,"2,174.65 x patient days",13048,Per diem,,13048,,"2,174.65 x patient days",13048,Per diem,,29358,,"4,892.96 x patient days",29358,Per diem,,19963,,"3,327.21 x patient days",19963,Per diem,,29358,,"4,892.96 x patient days",29358,Per diem,,18267,,"3,044.51 x patient days",18267,Per diem,,29358,,"4,892.96 x patient days",29358,Per diem,,35882,,"5,980.29 x patient days",35882,Per diem,,42276,,"7,045.87 x patient days",42276,Per diem,,28053,,"4,675.50 x patient days",28053,Per diem,,28053,,"4,675.50 x patient days",28053,Per diem,,16310,,"2,718.31 x patient days",16310,Per diem,,0.01,50813,
Hip and femur fracture repair,308-3,APR-DRG,,,,,,,,inpatient,,,349123.33,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,24269,,"4,044.85 x patient days",24269,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,75875,,"27,634 x DRG weight",75875,Other,base rate x DRG weight,64491,,"23,488 x DRG weight",64491,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,13048,,"2,174.65 x patient days",13048,Per diem,,13048,,"2,174.65 x patient days",13048,Per diem,,13048,,"2,174.65 x patient days",13048,Per diem,,13048,,"2,174.65 x patient days",13048,Per diem,,29358,,"4,892.96 x patient days",29358,Per diem,,19963,,"3,327.21 x patient days",19963,Per diem,,29358,,"4,892.96 x patient days",29358,Per diem,,18267,,"3,044.51 x patient days",18267,Per diem,,29358,,"4,892.96 x patient days",29358,Per diem,,35882,,"5,980.29 x patient days",35882,Per diem,,42276,,"7,045.87 x patient days",42276,Per diem,,28053,,"4,675.50 x patient days",28053,Per diem,,28053,,"4,675.50 x patient days",28053,Per diem,,16310,,"2,718.31 x patient days",16310,Per diem,,0.01,75875,
Hip and femur fracture repair,308-4,APR-DRG,,,,,,,,inpatient,,,493957.53,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,24269,,"4,044.85 x patient days",24269,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,159415,,"27,634 x DRG weight",159415,Other,base rate x DRG weight,135498,,"23,488 x DRG weight",135498,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,13048,,"2,174.65 x patient days",13048,Per diem,,13048,,"2,174.65 x patient days",13048,Per diem,,13048,,"2,174.65 x patient days",13048,Per diem,,13048,,"2,174.65 x patient days",13048,Per diem,,29358,,"4,892.96 x patient days",29358,Per diem,,19963,,"3,327.21 x patient days",19963,Per diem,,29358,,"4,892.96 x patient days",29358,Per diem,,18267,,"3,044.51 x patient days",18267,Per diem,,29358,,"4,892.96 x patient days",29358,Per diem,,35882,,"5,980.29 x patient days",35882,Per diem,,42276,,"7,045.87 x patient days",42276,Per diem,,28053,,"4,675.50 x patient days",28053,Per diem,,28053,,"4,675.50 x patient days",28053,Per diem,,16310,,"2,718.31 x patient days",16310,Per diem,,0.01,159415,
Other significant hip and femur surgery,309-1,APR-DRG,,,,,,,,inpatient,,,188202.96,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,20224,,"4,044.85 x patient days",20224,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,34415,,"27,634 x DRG weight",34415,Other,base rate x DRG weight,29252,,"23,488 x DRG weight",29252,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,16636,,"3,327.21 x patient days",16636,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,15222,,"3,044.51 x patient days",15222,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,29901,,"5,980.29 x patient days",29901,Per diem,,35229,,"7,045.87 x patient days",35229,Per diem,,23377,,"4,675.50 x patient days",23377,Per diem,,23377,,"4,675.50 x patient days",23377,Per diem,,13591,,"2,718.31 x patient days",13591,Per diem,,0.01,35229,
Other significant hip and femur surgery,309-2,APR-DRG,,,,,,,,inpatient,,,202463.54,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,20224,,"4,044.85 x patient days",20224,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,51808,,"27,634 x DRG weight",51808,Other,base rate x DRG weight,44035,,"23,488 x DRG weight",44035,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,16636,,"3,327.21 x patient days",16636,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,15222,,"3,044.51 x patient days",15222,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,29901,,"5,980.29 x patient days",29901,Per diem,,35229,,"7,045.87 x patient days",35229,Per diem,,23377,,"4,675.50 x patient days",23377,Per diem,,23377,,"4,675.50 x patient days",23377,Per diem,,13591,,"2,718.31 x patient days",13591,Per diem,,0.01,51808,
Other significant hip and femur surgery,309-3,APR-DRG,,,,,,,,inpatient,,,714745.36,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,20224,,"4,044.85 x patient days",20224,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,83507,,"27,634 x DRG weight",83507,Other,base rate x DRG weight,70978,,"23,488 x DRG weight",70978,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,16636,,"3,327.21 x patient days",16636,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,15222,,"3,044.51 x patient days",15222,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,29901,,"5,980.29 x patient days",29901,Per diem,,35229,,"7,045.87 x patient days",35229,Per diem,,23377,,"4,675.50 x patient days",23377,Per diem,,23377,,"4,675.50 x patient days",23377,Per diem,,13591,,"2,718.31 x patient days",13591,Per diem,,0.01,83507,
Other significant hip and femur surgery,309-4,APR-DRG,,,,,,,,inpatient,,,1173105.65,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,20224,,"4,044.85 x patient days",20224,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,158760,,"27,634 x DRG weight",158760,Other,base rate x DRG weight,134941,,"23,488 x DRG weight",134941,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,16636,,"3,327.21 x patient days",16636,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,15222,,"3,044.51 x patient days",15222,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,29901,,"5,980.29 x patient days",29901,Per diem,,35229,,"7,045.87 x patient days",35229,Per diem,,23377,,"4,675.50 x patient days",23377,Per diem,,23377,,"4,675.50 x patient days",23377,Per diem,,13591,,"2,718.31 x patient days",13591,Per diem,,0.01,158760,
Intervertebral disc excision & decompression,310-1,APR-DRG,,,,,,,,inpatient,,,186742.28,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12135,,"4,044.85 x patient days",12135,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,23818,,"27,634 x DRG weight",23818,Other,base rate x DRG weight,20244,,"23,488 x DRG weight",20244,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9982,,"3,327.21 x patient days",9982,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9134,,"3,044.51 x patient days",9134,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,17941,,"5,980.29 x patient days",17941,Per diem,,21138,,"7,045.87 x patient days",21138,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,8155,,"2,718.31 x patient days",8155,Per diem,,0.01,23818,
Intervertebral disc excision & decompression,310-2,APR-DRG,,,,,,,,inpatient,,,268237.65,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12135,,"4,044.85 x patient days",12135,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,33769,,"27,634 x DRG weight",33769,Other,base rate x DRG weight,28702,,"23,488 x DRG weight",28702,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9982,,"3,327.21 x patient days",9982,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9134,,"3,044.51 x patient days",9134,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,17941,,"5,980.29 x patient days",17941,Per diem,,21138,,"7,045.87 x patient days",21138,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,8155,,"2,718.31 x patient days",8155,Per diem,,0.01,33769,
Intervertebral disc excision & decompression,310-3,APR-DRG,,,,,,,,inpatient,,,396901.71,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12135,,"4,044.85 x patient days",12135,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,70329,,"27,634 x DRG weight",70329,Other,base rate x DRG weight,59777,,"23,488 x DRG weight",59777,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9982,,"3,327.21 x patient days",9982,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9134,,"3,044.51 x patient days",9134,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,17941,,"5,980.29 x patient days",17941,Per diem,,21138,,"7,045.87 x patient days",21138,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,8155,,"2,718.31 x patient days",8155,Per diem,,0.01,70329,
Intervertebral disc excision & decompression,310-4,APR-DRG,,,,,,,,inpatient,,,594634.01,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12135,,"4,044.85 x patient days",12135,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,189077,,"27,634 x DRG weight",189077,Other,base rate x DRG weight,160710,,"23,488 x DRG weight",160710,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9982,,"3,327.21 x patient days",9982,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9134,,"3,044.51 x patient days",9134,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,17941,,"5,980.29 x patient days",17941,Per diem,,21138,,"7,045.87 x patient days",21138,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,8155,,"2,718.31 x patient days",8155,Per diem,,0.01,189077,
"Skin graft, except hand, for musculoskeletal & connective tissue diagnoses",312-1,APR-DRG,,,,,,,,inpatient,,,195262.7,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,44493,,"4,044.85 x patient days",44493,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,33683,,"27,634 x DRG weight",33683,Other,base rate x DRG weight,28630,,"23,488 x DRG weight",28630,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,23921,,"2,174.65 x patient days",23921,Per diem,,23921,,"2,174.65 x patient days",23921,Per diem,,23921,,"2,174.65 x patient days",23921,Per diem,,23921,,"2,174.65 x patient days",23921,Per diem,,53822,,"4,892.96 x patient days",53822,Per diem,,36599,,"3,327.21 x patient days",36599,Per diem,,53822,,"4,892.96 x patient days",53822,Per diem,,33489,,"3,044.51 x patient days",33489,Per diem,,53822,,"4,892.96 x patient days",53822,Per diem,,65783,,"5,980.29 x patient days",65783,Per diem,,77504,,"7,045.87 x patient days",77504,Per diem,,51430,,"4,675.50 x patient days",51430,Per diem,,51430,,"4,675.50 x patient days",51430,Per diem,,29901,,"2,718.31 x patient days",29901,Per diem,,0.01,77504,
"Skin graft, except hand, for musculoskeletal & connective tissue diagnoses",312-2,APR-DRG,,,,,,,,inpatient,,,523226.19,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,44493,,"4,044.85 x patient days",44493,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,62268,,"27,634 x DRG weight",62268,Other,base rate x DRG weight,52926,,"23,488 x DRG weight",52926,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,23921,,"2,174.65 x patient days",23921,Per diem,,23921,,"2,174.65 x patient days",23921,Per diem,,23921,,"2,174.65 x patient days",23921,Per diem,,23921,,"2,174.65 x patient days",23921,Per diem,,53822,,"4,892.96 x patient days",53822,Per diem,,36599,,"3,327.21 x patient days",36599,Per diem,,53822,,"4,892.96 x patient days",53822,Per diem,,33489,,"3,044.51 x patient days",33489,Per diem,,53822,,"4,892.96 x patient days",53822,Per diem,,65783,,"5,980.29 x patient days",65783,Per diem,,77504,,"7,045.87 x patient days",77504,Per diem,,51430,,"4,675.50 x patient days",51430,Per diem,,51430,,"4,675.50 x patient days",51430,Per diem,,29901,,"2,718.31 x patient days",29901,Per diem,,0.01,77504,
"Skin graft, except hand, for musculoskeletal & connective tissue diagnoses",312-3,APR-DRG,,,,,,,,inpatient,,,239553.8,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,44493,,"4,044.85 x patient days",44493,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,125118,,"27,634 x DRG weight",125118,Other,base rate x DRG weight,106347,,"23,488 x DRG weight",106347,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,23921,,"2,174.65 x patient days",23921,Per diem,,23921,,"2,174.65 x patient days",23921,Per diem,,23921,,"2,174.65 x patient days",23921,Per diem,,23921,,"2,174.65 x patient days",23921,Per diem,,53822,,"4,892.96 x patient days",53822,Per diem,,36599,,"3,327.21 x patient days",36599,Per diem,,53822,,"4,892.96 x patient days",53822,Per diem,,33489,,"3,044.51 x patient days",33489,Per diem,,53822,,"4,892.96 x patient days",53822,Per diem,,65783,,"5,980.29 x patient days",65783,Per diem,,77504,,"7,045.87 x patient days",77504,Per diem,,51430,,"4,675.50 x patient days",51430,Per diem,,51430,,"4,675.50 x patient days",51430,Per diem,,29901,,"2,718.31 x patient days",29901,Per diem,,0.01,125118,
"Skin graft, except hand, for musculoskeletal & connective tissue diagnoses",312-4,APR-DRG,,,,,,,,inpatient,,,1431548.96,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,44493,,"4,044.85 x patient days",44493,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,248770,,"27,634 x DRG weight",248770,Other,base rate x DRG weight,211446,,"23,488 x DRG weight",211446,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,23921,,"2,174.65 x patient days",23921,Per diem,,23921,,"2,174.65 x patient days",23921,Per diem,,23921,,"2,174.65 x patient days",23921,Per diem,,23921,,"2,174.65 x patient days",23921,Per diem,,53822,,"4,892.96 x patient days",53822,Per diem,,36599,,"3,327.21 x patient days",36599,Per diem,,53822,,"4,892.96 x patient days",53822,Per diem,,33489,,"3,044.51 x patient days",33489,Per diem,,53822,,"4,892.96 x patient days",53822,Per diem,,65783,,"5,980.29 x patient days",65783,Per diem,,77504,,"7,045.87 x patient days",77504,Per diem,,51430,,"4,675.50 x patient days",51430,Per diem,,51430,,"4,675.50 x patient days",51430,Per diem,,29901,,"2,718.31 x patient days",29901,Per diem,,0.01,248770,
Knee & lower leg procedures except foot,313-1,APR-DRG,,,,,,,,inpatient,,,218809.15,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,16180,,"4,044.85 x patient days",16180,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,33059,,"27,634 x DRG weight",33059,Other,base rate x DRG weight,28099,,"23,488 x DRG weight",28099,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,13309,,"3,327.21 x patient days",13309,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,12179,,"3,044.51 x patient days",12179,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,23922,,"5,980.29 x patient days",23922,Per diem,,28185,,"7,045.87 x patient days",28185,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,10874,,"2,718.31 x patient days",10874,Per diem,,0.01,33059,
Knee & lower leg procedures except foot,313-2,APR-DRG,,,,,,,,inpatient,,,264676.63,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,16180,,"4,044.85 x patient days",16180,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,48514,,"27,634 x DRG weight",48514,Other,base rate x DRG weight,41236,,"23,488 x DRG weight",41236,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,13309,,"3,327.21 x patient days",13309,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,12179,,"3,044.51 x patient days",12179,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,23922,,"5,980.29 x patient days",23922,Per diem,,28185,,"7,045.87 x patient days",28185,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,10874,,"2,718.31 x patient days",10874,Per diem,,0.01,48514,
Knee & lower leg procedures except foot,313-3,APR-DRG,,,,,,,,inpatient,,,667069.93,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,16180,,"4,044.85 x patient days",16180,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,79448,,"27,634 x DRG weight",79448,Other,base rate x DRG weight,67528,,"23,488 x DRG weight",67528,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,13309,,"3,327.21 x patient days",13309,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,12179,,"3,044.51 x patient days",12179,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,23922,,"5,980.29 x patient days",23922,Per diem,,28185,,"7,045.87 x patient days",28185,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,10874,,"2,718.31 x patient days",10874,Per diem,,0.01,79448,
Knee & lower leg procedures except foot,313-4,APR-DRG,,,,,,,,inpatient,,,637267.49,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,16180,,"4,044.85 x patient days",16180,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,178828,,"27,634 x DRG weight",178828,Other,base rate x DRG weight,151998,,"23,488 x DRG weight",151998,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,13309,,"3,327.21 x patient days",13309,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,12179,,"3,044.51 x patient days",12179,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,23922,,"5,980.29 x patient days",23922,Per diem,,28185,,"7,045.87 x patient days",28185,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,10874,,"2,718.31 x patient days",10874,Per diem,,0.01,178828,
Foot & toe procedures,314-1,APR-DRG,,,,,,,,inpatient,,,151017.04,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,28315,,"4,044.85 x patient days",28315,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,29248,,"27,634 x DRG weight",29248,Other,base rate x DRG weight,24860,,"23,488 x DRG weight",24860,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,15223,,"2,174.65 x patient days",15223,Per diem,,15223,,"2,174.65 x patient days",15223,Per diem,,15223,,"2,174.65 x patient days",15223,Per diem,,15223,,"2,174.65 x patient days",15223,Per diem,,34252,,"4,892.96 x patient days",34252,Per diem,,23291,,"3,327.21 x patient days",23291,Per diem,,34252,,"4,892.96 x patient days",34252,Per diem,,21312,,"3,044.51 x patient days",21312,Per diem,,34252,,"4,892.96 x patient days",34252,Per diem,,41863,,"5,980.29 x patient days",41863,Per diem,,49323,,"7,045.87 x patient days",49323,Per diem,,32729,,"4,675.50 x patient days",32729,Per diem,,32729,,"4,675.50 x patient days",32729,Per diem,,19029,,"2,718.31 x patient days",19029,Per diem,,0.01,49323,
Foot & toe procedures,314-2,APR-DRG,,,,,,,,inpatient,,,229184.58,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,28315,,"4,044.85 x patient days",28315,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,37425,,"27,634 x DRG weight",37425,Other,base rate x DRG weight,31810,,"23,488 x DRG weight",31810,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,15223,,"2,174.65 x patient days",15223,Per diem,,15223,,"2,174.65 x patient days",15223,Per diem,,15223,,"2,174.65 x patient days",15223,Per diem,,15223,,"2,174.65 x patient days",15223,Per diem,,34252,,"4,892.96 x patient days",34252,Per diem,,23291,,"3,327.21 x patient days",23291,Per diem,,34252,,"4,892.96 x patient days",34252,Per diem,,21312,,"3,044.51 x patient days",21312,Per diem,,34252,,"4,892.96 x patient days",34252,Per diem,,41863,,"5,980.29 x patient days",41863,Per diem,,49323,,"7,045.87 x patient days",49323,Per diem,,32729,,"4,675.50 x patient days",32729,Per diem,,32729,,"4,675.50 x patient days",32729,Per diem,,19029,,"2,718.31 x patient days",19029,Per diem,,0.01,49323,
Foot & toe procedures,314-3,APR-DRG,,,,,,,,inpatient,,,353637.26,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,28315,,"4,044.85 x patient days",28315,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,56169,,"27,634 x DRG weight",56169,Other,base rate x DRG weight,47742,,"23,488 x DRG weight",47742,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,15223,,"2,174.65 x patient days",15223,Per diem,,15223,,"2,174.65 x patient days",15223,Per diem,,15223,,"2,174.65 x patient days",15223,Per diem,,15223,,"2,174.65 x patient days",15223,Per diem,,34252,,"4,892.96 x patient days",34252,Per diem,,23291,,"3,327.21 x patient days",23291,Per diem,,34252,,"4,892.96 x patient days",34252,Per diem,,21312,,"3,044.51 x patient days",21312,Per diem,,34252,,"4,892.96 x patient days",34252,Per diem,,41863,,"5,980.29 x patient days",41863,Per diem,,49323,,"7,045.87 x patient days",49323,Per diem,,32729,,"4,675.50 x patient days",32729,Per diem,,32729,,"4,675.50 x patient days",32729,Per diem,,19029,,"2,718.31 x patient days",19029,Per diem,,0.01,56169,
Foot & toe procedures,314-4,APR-DRG,,,,,,,,inpatient,,,380835.16,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,28315,,"4,044.85 x patient days",28315,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,106253,,"27,634 x DRG weight",106253,Other,base rate x DRG weight,90311,,"23,488 x DRG weight",90311,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,15223,,"2,174.65 x patient days",15223,Per diem,,15223,,"2,174.65 x patient days",15223,Per diem,,15223,,"2,174.65 x patient days",15223,Per diem,,15223,,"2,174.65 x patient days",15223,Per diem,,34252,,"4,892.96 x patient days",34252,Per diem,,23291,,"3,327.21 x patient days",23291,Per diem,,34252,,"4,892.96 x patient days",34252,Per diem,,21312,,"3,044.51 x patient days",21312,Per diem,,34252,,"4,892.96 x patient days",34252,Per diem,,41863,,"5,980.29 x patient days",41863,Per diem,,49323,,"7,045.87 x patient days",49323,Per diem,,32729,,"4,675.50 x patient days",32729,Per diem,,32729,,"4,675.50 x patient days",32729,Per diem,,19029,,"2,718.31 x patient days",19029,Per diem,,0.01,106253,
"Shoulder, upper arm & forearm procedures except joint replacement",315-1,APR-DRG,,,,,,,,inpatient,,,127992.88,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12135,,"4,044.85 x patient days",12135,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,22348,,"27,634 x DRG weight",22348,Other,base rate x DRG weight,18995,,"23,488 x DRG weight",18995,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9982,,"3,327.21 x patient days",9982,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9134,,"3,044.51 x patient days",9134,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,17941,,"5,980.29 x patient days",17941,Per diem,,21138,,"7,045.87 x patient days",21138,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,8155,,"2,718.31 x patient days",8155,Per diem,,0.01,22348,
"Shoulder, upper arm & forearm procedures except joint replacement",315-2,APR-DRG,,,,,,,,inpatient,,,232920.76,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12135,,"4,044.85 x patient days",12135,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,38218,,"27,634 x DRG weight",38218,Other,base rate x DRG weight,32484,,"23,488 x DRG weight",32484,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9982,,"3,327.21 x patient days",9982,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9134,,"3,044.51 x patient days",9134,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,17941,,"5,980.29 x patient days",17941,Per diem,,21138,,"7,045.87 x patient days",21138,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,8155,,"2,718.31 x patient days",8155,Per diem,,0.01,38218,
"Shoulder, upper arm & forearm procedures except joint replacement",315-3,APR-DRG,,,,,,,,inpatient,,,367391.1,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12135,,"4,044.85 x patient days",12135,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,73733,,"27,634 x DRG weight",73733,Other,base rate x DRG weight,62671,,"23,488 x DRG weight",62671,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9982,,"3,327.21 x patient days",9982,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9134,,"3,044.51 x patient days",9134,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,17941,,"5,980.29 x patient days",17941,Per diem,,21138,,"7,045.87 x patient days",21138,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,8155,,"2,718.31 x patient days",8155,Per diem,,0.01,73733,
"Shoulder, upper arm & forearm procedures except joint replacement",315-4,APR-DRG,,,,,,,,inpatient,,,549334.44,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12135,,"4,044.85 x patient days",12135,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,141856,,"27,634 x DRG weight",141856,Other,base rate x DRG weight,120573,,"23,488 x DRG weight",120573,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9982,,"3,327.21 x patient days",9982,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9134,,"3,044.51 x patient days",9134,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,17941,,"5,980.29 x patient days",17941,Per diem,,21138,,"7,045.87 x patient days",21138,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,8155,,"2,718.31 x patient days",8155,Per diem,,0.01,141856,
Hand & wrist procedures,316-1,APR-DRG,,,,,,,,inpatient,,,128483.42,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12135,,"4,044.85 x patient days",12135,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,19800,,"27,634 x DRG weight",19800,Other,base rate x DRG weight,16829,,"23,488 x DRG weight",16829,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9982,,"3,327.21 x patient days",9982,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9134,,"3,044.51 x patient days",9134,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,17941,,"5,980.29 x patient days",17941,Per diem,,21138,,"7,045.87 x patient days",21138,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,8155,,"2,718.31 x patient days",8155,Per diem,,0.01,21138,
Hand & wrist procedures,316-2,APR-DRG,,,,,,,,inpatient,,,216293.25,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12135,,"4,044.85 x patient days",12135,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,32625,,"27,634 x DRG weight",32625,Other,base rate x DRG weight,27730,,"23,488 x DRG weight",27730,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9982,,"3,327.21 x patient days",9982,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9134,,"3,044.51 x patient days",9134,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,17941,,"5,980.29 x patient days",17941,Per diem,,21138,,"7,045.87 x patient days",21138,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,8155,,"2,718.31 x patient days",8155,Per diem,,0.01,32625,
Hand & wrist procedures,316-3,APR-DRG,,,,,,,,inpatient,,,132593.33,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12135,,"4,044.85 x patient days",12135,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,58946,,"27,634 x DRG weight",58946,Other,base rate x DRG weight,50102,,"23,488 x DRG weight",50102,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9982,,"3,327.21 x patient days",9982,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9134,,"3,044.51 x patient days",9134,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,17941,,"5,980.29 x patient days",17941,Per diem,,21138,,"7,045.87 x patient days",21138,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,8155,,"2,718.31 x patient days",8155,Per diem,,0.01,58946,
Hand & wrist procedures,316-4,APR-DRG,,,,,,,,inpatient,,,132593.33,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12135,,"4,044.85 x patient days",12135,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,65973,,"27,634 x DRG weight",65973,Other,base rate x DRG weight,56075,,"23,488 x DRG weight",56075,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9982,,"3,327.21 x patient days",9982,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9134,,"3,044.51 x patient days",9134,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,17941,,"5,980.29 x patient days",17941,Per diem,,21138,,"7,045.87 x patient days",21138,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,8155,,"2,718.31 x patient days",8155,Per diem,,0.01,65973,
"Tendon, muscle & other soft tissue procedures",317-1,APR-DRG,,,,,,,,inpatient,,,170931.89,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,20224,,"4,044.85 x patient days",20224,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,24865,,"27,634 x DRG weight",24865,Other,base rate x DRG weight,21135,,"23,488 x DRG weight",21135,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,16636,,"3,327.21 x patient days",16636,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,15222,,"3,044.51 x patient days",15222,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,29901,,"5,980.29 x patient days",29901,Per diem,,35229,,"7,045.87 x patient days",35229,Per diem,,23377,,"4,675.50 x patient days",23377,Per diem,,23377,,"4,675.50 x patient days",23377,Per diem,,13591,,"2,718.31 x patient days",13591,Per diem,,0.01,35229,
"Tendon, muscle & other soft tissue procedures",317-2,APR-DRG,,,,,,,,inpatient,,,122473.26,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,20224,,"4,044.85 x patient days",20224,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,39652,,"27,634 x DRG weight",39652,Other,base rate x DRG weight,33703,,"23,488 x DRG weight",33703,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,16636,,"3,327.21 x patient days",16636,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,15222,,"3,044.51 x patient days",15222,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,29901,,"5,980.29 x patient days",29901,Per diem,,35229,,"7,045.87 x patient days",35229,Per diem,,23377,,"4,675.50 x patient days",23377,Per diem,,23377,,"4,675.50 x patient days",23377,Per diem,,13591,,"2,718.31 x patient days",13591,Per diem,,0.01,39652,
"Tendon, muscle & other soft tissue procedures",317-3,APR-DRG,,,,,,,,inpatient,,,350866.67,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,20224,,"4,044.85 x patient days",20224,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,72064,,"27,634 x DRG weight",72064,Other,base rate x DRG weight,61252,,"23,488 x DRG weight",61252,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,16636,,"3,327.21 x patient days",16636,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,15222,,"3,044.51 x patient days",15222,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,29901,,"5,980.29 x patient days",29901,Per diem,,35229,,"7,045.87 x patient days",35229,Per diem,,23377,,"4,675.50 x patient days",23377,Per diem,,23377,,"4,675.50 x patient days",23377,Per diem,,13591,,"2,718.31 x patient days",13591,Per diem,,0.01,72064,
"Tendon, muscle & other soft tissue procedures",317-4,APR-DRG,,,,,,,,inpatient,,,438312.39,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,20224,,"4,044.85 x patient days",20224,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,174592,,"27,634 x DRG weight",174592,Other,base rate x DRG weight,148397,,"23,488 x DRG weight",148397,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,16636,,"3,327.21 x patient days",16636,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,15222,,"3,044.51 x patient days",15222,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,29901,,"5,980.29 x patient days",29901,Per diem,,35229,,"7,045.87 x patient days",35229,Per diem,,23377,,"4,675.50 x patient days",23377,Per diem,,23377,,"4,675.50 x patient days",23377,Per diem,,13591,,"2,718.31 x patient days",13591,Per diem,,0.01,174592,
Other musculoskeletal system & connective tissue procedures,320-1,APR-DRG,,,,,,,,inpatient,,,155382.99,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,20224,,"4,044.85 x patient days",20224,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,28336,,"27,634 x DRG weight",28336,Other,base rate x DRG weight,24085,,"23,488 x DRG weight",24085,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,16636,,"3,327.21 x patient days",16636,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,15222,,"3,044.51 x patient days",15222,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,29901,,"5,980.29 x patient days",29901,Per diem,,35229,,"7,045.87 x patient days",35229,Per diem,,23377,,"4,675.50 x patient days",23377,Per diem,,23377,,"4,675.50 x patient days",23377,Per diem,,13591,,"2,718.31 x patient days",13591,Per diem,,0.01,35229,
Other musculoskeletal system & connective tissue procedures,320-2,APR-DRG,,,,,,,,inpatient,,,384955.42,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,20224,,"4,044.85 x patient days",20224,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,44983,,"27,634 x DRG weight",44983,Other,base rate x DRG weight,38234,,"23,488 x DRG weight",38234,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,16636,,"3,327.21 x patient days",16636,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,15222,,"3,044.51 x patient days",15222,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,29901,,"5,980.29 x patient days",29901,Per diem,,35229,,"7,045.87 x patient days",35229,Per diem,,23377,,"4,675.50 x patient days",23377,Per diem,,23377,,"4,675.50 x patient days",23377,Per diem,,13591,,"2,718.31 x patient days",13591,Per diem,,0.01,44983,
Other musculoskeletal system & connective tissue procedures,320-3,APR-DRG,,,,,,,,inpatient,,,270615.38,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,20224,,"4,044.85 x patient days",20224,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,69497,,"27,634 x DRG weight",69497,Other,base rate x DRG weight,59070,,"23,488 x DRG weight",59070,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,16636,,"3,327.21 x patient days",16636,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,15222,,"3,044.51 x patient days",15222,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,29901,,"5,980.29 x patient days",29901,Per diem,,35229,,"7,045.87 x patient days",35229,Per diem,,23377,,"4,675.50 x patient days",23377,Per diem,,23377,,"4,675.50 x patient days",23377,Per diem,,13591,,"2,718.31 x patient days",13591,Per diem,,0.01,69497,
Other musculoskeletal system & connective tissue procedures,320-4,APR-DRG,,,,,,,,inpatient,,,809801.38,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,20224,,"4,044.85 x patient days",20224,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,138269,,"27,634 x DRG weight",138269,Other,base rate x DRG weight,117525,,"23,488 x DRG weight",117525,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,16636,,"3,327.21 x patient days",16636,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,15222,,"3,044.51 x patient days",15222,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,29901,,"5,980.29 x patient days",29901,Per diem,,35229,,"7,045.87 x patient days",35229,Per diem,,23377,,"4,675.50 x patient days",23377,Per diem,,23377,,"4,675.50 x patient days",23377,Per diem,,13591,,"2,718.31 x patient days",13591,Per diem,,0.01,138269,
Cervical spinal fusion & other back/neck proc exc disc excis/decomp,321-1,APR-DRG,,,,,,,,inpatient,,,242825.56,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8089,,"4,044.85 x patient days",8089,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,45090,,"27,634 x DRG weight",45090,Other,base rate x DRG weight,38325,,"23,488 x DRG weight",38325,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6654,,"3,327.21 x patient days",6654,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6089,,"3,044.51 x patient days",6089,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,11960,,"5,980.29 x patient days",11960,Per diem,,14091,,"7,045.87 x patient days",14091,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,5436,,"2,718.31 x patient days",5436,Per diem,,0.01,45090,
Cervical spinal fusion & other back/neck proc exc disc excis/decomp,321-2,APR-DRG,,,,,,,,inpatient,,,290126.87,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8089,,"4,044.85 x patient days",8089,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,59333,,"27,634 x DRG weight",59333,Other,base rate x DRG weight,50431,,"23,488 x DRG weight",50431,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6654,,"3,327.21 x patient days",6654,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6089,,"3,044.51 x patient days",6089,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,11960,,"5,980.29 x patient days",11960,Per diem,,14091,,"7,045.87 x patient days",14091,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,5436,,"2,718.31 x patient days",5436,Per diem,,0.01,59333,
Cervical spinal fusion & other back/neck proc exc disc excis/decomp,321-3,APR-DRG,,,,,,,,inpatient,,,628457.4,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8089,,"4,044.85 x patient days",8089,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,102318,,"27,634 x DRG weight",102318,Other,base rate x DRG weight,86967,,"23,488 x DRG weight",86967,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6654,,"3,327.21 x patient days",6654,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6089,,"3,044.51 x patient days",6089,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,11960,,"5,980.29 x patient days",11960,Per diem,,14091,,"7,045.87 x patient days",14091,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,5436,,"2,718.31 x patient days",5436,Per diem,,0.01,102318,
Cervical spinal fusion & other back/neck proc exc disc excis/decomp,321-4,APR-DRG,,,,,,,,inpatient,,,526735.29,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8089,,"4,044.85 x patient days",8089,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,195212,,"27,634 x DRG weight",195212,Other,base rate x DRG weight,165924,,"23,488 x DRG weight",165924,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6654,,"3,327.21 x patient days",6654,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6089,,"3,044.51 x patient days",6089,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,11960,,"5,980.29 x patient days",11960,Per diem,,14091,,"7,045.87 x patient days",14091,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,5436,,"2,718.31 x patient days",5436,Per diem,,0.01,195212,
Shoulder & elbow joint replacement #,322-1,APR-DRG,,,,,,,,inpatient,,,309470.29,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8089,,"4,044.85 x patient days",8089,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,43670,,"27,634 x DRG weight",43670,Other,base rate x DRG weight,37118,,"23,488 x DRG weight",37118,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6654,,"3,327.21 x patient days",6654,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6089,,"3,044.51 x patient days",6089,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,11960,,"5,980.29 x patient days",11960,Per diem,,14091,,"7,045.87 x patient days",14091,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,5436,,"2,718.31 x patient days",5436,Per diem,,0.01,43670,
Shoulder & elbow joint replacement #,322-2,APR-DRG,,,,,,,,inpatient,,,267760.84,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8089,,"4,044.85 x patient days",8089,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,48238,,"27,634 x DRG weight",48238,Other,base rate x DRG weight,41001,,"23,488 x DRG weight",41001,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6654,,"3,327.21 x patient days",6654,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6089,,"3,044.51 x patient days",6089,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,11960,,"5,980.29 x patient days",11960,Per diem,,14091,,"7,045.87 x patient days",14091,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,5436,,"2,718.31 x patient days",5436,Per diem,,0.01,48238,
Shoulder & elbow joint replacement #,322-3,APR-DRG,,,,,,,,inpatient,,,309470.29,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8089,,"4,044.85 x patient days",8089,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,80791,,"27,634 x DRG weight",80791,Other,base rate x DRG weight,68670,,"23,488 x DRG weight",68670,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6654,,"3,327.21 x patient days",6654,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6089,,"3,044.51 x patient days",6089,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,11960,,"5,980.29 x patient days",11960,Per diem,,14091,,"7,045.87 x patient days",14091,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,5436,,"2,718.31 x patient days",5436,Per diem,,0.01,80791,
Shoulder & elbow joint replacement #,322-4,APR-DRG,,,,,,,,inpatient,,,309470.29,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8089,,"4,044.85 x patient days",8089,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,94464,,"27,634 x DRG weight",94464,Other,base rate x DRG weight,80291,,"23,488 x DRG weight",80291,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6654,,"3,327.21 x patient days",6654,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6089,,"3,044.51 x patient days",6089,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,11960,,"5,980.29 x patient days",11960,Per diem,,14091,,"7,045.87 x patient days",14091,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,5436,,"2,718.31 x patient days",5436,Per diem,,0.01,94464,
Fracture of femur,340-1,APR-DRG,,,,,,,,inpatient,,,87567.03,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,20224,,"4,044.85 x patient days",20224,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,14610,,"27,634 x DRG weight",14610,Other,base rate x DRG weight,12418,,"23,488 x DRG weight",12418,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,16636,,"3,327.21 x patient days",16636,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,15222,,"3,044.51 x patient days",15222,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,29901,,"5,980.29 x patient days",29901,Per diem,,35229,,"7,045.87 x patient days",35229,Per diem,,23377,,"4,675.50 x patient days",23377,Per diem,,23377,,"4,675.50 x patient days",23377,Per diem,,13591,,"2,718.31 x patient days",13591,Per diem,,0.01,35229,
Fracture of femur,340-2,APR-DRG,,,,,,,,inpatient,,,29468,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,20224,,"4,044.85 x patient days",20224,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,19568,,"27,634 x DRG weight",19568,Other,base rate x DRG weight,16632,,"23,488 x DRG weight",16632,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,16636,,"3,327.21 x patient days",16636,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,15222,,"3,044.51 x patient days",15222,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,29901,,"5,980.29 x patient days",29901,Per diem,,35229,,"7,045.87 x patient days",35229,Per diem,,23377,,"4,675.50 x patient days",23377,Per diem,,23377,,"4,675.50 x patient days",23377,Per diem,,13591,,"2,718.31 x patient days",13591,Per diem,,0.01,35229,
Fracture of femur,340-3,APR-DRG,,,,,,,,inpatient,,,169647.97,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,20224,,"4,044.85 x patient days",20224,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,47075,,"27,634 x DRG weight",47075,Other,base rate x DRG weight,40012,,"23,488 x DRG weight",40012,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,16636,,"3,327.21 x patient days",16636,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,15222,,"3,044.51 x patient days",15222,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,29901,,"5,980.29 x patient days",29901,Per diem,,35229,,"7,045.87 x patient days",35229,Per diem,,23377,,"4,675.50 x patient days",23377,Per diem,,23377,,"4,675.50 x patient days",23377,Per diem,,13591,,"2,718.31 x patient days",13591,Per diem,,0.01,47075,
Fracture of femur,340-4,APR-DRG,,,,,,,,inpatient,,,65287.86,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,20224,,"4,044.85 x patient days",20224,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,64058,,"27,634 x DRG weight",64058,Other,base rate x DRG weight,54448,,"23,488 x DRG weight",54448,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,16636,,"3,327.21 x patient days",16636,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,15222,,"3,044.51 x patient days",15222,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,29901,,"5,980.29 x patient days",29901,Per diem,,35229,,"7,045.87 x patient days",35229,Per diem,,23377,,"4,675.50 x patient days",23377,Per diem,,23377,,"4,675.50 x patient days",23377,Per diem,,13591,,"2,718.31 x patient days",13591,Per diem,,0.01,64058,
Fracture of pelvis or dislocation of hip,341-1,APR-DRG,,,,,,,,inpatient,,,78139.5,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,16180,,"4,044.85 x patient days",16180,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,15820,,"27,634 x DRG weight",15820,Other,base rate x DRG weight,13447,,"23,488 x DRG weight",13447,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,13309,,"3,327.21 x patient days",13309,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,12179,,"3,044.51 x patient days",12179,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,23922,,"5,980.29 x patient days",23922,Per diem,,28185,,"7,045.87 x patient days",28185,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,10874,,"2,718.31 x patient days",10874,Per diem,,0.01,28185,
Fracture of pelvis or dislocation of hip,341-2,APR-DRG,,,,,,,,inpatient,,,114028.5,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,16180,,"4,044.85 x patient days",16180,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,19725,,"27,634 x DRG weight",19725,Other,base rate x DRG weight,16766,,"23,488 x DRG weight",16766,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,13309,,"3,327.21 x patient days",13309,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,12179,,"3,044.51 x patient days",12179,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,23922,,"5,980.29 x patient days",23922,Per diem,,28185,,"7,045.87 x patient days",28185,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,10874,,"2,718.31 x patient days",10874,Per diem,,0.01,28185,
Fracture of pelvis or dislocation of hip,341-3,APR-DRG,,,,,,,,inpatient,,,188391.01,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,16180,,"4,044.85 x patient days",16180,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,26587,,"27,634 x DRG weight",26587,Other,base rate x DRG weight,22598,,"23,488 x DRG weight",22598,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,13309,,"3,327.21 x patient days",13309,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,12179,,"3,044.51 x patient days",12179,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,23922,,"5,980.29 x patient days",23922,Per diem,,28185,,"7,045.87 x patient days",28185,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,10874,,"2,718.31 x patient days",10874,Per diem,,0.01,28185,
Fracture of pelvis or dislocation of hip,341-4,APR-DRG,,,,,,,,inpatient,,,413970,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,16180,,"4,044.85 x patient days",16180,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,28292,,"27,634 x DRG weight",28292,Other,base rate x DRG weight,24047,,"23,488 x DRG weight",24047,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,13309,,"3,327.21 x patient days",13309,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,12179,,"3,044.51 x patient days",12179,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,23922,,"5,980.29 x patient days",23922,Per diem,,28185,,"7,045.87 x patient days",28185,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,10874,,"2,718.31 x patient days",10874,Per diem,,0.01,28292,
"Fractures & dislocations except femur, pelvis & back",342-1,APR-DRG,,,,,,,,inpatient,,,92965.78,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12135,,"4,044.85 x patient days",12135,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12286,,"27,634 x DRG weight",12286,Other,base rate x DRG weight,10443,,"23,488 x DRG weight",10443,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9982,,"3,327.21 x patient days",9982,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9134,,"3,044.51 x patient days",9134,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,17941,,"5,980.29 x patient days",17941,Per diem,,21138,,"7,045.87 x patient days",21138,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,8155,,"2,718.31 x patient days",8155,Per diem,,0.01,21138,
"Fractures & dislocations except femur, pelvis & back",342-2,APR-DRG,,,,,,,,inpatient,,,120322.77,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12135,,"4,044.85 x patient days",12135,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,18219,,"27,634 x DRG weight",18219,Other,base rate x DRG weight,15486,,"23,488 x DRG weight",15486,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9982,,"3,327.21 x patient days",9982,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9134,,"3,044.51 x patient days",9134,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,17941,,"5,980.29 x patient days",17941,Per diem,,21138,,"7,045.87 x patient days",21138,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,8155,,"2,718.31 x patient days",8155,Per diem,,0.01,21138,
"Fractures & dislocations except femur, pelvis & back",342-3,APR-DRG,,,,,,,,inpatient,,,192130.05,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12135,,"4,044.85 x patient days",12135,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,29939,,"27,634 x DRG weight",29939,Other,base rate x DRG weight,25447,,"23,488 x DRG weight",25447,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9982,,"3,327.21 x patient days",9982,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9134,,"3,044.51 x patient days",9134,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,17941,,"5,980.29 x patient days",17941,Per diem,,21138,,"7,045.87 x patient days",21138,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,8155,,"2,718.31 x patient days",8155,Per diem,,0.01,29939,
"Fractures & dislocations except femur, pelvis & back",342-4,APR-DRG,,,,,,,,inpatient,,,240902.52,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12135,,"4,044.85 x patient days",12135,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,73136,,"27,634 x DRG weight",73136,Other,base rate x DRG weight,62163,,"23,488 x DRG weight",62163,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9982,,"3,327.21 x patient days",9982,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9134,,"3,044.51 x patient days",9134,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,17941,,"5,980.29 x patient days",17941,Per diem,,21138,,"7,045.87 x patient days",21138,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,8155,,"2,718.31 x patient days",8155,Per diem,,0.01,73136,
Musculoskeletal malignancy & pathol fracture d/t muscskel malig,343-1,APR-DRG,,,,,,,,inpatient,,,305795.62,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,36404,,"4,044.85 x patient days",36404,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,22928,,"27,634 x DRG weight",22928,Other,base rate x DRG weight,19488,,"23,488 x DRG weight",19488,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,19572,,"2,174.65 x patient days",19572,Per diem,,19572,,"2,174.65 x patient days",19572,Per diem,,19572,,"2,174.65 x patient days",19572,Per diem,,19572,,"2,174.65 x patient days",19572,Per diem,,44037,,"4,892.96 x patient days",44037,Per diem,,29945,,"3,327.21 x patient days",29945,Per diem,,44037,,"4,892.96 x patient days",44037,Per diem,,27401,,"3,044.51 x patient days",27401,Per diem,,44037,,"4,892.96 x patient days",44037,Per diem,,53823,,"5,980.29 x patient days",53823,Per diem,,63413,,"7,045.87 x patient days",63413,Per diem,,42080,,"4,675.50 x patient days",42080,Per diem,,42080,,"4,675.50 x patient days",42080,Per diem,,24465,,"2,718.31 x patient days",24465,Per diem,,0.01,63413,
Musculoskeletal malignancy & pathol fracture d/t muscskel malig,343-2,APR-DRG,,,,,,,,inpatient,,,423823.32,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,36404,,"4,044.85 x patient days",36404,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,27568,,"27,634 x DRG weight",27568,Other,base rate x DRG weight,23432,,"23,488 x DRG weight",23432,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,19572,,"2,174.65 x patient days",19572,Per diem,,19572,,"2,174.65 x patient days",19572,Per diem,,19572,,"2,174.65 x patient days",19572,Per diem,,19572,,"2,174.65 x patient days",19572,Per diem,,44037,,"4,892.96 x patient days",44037,Per diem,,29945,,"3,327.21 x patient days",29945,Per diem,,44037,,"4,892.96 x patient days",44037,Per diem,,27401,,"3,044.51 x patient days",27401,Per diem,,44037,,"4,892.96 x patient days",44037,Per diem,,53823,,"5,980.29 x patient days",53823,Per diem,,63413,,"7,045.87 x patient days",63413,Per diem,,42080,,"4,675.50 x patient days",42080,Per diem,,42080,,"4,675.50 x patient days",42080,Per diem,,24465,,"2,718.31 x patient days",24465,Per diem,,0.01,63413,
Musculoskeletal malignancy & pathol fracture d/t muscskel malig,343-3,APR-DRG,,,,,,,,inpatient,,,479363.79,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,36404,,"4,044.85 x patient days",36404,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,59319,,"27,634 x DRG weight",59319,Other,base rate x DRG weight,50419,,"23,488 x DRG weight",50419,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,19572,,"2,174.65 x patient days",19572,Per diem,,19572,,"2,174.65 x patient days",19572,Per diem,,19572,,"2,174.65 x patient days",19572,Per diem,,19572,,"2,174.65 x patient days",19572,Per diem,,44037,,"4,892.96 x patient days",44037,Per diem,,29945,,"3,327.21 x patient days",29945,Per diem,,44037,,"4,892.96 x patient days",44037,Per diem,,27401,,"3,044.51 x patient days",27401,Per diem,,44037,,"4,892.96 x patient days",44037,Per diem,,53823,,"5,980.29 x patient days",53823,Per diem,,63413,,"7,045.87 x patient days",63413,Per diem,,42080,,"4,675.50 x patient days",42080,Per diem,,42080,,"4,675.50 x patient days",42080,Per diem,,24465,,"2,718.31 x patient days",24465,Per diem,,0.01,63413,
Musculoskeletal malignancy & pathol fracture d/t muscskel malig,343-4,APR-DRG,,,,,,,,inpatient,,,325773,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,36404,,"4,044.85 x patient days",36404,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,106441,,"27,634 x DRG weight",106441,Other,base rate x DRG weight,90471,,"23,488 x DRG weight",90471,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,19572,,"2,174.65 x patient days",19572,Per diem,,19572,,"2,174.65 x patient days",19572,Per diem,,19572,,"2,174.65 x patient days",19572,Per diem,,19572,,"2,174.65 x patient days",19572,Per diem,,44037,,"4,892.96 x patient days",44037,Per diem,,29945,,"3,327.21 x patient days",29945,Per diem,,44037,,"4,892.96 x patient days",44037,Per diem,,27401,,"3,044.51 x patient days",27401,Per diem,,44037,,"4,892.96 x patient days",44037,Per diem,,53823,,"5,980.29 x patient days",53823,Per diem,,63413,,"7,045.87 x patient days",63413,Per diem,,42080,,"4,675.50 x patient days",42080,Per diem,,42080,,"4,675.50 x patient days",42080,Per diem,,24465,,"2,718.31 x patient days",24465,Per diem,,0.01,106441,
"Osteomyelitis, septic arthritis & other musculoskeletal infections",344-1,APR-DRG,,,,,,,,inpatient,,,57913.98,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,28315,,"4,044.85 x patient days",28315,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,22220,,"27,634 x DRG weight",22220,Other,base rate x DRG weight,18887,,"23,488 x DRG weight",18887,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,15223,,"2,174.65 x patient days",15223,Per diem,,15223,,"2,174.65 x patient days",15223,Per diem,,15223,,"2,174.65 x patient days",15223,Per diem,,15223,,"2,174.65 x patient days",15223,Per diem,,34252,,"4,892.96 x patient days",34252,Per diem,,23291,,"3,327.21 x patient days",23291,Per diem,,34252,,"4,892.96 x patient days",34252,Per diem,,21312,,"3,044.51 x patient days",21312,Per diem,,34252,,"4,892.96 x patient days",34252,Per diem,,41863,,"5,980.29 x patient days",41863,Per diem,,49323,,"7,045.87 x patient days",49323,Per diem,,32729,,"4,675.50 x patient days",32729,Per diem,,32729,,"4,675.50 x patient days",32729,Per diem,,19029,,"2,718.31 x patient days",19029,Per diem,,0.01,49323,
"Osteomyelitis, septic arthritis & other musculoskeletal infections",344-2,APR-DRG,,,,,,,,inpatient,,,142328.16,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,28315,,"4,044.85 x patient days",28315,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,31774,,"27,634 x DRG weight",31774,Other,base rate x DRG weight,27007,,"23,488 x DRG weight",27007,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,15223,,"2,174.65 x patient days",15223,Per diem,,15223,,"2,174.65 x patient days",15223,Per diem,,15223,,"2,174.65 x patient days",15223,Per diem,,15223,,"2,174.65 x patient days",15223,Per diem,,34252,,"4,892.96 x patient days",34252,Per diem,,23291,,"3,327.21 x patient days",23291,Per diem,,34252,,"4,892.96 x patient days",34252,Per diem,,21312,,"3,044.51 x patient days",21312,Per diem,,34252,,"4,892.96 x patient days",34252,Per diem,,41863,,"5,980.29 x patient days",41863,Per diem,,49323,,"7,045.87 x patient days",49323,Per diem,,32729,,"4,675.50 x patient days",32729,Per diem,,32729,,"4,675.50 x patient days",32729,Per diem,,19029,,"2,718.31 x patient days",19029,Per diem,,0.01,49323,
"Osteomyelitis, septic arthritis & other musculoskeletal infections",344-3,APR-DRG,,,,,,,,inpatient,,,235243.34,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,28315,,"4,044.85 x patient days",28315,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,49282,,"27,634 x DRG weight",49282,Other,base rate x DRG weight,41888,,"23,488 x DRG weight",41888,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,15223,,"2,174.65 x patient days",15223,Per diem,,15223,,"2,174.65 x patient days",15223,Per diem,,15223,,"2,174.65 x patient days",15223,Per diem,,15223,,"2,174.65 x patient days",15223,Per diem,,34252,,"4,892.96 x patient days",34252,Per diem,,23291,,"3,327.21 x patient days",23291,Per diem,,34252,,"4,892.96 x patient days",34252,Per diem,,21312,,"3,044.51 x patient days",21312,Per diem,,34252,,"4,892.96 x patient days",34252,Per diem,,41863,,"5,980.29 x patient days",41863,Per diem,,49323,,"7,045.87 x patient days",49323,Per diem,,32729,,"4,675.50 x patient days",32729,Per diem,,32729,,"4,675.50 x patient days",32729,Per diem,,19029,,"2,718.31 x patient days",19029,Per diem,,0.01,49323,
"Osteomyelitis, septic arthritis & other musculoskeletal infections",344-4,APR-DRG,,,,,,,,inpatient,,,347789.16,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,28315,,"4,044.85 x patient days",28315,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,94862,,"27,634 x DRG weight",94862,Other,base rate x DRG weight,80630,,"23,488 x DRG weight",80630,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,15223,,"2,174.65 x patient days",15223,Per diem,,15223,,"2,174.65 x patient days",15223,Per diem,,15223,,"2,174.65 x patient days",15223,Per diem,,15223,,"2,174.65 x patient days",15223,Per diem,,34252,,"4,892.96 x patient days",34252,Per diem,,23291,,"3,327.21 x patient days",23291,Per diem,,34252,,"4,892.96 x patient days",34252,Per diem,,21312,,"3,044.51 x patient days",21312,Per diem,,34252,,"4,892.96 x patient days",34252,Per diem,,41863,,"5,980.29 x patient days",41863,Per diem,,49323,,"7,045.87 x patient days",49323,Per diem,,32729,,"4,675.50 x patient days",32729,Per diem,,32729,,"4,675.50 x patient days",32729,Per diem,,19029,,"2,718.31 x patient days",19029,Per diem,,0.01,94862,
Connective tissue disorders,346-1,APR-DRG,,,,,,,,inpatient,,,98482.73,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,20224,,"4,044.85 x patient days",20224,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,20214,,"27,634 x DRG weight",20214,Other,base rate x DRG weight,17181,,"23,488 x DRG weight",17181,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,16636,,"3,327.21 x patient days",16636,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,15222,,"3,044.51 x patient days",15222,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,29901,,"5,980.29 x patient days",29901,Per diem,,35229,,"7,045.87 x patient days",35229,Per diem,,23377,,"4,675.50 x patient days",23377,Per diem,,23377,,"4,675.50 x patient days",23377,Per diem,,13591,,"2,718.31 x patient days",13591,Per diem,,0.01,35229,
Connective tissue disorders,346-2,APR-DRG,,,,,,,,inpatient,,,147716.18,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,20224,,"4,044.85 x patient days",20224,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,26589,,"27,634 x DRG weight",26589,Other,base rate x DRG weight,22600,,"23,488 x DRG weight",22600,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,16636,,"3,327.21 x patient days",16636,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,15222,,"3,044.51 x patient days",15222,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,29901,,"5,980.29 x patient days",29901,Per diem,,35229,,"7,045.87 x patient days",35229,Per diem,,23377,,"4,675.50 x patient days",23377,Per diem,,23377,,"4,675.50 x patient days",23377,Per diem,,13591,,"2,718.31 x patient days",13591,Per diem,,0.01,35229,
Connective tissue disorders,346-3,APR-DRG,,,,,,,,inpatient,,,174289.57,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,20224,,"4,044.85 x patient days",20224,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,45953,,"27,634 x DRG weight",45953,Other,base rate x DRG weight,39058,,"23,488 x DRG weight",39058,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,16636,,"3,327.21 x patient days",16636,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,15222,,"3,044.51 x patient days",15222,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,29901,,"5,980.29 x patient days",29901,Per diem,,35229,,"7,045.87 x patient days",35229,Per diem,,23377,,"4,675.50 x patient days",23377,Per diem,,23377,,"4,675.50 x patient days",23377,Per diem,,13591,,"2,718.31 x patient days",13591,Per diem,,0.01,45953,
Connective tissue disorders,346-4,APR-DRG,,,,,,,,inpatient,,,414074.24,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,20224,,"4,044.85 x patient days",20224,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,134702,,"27,634 x DRG weight",134702,Other,base rate x DRG weight,114492,,"23,488 x DRG weight",114492,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,16636,,"3,327.21 x patient days",16636,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,15222,,"3,044.51 x patient days",15222,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,29901,,"5,980.29 x patient days",29901,Per diem,,35229,,"7,045.87 x patient days",35229,Per diem,,23377,,"4,675.50 x patient days",23377,Per diem,,23377,,"4,675.50 x patient days",23377,Per diem,,13591,,"2,718.31 x patient days",13591,Per diem,,0.01,134702,
"Other back & neck disorders, fractures & injuries",347-1,APR-DRG,,,,,,,,inpatient,,,112218.67,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12135,,"4,044.85 x patient days",12135,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,15174,,"27,634 x DRG weight",15174,Other,base rate x DRG weight,12897,,"23,488 x DRG weight",12897,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9982,,"3,327.21 x patient days",9982,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9134,,"3,044.51 x patient days",9134,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,17941,,"5,980.29 x patient days",17941,Per diem,,21138,,"7,045.87 x patient days",21138,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,8155,,"2,718.31 x patient days",8155,Per diem,,0.01,21138,
"Other back & neck disorders, fractures & injuries",347-2,APR-DRG,,,,,,,,inpatient,,,155698.86,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12135,,"4,044.85 x patient days",12135,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,20579,,"27,634 x DRG weight",20579,Other,base rate x DRG weight,17492,,"23,488 x DRG weight",17492,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9982,,"3,327.21 x patient days",9982,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9134,,"3,044.51 x patient days",9134,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,17941,,"5,980.29 x patient days",17941,Per diem,,21138,,"7,045.87 x patient days",21138,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,8155,,"2,718.31 x patient days",8155,Per diem,,0.01,21138,
"Other back & neck disorders, fractures & injuries",347-3,APR-DRG,,,,,,,,inpatient,,,157162.23,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12135,,"4,044.85 x patient days",12135,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,31052,,"27,634 x DRG weight",31052,Other,base rate x DRG weight,26393,,"23,488 x DRG weight",26393,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9982,,"3,327.21 x patient days",9982,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9134,,"3,044.51 x patient days",9134,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,17941,,"5,980.29 x patient days",17941,Per diem,,21138,,"7,045.87 x patient days",21138,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,8155,,"2,718.31 x patient days",8155,Per diem,,0.01,31052,
"Other back & neck disorders, fractures & injuries",347-4,APR-DRG,,,,,,,,inpatient,,,298192,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12135,,"4,044.85 x patient days",12135,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,87194,,"27,634 x DRG weight",87194,Other,base rate x DRG weight,74112,,"23,488 x DRG weight",74112,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9982,,"3,327.21 x patient days",9982,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9134,,"3,044.51 x patient days",9134,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,17941,,"5,980.29 x patient days",17941,Per diem,,21138,,"7,045.87 x patient days",21138,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,8155,,"2,718.31 x patient days",8155,Per diem,,0.01,87194,
"Malfunction, reaction, complic of orthopedic device or procedure",349-1,APR-DRG,,,,,,,,inpatient,,,36523.08,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,20224,,"4,044.85 x patient days",20224,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,15030,,"27,634 x DRG weight",15030,Other,base rate x DRG weight,12775,,"23,488 x DRG weight",12775,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,16636,,"3,327.21 x patient days",16636,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,15222,,"3,044.51 x patient days",15222,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,29901,,"5,980.29 x patient days",29901,Per diem,,35229,,"7,045.87 x patient days",35229,Per diem,,23377,,"4,675.50 x patient days",23377,Per diem,,23377,,"4,675.50 x patient days",23377,Per diem,,13591,,"2,718.31 x patient days",13591,Per diem,,0.01,35229,
"Malfunction, reaction, complic of orthopedic device or procedure",349-2,APR-DRG,,,,,,,,inpatient,,,71132.71,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,20224,,"4,044.85 x patient days",20224,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,24296,,"27,634 x DRG weight",24296,Other,base rate x DRG weight,20651,,"23,488 x DRG weight",20651,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,16636,,"3,327.21 x patient days",16636,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,15222,,"3,044.51 x patient days",15222,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,29901,,"5,980.29 x patient days",29901,Per diem,,35229,,"7,045.87 x patient days",35229,Per diem,,23377,,"4,675.50 x patient days",23377,Per diem,,23377,,"4,675.50 x patient days",23377,Per diem,,13591,,"2,718.31 x patient days",13591,Per diem,,0.01,35229,
"Malfunction, reaction, complic of orthopedic device or procedure",349-3,APR-DRG,,,,,,,,inpatient,,,278226.59,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,20224,,"4,044.85 x patient days",20224,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,43054,,"27,634 x DRG weight",43054,Other,base rate x DRG weight,36594,,"23,488 x DRG weight",36594,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,16636,,"3,327.21 x patient days",16636,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,15222,,"3,044.51 x patient days",15222,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,29901,,"5,980.29 x patient days",29901,Per diem,,35229,,"7,045.87 x patient days",35229,Per diem,,23377,,"4,675.50 x patient days",23377,Per diem,,23377,,"4,675.50 x patient days",23377,Per diem,,13591,,"2,718.31 x patient days",13591,Per diem,,0.01,43054,
"Malfunction, reaction, complic of orthopedic device or procedure",349-4,APR-DRG,,,,,,,,inpatient,,,278226.59,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,20224,,"4,044.85 x patient days",20224,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,98692,,"27,634 x DRG weight",98692,Other,base rate x DRG weight,83885,,"23,488 x DRG weight",83885,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,16636,,"3,327.21 x patient days",16636,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,15222,,"3,044.51 x patient days",15222,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,29901,,"5,980.29 x patient days",29901,Per diem,,35229,,"7,045.87 x patient days",35229,Per diem,,23377,,"4,675.50 x patient days",23377,Per diem,,23377,,"4,675.50 x patient days",23377,Per diem,,13591,,"2,718.31 x patient days",13591,Per diem,,0.01,98692,
Other musculoskeletal system & connective tissue diagnoses,351-1,APR-DRG,,,,,,,,inpatient,,,91941.21,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12135,,"4,044.85 x patient days",12135,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,13566,,"27,634 x DRG weight",13566,Other,base rate x DRG weight,11530,,"23,488 x DRG weight",11530,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9982,,"3,327.21 x patient days",9982,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9134,,"3,044.51 x patient days",9134,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,17941,,"5,980.29 x patient days",17941,Per diem,,21138,,"7,045.87 x patient days",21138,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,8155,,"2,718.31 x patient days",8155,Per diem,,0.01,21138,
Other musculoskeletal system & connective tissue diagnoses,351-2,APR-DRG,,,,,,,,inpatient,,,119058.79,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12135,,"4,044.85 x patient days",12135,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,17653,,"27,634 x DRG weight",17653,Other,base rate x DRG weight,15004,,"23,488 x DRG weight",15004,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9982,,"3,327.21 x patient days",9982,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9134,,"3,044.51 x patient days",9134,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,17941,,"5,980.29 x patient days",17941,Per diem,,21138,,"7,045.87 x patient days",21138,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,8155,,"2,718.31 x patient days",8155,Per diem,,0.01,21138,
Other musculoskeletal system & connective tissue diagnoses,351-3,APR-DRG,,,,,,,,inpatient,,,143633.73,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12135,,"4,044.85 x patient days",12135,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,31909,,"27,634 x DRG weight",31909,Other,base rate x DRG weight,27122,,"23,488 x DRG weight",27122,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9982,,"3,327.21 x patient days",9982,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9134,,"3,044.51 x patient days",9134,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,17941,,"5,980.29 x patient days",17941,Per diem,,21138,,"7,045.87 x patient days",21138,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,8155,,"2,718.31 x patient days",8155,Per diem,,0.01,31909,
Other musculoskeletal system & connective tissue diagnoses,351-4,APR-DRG,,,,,,,,inpatient,,,129634.25,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12135,,"4,044.85 x patient days",12135,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,85127,,"27,634 x DRG weight",85127,Other,base rate x DRG weight,72355,,"23,488 x DRG weight",72355,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9982,,"3,327.21 x patient days",9982,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9134,,"3,044.51 x patient days",9134,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,17941,,"5,980.29 x patient days",17941,Per diem,,21138,,"7,045.87 x patient days",21138,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,8155,,"2,718.31 x patient days",8155,Per diem,,0.01,85127,
Skin graft for skin & subcutaneous tissue diagnoses,361-1,APR-DRG,,,,,,,,inpatient,,,73123.42,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,24269,,"4,044.85 x patient days",24269,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,36651,,"27,634 x DRG weight",36651,Other,base rate x DRG weight,31152,,"23,488 x DRG weight",31152,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,13048,,"2,174.65 x patient days",13048,Per diem,,13048,,"2,174.65 x patient days",13048,Per diem,,13048,,"2,174.65 x patient days",13048,Per diem,,13048,,"2,174.65 x patient days",13048,Per diem,,29358,,"4,892.96 x patient days",29358,Per diem,,19963,,"3,327.21 x patient days",19963,Per diem,,29358,,"4,892.96 x patient days",29358,Per diem,,18267,,"3,044.51 x patient days",18267,Per diem,,29358,,"4,892.96 x patient days",29358,Per diem,,35882,,"5,980.29 x patient days",35882,Per diem,,42276,,"7,045.87 x patient days",42276,Per diem,,28053,,"4,675.50 x patient days",28053,Per diem,,28053,,"4,675.50 x patient days",28053,Per diem,,16310,,"2,718.31 x patient days",16310,Per diem,,0.01,42276,
Skin graft for skin & subcutaneous tissue diagnoses,361-2,APR-DRG,,,,,,,,inpatient,,,339404.31,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,24269,,"4,044.85 x patient days",24269,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,51894,,"27,634 x DRG weight",51894,Other,base rate x DRG weight,44108,,"23,488 x DRG weight",44108,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,13048,,"2,174.65 x patient days",13048,Per diem,,13048,,"2,174.65 x patient days",13048,Per diem,,13048,,"2,174.65 x patient days",13048,Per diem,,13048,,"2,174.65 x patient days",13048,Per diem,,29358,,"4,892.96 x patient days",29358,Per diem,,19963,,"3,327.21 x patient days",19963,Per diem,,29358,,"4,892.96 x patient days",29358,Per diem,,18267,,"3,044.51 x patient days",18267,Per diem,,29358,,"4,892.96 x patient days",29358,Per diem,,35882,,"5,980.29 x patient days",35882,Per diem,,42276,,"7,045.87 x patient days",42276,Per diem,,28053,,"4,675.50 x patient days",28053,Per diem,,28053,,"4,675.50 x patient days",28053,Per diem,,16310,,"2,718.31 x patient days",16310,Per diem,,0.01,51894,
Skin graft for skin & subcutaneous tissue diagnoses,361-3,APR-DRG,,,,,,,,inpatient,,,532079.41,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,24269,,"4,044.85 x patient days",24269,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,92292,,"27,634 x DRG weight",92292,Other,base rate x DRG weight,78445,,"23,488 x DRG weight",78445,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,13048,,"2,174.65 x patient days",13048,Per diem,,13048,,"2,174.65 x patient days",13048,Per diem,,13048,,"2,174.65 x patient days",13048,Per diem,,13048,,"2,174.65 x patient days",13048,Per diem,,29358,,"4,892.96 x patient days",29358,Per diem,,19963,,"3,327.21 x patient days",19963,Per diem,,29358,,"4,892.96 x patient days",29358,Per diem,,18267,,"3,044.51 x patient days",18267,Per diem,,29358,,"4,892.96 x patient days",29358,Per diem,,35882,,"5,980.29 x patient days",35882,Per diem,,42276,,"7,045.87 x patient days",42276,Per diem,,28053,,"4,675.50 x patient days",28053,Per diem,,28053,,"4,675.50 x patient days",28053,Per diem,,16310,,"2,718.31 x patient days",16310,Per diem,,0.01,92292,
Skin graft for skin & subcutaneous tissue diagnoses,361-4,APR-DRG,,,,,,,,inpatient,,,2455045.84,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,24269,,"4,044.85 x patient days",24269,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,265300,,"27,634 x DRG weight",265300,Other,base rate x DRG weight,225497,,"23,488 x DRG weight",225497,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,13048,,"2,174.65 x patient days",13048,Per diem,,13048,,"2,174.65 x patient days",13048,Per diem,,13048,,"2,174.65 x patient days",13048,Per diem,,13048,,"2,174.65 x patient days",13048,Per diem,,29358,,"4,892.96 x patient days",29358,Per diem,,19963,,"3,327.21 x patient days",19963,Per diem,,29358,,"4,892.96 x patient days",29358,Per diem,,18267,,"3,044.51 x patient days",18267,Per diem,,29358,,"4,892.96 x patient days",29358,Per diem,,35882,,"5,980.29 x patient days",35882,Per diem,,42276,,"7,045.87 x patient days",42276,Per diem,,28053,,"4,675.50 x patient days",28053,Per diem,,28053,,"4,675.50 x patient days",28053,Per diem,,16310,,"2,718.31 x patient days",16310,Per diem,,0.01,265300,
Mastectomy procedures,362-1,APR-DRG,,,,,,,,inpatient,,,148774.31,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8089,,"4,044.85 x patient days",8089,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,37684,,"27,634 x DRG weight",37684,Other,base rate x DRG weight,32031,,"23,488 x DRG weight",32031,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6654,,"3,327.21 x patient days",6654,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6089,,"3,044.51 x patient days",6089,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,11960,,"5,980.29 x patient days",11960,Per diem,,14091,,"7,045.87 x patient days",14091,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,5436,,"2,718.31 x patient days",5436,Per diem,,0.01,37684,
Mastectomy procedures,362-2,APR-DRG,,,,,,,,inpatient,,,276151.19,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8089,,"4,044.85 x patient days",8089,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,49888,,"27,634 x DRG weight",49888,Other,base rate x DRG weight,42403,,"23,488 x DRG weight",42403,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6654,,"3,327.21 x patient days",6654,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6089,,"3,044.51 x patient days",6089,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,11960,,"5,980.29 x patient days",11960,Per diem,,14091,,"7,045.87 x patient days",14091,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,5436,,"2,718.31 x patient days",5436,Per diem,,0.01,49888,
Mastectomy procedures,362-3,APR-DRG,,,,,,,,inpatient,,,148774.31,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8089,,"4,044.85 x patient days",8089,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,76776,,"27,634 x DRG weight",76776,Other,base rate x DRG weight,65257,,"23,488 x DRG weight",65257,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6654,,"3,327.21 x patient days",6654,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6089,,"3,044.51 x patient days",6089,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,11960,,"5,980.29 x patient days",11960,Per diem,,14091,,"7,045.87 x patient days",14091,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,5436,,"2,718.31 x patient days",5436,Per diem,,0.01,76776,
Mastectomy procedures,362-4,APR-DRG,,,,,,,,inpatient,,,148774.31,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8089,,"4,044.85 x patient days",8089,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,80241,,"27,634 x DRG weight",80241,Other,base rate x DRG weight,68202,,"23,488 x DRG weight",68202,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6654,,"3,327.21 x patient days",6654,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6089,,"3,044.51 x patient days",6089,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,11960,,"5,980.29 x patient days",11960,Per diem,,14091,,"7,045.87 x patient days",14091,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,5436,,"2,718.31 x patient days",5436,Per diem,,0.01,80241,
Breast procedures except mastectomy,363-1,APR-DRG,,,,,,,,inpatient,,,92974.07,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12135,,"4,044.85 x patient days",12135,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,25017,,"27,634 x DRG weight",25017,Other,base rate x DRG weight,21264,,"23,488 x DRG weight",21264,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9982,,"3,327.21 x patient days",9982,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9134,,"3,044.51 x patient days",9134,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,17941,,"5,980.29 x patient days",17941,Per diem,,21138,,"7,045.87 x patient days",21138,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,8155,,"2,718.31 x patient days",8155,Per diem,,0.01,25017,
Breast procedures except mastectomy,363-2,APR-DRG,,,,,,,,inpatient,,,185533.18,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12135,,"4,044.85 x patient days",12135,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,41959,,"27,634 x DRG weight",41959,Other,base rate x DRG weight,35664,,"23,488 x DRG weight",35664,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9982,,"3,327.21 x patient days",9982,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9134,,"3,044.51 x patient days",9134,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,17941,,"5,980.29 x patient days",17941,Per diem,,21138,,"7,045.87 x patient days",21138,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,8155,,"2,718.31 x patient days",8155,Per diem,,0.01,41959,
Breast procedures except mastectomy,363-3,APR-DRG,,,,,,,,inpatient,,,185533.18,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12135,,"4,044.85 x patient days",12135,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,63428,,"27,634 x DRG weight",63428,Other,base rate x DRG weight,53912,,"23,488 x DRG weight",53912,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9982,,"3,327.21 x patient days",9982,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9134,,"3,044.51 x patient days",9134,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,17941,,"5,980.29 x patient days",17941,Per diem,,21138,,"7,045.87 x patient days",21138,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,8155,,"2,718.31 x patient days",8155,Per diem,,0.01,63428,
Breast procedures except mastectomy,363-4,APR-DRG,,,,,,,,inpatient,,,185533.18,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12135,,"4,044.85 x patient days",12135,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,65225,,"27,634 x DRG weight",65225,Other,base rate x DRG weight,55439,,"23,488 x DRG weight",55439,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9982,,"3,327.21 x patient days",9982,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9134,,"3,044.51 x patient days",9134,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,17941,,"5,980.29 x patient days",17941,Per diem,,21138,,"7,045.87 x patient days",21138,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,8155,,"2,718.31 x patient days",8155,Per diem,,0.01,65225,
"Other skin, subcutaneous tissue & related procedures",364-1,APR-DRG,,,,,,,,inpatient,,,100955.06,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,16180,,"4,044.85 x patient days",16180,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,21264,,"27,634 x DRG weight",21264,Other,base rate x DRG weight,18074,,"23,488 x DRG weight",18074,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,13309,,"3,327.21 x patient days",13309,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,12179,,"3,044.51 x patient days",12179,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,23922,,"5,980.29 x patient days",23922,Per diem,,28185,,"7,045.87 x patient days",28185,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,10874,,"2,718.31 x patient days",10874,Per diem,,0.01,28185,
"Other skin, subcutaneous tissue & related procedures",364-2,APR-DRG,,,,,,,,inpatient,,,164365.11,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,16180,,"4,044.85 x patient days",16180,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,30668,,"27,634 x DRG weight",30668,Other,base rate x DRG weight,26067,,"23,488 x DRG weight",26067,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,13309,,"3,327.21 x patient days",13309,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,12179,,"3,044.51 x patient days",12179,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,23922,,"5,980.29 x patient days",23922,Per diem,,28185,,"7,045.87 x patient days",28185,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,10874,,"2,718.31 x patient days",10874,Per diem,,0.01,30668,
"Other skin, subcutaneous tissue & related procedures",364-3,APR-DRG,,,,,,,,inpatient,,,354842.22,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,16180,,"4,044.85 x patient days",16180,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,55906,,"27,634 x DRG weight",55906,Other,base rate x DRG weight,47519,,"23,488 x DRG weight",47519,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,13309,,"3,327.21 x patient days",13309,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,12179,,"3,044.51 x patient days",12179,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,23922,,"5,980.29 x patient days",23922,Per diem,,28185,,"7,045.87 x patient days",28185,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,10874,,"2,718.31 x patient days",10874,Per diem,,0.01,55906,
"Other skin, subcutaneous tissue & related procedures",364-4,APR-DRG,,,,,,,,inpatient,,,328437.61,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,16180,,"4,044.85 x patient days",16180,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,146717,,"27,634 x DRG weight",146717,Other,base rate x DRG weight,124705,,"23,488 x DRG weight",124705,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,13309,,"3,327.21 x patient days",13309,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,12179,,"3,044.51 x patient days",12179,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,23922,,"5,980.29 x patient days",23922,Per diem,,28185,,"7,045.87 x patient days",28185,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,10874,,"2,718.31 x patient days",10874,Per diem,,0.01,146717,
Skin ulcers,380-1,APR-DRG,,,,,,,,inpatient,,,60201.94,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,20224,,"4,044.85 x patient days",20224,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,18971,,"27,634 x DRG weight",18971,Other,base rate x DRG weight,16125,,"23,488 x DRG weight",16125,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,16636,,"3,327.21 x patient days",16636,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,15222,,"3,044.51 x patient days",15222,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,29901,,"5,980.29 x patient days",29901,Per diem,,35229,,"7,045.87 x patient days",35229,Per diem,,23377,,"4,675.50 x patient days",23377,Per diem,,23377,,"4,675.50 x patient days",23377,Per diem,,13591,,"2,718.31 x patient days",13591,Per diem,,0.01,35229,
Skin ulcers,380-2,APR-DRG,,,,,,,,inpatient,,,102054.89,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,20224,,"4,044.85 x patient days",20224,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,23055,,"27,634 x DRG weight",23055,Other,base rate x DRG weight,19596,,"23,488 x DRG weight",19596,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,16636,,"3,327.21 x patient days",16636,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,15222,,"3,044.51 x patient days",15222,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,29901,,"5,980.29 x patient days",29901,Per diem,,35229,,"7,045.87 x patient days",35229,Per diem,,23377,,"4,675.50 x patient days",23377,Per diem,,23377,,"4,675.50 x patient days",23377,Per diem,,13591,,"2,718.31 x patient days",13591,Per diem,,0.01,35229,
Skin ulcers,380-3,APR-DRG,,,,,,,,inpatient,,,232571.41,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,20224,,"4,044.85 x patient days",20224,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,35863,,"27,634 x DRG weight",35863,Other,base rate x DRG weight,30483,,"23,488 x DRG weight",30483,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,16636,,"3,327.21 x patient days",16636,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,15222,,"3,044.51 x patient days",15222,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,29901,,"5,980.29 x patient days",29901,Per diem,,35229,,"7,045.87 x patient days",35229,Per diem,,23377,,"4,675.50 x patient days",23377,Per diem,,23377,,"4,675.50 x patient days",23377,Per diem,,13591,,"2,718.31 x patient days",13591,Per diem,,0.01,35863,
Skin ulcers,380-4,APR-DRG,,,,,,,,inpatient,,,232571.41,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,20224,,"4,044.85 x patient days",20224,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,68872,,"27,634 x DRG weight",68872,Other,base rate x DRG weight,58539,,"23,488 x DRG weight",58539,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,16636,,"3,327.21 x patient days",16636,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,15222,,"3,044.51 x patient days",15222,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,29901,,"5,980.29 x patient days",29901,Per diem,,35229,,"7,045.87 x patient days",35229,Per diem,,23377,,"4,675.50 x patient days",23377,Per diem,,23377,,"4,675.50 x patient days",23377,Per diem,,13591,,"2,718.31 x patient days",13591,Per diem,,0.01,68872,
Major skin disorders,381-1,APR-DRG,,,,,,,,inpatient,,,108112.07,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,20224,,"4,044.85 x patient days",20224,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,16428,,"27,634 x DRG weight",16428,Other,base rate x DRG weight,13964,,"23,488 x DRG weight",13964,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,16636,,"3,327.21 x patient days",16636,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,15222,,"3,044.51 x patient days",15222,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,29901,,"5,980.29 x patient days",29901,Per diem,,35229,,"7,045.87 x patient days",35229,Per diem,,23377,,"4,675.50 x patient days",23377,Per diem,,23377,,"4,675.50 x patient days",23377,Per diem,,13591,,"2,718.31 x patient days",13591,Per diem,,0.01,35229,
Major skin disorders,381-2,APR-DRG,,,,,,,,inpatient,,,98673.25,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,20224,,"4,044.85 x patient days",20224,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,24335,,"27,634 x DRG weight",24335,Other,base rate x DRG weight,20684,,"23,488 x DRG weight",20684,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,16636,,"3,327.21 x patient days",16636,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,15222,,"3,044.51 x patient days",15222,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,29901,,"5,980.29 x patient days",29901,Per diem,,35229,,"7,045.87 x patient days",35229,Per diem,,23377,,"4,675.50 x patient days",23377,Per diem,,23377,,"4,675.50 x patient days",23377,Per diem,,13591,,"2,718.31 x patient days",13591,Per diem,,0.01,35229,
Major skin disorders,381-3,APR-DRG,,,,,,,,inpatient,,,394675.08,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,20224,,"4,044.85 x patient days",20224,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,53253,,"27,634 x DRG weight",53253,Other,base rate x DRG weight,45264,,"23,488 x DRG weight",45264,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,16636,,"3,327.21 x patient days",16636,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,15222,,"3,044.51 x patient days",15222,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,29901,,"5,980.29 x patient days",29901,Per diem,,35229,,"7,045.87 x patient days",35229,Per diem,,23377,,"4,675.50 x patient days",23377,Per diem,,23377,,"4,675.50 x patient days",23377,Per diem,,13591,,"2,718.31 x patient days",13591,Per diem,,0.01,53253,
Major skin disorders,381-4,APR-DRG,,,,,,,,inpatient,,,1427628.2,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,20224,,"4,044.85 x patient days",20224,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,163118,,"27,634 x DRG weight",163118,Other,base rate x DRG weight,138645,,"23,488 x DRG weight",138645,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,16636,,"3,327.21 x patient days",16636,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,15222,,"3,044.51 x patient days",15222,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,29901,,"5,980.29 x patient days",29901,Per diem,,35229,,"7,045.87 x patient days",35229,Per diem,,23377,,"4,675.50 x patient days",23377,Per diem,,23377,,"4,675.50 x patient days",23377,Per diem,,13591,,"2,718.31 x patient days",13591,Per diem,,0.01,163118,
Malignant breast disorders,382-1,APR-DRG,,,,,,,,inpatient,,,56201,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,28315,,"4,044.85 x patient days",28315,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,17202,,"27,634 x DRG weight",17202,Other,base rate x DRG weight,14621,,"23,488 x DRG weight",14621,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,15223,,"2,174.65 x patient days",15223,Per diem,,15223,,"2,174.65 x patient days",15223,Per diem,,15223,,"2,174.65 x patient days",15223,Per diem,,15223,,"2,174.65 x patient days",15223,Per diem,,34252,,"4,892.96 x patient days",34252,Per diem,,23291,,"3,327.21 x patient days",23291,Per diem,,34252,,"4,892.96 x patient days",34252,Per diem,,21312,,"3,044.51 x patient days",21312,Per diem,,34252,,"4,892.96 x patient days",34252,Per diem,,41863,,"5,980.29 x patient days",41863,Per diem,,49323,,"7,045.87 x patient days",49323,Per diem,,32729,,"4,675.50 x patient days",32729,Per diem,,32729,,"4,675.50 x patient days",32729,Per diem,,19029,,"2,718.31 x patient days",19029,Per diem,,0.01,49323,
Malignant breast disorders,382-2,APR-DRG,,,,,,,,inpatient,,,56201,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,28315,,"4,044.85 x patient days",28315,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,23030,,"27,634 x DRG weight",23030,Other,base rate x DRG weight,19575,,"23,488 x DRG weight",19575,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,15223,,"2,174.65 x patient days",15223,Per diem,,15223,,"2,174.65 x patient days",15223,Per diem,,15223,,"2,174.65 x patient days",15223,Per diem,,15223,,"2,174.65 x patient days",15223,Per diem,,34252,,"4,892.96 x patient days",34252,Per diem,,23291,,"3,327.21 x patient days",23291,Per diem,,34252,,"4,892.96 x patient days",34252,Per diem,,21312,,"3,044.51 x patient days",21312,Per diem,,34252,,"4,892.96 x patient days",34252,Per diem,,41863,,"5,980.29 x patient days",41863,Per diem,,49323,,"7,045.87 x patient days",49323,Per diem,,32729,,"4,675.50 x patient days",32729,Per diem,,32729,,"4,675.50 x patient days",32729,Per diem,,19029,,"2,718.31 x patient days",19029,Per diem,,0.01,49323,
Malignant breast disorders,382-3,APR-DRG,,,,,,,,inpatient,,,175779,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,28315,,"4,044.85 x patient days",28315,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,41620,,"27,634 x DRG weight",41620,Other,base rate x DRG weight,35375,,"23,488 x DRG weight",35375,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,15223,,"2,174.65 x patient days",15223,Per diem,,15223,,"2,174.65 x patient days",15223,Per diem,,15223,,"2,174.65 x patient days",15223,Per diem,,15223,,"2,174.65 x patient days",15223,Per diem,,34252,,"4,892.96 x patient days",34252,Per diem,,23291,,"3,327.21 x patient days",23291,Per diem,,34252,,"4,892.96 x patient days",34252,Per diem,,21312,,"3,044.51 x patient days",21312,Per diem,,34252,,"4,892.96 x patient days",34252,Per diem,,41863,,"5,980.29 x patient days",41863,Per diem,,49323,,"7,045.87 x patient days",49323,Per diem,,32729,,"4,675.50 x patient days",32729,Per diem,,32729,,"4,675.50 x patient days",32729,Per diem,,19029,,"2,718.31 x patient days",19029,Per diem,,0.01,49323,
Malignant breast disorders,382-4,APR-DRG,,,,,,,,inpatient,,,189087.2,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,28315,,"4,044.85 x patient days",28315,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,79965,,"27,634 x DRG weight",79965,Other,base rate x DRG weight,67967,,"23,488 x DRG weight",67967,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,15223,,"2,174.65 x patient days",15223,Per diem,,15223,,"2,174.65 x patient days",15223,Per diem,,15223,,"2,174.65 x patient days",15223,Per diem,,15223,,"2,174.65 x patient days",15223,Per diem,,34252,,"4,892.96 x patient days",34252,Per diem,,23291,,"3,327.21 x patient days",23291,Per diem,,34252,,"4,892.96 x patient days",34252,Per diem,,21312,,"3,044.51 x patient days",21312,Per diem,,34252,,"4,892.96 x patient days",34252,Per diem,,41863,,"5,980.29 x patient days",41863,Per diem,,49323,,"7,045.87 x patient days",49323,Per diem,,32729,,"4,675.50 x patient days",32729,Per diem,,32729,,"4,675.50 x patient days",32729,Per diem,,19029,,"2,718.31 x patient days",19029,Per diem,,0.01,79965,
Cellulitis & other skin infections,383-1,APR-DRG,,,,,,,,inpatient,,,70147.56,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,16180,,"4,044.85 x patient days",16180,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,13958,,"27,634 x DRG weight",13958,Other,base rate x DRG weight,11864,,"23,488 x DRG weight",11864,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,13309,,"3,327.21 x patient days",13309,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,12179,,"3,044.51 x patient days",12179,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,23922,,"5,980.29 x patient days",23922,Per diem,,28185,,"7,045.87 x patient days",28185,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,10874,,"2,718.31 x patient days",10874,Per diem,,0.01,28185,
Cellulitis & other skin infections,383-2,APR-DRG,,,,,,,,inpatient,,,88425.26,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,16180,,"4,044.85 x patient days",16180,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,18907,,"27,634 x DRG weight",18907,Other,base rate x DRG weight,16070,,"23,488 x DRG weight",16070,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,13309,,"3,327.21 x patient days",13309,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,12179,,"3,044.51 x patient days",12179,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,23922,,"5,980.29 x patient days",23922,Per diem,,28185,,"7,045.87 x patient days",28185,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,10874,,"2,718.31 x patient days",10874,Per diem,,0.01,28185,
Cellulitis & other skin infections,383-3,APR-DRG,,,,,,,,inpatient,,,150076.12,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,16180,,"4,044.85 x patient days",16180,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,32661,,"27,634 x DRG weight",32661,Other,base rate x DRG weight,27760,,"23,488 x DRG weight",27760,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,13309,,"3,327.21 x patient days",13309,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,12179,,"3,044.51 x patient days",12179,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,23922,,"5,980.29 x patient days",23922,Per diem,,28185,,"7,045.87 x patient days",28185,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,10874,,"2,718.31 x patient days",10874,Per diem,,0.01,32661,
Cellulitis & other skin infections,383-4,APR-DRG,,,,,,,,inpatient,,,334963.25,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,16180,,"4,044.85 x patient days",16180,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,77198,,"27,634 x DRG weight",77198,Other,base rate x DRG weight,65616,,"23,488 x DRG weight",65616,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,13309,,"3,327.21 x patient days",13309,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,12179,,"3,044.51 x patient days",12179,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,23922,,"5,980.29 x patient days",23922,Per diem,,28185,,"7,045.87 x patient days",28185,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,10874,,"2,718.31 x patient days",10874,Per diem,,0.01,77198,
"Contusion, open wound & other trauma to skin & subcutaneous tissue",384-1,APR-DRG,,,,,,,,inpatient,,,71053.7,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8089,,"4,044.85 x patient days",8089,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,11407,,"27,634 x DRG weight",11407,Other,base rate x DRG weight,9696,,"23,488 x DRG weight",9696,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6654,,"3,327.21 x patient days",6654,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6089,,"3,044.51 x patient days",6089,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,11960,,"5,980.29 x patient days",11960,Per diem,,14091,,"7,045.87 x patient days",14091,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,5436,,"2,718.31 x patient days",5436,Per diem,,0.01,14091,
"Contusion, open wound & other trauma to skin & subcutaneous tissue",384-2,APR-DRG,,,,,,,,inpatient,,,104747.59,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8089,,"4,044.85 x patient days",8089,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,16006,,"27,634 x DRG weight",16006,Other,base rate x DRG weight,13604,,"23,488 x DRG weight",13604,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6654,,"3,327.21 x patient days",6654,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6089,,"3,044.51 x patient days",6089,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,11960,,"5,980.29 x patient days",11960,Per diem,,14091,,"7,045.87 x patient days",14091,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,5436,,"2,718.31 x patient days",5436,Per diem,,0.01,16006,
"Contusion, open wound & other trauma to skin & subcutaneous tissue",384-3,APR-DRG,,,,,,,,inpatient,,,71480.9,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8089,,"4,044.85 x patient days",8089,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,27999,,"27,634 x DRG weight",27999,Other,base rate x DRG weight,23798,,"23,488 x DRG weight",23798,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6654,,"3,327.21 x patient days",6654,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6089,,"3,044.51 x patient days",6089,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,11960,,"5,980.29 x patient days",11960,Per diem,,14091,,"7,045.87 x patient days",14091,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,5436,,"2,718.31 x patient days",5436,Per diem,,0.01,27999,
"Contusion, open wound & other trauma to skin & subcutaneous tissue",384-4,APR-DRG,,,,,,,,inpatient,,,152701,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8089,,"4,044.85 x patient days",8089,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,50838,,"27,634 x DRG weight",50838,Other,base rate x DRG weight,43211,,"23,488 x DRG weight",43211,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6654,,"3,327.21 x patient days",6654,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6089,,"3,044.51 x patient days",6089,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,11960,,"5,980.29 x patient days",11960,Per diem,,14091,,"7,045.87 x patient days",14091,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,5436,,"2,718.31 x patient days",5436,Per diem,,0.01,50838,
"Other skin, subcutaneous tissue & breast disorders",385-1,APR-DRG,,,,,,,,inpatient,,,83964.44,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12135,,"4,044.85 x patient days",12135,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,13245,,"27,634 x DRG weight",13245,Other,base rate x DRG weight,11258,,"23,488 x DRG weight",11258,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9982,,"3,327.21 x patient days",9982,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9134,,"3,044.51 x patient days",9134,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,17941,,"5,980.29 x patient days",17941,Per diem,,21138,,"7,045.87 x patient days",21138,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,8155,,"2,718.31 x patient days",8155,Per diem,,0.01,21138,
"Other skin, subcutaneous tissue & breast disorders",385-2,APR-DRG,,,,,,,,inpatient,,,90574.6,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12135,,"4,044.85 x patient days",12135,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,18122,,"27,634 x DRG weight",18122,Other,base rate x DRG weight,15403,,"23,488 x DRG weight",15403,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9982,,"3,327.21 x patient days",9982,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9134,,"3,044.51 x patient days",9134,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,17941,,"5,980.29 x patient days",17941,Per diem,,21138,,"7,045.87 x patient days",21138,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,8155,,"2,718.31 x patient days",8155,Per diem,,0.01,21138,
"Other skin, subcutaneous tissue & breast disorders",385-3,APR-DRG,,,,,,,,inpatient,,,171031.94,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12135,,"4,044.85 x patient days",12135,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,29928,,"27,634 x DRG weight",29928,Other,base rate x DRG weight,25438,,"23,488 x DRG weight",25438,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9982,,"3,327.21 x patient days",9982,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9134,,"3,044.51 x patient days",9134,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,17941,,"5,980.29 x patient days",17941,Per diem,,21138,,"7,045.87 x patient days",21138,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,8155,,"2,718.31 x patient days",8155,Per diem,,0.01,29928,
"Other skin, subcutaneous tissue & breast disorders",385-4,APR-DRG,,,,,,,,inpatient,,,462863.09,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12135,,"4,044.85 x patient days",12135,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,79992,,"27,634 x DRG weight",79992,Other,base rate x DRG weight,67991,,"23,488 x DRG weight",67991,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9982,,"3,327.21 x patient days",9982,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9134,,"3,044.51 x patient days",9134,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,17941,,"5,980.29 x patient days",17941,Per diem,,21138,,"7,045.87 x patient days",21138,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,8155,,"2,718.31 x patient days",8155,Per diem,,0.01,79992,
Pituitary & adrenal procedures,401-1,APR-DRG,,,,,,,,inpatient,,,274171.94,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,16180,,"4,044.85 x patient days",16180,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,34186,,"27,634 x DRG weight",34186,Other,base rate x DRG weight,29057,,"23,488 x DRG weight",29057,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,13309,,"3,327.21 x patient days",13309,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,12179,,"3,044.51 x patient days",12179,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,23922,,"5,980.29 x patient days",23922,Per diem,,28185,,"7,045.87 x patient days",28185,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,10874,,"2,718.31 x patient days",10874,Per diem,,0.01,34186,
Pituitary & adrenal procedures,401-2,APR-DRG,,,,,,,,inpatient,,,266531.56,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,16180,,"4,044.85 x patient days",16180,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,46779,,"27,634 x DRG weight",46779,Other,base rate x DRG weight,39760,,"23,488 x DRG weight",39760,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,13309,,"3,327.21 x patient days",13309,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,12179,,"3,044.51 x patient days",12179,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,23922,,"5,980.29 x patient days",23922,Per diem,,28185,,"7,045.87 x patient days",28185,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,10874,,"2,718.31 x patient days",10874,Per diem,,0.01,46779,
Pituitary & adrenal procedures,401-3,APR-DRG,,,,,,,,inpatient,,,244178.54,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,16180,,"4,044.85 x patient days",16180,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,85635,,"27,634 x DRG weight",85635,Other,base rate x DRG weight,72787,,"23,488 x DRG weight",72787,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,13309,,"3,327.21 x patient days",13309,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,12179,,"3,044.51 x patient days",12179,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,23922,,"5,980.29 x patient days",23922,Per diem,,28185,,"7,045.87 x patient days",28185,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,10874,,"2,718.31 x patient days",10874,Per diem,,0.01,85635,
Pituitary & adrenal procedures,401-4,APR-DRG,,,,,,,,inpatient,,,1215138.73,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,16180,,"4,044.85 x patient days",16180,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,193098,,"27,634 x DRG weight",193098,Other,base rate x DRG weight,164127,,"23,488 x DRG weight",164127,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,13309,,"3,327.21 x patient days",13309,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,12179,,"3,044.51 x patient days",12179,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,23922,,"5,980.29 x patient days",23922,Per diem,,28185,,"7,045.87 x patient days",28185,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,10874,,"2,718.31 x patient days",10874,Per diem,,0.01,193098,
"Thyroid, parathyroid & thyroglossal procedures",404-1,APR-DRG,,,,,,,,inpatient,,,129539.14,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,4046,,"4,044.85 x patient days",4046,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,18471,,"27,634 x DRG weight",18471,Other,base rate x DRG weight,15699,,"23,488 x DRG weight",15699,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,2175,,"2,174.65 x patient days",2175,Per diem,,2175,,"2,174.65 x patient days",2175,Per diem,,2175,,"2,174.65 x patient days",2175,Per diem,,2175,,"2,174.65 x patient days",2175,Per diem,,4894,,"4,892.96 x patient days",4894,Per diem,,3328,,"3,327.21 x patient days",3328,Per diem,,4894,,"4,892.96 x patient days",4894,Per diem,,3045,,"3,044.51 x patient days",3045,Per diem,,4894,,"4,892.96 x patient days",4894,Per diem,,5981,,"5,980.29 x patient days",5981,Per diem,,7047,,"7,045.87 x patient days",7047,Per diem,,4676,,"4,675.50 x patient days",4676,Per diem,,4676,,"4,675.50 x patient days",4676,Per diem,,2719,,"2,718.31 x patient days",2719,Per diem,,0.01,18471,
"Thyroid, parathyroid & thyroglossal procedures",404-2,APR-DRG,,,,,,,,inpatient,,,163820.98,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,4046,,"4,044.85 x patient days",4046,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,23992,,"27,634 x DRG weight",23992,Other,base rate x DRG weight,20392,,"23,488 x DRG weight",20392,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,2175,,"2,174.65 x patient days",2175,Per diem,,2175,,"2,174.65 x patient days",2175,Per diem,,2175,,"2,174.65 x patient days",2175,Per diem,,2175,,"2,174.65 x patient days",2175,Per diem,,4894,,"4,892.96 x patient days",4894,Per diem,,3328,,"3,327.21 x patient days",3328,Per diem,,4894,,"4,892.96 x patient days",4894,Per diem,,3045,,"3,044.51 x patient days",3045,Per diem,,4894,,"4,892.96 x patient days",4894,Per diem,,5981,,"5,980.29 x patient days",5981,Per diem,,7047,,"7,045.87 x patient days",7047,Per diem,,4676,,"4,675.50 x patient days",4676,Per diem,,4676,,"4,675.50 x patient days",4676,Per diem,,2719,,"2,718.31 x patient days",2719,Per diem,,0.01,23992,
"Thyroid, parathyroid & thyroglossal procedures",404-3,APR-DRG,,,,,,,,inpatient,,,282536.75,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,4046,,"4,044.85 x patient days",4046,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,61610,,"27,634 x DRG weight",61610,Other,base rate x DRG weight,52366,,"23,488 x DRG weight",52366,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,2175,,"2,174.65 x patient days",2175,Per diem,,2175,,"2,174.65 x patient days",2175,Per diem,,2175,,"2,174.65 x patient days",2175,Per diem,,2175,,"2,174.65 x patient days",2175,Per diem,,4894,,"4,892.96 x patient days",4894,Per diem,,3328,,"3,327.21 x patient days",3328,Per diem,,4894,,"4,892.96 x patient days",4894,Per diem,,3045,,"3,044.51 x patient days",3045,Per diem,,4894,,"4,892.96 x patient days",4894,Per diem,,5981,,"5,980.29 x patient days",5981,Per diem,,7047,,"7,045.87 x patient days",7047,Per diem,,4676,,"4,675.50 x patient days",4676,Per diem,,4676,,"4,675.50 x patient days",4676,Per diem,,2719,,"2,718.31 x patient days",2719,Per diem,,0.01,61610,
"Thyroid, parathyroid & thyroglossal procedures",404-4,APR-DRG,,,,,,,,inpatient,,,755383.56,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,4046,,"4,044.85 x patient days",4046,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,73692,,"27,634 x DRG weight",73692,Other,base rate x DRG weight,62635,,"23,488 x DRG weight",62635,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,2175,,"2,174.65 x patient days",2175,Per diem,,2175,,"2,174.65 x patient days",2175,Per diem,,2175,,"2,174.65 x patient days",2175,Per diem,,2175,,"2,174.65 x patient days",2175,Per diem,,4894,,"4,892.96 x patient days",4894,Per diem,,3328,,"3,327.21 x patient days",3328,Per diem,,4894,,"4,892.96 x patient days",4894,Per diem,,3045,,"3,044.51 x patient days",3045,Per diem,,4894,,"4,892.96 x patient days",4894,Per diem,,5981,,"5,980.29 x patient days",5981,Per diem,,7047,,"7,045.87 x patient days",7047,Per diem,,4676,,"4,675.50 x patient days",4676,Per diem,,4676,,"4,675.50 x patient days",4676,Per diem,,2719,,"2,718.31 x patient days",2719,Per diem,,0.01,73692,
"Other procedures for endocrine, nutritional & metabolic disorders",405-1,APR-DRG,,,,,,,,inpatient,,,296577.89,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,48539,,"4,044.85 x patient days",48539,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,32216,,"27,634 x DRG weight",32216,Other,base rate x DRG weight,27382,,"23,488 x DRG weight",27382,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,26096,,"2,174.65 x patient days",26096,Per diem,,26096,,"2,174.65 x patient days",26096,Per diem,,26096,,"2,174.65 x patient days",26096,Per diem,,26096,,"2,174.65 x patient days",26096,Per diem,,58716,,"4,892.96 x patient days",58716,Per diem,,39927,,"3,327.21 x patient days",39927,Per diem,,58716,,"4,892.96 x patient days",58716,Per diem,,36534,,"3,044.51 x patient days",36534,Per diem,,58716,,"4,892.96 x patient days",58716,Per diem,,71764,,"5,980.29 x patient days",71764,Per diem,,84551,,"7,045.87 x patient days",84551,Per diem,,56106,,"4,675.50 x patient days",56106,Per diem,,56106,,"4,675.50 x patient days",56106,Per diem,,32620,,"2,718.31 x patient days",32620,Per diem,,0.01,84551,
"Other procedures for endocrine, nutritional & metabolic disorders",405-2,APR-DRG,,,,,,,,inpatient,,,206668.07,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,48539,,"4,044.85 x patient days",48539,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,46801,,"27,634 x DRG weight",46801,Other,base rate x DRG weight,39779,,"23,488 x DRG weight",39779,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,26096,,"2,174.65 x patient days",26096,Per diem,,26096,,"2,174.65 x patient days",26096,Per diem,,26096,,"2,174.65 x patient days",26096,Per diem,,26096,,"2,174.65 x patient days",26096,Per diem,,58716,,"4,892.96 x patient days",58716,Per diem,,39927,,"3,327.21 x patient days",39927,Per diem,,58716,,"4,892.96 x patient days",58716,Per diem,,36534,,"3,044.51 x patient days",36534,Per diem,,58716,,"4,892.96 x patient days",58716,Per diem,,71764,,"5,980.29 x patient days",71764,Per diem,,84551,,"7,045.87 x patient days",84551,Per diem,,56106,,"4,675.50 x patient days",56106,Per diem,,56106,,"4,675.50 x patient days",56106,Per diem,,32620,,"2,718.31 x patient days",32620,Per diem,,0.01,84551,
"Other procedures for endocrine, nutritional & metabolic disorders",405-3,APR-DRG,,,,,,,,inpatient,,,615415.96,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,48539,,"4,044.85 x patient days",48539,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,81385,,"27,634 x DRG weight",81385,Other,base rate x DRG weight,69175,,"23,488 x DRG weight",69175,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,26096,,"2,174.65 x patient days",26096,Per diem,,26096,,"2,174.65 x patient days",26096,Per diem,,26096,,"2,174.65 x patient days",26096,Per diem,,26096,,"2,174.65 x patient days",26096,Per diem,,58716,,"4,892.96 x patient days",58716,Per diem,,39927,,"3,327.21 x patient days",39927,Per diem,,58716,,"4,892.96 x patient days",58716,Per diem,,36534,,"3,044.51 x patient days",36534,Per diem,,58716,,"4,892.96 x patient days",58716,Per diem,,71764,,"5,980.29 x patient days",71764,Per diem,,84551,,"7,045.87 x patient days",84551,Per diem,,56106,,"4,675.50 x patient days",56106,Per diem,,56106,,"4,675.50 x patient days",56106,Per diem,,32620,,"2,718.31 x patient days",32620,Per diem,,0.01,84551,
"Other procedures for endocrine, nutritional & metabolic disorders",405-4,APR-DRG,,,,,,,,inpatient,,,213344.02,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,48539,,"4,044.85 x patient days",48539,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,231797,,"27,634 x DRG weight",231797,Other,base rate x DRG weight,197020,,"23,488 x DRG weight",197020,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,26096,,"2,174.65 x patient days",26096,Per diem,,26096,,"2,174.65 x patient days",26096,Per diem,,26096,,"2,174.65 x patient days",26096,Per diem,,26096,,"2,174.65 x patient days",26096,Per diem,,58716,,"4,892.96 x patient days",58716,Per diem,,39927,,"3,327.21 x patient days",39927,Per diem,,58716,,"4,892.96 x patient days",58716,Per diem,,36534,,"3,044.51 x patient days",36534,Per diem,,58716,,"4,892.96 x patient days",58716,Per diem,,71764,,"5,980.29 x patient days",71764,Per diem,,84551,,"7,045.87 x patient days",84551,Per diem,,56106,,"4,675.50 x patient days",56106,Per diem,,56106,,"4,675.50 x patient days",56106,Per diem,,32620,,"2,718.31 x patient days",32620,Per diem,,0.01,231797,
Diabetes,420-1,APR-DRG,,,,,,,,inpatient,,,62847.81,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12135,,"4,044.85 x patient days",12135,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12590,,"27,634 x DRG weight",12590,Other,base rate x DRG weight,10701,,"23,488 x DRG weight",10701,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9982,,"3,327.21 x patient days",9982,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9134,,"3,044.51 x patient days",9134,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,17941,,"5,980.29 x patient days",17941,Per diem,,21138,,"7,045.87 x patient days",21138,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,8155,,"2,718.31 x patient days",8155,Per diem,,0.01,21138,
Diabetes,420-2,APR-DRG,,,,,,,,inpatient,,,75207.28,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12135,,"4,044.85 x patient days",12135,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,17440,,"27,634 x DRG weight",17440,Other,base rate x DRG weight,14823,,"23,488 x DRG weight",14823,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9982,,"3,327.21 x patient days",9982,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9134,,"3,044.51 x patient days",9134,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,17941,,"5,980.29 x patient days",17941,Per diem,,21138,,"7,045.87 x patient days",21138,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,8155,,"2,718.31 x patient days",8155,Per diem,,0.01,21138,
Diabetes,420-3,APR-DRG,,,,,,,,inpatient,,,133976.81,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12135,,"4,044.85 x patient days",12135,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,27007,,"27,634 x DRG weight",27007,Other,base rate x DRG weight,22955,,"23,488 x DRG weight",22955,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9982,,"3,327.21 x patient days",9982,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9134,,"3,044.51 x patient days",9134,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,17941,,"5,980.29 x patient days",17941,Per diem,,21138,,"7,045.87 x patient days",21138,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,8155,,"2,718.31 x patient days",8155,Per diem,,0.01,27007,
Diabetes,420-4,APR-DRG,,,,,,,,inpatient,,,223694.25,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12135,,"4,044.85 x patient days",12135,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,70190,,"27,634 x DRG weight",70190,Other,base rate x DRG weight,59660,,"23,488 x DRG weight",59660,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9982,,"3,327.21 x patient days",9982,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9134,,"3,044.51 x patient days",9134,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,17941,,"5,980.29 x patient days",17941,Per diem,,21138,,"7,045.87 x patient days",21138,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,8155,,"2,718.31 x patient days",8155,Per diem,,0.01,70190,
"Malnutrition, failure to thrive & other nutritional disorders",421-1,APR-DRG,,,,,,,,inpatient,,,127625.58,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,24269,,"4,044.85 x patient days",24269,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,17271,,"27,634 x DRG weight",17271,Other,base rate x DRG weight,14680,,"23,488 x DRG weight",14680,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,13048,,"2,174.65 x patient days",13048,Per diem,,13048,,"2,174.65 x patient days",13048,Per diem,,13048,,"2,174.65 x patient days",13048,Per diem,,13048,,"2,174.65 x patient days",13048,Per diem,,29358,,"4,892.96 x patient days",29358,Per diem,,19963,,"3,327.21 x patient days",19963,Per diem,,29358,,"4,892.96 x patient days",29358,Per diem,,18267,,"3,044.51 x patient days",18267,Per diem,,29358,,"4,892.96 x patient days",29358,Per diem,,35882,,"5,980.29 x patient days",35882,Per diem,,42276,,"7,045.87 x patient days",42276,Per diem,,28053,,"4,675.50 x patient days",28053,Per diem,,28053,,"4,675.50 x patient days",28053,Per diem,,16310,,"2,718.31 x patient days",16310,Per diem,,0.01,42276,
"Malnutrition, failure to thrive & other nutritional disorders",421-2,APR-DRG,,,,,,,,inpatient,,,121725.63,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,24269,,"4,044.85 x patient days",24269,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,25238,,"27,634 x DRG weight",25238,Other,base rate x DRG weight,21452,,"23,488 x DRG weight",21452,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,13048,,"2,174.65 x patient days",13048,Per diem,,13048,,"2,174.65 x patient days",13048,Per diem,,13048,,"2,174.65 x patient days",13048,Per diem,,13048,,"2,174.65 x patient days",13048,Per diem,,29358,,"4,892.96 x patient days",29358,Per diem,,19963,,"3,327.21 x patient days",19963,Per diem,,29358,,"4,892.96 x patient days",29358,Per diem,,18267,,"3,044.51 x patient days",18267,Per diem,,29358,,"4,892.96 x patient days",29358,Per diem,,35882,,"5,980.29 x patient days",35882,Per diem,,42276,,"7,045.87 x patient days",42276,Per diem,,28053,,"4,675.50 x patient days",28053,Per diem,,28053,,"4,675.50 x patient days",28053,Per diem,,16310,,"2,718.31 x patient days",16310,Per diem,,0.01,42276,
"Malnutrition, failure to thrive & other nutritional disorders",421-3,APR-DRG,,,,,,,,inpatient,,,355059.19,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,24269,,"4,044.85 x patient days",24269,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,38345,,"27,634 x DRG weight",38345,Other,base rate x DRG weight,32592,,"23,488 x DRG weight",32592,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,13048,,"2,174.65 x patient days",13048,Per diem,,13048,,"2,174.65 x patient days",13048,Per diem,,13048,,"2,174.65 x patient days",13048,Per diem,,13048,,"2,174.65 x patient days",13048,Per diem,,29358,,"4,892.96 x patient days",29358,Per diem,,19963,,"3,327.21 x patient days",19963,Per diem,,29358,,"4,892.96 x patient days",29358,Per diem,,18267,,"3,044.51 x patient days",18267,Per diem,,29358,,"4,892.96 x patient days",29358,Per diem,,35882,,"5,980.29 x patient days",35882,Per diem,,42276,,"7,045.87 x patient days",42276,Per diem,,28053,,"4,675.50 x patient days",28053,Per diem,,28053,,"4,675.50 x patient days",28053,Per diem,,16310,,"2,718.31 x patient days",16310,Per diem,,0.01,42276,
"Malnutrition, failure to thrive & other nutritional disorders",421-4,APR-DRG,,,,,,,,inpatient,,,205682.34,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,24269,,"4,044.85 x patient days",24269,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,88465,,"27,634 x DRG weight",88465,Other,base rate x DRG weight,75192,,"23,488 x DRG weight",75192,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,13048,,"2,174.65 x patient days",13048,Per diem,,13048,,"2,174.65 x patient days",13048,Per diem,,13048,,"2,174.65 x patient days",13048,Per diem,,13048,,"2,174.65 x patient days",13048,Per diem,,29358,,"4,892.96 x patient days",29358,Per diem,,19963,,"3,327.21 x patient days",19963,Per diem,,29358,,"4,892.96 x patient days",29358,Per diem,,18267,,"3,044.51 x patient days",18267,Per diem,,29358,,"4,892.96 x patient days",29358,Per diem,,35882,,"5,980.29 x patient days",35882,Per diem,,42276,,"7,045.87 x patient days",42276,Per diem,,28053,,"4,675.50 x patient days",28053,Per diem,,28053,,"4,675.50 x patient days",28053,Per diem,,16310,,"2,718.31 x patient days",16310,Per diem,,0.01,88465,
Hypovolemia & related electrolyte disorders,422-1,APR-DRG,,,,,,,,inpatient,,,85262.25,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12135,,"4,044.85 x patient days",12135,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,10448,,"27,634 x DRG weight",10448,Other,base rate x DRG weight,8881,,"23,488 x DRG weight",8881,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9982,,"3,327.21 x patient days",9982,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9134,,"3,044.51 x patient days",9134,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,17941,,"5,980.29 x patient days",17941,Per diem,,21138,,"7,045.87 x patient days",21138,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,8155,,"2,718.31 x patient days",8155,Per diem,,0.01,21138,
Hypovolemia & related electrolyte disorders,422-2,APR-DRG,,,,,,,,inpatient,,,81502.25,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12135,,"4,044.85 x patient days",12135,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,14535,,"27,634 x DRG weight",14535,Other,base rate x DRG weight,12355,,"23,488 x DRG weight",12355,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9982,,"3,327.21 x patient days",9982,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9134,,"3,044.51 x patient days",9134,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,17941,,"5,980.29 x patient days",17941,Per diem,,21138,,"7,045.87 x patient days",21138,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,8155,,"2,718.31 x patient days",8155,Per diem,,0.01,21138,
Hypovolemia & related electrolyte disorders,422-3,APR-DRG,,,,,,,,inpatient,,,115102.3,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12135,,"4,044.85 x patient days",12135,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,24926,,"27,634 x DRG weight",24926,Other,base rate x DRG weight,21186,,"23,488 x DRG weight",21186,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9982,,"3,327.21 x patient days",9982,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9134,,"3,044.51 x patient days",9134,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,17941,,"5,980.29 x patient days",17941,Per diem,,21138,,"7,045.87 x patient days",21138,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,8155,,"2,718.31 x patient days",8155,Per diem,,0.01,24926,
Hypovolemia & related electrolyte disorders,422-4,APR-DRG,,,,,,,,inpatient,,,105920.44,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12135,,"4,044.85 x patient days",12135,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,62737,,"27,634 x DRG weight",62737,Other,base rate x DRG weight,53325,,"23,488 x DRG weight",53325,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9982,,"3,327.21 x patient days",9982,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9134,,"3,044.51 x patient days",9134,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,17941,,"5,980.29 x patient days",17941,Per diem,,21138,,"7,045.87 x patient days",21138,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,8155,,"2,718.31 x patient days",8155,Per diem,,0.01,62737,
Inborn errors of metabolism,423-1,APR-DRG,,,,,,,,inpatient,,,50691.92,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,20224,,"4,044.85 x patient days",20224,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,16978,,"27,634 x DRG weight",16978,Other,base rate x DRG weight,14431,,"23,488 x DRG weight",14431,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,16636,,"3,327.21 x patient days",16636,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,15222,,"3,044.51 x patient days",15222,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,29901,,"5,980.29 x patient days",29901,Per diem,,35229,,"7,045.87 x patient days",35229,Per diem,,23377,,"4,675.50 x patient days",23377,Per diem,,23377,,"4,675.50 x patient days",23377,Per diem,,13591,,"2,718.31 x patient days",13591,Per diem,,0.01,35229,
Inborn errors of metabolism,423-2,APR-DRG,,,,,,,,inpatient,,,93533.06,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,20224,,"4,044.85 x patient days",20224,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,27946,,"27,634 x DRG weight",27946,Other,base rate x DRG weight,23753,,"23,488 x DRG weight",23753,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,16636,,"3,327.21 x patient days",16636,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,15222,,"3,044.51 x patient days",15222,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,29901,,"5,980.29 x patient days",29901,Per diem,,35229,,"7,045.87 x patient days",35229,Per diem,,23377,,"4,675.50 x patient days",23377,Per diem,,23377,,"4,675.50 x patient days",23377,Per diem,,13591,,"2,718.31 x patient days",13591,Per diem,,0.01,35229,
Inborn errors of metabolism,423-3,APR-DRG,,,,,,,,inpatient,,,74556.86,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,20224,,"4,044.85 x patient days",20224,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,44209,,"27,634 x DRG weight",44209,Other,base rate x DRG weight,37576,,"23,488 x DRG weight",37576,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,16636,,"3,327.21 x patient days",16636,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,15222,,"3,044.51 x patient days",15222,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,29901,,"5,980.29 x patient days",29901,Per diem,,35229,,"7,045.87 x patient days",35229,Per diem,,23377,,"4,675.50 x patient days",23377,Per diem,,23377,,"4,675.50 x patient days",23377,Per diem,,13591,,"2,718.31 x patient days",13591,Per diem,,0.01,44209,
Inborn errors of metabolism,423-4,APR-DRG,,,,,,,,inpatient,,,93533.06,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,20224,,"4,044.85 x patient days",20224,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,150282,,"27,634 x DRG weight",150282,Other,base rate x DRG weight,127735,,"23,488 x DRG weight",127735,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,16636,,"3,327.21 x patient days",16636,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,15222,,"3,044.51 x patient days",15222,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,29901,,"5,980.29 x patient days",29901,Per diem,,35229,,"7,045.87 x patient days",35229,Per diem,,23377,,"4,675.50 x patient days",23377,Per diem,,23377,,"4,675.50 x patient days",23377,Per diem,,13591,,"2,718.31 x patient days",13591,Per diem,,0.01,150282,
Other endocrine disorders,424-1,APR-DRG,,,,,,,,inpatient,,,68263.39,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,16180,,"4,044.85 x patient days",16180,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,13787,,"27,634 x DRG weight",13787,Other,base rate x DRG weight,11718,,"23,488 x DRG weight",11718,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,13309,,"3,327.21 x patient days",13309,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,12179,,"3,044.51 x patient days",12179,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,23922,,"5,980.29 x patient days",23922,Per diem,,28185,,"7,045.87 x patient days",28185,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,10874,,"2,718.31 x patient days",10874,Per diem,,0.01,28185,
Other endocrine disorders,424-2,APR-DRG,,,,,,,,inpatient,,,95654.15,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,16180,,"4,044.85 x patient days",16180,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,20985,,"27,634 x DRG weight",20985,Other,base rate x DRG weight,17837,,"23,488 x DRG weight",17837,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,13309,,"3,327.21 x patient days",13309,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,12179,,"3,044.51 x patient days",12179,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,23922,,"5,980.29 x patient days",23922,Per diem,,28185,,"7,045.87 x patient days",28185,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,10874,,"2,718.31 x patient days",10874,Per diem,,0.01,28185,
Other endocrine disorders,424-3,APR-DRG,,,,,,,,inpatient,,,207825.95,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,16180,,"4,044.85 x patient days",16180,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,32755,,"27,634 x DRG weight",32755,Other,base rate x DRG weight,27840,,"23,488 x DRG weight",27840,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,13309,,"3,327.21 x patient days",13309,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,12179,,"3,044.51 x patient days",12179,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,23922,,"5,980.29 x patient days",23922,Per diem,,28185,,"7,045.87 x patient days",28185,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,10874,,"2,718.31 x patient days",10874,Per diem,,0.01,32755,
Other endocrine disorders,424-4,APR-DRG,,,,,,,,inpatient,,,388170.69,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,16180,,"4,044.85 x patient days",16180,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,76908,,"27,634 x DRG weight",76908,Other,base rate x DRG weight,65369,,"23,488 x DRG weight",65369,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,13309,,"3,327.21 x patient days",13309,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,12179,,"3,044.51 x patient days",12179,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,23922,,"5,980.29 x patient days",23922,Per diem,,28185,,"7,045.87 x patient days",28185,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,10874,,"2,718.31 x patient days",10874,Per diem,,0.01,76908,
Electrolyte disorders except hypovolemia related,425-1,APR-DRG,,,,,,,,inpatient,,,105839.05,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,16180,,"4,044.85 x patient days",16180,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,11905,,"27,634 x DRG weight",11905,Other,base rate x DRG weight,10119,,"23,488 x DRG weight",10119,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,13309,,"3,327.21 x patient days",13309,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,12179,,"3,044.51 x patient days",12179,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,23922,,"5,980.29 x patient days",23922,Per diem,,28185,,"7,045.87 x patient days",28185,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,10874,,"2,718.31 x patient days",10874,Per diem,,0.01,28185,
Electrolyte disorders except hypovolemia related,425-2,APR-DRG,,,,,,,,inpatient,,,120854.7,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,16180,,"4,044.85 x patient days",16180,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,16603,,"27,634 x DRG weight",16603,Other,base rate x DRG weight,14112,,"23,488 x DRG weight",14112,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,13309,,"3,327.21 x patient days",13309,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,12179,,"3,044.51 x patient days",12179,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,23922,,"5,980.29 x patient days",23922,Per diem,,28185,,"7,045.87 x patient days",28185,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,10874,,"2,718.31 x patient days",10874,Per diem,,0.01,28185,
Electrolyte disorders except hypovolemia related,425-3,APR-DRG,,,,,,,,inpatient,,,159337.12,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,16180,,"4,044.85 x patient days",16180,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,27590,,"27,634 x DRG weight",27590,Other,base rate x DRG weight,23450,,"23,488 x DRG weight",23450,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,13309,,"3,327.21 x patient days",13309,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,12179,,"3,044.51 x patient days",12179,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,23922,,"5,980.29 x patient days",23922,Per diem,,28185,,"7,045.87 x patient days",28185,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,10874,,"2,718.31 x patient days",10874,Per diem,,0.01,28185,
Electrolyte disorders except hypovolemia related,425-4,APR-DRG,,,,,,,,inpatient,,,303475.19,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,16180,,"4,044.85 x patient days",16180,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,68836,,"27,634 x DRG weight",68836,Other,base rate x DRG weight,58509,,"23,488 x DRG weight",58509,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,13309,,"3,327.21 x patient days",13309,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,12179,,"3,044.51 x patient days",12179,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,23922,,"5,980.29 x patient days",23922,Per diem,,28185,,"7,045.87 x patient days",28185,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,10874,,"2,718.31 x patient days",10874,Per diem,,0.01,68836,
Major bladder procedures,441-1,APR-DRG,,,,,,,,inpatient,,,180473.25,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,32358,,"4,044.85 x patient days",32358,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,35383,,"27,634 x DRG weight",35383,Other,base rate x DRG weight,30074,,"23,488 x DRG weight",30074,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,17397,,"2,174.65 x patient days",17397,Per diem,,17397,,"2,174.65 x patient days",17397,Per diem,,17397,,"2,174.65 x patient days",17397,Per diem,,17397,,"2,174.65 x patient days",17397,Per diem,,39143,,"4,892.96 x patient days",39143,Per diem,,26617,,"3,327.21 x patient days",26617,Per diem,,39143,,"4,892.96 x patient days",39143,Per diem,,24356,,"3,044.51 x patient days",24356,Per diem,,39143,,"4,892.96 x patient days",39143,Per diem,,47842,,"5,980.29 x patient days",47842,Per diem,,56366,,"7,045.87 x patient days",56366,Per diem,,37404,,"4,675.50 x patient days",37404,Per diem,,37404,,"4,675.50 x patient days",37404,Per diem,,21746,,"2,718.31 x patient days",21746,Per diem,,0.01,56366,
Major bladder procedures,441-2,APR-DRG,,,,,,,,inpatient,,,340110.47,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,32358,,"4,044.85 x patient days",32358,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,61522,,"27,634 x DRG weight",61522,Other,base rate x DRG weight,52291,,"23,488 x DRG weight",52291,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,17397,,"2,174.65 x patient days",17397,Per diem,,17397,,"2,174.65 x patient days",17397,Per diem,,17397,,"2,174.65 x patient days",17397,Per diem,,17397,,"2,174.65 x patient days",17397,Per diem,,39143,,"4,892.96 x patient days",39143,Per diem,,26617,,"3,327.21 x patient days",26617,Per diem,,39143,,"4,892.96 x patient days",39143,Per diem,,24356,,"3,044.51 x patient days",24356,Per diem,,39143,,"4,892.96 x patient days",39143,Per diem,,47842,,"5,980.29 x patient days",47842,Per diem,,56366,,"7,045.87 x patient days",56366,Per diem,,37404,,"4,675.50 x patient days",37404,Per diem,,37404,,"4,675.50 x patient days",37404,Per diem,,21746,,"2,718.31 x patient days",21746,Per diem,,0.01,61522,
Major bladder procedures,441-3,APR-DRG,,,,,,,,inpatient,,,322830.08,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,32358,,"4,044.85 x patient days",32358,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,86984,,"27,634 x DRG weight",86984,Other,base rate x DRG weight,73933,,"23,488 x DRG weight",73933,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,17397,,"2,174.65 x patient days",17397,Per diem,,17397,,"2,174.65 x patient days",17397,Per diem,,17397,,"2,174.65 x patient days",17397,Per diem,,17397,,"2,174.65 x patient days",17397,Per diem,,39143,,"4,892.96 x patient days",39143,Per diem,,26617,,"3,327.21 x patient days",26617,Per diem,,39143,,"4,892.96 x patient days",39143,Per diem,,24356,,"3,044.51 x patient days",24356,Per diem,,39143,,"4,892.96 x patient days",39143,Per diem,,47842,,"5,980.29 x patient days",47842,Per diem,,56366,,"7,045.87 x patient days",56366,Per diem,,37404,,"4,675.50 x patient days",37404,Per diem,,37404,,"4,675.50 x patient days",37404,Per diem,,21746,,"2,718.31 x patient days",21746,Per diem,,0.01,86984,
Major bladder procedures,441-4,APR-DRG,,,,,,,,inpatient,,,1688756.06,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,32358,,"4,044.85 x patient days",32358,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,186897,,"27,634 x DRG weight",186897,Other,base rate x DRG weight,158856,,"23,488 x DRG weight",158856,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,17397,,"2,174.65 x patient days",17397,Per diem,,17397,,"2,174.65 x patient days",17397,Per diem,,17397,,"2,174.65 x patient days",17397,Per diem,,17397,,"2,174.65 x patient days",17397,Per diem,,39143,,"4,892.96 x patient days",39143,Per diem,,26617,,"3,327.21 x patient days",26617,Per diem,,39143,,"4,892.96 x patient days",39143,Per diem,,24356,,"3,044.51 x patient days",24356,Per diem,,39143,,"4,892.96 x patient days",39143,Per diem,,47842,,"5,980.29 x patient days",47842,Per diem,,56366,,"7,045.87 x patient days",56366,Per diem,,37404,,"4,675.50 x patient days",37404,Per diem,,37404,,"4,675.50 x patient days",37404,Per diem,,21746,,"2,718.31 x patient days",21746,Per diem,,0.01,186897,
Kidney & urinary tract procedures for malignancy,442-1,APR-DRG,,,,,,,,inpatient,,,102373.65,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,16180,,"4,044.85 x patient days",16180,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,35758,,"27,634 x DRG weight",35758,Other,base rate x DRG weight,30393,,"23,488 x DRG weight",30393,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,13309,,"3,327.21 x patient days",13309,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,12179,,"3,044.51 x patient days",12179,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,23922,,"5,980.29 x patient days",23922,Per diem,,28185,,"7,045.87 x patient days",28185,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,10874,,"2,718.31 x patient days",10874,Per diem,,0.01,35758,
Kidney & urinary tract procedures for malignancy,442-2,APR-DRG,,,,,,,,inpatient,,,590501.21,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,16180,,"4,044.85 x patient days",16180,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,42482,,"27,634 x DRG weight",42482,Other,base rate x DRG weight,36108,,"23,488 x DRG weight",36108,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,13309,,"3,327.21 x patient days",13309,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,12179,,"3,044.51 x patient days",12179,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,23922,,"5,980.29 x patient days",23922,Per diem,,28185,,"7,045.87 x patient days",28185,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,10874,,"2,718.31 x patient days",10874,Per diem,,0.01,42482,
Kidney & urinary tract procedures for malignancy,442-3,APR-DRG,,,,,,,,inpatient,,,76036.4,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,16180,,"4,044.85 x patient days",16180,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,77809,,"27,634 x DRG weight",77809,Other,base rate x DRG weight,66135,,"23,488 x DRG weight",66135,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,13309,,"3,327.21 x patient days",13309,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,12179,,"3,044.51 x patient days",12179,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,23922,,"5,980.29 x patient days",23922,Per diem,,28185,,"7,045.87 x patient days",28185,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,10874,,"2,718.31 x patient days",10874,Per diem,,0.01,77809,
Kidney & urinary tract procedures for malignancy,442-4,APR-DRG,,,,,,,,inpatient,,,988215.49,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,16180,,"4,044.85 x patient days",16180,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,176192,,"27,634 x DRG weight",176192,Other,base rate x DRG weight,149757,,"23,488 x DRG weight",149757,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,13309,,"3,327.21 x patient days",13309,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,12179,,"3,044.51 x patient days",12179,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,23922,,"5,980.29 x patient days",23922,Per diem,,28185,,"7,045.87 x patient days",28185,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,10874,,"2,718.31 x patient days",10874,Per diem,,0.01,176192,
Kidney & urinary tract procedures for nonmalignancy,443-1,APR-DRG,,,,,,,,inpatient,,,104003.82,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12135,,"4,044.85 x patient days",12135,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,29637,,"27,634 x DRG weight",29637,Other,base rate x DRG weight,25191,,"23,488 x DRG weight",25191,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9982,,"3,327.21 x patient days",9982,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9134,,"3,044.51 x patient days",9134,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,17941,,"5,980.29 x patient days",17941,Per diem,,21138,,"7,045.87 x patient days",21138,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,8155,,"2,718.31 x patient days",8155,Per diem,,0.01,29637,
Kidney & urinary tract procedures for nonmalignancy,443-2,APR-DRG,,,,,,,,inpatient,,,167322.68,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12135,,"4,044.85 x patient days",12135,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,32937,,"27,634 x DRG weight",32937,Other,base rate x DRG weight,27995,,"23,488 x DRG weight",27995,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9982,,"3,327.21 x patient days",9982,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9134,,"3,044.51 x patient days",9134,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,17941,,"5,980.29 x patient days",17941,Per diem,,21138,,"7,045.87 x patient days",21138,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,8155,,"2,718.31 x patient days",8155,Per diem,,0.01,32937,
Kidney & urinary tract procedures for nonmalignancy,443-3,APR-DRG,,,,,,,,inpatient,,,388033.07,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12135,,"4,044.85 x patient days",12135,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,62779,,"27,634 x DRG weight",62779,Other,base rate x DRG weight,53360,,"23,488 x DRG weight",53360,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9982,,"3,327.21 x patient days",9982,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9134,,"3,044.51 x patient days",9134,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,17941,,"5,980.29 x patient days",17941,Per diem,,21138,,"7,045.87 x patient days",21138,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,8155,,"2,718.31 x patient days",8155,Per diem,,0.01,62779,
Kidney & urinary tract procedures for nonmalignancy,443-4,APR-DRG,,,,,,,,inpatient,,,689506.03,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12135,,"4,044.85 x patient days",12135,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,140044,,"27,634 x DRG weight",140044,Other,base rate x DRG weight,119032,,"23,488 x DRG weight",119032,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9982,,"3,327.21 x patient days",9982,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9134,,"3,044.51 x patient days",9134,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,17941,,"5,980.29 x patient days",17941,Per diem,,21138,,"7,045.87 x patient days",21138,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,8155,,"2,718.31 x patient days",8155,Per diem,,0.01,140044,
Renal dialysis access device procedure only,444-1,APR-DRG,,,,,,,,inpatient,,,321039.32,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,44493,,"4,044.85 x patient days",44493,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,27148,,"27,634 x DRG weight",27148,Other,base rate x DRG weight,23075,,"23,488 x DRG weight",23075,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,23921,,"2,174.65 x patient days",23921,Per diem,,23921,,"2,174.65 x patient days",23921,Per diem,,23921,,"2,174.65 x patient days",23921,Per diem,,23921,,"2,174.65 x patient days",23921,Per diem,,53822,,"4,892.96 x patient days",53822,Per diem,,36599,,"3,327.21 x patient days",36599,Per diem,,53822,,"4,892.96 x patient days",53822,Per diem,,33489,,"3,044.51 x patient days",33489,Per diem,,53822,,"4,892.96 x patient days",53822,Per diem,,65783,,"5,980.29 x patient days",65783,Per diem,,77504,,"7,045.87 x patient days",77504,Per diem,,51430,,"4,675.50 x patient days",51430,Per diem,,51430,,"4,675.50 x patient days",51430,Per diem,,29901,,"2,718.31 x patient days",29901,Per diem,,0.01,77504,
Renal dialysis access device procedure only,444-2,APR-DRG,,,,,,,,inpatient,,,321039.32,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,44493,,"4,044.85 x patient days",44493,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,48274,,"27,634 x DRG weight",48274,Other,base rate x DRG weight,41031,,"23,488 x DRG weight",41031,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,23921,,"2,174.65 x patient days",23921,Per diem,,23921,,"2,174.65 x patient days",23921,Per diem,,23921,,"2,174.65 x patient days",23921,Per diem,,23921,,"2,174.65 x patient days",23921,Per diem,,53822,,"4,892.96 x patient days",53822,Per diem,,36599,,"3,327.21 x patient days",36599,Per diem,,53822,,"4,892.96 x patient days",53822,Per diem,,33489,,"3,044.51 x patient days",33489,Per diem,,53822,,"4,892.96 x patient days",53822,Per diem,,65783,,"5,980.29 x patient days",65783,Per diem,,77504,,"7,045.87 x patient days",77504,Per diem,,51430,,"4,675.50 x patient days",51430,Per diem,,51430,,"4,675.50 x patient days",51430,Per diem,,29901,,"2,718.31 x patient days",29901,Per diem,,0.01,77504,
Renal dialysis access device procedure only,444-3,APR-DRG,,,,,,,,inpatient,,,556534.6,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,44493,,"4,044.85 x patient days",44493,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,89330,,"27,634 x DRG weight",89330,Other,base rate x DRG weight,75927,,"23,488 x DRG weight",75927,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,23921,,"2,174.65 x patient days",23921,Per diem,,23921,,"2,174.65 x patient days",23921,Per diem,,23921,,"2,174.65 x patient days",23921,Per diem,,23921,,"2,174.65 x patient days",23921,Per diem,,53822,,"4,892.96 x patient days",53822,Per diem,,36599,,"3,327.21 x patient days",36599,Per diem,,53822,,"4,892.96 x patient days",53822,Per diem,,33489,,"3,044.51 x patient days",33489,Per diem,,53822,,"4,892.96 x patient days",53822,Per diem,,65783,,"5,980.29 x patient days",65783,Per diem,,77504,,"7,045.87 x patient days",77504,Per diem,,51430,,"4,675.50 x patient days",51430,Per diem,,51430,,"4,675.50 x patient days",51430,Per diem,,29901,,"2,718.31 x patient days",29901,Per diem,,0.01,89330,
Renal dialysis access device procedure only,444-4,APR-DRG,,,,,,,,inpatient,,,1163823.62,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,44493,,"4,044.85 x patient days",44493,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,170941,,"27,634 x DRG weight",170941,Other,base rate x DRG weight,145294,,"23,488 x DRG weight",145294,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,23921,,"2,174.65 x patient days",23921,Per diem,,23921,,"2,174.65 x patient days",23921,Per diem,,23921,,"2,174.65 x patient days",23921,Per diem,,23921,,"2,174.65 x patient days",23921,Per diem,,53822,,"4,892.96 x patient days",53822,Per diem,,36599,,"3,327.21 x patient days",36599,Per diem,,53822,,"4,892.96 x patient days",53822,Per diem,,33489,,"3,044.51 x patient days",33489,Per diem,,53822,,"4,892.96 x patient days",53822,Per diem,,65783,,"5,980.29 x patient days",65783,Per diem,,77504,,"7,045.87 x patient days",77504,Per diem,,51430,,"4,675.50 x patient days",51430,Per diem,,51430,,"4,675.50 x patient days",51430,Per diem,,29901,,"2,718.31 x patient days",29901,Per diem,,0.01,170941,
Other bladder procedures,445-1,APR-DRG,,,,,,,,inpatient,,,101955.17,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,16180,,"4,044.85 x patient days",16180,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,22699,,"27,634 x DRG weight",22699,Other,base rate x DRG weight,19293,,"23,488 x DRG weight",19293,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,13309,,"3,327.21 x patient days",13309,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,12179,,"3,044.51 x patient days",12179,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,23922,,"5,980.29 x patient days",23922,Per diem,,28185,,"7,045.87 x patient days",28185,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,10874,,"2,718.31 x patient days",10874,Per diem,,0.01,28185,
Other bladder procedures,445-2,APR-DRG,,,,,,,,inpatient,,,205189.97,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,16180,,"4,044.85 x patient days",16180,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,35070,,"27,634 x DRG weight",35070,Other,base rate x DRG weight,29809,,"23,488 x DRG weight",29809,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,13309,,"3,327.21 x patient days",13309,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,12179,,"3,044.51 x patient days",12179,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,23922,,"5,980.29 x patient days",23922,Per diem,,28185,,"7,045.87 x patient days",28185,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,10874,,"2,718.31 x patient days",10874,Per diem,,0.01,35070,
Other bladder procedures,445-3,APR-DRG,,,,,,,,inpatient,,,132329.99,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,16180,,"4,044.85 x patient days",16180,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,51753,,"27,634 x DRG weight",51753,Other,base rate x DRG weight,43988,,"23,488 x DRG weight",43988,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,13309,,"3,327.21 x patient days",13309,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,12179,,"3,044.51 x patient days",12179,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,23922,,"5,980.29 x patient days",23922,Per diem,,28185,,"7,045.87 x patient days",28185,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,10874,,"2,718.31 x patient days",10874,Per diem,,0.01,51753,
Other bladder procedures,445-4,APR-DRG,,,,,,,,inpatient,,,196057.95,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,16180,,"4,044.85 x patient days",16180,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,67692,,"27,634 x DRG weight",67692,Other,base rate x DRG weight,57536,,"23,488 x DRG weight",57536,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,13309,,"3,327.21 x patient days",13309,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,12179,,"3,044.51 x patient days",12179,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,23922,,"5,980.29 x patient days",23922,Per diem,,28185,,"7,045.87 x patient days",28185,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,10874,,"2,718.31 x patient days",10874,Per diem,,0.01,67692,
Urethral & transurethral procedures,446-1,APR-DRG,,,,,,,,inpatient,,,66444.71,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8089,,"4,044.85 x patient days",8089,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,18915,,"27,634 x DRG weight",18915,Other,base rate x DRG weight,16078,,"23,488 x DRG weight",16078,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6654,,"3,327.21 x patient days",6654,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6089,,"3,044.51 x patient days",6089,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,11960,,"5,980.29 x patient days",11960,Per diem,,14091,,"7,045.87 x patient days",14091,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,5436,,"2,718.31 x patient days",5436,Per diem,,0.01,18915,
Urethral & transurethral procedures,446-2,APR-DRG,,,,,,,,inpatient,,,205189.97,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8089,,"4,044.85 x patient days",8089,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,21836,,"27,634 x DRG weight",21836,Other,base rate x DRG weight,18560,,"23,488 x DRG weight",18560,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6654,,"3,327.21 x patient days",6654,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6089,,"3,044.51 x patient days",6089,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,11960,,"5,980.29 x patient days",11960,Per diem,,14091,,"7,045.87 x patient days",14091,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,5436,,"2,718.31 x patient days",5436,Per diem,,0.01,21836,
Urethral & transurethral procedures,446-3,APR-DRG,,,,,,,,inpatient,,,196057.95,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8089,,"4,044.85 x patient days",8089,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,41667,,"27,634 x DRG weight",41667,Other,base rate x DRG weight,35415,,"23,488 x DRG weight",35415,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6654,,"3,327.21 x patient days",6654,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6089,,"3,044.51 x patient days",6089,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,11960,,"5,980.29 x patient days",11960,Per diem,,14091,,"7,045.87 x patient days",14091,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,5436,,"2,718.31 x patient days",5436,Per diem,,0.01,41667,
Urethral & transurethral procedures,446-4,APR-DRG,,,,,,,,inpatient,,,196057.95,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8089,,"4,044.85 x patient days",8089,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,90885,,"27,634 x DRG weight",90885,Other,base rate x DRG weight,77250,,"23,488 x DRG weight",77250,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6654,,"3,327.21 x patient days",6654,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6089,,"3,044.51 x patient days",6089,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,11960,,"5,980.29 x patient days",11960,Per diem,,14091,,"7,045.87 x patient days",14091,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,5436,,"2,718.31 x patient days",5436,Per diem,,0.01,90885,
"Other kidney, urinary tract & related procedures",447-1,APR-DRG,,,,,,,,inpatient,,,107041,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,36404,,"4,044.85 x patient days",36404,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,33070,,"27,634 x DRG weight",33070,Other,base rate x DRG weight,28108,,"23,488 x DRG weight",28108,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,19572,,"2,174.65 x patient days",19572,Per diem,,19572,,"2,174.65 x patient days",19572,Per diem,,19572,,"2,174.65 x patient days",19572,Per diem,,19572,,"2,174.65 x patient days",19572,Per diem,,44037,,"4,892.96 x patient days",44037,Per diem,,29945,,"3,327.21 x patient days",29945,Per diem,,44037,,"4,892.96 x patient days",44037,Per diem,,27401,,"3,044.51 x patient days",27401,Per diem,,44037,,"4,892.96 x patient days",44037,Per diem,,53823,,"5,980.29 x patient days",53823,Per diem,,63413,,"7,045.87 x patient days",63413,Per diem,,42080,,"4,675.50 x patient days",42080,Per diem,,42080,,"4,675.50 x patient days",42080,Per diem,,24465,,"2,718.31 x patient days",24465,Per diem,,0.01,63413,
"Other kidney, urinary tract & related procedures",447-2,APR-DRG,,,,,,,,inpatient,,,162930.24,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,36404,,"4,044.85 x patient days",36404,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,35991,,"27,634 x DRG weight",35991,Other,base rate x DRG weight,30591,,"23,488 x DRG weight",30591,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,19572,,"2,174.65 x patient days",19572,Per diem,,19572,,"2,174.65 x patient days",19572,Per diem,,19572,,"2,174.65 x patient days",19572,Per diem,,19572,,"2,174.65 x patient days",19572,Per diem,,44037,,"4,892.96 x patient days",44037,Per diem,,29945,,"3,327.21 x patient days",29945,Per diem,,44037,,"4,892.96 x patient days",44037,Per diem,,27401,,"3,044.51 x patient days",27401,Per diem,,44037,,"4,892.96 x patient days",44037,Per diem,,53823,,"5,980.29 x patient days",53823,Per diem,,63413,,"7,045.87 x patient days",63413,Per diem,,42080,,"4,675.50 x patient days",42080,Per diem,,42080,,"4,675.50 x patient days",42080,Per diem,,24465,,"2,718.31 x patient days",24465,Per diem,,0.01,63413,
"Other kidney, urinary tract & related procedures",447-3,APR-DRG,,,,,,,,inpatient,,,442194.01,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,36404,,"4,044.85 x patient days",36404,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,81001,,"27,634 x DRG weight",81001,Other,base rate x DRG weight,68848,,"23,488 x DRG weight",68848,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,19572,,"2,174.65 x patient days",19572,Per diem,,19572,,"2,174.65 x patient days",19572,Per diem,,19572,,"2,174.65 x patient days",19572,Per diem,,19572,,"2,174.65 x patient days",19572,Per diem,,44037,,"4,892.96 x patient days",44037,Per diem,,29945,,"3,327.21 x patient days",29945,Per diem,,44037,,"4,892.96 x patient days",44037,Per diem,,27401,,"3,044.51 x patient days",27401,Per diem,,44037,,"4,892.96 x patient days",44037,Per diem,,53823,,"5,980.29 x patient days",53823,Per diem,,63413,,"7,045.87 x patient days",63413,Per diem,,42080,,"4,675.50 x patient days",42080,Per diem,,42080,,"4,675.50 x patient days",42080,Per diem,,24465,,"2,718.31 x patient days",24465,Per diem,,0.01,81001,
"Other kidney, urinary tract & related procedures",447-4,APR-DRG,,,,,,,,inpatient,,,851118.64,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,36404,,"4,044.85 x patient days",36404,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,210864,,"27,634 x DRG weight",210864,Other,base rate x DRG weight,179228,,"23,488 x DRG weight",179228,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,19572,,"2,174.65 x patient days",19572,Per diem,,19572,,"2,174.65 x patient days",19572,Per diem,,19572,,"2,174.65 x patient days",19572,Per diem,,19572,,"2,174.65 x patient days",19572,Per diem,,44037,,"4,892.96 x patient days",44037,Per diem,,29945,,"3,327.21 x patient days",29945,Per diem,,44037,,"4,892.96 x patient days",44037,Per diem,,27401,,"3,044.51 x patient days",27401,Per diem,,44037,,"4,892.96 x patient days",44037,Per diem,,53823,,"5,980.29 x patient days",53823,Per diem,,63413,,"7,045.87 x patient days",63413,Per diem,,42080,,"4,675.50 x patient days",42080,Per diem,,42080,,"4,675.50 x patient days",42080,Per diem,,24465,,"2,718.31 x patient days",24465,Per diem,,0.01,210864,
Kidney & urinary tract malignancy,461-1,APR-DRG,,,,,,,,inpatient,,,107211.87,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,24269,,"4,044.85 x patient days",24269,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12562,,"27,634 x DRG weight",12562,Other,base rate x DRG weight,10678,,"23,488 x DRG weight",10678,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,13048,,"2,174.65 x patient days",13048,Per diem,,13048,,"2,174.65 x patient days",13048,Per diem,,13048,,"2,174.65 x patient days",13048,Per diem,,13048,,"2,174.65 x patient days",13048,Per diem,,29358,,"4,892.96 x patient days",29358,Per diem,,19963,,"3,327.21 x patient days",19963,Per diem,,29358,,"4,892.96 x patient days",29358,Per diem,,18267,,"3,044.51 x patient days",18267,Per diem,,29358,,"4,892.96 x patient days",29358,Per diem,,35882,,"5,980.29 x patient days",35882,Per diem,,42276,,"7,045.87 x patient days",42276,Per diem,,28053,,"4,675.50 x patient days",28053,Per diem,,28053,,"4,675.50 x patient days",28053,Per diem,,16310,,"2,718.31 x patient days",16310,Per diem,,0.01,42276,
Kidney & urinary tract malignancy,461-2,APR-DRG,,,,,,,,inpatient,,,270287.21,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,24269,,"4,044.85 x patient days",24269,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,22251,,"27,634 x DRG weight",22251,Other,base rate x DRG weight,18913,,"23,488 x DRG weight",18913,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,13048,,"2,174.65 x patient days",13048,Per diem,,13048,,"2,174.65 x patient days",13048,Per diem,,13048,,"2,174.65 x patient days",13048,Per diem,,13048,,"2,174.65 x patient days",13048,Per diem,,29358,,"4,892.96 x patient days",29358,Per diem,,19963,,"3,327.21 x patient days",19963,Per diem,,29358,,"4,892.96 x patient days",29358,Per diem,,18267,,"3,044.51 x patient days",18267,Per diem,,29358,,"4,892.96 x patient days",29358,Per diem,,35882,,"5,980.29 x patient days",35882,Per diem,,42276,,"7,045.87 x patient days",42276,Per diem,,28053,,"4,675.50 x patient days",28053,Per diem,,28053,,"4,675.50 x patient days",28053,Per diem,,16310,,"2,718.31 x patient days",16310,Per diem,,0.01,42276,
Kidney & urinary tract malignancy,461-3,APR-DRG,,,,,,,,inpatient,,,107211.87,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,24269,,"4,044.85 x patient days",24269,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,41531,,"27,634 x DRG weight",41531,Other,base rate x DRG weight,35300,,"23,488 x DRG weight",35300,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,13048,,"2,174.65 x patient days",13048,Per diem,,13048,,"2,174.65 x patient days",13048,Per diem,,13048,,"2,174.65 x patient days",13048,Per diem,,13048,,"2,174.65 x patient days",13048,Per diem,,29358,,"4,892.96 x patient days",29358,Per diem,,19963,,"3,327.21 x patient days",19963,Per diem,,29358,,"4,892.96 x patient days",29358,Per diem,,18267,,"3,044.51 x patient days",18267,Per diem,,29358,,"4,892.96 x patient days",29358,Per diem,,35882,,"5,980.29 x patient days",35882,Per diem,,42276,,"7,045.87 x patient days",42276,Per diem,,28053,,"4,675.50 x patient days",28053,Per diem,,28053,,"4,675.50 x patient days",28053,Per diem,,16310,,"2,718.31 x patient days",16310,Per diem,,0.01,42276,
Kidney & urinary tract malignancy,461-4,APR-DRG,,,,,,,,inpatient,,,165176,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,24269,,"4,044.85 x patient days",24269,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,64335,,"27,634 x DRG weight",64335,Other,base rate x DRG weight,54682,,"23,488 x DRG weight",54682,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,13048,,"2,174.65 x patient days",13048,Per diem,,13048,,"2,174.65 x patient days",13048,Per diem,,13048,,"2,174.65 x patient days",13048,Per diem,,13048,,"2,174.65 x patient days",13048,Per diem,,29358,,"4,892.96 x patient days",29358,Per diem,,19963,,"3,327.21 x patient days",19963,Per diem,,29358,,"4,892.96 x patient days",29358,Per diem,,18267,,"3,044.51 x patient days",18267,Per diem,,29358,,"4,892.96 x patient days",29358,Per diem,,35882,,"5,980.29 x patient days",35882,Per diem,,42276,,"7,045.87 x patient days",42276,Per diem,,28053,,"4,675.50 x patient days",28053,Per diem,,28053,,"4,675.50 x patient days",28053,Per diem,,16310,,"2,718.31 x patient days",16310,Per diem,,0.01,64335,
Nephritis & nephrosis,462-1,APR-DRG,,,,,,,,inpatient,,,101527,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,16180,,"4,044.85 x patient days",16180,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,16310,,"27,634 x DRG weight",16310,Other,base rate x DRG weight,13863,,"23,488 x DRG weight",13863,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,13309,,"3,327.21 x patient days",13309,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,12179,,"3,044.51 x patient days",12179,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,23922,,"5,980.29 x patient days",23922,Per diem,,28185,,"7,045.87 x patient days",28185,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,10874,,"2,718.31 x patient days",10874,Per diem,,0.01,28185,
Nephritis & nephrosis,462-2,APR-DRG,,,,,,,,inpatient,,,118283.36,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,16180,,"4,044.85 x patient days",16180,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,19811,,"27,634 x DRG weight",19811,Other,base rate x DRG weight,16839,,"23,488 x DRG weight",16839,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,13309,,"3,327.21 x patient days",13309,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,12179,,"3,044.51 x patient days",12179,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,23922,,"5,980.29 x patient days",23922,Per diem,,28185,,"7,045.87 x patient days",28185,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,10874,,"2,718.31 x patient days",10874,Per diem,,0.01,28185,
Nephritis & nephrosis,462-3,APR-DRG,,,,,,,,inpatient,,,159974.86,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,16180,,"4,044.85 x patient days",16180,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,34951,,"27,634 x DRG weight",34951,Other,base rate x DRG weight,29708,,"23,488 x DRG weight",29708,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,13309,,"3,327.21 x patient days",13309,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,12179,,"3,044.51 x patient days",12179,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,23922,,"5,980.29 x patient days",23922,Per diem,,28185,,"7,045.87 x patient days",28185,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,10874,,"2,718.31 x patient days",10874,Per diem,,0.01,34951,
Nephritis & nephrosis,462-4,APR-DRG,,,,,,,,inpatient,,,528355,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,16180,,"4,044.85 x patient days",16180,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,111036,,"27,634 x DRG weight",111036,Other,base rate x DRG weight,94377,,"23,488 x DRG weight",94377,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,13309,,"3,327.21 x patient days",13309,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,12179,,"3,044.51 x patient days",12179,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,23922,,"5,980.29 x patient days",23922,Per diem,,28185,,"7,045.87 x patient days",28185,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,10874,,"2,718.31 x patient days",10874,Per diem,,0.01,111036,
Kidney & urinary tract infections,463-1,APR-DRG,,,,,,,,inpatient,,,88371.52,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12135,,"4,044.85 x patient days",12135,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,13731,,"27,634 x DRG weight",13731,Other,base rate x DRG weight,11671,,"23,488 x DRG weight",11671,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9982,,"3,327.21 x patient days",9982,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9134,,"3,044.51 x patient days",9134,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,17941,,"5,980.29 x patient days",17941,Per diem,,21138,,"7,045.87 x patient days",21138,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,8155,,"2,718.31 x patient days",8155,Per diem,,0.01,21138,
Kidney & urinary tract infections,463-2,APR-DRG,,,,,,,,inpatient,,,98305.73,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12135,,"4,044.85 x patient days",12135,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,17415,,"27,634 x DRG weight",17415,Other,base rate x DRG weight,14802,,"23,488 x DRG weight",14802,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9982,,"3,327.21 x patient days",9982,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9134,,"3,044.51 x patient days",9134,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,17941,,"5,980.29 x patient days",17941,Per diem,,21138,,"7,045.87 x patient days",21138,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,8155,,"2,718.31 x patient days",8155,Per diem,,0.01,21138,
Kidney & urinary tract infections,463-3,APR-DRG,,,,,,,,inpatient,,,133813.3,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12135,,"4,044.85 x patient days",12135,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,27278,,"27,634 x DRG weight",27278,Other,base rate x DRG weight,23185,,"23,488 x DRG weight",23185,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9982,,"3,327.21 x patient days",9982,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9134,,"3,044.51 x patient days",9134,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,17941,,"5,980.29 x patient days",17941,Per diem,,21138,,"7,045.87 x patient days",21138,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,8155,,"2,718.31 x patient days",8155,Per diem,,0.01,27278,
Kidney & urinary tract infections,463-4,APR-DRG,,,,,,,,inpatient,,,201354.28,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12135,,"4,044.85 x patient days",12135,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,60270,,"27,634 x DRG weight",60270,Other,base rate x DRG weight,51227,,"23,488 x DRG weight",51227,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9982,,"3,327.21 x patient days",9982,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9134,,"3,044.51 x patient days",9134,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,17941,,"5,980.29 x patient days",17941,Per diem,,21138,,"7,045.87 x patient days",21138,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,8155,,"2,718.31 x patient days",8155,Per diem,,0.01,60270,
Urinary stones & acquired upper urinary tract obstruction,465-1,APR-DRG,,,,,,,,inpatient,,,77236.57,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8089,,"4,044.85 x patient days",8089,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12386,,"27,634 x DRG weight",12386,Other,base rate x DRG weight,10527,,"23,488 x DRG weight",10527,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6654,,"3,327.21 x patient days",6654,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6089,,"3,044.51 x patient days",6089,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,11960,,"5,980.29 x patient days",11960,Per diem,,14091,,"7,045.87 x patient days",14091,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,5436,,"2,718.31 x patient days",5436,Per diem,,0.01,14091,
Urinary stones & acquired upper urinary tract obstruction,465-2,APR-DRG,,,,,,,,inpatient,,,66276.31,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8089,,"4,044.85 x patient days",8089,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,14433,,"27,634 x DRG weight",14433,Other,base rate x DRG weight,12268,,"23,488 x DRG weight",12268,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6654,,"3,327.21 x patient days",6654,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6089,,"3,044.51 x patient days",6089,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,11960,,"5,980.29 x patient days",11960,Per diem,,14091,,"7,045.87 x patient days",14091,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,5436,,"2,718.31 x patient days",5436,Per diem,,0.01,14433,
Urinary stones & acquired upper urinary tract obstruction,465-3,APR-DRG,,,,,,,,inpatient,,,55073.64,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8089,,"4,044.85 x patient days",8089,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,24058,,"27,634 x DRG weight",24058,Other,base rate x DRG weight,20449,,"23,488 x DRG weight",20449,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6654,,"3,327.21 x patient days",6654,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6089,,"3,044.51 x patient days",6089,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,11960,,"5,980.29 x patient days",11960,Per diem,,14091,,"7,045.87 x patient days",14091,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,5436,,"2,718.31 x patient days",5436,Per diem,,0.01,24058,
Urinary stones & acquired upper urinary tract obstruction,465-4,APR-DRG,,,,,,,,inpatient,,,66276.31,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8089,,"4,044.85 x patient days",8089,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,59938,,"27,634 x DRG weight",59938,Other,base rate x DRG weight,50945,,"23,488 x DRG weight",50945,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6654,,"3,327.21 x patient days",6654,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6089,,"3,044.51 x patient days",6089,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,11960,,"5,980.29 x patient days",11960,Per diem,,14091,,"7,045.87 x patient days",14091,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,5436,,"2,718.31 x patient days",5436,Per diem,,0.01,59938,
"Malfunction, reaction, complic of genitourinary device or proc",466-1,APR-DRG,,,,,,,,inpatient,,,74000.35,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,20224,,"4,044.85 x patient days",20224,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,13881,,"27,634 x DRG weight",13881,Other,base rate x DRG weight,11798,,"23,488 x DRG weight",11798,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,16636,,"3,327.21 x patient days",16636,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,15222,,"3,044.51 x patient days",15222,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,29901,,"5,980.29 x patient days",29901,Per diem,,35229,,"7,045.87 x patient days",35229,Per diem,,23377,,"4,675.50 x patient days",23377,Per diem,,23377,,"4,675.50 x patient days",23377,Per diem,,13591,,"2,718.31 x patient days",13591,Per diem,,0.01,35229,
"Malfunction, reaction, complic of genitourinary device or proc",466-2,APR-DRG,,,,,,,,inpatient,,,142265.55,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,20224,,"4,044.85 x patient days",20224,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,19286,,"27,634 x DRG weight",19286,Other,base rate x DRG weight,16392,,"23,488 x DRG weight",16392,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,16636,,"3,327.21 x patient days",16636,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,15222,,"3,044.51 x patient days",15222,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,29901,,"5,980.29 x patient days",29901,Per diem,,35229,,"7,045.87 x patient days",35229,Per diem,,23377,,"4,675.50 x patient days",23377,Per diem,,23377,,"4,675.50 x patient days",23377,Per diem,,13591,,"2,718.31 x patient days",13591,Per diem,,0.01,35229,
"Malfunction, reaction, complic of genitourinary device or proc",466-3,APR-DRG,,,,,,,,inpatient,,,126134.28,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,20224,,"4,044.85 x patient days",20224,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,32152,,"27,634 x DRG weight",32152,Other,base rate x DRG weight,27328,,"23,488 x DRG weight",27328,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,16636,,"3,327.21 x patient days",16636,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,15222,,"3,044.51 x patient days",15222,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,29901,,"5,980.29 x patient days",29901,Per diem,,35229,,"7,045.87 x patient days",35229,Per diem,,23377,,"4,675.50 x patient days",23377,Per diem,,23377,,"4,675.50 x patient days",23377,Per diem,,13591,,"2,718.31 x patient days",13591,Per diem,,0.01,35229,
"Malfunction, reaction, complic of genitourinary device or proc",466-4,APR-DRG,,,,,,,,inpatient,,,252134.1,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,20224,,"4,044.85 x patient days",20224,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,64324,,"27,634 x DRG weight",64324,Other,base rate x DRG weight,54673,,"23,488 x DRG weight",54673,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,16636,,"3,327.21 x patient days",16636,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,15222,,"3,044.51 x patient days",15222,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,29901,,"5,980.29 x patient days",29901,Per diem,,35229,,"7,045.87 x patient days",35229,Per diem,,23377,,"4,675.50 x patient days",23377,Per diem,,23377,,"4,675.50 x patient days",23377,Per diem,,13591,,"2,718.31 x patient days",13591,Per diem,,0.01,64324,
"Other kidney & urinary tract diagnoses, signs & symptoms",468-1,APR-DRG,,,,,,,,inpatient,,,104668.6,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,16180,,"4,044.85 x patient days",16180,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,13916,,"27,634 x DRG weight",13916,Other,base rate x DRG weight,11829,,"23,488 x DRG weight",11829,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,13309,,"3,327.21 x patient days",13309,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,12179,,"3,044.51 x patient days",12179,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,23922,,"5,980.29 x patient days",23922,Per diem,,28185,,"7,045.87 x patient days",28185,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,10874,,"2,718.31 x patient days",10874,Per diem,,0.01,28185,
"Other kidney & urinary tract diagnoses, signs & symptoms",468-2,APR-DRG,,,,,,,,inpatient,,,163686.63,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,16180,,"4,044.85 x patient days",16180,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,20087,,"27,634 x DRG weight",20087,Other,base rate x DRG weight,17073,,"23,488 x DRG weight",17073,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,13309,,"3,327.21 x patient days",13309,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,12179,,"3,044.51 x patient days",12179,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,23922,,"5,980.29 x patient days",23922,Per diem,,28185,,"7,045.87 x patient days",28185,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,10874,,"2,718.31 x patient days",10874,Per diem,,0.01,28185,
"Other kidney & urinary tract diagnoses, signs & symptoms",468-3,APR-DRG,,,,,,,,inpatient,,,137408,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,16180,,"4,044.85 x patient days",16180,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,32868,,"27,634 x DRG weight",32868,Other,base rate x DRG weight,27937,,"23,488 x DRG weight",27937,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,13309,,"3,327.21 x patient days",13309,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,12179,,"3,044.51 x patient days",12179,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,23922,,"5,980.29 x patient days",23922,Per diem,,28185,,"7,045.87 x patient days",28185,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,10874,,"2,718.31 x patient days",10874,Per diem,,0.01,32868,
"Other kidney & urinary tract diagnoses, signs & symptoms",468-4,APR-DRG,,,,,,,,inpatient,,,274508.99,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,16180,,"4,044.85 x patient days",16180,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,77616,,"27,634 x DRG weight",77616,Other,base rate x DRG weight,65971,,"23,488 x DRG weight",65971,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,13309,,"3,327.21 x patient days",13309,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,12179,,"3,044.51 x patient days",12179,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,23922,,"5,980.29 x patient days",23922,Per diem,,28185,,"7,045.87 x patient days",28185,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,10874,,"2,718.31 x patient days",10874,Per diem,,0.01,77616,
Acute Kidney Injury #,469-1,APR-DRG,,,,,,,,inpatient,,,29936.1,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,20224,,"4,044.85 x patient days",20224,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,14549,,"27,634 x DRG weight",14549,Other,base rate x DRG weight,12366,,"23,488 x DRG weight",12366,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,16636,,"3,327.21 x patient days",16636,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,15222,,"3,044.51 x patient days",15222,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,29901,,"5,980.29 x patient days",29901,Per diem,,35229,,"7,045.87 x patient days",35229,Per diem,,23377,,"4,675.50 x patient days",23377,Per diem,,23377,,"4,675.50 x patient days",23377,Per diem,,13591,,"2,718.31 x patient days",13591,Per diem,,0.01,35229,
Acute Kidney Injury #,469-2,APR-DRG,,,,,,,,inpatient,,,120863.12,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,20224,,"4,044.85 x patient days",20224,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,20574,,"27,634 x DRG weight",20574,Other,base rate x DRG weight,17487,,"23,488 x DRG weight",17487,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,16636,,"3,327.21 x patient days",16636,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,15222,,"3,044.51 x patient days",15222,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,29901,,"5,980.29 x patient days",29901,Per diem,,35229,,"7,045.87 x patient days",35229,Per diem,,23377,,"4,675.50 x patient days",23377,Per diem,,23377,,"4,675.50 x patient days",23377,Per diem,,13591,,"2,718.31 x patient days",13591,Per diem,,0.01,35229,
Acute Kidney Injury #,469-3,APR-DRG,,,,,,,,inpatient,,,161358.66,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,20224,,"4,044.85 x patient days",20224,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,37532,,"27,634 x DRG weight",37532,Other,base rate x DRG weight,31901,,"23,488 x DRG weight",31901,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,16636,,"3,327.21 x patient days",16636,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,15222,,"3,044.51 x patient days",15222,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,29901,,"5,980.29 x patient days",29901,Per diem,,35229,,"7,045.87 x patient days",35229,Per diem,,23377,,"4,675.50 x patient days",23377,Per diem,,23377,,"4,675.50 x patient days",23377,Per diem,,13591,,"2,718.31 x patient days",13591,Per diem,,0.01,37532,
Acute Kidney Injury #,469-4,APR-DRG,,,,,,,,inpatient,,,543360.57,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,20224,,"4,044.85 x patient days",20224,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,91228,,"27,634 x DRG weight",91228,Other,base rate x DRG weight,77541,,"23,488 x DRG weight",77541,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,16636,,"3,327.21 x patient days",16636,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,15222,,"3,044.51 x patient days",15222,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,29901,,"5,980.29 x patient days",29901,Per diem,,35229,,"7,045.87 x patient days",35229,Per diem,,23377,,"4,675.50 x patient days",23377,Per diem,,23377,,"4,675.50 x patient days",23377,Per diem,,13591,,"2,718.31 x patient days",13591,Per diem,,0.01,91228,
Chronic Kidney Disease #,470-1,APR-DRG,,,,,,,,inpatient,,,174642.65,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,16180,,"4,044.85 x patient days",16180,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,13228,,"27,634 x DRG weight",13228,Other,base rate x DRG weight,11244,,"23,488 x DRG weight",11244,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,13309,,"3,327.21 x patient days",13309,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,12179,,"3,044.51 x patient days",12179,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,23922,,"5,980.29 x patient days",23922,Per diem,,28185,,"7,045.87 x patient days",28185,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,10874,,"2,718.31 x patient days",10874,Per diem,,0.01,28185,
Chronic Kidney Disease #,470-2,APR-DRG,,,,,,,,inpatient,,,262208.29,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,16180,,"4,044.85 x patient days",16180,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,18882,,"27,634 x DRG weight",18882,Other,base rate x DRG weight,16049,,"23,488 x DRG weight",16049,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,13309,,"3,327.21 x patient days",13309,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,12179,,"3,044.51 x patient days",12179,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,23922,,"5,980.29 x patient days",23922,Per diem,,28185,,"7,045.87 x patient days",28185,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,10874,,"2,718.31 x patient days",10874,Per diem,,0.01,28185,
Chronic Kidney Disease #,470-3,APR-DRG,,,,,,,,inpatient,,,174642.65,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,16180,,"4,044.85 x patient days",16180,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,32942,,"27,634 x DRG weight",32942,Other,base rate x DRG weight,28000,,"23,488 x DRG weight",28000,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,13309,,"3,327.21 x patient days",13309,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,12179,,"3,044.51 x patient days",12179,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,23922,,"5,980.29 x patient days",23922,Per diem,,28185,,"7,045.87 x patient days",28185,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,10874,,"2,718.31 x patient days",10874,Per diem,,0.01,32942,
Chronic Kidney Disease #,470-4,APR-DRG,,,,,,,,inpatient,,,617227.05,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,16180,,"4,044.85 x patient days",16180,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,73401,,"27,634 x DRG weight",73401,Other,base rate x DRG weight,62389,,"23,488 x DRG weight",62389,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,13309,,"3,327.21 x patient days",13309,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,12179,,"3,044.51 x patient days",12179,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,23922,,"5,980.29 x patient days",23922,Per diem,,28185,,"7,045.87 x patient days",28185,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,10874,,"2,718.31 x patient days",10874,Per diem,,0.01,73401,
Major male pelvic procedures,480-1,APR-DRG,,,,,,,,inpatient,,,155333.36,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8089,,"4,044.85 x patient days",8089,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,30359,,"27,634 x DRG weight",30359,Other,base rate x DRG weight,25804,,"23,488 x DRG weight",25804,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6654,,"3,327.21 x patient days",6654,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6089,,"3,044.51 x patient days",6089,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,11960,,"5,980.29 x patient days",11960,Per diem,,14091,,"7,045.87 x patient days",14091,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,5436,,"2,718.31 x patient days",5436,Per diem,,0.01,30359,
Major male pelvic procedures,480-2,APR-DRG,,,,,,,,inpatient,,,155333.36,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8089,,"4,044.85 x patient days",8089,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,34661,,"27,634 x DRG weight",34661,Other,base rate x DRG weight,29461,,"23,488 x DRG weight",29461,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6654,,"3,327.21 x patient days",6654,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6089,,"3,044.51 x patient days",6089,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,11960,,"5,980.29 x patient days",11960,Per diem,,14091,,"7,045.87 x patient days",14091,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,5436,,"2,718.31 x patient days",5436,Per diem,,0.01,34661,
Major male pelvic procedures,480-3,APR-DRG,,,,,,,,inpatient,,,155333.36,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8089,,"4,044.85 x patient days",8089,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,59615,,"27,634 x DRG weight",59615,Other,base rate x DRG weight,50671,,"23,488 x DRG weight",50671,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6654,,"3,327.21 x patient days",6654,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6089,,"3,044.51 x patient days",6089,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,11960,,"5,980.29 x patient days",11960,Per diem,,14091,,"7,045.87 x patient days",14091,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,5436,,"2,718.31 x patient days",5436,Per diem,,0.01,59615,
Major male pelvic procedures,480-4,APR-DRG,,,,,,,,inpatient,,,155333.36,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8089,,"4,044.85 x patient days",8089,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,71779,,"27,634 x DRG weight",71779,Other,base rate x DRG weight,61010,,"23,488 x DRG weight",61010,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6654,,"3,327.21 x patient days",6654,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6089,,"3,044.51 x patient days",6089,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,11960,,"5,980.29 x patient days",11960,Per diem,,14091,,"7,045.87 x patient days",14091,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,5436,,"2,718.31 x patient days",5436,Per diem,,0.01,71779,
Penis procedures,481-1,APR-DRG,,,,,,,,inpatient,,,76497.75,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8089,,"4,044.85 x patient days",8089,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,20507,,"27,634 x DRG weight",20507,Other,base rate x DRG weight,17430,,"23,488 x DRG weight",17430,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6654,,"3,327.21 x patient days",6654,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6089,,"3,044.51 x patient days",6089,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,11960,,"5,980.29 x patient days",11960,Per diem,,14091,,"7,045.87 x patient days",14091,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,5436,,"2,718.31 x patient days",5436,Per diem,,0.01,20507,
Penis procedures,481-2,APR-DRG,,,,,,,,inpatient,,,103094.9,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8089,,"4,044.85 x patient days",8089,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,33700,,"27,634 x DRG weight",33700,Other,base rate x DRG weight,28644,,"23,488 x DRG weight",28644,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6654,,"3,327.21 x patient days",6654,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6089,,"3,044.51 x patient days",6089,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,11960,,"5,980.29 x patient days",11960,Per diem,,14091,,"7,045.87 x patient days",14091,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,5436,,"2,718.31 x patient days",5436,Per diem,,0.01,33700,
Penis procedures,481-3,APR-DRG,,,,,,,,inpatient,,,103094.9,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8089,,"4,044.85 x patient days",8089,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,54013,,"27,634 x DRG weight",54013,Other,base rate x DRG weight,45910,,"23,488 x DRG weight",45910,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6654,,"3,327.21 x patient days",6654,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6089,,"3,044.51 x patient days",6089,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,11960,,"5,980.29 x patient days",11960,Per diem,,14091,,"7,045.87 x patient days",14091,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,5436,,"2,718.31 x patient days",5436,Per diem,,0.01,54013,
Penis procedures,481-4,APR-DRG,,,,,,,,inpatient,,,103094.9,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8089,,"4,044.85 x patient days",8089,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,57103,,"27,634 x DRG weight",57103,Other,base rate x DRG weight,48536,,"23,488 x DRG weight",48536,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6654,,"3,327.21 x patient days",6654,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6089,,"3,044.51 x patient days",6089,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,11960,,"5,980.29 x patient days",11960,Per diem,,14091,,"7,045.87 x patient days",14091,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,5436,,"2,718.31 x patient days",5436,Per diem,,0.01,57103,
Transurethral prostatectomy,482-1,APR-DRG,,,,,,,,inpatient,,,65399.53,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8089,,"4,044.85 x patient days",8089,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,16719,,"27,634 x DRG weight",16719,Other,base rate x DRG weight,14210,,"23,488 x DRG weight",14210,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6654,,"3,327.21 x patient days",6654,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6089,,"3,044.51 x patient days",6089,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,11960,,"5,980.29 x patient days",11960,Per diem,,14091,,"7,045.87 x patient days",14091,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,5436,,"2,718.31 x patient days",5436,Per diem,,0.01,16719,
Transurethral prostatectomy,482-2,APR-DRG,,,,,,,,inpatient,,,60783.67,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8089,,"4,044.85 x patient days",8089,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,23428,,"27,634 x DRG weight",23428,Other,base rate x DRG weight,19913,,"23,488 x DRG weight",19913,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6654,,"3,327.21 x patient days",6654,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6089,,"3,044.51 x patient days",6089,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,11960,,"5,980.29 x patient days",11960,Per diem,,14091,,"7,045.87 x patient days",14091,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,5436,,"2,718.31 x patient days",5436,Per diem,,0.01,23428,
Transurethral prostatectomy,482-3,APR-DRG,,,,,,,,inpatient,,,220449.75,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8089,,"4,044.85 x patient days",8089,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,65048,,"27,634 x DRG weight",65048,Other,base rate x DRG weight,55288,,"23,488 x DRG weight",55288,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6654,,"3,327.21 x patient days",6654,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6089,,"3,044.51 x patient days",6089,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,11960,,"5,980.29 x patient days",11960,Per diem,,14091,,"7,045.87 x patient days",14091,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,5436,,"2,718.31 x patient days",5436,Per diem,,0.01,65048,
Transurethral prostatectomy,482-4,APR-DRG,,,,,,,,inpatient,,,220449.75,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8089,,"4,044.85 x patient days",8089,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,74769,,"27,634 x DRG weight",74769,Other,base rate x DRG weight,63551,,"23,488 x DRG weight",63551,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6654,,"3,327.21 x patient days",6654,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6089,,"3,044.51 x patient days",6089,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,11960,,"5,980.29 x patient days",11960,Per diem,,14091,,"7,045.87 x patient days",14091,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,5436,,"2,718.31 x patient days",5436,Per diem,,0.01,74769,
Testes & scrotal procedures,483-1,APR-DRG,,,,,,,,inpatient,,,64859.42,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12135,,"4,044.85 x patient days",12135,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,17456,,"27,634 x DRG weight",17456,Other,base rate x DRG weight,14837,,"23,488 x DRG weight",14837,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9982,,"3,327.21 x patient days",9982,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9134,,"3,044.51 x patient days",9134,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,17941,,"5,980.29 x patient days",17941,Per diem,,21138,,"7,045.87 x patient days",21138,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,8155,,"2,718.31 x patient days",8155,Per diem,,0.01,21138,
Testes & scrotal procedures,483-2,APR-DRG,,,,,,,,inpatient,,,454050.94,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12135,,"4,044.85 x patient days",12135,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,35399,,"27,634 x DRG weight",35399,Other,base rate x DRG weight,30088,,"23,488 x DRG weight",30088,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9982,,"3,327.21 x patient days",9982,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9134,,"3,044.51 x patient days",9134,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,17941,,"5,980.29 x patient days",17941,Per diem,,21138,,"7,045.87 x patient days",21138,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,8155,,"2,718.31 x patient days",8155,Per diem,,0.01,35399,
Testes & scrotal procedures,483-3,APR-DRG,,,,,,,,inpatient,,,75664.11,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12135,,"4,044.85 x patient days",12135,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,87918,,"27,634 x DRG weight",87918,Other,base rate x DRG weight,74727,,"23,488 x DRG weight",74727,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9982,,"3,327.21 x patient days",9982,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9134,,"3,044.51 x patient days",9134,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,17941,,"5,980.29 x patient days",17941,Per diem,,21138,,"7,045.87 x patient days",21138,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,8155,,"2,718.31 x patient days",8155,Per diem,,0.01,87918,
Testes & scrotal procedures,483-4,APR-DRG,,,,,,,,inpatient,,,75664.11,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12135,,"4,044.85 x patient days",12135,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,118218,,"27,634 x DRG weight",118218,Other,base rate x DRG weight,100482,,"23,488 x DRG weight",100482,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9982,,"3,327.21 x patient days",9982,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9134,,"3,044.51 x patient days",9134,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,17941,,"5,980.29 x patient days",17941,Per diem,,21138,,"7,045.87 x patient days",21138,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,8155,,"2,718.31 x patient days",8155,Per diem,,0.01,118218,
Other male reproductive system & related procedures,484-1,APR-DRG,,,,,,,,inpatient,,,87760.87,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12135,,"4,044.85 x patient days",12135,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,24274,,"27,634 x DRG weight",24274,Other,base rate x DRG weight,20632,,"23,488 x DRG weight",20632,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9982,,"3,327.21 x patient days",9982,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9134,,"3,044.51 x patient days",9134,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,17941,,"5,980.29 x patient days",17941,Per diem,,21138,,"7,045.87 x patient days",21138,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,8155,,"2,718.31 x patient days",8155,Per diem,,0.01,24274,
Other male reproductive system & related procedures,484-2,APR-DRG,,,,,,,,inpatient,,,87760.87,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12135,,"4,044.85 x patient days",12135,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,32514,,"27,634 x DRG weight",32514,Other,base rate x DRG weight,27636,,"23,488 x DRG weight",27636,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9982,,"3,327.21 x patient days",9982,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9134,,"3,044.51 x patient days",9134,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,17941,,"5,980.29 x patient days",17941,Per diem,,21138,,"7,045.87 x patient days",21138,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,8155,,"2,718.31 x patient days",8155,Per diem,,0.01,32514,
Other male reproductive system & related procedures,484-3,APR-DRG,,,,,,,,inpatient,,,110586.17,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12135,,"4,044.85 x patient days",12135,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,54494,,"27,634 x DRG weight",54494,Other,base rate x DRG weight,46318,,"23,488 x DRG weight",46318,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9982,,"3,327.21 x patient days",9982,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9134,,"3,044.51 x patient days",9134,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,17941,,"5,980.29 x patient days",17941,Per diem,,21138,,"7,045.87 x patient days",21138,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,8155,,"2,718.31 x patient days",8155,Per diem,,0.01,54494,
Other male reproductive system & related procedures,484-4,APR-DRG,,,,,,,,inpatient,,,1687755.95,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12135,,"4,044.85 x patient days",12135,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,59355,,"27,634 x DRG weight",59355,Other,base rate x DRG weight,50450,,"23,488 x DRG weight",50450,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9982,,"3,327.21 x patient days",9982,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9134,,"3,044.51 x patient days",9134,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,17941,,"5,980.29 x patient days",17941,Per diem,,21138,,"7,045.87 x patient days",21138,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,8155,,"2,718.31 x patient days",8155,Per diem,,0.01,59355,
"Malignancy, male reproductive system",500-1,APR-DRG,,,,,,,,inpatient,,,19635,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,28315,,"4,044.85 x patient days",28315,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,11659,,"27,634 x DRG weight",11659,Other,base rate x DRG weight,9910,,"23,488 x DRG weight",9910,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,15223,,"2,174.65 x patient days",15223,Per diem,,15223,,"2,174.65 x patient days",15223,Per diem,,15223,,"2,174.65 x patient days",15223,Per diem,,15223,,"2,174.65 x patient days",15223,Per diem,,34252,,"4,892.96 x patient days",34252,Per diem,,23291,,"3,327.21 x patient days",23291,Per diem,,34252,,"4,892.96 x patient days",34252,Per diem,,21312,,"3,044.51 x patient days",21312,Per diem,,34252,,"4,892.96 x patient days",34252,Per diem,,41863,,"5,980.29 x patient days",41863,Per diem,,49323,,"7,045.87 x patient days",49323,Per diem,,32729,,"4,675.50 x patient days",32729,Per diem,,32729,,"4,675.50 x patient days",32729,Per diem,,19029,,"2,718.31 x patient days",19029,Per diem,,0.01,49323,
"Malignancy, male reproductive system",500-2,APR-DRG,,,,,,,,inpatient,,,236688.78,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,28315,,"4,044.85 x patient days",28315,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,26051,,"27,634 x DRG weight",26051,Other,base rate x DRG weight,22142,,"23,488 x DRG weight",22142,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,15223,,"2,174.65 x patient days",15223,Per diem,,15223,,"2,174.65 x patient days",15223,Per diem,,15223,,"2,174.65 x patient days",15223,Per diem,,15223,,"2,174.65 x patient days",15223,Per diem,,34252,,"4,892.96 x patient days",34252,Per diem,,23291,,"3,327.21 x patient days",23291,Per diem,,34252,,"4,892.96 x patient days",34252,Per diem,,21312,,"3,044.51 x patient days",21312,Per diem,,34252,,"4,892.96 x patient days",34252,Per diem,,41863,,"5,980.29 x patient days",41863,Per diem,,49323,,"7,045.87 x patient days",49323,Per diem,,32729,,"4,675.50 x patient days",32729,Per diem,,32729,,"4,675.50 x patient days",32729,Per diem,,19029,,"2,718.31 x patient days",19029,Per diem,,0.01,49323,
"Malignancy, male reproductive system",500-3,APR-DRG,,,,,,,,inpatient,,,265957.21,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,28315,,"4,044.85 x patient days",28315,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,43653,,"27,634 x DRG weight",43653,Other,base rate x DRG weight,37104,,"23,488 x DRG weight",37104,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,15223,,"2,174.65 x patient days",15223,Per diem,,15223,,"2,174.65 x patient days",15223,Per diem,,15223,,"2,174.65 x patient days",15223,Per diem,,15223,,"2,174.65 x patient days",15223,Per diem,,34252,,"4,892.96 x patient days",34252,Per diem,,23291,,"3,327.21 x patient days",23291,Per diem,,34252,,"4,892.96 x patient days",34252,Per diem,,21312,,"3,044.51 x patient days",21312,Per diem,,34252,,"4,892.96 x patient days",34252,Per diem,,41863,,"5,980.29 x patient days",41863,Per diem,,49323,,"7,045.87 x patient days",49323,Per diem,,32729,,"4,675.50 x patient days",32729,Per diem,,32729,,"4,675.50 x patient days",32729,Per diem,,19029,,"2,718.31 x patient days",19029,Per diem,,0.01,49323,
"Malignancy, male reproductive system",500-4,APR-DRG,,,,,,,,inpatient,,,265957.21,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,28315,,"4,044.85 x patient days",28315,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,50896,,"27,634 x DRG weight",50896,Other,base rate x DRG weight,43260,,"23,488 x DRG weight",43260,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,15223,,"2,174.65 x patient days",15223,Per diem,,15223,,"2,174.65 x patient days",15223,Per diem,,15223,,"2,174.65 x patient days",15223,Per diem,,15223,,"2,174.65 x patient days",15223,Per diem,,34252,,"4,892.96 x patient days",34252,Per diem,,23291,,"3,327.21 x patient days",23291,Per diem,,34252,,"4,892.96 x patient days",34252,Per diem,,21312,,"3,044.51 x patient days",21312,Per diem,,34252,,"4,892.96 x patient days",34252,Per diem,,41863,,"5,980.29 x patient days",41863,Per diem,,49323,,"7,045.87 x patient days",49323,Per diem,,32729,,"4,675.50 x patient days",32729,Per diem,,32729,,"4,675.50 x patient days",32729,Per diem,,19029,,"2,718.31 x patient days",19029,Per diem,,0.01,50896,
Male reproductive system diagnoses except malignancy,501-1,APR-DRG,,,,,,,,inpatient,,,77365.68,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12135,,"4,044.85 x patient days",12135,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,13358,,"27,634 x DRG weight",13358,Other,base rate x DRG weight,11354,,"23,488 x DRG weight",11354,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9982,,"3,327.21 x patient days",9982,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9134,,"3,044.51 x patient days",9134,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,17941,,"5,980.29 x patient days",17941,Per diem,,21138,,"7,045.87 x patient days",21138,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,8155,,"2,718.31 x patient days",8155,Per diem,,0.01,21138,
Male reproductive system diagnoses except malignancy,501-2,APR-DRG,,,,,,,,inpatient,,,127380.27,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12135,,"4,044.85 x patient days",12135,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,18954,,"27,634 x DRG weight",18954,Other,base rate x DRG weight,16110,,"23,488 x DRG weight",16110,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9982,,"3,327.21 x patient days",9982,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9134,,"3,044.51 x patient days",9134,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,17941,,"5,980.29 x patient days",17941,Per diem,,21138,,"7,045.87 x patient days",21138,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,8155,,"2,718.31 x patient days",8155,Per diem,,0.01,21138,
Male reproductive system diagnoses except malignancy,501-3,APR-DRG,,,,,,,,inpatient,,,179314.82,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12135,,"4,044.85 x patient days",12135,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,31025,,"27,634 x DRG weight",31025,Other,base rate x DRG weight,26370,,"23,488 x DRG weight",26370,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9982,,"3,327.21 x patient days",9982,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9134,,"3,044.51 x patient days",9134,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,17941,,"5,980.29 x patient days",17941,Per diem,,21138,,"7,045.87 x patient days",21138,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,8155,,"2,718.31 x patient days",8155,Per diem,,0.01,31025,
Male reproductive system diagnoses except malignancy,501-4,APR-DRG,,,,,,,,inpatient,,,121672.4,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12135,,"4,044.85 x patient days",12135,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,58932,,"27,634 x DRG weight",58932,Other,base rate x DRG weight,50091,,"23,488 x DRG weight",50091,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9982,,"3,327.21 x patient days",9982,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9134,,"3,044.51 x patient days",9134,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,17941,,"5,980.29 x patient days",17941,Per diem,,21138,,"7,045.87 x patient days",21138,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,8155,,"2,718.31 x patient days",8155,Per diem,,0.01,58932,
"Pelvic evisceration, radical hysterectomy & other radical GYN procs",510-1,APR-DRG,,,,,,,,inpatient,,,136847.81,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,16180,,"4,044.85 x patient days",16180,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,31072,,"27,634 x DRG weight",31072,Other,base rate x DRG weight,26410,,"23,488 x DRG weight",26410,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,13309,,"3,327.21 x patient days",13309,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,12179,,"3,044.51 x patient days",12179,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,23922,,"5,980.29 x patient days",23922,Per diem,,28185,,"7,045.87 x patient days",28185,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,10874,,"2,718.31 x patient days",10874,Per diem,,0.01,31072,
"Pelvic evisceration, radical hysterectomy & other radical GYN procs",510-2,APR-DRG,,,,,,,,inpatient,,,362405.56,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,16180,,"4,044.85 x patient days",16180,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,39622,,"27,634 x DRG weight",39622,Other,base rate x DRG weight,33677,,"23,488 x DRG weight",33677,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,13309,,"3,327.21 x patient days",13309,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,12179,,"3,044.51 x patient days",12179,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,23922,,"5,980.29 x patient days",23922,Per diem,,28185,,"7,045.87 x patient days",28185,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,10874,,"2,718.31 x patient days",10874,Per diem,,0.01,39622,
"Pelvic evisceration, radical hysterectomy & other radical GYN procs",510-3,APR-DRG,,,,,,,,inpatient,,,257184.01,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,16180,,"4,044.85 x patient days",16180,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,72713,,"27,634 x DRG weight",72713,Other,base rate x DRG weight,61804,,"23,488 x DRG weight",61804,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,13309,,"3,327.21 x patient days",13309,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,12179,,"3,044.51 x patient days",12179,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,23922,,"5,980.29 x patient days",23922,Per diem,,28185,,"7,045.87 x patient days",28185,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,10874,,"2,718.31 x patient days",10874,Per diem,,0.01,72713,
"Pelvic evisceration, radical hysterectomy & other radical GYN procs",510-4,APR-DRG,,,,,,,,inpatient,,,1688756.06,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,16180,,"4,044.85 x patient days",16180,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,177115,,"27,634 x DRG weight",177115,Other,base rate x DRG weight,150542,,"23,488 x DRG weight",150542,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,13309,,"3,327.21 x patient days",13309,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,12179,,"3,044.51 x patient days",12179,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,23922,,"5,980.29 x patient days",23922,Per diem,,28185,,"7,045.87 x patient days",28185,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,10874,,"2,718.31 x patient days",10874,Per diem,,0.01,177115,
Uterine & adnexa procedures for ovarian & adnexal malignancy,511-1,APR-DRG,,,,,,,,inpatient,,,126877.95,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,20224,,"4,044.85 x patient days",20224,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,35396,,"27,634 x DRG weight",35396,Other,base rate x DRG weight,30086,,"23,488 x DRG weight",30086,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,16636,,"3,327.21 x patient days",16636,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,15222,,"3,044.51 x patient days",15222,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,29901,,"5,980.29 x patient days",29901,Per diem,,35229,,"7,045.87 x patient days",35229,Per diem,,23377,,"4,675.50 x patient days",23377,Per diem,,23377,,"4,675.50 x patient days",23377,Per diem,,13591,,"2,718.31 x patient days",13591,Per diem,,0.01,35396,
Uterine & adnexa procedures for ovarian & adnexal malignancy,511-2,APR-DRG,,,,,,,,inpatient,,,191633.75,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,20224,,"4,044.85 x patient days",20224,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,42551,,"27,634 x DRG weight",42551,Other,base rate x DRG weight,36167,,"23,488 x DRG weight",36167,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,16636,,"3,327.21 x patient days",16636,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,15222,,"3,044.51 x patient days",15222,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,29901,,"5,980.29 x patient days",29901,Per diem,,35229,,"7,045.87 x patient days",35229,Per diem,,23377,,"4,675.50 x patient days",23377,Per diem,,23377,,"4,675.50 x patient days",23377,Per diem,,13591,,"2,718.31 x patient days",13591,Per diem,,0.01,42551,
Uterine & adnexa procedures for ovarian & adnexal malignancy,511-3,APR-DRG,,,,,,,,inpatient,,,440293.76,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,20224,,"4,044.85 x patient days",20224,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,70577,,"27,634 x DRG weight",70577,Other,base rate x DRG weight,59988,,"23,488 x DRG weight",59988,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,16636,,"3,327.21 x patient days",16636,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,15222,,"3,044.51 x patient days",15222,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,29901,,"5,980.29 x patient days",29901,Per diem,,35229,,"7,045.87 x patient days",35229,Per diem,,23377,,"4,675.50 x patient days",23377,Per diem,,23377,,"4,675.50 x patient days",23377,Per diem,,13591,,"2,718.31 x patient days",13591,Per diem,,0.01,70577,
Uterine & adnexa procedures for ovarian & adnexal malignancy,511-4,APR-DRG,,,,,,,,inpatient,,,504078.31,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,20224,,"4,044.85 x patient days",20224,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,172060,,"27,634 x DRG weight",172060,Other,base rate x DRG weight,146246,,"23,488 x DRG weight",146246,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,16636,,"3,327.21 x patient days",16636,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,15222,,"3,044.51 x patient days",15222,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,29901,,"5,980.29 x patient days",29901,Per diem,,35229,,"7,045.87 x patient days",35229,Per diem,,23377,,"4,675.50 x patient days",23377,Per diem,,23377,,"4,675.50 x patient days",23377,Per diem,,13591,,"2,718.31 x patient days",13591,Per diem,,0.01,172060,
Uterine & adnexa procedures for non-ovarian & non-adnexal malig,512-1,APR-DRG,,,,,,,,inpatient,,,239707.23,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12135,,"4,044.85 x patient days",12135,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,30262,,"27,634 x DRG weight",30262,Other,base rate x DRG weight,25722,,"23,488 x DRG weight",25722,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9982,,"3,327.21 x patient days",9982,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9134,,"3,044.51 x patient days",9134,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,17941,,"5,980.29 x patient days",17941,Per diem,,21138,,"7,045.87 x patient days",21138,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,8155,,"2,718.31 x patient days",8155,Per diem,,0.01,30262,
Uterine & adnexa procedures for non-ovarian & non-adnexal malig,512-2,APR-DRG,,,,,,,,inpatient,,,210970.38,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12135,,"4,044.85 x patient days",12135,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,37488,,"27,634 x DRG weight",37488,Other,base rate x DRG weight,31864,,"23,488 x DRG weight",31864,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9982,,"3,327.21 x patient days",9982,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9134,,"3,044.51 x patient days",9134,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,17941,,"5,980.29 x patient days",17941,Per diem,,21138,,"7,045.87 x patient days",21138,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,8155,,"2,718.31 x patient days",8155,Per diem,,0.01,37488,
Uterine & adnexa procedures for non-ovarian & non-adnexal malig,512-3,APR-DRG,,,,,,,,inpatient,,,315251.96,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12135,,"4,044.85 x patient days",12135,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,63685,,"27,634 x DRG weight",63685,Other,base rate x DRG weight,54130,,"23,488 x DRG weight",54130,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9982,,"3,327.21 x patient days",9982,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9134,,"3,044.51 x patient days",9134,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,17941,,"5,980.29 x patient days",17941,Per diem,,21138,,"7,045.87 x patient days",21138,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,8155,,"2,718.31 x patient days",8155,Per diem,,0.01,63685,
Uterine & adnexa procedures for non-ovarian & non-adnexal malig,512-4,APR-DRG,,,,,,,,inpatient,,,315251.96,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12135,,"4,044.85 x patient days",12135,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,207349,,"27,634 x DRG weight",207349,Other,base rate x DRG weight,176240,,"23,488 x DRG weight",176240,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9982,,"3,327.21 x patient days",9982,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9134,,"3,044.51 x patient days",9134,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,17941,,"5,980.29 x patient days",17941,Per diem,,21138,,"7,045.87 x patient days",21138,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,8155,,"2,718.31 x patient days",8155,Per diem,,0.01,207349,
Uterine & adnexa procedures for non-malignancy except leiomyoma,513-1,APR-DRG,,,,,,,,inpatient,,,108883.19,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8089,,"4,044.85 x patient days",8089,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,24116,,"27,634 x DRG weight",24116,Other,base rate x DRG weight,20498,,"23,488 x DRG weight",20498,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6654,,"3,327.21 x patient days",6654,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6089,,"3,044.51 x patient days",6089,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,11960,,"5,980.29 x patient days",11960,Per diem,,14091,,"7,045.87 x patient days",14091,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,5436,,"2,718.31 x patient days",5436,Per diem,,0.01,24116,
Uterine & adnexa procedures for non-malignancy except leiomyoma,513-2,APR-DRG,,,,,,,,inpatient,,,127769.06,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8089,,"4,044.85 x patient days",8089,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,28690,,"27,634 x DRG weight",28690,Other,base rate x DRG weight,24385,,"23,488 x DRG weight",24385,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6654,,"3,327.21 x patient days",6654,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6089,,"3,044.51 x patient days",6089,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,11960,,"5,980.29 x patient days",11960,Per diem,,14091,,"7,045.87 x patient days",14091,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,5436,,"2,718.31 x patient days",5436,Per diem,,0.01,28690,
Uterine & adnexa procedures for non-malignancy except leiomyoma,513-3,APR-DRG,,,,,,,,inpatient,,,156746.53,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8089,,"4,044.85 x patient days",8089,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,51128,,"27,634 x DRG weight",51128,Other,base rate x DRG weight,43457,,"23,488 x DRG weight",43457,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6654,,"3,327.21 x patient days",6654,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6089,,"3,044.51 x patient days",6089,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,11960,,"5,980.29 x patient days",11960,Per diem,,14091,,"7,045.87 x patient days",14091,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,5436,,"2,718.31 x patient days",5436,Per diem,,0.01,51128,
Uterine & adnexa procedures for non-malignancy except leiomyoma,513-4,APR-DRG,,,,,,,,inpatient,,,156746.53,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8089,,"4,044.85 x patient days",8089,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,132687,,"27,634 x DRG weight",132687,Other,base rate x DRG weight,112780,,"23,488 x DRG weight",112780,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6654,,"3,327.21 x patient days",6654,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6089,,"3,044.51 x patient days",6089,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,11960,,"5,980.29 x patient days",11960,Per diem,,14091,,"7,045.87 x patient days",14091,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,5436,,"2,718.31 x patient days",5436,Per diem,,0.01,132687,
Female reproductive system reconstructive procedures,514-1,APR-DRG,,,,,,,,inpatient,,,136418.46,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,4046,,"4,044.85 x patient days",4046,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,27474,,"27,634 x DRG weight",27474,Other,base rate x DRG weight,23352,,"23,488 x DRG weight",23352,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,2175,,"2,174.65 x patient days",2175,Per diem,,2175,,"2,174.65 x patient days",2175,Per diem,,2175,,"2,174.65 x patient days",2175,Per diem,,2175,,"2,174.65 x patient days",2175,Per diem,,4894,,"4,892.96 x patient days",4894,Per diem,,3328,,"3,327.21 x patient days",3328,Per diem,,4894,,"4,892.96 x patient days",4894,Per diem,,3045,,"3,044.51 x patient days",3045,Per diem,,4894,,"4,892.96 x patient days",4894,Per diem,,5981,,"5,980.29 x patient days",5981,Per diem,,7047,,"7,045.87 x patient days",7047,Per diem,,4676,,"4,675.50 x patient days",4676,Per diem,,4676,,"4,675.50 x patient days",4676,Per diem,,2719,,"2,718.31 x patient days",2719,Per diem,,0.01,27474,
Female reproductive system reconstructive procedures,514-2,APR-DRG,,,,,,,,inpatient,,,394980.59,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,4046,,"4,044.85 x patient days",4046,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,27474,,"27,634 x DRG weight",27474,Other,base rate x DRG weight,23352,,"23,488 x DRG weight",23352,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,2175,,"2,174.65 x patient days",2175,Per diem,,2175,,"2,174.65 x patient days",2175,Per diem,,2175,,"2,174.65 x patient days",2175,Per diem,,2175,,"2,174.65 x patient days",2175,Per diem,,4894,,"4,892.96 x patient days",4894,Per diem,,3328,,"3,327.21 x patient days",3328,Per diem,,4894,,"4,892.96 x patient days",4894,Per diem,,3045,,"3,044.51 x patient days",3045,Per diem,,4894,,"4,892.96 x patient days",4894,Per diem,,5981,,"5,980.29 x patient days",5981,Per diem,,7047,,"7,045.87 x patient days",7047,Per diem,,4676,,"4,675.50 x patient days",4676,Per diem,,4676,,"4,675.50 x patient days",4676,Per diem,,2719,,"2,718.31 x patient days",2719,Per diem,,0.01,27474,
Female reproductive system reconstructive procedures,514-3,APR-DRG,,,,,,,,inpatient,,,394980.59,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,4046,,"4,044.85 x patient days",4046,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,27474,,"27,634 x DRG weight",27474,Other,base rate x DRG weight,23352,,"23,488 x DRG weight",23352,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,2175,,"2,174.65 x patient days",2175,Per diem,,2175,,"2,174.65 x patient days",2175,Per diem,,2175,,"2,174.65 x patient days",2175,Per diem,,2175,,"2,174.65 x patient days",2175,Per diem,,4894,,"4,892.96 x patient days",4894,Per diem,,3328,,"3,327.21 x patient days",3328,Per diem,,4894,,"4,892.96 x patient days",4894,Per diem,,3045,,"3,044.51 x patient days",3045,Per diem,,4894,,"4,892.96 x patient days",4894,Per diem,,5981,,"5,980.29 x patient days",5981,Per diem,,7047,,"7,045.87 x patient days",7047,Per diem,,4676,,"4,675.50 x patient days",4676,Per diem,,4676,,"4,675.50 x patient days",4676,Per diem,,2719,,"2,718.31 x patient days",2719,Per diem,,0.01,27474,
Female reproductive system reconstructive procedures,514-4,APR-DRG,,,,,,,,inpatient,,,394980.59,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,4046,,"4,044.85 x patient days",4046,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,86359,,"27,634 x DRG weight",86359,Other,base rate x DRG weight,73402,,"23,488 x DRG weight",73402,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,2175,,"2,174.65 x patient days",2175,Per diem,,2175,,"2,174.65 x patient days",2175,Per diem,,2175,,"2,174.65 x patient days",2175,Per diem,,2175,,"2,174.65 x patient days",2175,Per diem,,4894,,"4,892.96 x patient days",4894,Per diem,,3328,,"3,327.21 x patient days",3328,Per diem,,4894,,"4,892.96 x patient days",4894,Per diem,,3045,,"3,044.51 x patient days",3045,Per diem,,4894,,"4,892.96 x patient days",4894,Per diem,,5981,,"5,980.29 x patient days",5981,Per diem,,7047,,"7,045.87 x patient days",7047,Per diem,,4676,,"4,675.50 x patient days",4676,Per diem,,4676,,"4,675.50 x patient days",4676,Per diem,,2719,,"2,718.31 x patient days",2719,Per diem,,0.01,86359,
Dilation & curettage for non-obstetric diagnoses,517-1,APR-DRG,,,,,,,,inpatient,,,163703.79,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12135,,"4,044.85 x patient days",12135,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,18451,,"27,634 x DRG weight",18451,Other,base rate x DRG weight,15683,,"23,488 x DRG weight",15683,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9982,,"3,327.21 x patient days",9982,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9134,,"3,044.51 x patient days",9134,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,17941,,"5,980.29 x patient days",17941,Per diem,,21138,,"7,045.87 x patient days",21138,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,8155,,"2,718.31 x patient days",8155,Per diem,,0.01,21138,
Dilation & curettage for non-obstetric diagnoses,517-2,APR-DRG,,,,,,,,inpatient,,,163703.79,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12135,,"4,044.85 x patient days",12135,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,25824,,"27,634 x DRG weight",25824,Other,base rate x DRG weight,21950,,"23,488 x DRG weight",21950,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9982,,"3,327.21 x patient days",9982,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9134,,"3,044.51 x patient days",9134,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,17941,,"5,980.29 x patient days",17941,Per diem,,21138,,"7,045.87 x patient days",21138,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,8155,,"2,718.31 x patient days",8155,Per diem,,0.01,25824,
Dilation & curettage for non-obstetric diagnoses,517-3,APR-DRG,,,,,,,,inpatient,,,488129.7,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12135,,"4,044.85 x patient days",12135,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,56260,,"27,634 x DRG weight",56260,Other,base rate x DRG weight,47819,,"23,488 x DRG weight",47819,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9982,,"3,327.21 x patient days",9982,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9134,,"3,044.51 x patient days",9134,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,17941,,"5,980.29 x patient days",17941,Per diem,,21138,,"7,045.87 x patient days",21138,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,8155,,"2,718.31 x patient days",8155,Per diem,,0.01,56260,
Dilation & curettage for non-obstetric diagnoses,517-4,APR-DRG,,,,,,,,inpatient,,,194724,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12135,,"4,044.85 x patient days",12135,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,59410,,"27,634 x DRG weight",59410,Other,base rate x DRG weight,50497,,"23,488 x DRG weight",50497,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9982,,"3,327.21 x patient days",9982,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9134,,"3,044.51 x patient days",9134,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,17941,,"5,980.29 x patient days",17941,Per diem,,21138,,"7,045.87 x patient days",21138,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,8155,,"2,718.31 x patient days",8155,Per diem,,0.01,59410,
Other female reproductive system & related procedures,518-1,APR-DRG,,,,,,,,inpatient,,,95382.64,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12135,,"4,044.85 x patient days",12135,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,20889,,"27,634 x DRG weight",20889,Other,base rate x DRG weight,17755,,"23,488 x DRG weight",17755,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9982,,"3,327.21 x patient days",9982,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9134,,"3,044.51 x patient days",9134,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,17941,,"5,980.29 x patient days",17941,Per diem,,21138,,"7,045.87 x patient days",21138,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,8155,,"2,718.31 x patient days",8155,Per diem,,0.01,21138,
Other female reproductive system & related procedures,518-2,APR-DRG,,,,,,,,inpatient,,,91113.67,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12135,,"4,044.85 x patient days",12135,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,29914,,"27,634 x DRG weight",29914,Other,base rate x DRG weight,25426,,"23,488 x DRG weight",25426,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9982,,"3,327.21 x patient days",9982,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9134,,"3,044.51 x patient days",9134,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,17941,,"5,980.29 x patient days",17941,Per diem,,21138,,"7,045.87 x patient days",21138,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,8155,,"2,718.31 x patient days",8155,Per diem,,0.01,29914,
Other female reproductive system & related procedures,518-3,APR-DRG,,,,,,,,inpatient,,,599314.63,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12135,,"4,044.85 x patient days",12135,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,58551,,"27,634 x DRG weight",58551,Other,base rate x DRG weight,49766,,"23,488 x DRG weight",49766,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9982,,"3,327.21 x patient days",9982,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9134,,"3,044.51 x patient days",9134,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,17941,,"5,980.29 x patient days",17941,Per diem,,21138,,"7,045.87 x patient days",21138,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,8155,,"2,718.31 x patient days",8155,Per diem,,0.01,58551,
Other female reproductive system & related procedures,518-4,APR-DRG,,,,,,,,inpatient,,,599314.63,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12135,,"4,044.85 x patient days",12135,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,165193,,"27,634 x DRG weight",165193,Other,base rate x DRG weight,140409,,"23,488 x DRG weight",140409,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9982,,"3,327.21 x patient days",9982,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9134,,"3,044.51 x patient days",9134,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,17941,,"5,980.29 x patient days",17941,Per diem,,21138,,"7,045.87 x patient days",21138,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,8155,,"2,718.31 x patient days",8155,Per diem,,0.01,165193,
Uterine & adnexa procedures for leiomyoma,519-1,APR-DRG,,,,,,,,inpatient,,,144735.82,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8089,,"4,044.85 x patient days",8089,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,23732,,"27,634 x DRG weight",23732,Other,base rate x DRG weight,20171,,"23,488 x DRG weight",20171,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6654,,"3,327.21 x patient days",6654,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6089,,"3,044.51 x patient days",6089,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,11960,,"5,980.29 x patient days",11960,Per diem,,14091,,"7,045.87 x patient days",14091,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,5436,,"2,718.31 x patient days",5436,Per diem,,0.01,23732,
Uterine & adnexa procedures for leiomyoma,519-2,APR-DRG,,,,,,,,inpatient,,,77003.59,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8089,,"4,044.85 x patient days",8089,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,29709,,"27,634 x DRG weight",29709,Other,base rate x DRG weight,25252,,"23,488 x DRG weight",25252,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6654,,"3,327.21 x patient days",6654,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6089,,"3,044.51 x patient days",6089,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,11960,,"5,980.29 x patient days",11960,Per diem,,14091,,"7,045.87 x patient days",14091,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,5436,,"2,718.31 x patient days",5436,Per diem,,0.01,29709,
Uterine & adnexa procedures for leiomyoma,519-3,APR-DRG,,,,,,,,inpatient,,,289488.83,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8089,,"4,044.85 x patient days",8089,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,54696,,"27,634 x DRG weight",54696,Other,base rate x DRG weight,46490,,"23,488 x DRG weight",46490,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6654,,"3,327.21 x patient days",6654,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6089,,"3,044.51 x patient days",6089,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,11960,,"5,980.29 x patient days",11960,Per diem,,14091,,"7,045.87 x patient days",14091,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,5436,,"2,718.31 x patient days",5436,Per diem,,0.01,54696,
Uterine & adnexa procedures for leiomyoma,519-4,APR-DRG,,,,,,,,inpatient,,,144735.82,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8089,,"4,044.85 x patient days",8089,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,167153,,"27,634 x DRG weight",167153,Other,base rate x DRG weight,142074,,"23,488 x DRG weight",142074,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6654,,"3,327.21 x patient days",6654,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6089,,"3,044.51 x patient days",6089,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,11960,,"5,980.29 x patient days",11960,Per diem,,14091,,"7,045.87 x patient days",14091,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,5436,,"2,718.31 x patient days",5436,Per diem,,0.01,167153,
Female reproductive system malignancy,530-1,APR-DRG,,,,,,,,inpatient,,,210556.88,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,24269,,"4,044.85 x patient days",24269,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,16862,,"27,634 x DRG weight",16862,Other,base rate x DRG weight,14332,,"23,488 x DRG weight",14332,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,13048,,"2,174.65 x patient days",13048,Per diem,,13048,,"2,174.65 x patient days",13048,Per diem,,13048,,"2,174.65 x patient days",13048,Per diem,,13048,,"2,174.65 x patient days",13048,Per diem,,29358,,"4,892.96 x patient days",29358,Per diem,,19963,,"3,327.21 x patient days",19963,Per diem,,29358,,"4,892.96 x patient days",29358,Per diem,,18267,,"3,044.51 x patient days",18267,Per diem,,29358,,"4,892.96 x patient days",29358,Per diem,,35882,,"5,980.29 x patient days",35882,Per diem,,42276,,"7,045.87 x patient days",42276,Per diem,,28053,,"4,675.50 x patient days",28053,Per diem,,28053,,"4,675.50 x patient days",28053,Per diem,,16310,,"2,718.31 x patient days",16310,Per diem,,0.01,42276,
Female reproductive system malignancy,530-2,APR-DRG,,,,,,,,inpatient,,,155050.5,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,24269,,"4,044.85 x patient days",24269,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,21618,,"27,634 x DRG weight",21618,Other,base rate x DRG weight,18375,,"23,488 x DRG weight",18375,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,13048,,"2,174.65 x patient days",13048,Per diem,,13048,,"2,174.65 x patient days",13048,Per diem,,13048,,"2,174.65 x patient days",13048,Per diem,,13048,,"2,174.65 x patient days",13048,Per diem,,29358,,"4,892.96 x patient days",29358,Per diem,,19963,,"3,327.21 x patient days",19963,Per diem,,29358,,"4,892.96 x patient days",29358,Per diem,,18267,,"3,044.51 x patient days",18267,Per diem,,29358,,"4,892.96 x patient days",29358,Per diem,,35882,,"5,980.29 x patient days",35882,Per diem,,42276,,"7,045.87 x patient days",42276,Per diem,,28053,,"4,675.50 x patient days",28053,Per diem,,28053,,"4,675.50 x patient days",28053,Per diem,,16310,,"2,718.31 x patient days",16310,Per diem,,0.01,42276,
Female reproductive system malignancy,530-3,APR-DRG,,,,,,,,inpatient,,,223676.53,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,24269,,"4,044.85 x patient days",24269,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,40122,,"27,634 x DRG weight",40122,Other,base rate x DRG weight,34102,,"23,488 x DRG weight",34102,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,13048,,"2,174.65 x patient days",13048,Per diem,,13048,,"2,174.65 x patient days",13048,Per diem,,13048,,"2,174.65 x patient days",13048,Per diem,,13048,,"2,174.65 x patient days",13048,Per diem,,29358,,"4,892.96 x patient days",29358,Per diem,,19963,,"3,327.21 x patient days",19963,Per diem,,29358,,"4,892.96 x patient days",29358,Per diem,,18267,,"3,044.51 x patient days",18267,Per diem,,29358,,"4,892.96 x patient days",29358,Per diem,,35882,,"5,980.29 x patient days",35882,Per diem,,42276,,"7,045.87 x patient days",42276,Per diem,,28053,,"4,675.50 x patient days",28053,Per diem,,28053,,"4,675.50 x patient days",28053,Per diem,,16310,,"2,718.31 x patient days",16310,Per diem,,0.01,42276,
Female reproductive system malignancy,530-4,APR-DRG,,,,,,,,inpatient,,,166942.36,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,24269,,"4,044.85 x patient days",24269,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,69281,,"27,634 x DRG weight",69281,Other,base rate x DRG weight,58887,,"23,488 x DRG weight",58887,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,13048,,"2,174.65 x patient days",13048,Per diem,,13048,,"2,174.65 x patient days",13048,Per diem,,13048,,"2,174.65 x patient days",13048,Per diem,,13048,,"2,174.65 x patient days",13048,Per diem,,29358,,"4,892.96 x patient days",29358,Per diem,,19963,,"3,327.21 x patient days",19963,Per diem,,29358,,"4,892.96 x patient days",29358,Per diem,,18267,,"3,044.51 x patient days",18267,Per diem,,29358,,"4,892.96 x patient days",29358,Per diem,,35882,,"5,980.29 x patient days",35882,Per diem,,42276,,"7,045.87 x patient days",42276,Per diem,,28053,,"4,675.50 x patient days",28053,Per diem,,28053,,"4,675.50 x patient days",28053,Per diem,,16310,,"2,718.31 x patient days",16310,Per diem,,0.01,69281,
Female reproductive system infections,531-1,APR-DRG,,,,,,,,inpatient,,,81959.58,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12135,,"4,044.85 x patient days",12135,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,14922,,"27,634 x DRG weight",14922,Other,base rate x DRG weight,12684,,"23,488 x DRG weight",12684,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9982,,"3,327.21 x patient days",9982,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9134,,"3,044.51 x patient days",9134,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,17941,,"5,980.29 x patient days",17941,Per diem,,21138,,"7,045.87 x patient days",21138,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,8155,,"2,718.31 x patient days",8155,Per diem,,0.01,21138,
Female reproductive system infections,531-2,APR-DRG,,,,,,,,inpatient,,,139796.04,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12135,,"4,044.85 x patient days",12135,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,20181,,"27,634 x DRG weight",20181,Other,base rate x DRG weight,17153,,"23,488 x DRG weight",17153,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9982,,"3,327.21 x patient days",9982,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9134,,"3,044.51 x patient days",9134,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,17941,,"5,980.29 x patient days",17941,Per diem,,21138,,"7,045.87 x patient days",21138,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,8155,,"2,718.31 x patient days",8155,Per diem,,0.01,21138,
Female reproductive system infections,531-3,APR-DRG,,,,,,,,inpatient,,,109572.96,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12135,,"4,044.85 x patient days",12135,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,32028,,"27,634 x DRG weight",32028,Other,base rate x DRG weight,27223,,"23,488 x DRG weight",27223,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9982,,"3,327.21 x patient days",9982,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9134,,"3,044.51 x patient days",9134,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,17941,,"5,980.29 x patient days",17941,Per diem,,21138,,"7,045.87 x patient days",21138,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,8155,,"2,718.31 x patient days",8155,Per diem,,0.01,32028,
Female reproductive system infections,531-4,APR-DRG,,,,,,,,inpatient,,,139796.04,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12135,,"4,044.85 x patient days",12135,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,35977,,"27,634 x DRG weight",35977,Other,base rate x DRG weight,30579,,"23,488 x DRG weight",30579,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9982,,"3,327.21 x patient days",9982,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9134,,"3,044.51 x patient days",9134,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,17941,,"5,980.29 x patient days",17941,Per diem,,21138,,"7,045.87 x patient days",21138,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,8155,,"2,718.31 x patient days",8155,Per diem,,0.01,35977,
Menstrual & other female reproductive system disorders,532-1,APR-DRG,,,,,,,,inpatient,,,46782.41,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8089,,"4,044.85 x patient days",8089,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,11156,,"27,634 x DRG weight",11156,Other,base rate x DRG weight,9482,,"23,488 x DRG weight",9482,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6654,,"3,327.21 x patient days",6654,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6089,,"3,044.51 x patient days",6089,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,11960,,"5,980.29 x patient days",11960,Per diem,,14091,,"7,045.87 x patient days",14091,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,5436,,"2,718.31 x patient days",5436,Per diem,,0.01,14091,
Menstrual & other female reproductive system disorders,532-2,APR-DRG,,,,,,,,inpatient,,,67751.58,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8089,,"4,044.85 x patient days",8089,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,15439,,"27,634 x DRG weight",15439,Other,base rate x DRG weight,13123,,"23,488 x DRG weight",13123,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6654,,"3,327.21 x patient days",6654,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6089,,"3,044.51 x patient days",6089,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,11960,,"5,980.29 x patient days",11960,Per diem,,14091,,"7,045.87 x patient days",14091,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,5436,,"2,718.31 x patient days",5436,Per diem,,0.01,15439,
Menstrual & other female reproductive system disorders,532-3,APR-DRG,,,,,,,,inpatient,,,128400.55,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8089,,"4,044.85 x patient days",8089,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,26824,,"27,634 x DRG weight",26824,Other,base rate x DRG weight,22800,,"23,488 x DRG weight",22800,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6654,,"3,327.21 x patient days",6654,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6089,,"3,044.51 x patient days",6089,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,11960,,"5,980.29 x patient days",11960,Per diem,,14091,,"7,045.87 x patient days",14091,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,5436,,"2,718.31 x patient days",5436,Per diem,,0.01,26824,
Menstrual & other female reproductive system disorders,532-4,APR-DRG,,,,,,,,inpatient,,,321608.2,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8089,,"4,044.85 x patient days",8089,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,28430,,"27,634 x DRG weight",28430,Other,base rate x DRG weight,24164,,"23,488 x DRG weight",24164,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6654,,"3,327.21 x patient days",6654,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6089,,"3,044.51 x patient days",6089,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,11960,,"5,980.29 x patient days",11960,Per diem,,14091,,"7,045.87 x patient days",14091,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,5436,,"2,718.31 x patient days",5436,Per diem,,0.01,28430,
Cesarean delivery,540-1,APR-DRG,,,,,,,,inpatient,,,105530.65,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,16180,,"4,044.85 x patient days",16180,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,22138,,"27,634 x DRG weight",22138,Other,base rate x DRG weight,18816,,"23,488 x DRG weight",18816,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,13309,,"3,327.21 x patient days",13309,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,12179,,"3,044.51 x patient days",12179,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,23922,,"5,980.29 x patient days",23922,Per diem,,28185,,"7,045.87 x patient days",28185,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,10874,,"2,718.31 x patient days",10874,Per diem,,0.01,28185,
Cesarean delivery,540-2,APR-DRG,,,,,,,,inpatient,,,140809.14,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,16180,,"4,044.85 x patient days",16180,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,25387,,"27,634 x DRG weight",25387,Other,base rate x DRG weight,21578,,"23,488 x DRG weight",21578,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,13309,,"3,327.21 x patient days",13309,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,12179,,"3,044.51 x patient days",12179,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,23922,,"5,980.29 x patient days",23922,Per diem,,28185,,"7,045.87 x patient days",28185,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,10874,,"2,718.31 x patient days",10874,Per diem,,0.01,28185,
Cesarean delivery,540-3,APR-DRG,,,,,,,,inpatient,,,185138.55,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,16180,,"4,044.85 x patient days",16180,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,32509,,"27,634 x DRG weight",32509,Other,base rate x DRG weight,27631,,"23,488 x DRG weight",27631,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,13309,,"3,327.21 x patient days",13309,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,12179,,"3,044.51 x patient days",12179,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,23922,,"5,980.29 x patient days",23922,Per diem,,28185,,"7,045.87 x patient days",28185,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,10874,,"2,718.31 x patient days",10874,Per diem,,0.01,32509,
Cesarean delivery,540-4,APR-DRG,,,,,,,,inpatient,,,334973.51,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,16180,,"4,044.85 x patient days",16180,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,74767,,"27,634 x DRG weight",74767,Other,base rate x DRG weight,63549,,"23,488 x DRG weight",63549,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,13309,,"3,327.21 x patient days",13309,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,12179,,"3,044.51 x patient days",12179,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,23922,,"5,980.29 x patient days",23922,Per diem,,28185,,"7,045.87 x patient days",28185,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,10874,,"2,718.31 x patient days",10874,Per diem,,0.01,74767,
Vaginal delivery w sterilization &/or D&C,541-1,APR-DRG,,,,,,,,inpatient,,,108561.75,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12135,,"4,044.85 x patient days",12135,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,19429,,"27,634 x DRG weight",19429,Other,base rate x DRG weight,16514,,"23,488 x DRG weight",16514,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9982,,"3,327.21 x patient days",9982,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9134,,"3,044.51 x patient days",9134,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,17941,,"5,980.29 x patient days",17941,Per diem,,21138,,"7,045.87 x patient days",21138,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,8155,,"2,718.31 x patient days",8155,Per diem,,0.01,21138,
Vaginal delivery w sterilization &/or D&C,541-2,APR-DRG,,,,,,,,inpatient,,,107615.9,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12135,,"4,044.85 x patient days",12135,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,21005,,"27,634 x DRG weight",21005,Other,base rate x DRG weight,17853,,"23,488 x DRG weight",17853,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9982,,"3,327.21 x patient days",9982,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9134,,"3,044.51 x patient days",9134,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,17941,,"5,980.29 x patient days",17941,Per diem,,21138,,"7,045.87 x patient days",21138,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,8155,,"2,718.31 x patient days",8155,Per diem,,0.01,21138,
Vaginal delivery w sterilization &/or D&C,541-3,APR-DRG,,,,,,,,inpatient,,,258103.07,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12135,,"4,044.85 x patient days",12135,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,27518,,"27,634 x DRG weight",27518,Other,base rate x DRG weight,23389,,"23,488 x DRG weight",23389,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9982,,"3,327.21 x patient days",9982,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9134,,"3,044.51 x patient days",9134,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,17941,,"5,980.29 x patient days",17941,Per diem,,21138,,"7,045.87 x patient days",21138,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,8155,,"2,718.31 x patient days",8155,Per diem,,0.01,27518,
Vaginal delivery w sterilization &/or D&C,541-4,APR-DRG,,,,,,,,inpatient,,,258103.07,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12135,,"4,044.85 x patient days",12135,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,30146,,"27,634 x DRG weight",30146,Other,base rate x DRG weight,25623,,"23,488 x DRG weight",25623,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9982,,"3,327.21 x patient days",9982,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9134,,"3,044.51 x patient days",9134,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,17941,,"5,980.29 x patient days",17941,Per diem,,21138,,"7,045.87 x patient days",21138,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,8155,,"2,718.31 x patient days",8155,Per diem,,0.01,30146,
Vaginal delivery w complicating procedures exc sterilization &/or D&C,542-1,APR-DRG,,,,,,,,inpatient,,,87122,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12135,,"4,044.85 x patient days",12135,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,16445,,"27,634 x DRG weight",16445,Other,base rate x DRG weight,13978,,"23,488 x DRG weight",13978,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9982,,"3,327.21 x patient days",9982,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9134,,"3,044.51 x patient days",9134,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,17941,,"5,980.29 x patient days",17941,Per diem,,21138,,"7,045.87 x patient days",21138,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,8155,,"2,718.31 x patient days",8155,Per diem,,0.01,21138,
Vaginal delivery w complicating procedures exc sterilization &/or D&C,542-2,APR-DRG,,,,,,,,inpatient,,,79363.09,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12135,,"4,044.85 x patient days",12135,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,18741,,"27,634 x DRG weight",18741,Other,base rate x DRG weight,15930,,"23,488 x DRG weight",15930,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9982,,"3,327.21 x patient days",9982,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9134,,"3,044.51 x patient days",9134,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,17941,,"5,980.29 x patient days",17941,Per diem,,21138,,"7,045.87 x patient days",21138,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,8155,,"2,718.31 x patient days",8155,Per diem,,0.01,21138,
Vaginal delivery w complicating procedures exc sterilization &/or D&C,542-3,APR-DRG,,,,,,,,inpatient,,,100826.77,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12135,,"4,044.85 x patient days",12135,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,33758,,"27,634 x DRG weight",33758,Other,base rate x DRG weight,28693,,"23,488 x DRG weight",28693,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9982,,"3,327.21 x patient days",9982,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9134,,"3,044.51 x patient days",9134,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,17941,,"5,980.29 x patient days",17941,Per diem,,21138,,"7,045.87 x patient days",21138,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,8155,,"2,718.31 x patient days",8155,Per diem,,0.01,33758,
Vaginal delivery w complicating procedures exc sterilization &/or D&C,542-4,APR-DRG,,,,,,,,inpatient,,,100826.77,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12135,,"4,044.85 x patient days",12135,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,42581,,"27,634 x DRG weight",42581,Other,base rate x DRG weight,36193,,"23,488 x DRG weight",36193,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9982,,"3,327.21 x patient days",9982,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9134,,"3,044.51 x patient days",9134,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,17941,,"5,980.29 x patient days",17941,Per diem,,21138,,"7,045.87 x patient days",21138,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,8155,,"2,718.31 x patient days",8155,Per diem,,0.01,42581,
"D&C, aspiration curettage or hysterotomy for obstetric diagnoses",544-1,APR-DRG,,,,,,,,inpatient,,,84340.4,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8089,,"4,044.85 x patient days",8089,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,13262,,"27,634 x DRG weight",13262,Other,base rate x DRG weight,11272,,"23,488 x DRG weight",11272,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6654,,"3,327.21 x patient days",6654,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6089,,"3,044.51 x patient days",6089,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,11960,,"5,980.29 x patient days",11960,Per diem,,14091,,"7,045.87 x patient days",14091,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,5436,,"2,718.31 x patient days",5436,Per diem,,0.01,14091,
"D&C, aspiration curettage or hysterotomy for obstetric diagnoses",544-2,APR-DRG,,,,,,,,inpatient,,,121236.15,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8089,,"4,044.85 x patient days",8089,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,17103,,"27,634 x DRG weight",17103,Other,base rate x DRG weight,14537,,"23,488 x DRG weight",14537,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6654,,"3,327.21 x patient days",6654,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6089,,"3,044.51 x patient days",6089,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,11960,,"5,980.29 x patient days",11960,Per diem,,14091,,"7,045.87 x patient days",14091,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,5436,,"2,718.31 x patient days",5436,Per diem,,0.01,17103,
"D&C, aspiration curettage or hysterotomy for obstetric diagnoses",544-3,APR-DRG,,,,,,,,inpatient,,,160697,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8089,,"4,044.85 x patient days",8089,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,30381,,"27,634 x DRG weight",30381,Other,base rate x DRG weight,25823,,"23,488 x DRG weight",25823,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6654,,"3,327.21 x patient days",6654,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6089,,"3,044.51 x patient days",6089,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,11960,,"5,980.29 x patient days",11960,Per diem,,14091,,"7,045.87 x patient days",14091,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,5436,,"2,718.31 x patient days",5436,Per diem,,0.01,30381,
"D&C, aspiration curettage or hysterotomy for obstetric diagnoses",544-4,APR-DRG,,,,,,,,inpatient,,,160697,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8089,,"4,044.85 x patient days",8089,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,79326,,"27,634 x DRG weight",79326,Other,base rate x DRG weight,67425,,"23,488 x DRG weight",67425,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6654,,"3,327.21 x patient days",6654,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6089,,"3,044.51 x patient days",6089,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,11960,,"5,980.29 x patient days",11960,Per diem,,14091,,"7,045.87 x patient days",14091,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,5436,,"2,718.31 x patient days",5436,Per diem,,0.01,79326,
Ectopic pregnancy procedure,545-1,APR-DRG,,,,,,,,inpatient,,,169587.19,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8089,,"4,044.85 x patient days",8089,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,19208,,"27,634 x DRG weight",19208,Other,base rate x DRG weight,16327,,"23,488 x DRG weight",16327,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6654,,"3,327.21 x patient days",6654,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6089,,"3,044.51 x patient days",6089,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,11960,,"5,980.29 x patient days",11960,Per diem,,14091,,"7,045.87 x patient days",14091,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,5436,,"2,718.31 x patient days",5436,Per diem,,0.01,19208,
Ectopic pregnancy procedure,545-2,APR-DRG,,,,,,,,inpatient,,,85244.06,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8089,,"4,044.85 x patient days",8089,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,21693,,"27,634 x DRG weight",21693,Other,base rate x DRG weight,18438,,"23,488 x DRG weight",18438,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6654,,"3,327.21 x patient days",6654,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6089,,"3,044.51 x patient days",6089,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,11960,,"5,980.29 x patient days",11960,Per diem,,14091,,"7,045.87 x patient days",14091,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,5436,,"2,718.31 x patient days",5436,Per diem,,0.01,21693,
Ectopic pregnancy procedure,545-3,APR-DRG,,,,,,,,inpatient,,,128311.29,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8089,,"4,044.85 x patient days",8089,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,30433,,"27,634 x DRG weight",30433,Other,base rate x DRG weight,25867,,"23,488 x DRG weight",25867,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6654,,"3,327.21 x patient days",6654,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6089,,"3,044.51 x patient days",6089,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,11960,,"5,980.29 x patient days",11960,Per diem,,14091,,"7,045.87 x patient days",14091,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,5436,,"2,718.31 x patient days",5436,Per diem,,0.01,30433,
Ectopic pregnancy procedure,545-4,APR-DRG,,,,,,,,inpatient,,,128311.29,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8089,,"4,044.85 x patient days",8089,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,32473,,"27,634 x DRG weight",32473,Other,base rate x DRG weight,27601,,"23,488 x DRG weight",27601,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6654,,"3,327.21 x patient days",6654,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6089,,"3,044.51 x patient days",6089,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,11960,,"5,980.29 x patient days",11960,Per diem,,14091,,"7,045.87 x patient days",14091,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,5436,,"2,718.31 x patient days",5436,Per diem,,0.01,32473,
Other O.R. proc for obstetric diagnoses except delivery diagnoses,546-1,APR-DRG,,,,,,,,inpatient,,,68684.62,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12135,,"4,044.85 x patient days",12135,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,15901,,"27,634 x DRG weight",15901,Other,base rate x DRG weight,13515,,"23,488 x DRG weight",13515,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9982,,"3,327.21 x patient days",9982,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9134,,"3,044.51 x patient days",9134,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,17941,,"5,980.29 x patient days",17941,Per diem,,21138,,"7,045.87 x patient days",21138,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,8155,,"2,718.31 x patient days",8155,Per diem,,0.01,21138,
Other O.R. proc for obstetric diagnoses except delivery diagnoses,546-2,APR-DRG,,,,,,,,inpatient,,,85260.13,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12135,,"4,044.85 x patient days",12135,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,21541,,"27,634 x DRG weight",21541,Other,base rate x DRG weight,18309,,"23,488 x DRG weight",18309,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9982,,"3,327.21 x patient days",9982,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9134,,"3,044.51 x patient days",9134,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,17941,,"5,980.29 x patient days",17941,Per diem,,21138,,"7,045.87 x patient days",21138,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,8155,,"2,718.31 x patient days",8155,Per diem,,0.01,21541,
Other O.R. proc for obstetric diagnoses except delivery diagnoses,546-3,APR-DRG,,,,,,,,inpatient,,,144112.9,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12135,,"4,044.85 x patient days",12135,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,46257,,"27,634 x DRG weight",46257,Other,base rate x DRG weight,39317,,"23,488 x DRG weight",39317,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9982,,"3,327.21 x patient days",9982,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9134,,"3,044.51 x patient days",9134,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,17941,,"5,980.29 x patient days",17941,Per diem,,21138,,"7,045.87 x patient days",21138,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,8155,,"2,718.31 x patient days",8155,Per diem,,0.01,46257,
Other O.R. proc for obstetric diagnoses except delivery diagnoses,546-4,APR-DRG,,,,,,,,inpatient,,,144112.9,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12135,,"4,044.85 x patient days",12135,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,119039,,"27,634 x DRG weight",119039,Other,base rate x DRG weight,101179,,"23,488 x DRG weight",101179,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9982,,"3,327.21 x patient days",9982,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9134,,"3,044.51 x patient days",9134,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,17941,,"5,980.29 x patient days",17941,Per diem,,21138,,"7,045.87 x patient days",21138,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,8155,,"2,718.31 x patient days",8155,Per diem,,0.01,119039,
Vaginal delivery,560-1,APR-DRG,,,,,,,,inpatient,,,66519.9,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8089,,"4,044.85 x patient days",8089,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,14632,,"27,634 x DRG weight",14632,Other,base rate x DRG weight,12437,,"23,488 x DRG weight",12437,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6654,,"3,327.21 x patient days",6654,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6089,,"3,044.51 x patient days",6089,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,11960,,"5,980.29 x patient days",11960,Per diem,,14091,,"7,045.87 x patient days",14091,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,5436,,"2,718.31 x patient days",5436,Per diem,,0.01,14632,
Vaginal delivery,560-2,APR-DRG,,,,,,,,inpatient,,,75829.33,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8089,,"4,044.85 x patient days",8089,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,16171,,"27,634 x DRG weight",16171,Other,base rate x DRG weight,13745,,"23,488 x DRG weight",13745,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6654,,"3,327.21 x patient days",6654,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6089,,"3,044.51 x patient days",6089,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,11960,,"5,980.29 x patient days",11960,Per diem,,14091,,"7,045.87 x patient days",14091,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,5436,,"2,718.31 x patient days",5436,Per diem,,0.01,16171,
Vaginal delivery,560-3,APR-DRG,,,,,,,,inpatient,,,118877.66,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8089,,"4,044.85 x patient days",8089,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,20073,,"27,634 x DRG weight",20073,Other,base rate x DRG weight,17062,,"23,488 x DRG weight",17062,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6654,,"3,327.21 x patient days",6654,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6089,,"3,044.51 x patient days",6089,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,11960,,"5,980.29 x patient days",11960,Per diem,,14091,,"7,045.87 x patient days",14091,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,5436,,"2,718.31 x patient days",5436,Per diem,,0.01,20073,
Vaginal delivery,560-4,APR-DRG,,,,,,,,inpatient,,,366963.67,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8089,,"4,044.85 x patient days",8089,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,46884,,"27,634 x DRG weight",46884,Other,base rate x DRG weight,39850,,"23,488 x DRG weight",39850,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6654,,"3,327.21 x patient days",6654,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6089,,"3,044.51 x patient days",6089,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,11960,,"5,980.29 x patient days",11960,Per diem,,14091,,"7,045.87 x patient days",14091,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,5436,,"2,718.31 x patient days",5436,Per diem,,0.01,46884,
Postpartum & post abortion diagnoses w/o procedure,561-1,APR-DRG,,,,,,,,inpatient,,,55444.25,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8089,,"4,044.85 x patient days",8089,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,10473,,"27,634 x DRG weight",10473,Other,base rate x DRG weight,8902,,"23,488 x DRG weight",8902,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6654,,"3,327.21 x patient days",6654,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6089,,"3,044.51 x patient days",6089,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,11960,,"5,980.29 x patient days",11960,Per diem,,14091,,"7,045.87 x patient days",14091,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,5436,,"2,718.31 x patient days",5436,Per diem,,0.01,14091,
Postpartum & post abortion diagnoses w/o procedure,561-2,APR-DRG,,,,,,,,inpatient,,,74019.48,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8089,,"4,044.85 x patient days",8089,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12397,,"27,634 x DRG weight",12397,Other,base rate x DRG weight,10537,,"23,488 x DRG weight",10537,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6654,,"3,327.21 x patient days",6654,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6089,,"3,044.51 x patient days",6089,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,11960,,"5,980.29 x patient days",11960,Per diem,,14091,,"7,045.87 x patient days",14091,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,5436,,"2,718.31 x patient days",5436,Per diem,,0.01,14091,
Postpartum & post abortion diagnoses w/o procedure,561-3,APR-DRG,,,,,,,,inpatient,,,86038.74,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8089,,"4,044.85 x patient days",8089,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,18617,,"27,634 x DRG weight",18617,Other,base rate x DRG weight,15824,,"23,488 x DRG weight",15824,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6654,,"3,327.21 x patient days",6654,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6089,,"3,044.51 x patient days",6089,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,11960,,"5,980.29 x patient days",11960,Per diem,,14091,,"7,045.87 x patient days",14091,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,5436,,"2,718.31 x patient days",5436,Per diem,,0.01,18617,
Postpartum & post abortion diagnoses w/o procedure,561-4,APR-DRG,,,,,,,,inpatient,,,86038.74,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8089,,"4,044.85 x patient days",8089,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,40285,,"27,634 x DRG weight",40285,Other,base rate x DRG weight,34241,,"23,488 x DRG weight",34241,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6654,,"3,327.21 x patient days",6654,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6089,,"3,044.51 x patient days",6089,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,11960,,"5,980.29 x patient days",11960,Per diem,,14091,,"7,045.87 x patient days",14091,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,5436,,"2,718.31 x patient days",5436,Per diem,,0.01,40285,
Preterm labor,563-1,APR-DRG,,,,,,,,inpatient,,,59757.84,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8089,,"4,044.85 x patient days",8089,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,9617,,"27,634 x DRG weight",9617,Other,base rate x DRG weight,8174,,"23,488 x DRG weight",8174,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6654,,"3,327.21 x patient days",6654,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6089,,"3,044.51 x patient days",6089,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,11960,,"5,980.29 x patient days",11960,Per diem,,14091,,"7,045.87 x patient days",14091,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,5436,,"2,718.31 x patient days",5436,Per diem,,0.01,14091,
Preterm labor,563-2,APR-DRG,,,,,,,,inpatient,,,62096.28,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8089,,"4,044.85 x patient days",8089,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,11573,,"27,634 x DRG weight",11573,Other,base rate x DRG weight,9837,,"23,488 x DRG weight",9837,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6654,,"3,327.21 x patient days",6654,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6089,,"3,044.51 x patient days",6089,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,11960,,"5,980.29 x patient days",11960,Per diem,,14091,,"7,045.87 x patient days",14091,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,5436,,"2,718.31 x patient days",5436,Per diem,,0.01,14091,
Preterm labor,563-3,APR-DRG,,,,,,,,inpatient,,,46332.08,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8089,,"4,044.85 x patient days",8089,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,16431,,"27,634 x DRG weight",16431,Other,base rate x DRG weight,13966,,"23,488 x DRG weight",13966,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6654,,"3,327.21 x patient days",6654,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6089,,"3,044.51 x patient days",6089,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,11960,,"5,980.29 x patient days",11960,Per diem,,14091,,"7,045.87 x patient days",14091,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,5436,,"2,718.31 x patient days",5436,Per diem,,0.01,16431,
Preterm labor,563-4,APR-DRG,,,,,,,,inpatient,,,62096.28,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8089,,"4,044.85 x patient days",8089,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,16431,,"27,634 x DRG weight",16431,Other,base rate x DRG weight,13966,,"23,488 x DRG weight",13966,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6654,,"3,327.21 x patient days",6654,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6089,,"3,044.51 x patient days",6089,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,11960,,"5,980.29 x patient days",11960,Per diem,,14091,,"7,045.87 x patient days",14091,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,5436,,"2,718.31 x patient days",5436,Per diem,,0.01,16431,
"Abortion w/o D&C, aspiration curettage or hysterotomy",564-1,APR-DRG,,,,,,,,inpatient,,,39420,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8089,,"4,044.85 x patient days",8089,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,10084,,"27,634 x DRG weight",10084,Other,base rate x DRG weight,8571,,"23,488 x DRG weight",8571,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6654,,"3,327.21 x patient days",6654,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6089,,"3,044.51 x patient days",6089,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,11960,,"5,980.29 x patient days",11960,Per diem,,14091,,"7,045.87 x patient days",14091,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,5436,,"2,718.31 x patient days",5436,Per diem,,0.01,14091,
"Abortion w/o D&C, aspiration curettage or hysterotomy",564-2,APR-DRG,,,,,,,,inpatient,,,49448.75,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8089,,"4,044.85 x patient days",8089,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,11670,,"27,634 x DRG weight",11670,Other,base rate x DRG weight,9919,,"23,488 x DRG weight",9919,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6654,,"3,327.21 x patient days",6654,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6089,,"3,044.51 x patient days",6089,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,11960,,"5,980.29 x patient days",11960,Per diem,,14091,,"7,045.87 x patient days",14091,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,5436,,"2,718.31 x patient days",5436,Per diem,,0.01,14091,
"Abortion w/o D&C, aspiration curettage or hysterotomy",564-3,APR-DRG,,,,,,,,inpatient,,,90792.44,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8089,,"4,044.85 x patient days",8089,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,16674,,"27,634 x DRG weight",16674,Other,base rate x DRG weight,14173,,"23,488 x DRG weight",14173,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6654,,"3,327.21 x patient days",6654,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6089,,"3,044.51 x patient days",6089,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,11960,,"5,980.29 x patient days",11960,Per diem,,14091,,"7,045.87 x patient days",14091,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,5436,,"2,718.31 x patient days",5436,Per diem,,0.01,16674,
"Abortion w/o D&C, aspiration curettage or hysterotomy",564-4,APR-DRG,,,,,,,,inpatient,,,90792.44,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8089,,"4,044.85 x patient days",8089,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,20043,,"27,634 x DRG weight",20043,Other,base rate x DRG weight,17036,,"23,488 x DRG weight",17036,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6654,,"3,327.21 x patient days",6654,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6089,,"3,044.51 x patient days",6089,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,11960,,"5,980.29 x patient days",11960,Per diem,,14091,,"7,045.87 x patient days",14091,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,5436,,"2,718.31 x patient days",5436,Per diem,,0.01,20043,
False labor,565-1,APR-DRG,,,,,,,,inpatient,,,25446,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,4046,,"4,044.85 x patient days",4046,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6289,,"27,634 x DRG weight",6289,Other,base rate x DRG weight,5346,,"23,488 x DRG weight",5346,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,2175,,"2,174.65 x patient days",2175,Per diem,,2175,,"2,174.65 x patient days",2175,Per diem,,2175,,"2,174.65 x patient days",2175,Per diem,,2175,,"2,174.65 x patient days",2175,Per diem,,4894,,"4,892.96 x patient days",4894,Per diem,,3328,,"3,327.21 x patient days",3328,Per diem,,4894,,"4,892.96 x patient days",4894,Per diem,,3045,,"3,044.51 x patient days",3045,Per diem,,4894,,"4,892.96 x patient days",4894,Per diem,,5981,,"5,980.29 x patient days",5981,Per diem,,7047,,"7,045.87 x patient days",7047,Per diem,,4676,,"4,675.50 x patient days",4676,Per diem,,4676,,"4,675.50 x patient days",4676,Per diem,,2719,,"2,718.31 x patient days",2719,Per diem,,0.01,7047,
False labor,565-2,APR-DRG,,,,,,,,inpatient,,,27853.5,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,4046,,"4,044.85 x patient days",4046,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,7804,,"27,634 x DRG weight",7804,Other,base rate x DRG weight,6633,,"23,488 x DRG weight",6633,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,2175,,"2,174.65 x patient days",2175,Per diem,,2175,,"2,174.65 x patient days",2175,Per diem,,2175,,"2,174.65 x patient days",2175,Per diem,,2175,,"2,174.65 x patient days",2175,Per diem,,4894,,"4,892.96 x patient days",4894,Per diem,,3328,,"3,327.21 x patient days",3328,Per diem,,4894,,"4,892.96 x patient days",4894,Per diem,,3045,,"3,044.51 x patient days",3045,Per diem,,4894,,"4,892.96 x patient days",4894,Per diem,,5981,,"5,980.29 x patient days",5981,Per diem,,7047,,"7,045.87 x patient days",7047,Per diem,,4676,,"4,675.50 x patient days",4676,Per diem,,4676,,"4,675.50 x patient days",4676,Per diem,,2719,,"2,718.31 x patient days",2719,Per diem,,0.01,7804,
False labor,565-3,APR-DRG,,,,,,,,inpatient,,,126573.8,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,4046,,"4,044.85 x patient days",4046,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,7942,,"27,634 x DRG weight",7942,Other,base rate x DRG weight,6750,,"23,488 x DRG weight",6750,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,2175,,"2,174.65 x patient days",2175,Per diem,,2175,,"2,174.65 x patient days",2175,Per diem,,2175,,"2,174.65 x patient days",2175,Per diem,,2175,,"2,174.65 x patient days",2175,Per diem,,4894,,"4,892.96 x patient days",4894,Per diem,,3328,,"3,327.21 x patient days",3328,Per diem,,4894,,"4,892.96 x patient days",4894,Per diem,,3045,,"3,044.51 x patient days",3045,Per diem,,4894,,"4,892.96 x patient days",4894,Per diem,,5981,,"5,980.29 x patient days",5981,Per diem,,7047,,"7,045.87 x patient days",7047,Per diem,,4676,,"4,675.50 x patient days",4676,Per diem,,4676,,"4,675.50 x patient days",4676,Per diem,,2719,,"2,718.31 x patient days",2719,Per diem,,0.01,7942,
False labor,565-4,APR-DRG,,,,,,,,inpatient,,,126573.8,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,4046,,"4,044.85 x patient days",4046,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,7942,,"27,634 x DRG weight",7942,Other,base rate x DRG weight,6750,,"23,488 x DRG weight",6750,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,2175,,"2,174.65 x patient days",2175,Per diem,,2175,,"2,174.65 x patient days",2175,Per diem,,2175,,"2,174.65 x patient days",2175,Per diem,,2175,,"2,174.65 x patient days",2175,Per diem,,4894,,"4,892.96 x patient days",4894,Per diem,,3328,,"3,327.21 x patient days",3328,Per diem,,4894,,"4,892.96 x patient days",4894,Per diem,,3045,,"3,044.51 x patient days",3045,Per diem,,4894,,"4,892.96 x patient days",4894,Per diem,,5981,,"5,980.29 x patient days",5981,Per diem,,7047,,"7,045.87 x patient days",7047,Per diem,,4676,,"4,675.50 x patient days",4676,Per diem,,4676,,"4,675.50 x patient days",4676,Per diem,,2719,,"2,718.31 x patient days",2719,Per diem,,0.01,7942,
Other antepartum diagnoses,566-1,APR-DRG,,,,,,,,inpatient,,,53309.78,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12135,,"4,044.85 x patient days",12135,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,9415,,"27,634 x DRG weight",9415,Other,base rate x DRG weight,8002,,"23,488 x DRG weight",8002,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9982,,"3,327.21 x patient days",9982,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9134,,"3,044.51 x patient days",9134,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,17941,,"5,980.29 x patient days",17941,Per diem,,21138,,"7,045.87 x patient days",21138,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,8155,,"2,718.31 x patient days",8155,Per diem,,0.01,21138,
Other antepartum diagnoses,566-2,APR-DRG,,,,,,,,inpatient,,,93972.09,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12135,,"4,044.85 x patient days",12135,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12322,,"27,634 x DRG weight",12322,Other,base rate x DRG weight,10473,,"23,488 x DRG weight",10473,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9982,,"3,327.21 x patient days",9982,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9134,,"3,044.51 x patient days",9134,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,17941,,"5,980.29 x patient days",17941,Per diem,,21138,,"7,045.87 x patient days",21138,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,8155,,"2,718.31 x patient days",8155,Per diem,,0.01,21138,
Other antepartum diagnoses,566-3,APR-DRG,,,,,,,,inpatient,,,124232.33,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12135,,"4,044.85 x patient days",12135,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,18131,,"27,634 x DRG weight",18131,Other,base rate x DRG weight,15410,,"23,488 x DRG weight",15410,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9982,,"3,327.21 x patient days",9982,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9134,,"3,044.51 x patient days",9134,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,17941,,"5,980.29 x patient days",17941,Per diem,,21138,,"7,045.87 x patient days",21138,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,8155,,"2,718.31 x patient days",8155,Per diem,,0.01,21138,
Other antepartum diagnoses,566-4,APR-DRG,,,,,,,,inpatient,,,114510.91,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12135,,"4,044.85 x patient days",12135,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,37632,,"27,634 x DRG weight",37632,Other,base rate x DRG weight,31986,,"23,488 x DRG weight",31986,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9982,,"3,327.21 x patient days",9982,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9134,,"3,044.51 x patient days",9134,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,17941,,"5,980.29 x patient days",17941,Per diem,,21138,,"7,045.87 x patient days",21138,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,8155,,"2,718.31 x patient days",8155,Per diem,,0.01,37632,
"Neonate, transferred <5 days old, not born here",580-1,APR-DRG,,,,,,,,inpatient,,,16942.33,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8089,,"4,044.85 x patient days",8089,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8426,,"27,634 x DRG weight",8426,Other,base rate x DRG weight,7161,,"23,488 x DRG weight",7161,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6654,,"3,327.21 x patient days",6654,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6089,,"3,044.51 x patient days",6089,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,11960,,"5,980.29 x patient days",11960,Per diem,,14091,,"7,045.87 x patient days",14091,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,5436,,"2,718.31 x patient days",5436,Per diem,,0.01,14091,
"Neonate, transferred <5 days old, not born here",580-2,APR-DRG,,,,,,,,inpatient,,,70194.06,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8089,,"4,044.85 x patient days",8089,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,10667,,"27,634 x DRG weight",10667,Other,base rate x DRG weight,9066,,"23,488 x DRG weight",9066,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6654,,"3,327.21 x patient days",6654,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6089,,"3,044.51 x patient days",6089,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,11960,,"5,980.29 x patient days",11960,Per diem,,14091,,"7,045.87 x patient days",14091,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,5436,,"2,718.31 x patient days",5436,Per diem,,0.01,14091,
"Neonate, transferred <5 days old, not born here",580-3,APR-DRG,,,,,,,,inpatient,,,161498.29,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8089,,"4,044.85 x patient days",8089,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,14972,,"27,634 x DRG weight",14972,Other,base rate x DRG weight,12726,,"23,488 x DRG weight",12726,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6654,,"3,327.21 x patient days",6654,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6089,,"3,044.51 x patient days",6089,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,11960,,"5,980.29 x patient days",11960,Per diem,,14091,,"7,045.87 x patient days",14091,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,5436,,"2,718.31 x patient days",5436,Per diem,,0.01,14972,
"Neonate, transferred <5 days old, not born here",580-4,APR-DRG,,,,,,,,inpatient,,,161498.29,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8089,,"4,044.85 x patient days",8089,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,30762,,"27,634 x DRG weight",30762,Other,base rate x DRG weight,26147,,"23,488 x DRG weight",26147,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6654,,"3,327.21 x patient days",6654,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6089,,"3,044.51 x patient days",6089,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,11960,,"5,980.29 x patient days",11960,Per diem,,14091,,"7,045.87 x patient days",14091,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,5436,,"2,718.31 x patient days",5436,Per diem,,0.01,30762,
"Neonate, transferred < 5 days old, born here",581-1,APR-DRG,,,,,,,,inpatient,,,22137.41,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,4046,,"4,044.85 x patient days",4046,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,3772,,"27,634 x DRG weight",3772,Other,base rate x DRG weight,3206,,"23,488 x DRG weight",3206,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,2175,,"2,174.65 x patient days",2175,Per diem,,2175,,"2,174.65 x patient days",2175,Per diem,,2175,,"2,174.65 x patient days",2175,Per diem,,2175,,"2,174.65 x patient days",2175,Per diem,,4894,,"4,892.96 x patient days",4894,Per diem,,3328,,"3,327.21 x patient days",3328,Per diem,,4894,,"4,892.96 x patient days",4894,Per diem,,3045,,"3,044.51 x patient days",3045,Per diem,,4894,,"4,892.96 x patient days",4894,Per diem,,5981,,"5,980.29 x patient days",5981,Per diem,,7047,,"7,045.87 x patient days",7047,Per diem,,4676,,"4,675.50 x patient days",4676,Per diem,,4676,,"4,675.50 x patient days",4676,Per diem,,2719,,"2,718.31 x patient days",2719,Per diem,,0.01,7047,
"Neonate, transferred < 5 days old, born here",581-2,APR-DRG,,,,,,,,inpatient,,,37661,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,4046,,"4,044.85 x patient days",4046,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,5134,,"27,634 x DRG weight",5134,Other,base rate x DRG weight,4364,,"23,488 x DRG weight",4364,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,2175,,"2,174.65 x patient days",2175,Per diem,,2175,,"2,174.65 x patient days",2175,Per diem,,2175,,"2,174.65 x patient days",2175,Per diem,,2175,,"2,174.65 x patient days",2175,Per diem,,4894,,"4,892.96 x patient days",4894,Per diem,,3328,,"3,327.21 x patient days",3328,Per diem,,4894,,"4,892.96 x patient days",4894,Per diem,,3045,,"3,044.51 x patient days",3045,Per diem,,4894,,"4,892.96 x patient days",4894,Per diem,,5981,,"5,980.29 x patient days",5981,Per diem,,7047,,"7,045.87 x patient days",7047,Per diem,,4676,,"4,675.50 x patient days",4676,Per diem,,4676,,"4,675.50 x patient days",4676,Per diem,,2719,,"2,718.31 x patient days",2719,Per diem,,0.01,7047,
"Neonate, transferred < 5 days old, born here",581-3,APR-DRG,,,,,,,,inpatient,,,130270.39,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,4046,,"4,044.85 x patient days",4046,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,7572,,"27,634 x DRG weight",7572,Other,base rate x DRG weight,6436,,"23,488 x DRG weight",6436,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,2175,,"2,174.65 x patient days",2175,Per diem,,2175,,"2,174.65 x patient days",2175,Per diem,,2175,,"2,174.65 x patient days",2175,Per diem,,2175,,"2,174.65 x patient days",2175,Per diem,,4894,,"4,892.96 x patient days",4894,Per diem,,3328,,"3,327.21 x patient days",3328,Per diem,,4894,,"4,892.96 x patient days",4894,Per diem,,3045,,"3,044.51 x patient days",3045,Per diem,,4894,,"4,892.96 x patient days",4894,Per diem,,5981,,"5,980.29 x patient days",5981,Per diem,,7047,,"7,045.87 x patient days",7047,Per diem,,4676,,"4,675.50 x patient days",4676,Per diem,,4676,,"4,675.50 x patient days",4676,Per diem,,2719,,"2,718.31 x patient days",2719,Per diem,,0.01,7572,
"Neonate, transferred < 5 days old, born here",581-4,APR-DRG,,,,,,,,inpatient,,,130270.39,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,4046,,"4,044.85 x patient days",4046,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,13668,,"27,634 x DRG weight",13668,Other,base rate x DRG weight,11617,,"23,488 x DRG weight",11617,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,2175,,"2,174.65 x patient days",2175,Per diem,,2175,,"2,174.65 x patient days",2175,Per diem,,2175,,"2,174.65 x patient days",2175,Per diem,,2175,,"2,174.65 x patient days",2175,Per diem,,4894,,"4,892.96 x patient days",4894,Per diem,,3328,,"3,327.21 x patient days",3328,Per diem,,4894,,"4,892.96 x patient days",4894,Per diem,,3045,,"3,044.51 x patient days",3045,Per diem,,4894,,"4,892.96 x patient days",4894,Per diem,,5981,,"5,980.29 x patient days",5981,Per diem,,7047,,"7,045.87 x patient days",7047,Per diem,,4676,,"4,675.50 x patient days",4676,Per diem,,4676,,"4,675.50 x patient days",4676,Per diem,,2719,,"2,718.31 x patient days",2719,Per diem,,0.01,13668,
Neonate w ECMO,583-1,APR-DRG,,,,,,,,inpatient,,,819584.95,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,157748,,"4,044.85 x patient days",157748,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,395705,,"27,634 x DRG weight",395705,Other,base rate x DRG weight,336336,,"23,488 x DRG weight",336336,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,84811,,"2,174.65 x patient days",84811,Per diem,,84811,,"2,174.65 x patient days",84811,Per diem,,84811,,"2,174.65 x patient days",84811,Per diem,,84811,,"2,174.65 x patient days",84811,Per diem,,190825,,"4,892.96 x patient days",190825,Per diem,,129761,,"3,327.21 x patient days",129761,Per diem,,190825,,"4,892.96 x patient days",190825,Per diem,,118735,,"3,044.51 x patient days",118735,Per diem,,190825,,"4,892.96 x patient days",190825,Per diem,,233230,,"5,980.29 x patient days",233230,Per diem,,274788,,"7,045.87 x patient days",274788,Per diem,,182344,,"4,675.50 x patient days",182344,Per diem,,182344,,"4,675.50 x patient days",182344,Per diem,,106014,,"2,718.31 x patient days",106014,Per diem,,0.01,395705,
Neonate w ECMO,583-2,APR-DRG,,,,,,,,inpatient,,,819584.95,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,157748,,"4,044.85 x patient days",157748,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,395705,,"27,634 x DRG weight",395705,Other,base rate x DRG weight,336336,,"23,488 x DRG weight",336336,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,84811,,"2,174.65 x patient days",84811,Per diem,,84811,,"2,174.65 x patient days",84811,Per diem,,84811,,"2,174.65 x patient days",84811,Per diem,,84811,,"2,174.65 x patient days",84811,Per diem,,190825,,"4,892.96 x patient days",190825,Per diem,,129761,,"3,327.21 x patient days",129761,Per diem,,190825,,"4,892.96 x patient days",190825,Per diem,,118735,,"3,044.51 x patient days",118735,Per diem,,190825,,"4,892.96 x patient days",190825,Per diem,,233230,,"5,980.29 x patient days",233230,Per diem,,274788,,"7,045.87 x patient days",274788,Per diem,,182344,,"4,675.50 x patient days",182344,Per diem,,182344,,"4,675.50 x patient days",182344,Per diem,,106014,,"2,718.31 x patient days",106014,Per diem,,0.01,395705,
Neonate w ECMO,583-3,APR-DRG,,,,,,,,inpatient,,,819584.95,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,157748,,"4,044.85 x patient days",157748,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,403246,,"27,634 x DRG weight",403246,Other,base rate x DRG weight,342746,,"23,488 x DRG weight",342746,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,84811,,"2,174.65 x patient days",84811,Per diem,,84811,,"2,174.65 x patient days",84811,Per diem,,84811,,"2,174.65 x patient days",84811,Per diem,,84811,,"2,174.65 x patient days",84811,Per diem,,190825,,"4,892.96 x patient days",190825,Per diem,,129761,,"3,327.21 x patient days",129761,Per diem,,190825,,"4,892.96 x patient days",190825,Per diem,,118735,,"3,044.51 x patient days",118735,Per diem,,190825,,"4,892.96 x patient days",190825,Per diem,,233230,,"5,980.29 x patient days",233230,Per diem,,274788,,"7,045.87 x patient days",274788,Per diem,,182344,,"4,675.50 x patient days",182344,Per diem,,182344,,"4,675.50 x patient days",182344,Per diem,,106014,,"2,718.31 x patient days",106014,Per diem,,0.01,403246,
Neonate w ECMO,583-4,APR-DRG,,,,,,,,inpatient,,,2948357.83,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,157748,,"4,044.85 x patient days",157748,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,709799,,"27,634 x DRG weight",709799,Other,base rate x DRG weight,603306,,"23,488 x DRG weight",603306,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,84811,,"2,174.65 x patient days",84811,Per diem,,84811,,"2,174.65 x patient days",84811,Per diem,,84811,,"2,174.65 x patient days",84811,Per diem,,84811,,"2,174.65 x patient days",84811,Per diem,,190825,,"4,892.96 x patient days",190825,Per diem,,129761,,"3,327.21 x patient days",129761,Per diem,,190825,,"4,892.96 x patient days",190825,Per diem,,118735,,"3,044.51 x patient days",118735,Per diem,,190825,,"4,892.96 x patient days",190825,Per diem,,233230,,"5,980.29 x patient days",233230,Per diem,,274788,,"7,045.87 x patient days",274788,Per diem,,182344,,"4,675.50 x patient days",182344,Per diem,,182344,,"4,675.50 x patient days",182344,Per diem,,106014,,"2,718.31 x patient days",106014,Per diem,,0.01,709799,
Neonate bwt <1500g w major procedure,588-1,APR-DRG,,,,,,,,inpatient,,,1630601.47,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,424709,,"4,044.85 x patient days",424709,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,533461,,"27,634 x DRG weight",533461,Other,base rate x DRG weight,453424,,"23,488 x DRG weight",453424,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,228338,,"2,174.65 x patient days",228338,Per diem,,228338,,"2,174.65 x patient days",228338,Per diem,,228338,,"2,174.65 x patient days",228338,Per diem,,228338,,"2,174.65 x patient days",228338,Per diem,,513761,,"4,892.96 x patient days",513761,Per diem,,349357,,"3,327.21 x patient days",349357,Per diem,,513761,,"4,892.96 x patient days",513761,Per diem,,319673,,"3,044.51 x patient days",319673,Per diem,,513761,,"4,892.96 x patient days",513761,Per diem,,627930,,"5,980.29 x patient days",627930,Per diem,,739815,,"7,045.87 x patient days",739815,Per diem,,490927,,"4,675.50 x patient days",490927,Per diem,,490927,,"4,675.50 x patient days",490927,Per diem,,285423,,"2,718.31 x patient days",285423,Per diem,,0.01,739815,
Neonate bwt <1500g w major procedure,588-2,APR-DRG,,,,,,,,inpatient,,,1630601.47,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,424709,,"4,044.85 x patient days",424709,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,533461,,"27,634 x DRG weight",533461,Other,base rate x DRG weight,453424,,"23,488 x DRG weight",453424,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,228338,,"2,174.65 x patient days",228338,Per diem,,228338,,"2,174.65 x patient days",228338,Per diem,,228338,,"2,174.65 x patient days",228338,Per diem,,228338,,"2,174.65 x patient days",228338,Per diem,,513761,,"4,892.96 x patient days",513761,Per diem,,349357,,"3,327.21 x patient days",349357,Per diem,,513761,,"4,892.96 x patient days",513761,Per diem,,319673,,"3,044.51 x patient days",319673,Per diem,,513761,,"4,892.96 x patient days",513761,Per diem,,627930,,"5,980.29 x patient days",627930,Per diem,,739815,,"7,045.87 x patient days",739815,Per diem,,490927,,"4,675.50 x patient days",490927,Per diem,,490927,,"4,675.50 x patient days",490927,Per diem,,285423,,"2,718.31 x patient days",285423,Per diem,,0.01,739815,
Neonate bwt <1500g w major procedure,588-3,APR-DRG,,,,,,,,inpatient,,,3057311.12,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,424709,,"4,044.85 x patient days",424709,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,697322,,"27,634 x DRG weight",697322,Other,base rate x DRG weight,592701,,"23,488 x DRG weight",592701,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,228338,,"2,174.65 x patient days",228338,Per diem,,228338,,"2,174.65 x patient days",228338,Per diem,,228338,,"2,174.65 x patient days",228338,Per diem,,228338,,"2,174.65 x patient days",228338,Per diem,,513761,,"4,892.96 x patient days",513761,Per diem,,349357,,"3,327.21 x patient days",349357,Per diem,,513761,,"4,892.96 x patient days",513761,Per diem,,319673,,"3,044.51 x patient days",319673,Per diem,,513761,,"4,892.96 x patient days",513761,Per diem,,627930,,"5,980.29 x patient days",627930,Per diem,,739815,,"7,045.87 x patient days",739815,Per diem,,490927,,"4,675.50 x patient days",490927,Per diem,,490927,,"4,675.50 x patient days",490927,Per diem,,285423,,"2,718.31 x patient days",285423,Per diem,,0.01,739815,
Neonate bwt <1500g w major procedure,588-4,APR-DRG,,,,,,,,inpatient,,,4190879.74,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,424709,,"4,044.85 x patient days",424709,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,697322,,"27,634 x DRG weight",697322,Other,base rate x DRG weight,592701,,"23,488 x DRG weight",592701,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,228338,,"2,174.65 x patient days",228338,Per diem,,228338,,"2,174.65 x patient days",228338,Per diem,,228338,,"2,174.65 x patient days",228338,Per diem,,228338,,"2,174.65 x patient days",228338,Per diem,,513761,,"4,892.96 x patient days",513761,Per diem,,349357,,"3,327.21 x patient days",349357,Per diem,,513761,,"4,892.96 x patient days",513761,Per diem,,319673,,"3,044.51 x patient days",319673,Per diem,,513761,,"4,892.96 x patient days",513761,Per diem,,627930,,"5,980.29 x patient days",627930,Per diem,,739815,,"7,045.87 x patient days",739815,Per diem,,490927,,"4,675.50 x patient days",490927,Per diem,,490927,,"4,675.50 x patient days",490927,Per diem,,285423,,"2,718.31 x patient days",285423,Per diem,,0.01,739815,
Neonate bwt <500g or GA <24 weeks,589-1,APR-DRG,,,,,,,,inpatient,,,3723435,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,32358,,"4,044.85 x patient days",32358,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,335446,,"27,634 x DRG weight",335446,Other,base rate x DRG weight,285118,,"23,488 x DRG weight",285118,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,17397,,"2,174.65 x patient days",17397,Per diem,,17397,,"2,174.65 x patient days",17397,Per diem,,17397,,"2,174.65 x patient days",17397,Per diem,,17397,,"2,174.65 x patient days",17397,Per diem,,39143,,"4,892.96 x patient days",39143,Per diem,,26617,,"3,327.21 x patient days",26617,Per diem,,39143,,"4,892.96 x patient days",39143,Per diem,,24356,,"3,044.51 x patient days",24356,Per diem,,39143,,"4,892.96 x patient days",39143,Per diem,,47842,,"5,980.29 x patient days",47842,Per diem,,56366,,"7,045.87 x patient days",56366,Per diem,,37404,,"4,675.50 x patient days",37404,Per diem,,37404,,"4,675.50 x patient days",37404,Per diem,,21746,,"2,718.31 x patient days",21746,Per diem,,0.01,335446,
Neonate bwt <500g or GA <24 weeks,589-2,APR-DRG,,,,,,,,inpatient,,,3632622.96,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,32358,,"4,044.85 x patient days",32358,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,335446,,"27,634 x DRG weight",335446,Other,base rate x DRG weight,285118,,"23,488 x DRG weight",285118,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,17397,,"2,174.65 x patient days",17397,Per diem,,17397,,"2,174.65 x patient days",17397,Per diem,,17397,,"2,174.65 x patient days",17397,Per diem,,17397,,"2,174.65 x patient days",17397,Per diem,,39143,,"4,892.96 x patient days",39143,Per diem,,26617,,"3,327.21 x patient days",26617,Per diem,,39143,,"4,892.96 x patient days",39143,Per diem,,24356,,"3,044.51 x patient days",24356,Per diem,,39143,,"4,892.96 x patient days",39143,Per diem,,47842,,"5,980.29 x patient days",47842,Per diem,,56366,,"7,045.87 x patient days",56366,Per diem,,37404,,"4,675.50 x patient days",37404,Per diem,,37404,,"4,675.50 x patient days",37404,Per diem,,21746,,"2,718.31 x patient days",21746,Per diem,,0.01,335446,
Neonate bwt <500g or GA <24 weeks,589-3,APR-DRG,,,,,,,,inpatient,,,4659798.87,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,32358,,"4,044.85 x patient days",32358,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,121587,,"27,634 x DRG weight",121587,Other,base rate x DRG weight,103345,,"23,488 x DRG weight",103345,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,17397,,"2,174.65 x patient days",17397,Per diem,,17397,,"2,174.65 x patient days",17397,Per diem,,17397,,"2,174.65 x patient days",17397,Per diem,,17397,,"2,174.65 x patient days",17397,Per diem,,39143,,"4,892.96 x patient days",39143,Per diem,,26617,,"3,327.21 x patient days",26617,Per diem,,39143,,"4,892.96 x patient days",39143,Per diem,,24356,,"3,044.51 x patient days",24356,Per diem,,39143,,"4,892.96 x patient days",39143,Per diem,,47842,,"5,980.29 x patient days",47842,Per diem,,56366,,"7,045.87 x patient days",56366,Per diem,,37404,,"4,675.50 x patient days",37404,Per diem,,37404,,"4,675.50 x patient days",37404,Per diem,,21746,,"2,718.31 x patient days",21746,Per diem,,0.01,121587,
Neonate bwt <500g or GA <24 weeks,589-4,APR-DRG,,,,,,,,inpatient,,,6068,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,32358,,"4,044.85 x patient days",32358,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,3136,,"27,634 x DRG weight",3136,Other,base rate x DRG weight,2666,,"23,488 x DRG weight",2666,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,17397,,"2,174.65 x patient days",17397,Per diem,,17397,,"2,174.65 x patient days",17397,Per diem,,17397,,"2,174.65 x patient days",17397,Per diem,,17397,,"2,174.65 x patient days",17397,Per diem,,39143,,"4,892.96 x patient days",39143,Per diem,,26617,,"3,327.21 x patient days",26617,Per diem,,39143,,"4,892.96 x patient days",39143,Per diem,,24356,,"3,044.51 x patient days",24356,Per diem,,39143,,"4,892.96 x patient days",39143,Per diem,,47842,,"5,980.29 x patient days",47842,Per diem,,56366,,"7,045.87 x patient days",56366,Per diem,,37404,,"4,675.50 x patient days",37404,Per diem,,37404,,"4,675.50 x patient days",37404,Per diem,,21746,,"2,718.31 x patient days",21746,Per diem,,0.01,56366,
Neonate birthwt 500-749g w/o major procedure,591-1,APR-DRG,,,,,,,,inpatient,,,29712,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,307408,,"4,044.85 x patient days",307408,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,245650,,"27,634 x DRG weight",245650,Other,base rate x DRG weight,208794,,"23,488 x DRG weight",208794,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,165273,,"2,174.65 x patient days",165273,Per diem,,165273,,"2,174.65 x patient days",165273,Per diem,,165273,,"2,174.65 x patient days",165273,Per diem,,165273,,"2,174.65 x patient days",165273,Per diem,,371864,,"4,892.96 x patient days",371864,Per diem,,252868,,"3,327.21 x patient days",252868,Per diem,,371864,,"4,892.96 x patient days",371864,Per diem,,231382,,"3,044.51 x patient days",231382,Per diem,,371864,,"4,892.96 x patient days",371864,Per diem,,454501,,"5,980.29 x patient days",454501,Per diem,,535485,,"7,045.87 x patient days",535485,Per diem,,355337,,"4,675.50 x patient days",355337,Per diem,,355337,,"4,675.50 x patient days",355337,Per diem,,206591,,"2,718.31 x patient days",206591,Per diem,,0.01,535485,
Neonate birthwt 500-749g w/o major procedure,591-2,APR-DRG,,,,,,,,inpatient,,,2735357.94,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,307408,,"4,044.85 x patient days",307408,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,304579,,"27,634 x DRG weight",304579,Other,base rate x DRG weight,258882,,"23,488 x DRG weight",258882,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,165273,,"2,174.65 x patient days",165273,Per diem,,165273,,"2,174.65 x patient days",165273,Per diem,,165273,,"2,174.65 x patient days",165273,Per diem,,165273,,"2,174.65 x patient days",165273,Per diem,,371864,,"4,892.96 x patient days",371864,Per diem,,252868,,"3,327.21 x patient days",252868,Per diem,,371864,,"4,892.96 x patient days",371864,Per diem,,231382,,"3,044.51 x patient days",231382,Per diem,,371864,,"4,892.96 x patient days",371864,Per diem,,454501,,"5,980.29 x patient days",454501,Per diem,,535485,,"7,045.87 x patient days",535485,Per diem,,355337,,"4,675.50 x patient days",355337,Per diem,,355337,,"4,675.50 x patient days",355337,Per diem,,206591,,"2,718.31 x patient days",206591,Per diem,,0.01,535485,
Neonate birthwt 500-749g w/o major procedure,591-3,APR-DRG,,,,,,,,inpatient,,,232053,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,307408,,"4,044.85 x patient days",307408,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,326490,,"27,634 x DRG weight",326490,Other,base rate x DRG weight,277506,,"23,488 x DRG weight",277506,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,165273,,"2,174.65 x patient days",165273,Per diem,,165273,,"2,174.65 x patient days",165273,Per diem,,165273,,"2,174.65 x patient days",165273,Per diem,,165273,,"2,174.65 x patient days",165273,Per diem,,371864,,"4,892.96 x patient days",371864,Per diem,,252868,,"3,327.21 x patient days",252868,Per diem,,371864,,"4,892.96 x patient days",371864,Per diem,,231382,,"3,044.51 x patient days",231382,Per diem,,371864,,"4,892.96 x patient days",371864,Per diem,,454501,,"5,980.29 x patient days",454501,Per diem,,535485,,"7,045.87 x patient days",535485,Per diem,,355337,,"4,675.50 x patient days",355337,Per diem,,355337,,"4,675.50 x patient days",355337,Per diem,,206591,,"2,718.31 x patient days",206591,Per diem,,0.01,535485,
Neonate birthwt 500-749g w/o major procedure,591-4,APR-DRG,,,,,,,,inpatient,,,4269592.92,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,307408,,"4,044.85 x patient days",307408,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,535395,,"27,634 x DRG weight",535395,Other,base rate x DRG weight,455068,,"23,488 x DRG weight",455068,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,165273,,"2,174.65 x patient days",165273,Per diem,,165273,,"2,174.65 x patient days",165273,Per diem,,165273,,"2,174.65 x patient days",165273,Per diem,,165273,,"2,174.65 x patient days",165273,Per diem,,371864,,"4,892.96 x patient days",371864,Per diem,,252868,,"3,327.21 x patient days",252868,Per diem,,371864,,"4,892.96 x patient days",371864,Per diem,,231382,,"3,044.51 x patient days",231382,Per diem,,371864,,"4,892.96 x patient days",371864,Per diem,,454501,,"5,980.29 x patient days",454501,Per diem,,535485,,"7,045.87 x patient days",535485,Per diem,,355337,,"4,675.50 x patient days",355337,Per diem,,355337,,"4,675.50 x patient days",355337,Per diem,,206591,,"2,718.31 x patient days",206591,Per diem,,0.01,535485,
Neonate birthwt 750-999g w/o major procedure,593-1,APR-DRG,,,,,,,,inpatient,,,1816271.51,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,287184,,"4,044.85 x patient days",287184,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,298525,,"27,634 x DRG weight",298525,Other,base rate x DRG weight,253736,,"23,488 x DRG weight",253736,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,154400,,"2,174.65 x patient days",154400,Per diem,,154400,,"2,174.65 x patient days",154400,Per diem,,154400,,"2,174.65 x patient days",154400,Per diem,,154400,,"2,174.65 x patient days",154400,Per diem,,347400,,"4,892.96 x patient days",347400,Per diem,,236232,,"3,327.21 x patient days",236232,Per diem,,347400,,"4,892.96 x patient days",347400,Per diem,,216160,,"3,044.51 x patient days",216160,Per diem,,347400,,"4,892.96 x patient days",347400,Per diem,,424600,,"5,980.29 x patient days",424600,Per diem,,500256,,"7,045.87 x patient days",500256,Per diem,,331960,,"4,675.50 x patient days",331960,Per diem,,331960,,"4,675.50 x patient days",331960,Per diem,,193000,,"2,718.31 x patient days",193000,Per diem,,0.01,500256,
Neonate birthwt 750-999g w/o major procedure,593-2,APR-DRG,,,,,,,,inpatient,,,1816271.51,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,287184,,"4,044.85 x patient days",287184,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,307901,,"27,634 x DRG weight",307901,Other,base rate x DRG weight,261706,,"23,488 x DRG weight",261706,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,154400,,"2,174.65 x patient days",154400,Per diem,,154400,,"2,174.65 x patient days",154400,Per diem,,154400,,"2,174.65 x patient days",154400,Per diem,,154400,,"2,174.65 x patient days",154400,Per diem,,347400,,"4,892.96 x patient days",347400,Per diem,,236232,,"3,327.21 x patient days",236232,Per diem,,347400,,"4,892.96 x patient days",347400,Per diem,,216160,,"3,044.51 x patient days",216160,Per diem,,347400,,"4,892.96 x patient days",347400,Per diem,,424600,,"5,980.29 x patient days",424600,Per diem,,500256,,"7,045.87 x patient days",500256,Per diem,,331960,,"4,675.50 x patient days",331960,Per diem,,331960,,"4,675.50 x patient days",331960,Per diem,,193000,,"2,718.31 x patient days",193000,Per diem,,0.01,500256,
Neonate birthwt 750-999g w/o major procedure,593-3,APR-DRG,,,,,,,,inpatient,,,2109601,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,287184,,"4,044.85 x patient days",287184,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,376320,,"27,634 x DRG weight",376320,Other,base rate x DRG weight,319860,,"23,488 x DRG weight",319860,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,154400,,"2,174.65 x patient days",154400,Per diem,,154400,,"2,174.65 x patient days",154400,Per diem,,154400,,"2,174.65 x patient days",154400,Per diem,,154400,,"2,174.65 x patient days",154400,Per diem,,347400,,"4,892.96 x patient days",347400,Per diem,,236232,,"3,327.21 x patient days",236232,Per diem,,347400,,"4,892.96 x patient days",347400,Per diem,,216160,,"3,044.51 x patient days",216160,Per diem,,347400,,"4,892.96 x patient days",347400,Per diem,,424600,,"5,980.29 x patient days",424600,Per diem,,500256,,"7,045.87 x patient days",500256,Per diem,,331960,,"4,675.50 x patient days",331960,Per diem,,331960,,"4,675.50 x patient days",331960,Per diem,,193000,,"2,718.31 x patient days",193000,Per diem,,0.01,500256,
Neonate birthwt 750-999g w/o major procedure,593-4,APR-DRG,,,,,,,,inpatient,,,2882995.51,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,287184,,"4,044.85 x patient days",287184,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,481824,,"27,634 x DRG weight",481824,Other,base rate x DRG weight,409534,,"23,488 x DRG weight",409534,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,154400,,"2,174.65 x patient days",154400,Per diem,,154400,,"2,174.65 x patient days",154400,Per diem,,154400,,"2,174.65 x patient days",154400,Per diem,,154400,,"2,174.65 x patient days",154400,Per diem,,347400,,"4,892.96 x patient days",347400,Per diem,,236232,,"3,327.21 x patient days",236232,Per diem,,347400,,"4,892.96 x patient days",347400,Per diem,,216160,,"3,044.51 x patient days",216160,Per diem,,347400,,"4,892.96 x patient days",347400,Per diem,,424600,,"5,980.29 x patient days",424600,Per diem,,500256,,"7,045.87 x patient days",500256,Per diem,,331960,,"4,675.50 x patient days",331960,Per diem,,331960,,"4,675.50 x patient days",331960,Per diem,,193000,,"2,718.31 x patient days",193000,Per diem,,0.01,500256,
Neonate bwt 1000-1249g w resp dist synd/oth maj resp or maj anom,602-1,APR-DRG,,,,,,,,inpatient,,,1630353.76,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,226511,,"4,044.85 x patient days",226511,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,179419,,"27,634 x DRG weight",179419,Other,base rate x DRG weight,152501,,"23,488 x DRG weight",152501,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,121780,,"2,174.65 x patient days",121780,Per diem,,121780,,"2,174.65 x patient days",121780,Per diem,,121780,,"2,174.65 x patient days",121780,Per diem,,121780,,"2,174.65 x patient days",121780,Per diem,,274005,,"4,892.96 x patient days",274005,Per diem,,186323,,"3,327.21 x patient days",186323,Per diem,,274005,,"4,892.96 x patient days",274005,Per diem,,170492,,"3,044.51 x patient days",170492,Per diem,,274005,,"4,892.96 x patient days",274005,Per diem,,334895,,"5,980.29 x patient days",334895,Per diem,,394567,,"7,045.87 x patient days",394567,Per diem,,261827,,"4,675.50 x patient days",261827,Per diem,,261827,,"4,675.50 x patient days",261827,Per diem,,152225,,"2,718.31 x patient days",152225,Per diem,,0.01,394567,
Neonate bwt 1000-1249g w resp dist synd/oth maj resp or maj anom,602-2,APR-DRG,,,,,,,,inpatient,,,1630353.76,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,226511,,"4,044.85 x patient days",226511,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,262081,,"27,634 x DRG weight",262081,Other,base rate x DRG weight,222760,,"23,488 x DRG weight",222760,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,121780,,"2,174.65 x patient days",121780,Per diem,,121780,,"2,174.65 x patient days",121780,Per diem,,121780,,"2,174.65 x patient days",121780,Per diem,,121780,,"2,174.65 x patient days",121780,Per diem,,274005,,"4,892.96 x patient days",274005,Per diem,,186323,,"3,327.21 x patient days",186323,Per diem,,274005,,"4,892.96 x patient days",274005,Per diem,,170492,,"3,044.51 x patient days",170492,Per diem,,274005,,"4,892.96 x patient days",274005,Per diem,,334895,,"5,980.29 x patient days",334895,Per diem,,394567,,"7,045.87 x patient days",394567,Per diem,,261827,,"4,675.50 x patient days",261827,Per diem,,261827,,"4,675.50 x patient days",261827,Per diem,,152225,,"2,718.31 x patient days",152225,Per diem,,0.01,394567,
Neonate bwt 1000-1249g w resp dist synd/oth maj resp or maj anom,602-3,APR-DRG,,,,,,,,inpatient,,,1653465.22,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,226511,,"4,044.85 x patient days",226511,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,308453,,"27,634 x DRG weight",308453,Other,base rate x DRG weight,262175,,"23,488 x DRG weight",262175,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,121780,,"2,174.65 x patient days",121780,Per diem,,121780,,"2,174.65 x patient days",121780,Per diem,,121780,,"2,174.65 x patient days",121780,Per diem,,121780,,"2,174.65 x patient days",121780,Per diem,,274005,,"4,892.96 x patient days",274005,Per diem,,186323,,"3,327.21 x patient days",186323,Per diem,,274005,,"4,892.96 x patient days",274005,Per diem,,170492,,"3,044.51 x patient days",170492,Per diem,,274005,,"4,892.96 x patient days",274005,Per diem,,334895,,"5,980.29 x patient days",334895,Per diem,,394567,,"7,045.87 x patient days",394567,Per diem,,261827,,"4,675.50 x patient days",261827,Per diem,,261827,,"4,675.50 x patient days",261827,Per diem,,152225,,"2,718.31 x patient days",152225,Per diem,,0.01,394567,
Neonate bwt 1000-1249g w resp dist synd/oth maj resp or maj anom,602-4,APR-DRG,,,,,,,,inpatient,,,3217411.26,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,226511,,"4,044.85 x patient days",226511,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,417870,,"27,634 x DRG weight",417870,Other,base rate x DRG weight,355176,,"23,488 x DRG weight",355176,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,121780,,"2,174.65 x patient days",121780,Per diem,,121780,,"2,174.65 x patient days",121780,Per diem,,121780,,"2,174.65 x patient days",121780,Per diem,,121780,,"2,174.65 x patient days",121780,Per diem,,274005,,"4,892.96 x patient days",274005,Per diem,,186323,,"3,327.21 x patient days",186323,Per diem,,274005,,"4,892.96 x patient days",274005,Per diem,,170492,,"3,044.51 x patient days",170492,Per diem,,274005,,"4,892.96 x patient days",274005,Per diem,,334895,,"5,980.29 x patient days",334895,Per diem,,394567,,"7,045.87 x patient days",394567,Per diem,,261827,,"4,675.50 x patient days",261827,Per diem,,261827,,"4,675.50 x patient days",261827,Per diem,,152225,,"2,718.31 x patient days",152225,Per diem,,0.01,417870,
Neonate birthwt 1000-1249g w or w/o other significant condition,603-1,APR-DRG,,,,,,,,inpatient,,,1630353.76,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,165839,,"4,044.85 x patient days",165839,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,142984,,"27,634 x DRG weight",142984,Other,base rate x DRG weight,121532,,"23,488 x DRG weight",121532,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,89161,,"2,174.65 x patient days",89161,Per diem,,89161,,"2,174.65 x patient days",89161,Per diem,,89161,,"2,174.65 x patient days",89161,Per diem,,89161,,"2,174.65 x patient days",89161,Per diem,,200612,,"4,892.96 x patient days",200612,Per diem,,136416,,"3,327.21 x patient days",136416,Per diem,,200612,,"4,892.96 x patient days",200612,Per diem,,124825,,"3,044.51 x patient days",124825,Per diem,,200612,,"4,892.96 x patient days",200612,Per diem,,245193,,"5,980.29 x patient days",245193,Per diem,,288882,,"7,045.87 x patient days",288882,Per diem,,191696,,"4,675.50 x patient days",191696,Per diem,,191696,,"4,675.50 x patient days",191696,Per diem,,111451,,"2,718.31 x patient days",111451,Per diem,,0.01,288882,
Neonate birthwt 1000-1249g w or w/o other significant condition,603-2,APR-DRG,,,,,,,,inpatient,,,1050935.5,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,165839,,"4,044.85 x patient days",165839,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,190633,,"27,634 x DRG weight",190633,Other,base rate x DRG weight,162032,,"23,488 x DRG weight",162032,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,89161,,"2,174.65 x patient days",89161,Per diem,,89161,,"2,174.65 x patient days",89161,Per diem,,89161,,"2,174.65 x patient days",89161,Per diem,,89161,,"2,174.65 x patient days",89161,Per diem,,200612,,"4,892.96 x patient days",200612,Per diem,,136416,,"3,327.21 x patient days",136416,Per diem,,200612,,"4,892.96 x patient days",200612,Per diem,,124825,,"3,044.51 x patient days",124825,Per diem,,200612,,"4,892.96 x patient days",200612,Per diem,,245193,,"5,980.29 x patient days",245193,Per diem,,288882,,"7,045.87 x patient days",288882,Per diem,,191696,,"4,675.50 x patient days",191696,Per diem,,191696,,"4,675.50 x patient days",191696,Per diem,,111451,,"2,718.31 x patient days",111451,Per diem,,0.01,288882,
Neonate birthwt 1000-1249g w or w/o other significant condition,603-3,APR-DRG,,,,,,,,inpatient,,,1987695,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,165839,,"4,044.85 x patient days",165839,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,248112,,"27,634 x DRG weight",248112,Other,base rate x DRG weight,210887,,"23,488 x DRG weight",210887,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,89161,,"2,174.65 x patient days",89161,Per diem,,89161,,"2,174.65 x patient days",89161,Per diem,,89161,,"2,174.65 x patient days",89161,Per diem,,89161,,"2,174.65 x patient days",89161,Per diem,,200612,,"4,892.96 x patient days",200612,Per diem,,136416,,"3,327.21 x patient days",136416,Per diem,,200612,,"4,892.96 x patient days",200612,Per diem,,124825,,"3,044.51 x patient days",124825,Per diem,,200612,,"4,892.96 x patient days",200612,Per diem,,245193,,"5,980.29 x patient days",245193,Per diem,,288882,,"7,045.87 x patient days",288882,Per diem,,191696,,"4,675.50 x patient days",191696,Per diem,,191696,,"4,675.50 x patient days",191696,Per diem,,111451,,"2,718.31 x patient days",111451,Per diem,,0.01,288882,
Neonate birthwt 1000-1249g w or w/o other significant condition,603-4,APR-DRG,,,,,,,,inpatient,,,3217411.26,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,165839,,"4,044.85 x patient days",165839,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,384936,,"27,634 x DRG weight",384936,Other,base rate x DRG weight,327183,,"23,488 x DRG weight",327183,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,89161,,"2,174.65 x patient days",89161,Per diem,,89161,,"2,174.65 x patient days",89161,Per diem,,89161,,"2,174.65 x patient days",89161,Per diem,,89161,,"2,174.65 x patient days",89161,Per diem,,200612,,"4,892.96 x patient days",200612,Per diem,,136416,,"3,327.21 x patient days",136416,Per diem,,200612,,"4,892.96 x patient days",200612,Per diem,,124825,,"3,044.51 x patient days",124825,Per diem,,200612,,"4,892.96 x patient days",200612,Per diem,,245193,,"5,980.29 x patient days",245193,Per diem,,288882,,"7,045.87 x patient days",288882,Per diem,,191696,,"4,675.50 x patient days",191696,Per diem,,191696,,"4,675.50 x patient days",191696,Per diem,,111451,,"2,718.31 x patient days",111451,Per diem,,0.01,384936,
Neonate bwt 1250-1499g w resp dist synd/oth maj resp or maj anom,607-1,APR-DRG,,,,,,,,inpatient,,,977492.2,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,173929,,"4,044.85 x patient days",173929,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,166943,,"27,634 x DRG weight",166943,Other,base rate x DRG weight,141896,,"23,488 x DRG weight",141896,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,93510,,"2,174.65 x patient days",93510,Per diem,,93510,,"2,174.65 x patient days",93510,Per diem,,93510,,"2,174.65 x patient days",93510,Per diem,,93510,,"2,174.65 x patient days",93510,Per diem,,210398,,"4,892.96 x patient days",210398,Per diem,,143070,,"3,327.21 x patient days",143070,Per diem,,210398,,"4,892.96 x patient days",210398,Per diem,,130914,,"3,044.51 x patient days",130914,Per diem,,210398,,"4,892.96 x patient days",210398,Per diem,,257153,,"5,980.29 x patient days",257153,Per diem,,302972,,"7,045.87 x patient days",302972,Per diem,,201047,,"4,675.50 x patient days",201047,Per diem,,201047,,"4,675.50 x patient days",201047,Per diem,,116888,,"2,718.31 x patient days",116888,Per diem,,0.01,302972,
Neonate bwt 1250-1499g w resp dist synd/oth maj resp or maj anom,607-2,APR-DRG,,,,,,,,inpatient,,,1190888.43,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,173929,,"4,044.85 x patient days",173929,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,206658,,"27,634 x DRG weight",206658,Other,base rate x DRG weight,175653,,"23,488 x DRG weight",175653,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,93510,,"2,174.65 x patient days",93510,Per diem,,93510,,"2,174.65 x patient days",93510,Per diem,,93510,,"2,174.65 x patient days",93510,Per diem,,93510,,"2,174.65 x patient days",93510,Per diem,,210398,,"4,892.96 x patient days",210398,Per diem,,143070,,"3,327.21 x patient days",143070,Per diem,,210398,,"4,892.96 x patient days",210398,Per diem,,130914,,"3,044.51 x patient days",130914,Per diem,,210398,,"4,892.96 x patient days",210398,Per diem,,257153,,"5,980.29 x patient days",257153,Per diem,,302972,,"7,045.87 x patient days",302972,Per diem,,201047,,"4,675.50 x patient days",201047,Per diem,,201047,,"4,675.50 x patient days",201047,Per diem,,116888,,"2,718.31 x patient days",116888,Per diem,,0.01,302972,
Neonate bwt 1250-1499g w resp dist synd/oth maj resp or maj anom,607-3,APR-DRG,,,,,,,,inpatient,,,977492.2,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,173929,,"4,044.85 x patient days",173929,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,252826,,"27,634 x DRG weight",252826,Other,base rate x DRG weight,214894,,"23,488 x DRG weight",214894,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,93510,,"2,174.65 x patient days",93510,Per diem,,93510,,"2,174.65 x patient days",93510,Per diem,,93510,,"2,174.65 x patient days",93510,Per diem,,93510,,"2,174.65 x patient days",93510,Per diem,,210398,,"4,892.96 x patient days",210398,Per diem,,143070,,"3,327.21 x patient days",143070,Per diem,,210398,,"4,892.96 x patient days",210398,Per diem,,130914,,"3,044.51 x patient days",130914,Per diem,,210398,,"4,892.96 x patient days",210398,Per diem,,257153,,"5,980.29 x patient days",257153,Per diem,,302972,,"7,045.87 x patient days",302972,Per diem,,201047,,"4,675.50 x patient days",201047,Per diem,,201047,,"4,675.50 x patient days",201047,Per diem,,116888,,"2,718.31 x patient days",116888,Per diem,,0.01,302972,
Neonate bwt 1250-1499g w resp dist synd/oth maj resp or maj anom,607-4,APR-DRG,,,,,,,,inpatient,,,2843505.91,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,173929,,"4,044.85 x patient days",173929,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,341158,,"27,634 x DRG weight",341158,Other,base rate x DRG weight,289973,,"23,488 x DRG weight",289973,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,93510,,"2,174.65 x patient days",93510,Per diem,,93510,,"2,174.65 x patient days",93510,Per diem,,93510,,"2,174.65 x patient days",93510,Per diem,,93510,,"2,174.65 x patient days",93510,Per diem,,210398,,"4,892.96 x patient days",210398,Per diem,,143070,,"3,327.21 x patient days",143070,Per diem,,210398,,"4,892.96 x patient days",210398,Per diem,,130914,,"3,044.51 x patient days",130914,Per diem,,210398,,"4,892.96 x patient days",210398,Per diem,,257153,,"5,980.29 x patient days",257153,Per diem,,302972,,"7,045.87 x patient days",302972,Per diem,,201047,,"4,675.50 x patient days",201047,Per diem,,201047,,"4,675.50 x patient days",201047,Per diem,,116888,,"2,718.31 x patient days",116888,Per diem,,0.01,341158,
Neonate bwt 1250-1499g w or w/o other significant condition,608-1,APR-DRG,,,,,,,,inpatient,,,840356,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,121346,,"4,044.85 x patient days",121346,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,117290,,"27,634 x DRG weight",117290,Other,base rate x DRG weight,99692,,"23,488 x DRG weight",99692,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,65240,,"2,174.65 x patient days",65240,Per diem,,65240,,"2,174.65 x patient days",65240,Per diem,,65240,,"2,174.65 x patient days",65240,Per diem,,65240,,"2,174.65 x patient days",65240,Per diem,,146790,,"4,892.96 x patient days",146790,Per diem,,99817,,"3,327.21 x patient days",99817,Per diem,,146790,,"4,892.96 x patient days",146790,Per diem,,91336,,"3,044.51 x patient days",91336,Per diem,,146790,,"4,892.96 x patient days",146790,Per diem,,179410,,"5,980.29 x patient days",179410,Per diem,,211378,,"7,045.87 x patient days",211378,Per diem,,140266,,"4,675.50 x patient days",140266,Per diem,,140266,,"4,675.50 x patient days",140266,Per diem,,81550,,"2,718.31 x patient days",81550,Per diem,,0.01,211378,
Neonate bwt 1250-1499g w or w/o other significant condition,608-2,APR-DRG,,,,,,,,inpatient,,,840356,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,121346,,"4,044.85 x patient days",121346,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,157127,,"27,634 x DRG weight",157127,Other,base rate x DRG weight,133553,,"23,488 x DRG weight",133553,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,65240,,"2,174.65 x patient days",65240,Per diem,,65240,,"2,174.65 x patient days",65240,Per diem,,65240,,"2,174.65 x patient days",65240,Per diem,,65240,,"2,174.65 x patient days",65240,Per diem,,146790,,"4,892.96 x patient days",146790,Per diem,,99817,,"3,327.21 x patient days",99817,Per diem,,146790,,"4,892.96 x patient days",146790,Per diem,,91336,,"3,044.51 x patient days",91336,Per diem,,146790,,"4,892.96 x patient days",146790,Per diem,,179410,,"5,980.29 x patient days",179410,Per diem,,211378,,"7,045.87 x patient days",211378,Per diem,,140266,,"4,675.50 x patient days",140266,Per diem,,140266,,"4,675.50 x patient days",140266,Per diem,,81550,,"2,718.31 x patient days",81550,Per diem,,0.01,211378,
Neonate bwt 1250-1499g w or w/o other significant condition,608-3,APR-DRG,,,,,,,,inpatient,,,977492.2,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,121346,,"4,044.85 x patient days",121346,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,188563,,"27,634 x DRG weight",188563,Other,base rate x DRG weight,160273,,"23,488 x DRG weight",160273,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,65240,,"2,174.65 x patient days",65240,Per diem,,65240,,"2,174.65 x patient days",65240,Per diem,,65240,,"2,174.65 x patient days",65240,Per diem,,65240,,"2,174.65 x patient days",65240,Per diem,,146790,,"4,892.96 x patient days",146790,Per diem,,99817,,"3,327.21 x patient days",99817,Per diem,,146790,,"4,892.96 x patient days",146790,Per diem,,91336,,"3,044.51 x patient days",91336,Per diem,,146790,,"4,892.96 x patient days",146790,Per diem,,179410,,"5,980.29 x patient days",179410,Per diem,,211378,,"7,045.87 x patient days",211378,Per diem,,140266,,"4,675.50 x patient days",140266,Per diem,,140266,,"4,675.50 x patient days",140266,Per diem,,81550,,"2,718.31 x patient days",81550,Per diem,,0.01,211378,
Neonate bwt 1250-1499g w or w/o other significant condition,608-4,APR-DRG,,,,,,,,inpatient,,,1190888.43,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,121346,,"4,044.85 x patient days",121346,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,198478,,"27,634 x DRG weight",198478,Other,base rate x DRG weight,168700,,"23,488 x DRG weight",168700,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,65240,,"2,174.65 x patient days",65240,Per diem,,65240,,"2,174.65 x patient days",65240,Per diem,,65240,,"2,174.65 x patient days",65240,Per diem,,65240,,"2,174.65 x patient days",65240,Per diem,,146790,,"4,892.96 x patient days",146790,Per diem,,99817,,"3,327.21 x patient days",99817,Per diem,,146790,,"4,892.96 x patient days",146790,Per diem,,91336,,"3,044.51 x patient days",91336,Per diem,,146790,,"4,892.96 x patient days",146790,Per diem,,179410,,"5,980.29 x patient days",179410,Per diem,,211378,,"7,045.87 x patient days",211378,Per diem,,140266,,"4,675.50 x patient days",140266,Per diem,,140266,,"4,675.50 x patient days",140266,Per diem,,81550,,"2,718.31 x patient days",81550,Per diem,,0.01,211378,
Neonate bwt 1500-2499g w major procedure,609-1,APR-DRG,,,,,,,,inpatient,,,430675,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,202243,,"4,044.85 x patient days",202243,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,98590,,"27,634 x DRG weight",98590,Other,base rate x DRG weight,83798,,"23,488 x DRG weight",83798,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,108733,,"2,174.65 x patient days",108733,Per diem,,108733,,"2,174.65 x patient days",108733,Per diem,,108733,,"2,174.65 x patient days",108733,Per diem,,108733,,"2,174.65 x patient days",108733,Per diem,,244649,,"4,892.96 x patient days",244649,Per diem,,166361,,"3,327.21 x patient days",166361,Per diem,,244649,,"4,892.96 x patient days",244649,Per diem,,152226,,"3,044.51 x patient days",152226,Per diem,,244649,,"4,892.96 x patient days",244649,Per diem,,299016,,"5,980.29 x patient days",299016,Per diem,,352295,,"7,045.87 x patient days",352295,Per diem,,233776,,"4,675.50 x patient days",233776,Per diem,,233776,,"4,675.50 x patient days",233776,Per diem,,135916,,"2,718.31 x patient days",135916,Per diem,,0.01,352295,
Neonate bwt 1500-2499g w major procedure,609-2,APR-DRG,,,,,,,,inpatient,,,430675,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,202243,,"4,044.85 x patient days",202243,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,99347,,"27,634 x DRG weight",99347,Other,base rate x DRG weight,84442,,"23,488 x DRG weight",84442,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,108733,,"2,174.65 x patient days",108733,Per diem,,108733,,"2,174.65 x patient days",108733,Per diem,,108733,,"2,174.65 x patient days",108733,Per diem,,108733,,"2,174.65 x patient days",108733,Per diem,,244649,,"4,892.96 x patient days",244649,Per diem,,166361,,"3,327.21 x patient days",166361,Per diem,,244649,,"4,892.96 x patient days",244649,Per diem,,152226,,"3,044.51 x patient days",152226,Per diem,,244649,,"4,892.96 x patient days",244649,Per diem,,299016,,"5,980.29 x patient days",299016,Per diem,,352295,,"7,045.87 x patient days",352295,Per diem,,233776,,"4,675.50 x patient days",233776,Per diem,,233776,,"4,675.50 x patient days",233776,Per diem,,135916,,"2,718.31 x patient days",135916,Per diem,,0.01,352295,
Neonate bwt 1500-2499g w major procedure,609-3,APR-DRG,,,,,,,,inpatient,,,1250219.15,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,202243,,"4,044.85 x patient days",202243,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,201261,,"27,634 x DRG weight",201261,Other,base rate x DRG weight,171065,,"23,488 x DRG weight",171065,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,108733,,"2,174.65 x patient days",108733,Per diem,,108733,,"2,174.65 x patient days",108733,Per diem,,108733,,"2,174.65 x patient days",108733,Per diem,,108733,,"2,174.65 x patient days",108733,Per diem,,244649,,"4,892.96 x patient days",244649,Per diem,,166361,,"3,327.21 x patient days",166361,Per diem,,244649,,"4,892.96 x patient days",244649,Per diem,,152226,,"3,044.51 x patient days",152226,Per diem,,244649,,"4,892.96 x patient days",244649,Per diem,,299016,,"5,980.29 x patient days",299016,Per diem,,352295,,"7,045.87 x patient days",352295,Per diem,,233776,,"4,675.50 x patient days",233776,Per diem,,233776,,"4,675.50 x patient days",233776,Per diem,,135916,,"2,718.31 x patient days",135916,Per diem,,0.01,352295,
Neonate bwt 1500-2499g w major procedure,609-4,APR-DRG,,,,,,,,inpatient,,,3369237.47,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,202243,,"4,044.85 x patient days",202243,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,441155,,"27,634 x DRG weight",441155,Other,base rate x DRG weight,374967,,"23,488 x DRG weight",374967,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,108733,,"2,174.65 x patient days",108733,Per diem,,108733,,"2,174.65 x patient days",108733,Per diem,,108733,,"2,174.65 x patient days",108733,Per diem,,108733,,"2,174.65 x patient days",108733,Per diem,,244649,,"4,892.96 x patient days",244649,Per diem,,166361,,"3,327.21 x patient days",166361,Per diem,,244649,,"4,892.96 x patient days",244649,Per diem,,152226,,"3,044.51 x patient days",152226,Per diem,,244649,,"4,892.96 x patient days",244649,Per diem,,299016,,"5,980.29 x patient days",299016,Per diem,,352295,,"7,045.87 x patient days",352295,Per diem,,233776,,"4,675.50 x patient days",233776,Per diem,,233776,,"4,675.50 x patient days",233776,Per diem,,135916,,"2,718.31 x patient days",135916,Per diem,,0.01,441155,
Neonate birthwt 1500-1999g w major anomaly,611-1,APR-DRG,,,,,,,,inpatient,,,279695.67,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,105166,,"4,044.85 x patient days",105166,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,69223,,"27,634 x DRG weight",69223,Other,base rate x DRG weight,58837,,"23,488 x DRG weight",58837,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,56541,,"2,174.65 x patient days",56541,Per diem,,56541,,"2,174.65 x patient days",56541,Per diem,,56541,,"2,174.65 x patient days",56541,Per diem,,56541,,"2,174.65 x patient days",56541,Per diem,,127217,,"4,892.96 x patient days",127217,Per diem,,86508,,"3,327.21 x patient days",86508,Per diem,,127217,,"4,892.96 x patient days",127217,Per diem,,79157,,"3,044.51 x patient days",79157,Per diem,,127217,,"4,892.96 x patient days",127217,Per diem,,155488,,"5,980.29 x patient days",155488,Per diem,,183193,,"7,045.87 x patient days",183193,Per diem,,121563,,"4,675.50 x patient days",121563,Per diem,,121563,,"4,675.50 x patient days",121563,Per diem,,70676,,"2,718.31 x patient days",70676,Per diem,,0.01,183193,
Neonate birthwt 1500-1999g w major anomaly,611-2,APR-DRG,,,,,,,,inpatient,,,172652.22,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,105166,,"4,044.85 x patient days",105166,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,111500,,"27,634 x DRG weight",111500,Other,base rate x DRG weight,94772,,"23,488 x DRG weight",94772,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,56541,,"2,174.65 x patient days",56541,Per diem,,56541,,"2,174.65 x patient days",56541,Per diem,,56541,,"2,174.65 x patient days",56541,Per diem,,56541,,"2,174.65 x patient days",56541,Per diem,,127217,,"4,892.96 x patient days",127217,Per diem,,86508,,"3,327.21 x patient days",86508,Per diem,,127217,,"4,892.96 x patient days",127217,Per diem,,79157,,"3,044.51 x patient days",79157,Per diem,,127217,,"4,892.96 x patient days",127217,Per diem,,155488,,"5,980.29 x patient days",155488,Per diem,,183193,,"7,045.87 x patient days",183193,Per diem,,121563,,"4,675.50 x patient days",121563,Per diem,,121563,,"4,675.50 x patient days",121563,Per diem,,70676,,"2,718.31 x patient days",70676,Per diem,,0.01,183193,
Neonate birthwt 1500-1999g w major anomaly,611-3,APR-DRG,,,,,,,,inpatient,,,1210512.11,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,105166,,"4,044.85 x patient days",105166,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,173149,,"27,634 x DRG weight",173149,Other,base rate x DRG weight,147171,,"23,488 x DRG weight",147171,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,56541,,"2,174.65 x patient days",56541,Per diem,,56541,,"2,174.65 x patient days",56541,Per diem,,56541,,"2,174.65 x patient days",56541,Per diem,,56541,,"2,174.65 x patient days",56541,Per diem,,127217,,"4,892.96 x patient days",127217,Per diem,,86508,,"3,327.21 x patient days",86508,Per diem,,127217,,"4,892.96 x patient days",127217,Per diem,,79157,,"3,044.51 x patient days",79157,Per diem,,127217,,"4,892.96 x patient days",127217,Per diem,,155488,,"5,980.29 x patient days",155488,Per diem,,183193,,"7,045.87 x patient days",183193,Per diem,,121563,,"4,675.50 x patient days",121563,Per diem,,121563,,"4,675.50 x patient days",121563,Per diem,,70676,,"2,718.31 x patient days",70676,Per diem,,0.01,183193,
Neonate birthwt 1500-1999g w major anomaly,611-4,APR-DRG,,,,,,,,inpatient,,,337029.34,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,105166,,"4,044.85 x patient days",105166,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,226977,,"27,634 x DRG weight",226977,Other,base rate x DRG weight,192923,,"23,488 x DRG weight",192923,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,56541,,"2,174.65 x patient days",56541,Per diem,,56541,,"2,174.65 x patient days",56541,Per diem,,56541,,"2,174.65 x patient days",56541,Per diem,,56541,,"2,174.65 x patient days",56541,Per diem,,127217,,"4,892.96 x patient days",127217,Per diem,,86508,,"3,327.21 x patient days",86508,Per diem,,127217,,"4,892.96 x patient days",127217,Per diem,,79157,,"3,044.51 x patient days",79157,Per diem,,127217,,"4,892.96 x patient days",127217,Per diem,,155488,,"5,980.29 x patient days",155488,Per diem,,183193,,"7,045.87 x patient days",183193,Per diem,,121563,,"4,675.50 x patient days",121563,Per diem,,121563,,"4,675.50 x patient days",121563,Per diem,,70676,,"2,718.31 x patient days",70676,Per diem,,0.01,226977,
Neonate bwt 1500-1999g w resp dist synd/oth maj resp cond,612-1,APR-DRG,,,,,,,,inpatient,,,529544,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,109212,,"4,044.85 x patient days",109212,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,97222,,"27,634 x DRG weight",97222,Other,base rate x DRG weight,82635,,"23,488 x DRG weight",82635,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,58716,,"2,174.65 x patient days",58716,Per diem,,58716,,"2,174.65 x patient days",58716,Per diem,,58716,,"2,174.65 x patient days",58716,Per diem,,58716,,"2,174.65 x patient days",58716,Per diem,,132111,,"4,892.96 x patient days",132111,Per diem,,89835,,"3,327.21 x patient days",89835,Per diem,,132111,,"4,892.96 x patient days",132111,Per diem,,82202,,"3,044.51 x patient days",82202,Per diem,,132111,,"4,892.96 x patient days",132111,Per diem,,161469,,"5,980.29 x patient days",161469,Per diem,,190240,,"7,045.87 x patient days",190240,Per diem,,126239,,"4,675.50 x patient days",126239,Per diem,,126239,,"4,675.50 x patient days",126239,Per diem,,73395,,"2,718.31 x patient days",73395,Per diem,,0.01,190240,
Neonate bwt 1500-1999g w resp dist synd/oth maj resp cond,612-2,APR-DRG,,,,,,,,inpatient,,,1012716.45,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,109212,,"4,044.85 x patient days",109212,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,125737,,"27,634 x DRG weight",125737,Other,base rate x DRG weight,106873,,"23,488 x DRG weight",106873,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,58716,,"2,174.65 x patient days",58716,Per diem,,58716,,"2,174.65 x patient days",58716,Per diem,,58716,,"2,174.65 x patient days",58716,Per diem,,58716,,"2,174.65 x patient days",58716,Per diem,,132111,,"4,892.96 x patient days",132111,Per diem,,89835,,"3,327.21 x patient days",89835,Per diem,,132111,,"4,892.96 x patient days",132111,Per diem,,82202,,"3,044.51 x patient days",82202,Per diem,,132111,,"4,892.96 x patient days",132111,Per diem,,161469,,"5,980.29 x patient days",161469,Per diem,,190240,,"7,045.87 x patient days",190240,Per diem,,126239,,"4,675.50 x patient days",126239,Per diem,,126239,,"4,675.50 x patient days",126239,Per diem,,73395,,"2,718.31 x patient days",73395,Per diem,,0.01,190240,
Neonate bwt 1500-1999g w resp dist synd/oth maj resp cond,612-3,APR-DRG,,,,,,,,inpatient,,,1436069.17,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,109212,,"4,044.85 x patient days",109212,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,175282,,"27,634 x DRG weight",175282,Other,base rate x DRG weight,148984,,"23,488 x DRG weight",148984,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,58716,,"2,174.65 x patient days",58716,Per diem,,58716,,"2,174.65 x patient days",58716,Per diem,,58716,,"2,174.65 x patient days",58716,Per diem,,58716,,"2,174.65 x patient days",58716,Per diem,,132111,,"4,892.96 x patient days",132111,Per diem,,89835,,"3,327.21 x patient days",89835,Per diem,,132111,,"4,892.96 x patient days",132111,Per diem,,82202,,"3,044.51 x patient days",82202,Per diem,,132111,,"4,892.96 x patient days",132111,Per diem,,161469,,"5,980.29 x patient days",161469,Per diem,,190240,,"7,045.87 x patient days",190240,Per diem,,126239,,"4,675.50 x patient days",126239,Per diem,,126239,,"4,675.50 x patient days",126239,Per diem,,73395,,"2,718.31 x patient days",73395,Per diem,,0.01,190240,
Neonate bwt 1500-1999g w resp dist synd/oth maj resp cond,612-4,APR-DRG,,,,,,,,inpatient,,,1436069.17,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,109212,,"4,044.85 x patient days",109212,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,234159,,"27,634 x DRG weight",234159,Other,base rate x DRG weight,199028,,"23,488 x DRG weight",199028,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,58716,,"2,174.65 x patient days",58716,Per diem,,58716,,"2,174.65 x patient days",58716,Per diem,,58716,,"2,174.65 x patient days",58716,Per diem,,58716,,"2,174.65 x patient days",58716,Per diem,,132111,,"4,892.96 x patient days",132111,Per diem,,89835,,"3,327.21 x patient days",89835,Per diem,,132111,,"4,892.96 x patient days",132111,Per diem,,82202,,"3,044.51 x patient days",82202,Per diem,,132111,,"4,892.96 x patient days",132111,Per diem,,161469,,"5,980.29 x patient days",161469,Per diem,,190240,,"7,045.87 x patient days",190240,Per diem,,126239,,"4,675.50 x patient days",126239,Per diem,,126239,,"4,675.50 x patient days",126239,Per diem,,73395,,"2,718.31 x patient days",73395,Per diem,,0.01,234159,
Neonate birthwt 1500-1999g w congenital/perinatal infection,613-1,APR-DRG,,,,,,,,inpatient,,,362914,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,84942,,"4,044.85 x patient days",84942,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,73620,,"27,634 x DRG weight",73620,Other,base rate x DRG weight,62574,,"23,488 x DRG weight",62574,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,45668,,"2,174.65 x patient days",45668,Per diem,,45668,,"2,174.65 x patient days",45668,Per diem,,45668,,"2,174.65 x patient days",45668,Per diem,,45668,,"2,174.65 x patient days",45668,Per diem,,102753,,"4,892.96 x patient days",102753,Per diem,,69872,,"3,327.21 x patient days",69872,Per diem,,102753,,"4,892.96 x patient days",102753,Per diem,,63935,,"3,044.51 x patient days",63935,Per diem,,102753,,"4,892.96 x patient days",102753,Per diem,,125587,,"5,980.29 x patient days",125587,Per diem,,147964,,"7,045.87 x patient days",147964,Per diem,,98186,,"4,675.50 x patient days",98186,Per diem,,98186,,"4,675.50 x patient days",98186,Per diem,,57085,,"2,718.31 x patient days",57085,Per diem,,0.01,147964,
Neonate birthwt 1500-1999g w congenital/perinatal infection,613-2,APR-DRG,,,,,,,,inpatient,,,1361680,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,84942,,"4,044.85 x patient days",84942,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,111299,,"27,634 x DRG weight",111299,Other,base rate x DRG weight,94600,,"23,488 x DRG weight",94600,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,45668,,"2,174.65 x patient days",45668,Per diem,,45668,,"2,174.65 x patient days",45668,Per diem,,45668,,"2,174.65 x patient days",45668,Per diem,,45668,,"2,174.65 x patient days",45668,Per diem,,102753,,"4,892.96 x patient days",102753,Per diem,,69872,,"3,327.21 x patient days",69872,Per diem,,102753,,"4,892.96 x patient days",102753,Per diem,,63935,,"3,044.51 x patient days",63935,Per diem,,102753,,"4,892.96 x patient days",102753,Per diem,,125587,,"5,980.29 x patient days",125587,Per diem,,147964,,"7,045.87 x patient days",147964,Per diem,,98186,,"4,675.50 x patient days",98186,Per diem,,98186,,"4,675.50 x patient days",98186,Per diem,,57085,,"2,718.31 x patient days",57085,Per diem,,0.01,147964,
Neonate birthwt 1500-1999g w congenital/perinatal infection,613-3,APR-DRG,,,,,,,,inpatient,,,814185.9,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,84942,,"4,044.85 x patient days",84942,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,139488,,"27,634 x DRG weight",139488,Other,base rate x DRG weight,118560,,"23,488 x DRG weight",118560,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,45668,,"2,174.65 x patient days",45668,Per diem,,45668,,"2,174.65 x patient days",45668,Per diem,,45668,,"2,174.65 x patient days",45668,Per diem,,45668,,"2,174.65 x patient days",45668,Per diem,,102753,,"4,892.96 x patient days",102753,Per diem,,69872,,"3,327.21 x patient days",69872,Per diem,,102753,,"4,892.96 x patient days",102753,Per diem,,63935,,"3,044.51 x patient days",63935,Per diem,,102753,,"4,892.96 x patient days",102753,Per diem,,125587,,"5,980.29 x patient days",125587,Per diem,,147964,,"7,045.87 x patient days",147964,Per diem,,98186,,"4,675.50 x patient days",98186,Per diem,,98186,,"4,675.50 x patient days",98186,Per diem,,57085,,"2,718.31 x patient days",57085,Per diem,,0.01,147964,
Neonate birthwt 1500-1999g w congenital/perinatal infection,613-4,APR-DRG,,,,,,,,inpatient,,,752150,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,84942,,"4,044.85 x patient days",84942,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,143092,,"27,634 x DRG weight",143092,Other,base rate x DRG weight,121623,,"23,488 x DRG weight",121623,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,45668,,"2,174.65 x patient days",45668,Per diem,,45668,,"2,174.65 x patient days",45668,Per diem,,45668,,"2,174.65 x patient days",45668,Per diem,,45668,,"2,174.65 x patient days",45668,Per diem,,102753,,"4,892.96 x patient days",102753,Per diem,,69872,,"3,327.21 x patient days",69872,Per diem,,102753,,"4,892.96 x patient days",102753,Per diem,,63935,,"3,044.51 x patient days",63935,Per diem,,102753,,"4,892.96 x patient days",102753,Per diem,,125587,,"5,980.29 x patient days",125587,Per diem,,147964,,"7,045.87 x patient days",147964,Per diem,,98186,,"4,675.50 x patient days",98186,Per diem,,98186,,"4,675.50 x patient days",98186,Per diem,,57085,,"2,718.31 x patient days",57085,Per diem,,0.01,147964,
Neonate bwt 1500-1999g w or w/o other significant condition,614-1,APR-DRG,,,,,,,,inpatient,,,236221,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,56628,,"4,044.85 x patient days",56628,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,55119,,"27,634 x DRG weight",55119,Other,base rate x DRG weight,46849,,"23,488 x DRG weight",46849,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,30445,,"2,174.65 x patient days",30445,Per diem,,30445,,"2,174.65 x patient days",30445,Per diem,,30445,,"2,174.65 x patient days",30445,Per diem,,30445,,"2,174.65 x patient days",30445,Per diem,,68501,,"4,892.96 x patient days",68501,Per diem,,46581,,"3,327.21 x patient days",46581,Per diem,,68501,,"4,892.96 x patient days",68501,Per diem,,42623,,"3,044.51 x patient days",42623,Per diem,,68501,,"4,892.96 x patient days",68501,Per diem,,83724,,"5,980.29 x patient days",83724,Per diem,,98642,,"7,045.87 x patient days",98642,Per diem,,65457,,"4,675.50 x patient days",65457,Per diem,,65457,,"4,675.50 x patient days",65457,Per diem,,38056,,"2,718.31 x patient days",38056,Per diem,,0.01,98642,
Neonate bwt 1500-1999g w or w/o other significant condition,614-2,APR-DRG,,,,,,,,inpatient,,,643544.69,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,56628,,"4,044.85 x patient days",56628,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,91145,,"27,634 x DRG weight",91145,Other,base rate x DRG weight,77470,,"23,488 x DRG weight",77470,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,30445,,"2,174.65 x patient days",30445,Per diem,,30445,,"2,174.65 x patient days",30445,Per diem,,30445,,"2,174.65 x patient days",30445,Per diem,,30445,,"2,174.65 x patient days",30445,Per diem,,68501,,"4,892.96 x patient days",68501,Per diem,,46581,,"3,327.21 x patient days",46581,Per diem,,68501,,"4,892.96 x patient days",68501,Per diem,,42623,,"3,044.51 x patient days",42623,Per diem,,68501,,"4,892.96 x patient days",68501,Per diem,,83724,,"5,980.29 x patient days",83724,Per diem,,98642,,"7,045.87 x patient days",98642,Per diem,,65457,,"4,675.50 x patient days",65457,Per diem,,65457,,"4,675.50 x patient days",65457,Per diem,,38056,,"2,718.31 x patient days",38056,Per diem,,0.01,98642,
Neonate bwt 1500-1999g w or w/o other significant condition,614-3,APR-DRG,,,,,,,,inpatient,,,1187147,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,56628,,"4,044.85 x patient days",56628,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,139168,,"27,634 x DRG weight",139168,Other,base rate x DRG weight,118288,,"23,488 x DRG weight",118288,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,30445,,"2,174.65 x patient days",30445,Per diem,,30445,,"2,174.65 x patient days",30445,Per diem,,30445,,"2,174.65 x patient days",30445,Per diem,,30445,,"2,174.65 x patient days",30445,Per diem,,68501,,"4,892.96 x patient days",68501,Per diem,,46581,,"3,327.21 x patient days",46581,Per diem,,68501,,"4,892.96 x patient days",68501,Per diem,,42623,,"3,044.51 x patient days",42623,Per diem,,68501,,"4,892.96 x patient days",68501,Per diem,,83724,,"5,980.29 x patient days",83724,Per diem,,98642,,"7,045.87 x patient days",98642,Per diem,,65457,,"4,675.50 x patient days",65457,Per diem,,65457,,"4,675.50 x patient days",65457,Per diem,,38056,,"2,718.31 x patient days",38056,Per diem,,0.01,139168,
Neonate bwt 1500-1999g w or w/o other significant condition,614-4,APR-DRG,,,,,,,,inpatient,,,31433,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,56628,,"4,044.85 x patient days",56628,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,139168,,"27,634 x DRG weight",139168,Other,base rate x DRG weight,118288,,"23,488 x DRG weight",118288,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,30445,,"2,174.65 x patient days",30445,Per diem,,30445,,"2,174.65 x patient days",30445,Per diem,,30445,,"2,174.65 x patient days",30445,Per diem,,30445,,"2,174.65 x patient days",30445,Per diem,,68501,,"4,892.96 x patient days",68501,Per diem,,46581,,"3,327.21 x patient days",46581,Per diem,,68501,,"4,892.96 x patient days",68501,Per diem,,42623,,"3,044.51 x patient days",42623,Per diem,,68501,,"4,892.96 x patient days",68501,Per diem,,83724,,"5,980.29 x patient days",83724,Per diem,,98642,,"7,045.87 x patient days",98642,Per diem,,65457,,"4,675.50 x patient days",65457,Per diem,,65457,,"4,675.50 x patient days",65457,Per diem,,38056,,"2,718.31 x patient days",38056,Per diem,,0.01,139168,
Neonate bwt 2000-2499g w major anomaly,621-1,APR-DRG,,,,,,,,inpatient,,,109375.5,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,56628,,"4,044.85 x patient days",56628,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,25083,,"27,634 x DRG weight",25083,Other,base rate x DRG weight,21320,,"23,488 x DRG weight",21320,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,30445,,"2,174.65 x patient days",30445,Per diem,,30445,,"2,174.65 x patient days",30445,Per diem,,30445,,"2,174.65 x patient days",30445,Per diem,,30445,,"2,174.65 x patient days",30445,Per diem,,68501,,"4,892.96 x patient days",68501,Per diem,,46581,,"3,327.21 x patient days",46581,Per diem,,68501,,"4,892.96 x patient days",68501,Per diem,,42623,,"3,044.51 x patient days",42623,Per diem,,68501,,"4,892.96 x patient days",68501,Per diem,,83724,,"5,980.29 x patient days",83724,Per diem,,98642,,"7,045.87 x patient days",98642,Per diem,,65457,,"4,675.50 x patient days",65457,Per diem,,65457,,"4,675.50 x patient days",65457,Per diem,,38056,,"2,718.31 x patient days",38056,Per diem,,0.01,98642,
Neonate bwt 2000-2499g w major anomaly,621-2,APR-DRG,,,,,,,,inpatient,,,575261.4,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,56628,,"4,044.85 x patient days",56628,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,57866,,"27,634 x DRG weight",57866,Other,base rate x DRG weight,49184,,"23,488 x DRG weight",49184,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,30445,,"2,174.65 x patient days",30445,Per diem,,30445,,"2,174.65 x patient days",30445,Per diem,,30445,,"2,174.65 x patient days",30445,Per diem,,30445,,"2,174.65 x patient days",30445,Per diem,,68501,,"4,892.96 x patient days",68501,Per diem,,46581,,"3,327.21 x patient days",46581,Per diem,,68501,,"4,892.96 x patient days",68501,Per diem,,42623,,"3,044.51 x patient days",42623,Per diem,,68501,,"4,892.96 x patient days",68501,Per diem,,83724,,"5,980.29 x patient days",83724,Per diem,,98642,,"7,045.87 x patient days",98642,Per diem,,65457,,"4,675.50 x patient days",65457,Per diem,,65457,,"4,675.50 x patient days",65457,Per diem,,38056,,"2,718.31 x patient days",38056,Per diem,,0.01,98642,
Neonate bwt 2000-2499g w major anomaly,621-3,APR-DRG,,,,,,,,inpatient,,,814185.9,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,56628,,"4,044.85 x patient days",56628,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,109936,,"27,634 x DRG weight",109936,Other,base rate x DRG weight,93442,,"23,488 x DRG weight",93442,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,30445,,"2,174.65 x patient days",30445,Per diem,,30445,,"2,174.65 x patient days",30445,Per diem,,30445,,"2,174.65 x patient days",30445,Per diem,,30445,,"2,174.65 x patient days",30445,Per diem,,68501,,"4,892.96 x patient days",68501,Per diem,,46581,,"3,327.21 x patient days",46581,Per diem,,68501,,"4,892.96 x patient days",68501,Per diem,,42623,,"3,044.51 x patient days",42623,Per diem,,68501,,"4,892.96 x patient days",68501,Per diem,,83724,,"5,980.29 x patient days",83724,Per diem,,98642,,"7,045.87 x patient days",98642,Per diem,,65457,,"4,675.50 x patient days",65457,Per diem,,65457,,"4,675.50 x patient days",65457,Per diem,,38056,,"2,718.31 x patient days",38056,Per diem,,0.01,109936,
Neonate bwt 2000-2499g w major anomaly,621-4,APR-DRG,,,,,,,,inpatient,,,752150,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,56628,,"4,044.85 x patient days",56628,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,187693,,"27,634 x DRG weight",187693,Other,base rate x DRG weight,159533,,"23,488 x DRG weight",159533,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,30445,,"2,174.65 x patient days",30445,Per diem,,30445,,"2,174.65 x patient days",30445,Per diem,,30445,,"2,174.65 x patient days",30445,Per diem,,30445,,"2,174.65 x patient days",30445,Per diem,,68501,,"4,892.96 x patient days",68501,Per diem,,46581,,"3,327.21 x patient days",46581,Per diem,,68501,,"4,892.96 x patient days",68501,Per diem,,42623,,"3,044.51 x patient days",42623,Per diem,,68501,,"4,892.96 x patient days",68501,Per diem,,83724,,"5,980.29 x patient days",83724,Per diem,,98642,,"7,045.87 x patient days",98642,Per diem,,65457,,"4,675.50 x patient days",65457,Per diem,,65457,,"4,675.50 x patient days",65457,Per diem,,38056,,"2,718.31 x patient days",38056,Per diem,,0.01,187693,
Neonate bwt 2000-2499g w resp dist synd/oth maj resp cond,622-1,APR-DRG,,,,,,,,inpatient,,,307909.9,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,56628,,"4,044.85 x patient days",56628,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,53535,,"27,634 x DRG weight",53535,Other,base rate x DRG weight,45503,,"23,488 x DRG weight",45503,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,30445,,"2,174.65 x patient days",30445,Per diem,,30445,,"2,174.65 x patient days",30445,Per diem,,30445,,"2,174.65 x patient days",30445,Per diem,,30445,,"2,174.65 x patient days",30445,Per diem,,68501,,"4,892.96 x patient days",68501,Per diem,,46581,,"3,327.21 x patient days",46581,Per diem,,68501,,"4,892.96 x patient days",68501,Per diem,,42623,,"3,044.51 x patient days",42623,Per diem,,68501,,"4,892.96 x patient days",68501,Per diem,,83724,,"5,980.29 x patient days",83724,Per diem,,98642,,"7,045.87 x patient days",98642,Per diem,,65457,,"4,675.50 x patient days",65457,Per diem,,65457,,"4,675.50 x patient days",65457,Per diem,,38056,,"2,718.31 x patient days",38056,Per diem,,0.01,98642,
Neonate bwt 2000-2499g w resp dist synd/oth maj resp cond,622-2,APR-DRG,,,,,,,,inpatient,,,519174,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,56628,,"4,044.85 x patient days",56628,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,72688,,"27,634 x DRG weight",72688,Other,base rate x DRG weight,61783,,"23,488 x DRG weight",61783,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,30445,,"2,174.65 x patient days",30445,Per diem,,30445,,"2,174.65 x patient days",30445,Per diem,,30445,,"2,174.65 x patient days",30445,Per diem,,30445,,"2,174.65 x patient days",30445,Per diem,,68501,,"4,892.96 x patient days",68501,Per diem,,46581,,"3,327.21 x patient days",46581,Per diem,,68501,,"4,892.96 x patient days",68501,Per diem,,42623,,"3,044.51 x patient days",42623,Per diem,,68501,,"4,892.96 x patient days",68501,Per diem,,83724,,"5,980.29 x patient days",83724,Per diem,,98642,,"7,045.87 x patient days",98642,Per diem,,65457,,"4,675.50 x patient days",65457,Per diem,,65457,,"4,675.50 x patient days",65457,Per diem,,38056,,"2,718.31 x patient days",38056,Per diem,,0.01,98642,
Neonate bwt 2000-2499g w resp dist synd/oth maj resp cond,622-3,APR-DRG,,,,,,,,inpatient,,,810939.13,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,56628,,"4,044.85 x patient days",56628,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,99643,,"27,634 x DRG weight",99643,Other,base rate x DRG weight,84693,,"23,488 x DRG weight",84693,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,30445,,"2,174.65 x patient days",30445,Per diem,,30445,,"2,174.65 x patient days",30445,Per diem,,30445,,"2,174.65 x patient days",30445,Per diem,,30445,,"2,174.65 x patient days",30445,Per diem,,68501,,"4,892.96 x patient days",68501,Per diem,,46581,,"3,327.21 x patient days",46581,Per diem,,68501,,"4,892.96 x patient days",68501,Per diem,,42623,,"3,044.51 x patient days",42623,Per diem,,68501,,"4,892.96 x patient days",68501,Per diem,,83724,,"5,980.29 x patient days",83724,Per diem,,98642,,"7,045.87 x patient days",98642,Per diem,,65457,,"4,675.50 x patient days",65457,Per diem,,65457,,"4,675.50 x patient days",65457,Per diem,,38056,,"2,718.31 x patient days",38056,Per diem,,0.01,99643,
Neonate bwt 2000-2499g w resp dist synd/oth maj resp cond,622-4,APR-DRG,,,,,,,,inpatient,,,579822.01,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,56628,,"4,044.85 x patient days",56628,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,142840,,"27,634 x DRG weight",142840,Other,base rate x DRG weight,121409,,"23,488 x DRG weight",121409,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,30445,,"2,174.65 x patient days",30445,Per diem,,30445,,"2,174.65 x patient days",30445,Per diem,,30445,,"2,174.65 x patient days",30445,Per diem,,30445,,"2,174.65 x patient days",30445,Per diem,,68501,,"4,892.96 x patient days",68501,Per diem,,46581,,"3,327.21 x patient days",46581,Per diem,,68501,,"4,892.96 x patient days",68501,Per diem,,42623,,"3,044.51 x patient days",42623,Per diem,,68501,,"4,892.96 x patient days",68501,Per diem,,83724,,"5,980.29 x patient days",83724,Per diem,,98642,,"7,045.87 x patient days",98642,Per diem,,65457,,"4,675.50 x patient days",65457,Per diem,,65457,,"4,675.50 x patient days",65457,Per diem,,38056,,"2,718.31 x patient days",38056,Per diem,,0.01,142840,
Neonate bwt 2000-2499g w congenital/perinatal infection,623-1,APR-DRG,,,,,,,,inpatient,,,316312.8,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,44493,,"4,044.85 x patient days",44493,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,40205,,"27,634 x DRG weight",40205,Other,base rate x DRG weight,34173,,"23,488 x DRG weight",34173,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,23921,,"2,174.65 x patient days",23921,Per diem,,23921,,"2,174.65 x patient days",23921,Per diem,,23921,,"2,174.65 x patient days",23921,Per diem,,23921,,"2,174.65 x patient days",23921,Per diem,,53822,,"4,892.96 x patient days",53822,Per diem,,36599,,"3,327.21 x patient days",36599,Per diem,,53822,,"4,892.96 x patient days",53822,Per diem,,33489,,"3,044.51 x patient days",33489,Per diem,,53822,,"4,892.96 x patient days",53822,Per diem,,65783,,"5,980.29 x patient days",65783,Per diem,,77504,,"7,045.87 x patient days",77504,Per diem,,51430,,"4,675.50 x patient days",51430,Per diem,,51430,,"4,675.50 x patient days",51430,Per diem,,29901,,"2,718.31 x patient days",29901,Per diem,,0.01,77504,
Neonate bwt 2000-2499g w congenital/perinatal infection,623-2,APR-DRG,,,,,,,,inpatient,,,472011.9,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,44493,,"4,044.85 x patient days",44493,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,59640,,"27,634 x DRG weight",59640,Other,base rate x DRG weight,50692,,"23,488 x DRG weight",50692,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,23921,,"2,174.65 x patient days",23921,Per diem,,23921,,"2,174.65 x patient days",23921,Per diem,,23921,,"2,174.65 x patient days",23921,Per diem,,23921,,"2,174.65 x patient days",23921,Per diem,,53822,,"4,892.96 x patient days",53822,Per diem,,36599,,"3,327.21 x patient days",36599,Per diem,,53822,,"4,892.96 x patient days",53822,Per diem,,33489,,"3,044.51 x patient days",33489,Per diem,,53822,,"4,892.96 x patient days",53822,Per diem,,65783,,"5,980.29 x patient days",65783,Per diem,,77504,,"7,045.87 x patient days",77504,Per diem,,51430,,"4,675.50 x patient days",51430,Per diem,,51430,,"4,675.50 x patient days",51430,Per diem,,29901,,"2,718.31 x patient days",29901,Per diem,,0.01,77504,
Neonate bwt 2000-2499g w congenital/perinatal infection,623-3,APR-DRG,,,,,,,,inpatient,,,549076,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,44493,,"4,044.85 x patient days",44493,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,86359,,"27,634 x DRG weight",86359,Other,base rate x DRG weight,73402,,"23,488 x DRG weight",73402,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,23921,,"2,174.65 x patient days",23921,Per diem,,23921,,"2,174.65 x patient days",23921,Per diem,,23921,,"2,174.65 x patient days",23921,Per diem,,23921,,"2,174.65 x patient days",23921,Per diem,,53822,,"4,892.96 x patient days",53822,Per diem,,36599,,"3,327.21 x patient days",36599,Per diem,,53822,,"4,892.96 x patient days",53822,Per diem,,33489,,"3,044.51 x patient days",33489,Per diem,,53822,,"4,892.96 x patient days",53822,Per diem,,65783,,"5,980.29 x patient days",65783,Per diem,,77504,,"7,045.87 x patient days",77504,Per diem,,51430,,"4,675.50 x patient days",51430,Per diem,,51430,,"4,675.50 x patient days",51430,Per diem,,29901,,"2,718.31 x patient days",29901,Per diem,,0.01,86359,
Neonate bwt 2000-2499g w congenital/perinatal infection,623-4,APR-DRG,,,,,,,,inpatient,,,549076,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,44493,,"4,044.85 x patient days",44493,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,86359,,"27,634 x DRG weight",86359,Other,base rate x DRG weight,73402,,"23,488 x DRG weight",73402,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,23921,,"2,174.65 x patient days",23921,Per diem,,23921,,"2,174.65 x patient days",23921,Per diem,,23921,,"2,174.65 x patient days",23921,Per diem,,23921,,"2,174.65 x patient days",23921,Per diem,,53822,,"4,892.96 x patient days",53822,Per diem,,36599,,"3,327.21 x patient days",36599,Per diem,,53822,,"4,892.96 x patient days",53822,Per diem,,33489,,"3,044.51 x patient days",33489,Per diem,,53822,,"4,892.96 x patient days",53822,Per diem,,65783,,"5,980.29 x patient days",65783,Per diem,,77504,,"7,045.87 x patient days",77504,Per diem,,51430,,"4,675.50 x patient days",51430,Per diem,,51430,,"4,675.50 x patient days",51430,Per diem,,29901,,"2,718.31 x patient days",29901,Per diem,,0.01,86359,
Neonate bwt 2000-2499g w other significant condition,625-1,APR-DRG,,,,,,,,inpatient,,,316312.8,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,44493,,"4,044.85 x patient days",44493,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,44209,,"27,634 x DRG weight",44209,Other,base rate x DRG weight,37576,,"23,488 x DRG weight",37576,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,23921,,"2,174.65 x patient days",23921,Per diem,,23921,,"2,174.65 x patient days",23921,Per diem,,23921,,"2,174.65 x patient days",23921,Per diem,,23921,,"2,174.65 x patient days",23921,Per diem,,53822,,"4,892.96 x patient days",53822,Per diem,,36599,,"3,327.21 x patient days",36599,Per diem,,53822,,"4,892.96 x patient days",53822,Per diem,,33489,,"3,044.51 x patient days",33489,Per diem,,53822,,"4,892.96 x patient days",53822,Per diem,,65783,,"5,980.29 x patient days",65783,Per diem,,77504,,"7,045.87 x patient days",77504,Per diem,,51430,,"4,675.50 x patient days",51430,Per diem,,51430,,"4,675.50 x patient days",51430,Per diem,,29901,,"2,718.31 x patient days",29901,Per diem,,0.01,77504,
Neonate bwt 2000-2499g w other significant condition,625-2,APR-DRG,,,,,,,,inpatient,,,472011.9,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,44493,,"4,044.85 x patient days",44493,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,71497,,"27,634 x DRG weight",71497,Other,base rate x DRG weight,60771,,"23,488 x DRG weight",60771,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,23921,,"2,174.65 x patient days",23921,Per diem,,23921,,"2,174.65 x patient days",23921,Per diem,,23921,,"2,174.65 x patient days",23921,Per diem,,23921,,"2,174.65 x patient days",23921,Per diem,,53822,,"4,892.96 x patient days",53822,Per diem,,36599,,"3,327.21 x patient days",36599,Per diem,,53822,,"4,892.96 x patient days",53822,Per diem,,33489,,"3,044.51 x patient days",33489,Per diem,,53822,,"4,892.96 x patient days",53822,Per diem,,65783,,"5,980.29 x patient days",65783,Per diem,,77504,,"7,045.87 x patient days",77504,Per diem,,51430,,"4,675.50 x patient days",51430,Per diem,,51430,,"4,675.50 x patient days",51430,Per diem,,29901,,"2,718.31 x patient days",29901,Per diem,,0.01,77504,
Neonate bwt 2000-2499g w other significant condition,625-3,APR-DRG,,,,,,,,inpatient,,,549076,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,44493,,"4,044.85 x patient days",44493,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,91035,,"27,634 x DRG weight",91035,Other,base rate x DRG weight,77377,,"23,488 x DRG weight",77377,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,23921,,"2,174.65 x patient days",23921,Per diem,,23921,,"2,174.65 x patient days",23921,Per diem,,23921,,"2,174.65 x patient days",23921,Per diem,,23921,,"2,174.65 x patient days",23921,Per diem,,53822,,"4,892.96 x patient days",53822,Per diem,,36599,,"3,327.21 x patient days",36599,Per diem,,53822,,"4,892.96 x patient days",53822,Per diem,,33489,,"3,044.51 x patient days",33489,Per diem,,53822,,"4,892.96 x patient days",53822,Per diem,,65783,,"5,980.29 x patient days",65783,Per diem,,77504,,"7,045.87 x patient days",77504,Per diem,,51430,,"4,675.50 x patient days",51430,Per diem,,51430,,"4,675.50 x patient days",51430,Per diem,,29901,,"2,718.31 x patient days",29901,Per diem,,0.01,91035,
Neonate bwt 2000-2499g w other significant condition,625-4,APR-DRG,,,,,,,,inpatient,,,549076,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,44493,,"4,044.85 x patient days",44493,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,91035,,"27,634 x DRG weight",91035,Other,base rate x DRG weight,77377,,"23,488 x DRG weight",77377,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,23921,,"2,174.65 x patient days",23921,Per diem,,23921,,"2,174.65 x patient days",23921,Per diem,,23921,,"2,174.65 x patient days",23921,Per diem,,23921,,"2,174.65 x patient days",23921,Per diem,,53822,,"4,892.96 x patient days",53822,Per diem,,36599,,"3,327.21 x patient days",36599,Per diem,,53822,,"4,892.96 x patient days",53822,Per diem,,33489,,"3,044.51 x patient days",33489,Per diem,,53822,,"4,892.96 x patient days",53822,Per diem,,65783,,"5,980.29 x patient days",65783,Per diem,,77504,,"7,045.87 x patient days",77504,Per diem,,51430,,"4,675.50 x patient days",51430,Per diem,,51430,,"4,675.50 x patient days",51430,Per diem,,29901,,"2,718.31 x patient days",29901,Per diem,,0.01,91035,
"Neonate bwt 2000-2499g, normal newborn or neonate w other problem",626-1,APR-DRG,,,,,,,,inpatient,,,16942.33,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,16180,,"4,044.85 x patient days",16180,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,5756,,"27,634 x DRG weight",5756,Other,base rate x DRG weight,4893,,"23,488 x DRG weight",4893,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,13309,,"3,327.21 x patient days",13309,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,12179,,"3,044.51 x patient days",12179,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,23922,,"5,980.29 x patient days",23922,Per diem,,28185,,"7,045.87 x patient days",28185,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,10874,,"2,718.31 x patient days",10874,Per diem,,0.01,28185,
"Neonate bwt 2000-2499g, normal newborn or neonate w other problem",626-2,APR-DRG,,,,,,,,inpatient,,,70194.06,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,16180,,"4,044.85 x patient days",16180,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,11512,,"27,634 x DRG weight",11512,Other,base rate x DRG weight,9785,,"23,488 x DRG weight",9785,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,13309,,"3,327.21 x patient days",13309,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,12179,,"3,044.51 x patient days",12179,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,23922,,"5,980.29 x patient days",23922,Per diem,,28185,,"7,045.87 x patient days",28185,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,10874,,"2,718.31 x patient days",10874,Per diem,,0.01,28185,
"Neonate bwt 2000-2499g, normal newborn or neonate w other problem",626-3,APR-DRG,,,,,,,,inpatient,,,161498.29,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,16180,,"4,044.85 x patient days",16180,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,36972,,"27,634 x DRG weight",36972,Other,base rate x DRG weight,31425,,"23,488 x DRG weight",31425,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,13309,,"3,327.21 x patient days",13309,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,12179,,"3,044.51 x patient days",12179,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,23922,,"5,980.29 x patient days",23922,Per diem,,28185,,"7,045.87 x patient days",28185,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,10874,,"2,718.31 x patient days",10874,Per diem,,0.01,36972,
"Neonate bwt 2000-2499g, normal newborn or neonate w other problem",626-4,APR-DRG,,,,,,,,inpatient,,,161498.29,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,16180,,"4,044.85 x patient days",16180,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,37013,,"27,634 x DRG weight",37013,Other,base rate x DRG weight,31460,,"23,488 x DRG weight",31460,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,13309,,"3,327.21 x patient days",13309,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,12179,,"3,044.51 x patient days",12179,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,23922,,"5,980.29 x patient days",23922,Per diem,,28185,,"7,045.87 x patient days",28185,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,10874,,"2,718.31 x patient days",10874,Per diem,,0.01,37013,
Neonate birthwt >2499g w major cardiovascular procedure,630-1,APR-DRG,,,,,,,,inpatient,,,318250,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,105166,,"4,044.85 x patient days",105166,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,95304,,"27,634 x DRG weight",95304,Other,base rate x DRG weight,81005,,"23,488 x DRG weight",81005,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,56541,,"2,174.65 x patient days",56541,Per diem,,56541,,"2,174.65 x patient days",56541,Per diem,,56541,,"2,174.65 x patient days",56541,Per diem,,56541,,"2,174.65 x patient days",56541,Per diem,,127217,,"4,892.96 x patient days",127217,Per diem,,86508,,"3,327.21 x patient days",86508,Per diem,,127217,,"4,892.96 x patient days",127217,Per diem,,79157,,"3,044.51 x patient days",79157,Per diem,,127217,,"4,892.96 x patient days",127217,Per diem,,155488,,"5,980.29 x patient days",155488,Per diem,,183193,,"7,045.87 x patient days",183193,Per diem,,121563,,"4,675.50 x patient days",121563,Per diem,,121563,,"4,675.50 x patient days",121563,Per diem,,70676,,"2,718.31 x patient days",70676,Per diem,,0.01,183193,
Neonate birthwt >2499g w major cardiovascular procedure,630-2,APR-DRG,,,,,,,,inpatient,,,519875,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,105166,,"4,044.85 x patient days",105166,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,99115,,"27,634 x DRG weight",99115,Other,base rate x DRG weight,84244,,"23,488 x DRG weight",84244,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,56541,,"2,174.65 x patient days",56541,Per diem,,56541,,"2,174.65 x patient days",56541,Per diem,,56541,,"2,174.65 x patient days",56541,Per diem,,56541,,"2,174.65 x patient days",56541,Per diem,,127217,,"4,892.96 x patient days",127217,Per diem,,86508,,"3,327.21 x patient days",86508,Per diem,,127217,,"4,892.96 x patient days",127217,Per diem,,79157,,"3,044.51 x patient days",79157,Per diem,,127217,,"4,892.96 x patient days",127217,Per diem,,155488,,"5,980.29 x patient days",155488,Per diem,,183193,,"7,045.87 x patient days",183193,Per diem,,121563,,"4,675.50 x patient days",121563,Per diem,,121563,,"4,675.50 x patient days",121563,Per diem,,70676,,"2,718.31 x patient days",70676,Per diem,,0.01,183193,
Neonate birthwt >2499g w major cardiovascular procedure,630-3,APR-DRG,,,,,,,,inpatient,,,868033.41,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,105166,,"4,044.85 x patient days",105166,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,163745,,"27,634 x DRG weight",163745,Other,base rate x DRG weight,139178,,"23,488 x DRG weight",139178,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,56541,,"2,174.65 x patient days",56541,Per diem,,56541,,"2,174.65 x patient days",56541,Per diem,,56541,,"2,174.65 x patient days",56541,Per diem,,56541,,"2,174.65 x patient days",56541,Per diem,,127217,,"4,892.96 x patient days",127217,Per diem,,86508,,"3,327.21 x patient days",86508,Per diem,,127217,,"4,892.96 x patient days",127217,Per diem,,79157,,"3,044.51 x patient days",79157,Per diem,,127217,,"4,892.96 x patient days",127217,Per diem,,155488,,"5,980.29 x patient days",155488,Per diem,,183193,,"7,045.87 x patient days",183193,Per diem,,121563,,"4,675.50 x patient days",121563,Per diem,,121563,,"4,675.50 x patient days",121563,Per diem,,70676,,"2,718.31 x patient days",70676,Per diem,,0.01,183193,
Neonate birthwt >2499g w major cardiovascular procedure,630-4,APR-DRG,,,,,,,,inpatient,,,809175.1,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,105166,,"4,044.85 x patient days",105166,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,337950,,"27,634 x DRG weight",337950,Other,base rate x DRG weight,287246,,"23,488 x DRG weight",287246,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,56541,,"2,174.65 x patient days",56541,Per diem,,56541,,"2,174.65 x patient days",56541,Per diem,,56541,,"2,174.65 x patient days",56541,Per diem,,56541,,"2,174.65 x patient days",56541,Per diem,,127217,,"4,892.96 x patient days",127217,Per diem,,86508,,"3,327.21 x patient days",86508,Per diem,,127217,,"4,892.96 x patient days",127217,Per diem,,79157,,"3,044.51 x patient days",79157,Per diem,,127217,,"4,892.96 x patient days",127217,Per diem,,155488,,"5,980.29 x patient days",155488,Per diem,,183193,,"7,045.87 x patient days",183193,Per diem,,121563,,"4,675.50 x patient days",121563,Per diem,,121563,,"4,675.50 x patient days",121563,Per diem,,70676,,"2,718.31 x patient days",70676,Per diem,,0.01,337950,
Neonate birthwt >2499g w other major procedure,631-1,APR-DRG,,,,,,,,inpatient,,,137924.5,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,101121,,"4,044.85 x patient days",101121,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,44991,,"27,634 x DRG weight",44991,Other,base rate x DRG weight,38241,,"23,488 x DRG weight",38241,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,54366,,"2,174.65 x patient days",54366,Per diem,,54366,,"2,174.65 x patient days",54366,Per diem,,54366,,"2,174.65 x patient days",54366,Per diem,,54366,,"2,174.65 x patient days",54366,Per diem,,122324,,"4,892.96 x patient days",122324,Per diem,,83180,,"3,327.21 x patient days",83180,Per diem,,122324,,"4,892.96 x patient days",122324,Per diem,,76112,,"3,044.51 x patient days",76112,Per diem,,122324,,"4,892.96 x patient days",122324,Per diem,,149507,,"5,980.29 x patient days",149507,Per diem,,176146,,"7,045.87 x patient days",176146,Per diem,,116887,,"4,675.50 x patient days",116887,Per diem,,116887,,"4,675.50 x patient days",116887,Per diem,,67958,,"2,718.31 x patient days",67958,Per diem,,0.01,176146,
Neonate birthwt >2499g w other major procedure,631-2,APR-DRG,,,,,,,,inpatient,,,513418.93,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,101121,,"4,044.85 x patient days",101121,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,81078,,"27,634 x DRG weight",81078,Other,base rate x DRG weight,68914,,"23,488 x DRG weight",68914,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,54366,,"2,174.65 x patient days",54366,Per diem,,54366,,"2,174.65 x patient days",54366,Per diem,,54366,,"2,174.65 x patient days",54366,Per diem,,54366,,"2,174.65 x patient days",54366,Per diem,,122324,,"4,892.96 x patient days",122324,Per diem,,83180,,"3,327.21 x patient days",83180,Per diem,,122324,,"4,892.96 x patient days",122324,Per diem,,76112,,"3,044.51 x patient days",76112,Per diem,,122324,,"4,892.96 x patient days",122324,Per diem,,149507,,"5,980.29 x patient days",149507,Per diem,,176146,,"7,045.87 x patient days",176146,Per diem,,116887,,"4,675.50 x patient days",116887,Per diem,,116887,,"4,675.50 x patient days",116887,Per diem,,67958,,"2,718.31 x patient days",67958,Per diem,,0.01,176146,
Neonate birthwt >2499g w other major procedure,631-3,APR-DRG,,,,,,,,inpatient,,,468154.86,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,101121,,"4,044.85 x patient days",101121,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,134743,,"27,634 x DRG weight",134743,Other,base rate x DRG weight,114527,,"23,488 x DRG weight",114527,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,54366,,"2,174.65 x patient days",54366,Per diem,,54366,,"2,174.65 x patient days",54366,Per diem,,54366,,"2,174.65 x patient days",54366,Per diem,,54366,,"2,174.65 x patient days",54366,Per diem,,122324,,"4,892.96 x patient days",122324,Per diem,,83180,,"3,327.21 x patient days",83180,Per diem,,122324,,"4,892.96 x patient days",122324,Per diem,,76112,,"3,044.51 x patient days",76112,Per diem,,122324,,"4,892.96 x patient days",122324,Per diem,,149507,,"5,980.29 x patient days",149507,Per diem,,176146,,"7,045.87 x patient days",176146,Per diem,,116887,,"4,675.50 x patient days",116887,Per diem,,116887,,"4,675.50 x patient days",116887,Per diem,,67958,,"2,718.31 x patient days",67958,Per diem,,0.01,176146,
Neonate birthwt >2499g w other major procedure,631-4,APR-DRG,,,,,,,,inpatient,,,4292618.39,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,101121,,"4,044.85 x patient days",101121,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,290527,,"27,634 x DRG weight",290527,Other,base rate x DRG weight,246939,,"23,488 x DRG weight",246939,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,54366,,"2,174.65 x patient days",54366,Per diem,,54366,,"2,174.65 x patient days",54366,Per diem,,54366,,"2,174.65 x patient days",54366,Per diem,,54366,,"2,174.65 x patient days",54366,Per diem,,122324,,"4,892.96 x patient days",122324,Per diem,,83180,,"3,327.21 x patient days",83180,Per diem,,122324,,"4,892.96 x patient days",122324,Per diem,,76112,,"3,044.51 x patient days",76112,Per diem,,122324,,"4,892.96 x patient days",122324,Per diem,,149507,,"5,980.29 x patient days",149507,Per diem,,176146,,"7,045.87 x patient days",176146,Per diem,,116887,,"4,675.50 x patient days",116887,Per diem,,116887,,"4,675.50 x patient days",116887,Per diem,,67958,,"2,718.31 x patient days",67958,Per diem,,0.01,290527,
Neonate birthwt >2499g w major anomaly,633-1,APR-DRG,,,,,,,,inpatient,,,80935.35,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,24269,,"4,044.85 x patient days",24269,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,7787,,"27,634 x DRG weight",7787,Other,base rate x DRG weight,6619,,"23,488 x DRG weight",6619,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,13048,,"2,174.65 x patient days",13048,Per diem,,13048,,"2,174.65 x patient days",13048,Per diem,,13048,,"2,174.65 x patient days",13048,Per diem,,13048,,"2,174.65 x patient days",13048,Per diem,,29358,,"4,892.96 x patient days",29358,Per diem,,19963,,"3,327.21 x patient days",19963,Per diem,,29358,,"4,892.96 x patient days",29358,Per diem,,18267,,"3,044.51 x patient days",18267,Per diem,,29358,,"4,892.96 x patient days",29358,Per diem,,35882,,"5,980.29 x patient days",35882,Per diem,,42276,,"7,045.87 x patient days",42276,Per diem,,28053,,"4,675.50 x patient days",28053,Per diem,,28053,,"4,675.50 x patient days",28053,Per diem,,16310,,"2,718.31 x patient days",16310,Per diem,,0.01,42276,
Neonate birthwt >2499g w major anomaly,633-2,APR-DRG,,,,,,,,inpatient,,,187603.02,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,24269,,"4,044.85 x patient days",24269,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,25161,,"27,634 x DRG weight",25161,Other,base rate x DRG weight,21386,,"23,488 x DRG weight",21386,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,13048,,"2,174.65 x patient days",13048,Per diem,,13048,,"2,174.65 x patient days",13048,Per diem,,13048,,"2,174.65 x patient days",13048,Per diem,,13048,,"2,174.65 x patient days",13048,Per diem,,29358,,"4,892.96 x patient days",29358,Per diem,,19963,,"3,327.21 x patient days",19963,Per diem,,29358,,"4,892.96 x patient days",29358,Per diem,,18267,,"3,044.51 x patient days",18267,Per diem,,29358,,"4,892.96 x patient days",29358,Per diem,,35882,,"5,980.29 x patient days",35882,Per diem,,42276,,"7,045.87 x patient days",42276,Per diem,,28053,,"4,675.50 x patient days",28053,Per diem,,28053,,"4,675.50 x patient days",28053,Per diem,,16310,,"2,718.31 x patient days",16310,Per diem,,0.01,42276,
Neonate birthwt >2499g w major anomaly,633-3,APR-DRG,,,,,,,,inpatient,,,888642.07,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,24269,,"4,044.85 x patient days",24269,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,66222,,"27,634 x DRG weight",66222,Other,base rate x DRG weight,56287,,"23,488 x DRG weight",56287,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,13048,,"2,174.65 x patient days",13048,Per diem,,13048,,"2,174.65 x patient days",13048,Per diem,,13048,,"2,174.65 x patient days",13048,Per diem,,13048,,"2,174.65 x patient days",13048,Per diem,,29358,,"4,892.96 x patient days",29358,Per diem,,19963,,"3,327.21 x patient days",19963,Per diem,,29358,,"4,892.96 x patient days",29358,Per diem,,18267,,"3,044.51 x patient days",18267,Per diem,,29358,,"4,892.96 x patient days",29358,Per diem,,35882,,"5,980.29 x patient days",35882,Per diem,,42276,,"7,045.87 x patient days",42276,Per diem,,28053,,"4,675.50 x patient days",28053,Per diem,,28053,,"4,675.50 x patient days",28053,Per diem,,16310,,"2,718.31 x patient days",16310,Per diem,,0.01,66222,
Neonate birthwt >2499g w major anomaly,633-4,APR-DRG,,,,,,,,inpatient,,,1280483.78,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,24269,,"4,044.85 x patient days",24269,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,147950,,"27,634 x DRG weight",147950,Other,base rate x DRG weight,125752,,"23,488 x DRG weight",125752,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,13048,,"2,174.65 x patient days",13048,Per diem,,13048,,"2,174.65 x patient days",13048,Per diem,,13048,,"2,174.65 x patient days",13048,Per diem,,13048,,"2,174.65 x patient days",13048,Per diem,,29358,,"4,892.96 x patient days",29358,Per diem,,19963,,"3,327.21 x patient days",19963,Per diem,,29358,,"4,892.96 x patient days",29358,Per diem,,18267,,"3,044.51 x patient days",18267,Per diem,,29358,,"4,892.96 x patient days",29358,Per diem,,35882,,"5,980.29 x patient days",35882,Per diem,,42276,,"7,045.87 x patient days",42276,Per diem,,28053,,"4,675.50 x patient days",28053,Per diem,,28053,,"4,675.50 x patient days",28053,Per diem,,16310,,"2,718.31 x patient days",16310,Per diem,,0.01,147950,
"Neonate, birthwt >2499g w resp dist synd/oth maj resp cond",634-1,APR-DRG,,,,,,,,inpatient,,,150597,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,28315,,"4,044.85 x patient days",28315,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,22220,,"27,634 x DRG weight",22220,Other,base rate x DRG weight,18887,,"23,488 x DRG weight",18887,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,15223,,"2,174.65 x patient days",15223,Per diem,,15223,,"2,174.65 x patient days",15223,Per diem,,15223,,"2,174.65 x patient days",15223,Per diem,,15223,,"2,174.65 x patient days",15223,Per diem,,34252,,"4,892.96 x patient days",34252,Per diem,,23291,,"3,327.21 x patient days",23291,Per diem,,34252,,"4,892.96 x patient days",34252,Per diem,,21312,,"3,044.51 x patient days",21312,Per diem,,34252,,"4,892.96 x patient days",34252,Per diem,,41863,,"5,980.29 x patient days",41863,Per diem,,49323,,"7,045.87 x patient days",49323,Per diem,,32729,,"4,675.50 x patient days",32729,Per diem,,32729,,"4,675.50 x patient days",32729,Per diem,,19029,,"2,718.31 x patient days",19029,Per diem,,0.01,49323,
"Neonate, birthwt >2499g w resp dist synd/oth maj resp cond",634-2,APR-DRG,,,,,,,,inpatient,,,224452.26,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,28315,,"4,044.85 x patient days",28315,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,36839,,"27,634 x DRG weight",36839,Other,base rate x DRG weight,31312,,"23,488 x DRG weight",31312,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,15223,,"2,174.65 x patient days",15223,Per diem,,15223,,"2,174.65 x patient days",15223,Per diem,,15223,,"2,174.65 x patient days",15223,Per diem,,15223,,"2,174.65 x patient days",15223,Per diem,,34252,,"4,892.96 x patient days",34252,Per diem,,23291,,"3,327.21 x patient days",23291,Per diem,,34252,,"4,892.96 x patient days",34252,Per diem,,21312,,"3,044.51 x patient days",21312,Per diem,,34252,,"4,892.96 x patient days",34252,Per diem,,41863,,"5,980.29 x patient days",41863,Per diem,,49323,,"7,045.87 x patient days",49323,Per diem,,32729,,"4,675.50 x patient days",32729,Per diem,,32729,,"4,675.50 x patient days",32729,Per diem,,19029,,"2,718.31 x patient days",19029,Per diem,,0.01,49323,
"Neonate, birthwt >2499g w resp dist synd/oth maj resp cond",634-3,APR-DRG,,,,,,,,inpatient,,,563011.08,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,28315,,"4,044.85 x patient days",28315,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,62237,,"27,634 x DRG weight",62237,Other,base rate x DRG weight,52900,,"23,488 x DRG weight",52900,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,15223,,"2,174.65 x patient days",15223,Per diem,,15223,,"2,174.65 x patient days",15223,Per diem,,15223,,"2,174.65 x patient days",15223,Per diem,,15223,,"2,174.65 x patient days",15223,Per diem,,34252,,"4,892.96 x patient days",34252,Per diem,,23291,,"3,327.21 x patient days",23291,Per diem,,34252,,"4,892.96 x patient days",34252,Per diem,,21312,,"3,044.51 x patient days",21312,Per diem,,34252,,"4,892.96 x patient days",34252,Per diem,,41863,,"5,980.29 x patient days",41863,Per diem,,49323,,"7,045.87 x patient days",49323,Per diem,,32729,,"4,675.50 x patient days",32729,Per diem,,32729,,"4,675.50 x patient days",32729,Per diem,,19029,,"2,718.31 x patient days",19029,Per diem,,0.01,62237,
"Neonate, birthwt >2499g w resp dist synd/oth maj resp cond",634-4,APR-DRG,,,,,,,,inpatient,,,1081304.96,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,28315,,"4,044.85 x patient days",28315,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,111462,,"27,634 x DRG weight",111462,Other,base rate x DRG weight,94739,,"23,488 x DRG weight",94739,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,15223,,"2,174.65 x patient days",15223,Per diem,,15223,,"2,174.65 x patient days",15223,Per diem,,15223,,"2,174.65 x patient days",15223,Per diem,,15223,,"2,174.65 x patient days",15223,Per diem,,34252,,"4,892.96 x patient days",34252,Per diem,,23291,,"3,327.21 x patient days",23291,Per diem,,34252,,"4,892.96 x patient days",34252,Per diem,,21312,,"3,044.51 x patient days",21312,Per diem,,34252,,"4,892.96 x patient days",34252,Per diem,,41863,,"5,980.29 x patient days",41863,Per diem,,49323,,"7,045.87 x patient days",49323,Per diem,,32729,,"4,675.50 x patient days",32729,Per diem,,32729,,"4,675.50 x patient days",32729,Per diem,,19029,,"2,718.31 x patient days",19029,Per diem,,0.01,111462,
Neonate birthwt >2499g w congenital/perinatal infection,636-1,APR-DRG,,,,,,,,inpatient,,,104221.67,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,24269,,"4,044.85 x patient days",24269,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,27286,,"27,634 x DRG weight",27286,Other,base rate x DRG weight,23192,,"23,488 x DRG weight",23192,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,13048,,"2,174.65 x patient days",13048,Per diem,,13048,,"2,174.65 x patient days",13048,Per diem,,13048,,"2,174.65 x patient days",13048,Per diem,,13048,,"2,174.65 x patient days",13048,Per diem,,29358,,"4,892.96 x patient days",29358,Per diem,,19963,,"3,327.21 x patient days",19963,Per diem,,29358,,"4,892.96 x patient days",29358,Per diem,,18267,,"3,044.51 x patient days",18267,Per diem,,29358,,"4,892.96 x patient days",29358,Per diem,,35882,,"5,980.29 x patient days",35882,Per diem,,42276,,"7,045.87 x patient days",42276,Per diem,,28053,,"4,675.50 x patient days",28053,Per diem,,28053,,"4,675.50 x patient days",28053,Per diem,,16310,,"2,718.31 x patient days",16310,Per diem,,0.01,42276,
Neonate birthwt >2499g w congenital/perinatal infection,636-2,APR-DRG,,,,,,,,inpatient,,,109625,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,24269,,"4,044.85 x patient days",24269,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,37030,,"27,634 x DRG weight",37030,Other,base rate x DRG weight,31474,,"23,488 x DRG weight",31474,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,13048,,"2,174.65 x patient days",13048,Per diem,,13048,,"2,174.65 x patient days",13048,Per diem,,13048,,"2,174.65 x patient days",13048,Per diem,,13048,,"2,174.65 x patient days",13048,Per diem,,29358,,"4,892.96 x patient days",29358,Per diem,,19963,,"3,327.21 x patient days",19963,Per diem,,29358,,"4,892.96 x patient days",29358,Per diem,,18267,,"3,044.51 x patient days",18267,Per diem,,29358,,"4,892.96 x patient days",29358,Per diem,,35882,,"5,980.29 x patient days",35882,Per diem,,42276,,"7,045.87 x patient days",42276,Per diem,,28053,,"4,675.50 x patient days",28053,Per diem,,28053,,"4,675.50 x patient days",28053,Per diem,,16310,,"2,718.31 x patient days",16310,Per diem,,0.01,42276,
Neonate birthwt >2499g w congenital/perinatal infection,636-3,APR-DRG,,,,,,,,inpatient,,,558449.5,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,24269,,"4,044.85 x patient days",24269,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,56846,,"27,634 x DRG weight",56846,Other,base rate x DRG weight,48317,,"23,488 x DRG weight",48317,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,13048,,"2,174.65 x patient days",13048,Per diem,,13048,,"2,174.65 x patient days",13048,Per diem,,13048,,"2,174.65 x patient days",13048,Per diem,,13048,,"2,174.65 x patient days",13048,Per diem,,29358,,"4,892.96 x patient days",29358,Per diem,,19963,,"3,327.21 x patient days",19963,Per diem,,29358,,"4,892.96 x patient days",29358,Per diem,,18267,,"3,044.51 x patient days",18267,Per diem,,29358,,"4,892.96 x patient days",29358,Per diem,,35882,,"5,980.29 x patient days",35882,Per diem,,42276,,"7,045.87 x patient days",42276,Per diem,,28053,,"4,675.50 x patient days",28053,Per diem,,28053,,"4,675.50 x patient days",28053,Per diem,,16310,,"2,718.31 x patient days",16310,Per diem,,0.01,56846,
Neonate birthwt >2499g w congenital/perinatal infection,636-4,APR-DRG,,,,,,,,inpatient,,,558449.5,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,24269,,"4,044.85 x patient days",24269,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,74106,,"27,634 x DRG weight",74106,Other,base rate x DRG weight,62988,,"23,488 x DRG weight",62988,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,13048,,"2,174.65 x patient days",13048,Per diem,,13048,,"2,174.65 x patient days",13048,Per diem,,13048,,"2,174.65 x patient days",13048,Per diem,,13048,,"2,174.65 x patient days",13048,Per diem,,29358,,"4,892.96 x patient days",29358,Per diem,,19963,,"3,327.21 x patient days",19963,Per diem,,29358,,"4,892.96 x patient days",29358,Per diem,,18267,,"3,044.51 x patient days",18267,Per diem,,29358,,"4,892.96 x patient days",29358,Per diem,,35882,,"5,980.29 x patient days",35882,Per diem,,42276,,"7,045.87 x patient days",42276,Per diem,,28053,,"4,675.50 x patient days",28053,Per diem,,28053,,"4,675.50 x patient days",28053,Per diem,,16310,,"2,718.31 x patient days",16310,Per diem,,0.01,74106,
Neonate birthwt >2499g w other significant condition,639-1,APR-DRG,,,,,,,,inpatient,,,151058.21,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,20224,,"4,044.85 x patient days",20224,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,14251,,"27,634 x DRG weight",14251,Other,base rate x DRG weight,12113,,"23,488 x DRG weight",12113,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,16636,,"3,327.21 x patient days",16636,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,15222,,"3,044.51 x patient days",15222,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,29901,,"5,980.29 x patient days",29901,Per diem,,35229,,"7,045.87 x patient days",35229,Per diem,,23377,,"4,675.50 x patient days",23377,Per diem,,23377,,"4,675.50 x patient days",23377,Per diem,,13591,,"2,718.31 x patient days",13591,Per diem,,0.01,35229,
Neonate birthwt >2499g w other significant condition,639-2,APR-DRG,,,,,,,,inpatient,,,441914.76,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,20224,,"4,044.85 x patient days",20224,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,35830,,"27,634 x DRG weight",35830,Other,base rate x DRG weight,30455,,"23,488 x DRG weight",30455,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,16636,,"3,327.21 x patient days",16636,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,15222,,"3,044.51 x patient days",15222,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,29901,,"5,980.29 x patient days",29901,Per diem,,35229,,"7,045.87 x patient days",35229,Per diem,,23377,,"4,675.50 x patient days",23377,Per diem,,23377,,"4,675.50 x patient days",23377,Per diem,,13591,,"2,718.31 x patient days",13591,Per diem,,0.01,35830,
Neonate birthwt >2499g w other significant condition,639-3,APR-DRG,,,,,,,,inpatient,,,433889.25,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,20224,,"4,044.85 x patient days",20224,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,51501,,"27,634 x DRG weight",51501,Other,base rate x DRG weight,43775,,"23,488 x DRG weight",43775,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,16636,,"3,327.21 x patient days",16636,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,15222,,"3,044.51 x patient days",15222,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,29901,,"5,980.29 x patient days",29901,Per diem,,35229,,"7,045.87 x patient days",35229,Per diem,,23377,,"4,675.50 x patient days",23377,Per diem,,23377,,"4,675.50 x patient days",23377,Per diem,,13591,,"2,718.31 x patient days",13591,Per diem,,0.01,51501,
Neonate birthwt >2499g w other significant condition,639-4,APR-DRG,,,,,,,,inpatient,,,3810096.82,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,20224,,"4,044.85 x patient days",20224,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,105957,,"27,634 x DRG weight",105957,Other,base rate x DRG weight,90060,,"23,488 x DRG weight",90060,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,16636,,"3,327.21 x patient days",16636,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,15222,,"3,044.51 x patient days",15222,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,29901,,"5,980.29 x patient days",29901,Per diem,,35229,,"7,045.87 x patient days",35229,Per diem,,23377,,"4,675.50 x patient days",23377,Per diem,,23377,,"4,675.50 x patient days",23377,Per diem,,13591,,"2,718.31 x patient days",13591,Per diem,,0.01,105957,
"Neonate birthwt >2499g, normal newborn or neonate w other problem",640-1,APR-DRG,,,,,,,,inpatient,,,22137.41,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8089,,"4,044.85 x patient days",8089,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,4833,,"27,634 x DRG weight",4833,Other,base rate x DRG weight,4108,,"23,488 x DRG weight",4108,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6654,,"3,327.21 x patient days",6654,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6089,,"3,044.51 x patient days",6089,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,11960,,"5,980.29 x patient days",11960,Per diem,,14091,,"7,045.87 x patient days",14091,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,5436,,"2,718.31 x patient days",5436,Per diem,,0.01,14091,
"Neonate birthwt >2499g, normal newborn or neonate w other problem",640-2,APR-DRG,,,,,,,,inpatient,,,37661,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8089,,"4,044.85 x patient days",8089,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6715,,"27,634 x DRG weight",6715,Other,base rate x DRG weight,5708,,"23,488 x DRG weight",5708,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6654,,"3,327.21 x patient days",6654,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6089,,"3,044.51 x patient days",6089,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,11960,,"5,980.29 x patient days",11960,Per diem,,14091,,"7,045.87 x patient days",14091,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,5436,,"2,718.31 x patient days",5436,Per diem,,0.01,14091,
"Neonate birthwt >2499g, normal newborn or neonate w other problem",640-3,APR-DRG,,,,,,,,inpatient,,,130270.39,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8089,,"4,044.85 x patient days",8089,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,14925,,"27,634 x DRG weight",14925,Other,base rate x DRG weight,12686,,"23,488 x DRG weight",12686,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6654,,"3,327.21 x patient days",6654,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6089,,"3,044.51 x patient days",6089,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,11960,,"5,980.29 x patient days",11960,Per diem,,14091,,"7,045.87 x patient days",14091,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,5436,,"2,718.31 x patient days",5436,Per diem,,0.01,14925,
"Neonate birthwt >2499g, normal newborn or neonate w other problem",640-4,APR-DRG,,,,,,,,inpatient,,,130270.39,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8089,,"4,044.85 x patient days",8089,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,14942,,"27,634 x DRG weight",14942,Other,base rate x DRG weight,12700,,"23,488 x DRG weight",12700,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6654,,"3,327.21 x patient days",6654,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6089,,"3,044.51 x patient days",6089,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,11960,,"5,980.29 x patient days",11960,Per diem,,14091,,"7,045.87 x patient days",14091,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,5436,,"2,718.31 x patient days",5436,Per diem,,0.01,14942,
Splenectomy,650-1,APR-DRG,,,,,,,,inpatient,,,81755.94,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,24269,,"4,044.85 x patient days",24269,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,35905,,"27,634 x DRG weight",35905,Other,base rate x DRG weight,30518,,"23,488 x DRG weight",30518,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,13048,,"2,174.65 x patient days",13048,Per diem,,13048,,"2,174.65 x patient days",13048,Per diem,,13048,,"2,174.65 x patient days",13048,Per diem,,13048,,"2,174.65 x patient days",13048,Per diem,,29358,,"4,892.96 x patient days",29358,Per diem,,19963,,"3,327.21 x patient days",19963,Per diem,,29358,,"4,892.96 x patient days",29358,Per diem,,18267,,"3,044.51 x patient days",18267,Per diem,,29358,,"4,892.96 x patient days",29358,Per diem,,35882,,"5,980.29 x patient days",35882,Per diem,,42276,,"7,045.87 x patient days",42276,Per diem,,28053,,"4,675.50 x patient days",28053,Per diem,,28053,,"4,675.50 x patient days",28053,Per diem,,16310,,"2,718.31 x patient days",16310,Per diem,,0.01,42276,
Splenectomy,650-2,APR-DRG,,,,,,,,inpatient,,,134326.23,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,24269,,"4,044.85 x patient days",24269,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,54837,,"27,634 x DRG weight",54837,Other,base rate x DRG weight,46610,,"23,488 x DRG weight",46610,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,13048,,"2,174.65 x patient days",13048,Per diem,,13048,,"2,174.65 x patient days",13048,Per diem,,13048,,"2,174.65 x patient days",13048,Per diem,,13048,,"2,174.65 x patient days",13048,Per diem,,29358,,"4,892.96 x patient days",29358,Per diem,,19963,,"3,327.21 x patient days",19963,Per diem,,29358,,"4,892.96 x patient days",29358,Per diem,,18267,,"3,044.51 x patient days",18267,Per diem,,29358,,"4,892.96 x patient days",29358,Per diem,,35882,,"5,980.29 x patient days",35882,Per diem,,42276,,"7,045.87 x patient days",42276,Per diem,,28053,,"4,675.50 x patient days",28053,Per diem,,28053,,"4,675.50 x patient days",28053,Per diem,,16310,,"2,718.31 x patient days",16310,Per diem,,0.01,54837,
Splenectomy,650-3,APR-DRG,,,,,,,,inpatient,,,245187.35,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,24269,,"4,044.85 x patient days",24269,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,66081,,"27,634 x DRG weight",66081,Other,base rate x DRG weight,56167,,"23,488 x DRG weight",56167,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,13048,,"2,174.65 x patient days",13048,Per diem,,13048,,"2,174.65 x patient days",13048,Per diem,,13048,,"2,174.65 x patient days",13048,Per diem,,13048,,"2,174.65 x patient days",13048,Per diem,,29358,,"4,892.96 x patient days",29358,Per diem,,19963,,"3,327.21 x patient days",19963,Per diem,,29358,,"4,892.96 x patient days",29358,Per diem,,18267,,"3,044.51 x patient days",18267,Per diem,,29358,,"4,892.96 x patient days",29358,Per diem,,35882,,"5,980.29 x patient days",35882,Per diem,,42276,,"7,045.87 x patient days",42276,Per diem,,28053,,"4,675.50 x patient days",28053,Per diem,,28053,,"4,675.50 x patient days",28053,Per diem,,16310,,"2,718.31 x patient days",16310,Per diem,,0.01,66081,
Splenectomy,650-4,APR-DRG,,,,,,,,inpatient,,,526890.28,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,24269,,"4,044.85 x patient days",24269,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,157597,,"27,634 x DRG weight",157597,Other,base rate x DRG weight,133952,,"23,488 x DRG weight",133952,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,13048,,"2,174.65 x patient days",13048,Per diem,,13048,,"2,174.65 x patient days",13048,Per diem,,13048,,"2,174.65 x patient days",13048,Per diem,,13048,,"2,174.65 x patient days",13048,Per diem,,29358,,"4,892.96 x patient days",29358,Per diem,,19963,,"3,327.21 x patient days",19963,Per diem,,29358,,"4,892.96 x patient days",29358,Per diem,,18267,,"3,044.51 x patient days",18267,Per diem,,29358,,"4,892.96 x patient days",29358,Per diem,,35882,,"5,980.29 x patient days",35882,Per diem,,42276,,"7,045.87 x patient days",42276,Per diem,,28053,,"4,675.50 x patient days",28053,Per diem,,28053,,"4,675.50 x patient days",28053,Per diem,,16310,,"2,718.31 x patient days",16310,Per diem,,0.01,157597,
Other procedures of blood & blood-forming organs,651-1,APR-DRG,,,,,,,,inpatient,,,149993.23,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,20224,,"4,044.85 x patient days",20224,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,28775,,"27,634 x DRG weight",28775,Other,base rate x DRG weight,24458,,"23,488 x DRG weight",24458,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,16636,,"3,327.21 x patient days",16636,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,15222,,"3,044.51 x patient days",15222,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,29901,,"5,980.29 x patient days",29901,Per diem,,35229,,"7,045.87 x patient days",35229,Per diem,,23377,,"4,675.50 x patient days",23377,Per diem,,23377,,"4,675.50 x patient days",23377,Per diem,,13591,,"2,718.31 x patient days",13591,Per diem,,0.01,35229,
Other procedures of blood & blood-forming organs,651-2,APR-DRG,,,,,,,,inpatient,,,138054.72,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,20224,,"4,044.85 x patient days",20224,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,38160,,"27,634 x DRG weight",38160,Other,base rate x DRG weight,32435,,"23,488 x DRG weight",32435,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,16636,,"3,327.21 x patient days",16636,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,15222,,"3,044.51 x patient days",15222,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,29901,,"5,980.29 x patient days",29901,Per diem,,35229,,"7,045.87 x patient days",35229,Per diem,,23377,,"4,675.50 x patient days",23377,Per diem,,23377,,"4,675.50 x patient days",23377,Per diem,,13591,,"2,718.31 x patient days",13591,Per diem,,0.01,38160,
Other procedures of blood & blood-forming organs,651-3,APR-DRG,,,,,,,,inpatient,,,470320.8,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,20224,,"4,044.85 x patient days",20224,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,72045,,"27,634 x DRG weight",72045,Other,base rate x DRG weight,61236,,"23,488 x DRG weight",61236,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,16636,,"3,327.21 x patient days",16636,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,15222,,"3,044.51 x patient days",15222,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,29901,,"5,980.29 x patient days",29901,Per diem,,35229,,"7,045.87 x patient days",35229,Per diem,,23377,,"4,675.50 x patient days",23377,Per diem,,23377,,"4,675.50 x patient days",23377,Per diem,,13591,,"2,718.31 x patient days",13591,Per diem,,0.01,72045,
Other procedures of blood & blood-forming organs,651-4,APR-DRG,,,,,,,,inpatient,,,5226480.17,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,20224,,"4,044.85 x patient days",20224,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,104233,,"27,634 x DRG weight",104233,Other,base rate x DRG weight,88594,,"23,488 x DRG weight",88594,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,16636,,"3,327.21 x patient days",16636,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,15222,,"3,044.51 x patient days",15222,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,29901,,"5,980.29 x patient days",29901,Per diem,,35229,,"7,045.87 x patient days",35229,Per diem,,23377,,"4,675.50 x patient days",23377,Per diem,,23377,,"4,675.50 x patient days",23377,Per diem,,13591,,"2,718.31 x patient days",13591,Per diem,,0.01,104233,
Major hematologic/immunologic diag exc sickle cell crisis & coagul,660-1,APR-DRG,,,,,,,,inpatient,,,252504.02,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,20224,,"4,044.85 x patient days",20224,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,19269,,"27,634 x DRG weight",19269,Other,base rate x DRG weight,16378,,"23,488 x DRG weight",16378,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,16636,,"3,327.21 x patient days",16636,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,15222,,"3,044.51 x patient days",15222,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,29901,,"5,980.29 x patient days",29901,Per diem,,35229,,"7,045.87 x patient days",35229,Per diem,,23377,,"4,675.50 x patient days",23377,Per diem,,23377,,"4,675.50 x patient days",23377,Per diem,,13591,,"2,718.31 x patient days",13591,Per diem,,0.01,35229,
Major hematologic/immunologic diag exc sickle cell crisis & coagul,660-2,APR-DRG,,,,,,,,inpatient,,,171773.58,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,20224,,"4,044.85 x patient days",20224,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,24868,,"27,634 x DRG weight",24868,Other,base rate x DRG weight,21137,,"23,488 x DRG weight",21137,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,16636,,"3,327.21 x patient days",16636,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,15222,,"3,044.51 x patient days",15222,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,29901,,"5,980.29 x patient days",29901,Per diem,,35229,,"7,045.87 x patient days",35229,Per diem,,23377,,"4,675.50 x patient days",23377,Per diem,,23377,,"4,675.50 x patient days",23377,Per diem,,13591,,"2,718.31 x patient days",13591,Per diem,,0.01,35229,
Major hematologic/immunologic diag exc sickle cell crisis & coagul,660-3,APR-DRG,,,,,,,,inpatient,,,208287.4,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,20224,,"4,044.85 x patient days",20224,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,42051,,"27,634 x DRG weight",42051,Other,base rate x DRG weight,35742,,"23,488 x DRG weight",35742,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,16636,,"3,327.21 x patient days",16636,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,15222,,"3,044.51 x patient days",15222,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,29901,,"5,980.29 x patient days",29901,Per diem,,35229,,"7,045.87 x patient days",35229,Per diem,,23377,,"4,675.50 x patient days",23377,Per diem,,23377,,"4,675.50 x patient days",23377,Per diem,,13591,,"2,718.31 x patient days",13591,Per diem,,0.01,42051,
Major hematologic/immunologic diag exc sickle cell crisis & coagul,660-4,APR-DRG,,,,,,,,inpatient,,,344483.25,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,20224,,"4,044.85 x patient days",20224,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,137562,,"27,634 x DRG weight",137562,Other,base rate x DRG weight,116923,,"23,488 x DRG weight",116923,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,16636,,"3,327.21 x patient days",16636,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,15222,,"3,044.51 x patient days",15222,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,29901,,"5,980.29 x patient days",29901,Per diem,,35229,,"7,045.87 x patient days",35229,Per diem,,23377,,"4,675.50 x patient days",23377,Per diem,,23377,,"4,675.50 x patient days",23377,Per diem,,13591,,"2,718.31 x patient days",13591,Per diem,,0.01,137562,
Coagulation & platelet disorders,661-1,APR-DRG,,,,,,,,inpatient,,,63070.67,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,16180,,"4,044.85 x patient days",16180,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,27899,,"27,634 x DRG weight",27899,Other,base rate x DRG weight,23713,,"23,488 x DRG weight",23713,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,13309,,"3,327.21 x patient days",13309,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,12179,,"3,044.51 x patient days",12179,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,23922,,"5,980.29 x patient days",23922,Per diem,,28185,,"7,045.87 x patient days",28185,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,10874,,"2,718.31 x patient days",10874,Per diem,,0.01,28185,
Coagulation & platelet disorders,661-2,APR-DRG,,,,,,,,inpatient,,,105753.81,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,16180,,"4,044.85 x patient days",16180,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,32768,,"27,634 x DRG weight",32768,Other,base rate x DRG weight,27852,,"23,488 x DRG weight",27852,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,13309,,"3,327.21 x patient days",13309,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,12179,,"3,044.51 x patient days",12179,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,23922,,"5,980.29 x patient days",23922,Per diem,,28185,,"7,045.87 x patient days",28185,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,10874,,"2,718.31 x patient days",10874,Per diem,,0.01,32768,
Coagulation & platelet disorders,661-3,APR-DRG,,,,,,,,inpatient,,,154412.12,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,16180,,"4,044.85 x patient days",16180,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,54047,,"27,634 x DRG weight",54047,Other,base rate x DRG weight,45938,,"23,488 x DRG weight",45938,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,13309,,"3,327.21 x patient days",13309,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,12179,,"3,044.51 x patient days",12179,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,23922,,"5,980.29 x patient days",23922,Per diem,,28185,,"7,045.87 x patient days",28185,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,10874,,"2,718.31 x patient days",10874,Per diem,,0.01,54047,
Coagulation & platelet disorders,661-4,APR-DRG,,,,,,,,inpatient,,,801302.4,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,16180,,"4,044.85 x patient days",16180,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,126180,,"27,634 x DRG weight",126180,Other,base rate x DRG weight,107249,,"23,488 x DRG weight",107249,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,13309,,"3,327.21 x patient days",13309,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,12179,,"3,044.51 x patient days",12179,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,23922,,"5,980.29 x patient days",23922,Per diem,,28185,,"7,045.87 x patient days",28185,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,10874,,"2,718.31 x patient days",10874,Per diem,,0.01,126180,
Sickle cell anemia crisis,662-1,APR-DRG,,,,,,,,inpatient,,,104438.37,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,20224,,"4,044.85 x patient days",20224,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,18482,,"27,634 x DRG weight",18482,Other,base rate x DRG weight,15709,,"23,488 x DRG weight",15709,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,16636,,"3,327.21 x patient days",16636,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,15222,,"3,044.51 x patient days",15222,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,29901,,"5,980.29 x patient days",29901,Per diem,,35229,,"7,045.87 x patient days",35229,Per diem,,23377,,"4,675.50 x patient days",23377,Per diem,,23377,,"4,675.50 x patient days",23377,Per diem,,13591,,"2,718.31 x patient days",13591,Per diem,,0.01,35229,
Sickle cell anemia crisis,662-2,APR-DRG,,,,,,,,inpatient,,,170158.57,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,20224,,"4,044.85 x patient days",20224,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,26672,,"27,634 x DRG weight",26672,Other,base rate x DRG weight,22671,,"23,488 x DRG weight",22671,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,16636,,"3,327.21 x patient days",16636,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,15222,,"3,044.51 x patient days",15222,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,29901,,"5,980.29 x patient days",29901,Per diem,,35229,,"7,045.87 x patient days",35229,Per diem,,23377,,"4,675.50 x patient days",23377,Per diem,,23377,,"4,675.50 x patient days",23377,Per diem,,13591,,"2,718.31 x patient days",13591,Per diem,,0.01,35229,
Sickle cell anemia crisis,662-3,APR-DRG,,,,,,,,inpatient,,,231736.07,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,20224,,"4,044.85 x patient days",20224,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,42576,,"27,634 x DRG weight",42576,Other,base rate x DRG weight,36188,,"23,488 x DRG weight",36188,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,16636,,"3,327.21 x patient days",16636,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,15222,,"3,044.51 x patient days",15222,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,29901,,"5,980.29 x patient days",29901,Per diem,,35229,,"7,045.87 x patient days",35229,Per diem,,23377,,"4,675.50 x patient days",23377,Per diem,,23377,,"4,675.50 x patient days",23377,Per diem,,13591,,"2,718.31 x patient days",13591,Per diem,,0.01,42576,
Sickle cell anemia crisis,662-4,APR-DRG,,,,,,,,inpatient,,,510760.39,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,20224,,"4,044.85 x patient days",20224,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,91532,,"27,634 x DRG weight",91532,Other,base rate x DRG weight,77799,,"23,488 x DRG weight",77799,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,16636,,"3,327.21 x patient days",16636,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,15222,,"3,044.51 x patient days",15222,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,29901,,"5,980.29 x patient days",29901,Per diem,,35229,,"7,045.87 x patient days",35229,Per diem,,23377,,"4,675.50 x patient days",23377,Per diem,,23377,,"4,675.50 x patient days",23377,Per diem,,13591,,"2,718.31 x patient days",13591,Per diem,,0.01,91532,
Other anemia & disorders of blood & blood-forming organs,663-1,APR-DRG,,,,,,,,inpatient,,,71386.2,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12135,,"4,044.85 x patient days",12135,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,14185,,"27,634 x DRG weight",14185,Other,base rate x DRG weight,12056,,"23,488 x DRG weight",12056,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9982,,"3,327.21 x patient days",9982,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9134,,"3,044.51 x patient days",9134,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,17941,,"5,980.29 x patient days",17941,Per diem,,21138,,"7,045.87 x patient days",21138,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,8155,,"2,718.31 x patient days",8155,Per diem,,0.01,21138,
Other anemia & disorders of blood & blood-forming organs,663-2,APR-DRG,,,,,,,,inpatient,,,99629.92,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12135,,"4,044.85 x patient days",12135,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,19471,,"27,634 x DRG weight",19471,Other,base rate x DRG weight,16550,,"23,488 x DRG weight",16550,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9982,,"3,327.21 x patient days",9982,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9134,,"3,044.51 x patient days",9134,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,17941,,"5,980.29 x patient days",17941,Per diem,,21138,,"7,045.87 x patient days",21138,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,8155,,"2,718.31 x patient days",8155,Per diem,,0.01,21138,
Other anemia & disorders of blood & blood-forming organs,663-3,APR-DRG,,,,,,,,inpatient,,,162030.83,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12135,,"4,044.85 x patient days",12135,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,30685,,"27,634 x DRG weight",30685,Other,base rate x DRG weight,26081,,"23,488 x DRG weight",26081,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9982,,"3,327.21 x patient days",9982,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9134,,"3,044.51 x patient days",9134,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,17941,,"5,980.29 x patient days",17941,Per diem,,21138,,"7,045.87 x patient days",21138,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,8155,,"2,718.31 x patient days",8155,Per diem,,0.01,30685,
Other anemia & disorders of blood & blood-forming organs,663-4,APR-DRG,,,,,,,,inpatient,,,575292.01,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12135,,"4,044.85 x patient days",12135,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,65089,,"27,634 x DRG weight",65089,Other,base rate x DRG weight,55324,,"23,488 x DRG weight",55324,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9982,,"3,327.21 x patient days",9982,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9134,,"3,044.51 x patient days",9134,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,17941,,"5,980.29 x patient days",17941,Per diem,,21138,,"7,045.87 x patient days",21138,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,8155,,"2,718.31 x patient days",8155,Per diem,,0.01,65089,
Major O.R. procedures for lymphatic/hematopoietic/other neoplasms,680-1,APR-DRG,,,,,,,,inpatient,,,81015.57,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,44493,,"4,044.85 x patient days",44493,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,38245,,"27,634 x DRG weight",38245,Other,base rate x DRG weight,32507,,"23,488 x DRG weight",32507,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,23921,,"2,174.65 x patient days",23921,Per diem,,23921,,"2,174.65 x patient days",23921,Per diem,,23921,,"2,174.65 x patient days",23921,Per diem,,23921,,"2,174.65 x patient days",23921,Per diem,,53822,,"4,892.96 x patient days",53822,Per diem,,36599,,"3,327.21 x patient days",36599,Per diem,,53822,,"4,892.96 x patient days",53822,Per diem,,33489,,"3,044.51 x patient days",33489,Per diem,,53822,,"4,892.96 x patient days",53822,Per diem,,65783,,"5,980.29 x patient days",65783,Per diem,,77504,,"7,045.87 x patient days",77504,Per diem,,51430,,"4,675.50 x patient days",51430,Per diem,,51430,,"4,675.50 x patient days",51430,Per diem,,29901,,"2,718.31 x patient days",29901,Per diem,,0.01,77504,
Major O.R. procedures for lymphatic/hematopoietic/other neoplasms,680-2,APR-DRG,,,,,,,,inpatient,,,570412.22,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,44493,,"4,044.85 x patient days",44493,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,60289,,"27,634 x DRG weight",60289,Other,base rate x DRG weight,51244,,"23,488 x DRG weight",51244,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,23921,,"2,174.65 x patient days",23921,Per diem,,23921,,"2,174.65 x patient days",23921,Per diem,,23921,,"2,174.65 x patient days",23921,Per diem,,23921,,"2,174.65 x patient days",23921,Per diem,,53822,,"4,892.96 x patient days",53822,Per diem,,36599,,"3,327.21 x patient days",36599,Per diem,,53822,,"4,892.96 x patient days",53822,Per diem,,33489,,"3,044.51 x patient days",33489,Per diem,,53822,,"4,892.96 x patient days",53822,Per diem,,65783,,"5,980.29 x patient days",65783,Per diem,,77504,,"7,045.87 x patient days",77504,Per diem,,51430,,"4,675.50 x patient days",51430,Per diem,,51430,,"4,675.50 x patient days",51430,Per diem,,29901,,"2,718.31 x patient days",29901,Per diem,,0.01,77504,
Major O.R. procedures for lymphatic/hematopoietic/other neoplasms,680-3,APR-DRG,,,,,,,,inpatient,,,456927.81,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,44493,,"4,044.85 x patient days",44493,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,106908,,"27,634 x DRG weight",106908,Other,base rate x DRG weight,90868,,"23,488 x DRG weight",90868,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,23921,,"2,174.65 x patient days",23921,Per diem,,23921,,"2,174.65 x patient days",23921,Per diem,,23921,,"2,174.65 x patient days",23921,Per diem,,23921,,"2,174.65 x patient days",23921,Per diem,,53822,,"4,892.96 x patient days",53822,Per diem,,36599,,"3,327.21 x patient days",36599,Per diem,,53822,,"4,892.96 x patient days",53822,Per diem,,33489,,"3,044.51 x patient days",33489,Per diem,,53822,,"4,892.96 x patient days",53822,Per diem,,65783,,"5,980.29 x patient days",65783,Per diem,,77504,,"7,045.87 x patient days",77504,Per diem,,51430,,"4,675.50 x patient days",51430,Per diem,,51430,,"4,675.50 x patient days",51430,Per diem,,29901,,"2,718.31 x patient days",29901,Per diem,,0.01,106908,
Major O.R. procedures for lymphatic/hematopoietic/other neoplasms,680-4,APR-DRG,,,,,,,,inpatient,,,1626126.18,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,44493,,"4,044.85 x patient days",44493,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,247222,,"27,634 x DRG weight",247222,Other,base rate x DRG weight,210131,,"23,488 x DRG weight",210131,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,23921,,"2,174.65 x patient days",23921,Per diem,,23921,,"2,174.65 x patient days",23921,Per diem,,23921,,"2,174.65 x patient days",23921,Per diem,,23921,,"2,174.65 x patient days",23921,Per diem,,53822,,"4,892.96 x patient days",53822,Per diem,,36599,,"3,327.21 x patient days",36599,Per diem,,53822,,"4,892.96 x patient days",53822,Per diem,,33489,,"3,044.51 x patient days",33489,Per diem,,53822,,"4,892.96 x patient days",53822,Per diem,,65783,,"5,980.29 x patient days",65783,Per diem,,77504,,"7,045.87 x patient days",77504,Per diem,,51430,,"4,675.50 x patient days",51430,Per diem,,51430,,"4,675.50 x patient days",51430,Per diem,,29901,,"2,718.31 x patient days",29901,Per diem,,0.01,247222,
Other O.R. procedures for lymphatic/hematopoietic/other neoplasms,681-1,APR-DRG,,,,,,,,inpatient,,,306613.95,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,36404,,"4,044.85 x patient days",36404,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,26203,,"27,634 x DRG weight",26203,Other,base rate x DRG weight,22271,,"23,488 x DRG weight",22271,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,19572,,"2,174.65 x patient days",19572,Per diem,,19572,,"2,174.65 x patient days",19572,Per diem,,19572,,"2,174.65 x patient days",19572,Per diem,,19572,,"2,174.65 x patient days",19572,Per diem,,44037,,"4,892.96 x patient days",44037,Per diem,,29945,,"3,327.21 x patient days",29945,Per diem,,44037,,"4,892.96 x patient days",44037,Per diem,,27401,,"3,044.51 x patient days",27401,Per diem,,44037,,"4,892.96 x patient days",44037,Per diem,,53823,,"5,980.29 x patient days",53823,Per diem,,63413,,"7,045.87 x patient days",63413,Per diem,,42080,,"4,675.50 x patient days",42080,Per diem,,42080,,"4,675.50 x patient days",42080,Per diem,,24465,,"2,718.31 x patient days",24465,Per diem,,0.01,63413,
Other O.R. procedures for lymphatic/hematopoietic/other neoplasms,681-2,APR-DRG,,,,,,,,inpatient,,,535313.46,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,36404,,"4,044.85 x patient days",36404,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,43814,,"27,634 x DRG weight",43814,Other,base rate x DRG weight,37240,,"23,488 x DRG weight",37240,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,19572,,"2,174.65 x patient days",19572,Per diem,,19572,,"2,174.65 x patient days",19572,Per diem,,19572,,"2,174.65 x patient days",19572,Per diem,,19572,,"2,174.65 x patient days",19572,Per diem,,44037,,"4,892.96 x patient days",44037,Per diem,,29945,,"3,327.21 x patient days",29945,Per diem,,44037,,"4,892.96 x patient days",44037,Per diem,,27401,,"3,044.51 x patient days",27401,Per diem,,44037,,"4,892.96 x patient days",44037,Per diem,,53823,,"5,980.29 x patient days",53823,Per diem,,63413,,"7,045.87 x patient days",63413,Per diem,,42080,,"4,675.50 x patient days",42080,Per diem,,42080,,"4,675.50 x patient days",42080,Per diem,,24465,,"2,718.31 x patient days",24465,Per diem,,0.01,63413,
Other O.R. procedures for lymphatic/hematopoietic/other neoplasms,681-3,APR-DRG,,,,,,,,inpatient,,,1036518.43,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,36404,,"4,044.85 x patient days",36404,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,105543,,"27,634 x DRG weight",105543,Other,base rate x DRG weight,89708,,"23,488 x DRG weight",89708,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,19572,,"2,174.65 x patient days",19572,Per diem,,19572,,"2,174.65 x patient days",19572,Per diem,,19572,,"2,174.65 x patient days",19572,Per diem,,19572,,"2,174.65 x patient days",19572,Per diem,,44037,,"4,892.96 x patient days",44037,Per diem,,29945,,"3,327.21 x patient days",29945,Per diem,,44037,,"4,892.96 x patient days",44037,Per diem,,27401,,"3,044.51 x patient days",27401,Per diem,,44037,,"4,892.96 x patient days",44037,Per diem,,53823,,"5,980.29 x patient days",53823,Per diem,,63413,,"7,045.87 x patient days",63413,Per diem,,42080,,"4,675.50 x patient days",42080,Per diem,,42080,,"4,675.50 x patient days",42080,Per diem,,24465,,"2,718.31 x patient days",24465,Per diem,,0.01,105543,
Other O.R. procedures for lymphatic/hematopoietic/other neoplasms,681-4,APR-DRG,,,,,,,,inpatient,,,1888179.27,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,36404,,"4,044.85 x patient days",36404,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,247910,,"27,634 x DRG weight",247910,Other,base rate x DRG weight,210716,,"23,488 x DRG weight",210716,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,19572,,"2,174.65 x patient days",19572,Per diem,,19572,,"2,174.65 x patient days",19572,Per diem,,19572,,"2,174.65 x patient days",19572,Per diem,,19572,,"2,174.65 x patient days",19572,Per diem,,44037,,"4,892.96 x patient days",44037,Per diem,,29945,,"3,327.21 x patient days",29945,Per diem,,44037,,"4,892.96 x patient days",44037,Per diem,,27401,,"3,044.51 x patient days",27401,Per diem,,44037,,"4,892.96 x patient days",44037,Per diem,,53823,,"5,980.29 x patient days",53823,Per diem,,63413,,"7,045.87 x patient days",63413,Per diem,,42080,,"4,675.50 x patient days",42080,Per diem,,42080,,"4,675.50 x patient days",42080,Per diem,,24465,,"2,718.31 x patient days",24465,Per diem,,0.01,247910,
Acute leukemia,690-1,APR-DRG,,,,,,,,inpatient,,,52522,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,84942,,"4,044.85 x patient days",84942,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,36938,,"27,634 x DRG weight",36938,Other,base rate x DRG weight,31396,,"23,488 x DRG weight",31396,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,45668,,"2,174.65 x patient days",45668,Per diem,,45668,,"2,174.65 x patient days",45668,Per diem,,45668,,"2,174.65 x patient days",45668,Per diem,,45668,,"2,174.65 x patient days",45668,Per diem,,102753,,"4,892.96 x patient days",102753,Per diem,,69872,,"3,327.21 x patient days",69872,Per diem,,102753,,"4,892.96 x patient days",102753,Per diem,,63935,,"3,044.51 x patient days",63935,Per diem,,102753,,"4,892.96 x patient days",102753,Per diem,,125587,,"5,980.29 x patient days",125587,Per diem,,147964,,"7,045.87 x patient days",147964,Per diem,,98186,,"4,675.50 x patient days",98186,Per diem,,98186,,"4,675.50 x patient days",98186,Per diem,,57085,,"2,718.31 x patient days",57085,Per diem,,0.01,147964,
Acute leukemia,690-2,APR-DRG,,,,,,,,inpatient,,,634081.05,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,84942,,"4,044.85 x patient days",84942,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,75129,,"27,634 x DRG weight",75129,Other,base rate x DRG weight,63857,,"23,488 x DRG weight",63857,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,45668,,"2,174.65 x patient days",45668,Per diem,,45668,,"2,174.65 x patient days",45668,Per diem,,45668,,"2,174.65 x patient days",45668,Per diem,,45668,,"2,174.65 x patient days",45668,Per diem,,102753,,"4,892.96 x patient days",102753,Per diem,,69872,,"3,327.21 x patient days",69872,Per diem,,102753,,"4,892.96 x patient days",102753,Per diem,,63935,,"3,044.51 x patient days",63935,Per diem,,102753,,"4,892.96 x patient days",102753,Per diem,,125587,,"5,980.29 x patient days",125587,Per diem,,147964,,"7,045.87 x patient days",147964,Per diem,,98186,,"4,675.50 x patient days",98186,Per diem,,98186,,"4,675.50 x patient days",98186,Per diem,,57085,,"2,718.31 x patient days",57085,Per diem,,0.01,147964,
Acute leukemia,690-3,APR-DRG,,,,,,,,inpatient,,,702609.28,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,84942,,"4,044.85 x patient days",84942,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,167542,,"27,634 x DRG weight",167542,Other,base rate x DRG weight,142405,,"23,488 x DRG weight",142405,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,45668,,"2,174.65 x patient days",45668,Per diem,,45668,,"2,174.65 x patient days",45668,Per diem,,45668,,"2,174.65 x patient days",45668,Per diem,,45668,,"2,174.65 x patient days",45668,Per diem,,102753,,"4,892.96 x patient days",102753,Per diem,,69872,,"3,327.21 x patient days",69872,Per diem,,102753,,"4,892.96 x patient days",102753,Per diem,,63935,,"3,044.51 x patient days",63935,Per diem,,102753,,"4,892.96 x patient days",102753,Per diem,,125587,,"5,980.29 x patient days",125587,Per diem,,147964,,"7,045.87 x patient days",147964,Per diem,,98186,,"4,675.50 x patient days",98186,Per diem,,98186,,"4,675.50 x patient days",98186,Per diem,,57085,,"2,718.31 x patient days",57085,Per diem,,0.01,167542,
Acute leukemia,690-4,APR-DRG,,,,,,,,inpatient,,,1803817.34,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,84942,,"4,044.85 x patient days",84942,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,241883,,"27,634 x DRG weight",241883,Other,base rate x DRG weight,205593,,"23,488 x DRG weight",205593,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,45668,,"2,174.65 x patient days",45668,Per diem,,45668,,"2,174.65 x patient days",45668,Per diem,,45668,,"2,174.65 x patient days",45668,Per diem,,45668,,"2,174.65 x patient days",45668,Per diem,,102753,,"4,892.96 x patient days",102753,Per diem,,69872,,"3,327.21 x patient days",69872,Per diem,,102753,,"4,892.96 x patient days",102753,Per diem,,63935,,"3,044.51 x patient days",63935,Per diem,,102753,,"4,892.96 x patient days",102753,Per diem,,125587,,"5,980.29 x patient days",125587,Per diem,,147964,,"7,045.87 x patient days",147964,Per diem,,98186,,"4,675.50 x patient days",98186,Per diem,,98186,,"4,675.50 x patient days",98186,Per diem,,57085,,"2,718.31 x patient days",57085,Per diem,,0.01,241883,
"Lymphoma, myeloma & non-acute leukemia",691-1,APR-DRG,,,,,,,,inpatient,,,65923,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,40449,,"4,044.85 x patient days",40449,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,28261,,"27,634 x DRG weight",28261,Other,base rate x DRG weight,24021,,"23,488 x DRG weight",24021,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,21747,,"2,174.65 x patient days",21747,Per diem,,21747,,"2,174.65 x patient days",21747,Per diem,,21747,,"2,174.65 x patient days",21747,Per diem,,21747,,"2,174.65 x patient days",21747,Per diem,,48931,,"4,892.96 x patient days",48931,Per diem,,33273,,"3,327.21 x patient days",33273,Per diem,,48931,,"4,892.96 x patient days",48931,Per diem,,30446,,"3,044.51 x patient days",30446,Per diem,,48931,,"4,892.96 x patient days",48931,Per diem,,59804,,"5,980.29 x patient days",59804,Per diem,,70460,,"7,045.87 x patient days",70460,Per diem,,46756,,"4,675.50 x patient days",46756,Per diem,,46756,,"4,675.50 x patient days",46756,Per diem,,27184,,"2,718.31 x patient days",27184,Per diem,,0.01,70460,
"Lymphoma, myeloma & non-acute leukemia",691-2,APR-DRG,,,,,,,,inpatient,,,179939.9,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,40449,,"4,044.85 x patient days",40449,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,41009,,"27,634 x DRG weight",41009,Other,base rate x DRG weight,34856,,"23,488 x DRG weight",34856,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,21747,,"2,174.65 x patient days",21747,Per diem,,21747,,"2,174.65 x patient days",21747,Per diem,,21747,,"2,174.65 x patient days",21747,Per diem,,21747,,"2,174.65 x patient days",21747,Per diem,,48931,,"4,892.96 x patient days",48931,Per diem,,33273,,"3,327.21 x patient days",33273,Per diem,,48931,,"4,892.96 x patient days",48931,Per diem,,30446,,"3,044.51 x patient days",30446,Per diem,,48931,,"4,892.96 x patient days",48931,Per diem,,59804,,"5,980.29 x patient days",59804,Per diem,,70460,,"7,045.87 x patient days",70460,Per diem,,46756,,"4,675.50 x patient days",46756,Per diem,,46756,,"4,675.50 x patient days",46756,Per diem,,27184,,"2,718.31 x patient days",27184,Per diem,,0.01,70460,
"Lymphoma, myeloma & non-acute leukemia",691-3,APR-DRG,,,,,,,,inpatient,,,301956.41,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,40449,,"4,044.85 x patient days",40449,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,69436,,"27,634 x DRG weight",69436,Other,base rate x DRG weight,59018,,"23,488 x DRG weight",59018,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,21747,,"2,174.65 x patient days",21747,Per diem,,21747,,"2,174.65 x patient days",21747,Per diem,,21747,,"2,174.65 x patient days",21747,Per diem,,21747,,"2,174.65 x patient days",21747,Per diem,,48931,,"4,892.96 x patient days",48931,Per diem,,33273,,"3,327.21 x patient days",33273,Per diem,,48931,,"4,892.96 x patient days",48931,Per diem,,30446,,"3,044.51 x patient days",30446,Per diem,,48931,,"4,892.96 x patient days",48931,Per diem,,59804,,"5,980.29 x patient days",59804,Per diem,,70460,,"7,045.87 x patient days",70460,Per diem,,46756,,"4,675.50 x patient days",46756,Per diem,,46756,,"4,675.50 x patient days",46756,Per diem,,27184,,"2,718.31 x patient days",27184,Per diem,,0.01,70460,
"Lymphoma, myeloma & non-acute leukemia",691-4,APR-DRG,,,,,,,,inpatient,,,807135.86,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,40449,,"4,044.85 x patient days",40449,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,175001,,"27,634 x DRG weight",175001,Other,base rate x DRG weight,148745,,"23,488 x DRG weight",148745,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,21747,,"2,174.65 x patient days",21747,Per diem,,21747,,"2,174.65 x patient days",21747,Per diem,,21747,,"2,174.65 x patient days",21747,Per diem,,21747,,"2,174.65 x patient days",21747,Per diem,,48931,,"4,892.96 x patient days",48931,Per diem,,33273,,"3,327.21 x patient days",33273,Per diem,,48931,,"4,892.96 x patient days",48931,Per diem,,30446,,"3,044.51 x patient days",30446,Per diem,,48931,,"4,892.96 x patient days",48931,Per diem,,59804,,"5,980.29 x patient days",59804,Per diem,,70460,,"7,045.87 x patient days",70460,Per diem,,46756,,"4,675.50 x patient days",46756,Per diem,,46756,,"4,675.50 x patient days",46756,Per diem,,27184,,"2,718.31 x patient days",27184,Per diem,,0.01,175001,
Radiotherapy,692-1,APR-DRG,,,,,,,,inpatient,,,121868.82,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,24269,,"4,044.85 x patient days",24269,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,16467,,"27,634 x DRG weight",16467,Other,base rate x DRG weight,13996,,"23,488 x DRG weight",13996,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,13048,,"2,174.65 x patient days",13048,Per diem,,13048,,"2,174.65 x patient days",13048,Per diem,,13048,,"2,174.65 x patient days",13048,Per diem,,13048,,"2,174.65 x patient days",13048,Per diem,,29358,,"4,892.96 x patient days",29358,Per diem,,19963,,"3,327.21 x patient days",19963,Per diem,,29358,,"4,892.96 x patient days",29358,Per diem,,18267,,"3,044.51 x patient days",18267,Per diem,,29358,,"4,892.96 x patient days",29358,Per diem,,35882,,"5,980.29 x patient days",35882,Per diem,,42276,,"7,045.87 x patient days",42276,Per diem,,28053,,"4,675.50 x patient days",28053,Per diem,,28053,,"4,675.50 x patient days",28053,Per diem,,16310,,"2,718.31 x patient days",16310,Per diem,,0.01,42276,
Radiotherapy,692-2,APR-DRG,,,,,,,,inpatient,,,95287,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,24269,,"4,044.85 x patient days",24269,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,35949,,"27,634 x DRG weight",35949,Other,base rate x DRG weight,30556,,"23,488 x DRG weight",30556,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,13048,,"2,174.65 x patient days",13048,Per diem,,13048,,"2,174.65 x patient days",13048,Per diem,,13048,,"2,174.65 x patient days",13048,Per diem,,13048,,"2,174.65 x patient days",13048,Per diem,,29358,,"4,892.96 x patient days",29358,Per diem,,19963,,"3,327.21 x patient days",19963,Per diem,,29358,,"4,892.96 x patient days",29358,Per diem,,18267,,"3,044.51 x patient days",18267,Per diem,,29358,,"4,892.96 x patient days",29358,Per diem,,35882,,"5,980.29 x patient days",35882,Per diem,,42276,,"7,045.87 x patient days",42276,Per diem,,28053,,"4,675.50 x patient days",28053,Per diem,,28053,,"4,675.50 x patient days",28053,Per diem,,16310,,"2,718.31 x patient days",16310,Per diem,,0.01,42276,
Radiotherapy,692-3,APR-DRG,,,,,,,,inpatient,,,653583.84,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,24269,,"4,044.85 x patient days",24269,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,76928,,"27,634 x DRG weight",76928,Other,base rate x DRG weight,65386,,"23,488 x DRG weight",65386,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,13048,,"2,174.65 x patient days",13048,Per diem,,13048,,"2,174.65 x patient days",13048,Per diem,,13048,,"2,174.65 x patient days",13048,Per diem,,13048,,"2,174.65 x patient days",13048,Per diem,,29358,,"4,892.96 x patient days",29358,Per diem,,19963,,"3,327.21 x patient days",19963,Per diem,,29358,,"4,892.96 x patient days",29358,Per diem,,18267,,"3,044.51 x patient days",18267,Per diem,,29358,,"4,892.96 x patient days",29358,Per diem,,35882,,"5,980.29 x patient days",35882,Per diem,,42276,,"7,045.87 x patient days",42276,Per diem,,28053,,"4,675.50 x patient days",28053,Per diem,,28053,,"4,675.50 x patient days",28053,Per diem,,16310,,"2,718.31 x patient days",16310,Per diem,,0.01,76928,
Radiotherapy,692-4,APR-DRG,,,,,,,,inpatient,,,653583.84,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,24269,,"4,044.85 x patient days",24269,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,86320,,"27,634 x DRG weight",86320,Other,base rate x DRG weight,73369,,"23,488 x DRG weight",73369,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,13048,,"2,174.65 x patient days",13048,Per diem,,13048,,"2,174.65 x patient days",13048,Per diem,,13048,,"2,174.65 x patient days",13048,Per diem,,13048,,"2,174.65 x patient days",13048,Per diem,,29358,,"4,892.96 x patient days",29358,Per diem,,19963,,"3,327.21 x patient days",19963,Per diem,,29358,,"4,892.96 x patient days",29358,Per diem,,18267,,"3,044.51 x patient days",18267,Per diem,,29358,,"4,892.96 x patient days",29358,Per diem,,35882,,"5,980.29 x patient days",35882,Per diem,,42276,,"7,045.87 x patient days",42276,Per diem,,28053,,"4,675.50 x patient days",28053,Per diem,,28053,,"4,675.50 x patient days",28053,Per diem,,16310,,"2,718.31 x patient days",16310,Per diem,,0.01,86320,
Lymphatic & other malignancies & neoplasms of uncertain behavior,694-1,APR-DRG,,,,,,,,inpatient,,,54228,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,28315,,"4,044.85 x patient days",28315,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,17208,,"27,634 x DRG weight",17208,Other,base rate x DRG weight,14626,,"23,488 x DRG weight",14626,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,15223,,"2,174.65 x patient days",15223,Per diem,,15223,,"2,174.65 x patient days",15223,Per diem,,15223,,"2,174.65 x patient days",15223,Per diem,,15223,,"2,174.65 x patient days",15223,Per diem,,34252,,"4,892.96 x patient days",34252,Per diem,,23291,,"3,327.21 x patient days",23291,Per diem,,34252,,"4,892.96 x patient days",34252,Per diem,,21312,,"3,044.51 x patient days",21312,Per diem,,34252,,"4,892.96 x patient days",34252,Per diem,,41863,,"5,980.29 x patient days",41863,Per diem,,49323,,"7,045.87 x patient days",49323,Per diem,,32729,,"4,675.50 x patient days",32729,Per diem,,32729,,"4,675.50 x patient days",32729,Per diem,,19029,,"2,718.31 x patient days",19029,Per diem,,0.01,49323,
Lymphatic & other malignancies & neoplasms of uncertain behavior,694-2,APR-DRG,,,,,,,,inpatient,,,133835.9,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,28315,,"4,044.85 x patient days",28315,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,27123,,"27,634 x DRG weight",27123,Other,base rate x DRG weight,23053,,"23,488 x DRG weight",23053,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,15223,,"2,174.65 x patient days",15223,Per diem,,15223,,"2,174.65 x patient days",15223,Per diem,,15223,,"2,174.65 x patient days",15223,Per diem,,15223,,"2,174.65 x patient days",15223,Per diem,,34252,,"4,892.96 x patient days",34252,Per diem,,23291,,"3,327.21 x patient days",23291,Per diem,,34252,,"4,892.96 x patient days",34252,Per diem,,21312,,"3,044.51 x patient days",21312,Per diem,,34252,,"4,892.96 x patient days",34252,Per diem,,41863,,"5,980.29 x patient days",41863,Per diem,,49323,,"7,045.87 x patient days",49323,Per diem,,32729,,"4,675.50 x patient days",32729,Per diem,,32729,,"4,675.50 x patient days",32729,Per diem,,19029,,"2,718.31 x patient days",19029,Per diem,,0.01,49323,
Lymphatic & other malignancies & neoplasms of uncertain behavior,694-3,APR-DRG,,,,,,,,inpatient,,,362205.5,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,28315,,"4,044.85 x patient days",28315,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,44792,,"27,634 x DRG weight",44792,Other,base rate x DRG weight,38072,,"23,488 x DRG weight",38072,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,15223,,"2,174.65 x patient days",15223,Per diem,,15223,,"2,174.65 x patient days",15223,Per diem,,15223,,"2,174.65 x patient days",15223,Per diem,,15223,,"2,174.65 x patient days",15223,Per diem,,34252,,"4,892.96 x patient days",34252,Per diem,,23291,,"3,327.21 x patient days",23291,Per diem,,34252,,"4,892.96 x patient days",34252,Per diem,,21312,,"3,044.51 x patient days",21312,Per diem,,34252,,"4,892.96 x patient days",34252,Per diem,,41863,,"5,980.29 x patient days",41863,Per diem,,49323,,"7,045.87 x patient days",49323,Per diem,,32729,,"4,675.50 x patient days",32729,Per diem,,32729,,"4,675.50 x patient days",32729,Per diem,,19029,,"2,718.31 x patient days",19029,Per diem,,0.01,49323,
Lymphatic & other malignancies & neoplasms of uncertain behavior,694-4,APR-DRG,,,,,,,,inpatient,,,569300.42,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,28315,,"4,044.85 x patient days",28315,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,93442,,"27,634 x DRG weight",93442,Other,base rate x DRG weight,79422,,"23,488 x DRG weight",79422,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,15223,,"2,174.65 x patient days",15223,Per diem,,15223,,"2,174.65 x patient days",15223,Per diem,,15223,,"2,174.65 x patient days",15223,Per diem,,15223,,"2,174.65 x patient days",15223,Per diem,,34252,,"4,892.96 x patient days",34252,Per diem,,23291,,"3,327.21 x patient days",23291,Per diem,,34252,,"4,892.96 x patient days",34252,Per diem,,21312,,"3,044.51 x patient days",21312,Per diem,,34252,,"4,892.96 x patient days",34252,Per diem,,41863,,"5,980.29 x patient days",41863,Per diem,,49323,,"7,045.87 x patient days",49323,Per diem,,32729,,"4,675.50 x patient days",32729,Per diem,,32729,,"4,675.50 x patient days",32729,Per diem,,19029,,"2,718.31 x patient days",19029,Per diem,,0.01,93442,
Chemotherapy for acute leukemia #,695-1,APR-DRG,,,,,,,,inpatient,,,125942.66,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,36404,,"4,044.85 x patient days",36404,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,25006,,"27,634 x DRG weight",25006,Other,base rate x DRG weight,21254,,"23,488 x DRG weight",21254,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,19572,,"2,174.65 x patient days",19572,Per diem,,19572,,"2,174.65 x patient days",19572,Per diem,,19572,,"2,174.65 x patient days",19572,Per diem,,19572,,"2,174.65 x patient days",19572,Per diem,,44037,,"4,892.96 x patient days",44037,Per diem,,29945,,"3,327.21 x patient days",29945,Per diem,,44037,,"4,892.96 x patient days",44037,Per diem,,27401,,"3,044.51 x patient days",27401,Per diem,,44037,,"4,892.96 x patient days",44037,Per diem,,53823,,"5,980.29 x patient days",53823,Per diem,,63413,,"7,045.87 x patient days",63413,Per diem,,42080,,"4,675.50 x patient days",42080,Per diem,,42080,,"4,675.50 x patient days",42080,Per diem,,24465,,"2,718.31 x patient days",24465,Per diem,,0.01,63413,
Chemotherapy for acute leukemia #,695-2,APR-DRG,,,,,,,,inpatient,,,125942.66,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,36404,,"4,044.85 x patient days",36404,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,25042,,"27,634 x DRG weight",25042,Other,base rate x DRG weight,21285,,"23,488 x DRG weight",21285,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,19572,,"2,174.65 x patient days",19572,Per diem,,19572,,"2,174.65 x patient days",19572,Per diem,,19572,,"2,174.65 x patient days",19572,Per diem,,19572,,"2,174.65 x patient days",19572,Per diem,,44037,,"4,892.96 x patient days",44037,Per diem,,29945,,"3,327.21 x patient days",29945,Per diem,,44037,,"4,892.96 x patient days",44037,Per diem,,27401,,"3,044.51 x patient days",27401,Per diem,,44037,,"4,892.96 x patient days",44037,Per diem,,53823,,"5,980.29 x patient days",53823,Per diem,,63413,,"7,045.87 x patient days",63413,Per diem,,42080,,"4,675.50 x patient days",42080,Per diem,,42080,,"4,675.50 x patient days",42080,Per diem,,24465,,"2,718.31 x patient days",24465,Per diem,,0.01,63413,
Chemotherapy for acute leukemia #,695-3,APR-DRG,,,,,,,,inpatient,,,354439.73,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,36404,,"4,044.85 x patient days",36404,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,67372,,"27,634 x DRG weight",67372,Other,base rate x DRG weight,57264,,"23,488 x DRG weight",57264,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,19572,,"2,174.65 x patient days",19572,Per diem,,19572,,"2,174.65 x patient days",19572,Per diem,,19572,,"2,174.65 x patient days",19572,Per diem,,19572,,"2,174.65 x patient days",19572,Per diem,,44037,,"4,892.96 x patient days",44037,Per diem,,29945,,"3,327.21 x patient days",29945,Per diem,,44037,,"4,892.96 x patient days",44037,Per diem,,27401,,"3,044.51 x patient days",27401,Per diem,,44037,,"4,892.96 x patient days",44037,Per diem,,53823,,"5,980.29 x patient days",53823,Per diem,,63413,,"7,045.87 x patient days",63413,Per diem,,42080,,"4,675.50 x patient days",42080,Per diem,,42080,,"4,675.50 x patient days",42080,Per diem,,24465,,"2,718.31 x patient days",24465,Per diem,,0.01,67372,
Chemotherapy for acute leukemia #,695-4,APR-DRG,,,,,,,,inpatient,,,391086.75,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,36404,,"4,044.85 x patient days",36404,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,204127,,"27,634 x DRG weight",204127,Other,base rate x DRG weight,173501,,"23,488 x DRG weight",173501,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,19572,,"2,174.65 x patient days",19572,Per diem,,19572,,"2,174.65 x patient days",19572,Per diem,,19572,,"2,174.65 x patient days",19572,Per diem,,19572,,"2,174.65 x patient days",19572,Per diem,,44037,,"4,892.96 x patient days",44037,Per diem,,29945,,"3,327.21 x patient days",29945,Per diem,,44037,,"4,892.96 x patient days",44037,Per diem,,27401,,"3,044.51 x patient days",27401,Per diem,,44037,,"4,892.96 x patient days",44037,Per diem,,53823,,"5,980.29 x patient days",53823,Per diem,,63413,,"7,045.87 x patient days",63413,Per diem,,42080,,"4,675.50 x patient days",42080,Per diem,,42080,,"4,675.50 x patient days",42080,Per diem,,24465,,"2,718.31 x patient days",24465,Per diem,,0.01,204127,
Other Chemotherapy #,696-1,APR-DRG,,,,,,,,inpatient,,,79950.62,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,16180,,"4,044.85 x patient days",16180,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,20640,,"27,634 x DRG weight",20640,Other,base rate x DRG weight,17543,,"23,488 x DRG weight",17543,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,13309,,"3,327.21 x patient days",13309,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,12179,,"3,044.51 x patient days",12179,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,23922,,"5,980.29 x patient days",23922,Per diem,,28185,,"7,045.87 x patient days",28185,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,10874,,"2,718.31 x patient days",10874,Per diem,,0.01,28185,
Other Chemotherapy #,696-2,APR-DRG,,,,,,,,inpatient,,,105337.83,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,16180,,"4,044.85 x patient days",16180,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,27756,,"27,634 x DRG weight",27756,Other,base rate x DRG weight,23591,,"23,488 x DRG weight",23591,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,13309,,"3,327.21 x patient days",13309,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,12179,,"3,044.51 x patient days",12179,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,23922,,"5,980.29 x patient days",23922,Per diem,,28185,,"7,045.87 x patient days",28185,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,10874,,"2,718.31 x patient days",10874,Per diem,,0.01,28185,
Other Chemotherapy #,696-3,APR-DRG,,,,,,,,inpatient,,,269183.02,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,16180,,"4,044.85 x patient days",16180,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,41866,,"27,634 x DRG weight",41866,Other,base rate x DRG weight,35584,,"23,488 x DRG weight",35584,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,13309,,"3,327.21 x patient days",13309,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,12179,,"3,044.51 x patient days",12179,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,23922,,"5,980.29 x patient days",23922,Per diem,,28185,,"7,045.87 x patient days",28185,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,10874,,"2,718.31 x patient days",10874,Per diem,,0.01,41866,
Other Chemotherapy #,696-4,APR-DRG,,,,,,,,inpatient,,,637148.33,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,16180,,"4,044.85 x patient days",16180,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,121435,,"27,634 x DRG weight",121435,Other,base rate x DRG weight,103216,,"23,488 x DRG weight",103216,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,13309,,"3,327.21 x patient days",13309,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,12179,,"3,044.51 x patient days",12179,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,23922,,"5,980.29 x patient days",23922,Per diem,,28185,,"7,045.87 x patient days",28185,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,10874,,"2,718.31 x patient days",10874,Per diem,,0.01,121435,
Infectious & parasitic diseases including HIV w O.R. procedure,710-1,APR-DRG,,,,,,,,inpatient,,,147260.52,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,60673,,"4,044.85 x patient days",60673,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,29952,,"27,634 x DRG weight",29952,Other,base rate x DRG weight,25459,,"23,488 x DRG weight",25459,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,32620,,"2,174.65 x patient days",32620,Per diem,,32620,,"2,174.65 x patient days",32620,Per diem,,32620,,"2,174.65 x patient days",32620,Per diem,,32620,,"2,174.65 x patient days",32620,Per diem,,73395,,"4,892.96 x patient days",73395,Per diem,,49909,,"3,327.21 x patient days",49909,Per diem,,73395,,"4,892.96 x patient days",73395,Per diem,,45668,,"3,044.51 x patient days",45668,Per diem,,73395,,"4,892.96 x patient days",73395,Per diem,,89705,,"5,980.29 x patient days",89705,Per diem,,105689,,"7,045.87 x patient days",105689,Per diem,,70133,,"4,675.50 x patient days",70133,Per diem,,70133,,"4,675.50 x patient days",70133,Per diem,,40775,,"2,718.31 x patient days",40775,Per diem,,0.01,105689,
Infectious & parasitic diseases including HIV w O.R. procedure,710-2,APR-DRG,,,,,,,,inpatient,,,148121.49,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,60673,,"4,044.85 x patient days",60673,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,46041,,"27,634 x DRG weight",46041,Other,base rate x DRG weight,39133,,"23,488 x DRG weight",39133,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,32620,,"2,174.65 x patient days",32620,Per diem,,32620,,"2,174.65 x patient days",32620,Per diem,,32620,,"2,174.65 x patient days",32620,Per diem,,32620,,"2,174.65 x patient days",32620,Per diem,,73395,,"4,892.96 x patient days",73395,Per diem,,49909,,"3,327.21 x patient days",49909,Per diem,,73395,,"4,892.96 x patient days",73395,Per diem,,45668,,"3,044.51 x patient days",45668,Per diem,,73395,,"4,892.96 x patient days",73395,Per diem,,89705,,"5,980.29 x patient days",89705,Per diem,,105689,,"7,045.87 x patient days",105689,Per diem,,70133,,"4,675.50 x patient days",70133,Per diem,,70133,,"4,675.50 x patient days",70133,Per diem,,40775,,"2,718.31 x patient days",40775,Per diem,,0.01,105689,
Infectious & parasitic diseases including HIV w O.R. procedure,710-3,APR-DRG,,,,,,,,inpatient,,,317633.24,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,60673,,"4,044.85 x patient days",60673,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,82228,,"27,634 x DRG weight",82228,Other,base rate x DRG weight,69891,,"23,488 x DRG weight",69891,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,32620,,"2,174.65 x patient days",32620,Per diem,,32620,,"2,174.65 x patient days",32620,Per diem,,32620,,"2,174.65 x patient days",32620,Per diem,,32620,,"2,174.65 x patient days",32620,Per diem,,73395,,"4,892.96 x patient days",73395,Per diem,,49909,,"3,327.21 x patient days",49909,Per diem,,73395,,"4,892.96 x patient days",73395,Per diem,,45668,,"3,044.51 x patient days",45668,Per diem,,73395,,"4,892.96 x patient days",73395,Per diem,,89705,,"5,980.29 x patient days",89705,Per diem,,105689,,"7,045.87 x patient days",105689,Per diem,,70133,,"4,675.50 x patient days",70133,Per diem,,70133,,"4,675.50 x patient days",70133,Per diem,,40775,,"2,718.31 x patient days",40775,Per diem,,0.01,105689,
Infectious & parasitic diseases including HIV w O.R. procedure,710-4,APR-DRG,,,,,,,,inpatient,,,891593.23,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,60673,,"4,044.85 x patient days",60673,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,174658,,"27,634 x DRG weight",174658,Other,base rate x DRG weight,148454,,"23,488 x DRG weight",148454,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,32620,,"2,174.65 x patient days",32620,Per diem,,32620,,"2,174.65 x patient days",32620,Per diem,,32620,,"2,174.65 x patient days",32620,Per diem,,32620,,"2,174.65 x patient days",32620,Per diem,,73395,,"4,892.96 x patient days",73395,Per diem,,49909,,"3,327.21 x patient days",49909,Per diem,,73395,,"4,892.96 x patient days",73395,Per diem,,45668,,"3,044.51 x patient days",45668,Per diem,,73395,,"4,892.96 x patient days",73395,Per diem,,89705,,"5,980.29 x patient days",89705,Per diem,,105689,,"7,045.87 x patient days",105689,Per diem,,70133,,"4,675.50 x patient days",70133,Per diem,,70133,,"4,675.50 x patient days",70133,Per diem,,40775,,"2,718.31 x patient days",40775,Per diem,,0.01,174658,
"Post-op, post-trauma, other device infections w O.R. procedure",711-1,APR-DRG,,,,,,,,inpatient,,,41655.17,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,36404,,"4,044.85 x patient days",36404,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,32008,,"27,634 x DRG weight",32008,Other,base rate x DRG weight,27206,,"23,488 x DRG weight",27206,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,19572,,"2,174.65 x patient days",19572,Per diem,,19572,,"2,174.65 x patient days",19572,Per diem,,19572,,"2,174.65 x patient days",19572,Per diem,,19572,,"2,174.65 x patient days",19572,Per diem,,44037,,"4,892.96 x patient days",44037,Per diem,,29945,,"3,327.21 x patient days",29945,Per diem,,44037,,"4,892.96 x patient days",44037,Per diem,,27401,,"3,044.51 x patient days",27401,Per diem,,44037,,"4,892.96 x patient days",44037,Per diem,,53823,,"5,980.29 x patient days",53823,Per diem,,63413,,"7,045.87 x patient days",63413,Per diem,,42080,,"4,675.50 x patient days",42080,Per diem,,42080,,"4,675.50 x patient days",42080,Per diem,,24465,,"2,718.31 x patient days",24465,Per diem,,0.01,63413,
"Post-op, post-trauma, other device infections w O.R. procedure",711-2,APR-DRG,,,,,,,,inpatient,,,311510.38,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,36404,,"4,044.85 x patient days",36404,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,43786,,"27,634 x DRG weight",43786,Other,base rate x DRG weight,37217,,"23,488 x DRG weight",37217,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,19572,,"2,174.65 x patient days",19572,Per diem,,19572,,"2,174.65 x patient days",19572,Per diem,,19572,,"2,174.65 x patient days",19572,Per diem,,19572,,"2,174.65 x patient days",19572,Per diem,,44037,,"4,892.96 x patient days",44037,Per diem,,29945,,"3,327.21 x patient days",29945,Per diem,,44037,,"4,892.96 x patient days",44037,Per diem,,27401,,"3,044.51 x patient days",27401,Per diem,,44037,,"4,892.96 x patient days",44037,Per diem,,53823,,"5,980.29 x patient days",53823,Per diem,,63413,,"7,045.87 x patient days",63413,Per diem,,42080,,"4,675.50 x patient days",42080,Per diem,,42080,,"4,675.50 x patient days",42080,Per diem,,24465,,"2,718.31 x patient days",24465,Per diem,,0.01,63413,
"Post-op, post-trauma, other device infections w O.R. procedure",711-3,APR-DRG,,,,,,,,inpatient,,,328470.08,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,36404,,"4,044.85 x patient days",36404,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,79445,,"27,634 x DRG weight",79445,Other,base rate x DRG weight,67526,,"23,488 x DRG weight",67526,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,19572,,"2,174.65 x patient days",19572,Per diem,,19572,,"2,174.65 x patient days",19572,Per diem,,19572,,"2,174.65 x patient days",19572,Per diem,,19572,,"2,174.65 x patient days",19572,Per diem,,44037,,"4,892.96 x patient days",44037,Per diem,,29945,,"3,327.21 x patient days",29945,Per diem,,44037,,"4,892.96 x patient days",44037,Per diem,,27401,,"3,044.51 x patient days",27401,Per diem,,44037,,"4,892.96 x patient days",44037,Per diem,,53823,,"5,980.29 x patient days",53823,Per diem,,63413,,"7,045.87 x patient days",63413,Per diem,,42080,,"4,675.50 x patient days",42080,Per diem,,42080,,"4,675.50 x patient days",42080,Per diem,,24465,,"2,718.31 x patient days",24465,Per diem,,0.01,79445,
"Post-op, post-trauma, other device infections w O.R. procedure",711-4,APR-DRG,,,,,,,,inpatient,,,754875.33,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,36404,,"4,044.85 x patient days",36404,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,166796,,"27,634 x DRG weight",166796,Other,base rate x DRG weight,141771,,"23,488 x DRG weight",141771,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,19572,,"2,174.65 x patient days",19572,Per diem,,19572,,"2,174.65 x patient days",19572,Per diem,,19572,,"2,174.65 x patient days",19572,Per diem,,19572,,"2,174.65 x patient days",19572,Per diem,,44037,,"4,892.96 x patient days",44037,Per diem,,29945,,"3,327.21 x patient days",29945,Per diem,,44037,,"4,892.96 x patient days",44037,Per diem,,27401,,"3,044.51 x patient days",27401,Per diem,,44037,,"4,892.96 x patient days",44037,Per diem,,53823,,"5,980.29 x patient days",53823,Per diem,,63413,,"7,045.87 x patient days",63413,Per diem,,42080,,"4,675.50 x patient days",42080,Per diem,,42080,,"4,675.50 x patient days",42080,Per diem,,24465,,"2,718.31 x patient days",24465,Per diem,,0.01,166796,
Septicemia & disseminated infections,720-1,APR-DRG,,,,,,,,inpatient,,,93993.74,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,28315,,"4,044.85 x patient days",28315,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,16702,,"27,634 x DRG weight",16702,Other,base rate x DRG weight,14196,,"23,488 x DRG weight",14196,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,15223,,"2,174.65 x patient days",15223,Per diem,,15223,,"2,174.65 x patient days",15223,Per diem,,15223,,"2,174.65 x patient days",15223,Per diem,,15223,,"2,174.65 x patient days",15223,Per diem,,34252,,"4,892.96 x patient days",34252,Per diem,,23291,,"3,327.21 x patient days",23291,Per diem,,34252,,"4,892.96 x patient days",34252,Per diem,,21312,,"3,044.51 x patient days",21312,Per diem,,34252,,"4,892.96 x patient days",34252,Per diem,,41863,,"5,980.29 x patient days",41863,Per diem,,49323,,"7,045.87 x patient days",49323,Per diem,,32729,,"4,675.50 x patient days",32729,Per diem,,32729,,"4,675.50 x patient days",32729,Per diem,,19029,,"2,718.31 x patient days",19029,Per diem,,0.01,49323,
Septicemia & disseminated infections,720-2,APR-DRG,,,,,,,,inpatient,,,116439.33,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,28315,,"4,044.85 x patient days",28315,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,23038,,"27,634 x DRG weight",23038,Other,base rate x DRG weight,19582,,"23,488 x DRG weight",19582,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,15223,,"2,174.65 x patient days",15223,Per diem,,15223,,"2,174.65 x patient days",15223,Per diem,,15223,,"2,174.65 x patient days",15223,Per diem,,15223,,"2,174.65 x patient days",15223,Per diem,,34252,,"4,892.96 x patient days",34252,Per diem,,23291,,"3,327.21 x patient days",23291,Per diem,,34252,,"4,892.96 x patient days",34252,Per diem,,21312,,"3,044.51 x patient days",21312,Per diem,,34252,,"4,892.96 x patient days",34252,Per diem,,41863,,"5,980.29 x patient days",41863,Per diem,,49323,,"7,045.87 x patient days",49323,Per diem,,32729,,"4,675.50 x patient days",32729,Per diem,,32729,,"4,675.50 x patient days",32729,Per diem,,19029,,"2,718.31 x patient days",19029,Per diem,,0.01,49323,
Septicemia & disseminated infections,720-3,APR-DRG,,,,,,,,inpatient,,,187547.32,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,28315,,"4,044.85 x patient days",28315,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,41119,,"27,634 x DRG weight",41119,Other,base rate x DRG weight,34950,,"23,488 x DRG weight",34950,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,15223,,"2,174.65 x patient days",15223,Per diem,,15223,,"2,174.65 x patient days",15223,Per diem,,15223,,"2,174.65 x patient days",15223,Per diem,,15223,,"2,174.65 x patient days",15223,Per diem,,34252,,"4,892.96 x patient days",34252,Per diem,,23291,,"3,327.21 x patient days",23291,Per diem,,34252,,"4,892.96 x patient days",34252,Per diem,,21312,,"3,044.51 x patient days",21312,Per diem,,34252,,"4,892.96 x patient days",34252,Per diem,,41863,,"5,980.29 x patient days",41863,Per diem,,49323,,"7,045.87 x patient days",49323,Per diem,,32729,,"4,675.50 x patient days",32729,Per diem,,32729,,"4,675.50 x patient days",32729,Per diem,,19029,,"2,718.31 x patient days",19029,Per diem,,0.01,49323,
Septicemia & disseminated infections,720-4,APR-DRG,,,,,,,,inpatient,,,358701.42,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,28315,,"4,044.85 x patient days",28315,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,88437,,"27,634 x DRG weight",88437,Other,base rate x DRG weight,75169,,"23,488 x DRG weight",75169,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,15223,,"2,174.65 x patient days",15223,Per diem,,15223,,"2,174.65 x patient days",15223,Per diem,,15223,,"2,174.65 x patient days",15223,Per diem,,15223,,"2,174.65 x patient days",15223,Per diem,,34252,,"4,892.96 x patient days",34252,Per diem,,23291,,"3,327.21 x patient days",23291,Per diem,,34252,,"4,892.96 x patient days",34252,Per diem,,21312,,"3,044.51 x patient days",21312,Per diem,,34252,,"4,892.96 x patient days",34252,Per diem,,41863,,"5,980.29 x patient days",41863,Per diem,,49323,,"7,045.87 x patient days",49323,Per diem,,32729,,"4,675.50 x patient days",32729,Per diem,,32729,,"4,675.50 x patient days",32729,Per diem,,19029,,"2,718.31 x patient days",19029,Per diem,,0.01,88437,
"Post-operative, post-traumatic, other device infections",721-1,APR-DRG,,,,,,,,inpatient,,,163560.5,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,24269,,"4,044.85 x patient days",24269,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,17791,,"27,634 x DRG weight",17791,Other,base rate x DRG weight,15122,,"23,488 x DRG weight",15122,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,13048,,"2,174.65 x patient days",13048,Per diem,,13048,,"2,174.65 x patient days",13048,Per diem,,13048,,"2,174.65 x patient days",13048,Per diem,,13048,,"2,174.65 x patient days",13048,Per diem,,29358,,"4,892.96 x patient days",29358,Per diem,,19963,,"3,327.21 x patient days",19963,Per diem,,29358,,"4,892.96 x patient days",29358,Per diem,,18267,,"3,044.51 x patient days",18267,Per diem,,29358,,"4,892.96 x patient days",29358,Per diem,,35882,,"5,980.29 x patient days",35882,Per diem,,42276,,"7,045.87 x patient days",42276,Per diem,,28053,,"4,675.50 x patient days",28053,Per diem,,28053,,"4,675.50 x patient days",28053,Per diem,,16310,,"2,718.31 x patient days",16310,Per diem,,0.01,42276,
"Post-operative, post-traumatic, other device infections",721-2,APR-DRG,,,,,,,,inpatient,,,139034.03,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,24269,,"4,044.85 x patient days",24269,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,23392,,"27,634 x DRG weight",23392,Other,base rate x DRG weight,19883,,"23,488 x DRG weight",19883,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,13048,,"2,174.65 x patient days",13048,Per diem,,13048,,"2,174.65 x patient days",13048,Per diem,,13048,,"2,174.65 x patient days",13048,Per diem,,13048,,"2,174.65 x patient days",13048,Per diem,,29358,,"4,892.96 x patient days",29358,Per diem,,19963,,"3,327.21 x patient days",19963,Per diem,,29358,,"4,892.96 x patient days",29358,Per diem,,18267,,"3,044.51 x patient days",18267,Per diem,,29358,,"4,892.96 x patient days",29358,Per diem,,35882,,"5,980.29 x patient days",35882,Per diem,,42276,,"7,045.87 x patient days",42276,Per diem,,28053,,"4,675.50 x patient days",28053,Per diem,,28053,,"4,675.50 x patient days",28053,Per diem,,16310,,"2,718.31 x patient days",16310,Per diem,,0.01,42276,
"Post-operative, post-traumatic, other device infections",721-3,APR-DRG,,,,,,,,inpatient,,,153353.48,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,24269,,"4,044.85 x patient days",24269,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,39561,,"27,634 x DRG weight",39561,Other,base rate x DRG weight,33625,,"23,488 x DRG weight",33625,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,13048,,"2,174.65 x patient days",13048,Per diem,,13048,,"2,174.65 x patient days",13048,Per diem,,13048,,"2,174.65 x patient days",13048,Per diem,,13048,,"2,174.65 x patient days",13048,Per diem,,29358,,"4,892.96 x patient days",29358,Per diem,,19963,,"3,327.21 x patient days",19963,Per diem,,29358,,"4,892.96 x patient days",29358,Per diem,,18267,,"3,044.51 x patient days",18267,Per diem,,29358,,"4,892.96 x patient days",29358,Per diem,,35882,,"5,980.29 x patient days",35882,Per diem,,42276,,"7,045.87 x patient days",42276,Per diem,,28053,,"4,675.50 x patient days",28053,Per diem,,28053,,"4,675.50 x patient days",28053,Per diem,,16310,,"2,718.31 x patient days",16310,Per diem,,0.01,42276,
"Post-operative, post-traumatic, other device infections",721-4,APR-DRG,,,,,,,,inpatient,,,427372.44,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,24269,,"4,044.85 x patient days",24269,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,78232,,"27,634 x DRG weight",78232,Other,base rate x DRG weight,66495,,"23,488 x DRG weight",66495,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,13048,,"2,174.65 x patient days",13048,Per diem,,13048,,"2,174.65 x patient days",13048,Per diem,,13048,,"2,174.65 x patient days",13048,Per diem,,13048,,"2,174.65 x patient days",13048,Per diem,,29358,,"4,892.96 x patient days",29358,Per diem,,19963,,"3,327.21 x patient days",19963,Per diem,,29358,,"4,892.96 x patient days",29358,Per diem,,18267,,"3,044.51 x patient days",18267,Per diem,,29358,,"4,892.96 x patient days",29358,Per diem,,35882,,"5,980.29 x patient days",35882,Per diem,,42276,,"7,045.87 x patient days",42276,Per diem,,28053,,"4,675.50 x patient days",28053,Per diem,,28053,,"4,675.50 x patient days",28053,Per diem,,16310,,"2,718.31 x patient days",16310,Per diem,,0.01,78232,
Fever,722-1,APR-DRG,,,,,,,,inpatient,,,59760.53,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12135,,"4,044.85 x patient days",12135,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,14187,,"27,634 x DRG weight",14187,Other,base rate x DRG weight,12059,,"23,488 x DRG weight",12059,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9982,,"3,327.21 x patient days",9982,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9134,,"3,044.51 x patient days",9134,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,17941,,"5,980.29 x patient days",17941,Per diem,,21138,,"7,045.87 x patient days",21138,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,8155,,"2,718.31 x patient days",8155,Per diem,,0.01,21138,
Fever,722-2,APR-DRG,,,,,,,,inpatient,,,55665.29,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12135,,"4,044.85 x patient days",12135,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,16163,,"27,634 x DRG weight",16163,Other,base rate x DRG weight,13738,,"23,488 x DRG weight",13738,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9982,,"3,327.21 x patient days",9982,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9134,,"3,044.51 x patient days",9134,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,17941,,"5,980.29 x patient days",17941,Per diem,,21138,,"7,045.87 x patient days",21138,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,8155,,"2,718.31 x patient days",8155,Per diem,,0.01,21138,
Fever,722-3,APR-DRG,,,,,,,,inpatient,,,96880,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12135,,"4,044.85 x patient days",12135,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,23461,,"27,634 x DRG weight",23461,Other,base rate x DRG weight,19941,,"23,488 x DRG weight",19941,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9982,,"3,327.21 x patient days",9982,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9134,,"3,044.51 x patient days",9134,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,17941,,"5,980.29 x patient days",17941,Per diem,,21138,,"7,045.87 x patient days",21138,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,8155,,"2,718.31 x patient days",8155,Per diem,,0.01,23461,
Fever,722-4,APR-DRG,,,,,,,,inpatient,,,57528.7,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12135,,"4,044.85 x patient days",12135,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,49520,,"27,634 x DRG weight",49520,Other,base rate x DRG weight,42090,,"23,488 x DRG weight",42090,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9982,,"3,327.21 x patient days",9982,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9134,,"3,044.51 x patient days",9134,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,17941,,"5,980.29 x patient days",17941,Per diem,,21138,,"7,045.87 x patient days",21138,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,8155,,"2,718.31 x patient days",8155,Per diem,,0.01,49520,
Viral illness,723-1,APR-DRG,,,,,,,,inpatient,,,69955.71,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12135,,"4,044.85 x patient days",12135,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12706,,"27,634 x DRG weight",12706,Other,base rate x DRG weight,10800,,"23,488 x DRG weight",10800,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9982,,"3,327.21 x patient days",9982,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9134,,"3,044.51 x patient days",9134,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,17941,,"5,980.29 x patient days",17941,Per diem,,21138,,"7,045.87 x patient days",21138,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,8155,,"2,718.31 x patient days",8155,Per diem,,0.01,21138,
Viral illness,723-2,APR-DRG,,,,,,,,inpatient,,,61965.4,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12135,,"4,044.85 x patient days",12135,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,15348,,"27,634 x DRG weight",15348,Other,base rate x DRG weight,13045,,"23,488 x DRG weight",13045,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9982,,"3,327.21 x patient days",9982,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9134,,"3,044.51 x patient days",9134,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,17941,,"5,980.29 x patient days",17941,Per diem,,21138,,"7,045.87 x patient days",21138,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,8155,,"2,718.31 x patient days",8155,Per diem,,0.01,21138,
Viral illness,723-3,APR-DRG,,,,,,,,inpatient,,,112808.06,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12135,,"4,044.85 x patient days",12135,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,23610,,"27,634 x DRG weight",23610,Other,base rate x DRG weight,20068,,"23,488 x DRG weight",20068,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9982,,"3,327.21 x patient days",9982,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9134,,"3,044.51 x patient days",9134,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,17941,,"5,980.29 x patient days",17941,Per diem,,21138,,"7,045.87 x patient days",21138,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,8155,,"2,718.31 x patient days",8155,Per diem,,0.01,23610,
Viral illness,723-4,APR-DRG,,,,,,,,inpatient,,,204410.98,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12135,,"4,044.85 x patient days",12135,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,74272,,"27,634 x DRG weight",74272,Other,base rate x DRG weight,63129,,"23,488 x DRG weight",63129,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9982,,"3,327.21 x patient days",9982,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9134,,"3,044.51 x patient days",9134,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,17941,,"5,980.29 x patient days",17941,Per diem,,21138,,"7,045.87 x patient days",21138,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,8155,,"2,718.31 x patient days",8155,Per diem,,0.01,74272,
Other infectious & parasitic diseases,724-1,APR-DRG,,,,,,,,inpatient,,,62714.23,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,20224,,"4,044.85 x patient days",20224,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,17854,,"27,634 x DRG weight",17854,Other,base rate x DRG weight,15176,,"23,488 x DRG weight",15176,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,16636,,"3,327.21 x patient days",16636,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,15222,,"3,044.51 x patient days",15222,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,29901,,"5,980.29 x patient days",29901,Per diem,,35229,,"7,045.87 x patient days",35229,Per diem,,23377,,"4,675.50 x patient days",23377,Per diem,,23377,,"4,675.50 x patient days",23377,Per diem,,13591,,"2,718.31 x patient days",13591,Per diem,,0.01,35229,
Other infectious & parasitic diseases,724-2,APR-DRG,,,,,,,,inpatient,,,82056.58,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,20224,,"4,044.85 x patient days",20224,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,21201,,"27,634 x DRG weight",21201,Other,base rate x DRG weight,18020,,"23,488 x DRG weight",18020,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,16636,,"3,327.21 x patient days",16636,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,15222,,"3,044.51 x patient days",15222,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,29901,,"5,980.29 x patient days",29901,Per diem,,35229,,"7,045.87 x patient days",35229,Per diem,,23377,,"4,675.50 x patient days",23377,Per diem,,23377,,"4,675.50 x patient days",23377,Per diem,,13591,,"2,718.31 x patient days",13591,Per diem,,0.01,35229,
Other infectious & parasitic diseases,724-3,APR-DRG,,,,,,,,inpatient,,,126325.31,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,20224,,"4,044.85 x patient days",20224,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,37662,,"27,634 x DRG weight",37662,Other,base rate x DRG weight,32012,,"23,488 x DRG weight",32012,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,16636,,"3,327.21 x patient days",16636,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,15222,,"3,044.51 x patient days",15222,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,29901,,"5,980.29 x patient days",29901,Per diem,,35229,,"7,045.87 x patient days",35229,Per diem,,23377,,"4,675.50 x patient days",23377,Per diem,,23377,,"4,675.50 x patient days",23377,Per diem,,13591,,"2,718.31 x patient days",13591,Per diem,,0.01,37662,
Other infectious & parasitic diseases,724-4,APR-DRG,,,,,,,,inpatient,,,93840.23,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,20224,,"4,044.85 x patient days",20224,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,100052,,"27,634 x DRG weight",100052,Other,base rate x DRG weight,85041,,"23,488 x DRG weight",85041,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,16636,,"3,327.21 x patient days",16636,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,15222,,"3,044.51 x patient days",15222,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,29901,,"5,980.29 x patient days",29901,Per diem,,35229,,"7,045.87 x patient days",35229,Per diem,,23377,,"4,675.50 x patient days",23377,Per diem,,23377,,"4,675.50 x patient days",23377,Per diem,,13591,,"2,718.31 x patient days",13591,Per diem,,0.01,100052,
O.R. procedure for other complications of treatment,791-1,APR-DRG,,,,,,,,inpatient,,,172544.08,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,24269,,"4,044.85 x patient days",24269,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,23434,,"27,634 x DRG weight",23434,Other,base rate x DRG weight,19918,,"23,488 x DRG weight",19918,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,13048,,"2,174.65 x patient days",13048,Per diem,,13048,,"2,174.65 x patient days",13048,Per diem,,13048,,"2,174.65 x patient days",13048,Per diem,,13048,,"2,174.65 x patient days",13048,Per diem,,29358,,"4,892.96 x patient days",29358,Per diem,,19963,,"3,327.21 x patient days",19963,Per diem,,29358,,"4,892.96 x patient days",29358,Per diem,,18267,,"3,044.51 x patient days",18267,Per diem,,29358,,"4,892.96 x patient days",29358,Per diem,,35882,,"5,980.29 x patient days",35882,Per diem,,42276,,"7,045.87 x patient days",42276,Per diem,,28053,,"4,675.50 x patient days",28053,Per diem,,28053,,"4,675.50 x patient days",28053,Per diem,,16310,,"2,718.31 x patient days",16310,Per diem,,0.01,42276,
O.R. procedure for other complications of treatment,791-2,APR-DRG,,,,,,,,inpatient,,,193040.14,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,24269,,"4,044.85 x patient days",24269,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,39331,,"27,634 x DRG weight",39331,Other,base rate x DRG weight,33430,,"23,488 x DRG weight",33430,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,13048,,"2,174.65 x patient days",13048,Per diem,,13048,,"2,174.65 x patient days",13048,Per diem,,13048,,"2,174.65 x patient days",13048,Per diem,,13048,,"2,174.65 x patient days",13048,Per diem,,29358,,"4,892.96 x patient days",29358,Per diem,,19963,,"3,327.21 x patient days",19963,Per diem,,29358,,"4,892.96 x patient days",29358,Per diem,,18267,,"3,044.51 x patient days",18267,Per diem,,29358,,"4,892.96 x patient days",29358,Per diem,,35882,,"5,980.29 x patient days",35882,Per diem,,42276,,"7,045.87 x patient days",42276,Per diem,,28053,,"4,675.50 x patient days",28053,Per diem,,28053,,"4,675.50 x patient days",28053,Per diem,,16310,,"2,718.31 x patient days",16310,Per diem,,0.01,42276,
O.R. procedure for other complications of treatment,791-3,APR-DRG,,,,,,,,inpatient,,,318880.06,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,24269,,"4,044.85 x patient days",24269,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,73896,,"27,634 x DRG weight",73896,Other,base rate x DRG weight,62809,,"23,488 x DRG weight",62809,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,13048,,"2,174.65 x patient days",13048,Per diem,,13048,,"2,174.65 x patient days",13048,Per diem,,13048,,"2,174.65 x patient days",13048,Per diem,,13048,,"2,174.65 x patient days",13048,Per diem,,29358,,"4,892.96 x patient days",29358,Per diem,,19963,,"3,327.21 x patient days",19963,Per diem,,29358,,"4,892.96 x patient days",29358,Per diem,,18267,,"3,044.51 x patient days",18267,Per diem,,29358,,"4,892.96 x patient days",29358,Per diem,,35882,,"5,980.29 x patient days",35882,Per diem,,42276,,"7,045.87 x patient days",42276,Per diem,,28053,,"4,675.50 x patient days",28053,Per diem,,28053,,"4,675.50 x patient days",28053,Per diem,,16310,,"2,718.31 x patient days",16310,Per diem,,0.01,73896,
O.R. procedure for other complications of treatment,791-4,APR-DRG,,,,,,,,inpatient,,,277307.33,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,24269,,"4,044.85 x patient days",24269,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,182680,,"27,634 x DRG weight",182680,Other,base rate x DRG weight,155272,,"23,488 x DRG weight",155272,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,13048,,"2,174.65 x patient days",13048,Per diem,,13048,,"2,174.65 x patient days",13048,Per diem,,13048,,"2,174.65 x patient days",13048,Per diem,,13048,,"2,174.65 x patient days",13048,Per diem,,29358,,"4,892.96 x patient days",29358,Per diem,,19963,,"3,327.21 x patient days",19963,Per diem,,29358,,"4,892.96 x patient days",29358,Per diem,,18267,,"3,044.51 x patient days",18267,Per diem,,29358,,"4,892.96 x patient days",29358,Per diem,,35882,,"5,980.29 x patient days",35882,Per diem,,42276,,"7,045.87 x patient days",42276,Per diem,,28053,,"4,675.50 x patient days",28053,Per diem,,28053,,"4,675.50 x patient days",28053,Per diem,,16310,,"2,718.31 x patient days",16310,Per diem,,0.01,182680,
Allergic reactions,811-1,APR-DRG,,,,,,,,inpatient,,,39948.24,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8089,,"4,044.85 x patient days",8089,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,9368,,"27,634 x DRG weight",9368,Other,base rate x DRG weight,7962,,"23,488 x DRG weight",7962,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6654,,"3,327.21 x patient days",6654,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6089,,"3,044.51 x patient days",6089,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,11960,,"5,980.29 x patient days",11960,Per diem,,14091,,"7,045.87 x patient days",14091,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,5436,,"2,718.31 x patient days",5436,Per diem,,0.01,14091,
Allergic reactions,811-2,APR-DRG,,,,,,,,inpatient,,,86685.39,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8089,,"4,044.85 x patient days",8089,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,13043,,"27,634 x DRG weight",13043,Other,base rate x DRG weight,11086,,"23,488 x DRG weight",11086,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6654,,"3,327.21 x patient days",6654,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6089,,"3,044.51 x patient days",6089,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,11960,,"5,980.29 x patient days",11960,Per diem,,14091,,"7,045.87 x patient days",14091,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,5436,,"2,718.31 x patient days",5436,Per diem,,0.01,14091,
Allergic reactions,811-3,APR-DRG,,,,,,,,inpatient,,,195596.31,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8089,,"4,044.85 x patient days",8089,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,28944,,"27,634 x DRG weight",28944,Other,base rate x DRG weight,24601,,"23,488 x DRG weight",24601,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6654,,"3,327.21 x patient days",6654,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6089,,"3,044.51 x patient days",6089,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,11960,,"5,980.29 x patient days",11960,Per diem,,14091,,"7,045.87 x patient days",14091,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,5436,,"2,718.31 x patient days",5436,Per diem,,0.01,28944,
Allergic reactions,811-4,APR-DRG,,,,,,,,inpatient,,,195596.31,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8089,,"4,044.85 x patient days",8089,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,65249,,"27,634 x DRG weight",65249,Other,base rate x DRG weight,55460,,"23,488 x DRG weight",55460,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,4349,,"2,174.65 x patient days",4349,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6654,,"3,327.21 x patient days",6654,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,6089,,"3,044.51 x patient days",6089,Per diem,,9785,,"4,892.96 x patient days",9785,Per diem,,11960,,"5,980.29 x patient days",11960,Per diem,,14091,,"7,045.87 x patient days",14091,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,9350,,"4,675.50 x patient days",9350,Per diem,,5436,,"2,718.31 x patient days",5436,Per diem,,0.01,65249,
Poisoning of medicinal agents,812-1,APR-DRG,,,,,,,,inpatient,,,46315.14,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12135,,"4,044.85 x patient days",12135,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,11316,,"27,634 x DRG weight",11316,Other,base rate x DRG weight,9618,,"23,488 x DRG weight",9618,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9982,,"3,327.21 x patient days",9982,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9134,,"3,044.51 x patient days",9134,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,17941,,"5,980.29 x patient days",17941,Per diem,,21138,,"7,045.87 x patient days",21138,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,8155,,"2,718.31 x patient days",8155,Per diem,,0.01,21138,
Poisoning of medicinal agents,812-2,APR-DRG,,,,,,,,inpatient,,,77729.8,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12135,,"4,044.85 x patient days",12135,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,14986,,"27,634 x DRG weight",14986,Other,base rate x DRG weight,12738,,"23,488 x DRG weight",12738,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9982,,"3,327.21 x patient days",9982,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9134,,"3,044.51 x patient days",9134,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,17941,,"5,980.29 x patient days",17941,Per diem,,21138,,"7,045.87 x patient days",21138,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,8155,,"2,718.31 x patient days",8155,Per diem,,0.01,21138,
Poisoning of medicinal agents,812-3,APR-DRG,,,,,,,,inpatient,,,110612.46,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12135,,"4,044.85 x patient days",12135,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,25423,,"27,634 x DRG weight",25423,Other,base rate x DRG weight,21609,,"23,488 x DRG weight",21609,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9982,,"3,327.21 x patient days",9982,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9134,,"3,044.51 x patient days",9134,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,17941,,"5,980.29 x patient days",17941,Per diem,,21138,,"7,045.87 x patient days",21138,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,8155,,"2,718.31 x patient days",8155,Per diem,,0.01,25423,
Poisoning of medicinal agents,812-4,APR-DRG,,,,,,,,inpatient,,,169448.14,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12135,,"4,044.85 x patient days",12135,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,60419,,"27,634 x DRG weight",60419,Other,base rate x DRG weight,51354,,"23,488 x DRG weight",51354,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9982,,"3,327.21 x patient days",9982,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9134,,"3,044.51 x patient days",9134,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,17941,,"5,980.29 x patient days",17941,Per diem,,21138,,"7,045.87 x patient days",21138,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,8155,,"2,718.31 x patient days",8155,Per diem,,0.01,60419,
Other complications of treatment,813-1,APR-DRG,,,,,,,,inpatient,,,64115.64,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12135,,"4,044.85 x patient days",12135,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,13748,,"27,634 x DRG weight",13748,Other,base rate x DRG weight,11685,,"23,488 x DRG weight",11685,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9982,,"3,327.21 x patient days",9982,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9134,,"3,044.51 x patient days",9134,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,17941,,"5,980.29 x patient days",17941,Per diem,,21138,,"7,045.87 x patient days",21138,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,8155,,"2,718.31 x patient days",8155,Per diem,,0.01,21138,
Other complications of treatment,813-2,APR-DRG,,,,,,,,inpatient,,,139069.74,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12135,,"4,044.85 x patient days",12135,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,18987,,"27,634 x DRG weight",18987,Other,base rate x DRG weight,16139,,"23,488 x DRG weight",16139,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9982,,"3,327.21 x patient days",9982,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9134,,"3,044.51 x patient days",9134,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,17941,,"5,980.29 x patient days",17941,Per diem,,21138,,"7,045.87 x patient days",21138,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,8155,,"2,718.31 x patient days",8155,Per diem,,0.01,21138,
Other complications of treatment,813-3,APR-DRG,,,,,,,,inpatient,,,157589.29,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12135,,"4,044.85 x patient days",12135,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,31450,,"27,634 x DRG weight",31450,Other,base rate x DRG weight,26732,,"23,488 x DRG weight",26732,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9982,,"3,327.21 x patient days",9982,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9134,,"3,044.51 x patient days",9134,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,17941,,"5,980.29 x patient days",17941,Per diem,,21138,,"7,045.87 x patient days",21138,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,8155,,"2,718.31 x patient days",8155,Per diem,,0.01,31450,
Other complications of treatment,813-4,APR-DRG,,,,,,,,inpatient,,,249158.17,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12135,,"4,044.85 x patient days",12135,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,72224,,"27,634 x DRG weight",72224,Other,base rate x DRG weight,61388,,"23,488 x DRG weight",61388,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9982,,"3,327.21 x patient days",9982,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9134,,"3,044.51 x patient days",9134,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,17941,,"5,980.29 x patient days",17941,Per diem,,21138,,"7,045.87 x patient days",21138,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,8155,,"2,718.31 x patient days",8155,Per diem,,0.01,72224,
"Other injury, poisoning & toxic effect diagnoses",815-1,APR-DRG,,,,,,,,inpatient,,,84439.99,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12135,,"4,044.85 x patient days",12135,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,9984,,"27,634 x DRG weight",9984,Other,base rate x DRG weight,8486,,"23,488 x DRG weight",8486,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9982,,"3,327.21 x patient days",9982,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9134,,"3,044.51 x patient days",9134,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,17941,,"5,980.29 x patient days",17941,Per diem,,21138,,"7,045.87 x patient days",21138,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,8155,,"2,718.31 x patient days",8155,Per diem,,0.01,21138,
"Other injury, poisoning & toxic effect diagnoses",815-2,APR-DRG,,,,,,,,inpatient,,,143510.07,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12135,,"4,044.85 x patient days",12135,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,17078,,"27,634 x DRG weight",17078,Other,base rate x DRG weight,14516,,"23,488 x DRG weight",14516,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9982,,"3,327.21 x patient days",9982,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9134,,"3,044.51 x patient days",9134,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,17941,,"5,980.29 x patient days",17941,Per diem,,21138,,"7,045.87 x patient days",21138,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,8155,,"2,718.31 x patient days",8155,Per diem,,0.01,21138,
"Other injury, poisoning & toxic effect diagnoses",815-3,APR-DRG,,,,,,,,inpatient,,,328313.63,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12135,,"4,044.85 x patient days",12135,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,29143,,"27,634 x DRG weight",29143,Other,base rate x DRG weight,24770,,"23,488 x DRG weight",24770,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9982,,"3,327.21 x patient days",9982,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9134,,"3,044.51 x patient days",9134,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,17941,,"5,980.29 x patient days",17941,Per diem,,21138,,"7,045.87 x patient days",21138,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,8155,,"2,718.31 x patient days",8155,Per diem,,0.01,29143,
"Other injury, poisoning & toxic effect diagnoses",815-4,APR-DRG,,,,,,,,inpatient,,,295702.79,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12135,,"4,044.85 x patient days",12135,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,74736,,"27,634 x DRG weight",74736,Other,base rate x DRG weight,63523,,"23,488 x DRG weight",63523,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9982,,"3,327.21 x patient days",9982,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9134,,"3,044.51 x patient days",9134,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,17941,,"5,980.29 x patient days",17941,Per diem,,21138,,"7,045.87 x patient days",21138,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,8155,,"2,718.31 x patient days",8155,Per diem,,0.01,74736,
Toxic effects of non-medicinal substances,816-1,APR-DRG,,,,,,,,inpatient,,,106006.35,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12135,,"4,044.85 x patient days",12135,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12380,,"27,634 x DRG weight",12380,Other,base rate x DRG weight,10523,,"23,488 x DRG weight",10523,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9982,,"3,327.21 x patient days",9982,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9134,,"3,044.51 x patient days",9134,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,17941,,"5,980.29 x patient days",17941,Per diem,,21138,,"7,045.87 x patient days",21138,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,8155,,"2,718.31 x patient days",8155,Per diem,,0.01,21138,
Toxic effects of non-medicinal substances,816-2,APR-DRG,,,,,,,,inpatient,,,83123.52,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12135,,"4,044.85 x patient days",12135,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,15652,,"27,634 x DRG weight",15652,Other,base rate x DRG weight,13304,,"23,488 x DRG weight",13304,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9982,,"3,327.21 x patient days",9982,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9134,,"3,044.51 x patient days",9134,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,17941,,"5,980.29 x patient days",17941,Per diem,,21138,,"7,045.87 x patient days",21138,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,8155,,"2,718.31 x patient days",8155,Per diem,,0.01,21138,
Toxic effects of non-medicinal substances,816-3,APR-DRG,,,,,,,,inpatient,,,137476.28,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12135,,"4,044.85 x patient days",12135,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,24348,,"27,634 x DRG weight",24348,Other,base rate x DRG weight,20695,,"23,488 x DRG weight",20695,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9982,,"3,327.21 x patient days",9982,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9134,,"3,044.51 x patient days",9134,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,17941,,"5,980.29 x patient days",17941,Per diem,,21138,,"7,045.87 x patient days",21138,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,8155,,"2,718.31 x patient days",8155,Per diem,,0.01,24348,
Toxic effects of non-medicinal substances,816-4,APR-DRG,,,,,,,,inpatient,,,157136.38,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12135,,"4,044.85 x patient days",12135,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,57866,,"27,634 x DRG weight",57866,Other,base rate x DRG weight,49184,,"23,488 x DRG weight",49184,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9982,,"3,327.21 x patient days",9982,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9134,,"3,044.51 x patient days",9134,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,17941,,"5,980.29 x patient days",17941,Per diem,,21138,,"7,045.87 x patient days",21138,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,8155,,"2,718.31 x patient days",8155,Per diem,,0.01,57866,
Extensive 3rd degree burns w skin graft,841-1,APR-DRG,,,,,,,,inpatient,,,1260874.74,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,182018,,"4,044.85 x patient days",182018,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,148306,,"27,634 x DRG weight",148306,Other,base rate x DRG weight,126055,,"23,488 x DRG weight",126055,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,97859,,"2,174.65 x patient days",97859,Per diem,,97859,,"2,174.65 x patient days",97859,Per diem,,97859,,"2,174.65 x patient days",97859,Per diem,,97859,,"2,174.65 x patient days",97859,Per diem,,220183,,"4,892.96 x patient days",220183,Per diem,,149724,,"3,327.21 x patient days",149724,Per diem,,220183,,"4,892.96 x patient days",220183,Per diem,,137003,,"3,044.51 x patient days",137003,Per diem,,220183,,"4,892.96 x patient days",220183,Per diem,,269112,,"5,980.29 x patient days",269112,Per diem,,317063,,"7,045.87 x patient days",317063,Per diem,,210397,,"4,675.50 x patient days",210397,Per diem,,210397,,"4,675.50 x patient days",210397,Per diem,,122324,,"2,718.31 x patient days",122324,Per diem,,0.01,317063,
Extensive 3rd degree burns w skin graft,841-2,APR-DRG,,,,,,,,inpatient,,,1260874.74,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,182018,,"4,044.85 x patient days",182018,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,195701,,"27,634 x DRG weight",195701,Other,base rate x DRG weight,166340,,"23,488 x DRG weight",166340,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,97859,,"2,174.65 x patient days",97859,Per diem,,97859,,"2,174.65 x patient days",97859,Per diem,,97859,,"2,174.65 x patient days",97859,Per diem,,97859,,"2,174.65 x patient days",97859,Per diem,,220183,,"4,892.96 x patient days",220183,Per diem,,149724,,"3,327.21 x patient days",149724,Per diem,,220183,,"4,892.96 x patient days",220183,Per diem,,137003,,"3,044.51 x patient days",137003,Per diem,,220183,,"4,892.96 x patient days",220183,Per diem,,269112,,"5,980.29 x patient days",269112,Per diem,,317063,,"7,045.87 x patient days",317063,Per diem,,210397,,"4,675.50 x patient days",210397,Per diem,,210397,,"4,675.50 x patient days",210397,Per diem,,122324,,"2,718.31 x patient days",122324,Per diem,,0.01,317063,
Extensive 3rd degree burns w skin graft,841-3,APR-DRG,,,,,,,,inpatient,,,1422878.29,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,182018,,"4,044.85 x patient days",182018,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,404642,,"27,634 x DRG weight",404642,Other,base rate x DRG weight,343932,,"23,488 x DRG weight",343932,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,97859,,"2,174.65 x patient days",97859,Per diem,,97859,,"2,174.65 x patient days",97859,Per diem,,97859,,"2,174.65 x patient days",97859,Per diem,,97859,,"2,174.65 x patient days",97859,Per diem,,220183,,"4,892.96 x patient days",220183,Per diem,,149724,,"3,327.21 x patient days",149724,Per diem,,220183,,"4,892.96 x patient days",220183,Per diem,,137003,,"3,044.51 x patient days",137003,Per diem,,220183,,"4,892.96 x patient days",220183,Per diem,,269112,,"5,980.29 x patient days",269112,Per diem,,317063,,"7,045.87 x patient days",317063,Per diem,,210397,,"4,675.50 x patient days",210397,Per diem,,210397,,"4,675.50 x patient days",210397,Per diem,,122324,,"2,718.31 x patient days",122324,Per diem,,0.01,404642,
Extensive 3rd degree burns w skin graft,841-4,APR-DRG,,,,,,,,inpatient,,,2504936.85,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,182018,,"4,044.85 x patient days",182018,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,517817,,"27,634 x DRG weight",517817,Other,base rate x DRG weight,440128,,"23,488 x DRG weight",440128,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,97859,,"2,174.65 x patient days",97859,Per diem,,97859,,"2,174.65 x patient days",97859,Per diem,,97859,,"2,174.65 x patient days",97859,Per diem,,97859,,"2,174.65 x patient days",97859,Per diem,,220183,,"4,892.96 x patient days",220183,Per diem,,149724,,"3,327.21 x patient days",149724,Per diem,,220183,,"4,892.96 x patient days",220183,Per diem,,137003,,"3,044.51 x patient days",137003,Per diem,,220183,,"4,892.96 x patient days",220183,Per diem,,269112,,"5,980.29 x patient days",269112,Per diem,,317063,,"7,045.87 x patient days",317063,Per diem,,210397,,"4,675.50 x patient days",210397,Per diem,,210397,,"4,675.50 x patient days",210397,Per diem,,122324,,"2,718.31 x patient days",122324,Per diem,,0.01,517817,
Burns with skin graft except extensive 3rd degree burns,842-1,APR-DRG,,,,,,,,inpatient,,,417507.42,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,52582,,"4,044.85 x patient days",52582,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,59557,,"27,634 x DRG weight",59557,Other,base rate x DRG weight,50621,,"23,488 x DRG weight",50621,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,28270,,"2,174.65 x patient days",28270,Per diem,,28270,,"2,174.65 x patient days",28270,Per diem,,28270,,"2,174.65 x patient days",28270,Per diem,,28270,,"2,174.65 x patient days",28270,Per diem,,63608,,"4,892.96 x patient days",63608,Per diem,,43253,,"3,327.21 x patient days",43253,Per diem,,63608,,"4,892.96 x patient days",63608,Per diem,,39578,,"3,044.51 x patient days",39578,Per diem,,63608,,"4,892.96 x patient days",63608,Per diem,,77743,,"5,980.29 x patient days",77743,Per diem,,91595,,"7,045.87 x patient days",91595,Per diem,,60781,,"4,675.50 x patient days",60781,Per diem,,60781,,"4,675.50 x patient days",60781,Per diem,,35338,,"2,718.31 x patient days",35338,Per diem,,0.01,91595,
Burns with skin graft except extensive 3rd degree burns,842-2,APR-DRG,,,,,,,,inpatient,,,597490.13,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,52582,,"4,044.85 x patient days",52582,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,78326,,"27,634 x DRG weight",78326,Other,base rate x DRG weight,66574,,"23,488 x DRG weight",66574,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,28270,,"2,174.65 x patient days",28270,Per diem,,28270,,"2,174.65 x patient days",28270,Per diem,,28270,,"2,174.65 x patient days",28270,Per diem,,28270,,"2,174.65 x patient days",28270,Per diem,,63608,,"4,892.96 x patient days",63608,Per diem,,43253,,"3,327.21 x patient days",43253,Per diem,,63608,,"4,892.96 x patient days",63608,Per diem,,39578,,"3,044.51 x patient days",39578,Per diem,,63608,,"4,892.96 x patient days",63608,Per diem,,77743,,"5,980.29 x patient days",77743,Per diem,,91595,,"7,045.87 x patient days",91595,Per diem,,60781,,"4,675.50 x patient days",60781,Per diem,,60781,,"4,675.50 x patient days",60781,Per diem,,35338,,"2,718.31 x patient days",35338,Per diem,,0.01,91595,
Burns with skin graft except extensive 3rd degree burns,842-3,APR-DRG,,,,,,,,inpatient,,,644723.08,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,52582,,"4,044.85 x patient days",52582,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,120581,,"27,634 x DRG weight",120581,Other,base rate x DRG weight,102490,,"23,488 x DRG weight",102490,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,28270,,"2,174.65 x patient days",28270,Per diem,,28270,,"2,174.65 x patient days",28270,Per diem,,28270,,"2,174.65 x patient days",28270,Per diem,,28270,,"2,174.65 x patient days",28270,Per diem,,63608,,"4,892.96 x patient days",63608,Per diem,,43253,,"3,327.21 x patient days",43253,Per diem,,63608,,"4,892.96 x patient days",63608,Per diem,,39578,,"3,044.51 x patient days",39578,Per diem,,63608,,"4,892.96 x patient days",63608,Per diem,,77743,,"5,980.29 x patient days",77743,Per diem,,91595,,"7,045.87 x patient days",91595,Per diem,,60781,,"4,675.50 x patient days",60781,Per diem,,60781,,"4,675.50 x patient days",60781,Per diem,,35338,,"2,718.31 x patient days",35338,Per diem,,0.01,120581,
Burns with skin graft except extensive 3rd degree burns,842-4,APR-DRG,,,,,,,,inpatient,,,1260874.74,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,52582,,"4,044.85 x patient days",52582,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,238694,,"27,634 x DRG weight",238694,Other,base rate x DRG weight,202882,,"23,488 x DRG weight",202882,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,28270,,"2,174.65 x patient days",28270,Per diem,,28270,,"2,174.65 x patient days",28270,Per diem,,28270,,"2,174.65 x patient days",28270,Per diem,,28270,,"2,174.65 x patient days",28270,Per diem,,63608,,"4,892.96 x patient days",63608,Per diem,,43253,,"3,327.21 x patient days",43253,Per diem,,63608,,"4,892.96 x patient days",63608,Per diem,,39578,,"3,044.51 x patient days",39578,Per diem,,63608,,"4,892.96 x patient days",63608,Per diem,,77743,,"5,980.29 x patient days",77743,Per diem,,91595,,"7,045.87 x patient days",91595,Per diem,,60781,,"4,675.50 x patient days",60781,Per diem,,60781,,"4,675.50 x patient days",60781,Per diem,,35338,,"2,718.31 x patient days",35338,Per diem,,0.01,238694,
Extensive 3rd degree or full thickness burns w/o skin graft,843-1,APR-DRG,,,,,,,,inpatient,,,232006.01,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,20224,,"4,044.85 x patient days",20224,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,54478,,"27,634 x DRG weight",54478,Other,base rate x DRG weight,46304,,"23,488 x DRG weight",46304,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,16636,,"3,327.21 x patient days",16636,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,15222,,"3,044.51 x patient days",15222,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,29901,,"5,980.29 x patient days",29901,Per diem,,35229,,"7,045.87 x patient days",35229,Per diem,,23377,,"4,675.50 x patient days",23377,Per diem,,23377,,"4,675.50 x patient days",23377,Per diem,,13591,,"2,718.31 x patient days",13591,Per diem,,0.01,54478,
Extensive 3rd degree or full thickness burns w/o skin graft,843-2,APR-DRG,,,,,,,,inpatient,,,232006.01,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,20224,,"4,044.85 x patient days",20224,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,54478,,"27,634 x DRG weight",54478,Other,base rate x DRG weight,46304,,"23,488 x DRG weight",46304,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,16636,,"3,327.21 x patient days",16636,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,15222,,"3,044.51 x patient days",15222,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,29901,,"5,980.29 x patient days",29901,Per diem,,35229,,"7,045.87 x patient days",35229,Per diem,,23377,,"4,675.50 x patient days",23377,Per diem,,23377,,"4,675.50 x patient days",23377,Per diem,,13591,,"2,718.31 x patient days",13591,Per diem,,0.01,54478,
Extensive 3rd degree or full thickness burns w/o skin graft,843-3,APR-DRG,,,,,,,,inpatient,,,232006.01,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,20224,,"4,044.85 x patient days",20224,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,54478,,"27,634 x DRG weight",54478,Other,base rate x DRG weight,46304,,"23,488 x DRG weight",46304,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,16636,,"3,327.21 x patient days",16636,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,15222,,"3,044.51 x patient days",15222,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,29901,,"5,980.29 x patient days",29901,Per diem,,35229,,"7,045.87 x patient days",35229,Per diem,,23377,,"4,675.50 x patient days",23377,Per diem,,23377,,"4,675.50 x patient days",23377,Per diem,,13591,,"2,718.31 x patient days",13591,Per diem,,0.01,54478,
Extensive 3rd degree or full thickness burns w/o skin graft,843-4,APR-DRG,,,,,,,,inpatient,,,232006.01,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,20224,,"4,044.85 x patient days",20224,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,54478,,"27,634 x DRG weight",54478,Other,base rate x DRG weight,46304,,"23,488 x DRG weight",46304,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,10873,,"2,174.65 x patient days",10873,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,16636,,"3,327.21 x patient days",16636,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,15222,,"3,044.51 x patient days",15222,Per diem,,24464,,"4,892.96 x patient days",24464,Per diem,,29901,,"5,980.29 x patient days",29901,Per diem,,35229,,"7,045.87 x patient days",35229,Per diem,,23377,,"4,675.50 x patient days",23377,Per diem,,23377,,"4,675.50 x patient days",23377,Per diem,,13591,,"2,718.31 x patient days",13591,Per diem,,0.01,54478,
Partial thickness burns without skin graft,844-1,APR-DRG,,,,,,,,inpatient,,,112166.66,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,16180,,"4,044.85 x patient days",16180,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,17943,,"27,634 x DRG weight",17943,Other,base rate x DRG weight,15251,,"23,488 x DRG weight",15251,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,13309,,"3,327.21 x patient days",13309,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,12179,,"3,044.51 x patient days",12179,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,23922,,"5,980.29 x patient days",23922,Per diem,,28185,,"7,045.87 x patient days",28185,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,10874,,"2,718.31 x patient days",10874,Per diem,,0.01,28185,
Partial thickness burns without skin graft,844-2,APR-DRG,,,,,,,,inpatient,,,185513.41,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,16180,,"4,044.85 x patient days",16180,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,29392,,"27,634 x DRG weight",29392,Other,base rate x DRG weight,24982,,"23,488 x DRG weight",24982,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,13309,,"3,327.21 x patient days",13309,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,12179,,"3,044.51 x patient days",12179,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,23922,,"5,980.29 x patient days",23922,Per diem,,28185,,"7,045.87 x patient days",28185,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,10874,,"2,718.31 x patient days",10874,Per diem,,0.01,29392,
Partial thickness burns without skin graft,844-3,APR-DRG,,,,,,,,inpatient,,,395848.34,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,16180,,"4,044.85 x patient days",16180,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,52010,,"27,634 x DRG weight",52010,Other,base rate x DRG weight,44207,,"23,488 x DRG weight",44207,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,13309,,"3,327.21 x patient days",13309,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,12179,,"3,044.51 x patient days",12179,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,23922,,"5,980.29 x patient days",23922,Per diem,,28185,,"7,045.87 x patient days",28185,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,10874,,"2,718.31 x patient days",10874,Per diem,,0.01,52010,
Partial thickness burns without skin graft,844-4,APR-DRG,,,,,,,,inpatient,,,955048.21,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,16180,,"4,044.85 x patient days",16180,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,140372,,"27,634 x DRG weight",140372,Other,base rate x DRG weight,119312,,"23,488 x DRG weight",119312,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,13309,,"3,327.21 x patient days",13309,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,12179,,"3,044.51 x patient days",12179,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,23922,,"5,980.29 x patient days",23922,Per diem,,28185,,"7,045.87 x patient days",28185,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,10874,,"2,718.31 x patient days",10874,Per diem,,0.01,140372,
"Signs, symptoms & other factors influencing health status",861-1,APR-DRG,,,,,,,,inpatient,,,66129.84,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12135,,"4,044.85 x patient days",12135,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12441,,"27,634 x DRG weight",12441,Other,base rate x DRG weight,10574,,"23,488 x DRG weight",10574,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9982,,"3,327.21 x patient days",9982,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9134,,"3,044.51 x patient days",9134,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,17941,,"5,980.29 x patient days",17941,Per diem,,21138,,"7,045.87 x patient days",21138,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,8155,,"2,718.31 x patient days",8155,Per diem,,0.01,21138,
"Signs, symptoms & other factors influencing health status",861-2,APR-DRG,,,,,,,,inpatient,,,119714.86,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12135,,"4,044.85 x patient days",12135,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,17418,,"27,634 x DRG weight",17418,Other,base rate x DRG weight,14804,,"23,488 x DRG weight",14804,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9982,,"3,327.21 x patient days",9982,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9134,,"3,044.51 x patient days",9134,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,17941,,"5,980.29 x patient days",17941,Per diem,,21138,,"7,045.87 x patient days",21138,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,8155,,"2,718.31 x patient days",8155,Per diem,,0.01,21138,
"Signs, symptoms & other factors influencing health status",861-3,APR-DRG,,,,,,,,inpatient,,,152104.95,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12135,,"4,044.85 x patient days",12135,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,29231,,"27,634 x DRG weight",29231,Other,base rate x DRG weight,24846,,"23,488 x DRG weight",24846,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9982,,"3,327.21 x patient days",9982,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9134,,"3,044.51 x patient days",9134,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,17941,,"5,980.29 x patient days",17941,Per diem,,21138,,"7,045.87 x patient days",21138,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,8155,,"2,718.31 x patient days",8155,Per diem,,0.01,29231,
"Signs, symptoms & other factors influencing health status",861-4,APR-DRG,,,,,,,,inpatient,,,398249,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12135,,"4,044.85 x patient days",12135,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,57761,,"27,634 x DRG weight",57761,Other,base rate x DRG weight,49095,,"23,488 x DRG weight",49095,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,6524,,"2,174.65 x patient days",6524,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9982,,"3,327.21 x patient days",9982,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,9134,,"3,044.51 x patient days",9134,Per diem,,14679,,"4,892.96 x patient days",14679,Per diem,,17941,,"5,980.29 x patient days",17941,Per diem,,21138,,"7,045.87 x patient days",21138,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,14027,,"4,675.50 x patient days",14027,Per diem,,8155,,"2,718.31 x patient days",8155,Per diem,,0.01,57761,
Neonatal aftercare,863-1,APR-DRG,,,,,,,,inpatient,,,54897,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,68762,,"4,044.85 x patient days",68762,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,25161,,"27,634 x DRG weight",25161,Other,base rate x DRG weight,21386,,"23,488 x DRG weight",21386,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,36969,,"2,174.65 x patient days",36969,Per diem,,36969,,"2,174.65 x patient days",36969,Per diem,,36969,,"2,174.65 x patient days",36969,Per diem,,36969,,"2,174.65 x patient days",36969,Per diem,,83180,,"4,892.96 x patient days",83180,Per diem,,56563,,"3,327.21 x patient days",56563,Per diem,,83180,,"4,892.96 x patient days",83180,Per diem,,51757,,"3,044.51 x patient days",51757,Per diem,,83180,,"4,892.96 x patient days",83180,Per diem,,101665,,"5,980.29 x patient days",101665,Per diem,,119780,,"7,045.87 x patient days",119780,Per diem,,79483,,"4,675.50 x patient days",79483,Per diem,,79483,,"4,675.50 x patient days",79483,Per diem,,46211,,"2,718.31 x patient days",46211,Per diem,,0.01,119780,
Neonatal aftercare,863-2,APR-DRG,,,,,,,,inpatient,,,54897,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,68762,,"4,044.85 x patient days",68762,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,60496,,"27,634 x DRG weight",60496,Other,base rate x DRG weight,51420,,"23,488 x DRG weight",51420,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,36969,,"2,174.65 x patient days",36969,Per diem,,36969,,"2,174.65 x patient days",36969,Per diem,,36969,,"2,174.65 x patient days",36969,Per diem,,36969,,"2,174.65 x patient days",36969,Per diem,,83180,,"4,892.96 x patient days",83180,Per diem,,56563,,"3,327.21 x patient days",56563,Per diem,,83180,,"4,892.96 x patient days",83180,Per diem,,51757,,"3,044.51 x patient days",51757,Per diem,,83180,,"4,892.96 x patient days",83180,Per diem,,101665,,"5,980.29 x patient days",101665,Per diem,,119780,,"7,045.87 x patient days",119780,Per diem,,79483,,"4,675.50 x patient days",79483,Per diem,,79483,,"4,675.50 x patient days",79483,Per diem,,46211,,"2,718.31 x patient days",46211,Per diem,,0.01,119780,
Neonatal aftercare,863-3,APR-DRG,,,,,,,,inpatient,,,1325617.15,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,68762,,"4,044.85 x patient days",68762,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,114723,,"27,634 x DRG weight",114723,Other,base rate x DRG weight,97510,,"23,488 x DRG weight",97510,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,36969,,"2,174.65 x patient days",36969,Per diem,,36969,,"2,174.65 x patient days",36969,Per diem,,36969,,"2,174.65 x patient days",36969,Per diem,,36969,,"2,174.65 x patient days",36969,Per diem,,83180,,"4,892.96 x patient days",83180,Per diem,,56563,,"3,327.21 x patient days",56563,Per diem,,83180,,"4,892.96 x patient days",83180,Per diem,,51757,,"3,044.51 x patient days",51757,Per diem,,83180,,"4,892.96 x patient days",83180,Per diem,,101665,,"5,980.29 x patient days",101665,Per diem,,119780,,"7,045.87 x patient days",119780,Per diem,,79483,,"4,675.50 x patient days",79483,Per diem,,79483,,"4,675.50 x patient days",79483,Per diem,,46211,,"2,718.31 x patient days",46211,Per diem,,0.01,119780,
Neonatal aftercare,863-4,APR-DRG,,,,,,,,inpatient,,,160075,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,68762,,"4,044.85 x patient days",68762,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,146433,,"27,634 x DRG weight",146433,Other,base rate x DRG weight,124463,,"23,488 x DRG weight",124463,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,36969,,"2,174.65 x patient days",36969,Per diem,,36969,,"2,174.65 x patient days",36969,Per diem,,36969,,"2,174.65 x patient days",36969,Per diem,,36969,,"2,174.65 x patient days",36969,Per diem,,83180,,"4,892.96 x patient days",83180,Per diem,,56563,,"3,327.21 x patient days",56563,Per diem,,83180,,"4,892.96 x patient days",83180,Per diem,,51757,,"3,044.51 x patient days",51757,Per diem,,83180,,"4,892.96 x patient days",83180,Per diem,,101665,,"5,980.29 x patient days",101665,Per diem,,119780,,"7,045.87 x patient days",119780,Per diem,,79483,,"4,675.50 x patient days",79483,Per diem,,79483,,"4,675.50 x patient days",79483,Per diem,,46211,,"2,718.31 x patient days",46211,Per diem,,0.01,146433,
HIV w multiple major HIV related conditions,890-1,APR-DRG,,,,,,,,inpatient,,,160075,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,52582,,"4,044.85 x patient days",52582,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,30770,,"27,634 x DRG weight",30770,Other,base rate x DRG weight,26154,,"23,488 x DRG weight",26154,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,28270,,"2,174.65 x patient days",28270,Per diem,,28270,,"2,174.65 x patient days",28270,Per diem,,28270,,"2,174.65 x patient days",28270,Per diem,,28270,,"2,174.65 x patient days",28270,Per diem,,63608,,"4,892.96 x patient days",63608,Per diem,,43253,,"3,327.21 x patient days",43253,Per diem,,63608,,"4,892.96 x patient days",63608,Per diem,,39578,,"3,044.51 x patient days",39578,Per diem,,63608,,"4,892.96 x patient days",63608,Per diem,,77743,,"5,980.29 x patient days",77743,Per diem,,91595,,"7,045.87 x patient days",91595,Per diem,,60781,,"4,675.50 x patient days",60781,Per diem,,60781,,"4,675.50 x patient days",60781,Per diem,,35338,,"2,718.31 x patient days",35338,Per diem,,0.01,91595,
HIV w multiple major HIV related conditions,890-2,APR-DRG,,,,,,,,inpatient,,,160075,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,52582,,"4,044.85 x patient days",52582,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,30815,,"27,634 x DRG weight",30815,Other,base rate x DRG weight,26191,,"23,488 x DRG weight",26191,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,28270,,"2,174.65 x patient days",28270,Per diem,,28270,,"2,174.65 x patient days",28270,Per diem,,28270,,"2,174.65 x patient days",28270,Per diem,,28270,,"2,174.65 x patient days",28270,Per diem,,63608,,"4,892.96 x patient days",63608,Per diem,,43253,,"3,327.21 x patient days",43253,Per diem,,63608,,"4,892.96 x patient days",63608,Per diem,,39578,,"3,044.51 x patient days",39578,Per diem,,63608,,"4,892.96 x patient days",63608,Per diem,,77743,,"5,980.29 x patient days",77743,Per diem,,91595,,"7,045.87 x patient days",91595,Per diem,,60781,,"4,675.50 x patient days",60781,Per diem,,60781,,"4,675.50 x patient days",60781,Per diem,,35338,,"2,718.31 x patient days",35338,Per diem,,0.01,91595,
HIV w multiple major HIV related conditions,890-3,APR-DRG,,,,,,,,inpatient,,,192976.57,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,52582,,"4,044.85 x patient days",52582,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,53223,,"27,634 x DRG weight",53223,Other,base rate x DRG weight,45238,,"23,488 x DRG weight",45238,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,28270,,"2,174.65 x patient days",28270,Per diem,,28270,,"2,174.65 x patient days",28270,Per diem,,28270,,"2,174.65 x patient days",28270,Per diem,,28270,,"2,174.65 x patient days",28270,Per diem,,63608,,"4,892.96 x patient days",63608,Per diem,,43253,,"3,327.21 x patient days",43253,Per diem,,63608,,"4,892.96 x patient days",63608,Per diem,,39578,,"3,044.51 x patient days",39578,Per diem,,63608,,"4,892.96 x patient days",63608,Per diem,,77743,,"5,980.29 x patient days",77743,Per diem,,91595,,"7,045.87 x patient days",91595,Per diem,,60781,,"4,675.50 x patient days",60781,Per diem,,60781,,"4,675.50 x patient days",60781,Per diem,,35338,,"2,718.31 x patient days",35338,Per diem,,0.01,91595,
HIV w multiple major HIV related conditions,890-4,APR-DRG,,,,,,,,inpatient,,,1536016.66,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,52582,,"4,044.85 x patient days",52582,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,104636,,"27,634 x DRG weight",104636,Other,base rate x DRG weight,88937,,"23,488 x DRG weight",88937,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,28270,,"2,174.65 x patient days",28270,Per diem,,28270,,"2,174.65 x patient days",28270,Per diem,,28270,,"2,174.65 x patient days",28270,Per diem,,28270,,"2,174.65 x patient days",28270,Per diem,,63608,,"4,892.96 x patient days",63608,Per diem,,43253,,"3,327.21 x patient days",43253,Per diem,,63608,,"4,892.96 x patient days",63608,Per diem,,39578,,"3,044.51 x patient days",39578,Per diem,,63608,,"4,892.96 x patient days",63608,Per diem,,77743,,"5,980.29 x patient days",77743,Per diem,,91595,,"7,045.87 x patient days",91595,Per diem,,60781,,"4,675.50 x patient days",60781,Per diem,,60781,,"4,675.50 x patient days",60781,Per diem,,35338,,"2,718.31 x patient days",35338,Per diem,,0.01,104636,
HIV w major HIV related condition,892-1,APR-DRG,,,,,,,,inpatient,,,136575.41,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,24269,,"4,044.85 x patient days",24269,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,19899,,"27,634 x DRG weight",19899,Other,base rate x DRG weight,16914,,"23,488 x DRG weight",16914,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,13048,,"2,174.65 x patient days",13048,Per diem,,13048,,"2,174.65 x patient days",13048,Per diem,,13048,,"2,174.65 x patient days",13048,Per diem,,13048,,"2,174.65 x patient days",13048,Per diem,,29358,,"4,892.96 x patient days",29358,Per diem,,19963,,"3,327.21 x patient days",19963,Per diem,,29358,,"4,892.96 x patient days",29358,Per diem,,18267,,"3,044.51 x patient days",18267,Per diem,,29358,,"4,892.96 x patient days",29358,Per diem,,35882,,"5,980.29 x patient days",35882,Per diem,,42276,,"7,045.87 x patient days",42276,Per diem,,28053,,"4,675.50 x patient days",28053,Per diem,,28053,,"4,675.50 x patient days",28053,Per diem,,16310,,"2,718.31 x patient days",16310,Per diem,,0.01,42276,
HIV w major HIV related condition,892-2,APR-DRG,,,,,,,,inpatient,,,136575.41,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,24269,,"4,044.85 x patient days",24269,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,25785,,"27,634 x DRG weight",25785,Other,base rate x DRG weight,21917,,"23,488 x DRG weight",21917,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,13048,,"2,174.65 x patient days",13048,Per diem,,13048,,"2,174.65 x patient days",13048,Per diem,,13048,,"2,174.65 x patient days",13048,Per diem,,13048,,"2,174.65 x patient days",13048,Per diem,,29358,,"4,892.96 x patient days",29358,Per diem,,19963,,"3,327.21 x patient days",19963,Per diem,,29358,,"4,892.96 x patient days",29358,Per diem,,18267,,"3,044.51 x patient days",18267,Per diem,,29358,,"4,892.96 x patient days",29358,Per diem,,35882,,"5,980.29 x patient days",35882,Per diem,,42276,,"7,045.87 x patient days",42276,Per diem,,28053,,"4,675.50 x patient days",28053,Per diem,,28053,,"4,675.50 x patient days",28053,Per diem,,16310,,"2,718.31 x patient days",16310,Per diem,,0.01,42276,
HIV w major HIV related condition,892-3,APR-DRG,,,,,,,,inpatient,,,238101.74,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,24269,,"4,044.85 x patient days",24269,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,36187,,"27,634 x DRG weight",36187,Other,base rate x DRG weight,30758,,"23,488 x DRG weight",30758,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,13048,,"2,174.65 x patient days",13048,Per diem,,13048,,"2,174.65 x patient days",13048,Per diem,,13048,,"2,174.65 x patient days",13048,Per diem,,13048,,"2,174.65 x patient days",13048,Per diem,,29358,,"4,892.96 x patient days",29358,Per diem,,19963,,"3,327.21 x patient days",19963,Per diem,,29358,,"4,892.96 x patient days",29358,Per diem,,18267,,"3,044.51 x patient days",18267,Per diem,,29358,,"4,892.96 x patient days",29358,Per diem,,35882,,"5,980.29 x patient days",35882,Per diem,,42276,,"7,045.87 x patient days",42276,Per diem,,28053,,"4,675.50 x patient days",28053,Per diem,,28053,,"4,675.50 x patient days",28053,Per diem,,16310,,"2,718.31 x patient days",16310,Per diem,,0.01,42276,
HIV w major HIV related condition,892-4,APR-DRG,,,,,,,,inpatient,,,157591.6,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,24269,,"4,044.85 x patient days",24269,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,64512,,"27,634 x DRG weight",64512,Other,base rate x DRG weight,54833,,"23,488 x DRG weight",54833,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,13048,,"2,174.65 x patient days",13048,Per diem,,13048,,"2,174.65 x patient days",13048,Per diem,,13048,,"2,174.65 x patient days",13048,Per diem,,13048,,"2,174.65 x patient days",13048,Per diem,,29358,,"4,892.96 x patient days",29358,Per diem,,19963,,"3,327.21 x patient days",19963,Per diem,,29358,,"4,892.96 x patient days",29358,Per diem,,18267,,"3,044.51 x patient days",18267,Per diem,,29358,,"4,892.96 x patient days",29358,Per diem,,35882,,"5,980.29 x patient days",35882,Per diem,,42276,,"7,045.87 x patient days",42276,Per diem,,28053,,"4,675.50 x patient days",28053,Per diem,,28053,,"4,675.50 x patient days",28053,Per diem,,16310,,"2,718.31 x patient days",16310,Per diem,,0.01,64512,
HIV w multiple significant HIV related conditions,893-1,APR-DRG,,,,,,,,inpatient,,,610134.92,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,24269,,"4,044.85 x patient days",24269,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,21618,,"27,634 x DRG weight",21618,Other,base rate x DRG weight,18375,,"23,488 x DRG weight",18375,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,13048,,"2,174.65 x patient days",13048,Per diem,,13048,,"2,174.65 x patient days",13048,Per diem,,13048,,"2,174.65 x patient days",13048,Per diem,,13048,,"2,174.65 x patient days",13048,Per diem,,29358,,"4,892.96 x patient days",29358,Per diem,,19963,,"3,327.21 x patient days",19963,Per diem,,29358,,"4,892.96 x patient days",29358,Per diem,,18267,,"3,044.51 x patient days",18267,Per diem,,29358,,"4,892.96 x patient days",29358,Per diem,,35882,,"5,980.29 x patient days",35882,Per diem,,42276,,"7,045.87 x patient days",42276,Per diem,,28053,,"4,675.50 x patient days",28053,Per diem,,28053,,"4,675.50 x patient days",28053,Per diem,,16310,,"2,718.31 x patient days",16310,Per diem,,0.01,42276,
HIV w multiple significant HIV related conditions,893-2,APR-DRG,,,,,,,,inpatient,,,610134.92,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,24269,,"4,044.85 x patient days",24269,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,25548,,"27,634 x DRG weight",25548,Other,base rate x DRG weight,21715,,"23,488 x DRG weight",21715,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,13048,,"2,174.65 x patient days",13048,Per diem,,13048,,"2,174.65 x patient days",13048,Per diem,,13048,,"2,174.65 x patient days",13048,Per diem,,13048,,"2,174.65 x patient days",13048,Per diem,,29358,,"4,892.96 x patient days",29358,Per diem,,19963,,"3,327.21 x patient days",19963,Per diem,,29358,,"4,892.96 x patient days",29358,Per diem,,18267,,"3,044.51 x patient days",18267,Per diem,,29358,,"4,892.96 x patient days",29358,Per diem,,35882,,"5,980.29 x patient days",35882,Per diem,,42276,,"7,045.87 x patient days",42276,Per diem,,28053,,"4,675.50 x patient days",28053,Per diem,,28053,,"4,675.50 x patient days",28053,Per diem,,16310,,"2,718.31 x patient days",16310,Per diem,,0.01,42276,
HIV w multiple significant HIV related conditions,893-3,APR-DRG,,,,,,,,inpatient,,,610134.92,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,24269,,"4,044.85 x patient days",24269,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,40136,,"27,634 x DRG weight",40136,Other,base rate x DRG weight,34114,,"23,488 x DRG weight",34114,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,13048,,"2,174.65 x patient days",13048,Per diem,,13048,,"2,174.65 x patient days",13048,Per diem,,13048,,"2,174.65 x patient days",13048,Per diem,,13048,,"2,174.65 x patient days",13048,Per diem,,29358,,"4,892.96 x patient days",29358,Per diem,,19963,,"3,327.21 x patient days",19963,Per diem,,29358,,"4,892.96 x patient days",29358,Per diem,,18267,,"3,044.51 x patient days",18267,Per diem,,29358,,"4,892.96 x patient days",29358,Per diem,,35882,,"5,980.29 x patient days",35882,Per diem,,42276,,"7,045.87 x patient days",42276,Per diem,,28053,,"4,675.50 x patient days",28053,Per diem,,28053,,"4,675.50 x patient days",28053,Per diem,,16310,,"2,718.31 x patient days",16310,Per diem,,0.01,42276,
HIV w multiple significant HIV related conditions,893-4,APR-DRG,,,,,,,,inpatient,,,610134.92,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,24269,,"4,044.85 x patient days",24269,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,40937,,"27,634 x DRG weight",40937,Other,base rate x DRG weight,34795,,"23,488 x DRG weight",34795,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,13048,,"2,174.65 x patient days",13048,Per diem,,13048,,"2,174.65 x patient days",13048,Per diem,,13048,,"2,174.65 x patient days",13048,Per diem,,13048,,"2,174.65 x patient days",13048,Per diem,,29358,,"4,892.96 x patient days",29358,Per diem,,19963,,"3,327.21 x patient days",19963,Per diem,,29358,,"4,892.96 x patient days",29358,Per diem,,18267,,"3,044.51 x patient days",18267,Per diem,,29358,,"4,892.96 x patient days",29358,Per diem,,35882,,"5,980.29 x patient days",35882,Per diem,,42276,,"7,045.87 x patient days",42276,Per diem,,28053,,"4,675.50 x patient days",28053,Per diem,,28053,,"4,675.50 x patient days",28053,Per diem,,16310,,"2,718.31 x patient days",16310,Per diem,,0.01,42276,
HIV w one signif HIV cond or w/o signif related cond,894-1,APR-DRG,,,,,,,,inpatient,,,79599,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,16180,,"4,044.85 x patient days",16180,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,16962,,"27,634 x DRG weight",16962,Other,base rate x DRG weight,14417,,"23,488 x DRG weight",14417,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,13309,,"3,327.21 x patient days",13309,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,12179,,"3,044.51 x patient days",12179,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,23922,,"5,980.29 x patient days",23922,Per diem,,28185,,"7,045.87 x patient days",28185,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,10874,,"2,718.31 x patient days",10874,Per diem,,0.01,28185,
HIV w one signif HIV cond or w/o signif related cond,894-2,APR-DRG,,,,,,,,inpatient,,,108793.55,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,16180,,"4,044.85 x patient days",16180,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,21057,,"27,634 x DRG weight",21057,Other,base rate x DRG weight,17898,,"23,488 x DRG weight",17898,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,13309,,"3,327.21 x patient days",13309,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,12179,,"3,044.51 x patient days",12179,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,23922,,"5,980.29 x patient days",23922,Per diem,,28185,,"7,045.87 x patient days",28185,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,10874,,"2,718.31 x patient days",10874,Per diem,,0.01,28185,
HIV w one signif HIV cond or w/o signif related cond,894-3,APR-DRG,,,,,,,,inpatient,,,338221.04,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,16180,,"4,044.85 x patient days",16180,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,32033,,"27,634 x DRG weight",32033,Other,base rate x DRG weight,27227,,"23,488 x DRG weight",27227,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,13309,,"3,327.21 x patient days",13309,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,12179,,"3,044.51 x patient days",12179,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,23922,,"5,980.29 x patient days",23922,Per diem,,28185,,"7,045.87 x patient days",28185,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,10874,,"2,718.31 x patient days",10874,Per diem,,0.01,32033,
HIV w one signif HIV cond or w/o signif related cond,894-4,APR-DRG,,,,,,,,inpatient,,,338221.04,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,16180,,"4,044.85 x patient days",16180,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,32033,,"27,634 x DRG weight",32033,Other,base rate x DRG weight,27227,,"23,488 x DRG weight",27227,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,8699,,"2,174.65 x patient days",8699,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,13309,,"3,327.21 x patient days",13309,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,12179,,"3,044.51 x patient days",12179,Per diem,,19573,,"4,892.96 x patient days",19573,Per diem,,23922,,"5,980.29 x patient days",23922,Per diem,,28185,,"7,045.87 x patient days",28185,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,18703,,"4,675.50 x patient days",18703,Per diem,,10874,,"2,718.31 x patient days",10874,Per diem,,0.01,32033,
Craniotomy for multiple significant trauma,910-1,APR-DRG,,,,,,,,inpatient,,,471439.81,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,60673,,"4,044.85 x patient days",60673,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,103887,,"27,634 x DRG weight",103887,Other,base rate x DRG weight,88301,,"23,488 x DRG weight",88301,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,32620,,"2,174.65 x patient days",32620,Per diem,,32620,,"2,174.65 x patient days",32620,Per diem,,32620,,"2,174.65 x patient days",32620,Per diem,,32620,,"2,174.65 x patient days",32620,Per diem,,73395,,"4,892.96 x patient days",73395,Per diem,,49909,,"3,327.21 x patient days",49909,Per diem,,73395,,"4,892.96 x patient days",73395,Per diem,,45668,,"3,044.51 x patient days",45668,Per diem,,73395,,"4,892.96 x patient days",73395,Per diem,,89705,,"5,980.29 x patient days",89705,Per diem,,105689,,"7,045.87 x patient days",105689,Per diem,,70133,,"4,675.50 x patient days",70133,Per diem,,70133,,"4,675.50 x patient days",70133,Per diem,,40775,,"2,718.31 x patient days",40775,Per diem,,0.01,105689,
Craniotomy for multiple significant trauma,910-2,APR-DRG,,,,,,,,inpatient,,,268119.64,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,60673,,"4,044.85 x patient days",60673,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,103887,,"27,634 x DRG weight",103887,Other,base rate x DRG weight,88301,,"23,488 x DRG weight",88301,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,32620,,"2,174.65 x patient days",32620,Per diem,,32620,,"2,174.65 x patient days",32620,Per diem,,32620,,"2,174.65 x patient days",32620,Per diem,,32620,,"2,174.65 x patient days",32620,Per diem,,73395,,"4,892.96 x patient days",73395,Per diem,,49909,,"3,327.21 x patient days",49909,Per diem,,73395,,"4,892.96 x patient days",73395,Per diem,,45668,,"3,044.51 x patient days",45668,Per diem,,73395,,"4,892.96 x patient days",73395,Per diem,,89705,,"5,980.29 x patient days",89705,Per diem,,105689,,"7,045.87 x patient days",105689,Per diem,,70133,,"4,675.50 x patient days",70133,Per diem,,70133,,"4,675.50 x patient days",70133,Per diem,,40775,,"2,718.31 x patient days",40775,Per diem,,0.01,105689,
Craniotomy for multiple significant trauma,910-3,APR-DRG,,,,,,,,inpatient,,,538732.64,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,60673,,"4,044.85 x patient days",60673,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,107140,,"27,634 x DRG weight",107140,Other,base rate x DRG weight,91065,,"23,488 x DRG weight",91065,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,32620,,"2,174.65 x patient days",32620,Per diem,,32620,,"2,174.65 x patient days",32620,Per diem,,32620,,"2,174.65 x patient days",32620,Per diem,,32620,,"2,174.65 x patient days",32620,Per diem,,73395,,"4,892.96 x patient days",73395,Per diem,,49909,,"3,327.21 x patient days",49909,Per diem,,73395,,"4,892.96 x patient days",73395,Per diem,,45668,,"3,044.51 x patient days",45668,Per diem,,73395,,"4,892.96 x patient days",73395,Per diem,,89705,,"5,980.29 x patient days",89705,Per diem,,105689,,"7,045.87 x patient days",105689,Per diem,,70133,,"4,675.50 x patient days",70133,Per diem,,70133,,"4,675.50 x patient days",70133,Per diem,,40775,,"2,718.31 x patient days",40775,Per diem,,0.01,107140,
Craniotomy for multiple significant trauma,910-4,APR-DRG,,,,,,,,inpatient,,,814911.51,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,60673,,"4,044.85 x patient days",60673,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,198481,,"27,634 x DRG weight",198481,Other,base rate x DRG weight,168703,,"23,488 x DRG weight",168703,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,32620,,"2,174.65 x patient days",32620,Per diem,,32620,,"2,174.65 x patient days",32620,Per diem,,32620,,"2,174.65 x patient days",32620,Per diem,,32620,,"2,174.65 x patient days",32620,Per diem,,73395,,"4,892.96 x patient days",73395,Per diem,,49909,,"3,327.21 x patient days",49909,Per diem,,73395,,"4,892.96 x patient days",73395,Per diem,,45668,,"3,044.51 x patient days",45668,Per diem,,73395,,"4,892.96 x patient days",73395,Per diem,,89705,,"5,980.29 x patient days",89705,Per diem,,105689,,"7,045.87 x patient days",105689,Per diem,,70133,,"4,675.50 x patient days",70133,Per diem,,70133,,"4,675.50 x patient days",70133,Per diem,,40775,,"2,718.31 x patient days",40775,Per diem,,0.01,198481,
Extensive abdominal/thoracic procedures for mult significant trauma,911-1,APR-DRG,,,,,,,,inpatient,,,165345.37,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,52582,,"4,044.85 x patient days",52582,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,51714,,"27,634 x DRG weight",51714,Other,base rate x DRG weight,43955,,"23,488 x DRG weight",43955,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,28270,,"2,174.65 x patient days",28270,Per diem,,28270,,"2,174.65 x patient days",28270,Per diem,,28270,,"2,174.65 x patient days",28270,Per diem,,28270,,"2,174.65 x patient days",28270,Per diem,,63608,,"4,892.96 x patient days",63608,Per diem,,43253,,"3,327.21 x patient days",43253,Per diem,,63608,,"4,892.96 x patient days",63608,Per diem,,39578,,"3,044.51 x patient days",39578,Per diem,,63608,,"4,892.96 x patient days",63608,Per diem,,77743,,"5,980.29 x patient days",77743,Per diem,,91595,,"7,045.87 x patient days",91595,Per diem,,60781,,"4,675.50 x patient days",60781,Per diem,,60781,,"4,675.50 x patient days",60781,Per diem,,35338,,"2,718.31 x patient days",35338,Per diem,,0.01,91595,
Extensive abdominal/thoracic procedures for mult significant trauma,911-2,APR-DRG,,,,,,,,inpatient,,,165345.37,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,52582,,"4,044.85 x patient days",52582,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,51714,,"27,634 x DRG weight",51714,Other,base rate x DRG weight,43955,,"23,488 x DRG weight",43955,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,28270,,"2,174.65 x patient days",28270,Per diem,,28270,,"2,174.65 x patient days",28270,Per diem,,28270,,"2,174.65 x patient days",28270,Per diem,,28270,,"2,174.65 x patient days",28270,Per diem,,63608,,"4,892.96 x patient days",63608,Per diem,,43253,,"3,327.21 x patient days",43253,Per diem,,63608,,"4,892.96 x patient days",63608,Per diem,,39578,,"3,044.51 x patient days",39578,Per diem,,63608,,"4,892.96 x patient days",63608,Per diem,,77743,,"5,980.29 x patient days",77743,Per diem,,91595,,"7,045.87 x patient days",91595,Per diem,,60781,,"4,675.50 x patient days",60781,Per diem,,60781,,"4,675.50 x patient days",60781,Per diem,,35338,,"2,718.31 x patient days",35338,Per diem,,0.01,91595,
Extensive abdominal/thoracic procedures for mult significant trauma,911-3,APR-DRG,,,,,,,,inpatient,,,373998.98,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,52582,,"4,044.85 x patient days",52582,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,70829,,"27,634 x DRG weight",70829,Other,base rate x DRG weight,60202,,"23,488 x DRG weight",60202,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,28270,,"2,174.65 x patient days",28270,Per diem,,28270,,"2,174.65 x patient days",28270,Per diem,,28270,,"2,174.65 x patient days",28270,Per diem,,28270,,"2,174.65 x patient days",28270,Per diem,,63608,,"4,892.96 x patient days",63608,Per diem,,43253,,"3,327.21 x patient days",43253,Per diem,,63608,,"4,892.96 x patient days",63608,Per diem,,39578,,"3,044.51 x patient days",39578,Per diem,,63608,,"4,892.96 x patient days",63608,Per diem,,77743,,"5,980.29 x patient days",77743,Per diem,,91595,,"7,045.87 x patient days",91595,Per diem,,60781,,"4,675.50 x patient days",60781,Per diem,,60781,,"4,675.50 x patient days",60781,Per diem,,35338,,"2,718.31 x patient days",35338,Per diem,,0.01,91595,
Extensive abdominal/thoracic procedures for mult significant trauma,911-4,APR-DRG,,,,,,,,inpatient,,,704549.44,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,52582,,"4,044.85 x patient days",52582,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,179353,,"27,634 x DRG weight",179353,Other,base rate x DRG weight,152444,,"23,488 x DRG weight",152444,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,28270,,"2,174.65 x patient days",28270,Per diem,,28270,,"2,174.65 x patient days",28270,Per diem,,28270,,"2,174.65 x patient days",28270,Per diem,,28270,,"2,174.65 x patient days",28270,Per diem,,63608,,"4,892.96 x patient days",63608,Per diem,,43253,,"3,327.21 x patient days",43253,Per diem,,63608,,"4,892.96 x patient days",63608,Per diem,,39578,,"3,044.51 x patient days",39578,Per diem,,63608,,"4,892.96 x patient days",63608,Per diem,,77743,,"5,980.29 x patient days",77743,Per diem,,91595,,"7,045.87 x patient days",91595,Per diem,,60781,,"4,675.50 x patient days",60781,Per diem,,60781,,"4,675.50 x patient days",60781,Per diem,,35338,,"2,718.31 x patient days",35338,Per diem,,0.01,179353,
Musculoskeletal & other procedures for multiple significant trauma,912-1,APR-DRG,,,,,,,,inpatient,,,358233.46,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,52582,,"4,044.85 x patient days",52582,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,65327,,"27,634 x DRG weight",65327,Other,base rate x DRG weight,55526,,"23,488 x DRG weight",55526,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,28270,,"2,174.65 x patient days",28270,Per diem,,28270,,"2,174.65 x patient days",28270,Per diem,,28270,,"2,174.65 x patient days",28270,Per diem,,28270,,"2,174.65 x patient days",28270,Per diem,,63608,,"4,892.96 x patient days",63608,Per diem,,43253,,"3,327.21 x patient days",43253,Per diem,,63608,,"4,892.96 x patient days",63608,Per diem,,39578,,"3,044.51 x patient days",39578,Per diem,,63608,,"4,892.96 x patient days",63608,Per diem,,77743,,"5,980.29 x patient days",77743,Per diem,,91595,,"7,045.87 x patient days",91595,Per diem,,60781,,"4,675.50 x patient days",60781,Per diem,,60781,,"4,675.50 x patient days",60781,Per diem,,35338,,"2,718.31 x patient days",35338,Per diem,,0.01,91595,
Musculoskeletal & other procedures for multiple significant trauma,912-2,APR-DRG,,,,,,,,inpatient,,,330220.32,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,52582,,"4,044.85 x patient days",52582,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,65377,,"27,634 x DRG weight",65377,Other,base rate x DRG weight,55568,,"23,488 x DRG weight",55568,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,28270,,"2,174.65 x patient days",28270,Per diem,,28270,,"2,174.65 x patient days",28270,Per diem,,28270,,"2,174.65 x patient days",28270,Per diem,,28270,,"2,174.65 x patient days",28270,Per diem,,63608,,"4,892.96 x patient days",63608,Per diem,,43253,,"3,327.21 x patient days",43253,Per diem,,63608,,"4,892.96 x patient days",63608,Per diem,,39578,,"3,044.51 x patient days",39578,Per diem,,63608,,"4,892.96 x patient days",63608,Per diem,,77743,,"5,980.29 x patient days",77743,Per diem,,91595,,"7,045.87 x patient days",91595,Per diem,,60781,,"4,675.50 x patient days",60781,Per diem,,60781,,"4,675.50 x patient days",60781,Per diem,,35338,,"2,718.31 x patient days",35338,Per diem,,0.01,91595,
Musculoskeletal & other procedures for multiple significant trauma,912-3,APR-DRG,,,,,,,,inpatient,,,535118.73,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,52582,,"4,044.85 x patient days",52582,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,108754,,"27,634 x DRG weight",108754,Other,base rate x DRG weight,92437,,"23,488 x DRG weight",92437,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,28270,,"2,174.65 x patient days",28270,Per diem,,28270,,"2,174.65 x patient days",28270,Per diem,,28270,,"2,174.65 x patient days",28270,Per diem,,28270,,"2,174.65 x patient days",28270,Per diem,,63608,,"4,892.96 x patient days",63608,Per diem,,43253,,"3,327.21 x patient days",43253,Per diem,,63608,,"4,892.96 x patient days",63608,Per diem,,39578,,"3,044.51 x patient days",39578,Per diem,,63608,,"4,892.96 x patient days",63608,Per diem,,77743,,"5,980.29 x patient days",77743,Per diem,,91595,,"7,045.87 x patient days",91595,Per diem,,60781,,"4,675.50 x patient days",60781,Per diem,,60781,,"4,675.50 x patient days",60781,Per diem,,35338,,"2,718.31 x patient days",35338,Per diem,,0.01,108754,
Musculoskeletal & other procedures for multiple significant trauma,912-4,APR-DRG,,,,,,,,inpatient,,,895444.01,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,52582,,"4,044.85 x patient days",52582,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,209372,,"27,634 x DRG weight",209372,Other,base rate x DRG weight,177959,,"23,488 x DRG weight",177959,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,28270,,"2,174.65 x patient days",28270,Per diem,,28270,,"2,174.65 x patient days",28270,Per diem,,28270,,"2,174.65 x patient days",28270,Per diem,,28270,,"2,174.65 x patient days",28270,Per diem,,63608,,"4,892.96 x patient days",63608,Per diem,,43253,,"3,327.21 x patient days",43253,Per diem,,63608,,"4,892.96 x patient days",63608,Per diem,,39578,,"3,044.51 x patient days",39578,Per diem,,63608,,"4,892.96 x patient days",63608,Per diem,,77743,,"5,980.29 x patient days",77743,Per diem,,91595,,"7,045.87 x patient days",91595,Per diem,,60781,,"4,675.50 x patient days",60781,Per diem,,60781,,"4,675.50 x patient days",60781,Per diem,,35338,,"2,718.31 x patient days",35338,Per diem,,0.01,209372,
Multiple significant trauma w/o O.R. procedure,930-1,APR-DRG,,,,,,,,inpatient,,,157058,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,24269,,"4,044.85 x patient days",24269,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,24370,,"27,634 x DRG weight",24370,Other,base rate x DRG weight,20714,,"23,488 x DRG weight",20714,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,13048,,"2,174.65 x patient days",13048,Per diem,,13048,,"2,174.65 x patient days",13048,Per diem,,13048,,"2,174.65 x patient days",13048,Per diem,,13048,,"2,174.65 x patient days",13048,Per diem,,29358,,"4,892.96 x patient days",29358,Per diem,,19963,,"3,327.21 x patient days",19963,Per diem,,29358,,"4,892.96 x patient days",29358,Per diem,,18267,,"3,044.51 x patient days",18267,Per diem,,29358,,"4,892.96 x patient days",29358,Per diem,,35882,,"5,980.29 x patient days",35882,Per diem,,42276,,"7,045.87 x patient days",42276,Per diem,,28053,,"4,675.50 x patient days",28053,Per diem,,28053,,"4,675.50 x patient days",28053,Per diem,,16310,,"2,718.31 x patient days",16310,Per diem,,0.01,42276,
Multiple significant trauma w/o O.R. procedure,930-2,APR-DRG,,,,,,,,inpatient,,,161187.65,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,24269,,"4,044.85 x patient days",24269,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,24498,,"27,634 x DRG weight",24498,Other,base rate x DRG weight,20822,,"23,488 x DRG weight",20822,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,13048,,"2,174.65 x patient days",13048,Per diem,,13048,,"2,174.65 x patient days",13048,Per diem,,13048,,"2,174.65 x patient days",13048,Per diem,,13048,,"2,174.65 x patient days",13048,Per diem,,29358,,"4,892.96 x patient days",29358,Per diem,,19963,,"3,327.21 x patient days",19963,Per diem,,29358,,"4,892.96 x patient days",29358,Per diem,,18267,,"3,044.51 x patient days",18267,Per diem,,29358,,"4,892.96 x patient days",29358,Per diem,,35882,,"5,980.29 x patient days",35882,Per diem,,42276,,"7,045.87 x patient days",42276,Per diem,,28053,,"4,675.50 x patient days",28053,Per diem,,28053,,"4,675.50 x patient days",28053,Per diem,,16310,,"2,718.31 x patient days",16310,Per diem,,0.01,42276,
Multiple significant trauma w/o O.R. procedure,930-3,APR-DRG,,,,,,,,inpatient,,,194551.13,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,24269,,"4,044.85 x patient days",24269,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,43736,,"27,634 x DRG weight",43736,Other,base rate x DRG weight,37174,,"23,488 x DRG weight",37174,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,13048,,"2,174.65 x patient days",13048,Per diem,,13048,,"2,174.65 x patient days",13048,Per diem,,13048,,"2,174.65 x patient days",13048,Per diem,,13048,,"2,174.65 x patient days",13048,Per diem,,29358,,"4,892.96 x patient days",29358,Per diem,,19963,,"3,327.21 x patient days",19963,Per diem,,29358,,"4,892.96 x patient days",29358,Per diem,,18267,,"3,044.51 x patient days",18267,Per diem,,29358,,"4,892.96 x patient days",29358,Per diem,,35882,,"5,980.29 x patient days",35882,Per diem,,42276,,"7,045.87 x patient days",42276,Per diem,,28053,,"4,675.50 x patient days",28053,Per diem,,28053,,"4,675.50 x patient days",28053,Per diem,,16310,,"2,718.31 x patient days",16310,Per diem,,0.01,43736,
Multiple significant trauma w/o O.R. procedure,930-4,APR-DRG,,,,,,,,inpatient,,,364385.02,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,24269,,"4,044.85 x patient days",24269,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,100975,,"27,634 x DRG weight",100975,Other,base rate x DRG weight,85825,,"23,488 x DRG weight",85825,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,13048,,"2,174.65 x patient days",13048,Per diem,,13048,,"2,174.65 x patient days",13048,Per diem,,13048,,"2,174.65 x patient days",13048,Per diem,,13048,,"2,174.65 x patient days",13048,Per diem,,29358,,"4,892.96 x patient days",29358,Per diem,,19963,,"3,327.21 x patient days",19963,Per diem,,29358,,"4,892.96 x patient days",29358,Per diem,,18267,,"3,044.51 x patient days",18267,Per diem,,29358,,"4,892.96 x patient days",29358,Per diem,,35882,,"5,980.29 x patient days",35882,Per diem,,42276,,"7,045.87 x patient days",42276,Per diem,,28053,,"4,675.50 x patient days",28053,Per diem,,28053,,"4,675.50 x patient days",28053,Per diem,,16310,,"2,718.31 x patient days",16310,Per diem,,0.01,100975,
Extensive procedure unrelated to principal diagnosis,950-1,APR-DRG,,,,,,,,inpatient,,,101207.35,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,48539,,"4,044.85 x patient days",48539,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,37649,,"27,634 x DRG weight",37649,Other,base rate x DRG weight,32000,,"23,488 x DRG weight",32000,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,26096,,"2,174.65 x patient days",26096,Per diem,,26096,,"2,174.65 x patient days",26096,Per diem,,26096,,"2,174.65 x patient days",26096,Per diem,,26096,,"2,174.65 x patient days",26096,Per diem,,58716,,"4,892.96 x patient days",58716,Per diem,,39927,,"3,327.21 x patient days",39927,Per diem,,58716,,"4,892.96 x patient days",58716,Per diem,,36534,,"3,044.51 x patient days",36534,Per diem,,58716,,"4,892.96 x patient days",58716,Per diem,,71764,,"5,980.29 x patient days",71764,Per diem,,84551,,"7,045.87 x patient days",84551,Per diem,,56106,,"4,675.50 x patient days",56106,Per diem,,56106,,"4,675.50 x patient days",56106,Per diem,,32620,,"2,718.31 x patient days",32620,Per diem,,0.01,84551,
Extensive procedure unrelated to principal diagnosis,950-2,APR-DRG,,,,,,,,inpatient,,,199694.51,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,48539,,"4,044.85 x patient days",48539,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,59662,,"27,634 x DRG weight",59662,Other,base rate x DRG weight,50711,,"23,488 x DRG weight",50711,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,26096,,"2,174.65 x patient days",26096,Per diem,,26096,,"2,174.65 x patient days",26096,Per diem,,26096,,"2,174.65 x patient days",26096,Per diem,,26096,,"2,174.65 x patient days",26096,Per diem,,58716,,"4,892.96 x patient days",58716,Per diem,,39927,,"3,327.21 x patient days",39927,Per diem,,58716,,"4,892.96 x patient days",58716,Per diem,,36534,,"3,044.51 x patient days",36534,Per diem,,58716,,"4,892.96 x patient days",58716,Per diem,,71764,,"5,980.29 x patient days",71764,Per diem,,84551,,"7,045.87 x patient days",84551,Per diem,,56106,,"4,675.50 x patient days",56106,Per diem,,56106,,"4,675.50 x patient days",56106,Per diem,,32620,,"2,718.31 x patient days",32620,Per diem,,0.01,84551,
Extensive procedure unrelated to principal diagnosis,950-3,APR-DRG,,,,,,,,inpatient,,,333490.77,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,48539,,"4,044.85 x patient days",48539,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,110381,,"27,634 x DRG weight",110381,Other,base rate x DRG weight,93820,,"23,488 x DRG weight",93820,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,26096,,"2,174.65 x patient days",26096,Per diem,,26096,,"2,174.65 x patient days",26096,Per diem,,26096,,"2,174.65 x patient days",26096,Per diem,,26096,,"2,174.65 x patient days",26096,Per diem,,58716,,"4,892.96 x patient days",58716,Per diem,,39927,,"3,327.21 x patient days",39927,Per diem,,58716,,"4,892.96 x patient days",58716,Per diem,,36534,,"3,044.51 x patient days",36534,Per diem,,58716,,"4,892.96 x patient days",58716,Per diem,,71764,,"5,980.29 x patient days",71764,Per diem,,84551,,"7,045.87 x patient days",84551,Per diem,,56106,,"4,675.50 x patient days",56106,Per diem,,56106,,"4,675.50 x patient days",56106,Per diem,,32620,,"2,718.31 x patient days",32620,Per diem,,0.01,110381,
Extensive procedure unrelated to principal diagnosis,950-4,APR-DRG,,,,,,,,inpatient,,,2096908.33,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,48539,,"4,044.85 x patient days",48539,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,224231,,"27,634 x DRG weight",224231,Other,base rate x DRG weight,190589,,"23,488 x DRG weight",190589,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,26096,,"2,174.65 x patient days",26096,Per diem,,26096,,"2,174.65 x patient days",26096,Per diem,,26096,,"2,174.65 x patient days",26096,Per diem,,26096,,"2,174.65 x patient days",26096,Per diem,,58716,,"4,892.96 x patient days",58716,Per diem,,39927,,"3,327.21 x patient days",39927,Per diem,,58716,,"4,892.96 x patient days",58716,Per diem,,36534,,"3,044.51 x patient days",36534,Per diem,,58716,,"4,892.96 x patient days",58716,Per diem,,71764,,"5,980.29 x patient days",71764,Per diem,,84551,,"7,045.87 x patient days",84551,Per diem,,56106,,"4,675.50 x patient days",56106,Per diem,,56106,,"4,675.50 x patient days",56106,Per diem,,32620,,"2,718.31 x patient days",32620,Per diem,,0.01,224231,
Moderately extensive procedure unrelated to principal diagnosis,951-1,APR-DRG,,,,,,,,inpatient,,,102862.03,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,32358,,"4,044.85 x patient days",32358,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,25454,,"27,634 x DRG weight",25454,Other,base rate x DRG weight,21635,,"23,488 x DRG weight",21635,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,17397,,"2,174.65 x patient days",17397,Per diem,,17397,,"2,174.65 x patient days",17397,Per diem,,17397,,"2,174.65 x patient days",17397,Per diem,,17397,,"2,174.65 x patient days",17397,Per diem,,39143,,"4,892.96 x patient days",39143,Per diem,,26617,,"3,327.21 x patient days",26617,Per diem,,39143,,"4,892.96 x patient days",39143,Per diem,,24356,,"3,044.51 x patient days",24356,Per diem,,39143,,"4,892.96 x patient days",39143,Per diem,,47842,,"5,980.29 x patient days",47842,Per diem,,56366,,"7,045.87 x patient days",56366,Per diem,,37404,,"4,675.50 x patient days",37404,Per diem,,37404,,"4,675.50 x patient days",37404,Per diem,,21746,,"2,718.31 x patient days",21746,Per diem,,0.01,56366,
Moderately extensive procedure unrelated to principal diagnosis,951-2,APR-DRG,,,,,,,,inpatient,,,210190.27,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,32358,,"4,044.85 x patient days",32358,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,38428,,"27,634 x DRG weight",38428,Other,base rate x DRG weight,32662,,"23,488 x DRG weight",32662,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,17397,,"2,174.65 x patient days",17397,Per diem,,17397,,"2,174.65 x patient days",17397,Per diem,,17397,,"2,174.65 x patient days",17397,Per diem,,17397,,"2,174.65 x patient days",17397,Per diem,,39143,,"4,892.96 x patient days",39143,Per diem,,26617,,"3,327.21 x patient days",26617,Per diem,,39143,,"4,892.96 x patient days",39143,Per diem,,24356,,"3,044.51 x patient days",24356,Per diem,,39143,,"4,892.96 x patient days",39143,Per diem,,47842,,"5,980.29 x patient days",47842,Per diem,,56366,,"7,045.87 x patient days",56366,Per diem,,37404,,"4,675.50 x patient days",37404,Per diem,,37404,,"4,675.50 x patient days",37404,Per diem,,21746,,"2,718.31 x patient days",21746,Per diem,,0.01,56366,
Moderately extensive procedure unrelated to principal diagnosis,951-3,APR-DRG,,,,,,,,inpatient,,,357428,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,32358,,"4,044.85 x patient days",32358,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,74938,,"27,634 x DRG weight",74938,Other,base rate x DRG weight,63695,,"23,488 x DRG weight",63695,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,17397,,"2,174.65 x patient days",17397,Per diem,,17397,,"2,174.65 x patient days",17397,Per diem,,17397,,"2,174.65 x patient days",17397,Per diem,,17397,,"2,174.65 x patient days",17397,Per diem,,39143,,"4,892.96 x patient days",39143,Per diem,,26617,,"3,327.21 x patient days",26617,Per diem,,39143,,"4,892.96 x patient days",39143,Per diem,,24356,,"3,044.51 x patient days",24356,Per diem,,39143,,"4,892.96 x patient days",39143,Per diem,,47842,,"5,980.29 x patient days",47842,Per diem,,56366,,"7,045.87 x patient days",56366,Per diem,,37404,,"4,675.50 x patient days",37404,Per diem,,37404,,"4,675.50 x patient days",37404,Per diem,,21746,,"2,718.31 x patient days",21746,Per diem,,0.01,74938,
Moderately extensive procedure unrelated to principal diagnosis,951-4,APR-DRG,,,,,,,,inpatient,,,535294.18,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,32358,,"4,044.85 x patient days",32358,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,173406,,"27,634 x DRG weight",173406,Other,base rate x DRG weight,147390,,"23,488 x DRG weight",147390,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,17397,,"2,174.65 x patient days",17397,Per diem,,17397,,"2,174.65 x patient days",17397,Per diem,,17397,,"2,174.65 x patient days",17397,Per diem,,17397,,"2,174.65 x patient days",17397,Per diem,,39143,,"4,892.96 x patient days",39143,Per diem,,26617,,"3,327.21 x patient days",26617,Per diem,,39143,,"4,892.96 x patient days",39143,Per diem,,24356,,"3,044.51 x patient days",24356,Per diem,,39143,,"4,892.96 x patient days",39143,Per diem,,47842,,"5,980.29 x patient days",47842,Per diem,,56366,,"7,045.87 x patient days",56366,Per diem,,37404,,"4,675.50 x patient days",37404,Per diem,,37404,,"4,675.50 x patient days",37404,Per diem,,21746,,"2,718.31 x patient days",21746,Per diem,,0.01,173406,
Nonextensive procedure unrelated to principal diagnosis,952-1,APR-DRG,,,,,,,,inpatient,,,86105.83,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,24269,,"4,044.85 x patient days",24269,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,21690,,"27,634 x DRG weight",21690,Other,base rate x DRG weight,18436,,"23,488 x DRG weight",18436,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,13048,,"2,174.65 x patient days",13048,Per diem,,13048,,"2,174.65 x patient days",13048,Per diem,,13048,,"2,174.65 x patient days",13048,Per diem,,13048,,"2,174.65 x patient days",13048,Per diem,,29358,,"4,892.96 x patient days",29358,Per diem,,19963,,"3,327.21 x patient days",19963,Per diem,,29358,,"4,892.96 x patient days",29358,Per diem,,18267,,"3,044.51 x patient days",18267,Per diem,,29358,,"4,892.96 x patient days",29358,Per diem,,35882,,"5,980.29 x patient days",35882,Per diem,,42276,,"7,045.87 x patient days",42276,Per diem,,28053,,"4,675.50 x patient days",28053,Per diem,,28053,,"4,675.50 x patient days",28053,Per diem,,16310,,"2,718.31 x patient days",16310,Per diem,,0.01,42276,
Nonextensive procedure unrelated to principal diagnosis,952-2,APR-DRG,,,,,,,,inpatient,,,194934,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,24269,,"4,044.85 x patient days",24269,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,33056,,"27,634 x DRG weight",33056,Other,base rate x DRG weight,28096,,"23,488 x DRG weight",28096,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,13048,,"2,174.65 x patient days",13048,Per diem,,13048,,"2,174.65 x patient days",13048,Per diem,,13048,,"2,174.65 x patient days",13048,Per diem,,13048,,"2,174.65 x patient days",13048,Per diem,,29358,,"4,892.96 x patient days",29358,Per diem,,19963,,"3,327.21 x patient days",19963,Per diem,,29358,,"4,892.96 x patient days",29358,Per diem,,18267,,"3,044.51 x patient days",18267,Per diem,,29358,,"4,892.96 x patient days",29358,Per diem,,35882,,"5,980.29 x patient days",35882,Per diem,,42276,,"7,045.87 x patient days",42276,Per diem,,28053,,"4,675.50 x patient days",28053,Per diem,,28053,,"4,675.50 x patient days",28053,Per diem,,16310,,"2,718.31 x patient days",16310,Per diem,,0.01,42276,
Nonextensive procedure unrelated to principal diagnosis,952-3,APR-DRG,,,,,,,,inpatient,,,322751.37,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,24269,,"4,044.85 x patient days",24269,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,67535,,"27,634 x DRG weight",67535,Other,base rate x DRG weight,57402,,"23,488 x DRG weight",57402,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,13048,,"2,174.65 x patient days",13048,Per diem,,13048,,"2,174.65 x patient days",13048,Per diem,,13048,,"2,174.65 x patient days",13048,Per diem,,13048,,"2,174.65 x patient days",13048,Per diem,,29358,,"4,892.96 x patient days",29358,Per diem,,19963,,"3,327.21 x patient days",19963,Per diem,,29358,,"4,892.96 x patient days",29358,Per diem,,18267,,"3,044.51 x patient days",18267,Per diem,,29358,,"4,892.96 x patient days",29358,Per diem,,35882,,"5,980.29 x patient days",35882,Per diem,,42276,,"7,045.87 x patient days",42276,Per diem,,28053,,"4,675.50 x patient days",28053,Per diem,,28053,,"4,675.50 x patient days",28053,Per diem,,16310,,"2,718.31 x patient days",16310,Per diem,,0.01,67535,
Nonextensive procedure unrelated to principal diagnosis,952-4,APR-DRG,,,,,,,,inpatient,,,411452.32,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,24269,,"4,044.85 x patient days",24269,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,163914,,"27,634 x DRG weight",163914,Other,base rate x DRG weight,139321,,"23,488 x DRG weight",139321,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,13048,,"2,174.65 x patient days",13048,Per diem,,13048,,"2,174.65 x patient days",13048,Per diem,,13048,,"2,174.65 x patient days",13048,Per diem,,13048,,"2,174.65 x patient days",13048,Per diem,,29358,,"4,892.96 x patient days",29358,Per diem,,19963,,"3,327.21 x patient days",19963,Per diem,,29358,,"4,892.96 x patient days",29358,Per diem,,18267,,"3,044.51 x patient days",18267,Per diem,,29358,,"4,892.96 x patient days",29358,Per diem,,35882,,"5,980.29 x patient days",35882,Per diem,,42276,,"7,045.87 x patient days",42276,Per diem,,28053,,"4,675.50 x patient days",28053,Per diem,,28053,,"4,675.50 x patient days",28053,Per diem,,16310,,"2,718.31 x patient days",16310,Per diem,,0.01,163914,
Fna bx w/o img gdn ea addl,10004,CPT,,,,,,,,both,,,32432.1,23999.75,74,,23999.75,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,14594.45,45,,14594.45,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,16053.89,49.5,,16053.89,percent of total billed charges,110% of Medicare,22053.83,68,,22053.83,percent of total billed charges,,1037.55,,,1037.55,Other,186% of Medicaid,25945.68,80,,25945.68,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,25945.68,80,,25945.68,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,22702.47,70,,22702.47,percent of total billed charges,,206.64,,,206.64,Fee Schedule,,175.14,,,175.14,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,557.82,,,557.82,Other,New York Medicaid APG methodology,557.82,,,557.82,Other,100% New York Medicaid APG,557.82,,,557.82,Other,100% New York Medicaid APG,557.82,,,557.82,Other,100% New York Medicaid APG,1255.1,,,1255.1,Other,225% New York Medicaid APG,853.47,,,853.47,Other,153% New York Medicaid APG,1255.1,,,1255.1,Other,225% New York Medicaid APG,780.95,,,780.95,Other,140% New York Medicaid APG,1255.1,,,1255.1,Other,225% New York Medicaid APG,1450.34,,,1450.34,Other,260% New York Medicaid APG,1807.35,,,1807.35,Other,324% New York Medicaid APG,1199.32,,,1199.32,Other,215% New York Medicaid APG,1199.32,,,1199.32,Other,215% New York Medicaid APG,697.28,,,697.28,Other,125% New York Medicaid APG,175.14,25945.68,
Fna bx w/us gdn 1st les,10005,CPT,,,,,,,,both,,,21618.49,15997.68,74,,15997.68,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,9728.32,45,,9728.32,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,10701.15,49.5,,10701.15,percent of total billed charges,110% of Medicare,14700.57,68,,14700.57,percent of total billed charges,,1037.55,,,1037.55,Other,186% of Medicaid,17294.79,80,,17294.79,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,17294.79,80,,17294.79,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,15132.94,70,,15132.94,percent of total billed charges,,357.52,,,357.52,Fee Schedule,,303.02,,,303.02,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,557.82,,,557.82,Other,New York Medicaid APG methodology,557.82,,,557.82,Other,100% New York Medicaid APG,557.82,,,557.82,Other,100% New York Medicaid APG,557.82,,,557.82,Other,100% New York Medicaid APG,1255.1,,,1255.1,Other,225% New York Medicaid APG,853.47,,,853.47,Other,153% New York Medicaid APG,1255.1,,,1255.1,Other,225% New York Medicaid APG,780.95,,,780.95,Other,140% New York Medicaid APG,1255.1,,,1255.1,Other,225% New York Medicaid APG,1450.34,,,1450.34,Other,260% New York Medicaid APG,1807.35,,,1807.35,Other,324% New York Medicaid APG,1199.32,,,1199.32,Other,215% New York Medicaid APG,1199.32,,,1199.32,Other,215% New York Medicaid APG,697.28,,,697.28,Other,125% New York Medicaid APG,303.02,17294.79,
Fna bx w/us gdn ea addl,10006,CPT,,,,,,,,both,,,32432.1,23999.75,74,,23999.75,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,14594.45,45,,14594.45,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,16053.89,49.5,,16053.89,percent of total billed charges,110% of Medicare,22053.83,68,,22053.83,percent of total billed charges,,1037.55,,,1037.55,Other,186% of Medicaid,25945.68,80,,25945.68,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,25945.68,80,,25945.68,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,22702.47,70,,22702.47,percent of total billed charges,,242.72,,,242.72,Fee Schedule,,205.72,,,205.72,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,557.82,,,557.82,Other,New York Medicaid APG methodology,557.82,,,557.82,Other,100% New York Medicaid APG,557.82,,,557.82,Other,100% New York Medicaid APG,557.82,,,557.82,Other,100% New York Medicaid APG,1255.1,,,1255.1,Other,225% New York Medicaid APG,853.47,,,853.47,Other,153% New York Medicaid APG,1255.1,,,1255.1,Other,225% New York Medicaid APG,780.95,,,780.95,Other,140% New York Medicaid APG,1255.1,,,1255.1,Other,225% New York Medicaid APG,1450.34,,,1450.34,Other,260% New York Medicaid APG,1807.35,,,1807.35,Other,324% New York Medicaid APG,1199.32,,,1199.32,Other,215% New York Medicaid APG,1199.32,,,1199.32,Other,215% New York Medicaid APG,697.28,,,697.28,Other,125% New York Medicaid APG,205.72,25945.68,
Fna bx w/fluor gdn 1st les,10007,CPT,,,,,,,,both,,,14798.8,10951.11,74,,10951.11,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,6659.46,45,,6659.46,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,7325.41,49.5,,7325.41,percent of total billed charges,110% of Medicare,10063.18,68,,10063.18,percent of total billed charges,,1037.55,,,1037.55,Other,186% of Medicaid,11839.04,80,,11839.04,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,11839.04,80,,11839.04,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,10359.16,70,,10359.16,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,557.82,,,557.82,Other,New York Medicaid APG methodology,557.82,,,557.82,Other,100% New York Medicaid APG,557.82,,,557.82,Other,100% New York Medicaid APG,557.82,,,557.82,Other,100% New York Medicaid APG,1255.1,,,1255.1,Other,225% New York Medicaid APG,853.47,,,853.47,Other,153% New York Medicaid APG,1255.1,,,1255.1,Other,225% New York Medicaid APG,780.95,,,780.95,Other,140% New York Medicaid APG,1255.1,,,1255.1,Other,225% New York Medicaid APG,1450.34,,,1450.34,Other,260% New York Medicaid APG,1807.35,,,1807.35,Other,324% New York Medicaid APG,1199.32,,,1199.32,Other,215% New York Medicaid APG,1199.32,,,1199.32,Other,215% New York Medicaid APG,697.28,,,697.28,Other,125% New York Medicaid APG,557.82,11839.04,
Fna bx w/fluor gdn ea addl,10008,CPT,,,,,,,,both,,,32432.1,23999.75,74,,23999.75,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,14594.45,45,,14594.45,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,16053.89,49.5,,16053.89,percent of total billed charges,110% of Medicare,22053.83,68,,22053.83,percent of total billed charges,,1037.55,,,1037.55,Other,186% of Medicaid,25945.68,80,,25945.68,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,25945.68,80,,25945.68,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,22702.47,70,,22702.47,percent of total billed charges,,254.2,,,254.2,Fee Schedule,,215.45,,,215.45,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,557.82,,,557.82,Other,New York Medicaid APG methodology,557.82,,,557.82,Other,100% New York Medicaid APG,557.82,,,557.82,Other,100% New York Medicaid APG,557.82,,,557.82,Other,100% New York Medicaid APG,1255.1,,,1255.1,Other,225% New York Medicaid APG,853.47,,,853.47,Other,153% New York Medicaid APG,1255.1,,,1255.1,Other,225% New York Medicaid APG,780.95,,,780.95,Other,140% New York Medicaid APG,1255.1,,,1255.1,Other,225% New York Medicaid APG,1450.34,,,1450.34,Other,260% New York Medicaid APG,1807.35,,,1807.35,Other,324% New York Medicaid APG,1199.32,,,1199.32,Other,215% New York Medicaid APG,1199.32,,,1199.32,Other,215% New York Medicaid APG,697.28,,,697.28,Other,125% New York Medicaid APG,215.45,25945.68,
Fna bx w/ct gdn 1st les,10009,CPT,,,,,,,,both,,,14798.8,10951.11,74,,10951.11,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,6659.46,45,,6659.46,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,7325.41,49.5,,7325.41,percent of total billed charges,110% of Medicare,10063.18,68,,10063.18,percent of total billed charges,,1037.55,,,1037.55,Other,186% of Medicaid,11839.04,80,,11839.04,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,11839.04,80,,11839.04,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,10359.16,70,,10359.16,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,557.82,,,557.82,Other,New York Medicaid APG methodology,557.82,,,557.82,Other,100% New York Medicaid APG,557.82,,,557.82,Other,100% New York Medicaid APG,557.82,,,557.82,Other,100% New York Medicaid APG,1255.1,,,1255.1,Other,225% New York Medicaid APG,853.47,,,853.47,Other,153% New York Medicaid APG,1255.1,,,1255.1,Other,225% New York Medicaid APG,780.95,,,780.95,Other,140% New York Medicaid APG,1255.1,,,1255.1,Other,225% New York Medicaid APG,1450.34,,,1450.34,Other,260% New York Medicaid APG,1807.35,,,1807.35,Other,324% New York Medicaid APG,1199.32,,,1199.32,Other,215% New York Medicaid APG,1199.32,,,1199.32,Other,215% New York Medicaid APG,697.28,,,697.28,Other,125% New York Medicaid APG,557.82,11839.04,
Fna bx w/ct gdn ea addl,10010,CPT,,,,,,,,both,,,32432.1,23999.75,74,,23999.75,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,14594.45,45,,14594.45,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,16053.89,49.5,,16053.89,percent of total billed charges,110% of Medicare,22053.83,68,,22053.83,percent of total billed charges,,1037.55,,,1037.55,Other,186% of Medicaid,25945.68,80,,25945.68,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,25945.68,80,,25945.68,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,22702.47,70,,22702.47,percent of total billed charges,,347.68,,,347.68,Fee Schedule,,294.68,,,294.68,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,557.82,,,557.82,Other,New York Medicaid APG methodology,557.82,,,557.82,Other,100% New York Medicaid APG,557.82,,,557.82,Other,100% New York Medicaid APG,557.82,,,557.82,Other,100% New York Medicaid APG,1255.1,,,1255.1,Other,225% New York Medicaid APG,853.47,,,853.47,Other,153% New York Medicaid APG,1255.1,,,1255.1,Other,225% New York Medicaid APG,780.95,,,780.95,Other,140% New York Medicaid APG,1255.1,,,1255.1,Other,225% New York Medicaid APG,1450.34,,,1450.34,Other,260% New York Medicaid APG,1807.35,,,1807.35,Other,324% New York Medicaid APG,1199.32,,,1199.32,Other,215% New York Medicaid APG,1199.32,,,1199.32,Other,215% New York Medicaid APG,697.28,,,697.28,Other,125% New York Medicaid APG,294.68,25945.68,
Fna bx w/mr gdn 1st les,10011,CPT,,,,,,,,both,,,14798.8,10951.11,74,,10951.11,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,6659.46,45,,6659.46,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,7325.41,49.5,,7325.41,percent of total billed charges,110% of Medicare,10063.18,68,,10063.18,percent of total billed charges,,1037.55,,,1037.55,Other,186% of Medicaid,11839.04,80,,11839.04,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,11839.04,80,,11839.04,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,10359.16,70,,10359.16,percent of total billed charges,,9619.22,65,,9619.22,percent of total billed charges,,9619.22,65,,9619.22,percent of total billed charges,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,557.82,,,557.82,Other,New York Medicaid APG methodology,557.82,,,557.82,Other,100% New York Medicaid APG,557.82,,,557.82,Other,100% New York Medicaid APG,557.82,,,557.82,Other,100% New York Medicaid APG,1255.1,,,1255.1,Other,225% New York Medicaid APG,853.47,,,853.47,Other,153% New York Medicaid APG,1255.1,,,1255.1,Other,225% New York Medicaid APG,780.95,,,780.95,Other,140% New York Medicaid APG,1255.1,,,1255.1,Other,225% New York Medicaid APG,1450.34,,,1450.34,Other,260% New York Medicaid APG,1807.35,,,1807.35,Other,324% New York Medicaid APG,1199.32,,,1199.32,Other,215% New York Medicaid APG,1199.32,,,1199.32,Other,215% New York Medicaid APG,697.28,,,697.28,Other,125% New York Medicaid APG,557.82,11839.04,
Fna bx w/mr gdn ea addl,10012,CPT,,,,,,,,both,,,32432.1,23999.75,74,,23999.75,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,14594.45,45,,14594.45,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,16053.89,49.5,,16053.89,percent of total billed charges,110% of Medicare,22053.83,68,,22053.83,percent of total billed charges,,1037.55,,,1037.55,Other,186% of Medicaid,25945.68,80,,25945.68,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,25945.68,80,,25945.68,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,22702.47,70,,22702.47,percent of total billed charges,,21080.87,65,,21080.87,percent of total billed charges,,21080.87,65,,21080.87,percent of total billed charges,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,557.82,,,557.82,Other,New York Medicaid APG methodology,557.82,,,557.82,Other,100% New York Medicaid APG,557.82,,,557.82,Other,100% New York Medicaid APG,557.82,,,557.82,Other,100% New York Medicaid APG,1255.1,,,1255.1,Other,225% New York Medicaid APG,853.47,,,853.47,Other,153% New York Medicaid APG,1255.1,,,1255.1,Other,225% New York Medicaid APG,780.95,,,780.95,Other,140% New York Medicaid APG,1255.1,,,1255.1,Other,225% New York Medicaid APG,1450.34,,,1450.34,Other,260% New York Medicaid APG,1807.35,,,1807.35,Other,324% New York Medicaid APG,1199.32,,,1199.32,Other,215% New York Medicaid APG,1199.32,,,1199.32,Other,215% New York Medicaid APG,697.28,,,697.28,Other,125% New York Medicaid APG,557.82,25945.68,
Fna bx w/o img gdn 1st les,10021,CPT,,,,,,,,both,,,34782.5,25739.05,74,,25739.05,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15652.13,45,,15652.13,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,17217.34,49.5,,17217.34,percent of total billed charges,110% of Medicare,23652.1,68,,23652.1,percent of total billed charges,,1037.55,,,1037.55,Other,186% of Medicaid,27826,80,,27826,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,27826,80,,27826,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,24347.75,70,,24347.75,percent of total billed charges,,267.32,,,267.32,Fee Schedule,,226.57,,,226.57,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,557.82,,,557.82,Other,New York Medicaid APG methodology,557.82,,,557.82,Other,100% New York Medicaid APG,557.82,,,557.82,Other,100% New York Medicaid APG,557.82,,,557.82,Other,100% New York Medicaid APG,1255.1,,,1255.1,Other,225% New York Medicaid APG,853.47,,,853.47,Other,153% New York Medicaid APG,1255.1,,,1255.1,Other,225% New York Medicaid APG,780.95,,,780.95,Other,140% New York Medicaid APG,1255.1,,,1255.1,Other,225% New York Medicaid APG,1450.34,,,1450.34,Other,260% New York Medicaid APG,1807.35,,,1807.35,Other,324% New York Medicaid APG,1199.32,,,1199.32,Other,215% New York Medicaid APG,1199.32,,,1199.32,Other,215% New York Medicaid APG,697.28,,,697.28,Other,125% New York Medicaid APG,226.57,27826,
Guide cathet fluid drainage,10030,CPT,,,,,,,,both,,,17675.66,13079.99,74,,13079.99,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,7954.05,45,,7954.05,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,8749.45,49.5,,8749.45,percent of total billed charges,110% of Medicare,12019.45,68,,12019.45,percent of total billed charges,,1207.1,,,1207.1,Other,186% of Medicaid,14140.53,80,,14140.53,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,14140.53,80,,14140.53,percent of total billed charges,,7216,,,7216,Case Rate,,3578,,"100% primary, 0% secondary procedures",3578,Other,MagnaCare ASC Grouper,12372.96,70,,12372.96,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,648.98,,,648.98,Other,New York Medicaid APG methodology,648.98,,,648.98,Other,100% New York Medicaid APG,648.98,,,648.98,Other,100% New York Medicaid APG,648.98,,,648.98,Other,100% New York Medicaid APG,1460.2,,,1460.2,Other,225% New York Medicaid APG,992.94,,,992.94,Other,153% New York Medicaid APG,1460.2,,,1460.2,Other,225% New York Medicaid APG,908.57,,,908.57,Other,140% New York Medicaid APG,1460.2,,,1460.2,Other,225% New York Medicaid APG,1687.34,,,1687.34,Other,260% New York Medicaid APG,2102.69,,,2102.69,Other,324% New York Medicaid APG,1395.3,,,1395.3,Other,215% New York Medicaid APG,1395.3,,,1395.3,Other,215% New York Medicaid APG,811.22,,,811.22,Other,125% New York Medicaid APG,648.98,14140.53,
Perq dev soft tiss 1st imag,10035,CPT,,,,,,,,both,,,14798.8,10951.11,74,,10951.11,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,6659.46,45,,6659.46,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,7325.41,49.5,,7325.41,percent of total billed charges,110% of Medicare,10063.18,68,,10063.18,percent of total billed charges,,1207.1,,,1207.1,Other,186% of Medicaid,11839.04,80,,11839.04,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,11839.04,80,,11839.04,percent of total billed charges,,7216,,,7216,Case Rate,,3578,,"100% primary, 0% secondary procedures",3578,Other,MagnaCare ASC Grouper,10359.16,70,,10359.16,percent of total billed charges,,410,,,410,Fee Schedule,,347.5,,,347.5,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,648.98,,,648.98,Other,New York Medicaid APG methodology,648.98,,,648.98,Other,100% New York Medicaid APG,648.98,,,648.98,Other,100% New York Medicaid APG,648.98,,,648.98,Other,100% New York Medicaid APG,1460.2,,,1460.2,Other,225% New York Medicaid APG,992.94,,,992.94,Other,153% New York Medicaid APG,1460.2,,,1460.2,Other,225% New York Medicaid APG,908.57,,,908.57,Other,140% New York Medicaid APG,1460.2,,,1460.2,Other,225% New York Medicaid APG,1687.34,,,1687.34,Other,260% New York Medicaid APG,2102.69,,,2102.69,Other,324% New York Medicaid APG,1395.3,,,1395.3,Other,215% New York Medicaid APG,1395.3,,,1395.3,Other,215% New York Medicaid APG,811.22,,,811.22,Other,125% New York Medicaid APG,347.5,11839.04,
Perq dev soft tiss add imag,10036,CPT,,,,,,,,both,,,32432.1,23999.75,74,,23999.75,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,14594.45,45,,14594.45,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,16053.89,49.5,,16053.89,percent of total billed charges,110% of Medicare,22053.83,68,,22053.83,percent of total billed charges,,1207.1,,,1207.1,Other,186% of Medicaid,25945.68,80,,25945.68,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,25945.68,80,,25945.68,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,22702.47,70,,22702.47,percent of total billed charges,,206.64,,,206.64,Fee Schedule,,175.14,,,175.14,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,648.98,,,648.98,Other,New York Medicaid APG methodology,648.98,,,648.98,Other,100% New York Medicaid APG,648.98,,,648.98,Other,100% New York Medicaid APG,648.98,,,648.98,Other,100% New York Medicaid APG,1460.2,,,1460.2,Other,225% New York Medicaid APG,992.94,,,992.94,Other,153% New York Medicaid APG,1460.2,,,1460.2,Other,225% New York Medicaid APG,908.57,,,908.57,Other,140% New York Medicaid APG,1460.2,,,1460.2,Other,225% New York Medicaid APG,1687.34,,,1687.34,Other,260% New York Medicaid APG,2102.69,,,2102.69,Other,324% New York Medicaid APG,1395.3,,,1395.3,Other,215% New York Medicaid APG,1395.3,,,1395.3,Other,215% New York Medicaid APG,811.22,,,811.22,Other,125% New York Medicaid APG,175.14,25945.68,
Acne surgery,10040,CPT,,,,,,,,both,,,4210.98,3116.13,74,,3116.13,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,1894.94,45,,1894.94,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,2084.44,49.5,,2084.44,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,733.11,,,733.11,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,2947.69,70,,2947.69,percent of total billed charges,,252.56,,,252.56,Fee Schedule,,214.06,,,214.06,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,394.14,,,394.14,Other,New York Medicaid APG methodology,394.14,,,394.14,Other,100% New York Medicaid APG,394.14,,,394.14,Other,100% New York Medicaid APG,394.14,,,394.14,Other,100% New York Medicaid APG,886.83,,,886.83,Other,225% New York Medicaid APG,603.04,,,603.04,Other,153% New York Medicaid APG,886.83,,,886.83,Other,225% New York Medicaid APG,551.8,,,551.8,Other,140% New York Medicaid APG,886.83,,,886.83,Other,225% New York Medicaid APG,1024.78,,,1024.78,Other,260% New York Medicaid APG,1277.03,,,1277.03,Other,324% New York Medicaid APG,847.41,,,847.41,Other,215% New York Medicaid APG,847.41,,,847.41,Other,215% New York Medicaid APG,492.68,,,492.68,Other,125% New York Medicaid APG,214.06,9473,
Drainage of skin abscess,10060,CPT,,,,,,,,both,,,4210.98,3116.13,74,,3116.13,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,1894.94,45,,1894.94,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,2084.44,49.5,,2084.44,percent of total billed charges,110% of Medicare,2863.47,68,,2863.47,percent of total billed charges,,733.11,,,733.11,Other,186% of Medicaid,3368.78,80,,3368.78,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,3368.78,80,,3368.78,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,2947.69,70,,2947.69,percent of total billed charges,,514.96,,,514.96,Fee Schedule,,436.46,,,436.46,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,394.14,,,394.14,Other,New York Medicaid APG methodology,394.14,,,394.14,Other,100% New York Medicaid APG,394.14,,,394.14,Other,100% New York Medicaid APG,394.14,,,394.14,Other,100% New York Medicaid APG,886.83,,,886.83,Other,225% New York Medicaid APG,603.04,,,603.04,Other,153% New York Medicaid APG,886.83,,,886.83,Other,225% New York Medicaid APG,551.8,,,551.8,Other,140% New York Medicaid APG,886.83,,,886.83,Other,225% New York Medicaid APG,1024.78,,,1024.78,Other,260% New York Medicaid APG,1277.03,,,1277.03,Other,324% New York Medicaid APG,847.41,,,847.41,Other,215% New York Medicaid APG,847.41,,,847.41,Other,215% New York Medicaid APG,492.68,,,492.68,Other,125% New York Medicaid APG,394.14,7216,
Drainage of skin abscess,10061,CPT,,,,,,,,both,,,8387.08,6206.44,74,,6206.44,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,3774.19,45,,3774.19,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,4151.6,49.5,,4151.6,percent of total billed charges,110% of Medicare,5703.21,68,,5703.21,percent of total billed charges,,733.11,,,733.11,Other,186% of Medicaid,6709.66,80,,6709.66,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,6709.66,80,,6709.66,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,5870.96,70,,5870.96,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,394.14,,,394.14,Other,New York Medicaid APG methodology,394.14,,,394.14,Other,100% New York Medicaid APG,394.14,,,394.14,Other,100% New York Medicaid APG,394.14,,,394.14,Other,100% New York Medicaid APG,886.83,,,886.83,Other,225% New York Medicaid APG,603.04,,,603.04,Other,153% New York Medicaid APG,886.83,,,886.83,Other,225% New York Medicaid APG,551.8,,,551.8,Other,140% New York Medicaid APG,886.83,,,886.83,Other,225% New York Medicaid APG,1024.78,,,1024.78,Other,260% New York Medicaid APG,1277.03,,,1277.03,Other,324% New York Medicaid APG,847.41,,,847.41,Other,215% New York Medicaid APG,847.41,,,847.41,Other,215% New York Medicaid APG,492.68,,,492.68,Other,125% New York Medicaid APG,394.14,7216,
Drainage of pilonidal cyst,10080,CPT,,,,,,,,both,,,35124.08,25991.82,74,,25991.82,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15805.84,45,,15805.84,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,17386.42,49.5,,17386.42,percent of total billed charges,110% of Medicare,23884.37,68,,23884.37,percent of total billed charges,,733.11,,,733.11,Other,186% of Medicaid,28099.26,80,,28099.26,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,28099.26,80,,28099.26,percent of total billed charges,,7216,,,7216,Case Rate,,3578,,"100% primary, 0% secondary procedures",3578,Other,MagnaCare ASC Grouper,24586.86,70,,24586.86,percent of total billed charges,,511.68,,,511.68,Fee Schedule,,433.68,,,433.68,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,394.14,,,394.14,Other,New York Medicaid APG methodology,394.14,,,394.14,Other,100% New York Medicaid APG,394.14,,,394.14,Other,100% New York Medicaid APG,394.14,,,394.14,Other,100% New York Medicaid APG,886.83,,,886.83,Other,225% New York Medicaid APG,603.04,,,603.04,Other,153% New York Medicaid APG,886.83,,,886.83,Other,225% New York Medicaid APG,551.8,,,551.8,Other,140% New York Medicaid APG,886.83,,,886.83,Other,225% New York Medicaid APG,1024.78,,,1024.78,Other,260% New York Medicaid APG,1277.03,,,1277.03,Other,324% New York Medicaid APG,847.41,,,847.41,Other,215% New York Medicaid APG,847.41,,,847.41,Other,215% New York Medicaid APG,492.68,,,492.68,Other,125% New York Medicaid APG,394.14,28099.26,
Drainage of pilonidal cyst,10081,CPT,,,,,,,,both,,,36188.86,26779.76,74,,26779.76,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,16284.99,45,,16284.99,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,17913.49,49.5,,17913.49,percent of total billed charges,110% of Medicare,24608.42,68,,24608.42,percent of total billed charges,,1207.1,,,1207.1,Other,186% of Medicaid,28951.09,80,,28951.09,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,28951.09,80,,28951.09,percent of total billed charges,,7216,,,7216,Case Rate,,3578,,"100% primary, 0% secondary procedures",3578,Other,MagnaCare ASC Grouper,25332.2,70,,25332.2,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,648.98,,,648.98,Other,New York Medicaid APG methodology,648.98,,,648.98,Other,100% New York Medicaid APG,648.98,,,648.98,Other,100% New York Medicaid APG,648.98,,,648.98,Other,100% New York Medicaid APG,1460.2,,,1460.2,Other,225% New York Medicaid APG,992.94,,,992.94,Other,153% New York Medicaid APG,1460.2,,,1460.2,Other,225% New York Medicaid APG,908.57,,,908.57,Other,140% New York Medicaid APG,1460.2,,,1460.2,Other,225% New York Medicaid APG,1687.34,,,1687.34,Other,260% New York Medicaid APG,2102.69,,,2102.69,Other,324% New York Medicaid APG,1395.3,,,1395.3,Other,215% New York Medicaid APG,1395.3,,,1395.3,Other,215% New York Medicaid APG,811.22,,,811.22,Other,125% New York Medicaid APG,648.98,28951.09,
Remove foreign body,10120,CPT,,,,,,,,both,,,35136.3,26000.86,74,,26000.86,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15811.34,45,,15811.34,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,17392.47,49.5,,17392.47,percent of total billed charges,110% of Medicare,23892.68,68,,23892.68,percent of total billed charges,,733.11,,,733.11,Other,186% of Medicaid,28109.04,80,,28109.04,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,28109.04,80,,28109.04,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,24595.41,70,,24595.41,percent of total billed charges,,514.96,,,514.96,Fee Schedule,,436.46,,,436.46,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,394.14,,,394.14,Other,New York Medicaid APG methodology,394.14,,,394.14,Other,100% New York Medicaid APG,394.14,,,394.14,Other,100% New York Medicaid APG,394.14,,,394.14,Other,100% New York Medicaid APG,886.83,,,886.83,Other,225% New York Medicaid APG,603.04,,,603.04,Other,153% New York Medicaid APG,886.83,,,886.83,Other,225% New York Medicaid APG,551.8,,,551.8,Other,140% New York Medicaid APG,886.83,,,886.83,Other,225% New York Medicaid APG,1024.78,,,1024.78,Other,260% New York Medicaid APG,1277.03,,,1277.03,Other,324% New York Medicaid APG,847.41,,,847.41,Other,215% New York Medicaid APG,847.41,,,847.41,Other,215% New York Medicaid APG,492.68,,,492.68,Other,125% New York Medicaid APG,394.14,28109.04,
Remove foreign body,10121,CPT,,,,,,,,both,,,34301.82,25383.35,74,,25383.35,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15435.82,45,,15435.82,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,16979.4,49.5,,16979.4,percent of total billed charges,110% of Medicare,23325.24,68,,23325.24,percent of total billed charges,,2241.85,,,2241.85,Other,186% of Medicaid,27441.46,80,,27441.46,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,27441.46,80,,27441.46,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,24011.27,70,,24011.27,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1205.3,,,1205.3,Other,New York Medicaid APG methodology,1205.3,,,1205.3,Other,100% New York Medicaid APG,1205.3,,,1205.3,Other,100% New York Medicaid APG,1205.3,,,1205.3,Other,100% New York Medicaid APG,2711.92,,,2711.92,Other,225% New York Medicaid APG,1844.1,,,1844.1,Other,153% New York Medicaid APG,2711.92,,,2711.92,Other,225% New York Medicaid APG,1687.41,,,1687.41,Other,140% New York Medicaid APG,2711.92,,,2711.92,Other,225% New York Medicaid APG,3133.77,,,3133.77,Other,260% New York Medicaid APG,3905.16,,,3905.16,Other,324% New York Medicaid APG,2591.39,,,2591.39,Other,215% New York Medicaid APG,2591.39,,,2591.39,Other,215% New York Medicaid APG,1506.62,,,1506.62,Other,125% New York Medicaid APG,1205.3,27441.46,
Drainage of hematoma/fluid,10140,CPT,,,,,,,,both,,,36245.27,26821.5,74,,26821.5,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,16310.37,45,,16310.37,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,17941.41,49.5,,17941.41,percent of total billed charges,110% of Medicare,24646.78,68,,24646.78,percent of total billed charges,,1207.1,,,1207.1,Other,186% of Medicaid,28996.22,80,,28996.22,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,28996.22,80,,28996.22,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,25371.69,70,,25371.69,percent of total billed charges,,575.64,,,575.64,Fee Schedule,,487.89,,,487.89,Fee Schedule,,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,648.98,,,648.98,Other,New York Medicaid APG methodology,648.98,,,648.98,Other,100% New York Medicaid APG,648.98,,,648.98,Other,100% New York Medicaid APG,648.98,,,648.98,Other,100% New York Medicaid APG,1460.2,,,1460.2,Other,225% New York Medicaid APG,992.94,,,992.94,Other,153% New York Medicaid APG,1460.2,,,1460.2,Other,225% New York Medicaid APG,908.57,,,908.57,Other,140% New York Medicaid APG,1460.2,,,1460.2,Other,225% New York Medicaid APG,1687.34,,,1687.34,Other,260% New York Medicaid APG,2102.69,,,2102.69,Other,324% New York Medicaid APG,1395.3,,,1395.3,Other,215% New York Medicaid APG,1395.3,,,1395.3,Other,215% New York Medicaid APG,811.22,,,811.22,Other,125% New York Medicaid APG,487.89,28996.22,
Puncture drainage of lesion,10160,CPT,,,,,,,,both,,,8387.08,6206.44,74,,6206.44,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,3774.19,45,,3774.19,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,4151.6,49.5,,4151.6,percent of total billed charges,110% of Medicare,5703.21,68,,5703.21,percent of total billed charges,,733.11,,,733.11,Other,186% of Medicaid,6709.66,80,,6709.66,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,6709.66,80,,6709.66,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,5870.96,70,,5870.96,percent of total billed charges,,472.32,,,472.32,Fee Schedule,,400.32,,,400.32,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,394.14,,,394.14,Other,New York Medicaid APG methodology,394.14,,,394.14,Other,100% New York Medicaid APG,394.14,,,394.14,Other,100% New York Medicaid APG,394.14,,,394.14,Other,100% New York Medicaid APG,886.83,,,886.83,Other,225% New York Medicaid APG,603.04,,,603.04,Other,153% New York Medicaid APG,886.83,,,886.83,Other,225% New York Medicaid APG,551.8,,,551.8,Other,140% New York Medicaid APG,886.83,,,886.83,Other,225% New York Medicaid APG,1024.78,,,1024.78,Other,260% New York Medicaid APG,1277.03,,,1277.03,Other,324% New York Medicaid APG,847.41,,,847.41,Other,215% New York Medicaid APG,847.41,,,847.41,Other,215% New York Medicaid APG,492.68,,,492.68,Other,125% New York Medicaid APG,394.14,7216,
Complex drainage wound,10180,CPT,,,,,,,,both,,,39608.75,29310.48,74,,29310.48,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,17823.94,45,,17823.94,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,19606.33,49.5,,19606.33,percent of total billed charges,110% of Medicare,26933.95,68,,26933.95,percent of total billed charges,,2492.85,,,2492.85,Other,186% of Medicaid,31687,80,,31687,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,31687,80,,31687,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,27726.13,70,,27726.13,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1340.24,,,1340.24,Other,New York Medicaid APG methodology,1340.24,,,1340.24,Other,100% New York Medicaid APG,1340.24,,,1340.24,Other,100% New York Medicaid APG,1340.24,,,1340.24,Other,100% New York Medicaid APG,3015.54,,,3015.54,Other,225% New York Medicaid APG,2050.57,,,2050.57,Other,153% New York Medicaid APG,3015.54,,,3015.54,Other,225% New York Medicaid APG,1876.34,,,1876.34,Other,140% New York Medicaid APG,3015.54,,,3015.54,Other,225% New York Medicaid APG,3484.62,,,3484.62,Other,260% New York Medicaid APG,4342.38,,,4342.38,Other,324% New York Medicaid APG,2881.52,,,2881.52,Other,215% New York Medicaid APG,2881.52,,,2881.52,Other,215% New York Medicaid APG,1675.3,,,1675.3,Other,125% New York Medicaid APG,1340.24,31687,
Debride infected skin,11000,CPT,,,,,,,,both,,,13210.22,9775.56,74,,9775.56,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,5944.6,45,,5944.6,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,6539.06,49.5,,6539.06,percent of total billed charges,110% of Medicare,8982.95,68,,8982.95,percent of total billed charges,,1352.53,,,1352.53,Other,186% of Medicaid,10568.18,80,,10568.18,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,10568.18,80,,10568.18,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,9247.15,70,,9247.15,percent of total billed charges,,131.2,,,131.2,Fee Schedule,,111.2,,,111.2,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,727.17,,,727.17,Other,New York Medicaid APG methodology,727.17,,,727.17,Other,100% New York Medicaid APG,727.17,,,727.17,Other,100% New York Medicaid APG,727.17,,,727.17,Other,100% New York Medicaid APG,1636.12,,,1636.12,Other,225% New York Medicaid APG,1112.56,,,1112.56,Other,153% New York Medicaid APG,1636.12,,,1636.12,Other,225% New York Medicaid APG,1018.03,,,1018.03,Other,140% New York Medicaid APG,1636.12,,,1636.12,Other,225% New York Medicaid APG,1890.63,,,1890.63,Other,260% New York Medicaid APG,2356.02,,,2356.02,Other,324% New York Medicaid APG,1563.41,,,1563.41,Other,215% New York Medicaid APG,1563.41,,,1563.41,Other,215% New York Medicaid APG,908.96,,,908.96,Other,125% New York Medicaid APG,111.2,10568.18,
Debride infected skin add-on,11001,CPT,,,,,,,,both,,,32432.1,23999.75,74,,23999.75,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,14594.45,45,,14594.45,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,16053.89,49.5,,16053.89,percent of total billed charges,110% of Medicare,22053.83,68,,22053.83,percent of total billed charges,,1352.53,,,1352.53,Other,186% of Medicaid,25945.68,80,,25945.68,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,25945.68,80,,25945.68,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,22702.47,70,,22702.47,percent of total billed charges,,72.16,,,72.16,Fee Schedule,,61.16,,,61.16,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,727.17,,,727.17,Other,New York Medicaid APG methodology,727.17,,,727.17,Other,100% New York Medicaid APG,727.17,,,727.17,Other,100% New York Medicaid APG,727.17,,,727.17,Other,100% New York Medicaid APG,1636.12,,,1636.12,Other,225% New York Medicaid APG,1112.56,,,1112.56,Other,153% New York Medicaid APG,1636.12,,,1636.12,Other,225% New York Medicaid APG,1018.03,,,1018.03,Other,140% New York Medicaid APG,1636.12,,,1636.12,Other,225% New York Medicaid APG,1890.63,,,1890.63,Other,260% New York Medicaid APG,2356.02,,,2356.02,Other,324% New York Medicaid APG,1563.41,,,1563.41,Other,215% New York Medicaid APG,1563.41,,,1563.41,Other,215% New York Medicaid APG,908.96,,,908.96,Other,125% New York Medicaid APG,61.16,25945.68,
Debride skin at fx site,11010,CPT,,,,,,,,both,,,14798.8,10951.11,74,,10951.11,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,6659.46,45,,6659.46,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,7325.41,49.5,,7325.41,percent of total billed charges,110% of Medicare,10063.18,68,,10063.18,percent of total billed charges,,1352.53,,,1352.53,Other,186% of Medicaid,11839.04,80,,11839.04,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,11839.04,80,,11839.04,percent of total billed charges,,7216,,,7216,Case Rate,,3578,,"100% primary, 0% secondary procedures",3578,Other,MagnaCare ASC Grouper,10359.16,70,,10359.16,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,727.17,,,727.17,Other,New York Medicaid APG methodology,727.17,,,727.17,Other,100% New York Medicaid APG,727.17,,,727.17,Other,100% New York Medicaid APG,727.17,,,727.17,Other,100% New York Medicaid APG,1636.12,,,1636.12,Other,225% New York Medicaid APG,1112.56,,,1112.56,Other,153% New York Medicaid APG,1636.12,,,1636.12,Other,225% New York Medicaid APG,1018.03,,,1018.03,Other,140% New York Medicaid APG,1636.12,,,1636.12,Other,225% New York Medicaid APG,1890.63,,,1890.63,Other,260% New York Medicaid APG,2356.02,,,2356.02,Other,324% New York Medicaid APG,1563.41,,,1563.41,Other,215% New York Medicaid APG,1563.41,,,1563.41,Other,215% New York Medicaid APG,908.96,,,908.96,Other,125% New York Medicaid APG,727.17,11839.04,
Debride skin musc at fx site,11011,CPT,,,,,,,,both,,,14798.8,10951.11,74,,10951.11,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,6659.46,45,,6659.46,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,7325.41,49.5,,7325.41,percent of total billed charges,110% of Medicare,10063.18,68,,10063.18,percent of total billed charges,,1352.53,,,1352.53,Other,186% of Medicaid,11839.04,80,,11839.04,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,11839.04,80,,11839.04,percent of total billed charges,,7216,,,7216,Case Rate,,3578,,"100% primary, 0% secondary procedures",3578,Other,MagnaCare ASC Grouper,10359.16,70,,10359.16,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,727.17,,,727.17,Other,New York Medicaid APG methodology,727.17,,,727.17,Other,100% New York Medicaid APG,727.17,,,727.17,Other,100% New York Medicaid APG,727.17,,,727.17,Other,100% New York Medicaid APG,1636.12,,,1636.12,Other,225% New York Medicaid APG,1112.56,,,1112.56,Other,153% New York Medicaid APG,1636.12,,,1636.12,Other,225% New York Medicaid APG,1018.03,,,1018.03,Other,140% New York Medicaid APG,1636.12,,,1636.12,Other,225% New York Medicaid APG,1890.63,,,1890.63,Other,260% New York Medicaid APG,2356.02,,,2356.02,Other,324% New York Medicaid APG,1563.41,,,1563.41,Other,215% New York Medicaid APG,1563.41,,,1563.41,Other,215% New York Medicaid APG,908.96,,,908.96,Other,125% New York Medicaid APG,727.17,11839.04,
Deb skin bone at fx site,11012,CPT,,,,,,,,both,,,60004.81,44403.56,74,,44403.56,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,27002.16,45,,27002.16,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,29702.38,49.5,,29702.38,percent of total billed charges,110% of Medicare,40803.27,68,,40803.27,percent of total billed charges,,2492.85,,,2492.85,Other,186% of Medicaid,48003.85,80,,48003.85,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,48003.85,80,,48003.85,percent of total billed charges,,7216,,,7216,Case Rate,,3578,,"100% primary, 0% secondary procedures",3578,Other,MagnaCare ASC Grouper,42003.37,70,,42003.37,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,1340.24,,,1340.24,Other,New York Medicaid APG methodology,1340.24,,,1340.24,Other,100% New York Medicaid APG,1340.24,,,1340.24,Other,100% New York Medicaid APG,1340.24,,,1340.24,Other,100% New York Medicaid APG,3015.54,,,3015.54,Other,225% New York Medicaid APG,2050.57,,,2050.57,Other,153% New York Medicaid APG,3015.54,,,3015.54,Other,225% New York Medicaid APG,1876.34,,,1876.34,Other,140% New York Medicaid APG,3015.54,,,3015.54,Other,225% New York Medicaid APG,3484.62,,,3484.62,Other,260% New York Medicaid APG,4342.38,,,4342.38,Other,324% New York Medicaid APG,2881.52,,,2881.52,Other,215% New York Medicaid APG,2881.52,,,2881.52,Other,215% New York Medicaid APG,1675.3,,,1675.3,Other,125% New York Medicaid APG,1340.24,48003.85,
Deb subq tissue 20 sq cm/<,11042,CPT,,,,,,,,both,,,37094.72,27450.09,74,,27450.09,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,16692.62,45,,16692.62,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,18361.89,49.5,,18361.89,percent of total billed charges,110% of Medicare,25224.41,68,,25224.41,percent of total billed charges,,1352.53,,,1352.53,Other,186% of Medicaid,29675.78,80,,29675.78,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,29675.78,80,,29675.78,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,25966.3,70,,25966.3,percent of total billed charges,,290.28,,,290.28,Fee Schedule,,246.03,,,246.03,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,727.17,,,727.17,Other,New York Medicaid APG methodology,727.17,,,727.17,Other,100% New York Medicaid APG,727.17,,,727.17,Other,100% New York Medicaid APG,727.17,,,727.17,Other,100% New York Medicaid APG,1636.12,,,1636.12,Other,225% New York Medicaid APG,1112.56,,,1112.56,Other,153% New York Medicaid APG,1636.12,,,1636.12,Other,225% New York Medicaid APG,1018.03,,,1018.03,Other,140% New York Medicaid APG,1636.12,,,1636.12,Other,225% New York Medicaid APG,1890.63,,,1890.63,Other,260% New York Medicaid APG,2356.02,,,2356.02,Other,324% New York Medicaid APG,1563.41,,,1563.41,Other,215% New York Medicaid APG,1563.41,,,1563.41,Other,215% New York Medicaid APG,908.96,,,908.96,Other,125% New York Medicaid APG,246.03,29675.78,
Deb musc/fascia 20 sq cm/<,11043,CPT,,,,,,,,both,,,39574.92,29285.44,74,,29285.44,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,17808.71,45,,17808.71,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,19589.59,49.5,,19589.59,percent of total billed charges,110% of Medicare,26910.95,68,,26910.95,percent of total billed charges,,1352.53,,,1352.53,Other,186% of Medicaid,31659.94,80,,31659.94,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,31659.94,80,,31659.94,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,27702.44,70,,27702.44,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,727.17,,,727.17,Other,New York Medicaid APG methodology,727.17,,,727.17,Other,100% New York Medicaid APG,727.17,,,727.17,Other,100% New York Medicaid APG,727.17,,,727.17,Other,100% New York Medicaid APG,1636.12,,,1636.12,Other,225% New York Medicaid APG,1112.56,,,1112.56,Other,153% New York Medicaid APG,1636.12,,,1636.12,Other,225% New York Medicaid APG,1018.03,,,1018.03,Other,140% New York Medicaid APG,1636.12,,,1636.12,Other,225% New York Medicaid APG,1890.63,,,1890.63,Other,260% New York Medicaid APG,2356.02,,,2356.02,Other,324% New York Medicaid APG,1563.41,,,1563.41,Other,215% New York Medicaid APG,1563.41,,,1563.41,Other,215% New York Medicaid APG,908.96,,,908.96,Other,125% New York Medicaid APG,727.17,31659.94,
Deb bone 20 sq cm/<,11044,CPT,,,,,,,,both,,,38476.71,28472.77,74,,28472.77,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,17314.52,45,,17314.52,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,19045.97,49.5,,19045.97,percent of total billed charges,110% of Medicare,26164.16,68,,26164.16,percent of total billed charges,,2492.85,,,2492.85,Other,186% of Medicaid,30781.37,80,,30781.37,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,30781.37,80,,30781.37,percent of total billed charges,,7216,,,7216,Case Rate,,3578,,"100% primary, 0% secondary procedures",3578,Other,MagnaCare ASC Grouper,26933.7,70,,26933.7,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,1340.24,,,1340.24,Other,New York Medicaid APG methodology,1340.24,,,1340.24,Other,100% New York Medicaid APG,1340.24,,,1340.24,Other,100% New York Medicaid APG,1340.24,,,1340.24,Other,100% New York Medicaid APG,3015.54,,,3015.54,Other,225% New York Medicaid APG,2050.57,,,2050.57,Other,153% New York Medicaid APG,3015.54,,,3015.54,Other,225% New York Medicaid APG,1876.34,,,1876.34,Other,140% New York Medicaid APG,3015.54,,,3015.54,Other,225% New York Medicaid APG,3484.62,,,3484.62,Other,260% New York Medicaid APG,4342.38,,,4342.38,Other,324% New York Medicaid APG,2881.52,,,2881.52,Other,215% New York Medicaid APG,2881.52,,,2881.52,Other,215% New York Medicaid APG,1675.3,,,1675.3,Other,125% New York Medicaid APG,1340.24,30781.37,
Deb subq tissue add-on,11045,CPT,,,,,,,,both,,,51572.04,38163.31,74,,38163.31,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,23207.42,45,,23207.42,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,25528.16,49.5,,25528.16,percent of total billed charges,110% of Medicare,35068.99,68,,35068.99,percent of total billed charges,,2492.85,,,2492.85,Other,186% of Medicaid,41257.63,80,,41257.63,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,41257.63,80,,41257.63,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,36100.43,70,,36100.43,percent of total billed charges,,123,,,123,Fee Schedule,,104.25,,,104.25,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,1340.24,,,1340.24,Other,New York Medicaid APG methodology,1340.24,,,1340.24,Other,100% New York Medicaid APG,1340.24,,,1340.24,Other,100% New York Medicaid APG,1340.24,,,1340.24,Other,100% New York Medicaid APG,3015.54,,,3015.54,Other,225% New York Medicaid APG,2050.57,,,2050.57,Other,153% New York Medicaid APG,3015.54,,,3015.54,Other,225% New York Medicaid APG,1876.34,,,1876.34,Other,140% New York Medicaid APG,3015.54,,,3015.54,Other,225% New York Medicaid APG,3484.62,,,3484.62,Other,260% New York Medicaid APG,4342.38,,,4342.38,Other,324% New York Medicaid APG,2881.52,,,2881.52,Other,215% New York Medicaid APG,2881.52,,,2881.52,Other,215% New York Medicaid APG,1675.3,,,1675.3,Other,125% New York Medicaid APG,104.25,41257.63,
Deb musc/fascia add-on,11046,CPT,,,,,,,,both,,,51572.04,38163.31,74,,38163.31,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,23207.42,45,,23207.42,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,25528.16,49.5,,25528.16,percent of total billed charges,110% of Medicare,35068.99,68,,35068.99,percent of total billed charges,,2492.85,,,2492.85,Other,186% of Medicaid,41257.63,80,,41257.63,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,41257.63,80,,41257.63,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,36100.43,70,,36100.43,percent of total billed charges,,265.68,,,265.68,Fee Schedule,,225.18,,,225.18,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,1340.24,,,1340.24,Other,New York Medicaid APG methodology,1340.24,,,1340.24,Other,100% New York Medicaid APG,1340.24,,,1340.24,Other,100% New York Medicaid APG,1340.24,,,1340.24,Other,100% New York Medicaid APG,3015.54,,,3015.54,Other,225% New York Medicaid APG,2050.57,,,2050.57,Other,153% New York Medicaid APG,3015.54,,,3015.54,Other,225% New York Medicaid APG,1876.34,,,1876.34,Other,140% New York Medicaid APG,3015.54,,,3015.54,Other,225% New York Medicaid APG,3484.62,,,3484.62,Other,260% New York Medicaid APG,4342.38,,,4342.38,Other,324% New York Medicaid APG,2881.52,,,2881.52,Other,215% New York Medicaid APG,2881.52,,,2881.52,Other,215% New York Medicaid APG,1675.3,,,1675.3,Other,125% New York Medicaid APG,225.18,41257.63,
Deb bone add-on,11047,CPT,,,,,,,,both,,,64479.48,47714.82,74,,47714.82,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,29015.77,45,,29015.77,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,31917.34,49.5,,31917.34,percent of total billed charges,110% of Medicare,43846.05,68,,43846.05,percent of total billed charges,,2492.85,,,2492.85,Other,186% of Medicaid,51583.58,80,,51583.58,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,51583.58,80,,51583.58,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,45135.64,70,,45135.64,percent of total billed charges,,470.68,,,470.68,Fee Schedule,,398.93,,,398.93,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,1340.24,,,1340.24,Other,New York Medicaid APG methodology,1340.24,,,1340.24,Other,100% New York Medicaid APG,1340.24,,,1340.24,Other,100% New York Medicaid APG,1340.24,,,1340.24,Other,100% New York Medicaid APG,3015.54,,,3015.54,Other,225% New York Medicaid APG,2050.57,,,2050.57,Other,153% New York Medicaid APG,3015.54,,,3015.54,Other,225% New York Medicaid APG,1876.34,,,1876.34,Other,140% New York Medicaid APG,3015.54,,,3015.54,Other,225% New York Medicaid APG,3484.62,,,3484.62,Other,260% New York Medicaid APG,4342.38,,,4342.38,Other,324% New York Medicaid APG,2881.52,,,2881.52,Other,215% New York Medicaid APG,2881.52,,,2881.52,Other,215% New York Medicaid APG,1675.3,,,1675.3,Other,125% New York Medicaid APG,398.93,51583.58,
Trim skin lesion,11055,CPT,,,,,,,,both,,,4210.98,3116.13,74,,3116.13,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,1894.94,45,,1894.94,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,2084.44,49.5,,2084.44,percent of total billed charges,110% of Medicare,2863.47,68,,2863.47,percent of total billed charges,,733.11,,,733.11,Other,186% of Medicaid,3368.78,80,,3368.78,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,3368.78,80,,3368.78,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,2947.69,70,,2947.69,percent of total billed charges,,77.08,,,77.08,Fee Schedule,,65.33,,,65.33,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,394.14,,,394.14,Other,New York Medicaid APG methodology,394.14,,,394.14,Other,100% New York Medicaid APG,394.14,,,394.14,Other,100% New York Medicaid APG,394.14,,,394.14,Other,100% New York Medicaid APG,886.83,,,886.83,Other,225% New York Medicaid APG,603.04,,,603.04,Other,153% New York Medicaid APG,886.83,,,886.83,Other,225% New York Medicaid APG,551.8,,,551.8,Other,140% New York Medicaid APG,886.83,,,886.83,Other,225% New York Medicaid APG,1024.78,,,1024.78,Other,260% New York Medicaid APG,1277.03,,,1277.03,Other,324% New York Medicaid APG,847.41,,,847.41,Other,215% New York Medicaid APG,847.41,,,847.41,Other,215% New York Medicaid APG,492.68,,,492.68,Other,125% New York Medicaid APG,65.33,7216,
Trim skin lesions 2 to 4,11056,CPT,,,,,,,,both,,,4210.98,3116.13,74,,3116.13,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,1894.94,45,,1894.94,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,2084.44,49.5,,2084.44,percent of total billed charges,110% of Medicare,2863.47,68,,2863.47,percent of total billed charges,,733.11,,,733.11,Other,186% of Medicaid,3368.78,80,,3368.78,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,3368.78,80,,3368.78,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,2947.69,70,,2947.69,percent of total billed charges,,106.6,,,106.6,Fee Schedule,,90.35,,,90.35,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,394.14,,,394.14,Other,New York Medicaid APG methodology,394.14,,,394.14,Other,100% New York Medicaid APG,394.14,,,394.14,Other,100% New York Medicaid APG,394.14,,,394.14,Other,100% New York Medicaid APG,886.83,,,886.83,Other,225% New York Medicaid APG,603.04,,,603.04,Other,153% New York Medicaid APG,886.83,,,886.83,Other,225% New York Medicaid APG,551.8,,,551.8,Other,140% New York Medicaid APG,886.83,,,886.83,Other,225% New York Medicaid APG,1024.78,,,1024.78,Other,260% New York Medicaid APG,1277.03,,,1277.03,Other,324% New York Medicaid APG,847.41,,,847.41,Other,215% New York Medicaid APG,847.41,,,847.41,Other,215% New York Medicaid APG,492.68,,,492.68,Other,125% New York Medicaid APG,90.35,7216,
Trim skin lesions over 4,11057,CPT,,,,,,,,both,,,4210.98,3116.13,74,,3116.13,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,1894.94,45,,1894.94,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,2084.44,49.5,,2084.44,percent of total billed charges,110% of Medicare,2863.47,68,,2863.47,percent of total billed charges,,733.11,,,733.11,Other,186% of Medicaid,3368.78,80,,3368.78,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,3368.78,80,,3368.78,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,2947.69,70,,2947.69,percent of total billed charges,,137.76,,,137.76,Fee Schedule,,116.76,,,116.76,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,394.14,,,394.14,Other,New York Medicaid APG methodology,394.14,,,394.14,Other,100% New York Medicaid APG,394.14,,,394.14,Other,100% New York Medicaid APG,394.14,,,394.14,Other,100% New York Medicaid APG,886.83,,,886.83,Other,225% New York Medicaid APG,603.04,,,603.04,Other,153% New York Medicaid APG,886.83,,,886.83,Other,225% New York Medicaid APG,551.8,,,551.8,Other,140% New York Medicaid APG,886.83,,,886.83,Other,225% New York Medicaid APG,1024.78,,,1024.78,Other,260% New York Medicaid APG,1277.03,,,1277.03,Other,324% New York Medicaid APG,847.41,,,847.41,Other,215% New York Medicaid APG,847.41,,,847.41,Other,215% New York Medicaid APG,492.68,,,492.68,Other,125% New York Medicaid APG,116.76,7216,
Tangntl bx skin single les,11102,CPT,,,,,,,,both,,,4210.98,3116.13,74,,3116.13,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,1894.94,45,,1894.94,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,2084.44,49.5,,2084.44,percent of total billed charges,110% of Medicare,2863.47,68,,2863.47,percent of total billed charges,,1240.83,,,1240.83,Other,186% of Medicaid,3368.78,80,,3368.78,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,3368.78,80,,3368.78,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,2947.69,70,,2947.69,percent of total billed charges,,183.68,,,183.68,Fee Schedule,,155.68,,,155.68,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,667.11,,,667.11,Other,New York Medicaid APG methodology,667.11,,,667.11,Other,100% New York Medicaid APG,667.11,,,667.11,Other,100% New York Medicaid APG,667.11,,,667.11,Other,100% New York Medicaid APG,1501,,,1501,Other,225% New York Medicaid APG,1020.68,,,1020.68,Other,153% New York Medicaid APG,1501,,,1501,Other,225% New York Medicaid APG,933.96,,,933.96,Other,140% New York Medicaid APG,1501,,,1501,Other,225% New York Medicaid APG,1734.49,,,1734.49,Other,260% New York Medicaid APG,2161.44,,,2161.44,Other,324% New York Medicaid APG,1434.29,,,1434.29,Other,215% New York Medicaid APG,1434.29,,,1434.29,Other,215% New York Medicaid APG,833.89,,,833.89,Other,125% New York Medicaid APG,155.68,7216,
Tangntl bx skin ea sep/addl,11103,CPT,,,,,,,,both,,,32432.1,23999.75,74,,23999.75,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,14594.45,45,,14594.45,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,16053.89,49.5,,16053.89,percent of total billed charges,110% of Medicare,22053.83,68,,22053.83,percent of total billed charges,,1240.83,,,1240.83,Other,186% of Medicaid,25945.68,80,,25945.68,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,25945.68,80,,25945.68,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,22702.47,70,,22702.47,percent of total billed charges,,104.96,,,104.96,Fee Schedule,,88.96,,,88.96,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,667.11,,,667.11,Other,New York Medicaid APG methodology,667.11,,,667.11,Other,100% New York Medicaid APG,667.11,,,667.11,Other,100% New York Medicaid APG,667.11,,,667.11,Other,100% New York Medicaid APG,1501,,,1501,Other,225% New York Medicaid APG,1020.68,,,1020.68,Other,153% New York Medicaid APG,1501,,,1501,Other,225% New York Medicaid APG,933.96,,,933.96,Other,140% New York Medicaid APG,1501,,,1501,Other,225% New York Medicaid APG,1734.49,,,1734.49,Other,260% New York Medicaid APG,2161.44,,,2161.44,Other,324% New York Medicaid APG,1434.29,,,1434.29,Other,215% New York Medicaid APG,1434.29,,,1434.29,Other,215% New York Medicaid APG,833.89,,,833.89,Other,125% New York Medicaid APG,88.96,25945.68,
Punch bx skin single lesion,11104,CPT,,,,,,,,both,,,8387.08,6206.44,74,,6206.44,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,3774.19,45,,3774.19,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,4151.6,49.5,,4151.6,percent of total billed charges,110% of Medicare,5703.21,68,,5703.21,percent of total billed charges,,1240.83,,,1240.83,Other,186% of Medicaid,6709.66,80,,6709.66,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,6709.66,80,,6709.66,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,5870.96,70,,5870.96,percent of total billed charges,,227.96,,,227.96,Fee Schedule,,193.21,,,193.21,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,667.11,,,667.11,Other,New York Medicaid APG methodology,667.11,,,667.11,Other,100% New York Medicaid APG,667.11,,,667.11,Other,100% New York Medicaid APG,667.11,,,667.11,Other,100% New York Medicaid APG,1501,,,1501,Other,225% New York Medicaid APG,1020.68,,,1020.68,Other,153% New York Medicaid APG,1501,,,1501,Other,225% New York Medicaid APG,933.96,,,933.96,Other,140% New York Medicaid APG,1501,,,1501,Other,225% New York Medicaid APG,1734.49,,,1734.49,Other,260% New York Medicaid APG,2161.44,,,2161.44,Other,324% New York Medicaid APG,1434.29,,,1434.29,Other,215% New York Medicaid APG,1434.29,,,1434.29,Other,215% New York Medicaid APG,833.89,,,833.89,Other,125% New York Medicaid APG,193.21,7216,
Punch bx skin ea sep/addl,11105,CPT,,,,,,,,both,,,32432.1,23999.75,74,,23999.75,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,14594.45,45,,14594.45,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,16053.89,49.5,,16053.89,percent of total billed charges,110% of Medicare,22053.83,68,,22053.83,percent of total billed charges,,1240.83,,,1240.83,Other,186% of Medicaid,25945.68,80,,25945.68,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,25945.68,80,,25945.68,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,22702.47,70,,22702.47,percent of total billed charges,,124.64,,,124.64,Fee Schedule,,105.64,,,105.64,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,667.11,,,667.11,Other,New York Medicaid APG methodology,667.11,,,667.11,Other,100% New York Medicaid APG,667.11,,,667.11,Other,100% New York Medicaid APG,667.11,,,667.11,Other,100% New York Medicaid APG,1501,,,1501,Other,225% New York Medicaid APG,1020.68,,,1020.68,Other,153% New York Medicaid APG,1501,,,1501,Other,225% New York Medicaid APG,933.96,,,933.96,Other,140% New York Medicaid APG,1501,,,1501,Other,225% New York Medicaid APG,1734.49,,,1734.49,Other,260% New York Medicaid APG,2161.44,,,2161.44,Other,324% New York Medicaid APG,1434.29,,,1434.29,Other,215% New York Medicaid APG,1434.29,,,1434.29,Other,215% New York Medicaid APG,833.89,,,833.89,Other,125% New York Medicaid APG,105.64,25945.68,
Incal bx skn single les,11106,CPT,,,,,,,,both,,,13210.22,9775.56,74,,9775.56,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,5944.6,45,,5944.6,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,6539.06,49.5,,6539.06,percent of total billed charges,110% of Medicare,8982.95,68,,8982.95,percent of total billed charges,,1240.83,,,1240.83,Other,186% of Medicaid,10568.18,80,,10568.18,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,10568.18,80,,10568.18,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,9247.15,70,,9247.15,percent of total billed charges,,273.88,,,273.88,Fee Schedule,,232.13,,,232.13,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,667.11,,,667.11,Other,New York Medicaid APG methodology,667.11,,,667.11,Other,100% New York Medicaid APG,667.11,,,667.11,Other,100% New York Medicaid APG,667.11,,,667.11,Other,100% New York Medicaid APG,1501,,,1501,Other,225% New York Medicaid APG,1020.68,,,1020.68,Other,153% New York Medicaid APG,1501,,,1501,Other,225% New York Medicaid APG,933.96,,,933.96,Other,140% New York Medicaid APG,1501,,,1501,Other,225% New York Medicaid APG,1734.49,,,1734.49,Other,260% New York Medicaid APG,2161.44,,,2161.44,Other,324% New York Medicaid APG,1434.29,,,1434.29,Other,215% New York Medicaid APG,1434.29,,,1434.29,Other,215% New York Medicaid APG,833.89,,,833.89,Other,125% New York Medicaid APG,232.13,10568.18,
Incal bx skn ea sep/addl,11107,CPT,,,,,,,,both,,,32432.1,23999.75,74,,23999.75,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,14594.45,45,,14594.45,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,16053.89,49.5,,16053.89,percent of total billed charges,110% of Medicare,22053.83,68,,22053.83,percent of total billed charges,,1240.83,,,1240.83,Other,186% of Medicaid,25945.68,80,,25945.68,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,25945.68,80,,25945.68,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,22702.47,70,,22702.47,percent of total billed charges,,149.24,,,149.24,Fee Schedule,,126.49,,,126.49,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,667.11,,,667.11,Other,New York Medicaid APG methodology,667.11,,,667.11,Other,100% New York Medicaid APG,667.11,,,667.11,Other,100% New York Medicaid APG,667.11,,,667.11,Other,100% New York Medicaid APG,1501,,,1501,Other,225% New York Medicaid APG,1020.68,,,1020.68,Other,153% New York Medicaid APG,1501,,,1501,Other,225% New York Medicaid APG,933.96,,,933.96,Other,140% New York Medicaid APG,1501,,,1501,Other,225% New York Medicaid APG,1734.49,,,1734.49,Other,260% New York Medicaid APG,2161.44,,,2161.44,Other,324% New York Medicaid APG,1434.29,,,1434.29,Other,215% New York Medicaid APG,1434.29,,,1434.29,Other,215% New York Medicaid APG,833.89,,,833.89,Other,125% New York Medicaid APG,126.49,25945.68,
Removal of skin tags <w/15,11200,CPT,,,,,,,,both,,,36910.34,27313.65,74,,27313.65,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,16609.65,45,,16609.65,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,18270.62,49.5,,18270.62,percent of total billed charges,110% of Medicare,25099.03,68,,25099.03,percent of total billed charges,,733.11,,,733.11,Other,186% of Medicaid,29528.27,80,,29528.27,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,29528.27,80,,29528.27,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,25837.24,70,,25837.24,percent of total billed charges,,373.92,,,373.92,Fee Schedule,,316.92,,,316.92,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,394.14,,,394.14,Other,New York Medicaid APG methodology,394.14,,,394.14,Other,100% New York Medicaid APG,394.14,,,394.14,Other,100% New York Medicaid APG,394.14,,,394.14,Other,100% New York Medicaid APG,886.83,,,886.83,Other,225% New York Medicaid APG,603.04,,,603.04,Other,153% New York Medicaid APG,886.83,,,886.83,Other,225% New York Medicaid APG,551.8,,,551.8,Other,140% New York Medicaid APG,886.83,,,886.83,Other,225% New York Medicaid APG,1024.78,,,1024.78,Other,260% New York Medicaid APG,1277.03,,,1277.03,Other,324% New York Medicaid APG,847.41,,,847.41,Other,215% New York Medicaid APG,847.41,,,847.41,Other,215% New York Medicaid APG,492.68,,,492.68,Other,125% New York Medicaid APG,316.92,29528.27,
Remove skin tags add-on,11201,CPT,,,,,,,,both,,,32432.1,23999.75,74,,23999.75,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,14594.45,45,,14594.45,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,16053.89,49.5,,16053.89,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,733.11,,,733.11,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,22702.47,70,,22702.47,percent of total billed charges,,80.36,,,80.36,Fee Schedule,,68.11,,,68.11,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,394.14,,,394.14,Other,New York Medicaid APG methodology,394.14,,,394.14,Other,100% New York Medicaid APG,394.14,,,394.14,Other,100% New York Medicaid APG,394.14,,,394.14,Other,100% New York Medicaid APG,886.83,,,886.83,Other,225% New York Medicaid APG,603.04,,,603.04,Other,153% New York Medicaid APG,886.83,,,886.83,Other,225% New York Medicaid APG,551.8,,,551.8,Other,140% New York Medicaid APG,886.83,,,886.83,Other,225% New York Medicaid APG,1024.78,,,1024.78,Other,260% New York Medicaid APG,1277.03,,,1277.03,Other,324% New York Medicaid APG,847.41,,,847.41,Other,215% New York Medicaid APG,847.41,,,847.41,Other,215% New York Medicaid APG,492.68,,,492.68,Other,125% New York Medicaid APG,68.11,23999.75,
Shave skin lesion 0.5 cm/<,11300,CPT,,,,,,,,both,,,8387.08,6206.44,74,,6206.44,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,3774.19,45,,3774.19,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,4151.6,49.5,,4151.6,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,733.11,,,733.11,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,5870.96,70,,5870.96,percent of total billed charges,,165.64,,,165.64,Fee Schedule,,140.39,,,140.39,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,394.14,,,394.14,Other,New York Medicaid APG methodology,394.14,,,394.14,Other,100% New York Medicaid APG,394.14,,,394.14,Other,100% New York Medicaid APG,394.14,,,394.14,Other,100% New York Medicaid APG,886.83,,,886.83,Other,225% New York Medicaid APG,603.04,,,603.04,Other,153% New York Medicaid APG,886.83,,,886.83,Other,225% New York Medicaid APG,551.8,,,551.8,Other,140% New York Medicaid APG,886.83,,,886.83,Other,225% New York Medicaid APG,1024.78,,,1024.78,Other,260% New York Medicaid APG,1277.03,,,1277.03,Other,324% New York Medicaid APG,847.41,,,847.41,Other,215% New York Medicaid APG,847.41,,,847.41,Other,215% New York Medicaid APG,492.68,,,492.68,Other,125% New York Medicaid APG,140.39,9473,
Shave skin lesion 0.6-1.0 cm,11301,CPT,,,,,,,,both,,,4210.98,3116.13,74,,3116.13,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,1894.94,45,,1894.94,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,2084.44,49.5,,2084.44,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,733.11,,,733.11,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,2947.69,70,,2947.69,percent of total billed charges,,249.28,,,249.28,Fee Schedule,,211.28,,,211.28,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,394.14,,,394.14,Other,New York Medicaid APG methodology,394.14,,,394.14,Other,100% New York Medicaid APG,394.14,,,394.14,Other,100% New York Medicaid APG,394.14,,,394.14,Other,100% New York Medicaid APG,886.83,,,886.83,Other,225% New York Medicaid APG,603.04,,,603.04,Other,153% New York Medicaid APG,886.83,,,886.83,Other,225% New York Medicaid APG,551.8,,,551.8,Other,140% New York Medicaid APG,886.83,,,886.83,Other,225% New York Medicaid APG,1024.78,,,1024.78,Other,260% New York Medicaid APG,1277.03,,,1277.03,Other,324% New York Medicaid APG,847.41,,,847.41,Other,215% New York Medicaid APG,847.41,,,847.41,Other,215% New York Medicaid APG,492.68,,,492.68,Other,125% New York Medicaid APG,211.28,9473,
Shave skin lesion 1.1-2.0 cm,11302,CPT,,,,,,,,both,,,4210.98,3116.13,74,,3116.13,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,1894.94,45,,1894.94,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,2084.44,49.5,,2084.44,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,733.11,,,733.11,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,2947.69,70,,2947.69,percent of total billed charges,,290.28,,,290.28,Fee Schedule,,246.03,,,246.03,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,394.14,,,394.14,Other,New York Medicaid APG methodology,394.14,,,394.14,Other,100% New York Medicaid APG,394.14,,,394.14,Other,100% New York Medicaid APG,394.14,,,394.14,Other,100% New York Medicaid APG,886.83,,,886.83,Other,225% New York Medicaid APG,603.04,,,603.04,Other,153% New York Medicaid APG,886.83,,,886.83,Other,225% New York Medicaid APG,551.8,,,551.8,Other,140% New York Medicaid APG,886.83,,,886.83,Other,225% New York Medicaid APG,1024.78,,,1024.78,Other,260% New York Medicaid APG,1277.03,,,1277.03,Other,324% New York Medicaid APG,847.41,,,847.41,Other,215% New York Medicaid APG,847.41,,,847.41,Other,215% New York Medicaid APG,492.68,,,492.68,Other,125% New York Medicaid APG,246.03,9473,
Shave skin lesion >2.0 cm,11303,CPT,,,,,,,,both,,,8387.08,6206.44,74,,6206.44,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,3774.19,45,,3774.19,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,4151.6,49.5,,4151.6,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,733.11,,,733.11,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,5870.96,70,,5870.96,percent of total billed charges,,344.4,,,344.4,Fee Schedule,,291.9,,,291.9,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,394.14,,,394.14,Other,New York Medicaid APG methodology,394.14,,,394.14,Other,100% New York Medicaid APG,394.14,,,394.14,Other,100% New York Medicaid APG,394.14,,,394.14,Other,100% New York Medicaid APG,886.83,,,886.83,Other,225% New York Medicaid APG,603.04,,,603.04,Other,153% New York Medicaid APG,886.83,,,886.83,Other,225% New York Medicaid APG,551.8,,,551.8,Other,140% New York Medicaid APG,886.83,,,886.83,Other,225% New York Medicaid APG,1024.78,,,1024.78,Other,260% New York Medicaid APG,1277.03,,,1277.03,Other,324% New York Medicaid APG,847.41,,,847.41,Other,215% New York Medicaid APG,847.41,,,847.41,Other,215% New York Medicaid APG,492.68,,,492.68,Other,125% New York Medicaid APG,291.9,9473,
Shave skin lesion 0.5 cm/<,11305,CPT,,,,,,,,both,,,4210.98,3116.13,74,,3116.13,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,1894.94,45,,1894.94,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,2084.44,49.5,,2084.44,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,733.11,,,733.11,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,2947.69,70,,2947.69,percent of total billed charges,,182.04,,,182.04,Fee Schedule,,154.29,,,154.29,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,394.14,,,394.14,Other,New York Medicaid APG methodology,394.14,,,394.14,Other,100% New York Medicaid APG,394.14,,,394.14,Other,100% New York Medicaid APG,394.14,,,394.14,Other,100% New York Medicaid APG,886.83,,,886.83,Other,225% New York Medicaid APG,603.04,,,603.04,Other,153% New York Medicaid APG,886.83,,,886.83,Other,225% New York Medicaid APG,551.8,,,551.8,Other,140% New York Medicaid APG,886.83,,,886.83,Other,225% New York Medicaid APG,1024.78,,,1024.78,Other,260% New York Medicaid APG,1277.03,,,1277.03,Other,324% New York Medicaid APG,847.41,,,847.41,Other,215% New York Medicaid APG,847.41,,,847.41,Other,215% New York Medicaid APG,492.68,,,492.68,Other,125% New York Medicaid APG,154.29,9473,
Shave skin lesion 0.6-1.0 cm,11306,CPT,,,,,,,,both,,,4210.98,3116.13,74,,3116.13,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,1894.94,45,,1894.94,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,2084.44,49.5,,2084.44,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,733.11,,,733.11,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,2947.69,70,,2947.69,percent of total billed charges,,239.44,,,239.44,Fee Schedule,,202.94,,,202.94,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,394.14,,,394.14,Other,New York Medicaid APG methodology,394.14,,,394.14,Other,100% New York Medicaid APG,394.14,,,394.14,Other,100% New York Medicaid APG,394.14,,,394.14,Other,100% New York Medicaid APG,886.83,,,886.83,Other,225% New York Medicaid APG,603.04,,,603.04,Other,153% New York Medicaid APG,886.83,,,886.83,Other,225% New York Medicaid APG,551.8,,,551.8,Other,140% New York Medicaid APG,886.83,,,886.83,Other,225% New York Medicaid APG,1024.78,,,1024.78,Other,260% New York Medicaid APG,1277.03,,,1277.03,Other,324% New York Medicaid APG,847.41,,,847.41,Other,215% New York Medicaid APG,847.41,,,847.41,Other,215% New York Medicaid APG,492.68,,,492.68,Other,125% New York Medicaid APG,202.94,9473,
Shave skin lesion 1.1-2.0 cm,11307,CPT,,,,,,,,both,,,4210.98,3116.13,74,,3116.13,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,1894.94,45,,1894.94,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,2084.44,49.5,,2084.44,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,733.11,,,733.11,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,2947.69,70,,2947.69,percent of total billed charges,,305.04,,,305.04,Fee Schedule,,258.54,,,258.54,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,394.14,,,394.14,Other,New York Medicaid APG methodology,394.14,,,394.14,Other,100% New York Medicaid APG,394.14,,,394.14,Other,100% New York Medicaid APG,394.14,,,394.14,Other,100% New York Medicaid APG,886.83,,,886.83,Other,225% New York Medicaid APG,603.04,,,603.04,Other,153% New York Medicaid APG,886.83,,,886.83,Other,225% New York Medicaid APG,551.8,,,551.8,Other,140% New York Medicaid APG,886.83,,,886.83,Other,225% New York Medicaid APG,1024.78,,,1024.78,Other,260% New York Medicaid APG,1277.03,,,1277.03,Other,324% New York Medicaid APG,847.41,,,847.41,Other,215% New York Medicaid APG,847.41,,,847.41,Other,215% New York Medicaid APG,492.68,,,492.68,Other,125% New York Medicaid APG,258.54,9473,
Shave skin lesion >2.0 cm,11308,CPT,,,,,,,,both,,,8387.08,6206.44,74,,6206.44,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,3774.19,45,,3774.19,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,4151.6,49.5,,4151.6,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,733.11,,,733.11,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,5870.96,70,,5870.96,percent of total billed charges,,339.48,,,339.48,Fee Schedule,,287.73,,,287.73,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,394.14,,,394.14,Other,New York Medicaid APG methodology,394.14,,,394.14,Other,100% New York Medicaid APG,394.14,,,394.14,Other,100% New York Medicaid APG,394.14,,,394.14,Other,100% New York Medicaid APG,886.83,,,886.83,Other,225% New York Medicaid APG,603.04,,,603.04,Other,153% New York Medicaid APG,886.83,,,886.83,Other,225% New York Medicaid APG,551.8,,,551.8,Other,140% New York Medicaid APG,886.83,,,886.83,Other,225% New York Medicaid APG,1024.78,,,1024.78,Other,260% New York Medicaid APG,1277.03,,,1277.03,Other,324% New York Medicaid APG,847.41,,,847.41,Other,215% New York Medicaid APG,847.41,,,847.41,Other,215% New York Medicaid APG,492.68,,,492.68,Other,125% New York Medicaid APG,287.73,9473,
Shave skin lesion 0.5 cm/<,11310,CPT,,,,,,,,both,,,4210.98,3116.13,74,,3116.13,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,1894.94,45,,1894.94,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,2084.44,49.5,,2084.44,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,733.11,,,733.11,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,2947.69,70,,2947.69,percent of total billed charges,,223.04,,,223.04,Fee Schedule,,189.04,,,189.04,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,394.14,,,394.14,Other,New York Medicaid APG methodology,394.14,,,394.14,Other,100% New York Medicaid APG,394.14,,,394.14,Other,100% New York Medicaid APG,394.14,,,394.14,Other,100% New York Medicaid APG,886.83,,,886.83,Other,225% New York Medicaid APG,603.04,,,603.04,Other,153% New York Medicaid APG,886.83,,,886.83,Other,225% New York Medicaid APG,551.8,,,551.8,Other,140% New York Medicaid APG,886.83,,,886.83,Other,225% New York Medicaid APG,1024.78,,,1024.78,Other,260% New York Medicaid APG,1277.03,,,1277.03,Other,324% New York Medicaid APG,847.41,,,847.41,Other,215% New York Medicaid APG,847.41,,,847.41,Other,215% New York Medicaid APG,492.68,,,492.68,Other,125% New York Medicaid APG,189.04,9473,
Shave skin lesion 0.6-1.0 cm,11311,CPT,,,,,,,,both,,,4210.98,3116.13,74,,3116.13,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,1894.94,45,,1894.94,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,2084.44,49.5,,2084.44,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,733.11,,,733.11,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,2947.69,70,,2947.69,percent of total billed charges,,305.04,,,305.04,Fee Schedule,,258.54,,,258.54,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,394.14,,,394.14,Other,New York Medicaid APG methodology,394.14,,,394.14,Other,100% New York Medicaid APG,394.14,,,394.14,Other,100% New York Medicaid APG,394.14,,,394.14,Other,100% New York Medicaid APG,886.83,,,886.83,Other,225% New York Medicaid APG,603.04,,,603.04,Other,153% New York Medicaid APG,886.83,,,886.83,Other,225% New York Medicaid APG,551.8,,,551.8,Other,140% New York Medicaid APG,886.83,,,886.83,Other,225% New York Medicaid APG,1024.78,,,1024.78,Other,260% New York Medicaid APG,1277.03,,,1277.03,Other,324% New York Medicaid APG,847.41,,,847.41,Other,215% New York Medicaid APG,847.41,,,847.41,Other,215% New York Medicaid APG,492.68,,,492.68,Other,125% New York Medicaid APG,258.54,9473,
Shave skin lesion 1.1-2.0 cm,11312,CPT,,,,,,,,both,,,8387.08,6206.44,74,,6206.44,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,3774.19,45,,3774.19,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,4151.6,49.5,,4151.6,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,733.11,,,733.11,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,5870.96,70,,5870.96,percent of total billed charges,,365.72,,,365.72,Fee Schedule,,309.97,,,309.97,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,394.14,,,394.14,Other,New York Medicaid APG methodology,394.14,,,394.14,Other,100% New York Medicaid APG,394.14,,,394.14,Other,100% New York Medicaid APG,394.14,,,394.14,Other,100% New York Medicaid APG,886.83,,,886.83,Other,225% New York Medicaid APG,603.04,,,603.04,Other,153% New York Medicaid APG,886.83,,,886.83,Other,225% New York Medicaid APG,551.8,,,551.8,Other,140% New York Medicaid APG,886.83,,,886.83,Other,225% New York Medicaid APG,1024.78,,,1024.78,Other,260% New York Medicaid APG,1277.03,,,1277.03,Other,324% New York Medicaid APG,847.41,,,847.41,Other,215% New York Medicaid APG,847.41,,,847.41,Other,215% New York Medicaid APG,492.68,,,492.68,Other,125% New York Medicaid APG,309.97,9473,
Shave skin lesion >2.0 cm,11313,CPT,,,,,,,,both,,,8387.08,6206.44,74,,6206.44,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,3774.19,45,,3774.19,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,4151.6,49.5,,4151.6,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,733.11,,,733.11,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,5870.96,70,,5870.96,percent of total billed charges,,464.12,,,464.12,Fee Schedule,,393.37,,,393.37,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,394.14,,,394.14,Other,New York Medicaid APG methodology,394.14,,,394.14,Other,100% New York Medicaid APG,394.14,,,394.14,Other,100% New York Medicaid APG,394.14,,,394.14,Other,100% New York Medicaid APG,886.83,,,886.83,Other,225% New York Medicaid APG,603.04,,,603.04,Other,153% New York Medicaid APG,886.83,,,886.83,Other,225% New York Medicaid APG,551.8,,,551.8,Other,140% New York Medicaid APG,886.83,,,886.83,Other,225% New York Medicaid APG,1024.78,,,1024.78,Other,260% New York Medicaid APG,1277.03,,,1277.03,Other,324% New York Medicaid APG,847.41,,,847.41,Other,215% New York Medicaid APG,847.41,,,847.41,Other,215% New York Medicaid APG,492.68,,,492.68,Other,125% New York Medicaid APG,393.37,9473,
Exc tr-ext b9+marg 0.5 cm<,11400,CPT,,,,,,,,both,,,35012.69,25909.39,74,,25909.39,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15755.71,45,,15755.71,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,17331.28,49.5,,17331.28,percent of total billed charges,110% of Medicare,23808.63,68,,23808.63,percent of total billed charges,,1240.83,,,1240.83,Other,186% of Medicaid,28010.15,80,,28010.15,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,28010.15,80,,28010.15,percent of total billed charges,,7216,,,7216,Case Rate,,3578,,"100% primary, 0% secondary procedures",3578,Other,MagnaCare ASC Grouper,24508.88,70,,24508.88,percent of total billed charges,,411.64,,,411.64,Fee Schedule,,348.89,,,348.89,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,667.11,,,667.11,Other,New York Medicaid APG methodology,667.11,,,667.11,Other,100% New York Medicaid APG,667.11,,,667.11,Other,100% New York Medicaid APG,667.11,,,667.11,Other,100% New York Medicaid APG,1501,,,1501,Other,225% New York Medicaid APG,1020.68,,,1020.68,Other,153% New York Medicaid APG,1501,,,1501,Other,225% New York Medicaid APG,933.96,,,933.96,Other,140% New York Medicaid APG,1501,,,1501,Other,225% New York Medicaid APG,1734.49,,,1734.49,Other,260% New York Medicaid APG,2161.44,,,2161.44,Other,324% New York Medicaid APG,1434.29,,,1434.29,Other,215% New York Medicaid APG,1434.29,,,1434.29,Other,215% New York Medicaid APG,833.89,,,833.89,Other,125% New York Medicaid APG,348.89,28010.15,
Exc tr-ext b9+marg 0.6-1 cm,11401,CPT,,,,,,,,both,,,34943.81,25858.42,74,,25858.42,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15724.71,45,,15724.71,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,17297.19,49.5,,17297.19,percent of total billed charges,110% of Medicare,23761.79,68,,23761.79,percent of total billed charges,,1240.83,,,1240.83,Other,186% of Medicaid,27955.05,80,,27955.05,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,27955.05,80,,27955.05,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,24460.67,70,,24460.67,percent of total billed charges,,519.88,,,519.88,Fee Schedule,,440.63,,,440.63,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,667.11,,,667.11,Other,New York Medicaid APG methodology,667.11,,,667.11,Other,100% New York Medicaid APG,667.11,,,667.11,Other,100% New York Medicaid APG,667.11,,,667.11,Other,100% New York Medicaid APG,1501,,,1501,Other,225% New York Medicaid APG,1020.68,,,1020.68,Other,153% New York Medicaid APG,1501,,,1501,Other,225% New York Medicaid APG,933.96,,,933.96,Other,140% New York Medicaid APG,1501,,,1501,Other,225% New York Medicaid APG,1734.49,,,1734.49,Other,260% New York Medicaid APG,2161.44,,,2161.44,Other,324% New York Medicaid APG,1434.29,,,1434.29,Other,215% New York Medicaid APG,1434.29,,,1434.29,Other,215% New York Medicaid APG,833.89,,,833.89,Other,125% New York Medicaid APG,440.63,27955.05,
Exc tr-ext b9+marg 1.1-2 cm,11402,CPT,,,,,,,,both,,,35381.88,26182.59,74,,26182.59,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15921.85,45,,15921.85,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,17514.03,49.5,,17514.03,percent of total billed charges,110% of Medicare,24059.68,68,,24059.68,percent of total billed charges,,1240.83,,,1240.83,Other,186% of Medicaid,28305.5,80,,28305.5,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,28305.5,80,,28305.5,percent of total billed charges,,7216,,,7216,Case Rate,,3578,,"100% primary, 0% secondary procedures",3578,Other,MagnaCare ASC Grouper,24767.32,70,,24767.32,percent of total billed charges,,565.8,,,565.8,Fee Schedule,,479.55,,,479.55,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,667.11,,,667.11,Other,New York Medicaid APG methodology,667.11,,,667.11,Other,100% New York Medicaid APG,667.11,,,667.11,Other,100% New York Medicaid APG,667.11,,,667.11,Other,100% New York Medicaid APG,1501,,,1501,Other,225% New York Medicaid APG,1020.68,,,1020.68,Other,153% New York Medicaid APG,1501,,,1501,Other,225% New York Medicaid APG,933.96,,,933.96,Other,140% New York Medicaid APG,1501,,,1501,Other,225% New York Medicaid APG,1734.49,,,1734.49,Other,260% New York Medicaid APG,2161.44,,,2161.44,Other,324% New York Medicaid APG,1434.29,,,1434.29,Other,215% New York Medicaid APG,1434.29,,,1434.29,Other,215% New York Medicaid APG,833.89,,,833.89,Other,125% New York Medicaid APG,479.55,28305.5,
Exc tr-ext b9+marg 2.1-3cm,11403,CPT,,,,,,,,both,,,35017.63,25913.05,74,,25913.05,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15757.93,45,,15757.93,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,17333.73,49.5,,17333.73,percent of total billed charges,110% of Medicare,23811.99,68,,23811.99,percent of total billed charges,,1240.83,,,1240.83,Other,186% of Medicaid,28014.1,80,,28014.1,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,28014.1,80,,28014.1,percent of total billed charges,,7216,,,7216,Case Rate,,3578,,"100% primary, 0% secondary procedures",3578,Other,MagnaCare ASC Grouper,24512.34,70,,24512.34,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,667.11,,,667.11,Other,New York Medicaid APG methodology,667.11,,,667.11,Other,100% New York Medicaid APG,667.11,,,667.11,Other,100% New York Medicaid APG,667.11,,,667.11,Other,100% New York Medicaid APG,1501,,,1501,Other,225% New York Medicaid APG,1020.68,,,1020.68,Other,153% New York Medicaid APG,1501,,,1501,Other,225% New York Medicaid APG,933.96,,,933.96,Other,140% New York Medicaid APG,1501,,,1501,Other,225% New York Medicaid APG,1734.49,,,1734.49,Other,260% New York Medicaid APG,2161.44,,,2161.44,Other,324% New York Medicaid APG,1434.29,,,1434.29,Other,215% New York Medicaid APG,1434.29,,,1434.29,Other,215% New York Medicaid APG,833.89,,,833.89,Other,125% New York Medicaid APG,667.11,28014.1,
Exc tr-ext b9+marg 3.1-4 cm,11404,CPT,,,,,,,,both,,,35816.42,26504.15,74,,26504.15,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,16117.39,45,,16117.39,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,17729.13,49.5,,17729.13,percent of total billed charges,110% of Medicare,24355.17,68,,24355.17,percent of total billed charges,,2241.85,,,2241.85,Other,186% of Medicaid,28653.14,80,,28653.14,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,28653.14,80,,28653.14,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,25071.49,70,,25071.49,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1205.3,,,1205.3,Other,New York Medicaid APG methodology,1205.3,,,1205.3,Other,100% New York Medicaid APG,1205.3,,,1205.3,Other,100% New York Medicaid APG,1205.3,,,1205.3,Other,100% New York Medicaid APG,2711.92,,,2711.92,Other,225% New York Medicaid APG,1844.1,,,1844.1,Other,153% New York Medicaid APG,2711.92,,,2711.92,Other,225% New York Medicaid APG,1687.41,,,1687.41,Other,140% New York Medicaid APG,2711.92,,,2711.92,Other,225% New York Medicaid APG,3133.77,,,3133.77,Other,260% New York Medicaid APG,3905.16,,,3905.16,Other,324% New York Medicaid APG,2591.39,,,2591.39,Other,215% New York Medicaid APG,2591.39,,,2591.39,Other,215% New York Medicaid APG,1506.62,,,1506.62,Other,125% New York Medicaid APG,1205.3,28653.14,
Exc tr-ext b9+marg >4.0 cm,11406,CPT,,,,,,,,both,,,37909.24,28052.84,74,,28052.84,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,17059.16,45,,17059.16,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,18765.07,49.5,,18765.07,percent of total billed charges,110% of Medicare,25778.28,68,,25778.28,percent of total billed charges,,3621.77,,,3621.77,Other,186% of Medicaid,30327.39,80,,30327.39,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,30327.39,80,,30327.39,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,26536.47,70,,26536.47,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1947.19,,,1947.19,Other,New York Medicaid APG methodology,1947.19,,,1947.19,Other,100% New York Medicaid APG,1947.19,,,1947.19,Other,100% New York Medicaid APG,1947.19,,,1947.19,Other,100% New York Medicaid APG,4381.17,,,4381.17,Other,225% New York Medicaid APG,2979.2,,,2979.2,Other,153% New York Medicaid APG,4381.17,,,4381.17,Other,225% New York Medicaid APG,2726.06,,,2726.06,Other,140% New York Medicaid APG,4381.17,,,4381.17,Other,225% New York Medicaid APG,5062.69,,,5062.69,Other,260% New York Medicaid APG,6308.89,,,6308.89,Other,324% New York Medicaid APG,4186.45,,,4186.45,Other,215% New York Medicaid APG,4186.45,,,4186.45,Other,215% New York Medicaid APG,2433.99,,,2433.99,Other,125% New York Medicaid APG,1947.19,30327.39,
Exc h-f-nk-sp b9+marg 0.5/<,11420,CPT,,,,,,,,both,,,37620.34,27839.05,74,,27839.05,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,16929.15,45,,16929.15,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,18622.07,49.5,,18622.07,percent of total billed charges,110% of Medicare,25581.83,68,,25581.83,percent of total billed charges,,2241.85,,,2241.85,Other,186% of Medicaid,30096.27,80,,30096.27,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,30096.27,80,,30096.27,percent of total billed charges,,7216,,,7216,Case Rate,,3578,,"100% primary, 0% secondary procedures",3578,Other,MagnaCare ASC Grouper,26334.24,70,,26334.24,percent of total billed charges,,401.8,,,401.8,Fee Schedule,,340.55,,,340.55,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,1205.3,,,1205.3,Other,New York Medicaid APG methodology,1205.3,,,1205.3,Other,100% New York Medicaid APG,1205.3,,,1205.3,Other,100% New York Medicaid APG,1205.3,,,1205.3,Other,100% New York Medicaid APG,2711.92,,,2711.92,Other,225% New York Medicaid APG,1844.1,,,1844.1,Other,153% New York Medicaid APG,2711.92,,,2711.92,Other,225% New York Medicaid APG,1687.41,,,1687.41,Other,140% New York Medicaid APG,2711.92,,,2711.92,Other,225% New York Medicaid APG,3133.77,,,3133.77,Other,260% New York Medicaid APG,3905.16,,,3905.16,Other,324% New York Medicaid APG,2591.39,,,2591.39,Other,215% New York Medicaid APG,2591.39,,,2591.39,Other,215% New York Medicaid APG,1506.62,,,1506.62,Other,125% New York Medicaid APG,340.55,30096.27,
Exc h-f-nk-sp b9+marg 0.6-1,11421,CPT,,,,,,,,both,,,38590.22,28556.76,74,,28556.76,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,17365.6,45,,17365.6,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,19102.16,49.5,,19102.16,percent of total billed charges,110% of Medicare,26241.35,68,,26241.35,percent of total billed charges,,1240.83,,,1240.83,Other,186% of Medicaid,30872.18,80,,30872.18,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,30872.18,80,,30872.18,percent of total billed charges,,7216,,,7216,Case Rate,,3578,,"100% primary, 0% secondary procedures",3578,Other,MagnaCare ASC Grouper,27013.15,70,,27013.15,percent of total billed charges,,536.28,,,536.28,Fee Schedule,,454.53,,,454.53,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,667.11,,,667.11,Other,New York Medicaid APG methodology,667.11,,,667.11,Other,100% New York Medicaid APG,667.11,,,667.11,Other,100% New York Medicaid APG,667.11,,,667.11,Other,100% New York Medicaid APG,1501,,,1501,Other,225% New York Medicaid APG,1020.68,,,1020.68,Other,153% New York Medicaid APG,1501,,,1501,Other,225% New York Medicaid APG,933.96,,,933.96,Other,140% New York Medicaid APG,1501,,,1501,Other,225% New York Medicaid APG,1734.49,,,1734.49,Other,260% New York Medicaid APG,2161.44,,,2161.44,Other,324% New York Medicaid APG,1434.29,,,1434.29,Other,215% New York Medicaid APG,1434.29,,,1434.29,Other,215% New York Medicaid APG,833.89,,,833.89,Other,125% New York Medicaid APG,454.53,30872.18,
Exc h-f-nk-sp b9+marg 1.1-2,11422,CPT,,,,,,,,both,,,37502.29,27751.69,74,,27751.69,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,16876.03,45,,16876.03,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,18563.63,49.5,,18563.63,percent of total billed charges,110% of Medicare,25501.56,68,,25501.56,percent of total billed charges,,2241.85,,,2241.85,Other,186% of Medicaid,30001.83,80,,30001.83,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,30001.83,80,,30001.83,percent of total billed charges,,7216,,,7216,Case Rate,,3578,,"100% primary, 0% secondary procedures",3578,Other,MagnaCare ASC Grouper,26251.6,70,,26251.6,percent of total billed charges,,664.2,,,664.2,Fee Schedule,,562.95,,,562.95,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,1205.3,,,1205.3,Other,New York Medicaid APG methodology,1205.3,,,1205.3,Other,100% New York Medicaid APG,1205.3,,,1205.3,Other,100% New York Medicaid APG,1205.3,,,1205.3,Other,100% New York Medicaid APG,2711.92,,,2711.92,Other,225% New York Medicaid APG,1844.1,,,1844.1,Other,153% New York Medicaid APG,2711.92,,,2711.92,Other,225% New York Medicaid APG,1687.41,,,1687.41,Other,140% New York Medicaid APG,2711.92,,,2711.92,Other,225% New York Medicaid APG,3133.77,,,3133.77,Other,260% New York Medicaid APG,3905.16,,,3905.16,Other,324% New York Medicaid APG,2591.39,,,2591.39,Other,215% New York Medicaid APG,2591.39,,,2591.39,Other,215% New York Medicaid APG,1506.62,,,1506.62,Other,125% New York Medicaid APG,562.95,30001.83,
Exc h-f-nk-sp b9+marg 2.1-3,11423,CPT,,,,,,,,both,,,36267.22,26837.74,74,,26837.74,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,16320.25,45,,16320.25,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,17952.27,49.5,,17952.27,percent of total billed charges,110% of Medicare,24661.71,68,,24661.71,percent of total billed charges,,2241.85,,,2241.85,Other,186% of Medicaid,29013.78,80,,29013.78,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,29013.78,80,,29013.78,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,25387.05,70,,25387.05,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1205.3,,,1205.3,Other,New York Medicaid APG methodology,1205.3,,,1205.3,Other,100% New York Medicaid APG,1205.3,,,1205.3,Other,100% New York Medicaid APG,1205.3,,,1205.3,Other,100% New York Medicaid APG,2711.92,,,2711.92,Other,225% New York Medicaid APG,1844.1,,,1844.1,Other,153% New York Medicaid APG,2711.92,,,2711.92,Other,225% New York Medicaid APG,1687.41,,,1687.41,Other,140% New York Medicaid APG,2711.92,,,2711.92,Other,225% New York Medicaid APG,3133.77,,,3133.77,Other,260% New York Medicaid APG,3905.16,,,3905.16,Other,324% New York Medicaid APG,2591.39,,,2591.39,Other,215% New York Medicaid APG,2591.39,,,2591.39,Other,215% New York Medicaid APG,1506.62,,,1506.62,Other,125% New York Medicaid APG,1205.3,29013.78,
Exc h-f-nk-sp b9+marg 3.1-4,11424,CPT,,,,,,,,both,,,34101.75,25235.3,74,,25235.3,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15345.79,45,,15345.79,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,16880.37,49.5,,16880.37,percent of total billed charges,110% of Medicare,23189.19,68,,23189.19,percent of total billed charges,,2241.85,,,2241.85,Other,186% of Medicaid,27281.4,80,,27281.4,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,27281.4,80,,27281.4,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,23871.23,70,,23871.23,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1205.3,,,1205.3,Other,New York Medicaid APG methodology,1205.3,,,1205.3,Other,100% New York Medicaid APG,1205.3,,,1205.3,Other,100% New York Medicaid APG,1205.3,,,1205.3,Other,100% New York Medicaid APG,2711.92,,,2711.92,Other,225% New York Medicaid APG,1844.1,,,1844.1,Other,153% New York Medicaid APG,2711.92,,,2711.92,Other,225% New York Medicaid APG,1687.41,,,1687.41,Other,140% New York Medicaid APG,2711.92,,,2711.92,Other,225% New York Medicaid APG,3133.77,,,3133.77,Other,260% New York Medicaid APG,3905.16,,,3905.16,Other,324% New York Medicaid APG,2591.39,,,2591.39,Other,215% New York Medicaid APG,2591.39,,,2591.39,Other,215% New York Medicaid APG,1506.62,,,1506.62,Other,125% New York Medicaid APG,1205.3,27281.4,
Exc h-f-nk-sp b9+marg >4 cm,11426,CPT,,,,,,,,both,,,36406.91,26941.11,74,,26941.11,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,16383.11,45,,16383.11,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,18021.42,49.5,,18021.42,percent of total billed charges,110% of Medicare,24756.7,68,,24756.7,percent of total billed charges,,3621.77,,,3621.77,Other,186% of Medicaid,29125.53,80,,29125.53,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,29125.53,80,,29125.53,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,25484.84,70,,25484.84,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1947.19,,,1947.19,Other,New York Medicaid APG methodology,1947.19,,,1947.19,Other,100% New York Medicaid APG,1947.19,,,1947.19,Other,100% New York Medicaid APG,1947.19,,,1947.19,Other,100% New York Medicaid APG,4381.17,,,4381.17,Other,225% New York Medicaid APG,2979.2,,,2979.2,Other,153% New York Medicaid APG,4381.17,,,4381.17,Other,225% New York Medicaid APG,2726.06,,,2726.06,Other,140% New York Medicaid APG,4381.17,,,4381.17,Other,225% New York Medicaid APG,5062.69,,,5062.69,Other,260% New York Medicaid APG,6308.89,,,6308.89,Other,324% New York Medicaid APG,4186.45,,,4186.45,Other,215% New York Medicaid APG,4186.45,,,4186.45,Other,215% New York Medicaid APG,2433.99,,,2433.99,Other,125% New York Medicaid APG,1947.19,29125.53,
Exc face-mm b9+marg 0.5 cm/<,11440,CPT,,,,,,,,both,,,36219.26,26802.25,74,,26802.25,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,16298.67,45,,16298.67,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,17928.53,49.5,,17928.53,percent of total billed charges,110% of Medicare,24629.1,68,,24629.1,percent of total billed charges,,1240.83,,,1240.83,Other,186% of Medicaid,28975.41,80,,28975.41,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,28975.41,80,,28975.41,percent of total billed charges,,7216,,,7216,Case Rate,,3578,,"100% primary, 0% secondary procedures",3578,Other,MagnaCare ASC Grouper,25353.48,70,,25353.48,percent of total billed charges,,519.88,,,519.88,Fee Schedule,,440.63,,,440.63,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,667.11,,,667.11,Other,New York Medicaid APG methodology,667.11,,,667.11,Other,100% New York Medicaid APG,667.11,,,667.11,Other,100% New York Medicaid APG,667.11,,,667.11,Other,100% New York Medicaid APG,1501,,,1501,Other,225% New York Medicaid APG,1020.68,,,1020.68,Other,153% New York Medicaid APG,1501,,,1501,Other,225% New York Medicaid APG,933.96,,,933.96,Other,140% New York Medicaid APG,1501,,,1501,Other,225% New York Medicaid APG,1734.49,,,1734.49,Other,260% New York Medicaid APG,2161.44,,,2161.44,Other,324% New York Medicaid APG,1434.29,,,1434.29,Other,215% New York Medicaid APG,1434.29,,,1434.29,Other,215% New York Medicaid APG,833.89,,,833.89,Other,125% New York Medicaid APG,440.63,28975.41,
Exc face-mm b9+marg 0.6-1 cm,11441,CPT,,,,,,,,both,,,34637.18,25631.51,74,,25631.51,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15586.73,45,,15586.73,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,17145.4,49.5,,17145.4,percent of total billed charges,110% of Medicare,23553.28,68,,23553.28,percent of total billed charges,,1240.83,,,1240.83,Other,186% of Medicaid,27709.74,80,,27709.74,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,27709.74,80,,27709.74,percent of total billed charges,,7216,,,7216,Case Rate,,3578,,"100% primary, 0% secondary procedures",3578,Other,MagnaCare ASC Grouper,24246.03,70,,24246.03,percent of total billed charges,,651.08,,,651.08,Fee Schedule,,551.83,,,551.83,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,667.11,,,667.11,Other,New York Medicaid APG methodology,667.11,,,667.11,Other,100% New York Medicaid APG,667.11,,,667.11,Other,100% New York Medicaid APG,667.11,,,667.11,Other,100% New York Medicaid APG,1501,,,1501,Other,225% New York Medicaid APG,1020.68,,,1020.68,Other,153% New York Medicaid APG,1501,,,1501,Other,225% New York Medicaid APG,933.96,,,933.96,Other,140% New York Medicaid APG,1501,,,1501,Other,225% New York Medicaid APG,1734.49,,,1734.49,Other,260% New York Medicaid APG,2161.44,,,2161.44,Other,324% New York Medicaid APG,1434.29,,,1434.29,Other,215% New York Medicaid APG,1434.29,,,1434.29,Other,215% New York Medicaid APG,833.89,,,833.89,Other,125% New York Medicaid APG,551.83,27709.74,
Exc face-mm b9+marg 1.1-2 cm,11442,CPT,,,,,,,,both,,,35219.66,26062.55,74,,26062.55,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15848.85,45,,15848.85,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,17433.73,49.5,,17433.73,percent of total billed charges,110% of Medicare,23949.37,68,,23949.37,percent of total billed charges,,1240.83,,,1240.83,Other,186% of Medicaid,28175.73,80,,28175.73,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,28175.73,80,,28175.73,percent of total billed charges,,7216,,,7216,Case Rate,,3578,,"100% primary, 0% secondary procedures",3578,Other,MagnaCare ASC Grouper,24653.76,70,,24653.76,percent of total billed charges,,718.32,,,718.32,Fee Schedule,,608.82,,,608.82,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,667.11,,,667.11,Other,New York Medicaid APG methodology,667.11,,,667.11,Other,100% New York Medicaid APG,667.11,,,667.11,Other,100% New York Medicaid APG,667.11,,,667.11,Other,100% New York Medicaid APG,1501,,,1501,Other,225% New York Medicaid APG,1020.68,,,1020.68,Other,153% New York Medicaid APG,1501,,,1501,Other,225% New York Medicaid APG,933.96,,,933.96,Other,140% New York Medicaid APG,1501,,,1501,Other,225% New York Medicaid APG,1734.49,,,1734.49,Other,260% New York Medicaid APG,2161.44,,,2161.44,Other,324% New York Medicaid APG,1434.29,,,1434.29,Other,215% New York Medicaid APG,1434.29,,,1434.29,Other,215% New York Medicaid APG,833.89,,,833.89,Other,125% New York Medicaid APG,608.82,28175.73,
Exc face-mm b9+marg 2.1-3 cm,11443,CPT,,,,,,,,both,,,37395.32,27672.54,74,,27672.54,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,16827.89,45,,16827.89,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,18510.68,49.5,,18510.68,percent of total billed charges,110% of Medicare,25428.82,68,,25428.82,percent of total billed charges,,2241.85,,,2241.85,Other,186% of Medicaid,29916.26,80,,29916.26,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,29916.26,80,,29916.26,percent of total billed charges,,7216,,,7216,Case Rate,,3578,,"100% primary, 0% secondary procedures",3578,Other,MagnaCare ASC Grouper,26176.72,70,,26176.72,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,1205.3,,,1205.3,Other,New York Medicaid APG methodology,1205.3,,,1205.3,Other,100% New York Medicaid APG,1205.3,,,1205.3,Other,100% New York Medicaid APG,1205.3,,,1205.3,Other,100% New York Medicaid APG,2711.92,,,2711.92,Other,225% New York Medicaid APG,1844.1,,,1844.1,Other,153% New York Medicaid APG,2711.92,,,2711.92,Other,225% New York Medicaid APG,1687.41,,,1687.41,Other,140% New York Medicaid APG,2711.92,,,2711.92,Other,225% New York Medicaid APG,3133.77,,,3133.77,Other,260% New York Medicaid APG,3905.16,,,3905.16,Other,324% New York Medicaid APG,2591.39,,,2591.39,Other,215% New York Medicaid APG,2591.39,,,2591.39,Other,215% New York Medicaid APG,1506.62,,,1506.62,Other,125% New York Medicaid APG,1205.3,29916.26,
Exc face-mm b9+marg 3.1-4 cm,11444,CPT,,,,,,,,both,,,44236.91,32735.31,74,,32735.31,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,19906.61,45,,19906.61,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,21897.27,49.5,,21897.27,percent of total billed charges,110% of Medicare,30081.1,68,,30081.1,percent of total billed charges,,2241.85,,,2241.85,Other,186% of Medicaid,35389.53,80,,35389.53,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,35389.53,80,,35389.53,percent of total billed charges,,7216,,,7216,Case Rate,,3578,,"100% primary, 0% secondary procedures",3578,Other,MagnaCare ASC Grouper,30965.84,70,,30965.84,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,1205.3,,,1205.3,Other,New York Medicaid APG methodology,1205.3,,,1205.3,Other,100% New York Medicaid APG,1205.3,,,1205.3,Other,100% New York Medicaid APG,1205.3,,,1205.3,Other,100% New York Medicaid APG,2711.92,,,2711.92,Other,225% New York Medicaid APG,1844.1,,,1844.1,Other,153% New York Medicaid APG,2711.92,,,2711.92,Other,225% New York Medicaid APG,1687.41,,,1687.41,Other,140% New York Medicaid APG,2711.92,,,2711.92,Other,225% New York Medicaid APG,3133.77,,,3133.77,Other,260% New York Medicaid APG,3905.16,,,3905.16,Other,324% New York Medicaid APG,2591.39,,,2591.39,Other,215% New York Medicaid APG,2591.39,,,2591.39,Other,215% New York Medicaid APG,1506.62,,,1506.62,Other,125% New York Medicaid APG,1205.3,35389.53,
Exc face-mm b9+marg >4 cm,11446,CPT,,,,,,,,both,,,43807.73,32417.72,74,,32417.72,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,19713.48,45,,19713.48,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,21684.83,49.5,,21684.83,percent of total billed charges,110% of Medicare,29789.26,68,,29789.26,percent of total billed charges,,3621.77,,,3621.77,Other,186% of Medicaid,35046.18,80,,35046.18,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,35046.18,80,,35046.18,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,30665.41,70,,30665.41,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1947.19,,,1947.19,Other,New York Medicaid APG methodology,1947.19,,,1947.19,Other,100% New York Medicaid APG,1947.19,,,1947.19,Other,100% New York Medicaid APG,1947.19,,,1947.19,Other,100% New York Medicaid APG,4381.17,,,4381.17,Other,225% New York Medicaid APG,2979.2,,,2979.2,Other,153% New York Medicaid APG,4381.17,,,4381.17,Other,225% New York Medicaid APG,2726.06,,,2726.06,Other,140% New York Medicaid APG,4381.17,,,4381.17,Other,225% New York Medicaid APG,5062.69,,,5062.69,Other,260% New York Medicaid APG,6308.89,,,6308.89,Other,324% New York Medicaid APG,4186.45,,,4186.45,Other,215% New York Medicaid APG,4186.45,,,4186.45,Other,215% New York Medicaid APG,2433.99,,,2433.99,Other,125% New York Medicaid APG,1947.19,35046.18,
Removal sweat gland lesion,11450,CPT,,,,,,,,both,,,59767.2,44227.73,74,,44227.73,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,26895.24,45,,26895.24,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,29584.76,49.5,,29584.76,percent of total billed charges,110% of Medicare,40641.7,68,,40641.7,percent of total billed charges,,3621.77,,,3621.77,Other,186% of Medicaid,47813.76,80,,47813.76,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,47813.76,80,,47813.76,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,41837.04,70,,41837.04,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1947.19,,,1947.19,Other,New York Medicaid APG methodology,1947.19,,,1947.19,Other,100% New York Medicaid APG,1947.19,,,1947.19,Other,100% New York Medicaid APG,1947.19,,,1947.19,Other,100% New York Medicaid APG,4381.17,,,4381.17,Other,225% New York Medicaid APG,2979.2,,,2979.2,Other,153% New York Medicaid APG,4381.17,,,4381.17,Other,225% New York Medicaid APG,2726.06,,,2726.06,Other,140% New York Medicaid APG,4381.17,,,4381.17,Other,225% New York Medicaid APG,5062.69,,,5062.69,Other,260% New York Medicaid APG,6308.89,,,6308.89,Other,324% New York Medicaid APG,4186.45,,,4186.45,Other,215% New York Medicaid APG,4186.45,,,4186.45,Other,215% New York Medicaid APG,2433.99,,,2433.99,Other,125% New York Medicaid APG,1947.19,47813.76,
Removal sweat gland lesion,11451,CPT,,,,,,,,both,,,59767.2,44227.73,74,,44227.73,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,26895.24,45,,26895.24,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,29584.76,49.5,,29584.76,percent of total billed charges,110% of Medicare,40641.7,68,,40641.7,percent of total billed charges,,3621.77,,,3621.77,Other,186% of Medicaid,47813.76,80,,47813.76,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,47813.76,80,,47813.76,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,41837.04,70,,41837.04,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1947.19,,,1947.19,Other,New York Medicaid APG methodology,1947.19,,,1947.19,Other,100% New York Medicaid APG,1947.19,,,1947.19,Other,100% New York Medicaid APG,1947.19,,,1947.19,Other,100% New York Medicaid APG,4381.17,,,4381.17,Other,225% New York Medicaid APG,2979.2,,,2979.2,Other,153% New York Medicaid APG,4381.17,,,4381.17,Other,225% New York Medicaid APG,2726.06,,,2726.06,Other,140% New York Medicaid APG,4381.17,,,4381.17,Other,225% New York Medicaid APG,5062.69,,,5062.69,Other,260% New York Medicaid APG,6308.89,,,6308.89,Other,324% New York Medicaid APG,4186.45,,,4186.45,Other,215% New York Medicaid APG,4186.45,,,4186.45,Other,215% New York Medicaid APG,2433.99,,,2433.99,Other,125% New York Medicaid APG,1947.19,47813.76,
Removal sweat gland lesion,11462,CPT,,,,,,,,both,,,59767.2,44227.73,74,,44227.73,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,26895.24,45,,26895.24,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,29584.76,49.5,,29584.76,percent of total billed charges,110% of Medicare,40641.7,68,,40641.7,percent of total billed charges,,3621.77,,,3621.77,Other,186% of Medicaid,47813.76,80,,47813.76,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,47813.76,80,,47813.76,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,41837.04,70,,41837.04,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1947.19,,,1947.19,Other,New York Medicaid APG methodology,1947.19,,,1947.19,Other,100% New York Medicaid APG,1947.19,,,1947.19,Other,100% New York Medicaid APG,1947.19,,,1947.19,Other,100% New York Medicaid APG,4381.17,,,4381.17,Other,225% New York Medicaid APG,2979.2,,,2979.2,Other,153% New York Medicaid APG,4381.17,,,4381.17,Other,225% New York Medicaid APG,2726.06,,,2726.06,Other,140% New York Medicaid APG,4381.17,,,4381.17,Other,225% New York Medicaid APG,5062.69,,,5062.69,Other,260% New York Medicaid APG,6308.89,,,6308.89,Other,324% New York Medicaid APG,4186.45,,,4186.45,Other,215% New York Medicaid APG,4186.45,,,4186.45,Other,215% New York Medicaid APG,2433.99,,,2433.99,Other,125% New York Medicaid APG,1947.19,47813.76,
Removal sweat gland lesion,11463,CPT,,,,,,,,both,,,79425.93,58775.19,74,,58775.19,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,35741.67,45,,35741.67,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,39315.84,49.5,,39315.84,percent of total billed charges,110% of Medicare,54009.63,68,,54009.63,percent of total billed charges,,3621.77,,,3621.77,Other,186% of Medicaid,63540.74,80,,63540.74,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,63540.74,80,,63540.74,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,55598.15,70,,55598.15,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1947.19,,,1947.19,Other,New York Medicaid APG methodology,1947.19,,,1947.19,Other,100% New York Medicaid APG,1947.19,,,1947.19,Other,100% New York Medicaid APG,1947.19,,,1947.19,Other,100% New York Medicaid APG,4381.17,,,4381.17,Other,225% New York Medicaid APG,2979.2,,,2979.2,Other,153% New York Medicaid APG,4381.17,,,4381.17,Other,225% New York Medicaid APG,2726.06,,,2726.06,Other,140% New York Medicaid APG,4381.17,,,4381.17,Other,225% New York Medicaid APG,5062.69,,,5062.69,Other,260% New York Medicaid APG,6308.89,,,6308.89,Other,324% New York Medicaid APG,4186.45,,,4186.45,Other,215% New York Medicaid APG,4186.45,,,4186.45,Other,215% New York Medicaid APG,2433.99,,,2433.99,Other,125% New York Medicaid APG,1947.19,63540.74,
Removal sweat gland lesion,11470,CPT,,,,,,,,both,,,59767.2,44227.73,74,,44227.73,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,26895.24,45,,26895.24,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,29584.76,49.5,,29584.76,percent of total billed charges,110% of Medicare,40641.7,68,,40641.7,percent of total billed charges,,3621.77,,,3621.77,Other,186% of Medicaid,47813.76,80,,47813.76,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,47813.76,80,,47813.76,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,41837.04,70,,41837.04,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1947.19,,,1947.19,Other,New York Medicaid APG methodology,1947.19,,,1947.19,Other,100% New York Medicaid APG,1947.19,,,1947.19,Other,100% New York Medicaid APG,1947.19,,,1947.19,Other,100% New York Medicaid APG,4381.17,,,4381.17,Other,225% New York Medicaid APG,2979.2,,,2979.2,Other,153% New York Medicaid APG,4381.17,,,4381.17,Other,225% New York Medicaid APG,2726.06,,,2726.06,Other,140% New York Medicaid APG,4381.17,,,4381.17,Other,225% New York Medicaid APG,5062.69,,,5062.69,Other,260% New York Medicaid APG,6308.89,,,6308.89,Other,324% New York Medicaid APG,4186.45,,,4186.45,Other,215% New York Medicaid APG,4186.45,,,4186.45,Other,215% New York Medicaid APG,2433.99,,,2433.99,Other,125% New York Medicaid APG,1947.19,47813.76,
Removal sweat gland lesion,11471,CPT,,,,,,,,both,,,59767.2,44227.73,74,,44227.73,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,26895.24,45,,26895.24,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,29584.76,49.5,,29584.76,percent of total billed charges,110% of Medicare,40641.7,68,,40641.7,percent of total billed charges,,3621.77,,,3621.77,Other,186% of Medicaid,47813.76,80,,47813.76,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,47813.76,80,,47813.76,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,41837.04,70,,41837.04,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1947.19,,,1947.19,Other,New York Medicaid APG methodology,1947.19,,,1947.19,Other,100% New York Medicaid APG,1947.19,,,1947.19,Other,100% New York Medicaid APG,1947.19,,,1947.19,Other,100% New York Medicaid APG,4381.17,,,4381.17,Other,225% New York Medicaid APG,2979.2,,,2979.2,Other,153% New York Medicaid APG,4381.17,,,4381.17,Other,225% New York Medicaid APG,2726.06,,,2726.06,Other,140% New York Medicaid APG,4381.17,,,4381.17,Other,225% New York Medicaid APG,5062.69,,,5062.69,Other,260% New York Medicaid APG,6308.89,,,6308.89,Other,324% New York Medicaid APG,4186.45,,,4186.45,Other,215% New York Medicaid APG,4186.45,,,4186.45,Other,215% New York Medicaid APG,2433.99,,,2433.99,Other,125% New York Medicaid APG,1947.19,47813.76,
Exc tr-ext mal+marg 0.5 cm/<,11600,CPT,,,,,,,,both,,,14798.8,10951.11,74,,10951.11,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,6659.46,45,,6659.46,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,7325.41,49.5,,7325.41,percent of total billed charges,110% of Medicare,10063.18,68,,10063.18,percent of total billed charges,,1240.83,,,1240.83,Other,186% of Medicaid,11839.04,80,,11839.04,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,11839.04,80,,11839.04,percent of total billed charges,,7216,,,7216,Case Rate,,3578,,"100% primary, 0% secondary procedures",3578,Other,MagnaCare ASC Grouper,10359.16,70,,10359.16,percent of total billed charges,,596.96,,,596.96,Fee Schedule,,505.96,,,505.96,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,667.11,,,667.11,Other,New York Medicaid APG methodology,667.11,,,667.11,Other,100% New York Medicaid APG,667.11,,,667.11,Other,100% New York Medicaid APG,667.11,,,667.11,Other,100% New York Medicaid APG,1501,,,1501,Other,225% New York Medicaid APG,1020.68,,,1020.68,Other,153% New York Medicaid APG,1501,,,1501,Other,225% New York Medicaid APG,933.96,,,933.96,Other,140% New York Medicaid APG,1501,,,1501,Other,225% New York Medicaid APG,1734.49,,,1734.49,Other,260% New York Medicaid APG,2161.44,,,2161.44,Other,324% New York Medicaid APG,1434.29,,,1434.29,Other,215% New York Medicaid APG,1434.29,,,1434.29,Other,215% New York Medicaid APG,833.89,,,833.89,Other,125% New York Medicaid APG,505.96,11839.04,
Exc tr-ext mal+marg 0.6-1 cm,11601,CPT,,,,,,,,both,,,14798.8,10951.11,74,,10951.11,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,6659.46,45,,6659.46,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,7325.41,49.5,,7325.41,percent of total billed charges,110% of Medicare,10063.18,68,,10063.18,percent of total billed charges,,1240.83,,,1240.83,Other,186% of Medicaid,11839.04,80,,11839.04,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,11839.04,80,,11839.04,percent of total billed charges,,7216,,,7216,Case Rate,,3578,,"100% primary, 0% secondary procedures",3578,Other,MagnaCare ASC Grouper,10359.16,70,,10359.16,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,667.11,,,667.11,Other,New York Medicaid APG methodology,667.11,,,667.11,Other,100% New York Medicaid APG,667.11,,,667.11,Other,100% New York Medicaid APG,667.11,,,667.11,Other,100% New York Medicaid APG,1501,,,1501,Other,225% New York Medicaid APG,1020.68,,,1020.68,Other,153% New York Medicaid APG,1501,,,1501,Other,225% New York Medicaid APG,933.96,,,933.96,Other,140% New York Medicaid APG,1501,,,1501,Other,225% New York Medicaid APG,1734.49,,,1734.49,Other,260% New York Medicaid APG,2161.44,,,2161.44,Other,324% New York Medicaid APG,1434.29,,,1434.29,Other,215% New York Medicaid APG,1434.29,,,1434.29,Other,215% New York Medicaid APG,833.89,,,833.89,Other,125% New York Medicaid APG,667.11,11839.04,
Exc tr-ext mal+marg 1.1-2 cm,11602,CPT,,,,,,,,both,,,36725.63,27176.97,74,,27176.97,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,16526.53,45,,16526.53,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,18179.19,49.5,,18179.19,percent of total billed charges,110% of Medicare,24973.43,68,,24973.43,percent of total billed charges,,1240.83,,,1240.83,Other,186% of Medicaid,29380.5,80,,29380.5,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,29380.5,80,,29380.5,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,25707.94,70,,25707.94,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,667.11,,,667.11,Other,New York Medicaid APG methodology,667.11,,,667.11,Other,100% New York Medicaid APG,667.11,,,667.11,Other,100% New York Medicaid APG,667.11,,,667.11,Other,100% New York Medicaid APG,1501,,,1501,Other,225% New York Medicaid APG,1020.68,,,1020.68,Other,153% New York Medicaid APG,1501,,,1501,Other,225% New York Medicaid APG,933.96,,,933.96,Other,140% New York Medicaid APG,1501,,,1501,Other,225% New York Medicaid APG,1734.49,,,1734.49,Other,260% New York Medicaid APG,2161.44,,,2161.44,Other,324% New York Medicaid APG,1434.29,,,1434.29,Other,215% New York Medicaid APG,1434.29,,,1434.29,Other,215% New York Medicaid APG,833.89,,,833.89,Other,125% New York Medicaid APG,667.11,29380.5,
Exc tr-ext mal+marg 2.1-3 cm,11603,CPT,,,,,,,,both,,,39565.02,29278.11,74,,29278.11,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,17804.26,45,,17804.26,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,19584.68,49.5,,19584.68,percent of total billed charges,110% of Medicare,26904.21,68,,26904.21,percent of total billed charges,,1240.83,,,1240.83,Other,186% of Medicaid,31652.02,80,,31652.02,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,31652.02,80,,31652.02,percent of total billed charges,,7216,,,7216,Case Rate,,3578,,"100% primary, 0% secondary procedures",3578,Other,MagnaCare ASC Grouper,27695.51,70,,27695.51,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,667.11,,,667.11,Other,New York Medicaid APG methodology,667.11,,,667.11,Other,100% New York Medicaid APG,667.11,,,667.11,Other,100% New York Medicaid APG,667.11,,,667.11,Other,100% New York Medicaid APG,1501,,,1501,Other,225% New York Medicaid APG,1020.68,,,1020.68,Other,153% New York Medicaid APG,1501,,,1501,Other,225% New York Medicaid APG,933.96,,,933.96,Other,140% New York Medicaid APG,1501,,,1501,Other,225% New York Medicaid APG,1734.49,,,1734.49,Other,260% New York Medicaid APG,2161.44,,,2161.44,Other,324% New York Medicaid APG,1434.29,,,1434.29,Other,215% New York Medicaid APG,1434.29,,,1434.29,Other,215% New York Medicaid APG,833.89,,,833.89,Other,125% New York Medicaid APG,667.11,31652.02,
Exc tr-ext mal+marg 3.1-4 cm,11604,CPT,,,,,,,,both,,,55886.11,41355.72,74,,41355.72,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,25148.75,45,,25148.75,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,27663.62,49.5,,27663.62,percent of total billed charges,110% of Medicare,38002.55,68,,38002.55,percent of total billed charges,,2241.85,,,2241.85,Other,186% of Medicaid,44708.89,80,,44708.89,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,44708.89,80,,44708.89,percent of total billed charges,,7216,,,7216,Case Rate,,3578,,"100% primary, 0% secondary procedures",3578,Other,MagnaCare ASC Grouper,39120.28,70,,39120.28,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,1205.3,,,1205.3,Other,New York Medicaid APG methodology,1205.3,,,1205.3,Other,100% New York Medicaid APG,1205.3,,,1205.3,Other,100% New York Medicaid APG,1205.3,,,1205.3,Other,100% New York Medicaid APG,2711.92,,,2711.92,Other,225% New York Medicaid APG,1844.1,,,1844.1,Other,153% New York Medicaid APG,2711.92,,,2711.92,Other,225% New York Medicaid APG,1687.41,,,1687.41,Other,140% New York Medicaid APG,2711.92,,,2711.92,Other,225% New York Medicaid APG,3133.77,,,3133.77,Other,260% New York Medicaid APG,3905.16,,,3905.16,Other,324% New York Medicaid APG,2591.39,,,2591.39,Other,215% New York Medicaid APG,2591.39,,,2591.39,Other,215% New York Medicaid APG,1506.62,,,1506.62,Other,125% New York Medicaid APG,1205.3,44708.89,
Exc tr-ext mal+marg >4 cm,11606,CPT,,,,,,,,both,,,34101.75,25235.3,74,,25235.3,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15345.79,45,,15345.79,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,16880.37,49.5,,16880.37,percent of total billed charges,110% of Medicare,23189.19,68,,23189.19,percent of total billed charges,,3621.77,,,3621.77,Other,186% of Medicaid,27281.4,80,,27281.4,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,27281.4,80,,27281.4,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,23871.23,70,,23871.23,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1947.19,,,1947.19,Other,New York Medicaid APG methodology,1947.19,,,1947.19,Other,100% New York Medicaid APG,1947.19,,,1947.19,Other,100% New York Medicaid APG,1947.19,,,1947.19,Other,100% New York Medicaid APG,4381.17,,,4381.17,Other,225% New York Medicaid APG,2979.2,,,2979.2,Other,153% New York Medicaid APG,4381.17,,,4381.17,Other,225% New York Medicaid APG,2726.06,,,2726.06,Other,140% New York Medicaid APG,4381.17,,,4381.17,Other,225% New York Medicaid APG,5062.69,,,5062.69,Other,260% New York Medicaid APG,6308.89,,,6308.89,Other,324% New York Medicaid APG,4186.45,,,4186.45,Other,215% New York Medicaid APG,4186.45,,,4186.45,Other,215% New York Medicaid APG,2433.99,,,2433.99,Other,125% New York Medicaid APG,1947.19,27281.4,
Exc h-f-nk-sp mal+marg 0.5/<,11620,CPT,,,,,,,,both,,,34101.75,25235.3,74,,25235.3,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15345.79,45,,15345.79,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,16880.37,49.5,,16880.37,percent of total billed charges,110% of Medicare,23189.19,68,,23189.19,percent of total billed charges,,2241.85,,,2241.85,Other,186% of Medicaid,27281.4,80,,27281.4,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,27281.4,80,,27281.4,percent of total billed charges,,7216,,,7216,Case Rate,,3578,,"100% primary, 0% secondary procedures",3578,Other,MagnaCare ASC Grouper,23871.23,70,,23871.23,percent of total billed charges,,600.24,,,600.24,Fee Schedule,,508.74,,,508.74,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,1205.3,,,1205.3,Other,New York Medicaid APG methodology,1205.3,,,1205.3,Other,100% New York Medicaid APG,1205.3,,,1205.3,Other,100% New York Medicaid APG,1205.3,,,1205.3,Other,100% New York Medicaid APG,2711.92,,,2711.92,Other,225% New York Medicaid APG,1844.1,,,1844.1,Other,153% New York Medicaid APG,2711.92,,,2711.92,Other,225% New York Medicaid APG,1687.41,,,1687.41,Other,140% New York Medicaid APG,2711.92,,,2711.92,Other,225% New York Medicaid APG,3133.77,,,3133.77,Other,260% New York Medicaid APG,3905.16,,,3905.16,Other,324% New York Medicaid APG,2591.39,,,2591.39,Other,215% New York Medicaid APG,2591.39,,,2591.39,Other,215% New York Medicaid APG,1506.62,,,1506.62,Other,125% New York Medicaid APG,508.74,27281.4,
Exc s/n/h/f/g mal+mrg 0.6-1,11621,CPT,,,,,,,,both,,,14798.8,10951.11,74,,10951.11,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,6659.46,45,,6659.46,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,7325.41,49.5,,7325.41,percent of total billed charges,110% of Medicare,10063.18,68,,10063.18,percent of total billed charges,,1240.83,,,1240.83,Other,186% of Medicaid,11839.04,80,,11839.04,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,11839.04,80,,11839.04,percent of total billed charges,,7216,,,7216,Case Rate,,3578,,"100% primary, 0% secondary procedures",3578,Other,MagnaCare ASC Grouper,10359.16,70,,10359.16,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,667.11,,,667.11,Other,New York Medicaid APG methodology,667.11,,,667.11,Other,100% New York Medicaid APG,667.11,,,667.11,Other,100% New York Medicaid APG,667.11,,,667.11,Other,100% New York Medicaid APG,1501,,,1501,Other,225% New York Medicaid APG,1020.68,,,1020.68,Other,153% New York Medicaid APG,1501,,,1501,Other,225% New York Medicaid APG,933.96,,,933.96,Other,140% New York Medicaid APG,1501,,,1501,Other,225% New York Medicaid APG,1734.49,,,1734.49,Other,260% New York Medicaid APG,2161.44,,,2161.44,Other,324% New York Medicaid APG,1434.29,,,1434.29,Other,215% New York Medicaid APG,1434.29,,,1434.29,Other,215% New York Medicaid APG,833.89,,,833.89,Other,125% New York Medicaid APG,667.11,11839.04,
Exc s/n/h/f/g mal+mrg 1.1-2,11622,CPT,,,,,,,,both,,,37185.15,27517.01,74,,27517.01,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,16733.32,45,,16733.32,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,18406.65,49.5,,18406.65,percent of total billed charges,110% of Medicare,25285.9,68,,25285.9,percent of total billed charges,,1240.83,,,1240.83,Other,186% of Medicaid,29748.12,80,,29748.12,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,29748.12,80,,29748.12,percent of total billed charges,,7216,,,7216,Case Rate,,3578,,"100% primary, 0% secondary procedures",3578,Other,MagnaCare ASC Grouper,26029.61,70,,26029.61,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,667.11,,,667.11,Other,New York Medicaid APG methodology,667.11,,,667.11,Other,100% New York Medicaid APG,667.11,,,667.11,Other,100% New York Medicaid APG,667.11,,,667.11,Other,100% New York Medicaid APG,1501,,,1501,Other,225% New York Medicaid APG,1020.68,,,1020.68,Other,153% New York Medicaid APG,1501,,,1501,Other,225% New York Medicaid APG,933.96,,,933.96,Other,140% New York Medicaid APG,1501,,,1501,Other,225% New York Medicaid APG,1734.49,,,1734.49,Other,260% New York Medicaid APG,2161.44,,,2161.44,Other,324% New York Medicaid APG,1434.29,,,1434.29,Other,215% New York Medicaid APG,1434.29,,,1434.29,Other,215% New York Medicaid APG,833.89,,,833.89,Other,125% New York Medicaid APG,667.11,29748.12,
Exc s/n/h/f/g mal+mrg 2.1-3,11623,CPT,,,,,,,,both,,,34101.75,25235.3,74,,25235.3,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15345.79,45,,15345.79,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,16880.37,49.5,,16880.37,percent of total billed charges,110% of Medicare,23189.19,68,,23189.19,percent of total billed charges,,2241.85,,,2241.85,Other,186% of Medicaid,27281.4,80,,27281.4,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,27281.4,80,,27281.4,percent of total billed charges,,7216,,,7216,Case Rate,,3578,,"100% primary, 0% secondary procedures",3578,Other,MagnaCare ASC Grouper,23871.23,70,,23871.23,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,1205.3,,,1205.3,Other,New York Medicaid APG methodology,1205.3,,,1205.3,Other,100% New York Medicaid APG,1205.3,,,1205.3,Other,100% New York Medicaid APG,1205.3,,,1205.3,Other,100% New York Medicaid APG,2711.92,,,2711.92,Other,225% New York Medicaid APG,1844.1,,,1844.1,Other,153% New York Medicaid APG,2711.92,,,2711.92,Other,225% New York Medicaid APG,1687.41,,,1687.41,Other,140% New York Medicaid APG,2711.92,,,2711.92,Other,225% New York Medicaid APG,3133.77,,,3133.77,Other,260% New York Medicaid APG,3905.16,,,3905.16,Other,324% New York Medicaid APG,2591.39,,,2591.39,Other,215% New York Medicaid APG,2591.39,,,2591.39,Other,215% New York Medicaid APG,1506.62,,,1506.62,Other,125% New York Medicaid APG,1205.3,27281.4,
Exc s/n/h/f/g mal+mrg 3.1-4,11624,CPT,,,,,,,,both,,,38581.78,28550.52,74,,28550.52,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,17361.8,45,,17361.8,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,19097.98,49.5,,19097.98,percent of total billed charges,110% of Medicare,26235.61,68,,26235.61,percent of total billed charges,,2241.85,,,2241.85,Other,186% of Medicaid,30865.42,80,,30865.42,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,30865.42,80,,30865.42,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,27007.25,70,,27007.25,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1205.3,,,1205.3,Other,New York Medicaid APG methodology,1205.3,,,1205.3,Other,100% New York Medicaid APG,1205.3,,,1205.3,Other,100% New York Medicaid APG,1205.3,,,1205.3,Other,100% New York Medicaid APG,2711.92,,,2711.92,Other,225% New York Medicaid APG,1844.1,,,1844.1,Other,153% New York Medicaid APG,2711.92,,,2711.92,Other,225% New York Medicaid APG,1687.41,,,1687.41,Other,140% New York Medicaid APG,2711.92,,,2711.92,Other,225% New York Medicaid APG,3133.77,,,3133.77,Other,260% New York Medicaid APG,3905.16,,,3905.16,Other,324% New York Medicaid APG,2591.39,,,2591.39,Other,215% New York Medicaid APG,2591.39,,,2591.39,Other,215% New York Medicaid APG,1506.62,,,1506.62,Other,125% New York Medicaid APG,1205.3,30865.42,
Exc s/n/h/f/g mal+mrg >4 cm,11626,CPT,,,,,,,,both,,,39290.13,29074.7,74,,29074.7,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,17680.56,45,,17680.56,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,19448.61,49.5,,19448.61,percent of total billed charges,110% of Medicare,26717.29,68,,26717.29,percent of total billed charges,,3621.77,,,3621.77,Other,186% of Medicaid,31432.1,80,,31432.1,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,31432.1,80,,31432.1,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,27503.09,70,,27503.09,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1947.19,,,1947.19,Other,New York Medicaid APG methodology,1947.19,,,1947.19,Other,100% New York Medicaid APG,1947.19,,,1947.19,Other,100% New York Medicaid APG,1947.19,,,1947.19,Other,100% New York Medicaid APG,4381.17,,,4381.17,Other,225% New York Medicaid APG,2979.2,,,2979.2,Other,153% New York Medicaid APG,4381.17,,,4381.17,Other,225% New York Medicaid APG,2726.06,,,2726.06,Other,140% New York Medicaid APG,4381.17,,,4381.17,Other,225% New York Medicaid APG,5062.69,,,5062.69,Other,260% New York Medicaid APG,6308.89,,,6308.89,Other,324% New York Medicaid APG,4186.45,,,4186.45,Other,215% New York Medicaid APG,4186.45,,,4186.45,Other,215% New York Medicaid APG,2433.99,,,2433.99,Other,125% New York Medicaid APG,1947.19,31432.1,
Exc f/e/e/n/l mal+mrg 0.5cm<,11640,CPT,,,,,,,,both,,,14798.8,10951.11,74,,10951.11,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,6659.46,45,,6659.46,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,7325.41,49.5,,7325.41,percent of total billed charges,110% of Medicare,10063.18,68,,10063.18,percent of total billed charges,,1240.83,,,1240.83,Other,186% of Medicaid,11839.04,80,,11839.04,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,11839.04,80,,11839.04,percent of total billed charges,,7216,,,7216,Case Rate,,3578,,"100% primary, 0% secondary procedures",3578,Other,MagnaCare ASC Grouper,10359.16,70,,10359.16,percent of total billed charges,,616.64,,,616.64,Fee Schedule,,522.64,,,522.64,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,667.11,,,667.11,Other,New York Medicaid APG methodology,667.11,,,667.11,Other,100% New York Medicaid APG,667.11,,,667.11,Other,100% New York Medicaid APG,667.11,,,667.11,Other,100% New York Medicaid APG,1501,,,1501,Other,225% New York Medicaid APG,1020.68,,,1020.68,Other,153% New York Medicaid APG,1501,,,1501,Other,225% New York Medicaid APG,933.96,,,933.96,Other,140% New York Medicaid APG,1501,,,1501,Other,225% New York Medicaid APG,1734.49,,,1734.49,Other,260% New York Medicaid APG,2161.44,,,2161.44,Other,324% New York Medicaid APG,1434.29,,,1434.29,Other,215% New York Medicaid APG,1434.29,,,1434.29,Other,215% New York Medicaid APG,833.89,,,833.89,Other,125% New York Medicaid APG,522.64,11839.04,
Exc f/e/e/n/l mal+mrg 0.6-1,11641,CPT,,,,,,,,both,,,37472.95,27729.98,74,,27729.98,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,16862.83,45,,16862.83,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,18549.11,49.5,,18549.11,percent of total billed charges,110% of Medicare,25481.61,68,,25481.61,percent of total billed charges,,1240.83,,,1240.83,Other,186% of Medicaid,29978.36,80,,29978.36,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,29978.36,80,,29978.36,percent of total billed charges,,7216,,,7216,Case Rate,,3578,,"100% primary, 0% secondary procedures",3578,Other,MagnaCare ASC Grouper,26231.07,70,,26231.07,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,667.11,,,667.11,Other,New York Medicaid APG methodology,667.11,,,667.11,Other,100% New York Medicaid APG,667.11,,,667.11,Other,100% New York Medicaid APG,667.11,,,667.11,Other,100% New York Medicaid APG,1501,,,1501,Other,225% New York Medicaid APG,1020.68,,,1020.68,Other,153% New York Medicaid APG,1501,,,1501,Other,225% New York Medicaid APG,933.96,,,933.96,Other,140% New York Medicaid APG,1501,,,1501,Other,225% New York Medicaid APG,1734.49,,,1734.49,Other,260% New York Medicaid APG,2161.44,,,2161.44,Other,324% New York Medicaid APG,1434.29,,,1434.29,Other,215% New York Medicaid APG,1434.29,,,1434.29,Other,215% New York Medicaid APG,833.89,,,833.89,Other,125% New York Medicaid APG,667.11,29978.36,
Exc f/e/e/n/l mal+mrg 1.1-2,11642,CPT,,,,,,,,both,,,14798.8,10951.11,74,,10951.11,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,6659.46,45,,6659.46,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,7325.41,49.5,,7325.41,percent of total billed charges,110% of Medicare,10063.18,68,,10063.18,percent of total billed charges,,1240.83,,,1240.83,Other,186% of Medicaid,11839.04,80,,11839.04,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,11839.04,80,,11839.04,percent of total billed charges,,7216,,,7216,Case Rate,,3578,,"100% primary, 0% secondary procedures",3578,Other,MagnaCare ASC Grouper,10359.16,70,,10359.16,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,667.11,,,667.11,Other,New York Medicaid APG methodology,667.11,,,667.11,Other,100% New York Medicaid APG,667.11,,,667.11,Other,100% New York Medicaid APG,667.11,,,667.11,Other,100% New York Medicaid APG,1501,,,1501,Other,225% New York Medicaid APG,1020.68,,,1020.68,Other,153% New York Medicaid APG,1501,,,1501,Other,225% New York Medicaid APG,933.96,,,933.96,Other,140% New York Medicaid APG,1501,,,1501,Other,225% New York Medicaid APG,1734.49,,,1734.49,Other,260% New York Medicaid APG,2161.44,,,2161.44,Other,324% New York Medicaid APG,1434.29,,,1434.29,Other,215% New York Medicaid APG,1434.29,,,1434.29,Other,215% New York Medicaid APG,833.89,,,833.89,Other,125% New York Medicaid APG,667.11,11839.04,
Exc f/e/e/n/l mal+mrg 2.1-3,11643,CPT,,,,,,,,both,,,51235.38,37914.18,74,,37914.18,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,23055.92,45,,23055.92,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,25361.51,49.5,,25361.51,percent of total billed charges,110% of Medicare,34840.06,68,,34840.06,percent of total billed charges,,2241.85,,,2241.85,Other,186% of Medicaid,40988.3,80,,40988.3,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,40988.3,80,,40988.3,percent of total billed charges,,7216,,,7216,Case Rate,,3578,,"100% primary, 0% secondary procedures",3578,Other,MagnaCare ASC Grouper,35864.77,70,,35864.77,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,1205.3,,,1205.3,Other,New York Medicaid APG methodology,1205.3,,,1205.3,Other,100% New York Medicaid APG,1205.3,,,1205.3,Other,100% New York Medicaid APG,1205.3,,,1205.3,Other,100% New York Medicaid APG,2711.92,,,2711.92,Other,225% New York Medicaid APG,1844.1,,,1844.1,Other,153% New York Medicaid APG,2711.92,,,2711.92,Other,225% New York Medicaid APG,1687.41,,,1687.41,Other,140% New York Medicaid APG,2711.92,,,2711.92,Other,225% New York Medicaid APG,3133.77,,,3133.77,Other,260% New York Medicaid APG,3905.16,,,3905.16,Other,324% New York Medicaid APG,2591.39,,,2591.39,Other,215% New York Medicaid APG,2591.39,,,2591.39,Other,215% New York Medicaid APG,1506.62,,,1506.62,Other,125% New York Medicaid APG,1205.3,40988.3,
Exc f/e/e/n/l mal+mrg 3.1-4,11644,CPT,,,,,,,,both,,,34101.75,25235.3,74,,25235.3,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15345.79,45,,15345.79,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,16880.37,49.5,,16880.37,percent of total billed charges,110% of Medicare,23189.19,68,,23189.19,percent of total billed charges,,2241.85,,,2241.85,Other,186% of Medicaid,27281.4,80,,27281.4,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,27281.4,80,,27281.4,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,23871.23,70,,23871.23,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1205.3,,,1205.3,Other,New York Medicaid APG methodology,1205.3,,,1205.3,Other,100% New York Medicaid APG,1205.3,,,1205.3,Other,100% New York Medicaid APG,1205.3,,,1205.3,Other,100% New York Medicaid APG,2711.92,,,2711.92,Other,225% New York Medicaid APG,1844.1,,,1844.1,Other,153% New York Medicaid APG,2711.92,,,2711.92,Other,225% New York Medicaid APG,1687.41,,,1687.41,Other,140% New York Medicaid APG,2711.92,,,2711.92,Other,225% New York Medicaid APG,3133.77,,,3133.77,Other,260% New York Medicaid APG,3905.16,,,3905.16,Other,324% New York Medicaid APG,2591.39,,,2591.39,Other,215% New York Medicaid APG,2591.39,,,2591.39,Other,215% New York Medicaid APG,1506.62,,,1506.62,Other,125% New York Medicaid APG,1205.3,27281.4,
Exc f/e/e/n/l mal+mrg >4 cm,11646,CPT,,,,,,,,both,,,59767.2,44227.73,74,,44227.73,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,26895.24,45,,26895.24,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,29584.76,49.5,,29584.76,percent of total billed charges,110% of Medicare,40641.7,68,,40641.7,percent of total billed charges,,3621.77,,,3621.77,Other,186% of Medicaid,47813.76,80,,47813.76,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,47813.76,80,,47813.76,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,41837.04,70,,41837.04,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1947.19,,,1947.19,Other,New York Medicaid APG methodology,1947.19,,,1947.19,Other,100% New York Medicaid APG,1947.19,,,1947.19,Other,100% New York Medicaid APG,1947.19,,,1947.19,Other,100% New York Medicaid APG,4381.17,,,4381.17,Other,225% New York Medicaid APG,2979.2,,,2979.2,Other,153% New York Medicaid APG,4381.17,,,4381.17,Other,225% New York Medicaid APG,2726.06,,,2726.06,Other,140% New York Medicaid APG,4381.17,,,4381.17,Other,225% New York Medicaid APG,5062.69,,,5062.69,Other,260% New York Medicaid APG,6308.89,,,6308.89,Other,324% New York Medicaid APG,4186.45,,,4186.45,Other,215% New York Medicaid APG,4186.45,,,4186.45,Other,215% New York Medicaid APG,2433.99,,,2433.99,Other,125% New York Medicaid APG,1947.19,47813.76,
Trim nail(s) any number,11719,CPT,,,,,,,,both,,,1286.58,952.07,74,,952.07,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,578.96,45,,578.96,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,636.86,49.5,,636.86,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,353.55,,,353.55,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,900.61,70,,900.61,percent of total billed charges,,36.08,,,36.08,Fee Schedule,,30.58,,,30.58,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,190.08,,,190.08,Other,New York Medicaid APG methodology,190.08,,,190.08,Other,100% New York Medicaid APG,190.08,,,190.08,Other,100% New York Medicaid APG,190.08,,,190.08,Other,100% New York Medicaid APG,427.68,,,427.68,Other,225% New York Medicaid APG,290.82,,,290.82,Other,153% New York Medicaid APG,427.68,,,427.68,Other,225% New York Medicaid APG,266.11,,,266.11,Other,140% New York Medicaid APG,427.68,,,427.68,Other,225% New York Medicaid APG,494.21,,,494.21,Other,260% New York Medicaid APG,615.86,,,615.86,Other,324% New York Medicaid APG,408.67,,,408.67,Other,215% New York Medicaid APG,408.67,,,408.67,Other,215% New York Medicaid APG,237.6,,,237.6,Other,125% New York Medicaid APG,30.58,9473,
Debride nail 1-5,11720,CPT,,,,,,,,both,,,1286.58,952.07,74,,952.07,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,578.96,45,,578.96,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,636.86,49.5,,636.86,percent of total billed charges,110% of Medicare,874.87,68,,874.87,percent of total billed charges,,353.55,,,353.55,Other,186% of Medicaid,1029.26,80,,1029.26,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,1029.26,80,,1029.26,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,900.61,70,,900.61,percent of total billed charges,,70.52,,,70.52,Fee Schedule,,59.77,,,59.77,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,190.08,,,190.08,Other,New York Medicaid APG methodology,190.08,,,190.08,Other,100% New York Medicaid APG,190.08,,,190.08,Other,100% New York Medicaid APG,190.08,,,190.08,Other,100% New York Medicaid APG,427.68,,,427.68,Other,225% New York Medicaid APG,290.82,,,290.82,Other,153% New York Medicaid APG,427.68,,,427.68,Other,225% New York Medicaid APG,266.11,,,266.11,Other,140% New York Medicaid APG,427.68,,,427.68,Other,225% New York Medicaid APG,494.21,,,494.21,Other,260% New York Medicaid APG,615.86,,,615.86,Other,324% New York Medicaid APG,408.67,,,408.67,Other,215% New York Medicaid APG,408.67,,,408.67,Other,215% New York Medicaid APG,237.6,,,237.6,Other,125% New York Medicaid APG,59.77,7216,
Debride nail 6 or more,11721,CPT,,,,,,,,both,,,1286.58,952.07,74,,952.07,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,578.96,45,,578.96,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,636.86,49.5,,636.86,percent of total billed charges,110% of Medicare,874.87,68,,874.87,percent of total billed charges,,353.55,,,353.55,Other,186% of Medicaid,1029.26,80,,1029.26,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,1029.26,80,,1029.26,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,900.61,70,,900.61,percent of total billed charges,,114.8,,,114.8,Fee Schedule,,97.3,,,97.3,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,190.08,,,190.08,Other,New York Medicaid APG methodology,190.08,,,190.08,Other,100% New York Medicaid APG,190.08,,,190.08,Other,100% New York Medicaid APG,190.08,,,190.08,Other,100% New York Medicaid APG,427.68,,,427.68,Other,225% New York Medicaid APG,290.82,,,290.82,Other,153% New York Medicaid APG,427.68,,,427.68,Other,225% New York Medicaid APG,266.11,,,266.11,Other,140% New York Medicaid APG,427.68,,,427.68,Other,225% New York Medicaid APG,494.21,,,494.21,Other,260% New York Medicaid APG,615.86,,,615.86,Other,324% New York Medicaid APG,408.67,,,408.67,Other,215% New York Medicaid APG,408.67,,,408.67,Other,215% New York Medicaid APG,237.6,,,237.6,Other,125% New York Medicaid APG,97.3,7216,
Removal of nail plate,11730,CPT,,,,,,,,both,,,35082.18,25960.81,74,,25960.81,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15786.98,45,,15786.98,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,17365.68,49.5,,17365.68,percent of total billed charges,110% of Medicare,23855.88,68,,23855.88,percent of total billed charges,,353.55,,,353.55,Other,186% of Medicaid,28065.74,80,,28065.74,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,28065.74,80,,28065.74,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,24557.53,70,,24557.53,percent of total billed charges,,260.76,,,260.76,Fee Schedule,,221.01,,,221.01,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,190.08,,,190.08,Other,New York Medicaid APG methodology,190.08,,,190.08,Other,100% New York Medicaid APG,190.08,,,190.08,Other,100% New York Medicaid APG,190.08,,,190.08,Other,100% New York Medicaid APG,427.68,,,427.68,Other,225% New York Medicaid APG,290.82,,,290.82,Other,153% New York Medicaid APG,427.68,,,427.68,Other,225% New York Medicaid APG,266.11,,,266.11,Other,140% New York Medicaid APG,427.68,,,427.68,Other,225% New York Medicaid APG,494.21,,,494.21,Other,260% New York Medicaid APG,615.86,,,615.86,Other,324% New York Medicaid APG,408.67,,,408.67,Other,215% New York Medicaid APG,408.67,,,408.67,Other,215% New York Medicaid APG,237.6,,,237.6,Other,125% New York Medicaid APG,190.08,28065.74,
Remove nail plate add-on,11732,CPT,,,,,,,,both,,,32432.1,23999.75,74,,23999.75,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,14594.45,45,,14594.45,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,16053.89,49.5,,16053.89,percent of total billed charges,110% of Medicare,22053.83,68,,22053.83,percent of total billed charges,,353.55,,,353.55,Other,186% of Medicaid,25945.68,80,,25945.68,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,25945.68,80,,25945.68,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,22702.47,70,,22702.47,percent of total billed charges,,83.64,,,83.64,Fee Schedule,,70.89,,,70.89,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,190.08,,,190.08,Other,New York Medicaid APG methodology,190.08,,,190.08,Other,100% New York Medicaid APG,190.08,,,190.08,Other,100% New York Medicaid APG,190.08,,,190.08,Other,100% New York Medicaid APG,427.68,,,427.68,Other,225% New York Medicaid APG,290.82,,,290.82,Other,153% New York Medicaid APG,427.68,,,427.68,Other,225% New York Medicaid APG,266.11,,,266.11,Other,140% New York Medicaid APG,427.68,,,427.68,Other,225% New York Medicaid APG,494.21,,,494.21,Other,260% New York Medicaid APG,615.86,,,615.86,Other,324% New York Medicaid APG,408.67,,,408.67,Other,215% New York Medicaid APG,408.67,,,408.67,Other,215% New York Medicaid APG,237.6,,,237.6,Other,125% New York Medicaid APG,70.89,25945.68,
Drain blood from under nail,11740,CPT,,,,,,,,both,,,2686.86,1988.28,74,,1988.28,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,1209.09,45,,1209.09,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,1330,49.5,,1330,percent of total billed charges,110% of Medicare,1827.06,68,,1827.06,percent of total billed charges,,353.55,,,353.55,Other,186% of Medicaid,2149.49,80,,2149.49,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,2149.49,80,,2149.49,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,1880.8,70,,1880.8,percent of total billed charges,,155.8,,,155.8,Fee Schedule,,132.05,,,132.05,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,190.08,,,190.08,Other,New York Medicaid APG methodology,190.08,,,190.08,Other,100% New York Medicaid APG,190.08,,,190.08,Other,100% New York Medicaid APG,190.08,,,190.08,Other,100% New York Medicaid APG,427.68,,,427.68,Other,225% New York Medicaid APG,290.82,,,290.82,Other,153% New York Medicaid APG,427.68,,,427.68,Other,225% New York Medicaid APG,266.11,,,266.11,Other,140% New York Medicaid APG,427.68,,,427.68,Other,225% New York Medicaid APG,494.21,,,494.21,Other,260% New York Medicaid APG,615.86,,,615.86,Other,324% New York Medicaid APG,408.67,,,408.67,Other,215% New York Medicaid APG,408.67,,,408.67,Other,215% New York Medicaid APG,237.6,,,237.6,Other,125% New York Medicaid APG,132.05,7216,
Removal of nail bed,11750,CPT,,,,,,,,both,,,34489.9,25522.53,74,,25522.53,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15520.46,45,,15520.46,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,17072.5,49.5,,17072.5,percent of total billed charges,110% of Medicare,23453.13,68,,23453.13,percent of total billed charges,,1240.83,,,1240.83,Other,186% of Medicaid,27591.92,80,,27591.92,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,27591.92,80,,27591.92,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,24142.93,70,,24142.93,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,667.11,,,667.11,Other,New York Medicaid APG methodology,667.11,,,667.11,Other,100% New York Medicaid APG,667.11,,,667.11,Other,100% New York Medicaid APG,667.11,,,667.11,Other,100% New York Medicaid APG,1501,,,1501,Other,225% New York Medicaid APG,1020.68,,,1020.68,Other,153% New York Medicaid APG,1501,,,1501,Other,225% New York Medicaid APG,933.96,,,933.96,Other,140% New York Medicaid APG,1501,,,1501,Other,225% New York Medicaid APG,1734.49,,,1734.49,Other,260% New York Medicaid APG,2161.44,,,2161.44,Other,324% New York Medicaid APG,1434.29,,,1434.29,Other,215% New York Medicaid APG,1434.29,,,1434.29,Other,215% New York Medicaid APG,833.89,,,833.89,Other,125% New York Medicaid APG,667.11,27591.92,
Biopsy nail unit,11755,CPT,,,,,,,,both,,,14798.8,10951.11,74,,10951.11,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,6659.46,45,,6659.46,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,7325.41,49.5,,7325.41,percent of total billed charges,110% of Medicare,10063.18,68,,10063.18,percent of total billed charges,,1240.83,,,1240.83,Other,186% of Medicaid,11839.04,80,,11839.04,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,11839.04,80,,11839.04,percent of total billed charges,,7216,,,7216,Case Rate,,3578,,"100% primary, 0% secondary procedures",3578,Other,MagnaCare ASC Grouper,10359.16,70,,10359.16,percent of total billed charges,,293.56,,,293.56,Fee Schedule,,248.81,,,248.81,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,667.11,,,667.11,Other,New York Medicaid APG methodology,667.11,,,667.11,Other,100% New York Medicaid APG,667.11,,,667.11,Other,100% New York Medicaid APG,667.11,,,667.11,Other,100% New York Medicaid APG,1501,,,1501,Other,225% New York Medicaid APG,1020.68,,,1020.68,Other,153% New York Medicaid APG,1501,,,1501,Other,225% New York Medicaid APG,933.96,,,933.96,Other,140% New York Medicaid APG,1501,,,1501,Other,225% New York Medicaid APG,1734.49,,,1734.49,Other,260% New York Medicaid APG,2161.44,,,2161.44,Other,324% New York Medicaid APG,1434.29,,,1434.29,Other,215% New York Medicaid APG,1434.29,,,1434.29,Other,215% New York Medicaid APG,833.89,,,833.89,Other,125% New York Medicaid APG,248.81,11839.04,
Repair of nail bed,11760,CPT,,,,,,,,both,,,35603.23,26346.39,74,,26346.39,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,16021.45,45,,16021.45,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,17623.6,49.5,,17623.6,percent of total billed charges,110% of Medicare,24210.2,68,,24210.2,percent of total billed charges,,353.55,,,353.55,Other,186% of Medicaid,28482.58,80,,28482.58,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,28482.58,80,,28482.58,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,24922.26,70,,24922.26,percent of total billed charges,,539.56,,,539.56,Fee Schedule,,457.31,,,457.31,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,190.08,,,190.08,Other,New York Medicaid APG methodology,190.08,,,190.08,Other,100% New York Medicaid APG,190.08,,,190.08,Other,100% New York Medicaid APG,190.08,,,190.08,Other,100% New York Medicaid APG,427.68,,,427.68,Other,225% New York Medicaid APG,290.82,,,290.82,Other,153% New York Medicaid APG,427.68,,,427.68,Other,225% New York Medicaid APG,266.11,,,266.11,Other,140% New York Medicaid APG,427.68,,,427.68,Other,225% New York Medicaid APG,494.21,,,494.21,Other,260% New York Medicaid APG,615.86,,,615.86,Other,324% New York Medicaid APG,408.67,,,408.67,Other,215% New York Medicaid APG,408.67,,,408.67,Other,215% New York Medicaid APG,237.6,,,237.6,Other,125% New York Medicaid APG,190.08,28482.58,
Reconstruction of nail bed,11762,CPT,,,,,,,,both,,,38357.55,28384.59,74,,28384.59,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,17260.9,45,,17260.9,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,18986.99,49.5,,18986.99,percent of total billed charges,110% of Medicare,26083.13,68,,26083.13,percent of total billed charges,,2241.85,,,2241.85,Other,186% of Medicaid,30686.04,80,,30686.04,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,30686.04,80,,30686.04,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,26850.29,70,,26850.29,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1205.3,,,1205.3,Other,New York Medicaid APG methodology,1205.3,,,1205.3,Other,100% New York Medicaid APG,1205.3,,,1205.3,Other,100% New York Medicaid APG,1205.3,,,1205.3,Other,100% New York Medicaid APG,2711.92,,,2711.92,Other,225% New York Medicaid APG,1844.1,,,1844.1,Other,153% New York Medicaid APG,2711.92,,,2711.92,Other,225% New York Medicaid APG,1687.41,,,1687.41,Other,140% New York Medicaid APG,2711.92,,,2711.92,Other,225% New York Medicaid APG,3133.77,,,3133.77,Other,260% New York Medicaid APG,3905.16,,,3905.16,Other,324% New York Medicaid APG,2591.39,,,2591.39,Other,215% New York Medicaid APG,2591.39,,,2591.39,Other,215% New York Medicaid APG,1506.62,,,1506.62,Other,125% New York Medicaid APG,1205.3,30686.04,
Excision of nail fold toe,11765,CPT,,,,,,,,both,,,8387.08,6206.44,74,,6206.44,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,3774.19,45,,3774.19,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,4151.6,49.5,,4151.6,percent of total billed charges,110% of Medicare,5703.21,68,,5703.21,percent of total billed charges,,353.55,,,353.55,Other,186% of Medicaid,6709.66,80,,6709.66,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,6709.66,80,,6709.66,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,5870.96,70,,5870.96,percent of total billed charges,,449.36,,,449.36,Fee Schedule,,380.86,,,380.86,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,190.08,,,190.08,Other,New York Medicaid APG methodology,190.08,,,190.08,Other,100% New York Medicaid APG,190.08,,,190.08,Other,100% New York Medicaid APG,190.08,,,190.08,Other,100% New York Medicaid APG,427.68,,,427.68,Other,225% New York Medicaid APG,290.82,,,290.82,Other,153% New York Medicaid APG,427.68,,,427.68,Other,225% New York Medicaid APG,266.11,,,266.11,Other,140% New York Medicaid APG,427.68,,,427.68,Other,225% New York Medicaid APG,494.21,,,494.21,Other,260% New York Medicaid APG,615.86,,,615.86,Other,324% New York Medicaid APG,408.67,,,408.67,Other,215% New York Medicaid APG,408.67,,,408.67,Other,215% New York Medicaid APG,237.6,,,237.6,Other,125% New York Medicaid APG,190.08,7216,
Remove pilonidal cyst simple,11770,CPT,,,,,,,,both,,,35492.13,26264.18,74,,26264.18,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15971.46,45,,15971.46,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,17568.6,49.5,,17568.6,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2241.85,,,2241.85,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,24844.49,70,,24844.49,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1205.3,,,1205.3,Other,New York Medicaid APG methodology,1205.3,,,1205.3,Other,100% New York Medicaid APG,1205.3,,,1205.3,Other,100% New York Medicaid APG,1205.3,,,1205.3,Other,100% New York Medicaid APG,2711.92,,,2711.92,Other,225% New York Medicaid APG,1844.1,,,1844.1,Other,153% New York Medicaid APG,2711.92,,,2711.92,Other,225% New York Medicaid APG,1687.41,,,1687.41,Other,140% New York Medicaid APG,2711.92,,,2711.92,Other,225% New York Medicaid APG,3133.77,,,3133.77,Other,260% New York Medicaid APG,3905.16,,,3905.16,Other,324% New York Medicaid APG,2591.39,,,2591.39,Other,215% New York Medicaid APG,2591.39,,,2591.39,Other,215% New York Medicaid APG,1506.62,,,1506.62,Other,125% New York Medicaid APG,1205.3,26264.18,
Remove pilonidal cyst exten,11771,CPT,,,,,,,,both,,,36470.63,26988.27,74,,26988.27,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,16411.78,45,,16411.78,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,18052.96,49.5,,18052.96,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3621.77,,,3621.77,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,25529.44,70,,25529.44,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1947.19,,,1947.19,Other,New York Medicaid APG methodology,1947.19,,,1947.19,Other,100% New York Medicaid APG,1947.19,,,1947.19,Other,100% New York Medicaid APG,1947.19,,,1947.19,Other,100% New York Medicaid APG,4381.17,,,4381.17,Other,225% New York Medicaid APG,2979.2,,,2979.2,Other,153% New York Medicaid APG,4381.17,,,4381.17,Other,225% New York Medicaid APG,2726.06,,,2726.06,Other,140% New York Medicaid APG,4381.17,,,4381.17,Other,225% New York Medicaid APG,5062.69,,,5062.69,Other,260% New York Medicaid APG,6308.89,,,6308.89,Other,324% New York Medicaid APG,4186.45,,,4186.45,Other,215% New York Medicaid APG,4186.45,,,4186.45,Other,215% New York Medicaid APG,2433.99,,,2433.99,Other,125% New York Medicaid APG,1947.19,26988.27,
Remove pilonidal cyst compl,11772,CPT,,,,,,,,both,,,37285.68,27591.4,74,,27591.4,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,16778.56,45,,16778.56,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,18456.41,49.5,,18456.41,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3621.77,,,3621.77,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,26099.98,70,,26099.98,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1947.19,,,1947.19,Other,New York Medicaid APG methodology,1947.19,,,1947.19,Other,100% New York Medicaid APG,1947.19,,,1947.19,Other,100% New York Medicaid APG,1947.19,,,1947.19,Other,100% New York Medicaid APG,4381.17,,,4381.17,Other,225% New York Medicaid APG,2979.2,,,2979.2,Other,153% New York Medicaid APG,4381.17,,,4381.17,Other,225% New York Medicaid APG,2726.06,,,2726.06,Other,140% New York Medicaid APG,4381.17,,,4381.17,Other,225% New York Medicaid APG,5062.69,,,5062.69,Other,260% New York Medicaid APG,6308.89,,,6308.89,Other,324% New York Medicaid APG,4186.45,,,4186.45,Other,215% New York Medicaid APG,4186.45,,,4186.45,Other,215% New York Medicaid APG,2433.99,,,2433.99,Other,125% New York Medicaid APG,1947.19,27591.4,
Inject skin lesions </w 7,11900,CPT,,,,,,,,both,,,4210.98,3116.13,74,,3116.13,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,1894.94,45,,1894.94,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,2084.44,49.5,,2084.44,percent of total billed charges,110% of Medicare,2863.47,68,,2863.47,percent of total billed charges,,733.11,,,733.11,Other,186% of Medicaid,3368.78,80,,3368.78,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,3368.78,80,,3368.78,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,2947.69,70,,2947.69,percent of total billed charges,,145.96,,,145.96,Fee Schedule,,123.71,,,123.71,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,394.14,,,394.14,Other,New York Medicaid APG methodology,394.14,,,394.14,Other,100% New York Medicaid APG,394.14,,,394.14,Other,100% New York Medicaid APG,394.14,,,394.14,Other,100% New York Medicaid APG,886.83,,,886.83,Other,225% New York Medicaid APG,603.04,,,603.04,Other,153% New York Medicaid APG,886.83,,,886.83,Other,225% New York Medicaid APG,551.8,,,551.8,Other,140% New York Medicaid APG,886.83,,,886.83,Other,225% New York Medicaid APG,1024.78,,,1024.78,Other,260% New York Medicaid APG,1277.03,,,1277.03,Other,324% New York Medicaid APG,847.41,,,847.41,Other,215% New York Medicaid APG,847.41,,,847.41,Other,215% New York Medicaid APG,492.68,,,492.68,Other,125% New York Medicaid APG,123.71,7216,
Inject skin lesions >7,11901,CPT,,,,,,,,both,,,4210.98,3116.13,74,,3116.13,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,1894.94,45,,1894.94,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,2084.44,49.5,,2084.44,percent of total billed charges,110% of Medicare,2863.47,68,,2863.47,percent of total billed charges,,733.11,,,733.11,Other,186% of Medicaid,3368.78,80,,3368.78,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,3368.78,80,,3368.78,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,2947.69,70,,2947.69,percent of total billed charges,,221.4,,,221.4,Fee Schedule,,187.65,,,187.65,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,394.14,,,394.14,Other,New York Medicaid APG methodology,394.14,,,394.14,Other,100% New York Medicaid APG,394.14,,,394.14,Other,100% New York Medicaid APG,394.14,,,394.14,Other,100% New York Medicaid APG,886.83,,,886.83,Other,225% New York Medicaid APG,603.04,,,603.04,Other,153% New York Medicaid APG,886.83,,,886.83,Other,225% New York Medicaid APG,551.8,,,551.8,Other,140% New York Medicaid APG,886.83,,,886.83,Other,225% New York Medicaid APG,1024.78,,,1024.78,Other,260% New York Medicaid APG,1277.03,,,1277.03,Other,324% New York Medicaid APG,847.41,,,847.41,Other,215% New York Medicaid APG,847.41,,,847.41,Other,215% New York Medicaid APG,492.68,,,492.68,Other,125% New York Medicaid APG,187.65,7216,
Correct skin color 6.0 cm/<,11920,CPT,,,,,,,,both,,,13210.22,9775.56,74,,9775.56,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,5944.6,45,,5944.6,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,6539.06,49.5,,6539.06,percent of total billed charges,110% of Medicare,8982.95,68,,8982.95,percent of total billed charges,,1240.83,,,1240.83,Other,186% of Medicaid,10568.18,80,,10568.18,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,10568.18,80,,10568.18,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,9247.15,70,,9247.15,percent of total billed charges,,531.36,,,531.36,Fee Schedule,,450.36,,,450.36,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,667.11,,,667.11,Other,New York Medicaid APG methodology,667.11,,,667.11,Other,100% New York Medicaid APG,667.11,,,667.11,Other,100% New York Medicaid APG,667.11,,,667.11,Other,100% New York Medicaid APG,1501,,,1501,Other,225% New York Medicaid APG,1020.68,,,1020.68,Other,153% New York Medicaid APG,1501,,,1501,Other,225% New York Medicaid APG,933.96,,,933.96,Other,140% New York Medicaid APG,1501,,,1501,Other,225% New York Medicaid APG,1734.49,,,1734.49,Other,260% New York Medicaid APG,2161.44,,,2161.44,Other,324% New York Medicaid APG,1434.29,,,1434.29,Other,215% New York Medicaid APG,1434.29,,,1434.29,Other,215% New York Medicaid APG,833.89,,,833.89,Other,125% New York Medicaid APG,450.36,10568.18,
Correct skn color 6.1-20.0cm,11921,CPT,,,,,,,,both,,,13210.22,9775.56,74,,9775.56,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,5944.6,45,,5944.6,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,6539.06,49.5,,6539.06,percent of total billed charges,110% of Medicare,8982.95,68,,8982.95,percent of total billed charges,,1240.83,,,1240.83,Other,186% of Medicaid,10568.18,80,,10568.18,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,10568.18,80,,10568.18,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,9247.15,70,,9247.15,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,667.11,,,667.11,Other,New York Medicaid APG methodology,667.11,,,667.11,Other,100% New York Medicaid APG,667.11,,,667.11,Other,100% New York Medicaid APG,667.11,,,667.11,Other,100% New York Medicaid APG,1501,,,1501,Other,225% New York Medicaid APG,1020.68,,,1020.68,Other,153% New York Medicaid APG,1501,,,1501,Other,225% New York Medicaid APG,933.96,,,933.96,Other,140% New York Medicaid APG,1501,,,1501,Other,225% New York Medicaid APG,1734.49,,,1734.49,Other,260% New York Medicaid APG,2161.44,,,2161.44,Other,324% New York Medicaid APG,1434.29,,,1434.29,Other,215% New York Medicaid APG,1434.29,,,1434.29,Other,215% New York Medicaid APG,833.89,,,833.89,Other,125% New York Medicaid APG,667.11,10568.18,
Correct skin color ea 20.0cm,11922,CPT,,,,,,,,both,,,32432.1,23999.75,74,,23999.75,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,14594.45,45,,14594.45,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,16053.89,49.5,,16053.89,percent of total billed charges,110% of Medicare,22053.83,68,,22053.83,percent of total billed charges,,1240.83,,,1240.83,Other,186% of Medicaid,25945.68,80,,25945.68,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,25945.68,80,,25945.68,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,22702.47,70,,22702.47,percent of total billed charges,,142.68,,,142.68,Fee Schedule,,120.93,,,120.93,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,667.11,,,667.11,Other,New York Medicaid APG methodology,667.11,,,667.11,Other,100% New York Medicaid APG,667.11,,,667.11,Other,100% New York Medicaid APG,667.11,,,667.11,Other,100% New York Medicaid APG,1501,,,1501,Other,225% New York Medicaid APG,1020.68,,,1020.68,Other,153% New York Medicaid APG,1501,,,1501,Other,225% New York Medicaid APG,933.96,,,933.96,Other,140% New York Medicaid APG,1501,,,1501,Other,225% New York Medicaid APG,1734.49,,,1734.49,Other,260% New York Medicaid APG,2161.44,,,2161.44,Other,324% New York Medicaid APG,1434.29,,,1434.29,Other,215% New York Medicaid APG,1434.29,,,1434.29,Other,215% New York Medicaid APG,833.89,,,833.89,Other,125% New York Medicaid APG,120.93,25945.68,
Tx contour defects 1 cc/<,11950,CPT,,,,,,,,both,,,4210.98,3116.13,74,,3116.13,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,1894.94,45,,1894.94,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,2084.44,49.5,,2084.44,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,1240.83,,,1240.83,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,2947.69,70,,2947.69,percent of total billed charges,,255.84,,,255.84,Fee Schedule,,216.84,,,216.84,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,667.11,,,667.11,Other,New York Medicaid APG methodology,667.11,,,667.11,Other,100% New York Medicaid APG,667.11,,,667.11,Other,100% New York Medicaid APG,667.11,,,667.11,Other,100% New York Medicaid APG,1501,,,1501,Other,225% New York Medicaid APG,1020.68,,,1020.68,Other,153% New York Medicaid APG,1501,,,1501,Other,225% New York Medicaid APG,933.96,,,933.96,Other,140% New York Medicaid APG,1501,,,1501,Other,225% New York Medicaid APG,1734.49,,,1734.49,Other,260% New York Medicaid APG,2161.44,,,2161.44,Other,324% New York Medicaid APG,1434.29,,,1434.29,Other,215% New York Medicaid APG,1434.29,,,1434.29,Other,215% New York Medicaid APG,833.89,,,833.89,Other,125% New York Medicaid APG,216.84,9473,
Tx contour defects 1.1-5.0cc,11951,CPT,,,,,,,,both,,,13210.22,9775.56,74,,9775.56,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,5944.6,45,,5944.6,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,6539.06,49.5,,6539.06,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,1240.83,,,1240.83,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,9247.15,70,,9247.15,percent of total billed charges,,355.88,,,355.88,Fee Schedule,,301.63,,,301.63,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,667.11,,,667.11,Other,New York Medicaid APG methodology,667.11,,,667.11,Other,100% New York Medicaid APG,667.11,,,667.11,Other,100% New York Medicaid APG,667.11,,,667.11,Other,100% New York Medicaid APG,1501,,,1501,Other,225% New York Medicaid APG,1020.68,,,1020.68,Other,153% New York Medicaid APG,1501,,,1501,Other,225% New York Medicaid APG,933.96,,,933.96,Other,140% New York Medicaid APG,1501,,,1501,Other,225% New York Medicaid APG,1734.49,,,1734.49,Other,260% New York Medicaid APG,2161.44,,,2161.44,Other,324% New York Medicaid APG,1434.29,,,1434.29,Other,215% New York Medicaid APG,1434.29,,,1434.29,Other,215% New York Medicaid APG,833.89,,,833.89,Other,125% New York Medicaid APG,301.63,9775.56,
Tx contour defects 5.1-10cc,11952,CPT,,,,,,,,both,,,13210.22,9775.56,74,,9775.56,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,5944.6,45,,5944.6,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,6539.06,49.5,,6539.06,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,1240.83,,,1240.83,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,9247.15,70,,9247.15,percent of total billed charges,,498.56,,,498.56,Fee Schedule,,422.56,,,422.56,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,667.11,,,667.11,Other,New York Medicaid APG methodology,667.11,,,667.11,Other,100% New York Medicaid APG,667.11,,,667.11,Other,100% New York Medicaid APG,667.11,,,667.11,Other,100% New York Medicaid APG,1501,,,1501,Other,225% New York Medicaid APG,1020.68,,,1020.68,Other,153% New York Medicaid APG,1501,,,1501,Other,225% New York Medicaid APG,933.96,,,933.96,Other,140% New York Medicaid APG,1501,,,1501,Other,225% New York Medicaid APG,1734.49,,,1734.49,Other,260% New York Medicaid APG,2161.44,,,2161.44,Other,324% New York Medicaid APG,1434.29,,,1434.29,Other,215% New York Medicaid APG,1434.29,,,1434.29,Other,215% New York Medicaid APG,833.89,,,833.89,Other,125% New York Medicaid APG,422.56,9775.56,
Tx contour defects >10.0 cc,11954,CPT,,,,,,,,both,,,13210.22,9775.56,74,,9775.56,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,5944.6,45,,5944.6,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,6539.06,49.5,,6539.06,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2241.85,,,2241.85,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,9247.15,70,,9247.15,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,1205.3,,,1205.3,Other,New York Medicaid APG methodology,1205.3,,,1205.3,Other,100% New York Medicaid APG,1205.3,,,1205.3,Other,100% New York Medicaid APG,1205.3,,,1205.3,Other,100% New York Medicaid APG,2711.92,,,2711.92,Other,225% New York Medicaid APG,1844.1,,,1844.1,Other,153% New York Medicaid APG,2711.92,,,2711.92,Other,225% New York Medicaid APG,1687.41,,,1687.41,Other,140% New York Medicaid APG,2711.92,,,2711.92,Other,225% New York Medicaid APG,3133.77,,,3133.77,Other,260% New York Medicaid APG,3905.16,,,3905.16,Other,324% New York Medicaid APG,2591.39,,,2591.39,Other,215% New York Medicaid APG,2591.39,,,2591.39,Other,215% New York Medicaid APG,1506.62,,,1506.62,Other,125% New York Medicaid APG,1205.3,9775.56,
Insert tissue expander(s),11960,CPT,,,,,,,,both,,,41203.11,30490.3,74,,30490.3,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,18541.4,45,,18541.4,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,20395.54,49.5,,20395.54,percent of total billed charges,110% of Medicare,28018.11,68,,28018.11,percent of total billed charges,,3621.77,,,3621.77,Other,186% of Medicaid,32962.49,80,,32962.49,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,32962.49,80,,32962.49,percent of total billed charges,,7216,,,7216,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,28842.18,70,,28842.18,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1947.19,,,1947.19,Other,New York Medicaid APG methodology,1947.19,,,1947.19,Other,100% New York Medicaid APG,1947.19,,,1947.19,Other,100% New York Medicaid APG,1947.19,,,1947.19,Other,100% New York Medicaid APG,4381.17,,,4381.17,Other,225% New York Medicaid APG,2979.2,,,2979.2,Other,153% New York Medicaid APG,4381.17,,,4381.17,Other,225% New York Medicaid APG,2726.06,,,2726.06,Other,140% New York Medicaid APG,4381.17,,,4381.17,Other,225% New York Medicaid APG,5062.69,,,5062.69,Other,260% New York Medicaid APG,6308.89,,,6308.89,Other,324% New York Medicaid APG,4186.45,,,4186.45,Other,215% New York Medicaid APG,4186.45,,,4186.45,Other,215% New York Medicaid APG,2433.99,,,2433.99,Other,125% New York Medicaid APG,1947.19,32962.49,
Rplcmt tiss xpndr perm implt,11970,CPT,,,,,,,,both,,,42031.03,31102.96,74,,31102.96,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,18913.96,45,,18913.96,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,20805.36,49.5,,20805.36,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3861.21,,,3861.21,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,29421.72,70,,29421.72,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,2075.92,,,2075.92,Other,New York Medicaid APG methodology,2075.92,,,2075.92,Other,100% New York Medicaid APG,2075.92,,,2075.92,Other,100% New York Medicaid APG,2075.92,,,2075.92,Other,100% New York Medicaid APG,4670.82,,,4670.82,Other,225% New York Medicaid APG,3176.15,,,3176.15,Other,153% New York Medicaid APG,4670.82,,,4670.82,Other,225% New York Medicaid APG,2906.29,,,2906.29,Other,140% New York Medicaid APG,4670.82,,,4670.82,Other,225% New York Medicaid APG,5397.39,,,5397.39,Other,260% New York Medicaid APG,6725.98,,,6725.98,Other,324% New York Medicaid APG,4463.22,,,4463.22,Other,215% New York Medicaid APG,4463.22,,,4463.22,Other,215% New York Medicaid APG,2594.9,,,2594.9,Other,125% New York Medicaid APG,2075.92,31102.96,
Rmvl tis xpndr wo insj implt,11971,CPT,,,,,,,,both,,,59767.2,44227.73,74,,44227.73,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,26895.24,45,,26895.24,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,29584.76,49.5,,29584.76,percent of total billed charges,110% of Medicare,40641.7,68,,40641.7,percent of total billed charges,,2793.39,,,2793.39,Other,186% of Medicaid,47813.76,80,,47813.76,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,47813.76,80,,47813.76,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,41837.04,70,,41837.04,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1501.82,,,1501.82,Other,New York Medicaid APG methodology,1501.82,,,1501.82,Other,100% New York Medicaid APG,1501.82,,,1501.82,Other,100% New York Medicaid APG,1501.82,,,1501.82,Other,100% New York Medicaid APG,3379.1,,,3379.1,Other,225% New York Medicaid APG,2297.79,,,2297.79,Other,153% New York Medicaid APG,3379.1,,,3379.1,Other,225% New York Medicaid APG,2102.55,,,2102.55,Other,140% New York Medicaid APG,3379.1,,,3379.1,Other,225% New York Medicaid APG,3904.73,,,3904.73,Other,260% New York Medicaid APG,4865.9,,,4865.9,Other,324% New York Medicaid APG,3228.91,,,3228.91,Other,215% New York Medicaid APG,3228.91,,,3228.91,Other,215% New York Medicaid APG,1877.28,,,1877.28,Other,125% New York Medicaid APG,1501.82,47813.76,
Remove contraceptive capsule,11976,CPT,,,,,,,,both,,,14798.8,10951.11,74,,10951.11,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,6659.46,45,,6659.46,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,7325.41,49.5,,7325.41,percent of total billed charges,110% of Medicare,10063.18,68,,10063.18,percent of total billed charges,,1240.83,,,1240.83,Other,186% of Medicaid,11839.04,80,,11839.04,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,11839.04,80,,11839.04,percent of total billed charges,,7216,,,7216,Case Rate,,3578,,"100% primary, 0% secondary procedures",3578,Other,MagnaCare ASC Grouper,10359.16,70,,10359.16,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,667.11,,,667.11,Other,New York Medicaid APG methodology,667.11,,,667.11,Other,100% New York Medicaid APG,667.11,,,667.11,Other,100% New York Medicaid APG,667.11,,,667.11,Other,100% New York Medicaid APG,1501,,,1501,Other,225% New York Medicaid APG,1020.68,,,1020.68,Other,153% New York Medicaid APG,1501,,,1501,Other,225% New York Medicaid APG,933.96,,,933.96,Other,140% New York Medicaid APG,1501,,,1501,Other,225% New York Medicaid APG,1734.49,,,1734.49,Other,260% New York Medicaid APG,2161.44,,,2161.44,Other,324% New York Medicaid APG,1434.29,,,1434.29,Other,215% New York Medicaid APG,1434.29,,,1434.29,Other,215% New York Medicaid APG,833.89,,,833.89,Other,125% New York Medicaid APG,667.11,11839.04,
Implant hormone pellet(s),11980,CPT,,,,,,,,both,,,8380.68,6201.7,74,,6201.7,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,3771.31,45,,3771.31,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,4148.44,49.5,,4148.44,percent of total billed charges,110% of Medicare,5698.86,68,,5698.86,percent of total billed charges,,1240.83,,,1240.83,Other,186% of Medicaid,6704.54,80,,6704.54,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,6704.54,80,,6704.54,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,5866.48,70,,5866.48,percent of total billed charges,,272.24,,,272.24,Fee Schedule,,230.74,,,230.74,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,667.11,,,667.11,Other,New York Medicaid APG methodology,667.11,,,667.11,Other,100% New York Medicaid APG,667.11,,,667.11,Other,100% New York Medicaid APG,667.11,,,667.11,Other,100% New York Medicaid APG,1501,,,1501,Other,225% New York Medicaid APG,1020.68,,,1020.68,Other,153% New York Medicaid APG,1501,,,1501,Other,225% New York Medicaid APG,933.96,,,933.96,Other,140% New York Medicaid APG,1501,,,1501,Other,225% New York Medicaid APG,1734.49,,,1734.49,Other,260% New York Medicaid APG,2161.44,,,2161.44,Other,324% New York Medicaid APG,1434.29,,,1434.29,Other,215% New York Medicaid APG,1434.29,,,1434.29,Other,215% New York Medicaid APG,833.89,,,833.89,Other,125% New York Medicaid APG,230.74,7216,
Insert drug implant device,11981,CPT,,,,,,,,both,,,34479.41,25514.76,74,,25514.76,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15515.73,45,,15515.73,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,17067.31,49.5,,17067.31,percent of total billed charges,110% of Medicare,23446,68,,23446,percent of total billed charges,,733.11,,,733.11,Other,186% of Medicaid,27583.53,80,,27583.53,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,27583.53,80,,27583.53,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,24135.59,70,,24135.59,percent of total billed charges,,305.04,,,305.04,Fee Schedule,,258.54,,,258.54,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,394.14,,,394.14,Other,New York Medicaid APG methodology,394.14,,,394.14,Other,100% New York Medicaid APG,394.14,,,394.14,Other,100% New York Medicaid APG,394.14,,,394.14,Other,100% New York Medicaid APG,886.83,,,886.83,Other,225% New York Medicaid APG,603.04,,,603.04,Other,153% New York Medicaid APG,886.83,,,886.83,Other,225% New York Medicaid APG,551.8,,,551.8,Other,140% New York Medicaid APG,886.83,,,886.83,Other,225% New York Medicaid APG,1024.78,,,1024.78,Other,260% New York Medicaid APG,1277.03,,,1277.03,Other,324% New York Medicaid APG,847.41,,,847.41,Other,215% New York Medicaid APG,847.41,,,847.41,Other,215% New York Medicaid APG,492.68,,,492.68,Other,125% New York Medicaid APG,258.54,27583.53,
Remove drug implant device,11982,CPT,,,,,,,,both,,,34480.35,25515.46,74,,25515.46,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15516.16,45,,15516.16,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,17067.77,49.5,,17067.77,percent of total billed charges,110% of Medicare,23446.64,68,,23446.64,percent of total billed charges,,733.11,,,733.11,Other,186% of Medicaid,27584.28,80,,27584.28,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,27584.28,80,,27584.28,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,24136.25,70,,24136.25,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,394.14,,,394.14,Other,New York Medicaid APG methodology,394.14,,,394.14,Other,100% New York Medicaid APG,394.14,,,394.14,Other,100% New York Medicaid APG,394.14,,,394.14,Other,100% New York Medicaid APG,886.83,,,886.83,Other,225% New York Medicaid APG,603.04,,,603.04,Other,153% New York Medicaid APG,886.83,,,886.83,Other,225% New York Medicaid APG,551.8,,,551.8,Other,140% New York Medicaid APG,886.83,,,886.83,Other,225% New York Medicaid APG,1024.78,,,1024.78,Other,260% New York Medicaid APG,1277.03,,,1277.03,Other,324% New York Medicaid APG,847.41,,,847.41,Other,215% New York Medicaid APG,847.41,,,847.41,Other,215% New York Medicaid APG,492.68,,,492.68,Other,125% New York Medicaid APG,394.14,27584.28,
Remove/insert drug implant,11983,CPT,,,,,,,,both,,,34458.47,25499.27,74,,25499.27,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15506.31,45,,15506.31,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,17056.94,49.5,,17056.94,percent of total billed charges,110% of Medicare,23431.76,68,,23431.76,percent of total billed charges,,733.11,,,733.11,Other,186% of Medicaid,27566.78,80,,27566.78,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,27566.78,80,,27566.78,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,24120.93,70,,24120.93,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,394.14,,,394.14,Other,New York Medicaid APG methodology,394.14,,,394.14,Other,100% New York Medicaid APG,394.14,,,394.14,Other,100% New York Medicaid APG,394.14,,,394.14,Other,100% New York Medicaid APG,886.83,,,886.83,Other,225% New York Medicaid APG,603.04,,,603.04,Other,153% New York Medicaid APG,886.83,,,886.83,Other,225% New York Medicaid APG,551.8,,,551.8,Other,140% New York Medicaid APG,886.83,,,886.83,Other,225% New York Medicaid APG,1024.78,,,1024.78,Other,260% New York Medicaid APG,1277.03,,,1277.03,Other,324% New York Medicaid APG,847.41,,,847.41,Other,215% New York Medicaid APG,847.41,,,847.41,Other,215% New York Medicaid APG,492.68,,,492.68,Other,125% New York Medicaid APG,394.14,27566.78,
Rpr s/n/ax/gen/trnk 2.5cm/<,12001,CPT,,,,,,,,both,,,4210.98,3116.13,74,,3116.13,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,1894.94,45,,1894.94,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,2084.44,49.5,,2084.44,percent of total billed charges,110% of Medicare,2863.47,68,,2863.47,percent of total billed charges,,957.71,,,957.71,Other,186% of Medicaid,3368.78,80,,3368.78,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,3368.78,80,,3368.78,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,2947.69,70,,2947.69,percent of total billed charges,,219.76,,,219.76,Fee Schedule,,186.26,,,186.26,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,514.9,,,514.9,Other,New York Medicaid APG methodology,514.9,,,514.9,Other,100% New York Medicaid APG,514.9,,,514.9,Other,100% New York Medicaid APG,514.9,,,514.9,Other,100% New York Medicaid APG,1158.52,,,1158.52,Other,225% New York Medicaid APG,787.8,,,787.8,Other,153% New York Medicaid APG,1158.52,,,1158.52,Other,225% New York Medicaid APG,720.86,,,720.86,Other,140% New York Medicaid APG,1158.52,,,1158.52,Other,225% New York Medicaid APG,1338.74,,,1338.74,Other,260% New York Medicaid APG,1668.27,,,1668.27,Other,324% New York Medicaid APG,1107.03,,,1107.03,Other,215% New York Medicaid APG,1107.03,,,1107.03,Other,215% New York Medicaid APG,643.62,,,643.62,Other,125% New York Medicaid APG,186.26,7216,
Rpr s/n/ax/gen/trnk2.6-7.5cm,12002,CPT,,,,,,,,both,,,4210.98,3116.13,74,,3116.13,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,1894.94,45,,1894.94,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,2084.44,49.5,,2084.44,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,957.71,,,957.71,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,2947.69,70,,2947.69,percent of total billed charges,,287,,,287,Fee Schedule,,243.25,,,243.25,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,514.9,,,514.9,Other,New York Medicaid APG methodology,514.9,,,514.9,Other,100% New York Medicaid APG,514.9,,,514.9,Other,100% New York Medicaid APG,514.9,,,514.9,Other,100% New York Medicaid APG,1158.52,,,1158.52,Other,225% New York Medicaid APG,787.8,,,787.8,Other,153% New York Medicaid APG,1158.52,,,1158.52,Other,225% New York Medicaid APG,720.86,,,720.86,Other,140% New York Medicaid APG,1158.52,,,1158.52,Other,225% New York Medicaid APG,1338.74,,,1338.74,Other,260% New York Medicaid APG,1668.27,,,1668.27,Other,324% New York Medicaid APG,1107.03,,,1107.03,Other,215% New York Medicaid APG,1107.03,,,1107.03,Other,215% New York Medicaid APG,643.62,,,643.62,Other,125% New York Medicaid APG,243.25,9473,
Rpr s/n/ax/gen/trk7.6-12.5cm,12004,CPT,,,,,,,,both,,,35302.99,26124.21,74,,26124.21,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15886.35,45,,15886.35,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,17474.98,49.5,,17474.98,percent of total billed charges,110% of Medicare,24006.03,68,,24006.03,percent of total billed charges,,957.71,,,957.71,Other,186% of Medicaid,28242.39,80,,28242.39,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,28242.39,80,,28242.39,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,24712.09,70,,24712.09,percent of total billed charges,,355.88,,,355.88,Fee Schedule,,301.63,,,301.63,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,514.9,,,514.9,Other,New York Medicaid APG methodology,514.9,,,514.9,Other,100% New York Medicaid APG,514.9,,,514.9,Other,100% New York Medicaid APG,514.9,,,514.9,Other,100% New York Medicaid APG,1158.52,,,1158.52,Other,225% New York Medicaid APG,787.8,,,787.8,Other,153% New York Medicaid APG,1158.52,,,1158.52,Other,225% New York Medicaid APG,720.86,,,720.86,Other,140% New York Medicaid APG,1158.52,,,1158.52,Other,225% New York Medicaid APG,1338.74,,,1338.74,Other,260% New York Medicaid APG,1668.27,,,1668.27,Other,324% New York Medicaid APG,1107.03,,,1107.03,Other,215% New York Medicaid APG,1107.03,,,1107.03,Other,215% New York Medicaid APG,643.62,,,643.62,Other,125% New York Medicaid APG,301.63,28242.39,
Rpr s/n/a/gen/trk12.6-20.0cm,12005,CPT,,,,,,,,both,,,8387.08,6206.44,74,,6206.44,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,3774.19,45,,3774.19,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,4151.6,49.5,,4151.6,percent of total billed charges,110% of Medicare,5703.21,68,,5703.21,percent of total billed charges,,957.71,,,957.71,Other,186% of Medicaid,6709.66,80,,6709.66,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,6709.66,80,,6709.66,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,5870.96,70,,5870.96,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,514.9,,,514.9,Other,New York Medicaid APG methodology,514.9,,,514.9,Other,100% New York Medicaid APG,514.9,,,514.9,Other,100% New York Medicaid APG,514.9,,,514.9,Other,100% New York Medicaid APG,1158.52,,,1158.52,Other,225% New York Medicaid APG,787.8,,,787.8,Other,153% New York Medicaid APG,1158.52,,,1158.52,Other,225% New York Medicaid APG,720.86,,,720.86,Other,140% New York Medicaid APG,1158.52,,,1158.52,Other,225% New York Medicaid APG,1338.74,,,1338.74,Other,260% New York Medicaid APG,1668.27,,,1668.27,Other,324% New York Medicaid APG,1107.03,,,1107.03,Other,215% New York Medicaid APG,1107.03,,,1107.03,Other,215% New York Medicaid APG,643.62,,,643.62,Other,125% New York Medicaid APG,514.9,7216,
Rpr s/n/a/gen/trk20.1-30.0cm,12006,CPT,,,,,,,,both,,,8387.08,6206.44,74,,6206.44,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,3774.19,45,,3774.19,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,4151.6,49.5,,4151.6,percent of total billed charges,110% of Medicare,5703.21,68,,5703.21,percent of total billed charges,,957.71,,,957.71,Other,186% of Medicaid,6709.66,80,,6709.66,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,6709.66,80,,6709.66,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,5870.96,70,,5870.96,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,514.9,,,514.9,Other,New York Medicaid APG methodology,514.9,,,514.9,Other,100% New York Medicaid APG,514.9,,,514.9,Other,100% New York Medicaid APG,514.9,,,514.9,Other,100% New York Medicaid APG,1158.52,,,1158.52,Other,225% New York Medicaid APG,787.8,,,787.8,Other,153% New York Medicaid APG,1158.52,,,1158.52,Other,225% New York Medicaid APG,720.86,,,720.86,Other,140% New York Medicaid APG,1158.52,,,1158.52,Other,225% New York Medicaid APG,1338.74,,,1338.74,Other,260% New York Medicaid APG,1668.27,,,1668.27,Other,324% New York Medicaid APG,1107.03,,,1107.03,Other,215% New York Medicaid APG,1107.03,,,1107.03,Other,215% New York Medicaid APG,643.62,,,643.62,Other,125% New York Medicaid APG,514.9,7216,
Rpr s/n/ax/gen/trnk >30.0 cm,12007,CPT,,,,,,,,both,,,4210.98,3116.13,74,,3116.13,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,1894.94,45,,1894.94,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,2084.44,49.5,,2084.44,percent of total billed charges,110% of Medicare,2863.47,68,,2863.47,percent of total billed charges,,957.71,,,957.71,Other,186% of Medicaid,3368.78,80,,3368.78,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,3368.78,80,,3368.78,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,2947.69,70,,2947.69,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,514.9,,,514.9,Other,New York Medicaid APG methodology,514.9,,,514.9,Other,100% New York Medicaid APG,514.9,,,514.9,Other,100% New York Medicaid APG,514.9,,,514.9,Other,100% New York Medicaid APG,1158.52,,,1158.52,Other,225% New York Medicaid APG,787.8,,,787.8,Other,153% New York Medicaid APG,1158.52,,,1158.52,Other,225% New York Medicaid APG,720.86,,,720.86,Other,140% New York Medicaid APG,1158.52,,,1158.52,Other,225% New York Medicaid APG,1338.74,,,1338.74,Other,260% New York Medicaid APG,1668.27,,,1668.27,Other,324% New York Medicaid APG,1107.03,,,1107.03,Other,215% New York Medicaid APG,1107.03,,,1107.03,Other,215% New York Medicaid APG,643.62,,,643.62,Other,125% New York Medicaid APG,514.9,7216,
Rpr f/e/e/n/l/m 2.5 cm/<,12011,CPT,,,,,,,,both,,,4210.98,3116.13,74,,3116.13,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,1894.94,45,,1894.94,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,2084.44,49.5,,2084.44,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,957.71,,,957.71,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,2947.69,70,,2947.69,percent of total billed charges,,268.96,,,268.96,Fee Schedule,,227.96,,,227.96,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,514.9,,,514.9,Other,New York Medicaid APG methodology,514.9,,,514.9,Other,100% New York Medicaid APG,514.9,,,514.9,Other,100% New York Medicaid APG,514.9,,,514.9,Other,100% New York Medicaid APG,1158.52,,,1158.52,Other,225% New York Medicaid APG,787.8,,,787.8,Other,153% New York Medicaid APG,1158.52,,,1158.52,Other,225% New York Medicaid APG,720.86,,,720.86,Other,140% New York Medicaid APG,1158.52,,,1158.52,Other,225% New York Medicaid APG,1338.74,,,1338.74,Other,260% New York Medicaid APG,1668.27,,,1668.27,Other,324% New York Medicaid APG,1107.03,,,1107.03,Other,215% New York Medicaid APG,1107.03,,,1107.03,Other,215% New York Medicaid APG,643.62,,,643.62,Other,125% New York Medicaid APG,227.96,9473,
Rpr f/e/e/n/l/m 2.6-5.0 cm,12013,CPT,,,,,,,,both,,,4210.98,3116.13,74,,3116.13,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,1894.94,45,,1894.94,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,2084.44,49.5,,2084.44,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,957.71,,,957.71,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,2947.69,70,,2947.69,percent of total billed charges,,285.36,,,285.36,Fee Schedule,,241.86,,,241.86,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,514.9,,,514.9,Other,New York Medicaid APG methodology,514.9,,,514.9,Other,100% New York Medicaid APG,514.9,,,514.9,Other,100% New York Medicaid APG,514.9,,,514.9,Other,100% New York Medicaid APG,1158.52,,,1158.52,Other,225% New York Medicaid APG,787.8,,,787.8,Other,153% New York Medicaid APG,1158.52,,,1158.52,Other,225% New York Medicaid APG,720.86,,,720.86,Other,140% New York Medicaid APG,1158.52,,,1158.52,Other,225% New York Medicaid APG,1338.74,,,1338.74,Other,260% New York Medicaid APG,1668.27,,,1668.27,Other,324% New York Medicaid APG,1107.03,,,1107.03,Other,215% New York Medicaid APG,1107.03,,,1107.03,Other,215% New York Medicaid APG,643.62,,,643.62,Other,125% New York Medicaid APG,241.86,9473,
Rpr f/e/e/n/l/m 5.1-7.5 cm,12014,CPT,,,,,,,,both,,,4210.98,3116.13,74,,3116.13,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,1894.94,45,,1894.94,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,2084.44,49.5,,2084.44,percent of total billed charges,110% of Medicare,2863.47,68,,2863.47,percent of total billed charges,,957.71,,,957.71,Other,186% of Medicaid,3368.78,80,,3368.78,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,3368.78,80,,3368.78,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,2947.69,70,,2947.69,percent of total billed charges,,364.08,,,364.08,Fee Schedule,,308.58,,,308.58,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,514.9,,,514.9,Other,New York Medicaid APG methodology,514.9,,,514.9,Other,100% New York Medicaid APG,514.9,,,514.9,Other,100% New York Medicaid APG,514.9,,,514.9,Other,100% New York Medicaid APG,1158.52,,,1158.52,Other,225% New York Medicaid APG,787.8,,,787.8,Other,153% New York Medicaid APG,1158.52,,,1158.52,Other,225% New York Medicaid APG,720.86,,,720.86,Other,140% New York Medicaid APG,1158.52,,,1158.52,Other,225% New York Medicaid APG,1338.74,,,1338.74,Other,260% New York Medicaid APG,1668.27,,,1668.27,Other,324% New York Medicaid APG,1107.03,,,1107.03,Other,215% New York Medicaid APG,1107.03,,,1107.03,Other,215% New York Medicaid APG,643.62,,,643.62,Other,125% New York Medicaid APG,308.58,7216,
Rpr f/e/e/n/l/m 7.6-12.5 cm,12015,CPT,,,,,,,,both,,,4210.98,3116.13,74,,3116.13,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,1894.94,45,,1894.94,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,2084.44,49.5,,2084.44,percent of total billed charges,110% of Medicare,2863.47,68,,2863.47,percent of total billed charges,,957.71,,,957.71,Other,186% of Medicaid,3368.78,80,,3368.78,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,3368.78,80,,3368.78,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,2947.69,70,,2947.69,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,514.9,,,514.9,Other,New York Medicaid APG methodology,514.9,,,514.9,Other,100% New York Medicaid APG,514.9,,,514.9,Other,100% New York Medicaid APG,514.9,,,514.9,Other,100% New York Medicaid APG,1158.52,,,1158.52,Other,225% New York Medicaid APG,787.8,,,787.8,Other,153% New York Medicaid APG,1158.52,,,1158.52,Other,225% New York Medicaid APG,720.86,,,720.86,Other,140% New York Medicaid APG,1158.52,,,1158.52,Other,225% New York Medicaid APG,1338.74,,,1338.74,Other,260% New York Medicaid APG,1668.27,,,1668.27,Other,324% New York Medicaid APG,1107.03,,,1107.03,Other,215% New York Medicaid APG,1107.03,,,1107.03,Other,215% New York Medicaid APG,643.62,,,643.62,Other,125% New York Medicaid APG,514.9,7216,
Rpr fe/e/en/l/m 12.6-20.0 cm,12016,CPT,,,,,,,,both,,,8387.08,6206.44,74,,6206.44,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,3774.19,45,,3774.19,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,4151.6,49.5,,4151.6,percent of total billed charges,110% of Medicare,5703.21,68,,5703.21,percent of total billed charges,,957.71,,,957.71,Other,186% of Medicaid,6709.66,80,,6709.66,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,6709.66,80,,6709.66,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,5870.96,70,,5870.96,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,514.9,,,514.9,Other,New York Medicaid APG methodology,514.9,,,514.9,Other,100% New York Medicaid APG,514.9,,,514.9,Other,100% New York Medicaid APG,514.9,,,514.9,Other,100% New York Medicaid APG,1158.52,,,1158.52,Other,225% New York Medicaid APG,787.8,,,787.8,Other,153% New York Medicaid APG,1158.52,,,1158.52,Other,225% New York Medicaid APG,720.86,,,720.86,Other,140% New York Medicaid APG,1158.52,,,1158.52,Other,225% New York Medicaid APG,1338.74,,,1338.74,Other,260% New York Medicaid APG,1668.27,,,1668.27,Other,324% New York Medicaid APG,1107.03,,,1107.03,Other,215% New York Medicaid APG,1107.03,,,1107.03,Other,215% New York Medicaid APG,643.62,,,643.62,Other,125% New York Medicaid APG,514.9,7216,
Rpr fe/e/en/l/m 20.1-30.0 cm,12017,CPT,,,,,,,,both,,,8387.08,6206.44,74,,6206.44,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,3774.19,45,,3774.19,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,4151.6,49.5,,4151.6,percent of total billed charges,110% of Medicare,5703.21,68,,5703.21,percent of total billed charges,,957.71,,,957.71,Other,186% of Medicaid,6709.66,80,,6709.66,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,6709.66,80,,6709.66,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,5870.96,70,,5870.96,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,514.9,,,514.9,Other,New York Medicaid APG methodology,514.9,,,514.9,Other,100% New York Medicaid APG,514.9,,,514.9,Other,100% New York Medicaid APG,514.9,,,514.9,Other,100% New York Medicaid APG,1158.52,,,1158.52,Other,225% New York Medicaid APG,787.8,,,787.8,Other,153% New York Medicaid APG,1158.52,,,1158.52,Other,225% New York Medicaid APG,720.86,,,720.86,Other,140% New York Medicaid APG,1158.52,,,1158.52,Other,225% New York Medicaid APG,1338.74,,,1338.74,Other,260% New York Medicaid APG,1668.27,,,1668.27,Other,324% New York Medicaid APG,1107.03,,,1107.03,Other,215% New York Medicaid APG,1107.03,,,1107.03,Other,215% New York Medicaid APG,643.62,,,643.62,Other,125% New York Medicaid APG,514.9,7216,
Rpr f/e/e/n/l/m >30.0 cm,12018,CPT,,,,,,,,both,,,4210.98,3116.13,74,,3116.13,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,1894.94,45,,1894.94,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,2084.44,49.5,,2084.44,percent of total billed charges,110% of Medicare,2863.47,68,,2863.47,percent of total billed charges,,957.71,,,957.71,Other,186% of Medicaid,3368.78,80,,3368.78,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,3368.78,80,,3368.78,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,2947.69,70,,2947.69,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,514.9,,,514.9,Other,New York Medicaid APG methodology,514.9,,,514.9,Other,100% New York Medicaid APG,514.9,,,514.9,Other,100% New York Medicaid APG,514.9,,,514.9,Other,100% New York Medicaid APG,1158.52,,,1158.52,Other,225% New York Medicaid APG,787.8,,,787.8,Other,153% New York Medicaid APG,1158.52,,,1158.52,Other,225% New York Medicaid APG,720.86,,,720.86,Other,140% New York Medicaid APG,1158.52,,,1158.52,Other,225% New York Medicaid APG,1338.74,,,1338.74,Other,260% New York Medicaid APG,1668.27,,,1668.27,Other,324% New York Medicaid APG,1107.03,,,1107.03,Other,215% New York Medicaid APG,1107.03,,,1107.03,Other,215% New York Medicaid APG,643.62,,,643.62,Other,125% New York Medicaid APG,514.9,7216,
Closure of split wound,12020,CPT,,,,,,,,both,,,35741.92,26449.02,74,,26449.02,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,16083.86,45,,16083.86,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,17692.25,49.5,,17692.25,percent of total billed charges,110% of Medicare,24304.51,68,,24304.51,percent of total billed charges,,1352.53,,,1352.53,Other,186% of Medicaid,28593.54,80,,28593.54,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,28593.54,80,,28593.54,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,25019.34,70,,25019.34,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,727.17,,,727.17,Other,New York Medicaid APG methodology,727.17,,,727.17,Other,100% New York Medicaid APG,727.17,,,727.17,Other,100% New York Medicaid APG,727.17,,,727.17,Other,100% New York Medicaid APG,1636.12,,,1636.12,Other,225% New York Medicaid APG,1112.56,,,1112.56,Other,153% New York Medicaid APG,1636.12,,,1636.12,Other,225% New York Medicaid APG,1018.03,,,1018.03,Other,140% New York Medicaid APG,1636.12,,,1636.12,Other,225% New York Medicaid APG,1890.63,,,1890.63,Other,260% New York Medicaid APG,2356.02,,,2356.02,Other,324% New York Medicaid APG,1563.41,,,1563.41,Other,215% New York Medicaid APG,1563.41,,,1563.41,Other,215% New York Medicaid APG,908.96,,,908.96,Other,125% New York Medicaid APG,727.17,28593.54,
Closure of split wound,12021,CPT,,,,,,,,both,,,33626.79,24883.82,74,,24883.82,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15132.06,45,,15132.06,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,16645.26,49.5,,16645.26,percent of total billed charges,110% of Medicare,22866.22,68,,22866.22,percent of total billed charges,,1352.53,,,1352.53,Other,186% of Medicaid,26901.43,80,,26901.43,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,26901.43,80,,26901.43,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,23538.75,70,,23538.75,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,727.17,,,727.17,Other,New York Medicaid APG methodology,727.17,,,727.17,Other,100% New York Medicaid APG,727.17,,,727.17,Other,100% New York Medicaid APG,727.17,,,727.17,Other,100% New York Medicaid APG,1636.12,,,1636.12,Other,225% New York Medicaid APG,1112.56,,,1112.56,Other,153% New York Medicaid APG,1636.12,,,1636.12,Other,225% New York Medicaid APG,1018.03,,,1018.03,Other,140% New York Medicaid APG,1636.12,,,1636.12,Other,225% New York Medicaid APG,1890.63,,,1890.63,Other,260% New York Medicaid APG,2356.02,,,2356.02,Other,324% New York Medicaid APG,1563.41,,,1563.41,Other,215% New York Medicaid APG,1563.41,,,1563.41,Other,215% New York Medicaid APG,908.96,,,908.96,Other,125% New York Medicaid APG,727.17,26901.43,
Intmd rpr s/a/t/ext 2.5 cm/<,12031,CPT,,,,,,,,both,,,37087.59,27444.82,74,,27444.82,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,16689.42,45,,16689.42,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,18358.36,49.5,,18358.36,percent of total billed charges,110% of Medicare,25219.56,68,,25219.56,percent of total billed charges,,1352.53,,,1352.53,Other,186% of Medicaid,29670.07,80,,29670.07,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,29670.07,80,,29670.07,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,25961.31,70,,25961.31,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,727.17,,,727.17,Other,New York Medicaid APG methodology,727.17,,,727.17,Other,100% New York Medicaid APG,727.17,,,727.17,Other,100% New York Medicaid APG,727.17,,,727.17,Other,100% New York Medicaid APG,1636.12,,,1636.12,Other,225% New York Medicaid APG,1112.56,,,1112.56,Other,153% New York Medicaid APG,1636.12,,,1636.12,Other,225% New York Medicaid APG,1018.03,,,1018.03,Other,140% New York Medicaid APG,1636.12,,,1636.12,Other,225% New York Medicaid APG,1890.63,,,1890.63,Other,260% New York Medicaid APG,2356.02,,,2356.02,Other,324% New York Medicaid APG,1563.41,,,1563.41,Other,215% New York Medicaid APG,1563.41,,,1563.41,Other,215% New York Medicaid APG,908.96,,,908.96,Other,125% New York Medicaid APG,727.17,29670.07,
Intmd rpr s/a/t/ext 2.6-7.5,12032,CPT,,,,,,,,both,,,34955.57,25867.12,74,,25867.12,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15730.01,45,,15730.01,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,17303.01,49.5,,17303.01,percent of total billed charges,110% of Medicare,23769.79,68,,23769.79,percent of total billed charges,,1352.53,,,1352.53,Other,186% of Medicaid,27964.46,80,,27964.46,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,27964.46,80,,27964.46,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,24468.9,70,,24468.9,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,727.17,,,727.17,Other,New York Medicaid APG methodology,727.17,,,727.17,Other,100% New York Medicaid APG,727.17,,,727.17,Other,100% New York Medicaid APG,727.17,,,727.17,Other,100% New York Medicaid APG,1636.12,,,1636.12,Other,225% New York Medicaid APG,1112.56,,,1112.56,Other,153% New York Medicaid APG,1636.12,,,1636.12,Other,225% New York Medicaid APG,1018.03,,,1018.03,Other,140% New York Medicaid APG,1636.12,,,1636.12,Other,225% New York Medicaid APG,1890.63,,,1890.63,Other,260% New York Medicaid APG,2356.02,,,2356.02,Other,324% New York Medicaid APG,1563.41,,,1563.41,Other,215% New York Medicaid APG,1563.41,,,1563.41,Other,215% New York Medicaid APG,908.96,,,908.96,Other,125% New York Medicaid APG,727.17,27964.46,
Intmd rpr s/tr/ext 7.6-12.5,12034,CPT,,,,,,,,both,,,8387.08,6206.44,74,,6206.44,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,3774.19,45,,3774.19,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,4151.6,49.5,,4151.6,percent of total billed charges,110% of Medicare,5703.21,68,,5703.21,percent of total billed charges,,1352.53,,,1352.53,Other,186% of Medicaid,6709.66,80,,6709.66,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,6709.66,80,,6709.66,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,5870.96,70,,5870.96,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,727.17,,,727.17,Other,New York Medicaid APG methodology,727.17,,,727.17,Other,100% New York Medicaid APG,727.17,,,727.17,Other,100% New York Medicaid APG,727.17,,,727.17,Other,100% New York Medicaid APG,1636.12,,,1636.12,Other,225% New York Medicaid APG,1112.56,,,1112.56,Other,153% New York Medicaid APG,1636.12,,,1636.12,Other,225% New York Medicaid APG,1018.03,,,1018.03,Other,140% New York Medicaid APG,1636.12,,,1636.12,Other,225% New York Medicaid APG,1890.63,,,1890.63,Other,260% New York Medicaid APG,2356.02,,,2356.02,Other,324% New York Medicaid APG,1563.41,,,1563.41,Other,215% New York Medicaid APG,1563.41,,,1563.41,Other,215% New York Medicaid APG,908.96,,,908.96,Other,125% New York Medicaid APG,727.17,7216,
Intmd rpr s/a/t/ext 12.6-20,12035,CPT,,,,,,,,both,,,8387.08,6206.44,74,,6206.44,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,3774.19,45,,3774.19,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,4151.6,49.5,,4151.6,percent of total billed charges,110% of Medicare,5703.21,68,,5703.21,percent of total billed charges,,1352.53,,,1352.53,Other,186% of Medicaid,6709.66,80,,6709.66,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,6709.66,80,,6709.66,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,5870.96,70,,5870.96,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,727.17,,,727.17,Other,New York Medicaid APG methodology,727.17,,,727.17,Other,100% New York Medicaid APG,727.17,,,727.17,Other,100% New York Medicaid APG,727.17,,,727.17,Other,100% New York Medicaid APG,1636.12,,,1636.12,Other,225% New York Medicaid APG,1112.56,,,1112.56,Other,153% New York Medicaid APG,1636.12,,,1636.12,Other,225% New York Medicaid APG,1018.03,,,1018.03,Other,140% New York Medicaid APG,1636.12,,,1636.12,Other,225% New York Medicaid APG,1890.63,,,1890.63,Other,260% New York Medicaid APG,2356.02,,,2356.02,Other,324% New York Medicaid APG,1563.41,,,1563.41,Other,215% New York Medicaid APG,1563.41,,,1563.41,Other,215% New York Medicaid APG,908.96,,,908.96,Other,125% New York Medicaid APG,727.17,7216,
Intmd rpr s/a/t/ext 20.1-30,12036,CPT,,,,,,,,both,,,13210.22,9775.56,74,,9775.56,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,5944.6,45,,5944.6,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,6539.06,49.5,,6539.06,percent of total billed charges,110% of Medicare,8982.95,68,,8982.95,percent of total billed charges,,1352.53,,,1352.53,Other,186% of Medicaid,10568.18,80,,10568.18,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,10568.18,80,,10568.18,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,9247.15,70,,9247.15,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,727.17,,,727.17,Other,New York Medicaid APG methodology,727.17,,,727.17,Other,100% New York Medicaid APG,727.17,,,727.17,Other,100% New York Medicaid APG,727.17,,,727.17,Other,100% New York Medicaid APG,1636.12,,,1636.12,Other,225% New York Medicaid APG,1112.56,,,1112.56,Other,153% New York Medicaid APG,1636.12,,,1636.12,Other,225% New York Medicaid APG,1018.03,,,1018.03,Other,140% New York Medicaid APG,1636.12,,,1636.12,Other,225% New York Medicaid APG,1890.63,,,1890.63,Other,260% New York Medicaid APG,2356.02,,,2356.02,Other,324% New York Medicaid APG,1563.41,,,1563.41,Other,215% New York Medicaid APG,1563.41,,,1563.41,Other,215% New York Medicaid APG,908.96,,,908.96,Other,125% New York Medicaid APG,727.17,10568.18,
Intmd rpr s/tr/ext >30.0 cm,12037,CPT,,,,,,,,both,,,38357.55,28384.59,74,,28384.59,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,17260.9,45,,17260.9,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,18986.99,49.5,,18986.99,percent of total billed charges,110% of Medicare,26083.13,68,,26083.13,percent of total billed charges,,1352.53,,,1352.53,Other,186% of Medicaid,30686.04,80,,30686.04,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,30686.04,80,,30686.04,percent of total billed charges,,7216,,,7216,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,26850.29,70,,26850.29,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,727.17,,,727.17,Other,New York Medicaid APG methodology,727.17,,,727.17,Other,100% New York Medicaid APG,727.17,,,727.17,Other,100% New York Medicaid APG,727.17,,,727.17,Other,100% New York Medicaid APG,1636.12,,,1636.12,Other,225% New York Medicaid APG,1112.56,,,1112.56,Other,153% New York Medicaid APG,1636.12,,,1636.12,Other,225% New York Medicaid APG,1018.03,,,1018.03,Other,140% New York Medicaid APG,1636.12,,,1636.12,Other,225% New York Medicaid APG,1890.63,,,1890.63,Other,260% New York Medicaid APG,2356.02,,,2356.02,Other,324% New York Medicaid APG,1563.41,,,1563.41,Other,215% New York Medicaid APG,1563.41,,,1563.41,Other,215% New York Medicaid APG,908.96,,,908.96,Other,125% New York Medicaid APG,727.17,30686.04,
Intmd rpr n-hf/genit 2.5cm/<,12041,CPT,,,,,,,,both,,,8387.08,6206.44,74,,6206.44,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,3774.19,45,,3774.19,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,4151.6,49.5,,4151.6,percent of total billed charges,110% of Medicare,5703.21,68,,5703.21,percent of total billed charges,,1352.53,,,1352.53,Other,186% of Medicaid,6709.66,80,,6709.66,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,6709.66,80,,6709.66,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,5870.96,70,,5870.96,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,727.17,,,727.17,Other,New York Medicaid APG methodology,727.17,,,727.17,Other,100% New York Medicaid APG,727.17,,,727.17,Other,100% New York Medicaid APG,727.17,,,727.17,Other,100% New York Medicaid APG,1636.12,,,1636.12,Other,225% New York Medicaid APG,1112.56,,,1112.56,Other,153% New York Medicaid APG,1636.12,,,1636.12,Other,225% New York Medicaid APG,1018.03,,,1018.03,Other,140% New York Medicaid APG,1636.12,,,1636.12,Other,225% New York Medicaid APG,1890.63,,,1890.63,Other,260% New York Medicaid APG,2356.02,,,2356.02,Other,324% New York Medicaid APG,1563.41,,,1563.41,Other,215% New York Medicaid APG,1563.41,,,1563.41,Other,215% New York Medicaid APG,908.96,,,908.96,Other,125% New York Medicaid APG,727.17,7216,
Intmd rpr n-hf/genit2.6-7.5,12042,CPT,,,,,,,,both,,,8387.08,6206.44,74,,6206.44,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,3774.19,45,,3774.19,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,4151.6,49.5,,4151.6,percent of total billed charges,110% of Medicare,5703.21,68,,5703.21,percent of total billed charges,,1352.53,,,1352.53,Other,186% of Medicaid,6709.66,80,,6709.66,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,6709.66,80,,6709.66,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,5870.96,70,,5870.96,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,727.17,,,727.17,Other,New York Medicaid APG methodology,727.17,,,727.17,Other,100% New York Medicaid APG,727.17,,,727.17,Other,100% New York Medicaid APG,727.17,,,727.17,Other,100% New York Medicaid APG,1636.12,,,1636.12,Other,225% New York Medicaid APG,1112.56,,,1112.56,Other,153% New York Medicaid APG,1636.12,,,1636.12,Other,225% New York Medicaid APG,1018.03,,,1018.03,Other,140% New York Medicaid APG,1636.12,,,1636.12,Other,225% New York Medicaid APG,1890.63,,,1890.63,Other,260% New York Medicaid APG,2356.02,,,2356.02,Other,324% New York Medicaid APG,1563.41,,,1563.41,Other,215% New York Medicaid APG,1563.41,,,1563.41,Other,215% New York Medicaid APG,908.96,,,908.96,Other,125% New York Medicaid APG,727.17,7216,
Intmd rpr n-hf/genit7.6-12.5,12044,CPT,,,,,,,,both,,,13210.22,9775.56,74,,9775.56,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,5944.6,45,,5944.6,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,6539.06,49.5,,6539.06,percent of total billed charges,110% of Medicare,8982.95,68,,8982.95,percent of total billed charges,,1352.53,,,1352.53,Other,186% of Medicaid,10568.18,80,,10568.18,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,10568.18,80,,10568.18,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,9247.15,70,,9247.15,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,727.17,,,727.17,Other,New York Medicaid APG methodology,727.17,,,727.17,Other,100% New York Medicaid APG,727.17,,,727.17,Other,100% New York Medicaid APG,727.17,,,727.17,Other,100% New York Medicaid APG,1636.12,,,1636.12,Other,225% New York Medicaid APG,1112.56,,,1112.56,Other,153% New York Medicaid APG,1636.12,,,1636.12,Other,225% New York Medicaid APG,1018.03,,,1018.03,Other,140% New York Medicaid APG,1636.12,,,1636.12,Other,225% New York Medicaid APG,1890.63,,,1890.63,Other,260% New York Medicaid APG,2356.02,,,2356.02,Other,324% New York Medicaid APG,1563.41,,,1563.41,Other,215% New York Medicaid APG,1563.41,,,1563.41,Other,215% New York Medicaid APG,908.96,,,908.96,Other,125% New York Medicaid APG,727.17,10568.18,
Intmd rpr n-hf/genit12.6-20,12045,CPT,,,,,,,,both,,,13210.22,9775.56,74,,9775.56,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,5944.6,45,,5944.6,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,6539.06,49.5,,6539.06,percent of total billed charges,110% of Medicare,8982.95,68,,8982.95,percent of total billed charges,,1352.53,,,1352.53,Other,186% of Medicaid,10568.18,80,,10568.18,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,10568.18,80,,10568.18,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,9247.15,70,,9247.15,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,727.17,,,727.17,Other,New York Medicaid APG methodology,727.17,,,727.17,Other,100% New York Medicaid APG,727.17,,,727.17,Other,100% New York Medicaid APG,727.17,,,727.17,Other,100% New York Medicaid APG,1636.12,,,1636.12,Other,225% New York Medicaid APG,1112.56,,,1112.56,Other,153% New York Medicaid APG,1636.12,,,1636.12,Other,225% New York Medicaid APG,1018.03,,,1018.03,Other,140% New York Medicaid APG,1636.12,,,1636.12,Other,225% New York Medicaid APG,1890.63,,,1890.63,Other,260% New York Medicaid APG,2356.02,,,2356.02,Other,324% New York Medicaid APG,1563.41,,,1563.41,Other,215% New York Medicaid APG,1563.41,,,1563.41,Other,215% New York Medicaid APG,908.96,,,908.96,Other,125% New York Medicaid APG,727.17,10568.18,
Intmd rpr n-hf/genit20.1-30,12046,CPT,,,,,,,,both,,,13210.22,9775.56,74,,9775.56,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,5944.6,45,,5944.6,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,6539.06,49.5,,6539.06,percent of total billed charges,110% of Medicare,8982.95,68,,8982.95,percent of total billed charges,,1352.53,,,1352.53,Other,186% of Medicaid,10568.18,80,,10568.18,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,10568.18,80,,10568.18,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,9247.15,70,,9247.15,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,727.17,,,727.17,Other,New York Medicaid APG methodology,727.17,,,727.17,Other,100% New York Medicaid APG,727.17,,,727.17,Other,100% New York Medicaid APG,727.17,,,727.17,Other,100% New York Medicaid APG,1636.12,,,1636.12,Other,225% New York Medicaid APG,1112.56,,,1112.56,Other,153% New York Medicaid APG,1636.12,,,1636.12,Other,225% New York Medicaid APG,1018.03,,,1018.03,Other,140% New York Medicaid APG,1636.12,,,1636.12,Other,225% New York Medicaid APG,1890.63,,,1890.63,Other,260% New York Medicaid APG,2356.02,,,2356.02,Other,324% New York Medicaid APG,1563.41,,,1563.41,Other,215% New York Medicaid APG,1563.41,,,1563.41,Other,215% New York Medicaid APG,908.96,,,908.96,Other,125% New York Medicaid APG,727.17,10568.18,
Intmd rpr n-hf/genit >30.0cm,12047,CPT,,,,,,,,both,,,38357.55,28384.59,74,,28384.59,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,17260.9,45,,17260.9,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,18986.99,49.5,,18986.99,percent of total billed charges,110% of Medicare,26083.13,68,,26083.13,percent of total billed charges,,1352.53,,,1352.53,Other,186% of Medicaid,30686.04,80,,30686.04,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,30686.04,80,,30686.04,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,26850.29,70,,26850.29,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,727.17,,,727.17,Other,New York Medicaid APG methodology,727.17,,,727.17,Other,100% New York Medicaid APG,727.17,,,727.17,Other,100% New York Medicaid APG,727.17,,,727.17,Other,100% New York Medicaid APG,1636.12,,,1636.12,Other,225% New York Medicaid APG,1112.56,,,1112.56,Other,153% New York Medicaid APG,1636.12,,,1636.12,Other,225% New York Medicaid APG,1018.03,,,1018.03,Other,140% New York Medicaid APG,1636.12,,,1636.12,Other,225% New York Medicaid APG,1890.63,,,1890.63,Other,260% New York Medicaid APG,2356.02,,,2356.02,Other,324% New York Medicaid APG,1563.41,,,1563.41,Other,215% New York Medicaid APG,1563.41,,,1563.41,Other,215% New York Medicaid APG,908.96,,,908.96,Other,125% New York Medicaid APG,727.17,30686.04,
Intmd rpr face/mm 2.5 cm/<,12051,CPT,,,,,,,,both,,,35324.33,26140,74,,26140,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15895.95,45,,15895.95,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,17485.54,49.5,,17485.54,percent of total billed charges,110% of Medicare,24020.54,68,,24020.54,percent of total billed charges,,1352.53,,,1352.53,Other,186% of Medicaid,28259.46,80,,28259.46,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,28259.46,80,,28259.46,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,24727.03,70,,24727.03,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,727.17,,,727.17,Other,New York Medicaid APG methodology,727.17,,,727.17,Other,100% New York Medicaid APG,727.17,,,727.17,Other,100% New York Medicaid APG,727.17,,,727.17,Other,100% New York Medicaid APG,1636.12,,,1636.12,Other,225% New York Medicaid APG,1112.56,,,1112.56,Other,153% New York Medicaid APG,1636.12,,,1636.12,Other,225% New York Medicaid APG,1018.03,,,1018.03,Other,140% New York Medicaid APG,1636.12,,,1636.12,Other,225% New York Medicaid APG,1890.63,,,1890.63,Other,260% New York Medicaid APG,2356.02,,,2356.02,Other,324% New York Medicaid APG,1563.41,,,1563.41,Other,215% New York Medicaid APG,1563.41,,,1563.41,Other,215% New York Medicaid APG,908.96,,,908.96,Other,125% New York Medicaid APG,727.17,28259.46,
Intmd rpr face/mm 2.6-5.0 cm,12052,CPT,,,,,,,,both,,,8387.08,6206.44,74,,6206.44,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,3774.19,45,,3774.19,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,4151.6,49.5,,4151.6,percent of total billed charges,110% of Medicare,5703.21,68,,5703.21,percent of total billed charges,,1352.53,,,1352.53,Other,186% of Medicaid,6709.66,80,,6709.66,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,6709.66,80,,6709.66,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,5870.96,70,,5870.96,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,727.17,,,727.17,Other,New York Medicaid APG methodology,727.17,,,727.17,Other,100% New York Medicaid APG,727.17,,,727.17,Other,100% New York Medicaid APG,727.17,,,727.17,Other,100% New York Medicaid APG,1636.12,,,1636.12,Other,225% New York Medicaid APG,1112.56,,,1112.56,Other,153% New York Medicaid APG,1636.12,,,1636.12,Other,225% New York Medicaid APG,1018.03,,,1018.03,Other,140% New York Medicaid APG,1636.12,,,1636.12,Other,225% New York Medicaid APG,1890.63,,,1890.63,Other,260% New York Medicaid APG,2356.02,,,2356.02,Other,324% New York Medicaid APG,1563.41,,,1563.41,Other,215% New York Medicaid APG,1563.41,,,1563.41,Other,215% New York Medicaid APG,908.96,,,908.96,Other,125% New York Medicaid APG,727.17,7216,
Intmd rpr face/mm 5.1-7.5 cm,12053,CPT,,,,,,,,both,,,8387.08,6206.44,74,,6206.44,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,3774.19,45,,3774.19,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,4151.6,49.5,,4151.6,percent of total billed charges,110% of Medicare,5703.21,68,,5703.21,percent of total billed charges,,1352.53,,,1352.53,Other,186% of Medicaid,6709.66,80,,6709.66,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,6709.66,80,,6709.66,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,5870.96,70,,5870.96,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,727.17,,,727.17,Other,New York Medicaid APG methodology,727.17,,,727.17,Other,100% New York Medicaid APG,727.17,,,727.17,Other,100% New York Medicaid APG,727.17,,,727.17,Other,100% New York Medicaid APG,1636.12,,,1636.12,Other,225% New York Medicaid APG,1112.56,,,1112.56,Other,153% New York Medicaid APG,1636.12,,,1636.12,Other,225% New York Medicaid APG,1018.03,,,1018.03,Other,140% New York Medicaid APG,1636.12,,,1636.12,Other,225% New York Medicaid APG,1890.63,,,1890.63,Other,260% New York Medicaid APG,2356.02,,,2356.02,Other,324% New York Medicaid APG,1563.41,,,1563.41,Other,215% New York Medicaid APG,1563.41,,,1563.41,Other,215% New York Medicaid APG,908.96,,,908.96,Other,125% New York Medicaid APG,727.17,7216,
Intmd rpr face/mm 7.6-12.5cm,12054,CPT,,,,,,,,both,,,8387.08,6206.44,74,,6206.44,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,3774.19,45,,3774.19,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,4151.6,49.5,,4151.6,percent of total billed charges,110% of Medicare,5703.21,68,,5703.21,percent of total billed charges,,1352.53,,,1352.53,Other,186% of Medicaid,6709.66,80,,6709.66,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,6709.66,80,,6709.66,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,5870.96,70,,5870.96,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,727.17,,,727.17,Other,New York Medicaid APG methodology,727.17,,,727.17,Other,100% New York Medicaid APG,727.17,,,727.17,Other,100% New York Medicaid APG,727.17,,,727.17,Other,100% New York Medicaid APG,1636.12,,,1636.12,Other,225% New York Medicaid APG,1112.56,,,1112.56,Other,153% New York Medicaid APG,1636.12,,,1636.12,Other,225% New York Medicaid APG,1018.03,,,1018.03,Other,140% New York Medicaid APG,1636.12,,,1636.12,Other,225% New York Medicaid APG,1890.63,,,1890.63,Other,260% New York Medicaid APG,2356.02,,,2356.02,Other,324% New York Medicaid APG,1563.41,,,1563.41,Other,215% New York Medicaid APG,1563.41,,,1563.41,Other,215% New York Medicaid APG,908.96,,,908.96,Other,125% New York Medicaid APG,727.17,7216,
Intmd rpr face/mm 12.6-20 cm,12055,CPT,,,,,,,,both,,,8387.08,6206.44,74,,6206.44,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,3774.19,45,,3774.19,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,4151.6,49.5,,4151.6,percent of total billed charges,110% of Medicare,5703.21,68,,5703.21,percent of total billed charges,,1352.53,,,1352.53,Other,186% of Medicaid,6709.66,80,,6709.66,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,6709.66,80,,6709.66,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,5870.96,70,,5870.96,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,727.17,,,727.17,Other,New York Medicaid APG methodology,727.17,,,727.17,Other,100% New York Medicaid APG,727.17,,,727.17,Other,100% New York Medicaid APG,727.17,,,727.17,Other,100% New York Medicaid APG,1636.12,,,1636.12,Other,225% New York Medicaid APG,1112.56,,,1112.56,Other,153% New York Medicaid APG,1636.12,,,1636.12,Other,225% New York Medicaid APG,1018.03,,,1018.03,Other,140% New York Medicaid APG,1636.12,,,1636.12,Other,225% New York Medicaid APG,1890.63,,,1890.63,Other,260% New York Medicaid APG,2356.02,,,2356.02,Other,324% New York Medicaid APG,1563.41,,,1563.41,Other,215% New York Medicaid APG,1563.41,,,1563.41,Other,215% New York Medicaid APG,908.96,,,908.96,Other,125% New York Medicaid APG,727.17,7216,
Intmd rpr face/mm 20.1-30.0,12056,CPT,,,,,,,,both,,,8387.08,6206.44,74,,6206.44,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,3774.19,45,,3774.19,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,4151.6,49.5,,4151.6,percent of total billed charges,110% of Medicare,5703.21,68,,5703.21,percent of total billed charges,,1352.53,,,1352.53,Other,186% of Medicaid,6709.66,80,,6709.66,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,6709.66,80,,6709.66,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,5870.96,70,,5870.96,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,727.17,,,727.17,Other,New York Medicaid APG methodology,727.17,,,727.17,Other,100% New York Medicaid APG,727.17,,,727.17,Other,100% New York Medicaid APG,727.17,,,727.17,Other,100% New York Medicaid APG,1636.12,,,1636.12,Other,225% New York Medicaid APG,1112.56,,,1112.56,Other,153% New York Medicaid APG,1636.12,,,1636.12,Other,225% New York Medicaid APG,1018.03,,,1018.03,Other,140% New York Medicaid APG,1636.12,,,1636.12,Other,225% New York Medicaid APG,1890.63,,,1890.63,Other,260% New York Medicaid APG,2356.02,,,2356.02,Other,324% New York Medicaid APG,1563.41,,,1563.41,Other,215% New York Medicaid APG,1563.41,,,1563.41,Other,215% New York Medicaid APG,908.96,,,908.96,Other,125% New York Medicaid APG,727.17,7216,
Intmd rpr face/mm >30.0 cm,12057,CPT,,,,,,,,both,,,8387.08,6206.44,74,,6206.44,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,3774.19,45,,3774.19,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,4151.6,49.5,,4151.6,percent of total billed charges,110% of Medicare,5703.21,68,,5703.21,percent of total billed charges,,1352.53,,,1352.53,Other,186% of Medicaid,6709.66,80,,6709.66,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,6709.66,80,,6709.66,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,5870.96,70,,5870.96,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,727.17,,,727.17,Other,New York Medicaid APG methodology,727.17,,,727.17,Other,100% New York Medicaid APG,727.17,,,727.17,Other,100% New York Medicaid APG,727.17,,,727.17,Other,100% New York Medicaid APG,1636.12,,,1636.12,Other,225% New York Medicaid APG,1112.56,,,1112.56,Other,153% New York Medicaid APG,1636.12,,,1636.12,Other,225% New York Medicaid APG,1018.03,,,1018.03,Other,140% New York Medicaid APG,1636.12,,,1636.12,Other,225% New York Medicaid APG,1890.63,,,1890.63,Other,260% New York Medicaid APG,2356.02,,,2356.02,Other,324% New York Medicaid APG,1563.41,,,1563.41,Other,215% New York Medicaid APG,1563.41,,,1563.41,Other,215% New York Medicaid APG,908.96,,,908.96,Other,125% New York Medicaid APG,727.17,7216,
Cmplx rpr trunk 1.1-2.5 cm,13100,CPT,,,,,,,,both,,,13210.22,9775.56,74,,9775.56,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,5944.6,45,,5944.6,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,6539.06,49.5,,6539.06,percent of total billed charges,110% of Medicare,8982.95,68,,8982.95,percent of total billed charges,,1240.83,,,1240.83,Other,186% of Medicaid,10568.18,80,,10568.18,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,10568.18,80,,10568.18,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,9247.15,70,,9247.15,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,667.11,,,667.11,Other,New York Medicaid APG methodology,667.11,,,667.11,Other,100% New York Medicaid APG,667.11,,,667.11,Other,100% New York Medicaid APG,667.11,,,667.11,Other,100% New York Medicaid APG,1501,,,1501,Other,225% New York Medicaid APG,1020.68,,,1020.68,Other,153% New York Medicaid APG,1501,,,1501,Other,225% New York Medicaid APG,933.96,,,933.96,Other,140% New York Medicaid APG,1501,,,1501,Other,225% New York Medicaid APG,1734.49,,,1734.49,Other,260% New York Medicaid APG,2161.44,,,2161.44,Other,324% New York Medicaid APG,1434.29,,,1434.29,Other,215% New York Medicaid APG,1434.29,,,1434.29,Other,215% New York Medicaid APG,833.89,,,833.89,Other,125% New York Medicaid APG,667.11,10568.18,
Cmplx rpr trunk 2.6-7.5 cm,13101,CPT,,,,,,,,both,,,34403.66,25458.71,74,,25458.71,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15481.65,45,,15481.65,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,17029.81,49.5,,17029.81,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,1240.83,,,1240.83,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,24082.56,70,,24082.56,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,667.11,,,667.11,Other,New York Medicaid APG methodology,667.11,,,667.11,Other,100% New York Medicaid APG,667.11,,,667.11,Other,100% New York Medicaid APG,667.11,,,667.11,Other,100% New York Medicaid APG,1501,,,1501,Other,225% New York Medicaid APG,1020.68,,,1020.68,Other,153% New York Medicaid APG,1501,,,1501,Other,225% New York Medicaid APG,933.96,,,933.96,Other,140% New York Medicaid APG,1501,,,1501,Other,225% New York Medicaid APG,1734.49,,,1734.49,Other,260% New York Medicaid APG,2161.44,,,2161.44,Other,324% New York Medicaid APG,1434.29,,,1434.29,Other,215% New York Medicaid APG,1434.29,,,1434.29,Other,215% New York Medicaid APG,833.89,,,833.89,Other,125% New York Medicaid APG,667.11,25458.71,
Cmplx rpr trunk addl 5cm/<,13102,CPT,,,,,,,,both,,,51572.04,38163.31,74,,38163.31,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,23207.42,45,,23207.42,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,25528.16,49.5,,25528.16,percent of total billed charges,110% of Medicare,35068.99,68,,35068.99,percent of total billed charges,,1240.83,,,1240.83,Other,186% of Medicaid,41257.63,80,,41257.63,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,41257.63,80,,41257.63,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,36100.43,70,,36100.43,percent of total billed charges,,347.68,,,347.68,Fee Schedule,,294.68,,,294.68,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,667.11,,,667.11,Other,New York Medicaid APG methodology,667.11,,,667.11,Other,100% New York Medicaid APG,667.11,,,667.11,Other,100% New York Medicaid APG,667.11,,,667.11,Other,100% New York Medicaid APG,1501,,,1501,Other,225% New York Medicaid APG,1020.68,,,1020.68,Other,153% New York Medicaid APG,1501,,,1501,Other,225% New York Medicaid APG,933.96,,,933.96,Other,140% New York Medicaid APG,1501,,,1501,Other,225% New York Medicaid APG,1734.49,,,1734.49,Other,260% New York Medicaid APG,2161.44,,,2161.44,Other,324% New York Medicaid APG,1434.29,,,1434.29,Other,215% New York Medicaid APG,1434.29,,,1434.29,Other,215% New York Medicaid APG,833.89,,,833.89,Other,125% New York Medicaid APG,294.68,41257.63,
Cmplx rpr s/a/l 1.1-2.5 cm,13120,CPT,,,,,,,,both,,,38708.34,28644.17,74,,28644.17,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,17418.75,45,,17418.75,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,19160.63,49.5,,19160.63,percent of total billed charges,110% of Medicare,26321.67,68,,26321.67,percent of total billed charges,,1240.83,,,1240.83,Other,186% of Medicaid,30966.67,80,,30966.67,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,30966.67,80,,30966.67,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,27095.84,70,,27095.84,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,667.11,,,667.11,Other,New York Medicaid APG methodology,667.11,,,667.11,Other,100% New York Medicaid APG,667.11,,,667.11,Other,100% New York Medicaid APG,667.11,,,667.11,Other,100% New York Medicaid APG,1501,,,1501,Other,225% New York Medicaid APG,1020.68,,,1020.68,Other,153% New York Medicaid APG,1501,,,1501,Other,225% New York Medicaid APG,933.96,,,933.96,Other,140% New York Medicaid APG,1501,,,1501,Other,225% New York Medicaid APG,1734.49,,,1734.49,Other,260% New York Medicaid APG,2161.44,,,2161.44,Other,324% New York Medicaid APG,1434.29,,,1434.29,Other,215% New York Medicaid APG,1434.29,,,1434.29,Other,215% New York Medicaid APG,833.89,,,833.89,Other,125% New York Medicaid APG,667.11,30966.67,
Cmplx rpr s/a/l 2.6-7.5 cm,13121,CPT,,,,,,,,both,,,34012,25168.88,74,,25168.88,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15305.4,45,,15305.4,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,16835.94,49.5,,16835.94,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,1240.83,,,1240.83,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,23808.4,70,,23808.4,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,667.11,,,667.11,Other,New York Medicaid APG methodology,667.11,,,667.11,Other,100% New York Medicaid APG,667.11,,,667.11,Other,100% New York Medicaid APG,667.11,,,667.11,Other,100% New York Medicaid APG,1501,,,1501,Other,225% New York Medicaid APG,1020.68,,,1020.68,Other,153% New York Medicaid APG,1501,,,1501,Other,225% New York Medicaid APG,933.96,,,933.96,Other,140% New York Medicaid APG,1501,,,1501,Other,225% New York Medicaid APG,1734.49,,,1734.49,Other,260% New York Medicaid APG,2161.44,,,2161.44,Other,324% New York Medicaid APG,1434.29,,,1434.29,Other,215% New York Medicaid APG,1434.29,,,1434.29,Other,215% New York Medicaid APG,833.89,,,833.89,Other,125% New York Medicaid APG,667.11,25168.88,
Cmplx rpr s/a/l addl 5 cm/>,13122,CPT,,,,,,,,both,,,51572.04,38163.31,74,,38163.31,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,23207.42,45,,23207.42,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,25528.16,49.5,,25528.16,percent of total billed charges,110% of Medicare,35068.99,68,,35068.99,percent of total billed charges,,1240.83,,,1240.83,Other,186% of Medicaid,41257.63,80,,41257.63,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,41257.63,80,,41257.63,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,36100.43,70,,36100.43,percent of total billed charges,,401.8,,,401.8,Fee Schedule,,340.55,,,340.55,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,667.11,,,667.11,Other,New York Medicaid APG methodology,667.11,,,667.11,Other,100% New York Medicaid APG,667.11,,,667.11,Other,100% New York Medicaid APG,667.11,,,667.11,Other,100% New York Medicaid APG,1501,,,1501,Other,225% New York Medicaid APG,1020.68,,,1020.68,Other,153% New York Medicaid APG,1501,,,1501,Other,225% New York Medicaid APG,933.96,,,933.96,Other,140% New York Medicaid APG,1501,,,1501,Other,225% New York Medicaid APG,1734.49,,,1734.49,Other,260% New York Medicaid APG,2161.44,,,2161.44,Other,324% New York Medicaid APG,1434.29,,,1434.29,Other,215% New York Medicaid APG,1434.29,,,1434.29,Other,215% New York Medicaid APG,833.89,,,833.89,Other,125% New York Medicaid APG,340.55,41257.63,
Cmplx rpr f/c/c/m/n/ax/g/h/f,13131,CPT,,,,,,,,both,,,34288.5,25373.49,74,,25373.49,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15429.83,45,,15429.83,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,16972.81,49.5,,16972.81,percent of total billed charges,110% of Medicare,23316.18,68,,23316.18,percent of total billed charges,,1240.83,,,1240.83,Other,186% of Medicaid,27430.8,80,,27430.8,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,27430.8,80,,27430.8,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,24001.95,70,,24001.95,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,667.11,,,667.11,Other,New York Medicaid APG methodology,667.11,,,667.11,Other,100% New York Medicaid APG,667.11,,,667.11,Other,100% New York Medicaid APG,667.11,,,667.11,Other,100% New York Medicaid APG,1501,,,1501,Other,225% New York Medicaid APG,1020.68,,,1020.68,Other,153% New York Medicaid APG,1501,,,1501,Other,225% New York Medicaid APG,933.96,,,933.96,Other,140% New York Medicaid APG,1501,,,1501,Other,225% New York Medicaid APG,1734.49,,,1734.49,Other,260% New York Medicaid APG,2161.44,,,2161.44,Other,324% New York Medicaid APG,1434.29,,,1434.29,Other,215% New York Medicaid APG,1434.29,,,1434.29,Other,215% New York Medicaid APG,833.89,,,833.89,Other,125% New York Medicaid APG,667.11,27430.8,
Cmplx rpr f/c/c/m/n/ax/g/h/f,13132,CPT,,,,,,,,both,,,36334.59,26887.6,74,,26887.6,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,16350.57,45,,16350.57,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,17985.62,49.5,,17985.62,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,1240.83,,,1240.83,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,25434.21,70,,25434.21,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,667.11,,,667.11,Other,New York Medicaid APG methodology,667.11,,,667.11,Other,100% New York Medicaid APG,667.11,,,667.11,Other,100% New York Medicaid APG,667.11,,,667.11,Other,100% New York Medicaid APG,1501,,,1501,Other,225% New York Medicaid APG,1020.68,,,1020.68,Other,153% New York Medicaid APG,1501,,,1501,Other,225% New York Medicaid APG,933.96,,,933.96,Other,140% New York Medicaid APG,1501,,,1501,Other,225% New York Medicaid APG,1734.49,,,1734.49,Other,260% New York Medicaid APG,2161.44,,,2161.44,Other,324% New York Medicaid APG,1434.29,,,1434.29,Other,215% New York Medicaid APG,1434.29,,,1434.29,Other,215% New York Medicaid APG,833.89,,,833.89,Other,125% New York Medicaid APG,667.11,26887.6,
Cmplx rpr f/c/c/m/n/ax/g/h/f,13133,CPT,,,,,,,,both,,,51572.04,38163.31,74,,38163.31,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,23207.42,45,,23207.42,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,25528.16,49.5,,25528.16,percent of total billed charges,110% of Medicare,35068.99,68,,35068.99,percent of total billed charges,,1240.83,,,1240.83,Other,186% of Medicaid,41257.63,80,,41257.63,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,41257.63,80,,41257.63,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,36100.43,70,,36100.43,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,667.11,,,667.11,Other,New York Medicaid APG methodology,667.11,,,667.11,Other,100% New York Medicaid APG,667.11,,,667.11,Other,100% New York Medicaid APG,667.11,,,667.11,Other,100% New York Medicaid APG,1501,,,1501,Other,225% New York Medicaid APG,1020.68,,,1020.68,Other,153% New York Medicaid APG,1501,,,1501,Other,225% New York Medicaid APG,933.96,,,933.96,Other,140% New York Medicaid APG,1501,,,1501,Other,225% New York Medicaid APG,1734.49,,,1734.49,Other,260% New York Medicaid APG,2161.44,,,2161.44,Other,324% New York Medicaid APG,1434.29,,,1434.29,Other,215% New York Medicaid APG,1434.29,,,1434.29,Other,215% New York Medicaid APG,833.89,,,833.89,Other,125% New York Medicaid APG,667.11,41257.63,
Cmplx rpr e/n/e/l 1.1-2.5 cm,13151,CPT,,,,,,,,both,,,13210.22,9775.56,74,,9775.56,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,5944.6,45,,5944.6,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,6539.06,49.5,,6539.06,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,1240.83,,,1240.83,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,9247.15,70,,9247.15,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,667.11,,,667.11,Other,New York Medicaid APG methodology,667.11,,,667.11,Other,100% New York Medicaid APG,667.11,,,667.11,Other,100% New York Medicaid APG,667.11,,,667.11,Other,100% New York Medicaid APG,1501,,,1501,Other,225% New York Medicaid APG,1020.68,,,1020.68,Other,153% New York Medicaid APG,1501,,,1501,Other,225% New York Medicaid APG,933.96,,,933.96,Other,140% New York Medicaid APG,1501,,,1501,Other,225% New York Medicaid APG,1734.49,,,1734.49,Other,260% New York Medicaid APG,2161.44,,,2161.44,Other,324% New York Medicaid APG,1434.29,,,1434.29,Other,215% New York Medicaid APG,1434.29,,,1434.29,Other,215% New York Medicaid APG,833.89,,,833.89,Other,125% New York Medicaid APG,667.11,9775.56,
Cmplx rpr e/n/e/l 2.6-7.5 cm,13152,CPT,,,,,,,,both,,,13210.22,9775.56,74,,9775.56,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,5944.6,45,,5944.6,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,6539.06,49.5,,6539.06,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,1240.83,,,1240.83,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,9247.15,70,,9247.15,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,667.11,,,667.11,Other,New York Medicaid APG methodology,667.11,,,667.11,Other,100% New York Medicaid APG,667.11,,,667.11,Other,100% New York Medicaid APG,667.11,,,667.11,Other,100% New York Medicaid APG,1501,,,1501,Other,225% New York Medicaid APG,1020.68,,,1020.68,Other,153% New York Medicaid APG,1501,,,1501,Other,225% New York Medicaid APG,933.96,,,933.96,Other,140% New York Medicaid APG,1501,,,1501,Other,225% New York Medicaid APG,1734.49,,,1734.49,Other,260% New York Medicaid APG,2161.44,,,2161.44,Other,324% New York Medicaid APG,1434.29,,,1434.29,Other,215% New York Medicaid APG,1434.29,,,1434.29,Other,215% New York Medicaid APG,833.89,,,833.89,Other,125% New York Medicaid APG,667.11,9775.56,
Cmplx rpr e/n/e/l addl 5cm/<,13153,CPT,,,,,,,,both,,,51572.04,38163.31,74,,38163.31,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,23207.42,45,,23207.42,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,25528.16,49.5,,25528.16,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2241.85,,,2241.85,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,36100.43,70,,36100.43,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,1205.3,,,1205.3,Other,New York Medicaid APG methodology,1205.3,,,1205.3,Other,100% New York Medicaid APG,1205.3,,,1205.3,Other,100% New York Medicaid APG,1205.3,,,1205.3,Other,100% New York Medicaid APG,2711.92,,,2711.92,Other,225% New York Medicaid APG,1844.1,,,1844.1,Other,153% New York Medicaid APG,2711.92,,,2711.92,Other,225% New York Medicaid APG,1687.41,,,1687.41,Other,140% New York Medicaid APG,2711.92,,,2711.92,Other,225% New York Medicaid APG,3133.77,,,3133.77,Other,260% New York Medicaid APG,3905.16,,,3905.16,Other,324% New York Medicaid APG,2591.39,,,2591.39,Other,215% New York Medicaid APG,2591.39,,,2591.39,Other,215% New York Medicaid APG,1506.62,,,1506.62,Other,125% New York Medicaid APG,1205.3,38163.31,
Late closure of wound,13160,CPT,,,,,,,,both,,,42510.74,31457.95,74,,31457.95,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,19129.83,45,,19129.83,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,21042.82,49.5,,21042.82,percent of total billed charges,110% of Medicare,28907.3,68,,28907.3,percent of total billed charges,,2492.85,,,2492.85,Other,186% of Medicaid,34008.59,80,,34008.59,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,34008.59,80,,34008.59,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,29757.52,70,,29757.52,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1340.24,,,1340.24,Other,New York Medicaid APG methodology,1340.24,,,1340.24,Other,100% New York Medicaid APG,1340.24,,,1340.24,Other,100% New York Medicaid APG,1340.24,,,1340.24,Other,100% New York Medicaid APG,3015.54,,,3015.54,Other,225% New York Medicaid APG,2050.57,,,2050.57,Other,153% New York Medicaid APG,3015.54,,,3015.54,Other,225% New York Medicaid APG,1876.34,,,1876.34,Other,140% New York Medicaid APG,3015.54,,,3015.54,Other,225% New York Medicaid APG,3484.62,,,3484.62,Other,260% New York Medicaid APG,4342.38,,,4342.38,Other,324% New York Medicaid APG,2881.52,,,2881.52,Other,215% New York Medicaid APG,2881.52,,,2881.52,Other,215% New York Medicaid APG,1675.3,,,1675.3,Other,125% New York Medicaid APG,1340.24,34008.59,
Tis trnfr trunk 10 sq cm/<,14000,CPT,,,,,,,,both,,,37536.83,27777.25,74,,27777.25,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,16891.57,45,,16891.57,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,18580.73,49.5,,18580.73,percent of total billed charges,110% of Medicare,25525.04,68,,25525.04,percent of total billed charges,,2593.54,,,2593.54,Other,186% of Medicaid,30029.46,80,,30029.46,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,30029.46,80,,30029.46,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,26275.78,70,,26275.78,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1394.38,,,1394.38,Other,New York Medicaid APG methodology,1394.38,,,1394.38,Other,100% New York Medicaid APG,1394.38,,,1394.38,Other,100% New York Medicaid APG,1394.38,,,1394.38,Other,100% New York Medicaid APG,3137.35,,,3137.35,Other,225% New York Medicaid APG,2133.39,,,2133.39,Other,153% New York Medicaid APG,3137.35,,,3137.35,Other,225% New York Medicaid APG,1952.13,,,1952.13,Other,140% New York Medicaid APG,3137.35,,,3137.35,Other,225% New York Medicaid APG,3625.38,,,3625.38,Other,260% New York Medicaid APG,4517.78,,,4517.78,Other,324% New York Medicaid APG,2997.91,,,2997.91,Other,215% New York Medicaid APG,2997.91,,,2997.91,Other,215% New York Medicaid APG,1742.97,,,1742.97,Other,125% New York Medicaid APG,1394.38,30029.46,
Tis trnfr trunk 10.1-30sqcm,14001,CPT,,,,,,,,both,,,45392.1,33590.15,74,,33590.15,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,20426.45,45,,20426.45,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,22469.09,49.5,,22469.09,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2593.54,,,2593.54,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,31774.47,70,,31774.47,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1394.38,,,1394.38,Other,New York Medicaid APG methodology,1394.38,,,1394.38,Other,100% New York Medicaid APG,1394.38,,,1394.38,Other,100% New York Medicaid APG,1394.38,,,1394.38,Other,100% New York Medicaid APG,3137.35,,,3137.35,Other,225% New York Medicaid APG,2133.39,,,2133.39,Other,153% New York Medicaid APG,3137.35,,,3137.35,Other,225% New York Medicaid APG,1952.13,,,1952.13,Other,140% New York Medicaid APG,3137.35,,,3137.35,Other,225% New York Medicaid APG,3625.38,,,3625.38,Other,260% New York Medicaid APG,4517.78,,,4517.78,Other,324% New York Medicaid APG,2997.91,,,2997.91,Other,215% New York Medicaid APG,2997.91,,,2997.91,Other,215% New York Medicaid APG,1742.97,,,1742.97,Other,125% New York Medicaid APG,1394.38,33590.15,
Tis trnfr s/a/l 10 sq cm/<,14020,CPT,,,,,,,,both,,,39919.58,29540.49,74,,29540.49,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,17963.81,45,,17963.81,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,19760.19,49.5,,19760.19,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2593.54,,,2593.54,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,27943.71,70,,27943.71,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1394.38,,,1394.38,Other,New York Medicaid APG methodology,1394.38,,,1394.38,Other,100% New York Medicaid APG,1394.38,,,1394.38,Other,100% New York Medicaid APG,1394.38,,,1394.38,Other,100% New York Medicaid APG,3137.35,,,3137.35,Other,225% New York Medicaid APG,2133.39,,,2133.39,Other,153% New York Medicaid APG,3137.35,,,3137.35,Other,225% New York Medicaid APG,1952.13,,,1952.13,Other,140% New York Medicaid APG,3137.35,,,3137.35,Other,225% New York Medicaid APG,3625.38,,,3625.38,Other,260% New York Medicaid APG,4517.78,,,4517.78,Other,324% New York Medicaid APG,2997.91,,,2997.91,Other,215% New York Medicaid APG,2997.91,,,2997.91,Other,215% New York Medicaid APG,1742.97,,,1742.97,Other,125% New York Medicaid APG,1394.38,29540.49,
Tis trnfr s/a/l 10.1-30 sqcm,14021,CPT,,,,,,,,both,,,39136.09,28960.71,74,,28960.71,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,17611.24,45,,17611.24,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,19372.36,49.5,,19372.36,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2593.54,,,2593.54,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,27395.26,70,,27395.26,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1394.38,,,1394.38,Other,New York Medicaid APG methodology,1394.38,,,1394.38,Other,100% New York Medicaid APG,1394.38,,,1394.38,Other,100% New York Medicaid APG,1394.38,,,1394.38,Other,100% New York Medicaid APG,3137.35,,,3137.35,Other,225% New York Medicaid APG,2133.39,,,2133.39,Other,153% New York Medicaid APG,3137.35,,,3137.35,Other,225% New York Medicaid APG,1952.13,,,1952.13,Other,140% New York Medicaid APG,3137.35,,,3137.35,Other,225% New York Medicaid APG,3625.38,,,3625.38,Other,260% New York Medicaid APG,4517.78,,,4517.78,Other,324% New York Medicaid APG,2997.91,,,2997.91,Other,215% New York Medicaid APG,2997.91,,,2997.91,Other,215% New York Medicaid APG,1742.97,,,1742.97,Other,125% New York Medicaid APG,1394.38,28960.71,
Tis trnfr f/c/c/m/n/a/g/h/f,14040,CPT,,,,,,,,both,,,35494.9,26266.23,74,,26266.23,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15972.71,45,,15972.71,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,17569.98,49.5,,17569.98,percent of total billed charges,110% of Medicare,24136.53,68,,24136.53,percent of total billed charges,,2593.54,,,2593.54,Other,186% of Medicaid,28395.92,80,,28395.92,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,28395.92,80,,28395.92,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,24846.43,70,,24846.43,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1394.38,,,1394.38,Other,New York Medicaid APG methodology,1394.38,,,1394.38,Other,100% New York Medicaid APG,1394.38,,,1394.38,Other,100% New York Medicaid APG,1394.38,,,1394.38,Other,100% New York Medicaid APG,3137.35,,,3137.35,Other,225% New York Medicaid APG,2133.39,,,2133.39,Other,153% New York Medicaid APG,3137.35,,,3137.35,Other,225% New York Medicaid APG,1952.13,,,1952.13,Other,140% New York Medicaid APG,3137.35,,,3137.35,Other,225% New York Medicaid APG,3625.38,,,3625.38,Other,260% New York Medicaid APG,4517.78,,,4517.78,Other,324% New York Medicaid APG,2997.91,,,2997.91,Other,215% New York Medicaid APG,2997.91,,,2997.91,Other,215% New York Medicaid APG,1742.97,,,1742.97,Other,125% New York Medicaid APG,1394.38,28395.92,
Tis trnfr f/c/c/m/n/a/g/h/f,14041,CPT,,,,,,,,both,,,36489.01,27001.87,74,,27001.87,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,16420.05,45,,16420.05,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,18062.06,49.5,,18062.06,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2593.54,,,2593.54,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,25542.31,70,,25542.31,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1394.38,,,1394.38,Other,New York Medicaid APG methodology,1394.38,,,1394.38,Other,100% New York Medicaid APG,1394.38,,,1394.38,Other,100% New York Medicaid APG,1394.38,,,1394.38,Other,100% New York Medicaid APG,3137.35,,,3137.35,Other,225% New York Medicaid APG,2133.39,,,2133.39,Other,153% New York Medicaid APG,3137.35,,,3137.35,Other,225% New York Medicaid APG,1952.13,,,1952.13,Other,140% New York Medicaid APG,3137.35,,,3137.35,Other,225% New York Medicaid APG,3625.38,,,3625.38,Other,260% New York Medicaid APG,4517.78,,,4517.78,Other,324% New York Medicaid APG,2997.91,,,2997.91,Other,215% New York Medicaid APG,2997.91,,,2997.91,Other,215% New York Medicaid APG,1742.97,,,1742.97,Other,125% New York Medicaid APG,1394.38,27001.87,
Tis trnfr e/n/e/l 10 sq cm/<,14060,CPT,,,,,,,,both,,,37887.21,28036.54,74,,28036.54,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,17049.24,45,,17049.24,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,18754.17,49.5,,18754.17,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2593.54,,,2593.54,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,26521.05,70,,26521.05,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1394.38,,,1394.38,Other,New York Medicaid APG methodology,1394.38,,,1394.38,Other,100% New York Medicaid APG,1394.38,,,1394.38,Other,100% New York Medicaid APG,1394.38,,,1394.38,Other,100% New York Medicaid APG,3137.35,,,3137.35,Other,225% New York Medicaid APG,2133.39,,,2133.39,Other,153% New York Medicaid APG,3137.35,,,3137.35,Other,225% New York Medicaid APG,1952.13,,,1952.13,Other,140% New York Medicaid APG,3137.35,,,3137.35,Other,225% New York Medicaid APG,3625.38,,,3625.38,Other,260% New York Medicaid APG,4517.78,,,4517.78,Other,324% New York Medicaid APG,2997.91,,,2997.91,Other,215% New York Medicaid APG,2997.91,,,2997.91,Other,215% New York Medicaid APG,1742.97,,,1742.97,Other,125% New York Medicaid APG,1394.38,28036.54,
Tis trnfr e/n/e/l10.1-30sqcm,14061,CPT,,,,,,,,both,,,41980.43,31065.52,74,,31065.52,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,18891.19,45,,18891.19,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,20780.31,49.5,,20780.31,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2593.54,,,2593.54,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,29386.3,70,,29386.3,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1394.38,,,1394.38,Other,New York Medicaid APG methodology,1394.38,,,1394.38,Other,100% New York Medicaid APG,1394.38,,,1394.38,Other,100% New York Medicaid APG,1394.38,,,1394.38,Other,100% New York Medicaid APG,3137.35,,,3137.35,Other,225% New York Medicaid APG,2133.39,,,2133.39,Other,153% New York Medicaid APG,3137.35,,,3137.35,Other,225% New York Medicaid APG,1952.13,,,1952.13,Other,140% New York Medicaid APG,3137.35,,,3137.35,Other,225% New York Medicaid APG,3625.38,,,3625.38,Other,260% New York Medicaid APG,4517.78,,,4517.78,Other,324% New York Medicaid APG,2997.91,,,2997.91,Other,215% New York Medicaid APG,2997.91,,,2997.91,Other,215% New York Medicaid APG,1742.97,,,1742.97,Other,125% New York Medicaid APG,1394.38,31065.52,
Tis trnfr any 30.1-60 sq cm,14301,CPT,,,,,,,,both,,,38120.07,28208.85,74,,28208.85,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,17154.03,45,,17154.03,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,18869.43,49.5,,18869.43,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2593.54,,,2593.54,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,26684.05,70,,26684.05,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1394.38,,,1394.38,Other,New York Medicaid APG methodology,1394.38,,,1394.38,Other,100% New York Medicaid APG,1394.38,,,1394.38,Other,100% New York Medicaid APG,1394.38,,,1394.38,Other,100% New York Medicaid APG,3137.35,,,3137.35,Other,225% New York Medicaid APG,2133.39,,,2133.39,Other,153% New York Medicaid APG,3137.35,,,3137.35,Other,225% New York Medicaid APG,1952.13,,,1952.13,Other,140% New York Medicaid APG,3137.35,,,3137.35,Other,225% New York Medicaid APG,3625.38,,,3625.38,Other,260% New York Medicaid APG,4517.78,,,4517.78,Other,324% New York Medicaid APG,2997.91,,,2997.91,Other,215% New York Medicaid APG,2997.91,,,2997.91,Other,215% New York Medicaid APG,1742.97,,,1742.97,Other,125% New York Medicaid APG,1394.38,28208.85,
Tis trnfr addl 30 sq cm,14302,CPT,,,,,,,,both,,,83504,61792.96,74,,61792.96,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,37576.8,45,,37576.8,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,41334.48,49.5,,41334.48,percent of total billed charges,110% of Medicare,56782.72,68,,56782.72,percent of total billed charges,,2593.54,,,2593.54,Other,186% of Medicaid,66803.2,80,,66803.2,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,66803.2,80,,66803.2,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,58452.8,70,,58452.8,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,1394.38,,,1394.38,Other,New York Medicaid APG methodology,1394.38,,,1394.38,Other,100% New York Medicaid APG,1394.38,,,1394.38,Other,100% New York Medicaid APG,1394.38,,,1394.38,Other,100% New York Medicaid APG,3137.35,,,3137.35,Other,225% New York Medicaid APG,2133.39,,,2133.39,Other,153% New York Medicaid APG,3137.35,,,3137.35,Other,225% New York Medicaid APG,1952.13,,,1952.13,Other,140% New York Medicaid APG,3137.35,,,3137.35,Other,225% New York Medicaid APG,3625.38,,,3625.38,Other,260% New York Medicaid APG,4517.78,,,4517.78,Other,324% New York Medicaid APG,2997.91,,,2997.91,Other,215% New York Medicaid APG,2997.91,,,2997.91,Other,215% New York Medicaid APG,1742.97,,,1742.97,Other,125% New York Medicaid APG,1394.38,66803.2,
Filleted finger/toe flap,14350,CPT,,,,,,,,both,,,38357.55,28384.59,74,,28384.59,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,17260.9,45,,17260.9,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,18986.99,49.5,,18986.99,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2593.54,,,2593.54,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,26850.29,70,,26850.29,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1394.38,,,1394.38,Other,New York Medicaid APG methodology,1394.38,,,1394.38,Other,100% New York Medicaid APG,1394.38,,,1394.38,Other,100% New York Medicaid APG,1394.38,,,1394.38,Other,100% New York Medicaid APG,3137.35,,,3137.35,Other,225% New York Medicaid APG,2133.39,,,2133.39,Other,153% New York Medicaid APG,3137.35,,,3137.35,Other,225% New York Medicaid APG,1952.13,,,1952.13,Other,140% New York Medicaid APG,3137.35,,,3137.35,Other,225% New York Medicaid APG,3625.38,,,3625.38,Other,260% New York Medicaid APG,4517.78,,,4517.78,Other,324% New York Medicaid APG,2997.91,,,2997.91,Other,215% New York Medicaid APG,2997.91,,,2997.91,Other,215% New York Medicaid APG,1742.97,,,1742.97,Other,125% New York Medicaid APG,1394.38,28384.59,
Wound prep trk/arm/leg,15002,CPT,,,,,,,,both,,,52099.26,38553.45,74,,38553.45,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,23444.67,45,,23444.67,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,25789.13,49.5,,25789.13,percent of total billed charges,110% of Medicare,35427.5,68,,35427.5,percent of total billed charges,,2492.85,,,2492.85,Other,186% of Medicaid,41679.41,80,,41679.41,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,41679.41,80,,41679.41,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,36469.48,70,,36469.48,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1340.24,,,1340.24,Other,New York Medicaid APG methodology,1340.24,,,1340.24,Other,100% New York Medicaid APG,1340.24,,,1340.24,Other,100% New York Medicaid APG,1340.24,,,1340.24,Other,100% New York Medicaid APG,3015.54,,,3015.54,Other,225% New York Medicaid APG,2050.57,,,2050.57,Other,153% New York Medicaid APG,3015.54,,,3015.54,Other,225% New York Medicaid APG,1876.34,,,1876.34,Other,140% New York Medicaid APG,3015.54,,,3015.54,Other,225% New York Medicaid APG,3484.62,,,3484.62,Other,260% New York Medicaid APG,4342.38,,,4342.38,Other,324% New York Medicaid APG,2881.52,,,2881.52,Other,215% New York Medicaid APG,2881.52,,,2881.52,Other,215% New York Medicaid APG,1675.3,,,1675.3,Other,125% New York Medicaid APG,1340.24,41679.41,
Wound prep addl 100 cm,15003,CPT,,,,,,,,both,,,32432.1,23999.75,74,,23999.75,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,14594.45,45,,14594.45,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,16053.89,49.5,,16053.89,percent of total billed charges,110% of Medicare,22053.83,68,,22053.83,percent of total billed charges,,1352.53,,,1352.53,Other,186% of Medicaid,25945.68,80,,25945.68,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,25945.68,80,,25945.68,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,22702.47,70,,22702.47,percent of total billed charges,,219.76,,,219.76,Fee Schedule,,186.26,,,186.26,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,727.17,,,727.17,Other,New York Medicaid APG methodology,727.17,,,727.17,Other,100% New York Medicaid APG,727.17,,,727.17,Other,100% New York Medicaid APG,727.17,,,727.17,Other,100% New York Medicaid APG,1636.12,,,1636.12,Other,225% New York Medicaid APG,1112.56,,,1112.56,Other,153% New York Medicaid APG,1636.12,,,1636.12,Other,225% New York Medicaid APG,1018.03,,,1018.03,Other,140% New York Medicaid APG,1636.12,,,1636.12,Other,225% New York Medicaid APG,1890.63,,,1890.63,Other,260% New York Medicaid APG,2356.02,,,2356.02,Other,324% New York Medicaid APG,1563.41,,,1563.41,Other,215% New York Medicaid APG,1563.41,,,1563.41,Other,215% New York Medicaid APG,908.96,,,908.96,Other,125% New York Medicaid APG,186.26,25945.68,
Wound prep f/n/hf/g,15004,CPT,,,,,,,,both,,,53677.47,39721.33,74,,39721.33,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,24154.86,45,,24154.86,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,26570.35,49.5,,26570.35,percent of total billed charges,110% of Medicare,36500.68,68,,36500.68,percent of total billed charges,,2492.85,,,2492.85,Other,186% of Medicaid,42941.98,80,,42941.98,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,42941.98,80,,42941.98,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,37574.23,70,,37574.23,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,1340.24,,,1340.24,Other,New York Medicaid APG methodology,1340.24,,,1340.24,Other,100% New York Medicaid APG,1340.24,,,1340.24,Other,100% New York Medicaid APG,1340.24,,,1340.24,Other,100% New York Medicaid APG,3015.54,,,3015.54,Other,225% New York Medicaid APG,2050.57,,,2050.57,Other,153% New York Medicaid APG,3015.54,,,3015.54,Other,225% New York Medicaid APG,1876.34,,,1876.34,Other,140% New York Medicaid APG,3015.54,,,3015.54,Other,225% New York Medicaid APG,3484.62,,,3484.62,Other,260% New York Medicaid APG,4342.38,,,4342.38,Other,324% New York Medicaid APG,2881.52,,,2881.52,Other,215% New York Medicaid APG,2881.52,,,2881.52,Other,215% New York Medicaid APG,1675.3,,,1675.3,Other,125% New York Medicaid APG,1340.24,42941.98,
Wnd prep f/n/hf/g addl cm,15005,CPT,,,,,,,,both,,,32432.1,23999.75,74,,23999.75,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,14594.45,45,,14594.45,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,16053.89,49.5,,16053.89,percent of total billed charges,110% of Medicare,22053.83,68,,22053.83,percent of total billed charges,,1352.53,,,1352.53,Other,186% of Medicaid,25945.68,80,,25945.68,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,25945.68,80,,25945.68,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,22702.47,70,,22702.47,percent of total billed charges,,434.6,,,434.6,Fee Schedule,,368.35,,,368.35,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,727.17,,,727.17,Other,New York Medicaid APG methodology,727.17,,,727.17,Other,100% New York Medicaid APG,727.17,,,727.17,Other,100% New York Medicaid APG,727.17,,,727.17,Other,100% New York Medicaid APG,1636.12,,,1636.12,Other,225% New York Medicaid APG,1112.56,,,1112.56,Other,153% New York Medicaid APG,1636.12,,,1636.12,Other,225% New York Medicaid APG,1018.03,,,1018.03,Other,140% New York Medicaid APG,1636.12,,,1636.12,Other,225% New York Medicaid APG,1890.63,,,1890.63,Other,260% New York Medicaid APG,2356.02,,,2356.02,Other,324% New York Medicaid APG,1563.41,,,1563.41,Other,215% New York Medicaid APG,1563.41,,,1563.41,Other,215% New York Medicaid APG,908.96,,,908.96,Other,125% New York Medicaid APG,368.35,25945.68,
Harvest cultured skin graft,15040,CPT,,,,,,,,both,,,38357.55,28384.59,74,,28384.59,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,17260.9,45,,17260.9,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,18986.99,49.5,,18986.99,percent of total billed charges,110% of Medicare,26083.13,68,,26083.13,percent of total billed charges,,2593.54,,,2593.54,Other,186% of Medicaid,30686.04,80,,30686.04,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,30686.04,80,,30686.04,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,26850.29,70,,26850.29,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1394.38,,,1394.38,Other,New York Medicaid APG methodology,1394.38,,,1394.38,Other,100% New York Medicaid APG,1394.38,,,1394.38,Other,100% New York Medicaid APG,1394.38,,,1394.38,Other,100% New York Medicaid APG,3137.35,,,3137.35,Other,225% New York Medicaid APG,2133.39,,,2133.39,Other,153% New York Medicaid APG,3137.35,,,3137.35,Other,225% New York Medicaid APG,1952.13,,,1952.13,Other,140% New York Medicaid APG,3137.35,,,3137.35,Other,225% New York Medicaid APG,3625.38,,,3625.38,Other,260% New York Medicaid APG,4517.78,,,4517.78,Other,324% New York Medicaid APG,2997.91,,,2997.91,Other,215% New York Medicaid APG,2997.91,,,2997.91,Other,215% New York Medicaid APG,1742.97,,,1742.97,Other,125% New York Medicaid APG,1394.38,30686.04,
Skin pinch graft,15050,CPT,,,,,,,,both,,,13210.22,9775.56,74,,9775.56,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,5944.6,45,,5944.6,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,6539.06,49.5,,6539.06,percent of total billed charges,110% of Medicare,8982.95,68,,8982.95,percent of total billed charges,,1240.83,,,1240.83,Other,186% of Medicaid,10568.18,80,,10568.18,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,10568.18,80,,10568.18,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,9247.15,70,,9247.15,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,667.11,,,667.11,Other,New York Medicaid APG methodology,667.11,,,667.11,Other,100% New York Medicaid APG,667.11,,,667.11,Other,100% New York Medicaid APG,667.11,,,667.11,Other,100% New York Medicaid APG,1501,,,1501,Other,225% New York Medicaid APG,1020.68,,,1020.68,Other,153% New York Medicaid APG,1501,,,1501,Other,225% New York Medicaid APG,933.96,,,933.96,Other,140% New York Medicaid APG,1501,,,1501,Other,225% New York Medicaid APG,1734.49,,,1734.49,Other,260% New York Medicaid APG,2161.44,,,2161.44,Other,324% New York Medicaid APG,1434.29,,,1434.29,Other,215% New York Medicaid APG,1434.29,,,1434.29,Other,215% New York Medicaid APG,833.89,,,833.89,Other,125% New York Medicaid APG,667.11,10568.18,
Skin splt grft trnk/arm/leg,15100,CPT,,,,,,,,both,,,44592.35,32998.34,74,,32998.34,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,20066.56,45,,20066.56,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,22073.21,49.5,,22073.21,percent of total billed charges,110% of Medicare,30322.8,68,,30322.8,percent of total billed charges,,2593.54,,,2593.54,Other,186% of Medicaid,35673.88,80,,35673.88,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,35673.88,80,,35673.88,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,31214.65,70,,31214.65,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1394.38,,,1394.38,Other,New York Medicaid APG methodology,1394.38,,,1394.38,Other,100% New York Medicaid APG,1394.38,,,1394.38,Other,100% New York Medicaid APG,1394.38,,,1394.38,Other,100% New York Medicaid APG,3137.35,,,3137.35,Other,225% New York Medicaid APG,2133.39,,,2133.39,Other,153% New York Medicaid APG,3137.35,,,3137.35,Other,225% New York Medicaid APG,1952.13,,,1952.13,Other,140% New York Medicaid APG,3137.35,,,3137.35,Other,225% New York Medicaid APG,3625.38,,,3625.38,Other,260% New York Medicaid APG,4517.78,,,4517.78,Other,324% New York Medicaid APG,2997.91,,,2997.91,Other,215% New York Medicaid APG,2997.91,,,2997.91,Other,215% New York Medicaid APG,1742.97,,,1742.97,Other,125% New York Medicaid APG,1394.38,35673.88,
Skin splt grft t/a/l add-on,15101,CPT,,,,,,,,both,,,64479.48,47714.82,74,,47714.82,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,29015.77,45,,29015.77,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,31917.34,49.5,,31917.34,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2593.54,,,2593.54,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,45135.64,70,,45135.64,percent of total billed charges,,539.56,,,539.56,Fee Schedule,,457.31,,,457.31,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,1394.38,,,1394.38,Other,New York Medicaid APG methodology,1394.38,,,1394.38,Other,100% New York Medicaid APG,1394.38,,,1394.38,Other,100% New York Medicaid APG,1394.38,,,1394.38,Other,100% New York Medicaid APG,3137.35,,,3137.35,Other,225% New York Medicaid APG,2133.39,,,2133.39,Other,153% New York Medicaid APG,3137.35,,,3137.35,Other,225% New York Medicaid APG,1952.13,,,1952.13,Other,140% New York Medicaid APG,3137.35,,,3137.35,Other,225% New York Medicaid APG,3625.38,,,3625.38,Other,260% New York Medicaid APG,4517.78,,,4517.78,Other,324% New York Medicaid APG,2997.91,,,2997.91,Other,215% New York Medicaid APG,2997.91,,,2997.91,Other,215% New York Medicaid APG,1742.97,,,1742.97,Other,125% New York Medicaid APG,457.31,47714.82,
Epidrm autogrft trnk/arm/leg,15110,CPT,,,,,,,,both,,,38357.55,28384.59,74,,28384.59,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,17260.9,45,,17260.9,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,18986.99,49.5,,18986.99,percent of total billed charges,110% of Medicare,26083.13,68,,26083.13,percent of total billed charges,,2593.54,,,2593.54,Other,186% of Medicaid,30686.04,80,,30686.04,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,30686.04,80,,30686.04,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,26850.29,70,,26850.29,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1394.38,,,1394.38,Other,New York Medicaid APG methodology,1394.38,,,1394.38,Other,100% New York Medicaid APG,1394.38,,,1394.38,Other,100% New York Medicaid APG,1394.38,,,1394.38,Other,100% New York Medicaid APG,3137.35,,,3137.35,Other,225% New York Medicaid APG,2133.39,,,2133.39,Other,153% New York Medicaid APG,3137.35,,,3137.35,Other,225% New York Medicaid APG,1952.13,,,1952.13,Other,140% New York Medicaid APG,3137.35,,,3137.35,Other,225% New York Medicaid APG,3625.38,,,3625.38,Other,260% New York Medicaid APG,4517.78,,,4517.78,Other,324% New York Medicaid APG,2997.91,,,2997.91,Other,215% New York Medicaid APG,2997.91,,,2997.91,Other,215% New York Medicaid APG,1742.97,,,1742.97,Other,125% New York Medicaid APG,1394.38,30686.04,
Epidrm autogrft t/a/l add-on,15111,CPT,,,,,,,,both,,,51572.04,38163.31,74,,38163.31,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,23207.42,45,,23207.42,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,25528.16,49.5,,25528.16,percent of total billed charges,110% of Medicare,35068.99,68,,35068.99,percent of total billed charges,,2593.54,,,2593.54,Other,186% of Medicaid,41257.63,80,,41257.63,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,41257.63,80,,41257.63,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,36100.43,70,,36100.43,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,1394.38,,,1394.38,Other,New York Medicaid APG methodology,1394.38,,,1394.38,Other,100% New York Medicaid APG,1394.38,,,1394.38,Other,100% New York Medicaid APG,1394.38,,,1394.38,Other,100% New York Medicaid APG,3137.35,,,3137.35,Other,225% New York Medicaid APG,2133.39,,,2133.39,Other,153% New York Medicaid APG,3137.35,,,3137.35,Other,225% New York Medicaid APG,1952.13,,,1952.13,Other,140% New York Medicaid APG,3137.35,,,3137.35,Other,225% New York Medicaid APG,3625.38,,,3625.38,Other,260% New York Medicaid APG,4517.78,,,4517.78,Other,324% New York Medicaid APG,2997.91,,,2997.91,Other,215% New York Medicaid APG,2997.91,,,2997.91,Other,215% New York Medicaid APG,1742.97,,,1742.97,Other,125% New York Medicaid APG,1394.38,41257.63,
Epidrm a-grft face/nck/hf/g,15115,CPT,,,,,,,,both,,,38357.55,28384.59,74,,28384.59,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,17260.9,45,,17260.9,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,18986.99,49.5,,18986.99,percent of total billed charges,110% of Medicare,26083.13,68,,26083.13,percent of total billed charges,,2593.54,,,2593.54,Other,186% of Medicaid,30686.04,80,,30686.04,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,30686.04,80,,30686.04,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,26850.29,70,,26850.29,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1394.38,,,1394.38,Other,New York Medicaid APG methodology,1394.38,,,1394.38,Other,100% New York Medicaid APG,1394.38,,,1394.38,Other,100% New York Medicaid APG,1394.38,,,1394.38,Other,100% New York Medicaid APG,3137.35,,,3137.35,Other,225% New York Medicaid APG,2133.39,,,2133.39,Other,153% New York Medicaid APG,3137.35,,,3137.35,Other,225% New York Medicaid APG,1952.13,,,1952.13,Other,140% New York Medicaid APG,3137.35,,,3137.35,Other,225% New York Medicaid APG,3625.38,,,3625.38,Other,260% New York Medicaid APG,4517.78,,,4517.78,Other,324% New York Medicaid APG,2997.91,,,2997.91,Other,215% New York Medicaid APG,2997.91,,,2997.91,Other,215% New York Medicaid APG,1742.97,,,1742.97,Other,125% New York Medicaid APG,1394.38,30686.04,
Epidrm a-grft f/n/hf/g addl,15116,CPT,,,,,,,,both,,,32432.1,23999.75,74,,23999.75,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,14594.45,45,,14594.45,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,16053.89,49.5,,16053.89,percent of total billed charges,110% of Medicare,22053.83,68,,22053.83,percent of total billed charges,,2593.54,,,2593.54,Other,186% of Medicaid,25945.68,80,,25945.68,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,25945.68,80,,25945.68,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,22702.47,70,,22702.47,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,1394.38,,,1394.38,Other,New York Medicaid APG methodology,1394.38,,,1394.38,Other,100% New York Medicaid APG,1394.38,,,1394.38,Other,100% New York Medicaid APG,1394.38,,,1394.38,Other,100% New York Medicaid APG,3137.35,,,3137.35,Other,225% New York Medicaid APG,2133.39,,,2133.39,Other,153% New York Medicaid APG,3137.35,,,3137.35,Other,225% New York Medicaid APG,1952.13,,,1952.13,Other,140% New York Medicaid APG,3137.35,,,3137.35,Other,225% New York Medicaid APG,3625.38,,,3625.38,Other,260% New York Medicaid APG,4517.78,,,4517.78,Other,324% New York Medicaid APG,2997.91,,,2997.91,Other,215% New York Medicaid APG,2997.91,,,2997.91,Other,215% New York Medicaid APG,1742.97,,,1742.97,Other,125% New York Medicaid APG,1394.38,25945.68,
Skn splt a-grft fac/nck/hf/g,15120,CPT,,,,,,,,both,,,43467.36,32165.85,74,,32165.85,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,19560.31,45,,19560.31,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,21516.34,49.5,,21516.34,percent of total billed charges,110% of Medicare,29557.8,68,,29557.8,percent of total billed charges,,2593.54,,,2593.54,Other,186% of Medicaid,34773.89,80,,34773.89,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,34773.89,80,,34773.89,percent of total billed charges,,7216,,,7216,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,30427.15,70,,30427.15,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1394.38,,,1394.38,Other,New York Medicaid APG methodology,1394.38,,,1394.38,Other,100% New York Medicaid APG,1394.38,,,1394.38,Other,100% New York Medicaid APG,1394.38,,,1394.38,Other,100% New York Medicaid APG,3137.35,,,3137.35,Other,225% New York Medicaid APG,2133.39,,,2133.39,Other,153% New York Medicaid APG,3137.35,,,3137.35,Other,225% New York Medicaid APG,1952.13,,,1952.13,Other,140% New York Medicaid APG,3137.35,,,3137.35,Other,225% New York Medicaid APG,3625.38,,,3625.38,Other,260% New York Medicaid APG,4517.78,,,4517.78,Other,324% New York Medicaid APG,2997.91,,,2997.91,Other,215% New York Medicaid APG,2997.91,,,2997.91,Other,215% New York Medicaid APG,1742.97,,,1742.97,Other,125% New York Medicaid APG,1394.38,34773.89,
Skn splt a-grft f/n/hf/g add,15121,CPT,,,,,,,,both,,,64479.48,47714.82,74,,47714.82,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,29015.77,45,,29015.77,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,31917.34,49.5,,31917.34,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2593.54,,,2593.54,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,45135.64,70,,45135.64,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,1394.38,,,1394.38,Other,New York Medicaid APG methodology,1394.38,,,1394.38,Other,100% New York Medicaid APG,1394.38,,,1394.38,Other,100% New York Medicaid APG,1394.38,,,1394.38,Other,100% New York Medicaid APG,3137.35,,,3137.35,Other,225% New York Medicaid APG,2133.39,,,2133.39,Other,153% New York Medicaid APG,3137.35,,,3137.35,Other,225% New York Medicaid APG,1952.13,,,1952.13,Other,140% New York Medicaid APG,3137.35,,,3137.35,Other,225% New York Medicaid APG,3625.38,,,3625.38,Other,260% New York Medicaid APG,4517.78,,,4517.78,Other,324% New York Medicaid APG,2997.91,,,2997.91,Other,215% New York Medicaid APG,2997.91,,,2997.91,Other,215% New York Medicaid APG,1742.97,,,1742.97,Other,125% New York Medicaid APG,1394.38,47714.82,
Derm autograft trnk/arm/leg,15130,CPT,,,,,,,,both,,,38357.55,28384.59,74,,28384.59,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,17260.9,45,,17260.9,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,18986.99,49.5,,18986.99,percent of total billed charges,110% of Medicare,26083.13,68,,26083.13,percent of total billed charges,,2593.54,,,2593.54,Other,186% of Medicaid,30686.04,80,,30686.04,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,30686.04,80,,30686.04,percent of total billed charges,,7216,,,7216,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,26850.29,70,,26850.29,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1394.38,,,1394.38,Other,New York Medicaid APG methodology,1394.38,,,1394.38,Other,100% New York Medicaid APG,1394.38,,,1394.38,Other,100% New York Medicaid APG,1394.38,,,1394.38,Other,100% New York Medicaid APG,3137.35,,,3137.35,Other,225% New York Medicaid APG,2133.39,,,2133.39,Other,153% New York Medicaid APG,3137.35,,,3137.35,Other,225% New York Medicaid APG,1952.13,,,1952.13,Other,140% New York Medicaid APG,3137.35,,,3137.35,Other,225% New York Medicaid APG,3625.38,,,3625.38,Other,260% New York Medicaid APG,4517.78,,,4517.78,Other,324% New York Medicaid APG,2997.91,,,2997.91,Other,215% New York Medicaid APG,2997.91,,,2997.91,Other,215% New York Medicaid APG,1742.97,,,1742.97,Other,125% New York Medicaid APG,1394.38,30686.04,
Derm autograft t/a/l add-on,15131,CPT,,,,,,,,both,,,32432.1,23999.75,74,,23999.75,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,14594.45,45,,14594.45,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,16053.89,49.5,,16053.89,percent of total billed charges,110% of Medicare,22053.83,68,,22053.83,percent of total billed charges,,2593.54,,,2593.54,Other,186% of Medicaid,25945.68,80,,25945.68,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,25945.68,80,,25945.68,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,22702.47,70,,22702.47,percent of total billed charges,,436.24,,,436.24,Fee Schedule,,369.74,,,369.74,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,1394.38,,,1394.38,Other,New York Medicaid APG methodology,1394.38,,,1394.38,Other,100% New York Medicaid APG,1394.38,,,1394.38,Other,100% New York Medicaid APG,1394.38,,,1394.38,Other,100% New York Medicaid APG,3137.35,,,3137.35,Other,225% New York Medicaid APG,2133.39,,,2133.39,Other,153% New York Medicaid APG,3137.35,,,3137.35,Other,225% New York Medicaid APG,1952.13,,,1952.13,Other,140% New York Medicaid APG,3137.35,,,3137.35,Other,225% New York Medicaid APG,3625.38,,,3625.38,Other,260% New York Medicaid APG,4517.78,,,4517.78,Other,324% New York Medicaid APG,2997.91,,,2997.91,Other,215% New York Medicaid APG,2997.91,,,2997.91,Other,215% New York Medicaid APG,1742.97,,,1742.97,Other,125% New York Medicaid APG,369.74,25945.68,
Derm autograft face/nck/hf/g,15135,CPT,,,,,,,,both,,,75461.18,55841.27,74,,55841.27,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,33957.53,45,,33957.53,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,37353.28,49.5,,37353.28,percent of total billed charges,110% of Medicare,51313.6,68,,51313.6,percent of total billed charges,,2593.54,,,2593.54,Other,186% of Medicaid,60368.94,80,,60368.94,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,60368.94,80,,60368.94,percent of total billed charges,,7216,,,7216,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,52822.83,70,,52822.83,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1394.38,,,1394.38,Other,New York Medicaid APG methodology,1394.38,,,1394.38,Other,100% New York Medicaid APG,1394.38,,,1394.38,Other,100% New York Medicaid APG,1394.38,,,1394.38,Other,100% New York Medicaid APG,3137.35,,,3137.35,Other,225% New York Medicaid APG,2133.39,,,2133.39,Other,153% New York Medicaid APG,3137.35,,,3137.35,Other,225% New York Medicaid APG,1952.13,,,1952.13,Other,140% New York Medicaid APG,3137.35,,,3137.35,Other,225% New York Medicaid APG,3625.38,,,3625.38,Other,260% New York Medicaid APG,4517.78,,,4517.78,Other,324% New York Medicaid APG,2997.91,,,2997.91,Other,215% New York Medicaid APG,2997.91,,,2997.91,Other,215% New York Medicaid APG,1742.97,,,1742.97,Other,125% New York Medicaid APG,1394.38,60368.94,
Derm autograft f/n/hf/g add,15136,CPT,,,,,,,,both,,,32432.1,23999.75,74,,23999.75,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,14594.45,45,,14594.45,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,16053.89,49.5,,16053.89,percent of total billed charges,110% of Medicare,22053.83,68,,22053.83,percent of total billed charges,,2593.54,,,2593.54,Other,186% of Medicaid,25945.68,80,,25945.68,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,25945.68,80,,25945.68,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,22702.47,70,,22702.47,percent of total billed charges,,436.24,,,436.24,Fee Schedule,,369.74,,,369.74,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,1394.38,,,1394.38,Other,New York Medicaid APG methodology,1394.38,,,1394.38,Other,100% New York Medicaid APG,1394.38,,,1394.38,Other,100% New York Medicaid APG,1394.38,,,1394.38,Other,100% New York Medicaid APG,3137.35,,,3137.35,Other,225% New York Medicaid APG,2133.39,,,2133.39,Other,153% New York Medicaid APG,3137.35,,,3137.35,Other,225% New York Medicaid APG,1952.13,,,1952.13,Other,140% New York Medicaid APG,3137.35,,,3137.35,Other,225% New York Medicaid APG,3625.38,,,3625.38,Other,260% New York Medicaid APG,4517.78,,,4517.78,Other,324% New York Medicaid APG,2997.91,,,2997.91,Other,215% New York Medicaid APG,2997.91,,,2997.91,Other,215% New York Medicaid APG,1742.97,,,1742.97,Other,125% New York Medicaid APG,369.74,25945.68,
Cult skin grft t/arm/leg,15150,CPT,,,,,,,,both,,,38357.55,28384.59,74,,28384.59,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,17260.9,45,,17260.9,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,18986.99,49.5,,18986.99,percent of total billed charges,110% of Medicare,26083.13,68,,26083.13,percent of total billed charges,,2593.54,,,2593.54,Other,186% of Medicaid,30686.04,80,,30686.04,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,30686.04,80,,30686.04,percent of total billed charges,,7216,,,7216,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,26850.29,70,,26850.29,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1394.38,,,1394.38,Other,New York Medicaid APG methodology,1394.38,,,1394.38,Other,100% New York Medicaid APG,1394.38,,,1394.38,Other,100% New York Medicaid APG,1394.38,,,1394.38,Other,100% New York Medicaid APG,3137.35,,,3137.35,Other,225% New York Medicaid APG,2133.39,,,2133.39,Other,153% New York Medicaid APG,3137.35,,,3137.35,Other,225% New York Medicaid APG,1952.13,,,1952.13,Other,140% New York Medicaid APG,3137.35,,,3137.35,Other,225% New York Medicaid APG,3625.38,,,3625.38,Other,260% New York Medicaid APG,4517.78,,,4517.78,Other,324% New York Medicaid APG,2997.91,,,2997.91,Other,215% New York Medicaid APG,2997.91,,,2997.91,Other,215% New York Medicaid APG,1742.97,,,1742.97,Other,125% New York Medicaid APG,1394.38,30686.04,
Cult skin grft t/a/l addl,15151,CPT,,,,,,,,both,,,32432.1,23999.75,74,,23999.75,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,14594.45,45,,14594.45,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,16053.89,49.5,,16053.89,percent of total billed charges,110% of Medicare,22053.83,68,,22053.83,percent of total billed charges,,2593.54,,,2593.54,Other,186% of Medicaid,25945.68,80,,25945.68,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,25945.68,80,,25945.68,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,22702.47,70,,22702.47,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,1394.38,,,1394.38,Other,New York Medicaid APG methodology,1394.38,,,1394.38,Other,100% New York Medicaid APG,1394.38,,,1394.38,Other,100% New York Medicaid APG,1394.38,,,1394.38,Other,100% New York Medicaid APG,3137.35,,,3137.35,Other,225% New York Medicaid APG,2133.39,,,2133.39,Other,153% New York Medicaid APG,3137.35,,,3137.35,Other,225% New York Medicaid APG,1952.13,,,1952.13,Other,140% New York Medicaid APG,3137.35,,,3137.35,Other,225% New York Medicaid APG,3625.38,,,3625.38,Other,260% New York Medicaid APG,4517.78,,,4517.78,Other,324% New York Medicaid APG,2997.91,,,2997.91,Other,215% New York Medicaid APG,2997.91,,,2997.91,Other,215% New York Medicaid APG,1742.97,,,1742.97,Other,125% New York Medicaid APG,1394.38,25945.68,
Cult skin graft t/a/l +%,15152,CPT,,,,,,,,both,,,32432.1,23999.75,74,,23999.75,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,14594.45,45,,14594.45,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,16053.89,49.5,,16053.89,percent of total billed charges,110% of Medicare,22053.83,68,,22053.83,percent of total billed charges,,2593.54,,,2593.54,Other,186% of Medicaid,25945.68,80,,25945.68,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,25945.68,80,,25945.68,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,22702.47,70,,22702.47,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,1394.38,,,1394.38,Other,New York Medicaid APG methodology,1394.38,,,1394.38,Other,100% New York Medicaid APG,1394.38,,,1394.38,Other,100% New York Medicaid APG,1394.38,,,1394.38,Other,100% New York Medicaid APG,3137.35,,,3137.35,Other,225% New York Medicaid APG,2133.39,,,2133.39,Other,153% New York Medicaid APG,3137.35,,,3137.35,Other,225% New York Medicaid APG,1952.13,,,1952.13,Other,140% New York Medicaid APG,3137.35,,,3137.35,Other,225% New York Medicaid APG,3625.38,,,3625.38,Other,260% New York Medicaid APG,4517.78,,,4517.78,Other,324% New York Medicaid APG,2997.91,,,2997.91,Other,215% New York Medicaid APG,2997.91,,,2997.91,Other,215% New York Medicaid APG,1742.97,,,1742.97,Other,125% New York Medicaid APG,1394.38,25945.68,
Cult skin graft f/n/hf/g,15155,CPT,,,,,,,,both,,,75461.18,55841.27,74,,55841.27,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,33957.53,45,,33957.53,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,37353.28,49.5,,37353.28,percent of total billed charges,110% of Medicare,51313.6,68,,51313.6,percent of total billed charges,,2593.54,,,2593.54,Other,186% of Medicaid,60368.94,80,,60368.94,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,60368.94,80,,60368.94,percent of total billed charges,,7216,,,7216,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,52822.83,70,,52822.83,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1394.38,,,1394.38,Other,New York Medicaid APG methodology,1394.38,,,1394.38,Other,100% New York Medicaid APG,1394.38,,,1394.38,Other,100% New York Medicaid APG,1394.38,,,1394.38,Other,100% New York Medicaid APG,3137.35,,,3137.35,Other,225% New York Medicaid APG,2133.39,,,2133.39,Other,153% New York Medicaid APG,3137.35,,,3137.35,Other,225% New York Medicaid APG,1952.13,,,1952.13,Other,140% New York Medicaid APG,3137.35,,,3137.35,Other,225% New York Medicaid APG,3625.38,,,3625.38,Other,260% New York Medicaid APG,4517.78,,,4517.78,Other,324% New York Medicaid APG,2997.91,,,2997.91,Other,215% New York Medicaid APG,2997.91,,,2997.91,Other,215% New York Medicaid APG,1742.97,,,1742.97,Other,125% New York Medicaid APG,1394.38,60368.94,
Cult skin grft f/n/hfg add,15156,CPT,,,,,,,,both,,,32432.1,23999.75,74,,23999.75,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,14594.45,45,,14594.45,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,16053.89,49.5,,16053.89,percent of total billed charges,110% of Medicare,22053.83,68,,22053.83,percent of total billed charges,,2593.54,,,2593.54,Other,186% of Medicaid,25945.68,80,,25945.68,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,25945.68,80,,25945.68,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,22702.47,70,,22702.47,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,1394.38,,,1394.38,Other,New York Medicaid APG methodology,1394.38,,,1394.38,Other,100% New York Medicaid APG,1394.38,,,1394.38,Other,100% New York Medicaid APG,1394.38,,,1394.38,Other,100% New York Medicaid APG,3137.35,,,3137.35,Other,225% New York Medicaid APG,2133.39,,,2133.39,Other,153% New York Medicaid APG,3137.35,,,3137.35,Other,225% New York Medicaid APG,1952.13,,,1952.13,Other,140% New York Medicaid APG,3137.35,,,3137.35,Other,225% New York Medicaid APG,3625.38,,,3625.38,Other,260% New York Medicaid APG,4517.78,,,4517.78,Other,324% New York Medicaid APG,2997.91,,,2997.91,Other,215% New York Medicaid APG,2997.91,,,2997.91,Other,215% New York Medicaid APG,1742.97,,,1742.97,Other,125% New York Medicaid APG,1394.38,25945.68,
Cult epiderm grft f/n/hfg +%,15157,CPT,,,,,,,,both,,,32432.1,23999.75,74,,23999.75,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,14594.45,45,,14594.45,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,16053.89,49.5,,16053.89,percent of total billed charges,110% of Medicare,22053.83,68,,22053.83,percent of total billed charges,,2593.54,,,2593.54,Other,186% of Medicaid,25945.68,80,,25945.68,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,25945.68,80,,25945.68,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,22702.47,70,,22702.47,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,1394.38,,,1394.38,Other,New York Medicaid APG methodology,1394.38,,,1394.38,Other,100% New York Medicaid APG,1394.38,,,1394.38,Other,100% New York Medicaid APG,1394.38,,,1394.38,Other,100% New York Medicaid APG,3137.35,,,3137.35,Other,225% New York Medicaid APG,2133.39,,,2133.39,Other,153% New York Medicaid APG,3137.35,,,3137.35,Other,225% New York Medicaid APG,1952.13,,,1952.13,Other,140% New York Medicaid APG,3137.35,,,3137.35,Other,225% New York Medicaid APG,3625.38,,,3625.38,Other,260% New York Medicaid APG,4517.78,,,4517.78,Other,324% New York Medicaid APG,2997.91,,,2997.91,Other,215% New York Medicaid APG,2997.91,,,2997.91,Other,215% New York Medicaid APG,1742.97,,,1742.97,Other,125% New York Medicaid APG,1394.38,25945.68,
Skin full graft trunk,15200,CPT,,,,,,,,both,,,38357.55,28384.59,74,,28384.59,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,17260.9,45,,17260.9,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,18986.99,49.5,,18986.99,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2593.54,,,2593.54,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,26850.29,70,,26850.29,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1394.38,,,1394.38,Other,New York Medicaid APG methodology,1394.38,,,1394.38,Other,100% New York Medicaid APG,1394.38,,,1394.38,Other,100% New York Medicaid APG,1394.38,,,1394.38,Other,100% New York Medicaid APG,3137.35,,,3137.35,Other,225% New York Medicaid APG,2133.39,,,2133.39,Other,153% New York Medicaid APG,3137.35,,,3137.35,Other,225% New York Medicaid APG,1952.13,,,1952.13,Other,140% New York Medicaid APG,3137.35,,,3137.35,Other,225% New York Medicaid APG,3625.38,,,3625.38,Other,260% New York Medicaid APG,4517.78,,,4517.78,Other,324% New York Medicaid APG,2997.91,,,2997.91,Other,215% New York Medicaid APG,2997.91,,,2997.91,Other,215% New York Medicaid APG,1742.97,,,1742.97,Other,125% New York Medicaid APG,1394.38,28384.59,
Skin full graft trunk add-on,15201,CPT,,,,,,,,both,,,51572.04,38163.31,74,,38163.31,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,23207.42,45,,23207.42,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,25528.16,49.5,,25528.16,percent of total billed charges,110% of Medicare,35068.99,68,,35068.99,percent of total billed charges,,2593.54,,,2593.54,Other,186% of Medicaid,41257.63,80,,41257.63,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,41257.63,80,,41257.63,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,36100.43,70,,36100.43,percent of total billed charges,,372.28,,,372.28,Fee Schedule,,315.53,,,315.53,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,1394.38,,,1394.38,Other,New York Medicaid APG methodology,1394.38,,,1394.38,Other,100% New York Medicaid APG,1394.38,,,1394.38,Other,100% New York Medicaid APG,1394.38,,,1394.38,Other,100% New York Medicaid APG,3137.35,,,3137.35,Other,225% New York Medicaid APG,2133.39,,,2133.39,Other,153% New York Medicaid APG,3137.35,,,3137.35,Other,225% New York Medicaid APG,1952.13,,,1952.13,Other,140% New York Medicaid APG,3137.35,,,3137.35,Other,225% New York Medicaid APG,3625.38,,,3625.38,Other,260% New York Medicaid APG,4517.78,,,4517.78,Other,324% New York Medicaid APG,2997.91,,,2997.91,Other,215% New York Medicaid APG,2997.91,,,2997.91,Other,215% New York Medicaid APG,1742.97,,,1742.97,Other,125% New York Medicaid APG,315.53,41257.63,
Skin full graft sclp/arm/leg,15220,CPT,,,,,,,,both,,,38357.55,28384.59,74,,28384.59,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,17260.9,45,,17260.9,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,18986.99,49.5,,18986.99,percent of total billed charges,110% of Medicare,26083.13,68,,26083.13,percent of total billed charges,,2593.54,,,2593.54,Other,186% of Medicaid,30686.04,80,,30686.04,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,30686.04,80,,30686.04,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,26850.29,70,,26850.29,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1394.38,,,1394.38,Other,New York Medicaid APG methodology,1394.38,,,1394.38,Other,100% New York Medicaid APG,1394.38,,,1394.38,Other,100% New York Medicaid APG,1394.38,,,1394.38,Other,100% New York Medicaid APG,3137.35,,,3137.35,Other,225% New York Medicaid APG,2133.39,,,2133.39,Other,153% New York Medicaid APG,3137.35,,,3137.35,Other,225% New York Medicaid APG,1952.13,,,1952.13,Other,140% New York Medicaid APG,3137.35,,,3137.35,Other,225% New York Medicaid APG,3625.38,,,3625.38,Other,260% New York Medicaid APG,4517.78,,,4517.78,Other,324% New York Medicaid APG,2997.91,,,2997.91,Other,215% New York Medicaid APG,2997.91,,,2997.91,Other,215% New York Medicaid APG,1742.97,,,1742.97,Other,125% New York Medicaid APG,1394.38,30686.04,
Skin full graft add-on,15221,CPT,,,,,,,,both,,,51572.04,38163.31,74,,38163.31,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,23207.42,45,,23207.42,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,25528.16,49.5,,25528.16,percent of total billed charges,110% of Medicare,35068.99,68,,35068.99,percent of total billed charges,,2593.54,,,2593.54,Other,186% of Medicaid,41257.63,80,,41257.63,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,41257.63,80,,41257.63,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,36100.43,70,,36100.43,percent of total billed charges,,334.56,,,334.56,Fee Schedule,,283.56,,,283.56,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,1394.38,,,1394.38,Other,New York Medicaid APG methodology,1394.38,,,1394.38,Other,100% New York Medicaid APG,1394.38,,,1394.38,Other,100% New York Medicaid APG,1394.38,,,1394.38,Other,100% New York Medicaid APG,3137.35,,,3137.35,Other,225% New York Medicaid APG,2133.39,,,2133.39,Other,153% New York Medicaid APG,3137.35,,,3137.35,Other,225% New York Medicaid APG,1952.13,,,1952.13,Other,140% New York Medicaid APG,3137.35,,,3137.35,Other,225% New York Medicaid APG,3625.38,,,3625.38,Other,260% New York Medicaid APG,4517.78,,,4517.78,Other,324% New York Medicaid APG,2997.91,,,2997.91,Other,215% New York Medicaid APG,2997.91,,,2997.91,Other,215% New York Medicaid APG,1742.97,,,1742.97,Other,125% New York Medicaid APG,283.56,41257.63,
Skin full grft face/genit/hf,15240,CPT,,,,,,,,both,,,35564.94,26318.06,74,,26318.06,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,16004.22,45,,16004.22,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,17604.65,49.5,,17604.65,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2593.54,,,2593.54,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,24895.46,70,,24895.46,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1394.38,,,1394.38,Other,New York Medicaid APG methodology,1394.38,,,1394.38,Other,100% New York Medicaid APG,1394.38,,,1394.38,Other,100% New York Medicaid APG,1394.38,,,1394.38,Other,100% New York Medicaid APG,3137.35,,,3137.35,Other,225% New York Medicaid APG,2133.39,,,2133.39,Other,153% New York Medicaid APG,3137.35,,,3137.35,Other,225% New York Medicaid APG,1952.13,,,1952.13,Other,140% New York Medicaid APG,3137.35,,,3137.35,Other,225% New York Medicaid APG,3625.38,,,3625.38,Other,260% New York Medicaid APG,4517.78,,,4517.78,Other,324% New York Medicaid APG,2997.91,,,2997.91,Other,215% New York Medicaid APG,2997.91,,,2997.91,Other,215% New York Medicaid APG,1742.97,,,1742.97,Other,125% New York Medicaid APG,1394.38,26318.06,
Skin full graft add-on,15241,CPT,,,,,,,,both,,,64479.48,47714.82,74,,47714.82,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,29015.77,45,,29015.77,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,31917.34,49.5,,31917.34,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2593.54,,,2593.54,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,45135.64,70,,45135.64,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,1394.38,,,1394.38,Other,New York Medicaid APG methodology,1394.38,,,1394.38,Other,100% New York Medicaid APG,1394.38,,,1394.38,Other,100% New York Medicaid APG,1394.38,,,1394.38,Other,100% New York Medicaid APG,3137.35,,,3137.35,Other,225% New York Medicaid APG,2133.39,,,2133.39,Other,153% New York Medicaid APG,3137.35,,,3137.35,Other,225% New York Medicaid APG,1952.13,,,1952.13,Other,140% New York Medicaid APG,3137.35,,,3137.35,Other,225% New York Medicaid APG,3625.38,,,3625.38,Other,260% New York Medicaid APG,4517.78,,,4517.78,Other,324% New York Medicaid APG,2997.91,,,2997.91,Other,215% New York Medicaid APG,2997.91,,,2997.91,Other,215% New York Medicaid APG,1742.97,,,1742.97,Other,125% New York Medicaid APG,1394.38,47714.82,
Skin full graft een & lips,15260,CPT,,,,,,,,both,,,36243.1,26819.89,74,,26819.89,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,16309.4,45,,16309.4,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,17940.33,49.5,,17940.33,percent of total billed charges,110% of Medicare,24645.31,68,,24645.31,percent of total billed charges,,2593.54,,,2593.54,Other,186% of Medicaid,28994.48,80,,28994.48,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,28994.48,80,,28994.48,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,25370.17,70,,25370.17,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1394.38,,,1394.38,Other,New York Medicaid APG methodology,1394.38,,,1394.38,Other,100% New York Medicaid APG,1394.38,,,1394.38,Other,100% New York Medicaid APG,1394.38,,,1394.38,Other,100% New York Medicaid APG,3137.35,,,3137.35,Other,225% New York Medicaid APG,2133.39,,,2133.39,Other,153% New York Medicaid APG,3137.35,,,3137.35,Other,225% New York Medicaid APG,1952.13,,,1952.13,Other,140% New York Medicaid APG,3137.35,,,3137.35,Other,225% New York Medicaid APG,3625.38,,,3625.38,Other,260% New York Medicaid APG,4517.78,,,4517.78,Other,324% New York Medicaid APG,2997.91,,,2997.91,Other,215% New York Medicaid APG,2997.91,,,2997.91,Other,215% New York Medicaid APG,1742.97,,,1742.97,Other,125% New York Medicaid APG,1394.38,28994.48,
Skin full graft add-on,15261,CPT,,,,,,,,both,,,51572.04,38163.31,74,,38163.31,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,23207.42,45,,23207.42,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,25528.16,49.5,,25528.16,percent of total billed charges,110% of Medicare,35068.99,68,,35068.99,percent of total billed charges,,2593.54,,,2593.54,Other,186% of Medicaid,41257.63,80,,41257.63,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,41257.63,80,,41257.63,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,36100.43,70,,36100.43,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,1394.38,,,1394.38,Other,New York Medicaid APG methodology,1394.38,,,1394.38,Other,100% New York Medicaid APG,1394.38,,,1394.38,Other,100% New York Medicaid APG,1394.38,,,1394.38,Other,100% New York Medicaid APG,3137.35,,,3137.35,Other,225% New York Medicaid APG,2133.39,,,2133.39,Other,153% New York Medicaid APG,3137.35,,,3137.35,Other,225% New York Medicaid APG,1952.13,,,1952.13,Other,140% New York Medicaid APG,3137.35,,,3137.35,Other,225% New York Medicaid APG,3625.38,,,3625.38,Other,260% New York Medicaid APG,4517.78,,,4517.78,Other,324% New York Medicaid APG,2997.91,,,2997.91,Other,215% New York Medicaid APG,2997.91,,,2997.91,Other,215% New York Medicaid APG,1742.97,,,1742.97,Other,125% New York Medicaid APG,1394.38,41257.63,
Skin sub graft trnk/arm/leg,15271,CPT,,,,,,,,both,,,48047.99,35555.51,74,,35555.51,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,21621.6,45,,21621.6,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,23783.76,49.5,,23783.76,percent of total billed charges,110% of Medicare,32672.63,68,,32672.63,percent of total billed charges,,2593.54,,,2593.54,Other,186% of Medicaid,38438.39,80,,38438.39,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,38438.39,80,,38438.39,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,33633.59,70,,33633.59,percent of total billed charges,,405.08,,,405.08,Fee Schedule,,343.33,,,343.33,Fee Schedule,,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1394.38,,,1394.38,Other,New York Medicaid APG methodology,1394.38,,,1394.38,Other,100% New York Medicaid APG,1394.38,,,1394.38,Other,100% New York Medicaid APG,1394.38,,,1394.38,Other,100% New York Medicaid APG,3137.35,,,3137.35,Other,225% New York Medicaid APG,2133.39,,,2133.39,Other,153% New York Medicaid APG,3137.35,,,3137.35,Other,225% New York Medicaid APG,1952.13,,,1952.13,Other,140% New York Medicaid APG,3137.35,,,3137.35,Other,225% New York Medicaid APG,3625.38,,,3625.38,Other,260% New York Medicaid APG,4517.78,,,4517.78,Other,324% New York Medicaid APG,2997.91,,,2997.91,Other,215% New York Medicaid APG,2997.91,,,2997.91,Other,215% New York Medicaid APG,1742.97,,,1742.97,Other,125% New York Medicaid APG,343.33,38438.39,
Skin sub graft t/a/l add-on,15272,CPT,,,,,,,,both,,,32432.1,23999.75,74,,23999.75,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,14594.45,45,,14594.45,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,16053.89,49.5,,16053.89,percent of total billed charges,110% of Medicare,22053.83,68,,22053.83,percent of total billed charges,,2593.54,,,2593.54,Other,186% of Medicaid,25945.68,80,,25945.68,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,25945.68,80,,25945.68,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,22702.47,70,,22702.47,percent of total billed charges,,80.36,,,80.36,Fee Schedule,,68.11,,,68.11,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,1394.38,,,1394.38,Other,New York Medicaid APG methodology,1394.38,,,1394.38,Other,100% New York Medicaid APG,1394.38,,,1394.38,Other,100% New York Medicaid APG,1394.38,,,1394.38,Other,100% New York Medicaid APG,3137.35,,,3137.35,Other,225% New York Medicaid APG,2133.39,,,2133.39,Other,153% New York Medicaid APG,3137.35,,,3137.35,Other,225% New York Medicaid APG,1952.13,,,1952.13,Other,140% New York Medicaid APG,3137.35,,,3137.35,Other,225% New York Medicaid APG,3625.38,,,3625.38,Other,260% New York Medicaid APG,4517.78,,,4517.78,Other,324% New York Medicaid APG,2997.91,,,2997.91,Other,215% New York Medicaid APG,2997.91,,,2997.91,Other,215% New York Medicaid APG,1742.97,,,1742.97,Other,125% New York Medicaid APG,68.11,25945.68,
Skin sub grft t/arm/lg child,15273,CPT,,,,,,,,both,,,76185.34,56377.15,74,,56377.15,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,34283.4,45,,34283.4,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,37711.74,49.5,,37711.74,percent of total billed charges,110% of Medicare,51806.03,68,,51806.03,percent of total billed charges,,2593.54,,,2593.54,Other,186% of Medicaid,60948.27,80,,60948.27,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,60948.27,80,,60948.27,percent of total billed charges,,7216,,,7216,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,53329.74,70,,53329.74,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1394.38,,,1394.38,Other,New York Medicaid APG methodology,1394.38,,,1394.38,Other,100% New York Medicaid APG,1394.38,,,1394.38,Other,100% New York Medicaid APG,1394.38,,,1394.38,Other,100% New York Medicaid APG,3137.35,,,3137.35,Other,225% New York Medicaid APG,2133.39,,,2133.39,Other,153% New York Medicaid APG,3137.35,,,3137.35,Other,225% New York Medicaid APG,1952.13,,,1952.13,Other,140% New York Medicaid APG,3137.35,,,3137.35,Other,225% New York Medicaid APG,3625.38,,,3625.38,Other,260% New York Medicaid APG,4517.78,,,4517.78,Other,324% New York Medicaid APG,2997.91,,,2997.91,Other,215% New York Medicaid APG,2997.91,,,2997.91,Other,215% New York Medicaid APG,1742.97,,,1742.97,Other,125% New York Medicaid APG,1394.38,60948.27,
Skn sub grft t/a/l child add,15274,CPT,,,,,,,,both,,,32432.1,23999.75,74,,23999.75,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,14594.45,45,,14594.45,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,16053.89,49.5,,16053.89,percent of total billed charges,110% of Medicare,22053.83,68,,22053.83,percent of total billed charges,,2593.54,,,2593.54,Other,186% of Medicaid,25945.68,80,,25945.68,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,25945.68,80,,25945.68,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,22702.47,70,,22702.47,percent of total billed charges,,218.12,,,218.12,Fee Schedule,,184.87,,,184.87,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,1394.38,,,1394.38,Other,New York Medicaid APG methodology,1394.38,,,1394.38,Other,100% New York Medicaid APG,1394.38,,,1394.38,Other,100% New York Medicaid APG,1394.38,,,1394.38,Other,100% New York Medicaid APG,3137.35,,,3137.35,Other,225% New York Medicaid APG,2133.39,,,2133.39,Other,153% New York Medicaid APG,3137.35,,,3137.35,Other,225% New York Medicaid APG,1952.13,,,1952.13,Other,140% New York Medicaid APG,3137.35,,,3137.35,Other,225% New York Medicaid APG,3625.38,,,3625.38,Other,260% New York Medicaid APG,4517.78,,,4517.78,Other,324% New York Medicaid APG,2997.91,,,2997.91,Other,215% New York Medicaid APG,2997.91,,,2997.91,Other,215% New York Medicaid APG,1742.97,,,1742.97,Other,125% New York Medicaid APG,184.87,25945.68,
Skin sub graft face/nk/hf/g,15275,CPT,,,,,,,,both,,,45432.24,33619.86,74,,33619.86,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,20444.51,45,,20444.51,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,22488.96,49.5,,22488.96,percent of total billed charges,110% of Medicare,30893.92,68,,30893.92,percent of total billed charges,,2593.54,,,2593.54,Other,186% of Medicaid,36345.79,80,,36345.79,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,36345.79,80,,36345.79,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,31802.57,70,,31802.57,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1394.38,,,1394.38,Other,New York Medicaid APG methodology,1394.38,,,1394.38,Other,100% New York Medicaid APG,1394.38,,,1394.38,Other,100% New York Medicaid APG,1394.38,,,1394.38,Other,100% New York Medicaid APG,3137.35,,,3137.35,Other,225% New York Medicaid APG,2133.39,,,2133.39,Other,153% New York Medicaid APG,3137.35,,,3137.35,Other,225% New York Medicaid APG,1952.13,,,1952.13,Other,140% New York Medicaid APG,3137.35,,,3137.35,Other,225% New York Medicaid APG,3625.38,,,3625.38,Other,260% New York Medicaid APG,4517.78,,,4517.78,Other,324% New York Medicaid APG,2997.91,,,2997.91,Other,215% New York Medicaid APG,2997.91,,,2997.91,Other,215% New York Medicaid APG,1742.97,,,1742.97,Other,125% New York Medicaid APG,1394.38,36345.79,
Skin sub graft f/n/hf/g addl,15276,CPT,,,,,,,,both,,,32432.1,23999.75,74,,23999.75,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,14594.45,45,,14594.45,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,16053.89,49.5,,16053.89,percent of total billed charges,110% of Medicare,22053.83,68,,22053.83,percent of total billed charges,,2593.54,,,2593.54,Other,186% of Medicaid,25945.68,80,,25945.68,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,25945.68,80,,25945.68,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,22702.47,70,,22702.47,percent of total billed charges,,121.36,,,121.36,Fee Schedule,,102.86,,,102.86,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,1394.38,,,1394.38,Other,New York Medicaid APG methodology,1394.38,,,1394.38,Other,100% New York Medicaid APG,1394.38,,,1394.38,Other,100% New York Medicaid APG,1394.38,,,1394.38,Other,100% New York Medicaid APG,3137.35,,,3137.35,Other,225% New York Medicaid APG,2133.39,,,2133.39,Other,153% New York Medicaid APG,3137.35,,,3137.35,Other,225% New York Medicaid APG,1952.13,,,1952.13,Other,140% New York Medicaid APG,3137.35,,,3137.35,Other,225% New York Medicaid APG,3625.38,,,3625.38,Other,260% New York Medicaid APG,4517.78,,,4517.78,Other,324% New York Medicaid APG,2997.91,,,2997.91,Other,215% New York Medicaid APG,2997.91,,,2997.91,Other,215% New York Medicaid APG,1742.97,,,1742.97,Other,125% New York Medicaid APG,102.86,25945.68,
Skn sub grft f/n/hf/g child,15277,CPT,,,,,,,,both,,,68206.6,50472.88,74,,50472.88,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30692.97,45,,30692.97,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,33762.27,49.5,,33762.27,percent of total billed charges,110% of Medicare,46380.49,68,,46380.49,percent of total billed charges,,2593.54,,,2593.54,Other,186% of Medicaid,54565.28,80,,54565.28,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,54565.28,80,,54565.28,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,47744.62,70,,47744.62,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1394.38,,,1394.38,Other,New York Medicaid APG methodology,1394.38,,,1394.38,Other,100% New York Medicaid APG,1394.38,,,1394.38,Other,100% New York Medicaid APG,1394.38,,,1394.38,Other,100% New York Medicaid APG,3137.35,,,3137.35,Other,225% New York Medicaid APG,2133.39,,,2133.39,Other,153% New York Medicaid APG,3137.35,,,3137.35,Other,225% New York Medicaid APG,1952.13,,,1952.13,Other,140% New York Medicaid APG,3137.35,,,3137.35,Other,225% New York Medicaid APG,3625.38,,,3625.38,Other,260% New York Medicaid APG,4517.78,,,4517.78,Other,324% New York Medicaid APG,2997.91,,,2997.91,Other,215% New York Medicaid APG,2997.91,,,2997.91,Other,215% New York Medicaid APG,1742.97,,,1742.97,Other,125% New York Medicaid APG,1394.38,54565.28,
Skn sub grft f/n/hf/g ch add,15278,CPT,,,,,,,,both,,,32432.1,23999.75,74,,23999.75,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,14594.45,45,,14594.45,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,16053.89,49.5,,16053.89,percent of total billed charges,110% of Medicare,22053.83,68,,22053.83,percent of total billed charges,,2593.54,,,2593.54,Other,186% of Medicaid,25945.68,80,,25945.68,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,25945.68,80,,25945.68,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,22702.47,70,,22702.47,percent of total billed charges,,270.6,,,270.6,Fee Schedule,,229.35,,,229.35,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,1394.38,,,1394.38,Other,New York Medicaid APG methodology,1394.38,,,1394.38,Other,100% New York Medicaid APG,1394.38,,,1394.38,Other,100% New York Medicaid APG,1394.38,,,1394.38,Other,100% New York Medicaid APG,3137.35,,,3137.35,Other,225% New York Medicaid APG,2133.39,,,2133.39,Other,153% New York Medicaid APG,3137.35,,,3137.35,Other,225% New York Medicaid APG,1952.13,,,1952.13,Other,140% New York Medicaid APG,3137.35,,,3137.35,Other,225% New York Medicaid APG,3625.38,,,3625.38,Other,260% New York Medicaid APG,4517.78,,,4517.78,Other,324% New York Medicaid APG,2997.91,,,2997.91,Other,215% New York Medicaid APG,2997.91,,,2997.91,Other,215% New York Medicaid APG,1742.97,,,1742.97,Other,125% New York Medicaid APG,229.35,25945.68,
Skin pedicle flap trunk,15570,CPT,,,,,,,,both,,,38357.55,28384.59,74,,28384.59,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,17260.9,45,,17260.9,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,18986.99,49.5,,18986.99,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2593.54,,,2593.54,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,26850.29,70,,26850.29,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1394.38,,,1394.38,Other,New York Medicaid APG methodology,1394.38,,,1394.38,Other,100% New York Medicaid APG,1394.38,,,1394.38,Other,100% New York Medicaid APG,1394.38,,,1394.38,Other,100% New York Medicaid APG,3137.35,,,3137.35,Other,225% New York Medicaid APG,2133.39,,,2133.39,Other,153% New York Medicaid APG,3137.35,,,3137.35,Other,225% New York Medicaid APG,1952.13,,,1952.13,Other,140% New York Medicaid APG,3137.35,,,3137.35,Other,225% New York Medicaid APG,3625.38,,,3625.38,Other,260% New York Medicaid APG,4517.78,,,4517.78,Other,324% New York Medicaid APG,2997.91,,,2997.91,Other,215% New York Medicaid APG,2997.91,,,2997.91,Other,215% New York Medicaid APG,1742.97,,,1742.97,Other,125% New York Medicaid APG,1394.38,28384.59,
Skin pedicle flap arms/legs,15572,CPT,,,,,,,,both,,,75461.18,55841.27,74,,55841.27,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,33957.53,45,,33957.53,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,37353.28,49.5,,37353.28,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2593.54,,,2593.54,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,52822.83,70,,52822.83,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1394.38,,,1394.38,Other,New York Medicaid APG methodology,1394.38,,,1394.38,Other,100% New York Medicaid APG,1394.38,,,1394.38,Other,100% New York Medicaid APG,1394.38,,,1394.38,Other,100% New York Medicaid APG,3137.35,,,3137.35,Other,225% New York Medicaid APG,2133.39,,,2133.39,Other,153% New York Medicaid APG,3137.35,,,3137.35,Other,225% New York Medicaid APG,1952.13,,,1952.13,Other,140% New York Medicaid APG,3137.35,,,3137.35,Other,225% New York Medicaid APG,3625.38,,,3625.38,Other,260% New York Medicaid APG,4517.78,,,4517.78,Other,324% New York Medicaid APG,2997.91,,,2997.91,Other,215% New York Medicaid APG,2997.91,,,2997.91,Other,215% New York Medicaid APG,1742.97,,,1742.97,Other,125% New York Medicaid APG,1394.38,55841.27,
Pedcle fh/ch/ch/m/n/ax/g/h/f,15574,CPT,,,,,,,,both,,,38357.55,28384.59,74,,28384.59,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,17260.9,45,,17260.9,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,18986.99,49.5,,18986.99,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2593.54,,,2593.54,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,26850.29,70,,26850.29,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1394.38,,,1394.38,Other,New York Medicaid APG methodology,1394.38,,,1394.38,Other,100% New York Medicaid APG,1394.38,,,1394.38,Other,100% New York Medicaid APG,1394.38,,,1394.38,Other,100% New York Medicaid APG,3137.35,,,3137.35,Other,225% New York Medicaid APG,2133.39,,,2133.39,Other,153% New York Medicaid APG,3137.35,,,3137.35,Other,225% New York Medicaid APG,1952.13,,,1952.13,Other,140% New York Medicaid APG,3137.35,,,3137.35,Other,225% New York Medicaid APG,3625.38,,,3625.38,Other,260% New York Medicaid APG,4517.78,,,4517.78,Other,324% New York Medicaid APG,2997.91,,,2997.91,Other,215% New York Medicaid APG,2997.91,,,2997.91,Other,215% New York Medicaid APG,1742.97,,,1742.97,Other,125% New York Medicaid APG,1394.38,28384.59,
Pedicle e/n/e/l/ntroral,15576,CPT,,,,,,,,both,,,38357.55,28384.59,74,,28384.59,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,17260.9,45,,17260.9,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,18986.99,49.5,,18986.99,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2593.54,,,2593.54,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,26850.29,70,,26850.29,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1394.38,,,1394.38,Other,New York Medicaid APG methodology,1394.38,,,1394.38,Other,100% New York Medicaid APG,1394.38,,,1394.38,Other,100% New York Medicaid APG,1394.38,,,1394.38,Other,100% New York Medicaid APG,3137.35,,,3137.35,Other,225% New York Medicaid APG,2133.39,,,2133.39,Other,153% New York Medicaid APG,3137.35,,,3137.35,Other,225% New York Medicaid APG,1952.13,,,1952.13,Other,140% New York Medicaid APG,3137.35,,,3137.35,Other,225% New York Medicaid APG,3625.38,,,3625.38,Other,260% New York Medicaid APG,4517.78,,,4517.78,Other,324% New York Medicaid APG,2997.91,,,2997.91,Other,215% New York Medicaid APG,2997.91,,,2997.91,Other,215% New York Medicaid APG,1742.97,,,1742.97,Other,125% New York Medicaid APG,1394.38,28384.59,
Delay flap trunk,15600,CPT,,,,,,,,both,,,75461.18,55841.27,74,,55841.27,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,33957.53,45,,33957.53,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,37353.28,49.5,,37353.28,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2593.54,,,2593.54,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,52822.83,70,,52822.83,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1394.38,,,1394.38,Other,New York Medicaid APG methodology,1394.38,,,1394.38,Other,100% New York Medicaid APG,1394.38,,,1394.38,Other,100% New York Medicaid APG,1394.38,,,1394.38,Other,100% New York Medicaid APG,3137.35,,,3137.35,Other,225% New York Medicaid APG,2133.39,,,2133.39,Other,153% New York Medicaid APG,3137.35,,,3137.35,Other,225% New York Medicaid APG,1952.13,,,1952.13,Other,140% New York Medicaid APG,3137.35,,,3137.35,Other,225% New York Medicaid APG,3625.38,,,3625.38,Other,260% New York Medicaid APG,4517.78,,,4517.78,Other,324% New York Medicaid APG,2997.91,,,2997.91,Other,215% New York Medicaid APG,2997.91,,,2997.91,Other,215% New York Medicaid APG,1742.97,,,1742.97,Other,125% New York Medicaid APG,1394.38,55841.27,
Delay flap arms/legs,15610,CPT,,,,,,,,both,,,38357.55,28384.59,74,,28384.59,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,17260.9,45,,17260.9,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,18986.99,49.5,,18986.99,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2593.54,,,2593.54,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,26850.29,70,,26850.29,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1394.38,,,1394.38,Other,New York Medicaid APG methodology,1394.38,,,1394.38,Other,100% New York Medicaid APG,1394.38,,,1394.38,Other,100% New York Medicaid APG,1394.38,,,1394.38,Other,100% New York Medicaid APG,3137.35,,,3137.35,Other,225% New York Medicaid APG,2133.39,,,2133.39,Other,153% New York Medicaid APG,3137.35,,,3137.35,Other,225% New York Medicaid APG,1952.13,,,1952.13,Other,140% New York Medicaid APG,3137.35,,,3137.35,Other,225% New York Medicaid APG,3625.38,,,3625.38,Other,260% New York Medicaid APG,4517.78,,,4517.78,Other,324% New York Medicaid APG,2997.91,,,2997.91,Other,215% New York Medicaid APG,2997.91,,,2997.91,Other,215% New York Medicaid APG,1742.97,,,1742.97,Other,125% New York Medicaid APG,1394.38,28384.59,
Delay flap f/c/c/n/ax/g/h/f,15620,CPT,,,,,,,,both,,,38357.55,28384.59,74,,28384.59,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,17260.9,45,,17260.9,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,18986.99,49.5,,18986.99,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2593.54,,,2593.54,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,26850.29,70,,26850.29,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1394.38,,,1394.38,Other,New York Medicaid APG methodology,1394.38,,,1394.38,Other,100% New York Medicaid APG,1394.38,,,1394.38,Other,100% New York Medicaid APG,1394.38,,,1394.38,Other,100% New York Medicaid APG,3137.35,,,3137.35,Other,225% New York Medicaid APG,2133.39,,,2133.39,Other,153% New York Medicaid APG,3137.35,,,3137.35,Other,225% New York Medicaid APG,1952.13,,,1952.13,Other,140% New York Medicaid APG,3137.35,,,3137.35,Other,225% New York Medicaid APG,3625.38,,,3625.38,Other,260% New York Medicaid APG,4517.78,,,4517.78,Other,324% New York Medicaid APG,2997.91,,,2997.91,Other,215% New York Medicaid APG,2997.91,,,2997.91,Other,215% New York Medicaid APG,1742.97,,,1742.97,Other,125% New York Medicaid APG,1394.38,28384.59,
Delay flap eye/nos/ear/lip,15630,CPT,,,,,,,,both,,,35844.47,26524.91,74,,26524.91,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,16130.01,45,,16130.01,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,17743.01,49.5,,17743.01,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2593.54,,,2593.54,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,25091.13,70,,25091.13,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1394.38,,,1394.38,Other,New York Medicaid APG methodology,1394.38,,,1394.38,Other,100% New York Medicaid APG,1394.38,,,1394.38,Other,100% New York Medicaid APG,1394.38,,,1394.38,Other,100% New York Medicaid APG,3137.35,,,3137.35,Other,225% New York Medicaid APG,2133.39,,,2133.39,Other,153% New York Medicaid APG,3137.35,,,3137.35,Other,225% New York Medicaid APG,1952.13,,,1952.13,Other,140% New York Medicaid APG,3137.35,,,3137.35,Other,225% New York Medicaid APG,3625.38,,,3625.38,Other,260% New York Medicaid APG,4517.78,,,4517.78,Other,324% New York Medicaid APG,2997.91,,,2997.91,Other,215% New York Medicaid APG,2997.91,,,2997.91,Other,215% New York Medicaid APG,1742.97,,,1742.97,Other,125% New York Medicaid APG,1394.38,26524.91,
Transfer skin pedicle flap,15650,CPT,,,,,,,,both,,,38357.55,28384.59,74,,28384.59,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,17260.9,45,,17260.9,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,18986.99,49.5,,18986.99,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2593.54,,,2593.54,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,26850.29,70,,26850.29,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1394.38,,,1394.38,Other,New York Medicaid APG methodology,1394.38,,,1394.38,Other,100% New York Medicaid APG,1394.38,,,1394.38,Other,100% New York Medicaid APG,1394.38,,,1394.38,Other,100% New York Medicaid APG,3137.35,,,3137.35,Other,225% New York Medicaid APG,2133.39,,,2133.39,Other,153% New York Medicaid APG,3137.35,,,3137.35,Other,225% New York Medicaid APG,1952.13,,,1952.13,Other,140% New York Medicaid APG,3137.35,,,3137.35,Other,225% New York Medicaid APG,3625.38,,,3625.38,Other,260% New York Medicaid APG,4517.78,,,4517.78,Other,324% New York Medicaid APG,2997.91,,,2997.91,Other,215% New York Medicaid APG,2997.91,,,2997.91,Other,215% New York Medicaid APG,1742.97,,,1742.97,Other,125% New York Medicaid APG,1394.38,28384.59,
Mdfc flap w/prsrv vasc pedcl,15730,CPT,,,,,,,,both,,,75461.18,55841.27,74,,55841.27,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,33957.53,45,,33957.53,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,37353.28,49.5,,37353.28,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2593.54,,,2593.54,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,52822.83,70,,52822.83,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1394.38,,,1394.38,Other,New York Medicaid APG methodology,1394.38,,,1394.38,Other,100% New York Medicaid APG,1394.38,,,1394.38,Other,100% New York Medicaid APG,1394.38,,,1394.38,Other,100% New York Medicaid APG,3137.35,,,3137.35,Other,225% New York Medicaid APG,2133.39,,,2133.39,Other,153% New York Medicaid APG,3137.35,,,3137.35,Other,225% New York Medicaid APG,1952.13,,,1952.13,Other,140% New York Medicaid APG,3137.35,,,3137.35,Other,225% New York Medicaid APG,3625.38,,,3625.38,Other,260% New York Medicaid APG,4517.78,,,4517.78,Other,324% New York Medicaid APG,2997.91,,,2997.91,Other,215% New York Medicaid APG,2997.91,,,2997.91,Other,215% New York Medicaid APG,1742.97,,,1742.97,Other,125% New York Medicaid APG,1394.38,55841.27,
Forehead flap w/vasc pedicle,15731,CPT,,,,,,,,both,,,37166,27502.84,74,,27502.84,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,16724.7,45,,16724.7,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,18397.17,49.5,,18397.17,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2593.54,,,2593.54,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,26016.2,70,,26016.2,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1394.38,,,1394.38,Other,New York Medicaid APG methodology,1394.38,,,1394.38,Other,100% New York Medicaid APG,1394.38,,,1394.38,Other,100% New York Medicaid APG,1394.38,,,1394.38,Other,100% New York Medicaid APG,3137.35,,,3137.35,Other,225% New York Medicaid APG,2133.39,,,2133.39,Other,153% New York Medicaid APG,3137.35,,,3137.35,Other,225% New York Medicaid APG,1952.13,,,1952.13,Other,140% New York Medicaid APG,3137.35,,,3137.35,Other,225% New York Medicaid APG,3625.38,,,3625.38,Other,260% New York Medicaid APG,4517.78,,,4517.78,Other,324% New York Medicaid APG,2997.91,,,2997.91,Other,215% New York Medicaid APG,2997.91,,,2997.91,Other,215% New York Medicaid APG,1742.97,,,1742.97,Other,125% New York Medicaid APG,1394.38,27502.84,
Musc myoq/fscq flp h&n pedcl,15733,CPT,,,,,,,,both,,,114832.81,84976.28,74,,84976.28,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,51674.76,45,,51674.76,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,56842.24,49.5,,56842.24,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2593.54,,,2593.54,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,80382.97,70,,80382.97,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1394.38,,,1394.38,Other,New York Medicaid APG methodology,1394.38,,,1394.38,Other,100% New York Medicaid APG,1394.38,,,1394.38,Other,100% New York Medicaid APG,1394.38,,,1394.38,Other,100% New York Medicaid APG,3137.35,,,3137.35,Other,225% New York Medicaid APG,2133.39,,,2133.39,Other,153% New York Medicaid APG,3137.35,,,3137.35,Other,225% New York Medicaid APG,1952.13,,,1952.13,Other,140% New York Medicaid APG,3137.35,,,3137.35,Other,225% New York Medicaid APG,3625.38,,,3625.38,Other,260% New York Medicaid APG,4517.78,,,4517.78,Other,324% New York Medicaid APG,2997.91,,,2997.91,Other,215% New York Medicaid APG,2997.91,,,2997.91,Other,215% New York Medicaid APG,1742.97,,,1742.97,Other,125% New York Medicaid APG,1394.38,84976.28,
Muscle-skin graft trunk,15734,CPT,,,,,,,,both,,,41979.88,31065.11,74,,31065.11,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,18890.95,45,,18890.95,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,20780.04,49.5,,20780.04,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2593.54,,,2593.54,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,29385.92,70,,29385.92,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1394.38,,,1394.38,Other,New York Medicaid APG methodology,1394.38,,,1394.38,Other,100% New York Medicaid APG,1394.38,,,1394.38,Other,100% New York Medicaid APG,1394.38,,,1394.38,Other,100% New York Medicaid APG,3137.35,,,3137.35,Other,225% New York Medicaid APG,2133.39,,,2133.39,Other,153% New York Medicaid APG,3137.35,,,3137.35,Other,225% New York Medicaid APG,1952.13,,,1952.13,Other,140% New York Medicaid APG,3137.35,,,3137.35,Other,225% New York Medicaid APG,3625.38,,,3625.38,Other,260% New York Medicaid APG,4517.78,,,4517.78,Other,324% New York Medicaid APG,2997.91,,,2997.91,Other,215% New York Medicaid APG,2997.91,,,2997.91,Other,215% New York Medicaid APG,1742.97,,,1742.97,Other,125% New York Medicaid APG,1394.38,31065.11,
Muscle-skin graft arm,15736,CPT,,,,,,,,both,,,38357.55,28384.59,74,,28384.59,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,17260.9,45,,17260.9,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,18986.99,49.5,,18986.99,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2593.54,,,2593.54,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,26850.29,70,,26850.29,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1394.38,,,1394.38,Other,New York Medicaid APG methodology,1394.38,,,1394.38,Other,100% New York Medicaid APG,1394.38,,,1394.38,Other,100% New York Medicaid APG,1394.38,,,1394.38,Other,100% New York Medicaid APG,3137.35,,,3137.35,Other,225% New York Medicaid APG,2133.39,,,2133.39,Other,153% New York Medicaid APG,3137.35,,,3137.35,Other,225% New York Medicaid APG,1952.13,,,1952.13,Other,140% New York Medicaid APG,3137.35,,,3137.35,Other,225% New York Medicaid APG,3625.38,,,3625.38,Other,260% New York Medicaid APG,4517.78,,,4517.78,Other,324% New York Medicaid APG,2997.91,,,2997.91,Other,215% New York Medicaid APG,2997.91,,,2997.91,Other,215% New York Medicaid APG,1742.97,,,1742.97,Other,125% New York Medicaid APG,1394.38,28384.59,
Muscle-skin graft leg,15738,CPT,,,,,,,,both,,,75461.18,55841.27,74,,55841.27,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,33957.53,45,,33957.53,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,37353.28,49.5,,37353.28,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2593.54,,,2593.54,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,52822.83,70,,52822.83,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1394.38,,,1394.38,Other,New York Medicaid APG methodology,1394.38,,,1394.38,Other,100% New York Medicaid APG,1394.38,,,1394.38,Other,100% New York Medicaid APG,1394.38,,,1394.38,Other,100% New York Medicaid APG,3137.35,,,3137.35,Other,225% New York Medicaid APG,2133.39,,,2133.39,Other,153% New York Medicaid APG,3137.35,,,3137.35,Other,225% New York Medicaid APG,1952.13,,,1952.13,Other,140% New York Medicaid APG,3137.35,,,3137.35,Other,225% New York Medicaid APG,3625.38,,,3625.38,Other,260% New York Medicaid APG,4517.78,,,4517.78,Other,324% New York Medicaid APG,2997.91,,,2997.91,Other,215% New York Medicaid APG,2997.91,,,2997.91,Other,215% New York Medicaid APG,1742.97,,,1742.97,Other,125% New York Medicaid APG,1394.38,55841.27,
Island pedicle flap graft,15740,CPT,,,,,,,,both,,,38357.55,28384.59,74,,28384.59,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,17260.9,45,,17260.9,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,18986.99,49.5,,18986.99,percent of total billed charges,110% of Medicare,26083.13,68,,26083.13,percent of total billed charges,,2593.54,,,2593.54,Other,186% of Medicaid,30686.04,80,,30686.04,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,30686.04,80,,30686.04,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,26850.29,70,,26850.29,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1394.38,,,1394.38,Other,New York Medicaid APG methodology,1394.38,,,1394.38,Other,100% New York Medicaid APG,1394.38,,,1394.38,Other,100% New York Medicaid APG,1394.38,,,1394.38,Other,100% New York Medicaid APG,3137.35,,,3137.35,Other,225% New York Medicaid APG,2133.39,,,2133.39,Other,153% New York Medicaid APG,3137.35,,,3137.35,Other,225% New York Medicaid APG,1952.13,,,1952.13,Other,140% New York Medicaid APG,3137.35,,,3137.35,Other,225% New York Medicaid APG,3625.38,,,3625.38,Other,260% New York Medicaid APG,4517.78,,,4517.78,Other,324% New York Medicaid APG,2997.91,,,2997.91,Other,215% New York Medicaid APG,2997.91,,,2997.91,Other,215% New York Medicaid APG,1742.97,,,1742.97,Other,125% New York Medicaid APG,1394.38,30686.04,
Neurovascular pedicle flap,15750,CPT,,,,,,,,both,,,75461.18,55841.27,74,,55841.27,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,33957.53,45,,33957.53,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,37353.28,49.5,,37353.28,percent of total billed charges,110% of Medicare,51313.6,68,,51313.6,percent of total billed charges,,2593.54,,,2593.54,Other,186% of Medicaid,60368.94,80,,60368.94,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,60368.94,80,,60368.94,percent of total billed charges,,7216,,,7216,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,52822.83,70,,52822.83,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1394.38,,,1394.38,Other,New York Medicaid APG methodology,1394.38,,,1394.38,Other,100% New York Medicaid APG,1394.38,,,1394.38,Other,100% New York Medicaid APG,1394.38,,,1394.38,Other,100% New York Medicaid APG,3137.35,,,3137.35,Other,225% New York Medicaid APG,2133.39,,,2133.39,Other,153% New York Medicaid APG,3137.35,,,3137.35,Other,225% New York Medicaid APG,1952.13,,,1952.13,Other,140% New York Medicaid APG,3137.35,,,3137.35,Other,225% New York Medicaid APG,3625.38,,,3625.38,Other,260% New York Medicaid APG,4517.78,,,4517.78,Other,324% New York Medicaid APG,2997.91,,,2997.91,Other,215% New York Medicaid APG,2997.91,,,2997.91,Other,215% New York Medicaid APG,1742.97,,,1742.97,Other,125% New York Medicaid APG,1394.38,60368.94,
Composite skin graft,15760,CPT,,,,,,,,both,,,38357.55,28384.59,74,,28384.59,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,17260.9,45,,17260.9,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,18986.99,49.5,,18986.99,percent of total billed charges,110% of Medicare,26083.13,68,,26083.13,percent of total billed charges,,2593.54,,,2593.54,Other,186% of Medicaid,30686.04,80,,30686.04,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,30686.04,80,,30686.04,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,26850.29,70,,26850.29,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1394.38,,,1394.38,Other,New York Medicaid APG methodology,1394.38,,,1394.38,Other,100% New York Medicaid APG,1394.38,,,1394.38,Other,100% New York Medicaid APG,1394.38,,,1394.38,Other,100% New York Medicaid APG,3137.35,,,3137.35,Other,225% New York Medicaid APG,2133.39,,,2133.39,Other,153% New York Medicaid APG,3137.35,,,3137.35,Other,225% New York Medicaid APG,1952.13,,,1952.13,Other,140% New York Medicaid APG,3137.35,,,3137.35,Other,225% New York Medicaid APG,3625.38,,,3625.38,Other,260% New York Medicaid APG,4517.78,,,4517.78,Other,324% New York Medicaid APG,2997.91,,,2997.91,Other,215% New York Medicaid APG,2997.91,,,2997.91,Other,215% New York Medicaid APG,1742.97,,,1742.97,Other,125% New York Medicaid APG,1394.38,30686.04,
Grfg autol soft tiss dir exc,15769,CPT,,,,,,,,both,,,75461.18,55841.27,74,,55841.27,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,33957.53,45,,33957.53,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,37353.28,49.5,,37353.28,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2593.54,,,2593.54,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,52822.83,70,,52822.83,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1394.38,,,1394.38,Other,New York Medicaid APG methodology,1394.38,,,1394.38,Other,100% New York Medicaid APG,1394.38,,,1394.38,Other,100% New York Medicaid APG,1394.38,,,1394.38,Other,100% New York Medicaid APG,3137.35,,,3137.35,Other,225% New York Medicaid APG,2133.39,,,2133.39,Other,153% New York Medicaid APG,3137.35,,,3137.35,Other,225% New York Medicaid APG,1952.13,,,1952.13,Other,140% New York Medicaid APG,3137.35,,,3137.35,Other,225% New York Medicaid APG,3625.38,,,3625.38,Other,260% New York Medicaid APG,4517.78,,,4517.78,Other,324% New York Medicaid APG,2997.91,,,2997.91,Other,215% New York Medicaid APG,2997.91,,,2997.91,Other,215% New York Medicaid APG,1742.97,,,1742.97,Other,125% New York Medicaid APG,1394.38,55841.27,
Derma-fat-fascia graft,15770,CPT,,,,,,,,both,,,75461.18,55841.27,74,,55841.27,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,33957.53,45,,33957.53,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,37353.28,49.5,,37353.28,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2593.54,,,2593.54,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,52822.83,70,,52822.83,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1394.38,,,1394.38,Other,New York Medicaid APG methodology,1394.38,,,1394.38,Other,100% New York Medicaid APG,1394.38,,,1394.38,Other,100% New York Medicaid APG,1394.38,,,1394.38,Other,100% New York Medicaid APG,3137.35,,,3137.35,Other,225% New York Medicaid APG,2133.39,,,2133.39,Other,153% New York Medicaid APG,3137.35,,,3137.35,Other,225% New York Medicaid APG,1952.13,,,1952.13,Other,140% New York Medicaid APG,3137.35,,,3137.35,Other,225% New York Medicaid APG,3625.38,,,3625.38,Other,260% New York Medicaid APG,4517.78,,,4517.78,Other,324% New York Medicaid APG,2997.91,,,2997.91,Other,215% New York Medicaid APG,2997.91,,,2997.91,Other,215% New York Medicaid APG,1742.97,,,1742.97,Other,125% New York Medicaid APG,1394.38,55841.27,
Grfg autol fat lipo 50 cc/<,15771,CPT,,,,,,,,both,,,37767.03,27947.6,74,,27947.6,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,16995.16,45,,16995.16,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,18694.68,49.5,,18694.68,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2593.54,,,2593.54,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,26436.92,70,,26436.92,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1394.38,,,1394.38,Other,New York Medicaid APG methodology,1394.38,,,1394.38,Other,100% New York Medicaid APG,1394.38,,,1394.38,Other,100% New York Medicaid APG,1394.38,,,1394.38,Other,100% New York Medicaid APG,3137.35,,,3137.35,Other,225% New York Medicaid APG,2133.39,,,2133.39,Other,153% New York Medicaid APG,3137.35,,,3137.35,Other,225% New York Medicaid APG,1952.13,,,1952.13,Other,140% New York Medicaid APG,3137.35,,,3137.35,Other,225% New York Medicaid APG,3625.38,,,3625.38,Other,260% New York Medicaid APG,4517.78,,,4517.78,Other,324% New York Medicaid APG,2997.91,,,2997.91,Other,215% New York Medicaid APG,2997.91,,,2997.91,Other,215% New York Medicaid APG,1742.97,,,1742.97,Other,125% New York Medicaid APG,1394.38,27947.6,
Grfg autol fat lipo 25 cc/<,15773,CPT,,,,,,,,both,,,36802.85,27234.11,74,,27234.11,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,16561.28,45,,16561.28,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,18217.41,49.5,,18217.41,percent of total billed charges,110% of Medicare,25025.94,68,,25025.94,percent of total billed charges,,2593.54,,,2593.54,Other,186% of Medicaid,29442.28,80,,29442.28,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,29442.28,80,,29442.28,percent of total billed charges,,7216,,,7216,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,25762,70,,25762,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1394.38,,,1394.38,Other,New York Medicaid APG methodology,1394.38,,,1394.38,Other,100% New York Medicaid APG,1394.38,,,1394.38,Other,100% New York Medicaid APG,1394.38,,,1394.38,Other,100% New York Medicaid APG,3137.35,,,3137.35,Other,225% New York Medicaid APG,2133.39,,,2133.39,Other,153% New York Medicaid APG,3137.35,,,3137.35,Other,225% New York Medicaid APG,1952.13,,,1952.13,Other,140% New York Medicaid APG,3137.35,,,3137.35,Other,225% New York Medicaid APG,3625.38,,,3625.38,Other,260% New York Medicaid APG,4517.78,,,4517.78,Other,324% New York Medicaid APG,2997.91,,,2997.91,Other,215% New York Medicaid APG,2997.91,,,2997.91,Other,215% New York Medicaid APG,1742.97,,,1742.97,Other,125% New York Medicaid APG,1394.38,29442.28,
Hair trnspl 1-15 punch grfts,15775,CPT,,,,,,,,both,,,8387.08,6206.44,74,,6206.44,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,3774.19,45,,3774.19,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,4151.6,49.5,,4151.6,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,1240.83,,,1240.83,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,5870.96,70,,5870.96,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,667.11,,,667.11,Other,New York Medicaid APG methodology,667.11,,,667.11,Other,100% New York Medicaid APG,667.11,,,667.11,Other,100% New York Medicaid APG,667.11,,,667.11,Other,100% New York Medicaid APG,1501,,,1501,Other,225% New York Medicaid APG,1020.68,,,1020.68,Other,153% New York Medicaid APG,1501,,,1501,Other,225% New York Medicaid APG,933.96,,,933.96,Other,140% New York Medicaid APG,1501,,,1501,Other,225% New York Medicaid APG,1734.49,,,1734.49,Other,260% New York Medicaid APG,2161.44,,,2161.44,Other,324% New York Medicaid APG,1434.29,,,1434.29,Other,215% New York Medicaid APG,1434.29,,,1434.29,Other,215% New York Medicaid APG,833.89,,,833.89,Other,125% New York Medicaid APG,667.11,9473,
Hair trnspl >15 punch grafts,15776,CPT,,,,,,,,both,,,8387.08,6206.44,74,,6206.44,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,3774.19,45,,3774.19,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,4151.6,49.5,,4151.6,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,1240.83,,,1240.83,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,5870.96,70,,5870.96,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,667.11,,,667.11,Other,New York Medicaid APG methodology,667.11,,,667.11,Other,100% New York Medicaid APG,667.11,,,667.11,Other,100% New York Medicaid APG,667.11,,,667.11,Other,100% New York Medicaid APG,1501,,,1501,Other,225% New York Medicaid APG,1020.68,,,1020.68,Other,153% New York Medicaid APG,1501,,,1501,Other,225% New York Medicaid APG,933.96,,,933.96,Other,140% New York Medicaid APG,1501,,,1501,Other,225% New York Medicaid APG,1734.49,,,1734.49,Other,260% New York Medicaid APG,2161.44,,,2161.44,Other,324% New York Medicaid APG,1434.29,,,1434.29,Other,215% New York Medicaid APG,1434.29,,,1434.29,Other,215% New York Medicaid APG,833.89,,,833.89,Other,125% New York Medicaid APG,667.11,9473,
Acellular derm matrix implt,15777,CPT,,,,,,,,both,,,51572.04,38163.31,74,,38163.31,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,23207.42,45,,23207.42,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,25528.16,49.5,,25528.16,percent of total billed charges,110% of Medicare,35068.99,68,,35068.99,percent of total billed charges,,2593.54,,,2593.54,Other,186% of Medicaid,41257.63,80,,41257.63,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,41257.63,80,,41257.63,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,36100.43,70,,36100.43,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,1394.38,,,1394.38,Other,New York Medicaid APG methodology,1394.38,,,1394.38,Other,100% New York Medicaid APG,1394.38,,,1394.38,Other,100% New York Medicaid APG,1394.38,,,1394.38,Other,100% New York Medicaid APG,3137.35,,,3137.35,Other,225% New York Medicaid APG,2133.39,,,2133.39,Other,153% New York Medicaid APG,3137.35,,,3137.35,Other,225% New York Medicaid APG,1952.13,,,1952.13,Other,140% New York Medicaid APG,3137.35,,,3137.35,Other,225% New York Medicaid APG,3625.38,,,3625.38,Other,260% New York Medicaid APG,4517.78,,,4517.78,Other,324% New York Medicaid APG,2997.91,,,2997.91,Other,215% New York Medicaid APG,2997.91,,,2997.91,Other,215% New York Medicaid APG,1742.97,,,1742.97,Other,125% New York Medicaid APG,1394.38,41257.63,
Dermabrasion total face,15780,CPT,,,,,,,,both,,,59767.2,44227.73,74,,44227.73,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,26895.24,45,,26895.24,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,29584.76,49.5,,29584.76,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,1207.1,,,1207.1,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,41837.04,70,,41837.04,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,648.98,,,648.98,Other,New York Medicaid APG methodology,648.98,,,648.98,Other,100% New York Medicaid APG,648.98,,,648.98,Other,100% New York Medicaid APG,648.98,,,648.98,Other,100% New York Medicaid APG,1460.2,,,1460.2,Other,225% New York Medicaid APG,992.94,,,992.94,Other,153% New York Medicaid APG,1460.2,,,1460.2,Other,225% New York Medicaid APG,908.57,,,908.57,Other,140% New York Medicaid APG,1460.2,,,1460.2,Other,225% New York Medicaid APG,1687.34,,,1687.34,Other,260% New York Medicaid APG,2102.69,,,2102.69,Other,324% New York Medicaid APG,1395.3,,,1395.3,Other,215% New York Medicaid APG,1395.3,,,1395.3,Other,215% New York Medicaid APG,811.22,,,811.22,Other,125% New York Medicaid APG,648.98,44227.73,
Dermabrasion segmental face,15781,CPT,,,,,,,,both,,,14798.8,10951.11,74,,10951.11,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,6659.46,45,,6659.46,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,7325.41,49.5,,7325.41,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,1207.1,,,1207.1,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,3578,,"100% primary, 0% secondary procedures",3578,Other,MagnaCare ASC Grouper,10359.16,70,,10359.16,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,648.98,,,648.98,Other,New York Medicaid APG methodology,648.98,,,648.98,Other,100% New York Medicaid APG,648.98,,,648.98,Other,100% New York Medicaid APG,648.98,,,648.98,Other,100% New York Medicaid APG,1460.2,,,1460.2,Other,225% New York Medicaid APG,992.94,,,992.94,Other,153% New York Medicaid APG,1460.2,,,1460.2,Other,225% New York Medicaid APG,908.57,,,908.57,Other,140% New York Medicaid APG,1460.2,,,1460.2,Other,225% New York Medicaid APG,1687.34,,,1687.34,Other,260% New York Medicaid APG,2102.69,,,2102.69,Other,324% New York Medicaid APG,1395.3,,,1395.3,Other,215% New York Medicaid APG,1395.3,,,1395.3,Other,215% New York Medicaid APG,811.22,,,811.22,Other,125% New York Medicaid APG,648.98,10951.11,
Dermabrasion other than face,15782,CPT,,,,,,,,both,,,59767.2,44227.73,74,,44227.73,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,26895.24,45,,26895.24,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,29584.76,49.5,,29584.76,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,1207.1,,,1207.1,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,3578,,"100% primary, 0% secondary procedures",3578,Other,MagnaCare ASC Grouper,41837.04,70,,41837.04,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,648.98,,,648.98,Other,New York Medicaid APG methodology,648.98,,,648.98,Other,100% New York Medicaid APG,648.98,,,648.98,Other,100% New York Medicaid APG,648.98,,,648.98,Other,100% New York Medicaid APG,1460.2,,,1460.2,Other,225% New York Medicaid APG,992.94,,,992.94,Other,153% New York Medicaid APG,1460.2,,,1460.2,Other,225% New York Medicaid APG,908.57,,,908.57,Other,140% New York Medicaid APG,1460.2,,,1460.2,Other,225% New York Medicaid APG,1687.34,,,1687.34,Other,260% New York Medicaid APG,2102.69,,,2102.69,Other,324% New York Medicaid APG,1395.3,,,1395.3,Other,215% New York Medicaid APG,1395.3,,,1395.3,Other,215% New York Medicaid APG,811.22,,,811.22,Other,125% New York Medicaid APG,648.98,44227.73,
Dermabrasion suprfl any site,15783,CPT,,,,,,,,both,,,8387.08,6206.44,74,,6206.44,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,3774.19,45,,3774.19,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,4151.6,49.5,,4151.6,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,1207.1,,,1207.1,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,5870.96,70,,5870.96,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,648.98,,,648.98,Other,New York Medicaid APG methodology,648.98,,,648.98,Other,100% New York Medicaid APG,648.98,,,648.98,Other,100% New York Medicaid APG,648.98,,,648.98,Other,100% New York Medicaid APG,1460.2,,,1460.2,Other,225% New York Medicaid APG,992.94,,,992.94,Other,153% New York Medicaid APG,1460.2,,,1460.2,Other,225% New York Medicaid APG,908.57,,,908.57,Other,140% New York Medicaid APG,1460.2,,,1460.2,Other,225% New York Medicaid APG,1687.34,,,1687.34,Other,260% New York Medicaid APG,2102.69,,,2102.69,Other,324% New York Medicaid APG,1395.3,,,1395.3,Other,215% New York Medicaid APG,1395.3,,,1395.3,Other,215% New York Medicaid APG,811.22,,,811.22,Other,125% New York Medicaid APG,648.98,9473,
Abrasion lesion single,15786,CPT,,,,,,,,both,,,4210.98,3116.13,74,,3116.13,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,1894.94,45,,1894.94,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,2084.44,49.5,,2084.44,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,733.11,,,733.11,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,2947.69,70,,2947.69,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,394.14,,,394.14,Other,New York Medicaid APG methodology,394.14,,,394.14,Other,100% New York Medicaid APG,394.14,,,394.14,Other,100% New York Medicaid APG,394.14,,,394.14,Other,100% New York Medicaid APG,886.83,,,886.83,Other,225% New York Medicaid APG,603.04,,,603.04,Other,153% New York Medicaid APG,886.83,,,886.83,Other,225% New York Medicaid APG,551.8,,,551.8,Other,140% New York Medicaid APG,886.83,,,886.83,Other,225% New York Medicaid APG,1024.78,,,1024.78,Other,260% New York Medicaid APG,1277.03,,,1277.03,Other,324% New York Medicaid APG,847.41,,,847.41,Other,215% New York Medicaid APG,847.41,,,847.41,Other,215% New York Medicaid APG,492.68,,,492.68,Other,125% New York Medicaid APG,394.14,9473,
Abrasion lesions add-on,15787,CPT,,,,,,,,both,,,64479.48,47714.82,74,,47714.82,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,29015.77,45,,29015.77,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,31917.34,49.5,,31917.34,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,733.11,,,733.11,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,45135.64,70,,45135.64,percent of total billed charges,,80.36,,,80.36,Fee Schedule,,68.11,,,68.11,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,394.14,,,394.14,Other,New York Medicaid APG methodology,394.14,,,394.14,Other,100% New York Medicaid APG,394.14,,,394.14,Other,100% New York Medicaid APG,394.14,,,394.14,Other,100% New York Medicaid APG,886.83,,,886.83,Other,225% New York Medicaid APG,603.04,,,603.04,Other,153% New York Medicaid APG,886.83,,,886.83,Other,225% New York Medicaid APG,551.8,,,551.8,Other,140% New York Medicaid APG,886.83,,,886.83,Other,225% New York Medicaid APG,1024.78,,,1024.78,Other,260% New York Medicaid APG,1277.03,,,1277.03,Other,324% New York Medicaid APG,847.41,,,847.41,Other,215% New York Medicaid APG,847.41,,,847.41,Other,215% New York Medicaid APG,492.68,,,492.68,Other,125% New York Medicaid APG,68.11,47714.82,
Chemical peel face epiderm,15788,CPT,,,,,,,,both,,,8387.08,6206.44,74,,6206.44,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,3774.19,45,,3774.19,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,4151.6,49.5,,4151.6,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,733.11,,,733.11,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,5870.96,70,,5870.96,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,394.14,,,394.14,Other,New York Medicaid APG methodology,394.14,,,394.14,Other,100% New York Medicaid APG,394.14,,,394.14,Other,100% New York Medicaid APG,394.14,,,394.14,Other,100% New York Medicaid APG,886.83,,,886.83,Other,225% New York Medicaid APG,603.04,,,603.04,Other,153% New York Medicaid APG,886.83,,,886.83,Other,225% New York Medicaid APG,551.8,,,551.8,Other,140% New York Medicaid APG,886.83,,,886.83,Other,225% New York Medicaid APG,1024.78,,,1024.78,Other,260% New York Medicaid APG,1277.03,,,1277.03,Other,324% New York Medicaid APG,847.41,,,847.41,Other,215% New York Medicaid APG,847.41,,,847.41,Other,215% New York Medicaid APG,492.68,,,492.68,Other,125% New York Medicaid APG,394.14,9473,
Chemical peel face dermal,15789,CPT,,,,,,,,both,,,13210.22,9775.56,74,,9775.56,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,5944.6,45,,5944.6,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,6539.06,49.5,,6539.06,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,733.11,,,733.11,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,9247.15,70,,9247.15,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,394.14,,,394.14,Other,New York Medicaid APG methodology,394.14,,,394.14,Other,100% New York Medicaid APG,394.14,,,394.14,Other,100% New York Medicaid APG,394.14,,,394.14,Other,100% New York Medicaid APG,886.83,,,886.83,Other,225% New York Medicaid APG,603.04,,,603.04,Other,153% New York Medicaid APG,886.83,,,886.83,Other,225% New York Medicaid APG,551.8,,,551.8,Other,140% New York Medicaid APG,886.83,,,886.83,Other,225% New York Medicaid APG,1024.78,,,1024.78,Other,260% New York Medicaid APG,1277.03,,,1277.03,Other,324% New York Medicaid APG,847.41,,,847.41,Other,215% New York Medicaid APG,847.41,,,847.41,Other,215% New York Medicaid APG,492.68,,,492.68,Other,125% New York Medicaid APG,394.14,9775.56,
Chemical peel nonfacial,15792,CPT,,,,,,,,both,,,13210.22,9775.56,74,,9775.56,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,5944.6,45,,5944.6,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,6539.06,49.5,,6539.06,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,733.11,,,733.11,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,9247.15,70,,9247.15,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,394.14,,,394.14,Other,New York Medicaid APG methodology,394.14,,,394.14,Other,100% New York Medicaid APG,394.14,,,394.14,Other,100% New York Medicaid APG,394.14,,,394.14,Other,100% New York Medicaid APG,886.83,,,886.83,Other,225% New York Medicaid APG,603.04,,,603.04,Other,153% New York Medicaid APG,886.83,,,886.83,Other,225% New York Medicaid APG,551.8,,,551.8,Other,140% New York Medicaid APG,886.83,,,886.83,Other,225% New York Medicaid APG,1024.78,,,1024.78,Other,260% New York Medicaid APG,1277.03,,,1277.03,Other,324% New York Medicaid APG,847.41,,,847.41,Other,215% New York Medicaid APG,847.41,,,847.41,Other,215% New York Medicaid APG,492.68,,,492.68,Other,125% New York Medicaid APG,394.14,9775.56,
Chemical peel nonfacial,15793,CPT,,,,,,,,both,,,8387.08,6206.44,74,,6206.44,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,3774.19,45,,3774.19,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,4151.6,49.5,,4151.6,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,733.11,,,733.11,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,5870.96,70,,5870.96,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,394.14,,,394.14,Other,New York Medicaid APG methodology,394.14,,,394.14,Other,100% New York Medicaid APG,394.14,,,394.14,Other,100% New York Medicaid APG,394.14,,,394.14,Other,100% New York Medicaid APG,886.83,,,886.83,Other,225% New York Medicaid APG,603.04,,,603.04,Other,153% New York Medicaid APG,886.83,,,886.83,Other,225% New York Medicaid APG,551.8,,,551.8,Other,140% New York Medicaid APG,886.83,,,886.83,Other,225% New York Medicaid APG,1024.78,,,1024.78,Other,260% New York Medicaid APG,1277.03,,,1277.03,Other,324% New York Medicaid APG,847.41,,,847.41,Other,215% New York Medicaid APG,847.41,,,847.41,Other,215% New York Medicaid APG,492.68,,,492.68,Other,125% New York Medicaid APG,394.14,9473,
Plastic surgery neck,15819,CPT,,,,,,,,both,,,42554.16,31490.08,74,,31490.08,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,19149.37,45,,19149.37,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,21064.31,49.5,,21064.31,percent of total billed charges,110% of Medicare,28936.83,68,,28936.83,percent of total billed charges,,3621.77,,,3621.77,Other,186% of Medicaid,34043.33,80,,34043.33,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,34043.33,80,,34043.33,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,29787.91,70,,29787.91,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1947.19,,,1947.19,Other,New York Medicaid APG methodology,1947.19,,,1947.19,Other,100% New York Medicaid APG,1947.19,,,1947.19,Other,100% New York Medicaid APG,1947.19,,,1947.19,Other,100% New York Medicaid APG,4381.17,,,4381.17,Other,225% New York Medicaid APG,2979.2,,,2979.2,Other,153% New York Medicaid APG,4381.17,,,4381.17,Other,225% New York Medicaid APG,2726.06,,,2726.06,Other,140% New York Medicaid APG,4381.17,,,4381.17,Other,225% New York Medicaid APG,5062.69,,,5062.69,Other,260% New York Medicaid APG,6308.89,,,6308.89,Other,324% New York Medicaid APG,4186.45,,,4186.45,Other,215% New York Medicaid APG,4186.45,,,4186.45,Other,215% New York Medicaid APG,2433.99,,,2433.99,Other,125% New York Medicaid APG,1947.19,34043.33,
Revision of lower eyelid,15820,CPT,,,,,,,,both,,,52507.66,38855.67,74,,38855.67,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,23628.45,45,,23628.45,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,25991.29,49.5,,25991.29,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3621.77,,,3621.77,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,36755.36,70,,36755.36,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1947.19,,,1947.19,Other,New York Medicaid APG methodology,1947.19,,,1947.19,Other,100% New York Medicaid APG,1947.19,,,1947.19,Other,100% New York Medicaid APG,1947.19,,,1947.19,Other,100% New York Medicaid APG,4381.17,,,4381.17,Other,225% New York Medicaid APG,2979.2,,,2979.2,Other,153% New York Medicaid APG,4381.17,,,4381.17,Other,225% New York Medicaid APG,2726.06,,,2726.06,Other,140% New York Medicaid APG,4381.17,,,4381.17,Other,225% New York Medicaid APG,5062.69,,,5062.69,Other,260% New York Medicaid APG,6308.89,,,6308.89,Other,324% New York Medicaid APG,4186.45,,,4186.45,Other,215% New York Medicaid APG,4186.45,,,4186.45,Other,215% New York Medicaid APG,2433.99,,,2433.99,Other,125% New York Medicaid APG,1947.19,38855.67,
Revision of lower eyelid,15821,CPT,,,,,,,,both,,,38470.57,28468.22,74,,28468.22,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,17311.76,45,,17311.76,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,19042.93,49.5,,19042.93,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3621.77,,,3621.77,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,26929.4,70,,26929.4,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1947.19,,,1947.19,Other,New York Medicaid APG methodology,1947.19,,,1947.19,Other,100% New York Medicaid APG,1947.19,,,1947.19,Other,100% New York Medicaid APG,1947.19,,,1947.19,Other,100% New York Medicaid APG,4381.17,,,4381.17,Other,225% New York Medicaid APG,2979.2,,,2979.2,Other,153% New York Medicaid APG,4381.17,,,4381.17,Other,225% New York Medicaid APG,2726.06,,,2726.06,Other,140% New York Medicaid APG,4381.17,,,4381.17,Other,225% New York Medicaid APG,5062.69,,,5062.69,Other,260% New York Medicaid APG,6308.89,,,6308.89,Other,324% New York Medicaid APG,4186.45,,,4186.45,Other,215% New York Medicaid APG,4186.45,,,4186.45,Other,215% New York Medicaid APG,2433.99,,,2433.99,Other,125% New York Medicaid APG,1947.19,28468.22,
Revision of upper eyelid,15822,CPT,,,,,,,,both,,,33859.66,25056.15,74,,25056.15,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15236.85,45,,15236.85,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,16760.53,49.5,,16760.53,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3621.77,,,3621.77,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,23701.76,70,,23701.76,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1947.19,,,1947.19,Other,New York Medicaid APG methodology,1947.19,,,1947.19,Other,100% New York Medicaid APG,1947.19,,,1947.19,Other,100% New York Medicaid APG,1947.19,,,1947.19,Other,100% New York Medicaid APG,4381.17,,,4381.17,Other,225% New York Medicaid APG,2979.2,,,2979.2,Other,153% New York Medicaid APG,4381.17,,,4381.17,Other,225% New York Medicaid APG,2726.06,,,2726.06,Other,140% New York Medicaid APG,4381.17,,,4381.17,Other,225% New York Medicaid APG,5062.69,,,5062.69,Other,260% New York Medicaid APG,6308.89,,,6308.89,Other,324% New York Medicaid APG,4186.45,,,4186.45,Other,215% New York Medicaid APG,4186.45,,,4186.45,Other,215% New York Medicaid APG,2433.99,,,2433.99,Other,125% New York Medicaid APG,1947.19,25056.15,
Revision of upper eyelid,15823,CPT,,,,,,,,both,,,35176.52,26030.62,74,,26030.62,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15829.43,45,,15829.43,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,17412.38,49.5,,17412.38,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3621.77,,,3621.77,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,24623.56,70,,24623.56,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1947.19,,,1947.19,Other,New York Medicaid APG methodology,1947.19,,,1947.19,Other,100% New York Medicaid APG,1947.19,,,1947.19,Other,100% New York Medicaid APG,1947.19,,,1947.19,Other,100% New York Medicaid APG,4381.17,,,4381.17,Other,225% New York Medicaid APG,2979.2,,,2979.2,Other,153% New York Medicaid APG,4381.17,,,4381.17,Other,225% New York Medicaid APG,2726.06,,,2726.06,Other,140% New York Medicaid APG,4381.17,,,4381.17,Other,225% New York Medicaid APG,5062.69,,,5062.69,Other,260% New York Medicaid APG,6308.89,,,6308.89,Other,324% New York Medicaid APG,4186.45,,,4186.45,Other,215% New York Medicaid APG,4186.45,,,4186.45,Other,215% New York Medicaid APG,2433.99,,,2433.99,Other,125% New York Medicaid APG,1947.19,26030.62,
Removal of forehead wrinkles,15824,CPT,,,,,,,,both,,,38357.55,28384.59,74,,28384.59,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,17260.9,45,,17260.9,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,18986.99,49.5,,18986.99,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3621.77,,,3621.77,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,26850.29,70,,26850.29,percent of total billed charges,,24932.41,65,,24932.41,percent of total billed charges,,24932.41,65,,24932.41,percent of total billed charges,,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1947.19,,,1947.19,Other,New York Medicaid APG methodology,1947.19,,,1947.19,Other,100% New York Medicaid APG,1947.19,,,1947.19,Other,100% New York Medicaid APG,1947.19,,,1947.19,Other,100% New York Medicaid APG,4381.17,,,4381.17,Other,225% New York Medicaid APG,2979.2,,,2979.2,Other,153% New York Medicaid APG,4381.17,,,4381.17,Other,225% New York Medicaid APG,2726.06,,,2726.06,Other,140% New York Medicaid APG,4381.17,,,4381.17,Other,225% New York Medicaid APG,5062.69,,,5062.69,Other,260% New York Medicaid APG,6308.89,,,6308.89,Other,324% New York Medicaid APG,4186.45,,,4186.45,Other,215% New York Medicaid APG,4186.45,,,4186.45,Other,215% New York Medicaid APG,2433.99,,,2433.99,Other,125% New York Medicaid APG,1947.19,28384.59,
Removal of neck wrinkles,15825,CPT,,,,,,,,both,,,75461.18,55841.27,74,,55841.27,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,33957.53,45,,33957.53,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,37353.28,49.5,,37353.28,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3621.77,,,3621.77,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,52822.83,70,,52822.83,percent of total billed charges,,49049.77,65,,49049.77,percent of total billed charges,,49049.77,65,,49049.77,percent of total billed charges,,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1947.19,,,1947.19,Other,New York Medicaid APG methodology,1947.19,,,1947.19,Other,100% New York Medicaid APG,1947.19,,,1947.19,Other,100% New York Medicaid APG,1947.19,,,1947.19,Other,100% New York Medicaid APG,4381.17,,,4381.17,Other,225% New York Medicaid APG,2979.2,,,2979.2,Other,153% New York Medicaid APG,4381.17,,,4381.17,Other,225% New York Medicaid APG,2726.06,,,2726.06,Other,140% New York Medicaid APG,4381.17,,,4381.17,Other,225% New York Medicaid APG,5062.69,,,5062.69,Other,260% New York Medicaid APG,6308.89,,,6308.89,Other,324% New York Medicaid APG,4186.45,,,4186.45,Other,215% New York Medicaid APG,4186.45,,,4186.45,Other,215% New York Medicaid APG,2433.99,,,2433.99,Other,125% New York Medicaid APG,1947.19,55841.27,
Removal of brow wrinkles,15826,CPT,,,,,,,,both,,,75461.18,55841.27,74,,55841.27,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,33957.53,45,,33957.53,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,37353.28,49.5,,37353.28,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3621.77,,,3621.77,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,52822.83,70,,52822.83,percent of total billed charges,,49049.77,65,,49049.77,percent of total billed charges,,49049.77,65,,49049.77,percent of total billed charges,,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1947.19,,,1947.19,Other,New York Medicaid APG methodology,1947.19,,,1947.19,Other,100% New York Medicaid APG,1947.19,,,1947.19,Other,100% New York Medicaid APG,1947.19,,,1947.19,Other,100% New York Medicaid APG,4381.17,,,4381.17,Other,225% New York Medicaid APG,2979.2,,,2979.2,Other,153% New York Medicaid APG,4381.17,,,4381.17,Other,225% New York Medicaid APG,2726.06,,,2726.06,Other,140% New York Medicaid APG,4381.17,,,4381.17,Other,225% New York Medicaid APG,5062.69,,,5062.69,Other,260% New York Medicaid APG,6308.89,,,6308.89,Other,324% New York Medicaid APG,4186.45,,,4186.45,Other,215% New York Medicaid APG,4186.45,,,4186.45,Other,215% New York Medicaid APG,2433.99,,,2433.99,Other,125% New York Medicaid APG,1947.19,55841.27,
Removal of face wrinkles,15828,CPT,,,,,,,,both,,,75461.18,55841.27,74,,55841.27,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,33957.53,45,,33957.53,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,37353.28,49.5,,37353.28,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3621.77,,,3621.77,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,52822.83,70,,52822.83,percent of total billed charges,,49049.77,65,,49049.77,percent of total billed charges,,49049.77,65,,49049.77,percent of total billed charges,,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1947.19,,,1947.19,Other,New York Medicaid APG methodology,1947.19,,,1947.19,Other,100% New York Medicaid APG,1947.19,,,1947.19,Other,100% New York Medicaid APG,1947.19,,,1947.19,Other,100% New York Medicaid APG,4381.17,,,4381.17,Other,225% New York Medicaid APG,2979.2,,,2979.2,Other,153% New York Medicaid APG,4381.17,,,4381.17,Other,225% New York Medicaid APG,2726.06,,,2726.06,Other,140% New York Medicaid APG,4381.17,,,4381.17,Other,225% New York Medicaid APG,5062.69,,,5062.69,Other,260% New York Medicaid APG,6308.89,,,6308.89,Other,324% New York Medicaid APG,4186.45,,,4186.45,Other,215% New York Medicaid APG,4186.45,,,4186.45,Other,215% New York Medicaid APG,2433.99,,,2433.99,Other,125% New York Medicaid APG,1947.19,55841.27,
Removal of skin wrinkles,15829,CPT,,,,,,,,both,,,70986.49,52530,74,,52530,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,31943.92,45,,31943.92,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,35138.31,49.5,,35138.31,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3621.77,,,3621.77,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,49690.54,70,,49690.54,percent of total billed charges,,46141.22,65,,46141.22,percent of total billed charges,,46141.22,65,,46141.22,percent of total billed charges,,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1947.19,,,1947.19,Other,New York Medicaid APG methodology,1947.19,,,1947.19,Other,100% New York Medicaid APG,1947.19,,,1947.19,Other,100% New York Medicaid APG,1947.19,,,1947.19,Other,100% New York Medicaid APG,4381.17,,,4381.17,Other,225% New York Medicaid APG,2979.2,,,2979.2,Other,153% New York Medicaid APG,4381.17,,,4381.17,Other,225% New York Medicaid APG,2726.06,,,2726.06,Other,140% New York Medicaid APG,4381.17,,,4381.17,Other,225% New York Medicaid APG,5062.69,,,5062.69,Other,260% New York Medicaid APG,6308.89,,,6308.89,Other,324% New York Medicaid APG,4186.45,,,4186.45,Other,215% New York Medicaid APG,4186.45,,,4186.45,Other,215% New York Medicaid APG,2433.99,,,2433.99,Other,125% New York Medicaid APG,1947.19,52530,
Exc skin abd,15830,CPT,,,,,,,,both,,,54151.53,40072.13,74,,40072.13,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,24368.19,45,,24368.19,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,7266,,"100% primary, 50% secondary, 25% supplemental procedure",7266,Other,Blue Cross ASC Grouper,6539,,"100% primary, 50% secondary, 25% supplemental procedure",6539,Other,Blue Cross ASC Grouper,6176,,"100% primary, 50% secondary, 25% supplemental procedure",6176,Other,Blue Cross ASC Grouper,26805.01,49.5,,26805.01,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3621.77,,,3621.77,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,37906.07,70,,37906.07,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,1947.19,,,1947.19,Other,New York Medicaid APG methodology,1947.19,,,1947.19,Other,100% New York Medicaid APG,1947.19,,,1947.19,Other,100% New York Medicaid APG,1947.19,,,1947.19,Other,100% New York Medicaid APG,4381.17,,,4381.17,Other,225% New York Medicaid APG,2979.2,,,2979.2,Other,153% New York Medicaid APG,4381.17,,,4381.17,Other,225% New York Medicaid APG,2726.06,,,2726.06,Other,140% New York Medicaid APG,4381.17,,,4381.17,Other,225% New York Medicaid APG,5062.69,,,5062.69,Other,260% New York Medicaid APG,6308.89,,,6308.89,Other,324% New York Medicaid APG,4186.45,,,4186.45,Other,215% New York Medicaid APG,4186.45,,,4186.45,Other,215% New York Medicaid APG,2433.99,,,2433.99,Other,125% New York Medicaid APG,1947.19,40072.13,
Excise excessive skin thigh,15832,CPT,,,,,,,,both,,,34291.71,25375.87,74,,25375.87,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15431.27,45,,15431.27,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,16974.4,49.5,,16974.4,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3621.77,,,3621.77,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,24004.2,70,,24004.2,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1947.19,,,1947.19,Other,New York Medicaid APG methodology,1947.19,,,1947.19,Other,100% New York Medicaid APG,1947.19,,,1947.19,Other,100% New York Medicaid APG,1947.19,,,1947.19,Other,100% New York Medicaid APG,4381.17,,,4381.17,Other,225% New York Medicaid APG,2979.2,,,2979.2,Other,153% New York Medicaid APG,4381.17,,,4381.17,Other,225% New York Medicaid APG,2726.06,,,2726.06,Other,140% New York Medicaid APG,4381.17,,,4381.17,Other,225% New York Medicaid APG,5062.69,,,5062.69,Other,260% New York Medicaid APG,6308.89,,,6308.89,Other,324% New York Medicaid APG,4186.45,,,4186.45,Other,215% New York Medicaid APG,4186.45,,,4186.45,Other,215% New York Medicaid APG,2433.99,,,2433.99,Other,125% New York Medicaid APG,1947.19,25375.87,
Excise excessive skin leg,15833,CPT,,,,,,,,both,,,59767.2,44227.73,74,,44227.73,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,26895.24,45,,26895.24,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,29584.76,49.5,,29584.76,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3621.77,,,3621.77,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,41837.04,70,,41837.04,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1947.19,,,1947.19,Other,New York Medicaid APG methodology,1947.19,,,1947.19,Other,100% New York Medicaid APG,1947.19,,,1947.19,Other,100% New York Medicaid APG,1947.19,,,1947.19,Other,100% New York Medicaid APG,4381.17,,,4381.17,Other,225% New York Medicaid APG,2979.2,,,2979.2,Other,153% New York Medicaid APG,4381.17,,,4381.17,Other,225% New York Medicaid APG,2726.06,,,2726.06,Other,140% New York Medicaid APG,4381.17,,,4381.17,Other,225% New York Medicaid APG,5062.69,,,5062.69,Other,260% New York Medicaid APG,6308.89,,,6308.89,Other,324% New York Medicaid APG,4186.45,,,4186.45,Other,215% New York Medicaid APG,4186.45,,,4186.45,Other,215% New York Medicaid APG,2433.99,,,2433.99,Other,125% New York Medicaid APG,1947.19,44227.73,
Excise excessive skin hip,15834,CPT,,,,,,,,both,,,59767.2,44227.73,74,,44227.73,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,26895.24,45,,26895.24,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,29584.76,49.5,,29584.76,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3621.77,,,3621.77,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,41837.04,70,,41837.04,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1947.19,,,1947.19,Other,New York Medicaid APG methodology,1947.19,,,1947.19,Other,100% New York Medicaid APG,1947.19,,,1947.19,Other,100% New York Medicaid APG,1947.19,,,1947.19,Other,100% New York Medicaid APG,4381.17,,,4381.17,Other,225% New York Medicaid APG,2979.2,,,2979.2,Other,153% New York Medicaid APG,4381.17,,,4381.17,Other,225% New York Medicaid APG,2726.06,,,2726.06,Other,140% New York Medicaid APG,4381.17,,,4381.17,Other,225% New York Medicaid APG,5062.69,,,5062.69,Other,260% New York Medicaid APG,6308.89,,,6308.89,Other,324% New York Medicaid APG,4186.45,,,4186.45,Other,215% New York Medicaid APG,4186.45,,,4186.45,Other,215% New York Medicaid APG,2433.99,,,2433.99,Other,125% New York Medicaid APG,1947.19,44227.73,
Excise excessive skin buttck,15835,CPT,,,,,,,,both,,,59767.2,44227.73,74,,44227.73,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,26895.24,45,,26895.24,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,29584.76,49.5,,29584.76,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3621.77,,,3621.77,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,41837.04,70,,41837.04,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1947.19,,,1947.19,Other,New York Medicaid APG methodology,1947.19,,,1947.19,Other,100% New York Medicaid APG,1947.19,,,1947.19,Other,100% New York Medicaid APG,1947.19,,,1947.19,Other,100% New York Medicaid APG,4381.17,,,4381.17,Other,225% New York Medicaid APG,2979.2,,,2979.2,Other,153% New York Medicaid APG,4381.17,,,4381.17,Other,225% New York Medicaid APG,2726.06,,,2726.06,Other,140% New York Medicaid APG,4381.17,,,4381.17,Other,225% New York Medicaid APG,5062.69,,,5062.69,Other,260% New York Medicaid APG,6308.89,,,6308.89,Other,324% New York Medicaid APG,4186.45,,,4186.45,Other,215% New York Medicaid APG,4186.45,,,4186.45,Other,215% New York Medicaid APG,2433.99,,,2433.99,Other,125% New York Medicaid APG,1947.19,44227.73,
Excise excessive skin arm,15836,CPT,,,,,,,,both,,,67795.49,50168.66,74,,50168.66,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30507.97,45,,30507.97,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33558.77,49.5,,33558.77,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3621.77,,,3621.77,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,47456.84,70,,47456.84,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1947.19,,,1947.19,Other,New York Medicaid APG methodology,1947.19,,,1947.19,Other,100% New York Medicaid APG,1947.19,,,1947.19,Other,100% New York Medicaid APG,1947.19,,,1947.19,Other,100% New York Medicaid APG,4381.17,,,4381.17,Other,225% New York Medicaid APG,2979.2,,,2979.2,Other,153% New York Medicaid APG,4381.17,,,4381.17,Other,225% New York Medicaid APG,2726.06,,,2726.06,Other,140% New York Medicaid APG,4381.17,,,4381.17,Other,225% New York Medicaid APG,5062.69,,,5062.69,Other,260% New York Medicaid APG,6308.89,,,6308.89,Other,324% New York Medicaid APG,4186.45,,,4186.45,Other,215% New York Medicaid APG,4186.45,,,4186.45,Other,215% New York Medicaid APG,2433.99,,,2433.99,Other,125% New York Medicaid APG,1947.19,50168.66,
Excise excess skin arm/hand,15837,CPT,,,,,,,,both,,,59767.2,44227.73,74,,44227.73,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,26895.24,45,,26895.24,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,29584.76,49.5,,29584.76,percent of total billed charges,110% of Medicare,40641.7,68,,40641.7,percent of total billed charges,,3621.77,,,3621.77,Other,186% of Medicaid,47813.76,80,,47813.76,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,47813.76,80,,47813.76,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,41837.04,70,,41837.04,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1947.19,,,1947.19,Other,New York Medicaid APG methodology,1947.19,,,1947.19,Other,100% New York Medicaid APG,1947.19,,,1947.19,Other,100% New York Medicaid APG,1947.19,,,1947.19,Other,100% New York Medicaid APG,4381.17,,,4381.17,Other,225% New York Medicaid APG,2979.2,,,2979.2,Other,153% New York Medicaid APG,4381.17,,,4381.17,Other,225% New York Medicaid APG,2726.06,,,2726.06,Other,140% New York Medicaid APG,4381.17,,,4381.17,Other,225% New York Medicaid APG,5062.69,,,5062.69,Other,260% New York Medicaid APG,6308.89,,,6308.89,Other,324% New York Medicaid APG,4186.45,,,4186.45,Other,215% New York Medicaid APG,4186.45,,,4186.45,Other,215% New York Medicaid APG,2433.99,,,2433.99,Other,125% New York Medicaid APG,1947.19,47813.76,
Excise excess skin fat pad,15838,CPT,,,,,,,,both,,,59767.2,44227.73,74,,44227.73,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,26895.24,45,,26895.24,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,29584.76,49.5,,29584.76,percent of total billed charges,110% of Medicare,40641.7,68,,40641.7,percent of total billed charges,,3621.77,,,3621.77,Other,186% of Medicaid,47813.76,80,,47813.76,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,47813.76,80,,47813.76,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,41837.04,70,,41837.04,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1947.19,,,1947.19,Other,New York Medicaid APG methodology,1947.19,,,1947.19,Other,100% New York Medicaid APG,1947.19,,,1947.19,Other,100% New York Medicaid APG,1947.19,,,1947.19,Other,100% New York Medicaid APG,4381.17,,,4381.17,Other,225% New York Medicaid APG,2979.2,,,2979.2,Other,153% New York Medicaid APG,4381.17,,,4381.17,Other,225% New York Medicaid APG,2726.06,,,2726.06,Other,140% New York Medicaid APG,4381.17,,,4381.17,Other,225% New York Medicaid APG,5062.69,,,5062.69,Other,260% New York Medicaid APG,6308.89,,,6308.89,Other,324% New York Medicaid APG,4186.45,,,4186.45,Other,215% New York Medicaid APG,4186.45,,,4186.45,Other,215% New York Medicaid APG,2433.99,,,2433.99,Other,125% New York Medicaid APG,1947.19,47813.76,
Excise excess skin & tissue,15839,CPT,,,,,,,,both,,,42064.03,31127.38,74,,31127.38,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,18928.81,45,,18928.81,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,20821.69,49.5,,20821.69,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3621.77,,,3621.77,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,29444.82,70,,29444.82,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1947.19,,,1947.19,Other,New York Medicaid APG methodology,1947.19,,,1947.19,Other,100% New York Medicaid APG,1947.19,,,1947.19,Other,100% New York Medicaid APG,1947.19,,,1947.19,Other,100% New York Medicaid APG,4381.17,,,4381.17,Other,225% New York Medicaid APG,2979.2,,,2979.2,Other,153% New York Medicaid APG,4381.17,,,4381.17,Other,225% New York Medicaid APG,2726.06,,,2726.06,Other,140% New York Medicaid APG,4381.17,,,4381.17,Other,225% New York Medicaid APG,5062.69,,,5062.69,Other,260% New York Medicaid APG,6308.89,,,6308.89,Other,324% New York Medicaid APG,4186.45,,,4186.45,Other,215% New York Medicaid APG,4186.45,,,4186.45,Other,215% New York Medicaid APG,2433.99,,,2433.99,Other,125% New York Medicaid APG,1947.19,31127.38,
Nerve palsy fascial graft,15840,CPT,,,,,,,,both,,,75461.18,55841.27,74,,55841.27,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,33957.53,45,,33957.53,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,37353.28,49.5,,37353.28,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2593.54,,,2593.54,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,52822.83,70,,52822.83,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1394.38,,,1394.38,Other,New York Medicaid APG methodology,1394.38,,,1394.38,Other,100% New York Medicaid APG,1394.38,,,1394.38,Other,100% New York Medicaid APG,1394.38,,,1394.38,Other,100% New York Medicaid APG,3137.35,,,3137.35,Other,225% New York Medicaid APG,2133.39,,,2133.39,Other,153% New York Medicaid APG,3137.35,,,3137.35,Other,225% New York Medicaid APG,1952.13,,,1952.13,Other,140% New York Medicaid APG,3137.35,,,3137.35,Other,225% New York Medicaid APG,3625.38,,,3625.38,Other,260% New York Medicaid APG,4517.78,,,4517.78,Other,324% New York Medicaid APG,2997.91,,,2997.91,Other,215% New York Medicaid APG,2997.91,,,2997.91,Other,215% New York Medicaid APG,1742.97,,,1742.97,Other,125% New York Medicaid APG,1394.38,55841.27,
Nerve palsy muscle graft,15841,CPT,,,,,,,,both,,,75461.18,55841.27,74,,55841.27,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,33957.53,45,,33957.53,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,37353.28,49.5,,37353.28,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2593.54,,,2593.54,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,52822.83,70,,52822.83,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1394.38,,,1394.38,Other,New York Medicaid APG methodology,1394.38,,,1394.38,Other,100% New York Medicaid APG,1394.38,,,1394.38,Other,100% New York Medicaid APG,1394.38,,,1394.38,Other,100% New York Medicaid APG,3137.35,,,3137.35,Other,225% New York Medicaid APG,2133.39,,,2133.39,Other,153% New York Medicaid APG,3137.35,,,3137.35,Other,225% New York Medicaid APG,1952.13,,,1952.13,Other,140% New York Medicaid APG,3137.35,,,3137.35,Other,225% New York Medicaid APG,3625.38,,,3625.38,Other,260% New York Medicaid APG,4517.78,,,4517.78,Other,324% New York Medicaid APG,2997.91,,,2997.91,Other,215% New York Medicaid APG,2997.91,,,2997.91,Other,215% New York Medicaid APG,1742.97,,,1742.97,Other,125% New York Medicaid APG,1394.38,55841.27,
Nerve palsy microsurg graft,15842,CPT,,,,,,,,both,,,38357.55,28384.59,74,,28384.59,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,17260.9,45,,17260.9,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,18986.99,49.5,,18986.99,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2593.54,,,2593.54,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,26850.29,70,,26850.29,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1394.38,,,1394.38,Other,New York Medicaid APG methodology,1394.38,,,1394.38,Other,100% New York Medicaid APG,1394.38,,,1394.38,Other,100% New York Medicaid APG,1394.38,,,1394.38,Other,100% New York Medicaid APG,3137.35,,,3137.35,Other,225% New York Medicaid APG,2133.39,,,2133.39,Other,153% New York Medicaid APG,3137.35,,,3137.35,Other,225% New York Medicaid APG,1952.13,,,1952.13,Other,140% New York Medicaid APG,3137.35,,,3137.35,Other,225% New York Medicaid APG,3625.38,,,3625.38,Other,260% New York Medicaid APG,4517.78,,,4517.78,Other,324% New York Medicaid APG,2997.91,,,2997.91,Other,215% New York Medicaid APG,2997.91,,,2997.91,Other,215% New York Medicaid APG,1742.97,,,1742.97,Other,125% New York Medicaid APG,1394.38,28384.59,
Skin and muscle repair face,15845,CPT,,,,,,,,both,,,75461.18,55841.27,74,,55841.27,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,33957.53,45,,33957.53,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,37353.28,49.5,,37353.28,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2593.54,,,2593.54,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,52822.83,70,,52822.83,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1394.38,,,1394.38,Other,New York Medicaid APG methodology,1394.38,,,1394.38,Other,100% New York Medicaid APG,1394.38,,,1394.38,Other,100% New York Medicaid APG,1394.38,,,1394.38,Other,100% New York Medicaid APG,3137.35,,,3137.35,Other,225% New York Medicaid APG,2133.39,,,2133.39,Other,153% New York Medicaid APG,3137.35,,,3137.35,Other,225% New York Medicaid APG,1952.13,,,1952.13,Other,140% New York Medicaid APG,3137.35,,,3137.35,Other,225% New York Medicaid APG,3625.38,,,3625.38,Other,260% New York Medicaid APG,4517.78,,,4517.78,Other,324% New York Medicaid APG,2997.91,,,2997.91,Other,215% New York Medicaid APG,2997.91,,,2997.91,Other,215% New York Medicaid APG,1742.97,,,1742.97,Other,125% New York Medicaid APG,1394.38,55841.27,
Exc skin abd add-on,15847,CPT,,,,,,,,both,,,64479.48,47714.82,74,,47714.82,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,29015.77,45,,29015.77,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,31917.34,49.5,,31917.34,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3621.77,,,3621.77,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,45135.64,70,,45135.64,percent of total billed charges,,41911.66,65,,41911.66,percent of total billed charges,,41911.66,65,,41911.66,percent of total billed charges,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,1947.19,,,1947.19,Other,New York Medicaid APG methodology,1947.19,,,1947.19,Other,100% New York Medicaid APG,1947.19,,,1947.19,Other,100% New York Medicaid APG,1947.19,,,1947.19,Other,100% New York Medicaid APG,4381.17,,,4381.17,Other,225% New York Medicaid APG,2979.2,,,2979.2,Other,153% New York Medicaid APG,4381.17,,,4381.17,Other,225% New York Medicaid APG,2726.06,,,2726.06,Other,140% New York Medicaid APG,4381.17,,,4381.17,Other,225% New York Medicaid APG,5062.69,,,5062.69,Other,260% New York Medicaid APG,6308.89,,,6308.89,Other,324% New York Medicaid APG,4186.45,,,4186.45,Other,215% New York Medicaid APG,4186.45,,,4186.45,Other,215% New York Medicaid APG,2433.99,,,2433.99,Other,125% New York Medicaid APG,1947.19,47714.82,
Remove sutures diff surgeon,15851,CPT,,,,,,,,both,,,34850.17,25789.13,74,,25789.13,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15682.58,45,,15682.58,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,17250.83,49.5,,17250.83,percent of total billed charges,110% of Medicare,23698.12,68,,23698.12,percent of total billed charges,,2241.85,,,2241.85,Other,186% of Medicaid,27880.14,80,,27880.14,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,27880.14,80,,27880.14,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,24395.12,70,,24395.12,percent of total billed charges,,316.52,,,316.52,Fee Schedule,,268.27,,,268.27,Fee Schedule,,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1205.3,,,1205.3,Other,New York Medicaid APG methodology,1205.3,,,1205.3,Other,100% New York Medicaid APG,1205.3,,,1205.3,Other,100% New York Medicaid APG,1205.3,,,1205.3,Other,100% New York Medicaid APG,2711.92,,,2711.92,Other,225% New York Medicaid APG,1844.1,,,1844.1,Other,153% New York Medicaid APG,2711.92,,,2711.92,Other,225% New York Medicaid APG,1687.41,,,1687.41,Other,140% New York Medicaid APG,2711.92,,,2711.92,Other,225% New York Medicaid APG,3133.77,,,3133.77,Other,260% New York Medicaid APG,3905.16,,,3905.16,Other,324% New York Medicaid APG,2591.39,,,2591.39,Other,215% New York Medicaid APG,2591.39,,,2591.39,Other,215% New York Medicaid APG,1506.62,,,1506.62,Other,125% New York Medicaid APG,268.27,27880.14,
Dressing change not for burn,15852,CPT,,,,,,,,both,,,35304.33,26125.2,74,,26125.2,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15886.95,45,,15886.95,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,17475.64,49.5,,17475.64,percent of total billed charges,110% of Medicare,24006.94,68,,24006.94,percent of total billed charges,,957.71,,,957.71,Other,186% of Medicaid,28243.46,80,,28243.46,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,28243.46,80,,28243.46,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,24713.03,70,,24713.03,percent of total billed charges,,224.68,,,224.68,Fee Schedule,,190.43,,,190.43,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,514.9,,,514.9,Other,New York Medicaid APG methodology,514.9,,,514.9,Other,100% New York Medicaid APG,514.9,,,514.9,Other,100% New York Medicaid APG,514.9,,,514.9,Other,100% New York Medicaid APG,1158.52,,,1158.52,Other,225% New York Medicaid APG,787.8,,,787.8,Other,153% New York Medicaid APG,1158.52,,,1158.52,Other,225% New York Medicaid APG,720.86,,,720.86,Other,140% New York Medicaid APG,1158.52,,,1158.52,Other,225% New York Medicaid APG,1338.74,,,1338.74,Other,260% New York Medicaid APG,1668.27,,,1668.27,Other,324% New York Medicaid APG,1107.03,,,1107.03,Other,215% New York Medicaid APG,1107.03,,,1107.03,Other,215% New York Medicaid APG,643.62,,,643.62,Other,125% New York Medicaid APG,190.43,28243.46,
Test for blood flow in graft,15860,CPT,,,,,,,,both,,,8380.68,6201.7,74,,6201.7,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,3771.31,45,,3771.31,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,4148.44,49.5,,4148.44,percent of total billed charges,110% of Medicare,5698.86,68,,5698.86,percent of total billed charges,,966.93,,,966.93,Other,186% of Medicaid,6704.54,80,,6704.54,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,6704.54,80,,6704.54,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,5866.48,70,,5866.48,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,519.86,,,519.86,Other,New York Medicaid APG methodology,519.86,,,519.86,Other,100% New York Medicaid APG,519.86,,,519.86,Other,100% New York Medicaid APG,519.86,,,519.86,Other,100% New York Medicaid APG,1169.68,,,1169.68,Other,225% New York Medicaid APG,795.38,,,795.38,Other,153% New York Medicaid APG,1169.68,,,1169.68,Other,225% New York Medicaid APG,727.8,,,727.8,Other,140% New York Medicaid APG,1169.68,,,1169.68,Other,225% New York Medicaid APG,1351.62,,,1351.62,Other,260% New York Medicaid APG,1684.33,,,1684.33,Other,324% New York Medicaid APG,1117.69,,,1117.69,Other,215% New York Medicaid APG,1117.69,,,1117.69,Other,215% New York Medicaid APG,649.82,,,649.82,Other,125% New York Medicaid APG,519.86,7216,
Suction lipectomy head&neck,15876,CPT,,,,,,,,both,,,51329.22,37983.62,74,,37983.62,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,23098.15,45,,23098.15,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,25407.96,49.5,,25407.96,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3621.77,,,3621.77,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,35930.45,70,,35930.45,percent of total billed charges,,33363.99,65,,33363.99,percent of total billed charges,,33363.99,65,,33363.99,percent of total billed charges,,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1947.19,,,1947.19,Other,New York Medicaid APG methodology,1947.19,,,1947.19,Other,100% New York Medicaid APG,1947.19,,,1947.19,Other,100% New York Medicaid APG,1947.19,,,1947.19,Other,100% New York Medicaid APG,4381.17,,,4381.17,Other,225% New York Medicaid APG,2979.2,,,2979.2,Other,153% New York Medicaid APG,4381.17,,,4381.17,Other,225% New York Medicaid APG,2726.06,,,2726.06,Other,140% New York Medicaid APG,4381.17,,,4381.17,Other,225% New York Medicaid APG,5062.69,,,5062.69,Other,260% New York Medicaid APG,6308.89,,,6308.89,Other,324% New York Medicaid APG,4186.45,,,4186.45,Other,215% New York Medicaid APG,4186.45,,,4186.45,Other,215% New York Medicaid APG,2433.99,,,2433.99,Other,125% New York Medicaid APG,1947.19,37983.62,
Suction lipectomy trunk,15877,CPT,,,,,,,,both,,,31862.45,23578.21,74,,23578.21,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,14338.1,45,,14338.1,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,15771.91,49.5,,15771.91,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3621.77,,,3621.77,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,22303.72,70,,22303.72,percent of total billed charges,,20710.59,65,,20710.59,percent of total billed charges,,20710.59,65,,20710.59,percent of total billed charges,,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1947.19,,,1947.19,Other,New York Medicaid APG methodology,1947.19,,,1947.19,Other,100% New York Medicaid APG,1947.19,,,1947.19,Other,100% New York Medicaid APG,1947.19,,,1947.19,Other,100% New York Medicaid APG,4381.17,,,4381.17,Other,225% New York Medicaid APG,2979.2,,,2979.2,Other,153% New York Medicaid APG,4381.17,,,4381.17,Other,225% New York Medicaid APG,2726.06,,,2726.06,Other,140% New York Medicaid APG,4381.17,,,4381.17,Other,225% New York Medicaid APG,5062.69,,,5062.69,Other,260% New York Medicaid APG,6308.89,,,6308.89,Other,324% New York Medicaid APG,4186.45,,,4186.45,Other,215% New York Medicaid APG,4186.45,,,4186.45,Other,215% New York Medicaid APG,2433.99,,,2433.99,Other,125% New York Medicaid APG,1947.19,23578.21,
Suction lipectomy upr extrem,15878,CPT,,,,,,,,both,,,38357.55,28384.59,74,,28384.59,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,17260.9,45,,17260.9,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,18986.99,49.5,,18986.99,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3621.77,,,3621.77,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,26850.29,70,,26850.29,percent of total billed charges,,24932.41,65,,24932.41,percent of total billed charges,,24932.41,65,,24932.41,percent of total billed charges,,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1947.19,,,1947.19,Other,New York Medicaid APG methodology,1947.19,,,1947.19,Other,100% New York Medicaid APG,1947.19,,,1947.19,Other,100% New York Medicaid APG,1947.19,,,1947.19,Other,100% New York Medicaid APG,4381.17,,,4381.17,Other,225% New York Medicaid APG,2979.2,,,2979.2,Other,153% New York Medicaid APG,4381.17,,,4381.17,Other,225% New York Medicaid APG,2726.06,,,2726.06,Other,140% New York Medicaid APG,4381.17,,,4381.17,Other,225% New York Medicaid APG,5062.69,,,5062.69,Other,260% New York Medicaid APG,6308.89,,,6308.89,Other,324% New York Medicaid APG,4186.45,,,4186.45,Other,215% New York Medicaid APG,4186.45,,,4186.45,Other,215% New York Medicaid APG,2433.99,,,2433.99,Other,125% New York Medicaid APG,1947.19,28384.59,
Suction lipectomy lwr extrem,15879,CPT,,,,,,,,both,,,38854.71,28752.49,74,,28752.49,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,17484.62,45,,17484.62,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,19233.08,49.5,,19233.08,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3621.77,,,3621.77,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,27198.3,70,,27198.3,percent of total billed charges,,25255.56,65,,25255.56,percent of total billed charges,,25255.56,65,,25255.56,percent of total billed charges,,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1947.19,,,1947.19,Other,New York Medicaid APG methodology,1947.19,,,1947.19,Other,100% New York Medicaid APG,1947.19,,,1947.19,Other,100% New York Medicaid APG,1947.19,,,1947.19,Other,100% New York Medicaid APG,4381.17,,,4381.17,Other,225% New York Medicaid APG,2979.2,,,2979.2,Other,153% New York Medicaid APG,4381.17,,,4381.17,Other,225% New York Medicaid APG,2726.06,,,2726.06,Other,140% New York Medicaid APG,4381.17,,,4381.17,Other,225% New York Medicaid APG,5062.69,,,5062.69,Other,260% New York Medicaid APG,6308.89,,,6308.89,Other,324% New York Medicaid APG,4186.45,,,4186.45,Other,215% New York Medicaid APG,4186.45,,,4186.45,Other,215% New York Medicaid APG,2433.99,,,2433.99,Other,125% New York Medicaid APG,1947.19,28752.49,
Removal of tail bone ulcer,15920,CPT,,,,,,,,both,,,59767.2,44227.73,74,,44227.73,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,26895.24,45,,26895.24,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,29584.76,49.5,,29584.76,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2492.85,,,2492.85,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,41837.04,70,,41837.04,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1340.24,,,1340.24,Other,New York Medicaid APG methodology,1340.24,,,1340.24,Other,100% New York Medicaid APG,1340.24,,,1340.24,Other,100% New York Medicaid APG,1340.24,,,1340.24,Other,100% New York Medicaid APG,3015.54,,,3015.54,Other,225% New York Medicaid APG,2050.57,,,2050.57,Other,153% New York Medicaid APG,3015.54,,,3015.54,Other,225% New York Medicaid APG,1876.34,,,1876.34,Other,140% New York Medicaid APG,3015.54,,,3015.54,Other,225% New York Medicaid APG,3484.62,,,3484.62,Other,260% New York Medicaid APG,4342.38,,,4342.38,Other,324% New York Medicaid APG,2881.52,,,2881.52,Other,215% New York Medicaid APG,2881.52,,,2881.52,Other,215% New York Medicaid APG,1675.3,,,1675.3,Other,125% New York Medicaid APG,1340.24,44227.73,
Removal of tail bone ulcer,15922,CPT,,,,,,,,both,,,75461.18,55841.27,74,,55841.27,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,33957.53,45,,33957.53,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,37353.28,49.5,,37353.28,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2492.85,,,2492.85,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,52822.83,70,,52822.83,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1340.24,,,1340.24,Other,New York Medicaid APG methodology,1340.24,,,1340.24,Other,100% New York Medicaid APG,1340.24,,,1340.24,Other,100% New York Medicaid APG,1340.24,,,1340.24,Other,100% New York Medicaid APG,3015.54,,,3015.54,Other,225% New York Medicaid APG,2050.57,,,2050.57,Other,153% New York Medicaid APG,3015.54,,,3015.54,Other,225% New York Medicaid APG,1876.34,,,1876.34,Other,140% New York Medicaid APG,3015.54,,,3015.54,Other,225% New York Medicaid APG,3484.62,,,3484.62,Other,260% New York Medicaid APG,4342.38,,,4342.38,Other,324% New York Medicaid APG,2881.52,,,2881.52,Other,215% New York Medicaid APG,2881.52,,,2881.52,Other,215% New York Medicaid APG,1675.3,,,1675.3,Other,125% New York Medicaid APG,1340.24,55841.27,
Remove sacrum pressure sore,15931,CPT,,,,,,,,both,,,59767.2,44227.73,74,,44227.73,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,26895.24,45,,26895.24,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,29584.76,49.5,,29584.76,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2492.85,,,2492.85,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,41837.04,70,,41837.04,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1340.24,,,1340.24,Other,New York Medicaid APG methodology,1340.24,,,1340.24,Other,100% New York Medicaid APG,1340.24,,,1340.24,Other,100% New York Medicaid APG,1340.24,,,1340.24,Other,100% New York Medicaid APG,3015.54,,,3015.54,Other,225% New York Medicaid APG,2050.57,,,2050.57,Other,153% New York Medicaid APG,3015.54,,,3015.54,Other,225% New York Medicaid APG,1876.34,,,1876.34,Other,140% New York Medicaid APG,3015.54,,,3015.54,Other,225% New York Medicaid APG,3484.62,,,3484.62,Other,260% New York Medicaid APG,4342.38,,,4342.38,Other,324% New York Medicaid APG,2881.52,,,2881.52,Other,215% New York Medicaid APG,2881.52,,,2881.52,Other,215% New York Medicaid APG,1675.3,,,1675.3,Other,125% New York Medicaid APG,1340.24,44227.73,
Remove sacrum pressure sore,15933,CPT,,,,,,,,both,,,59767.2,44227.73,74,,44227.73,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,26895.24,45,,26895.24,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,29584.76,49.5,,29584.76,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2492.85,,,2492.85,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,41837.04,70,,41837.04,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1340.24,,,1340.24,Other,New York Medicaid APG methodology,1340.24,,,1340.24,Other,100% New York Medicaid APG,1340.24,,,1340.24,Other,100% New York Medicaid APG,1340.24,,,1340.24,Other,100% New York Medicaid APG,3015.54,,,3015.54,Other,225% New York Medicaid APG,2050.57,,,2050.57,Other,153% New York Medicaid APG,3015.54,,,3015.54,Other,225% New York Medicaid APG,1876.34,,,1876.34,Other,140% New York Medicaid APG,3015.54,,,3015.54,Other,225% New York Medicaid APG,3484.62,,,3484.62,Other,260% New York Medicaid APG,4342.38,,,4342.38,Other,324% New York Medicaid APG,2881.52,,,2881.52,Other,215% New York Medicaid APG,2881.52,,,2881.52,Other,215% New York Medicaid APG,1675.3,,,1675.3,Other,125% New York Medicaid APG,1340.24,44227.73,
Remove sacrum pressure sore,15934,CPT,,,,,,,,both,,,75461.18,55841.27,74,,55841.27,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,33957.53,45,,33957.53,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,37353.28,49.5,,37353.28,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2492.85,,,2492.85,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,52822.83,70,,52822.83,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1340.24,,,1340.24,Other,New York Medicaid APG methodology,1340.24,,,1340.24,Other,100% New York Medicaid APG,1340.24,,,1340.24,Other,100% New York Medicaid APG,1340.24,,,1340.24,Other,100% New York Medicaid APG,3015.54,,,3015.54,Other,225% New York Medicaid APG,2050.57,,,2050.57,Other,153% New York Medicaid APG,3015.54,,,3015.54,Other,225% New York Medicaid APG,1876.34,,,1876.34,Other,140% New York Medicaid APG,3015.54,,,3015.54,Other,225% New York Medicaid APG,3484.62,,,3484.62,Other,260% New York Medicaid APG,4342.38,,,4342.38,Other,324% New York Medicaid APG,2881.52,,,2881.52,Other,215% New York Medicaid APG,2881.52,,,2881.52,Other,215% New York Medicaid APG,1675.3,,,1675.3,Other,125% New York Medicaid APG,1340.24,55841.27,
Remove sacrum pressure sore,15935,CPT,,,,,,,,both,,,75461.18,55841.27,74,,55841.27,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,33957.53,45,,33957.53,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,37353.28,49.5,,37353.28,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2492.85,,,2492.85,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,52822.83,70,,52822.83,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1340.24,,,1340.24,Other,New York Medicaid APG methodology,1340.24,,,1340.24,Other,100% New York Medicaid APG,1340.24,,,1340.24,Other,100% New York Medicaid APG,1340.24,,,1340.24,Other,100% New York Medicaid APG,3015.54,,,3015.54,Other,225% New York Medicaid APG,2050.57,,,2050.57,Other,153% New York Medicaid APG,3015.54,,,3015.54,Other,225% New York Medicaid APG,1876.34,,,1876.34,Other,140% New York Medicaid APG,3015.54,,,3015.54,Other,225% New York Medicaid APG,3484.62,,,3484.62,Other,260% New York Medicaid APG,4342.38,,,4342.38,Other,324% New York Medicaid APG,2881.52,,,2881.52,Other,215% New York Medicaid APG,2881.52,,,2881.52,Other,215% New York Medicaid APG,1675.3,,,1675.3,Other,125% New York Medicaid APG,1340.24,55841.27,
Remove sacrum pressure sore,15936,CPT,,,,,,,,both,,,38357.55,28384.59,74,,28384.59,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,17260.9,45,,17260.9,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,18986.99,49.5,,18986.99,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2492.85,,,2492.85,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,26850.29,70,,26850.29,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1340.24,,,1340.24,Other,New York Medicaid APG methodology,1340.24,,,1340.24,Other,100% New York Medicaid APG,1340.24,,,1340.24,Other,100% New York Medicaid APG,1340.24,,,1340.24,Other,100% New York Medicaid APG,3015.54,,,3015.54,Other,225% New York Medicaid APG,2050.57,,,2050.57,Other,153% New York Medicaid APG,3015.54,,,3015.54,Other,225% New York Medicaid APG,1876.34,,,1876.34,Other,140% New York Medicaid APG,3015.54,,,3015.54,Other,225% New York Medicaid APG,3484.62,,,3484.62,Other,260% New York Medicaid APG,4342.38,,,4342.38,Other,324% New York Medicaid APG,2881.52,,,2881.52,Other,215% New York Medicaid APG,2881.52,,,2881.52,Other,215% New York Medicaid APG,1675.3,,,1675.3,Other,125% New York Medicaid APG,1340.24,28384.59,
Remove sacrum pressure sore,15937,CPT,,,,,,,,both,,,38357.55,28384.59,74,,28384.59,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,17260.9,45,,17260.9,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,18986.99,49.5,,18986.99,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2492.85,,,2492.85,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,26850.29,70,,26850.29,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1340.24,,,1340.24,Other,New York Medicaid APG methodology,1340.24,,,1340.24,Other,100% New York Medicaid APG,1340.24,,,1340.24,Other,100% New York Medicaid APG,1340.24,,,1340.24,Other,100% New York Medicaid APG,3015.54,,,3015.54,Other,225% New York Medicaid APG,2050.57,,,2050.57,Other,153% New York Medicaid APG,3015.54,,,3015.54,Other,225% New York Medicaid APG,1876.34,,,1876.34,Other,140% New York Medicaid APG,3015.54,,,3015.54,Other,225% New York Medicaid APG,3484.62,,,3484.62,Other,260% New York Medicaid APG,4342.38,,,4342.38,Other,324% New York Medicaid APG,2881.52,,,2881.52,Other,215% New York Medicaid APG,2881.52,,,2881.52,Other,215% New York Medicaid APG,1675.3,,,1675.3,Other,125% New York Medicaid APG,1340.24,28384.59,
Remove hip pressure sore,15940,CPT,,,,,,,,both,,,59767.2,44227.73,74,,44227.73,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,26895.24,45,,26895.24,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,29584.76,49.5,,29584.76,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2492.85,,,2492.85,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,41837.04,70,,41837.04,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1340.24,,,1340.24,Other,New York Medicaid APG methodology,1340.24,,,1340.24,Other,100% New York Medicaid APG,1340.24,,,1340.24,Other,100% New York Medicaid APG,1340.24,,,1340.24,Other,100% New York Medicaid APG,3015.54,,,3015.54,Other,225% New York Medicaid APG,2050.57,,,2050.57,Other,153% New York Medicaid APG,3015.54,,,3015.54,Other,225% New York Medicaid APG,1876.34,,,1876.34,Other,140% New York Medicaid APG,3015.54,,,3015.54,Other,225% New York Medicaid APG,3484.62,,,3484.62,Other,260% New York Medicaid APG,4342.38,,,4342.38,Other,324% New York Medicaid APG,2881.52,,,2881.52,Other,215% New York Medicaid APG,2881.52,,,2881.52,Other,215% New York Medicaid APG,1675.3,,,1675.3,Other,125% New York Medicaid APG,1340.24,44227.73,
Remove hip pressure sore,15941,CPT,,,,,,,,both,,,59767.2,44227.73,74,,44227.73,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,26895.24,45,,26895.24,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,29584.76,49.5,,29584.76,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2492.85,,,2492.85,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,41837.04,70,,41837.04,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1340.24,,,1340.24,Other,New York Medicaid APG methodology,1340.24,,,1340.24,Other,100% New York Medicaid APG,1340.24,,,1340.24,Other,100% New York Medicaid APG,1340.24,,,1340.24,Other,100% New York Medicaid APG,3015.54,,,3015.54,Other,225% New York Medicaid APG,2050.57,,,2050.57,Other,153% New York Medicaid APG,3015.54,,,3015.54,Other,225% New York Medicaid APG,1876.34,,,1876.34,Other,140% New York Medicaid APG,3015.54,,,3015.54,Other,225% New York Medicaid APG,3484.62,,,3484.62,Other,260% New York Medicaid APG,4342.38,,,4342.38,Other,324% New York Medicaid APG,2881.52,,,2881.52,Other,215% New York Medicaid APG,2881.52,,,2881.52,Other,215% New York Medicaid APG,1675.3,,,1675.3,Other,125% New York Medicaid APG,1340.24,44227.73,
Remove hip pressure sore,15944,CPT,,,,,,,,both,,,75461.18,55841.27,74,,55841.27,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,33957.53,45,,33957.53,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,37353.28,49.5,,37353.28,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2492.85,,,2492.85,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,52822.83,70,,52822.83,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1340.24,,,1340.24,Other,New York Medicaid APG methodology,1340.24,,,1340.24,Other,100% New York Medicaid APG,1340.24,,,1340.24,Other,100% New York Medicaid APG,1340.24,,,1340.24,Other,100% New York Medicaid APG,3015.54,,,3015.54,Other,225% New York Medicaid APG,2050.57,,,2050.57,Other,153% New York Medicaid APG,3015.54,,,3015.54,Other,225% New York Medicaid APG,1876.34,,,1876.34,Other,140% New York Medicaid APG,3015.54,,,3015.54,Other,225% New York Medicaid APG,3484.62,,,3484.62,Other,260% New York Medicaid APG,4342.38,,,4342.38,Other,324% New York Medicaid APG,2881.52,,,2881.52,Other,215% New York Medicaid APG,2881.52,,,2881.52,Other,215% New York Medicaid APG,1675.3,,,1675.3,Other,125% New York Medicaid APG,1340.24,55841.27,
Remove hip pressure sore,15945,CPT,,,,,,,,both,,,38357.55,28384.59,74,,28384.59,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,17260.9,45,,17260.9,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,18986.99,49.5,,18986.99,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2492.85,,,2492.85,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,26850.29,70,,26850.29,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1340.24,,,1340.24,Other,New York Medicaid APG methodology,1340.24,,,1340.24,Other,100% New York Medicaid APG,1340.24,,,1340.24,Other,100% New York Medicaid APG,1340.24,,,1340.24,Other,100% New York Medicaid APG,3015.54,,,3015.54,Other,225% New York Medicaid APG,2050.57,,,2050.57,Other,153% New York Medicaid APG,3015.54,,,3015.54,Other,225% New York Medicaid APG,1876.34,,,1876.34,Other,140% New York Medicaid APG,3015.54,,,3015.54,Other,225% New York Medicaid APG,3484.62,,,3484.62,Other,260% New York Medicaid APG,4342.38,,,4342.38,Other,324% New York Medicaid APG,2881.52,,,2881.52,Other,215% New York Medicaid APG,2881.52,,,2881.52,Other,215% New York Medicaid APG,1675.3,,,1675.3,Other,125% New York Medicaid APG,1340.24,28384.59,
Remove hip pressure sore,15946,CPT,,,,,,,,both,,,38357.55,28384.59,74,,28384.59,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,17260.9,45,,17260.9,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,18986.99,49.5,,18986.99,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2492.85,,,2492.85,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,26850.29,70,,26850.29,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1340.24,,,1340.24,Other,New York Medicaid APG methodology,1340.24,,,1340.24,Other,100% New York Medicaid APG,1340.24,,,1340.24,Other,100% New York Medicaid APG,1340.24,,,1340.24,Other,100% New York Medicaid APG,3015.54,,,3015.54,Other,225% New York Medicaid APG,2050.57,,,2050.57,Other,153% New York Medicaid APG,3015.54,,,3015.54,Other,225% New York Medicaid APG,1876.34,,,1876.34,Other,140% New York Medicaid APG,3015.54,,,3015.54,Other,225% New York Medicaid APG,3484.62,,,3484.62,Other,260% New York Medicaid APG,4342.38,,,4342.38,Other,324% New York Medicaid APG,2881.52,,,2881.52,Other,215% New York Medicaid APG,2881.52,,,2881.52,Other,215% New York Medicaid APG,1675.3,,,1675.3,Other,125% New York Medicaid APG,1340.24,28384.59,
Remove thigh pressure sore,15950,CPT,,,,,,,,both,,,34101.75,25235.3,74,,25235.3,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15345.79,45,,15345.79,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,16880.37,49.5,,16880.37,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2492.85,,,2492.85,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,23871.23,70,,23871.23,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1340.24,,,1340.24,Other,New York Medicaid APG methodology,1340.24,,,1340.24,Other,100% New York Medicaid APG,1340.24,,,1340.24,Other,100% New York Medicaid APG,1340.24,,,1340.24,Other,100% New York Medicaid APG,3015.54,,,3015.54,Other,225% New York Medicaid APG,2050.57,,,2050.57,Other,153% New York Medicaid APG,3015.54,,,3015.54,Other,225% New York Medicaid APG,1876.34,,,1876.34,Other,140% New York Medicaid APG,3015.54,,,3015.54,Other,225% New York Medicaid APG,3484.62,,,3484.62,Other,260% New York Medicaid APG,4342.38,,,4342.38,Other,324% New York Medicaid APG,2881.52,,,2881.52,Other,215% New York Medicaid APG,2881.52,,,2881.52,Other,215% New York Medicaid APG,1675.3,,,1675.3,Other,125% New York Medicaid APG,1340.24,25235.3,
Remove thigh pressure sore,15951,CPT,,,,,,,,both,,,59767.2,44227.73,74,,44227.73,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,26895.24,45,,26895.24,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,29584.76,49.5,,29584.76,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2492.85,,,2492.85,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,41837.04,70,,41837.04,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1340.24,,,1340.24,Other,New York Medicaid APG methodology,1340.24,,,1340.24,Other,100% New York Medicaid APG,1340.24,,,1340.24,Other,100% New York Medicaid APG,1340.24,,,1340.24,Other,100% New York Medicaid APG,3015.54,,,3015.54,Other,225% New York Medicaid APG,2050.57,,,2050.57,Other,153% New York Medicaid APG,3015.54,,,3015.54,Other,225% New York Medicaid APG,1876.34,,,1876.34,Other,140% New York Medicaid APG,3015.54,,,3015.54,Other,225% New York Medicaid APG,3484.62,,,3484.62,Other,260% New York Medicaid APG,4342.38,,,4342.38,Other,324% New York Medicaid APG,2881.52,,,2881.52,Other,215% New York Medicaid APG,2881.52,,,2881.52,Other,215% New York Medicaid APG,1675.3,,,1675.3,Other,125% New York Medicaid APG,1340.24,44227.73,
Remove thigh pressure sore,15952,CPT,,,,,,,,both,,,38357.55,28384.59,74,,28384.59,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,17260.9,45,,17260.9,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,18986.99,49.5,,18986.99,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2492.85,,,2492.85,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,26850.29,70,,26850.29,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1340.24,,,1340.24,Other,New York Medicaid APG methodology,1340.24,,,1340.24,Other,100% New York Medicaid APG,1340.24,,,1340.24,Other,100% New York Medicaid APG,1340.24,,,1340.24,Other,100% New York Medicaid APG,3015.54,,,3015.54,Other,225% New York Medicaid APG,2050.57,,,2050.57,Other,153% New York Medicaid APG,3015.54,,,3015.54,Other,225% New York Medicaid APG,1876.34,,,1876.34,Other,140% New York Medicaid APG,3015.54,,,3015.54,Other,225% New York Medicaid APG,3484.62,,,3484.62,Other,260% New York Medicaid APG,4342.38,,,4342.38,Other,324% New York Medicaid APG,2881.52,,,2881.52,Other,215% New York Medicaid APG,2881.52,,,2881.52,Other,215% New York Medicaid APG,1675.3,,,1675.3,Other,125% New York Medicaid APG,1340.24,28384.59,
Remove thigh pressure sore,15953,CPT,,,,,,,,both,,,75461.18,55841.27,74,,55841.27,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,33957.53,45,,33957.53,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,37353.28,49.5,,37353.28,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2492.85,,,2492.85,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,52822.83,70,,52822.83,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1340.24,,,1340.24,Other,New York Medicaid APG methodology,1340.24,,,1340.24,Other,100% New York Medicaid APG,1340.24,,,1340.24,Other,100% New York Medicaid APG,1340.24,,,1340.24,Other,100% New York Medicaid APG,3015.54,,,3015.54,Other,225% New York Medicaid APG,2050.57,,,2050.57,Other,153% New York Medicaid APG,3015.54,,,3015.54,Other,225% New York Medicaid APG,1876.34,,,1876.34,Other,140% New York Medicaid APG,3015.54,,,3015.54,Other,225% New York Medicaid APG,3484.62,,,3484.62,Other,260% New York Medicaid APG,4342.38,,,4342.38,Other,324% New York Medicaid APG,2881.52,,,2881.52,Other,215% New York Medicaid APG,2881.52,,,2881.52,Other,215% New York Medicaid APG,1675.3,,,1675.3,Other,125% New York Medicaid APG,1340.24,55841.27,
Remove thigh pressure sore,15956,CPT,,,,,,,,both,,,38357.55,28384.59,74,,28384.59,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,17260.9,45,,17260.9,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,18986.99,49.5,,18986.99,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2492.85,,,2492.85,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,26850.29,70,,26850.29,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1340.24,,,1340.24,Other,New York Medicaid APG methodology,1340.24,,,1340.24,Other,100% New York Medicaid APG,1340.24,,,1340.24,Other,100% New York Medicaid APG,1340.24,,,1340.24,Other,100% New York Medicaid APG,3015.54,,,3015.54,Other,225% New York Medicaid APG,2050.57,,,2050.57,Other,153% New York Medicaid APG,3015.54,,,3015.54,Other,225% New York Medicaid APG,1876.34,,,1876.34,Other,140% New York Medicaid APG,3015.54,,,3015.54,Other,225% New York Medicaid APG,3484.62,,,3484.62,Other,260% New York Medicaid APG,4342.38,,,4342.38,Other,324% New York Medicaid APG,2881.52,,,2881.52,Other,215% New York Medicaid APG,2881.52,,,2881.52,Other,215% New York Medicaid APG,1675.3,,,1675.3,Other,125% New York Medicaid APG,1340.24,28384.59,
Remove thigh pressure sore,15958,CPT,,,,,,,,both,,,75461.18,55841.27,74,,55841.27,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,33957.53,45,,33957.53,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,37353.28,49.5,,37353.28,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2492.85,,,2492.85,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,52822.83,70,,52822.83,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1340.24,,,1340.24,Other,New York Medicaid APG methodology,1340.24,,,1340.24,Other,100% New York Medicaid APG,1340.24,,,1340.24,Other,100% New York Medicaid APG,1340.24,,,1340.24,Other,100% New York Medicaid APG,3015.54,,,3015.54,Other,225% New York Medicaid APG,2050.57,,,2050.57,Other,153% New York Medicaid APG,3015.54,,,3015.54,Other,225% New York Medicaid APG,1876.34,,,1876.34,Other,140% New York Medicaid APG,3015.54,,,3015.54,Other,225% New York Medicaid APG,3484.62,,,3484.62,Other,260% New York Medicaid APG,4342.38,,,4342.38,Other,324% New York Medicaid APG,2881.52,,,2881.52,Other,215% New York Medicaid APG,2881.52,,,2881.52,Other,215% New York Medicaid APG,1675.3,,,1675.3,Other,125% New York Medicaid APG,1340.24,55841.27,
Initial treatment of burn(s),16000,CPT,,,,,,,,both,,,4210.98,3116.13,74,,3116.13,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,1894.94,45,,1894.94,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,2084.44,49.5,,2084.44,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,957.71,,,957.71,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,2947.69,70,,2947.69,percent of total billed charges,,223.04,,,223.04,Fee Schedule,,189.04,,,189.04,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,514.9,,,514.9,Other,New York Medicaid APG methodology,514.9,,,514.9,Other,100% New York Medicaid APG,514.9,,,514.9,Other,100% New York Medicaid APG,514.9,,,514.9,Other,100% New York Medicaid APG,1158.52,,,1158.52,Other,225% New York Medicaid APG,787.8,,,787.8,Other,153% New York Medicaid APG,1158.52,,,1158.52,Other,225% New York Medicaid APG,720.86,,,720.86,Other,140% New York Medicaid APG,1158.52,,,1158.52,Other,225% New York Medicaid APG,1338.74,,,1338.74,Other,260% New York Medicaid APG,1668.27,,,1668.27,Other,324% New York Medicaid APG,1107.03,,,1107.03,Other,215% New York Medicaid APG,1107.03,,,1107.03,Other,215% New York Medicaid APG,643.62,,,643.62,Other,125% New York Medicaid APG,189.04,9473,
Dress/debrid p-thick burn s,16020,CPT,,,,,,,,both,,,33793.97,25007.54,74,,25007.54,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15207.29,45,,15207.29,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,16728.02,49.5,,16728.02,percent of total billed charges,110% of Medicare,22979.9,68,,22979.9,percent of total billed charges,,957.71,,,957.71,Other,186% of Medicaid,27035.18,80,,27035.18,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,27035.18,80,,27035.18,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,23655.78,70,,23655.78,percent of total billed charges,,270.6,,,270.6,Fee Schedule,,229.35,,,229.35,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,514.9,,,514.9,Other,New York Medicaid APG methodology,514.9,,,514.9,Other,100% New York Medicaid APG,514.9,,,514.9,Other,100% New York Medicaid APG,514.9,,,514.9,Other,100% New York Medicaid APG,1158.52,,,1158.52,Other,225% New York Medicaid APG,787.8,,,787.8,Other,153% New York Medicaid APG,1158.52,,,1158.52,Other,225% New York Medicaid APG,720.86,,,720.86,Other,140% New York Medicaid APG,1158.52,,,1158.52,Other,225% New York Medicaid APG,1338.74,,,1338.74,Other,260% New York Medicaid APG,1668.27,,,1668.27,Other,324% New York Medicaid APG,1107.03,,,1107.03,Other,215% New York Medicaid APG,1107.03,,,1107.03,Other,215% New York Medicaid APG,643.62,,,643.62,Other,125% New York Medicaid APG,229.35,27035.18,
Dress/debrid p-thick burn m,16025,CPT,,,,,,,,both,,,38051.11,28157.82,74,,28157.82,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,17123,45,,17123,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,18835.3,49.5,,18835.3,percent of total billed charges,110% of Medicare,25874.75,68,,25874.75,percent of total billed charges,,957.71,,,957.71,Other,186% of Medicaid,30440.89,80,,30440.89,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,30440.89,80,,30440.89,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,26635.78,70,,26635.78,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,514.9,,,514.9,Other,New York Medicaid APG methodology,514.9,,,514.9,Other,100% New York Medicaid APG,514.9,,,514.9,Other,100% New York Medicaid APG,514.9,,,514.9,Other,100% New York Medicaid APG,1158.52,,,1158.52,Other,225% New York Medicaid APG,787.8,,,787.8,Other,153% New York Medicaid APG,1158.52,,,1158.52,Other,225% New York Medicaid APG,720.86,,,720.86,Other,140% New York Medicaid APG,1158.52,,,1158.52,Other,225% New York Medicaid APG,1338.74,,,1338.74,Other,260% New York Medicaid APG,1668.27,,,1668.27,Other,324% New York Medicaid APG,1107.03,,,1107.03,Other,215% New York Medicaid APG,1107.03,,,1107.03,Other,215% New York Medicaid APG,643.62,,,643.62,Other,125% New York Medicaid APG,514.9,30440.89,
Dress/debrid p-thick burn l,16030,CPT,,,,,,,,both,,,34605.58,25608.13,74,,25608.13,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15572.51,45,,15572.51,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,17129.76,49.5,,17129.76,percent of total billed charges,110% of Medicare,23531.79,68,,23531.79,percent of total billed charges,,1352.53,,,1352.53,Other,186% of Medicaid,27684.46,80,,27684.46,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,27684.46,80,,27684.46,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,24223.91,70,,24223.91,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,727.17,,,727.17,Other,New York Medicaid APG methodology,727.17,,,727.17,Other,100% New York Medicaid APG,727.17,,,727.17,Other,100% New York Medicaid APG,727.17,,,727.17,Other,100% New York Medicaid APG,1636.12,,,1636.12,Other,225% New York Medicaid APG,1112.56,,,1112.56,Other,153% New York Medicaid APG,1636.12,,,1636.12,Other,225% New York Medicaid APG,1018.03,,,1018.03,Other,140% New York Medicaid APG,1636.12,,,1636.12,Other,225% New York Medicaid APG,1890.63,,,1890.63,Other,260% New York Medicaid APG,2356.02,,,2356.02,Other,324% New York Medicaid APG,1563.41,,,1563.41,Other,215% New York Medicaid APG,1563.41,,,1563.41,Other,215% New York Medicaid APG,908.96,,,908.96,Other,125% New York Medicaid APG,727.17,27684.46,
Incision of burn scab initi,16035,CPT,,,,,,,,both,,,8387.08,6206.44,74,,6206.44,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,3774.19,45,,3774.19,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,4151.6,49.5,,4151.6,percent of total billed charges,110% of Medicare,5703.21,68,,5703.21,percent of total billed charges,,1352.53,,,1352.53,Other,186% of Medicaid,6709.66,80,,6709.66,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,6709.66,80,,6709.66,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,5870.96,70,,5870.96,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,727.17,,,727.17,Other,New York Medicaid APG methodology,727.17,,,727.17,Other,100% New York Medicaid APG,727.17,,,727.17,Other,100% New York Medicaid APG,727.17,,,727.17,Other,100% New York Medicaid APG,1636.12,,,1636.12,Other,225% New York Medicaid APG,1112.56,,,1112.56,Other,153% New York Medicaid APG,1636.12,,,1636.12,Other,225% New York Medicaid APG,1018.03,,,1018.03,Other,140% New York Medicaid APG,1636.12,,,1636.12,Other,225% New York Medicaid APG,1890.63,,,1890.63,Other,260% New York Medicaid APG,2356.02,,,2356.02,Other,324% New York Medicaid APG,1563.41,,,1563.41,Other,215% New York Medicaid APG,1563.41,,,1563.41,Other,215% New York Medicaid APG,908.96,,,908.96,Other,125% New York Medicaid APG,727.17,7216,
Destruct premalg lesion,17000,CPT,,,,,,,,both,,,4210.98,3116.13,74,,3116.13,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,1894.94,45,,1894.94,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,2084.44,49.5,,2084.44,percent of total billed charges,110% of Medicare,2863.47,68,,2863.47,percent of total billed charges,,733.11,,,733.11,Other,186% of Medicaid,3368.78,80,,3368.78,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,3368.78,80,,3368.78,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,2947.69,70,,2947.69,percent of total billed charges,,267.32,,,267.32,Fee Schedule,,226.57,,,226.57,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,394.14,,,394.14,Other,New York Medicaid APG methodology,394.14,,,394.14,Other,100% New York Medicaid APG,394.14,,,394.14,Other,100% New York Medicaid APG,394.14,,,394.14,Other,100% New York Medicaid APG,886.83,,,886.83,Other,225% New York Medicaid APG,603.04,,,603.04,Other,153% New York Medicaid APG,886.83,,,886.83,Other,225% New York Medicaid APG,551.8,,,551.8,Other,140% New York Medicaid APG,886.83,,,886.83,Other,225% New York Medicaid APG,1024.78,,,1024.78,Other,260% New York Medicaid APG,1277.03,,,1277.03,Other,324% New York Medicaid APG,847.41,,,847.41,Other,215% New York Medicaid APG,847.41,,,847.41,Other,215% New York Medicaid APG,492.68,,,492.68,Other,125% New York Medicaid APG,226.57,7216,
Destruct premalg les 2-14,17003,CPT,,,,,,,,both,,,32432.1,23999.75,74,,23999.75,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,14594.45,45,,14594.45,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,16053.89,49.5,,16053.89,percent of total billed charges,110% of Medicare,22053.83,68,,22053.83,percent of total billed charges,,733.11,,,733.11,Other,186% of Medicaid,25945.68,80,,25945.68,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,25945.68,80,,25945.68,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,22702.47,70,,22702.47,percent of total billed charges,,9.84,,,9.84,Fee Schedule,,8.34,,,8.34,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,394.14,,,394.14,Other,New York Medicaid APG methodology,394.14,,,394.14,Other,100% New York Medicaid APG,394.14,,,394.14,Other,100% New York Medicaid APG,394.14,,,394.14,Other,100% New York Medicaid APG,886.83,,,886.83,Other,225% New York Medicaid APG,603.04,,,603.04,Other,153% New York Medicaid APG,886.83,,,886.83,Other,225% New York Medicaid APG,551.8,,,551.8,Other,140% New York Medicaid APG,886.83,,,886.83,Other,225% New York Medicaid APG,1024.78,,,1024.78,Other,260% New York Medicaid APG,1277.03,,,1277.03,Other,324% New York Medicaid APG,847.41,,,847.41,Other,215% New York Medicaid APG,847.41,,,847.41,Other,215% New York Medicaid APG,492.68,,,492.68,Other,125% New York Medicaid APG,8.34,25945.68,
Destroy premal lesions 15/>,17004,CPT,,,,,,,,both,,,8387.08,6206.44,74,,6206.44,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,3774.19,45,,3774.19,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,4151.6,49.5,,4151.6,percent of total billed charges,110% of Medicare,5703.21,68,,5703.21,percent of total billed charges,,733.11,,,733.11,Other,186% of Medicaid,6709.66,80,,6709.66,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,6709.66,80,,6709.66,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,5870.96,70,,5870.96,percent of total billed charges,,483.8,,,483.8,Fee Schedule,,410.05,,,410.05,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,394.14,,,394.14,Other,New York Medicaid APG methodology,394.14,,,394.14,Other,100% New York Medicaid APG,394.14,,,394.14,Other,100% New York Medicaid APG,394.14,,,394.14,Other,100% New York Medicaid APG,886.83,,,886.83,Other,225% New York Medicaid APG,603.04,,,603.04,Other,153% New York Medicaid APG,886.83,,,886.83,Other,225% New York Medicaid APG,551.8,,,551.8,Other,140% New York Medicaid APG,886.83,,,886.83,Other,225% New York Medicaid APG,1024.78,,,1024.78,Other,260% New York Medicaid APG,1277.03,,,1277.03,Other,324% New York Medicaid APG,847.41,,,847.41,Other,215% New York Medicaid APG,847.41,,,847.41,Other,215% New York Medicaid APG,492.68,,,492.68,Other,125% New York Medicaid APG,394.14,7216,
Destruction of skin lesions,17106,CPT,,,,,,,,both,,,8387.08,6206.44,74,,6206.44,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,3774.19,45,,3774.19,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,4151.6,49.5,,4151.6,percent of total billed charges,110% of Medicare,5703.21,68,,5703.21,percent of total billed charges,,1207.1,,,1207.1,Other,186% of Medicaid,6709.66,80,,6709.66,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,6709.66,80,,6709.66,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,5870.96,70,,5870.96,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,648.98,,,648.98,Other,New York Medicaid APG methodology,648.98,,,648.98,Other,100% New York Medicaid APG,648.98,,,648.98,Other,100% New York Medicaid APG,648.98,,,648.98,Other,100% New York Medicaid APG,1460.2,,,1460.2,Other,225% New York Medicaid APG,992.94,,,992.94,Other,153% New York Medicaid APG,1460.2,,,1460.2,Other,225% New York Medicaid APG,908.57,,,908.57,Other,140% New York Medicaid APG,1460.2,,,1460.2,Other,225% New York Medicaid APG,1687.34,,,1687.34,Other,260% New York Medicaid APG,2102.69,,,2102.69,Other,324% New York Medicaid APG,1395.3,,,1395.3,Other,215% New York Medicaid APG,1395.3,,,1395.3,Other,215% New York Medicaid APG,811.22,,,811.22,Other,125% New York Medicaid APG,648.98,7216,
Destruction of skin lesions,17107,CPT,,,,,,,,both,,,13210.22,9775.56,74,,9775.56,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,5944.6,45,,5944.6,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,6539.06,49.5,,6539.06,percent of total billed charges,110% of Medicare,8982.95,68,,8982.95,percent of total billed charges,,1207.1,,,1207.1,Other,186% of Medicaid,10568.18,80,,10568.18,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,10568.18,80,,10568.18,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,9247.15,70,,9247.15,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,648.98,,,648.98,Other,New York Medicaid APG methodology,648.98,,,648.98,Other,100% New York Medicaid APG,648.98,,,648.98,Other,100% New York Medicaid APG,648.98,,,648.98,Other,100% New York Medicaid APG,1460.2,,,1460.2,Other,225% New York Medicaid APG,992.94,,,992.94,Other,153% New York Medicaid APG,1460.2,,,1460.2,Other,225% New York Medicaid APG,908.57,,,908.57,Other,140% New York Medicaid APG,1460.2,,,1460.2,Other,225% New York Medicaid APG,1687.34,,,1687.34,Other,260% New York Medicaid APG,2102.69,,,2102.69,Other,324% New York Medicaid APG,1395.3,,,1395.3,Other,215% New York Medicaid APG,1395.3,,,1395.3,Other,215% New York Medicaid APG,811.22,,,811.22,Other,125% New York Medicaid APG,648.98,10568.18,
Destruction of skin lesions,17108,CPT,,,,,,,,both,,,38357.55,28384.59,74,,28384.59,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,17260.9,45,,17260.9,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,18986.99,49.5,,18986.99,percent of total billed charges,110% of Medicare,26083.13,68,,26083.13,percent of total billed charges,,1207.1,,,1207.1,Other,186% of Medicaid,30686.04,80,,30686.04,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,30686.04,80,,30686.04,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,26850.29,70,,26850.29,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,648.98,,,648.98,Other,New York Medicaid APG methodology,648.98,,,648.98,Other,100% New York Medicaid APG,648.98,,,648.98,Other,100% New York Medicaid APG,648.98,,,648.98,Other,100% New York Medicaid APG,1460.2,,,1460.2,Other,225% New York Medicaid APG,992.94,,,992.94,Other,153% New York Medicaid APG,1460.2,,,1460.2,Other,225% New York Medicaid APG,908.57,,,908.57,Other,140% New York Medicaid APG,1460.2,,,1460.2,Other,225% New York Medicaid APG,1687.34,,,1687.34,Other,260% New York Medicaid APG,2102.69,,,2102.69,Other,324% New York Medicaid APG,1395.3,,,1395.3,Other,215% New York Medicaid APG,1395.3,,,1395.3,Other,215% New York Medicaid APG,811.22,,,811.22,Other,125% New York Medicaid APG,648.98,30686.04,
Destruct b9 lesion 1-14,17110,CPT,,,,,,,,both,,,36111.92,26722.82,74,,26722.82,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,16250.36,45,,16250.36,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,17875.4,49.5,,17875.4,percent of total billed charges,110% of Medicare,24556.11,68,,24556.11,percent of total billed charges,,733.11,,,733.11,Other,186% of Medicaid,28889.54,80,,28889.54,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,28889.54,80,,28889.54,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,25278.34,70,,25278.34,percent of total billed charges,,328,,,328,Fee Schedule,,278,,,278,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,394.14,,,394.14,Other,New York Medicaid APG methodology,394.14,,,394.14,Other,100% New York Medicaid APG,394.14,,,394.14,Other,100% New York Medicaid APG,394.14,,,394.14,Other,100% New York Medicaid APG,886.83,,,886.83,Other,225% New York Medicaid APG,603.04,,,603.04,Other,153% New York Medicaid APG,886.83,,,886.83,Other,225% New York Medicaid APG,551.8,,,551.8,Other,140% New York Medicaid APG,886.83,,,886.83,Other,225% New York Medicaid APG,1024.78,,,1024.78,Other,260% New York Medicaid APG,1277.03,,,1277.03,Other,324% New York Medicaid APG,847.41,,,847.41,Other,215% New York Medicaid APG,847.41,,,847.41,Other,215% New York Medicaid APG,492.68,,,492.68,Other,125% New York Medicaid APG,278,28889.54,
Destruct lesion 15 or more,17111,CPT,,,,,,,,both,,,4210.98,3116.13,74,,3116.13,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,1894.94,45,,1894.94,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,2084.44,49.5,,2084.44,percent of total billed charges,110% of Medicare,2863.47,68,,2863.47,percent of total billed charges,,733.11,,,733.11,Other,186% of Medicaid,3368.78,80,,3368.78,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,3368.78,80,,3368.78,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,2947.69,70,,2947.69,percent of total billed charges,,401.8,,,401.8,Fee Schedule,,340.55,,,340.55,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,394.14,,,394.14,Other,New York Medicaid APG methodology,394.14,,,394.14,Other,100% New York Medicaid APG,394.14,,,394.14,Other,100% New York Medicaid APG,394.14,,,394.14,Other,100% New York Medicaid APG,886.83,,,886.83,Other,225% New York Medicaid APG,603.04,,,603.04,Other,153% New York Medicaid APG,886.83,,,886.83,Other,225% New York Medicaid APG,551.8,,,551.8,Other,140% New York Medicaid APG,886.83,,,886.83,Other,225% New York Medicaid APG,1024.78,,,1024.78,Other,260% New York Medicaid APG,1277.03,,,1277.03,Other,324% New York Medicaid APG,847.41,,,847.41,Other,215% New York Medicaid APG,847.41,,,847.41,Other,215% New York Medicaid APG,492.68,,,492.68,Other,125% New York Medicaid APG,340.55,7216,
Chem caut of granltj tissue,17250,CPT,,,,,,,,both,,,4210.98,3116.13,74,,3116.13,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,1894.94,45,,1894.94,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,2084.44,49.5,,2084.44,percent of total billed charges,110% of Medicare,2863.47,68,,2863.47,percent of total billed charges,,733.11,,,733.11,Other,186% of Medicaid,3368.78,80,,3368.78,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,3368.78,80,,3368.78,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,2947.69,70,,2947.69,percent of total billed charges,,182.04,,,182.04,Fee Schedule,,154.29,,,154.29,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,394.14,,,394.14,Other,New York Medicaid APG methodology,394.14,,,394.14,Other,100% New York Medicaid APG,394.14,,,394.14,Other,100% New York Medicaid APG,394.14,,,394.14,Other,100% New York Medicaid APG,886.83,,,886.83,Other,225% New York Medicaid APG,603.04,,,603.04,Other,153% New York Medicaid APG,886.83,,,886.83,Other,225% New York Medicaid APG,551.8,,,551.8,Other,140% New York Medicaid APG,886.83,,,886.83,Other,225% New York Medicaid APG,1024.78,,,1024.78,Other,260% New York Medicaid APG,1277.03,,,1277.03,Other,324% New York Medicaid APG,847.41,,,847.41,Other,215% New York Medicaid APG,847.41,,,847.41,Other,215% New York Medicaid APG,492.68,,,492.68,Other,125% New York Medicaid APG,154.29,7216,
Destruction of skin lesions,17260,CPT,,,,,,,,both,,,4210.98,3116.13,74,,3116.13,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,1894.94,45,,1894.94,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,2084.44,49.5,,2084.44,percent of total billed charges,110% of Medicare,2863.47,68,,2863.47,percent of total billed charges,,733.11,,,733.11,Other,186% of Medicaid,3368.78,80,,3368.78,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,3368.78,80,,3368.78,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,2947.69,70,,2947.69,percent of total billed charges,,344.4,,,344.4,Fee Schedule,,291.9,,,291.9,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,394.14,,,394.14,Other,New York Medicaid APG methodology,394.14,,,394.14,Other,100% New York Medicaid APG,394.14,,,394.14,Other,100% New York Medicaid APG,394.14,,,394.14,Other,100% New York Medicaid APG,886.83,,,886.83,Other,225% New York Medicaid APG,603.04,,,603.04,Other,153% New York Medicaid APG,886.83,,,886.83,Other,225% New York Medicaid APG,551.8,,,551.8,Other,140% New York Medicaid APG,886.83,,,886.83,Other,225% New York Medicaid APG,1024.78,,,1024.78,Other,260% New York Medicaid APG,1277.03,,,1277.03,Other,324% New York Medicaid APG,847.41,,,847.41,Other,215% New York Medicaid APG,847.41,,,847.41,Other,215% New York Medicaid APG,492.68,,,492.68,Other,125% New York Medicaid APG,291.9,7216,
Destruction of skin lesions,17261,CPT,,,,,,,,both,,,4210.98,3116.13,74,,3116.13,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,1894.94,45,,1894.94,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,2084.44,49.5,,2084.44,percent of total billed charges,110% of Medicare,2863.47,68,,2863.47,percent of total billed charges,,733.11,,,733.11,Other,186% of Medicaid,3368.78,80,,3368.78,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,3368.78,80,,3368.78,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,2947.69,70,,2947.69,percent of total billed charges,,421.48,,,421.48,Fee Schedule,,357.23,,,357.23,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,394.14,,,394.14,Other,New York Medicaid APG methodology,394.14,,,394.14,Other,100% New York Medicaid APG,394.14,,,394.14,Other,100% New York Medicaid APG,394.14,,,394.14,Other,100% New York Medicaid APG,886.83,,,886.83,Other,225% New York Medicaid APG,603.04,,,603.04,Other,153% New York Medicaid APG,886.83,,,886.83,Other,225% New York Medicaid APG,551.8,,,551.8,Other,140% New York Medicaid APG,886.83,,,886.83,Other,225% New York Medicaid APG,1024.78,,,1024.78,Other,260% New York Medicaid APG,1277.03,,,1277.03,Other,324% New York Medicaid APG,847.41,,,847.41,Other,215% New York Medicaid APG,847.41,,,847.41,Other,215% New York Medicaid APG,492.68,,,492.68,Other,125% New York Medicaid APG,357.23,7216,
Destruction of skin lesions,17262,CPT,,,,,,,,both,,,4210.98,3116.13,74,,3116.13,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,1894.94,45,,1894.94,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,2084.44,49.5,,2084.44,percent of total billed charges,110% of Medicare,2863.47,68,,2863.47,percent of total billed charges,,733.11,,,733.11,Other,186% of Medicaid,3368.78,80,,3368.78,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,3368.78,80,,3368.78,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,2947.69,70,,2947.69,percent of total billed charges,,537.92,,,537.92,Fee Schedule,,455.92,,,455.92,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,394.14,,,394.14,Other,New York Medicaid APG methodology,394.14,,,394.14,Other,100% New York Medicaid APG,394.14,,,394.14,Other,100% New York Medicaid APG,394.14,,,394.14,Other,100% New York Medicaid APG,886.83,,,886.83,Other,225% New York Medicaid APG,603.04,,,603.04,Other,153% New York Medicaid APG,886.83,,,886.83,Other,225% New York Medicaid APG,551.8,,,551.8,Other,140% New York Medicaid APG,886.83,,,886.83,Other,225% New York Medicaid APG,1024.78,,,1024.78,Other,260% New York Medicaid APG,1277.03,,,1277.03,Other,324% New York Medicaid APG,847.41,,,847.41,Other,215% New York Medicaid APG,847.41,,,847.41,Other,215% New York Medicaid APG,492.68,,,492.68,Other,125% New York Medicaid APG,394.14,7216,
Destruction of skin lesions,17263,CPT,,,,,,,,both,,,4210.98,3116.13,74,,3116.13,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,1894.94,45,,1894.94,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,2084.44,49.5,,2084.44,percent of total billed charges,110% of Medicare,2863.47,68,,2863.47,percent of total billed charges,,733.11,,,733.11,Other,186% of Medicaid,3368.78,80,,3368.78,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,3368.78,80,,3368.78,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,2947.69,70,,2947.69,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,394.14,,,394.14,Other,New York Medicaid APG methodology,394.14,,,394.14,Other,100% New York Medicaid APG,394.14,,,394.14,Other,100% New York Medicaid APG,394.14,,,394.14,Other,100% New York Medicaid APG,886.83,,,886.83,Other,225% New York Medicaid APG,603.04,,,603.04,Other,153% New York Medicaid APG,886.83,,,886.83,Other,225% New York Medicaid APG,551.8,,,551.8,Other,140% New York Medicaid APG,886.83,,,886.83,Other,225% New York Medicaid APG,1024.78,,,1024.78,Other,260% New York Medicaid APG,1277.03,,,1277.03,Other,324% New York Medicaid APG,847.41,,,847.41,Other,215% New York Medicaid APG,847.41,,,847.41,Other,215% New York Medicaid APG,492.68,,,492.68,Other,125% New York Medicaid APG,394.14,7216,
Destruction of skin lesions,17264,CPT,,,,,,,,both,,,8387.08,6206.44,74,,6206.44,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,3774.19,45,,3774.19,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,4151.6,49.5,,4151.6,percent of total billed charges,110% of Medicare,5703.21,68,,5703.21,percent of total billed charges,,733.11,,,733.11,Other,186% of Medicaid,6709.66,80,,6709.66,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,6709.66,80,,6709.66,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,5870.96,70,,5870.96,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,394.14,,,394.14,Other,New York Medicaid APG methodology,394.14,,,394.14,Other,100% New York Medicaid APG,394.14,,,394.14,Other,100% New York Medicaid APG,394.14,,,394.14,Other,100% New York Medicaid APG,886.83,,,886.83,Other,225% New York Medicaid APG,603.04,,,603.04,Other,153% New York Medicaid APG,886.83,,,886.83,Other,225% New York Medicaid APG,551.8,,,551.8,Other,140% New York Medicaid APG,886.83,,,886.83,Other,225% New York Medicaid APG,1024.78,,,1024.78,Other,260% New York Medicaid APG,1277.03,,,1277.03,Other,324% New York Medicaid APG,847.41,,,847.41,Other,215% New York Medicaid APG,847.41,,,847.41,Other,215% New York Medicaid APG,492.68,,,492.68,Other,125% New York Medicaid APG,394.14,7216,
Destruction of skin lesions,17266,CPT,,,,,,,,both,,,8387.08,6206.44,74,,6206.44,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,3774.19,45,,3774.19,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,4151.6,49.5,,4151.6,percent of total billed charges,110% of Medicare,5703.21,68,,5703.21,percent of total billed charges,,733.11,,,733.11,Other,186% of Medicaid,6709.66,80,,6709.66,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,6709.66,80,,6709.66,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,5870.96,70,,5870.96,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,394.14,,,394.14,Other,New York Medicaid APG methodology,394.14,,,394.14,Other,100% New York Medicaid APG,394.14,,,394.14,Other,100% New York Medicaid APG,394.14,,,394.14,Other,100% New York Medicaid APG,886.83,,,886.83,Other,225% New York Medicaid APG,603.04,,,603.04,Other,153% New York Medicaid APG,886.83,,,886.83,Other,225% New York Medicaid APG,551.8,,,551.8,Other,140% New York Medicaid APG,886.83,,,886.83,Other,225% New York Medicaid APG,1024.78,,,1024.78,Other,260% New York Medicaid APG,1277.03,,,1277.03,Other,324% New York Medicaid APG,847.41,,,847.41,Other,215% New York Medicaid APG,847.41,,,847.41,Other,215% New York Medicaid APG,492.68,,,492.68,Other,125% New York Medicaid APG,394.14,7216,
Destruction of skin lesions,17270,CPT,,,,,,,,both,,,4210.98,3116.13,74,,3116.13,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,1894.94,45,,1894.94,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,2084.44,49.5,,2084.44,percent of total billed charges,110% of Medicare,2863.47,68,,2863.47,percent of total billed charges,,733.11,,,733.11,Other,186% of Medicaid,3368.78,80,,3368.78,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,3368.78,80,,3368.78,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,2947.69,70,,2947.69,percent of total billed charges,,465.76,,,465.76,Fee Schedule,,394.76,,,394.76,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,394.14,,,394.14,Other,New York Medicaid APG methodology,394.14,,,394.14,Other,100% New York Medicaid APG,394.14,,,394.14,Other,100% New York Medicaid APG,394.14,,,394.14,Other,100% New York Medicaid APG,886.83,,,886.83,Other,225% New York Medicaid APG,603.04,,,603.04,Other,153% New York Medicaid APG,886.83,,,886.83,Other,225% New York Medicaid APG,551.8,,,551.8,Other,140% New York Medicaid APG,886.83,,,886.83,Other,225% New York Medicaid APG,1024.78,,,1024.78,Other,260% New York Medicaid APG,1277.03,,,1277.03,Other,324% New York Medicaid APG,847.41,,,847.41,Other,215% New York Medicaid APG,847.41,,,847.41,Other,215% New York Medicaid APG,492.68,,,492.68,Other,125% New York Medicaid APG,394.14,7216,
Destruction of skin lesions,17271,CPT,,,,,,,,both,,,4210.98,3116.13,74,,3116.13,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,1894.94,45,,1894.94,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,2084.44,49.5,,2084.44,percent of total billed charges,110% of Medicare,2863.47,68,,2863.47,percent of total billed charges,,733.11,,,733.11,Other,186% of Medicaid,3368.78,80,,3368.78,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,3368.78,80,,3368.78,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,2947.69,70,,2947.69,percent of total billed charges,,513.32,,,513.32,Fee Schedule,,435.07,,,435.07,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,394.14,,,394.14,Other,New York Medicaid APG methodology,394.14,,,394.14,Other,100% New York Medicaid APG,394.14,,,394.14,Other,100% New York Medicaid APG,394.14,,,394.14,Other,100% New York Medicaid APG,886.83,,,886.83,Other,225% New York Medicaid APG,603.04,,,603.04,Other,153% New York Medicaid APG,886.83,,,886.83,Other,225% New York Medicaid APG,551.8,,,551.8,Other,140% New York Medicaid APG,886.83,,,886.83,Other,225% New York Medicaid APG,1024.78,,,1024.78,Other,260% New York Medicaid APG,1277.03,,,1277.03,Other,324% New York Medicaid APG,847.41,,,847.41,Other,215% New York Medicaid APG,847.41,,,847.41,Other,215% New York Medicaid APG,492.68,,,492.68,Other,125% New York Medicaid APG,394.14,7216,
Destruction of skin lesions,17272,CPT,,,,,,,,both,,,4210.98,3116.13,74,,3116.13,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,1894.94,45,,1894.94,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,2084.44,49.5,,2084.44,percent of total billed charges,110% of Medicare,2863.47,68,,2863.47,percent of total billed charges,,733.11,,,733.11,Other,186% of Medicaid,3368.78,80,,3368.78,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,3368.78,80,,3368.78,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,2947.69,70,,2947.69,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,394.14,,,394.14,Other,New York Medicaid APG methodology,394.14,,,394.14,Other,100% New York Medicaid APG,394.14,,,394.14,Other,100% New York Medicaid APG,394.14,,,394.14,Other,100% New York Medicaid APG,886.83,,,886.83,Other,225% New York Medicaid APG,603.04,,,603.04,Other,153% New York Medicaid APG,886.83,,,886.83,Other,225% New York Medicaid APG,551.8,,,551.8,Other,140% New York Medicaid APG,886.83,,,886.83,Other,225% New York Medicaid APG,1024.78,,,1024.78,Other,260% New York Medicaid APG,1277.03,,,1277.03,Other,324% New York Medicaid APG,847.41,,,847.41,Other,215% New York Medicaid APG,847.41,,,847.41,Other,215% New York Medicaid APG,492.68,,,492.68,Other,125% New York Medicaid APG,394.14,7216,
Destruction of skin lesions,17273,CPT,,,,,,,,both,,,8387.08,6206.44,74,,6206.44,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,3774.19,45,,3774.19,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,4151.6,49.5,,4151.6,percent of total billed charges,110% of Medicare,5703.21,68,,5703.21,percent of total billed charges,,733.11,,,733.11,Other,186% of Medicaid,6709.66,80,,6709.66,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,6709.66,80,,6709.66,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,5870.96,70,,5870.96,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,394.14,,,394.14,Other,New York Medicaid APG methodology,394.14,,,394.14,Other,100% New York Medicaid APG,394.14,,,394.14,Other,100% New York Medicaid APG,394.14,,,394.14,Other,100% New York Medicaid APG,886.83,,,886.83,Other,225% New York Medicaid APG,603.04,,,603.04,Other,153% New York Medicaid APG,886.83,,,886.83,Other,225% New York Medicaid APG,551.8,,,551.8,Other,140% New York Medicaid APG,886.83,,,886.83,Other,225% New York Medicaid APG,1024.78,,,1024.78,Other,260% New York Medicaid APG,1277.03,,,1277.03,Other,324% New York Medicaid APG,847.41,,,847.41,Other,215% New York Medicaid APG,847.41,,,847.41,Other,215% New York Medicaid APG,492.68,,,492.68,Other,125% New York Medicaid APG,394.14,7216,
Destruction of skin lesions,17274,CPT,,,,,,,,both,,,8387.08,6206.44,74,,6206.44,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,3774.19,45,,3774.19,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,4151.6,49.5,,4151.6,percent of total billed charges,110% of Medicare,5703.21,68,,5703.21,percent of total billed charges,,733.11,,,733.11,Other,186% of Medicaid,6709.66,80,,6709.66,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,6709.66,80,,6709.66,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,5870.96,70,,5870.96,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,394.14,,,394.14,Other,New York Medicaid APG methodology,394.14,,,394.14,Other,100% New York Medicaid APG,394.14,,,394.14,Other,100% New York Medicaid APG,394.14,,,394.14,Other,100% New York Medicaid APG,886.83,,,886.83,Other,225% New York Medicaid APG,603.04,,,603.04,Other,153% New York Medicaid APG,886.83,,,886.83,Other,225% New York Medicaid APG,551.8,,,551.8,Other,140% New York Medicaid APG,886.83,,,886.83,Other,225% New York Medicaid APG,1024.78,,,1024.78,Other,260% New York Medicaid APG,1277.03,,,1277.03,Other,324% New York Medicaid APG,847.41,,,847.41,Other,215% New York Medicaid APG,847.41,,,847.41,Other,215% New York Medicaid APG,492.68,,,492.68,Other,125% New York Medicaid APG,394.14,7216,
Destruction of skin lesions,17276,CPT,,,,,,,,both,,,8387.08,6206.44,74,,6206.44,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,3774.19,45,,3774.19,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,4151.6,49.5,,4151.6,percent of total billed charges,110% of Medicare,5703.21,68,,5703.21,percent of total billed charges,,733.11,,,733.11,Other,186% of Medicaid,6709.66,80,,6709.66,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,6709.66,80,,6709.66,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,5870.96,70,,5870.96,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,394.14,,,394.14,Other,New York Medicaid APG methodology,394.14,,,394.14,Other,100% New York Medicaid APG,394.14,,,394.14,Other,100% New York Medicaid APG,394.14,,,394.14,Other,100% New York Medicaid APG,886.83,,,886.83,Other,225% New York Medicaid APG,603.04,,,603.04,Other,153% New York Medicaid APG,886.83,,,886.83,Other,225% New York Medicaid APG,551.8,,,551.8,Other,140% New York Medicaid APG,886.83,,,886.83,Other,225% New York Medicaid APG,1024.78,,,1024.78,Other,260% New York Medicaid APG,1277.03,,,1277.03,Other,324% New York Medicaid APG,847.41,,,847.41,Other,215% New York Medicaid APG,847.41,,,847.41,Other,215% New York Medicaid APG,492.68,,,492.68,Other,125% New York Medicaid APG,394.14,7216,
Destruction of skin lesions,17280,CPT,,,,,,,,both,,,4210.98,3116.13,74,,3116.13,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,1894.94,45,,1894.94,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,2084.44,49.5,,2084.44,percent of total billed charges,110% of Medicare,2863.47,68,,2863.47,percent of total billed charges,,733.11,,,733.11,Other,186% of Medicaid,3368.78,80,,3368.78,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,3368.78,80,,3368.78,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,2947.69,70,,2947.69,percent of total billed charges,,419.84,,,419.84,Fee Schedule,,355.84,,,355.84,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,394.14,,,394.14,Other,New York Medicaid APG methodology,394.14,,,394.14,Other,100% New York Medicaid APG,394.14,,,394.14,Other,100% New York Medicaid APG,394.14,,,394.14,Other,100% New York Medicaid APG,886.83,,,886.83,Other,225% New York Medicaid APG,603.04,,,603.04,Other,153% New York Medicaid APG,886.83,,,886.83,Other,225% New York Medicaid APG,551.8,,,551.8,Other,140% New York Medicaid APG,886.83,,,886.83,Other,225% New York Medicaid APG,1024.78,,,1024.78,Other,260% New York Medicaid APG,1277.03,,,1277.03,Other,324% New York Medicaid APG,847.41,,,847.41,Other,215% New York Medicaid APG,847.41,,,847.41,Other,215% New York Medicaid APG,492.68,,,492.68,Other,125% New York Medicaid APG,355.84,7216,
Destruction of skin lesions,17281,CPT,,,,,,,,both,,,8387.08,6206.44,74,,6206.44,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,3774.19,45,,3774.19,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,4151.6,49.5,,4151.6,percent of total billed charges,110% of Medicare,5703.21,68,,5703.21,percent of total billed charges,,733.11,,,733.11,Other,186% of Medicaid,6709.66,80,,6709.66,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,6709.66,80,,6709.66,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,5870.96,70,,5870.96,percent of total billed charges,,575.64,,,575.64,Fee Schedule,,487.89,,,487.89,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,394.14,,,394.14,Other,New York Medicaid APG methodology,394.14,,,394.14,Other,100% New York Medicaid APG,394.14,,,394.14,Other,100% New York Medicaid APG,394.14,,,394.14,Other,100% New York Medicaid APG,886.83,,,886.83,Other,225% New York Medicaid APG,603.04,,,603.04,Other,153% New York Medicaid APG,886.83,,,886.83,Other,225% New York Medicaid APG,551.8,,,551.8,Other,140% New York Medicaid APG,886.83,,,886.83,Other,225% New York Medicaid APG,1024.78,,,1024.78,Other,260% New York Medicaid APG,1277.03,,,1277.03,Other,324% New York Medicaid APG,847.41,,,847.41,Other,215% New York Medicaid APG,847.41,,,847.41,Other,215% New York Medicaid APG,492.68,,,492.68,Other,125% New York Medicaid APG,394.14,7216,
Destruction of skin lesions,17282,CPT,,,,,,,,both,,,8387.08,6206.44,74,,6206.44,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,3774.19,45,,3774.19,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,4151.6,49.5,,4151.6,percent of total billed charges,110% of Medicare,5703.21,68,,5703.21,percent of total billed charges,,733.11,,,733.11,Other,186% of Medicaid,6709.66,80,,6709.66,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,6709.66,80,,6709.66,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,5870.96,70,,5870.96,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,394.14,,,394.14,Other,New York Medicaid APG methodology,394.14,,,394.14,Other,100% New York Medicaid APG,394.14,,,394.14,Other,100% New York Medicaid APG,394.14,,,394.14,Other,100% New York Medicaid APG,886.83,,,886.83,Other,225% New York Medicaid APG,603.04,,,603.04,Other,153% New York Medicaid APG,886.83,,,886.83,Other,225% New York Medicaid APG,551.8,,,551.8,Other,140% New York Medicaid APG,886.83,,,886.83,Other,225% New York Medicaid APG,1024.78,,,1024.78,Other,260% New York Medicaid APG,1277.03,,,1277.03,Other,324% New York Medicaid APG,847.41,,,847.41,Other,215% New York Medicaid APG,847.41,,,847.41,Other,215% New York Medicaid APG,492.68,,,492.68,Other,125% New York Medicaid APG,394.14,7216,
Destruction of skin lesions,17283,CPT,,,,,,,,both,,,8387.08,6206.44,74,,6206.44,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,3774.19,45,,3774.19,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,4151.6,49.5,,4151.6,percent of total billed charges,110% of Medicare,5703.21,68,,5703.21,percent of total billed charges,,733.11,,,733.11,Other,186% of Medicaid,6709.66,80,,6709.66,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,6709.66,80,,6709.66,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,5870.96,70,,5870.96,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,394.14,,,394.14,Other,New York Medicaid APG methodology,394.14,,,394.14,Other,100% New York Medicaid APG,394.14,,,394.14,Other,100% New York Medicaid APG,394.14,,,394.14,Other,100% New York Medicaid APG,886.83,,,886.83,Other,225% New York Medicaid APG,603.04,,,603.04,Other,153% New York Medicaid APG,886.83,,,886.83,Other,225% New York Medicaid APG,551.8,,,551.8,Other,140% New York Medicaid APG,886.83,,,886.83,Other,225% New York Medicaid APG,1024.78,,,1024.78,Other,260% New York Medicaid APG,1277.03,,,1277.03,Other,324% New York Medicaid APG,847.41,,,847.41,Other,215% New York Medicaid APG,847.41,,,847.41,Other,215% New York Medicaid APG,492.68,,,492.68,Other,125% New York Medicaid APG,394.14,7216,
Destruction of skin lesions,17284,CPT,,,,,,,,both,,,13210.22,9775.56,74,,9775.56,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,5944.6,45,,5944.6,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,6539.06,49.5,,6539.06,percent of total billed charges,110% of Medicare,8982.95,68,,8982.95,percent of total billed charges,,733.11,,,733.11,Other,186% of Medicaid,10568.18,80,,10568.18,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,10568.18,80,,10568.18,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,9247.15,70,,9247.15,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,394.14,,,394.14,Other,New York Medicaid APG methodology,394.14,,,394.14,Other,100% New York Medicaid APG,394.14,,,394.14,Other,100% New York Medicaid APG,394.14,,,394.14,Other,100% New York Medicaid APG,886.83,,,886.83,Other,225% New York Medicaid APG,603.04,,,603.04,Other,153% New York Medicaid APG,886.83,,,886.83,Other,225% New York Medicaid APG,551.8,,,551.8,Other,140% New York Medicaid APG,886.83,,,886.83,Other,225% New York Medicaid APG,1024.78,,,1024.78,Other,260% New York Medicaid APG,1277.03,,,1277.03,Other,324% New York Medicaid APG,847.41,,,847.41,Other,215% New York Medicaid APG,847.41,,,847.41,Other,215% New York Medicaid APG,492.68,,,492.68,Other,125% New York Medicaid APG,394.14,10568.18,
Destruction of skin lesions,17286,CPT,,,,,,,,both,,,13210.22,9775.56,74,,9775.56,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,5944.6,45,,5944.6,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,6539.06,49.5,,6539.06,percent of total billed charges,110% of Medicare,8982.95,68,,8982.95,percent of total billed charges,,733.11,,,733.11,Other,186% of Medicaid,10568.18,80,,10568.18,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,10568.18,80,,10568.18,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,9247.15,70,,9247.15,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,394.14,,,394.14,Other,New York Medicaid APG methodology,394.14,,,394.14,Other,100% New York Medicaid APG,394.14,,,394.14,Other,100% New York Medicaid APG,394.14,,,394.14,Other,100% New York Medicaid APG,886.83,,,886.83,Other,225% New York Medicaid APG,603.04,,,603.04,Other,153% New York Medicaid APG,886.83,,,886.83,Other,225% New York Medicaid APG,551.8,,,551.8,Other,140% New York Medicaid APG,886.83,,,886.83,Other,225% New York Medicaid APG,1024.78,,,1024.78,Other,260% New York Medicaid APG,1277.03,,,1277.03,Other,324% New York Medicaid APG,847.41,,,847.41,Other,215% New York Medicaid APG,847.41,,,847.41,Other,215% New York Medicaid APG,492.68,,,492.68,Other,125% New York Medicaid APG,394.14,10568.18,
Mohs 1 stage h/n/hf/g,17311,CPT,,,,,,,,both,,,13210.22,9775.56,74,,9775.56,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,5944.6,45,,5944.6,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,6539.06,49.5,,6539.06,percent of total billed charges,110% of Medicare,8982.95,68,,8982.95,percent of total billed charges,,2241.86,,,2241.86,Other,186% of Medicaid,10568.18,80,,10568.18,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,10568.18,80,,10568.18,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,9247.15,70,,9247.15,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,1205.3,,,1205.3,Other,New York Medicaid APG methodology,1205.3,,,1205.3,Other,100% New York Medicaid APG,1205.3,,,1205.3,Other,100% New York Medicaid APG,1205.3,,,1205.3,Other,100% New York Medicaid APG,2711.92,,,2711.92,Other,225% New York Medicaid APG,1844.11,,,1844.11,Other,153% New York Medicaid APG,2711.92,,,2711.92,Other,225% New York Medicaid APG,1687.42,,,1687.42,Other,140% New York Medicaid APG,2711.92,,,2711.92,Other,225% New York Medicaid APG,3133.78,,,3133.78,Other,260% New York Medicaid APG,3905.17,,,3905.17,Other,324% New York Medicaid APG,2591.39,,,2591.39,Other,215% New York Medicaid APG,2591.39,,,2591.39,Other,215% New York Medicaid APG,1506.62,,,1506.62,Other,125% New York Medicaid APG,1205.3,10568.18,
Mohs addl stage,17312,CPT,,,,,,,,both,,,51572.04,38163.31,74,,38163.31,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,23207.42,45,,23207.42,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,25528.16,49.5,,25528.16,percent of total billed charges,110% of Medicare,35068.99,68,,35068.99,percent of total billed charges,,2241.86,,,2241.86,Other,186% of Medicaid,41257.63,80,,41257.63,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,41257.63,80,,41257.63,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,36100.43,70,,36100.43,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,1205.3,,,1205.3,Other,New York Medicaid APG methodology,1205.3,,,1205.3,Other,100% New York Medicaid APG,1205.3,,,1205.3,Other,100% New York Medicaid APG,1205.3,,,1205.3,Other,100% New York Medicaid APG,2711.92,,,2711.92,Other,225% New York Medicaid APG,1844.11,,,1844.11,Other,153% New York Medicaid APG,2711.92,,,2711.92,Other,225% New York Medicaid APG,1687.42,,,1687.42,Other,140% New York Medicaid APG,2711.92,,,2711.92,Other,225% New York Medicaid APG,3133.78,,,3133.78,Other,260% New York Medicaid APG,3905.17,,,3905.17,Other,324% New York Medicaid APG,2591.39,,,2591.39,Other,215% New York Medicaid APG,2591.39,,,2591.39,Other,215% New York Medicaid APG,1506.62,,,1506.62,Other,125% New York Medicaid APG,1205.3,41257.63,
Mohs 1 stage t/a/l,17313,CPT,,,,,,,,both,,,13210.22,9775.56,74,,9775.56,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,5944.6,45,,5944.6,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,6539.06,49.5,,6539.06,percent of total billed charges,110% of Medicare,8982.95,68,,8982.95,percent of total billed charges,,2241.86,,,2241.86,Other,186% of Medicaid,10568.18,80,,10568.18,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,10568.18,80,,10568.18,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,9247.15,70,,9247.15,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,1205.3,,,1205.3,Other,New York Medicaid APG methodology,1205.3,,,1205.3,Other,100% New York Medicaid APG,1205.3,,,1205.3,Other,100% New York Medicaid APG,1205.3,,,1205.3,Other,100% New York Medicaid APG,2711.92,,,2711.92,Other,225% New York Medicaid APG,1844.11,,,1844.11,Other,153% New York Medicaid APG,2711.92,,,2711.92,Other,225% New York Medicaid APG,1687.42,,,1687.42,Other,140% New York Medicaid APG,2711.92,,,2711.92,Other,225% New York Medicaid APG,3133.78,,,3133.78,Other,260% New York Medicaid APG,3905.17,,,3905.17,Other,324% New York Medicaid APG,2591.39,,,2591.39,Other,215% New York Medicaid APG,2591.39,,,2591.39,Other,215% New York Medicaid APG,1506.62,,,1506.62,Other,125% New York Medicaid APG,1205.3,10568.18,
Mohs addl stage t/a/l,17314,CPT,,,,,,,,both,,,51572.04,38163.31,74,,38163.31,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,23207.42,45,,23207.42,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,25528.16,49.5,,25528.16,percent of total billed charges,110% of Medicare,35068.99,68,,35068.99,percent of total billed charges,,2241.86,,,2241.86,Other,186% of Medicaid,41257.63,80,,41257.63,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,41257.63,80,,41257.63,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,36100.43,70,,36100.43,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,1205.3,,,1205.3,Other,New York Medicaid APG methodology,1205.3,,,1205.3,Other,100% New York Medicaid APG,1205.3,,,1205.3,Other,100% New York Medicaid APG,1205.3,,,1205.3,Other,100% New York Medicaid APG,2711.92,,,2711.92,Other,225% New York Medicaid APG,1844.11,,,1844.11,Other,153% New York Medicaid APG,2711.92,,,2711.92,Other,225% New York Medicaid APG,1687.42,,,1687.42,Other,140% New York Medicaid APG,2711.92,,,2711.92,Other,225% New York Medicaid APG,3133.78,,,3133.78,Other,260% New York Medicaid APG,3905.17,,,3905.17,Other,324% New York Medicaid APG,2591.39,,,2591.39,Other,215% New York Medicaid APG,2591.39,,,2591.39,Other,215% New York Medicaid APG,1506.62,,,1506.62,Other,125% New York Medicaid APG,1205.3,41257.63,
Mohs surg addl block,17315,CPT,,,,,,,,both,,,51572.04,38163.31,74,,38163.31,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,23207.42,45,,23207.42,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,25528.16,49.5,,25528.16,percent of total billed charges,110% of Medicare,35068.99,68,,35068.99,percent of total billed charges,,2241.86,,,2241.86,Other,186% of Medicaid,41257.63,80,,41257.63,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,41257.63,80,,41257.63,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,36100.43,70,,36100.43,percent of total billed charges,,244.36,,,244.36,Fee Schedule,,207.11,,,207.11,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,1205.3,,,1205.3,Other,New York Medicaid APG methodology,1205.3,,,1205.3,Other,100% New York Medicaid APG,1205.3,,,1205.3,Other,100% New York Medicaid APG,1205.3,,,1205.3,Other,100% New York Medicaid APG,2711.92,,,2711.92,Other,225% New York Medicaid APG,1844.11,,,1844.11,Other,153% New York Medicaid APG,2711.92,,,2711.92,Other,225% New York Medicaid APG,1687.42,,,1687.42,Other,140% New York Medicaid APG,2711.92,,,2711.92,Other,225% New York Medicaid APG,3133.78,,,3133.78,Other,260% New York Medicaid APG,3905.17,,,3905.17,Other,324% New York Medicaid APG,2591.39,,,2591.39,Other,215% New York Medicaid APG,2591.39,,,2591.39,Other,215% New York Medicaid APG,1506.62,,,1506.62,Other,125% New York Medicaid APG,207.11,41257.63,
Cryotherapy of skin,17340,CPT,,,,,,,,both,,,1286.58,952.07,74,,952.07,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,578.96,45,,578.96,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,636.86,49.5,,636.86,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,733.11,,,733.11,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,900.61,70,,900.61,percent of total billed charges,,241.08,,,241.08,Fee Schedule,,204.33,,,204.33,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,394.14,,,394.14,Other,New York Medicaid APG methodology,394.14,,,394.14,Other,100% New York Medicaid APG,394.14,,,394.14,Other,100% New York Medicaid APG,394.14,,,394.14,Other,100% New York Medicaid APG,886.83,,,886.83,Other,225% New York Medicaid APG,603.04,,,603.04,Other,153% New York Medicaid APG,886.83,,,886.83,Other,225% New York Medicaid APG,551.8,,,551.8,Other,140% New York Medicaid APG,886.83,,,886.83,Other,225% New York Medicaid APG,1024.78,,,1024.78,Other,260% New York Medicaid APG,1277.03,,,1277.03,Other,324% New York Medicaid APG,847.41,,,847.41,Other,215% New York Medicaid APG,847.41,,,847.41,Other,215% New York Medicaid APG,492.68,,,492.68,Other,125% New York Medicaid APG,204.33,9473,
Skin peel therapy,17360,CPT,,,,,,,,both,,,4210.98,3116.13,74,,3116.13,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,1894.94,45,,1894.94,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,2084.44,49.5,,2084.44,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,733.11,,,733.11,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,2947.69,70,,2947.69,percent of total billed charges,,454.28,,,454.28,Fee Schedule,,385.03,,,385.03,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,394.14,,,394.14,Other,New York Medicaid APG methodology,394.14,,,394.14,Other,100% New York Medicaid APG,394.14,,,394.14,Other,100% New York Medicaid APG,394.14,,,394.14,Other,100% New York Medicaid APG,886.83,,,886.83,Other,225% New York Medicaid APG,603.04,,,603.04,Other,153% New York Medicaid APG,886.83,,,886.83,Other,225% New York Medicaid APG,551.8,,,551.8,Other,140% New York Medicaid APG,886.83,,,886.83,Other,225% New York Medicaid APG,1024.78,,,1024.78,Other,260% New York Medicaid APG,1277.03,,,1277.03,Other,324% New York Medicaid APG,847.41,,,847.41,Other,215% New York Medicaid APG,847.41,,,847.41,Other,215% New York Medicaid APG,492.68,,,492.68,Other,125% New York Medicaid APG,385.03,9473,
Hair removal by electrolysis,17380,CPT,,,,,,,,both,,,13210.22,9775.56,74,,9775.56,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,5944.6,45,,5944.6,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,6539.06,49.5,,6539.06,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,733.11,,,733.11,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,9247.15,70,,9247.15,percent of total billed charges,,8586.64,65,,8586.64,percent of total billed charges,,8586.64,65,,8586.64,percent of total billed charges,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,394.14,,,394.14,Other,New York Medicaid APG methodology,394.14,,,394.14,Other,100% New York Medicaid APG,394.14,,,394.14,Other,100% New York Medicaid APG,394.14,,,394.14,Other,100% New York Medicaid APG,886.83,,,886.83,Other,225% New York Medicaid APG,603.04,,,603.04,Other,153% New York Medicaid APG,886.83,,,886.83,Other,225% New York Medicaid APG,551.8,,,551.8,Other,140% New York Medicaid APG,886.83,,,886.83,Other,225% New York Medicaid APG,1024.78,,,1024.78,Other,260% New York Medicaid APG,1277.03,,,1277.03,Other,324% New York Medicaid APG,847.41,,,847.41,Other,215% New York Medicaid APG,847.41,,,847.41,Other,215% New York Medicaid APG,492.68,,,492.68,Other,125% New York Medicaid APG,394.14,9775.56,
Drainage of breast lesion,19000,CPT,,,,,,,,both,,,14798.8,10951.11,74,,10951.11,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,6659.46,45,,6659.46,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,7325.41,49.5,,7325.41,percent of total billed charges,110% of Medicare,10063.18,68,,10063.18,percent of total billed charges,,1037.55,,,1037.55,Other,186% of Medicaid,11839.04,80,,11839.04,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,11839.04,80,,11839.04,percent of total billed charges,,7216,,,7216,Case Rate,,3578,,"100% primary, 0% secondary procedures",3578,Other,MagnaCare ASC Grouper,10359.16,70,,10359.16,percent of total billed charges,,206.64,,,206.64,Fee Schedule,,175.14,,,175.14,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,557.82,,,557.82,Other,New York Medicaid APG methodology,557.82,,,557.82,Other,100% New York Medicaid APG,557.82,,,557.82,Other,100% New York Medicaid APG,557.82,,,557.82,Other,100% New York Medicaid APG,1255.1,,,1255.1,Other,225% New York Medicaid APG,853.47,,,853.47,Other,153% New York Medicaid APG,1255.1,,,1255.1,Other,225% New York Medicaid APG,780.95,,,780.95,Other,140% New York Medicaid APG,1255.1,,,1255.1,Other,225% New York Medicaid APG,1450.34,,,1450.34,Other,260% New York Medicaid APG,1807.35,,,1807.35,Other,324% New York Medicaid APG,1199.32,,,1199.32,Other,215% New York Medicaid APG,1199.32,,,1199.32,Other,215% New York Medicaid APG,697.28,,,697.28,Other,125% New York Medicaid APG,175.14,11839.04,
Drain breast lesion add-on,19001,CPT,,,,,,,,both,,,32432.1,23999.75,74,,23999.75,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,14594.45,45,,14594.45,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,16053.89,49.5,,16053.89,percent of total billed charges,110% of Medicare,22053.83,68,,22053.83,percent of total billed charges,,1037.55,,,1037.55,Other,186% of Medicaid,25945.68,80,,25945.68,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,25945.68,80,,25945.68,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,22702.47,70,,22702.47,percent of total billed charges,,100.04,,,100.04,Fee Schedule,,84.79,,,84.79,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,557.82,,,557.82,Other,New York Medicaid APG methodology,557.82,,,557.82,Other,100% New York Medicaid APG,557.82,,,557.82,Other,100% New York Medicaid APG,557.82,,,557.82,Other,100% New York Medicaid APG,1255.1,,,1255.1,Other,225% New York Medicaid APG,853.47,,,853.47,Other,153% New York Medicaid APG,1255.1,,,1255.1,Other,225% New York Medicaid APG,780.95,,,780.95,Other,140% New York Medicaid APG,1255.1,,,1255.1,Other,225% New York Medicaid APG,1450.34,,,1450.34,Other,260% New York Medicaid APG,1807.35,,,1807.35,Other,324% New York Medicaid APG,1199.32,,,1199.32,Other,215% New York Medicaid APG,1199.32,,,1199.32,Other,215% New York Medicaid APG,697.28,,,697.28,Other,125% New York Medicaid APG,84.79,25945.68,
Incision of breast lesion,19020,CPT,,,,,,,,both,,,34101.75,25235.3,74,,25235.3,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15345.79,45,,15345.79,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,16880.37,49.5,,16880.37,percent of total billed charges,110% of Medicare,23189.19,68,,23189.19,percent of total billed charges,,2793.39,,,2793.39,Other,186% of Medicaid,27281.4,80,,27281.4,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,27281.4,80,,27281.4,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,23871.23,70,,23871.23,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1501.82,,,1501.82,Other,New York Medicaid APG methodology,1501.82,,,1501.82,Other,100% New York Medicaid APG,1501.82,,,1501.82,Other,100% New York Medicaid APG,1501.82,,,1501.82,Other,100% New York Medicaid APG,3379.1,,,3379.1,Other,225% New York Medicaid APG,2297.79,,,2297.79,Other,153% New York Medicaid APG,3379.1,,,3379.1,Other,225% New York Medicaid APG,2102.55,,,2102.55,Other,140% New York Medicaid APG,3379.1,,,3379.1,Other,225% New York Medicaid APG,3904.73,,,3904.73,Other,260% New York Medicaid APG,4865.9,,,4865.9,Other,324% New York Medicaid APG,3228.91,,,3228.91,Other,215% New York Medicaid APG,3228.91,,,3228.91,Other,215% New York Medicaid APG,1877.28,,,1877.28,Other,125% New York Medicaid APG,1501.82,27281.4,
Injection for breast x-ray,19030,CPT,,,,,,,,both,,,32432.1,23999.75,74,,23999.75,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,14594.45,45,,14594.45,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,16053.89,49.5,,16053.89,percent of total billed charges,110% of Medicare,22053.83,68,,22053.83,percent of total billed charges,,966.93,,,966.93,Other,186% of Medicaid,25945.68,80,,25945.68,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,25945.68,80,,25945.68,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,22702.47,70,,22702.47,percent of total billed charges,,370.64,,,370.64,Fee Schedule,,314.14,,,314.14,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,519.86,,,519.86,Other,New York Medicaid APG methodology,519.86,,,519.86,Other,100% New York Medicaid APG,519.86,,,519.86,Other,100% New York Medicaid APG,519.86,,,519.86,Other,100% New York Medicaid APG,1169.68,,,1169.68,Other,225% New York Medicaid APG,795.38,,,795.38,Other,153% New York Medicaid APG,1169.68,,,1169.68,Other,225% New York Medicaid APG,727.8,,,727.8,Other,140% New York Medicaid APG,1169.68,,,1169.68,Other,225% New York Medicaid APG,1351.62,,,1351.62,Other,260% New York Medicaid APG,1684.33,,,1684.33,Other,324% New York Medicaid APG,1117.69,,,1117.69,Other,215% New York Medicaid APG,1117.69,,,1117.69,Other,215% New York Medicaid APG,649.82,,,649.82,Other,125% New York Medicaid APG,314.14,25945.68,
Bx breast 1st lesion strtctc,19081,CPT,,,,,,,,both,,,34101.75,25235.3,74,,25235.3,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15345.79,45,,15345.79,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,16880.37,49.5,,16880.37,percent of total billed charges,110% of Medicare,23189.19,68,,23189.19,percent of total billed charges,,2793.39,,,2793.39,Other,186% of Medicaid,27281.4,80,,27281.4,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,27281.4,80,,27281.4,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,23871.23,70,,23871.23,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1501.82,,,1501.82,Other,New York Medicaid APG methodology,1501.82,,,1501.82,Other,100% New York Medicaid APG,1501.82,,,1501.82,Other,100% New York Medicaid APG,1501.82,,,1501.82,Other,100% New York Medicaid APG,3379.1,,,3379.1,Other,225% New York Medicaid APG,2297.79,,,2297.79,Other,153% New York Medicaid APG,3379.1,,,3379.1,Other,225% New York Medicaid APG,2102.55,,,2102.55,Other,140% New York Medicaid APG,3379.1,,,3379.1,Other,225% New York Medicaid APG,3904.73,,,3904.73,Other,260% New York Medicaid APG,4865.9,,,4865.9,Other,324% New York Medicaid APG,3228.91,,,3228.91,Other,215% New York Medicaid APG,3228.91,,,3228.91,Other,215% New York Medicaid APG,1877.28,,,1877.28,Other,125% New York Medicaid APG,1501.82,27281.4,
Bx breast add lesion strtctc,19082,CPT,,,,,,,,both,,,51572.04,38163.31,74,,38163.31,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,23207.42,45,,23207.42,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,25528.16,49.5,,25528.16,percent of total billed charges,110% of Medicare,35068.99,68,,35068.99,percent of total billed charges,,2793.39,,,2793.39,Other,186% of Medicaid,41257.63,80,,41257.63,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,41257.63,80,,41257.63,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,36100.43,70,,36100.43,percent of total billed charges,,398.52,,,398.52,Fee Schedule,,337.77,,,337.77,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,1501.82,,,1501.82,Other,New York Medicaid APG methodology,1501.82,,,1501.82,Other,100% New York Medicaid APG,1501.82,,,1501.82,Other,100% New York Medicaid APG,1501.82,,,1501.82,Other,100% New York Medicaid APG,3379.1,,,3379.1,Other,225% New York Medicaid APG,2297.79,,,2297.79,Other,153% New York Medicaid APG,3379.1,,,3379.1,Other,225% New York Medicaid APG,2102.55,,,2102.55,Other,140% New York Medicaid APG,3379.1,,,3379.1,Other,225% New York Medicaid APG,3904.73,,,3904.73,Other,260% New York Medicaid APG,4865.9,,,4865.9,Other,324% New York Medicaid APG,3228.91,,,3228.91,Other,215% New York Medicaid APG,3228.91,,,3228.91,Other,215% New York Medicaid APG,1877.28,,,1877.28,Other,125% New York Medicaid APG,337.77,41257.63,
Bx breast 1st lesion us imag,19083,CPT,,,,,,,,both,,,34101.75,25235.3,74,,25235.3,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15345.79,45,,15345.79,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,16880.37,49.5,,16880.37,percent of total billed charges,110% of Medicare,23189.19,68,,23189.19,percent of total billed charges,,2793.39,,,2793.39,Other,186% of Medicaid,27281.4,80,,27281.4,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,27281.4,80,,27281.4,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,23871.23,70,,23871.23,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1501.82,,,1501.82,Other,New York Medicaid APG methodology,1501.82,,,1501.82,Other,100% New York Medicaid APG,1501.82,,,1501.82,Other,100% New York Medicaid APG,1501.82,,,1501.82,Other,100% New York Medicaid APG,3379.1,,,3379.1,Other,225% New York Medicaid APG,2297.79,,,2297.79,Other,153% New York Medicaid APG,3379.1,,,3379.1,Other,225% New York Medicaid APG,2102.55,,,2102.55,Other,140% New York Medicaid APG,3379.1,,,3379.1,Other,225% New York Medicaid APG,3904.73,,,3904.73,Other,260% New York Medicaid APG,4865.9,,,4865.9,Other,324% New York Medicaid APG,3228.91,,,3228.91,Other,215% New York Medicaid APG,3228.91,,,3228.91,Other,215% New York Medicaid APG,1877.28,,,1877.28,Other,125% New York Medicaid APG,1501.82,27281.4,
Bx breast add lesion us imag,19084,CPT,,,,,,,,both,,,51572.04,38163.31,74,,38163.31,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,23207.42,45,,23207.42,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,25528.16,49.5,,25528.16,percent of total billed charges,110% of Medicare,35068.99,68,,35068.99,percent of total billed charges,,2793.39,,,2793.39,Other,186% of Medicaid,41257.63,80,,41257.63,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,41257.63,80,,41257.63,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,36100.43,70,,36100.43,percent of total billed charges,,375.56,,,375.56,Fee Schedule,,318.31,,,318.31,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,1501.82,,,1501.82,Other,New York Medicaid APG methodology,1501.82,,,1501.82,Other,100% New York Medicaid APG,1501.82,,,1501.82,Other,100% New York Medicaid APG,1501.82,,,1501.82,Other,100% New York Medicaid APG,3379.1,,,3379.1,Other,225% New York Medicaid APG,2297.79,,,2297.79,Other,153% New York Medicaid APG,3379.1,,,3379.1,Other,225% New York Medicaid APG,2102.55,,,2102.55,Other,140% New York Medicaid APG,3379.1,,,3379.1,Other,225% New York Medicaid APG,3904.73,,,3904.73,Other,260% New York Medicaid APG,4865.9,,,4865.9,Other,324% New York Medicaid APG,3228.91,,,3228.91,Other,215% New York Medicaid APG,3228.91,,,3228.91,Other,215% New York Medicaid APG,1877.28,,,1877.28,Other,125% New York Medicaid APG,318.31,41257.63,
Bx breast 1st lesion mr imag,19085,CPT,,,,,,,,both,,,34101.75,25235.3,74,,25235.3,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15345.79,45,,15345.79,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,16880.37,49.5,,16880.37,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2793.39,,,2793.39,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,23871.23,70,,23871.23,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1501.82,,,1501.82,Other,New York Medicaid APG methodology,1501.82,,,1501.82,Other,100% New York Medicaid APG,1501.82,,,1501.82,Other,100% New York Medicaid APG,1501.82,,,1501.82,Other,100% New York Medicaid APG,3379.1,,,3379.1,Other,225% New York Medicaid APG,2297.79,,,2297.79,Other,153% New York Medicaid APG,3379.1,,,3379.1,Other,225% New York Medicaid APG,2102.55,,,2102.55,Other,140% New York Medicaid APG,3379.1,,,3379.1,Other,225% New York Medicaid APG,3904.73,,,3904.73,Other,260% New York Medicaid APG,4865.9,,,4865.9,Other,324% New York Medicaid APG,3228.91,,,3228.91,Other,215% New York Medicaid APG,3228.91,,,3228.91,Other,215% New York Medicaid APG,1877.28,,,1877.28,Other,125% New York Medicaid APG,1501.82,25235.3,
Bx breast add lesion mr imag,19086,CPT,,,,,,,,both,,,51572.04,38163.31,74,,38163.31,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,23207.42,45,,23207.42,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,25528.16,49.5,,25528.16,percent of total billed charges,110% of Medicare,35068.99,68,,35068.99,percent of total billed charges,,2793.39,,,2793.39,Other,186% of Medicaid,41257.63,80,,41257.63,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,41257.63,80,,41257.63,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,36100.43,70,,36100.43,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,1501.82,,,1501.82,Other,New York Medicaid APG methodology,1501.82,,,1501.82,Other,100% New York Medicaid APG,1501.82,,,1501.82,Other,100% New York Medicaid APG,1501.82,,,1501.82,Other,100% New York Medicaid APG,3379.1,,,3379.1,Other,225% New York Medicaid APG,2297.79,,,2297.79,Other,153% New York Medicaid APG,3379.1,,,3379.1,Other,225% New York Medicaid APG,2102.55,,,2102.55,Other,140% New York Medicaid APG,3379.1,,,3379.1,Other,225% New York Medicaid APG,3904.73,,,3904.73,Other,260% New York Medicaid APG,4865.9,,,4865.9,Other,324% New York Medicaid APG,3228.91,,,3228.91,Other,215% New York Medicaid APG,3228.91,,,3228.91,Other,215% New York Medicaid APG,1877.28,,,1877.28,Other,125% New York Medicaid APG,1501.82,41257.63,
Bx breast percut w/o image,19100,CPT,,,,,,,,both,,,34101.75,25235.3,74,,25235.3,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15345.79,45,,15345.79,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,16880.37,49.5,,16880.37,percent of total billed charges,110% of Medicare,23189.19,68,,23189.19,percent of total billed charges,,2793.39,,,2793.39,Other,186% of Medicaid,27281.4,80,,27281.4,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,27281.4,80,,27281.4,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,23871.23,70,,23871.23,percent of total billed charges,,336.2,,,336.2,Fee Schedule,,284.95,,,284.95,Fee Schedule,,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1501.82,,,1501.82,Other,New York Medicaid APG methodology,1501.82,,,1501.82,Other,100% New York Medicaid APG,1501.82,,,1501.82,Other,100% New York Medicaid APG,1501.82,,,1501.82,Other,100% New York Medicaid APG,3379.1,,,3379.1,Other,225% New York Medicaid APG,2297.79,,,2297.79,Other,153% New York Medicaid APG,3379.1,,,3379.1,Other,225% New York Medicaid APG,2102.55,,,2102.55,Other,140% New York Medicaid APG,3379.1,,,3379.1,Other,225% New York Medicaid APG,3904.73,,,3904.73,Other,260% New York Medicaid APG,4865.9,,,4865.9,Other,324% New York Medicaid APG,3228.91,,,3228.91,Other,215% New York Medicaid APG,3228.91,,,3228.91,Other,215% New York Medicaid APG,1877.28,,,1877.28,Other,125% New York Medicaid APG,284.95,27281.4,
Biopsy of breast open,19101,CPT,,,,,,,,both,,,80175.05,59329.54,74,,59329.54,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,36078.77,45,,36078.77,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,39686.65,49.5,,39686.65,percent of total billed charges,110% of Medicare,54519.03,68,,54519.03,percent of total billed charges,,2793.39,,,2793.39,Other,186% of Medicaid,64140.04,80,,64140.04,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,64140.04,80,,64140.04,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,56122.54,70,,56122.54,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1501.82,,,1501.82,Other,New York Medicaid APG methodology,1501.82,,,1501.82,Other,100% New York Medicaid APG,1501.82,,,1501.82,Other,100% New York Medicaid APG,1501.82,,,1501.82,Other,100% New York Medicaid APG,3379.1,,,3379.1,Other,225% New York Medicaid APG,2297.79,,,2297.79,Other,153% New York Medicaid APG,3379.1,,,3379.1,Other,225% New York Medicaid APG,2102.55,,,2102.55,Other,140% New York Medicaid APG,3379.1,,,3379.1,Other,225% New York Medicaid APG,3904.73,,,3904.73,Other,260% New York Medicaid APG,4865.9,,,4865.9,Other,324% New York Medicaid APG,3228.91,,,3228.91,Other,215% New York Medicaid APG,3228.91,,,3228.91,Other,215% New York Medicaid APG,1877.28,,,1877.28,Other,125% New York Medicaid APG,1501.82,64140.04,
Cryosurg ablate fa each,19105,CPT,,,,,,,,both,,,80175.05,59329.54,74,,59329.54,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,36078.77,45,,36078.77,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,39686.65,49.5,,39686.65,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2793.39,,,2793.39,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,56122.54,70,,56122.54,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1501.82,,,1501.82,Other,New York Medicaid APG methodology,1501.82,,,1501.82,Other,100% New York Medicaid APG,1501.82,,,1501.82,Other,100% New York Medicaid APG,1501.82,,,1501.82,Other,100% New York Medicaid APG,3379.1,,,3379.1,Other,225% New York Medicaid APG,2297.79,,,2297.79,Other,153% New York Medicaid APG,3379.1,,,3379.1,Other,225% New York Medicaid APG,2102.55,,,2102.55,Other,140% New York Medicaid APG,3379.1,,,3379.1,Other,225% New York Medicaid APG,3904.73,,,3904.73,Other,260% New York Medicaid APG,4865.9,,,4865.9,Other,324% New York Medicaid APG,3228.91,,,3228.91,Other,215% New York Medicaid APG,3228.91,,,3228.91,Other,215% New York Medicaid APG,1877.28,,,1877.28,Other,125% New York Medicaid APG,1501.82,59329.54,
Nipple exploration,19110,CPT,,,,,,,,both,,,80175.05,59329.54,74,,59329.54,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,36078.77,45,,36078.77,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,39686.65,49.5,,39686.65,percent of total billed charges,110% of Medicare,54519.03,68,,54519.03,percent of total billed charges,,2793.39,,,2793.39,Other,186% of Medicaid,64140.04,80,,64140.04,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,64140.04,80,,64140.04,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,56122.54,70,,56122.54,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1501.82,,,1501.82,Other,New York Medicaid APG methodology,1501.82,,,1501.82,Other,100% New York Medicaid APG,1501.82,,,1501.82,Other,100% New York Medicaid APG,1501.82,,,1501.82,Other,100% New York Medicaid APG,3379.1,,,3379.1,Other,225% New York Medicaid APG,2297.79,,,2297.79,Other,153% New York Medicaid APG,3379.1,,,3379.1,Other,225% New York Medicaid APG,2102.55,,,2102.55,Other,140% New York Medicaid APG,3379.1,,,3379.1,Other,225% New York Medicaid APG,3904.73,,,3904.73,Other,260% New York Medicaid APG,4865.9,,,4865.9,Other,324% New York Medicaid APG,3228.91,,,3228.91,Other,215% New York Medicaid APG,3228.91,,,3228.91,Other,215% New York Medicaid APG,1877.28,,,1877.28,Other,125% New York Medicaid APG,1501.82,64140.04,
Excise breast duct fistula,19112,CPT,,,,,,,,both,,,80175.05,59329.54,74,,59329.54,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,36078.77,45,,36078.77,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,39686.65,49.5,,39686.65,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2793.39,,,2793.39,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,56122.54,70,,56122.54,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1501.82,,,1501.82,Other,New York Medicaid APG methodology,1501.82,,,1501.82,Other,100% New York Medicaid APG,1501.82,,,1501.82,Other,100% New York Medicaid APG,1501.82,,,1501.82,Other,100% New York Medicaid APG,3379.1,,,3379.1,Other,225% New York Medicaid APG,2297.79,,,2297.79,Other,153% New York Medicaid APG,3379.1,,,3379.1,Other,225% New York Medicaid APG,2102.55,,,2102.55,Other,140% New York Medicaid APG,3379.1,,,3379.1,Other,225% New York Medicaid APG,3904.73,,,3904.73,Other,260% New York Medicaid APG,4865.9,,,4865.9,Other,324% New York Medicaid APG,3228.91,,,3228.91,Other,215% New York Medicaid APG,3228.91,,,3228.91,Other,215% New York Medicaid APG,1877.28,,,1877.28,Other,125% New York Medicaid APG,1501.82,59329.54,
Removal of breast lesion,19120,CPT,,,,,,,,both,,,38519.06,28504.1,74,,28504.1,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,17333.58,45,,17333.58,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,19066.93,49.5,,19066.93,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2793.39,,,2793.39,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,26963.34,70,,26963.34,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1501.82,,,1501.82,Other,New York Medicaid APG methodology,1501.82,,,1501.82,Other,100% New York Medicaid APG,1501.82,,,1501.82,Other,100% New York Medicaid APG,1501.82,,,1501.82,Other,100% New York Medicaid APG,3379.1,,,3379.1,Other,225% New York Medicaid APG,2297.79,,,2297.79,Other,153% New York Medicaid APG,3379.1,,,3379.1,Other,225% New York Medicaid APG,2102.55,,,2102.55,Other,140% New York Medicaid APG,3379.1,,,3379.1,Other,225% New York Medicaid APG,3904.73,,,3904.73,Other,260% New York Medicaid APG,4865.9,,,4865.9,Other,324% New York Medicaid APG,3228.91,,,3228.91,Other,215% New York Medicaid APG,3228.91,,,3228.91,Other,215% New York Medicaid APG,1877.28,,,1877.28,Other,125% New York Medicaid APG,1501.82,28504.1,
Excision breast lesion,19125,CPT,,,,,,,,both,,,68236.71,50495.17,74,,50495.17,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30706.52,45,,30706.52,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33777.17,49.5,,33777.17,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2793.39,,,2793.39,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,47765.7,70,,47765.7,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1501.82,,,1501.82,Other,New York Medicaid APG methodology,1501.82,,,1501.82,Other,100% New York Medicaid APG,1501.82,,,1501.82,Other,100% New York Medicaid APG,1501.82,,,1501.82,Other,100% New York Medicaid APG,3379.1,,,3379.1,Other,225% New York Medicaid APG,2297.79,,,2297.79,Other,153% New York Medicaid APG,3379.1,,,3379.1,Other,225% New York Medicaid APG,2102.55,,,2102.55,Other,140% New York Medicaid APG,3379.1,,,3379.1,Other,225% New York Medicaid APG,3904.73,,,3904.73,Other,260% New York Medicaid APG,4865.9,,,4865.9,Other,324% New York Medicaid APG,3228.91,,,3228.91,Other,215% New York Medicaid APG,3228.91,,,3228.91,Other,215% New York Medicaid APG,1877.28,,,1877.28,Other,125% New York Medicaid APG,1501.82,50495.17,
Excision addl breast lesion,19126,CPT,,,,,,,,both,,,64479.48,47714.82,74,,47714.82,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,29015.77,45,,29015.77,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,31917.34,49.5,,31917.34,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2793.39,,,2793.39,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,45135.64,70,,45135.64,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,1501.82,,,1501.82,Other,New York Medicaid APG methodology,1501.82,,,1501.82,Other,100% New York Medicaid APG,1501.82,,,1501.82,Other,100% New York Medicaid APG,1501.82,,,1501.82,Other,100% New York Medicaid APG,3379.1,,,3379.1,Other,225% New York Medicaid APG,2297.79,,,2297.79,Other,153% New York Medicaid APG,3379.1,,,3379.1,Other,225% New York Medicaid APG,2102.55,,,2102.55,Other,140% New York Medicaid APG,3379.1,,,3379.1,Other,225% New York Medicaid APG,3904.73,,,3904.73,Other,260% New York Medicaid APG,4865.9,,,4865.9,Other,324% New York Medicaid APG,3228.91,,,3228.91,Other,215% New York Medicaid APG,3228.91,,,3228.91,Other,215% New York Medicaid APG,1877.28,,,1877.28,Other,125% New York Medicaid APG,1501.82,47714.82,
Perq device breast 1st imag,19281,CPT,,,,,,,,both,,,34101.75,25235.3,74,,25235.3,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15345.79,45,,15345.79,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,16880.37,49.5,,16880.37,percent of total billed charges,110% of Medicare,23189.19,68,,23189.19,percent of total billed charges,,2793.39,,,2793.39,Other,186% of Medicaid,27281.4,80,,27281.4,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,27281.4,80,,27281.4,percent of total billed charges,,7216,,,7216,Case Rate,,3578,,"100% primary, 0% secondary procedures",3578,Other,MagnaCare ASC Grouper,23871.23,70,,23871.23,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1501.82,,,1501.82,Other,New York Medicaid APG methodology,1501.82,,,1501.82,Other,100% New York Medicaid APG,1501.82,,,1501.82,Other,100% New York Medicaid APG,1501.82,,,1501.82,Other,100% New York Medicaid APG,3379.1,,,3379.1,Other,225% New York Medicaid APG,2297.79,,,2297.79,Other,153% New York Medicaid APG,3379.1,,,3379.1,Other,225% New York Medicaid APG,2102.55,,,2102.55,Other,140% New York Medicaid APG,3379.1,,,3379.1,Other,225% New York Medicaid APG,3904.73,,,3904.73,Other,260% New York Medicaid APG,4865.9,,,4865.9,Other,324% New York Medicaid APG,3228.91,,,3228.91,Other,215% New York Medicaid APG,3228.91,,,3228.91,Other,215% New York Medicaid APG,1877.28,,,1877.28,Other,125% New York Medicaid APG,1501.82,27281.4,
Perq device breast ea imag,19282,CPT,,,,,,,,both,,,32432.1,23999.75,74,,23999.75,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,14594.45,45,,14594.45,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,16053.89,49.5,,16053.89,percent of total billed charges,110% of Medicare,22053.83,68,,22053.83,percent of total billed charges,,2793.39,,,2793.39,Other,186% of Medicaid,25945.68,80,,25945.68,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,25945.68,80,,25945.68,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,22702.47,70,,22702.47,percent of total billed charges,,241.08,,,241.08,Fee Schedule,,204.33,,,204.33,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,1501.82,,,1501.82,Other,New York Medicaid APG methodology,1501.82,,,1501.82,Other,100% New York Medicaid APG,1501.82,,,1501.82,Other,100% New York Medicaid APG,1501.82,,,1501.82,Other,100% New York Medicaid APG,3379.1,,,3379.1,Other,225% New York Medicaid APG,2297.79,,,2297.79,Other,153% New York Medicaid APG,3379.1,,,3379.1,Other,225% New York Medicaid APG,2102.55,,,2102.55,Other,140% New York Medicaid APG,3379.1,,,3379.1,Other,225% New York Medicaid APG,3904.73,,,3904.73,Other,260% New York Medicaid APG,4865.9,,,4865.9,Other,324% New York Medicaid APG,3228.91,,,3228.91,Other,215% New York Medicaid APG,3228.91,,,3228.91,Other,215% New York Medicaid APG,1877.28,,,1877.28,Other,125% New York Medicaid APG,204.33,25945.68,
Perq dev breast 1st strtctc,19283,CPT,,,,,,,,both,,,14798.8,10951.11,74,,10951.11,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,6659.46,45,,6659.46,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,7325.41,49.5,,7325.41,percent of total billed charges,110% of Medicare,10063.18,68,,10063.18,percent of total billed charges,,2793.39,,,2793.39,Other,186% of Medicaid,11839.04,80,,11839.04,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,11839.04,80,,11839.04,percent of total billed charges,,7216,,,7216,Case Rate,,3578,,"100% primary, 0% secondary procedures",3578,Other,MagnaCare ASC Grouper,10359.16,70,,10359.16,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,1501.82,,,1501.82,Other,New York Medicaid APG methodology,1501.82,,,1501.82,Other,100% New York Medicaid APG,1501.82,,,1501.82,Other,100% New York Medicaid APG,1501.82,,,1501.82,Other,100% New York Medicaid APG,3379.1,,,3379.1,Other,225% New York Medicaid APG,2297.79,,,2297.79,Other,153% New York Medicaid APG,3379.1,,,3379.1,Other,225% New York Medicaid APG,2102.55,,,2102.55,Other,140% New York Medicaid APG,3379.1,,,3379.1,Other,225% New York Medicaid APG,3904.73,,,3904.73,Other,260% New York Medicaid APG,4865.9,,,4865.9,Other,324% New York Medicaid APG,3228.91,,,3228.91,Other,215% New York Medicaid APG,3228.91,,,3228.91,Other,215% New York Medicaid APG,1877.28,,,1877.28,Other,125% New York Medicaid APG,1501.82,11839.04,
Perq dev breast add strtctc,19284,CPT,,,,,,,,both,,,32432.1,23999.75,74,,23999.75,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,14594.45,45,,14594.45,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,16053.89,49.5,,16053.89,percent of total billed charges,110% of Medicare,22053.83,68,,22053.83,percent of total billed charges,,2793.39,,,2793.39,Other,186% of Medicaid,25945.68,80,,25945.68,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,25945.68,80,,25945.68,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,22702.47,70,,22702.47,percent of total billed charges,,241.08,,,241.08,Fee Schedule,,204.33,,,204.33,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,1501.82,,,1501.82,Other,New York Medicaid APG methodology,1501.82,,,1501.82,Other,100% New York Medicaid APG,1501.82,,,1501.82,Other,100% New York Medicaid APG,1501.82,,,1501.82,Other,100% New York Medicaid APG,3379.1,,,3379.1,Other,225% New York Medicaid APG,2297.79,,,2297.79,Other,153% New York Medicaid APG,3379.1,,,3379.1,Other,225% New York Medicaid APG,2102.55,,,2102.55,Other,140% New York Medicaid APG,3379.1,,,3379.1,Other,225% New York Medicaid APG,3904.73,,,3904.73,Other,260% New York Medicaid APG,4865.9,,,4865.9,Other,324% New York Medicaid APG,3228.91,,,3228.91,Other,215% New York Medicaid APG,3228.91,,,3228.91,Other,215% New York Medicaid APG,1877.28,,,1877.28,Other,125% New York Medicaid APG,204.33,25945.68,
Perq dev breast 1st us imag,19285,CPT,,,,,,,,both,,,14798.8,10951.11,74,,10951.11,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,6659.46,45,,6659.46,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,7325.41,49.5,,7325.41,percent of total billed charges,110% of Medicare,10063.18,68,,10063.18,percent of total billed charges,,2793.39,,,2793.39,Other,186% of Medicaid,11839.04,80,,11839.04,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,11839.04,80,,11839.04,percent of total billed charges,,7216,,,7216,Case Rate,,3578,,"100% primary, 0% secondary procedures",3578,Other,MagnaCare ASC Grouper,10359.16,70,,10359.16,percent of total billed charges,,410,,,410,Fee Schedule,,347.5,,,347.5,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,1501.82,,,1501.82,Other,New York Medicaid APG methodology,1501.82,,,1501.82,Other,100% New York Medicaid APG,1501.82,,,1501.82,Other,100% New York Medicaid APG,1501.82,,,1501.82,Other,100% New York Medicaid APG,3379.1,,,3379.1,Other,225% New York Medicaid APG,2297.79,,,2297.79,Other,153% New York Medicaid APG,3379.1,,,3379.1,Other,225% New York Medicaid APG,2102.55,,,2102.55,Other,140% New York Medicaid APG,3379.1,,,3379.1,Other,225% New York Medicaid APG,3904.73,,,3904.73,Other,260% New York Medicaid APG,4865.9,,,4865.9,Other,324% New York Medicaid APG,3228.91,,,3228.91,Other,215% New York Medicaid APG,3228.91,,,3228.91,Other,215% New York Medicaid APG,1877.28,,,1877.28,Other,125% New York Medicaid APG,347.5,11839.04,
Perq dev breast add us imag,19286,CPT,,,,,,,,both,,,32432.1,23999.75,74,,23999.75,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,14594.45,45,,14594.45,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,16053.89,49.5,,16053.89,percent of total billed charges,110% of Medicare,22053.83,68,,22053.83,percent of total billed charges,,2793.39,,,2793.39,Other,186% of Medicaid,25945.68,80,,25945.68,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,25945.68,80,,25945.68,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,22702.47,70,,22702.47,percent of total billed charges,,206.64,,,206.64,Fee Schedule,,175.14,,,175.14,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,1501.82,,,1501.82,Other,New York Medicaid APG methodology,1501.82,,,1501.82,Other,100% New York Medicaid APG,1501.82,,,1501.82,Other,100% New York Medicaid APG,1501.82,,,1501.82,Other,100% New York Medicaid APG,3379.1,,,3379.1,Other,225% New York Medicaid APG,2297.79,,,2297.79,Other,153% New York Medicaid APG,3379.1,,,3379.1,Other,225% New York Medicaid APG,2102.55,,,2102.55,Other,140% New York Medicaid APG,3379.1,,,3379.1,Other,225% New York Medicaid APG,3904.73,,,3904.73,Other,260% New York Medicaid APG,4865.9,,,4865.9,Other,324% New York Medicaid APG,3228.91,,,3228.91,Other,215% New York Medicaid APG,3228.91,,,3228.91,Other,215% New York Medicaid APG,1877.28,,,1877.28,Other,125% New York Medicaid APG,175.14,25945.68,
Perq dev breast 1st mr guide,19287,CPT,,,,,,,,both,,,14798.8,10951.11,74,,10951.11,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,6659.46,45,,6659.46,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,7325.41,49.5,,7325.41,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2793.39,,,2793.39,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,3578,,"100% primary, 0% secondary procedures",3578,Other,MagnaCare ASC Grouper,10359.16,70,,10359.16,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,1501.82,,,1501.82,Other,New York Medicaid APG methodology,1501.82,,,1501.82,Other,100% New York Medicaid APG,1501.82,,,1501.82,Other,100% New York Medicaid APG,1501.82,,,1501.82,Other,100% New York Medicaid APG,3379.1,,,3379.1,Other,225% New York Medicaid APG,2297.79,,,2297.79,Other,153% New York Medicaid APG,3379.1,,,3379.1,Other,225% New York Medicaid APG,2102.55,,,2102.55,Other,140% New York Medicaid APG,3379.1,,,3379.1,Other,225% New York Medicaid APG,3904.73,,,3904.73,Other,260% New York Medicaid APG,4865.9,,,4865.9,Other,324% New York Medicaid APG,3228.91,,,3228.91,Other,215% New York Medicaid APG,3228.91,,,3228.91,Other,215% New York Medicaid APG,1877.28,,,1877.28,Other,125% New York Medicaid APG,1501.82,10951.11,
Perq dev breast add mr guide,19288,CPT,,,,,,,,both,,,32432.1,23999.75,74,,23999.75,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,14594.45,45,,14594.45,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,16053.89,49.5,,16053.89,percent of total billed charges,110% of Medicare,22053.83,68,,22053.83,percent of total billed charges,,2793.39,,,2793.39,Other,186% of Medicaid,25945.68,80,,25945.68,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,25945.68,80,,25945.68,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,22702.47,70,,22702.47,percent of total billed charges,,305.04,,,305.04,Fee Schedule,,258.54,,,258.54,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,1501.82,,,1501.82,Other,New York Medicaid APG methodology,1501.82,,,1501.82,Other,100% New York Medicaid APG,1501.82,,,1501.82,Other,100% New York Medicaid APG,1501.82,,,1501.82,Other,100% New York Medicaid APG,3379.1,,,3379.1,Other,225% New York Medicaid APG,2297.79,,,2297.79,Other,153% New York Medicaid APG,3379.1,,,3379.1,Other,225% New York Medicaid APG,2102.55,,,2102.55,Other,140% New York Medicaid APG,3379.1,,,3379.1,Other,225% New York Medicaid APG,3904.73,,,3904.73,Other,260% New York Medicaid APG,4865.9,,,4865.9,Other,324% New York Medicaid APG,3228.91,,,3228.91,Other,215% New York Medicaid APG,3228.91,,,3228.91,Other,215% New York Medicaid APG,1877.28,,,1877.28,Other,125% New York Medicaid APG,258.54,25945.68,
Prep tum cav iort prtl mast,19294,CPT,,,,,,,,both,,,32432.1,23999.75,74,,23999.75,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,14594.45,45,,14594.45,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,16053.89,49.5,,16053.89,percent of total billed charges,110% of Medicare,22053.83,68,,22053.83,percent of total billed charges,,5442.71,,,5442.71,Other,186% of Medicaid,25945.68,80,,25945.68,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,25945.68,80,,25945.68,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,22702.47,70,,22702.47,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,2926.19,,,2926.19,Other,New York Medicaid APG methodology,2926.19,,,2926.19,Other,100% New York Medicaid APG,2926.19,,,2926.19,Other,100% New York Medicaid APG,2926.19,,,2926.19,Other,100% New York Medicaid APG,6583.92,,,6583.92,Other,225% New York Medicaid APG,4477.07,,,4477.07,Other,153% New York Medicaid APG,6583.92,,,6583.92,Other,225% New York Medicaid APG,4096.66,,,4096.66,Other,140% New York Medicaid APG,6583.92,,,6583.92,Other,225% New York Medicaid APG,7608.09,,,7608.09,Other,260% New York Medicaid APG,9480.85,,,9480.85,Other,324% New York Medicaid APG,6291.3,,,6291.3,Other,215% New York Medicaid APG,6291.3,,,6291.3,Other,215% New York Medicaid APG,3657.74,,,3657.74,Other,125% New York Medicaid APG,2053,25945.68,
Place po breast cath for rad,19296,CPT,,,,,,,,both,,,198277.38,146725.26,74,,146725.26,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,89224.82,45,,89224.82,percent of total billed charges,Medicare Ratio of cost to charges,7938,,"100% primary, 50% supplemental procedure",7938,Other,Aetna ASC Grouper,7144,,"100% primary, 50% supplemental procedure",7144,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,98147.3,49.5,,98147.3,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3861.21,,,3861.21,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,138794.17,70,,138794.17,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,2075.92,,,2075.92,Other,New York Medicaid APG methodology,2075.92,,,2075.92,Other,100% New York Medicaid APG,2075.92,,,2075.92,Other,100% New York Medicaid APG,2075.92,,,2075.92,Other,100% New York Medicaid APG,4670.82,,,4670.82,Other,225% New York Medicaid APG,3176.15,,,3176.15,Other,153% New York Medicaid APG,4670.82,,,4670.82,Other,225% New York Medicaid APG,2906.29,,,2906.29,Other,140% New York Medicaid APG,4670.82,,,4670.82,Other,225% New York Medicaid APG,5397.39,,,5397.39,Other,260% New York Medicaid APG,6725.98,,,6725.98,Other,324% New York Medicaid APG,4463.22,,,4463.22,Other,215% New York Medicaid APG,4463.22,,,4463.22,Other,215% New York Medicaid APG,2594.9,,,2594.9,Other,125% New York Medicaid APG,2075.92,146725.26,
Place breast cath for rad,19297,CPT,,,,,,,,both,,,98219.64,72682.53,74,,72682.53,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,44198.84,45,,44198.84,percent of total billed charges,Medicare Ratio of cost to charges,7938,,"100% primary, 50% supplemental procedure",7938,Other,Aetna ASC Grouper,7144,,"100% primary, 50% supplemental procedure",7144,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,48618.72,49.5,,48618.72,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5442.71,,,5442.71,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,68753.75,70,,68753.75,percent of total billed charges,,459.2,,,459.2,Fee Schedule,,389.2,,,389.2,Fee Schedule,,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,2926.19,,,2926.19,Other,New York Medicaid APG methodology,2926.19,,,2926.19,Other,100% New York Medicaid APG,2926.19,,,2926.19,Other,100% New York Medicaid APG,2926.19,,,2926.19,Other,100% New York Medicaid APG,6583.92,,,6583.92,Other,225% New York Medicaid APG,4477.07,,,4477.07,Other,153% New York Medicaid APG,6583.92,,,6583.92,Other,225% New York Medicaid APG,4096.66,,,4096.66,Other,140% New York Medicaid APG,6583.92,,,6583.92,Other,225% New York Medicaid APG,7608.09,,,7608.09,Other,260% New York Medicaid APG,9480.85,,,9480.85,Other,324% New York Medicaid APG,6291.3,,,6291.3,Other,215% New York Medicaid APG,6291.3,,,6291.3,Other,215% New York Medicaid APG,3657.74,,,3657.74,Other,125% New York Medicaid APG,389.2,72682.53,
Place breast rad tube/caths,19298,CPT,,,,,,,,both,,,137162.89,101500.54,74,,101500.54,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,61723.3,45,,61723.3,percent of total billed charges,Medicare Ratio of cost to charges,5459,,"100% primary, 50% supplemental procedure",5459,Other,Aetna ASC Grouper,4913,,"100% primary, 50% supplemental procedure",4913,Other,Aetna ASC Grouper,7266,,"100% primary, 50% secondary, 25% supplemental procedure",7266,Other,Blue Cross ASC Grouper,6539,,"100% primary, 50% secondary, 25% supplemental procedure",6539,Other,Blue Cross ASC Grouper,6176,,"100% primary, 50% secondary, 25% supplemental procedure",6176,Other,Blue Cross ASC Grouper,67895.63,49.5,,67895.63,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3861.21,,,3861.21,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,96014.02,70,,96014.02,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,2075.92,,,2075.92,Other,New York Medicaid APG methodology,2075.92,,,2075.92,Other,100% New York Medicaid APG,2075.92,,,2075.92,Other,100% New York Medicaid APG,2075.92,,,2075.92,Other,100% New York Medicaid APG,4670.82,,,4670.82,Other,225% New York Medicaid APG,3176.15,,,3176.15,Other,153% New York Medicaid APG,4670.82,,,4670.82,Other,225% New York Medicaid APG,2906.29,,,2906.29,Other,140% New York Medicaid APG,4670.82,,,4670.82,Other,225% New York Medicaid APG,5397.39,,,5397.39,Other,260% New York Medicaid APG,6725.98,,,6725.98,Other,324% New York Medicaid APG,4463.22,,,4463.22,Other,215% New York Medicaid APG,4463.22,,,4463.22,Other,215% New York Medicaid APG,2594.9,,,2594.9,Other,125% New York Medicaid APG,2075.92,101500.54,
Removal of breast tissue,19300,CPT,,,,,,,,both,,,45740.64,33848.07,74,,33848.07,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,20583.29,45,,20583.29,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,22641.62,49.5,,22641.62,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2793.39,,,2793.39,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,32018.45,70,,32018.45,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1501.82,,,1501.82,Other,New York Medicaid APG methodology,1501.82,,,1501.82,Other,100% New York Medicaid APG,1501.82,,,1501.82,Other,100% New York Medicaid APG,1501.82,,,1501.82,Other,100% New York Medicaid APG,3379.1,,,3379.1,Other,225% New York Medicaid APG,2297.79,,,2297.79,Other,153% New York Medicaid APG,3379.1,,,3379.1,Other,225% New York Medicaid APG,2102.55,,,2102.55,Other,140% New York Medicaid APG,3379.1,,,3379.1,Other,225% New York Medicaid APG,3904.73,,,3904.73,Other,260% New York Medicaid APG,4865.9,,,4865.9,Other,324% New York Medicaid APG,3228.91,,,3228.91,Other,215% New York Medicaid APG,3228.91,,,3228.91,Other,215% New York Medicaid APG,1877.28,,,1877.28,Other,125% New York Medicaid APG,1501.82,33848.07,
Partial mastectomy,19301,CPT,,,,,,,,both,,,76143.29,56346.03,74,,56346.03,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,34264.48,45,,34264.48,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,37690.93,49.5,,37690.93,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3861.21,,,3861.21,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,53300.3,70,,53300.3,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,2075.92,,,2075.92,Other,New York Medicaid APG methodology,2075.92,,,2075.92,Other,100% New York Medicaid APG,2075.92,,,2075.92,Other,100% New York Medicaid APG,2075.92,,,2075.92,Other,100% New York Medicaid APG,4670.82,,,4670.82,Other,225% New York Medicaid APG,3176.15,,,3176.15,Other,153% New York Medicaid APG,4670.82,,,4670.82,Other,225% New York Medicaid APG,2906.29,,,2906.29,Other,140% New York Medicaid APG,4670.82,,,4670.82,Other,225% New York Medicaid APG,5397.39,,,5397.39,Other,260% New York Medicaid APG,6725.98,,,6725.98,Other,324% New York Medicaid APG,4463.22,,,4463.22,Other,215% New York Medicaid APG,4463.22,,,4463.22,Other,215% New York Medicaid APG,2594.9,,,2594.9,Other,125% New York Medicaid APG,2075.92,56346.03,
P-mastectomy w/ln removal,19302,CPT,,,,,,,,both,,,137162.89,101500.54,74,,101500.54,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,61723.3,45,,61723.3,percent of total billed charges,Medicare Ratio of cost to charges,5954,,"100% primary, 50% supplemental procedure",5954,Other,Aetna ASC Grouper,5359,,"100% primary, 50% supplemental procedure",5359,Other,Aetna ASC Grouper,7266,,"100% primary, 50% secondary, 25% supplemental procedure",7266,Other,Blue Cross ASC Grouper,6539,,"100% primary, 50% secondary, 25% supplemental procedure",6539,Other,Blue Cross ASC Grouper,6176,,"100% primary, 50% secondary, 25% supplemental procedure",6176,Other,Blue Cross ASC Grouper,67895.63,49.5,,67895.63,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3861.21,,,3861.21,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,96014.02,70,,96014.02,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,2075.92,,,2075.92,Other,New York Medicaid APG methodology,2075.92,,,2075.92,Other,100% New York Medicaid APG,2075.92,,,2075.92,Other,100% New York Medicaid APG,2075.92,,,2075.92,Other,100% New York Medicaid APG,4670.82,,,4670.82,Other,225% New York Medicaid APG,3176.15,,,3176.15,Other,153% New York Medicaid APG,4670.82,,,4670.82,Other,225% New York Medicaid APG,2906.29,,,2906.29,Other,140% New York Medicaid APG,4670.82,,,4670.82,Other,225% New York Medicaid APG,5397.39,,,5397.39,Other,260% New York Medicaid APG,6725.98,,,6725.98,Other,324% New York Medicaid APG,4463.22,,,4463.22,Other,215% New York Medicaid APG,4463.22,,,4463.22,Other,215% New York Medicaid APG,2594.9,,,2594.9,Other,125% New York Medicaid APG,2075.92,101500.54,
Mast simple complete,19303,CPT,,,,,,,,both,,,62715.23,46409.27,74,,46409.27,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,28221.85,45,,28221.85,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,7266,,"100% primary, 50% secondary, 25% supplemental procedure",7266,Other,Blue Cross ASC Grouper,6539,,"100% primary, 50% secondary, 25% supplemental procedure",6539,Other,Blue Cross ASC Grouper,6176,,"100% primary, 50% secondary, 25% supplemental procedure",6176,Other,Blue Cross ASC Grouper,31044.04,49.5,,31044.04,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3861.21,,,3861.21,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,43900.66,70,,43900.66,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,2075.92,,,2075.92,Other,New York Medicaid APG methodology,2075.92,,,2075.92,Other,100% New York Medicaid APG,2075.92,,,2075.92,Other,100% New York Medicaid APG,2075.92,,,2075.92,Other,100% New York Medicaid APG,4670.82,,,4670.82,Other,225% New York Medicaid APG,3176.15,,,3176.15,Other,153% New York Medicaid APG,4670.82,,,4670.82,Other,225% New York Medicaid APG,2906.29,,,2906.29,Other,140% New York Medicaid APG,4670.82,,,4670.82,Other,225% New York Medicaid APG,5397.39,,,5397.39,Other,260% New York Medicaid APG,6725.98,,,6725.98,Other,324% New York Medicaid APG,4463.22,,,4463.22,Other,215% New York Medicaid APG,4463.22,,,4463.22,Other,215% New York Medicaid APG,2594.9,,,2594.9,Other,125% New York Medicaid APG,2075.92,46409.27,
Mast mod rad,19307,CPT,,,,,,,,both,,,137162.89,101500.54,74,,101500.54,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,61723.3,45,,61723.3,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,7266,,"100% primary, 50% secondary, 25% supplemental procedure",7266,Other,Blue Cross ASC Grouper,6539,,"100% primary, 50% secondary, 25% supplemental procedure",6539,Other,Blue Cross ASC Grouper,6176,,"100% primary, 50% secondary, 25% supplemental procedure",6176,Other,Blue Cross ASC Grouper,67895.63,49.5,,67895.63,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5442.71,,,5442.71,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,96014.02,70,,96014.02,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,2926.19,,,2926.19,Other,New York Medicaid APG methodology,2926.19,,,2926.19,Other,100% New York Medicaid APG,2926.19,,,2926.19,Other,100% New York Medicaid APG,2926.19,,,2926.19,Other,100% New York Medicaid APG,6583.92,,,6583.92,Other,225% New York Medicaid APG,4477.07,,,4477.07,Other,153% New York Medicaid APG,6583.92,,,6583.92,Other,225% New York Medicaid APG,4096.66,,,4096.66,Other,140% New York Medicaid APG,6583.92,,,6583.92,Other,225% New York Medicaid APG,7608.09,,,7608.09,Other,260% New York Medicaid APG,9480.85,,,9480.85,Other,324% New York Medicaid APG,6291.3,,,6291.3,Other,215% New York Medicaid APG,6291.3,,,6291.3,Other,215% New York Medicaid APG,3657.74,,,3657.74,Other,125% New York Medicaid APG,2926.19,101500.54,
Suspension of breast,19316,CPT,,,,,,,,both,,,46805.83,34636.31,74,,34636.31,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,21062.62,45,,21062.62,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,7266,,"100% primary, 50% secondary, 25% supplemental procedure",7266,Other,Blue Cross ASC Grouper,6539,,"100% primary, 50% secondary, 25% supplemental procedure",6539,Other,Blue Cross ASC Grouper,6176,,"100% primary, 50% secondary, 25% supplemental procedure",6176,Other,Blue Cross ASC Grouper,23168.89,49.5,,23168.89,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3861.21,,,3861.21,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,32764.08,70,,32764.08,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,2075.92,,,2075.92,Other,New York Medicaid APG methodology,2075.92,,,2075.92,Other,100% New York Medicaid APG,2075.92,,,2075.92,Other,100% New York Medicaid APG,2075.92,,,2075.92,Other,100% New York Medicaid APG,4670.82,,,4670.82,Other,225% New York Medicaid APG,3176.15,,,3176.15,Other,153% New York Medicaid APG,4670.82,,,4670.82,Other,225% New York Medicaid APG,2906.29,,,2906.29,Other,140% New York Medicaid APG,4670.82,,,4670.82,Other,225% New York Medicaid APG,5397.39,,,5397.39,Other,260% New York Medicaid APG,6725.98,,,6725.98,Other,324% New York Medicaid APG,4463.22,,,4463.22,Other,215% New York Medicaid APG,4463.22,,,4463.22,Other,215% New York Medicaid APG,2594.9,,,2594.9,Other,125% New York Medicaid APG,2075.92,34636.31,
Breast reduction,19318,CPT,,,,,,,,both,,,61371.41,45414.84,74,,45414.84,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,27617.13,45,,27617.13,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,7266,,"100% primary, 50% secondary, 25% supplemental procedure",7266,Other,Blue Cross ASC Grouper,6539,,"100% primary, 50% secondary, 25% supplemental procedure",6539,Other,Blue Cross ASC Grouper,6176,,"100% primary, 50% secondary, 25% supplemental procedure",6176,Other,Blue Cross ASC Grouper,30378.85,49.5,,30378.85,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5442.71,,,5442.71,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,42959.99,70,,42959.99,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,2926.19,,,2926.19,Other,New York Medicaid APG methodology,2926.19,,,2926.19,Other,100% New York Medicaid APG,2926.19,,,2926.19,Other,100% New York Medicaid APG,2926.19,,,2926.19,Other,100% New York Medicaid APG,6583.92,,,6583.92,Other,225% New York Medicaid APG,4477.07,,,4477.07,Other,153% New York Medicaid APG,6583.92,,,6583.92,Other,225% New York Medicaid APG,4096.66,,,4096.66,Other,140% New York Medicaid APG,6583.92,,,6583.92,Other,225% New York Medicaid APG,7608.09,,,7608.09,Other,260% New York Medicaid APG,9480.85,,,9480.85,Other,324% New York Medicaid APG,6291.3,,,6291.3,Other,215% New York Medicaid APG,6291.3,,,6291.3,Other,215% New York Medicaid APG,3657.74,,,3657.74,Other,125% New York Medicaid APG,2926.19,45414.84,
Breast augmentation w/implt,19325,CPT,,,,,,,,both,,,47509.98,35157.39,74,,35157.39,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,21379.49,45,,21379.49,percent of total billed charges,Medicare Ratio of cost to charges,7938,,"100% primary, 50% supplemental procedure",7938,Other,Aetna ASC Grouper,7144,,"100% primary, 50% supplemental procedure",7144,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,23517.44,49.5,,23517.44,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3861.21,,,3861.21,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,33256.99,70,,33256.99,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,2075.92,,,2075.92,Other,New York Medicaid APG methodology,2075.92,,,2075.92,Other,100% New York Medicaid APG,2075.92,,,2075.92,Other,100% New York Medicaid APG,2075.92,,,2075.92,Other,100% New York Medicaid APG,4670.82,,,4670.82,Other,225% New York Medicaid APG,3176.15,,,3176.15,Other,153% New York Medicaid APG,4670.82,,,4670.82,Other,225% New York Medicaid APG,2906.29,,,2906.29,Other,140% New York Medicaid APG,4670.82,,,4670.82,Other,225% New York Medicaid APG,5397.39,,,5397.39,Other,260% New York Medicaid APG,6725.98,,,6725.98,Other,324% New York Medicaid APG,4463.22,,,4463.22,Other,215% New York Medicaid APG,4463.22,,,4463.22,Other,215% New York Medicaid APG,2594.9,,,2594.9,Other,125% New York Medicaid APG,2075.92,35157.39,
Rmvl intact breast implant,19328,CPT,,,,,,,,both,,,39084.49,28922.52,74,,28922.52,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,17588.02,45,,17588.02,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,19346.82,49.5,,19346.82,percent of total billed charges,110% of Medicare,26577.45,68,,26577.45,percent of total billed charges,,3861.21,,,3861.21,Other,186% of Medicaid,31267.59,80,,31267.59,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,31267.59,80,,31267.59,percent of total billed charges,,7216,,,7216,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,27359.14,70,,27359.14,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,2075.92,,,2075.92,Other,New York Medicaid APG methodology,2075.92,,,2075.92,Other,100% New York Medicaid APG,2075.92,,,2075.92,Other,100% New York Medicaid APG,2075.92,,,2075.92,Other,100% New York Medicaid APG,4670.82,,,4670.82,Other,225% New York Medicaid APG,3176.15,,,3176.15,Other,153% New York Medicaid APG,4670.82,,,4670.82,Other,225% New York Medicaid APG,2906.29,,,2906.29,Other,140% New York Medicaid APG,4670.82,,,4670.82,Other,225% New York Medicaid APG,5397.39,,,5397.39,Other,260% New York Medicaid APG,6725.98,,,6725.98,Other,324% New York Medicaid APG,4463.22,,,4463.22,Other,215% New York Medicaid APG,4463.22,,,4463.22,Other,215% New York Medicaid APG,2594.9,,,2594.9,Other,125% New York Medicaid APG,2053,31267.59,
Rmvl ruptured breast implant,19330,CPT,,,,,,,,both,,,40997.58,30338.21,74,,30338.21,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,18448.91,45,,18448.91,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,20293.8,49.5,,20293.8,percent of total billed charges,110% of Medicare,27878.35,68,,27878.35,percent of total billed charges,,3861.21,,,3861.21,Other,186% of Medicaid,32798.06,80,,32798.06,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,32798.06,80,,32798.06,percent of total billed charges,,7216,,,7216,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,28698.31,70,,28698.31,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,2075.92,,,2075.92,Other,New York Medicaid APG methodology,2075.92,,,2075.92,Other,100% New York Medicaid APG,2075.92,,,2075.92,Other,100% New York Medicaid APG,2075.92,,,2075.92,Other,100% New York Medicaid APG,4670.82,,,4670.82,Other,225% New York Medicaid APG,3176.15,,,3176.15,Other,153% New York Medicaid APG,4670.82,,,4670.82,Other,225% New York Medicaid APG,2906.29,,,2906.29,Other,140% New York Medicaid APG,4670.82,,,4670.82,Other,225% New York Medicaid APG,5397.39,,,5397.39,Other,260% New York Medicaid APG,6725.98,,,6725.98,Other,324% New York Medicaid APG,4463.22,,,4463.22,Other,215% New York Medicaid APG,4463.22,,,4463.22,Other,215% New York Medicaid APG,2594.9,,,2594.9,Other,125% New York Medicaid APG,2053,32798.06,
Insj breast implt sm d mast,19340,CPT,,,,,,,,both,,,137162.89,101500.54,74,,101500.54,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,61723.3,45,,61723.3,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,7266,,"100% primary, 50% secondary, 25% supplemental procedure",7266,Other,Blue Cross ASC Grouper,6539,,"100% primary, 50% secondary, 25% supplemental procedure",6539,Other,Blue Cross ASC Grouper,6176,,"100% primary, 50% secondary, 25% supplemental procedure",6176,Other,Blue Cross ASC Grouper,67895.63,49.5,,67895.63,percent of total billed charges,110% of Medicare,93270.77,68,,93270.77,percent of total billed charges,,3861.21,,,3861.21,Other,186% of Medicaid,109730.31,80,,109730.31,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,109730.31,80,,109730.31,percent of total billed charges,,7216,,,7216,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,96014.02,70,,96014.02,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,2075.92,,,2075.92,Other,New York Medicaid APG methodology,2075.92,,,2075.92,Other,100% New York Medicaid APG,2075.92,,,2075.92,Other,100% New York Medicaid APG,2075.92,,,2075.92,Other,100% New York Medicaid APG,4670.82,,,4670.82,Other,225% New York Medicaid APG,3176.15,,,3176.15,Other,153% New York Medicaid APG,4670.82,,,4670.82,Other,225% New York Medicaid APG,2906.29,,,2906.29,Other,140% New York Medicaid APG,4670.82,,,4670.82,Other,225% New York Medicaid APG,5397.39,,,5397.39,Other,260% New York Medicaid APG,6725.98,,,6725.98,Other,324% New York Medicaid APG,4463.22,,,4463.22,Other,215% New York Medicaid APG,4463.22,,,4463.22,Other,215% New York Medicaid APG,2594.9,,,2594.9,Other,125% New York Medicaid APG,2075.92,109730.31,
Insj/rplcmt brst implt sep d,19342,CPT,,,,,,,,both,,,50740.85,37548.23,74,,37548.23,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,22833.38,45,,22833.38,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,25116.72,49.5,,25116.72,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3861.21,,,3861.21,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,35518.6,70,,35518.6,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,2075.92,,,2075.92,Other,New York Medicaid APG methodology,2075.92,,,2075.92,Other,100% New York Medicaid APG,2075.92,,,2075.92,Other,100% New York Medicaid APG,2075.92,,,2075.92,Other,100% New York Medicaid APG,4670.82,,,4670.82,Other,225% New York Medicaid APG,3176.15,,,3176.15,Other,153% New York Medicaid APG,4670.82,,,4670.82,Other,225% New York Medicaid APG,2906.29,,,2906.29,Other,140% New York Medicaid APG,4670.82,,,4670.82,Other,225% New York Medicaid APG,5397.39,,,5397.39,Other,260% New York Medicaid APG,6725.98,,,6725.98,Other,324% New York Medicaid APG,4463.22,,,4463.22,Other,215% New York Medicaid APG,4463.22,,,4463.22,Other,215% New York Medicaid APG,2594.9,,,2594.9,Other,125% New York Medicaid APG,2075.92,37548.23,
Breast reconstruction,19350,CPT,,,,,,,,both,,,80175.05,59329.54,74,,59329.54,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,36078.77,45,,36078.77,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,39686.65,49.5,,39686.65,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3861.21,,,3861.21,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,56122.54,70,,56122.54,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,2075.92,,,2075.92,Other,New York Medicaid APG methodology,2075.92,,,2075.92,Other,100% New York Medicaid APG,2075.92,,,2075.92,Other,100% New York Medicaid APG,2075.92,,,2075.92,Other,100% New York Medicaid APG,4670.82,,,4670.82,Other,225% New York Medicaid APG,3176.15,,,3176.15,Other,153% New York Medicaid APG,4670.82,,,4670.82,Other,225% New York Medicaid APG,2906.29,,,2906.29,Other,140% New York Medicaid APG,4670.82,,,4670.82,Other,225% New York Medicaid APG,5397.39,,,5397.39,Other,260% New York Medicaid APG,6725.98,,,6725.98,Other,324% New York Medicaid APG,4463.22,,,4463.22,Other,215% New York Medicaid APG,4463.22,,,4463.22,Other,215% New York Medicaid APG,2594.9,,,2594.9,Other,125% New York Medicaid APG,2075.92,59329.54,
Correct inverted nipple(s),19355,CPT,,,,,,,,both,,,35214.64,26058.83,74,,26058.83,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15846.59,45,,15846.59,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,17431.25,49.5,,17431.25,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3861.21,,,3861.21,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,24650.25,70,,24650.25,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,2075.92,,,2075.92,Other,New York Medicaid APG methodology,2075.92,,,2075.92,Other,100% New York Medicaid APG,2075.92,,,2075.92,Other,100% New York Medicaid APG,2075.92,,,2075.92,Other,100% New York Medicaid APG,4670.82,,,4670.82,Other,225% New York Medicaid APG,3176.15,,,3176.15,Other,153% New York Medicaid APG,4670.82,,,4670.82,Other,225% New York Medicaid APG,2906.29,,,2906.29,Other,140% New York Medicaid APG,4670.82,,,4670.82,Other,225% New York Medicaid APG,5397.39,,,5397.39,Other,260% New York Medicaid APG,6725.98,,,6725.98,Other,324% New York Medicaid APG,4463.22,,,4463.22,Other,215% New York Medicaid APG,4463.22,,,4463.22,Other,215% New York Medicaid APG,2594.9,,,2594.9,Other,125% New York Medicaid APG,2075.92,26058.83,
Tiss xpndr plmt brst rcnstj,19357,CPT,,,,,,,,both,,,42861.71,31717.67,74,,31717.67,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,19287.77,45,,19287.77,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,21216.55,49.5,,21216.55,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5442.71,,,5442.71,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,30003.2,70,,30003.2,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,2926.19,,,2926.19,Other,New York Medicaid APG methodology,2926.19,,,2926.19,Other,100% New York Medicaid APG,2926.19,,,2926.19,Other,100% New York Medicaid APG,2926.19,,,2926.19,Other,100% New York Medicaid APG,6583.92,,,6583.92,Other,225% New York Medicaid APG,4477.07,,,4477.07,Other,153% New York Medicaid APG,6583.92,,,6583.92,Other,225% New York Medicaid APG,4096.66,,,4096.66,Other,140% New York Medicaid APG,6583.92,,,6583.92,Other,225% New York Medicaid APG,7608.09,,,7608.09,Other,260% New York Medicaid APG,9480.85,,,9480.85,Other,324% New York Medicaid APG,6291.3,,,6291.3,Other,215% New York Medicaid APG,6291.3,,,6291.3,Other,215% New York Medicaid APG,3657.74,,,3657.74,Other,125% New York Medicaid APG,2926.19,31717.67,
Revj peri-implt capsule brst,19370,CPT,,,,,,,,both,,,80175.05,59329.54,74,,59329.54,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,36078.77,45,,36078.77,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,39686.65,49.5,,39686.65,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3861.21,,,3861.21,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,56122.54,70,,56122.54,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,2075.92,,,2075.92,Other,New York Medicaid APG methodology,2075.92,,,2075.92,Other,100% New York Medicaid APG,2075.92,,,2075.92,Other,100% New York Medicaid APG,2075.92,,,2075.92,Other,100% New York Medicaid APG,4670.82,,,4670.82,Other,225% New York Medicaid APG,3176.15,,,3176.15,Other,153% New York Medicaid APG,4670.82,,,4670.82,Other,225% New York Medicaid APG,2906.29,,,2906.29,Other,140% New York Medicaid APG,4670.82,,,4670.82,Other,225% New York Medicaid APG,5397.39,,,5397.39,Other,260% New York Medicaid APG,6725.98,,,6725.98,Other,324% New York Medicaid APG,4463.22,,,4463.22,Other,215% New York Medicaid APG,4463.22,,,4463.22,Other,215% New York Medicaid APG,2594.9,,,2594.9,Other,125% New York Medicaid APG,2075.92,59329.54,
Peri-implt capslc brst compl,19371,CPT,,,,,,,,both,,,51010.09,37747.47,74,,37747.47,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,22954.54,45,,22954.54,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,25249.99,49.5,,25249.99,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3861.21,,,3861.21,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,35707.06,70,,35707.06,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,2075.92,,,2075.92,Other,New York Medicaid APG methodology,2075.92,,,2075.92,Other,100% New York Medicaid APG,2075.92,,,2075.92,Other,100% New York Medicaid APG,2075.92,,,2075.92,Other,100% New York Medicaid APG,4670.82,,,4670.82,Other,225% New York Medicaid APG,3176.15,,,3176.15,Other,153% New York Medicaid APG,4670.82,,,4670.82,Other,225% New York Medicaid APG,2906.29,,,2906.29,Other,140% New York Medicaid APG,4670.82,,,4670.82,Other,225% New York Medicaid APG,5397.39,,,5397.39,Other,260% New York Medicaid APG,6725.98,,,6725.98,Other,324% New York Medicaid APG,4463.22,,,4463.22,Other,215% New York Medicaid APG,4463.22,,,4463.22,Other,215% New York Medicaid APG,2594.9,,,2594.9,Other,125% New York Medicaid APG,2075.92,37747.47,
Revj reconstructed breast,19380,CPT,,,,,,,,both,,,42520.22,31464.96,74,,31464.96,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,19134.1,45,,19134.1,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,7266,,"100% primary, 50% secondary, 25% supplemental procedure",7266,Other,Blue Cross ASC Grouper,6539,,"100% primary, 50% secondary, 25% supplemental procedure",6539,Other,Blue Cross ASC Grouper,6176,,"100% primary, 50% secondary, 25% supplemental procedure",6176,Other,Blue Cross ASC Grouper,21047.51,49.5,,21047.51,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3861.21,,,3861.21,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,29764.15,70,,29764.15,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,2075.92,,,2075.92,Other,New York Medicaid APG methodology,2075.92,,,2075.92,Other,100% New York Medicaid APG,2075.92,,,2075.92,Other,100% New York Medicaid APG,2075.92,,,2075.92,Other,100% New York Medicaid APG,4670.82,,,4670.82,Other,225% New York Medicaid APG,3176.15,,,3176.15,Other,153% New York Medicaid APG,4670.82,,,4670.82,Other,225% New York Medicaid APG,2906.29,,,2906.29,Other,140% New York Medicaid APG,4670.82,,,4670.82,Other,225% New York Medicaid APG,5397.39,,,5397.39,Other,260% New York Medicaid APG,6725.98,,,6725.98,Other,324% New York Medicaid APG,4463.22,,,4463.22,Other,215% New York Medicaid APG,4463.22,,,4463.22,Other,215% New York Medicaid APG,2594.9,,,2594.9,Other,125% New York Medicaid APG,2075.92,31464.96,
Design custom breast implant,19396,CPT,,,,,,,,both,,,80175.05,59329.54,74,,59329.54,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,36078.77,45,,36078.77,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,39686.65,49.5,,39686.65,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2793.39,,,2793.39,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,56122.54,70,,56122.54,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1501.82,,,1501.82,Other,New York Medicaid APG methodology,1501.82,,,1501.82,Other,100% New York Medicaid APG,1501.82,,,1501.82,Other,100% New York Medicaid APG,1501.82,,,1501.82,Other,100% New York Medicaid APG,3379.1,,,3379.1,Other,225% New York Medicaid APG,2297.79,,,2297.79,Other,153% New York Medicaid APG,3379.1,,,3379.1,Other,225% New York Medicaid APG,2102.55,,,2102.55,Other,140% New York Medicaid APG,3379.1,,,3379.1,Other,225% New York Medicaid APG,3904.73,,,3904.73,Other,260% New York Medicaid APG,4865.9,,,4865.9,Other,324% New York Medicaid APG,3228.91,,,3228.91,Other,215% New York Medicaid APG,3228.91,,,3228.91,Other,215% New York Medicaid APG,1877.28,,,1877.28,Other,125% New York Medicaid APG,1501.82,59329.54,
Explore wound neck,20100,CPT,,,,,,,,both,,,11572.85,8563.91,74,,8563.91,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,5207.78,45,,5207.78,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,5728.56,49.5,,5728.56,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2492.85,,,2492.85,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,8101,70,,8101,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,1340.24,,,1340.24,Other,New York Medicaid APG methodology,1340.24,,,1340.24,Other,100% New York Medicaid APG,1340.24,,,1340.24,Other,100% New York Medicaid APG,1340.24,,,1340.24,Other,100% New York Medicaid APG,3015.54,,,3015.54,Other,225% New York Medicaid APG,2050.57,,,2050.57,Other,153% New York Medicaid APG,3015.54,,,3015.54,Other,225% New York Medicaid APG,1876.34,,,1876.34,Other,140% New York Medicaid APG,3015.54,,,3015.54,Other,225% New York Medicaid APG,3484.62,,,3484.62,Other,260% New York Medicaid APG,4342.38,,,4342.38,Other,324% New York Medicaid APG,2881.52,,,2881.52,Other,215% New York Medicaid APG,2881.52,,,2881.52,Other,215% New York Medicaid APG,1675.3,,,1675.3,Other,125% New York Medicaid APG,1340.24,9473,
Explore wound chest,20101,CPT,,,,,,,,both,,,38357.55,28384.59,74,,28384.59,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,17260.9,45,,17260.9,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,18986.99,49.5,,18986.99,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2492.85,,,2492.85,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,26850.29,70,,26850.29,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1340.24,,,1340.24,Other,New York Medicaid APG methodology,1340.24,,,1340.24,Other,100% New York Medicaid APG,1340.24,,,1340.24,Other,100% New York Medicaid APG,1340.24,,,1340.24,Other,100% New York Medicaid APG,3015.54,,,3015.54,Other,225% New York Medicaid APG,2050.57,,,2050.57,Other,153% New York Medicaid APG,3015.54,,,3015.54,Other,225% New York Medicaid APG,1876.34,,,1876.34,Other,140% New York Medicaid APG,3015.54,,,3015.54,Other,225% New York Medicaid APG,3484.62,,,3484.62,Other,260% New York Medicaid APG,4342.38,,,4342.38,Other,324% New York Medicaid APG,2881.52,,,2881.52,Other,215% New York Medicaid APG,2881.52,,,2881.52,Other,215% New York Medicaid APG,1675.3,,,1675.3,Other,125% New York Medicaid APG,1340.24,28384.59,
Explore wound abdomen,20102,CPT,,,,,,,,both,,,38357.55,28384.59,74,,28384.59,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,17260.9,45,,17260.9,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,18986.99,49.5,,18986.99,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2492.85,,,2492.85,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,26850.29,70,,26850.29,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1340.24,,,1340.24,Other,New York Medicaid APG methodology,1340.24,,,1340.24,Other,100% New York Medicaid APG,1340.24,,,1340.24,Other,100% New York Medicaid APG,1340.24,,,1340.24,Other,100% New York Medicaid APG,3015.54,,,3015.54,Other,225% New York Medicaid APG,2050.57,,,2050.57,Other,153% New York Medicaid APG,3015.54,,,3015.54,Other,225% New York Medicaid APG,1876.34,,,1876.34,Other,140% New York Medicaid APG,3015.54,,,3015.54,Other,225% New York Medicaid APG,3484.62,,,3484.62,Other,260% New York Medicaid APG,4342.38,,,4342.38,Other,324% New York Medicaid APG,2881.52,,,2881.52,Other,215% New York Medicaid APG,2881.52,,,2881.52,Other,215% New York Medicaid APG,1675.3,,,1675.3,Other,125% New York Medicaid APG,1340.24,28384.59,
Explore wound extremity,20103,CPT,,,,,,,,both,,,34101.75,25235.3,74,,25235.3,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15345.79,45,,15345.79,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,16880.37,49.5,,16880.37,percent of total billed charges,110% of Medicare,23189.19,68,,23189.19,percent of total billed charges,,1352.53,,,1352.53,Other,186% of Medicaid,27281.4,80,,27281.4,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,27281.4,80,,27281.4,percent of total billed charges,,7216,,,7216,Case Rate,,3578,,"100% primary, 0% secondary procedures",3578,Other,MagnaCare ASC Grouper,23871.23,70,,23871.23,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,727.17,,,727.17,Other,New York Medicaid APG methodology,727.17,,,727.17,Other,100% New York Medicaid APG,727.17,,,727.17,Other,100% New York Medicaid APG,727.17,,,727.17,Other,100% New York Medicaid APG,1636.12,,,1636.12,Other,225% New York Medicaid APG,1112.56,,,1112.56,Other,153% New York Medicaid APG,1636.12,,,1636.12,Other,225% New York Medicaid APG,1018.03,,,1018.03,Other,140% New York Medicaid APG,1636.12,,,1636.12,Other,225% New York Medicaid APG,1890.63,,,1890.63,Other,260% New York Medicaid APG,2356.02,,,2356.02,Other,324% New York Medicaid APG,1563.41,,,1563.41,Other,215% New York Medicaid APG,1563.41,,,1563.41,Other,215% New York Medicaid APG,908.96,,,908.96,Other,125% New York Medicaid APG,727.17,27281.4,
Excise epiphyseal bar,20150,CPT,,,,,,,,both,,,68082.75,50381.24,74,,50381.24,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30637.24,45,,30637.24,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33700.96,49.5,,33700.96,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,1973.06,,,1973.06,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,47657.93,70,,47657.93,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,1060.79,,,1060.79,Other,New York Medicaid APG methodology,1060.79,,,1060.79,Other,100% New York Medicaid APG,1060.79,,,1060.79,Other,100% New York Medicaid APG,1060.79,,,1060.79,Other,100% New York Medicaid APG,2386.77,,,2386.77,Other,225% New York Medicaid APG,1623,,,1623,Other,153% New York Medicaid APG,2386.77,,,2386.77,Other,225% New York Medicaid APG,1485.1,,,1485.1,Other,140% New York Medicaid APG,2386.77,,,2386.77,Other,225% New York Medicaid APG,2758.05,,,2758.05,Other,260% New York Medicaid APG,3436.95,,,3436.95,Other,324% New York Medicaid APG,2280.69,,,2280.69,Other,215% New York Medicaid APG,2280.69,,,2280.69,Other,215% New York Medicaid APG,1325.98,,,1325.98,Other,125% New York Medicaid APG,1060.79,50381.24,
Muscle biopsy,20200,CPT,,,,,,,,both,,,34101.75,25235.3,74,,25235.3,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15345.79,45,,15345.79,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,16880.37,49.5,,16880.37,percent of total billed charges,110% of Medicare,23189.19,68,,23189.19,percent of total billed charges,,1973.06,,,1973.06,Other,186% of Medicaid,27281.4,80,,27281.4,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,27281.4,80,,27281.4,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,23871.23,70,,23871.23,percent of total billed charges,,464.12,,,464.12,Fee Schedule,,393.37,,,393.37,Fee Schedule,,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1060.79,,,1060.79,Other,New York Medicaid APG methodology,1060.79,,,1060.79,Other,100% New York Medicaid APG,1060.79,,,1060.79,Other,100% New York Medicaid APG,1060.79,,,1060.79,Other,100% New York Medicaid APG,2386.77,,,2386.77,Other,225% New York Medicaid APG,1623,,,1623,Other,153% New York Medicaid APG,2386.77,,,2386.77,Other,225% New York Medicaid APG,1485.1,,,1485.1,Other,140% New York Medicaid APG,2386.77,,,2386.77,Other,225% New York Medicaid APG,2758.05,,,2758.05,Other,260% New York Medicaid APG,3436.95,,,3436.95,Other,324% New York Medicaid APG,2280.69,,,2280.69,Other,215% New York Medicaid APG,2280.69,,,2280.69,Other,215% New York Medicaid APG,1325.98,,,1325.98,Other,125% New York Medicaid APG,393.37,27281.4,
Deep muscle biopsy,20205,CPT,,,,,,,,both,,,42752,31636.48,74,,31636.48,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,19238.4,45,,19238.4,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,21162.24,49.5,,21162.24,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,1973.06,,,1973.06,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,29926.4,70,,29926.4,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1060.79,,,1060.79,Other,New York Medicaid APG methodology,1060.79,,,1060.79,Other,100% New York Medicaid APG,1060.79,,,1060.79,Other,100% New York Medicaid APG,1060.79,,,1060.79,Other,100% New York Medicaid APG,2386.77,,,2386.77,Other,225% New York Medicaid APG,1623,,,1623,Other,153% New York Medicaid APG,2386.77,,,2386.77,Other,225% New York Medicaid APG,1485.1,,,1485.1,Other,140% New York Medicaid APG,2386.77,,,2386.77,Other,225% New York Medicaid APG,2758.05,,,2758.05,Other,260% New York Medicaid APG,3436.95,,,3436.95,Other,324% New York Medicaid APG,2280.69,,,2280.69,Other,215% New York Medicaid APG,2280.69,,,2280.69,Other,215% New York Medicaid APG,1325.98,,,1325.98,Other,125% New York Medicaid APG,1060.79,31636.48,
Needle biopsy muscle,20206,CPT,,,,,,,,both,,,67811.2,50180.29,74,,50180.29,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30515.04,45,,30515.04,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,33566.54,49.5,,33566.54,percent of total billed charges,110% of Medicare,46111.62,68,,46111.62,percent of total billed charges,,1037.55,,,1037.55,Other,186% of Medicaid,54248.96,80,,54248.96,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,54248.96,80,,54248.96,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,47467.84,70,,47467.84,percent of total billed charges,,277.16,,,277.16,Fee Schedule,,234.91,,,234.91,Fee Schedule,,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,557.82,,,557.82,Other,New York Medicaid APG methodology,557.82,,,557.82,Other,100% New York Medicaid APG,557.82,,,557.82,Other,100% New York Medicaid APG,557.82,,,557.82,Other,100% New York Medicaid APG,1255.1,,,1255.1,Other,225% New York Medicaid APG,853.47,,,853.47,Other,153% New York Medicaid APG,1255.1,,,1255.1,Other,225% New York Medicaid APG,780.95,,,780.95,Other,140% New York Medicaid APG,1255.1,,,1255.1,Other,225% New York Medicaid APG,1450.34,,,1450.34,Other,260% New York Medicaid APG,1807.35,,,1807.35,Other,324% New York Medicaid APG,1199.32,,,1199.32,Other,215% New York Medicaid APG,1199.32,,,1199.32,Other,215% New York Medicaid APG,697.28,,,697.28,Other,125% New York Medicaid APG,234.91,54248.96,
Bone biopsy trocar/needle,20220,CPT,,,,,,,,both,,,41632.49,30808.04,74,,30808.04,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,18734.62,45,,18734.62,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,20608.08,49.5,,20608.08,percent of total billed charges,110% of Medicare,28310.09,68,,28310.09,percent of total billed charges,,1037.55,,,1037.55,Other,186% of Medicaid,33305.99,80,,33305.99,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,33305.99,80,,33305.99,percent of total billed charges,,7216,,,7216,Case Rate,,3578,,"100% primary, 0% secondary procedures",3578,Other,MagnaCare ASC Grouper,29142.74,70,,29142.74,percent of total billed charges,,424.76,,,424.76,Fee Schedule,,360.01,,,360.01,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,557.82,,,557.82,Other,New York Medicaid APG methodology,557.82,,,557.82,Other,100% New York Medicaid APG,557.82,,,557.82,Other,100% New York Medicaid APG,557.82,,,557.82,Other,100% New York Medicaid APG,1255.1,,,1255.1,Other,225% New York Medicaid APG,853.47,,,853.47,Other,153% New York Medicaid APG,1255.1,,,1255.1,Other,225% New York Medicaid APG,780.95,,,780.95,Other,140% New York Medicaid APG,1255.1,,,1255.1,Other,225% New York Medicaid APG,1450.34,,,1450.34,Other,260% New York Medicaid APG,1807.35,,,1807.35,Other,324% New York Medicaid APG,1199.32,,,1199.32,Other,215% New York Medicaid APG,1199.32,,,1199.32,Other,215% New York Medicaid APG,697.28,,,697.28,Other,125% New York Medicaid APG,360.01,33305.99,
Bone biopsy trocar/needle,20225,CPT,,,,,,,,both,,,40382.03,29882.7,74,,29882.7,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,18171.91,45,,18171.91,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,19989.1,49.5,,19989.1,percent of total billed charges,110% of Medicare,27459.78,68,,27459.78,percent of total billed charges,,1973.06,,,1973.06,Other,186% of Medicaid,32305.62,80,,32305.62,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,32305.62,80,,32305.62,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,28267.42,70,,28267.42,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1060.79,,,1060.79,Other,New York Medicaid APG methodology,1060.79,,,1060.79,Other,100% New York Medicaid APG,1060.79,,,1060.79,Other,100% New York Medicaid APG,1060.79,,,1060.79,Other,100% New York Medicaid APG,2386.77,,,2386.77,Other,225% New York Medicaid APG,1623,,,1623,Other,153% New York Medicaid APG,2386.77,,,2386.77,Other,225% New York Medicaid APG,1485.1,,,1485.1,Other,140% New York Medicaid APG,2386.77,,,2386.77,Other,225% New York Medicaid APG,2758.05,,,2758.05,Other,260% New York Medicaid APG,3436.95,,,3436.95,Other,324% New York Medicaid APG,2280.69,,,2280.69,Other,215% New York Medicaid APG,2280.69,,,2280.69,Other,215% New York Medicaid APG,1325.98,,,1325.98,Other,125% New York Medicaid APG,1060.79,32305.62,
Bone biopsy open superficial,20240,CPT,,,,,,,,both,,,59767.2,44227.73,74,,44227.73,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,26895.24,45,,26895.24,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,29584.76,49.5,,29584.76,percent of total billed charges,110% of Medicare,40641.7,68,,40641.7,percent of total billed charges,,1973.06,,,1973.06,Other,186% of Medicaid,47813.76,80,,47813.76,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,47813.76,80,,47813.76,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,41837.04,70,,41837.04,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1060.79,,,1060.79,Other,New York Medicaid APG methodology,1060.79,,,1060.79,Other,100% New York Medicaid APG,1060.79,,,1060.79,Other,100% New York Medicaid APG,1060.79,,,1060.79,Other,100% New York Medicaid APG,2386.77,,,2386.77,Other,225% New York Medicaid APG,1623,,,1623,Other,153% New York Medicaid APG,2386.77,,,2386.77,Other,225% New York Medicaid APG,1485.1,,,1485.1,Other,140% New York Medicaid APG,2386.77,,,2386.77,Other,225% New York Medicaid APG,2758.05,,,2758.05,Other,260% New York Medicaid APG,3436.95,,,3436.95,Other,324% New York Medicaid APG,2280.69,,,2280.69,Other,215% New York Medicaid APG,2280.69,,,2280.69,Other,215% New York Medicaid APG,1325.98,,,1325.98,Other,125% New York Medicaid APG,1060.79,47813.76,
Bone biopsy open deep,20245,CPT,,,,,,,,both,,,47982.32,35506.92,74,,35506.92,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,21592.04,45,,21592.04,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,23751.25,49.5,,23751.25,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,1973.06,,,1973.06,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,33587.62,70,,33587.62,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1060.79,,,1060.79,Other,New York Medicaid APG methodology,1060.79,,,1060.79,Other,100% New York Medicaid APG,1060.79,,,1060.79,Other,100% New York Medicaid APG,1060.79,,,1060.79,Other,100% New York Medicaid APG,2386.77,,,2386.77,Other,225% New York Medicaid APG,1623,,,1623,Other,153% New York Medicaid APG,2386.77,,,2386.77,Other,225% New York Medicaid APG,1485.1,,,1485.1,Other,140% New York Medicaid APG,2386.77,,,2386.77,Other,225% New York Medicaid APG,2758.05,,,2758.05,Other,260% New York Medicaid APG,3436.95,,,3436.95,Other,324% New York Medicaid APG,2280.69,,,2280.69,Other,215% New York Medicaid APG,2280.69,,,2280.69,Other,215% New York Medicaid APG,1325.98,,,1325.98,Other,125% New York Medicaid APG,1060.79,35506.92,
Open bone biopsy,20250,CPT,,,,,,,,both,,,68082.75,50381.24,74,,50381.24,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30637.24,45,,30637.24,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33700.96,49.5,,33700.96,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5525.48,,,5525.48,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,47657.93,70,,47657.93,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,2970.69,,,2970.69,Other,New York Medicaid APG methodology,2970.69,,,2970.69,Other,100% New York Medicaid APG,2970.69,,,2970.69,Other,100% New York Medicaid APG,2970.69,,,2970.69,Other,100% New York Medicaid APG,6684.05,,,6684.05,Other,225% New York Medicaid APG,4545.16,,,4545.16,Other,153% New York Medicaid APG,6684.05,,,6684.05,Other,225% New York Medicaid APG,4158.97,,,4158.97,Other,140% New York Medicaid APG,6684.05,,,6684.05,Other,225% New York Medicaid APG,7723.79,,,7723.79,Other,260% New York Medicaid APG,9625.03,,,9625.03,Other,324% New York Medicaid APG,6386.98,,,6386.98,Other,215% New York Medicaid APG,6386.98,,,6386.98,Other,215% New York Medicaid APG,3713.36,,,3713.36,Other,125% New York Medicaid APG,2970.69,50381.24,
Open bone biopsy,20251,CPT,,,,,,,,both,,,150476.65,111352.72,74,,111352.72,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,67714.49,45,,67714.49,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,74485.94,49.5,,74485.94,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5525.48,,,5525.48,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,105333.66,70,,105333.66,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,2970.69,,,2970.69,Other,New York Medicaid APG methodology,2970.69,,,2970.69,Other,100% New York Medicaid APG,2970.69,,,2970.69,Other,100% New York Medicaid APG,2970.69,,,2970.69,Other,100% New York Medicaid APG,6684.05,,,6684.05,Other,225% New York Medicaid APG,4545.16,,,4545.16,Other,153% New York Medicaid APG,6684.05,,,6684.05,Other,225% New York Medicaid APG,4158.97,,,4158.97,Other,140% New York Medicaid APG,6684.05,,,6684.05,Other,225% New York Medicaid APG,7723.79,,,7723.79,Other,260% New York Medicaid APG,9625.03,,,9625.03,Other,324% New York Medicaid APG,6386.98,,,6386.98,Other,215% New York Medicaid APG,6386.98,,,6386.98,Other,215% New York Medicaid APG,3713.36,,,3713.36,Other,125% New York Medicaid APG,2970.69,111352.72,
Injection of sinus tract,20500,CPT,,,,,,,,both,,,32077.39,23737.27,74,,23737.27,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,14434.83,45,,14434.83,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,15878.31,49.5,,15878.31,percent of total billed charges,110% of Medicare,21812.63,68,,21812.63,percent of total billed charges,,2256.57,,,2256.57,Other,186% of Medicaid,25661.91,80,,25661.91,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,25661.91,80,,25661.91,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,22454.17,70,,22454.17,percent of total billed charges,,436.24,,,436.24,Fee Schedule,,369.74,,,369.74,Fee Schedule,,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1213.21,,,1213.21,Other,New York Medicaid APG methodology,1213.21,,,1213.21,Other,100% New York Medicaid APG,1213.21,,,1213.21,Other,100% New York Medicaid APG,1213.21,,,1213.21,Other,100% New York Medicaid APG,2729.72,,,2729.72,Other,225% New York Medicaid APG,1856.21,,,1856.21,Other,153% New York Medicaid APG,2729.72,,,2729.72,Other,225% New York Medicaid APG,1698.49,,,1698.49,Other,140% New York Medicaid APG,2729.72,,,2729.72,Other,225% New York Medicaid APG,3154.34,,,3154.34,Other,260% New York Medicaid APG,3930.79,,,3930.79,Other,324% New York Medicaid APG,2608.4,,,2608.4,Other,215% New York Medicaid APG,2608.4,,,2608.4,Other,215% New York Medicaid APG,1516.51,,,1516.51,Other,125% New York Medicaid APG,369.74,25661.91,
Inject sinus tract for x-ray,20501,CPT,,,,,,,,both,,,32432.1,23999.75,74,,23999.75,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,14594.45,45,,14594.45,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,16053.89,49.5,,16053.89,percent of total billed charges,110% of Medicare,22053.83,68,,22053.83,percent of total billed charges,,966.93,,,966.93,Other,186% of Medicaid,25945.68,80,,25945.68,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,25945.68,80,,25945.68,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,22702.47,70,,22702.47,percent of total billed charges,,177.12,,,177.12,Fee Schedule,,150.12,,,150.12,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,519.86,,,519.86,Other,New York Medicaid APG methodology,519.86,,,519.86,Other,100% New York Medicaid APG,519.86,,,519.86,Other,100% New York Medicaid APG,519.86,,,519.86,Other,100% New York Medicaid APG,1169.68,,,1169.68,Other,225% New York Medicaid APG,795.38,,,795.38,Other,153% New York Medicaid APG,1169.68,,,1169.68,Other,225% New York Medicaid APG,727.8,,,727.8,Other,140% New York Medicaid APG,1169.68,,,1169.68,Other,225% New York Medicaid APG,1351.62,,,1351.62,Other,260% New York Medicaid APG,1684.33,,,1684.33,Other,324% New York Medicaid APG,1117.69,,,1117.69,Other,215% New York Medicaid APG,1117.69,,,1117.69,Other,215% New York Medicaid APG,649.82,,,649.82,Other,125% New York Medicaid APG,150.12,25945.68,
Removal of foreign body,20520,CPT,,,,,,,,both,,,34057.08,25202.24,74,,25202.24,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15325.69,45,,15325.69,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,16858.25,49.5,,16858.25,percent of total billed charges,110% of Medicare,23158.81,68,,23158.81,percent of total billed charges,,1973.06,,,1973.06,Other,186% of Medicaid,27245.66,80,,27245.66,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,27245.66,80,,27245.66,percent of total billed charges,,7216,,,7216,Case Rate,,3578,,"100% primary, 0% secondary procedures",3578,Other,MagnaCare ASC Grouper,23839.96,70,,23839.96,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,1060.79,,,1060.79,Other,New York Medicaid APG methodology,1060.79,,,1060.79,Other,100% New York Medicaid APG,1060.79,,,1060.79,Other,100% New York Medicaid APG,1060.79,,,1060.79,Other,100% New York Medicaid APG,2386.77,,,2386.77,Other,225% New York Medicaid APG,1623,,,1623,Other,153% New York Medicaid APG,2386.77,,,2386.77,Other,225% New York Medicaid APG,1485.1,,,1485.1,Other,140% New York Medicaid APG,2386.77,,,2386.77,Other,225% New York Medicaid APG,2758.05,,,2758.05,Other,260% New York Medicaid APG,3436.95,,,3436.95,Other,324% New York Medicaid APG,2280.69,,,2280.69,Other,215% New York Medicaid APG,2280.69,,,2280.69,Other,215% New York Medicaid APG,1325.98,,,1325.98,Other,125% New York Medicaid APG,1060.79,27245.66,
Removal of foreign body,20525,CPT,,,,,,,,both,,,33471.9,24769.21,74,,24769.21,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15062.36,45,,15062.36,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,16568.59,49.5,,16568.59,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,1973.06,,,1973.06,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,23430.33,70,,23430.33,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1060.79,,,1060.79,Other,New York Medicaid APG methodology,1060.79,,,1060.79,Other,100% New York Medicaid APG,1060.79,,,1060.79,Other,100% New York Medicaid APG,1060.79,,,1060.79,Other,100% New York Medicaid APG,2386.77,,,2386.77,Other,225% New York Medicaid APG,1623,,,1623,Other,153% New York Medicaid APG,2386.77,,,2386.77,Other,225% New York Medicaid APG,1485.1,,,1485.1,Other,140% New York Medicaid APG,2386.77,,,2386.77,Other,225% New York Medicaid APG,2758.05,,,2758.05,Other,260% New York Medicaid APG,3436.95,,,3436.95,Other,324% New York Medicaid APG,2280.69,,,2280.69,Other,215% New York Medicaid APG,2280.69,,,2280.69,Other,215% New York Medicaid APG,1325.98,,,1325.98,Other,125% New York Medicaid APG,1060.79,24769.21,
Ther injection carp tunnel,20526,CPT,,,,,,,,both,,,6229.82,4610.07,74,,4610.07,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,2803.42,45,,2803.42,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,3083.76,49.5,,3083.76,percent of total billed charges,110% of Medicare,4236.28,68,,4236.28,percent of total billed charges,,685.67,,,685.67,Other,186% of Medicaid,4983.86,80,,4983.86,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,4983.86,80,,4983.86,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,4360.87,70,,4360.87,percent of total billed charges,,278.8,,,278.8,Fee Schedule,,236.3,,,236.3,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,368.64,,,368.64,Other,New York Medicaid APG methodology,368.64,,,368.64,Other,100% New York Medicaid APG,368.64,,,368.64,Other,100% New York Medicaid APG,368.64,,,368.64,Other,100% New York Medicaid APG,829.44,,,829.44,Other,225% New York Medicaid APG,564.02,,,564.02,Other,153% New York Medicaid APG,829.44,,,829.44,Other,225% New York Medicaid APG,516.1,,,516.1,Other,140% New York Medicaid APG,829.44,,,829.44,Other,225% New York Medicaid APG,958.46,,,958.46,Other,260% New York Medicaid APG,1194.39,,,1194.39,Other,324% New York Medicaid APG,792.58,,,792.58,Other,215% New York Medicaid APG,792.58,,,792.58,Other,215% New York Medicaid APG,460.8,,,460.8,Other,125% New York Medicaid APG,236.3,7216,
Inj dupuytren cord w/enzyme,20527,CPT,,,,,,,,both,,,6229.82,4610.07,74,,4610.07,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,2803.42,45,,2803.42,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,3083.76,49.5,,3083.76,percent of total billed charges,110% of Medicare,4236.28,68,,4236.28,percent of total billed charges,,685.67,,,685.67,Other,186% of Medicaid,4983.86,80,,4983.86,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,4983.86,80,,4983.86,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,4360.87,70,,4360.87,percent of total billed charges,,321.44,,,321.44,Fee Schedule,,272.44,,,272.44,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,368.64,,,368.64,Other,New York Medicaid APG methodology,368.64,,,368.64,Other,100% New York Medicaid APG,368.64,,,368.64,Other,100% New York Medicaid APG,368.64,,,368.64,Other,100% New York Medicaid APG,829.44,,,829.44,Other,225% New York Medicaid APG,564.02,,,564.02,Other,153% New York Medicaid APG,829.44,,,829.44,Other,225% New York Medicaid APG,516.1,,,516.1,Other,140% New York Medicaid APG,829.44,,,829.44,Other,225% New York Medicaid APG,958.46,,,958.46,Other,260% New York Medicaid APG,1194.39,,,1194.39,Other,324% New York Medicaid APG,792.58,,,792.58,Other,215% New York Medicaid APG,792.58,,,792.58,Other,215% New York Medicaid APG,460.8,,,460.8,Other,125% New York Medicaid APG,272.44,7216,
Inj tendon sheath/ligament,20550,CPT,,,,,,,,both,,,6229.82,4610.07,74,,4610.07,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,2803.42,45,,2803.42,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,3083.76,49.5,,3083.76,percent of total billed charges,110% of Medicare,4236.28,68,,4236.28,percent of total billed charges,,685.67,,,685.67,Other,186% of Medicaid,4983.86,80,,4983.86,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,4983.86,80,,4983.86,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,4360.87,70,,4360.87,percent of total billed charges,,190.24,,,190.24,Fee Schedule,,161.24,,,161.24,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,368.64,,,368.64,Other,New York Medicaid APG methodology,368.64,,,368.64,Other,100% New York Medicaid APG,368.64,,,368.64,Other,100% New York Medicaid APG,368.64,,,368.64,Other,100% New York Medicaid APG,829.44,,,829.44,Other,225% New York Medicaid APG,564.02,,,564.02,Other,153% New York Medicaid APG,829.44,,,829.44,Other,225% New York Medicaid APG,516.1,,,516.1,Other,140% New York Medicaid APG,829.44,,,829.44,Other,225% New York Medicaid APG,958.46,,,958.46,Other,260% New York Medicaid APG,1194.39,,,1194.39,Other,324% New York Medicaid APG,792.58,,,792.58,Other,215% New York Medicaid APG,792.58,,,792.58,Other,215% New York Medicaid APG,460.8,,,460.8,Other,125% New York Medicaid APG,161.24,7216,
Inj tendon origin/insertion,20551,CPT,,,,,,,,both,,,6229.82,4610.07,74,,4610.07,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,2803.42,45,,2803.42,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,3083.76,49.5,,3083.76,percent of total billed charges,110% of Medicare,4236.28,68,,4236.28,percent of total billed charges,,685.67,,,685.67,Other,186% of Medicaid,4983.86,80,,4983.86,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,4983.86,80,,4983.86,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,4360.87,70,,4360.87,percent of total billed charges,,190.24,,,190.24,Fee Schedule,,161.24,,,161.24,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,368.64,,,368.64,Other,New York Medicaid APG methodology,368.64,,,368.64,Other,100% New York Medicaid APG,368.64,,,368.64,Other,100% New York Medicaid APG,368.64,,,368.64,Other,100% New York Medicaid APG,829.44,,,829.44,Other,225% New York Medicaid APG,564.02,,,564.02,Other,153% New York Medicaid APG,829.44,,,829.44,Other,225% New York Medicaid APG,516.1,,,516.1,Other,140% New York Medicaid APG,829.44,,,829.44,Other,225% New York Medicaid APG,958.46,,,958.46,Other,260% New York Medicaid APG,1194.39,,,1194.39,Other,324% New York Medicaid APG,792.58,,,792.58,Other,215% New York Medicaid APG,792.58,,,792.58,Other,215% New York Medicaid APG,460.8,,,460.8,Other,125% New York Medicaid APG,161.24,7216,
Inj trigger point 1/2 muscl,20552,CPT,,,,,,,,both,,,10572.63,7823.75,74,,7823.75,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,4757.68,45,,4757.68,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,5233.45,49.5,,5233.45,percent of total billed charges,110% of Medicare,7189.39,68,,7189.39,percent of total billed charges,,685.67,,,685.67,Other,186% of Medicaid,8458.1,80,,8458.1,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,8458.1,80,,8458.1,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,7400.84,70,,7400.84,percent of total billed charges,,180.4,,,180.4,Fee Schedule,,152.9,,,152.9,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,368.64,,,368.64,Other,New York Medicaid APG methodology,368.64,,,368.64,Other,100% New York Medicaid APG,368.64,,,368.64,Other,100% New York Medicaid APG,368.64,,,368.64,Other,100% New York Medicaid APG,829.44,,,829.44,Other,225% New York Medicaid APG,564.02,,,564.02,Other,153% New York Medicaid APG,829.44,,,829.44,Other,225% New York Medicaid APG,516.1,,,516.1,Other,140% New York Medicaid APG,829.44,,,829.44,Other,225% New York Medicaid APG,958.46,,,958.46,Other,260% New York Medicaid APG,1194.39,,,1194.39,Other,324% New York Medicaid APG,792.58,,,792.58,Other,215% New York Medicaid APG,792.58,,,792.58,Other,215% New York Medicaid APG,460.8,,,460.8,Other,125% New York Medicaid APG,152.9,8458.1,
Inject trigger points 3/>,20553,CPT,,,,,,,,both,,,6229.82,4610.07,74,,4610.07,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,2803.42,45,,2803.42,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,3083.76,49.5,,3083.76,percent of total billed charges,110% of Medicare,4236.28,68,,4236.28,percent of total billed charges,,685.67,,,685.67,Other,186% of Medicaid,4983.86,80,,4983.86,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,4983.86,80,,4983.86,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,4360.87,70,,4360.87,percent of total billed charges,,206.64,,,206.64,Fee Schedule,,175.14,,,175.14,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,368.64,,,368.64,Other,New York Medicaid APG methodology,368.64,,,368.64,Other,100% New York Medicaid APG,368.64,,,368.64,Other,100% New York Medicaid APG,368.64,,,368.64,Other,100% New York Medicaid APG,829.44,,,829.44,Other,225% New York Medicaid APG,564.02,,,564.02,Other,153% New York Medicaid APG,829.44,,,829.44,Other,225% New York Medicaid APG,516.1,,,516.1,Other,140% New York Medicaid APG,829.44,,,829.44,Other,225% New York Medicaid APG,958.46,,,958.46,Other,260% New York Medicaid APG,1194.39,,,1194.39,Other,324% New York Medicaid APG,792.58,,,792.58,Other,215% New York Medicaid APG,792.58,,,792.58,Other,215% New York Medicaid APG,460.8,,,460.8,Other,125% New York Medicaid APG,175.14,7216,
Place ndl musc/tis for rt,20555,CPT,,,,,,,,both,,,68082.75,50381.24,74,,50381.24,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30637.24,45,,30637.24,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33700.96,49.5,,33700.96,percent of total billed charges,110% of Medicare,46296.27,68,,46296.27,percent of total billed charges,,1973.06,,,1973.06,Other,186% of Medicaid,54466.2,80,,54466.2,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,54466.2,80,,54466.2,percent of total billed charges,,7216,,,7216,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,47657.93,70,,47657.93,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1060.79,,,1060.79,Other,New York Medicaid APG methodology,1060.79,,,1060.79,Other,100% New York Medicaid APG,1060.79,,,1060.79,Other,100% New York Medicaid APG,1060.79,,,1060.79,Other,100% New York Medicaid APG,2386.77,,,2386.77,Other,225% New York Medicaid APG,1623,,,1623,Other,153% New York Medicaid APG,2386.77,,,2386.77,Other,225% New York Medicaid APG,1485.1,,,1485.1,Other,140% New York Medicaid APG,2386.77,,,2386.77,Other,225% New York Medicaid APG,2758.05,,,2758.05,Other,260% New York Medicaid APG,3436.95,,,3436.95,Other,324% New York Medicaid APG,2280.69,,,2280.69,Other,215% New York Medicaid APG,2280.69,,,2280.69,Other,215% New York Medicaid APG,1325.98,,,1325.98,Other,125% New York Medicaid APG,1060.79,54466.2,
Drain/inj joint/bursa w/o us,20600,CPT,,,,,,,,both,,,34087.51,25224.76,74,,25224.76,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15339.38,45,,15339.38,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,16873.32,49.5,,16873.32,percent of total billed charges,110% of Medicare,23179.51,68,,23179.51,percent of total billed charges,,685.67,,,685.67,Other,186% of Medicaid,27270.01,80,,27270.01,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,27270.01,80,,27270.01,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,23861.26,70,,23861.26,percent of total billed charges,,172.2,,,172.2,Fee Schedule,,145.95,,,145.95,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,368.64,,,368.64,Other,New York Medicaid APG methodology,368.64,,,368.64,Other,100% New York Medicaid APG,368.64,,,368.64,Other,100% New York Medicaid APG,368.64,,,368.64,Other,100% New York Medicaid APG,829.44,,,829.44,Other,225% New York Medicaid APG,564.02,,,564.02,Other,153% New York Medicaid APG,829.44,,,829.44,Other,225% New York Medicaid APG,516.1,,,516.1,Other,140% New York Medicaid APG,829.44,,,829.44,Other,225% New York Medicaid APG,958.46,,,958.46,Other,260% New York Medicaid APG,1194.39,,,1194.39,Other,324% New York Medicaid APG,792.58,,,792.58,Other,215% New York Medicaid APG,792.58,,,792.58,Other,215% New York Medicaid APG,460.8,,,460.8,Other,125% New York Medicaid APG,145.95,27270.01,
Drain/inj joint/bursa w/us,20604,CPT,,,,,,,,both,,,6229.82,4610.07,74,,4610.07,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,2803.42,45,,2803.42,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,3083.76,49.5,,3083.76,percent of total billed charges,110% of Medicare,4236.28,68,,4236.28,percent of total billed charges,,1079.62,,,1079.62,Other,186% of Medicaid,4983.86,80,,4983.86,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,4983.86,80,,4983.86,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,4360.87,70,,4360.87,percent of total billed charges,,223.04,,,223.04,Fee Schedule,,189.04,,,189.04,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,580.44,,,580.44,Other,New York Medicaid APG methodology,580.44,,,580.44,Other,100% New York Medicaid APG,580.44,,,580.44,Other,100% New York Medicaid APG,580.44,,,580.44,Other,100% New York Medicaid APG,1306,,,1306,Other,225% New York Medicaid APG,888.08,,,888.08,Other,153% New York Medicaid APG,1306,,,1306,Other,225% New York Medicaid APG,812.62,,,812.62,Other,140% New York Medicaid APG,1306,,,1306,Other,225% New York Medicaid APG,1509.15,,,1509.15,Other,260% New York Medicaid APG,1880.64,,,1880.64,Other,324% New York Medicaid APG,1247.95,,,1247.95,Other,215% New York Medicaid APG,1247.95,,,1247.95,Other,215% New York Medicaid APG,725.55,,,725.55,Other,125% New York Medicaid APG,189.04,7216,
Drain/inj joint/bursa w/o us,20605,CPT,,,,,,,,both,,,3766.45,2787.17,74,,2787.17,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,1694.9,45,,1694.9,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,1864.39,49.5,,1864.39,percent of total billed charges,110% of Medicare,2561.19,68,,2561.19,percent of total billed charges,,685.67,,,685.67,Other,186% of Medicaid,3013.16,80,,3013.16,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,3013.16,80,,3013.16,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,2636.52,70,,2636.52,percent of total billed charges,,180.4,,,180.4,Fee Schedule,,152.9,,,152.9,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,368.64,,,368.64,Other,New York Medicaid APG methodology,368.64,,,368.64,Other,100% New York Medicaid APG,368.64,,,368.64,Other,100% New York Medicaid APG,368.64,,,368.64,Other,100% New York Medicaid APG,829.44,,,829.44,Other,225% New York Medicaid APG,564.02,,,564.02,Other,153% New York Medicaid APG,829.44,,,829.44,Other,225% New York Medicaid APG,516.1,,,516.1,Other,140% New York Medicaid APG,829.44,,,829.44,Other,225% New York Medicaid APG,958.46,,,958.46,Other,260% New York Medicaid APG,1194.39,,,1194.39,Other,324% New York Medicaid APG,792.58,,,792.58,Other,215% New York Medicaid APG,792.58,,,792.58,Other,215% New York Medicaid APG,460.8,,,460.8,Other,125% New York Medicaid APG,152.9,7216,
Drain/inj joint/bursa w/us,20606,CPT,,,,,,,,both,,,3266.33,2417.08,74,,2417.08,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,1469.85,45,,1469.85,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,1616.83,49.5,,1616.83,percent of total billed charges,110% of Medicare,2221.1,68,,2221.1,percent of total billed charges,,1079.62,,,1079.62,Other,186% of Medicaid,2613.06,80,,2613.06,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,2613.06,80,,2613.06,percent of total billed charges,,7216,,,7216,Case Rate,,3578,,"100% primary, 0% secondary procedures",3578,Other,MagnaCare ASC Grouper,2286.43,70,,2286.43,percent of total billed charges,,252.56,,,252.56,Fee Schedule,,214.06,,,214.06,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,580.44,,,580.44,Other,New York Medicaid APG methodology,580.44,,,580.44,Other,100% New York Medicaid APG,580.44,,,580.44,Other,100% New York Medicaid APG,580.44,,,580.44,Other,100% New York Medicaid APG,1306,,,1306,Other,225% New York Medicaid APG,888.08,,,888.08,Other,153% New York Medicaid APG,1306,,,1306,Other,225% New York Medicaid APG,812.62,,,812.62,Other,140% New York Medicaid APG,1306,,,1306,Other,225% New York Medicaid APG,1509.15,,,1509.15,Other,260% New York Medicaid APG,1880.64,,,1880.64,Other,324% New York Medicaid APG,1247.95,,,1247.95,Other,215% New York Medicaid APG,1247.95,,,1247.95,Other,215% New York Medicaid APG,725.55,,,725.55,Other,125% New York Medicaid APG,214.06,7216,
Drain/inj joint/bursa w/o us,20610,CPT,,,,,,,,both,,,9021.14,6675.64,74,,6675.64,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,4059.51,45,,4059.51,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,4465.46,49.5,,4465.46,percent of total billed charges,110% of Medicare,6134.38,68,,6134.38,percent of total billed charges,,685.67,,,685.67,Other,186% of Medicaid,7216.91,80,,7216.91,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,7216.91,80,,7216.91,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,6314.8,70,,6314.8,percent of total billed charges,,219.76,,,219.76,Fee Schedule,,186.26,,,186.26,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,368.64,,,368.64,Other,New York Medicaid APG methodology,368.64,,,368.64,Other,100% New York Medicaid APG,368.64,,,368.64,Other,100% New York Medicaid APG,368.64,,,368.64,Other,100% New York Medicaid APG,829.44,,,829.44,Other,225% New York Medicaid APG,564.02,,,564.02,Other,153% New York Medicaid APG,829.44,,,829.44,Other,225% New York Medicaid APG,516.1,,,516.1,Other,140% New York Medicaid APG,829.44,,,829.44,Other,225% New York Medicaid APG,958.46,,,958.46,Other,260% New York Medicaid APG,1194.39,,,1194.39,Other,324% New York Medicaid APG,792.58,,,792.58,Other,215% New York Medicaid APG,792.58,,,792.58,Other,215% New York Medicaid APG,460.8,,,460.8,Other,125% New York Medicaid APG,186.26,7216.91,
Drain/inj joint/bursa w/us,20611,CPT,,,,,,,,both,,,19379.67,14340.96,74,,14340.96,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,8720.85,45,,8720.85,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,9592.94,49.5,,9592.94,percent of total billed charges,110% of Medicare,13178.18,68,,13178.18,percent of total billed charges,,1079.62,,,1079.62,Other,186% of Medicaid,15503.74,80,,15503.74,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,15503.74,80,,15503.74,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,13565.77,70,,13565.77,percent of total billed charges,,291.92,,,291.92,Fee Schedule,,247.42,,,247.42,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,580.44,,,580.44,Other,New York Medicaid APG methodology,580.44,,,580.44,Other,100% New York Medicaid APG,580.44,,,580.44,Other,100% New York Medicaid APG,580.44,,,580.44,Other,100% New York Medicaid APG,1306,,,1306,Other,225% New York Medicaid APG,888.08,,,888.08,Other,153% New York Medicaid APG,1306,,,1306,Other,225% New York Medicaid APG,812.62,,,812.62,Other,140% New York Medicaid APG,1306,,,1306,Other,225% New York Medicaid APG,1509.15,,,1509.15,Other,260% New York Medicaid APG,1880.64,,,1880.64,Other,324% New York Medicaid APG,1247.95,,,1247.95,Other,215% New York Medicaid APG,1247.95,,,1247.95,Other,215% New York Medicaid APG,725.55,,,725.55,Other,125% New York Medicaid APG,247.42,15503.74,
Aspirate/inj ganglion cyst,20612,CPT,,,,,,,,both,,,6229.82,4610.07,74,,4610.07,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,2803.42,45,,2803.42,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,3083.76,49.5,,3083.76,percent of total billed charges,110% of Medicare,4236.28,68,,4236.28,percent of total billed charges,,685.67,,,685.67,Other,186% of Medicaid,4983.86,80,,4983.86,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,4983.86,80,,4983.86,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,4360.87,70,,4360.87,percent of total billed charges,,200.08,,,200.08,Fee Schedule,,169.58,,,169.58,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,368.64,,,368.64,Other,New York Medicaid APG methodology,368.64,,,368.64,Other,100% New York Medicaid APG,368.64,,,368.64,Other,100% New York Medicaid APG,368.64,,,368.64,Other,100% New York Medicaid APG,829.44,,,829.44,Other,225% New York Medicaid APG,564.02,,,564.02,Other,153% New York Medicaid APG,829.44,,,829.44,Other,225% New York Medicaid APG,516.1,,,516.1,Other,140% New York Medicaid APG,829.44,,,829.44,Other,225% New York Medicaid APG,958.46,,,958.46,Other,260% New York Medicaid APG,1194.39,,,1194.39,Other,324% New York Medicaid APG,792.58,,,792.58,Other,215% New York Medicaid APG,792.58,,,792.58,Other,215% New York Medicaid APG,460.8,,,460.8,Other,125% New York Medicaid APG,169.58,7216,
Treatment of bone cyst,20615,CPT,,,,,,,,both,,,56392.4,41730.38,74,,41730.38,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,25376.58,45,,25376.58,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,27914.24,49.5,,27914.24,percent of total billed charges,110% of Medicare,38346.83,68,,38346.83,percent of total billed charges,,1079.62,,,1079.62,Other,186% of Medicaid,45113.92,80,,45113.92,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,45113.92,80,,45113.92,percent of total billed charges,,7216,,,7216,Case Rate,,3578,,"100% primary, 0% secondary procedures",3578,Other,MagnaCare ASC Grouper,39474.68,70,,39474.68,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,580.44,,,580.44,Other,New York Medicaid APG methodology,580.44,,,580.44,Other,100% New York Medicaid APG,580.44,,,580.44,Other,100% New York Medicaid APG,580.44,,,580.44,Other,100% New York Medicaid APG,1306,,,1306,Other,225% New York Medicaid APG,888.08,,,888.08,Other,153% New York Medicaid APG,1306,,,1306,Other,225% New York Medicaid APG,812.62,,,812.62,Other,140% New York Medicaid APG,1306,,,1306,Other,225% New York Medicaid APG,1509.15,,,1509.15,Other,260% New York Medicaid APG,1880.64,,,1880.64,Other,324% New York Medicaid APG,1247.95,,,1247.95,Other,215% New York Medicaid APG,1247.95,,,1247.95,Other,215% New York Medicaid APG,725.55,,,725.55,Other,125% New York Medicaid APG,580.44,45113.92,
Insert and remove bone pin,20650,CPT,,,,,,,,both,,,68082.75,50381.24,74,,50381.24,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30637.24,45,,30637.24,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33700.96,49.5,,33700.96,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3028.14,,,3028.14,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,47657.93,70,,47657.93,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1628.03,,,1628.03,Other,New York Medicaid APG methodology,1628.03,,,1628.03,Other,100% New York Medicaid APG,1628.03,,,1628.03,Other,100% New York Medicaid APG,1628.03,,,1628.03,Other,100% New York Medicaid APG,3663.07,,,3663.07,Other,225% New York Medicaid APG,2490.89,,,2490.89,Other,153% New York Medicaid APG,3663.07,,,3663.07,Other,225% New York Medicaid APG,2279.24,,,2279.24,Other,140% New York Medicaid APG,3663.07,,,3663.07,Other,225% New York Medicaid APG,4232.88,,,4232.88,Other,260% New York Medicaid APG,5274.82,,,5274.82,Other,324% New York Medicaid APG,3500.27,,,3500.27,Other,215% New York Medicaid APG,3500.27,,,3500.27,Other,215% New York Medicaid APG,2035.04,,,2035.04,Other,125% New York Medicaid APG,1628.03,50381.24,
Apply rem fixation device,20660,CPT,,,,,,,,both,,,33805.49,25016.06,74,,25016.06,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15212.47,45,,15212.47,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,16733.72,49.5,,16733.72,percent of total billed charges,110% of Medicare,22987.73,68,,22987.73,percent of total billed charges,,3028.14,,,3028.14,Other,186% of Medicaid,27044.39,80,,27044.39,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,27044.39,80,,27044.39,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,23663.84,70,,23663.84,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1628.03,,,1628.03,Other,New York Medicaid APG methodology,1628.03,,,1628.03,Other,100% New York Medicaid APG,1628.03,,,1628.03,Other,100% New York Medicaid APG,1628.03,,,1628.03,Other,100% New York Medicaid APG,3663.07,,,3663.07,Other,225% New York Medicaid APG,2490.89,,,2490.89,Other,153% New York Medicaid APG,3663.07,,,3663.07,Other,225% New York Medicaid APG,2279.24,,,2279.24,Other,140% New York Medicaid APG,3663.07,,,3663.07,Other,225% New York Medicaid APG,4232.88,,,4232.88,Other,260% New York Medicaid APG,5274.82,,,5274.82,Other,324% New York Medicaid APG,3500.27,,,3500.27,Other,215% New York Medicaid APG,3500.27,,,3500.27,Other,215% New York Medicaid APG,2035.04,,,2035.04,Other,125% New York Medicaid APG,1628.03,27044.39,
Application of pelvis brace,20662,CPT,,,,,,,,both,,,33805.49,25016.06,74,,25016.06,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15212.47,45,,15212.47,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,16733.72,49.5,,16733.72,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3028.14,,,3028.14,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,23663.84,70,,23663.84,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1628.03,,,1628.03,Other,New York Medicaid APG methodology,1628.03,,,1628.03,Other,100% New York Medicaid APG,1628.03,,,1628.03,Other,100% New York Medicaid APG,1628.03,,,1628.03,Other,100% New York Medicaid APG,3663.07,,,3663.07,Other,225% New York Medicaid APG,2490.89,,,2490.89,Other,153% New York Medicaid APG,3663.07,,,3663.07,Other,225% New York Medicaid APG,2279.24,,,2279.24,Other,140% New York Medicaid APG,3663.07,,,3663.07,Other,225% New York Medicaid APG,4232.88,,,4232.88,Other,260% New York Medicaid APG,5274.82,,,5274.82,Other,324% New York Medicaid APG,3500.27,,,3500.27,Other,215% New York Medicaid APG,3500.27,,,3500.27,Other,215% New York Medicaid APG,2035.04,,,2035.04,Other,125% New York Medicaid APG,1628.03,25016.06,
Application of thigh brace,20663,CPT,,,,,,,,both,,,68082.75,50381.24,74,,50381.24,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30637.24,45,,30637.24,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33700.96,49.5,,33700.96,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3028.14,,,3028.14,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,47657.93,70,,47657.93,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1628.03,,,1628.03,Other,New York Medicaid APG methodology,1628.03,,,1628.03,Other,100% New York Medicaid APG,1628.03,,,1628.03,Other,100% New York Medicaid APG,1628.03,,,1628.03,Other,100% New York Medicaid APG,3663.07,,,3663.07,Other,225% New York Medicaid APG,2490.89,,,2490.89,Other,153% New York Medicaid APG,3663.07,,,3663.07,Other,225% New York Medicaid APG,2279.24,,,2279.24,Other,140% New York Medicaid APG,3663.07,,,3663.07,Other,225% New York Medicaid APG,4232.88,,,4232.88,Other,260% New York Medicaid APG,5274.82,,,5274.82,Other,324% New York Medicaid APG,3500.27,,,3500.27,Other,215% New York Medicaid APG,3500.27,,,3500.27,Other,215% New York Medicaid APG,2035.04,,,2035.04,Other,125% New York Medicaid APG,1628.03,50381.24,
Removal of fixation device,20665,CPT,,,,,,,,both,,,8380.68,6201.7,74,,6201.7,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,3771.31,45,,3771.31,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,4148.44,49.5,,4148.44,percent of total billed charges,110% of Medicare,5698.86,68,,5698.86,percent of total billed charges,,982.05,,,982.05,Other,186% of Medicaid,6704.54,80,,6704.54,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,6704.54,80,,6704.54,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,5866.48,70,,5866.48,percent of total billed charges,,477.24,,,477.24,Fee Schedule,,404.49,,,404.49,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,527.98,,,527.98,Other,New York Medicaid APG methodology,527.98,,,527.98,Other,100% New York Medicaid APG,527.98,,,527.98,Other,100% New York Medicaid APG,527.98,,,527.98,Other,100% New York Medicaid APG,1187.96,,,1187.96,Other,225% New York Medicaid APG,807.81,,,807.81,Other,153% New York Medicaid APG,1187.96,,,1187.96,Other,225% New York Medicaid APG,739.17,,,739.17,Other,140% New York Medicaid APG,1187.96,,,1187.96,Other,225% New York Medicaid APG,1372.75,,,1372.75,Other,260% New York Medicaid APG,1710.66,,,1710.66,Other,324% New York Medicaid APG,1135.16,,,1135.16,Other,215% New York Medicaid APG,1135.16,,,1135.16,Other,215% New York Medicaid APG,659.98,,,659.98,Other,125% New York Medicaid APG,404.49,7216,
Removal of support implant,20670,CPT,,,,,,,,both,,,37746.38,27932.32,74,,27932.32,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,16985.87,45,,16985.87,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,18684.46,49.5,,18684.46,percent of total billed charges,110% of Medicare,25667.54,68,,25667.54,percent of total billed charges,,3028.14,,,3028.14,Other,186% of Medicaid,30197.1,80,,30197.1,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,30197.1,80,,30197.1,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,26422.47,70,,26422.47,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1628.03,,,1628.03,Other,New York Medicaid APG methodology,1628.03,,,1628.03,Other,100% New York Medicaid APG,1628.03,,,1628.03,Other,100% New York Medicaid APG,1628.03,,,1628.03,Other,100% New York Medicaid APG,3663.07,,,3663.07,Other,225% New York Medicaid APG,2490.89,,,2490.89,Other,153% New York Medicaid APG,3663.07,,,3663.07,Other,225% New York Medicaid APG,2279.24,,,2279.24,Other,140% New York Medicaid APG,3663.07,,,3663.07,Other,225% New York Medicaid APG,4232.88,,,4232.88,Other,260% New York Medicaid APG,5274.82,,,5274.82,Other,324% New York Medicaid APG,3500.27,,,3500.27,Other,215% New York Medicaid APG,3500.27,,,3500.27,Other,215% New York Medicaid APG,2035.04,,,2035.04,Other,125% New York Medicaid APG,1628.03,30197.1,
Removal of support implant,20680,CPT,,,,,,,,both,,,50892.55,37660.49,74,,37660.49,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,22901.65,45,,22901.65,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,25191.81,49.5,,25191.81,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3028.14,,,3028.14,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,35624.79,70,,35624.79,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1628.03,,,1628.03,Other,New York Medicaid APG methodology,1628.03,,,1628.03,Other,100% New York Medicaid APG,1628.03,,,1628.03,Other,100% New York Medicaid APG,1628.03,,,1628.03,Other,100% New York Medicaid APG,3663.07,,,3663.07,Other,225% New York Medicaid APG,2490.89,,,2490.89,Other,153% New York Medicaid APG,3663.07,,,3663.07,Other,225% New York Medicaid APG,2279.24,,,2279.24,Other,140% New York Medicaid APG,3663.07,,,3663.07,Other,225% New York Medicaid APG,4232.88,,,4232.88,Other,260% New York Medicaid APG,5274.82,,,5274.82,Other,324% New York Medicaid APG,3500.27,,,3500.27,Other,215% New York Medicaid APG,3500.27,,,3500.27,Other,215% New York Medicaid APG,2035.04,,,2035.04,Other,125% New York Medicaid APG,1628.03,37660.49,
Apply bone fixation device,20690,CPT,,,,,,,,both,,,150476.65,111352.72,74,,111352.72,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,67714.49,45,,67714.49,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,74485.94,49.5,,74485.94,percent of total billed charges,110% of Medicare,102324.12,68,,102324.12,percent of total billed charges,,3028.14,,,3028.14,Other,186% of Medicaid,120381.32,80,,120381.32,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,120381.32,80,,120381.32,percent of total billed charges,,7216,,,7216,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,105333.66,70,,105333.66,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1628.03,,,1628.03,Other,New York Medicaid APG methodology,1628.03,,,1628.03,Other,100% New York Medicaid APG,1628.03,,,1628.03,Other,100% New York Medicaid APG,1628.03,,,1628.03,Other,100% New York Medicaid APG,3663.07,,,3663.07,Other,225% New York Medicaid APG,2490.89,,,2490.89,Other,153% New York Medicaid APG,3663.07,,,3663.07,Other,225% New York Medicaid APG,2279.24,,,2279.24,Other,140% New York Medicaid APG,3663.07,,,3663.07,Other,225% New York Medicaid APG,4232.88,,,4232.88,Other,260% New York Medicaid APG,5274.82,,,5274.82,Other,324% New York Medicaid APG,3500.27,,,3500.27,Other,215% New York Medicaid APG,3500.27,,,3500.27,Other,215% New York Medicaid APG,2035.04,,,2035.04,Other,125% New York Medicaid APG,1628.03,120381.32,
Apply bone fixation device,20692,CPT,,,,,,,,both,,,276827.87,204852.62,74,,204852.62,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,124572.54,45,,124572.54,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,137029.8,49.5,,137029.8,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3028.14,,,3028.14,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,193779.51,70,,193779.51,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1628.03,,,1628.03,Other,New York Medicaid APG methodology,1628.03,,,1628.03,Other,100% New York Medicaid APG,1628.03,,,1628.03,Other,100% New York Medicaid APG,1628.03,,,1628.03,Other,100% New York Medicaid APG,3663.07,,,3663.07,Other,225% New York Medicaid APG,2490.89,,,2490.89,Other,153% New York Medicaid APG,3663.07,,,3663.07,Other,225% New York Medicaid APG,2279.24,,,2279.24,Other,140% New York Medicaid APG,3663.07,,,3663.07,Other,225% New York Medicaid APG,4232.88,,,4232.88,Other,260% New York Medicaid APG,5274.82,,,5274.82,Other,324% New York Medicaid APG,3500.27,,,3500.27,Other,215% New York Medicaid APG,3500.27,,,3500.27,Other,215% New York Medicaid APG,2035.04,,,2035.04,Other,125% New York Medicaid APG,1628.03,204852.62,
Adjust bone fixation device,20693,CPT,,,,,,,,both,,,150476.65,111352.72,74,,111352.72,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,67714.49,45,,67714.49,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,74485.94,49.5,,74485.94,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3028.14,,,3028.14,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,105333.66,70,,105333.66,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1628.03,,,1628.03,Other,New York Medicaid APG methodology,1628.03,,,1628.03,Other,100% New York Medicaid APG,1628.03,,,1628.03,Other,100% New York Medicaid APG,1628.03,,,1628.03,Other,100% New York Medicaid APG,3663.07,,,3663.07,Other,225% New York Medicaid APG,2490.89,,,2490.89,Other,153% New York Medicaid APG,3663.07,,,3663.07,Other,225% New York Medicaid APG,2279.24,,,2279.24,Other,140% New York Medicaid APG,3663.07,,,3663.07,Other,225% New York Medicaid APG,4232.88,,,4232.88,Other,260% New York Medicaid APG,5274.82,,,5274.82,Other,324% New York Medicaid APG,3500.27,,,3500.27,Other,215% New York Medicaid APG,3500.27,,,3500.27,Other,215% New York Medicaid APG,2035.04,,,2035.04,Other,125% New York Medicaid APG,1628.03,111352.72,
Remove bone fixation device,20694,CPT,,,,,,,,both,,,37783.1,27959.49,74,,27959.49,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,17002.4,45,,17002.4,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,18702.63,49.5,,18702.63,percent of total billed charges,110% of Medicare,25692.51,68,,25692.51,percent of total billed charges,,3028.14,,,3028.14,Other,186% of Medicaid,30226.48,80,,30226.48,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,30226.48,80,,30226.48,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,26448.17,70,,26448.17,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1628.03,,,1628.03,Other,New York Medicaid APG methodology,1628.03,,,1628.03,Other,100% New York Medicaid APG,1628.03,,,1628.03,Other,100% New York Medicaid APG,1628.03,,,1628.03,Other,100% New York Medicaid APG,3663.07,,,3663.07,Other,225% New York Medicaid APG,2490.89,,,2490.89,Other,153% New York Medicaid APG,3663.07,,,3663.07,Other,225% New York Medicaid APG,2279.24,,,2279.24,Other,140% New York Medicaid APG,3663.07,,,3663.07,Other,225% New York Medicaid APG,4232.88,,,4232.88,Other,260% New York Medicaid APG,5274.82,,,5274.82,Other,324% New York Medicaid APG,3500.27,,,3500.27,Other,215% New York Medicaid APG,3500.27,,,3500.27,Other,215% New York Medicaid APG,2035.04,,,2035.04,Other,125% New York Medicaid APG,1628.03,30226.48,
Comp multiplane ext fixation,20696,CPT,,,,,,,,both,,,391985.94,290069.6,74,,290069.6,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,176393.67,45,,176393.67,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,194033.04,49.5,,194033.04,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3028.14,,,3028.14,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,274390.16,70,,274390.16,percent of total billed charges,,5746.56,,,5746.56,Fee Schedule,,4870.56,,,4870.56,Fee Schedule,,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1628.03,,,1628.03,Other,New York Medicaid APG methodology,1628.03,,,1628.03,Other,100% New York Medicaid APG,1628.03,,,1628.03,Other,100% New York Medicaid APG,1628.03,,,1628.03,Other,100% New York Medicaid APG,3663.07,,,3663.07,Other,225% New York Medicaid APG,2490.89,,,2490.89,Other,153% New York Medicaid APG,3663.07,,,3663.07,Other,225% New York Medicaid APG,2279.24,,,2279.24,Other,140% New York Medicaid APG,3663.07,,,3663.07,Other,225% New York Medicaid APG,4232.88,,,4232.88,Other,260% New York Medicaid APG,5274.82,,,5274.82,Other,324% New York Medicaid APG,3500.27,,,3500.27,Other,215% New York Medicaid APG,3500.27,,,3500.27,Other,215% New York Medicaid APG,2035.04,,,2035.04,Other,125% New York Medicaid APG,1628.03,290069.6,
Comp ext fixate strut change,20697,CPT,,,,,,,,both,,,33805.49,25016.06,74,,25016.06,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15212.47,45,,15212.47,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,16733.72,49.5,,16733.72,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3028.14,,,3028.14,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,3578,,"100% primary, 0% secondary procedures",3578,Other,MagnaCare ASC Grouper,23663.84,70,,23663.84,percent of total billed charges,,9005.24,,,9005.24,Fee Schedule,,7632.49,,,7632.49,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,1628.03,,,1628.03,Other,New York Medicaid APG methodology,1628.03,,,1628.03,Other,100% New York Medicaid APG,1628.03,,,1628.03,Other,100% New York Medicaid APG,1628.03,,,1628.03,Other,100% New York Medicaid APG,3663.07,,,3663.07,Other,225% New York Medicaid APG,2490.89,,,2490.89,Other,153% New York Medicaid APG,3663.07,,,3663.07,Other,225% New York Medicaid APG,2279.24,,,2279.24,Other,140% New York Medicaid APG,3663.07,,,3663.07,Other,225% New York Medicaid APG,4232.88,,,4232.88,Other,260% New York Medicaid APG,5274.82,,,5274.82,Other,324% New York Medicaid APG,3500.27,,,3500.27,Other,215% New York Medicaid APG,3500.27,,,3500.27,Other,215% New York Medicaid APG,2035.04,,,2035.04,Other,125% New York Medicaid APG,1628.03,25016.06,
Replantation digit complete,20822,CPT,,,,,,,,both,,,33805.49,25016.06,74,,25016.06,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15212.47,45,,15212.47,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,16733.72,49.5,,16733.72,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3654.9,,,3654.9,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,23663.84,70,,23663.84,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1965,,,1965,Other,New York Medicaid APG methodology,1965,,,1965,Other,100% New York Medicaid APG,1965,,,1965,Other,100% New York Medicaid APG,1965,,,1965,Other,100% New York Medicaid APG,4421.25,,,4421.25,Other,225% New York Medicaid APG,3006.45,,,3006.45,Other,153% New York Medicaid APG,4421.25,,,4421.25,Other,225% New York Medicaid APG,2751,,,2751,Other,140% New York Medicaid APG,4421.25,,,4421.25,Other,225% New York Medicaid APG,5109,,,5109,Other,260% New York Medicaid APG,6366.6,,,6366.6,Other,324% New York Medicaid APG,4224.75,,,4224.75,Other,215% New York Medicaid APG,4224.75,,,4224.75,Other,215% New York Medicaid APG,2456.25,,,2456.25,Other,125% New York Medicaid APG,1965,25016.06,
Removal of bone for graft,20900,CPT,,,,,,,,both,,,105951.37,78404.01,74,,78404.01,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,47678.12,45,,47678.12,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,52445.93,49.5,,52445.93,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2593.54,,,2593.54,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,74165.96,70,,74165.96,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1394.38,,,1394.38,Other,New York Medicaid APG methodology,1394.38,,,1394.38,Other,100% New York Medicaid APG,1394.38,,,1394.38,Other,100% New York Medicaid APG,1394.38,,,1394.38,Other,100% New York Medicaid APG,3137.35,,,3137.35,Other,225% New York Medicaid APG,2133.39,,,2133.39,Other,153% New York Medicaid APG,3137.35,,,3137.35,Other,225% New York Medicaid APG,1952.13,,,1952.13,Other,140% New York Medicaid APG,3137.35,,,3137.35,Other,225% New York Medicaid APG,3625.38,,,3625.38,Other,260% New York Medicaid APG,4517.78,,,4517.78,Other,324% New York Medicaid APG,2997.91,,,2997.91,Other,215% New York Medicaid APG,2997.91,,,2997.91,Other,215% New York Medicaid APG,1742.97,,,1742.97,Other,125% New York Medicaid APG,1394.38,78404.01,
Removal of bone for graft,20902,CPT,,,,,,,,both,,,144359.91,106826.33,74,,106826.33,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,64961.96,45,,64961.96,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,71458.16,49.5,,71458.16,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2593.54,,,2593.54,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,101051.94,70,,101051.94,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1394.38,,,1394.38,Other,New York Medicaid APG methodology,1394.38,,,1394.38,Other,100% New York Medicaid APG,1394.38,,,1394.38,Other,100% New York Medicaid APG,1394.38,,,1394.38,Other,100% New York Medicaid APG,3137.35,,,3137.35,Other,225% New York Medicaid APG,2133.39,,,2133.39,Other,153% New York Medicaid APG,3137.35,,,3137.35,Other,225% New York Medicaid APG,1952.13,,,1952.13,Other,140% New York Medicaid APG,3137.35,,,3137.35,Other,225% New York Medicaid APG,3625.38,,,3625.38,Other,260% New York Medicaid APG,4517.78,,,4517.78,Other,324% New York Medicaid APG,2997.91,,,2997.91,Other,215% New York Medicaid APG,2997.91,,,2997.91,Other,215% New York Medicaid APG,1742.97,,,1742.97,Other,125% New York Medicaid APG,1394.38,106826.33,
Remove cartilage for graft,20910,CPT,,,,,,,,both,,,13210.22,9775.56,74,,9775.56,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,5944.6,45,,5944.6,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,6539.06,49.5,,6539.06,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2593.54,,,2593.54,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,9247.15,70,,9247.15,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,1394.38,,,1394.38,Other,New York Medicaid APG methodology,1394.38,,,1394.38,Other,100% New York Medicaid APG,1394.38,,,1394.38,Other,100% New York Medicaid APG,1394.38,,,1394.38,Other,100% New York Medicaid APG,3137.35,,,3137.35,Other,225% New York Medicaid APG,2133.39,,,2133.39,Other,153% New York Medicaid APG,3137.35,,,3137.35,Other,225% New York Medicaid APG,1952.13,,,1952.13,Other,140% New York Medicaid APG,3137.35,,,3137.35,Other,225% New York Medicaid APG,3625.38,,,3625.38,Other,260% New York Medicaid APG,4517.78,,,4517.78,Other,324% New York Medicaid APG,2997.91,,,2997.91,Other,215% New York Medicaid APG,2997.91,,,2997.91,Other,215% New York Medicaid APG,1742.97,,,1742.97,Other,125% New York Medicaid APG,1394.38,9775.56,
Remove cartilage for graft,20912,CPT,,,,,,,,both,,,75461.18,55841.27,74,,55841.27,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,33957.53,45,,33957.53,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,37353.28,49.5,,37353.28,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2593.54,,,2593.54,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,52822.83,70,,52822.83,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1394.38,,,1394.38,Other,New York Medicaid APG methodology,1394.38,,,1394.38,Other,100% New York Medicaid APG,1394.38,,,1394.38,Other,100% New York Medicaid APG,1394.38,,,1394.38,Other,100% New York Medicaid APG,3137.35,,,3137.35,Other,225% New York Medicaid APG,2133.39,,,2133.39,Other,153% New York Medicaid APG,3137.35,,,3137.35,Other,225% New York Medicaid APG,1952.13,,,1952.13,Other,140% New York Medicaid APG,3137.35,,,3137.35,Other,225% New York Medicaid APG,3625.38,,,3625.38,Other,260% New York Medicaid APG,4517.78,,,4517.78,Other,324% New York Medicaid APG,2997.91,,,2997.91,Other,215% New York Medicaid APG,2997.91,,,2997.91,Other,215% New York Medicaid APG,1742.97,,,1742.97,Other,125% New York Medicaid APG,1394.38,55841.27,
Removal of fascia for graft,20920,CPT,,,,,,,,both,,,38357.55,28384.59,74,,28384.59,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,17260.9,45,,17260.9,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,18986.99,49.5,,18986.99,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2593.54,,,2593.54,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,26850.29,70,,26850.29,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1394.38,,,1394.38,Other,New York Medicaid APG methodology,1394.38,,,1394.38,Other,100% New York Medicaid APG,1394.38,,,1394.38,Other,100% New York Medicaid APG,1394.38,,,1394.38,Other,100% New York Medicaid APG,3137.35,,,3137.35,Other,225% New York Medicaid APG,2133.39,,,2133.39,Other,153% New York Medicaid APG,3137.35,,,3137.35,Other,225% New York Medicaid APG,1952.13,,,1952.13,Other,140% New York Medicaid APG,3137.35,,,3137.35,Other,225% New York Medicaid APG,3625.38,,,3625.38,Other,260% New York Medicaid APG,4517.78,,,4517.78,Other,324% New York Medicaid APG,2997.91,,,2997.91,Other,215% New York Medicaid APG,2997.91,,,2997.91,Other,215% New York Medicaid APG,1742.97,,,1742.97,Other,125% New York Medicaid APG,1394.38,28384.59,
Removal of fascia for graft,20922,CPT,,,,,,,,both,,,38357.55,28384.59,74,,28384.59,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,17260.9,45,,17260.9,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,18986.99,49.5,,18986.99,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2593.54,,,2593.54,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,26850.29,70,,26850.29,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1394.38,,,1394.38,Other,New York Medicaid APG methodology,1394.38,,,1394.38,Other,100% New York Medicaid APG,1394.38,,,1394.38,Other,100% New York Medicaid APG,1394.38,,,1394.38,Other,100% New York Medicaid APG,3137.35,,,3137.35,Other,225% New York Medicaid APG,2133.39,,,2133.39,Other,153% New York Medicaid APG,3137.35,,,3137.35,Other,225% New York Medicaid APG,1952.13,,,1952.13,Other,140% New York Medicaid APG,3137.35,,,3137.35,Other,225% New York Medicaid APG,3625.38,,,3625.38,Other,260% New York Medicaid APG,4517.78,,,4517.78,Other,324% New York Medicaid APG,2997.91,,,2997.91,Other,215% New York Medicaid APG,2997.91,,,2997.91,Other,215% New York Medicaid APG,1742.97,,,1742.97,Other,125% New York Medicaid APG,1394.38,28384.59,
Removal of tendon for graft,20924,CPT,,,,,,,,both,,,150476.65,111352.72,74,,111352.72,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,67714.49,45,,67714.49,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,74485.94,49.5,,74485.94,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2593.54,,,2593.54,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,105333.66,70,,105333.66,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1394.38,,,1394.38,Other,New York Medicaid APG methodology,1394.38,,,1394.38,Other,100% New York Medicaid APG,1394.38,,,1394.38,Other,100% New York Medicaid APG,1394.38,,,1394.38,Other,100% New York Medicaid APG,3137.35,,,3137.35,Other,225% New York Medicaid APG,2133.39,,,2133.39,Other,153% New York Medicaid APG,3137.35,,,3137.35,Other,225% New York Medicaid APG,1952.13,,,1952.13,Other,140% New York Medicaid APG,3137.35,,,3137.35,Other,225% New York Medicaid APG,3625.38,,,3625.38,Other,260% New York Medicaid APG,4517.78,,,4517.78,Other,324% New York Medicaid APG,2997.91,,,2997.91,Other,215% New York Medicaid APG,2997.91,,,2997.91,Other,215% New York Medicaid APG,1742.97,,,1742.97,Other,125% New York Medicaid APG,1394.38,111352.72,
Sp bone algrft morsel add-on,20930,CPT,,,,,,,,both,,,36356.27,26903.64,74,,26903.64,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,16360.32,45,,16360.32,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,21813.76,60,,21813.76,percent of total billed charges,,20359.51,56,,20359.51,percent of total billed charges,,19632.39,54,,19632.39,percent of total billed charges,,17996.35,49.5,,17996.35,percent of total billed charges,110% of Medicare,24722.26,68,,24722.26,percent of total billed charges,,6658.36,,,6658.36,Other,186% of Medicaid,29085.02,80,,29085.02,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,29085.02,80,,29085.02,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,25449.39,70,,25449.39,percent of total billed charges,,23631.58,65,,23631.58,percent of total billed charges,,23631.58,65,,23631.58,percent of total billed charges,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,3579.77,,,3579.77,Other,New York Medicaid APG methodology,3579.77,,,3579.77,Other,100% New York Medicaid APG,3579.77,,,3579.77,Other,100% New York Medicaid APG,3579.77,,,3579.77,Other,100% New York Medicaid APG,8054.47,,,8054.47,Other,225% New York Medicaid APG,5477.04,,,5477.04,Other,153% New York Medicaid APG,8054.47,,,8054.47,Other,225% New York Medicaid APG,5011.67,,,5011.67,Other,140% New York Medicaid APG,8054.47,,,8054.47,Other,225% New York Medicaid APG,9307.39,,,9307.39,Other,260% New York Medicaid APG,11598.44,,,11598.44,Other,324% New York Medicaid APG,7696.5,,,7696.5,Other,215% New York Medicaid APG,7696.5,,,7696.5,Other,215% New York Medicaid APG,4474.71,,,4474.71,Other,125% New York Medicaid APG,2053,29085.02,
Sp bone algrft struct add-on,20931,CPT,,,,,,,,both,,,51572.04,38163.31,74,,38163.31,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,23207.42,45,,23207.42,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,25528.16,49.5,,25528.16,percent of total billed charges,110% of Medicare,35068.99,68,,35068.99,percent of total billed charges,,6658.36,,,6658.36,Other,186% of Medicaid,41257.63,80,,41257.63,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,41257.63,80,,41257.63,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,36100.43,70,,36100.43,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,3579.77,,,3579.77,Other,New York Medicaid APG methodology,3579.77,,,3579.77,Other,100% New York Medicaid APG,3579.77,,,3579.77,Other,100% New York Medicaid APG,3579.77,,,3579.77,Other,100% New York Medicaid APG,8054.47,,,8054.47,Other,225% New York Medicaid APG,5477.04,,,5477.04,Other,153% New York Medicaid APG,8054.47,,,8054.47,Other,225% New York Medicaid APG,5011.67,,,5011.67,Other,140% New York Medicaid APG,8054.47,,,8054.47,Other,225% New York Medicaid APG,9307.39,,,9307.39,Other,260% New York Medicaid APG,11598.44,,,11598.44,Other,324% New York Medicaid APG,7696.5,,,7696.5,Other,215% New York Medicaid APG,7696.5,,,7696.5,Other,215% New York Medicaid APG,4474.71,,,4474.71,Other,125% New York Medicaid APG,2053,41257.63,
Osteoart algrft w/surf & b1,20932,CPT,,,,,,,,both,,,64479.48,47714.82,74,,47714.82,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,29015.77,45,,29015.77,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,31917.34,49.5,,31917.34,percent of total billed charges,110% of Medicare,43846.05,68,,43846.05,percent of total billed charges,,2593.54,,,2593.54,Other,186% of Medicaid,51583.58,80,,51583.58,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,51583.58,80,,51583.58,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,45135.64,70,,45135.64,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,1394.38,,,1394.38,Other,New York Medicaid APG methodology,1394.38,,,1394.38,Other,100% New York Medicaid APG,1394.38,,,1394.38,Other,100% New York Medicaid APG,1394.38,,,1394.38,Other,100% New York Medicaid APG,3137.35,,,3137.35,Other,225% New York Medicaid APG,2133.39,,,2133.39,Other,153% New York Medicaid APG,3137.35,,,3137.35,Other,225% New York Medicaid APG,1952.13,,,1952.13,Other,140% New York Medicaid APG,3137.35,,,3137.35,Other,225% New York Medicaid APG,3625.38,,,3625.38,Other,260% New York Medicaid APG,4517.78,,,4517.78,Other,324% New York Medicaid APG,2997.91,,,2997.91,Other,215% New York Medicaid APG,2997.91,,,2997.91,Other,215% New York Medicaid APG,1742.97,,,1742.97,Other,125% New York Medicaid APG,1394.38,51583.58,
Hemicrt intrclry algrft prtl,20933,CPT,,,,,,,,both,,,64479.48,47714.82,74,,47714.82,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,29015.77,45,,29015.77,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,31917.34,49.5,,31917.34,percent of total billed charges,110% of Medicare,43846.05,68,,43846.05,percent of total billed charges,,2593.54,,,2593.54,Other,186% of Medicaid,51583.58,80,,51583.58,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,51583.58,80,,51583.58,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,45135.64,70,,45135.64,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,1394.38,,,1394.38,Other,New York Medicaid APG methodology,1394.38,,,1394.38,Other,100% New York Medicaid APG,1394.38,,,1394.38,Other,100% New York Medicaid APG,1394.38,,,1394.38,Other,100% New York Medicaid APG,3137.35,,,3137.35,Other,225% New York Medicaid APG,2133.39,,,2133.39,Other,153% New York Medicaid APG,3137.35,,,3137.35,Other,225% New York Medicaid APG,1952.13,,,1952.13,Other,140% New York Medicaid APG,3137.35,,,3137.35,Other,225% New York Medicaid APG,3625.38,,,3625.38,Other,260% New York Medicaid APG,4517.78,,,4517.78,Other,324% New York Medicaid APG,2997.91,,,2997.91,Other,215% New York Medicaid APG,2997.91,,,2997.91,Other,215% New York Medicaid APG,1742.97,,,1742.97,Other,125% New York Medicaid APG,1394.38,51583.58,
Intercalary algrft compl,20934,CPT,,,,,,,,both,,,64479.48,47714.82,74,,47714.82,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,29015.77,45,,29015.77,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,31917.34,49.5,,31917.34,percent of total billed charges,110% of Medicare,43846.05,68,,43846.05,percent of total billed charges,,2593.54,,,2593.54,Other,186% of Medicaid,51583.58,80,,51583.58,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,51583.58,80,,51583.58,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,45135.64,70,,45135.64,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,1394.38,,,1394.38,Other,New York Medicaid APG methodology,1394.38,,,1394.38,Other,100% New York Medicaid APG,1394.38,,,1394.38,Other,100% New York Medicaid APG,1394.38,,,1394.38,Other,100% New York Medicaid APG,3137.35,,,3137.35,Other,225% New York Medicaid APG,2133.39,,,2133.39,Other,153% New York Medicaid APG,3137.35,,,3137.35,Other,225% New York Medicaid APG,1952.13,,,1952.13,Other,140% New York Medicaid APG,3137.35,,,3137.35,Other,225% New York Medicaid APG,3625.38,,,3625.38,Other,260% New York Medicaid APG,4517.78,,,4517.78,Other,324% New York Medicaid APG,2997.91,,,2997.91,Other,215% New York Medicaid APG,2997.91,,,2997.91,Other,215% New York Medicaid APG,1742.97,,,1742.97,Other,125% New York Medicaid APG,1394.38,51583.58,
Sp bone agrft local add-on,20936,CPT,,,,,,,,both,,,36356.27,26903.64,74,,26903.64,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,16360.32,45,,16360.32,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,21813.76,60,,21813.76,percent of total billed charges,,20359.51,56,,20359.51,percent of total billed charges,,19632.39,54,,19632.39,percent of total billed charges,,17996.35,49.5,,17996.35,percent of total billed charges,110% of Medicare,24722.26,68,,24722.26,percent of total billed charges,,6658.36,,,6658.36,Other,186% of Medicaid,29085.02,80,,29085.02,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,29085.02,80,,29085.02,percent of total billed charges,,7216,,,7216,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,25449.39,70,,25449.39,percent of total billed charges,,23631.58,65,,23631.58,percent of total billed charges,,23631.58,65,,23631.58,percent of total billed charges,,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,3579.77,,,3579.77,Other,New York Medicaid APG methodology,3579.77,,,3579.77,Other,100% New York Medicaid APG,3579.77,,,3579.77,Other,100% New York Medicaid APG,3579.77,,,3579.77,Other,100% New York Medicaid APG,8054.47,,,8054.47,Other,225% New York Medicaid APG,5477.04,,,5477.04,Other,153% New York Medicaid APG,8054.47,,,8054.47,Other,225% New York Medicaid APG,5011.67,,,5011.67,Other,140% New York Medicaid APG,8054.47,,,8054.47,Other,225% New York Medicaid APG,9307.39,,,9307.39,Other,260% New York Medicaid APG,11598.44,,,11598.44,Other,324% New York Medicaid APG,7696.5,,,7696.5,Other,215% New York Medicaid APG,7696.5,,,7696.5,Other,215% New York Medicaid APG,4474.71,,,4474.71,Other,125% New York Medicaid APG,2053,29085.02,
Sp bone agrft morsel add-on,20937,CPT,,,,,,,,both,,,51572.04,38163.31,74,,38163.31,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,23207.42,45,,23207.42,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,25528.16,49.5,,25528.16,percent of total billed charges,110% of Medicare,35068.99,68,,35068.99,percent of total billed charges,,6658.36,,,6658.36,Other,186% of Medicaid,41257.63,80,,41257.63,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,41257.63,80,,41257.63,percent of total billed charges,,7216,,,7216,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,36100.43,70,,36100.43,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,3579.77,,,3579.77,Other,New York Medicaid APG methodology,3579.77,,,3579.77,Other,100% New York Medicaid APG,3579.77,,,3579.77,Other,100% New York Medicaid APG,3579.77,,,3579.77,Other,100% New York Medicaid APG,8054.47,,,8054.47,Other,225% New York Medicaid APG,5477.04,,,5477.04,Other,153% New York Medicaid APG,8054.47,,,8054.47,Other,225% New York Medicaid APG,5011.67,,,5011.67,Other,140% New York Medicaid APG,8054.47,,,8054.47,Other,225% New York Medicaid APG,9307.39,,,9307.39,Other,260% New York Medicaid APG,11598.44,,,11598.44,Other,324% New York Medicaid APG,7696.5,,,7696.5,Other,215% New York Medicaid APG,7696.5,,,7696.5,Other,215% New York Medicaid APG,4474.71,,,4474.71,Other,125% New York Medicaid APG,2053,41257.63,
Sp bone agrft struct add-on,20938,CPT,,,,,,,,both,,,51572.04,38163.31,74,,38163.31,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,23207.42,45,,23207.42,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,25528.16,49.5,,25528.16,percent of total billed charges,110% of Medicare,35068.99,68,,35068.99,percent of total billed charges,,6658.36,,,6658.36,Other,186% of Medicaid,41257.63,80,,41257.63,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,41257.63,80,,41257.63,percent of total billed charges,,7216,,,7216,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,36100.43,70,,36100.43,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,3579.77,,,3579.77,Other,New York Medicaid APG methodology,3579.77,,,3579.77,Other,100% New York Medicaid APG,3579.77,,,3579.77,Other,100% New York Medicaid APG,3579.77,,,3579.77,Other,100% New York Medicaid APG,8054.47,,,8054.47,Other,225% New York Medicaid APG,5477.04,,,5477.04,Other,153% New York Medicaid APG,8054.47,,,8054.47,Other,225% New York Medicaid APG,5011.67,,,5011.67,Other,140% New York Medicaid APG,8054.47,,,8054.47,Other,225% New York Medicaid APG,9307.39,,,9307.39,Other,260% New York Medicaid APG,11598.44,,,11598.44,Other,324% New York Medicaid APG,7696.5,,,7696.5,Other,215% New York Medicaid APG,7696.5,,,7696.5,Other,215% New York Medicaid APG,4474.71,,,4474.71,Other,125% New York Medicaid APG,2053,41257.63,
Bone marrow aspir bone grfg,20939,CPT,,,,,,,,both,,,83504,61792.96,74,,61792.96,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,37576.8,45,,37576.8,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,41334.48,49.5,,41334.48,percent of total billed charges,110% of Medicare,56782.72,68,,56782.72,percent of total billed charges,,6658.36,,,6658.36,Other,186% of Medicaid,66803.2,80,,66803.2,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,66803.2,80,,66803.2,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,58452.8,70,,58452.8,percent of total billed charges,,342.76,,,342.76,Fee Schedule,,290.51,,,290.51,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,3579.77,,,3579.77,Other,New York Medicaid APG methodology,3579.77,,,3579.77,Other,100% New York Medicaid APG,3579.77,,,3579.77,Other,100% New York Medicaid APG,3579.77,,,3579.77,Other,100% New York Medicaid APG,8054.47,,,8054.47,Other,225% New York Medicaid APG,5477.04,,,5477.04,Other,153% New York Medicaid APG,8054.47,,,8054.47,Other,225% New York Medicaid APG,5011.67,,,5011.67,Other,140% New York Medicaid APG,8054.47,,,8054.47,Other,225% New York Medicaid APG,9307.39,,,9307.39,Other,260% New York Medicaid APG,11598.44,,,11598.44,Other,324% New York Medicaid APG,7696.5,,,7696.5,Other,215% New York Medicaid APG,7696.5,,,7696.5,Other,215% New York Medicaid APG,4474.71,,,4474.71,Other,125% New York Medicaid APG,290.51,66803.2,
Fluid pressure muscle,20950,CPT,,,,,,,,both,,,14798.8,10951.11,74,,10951.11,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,6659.46,45,,6659.46,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,7325.41,49.5,,7325.41,percent of total billed charges,110% of Medicare,10063.18,68,,10063.18,percent of total billed charges,,982.05,,,982.05,Other,186% of Medicaid,11839.04,80,,11839.04,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,11839.04,80,,11839.04,percent of total billed charges,,7216,,,7216,Case Rate,,3578,,"100% primary, 0% secondary procedures",3578,Other,MagnaCare ASC Grouper,10359.16,70,,10359.16,percent of total billed charges,,428.04,,,428.04,Fee Schedule,,362.79,,,362.79,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,527.98,,,527.98,Other,New York Medicaid APG methodology,527.98,,,527.98,Other,100% New York Medicaid APG,527.98,,,527.98,Other,100% New York Medicaid APG,527.98,,,527.98,Other,100% New York Medicaid APG,1187.96,,,1187.96,Other,225% New York Medicaid APG,807.81,,,807.81,Other,153% New York Medicaid APG,1187.96,,,1187.96,Other,225% New York Medicaid APG,739.17,,,739.17,Other,140% New York Medicaid APG,1187.96,,,1187.96,Other,225% New York Medicaid APG,1372.75,,,1372.75,Other,260% New York Medicaid APG,1710.66,,,1710.66,Other,324% New York Medicaid APG,1135.16,,,1135.16,Other,215% New York Medicaid APG,1135.16,,,1135.16,Other,215% New York Medicaid APG,659.98,,,659.98,Other,125% New York Medicaid APG,362.79,11839.04,
Bone/skin graft metatarsal,20972,CPT,,,,,,,,both,,,150476.65,111352.72,74,,111352.72,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,67714.49,45,,67714.49,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,74485.94,49.5,,74485.94,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3642.86,,,3642.86,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,105333.66,70,,105333.66,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,1958.52,,,1958.52,Other,New York Medicaid APG methodology,1958.52,,,1958.52,Other,100% New York Medicaid APG,1958.52,,,1958.52,Other,100% New York Medicaid APG,1958.52,,,1958.52,Other,100% New York Medicaid APG,4406.68,,,4406.68,Other,225% New York Medicaid APG,2996.54,,,2996.54,Other,153% New York Medicaid APG,4406.68,,,4406.68,Other,225% New York Medicaid APG,2741.93,,,2741.93,Other,140% New York Medicaid APG,4406.68,,,4406.68,Other,225% New York Medicaid APG,5092.16,,,5092.16,Other,260% New York Medicaid APG,6345.62,,,6345.62,Other,324% New York Medicaid APG,4210.83,,,4210.83,Other,215% New York Medicaid APG,4210.83,,,4210.83,Other,215% New York Medicaid APG,2448.16,,,2448.16,Other,125% New York Medicaid APG,1958.52,111352.72,
Bone/skin graft great toe,20973,CPT,,,,,,,,both,,,150476.65,111352.72,74,,111352.72,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,67714.49,45,,67714.49,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,74485.94,49.5,,74485.94,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3642.86,,,3642.86,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,105333.66,70,,105333.66,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,1958.52,,,1958.52,Other,New York Medicaid APG methodology,1958.52,,,1958.52,Other,100% New York Medicaid APG,1958.52,,,1958.52,Other,100% New York Medicaid APG,1958.52,,,1958.52,Other,100% New York Medicaid APG,4406.68,,,4406.68,Other,225% New York Medicaid APG,2996.54,,,2996.54,Other,153% New York Medicaid APG,4406.68,,,4406.68,Other,225% New York Medicaid APG,2741.93,,,2741.93,Other,140% New York Medicaid APG,4406.68,,,4406.68,Other,225% New York Medicaid APG,5092.16,,,5092.16,Other,260% New York Medicaid APG,6345.62,,,6345.62,Other,324% New York Medicaid APG,4210.83,,,4210.83,Other,215% New York Medicaid APG,4210.83,,,4210.83,Other,215% New York Medicaid APG,2448.16,,,2448.16,Other,125% New York Medicaid APG,1958.52,111352.72,
Electrical bone stimulation,20975,CPT,,,,,,,,both,,,51572.04,38163.31,74,,38163.31,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,23207.42,45,,23207.42,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,25528.16,49.5,,25528.16,percent of total billed charges,110% of Medicare,35068.99,68,,35068.99,percent of total billed charges,,1973.06,,,1973.06,Other,186% of Medicaid,41257.63,80,,41257.63,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,41257.63,80,,41257.63,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,36100.43,70,,36100.43,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,1060.79,,,1060.79,Other,New York Medicaid APG methodology,1060.79,,,1060.79,Other,100% New York Medicaid APG,1060.79,,,1060.79,Other,100% New York Medicaid APG,1060.79,,,1060.79,Other,100% New York Medicaid APG,2386.77,,,2386.77,Other,225% New York Medicaid APG,1623,,,1623,Other,153% New York Medicaid APG,2386.77,,,2386.77,Other,225% New York Medicaid APG,1485.1,,,1485.1,Other,140% New York Medicaid APG,2386.77,,,2386.77,Other,225% New York Medicaid APG,2758.05,,,2758.05,Other,260% New York Medicaid APG,3436.95,,,3436.95,Other,324% New York Medicaid APG,2280.69,,,2280.69,Other,215% New York Medicaid APG,2280.69,,,2280.69,Other,215% New York Medicaid APG,1325.98,,,1325.98,Other,125% New York Medicaid APG,1060.79,41257.63,
Us bone stimulation,20979,CPT,,,,,,,,both,,,626.29,463.45,74,,463.45,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,281.83,45,,281.83,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,310.01,49.5,,310.01,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,982.05,,,982.05,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,438.4,70,,438.4,percent of total billed charges,,157.44,,,157.44,Fee Schedule,,133.44,,,133.44,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,527.98,,,527.98,Other,New York Medicaid APG methodology,527.98,,,527.98,Other,100% New York Medicaid APG,527.98,,,527.98,Other,100% New York Medicaid APG,527.98,,,527.98,Other,100% New York Medicaid APG,1187.96,,,1187.96,Other,225% New York Medicaid APG,807.81,,,807.81,Other,153% New York Medicaid APG,1187.96,,,1187.96,Other,225% New York Medicaid APG,739.17,,,739.17,Other,140% New York Medicaid APG,1187.96,,,1187.96,Other,225% New York Medicaid APG,1372.75,,,1372.75,Other,260% New York Medicaid APG,1710.66,,,1710.66,Other,324% New York Medicaid APG,1135.16,,,1135.16,Other,215% New York Medicaid APG,1135.16,,,1135.16,Other,215% New York Medicaid APG,659.98,,,659.98,Other,125% New York Medicaid APG,133.44,9473,
Ablate bone tumor(s) perq,20982,CPT,,,,,,,,both,,,276827.87,204852.62,74,,204852.62,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,124572.54,45,,124572.54,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,137029.8,49.5,,137029.8,percent of total billed charges,110% of Medicare,188242.95,68,,188242.95,percent of total billed charges,,1973.06,,,1973.06,Other,186% of Medicaid,221462.3,80,,221462.3,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,221462.3,80,,221462.3,percent of total billed charges,,7216,,,7216,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,193779.51,70,,193779.51,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,1060.79,,,1060.79,Other,New York Medicaid APG methodology,1060.79,,,1060.79,Other,100% New York Medicaid APG,1060.79,,,1060.79,Other,100% New York Medicaid APG,1060.79,,,1060.79,Other,100% New York Medicaid APG,2386.77,,,2386.77,Other,225% New York Medicaid APG,1623,,,1623,Other,153% New York Medicaid APG,2386.77,,,2386.77,Other,225% New York Medicaid APG,1485.1,,,1485.1,Other,140% New York Medicaid APG,2386.77,,,2386.77,Other,225% New York Medicaid APG,2758.05,,,2758.05,Other,260% New York Medicaid APG,3436.95,,,3436.95,Other,324% New York Medicaid APG,2280.69,,,2280.69,Other,215% New York Medicaid APG,2280.69,,,2280.69,Other,215% New York Medicaid APG,1325.98,,,1325.98,Other,125% New York Medicaid APG,1060.79,221462.3,
Ablate bone tumor(s) perq,20983,CPT,,,,,,,,both,,,150476.65,111352.72,74,,111352.72,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,67714.49,45,,67714.49,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,74485.94,49.5,,74485.94,percent of total billed charges,110% of Medicare,102324.12,68,,102324.12,percent of total billed charges,,1973.06,,,1973.06,Other,186% of Medicaid,120381.32,80,,120381.32,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,120381.32,80,,120381.32,percent of total billed charges,,7216,,,7216,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,105333.66,70,,105333.66,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,1060.79,,,1060.79,Other,New York Medicaid APG methodology,1060.79,,,1060.79,Other,100% New York Medicaid APG,1060.79,,,1060.79,Other,100% New York Medicaid APG,1060.79,,,1060.79,Other,100% New York Medicaid APG,2386.77,,,2386.77,Other,225% New York Medicaid APG,1623,,,1623,Other,153% New York Medicaid APG,2386.77,,,2386.77,Other,225% New York Medicaid APG,1485.1,,,1485.1,Other,140% New York Medicaid APG,2386.77,,,2386.77,Other,225% New York Medicaid APG,2758.05,,,2758.05,Other,260% New York Medicaid APG,3436.95,,,3436.95,Other,324% New York Medicaid APG,2280.69,,,2280.69,Other,215% New York Medicaid APG,2280.69,,,2280.69,Other,215% New York Medicaid APG,1325.98,,,1325.98,Other,125% New York Medicaid APG,1060.79,120381.32,
Cptr-asst dir ms px,20985,CPT,,,,,,,,both,,,36356.27,26903.64,74,,26903.64,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,16360.32,45,,16360.32,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,21813.76,60,,21813.76,percent of total billed charges,,20359.51,56,,20359.51,percent of total billed charges,,19632.39,54,,19632.39,percent of total billed charges,,17996.35,49.5,,17996.35,percent of total billed charges,110% of Medicare,24722.26,68,,24722.26,percent of total billed charges,,0.02,,,0.02,Other,186% of Medicaid,29085.02,80,,29085.02,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,29085.02,80,,29085.02,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,25449.39,70,,25449.39,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% New York Medicaid APG,0.01,,,0.01,Other,100% New York Medicaid APG,0.01,,,0.01,Other,100% New York Medicaid APG,0.02,,,0.02,Other,225% New York Medicaid APG,0.02,,,0.02,Other,153% New York Medicaid APG,0.02,,,0.02,Other,225% New York Medicaid APG,0.01,,,0.01,Other,140% New York Medicaid APG,0.02,,,0.02,Other,225% New York Medicaid APG,0.03,,,0.03,Other,260% New York Medicaid APG,0.03,,,0.03,Other,324% New York Medicaid APG,0.02,,,0.02,Other,215% New York Medicaid APG,0.02,,,0.02,Other,215% New York Medicaid APG,0.01,,,0.01,Other,125% New York Medicaid APG,0.01,29085.02,
Incision of jaw joint,21010,CPT,,,,,,,,both,,,67720.49,50113.16,74,,50113.16,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30474.22,45,,30474.22,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,33521.64,49.5,,33521.64,percent of total billed charges,110% of Medicare,46049.93,68,,46049.93,percent of total billed charges,,4398.22,,,4398.22,Other,186% of Medicaid,54176.39,80,,54176.39,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,54176.39,80,,54176.39,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,47404.34,70,,47404.34,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,2364.64,,,2364.64,Other,New York Medicaid APG methodology,2364.64,,,2364.64,Other,100% New York Medicaid APG,2364.64,,,2364.64,Other,100% New York Medicaid APG,2364.64,,,2364.64,Other,100% New York Medicaid APG,5320.43,,,5320.43,Other,225% New York Medicaid APG,3617.89,,,3617.89,Other,153% New York Medicaid APG,5320.43,,,5320.43,Other,225% New York Medicaid APG,3310.49,,,3310.49,Other,140% New York Medicaid APG,5320.43,,,5320.43,Other,225% New York Medicaid APG,6148.05,,,6148.05,Other,260% New York Medicaid APG,7661.42,,,7661.42,Other,324% New York Medicaid APG,5083.97,,,5083.97,Other,215% New York Medicaid APG,5083.97,,,5083.97,Other,215% New York Medicaid APG,2955.8,,,2955.8,Other,125% New York Medicaid APG,2232,54176.39,
Exc face les sc <2 cm,21011,CPT,,,,,,,,both,,,37587.99,27815.11,74,,27815.11,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,16914.6,45,,16914.6,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,18606.06,49.5,,18606.06,percent of total billed charges,110% of Medicare,25559.83,68,,25559.83,percent of total billed charges,,1973.06,,,1973.06,Other,186% of Medicaid,30070.39,80,,30070.39,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,30070.39,80,,30070.39,percent of total billed charges,,7216,,,7216,Case Rate,,3578,,"100% primary, 0% secondary procedures",3578,Other,MagnaCare ASC Grouper,26311.59,70,,26311.59,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,1060.79,,,1060.79,Other,New York Medicaid APG methodology,1060.79,,,1060.79,Other,100% New York Medicaid APG,1060.79,,,1060.79,Other,100% New York Medicaid APG,1060.79,,,1060.79,Other,100% New York Medicaid APG,2386.77,,,2386.77,Other,225% New York Medicaid APG,1623,,,1623,Other,153% New York Medicaid APG,2386.77,,,2386.77,Other,225% New York Medicaid APG,1485.1,,,1485.1,Other,140% New York Medicaid APG,2386.77,,,2386.77,Other,225% New York Medicaid APG,2758.05,,,2758.05,Other,260% New York Medicaid APG,3436.95,,,3436.95,Other,324% New York Medicaid APG,2280.69,,,2280.69,Other,215% New York Medicaid APG,2280.69,,,2280.69,Other,215% New York Medicaid APG,1325.98,,,1325.98,Other,125% New York Medicaid APG,1060.79,30070.39,
Exc face les sbq 2 cm/>,21012,CPT,,,,,,,,both,,,35914.52,26576.74,74,,26576.74,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,16161.53,45,,16161.53,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,17777.69,49.5,,17777.69,percent of total billed charges,110% of Medicare,24421.87,68,,24421.87,percent of total billed charges,,1973.06,,,1973.06,Other,186% of Medicaid,28731.62,80,,28731.62,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,28731.62,80,,28731.62,percent of total billed charges,,7216,,,7216,Case Rate,,3578,,"100% primary, 0% secondary procedures",3578,Other,MagnaCare ASC Grouper,25140.16,70,,25140.16,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,1060.79,,,1060.79,Other,New York Medicaid APG methodology,1060.79,,,1060.79,Other,100% New York Medicaid APG,1060.79,,,1060.79,Other,100% New York Medicaid APG,1060.79,,,1060.79,Other,100% New York Medicaid APG,2386.77,,,2386.77,Other,225% New York Medicaid APG,1623,,,1623,Other,153% New York Medicaid APG,2386.77,,,2386.77,Other,225% New York Medicaid APG,1485.1,,,1485.1,Other,140% New York Medicaid APG,2386.77,,,2386.77,Other,225% New York Medicaid APG,2758.05,,,2758.05,Other,260% New York Medicaid APG,3436.95,,,3436.95,Other,324% New York Medicaid APG,2280.69,,,2280.69,Other,215% New York Medicaid APG,2280.69,,,2280.69,Other,215% New York Medicaid APG,1325.98,,,1325.98,Other,125% New York Medicaid APG,1060.79,28731.62,
Exc face tum deep < 2 cm,21013,CPT,,,,,,,,both,,,42004.82,31083.57,74,,31083.57,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,18902.17,45,,18902.17,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,20792.39,49.5,,20792.39,percent of total billed charges,110% of Medicare,28563.28,68,,28563.28,percent of total billed charges,,1973.06,,,1973.06,Other,186% of Medicaid,33603.86,80,,33603.86,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,33603.86,80,,33603.86,percent of total billed charges,,7216,,,7216,Case Rate,,3578,,"100% primary, 0% secondary procedures",3578,Other,MagnaCare ASC Grouper,29403.37,70,,29403.37,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,1060.79,,,1060.79,Other,New York Medicaid APG methodology,1060.79,,,1060.79,Other,100% New York Medicaid APG,1060.79,,,1060.79,Other,100% New York Medicaid APG,1060.79,,,1060.79,Other,100% New York Medicaid APG,2386.77,,,2386.77,Other,225% New York Medicaid APG,1623,,,1623,Other,153% New York Medicaid APG,2386.77,,,2386.77,Other,225% New York Medicaid APG,1485.1,,,1485.1,Other,140% New York Medicaid APG,2386.77,,,2386.77,Other,225% New York Medicaid APG,2758.05,,,2758.05,Other,260% New York Medicaid APG,3436.95,,,3436.95,Other,324% New York Medicaid APG,2280.69,,,2280.69,Other,215% New York Medicaid APG,2280.69,,,2280.69,Other,215% New York Medicaid APG,1325.98,,,1325.98,Other,125% New York Medicaid APG,1060.79,33603.86,
Exc face tum deep 2 cm/>,21014,CPT,,,,,,,,both,,,42535.57,31476.32,74,,31476.32,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,19141.01,45,,19141.01,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,21055.11,49.5,,21055.11,percent of total billed charges,110% of Medicare,28924.19,68,,28924.19,percent of total billed charges,,1973.06,,,1973.06,Other,186% of Medicaid,34028.46,80,,34028.46,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,34028.46,80,,34028.46,percent of total billed charges,,7216,,,7216,Case Rate,,3578,,"100% primary, 0% secondary procedures",3578,Other,MagnaCare ASC Grouper,29774.9,70,,29774.9,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,1060.79,,,1060.79,Other,New York Medicaid APG methodology,1060.79,,,1060.79,Other,100% New York Medicaid APG,1060.79,,,1060.79,Other,100% New York Medicaid APG,1060.79,,,1060.79,Other,100% New York Medicaid APG,2386.77,,,2386.77,Other,225% New York Medicaid APG,1623,,,1623,Other,153% New York Medicaid APG,2386.77,,,2386.77,Other,225% New York Medicaid APG,1485.1,,,1485.1,Other,140% New York Medicaid APG,2386.77,,,2386.77,Other,225% New York Medicaid APG,2758.05,,,2758.05,Other,260% New York Medicaid APG,3436.95,,,3436.95,Other,324% New York Medicaid APG,2280.69,,,2280.69,Other,215% New York Medicaid APG,2280.69,,,2280.69,Other,215% New York Medicaid APG,1325.98,,,1325.98,Other,125% New York Medicaid APG,1060.79,34028.46,
Resect face/scalp tum < 2 cm,21015,CPT,,,,,,,,both,,,59767.2,44227.73,74,,44227.73,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,26895.24,45,,26895.24,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,29584.76,49.5,,29584.76,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,1973.06,,,1973.06,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,41837.04,70,,41837.04,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1060.79,,,1060.79,Other,New York Medicaid APG methodology,1060.79,,,1060.79,Other,100% New York Medicaid APG,1060.79,,,1060.79,Other,100% New York Medicaid APG,1060.79,,,1060.79,Other,100% New York Medicaid APG,2386.77,,,2386.77,Other,225% New York Medicaid APG,1623,,,1623,Other,153% New York Medicaid APG,2386.77,,,2386.77,Other,225% New York Medicaid APG,1485.1,,,1485.1,Other,140% New York Medicaid APG,2386.77,,,2386.77,Other,225% New York Medicaid APG,2758.05,,,2758.05,Other,260% New York Medicaid APG,3436.95,,,3436.95,Other,324% New York Medicaid APG,2280.69,,,2280.69,Other,215% New York Medicaid APG,2280.69,,,2280.69,Other,215% New York Medicaid APG,1325.98,,,1325.98,Other,125% New York Medicaid APG,1060.79,44227.73,
Resect face/scalp tum 2 cm/>,21016,CPT,,,,,,,,both,,,59767.2,44227.73,74,,44227.73,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,26895.24,45,,26895.24,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,29584.76,49.5,,29584.76,percent of total billed charges,110% of Medicare,40641.7,68,,40641.7,percent of total billed charges,,1973.06,,,1973.06,Other,186% of Medicaid,47813.76,80,,47813.76,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,47813.76,80,,47813.76,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,41837.04,70,,41837.04,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1060.79,,,1060.79,Other,New York Medicaid APG methodology,1060.79,,,1060.79,Other,100% New York Medicaid APG,1060.79,,,1060.79,Other,100% New York Medicaid APG,1060.79,,,1060.79,Other,100% New York Medicaid APG,2386.77,,,2386.77,Other,225% New York Medicaid APG,1623,,,1623,Other,153% New York Medicaid APG,2386.77,,,2386.77,Other,225% New York Medicaid APG,1485.1,,,1485.1,Other,140% New York Medicaid APG,2386.77,,,2386.77,Other,225% New York Medicaid APG,2758.05,,,2758.05,Other,260% New York Medicaid APG,3436.95,,,3436.95,Other,324% New York Medicaid APG,2280.69,,,2280.69,Other,215% New York Medicaid APG,2280.69,,,2280.69,Other,215% New York Medicaid APG,1325.98,,,1325.98,Other,125% New York Medicaid APG,1060.79,47813.76,
Excision of bone lower jaw,21025,CPT,,,,,,,,both,,,123177.14,91151.08,74,,91151.08,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,55429.71,45,,55429.71,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,60972.68,49.5,,60972.68,percent of total billed charges,110% of Medicare,83760.46,68,,83760.46,percent of total billed charges,,4398.22,,,4398.22,Other,186% of Medicaid,98541.71,80,,98541.71,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,98541.71,80,,98541.71,percent of total billed charges,,7216,,,7216,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,86224,70,,86224,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,2364.64,,,2364.64,Other,New York Medicaid APG methodology,2364.64,,,2364.64,Other,100% New York Medicaid APG,2364.64,,,2364.64,Other,100% New York Medicaid APG,2364.64,,,2364.64,Other,100% New York Medicaid APG,5320.43,,,5320.43,Other,225% New York Medicaid APG,3617.89,,,3617.89,Other,153% New York Medicaid APG,5320.43,,,5320.43,Other,225% New York Medicaid APG,3310.49,,,3310.49,Other,140% New York Medicaid APG,5320.43,,,5320.43,Other,225% New York Medicaid APG,6148.05,,,6148.05,Other,260% New York Medicaid APG,7661.42,,,7661.42,Other,324% New York Medicaid APG,5083.97,,,5083.97,Other,215% New York Medicaid APG,5083.97,,,5083.97,Other,215% New York Medicaid APG,2955.8,,,2955.8,Other,125% New York Medicaid APG,2232,98541.71,
Excision of facial bone(s),21026,CPT,,,,,,,,both,,,123177.14,91151.08,74,,91151.08,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,55429.71,45,,55429.71,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,60972.68,49.5,,60972.68,percent of total billed charges,110% of Medicare,83760.46,68,,83760.46,percent of total billed charges,,4398.22,,,4398.22,Other,186% of Medicaid,98541.71,80,,98541.71,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,98541.71,80,,98541.71,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,86224,70,,86224,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,2364.64,,,2364.64,Other,New York Medicaid APG methodology,2364.64,,,2364.64,Other,100% New York Medicaid APG,2364.64,,,2364.64,Other,100% New York Medicaid APG,2364.64,,,2364.64,Other,100% New York Medicaid APG,5320.43,,,5320.43,Other,225% New York Medicaid APG,3617.89,,,3617.89,Other,153% New York Medicaid APG,5320.43,,,5320.43,Other,225% New York Medicaid APG,3310.49,,,3310.49,Other,140% New York Medicaid APG,5320.43,,,5320.43,Other,225% New York Medicaid APG,6148.05,,,6148.05,Other,260% New York Medicaid APG,7661.42,,,7661.42,Other,324% New York Medicaid APG,5083.97,,,5083.97,Other,215% New York Medicaid APG,5083.97,,,5083.97,Other,215% New York Medicaid APG,2955.8,,,2955.8,Other,125% New York Medicaid APG,2232,98541.71,
Contour of face bone lesion,21029,CPT,,,,,,,,both,,,67720.49,50113.16,74,,50113.16,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30474.22,45,,30474.22,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,33521.64,49.5,,33521.64,percent of total billed charges,110% of Medicare,46049.93,68,,46049.93,percent of total billed charges,,4398.22,,,4398.22,Other,186% of Medicaid,54176.39,80,,54176.39,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,54176.39,80,,54176.39,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,47404.34,70,,47404.34,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,2364.64,,,2364.64,Other,New York Medicaid APG methodology,2364.64,,,2364.64,Other,100% New York Medicaid APG,2364.64,,,2364.64,Other,100% New York Medicaid APG,2364.64,,,2364.64,Other,100% New York Medicaid APG,5320.43,,,5320.43,Other,225% New York Medicaid APG,3617.89,,,3617.89,Other,153% New York Medicaid APG,5320.43,,,5320.43,Other,225% New York Medicaid APG,3310.49,,,3310.49,Other,140% New York Medicaid APG,5320.43,,,5320.43,Other,225% New York Medicaid APG,6148.05,,,6148.05,Other,260% New York Medicaid APG,7661.42,,,7661.42,Other,324% New York Medicaid APG,5083.97,,,5083.97,Other,215% New York Medicaid APG,5083.97,,,5083.97,Other,215% New York Medicaid APG,2955.8,,,2955.8,Other,125% New York Medicaid APG,2232,54176.39,
Excise max/zygoma b9 tumor,21030,CPT,,,,,,,,both,,,123177.14,91151.08,74,,91151.08,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,55429.71,45,,55429.71,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,60972.68,49.5,,60972.68,percent of total billed charges,110% of Medicare,83760.46,68,,83760.46,percent of total billed charges,,4398.22,,,4398.22,Other,186% of Medicaid,98541.71,80,,98541.71,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,98541.71,80,,98541.71,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,86224,70,,86224,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,2364.64,,,2364.64,Other,New York Medicaid APG methodology,2364.64,,,2364.64,Other,100% New York Medicaid APG,2364.64,,,2364.64,Other,100% New York Medicaid APG,2364.64,,,2364.64,Other,100% New York Medicaid APG,5320.43,,,5320.43,Other,225% New York Medicaid APG,3617.89,,,3617.89,Other,153% New York Medicaid APG,5320.43,,,5320.43,Other,225% New York Medicaid APG,3310.49,,,3310.49,Other,140% New York Medicaid APG,5320.43,,,5320.43,Other,225% New York Medicaid APG,6148.05,,,6148.05,Other,260% New York Medicaid APG,7661.42,,,7661.42,Other,324% New York Medicaid APG,5083.97,,,5083.97,Other,215% New York Medicaid APG,5083.97,,,5083.97,Other,215% New York Medicaid APG,2955.8,,,2955.8,Other,125% New York Medicaid APG,2232,98541.71,
Remove exostosis mandible,21031,CPT,,,,,,,,both,,,67720.49,50113.16,74,,50113.16,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30474.22,45,,30474.22,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,33521.64,49.5,,33521.64,percent of total billed charges,110% of Medicare,46049.93,68,,46049.93,percent of total billed charges,,4398.22,,,4398.22,Other,186% of Medicaid,54176.39,80,,54176.39,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,54176.39,80,,54176.39,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,47404.34,70,,47404.34,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,2364.64,,,2364.64,Other,New York Medicaid APG methodology,2364.64,,,2364.64,Other,100% New York Medicaid APG,2364.64,,,2364.64,Other,100% New York Medicaid APG,2364.64,,,2364.64,Other,100% New York Medicaid APG,5320.43,,,5320.43,Other,225% New York Medicaid APG,3617.89,,,3617.89,Other,153% New York Medicaid APG,5320.43,,,5320.43,Other,225% New York Medicaid APG,3310.49,,,3310.49,Other,140% New York Medicaid APG,5320.43,,,5320.43,Other,225% New York Medicaid APG,6148.05,,,6148.05,Other,260% New York Medicaid APG,7661.42,,,7661.42,Other,324% New York Medicaid APG,5083.97,,,5083.97,Other,215% New York Medicaid APG,5083.97,,,5083.97,Other,215% New York Medicaid APG,2955.8,,,2955.8,Other,125% New York Medicaid APG,2053,54176.39,
Remove exostosis maxilla,21032,CPT,,,,,,,,both,,,67720.49,50113.16,74,,50113.16,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30474.22,45,,30474.22,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,33521.64,49.5,,33521.64,percent of total billed charges,110% of Medicare,46049.93,68,,46049.93,percent of total billed charges,,4398.22,,,4398.22,Other,186% of Medicaid,54176.39,80,,54176.39,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,54176.39,80,,54176.39,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,47404.34,70,,47404.34,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,2364.64,,,2364.64,Other,New York Medicaid APG methodology,2364.64,,,2364.64,Other,100% New York Medicaid APG,2364.64,,,2364.64,Other,100% New York Medicaid APG,2364.64,,,2364.64,Other,100% New York Medicaid APG,5320.43,,,5320.43,Other,225% New York Medicaid APG,3617.89,,,3617.89,Other,153% New York Medicaid APG,5320.43,,,5320.43,Other,225% New York Medicaid APG,3310.49,,,3310.49,Other,140% New York Medicaid APG,5320.43,,,5320.43,Other,225% New York Medicaid APG,6148.05,,,6148.05,Other,260% New York Medicaid APG,7661.42,,,7661.42,Other,324% New York Medicaid APG,5083.97,,,5083.97,Other,215% New York Medicaid APG,5083.97,,,5083.97,Other,215% New York Medicaid APG,2955.8,,,2955.8,Other,125% New York Medicaid APG,2053,54176.39,
Excise max/zygoma mal tumor,21034,CPT,,,,,,,,both,,,123177.14,91151.08,74,,91151.08,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,55429.71,45,,55429.71,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,60972.68,49.5,,60972.68,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5482.74,,,5482.74,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,86224,70,,86224,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,2947.71,,,2947.71,Other,New York Medicaid APG methodology,2947.71,,,2947.71,Other,100% New York Medicaid APG,2947.71,,,2947.71,Other,100% New York Medicaid APG,2947.71,,,2947.71,Other,100% New York Medicaid APG,6632.35,,,6632.35,Other,225% New York Medicaid APG,4510,,,4510,Other,153% New York Medicaid APG,6632.35,,,6632.35,Other,225% New York Medicaid APG,4126.79,,,4126.79,Other,140% New York Medicaid APG,6632.35,,,6632.35,Other,225% New York Medicaid APG,7664.04,,,7664.04,Other,260% New York Medicaid APG,9550.58,,,9550.58,Other,324% New York Medicaid APG,6337.58,,,6337.58,Other,215% New York Medicaid APG,6337.58,,,6337.58,Other,215% New York Medicaid APG,3684.64,,,3684.64,Other,125% New York Medicaid APG,2947.71,91151.08,
Excise mandible lesion,21040,CPT,,,,,,,,both,,,92070.37,68132.07,74,,68132.07,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,41431.67,45,,41431.67,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,45574.83,49.5,,45574.83,percent of total billed charges,110% of Medicare,62607.85,68,,62607.85,percent of total billed charges,,4398.22,,,4398.22,Other,186% of Medicaid,73656.3,80,,73656.3,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,73656.3,80,,73656.3,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,64449.26,70,,64449.26,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,2364.64,,,2364.64,Other,New York Medicaid APG methodology,2364.64,,,2364.64,Other,100% New York Medicaid APG,2364.64,,,2364.64,Other,100% New York Medicaid APG,2364.64,,,2364.64,Other,100% New York Medicaid APG,5320.43,,,5320.43,Other,225% New York Medicaid APG,3617.89,,,3617.89,Other,153% New York Medicaid APG,5320.43,,,5320.43,Other,225% New York Medicaid APG,3310.49,,,3310.49,Other,140% New York Medicaid APG,5320.43,,,5320.43,Other,225% New York Medicaid APG,6148.05,,,6148.05,Other,260% New York Medicaid APG,7661.42,,,7661.42,Other,324% New York Medicaid APG,5083.97,,,5083.97,Other,215% New York Medicaid APG,5083.97,,,5083.97,Other,215% New York Medicaid APG,2955.8,,,2955.8,Other,125% New York Medicaid APG,2232,73656.3,
Removal of jaw bone lesion,21044,CPT,,,,,,,,both,,,123177.14,91151.08,74,,91151.08,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,55429.71,45,,55429.71,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,60972.68,49.5,,60972.68,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5482.74,,,5482.74,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,86224,70,,86224,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,2947.71,,,2947.71,Other,New York Medicaid APG methodology,2947.71,,,2947.71,Other,100% New York Medicaid APG,2947.71,,,2947.71,Other,100% New York Medicaid APG,2947.71,,,2947.71,Other,100% New York Medicaid APG,6632.35,,,6632.35,Other,225% New York Medicaid APG,4510,,,4510,Other,153% New York Medicaid APG,6632.35,,,6632.35,Other,225% New York Medicaid APG,4126.79,,,4126.79,Other,140% New York Medicaid APG,6632.35,,,6632.35,Other,225% New York Medicaid APG,7664.04,,,7664.04,Other,260% New York Medicaid APG,9550.58,,,9550.58,Other,324% New York Medicaid APG,6337.58,,,6337.58,Other,215% New York Medicaid APG,6337.58,,,6337.58,Other,215% New York Medicaid APG,3684.64,,,3684.64,Other,125% New York Medicaid APG,2947.71,91151.08,
Remove mandible cyst complex,21046,CPT,,,,,,,,both,,,123177.14,91151.08,74,,91151.08,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,55429.71,45,,55429.71,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,60972.68,49.5,,60972.68,percent of total billed charges,110% of Medicare,83760.46,68,,83760.46,percent of total billed charges,,5482.74,,,5482.74,Other,186% of Medicaid,98541.71,80,,98541.71,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,98541.71,80,,98541.71,percent of total billed charges,,7216,,,7216,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,86224,70,,86224,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,2947.71,,,2947.71,Other,New York Medicaid APG methodology,2947.71,,,2947.71,Other,100% New York Medicaid APG,2947.71,,,2947.71,Other,100% New York Medicaid APG,2947.71,,,2947.71,Other,100% New York Medicaid APG,6632.35,,,6632.35,Other,225% New York Medicaid APG,4510,,,4510,Other,153% New York Medicaid APG,6632.35,,,6632.35,Other,225% New York Medicaid APG,4126.79,,,4126.79,Other,140% New York Medicaid APG,6632.35,,,6632.35,Other,225% New York Medicaid APG,7664.04,,,7664.04,Other,260% New York Medicaid APG,9550.58,,,9550.58,Other,324% New York Medicaid APG,6337.58,,,6337.58,Other,215% New York Medicaid APG,6337.58,,,6337.58,Other,215% New York Medicaid APG,3684.64,,,3684.64,Other,125% New York Medicaid APG,2232,98541.71,
Excise lwr jaw cyst w/repair,21047,CPT,,,,,,,,both,,,56587.86,41875.02,74,,41875.02,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,25464.54,45,,25464.54,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,28010.99,49.5,,28010.99,percent of total billed charges,110% of Medicare,38479.74,68,,38479.74,percent of total billed charges,,5482.74,,,5482.74,Other,186% of Medicaid,45270.29,80,,45270.29,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,45270.29,80,,45270.29,percent of total billed charges,,7216,,,7216,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,39611.5,70,,39611.5,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,2947.71,,,2947.71,Other,New York Medicaid APG methodology,2947.71,,,2947.71,Other,100% New York Medicaid APG,2947.71,,,2947.71,Other,100% New York Medicaid APG,2947.71,,,2947.71,Other,100% New York Medicaid APG,6632.35,,,6632.35,Other,225% New York Medicaid APG,4510,,,4510,Other,153% New York Medicaid APG,6632.35,,,6632.35,Other,225% New York Medicaid APG,4126.79,,,4126.79,Other,140% New York Medicaid APG,6632.35,,,6632.35,Other,225% New York Medicaid APG,7664.04,,,7664.04,Other,260% New York Medicaid APG,9550.58,,,9550.58,Other,324% New York Medicaid APG,6337.58,,,6337.58,Other,215% New York Medicaid APG,6337.58,,,6337.58,Other,215% New York Medicaid APG,3684.64,,,3684.64,Other,125% New York Medicaid APG,2232,45270.29,
Remove maxilla cyst complex,21048,CPT,,,,,,,,both,,,123177.14,91151.08,74,,91151.08,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,55429.71,45,,55429.71,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,60972.68,49.5,,60972.68,percent of total billed charges,110% of Medicare,83760.46,68,,83760.46,percent of total billed charges,,5482.74,,,5482.74,Other,186% of Medicaid,98541.71,80,,98541.71,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,98541.71,80,,98541.71,percent of total billed charges,,7216,,,7216,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,86224,70,,86224,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,2947.71,,,2947.71,Other,New York Medicaid APG methodology,2947.71,,,2947.71,Other,100% New York Medicaid APG,2947.71,,,2947.71,Other,100% New York Medicaid APG,2947.71,,,2947.71,Other,100% New York Medicaid APG,6632.35,,,6632.35,Other,225% New York Medicaid APG,4510,,,4510,Other,153% New York Medicaid APG,6632.35,,,6632.35,Other,225% New York Medicaid APG,4126.79,,,4126.79,Other,140% New York Medicaid APG,6632.35,,,6632.35,Other,225% New York Medicaid APG,7664.04,,,7664.04,Other,260% New York Medicaid APG,9550.58,,,9550.58,Other,324% New York Medicaid APG,6337.58,,,6337.58,Other,215% New York Medicaid APG,6337.58,,,6337.58,Other,215% New York Medicaid APG,3684.64,,,3684.64,Other,125% New York Medicaid APG,2232,98541.71,
Excis uppr jaw cyst w/repair,21049,CPT,,,,,,,,both,,,123177.14,91151.08,74,,91151.08,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,55429.71,45,,55429.71,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,60972.68,49.5,,60972.68,percent of total billed charges,110% of Medicare,83760.46,68,,83760.46,percent of total billed charges,,5482.74,,,5482.74,Other,186% of Medicaid,98541.71,80,,98541.71,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,98541.71,80,,98541.71,percent of total billed charges,,7216,,,7216,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,86224,70,,86224,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,2947.71,,,2947.71,Other,New York Medicaid APG methodology,2947.71,,,2947.71,Other,100% New York Medicaid APG,2947.71,,,2947.71,Other,100% New York Medicaid APG,2947.71,,,2947.71,Other,100% New York Medicaid APG,6632.35,,,6632.35,Other,225% New York Medicaid APG,4510,,,4510,Other,153% New York Medicaid APG,6632.35,,,6632.35,Other,225% New York Medicaid APG,4126.79,,,4126.79,Other,140% New York Medicaid APG,6632.35,,,6632.35,Other,225% New York Medicaid APG,7664.04,,,7664.04,Other,260% New York Medicaid APG,9550.58,,,9550.58,Other,324% New York Medicaid APG,6337.58,,,6337.58,Other,215% New York Medicaid APG,6337.58,,,6337.58,Other,215% New York Medicaid APG,3684.64,,,3684.64,Other,125% New York Medicaid APG,2232,98541.71,
Removal of jaw joint,21050,CPT,,,,,,,,both,,,123177.14,91151.08,74,,91151.08,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,55429.71,45,,55429.71,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,60972.68,49.5,,60972.68,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5482.74,,,5482.74,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,86224,70,,86224,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,2947.71,,,2947.71,Other,New York Medicaid APG methodology,2947.71,,,2947.71,Other,100% New York Medicaid APG,2947.71,,,2947.71,Other,100% New York Medicaid APG,2947.71,,,2947.71,Other,100% New York Medicaid APG,6632.35,,,6632.35,Other,225% New York Medicaid APG,4510,,,4510,Other,153% New York Medicaid APG,6632.35,,,6632.35,Other,225% New York Medicaid APG,4126.79,,,4126.79,Other,140% New York Medicaid APG,6632.35,,,6632.35,Other,225% New York Medicaid APG,7664.04,,,7664.04,Other,260% New York Medicaid APG,9550.58,,,9550.58,Other,324% New York Medicaid APG,6337.58,,,6337.58,Other,215% New York Medicaid APG,6337.58,,,6337.58,Other,215% New York Medicaid APG,3684.64,,,3684.64,Other,125% New York Medicaid APG,2947.71,91151.08,
Remove jaw joint cartilage,21060,CPT,,,,,,,,both,,,123177.14,91151.08,74,,91151.08,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,55429.71,45,,55429.71,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,60972.68,49.5,,60972.68,percent of total billed charges,110% of Medicare,83760.46,68,,83760.46,percent of total billed charges,,5482.74,,,5482.74,Other,186% of Medicaid,98541.71,80,,98541.71,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,98541.71,80,,98541.71,percent of total billed charges,,7216,,,7216,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,86224,70,,86224,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,2947.71,,,2947.71,Other,New York Medicaid APG methodology,2947.71,,,2947.71,Other,100% New York Medicaid APG,2947.71,,,2947.71,Other,100% New York Medicaid APG,2947.71,,,2947.71,Other,100% New York Medicaid APG,6632.35,,,6632.35,Other,225% New York Medicaid APG,4510,,,4510,Other,153% New York Medicaid APG,6632.35,,,6632.35,Other,225% New York Medicaid APG,4126.79,,,4126.79,Other,140% New York Medicaid APG,6632.35,,,6632.35,Other,225% New York Medicaid APG,7664.04,,,7664.04,Other,260% New York Medicaid APG,9550.58,,,9550.58,Other,324% New York Medicaid APG,6337.58,,,6337.58,Other,215% New York Medicaid APG,6337.58,,,6337.58,Other,215% New York Medicaid APG,3684.64,,,3684.64,Other,125% New York Medicaid APG,2232,98541.71,
Remove coronoid process,21070,CPT,,,,,,,,both,,,123177.14,91151.08,74,,91151.08,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,55429.71,45,,55429.71,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,60972.68,49.5,,60972.68,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5482.74,,,5482.74,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,86224,70,,86224,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,2947.71,,,2947.71,Other,New York Medicaid APG methodology,2947.71,,,2947.71,Other,100% New York Medicaid APG,2947.71,,,2947.71,Other,100% New York Medicaid APG,2947.71,,,2947.71,Other,100% New York Medicaid APG,6632.35,,,6632.35,Other,225% New York Medicaid APG,4510,,,4510,Other,153% New York Medicaid APG,6632.35,,,6632.35,Other,225% New York Medicaid APG,4126.79,,,4126.79,Other,140% New York Medicaid APG,6632.35,,,6632.35,Other,225% New York Medicaid APG,7664.04,,,7664.04,Other,260% New York Medicaid APG,9550.58,,,9550.58,Other,324% New York Medicaid APG,6337.58,,,6337.58,Other,215% New York Medicaid APG,6337.58,,,6337.58,Other,215% New York Medicaid APG,3684.64,,,3684.64,Other,125% New York Medicaid APG,2947.71,91151.08,
Mnpj of tmj w/anesth,21073,CPT,,,,,,,,both,,,32077.39,23737.27,74,,23737.27,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,14434.83,45,,14434.83,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,15878.31,49.5,,15878.31,percent of total billed charges,110% of Medicare,21812.63,68,,21812.63,percent of total billed charges,,1730.38,,,1730.38,Other,186% of Medicaid,25661.91,80,,25661.91,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,25661.91,80,,25661.91,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,22454.17,70,,22454.17,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,930.31,,,930.31,Other,New York Medicaid APG methodology,930.31,,,930.31,Other,100% New York Medicaid APG,930.31,,,930.31,Other,100% New York Medicaid APG,930.31,,,930.31,Other,100% New York Medicaid APG,2093.21,,,2093.21,Other,225% New York Medicaid APG,1423.38,,,1423.38,Other,153% New York Medicaid APG,2093.21,,,2093.21,Other,225% New York Medicaid APG,1302.44,,,1302.44,Other,140% New York Medicaid APG,2093.21,,,2093.21,Other,225% New York Medicaid APG,2418.82,,,2418.82,Other,260% New York Medicaid APG,3014.22,,,3014.22,Other,324% New York Medicaid APG,2000.18,,,2000.18,Other,215% New York Medicaid APG,2000.18,,,2000.18,Other,215% New York Medicaid APG,1162.89,,,1162.89,Other,125% New York Medicaid APG,930.31,25661.91,
Prepare face/oral prosthesis,21076,CPT,,,,,,,,both,,,32077.39,23737.27,74,,23737.27,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,14434.83,45,,14434.83,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,15878.31,49.5,,15878.31,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,279.58,,,279.58,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,22454.17,70,,22454.17,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,150.31,,,150.31,Other,New York Medicaid APG methodology,150.31,,,150.31,Other,100% New York Medicaid APG,150.31,,,150.31,Other,100% New York Medicaid APG,150.31,,,150.31,Other,100% New York Medicaid APG,338.21,,,338.21,Other,225% New York Medicaid APG,229.98,,,229.98,Other,153% New York Medicaid APG,338.21,,,338.21,Other,225% New York Medicaid APG,210.44,,,210.44,Other,140% New York Medicaid APG,338.21,,,338.21,Other,225% New York Medicaid APG,390.81,,,390.81,Other,260% New York Medicaid APG,487.02,,,487.02,Other,324% New York Medicaid APG,323.17,,,323.17,Other,215% New York Medicaid APG,323.17,,,323.17,Other,215% New York Medicaid APG,187.89,,,187.89,Other,125% New York Medicaid APG,150.31,23737.27,
Prepare face/oral prosthesis,21077,CPT,,,,,,,,both,,,123177.14,91151.08,74,,91151.08,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,55429.71,45,,55429.71,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,6125,,"100% primary, 50% secondary, 25% supplemental procedure",6125,Other,Blue Cross ASC Grouper,5513,,"100% primary, 50% secondary, 25% supplemental procedure",5513,Other,Blue Cross ASC Grouper,5206,,"100% primary, 50% secondary, 25% supplemental procedure",5206,Other,Blue Cross ASC Grouper,60972.68,49.5,,60972.68,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,606.58,,,606.58,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,86224,70,,86224,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,326.12,,,326.12,Other,New York Medicaid APG methodology,326.12,,,326.12,Other,100% New York Medicaid APG,326.12,,,326.12,Other,100% New York Medicaid APG,326.12,,,326.12,Other,100% New York Medicaid APG,733.77,,,733.77,Other,225% New York Medicaid APG,498.96,,,498.96,Other,153% New York Medicaid APG,733.77,,,733.77,Other,225% New York Medicaid APG,456.57,,,456.57,Other,140% New York Medicaid APG,733.77,,,733.77,Other,225% New York Medicaid APG,847.91,,,847.91,Other,260% New York Medicaid APG,1056.63,,,1056.63,Other,324% New York Medicaid APG,701.16,,,701.16,Other,215% New York Medicaid APG,701.16,,,701.16,Other,215% New York Medicaid APG,407.65,,,407.65,Other,125% New York Medicaid APG,326.12,91151.08,
Prepare face/oral prosthesis,21079,CPT,,,,,,,,both,,,67720.49,50113.16,74,,50113.16,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30474.22,45,,30474.22,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33521.64,49.5,,33521.64,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,279.58,,,279.58,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,47404.34,70,,47404.34,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,150.31,,,150.31,Other,New York Medicaid APG methodology,150.31,,,150.31,Other,100% New York Medicaid APG,150.31,,,150.31,Other,100% New York Medicaid APG,150.31,,,150.31,Other,100% New York Medicaid APG,338.21,,,338.21,Other,225% New York Medicaid APG,229.98,,,229.98,Other,153% New York Medicaid APG,338.21,,,338.21,Other,225% New York Medicaid APG,210.44,,,210.44,Other,140% New York Medicaid APG,338.21,,,338.21,Other,225% New York Medicaid APG,390.81,,,390.81,Other,260% New York Medicaid APG,487.02,,,487.02,Other,324% New York Medicaid APG,323.17,,,323.17,Other,215% New York Medicaid APG,323.17,,,323.17,Other,215% New York Medicaid APG,187.89,,,187.89,Other,125% New York Medicaid APG,150.31,50113.16,
Prepare face/oral prosthesis,21080,CPT,,,,,,,,both,,,67720.49,50113.16,74,,50113.16,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30474.22,45,,30474.22,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33521.64,49.5,,33521.64,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,279.58,,,279.58,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,47404.34,70,,47404.34,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,150.31,,,150.31,Other,New York Medicaid APG methodology,150.31,,,150.31,Other,100% New York Medicaid APG,150.31,,,150.31,Other,100% New York Medicaid APG,150.31,,,150.31,Other,100% New York Medicaid APG,338.21,,,338.21,Other,225% New York Medicaid APG,229.98,,,229.98,Other,153% New York Medicaid APG,338.21,,,338.21,Other,225% New York Medicaid APG,210.44,,,210.44,Other,140% New York Medicaid APG,338.21,,,338.21,Other,225% New York Medicaid APG,390.81,,,390.81,Other,260% New York Medicaid APG,487.02,,,487.02,Other,324% New York Medicaid APG,323.17,,,323.17,Other,215% New York Medicaid APG,323.17,,,323.17,Other,215% New York Medicaid APG,187.89,,,187.89,Other,125% New York Medicaid APG,150.31,50113.16,
Prepare face/oral prosthesis,21081,CPT,,,,,,,,both,,,123177.14,91151.08,74,,91151.08,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,55429.71,45,,55429.71,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,6125,,"100% primary, 50% secondary, 25% supplemental procedure",6125,Other,Blue Cross ASC Grouper,5513,,"100% primary, 50% secondary, 25% supplemental procedure",5513,Other,Blue Cross ASC Grouper,5206,,"100% primary, 50% secondary, 25% supplemental procedure",5206,Other,Blue Cross ASC Grouper,60972.68,49.5,,60972.68,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,606.58,,,606.58,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,86224,70,,86224,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,326.12,,,326.12,Other,New York Medicaid APG methodology,326.12,,,326.12,Other,100% New York Medicaid APG,326.12,,,326.12,Other,100% New York Medicaid APG,326.12,,,326.12,Other,100% New York Medicaid APG,733.77,,,733.77,Other,225% New York Medicaid APG,498.96,,,498.96,Other,153% New York Medicaid APG,733.77,,,733.77,Other,225% New York Medicaid APG,456.57,,,456.57,Other,140% New York Medicaid APG,733.77,,,733.77,Other,225% New York Medicaid APG,847.91,,,847.91,Other,260% New York Medicaid APG,1056.63,,,1056.63,Other,324% New York Medicaid APG,701.16,,,701.16,Other,215% New York Medicaid APG,701.16,,,701.16,Other,215% New York Medicaid APG,407.65,,,407.65,Other,125% New York Medicaid APG,326.12,91151.08,
Prepare face/oral prosthesis,21082,CPT,,,,,,,,both,,,67720.49,50113.16,74,,50113.16,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30474.22,45,,30474.22,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33521.64,49.5,,33521.64,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,606.58,,,606.58,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,47404.34,70,,47404.34,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,326.12,,,326.12,Other,New York Medicaid APG methodology,326.12,,,326.12,Other,100% New York Medicaid APG,326.12,,,326.12,Other,100% New York Medicaid APG,326.12,,,326.12,Other,100% New York Medicaid APG,733.77,,,733.77,Other,225% New York Medicaid APG,498.96,,,498.96,Other,153% New York Medicaid APG,733.77,,,733.77,Other,225% New York Medicaid APG,456.57,,,456.57,Other,140% New York Medicaid APG,733.77,,,733.77,Other,225% New York Medicaid APG,847.91,,,847.91,Other,260% New York Medicaid APG,1056.63,,,1056.63,Other,324% New York Medicaid APG,701.16,,,701.16,Other,215% New York Medicaid APG,701.16,,,701.16,Other,215% New York Medicaid APG,407.65,,,407.65,Other,125% New York Medicaid APG,326.12,50113.16,
Prepare face/oral prosthesis,21083,CPT,,,,,,,,both,,,67720.49,50113.16,74,,50113.16,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30474.22,45,,30474.22,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33521.64,49.5,,33521.64,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,279.58,,,279.58,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,47404.34,70,,47404.34,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,150.31,,,150.31,Other,New York Medicaid APG methodology,150.31,,,150.31,Other,100% New York Medicaid APG,150.31,,,150.31,Other,100% New York Medicaid APG,150.31,,,150.31,Other,100% New York Medicaid APG,338.21,,,338.21,Other,225% New York Medicaid APG,229.98,,,229.98,Other,153% New York Medicaid APG,338.21,,,338.21,Other,225% New York Medicaid APG,210.44,,,210.44,Other,140% New York Medicaid APG,338.21,,,338.21,Other,225% New York Medicaid APG,390.81,,,390.81,Other,260% New York Medicaid APG,487.02,,,487.02,Other,324% New York Medicaid APG,323.17,,,323.17,Other,215% New York Medicaid APG,323.17,,,323.17,Other,215% New York Medicaid APG,187.89,,,187.89,Other,125% New York Medicaid APG,150.31,50113.16,
Prepare face/oral prosthesis,21084,CPT,,,,,,,,both,,,67720.49,50113.16,74,,50113.16,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30474.22,45,,30474.22,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33521.64,49.5,,33521.64,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,279.58,,,279.58,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,47404.34,70,,47404.34,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,150.31,,,150.31,Other,New York Medicaid APG methodology,150.31,,,150.31,Other,100% New York Medicaid APG,150.31,,,150.31,Other,100% New York Medicaid APG,150.31,,,150.31,Other,100% New York Medicaid APG,338.21,,,338.21,Other,225% New York Medicaid APG,229.98,,,229.98,Other,153% New York Medicaid APG,338.21,,,338.21,Other,225% New York Medicaid APG,210.44,,,210.44,Other,140% New York Medicaid APG,338.21,,,338.21,Other,225% New York Medicaid APG,390.81,,,390.81,Other,260% New York Medicaid APG,487.02,,,487.02,Other,324% New York Medicaid APG,323.17,,,323.17,Other,215% New York Medicaid APG,323.17,,,323.17,Other,215% New York Medicaid APG,187.89,,,187.89,Other,125% New York Medicaid APG,150.31,50113.16,
Prepare face/oral prosthesis,21085,CPT,,,,,,,,both,,,5137.73,3801.92,74,,3801.92,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,2311.98,45,,2311.98,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,2543.18,49.5,,2543.18,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,279.58,,,279.58,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,3596.41,70,,3596.41,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,150.31,,,150.31,Other,New York Medicaid APG methodology,150.31,,,150.31,Other,100% New York Medicaid APG,150.31,,,150.31,Other,100% New York Medicaid APG,150.31,,,150.31,Other,100% New York Medicaid APG,338.21,,,338.21,Other,225% New York Medicaid APG,229.98,,,229.98,Other,153% New York Medicaid APG,338.21,,,338.21,Other,225% New York Medicaid APG,210.44,,,210.44,Other,140% New York Medicaid APG,338.21,,,338.21,Other,225% New York Medicaid APG,390.81,,,390.81,Other,260% New York Medicaid APG,487.02,,,487.02,Other,324% New York Medicaid APG,323.17,,,323.17,Other,215% New York Medicaid APG,323.17,,,323.17,Other,215% New York Medicaid APG,187.89,,,187.89,Other,125% New York Medicaid APG,150.31,9473,
Prepare face/oral prosthesis,21086,CPT,,,,,,,,both,,,117516.12,86961.93,74,,86961.93,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,52882.25,45,,52882.25,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,58170.48,49.5,,58170.48,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,606.58,,,606.58,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,82261.28,70,,82261.28,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,326.12,,,326.12,Other,New York Medicaid APG methodology,326.12,,,326.12,Other,100% New York Medicaid APG,326.12,,,326.12,Other,100% New York Medicaid APG,326.12,,,326.12,Other,100% New York Medicaid APG,733.77,,,733.77,Other,225% New York Medicaid APG,498.96,,,498.96,Other,153% New York Medicaid APG,733.77,,,733.77,Other,225% New York Medicaid APG,456.57,,,456.57,Other,140% New York Medicaid APG,733.77,,,733.77,Other,225% New York Medicaid APG,847.91,,,847.91,Other,260% New York Medicaid APG,1056.63,,,1056.63,Other,324% New York Medicaid APG,701.16,,,701.16,Other,215% New York Medicaid APG,701.16,,,701.16,Other,215% New York Medicaid APG,407.65,,,407.65,Other,125% New York Medicaid APG,326.12,86961.93,
Prepare face/oral prosthesis,21087,CPT,,,,,,,,both,,,123177.14,91151.08,74,,91151.08,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,55429.71,45,,55429.71,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,6125,,"100% primary, 50% secondary, 25% supplemental procedure",6125,Other,Blue Cross ASC Grouper,5513,,"100% primary, 50% secondary, 25% supplemental procedure",5513,Other,Blue Cross ASC Grouper,5206,,"100% primary, 50% secondary, 25% supplemental procedure",5206,Other,Blue Cross ASC Grouper,60972.68,49.5,,60972.68,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,606.58,,,606.58,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,86224,70,,86224,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,326.12,,,326.12,Other,New York Medicaid APG methodology,326.12,,,326.12,Other,100% New York Medicaid APG,326.12,,,326.12,Other,100% New York Medicaid APG,326.12,,,326.12,Other,100% New York Medicaid APG,733.77,,,733.77,Other,225% New York Medicaid APG,498.96,,,498.96,Other,153% New York Medicaid APG,733.77,,,733.77,Other,225% New York Medicaid APG,456.57,,,456.57,Other,140% New York Medicaid APG,733.77,,,733.77,Other,225% New York Medicaid APG,847.91,,,847.91,Other,260% New York Medicaid APG,1056.63,,,1056.63,Other,324% New York Medicaid APG,701.16,,,701.16,Other,215% New York Medicaid APG,701.16,,,701.16,Other,215% New York Medicaid APG,407.65,,,407.65,Other,125% New York Medicaid APG,326.12,91151.08,
Prepare face/oral prosthesis,21088,CPT,,,,,,,,both,,,67720.49,50113.16,74,,50113.16,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30474.22,45,,30474.22,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33521.64,49.5,,33521.64,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,279.58,,,279.58,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,47404.34,70,,47404.34,percent of total billed charges,,44018.32,65,,44018.32,percent of total billed charges,,44018.32,65,,44018.32,percent of total billed charges,,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,150.31,,,150.31,Other,New York Medicaid APG methodology,150.31,,,150.31,Other,100% New York Medicaid APG,150.31,,,150.31,Other,100% New York Medicaid APG,150.31,,,150.31,Other,100% New York Medicaid APG,338.21,,,338.21,Other,225% New York Medicaid APG,229.98,,,229.98,Other,153% New York Medicaid APG,338.21,,,338.21,Other,225% New York Medicaid APG,210.44,,,210.44,Other,140% New York Medicaid APG,338.21,,,338.21,Other,225% New York Medicaid APG,390.81,,,390.81,Other,260% New York Medicaid APG,487.02,,,487.02,Other,324% New York Medicaid APG,323.17,,,323.17,Other,215% New York Medicaid APG,323.17,,,323.17,Other,215% New York Medicaid APG,187.89,,,187.89,Other,125% New York Medicaid APG,150.31,50113.16,
Maxillofacial fixation,21100,CPT,,,,,,,,both,,,123177.14,91151.08,74,,91151.08,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,55429.71,45,,55429.71,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,60972.68,49.5,,60972.68,percent of total billed charges,110% of Medicare,83760.46,68,,83760.46,percent of total billed charges,,3028.14,,,3028.14,Other,186% of Medicaid,98541.71,80,,98541.71,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,98541.71,80,,98541.71,percent of total billed charges,,7216,,,7216,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,86224,70,,86224,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,1628.03,,,1628.03,Other,New York Medicaid APG methodology,1628.03,,,1628.03,Other,100% New York Medicaid APG,1628.03,,,1628.03,Other,100% New York Medicaid APG,1628.03,,,1628.03,Other,100% New York Medicaid APG,3663.07,,,3663.07,Other,225% New York Medicaid APG,2490.89,,,2490.89,Other,153% New York Medicaid APG,3663.07,,,3663.07,Other,225% New York Medicaid APG,2279.24,,,2279.24,Other,140% New York Medicaid APG,3663.07,,,3663.07,Other,225% New York Medicaid APG,4232.88,,,4232.88,Other,260% New York Medicaid APG,5274.82,,,5274.82,Other,324% New York Medicaid APG,3500.27,,,3500.27,Other,215% New York Medicaid APG,3500.27,,,3500.27,Other,215% New York Medicaid APG,2035.04,,,2035.04,Other,125% New York Medicaid APG,1628.03,98541.71,
Interdental fixation,21110,CPT,,,,,,,,both,,,32077.39,23737.27,74,,23737.27,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,14434.83,45,,14434.83,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,15878.31,49.5,,15878.31,percent of total billed charges,110% of Medicare,21812.63,68,,21812.63,percent of total billed charges,,428.6,,,428.6,Other,186% of Medicaid,25661.91,80,,25661.91,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,25661.91,80,,25661.91,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,22454.17,70,,22454.17,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,230.43,,,230.43,Other,New York Medicaid APG methodology,230.43,,,230.43,Other,100% New York Medicaid APG,230.43,,,230.43,Other,100% New York Medicaid APG,230.43,,,230.43,Other,100% New York Medicaid APG,518.46,,,518.46,Other,225% New York Medicaid APG,352.55,,,352.55,Other,153% New York Medicaid APG,518.46,,,518.46,Other,225% New York Medicaid APG,322.6,,,322.6,Other,140% New York Medicaid APG,518.46,,,518.46,Other,225% New York Medicaid APG,599.11,,,599.11,Other,260% New York Medicaid APG,746.59,,,746.59,Other,324% New York Medicaid APG,495.42,,,495.42,Other,215% New York Medicaid APG,495.42,,,495.42,Other,215% New York Medicaid APG,288.03,,,288.03,Other,125% New York Medicaid APG,230.43,25661.91,
Injection jaw joint x-ray,21116,CPT,,,,,,,,both,,,32432.1,23999.75,74,,23999.75,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,14594.45,45,,14594.45,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,16053.89,49.5,,16053.89,percent of total billed charges,110% of Medicare,22053.83,68,,22053.83,percent of total billed charges,,966.93,,,966.93,Other,186% of Medicaid,25945.68,80,,25945.68,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,25945.68,80,,25945.68,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,22702.47,70,,22702.47,percent of total billed charges,,218.12,,,218.12,Fee Schedule,,184.87,,,184.87,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,519.86,,,519.86,Other,New York Medicaid APG methodology,519.86,,,519.86,Other,100% New York Medicaid APG,519.86,,,519.86,Other,100% New York Medicaid APG,519.86,,,519.86,Other,100% New York Medicaid APG,1169.68,,,1169.68,Other,225% New York Medicaid APG,795.38,,,795.38,Other,153% New York Medicaid APG,1169.68,,,1169.68,Other,225% New York Medicaid APG,727.8,,,727.8,Other,140% New York Medicaid APG,1169.68,,,1169.68,Other,225% New York Medicaid APG,1351.62,,,1351.62,Other,260% New York Medicaid APG,1684.33,,,1684.33,Other,324% New York Medicaid APG,1117.69,,,1117.69,Other,215% New York Medicaid APG,1117.69,,,1117.69,Other,215% New York Medicaid APG,649.82,,,649.82,Other,125% New York Medicaid APG,184.87,25945.68,
Reconstruction of chin,21120,CPT,,,,,,,,both,,,123177.14,91151.08,74,,91151.08,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,55429.71,45,,55429.71,percent of total billed charges,Medicare Ratio of cost to charges,5954,,"100% primary, 50% supplemental procedure",5954,Other,Aetna ASC Grouper,5359,,"100% primary, 50% supplemental procedure",5359,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,60972.68,49.5,,60972.68,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5482.74,,,5482.74,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,86224,70,,86224,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,2947.71,,,2947.71,Other,New York Medicaid APG methodology,2947.71,,,2947.71,Other,100% New York Medicaid APG,2947.71,,,2947.71,Other,100% New York Medicaid APG,2947.71,,,2947.71,Other,100% New York Medicaid APG,6632.35,,,6632.35,Other,225% New York Medicaid APG,4510,,,4510,Other,153% New York Medicaid APG,6632.35,,,6632.35,Other,225% New York Medicaid APG,4126.79,,,4126.79,Other,140% New York Medicaid APG,6632.35,,,6632.35,Other,225% New York Medicaid APG,7664.04,,,7664.04,Other,260% New York Medicaid APG,9550.58,,,9550.58,Other,324% New York Medicaid APG,6337.58,,,6337.58,Other,215% New York Medicaid APG,6337.58,,,6337.58,Other,215% New York Medicaid APG,3684.64,,,3684.64,Other,125% New York Medicaid APG,2947.71,91151.08,
Reconstruction of chin,21121,CPT,,,,,,,,both,,,67720.49,50113.16,74,,50113.16,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30474.22,45,,30474.22,percent of total billed charges,Medicare Ratio of cost to charges,5954,,"100% primary, 50% supplemental procedure",5954,Other,Aetna ASC Grouper,5359,,"100% primary, 50% supplemental procedure",5359,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,33521.64,49.5,,33521.64,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,4398.22,,,4398.22,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,47404.34,70,,47404.34,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,2364.64,,,2364.64,Other,New York Medicaid APG methodology,2364.64,,,2364.64,Other,100% New York Medicaid APG,2364.64,,,2364.64,Other,100% New York Medicaid APG,2364.64,,,2364.64,Other,100% New York Medicaid APG,5320.43,,,5320.43,Other,225% New York Medicaid APG,3617.89,,,3617.89,Other,153% New York Medicaid APG,5320.43,,,5320.43,Other,225% New York Medicaid APG,3310.49,,,3310.49,Other,140% New York Medicaid APG,5320.43,,,5320.43,Other,225% New York Medicaid APG,6148.05,,,6148.05,Other,260% New York Medicaid APG,7661.42,,,7661.42,Other,324% New York Medicaid APG,5083.97,,,5083.97,Other,215% New York Medicaid APG,5083.97,,,5083.97,Other,215% New York Medicaid APG,2955.8,,,2955.8,Other,125% New York Medicaid APG,2364.64,50113.16,
Reconstruction of chin,21122,CPT,,,,,,,,both,,,123177.14,91151.08,74,,91151.08,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,55429.71,45,,55429.71,percent of total billed charges,Medicare Ratio of cost to charges,5954,,"100% primary, 50% supplemental procedure",5954,Other,Aetna ASC Grouper,5359,,"100% primary, 50% supplemental procedure",5359,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,60972.68,49.5,,60972.68,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5482.74,,,5482.74,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,86224,70,,86224,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,2947.71,,,2947.71,Other,New York Medicaid APG methodology,2947.71,,,2947.71,Other,100% New York Medicaid APG,2947.71,,,2947.71,Other,100% New York Medicaid APG,2947.71,,,2947.71,Other,100% New York Medicaid APG,6632.35,,,6632.35,Other,225% New York Medicaid APG,4510,,,4510,Other,153% New York Medicaid APG,6632.35,,,6632.35,Other,225% New York Medicaid APG,4126.79,,,4126.79,Other,140% New York Medicaid APG,6632.35,,,6632.35,Other,225% New York Medicaid APG,7664.04,,,7664.04,Other,260% New York Medicaid APG,9550.58,,,9550.58,Other,324% New York Medicaid APG,6337.58,,,6337.58,Other,215% New York Medicaid APG,6337.58,,,6337.58,Other,215% New York Medicaid APG,3684.64,,,3684.64,Other,125% New York Medicaid APG,2947.71,91151.08,
Reconstruction of chin,21123,CPT,,,,,,,,both,,,67720.49,50113.16,74,,50113.16,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30474.22,45,,30474.22,percent of total billed charges,Medicare Ratio of cost to charges,5954,,"100% primary, 50% supplemental procedure",5954,Other,Aetna ASC Grouper,5359,,"100% primary, 50% supplemental procedure",5359,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,33521.64,49.5,,33521.64,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,4398.22,,,4398.22,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,47404.34,70,,47404.34,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,2364.64,,,2364.64,Other,New York Medicaid APG methodology,2364.64,,,2364.64,Other,100% New York Medicaid APG,2364.64,,,2364.64,Other,100% New York Medicaid APG,2364.64,,,2364.64,Other,100% New York Medicaid APG,5320.43,,,5320.43,Other,225% New York Medicaid APG,3617.89,,,3617.89,Other,153% New York Medicaid APG,5320.43,,,5320.43,Other,225% New York Medicaid APG,3310.49,,,3310.49,Other,140% New York Medicaid APG,5320.43,,,5320.43,Other,225% New York Medicaid APG,6148.05,,,6148.05,Other,260% New York Medicaid APG,7661.42,,,7661.42,Other,324% New York Medicaid APG,5083.97,,,5083.97,Other,215% New York Medicaid APG,5083.97,,,5083.97,Other,215% New York Medicaid APG,2955.8,,,2955.8,Other,125% New York Medicaid APG,2364.64,50113.16,
Augmentation lower jaw bone,21125,CPT,,,,,,,,both,,,123177.14,91151.08,74,,91151.08,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,55429.71,45,,55429.71,percent of total billed charges,Medicare Ratio of cost to charges,5954,,"100% primary, 50% supplemental procedure",5954,Other,Aetna ASC Grouper,5359,,"100% primary, 50% supplemental procedure",5359,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,60972.68,49.5,,60972.68,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5482.74,,,5482.74,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,86224,70,,86224,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,2947.71,,,2947.71,Other,New York Medicaid APG methodology,2947.71,,,2947.71,Other,100% New York Medicaid APG,2947.71,,,2947.71,Other,100% New York Medicaid APG,2947.71,,,2947.71,Other,100% New York Medicaid APG,6632.35,,,6632.35,Other,225% New York Medicaid APG,4510,,,4510,Other,153% New York Medicaid APG,6632.35,,,6632.35,Other,225% New York Medicaid APG,4126.79,,,4126.79,Other,140% New York Medicaid APG,6632.35,,,6632.35,Other,225% New York Medicaid APG,7664.04,,,7664.04,Other,260% New York Medicaid APG,9550.58,,,9550.58,Other,324% New York Medicaid APG,6337.58,,,6337.58,Other,215% New York Medicaid APG,6337.58,,,6337.58,Other,215% New York Medicaid APG,3684.64,,,3684.64,Other,125% New York Medicaid APG,2947.71,91151.08,
Augmentation lower jaw bone,21127,CPT,,,,,,,,both,,,123177.14,91151.08,74,,91151.08,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,55429.71,45,,55429.71,percent of total billed charges,Medicare Ratio of cost to charges,5459,,"100% primary, 50% supplemental procedure",5459,Other,Aetna ASC Grouper,4913,,"100% primary, 50% supplemental procedure",4913,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,60972.68,49.5,,60972.68,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5482.74,,,5482.74,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,86224,70,,86224,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,2947.71,,,2947.71,Other,New York Medicaid APG methodology,2947.71,,,2947.71,Other,100% New York Medicaid APG,2947.71,,,2947.71,Other,100% New York Medicaid APG,2947.71,,,2947.71,Other,100% New York Medicaid APG,6632.35,,,6632.35,Other,225% New York Medicaid APG,4510,,,4510,Other,153% New York Medicaid APG,6632.35,,,6632.35,Other,225% New York Medicaid APG,4126.79,,,4126.79,Other,140% New York Medicaid APG,6632.35,,,6632.35,Other,225% New York Medicaid APG,7664.04,,,7664.04,Other,260% New York Medicaid APG,9550.58,,,9550.58,Other,324% New York Medicaid APG,6337.58,,,6337.58,Other,215% New York Medicaid APG,6337.58,,,6337.58,Other,215% New York Medicaid APG,3684.64,,,3684.64,Other,125% New York Medicaid APG,2947.71,91151.08,
Reduction of forehead,21137,CPT,,,,,,,,both,,,67720.49,50113.16,74,,50113.16,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30474.22,45,,30474.22,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,33521.64,49.5,,33521.64,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5482.74,,,5482.74,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,47404.34,70,,47404.34,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,2947.71,,,2947.71,Other,New York Medicaid APG methodology,2947.71,,,2947.71,Other,100% New York Medicaid APG,2947.71,,,2947.71,Other,100% New York Medicaid APG,2947.71,,,2947.71,Other,100% New York Medicaid APG,6632.35,,,6632.35,Other,225% New York Medicaid APG,4510,,,4510,Other,153% New York Medicaid APG,6632.35,,,6632.35,Other,225% New York Medicaid APG,4126.79,,,4126.79,Other,140% New York Medicaid APG,6632.35,,,6632.35,Other,225% New York Medicaid APG,7664.04,,,7664.04,Other,260% New York Medicaid APG,9550.58,,,9550.58,Other,324% New York Medicaid APG,6337.58,,,6337.58,Other,215% New York Medicaid APG,6337.58,,,6337.58,Other,215% New York Medicaid APG,3684.64,,,3684.64,Other,125% New York Medicaid APG,2947.71,50113.16,
Reduction of forehead,21138,CPT,,,,,,,,both,,,123177.14,91151.08,74,,91151.08,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,55429.71,45,,55429.71,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,60972.68,49.5,,60972.68,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5482.74,,,5482.74,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,86224,70,,86224,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,2947.71,,,2947.71,Other,New York Medicaid APG methodology,2947.71,,,2947.71,Other,100% New York Medicaid APG,2947.71,,,2947.71,Other,100% New York Medicaid APG,2947.71,,,2947.71,Other,100% New York Medicaid APG,6632.35,,,6632.35,Other,225% New York Medicaid APG,4510,,,4510,Other,153% New York Medicaid APG,6632.35,,,6632.35,Other,225% New York Medicaid APG,4126.79,,,4126.79,Other,140% New York Medicaid APG,6632.35,,,6632.35,Other,225% New York Medicaid APG,7664.04,,,7664.04,Other,260% New York Medicaid APG,9550.58,,,9550.58,Other,324% New York Medicaid APG,6337.58,,,6337.58,Other,215% New York Medicaid APG,6337.58,,,6337.58,Other,215% New York Medicaid APG,3684.64,,,3684.64,Other,125% New York Medicaid APG,2947.71,91151.08,
Reduction of forehead,21139,CPT,,,,,,,,both,,,123177.14,91151.08,74,,91151.08,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,55429.71,45,,55429.71,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,60972.68,49.5,,60972.68,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5482.74,,,5482.74,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,86224,70,,86224,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,2947.71,,,2947.71,Other,New York Medicaid APG methodology,2947.71,,,2947.71,Other,100% New York Medicaid APG,2947.71,,,2947.71,Other,100% New York Medicaid APG,2947.71,,,2947.71,Other,100% New York Medicaid APG,6632.35,,,6632.35,Other,225% New York Medicaid APG,4510,,,4510,Other,153% New York Medicaid APG,6632.35,,,6632.35,Other,225% New York Medicaid APG,4126.79,,,4126.79,Other,140% New York Medicaid APG,6632.35,,,6632.35,Other,225% New York Medicaid APG,7664.04,,,7664.04,Other,260% New York Medicaid APG,9550.58,,,9550.58,Other,324% New York Medicaid APG,6337.58,,,6337.58,Other,215% New York Medicaid APG,6337.58,,,6337.58,Other,215% New York Medicaid APG,3684.64,,,3684.64,Other,125% New York Medicaid APG,2947.71,91151.08,
Lefort ii anterior intrusion,21150,CPT,,,,,,,,both,,,123177.14,91151.08,74,,91151.08,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,55429.71,45,,55429.71,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,60972.68,49.5,,60972.68,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5482.74,,,5482.74,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,86224,70,,86224,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,2947.71,,,2947.71,Other,New York Medicaid APG methodology,2947.71,,,2947.71,Other,100% New York Medicaid APG,2947.71,,,2947.71,Other,100% New York Medicaid APG,2947.71,,,2947.71,Other,100% New York Medicaid APG,6632.35,,,6632.35,Other,225% New York Medicaid APG,4510,,,4510,Other,153% New York Medicaid APG,6632.35,,,6632.35,Other,225% New York Medicaid APG,4126.79,,,4126.79,Other,140% New York Medicaid APG,6632.35,,,6632.35,Other,225% New York Medicaid APG,7664.04,,,7664.04,Other,260% New York Medicaid APG,9550.58,,,9550.58,Other,324% New York Medicaid APG,6337.58,,,6337.58,Other,215% New York Medicaid APG,6337.58,,,6337.58,Other,215% New York Medicaid APG,3684.64,,,3684.64,Other,125% New York Medicaid APG,2947.71,91151.08,
Reconstruct orbit/forehead,21172,CPT,,,,,,,,both,,,123177.14,91151.08,74,,91151.08,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,55429.71,45,,55429.71,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,60972.68,49.5,,60972.68,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5482.74,,,5482.74,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,86224,70,,86224,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,2947.71,,,2947.71,Other,New York Medicaid APG methodology,2947.71,,,2947.71,Other,100% New York Medicaid APG,2947.71,,,2947.71,Other,100% New York Medicaid APG,2947.71,,,2947.71,Other,100% New York Medicaid APG,6632.35,,,6632.35,Other,225% New York Medicaid APG,4510,,,4510,Other,153% New York Medicaid APG,6632.35,,,6632.35,Other,225% New York Medicaid APG,4126.79,,,4126.79,Other,140% New York Medicaid APG,6632.35,,,6632.35,Other,225% New York Medicaid APG,7664.04,,,7664.04,Other,260% New York Medicaid APG,9550.58,,,9550.58,Other,324% New York Medicaid APG,6337.58,,,6337.58,Other,215% New York Medicaid APG,6337.58,,,6337.58,Other,215% New York Medicaid APG,3684.64,,,3684.64,Other,125% New York Medicaid APG,2947.71,91151.08,
Reconstruct orbit/forehead,21175,CPT,,,,,,,,both,,,123177.14,91151.08,74,,91151.08,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,55429.71,45,,55429.71,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,60972.68,49.5,,60972.68,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5482.74,,,5482.74,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,86224,70,,86224,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,2947.71,,,2947.71,Other,New York Medicaid APG methodology,2947.71,,,2947.71,Other,100% New York Medicaid APG,2947.71,,,2947.71,Other,100% New York Medicaid APG,2947.71,,,2947.71,Other,100% New York Medicaid APG,6632.35,,,6632.35,Other,225% New York Medicaid APG,4510,,,4510,Other,153% New York Medicaid APG,6632.35,,,6632.35,Other,225% New York Medicaid APG,4126.79,,,4126.79,Other,140% New York Medicaid APG,6632.35,,,6632.35,Other,225% New York Medicaid APG,7664.04,,,7664.04,Other,260% New York Medicaid APG,9550.58,,,9550.58,Other,324% New York Medicaid APG,6337.58,,,6337.58,Other,215% New York Medicaid APG,6337.58,,,6337.58,Other,215% New York Medicaid APG,3684.64,,,3684.64,Other,125% New York Medicaid APG,2947.71,91151.08,
Contour cranial bone lesion,21181,CPT,,,,,,,,both,,,123177.14,91151.08,74,,91151.08,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,55429.71,45,,55429.71,percent of total billed charges,Medicare Ratio of cost to charges,5954,,"100% primary, 50% supplemental procedure",5954,Other,Aetna ASC Grouper,5359,,"100% primary, 50% supplemental procedure",5359,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,60972.68,49.5,,60972.68,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,4398.22,,,4398.22,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,86224,70,,86224,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,2364.64,,,2364.64,Other,New York Medicaid APG methodology,2364.64,,,2364.64,Other,100% New York Medicaid APG,2364.64,,,2364.64,Other,100% New York Medicaid APG,2364.64,,,2364.64,Other,100% New York Medicaid APG,5320.43,,,5320.43,Other,225% New York Medicaid APG,3617.89,,,3617.89,Other,153% New York Medicaid APG,5320.43,,,5320.43,Other,225% New York Medicaid APG,3310.49,,,3310.49,Other,140% New York Medicaid APG,5320.43,,,5320.43,Other,225% New York Medicaid APG,6148.05,,,6148.05,Other,260% New York Medicaid APG,7661.42,,,7661.42,Other,324% New York Medicaid APG,5083.97,,,5083.97,Other,215% New York Medicaid APG,5083.97,,,5083.97,Other,215% New York Medicaid APG,2955.8,,,2955.8,Other,125% New York Medicaid APG,2364.64,91151.08,
Reconst lwr jaw w/o graft,21193,CPT,,,,,,,,both,,,123177.14,91151.08,74,,91151.08,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,55429.71,45,,55429.71,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,60972.68,49.5,,60972.68,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,4398.22,,,4398.22,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,86224,70,,86224,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,2364.64,,,2364.64,Other,New York Medicaid APG methodology,2364.64,,,2364.64,Other,100% New York Medicaid APG,2364.64,,,2364.64,Other,100% New York Medicaid APG,2364.64,,,2364.64,Other,100% New York Medicaid APG,5320.43,,,5320.43,Other,225% New York Medicaid APG,3617.89,,,3617.89,Other,153% New York Medicaid APG,5320.43,,,5320.43,Other,225% New York Medicaid APG,3310.49,,,3310.49,Other,140% New York Medicaid APG,5320.43,,,5320.43,Other,225% New York Medicaid APG,6148.05,,,6148.05,Other,260% New York Medicaid APG,7661.42,,,7661.42,Other,324% New York Medicaid APG,5083.97,,,5083.97,Other,215% New York Medicaid APG,5083.97,,,5083.97,Other,215% New York Medicaid APG,2955.8,,,2955.8,Other,125% New York Medicaid APG,2364.64,91151.08,
Reconst lwr jaw w/o fixation,21195,CPT,,,,,,,,both,,,123177.14,91151.08,74,,91151.08,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,55429.71,45,,55429.71,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,60972.68,49.5,,60972.68,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5482.74,,,5482.74,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,86224,70,,86224,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,2947.71,,,2947.71,Other,New York Medicaid APG methodology,2947.71,,,2947.71,Other,100% New York Medicaid APG,2947.71,,,2947.71,Other,100% New York Medicaid APG,2947.71,,,2947.71,Other,100% New York Medicaid APG,6632.35,,,6632.35,Other,225% New York Medicaid APG,4510,,,4510,Other,153% New York Medicaid APG,6632.35,,,6632.35,Other,225% New York Medicaid APG,4126.79,,,4126.79,Other,140% New York Medicaid APG,6632.35,,,6632.35,Other,225% New York Medicaid APG,7664.04,,,7664.04,Other,260% New York Medicaid APG,9550.58,,,9550.58,Other,324% New York Medicaid APG,6337.58,,,6337.58,Other,215% New York Medicaid APG,6337.58,,,6337.58,Other,215% New York Medicaid APG,3684.64,,,3684.64,Other,125% New York Medicaid APG,2947.71,91151.08,
Reconstr lwr jaw segment,21198,CPT,,,,,,,,both,,,123177.14,91151.08,74,,91151.08,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,55429.71,45,,55429.71,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,60972.68,49.5,,60972.68,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5482.74,,,5482.74,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,86224,70,,86224,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,2947.71,,,2947.71,Other,New York Medicaid APG methodology,2947.71,,,2947.71,Other,100% New York Medicaid APG,2947.71,,,2947.71,Other,100% New York Medicaid APG,2947.71,,,2947.71,Other,100% New York Medicaid APG,6632.35,,,6632.35,Other,225% New York Medicaid APG,4510,,,4510,Other,153% New York Medicaid APG,6632.35,,,6632.35,Other,225% New York Medicaid APG,4126.79,,,4126.79,Other,140% New York Medicaid APG,6632.35,,,6632.35,Other,225% New York Medicaid APG,7664.04,,,7664.04,Other,260% New York Medicaid APG,9550.58,,,9550.58,Other,324% New York Medicaid APG,6337.58,,,6337.58,Other,215% New York Medicaid APG,6337.58,,,6337.58,Other,215% New York Medicaid APG,3684.64,,,3684.64,Other,125% New York Medicaid APG,2947.71,91151.08,
Reconstr lwr jaw w/advance,21199,CPT,,,,,,,,both,,,123177.14,91151.08,74,,91151.08,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,55429.71,45,,55429.71,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,6125,,"100% primary, 50% secondary, 25% supplemental procedure",6125,Other,Blue Cross ASC Grouper,5513,,"100% primary, 50% secondary, 25% supplemental procedure",5513,Other,Blue Cross ASC Grouper,5206,,"100% primary, 50% secondary, 25% supplemental procedure",5206,Other,Blue Cross ASC Grouper,60972.68,49.5,,60972.68,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,4398.22,,,4398.22,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,86224,70,,86224,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,2364.64,,,2364.64,Other,New York Medicaid APG methodology,2364.64,,,2364.64,Other,100% New York Medicaid APG,2364.64,,,2364.64,Other,100% New York Medicaid APG,2364.64,,,2364.64,Other,100% New York Medicaid APG,5320.43,,,5320.43,Other,225% New York Medicaid APG,3617.89,,,3617.89,Other,153% New York Medicaid APG,5320.43,,,5320.43,Other,225% New York Medicaid APG,3310.49,,,3310.49,Other,140% New York Medicaid APG,5320.43,,,5320.43,Other,225% New York Medicaid APG,6148.05,,,6148.05,Other,260% New York Medicaid APG,7661.42,,,7661.42,Other,324% New York Medicaid APG,5083.97,,,5083.97,Other,215% New York Medicaid APG,5083.97,,,5083.97,Other,215% New York Medicaid APG,2955.8,,,2955.8,Other,125% New York Medicaid APG,2364.64,91151.08,
Reconstruct upper jaw bone,21206,CPT,,,,,,,,both,,,123177.14,91151.08,74,,91151.08,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,55429.71,45,,55429.71,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,60972.68,49.5,,60972.68,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5482.74,,,5482.74,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,86224,70,,86224,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,2947.71,,,2947.71,Other,New York Medicaid APG methodology,2947.71,,,2947.71,Other,100% New York Medicaid APG,2947.71,,,2947.71,Other,100% New York Medicaid APG,2947.71,,,2947.71,Other,100% New York Medicaid APG,6632.35,,,6632.35,Other,225% New York Medicaid APG,4510,,,4510,Other,153% New York Medicaid APG,6632.35,,,6632.35,Other,225% New York Medicaid APG,4126.79,,,4126.79,Other,140% New York Medicaid APG,6632.35,,,6632.35,Other,225% New York Medicaid APG,7664.04,,,7664.04,Other,260% New York Medicaid APG,9550.58,,,9550.58,Other,324% New York Medicaid APG,6337.58,,,6337.58,Other,215% New York Medicaid APG,6337.58,,,6337.58,Other,215% New York Medicaid APG,3684.64,,,3684.64,Other,125% New York Medicaid APG,2947.71,91151.08,
Augmentation of facial bones,21208,CPT,,,,,,,,both,,,123177.14,91151.08,74,,91151.08,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,55429.71,45,,55429.71,percent of total billed charges,Medicare Ratio of cost to charges,5954,,"100% primary, 50% supplemental procedure",5954,Other,Aetna ASC Grouper,5359,,"100% primary, 50% supplemental procedure",5359,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,60972.68,49.5,,60972.68,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5482.74,,,5482.74,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,86224,70,,86224,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,2947.71,,,2947.71,Other,New York Medicaid APG methodology,2947.71,,,2947.71,Other,100% New York Medicaid APG,2947.71,,,2947.71,Other,100% New York Medicaid APG,2947.71,,,2947.71,Other,100% New York Medicaid APG,6632.35,,,6632.35,Other,225% New York Medicaid APG,4510,,,4510,Other,153% New York Medicaid APG,6632.35,,,6632.35,Other,225% New York Medicaid APG,4126.79,,,4126.79,Other,140% New York Medicaid APG,6632.35,,,6632.35,Other,225% New York Medicaid APG,7664.04,,,7664.04,Other,260% New York Medicaid APG,9550.58,,,9550.58,Other,324% New York Medicaid APG,6337.58,,,6337.58,Other,215% New York Medicaid APG,6337.58,,,6337.58,Other,215% New York Medicaid APG,3684.64,,,3684.64,Other,125% New York Medicaid APG,2947.71,91151.08,
Reduction of facial bones,21209,CPT,,,,,,,,both,,,123177.14,91151.08,74,,91151.08,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,55429.71,45,,55429.71,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,60972.68,49.5,,60972.68,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5482.74,,,5482.74,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,86224,70,,86224,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,2947.71,,,2947.71,Other,New York Medicaid APG methodology,2947.71,,,2947.71,Other,100% New York Medicaid APG,2947.71,,,2947.71,Other,100% New York Medicaid APG,2947.71,,,2947.71,Other,100% New York Medicaid APG,6632.35,,,6632.35,Other,225% New York Medicaid APG,4510,,,4510,Other,153% New York Medicaid APG,6632.35,,,6632.35,Other,225% New York Medicaid APG,4126.79,,,4126.79,Other,140% New York Medicaid APG,6632.35,,,6632.35,Other,225% New York Medicaid APG,7664.04,,,7664.04,Other,260% New York Medicaid APG,9550.58,,,9550.58,Other,324% New York Medicaid APG,6337.58,,,6337.58,Other,215% New York Medicaid APG,6337.58,,,6337.58,Other,215% New York Medicaid APG,3684.64,,,3684.64,Other,125% New York Medicaid APG,2947.71,91151.08,
Face bone graft,21210,CPT,,,,,,,,both,,,123177.14,91151.08,74,,91151.08,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,55429.71,45,,55429.71,percent of total billed charges,Medicare Ratio of cost to charges,5954,,"100% primary, 50% supplemental procedure",5954,Other,Aetna ASC Grouper,5359,,"100% primary, 50% supplemental procedure",5359,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,60972.68,49.5,,60972.68,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5482.74,,,5482.74,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,86224,70,,86224,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,2947.71,,,2947.71,Other,New York Medicaid APG methodology,2947.71,,,2947.71,Other,100% New York Medicaid APG,2947.71,,,2947.71,Other,100% New York Medicaid APG,2947.71,,,2947.71,Other,100% New York Medicaid APG,6632.35,,,6632.35,Other,225% New York Medicaid APG,4510,,,4510,Other,153% New York Medicaid APG,6632.35,,,6632.35,Other,225% New York Medicaid APG,4126.79,,,4126.79,Other,140% New York Medicaid APG,6632.35,,,6632.35,Other,225% New York Medicaid APG,7664.04,,,7664.04,Other,260% New York Medicaid APG,9550.58,,,9550.58,Other,324% New York Medicaid APG,6337.58,,,6337.58,Other,215% New York Medicaid APG,6337.58,,,6337.58,Other,215% New York Medicaid APG,3684.64,,,3684.64,Other,125% New York Medicaid APG,2947.71,91151.08,
Lower jaw bone graft,21215,CPT,,,,,,,,both,,,123177.14,91151.08,74,,91151.08,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,55429.71,45,,55429.71,percent of total billed charges,Medicare Ratio of cost to charges,5954,,"100% primary, 50% supplemental procedure",5954,Other,Aetna ASC Grouper,5359,,"100% primary, 50% supplemental procedure",5359,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,60972.68,49.5,,60972.68,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5482.74,,,5482.74,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,86224,70,,86224,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,2947.71,,,2947.71,Other,New York Medicaid APG methodology,2947.71,,,2947.71,Other,100% New York Medicaid APG,2947.71,,,2947.71,Other,100% New York Medicaid APG,2947.71,,,2947.71,Other,100% New York Medicaid APG,6632.35,,,6632.35,Other,225% New York Medicaid APG,4510,,,4510,Other,153% New York Medicaid APG,6632.35,,,6632.35,Other,225% New York Medicaid APG,4126.79,,,4126.79,Other,140% New York Medicaid APG,6632.35,,,6632.35,Other,225% New York Medicaid APG,7664.04,,,7664.04,Other,260% New York Medicaid APG,9550.58,,,9550.58,Other,324% New York Medicaid APG,6337.58,,,6337.58,Other,215% New York Medicaid APG,6337.58,,,6337.58,Other,215% New York Medicaid APG,3684.64,,,3684.64,Other,125% New York Medicaid APG,2947.71,91151.08,
Rib cartilage graft,21230,CPT,,,,,,,,both,,,123177.14,91151.08,74,,91151.08,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,55429.71,45,,55429.71,percent of total billed charges,Medicare Ratio of cost to charges,5954,,"100% primary, 50% supplemental procedure",5954,Other,Aetna ASC Grouper,5359,,"100% primary, 50% supplemental procedure",5359,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,60972.68,49.5,,60972.68,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5482.74,,,5482.74,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,86224,70,,86224,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,2947.71,,,2947.71,Other,New York Medicaid APG methodology,2947.71,,,2947.71,Other,100% New York Medicaid APG,2947.71,,,2947.71,Other,100% New York Medicaid APG,2947.71,,,2947.71,Other,100% New York Medicaid APG,6632.35,,,6632.35,Other,225% New York Medicaid APG,4510,,,4510,Other,153% New York Medicaid APG,6632.35,,,6632.35,Other,225% New York Medicaid APG,4126.79,,,4126.79,Other,140% New York Medicaid APG,6632.35,,,6632.35,Other,225% New York Medicaid APG,7664.04,,,7664.04,Other,260% New York Medicaid APG,9550.58,,,9550.58,Other,324% New York Medicaid APG,6337.58,,,6337.58,Other,215% New York Medicaid APG,6337.58,,,6337.58,Other,215% New York Medicaid APG,3684.64,,,3684.64,Other,125% New York Medicaid APG,2947.71,91151.08,
Ear cartilage graft,21235,CPT,,,,,,,,both,,,43855.99,32453.43,74,,32453.43,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,19735.2,45,,19735.2,percent of total billed charges,Medicare Ratio of cost to charges,5954,,"100% primary, 50% supplemental procedure",5954,Other,Aetna ASC Grouper,5359,,"100% primary, 50% supplemental procedure",5359,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,21708.72,49.5,,21708.72,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,4398.22,,,4398.22,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,30699.19,70,,30699.19,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,2364.64,,,2364.64,Other,New York Medicaid APG methodology,2364.64,,,2364.64,Other,100% New York Medicaid APG,2364.64,,,2364.64,Other,100% New York Medicaid APG,2364.64,,,2364.64,Other,100% New York Medicaid APG,5320.43,,,5320.43,Other,225% New York Medicaid APG,3617.89,,,3617.89,Other,153% New York Medicaid APG,5320.43,,,5320.43,Other,225% New York Medicaid APG,3310.49,,,3310.49,Other,140% New York Medicaid APG,5320.43,,,5320.43,Other,225% New York Medicaid APG,6148.05,,,6148.05,Other,260% New York Medicaid APG,7661.42,,,7661.42,Other,324% New York Medicaid APG,5083.97,,,5083.97,Other,215% New York Medicaid APG,5083.97,,,5083.97,Other,215% New York Medicaid APG,2955.8,,,2955.8,Other,125% New York Medicaid APG,2364.64,32453.43,
Reconstruction of jaw joint,21240,CPT,,,,,,,,both,,,123177.14,91151.08,74,,91151.08,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,55429.71,45,,55429.71,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,60972.68,49.5,,60972.68,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5482.74,,,5482.74,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,86224,70,,86224,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,2947.71,,,2947.71,Other,New York Medicaid APG methodology,2947.71,,,2947.71,Other,100% New York Medicaid APG,2947.71,,,2947.71,Other,100% New York Medicaid APG,2947.71,,,2947.71,Other,100% New York Medicaid APG,6632.35,,,6632.35,Other,225% New York Medicaid APG,4510,,,4510,Other,153% New York Medicaid APG,6632.35,,,6632.35,Other,225% New York Medicaid APG,4126.79,,,4126.79,Other,140% New York Medicaid APG,6632.35,,,6632.35,Other,225% New York Medicaid APG,7664.04,,,7664.04,Other,260% New York Medicaid APG,9550.58,,,9550.58,Other,324% New York Medicaid APG,6337.58,,,6337.58,Other,215% New York Medicaid APG,6337.58,,,6337.58,Other,215% New York Medicaid APG,3684.64,,,3684.64,Other,125% New York Medicaid APG,2947.71,91151.08,
Reconstruction of jaw joint,21242,CPT,,,,,,,,both,,,123177.14,91151.08,74,,91151.08,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,55429.71,45,,55429.71,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,60972.68,49.5,,60972.68,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5482.74,,,5482.74,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,86224,70,,86224,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,2947.71,,,2947.71,Other,New York Medicaid APG methodology,2947.71,,,2947.71,Other,100% New York Medicaid APG,2947.71,,,2947.71,Other,100% New York Medicaid APG,2947.71,,,2947.71,Other,100% New York Medicaid APG,6632.35,,,6632.35,Other,225% New York Medicaid APG,4510,,,4510,Other,153% New York Medicaid APG,6632.35,,,6632.35,Other,225% New York Medicaid APG,4126.79,,,4126.79,Other,140% New York Medicaid APG,6632.35,,,6632.35,Other,225% New York Medicaid APG,7664.04,,,7664.04,Other,260% New York Medicaid APG,9550.58,,,9550.58,Other,324% New York Medicaid APG,6337.58,,,6337.58,Other,215% New York Medicaid APG,6337.58,,,6337.58,Other,215% New York Medicaid APG,3684.64,,,3684.64,Other,125% New York Medicaid APG,2947.71,91151.08,
Reconstruction of jaw joint,21243,CPT,,,,,,,,both,,,391985.94,290069.6,74,,290069.6,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,176393.67,45,,176393.67,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,194033.04,49.5,,194033.04,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5965.25,,,5965.25,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,274390.16,70,,274390.16,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,3207.13,,,3207.13,Other,New York Medicaid APG methodology,3207.13,,,3207.13,Other,100% New York Medicaid APG,3207.13,,,3207.13,Other,100% New York Medicaid APG,3207.13,,,3207.13,Other,100% New York Medicaid APG,7216.03,,,7216.03,Other,225% New York Medicaid APG,4906.9,,,4906.9,Other,153% New York Medicaid APG,7216.03,,,7216.03,Other,225% New York Medicaid APG,4489.98,,,4489.98,Other,140% New York Medicaid APG,7216.03,,,7216.03,Other,225% New York Medicaid APG,8338.53,,,8338.53,Other,260% New York Medicaid APG,10391.09,,,10391.09,Other,324% New York Medicaid APG,6895.32,,,6895.32,Other,215% New York Medicaid APG,6895.32,,,6895.32,Other,215% New York Medicaid APG,4008.91,,,4008.91,Other,125% New York Medicaid APG,3207.13,290069.6,
Reconstruction of lower jaw,21244,CPT,,,,,,,,both,,,123177.14,91151.08,74,,91151.08,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,55429.71,45,,55429.71,percent of total billed charges,Medicare Ratio of cost to charges,5954,,"100% primary, 50% supplemental procedure",5954,Other,Aetna ASC Grouper,5359,,"100% primary, 50% supplemental procedure",5359,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,60972.68,49.5,,60972.68,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5482.74,,,5482.74,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,86224,70,,86224,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,2947.71,,,2947.71,Other,New York Medicaid APG methodology,2947.71,,,2947.71,Other,100% New York Medicaid APG,2947.71,,,2947.71,Other,100% New York Medicaid APG,2947.71,,,2947.71,Other,100% New York Medicaid APG,6632.35,,,6632.35,Other,225% New York Medicaid APG,4510,,,4510,Other,153% New York Medicaid APG,6632.35,,,6632.35,Other,225% New York Medicaid APG,4126.79,,,4126.79,Other,140% New York Medicaid APG,6632.35,,,6632.35,Other,225% New York Medicaid APG,7664.04,,,7664.04,Other,260% New York Medicaid APG,9550.58,,,9550.58,Other,324% New York Medicaid APG,6337.58,,,6337.58,Other,215% New York Medicaid APG,6337.58,,,6337.58,Other,215% New York Medicaid APG,3684.64,,,3684.64,Other,125% New York Medicaid APG,2947.71,91151.08,
Reconstruction of jaw,21245,CPT,,,,,,,,both,,,123177.14,91151.08,74,,91151.08,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,55429.71,45,,55429.71,percent of total billed charges,Medicare Ratio of cost to charges,5954,,"100% primary, 50% supplemental procedure",5954,Other,Aetna ASC Grouper,5359,,"100% primary, 50% supplemental procedure",5359,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,60972.68,49.5,,60972.68,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5482.74,,,5482.74,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,86224,70,,86224,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,2947.71,,,2947.71,Other,New York Medicaid APG methodology,2947.71,,,2947.71,Other,100% New York Medicaid APG,2947.71,,,2947.71,Other,100% New York Medicaid APG,2947.71,,,2947.71,Other,100% New York Medicaid APG,6632.35,,,6632.35,Other,225% New York Medicaid APG,4510,,,4510,Other,153% New York Medicaid APG,6632.35,,,6632.35,Other,225% New York Medicaid APG,4126.79,,,4126.79,Other,140% New York Medicaid APG,6632.35,,,6632.35,Other,225% New York Medicaid APG,7664.04,,,7664.04,Other,260% New York Medicaid APG,9550.58,,,9550.58,Other,324% New York Medicaid APG,6337.58,,,6337.58,Other,215% New York Medicaid APG,6337.58,,,6337.58,Other,215% New York Medicaid APG,3684.64,,,3684.64,Other,125% New York Medicaid APG,2947.71,91151.08,
Reconstruction of jaw,21246,CPT,,,,,,,,both,,,123177.14,91151.08,74,,91151.08,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,55429.71,45,,55429.71,percent of total billed charges,Medicare Ratio of cost to charges,5954,,"100% primary, 50% supplemental procedure",5954,Other,Aetna ASC Grouper,5359,,"100% primary, 50% supplemental procedure",5359,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,60972.68,49.5,,60972.68,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5482.74,,,5482.74,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,86224,70,,86224,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,2947.71,,,2947.71,Other,New York Medicaid APG methodology,2947.71,,,2947.71,Other,100% New York Medicaid APG,2947.71,,,2947.71,Other,100% New York Medicaid APG,2947.71,,,2947.71,Other,100% New York Medicaid APG,6632.35,,,6632.35,Other,225% New York Medicaid APG,4510,,,4510,Other,153% New York Medicaid APG,6632.35,,,6632.35,Other,225% New York Medicaid APG,4126.79,,,4126.79,Other,140% New York Medicaid APG,6632.35,,,6632.35,Other,225% New York Medicaid APG,7664.04,,,7664.04,Other,260% New York Medicaid APG,9550.58,,,9550.58,Other,324% New York Medicaid APG,6337.58,,,6337.58,Other,215% New York Medicaid APG,6337.58,,,6337.58,Other,215% New York Medicaid APG,3684.64,,,3684.64,Other,125% New York Medicaid APG,2947.71,91151.08,
Reconstruction of jaw,21248,CPT,,,,,,,,both,,,123177.14,91151.08,74,,91151.08,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,55429.71,45,,55429.71,percent of total billed charges,Medicare Ratio of cost to charges,5954,,"100% primary, 50% supplemental procedure",5954,Other,Aetna ASC Grouper,5359,,"100% primary, 50% supplemental procedure",5359,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,60972.68,49.5,,60972.68,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5482.74,,,5482.74,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,86224,70,,86224,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,2947.71,,,2947.71,Other,New York Medicaid APG methodology,2947.71,,,2947.71,Other,100% New York Medicaid APG,2947.71,,,2947.71,Other,100% New York Medicaid APG,2947.71,,,2947.71,Other,100% New York Medicaid APG,6632.35,,,6632.35,Other,225% New York Medicaid APG,4510,,,4510,Other,153% New York Medicaid APG,6632.35,,,6632.35,Other,225% New York Medicaid APG,4126.79,,,4126.79,Other,140% New York Medicaid APG,6632.35,,,6632.35,Other,225% New York Medicaid APG,7664.04,,,7664.04,Other,260% New York Medicaid APG,9550.58,,,9550.58,Other,324% New York Medicaid APG,6337.58,,,6337.58,Other,215% New York Medicaid APG,6337.58,,,6337.58,Other,215% New York Medicaid APG,3684.64,,,3684.64,Other,125% New York Medicaid APG,2947.71,91151.08,
Reconstruction of jaw,21249,CPT,,,,,,,,both,,,123177.14,91151.08,74,,91151.08,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,55429.71,45,,55429.71,percent of total billed charges,Medicare Ratio of cost to charges,5954,,"100% primary, 50% supplemental procedure",5954,Other,Aetna ASC Grouper,5359,,"100% primary, 50% supplemental procedure",5359,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,60972.68,49.5,,60972.68,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5482.74,,,5482.74,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,86224,70,,86224,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,2947.71,,,2947.71,Other,New York Medicaid APG methodology,2947.71,,,2947.71,Other,100% New York Medicaid APG,2947.71,,,2947.71,Other,100% New York Medicaid APG,2947.71,,,2947.71,Other,100% New York Medicaid APG,6632.35,,,6632.35,Other,225% New York Medicaid APG,4510,,,4510,Other,153% New York Medicaid APG,6632.35,,,6632.35,Other,225% New York Medicaid APG,4126.79,,,4126.79,Other,140% New York Medicaid APG,6632.35,,,6632.35,Other,225% New York Medicaid APG,7664.04,,,7664.04,Other,260% New York Medicaid APG,9550.58,,,9550.58,Other,324% New York Medicaid APG,6337.58,,,6337.58,Other,215% New York Medicaid APG,6337.58,,,6337.58,Other,215% New York Medicaid APG,3684.64,,,3684.64,Other,125% New York Medicaid APG,2947.71,91151.08,
Reconstruction of orbit,21256,CPT,,,,,,,,both,,,123177.14,91151.08,74,,91151.08,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,55429.71,45,,55429.71,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,60972.68,49.5,,60972.68,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5482.74,,,5482.74,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,86224,70,,86224,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,2947.71,,,2947.71,Other,New York Medicaid APG methodology,2947.71,,,2947.71,Other,100% New York Medicaid APG,2947.71,,,2947.71,Other,100% New York Medicaid APG,2947.71,,,2947.71,Other,100% New York Medicaid APG,6632.35,,,6632.35,Other,225% New York Medicaid APG,4510,,,4510,Other,153% New York Medicaid APG,6632.35,,,6632.35,Other,225% New York Medicaid APG,4126.79,,,4126.79,Other,140% New York Medicaid APG,6632.35,,,6632.35,Other,225% New York Medicaid APG,7664.04,,,7664.04,Other,260% New York Medicaid APG,9550.58,,,9550.58,Other,324% New York Medicaid APG,6337.58,,,6337.58,Other,215% New York Medicaid APG,6337.58,,,6337.58,Other,215% New York Medicaid APG,3684.64,,,3684.64,Other,125% New York Medicaid APG,2947.71,91151.08,
Revise eye sockets,21260,CPT,,,,,,,,both,,,123177.14,91151.08,74,,91151.08,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,55429.71,45,,55429.71,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,60972.68,49.5,,60972.68,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5482.74,,,5482.74,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,86224,70,,86224,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,2947.71,,,2947.71,Other,New York Medicaid APG methodology,2947.71,,,2947.71,Other,100% New York Medicaid APG,2947.71,,,2947.71,Other,100% New York Medicaid APG,2947.71,,,2947.71,Other,100% New York Medicaid APG,6632.35,,,6632.35,Other,225% New York Medicaid APG,4510,,,4510,Other,153% New York Medicaid APG,6632.35,,,6632.35,Other,225% New York Medicaid APG,4126.79,,,4126.79,Other,140% New York Medicaid APG,6632.35,,,6632.35,Other,225% New York Medicaid APG,7664.04,,,7664.04,Other,260% New York Medicaid APG,9550.58,,,9550.58,Other,324% New York Medicaid APG,6337.58,,,6337.58,Other,215% New York Medicaid APG,6337.58,,,6337.58,Other,215% New York Medicaid APG,3684.64,,,3684.64,Other,125% New York Medicaid APG,2947.71,91151.08,
Revise eye sockets,21261,CPT,,,,,,,,both,,,123177.14,91151.08,74,,91151.08,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,55429.71,45,,55429.71,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,60972.68,49.5,,60972.68,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5482.74,,,5482.74,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,86224,70,,86224,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,2947.71,,,2947.71,Other,New York Medicaid APG methodology,2947.71,,,2947.71,Other,100% New York Medicaid APG,2947.71,,,2947.71,Other,100% New York Medicaid APG,2947.71,,,2947.71,Other,100% New York Medicaid APG,6632.35,,,6632.35,Other,225% New York Medicaid APG,4510,,,4510,Other,153% New York Medicaid APG,6632.35,,,6632.35,Other,225% New York Medicaid APG,4126.79,,,4126.79,Other,140% New York Medicaid APG,6632.35,,,6632.35,Other,225% New York Medicaid APG,7664.04,,,7664.04,Other,260% New York Medicaid APG,9550.58,,,9550.58,Other,324% New York Medicaid APG,6337.58,,,6337.58,Other,215% New York Medicaid APG,6337.58,,,6337.58,Other,215% New York Medicaid APG,3684.64,,,3684.64,Other,125% New York Medicaid APG,2947.71,91151.08,
Revise eye sockets,21263,CPT,,,,,,,,both,,,123177.14,91151.08,74,,91151.08,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,55429.71,45,,55429.71,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,60972.68,49.5,,60972.68,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5482.74,,,5482.74,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,86224,70,,86224,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,2947.71,,,2947.71,Other,New York Medicaid APG methodology,2947.71,,,2947.71,Other,100% New York Medicaid APG,2947.71,,,2947.71,Other,100% New York Medicaid APG,2947.71,,,2947.71,Other,100% New York Medicaid APG,6632.35,,,6632.35,Other,225% New York Medicaid APG,4510,,,4510,Other,153% New York Medicaid APG,6632.35,,,6632.35,Other,225% New York Medicaid APG,4126.79,,,4126.79,Other,140% New York Medicaid APG,6632.35,,,6632.35,Other,225% New York Medicaid APG,7664.04,,,7664.04,Other,260% New York Medicaid APG,9550.58,,,9550.58,Other,324% New York Medicaid APG,6337.58,,,6337.58,Other,215% New York Medicaid APG,6337.58,,,6337.58,Other,215% New York Medicaid APG,3684.64,,,3684.64,Other,125% New York Medicaid APG,2947.71,91151.08,
Revise eye sockets,21267,CPT,,,,,,,,both,,,123177.14,91151.08,74,,91151.08,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,55429.71,45,,55429.71,percent of total billed charges,Medicare Ratio of cost to charges,5954,,"100% primary, 50% supplemental procedure",5954,Other,Aetna ASC Grouper,5359,,"100% primary, 50% supplemental procedure",5359,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,60972.68,49.5,,60972.68,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,4398.22,,,4398.22,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,86224,70,,86224,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,2364.64,,,2364.64,Other,New York Medicaid APG methodology,2364.64,,,2364.64,Other,100% New York Medicaid APG,2364.64,,,2364.64,Other,100% New York Medicaid APG,2364.64,,,2364.64,Other,100% New York Medicaid APG,5320.43,,,5320.43,Other,225% New York Medicaid APG,3617.89,,,3617.89,Other,153% New York Medicaid APG,5320.43,,,5320.43,Other,225% New York Medicaid APG,3310.49,,,3310.49,Other,140% New York Medicaid APG,5320.43,,,5320.43,Other,225% New York Medicaid APG,6148.05,,,6148.05,Other,260% New York Medicaid APG,7661.42,,,7661.42,Other,324% New York Medicaid APG,5083.97,,,5083.97,Other,215% New York Medicaid APG,5083.97,,,5083.97,Other,215% New York Medicaid APG,2955.8,,,2955.8,Other,125% New York Medicaid APG,2364.64,91151.08,
Augmentation cheek bone,21270,CPT,,,,,,,,both,,,123177.14,91151.08,74,,91151.08,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,55429.71,45,,55429.71,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,60972.68,49.5,,60972.68,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5482.74,,,5482.74,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,86224,70,,86224,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,2947.71,,,2947.71,Other,New York Medicaid APG methodology,2947.71,,,2947.71,Other,100% New York Medicaid APG,2947.71,,,2947.71,Other,100% New York Medicaid APG,2947.71,,,2947.71,Other,100% New York Medicaid APG,6632.35,,,6632.35,Other,225% New York Medicaid APG,4510,,,4510,Other,153% New York Medicaid APG,6632.35,,,6632.35,Other,225% New York Medicaid APG,4126.79,,,4126.79,Other,140% New York Medicaid APG,6632.35,,,6632.35,Other,225% New York Medicaid APG,7664.04,,,7664.04,Other,260% New York Medicaid APG,9550.58,,,9550.58,Other,324% New York Medicaid APG,6337.58,,,6337.58,Other,215% New York Medicaid APG,6337.58,,,6337.58,Other,215% New York Medicaid APG,3684.64,,,3684.64,Other,125% New York Medicaid APG,2947.71,91151.08,
Revision orbitofacial bones,21275,CPT,,,,,,,,both,,,123177.14,91151.08,74,,91151.08,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,55429.71,45,,55429.71,percent of total billed charges,Medicare Ratio of cost to charges,5954,,"100% primary, 50% supplemental procedure",5954,Other,Aetna ASC Grouper,5359,,"100% primary, 50% supplemental procedure",5359,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,60972.68,49.5,,60972.68,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,4398.22,,,4398.22,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,86224,70,,86224,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,2364.64,,,2364.64,Other,New York Medicaid APG methodology,2364.64,,,2364.64,Other,100% New York Medicaid APG,2364.64,,,2364.64,Other,100% New York Medicaid APG,2364.64,,,2364.64,Other,100% New York Medicaid APG,5320.43,,,5320.43,Other,225% New York Medicaid APG,3617.89,,,3617.89,Other,153% New York Medicaid APG,5320.43,,,5320.43,Other,225% New York Medicaid APG,3310.49,,,3310.49,Other,140% New York Medicaid APG,5320.43,,,5320.43,Other,225% New York Medicaid APG,6148.05,,,6148.05,Other,260% New York Medicaid APG,7661.42,,,7661.42,Other,324% New York Medicaid APG,5083.97,,,5083.97,Other,215% New York Medicaid APG,5083.97,,,5083.97,Other,215% New York Medicaid APG,2955.8,,,2955.8,Other,125% New York Medicaid APG,2364.64,91151.08,
Revision of eyelid,21280,CPT,,,,,,,,both,,,67720.49,50113.16,74,,50113.16,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30474.22,45,,30474.22,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,33521.64,49.5,,33521.64,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3349.26,,,3349.26,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,47404.34,70,,47404.34,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,1800.68,,,1800.68,Other,New York Medicaid APG methodology,1800.68,,,1800.68,Other,100% New York Medicaid APG,1800.68,,,1800.68,Other,100% New York Medicaid APG,1800.68,,,1800.68,Other,100% New York Medicaid APG,4051.52,,,4051.52,Other,225% New York Medicaid APG,2755.03,,,2755.03,Other,153% New York Medicaid APG,4051.52,,,4051.52,Other,225% New York Medicaid APG,2520.95,,,2520.95,Other,140% New York Medicaid APG,4051.52,,,4051.52,Other,225% New York Medicaid APG,4681.76,,,4681.76,Other,260% New York Medicaid APG,5834.19,,,5834.19,Other,324% New York Medicaid APG,3871.45,,,3871.45,Other,215% New York Medicaid APG,3871.45,,,3871.45,Other,215% New York Medicaid APG,2250.84,,,2250.84,Other,125% New York Medicaid APG,1800.68,50113.16,
Revision of eyelid,21282,CPT,,,,,,,,both,,,67720.49,50113.16,74,,50113.16,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30474.22,45,,30474.22,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,33521.64,49.5,,33521.64,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3349.26,,,3349.26,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,47404.34,70,,47404.34,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1800.68,,,1800.68,Other,New York Medicaid APG methodology,1800.68,,,1800.68,Other,100% New York Medicaid APG,1800.68,,,1800.68,Other,100% New York Medicaid APG,1800.68,,,1800.68,Other,100% New York Medicaid APG,4051.52,,,4051.52,Other,225% New York Medicaid APG,2755.03,,,2755.03,Other,153% New York Medicaid APG,4051.52,,,4051.52,Other,225% New York Medicaid APG,2520.95,,,2520.95,Other,140% New York Medicaid APG,4051.52,,,4051.52,Other,225% New York Medicaid APG,4681.76,,,4681.76,Other,260% New York Medicaid APG,5834.19,,,5834.19,Other,324% New York Medicaid APG,3871.45,,,3871.45,Other,215% New York Medicaid APG,3871.45,,,3871.45,Other,215% New York Medicaid APG,2250.84,,,2250.84,Other,125% New York Medicaid APG,1800.68,50113.16,
Revision of jaw muscle/bone,21295,CPT,,,,,,,,both,,,32077.39,23737.27,74,,23737.27,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,14434.83,45,,14434.83,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,15878.31,49.5,,15878.31,percent of total billed charges,110% of Medicare,21812.63,68,,21812.63,percent of total billed charges,,4398.22,,,4398.22,Other,186% of Medicaid,25661.91,80,,25661.91,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,25661.91,80,,25661.91,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,22454.17,70,,22454.17,percent of total billed charges,,970.88,,,970.88,Fee Schedule,,822.88,,,822.88,Fee Schedule,,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,2364.64,,,2364.64,Other,New York Medicaid APG methodology,2364.64,,,2364.64,Other,100% New York Medicaid APG,2364.64,,,2364.64,Other,100% New York Medicaid APG,2364.64,,,2364.64,Other,100% New York Medicaid APG,5320.43,,,5320.43,Other,225% New York Medicaid APG,3617.89,,,3617.89,Other,153% New York Medicaid APG,5320.43,,,5320.43,Other,225% New York Medicaid APG,3310.49,,,3310.49,Other,140% New York Medicaid APG,5320.43,,,5320.43,Other,225% New York Medicaid APG,6148.05,,,6148.05,Other,260% New York Medicaid APG,7661.42,,,7661.42,Other,324% New York Medicaid APG,5083.97,,,5083.97,Other,215% New York Medicaid APG,5083.97,,,5083.97,Other,215% New York Medicaid APG,2955.8,,,2955.8,Other,125% New York Medicaid APG,822.88,25661.91,
Revision of jaw muscle/bone,21296,CPT,,,,,,,,both,,,67720.49,50113.16,74,,50113.16,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30474.22,45,,30474.22,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,33521.64,49.5,,33521.64,percent of total billed charges,110% of Medicare,46049.93,68,,46049.93,percent of total billed charges,,4398.22,,,4398.22,Other,186% of Medicaid,54176.39,80,,54176.39,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,54176.39,80,,54176.39,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,47404.34,70,,47404.34,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,2364.64,,,2364.64,Other,New York Medicaid APG methodology,2364.64,,,2364.64,Other,100% New York Medicaid APG,2364.64,,,2364.64,Other,100% New York Medicaid APG,2364.64,,,2364.64,Other,100% New York Medicaid APG,5320.43,,,5320.43,Other,225% New York Medicaid APG,3617.89,,,3617.89,Other,153% New York Medicaid APG,5320.43,,,5320.43,Other,225% New York Medicaid APG,3310.49,,,3310.49,Other,140% New York Medicaid APG,5320.43,,,5320.43,Other,225% New York Medicaid APG,6148.05,,,6148.05,Other,260% New York Medicaid APG,7661.42,,,7661.42,Other,324% New York Medicaid APG,5083.97,,,5083.97,Other,215% New York Medicaid APG,5083.97,,,5083.97,Other,215% New York Medicaid APG,2955.8,,,2955.8,Other,125% New York Medicaid APG,2053,54176.39,
Closed tx nose fx w/o stablj,21315,CPT,,,,,,,,both,,,33597.35,24862.04,74,,24862.04,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15118.81,45,,15118.81,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,16630.69,49.5,,16630.69,percent of total billed charges,110% of Medicare,22846.2,68,,22846.2,percent of total billed charges,,1031.43,,,1031.43,Other,186% of Medicaid,26877.88,80,,26877.88,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,26877.88,80,,26877.88,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,23518.15,70,,23518.15,percent of total billed charges,,295.2,,,295.2,Fee Schedule,,250.2,,,250.2,Fee Schedule,,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,554.53,,,554.53,Other,New York Medicaid APG methodology,554.53,,,554.53,Other,100% New York Medicaid APG,554.53,,,554.53,Other,100% New York Medicaid APG,554.53,,,554.53,Other,100% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,848.43,,,848.43,Other,153% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,776.34,,,776.34,Other,140% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,1441.78,,,1441.78,Other,260% New York Medicaid APG,1796.68,,,1796.68,Other,324% New York Medicaid APG,1192.24,,,1192.24,Other,215% New York Medicaid APG,1192.24,,,1192.24,Other,215% New York Medicaid APG,693.16,,,693.16,Other,125% New York Medicaid APG,250.2,26877.88,
Closed tx nose fx w/ stablj,21320,CPT,,,,,,,,both,,,35105.05,25977.74,74,,25977.74,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15797.27,45,,15797.27,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,17377,49.5,,17377,percent of total billed charges,110% of Medicare,23871.43,68,,23871.43,percent of total billed charges,,1031.43,,,1031.43,Other,186% of Medicaid,28084.04,80,,28084.04,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,28084.04,80,,28084.04,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,24573.54,70,,24573.54,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,554.53,,,554.53,Other,New York Medicaid APG methodology,554.53,,,554.53,Other,100% New York Medicaid APG,554.53,,,554.53,Other,100% New York Medicaid APG,554.53,,,554.53,Other,100% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,848.43,,,848.43,Other,153% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,776.34,,,776.34,Other,140% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,1441.78,,,1441.78,Other,260% New York Medicaid APG,1796.68,,,1796.68,Other,324% New York Medicaid APG,1192.24,,,1192.24,Other,215% New York Medicaid APG,1192.24,,,1192.24,Other,215% New York Medicaid APG,693.16,,,693.16,Other,125% New York Medicaid APG,554.53,28084.04,
Open tx nose fx uncomplicatd,21325,CPT,,,,,,,,both,,,67720.49,50113.16,74,,50113.16,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30474.22,45,,30474.22,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,33521.64,49.5,,33521.64,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,4398.22,,,4398.22,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,47404.34,70,,47404.34,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,2364.64,,,2364.64,Other,New York Medicaid APG methodology,2364.64,,,2364.64,Other,100% New York Medicaid APG,2364.64,,,2364.64,Other,100% New York Medicaid APG,2364.64,,,2364.64,Other,100% New York Medicaid APG,5320.43,,,5320.43,Other,225% New York Medicaid APG,3617.89,,,3617.89,Other,153% New York Medicaid APG,5320.43,,,5320.43,Other,225% New York Medicaid APG,3310.49,,,3310.49,Other,140% New York Medicaid APG,5320.43,,,5320.43,Other,225% New York Medicaid APG,6148.05,,,6148.05,Other,260% New York Medicaid APG,7661.42,,,7661.42,Other,324% New York Medicaid APG,5083.97,,,5083.97,Other,215% New York Medicaid APG,5083.97,,,5083.97,Other,215% New York Medicaid APG,2955.8,,,2955.8,Other,125% New York Medicaid APG,2364.64,50113.16,
Open tx nose fx w/skele fixj,21330,CPT,,,,,,,,both,,,123177.14,91151.08,74,,91151.08,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,55429.71,45,,55429.71,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,60972.68,49.5,,60972.68,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,4398.22,,,4398.22,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,86224,70,,86224,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,2364.64,,,2364.64,Other,New York Medicaid APG methodology,2364.64,,,2364.64,Other,100% New York Medicaid APG,2364.64,,,2364.64,Other,100% New York Medicaid APG,2364.64,,,2364.64,Other,100% New York Medicaid APG,5320.43,,,5320.43,Other,225% New York Medicaid APG,3617.89,,,3617.89,Other,153% New York Medicaid APG,5320.43,,,5320.43,Other,225% New York Medicaid APG,3310.49,,,3310.49,Other,140% New York Medicaid APG,5320.43,,,5320.43,Other,225% New York Medicaid APG,6148.05,,,6148.05,Other,260% New York Medicaid APG,7661.42,,,7661.42,Other,324% New York Medicaid APG,5083.97,,,5083.97,Other,215% New York Medicaid APG,5083.97,,,5083.97,Other,215% New York Medicaid APG,2955.8,,,2955.8,Other,125% New York Medicaid APG,2364.64,91151.08,
Open tx nose & septal fx,21335,CPT,,,,,,,,both,,,67720.49,50113.16,74,,50113.16,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30474.22,45,,30474.22,percent of total billed charges,Medicare Ratio of cost to charges,5954,,"100% primary, 50% supplemental procedure",5954,Other,Aetna ASC Grouper,5359,,"100% primary, 50% supplemental procedure",5359,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,33521.64,49.5,,33521.64,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,4398.22,,,4398.22,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,47404.34,70,,47404.34,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,2364.64,,,2364.64,Other,New York Medicaid APG methodology,2364.64,,,2364.64,Other,100% New York Medicaid APG,2364.64,,,2364.64,Other,100% New York Medicaid APG,2364.64,,,2364.64,Other,100% New York Medicaid APG,5320.43,,,5320.43,Other,225% New York Medicaid APG,3617.89,,,3617.89,Other,153% New York Medicaid APG,5320.43,,,5320.43,Other,225% New York Medicaid APG,3310.49,,,3310.49,Other,140% New York Medicaid APG,5320.43,,,5320.43,Other,225% New York Medicaid APG,6148.05,,,6148.05,Other,260% New York Medicaid APG,7661.42,,,7661.42,Other,324% New York Medicaid APG,5083.97,,,5083.97,Other,215% New York Medicaid APG,5083.97,,,5083.97,Other,215% New York Medicaid APG,2955.8,,,2955.8,Other,125% New York Medicaid APG,2364.64,50113.16,
Open tx septal fx w/wo stabj,21336,CPT,,,,,,,,both,,,68082.75,50381.24,74,,50381.24,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30637.24,45,,30637.24,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33700.96,49.5,,33700.96,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5092.5,,,5092.5,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,47657.93,70,,47657.93,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,2737.91,,,2737.91,Other,New York Medicaid APG methodology,2737.91,,,2737.91,Other,100% New York Medicaid APG,2737.91,,,2737.91,Other,100% New York Medicaid APG,2737.91,,,2737.91,Other,100% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,4189,,,4189,Other,153% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,3833.07,,,3833.07,Other,140% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,7118.55,,,7118.55,Other,260% New York Medicaid APG,8870.81,,,8870.81,Other,324% New York Medicaid APG,5886.5,,,5886.5,Other,215% New York Medicaid APG,5886.5,,,5886.5,Other,215% New York Medicaid APG,3422.38,,,3422.38,Other,125% New York Medicaid APG,2737.91,50381.24,
Closed tx septal&nose fx,21337,CPT,,,,,,,,both,,,35285.27,26111.1,74,,26111.1,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15878.37,45,,15878.37,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,17466.21,49.5,,17466.21,percent of total billed charges,110% of Medicare,23993.98,68,,23993.98,percent of total billed charges,,1031.43,,,1031.43,Other,186% of Medicaid,28228.22,80,,28228.22,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,28228.22,80,,28228.22,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,24699.69,70,,24699.69,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,554.53,,,554.53,Other,New York Medicaid APG methodology,554.53,,,554.53,Other,100% New York Medicaid APG,554.53,,,554.53,Other,100% New York Medicaid APG,554.53,,,554.53,Other,100% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,848.43,,,848.43,Other,153% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,776.34,,,776.34,Other,140% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,1441.78,,,1441.78,Other,260% New York Medicaid APG,1796.68,,,1796.68,Other,324% New York Medicaid APG,1192.24,,,1192.24,Other,215% New York Medicaid APG,1192.24,,,1192.24,Other,215% New York Medicaid APG,693.16,,,693.16,Other,125% New York Medicaid APG,554.53,28228.22,
Open nasoethmoid fx w/o fixj,21338,CPT,,,,,,,,both,,,123177.14,91151.08,74,,91151.08,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,55429.71,45,,55429.71,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,60972.68,49.5,,60972.68,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5482.74,,,5482.74,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,86224,70,,86224,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,2947.71,,,2947.71,Other,New York Medicaid APG methodology,2947.71,,,2947.71,Other,100% New York Medicaid APG,2947.71,,,2947.71,Other,100% New York Medicaid APG,2947.71,,,2947.71,Other,100% New York Medicaid APG,6632.35,,,6632.35,Other,225% New York Medicaid APG,4510,,,4510,Other,153% New York Medicaid APG,6632.35,,,6632.35,Other,225% New York Medicaid APG,4126.79,,,4126.79,Other,140% New York Medicaid APG,6632.35,,,6632.35,Other,225% New York Medicaid APG,7664.04,,,7664.04,Other,260% New York Medicaid APG,9550.58,,,9550.58,Other,324% New York Medicaid APG,6337.58,,,6337.58,Other,215% New York Medicaid APG,6337.58,,,6337.58,Other,215% New York Medicaid APG,3684.64,,,3684.64,Other,125% New York Medicaid APG,2947.71,91151.08,
Open nasoethmoid fx w/ fixj,21339,CPT,,,,,,,,both,,,123177.14,91151.08,74,,91151.08,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,55429.71,45,,55429.71,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,60972.68,49.5,,60972.68,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5482.74,,,5482.74,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,86224,70,,86224,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,2947.71,,,2947.71,Other,New York Medicaid APG methodology,2947.71,,,2947.71,Other,100% New York Medicaid APG,2947.71,,,2947.71,Other,100% New York Medicaid APG,2947.71,,,2947.71,Other,100% New York Medicaid APG,6632.35,,,6632.35,Other,225% New York Medicaid APG,4510,,,4510,Other,153% New York Medicaid APG,6632.35,,,6632.35,Other,225% New York Medicaid APG,4126.79,,,4126.79,Other,140% New York Medicaid APG,6632.35,,,6632.35,Other,225% New York Medicaid APG,7664.04,,,7664.04,Other,260% New York Medicaid APG,9550.58,,,9550.58,Other,324% New York Medicaid APG,6337.58,,,6337.58,Other,215% New York Medicaid APG,6337.58,,,6337.58,Other,215% New York Medicaid APG,3684.64,,,3684.64,Other,125% New York Medicaid APG,2947.71,91151.08,
Perq tx nasoethmoid fx,21340,CPT,,,,,,,,both,,,67720.49,50113.16,74,,50113.16,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30474.22,45,,30474.22,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,33521.64,49.5,,33521.64,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,4398.22,,,4398.22,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,47404.34,70,,47404.34,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,2364.64,,,2364.64,Other,New York Medicaid APG methodology,2364.64,,,2364.64,Other,100% New York Medicaid APG,2364.64,,,2364.64,Other,100% New York Medicaid APG,2364.64,,,2364.64,Other,100% New York Medicaid APG,5320.43,,,5320.43,Other,225% New York Medicaid APG,3617.89,,,3617.89,Other,153% New York Medicaid APG,5320.43,,,5320.43,Other,225% New York Medicaid APG,3310.49,,,3310.49,Other,140% New York Medicaid APG,5320.43,,,5320.43,Other,225% New York Medicaid APG,6148.05,,,6148.05,Other,260% New York Medicaid APG,7661.42,,,7661.42,Other,324% New York Medicaid APG,5083.97,,,5083.97,Other,215% New York Medicaid APG,5083.97,,,5083.97,Other,215% New York Medicaid APG,2955.8,,,2955.8,Other,125% New York Medicaid APG,2364.64,50113.16,
Closed tx nose/jaw fx,21345,CPT,,,,,,,,both,,,32077.39,23737.27,74,,23737.27,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,14434.83,45,,14434.83,percent of total billed charges,Medicare Ratio of cost to charges,5954,,"100% primary, 50% supplemental procedure",5954,Other,Aetna ASC Grouper,5359,,"100% primary, 50% supplemental procedure",5359,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,15878.31,49.5,,15878.31,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,1031.43,,,1031.43,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,22454.17,70,,22454.17,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,554.53,,,554.53,Other,New York Medicaid APG methodology,554.53,,,554.53,Other,100% New York Medicaid APG,554.53,,,554.53,Other,100% New York Medicaid APG,554.53,,,554.53,Other,100% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,848.43,,,848.43,Other,153% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,776.34,,,776.34,Other,140% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,1441.78,,,1441.78,Other,260% New York Medicaid APG,1796.68,,,1796.68,Other,324% New York Medicaid APG,1192.24,,,1192.24,Other,215% New York Medicaid APG,1192.24,,,1192.24,Other,215% New York Medicaid APG,693.16,,,693.16,Other,125% New York Medicaid APG,554.53,23737.27,
Opn tx nasomax fx w/fixj,21346,CPT,,,,,,,,both,,,123177.14,91151.08,74,,91151.08,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,55429.71,45,,55429.71,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,60972.68,49.5,,60972.68,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5482.74,,,5482.74,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,86224,70,,86224,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,2947.71,,,2947.71,Other,New York Medicaid APG methodology,2947.71,,,2947.71,Other,100% New York Medicaid APG,2947.71,,,2947.71,Other,100% New York Medicaid APG,2947.71,,,2947.71,Other,100% New York Medicaid APG,6632.35,,,6632.35,Other,225% New York Medicaid APG,4510,,,4510,Other,153% New York Medicaid APG,6632.35,,,6632.35,Other,225% New York Medicaid APG,4126.79,,,4126.79,Other,140% New York Medicaid APG,6632.35,,,6632.35,Other,225% New York Medicaid APG,7664.04,,,7664.04,Other,260% New York Medicaid APG,9550.58,,,9550.58,Other,324% New York Medicaid APG,6337.58,,,6337.58,Other,215% New York Medicaid APG,6337.58,,,6337.58,Other,215% New York Medicaid APG,3684.64,,,3684.64,Other,125% New York Medicaid APG,2947.71,91151.08,
Perq tx malar fracture,21355,CPT,,,,,,,,both,,,67720.49,50113.16,74,,50113.16,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30474.22,45,,30474.22,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,33521.64,49.5,,33521.64,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,4398.22,,,4398.22,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,47404.34,70,,47404.34,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,2364.64,,,2364.64,Other,New York Medicaid APG methodology,2364.64,,,2364.64,Other,100% New York Medicaid APG,2364.64,,,2364.64,Other,100% New York Medicaid APG,2364.64,,,2364.64,Other,100% New York Medicaid APG,5320.43,,,5320.43,Other,225% New York Medicaid APG,3617.89,,,3617.89,Other,153% New York Medicaid APG,5320.43,,,5320.43,Other,225% New York Medicaid APG,3310.49,,,3310.49,Other,140% New York Medicaid APG,5320.43,,,5320.43,Other,225% New York Medicaid APG,6148.05,,,6148.05,Other,260% New York Medicaid APG,7661.42,,,7661.42,Other,324% New York Medicaid APG,5083.97,,,5083.97,Other,215% New York Medicaid APG,5083.97,,,5083.97,Other,215% New York Medicaid APG,2955.8,,,2955.8,Other,125% New York Medicaid APG,2364.64,50113.16,
Opn tx dprsd zygomatic arch,21356,CPT,,,,,,,,both,,,35212.73,26057.42,74,,26057.42,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15845.73,45,,15845.73,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,17430.3,49.5,,17430.3,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,4398.22,,,4398.22,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,24648.91,70,,24648.91,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,2364.64,,,2364.64,Other,New York Medicaid APG methodology,2364.64,,,2364.64,Other,100% New York Medicaid APG,2364.64,,,2364.64,Other,100% New York Medicaid APG,2364.64,,,2364.64,Other,100% New York Medicaid APG,5320.43,,,5320.43,Other,225% New York Medicaid APG,3617.89,,,3617.89,Other,153% New York Medicaid APG,5320.43,,,5320.43,Other,225% New York Medicaid APG,3310.49,,,3310.49,Other,140% New York Medicaid APG,5320.43,,,5320.43,Other,225% New York Medicaid APG,6148.05,,,6148.05,Other,260% New York Medicaid APG,7661.42,,,7661.42,Other,324% New York Medicaid APG,5083.97,,,5083.97,Other,215% New York Medicaid APG,5083.97,,,5083.97,Other,215% New York Medicaid APG,2955.8,,,2955.8,Other,125% New York Medicaid APG,2364.64,26057.42,
Opn tx dprsd malar fracture,21360,CPT,,,,,,,,both,,,123177.14,91151.08,74,,91151.08,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,55429.71,45,,55429.71,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,60972.68,49.5,,60972.68,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,4398.22,,,4398.22,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,86224,70,,86224,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,2364.64,,,2364.64,Other,New York Medicaid APG methodology,2364.64,,,2364.64,Other,100% New York Medicaid APG,2364.64,,,2364.64,Other,100% New York Medicaid APG,2364.64,,,2364.64,Other,100% New York Medicaid APG,5320.43,,,5320.43,Other,225% New York Medicaid APG,3617.89,,,3617.89,Other,153% New York Medicaid APG,5320.43,,,5320.43,Other,225% New York Medicaid APG,3310.49,,,3310.49,Other,140% New York Medicaid APG,5320.43,,,5320.43,Other,225% New York Medicaid APG,6148.05,,,6148.05,Other,260% New York Medicaid APG,7661.42,,,7661.42,Other,324% New York Medicaid APG,5083.97,,,5083.97,Other,215% New York Medicaid APG,5083.97,,,5083.97,Other,215% New York Medicaid APG,2955.8,,,2955.8,Other,125% New York Medicaid APG,2364.64,91151.08,
Opn tx complx malar fx,21365,CPT,,,,,,,,both,,,61736.97,45685.36,74,,45685.36,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,27781.64,45,,27781.64,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,30559.8,49.5,,30559.8,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5482.74,,,5482.74,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,43215.88,70,,43215.88,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,2947.71,,,2947.71,Other,New York Medicaid APG methodology,2947.71,,,2947.71,Other,100% New York Medicaid APG,2947.71,,,2947.71,Other,100% New York Medicaid APG,2947.71,,,2947.71,Other,100% New York Medicaid APG,6632.35,,,6632.35,Other,225% New York Medicaid APG,4510,,,4510,Other,153% New York Medicaid APG,6632.35,,,6632.35,Other,225% New York Medicaid APG,4126.79,,,4126.79,Other,140% New York Medicaid APG,6632.35,,,6632.35,Other,225% New York Medicaid APG,7664.04,,,7664.04,Other,260% New York Medicaid APG,9550.58,,,9550.58,Other,324% New York Medicaid APG,6337.58,,,6337.58,Other,215% New York Medicaid APG,6337.58,,,6337.58,Other,215% New York Medicaid APG,3684.64,,,3684.64,Other,125% New York Medicaid APG,2947.71,45685.36,
Opn tx orbit fx transantral,21385,CPT,,,,,,,,both,,,123177.14,91151.08,74,,91151.08,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,55429.71,45,,55429.71,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,60972.68,49.5,,60972.68,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5482.74,,,5482.74,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,86224,70,,86224,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,2947.71,,,2947.71,Other,New York Medicaid APG methodology,2947.71,,,2947.71,Other,100% New York Medicaid APG,2947.71,,,2947.71,Other,100% New York Medicaid APG,2947.71,,,2947.71,Other,100% New York Medicaid APG,6632.35,,,6632.35,Other,225% New York Medicaid APG,4510,,,4510,Other,153% New York Medicaid APG,6632.35,,,6632.35,Other,225% New York Medicaid APG,4126.79,,,4126.79,Other,140% New York Medicaid APG,6632.35,,,6632.35,Other,225% New York Medicaid APG,7664.04,,,7664.04,Other,260% New York Medicaid APG,9550.58,,,9550.58,Other,324% New York Medicaid APG,6337.58,,,6337.58,Other,215% New York Medicaid APG,6337.58,,,6337.58,Other,215% New York Medicaid APG,3684.64,,,3684.64,Other,125% New York Medicaid APG,2947.71,91151.08,
Opn tx orbit fx periorbital,21386,CPT,,,,,,,,both,,,123177.14,91151.08,74,,91151.08,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,55429.71,45,,55429.71,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,60972.68,49.5,,60972.68,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5482.74,,,5482.74,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,86224,70,,86224,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,2947.71,,,2947.71,Other,New York Medicaid APG methodology,2947.71,,,2947.71,Other,100% New York Medicaid APG,2947.71,,,2947.71,Other,100% New York Medicaid APG,2947.71,,,2947.71,Other,100% New York Medicaid APG,6632.35,,,6632.35,Other,225% New York Medicaid APG,4510,,,4510,Other,153% New York Medicaid APG,6632.35,,,6632.35,Other,225% New York Medicaid APG,4126.79,,,4126.79,Other,140% New York Medicaid APG,6632.35,,,6632.35,Other,225% New York Medicaid APG,7664.04,,,7664.04,Other,260% New York Medicaid APG,9550.58,,,9550.58,Other,324% New York Medicaid APG,6337.58,,,6337.58,Other,215% New York Medicaid APG,6337.58,,,6337.58,Other,215% New York Medicaid APG,3684.64,,,3684.64,Other,125% New York Medicaid APG,2947.71,91151.08,
Opn tx orbit fx combined,21387,CPT,,,,,,,,both,,,123177.14,91151.08,74,,91151.08,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,55429.71,45,,55429.71,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,60972.68,49.5,,60972.68,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5482.74,,,5482.74,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,86224,70,,86224,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,2947.71,,,2947.71,Other,New York Medicaid APG methodology,2947.71,,,2947.71,Other,100% New York Medicaid APG,2947.71,,,2947.71,Other,100% New York Medicaid APG,2947.71,,,2947.71,Other,100% New York Medicaid APG,6632.35,,,6632.35,Other,225% New York Medicaid APG,4510,,,4510,Other,153% New York Medicaid APG,6632.35,,,6632.35,Other,225% New York Medicaid APG,4126.79,,,4126.79,Other,140% New York Medicaid APG,6632.35,,,6632.35,Other,225% New York Medicaid APG,7664.04,,,7664.04,Other,260% New York Medicaid APG,9550.58,,,9550.58,Other,324% New York Medicaid APG,6337.58,,,6337.58,Other,215% New York Medicaid APG,6337.58,,,6337.58,Other,215% New York Medicaid APG,3684.64,,,3684.64,Other,125% New York Medicaid APG,2947.71,91151.08,
Opn tx orbit periorbtl implt,21390,CPT,,,,,,,,both,,,53237.37,39395.65,74,,39395.65,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,23956.82,45,,23956.82,percent of total billed charges,Medicare Ratio of cost to charges,5954,,"100% primary, 50% supplemental procedure",5954,Other,Aetna ASC Grouper,5359,,"100% primary, 50% supplemental procedure",5359,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,26352.5,49.5,,26352.5,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5482.74,,,5482.74,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,37266.16,70,,37266.16,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,2947.71,,,2947.71,Other,New York Medicaid APG methodology,2947.71,,,2947.71,Other,100% New York Medicaid APG,2947.71,,,2947.71,Other,100% New York Medicaid APG,2947.71,,,2947.71,Other,100% New York Medicaid APG,6632.35,,,6632.35,Other,225% New York Medicaid APG,4510,,,4510,Other,153% New York Medicaid APG,6632.35,,,6632.35,Other,225% New York Medicaid APG,4126.79,,,4126.79,Other,140% New York Medicaid APG,6632.35,,,6632.35,Other,225% New York Medicaid APG,7664.04,,,7664.04,Other,260% New York Medicaid APG,9550.58,,,9550.58,Other,324% New York Medicaid APG,6337.58,,,6337.58,Other,215% New York Medicaid APG,6337.58,,,6337.58,Other,215% New York Medicaid APG,3684.64,,,3684.64,Other,125% New York Medicaid APG,2947.71,39395.65,
Opn tx orbit periorbt w/grft,21395,CPT,,,,,,,,both,,,36969.66,27357.55,74,,27357.55,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,16636.35,45,,16636.35,percent of total billed charges,Medicare Ratio of cost to charges,5954,,"100% primary, 50% supplemental procedure",5954,Other,Aetna ASC Grouper,5359,,"100% primary, 50% supplemental procedure",5359,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,18299.98,49.5,,18299.98,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5482.74,,,5482.74,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,25878.76,70,,25878.76,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,2947.71,,,2947.71,Other,New York Medicaid APG methodology,2947.71,,,2947.71,Other,100% New York Medicaid APG,2947.71,,,2947.71,Other,100% New York Medicaid APG,2947.71,,,2947.71,Other,100% New York Medicaid APG,6632.35,,,6632.35,Other,225% New York Medicaid APG,4510,,,4510,Other,153% New York Medicaid APG,6632.35,,,6632.35,Other,225% New York Medicaid APG,4126.79,,,4126.79,Other,140% New York Medicaid APG,6632.35,,,6632.35,Other,225% New York Medicaid APG,7664.04,,,7664.04,Other,260% New York Medicaid APG,9550.58,,,9550.58,Other,324% New York Medicaid APG,6337.58,,,6337.58,Other,215% New York Medicaid APG,6337.58,,,6337.58,Other,215% New York Medicaid APG,3684.64,,,3684.64,Other,125% New York Medicaid APG,2947.71,27357.55,
Closed tx orbit w/o manipulj,21400,CPT,,,,,,,,both,,,11572.85,8563.91,74,,8563.91,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,5207.78,45,,5207.78,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,5728.56,49.5,,5728.56,percent of total billed charges,110% of Medicare,7869.54,68,,7869.54,percent of total billed charges,,1031.43,,,1031.43,Other,186% of Medicaid,9258.28,80,,9258.28,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,9258.28,80,,9258.28,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,8101,70,,8101,percent of total billed charges,,828.2,,,828.2,Fee Schedule,,701.95,,,701.95,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,554.53,,,554.53,Other,New York Medicaid APG methodology,554.53,,,554.53,Other,100% New York Medicaid APG,554.53,,,554.53,Other,100% New York Medicaid APG,554.53,,,554.53,Other,100% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,848.43,,,848.43,Other,153% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,776.34,,,776.34,Other,140% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,1441.78,,,1441.78,Other,260% New York Medicaid APG,1796.68,,,1796.68,Other,324% New York Medicaid APG,1192.24,,,1192.24,Other,215% New York Medicaid APG,1192.24,,,1192.24,Other,215% New York Medicaid APG,693.16,,,693.16,Other,125% New York Medicaid APG,554.53,9258.28,
Closed tx orbit w/manipulj,21401,CPT,,,,,,,,both,,,32077.39,23737.27,74,,23737.27,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,14434.83,45,,14434.83,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,15878.31,49.5,,15878.31,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,1031.43,,,1031.43,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,22454.17,70,,22454.17,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,554.53,,,554.53,Other,New York Medicaid APG methodology,554.53,,,554.53,Other,100% New York Medicaid APG,554.53,,,554.53,Other,100% New York Medicaid APG,554.53,,,554.53,Other,100% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,848.43,,,848.43,Other,153% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,776.34,,,776.34,Other,140% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,1441.78,,,1441.78,Other,260% New York Medicaid APG,1796.68,,,1796.68,Other,324% New York Medicaid APG,1192.24,,,1192.24,Other,215% New York Medicaid APG,1192.24,,,1192.24,Other,215% New York Medicaid APG,693.16,,,693.16,Other,125% New York Medicaid APG,554.53,23737.27,
Opn tx orbit fx w/o implant,21406,CPT,,,,,,,,both,,,123177.14,91151.08,74,,91151.08,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,55429.71,45,,55429.71,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,60972.68,49.5,,60972.68,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5482.74,,,5482.74,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,86224,70,,86224,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,2947.71,,,2947.71,Other,New York Medicaid APG methodology,2947.71,,,2947.71,Other,100% New York Medicaid APG,2947.71,,,2947.71,Other,100% New York Medicaid APG,2947.71,,,2947.71,Other,100% New York Medicaid APG,6632.35,,,6632.35,Other,225% New York Medicaid APG,4510,,,4510,Other,153% New York Medicaid APG,6632.35,,,6632.35,Other,225% New York Medicaid APG,4126.79,,,4126.79,Other,140% New York Medicaid APG,6632.35,,,6632.35,Other,225% New York Medicaid APG,7664.04,,,7664.04,Other,260% New York Medicaid APG,9550.58,,,9550.58,Other,324% New York Medicaid APG,6337.58,,,6337.58,Other,215% New York Medicaid APG,6337.58,,,6337.58,Other,215% New York Medicaid APG,3684.64,,,3684.64,Other,125% New York Medicaid APG,2947.71,91151.08,
Opn tx orbit fx w/implant,21407,CPT,,,,,,,,both,,,89055.11,65900.78,74,,65900.78,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,40074.8,45,,40074.8,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,44082.28,49.5,,44082.28,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,4398.22,,,4398.22,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,62338.58,70,,62338.58,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,2364.64,,,2364.64,Other,New York Medicaid APG methodology,2364.64,,,2364.64,Other,100% New York Medicaid APG,2364.64,,,2364.64,Other,100% New York Medicaid APG,2364.64,,,2364.64,Other,100% New York Medicaid APG,5320.43,,,5320.43,Other,225% New York Medicaid APG,3617.89,,,3617.89,Other,153% New York Medicaid APG,5320.43,,,5320.43,Other,225% New York Medicaid APG,3310.49,,,3310.49,Other,140% New York Medicaid APG,5320.43,,,5320.43,Other,225% New York Medicaid APG,6148.05,,,6148.05,Other,260% New York Medicaid APG,7661.42,,,7661.42,Other,324% New York Medicaid APG,5083.97,,,5083.97,Other,215% New York Medicaid APG,5083.97,,,5083.97,Other,215% New York Medicaid APG,2955.8,,,2955.8,Other,125% New York Medicaid APG,2364.64,65900.78,
Opn tx orbit fx w/bone grft,21408,CPT,,,,,,,,both,,,123177.14,91151.08,74,,91151.08,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,55429.71,45,,55429.71,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,60972.68,49.5,,60972.68,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,4398.22,,,4398.22,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,86224,70,,86224,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,2364.64,,,2364.64,Other,New York Medicaid APG methodology,2364.64,,,2364.64,Other,100% New York Medicaid APG,2364.64,,,2364.64,Other,100% New York Medicaid APG,2364.64,,,2364.64,Other,100% New York Medicaid APG,5320.43,,,5320.43,Other,225% New York Medicaid APG,3617.89,,,3617.89,Other,153% New York Medicaid APG,5320.43,,,5320.43,Other,225% New York Medicaid APG,3310.49,,,3310.49,Other,140% New York Medicaid APG,5320.43,,,5320.43,Other,225% New York Medicaid APG,6148.05,,,6148.05,Other,260% New York Medicaid APG,7661.42,,,7661.42,Other,324% New York Medicaid APG,5083.97,,,5083.97,Other,215% New York Medicaid APG,5083.97,,,5083.97,Other,215% New York Medicaid APG,2955.8,,,2955.8,Other,125% New York Medicaid APG,2364.64,91151.08,
Treat mouth roof fracture,21421,CPT,,,,,,,,both,,,67720.49,50113.16,74,,50113.16,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30474.22,45,,30474.22,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,33521.64,49.5,,33521.64,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,4398.22,,,4398.22,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,47404.34,70,,47404.34,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,2364.64,,,2364.64,Other,New York Medicaid APG methodology,2364.64,,,2364.64,Other,100% New York Medicaid APG,2364.64,,,2364.64,Other,100% New York Medicaid APG,2364.64,,,2364.64,Other,100% New York Medicaid APG,5320.43,,,5320.43,Other,225% New York Medicaid APG,3617.89,,,3617.89,Other,153% New York Medicaid APG,5320.43,,,5320.43,Other,225% New York Medicaid APG,3310.49,,,3310.49,Other,140% New York Medicaid APG,5320.43,,,5320.43,Other,225% New York Medicaid APG,6148.05,,,6148.05,Other,260% New York Medicaid APG,7661.42,,,7661.42,Other,324% New York Medicaid APG,5083.97,,,5083.97,Other,215% New York Medicaid APG,5083.97,,,5083.97,Other,215% New York Medicaid APG,2955.8,,,2955.8,Other,125% New York Medicaid APG,2364.64,50113.16,
Treat dental ridge fracture,21440,CPT,,,,,,,,both,,,67720.49,50113.16,74,,50113.16,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30474.22,45,,30474.22,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,33521.64,49.5,,33521.64,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,4398.22,,,4398.22,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,47404.34,70,,47404.34,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,2364.64,,,2364.64,Other,New York Medicaid APG methodology,2364.64,,,2364.64,Other,100% New York Medicaid APG,2364.64,,,2364.64,Other,100% New York Medicaid APG,2364.64,,,2364.64,Other,100% New York Medicaid APG,5320.43,,,5320.43,Other,225% New York Medicaid APG,3617.89,,,3617.89,Other,153% New York Medicaid APG,5320.43,,,5320.43,Other,225% New York Medicaid APG,3310.49,,,3310.49,Other,140% New York Medicaid APG,5320.43,,,5320.43,Other,225% New York Medicaid APG,6148.05,,,6148.05,Other,260% New York Medicaid APG,7661.42,,,7661.42,Other,324% New York Medicaid APG,5083.97,,,5083.97,Other,215% New York Medicaid APG,5083.97,,,5083.97,Other,215% New York Medicaid APG,2955.8,,,2955.8,Other,125% New York Medicaid APG,2364.64,50113.16,
Treat dental ridge fracture,21445,CPT,,,,,,,,both,,,123177.14,91151.08,74,,91151.08,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,55429.71,45,,55429.71,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,60972.68,49.5,,60972.68,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5482.74,,,5482.74,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,86224,70,,86224,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,2947.71,,,2947.71,Other,New York Medicaid APG methodology,2947.71,,,2947.71,Other,100% New York Medicaid APG,2947.71,,,2947.71,Other,100% New York Medicaid APG,2947.71,,,2947.71,Other,100% New York Medicaid APG,6632.35,,,6632.35,Other,225% New York Medicaid APG,4510,,,4510,Other,153% New York Medicaid APG,6632.35,,,6632.35,Other,225% New York Medicaid APG,4126.79,,,4126.79,Other,140% New York Medicaid APG,6632.35,,,6632.35,Other,225% New York Medicaid APG,7664.04,,,7664.04,Other,260% New York Medicaid APG,9550.58,,,9550.58,Other,324% New York Medicaid APG,6337.58,,,6337.58,Other,215% New York Medicaid APG,6337.58,,,6337.58,Other,215% New York Medicaid APG,3684.64,,,3684.64,Other,125% New York Medicaid APG,2947.71,91151.08,
Treat lower jaw fracture,21450,CPT,,,,,,,,both,,,11572.85,8563.91,74,,8563.91,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,5207.78,45,,5207.78,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,5728.56,49.5,,5728.56,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,1031.43,,,1031.43,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,8101,70,,8101,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,554.53,,,554.53,Other,New York Medicaid APG methodology,554.53,,,554.53,Other,100% New York Medicaid APG,554.53,,,554.53,Other,100% New York Medicaid APG,554.53,,,554.53,Other,100% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,848.43,,,848.43,Other,153% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,776.34,,,776.34,Other,140% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,1441.78,,,1441.78,Other,260% New York Medicaid APG,1796.68,,,1796.68,Other,324% New York Medicaid APG,1192.24,,,1192.24,Other,215% New York Medicaid APG,1192.24,,,1192.24,Other,215% New York Medicaid APG,693.16,,,693.16,Other,125% New York Medicaid APG,554.53,9473,
Treat lower jaw fracture,21451,CPT,,,,,,,,both,,,32077.39,23737.27,74,,23737.27,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,14434.83,45,,14434.83,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,15878.31,49.5,,15878.31,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,1031.43,,,1031.43,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,22454.17,70,,22454.17,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,554.53,,,554.53,Other,New York Medicaid APG methodology,554.53,,,554.53,Other,100% New York Medicaid APG,554.53,,,554.53,Other,100% New York Medicaid APG,554.53,,,554.53,Other,100% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,848.43,,,848.43,Other,153% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,776.34,,,776.34,Other,140% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,1441.78,,,1441.78,Other,260% New York Medicaid APG,1796.68,,,1796.68,Other,324% New York Medicaid APG,1192.24,,,1192.24,Other,215% New York Medicaid APG,1192.24,,,1192.24,Other,215% New York Medicaid APG,693.16,,,693.16,Other,125% New York Medicaid APG,554.53,23737.27,
Treat lower jaw fracture,21452,CPT,,,,,,,,both,,,123177.14,91151.08,74,,91151.08,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,55429.71,45,,55429.71,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,60972.68,49.5,,60972.68,percent of total billed charges,110% of Medicare,83760.46,68,,83760.46,percent of total billed charges,,5482.74,,,5482.74,Other,186% of Medicaid,98541.71,80,,98541.71,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,98541.71,80,,98541.71,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,86224,70,,86224,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,2947.71,,,2947.71,Other,New York Medicaid APG methodology,2947.71,,,2947.71,Other,100% New York Medicaid APG,2947.71,,,2947.71,Other,100% New York Medicaid APG,2947.71,,,2947.71,Other,100% New York Medicaid APG,6632.35,,,6632.35,Other,225% New York Medicaid APG,4510,,,4510,Other,153% New York Medicaid APG,6632.35,,,6632.35,Other,225% New York Medicaid APG,4126.79,,,4126.79,Other,140% New York Medicaid APG,6632.35,,,6632.35,Other,225% New York Medicaid APG,7664.04,,,7664.04,Other,260% New York Medicaid APG,9550.58,,,9550.58,Other,324% New York Medicaid APG,6337.58,,,6337.58,Other,215% New York Medicaid APG,6337.58,,,6337.58,Other,215% New York Medicaid APG,3684.64,,,3684.64,Other,125% New York Medicaid APG,2232,98541.71,
Treat lower jaw fracture,21453,CPT,,,,,,,,both,,,62366.91,46151.51,74,,46151.51,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,28065.11,45,,28065.11,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,30871.62,49.5,,30871.62,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5482.74,,,5482.74,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,43656.84,70,,43656.84,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,2947.71,,,2947.71,Other,New York Medicaid APG methodology,2947.71,,,2947.71,Other,100% New York Medicaid APG,2947.71,,,2947.71,Other,100% New York Medicaid APG,2947.71,,,2947.71,Other,100% New York Medicaid APG,6632.35,,,6632.35,Other,225% New York Medicaid APG,4510,,,4510,Other,153% New York Medicaid APG,6632.35,,,6632.35,Other,225% New York Medicaid APG,4126.79,,,4126.79,Other,140% New York Medicaid APG,6632.35,,,6632.35,Other,225% New York Medicaid APG,7664.04,,,7664.04,Other,260% New York Medicaid APG,9550.58,,,9550.58,Other,324% New York Medicaid APG,6337.58,,,6337.58,Other,215% New York Medicaid APG,6337.58,,,6337.58,Other,215% New York Medicaid APG,3684.64,,,3684.64,Other,125% New York Medicaid APG,2947.71,46151.51,
Treat lower jaw fracture,21454,CPT,,,,,,,,both,,,123177.14,91151.08,74,,91151.08,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,55429.71,45,,55429.71,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,60972.68,49.5,,60972.68,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5482.74,,,5482.74,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,86224,70,,86224,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,2947.71,,,2947.71,Other,New York Medicaid APG methodology,2947.71,,,2947.71,Other,100% New York Medicaid APG,2947.71,,,2947.71,Other,100% New York Medicaid APG,2947.71,,,2947.71,Other,100% New York Medicaid APG,6632.35,,,6632.35,Other,225% New York Medicaid APG,4510,,,4510,Other,153% New York Medicaid APG,6632.35,,,6632.35,Other,225% New York Medicaid APG,4126.79,,,4126.79,Other,140% New York Medicaid APG,6632.35,,,6632.35,Other,225% New York Medicaid APG,7664.04,,,7664.04,Other,260% New York Medicaid APG,9550.58,,,9550.58,Other,324% New York Medicaid APG,6337.58,,,6337.58,Other,215% New York Medicaid APG,6337.58,,,6337.58,Other,215% New York Medicaid APG,3684.64,,,3684.64,Other,125% New York Medicaid APG,2947.71,91151.08,
Treat lower jaw fracture,21461,CPT,,,,,,,,both,,,78075.46,57775.84,74,,57775.84,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,35133.96,45,,35133.96,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,38647.35,49.5,,38647.35,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5482.74,,,5482.74,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,54652.82,70,,54652.82,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,2947.71,,,2947.71,Other,New York Medicaid APG methodology,2947.71,,,2947.71,Other,100% New York Medicaid APG,2947.71,,,2947.71,Other,100% New York Medicaid APG,2947.71,,,2947.71,Other,100% New York Medicaid APG,6632.35,,,6632.35,Other,225% New York Medicaid APG,4510,,,4510,Other,153% New York Medicaid APG,6632.35,,,6632.35,Other,225% New York Medicaid APG,4126.79,,,4126.79,Other,140% New York Medicaid APG,6632.35,,,6632.35,Other,225% New York Medicaid APG,7664.04,,,7664.04,Other,260% New York Medicaid APG,9550.58,,,9550.58,Other,324% New York Medicaid APG,6337.58,,,6337.58,Other,215% New York Medicaid APG,6337.58,,,6337.58,Other,215% New York Medicaid APG,3684.64,,,3684.64,Other,125% New York Medicaid APG,2947.71,57775.84,
Treat lower jaw fracture,21462,CPT,,,,,,,,both,,,88543.08,65521.88,74,,65521.88,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,39844.39,45,,39844.39,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,43828.82,49.5,,43828.82,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5482.74,,,5482.74,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,61980.16,70,,61980.16,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,2947.71,,,2947.71,Other,New York Medicaid APG methodology,2947.71,,,2947.71,Other,100% New York Medicaid APG,2947.71,,,2947.71,Other,100% New York Medicaid APG,2947.71,,,2947.71,Other,100% New York Medicaid APG,6632.35,,,6632.35,Other,225% New York Medicaid APG,4510,,,4510,Other,153% New York Medicaid APG,6632.35,,,6632.35,Other,225% New York Medicaid APG,4126.79,,,4126.79,Other,140% New York Medicaid APG,6632.35,,,6632.35,Other,225% New York Medicaid APG,7664.04,,,7664.04,Other,260% New York Medicaid APG,9550.58,,,9550.58,Other,324% New York Medicaid APG,6337.58,,,6337.58,Other,215% New York Medicaid APG,6337.58,,,6337.58,Other,215% New York Medicaid APG,3684.64,,,3684.64,Other,125% New York Medicaid APG,2947.71,65521.88,
Treat lower jaw fracture,21465,CPT,,,,,,,,both,,,131486.31,97299.87,74,,97299.87,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,59168.84,45,,59168.84,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,65085.72,49.5,,65085.72,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5482.74,,,5482.74,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,92040.42,70,,92040.42,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,2947.71,,,2947.71,Other,New York Medicaid APG methodology,2947.71,,,2947.71,Other,100% New York Medicaid APG,2947.71,,,2947.71,Other,100% New York Medicaid APG,2947.71,,,2947.71,Other,100% New York Medicaid APG,6632.35,,,6632.35,Other,225% New York Medicaid APG,4510,,,4510,Other,153% New York Medicaid APG,6632.35,,,6632.35,Other,225% New York Medicaid APG,4126.79,,,4126.79,Other,140% New York Medicaid APG,6632.35,,,6632.35,Other,225% New York Medicaid APG,7664.04,,,7664.04,Other,260% New York Medicaid APG,9550.58,,,9550.58,Other,324% New York Medicaid APG,6337.58,,,6337.58,Other,215% New York Medicaid APG,6337.58,,,6337.58,Other,215% New York Medicaid APG,3684.64,,,3684.64,Other,125% New York Medicaid APG,2947.71,97299.87,
Treat lower jaw fracture,21470,CPT,,,,,,,,both,,,131285.49,97151.26,74,,97151.26,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,59078.47,45,,59078.47,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,64986.32,49.5,,64986.32,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5482.74,,,5482.74,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,91899.84,70,,91899.84,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,2947.71,,,2947.71,Other,New York Medicaid APG methodology,2947.71,,,2947.71,Other,100% New York Medicaid APG,2947.71,,,2947.71,Other,100% New York Medicaid APG,2947.71,,,2947.71,Other,100% New York Medicaid APG,6632.35,,,6632.35,Other,225% New York Medicaid APG,4510,,,4510,Other,153% New York Medicaid APG,6632.35,,,6632.35,Other,225% New York Medicaid APG,4126.79,,,4126.79,Other,140% New York Medicaid APG,6632.35,,,6632.35,Other,225% New York Medicaid APG,7664.04,,,7664.04,Other,260% New York Medicaid APG,9550.58,,,9550.58,Other,324% New York Medicaid APG,6337.58,,,6337.58,Other,215% New York Medicaid APG,6337.58,,,6337.58,Other,215% New York Medicaid APG,3684.64,,,3684.64,Other,125% New York Medicaid APG,2947.71,97151.26,
Reset dislocated jaw,21480,CPT,,,,,,,,both,,,4960.23,3670.57,74,,3670.57,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,2232.1,45,,2232.1,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,2455.31,49.5,,2455.31,percent of total billed charges,110% of Medicare,3372.96,68,,3372.96,percent of total billed charges,,423.06,,,423.06,Other,186% of Medicaid,3968.18,80,,3968.18,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,3968.18,80,,3968.18,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,3472.16,70,,3472.16,percent of total billed charges,,152.52,,,152.52,Fee Schedule,,129.27,,,129.27,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,227.45,,,227.45,Other,New York Medicaid APG methodology,227.45,,,227.45,Other,100% New York Medicaid APG,227.45,,,227.45,Other,100% New York Medicaid APG,227.45,,,227.45,Other,100% New York Medicaid APG,511.76,,,511.76,Other,225% New York Medicaid APG,348,,,348,Other,153% New York Medicaid APG,511.76,,,511.76,Other,225% New York Medicaid APG,318.43,,,318.43,Other,140% New York Medicaid APG,511.76,,,511.76,Other,225% New York Medicaid APG,591.37,,,591.37,Other,260% New York Medicaid APG,736.94,,,736.94,Other,324% New York Medicaid APG,489.02,,,489.02,Other,215% New York Medicaid APG,489.02,,,489.02,Other,215% New York Medicaid APG,284.31,,,284.31,Other,125% New York Medicaid APG,129.27,7216,
Reset dislocated jaw,21485,CPT,,,,,,,,both,,,32077.39,23737.27,74,,23737.27,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,14434.83,45,,14434.83,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,15878.31,49.5,,15878.31,percent of total billed charges,110% of Medicare,21812.63,68,,21812.63,percent of total billed charges,,1730.38,,,1730.38,Other,186% of Medicaid,25661.91,80,,25661.91,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,25661.91,80,,25661.91,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,22454.17,70,,22454.17,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,930.31,,,930.31,Other,New York Medicaid APG methodology,930.31,,,930.31,Other,100% New York Medicaid APG,930.31,,,930.31,Other,100% New York Medicaid APG,930.31,,,930.31,Other,100% New York Medicaid APG,2093.21,,,2093.21,Other,225% New York Medicaid APG,1423.38,,,1423.38,Other,153% New York Medicaid APG,2093.21,,,2093.21,Other,225% New York Medicaid APG,1302.44,,,1302.44,Other,140% New York Medicaid APG,2093.21,,,2093.21,Other,225% New York Medicaid APG,2418.82,,,2418.82,Other,260% New York Medicaid APG,3014.22,,,3014.22,Other,324% New York Medicaid APG,2000.18,,,2000.18,Other,215% New York Medicaid APG,2000.18,,,2000.18,Other,215% New York Medicaid APG,1162.89,,,1162.89,Other,125% New York Medicaid APG,930.31,25661.91,
Repair dislocated jaw,21490,CPT,,,,,,,,both,,,67720.49,50113.16,74,,50113.16,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30474.22,45,,30474.22,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,33521.64,49.5,,33521.64,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,4398.22,,,4398.22,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,47404.34,70,,47404.34,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,2364.64,,,2364.64,Other,New York Medicaid APG methodology,2364.64,,,2364.64,Other,100% New York Medicaid APG,2364.64,,,2364.64,Other,100% New York Medicaid APG,2364.64,,,2364.64,Other,100% New York Medicaid APG,5320.43,,,5320.43,Other,225% New York Medicaid APG,3617.89,,,3617.89,Other,153% New York Medicaid APG,5320.43,,,5320.43,Other,225% New York Medicaid APG,3310.49,,,3310.49,Other,140% New York Medicaid APG,5320.43,,,5320.43,Other,225% New York Medicaid APG,6148.05,,,6148.05,Other,260% New York Medicaid APG,7661.42,,,7661.42,Other,324% New York Medicaid APG,5083.97,,,5083.97,Other,215% New York Medicaid APG,5083.97,,,5083.97,Other,215% New York Medicaid APG,2955.8,,,2955.8,Other,125% New York Medicaid APG,2364.64,50113.16,
Interdental wiring,21497,CPT,,,,,,,,both,,,32077.39,23737.27,74,,23737.27,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,14434.83,45,,14434.83,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,15878.31,49.5,,15878.31,percent of total billed charges,110% of Medicare,21812.63,68,,21812.63,percent of total billed charges,,428.6,,,428.6,Other,186% of Medicaid,25661.91,80,,25661.91,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,25661.91,80,,25661.91,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,22454.17,70,,22454.17,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,230.43,,,230.43,Other,New York Medicaid APG methodology,230.43,,,230.43,Other,100% New York Medicaid APG,230.43,,,230.43,Other,100% New York Medicaid APG,230.43,,,230.43,Other,100% New York Medicaid APG,518.46,,,518.46,Other,225% New York Medicaid APG,352.55,,,352.55,Other,153% New York Medicaid APG,518.46,,,518.46,Other,225% New York Medicaid APG,322.6,,,322.6,Other,140% New York Medicaid APG,518.46,,,518.46,Other,225% New York Medicaid APG,599.11,,,599.11,Other,260% New York Medicaid APG,746.59,,,746.59,Other,324% New York Medicaid APG,495.42,,,495.42,Other,215% New York Medicaid APG,495.42,,,495.42,Other,215% New York Medicaid APG,288.03,,,288.03,Other,125% New York Medicaid APG,230.43,25661.91,
Drain neck/chest lesion,21501,CPT,,,,,,,,both,,,35589.06,26335.9,74,,26335.9,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,16015.08,45,,16015.08,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,17616.58,49.5,,17616.58,percent of total billed charges,110% of Medicare,24200.56,68,,24200.56,percent of total billed charges,,3164.53,,,3164.53,Other,186% of Medicaid,28471.25,80,,28471.25,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,28471.25,80,,28471.25,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,24912.34,70,,24912.34,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1701.36,,,1701.36,Other,New York Medicaid APG methodology,1701.36,,,1701.36,Other,100% New York Medicaid APG,1701.36,,,1701.36,Other,100% New York Medicaid APG,1701.36,,,1701.36,Other,100% New York Medicaid APG,3828.06,,,3828.06,Other,225% New York Medicaid APG,2603.08,,,2603.08,Other,153% New York Medicaid APG,3828.06,,,3828.06,Other,225% New York Medicaid APG,2381.9,,,2381.9,Other,140% New York Medicaid APG,3828.06,,,3828.06,Other,225% New York Medicaid APG,4423.54,,,4423.54,Other,260% New York Medicaid APG,5512.41,,,5512.41,Other,324% New York Medicaid APG,3657.92,,,3657.92,Other,215% New York Medicaid APG,3657.92,,,3657.92,Other,215% New York Medicaid APG,2126.7,,,2126.7,Other,125% New York Medicaid APG,1701.36,28471.25,
Drain chest lesion,21502,CPT,,,,,,,,both,,,68082.75,50381.24,74,,50381.24,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30637.24,45,,30637.24,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33700.96,49.5,,33700.96,percent of total billed charges,110% of Medicare,46296.27,68,,46296.27,percent of total billed charges,,3164.53,,,3164.53,Other,186% of Medicaid,54466.2,80,,54466.2,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,54466.2,80,,54466.2,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,47657.93,70,,47657.93,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1701.36,,,1701.36,Other,New York Medicaid APG methodology,1701.36,,,1701.36,Other,100% New York Medicaid APG,1701.36,,,1701.36,Other,100% New York Medicaid APG,1701.36,,,1701.36,Other,100% New York Medicaid APG,3828.06,,,3828.06,Other,225% New York Medicaid APG,2603.08,,,2603.08,Other,153% New York Medicaid APG,3828.06,,,3828.06,Other,225% New York Medicaid APG,2381.9,,,2381.9,Other,140% New York Medicaid APG,3828.06,,,3828.06,Other,225% New York Medicaid APG,4423.54,,,4423.54,Other,260% New York Medicaid APG,5512.41,,,5512.41,Other,324% New York Medicaid APG,3657.92,,,3657.92,Other,215% New York Medicaid APG,3657.92,,,3657.92,Other,215% New York Medicaid APG,2126.7,,,2126.7,Other,125% New York Medicaid APG,1701.36,54466.2,
Biopsy of neck/chest,21550,CPT,,,,,,,,both,,,34101.75,25235.3,74,,25235.3,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15345.79,45,,15345.79,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,16880.37,49.5,,16880.37,percent of total billed charges,110% of Medicare,23189.19,68,,23189.19,percent of total billed charges,,3164.53,,,3164.53,Other,186% of Medicaid,27281.4,80,,27281.4,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,27281.4,80,,27281.4,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,23871.23,70,,23871.23,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1701.36,,,1701.36,Other,New York Medicaid APG methodology,1701.36,,,1701.36,Other,100% New York Medicaid APG,1701.36,,,1701.36,Other,100% New York Medicaid APG,1701.36,,,1701.36,Other,100% New York Medicaid APG,3828.06,,,3828.06,Other,225% New York Medicaid APG,2603.08,,,2603.08,Other,153% New York Medicaid APG,3828.06,,,3828.06,Other,225% New York Medicaid APG,2381.9,,,2381.9,Other,140% New York Medicaid APG,3828.06,,,3828.06,Other,225% New York Medicaid APG,4423.54,,,4423.54,Other,260% New York Medicaid APG,5512.41,,,5512.41,Other,324% New York Medicaid APG,3657.92,,,3657.92,Other,215% New York Medicaid APG,3657.92,,,3657.92,Other,215% New York Medicaid APG,2126.7,,,2126.7,Other,125% New York Medicaid APG,1701.36,27281.4,
Exc neck les sc 3 cm/>,21552,CPT,,,,,,,,both,,,36268.05,26838.36,74,,26838.36,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,16320.62,45,,16320.62,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,17952.68,49.5,,17952.68,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3164.53,,,3164.53,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,25387.64,70,,25387.64,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1701.36,,,1701.36,Other,New York Medicaid APG methodology,1701.36,,,1701.36,Other,100% New York Medicaid APG,1701.36,,,1701.36,Other,100% New York Medicaid APG,1701.36,,,1701.36,Other,100% New York Medicaid APG,3828.06,,,3828.06,Other,225% New York Medicaid APG,2603.08,,,2603.08,Other,153% New York Medicaid APG,3828.06,,,3828.06,Other,225% New York Medicaid APG,2381.9,,,2381.9,Other,140% New York Medicaid APG,3828.06,,,3828.06,Other,225% New York Medicaid APG,4423.54,,,4423.54,Other,260% New York Medicaid APG,5512.41,,,5512.41,Other,324% New York Medicaid APG,3657.92,,,3657.92,Other,215% New York Medicaid APG,3657.92,,,3657.92,Other,215% New York Medicaid APG,2126.7,,,2126.7,Other,125% New York Medicaid APG,1701.36,26838.36,
Exc neck tum deep 5 cm/>,21554,CPT,,,,,,,,both,,,38757.88,28680.83,74,,28680.83,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,17441.05,45,,17441.05,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,19185.15,49.5,,19185.15,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3164.53,,,3164.53,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,27130.52,70,,27130.52,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1701.36,,,1701.36,Other,New York Medicaid APG methodology,1701.36,,,1701.36,Other,100% New York Medicaid APG,1701.36,,,1701.36,Other,100% New York Medicaid APG,1701.36,,,1701.36,Other,100% New York Medicaid APG,3828.06,,,3828.06,Other,225% New York Medicaid APG,2603.08,,,2603.08,Other,153% New York Medicaid APG,3828.06,,,3828.06,Other,225% New York Medicaid APG,2381.9,,,2381.9,Other,140% New York Medicaid APG,3828.06,,,3828.06,Other,225% New York Medicaid APG,4423.54,,,4423.54,Other,260% New York Medicaid APG,5512.41,,,5512.41,Other,324% New York Medicaid APG,3657.92,,,3657.92,Other,215% New York Medicaid APG,3657.92,,,3657.92,Other,215% New York Medicaid APG,2126.7,,,2126.7,Other,125% New York Medicaid APG,1701.36,28680.83,
Exc neck les sc < 3 cm,21555,CPT,,,,,,,,both,,,39200.03,29008.02,74,,29008.02,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,17640.01,45,,17640.01,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,19404.01,49.5,,19404.01,percent of total billed charges,110% of Medicare,26656.02,68,,26656.02,percent of total billed charges,,3164.53,,,3164.53,Other,186% of Medicaid,31360.02,80,,31360.02,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,31360.02,80,,31360.02,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,27440.02,70,,27440.02,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1701.36,,,1701.36,Other,New York Medicaid APG methodology,1701.36,,,1701.36,Other,100% New York Medicaid APG,1701.36,,,1701.36,Other,100% New York Medicaid APG,1701.36,,,1701.36,Other,100% New York Medicaid APG,3828.06,,,3828.06,Other,225% New York Medicaid APG,2603.08,,,2603.08,Other,153% New York Medicaid APG,3828.06,,,3828.06,Other,225% New York Medicaid APG,2381.9,,,2381.9,Other,140% New York Medicaid APG,3828.06,,,3828.06,Other,225% New York Medicaid APG,4423.54,,,4423.54,Other,260% New York Medicaid APG,5512.41,,,5512.41,Other,324% New York Medicaid APG,3657.92,,,3657.92,Other,215% New York Medicaid APG,3657.92,,,3657.92,Other,215% New York Medicaid APG,2126.7,,,2126.7,Other,125% New York Medicaid APG,1701.36,31360.02,
Exc neck tum deep < 5 cm,21556,CPT,,,,,,,,both,,,47349.43,35038.58,74,,35038.58,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,21307.24,45,,21307.24,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,23437.97,49.5,,23437.97,percent of total billed charges,110% of Medicare,32197.61,68,,32197.61,percent of total billed charges,,3164.53,,,3164.53,Other,186% of Medicaid,37879.54,80,,37879.54,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,37879.54,80,,37879.54,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,33144.6,70,,33144.6,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1701.36,,,1701.36,Other,New York Medicaid APG methodology,1701.36,,,1701.36,Other,100% New York Medicaid APG,1701.36,,,1701.36,Other,100% New York Medicaid APG,1701.36,,,1701.36,Other,100% New York Medicaid APG,3828.06,,,3828.06,Other,225% New York Medicaid APG,2603.08,,,2603.08,Other,153% New York Medicaid APG,3828.06,,,3828.06,Other,225% New York Medicaid APG,2381.9,,,2381.9,Other,140% New York Medicaid APG,3828.06,,,3828.06,Other,225% New York Medicaid APG,4423.54,,,4423.54,Other,260% New York Medicaid APG,5512.41,,,5512.41,Other,324% New York Medicaid APG,3657.92,,,3657.92,Other,215% New York Medicaid APG,3657.92,,,3657.92,Other,215% New York Medicaid APG,2126.7,,,2126.7,Other,125% New York Medicaid APG,1701.36,37879.54,
Resect neck thorax tumor<5cm,21557,CPT,,,,,,,,both,,,59767.2,44227.73,74,,44227.73,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,26895.24,45,,26895.24,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,29584.76,49.5,,29584.76,percent of total billed charges,110% of Medicare,40641.7,68,,40641.7,percent of total billed charges,,3164.53,,,3164.53,Other,186% of Medicaid,47813.76,80,,47813.76,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,47813.76,80,,47813.76,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,41837.04,70,,41837.04,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1701.36,,,1701.36,Other,New York Medicaid APG methodology,1701.36,,,1701.36,Other,100% New York Medicaid APG,1701.36,,,1701.36,Other,100% New York Medicaid APG,1701.36,,,1701.36,Other,100% New York Medicaid APG,3828.06,,,3828.06,Other,225% New York Medicaid APG,2603.08,,,2603.08,Other,153% New York Medicaid APG,3828.06,,,3828.06,Other,225% New York Medicaid APG,2381.9,,,2381.9,Other,140% New York Medicaid APG,3828.06,,,3828.06,Other,225% New York Medicaid APG,4423.54,,,4423.54,Other,260% New York Medicaid APG,5512.41,,,5512.41,Other,324% New York Medicaid APG,3657.92,,,3657.92,Other,215% New York Medicaid APG,3657.92,,,3657.92,Other,215% New York Medicaid APG,2126.7,,,2126.7,Other,125% New York Medicaid APG,1701.36,47813.76,
Resect neck tumor 5 cm/>,21558,CPT,,,,,,,,both,,,38983.69,28847.93,74,,28847.93,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,17542.66,45,,17542.66,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,19296.93,49.5,,19296.93,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,4046.72,,,4046.72,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,27288.58,70,,27288.58,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,2175.66,,,2175.66,Other,New York Medicaid APG methodology,2175.66,,,2175.66,Other,100% New York Medicaid APG,2175.66,,,2175.66,Other,100% New York Medicaid APG,2175.66,,,2175.66,Other,100% New York Medicaid APG,4895.23,,,4895.23,Other,225% New York Medicaid APG,3328.76,,,3328.76,Other,153% New York Medicaid APG,4895.23,,,4895.23,Other,225% New York Medicaid APG,3045.92,,,3045.92,Other,140% New York Medicaid APG,4895.23,,,4895.23,Other,225% New York Medicaid APG,5656.71,,,5656.71,Other,260% New York Medicaid APG,7049.13,,,7049.13,Other,324% New York Medicaid APG,4677.66,,,4677.66,Other,215% New York Medicaid APG,4677.66,,,4677.66,Other,215% New York Medicaid APG,2719.57,,,2719.57,Other,125% New York Medicaid APG,2175.66,28847.93,
Partial removal of rib,21600,CPT,,,,,,,,both,,,38379.86,28401.1,74,,28401.1,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,17270.94,45,,17270.94,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,18998.03,49.5,,18998.03,percent of total billed charges,110% of Medicare,26098.3,68,,26098.3,percent of total billed charges,,3164.53,,,3164.53,Other,186% of Medicaid,30703.89,80,,30703.89,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,30703.89,80,,30703.89,percent of total billed charges,,7216,,,7216,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,26865.9,70,,26865.9,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1701.36,,,1701.36,Other,New York Medicaid APG methodology,1701.36,,,1701.36,Other,100% New York Medicaid APG,1701.36,,,1701.36,Other,100% New York Medicaid APG,1701.36,,,1701.36,Other,100% New York Medicaid APG,3828.06,,,3828.06,Other,225% New York Medicaid APG,2603.08,,,2603.08,Other,153% New York Medicaid APG,3828.06,,,3828.06,Other,225% New York Medicaid APG,2381.9,,,2381.9,Other,140% New York Medicaid APG,3828.06,,,3828.06,Other,225% New York Medicaid APG,4423.54,,,4423.54,Other,260% New York Medicaid APG,5512.41,,,5512.41,Other,324% New York Medicaid APG,3657.92,,,3657.92,Other,215% New York Medicaid APG,3657.92,,,3657.92,Other,215% New York Medicaid APG,2126.7,,,2126.7,Other,125% New York Medicaid APG,1701.36,30703.89,
Exc chest wall tumor w/ribs,21601,CPT,,,,,,,,both,,,59767.2,44227.73,74,,44227.73,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,26895.24,45,,26895.24,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,6125,,"100% primary, 50% secondary, 25% supplemental procedure",6125,Other,Blue Cross ASC Grouper,5513,,"100% primary, 50% secondary, 25% supplemental procedure",5513,Other,Blue Cross ASC Grouper,5206,,"100% primary, 50% secondary, 25% supplemental procedure",5206,Other,Blue Cross ASC Grouper,29584.76,49.5,,29584.76,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3164.53,,,3164.53,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,47813.76,80,,47813.76,percent of total billed charges,,41837.04,70,,41837.04,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1701.36,,,1701.36,Other,New York Medicaid APG methodology,1701.36,,,1701.36,Other,100% New York Medicaid APG,1701.36,,,1701.36,Other,100% New York Medicaid APG,1701.36,,,1701.36,Other,100% New York Medicaid APG,3828.06,,,3828.06,Other,225% New York Medicaid APG,2603.08,,,2603.08,Other,153% New York Medicaid APG,3828.06,,,3828.06,Other,225% New York Medicaid APG,2381.9,,,2381.9,Other,140% New York Medicaid APG,3828.06,,,3828.06,Other,225% New York Medicaid APG,4423.54,,,4423.54,Other,260% New York Medicaid APG,5512.41,,,5512.41,Other,324% New York Medicaid APG,3657.92,,,3657.92,Other,215% New York Medicaid APG,3657.92,,,3657.92,Other,215% New York Medicaid APG,2126.7,,,2126.7,Other,125% New York Medicaid APG,1701.36,47813.76,
Partial removal of rib,21610,CPT,,,,,,,,both,,,68082.75,50381.24,74,,50381.24,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30637.24,45,,30637.24,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33700.96,49.5,,33700.96,percent of total billed charges,110% of Medicare,46296.27,68,,46296.27,percent of total billed charges,,5525.48,,,5525.48,Other,186% of Medicaid,54466.2,80,,54466.2,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,54466.2,80,,54466.2,percent of total billed charges,,7216,,,7216,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,47657.93,70,,47657.93,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,2970.69,,,2970.69,Other,New York Medicaid APG methodology,2970.69,,,2970.69,Other,100% New York Medicaid APG,2970.69,,,2970.69,Other,100% New York Medicaid APG,2970.69,,,2970.69,Other,100% New York Medicaid APG,6684.05,,,6684.05,Other,225% New York Medicaid APG,4545.16,,,4545.16,Other,153% New York Medicaid APG,6684.05,,,6684.05,Other,225% New York Medicaid APG,4158.97,,,4158.97,Other,140% New York Medicaid APG,6684.05,,,6684.05,Other,225% New York Medicaid APG,7723.79,,,7723.79,Other,260% New York Medicaid APG,9625.03,,,9625.03,Other,324% New York Medicaid APG,6386.98,,,6386.98,Other,215% New York Medicaid APG,6386.98,,,6386.98,Other,215% New York Medicaid APG,3713.36,,,3713.36,Other,125% New York Medicaid APG,2232,54466.2,
Hyoid myotomy & suspension,21685,CPT,,,,,,,,both,,,53041.12,39250.43,74,,39250.43,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,23868.5,45,,23868.5,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,26255.35,49.5,,26255.35,percent of total billed charges,110% of Medicare,36067.96,68,,36067.96,percent of total billed charges,,5482.74,,,5482.74,Other,186% of Medicaid,42432.9,80,,42432.9,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,42432.9,80,,42432.9,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,37128.78,70,,37128.78,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,2947.71,,,2947.71,Other,New York Medicaid APG methodology,2947.71,,,2947.71,Other,100% New York Medicaid APG,2947.71,,,2947.71,Other,100% New York Medicaid APG,2947.71,,,2947.71,Other,100% New York Medicaid APG,6632.35,,,6632.35,Other,225% New York Medicaid APG,4510,,,4510,Other,153% New York Medicaid APG,6632.35,,,6632.35,Other,225% New York Medicaid APG,4126.79,,,4126.79,Other,140% New York Medicaid APG,6632.35,,,6632.35,Other,225% New York Medicaid APG,7664.04,,,7664.04,Other,260% New York Medicaid APG,9550.58,,,9550.58,Other,324% New York Medicaid APG,6337.58,,,6337.58,Other,215% New York Medicaid APG,6337.58,,,6337.58,Other,215% New York Medicaid APG,3684.64,,,3684.64,Other,125% New York Medicaid APG,2232,42432.9,
Revision of neck muscle,21700,CPT,,,,,,,,both,,,150476.65,111352.72,74,,111352.72,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,67714.49,45,,67714.49,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,74485.94,49.5,,74485.94,percent of total billed charges,110% of Medicare,102324.12,68,,102324.12,percent of total billed charges,,5525.48,,,5525.48,Other,186% of Medicaid,120381.32,80,,120381.32,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,120381.32,80,,120381.32,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,105333.66,70,,105333.66,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,2970.69,,,2970.69,Other,New York Medicaid APG methodology,2970.69,,,2970.69,Other,100% New York Medicaid APG,2970.69,,,2970.69,Other,100% New York Medicaid APG,2970.69,,,2970.69,Other,100% New York Medicaid APG,6684.05,,,6684.05,Other,225% New York Medicaid APG,4545.16,,,4545.16,Other,153% New York Medicaid APG,6684.05,,,6684.05,Other,225% New York Medicaid APG,4158.97,,,4158.97,Other,140% New York Medicaid APG,6684.05,,,6684.05,Other,225% New York Medicaid APG,7723.79,,,7723.79,Other,260% New York Medicaid APG,9625.03,,,9625.03,Other,324% New York Medicaid APG,6386.98,,,6386.98,Other,215% New York Medicaid APG,6386.98,,,6386.98,Other,215% New York Medicaid APG,3713.36,,,3713.36,Other,125% New York Medicaid APG,2232,120381.32,
Revision of neck muscle,21720,CPT,,,,,,,,both,,,68082.75,50381.24,74,,50381.24,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30637.24,45,,30637.24,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33700.96,49.5,,33700.96,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3164.53,,,3164.53,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,47657.93,70,,47657.93,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1701.36,,,1701.36,Other,New York Medicaid APG methodology,1701.36,,,1701.36,Other,100% New York Medicaid APG,1701.36,,,1701.36,Other,100% New York Medicaid APG,1701.36,,,1701.36,Other,100% New York Medicaid APG,3828.06,,,3828.06,Other,225% New York Medicaid APG,2603.08,,,2603.08,Other,153% New York Medicaid APG,3828.06,,,3828.06,Other,225% New York Medicaid APG,2381.9,,,2381.9,Other,140% New York Medicaid APG,3828.06,,,3828.06,Other,225% New York Medicaid APG,4423.54,,,4423.54,Other,260% New York Medicaid APG,5512.41,,,5512.41,Other,324% New York Medicaid APG,3657.92,,,3657.92,Other,215% New York Medicaid APG,3657.92,,,3657.92,Other,215% New York Medicaid APG,2126.7,,,2126.7,Other,125% New York Medicaid APG,1701.36,50381.24,
Revision of neck muscle,21725,CPT,,,,,,,,both,,,14798.8,10951.11,74,,10951.11,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,6659.46,45,,6659.46,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,7325.41,49.5,,7325.41,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5525.48,,,5525.48,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,3578,,"100% primary, 0% secondary procedures",3578,Other,MagnaCare ASC Grouper,10359.16,70,,10359.16,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,2970.69,,,2970.69,Other,New York Medicaid APG methodology,2970.69,,,2970.69,Other,100% New York Medicaid APG,2970.69,,,2970.69,Other,100% New York Medicaid APG,2970.69,,,2970.69,Other,100% New York Medicaid APG,6684.05,,,6684.05,Other,225% New York Medicaid APG,4545.16,,,4545.16,Other,153% New York Medicaid APG,6684.05,,,6684.05,Other,225% New York Medicaid APG,4158.97,,,4158.97,Other,140% New York Medicaid APG,6684.05,,,6684.05,Other,225% New York Medicaid APG,7723.79,,,7723.79,Other,260% New York Medicaid APG,9625.03,,,9625.03,Other,324% New York Medicaid APG,6386.98,,,6386.98,Other,215% New York Medicaid APG,6386.98,,,6386.98,Other,215% New York Medicaid APG,3713.36,,,3713.36,Other,125% New York Medicaid APG,2743,10951.11,
Repair stern/nuss w/o scope,21742,CPT,,,,,,,,both,,,68082.75,50381.24,74,,50381.24,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30637.24,45,,30637.24,percent of total billed charges,Medicare Ratio of cost to charges,5459,,"100% primary, 50% supplemental procedure",5459,Other,Aetna ASC Grouper,4913,,"100% primary, 50% supplemental procedure",4913,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33700.96,49.5,,33700.96,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3164.53,,,3164.53,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,47657.93,70,,47657.93,percent of total billed charges,,44253.79,65,,44253.79,percent of total billed charges,,44253.79,65,,44253.79,percent of total billed charges,,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,1701.36,,,1701.36,Other,New York Medicaid APG methodology,1701.36,,,1701.36,Other,100% New York Medicaid APG,1701.36,,,1701.36,Other,100% New York Medicaid APG,1701.36,,,1701.36,Other,100% New York Medicaid APG,3828.06,,,3828.06,Other,225% New York Medicaid APG,2603.08,,,2603.08,Other,153% New York Medicaid APG,3828.06,,,3828.06,Other,225% New York Medicaid APG,2381.9,,,2381.9,Other,140% New York Medicaid APG,3828.06,,,3828.06,Other,225% New York Medicaid APG,4423.54,,,4423.54,Other,260% New York Medicaid APG,5512.41,,,5512.41,Other,324% New York Medicaid APG,3657.92,,,3657.92,Other,215% New York Medicaid APG,3657.92,,,3657.92,Other,215% New York Medicaid APG,2126.7,,,2126.7,Other,125% New York Medicaid APG,1701.36,50381.24,
Repair sternum/nuss w/scope,21743,CPT,,,,,,,,both,,,68082.75,50381.24,74,,50381.24,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30637.24,45,,30637.24,percent of total billed charges,Medicare Ratio of cost to charges,5459,,"100% primary, 50% supplemental procedure",5459,Other,Aetna ASC Grouper,4913,,"100% primary, 50% supplemental procedure",4913,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33700.96,49.5,,33700.96,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3164.53,,,3164.53,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,47657.93,70,,47657.93,percent of total billed charges,,44253.79,65,,44253.79,percent of total billed charges,,44253.79,65,,44253.79,percent of total billed charges,,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,1701.36,,,1701.36,Other,New York Medicaid APG methodology,1701.36,,,1701.36,Other,100% New York Medicaid APG,1701.36,,,1701.36,Other,100% New York Medicaid APG,1701.36,,,1701.36,Other,100% New York Medicaid APG,3828.06,,,3828.06,Other,225% New York Medicaid APG,2603.08,,,2603.08,Other,153% New York Medicaid APG,3828.06,,,3828.06,Other,225% New York Medicaid APG,2381.9,,,2381.9,Other,140% New York Medicaid APG,3828.06,,,3828.06,Other,225% New York Medicaid APG,4423.54,,,4423.54,Other,260% New York Medicaid APG,5512.41,,,5512.41,Other,324% New York Medicaid APG,3657.92,,,3657.92,Other,215% New York Medicaid APG,3657.92,,,3657.92,Other,215% New York Medicaid APG,2126.7,,,2126.7,Other,125% New York Medicaid APG,1701.36,50381.24,
Treat sternum fracture,21820,CPT,,,,,,,,both,,,4960.23,3670.57,74,,3670.57,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,2232.1,45,,2232.1,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,2455.31,49.5,,2455.31,percent of total billed charges,110% of Medicare,3372.96,68,,3372.96,percent of total billed charges,,1031.43,,,1031.43,Other,186% of Medicaid,3968.18,80,,3968.18,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,3968.18,80,,3968.18,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,3472.16,70,,3472.16,percent of total billed charges,,741.28,,,741.28,Fee Schedule,,628.28,,,628.28,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,554.53,,,554.53,Other,New York Medicaid APG methodology,554.53,,,554.53,Other,100% New York Medicaid APG,554.53,,,554.53,Other,100% New York Medicaid APG,554.53,,,554.53,Other,100% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,848.43,,,848.43,Other,153% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,776.34,,,776.34,Other,140% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,1441.78,,,1441.78,Other,260% New York Medicaid APG,1796.68,,,1796.68,Other,324% New York Medicaid APG,1192.24,,,1192.24,Other,215% New York Medicaid APG,1192.24,,,1192.24,Other,215% New York Medicaid APG,693.16,,,693.16,Other,125% New York Medicaid APG,554.53,7216,
Biopsy soft tissue of back,21920,CPT,,,,,,,,both,,,34101.75,25235.3,74,,25235.3,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15345.79,45,,15345.79,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,16880.37,49.5,,16880.37,percent of total billed charges,110% of Medicare,23189.19,68,,23189.19,percent of total billed charges,,1973.06,,,1973.06,Other,186% of Medicaid,27281.4,80,,27281.4,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,27281.4,80,,27281.4,percent of total billed charges,,7216,,,7216,Case Rate,,3578,,"100% primary, 0% secondary procedures",3578,Other,MagnaCare ASC Grouper,23871.23,70,,23871.23,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,1060.79,,,1060.79,Other,New York Medicaid APG methodology,1060.79,,,1060.79,Other,100% New York Medicaid APG,1060.79,,,1060.79,Other,100% New York Medicaid APG,1060.79,,,1060.79,Other,100% New York Medicaid APG,2386.77,,,2386.77,Other,225% New York Medicaid APG,1623,,,1623,Other,153% New York Medicaid APG,2386.77,,,2386.77,Other,225% New York Medicaid APG,1485.1,,,1485.1,Other,140% New York Medicaid APG,2386.77,,,2386.77,Other,225% New York Medicaid APG,2758.05,,,2758.05,Other,260% New York Medicaid APG,3436.95,,,3436.95,Other,324% New York Medicaid APG,2280.69,,,2280.69,Other,215% New York Medicaid APG,2280.69,,,2280.69,Other,215% New York Medicaid APG,1325.98,,,1325.98,Other,125% New York Medicaid APG,1060.79,27281.4,
Biopsy soft tissue of back,21925,CPT,,,,,,,,both,,,34101.75,25235.3,74,,25235.3,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15345.79,45,,15345.79,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,16880.37,49.5,,16880.37,percent of total billed charges,110% of Medicare,23189.19,68,,23189.19,percent of total billed charges,,1973.06,,,1973.06,Other,186% of Medicaid,27281.4,80,,27281.4,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,27281.4,80,,27281.4,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,23871.23,70,,23871.23,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1060.79,,,1060.79,Other,New York Medicaid APG methodology,1060.79,,,1060.79,Other,100% New York Medicaid APG,1060.79,,,1060.79,Other,100% New York Medicaid APG,1060.79,,,1060.79,Other,100% New York Medicaid APG,2386.77,,,2386.77,Other,225% New York Medicaid APG,1623,,,1623,Other,153% New York Medicaid APG,2386.77,,,2386.77,Other,225% New York Medicaid APG,1485.1,,,1485.1,Other,140% New York Medicaid APG,2386.77,,,2386.77,Other,225% New York Medicaid APG,2758.05,,,2758.05,Other,260% New York Medicaid APG,3436.95,,,3436.95,Other,324% New York Medicaid APG,2280.69,,,2280.69,Other,215% New York Medicaid APG,2280.69,,,2280.69,Other,215% New York Medicaid APG,1325.98,,,1325.98,Other,125% New York Medicaid APG,1060.79,27281.4,
Exc back les sc < 3 cm,21930,CPT,,,,,,,,both,,,34713.64,25688.09,74,,25688.09,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15621.14,45,,15621.14,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,17183.25,49.5,,17183.25,percent of total billed charges,110% of Medicare,23605.28,68,,23605.28,percent of total billed charges,,1973.06,,,1973.06,Other,186% of Medicaid,27770.91,80,,27770.91,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,27770.91,80,,27770.91,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,24299.55,70,,24299.55,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1060.79,,,1060.79,Other,New York Medicaid APG methodology,1060.79,,,1060.79,Other,100% New York Medicaid APG,1060.79,,,1060.79,Other,100% New York Medicaid APG,1060.79,,,1060.79,Other,100% New York Medicaid APG,2386.77,,,2386.77,Other,225% New York Medicaid APG,1623,,,1623,Other,153% New York Medicaid APG,2386.77,,,2386.77,Other,225% New York Medicaid APG,1485.1,,,1485.1,Other,140% New York Medicaid APG,2386.77,,,2386.77,Other,225% New York Medicaid APG,2758.05,,,2758.05,Other,260% New York Medicaid APG,3436.95,,,3436.95,Other,324% New York Medicaid APG,2280.69,,,2280.69,Other,215% New York Medicaid APG,2280.69,,,2280.69,Other,215% New York Medicaid APG,1325.98,,,1325.98,Other,125% New York Medicaid APG,1060.79,27770.91,
Exc back les sc 3 cm/>,21931,CPT,,,,,,,,both,,,35507.52,26275.56,74,,26275.56,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15978.38,45,,15978.38,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,17576.22,49.5,,17576.22,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,1973.06,,,1973.06,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,24855.26,70,,24855.26,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1060.79,,,1060.79,Other,New York Medicaid APG methodology,1060.79,,,1060.79,Other,100% New York Medicaid APG,1060.79,,,1060.79,Other,100% New York Medicaid APG,1060.79,,,1060.79,Other,100% New York Medicaid APG,2386.77,,,2386.77,Other,225% New York Medicaid APG,1623,,,1623,Other,153% New York Medicaid APG,2386.77,,,2386.77,Other,225% New York Medicaid APG,1485.1,,,1485.1,Other,140% New York Medicaid APG,2386.77,,,2386.77,Other,225% New York Medicaid APG,2758.05,,,2758.05,Other,260% New York Medicaid APG,3436.95,,,3436.95,Other,324% New York Medicaid APG,2280.69,,,2280.69,Other,215% New York Medicaid APG,2280.69,,,2280.69,Other,215% New York Medicaid APG,1325.98,,,1325.98,Other,125% New York Medicaid APG,1060.79,26275.56,
Exc back tum deep < 5 cm,21932,CPT,,,,,,,,both,,,59767.2,44227.73,74,,44227.73,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,26895.24,45,,26895.24,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,29584.76,49.5,,29584.76,percent of total billed charges,110% of Medicare,40641.7,68,,40641.7,percent of total billed charges,,1973.06,,,1973.06,Other,186% of Medicaid,47813.76,80,,47813.76,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,47813.76,80,,47813.76,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,41837.04,70,,41837.04,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1060.79,,,1060.79,Other,New York Medicaid APG methodology,1060.79,,,1060.79,Other,100% New York Medicaid APG,1060.79,,,1060.79,Other,100% New York Medicaid APG,1060.79,,,1060.79,Other,100% New York Medicaid APG,2386.77,,,2386.77,Other,225% New York Medicaid APG,1623,,,1623,Other,153% New York Medicaid APG,2386.77,,,2386.77,Other,225% New York Medicaid APG,1485.1,,,1485.1,Other,140% New York Medicaid APG,2386.77,,,2386.77,Other,225% New York Medicaid APG,2758.05,,,2758.05,Other,260% New York Medicaid APG,3436.95,,,3436.95,Other,324% New York Medicaid APG,2280.69,,,2280.69,Other,215% New York Medicaid APG,2280.69,,,2280.69,Other,215% New York Medicaid APG,1325.98,,,1325.98,Other,125% New York Medicaid APG,1060.79,47813.76,
Exc back tum deep 5 cm/>,21933,CPT,,,,,,,,both,,,35676.57,26400.66,74,,26400.66,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,16054.46,45,,16054.46,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,17659.9,49.5,,17659.9,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,1973.06,,,1973.06,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,24973.6,70,,24973.6,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1060.79,,,1060.79,Other,New York Medicaid APG methodology,1060.79,,,1060.79,Other,100% New York Medicaid APG,1060.79,,,1060.79,Other,100% New York Medicaid APG,1060.79,,,1060.79,Other,100% New York Medicaid APG,2386.77,,,2386.77,Other,225% New York Medicaid APG,1623,,,1623,Other,153% New York Medicaid APG,2386.77,,,2386.77,Other,225% New York Medicaid APG,1485.1,,,1485.1,Other,140% New York Medicaid APG,2386.77,,,2386.77,Other,225% New York Medicaid APG,2758.05,,,2758.05,Other,260% New York Medicaid APG,3436.95,,,3436.95,Other,324% New York Medicaid APG,2280.69,,,2280.69,Other,215% New York Medicaid APG,2280.69,,,2280.69,Other,215% New York Medicaid APG,1325.98,,,1325.98,Other,125% New York Medicaid APG,1060.79,26400.66,
Resect back tum < 5 cm,21935,CPT,,,,,,,,both,,,59767.2,44227.73,74,,44227.73,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,26895.24,45,,26895.24,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,29584.76,49.5,,29584.76,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,1973.06,,,1973.06,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,41837.04,70,,41837.04,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1060.79,,,1060.79,Other,New York Medicaid APG methodology,1060.79,,,1060.79,Other,100% New York Medicaid APG,1060.79,,,1060.79,Other,100% New York Medicaid APG,1060.79,,,1060.79,Other,100% New York Medicaid APG,2386.77,,,2386.77,Other,225% New York Medicaid APG,1623,,,1623,Other,153% New York Medicaid APG,2386.77,,,2386.77,Other,225% New York Medicaid APG,1485.1,,,1485.1,Other,140% New York Medicaid APG,2386.77,,,2386.77,Other,225% New York Medicaid APG,2758.05,,,2758.05,Other,260% New York Medicaid APG,3436.95,,,3436.95,Other,324% New York Medicaid APG,2280.69,,,2280.69,Other,215% New York Medicaid APG,2280.69,,,2280.69,Other,215% New York Medicaid APG,1325.98,,,1325.98,Other,125% New York Medicaid APG,1060.79,44227.73,
Resect back tum 5 cm/>,21936,CPT,,,,,,,,both,,,59767.2,44227.73,74,,44227.73,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,26895.24,45,,26895.24,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,29584.76,49.5,,29584.76,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,1973.06,,,1973.06,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,41837.04,70,,41837.04,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1060.79,,,1060.79,Other,New York Medicaid APG methodology,1060.79,,,1060.79,Other,100% New York Medicaid APG,1060.79,,,1060.79,Other,100% New York Medicaid APG,1060.79,,,1060.79,Other,100% New York Medicaid APG,2386.77,,,2386.77,Other,225% New York Medicaid APG,1623,,,1623,Other,153% New York Medicaid APG,2386.77,,,2386.77,Other,225% New York Medicaid APG,1485.1,,,1485.1,Other,140% New York Medicaid APG,2386.77,,,2386.77,Other,225% New York Medicaid APG,2758.05,,,2758.05,Other,260% New York Medicaid APG,3436.95,,,3436.95,Other,324% New York Medicaid APG,2280.69,,,2280.69,Other,215% New York Medicaid APG,2280.69,,,2280.69,Other,215% New York Medicaid APG,1325.98,,,1325.98,Other,125% New York Medicaid APG,1060.79,44227.73,
Remove part of neck vertebra,22100,CPT,,,,,,,,both,,,46679.93,34543.15,74,,34543.15,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,21005.97,45,,21005.97,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,23106.57,49.5,,23106.57,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5525.48,,,5525.48,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,32675.95,70,,32675.95,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,2970.69,,,2970.69,Other,New York Medicaid APG methodology,2970.69,,,2970.69,Other,100% New York Medicaid APG,2970.69,,,2970.69,Other,100% New York Medicaid APG,2970.69,,,2970.69,Other,100% New York Medicaid APG,6684.05,,,6684.05,Other,225% New York Medicaid APG,4545.16,,,4545.16,Other,153% New York Medicaid APG,6684.05,,,6684.05,Other,225% New York Medicaid APG,4158.97,,,4158.97,Other,140% New York Medicaid APG,6684.05,,,6684.05,Other,225% New York Medicaid APG,7723.79,,,7723.79,Other,260% New York Medicaid APG,9625.03,,,9625.03,Other,324% New York Medicaid APG,6386.98,,,6386.98,Other,215% New York Medicaid APG,6386.98,,,6386.98,Other,215% New York Medicaid APG,3713.36,,,3713.36,Other,125% New York Medicaid APG,2970.69,34543.15,
Remove part thorax vertebra,22101,CPT,,,,,,,,both,,,150476.65,111352.72,74,,111352.72,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,67714.49,45,,67714.49,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,74485.94,49.5,,74485.94,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5525.48,,,5525.48,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,105333.66,70,,105333.66,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,2970.69,,,2970.69,Other,New York Medicaid APG methodology,2970.69,,,2970.69,Other,100% New York Medicaid APG,2970.69,,,2970.69,Other,100% New York Medicaid APG,2970.69,,,2970.69,Other,100% New York Medicaid APG,6684.05,,,6684.05,Other,225% New York Medicaid APG,4545.16,,,4545.16,Other,153% New York Medicaid APG,6684.05,,,6684.05,Other,225% New York Medicaid APG,4158.97,,,4158.97,Other,140% New York Medicaid APG,6684.05,,,6684.05,Other,225% New York Medicaid APG,7723.79,,,7723.79,Other,260% New York Medicaid APG,9625.03,,,9625.03,Other,324% New York Medicaid APG,6386.98,,,6386.98,Other,215% New York Medicaid APG,6386.98,,,6386.98,Other,215% New York Medicaid APG,3713.36,,,3713.36,Other,125% New York Medicaid APG,2970.69,111352.72,
Remove part lumbar vertebra,22102,CPT,,,,,,,,both,,,150476.65,111352.72,74,,111352.72,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,67714.49,45,,67714.49,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,74485.94,49.5,,74485.94,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5525.48,,,5525.48,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,105333.66,70,,105333.66,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,2970.69,,,2970.69,Other,New York Medicaid APG methodology,2970.69,,,2970.69,Other,100% New York Medicaid APG,2970.69,,,2970.69,Other,100% New York Medicaid APG,2970.69,,,2970.69,Other,100% New York Medicaid APG,6684.05,,,6684.05,Other,225% New York Medicaid APG,4545.16,,,4545.16,Other,153% New York Medicaid APG,6684.05,,,6684.05,Other,225% New York Medicaid APG,4158.97,,,4158.97,Other,140% New York Medicaid APG,6684.05,,,6684.05,Other,225% New York Medicaid APG,7723.79,,,7723.79,Other,260% New York Medicaid APG,9625.03,,,9625.03,Other,324% New York Medicaid APG,6386.98,,,6386.98,Other,215% New York Medicaid APG,6386.98,,,6386.98,Other,215% New York Medicaid APG,3713.36,,,3713.36,Other,125% New York Medicaid APG,2970.69,111352.72,
Remove extra spine segment,22103,CPT,,,,,,,,both,,,64479.48,47714.82,74,,47714.82,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,29015.77,45,,29015.77,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,31917.34,49.5,,31917.34,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5525.48,,,5525.48,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,45135.64,70,,45135.64,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,2970.69,,,2970.69,Other,New York Medicaid APG methodology,2970.69,,,2970.69,Other,100% New York Medicaid APG,2970.69,,,2970.69,Other,100% New York Medicaid APG,2970.69,,,2970.69,Other,100% New York Medicaid APG,6684.05,,,6684.05,Other,225% New York Medicaid APG,4545.16,,,4545.16,Other,153% New York Medicaid APG,6684.05,,,6684.05,Other,225% New York Medicaid APG,4158.97,,,4158.97,Other,140% New York Medicaid APG,6684.05,,,6684.05,Other,225% New York Medicaid APG,7723.79,,,7723.79,Other,260% New York Medicaid APG,9625.03,,,9625.03,Other,324% New York Medicaid APG,6386.98,,,6386.98,Other,215% New York Medicaid APG,6386.98,,,6386.98,Other,215% New York Medicaid APG,3713.36,,,3713.36,Other,125% New York Medicaid APG,2743,47714.82,
Closed tx vert fx w/o manj,22310,CPT,,,,,,,,both,,,4960.23,3670.57,74,,3670.57,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,2232.1,45,,2232.1,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,2455.31,49.5,,2455.31,percent of total billed charges,110% of Medicare,3372.96,68,,3372.96,percent of total billed charges,,1031.43,,,1031.43,Other,186% of Medicaid,3968.18,80,,3968.18,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,3968.18,80,,3968.18,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,3472.16,70,,3472.16,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,554.53,,,554.53,Other,New York Medicaid APG methodology,554.53,,,554.53,Other,100% New York Medicaid APG,554.53,,,554.53,Other,100% New York Medicaid APG,554.53,,,554.53,Other,100% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,848.43,,,848.43,Other,153% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,776.34,,,776.34,Other,140% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,1441.78,,,1441.78,Other,260% New York Medicaid APG,1796.68,,,1796.68,Other,324% New York Medicaid APG,1192.24,,,1192.24,Other,215% New York Medicaid APG,1192.24,,,1192.24,Other,215% New York Medicaid APG,693.16,,,693.16,Other,125% New York Medicaid APG,554.53,7216,
Closed tx vert fx w/manj,22315,CPT,,,,,,,,both,,,68082.75,50381.24,74,,50381.24,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30637.24,45,,30637.24,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33700.96,49.5,,33700.96,percent of total billed charges,110% of Medicare,46296.27,68,,46296.27,percent of total billed charges,,1031.43,,,1031.43,Other,186% of Medicaid,54466.2,80,,54466.2,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,54466.2,80,,54466.2,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,47657.93,70,,47657.93,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,554.53,,,554.53,Other,New York Medicaid APG methodology,554.53,,,554.53,Other,100% New York Medicaid APG,554.53,,,554.53,Other,100% New York Medicaid APG,554.53,,,554.53,Other,100% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,848.43,,,848.43,Other,153% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,776.34,,,776.34,Other,140% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,1441.78,,,1441.78,Other,260% New York Medicaid APG,1796.68,,,1796.68,Other,324% New York Medicaid APG,1192.24,,,1192.24,Other,215% New York Medicaid APG,1192.24,,,1192.24,Other,215% New York Medicaid APG,693.16,,,693.16,Other,125% New York Medicaid APG,554.53,54466.2,
Manipulation of spine,22505,CPT,,,,,,,,both,,,33805.49,25016.06,74,,25016.06,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15212.47,45,,15212.47,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,16733.72,49.5,,16733.72,percent of total billed charges,110% of Medicare,22987.73,68,,22987.73,percent of total billed charges,,1730.38,,,1730.38,Other,186% of Medicaid,27044.39,80,,27044.39,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,27044.39,80,,27044.39,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,23663.84,70,,23663.84,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,930.31,,,930.31,Other,New York Medicaid APG methodology,930.31,,,930.31,Other,100% New York Medicaid APG,930.31,,,930.31,Other,100% New York Medicaid APG,930.31,,,930.31,Other,100% New York Medicaid APG,2093.21,,,2093.21,Other,225% New York Medicaid APG,1423.38,,,1423.38,Other,153% New York Medicaid APG,2093.21,,,2093.21,Other,225% New York Medicaid APG,1302.44,,,1302.44,Other,140% New York Medicaid APG,2093.21,,,2093.21,Other,225% New York Medicaid APG,2418.82,,,2418.82,Other,260% New York Medicaid APG,3014.22,,,3014.22,Other,324% New York Medicaid APG,2000.18,,,2000.18,Other,215% New York Medicaid APG,2000.18,,,2000.18,Other,215% New York Medicaid APG,1162.89,,,1162.89,Other,125% New York Medicaid APG,930.31,27044.39,
Perq cervicothoracic inject,22510,CPT,,,,,,,,both,,,68082.75,50381.24,74,,50381.24,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30637.24,45,,30637.24,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33700.96,49.5,,33700.96,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5525.48,,,5525.48,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,47657.93,70,,47657.93,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,2970.69,,,2970.69,Other,New York Medicaid APG methodology,2970.69,,,2970.69,Other,100% New York Medicaid APG,2970.69,,,2970.69,Other,100% New York Medicaid APG,2970.69,,,2970.69,Other,100% New York Medicaid APG,6684.05,,,6684.05,Other,225% New York Medicaid APG,4545.16,,,4545.16,Other,153% New York Medicaid APG,6684.05,,,6684.05,Other,225% New York Medicaid APG,4158.97,,,4158.97,Other,140% New York Medicaid APG,6684.05,,,6684.05,Other,225% New York Medicaid APG,7723.79,,,7723.79,Other,260% New York Medicaid APG,9625.03,,,9625.03,Other,324% New York Medicaid APG,6386.98,,,6386.98,Other,215% New York Medicaid APG,6386.98,,,6386.98,Other,215% New York Medicaid APG,3713.36,,,3713.36,Other,125% New York Medicaid APG,2970.69,50381.24,
Perq lumbosacral injection,22511,CPT,,,,,,,,both,,,68082.75,50381.24,74,,50381.24,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30637.24,45,,30637.24,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33700.96,49.5,,33700.96,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5525.48,,,5525.48,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,47657.93,70,,47657.93,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,2970.69,,,2970.69,Other,New York Medicaid APG methodology,2970.69,,,2970.69,Other,100% New York Medicaid APG,2970.69,,,2970.69,Other,100% New York Medicaid APG,2970.69,,,2970.69,Other,100% New York Medicaid APG,6684.05,,,6684.05,Other,225% New York Medicaid APG,4545.16,,,4545.16,Other,153% New York Medicaid APG,6684.05,,,6684.05,Other,225% New York Medicaid APG,4158.97,,,4158.97,Other,140% New York Medicaid APG,6684.05,,,6684.05,Other,225% New York Medicaid APG,7723.79,,,7723.79,Other,260% New York Medicaid APG,9625.03,,,9625.03,Other,324% New York Medicaid APG,6386.98,,,6386.98,Other,215% New York Medicaid APG,6386.98,,,6386.98,Other,215% New York Medicaid APG,3713.36,,,3713.36,Other,125% New York Medicaid APG,2970.69,50381.24,
Vertebroplasty addl inject,22512,CPT,,,,,,,,both,,,64479.48,47714.82,74,,47714.82,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,29015.77,45,,29015.77,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,31917.34,49.5,,31917.34,percent of total billed charges,110% of Medicare,43846.05,68,,43846.05,percent of total billed charges,,5525.48,,,5525.48,Other,186% of Medicaid,51583.58,80,,51583.58,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,51583.58,80,,51583.58,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,45135.64,70,,45135.64,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,2970.69,,,2970.69,Other,New York Medicaid APG methodology,2970.69,,,2970.69,Other,100% New York Medicaid APG,2970.69,,,2970.69,Other,100% New York Medicaid APG,2970.69,,,2970.69,Other,100% New York Medicaid APG,6684.05,,,6684.05,Other,225% New York Medicaid APG,4545.16,,,4545.16,Other,153% New York Medicaid APG,6684.05,,,6684.05,Other,225% New York Medicaid APG,4158.97,,,4158.97,Other,140% New York Medicaid APG,6684.05,,,6684.05,Other,225% New York Medicaid APG,7723.79,,,7723.79,Other,260% New York Medicaid APG,9625.03,,,9625.03,Other,324% New York Medicaid APG,6386.98,,,6386.98,Other,215% New York Medicaid APG,6386.98,,,6386.98,Other,215% New York Medicaid APG,3713.36,,,3713.36,Other,125% New York Medicaid APG,2053,51583.58,
Perq vertebral augmentation,22513,CPT,,,,,,,,both,,,75398.29,55794.73,74,,55794.73,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,33929.23,45,,33929.23,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,37322.15,49.5,,37322.15,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5525.48,,,5525.48,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,52778.8,70,,52778.8,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,2970.69,,,2970.69,Other,New York Medicaid APG methodology,2970.69,,,2970.69,Other,100% New York Medicaid APG,2970.69,,,2970.69,Other,100% New York Medicaid APG,2970.69,,,2970.69,Other,100% New York Medicaid APG,6684.05,,,6684.05,Other,225% New York Medicaid APG,4545.16,,,4545.16,Other,153% New York Medicaid APG,6684.05,,,6684.05,Other,225% New York Medicaid APG,4158.97,,,4158.97,Other,140% New York Medicaid APG,6684.05,,,6684.05,Other,225% New York Medicaid APG,7723.79,,,7723.79,Other,260% New York Medicaid APG,9625.03,,,9625.03,Other,324% New York Medicaid APG,6386.98,,,6386.98,Other,215% New York Medicaid APG,6386.98,,,6386.98,Other,215% New York Medicaid APG,3713.36,,,3713.36,Other,125% New York Medicaid APG,2970.69,55794.73,
Perq vertebral augmentation,22514,CPT,,,,,,,,both,,,62785.99,46461.63,74,,46461.63,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,28253.7,45,,28253.7,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,31079.07,49.5,,31079.07,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5525.48,,,5525.48,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,43950.19,70,,43950.19,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,2970.69,,,2970.69,Other,New York Medicaid APG methodology,2970.69,,,2970.69,Other,100% New York Medicaid APG,2970.69,,,2970.69,Other,100% New York Medicaid APG,2970.69,,,2970.69,Other,100% New York Medicaid APG,6684.05,,,6684.05,Other,225% New York Medicaid APG,4545.16,,,4545.16,Other,153% New York Medicaid APG,6684.05,,,6684.05,Other,225% New York Medicaid APG,4158.97,,,4158.97,Other,140% New York Medicaid APG,6684.05,,,6684.05,Other,225% New York Medicaid APG,7723.79,,,7723.79,Other,260% New York Medicaid APG,9625.03,,,9625.03,Other,324% New York Medicaid APG,6386.98,,,6386.98,Other,215% New York Medicaid APG,6386.98,,,6386.98,Other,215% New York Medicaid APG,3713.36,,,3713.36,Other,125% New York Medicaid APG,2970.69,46461.63,
Perq vertebral augmentation,22515,CPT,,,,,,,,both,,,83504,61792.96,74,,61792.96,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,37576.8,45,,37576.8,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,41334.48,49.5,,41334.48,percent of total billed charges,110% of Medicare,56782.72,68,,56782.72,percent of total billed charges,,5525.48,,,5525.48,Other,186% of Medicaid,66803.2,80,,66803.2,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,66803.2,80,,66803.2,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,58452.8,70,,58452.8,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,2970.69,,,2970.69,Other,New York Medicaid APG methodology,2970.69,,,2970.69,Other,100% New York Medicaid APG,2970.69,,,2970.69,Other,100% New York Medicaid APG,2970.69,,,2970.69,Other,100% New York Medicaid APG,6684.05,,,6684.05,Other,225% New York Medicaid APG,4545.16,,,4545.16,Other,153% New York Medicaid APG,6684.05,,,6684.05,Other,225% New York Medicaid APG,4158.97,,,4158.97,Other,140% New York Medicaid APG,6684.05,,,6684.05,Other,225% New York Medicaid APG,7723.79,,,7723.79,Other,260% New York Medicaid APG,9625.03,,,9625.03,Other,324% New York Medicaid APG,6386.98,,,6386.98,Other,215% New York Medicaid APG,6386.98,,,6386.98,Other,215% New York Medicaid APG,3713.36,,,3713.36,Other,125% New York Medicaid APG,2053,66803.2,
Neck spine fuse&remov bel c2,22551,CPT,,,,,,,,both,,,127397.61,94274.23,74,,94274.23,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,57328.92,45,,57328.92,percent of total billed charges,Medicare Ratio of cost to charges,5459,,"100% primary, 50% supplemental procedure",5459,Other,Aetna ASC Grouper,4913,,"100% primary, 50% supplemental procedure",4913,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,63061.82,49.5,,63061.82,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,6658.36,,,6658.36,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,89178.33,70,,89178.33,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,3579.77,,,3579.77,Other,New York Medicaid APG methodology,3579.77,,,3579.77,Other,100% New York Medicaid APG,3579.77,,,3579.77,Other,100% New York Medicaid APG,3579.77,,,3579.77,Other,100% New York Medicaid APG,8054.47,,,8054.47,Other,225% New York Medicaid APG,5477.04,,,5477.04,Other,153% New York Medicaid APG,8054.47,,,8054.47,Other,225% New York Medicaid APG,5011.67,,,5011.67,Other,140% New York Medicaid APG,8054.47,,,8054.47,Other,225% New York Medicaid APG,9307.39,,,9307.39,Other,260% New York Medicaid APG,11598.44,,,11598.44,Other,324% New York Medicaid APG,7696.5,,,7696.5,Other,215% New York Medicaid APG,7696.5,,,7696.5,Other,215% New York Medicaid APG,4474.71,,,4474.71,Other,125% New York Medicaid APG,3343,94274.23,
Addl neck spine fusion,22552,CPT,,,,,,,,both,,,90852.2,67230.63,74,,67230.63,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,40883.49,45,,40883.49,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,7266,,"100% primary, 50% secondary, 25% supplemental procedure",7266,Other,Blue Cross ASC Grouper,6539,,"100% primary, 50% secondary, 25% supplemental procedure",6539,Other,Blue Cross ASC Grouper,6176,,"100% primary, 50% secondary, 25% supplemental procedure",6176,Other,Blue Cross ASC Grouper,44971.84,49.5,,44971.84,percent of total billed charges,110% of Medicare,61779.5,68,,61779.5,percent of total billed charges,,6658.36,,,6658.36,Other,186% of Medicaid,72681.76,80,,72681.76,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,72681.76,80,,72681.76,percent of total billed charges,,7216,,,7216,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,63596.54,70,,63596.54,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,3579.77,,,3579.77,Other,New York Medicaid APG methodology,3579.77,,,3579.77,Other,100% New York Medicaid APG,3579.77,,,3579.77,Other,100% New York Medicaid APG,3579.77,,,3579.77,Other,100% New York Medicaid APG,8054.47,,,8054.47,Other,225% New York Medicaid APG,5477.04,,,5477.04,Other,153% New York Medicaid APG,8054.47,,,8054.47,Other,225% New York Medicaid APG,5011.67,,,5011.67,Other,140% New York Medicaid APG,8054.47,,,8054.47,Other,225% New York Medicaid APG,9307.39,,,9307.39,Other,260% New York Medicaid APG,11598.44,,,11598.44,Other,324% New York Medicaid APG,7696.5,,,7696.5,Other,215% New York Medicaid APG,7696.5,,,7696.5,Other,215% New York Medicaid APG,4474.71,,,4474.71,Other,125% New York Medicaid APG,2053,72681.76,
Neck spine fusion,22554,CPT,,,,,,,,both,,,276827.87,204852.62,74,,204852.62,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,124572.54,45,,124572.54,percent of total billed charges,Medicare Ratio of cost to charges,5459,,"100% primary, 50% supplemental procedure",5459,Other,Aetna ASC Grouper,4913,,"100% primary, 50% supplemental procedure",4913,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,137029.8,49.5,,137029.8,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,6658.36,,,6658.36,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,193779.51,70,,193779.51,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,3579.77,,,3579.77,Other,New York Medicaid APG methodology,3579.77,,,3579.77,Other,100% New York Medicaid APG,3579.77,,,3579.77,Other,100% New York Medicaid APG,3579.77,,,3579.77,Other,100% New York Medicaid APG,8054.47,,,8054.47,Other,225% New York Medicaid APG,5477.04,,,5477.04,Other,153% New York Medicaid APG,8054.47,,,8054.47,Other,225% New York Medicaid APG,5011.67,,,5011.67,Other,140% New York Medicaid APG,8054.47,,,8054.47,Other,225% New York Medicaid APG,9307.39,,,9307.39,Other,260% New York Medicaid APG,11598.44,,,11598.44,Other,324% New York Medicaid APG,7696.5,,,7696.5,Other,215% New York Medicaid APG,7696.5,,,7696.5,Other,215% New York Medicaid APG,4474.71,,,4474.71,Other,125% New York Medicaid APG,3343,204852.62,
Additional spinal fusion,22585,CPT,,,,,,,,both,,,90852.2,67230.63,74,,67230.63,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,40883.49,45,,40883.49,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,7266,,"100% primary, 50% secondary, 25% supplemental procedure",7266,Other,Blue Cross ASC Grouper,6539,,"100% primary, 50% secondary, 25% supplemental procedure",6539,Other,Blue Cross ASC Grouper,6176,,"100% primary, 50% secondary, 25% supplemental procedure",6176,Other,Blue Cross ASC Grouper,44971.84,49.5,,44971.84,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,6658.36,,,6658.36,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,63596.54,70,,63596.54,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,3579.77,,,3579.77,Other,New York Medicaid APG methodology,3579.77,,,3579.77,Other,100% New York Medicaid APG,3579.77,,,3579.77,Other,100% New York Medicaid APG,3579.77,,,3579.77,Other,100% New York Medicaid APG,8054.47,,,8054.47,Other,225% New York Medicaid APG,5477.04,,,5477.04,Other,153% New York Medicaid APG,8054.47,,,8054.47,Other,225% New York Medicaid APG,5011.67,,,5011.67,Other,140% New York Medicaid APG,8054.47,,,8054.47,Other,225% New York Medicaid APG,9307.39,,,9307.39,Other,260% New York Medicaid APG,11598.44,,,11598.44,Other,324% New York Medicaid APG,7696.5,,,7696.5,Other,215% New York Medicaid APG,7696.5,,,7696.5,Other,215% New York Medicaid APG,4474.71,,,4474.71,Other,125% New York Medicaid APG,3343,67230.63,
Lumbar spine fusion,22612,CPT,,,,,,,,both,,,165681.16,122604.06,74,,122604.06,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,74556.52,45,,74556.52,percent of total billed charges,Medicare Ratio of cost to charges,5459,,"100% primary, 50% supplemental procedure",5459,Other,Aetna ASC Grouper,4913,,"100% primary, 50% supplemental procedure",4913,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,82012.17,49.5,,82012.17,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,6658.36,,,6658.36,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,115976.81,70,,115976.81,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,3579.77,,,3579.77,Other,New York Medicaid APG methodology,3579.77,,,3579.77,Other,100% New York Medicaid APG,3579.77,,,3579.77,Other,100% New York Medicaid APG,3579.77,,,3579.77,Other,100% New York Medicaid APG,8054.47,,,8054.47,Other,225% New York Medicaid APG,5477.04,,,5477.04,Other,153% New York Medicaid APG,8054.47,,,8054.47,Other,225% New York Medicaid APG,5011.67,,,5011.67,Other,140% New York Medicaid APG,8054.47,,,8054.47,Other,225% New York Medicaid APG,9307.39,,,9307.39,Other,260% New York Medicaid APG,11598.44,,,11598.44,Other,324% New York Medicaid APG,7696.5,,,7696.5,Other,215% New York Medicaid APG,7696.5,,,7696.5,Other,215% New York Medicaid APG,4474.71,,,4474.71,Other,125% New York Medicaid APG,3343,122604.06,
Spine fusion extra segment,22614,CPT,,,,,,,,both,,,86591.4,64077.64,74,,64077.64,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,38966.13,45,,38966.13,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,6125,,"100% primary, 50% secondary, 25% supplemental procedure",6125,Other,Blue Cross ASC Grouper,5513,,"100% primary, 50% secondary, 25% supplemental procedure",5513,Other,Blue Cross ASC Grouper,5206,,"100% primary, 50% secondary, 25% supplemental procedure",5206,Other,Blue Cross ASC Grouper,42862.74,49.5,,42862.74,percent of total billed charges,110% of Medicare,58882.15,68,,58882.15,percent of total billed charges,,6658.36,,,6658.36,Other,186% of Medicaid,69273.12,80,,69273.12,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,69273.12,80,,69273.12,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,60613.98,70,,60613.98,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,3579.77,,,3579.77,Other,New York Medicaid APG methodology,3579.77,,,3579.77,Other,100% New York Medicaid APG,3579.77,,,3579.77,Other,100% New York Medicaid APG,3579.77,,,3579.77,Other,100% New York Medicaid APG,8054.47,,,8054.47,Other,225% New York Medicaid APG,5477.04,,,5477.04,Other,153% New York Medicaid APG,8054.47,,,8054.47,Other,225% New York Medicaid APG,5011.67,,,5011.67,Other,140% New York Medicaid APG,8054.47,,,8054.47,Other,225% New York Medicaid APG,9307.39,,,9307.39,Other,260% New York Medicaid APG,11598.44,,,11598.44,Other,324% New York Medicaid APG,7696.5,,,7696.5,Other,215% New York Medicaid APG,7696.5,,,7696.5,Other,215% New York Medicaid APG,4474.71,,,4474.71,Other,125% New York Medicaid APG,2053,69273.12,
Insert spine fixation device,22840,CPT,,,,,,,,both,,,90852.2,67230.63,74,,67230.63,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,40883.49,45,,40883.49,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,7266,,"100% primary, 50% secondary, 25% supplemental procedure",7266,Other,Blue Cross ASC Grouper,6539,,"100% primary, 50% secondary, 25% supplemental procedure",6539,Other,Blue Cross ASC Grouper,6176,,"100% primary, 50% secondary, 25% supplemental procedure",6176,Other,Blue Cross ASC Grouper,44971.84,49.5,,44971.84,percent of total billed charges,110% of Medicare,61779.5,68,,61779.5,percent of total billed charges,,6658.36,,,6658.36,Other,186% of Medicaid,72681.76,80,,72681.76,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,72681.76,80,,72681.76,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,63596.54,70,,63596.54,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,3579.77,,,3579.77,Other,New York Medicaid APG methodology,3579.77,,,3579.77,Other,100% New York Medicaid APG,3579.77,,,3579.77,Other,100% New York Medicaid APG,3579.77,,,3579.77,Other,100% New York Medicaid APG,8054.47,,,8054.47,Other,225% New York Medicaid APG,5477.04,,,5477.04,Other,153% New York Medicaid APG,8054.47,,,8054.47,Other,225% New York Medicaid APG,5011.67,,,5011.67,Other,140% New York Medicaid APG,8054.47,,,8054.47,Other,225% New York Medicaid APG,9307.39,,,9307.39,Other,260% New York Medicaid APG,11598.44,,,11598.44,Other,324% New York Medicaid APG,7696.5,,,7696.5,Other,215% New York Medicaid APG,7696.5,,,7696.5,Other,215% New York Medicaid APG,4474.71,,,4474.71,Other,125% New York Medicaid APG,2053,72681.76,
Insert spine fixation device,22842,CPT,,,,,,,,both,,,90852.2,67230.63,74,,67230.63,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,40883.49,45,,40883.49,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,7266,,"100% primary, 50% secondary, 25% supplemental procedure",7266,Other,Blue Cross ASC Grouper,6539,,"100% primary, 50% secondary, 25% supplemental procedure",6539,Other,Blue Cross ASC Grouper,6176,,"100% primary, 50% secondary, 25% supplemental procedure",6176,Other,Blue Cross ASC Grouper,44971.84,49.5,,44971.84,percent of total billed charges,110% of Medicare,61779.5,68,,61779.5,percent of total billed charges,,6658.36,,,6658.36,Other,186% of Medicaid,72681.76,80,,72681.76,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,72681.76,80,,72681.76,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,63596.54,70,,63596.54,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,3579.77,,,3579.77,Other,New York Medicaid APG methodology,3579.77,,,3579.77,Other,100% New York Medicaid APG,3579.77,,,3579.77,Other,100% New York Medicaid APG,3579.77,,,3579.77,Other,100% New York Medicaid APG,8054.47,,,8054.47,Other,225% New York Medicaid APG,5477.04,,,5477.04,Other,153% New York Medicaid APG,8054.47,,,8054.47,Other,225% New York Medicaid APG,5011.67,,,5011.67,Other,140% New York Medicaid APG,8054.47,,,8054.47,Other,225% New York Medicaid APG,9307.39,,,9307.39,Other,260% New York Medicaid APG,11598.44,,,11598.44,Other,324% New York Medicaid APG,7696.5,,,7696.5,Other,215% New York Medicaid APG,7696.5,,,7696.5,Other,215% New York Medicaid APG,4474.71,,,4474.71,Other,125% New York Medicaid APG,2053,72681.76,
Insert spine fixation device,22845,CPT,,,,,,,,both,,,90852.2,67230.63,74,,67230.63,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,40883.49,45,,40883.49,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,7266,,"100% primary, 50% secondary, 25% supplemental procedure",7266,Other,Blue Cross ASC Grouper,6539,,"100% primary, 50% secondary, 25% supplemental procedure",6539,Other,Blue Cross ASC Grouper,6176,,"100% primary, 50% secondary, 25% supplemental procedure",6176,Other,Blue Cross ASC Grouper,44971.84,49.5,,44971.84,percent of total billed charges,110% of Medicare,61779.5,68,,61779.5,percent of total billed charges,,6658.36,,,6658.36,Other,186% of Medicaid,72681.76,80,,72681.76,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,72681.76,80,,72681.76,percent of total billed charges,,7216,,,7216,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,63596.54,70,,63596.54,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,3579.77,,,3579.77,Other,New York Medicaid APG methodology,3579.77,,,3579.77,Other,100% New York Medicaid APG,3579.77,,,3579.77,Other,100% New York Medicaid APG,3579.77,,,3579.77,Other,100% New York Medicaid APG,8054.47,,,8054.47,Other,225% New York Medicaid APG,5477.04,,,5477.04,Other,153% New York Medicaid APG,8054.47,,,8054.47,Other,225% New York Medicaid APG,5011.67,,,5011.67,Other,140% New York Medicaid APG,8054.47,,,8054.47,Other,225% New York Medicaid APG,9307.39,,,9307.39,Other,260% New York Medicaid APG,11598.44,,,11598.44,Other,324% New York Medicaid APG,7696.5,,,7696.5,Other,215% New York Medicaid APG,7696.5,,,7696.5,Other,215% New York Medicaid APG,4474.71,,,4474.71,Other,125% New York Medicaid APG,2053,72681.76,
Insj biomechanical device,22853,CPT,,,,,,,,both,,,90852.2,67230.63,74,,67230.63,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,40883.49,45,,40883.49,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,7266,,"100% primary, 50% secondary, 25% supplemental procedure",7266,Other,Blue Cross ASC Grouper,6539,,"100% primary, 50% secondary, 25% supplemental procedure",6539,Other,Blue Cross ASC Grouper,6176,,"100% primary, 50% secondary, 25% supplemental procedure",6176,Other,Blue Cross ASC Grouper,44971.84,49.5,,44971.84,percent of total billed charges,110% of Medicare,61779.5,68,,61779.5,percent of total billed charges,,6658.36,,,6658.36,Other,186% of Medicaid,72681.76,80,,72681.76,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,72681.76,80,,72681.76,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,63596.54,70,,63596.54,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,3579.77,,,3579.77,Other,New York Medicaid APG methodology,3579.77,,,3579.77,Other,100% New York Medicaid APG,3579.77,,,3579.77,Other,100% New York Medicaid APG,3579.77,,,3579.77,Other,100% New York Medicaid APG,8054.47,,,8054.47,Other,225% New York Medicaid APG,5477.04,,,5477.04,Other,153% New York Medicaid APG,8054.47,,,8054.47,Other,225% New York Medicaid APG,5011.67,,,5011.67,Other,140% New York Medicaid APG,8054.47,,,8054.47,Other,225% New York Medicaid APG,9307.39,,,9307.39,Other,260% New York Medicaid APG,11598.44,,,11598.44,Other,324% New York Medicaid APG,7696.5,,,7696.5,Other,215% New York Medicaid APG,7696.5,,,7696.5,Other,215% New York Medicaid APG,4474.71,,,4474.71,Other,125% New York Medicaid APG,2053,72681.76,
Insj biomechanical device,22854,CPT,,,,,,,,both,,,90852.2,67230.63,74,,67230.63,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,40883.49,45,,40883.49,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,7266,,"100% primary, 50% secondary, 25% supplemental procedure",7266,Other,Blue Cross ASC Grouper,6539,,"100% primary, 50% secondary, 25% supplemental procedure",6539,Other,Blue Cross ASC Grouper,6176,,"100% primary, 50% secondary, 25% supplemental procedure",6176,Other,Blue Cross ASC Grouper,44971.84,49.5,,44971.84,percent of total billed charges,110% of Medicare,61779.5,68,,61779.5,percent of total billed charges,,6658.36,,,6658.36,Other,186% of Medicaid,72681.76,80,,72681.76,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,72681.76,80,,72681.76,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,63596.54,70,,63596.54,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,3579.77,,,3579.77,Other,New York Medicaid APG methodology,3579.77,,,3579.77,Other,100% New York Medicaid APG,3579.77,,,3579.77,Other,100% New York Medicaid APG,3579.77,,,3579.77,Other,100% New York Medicaid APG,8054.47,,,8054.47,Other,225% New York Medicaid APG,5477.04,,,5477.04,Other,153% New York Medicaid APG,8054.47,,,8054.47,Other,225% New York Medicaid APG,5011.67,,,5011.67,Other,140% New York Medicaid APG,8054.47,,,8054.47,Other,225% New York Medicaid APG,9307.39,,,9307.39,Other,260% New York Medicaid APG,11598.44,,,11598.44,Other,324% New York Medicaid APG,7696.5,,,7696.5,Other,215% New York Medicaid APG,7696.5,,,7696.5,Other,215% New York Medicaid APG,4474.71,,,4474.71,Other,125% New York Medicaid APG,2053,72681.76,
Cerv artific diskectomy,22856,CPT,,,,,,,,both,,,138249.61,102304.71,74,,102304.71,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,62212.32,45,,62212.32,percent of total billed charges,Medicare Ratio of cost to charges,5459,,"100% primary, 50% supplemental procedure",5459,Other,Aetna ASC Grouper,4913,,"100% primary, 50% supplemental procedure",4913,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,68433.56,49.5,,68433.56,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,6658.36,,,6658.36,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,96774.73,70,,96774.73,percent of total billed charges,,7999.92,,,7999.92,Fee Schedule,,6780.42,,,6780.42,Fee Schedule,,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,3579.77,,,3579.77,Other,New York Medicaid APG methodology,3579.77,,,3579.77,Other,100% New York Medicaid APG,3579.77,,,3579.77,Other,100% New York Medicaid APG,3579.77,,,3579.77,Other,100% New York Medicaid APG,8054.47,,,8054.47,Other,225% New York Medicaid APG,5477.04,,,5477.04,Other,153% New York Medicaid APG,8054.47,,,8054.47,Other,225% New York Medicaid APG,5011.67,,,5011.67,Other,140% New York Medicaid APG,8054.47,,,8054.47,Other,225% New York Medicaid APG,9307.39,,,9307.39,Other,260% New York Medicaid APG,11598.44,,,11598.44,Other,324% New York Medicaid APG,7696.5,,,7696.5,Other,215% New York Medicaid APG,7696.5,,,7696.5,Other,215% New York Medicaid APG,4474.71,,,4474.71,Other,125% New York Medicaid APG,3579.77,102304.71,
Second level cer diskectomy,22858,CPT,,,,,,,,both,,,83504,61792.96,74,,61792.96,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,37576.8,45,,37576.8,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,41334.48,49.5,,41334.48,percent of total billed charges,110% of Medicare,56782.72,68,,56782.72,percent of total billed charges,,6658.36,,,6658.36,Other,186% of Medicaid,66803.2,80,,66803.2,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,66803.2,80,,66803.2,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,58452.8,70,,58452.8,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,3579.77,,,3579.77,Other,New York Medicaid APG methodology,3579.77,,,3579.77,Other,100% New York Medicaid APG,3579.77,,,3579.77,Other,100% New York Medicaid APG,3579.77,,,3579.77,Other,100% New York Medicaid APG,8054.47,,,8054.47,Other,225% New York Medicaid APG,5477.04,,,5477.04,Other,153% New York Medicaid APG,8054.47,,,8054.47,Other,225% New York Medicaid APG,5011.67,,,5011.67,Other,140% New York Medicaid APG,8054.47,,,8054.47,Other,225% New York Medicaid APG,9307.39,,,9307.39,Other,260% New York Medicaid APG,11598.44,,,11598.44,Other,324% New York Medicaid APG,7696.5,,,7696.5,Other,215% New York Medicaid APG,7696.5,,,7696.5,Other,215% New York Medicaid APG,4474.71,,,4474.71,Other,125% New York Medicaid APG,2053,66803.2,
Insj biomechanical device,22859,CPT,,,,,,,,both,,,90852.2,67230.63,74,,67230.63,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,40883.49,45,,40883.49,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,7266,,"100% primary, 50% secondary, 25% supplemental procedure",7266,Other,Blue Cross ASC Grouper,6539,,"100% primary, 50% secondary, 25% supplemental procedure",6539,Other,Blue Cross ASC Grouper,6176,,"100% primary, 50% secondary, 25% supplemental procedure",6176,Other,Blue Cross ASC Grouper,44971.84,49.5,,44971.84,percent of total billed charges,110% of Medicare,61779.5,68,,61779.5,percent of total billed charges,,6658.36,,,6658.36,Other,186% of Medicaid,72681.76,80,,72681.76,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,72681.76,80,,72681.76,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,63596.54,70,,63596.54,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,3579.77,,,3579.77,Other,New York Medicaid APG methodology,3579.77,,,3579.77,Other,100% New York Medicaid APG,3579.77,,,3579.77,Other,100% New York Medicaid APG,3579.77,,,3579.77,Other,100% New York Medicaid APG,8054.47,,,8054.47,Other,225% New York Medicaid APG,5477.04,,,5477.04,Other,153% New York Medicaid APG,8054.47,,,8054.47,Other,225% New York Medicaid APG,5011.67,,,5011.67,Other,140% New York Medicaid APG,8054.47,,,8054.47,Other,225% New York Medicaid APG,9307.39,,,9307.39,Other,260% New York Medicaid APG,11598.44,,,11598.44,Other,324% New York Medicaid APG,7696.5,,,7696.5,Other,215% New York Medicaid APG,7696.5,,,7696.5,Other,215% New York Medicaid APG,4474.71,,,4474.71,Other,125% New York Medicaid APG,2053,72681.76,
Insj stablj dev w/dcmprn,22867,CPT,,,,,,,,both,,,391985.94,290069.6,74,,290069.6,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,176393.67,45,,176393.67,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,194033.04,49.5,,194033.04,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,6658.36,,,6658.36,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,274390.16,70,,274390.16,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,3579.77,,,3579.77,Other,New York Medicaid APG methodology,3579.77,,,3579.77,Other,100% New York Medicaid APG,3579.77,,,3579.77,Other,100% New York Medicaid APG,3579.77,,,3579.77,Other,100% New York Medicaid APG,8054.47,,,8054.47,Other,225% New York Medicaid APG,5477.04,,,5477.04,Other,153% New York Medicaid APG,8054.47,,,8054.47,Other,225% New York Medicaid APG,5011.67,,,5011.67,Other,140% New York Medicaid APG,8054.47,,,8054.47,Other,225% New York Medicaid APG,9307.39,,,9307.39,Other,260% New York Medicaid APG,11598.44,,,11598.44,Other,324% New York Medicaid APG,7696.5,,,7696.5,Other,215% New York Medicaid APG,7696.5,,,7696.5,Other,215% New York Medicaid APG,4474.71,,,4474.71,Other,125% New York Medicaid APG,3343,290069.6,
Insj stablj dev w/dcmprn,22868,CPT,,,,,,,,both,,,51572.04,38163.31,74,,38163.31,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,23207.42,45,,23207.42,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,25528.16,49.5,,25528.16,percent of total billed charges,110% of Medicare,35068.99,68,,35068.99,percent of total billed charges,,6658.36,,,6658.36,Other,186% of Medicaid,41257.63,80,,41257.63,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,41257.63,80,,41257.63,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,36100.43,70,,36100.43,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,3579.77,,,3579.77,Other,New York Medicaid APG methodology,3579.77,,,3579.77,Other,100% New York Medicaid APG,3579.77,,,3579.77,Other,100% New York Medicaid APG,3579.77,,,3579.77,Other,100% New York Medicaid APG,8054.47,,,8054.47,Other,225% New York Medicaid APG,5477.04,,,5477.04,Other,153% New York Medicaid APG,8054.47,,,8054.47,Other,225% New York Medicaid APG,5011.67,,,5011.67,Other,140% New York Medicaid APG,8054.47,,,8054.47,Other,225% New York Medicaid APG,9307.39,,,9307.39,Other,260% New York Medicaid APG,11598.44,,,11598.44,Other,324% New York Medicaid APG,7696.5,,,7696.5,Other,215% New York Medicaid APG,7696.5,,,7696.5,Other,215% New York Medicaid APG,4474.71,,,4474.71,Other,125% New York Medicaid APG,2053,41257.63,
Insj stablj dev w/o dcmprn,22869,CPT,,,,,,,,both,,,60822,45008.28,74,,45008.28,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,27369.9,45,,27369.9,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,30106.89,49.5,,30106.89,percent of total billed charges,110% of Medicare,41358.96,68,,41358.96,percent of total billed charges,,6658.36,,,6658.36,Other,186% of Medicaid,48657.6,80,,48657.6,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,48657.6,80,,48657.6,percent of total billed charges,,7216,,,7216,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,42575.4,70,,42575.4,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,3579.77,,,3579.77,Other,New York Medicaid APG methodology,3579.77,,,3579.77,Other,100% New York Medicaid APG,3579.77,,,3579.77,Other,100% New York Medicaid APG,3579.77,,,3579.77,Other,100% New York Medicaid APG,8054.47,,,8054.47,Other,225% New York Medicaid APG,5477.04,,,5477.04,Other,153% New York Medicaid APG,8054.47,,,8054.47,Other,225% New York Medicaid APG,5011.67,,,5011.67,Other,140% New York Medicaid APG,8054.47,,,8054.47,Other,225% New York Medicaid APG,9307.39,,,9307.39,Other,260% New York Medicaid APG,11598.44,,,11598.44,Other,324% New York Medicaid APG,7696.5,,,7696.5,Other,215% New York Medicaid APG,7696.5,,,7696.5,Other,215% New York Medicaid APG,4474.71,,,4474.71,Other,125% New York Medicaid APG,2232,48657.6,
Insj stablj dev w/o dcmprn,22870,CPT,,,,,,,,both,,,51572.04,38163.31,74,,38163.31,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,23207.42,45,,23207.42,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,25528.16,49.5,,25528.16,percent of total billed charges,110% of Medicare,35068.99,68,,35068.99,percent of total billed charges,,6658.36,,,6658.36,Other,186% of Medicaid,41257.63,80,,41257.63,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,41257.63,80,,41257.63,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,36100.43,70,,36100.43,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,3579.77,,,3579.77,Other,New York Medicaid APG methodology,3579.77,,,3579.77,Other,100% New York Medicaid APG,3579.77,,,3579.77,Other,100% New York Medicaid APG,3579.77,,,3579.77,Other,100% New York Medicaid APG,8054.47,,,8054.47,Other,225% New York Medicaid APG,5477.04,,,5477.04,Other,153% New York Medicaid APG,8054.47,,,8054.47,Other,225% New York Medicaid APG,5011.67,,,5011.67,Other,140% New York Medicaid APG,8054.47,,,8054.47,Other,225% New York Medicaid APG,9307.39,,,9307.39,Other,260% New York Medicaid APG,11598.44,,,11598.44,Other,324% New York Medicaid APG,7696.5,,,7696.5,Other,215% New York Medicaid APG,7696.5,,,7696.5,Other,215% New York Medicaid APG,4474.71,,,4474.71,Other,125% New York Medicaid APG,2053,41257.63,
Exc abdl tum deep < 5 cm,22900,CPT,,,,,,,,both,,,59767.2,44227.73,74,,44227.73,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,26895.24,45,,26895.24,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,29584.76,49.5,,29584.76,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,1973.06,,,1973.06,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,41837.04,70,,41837.04,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1060.79,,,1060.79,Other,New York Medicaid APG methodology,1060.79,,,1060.79,Other,100% New York Medicaid APG,1060.79,,,1060.79,Other,100% New York Medicaid APG,1060.79,,,1060.79,Other,100% New York Medicaid APG,2386.77,,,2386.77,Other,225% New York Medicaid APG,1623,,,1623,Other,153% New York Medicaid APG,2386.77,,,2386.77,Other,225% New York Medicaid APG,1485.1,,,1485.1,Other,140% New York Medicaid APG,2386.77,,,2386.77,Other,225% New York Medicaid APG,2758.05,,,2758.05,Other,260% New York Medicaid APG,3436.95,,,3436.95,Other,324% New York Medicaid APG,2280.69,,,2280.69,Other,215% New York Medicaid APG,2280.69,,,2280.69,Other,215% New York Medicaid APG,1325.98,,,1325.98,Other,125% New York Medicaid APG,1060.79,44227.73,
Exc abdl tum deep 5 cm/>,22901,CPT,,,,,,,,both,,,37474.21,27730.92,74,,27730.92,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,16863.39,45,,16863.39,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,18549.73,49.5,,18549.73,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,1973.06,,,1973.06,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,26231.95,70,,26231.95,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1060.79,,,1060.79,Other,New York Medicaid APG methodology,1060.79,,,1060.79,Other,100% New York Medicaid APG,1060.79,,,1060.79,Other,100% New York Medicaid APG,1060.79,,,1060.79,Other,100% New York Medicaid APG,2386.77,,,2386.77,Other,225% New York Medicaid APG,1623,,,1623,Other,153% New York Medicaid APG,2386.77,,,2386.77,Other,225% New York Medicaid APG,1485.1,,,1485.1,Other,140% New York Medicaid APG,2386.77,,,2386.77,Other,225% New York Medicaid APG,2758.05,,,2758.05,Other,260% New York Medicaid APG,3436.95,,,3436.95,Other,324% New York Medicaid APG,2280.69,,,2280.69,Other,215% New York Medicaid APG,2280.69,,,2280.69,Other,215% New York Medicaid APG,1325.98,,,1325.98,Other,125% New York Medicaid APG,1060.79,27730.92,
Exc abd les sc < 3 cm,22902,CPT,,,,,,,,both,,,38632.15,28587.79,74,,28587.79,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,17384.47,45,,17384.47,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,19122.91,49.5,,19122.91,percent of total billed charges,110% of Medicare,26269.86,68,,26269.86,percent of total billed charges,,1973.06,,,1973.06,Other,186% of Medicaid,30905.72,80,,30905.72,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,30905.72,80,,30905.72,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,27042.51,70,,27042.51,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1060.79,,,1060.79,Other,New York Medicaid APG methodology,1060.79,,,1060.79,Other,100% New York Medicaid APG,1060.79,,,1060.79,Other,100% New York Medicaid APG,1060.79,,,1060.79,Other,100% New York Medicaid APG,2386.77,,,2386.77,Other,225% New York Medicaid APG,1623,,,1623,Other,153% New York Medicaid APG,2386.77,,,2386.77,Other,225% New York Medicaid APG,1485.1,,,1485.1,Other,140% New York Medicaid APG,2386.77,,,2386.77,Other,225% New York Medicaid APG,2758.05,,,2758.05,Other,260% New York Medicaid APG,3436.95,,,3436.95,Other,324% New York Medicaid APG,2280.69,,,2280.69,Other,215% New York Medicaid APG,2280.69,,,2280.69,Other,215% New York Medicaid APG,1325.98,,,1325.98,Other,125% New York Medicaid APG,1060.79,30905.72,
Exc abd les sc 3 cm/>,22903,CPT,,,,,,,,both,,,36069.68,26691.56,74,,26691.56,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,16231.36,45,,16231.36,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,17854.49,49.5,,17854.49,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,1973.06,,,1973.06,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,25248.78,70,,25248.78,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1060.79,,,1060.79,Other,New York Medicaid APG methodology,1060.79,,,1060.79,Other,100% New York Medicaid APG,1060.79,,,1060.79,Other,100% New York Medicaid APG,1060.79,,,1060.79,Other,100% New York Medicaid APG,2386.77,,,2386.77,Other,225% New York Medicaid APG,1623,,,1623,Other,153% New York Medicaid APG,2386.77,,,2386.77,Other,225% New York Medicaid APG,1485.1,,,1485.1,Other,140% New York Medicaid APG,2386.77,,,2386.77,Other,225% New York Medicaid APG,2758.05,,,2758.05,Other,260% New York Medicaid APG,3436.95,,,3436.95,Other,324% New York Medicaid APG,2280.69,,,2280.69,Other,215% New York Medicaid APG,2280.69,,,2280.69,Other,215% New York Medicaid APG,1325.98,,,1325.98,Other,125% New York Medicaid APG,1060.79,26691.56,
Radical resect abd tumor<5cm,22904,CPT,,,,,,,,both,,,59767.2,44227.73,74,,44227.73,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,26895.24,45,,26895.24,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,29584.76,49.5,,29584.76,percent of total billed charges,110% of Medicare,40641.7,68,,40641.7,percent of total billed charges,,1973.06,,,1973.06,Other,186% of Medicaid,47813.76,80,,47813.76,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,47813.76,80,,47813.76,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,41837.04,70,,41837.04,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1060.79,,,1060.79,Other,New York Medicaid APG methodology,1060.79,,,1060.79,Other,100% New York Medicaid APG,1060.79,,,1060.79,Other,100% New York Medicaid APG,1060.79,,,1060.79,Other,100% New York Medicaid APG,2386.77,,,2386.77,Other,225% New York Medicaid APG,1623,,,1623,Other,153% New York Medicaid APG,2386.77,,,2386.77,Other,225% New York Medicaid APG,1485.1,,,1485.1,Other,140% New York Medicaid APG,2386.77,,,2386.77,Other,225% New York Medicaid APG,2758.05,,,2758.05,Other,260% New York Medicaid APG,3436.95,,,3436.95,Other,324% New York Medicaid APG,2280.69,,,2280.69,Other,215% New York Medicaid APG,2280.69,,,2280.69,Other,215% New York Medicaid APG,1325.98,,,1325.98,Other,125% New York Medicaid APG,1060.79,47813.76,
Rad resect abd tumor 5 cm/>,22905,CPT,,,,,,,,both,,,59767.2,44227.73,74,,44227.73,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,26895.24,45,,26895.24,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,29584.76,49.5,,29584.76,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,1973.06,,,1973.06,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,41837.04,70,,41837.04,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1060.79,,,1060.79,Other,New York Medicaid APG methodology,1060.79,,,1060.79,Other,100% New York Medicaid APG,1060.79,,,1060.79,Other,100% New York Medicaid APG,1060.79,,,1060.79,Other,100% New York Medicaid APG,2386.77,,,2386.77,Other,225% New York Medicaid APG,1623,,,1623,Other,153% New York Medicaid APG,2386.77,,,2386.77,Other,225% New York Medicaid APG,1485.1,,,1485.1,Other,140% New York Medicaid APG,2386.77,,,2386.77,Other,225% New York Medicaid APG,2758.05,,,2758.05,Other,260% New York Medicaid APG,3436.95,,,3436.95,Other,324% New York Medicaid APG,2280.69,,,2280.69,Other,215% New York Medicaid APG,2280.69,,,2280.69,Other,215% New York Medicaid APG,1325.98,,,1325.98,Other,125% New York Medicaid APG,1060.79,44227.73,
Removal of calcium deposits,23000,CPT,,,,,,,,both,,,59767.2,44227.73,74,,44227.73,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,26895.24,45,,26895.24,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,29584.76,49.5,,29584.76,percent of total billed charges,110% of Medicare,40641.7,68,,40641.7,percent of total billed charges,,1973.06,,,1973.06,Other,186% of Medicaid,47813.76,80,,47813.76,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,47813.76,80,,47813.76,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,41837.04,70,,41837.04,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1060.79,,,1060.79,Other,New York Medicaid APG methodology,1060.79,,,1060.79,Other,100% New York Medicaid APG,1060.79,,,1060.79,Other,100% New York Medicaid APG,1060.79,,,1060.79,Other,100% New York Medicaid APG,2386.77,,,2386.77,Other,225% New York Medicaid APG,1623,,,1623,Other,153% New York Medicaid APG,2386.77,,,2386.77,Other,225% New York Medicaid APG,1485.1,,,1485.1,Other,140% New York Medicaid APG,2386.77,,,2386.77,Other,225% New York Medicaid APG,2758.05,,,2758.05,Other,260% New York Medicaid APG,3436.95,,,3436.95,Other,324% New York Medicaid APG,2280.69,,,2280.69,Other,215% New York Medicaid APG,2280.69,,,2280.69,Other,215% New York Medicaid APG,1325.98,,,1325.98,Other,125% New York Medicaid APG,1060.79,47813.76,
Release shoulder joint,23020,CPT,,,,,,,,both,,,68082.75,50381.24,74,,50381.24,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30637.24,45,,30637.24,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33700.96,49.5,,33700.96,percent of total billed charges,110% of Medicare,46296.27,68,,46296.27,percent of total billed charges,,3960.57,,,3960.57,Other,186% of Medicaid,54466.2,80,,54466.2,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,54466.2,80,,54466.2,percent of total billed charges,,7216,,,7216,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,47657.93,70,,47657.93,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,2129.34,,,2129.34,Other,New York Medicaid APG methodology,2129.34,,,2129.34,Other,100% New York Medicaid APG,2129.34,,,2129.34,Other,100% New York Medicaid APG,2129.34,,,2129.34,Other,100% New York Medicaid APG,4791.01,,,4791.01,Other,225% New York Medicaid APG,3257.89,,,3257.89,Other,153% New York Medicaid APG,4791.01,,,4791.01,Other,225% New York Medicaid APG,2981.08,,,2981.08,Other,140% New York Medicaid APG,4791.01,,,4791.01,Other,225% New York Medicaid APG,5536.28,,,5536.28,Other,260% New York Medicaid APG,6899.06,,,6899.06,Other,324% New York Medicaid APG,4578.08,,,4578.08,Other,215% New York Medicaid APG,4578.08,,,4578.08,Other,215% New York Medicaid APG,2661.67,,,2661.67,Other,125% New York Medicaid APG,2129.34,54466.2,
Drain shoulder lesion,23030,CPT,,,,,,,,both,,,59767.2,44227.73,74,,44227.73,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,26895.24,45,,26895.24,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,29584.76,49.5,,29584.76,percent of total billed charges,110% of Medicare,40641.7,68,,40641.7,percent of total billed charges,,1973.06,,,1973.06,Other,186% of Medicaid,47813.76,80,,47813.76,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,47813.76,80,,47813.76,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,41837.04,70,,41837.04,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1060.79,,,1060.79,Other,New York Medicaid APG methodology,1060.79,,,1060.79,Other,100% New York Medicaid APG,1060.79,,,1060.79,Other,100% New York Medicaid APG,1060.79,,,1060.79,Other,100% New York Medicaid APG,2386.77,,,2386.77,Other,225% New York Medicaid APG,1623,,,1623,Other,153% New York Medicaid APG,2386.77,,,2386.77,Other,225% New York Medicaid APG,1485.1,,,1485.1,Other,140% New York Medicaid APG,2386.77,,,2386.77,Other,225% New York Medicaid APG,2758.05,,,2758.05,Other,260% New York Medicaid APG,3436.95,,,3436.95,Other,324% New York Medicaid APG,2280.69,,,2280.69,Other,215% New York Medicaid APG,2280.69,,,2280.69,Other,215% New York Medicaid APG,1325.98,,,1325.98,Other,125% New York Medicaid APG,1060.79,47813.76,
Drain shoulder bursa,23031,CPT,,,,,,,,both,,,59767.2,44227.73,74,,44227.73,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,26895.24,45,,26895.24,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,29584.76,49.5,,29584.76,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,1973.06,,,1973.06,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,41837.04,70,,41837.04,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1060.79,,,1060.79,Other,New York Medicaid APG methodology,1060.79,,,1060.79,Other,100% New York Medicaid APG,1060.79,,,1060.79,Other,100% New York Medicaid APG,1060.79,,,1060.79,Other,100% New York Medicaid APG,2386.77,,,2386.77,Other,225% New York Medicaid APG,1623,,,1623,Other,153% New York Medicaid APG,2386.77,,,2386.77,Other,225% New York Medicaid APG,1485.1,,,1485.1,Other,140% New York Medicaid APG,2386.77,,,2386.77,Other,225% New York Medicaid APG,2758.05,,,2758.05,Other,260% New York Medicaid APG,3436.95,,,3436.95,Other,324% New York Medicaid APG,2280.69,,,2280.69,Other,215% New York Medicaid APG,2280.69,,,2280.69,Other,215% New York Medicaid APG,1325.98,,,1325.98,Other,125% New York Medicaid APG,1060.79,44227.73,
Drain shoulder bone lesion,23035,CPT,,,,,,,,both,,,33805.49,25016.06,74,,25016.06,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15212.47,45,,15212.47,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,16733.72,49.5,,16733.72,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3960.57,,,3960.57,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,23663.84,70,,23663.84,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,2129.34,,,2129.34,Other,New York Medicaid APG methodology,2129.34,,,2129.34,Other,100% New York Medicaid APG,2129.34,,,2129.34,Other,100% New York Medicaid APG,2129.34,,,2129.34,Other,100% New York Medicaid APG,4791.01,,,4791.01,Other,225% New York Medicaid APG,3257.89,,,3257.89,Other,153% New York Medicaid APG,4791.01,,,4791.01,Other,225% New York Medicaid APG,2981.08,,,2981.08,Other,140% New York Medicaid APG,4791.01,,,4791.01,Other,225% New York Medicaid APG,5536.28,,,5536.28,Other,260% New York Medicaid APG,6899.06,,,6899.06,Other,324% New York Medicaid APG,4578.08,,,4578.08,Other,215% New York Medicaid APG,4578.08,,,4578.08,Other,215% New York Medicaid APG,2661.67,,,2661.67,Other,125% New York Medicaid APG,2129.34,25016.06,
Exploratory shoulder surgery,23040,CPT,,,,,,,,both,,,68082.75,50381.24,74,,50381.24,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30637.24,45,,30637.24,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33700.96,49.5,,33700.96,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3960.57,,,3960.57,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,47657.93,70,,47657.93,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,2129.34,,,2129.34,Other,New York Medicaid APG methodology,2129.34,,,2129.34,Other,100% New York Medicaid APG,2129.34,,,2129.34,Other,100% New York Medicaid APG,2129.34,,,2129.34,Other,100% New York Medicaid APG,4791.01,,,4791.01,Other,225% New York Medicaid APG,3257.89,,,3257.89,Other,153% New York Medicaid APG,4791.01,,,4791.01,Other,225% New York Medicaid APG,2981.08,,,2981.08,Other,140% New York Medicaid APG,4791.01,,,4791.01,Other,225% New York Medicaid APG,5536.28,,,5536.28,Other,260% New York Medicaid APG,6899.06,,,6899.06,Other,324% New York Medicaid APG,4578.08,,,4578.08,Other,215% New York Medicaid APG,4578.08,,,4578.08,Other,215% New York Medicaid APG,2661.67,,,2661.67,Other,125% New York Medicaid APG,2129.34,50381.24,
Exploratory shoulder surgery,23044,CPT,,,,,,,,both,,,68082.75,50381.24,74,,50381.24,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30637.24,45,,30637.24,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33700.96,49.5,,33700.96,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3960.57,,,3960.57,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,47657.93,70,,47657.93,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,2129.34,,,2129.34,Other,New York Medicaid APG methodology,2129.34,,,2129.34,Other,100% New York Medicaid APG,2129.34,,,2129.34,Other,100% New York Medicaid APG,2129.34,,,2129.34,Other,100% New York Medicaid APG,4791.01,,,4791.01,Other,225% New York Medicaid APG,3257.89,,,3257.89,Other,153% New York Medicaid APG,4791.01,,,4791.01,Other,225% New York Medicaid APG,2981.08,,,2981.08,Other,140% New York Medicaid APG,4791.01,,,4791.01,Other,225% New York Medicaid APG,5536.28,,,5536.28,Other,260% New York Medicaid APG,6899.06,,,6899.06,Other,324% New York Medicaid APG,4578.08,,,4578.08,Other,215% New York Medicaid APG,4578.08,,,4578.08,Other,215% New York Medicaid APG,2661.67,,,2661.67,Other,125% New York Medicaid APG,2129.34,50381.24,
Biopsy shoulder tissues,23065,CPT,,,,,,,,both,,,34101.75,25235.3,74,,25235.3,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15345.79,45,,15345.79,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,16880.37,49.5,,16880.37,percent of total billed charges,110% of Medicare,23189.19,68,,23189.19,percent of total billed charges,,1973.06,,,1973.06,Other,186% of Medicaid,27281.4,80,,27281.4,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,27281.4,80,,27281.4,percent of total billed charges,,7216,,,7216,Case Rate,,3578,,"100% primary, 0% secondary procedures",3578,Other,MagnaCare ASC Grouper,23871.23,70,,23871.23,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,1060.79,,,1060.79,Other,New York Medicaid APG methodology,1060.79,,,1060.79,Other,100% New York Medicaid APG,1060.79,,,1060.79,Other,100% New York Medicaid APG,1060.79,,,1060.79,Other,100% New York Medicaid APG,2386.77,,,2386.77,Other,225% New York Medicaid APG,1623,,,1623,Other,153% New York Medicaid APG,2386.77,,,2386.77,Other,225% New York Medicaid APG,1485.1,,,1485.1,Other,140% New York Medicaid APG,2386.77,,,2386.77,Other,225% New York Medicaid APG,2758.05,,,2758.05,Other,260% New York Medicaid APG,3436.95,,,3436.95,Other,324% New York Medicaid APG,2280.69,,,2280.69,Other,215% New York Medicaid APG,2280.69,,,2280.69,Other,215% New York Medicaid APG,1325.98,,,1325.98,Other,125% New York Medicaid APG,1060.79,27281.4,
Biopsy shoulder tissues,23066,CPT,,,,,,,,both,,,59767.2,44227.73,74,,44227.73,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,26895.24,45,,26895.24,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,29584.76,49.5,,29584.76,percent of total billed charges,110% of Medicare,40641.7,68,,40641.7,percent of total billed charges,,1973.06,,,1973.06,Other,186% of Medicaid,47813.76,80,,47813.76,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,47813.76,80,,47813.76,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,41837.04,70,,41837.04,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1060.79,,,1060.79,Other,New York Medicaid APG methodology,1060.79,,,1060.79,Other,100% New York Medicaid APG,1060.79,,,1060.79,Other,100% New York Medicaid APG,1060.79,,,1060.79,Other,100% New York Medicaid APG,2386.77,,,2386.77,Other,225% New York Medicaid APG,1623,,,1623,Other,153% New York Medicaid APG,2386.77,,,2386.77,Other,225% New York Medicaid APG,1485.1,,,1485.1,Other,140% New York Medicaid APG,2386.77,,,2386.77,Other,225% New York Medicaid APG,2758.05,,,2758.05,Other,260% New York Medicaid APG,3436.95,,,3436.95,Other,324% New York Medicaid APG,2280.69,,,2280.69,Other,215% New York Medicaid APG,2280.69,,,2280.69,Other,215% New York Medicaid APG,1325.98,,,1325.98,Other,125% New York Medicaid APG,1060.79,47813.76,
Exc shoulder les sc 3 cm/>,23071,CPT,,,,,,,,both,,,36184.86,26776.8,74,,26776.8,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,16283.19,45,,16283.19,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,17911.51,49.5,,17911.51,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,1973.06,,,1973.06,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,25329.4,70,,25329.4,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1060.79,,,1060.79,Other,New York Medicaid APG methodology,1060.79,,,1060.79,Other,100% New York Medicaid APG,1060.79,,,1060.79,Other,100% New York Medicaid APG,1060.79,,,1060.79,Other,100% New York Medicaid APG,2386.77,,,2386.77,Other,225% New York Medicaid APG,1623,,,1623,Other,153% New York Medicaid APG,2386.77,,,2386.77,Other,225% New York Medicaid APG,1485.1,,,1485.1,Other,140% New York Medicaid APG,2386.77,,,2386.77,Other,225% New York Medicaid APG,2758.05,,,2758.05,Other,260% New York Medicaid APG,3436.95,,,3436.95,Other,324% New York Medicaid APG,2280.69,,,2280.69,Other,215% New York Medicaid APG,2280.69,,,2280.69,Other,215% New York Medicaid APG,1325.98,,,1325.98,Other,125% New York Medicaid APG,1060.79,26776.8,
Exc shoulder tum deep 5 cm/>,23073,CPT,,,,,,,,both,,,34368.36,25432.59,74,,25432.59,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15465.76,45,,15465.76,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,17012.34,49.5,,17012.34,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,1973.06,,,1973.06,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,24057.85,70,,24057.85,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1060.79,,,1060.79,Other,New York Medicaid APG methodology,1060.79,,,1060.79,Other,100% New York Medicaid APG,1060.79,,,1060.79,Other,100% New York Medicaid APG,1060.79,,,1060.79,Other,100% New York Medicaid APG,2386.77,,,2386.77,Other,225% New York Medicaid APG,1623,,,1623,Other,153% New York Medicaid APG,2386.77,,,2386.77,Other,225% New York Medicaid APG,1485.1,,,1485.1,Other,140% New York Medicaid APG,2386.77,,,2386.77,Other,225% New York Medicaid APG,2758.05,,,2758.05,Other,260% New York Medicaid APG,3436.95,,,3436.95,Other,324% New York Medicaid APG,2280.69,,,2280.69,Other,215% New York Medicaid APG,2280.69,,,2280.69,Other,215% New York Medicaid APG,1325.98,,,1325.98,Other,125% New York Medicaid APG,1060.79,25432.59,
Exc shoulder les sc < 3 cm,23075,CPT,,,,,,,,both,,,34101.75,25235.3,74,,25235.3,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15345.79,45,,15345.79,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,16880.37,49.5,,16880.37,percent of total billed charges,110% of Medicare,23189.19,68,,23189.19,percent of total billed charges,,1973.06,,,1973.06,Other,186% of Medicaid,27281.4,80,,27281.4,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,27281.4,80,,27281.4,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,23871.23,70,,23871.23,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1060.79,,,1060.79,Other,New York Medicaid APG methodology,1060.79,,,1060.79,Other,100% New York Medicaid APG,1060.79,,,1060.79,Other,100% New York Medicaid APG,1060.79,,,1060.79,Other,100% New York Medicaid APG,2386.77,,,2386.77,Other,225% New York Medicaid APG,1623,,,1623,Other,153% New York Medicaid APG,2386.77,,,2386.77,Other,225% New York Medicaid APG,1485.1,,,1485.1,Other,140% New York Medicaid APG,2386.77,,,2386.77,Other,225% New York Medicaid APG,2758.05,,,2758.05,Other,260% New York Medicaid APG,3436.95,,,3436.95,Other,324% New York Medicaid APG,2280.69,,,2280.69,Other,215% New York Medicaid APG,2280.69,,,2280.69,Other,215% New York Medicaid APG,1325.98,,,1325.98,Other,125% New York Medicaid APG,1060.79,27281.4,
Exc shoulder tum deep < 5 cm,23076,CPT,,,,,,,,both,,,59767.2,44227.73,74,,44227.73,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,26895.24,45,,26895.24,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,29584.76,49.5,,29584.76,percent of total billed charges,110% of Medicare,40641.7,68,,40641.7,percent of total billed charges,,1973.06,,,1973.06,Other,186% of Medicaid,47813.76,80,,47813.76,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,47813.76,80,,47813.76,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,41837.04,70,,41837.04,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1060.79,,,1060.79,Other,New York Medicaid APG methodology,1060.79,,,1060.79,Other,100% New York Medicaid APG,1060.79,,,1060.79,Other,100% New York Medicaid APG,1060.79,,,1060.79,Other,100% New York Medicaid APG,2386.77,,,2386.77,Other,225% New York Medicaid APG,1623,,,1623,Other,153% New York Medicaid APG,2386.77,,,2386.77,Other,225% New York Medicaid APG,1485.1,,,1485.1,Other,140% New York Medicaid APG,2386.77,,,2386.77,Other,225% New York Medicaid APG,2758.05,,,2758.05,Other,260% New York Medicaid APG,3436.95,,,3436.95,Other,324% New York Medicaid APG,2280.69,,,2280.69,Other,215% New York Medicaid APG,2280.69,,,2280.69,Other,215% New York Medicaid APG,1325.98,,,1325.98,Other,125% New York Medicaid APG,1060.79,47813.76,
Resect shoulder tumor < 5 cm,23077,CPT,,,,,,,,both,,,59767.2,44227.73,74,,44227.73,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,26895.24,45,,26895.24,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,29584.76,49.5,,29584.76,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3960.57,,,3960.57,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,41837.04,70,,41837.04,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,2129.34,,,2129.34,Other,New York Medicaid APG methodology,2129.34,,,2129.34,Other,100% New York Medicaid APG,2129.34,,,2129.34,Other,100% New York Medicaid APG,2129.34,,,2129.34,Other,100% New York Medicaid APG,4791.01,,,4791.01,Other,225% New York Medicaid APG,3257.89,,,3257.89,Other,153% New York Medicaid APG,4791.01,,,4791.01,Other,225% New York Medicaid APG,2981.08,,,2981.08,Other,140% New York Medicaid APG,4791.01,,,4791.01,Other,225% New York Medicaid APG,5536.28,,,5536.28,Other,260% New York Medicaid APG,6899.06,,,6899.06,Other,324% New York Medicaid APG,4578.08,,,4578.08,Other,215% New York Medicaid APG,4578.08,,,4578.08,Other,215% New York Medicaid APG,2661.67,,,2661.67,Other,125% New York Medicaid APG,2129.34,44227.73,
Resect shoulder tumor 5 cm/>,23078,CPT,,,,,,,,both,,,59767.2,44227.73,74,,44227.73,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,26895.24,45,,26895.24,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,29584.76,49.5,,29584.76,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3960.57,,,3960.57,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,41837.04,70,,41837.04,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,2129.34,,,2129.34,Other,New York Medicaid APG methodology,2129.34,,,2129.34,Other,100% New York Medicaid APG,2129.34,,,2129.34,Other,100% New York Medicaid APG,2129.34,,,2129.34,Other,100% New York Medicaid APG,4791.01,,,4791.01,Other,225% New York Medicaid APG,3257.89,,,3257.89,Other,153% New York Medicaid APG,4791.01,,,4791.01,Other,225% New York Medicaid APG,2981.08,,,2981.08,Other,140% New York Medicaid APG,4791.01,,,4791.01,Other,225% New York Medicaid APG,5536.28,,,5536.28,Other,260% New York Medicaid APG,6899.06,,,6899.06,Other,324% New York Medicaid APG,4578.08,,,4578.08,Other,215% New York Medicaid APG,4578.08,,,4578.08,Other,215% New York Medicaid APG,2661.67,,,2661.67,Other,125% New York Medicaid APG,2129.34,44227.73,
Biopsy of shoulder joint,23100,CPT,,,,,,,,both,,,68082.75,50381.24,74,,50381.24,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30637.24,45,,30637.24,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33700.96,49.5,,33700.96,percent of total billed charges,110% of Medicare,46296.27,68,,46296.27,percent of total billed charges,,3960.57,,,3960.57,Other,186% of Medicaid,54466.2,80,,54466.2,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,54466.2,80,,54466.2,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,47657.93,70,,47657.93,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,2129.34,,,2129.34,Other,New York Medicaid APG methodology,2129.34,,,2129.34,Other,100% New York Medicaid APG,2129.34,,,2129.34,Other,100% New York Medicaid APG,2129.34,,,2129.34,Other,100% New York Medicaid APG,4791.01,,,4791.01,Other,225% New York Medicaid APG,3257.89,,,3257.89,Other,153% New York Medicaid APG,4791.01,,,4791.01,Other,225% New York Medicaid APG,2981.08,,,2981.08,Other,140% New York Medicaid APG,4791.01,,,4791.01,Other,225% New York Medicaid APG,5536.28,,,5536.28,Other,260% New York Medicaid APG,6899.06,,,6899.06,Other,324% New York Medicaid APG,4578.08,,,4578.08,Other,215% New York Medicaid APG,4578.08,,,4578.08,Other,215% New York Medicaid APG,2661.67,,,2661.67,Other,125% New York Medicaid APG,2129.34,54466.2,
Shoulder joint surgery,23101,CPT,,,,,,,,both,,,68082.75,50381.24,74,,50381.24,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30637.24,45,,30637.24,percent of total billed charges,Medicare Ratio of cost to charges,5954,,"100% primary, 50% supplemental procedure",5954,Other,Aetna ASC Grouper,5359,,"100% primary, 50% supplemental procedure",5359,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33700.96,49.5,,33700.96,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3960.57,,,3960.57,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,47657.93,70,,47657.93,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,2129.34,,,2129.34,Other,New York Medicaid APG methodology,2129.34,,,2129.34,Other,100% New York Medicaid APG,2129.34,,,2129.34,Other,100% New York Medicaid APG,2129.34,,,2129.34,Other,100% New York Medicaid APG,4791.01,,,4791.01,Other,225% New York Medicaid APG,3257.89,,,3257.89,Other,153% New York Medicaid APG,4791.01,,,4791.01,Other,225% New York Medicaid APG,2981.08,,,2981.08,Other,140% New York Medicaid APG,4791.01,,,4791.01,Other,225% New York Medicaid APG,5536.28,,,5536.28,Other,260% New York Medicaid APG,6899.06,,,6899.06,Other,324% New York Medicaid APG,4578.08,,,4578.08,Other,215% New York Medicaid APG,4578.08,,,4578.08,Other,215% New York Medicaid APG,2661.67,,,2661.67,Other,125% New York Medicaid APG,2129.34,50381.24,
Remove shoulder joint lining,23105,CPT,,,,,,,,both,,,150476.65,111352.72,74,,111352.72,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,67714.49,45,,67714.49,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,74485.94,49.5,,74485.94,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3960.57,,,3960.57,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,105333.66,70,,105333.66,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,2129.34,,,2129.34,Other,New York Medicaid APG methodology,2129.34,,,2129.34,Other,100% New York Medicaid APG,2129.34,,,2129.34,Other,100% New York Medicaid APG,2129.34,,,2129.34,Other,100% New York Medicaid APG,4791.01,,,4791.01,Other,225% New York Medicaid APG,3257.89,,,3257.89,Other,153% New York Medicaid APG,4791.01,,,4791.01,Other,225% New York Medicaid APG,2981.08,,,2981.08,Other,140% New York Medicaid APG,4791.01,,,4791.01,Other,225% New York Medicaid APG,5536.28,,,5536.28,Other,260% New York Medicaid APG,6899.06,,,6899.06,Other,324% New York Medicaid APG,4578.08,,,4578.08,Other,215% New York Medicaid APG,4578.08,,,4578.08,Other,215% New York Medicaid APG,2661.67,,,2661.67,Other,125% New York Medicaid APG,2129.34,111352.72,
Incision of collarbone joint,23106,CPT,,,,,,,,both,,,68082.75,50381.24,74,,50381.24,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30637.24,45,,30637.24,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33700.96,49.5,,33700.96,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3960.57,,,3960.57,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,47657.93,70,,47657.93,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,2129.34,,,2129.34,Other,New York Medicaid APG methodology,2129.34,,,2129.34,Other,100% New York Medicaid APG,2129.34,,,2129.34,Other,100% New York Medicaid APG,2129.34,,,2129.34,Other,100% New York Medicaid APG,4791.01,,,4791.01,Other,225% New York Medicaid APG,3257.89,,,3257.89,Other,153% New York Medicaid APG,4791.01,,,4791.01,Other,225% New York Medicaid APG,2981.08,,,2981.08,Other,140% New York Medicaid APG,4791.01,,,4791.01,Other,225% New York Medicaid APG,5536.28,,,5536.28,Other,260% New York Medicaid APG,6899.06,,,6899.06,Other,324% New York Medicaid APG,4578.08,,,4578.08,Other,215% New York Medicaid APG,4578.08,,,4578.08,Other,215% New York Medicaid APG,2661.67,,,2661.67,Other,125% New York Medicaid APG,2129.34,50381.24,
Explore treat shoulder joint,23107,CPT,,,,,,,,both,,,150476.65,111352.72,74,,111352.72,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,67714.49,45,,67714.49,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,74485.94,49.5,,74485.94,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3960.57,,,3960.57,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,105333.66,70,,105333.66,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,2129.34,,,2129.34,Other,New York Medicaid APG methodology,2129.34,,,2129.34,Other,100% New York Medicaid APG,2129.34,,,2129.34,Other,100% New York Medicaid APG,2129.34,,,2129.34,Other,100% New York Medicaid APG,4791.01,,,4791.01,Other,225% New York Medicaid APG,3257.89,,,3257.89,Other,153% New York Medicaid APG,4791.01,,,4791.01,Other,225% New York Medicaid APG,2981.08,,,2981.08,Other,140% New York Medicaid APG,4791.01,,,4791.01,Other,225% New York Medicaid APG,5536.28,,,5536.28,Other,260% New York Medicaid APG,6899.06,,,6899.06,Other,324% New York Medicaid APG,4578.08,,,4578.08,Other,215% New York Medicaid APG,4578.08,,,4578.08,Other,215% New York Medicaid APG,2661.67,,,2661.67,Other,125% New York Medicaid APG,2129.34,111352.72,
Partial removal collar bone,23120,CPT,,,,,,,,both,,,68082.75,50381.24,74,,50381.24,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30637.24,45,,30637.24,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33700.96,49.5,,33700.96,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3960.57,,,3960.57,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,47657.93,70,,47657.93,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,2129.34,,,2129.34,Other,New York Medicaid APG methodology,2129.34,,,2129.34,Other,100% New York Medicaid APG,2129.34,,,2129.34,Other,100% New York Medicaid APG,2129.34,,,2129.34,Other,100% New York Medicaid APG,4791.01,,,4791.01,Other,225% New York Medicaid APG,3257.89,,,3257.89,Other,153% New York Medicaid APG,4791.01,,,4791.01,Other,225% New York Medicaid APG,2981.08,,,2981.08,Other,140% New York Medicaid APG,4791.01,,,4791.01,Other,225% New York Medicaid APG,5536.28,,,5536.28,Other,260% New York Medicaid APG,6899.06,,,6899.06,Other,324% New York Medicaid APG,4578.08,,,4578.08,Other,215% New York Medicaid APG,4578.08,,,4578.08,Other,215% New York Medicaid APG,2661.67,,,2661.67,Other,125% New York Medicaid APG,2129.34,50381.24,
Removal of collar bone,23125,CPT,,,,,,,,both,,,68082.75,50381.24,74,,50381.24,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30637.24,45,,30637.24,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33700.96,49.5,,33700.96,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3960.57,,,3960.57,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,47657.93,70,,47657.93,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,2129.34,,,2129.34,Other,New York Medicaid APG methodology,2129.34,,,2129.34,Other,100% New York Medicaid APG,2129.34,,,2129.34,Other,100% New York Medicaid APG,2129.34,,,2129.34,Other,100% New York Medicaid APG,4791.01,,,4791.01,Other,225% New York Medicaid APG,3257.89,,,3257.89,Other,153% New York Medicaid APG,4791.01,,,4791.01,Other,225% New York Medicaid APG,2981.08,,,2981.08,Other,140% New York Medicaid APG,4791.01,,,4791.01,Other,225% New York Medicaid APG,5536.28,,,5536.28,Other,260% New York Medicaid APG,6899.06,,,6899.06,Other,324% New York Medicaid APG,4578.08,,,4578.08,Other,215% New York Medicaid APG,4578.08,,,4578.08,Other,215% New York Medicaid APG,2661.67,,,2661.67,Other,125% New York Medicaid APG,2129.34,50381.24,
Remove shoulder bone part,23130,CPT,,,,,,,,both,,,68082.75,50381.24,74,,50381.24,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30637.24,45,,30637.24,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33700.96,49.5,,33700.96,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3960.57,,,3960.57,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,47657.93,70,,47657.93,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,2129.34,,,2129.34,Other,New York Medicaid APG methodology,2129.34,,,2129.34,Other,100% New York Medicaid APG,2129.34,,,2129.34,Other,100% New York Medicaid APG,2129.34,,,2129.34,Other,100% New York Medicaid APG,4791.01,,,4791.01,Other,225% New York Medicaid APG,3257.89,,,3257.89,Other,153% New York Medicaid APG,4791.01,,,4791.01,Other,225% New York Medicaid APG,2981.08,,,2981.08,Other,140% New York Medicaid APG,4791.01,,,4791.01,Other,225% New York Medicaid APG,5536.28,,,5536.28,Other,260% New York Medicaid APG,6899.06,,,6899.06,Other,324% New York Medicaid APG,4578.08,,,4578.08,Other,215% New York Medicaid APG,4578.08,,,4578.08,Other,215% New York Medicaid APG,2661.67,,,2661.67,Other,125% New York Medicaid APG,2129.34,50381.24,
Removal of bone lesion,23140,CPT,,,,,,,,both,,,68082.75,50381.24,74,,50381.24,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30637.24,45,,30637.24,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33700.96,49.5,,33700.96,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3960.57,,,3960.57,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,47657.93,70,,47657.93,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,2129.34,,,2129.34,Other,New York Medicaid APG methodology,2129.34,,,2129.34,Other,100% New York Medicaid APG,2129.34,,,2129.34,Other,100% New York Medicaid APG,2129.34,,,2129.34,Other,100% New York Medicaid APG,4791.01,,,4791.01,Other,225% New York Medicaid APG,3257.89,,,3257.89,Other,153% New York Medicaid APG,4791.01,,,4791.01,Other,225% New York Medicaid APG,2981.08,,,2981.08,Other,140% New York Medicaid APG,4791.01,,,4791.01,Other,225% New York Medicaid APG,5536.28,,,5536.28,Other,260% New York Medicaid APG,6899.06,,,6899.06,Other,324% New York Medicaid APG,4578.08,,,4578.08,Other,215% New York Medicaid APG,4578.08,,,4578.08,Other,215% New York Medicaid APG,2661.67,,,2661.67,Other,125% New York Medicaid APG,2129.34,50381.24,
Removal of bone lesion,23145,CPT,,,,,,,,both,,,68082.75,50381.24,74,,50381.24,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30637.24,45,,30637.24,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33700.96,49.5,,33700.96,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3960.57,,,3960.57,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,47657.93,70,,47657.93,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,2129.34,,,2129.34,Other,New York Medicaid APG methodology,2129.34,,,2129.34,Other,100% New York Medicaid APG,2129.34,,,2129.34,Other,100% New York Medicaid APG,2129.34,,,2129.34,Other,100% New York Medicaid APG,4791.01,,,4791.01,Other,225% New York Medicaid APG,3257.89,,,3257.89,Other,153% New York Medicaid APG,4791.01,,,4791.01,Other,225% New York Medicaid APG,2981.08,,,2981.08,Other,140% New York Medicaid APG,4791.01,,,4791.01,Other,225% New York Medicaid APG,5536.28,,,5536.28,Other,260% New York Medicaid APG,6899.06,,,6899.06,Other,324% New York Medicaid APG,4578.08,,,4578.08,Other,215% New York Medicaid APG,4578.08,,,4578.08,Other,215% New York Medicaid APG,2661.67,,,2661.67,Other,125% New York Medicaid APG,2129.34,50381.24,
Removal of bone lesion,23146,CPT,,,,,,,,both,,,150476.65,111352.72,74,,111352.72,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,67714.49,45,,67714.49,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,74485.94,49.5,,74485.94,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3960.57,,,3960.57,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,105333.66,70,,105333.66,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,2129.34,,,2129.34,Other,New York Medicaid APG methodology,2129.34,,,2129.34,Other,100% New York Medicaid APG,2129.34,,,2129.34,Other,100% New York Medicaid APG,2129.34,,,2129.34,Other,100% New York Medicaid APG,4791.01,,,4791.01,Other,225% New York Medicaid APG,3257.89,,,3257.89,Other,153% New York Medicaid APG,4791.01,,,4791.01,Other,225% New York Medicaid APG,2981.08,,,2981.08,Other,140% New York Medicaid APG,4791.01,,,4791.01,Other,225% New York Medicaid APG,5536.28,,,5536.28,Other,260% New York Medicaid APG,6899.06,,,6899.06,Other,324% New York Medicaid APG,4578.08,,,4578.08,Other,215% New York Medicaid APG,4578.08,,,4578.08,Other,215% New York Medicaid APG,2661.67,,,2661.67,Other,125% New York Medicaid APG,2129.34,111352.72,
Removal of humerus lesion,23150,CPT,,,,,,,,both,,,72471.02,53628.55,74,,53628.55,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,32611.96,45,,32611.96,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,35873.15,49.5,,35873.15,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3960.57,,,3960.57,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,50729.71,70,,50729.71,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,2129.34,,,2129.34,Other,New York Medicaid APG methodology,2129.34,,,2129.34,Other,100% New York Medicaid APG,2129.34,,,2129.34,Other,100% New York Medicaid APG,2129.34,,,2129.34,Other,100% New York Medicaid APG,4791.01,,,4791.01,Other,225% New York Medicaid APG,3257.89,,,3257.89,Other,153% New York Medicaid APG,4791.01,,,4791.01,Other,225% New York Medicaid APG,2981.08,,,2981.08,Other,140% New York Medicaid APG,4791.01,,,4791.01,Other,225% New York Medicaid APG,5536.28,,,5536.28,Other,260% New York Medicaid APG,6899.06,,,6899.06,Other,324% New York Medicaid APG,4578.08,,,4578.08,Other,215% New York Medicaid APG,4578.08,,,4578.08,Other,215% New York Medicaid APG,2661.67,,,2661.67,Other,125% New York Medicaid APG,2129.34,53628.55,
Removal of humerus lesion,23155,CPT,,,,,,,,both,,,150476.65,111352.72,74,,111352.72,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,67714.49,45,,67714.49,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,74485.94,49.5,,74485.94,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3960.57,,,3960.57,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,105333.66,70,,105333.66,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,2129.34,,,2129.34,Other,New York Medicaid APG methodology,2129.34,,,2129.34,Other,100% New York Medicaid APG,2129.34,,,2129.34,Other,100% New York Medicaid APG,2129.34,,,2129.34,Other,100% New York Medicaid APG,4791.01,,,4791.01,Other,225% New York Medicaid APG,3257.89,,,3257.89,Other,153% New York Medicaid APG,4791.01,,,4791.01,Other,225% New York Medicaid APG,2981.08,,,2981.08,Other,140% New York Medicaid APG,4791.01,,,4791.01,Other,225% New York Medicaid APG,5536.28,,,5536.28,Other,260% New York Medicaid APG,6899.06,,,6899.06,Other,324% New York Medicaid APG,4578.08,,,4578.08,Other,215% New York Medicaid APG,4578.08,,,4578.08,Other,215% New York Medicaid APG,2661.67,,,2661.67,Other,125% New York Medicaid APG,2129.34,111352.72,
Removal of humerus lesion,23156,CPT,,,,,,,,both,,,150476.65,111352.72,74,,111352.72,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,67714.49,45,,67714.49,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,74485.94,49.5,,74485.94,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3960.57,,,3960.57,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,105333.66,70,,105333.66,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,2129.34,,,2129.34,Other,New York Medicaid APG methodology,2129.34,,,2129.34,Other,100% New York Medicaid APG,2129.34,,,2129.34,Other,100% New York Medicaid APG,2129.34,,,2129.34,Other,100% New York Medicaid APG,4791.01,,,4791.01,Other,225% New York Medicaid APG,3257.89,,,3257.89,Other,153% New York Medicaid APG,4791.01,,,4791.01,Other,225% New York Medicaid APG,2981.08,,,2981.08,Other,140% New York Medicaid APG,4791.01,,,4791.01,Other,225% New York Medicaid APG,5536.28,,,5536.28,Other,260% New York Medicaid APG,6899.06,,,6899.06,Other,324% New York Medicaid APG,4578.08,,,4578.08,Other,215% New York Medicaid APG,4578.08,,,4578.08,Other,215% New York Medicaid APG,2661.67,,,2661.67,Other,125% New York Medicaid APG,2129.34,111352.72,
Remove collar bone lesion,23170,CPT,,,,,,,,both,,,68082.75,50381.24,74,,50381.24,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30637.24,45,,30637.24,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33700.96,49.5,,33700.96,percent of total billed charges,110% of Medicare,46296.27,68,,46296.27,percent of total billed charges,,3960.57,,,3960.57,Other,186% of Medicaid,54466.2,80,,54466.2,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,54466.2,80,,54466.2,percent of total billed charges,,7216,,,7216,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,47657.93,70,,47657.93,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,2129.34,,,2129.34,Other,New York Medicaid APG methodology,2129.34,,,2129.34,Other,100% New York Medicaid APG,2129.34,,,2129.34,Other,100% New York Medicaid APG,2129.34,,,2129.34,Other,100% New York Medicaid APG,4791.01,,,4791.01,Other,225% New York Medicaid APG,3257.89,,,3257.89,Other,153% New York Medicaid APG,4791.01,,,4791.01,Other,225% New York Medicaid APG,2981.08,,,2981.08,Other,140% New York Medicaid APG,4791.01,,,4791.01,Other,225% New York Medicaid APG,5536.28,,,5536.28,Other,260% New York Medicaid APG,6899.06,,,6899.06,Other,324% New York Medicaid APG,4578.08,,,4578.08,Other,215% New York Medicaid APG,4578.08,,,4578.08,Other,215% New York Medicaid APG,2661.67,,,2661.67,Other,125% New York Medicaid APG,2129.34,54466.2,
Remove shoulder blade lesion,23172,CPT,,,,,,,,both,,,68082.75,50381.24,74,,50381.24,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30637.24,45,,30637.24,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33700.96,49.5,,33700.96,percent of total billed charges,110% of Medicare,46296.27,68,,46296.27,percent of total billed charges,,3960.57,,,3960.57,Other,186% of Medicaid,54466.2,80,,54466.2,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,54466.2,80,,54466.2,percent of total billed charges,,7216,,,7216,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,47657.93,70,,47657.93,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,2129.34,,,2129.34,Other,New York Medicaid APG methodology,2129.34,,,2129.34,Other,100% New York Medicaid APG,2129.34,,,2129.34,Other,100% New York Medicaid APG,2129.34,,,2129.34,Other,100% New York Medicaid APG,4791.01,,,4791.01,Other,225% New York Medicaid APG,3257.89,,,3257.89,Other,153% New York Medicaid APG,4791.01,,,4791.01,Other,225% New York Medicaid APG,2981.08,,,2981.08,Other,140% New York Medicaid APG,4791.01,,,4791.01,Other,225% New York Medicaid APG,5536.28,,,5536.28,Other,260% New York Medicaid APG,6899.06,,,6899.06,Other,324% New York Medicaid APG,4578.08,,,4578.08,Other,215% New York Medicaid APG,4578.08,,,4578.08,Other,215% New York Medicaid APG,2661.67,,,2661.67,Other,125% New York Medicaid APG,2129.34,54466.2,
Remove humerus lesion,23174,CPT,,,,,,,,both,,,150476.65,111352.72,74,,111352.72,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,67714.49,45,,67714.49,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,74485.94,49.5,,74485.94,percent of total billed charges,110% of Medicare,102324.12,68,,102324.12,percent of total billed charges,,3960.57,,,3960.57,Other,186% of Medicaid,120381.32,80,,120381.32,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,120381.32,80,,120381.32,percent of total billed charges,,7216,,,7216,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,105333.66,70,,105333.66,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,2129.34,,,2129.34,Other,New York Medicaid APG methodology,2129.34,,,2129.34,Other,100% New York Medicaid APG,2129.34,,,2129.34,Other,100% New York Medicaid APG,2129.34,,,2129.34,Other,100% New York Medicaid APG,4791.01,,,4791.01,Other,225% New York Medicaid APG,3257.89,,,3257.89,Other,153% New York Medicaid APG,4791.01,,,4791.01,Other,225% New York Medicaid APG,2981.08,,,2981.08,Other,140% New York Medicaid APG,4791.01,,,4791.01,Other,225% New York Medicaid APG,5536.28,,,5536.28,Other,260% New York Medicaid APG,6899.06,,,6899.06,Other,324% New York Medicaid APG,4578.08,,,4578.08,Other,215% New York Medicaid APG,4578.08,,,4578.08,Other,215% New York Medicaid APG,2661.67,,,2661.67,Other,125% New York Medicaid APG,2129.34,120381.32,
Remove collar bone lesion,23180,CPT,,,,,,,,both,,,150476.65,111352.72,74,,111352.72,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,67714.49,45,,67714.49,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,74485.94,49.5,,74485.94,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3960.57,,,3960.57,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,105333.66,70,,105333.66,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,2129.34,,,2129.34,Other,New York Medicaid APG methodology,2129.34,,,2129.34,Other,100% New York Medicaid APG,2129.34,,,2129.34,Other,100% New York Medicaid APG,2129.34,,,2129.34,Other,100% New York Medicaid APG,4791.01,,,4791.01,Other,225% New York Medicaid APG,3257.89,,,3257.89,Other,153% New York Medicaid APG,4791.01,,,4791.01,Other,225% New York Medicaid APG,2981.08,,,2981.08,Other,140% New York Medicaid APG,4791.01,,,4791.01,Other,225% New York Medicaid APG,5536.28,,,5536.28,Other,260% New York Medicaid APG,6899.06,,,6899.06,Other,324% New York Medicaid APG,4578.08,,,4578.08,Other,215% New York Medicaid APG,4578.08,,,4578.08,Other,215% New York Medicaid APG,2661.67,,,2661.67,Other,125% New York Medicaid APG,2129.34,111352.72,
Remove shoulder blade lesion,23182,CPT,,,,,,,,both,,,150476.65,111352.72,74,,111352.72,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,67714.49,45,,67714.49,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,74485.94,49.5,,74485.94,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3960.57,,,3960.57,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,105333.66,70,,105333.66,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,2129.34,,,2129.34,Other,New York Medicaid APG methodology,2129.34,,,2129.34,Other,100% New York Medicaid APG,2129.34,,,2129.34,Other,100% New York Medicaid APG,2129.34,,,2129.34,Other,100% New York Medicaid APG,4791.01,,,4791.01,Other,225% New York Medicaid APG,3257.89,,,3257.89,Other,153% New York Medicaid APG,4791.01,,,4791.01,Other,225% New York Medicaid APG,2981.08,,,2981.08,Other,140% New York Medicaid APG,4791.01,,,4791.01,Other,225% New York Medicaid APG,5536.28,,,5536.28,Other,260% New York Medicaid APG,6899.06,,,6899.06,Other,324% New York Medicaid APG,4578.08,,,4578.08,Other,215% New York Medicaid APG,4578.08,,,4578.08,Other,215% New York Medicaid APG,2661.67,,,2661.67,Other,125% New York Medicaid APG,2129.34,111352.72,
Remove humerus lesion,23184,CPT,,,,,,,,both,,,150476.65,111352.72,74,,111352.72,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,67714.49,45,,67714.49,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,74485.94,49.5,,74485.94,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3960.57,,,3960.57,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,105333.66,70,,105333.66,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,2129.34,,,2129.34,Other,New York Medicaid APG methodology,2129.34,,,2129.34,Other,100% New York Medicaid APG,2129.34,,,2129.34,Other,100% New York Medicaid APG,2129.34,,,2129.34,Other,100% New York Medicaid APG,4791.01,,,4791.01,Other,225% New York Medicaid APG,3257.89,,,3257.89,Other,153% New York Medicaid APG,4791.01,,,4791.01,Other,225% New York Medicaid APG,2981.08,,,2981.08,Other,140% New York Medicaid APG,4791.01,,,4791.01,Other,225% New York Medicaid APG,5536.28,,,5536.28,Other,260% New York Medicaid APG,6899.06,,,6899.06,Other,324% New York Medicaid APG,4578.08,,,4578.08,Other,215% New York Medicaid APG,4578.08,,,4578.08,Other,215% New York Medicaid APG,2661.67,,,2661.67,Other,125% New York Medicaid APG,2129.34,111352.72,
Partial removal of scapula,23190,CPT,,,,,,,,both,,,68082.75,50381.24,74,,50381.24,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30637.24,45,,30637.24,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33700.96,49.5,,33700.96,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3960.57,,,3960.57,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,47657.93,70,,47657.93,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,2129.34,,,2129.34,Other,New York Medicaid APG methodology,2129.34,,,2129.34,Other,100% New York Medicaid APG,2129.34,,,2129.34,Other,100% New York Medicaid APG,2129.34,,,2129.34,Other,100% New York Medicaid APG,4791.01,,,4791.01,Other,225% New York Medicaid APG,3257.89,,,3257.89,Other,153% New York Medicaid APG,4791.01,,,4791.01,Other,225% New York Medicaid APG,2981.08,,,2981.08,Other,140% New York Medicaid APG,4791.01,,,4791.01,Other,225% New York Medicaid APG,5536.28,,,5536.28,Other,260% New York Medicaid APG,6899.06,,,6899.06,Other,324% New York Medicaid APG,4578.08,,,4578.08,Other,215% New York Medicaid APG,4578.08,,,4578.08,Other,215% New York Medicaid APG,2661.67,,,2661.67,Other,125% New York Medicaid APG,2129.34,50381.24,
Removal of head of humerus,23195,CPT,,,,,,,,both,,,150476.65,111352.72,74,,111352.72,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,67714.49,45,,67714.49,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,74485.94,49.5,,74485.94,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3960.57,,,3960.57,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,105333.66,70,,105333.66,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,2129.34,,,2129.34,Other,New York Medicaid APG methodology,2129.34,,,2129.34,Other,100% New York Medicaid APG,2129.34,,,2129.34,Other,100% New York Medicaid APG,2129.34,,,2129.34,Other,100% New York Medicaid APG,4791.01,,,4791.01,Other,225% New York Medicaid APG,3257.89,,,3257.89,Other,153% New York Medicaid APG,4791.01,,,4791.01,Other,225% New York Medicaid APG,2981.08,,,2981.08,Other,140% New York Medicaid APG,4791.01,,,4791.01,Other,225% New York Medicaid APG,5536.28,,,5536.28,Other,260% New York Medicaid APG,6899.06,,,6899.06,Other,324% New York Medicaid APG,4578.08,,,4578.08,Other,215% New York Medicaid APG,4578.08,,,4578.08,Other,215% New York Medicaid APG,2661.67,,,2661.67,Other,125% New York Medicaid APG,2129.34,111352.72,
Remove shoulder foreign body,23330,CPT,,,,,,,,both,,,36843.73,27264.36,74,,27264.36,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,16579.68,45,,16579.68,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,18237.65,49.5,,18237.65,percent of total billed charges,110% of Medicare,25053.74,68,,25053.74,percent of total billed charges,,1973.06,,,1973.06,Other,186% of Medicaid,29474.98,80,,29474.98,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,29474.98,80,,29474.98,percent of total billed charges,,7216,,,7216,Case Rate,,3578,,"100% primary, 0% secondary procedures",3578,Other,MagnaCare ASC Grouper,25790.61,70,,25790.61,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,1060.79,,,1060.79,Other,New York Medicaid APG methodology,1060.79,,,1060.79,Other,100% New York Medicaid APG,1060.79,,,1060.79,Other,100% New York Medicaid APG,1060.79,,,1060.79,Other,100% New York Medicaid APG,2386.77,,,2386.77,Other,225% New York Medicaid APG,1623,,,1623,Other,153% New York Medicaid APG,2386.77,,,2386.77,Other,225% New York Medicaid APG,1485.1,,,1485.1,Other,140% New York Medicaid APG,2386.77,,,2386.77,Other,225% New York Medicaid APG,2758.05,,,2758.05,Other,260% New York Medicaid APG,3436.95,,,3436.95,Other,324% New York Medicaid APG,2280.69,,,2280.69,Other,215% New York Medicaid APG,2280.69,,,2280.69,Other,215% New York Medicaid APG,1325.98,,,1325.98,Other,125% New York Medicaid APG,1060.79,29474.98,
Remove shoulder fb deep,23333,CPT,,,,,,,,both,,,59767.2,44227.73,74,,44227.73,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,26895.24,45,,26895.24,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,29584.76,49.5,,29584.76,percent of total billed charges,110% of Medicare,40641.7,68,,40641.7,percent of total billed charges,,1973.06,,,1973.06,Other,186% of Medicaid,47813.76,80,,47813.76,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,47813.76,80,,47813.76,percent of total billed charges,,7216,,,7216,Case Rate,,3578,,"100% primary, 0% secondary procedures",3578,Other,MagnaCare ASC Grouper,41837.04,70,,41837.04,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,1060.79,,,1060.79,Other,New York Medicaid APG methodology,1060.79,,,1060.79,Other,100% New York Medicaid APG,1060.79,,,1060.79,Other,100% New York Medicaid APG,1060.79,,,1060.79,Other,100% New York Medicaid APG,2386.77,,,2386.77,Other,225% New York Medicaid APG,1623,,,1623,Other,153% New York Medicaid APG,2386.77,,,2386.77,Other,225% New York Medicaid APG,1485.1,,,1485.1,Other,140% New York Medicaid APG,2386.77,,,2386.77,Other,225% New York Medicaid APG,2758.05,,,2758.05,Other,260% New York Medicaid APG,3436.95,,,3436.95,Other,324% New York Medicaid APG,2280.69,,,2280.69,Other,215% New York Medicaid APG,2280.69,,,2280.69,Other,215% New York Medicaid APG,1325.98,,,1325.98,Other,125% New York Medicaid APG,1060.79,47813.76,
Shoulder prosthesis removal,23334,CPT,,,,,,,,both,,,59767.2,44227.73,74,,44227.73,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,26895.24,45,,26895.24,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,29584.76,49.5,,29584.76,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3960.57,,,3960.57,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,41837.04,70,,41837.04,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,2129.34,,,2129.34,Other,New York Medicaid APG methodology,2129.34,,,2129.34,Other,100% New York Medicaid APG,2129.34,,,2129.34,Other,100% New York Medicaid APG,2129.34,,,2129.34,Other,100% New York Medicaid APG,4791.01,,,4791.01,Other,225% New York Medicaid APG,3257.89,,,3257.89,Other,153% New York Medicaid APG,4791.01,,,4791.01,Other,225% New York Medicaid APG,2981.08,,,2981.08,Other,140% New York Medicaid APG,4791.01,,,4791.01,Other,225% New York Medicaid APG,5536.28,,,5536.28,Other,260% New York Medicaid APG,6899.06,,,6899.06,Other,324% New York Medicaid APG,4578.08,,,4578.08,Other,215% New York Medicaid APG,4578.08,,,4578.08,Other,215% New York Medicaid APG,2661.67,,,2661.67,Other,125% New York Medicaid APG,2129.34,44227.73,
Injection for shoulder x-ray,23350,CPT,,,,,,,,both,,,17336.09,12828.71,74,,12828.71,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,7801.24,45,,7801.24,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,8581.36,49.5,,8581.36,percent of total billed charges,110% of Medicare,11788.54,68,,11788.54,percent of total billed charges,,966.93,,,966.93,Other,186% of Medicaid,13868.87,80,,13868.87,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,13868.87,80,,13868.87,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,12135.26,70,,12135.26,percent of total billed charges,,242.72,,,242.72,Fee Schedule,,205.72,,,205.72,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,519.86,,,519.86,Other,New York Medicaid APG methodology,519.86,,,519.86,Other,100% New York Medicaid APG,519.86,,,519.86,Other,100% New York Medicaid APG,519.86,,,519.86,Other,100% New York Medicaid APG,1169.68,,,1169.68,Other,225% New York Medicaid APG,795.38,,,795.38,Other,153% New York Medicaid APG,1169.68,,,1169.68,Other,225% New York Medicaid APG,727.8,,,727.8,Other,140% New York Medicaid APG,1169.68,,,1169.68,Other,225% New York Medicaid APG,1351.62,,,1351.62,Other,260% New York Medicaid APG,1684.33,,,1684.33,Other,324% New York Medicaid APG,1117.69,,,1117.69,Other,215% New York Medicaid APG,1117.69,,,1117.69,Other,215% New York Medicaid APG,649.82,,,649.82,Other,125% New York Medicaid APG,205.72,13868.87,
Muscle transfer shoulder/arm,23395,CPT,,,,,,,,both,,,150476.65,111352.72,74,,111352.72,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,67714.49,45,,67714.49,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,74485.94,49.5,,74485.94,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3960.57,,,3960.57,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,105333.66,70,,105333.66,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,2129.34,,,2129.34,Other,New York Medicaid APG methodology,2129.34,,,2129.34,Other,100% New York Medicaid APG,2129.34,,,2129.34,Other,100% New York Medicaid APG,2129.34,,,2129.34,Other,100% New York Medicaid APG,4791.01,,,4791.01,Other,225% New York Medicaid APG,3257.89,,,3257.89,Other,153% New York Medicaid APG,4791.01,,,4791.01,Other,225% New York Medicaid APG,2981.08,,,2981.08,Other,140% New York Medicaid APG,4791.01,,,4791.01,Other,225% New York Medicaid APG,5536.28,,,5536.28,Other,260% New York Medicaid APG,6899.06,,,6899.06,Other,324% New York Medicaid APG,4578.08,,,4578.08,Other,215% New York Medicaid APG,4578.08,,,4578.08,Other,215% New York Medicaid APG,2661.67,,,2661.67,Other,125% New York Medicaid APG,2129.34,111352.72,
Muscle transfers,23397,CPT,,,,,,,,both,,,150476.65,111352.72,74,,111352.72,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,67714.49,45,,67714.49,percent of total billed charges,Medicare Ratio of cost to charges,5954,,"100% primary, 50% supplemental procedure",5954,Other,Aetna ASC Grouper,5359,,"100% primary, 50% supplemental procedure",5359,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,74485.94,49.5,,74485.94,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3960.57,,,3960.57,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,105333.66,70,,105333.66,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,2129.34,,,2129.34,Other,New York Medicaid APG methodology,2129.34,,,2129.34,Other,100% New York Medicaid APG,2129.34,,,2129.34,Other,100% New York Medicaid APG,2129.34,,,2129.34,Other,100% New York Medicaid APG,4791.01,,,4791.01,Other,225% New York Medicaid APG,3257.89,,,3257.89,Other,153% New York Medicaid APG,4791.01,,,4791.01,Other,225% New York Medicaid APG,2981.08,,,2981.08,Other,140% New York Medicaid APG,4791.01,,,4791.01,Other,225% New York Medicaid APG,5536.28,,,5536.28,Other,260% New York Medicaid APG,6899.06,,,6899.06,Other,324% New York Medicaid APG,4578.08,,,4578.08,Other,215% New York Medicaid APG,4578.08,,,4578.08,Other,215% New York Medicaid APG,2661.67,,,2661.67,Other,125% New York Medicaid APG,2129.34,111352.72,
Fixation of shoulder blade,23400,CPT,,,,,,,,both,,,150476.65,111352.72,74,,111352.72,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,67714.49,45,,67714.49,percent of total billed charges,Medicare Ratio of cost to charges,5954,,"100% primary, 50% supplemental procedure",5954,Other,Aetna ASC Grouper,5359,,"100% primary, 50% supplemental procedure",5359,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,74485.94,49.5,,74485.94,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3960.57,,,3960.57,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,105333.66,70,,105333.66,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,2129.34,,,2129.34,Other,New York Medicaid APG methodology,2129.34,,,2129.34,Other,100% New York Medicaid APG,2129.34,,,2129.34,Other,100% New York Medicaid APG,2129.34,,,2129.34,Other,100% New York Medicaid APG,4791.01,,,4791.01,Other,225% New York Medicaid APG,3257.89,,,3257.89,Other,153% New York Medicaid APG,4791.01,,,4791.01,Other,225% New York Medicaid APG,2981.08,,,2981.08,Other,140% New York Medicaid APG,4791.01,,,4791.01,Other,225% New York Medicaid APG,5536.28,,,5536.28,Other,260% New York Medicaid APG,6899.06,,,6899.06,Other,324% New York Medicaid APG,4578.08,,,4578.08,Other,215% New York Medicaid APG,4578.08,,,4578.08,Other,215% New York Medicaid APG,2661.67,,,2661.67,Other,125% New York Medicaid APG,2129.34,111352.72,
Incision of tendon & muscle,23405,CPT,,,,,,,,both,,,150476.65,111352.72,74,,111352.72,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,67714.49,45,,67714.49,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,74485.94,49.5,,74485.94,percent of total billed charges,110% of Medicare,102324.12,68,,102324.12,percent of total billed charges,,3960.57,,,3960.57,Other,186% of Medicaid,120381.32,80,,120381.32,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,120381.32,80,,120381.32,percent of total billed charges,,7216,,,7216,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,105333.66,70,,105333.66,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,2129.34,,,2129.34,Other,New York Medicaid APG methodology,2129.34,,,2129.34,Other,100% New York Medicaid APG,2129.34,,,2129.34,Other,100% New York Medicaid APG,2129.34,,,2129.34,Other,100% New York Medicaid APG,4791.01,,,4791.01,Other,225% New York Medicaid APG,3257.89,,,3257.89,Other,153% New York Medicaid APG,4791.01,,,4791.01,Other,225% New York Medicaid APG,2981.08,,,2981.08,Other,140% New York Medicaid APG,4791.01,,,4791.01,Other,225% New York Medicaid APG,5536.28,,,5536.28,Other,260% New York Medicaid APG,6899.06,,,6899.06,Other,324% New York Medicaid APG,4578.08,,,4578.08,Other,215% New York Medicaid APG,4578.08,,,4578.08,Other,215% New York Medicaid APG,2661.67,,,2661.67,Other,125% New York Medicaid APG,2129.34,120381.32,
Incise tendon(s) & muscle(s),23406,CPT,,,,,,,,both,,,150476.65,111352.72,74,,111352.72,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,67714.49,45,,67714.49,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,74485.94,49.5,,74485.94,percent of total billed charges,110% of Medicare,102324.12,68,,102324.12,percent of total billed charges,,3960.57,,,3960.57,Other,186% of Medicaid,120381.32,80,,120381.32,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,120381.32,80,,120381.32,percent of total billed charges,,7216,,,7216,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,105333.66,70,,105333.66,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,2129.34,,,2129.34,Other,New York Medicaid APG methodology,2129.34,,,2129.34,Other,100% New York Medicaid APG,2129.34,,,2129.34,Other,100% New York Medicaid APG,2129.34,,,2129.34,Other,100% New York Medicaid APG,4791.01,,,4791.01,Other,225% New York Medicaid APG,3257.89,,,3257.89,Other,153% New York Medicaid APG,4791.01,,,4791.01,Other,225% New York Medicaid APG,2981.08,,,2981.08,Other,140% New York Medicaid APG,4791.01,,,4791.01,Other,225% New York Medicaid APG,5536.28,,,5536.28,Other,260% New York Medicaid APG,6899.06,,,6899.06,Other,324% New York Medicaid APG,4578.08,,,4578.08,Other,215% New York Medicaid APG,4578.08,,,4578.08,Other,215% New York Medicaid APG,2661.67,,,2661.67,Other,125% New York Medicaid APG,2129.34,120381.32,
Repair rotator cuff acute,23410,CPT,,,,,,,,both,,,64366.42,47631.15,74,,47631.15,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,28964.89,45,,28964.89,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,31861.38,49.5,,31861.38,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3960.57,,,3960.57,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,45056.49,70,,45056.49,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,2129.34,,,2129.34,Other,New York Medicaid APG methodology,2129.34,,,2129.34,Other,100% New York Medicaid APG,2129.34,,,2129.34,Other,100% New York Medicaid APG,2129.34,,,2129.34,Other,100% New York Medicaid APG,4791.01,,,4791.01,Other,225% New York Medicaid APG,3257.89,,,3257.89,Other,153% New York Medicaid APG,4791.01,,,4791.01,Other,225% New York Medicaid APG,2981.08,,,2981.08,Other,140% New York Medicaid APG,4791.01,,,4791.01,Other,225% New York Medicaid APG,5536.28,,,5536.28,Other,260% New York Medicaid APG,6899.06,,,6899.06,Other,324% New York Medicaid APG,4578.08,,,4578.08,Other,215% New York Medicaid APG,4578.08,,,4578.08,Other,215% New York Medicaid APG,2661.67,,,2661.67,Other,125% New York Medicaid APG,2129.34,47631.15,
Repair rotator cuff chronic,23412,CPT,,,,,,,,both,,,77787.8,57562.97,74,,57562.97,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,35004.51,45,,35004.51,percent of total billed charges,Medicare Ratio of cost to charges,5954,,"100% primary, 50% supplemental procedure",5954,Other,Aetna ASC Grouper,5359,,"100% primary, 50% supplemental procedure",5359,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,38504.96,49.5,,38504.96,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3960.57,,,3960.57,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,54451.46,70,,54451.46,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,2129.34,,,2129.34,Other,New York Medicaid APG methodology,2129.34,,,2129.34,Other,100% New York Medicaid APG,2129.34,,,2129.34,Other,100% New York Medicaid APG,2129.34,,,2129.34,Other,100% New York Medicaid APG,4791.01,,,4791.01,Other,225% New York Medicaid APG,3257.89,,,3257.89,Other,153% New York Medicaid APG,4791.01,,,4791.01,Other,225% New York Medicaid APG,2981.08,,,2981.08,Other,140% New York Medicaid APG,4791.01,,,4791.01,Other,225% New York Medicaid APG,5536.28,,,5536.28,Other,260% New York Medicaid APG,6899.06,,,6899.06,Other,324% New York Medicaid APG,4578.08,,,4578.08,Other,215% New York Medicaid APG,4578.08,,,4578.08,Other,215% New York Medicaid APG,2661.67,,,2661.67,Other,125% New York Medicaid APG,2129.34,57562.97,
Release of shoulder ligament,23415,CPT,,,,,,,,both,,,33231.42,24591.25,74,,24591.25,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,14954.14,45,,14954.14,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,16449.55,49.5,,16449.55,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3960.57,,,3960.57,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,23261.99,70,,23261.99,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,2129.34,,,2129.34,Other,New York Medicaid APG methodology,2129.34,,,2129.34,Other,100% New York Medicaid APG,2129.34,,,2129.34,Other,100% New York Medicaid APG,2129.34,,,2129.34,Other,100% New York Medicaid APG,4791.01,,,4791.01,Other,225% New York Medicaid APG,3257.89,,,3257.89,Other,153% New York Medicaid APG,4791.01,,,4791.01,Other,225% New York Medicaid APG,2981.08,,,2981.08,Other,140% New York Medicaid APG,4791.01,,,4791.01,Other,225% New York Medicaid APG,5536.28,,,5536.28,Other,260% New York Medicaid APG,6899.06,,,6899.06,Other,324% New York Medicaid APG,4578.08,,,4578.08,Other,215% New York Medicaid APG,4578.08,,,4578.08,Other,215% New York Medicaid APG,2661.67,,,2661.67,Other,125% New York Medicaid APG,2129.34,24591.25,
Repair of shoulder,23420,CPT,,,,,,,,both,,,82673.24,61178.2,74,,61178.2,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,37202.96,45,,37202.96,percent of total billed charges,Medicare Ratio of cost to charges,5954,,"100% primary, 50% supplemental procedure",5954,Other,Aetna ASC Grouper,5359,,"100% primary, 50% supplemental procedure",5359,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,40923.25,49.5,,40923.25,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3960.57,,,3960.57,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,57871.27,70,,57871.27,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,2129.34,,,2129.34,Other,New York Medicaid APG methodology,2129.34,,,2129.34,Other,100% New York Medicaid APG,2129.34,,,2129.34,Other,100% New York Medicaid APG,2129.34,,,2129.34,Other,100% New York Medicaid APG,4791.01,,,4791.01,Other,225% New York Medicaid APG,3257.89,,,3257.89,Other,153% New York Medicaid APG,4791.01,,,4791.01,Other,225% New York Medicaid APG,2981.08,,,2981.08,Other,140% New York Medicaid APG,4791.01,,,4791.01,Other,225% New York Medicaid APG,5536.28,,,5536.28,Other,260% New York Medicaid APG,6899.06,,,6899.06,Other,324% New York Medicaid APG,4578.08,,,4578.08,Other,215% New York Medicaid APG,4578.08,,,4578.08,Other,215% New York Medicaid APG,2661.67,,,2661.67,Other,125% New York Medicaid APG,2129.34,61178.2,
Repair biceps tendon,23430,CPT,,,,,,,,both,,,75416.77,55808.41,74,,55808.41,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,33937.55,45,,33937.55,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,37331.3,49.5,,37331.3,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3960.57,,,3960.57,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,52791.74,70,,52791.74,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,2129.34,,,2129.34,Other,New York Medicaid APG methodology,2129.34,,,2129.34,Other,100% New York Medicaid APG,2129.34,,,2129.34,Other,100% New York Medicaid APG,2129.34,,,2129.34,Other,100% New York Medicaid APG,4791.01,,,4791.01,Other,225% New York Medicaid APG,3257.89,,,3257.89,Other,153% New York Medicaid APG,4791.01,,,4791.01,Other,225% New York Medicaid APG,2981.08,,,2981.08,Other,140% New York Medicaid APG,4791.01,,,4791.01,Other,225% New York Medicaid APG,5536.28,,,5536.28,Other,260% New York Medicaid APG,6899.06,,,6899.06,Other,324% New York Medicaid APG,4578.08,,,4578.08,Other,215% New York Medicaid APG,4578.08,,,4578.08,Other,215% New York Medicaid APG,2661.67,,,2661.67,Other,125% New York Medicaid APG,2129.34,55808.41,
Remove/transplant tendon,23440,CPT,,,,,,,,both,,,150476.65,111352.72,74,,111352.72,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,67714.49,45,,67714.49,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,74485.94,49.5,,74485.94,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3960.57,,,3960.57,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,105333.66,70,,105333.66,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,2129.34,,,2129.34,Other,New York Medicaid APG methodology,2129.34,,,2129.34,Other,100% New York Medicaid APG,2129.34,,,2129.34,Other,100% New York Medicaid APG,2129.34,,,2129.34,Other,100% New York Medicaid APG,4791.01,,,4791.01,Other,225% New York Medicaid APG,3257.89,,,3257.89,Other,153% New York Medicaid APG,4791.01,,,4791.01,Other,225% New York Medicaid APG,2981.08,,,2981.08,Other,140% New York Medicaid APG,4791.01,,,4791.01,Other,225% New York Medicaid APG,5536.28,,,5536.28,Other,260% New York Medicaid APG,6899.06,,,6899.06,Other,324% New York Medicaid APG,4578.08,,,4578.08,Other,215% New York Medicaid APG,4578.08,,,4578.08,Other,215% New York Medicaid APG,2661.67,,,2661.67,Other,125% New York Medicaid APG,2129.34,111352.72,
Repair shoulder capsule,23450,CPT,,,,,,,,both,,,150476.65,111352.72,74,,111352.72,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,67714.49,45,,67714.49,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,74485.94,49.5,,74485.94,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3960.57,,,3960.57,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,105333.66,70,,105333.66,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,2129.34,,,2129.34,Other,New York Medicaid APG methodology,2129.34,,,2129.34,Other,100% New York Medicaid APG,2129.34,,,2129.34,Other,100% New York Medicaid APG,2129.34,,,2129.34,Other,100% New York Medicaid APG,4791.01,,,4791.01,Other,225% New York Medicaid APG,3257.89,,,3257.89,Other,153% New York Medicaid APG,4791.01,,,4791.01,Other,225% New York Medicaid APG,2981.08,,,2981.08,Other,140% New York Medicaid APG,4791.01,,,4791.01,Other,225% New York Medicaid APG,5536.28,,,5536.28,Other,260% New York Medicaid APG,6899.06,,,6899.06,Other,324% New York Medicaid APG,4578.08,,,4578.08,Other,215% New York Medicaid APG,4578.08,,,4578.08,Other,215% New York Medicaid APG,2661.67,,,2661.67,Other,125% New York Medicaid APG,2129.34,111352.72,
Repair shoulder capsule,23455,CPT,,,,,,,,both,,,98387.69,72806.89,74,,72806.89,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,44274.46,45,,44274.46,percent of total billed charges,Medicare Ratio of cost to charges,5954,,"100% primary, 50% supplemental procedure",5954,Other,Aetna ASC Grouper,5359,,"100% primary, 50% supplemental procedure",5359,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,48701.91,49.5,,48701.91,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3960.57,,,3960.57,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,68871.38,70,,68871.38,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,2129.34,,,2129.34,Other,New York Medicaid APG methodology,2129.34,,,2129.34,Other,100% New York Medicaid APG,2129.34,,,2129.34,Other,100% New York Medicaid APG,2129.34,,,2129.34,Other,100% New York Medicaid APG,4791.01,,,4791.01,Other,225% New York Medicaid APG,3257.89,,,3257.89,Other,153% New York Medicaid APG,4791.01,,,4791.01,Other,225% New York Medicaid APG,2981.08,,,2981.08,Other,140% New York Medicaid APG,4791.01,,,4791.01,Other,225% New York Medicaid APG,5536.28,,,5536.28,Other,260% New York Medicaid APG,6899.06,,,6899.06,Other,324% New York Medicaid APG,4578.08,,,4578.08,Other,215% New York Medicaid APG,4578.08,,,4578.08,Other,215% New York Medicaid APG,2661.67,,,2661.67,Other,125% New York Medicaid APG,2129.34,72806.89,
Repair shoulder capsule,23460,CPT,,,,,,,,both,,,150476.65,111352.72,74,,111352.72,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,67714.49,45,,67714.49,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,74485.94,49.5,,74485.94,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3960.57,,,3960.57,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,105333.66,70,,105333.66,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,2129.34,,,2129.34,Other,New York Medicaid APG methodology,2129.34,,,2129.34,Other,100% New York Medicaid APG,2129.34,,,2129.34,Other,100% New York Medicaid APG,2129.34,,,2129.34,Other,100% New York Medicaid APG,4791.01,,,4791.01,Other,225% New York Medicaid APG,3257.89,,,3257.89,Other,153% New York Medicaid APG,4791.01,,,4791.01,Other,225% New York Medicaid APG,2981.08,,,2981.08,Other,140% New York Medicaid APG,4791.01,,,4791.01,Other,225% New York Medicaid APG,5536.28,,,5536.28,Other,260% New York Medicaid APG,6899.06,,,6899.06,Other,324% New York Medicaid APG,4578.08,,,4578.08,Other,215% New York Medicaid APG,4578.08,,,4578.08,Other,215% New York Medicaid APG,2661.67,,,2661.67,Other,125% New York Medicaid APG,2129.34,111352.72,
Repair shoulder capsule,23462,CPT,,,,,,,,both,,,150476.65,111352.72,74,,111352.72,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,67714.49,45,,67714.49,percent of total billed charges,Medicare Ratio of cost to charges,5954,,"100% primary, 50% supplemental procedure",5954,Other,Aetna ASC Grouper,5359,,"100% primary, 50% supplemental procedure",5359,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,74485.94,49.5,,74485.94,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3960.57,,,3960.57,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,105333.66,70,,105333.66,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,2129.34,,,2129.34,Other,New York Medicaid APG methodology,2129.34,,,2129.34,Other,100% New York Medicaid APG,2129.34,,,2129.34,Other,100% New York Medicaid APG,2129.34,,,2129.34,Other,100% New York Medicaid APG,4791.01,,,4791.01,Other,225% New York Medicaid APG,3257.89,,,3257.89,Other,153% New York Medicaid APG,4791.01,,,4791.01,Other,225% New York Medicaid APG,2981.08,,,2981.08,Other,140% New York Medicaid APG,4791.01,,,4791.01,Other,225% New York Medicaid APG,5536.28,,,5536.28,Other,260% New York Medicaid APG,6899.06,,,6899.06,Other,324% New York Medicaid APG,4578.08,,,4578.08,Other,215% New York Medicaid APG,4578.08,,,4578.08,Other,215% New York Medicaid APG,2661.67,,,2661.67,Other,125% New York Medicaid APG,2129.34,111352.72,
Repair shoulder capsule,23465,CPT,,,,,,,,both,,,77128.57,57075.14,74,,57075.14,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,34707.86,45,,34707.86,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,38178.64,49.5,,38178.64,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3960.57,,,3960.57,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,53990,70,,53990,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,2129.34,,,2129.34,Other,New York Medicaid APG methodology,2129.34,,,2129.34,Other,100% New York Medicaid APG,2129.34,,,2129.34,Other,100% New York Medicaid APG,2129.34,,,2129.34,Other,100% New York Medicaid APG,4791.01,,,4791.01,Other,225% New York Medicaid APG,3257.89,,,3257.89,Other,153% New York Medicaid APG,4791.01,,,4791.01,Other,225% New York Medicaid APG,2981.08,,,2981.08,Other,140% New York Medicaid APG,4791.01,,,4791.01,Other,225% New York Medicaid APG,5536.28,,,5536.28,Other,260% New York Medicaid APG,6899.06,,,6899.06,Other,324% New York Medicaid APG,4578.08,,,4578.08,Other,215% New York Medicaid APG,4578.08,,,4578.08,Other,215% New York Medicaid APG,2661.67,,,2661.67,Other,125% New York Medicaid APG,2129.34,57075.14,
Repair shoulder capsule,23466,CPT,,,,,,,,both,,,150476.65,111352.72,74,,111352.72,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,67714.49,45,,67714.49,percent of total billed charges,Medicare Ratio of cost to charges,5954,,"100% primary, 50% supplemental procedure",5954,Other,Aetna ASC Grouper,5359,,"100% primary, 50% supplemental procedure",5359,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,74485.94,49.5,,74485.94,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3960.57,,,3960.57,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,105333.66,70,,105333.66,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,2129.34,,,2129.34,Other,New York Medicaid APG methodology,2129.34,,,2129.34,Other,100% New York Medicaid APG,2129.34,,,2129.34,Other,100% New York Medicaid APG,2129.34,,,2129.34,Other,100% New York Medicaid APG,4791.01,,,4791.01,Other,225% New York Medicaid APG,3257.89,,,3257.89,Other,153% New York Medicaid APG,4791.01,,,4791.01,Other,225% New York Medicaid APG,2981.08,,,2981.08,Other,140% New York Medicaid APG,4791.01,,,4791.01,Other,225% New York Medicaid APG,5536.28,,,5536.28,Other,260% New York Medicaid APG,6899.06,,,6899.06,Other,324% New York Medicaid APG,4578.08,,,4578.08,Other,215% New York Medicaid APG,4578.08,,,4578.08,Other,215% New York Medicaid APG,2661.67,,,2661.67,Other,125% New York Medicaid APG,2129.34,111352.72,
Reconstruct shoulder joint,23470,CPT,,,,,,,,both,,,135326.42,100141.55,74,,100141.55,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,60896.89,45,,60896.89,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,66986.58,49.5,,66986.58,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5965.25,,,5965.25,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9196,,"100% primary, 0% secondary procedures",9196,Other,MagnaCare ASC Grouper,94728.49,70,,94728.49,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6956,,"100% primary, 50% secondary, 25% tertiary procedure",6956,Other,United Healthcare ASC Grouper,6261,,"100% primary, 50% secondary, 25% tertiary procedure",6261,Other,United Healthcare ASC Grouper,6956,,"100% primary, 50% secondary, 25% tertiary procedure",6956,Other,United Healthcare ASC Grouper,5913,,"100% primary, 50% secondary, 25% tertiary procedure",5913,Other,United Healthcare ASC Grouper,3207.13,,,3207.13,Other,New York Medicaid APG methodology,3207.13,,,3207.13,Other,100% New York Medicaid APG,3207.13,,,3207.13,Other,100% New York Medicaid APG,3207.13,,,3207.13,Other,100% New York Medicaid APG,7216.03,,,7216.03,Other,225% New York Medicaid APG,4906.9,,,4906.9,Other,153% New York Medicaid APG,7216.03,,,7216.03,Other,225% New York Medicaid APG,4489.98,,,4489.98,Other,140% New York Medicaid APG,7216.03,,,7216.03,Other,225% New York Medicaid APG,8338.53,,,8338.53,Other,260% New York Medicaid APG,10391.09,,,10391.09,Other,324% New York Medicaid APG,6895.32,,,6895.32,Other,215% New York Medicaid APG,6895.32,,,6895.32,Other,215% New York Medicaid APG,4008.91,,,4008.91,Other,125% New York Medicaid APG,3207.13,100141.55,
Revis reconst shoulder joint,23473,CPT,,,,,,,,both,,,276827.87,204852.62,74,,204852.62,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,124572.54,45,,124572.54,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,137029.8,49.5,,137029.8,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5965.25,,,5965.25,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,193779.51,70,,193779.51,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,3207.13,,,3207.13,Other,New York Medicaid APG methodology,3207.13,,,3207.13,Other,100% New York Medicaid APG,3207.13,,,3207.13,Other,100% New York Medicaid APG,3207.13,,,3207.13,Other,100% New York Medicaid APG,7216.03,,,7216.03,Other,225% New York Medicaid APG,4906.9,,,4906.9,Other,153% New York Medicaid APG,7216.03,,,7216.03,Other,225% New York Medicaid APG,4489.98,,,4489.98,Other,140% New York Medicaid APG,7216.03,,,7216.03,Other,225% New York Medicaid APG,8338.53,,,8338.53,Other,260% New York Medicaid APG,10391.09,,,10391.09,Other,324% New York Medicaid APG,6895.32,,,6895.32,Other,215% New York Medicaid APG,6895.32,,,6895.32,Other,215% New York Medicaid APG,4008.91,,,4008.91,Other,125% New York Medicaid APG,3207.13,204852.62,
Revision of collar bone,23480,CPT,,,,,,,,both,,,150476.65,111352.72,74,,111352.72,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,67714.49,45,,67714.49,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,74485.94,49.5,,74485.94,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3960.57,,,3960.57,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,105333.66,70,,105333.66,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,2129.34,,,2129.34,Other,New York Medicaid APG methodology,2129.34,,,2129.34,Other,100% New York Medicaid APG,2129.34,,,2129.34,Other,100% New York Medicaid APG,2129.34,,,2129.34,Other,100% New York Medicaid APG,4791.01,,,4791.01,Other,225% New York Medicaid APG,3257.89,,,3257.89,Other,153% New York Medicaid APG,4791.01,,,4791.01,Other,225% New York Medicaid APG,2981.08,,,2981.08,Other,140% New York Medicaid APG,4791.01,,,4791.01,Other,225% New York Medicaid APG,5536.28,,,5536.28,Other,260% New York Medicaid APG,6899.06,,,6899.06,Other,324% New York Medicaid APG,4578.08,,,4578.08,Other,215% New York Medicaid APG,4578.08,,,4578.08,Other,215% New York Medicaid APG,2661.67,,,2661.67,Other,125% New York Medicaid APG,2129.34,111352.72,
Revision of collar bone,23485,CPT,,,,,,,,both,,,276827.87,204852.62,74,,204852.62,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,124572.54,45,,124572.54,percent of total billed charges,Medicare Ratio of cost to charges,5954,,"100% primary, 50% supplemental procedure",5954,Other,Aetna ASC Grouper,5359,,"100% primary, 50% supplemental procedure",5359,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,137029.8,49.5,,137029.8,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3960.57,,,3960.57,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,193779.51,70,,193779.51,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,2129.34,,,2129.34,Other,New York Medicaid APG methodology,2129.34,,,2129.34,Other,100% New York Medicaid APG,2129.34,,,2129.34,Other,100% New York Medicaid APG,2129.34,,,2129.34,Other,100% New York Medicaid APG,4791.01,,,4791.01,Other,225% New York Medicaid APG,3257.89,,,3257.89,Other,153% New York Medicaid APG,4791.01,,,4791.01,Other,225% New York Medicaid APG,2981.08,,,2981.08,Other,140% New York Medicaid APG,4791.01,,,4791.01,Other,225% New York Medicaid APG,5536.28,,,5536.28,Other,260% New York Medicaid APG,6899.06,,,6899.06,Other,324% New York Medicaid APG,4578.08,,,4578.08,Other,215% New York Medicaid APG,4578.08,,,4578.08,Other,215% New York Medicaid APG,2661.67,,,2661.67,Other,125% New York Medicaid APG,2129.34,204852.62,
Reinforce clavicle,23490,CPT,,,,,,,,both,,,150476.65,111352.72,74,,111352.72,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,67714.49,45,,67714.49,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,74485.94,49.5,,74485.94,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3960.57,,,3960.57,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,105333.66,70,,105333.66,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,2129.34,,,2129.34,Other,New York Medicaid APG methodology,2129.34,,,2129.34,Other,100% New York Medicaid APG,2129.34,,,2129.34,Other,100% New York Medicaid APG,2129.34,,,2129.34,Other,100% New York Medicaid APG,4791.01,,,4791.01,Other,225% New York Medicaid APG,3257.89,,,3257.89,Other,153% New York Medicaid APG,4791.01,,,4791.01,Other,225% New York Medicaid APG,2981.08,,,2981.08,Other,140% New York Medicaid APG,4791.01,,,4791.01,Other,225% New York Medicaid APG,5536.28,,,5536.28,Other,260% New York Medicaid APG,6899.06,,,6899.06,Other,324% New York Medicaid APG,4578.08,,,4578.08,Other,215% New York Medicaid APG,4578.08,,,4578.08,Other,215% New York Medicaid APG,2661.67,,,2661.67,Other,125% New York Medicaid APG,2129.34,111352.72,
Reinforce shoulder bones,23491,CPT,,,,,,,,both,,,276827.87,204852.62,74,,204852.62,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,124572.54,45,,124572.54,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,137029.8,49.5,,137029.8,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3960.57,,,3960.57,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,193779.51,70,,193779.51,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,2129.34,,,2129.34,Other,New York Medicaid APG methodology,2129.34,,,2129.34,Other,100% New York Medicaid APG,2129.34,,,2129.34,Other,100% New York Medicaid APG,2129.34,,,2129.34,Other,100% New York Medicaid APG,4791.01,,,4791.01,Other,225% New York Medicaid APG,3257.89,,,3257.89,Other,153% New York Medicaid APG,4791.01,,,4791.01,Other,225% New York Medicaid APG,2981.08,,,2981.08,Other,140% New York Medicaid APG,4791.01,,,4791.01,Other,225% New York Medicaid APG,5536.28,,,5536.28,Other,260% New York Medicaid APG,6899.06,,,6899.06,Other,324% New York Medicaid APG,4578.08,,,4578.08,Other,215% New York Medicaid APG,4578.08,,,4578.08,Other,215% New York Medicaid APG,2661.67,,,2661.67,Other,125% New York Medicaid APG,2129.34,204852.62,
Treat clavicle fracture,23500,CPT,,,,,,,,both,,,4960.23,3670.57,74,,3670.57,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,2232.1,45,,2232.1,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,2455.31,49.5,,2455.31,percent of total billed charges,110% of Medicare,3372.96,68,,3372.96,percent of total billed charges,,1031.43,,,1031.43,Other,186% of Medicaid,3968.18,80,,3968.18,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,3968.18,80,,3968.18,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,3472.16,70,,3472.16,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,554.53,,,554.53,Other,New York Medicaid APG methodology,554.53,,,554.53,Other,100% New York Medicaid APG,554.53,,,554.53,Other,100% New York Medicaid APG,554.53,,,554.53,Other,100% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,848.43,,,848.43,Other,153% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,776.34,,,776.34,Other,140% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,1441.78,,,1441.78,Other,260% New York Medicaid APG,1796.68,,,1796.68,Other,324% New York Medicaid APG,1192.24,,,1192.24,Other,215% New York Medicaid APG,1192.24,,,1192.24,Other,215% New York Medicaid APG,693.16,,,693.16,Other,125% New York Medicaid APG,554.53,7216,
Treat clavicle fracture,23505,CPT,,,,,,,,both,,,34955.66,25867.19,74,,25867.19,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15730.05,45,,15730.05,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,17303.05,49.5,,17303.05,percent of total billed charges,110% of Medicare,23769.85,68,,23769.85,percent of total billed charges,,1031.43,,,1031.43,Other,186% of Medicaid,27964.53,80,,27964.53,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,27964.53,80,,27964.53,percent of total billed charges,,7216,,,7216,Case Rate,,3578,,"100% primary, 0% secondary procedures",3578,Other,MagnaCare ASC Grouper,24468.96,70,,24468.96,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,554.53,,,554.53,Other,New York Medicaid APG methodology,554.53,,,554.53,Other,100% New York Medicaid APG,554.53,,,554.53,Other,100% New York Medicaid APG,554.53,,,554.53,Other,100% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,848.43,,,848.43,Other,153% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,776.34,,,776.34,Other,140% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,1441.78,,,1441.78,Other,260% New York Medicaid APG,1796.68,,,1796.68,Other,324% New York Medicaid APG,1192.24,,,1192.24,Other,215% New York Medicaid APG,1192.24,,,1192.24,Other,215% New York Medicaid APG,693.16,,,693.16,Other,125% New York Medicaid APG,554.53,27964.53,
Treat clavicle fracture,23515,CPT,,,,,,,,both,,,90442.05,66927.12,74,,66927.12,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,40698.92,45,,40698.92,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,44768.81,49.5,,44768.81,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5092.5,,,5092.5,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,63309.44,70,,63309.44,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,2737.91,,,2737.91,Other,New York Medicaid APG methodology,2737.91,,,2737.91,Other,100% New York Medicaid APG,2737.91,,,2737.91,Other,100% New York Medicaid APG,2737.91,,,2737.91,Other,100% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,4189,,,4189,Other,153% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,3833.07,,,3833.07,Other,140% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,7118.55,,,7118.55,Other,260% New York Medicaid APG,8870.81,,,8870.81,Other,324% New York Medicaid APG,5886.5,,,5886.5,Other,215% New York Medicaid APG,5886.5,,,5886.5,Other,215% New York Medicaid APG,3422.38,,,3422.38,Other,125% New York Medicaid APG,2737.91,66927.12,
Treat clavicle dislocation,23520,CPT,,,,,,,,both,,,33805.49,25016.06,74,,25016.06,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15212.47,45,,15212.47,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,16733.72,49.5,,16733.72,percent of total billed charges,110% of Medicare,22987.73,68,,22987.73,percent of total billed charges,,1031.43,,,1031.43,Other,186% of Medicaid,27044.39,80,,27044.39,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,27044.39,80,,27044.39,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,23663.84,70,,23663.84,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,554.53,,,554.53,Other,New York Medicaid APG methodology,554.53,,,554.53,Other,100% New York Medicaid APG,554.53,,,554.53,Other,100% New York Medicaid APG,554.53,,,554.53,Other,100% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,848.43,,,848.43,Other,153% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,776.34,,,776.34,Other,140% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,1441.78,,,1441.78,Other,260% New York Medicaid APG,1796.68,,,1796.68,Other,324% New York Medicaid APG,1192.24,,,1192.24,Other,215% New York Medicaid APG,1192.24,,,1192.24,Other,215% New York Medicaid APG,693.16,,,693.16,Other,125% New York Medicaid APG,554.53,27044.39,
Treat clavicle dislocation,23525,CPT,,,,,,,,both,,,4960.23,3670.57,74,,3670.57,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,2232.1,45,,2232.1,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,2455.31,49.5,,2455.31,percent of total billed charges,110% of Medicare,3372.96,68,,3372.96,percent of total billed charges,,1031.43,,,1031.43,Other,186% of Medicaid,3968.18,80,,3968.18,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,3968.18,80,,3968.18,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,3472.16,70,,3472.16,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,554.53,,,554.53,Other,New York Medicaid APG methodology,554.53,,,554.53,Other,100% New York Medicaid APG,554.53,,,554.53,Other,100% New York Medicaid APG,554.53,,,554.53,Other,100% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,848.43,,,848.43,Other,153% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,776.34,,,776.34,Other,140% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,1441.78,,,1441.78,Other,260% New York Medicaid APG,1796.68,,,1796.68,Other,324% New York Medicaid APG,1192.24,,,1192.24,Other,215% New York Medicaid APG,1192.24,,,1192.24,Other,215% New York Medicaid APG,693.16,,,693.16,Other,125% New York Medicaid APG,554.53,7216,
Treat clavicle dislocation,23530,CPT,,,,,,,,both,,,150476.65,111352.72,74,,111352.72,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,67714.49,45,,67714.49,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,74485.94,49.5,,74485.94,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5092.5,,,5092.5,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,105333.66,70,,105333.66,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,2737.91,,,2737.91,Other,New York Medicaid APG methodology,2737.91,,,2737.91,Other,100% New York Medicaid APG,2737.91,,,2737.91,Other,100% New York Medicaid APG,2737.91,,,2737.91,Other,100% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,4189,,,4189,Other,153% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,3833.07,,,3833.07,Other,140% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,7118.55,,,7118.55,Other,260% New York Medicaid APG,8870.81,,,8870.81,Other,324% New York Medicaid APG,5886.5,,,5886.5,Other,215% New York Medicaid APG,5886.5,,,5886.5,Other,215% New York Medicaid APG,3422.38,,,3422.38,Other,125% New York Medicaid APG,2737.91,111352.72,
Treat clavicle dislocation,23532,CPT,,,,,,,,both,,,150476.65,111352.72,74,,111352.72,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,67714.49,45,,67714.49,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,74485.94,49.5,,74485.94,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5092.5,,,5092.5,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,105333.66,70,,105333.66,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,2737.91,,,2737.91,Other,New York Medicaid APG methodology,2737.91,,,2737.91,Other,100% New York Medicaid APG,2737.91,,,2737.91,Other,100% New York Medicaid APG,2737.91,,,2737.91,Other,100% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,4189,,,4189,Other,153% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,3833.07,,,3833.07,Other,140% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,7118.55,,,7118.55,Other,260% New York Medicaid APG,8870.81,,,8870.81,Other,324% New York Medicaid APG,5886.5,,,5886.5,Other,215% New York Medicaid APG,5886.5,,,5886.5,Other,215% New York Medicaid APG,3422.38,,,3422.38,Other,125% New York Medicaid APG,2737.91,111352.72,
Treat clavicle dislocation,23540,CPT,,,,,,,,both,,,4960.23,3670.57,74,,3670.57,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,2232.1,45,,2232.1,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,2455.31,49.5,,2455.31,percent of total billed charges,110% of Medicare,3372.96,68,,3372.96,percent of total billed charges,,1031.43,,,1031.43,Other,186% of Medicaid,3968.18,80,,3968.18,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,3968.18,80,,3968.18,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,3472.16,70,,3472.16,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,554.53,,,554.53,Other,New York Medicaid APG methodology,554.53,,,554.53,Other,100% New York Medicaid APG,554.53,,,554.53,Other,100% New York Medicaid APG,554.53,,,554.53,Other,100% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,848.43,,,848.43,Other,153% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,776.34,,,776.34,Other,140% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,1441.78,,,1441.78,Other,260% New York Medicaid APG,1796.68,,,1796.68,Other,324% New York Medicaid APG,1192.24,,,1192.24,Other,215% New York Medicaid APG,1192.24,,,1192.24,Other,215% New York Medicaid APG,693.16,,,693.16,Other,125% New York Medicaid APG,554.53,7216,
Treat clavicle dislocation,23545,CPT,,,,,,,,both,,,4960.23,3670.57,74,,3670.57,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,2232.1,45,,2232.1,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,2455.31,49.5,,2455.31,percent of total billed charges,110% of Medicare,3372.96,68,,3372.96,percent of total billed charges,,1031.43,,,1031.43,Other,186% of Medicaid,3968.18,80,,3968.18,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,3968.18,80,,3968.18,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,3472.16,70,,3472.16,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,554.53,,,554.53,Other,New York Medicaid APG methodology,554.53,,,554.53,Other,100% New York Medicaid APG,554.53,,,554.53,Other,100% New York Medicaid APG,554.53,,,554.53,Other,100% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,848.43,,,848.43,Other,153% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,776.34,,,776.34,Other,140% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,1441.78,,,1441.78,Other,260% New York Medicaid APG,1796.68,,,1796.68,Other,324% New York Medicaid APG,1192.24,,,1192.24,Other,215% New York Medicaid APG,1192.24,,,1192.24,Other,215% New York Medicaid APG,693.16,,,693.16,Other,125% New York Medicaid APG,554.53,7216,
Treat clavicle dislocation,23550,CPT,,,,,,,,both,,,150476.65,111352.72,74,,111352.72,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,67714.49,45,,67714.49,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,74485.94,49.5,,74485.94,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5092.5,,,5092.5,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,105333.66,70,,105333.66,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,2737.91,,,2737.91,Other,New York Medicaid APG methodology,2737.91,,,2737.91,Other,100% New York Medicaid APG,2737.91,,,2737.91,Other,100% New York Medicaid APG,2737.91,,,2737.91,Other,100% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,4189,,,4189,Other,153% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,3833.07,,,3833.07,Other,140% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,7118.55,,,7118.55,Other,260% New York Medicaid APG,8870.81,,,8870.81,Other,324% New York Medicaid APG,5886.5,,,5886.5,Other,215% New York Medicaid APG,5886.5,,,5886.5,Other,215% New York Medicaid APG,3422.38,,,3422.38,Other,125% New York Medicaid APG,2737.91,111352.72,
Treat clavicle dislocation,23552,CPT,,,,,,,,both,,,150476.65,111352.72,74,,111352.72,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,67714.49,45,,67714.49,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,74485.94,49.5,,74485.94,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5092.5,,,5092.5,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,105333.66,70,,105333.66,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,2737.91,,,2737.91,Other,New York Medicaid APG methodology,2737.91,,,2737.91,Other,100% New York Medicaid APG,2737.91,,,2737.91,Other,100% New York Medicaid APG,2737.91,,,2737.91,Other,100% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,4189,,,4189,Other,153% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,3833.07,,,3833.07,Other,140% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,7118.55,,,7118.55,Other,260% New York Medicaid APG,8870.81,,,8870.81,Other,324% New York Medicaid APG,5886.5,,,5886.5,Other,215% New York Medicaid APG,5886.5,,,5886.5,Other,215% New York Medicaid APG,3422.38,,,3422.38,Other,125% New York Medicaid APG,2737.91,111352.72,
Treat shoulder blade fx,23570,CPT,,,,,,,,both,,,4960.23,3670.57,74,,3670.57,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,2232.1,45,,2232.1,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,2455.31,49.5,,2455.31,percent of total billed charges,110% of Medicare,3372.96,68,,3372.96,percent of total billed charges,,1031.43,,,1031.43,Other,186% of Medicaid,3968.18,80,,3968.18,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,3968.18,80,,3968.18,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,3472.16,70,,3472.16,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,554.53,,,554.53,Other,New York Medicaid APG methodology,554.53,,,554.53,Other,100% New York Medicaid APG,554.53,,,554.53,Other,100% New York Medicaid APG,554.53,,,554.53,Other,100% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,848.43,,,848.43,Other,153% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,776.34,,,776.34,Other,140% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,1441.78,,,1441.78,Other,260% New York Medicaid APG,1796.68,,,1796.68,Other,324% New York Medicaid APG,1192.24,,,1192.24,Other,215% New York Medicaid APG,1192.24,,,1192.24,Other,215% New York Medicaid APG,693.16,,,693.16,Other,125% New York Medicaid APG,554.53,7216,
Treat shoulder blade fx,23575,CPT,,,,,,,,both,,,33805.49,25016.06,74,,25016.06,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15212.47,45,,15212.47,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,16733.72,49.5,,16733.72,percent of total billed charges,110% of Medicare,22987.73,68,,22987.73,percent of total billed charges,,1031.43,,,1031.43,Other,186% of Medicaid,27044.39,80,,27044.39,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,27044.39,80,,27044.39,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,23663.84,70,,23663.84,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,554.53,,,554.53,Other,New York Medicaid APG methodology,554.53,,,554.53,Other,100% New York Medicaid APG,554.53,,,554.53,Other,100% New York Medicaid APG,554.53,,,554.53,Other,100% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,848.43,,,848.43,Other,153% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,776.34,,,776.34,Other,140% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,1441.78,,,1441.78,Other,260% New York Medicaid APG,1796.68,,,1796.68,Other,324% New York Medicaid APG,1192.24,,,1192.24,Other,215% New York Medicaid APG,1192.24,,,1192.24,Other,215% New York Medicaid APG,693.16,,,693.16,Other,125% New York Medicaid APG,554.53,27044.39,
Treat scapula fracture,23585,CPT,,,,,,,,both,,,150476.65,111352.72,74,,111352.72,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,67714.49,45,,67714.49,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,74485.94,49.5,,74485.94,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5092.5,,,5092.5,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,105333.66,70,,105333.66,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,2737.91,,,2737.91,Other,New York Medicaid APG methodology,2737.91,,,2737.91,Other,100% New York Medicaid APG,2737.91,,,2737.91,Other,100% New York Medicaid APG,2737.91,,,2737.91,Other,100% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,4189,,,4189,Other,153% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,3833.07,,,3833.07,Other,140% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,7118.55,,,7118.55,Other,260% New York Medicaid APG,8870.81,,,8870.81,Other,324% New York Medicaid APG,5886.5,,,5886.5,Other,215% New York Medicaid APG,5886.5,,,5886.5,Other,215% New York Medicaid APG,3422.38,,,3422.38,Other,125% New York Medicaid APG,2737.91,111352.72,
Treat humerus fracture,23600,CPT,,,,,,,,both,,,4960.23,3670.57,74,,3670.57,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,2232.1,45,,2232.1,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,2455.31,49.5,,2455.31,percent of total billed charges,110% of Medicare,3372.96,68,,3372.96,percent of total billed charges,,1031.43,,,1031.43,Other,186% of Medicaid,3968.18,80,,3968.18,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,3968.18,80,,3968.18,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,3472.16,70,,3472.16,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,554.53,,,554.53,Other,New York Medicaid APG methodology,554.53,,,554.53,Other,100% New York Medicaid APG,554.53,,,554.53,Other,100% New York Medicaid APG,554.53,,,554.53,Other,100% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,848.43,,,848.43,Other,153% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,776.34,,,776.34,Other,140% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,1441.78,,,1441.78,Other,260% New York Medicaid APG,1796.68,,,1796.68,Other,324% New York Medicaid APG,1192.24,,,1192.24,Other,215% New York Medicaid APG,1192.24,,,1192.24,Other,215% New York Medicaid APG,693.16,,,693.16,Other,125% New York Medicaid APG,554.53,7216,
Treat humerus fracture,23605,CPT,,,,,,,,both,,,33805.49,25016.06,74,,25016.06,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15212.47,45,,15212.47,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,16733.72,49.5,,16733.72,percent of total billed charges,110% of Medicare,22987.73,68,,22987.73,percent of total billed charges,,1031.43,,,1031.43,Other,186% of Medicaid,27044.39,80,,27044.39,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,27044.39,80,,27044.39,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,23663.84,70,,23663.84,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,554.53,,,554.53,Other,New York Medicaid APG methodology,554.53,,,554.53,Other,100% New York Medicaid APG,554.53,,,554.53,Other,100% New York Medicaid APG,554.53,,,554.53,Other,100% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,848.43,,,848.43,Other,153% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,776.34,,,776.34,Other,140% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,1441.78,,,1441.78,Other,260% New York Medicaid APG,1796.68,,,1796.68,Other,324% New York Medicaid APG,1192.24,,,1192.24,Other,215% New York Medicaid APG,1192.24,,,1192.24,Other,215% New York Medicaid APG,693.16,,,693.16,Other,125% New York Medicaid APG,554.53,27044.39,
Treat humerus fracture,23615,CPT,,,,,,,,both,,,58174.44,43049.09,74,,43049.09,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,26178.5,45,,26178.5,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,28796.35,49.5,,28796.35,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5092.5,,,5092.5,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,40722.11,70,,40722.11,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,2737.91,,,2737.91,Other,New York Medicaid APG methodology,2737.91,,,2737.91,Other,100% New York Medicaid APG,2737.91,,,2737.91,Other,100% New York Medicaid APG,2737.91,,,2737.91,Other,100% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,4189,,,4189,Other,153% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,3833.07,,,3833.07,Other,140% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,7118.55,,,7118.55,Other,260% New York Medicaid APG,8870.81,,,8870.81,Other,324% New York Medicaid APG,5886.5,,,5886.5,Other,215% New York Medicaid APG,5886.5,,,5886.5,Other,215% New York Medicaid APG,3422.38,,,3422.38,Other,125% New York Medicaid APG,2737.91,43049.09,
Treat humerus fracture,23616,CPT,,,,,,,,both,,,391985.94,290069.6,74,,290069.6,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,176393.67,45,,176393.67,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,194033.04,49.5,,194033.04,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5092.5,,,5092.5,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,274390.16,70,,274390.16,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,2737.91,,,2737.91,Other,New York Medicaid APG methodology,2737.91,,,2737.91,Other,100% New York Medicaid APG,2737.91,,,2737.91,Other,100% New York Medicaid APG,2737.91,,,2737.91,Other,100% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,4189,,,4189,Other,153% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,3833.07,,,3833.07,Other,140% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,7118.55,,,7118.55,Other,260% New York Medicaid APG,8870.81,,,8870.81,Other,324% New York Medicaid APG,5886.5,,,5886.5,Other,215% New York Medicaid APG,5886.5,,,5886.5,Other,215% New York Medicaid APG,3422.38,,,3422.38,Other,125% New York Medicaid APG,2737.91,290069.6,
Treat humerus fracture,23620,CPT,,,,,,,,both,,,4960.23,3670.57,74,,3670.57,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,2232.1,45,,2232.1,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,2455.31,49.5,,2455.31,percent of total billed charges,110% of Medicare,3372.96,68,,3372.96,percent of total billed charges,,1031.43,,,1031.43,Other,186% of Medicaid,3968.18,80,,3968.18,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,3968.18,80,,3968.18,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,3472.16,70,,3472.16,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,554.53,,,554.53,Other,New York Medicaid APG methodology,554.53,,,554.53,Other,100% New York Medicaid APG,554.53,,,554.53,Other,100% New York Medicaid APG,554.53,,,554.53,Other,100% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,848.43,,,848.43,Other,153% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,776.34,,,776.34,Other,140% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,1441.78,,,1441.78,Other,260% New York Medicaid APG,1796.68,,,1796.68,Other,324% New York Medicaid APG,1192.24,,,1192.24,Other,215% New York Medicaid APG,1192.24,,,1192.24,Other,215% New York Medicaid APG,693.16,,,693.16,Other,125% New York Medicaid APG,554.53,7216,
Treat humerus fracture,23625,CPT,,,,,,,,both,,,33805.49,25016.06,74,,25016.06,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15212.47,45,,15212.47,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,16733.72,49.5,,16733.72,percent of total billed charges,110% of Medicare,22987.73,68,,22987.73,percent of total billed charges,,1031.43,,,1031.43,Other,186% of Medicaid,27044.39,80,,27044.39,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,27044.39,80,,27044.39,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,23663.84,70,,23663.84,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,554.53,,,554.53,Other,New York Medicaid APG methodology,554.53,,,554.53,Other,100% New York Medicaid APG,554.53,,,554.53,Other,100% New York Medicaid APG,554.53,,,554.53,Other,100% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,848.43,,,848.43,Other,153% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,776.34,,,776.34,Other,140% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,1441.78,,,1441.78,Other,260% New York Medicaid APG,1796.68,,,1796.68,Other,324% New York Medicaid APG,1192.24,,,1192.24,Other,215% New York Medicaid APG,1192.24,,,1192.24,Other,215% New York Medicaid APG,693.16,,,693.16,Other,125% New York Medicaid APG,554.53,27044.39,
Treat humerus fracture,23630,CPT,,,,,,,,both,,,150476.65,111352.72,74,,111352.72,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,67714.49,45,,67714.49,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,74485.94,49.5,,74485.94,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5092.5,,,5092.5,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,105333.66,70,,105333.66,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,2737.91,,,2737.91,Other,New York Medicaid APG methodology,2737.91,,,2737.91,Other,100% New York Medicaid APG,2737.91,,,2737.91,Other,100% New York Medicaid APG,2737.91,,,2737.91,Other,100% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,4189,,,4189,Other,153% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,3833.07,,,3833.07,Other,140% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,7118.55,,,7118.55,Other,260% New York Medicaid APG,8870.81,,,8870.81,Other,324% New York Medicaid APG,5886.5,,,5886.5,Other,215% New York Medicaid APG,5886.5,,,5886.5,Other,215% New York Medicaid APG,3422.38,,,3422.38,Other,125% New York Medicaid APG,2737.91,111352.72,
Treat shoulder dislocation,23650,CPT,,,,,,,,both,,,4960.23,3670.57,74,,3670.57,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,2232.1,45,,2232.1,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,2455.31,49.5,,2455.31,percent of total billed charges,110% of Medicare,3372.96,68,,3372.96,percent of total billed charges,,1031.43,,,1031.43,Other,186% of Medicaid,3968.18,80,,3968.18,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,3968.18,80,,3968.18,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,3472.16,70,,3472.16,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,554.53,,,554.53,Other,New York Medicaid APG methodology,554.53,,,554.53,Other,100% New York Medicaid APG,554.53,,,554.53,Other,100% New York Medicaid APG,554.53,,,554.53,Other,100% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,848.43,,,848.43,Other,153% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,776.34,,,776.34,Other,140% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,1441.78,,,1441.78,Other,260% New York Medicaid APG,1796.68,,,1796.68,Other,324% New York Medicaid APG,1192.24,,,1192.24,Other,215% New York Medicaid APG,1192.24,,,1192.24,Other,215% New York Medicaid APG,693.16,,,693.16,Other,125% New York Medicaid APG,554.53,7216,
Treat shoulder dislocation,23655,CPT,,,,,,,,both,,,32785,24260.9,74,,24260.9,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,14753.25,45,,14753.25,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,16228.58,49.5,,16228.58,percent of total billed charges,110% of Medicare,22293.8,68,,22293.8,percent of total billed charges,,1730.38,,,1730.38,Other,186% of Medicaid,26228,80,,26228,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,26228,80,,26228,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,22949.5,70,,22949.5,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,930.31,,,930.31,Other,New York Medicaid APG methodology,930.31,,,930.31,Other,100% New York Medicaid APG,930.31,,,930.31,Other,100% New York Medicaid APG,930.31,,,930.31,Other,100% New York Medicaid APG,2093.21,,,2093.21,Other,225% New York Medicaid APG,1423.38,,,1423.38,Other,153% New York Medicaid APG,2093.21,,,2093.21,Other,225% New York Medicaid APG,1302.44,,,1302.44,Other,140% New York Medicaid APG,2093.21,,,2093.21,Other,225% New York Medicaid APG,2418.82,,,2418.82,Other,260% New York Medicaid APG,3014.22,,,3014.22,Other,324% New York Medicaid APG,2000.18,,,2000.18,Other,215% New York Medicaid APG,2000.18,,,2000.18,Other,215% New York Medicaid APG,1162.89,,,1162.89,Other,125% New York Medicaid APG,930.31,26228,
Treat shoulder dislocation,23660,CPT,,,,,,,,both,,,150476.65,111352.72,74,,111352.72,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,67714.49,45,,67714.49,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,74485.94,49.5,,74485.94,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5092.5,,,5092.5,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,105333.66,70,,105333.66,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,2737.91,,,2737.91,Other,New York Medicaid APG methodology,2737.91,,,2737.91,Other,100% New York Medicaid APG,2737.91,,,2737.91,Other,100% New York Medicaid APG,2737.91,,,2737.91,Other,100% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,4189,,,4189,Other,153% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,3833.07,,,3833.07,Other,140% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,7118.55,,,7118.55,Other,260% New York Medicaid APG,8870.81,,,8870.81,Other,324% New York Medicaid APG,5886.5,,,5886.5,Other,215% New York Medicaid APG,5886.5,,,5886.5,Other,215% New York Medicaid APG,3422.38,,,3422.38,Other,125% New York Medicaid APG,2737.91,111352.72,
Treat dislocation/fracture,23665,CPT,,,,,,,,both,,,33805.49,25016.06,74,,25016.06,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15212.47,45,,15212.47,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,16733.72,49.5,,16733.72,percent of total billed charges,110% of Medicare,22987.73,68,,22987.73,percent of total billed charges,,1031.43,,,1031.43,Other,186% of Medicaid,27044.39,80,,27044.39,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,27044.39,80,,27044.39,percent of total billed charges,,7216,,,7216,Case Rate,,3578,,"100% primary, 0% secondary procedures",3578,Other,MagnaCare ASC Grouper,23663.84,70,,23663.84,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,554.53,,,554.53,Other,New York Medicaid APG methodology,554.53,,,554.53,Other,100% New York Medicaid APG,554.53,,,554.53,Other,100% New York Medicaid APG,554.53,,,554.53,Other,100% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,848.43,,,848.43,Other,153% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,776.34,,,776.34,Other,140% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,1441.78,,,1441.78,Other,260% New York Medicaid APG,1796.68,,,1796.68,Other,324% New York Medicaid APG,1192.24,,,1192.24,Other,215% New York Medicaid APG,1192.24,,,1192.24,Other,215% New York Medicaid APG,693.16,,,693.16,Other,125% New York Medicaid APG,554.53,27044.39,
Treat dislocation/fracture,23670,CPT,,,,,,,,both,,,113841.17,84242.47,74,,84242.47,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,51228.53,45,,51228.53,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,56351.38,49.5,,56351.38,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5092.5,,,5092.5,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,79688.82,70,,79688.82,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,2737.91,,,2737.91,Other,New York Medicaid APG methodology,2737.91,,,2737.91,Other,100% New York Medicaid APG,2737.91,,,2737.91,Other,100% New York Medicaid APG,2737.91,,,2737.91,Other,100% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,4189,,,4189,Other,153% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,3833.07,,,3833.07,Other,140% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,7118.55,,,7118.55,Other,260% New York Medicaid APG,8870.81,,,8870.81,Other,324% New York Medicaid APG,5886.5,,,5886.5,Other,215% New York Medicaid APG,5886.5,,,5886.5,Other,215% New York Medicaid APG,3422.38,,,3422.38,Other,125% New York Medicaid APG,2737.91,84242.47,
Treat dislocation/fracture,23675,CPT,,,,,,,,both,,,33805.49,25016.06,74,,25016.06,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15212.47,45,,15212.47,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,16733.72,49.5,,16733.72,percent of total billed charges,110% of Medicare,22987.73,68,,22987.73,percent of total billed charges,,1031.43,,,1031.43,Other,186% of Medicaid,27044.39,80,,27044.39,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,27044.39,80,,27044.39,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,23663.84,70,,23663.84,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,554.53,,,554.53,Other,New York Medicaid APG methodology,554.53,,,554.53,Other,100% New York Medicaid APG,554.53,,,554.53,Other,100% New York Medicaid APG,554.53,,,554.53,Other,100% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,848.43,,,848.43,Other,153% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,776.34,,,776.34,Other,140% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,1441.78,,,1441.78,Other,260% New York Medicaid APG,1796.68,,,1796.68,Other,324% New York Medicaid APG,1192.24,,,1192.24,Other,215% New York Medicaid APG,1192.24,,,1192.24,Other,215% New York Medicaid APG,693.16,,,693.16,Other,125% New York Medicaid APG,554.53,27044.39,
Treat dislocation/fracture,23680,CPT,,,,,,,,both,,,276827.87,204852.62,74,,204852.62,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,124572.54,45,,124572.54,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,137029.8,49.5,,137029.8,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5092.5,,,5092.5,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,193779.51,70,,193779.51,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,2737.91,,,2737.91,Other,New York Medicaid APG methodology,2737.91,,,2737.91,Other,100% New York Medicaid APG,2737.91,,,2737.91,Other,100% New York Medicaid APG,2737.91,,,2737.91,Other,100% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,4189,,,4189,Other,153% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,3833.07,,,3833.07,Other,140% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,7118.55,,,7118.55,Other,260% New York Medicaid APG,8870.81,,,8870.81,Other,324% New York Medicaid APG,5886.5,,,5886.5,Other,215% New York Medicaid APG,5886.5,,,5886.5,Other,215% New York Medicaid APG,3422.38,,,3422.38,Other,125% New York Medicaid APG,2737.91,204852.62,
Fixation of shoulder,23700,CPT,,,,,,,,both,,,34321,25397.54,74,,25397.54,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15444.45,45,,15444.45,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,16988.9,49.5,,16988.9,percent of total billed charges,110% of Medicare,23338.28,68,,23338.28,percent of total billed charges,,1730.38,,,1730.38,Other,186% of Medicaid,27456.8,80,,27456.8,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,27456.8,80,,27456.8,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,24024.7,70,,24024.7,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,930.31,,,930.31,Other,New York Medicaid APG methodology,930.31,,,930.31,Other,100% New York Medicaid APG,930.31,,,930.31,Other,100% New York Medicaid APG,930.31,,,930.31,Other,100% New York Medicaid APG,2093.21,,,2093.21,Other,225% New York Medicaid APG,1423.38,,,1423.38,Other,153% New York Medicaid APG,2093.21,,,2093.21,Other,225% New York Medicaid APG,1302.44,,,1302.44,Other,140% New York Medicaid APG,2093.21,,,2093.21,Other,225% New York Medicaid APG,2418.82,,,2418.82,Other,260% New York Medicaid APG,3014.22,,,3014.22,Other,324% New York Medicaid APG,2000.18,,,2000.18,Other,215% New York Medicaid APG,2000.18,,,2000.18,Other,215% New York Medicaid APG,1162.89,,,1162.89,Other,125% New York Medicaid APG,930.31,27456.8,
Fusion of shoulder joint,23800,CPT,,,,,,,,both,,,150476.65,111352.72,74,,111352.72,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,67714.49,45,,67714.49,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,74485.94,49.5,,74485.94,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3960.57,,,3960.57,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,105333.66,70,,105333.66,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,2129.34,,,2129.34,Other,New York Medicaid APG methodology,2129.34,,,2129.34,Other,100% New York Medicaid APG,2129.34,,,2129.34,Other,100% New York Medicaid APG,2129.34,,,2129.34,Other,100% New York Medicaid APG,4791.01,,,4791.01,Other,225% New York Medicaid APG,3257.89,,,3257.89,Other,153% New York Medicaid APG,4791.01,,,4791.01,Other,225% New York Medicaid APG,2981.08,,,2981.08,Other,140% New York Medicaid APG,4791.01,,,4791.01,Other,225% New York Medicaid APG,5536.28,,,5536.28,Other,260% New York Medicaid APG,6899.06,,,6899.06,Other,324% New York Medicaid APG,4578.08,,,4578.08,Other,215% New York Medicaid APG,4578.08,,,4578.08,Other,215% New York Medicaid APG,2661.67,,,2661.67,Other,125% New York Medicaid APG,2129.34,111352.72,
Fusion of shoulder joint,23802,CPT,,,,,,,,both,,,276827.87,204852.62,74,,204852.62,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,124572.54,45,,124572.54,percent of total billed charges,Medicare Ratio of cost to charges,5954,,"100% primary, 50% supplemental procedure",5954,Other,Aetna ASC Grouper,5359,,"100% primary, 50% supplemental procedure",5359,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,137029.8,49.5,,137029.8,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3960.57,,,3960.57,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,193779.51,70,,193779.51,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,2129.34,,,2129.34,Other,New York Medicaid APG methodology,2129.34,,,2129.34,Other,100% New York Medicaid APG,2129.34,,,2129.34,Other,100% New York Medicaid APG,2129.34,,,2129.34,Other,100% New York Medicaid APG,4791.01,,,4791.01,Other,225% New York Medicaid APG,3257.89,,,3257.89,Other,153% New York Medicaid APG,4791.01,,,4791.01,Other,225% New York Medicaid APG,2981.08,,,2981.08,Other,140% New York Medicaid APG,4791.01,,,4791.01,Other,225% New York Medicaid APG,5536.28,,,5536.28,Other,260% New York Medicaid APG,6899.06,,,6899.06,Other,324% New York Medicaid APG,4578.08,,,4578.08,Other,215% New York Medicaid APG,4578.08,,,4578.08,Other,215% New York Medicaid APG,2661.67,,,2661.67,Other,125% New York Medicaid APG,2129.34,204852.62,
Amputation follow-up surgery,23921,CPT,,,,,,,,both,,,38357.55,28384.59,74,,28384.59,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,17260.9,45,,17260.9,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,18986.99,49.5,,18986.99,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,1973.06,,,1973.06,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,26850.29,70,,26850.29,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1060.79,,,1060.79,Other,New York Medicaid APG methodology,1060.79,,,1060.79,Other,100% New York Medicaid APG,1060.79,,,1060.79,Other,100% New York Medicaid APG,1060.79,,,1060.79,Other,100% New York Medicaid APG,2386.77,,,2386.77,Other,225% New York Medicaid APG,1623,,,1623,Other,153% New York Medicaid APG,2386.77,,,2386.77,Other,225% New York Medicaid APG,1485.1,,,1485.1,Other,140% New York Medicaid APG,2386.77,,,2386.77,Other,225% New York Medicaid APG,2758.05,,,2758.05,Other,260% New York Medicaid APG,3436.95,,,3436.95,Other,324% New York Medicaid APG,2280.69,,,2280.69,Other,215% New York Medicaid APG,2280.69,,,2280.69,Other,215% New York Medicaid APG,1325.98,,,1325.98,Other,125% New York Medicaid APG,1060.79,28384.59,
Drainage of arm lesion,23930,CPT,,,,,,,,both,,,59767.2,44227.73,74,,44227.73,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,26895.24,45,,26895.24,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,29584.76,49.5,,29584.76,percent of total billed charges,110% of Medicare,40641.7,68,,40641.7,percent of total billed charges,,1973.06,,,1973.06,Other,186% of Medicaid,47813.76,80,,47813.76,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,47813.76,80,,47813.76,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,41837.04,70,,41837.04,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1060.79,,,1060.79,Other,New York Medicaid APG methodology,1060.79,,,1060.79,Other,100% New York Medicaid APG,1060.79,,,1060.79,Other,100% New York Medicaid APG,1060.79,,,1060.79,Other,100% New York Medicaid APG,2386.77,,,2386.77,Other,225% New York Medicaid APG,1623,,,1623,Other,153% New York Medicaid APG,2386.77,,,2386.77,Other,225% New York Medicaid APG,1485.1,,,1485.1,Other,140% New York Medicaid APG,2386.77,,,2386.77,Other,225% New York Medicaid APG,2758.05,,,2758.05,Other,260% New York Medicaid APG,3436.95,,,3436.95,Other,324% New York Medicaid APG,2280.69,,,2280.69,Other,215% New York Medicaid APG,2280.69,,,2280.69,Other,215% New York Medicaid APG,1325.98,,,1325.98,Other,125% New York Medicaid APG,1060.79,47813.76,
Drainage of arm bursa,23931,CPT,,,,,,,,both,,,34101.75,25235.3,74,,25235.3,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15345.79,45,,15345.79,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,16880.37,49.5,,16880.37,percent of total billed charges,110% of Medicare,23189.19,68,,23189.19,percent of total billed charges,,1973.06,,,1973.06,Other,186% of Medicaid,27281.4,80,,27281.4,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,27281.4,80,,27281.4,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,23871.23,70,,23871.23,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1060.79,,,1060.79,Other,New York Medicaid APG methodology,1060.79,,,1060.79,Other,100% New York Medicaid APG,1060.79,,,1060.79,Other,100% New York Medicaid APG,1060.79,,,1060.79,Other,100% New York Medicaid APG,2386.77,,,2386.77,Other,225% New York Medicaid APG,1623,,,1623,Other,153% New York Medicaid APG,2386.77,,,2386.77,Other,225% New York Medicaid APG,1485.1,,,1485.1,Other,140% New York Medicaid APG,2386.77,,,2386.77,Other,225% New York Medicaid APG,2758.05,,,2758.05,Other,260% New York Medicaid APG,3436.95,,,3436.95,Other,324% New York Medicaid APG,2280.69,,,2280.69,Other,215% New York Medicaid APG,2280.69,,,2280.69,Other,215% New York Medicaid APG,1325.98,,,1325.98,Other,125% New York Medicaid APG,1060.79,27281.4,
Drain arm/elbow bone lesion,23935,CPT,,,,,,,,both,,,68082.75,50381.24,74,,50381.24,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30637.24,45,,30637.24,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33700.96,49.5,,33700.96,percent of total billed charges,110% of Medicare,46296.27,68,,46296.27,percent of total billed charges,,3937.21,,,3937.21,Other,186% of Medicaid,54466.2,80,,54466.2,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,54466.2,80,,54466.2,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,47657.93,70,,47657.93,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,2116.78,,,2116.78,Other,New York Medicaid APG methodology,2116.78,,,2116.78,Other,100% New York Medicaid APG,2116.78,,,2116.78,Other,100% New York Medicaid APG,2116.78,,,2116.78,Other,100% New York Medicaid APG,4762.75,,,4762.75,Other,225% New York Medicaid APG,3238.67,,,3238.67,Other,153% New York Medicaid APG,4762.75,,,4762.75,Other,225% New York Medicaid APG,2963.49,,,2963.49,Other,140% New York Medicaid APG,4762.75,,,4762.75,Other,225% New York Medicaid APG,5503.62,,,5503.62,Other,260% New York Medicaid APG,6858.36,,,6858.36,Other,324% New York Medicaid APG,4551.07,,,4551.07,Other,215% New York Medicaid APG,4551.07,,,4551.07,Other,215% New York Medicaid APG,2645.97,,,2645.97,Other,125% New York Medicaid APG,2116.78,54466.2,
Exploratory elbow surgery,24000,CPT,,,,,,,,both,,,32829.65,24293.94,74,,24293.94,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,14773.34,45,,14773.34,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,16250.68,49.5,,16250.68,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3479.6,,,3479.6,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,22980.76,70,,22980.76,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1870.75,,,1870.75,Other,New York Medicaid APG methodology,1870.75,,,1870.75,Other,100% New York Medicaid APG,1870.75,,,1870.75,Other,100% New York Medicaid APG,1870.75,,,1870.75,Other,100% New York Medicaid APG,4209.2,,,4209.2,Other,225% New York Medicaid APG,2862.25,,,2862.25,Other,153% New York Medicaid APG,4209.2,,,4209.2,Other,225% New York Medicaid APG,2619.06,,,2619.06,Other,140% New York Medicaid APG,4209.2,,,4209.2,Other,225% New York Medicaid APG,4863.96,,,4863.96,Other,260% New York Medicaid APG,6061.24,,,6061.24,Other,324% New York Medicaid APG,4022.12,,,4022.12,Other,215% New York Medicaid APG,4022.12,,,4022.12,Other,215% New York Medicaid APG,2338.44,,,2338.44,Other,125% New York Medicaid APG,1870.75,24293.94,
Release elbow joint,24006,CPT,,,,,,,,both,,,99422.14,73572.38,74,,73572.38,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,44739.96,45,,44739.96,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,49213.96,49.5,,49213.96,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3479.6,,,3479.6,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,69595.5,70,,69595.5,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1870.75,,,1870.75,Other,New York Medicaid APG methodology,1870.75,,,1870.75,Other,100% New York Medicaid APG,1870.75,,,1870.75,Other,100% New York Medicaid APG,1870.75,,,1870.75,Other,100% New York Medicaid APG,4209.2,,,4209.2,Other,225% New York Medicaid APG,2862.25,,,2862.25,Other,153% New York Medicaid APG,4209.2,,,4209.2,Other,225% New York Medicaid APG,2619.06,,,2619.06,Other,140% New York Medicaid APG,4209.2,,,4209.2,Other,225% New York Medicaid APG,4863.96,,,4863.96,Other,260% New York Medicaid APG,6061.24,,,6061.24,Other,324% New York Medicaid APG,4022.12,,,4022.12,Other,215% New York Medicaid APG,4022.12,,,4022.12,Other,215% New York Medicaid APG,2338.44,,,2338.44,Other,125% New York Medicaid APG,1870.75,73572.38,
Biopsy arm/elbow soft tissue,24065,CPT,,,,,,,,both,,,34101.75,25235.3,74,,25235.3,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15345.79,45,,15345.79,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,16880.37,49.5,,16880.37,percent of total billed charges,110% of Medicare,23189.19,68,,23189.19,percent of total billed charges,,1973.06,,,1973.06,Other,186% of Medicaid,27281.4,80,,27281.4,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,27281.4,80,,27281.4,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,23871.23,70,,23871.23,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1060.79,,,1060.79,Other,New York Medicaid APG methodology,1060.79,,,1060.79,Other,100% New York Medicaid APG,1060.79,,,1060.79,Other,100% New York Medicaid APG,1060.79,,,1060.79,Other,100% New York Medicaid APG,2386.77,,,2386.77,Other,225% New York Medicaid APG,1623,,,1623,Other,153% New York Medicaid APG,2386.77,,,2386.77,Other,225% New York Medicaid APG,1485.1,,,1485.1,Other,140% New York Medicaid APG,2386.77,,,2386.77,Other,225% New York Medicaid APG,2758.05,,,2758.05,Other,260% New York Medicaid APG,3436.95,,,3436.95,Other,324% New York Medicaid APG,2280.69,,,2280.69,Other,215% New York Medicaid APG,2280.69,,,2280.69,Other,215% New York Medicaid APG,1325.98,,,1325.98,Other,125% New York Medicaid APG,1060.79,27281.4,
Biopsy arm/elbow soft tissue,24066,CPT,,,,,,,,both,,,59767.2,44227.73,74,,44227.73,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,26895.24,45,,26895.24,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,29584.76,49.5,,29584.76,percent of total billed charges,110% of Medicare,40641.7,68,,40641.7,percent of total billed charges,,1973.06,,,1973.06,Other,186% of Medicaid,47813.76,80,,47813.76,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,47813.76,80,,47813.76,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,41837.04,70,,41837.04,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1060.79,,,1060.79,Other,New York Medicaid APG methodology,1060.79,,,1060.79,Other,100% New York Medicaid APG,1060.79,,,1060.79,Other,100% New York Medicaid APG,1060.79,,,1060.79,Other,100% New York Medicaid APG,2386.77,,,2386.77,Other,225% New York Medicaid APG,1623,,,1623,Other,153% New York Medicaid APG,2386.77,,,2386.77,Other,225% New York Medicaid APG,1485.1,,,1485.1,Other,140% New York Medicaid APG,2386.77,,,2386.77,Other,225% New York Medicaid APG,2758.05,,,2758.05,Other,260% New York Medicaid APG,3436.95,,,3436.95,Other,324% New York Medicaid APG,2280.69,,,2280.69,Other,215% New York Medicaid APG,2280.69,,,2280.69,Other,215% New York Medicaid APG,1325.98,,,1325.98,Other,125% New York Medicaid APG,1060.79,47813.76,
Exc arm/elbow les sc 3 cm/>,24071,CPT,,,,,,,,both,,,38614.54,28574.76,74,,28574.76,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,17376.54,45,,17376.54,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,19114.2,49.5,,19114.2,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,1973.06,,,1973.06,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,27030.18,70,,27030.18,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1060.79,,,1060.79,Other,New York Medicaid APG methodology,1060.79,,,1060.79,Other,100% New York Medicaid APG,1060.79,,,1060.79,Other,100% New York Medicaid APG,1060.79,,,1060.79,Other,100% New York Medicaid APG,2386.77,,,2386.77,Other,225% New York Medicaid APG,1623,,,1623,Other,153% New York Medicaid APG,2386.77,,,2386.77,Other,225% New York Medicaid APG,1485.1,,,1485.1,Other,140% New York Medicaid APG,2386.77,,,2386.77,Other,225% New York Medicaid APG,2758.05,,,2758.05,Other,260% New York Medicaid APG,3436.95,,,3436.95,Other,324% New York Medicaid APG,2280.69,,,2280.69,Other,215% New York Medicaid APG,2280.69,,,2280.69,Other,215% New York Medicaid APG,1325.98,,,1325.98,Other,125% New York Medicaid APG,1060.79,28574.76,
Ex arm/elbow tum deep 5 cm/>,24073,CPT,,,,,,,,both,,,36465.26,26984.29,74,,26984.29,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,16409.37,45,,16409.37,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,18050.3,49.5,,18050.3,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3479.6,,,3479.6,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,25525.68,70,,25525.68,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1870.75,,,1870.75,Other,New York Medicaid APG methodology,1870.75,,,1870.75,Other,100% New York Medicaid APG,1870.75,,,1870.75,Other,100% New York Medicaid APG,1870.75,,,1870.75,Other,100% New York Medicaid APG,4209.2,,,4209.2,Other,225% New York Medicaid APG,2862.25,,,2862.25,Other,153% New York Medicaid APG,4209.2,,,4209.2,Other,225% New York Medicaid APG,2619.06,,,2619.06,Other,140% New York Medicaid APG,4209.2,,,4209.2,Other,225% New York Medicaid APG,4863.96,,,4863.96,Other,260% New York Medicaid APG,6061.24,,,6061.24,Other,324% New York Medicaid APG,4022.12,,,4022.12,Other,215% New York Medicaid APG,4022.12,,,4022.12,Other,215% New York Medicaid APG,2338.44,,,2338.44,Other,125% New York Medicaid APG,1870.75,26984.29,
Exc arm/elbow les sc < 3 cm,24075,CPT,,,,,,,,both,,,34597,25601.78,74,,25601.78,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15568.65,45,,15568.65,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,17125.52,49.5,,17125.52,percent of total billed charges,110% of Medicare,23525.96,68,,23525.96,percent of total billed charges,,1973.06,,,1973.06,Other,186% of Medicaid,27677.6,80,,27677.6,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,27677.6,80,,27677.6,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,24217.9,70,,24217.9,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1060.79,,,1060.79,Other,New York Medicaid APG methodology,1060.79,,,1060.79,Other,100% New York Medicaid APG,1060.79,,,1060.79,Other,100% New York Medicaid APG,1060.79,,,1060.79,Other,100% New York Medicaid APG,2386.77,,,2386.77,Other,225% New York Medicaid APG,1623,,,1623,Other,153% New York Medicaid APG,2386.77,,,2386.77,Other,225% New York Medicaid APG,1485.1,,,1485.1,Other,140% New York Medicaid APG,2386.77,,,2386.77,Other,225% New York Medicaid APG,2758.05,,,2758.05,Other,260% New York Medicaid APG,3436.95,,,3436.95,Other,324% New York Medicaid APG,2280.69,,,2280.69,Other,215% New York Medicaid APG,2280.69,,,2280.69,Other,215% New York Medicaid APG,1325.98,,,1325.98,Other,125% New York Medicaid APG,1060.79,27677.6,
Ex arm/elbow tum deep < 5 cm,24076,CPT,,,,,,,,both,,,59475.75,44012.06,74,,44012.06,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,26764.09,45,,26764.09,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,29440.5,49.5,,29440.5,percent of total billed charges,110% of Medicare,40443.51,68,,40443.51,percent of total billed charges,,1973.06,,,1973.06,Other,186% of Medicaid,47580.6,80,,47580.6,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,47580.6,80,,47580.6,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,41633.03,70,,41633.03,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1060.79,,,1060.79,Other,New York Medicaid APG methodology,1060.79,,,1060.79,Other,100% New York Medicaid APG,1060.79,,,1060.79,Other,100% New York Medicaid APG,1060.79,,,1060.79,Other,100% New York Medicaid APG,2386.77,,,2386.77,Other,225% New York Medicaid APG,1623,,,1623,Other,153% New York Medicaid APG,2386.77,,,2386.77,Other,225% New York Medicaid APG,1485.1,,,1485.1,Other,140% New York Medicaid APG,2386.77,,,2386.77,Other,225% New York Medicaid APG,2758.05,,,2758.05,Other,260% New York Medicaid APG,3436.95,,,3436.95,Other,324% New York Medicaid APG,2280.69,,,2280.69,Other,215% New York Medicaid APG,2280.69,,,2280.69,Other,215% New York Medicaid APG,1325.98,,,1325.98,Other,125% New York Medicaid APG,1060.79,47580.6,
Resect arm/elbow tum < 5 cm,24077,CPT,,,,,,,,both,,,59767.2,44227.73,74,,44227.73,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,26895.24,45,,26895.24,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,29584.76,49.5,,29584.76,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3960.57,,,3960.57,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,41837.04,70,,41837.04,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,2129.34,,,2129.34,Other,New York Medicaid APG methodology,2129.34,,,2129.34,Other,100% New York Medicaid APG,2129.34,,,2129.34,Other,100% New York Medicaid APG,2129.34,,,2129.34,Other,100% New York Medicaid APG,4791.01,,,4791.01,Other,225% New York Medicaid APG,3257.89,,,3257.89,Other,153% New York Medicaid APG,4791.01,,,4791.01,Other,225% New York Medicaid APG,2981.08,,,2981.08,Other,140% New York Medicaid APG,4791.01,,,4791.01,Other,225% New York Medicaid APG,5536.28,,,5536.28,Other,260% New York Medicaid APG,6899.06,,,6899.06,Other,324% New York Medicaid APG,4578.08,,,4578.08,Other,215% New York Medicaid APG,4578.08,,,4578.08,Other,215% New York Medicaid APG,2661.67,,,2661.67,Other,125% New York Medicaid APG,2129.34,44227.73,
Resect arm/elbow tum 5 cm/>,24079,CPT,,,,,,,,both,,,59767.2,44227.73,74,,44227.73,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,26895.24,45,,26895.24,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,29584.76,49.5,,29584.76,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3960.57,,,3960.57,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,41837.04,70,,41837.04,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,2129.34,,,2129.34,Other,New York Medicaid APG methodology,2129.34,,,2129.34,Other,100% New York Medicaid APG,2129.34,,,2129.34,Other,100% New York Medicaid APG,2129.34,,,2129.34,Other,100% New York Medicaid APG,4791.01,,,4791.01,Other,225% New York Medicaid APG,3257.89,,,3257.89,Other,153% New York Medicaid APG,4791.01,,,4791.01,Other,225% New York Medicaid APG,2981.08,,,2981.08,Other,140% New York Medicaid APG,4791.01,,,4791.01,Other,225% New York Medicaid APG,5536.28,,,5536.28,Other,260% New York Medicaid APG,6899.06,,,6899.06,Other,324% New York Medicaid APG,4578.08,,,4578.08,Other,215% New York Medicaid APG,4578.08,,,4578.08,Other,215% New York Medicaid APG,2661.67,,,2661.67,Other,125% New York Medicaid APG,2129.34,44227.73,
Biopsy elbow joint lining,24100,CPT,,,,,,,,both,,,68082.75,50381.24,74,,50381.24,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30637.24,45,,30637.24,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33700.96,49.5,,33700.96,percent of total billed charges,110% of Medicare,46296.27,68,,46296.27,percent of total billed charges,,3479.6,,,3479.6,Other,186% of Medicaid,54466.2,80,,54466.2,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,54466.2,80,,54466.2,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,47657.93,70,,47657.93,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1870.75,,,1870.75,Other,New York Medicaid APG methodology,1870.75,,,1870.75,Other,100% New York Medicaid APG,1870.75,,,1870.75,Other,100% New York Medicaid APG,1870.75,,,1870.75,Other,100% New York Medicaid APG,4209.2,,,4209.2,Other,225% New York Medicaid APG,2862.25,,,2862.25,Other,153% New York Medicaid APG,4209.2,,,4209.2,Other,225% New York Medicaid APG,2619.06,,,2619.06,Other,140% New York Medicaid APG,4209.2,,,4209.2,Other,225% New York Medicaid APG,4863.96,,,4863.96,Other,260% New York Medicaid APG,6061.24,,,6061.24,Other,324% New York Medicaid APG,4022.12,,,4022.12,Other,215% New York Medicaid APG,4022.12,,,4022.12,Other,215% New York Medicaid APG,2338.44,,,2338.44,Other,125% New York Medicaid APG,1870.75,54466.2,
Explore/treat elbow joint,24101,CPT,,,,,,,,both,,,57993.89,42915.48,74,,42915.48,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,26097.25,45,,26097.25,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,28706.98,49.5,,28706.98,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3479.6,,,3479.6,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,40595.72,70,,40595.72,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1870.75,,,1870.75,Other,New York Medicaid APG methodology,1870.75,,,1870.75,Other,100% New York Medicaid APG,1870.75,,,1870.75,Other,100% New York Medicaid APG,1870.75,,,1870.75,Other,100% New York Medicaid APG,4209.2,,,4209.2,Other,225% New York Medicaid APG,2862.25,,,2862.25,Other,153% New York Medicaid APG,4209.2,,,4209.2,Other,225% New York Medicaid APG,2619.06,,,2619.06,Other,140% New York Medicaid APG,4209.2,,,4209.2,Other,225% New York Medicaid APG,4863.96,,,4863.96,Other,260% New York Medicaid APG,6061.24,,,6061.24,Other,324% New York Medicaid APG,4022.12,,,4022.12,Other,215% New York Medicaid APG,4022.12,,,4022.12,Other,215% New York Medicaid APG,2338.44,,,2338.44,Other,125% New York Medicaid APG,1870.75,42915.48,
Remove elbow joint lining,24102,CPT,,,,,,,,both,,,68082.75,50381.24,74,,50381.24,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30637.24,45,,30637.24,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33700.96,49.5,,33700.96,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3479.6,,,3479.6,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,47657.93,70,,47657.93,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1870.75,,,1870.75,Other,New York Medicaid APG methodology,1870.75,,,1870.75,Other,100% New York Medicaid APG,1870.75,,,1870.75,Other,100% New York Medicaid APG,1870.75,,,1870.75,Other,100% New York Medicaid APG,4209.2,,,4209.2,Other,225% New York Medicaid APG,2862.25,,,2862.25,Other,153% New York Medicaid APG,4209.2,,,4209.2,Other,225% New York Medicaid APG,2619.06,,,2619.06,Other,140% New York Medicaid APG,4209.2,,,4209.2,Other,225% New York Medicaid APG,4863.96,,,4863.96,Other,260% New York Medicaid APG,6061.24,,,6061.24,Other,324% New York Medicaid APG,4022.12,,,4022.12,Other,215% New York Medicaid APG,4022.12,,,4022.12,Other,215% New York Medicaid APG,2338.44,,,2338.44,Other,125% New York Medicaid APG,1870.75,50381.24,
Removal of elbow bursa,24105,CPT,,,,,,,,both,,,68082.75,50381.24,74,,50381.24,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30637.24,45,,30637.24,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33700.96,49.5,,33700.96,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3479.6,,,3479.6,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,47657.93,70,,47657.93,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1870.75,,,1870.75,Other,New York Medicaid APG methodology,1870.75,,,1870.75,Other,100% New York Medicaid APG,1870.75,,,1870.75,Other,100% New York Medicaid APG,1870.75,,,1870.75,Other,100% New York Medicaid APG,4209.2,,,4209.2,Other,225% New York Medicaid APG,2862.25,,,2862.25,Other,153% New York Medicaid APG,4209.2,,,4209.2,Other,225% New York Medicaid APG,2619.06,,,2619.06,Other,140% New York Medicaid APG,4209.2,,,4209.2,Other,225% New York Medicaid APG,4863.96,,,4863.96,Other,260% New York Medicaid APG,6061.24,,,6061.24,Other,324% New York Medicaid APG,4022.12,,,4022.12,Other,215% New York Medicaid APG,4022.12,,,4022.12,Other,215% New York Medicaid APG,2338.44,,,2338.44,Other,125% New York Medicaid APG,1870.75,50381.24,
Remove humerus lesion,24110,CPT,,,,,,,,both,,,68082.75,50381.24,74,,50381.24,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30637.24,45,,30637.24,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33700.96,49.5,,33700.96,percent of total billed charges,110% of Medicare,46296.27,68,,46296.27,percent of total billed charges,,3960.57,,,3960.57,Other,186% of Medicaid,54466.2,80,,54466.2,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,54466.2,80,,54466.2,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,47657.93,70,,47657.93,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,2129.34,,,2129.34,Other,New York Medicaid APG methodology,2129.34,,,2129.34,Other,100% New York Medicaid APG,2129.34,,,2129.34,Other,100% New York Medicaid APG,2129.34,,,2129.34,Other,100% New York Medicaid APG,4791.01,,,4791.01,Other,225% New York Medicaid APG,3257.89,,,3257.89,Other,153% New York Medicaid APG,4791.01,,,4791.01,Other,225% New York Medicaid APG,2981.08,,,2981.08,Other,140% New York Medicaid APG,4791.01,,,4791.01,Other,225% New York Medicaid APG,5536.28,,,5536.28,Other,260% New York Medicaid APG,6899.06,,,6899.06,Other,324% New York Medicaid APG,4578.08,,,4578.08,Other,215% New York Medicaid APG,4578.08,,,4578.08,Other,215% New York Medicaid APG,2661.67,,,2661.67,Other,125% New York Medicaid APG,2129.34,54466.2,
Remove/graft bone lesion,24115,CPT,,,,,,,,both,,,150476.65,111352.72,74,,111352.72,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,67714.49,45,,67714.49,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,74485.94,49.5,,74485.94,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3960.57,,,3960.57,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,105333.66,70,,105333.66,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,2129.34,,,2129.34,Other,New York Medicaid APG methodology,2129.34,,,2129.34,Other,100% New York Medicaid APG,2129.34,,,2129.34,Other,100% New York Medicaid APG,2129.34,,,2129.34,Other,100% New York Medicaid APG,4791.01,,,4791.01,Other,225% New York Medicaid APG,3257.89,,,3257.89,Other,153% New York Medicaid APG,4791.01,,,4791.01,Other,225% New York Medicaid APG,2981.08,,,2981.08,Other,140% New York Medicaid APG,4791.01,,,4791.01,Other,225% New York Medicaid APG,5536.28,,,5536.28,Other,260% New York Medicaid APG,6899.06,,,6899.06,Other,324% New York Medicaid APG,4578.08,,,4578.08,Other,215% New York Medicaid APG,4578.08,,,4578.08,Other,215% New York Medicaid APG,2661.67,,,2661.67,Other,125% New York Medicaid APG,2129.34,111352.72,
Remove/graft bone lesion,24116,CPT,,,,,,,,both,,,150476.65,111352.72,74,,111352.72,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,67714.49,45,,67714.49,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,74485.94,49.5,,74485.94,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3960.57,,,3960.57,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,105333.66,70,,105333.66,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,2129.34,,,2129.34,Other,New York Medicaid APG methodology,2129.34,,,2129.34,Other,100% New York Medicaid APG,2129.34,,,2129.34,Other,100% New York Medicaid APG,2129.34,,,2129.34,Other,100% New York Medicaid APG,4791.01,,,4791.01,Other,225% New York Medicaid APG,3257.89,,,3257.89,Other,153% New York Medicaid APG,4791.01,,,4791.01,Other,225% New York Medicaid APG,2981.08,,,2981.08,Other,140% New York Medicaid APG,4791.01,,,4791.01,Other,225% New York Medicaid APG,5536.28,,,5536.28,Other,260% New York Medicaid APG,6899.06,,,6899.06,Other,324% New York Medicaid APG,4578.08,,,4578.08,Other,215% New York Medicaid APG,4578.08,,,4578.08,Other,215% New York Medicaid APG,2661.67,,,2661.67,Other,125% New York Medicaid APG,2129.34,111352.72,
Remove elbow lesion,24120,CPT,,,,,,,,both,,,44500.73,32930.54,74,,32930.54,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,20025.33,45,,20025.33,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,22027.86,49.5,,22027.86,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3479.6,,,3479.6,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,31150.51,70,,31150.51,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1870.75,,,1870.75,Other,New York Medicaid APG methodology,1870.75,,,1870.75,Other,100% New York Medicaid APG,1870.75,,,1870.75,Other,100% New York Medicaid APG,1870.75,,,1870.75,Other,100% New York Medicaid APG,4209.2,,,4209.2,Other,225% New York Medicaid APG,2862.25,,,2862.25,Other,153% New York Medicaid APG,4209.2,,,4209.2,Other,225% New York Medicaid APG,2619.06,,,2619.06,Other,140% New York Medicaid APG,4209.2,,,4209.2,Other,225% New York Medicaid APG,4863.96,,,4863.96,Other,260% New York Medicaid APG,6061.24,,,6061.24,Other,324% New York Medicaid APG,4022.12,,,4022.12,Other,215% New York Medicaid APG,4022.12,,,4022.12,Other,215% New York Medicaid APG,2338.44,,,2338.44,Other,125% New York Medicaid APG,1870.75,32930.54,
Remove/graft bone lesion,24125,CPT,,,,,,,,both,,,68082.75,50381.24,74,,50381.24,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30637.24,45,,30637.24,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33700.96,49.5,,33700.96,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3479.6,,,3479.6,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,47657.93,70,,47657.93,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1870.75,,,1870.75,Other,New York Medicaid APG methodology,1870.75,,,1870.75,Other,100% New York Medicaid APG,1870.75,,,1870.75,Other,100% New York Medicaid APG,1870.75,,,1870.75,Other,100% New York Medicaid APG,4209.2,,,4209.2,Other,225% New York Medicaid APG,2862.25,,,2862.25,Other,153% New York Medicaid APG,4209.2,,,4209.2,Other,225% New York Medicaid APG,2619.06,,,2619.06,Other,140% New York Medicaid APG,4209.2,,,4209.2,Other,225% New York Medicaid APG,4863.96,,,4863.96,Other,260% New York Medicaid APG,6061.24,,,6061.24,Other,324% New York Medicaid APG,4022.12,,,4022.12,Other,215% New York Medicaid APG,4022.12,,,4022.12,Other,215% New York Medicaid APG,2338.44,,,2338.44,Other,125% New York Medicaid APG,1870.75,50381.24,
Remove/graft bone lesion,24126,CPT,,,,,,,,both,,,150476.65,111352.72,74,,111352.72,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,67714.49,45,,67714.49,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,74485.94,49.5,,74485.94,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3937.21,,,3937.21,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,105333.66,70,,105333.66,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,2116.78,,,2116.78,Other,New York Medicaid APG methodology,2116.78,,,2116.78,Other,100% New York Medicaid APG,2116.78,,,2116.78,Other,100% New York Medicaid APG,2116.78,,,2116.78,Other,100% New York Medicaid APG,4762.75,,,4762.75,Other,225% New York Medicaid APG,3238.67,,,3238.67,Other,153% New York Medicaid APG,4762.75,,,4762.75,Other,225% New York Medicaid APG,2963.49,,,2963.49,Other,140% New York Medicaid APG,4762.75,,,4762.75,Other,225% New York Medicaid APG,5503.62,,,5503.62,Other,260% New York Medicaid APG,6858.36,,,6858.36,Other,324% New York Medicaid APG,4551.07,,,4551.07,Other,215% New York Medicaid APG,4551.07,,,4551.07,Other,215% New York Medicaid APG,2645.97,,,2645.97,Other,125% New York Medicaid APG,2116.78,111352.72,
Removal of head of radius,24130,CPT,,,,,,,,both,,,68082.75,50381.24,74,,50381.24,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30637.24,45,,30637.24,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33700.96,49.5,,33700.96,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3937.21,,,3937.21,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,47657.93,70,,47657.93,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,2116.78,,,2116.78,Other,New York Medicaid APG methodology,2116.78,,,2116.78,Other,100% New York Medicaid APG,2116.78,,,2116.78,Other,100% New York Medicaid APG,2116.78,,,2116.78,Other,100% New York Medicaid APG,4762.75,,,4762.75,Other,225% New York Medicaid APG,3238.67,,,3238.67,Other,153% New York Medicaid APG,4762.75,,,4762.75,Other,225% New York Medicaid APG,2963.49,,,2963.49,Other,140% New York Medicaid APG,4762.75,,,4762.75,Other,225% New York Medicaid APG,5503.62,,,5503.62,Other,260% New York Medicaid APG,6858.36,,,6858.36,Other,324% New York Medicaid APG,4551.07,,,4551.07,Other,215% New York Medicaid APG,4551.07,,,4551.07,Other,215% New York Medicaid APG,2645.97,,,2645.97,Other,125% New York Medicaid APG,2116.78,50381.24,
Removal of arm bone lesion,24134,CPT,,,,,,,,both,,,150476.65,111352.72,74,,111352.72,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,67714.49,45,,67714.49,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,74485.94,49.5,,74485.94,percent of total billed charges,110% of Medicare,102324.12,68,,102324.12,percent of total billed charges,,3960.57,,,3960.57,Other,186% of Medicaid,120381.32,80,,120381.32,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,120381.32,80,,120381.32,percent of total billed charges,,7216,,,7216,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,105333.66,70,,105333.66,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,2129.34,,,2129.34,Other,New York Medicaid APG methodology,2129.34,,,2129.34,Other,100% New York Medicaid APG,2129.34,,,2129.34,Other,100% New York Medicaid APG,2129.34,,,2129.34,Other,100% New York Medicaid APG,4791.01,,,4791.01,Other,225% New York Medicaid APG,3257.89,,,3257.89,Other,153% New York Medicaid APG,4791.01,,,4791.01,Other,225% New York Medicaid APG,2981.08,,,2981.08,Other,140% New York Medicaid APG,4791.01,,,4791.01,Other,225% New York Medicaid APG,5536.28,,,5536.28,Other,260% New York Medicaid APG,6899.06,,,6899.06,Other,324% New York Medicaid APG,4578.08,,,4578.08,Other,215% New York Medicaid APG,4578.08,,,4578.08,Other,215% New York Medicaid APG,2661.67,,,2661.67,Other,125% New York Medicaid APG,2129.34,120381.32,
Remove radius bone lesion,24136,CPT,,,,,,,,both,,,68082.75,50381.24,74,,50381.24,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30637.24,45,,30637.24,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33700.96,49.5,,33700.96,percent of total billed charges,110% of Medicare,46296.27,68,,46296.27,percent of total billed charges,,3479.6,,,3479.6,Other,186% of Medicaid,54466.2,80,,54466.2,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,54466.2,80,,54466.2,percent of total billed charges,,7216,,,7216,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,47657.93,70,,47657.93,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1870.75,,,1870.75,Other,New York Medicaid APG methodology,1870.75,,,1870.75,Other,100% New York Medicaid APG,1870.75,,,1870.75,Other,100% New York Medicaid APG,1870.75,,,1870.75,Other,100% New York Medicaid APG,4209.2,,,4209.2,Other,225% New York Medicaid APG,2862.25,,,2862.25,Other,153% New York Medicaid APG,4209.2,,,4209.2,Other,225% New York Medicaid APG,2619.06,,,2619.06,Other,140% New York Medicaid APG,4209.2,,,4209.2,Other,225% New York Medicaid APG,4863.96,,,4863.96,Other,260% New York Medicaid APG,6061.24,,,6061.24,Other,324% New York Medicaid APG,4022.12,,,4022.12,Other,215% New York Medicaid APG,4022.12,,,4022.12,Other,215% New York Medicaid APG,2338.44,,,2338.44,Other,125% New York Medicaid APG,1870.75,54466.2,
Remove elbow bone lesion,24138,CPT,,,,,,,,both,,,150476.65,111352.72,74,,111352.72,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,67714.49,45,,67714.49,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,74485.94,49.5,,74485.94,percent of total billed charges,110% of Medicare,102324.12,68,,102324.12,percent of total billed charges,,3937.21,,,3937.21,Other,186% of Medicaid,120381.32,80,,120381.32,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,120381.32,80,,120381.32,percent of total billed charges,,7216,,,7216,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,105333.66,70,,105333.66,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,2116.78,,,2116.78,Other,New York Medicaid APG methodology,2116.78,,,2116.78,Other,100% New York Medicaid APG,2116.78,,,2116.78,Other,100% New York Medicaid APG,2116.78,,,2116.78,Other,100% New York Medicaid APG,4762.75,,,4762.75,Other,225% New York Medicaid APG,3238.67,,,3238.67,Other,153% New York Medicaid APG,4762.75,,,4762.75,Other,225% New York Medicaid APG,2963.49,,,2963.49,Other,140% New York Medicaid APG,4762.75,,,4762.75,Other,225% New York Medicaid APG,5503.62,,,5503.62,Other,260% New York Medicaid APG,6858.36,,,6858.36,Other,324% New York Medicaid APG,4551.07,,,4551.07,Other,215% New York Medicaid APG,4551.07,,,4551.07,Other,215% New York Medicaid APG,2645.97,,,2645.97,Other,125% New York Medicaid APG,2116.78,120381.32,
Partial removal of arm bone,24140,CPT,,,,,,,,both,,,68082.75,50381.24,74,,50381.24,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30637.24,45,,30637.24,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33700.96,49.5,,33700.96,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3960.57,,,3960.57,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,47657.93,70,,47657.93,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,2129.34,,,2129.34,Other,New York Medicaid APG methodology,2129.34,,,2129.34,Other,100% New York Medicaid APG,2129.34,,,2129.34,Other,100% New York Medicaid APG,2129.34,,,2129.34,Other,100% New York Medicaid APG,4791.01,,,4791.01,Other,225% New York Medicaid APG,3257.89,,,3257.89,Other,153% New York Medicaid APG,4791.01,,,4791.01,Other,225% New York Medicaid APG,2981.08,,,2981.08,Other,140% New York Medicaid APG,4791.01,,,4791.01,Other,225% New York Medicaid APG,5536.28,,,5536.28,Other,260% New York Medicaid APG,6899.06,,,6899.06,Other,324% New York Medicaid APG,4578.08,,,4578.08,Other,215% New York Medicaid APG,4578.08,,,4578.08,Other,215% New York Medicaid APG,2661.67,,,2661.67,Other,125% New York Medicaid APG,2129.34,50381.24,
Partial removal of radius,24145,CPT,,,,,,,,both,,,150476.65,111352.72,74,,111352.72,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,67714.49,45,,67714.49,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,74485.94,49.5,,74485.94,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3937.21,,,3937.21,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,105333.66,70,,105333.66,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,2116.78,,,2116.78,Other,New York Medicaid APG methodology,2116.78,,,2116.78,Other,100% New York Medicaid APG,2116.78,,,2116.78,Other,100% New York Medicaid APG,2116.78,,,2116.78,Other,100% New York Medicaid APG,4762.75,,,4762.75,Other,225% New York Medicaid APG,3238.67,,,3238.67,Other,153% New York Medicaid APG,4762.75,,,4762.75,Other,225% New York Medicaid APG,2963.49,,,2963.49,Other,140% New York Medicaid APG,4762.75,,,4762.75,Other,225% New York Medicaid APG,5503.62,,,5503.62,Other,260% New York Medicaid APG,6858.36,,,6858.36,Other,324% New York Medicaid APG,4551.07,,,4551.07,Other,215% New York Medicaid APG,4551.07,,,4551.07,Other,215% New York Medicaid APG,2645.97,,,2645.97,Other,125% New York Medicaid APG,2116.78,111352.72,
Partial removal of elbow,24147,CPT,,,,,,,,both,,,53513.08,39599.68,74,,39599.68,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,24080.89,45,,24080.89,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,26488.97,49.5,,26488.97,percent of total billed charges,110% of Medicare,36388.89,68,,36388.89,percent of total billed charges,,3479.6,,,3479.6,Other,186% of Medicaid,42810.46,80,,42810.46,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,42810.46,80,,42810.46,percent of total billed charges,,7216,,,7216,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,37459.16,70,,37459.16,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1870.75,,,1870.75,Other,New York Medicaid APG methodology,1870.75,,,1870.75,Other,100% New York Medicaid APG,1870.75,,,1870.75,Other,100% New York Medicaid APG,1870.75,,,1870.75,Other,100% New York Medicaid APG,4209.2,,,4209.2,Other,225% New York Medicaid APG,2862.25,,,2862.25,Other,153% New York Medicaid APG,4209.2,,,4209.2,Other,225% New York Medicaid APG,2619.06,,,2619.06,Other,140% New York Medicaid APG,4209.2,,,4209.2,Other,225% New York Medicaid APG,4863.96,,,4863.96,Other,260% New York Medicaid APG,6061.24,,,6061.24,Other,324% New York Medicaid APG,4022.12,,,4022.12,Other,215% New York Medicaid APG,4022.12,,,4022.12,Other,215% New York Medicaid APG,2338.44,,,2338.44,Other,125% New York Medicaid APG,1870.75,42810.46,
Radical resection of elbow,24149,CPT,,,,,,,,both,,,63247.95,46803.48,74,,46803.48,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,28461.58,45,,28461.58,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,31307.74,49.5,,31307.74,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3937.21,,,3937.21,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,44273.57,70,,44273.57,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,2116.78,,,2116.78,Other,New York Medicaid APG methodology,2116.78,,,2116.78,Other,100% New York Medicaid APG,2116.78,,,2116.78,Other,100% New York Medicaid APG,2116.78,,,2116.78,Other,100% New York Medicaid APG,4762.75,,,4762.75,Other,225% New York Medicaid APG,3238.67,,,3238.67,Other,153% New York Medicaid APG,4762.75,,,4762.75,Other,225% New York Medicaid APG,2963.49,,,2963.49,Other,140% New York Medicaid APG,4762.75,,,4762.75,Other,225% New York Medicaid APG,5503.62,,,5503.62,Other,260% New York Medicaid APG,6858.36,,,6858.36,Other,324% New York Medicaid APG,4551.07,,,4551.07,Other,215% New York Medicaid APG,4551.07,,,4551.07,Other,215% New York Medicaid APG,2645.97,,,2645.97,Other,125% New York Medicaid APG,2116.78,46803.48,
Resect distal humerus tumor,24150,CPT,,,,,,,,both,,,150476.65,111352.72,74,,111352.72,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,67714.49,45,,67714.49,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,74485.94,49.5,,74485.94,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3960.57,,,3960.57,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,105333.66,70,,105333.66,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,2129.34,,,2129.34,Other,New York Medicaid APG methodology,2129.34,,,2129.34,Other,100% New York Medicaid APG,2129.34,,,2129.34,Other,100% New York Medicaid APG,2129.34,,,2129.34,Other,100% New York Medicaid APG,4791.01,,,4791.01,Other,225% New York Medicaid APG,3257.89,,,3257.89,Other,153% New York Medicaid APG,4791.01,,,4791.01,Other,225% New York Medicaid APG,2981.08,,,2981.08,Other,140% New York Medicaid APG,4791.01,,,4791.01,Other,225% New York Medicaid APG,5536.28,,,5536.28,Other,260% New York Medicaid APG,6899.06,,,6899.06,Other,324% New York Medicaid APG,4578.08,,,4578.08,Other,215% New York Medicaid APG,4578.08,,,4578.08,Other,215% New York Medicaid APG,2661.67,,,2661.67,Other,125% New York Medicaid APG,2129.34,111352.72,
Resect radius tumor,24152,CPT,,,,,,,,both,,,150476.65,111352.72,74,,111352.72,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,67714.49,45,,67714.49,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,74485.94,49.5,,74485.94,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3937.21,,,3937.21,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,105333.66,70,,105333.66,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,2116.78,,,2116.78,Other,New York Medicaid APG methodology,2116.78,,,2116.78,Other,100% New York Medicaid APG,2116.78,,,2116.78,Other,100% New York Medicaid APG,2116.78,,,2116.78,Other,100% New York Medicaid APG,4762.75,,,4762.75,Other,225% New York Medicaid APG,3238.67,,,3238.67,Other,153% New York Medicaid APG,4762.75,,,4762.75,Other,225% New York Medicaid APG,2963.49,,,2963.49,Other,140% New York Medicaid APG,4762.75,,,4762.75,Other,225% New York Medicaid APG,5503.62,,,5503.62,Other,260% New York Medicaid APG,6858.36,,,6858.36,Other,324% New York Medicaid APG,4551.07,,,4551.07,Other,215% New York Medicaid APG,4551.07,,,4551.07,Other,215% New York Medicaid APG,2645.97,,,2645.97,Other,125% New York Medicaid APG,2116.78,111352.72,
Removal of elbow joint,24155,CPT,,,,,,,,both,,,68082.75,50381.24,74,,50381.24,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30637.24,45,,30637.24,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33700.96,49.5,,33700.96,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3479.6,,,3479.6,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,47657.93,70,,47657.93,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1870.75,,,1870.75,Other,New York Medicaid APG methodology,1870.75,,,1870.75,Other,100% New York Medicaid APG,1870.75,,,1870.75,Other,100% New York Medicaid APG,1870.75,,,1870.75,Other,100% New York Medicaid APG,4209.2,,,4209.2,Other,225% New York Medicaid APG,2862.25,,,2862.25,Other,153% New York Medicaid APG,4209.2,,,4209.2,Other,225% New York Medicaid APG,2619.06,,,2619.06,Other,140% New York Medicaid APG,4209.2,,,4209.2,Other,225% New York Medicaid APG,4863.96,,,4863.96,Other,260% New York Medicaid APG,6061.24,,,6061.24,Other,324% New York Medicaid APG,4022.12,,,4022.12,Other,215% New York Medicaid APG,4022.12,,,4022.12,Other,215% New York Medicaid APG,2338.44,,,2338.44,Other,125% New York Medicaid APG,1870.75,50381.24,
Remove elbow joint implant,24160,CPT,,,,,,,,both,,,68082.75,50381.24,74,,50381.24,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30637.24,45,,30637.24,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33700.96,49.5,,33700.96,percent of total billed charges,110% of Medicare,46296.27,68,,46296.27,percent of total billed charges,,3479.6,,,3479.6,Other,186% of Medicaid,54466.2,80,,54466.2,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,54466.2,80,,54466.2,percent of total billed charges,,7216,,,7216,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,47657.93,70,,47657.93,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1870.75,,,1870.75,Other,New York Medicaid APG methodology,1870.75,,,1870.75,Other,100% New York Medicaid APG,1870.75,,,1870.75,Other,100% New York Medicaid APG,1870.75,,,1870.75,Other,100% New York Medicaid APG,4209.2,,,4209.2,Other,225% New York Medicaid APG,2862.25,,,2862.25,Other,153% New York Medicaid APG,4209.2,,,4209.2,Other,225% New York Medicaid APG,2619.06,,,2619.06,Other,140% New York Medicaid APG,4209.2,,,4209.2,Other,225% New York Medicaid APG,4863.96,,,4863.96,Other,260% New York Medicaid APG,6061.24,,,6061.24,Other,324% New York Medicaid APG,4022.12,,,4022.12,Other,215% New York Medicaid APG,4022.12,,,4022.12,Other,215% New York Medicaid APG,2338.44,,,2338.44,Other,125% New York Medicaid APG,1870.75,54466.2,
Remove radius head implant,24164,CPT,,,,,,,,both,,,68082.75,50381.24,74,,50381.24,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30637.24,45,,30637.24,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33700.96,49.5,,33700.96,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3479.6,,,3479.6,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,47657.93,70,,47657.93,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1870.75,,,1870.75,Other,New York Medicaid APG methodology,1870.75,,,1870.75,Other,100% New York Medicaid APG,1870.75,,,1870.75,Other,100% New York Medicaid APG,1870.75,,,1870.75,Other,100% New York Medicaid APG,4209.2,,,4209.2,Other,225% New York Medicaid APG,2862.25,,,2862.25,Other,153% New York Medicaid APG,4209.2,,,4209.2,Other,225% New York Medicaid APG,2619.06,,,2619.06,Other,140% New York Medicaid APG,4209.2,,,4209.2,Other,225% New York Medicaid APG,4863.96,,,4863.96,Other,260% New York Medicaid APG,6061.24,,,6061.24,Other,324% New York Medicaid APG,4022.12,,,4022.12,Other,215% New York Medicaid APG,4022.12,,,4022.12,Other,215% New York Medicaid APG,2338.44,,,2338.44,Other,125% New York Medicaid APG,1870.75,50381.24,
Removal of arm foreign body,24200,CPT,,,,,,,,both,,,34101.75,25235.3,74,,25235.3,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15345.79,45,,15345.79,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,16880.37,49.5,,16880.37,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,1973.06,,,1973.06,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,3578,,"100% primary, 0% secondary procedures",3578,Other,MagnaCare ASC Grouper,23871.23,70,,23871.23,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,1060.79,,,1060.79,Other,New York Medicaid APG methodology,1060.79,,,1060.79,Other,100% New York Medicaid APG,1060.79,,,1060.79,Other,100% New York Medicaid APG,1060.79,,,1060.79,Other,100% New York Medicaid APG,2386.77,,,2386.77,Other,225% New York Medicaid APG,1623,,,1623,Other,153% New York Medicaid APG,2386.77,,,2386.77,Other,225% New York Medicaid APG,1485.1,,,1485.1,Other,140% New York Medicaid APG,2386.77,,,2386.77,Other,225% New York Medicaid APG,2758.05,,,2758.05,Other,260% New York Medicaid APG,3436.95,,,3436.95,Other,324% New York Medicaid APG,2280.69,,,2280.69,Other,215% New York Medicaid APG,2280.69,,,2280.69,Other,215% New York Medicaid APG,1325.98,,,1325.98,Other,125% New York Medicaid APG,1060.79,25235.3,
Removal of arm foreign body,24201,CPT,,,,,,,,both,,,59767.2,44227.73,74,,44227.73,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,26895.24,45,,26895.24,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,29584.76,49.5,,29584.76,percent of total billed charges,110% of Medicare,40641.7,68,,40641.7,percent of total billed charges,,1973.06,,,1973.06,Other,186% of Medicaid,47813.76,80,,47813.76,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,47813.76,80,,47813.76,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,41837.04,70,,41837.04,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1060.79,,,1060.79,Other,New York Medicaid APG methodology,1060.79,,,1060.79,Other,100% New York Medicaid APG,1060.79,,,1060.79,Other,100% New York Medicaid APG,1060.79,,,1060.79,Other,100% New York Medicaid APG,2386.77,,,2386.77,Other,225% New York Medicaid APG,1623,,,1623,Other,153% New York Medicaid APG,2386.77,,,2386.77,Other,225% New York Medicaid APG,1485.1,,,1485.1,Other,140% New York Medicaid APG,2386.77,,,2386.77,Other,225% New York Medicaid APG,2758.05,,,2758.05,Other,260% New York Medicaid APG,3436.95,,,3436.95,Other,324% New York Medicaid APG,2280.69,,,2280.69,Other,215% New York Medicaid APG,2280.69,,,2280.69,Other,215% New York Medicaid APG,1325.98,,,1325.98,Other,125% New York Medicaid APG,1060.79,47813.76,
Injection for elbow x-ray,24220,CPT,,,,,,,,both,,,34215,25319.1,74,,25319.1,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15396.75,45,,15396.75,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,16936.43,49.5,,16936.43,percent of total billed charges,110% of Medicare,23266.2,68,,23266.2,percent of total billed charges,,966.93,,,966.93,Other,186% of Medicaid,27372,80,,27372,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,27372,80,,27372,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,23950.5,70,,23950.5,percent of total billed charges,,323.08,,,323.08,Fee Schedule,,273.83,,,273.83,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,519.86,,,519.86,Other,New York Medicaid APG methodology,519.86,,,519.86,Other,100% New York Medicaid APG,519.86,,,519.86,Other,100% New York Medicaid APG,519.86,,,519.86,Other,100% New York Medicaid APG,1169.68,,,1169.68,Other,225% New York Medicaid APG,795.38,,,795.38,Other,153% New York Medicaid APG,1169.68,,,1169.68,Other,225% New York Medicaid APG,727.8,,,727.8,Other,140% New York Medicaid APG,1169.68,,,1169.68,Other,225% New York Medicaid APG,1351.62,,,1351.62,Other,260% New York Medicaid APG,1684.33,,,1684.33,Other,324% New York Medicaid APG,1117.69,,,1117.69,Other,215% New York Medicaid APG,1117.69,,,1117.69,Other,215% New York Medicaid APG,649.82,,,649.82,Other,125% New York Medicaid APG,273.83,27372,
Manipulate elbow w/anesth,24300,CPT,,,,,,,,both,,,33805.49,25016.06,74,,25016.06,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15212.47,45,,15212.47,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,16733.72,49.5,,16733.72,percent of total billed charges,110% of Medicare,22987.73,68,,22987.73,percent of total billed charges,,1730.38,,,1730.38,Other,186% of Medicaid,27044.39,80,,27044.39,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,27044.39,80,,27044.39,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,23663.84,70,,23663.84,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,930.31,,,930.31,Other,New York Medicaid APG methodology,930.31,,,930.31,Other,100% New York Medicaid APG,930.31,,,930.31,Other,100% New York Medicaid APG,930.31,,,930.31,Other,100% New York Medicaid APG,2093.21,,,2093.21,Other,225% New York Medicaid APG,1423.38,,,1423.38,Other,153% New York Medicaid APG,2093.21,,,2093.21,Other,225% New York Medicaid APG,1302.44,,,1302.44,Other,140% New York Medicaid APG,2093.21,,,2093.21,Other,225% New York Medicaid APG,2418.82,,,2418.82,Other,260% New York Medicaid APG,3014.22,,,3014.22,Other,324% New York Medicaid APG,2000.18,,,2000.18,Other,215% New York Medicaid APG,2000.18,,,2000.18,Other,215% New York Medicaid APG,1162.89,,,1162.89,Other,125% New York Medicaid APG,930.31,27044.39,
Muscle/tendon transfer,24301,CPT,,,,,,,,both,,,150476.65,111352.72,74,,111352.72,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,67714.49,45,,67714.49,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,74485.94,49.5,,74485.94,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3937.21,,,3937.21,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,105333.66,70,,105333.66,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,2116.78,,,2116.78,Other,New York Medicaid APG methodology,2116.78,,,2116.78,Other,100% New York Medicaid APG,2116.78,,,2116.78,Other,100% New York Medicaid APG,2116.78,,,2116.78,Other,100% New York Medicaid APG,4762.75,,,4762.75,Other,225% New York Medicaid APG,3238.67,,,3238.67,Other,153% New York Medicaid APG,4762.75,,,4762.75,Other,225% New York Medicaid APG,2963.49,,,2963.49,Other,140% New York Medicaid APG,4762.75,,,4762.75,Other,225% New York Medicaid APG,5503.62,,,5503.62,Other,260% New York Medicaid APG,6858.36,,,6858.36,Other,324% New York Medicaid APG,4551.07,,,4551.07,Other,215% New York Medicaid APG,4551.07,,,4551.07,Other,215% New York Medicaid APG,2645.97,,,2645.97,Other,125% New York Medicaid APG,2116.78,111352.72,
Arm tendon lengthening,24305,CPT,,,,,,,,both,,,68082.75,50381.24,74,,50381.24,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30637.24,45,,30637.24,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33700.96,49.5,,33700.96,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3479.6,,,3479.6,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,47657.93,70,,47657.93,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1870.75,,,1870.75,Other,New York Medicaid APG methodology,1870.75,,,1870.75,Other,100% New York Medicaid APG,1870.75,,,1870.75,Other,100% New York Medicaid APG,1870.75,,,1870.75,Other,100% New York Medicaid APG,4209.2,,,4209.2,Other,225% New York Medicaid APG,2862.25,,,2862.25,Other,153% New York Medicaid APG,4209.2,,,4209.2,Other,225% New York Medicaid APG,2619.06,,,2619.06,Other,140% New York Medicaid APG,4209.2,,,4209.2,Other,225% New York Medicaid APG,4863.96,,,4863.96,Other,260% New York Medicaid APG,6061.24,,,6061.24,Other,324% New York Medicaid APG,4022.12,,,4022.12,Other,215% New York Medicaid APG,4022.12,,,4022.12,Other,215% New York Medicaid APG,2338.44,,,2338.44,Other,125% New York Medicaid APG,1870.75,50381.24,
Revision of arm tendon,24310,CPT,,,,,,,,both,,,68082.75,50381.24,74,,50381.24,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30637.24,45,,30637.24,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33700.96,49.5,,33700.96,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3960.57,,,3960.57,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,47657.93,70,,47657.93,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,2129.34,,,2129.34,Other,New York Medicaid APG methodology,2129.34,,,2129.34,Other,100% New York Medicaid APG,2129.34,,,2129.34,Other,100% New York Medicaid APG,2129.34,,,2129.34,Other,100% New York Medicaid APG,4791.01,,,4791.01,Other,225% New York Medicaid APG,3257.89,,,3257.89,Other,153% New York Medicaid APG,4791.01,,,4791.01,Other,225% New York Medicaid APG,2981.08,,,2981.08,Other,140% New York Medicaid APG,4791.01,,,4791.01,Other,225% New York Medicaid APG,5536.28,,,5536.28,Other,260% New York Medicaid APG,6899.06,,,6899.06,Other,324% New York Medicaid APG,4578.08,,,4578.08,Other,215% New York Medicaid APG,4578.08,,,4578.08,Other,215% New York Medicaid APG,2661.67,,,2661.67,Other,125% New York Medicaid APG,2129.34,50381.24,
Repair of arm tendon,24320,CPT,,,,,,,,both,,,150476.65,111352.72,74,,111352.72,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,67714.49,45,,67714.49,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,74485.94,49.5,,74485.94,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3960.57,,,3960.57,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,105333.66,70,,105333.66,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,2129.34,,,2129.34,Other,New York Medicaid APG methodology,2129.34,,,2129.34,Other,100% New York Medicaid APG,2129.34,,,2129.34,Other,100% New York Medicaid APG,2129.34,,,2129.34,Other,100% New York Medicaid APG,4791.01,,,4791.01,Other,225% New York Medicaid APG,3257.89,,,3257.89,Other,153% New York Medicaid APG,4791.01,,,4791.01,Other,225% New York Medicaid APG,2981.08,,,2981.08,Other,140% New York Medicaid APG,4791.01,,,4791.01,Other,225% New York Medicaid APG,5536.28,,,5536.28,Other,260% New York Medicaid APG,6899.06,,,6899.06,Other,324% New York Medicaid APG,4578.08,,,4578.08,Other,215% New York Medicaid APG,4578.08,,,4578.08,Other,215% New York Medicaid APG,2661.67,,,2661.67,Other,125% New York Medicaid APG,2129.34,111352.72,
Revision of arm muscles,24330,CPT,,,,,,,,both,,,150476.65,111352.72,74,,111352.72,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,67714.49,45,,67714.49,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,74485.94,49.5,,74485.94,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3937.21,,,3937.21,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,105333.66,70,,105333.66,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,2116.78,,,2116.78,Other,New York Medicaid APG methodology,2116.78,,,2116.78,Other,100% New York Medicaid APG,2116.78,,,2116.78,Other,100% New York Medicaid APG,2116.78,,,2116.78,Other,100% New York Medicaid APG,4762.75,,,4762.75,Other,225% New York Medicaid APG,3238.67,,,3238.67,Other,153% New York Medicaid APG,4762.75,,,4762.75,Other,225% New York Medicaid APG,2963.49,,,2963.49,Other,140% New York Medicaid APG,4762.75,,,4762.75,Other,225% New York Medicaid APG,5503.62,,,5503.62,Other,260% New York Medicaid APG,6858.36,,,6858.36,Other,324% New York Medicaid APG,4551.07,,,4551.07,Other,215% New York Medicaid APG,4551.07,,,4551.07,Other,215% New York Medicaid APG,2645.97,,,2645.97,Other,125% New York Medicaid APG,2116.78,111352.72,
Revision of arm muscles,24331,CPT,,,,,,,,both,,,150476.65,111352.72,74,,111352.72,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,67714.49,45,,67714.49,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,74485.94,49.5,,74485.94,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3479.6,,,3479.6,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,105333.66,70,,105333.66,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,1870.75,,,1870.75,Other,New York Medicaid APG methodology,1870.75,,,1870.75,Other,100% New York Medicaid APG,1870.75,,,1870.75,Other,100% New York Medicaid APG,1870.75,,,1870.75,Other,100% New York Medicaid APG,4209.2,,,4209.2,Other,225% New York Medicaid APG,2862.25,,,2862.25,Other,153% New York Medicaid APG,4209.2,,,4209.2,Other,225% New York Medicaid APG,2619.06,,,2619.06,Other,140% New York Medicaid APG,4209.2,,,4209.2,Other,225% New York Medicaid APG,4863.96,,,4863.96,Other,260% New York Medicaid APG,6061.24,,,6061.24,Other,324% New York Medicaid APG,4022.12,,,4022.12,Other,215% New York Medicaid APG,4022.12,,,4022.12,Other,215% New York Medicaid APG,2338.44,,,2338.44,Other,125% New York Medicaid APG,1870.75,111352.72,
Tenolysis triceps,24332,CPT,,,,,,,,both,,,68082.75,50381.24,74,,50381.24,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30637.24,45,,30637.24,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33700.96,49.5,,33700.96,percent of total billed charges,110% of Medicare,46296.27,68,,46296.27,percent of total billed charges,,3960.57,,,3960.57,Other,186% of Medicaid,54466.2,80,,54466.2,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,54466.2,80,,54466.2,percent of total billed charges,,7216,,,7216,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,47657.93,70,,47657.93,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,2129.34,,,2129.34,Other,New York Medicaid APG methodology,2129.34,,,2129.34,Other,100% New York Medicaid APG,2129.34,,,2129.34,Other,100% New York Medicaid APG,2129.34,,,2129.34,Other,100% New York Medicaid APG,4791.01,,,4791.01,Other,225% New York Medicaid APG,3257.89,,,3257.89,Other,153% New York Medicaid APG,4791.01,,,4791.01,Other,225% New York Medicaid APG,2981.08,,,2981.08,Other,140% New York Medicaid APG,4791.01,,,4791.01,Other,225% New York Medicaid APG,5536.28,,,5536.28,Other,260% New York Medicaid APG,6899.06,,,6899.06,Other,324% New York Medicaid APG,4578.08,,,4578.08,Other,215% New York Medicaid APG,4578.08,,,4578.08,Other,215% New York Medicaid APG,2661.67,,,2661.67,Other,125% New York Medicaid APG,2129.34,54466.2,
Repair of biceps tendon,24340,CPT,,,,,,,,both,,,150476.65,111352.72,74,,111352.72,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,67714.49,45,,67714.49,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,74485.94,49.5,,74485.94,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3960.57,,,3960.57,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,105333.66,70,,105333.66,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,2129.34,,,2129.34,Other,New York Medicaid APG methodology,2129.34,,,2129.34,Other,100% New York Medicaid APG,2129.34,,,2129.34,Other,100% New York Medicaid APG,2129.34,,,2129.34,Other,100% New York Medicaid APG,4791.01,,,4791.01,Other,225% New York Medicaid APG,3257.89,,,3257.89,Other,153% New York Medicaid APG,4791.01,,,4791.01,Other,225% New York Medicaid APG,2981.08,,,2981.08,Other,140% New York Medicaid APG,4791.01,,,4791.01,Other,225% New York Medicaid APG,5536.28,,,5536.28,Other,260% New York Medicaid APG,6899.06,,,6899.06,Other,324% New York Medicaid APG,4578.08,,,4578.08,Other,215% New York Medicaid APG,4578.08,,,4578.08,Other,215% New York Medicaid APG,2661.67,,,2661.67,Other,125% New York Medicaid APG,2129.34,111352.72,
Repair arm tendon/muscle,24341,CPT,,,,,,,,both,,,34715.08,25689.16,74,,25689.16,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15621.79,45,,15621.79,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,17183.96,49.5,,17183.96,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3960.57,,,3960.57,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,24300.56,70,,24300.56,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,2129.34,,,2129.34,Other,New York Medicaid APG methodology,2129.34,,,2129.34,Other,100% New York Medicaid APG,2129.34,,,2129.34,Other,100% New York Medicaid APG,2129.34,,,2129.34,Other,100% New York Medicaid APG,4791.01,,,4791.01,Other,225% New York Medicaid APG,3257.89,,,3257.89,Other,153% New York Medicaid APG,4791.01,,,4791.01,Other,225% New York Medicaid APG,2981.08,,,2981.08,Other,140% New York Medicaid APG,4791.01,,,4791.01,Other,225% New York Medicaid APG,5536.28,,,5536.28,Other,260% New York Medicaid APG,6899.06,,,6899.06,Other,324% New York Medicaid APG,4578.08,,,4578.08,Other,215% New York Medicaid APG,4578.08,,,4578.08,Other,215% New York Medicaid APG,2661.67,,,2661.67,Other,125% New York Medicaid APG,2129.34,25689.16,
Repair of ruptured tendon,24342,CPT,,,,,,,,both,,,45187.14,33438.48,74,,33438.48,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,20334.21,45,,20334.21,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,22367.63,49.5,,22367.63,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3960.57,,,3960.57,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,31631,70,,31631,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,2129.34,,,2129.34,Other,New York Medicaid APG methodology,2129.34,,,2129.34,Other,100% New York Medicaid APG,2129.34,,,2129.34,Other,100% New York Medicaid APG,2129.34,,,2129.34,Other,100% New York Medicaid APG,4791.01,,,4791.01,Other,225% New York Medicaid APG,3257.89,,,3257.89,Other,153% New York Medicaid APG,4791.01,,,4791.01,Other,225% New York Medicaid APG,2981.08,,,2981.08,Other,140% New York Medicaid APG,4791.01,,,4791.01,Other,225% New York Medicaid APG,5536.28,,,5536.28,Other,260% New York Medicaid APG,6899.06,,,6899.06,Other,324% New York Medicaid APG,4578.08,,,4578.08,Other,215% New York Medicaid APG,4578.08,,,4578.08,Other,215% New York Medicaid APG,2661.67,,,2661.67,Other,125% New York Medicaid APG,2129.34,33438.48,
Repr elbow lat ligmnt w/tiss,24343,CPT,,,,,,,,both,,,68082.75,50381.24,74,,50381.24,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30637.24,45,,30637.24,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33700.96,49.5,,33700.96,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3479.6,,,3479.6,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,47657.93,70,,47657.93,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1870.75,,,1870.75,Other,New York Medicaid APG methodology,1870.75,,,1870.75,Other,100% New York Medicaid APG,1870.75,,,1870.75,Other,100% New York Medicaid APG,1870.75,,,1870.75,Other,100% New York Medicaid APG,4209.2,,,4209.2,Other,225% New York Medicaid APG,2862.25,,,2862.25,Other,153% New York Medicaid APG,4209.2,,,4209.2,Other,225% New York Medicaid APG,2619.06,,,2619.06,Other,140% New York Medicaid APG,4209.2,,,4209.2,Other,225% New York Medicaid APG,4863.96,,,4863.96,Other,260% New York Medicaid APG,6061.24,,,6061.24,Other,324% New York Medicaid APG,4022.12,,,4022.12,Other,215% New York Medicaid APG,4022.12,,,4022.12,Other,215% New York Medicaid APG,2338.44,,,2338.44,Other,125% New York Medicaid APG,1870.75,50381.24,
Reconstruct elbow lat ligmnt,24344,CPT,,,,,,,,both,,,93480.65,69175.68,74,,69175.68,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,42066.29,45,,42066.29,percent of total billed charges,Medicare Ratio of cost to charges,7938,,"100% primary, 50% supplemental procedure",7938,Other,Aetna ASC Grouper,7144,,"100% primary, 50% supplemental procedure",7144,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,46272.92,49.5,,46272.92,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3937.21,,,3937.21,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,65436.46,70,,65436.46,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,2116.78,,,2116.78,Other,New York Medicaid APG methodology,2116.78,,,2116.78,Other,100% New York Medicaid APG,2116.78,,,2116.78,Other,100% New York Medicaid APG,2116.78,,,2116.78,Other,100% New York Medicaid APG,4762.75,,,4762.75,Other,225% New York Medicaid APG,3238.67,,,3238.67,Other,153% New York Medicaid APG,4762.75,,,4762.75,Other,225% New York Medicaid APG,2963.49,,,2963.49,Other,140% New York Medicaid APG,4762.75,,,4762.75,Other,225% New York Medicaid APG,5503.62,,,5503.62,Other,260% New York Medicaid APG,6858.36,,,6858.36,Other,324% New York Medicaid APG,4551.07,,,4551.07,Other,215% New York Medicaid APG,4551.07,,,4551.07,Other,215% New York Medicaid APG,2645.97,,,2645.97,Other,125% New York Medicaid APG,2116.78,69175.68,
Repr elbw med ligmnt w/tissu,24345,CPT,,,,,,,,both,,,36880.56,27291.61,74,,27291.61,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,16596.25,45,,16596.25,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,18255.88,49.5,,18255.88,percent of total billed charges,110% of Medicare,25078.78,68,,25078.78,percent of total billed charges,,3937.21,,,3937.21,Other,186% of Medicaid,29504.45,80,,29504.45,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,29504.45,80,,29504.45,percent of total billed charges,,7216,,,7216,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,25816.39,70,,25816.39,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,2116.78,,,2116.78,Other,New York Medicaid APG methodology,2116.78,,,2116.78,Other,100% New York Medicaid APG,2116.78,,,2116.78,Other,100% New York Medicaid APG,2116.78,,,2116.78,Other,100% New York Medicaid APG,4762.75,,,4762.75,Other,225% New York Medicaid APG,3238.67,,,3238.67,Other,153% New York Medicaid APG,4762.75,,,4762.75,Other,225% New York Medicaid APG,2963.49,,,2963.49,Other,140% New York Medicaid APG,4762.75,,,4762.75,Other,225% New York Medicaid APG,5503.62,,,5503.62,Other,260% New York Medicaid APG,6858.36,,,6858.36,Other,324% New York Medicaid APG,4551.07,,,4551.07,Other,215% New York Medicaid APG,4551.07,,,4551.07,Other,215% New York Medicaid APG,2645.97,,,2645.97,Other,125% New York Medicaid APG,2116.78,29504.45,
Reconstruct elbow med ligmnt,24346,CPT,,,,,,,,both,,,276827.87,204852.62,74,,204852.62,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,124572.54,45,,124572.54,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,137029.8,49.5,,137029.8,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3937.21,,,3937.21,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,193779.51,70,,193779.51,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,2116.78,,,2116.78,Other,New York Medicaid APG methodology,2116.78,,,2116.78,Other,100% New York Medicaid APG,2116.78,,,2116.78,Other,100% New York Medicaid APG,2116.78,,,2116.78,Other,100% New York Medicaid APG,4762.75,,,4762.75,Other,225% New York Medicaid APG,3238.67,,,3238.67,Other,153% New York Medicaid APG,4762.75,,,4762.75,Other,225% New York Medicaid APG,2963.49,,,2963.49,Other,140% New York Medicaid APG,4762.75,,,4762.75,Other,225% New York Medicaid APG,5503.62,,,5503.62,Other,260% New York Medicaid APG,6858.36,,,6858.36,Other,324% New York Medicaid APG,4551.07,,,4551.07,Other,215% New York Medicaid APG,4551.07,,,4551.07,Other,215% New York Medicaid APG,2645.97,,,2645.97,Other,125% New York Medicaid APG,2116.78,204852.62,
Repair elbow perc,24357,CPT,,,,,,,,both,,,68082.75,50381.24,74,,50381.24,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30637.24,45,,30637.24,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33700.96,49.5,,33700.96,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3479.6,,,3479.6,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,47657.93,70,,47657.93,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1870.75,,,1870.75,Other,New York Medicaid APG methodology,1870.75,,,1870.75,Other,100% New York Medicaid APG,1870.75,,,1870.75,Other,100% New York Medicaid APG,1870.75,,,1870.75,Other,100% New York Medicaid APG,4209.2,,,4209.2,Other,225% New York Medicaid APG,2862.25,,,2862.25,Other,153% New York Medicaid APG,4209.2,,,4209.2,Other,225% New York Medicaid APG,2619.06,,,2619.06,Other,140% New York Medicaid APG,4209.2,,,4209.2,Other,225% New York Medicaid APG,4863.96,,,4863.96,Other,260% New York Medicaid APG,6061.24,,,6061.24,Other,324% New York Medicaid APG,4022.12,,,4022.12,Other,215% New York Medicaid APG,4022.12,,,4022.12,Other,215% New York Medicaid APG,2338.44,,,2338.44,Other,125% New York Medicaid APG,1870.75,50381.24,
Repair elbow w/deb open,24358,CPT,,,,,,,,both,,,37172.82,27507.89,74,,27507.89,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,16727.77,45,,16727.77,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,18400.55,49.5,,18400.55,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3479.6,,,3479.6,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,26020.97,70,,26020.97,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1870.75,,,1870.75,Other,New York Medicaid APG methodology,1870.75,,,1870.75,Other,100% New York Medicaid APG,1870.75,,,1870.75,Other,100% New York Medicaid APG,1870.75,,,1870.75,Other,100% New York Medicaid APG,4209.2,,,4209.2,Other,225% New York Medicaid APG,2862.25,,,2862.25,Other,153% New York Medicaid APG,4209.2,,,4209.2,Other,225% New York Medicaid APG,2619.06,,,2619.06,Other,140% New York Medicaid APG,4209.2,,,4209.2,Other,225% New York Medicaid APG,4863.96,,,4863.96,Other,260% New York Medicaid APG,6061.24,,,6061.24,Other,324% New York Medicaid APG,4022.12,,,4022.12,Other,215% New York Medicaid APG,4022.12,,,4022.12,Other,215% New York Medicaid APG,2338.44,,,2338.44,Other,125% New York Medicaid APG,1870.75,27507.89,
Repair elbow deb/attch open,24359,CPT,,,,,,,,both,,,36006.59,26644.88,74,,26644.88,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,16202.97,45,,16202.97,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,17823.26,49.5,,17823.26,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3479.6,,,3479.6,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,25204.61,70,,25204.61,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1870.75,,,1870.75,Other,New York Medicaid APG methodology,1870.75,,,1870.75,Other,100% New York Medicaid APG,1870.75,,,1870.75,Other,100% New York Medicaid APG,1870.75,,,1870.75,Other,100% New York Medicaid APG,4209.2,,,4209.2,Other,225% New York Medicaid APG,2862.25,,,2862.25,Other,153% New York Medicaid APG,4209.2,,,4209.2,Other,225% New York Medicaid APG,2619.06,,,2619.06,Other,140% New York Medicaid APG,4209.2,,,4209.2,Other,225% New York Medicaid APG,4863.96,,,4863.96,Other,260% New York Medicaid APG,6061.24,,,6061.24,Other,324% New York Medicaid APG,4022.12,,,4022.12,Other,215% New York Medicaid APG,4022.12,,,4022.12,Other,215% New York Medicaid APG,2338.44,,,2338.44,Other,125% New York Medicaid APG,1870.75,26644.88,
Reconstruct elbow joint,24360,CPT,,,,,,,,both,,,150476.65,111352.72,74,,111352.72,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,67714.49,45,,67714.49,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,74485.94,49.5,,74485.94,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5218.57,,,5218.57,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,105333.66,70,,105333.66,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,2805.68,,,2805.68,Other,New York Medicaid APG methodology,2805.68,,,2805.68,Other,100% New York Medicaid APG,2805.68,,,2805.68,Other,100% New York Medicaid APG,2805.68,,,2805.68,Other,100% New York Medicaid APG,6312.79,,,6312.79,Other,225% New York Medicaid APG,4292.7,,,4292.7,Other,153% New York Medicaid APG,6312.79,,,6312.79,Other,225% New York Medicaid APG,3927.96,,,3927.96,Other,140% New York Medicaid APG,6312.79,,,6312.79,Other,225% New York Medicaid APG,7294.78,,,7294.78,Other,260% New York Medicaid APG,9090.42,,,9090.42,Other,324% New York Medicaid APG,6032.22,,,6032.22,Other,215% New York Medicaid APG,6032.22,,,6032.22,Other,215% New York Medicaid APG,3507.11,,,3507.11,Other,125% New York Medicaid APG,2805.68,111352.72,
Reconstruct elbow joint,24361,CPT,,,,,,,,both,,,391985.94,290069.6,74,,290069.6,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,176393.67,45,,176393.67,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,194033.04,49.5,,194033.04,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5965.25,,,5965.25,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9196,,"100% primary, 0% secondary procedures",9196,Other,MagnaCare ASC Grouper,274390.16,70,,274390.16,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6956,,"100% primary, 50% secondary, 25% tertiary procedure",6956,Other,United Healthcare ASC Grouper,6261,,"100% primary, 50% secondary, 25% tertiary procedure",6261,Other,United Healthcare ASC Grouper,6956,,"100% primary, 50% secondary, 25% tertiary procedure",6956,Other,United Healthcare ASC Grouper,5913,,"100% primary, 50% secondary, 25% tertiary procedure",5913,Other,United Healthcare ASC Grouper,3207.13,,,3207.13,Other,New York Medicaid APG methodology,3207.13,,,3207.13,Other,100% New York Medicaid APG,3207.13,,,3207.13,Other,100% New York Medicaid APG,3207.13,,,3207.13,Other,100% New York Medicaid APG,7216.03,,,7216.03,Other,225% New York Medicaid APG,4906.9,,,4906.9,Other,153% New York Medicaid APG,7216.03,,,7216.03,Other,225% New York Medicaid APG,4489.98,,,4489.98,Other,140% New York Medicaid APG,7216.03,,,7216.03,Other,225% New York Medicaid APG,8338.53,,,8338.53,Other,260% New York Medicaid APG,10391.09,,,10391.09,Other,324% New York Medicaid APG,6895.32,,,6895.32,Other,215% New York Medicaid APG,6895.32,,,6895.32,Other,215% New York Medicaid APG,4008.91,,,4008.91,Other,125% New York Medicaid APG,3207.13,290069.6,
Reconstruct elbow joint,24362,CPT,,,,,,,,both,,,276827.87,204852.62,74,,204852.62,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,124572.54,45,,124572.54,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,137029.8,49.5,,137029.8,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5965.25,,,5965.25,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,193779.51,70,,193779.51,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,3207.13,,,3207.13,Other,New York Medicaid APG methodology,3207.13,,,3207.13,Other,100% New York Medicaid APG,3207.13,,,3207.13,Other,100% New York Medicaid APG,3207.13,,,3207.13,Other,100% New York Medicaid APG,7216.03,,,7216.03,Other,225% New York Medicaid APG,4906.9,,,4906.9,Other,153% New York Medicaid APG,7216.03,,,7216.03,Other,225% New York Medicaid APG,4489.98,,,4489.98,Other,140% New York Medicaid APG,7216.03,,,7216.03,Other,225% New York Medicaid APG,8338.53,,,8338.53,Other,260% New York Medicaid APG,10391.09,,,10391.09,Other,324% New York Medicaid APG,6895.32,,,6895.32,Other,215% New York Medicaid APG,6895.32,,,6895.32,Other,215% New York Medicaid APG,4008.91,,,4008.91,Other,125% New York Medicaid APG,3207.13,204852.62,
Replace elbow joint,24363,CPT,,,,,,,,both,,,391985.94,290069.6,74,,290069.6,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,176393.67,45,,176393.67,percent of total billed charges,Medicare Ratio of cost to charges,5954,,"100% primary, 50% supplemental procedure",5954,Other,Aetna ASC Grouper,5359,,"100% primary, 50% supplemental procedure",5359,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,194033.04,49.5,,194033.04,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5965.25,,,5965.25,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9196,,"100% primary, 0% secondary procedures",9196,Other,MagnaCare ASC Grouper,274390.16,70,,274390.16,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6956,,"100% primary, 50% secondary, 25% tertiary procedure",6956,Other,United Healthcare ASC Grouper,6261,,"100% primary, 50% secondary, 25% tertiary procedure",6261,Other,United Healthcare ASC Grouper,6956,,"100% primary, 50% secondary, 25% tertiary procedure",6956,Other,United Healthcare ASC Grouper,5913,,"100% primary, 50% secondary, 25% tertiary procedure",5913,Other,United Healthcare ASC Grouper,3207.13,,,3207.13,Other,New York Medicaid APG methodology,3207.13,,,3207.13,Other,100% New York Medicaid APG,3207.13,,,3207.13,Other,100% New York Medicaid APG,3207.13,,,3207.13,Other,100% New York Medicaid APG,7216.03,,,7216.03,Other,225% New York Medicaid APG,4906.9,,,4906.9,Other,153% New York Medicaid APG,7216.03,,,7216.03,Other,225% New York Medicaid APG,4489.98,,,4489.98,Other,140% New York Medicaid APG,7216.03,,,7216.03,Other,225% New York Medicaid APG,8338.53,,,8338.53,Other,260% New York Medicaid APG,10391.09,,,10391.09,Other,324% New York Medicaid APG,6895.32,,,6895.32,Other,215% New York Medicaid APG,6895.32,,,6895.32,Other,215% New York Medicaid APG,4008.91,,,4008.91,Other,125% New York Medicaid APG,3207.13,290069.6,
Reconstruct head of radius,24365,CPT,,,,,,,,both,,,276827.87,204852.62,74,,204852.62,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,124572.54,45,,124572.54,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,137029.8,49.5,,137029.8,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5965.25,,,5965.25,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,193779.51,70,,193779.51,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,3207.13,,,3207.13,Other,New York Medicaid APG methodology,3207.13,,,3207.13,Other,100% New York Medicaid APG,3207.13,,,3207.13,Other,100% New York Medicaid APG,3207.13,,,3207.13,Other,100% New York Medicaid APG,7216.03,,,7216.03,Other,225% New York Medicaid APG,4906.9,,,4906.9,Other,153% New York Medicaid APG,7216.03,,,7216.03,Other,225% New York Medicaid APG,4489.98,,,4489.98,Other,140% New York Medicaid APG,7216.03,,,7216.03,Other,225% New York Medicaid APG,8338.53,,,8338.53,Other,260% New York Medicaid APG,10391.09,,,10391.09,Other,324% New York Medicaid APG,6895.32,,,6895.32,Other,215% New York Medicaid APG,6895.32,,,6895.32,Other,215% New York Medicaid APG,4008.91,,,4008.91,Other,125% New York Medicaid APG,3207.13,204852.62,
Reconstruct head of radius,24366,CPT,,,,,,,,both,,,140987.9,104331.05,74,,104331.05,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,63444.56,45,,63444.56,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,69789.01,49.5,,69789.01,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5965.25,,,5965.25,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9196,,"100% primary, 0% secondary procedures",9196,Other,MagnaCare ASC Grouper,98691.53,70,,98691.53,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6956,,"100% primary, 50% secondary, 25% tertiary procedure",6956,Other,United Healthcare ASC Grouper,6261,,"100% primary, 50% secondary, 25% tertiary procedure",6261,Other,United Healthcare ASC Grouper,6956,,"100% primary, 50% secondary, 25% tertiary procedure",6956,Other,United Healthcare ASC Grouper,5913,,"100% primary, 50% secondary, 25% tertiary procedure",5913,Other,United Healthcare ASC Grouper,3207.13,,,3207.13,Other,New York Medicaid APG methodology,3207.13,,,3207.13,Other,100% New York Medicaid APG,3207.13,,,3207.13,Other,100% New York Medicaid APG,3207.13,,,3207.13,Other,100% New York Medicaid APG,7216.03,,,7216.03,Other,225% New York Medicaid APG,4906.9,,,4906.9,Other,153% New York Medicaid APG,7216.03,,,7216.03,Other,225% New York Medicaid APG,4489.98,,,4489.98,Other,140% New York Medicaid APG,7216.03,,,7216.03,Other,225% New York Medicaid APG,8338.53,,,8338.53,Other,260% New York Medicaid APG,10391.09,,,10391.09,Other,324% New York Medicaid APG,6895.32,,,6895.32,Other,215% New York Medicaid APG,6895.32,,,6895.32,Other,215% New York Medicaid APG,4008.91,,,4008.91,Other,125% New York Medicaid APG,3207.13,104331.05,
Revise reconst elbow joint,24370,CPT,,,,,,,,both,,,108194.17,80063.69,74,,80063.69,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,48687.38,45,,48687.38,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,53556.11,49.5,,53556.11,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5965.25,,,5965.25,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9196,,"100% primary, 0% secondary procedures",9196,Other,MagnaCare ASC Grouper,75735.92,70,,75735.92,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6956,,"100% primary, 50% secondary, 25% tertiary procedure",6956,Other,United Healthcare ASC Grouper,6261,,"100% primary, 50% secondary, 25% tertiary procedure",6261,Other,United Healthcare ASC Grouper,6956,,"100% primary, 50% secondary, 25% tertiary procedure",6956,Other,United Healthcare ASC Grouper,5913,,"100% primary, 50% secondary, 25% tertiary procedure",5913,Other,United Healthcare ASC Grouper,3207.13,,,3207.13,Other,New York Medicaid APG methodology,3207.13,,,3207.13,Other,100% New York Medicaid APG,3207.13,,,3207.13,Other,100% New York Medicaid APG,3207.13,,,3207.13,Other,100% New York Medicaid APG,7216.03,,,7216.03,Other,225% New York Medicaid APG,4906.9,,,4906.9,Other,153% New York Medicaid APG,7216.03,,,7216.03,Other,225% New York Medicaid APG,4489.98,,,4489.98,Other,140% New York Medicaid APG,7216.03,,,7216.03,Other,225% New York Medicaid APG,8338.53,,,8338.53,Other,260% New York Medicaid APG,10391.09,,,10391.09,Other,324% New York Medicaid APG,6895.32,,,6895.32,Other,215% New York Medicaid APG,6895.32,,,6895.32,Other,215% New York Medicaid APG,4008.91,,,4008.91,Other,125% New York Medicaid APG,3207.13,80063.69,
Revise reconst elbow joint,24371,CPT,,,,,,,,both,,,391985.94,290069.6,74,,290069.6,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,176393.67,45,,176393.67,percent of total billed charges,Medicare Ratio of cost to charges,5954,,"100% primary, 50% supplemental procedure",5954,Other,Aetna ASC Grouper,5359,,"100% primary, 50% supplemental procedure",5359,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,194033.04,49.5,,194033.04,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5965.25,,,5965.25,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9196,,"100% primary, 0% secondary procedures",9196,Other,MagnaCare ASC Grouper,274390.16,70,,274390.16,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6956,,"100% primary, 50% secondary, 25% tertiary procedure",6956,Other,United Healthcare ASC Grouper,6261,,"100% primary, 50% secondary, 25% tertiary procedure",6261,Other,United Healthcare ASC Grouper,6956,,"100% primary, 50% secondary, 25% tertiary procedure",6956,Other,United Healthcare ASC Grouper,5913,,"100% primary, 50% secondary, 25% tertiary procedure",5913,Other,United Healthcare ASC Grouper,3207.13,,,3207.13,Other,New York Medicaid APG methodology,3207.13,,,3207.13,Other,100% New York Medicaid APG,3207.13,,,3207.13,Other,100% New York Medicaid APG,3207.13,,,3207.13,Other,100% New York Medicaid APG,7216.03,,,7216.03,Other,225% New York Medicaid APG,4906.9,,,4906.9,Other,153% New York Medicaid APG,7216.03,,,7216.03,Other,225% New York Medicaid APG,4489.98,,,4489.98,Other,140% New York Medicaid APG,7216.03,,,7216.03,Other,225% New York Medicaid APG,8338.53,,,8338.53,Other,260% New York Medicaid APG,10391.09,,,10391.09,Other,324% New York Medicaid APG,6895.32,,,6895.32,Other,215% New York Medicaid APG,6895.32,,,6895.32,Other,215% New York Medicaid APG,4008.91,,,4008.91,Other,125% New York Medicaid APG,3207.13,290069.6,
Revision of humerus,24400,CPT,,,,,,,,both,,,66665.03,49332.12,74,,49332.12,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,29999.26,45,,29999.26,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,32999.19,49.5,,32999.19,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3960.57,,,3960.57,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,46665.52,70,,46665.52,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,2129.34,,,2129.34,Other,New York Medicaid APG methodology,2129.34,,,2129.34,Other,100% New York Medicaid APG,2129.34,,,2129.34,Other,100% New York Medicaid APG,2129.34,,,2129.34,Other,100% New York Medicaid APG,4791.01,,,4791.01,Other,225% New York Medicaid APG,3257.89,,,3257.89,Other,153% New York Medicaid APG,4791.01,,,4791.01,Other,225% New York Medicaid APG,2981.08,,,2981.08,Other,140% New York Medicaid APG,4791.01,,,4791.01,Other,225% New York Medicaid APG,5536.28,,,5536.28,Other,260% New York Medicaid APG,6899.06,,,6899.06,Other,324% New York Medicaid APG,4578.08,,,4578.08,Other,215% New York Medicaid APG,4578.08,,,4578.08,Other,215% New York Medicaid APG,2661.67,,,2661.67,Other,125% New York Medicaid APG,2129.34,49332.12,
Revision of humerus,24410,CPT,,,,,,,,both,,,276827.87,204852.62,74,,204852.62,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,124572.54,45,,124572.54,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,137029.8,49.5,,137029.8,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3960.57,,,3960.57,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,193779.51,70,,193779.51,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,2129.34,,,2129.34,Other,New York Medicaid APG methodology,2129.34,,,2129.34,Other,100% New York Medicaid APG,2129.34,,,2129.34,Other,100% New York Medicaid APG,2129.34,,,2129.34,Other,100% New York Medicaid APG,4791.01,,,4791.01,Other,225% New York Medicaid APG,3257.89,,,3257.89,Other,153% New York Medicaid APG,4791.01,,,4791.01,Other,225% New York Medicaid APG,2981.08,,,2981.08,Other,140% New York Medicaid APG,4791.01,,,4791.01,Other,225% New York Medicaid APG,5536.28,,,5536.28,Other,260% New York Medicaid APG,6899.06,,,6899.06,Other,324% New York Medicaid APG,4578.08,,,4578.08,Other,215% New York Medicaid APG,4578.08,,,4578.08,Other,215% New York Medicaid APG,2661.67,,,2661.67,Other,125% New York Medicaid APG,2129.34,204852.62,
Revision of humerus,24420,CPT,,,,,,,,both,,,150476.65,111352.72,74,,111352.72,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,67714.49,45,,67714.49,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,74485.94,49.5,,74485.94,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3960.57,,,3960.57,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,105333.66,70,,105333.66,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,2129.34,,,2129.34,Other,New York Medicaid APG methodology,2129.34,,,2129.34,Other,100% New York Medicaid APG,2129.34,,,2129.34,Other,100% New York Medicaid APG,2129.34,,,2129.34,Other,100% New York Medicaid APG,4791.01,,,4791.01,Other,225% New York Medicaid APG,3257.89,,,3257.89,Other,153% New York Medicaid APG,4791.01,,,4791.01,Other,225% New York Medicaid APG,2981.08,,,2981.08,Other,140% New York Medicaid APG,4791.01,,,4791.01,Other,225% New York Medicaid APG,5536.28,,,5536.28,Other,260% New York Medicaid APG,6899.06,,,6899.06,Other,324% New York Medicaid APG,4578.08,,,4578.08,Other,215% New York Medicaid APG,4578.08,,,4578.08,Other,215% New York Medicaid APG,2661.67,,,2661.67,Other,125% New York Medicaid APG,2129.34,111352.72,
Repair of humerus,24430,CPT,,,,,,,,both,,,49923.06,36943.06,74,,36943.06,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,22465.38,45,,22465.38,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,24711.91,49.5,,24711.91,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3960.57,,,3960.57,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,34946.14,70,,34946.14,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,2129.34,,,2129.34,Other,New York Medicaid APG methodology,2129.34,,,2129.34,Other,100% New York Medicaid APG,2129.34,,,2129.34,Other,100% New York Medicaid APG,2129.34,,,2129.34,Other,100% New York Medicaid APG,4791.01,,,4791.01,Other,225% New York Medicaid APG,3257.89,,,3257.89,Other,153% New York Medicaid APG,4791.01,,,4791.01,Other,225% New York Medicaid APG,2981.08,,,2981.08,Other,140% New York Medicaid APG,4791.01,,,4791.01,Other,225% New York Medicaid APG,5536.28,,,5536.28,Other,260% New York Medicaid APG,6899.06,,,6899.06,Other,324% New York Medicaid APG,4578.08,,,4578.08,Other,215% New York Medicaid APG,4578.08,,,4578.08,Other,215% New York Medicaid APG,2661.67,,,2661.67,Other,125% New York Medicaid APG,2129.34,36943.06,
Repair humerus with graft,24435,CPT,,,,,,,,both,,,217636.6,161051.08,74,,161051.08,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,97936.47,45,,97936.47,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,107730.12,49.5,,107730.12,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3960.57,,,3960.57,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,152345.62,70,,152345.62,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,2129.34,,,2129.34,Other,New York Medicaid APG methodology,2129.34,,,2129.34,Other,100% New York Medicaid APG,2129.34,,,2129.34,Other,100% New York Medicaid APG,2129.34,,,2129.34,Other,100% New York Medicaid APG,4791.01,,,4791.01,Other,225% New York Medicaid APG,3257.89,,,3257.89,Other,153% New York Medicaid APG,4791.01,,,4791.01,Other,225% New York Medicaid APG,2981.08,,,2981.08,Other,140% New York Medicaid APG,4791.01,,,4791.01,Other,225% New York Medicaid APG,5536.28,,,5536.28,Other,260% New York Medicaid APG,6899.06,,,6899.06,Other,324% New York Medicaid APG,4578.08,,,4578.08,Other,215% New York Medicaid APG,4578.08,,,4578.08,Other,215% New York Medicaid APG,2661.67,,,2661.67,Other,125% New York Medicaid APG,2129.34,161051.08,
Revision of elbow joint,24470,CPT,,,,,,,,both,,,68082.75,50381.24,74,,50381.24,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30637.24,45,,30637.24,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33700.96,49.5,,33700.96,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3479.6,,,3479.6,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,47657.93,70,,47657.93,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,1870.75,,,1870.75,Other,New York Medicaid APG methodology,1870.75,,,1870.75,Other,100% New York Medicaid APG,1870.75,,,1870.75,Other,100% New York Medicaid APG,1870.75,,,1870.75,Other,100% New York Medicaid APG,4209.2,,,4209.2,Other,225% New York Medicaid APG,2862.25,,,2862.25,Other,153% New York Medicaid APG,4209.2,,,4209.2,Other,225% New York Medicaid APG,2619.06,,,2619.06,Other,140% New York Medicaid APG,4209.2,,,4209.2,Other,225% New York Medicaid APG,4863.96,,,4863.96,Other,260% New York Medicaid APG,6061.24,,,6061.24,Other,324% New York Medicaid APG,4022.12,,,4022.12,Other,215% New York Medicaid APG,4022.12,,,4022.12,Other,215% New York Medicaid APG,2338.44,,,2338.44,Other,125% New York Medicaid APG,1870.75,50381.24,
Decompression of forearm,24495,CPT,,,,,,,,both,,,150476.65,111352.72,74,,111352.72,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,67714.49,45,,67714.49,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,74485.94,49.5,,74485.94,percent of total billed charges,110% of Medicare,102324.12,68,,102324.12,percent of total billed charges,,3937.21,,,3937.21,Other,186% of Medicaid,120381.32,80,,120381.32,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,120381.32,80,,120381.32,percent of total billed charges,,7216,,,7216,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,105333.66,70,,105333.66,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,2116.78,,,2116.78,Other,New York Medicaid APG methodology,2116.78,,,2116.78,Other,100% New York Medicaid APG,2116.78,,,2116.78,Other,100% New York Medicaid APG,2116.78,,,2116.78,Other,100% New York Medicaid APG,4762.75,,,4762.75,Other,225% New York Medicaid APG,3238.67,,,3238.67,Other,153% New York Medicaid APG,4762.75,,,4762.75,Other,225% New York Medicaid APG,2963.49,,,2963.49,Other,140% New York Medicaid APG,4762.75,,,4762.75,Other,225% New York Medicaid APG,5503.62,,,5503.62,Other,260% New York Medicaid APG,6858.36,,,6858.36,Other,324% New York Medicaid APG,4551.07,,,4551.07,Other,215% New York Medicaid APG,4551.07,,,4551.07,Other,215% New York Medicaid APG,2645.97,,,2645.97,Other,125% New York Medicaid APG,2116.78,120381.32,
Reinforce humerus,24498,CPT,,,,,,,,both,,,276827.87,204852.62,74,,204852.62,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,124572.54,45,,124572.54,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,137029.8,49.5,,137029.8,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3960.57,,,3960.57,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,193779.51,70,,193779.51,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,2129.34,,,2129.34,Other,New York Medicaid APG methodology,2129.34,,,2129.34,Other,100% New York Medicaid APG,2129.34,,,2129.34,Other,100% New York Medicaid APG,2129.34,,,2129.34,Other,100% New York Medicaid APG,4791.01,,,4791.01,Other,225% New York Medicaid APG,3257.89,,,3257.89,Other,153% New York Medicaid APG,4791.01,,,4791.01,Other,225% New York Medicaid APG,2981.08,,,2981.08,Other,140% New York Medicaid APG,4791.01,,,4791.01,Other,225% New York Medicaid APG,5536.28,,,5536.28,Other,260% New York Medicaid APG,6899.06,,,6899.06,Other,324% New York Medicaid APG,4578.08,,,4578.08,Other,215% New York Medicaid APG,4578.08,,,4578.08,Other,215% New York Medicaid APG,2661.67,,,2661.67,Other,125% New York Medicaid APG,2129.34,204852.62,
Treat humerus fracture,24500,CPT,,,,,,,,both,,,4960.23,3670.57,74,,3670.57,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,2232.1,45,,2232.1,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,2455.31,49.5,,2455.31,percent of total billed charges,110% of Medicare,3372.96,68,,3372.96,percent of total billed charges,,1031.43,,,1031.43,Other,186% of Medicaid,3968.18,80,,3968.18,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,3968.18,80,,3968.18,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,3472.16,70,,3472.16,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,554.53,,,554.53,Other,New York Medicaid APG methodology,554.53,,,554.53,Other,100% New York Medicaid APG,554.53,,,554.53,Other,100% New York Medicaid APG,554.53,,,554.53,Other,100% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,848.43,,,848.43,Other,153% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,776.34,,,776.34,Other,140% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,1441.78,,,1441.78,Other,260% New York Medicaid APG,1796.68,,,1796.68,Other,324% New York Medicaid APG,1192.24,,,1192.24,Other,215% New York Medicaid APG,1192.24,,,1192.24,Other,215% New York Medicaid APG,693.16,,,693.16,Other,125% New York Medicaid APG,554.53,7216,
Treat humerus fracture,24505,CPT,,,,,,,,both,,,33805.49,25016.06,74,,25016.06,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15212.47,45,,15212.47,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,16733.72,49.5,,16733.72,percent of total billed charges,110% of Medicare,22987.73,68,,22987.73,percent of total billed charges,,1031.43,,,1031.43,Other,186% of Medicaid,27044.39,80,,27044.39,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,27044.39,80,,27044.39,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,23663.84,70,,23663.84,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,554.53,,,554.53,Other,New York Medicaid APG methodology,554.53,,,554.53,Other,100% New York Medicaid APG,554.53,,,554.53,Other,100% New York Medicaid APG,554.53,,,554.53,Other,100% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,848.43,,,848.43,Other,153% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,776.34,,,776.34,Other,140% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,1441.78,,,1441.78,Other,260% New York Medicaid APG,1796.68,,,1796.68,Other,324% New York Medicaid APG,1192.24,,,1192.24,Other,215% New York Medicaid APG,1192.24,,,1192.24,Other,215% New York Medicaid APG,693.16,,,693.16,Other,125% New York Medicaid APG,554.53,27044.39,
Treat humerus fracture,24515,CPT,,,,,,,,both,,,94061.82,69605.75,74,,69605.75,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,42327.82,45,,42327.82,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,46560.6,49.5,,46560.6,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5092.5,,,5092.5,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,65843.27,70,,65843.27,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,2737.91,,,2737.91,Other,New York Medicaid APG methodology,2737.91,,,2737.91,Other,100% New York Medicaid APG,2737.91,,,2737.91,Other,100% New York Medicaid APG,2737.91,,,2737.91,Other,100% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,4189,,,4189,Other,153% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,3833.07,,,3833.07,Other,140% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,7118.55,,,7118.55,Other,260% New York Medicaid APG,8870.81,,,8870.81,Other,324% New York Medicaid APG,5886.5,,,5886.5,Other,215% New York Medicaid APG,5886.5,,,5886.5,Other,215% New York Medicaid APG,3422.38,,,3422.38,Other,125% New York Medicaid APG,2737.91,69605.75,
Treat humerus fracture,24516,CPT,,,,,,,,both,,,276827.87,204852.62,74,,204852.62,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,124572.54,45,,124572.54,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,137029.8,49.5,,137029.8,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5092.5,,,5092.5,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,193779.51,70,,193779.51,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,2737.91,,,2737.91,Other,New York Medicaid APG methodology,2737.91,,,2737.91,Other,100% New York Medicaid APG,2737.91,,,2737.91,Other,100% New York Medicaid APG,2737.91,,,2737.91,Other,100% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,4189,,,4189,Other,153% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,3833.07,,,3833.07,Other,140% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,7118.55,,,7118.55,Other,260% New York Medicaid APG,8870.81,,,8870.81,Other,324% New York Medicaid APG,5886.5,,,5886.5,Other,215% New York Medicaid APG,5886.5,,,5886.5,Other,215% New York Medicaid APG,3422.38,,,3422.38,Other,125% New York Medicaid APG,2737.91,204852.62,
Treat humerus fracture,24530,CPT,,,,,,,,both,,,4960.23,3670.57,74,,3670.57,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,2232.1,45,,2232.1,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,2455.31,49.5,,2455.31,percent of total billed charges,110% of Medicare,3372.96,68,,3372.96,percent of total billed charges,,1031.43,,,1031.43,Other,186% of Medicaid,3968.18,80,,3968.18,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,3968.18,80,,3968.18,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,3472.16,70,,3472.16,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,554.53,,,554.53,Other,New York Medicaid APG methodology,554.53,,,554.53,Other,100% New York Medicaid APG,554.53,,,554.53,Other,100% New York Medicaid APG,554.53,,,554.53,Other,100% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,848.43,,,848.43,Other,153% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,776.34,,,776.34,Other,140% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,1441.78,,,1441.78,Other,260% New York Medicaid APG,1796.68,,,1796.68,Other,324% New York Medicaid APG,1192.24,,,1192.24,Other,215% New York Medicaid APG,1192.24,,,1192.24,Other,215% New York Medicaid APG,693.16,,,693.16,Other,125% New York Medicaid APG,554.53,7216,
Treat humerus fracture,24535,CPT,,,,,,,,both,,,33805.49,25016.06,74,,25016.06,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15212.47,45,,15212.47,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,16733.72,49.5,,16733.72,percent of total billed charges,110% of Medicare,22987.73,68,,22987.73,percent of total billed charges,,1031.43,,,1031.43,Other,186% of Medicaid,27044.39,80,,27044.39,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,27044.39,80,,27044.39,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,23663.84,70,,23663.84,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,554.53,,,554.53,Other,New York Medicaid APG methodology,554.53,,,554.53,Other,100% New York Medicaid APG,554.53,,,554.53,Other,100% New York Medicaid APG,554.53,,,554.53,Other,100% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,848.43,,,848.43,Other,153% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,776.34,,,776.34,Other,140% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,1441.78,,,1441.78,Other,260% New York Medicaid APG,1796.68,,,1796.68,Other,324% New York Medicaid APG,1192.24,,,1192.24,Other,215% New York Medicaid APG,1192.24,,,1192.24,Other,215% New York Medicaid APG,693.16,,,693.16,Other,125% New York Medicaid APG,554.53,27044.39,
Treat humerus fracture,24538,CPT,,,,,,,,both,,,36409.89,26943.32,74,,26943.32,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,16384.45,45,,16384.45,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,18022.9,49.5,,18022.9,percent of total billed charges,110% of Medicare,24758.73,68,,24758.73,percent of total billed charges,,5092.5,,,5092.5,Other,186% of Medicaid,29127.91,80,,29127.91,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,29127.91,80,,29127.91,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,25486.92,70,,25486.92,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,2737.91,,,2737.91,Other,New York Medicaid APG methodology,2737.91,,,2737.91,Other,100% New York Medicaid APG,2737.91,,,2737.91,Other,100% New York Medicaid APG,2737.91,,,2737.91,Other,100% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,4189,,,4189,Other,153% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,3833.07,,,3833.07,Other,140% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,7118.55,,,7118.55,Other,260% New York Medicaid APG,8870.81,,,8870.81,Other,324% New York Medicaid APG,5886.5,,,5886.5,Other,215% New York Medicaid APG,5886.5,,,5886.5,Other,215% New York Medicaid APG,3422.38,,,3422.38,Other,125% New York Medicaid APG,2232,29127.91,
Treat humerus fracture,24545,CPT,,,,,,,,both,,,276827.87,204852.62,74,,204852.62,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,124572.54,45,,124572.54,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,137029.8,49.5,,137029.8,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5092.5,,,5092.5,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,193779.51,70,,193779.51,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,2737.91,,,2737.91,Other,New York Medicaid APG methodology,2737.91,,,2737.91,Other,100% New York Medicaid APG,2737.91,,,2737.91,Other,100% New York Medicaid APG,2737.91,,,2737.91,Other,100% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,4189,,,4189,Other,153% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,3833.07,,,3833.07,Other,140% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,7118.55,,,7118.55,Other,260% New York Medicaid APG,8870.81,,,8870.81,Other,324% New York Medicaid APG,5886.5,,,5886.5,Other,215% New York Medicaid APG,5886.5,,,5886.5,Other,215% New York Medicaid APG,3422.38,,,3422.38,Other,125% New York Medicaid APG,2737.91,204852.62,
Treat humerus fracture,24546,CPT,,,,,,,,both,,,276827.87,204852.62,74,,204852.62,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,124572.54,45,,124572.54,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,137029.8,49.5,,137029.8,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5092.5,,,5092.5,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,193779.51,70,,193779.51,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,2737.91,,,2737.91,Other,New York Medicaid APG methodology,2737.91,,,2737.91,Other,100% New York Medicaid APG,2737.91,,,2737.91,Other,100% New York Medicaid APG,2737.91,,,2737.91,Other,100% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,4189,,,4189,Other,153% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,3833.07,,,3833.07,Other,140% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,7118.55,,,7118.55,Other,260% New York Medicaid APG,8870.81,,,8870.81,Other,324% New York Medicaid APG,5886.5,,,5886.5,Other,215% New York Medicaid APG,5886.5,,,5886.5,Other,215% New York Medicaid APG,3422.38,,,3422.38,Other,125% New York Medicaid APG,2737.91,204852.62,
Treat humerus fracture,24560,CPT,,,,,,,,both,,,4960.23,3670.57,74,,3670.57,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,2232.1,45,,2232.1,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,2455.31,49.5,,2455.31,percent of total billed charges,110% of Medicare,3372.96,68,,3372.96,percent of total billed charges,,1031.43,,,1031.43,Other,186% of Medicaid,3968.18,80,,3968.18,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,3968.18,80,,3968.18,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,3472.16,70,,3472.16,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,554.53,,,554.53,Other,New York Medicaid APG methodology,554.53,,,554.53,Other,100% New York Medicaid APG,554.53,,,554.53,Other,100% New York Medicaid APG,554.53,,,554.53,Other,100% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,848.43,,,848.43,Other,153% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,776.34,,,776.34,Other,140% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,1441.78,,,1441.78,Other,260% New York Medicaid APG,1796.68,,,1796.68,Other,324% New York Medicaid APG,1192.24,,,1192.24,Other,215% New York Medicaid APG,1192.24,,,1192.24,Other,215% New York Medicaid APG,693.16,,,693.16,Other,125% New York Medicaid APG,554.53,7216,
Treat humerus fracture,24565,CPT,,,,,,,,both,,,33805.49,25016.06,74,,25016.06,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15212.47,45,,15212.47,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,16733.72,49.5,,16733.72,percent of total billed charges,110% of Medicare,22987.73,68,,22987.73,percent of total billed charges,,1031.43,,,1031.43,Other,186% of Medicaid,27044.39,80,,27044.39,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,27044.39,80,,27044.39,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,23663.84,70,,23663.84,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,554.53,,,554.53,Other,New York Medicaid APG methodology,554.53,,,554.53,Other,100% New York Medicaid APG,554.53,,,554.53,Other,100% New York Medicaid APG,554.53,,,554.53,Other,100% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,848.43,,,848.43,Other,153% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,776.34,,,776.34,Other,140% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,1441.78,,,1441.78,Other,260% New York Medicaid APG,1796.68,,,1796.68,Other,324% New York Medicaid APG,1192.24,,,1192.24,Other,215% New York Medicaid APG,1192.24,,,1192.24,Other,215% New York Medicaid APG,693.16,,,693.16,Other,125% New York Medicaid APG,554.53,27044.39,
Treat humerus fracture,24566,CPT,,,,,,,,both,,,33805.49,25016.06,74,,25016.06,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15212.47,45,,15212.47,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,16733.72,49.5,,16733.72,percent of total billed charges,110% of Medicare,22987.73,68,,22987.73,percent of total billed charges,,5092.5,,,5092.5,Other,186% of Medicaid,27044.39,80,,27044.39,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,27044.39,80,,27044.39,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,23663.84,70,,23663.84,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,2737.91,,,2737.91,Other,New York Medicaid APG methodology,2737.91,,,2737.91,Other,100% New York Medicaid APG,2737.91,,,2737.91,Other,100% New York Medicaid APG,2737.91,,,2737.91,Other,100% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,4189,,,4189,Other,153% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,3833.07,,,3833.07,Other,140% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,7118.55,,,7118.55,Other,260% New York Medicaid APG,8870.81,,,8870.81,Other,324% New York Medicaid APG,5886.5,,,5886.5,Other,215% New York Medicaid APG,5886.5,,,5886.5,Other,215% New York Medicaid APG,3422.38,,,3422.38,Other,125% New York Medicaid APG,2232,27044.39,
Treat humerus fracture,24575,CPT,,,,,,,,both,,,69504.72,51433.49,74,,51433.49,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,31277.12,45,,31277.12,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,34404.84,49.5,,34404.84,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5092.5,,,5092.5,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,48653.3,70,,48653.3,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,2737.91,,,2737.91,Other,New York Medicaid APG methodology,2737.91,,,2737.91,Other,100% New York Medicaid APG,2737.91,,,2737.91,Other,100% New York Medicaid APG,2737.91,,,2737.91,Other,100% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,4189,,,4189,Other,153% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,3833.07,,,3833.07,Other,140% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,7118.55,,,7118.55,Other,260% New York Medicaid APG,8870.81,,,8870.81,Other,324% New York Medicaid APG,5886.5,,,5886.5,Other,215% New York Medicaid APG,5886.5,,,5886.5,Other,215% New York Medicaid APG,3422.38,,,3422.38,Other,125% New York Medicaid APG,2737.91,51433.49,
Treat humerus fracture,24576,CPT,,,,,,,,both,,,4960.23,3670.57,74,,3670.57,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,2232.1,45,,2232.1,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,2455.31,49.5,,2455.31,percent of total billed charges,110% of Medicare,3372.96,68,,3372.96,percent of total billed charges,,1031.43,,,1031.43,Other,186% of Medicaid,3968.18,80,,3968.18,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,3968.18,80,,3968.18,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,3472.16,70,,3472.16,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,554.53,,,554.53,Other,New York Medicaid APG methodology,554.53,,,554.53,Other,100% New York Medicaid APG,554.53,,,554.53,Other,100% New York Medicaid APG,554.53,,,554.53,Other,100% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,848.43,,,848.43,Other,153% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,776.34,,,776.34,Other,140% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,1441.78,,,1441.78,Other,260% New York Medicaid APG,1796.68,,,1796.68,Other,324% New York Medicaid APG,1192.24,,,1192.24,Other,215% New York Medicaid APG,1192.24,,,1192.24,Other,215% New York Medicaid APG,693.16,,,693.16,Other,125% New York Medicaid APG,554.53,7216,
Treat humerus fracture,24577,CPT,,,,,,,,both,,,33805.49,25016.06,74,,25016.06,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15212.47,45,,15212.47,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,16733.72,49.5,,16733.72,percent of total billed charges,110% of Medicare,22987.73,68,,22987.73,percent of total billed charges,,1031.43,,,1031.43,Other,186% of Medicaid,27044.39,80,,27044.39,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,27044.39,80,,27044.39,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,23663.84,70,,23663.84,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,554.53,,,554.53,Other,New York Medicaid APG methodology,554.53,,,554.53,Other,100% New York Medicaid APG,554.53,,,554.53,Other,100% New York Medicaid APG,554.53,,,554.53,Other,100% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,848.43,,,848.43,Other,153% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,776.34,,,776.34,Other,140% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,1441.78,,,1441.78,Other,260% New York Medicaid APG,1796.68,,,1796.68,Other,324% New York Medicaid APG,1192.24,,,1192.24,Other,215% New York Medicaid APG,1192.24,,,1192.24,Other,215% New York Medicaid APG,693.16,,,693.16,Other,125% New York Medicaid APG,554.53,27044.39,
Treat humerus fracture,24579,CPT,,,,,,,,both,,,54780.48,40537.56,74,,40537.56,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,24651.22,45,,24651.22,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,27116.34,49.5,,27116.34,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5092.5,,,5092.5,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,38346.34,70,,38346.34,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,2737.91,,,2737.91,Other,New York Medicaid APG methodology,2737.91,,,2737.91,Other,100% New York Medicaid APG,2737.91,,,2737.91,Other,100% New York Medicaid APG,2737.91,,,2737.91,Other,100% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,4189,,,4189,Other,153% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,3833.07,,,3833.07,Other,140% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,7118.55,,,7118.55,Other,260% New York Medicaid APG,8870.81,,,8870.81,Other,324% New York Medicaid APG,5886.5,,,5886.5,Other,215% New York Medicaid APG,5886.5,,,5886.5,Other,215% New York Medicaid APG,3422.38,,,3422.38,Other,125% New York Medicaid APG,2737.91,40537.56,
Treat humerus fracture,24582,CPT,,,,,,,,both,,,150476.65,111352.72,74,,111352.72,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,67714.49,45,,67714.49,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,74485.94,49.5,,74485.94,percent of total billed charges,110% of Medicare,102324.12,68,,102324.12,percent of total billed charges,,5092.5,,,5092.5,Other,186% of Medicaid,120381.32,80,,120381.32,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,120381.32,80,,120381.32,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,105333.66,70,,105333.66,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,2737.91,,,2737.91,Other,New York Medicaid APG methodology,2737.91,,,2737.91,Other,100% New York Medicaid APG,2737.91,,,2737.91,Other,100% New York Medicaid APG,2737.91,,,2737.91,Other,100% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,4189,,,4189,Other,153% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,3833.07,,,3833.07,Other,140% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,7118.55,,,7118.55,Other,260% New York Medicaid APG,8870.81,,,8870.81,Other,324% New York Medicaid APG,5886.5,,,5886.5,Other,215% New York Medicaid APG,5886.5,,,5886.5,Other,215% New York Medicaid APG,3422.38,,,3422.38,Other,125% New York Medicaid APG,2232,120381.32,
Treat elbow fracture,24586,CPT,,,,,,,,both,,,276827.87,204852.62,74,,204852.62,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,124572.54,45,,124572.54,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,137029.8,49.5,,137029.8,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5092.5,,,5092.5,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,193779.51,70,,193779.51,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,2737.91,,,2737.91,Other,New York Medicaid APG methodology,2737.91,,,2737.91,Other,100% New York Medicaid APG,2737.91,,,2737.91,Other,100% New York Medicaid APG,2737.91,,,2737.91,Other,100% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,4189,,,4189,Other,153% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,3833.07,,,3833.07,Other,140% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,7118.55,,,7118.55,Other,260% New York Medicaid APG,8870.81,,,8870.81,Other,324% New York Medicaid APG,5886.5,,,5886.5,Other,215% New York Medicaid APG,5886.5,,,5886.5,Other,215% New York Medicaid APG,3422.38,,,3422.38,Other,125% New York Medicaid APG,2737.91,204852.62,
Treat elbow fracture,24587,CPT,,,,,,,,both,,,276827.87,204852.62,74,,204852.62,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,124572.54,45,,124572.54,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,137029.8,49.5,,137029.8,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5092.5,,,5092.5,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,193779.51,70,,193779.51,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,2737.91,,,2737.91,Other,New York Medicaid APG methodology,2737.91,,,2737.91,Other,100% New York Medicaid APG,2737.91,,,2737.91,Other,100% New York Medicaid APG,2737.91,,,2737.91,Other,100% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,4189,,,4189,Other,153% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,3833.07,,,3833.07,Other,140% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,7118.55,,,7118.55,Other,260% New York Medicaid APG,8870.81,,,8870.81,Other,324% New York Medicaid APG,5886.5,,,5886.5,Other,215% New York Medicaid APG,5886.5,,,5886.5,Other,215% New York Medicaid APG,3422.38,,,3422.38,Other,125% New York Medicaid APG,2737.91,204852.62,
Treat elbow dislocation,24600,CPT,,,,,,,,both,,,4960.23,3670.57,74,,3670.57,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,2232.1,45,,2232.1,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,2455.31,49.5,,2455.31,percent of total billed charges,110% of Medicare,3372.96,68,,3372.96,percent of total billed charges,,1031.43,,,1031.43,Other,186% of Medicaid,3968.18,80,,3968.18,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,3968.18,80,,3968.18,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,3472.16,70,,3472.16,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,554.53,,,554.53,Other,New York Medicaid APG methodology,554.53,,,554.53,Other,100% New York Medicaid APG,554.53,,,554.53,Other,100% New York Medicaid APG,554.53,,,554.53,Other,100% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,848.43,,,848.43,Other,153% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,776.34,,,776.34,Other,140% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,1441.78,,,1441.78,Other,260% New York Medicaid APG,1796.68,,,1796.68,Other,324% New York Medicaid APG,1192.24,,,1192.24,Other,215% New York Medicaid APG,1192.24,,,1192.24,Other,215% New York Medicaid APG,693.16,,,693.16,Other,125% New York Medicaid APG,554.53,7216,
Treat elbow dislocation,24605,CPT,,,,,,,,both,,,33805.49,25016.06,74,,25016.06,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15212.47,45,,15212.47,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,16733.72,49.5,,16733.72,percent of total billed charges,110% of Medicare,22987.73,68,,22987.73,percent of total billed charges,,1730.38,,,1730.38,Other,186% of Medicaid,27044.39,80,,27044.39,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,27044.39,80,,27044.39,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,23663.84,70,,23663.84,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,930.31,,,930.31,Other,New York Medicaid APG methodology,930.31,,,930.31,Other,100% New York Medicaid APG,930.31,,,930.31,Other,100% New York Medicaid APG,930.31,,,930.31,Other,100% New York Medicaid APG,2093.21,,,2093.21,Other,225% New York Medicaid APG,1423.38,,,1423.38,Other,153% New York Medicaid APG,2093.21,,,2093.21,Other,225% New York Medicaid APG,1302.44,,,1302.44,Other,140% New York Medicaid APG,2093.21,,,2093.21,Other,225% New York Medicaid APG,2418.82,,,2418.82,Other,260% New York Medicaid APG,3014.22,,,3014.22,Other,324% New York Medicaid APG,2000.18,,,2000.18,Other,215% New York Medicaid APG,2000.18,,,2000.18,Other,215% New York Medicaid APG,1162.89,,,1162.89,Other,125% New York Medicaid APG,930.31,27044.39,
Treat elbow dislocation,24615,CPT,,,,,,,,both,,,150476.65,111352.72,74,,111352.72,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,67714.49,45,,67714.49,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,74485.94,49.5,,74485.94,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5092.5,,,5092.5,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,105333.66,70,,105333.66,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,2737.91,,,2737.91,Other,New York Medicaid APG methodology,2737.91,,,2737.91,Other,100% New York Medicaid APG,2737.91,,,2737.91,Other,100% New York Medicaid APG,2737.91,,,2737.91,Other,100% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,4189,,,4189,Other,153% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,3833.07,,,3833.07,Other,140% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,7118.55,,,7118.55,Other,260% New York Medicaid APG,8870.81,,,8870.81,Other,324% New York Medicaid APG,5886.5,,,5886.5,Other,215% New York Medicaid APG,5886.5,,,5886.5,Other,215% New York Medicaid APG,3422.38,,,3422.38,Other,125% New York Medicaid APG,2737.91,111352.72,
Treat elbow fracture,24620,CPT,,,,,,,,both,,,33805.49,25016.06,74,,25016.06,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15212.47,45,,15212.47,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,16733.72,49.5,,16733.72,percent of total billed charges,110% of Medicare,22987.73,68,,22987.73,percent of total billed charges,,1031.43,,,1031.43,Other,186% of Medicaid,27044.39,80,,27044.39,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,27044.39,80,,27044.39,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,23663.84,70,,23663.84,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,554.53,,,554.53,Other,New York Medicaid APG methodology,554.53,,,554.53,Other,100% New York Medicaid APG,554.53,,,554.53,Other,100% New York Medicaid APG,554.53,,,554.53,Other,100% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,848.43,,,848.43,Other,153% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,776.34,,,776.34,Other,140% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,1441.78,,,1441.78,Other,260% New York Medicaid APG,1796.68,,,1796.68,Other,324% New York Medicaid APG,1192.24,,,1192.24,Other,215% New York Medicaid APG,1192.24,,,1192.24,Other,215% New York Medicaid APG,693.16,,,693.16,Other,125% New York Medicaid APG,554.53,27044.39,
Treat elbow fracture,24635,CPT,,,,,,,,both,,,105508.14,78076.02,74,,78076.02,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,47478.66,45,,47478.66,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,52226.53,49.5,,52226.53,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5092.5,,,5092.5,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,73855.7,70,,73855.7,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,2737.91,,,2737.91,Other,New York Medicaid APG methodology,2737.91,,,2737.91,Other,100% New York Medicaid APG,2737.91,,,2737.91,Other,100% New York Medicaid APG,2737.91,,,2737.91,Other,100% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,4189,,,4189,Other,153% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,3833.07,,,3833.07,Other,140% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,7118.55,,,7118.55,Other,260% New York Medicaid APG,8870.81,,,8870.81,Other,324% New York Medicaid APG,5886.5,,,5886.5,Other,215% New York Medicaid APG,5886.5,,,5886.5,Other,215% New York Medicaid APG,3422.38,,,3422.38,Other,125% New York Medicaid APG,2737.91,78076.02,
Treat elbow dislocation,24640,CPT,,,,,,,,both,,,4960.23,3670.57,74,,3670.57,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,2232.1,45,,2232.1,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,2455.31,49.5,,2455.31,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,1031.43,,,1031.43,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,3472.16,70,,3472.16,percent of total billed charges,,391.96,,,391.96,Fee Schedule,,332.21,,,332.21,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,554.53,,,554.53,Other,New York Medicaid APG methodology,554.53,,,554.53,Other,100% New York Medicaid APG,554.53,,,554.53,Other,100% New York Medicaid APG,554.53,,,554.53,Other,100% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,848.43,,,848.43,Other,153% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,776.34,,,776.34,Other,140% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,1441.78,,,1441.78,Other,260% New York Medicaid APG,1796.68,,,1796.68,Other,324% New York Medicaid APG,1192.24,,,1192.24,Other,215% New York Medicaid APG,1192.24,,,1192.24,Other,215% New York Medicaid APG,693.16,,,693.16,Other,125% New York Medicaid APG,332.21,9473,
Treat radius fracture,24650,CPT,,,,,,,,both,,,4960.23,3670.57,74,,3670.57,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,2232.1,45,,2232.1,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,2455.31,49.5,,2455.31,percent of total billed charges,110% of Medicare,3372.96,68,,3372.96,percent of total billed charges,,1031.43,,,1031.43,Other,186% of Medicaid,3968.18,80,,3968.18,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,3968.18,80,,3968.18,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,3472.16,70,,3472.16,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,554.53,,,554.53,Other,New York Medicaid APG methodology,554.53,,,554.53,Other,100% New York Medicaid APG,554.53,,,554.53,Other,100% New York Medicaid APG,554.53,,,554.53,Other,100% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,848.43,,,848.43,Other,153% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,776.34,,,776.34,Other,140% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,1441.78,,,1441.78,Other,260% New York Medicaid APG,1796.68,,,1796.68,Other,324% New York Medicaid APG,1192.24,,,1192.24,Other,215% New York Medicaid APG,1192.24,,,1192.24,Other,215% New York Medicaid APG,693.16,,,693.16,Other,125% New York Medicaid APG,554.53,7216,
Treat radius fracture,24655,CPT,,,,,,,,both,,,35625.51,26362.88,74,,26362.88,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,16031.48,45,,16031.48,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,17634.63,49.5,,17634.63,percent of total billed charges,110% of Medicare,24225.35,68,,24225.35,percent of total billed charges,,1031.43,,,1031.43,Other,186% of Medicaid,28500.41,80,,28500.41,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,28500.41,80,,28500.41,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,24937.86,70,,24937.86,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,554.53,,,554.53,Other,New York Medicaid APG methodology,554.53,,,554.53,Other,100% New York Medicaid APG,554.53,,,554.53,Other,100% New York Medicaid APG,554.53,,,554.53,Other,100% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,848.43,,,848.43,Other,153% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,776.34,,,776.34,Other,140% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,1441.78,,,1441.78,Other,260% New York Medicaid APG,1796.68,,,1796.68,Other,324% New York Medicaid APG,1192.24,,,1192.24,Other,215% New York Medicaid APG,1192.24,,,1192.24,Other,215% New York Medicaid APG,693.16,,,693.16,Other,125% New York Medicaid APG,554.53,28500.41,
Treat radius fracture,24665,CPT,,,,,,,,both,,,150476.65,111352.72,74,,111352.72,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,67714.49,45,,67714.49,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,74485.94,49.5,,74485.94,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5092.5,,,5092.5,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,105333.66,70,,105333.66,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,2737.91,,,2737.91,Other,New York Medicaid APG methodology,2737.91,,,2737.91,Other,100% New York Medicaid APG,2737.91,,,2737.91,Other,100% New York Medicaid APG,2737.91,,,2737.91,Other,100% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,4189,,,4189,Other,153% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,3833.07,,,3833.07,Other,140% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,7118.55,,,7118.55,Other,260% New York Medicaid APG,8870.81,,,8870.81,Other,324% New York Medicaid APG,5886.5,,,5886.5,Other,215% New York Medicaid APG,5886.5,,,5886.5,Other,215% New York Medicaid APG,3422.38,,,3422.38,Other,125% New York Medicaid APG,2737.91,111352.72,
Treat radius fracture,24666,CPT,,,,,,,,both,,,147376.01,109058.25,74,,109058.25,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,66319.2,45,,66319.2,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,72951.12,49.5,,72951.12,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5092.5,,,5092.5,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,103163.21,70,,103163.21,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,2737.91,,,2737.91,Other,New York Medicaid APG methodology,2737.91,,,2737.91,Other,100% New York Medicaid APG,2737.91,,,2737.91,Other,100% New York Medicaid APG,2737.91,,,2737.91,Other,100% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,4189,,,4189,Other,153% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,3833.07,,,3833.07,Other,140% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,7118.55,,,7118.55,Other,260% New York Medicaid APG,8870.81,,,8870.81,Other,324% New York Medicaid APG,5886.5,,,5886.5,Other,215% New York Medicaid APG,5886.5,,,5886.5,Other,215% New York Medicaid APG,3422.38,,,3422.38,Other,125% New York Medicaid APG,2737.91,109058.25,
Treat ulnar fracture,24670,CPT,,,,,,,,both,,,4960.23,3670.57,74,,3670.57,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,2232.1,45,,2232.1,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,2455.31,49.5,,2455.31,percent of total billed charges,110% of Medicare,3372.96,68,,3372.96,percent of total billed charges,,1031.43,,,1031.43,Other,186% of Medicaid,3968.18,80,,3968.18,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,3968.18,80,,3968.18,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,3472.16,70,,3472.16,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,554.53,,,554.53,Other,New York Medicaid APG methodology,554.53,,,554.53,Other,100% New York Medicaid APG,554.53,,,554.53,Other,100% New York Medicaid APG,554.53,,,554.53,Other,100% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,848.43,,,848.43,Other,153% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,776.34,,,776.34,Other,140% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,1441.78,,,1441.78,Other,260% New York Medicaid APG,1796.68,,,1796.68,Other,324% New York Medicaid APG,1192.24,,,1192.24,Other,215% New York Medicaid APG,1192.24,,,1192.24,Other,215% New York Medicaid APG,693.16,,,693.16,Other,125% New York Medicaid APG,554.53,7216,
Treat ulnar fracture,24675,CPT,,,,,,,,both,,,33805.49,25016.06,74,,25016.06,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15212.47,45,,15212.47,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,16733.72,49.5,,16733.72,percent of total billed charges,110% of Medicare,22987.73,68,,22987.73,percent of total billed charges,,1031.43,,,1031.43,Other,186% of Medicaid,27044.39,80,,27044.39,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,27044.39,80,,27044.39,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,23663.84,70,,23663.84,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,554.53,,,554.53,Other,New York Medicaid APG methodology,554.53,,,554.53,Other,100% New York Medicaid APG,554.53,,,554.53,Other,100% New York Medicaid APG,554.53,,,554.53,Other,100% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,848.43,,,848.43,Other,153% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,776.34,,,776.34,Other,140% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,1441.78,,,1441.78,Other,260% New York Medicaid APG,1796.68,,,1796.68,Other,324% New York Medicaid APG,1192.24,,,1192.24,Other,215% New York Medicaid APG,1192.24,,,1192.24,Other,215% New York Medicaid APG,693.16,,,693.16,Other,125% New York Medicaid APG,554.53,27044.39,
Treat ulnar fracture,24685,CPT,,,,,,,,both,,,81461.92,60281.82,74,,60281.82,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,36657.86,45,,36657.86,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,40323.65,49.5,,40323.65,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5092.5,,,5092.5,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,57023.34,70,,57023.34,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,2737.91,,,2737.91,Other,New York Medicaid APG methodology,2737.91,,,2737.91,Other,100% New York Medicaid APG,2737.91,,,2737.91,Other,100% New York Medicaid APG,2737.91,,,2737.91,Other,100% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,4189,,,4189,Other,153% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,3833.07,,,3833.07,Other,140% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,7118.55,,,7118.55,Other,260% New York Medicaid APG,8870.81,,,8870.81,Other,324% New York Medicaid APG,5886.5,,,5886.5,Other,215% New York Medicaid APG,5886.5,,,5886.5,Other,215% New York Medicaid APG,3422.38,,,3422.38,Other,125% New York Medicaid APG,2737.91,60281.82,
Fusion of elbow joint,24800,CPT,,,,,,,,both,,,121655.19,90024.84,74,,90024.84,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,54744.84,45,,54744.84,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,60219.32,49.5,,60219.32,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3937.21,,,3937.21,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,85158.63,70,,85158.63,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,2116.78,,,2116.78,Other,New York Medicaid APG methodology,2116.78,,,2116.78,Other,100% New York Medicaid APG,2116.78,,,2116.78,Other,100% New York Medicaid APG,2116.78,,,2116.78,Other,100% New York Medicaid APG,4762.75,,,4762.75,Other,225% New York Medicaid APG,3238.67,,,3238.67,Other,153% New York Medicaid APG,4762.75,,,4762.75,Other,225% New York Medicaid APG,2963.49,,,2963.49,Other,140% New York Medicaid APG,4762.75,,,4762.75,Other,225% New York Medicaid APG,5503.62,,,5503.62,Other,260% New York Medicaid APG,6858.36,,,6858.36,Other,324% New York Medicaid APG,4551.07,,,4551.07,Other,215% New York Medicaid APG,4551.07,,,4551.07,Other,215% New York Medicaid APG,2645.97,,,2645.97,Other,125% New York Medicaid APG,2116.78,90024.84,
Fusion/graft of elbow joint,24802,CPT,,,,,,,,both,,,276827.87,204852.62,74,,204852.62,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,124572.54,45,,124572.54,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,137029.8,49.5,,137029.8,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3937.21,,,3937.21,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,193779.51,70,,193779.51,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,2116.78,,,2116.78,Other,New York Medicaid APG methodology,2116.78,,,2116.78,Other,100% New York Medicaid APG,2116.78,,,2116.78,Other,100% New York Medicaid APG,2116.78,,,2116.78,Other,100% New York Medicaid APG,4762.75,,,4762.75,Other,225% New York Medicaid APG,3238.67,,,3238.67,Other,153% New York Medicaid APG,4762.75,,,4762.75,Other,225% New York Medicaid APG,2963.49,,,2963.49,Other,140% New York Medicaid APG,4762.75,,,4762.75,Other,225% New York Medicaid APG,5503.62,,,5503.62,Other,260% New York Medicaid APG,6858.36,,,6858.36,Other,324% New York Medicaid APG,4551.07,,,4551.07,Other,215% New York Medicaid APG,4551.07,,,4551.07,Other,215% New York Medicaid APG,2645.97,,,2645.97,Other,125% New York Medicaid APG,2116.78,204852.62,
Amputation follow-up surgery,24925,CPT,,,,,,,,both,,,33870,25063.8,74,,25063.8,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15241.5,45,,15241.5,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,16765.65,49.5,,16765.65,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3960.57,,,3960.57,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,23709,70,,23709,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,2129.34,,,2129.34,Other,New York Medicaid APG methodology,2129.34,,,2129.34,Other,100% New York Medicaid APG,2129.34,,,2129.34,Other,100% New York Medicaid APG,2129.34,,,2129.34,Other,100% New York Medicaid APG,4791.01,,,4791.01,Other,225% New York Medicaid APG,3257.89,,,3257.89,Other,153% New York Medicaid APG,4791.01,,,4791.01,Other,225% New York Medicaid APG,2981.08,,,2981.08,Other,140% New York Medicaid APG,4791.01,,,4791.01,Other,225% New York Medicaid APG,5536.28,,,5536.28,Other,260% New York Medicaid APG,6899.06,,,6899.06,Other,324% New York Medicaid APG,4578.08,,,4578.08,Other,215% New York Medicaid APG,4578.08,,,4578.08,Other,215% New York Medicaid APG,2661.67,,,2661.67,Other,125% New York Medicaid APG,2129.34,25063.8,
Revision of amputation,24935,CPT,,,,,,,,both,,,150476.65,111352.72,74,,111352.72,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,67714.49,45,,67714.49,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,74485.94,49.5,,74485.94,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3960.57,,,3960.57,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,105333.66,70,,105333.66,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,2129.34,,,2129.34,Other,New York Medicaid APG methodology,2129.34,,,2129.34,Other,100% New York Medicaid APG,2129.34,,,2129.34,Other,100% New York Medicaid APG,2129.34,,,2129.34,Other,100% New York Medicaid APG,4791.01,,,4791.01,Other,225% New York Medicaid APG,3257.89,,,3257.89,Other,153% New York Medicaid APG,4791.01,,,4791.01,Other,225% New York Medicaid APG,2981.08,,,2981.08,Other,140% New York Medicaid APG,4791.01,,,4791.01,Other,225% New York Medicaid APG,5536.28,,,5536.28,Other,260% New York Medicaid APG,6899.06,,,6899.06,Other,324% New York Medicaid APG,4578.08,,,4578.08,Other,215% New York Medicaid APG,4578.08,,,4578.08,Other,215% New York Medicaid APG,2661.67,,,2661.67,Other,125% New York Medicaid APG,2129.34,111352.72,
Incision of tendon sheath,25000,CPT,,,,,,,,both,,,33625.42,24882.81,74,,24882.81,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15131.44,45,,15131.44,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,16644.58,49.5,,16644.58,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3479.6,,,3479.6,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,23537.79,70,,23537.79,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1870.75,,,1870.75,Other,New York Medicaid APG methodology,1870.75,,,1870.75,Other,100% New York Medicaid APG,1870.75,,,1870.75,Other,100% New York Medicaid APG,1870.75,,,1870.75,Other,100% New York Medicaid APG,4209.2,,,4209.2,Other,225% New York Medicaid APG,2862.25,,,2862.25,Other,153% New York Medicaid APG,4209.2,,,4209.2,Other,225% New York Medicaid APG,2619.06,,,2619.06,Other,140% New York Medicaid APG,4209.2,,,4209.2,Other,225% New York Medicaid APG,4863.96,,,4863.96,Other,260% New York Medicaid APG,6061.24,,,6061.24,Other,324% New York Medicaid APG,4022.12,,,4022.12,Other,215% New York Medicaid APG,4022.12,,,4022.12,Other,215% New York Medicaid APG,2338.44,,,2338.44,Other,125% New York Medicaid APG,1870.75,24882.81,
Incise flexor carpi radialis,25001,CPT,,,,,,,,both,,,68082.75,50381.24,74,,50381.24,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30637.24,45,,30637.24,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33700.96,49.5,,33700.96,percent of total billed charges,110% of Medicare,46296.27,68,,46296.27,percent of total billed charges,,2289.65,,,2289.65,Other,186% of Medicaid,54466.2,80,,54466.2,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,54466.2,80,,54466.2,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,47657.93,70,,47657.93,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1231,,,1231,Other,New York Medicaid APG methodology,1231,,,1231,Other,100% New York Medicaid APG,1231,,,1231,Other,100% New York Medicaid APG,1231,,,1231,Other,100% New York Medicaid APG,2769.74,,,2769.74,Other,225% New York Medicaid APG,1883.42,,,1883.42,Other,153% New York Medicaid APG,2769.74,,,2769.74,Other,225% New York Medicaid APG,1723.39,,,1723.39,Other,140% New York Medicaid APG,2769.74,,,2769.74,Other,225% New York Medicaid APG,3200.59,,,3200.59,Other,260% New York Medicaid APG,3988.42,,,3988.42,Other,324% New York Medicaid APG,2646.64,,,2646.64,Other,215% New York Medicaid APG,2646.64,,,2646.64,Other,215% New York Medicaid APG,1538.74,,,1538.74,Other,125% New York Medicaid APG,1231,54466.2,
Decompress forearm 1 space,25020,CPT,,,,,,,,both,,,33805.49,25016.06,74,,25016.06,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15212.47,45,,15212.47,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,16733.72,49.5,,16733.72,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3479.6,,,3479.6,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,23663.84,70,,23663.84,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1870.75,,,1870.75,Other,New York Medicaid APG methodology,1870.75,,,1870.75,Other,100% New York Medicaid APG,1870.75,,,1870.75,Other,100% New York Medicaid APG,1870.75,,,1870.75,Other,100% New York Medicaid APG,4209.2,,,4209.2,Other,225% New York Medicaid APG,2862.25,,,2862.25,Other,153% New York Medicaid APG,4209.2,,,4209.2,Other,225% New York Medicaid APG,2619.06,,,2619.06,Other,140% New York Medicaid APG,4209.2,,,4209.2,Other,225% New York Medicaid APG,4863.96,,,4863.96,Other,260% New York Medicaid APG,6061.24,,,6061.24,Other,324% New York Medicaid APG,4022.12,,,4022.12,Other,215% New York Medicaid APG,4022.12,,,4022.12,Other,215% New York Medicaid APG,2338.44,,,2338.44,Other,125% New York Medicaid APG,1870.75,25016.06,
Decompress forearm 1 space,25023,CPT,,,,,,,,both,,,68082.75,50381.24,74,,50381.24,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30637.24,45,,30637.24,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33700.96,49.5,,33700.96,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3479.6,,,3479.6,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,47657.93,70,,47657.93,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1870.75,,,1870.75,Other,New York Medicaid APG methodology,1870.75,,,1870.75,Other,100% New York Medicaid APG,1870.75,,,1870.75,Other,100% New York Medicaid APG,1870.75,,,1870.75,Other,100% New York Medicaid APG,4209.2,,,4209.2,Other,225% New York Medicaid APG,2862.25,,,2862.25,Other,153% New York Medicaid APG,4209.2,,,4209.2,Other,225% New York Medicaid APG,2619.06,,,2619.06,Other,140% New York Medicaid APG,4209.2,,,4209.2,Other,225% New York Medicaid APG,4863.96,,,4863.96,Other,260% New York Medicaid APG,6061.24,,,6061.24,Other,324% New York Medicaid APG,4022.12,,,4022.12,Other,215% New York Medicaid APG,4022.12,,,4022.12,Other,215% New York Medicaid APG,2338.44,,,2338.44,Other,125% New York Medicaid APG,1870.75,50381.24,
Decompress forearm 2 spaces,25024,CPT,,,,,,,,both,,,68082.75,50381.24,74,,50381.24,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30637.24,45,,30637.24,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33700.96,49.5,,33700.96,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3479.6,,,3479.6,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,47657.93,70,,47657.93,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1870.75,,,1870.75,Other,New York Medicaid APG methodology,1870.75,,,1870.75,Other,100% New York Medicaid APG,1870.75,,,1870.75,Other,100% New York Medicaid APG,1870.75,,,1870.75,Other,100% New York Medicaid APG,4209.2,,,4209.2,Other,225% New York Medicaid APG,2862.25,,,2862.25,Other,153% New York Medicaid APG,4209.2,,,4209.2,Other,225% New York Medicaid APG,2619.06,,,2619.06,Other,140% New York Medicaid APG,4209.2,,,4209.2,Other,225% New York Medicaid APG,4863.96,,,4863.96,Other,260% New York Medicaid APG,6061.24,,,6061.24,Other,324% New York Medicaid APG,4022.12,,,4022.12,Other,215% New York Medicaid APG,4022.12,,,4022.12,Other,215% New York Medicaid APG,2338.44,,,2338.44,Other,125% New York Medicaid APG,1870.75,50381.24,
Decompress forearm 2 spaces,25025,CPT,,,,,,,,both,,,33805.49,25016.06,74,,25016.06,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15212.47,45,,15212.47,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,16733.72,49.5,,16733.72,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3479.6,,,3479.6,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,23663.84,70,,23663.84,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1870.75,,,1870.75,Other,New York Medicaid APG methodology,1870.75,,,1870.75,Other,100% New York Medicaid APG,1870.75,,,1870.75,Other,100% New York Medicaid APG,1870.75,,,1870.75,Other,100% New York Medicaid APG,4209.2,,,4209.2,Other,225% New York Medicaid APG,2862.25,,,2862.25,Other,153% New York Medicaid APG,4209.2,,,4209.2,Other,225% New York Medicaid APG,2619.06,,,2619.06,Other,140% New York Medicaid APG,4209.2,,,4209.2,Other,225% New York Medicaid APG,4863.96,,,4863.96,Other,260% New York Medicaid APG,6061.24,,,6061.24,Other,324% New York Medicaid APG,4022.12,,,4022.12,Other,215% New York Medicaid APG,4022.12,,,4022.12,Other,215% New York Medicaid APG,2338.44,,,2338.44,Other,125% New York Medicaid APG,1870.75,25016.06,
Drainage of forearm lesion,25028,CPT,,,,,,,,both,,,68082.75,50381.24,74,,50381.24,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30637.24,45,,30637.24,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33700.96,49.5,,33700.96,percent of total billed charges,110% of Medicare,46296.27,68,,46296.27,percent of total billed charges,,3479.6,,,3479.6,Other,186% of Medicaid,54466.2,80,,54466.2,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,54466.2,80,,54466.2,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,47657.93,70,,47657.93,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1870.75,,,1870.75,Other,New York Medicaid APG methodology,1870.75,,,1870.75,Other,100% New York Medicaid APG,1870.75,,,1870.75,Other,100% New York Medicaid APG,1870.75,,,1870.75,Other,100% New York Medicaid APG,4209.2,,,4209.2,Other,225% New York Medicaid APG,2862.25,,,2862.25,Other,153% New York Medicaid APG,4209.2,,,4209.2,Other,225% New York Medicaid APG,2619.06,,,2619.06,Other,140% New York Medicaid APG,4209.2,,,4209.2,Other,225% New York Medicaid APG,4863.96,,,4863.96,Other,260% New York Medicaid APG,6061.24,,,6061.24,Other,324% New York Medicaid APG,4022.12,,,4022.12,Other,215% New York Medicaid APG,4022.12,,,4022.12,Other,215% New York Medicaid APG,2338.44,,,2338.44,Other,125% New York Medicaid APG,1870.75,54466.2,
Drainage of forearm bursa,25031,CPT,,,,,,,,both,,,33805.49,25016.06,74,,25016.06,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15212.47,45,,15212.47,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,16733.72,49.5,,16733.72,percent of total billed charges,110% of Medicare,22987.73,68,,22987.73,percent of total billed charges,,3479.6,,,3479.6,Other,186% of Medicaid,27044.39,80,,27044.39,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,27044.39,80,,27044.39,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,23663.84,70,,23663.84,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1870.75,,,1870.75,Other,New York Medicaid APG methodology,1870.75,,,1870.75,Other,100% New York Medicaid APG,1870.75,,,1870.75,Other,100% New York Medicaid APG,1870.75,,,1870.75,Other,100% New York Medicaid APG,4209.2,,,4209.2,Other,225% New York Medicaid APG,2862.25,,,2862.25,Other,153% New York Medicaid APG,4209.2,,,4209.2,Other,225% New York Medicaid APG,2619.06,,,2619.06,Other,140% New York Medicaid APG,4209.2,,,4209.2,Other,225% New York Medicaid APG,4863.96,,,4863.96,Other,260% New York Medicaid APG,6061.24,,,6061.24,Other,324% New York Medicaid APG,4022.12,,,4022.12,Other,215% New York Medicaid APG,4022.12,,,4022.12,Other,215% New York Medicaid APG,2338.44,,,2338.44,Other,125% New York Medicaid APG,1870.75,27044.39,
Treat forearm bone lesion,25035,CPT,,,,,,,,both,,,150476.65,111352.72,74,,111352.72,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,67714.49,45,,67714.49,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,74485.94,49.5,,74485.94,percent of total billed charges,110% of Medicare,102324.12,68,,102324.12,percent of total billed charges,,3937.21,,,3937.21,Other,186% of Medicaid,120381.32,80,,120381.32,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,120381.32,80,,120381.32,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,105333.66,70,,105333.66,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,2116.78,,,2116.78,Other,New York Medicaid APG methodology,2116.78,,,2116.78,Other,100% New York Medicaid APG,2116.78,,,2116.78,Other,100% New York Medicaid APG,2116.78,,,2116.78,Other,100% New York Medicaid APG,4762.75,,,4762.75,Other,225% New York Medicaid APG,3238.67,,,3238.67,Other,153% New York Medicaid APG,4762.75,,,4762.75,Other,225% New York Medicaid APG,2963.49,,,2963.49,Other,140% New York Medicaid APG,4762.75,,,4762.75,Other,225% New York Medicaid APG,5503.62,,,5503.62,Other,260% New York Medicaid APG,6858.36,,,6858.36,Other,324% New York Medicaid APG,4551.07,,,4551.07,Other,215% New York Medicaid APG,4551.07,,,4551.07,Other,215% New York Medicaid APG,2645.97,,,2645.97,Other,125% New York Medicaid APG,2116.78,120381.32,
Explore/treat wrist joint,25040,CPT,,,,,,,,both,,,68082.75,50381.24,74,,50381.24,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30637.24,45,,30637.24,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33700.96,49.5,,33700.96,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3479.6,,,3479.6,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,47657.93,70,,47657.93,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1870.75,,,1870.75,Other,New York Medicaid APG methodology,1870.75,,,1870.75,Other,100% New York Medicaid APG,1870.75,,,1870.75,Other,100% New York Medicaid APG,1870.75,,,1870.75,Other,100% New York Medicaid APG,4209.2,,,4209.2,Other,225% New York Medicaid APG,2862.25,,,2862.25,Other,153% New York Medicaid APG,4209.2,,,4209.2,Other,225% New York Medicaid APG,2619.06,,,2619.06,Other,140% New York Medicaid APG,4209.2,,,4209.2,Other,225% New York Medicaid APG,4863.96,,,4863.96,Other,260% New York Medicaid APG,6061.24,,,6061.24,Other,324% New York Medicaid APG,4022.12,,,4022.12,Other,215% New York Medicaid APG,4022.12,,,4022.12,Other,215% New York Medicaid APG,2338.44,,,2338.44,Other,125% New York Medicaid APG,1870.75,50381.24,
Biopsy forearm soft tissues,25065,CPT,,,,,,,,both,,,34101.75,25235.3,74,,25235.3,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15345.79,45,,15345.79,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,16880.37,49.5,,16880.37,percent of total billed charges,110% of Medicare,23189.19,68,,23189.19,percent of total billed charges,,3479.6,,,3479.6,Other,186% of Medicaid,27281.4,80,,27281.4,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,27281.4,80,,27281.4,percent of total billed charges,,7216,,,7216,Case Rate,,3578,,"100% primary, 0% secondary procedures",3578,Other,MagnaCare ASC Grouper,23871.23,70,,23871.23,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,1870.75,,,1870.75,Other,New York Medicaid APG methodology,1870.75,,,1870.75,Other,100% New York Medicaid APG,1870.75,,,1870.75,Other,100% New York Medicaid APG,1870.75,,,1870.75,Other,100% New York Medicaid APG,4209.2,,,4209.2,Other,225% New York Medicaid APG,2862.25,,,2862.25,Other,153% New York Medicaid APG,4209.2,,,4209.2,Other,225% New York Medicaid APG,2619.06,,,2619.06,Other,140% New York Medicaid APG,4209.2,,,4209.2,Other,225% New York Medicaid APG,4863.96,,,4863.96,Other,260% New York Medicaid APG,6061.24,,,6061.24,Other,324% New York Medicaid APG,4022.12,,,4022.12,Other,215% New York Medicaid APG,4022.12,,,4022.12,Other,215% New York Medicaid APG,2338.44,,,2338.44,Other,125% New York Medicaid APG,1870.75,27281.4,
Biopsy forearm soft tissues,25066,CPT,,,,,,,,both,,,59767.2,44227.73,74,,44227.73,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,26895.24,45,,26895.24,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,29584.76,49.5,,29584.76,percent of total billed charges,110% of Medicare,40641.7,68,,40641.7,percent of total billed charges,,3479.6,,,3479.6,Other,186% of Medicaid,47813.76,80,,47813.76,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,47813.76,80,,47813.76,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,41837.04,70,,41837.04,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1870.75,,,1870.75,Other,New York Medicaid APG methodology,1870.75,,,1870.75,Other,100% New York Medicaid APG,1870.75,,,1870.75,Other,100% New York Medicaid APG,1870.75,,,1870.75,Other,100% New York Medicaid APG,4209.2,,,4209.2,Other,225% New York Medicaid APG,2862.25,,,2862.25,Other,153% New York Medicaid APG,4209.2,,,4209.2,Other,225% New York Medicaid APG,2619.06,,,2619.06,Other,140% New York Medicaid APG,4209.2,,,4209.2,Other,225% New York Medicaid APG,4863.96,,,4863.96,Other,260% New York Medicaid APG,6061.24,,,6061.24,Other,324% New York Medicaid APG,4022.12,,,4022.12,Other,215% New York Medicaid APG,4022.12,,,4022.12,Other,215% New York Medicaid APG,2338.44,,,2338.44,Other,125% New York Medicaid APG,1870.75,47813.76,
Exc forearm les sc 3 cm/>,25071,CPT,,,,,,,,both,,,34918.19,25839.46,74,,25839.46,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15713.19,45,,15713.19,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,17284.5,49.5,,17284.5,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3479.6,,,3479.6,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,24442.73,70,,24442.73,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1870.75,,,1870.75,Other,New York Medicaid APG methodology,1870.75,,,1870.75,Other,100% New York Medicaid APG,1870.75,,,1870.75,Other,100% New York Medicaid APG,1870.75,,,1870.75,Other,100% New York Medicaid APG,4209.2,,,4209.2,Other,225% New York Medicaid APG,2862.25,,,2862.25,Other,153% New York Medicaid APG,4209.2,,,4209.2,Other,225% New York Medicaid APG,2619.06,,,2619.06,Other,140% New York Medicaid APG,4209.2,,,4209.2,Other,225% New York Medicaid APG,4863.96,,,4863.96,Other,260% New York Medicaid APG,6061.24,,,6061.24,Other,324% New York Medicaid APG,4022.12,,,4022.12,Other,215% New York Medicaid APG,4022.12,,,4022.12,Other,215% New York Medicaid APG,2338.44,,,2338.44,Other,125% New York Medicaid APG,1870.75,25839.46,
Exc forearm tum deep 3 cm/>,25073,CPT,,,,,,,,both,,,38778.36,28695.99,74,,28695.99,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,17450.26,45,,17450.26,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,19195.29,49.5,,19195.29,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3479.6,,,3479.6,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,27144.85,70,,27144.85,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1870.75,,,1870.75,Other,New York Medicaid APG methodology,1870.75,,,1870.75,Other,100% New York Medicaid APG,1870.75,,,1870.75,Other,100% New York Medicaid APG,1870.75,,,1870.75,Other,100% New York Medicaid APG,4209.2,,,4209.2,Other,225% New York Medicaid APG,2862.25,,,2862.25,Other,153% New York Medicaid APG,4209.2,,,4209.2,Other,225% New York Medicaid APG,2619.06,,,2619.06,Other,140% New York Medicaid APG,4209.2,,,4209.2,Other,225% New York Medicaid APG,4863.96,,,4863.96,Other,260% New York Medicaid APG,6061.24,,,6061.24,Other,324% New York Medicaid APG,4022.12,,,4022.12,Other,215% New York Medicaid APG,4022.12,,,4022.12,Other,215% New York Medicaid APG,2338.44,,,2338.44,Other,125% New York Medicaid APG,1870.75,28695.99,
Exc forearm les sc < 3 cm,25075,CPT,,,,,,,,both,,,36818.43,27245.64,74,,27245.64,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,16568.29,45,,16568.29,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,18225.12,49.5,,18225.12,percent of total billed charges,110% of Medicare,25036.53,68,,25036.53,percent of total billed charges,,3479.6,,,3479.6,Other,186% of Medicaid,29454.74,80,,29454.74,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,29454.74,80,,29454.74,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,25772.9,70,,25772.9,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1870.75,,,1870.75,Other,New York Medicaid APG methodology,1870.75,,,1870.75,Other,100% New York Medicaid APG,1870.75,,,1870.75,Other,100% New York Medicaid APG,1870.75,,,1870.75,Other,100% New York Medicaid APG,4209.2,,,4209.2,Other,225% New York Medicaid APG,2862.25,,,2862.25,Other,153% New York Medicaid APG,4209.2,,,4209.2,Other,225% New York Medicaid APG,2619.06,,,2619.06,Other,140% New York Medicaid APG,4209.2,,,4209.2,Other,225% New York Medicaid APG,4863.96,,,4863.96,Other,260% New York Medicaid APG,6061.24,,,6061.24,Other,324% New York Medicaid APG,4022.12,,,4022.12,Other,215% New York Medicaid APG,4022.12,,,4022.12,Other,215% New York Medicaid APG,2338.44,,,2338.44,Other,125% New York Medicaid APG,1870.75,29454.74,
Exc forearm tum deep < 3 cm,25076,CPT,,,,,,,,both,,,34101.75,25235.3,74,,25235.3,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15345.79,45,,15345.79,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,16880.37,49.5,,16880.37,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3479.6,,,3479.6,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,23871.23,70,,23871.23,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1870.75,,,1870.75,Other,New York Medicaid APG methodology,1870.75,,,1870.75,Other,100% New York Medicaid APG,1870.75,,,1870.75,Other,100% New York Medicaid APG,1870.75,,,1870.75,Other,100% New York Medicaid APG,4209.2,,,4209.2,Other,225% New York Medicaid APG,2862.25,,,2862.25,Other,153% New York Medicaid APG,4209.2,,,4209.2,Other,225% New York Medicaid APG,2619.06,,,2619.06,Other,140% New York Medicaid APG,4209.2,,,4209.2,Other,225% New York Medicaid APG,4863.96,,,4863.96,Other,260% New York Medicaid APG,6061.24,,,6061.24,Other,324% New York Medicaid APG,4022.12,,,4022.12,Other,215% New York Medicaid APG,4022.12,,,4022.12,Other,215% New York Medicaid APG,2338.44,,,2338.44,Other,125% New York Medicaid APG,1870.75,25235.3,
Resect forearm/wrist tum<3cm,25077,CPT,,,,,,,,both,,,59767.2,44227.73,74,,44227.73,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,26895.24,45,,26895.24,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,29584.76,49.5,,29584.76,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3937.21,,,3937.21,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,41837.04,70,,41837.04,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,2116.78,,,2116.78,Other,New York Medicaid APG methodology,2116.78,,,2116.78,Other,100% New York Medicaid APG,2116.78,,,2116.78,Other,100% New York Medicaid APG,2116.78,,,2116.78,Other,100% New York Medicaid APG,4762.75,,,4762.75,Other,225% New York Medicaid APG,3238.67,,,3238.67,Other,153% New York Medicaid APG,4762.75,,,4762.75,Other,225% New York Medicaid APG,2963.49,,,2963.49,Other,140% New York Medicaid APG,4762.75,,,4762.75,Other,225% New York Medicaid APG,5503.62,,,5503.62,Other,260% New York Medicaid APG,6858.36,,,6858.36,Other,324% New York Medicaid APG,4551.07,,,4551.07,Other,215% New York Medicaid APG,4551.07,,,4551.07,Other,215% New York Medicaid APG,2645.97,,,2645.97,Other,125% New York Medicaid APG,2116.78,44227.73,
Resect forarm/wrist tum 3cm>,25078,CPT,,,,,,,,both,,,59767.2,44227.73,74,,44227.73,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,26895.24,45,,26895.24,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,29584.76,49.5,,29584.76,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3937.21,,,3937.21,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,41837.04,70,,41837.04,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,2116.78,,,2116.78,Other,New York Medicaid APG methodology,2116.78,,,2116.78,Other,100% New York Medicaid APG,2116.78,,,2116.78,Other,100% New York Medicaid APG,2116.78,,,2116.78,Other,100% New York Medicaid APG,4762.75,,,4762.75,Other,225% New York Medicaid APG,3238.67,,,3238.67,Other,153% New York Medicaid APG,4762.75,,,4762.75,Other,225% New York Medicaid APG,2963.49,,,2963.49,Other,140% New York Medicaid APG,4762.75,,,4762.75,Other,225% New York Medicaid APG,5503.62,,,5503.62,Other,260% New York Medicaid APG,6858.36,,,6858.36,Other,324% New York Medicaid APG,4551.07,,,4551.07,Other,215% New York Medicaid APG,4551.07,,,4551.07,Other,215% New York Medicaid APG,2645.97,,,2645.97,Other,125% New York Medicaid APG,2116.78,44227.73,
Incision of wrist capsule,25085,CPT,,,,,,,,both,,,68082.75,50381.24,74,,50381.24,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30637.24,45,,30637.24,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33700.96,49.5,,33700.96,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3479.6,,,3479.6,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,47657.93,70,,47657.93,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1870.75,,,1870.75,Other,New York Medicaid APG methodology,1870.75,,,1870.75,Other,100% New York Medicaid APG,1870.75,,,1870.75,Other,100% New York Medicaid APG,1870.75,,,1870.75,Other,100% New York Medicaid APG,4209.2,,,4209.2,Other,225% New York Medicaid APG,2862.25,,,2862.25,Other,153% New York Medicaid APG,4209.2,,,4209.2,Other,225% New York Medicaid APG,2619.06,,,2619.06,Other,140% New York Medicaid APG,4209.2,,,4209.2,Other,225% New York Medicaid APG,4863.96,,,4863.96,Other,260% New York Medicaid APG,6061.24,,,6061.24,Other,324% New York Medicaid APG,4022.12,,,4022.12,Other,215% New York Medicaid APG,4022.12,,,4022.12,Other,215% New York Medicaid APG,2338.44,,,2338.44,Other,125% New York Medicaid APG,1870.75,50381.24,
Biopsy of wrist joint,25100,CPT,,,,,,,,both,,,68082.75,50381.24,74,,50381.24,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30637.24,45,,30637.24,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33700.96,49.5,,33700.96,percent of total billed charges,110% of Medicare,46296.27,68,,46296.27,percent of total billed charges,,3479.6,,,3479.6,Other,186% of Medicaid,54466.2,80,,54466.2,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,54466.2,80,,54466.2,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,47657.93,70,,47657.93,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1870.75,,,1870.75,Other,New York Medicaid APG methodology,1870.75,,,1870.75,Other,100% New York Medicaid APG,1870.75,,,1870.75,Other,100% New York Medicaid APG,1870.75,,,1870.75,Other,100% New York Medicaid APG,4209.2,,,4209.2,Other,225% New York Medicaid APG,2862.25,,,2862.25,Other,153% New York Medicaid APG,4209.2,,,4209.2,Other,225% New York Medicaid APG,2619.06,,,2619.06,Other,140% New York Medicaid APG,4209.2,,,4209.2,Other,225% New York Medicaid APG,4863.96,,,4863.96,Other,260% New York Medicaid APG,6061.24,,,6061.24,Other,324% New York Medicaid APG,4022.12,,,4022.12,Other,215% New York Medicaid APG,4022.12,,,4022.12,Other,215% New York Medicaid APG,2338.44,,,2338.44,Other,125% New York Medicaid APG,1870.75,54466.2,
Explore/treat wrist joint,25101,CPT,,,,,,,,both,,,39926.3,29545.46,74,,29545.46,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,17966.84,45,,17966.84,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,19763.52,49.5,,19763.52,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3479.6,,,3479.6,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,27948.41,70,,27948.41,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1870.75,,,1870.75,Other,New York Medicaid APG methodology,1870.75,,,1870.75,Other,100% New York Medicaid APG,1870.75,,,1870.75,Other,100% New York Medicaid APG,1870.75,,,1870.75,Other,100% New York Medicaid APG,4209.2,,,4209.2,Other,225% New York Medicaid APG,2862.25,,,2862.25,Other,153% New York Medicaid APG,4209.2,,,4209.2,Other,225% New York Medicaid APG,2619.06,,,2619.06,Other,140% New York Medicaid APG,4209.2,,,4209.2,Other,225% New York Medicaid APG,4863.96,,,4863.96,Other,260% New York Medicaid APG,6061.24,,,6061.24,Other,324% New York Medicaid APG,4022.12,,,4022.12,Other,215% New York Medicaid APG,4022.12,,,4022.12,Other,215% New York Medicaid APG,2338.44,,,2338.44,Other,125% New York Medicaid APG,1870.75,29545.46,
Remove wrist joint lining,25105,CPT,,,,,,,,both,,,68082.75,50381.24,74,,50381.24,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30637.24,45,,30637.24,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33700.96,49.5,,33700.96,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3479.6,,,3479.6,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,47657.93,70,,47657.93,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1870.75,,,1870.75,Other,New York Medicaid APG methodology,1870.75,,,1870.75,Other,100% New York Medicaid APG,1870.75,,,1870.75,Other,100% New York Medicaid APG,1870.75,,,1870.75,Other,100% New York Medicaid APG,4209.2,,,4209.2,Other,225% New York Medicaid APG,2862.25,,,2862.25,Other,153% New York Medicaid APG,4209.2,,,4209.2,Other,225% New York Medicaid APG,2619.06,,,2619.06,Other,140% New York Medicaid APG,4209.2,,,4209.2,Other,225% New York Medicaid APG,4863.96,,,4863.96,Other,260% New York Medicaid APG,6061.24,,,6061.24,Other,324% New York Medicaid APG,4022.12,,,4022.12,Other,215% New York Medicaid APG,4022.12,,,4022.12,Other,215% New York Medicaid APG,2338.44,,,2338.44,Other,125% New York Medicaid APG,1870.75,50381.24,
Remove wrist joint cartilage,25107,CPT,,,,,,,,both,,,68082.75,50381.24,74,,50381.24,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30637.24,45,,30637.24,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33700.96,49.5,,33700.96,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3479.6,,,3479.6,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,47657.93,70,,47657.93,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1870.75,,,1870.75,Other,New York Medicaid APG methodology,1870.75,,,1870.75,Other,100% New York Medicaid APG,1870.75,,,1870.75,Other,100% New York Medicaid APG,1870.75,,,1870.75,Other,100% New York Medicaid APG,4209.2,,,4209.2,Other,225% New York Medicaid APG,2862.25,,,2862.25,Other,153% New York Medicaid APG,4209.2,,,4209.2,Other,225% New York Medicaid APG,2619.06,,,2619.06,Other,140% New York Medicaid APG,4209.2,,,4209.2,Other,225% New York Medicaid APG,4863.96,,,4863.96,Other,260% New York Medicaid APG,6061.24,,,6061.24,Other,324% New York Medicaid APG,4022.12,,,4022.12,Other,215% New York Medicaid APG,4022.12,,,4022.12,Other,215% New York Medicaid APG,2338.44,,,2338.44,Other,125% New York Medicaid APG,1870.75,50381.24,
Excise tendon forearm/wrist,25109,CPT,,,,,,,,both,,,68082.75,50381.24,74,,50381.24,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30637.24,45,,30637.24,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33700.96,49.5,,33700.96,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3479.6,,,3479.6,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,47657.93,70,,47657.93,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1870.75,,,1870.75,Other,New York Medicaid APG methodology,1870.75,,,1870.75,Other,100% New York Medicaid APG,1870.75,,,1870.75,Other,100% New York Medicaid APG,1870.75,,,1870.75,Other,100% New York Medicaid APG,4209.2,,,4209.2,Other,225% New York Medicaid APG,2862.25,,,2862.25,Other,153% New York Medicaid APG,4209.2,,,4209.2,Other,225% New York Medicaid APG,2619.06,,,2619.06,Other,140% New York Medicaid APG,4209.2,,,4209.2,Other,225% New York Medicaid APG,4863.96,,,4863.96,Other,260% New York Medicaid APG,6061.24,,,6061.24,Other,324% New York Medicaid APG,4022.12,,,4022.12,Other,215% New York Medicaid APG,4022.12,,,4022.12,Other,215% New York Medicaid APG,2338.44,,,2338.44,Other,125% New York Medicaid APG,1870.75,50381.24,
Remove wrist tendon lesion,25110,CPT,,,,,,,,both,,,33805.49,25016.06,74,,25016.06,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15212.47,45,,15212.47,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,16733.72,49.5,,16733.72,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3479.6,,,3479.6,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,23663.84,70,,23663.84,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1870.75,,,1870.75,Other,New York Medicaid APG methodology,1870.75,,,1870.75,Other,100% New York Medicaid APG,1870.75,,,1870.75,Other,100% New York Medicaid APG,1870.75,,,1870.75,Other,100% New York Medicaid APG,4209.2,,,4209.2,Other,225% New York Medicaid APG,2862.25,,,2862.25,Other,153% New York Medicaid APG,4209.2,,,4209.2,Other,225% New York Medicaid APG,2619.06,,,2619.06,Other,140% New York Medicaid APG,4209.2,,,4209.2,Other,225% New York Medicaid APG,4863.96,,,4863.96,Other,260% New York Medicaid APG,6061.24,,,6061.24,Other,324% New York Medicaid APG,4022.12,,,4022.12,Other,215% New York Medicaid APG,4022.12,,,4022.12,Other,215% New York Medicaid APG,2338.44,,,2338.44,Other,125% New York Medicaid APG,1870.75,25016.06,
Remove wrist tendon lesion,25111,CPT,,,,,,,,both,,,34202.63,25309.95,74,,25309.95,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15391.18,45,,15391.18,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,16930.3,49.5,,16930.3,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2289.65,,,2289.65,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,23941.84,70,,23941.84,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1231,,,1231,Other,New York Medicaid APG methodology,1231,,,1231,Other,100% New York Medicaid APG,1231,,,1231,Other,100% New York Medicaid APG,1231,,,1231,Other,100% New York Medicaid APG,2769.74,,,2769.74,Other,225% New York Medicaid APG,1883.42,,,1883.42,Other,153% New York Medicaid APG,2769.74,,,2769.74,Other,225% New York Medicaid APG,1723.39,,,1723.39,Other,140% New York Medicaid APG,2769.74,,,2769.74,Other,225% New York Medicaid APG,3200.59,,,3200.59,Other,260% New York Medicaid APG,3988.42,,,3988.42,Other,324% New York Medicaid APG,2646.64,,,2646.64,Other,215% New York Medicaid APG,2646.64,,,2646.64,Other,215% New York Medicaid APG,1538.74,,,1538.74,Other,125% New York Medicaid APG,1231,25309.95,
Reremove wrist tendon lesion,25112,CPT,,,,,,,,both,,,32239.98,23857.59,74,,23857.59,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,14507.99,45,,14507.99,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,15958.79,49.5,,15958.79,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2289.65,,,2289.65,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,22567.99,70,,22567.99,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1231,,,1231,Other,New York Medicaid APG methodology,1231,,,1231,Other,100% New York Medicaid APG,1231,,,1231,Other,100% New York Medicaid APG,1231,,,1231,Other,100% New York Medicaid APG,2769.74,,,2769.74,Other,225% New York Medicaid APG,1883.42,,,1883.42,Other,153% New York Medicaid APG,2769.74,,,2769.74,Other,225% New York Medicaid APG,1723.39,,,1723.39,Other,140% New York Medicaid APG,2769.74,,,2769.74,Other,225% New York Medicaid APG,3200.59,,,3200.59,Other,260% New York Medicaid APG,3988.42,,,3988.42,Other,324% New York Medicaid APG,2646.64,,,2646.64,Other,215% New York Medicaid APG,2646.64,,,2646.64,Other,215% New York Medicaid APG,1538.74,,,1538.74,Other,125% New York Medicaid APG,1231,23857.59,
Remove wrist/forearm lesion,25115,CPT,,,,,,,,both,,,34227.66,25328.47,74,,25328.47,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15402.45,45,,15402.45,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,16942.69,49.5,,16942.69,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3479.6,,,3479.6,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,23959.36,70,,23959.36,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1870.75,,,1870.75,Other,New York Medicaid APG methodology,1870.75,,,1870.75,Other,100% New York Medicaid APG,1870.75,,,1870.75,Other,100% New York Medicaid APG,1870.75,,,1870.75,Other,100% New York Medicaid APG,4209.2,,,4209.2,Other,225% New York Medicaid APG,2862.25,,,2862.25,Other,153% New York Medicaid APG,4209.2,,,4209.2,Other,225% New York Medicaid APG,2619.06,,,2619.06,Other,140% New York Medicaid APG,4209.2,,,4209.2,Other,225% New York Medicaid APG,4863.96,,,4863.96,Other,260% New York Medicaid APG,6061.24,,,6061.24,Other,324% New York Medicaid APG,4022.12,,,4022.12,Other,215% New York Medicaid APG,4022.12,,,4022.12,Other,215% New York Medicaid APG,2338.44,,,2338.44,Other,125% New York Medicaid APG,1870.75,25328.47,
Remove wrist/forearm lesion,25116,CPT,,,,,,,,both,,,32789.65,24264.34,74,,24264.34,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,14755.34,45,,14755.34,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,16230.88,49.5,,16230.88,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3479.6,,,3479.6,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,22952.76,70,,22952.76,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1870.75,,,1870.75,Other,New York Medicaid APG methodology,1870.75,,,1870.75,Other,100% New York Medicaid APG,1870.75,,,1870.75,Other,100% New York Medicaid APG,1870.75,,,1870.75,Other,100% New York Medicaid APG,4209.2,,,4209.2,Other,225% New York Medicaid APG,2862.25,,,2862.25,Other,153% New York Medicaid APG,4209.2,,,4209.2,Other,225% New York Medicaid APG,2619.06,,,2619.06,Other,140% New York Medicaid APG,4209.2,,,4209.2,Other,225% New York Medicaid APG,4863.96,,,4863.96,Other,260% New York Medicaid APG,6061.24,,,6061.24,Other,324% New York Medicaid APG,4022.12,,,4022.12,Other,215% New York Medicaid APG,4022.12,,,4022.12,Other,215% New York Medicaid APG,2338.44,,,2338.44,Other,125% New York Medicaid APG,1870.75,24264.34,
Excise wrist tendon sheath,25118,CPT,,,,,,,,both,,,33805.49,25016.06,74,,25016.06,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15212.47,45,,15212.47,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,16733.72,49.5,,16733.72,percent of total billed charges,110% of Medicare,22987.73,68,,22987.73,percent of total billed charges,,3479.6,,,3479.6,Other,186% of Medicaid,27044.39,80,,27044.39,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,27044.39,80,,27044.39,percent of total billed charges,,7216,,,7216,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,23663.84,70,,23663.84,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1870.75,,,1870.75,Other,New York Medicaid APG methodology,1870.75,,,1870.75,Other,100% New York Medicaid APG,1870.75,,,1870.75,Other,100% New York Medicaid APG,1870.75,,,1870.75,Other,100% New York Medicaid APG,4209.2,,,4209.2,Other,225% New York Medicaid APG,2862.25,,,2862.25,Other,153% New York Medicaid APG,4209.2,,,4209.2,Other,225% New York Medicaid APG,2619.06,,,2619.06,Other,140% New York Medicaid APG,4209.2,,,4209.2,Other,225% New York Medicaid APG,4863.96,,,4863.96,Other,260% New York Medicaid APG,6061.24,,,6061.24,Other,324% New York Medicaid APG,4022.12,,,4022.12,Other,215% New York Medicaid APG,4022.12,,,4022.12,Other,215% New York Medicaid APG,2338.44,,,2338.44,Other,125% New York Medicaid APG,1870.75,27044.39,
Partial removal of ulna,25119,CPT,,,,,,,,both,,,68082.75,50381.24,74,,50381.24,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30637.24,45,,30637.24,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33700.96,49.5,,33700.96,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3479.6,,,3479.6,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,47657.93,70,,47657.93,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1870.75,,,1870.75,Other,New York Medicaid APG methodology,1870.75,,,1870.75,Other,100% New York Medicaid APG,1870.75,,,1870.75,Other,100% New York Medicaid APG,1870.75,,,1870.75,Other,100% New York Medicaid APG,4209.2,,,4209.2,Other,225% New York Medicaid APG,2862.25,,,2862.25,Other,153% New York Medicaid APG,4209.2,,,4209.2,Other,225% New York Medicaid APG,2619.06,,,2619.06,Other,140% New York Medicaid APG,4209.2,,,4209.2,Other,225% New York Medicaid APG,4863.96,,,4863.96,Other,260% New York Medicaid APG,6061.24,,,6061.24,Other,324% New York Medicaid APG,4022.12,,,4022.12,Other,215% New York Medicaid APG,4022.12,,,4022.12,Other,215% New York Medicaid APG,2338.44,,,2338.44,Other,125% New York Medicaid APG,1870.75,50381.24,
Removal of forearm lesion,25120,CPT,,,,,,,,both,,,71784.48,53120.52,74,,53120.52,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,32303.02,45,,32303.02,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,35533.32,49.5,,35533.32,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3479.6,,,3479.6,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,50249.14,70,,50249.14,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1870.75,,,1870.75,Other,New York Medicaid APG methodology,1870.75,,,1870.75,Other,100% New York Medicaid APG,1870.75,,,1870.75,Other,100% New York Medicaid APG,1870.75,,,1870.75,Other,100% New York Medicaid APG,4209.2,,,4209.2,Other,225% New York Medicaid APG,2862.25,,,2862.25,Other,153% New York Medicaid APG,4209.2,,,4209.2,Other,225% New York Medicaid APG,2619.06,,,2619.06,Other,140% New York Medicaid APG,4209.2,,,4209.2,Other,225% New York Medicaid APG,4863.96,,,4863.96,Other,260% New York Medicaid APG,6061.24,,,6061.24,Other,324% New York Medicaid APG,4022.12,,,4022.12,Other,215% New York Medicaid APG,4022.12,,,4022.12,Other,215% New York Medicaid APG,2338.44,,,2338.44,Other,125% New York Medicaid APG,1870.75,53120.52,
Remove/graft forearm lesion,25125,CPT,,,,,,,,both,,,33805.49,25016.06,74,,25016.06,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15212.47,45,,15212.47,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,16733.72,49.5,,16733.72,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3479.6,,,3479.6,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,23663.84,70,,23663.84,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1870.75,,,1870.75,Other,New York Medicaid APG methodology,1870.75,,,1870.75,Other,100% New York Medicaid APG,1870.75,,,1870.75,Other,100% New York Medicaid APG,1870.75,,,1870.75,Other,100% New York Medicaid APG,4209.2,,,4209.2,Other,225% New York Medicaid APG,2862.25,,,2862.25,Other,153% New York Medicaid APG,4209.2,,,4209.2,Other,225% New York Medicaid APG,2619.06,,,2619.06,Other,140% New York Medicaid APG,4209.2,,,4209.2,Other,225% New York Medicaid APG,4863.96,,,4863.96,Other,260% New York Medicaid APG,6061.24,,,6061.24,Other,324% New York Medicaid APG,4022.12,,,4022.12,Other,215% New York Medicaid APG,4022.12,,,4022.12,Other,215% New York Medicaid APG,2338.44,,,2338.44,Other,125% New York Medicaid APG,1870.75,25016.06,
Remove/graft forearm lesion,25126,CPT,,,,,,,,both,,,68082.75,50381.24,74,,50381.24,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30637.24,45,,30637.24,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33700.96,49.5,,33700.96,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3479.6,,,3479.6,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,47657.93,70,,47657.93,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1870.75,,,1870.75,Other,New York Medicaid APG methodology,1870.75,,,1870.75,Other,100% New York Medicaid APG,1870.75,,,1870.75,Other,100% New York Medicaid APG,1870.75,,,1870.75,Other,100% New York Medicaid APG,4209.2,,,4209.2,Other,225% New York Medicaid APG,2862.25,,,2862.25,Other,153% New York Medicaid APG,4209.2,,,4209.2,Other,225% New York Medicaid APG,2619.06,,,2619.06,Other,140% New York Medicaid APG,4209.2,,,4209.2,Other,225% New York Medicaid APG,4863.96,,,4863.96,Other,260% New York Medicaid APG,6061.24,,,6061.24,Other,324% New York Medicaid APG,4022.12,,,4022.12,Other,215% New York Medicaid APG,4022.12,,,4022.12,Other,215% New York Medicaid APG,2338.44,,,2338.44,Other,125% New York Medicaid APG,1870.75,50381.24,
Removal of wrist lesion,25130,CPT,,,,,,,,both,,,35523.66,26287.51,74,,26287.51,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15985.65,45,,15985.65,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,17584.21,49.5,,17584.21,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3479.6,,,3479.6,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,24866.56,70,,24866.56,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1870.75,,,1870.75,Other,New York Medicaid APG methodology,1870.75,,,1870.75,Other,100% New York Medicaid APG,1870.75,,,1870.75,Other,100% New York Medicaid APG,1870.75,,,1870.75,Other,100% New York Medicaid APG,4209.2,,,4209.2,Other,225% New York Medicaid APG,2862.25,,,2862.25,Other,153% New York Medicaid APG,4209.2,,,4209.2,Other,225% New York Medicaid APG,2619.06,,,2619.06,Other,140% New York Medicaid APG,4209.2,,,4209.2,Other,225% New York Medicaid APG,4863.96,,,4863.96,Other,260% New York Medicaid APG,6061.24,,,6061.24,Other,324% New York Medicaid APG,4022.12,,,4022.12,Other,215% New York Medicaid APG,4022.12,,,4022.12,Other,215% New York Medicaid APG,2338.44,,,2338.44,Other,125% New York Medicaid APG,1870.75,26287.51,
Remove & graft wrist lesion,25135,CPT,,,,,,,,both,,,150476.65,111352.72,74,,111352.72,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,67714.49,45,,67714.49,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,74485.94,49.5,,74485.94,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3479.6,,,3479.6,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,105333.66,70,,105333.66,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1870.75,,,1870.75,Other,New York Medicaid APG methodology,1870.75,,,1870.75,Other,100% New York Medicaid APG,1870.75,,,1870.75,Other,100% New York Medicaid APG,1870.75,,,1870.75,Other,100% New York Medicaid APG,4209.2,,,4209.2,Other,225% New York Medicaid APG,2862.25,,,2862.25,Other,153% New York Medicaid APG,4209.2,,,4209.2,Other,225% New York Medicaid APG,2619.06,,,2619.06,Other,140% New York Medicaid APG,4209.2,,,4209.2,Other,225% New York Medicaid APG,4863.96,,,4863.96,Other,260% New York Medicaid APG,6061.24,,,6061.24,Other,324% New York Medicaid APG,4022.12,,,4022.12,Other,215% New York Medicaid APG,4022.12,,,4022.12,Other,215% New York Medicaid APG,2338.44,,,2338.44,Other,125% New York Medicaid APG,1870.75,111352.72,
Remove & graft wrist lesion,25136,CPT,,,,,,,,both,,,150476.65,111352.72,74,,111352.72,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,67714.49,45,,67714.49,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,74485.94,49.5,,74485.94,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3654.9,,,3654.9,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,105333.66,70,,105333.66,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1965,,,1965,Other,New York Medicaid APG methodology,1965,,,1965,Other,100% New York Medicaid APG,1965,,,1965,Other,100% New York Medicaid APG,1965,,,1965,Other,100% New York Medicaid APG,4421.25,,,4421.25,Other,225% New York Medicaid APG,3006.45,,,3006.45,Other,153% New York Medicaid APG,4421.25,,,4421.25,Other,225% New York Medicaid APG,2751,,,2751,Other,140% New York Medicaid APG,4421.25,,,4421.25,Other,225% New York Medicaid APG,5109,,,5109,Other,260% New York Medicaid APG,6366.6,,,6366.6,Other,324% New York Medicaid APG,4224.75,,,4224.75,Other,215% New York Medicaid APG,4224.75,,,4224.75,Other,215% New York Medicaid APG,2456.25,,,2456.25,Other,125% New York Medicaid APG,1965,111352.72,
Remove forearm bone lesion,25145,CPT,,,,,,,,both,,,68082.75,50381.24,74,,50381.24,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30637.24,45,,30637.24,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33700.96,49.5,,33700.96,percent of total billed charges,110% of Medicare,46296.27,68,,46296.27,percent of total billed charges,,3937.21,,,3937.21,Other,186% of Medicaid,54466.2,80,,54466.2,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,54466.2,80,,54466.2,percent of total billed charges,,7216,,,7216,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,47657.93,70,,47657.93,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,2116.78,,,2116.78,Other,New York Medicaid APG methodology,2116.78,,,2116.78,Other,100% New York Medicaid APG,2116.78,,,2116.78,Other,100% New York Medicaid APG,2116.78,,,2116.78,Other,100% New York Medicaid APG,4762.75,,,4762.75,Other,225% New York Medicaid APG,3238.67,,,3238.67,Other,153% New York Medicaid APG,4762.75,,,4762.75,Other,225% New York Medicaid APG,2963.49,,,2963.49,Other,140% New York Medicaid APG,4762.75,,,4762.75,Other,225% New York Medicaid APG,5503.62,,,5503.62,Other,260% New York Medicaid APG,6858.36,,,6858.36,Other,324% New York Medicaid APG,4551.07,,,4551.07,Other,215% New York Medicaid APG,4551.07,,,4551.07,Other,215% New York Medicaid APG,2645.97,,,2645.97,Other,125% New York Medicaid APG,2116.78,54466.2,
Partial removal of ulna,25150,CPT,,,,,,,,both,,,68082.75,50381.24,74,,50381.24,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30637.24,45,,30637.24,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33700.96,49.5,,33700.96,percent of total billed charges,110% of Medicare,46296.27,68,,46296.27,percent of total billed charges,,3479.6,,,3479.6,Other,186% of Medicaid,54466.2,80,,54466.2,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,54466.2,80,,54466.2,percent of total billed charges,,7216,,,7216,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,47657.93,70,,47657.93,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1870.75,,,1870.75,Other,New York Medicaid APG methodology,1870.75,,,1870.75,Other,100% New York Medicaid APG,1870.75,,,1870.75,Other,100% New York Medicaid APG,1870.75,,,1870.75,Other,100% New York Medicaid APG,4209.2,,,4209.2,Other,225% New York Medicaid APG,2862.25,,,2862.25,Other,153% New York Medicaid APG,4209.2,,,4209.2,Other,225% New York Medicaid APG,2619.06,,,2619.06,Other,140% New York Medicaid APG,4209.2,,,4209.2,Other,225% New York Medicaid APG,4863.96,,,4863.96,Other,260% New York Medicaid APG,6061.24,,,6061.24,Other,324% New York Medicaid APG,4022.12,,,4022.12,Other,215% New York Medicaid APG,4022.12,,,4022.12,Other,215% New York Medicaid APG,2338.44,,,2338.44,Other,125% New York Medicaid APG,1870.75,54466.2,
Partial removal of radius,25151,CPT,,,,,,,,both,,,68082.75,50381.24,74,,50381.24,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30637.24,45,,30637.24,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33700.96,49.5,,33700.96,percent of total billed charges,110% of Medicare,46296.27,68,,46296.27,percent of total billed charges,,3479.6,,,3479.6,Other,186% of Medicaid,54466.2,80,,54466.2,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,54466.2,80,,54466.2,percent of total billed charges,,7216,,,7216,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,47657.93,70,,47657.93,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1870.75,,,1870.75,Other,New York Medicaid APG methodology,1870.75,,,1870.75,Other,100% New York Medicaid APG,1870.75,,,1870.75,Other,100% New York Medicaid APG,1870.75,,,1870.75,Other,100% New York Medicaid APG,4209.2,,,4209.2,Other,225% New York Medicaid APG,2862.25,,,2862.25,Other,153% New York Medicaid APG,4209.2,,,4209.2,Other,225% New York Medicaid APG,2619.06,,,2619.06,Other,140% New York Medicaid APG,4209.2,,,4209.2,Other,225% New York Medicaid APG,4863.96,,,4863.96,Other,260% New York Medicaid APG,6061.24,,,6061.24,Other,324% New York Medicaid APG,4022.12,,,4022.12,Other,215% New York Medicaid APG,4022.12,,,4022.12,Other,215% New York Medicaid APG,2338.44,,,2338.44,Other,125% New York Medicaid APG,1870.75,54466.2,
Resect radius/ulnar tumor,25170,CPT,,,,,,,,both,,,150476.65,111352.72,74,,111352.72,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,67714.49,45,,67714.49,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,74485.94,49.5,,74485.94,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3937.21,,,3937.21,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,105333.66,70,,105333.66,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,2116.78,,,2116.78,Other,New York Medicaid APG methodology,2116.78,,,2116.78,Other,100% New York Medicaid APG,2116.78,,,2116.78,Other,100% New York Medicaid APG,2116.78,,,2116.78,Other,100% New York Medicaid APG,4762.75,,,4762.75,Other,225% New York Medicaid APG,3238.67,,,3238.67,Other,153% New York Medicaid APG,4762.75,,,4762.75,Other,225% New York Medicaid APG,2963.49,,,2963.49,Other,140% New York Medicaid APG,4762.75,,,4762.75,Other,225% New York Medicaid APG,5503.62,,,5503.62,Other,260% New York Medicaid APG,6858.36,,,6858.36,Other,324% New York Medicaid APG,4551.07,,,4551.07,Other,215% New York Medicaid APG,4551.07,,,4551.07,Other,215% New York Medicaid APG,2645.97,,,2645.97,Other,125% New York Medicaid APG,2116.78,111352.72,
Removal of wrist bone,25210,CPT,,,,,,,,both,,,68082.75,50381.24,74,,50381.24,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30637.24,45,,30637.24,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33700.96,49.5,,33700.96,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2289.65,,,2289.65,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,47657.93,70,,47657.93,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1231,,,1231,Other,New York Medicaid APG methodology,1231,,,1231,Other,100% New York Medicaid APG,1231,,,1231,Other,100% New York Medicaid APG,1231,,,1231,Other,100% New York Medicaid APG,2769.74,,,2769.74,Other,225% New York Medicaid APG,1883.42,,,1883.42,Other,153% New York Medicaid APG,2769.74,,,2769.74,Other,225% New York Medicaid APG,1723.39,,,1723.39,Other,140% New York Medicaid APG,2769.74,,,2769.74,Other,225% New York Medicaid APG,3200.59,,,3200.59,Other,260% New York Medicaid APG,3988.42,,,3988.42,Other,324% New York Medicaid APG,2646.64,,,2646.64,Other,215% New York Medicaid APG,2646.64,,,2646.64,Other,215% New York Medicaid APG,1538.74,,,1538.74,Other,125% New York Medicaid APG,1231,50381.24,
Removal of wrist bones,25215,CPT,,,,,,,,both,,,37702.27,27899.68,74,,27899.68,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,16966.02,45,,16966.02,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,18662.62,49.5,,18662.62,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3654.9,,,3654.9,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,26391.59,70,,26391.59,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1965,,,1965,Other,New York Medicaid APG methodology,1965,,,1965,Other,100% New York Medicaid APG,1965,,,1965,Other,100% New York Medicaid APG,1965,,,1965,Other,100% New York Medicaid APG,4421.25,,,4421.25,Other,225% New York Medicaid APG,3006.45,,,3006.45,Other,153% New York Medicaid APG,4421.25,,,4421.25,Other,225% New York Medicaid APG,2751,,,2751,Other,140% New York Medicaid APG,4421.25,,,4421.25,Other,225% New York Medicaid APG,5109,,,5109,Other,260% New York Medicaid APG,6366.6,,,6366.6,Other,324% New York Medicaid APG,4224.75,,,4224.75,Other,215% New York Medicaid APG,4224.75,,,4224.75,Other,215% New York Medicaid APG,2456.25,,,2456.25,Other,125% New York Medicaid APG,1965,27899.68,
Partial removal of radius,25230,CPT,,,,,,,,both,,,44454.65,32896.44,74,,32896.44,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,20004.59,45,,20004.59,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,22005.05,49.5,,22005.05,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3479.6,,,3479.6,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,31118.26,70,,31118.26,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1870.75,,,1870.75,Other,New York Medicaid APG methodology,1870.75,,,1870.75,Other,100% New York Medicaid APG,1870.75,,,1870.75,Other,100% New York Medicaid APG,1870.75,,,1870.75,Other,100% New York Medicaid APG,4209.2,,,4209.2,Other,225% New York Medicaid APG,2862.25,,,2862.25,Other,153% New York Medicaid APG,4209.2,,,4209.2,Other,225% New York Medicaid APG,2619.06,,,2619.06,Other,140% New York Medicaid APG,4209.2,,,4209.2,Other,225% New York Medicaid APG,4863.96,,,4863.96,Other,260% New York Medicaid APG,6061.24,,,6061.24,Other,324% New York Medicaid APG,4022.12,,,4022.12,Other,215% New York Medicaid APG,4022.12,,,4022.12,Other,215% New York Medicaid APG,2338.44,,,2338.44,Other,125% New York Medicaid APG,1870.75,32896.44,
Partial removal of ulna,25240,CPT,,,,,,,,both,,,44514.25,32940.55,74,,32940.55,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,20031.41,45,,20031.41,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,22034.55,49.5,,22034.55,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3479.6,,,3479.6,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,31159.98,70,,31159.98,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1870.75,,,1870.75,Other,New York Medicaid APG methodology,1870.75,,,1870.75,Other,100% New York Medicaid APG,1870.75,,,1870.75,Other,100% New York Medicaid APG,1870.75,,,1870.75,Other,100% New York Medicaid APG,4209.2,,,4209.2,Other,225% New York Medicaid APG,2862.25,,,2862.25,Other,153% New York Medicaid APG,4209.2,,,4209.2,Other,225% New York Medicaid APG,2619.06,,,2619.06,Other,140% New York Medicaid APG,4209.2,,,4209.2,Other,225% New York Medicaid APG,4863.96,,,4863.96,Other,260% New York Medicaid APG,6061.24,,,6061.24,Other,324% New York Medicaid APG,4022.12,,,4022.12,Other,215% New York Medicaid APG,4022.12,,,4022.12,Other,215% New York Medicaid APG,2338.44,,,2338.44,Other,125% New York Medicaid APG,1870.75,32940.55,
Injection for wrist x-ray,25246,CPT,,,,,,,,both,,,32432.1,23999.75,74,,23999.75,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,14594.45,45,,14594.45,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,16053.89,49.5,,16053.89,percent of total billed charges,110% of Medicare,22053.83,68,,22053.83,percent of total billed charges,,966.93,,,966.93,Other,186% of Medicaid,25945.68,80,,25945.68,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,25945.68,80,,25945.68,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,22702.47,70,,22702.47,percent of total billed charges,,352.6,,,352.6,Fee Schedule,,298.85,,,298.85,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,519.86,,,519.86,Other,New York Medicaid APG methodology,519.86,,,519.86,Other,100% New York Medicaid APG,519.86,,,519.86,Other,100% New York Medicaid APG,519.86,,,519.86,Other,100% New York Medicaid APG,1169.68,,,1169.68,Other,225% New York Medicaid APG,795.38,,,795.38,Other,153% New York Medicaid APG,1169.68,,,1169.68,Other,225% New York Medicaid APG,727.8,,,727.8,Other,140% New York Medicaid APG,1169.68,,,1169.68,Other,225% New York Medicaid APG,1351.62,,,1351.62,Other,260% New York Medicaid APG,1684.33,,,1684.33,Other,324% New York Medicaid APG,1117.69,,,1117.69,Other,215% New York Medicaid APG,1117.69,,,1117.69,Other,215% New York Medicaid APG,649.82,,,649.82,Other,125% New York Medicaid APG,298.85,25945.68,
Remove forearm foreign body,25248,CPT,,,,,,,,both,,,33805.49,25016.06,74,,25016.06,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15212.47,45,,15212.47,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,16733.72,49.5,,16733.72,percent of total billed charges,110% of Medicare,22987.73,68,,22987.73,percent of total billed charges,,3479.6,,,3479.6,Other,186% of Medicaid,27044.39,80,,27044.39,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,27044.39,80,,27044.39,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,23663.84,70,,23663.84,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1870.75,,,1870.75,Other,New York Medicaid APG methodology,1870.75,,,1870.75,Other,100% New York Medicaid APG,1870.75,,,1870.75,Other,100% New York Medicaid APG,1870.75,,,1870.75,Other,100% New York Medicaid APG,4209.2,,,4209.2,Other,225% New York Medicaid APG,2862.25,,,2862.25,Other,153% New York Medicaid APG,4209.2,,,4209.2,Other,225% New York Medicaid APG,2619.06,,,2619.06,Other,140% New York Medicaid APG,4209.2,,,4209.2,Other,225% New York Medicaid APG,4863.96,,,4863.96,Other,260% New York Medicaid APG,6061.24,,,6061.24,Other,324% New York Medicaid APG,4022.12,,,4022.12,Other,215% New York Medicaid APG,4022.12,,,4022.12,Other,215% New York Medicaid APG,2338.44,,,2338.44,Other,125% New York Medicaid APG,1870.75,27044.39,
Removal of wrist prosthesis,25250,CPT,,,,,,,,both,,,33805.49,25016.06,74,,25016.06,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15212.47,45,,15212.47,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,16733.72,49.5,,16733.72,percent of total billed charges,110% of Medicare,22987.73,68,,22987.73,percent of total billed charges,,3479.6,,,3479.6,Other,186% of Medicaid,27044.39,80,,27044.39,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,27044.39,80,,27044.39,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,23663.84,70,,23663.84,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1870.75,,,1870.75,Other,New York Medicaid APG methodology,1870.75,,,1870.75,Other,100% New York Medicaid APG,1870.75,,,1870.75,Other,100% New York Medicaid APG,1870.75,,,1870.75,Other,100% New York Medicaid APG,4209.2,,,4209.2,Other,225% New York Medicaid APG,2862.25,,,2862.25,Other,153% New York Medicaid APG,4209.2,,,4209.2,Other,225% New York Medicaid APG,2619.06,,,2619.06,Other,140% New York Medicaid APG,4209.2,,,4209.2,Other,225% New York Medicaid APG,4863.96,,,4863.96,Other,260% New York Medicaid APG,6061.24,,,6061.24,Other,324% New York Medicaid APG,4022.12,,,4022.12,Other,215% New York Medicaid APG,4022.12,,,4022.12,Other,215% New York Medicaid APG,2338.44,,,2338.44,Other,125% New York Medicaid APG,1870.75,27044.39,
Removal of wrist prosthesis,25251,CPT,,,,,,,,both,,,68082.75,50381.24,74,,50381.24,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30637.24,45,,30637.24,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33700.96,49.5,,33700.96,percent of total billed charges,110% of Medicare,46296.27,68,,46296.27,percent of total billed charges,,3479.6,,,3479.6,Other,186% of Medicaid,54466.2,80,,54466.2,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,54466.2,80,,54466.2,percent of total billed charges,,7216,,,7216,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,47657.93,70,,47657.93,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1870.75,,,1870.75,Other,New York Medicaid APG methodology,1870.75,,,1870.75,Other,100% New York Medicaid APG,1870.75,,,1870.75,Other,100% New York Medicaid APG,1870.75,,,1870.75,Other,100% New York Medicaid APG,4209.2,,,4209.2,Other,225% New York Medicaid APG,2862.25,,,2862.25,Other,153% New York Medicaid APG,4209.2,,,4209.2,Other,225% New York Medicaid APG,2619.06,,,2619.06,Other,140% New York Medicaid APG,4209.2,,,4209.2,Other,225% New York Medicaid APG,4863.96,,,4863.96,Other,260% New York Medicaid APG,6061.24,,,6061.24,Other,324% New York Medicaid APG,4022.12,,,4022.12,Other,215% New York Medicaid APG,4022.12,,,4022.12,Other,215% New York Medicaid APG,2338.44,,,2338.44,Other,125% New York Medicaid APG,1870.75,54466.2,
Manipulate wrist w/anesthes,25259,CPT,,,,,,,,both,,,33805.49,25016.06,74,,25016.06,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15212.47,45,,15212.47,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,16733.72,49.5,,16733.72,percent of total billed charges,110% of Medicare,22987.73,68,,22987.73,percent of total billed charges,,1730.38,,,1730.38,Other,186% of Medicaid,27044.39,80,,27044.39,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,27044.39,80,,27044.39,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,23663.84,70,,23663.84,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,930.31,,,930.31,Other,New York Medicaid APG methodology,930.31,,,930.31,Other,100% New York Medicaid APG,930.31,,,930.31,Other,100% New York Medicaid APG,930.31,,,930.31,Other,100% New York Medicaid APG,2093.21,,,2093.21,Other,225% New York Medicaid APG,1423.38,,,1423.38,Other,153% New York Medicaid APG,2093.21,,,2093.21,Other,225% New York Medicaid APG,1302.44,,,1302.44,Other,140% New York Medicaid APG,2093.21,,,2093.21,Other,225% New York Medicaid APG,2418.82,,,2418.82,Other,260% New York Medicaid APG,3014.22,,,3014.22,Other,324% New York Medicaid APG,2000.18,,,2000.18,Other,215% New York Medicaid APG,2000.18,,,2000.18,Other,215% New York Medicaid APG,1162.89,,,1162.89,Other,125% New York Medicaid APG,930.31,27044.39,
Repair forearm tendon/muscle,25260,CPT,,,,,,,,both,,,68082.75,50381.24,74,,50381.24,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30637.24,45,,30637.24,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33700.96,49.5,,33700.96,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3479.6,,,3479.6,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,47657.93,70,,47657.93,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1870.75,,,1870.75,Other,New York Medicaid APG methodology,1870.75,,,1870.75,Other,100% New York Medicaid APG,1870.75,,,1870.75,Other,100% New York Medicaid APG,1870.75,,,1870.75,Other,100% New York Medicaid APG,4209.2,,,4209.2,Other,225% New York Medicaid APG,2862.25,,,2862.25,Other,153% New York Medicaid APG,4209.2,,,4209.2,Other,225% New York Medicaid APG,2619.06,,,2619.06,Other,140% New York Medicaid APG,4209.2,,,4209.2,Other,225% New York Medicaid APG,4863.96,,,4863.96,Other,260% New York Medicaid APG,6061.24,,,6061.24,Other,324% New York Medicaid APG,4022.12,,,4022.12,Other,215% New York Medicaid APG,4022.12,,,4022.12,Other,215% New York Medicaid APG,2338.44,,,2338.44,Other,125% New York Medicaid APG,1870.75,50381.24,
Repair forearm tendon/muscle,25263,CPT,,,,,,,,both,,,150476.65,111352.72,74,,111352.72,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,67714.49,45,,67714.49,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,74485.94,49.5,,74485.94,percent of total billed charges,110% of Medicare,102324.12,68,,102324.12,percent of total billed charges,,3479.6,,,3479.6,Other,186% of Medicaid,120381.32,80,,120381.32,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,120381.32,80,,120381.32,percent of total billed charges,,7216,,,7216,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,105333.66,70,,105333.66,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1870.75,,,1870.75,Other,New York Medicaid APG methodology,1870.75,,,1870.75,Other,100% New York Medicaid APG,1870.75,,,1870.75,Other,100% New York Medicaid APG,1870.75,,,1870.75,Other,100% New York Medicaid APG,4209.2,,,4209.2,Other,225% New York Medicaid APG,2862.25,,,2862.25,Other,153% New York Medicaid APG,4209.2,,,4209.2,Other,225% New York Medicaid APG,2619.06,,,2619.06,Other,140% New York Medicaid APG,4209.2,,,4209.2,Other,225% New York Medicaid APG,4863.96,,,4863.96,Other,260% New York Medicaid APG,6061.24,,,6061.24,Other,324% New York Medicaid APG,4022.12,,,4022.12,Other,215% New York Medicaid APG,4022.12,,,4022.12,Other,215% New York Medicaid APG,2338.44,,,2338.44,Other,125% New York Medicaid APG,1870.75,120381.32,
Repair forearm tendon/muscle,25265,CPT,,,,,,,,both,,,68082.75,50381.24,74,,50381.24,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30637.24,45,,30637.24,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33700.96,49.5,,33700.96,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3479.6,,,3479.6,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,47657.93,70,,47657.93,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1870.75,,,1870.75,Other,New York Medicaid APG methodology,1870.75,,,1870.75,Other,100% New York Medicaid APG,1870.75,,,1870.75,Other,100% New York Medicaid APG,1870.75,,,1870.75,Other,100% New York Medicaid APG,4209.2,,,4209.2,Other,225% New York Medicaid APG,2862.25,,,2862.25,Other,153% New York Medicaid APG,4209.2,,,4209.2,Other,225% New York Medicaid APG,2619.06,,,2619.06,Other,140% New York Medicaid APG,4209.2,,,4209.2,Other,225% New York Medicaid APG,4863.96,,,4863.96,Other,260% New York Medicaid APG,6061.24,,,6061.24,Other,324% New York Medicaid APG,4022.12,,,4022.12,Other,215% New York Medicaid APG,4022.12,,,4022.12,Other,215% New York Medicaid APG,2338.44,,,2338.44,Other,125% New York Medicaid APG,1870.75,50381.24,
Repair forearm tendon/muscle,25270,CPT,,,,,,,,both,,,36049.16,26676.38,74,,26676.38,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,16222.12,45,,16222.12,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,17844.33,49.5,,17844.33,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3479.6,,,3479.6,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,25234.41,70,,25234.41,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1870.75,,,1870.75,Other,New York Medicaid APG methodology,1870.75,,,1870.75,Other,100% New York Medicaid APG,1870.75,,,1870.75,Other,100% New York Medicaid APG,1870.75,,,1870.75,Other,100% New York Medicaid APG,4209.2,,,4209.2,Other,225% New York Medicaid APG,2862.25,,,2862.25,Other,153% New York Medicaid APG,4209.2,,,4209.2,Other,225% New York Medicaid APG,2619.06,,,2619.06,Other,140% New York Medicaid APG,4209.2,,,4209.2,Other,225% New York Medicaid APG,4863.96,,,4863.96,Other,260% New York Medicaid APG,6061.24,,,6061.24,Other,324% New York Medicaid APG,4022.12,,,4022.12,Other,215% New York Medicaid APG,4022.12,,,4022.12,Other,215% New York Medicaid APG,2338.44,,,2338.44,Other,125% New York Medicaid APG,1870.75,26676.38,
Repair forearm tendon/muscle,25272,CPT,,,,,,,,both,,,68082.75,50381.24,74,,50381.24,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30637.24,45,,30637.24,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33700.96,49.5,,33700.96,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3479.6,,,3479.6,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,47657.93,70,,47657.93,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1870.75,,,1870.75,Other,New York Medicaid APG methodology,1870.75,,,1870.75,Other,100% New York Medicaid APG,1870.75,,,1870.75,Other,100% New York Medicaid APG,1870.75,,,1870.75,Other,100% New York Medicaid APG,4209.2,,,4209.2,Other,225% New York Medicaid APG,2862.25,,,2862.25,Other,153% New York Medicaid APG,4209.2,,,4209.2,Other,225% New York Medicaid APG,2619.06,,,2619.06,Other,140% New York Medicaid APG,4209.2,,,4209.2,Other,225% New York Medicaid APG,4863.96,,,4863.96,Other,260% New York Medicaid APG,6061.24,,,6061.24,Other,324% New York Medicaid APG,4022.12,,,4022.12,Other,215% New York Medicaid APG,4022.12,,,4022.12,Other,215% New York Medicaid APG,2338.44,,,2338.44,Other,125% New York Medicaid APG,1870.75,50381.24,
Repair forearm tendon/muscle,25274,CPT,,,,,,,,both,,,68082.75,50381.24,74,,50381.24,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30637.24,45,,30637.24,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33700.96,49.5,,33700.96,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3479.6,,,3479.6,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,47657.93,70,,47657.93,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1870.75,,,1870.75,Other,New York Medicaid APG methodology,1870.75,,,1870.75,Other,100% New York Medicaid APG,1870.75,,,1870.75,Other,100% New York Medicaid APG,1870.75,,,1870.75,Other,100% New York Medicaid APG,4209.2,,,4209.2,Other,225% New York Medicaid APG,2862.25,,,2862.25,Other,153% New York Medicaid APG,4209.2,,,4209.2,Other,225% New York Medicaid APG,2619.06,,,2619.06,Other,140% New York Medicaid APG,4209.2,,,4209.2,Other,225% New York Medicaid APG,4863.96,,,4863.96,Other,260% New York Medicaid APG,6061.24,,,6061.24,Other,324% New York Medicaid APG,4022.12,,,4022.12,Other,215% New York Medicaid APG,4022.12,,,4022.12,Other,215% New York Medicaid APG,2338.44,,,2338.44,Other,125% New York Medicaid APG,1870.75,50381.24,
Repair forearm tendon sheath,25275,CPT,,,,,,,,both,,,68082.75,50381.24,74,,50381.24,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30637.24,45,,30637.24,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33700.96,49.5,,33700.96,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3479.6,,,3479.6,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,47657.93,70,,47657.93,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1870.75,,,1870.75,Other,New York Medicaid APG methodology,1870.75,,,1870.75,Other,100% New York Medicaid APG,1870.75,,,1870.75,Other,100% New York Medicaid APG,1870.75,,,1870.75,Other,100% New York Medicaid APG,4209.2,,,4209.2,Other,225% New York Medicaid APG,2862.25,,,2862.25,Other,153% New York Medicaid APG,4209.2,,,4209.2,Other,225% New York Medicaid APG,2619.06,,,2619.06,Other,140% New York Medicaid APG,4209.2,,,4209.2,Other,225% New York Medicaid APG,4863.96,,,4863.96,Other,260% New York Medicaid APG,6061.24,,,6061.24,Other,324% New York Medicaid APG,4022.12,,,4022.12,Other,215% New York Medicaid APG,4022.12,,,4022.12,Other,215% New York Medicaid APG,2338.44,,,2338.44,Other,125% New York Medicaid APG,1870.75,50381.24,
Revise wrist/forearm tendon,25280,CPT,,,,,,,,both,,,33503.24,24792.4,74,,24792.4,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15076.46,45,,15076.46,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,16584.1,49.5,,16584.1,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3479.6,,,3479.6,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,23452.27,70,,23452.27,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1870.75,,,1870.75,Other,New York Medicaid APG methodology,1870.75,,,1870.75,Other,100% New York Medicaid APG,1870.75,,,1870.75,Other,100% New York Medicaid APG,1870.75,,,1870.75,Other,100% New York Medicaid APG,4209.2,,,4209.2,Other,225% New York Medicaid APG,2862.25,,,2862.25,Other,153% New York Medicaid APG,4209.2,,,4209.2,Other,225% New York Medicaid APG,2619.06,,,2619.06,Other,140% New York Medicaid APG,4209.2,,,4209.2,Other,225% New York Medicaid APG,4863.96,,,4863.96,Other,260% New York Medicaid APG,6061.24,,,6061.24,Other,324% New York Medicaid APG,4022.12,,,4022.12,Other,215% New York Medicaid APG,4022.12,,,4022.12,Other,215% New York Medicaid APG,2338.44,,,2338.44,Other,125% New York Medicaid APG,1870.75,24792.4,
Incise wrist/forearm tendon,25290,CPT,,,,,,,,both,,,68082.75,50381.24,74,,50381.24,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30637.24,45,,30637.24,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33700.96,49.5,,33700.96,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3479.6,,,3479.6,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,47657.93,70,,47657.93,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1870.75,,,1870.75,Other,New York Medicaid APG methodology,1870.75,,,1870.75,Other,100% New York Medicaid APG,1870.75,,,1870.75,Other,100% New York Medicaid APG,1870.75,,,1870.75,Other,100% New York Medicaid APG,4209.2,,,4209.2,Other,225% New York Medicaid APG,2862.25,,,2862.25,Other,153% New York Medicaid APG,4209.2,,,4209.2,Other,225% New York Medicaid APG,2619.06,,,2619.06,Other,140% New York Medicaid APG,4209.2,,,4209.2,Other,225% New York Medicaid APG,4863.96,,,4863.96,Other,260% New York Medicaid APG,6061.24,,,6061.24,Other,324% New York Medicaid APG,4022.12,,,4022.12,Other,215% New York Medicaid APG,4022.12,,,4022.12,Other,215% New York Medicaid APG,2338.44,,,2338.44,Other,125% New York Medicaid APG,1870.75,50381.24,
Release wrist/forearm tendon,25295,CPT,,,,,,,,both,,,37971.28,28098.75,74,,28098.75,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,17087.08,45,,17087.08,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,18795.78,49.5,,18795.78,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3479.6,,,3479.6,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,26579.9,70,,26579.9,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1870.75,,,1870.75,Other,New York Medicaid APG methodology,1870.75,,,1870.75,Other,100% New York Medicaid APG,1870.75,,,1870.75,Other,100% New York Medicaid APG,1870.75,,,1870.75,Other,100% New York Medicaid APG,4209.2,,,4209.2,Other,225% New York Medicaid APG,2862.25,,,2862.25,Other,153% New York Medicaid APG,4209.2,,,4209.2,Other,225% New York Medicaid APG,2619.06,,,2619.06,Other,140% New York Medicaid APG,4209.2,,,4209.2,Other,225% New York Medicaid APG,4863.96,,,4863.96,Other,260% New York Medicaid APG,6061.24,,,6061.24,Other,324% New York Medicaid APG,4022.12,,,4022.12,Other,215% New York Medicaid APG,4022.12,,,4022.12,Other,215% New York Medicaid APG,2338.44,,,2338.44,Other,125% New York Medicaid APG,1870.75,28098.75,
Fusion of tendons at wrist,25300,CPT,,,,,,,,both,,,68082.75,50381.24,74,,50381.24,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30637.24,45,,30637.24,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33700.96,49.5,,33700.96,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3937.21,,,3937.21,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,47657.93,70,,47657.93,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,2116.78,,,2116.78,Other,New York Medicaid APG methodology,2116.78,,,2116.78,Other,100% New York Medicaid APG,2116.78,,,2116.78,Other,100% New York Medicaid APG,2116.78,,,2116.78,Other,100% New York Medicaid APG,4762.75,,,4762.75,Other,225% New York Medicaid APG,3238.67,,,3238.67,Other,153% New York Medicaid APG,4762.75,,,4762.75,Other,225% New York Medicaid APG,2963.49,,,2963.49,Other,140% New York Medicaid APG,4762.75,,,4762.75,Other,225% New York Medicaid APG,5503.62,,,5503.62,Other,260% New York Medicaid APG,6858.36,,,6858.36,Other,324% New York Medicaid APG,4551.07,,,4551.07,Other,215% New York Medicaid APG,4551.07,,,4551.07,Other,215% New York Medicaid APG,2645.97,,,2645.97,Other,125% New York Medicaid APG,2116.78,50381.24,
Fusion of tendons at wrist,25301,CPT,,,,,,,,both,,,68082.75,50381.24,74,,50381.24,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30637.24,45,,30637.24,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33700.96,49.5,,33700.96,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3479.6,,,3479.6,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,47657.93,70,,47657.93,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1870.75,,,1870.75,Other,New York Medicaid APG methodology,1870.75,,,1870.75,Other,100% New York Medicaid APG,1870.75,,,1870.75,Other,100% New York Medicaid APG,1870.75,,,1870.75,Other,100% New York Medicaid APG,4209.2,,,4209.2,Other,225% New York Medicaid APG,2862.25,,,2862.25,Other,153% New York Medicaid APG,4209.2,,,4209.2,Other,225% New York Medicaid APG,2619.06,,,2619.06,Other,140% New York Medicaid APG,4209.2,,,4209.2,Other,225% New York Medicaid APG,4863.96,,,4863.96,Other,260% New York Medicaid APG,6061.24,,,6061.24,Other,324% New York Medicaid APG,4022.12,,,4022.12,Other,215% New York Medicaid APG,4022.12,,,4022.12,Other,215% New York Medicaid APG,2338.44,,,2338.44,Other,125% New York Medicaid APG,1870.75,50381.24,
Transplant forearm tendon,25310,CPT,,,,,,,,both,,,33536.25,24816.83,74,,24816.83,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15091.31,45,,15091.31,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,16600.44,49.5,,16600.44,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3479.6,,,3479.6,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,23475.38,70,,23475.38,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1870.75,,,1870.75,Other,New York Medicaid APG methodology,1870.75,,,1870.75,Other,100% New York Medicaid APG,1870.75,,,1870.75,Other,100% New York Medicaid APG,1870.75,,,1870.75,Other,100% New York Medicaid APG,4209.2,,,4209.2,Other,225% New York Medicaid APG,2862.25,,,2862.25,Other,153% New York Medicaid APG,4209.2,,,4209.2,Other,225% New York Medicaid APG,2619.06,,,2619.06,Other,140% New York Medicaid APG,4209.2,,,4209.2,Other,225% New York Medicaid APG,4863.96,,,4863.96,Other,260% New York Medicaid APG,6061.24,,,6061.24,Other,324% New York Medicaid APG,4022.12,,,4022.12,Other,215% New York Medicaid APG,4022.12,,,4022.12,Other,215% New York Medicaid APG,2338.44,,,2338.44,Other,125% New York Medicaid APG,1870.75,24816.83,
Transplant forearm tendon,25312,CPT,,,,,,,,both,,,68082.75,50381.24,74,,50381.24,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30637.24,45,,30637.24,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33700.96,49.5,,33700.96,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3479.6,,,3479.6,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,47657.93,70,,47657.93,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,1870.75,,,1870.75,Other,New York Medicaid APG methodology,1870.75,,,1870.75,Other,100% New York Medicaid APG,1870.75,,,1870.75,Other,100% New York Medicaid APG,1870.75,,,1870.75,Other,100% New York Medicaid APG,4209.2,,,4209.2,Other,225% New York Medicaid APG,2862.25,,,2862.25,Other,153% New York Medicaid APG,4209.2,,,4209.2,Other,225% New York Medicaid APG,2619.06,,,2619.06,Other,140% New York Medicaid APG,4209.2,,,4209.2,Other,225% New York Medicaid APG,4863.96,,,4863.96,Other,260% New York Medicaid APG,6061.24,,,6061.24,Other,324% New York Medicaid APG,4022.12,,,4022.12,Other,215% New York Medicaid APG,4022.12,,,4022.12,Other,215% New York Medicaid APG,2338.44,,,2338.44,Other,125% New York Medicaid APG,1870.75,50381.24,
Revise palsy hand tendon(s),25315,CPT,,,,,,,,both,,,150476.65,111352.72,74,,111352.72,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,67714.49,45,,67714.49,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,74485.94,49.5,,74485.94,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3654.9,,,3654.9,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,105333.66,70,,105333.66,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1965,,,1965,Other,New York Medicaid APG methodology,1965,,,1965,Other,100% New York Medicaid APG,1965,,,1965,Other,100% New York Medicaid APG,1965,,,1965,Other,100% New York Medicaid APG,4421.25,,,4421.25,Other,225% New York Medicaid APG,3006.45,,,3006.45,Other,153% New York Medicaid APG,4421.25,,,4421.25,Other,225% New York Medicaid APG,2751,,,2751,Other,140% New York Medicaid APG,4421.25,,,4421.25,Other,225% New York Medicaid APG,5109,,,5109,Other,260% New York Medicaid APG,6366.6,,,6366.6,Other,324% New York Medicaid APG,4224.75,,,4224.75,Other,215% New York Medicaid APG,4224.75,,,4224.75,Other,215% New York Medicaid APG,2456.25,,,2456.25,Other,125% New York Medicaid APG,1965,111352.72,
Revise palsy hand tendon(s),25316,CPT,,,,,,,,both,,,150476.65,111352.72,74,,111352.72,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,67714.49,45,,67714.49,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,74485.94,49.5,,74485.94,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3654.9,,,3654.9,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,105333.66,70,,105333.66,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,1965,,,1965,Other,New York Medicaid APG methodology,1965,,,1965,Other,100% New York Medicaid APG,1965,,,1965,Other,100% New York Medicaid APG,1965,,,1965,Other,100% New York Medicaid APG,4421.25,,,4421.25,Other,225% New York Medicaid APG,3006.45,,,3006.45,Other,153% New York Medicaid APG,4421.25,,,4421.25,Other,225% New York Medicaid APG,2751,,,2751,Other,140% New York Medicaid APG,4421.25,,,4421.25,Other,225% New York Medicaid APG,5109,,,5109,Other,260% New York Medicaid APG,6366.6,,,6366.6,Other,324% New York Medicaid APG,4224.75,,,4224.75,Other,215% New York Medicaid APG,4224.75,,,4224.75,Other,215% New York Medicaid APG,2456.25,,,2456.25,Other,125% New York Medicaid APG,1965,111352.72,
Repair/revise wrist joint,25320,CPT,,,,,,,,both,,,60861.39,45037.43,74,,45037.43,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,27387.63,45,,27387.63,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,30126.39,49.5,,30126.39,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3937.21,,,3937.21,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,42602.97,70,,42602.97,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,2116.78,,,2116.78,Other,New York Medicaid APG methodology,2116.78,,,2116.78,Other,100% New York Medicaid APG,2116.78,,,2116.78,Other,100% New York Medicaid APG,2116.78,,,2116.78,Other,100% New York Medicaid APG,4762.75,,,4762.75,Other,225% New York Medicaid APG,3238.67,,,3238.67,Other,153% New York Medicaid APG,4762.75,,,4762.75,Other,225% New York Medicaid APG,2963.49,,,2963.49,Other,140% New York Medicaid APG,4762.75,,,4762.75,Other,225% New York Medicaid APG,5503.62,,,5503.62,Other,260% New York Medicaid APG,6858.36,,,6858.36,Other,324% New York Medicaid APG,4551.07,,,4551.07,Other,215% New York Medicaid APG,4551.07,,,4551.07,Other,215% New York Medicaid APG,2645.97,,,2645.97,Other,125% New York Medicaid APG,2116.78,45037.43,
Revise wrist joint,25332,CPT,,,,,,,,both,,,68082.75,50381.24,74,,50381.24,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30637.24,45,,30637.24,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33700.96,49.5,,33700.96,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5218.57,,,5218.57,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,47657.93,70,,47657.93,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,2805.68,,,2805.68,Other,New York Medicaid APG methodology,2805.68,,,2805.68,Other,100% New York Medicaid APG,2805.68,,,2805.68,Other,100% New York Medicaid APG,2805.68,,,2805.68,Other,100% New York Medicaid APG,6312.79,,,6312.79,Other,225% New York Medicaid APG,4292.7,,,4292.7,Other,153% New York Medicaid APG,6312.79,,,6312.79,Other,225% New York Medicaid APG,3927.96,,,3927.96,Other,140% New York Medicaid APG,6312.79,,,6312.79,Other,225% New York Medicaid APG,7294.78,,,7294.78,Other,260% New York Medicaid APG,9090.42,,,9090.42,Other,324% New York Medicaid APG,6032.22,,,6032.22,Other,215% New York Medicaid APG,6032.22,,,6032.22,Other,215% New York Medicaid APG,3507.11,,,3507.11,Other,125% New York Medicaid APG,2805.68,50381.24,
Realignment of hand,25335,CPT,,,,,,,,both,,,68082.75,50381.24,74,,50381.24,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30637.24,45,,30637.24,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33700.96,49.5,,33700.96,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3479.6,,,3479.6,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,47657.93,70,,47657.93,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,1870.75,,,1870.75,Other,New York Medicaid APG methodology,1870.75,,,1870.75,Other,100% New York Medicaid APG,1870.75,,,1870.75,Other,100% New York Medicaid APG,1870.75,,,1870.75,Other,100% New York Medicaid APG,4209.2,,,4209.2,Other,225% New York Medicaid APG,2862.25,,,2862.25,Other,153% New York Medicaid APG,4209.2,,,4209.2,Other,225% New York Medicaid APG,2619.06,,,2619.06,Other,140% New York Medicaid APG,4209.2,,,4209.2,Other,225% New York Medicaid APG,4863.96,,,4863.96,Other,260% New York Medicaid APG,6061.24,,,6061.24,Other,324% New York Medicaid APG,4022.12,,,4022.12,Other,215% New York Medicaid APG,4022.12,,,4022.12,Other,215% New York Medicaid APG,2338.44,,,2338.44,Other,125% New York Medicaid APG,1870.75,50381.24,
Reconstruct ulna/radioulnar,25337,CPT,,,,,,,,both,,,150476.65,111352.72,74,,111352.72,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,67714.49,45,,67714.49,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,74485.94,49.5,,74485.94,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3937.21,,,3937.21,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,105333.66,70,,105333.66,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,2116.78,,,2116.78,Other,New York Medicaid APG methodology,2116.78,,,2116.78,Other,100% New York Medicaid APG,2116.78,,,2116.78,Other,100% New York Medicaid APG,2116.78,,,2116.78,Other,100% New York Medicaid APG,4762.75,,,4762.75,Other,225% New York Medicaid APG,3238.67,,,3238.67,Other,153% New York Medicaid APG,4762.75,,,4762.75,Other,225% New York Medicaid APG,2963.49,,,2963.49,Other,140% New York Medicaid APG,4762.75,,,4762.75,Other,225% New York Medicaid APG,5503.62,,,5503.62,Other,260% New York Medicaid APG,6858.36,,,6858.36,Other,324% New York Medicaid APG,4551.07,,,4551.07,Other,215% New York Medicaid APG,4551.07,,,4551.07,Other,215% New York Medicaid APG,2645.97,,,2645.97,Other,125% New York Medicaid APG,2116.78,111352.72,
Revision of radius,25350,CPT,,,,,,,,both,,,67938.48,50274.48,74,,50274.48,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30572.32,45,,30572.32,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,33629.55,49.5,,33629.55,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3937.21,,,3937.21,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,47556.94,70,,47556.94,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,2116.78,,,2116.78,Other,New York Medicaid APG methodology,2116.78,,,2116.78,Other,100% New York Medicaid APG,2116.78,,,2116.78,Other,100% New York Medicaid APG,2116.78,,,2116.78,Other,100% New York Medicaid APG,4762.75,,,4762.75,Other,225% New York Medicaid APG,3238.67,,,3238.67,Other,153% New York Medicaid APG,4762.75,,,4762.75,Other,225% New York Medicaid APG,2963.49,,,2963.49,Other,140% New York Medicaid APG,4762.75,,,4762.75,Other,225% New York Medicaid APG,5503.62,,,5503.62,Other,260% New York Medicaid APG,6858.36,,,6858.36,Other,324% New York Medicaid APG,4551.07,,,4551.07,Other,215% New York Medicaid APG,4551.07,,,4551.07,Other,215% New York Medicaid APG,2645.97,,,2645.97,Other,125% New York Medicaid APG,2116.78,50274.48,
Revision of radius,25355,CPT,,,,,,,,both,,,68082.75,50381.24,74,,50381.24,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30637.24,45,,30637.24,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33700.96,49.5,,33700.96,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3479.6,,,3479.6,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,47657.93,70,,47657.93,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,1870.75,,,1870.75,Other,New York Medicaid APG methodology,1870.75,,,1870.75,Other,100% New York Medicaid APG,1870.75,,,1870.75,Other,100% New York Medicaid APG,1870.75,,,1870.75,Other,100% New York Medicaid APG,4209.2,,,4209.2,Other,225% New York Medicaid APG,2862.25,,,2862.25,Other,153% New York Medicaid APG,4209.2,,,4209.2,Other,225% New York Medicaid APG,2619.06,,,2619.06,Other,140% New York Medicaid APG,4209.2,,,4209.2,Other,225% New York Medicaid APG,4863.96,,,4863.96,Other,260% New York Medicaid APG,6061.24,,,6061.24,Other,324% New York Medicaid APG,4022.12,,,4022.12,Other,215% New York Medicaid APG,4022.12,,,4022.12,Other,215% New York Medicaid APG,2338.44,,,2338.44,Other,125% New York Medicaid APG,1870.75,50381.24,
Revision of ulna,25360,CPT,,,,,,,,both,,,150476.65,111352.72,74,,111352.72,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,67714.49,45,,67714.49,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,74485.94,49.5,,74485.94,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3937.21,,,3937.21,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,105333.66,70,,105333.66,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,2116.78,,,2116.78,Other,New York Medicaid APG methodology,2116.78,,,2116.78,Other,100% New York Medicaid APG,2116.78,,,2116.78,Other,100% New York Medicaid APG,2116.78,,,2116.78,Other,100% New York Medicaid APG,4762.75,,,4762.75,Other,225% New York Medicaid APG,3238.67,,,3238.67,Other,153% New York Medicaid APG,4762.75,,,4762.75,Other,225% New York Medicaid APG,2963.49,,,2963.49,Other,140% New York Medicaid APG,4762.75,,,4762.75,Other,225% New York Medicaid APG,5503.62,,,5503.62,Other,260% New York Medicaid APG,6858.36,,,6858.36,Other,324% New York Medicaid APG,4551.07,,,4551.07,Other,215% New York Medicaid APG,4551.07,,,4551.07,Other,215% New York Medicaid APG,2645.97,,,2645.97,Other,125% New York Medicaid APG,2116.78,111352.72,
Revise radius & ulna,25365,CPT,,,,,,,,both,,,276827.87,204852.62,74,,204852.62,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,124572.54,45,,124572.54,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,137029.8,49.5,,137029.8,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3937.21,,,3937.21,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,193779.51,70,,193779.51,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,2116.78,,,2116.78,Other,New York Medicaid APG methodology,2116.78,,,2116.78,Other,100% New York Medicaid APG,2116.78,,,2116.78,Other,100% New York Medicaid APG,2116.78,,,2116.78,Other,100% New York Medicaid APG,4762.75,,,4762.75,Other,225% New York Medicaid APG,3238.67,,,3238.67,Other,153% New York Medicaid APG,4762.75,,,4762.75,Other,225% New York Medicaid APG,2963.49,,,2963.49,Other,140% New York Medicaid APG,4762.75,,,4762.75,Other,225% New York Medicaid APG,5503.62,,,5503.62,Other,260% New York Medicaid APG,6858.36,,,6858.36,Other,324% New York Medicaid APG,4551.07,,,4551.07,Other,215% New York Medicaid APG,4551.07,,,4551.07,Other,215% New York Medicaid APG,2645.97,,,2645.97,Other,125% New York Medicaid APG,2116.78,204852.62,
Revise radius or ulna,25370,CPT,,,,,,,,both,,,68082.75,50381.24,74,,50381.24,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30637.24,45,,30637.24,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33700.96,49.5,,33700.96,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3479.6,,,3479.6,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,47657.93,70,,47657.93,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,1870.75,,,1870.75,Other,New York Medicaid APG methodology,1870.75,,,1870.75,Other,100% New York Medicaid APG,1870.75,,,1870.75,Other,100% New York Medicaid APG,1870.75,,,1870.75,Other,100% New York Medicaid APG,4209.2,,,4209.2,Other,225% New York Medicaid APG,2862.25,,,2862.25,Other,153% New York Medicaid APG,4209.2,,,4209.2,Other,225% New York Medicaid APG,2619.06,,,2619.06,Other,140% New York Medicaid APG,4209.2,,,4209.2,Other,225% New York Medicaid APG,4863.96,,,4863.96,Other,260% New York Medicaid APG,6061.24,,,6061.24,Other,324% New York Medicaid APG,4022.12,,,4022.12,Other,215% New York Medicaid APG,4022.12,,,4022.12,Other,215% New York Medicaid APG,2338.44,,,2338.44,Other,125% New York Medicaid APG,1870.75,50381.24,
Revise radius & ulna,25375,CPT,,,,,,,,both,,,68082.75,50381.24,74,,50381.24,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30637.24,45,,30637.24,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33700.96,49.5,,33700.96,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3479.6,,,3479.6,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,47657.93,70,,47657.93,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,1870.75,,,1870.75,Other,New York Medicaid APG methodology,1870.75,,,1870.75,Other,100% New York Medicaid APG,1870.75,,,1870.75,Other,100% New York Medicaid APG,1870.75,,,1870.75,Other,100% New York Medicaid APG,4209.2,,,4209.2,Other,225% New York Medicaid APG,2862.25,,,2862.25,Other,153% New York Medicaid APG,4209.2,,,4209.2,Other,225% New York Medicaid APG,2619.06,,,2619.06,Other,140% New York Medicaid APG,4209.2,,,4209.2,Other,225% New York Medicaid APG,4863.96,,,4863.96,Other,260% New York Medicaid APG,6061.24,,,6061.24,Other,324% New York Medicaid APG,4022.12,,,4022.12,Other,215% New York Medicaid APG,4022.12,,,4022.12,Other,215% New York Medicaid APG,2338.44,,,2338.44,Other,125% New York Medicaid APG,1870.75,50381.24,
Shorten radius or ulna,25390,CPT,,,,,,,,both,,,79263.94,58655.32,74,,58655.32,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,35668.77,45,,35668.77,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,39235.65,49.5,,39235.65,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3937.21,,,3937.21,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,55484.76,70,,55484.76,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,2116.78,,,2116.78,Other,New York Medicaid APG methodology,2116.78,,,2116.78,Other,100% New York Medicaid APG,2116.78,,,2116.78,Other,100% New York Medicaid APG,2116.78,,,2116.78,Other,100% New York Medicaid APG,4762.75,,,4762.75,Other,225% New York Medicaid APG,3238.67,,,3238.67,Other,153% New York Medicaid APG,4762.75,,,4762.75,Other,225% New York Medicaid APG,2963.49,,,2963.49,Other,140% New York Medicaid APG,4762.75,,,4762.75,Other,225% New York Medicaid APG,5503.62,,,5503.62,Other,260% New York Medicaid APG,6858.36,,,6858.36,Other,324% New York Medicaid APG,4551.07,,,4551.07,Other,215% New York Medicaid APG,4551.07,,,4551.07,Other,215% New York Medicaid APG,2645.97,,,2645.97,Other,125% New York Medicaid APG,2116.78,58655.32,
Lengthen radius or ulna,25391,CPT,,,,,,,,both,,,56622.67,41900.78,74,,41900.78,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,25480.2,45,,25480.2,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,28028.22,49.5,,28028.22,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3937.21,,,3937.21,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,39635.87,70,,39635.87,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,2116.78,,,2116.78,Other,New York Medicaid APG methodology,2116.78,,,2116.78,Other,100% New York Medicaid APG,2116.78,,,2116.78,Other,100% New York Medicaid APG,2116.78,,,2116.78,Other,100% New York Medicaid APG,4762.75,,,4762.75,Other,225% New York Medicaid APG,3238.67,,,3238.67,Other,153% New York Medicaid APG,4762.75,,,4762.75,Other,225% New York Medicaid APG,2963.49,,,2963.49,Other,140% New York Medicaid APG,4762.75,,,4762.75,Other,225% New York Medicaid APG,5503.62,,,5503.62,Other,260% New York Medicaid APG,6858.36,,,6858.36,Other,324% New York Medicaid APG,4551.07,,,4551.07,Other,215% New York Medicaid APG,4551.07,,,4551.07,Other,215% New York Medicaid APG,2645.97,,,2645.97,Other,125% New York Medicaid APG,2116.78,41900.78,
Shorten radius & ulna,25392,CPT,,,,,,,,both,,,150476.65,111352.72,74,,111352.72,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,67714.49,45,,67714.49,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,74485.94,49.5,,74485.94,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3937.21,,,3937.21,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,105333.66,70,,105333.66,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,2116.78,,,2116.78,Other,New York Medicaid APG methodology,2116.78,,,2116.78,Other,100% New York Medicaid APG,2116.78,,,2116.78,Other,100% New York Medicaid APG,2116.78,,,2116.78,Other,100% New York Medicaid APG,4762.75,,,4762.75,Other,225% New York Medicaid APG,3238.67,,,3238.67,Other,153% New York Medicaid APG,4762.75,,,4762.75,Other,225% New York Medicaid APG,2963.49,,,2963.49,Other,140% New York Medicaid APG,4762.75,,,4762.75,Other,225% New York Medicaid APG,5503.62,,,5503.62,Other,260% New York Medicaid APG,6858.36,,,6858.36,Other,324% New York Medicaid APG,4551.07,,,4551.07,Other,215% New York Medicaid APG,4551.07,,,4551.07,Other,215% New York Medicaid APG,2645.97,,,2645.97,Other,125% New York Medicaid APG,2116.78,111352.72,
Lengthen radius & ulna,25393,CPT,,,,,,,,both,,,150476.65,111352.72,74,,111352.72,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,67714.49,45,,67714.49,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,74485.94,49.5,,74485.94,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3937.21,,,3937.21,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,105333.66,70,,105333.66,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,2116.78,,,2116.78,Other,New York Medicaid APG methodology,2116.78,,,2116.78,Other,100% New York Medicaid APG,2116.78,,,2116.78,Other,100% New York Medicaid APG,2116.78,,,2116.78,Other,100% New York Medicaid APG,4762.75,,,4762.75,Other,225% New York Medicaid APG,3238.67,,,3238.67,Other,153% New York Medicaid APG,4762.75,,,4762.75,Other,225% New York Medicaid APG,2963.49,,,2963.49,Other,140% New York Medicaid APG,4762.75,,,4762.75,Other,225% New York Medicaid APG,5503.62,,,5503.62,Other,260% New York Medicaid APG,6858.36,,,6858.36,Other,324% New York Medicaid APG,4551.07,,,4551.07,Other,215% New York Medicaid APG,4551.07,,,4551.07,Other,215% New York Medicaid APG,2645.97,,,2645.97,Other,125% New York Medicaid APG,2116.78,111352.72,
Repair carpal bone shorten,25394,CPT,,,,,,,,both,,,68082.75,50381.24,74,,50381.24,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30637.24,45,,30637.24,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33700.96,49.5,,33700.96,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3654.9,,,3654.9,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,47657.93,70,,47657.93,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,1965,,,1965,Other,New York Medicaid APG methodology,1965,,,1965,Other,100% New York Medicaid APG,1965,,,1965,Other,100% New York Medicaid APG,1965,,,1965,Other,100% New York Medicaid APG,4421.25,,,4421.25,Other,225% New York Medicaid APG,3006.45,,,3006.45,Other,153% New York Medicaid APG,4421.25,,,4421.25,Other,225% New York Medicaid APG,2751,,,2751,Other,140% New York Medicaid APG,4421.25,,,4421.25,Other,225% New York Medicaid APG,5109,,,5109,Other,260% New York Medicaid APG,6366.6,,,6366.6,Other,324% New York Medicaid APG,4224.75,,,4224.75,Other,215% New York Medicaid APG,4224.75,,,4224.75,Other,215% New York Medicaid APG,2456.25,,,2456.25,Other,125% New York Medicaid APG,1965,50381.24,
Repair radius or ulna,25400,CPT,,,,,,,,both,,,68184.32,50456.4,74,,50456.4,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30682.94,45,,30682.94,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,33751.24,49.5,,33751.24,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3937.21,,,3937.21,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,47729.02,70,,47729.02,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,2116.78,,,2116.78,Other,New York Medicaid APG methodology,2116.78,,,2116.78,Other,100% New York Medicaid APG,2116.78,,,2116.78,Other,100% New York Medicaid APG,2116.78,,,2116.78,Other,100% New York Medicaid APG,4762.75,,,4762.75,Other,225% New York Medicaid APG,3238.67,,,3238.67,Other,153% New York Medicaid APG,4762.75,,,4762.75,Other,225% New York Medicaid APG,2963.49,,,2963.49,Other,140% New York Medicaid APG,4762.75,,,4762.75,Other,225% New York Medicaid APG,5503.62,,,5503.62,Other,260% New York Medicaid APG,6858.36,,,6858.36,Other,324% New York Medicaid APG,4551.07,,,4551.07,Other,215% New York Medicaid APG,4551.07,,,4551.07,Other,215% New York Medicaid APG,2645.97,,,2645.97,Other,125% New York Medicaid APG,2116.78,50456.4,
Repair/graft radius or ulna,25405,CPT,,,,,,,,both,,,71753.49,53097.58,74,,53097.58,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,32289.07,45,,32289.07,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,35517.98,49.5,,35517.98,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3937.21,,,3937.21,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,50227.44,70,,50227.44,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,2116.78,,,2116.78,Other,New York Medicaid APG methodology,2116.78,,,2116.78,Other,100% New York Medicaid APG,2116.78,,,2116.78,Other,100% New York Medicaid APG,2116.78,,,2116.78,Other,100% New York Medicaid APG,4762.75,,,4762.75,Other,225% New York Medicaid APG,3238.67,,,3238.67,Other,153% New York Medicaid APG,4762.75,,,4762.75,Other,225% New York Medicaid APG,2963.49,,,2963.49,Other,140% New York Medicaid APG,4762.75,,,4762.75,Other,225% New York Medicaid APG,5503.62,,,5503.62,Other,260% New York Medicaid APG,6858.36,,,6858.36,Other,324% New York Medicaid APG,4551.07,,,4551.07,Other,215% New York Medicaid APG,4551.07,,,4551.07,Other,215% New York Medicaid APG,2645.97,,,2645.97,Other,125% New York Medicaid APG,2116.78,53097.58,
Repair radius & ulna,25415,CPT,,,,,,,,both,,,120422.45,89112.61,74,,89112.61,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,54190.1,45,,54190.1,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,59609.11,49.5,,59609.11,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3937.21,,,3937.21,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,84295.72,70,,84295.72,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,2116.78,,,2116.78,Other,New York Medicaid APG methodology,2116.78,,,2116.78,Other,100% New York Medicaid APG,2116.78,,,2116.78,Other,100% New York Medicaid APG,2116.78,,,2116.78,Other,100% New York Medicaid APG,4762.75,,,4762.75,Other,225% New York Medicaid APG,3238.67,,,3238.67,Other,153% New York Medicaid APG,4762.75,,,4762.75,Other,225% New York Medicaid APG,2963.49,,,2963.49,Other,140% New York Medicaid APG,4762.75,,,4762.75,Other,225% New York Medicaid APG,5503.62,,,5503.62,Other,260% New York Medicaid APG,6858.36,,,6858.36,Other,324% New York Medicaid APG,4551.07,,,4551.07,Other,215% New York Medicaid APG,4551.07,,,4551.07,Other,215% New York Medicaid APG,2645.97,,,2645.97,Other,125% New York Medicaid APG,2116.78,89112.61,
Repair/graft radius & ulna,25420,CPT,,,,,,,,both,,,89164.01,65981.37,74,,65981.37,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,40123.8,45,,40123.8,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,44136.18,49.5,,44136.18,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3937.21,,,3937.21,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,62414.81,70,,62414.81,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,2116.78,,,2116.78,Other,New York Medicaid APG methodology,2116.78,,,2116.78,Other,100% New York Medicaid APG,2116.78,,,2116.78,Other,100% New York Medicaid APG,2116.78,,,2116.78,Other,100% New York Medicaid APG,4762.75,,,4762.75,Other,225% New York Medicaid APG,3238.67,,,3238.67,Other,153% New York Medicaid APG,4762.75,,,4762.75,Other,225% New York Medicaid APG,2963.49,,,2963.49,Other,140% New York Medicaid APG,4762.75,,,4762.75,Other,225% New York Medicaid APG,5503.62,,,5503.62,Other,260% New York Medicaid APG,6858.36,,,6858.36,Other,324% New York Medicaid APG,4551.07,,,4551.07,Other,215% New York Medicaid APG,4551.07,,,4551.07,Other,215% New York Medicaid APG,2645.97,,,2645.97,Other,125% New York Medicaid APG,2116.78,65981.37,
Repair/graft radius or ulna,25425,CPT,,,,,,,,both,,,150476.65,111352.72,74,,111352.72,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,67714.49,45,,67714.49,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,74485.94,49.5,,74485.94,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3937.21,,,3937.21,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,105333.66,70,,105333.66,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,2116.78,,,2116.78,Other,New York Medicaid APG methodology,2116.78,,,2116.78,Other,100% New York Medicaid APG,2116.78,,,2116.78,Other,100% New York Medicaid APG,2116.78,,,2116.78,Other,100% New York Medicaid APG,4762.75,,,4762.75,Other,225% New York Medicaid APG,3238.67,,,3238.67,Other,153% New York Medicaid APG,4762.75,,,4762.75,Other,225% New York Medicaid APG,2963.49,,,2963.49,Other,140% New York Medicaid APG,4762.75,,,4762.75,Other,225% New York Medicaid APG,5503.62,,,5503.62,Other,260% New York Medicaid APG,6858.36,,,6858.36,Other,324% New York Medicaid APG,4551.07,,,4551.07,Other,215% New York Medicaid APG,4551.07,,,4551.07,Other,215% New York Medicaid APG,2645.97,,,2645.97,Other,125% New York Medicaid APG,2116.78,111352.72,
Repair/graft radius & ulna,25426,CPT,,,,,,,,both,,,68082.75,50381.24,74,,50381.24,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30637.24,45,,30637.24,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33700.96,49.5,,33700.96,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3937.21,,,3937.21,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,47657.93,70,,47657.93,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,2116.78,,,2116.78,Other,New York Medicaid APG methodology,2116.78,,,2116.78,Other,100% New York Medicaid APG,2116.78,,,2116.78,Other,100% New York Medicaid APG,2116.78,,,2116.78,Other,100% New York Medicaid APG,4762.75,,,4762.75,Other,225% New York Medicaid APG,3238.67,,,3238.67,Other,153% New York Medicaid APG,4762.75,,,4762.75,Other,225% New York Medicaid APG,2963.49,,,2963.49,Other,140% New York Medicaid APG,4762.75,,,4762.75,Other,225% New York Medicaid APG,5503.62,,,5503.62,Other,260% New York Medicaid APG,6858.36,,,6858.36,Other,324% New York Medicaid APG,4551.07,,,4551.07,Other,215% New York Medicaid APG,4551.07,,,4551.07,Other,215% New York Medicaid APG,2645.97,,,2645.97,Other,125% New York Medicaid APG,2116.78,50381.24,
Vasc graft into carpal bone,25430,CPT,,,,,,,,both,,,68082.75,50381.24,74,,50381.24,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30637.24,45,,30637.24,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33700.96,49.5,,33700.96,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3654.9,,,3654.9,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,47657.93,70,,47657.93,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,1965,,,1965,Other,New York Medicaid APG methodology,1965,,,1965,Other,100% New York Medicaid APG,1965,,,1965,Other,100% New York Medicaid APG,1965,,,1965,Other,100% New York Medicaid APG,4421.25,,,4421.25,Other,225% New York Medicaid APG,3006.45,,,3006.45,Other,153% New York Medicaid APG,4421.25,,,4421.25,Other,225% New York Medicaid APG,2751,,,2751,Other,140% New York Medicaid APG,4421.25,,,4421.25,Other,225% New York Medicaid APG,5109,,,5109,Other,260% New York Medicaid APG,6366.6,,,6366.6,Other,324% New York Medicaid APG,4224.75,,,4224.75,Other,215% New York Medicaid APG,4224.75,,,4224.75,Other,215% New York Medicaid APG,2456.25,,,2456.25,Other,125% New York Medicaid APG,1965,50381.24,
Repair nonunion carpal bone,25431,CPT,,,,,,,,both,,,150476.65,111352.72,74,,111352.72,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,67714.49,45,,67714.49,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,74485.94,49.5,,74485.94,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5092.5,,,5092.5,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,105333.66,70,,105333.66,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,2737.91,,,2737.91,Other,New York Medicaid APG methodology,2737.91,,,2737.91,Other,100% New York Medicaid APG,2737.91,,,2737.91,Other,100% New York Medicaid APG,2737.91,,,2737.91,Other,100% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,4189,,,4189,Other,153% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,3833.07,,,3833.07,Other,140% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,7118.55,,,7118.55,Other,260% New York Medicaid APG,8870.81,,,8870.81,Other,324% New York Medicaid APG,5886.5,,,5886.5,Other,215% New York Medicaid APG,5886.5,,,5886.5,Other,215% New York Medicaid APG,3422.38,,,3422.38,Other,125% New York Medicaid APG,2737.91,111352.72,
Repair/graft wrist bone,25440,CPT,,,,,,,,both,,,150476.65,111352.72,74,,111352.72,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,67714.49,45,,67714.49,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,74485.94,49.5,,74485.94,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3937.21,,,3937.21,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,105333.66,70,,105333.66,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,2116.78,,,2116.78,Other,New York Medicaid APG methodology,2116.78,,,2116.78,Other,100% New York Medicaid APG,2116.78,,,2116.78,Other,100% New York Medicaid APG,2116.78,,,2116.78,Other,100% New York Medicaid APG,4762.75,,,4762.75,Other,225% New York Medicaid APG,3238.67,,,3238.67,Other,153% New York Medicaid APG,4762.75,,,4762.75,Other,225% New York Medicaid APG,2963.49,,,2963.49,Other,140% New York Medicaid APG,4762.75,,,4762.75,Other,225% New York Medicaid APG,5503.62,,,5503.62,Other,260% New York Medicaid APG,6858.36,,,6858.36,Other,324% New York Medicaid APG,4551.07,,,4551.07,Other,215% New York Medicaid APG,4551.07,,,4551.07,Other,215% New York Medicaid APG,2645.97,,,2645.97,Other,125% New York Medicaid APG,2116.78,111352.72,
Reconstruct wrist joint,25441,CPT,,,,,,,,both,,,276827.87,204852.62,74,,204852.62,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,124572.54,45,,124572.54,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,137029.8,49.5,,137029.8,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5965.25,,,5965.25,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9196,,"100% primary, 0% secondary procedures",9196,Other,MagnaCare ASC Grouper,193779.51,70,,193779.51,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6956,,"100% primary, 50% secondary, 25% tertiary procedure",6956,Other,United Healthcare ASC Grouper,6261,,"100% primary, 50% secondary, 25% tertiary procedure",6261,Other,United Healthcare ASC Grouper,6956,,"100% primary, 50% secondary, 25% tertiary procedure",6956,Other,United Healthcare ASC Grouper,5913,,"100% primary, 50% secondary, 25% tertiary procedure",5913,Other,United Healthcare ASC Grouper,3207.13,,,3207.13,Other,New York Medicaid APG methodology,3207.13,,,3207.13,Other,100% New York Medicaid APG,3207.13,,,3207.13,Other,100% New York Medicaid APG,3207.13,,,3207.13,Other,100% New York Medicaid APG,7216.03,,,7216.03,Other,225% New York Medicaid APG,4906.9,,,4906.9,Other,153% New York Medicaid APG,7216.03,,,7216.03,Other,225% New York Medicaid APG,4489.98,,,4489.98,Other,140% New York Medicaid APG,7216.03,,,7216.03,Other,225% New York Medicaid APG,8338.53,,,8338.53,Other,260% New York Medicaid APG,10391.09,,,10391.09,Other,324% New York Medicaid APG,6895.32,,,6895.32,Other,215% New York Medicaid APG,6895.32,,,6895.32,Other,215% New York Medicaid APG,4008.91,,,4008.91,Other,125% New York Medicaid APG,3207.13,204852.62,
Reconstruct wrist joint,25442,CPT,,,,,,,,both,,,391985.94,290069.6,74,,290069.6,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,176393.67,45,,176393.67,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,194033.04,49.5,,194033.04,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5965.25,,,5965.25,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9196,,"100% primary, 0% secondary procedures",9196,Other,MagnaCare ASC Grouper,274390.16,70,,274390.16,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6956,,"100% primary, 50% secondary, 25% tertiary procedure",6956,Other,United Healthcare ASC Grouper,6261,,"100% primary, 50% secondary, 25% tertiary procedure",6261,Other,United Healthcare ASC Grouper,6956,,"100% primary, 50% secondary, 25% tertiary procedure",6956,Other,United Healthcare ASC Grouper,5913,,"100% primary, 50% secondary, 25% tertiary procedure",5913,Other,United Healthcare ASC Grouper,3207.13,,,3207.13,Other,New York Medicaid APG methodology,3207.13,,,3207.13,Other,100% New York Medicaid APG,3207.13,,,3207.13,Other,100% New York Medicaid APG,3207.13,,,3207.13,Other,100% New York Medicaid APG,7216.03,,,7216.03,Other,225% New York Medicaid APG,4906.9,,,4906.9,Other,153% New York Medicaid APG,7216.03,,,7216.03,Other,225% New York Medicaid APG,4489.98,,,4489.98,Other,140% New York Medicaid APG,7216.03,,,7216.03,Other,225% New York Medicaid APG,8338.53,,,8338.53,Other,260% New York Medicaid APG,10391.09,,,10391.09,Other,324% New York Medicaid APG,6895.32,,,6895.32,Other,215% New York Medicaid APG,6895.32,,,6895.32,Other,215% New York Medicaid APG,4008.91,,,4008.91,Other,125% New York Medicaid APG,3207.13,290069.6,
Reconstruct wrist joint,25443,CPT,,,,,,,,both,,,150476.65,111352.72,74,,111352.72,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,67714.49,45,,67714.49,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,74485.94,49.5,,74485.94,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5218.57,,,5218.57,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,105333.66,70,,105333.66,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,2805.68,,,2805.68,Other,New York Medicaid APG methodology,2805.68,,,2805.68,Other,100% New York Medicaid APG,2805.68,,,2805.68,Other,100% New York Medicaid APG,2805.68,,,2805.68,Other,100% New York Medicaid APG,6312.79,,,6312.79,Other,225% New York Medicaid APG,4292.7,,,4292.7,Other,153% New York Medicaid APG,6312.79,,,6312.79,Other,225% New York Medicaid APG,3927.96,,,3927.96,Other,140% New York Medicaid APG,6312.79,,,6312.79,Other,225% New York Medicaid APG,7294.78,,,7294.78,Other,260% New York Medicaid APG,9090.42,,,9090.42,Other,324% New York Medicaid APG,6032.22,,,6032.22,Other,215% New York Medicaid APG,6032.22,,,6032.22,Other,215% New York Medicaid APG,3507.11,,,3507.11,Other,125% New York Medicaid APG,2805.68,111352.72,
Reconstruct wrist joint,25444,CPT,,,,,,,,both,,,276827.87,204852.62,74,,204852.62,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,124572.54,45,,124572.54,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,137029.8,49.5,,137029.8,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5965.25,,,5965.25,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,193779.51,70,,193779.51,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,3207.13,,,3207.13,Other,New York Medicaid APG methodology,3207.13,,,3207.13,Other,100% New York Medicaid APG,3207.13,,,3207.13,Other,100% New York Medicaid APG,3207.13,,,3207.13,Other,100% New York Medicaid APG,7216.03,,,7216.03,Other,225% New York Medicaid APG,4906.9,,,4906.9,Other,153% New York Medicaid APG,7216.03,,,7216.03,Other,225% New York Medicaid APG,4489.98,,,4489.98,Other,140% New York Medicaid APG,7216.03,,,7216.03,Other,225% New York Medicaid APG,8338.53,,,8338.53,Other,260% New York Medicaid APG,10391.09,,,10391.09,Other,324% New York Medicaid APG,6895.32,,,6895.32,Other,215% New York Medicaid APG,6895.32,,,6895.32,Other,215% New York Medicaid APG,4008.91,,,4008.91,Other,125% New York Medicaid APG,3207.13,204852.62,
Reconstruct wrist joint,25445,CPT,,,,,,,,both,,,150476.65,111352.72,74,,111352.72,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,67714.49,45,,67714.49,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,74485.94,49.5,,74485.94,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5218.57,,,5218.57,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,105333.66,70,,105333.66,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,2805.68,,,2805.68,Other,New York Medicaid APG methodology,2805.68,,,2805.68,Other,100% New York Medicaid APG,2805.68,,,2805.68,Other,100% New York Medicaid APG,2805.68,,,2805.68,Other,100% New York Medicaid APG,6312.79,,,6312.79,Other,225% New York Medicaid APG,4292.7,,,4292.7,Other,153% New York Medicaid APG,6312.79,,,6312.79,Other,225% New York Medicaid APG,3927.96,,,3927.96,Other,140% New York Medicaid APG,6312.79,,,6312.79,Other,225% New York Medicaid APG,7294.78,,,7294.78,Other,260% New York Medicaid APG,9090.42,,,9090.42,Other,324% New York Medicaid APG,6032.22,,,6032.22,Other,215% New York Medicaid APG,6032.22,,,6032.22,Other,215% New York Medicaid APG,3507.11,,,3507.11,Other,125% New York Medicaid APG,2805.68,111352.72,
Wrist replacement,25446,CPT,,,,,,,,both,,,391985.94,290069.6,74,,290069.6,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,176393.67,45,,176393.67,percent of total billed charges,Medicare Ratio of cost to charges,5954,,"100% primary, 50% supplemental procedure",5954,Other,Aetna ASC Grouper,5359,,"100% primary, 50% supplemental procedure",5359,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,194033.04,49.5,,194033.04,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5965.25,,,5965.25,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9196,,"100% primary, 0% secondary procedures",9196,Other,MagnaCare ASC Grouper,274390.16,70,,274390.16,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6956,,"100% primary, 50% secondary, 25% tertiary procedure",6956,Other,United Healthcare ASC Grouper,6261,,"100% primary, 50% secondary, 25% tertiary procedure",6261,Other,United Healthcare ASC Grouper,6956,,"100% primary, 50% secondary, 25% tertiary procedure",6956,Other,United Healthcare ASC Grouper,5913,,"100% primary, 50% secondary, 25% tertiary procedure",5913,Other,United Healthcare ASC Grouper,3207.13,,,3207.13,Other,New York Medicaid APG methodology,3207.13,,,3207.13,Other,100% New York Medicaid APG,3207.13,,,3207.13,Other,100% New York Medicaid APG,3207.13,,,3207.13,Other,100% New York Medicaid APG,7216.03,,,7216.03,Other,225% New York Medicaid APG,4906.9,,,4906.9,Other,153% New York Medicaid APG,7216.03,,,7216.03,Other,225% New York Medicaid APG,4489.98,,,4489.98,Other,140% New York Medicaid APG,7216.03,,,7216.03,Other,225% New York Medicaid APG,8338.53,,,8338.53,Other,260% New York Medicaid APG,10391.09,,,10391.09,Other,324% New York Medicaid APG,6895.32,,,6895.32,Other,215% New York Medicaid APG,6895.32,,,6895.32,Other,215% New York Medicaid APG,4008.91,,,4008.91,Other,125% New York Medicaid APG,3207.13,290069.6,
Repair wrist joints,25447,CPT,,,,,,,,both,,,53642.7,39695.6,74,,39695.6,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,24139.22,45,,24139.22,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,26553.14,49.5,,26553.14,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5218.57,,,5218.57,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,37549.89,70,,37549.89,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,2805.68,,,2805.68,Other,New York Medicaid APG methodology,2805.68,,,2805.68,Other,100% New York Medicaid APG,2805.68,,,2805.68,Other,100% New York Medicaid APG,2805.68,,,2805.68,Other,100% New York Medicaid APG,6312.79,,,6312.79,Other,225% New York Medicaid APG,4292.7,,,4292.7,Other,153% New York Medicaid APG,6312.79,,,6312.79,Other,225% New York Medicaid APG,3927.96,,,3927.96,Other,140% New York Medicaid APG,6312.79,,,6312.79,Other,225% New York Medicaid APG,7294.78,,,7294.78,Other,260% New York Medicaid APG,9090.42,,,9090.42,Other,324% New York Medicaid APG,6032.22,,,6032.22,Other,215% New York Medicaid APG,6032.22,,,6032.22,Other,215% New York Medicaid APG,3507.11,,,3507.11,Other,125% New York Medicaid APG,2805.68,39695.6,
Remove wrist joint implant,25449,CPT,,,,,,,,both,,,150476.65,111352.72,74,,111352.72,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,67714.49,45,,67714.49,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,74485.94,49.5,,74485.94,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5218.57,,,5218.57,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,105333.66,70,,105333.66,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,2805.68,,,2805.68,Other,New York Medicaid APG methodology,2805.68,,,2805.68,Other,100% New York Medicaid APG,2805.68,,,2805.68,Other,100% New York Medicaid APG,2805.68,,,2805.68,Other,100% New York Medicaid APG,6312.79,,,6312.79,Other,225% New York Medicaid APG,4292.7,,,4292.7,Other,153% New York Medicaid APG,6312.79,,,6312.79,Other,225% New York Medicaid APG,3927.96,,,3927.96,Other,140% New York Medicaid APG,6312.79,,,6312.79,Other,225% New York Medicaid APG,7294.78,,,7294.78,Other,260% New York Medicaid APG,9090.42,,,9090.42,Other,324% New York Medicaid APG,6032.22,,,6032.22,Other,215% New York Medicaid APG,6032.22,,,6032.22,Other,215% New York Medicaid APG,3507.11,,,3507.11,Other,125% New York Medicaid APG,2805.68,111352.72,
Revision of wrist joint,25450,CPT,,,,,,,,both,,,68082.75,50381.24,74,,50381.24,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30637.24,45,,30637.24,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33700.96,49.5,,33700.96,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3479.6,,,3479.6,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,47657.93,70,,47657.93,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,1870.75,,,1870.75,Other,New York Medicaid APG methodology,1870.75,,,1870.75,Other,100% New York Medicaid APG,1870.75,,,1870.75,Other,100% New York Medicaid APG,1870.75,,,1870.75,Other,100% New York Medicaid APG,4209.2,,,4209.2,Other,225% New York Medicaid APG,2862.25,,,2862.25,Other,153% New York Medicaid APG,4209.2,,,4209.2,Other,225% New York Medicaid APG,2619.06,,,2619.06,Other,140% New York Medicaid APG,4209.2,,,4209.2,Other,225% New York Medicaid APG,4863.96,,,4863.96,Other,260% New York Medicaid APG,6061.24,,,6061.24,Other,324% New York Medicaid APG,4022.12,,,4022.12,Other,215% New York Medicaid APG,4022.12,,,4022.12,Other,215% New York Medicaid APG,2338.44,,,2338.44,Other,125% New York Medicaid APG,1870.75,50381.24,
Revision of wrist joint,25455,CPT,,,,,,,,both,,,68082.75,50381.24,74,,50381.24,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30637.24,45,,30637.24,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33700.96,49.5,,33700.96,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3479.6,,,3479.6,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,47657.93,70,,47657.93,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,1870.75,,,1870.75,Other,New York Medicaid APG methodology,1870.75,,,1870.75,Other,100% New York Medicaid APG,1870.75,,,1870.75,Other,100% New York Medicaid APG,1870.75,,,1870.75,Other,100% New York Medicaid APG,4209.2,,,4209.2,Other,225% New York Medicaid APG,2862.25,,,2862.25,Other,153% New York Medicaid APG,4209.2,,,4209.2,Other,225% New York Medicaid APG,2619.06,,,2619.06,Other,140% New York Medicaid APG,4209.2,,,4209.2,Other,225% New York Medicaid APG,4863.96,,,4863.96,Other,260% New York Medicaid APG,6061.24,,,6061.24,Other,324% New York Medicaid APG,4022.12,,,4022.12,Other,215% New York Medicaid APG,4022.12,,,4022.12,Other,215% New York Medicaid APG,2338.44,,,2338.44,Other,125% New York Medicaid APG,1870.75,50381.24,
Reinforce radius,25490,CPT,,,,,,,,both,,,150476.65,111352.72,74,,111352.72,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,67714.49,45,,67714.49,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,74485.94,49.5,,74485.94,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3937.21,,,3937.21,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,105333.66,70,,105333.66,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,2116.78,,,2116.78,Other,New York Medicaid APG methodology,2116.78,,,2116.78,Other,100% New York Medicaid APG,2116.78,,,2116.78,Other,100% New York Medicaid APG,2116.78,,,2116.78,Other,100% New York Medicaid APG,4762.75,,,4762.75,Other,225% New York Medicaid APG,3238.67,,,3238.67,Other,153% New York Medicaid APG,4762.75,,,4762.75,Other,225% New York Medicaid APG,2963.49,,,2963.49,Other,140% New York Medicaid APG,4762.75,,,4762.75,Other,225% New York Medicaid APG,5503.62,,,5503.62,Other,260% New York Medicaid APG,6858.36,,,6858.36,Other,324% New York Medicaid APG,4551.07,,,4551.07,Other,215% New York Medicaid APG,4551.07,,,4551.07,Other,215% New York Medicaid APG,2645.97,,,2645.97,Other,125% New York Medicaid APG,2116.78,111352.72,
Reinforce ulna,25491,CPT,,,,,,,,both,,,276827.87,204852.62,74,,204852.62,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,124572.54,45,,124572.54,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,137029.8,49.5,,137029.8,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3937.21,,,3937.21,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,193779.51,70,,193779.51,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,2116.78,,,2116.78,Other,New York Medicaid APG methodology,2116.78,,,2116.78,Other,100% New York Medicaid APG,2116.78,,,2116.78,Other,100% New York Medicaid APG,2116.78,,,2116.78,Other,100% New York Medicaid APG,4762.75,,,4762.75,Other,225% New York Medicaid APG,3238.67,,,3238.67,Other,153% New York Medicaid APG,4762.75,,,4762.75,Other,225% New York Medicaid APG,2963.49,,,2963.49,Other,140% New York Medicaid APG,4762.75,,,4762.75,Other,225% New York Medicaid APG,5503.62,,,5503.62,Other,260% New York Medicaid APG,6858.36,,,6858.36,Other,324% New York Medicaid APG,4551.07,,,4551.07,Other,215% New York Medicaid APG,4551.07,,,4551.07,Other,215% New York Medicaid APG,2645.97,,,2645.97,Other,125% New York Medicaid APG,2116.78,204852.62,
Reinforce radius and ulna,25492,CPT,,,,,,,,both,,,68082.75,50381.24,74,,50381.24,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30637.24,45,,30637.24,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33700.96,49.5,,33700.96,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3479.6,,,3479.6,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,47657.93,70,,47657.93,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,1870.75,,,1870.75,Other,New York Medicaid APG methodology,1870.75,,,1870.75,Other,100% New York Medicaid APG,1870.75,,,1870.75,Other,100% New York Medicaid APG,1870.75,,,1870.75,Other,100% New York Medicaid APG,4209.2,,,4209.2,Other,225% New York Medicaid APG,2862.25,,,2862.25,Other,153% New York Medicaid APG,4209.2,,,4209.2,Other,225% New York Medicaid APG,2619.06,,,2619.06,Other,140% New York Medicaid APG,4209.2,,,4209.2,Other,225% New York Medicaid APG,4863.96,,,4863.96,Other,260% New York Medicaid APG,6061.24,,,6061.24,Other,324% New York Medicaid APG,4022.12,,,4022.12,Other,215% New York Medicaid APG,4022.12,,,4022.12,Other,215% New York Medicaid APG,2338.44,,,2338.44,Other,125% New York Medicaid APG,1870.75,50381.24,
Treat fracture of radius,25500,CPT,,,,,,,,both,,,4960.23,3670.57,74,,3670.57,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,2232.1,45,,2232.1,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,2455.31,49.5,,2455.31,percent of total billed charges,110% of Medicare,3372.96,68,,3372.96,percent of total billed charges,,1031.43,,,1031.43,Other,186% of Medicaid,3968.18,80,,3968.18,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,3968.18,80,,3968.18,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,3472.16,70,,3472.16,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,554.53,,,554.53,Other,New York Medicaid APG methodology,554.53,,,554.53,Other,100% New York Medicaid APG,554.53,,,554.53,Other,100% New York Medicaid APG,554.53,,,554.53,Other,100% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,848.43,,,848.43,Other,153% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,776.34,,,776.34,Other,140% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,1441.78,,,1441.78,Other,260% New York Medicaid APG,1796.68,,,1796.68,Other,324% New York Medicaid APG,1192.24,,,1192.24,Other,215% New York Medicaid APG,1192.24,,,1192.24,Other,215% New York Medicaid APG,693.16,,,693.16,Other,125% New York Medicaid APG,554.53,7216,
Treat fracture of radius,25505,CPT,,,,,,,,both,,,33805.49,25016.06,74,,25016.06,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15212.47,45,,15212.47,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,16733.72,49.5,,16733.72,percent of total billed charges,110% of Medicare,22987.73,68,,22987.73,percent of total billed charges,,1031.43,,,1031.43,Other,186% of Medicaid,27044.39,80,,27044.39,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,27044.39,80,,27044.39,percent of total billed charges,,7216,,,7216,Case Rate,,3578,,"100% primary, 0% secondary procedures",3578,Other,MagnaCare ASC Grouper,23663.84,70,,23663.84,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,554.53,,,554.53,Other,New York Medicaid APG methodology,554.53,,,554.53,Other,100% New York Medicaid APG,554.53,,,554.53,Other,100% New York Medicaid APG,554.53,,,554.53,Other,100% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,848.43,,,848.43,Other,153% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,776.34,,,776.34,Other,140% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,1441.78,,,1441.78,Other,260% New York Medicaid APG,1796.68,,,1796.68,Other,324% New York Medicaid APG,1192.24,,,1192.24,Other,215% New York Medicaid APG,1192.24,,,1192.24,Other,215% New York Medicaid APG,693.16,,,693.16,Other,125% New York Medicaid APG,554.53,27044.39,
Treat fracture of radius,25515,CPT,,,,,,,,both,,,85719.93,63432.75,74,,63432.75,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,38573.97,45,,38573.97,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,42431.37,49.5,,42431.37,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5092.5,,,5092.5,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,60003.95,70,,60003.95,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,2737.91,,,2737.91,Other,New York Medicaid APG methodology,2737.91,,,2737.91,Other,100% New York Medicaid APG,2737.91,,,2737.91,Other,100% New York Medicaid APG,2737.91,,,2737.91,Other,100% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,4189,,,4189,Other,153% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,3833.07,,,3833.07,Other,140% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,7118.55,,,7118.55,Other,260% New York Medicaid APG,8870.81,,,8870.81,Other,324% New York Medicaid APG,5886.5,,,5886.5,Other,215% New York Medicaid APG,5886.5,,,5886.5,Other,215% New York Medicaid APG,3422.38,,,3422.38,Other,125% New York Medicaid APG,2737.91,63432.75,
Treat fracture of radius,25520,CPT,,,,,,,,both,,,33805.49,25016.06,74,,25016.06,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15212.47,45,,15212.47,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,16733.72,49.5,,16733.72,percent of total billed charges,110% of Medicare,22987.73,68,,22987.73,percent of total billed charges,,1031.43,,,1031.43,Other,186% of Medicaid,27044.39,80,,27044.39,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,27044.39,80,,27044.39,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,23663.84,70,,23663.84,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,554.53,,,554.53,Other,New York Medicaid APG methodology,554.53,,,554.53,Other,100% New York Medicaid APG,554.53,,,554.53,Other,100% New York Medicaid APG,554.53,,,554.53,Other,100% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,848.43,,,848.43,Other,153% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,776.34,,,776.34,Other,140% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,1441.78,,,1441.78,Other,260% New York Medicaid APG,1796.68,,,1796.68,Other,324% New York Medicaid APG,1192.24,,,1192.24,Other,215% New York Medicaid APG,1192.24,,,1192.24,Other,215% New York Medicaid APG,693.16,,,693.16,Other,125% New York Medicaid APG,554.53,27044.39,
Treat fracture of radius,25525,CPT,,,,,,,,both,,,150476.65,111352.72,74,,111352.72,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,67714.49,45,,67714.49,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,74485.94,49.5,,74485.94,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5092.5,,,5092.5,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,105333.66,70,,105333.66,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,2737.91,,,2737.91,Other,New York Medicaid APG methodology,2737.91,,,2737.91,Other,100% New York Medicaid APG,2737.91,,,2737.91,Other,100% New York Medicaid APG,2737.91,,,2737.91,Other,100% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,4189,,,4189,Other,153% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,3833.07,,,3833.07,Other,140% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,7118.55,,,7118.55,Other,260% New York Medicaid APG,8870.81,,,8870.81,Other,324% New York Medicaid APG,5886.5,,,5886.5,Other,215% New York Medicaid APG,5886.5,,,5886.5,Other,215% New York Medicaid APG,3422.38,,,3422.38,Other,125% New York Medicaid APG,2737.91,111352.72,
Treat fracture of radius,25526,CPT,,,,,,,,both,,,86255.66,63829.19,74,,63829.19,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,38815.05,45,,38815.05,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,42696.55,49.5,,42696.55,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5092.5,,,5092.5,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,60378.96,70,,60378.96,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,2737.91,,,2737.91,Other,New York Medicaid APG methodology,2737.91,,,2737.91,Other,100% New York Medicaid APG,2737.91,,,2737.91,Other,100% New York Medicaid APG,2737.91,,,2737.91,Other,100% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,4189,,,4189,Other,153% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,3833.07,,,3833.07,Other,140% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,7118.55,,,7118.55,Other,260% New York Medicaid APG,8870.81,,,8870.81,Other,324% New York Medicaid APG,5886.5,,,5886.5,Other,215% New York Medicaid APG,5886.5,,,5886.5,Other,215% New York Medicaid APG,3422.38,,,3422.38,Other,125% New York Medicaid APG,2737.91,63829.19,
Treat fracture of ulna,25530,CPT,,,,,,,,both,,,4960.23,3670.57,74,,3670.57,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,2232.1,45,,2232.1,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,2455.31,49.5,,2455.31,percent of total billed charges,110% of Medicare,3372.96,68,,3372.96,percent of total billed charges,,1031.43,,,1031.43,Other,186% of Medicaid,3968.18,80,,3968.18,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,3968.18,80,,3968.18,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,3472.16,70,,3472.16,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,554.53,,,554.53,Other,New York Medicaid APG methodology,554.53,,,554.53,Other,100% New York Medicaid APG,554.53,,,554.53,Other,100% New York Medicaid APG,554.53,,,554.53,Other,100% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,848.43,,,848.43,Other,153% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,776.34,,,776.34,Other,140% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,1441.78,,,1441.78,Other,260% New York Medicaid APG,1796.68,,,1796.68,Other,324% New York Medicaid APG,1192.24,,,1192.24,Other,215% New York Medicaid APG,1192.24,,,1192.24,Other,215% New York Medicaid APG,693.16,,,693.16,Other,125% New York Medicaid APG,554.53,7216,
Treat fracture of ulna,25535,CPT,,,,,,,,both,,,4960.23,3670.57,74,,3670.57,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,2232.1,45,,2232.1,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,2455.31,49.5,,2455.31,percent of total billed charges,110% of Medicare,3372.96,68,,3372.96,percent of total billed charges,,1031.43,,,1031.43,Other,186% of Medicaid,3968.18,80,,3968.18,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,3968.18,80,,3968.18,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,3472.16,70,,3472.16,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,554.53,,,554.53,Other,New York Medicaid APG methodology,554.53,,,554.53,Other,100% New York Medicaid APG,554.53,,,554.53,Other,100% New York Medicaid APG,554.53,,,554.53,Other,100% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,848.43,,,848.43,Other,153% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,776.34,,,776.34,Other,140% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,1441.78,,,1441.78,Other,260% New York Medicaid APG,1796.68,,,1796.68,Other,324% New York Medicaid APG,1192.24,,,1192.24,Other,215% New York Medicaid APG,1192.24,,,1192.24,Other,215% New York Medicaid APG,693.16,,,693.16,Other,125% New York Medicaid APG,554.53,7216,
Treat fracture of ulna,25545,CPT,,,,,,,,both,,,150476.65,111352.72,74,,111352.72,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,67714.49,45,,67714.49,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,74485.94,49.5,,74485.94,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5092.5,,,5092.5,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,105333.66,70,,105333.66,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,2737.91,,,2737.91,Other,New York Medicaid APG methodology,2737.91,,,2737.91,Other,100% New York Medicaid APG,2737.91,,,2737.91,Other,100% New York Medicaid APG,2737.91,,,2737.91,Other,100% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,4189,,,4189,Other,153% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,3833.07,,,3833.07,Other,140% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,7118.55,,,7118.55,Other,260% New York Medicaid APG,8870.81,,,8870.81,Other,324% New York Medicaid APG,5886.5,,,5886.5,Other,215% New York Medicaid APG,5886.5,,,5886.5,Other,215% New York Medicaid APG,3422.38,,,3422.38,Other,125% New York Medicaid APG,2737.91,111352.72,
Treat fracture radius & ulna,25560,CPT,,,,,,,,both,,,4960.23,3670.57,74,,3670.57,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,2232.1,45,,2232.1,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,2455.31,49.5,,2455.31,percent of total billed charges,110% of Medicare,3372.96,68,,3372.96,percent of total billed charges,,1031.43,,,1031.43,Other,186% of Medicaid,3968.18,80,,3968.18,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,3968.18,80,,3968.18,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,3472.16,70,,3472.16,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,554.53,,,554.53,Other,New York Medicaid APG methodology,554.53,,,554.53,Other,100% New York Medicaid APG,554.53,,,554.53,Other,100% New York Medicaid APG,554.53,,,554.53,Other,100% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,848.43,,,848.43,Other,153% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,776.34,,,776.34,Other,140% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,1441.78,,,1441.78,Other,260% New York Medicaid APG,1796.68,,,1796.68,Other,324% New York Medicaid APG,1192.24,,,1192.24,Other,215% New York Medicaid APG,1192.24,,,1192.24,Other,215% New York Medicaid APG,693.16,,,693.16,Other,125% New York Medicaid APG,554.53,7216,
Treat fracture radius & ulna,25565,CPT,,,,,,,,both,,,33805.49,25016.06,74,,25016.06,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15212.47,45,,15212.47,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,16733.72,49.5,,16733.72,percent of total billed charges,110% of Medicare,22987.73,68,,22987.73,percent of total billed charges,,1031.43,,,1031.43,Other,186% of Medicaid,27044.39,80,,27044.39,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,27044.39,80,,27044.39,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,23663.84,70,,23663.84,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,554.53,,,554.53,Other,New York Medicaid APG methodology,554.53,,,554.53,Other,100% New York Medicaid APG,554.53,,,554.53,Other,100% New York Medicaid APG,554.53,,,554.53,Other,100% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,848.43,,,848.43,Other,153% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,776.34,,,776.34,Other,140% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,1441.78,,,1441.78,Other,260% New York Medicaid APG,1796.68,,,1796.68,Other,324% New York Medicaid APG,1192.24,,,1192.24,Other,215% New York Medicaid APG,1192.24,,,1192.24,Other,215% New York Medicaid APG,693.16,,,693.16,Other,125% New York Medicaid APG,554.53,27044.39,
Treat fracture radius & ulna,25574,CPT,,,,,,,,both,,,150476.65,111352.72,74,,111352.72,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,67714.49,45,,67714.49,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,74485.94,49.5,,74485.94,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5092.5,,,5092.5,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,105333.66,70,,105333.66,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,2737.91,,,2737.91,Other,New York Medicaid APG methodology,2737.91,,,2737.91,Other,100% New York Medicaid APG,2737.91,,,2737.91,Other,100% New York Medicaid APG,2737.91,,,2737.91,Other,100% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,4189,,,4189,Other,153% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,3833.07,,,3833.07,Other,140% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,7118.55,,,7118.55,Other,260% New York Medicaid APG,8870.81,,,8870.81,Other,324% New York Medicaid APG,5886.5,,,5886.5,Other,215% New York Medicaid APG,5886.5,,,5886.5,Other,215% New York Medicaid APG,3422.38,,,3422.38,Other,125% New York Medicaid APG,2737.91,111352.72,
Treat fracture radius/ulna,25575,CPT,,,,,,,,both,,,78802.27,58313.68,74,,58313.68,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,35461.02,45,,35461.02,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,39007.12,49.5,,39007.12,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5092.5,,,5092.5,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,55161.59,70,,55161.59,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,2737.91,,,2737.91,Other,New York Medicaid APG methodology,2737.91,,,2737.91,Other,100% New York Medicaid APG,2737.91,,,2737.91,Other,100% New York Medicaid APG,2737.91,,,2737.91,Other,100% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,4189,,,4189,Other,153% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,3833.07,,,3833.07,Other,140% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,7118.55,,,7118.55,Other,260% New York Medicaid APG,8870.81,,,8870.81,Other,324% New York Medicaid APG,5886.5,,,5886.5,Other,215% New York Medicaid APG,5886.5,,,5886.5,Other,215% New York Medicaid APG,3422.38,,,3422.38,Other,125% New York Medicaid APG,2737.91,58313.68,
Treat fracture radius/ulna,25600,CPT,,,,,,,,both,,,4960.23,3670.57,74,,3670.57,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,2232.1,45,,2232.1,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,2455.31,49.5,,2455.31,percent of total billed charges,110% of Medicare,3372.96,68,,3372.96,percent of total billed charges,,1031.43,,,1031.43,Other,186% of Medicaid,3968.18,80,,3968.18,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,3968.18,80,,3968.18,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,3472.16,70,,3472.16,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,554.53,,,554.53,Other,New York Medicaid APG methodology,554.53,,,554.53,Other,100% New York Medicaid APG,554.53,,,554.53,Other,100% New York Medicaid APG,554.53,,,554.53,Other,100% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,848.43,,,848.43,Other,153% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,776.34,,,776.34,Other,140% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,1441.78,,,1441.78,Other,260% New York Medicaid APG,1796.68,,,1796.68,Other,324% New York Medicaid APG,1192.24,,,1192.24,Other,215% New York Medicaid APG,1192.24,,,1192.24,Other,215% New York Medicaid APG,693.16,,,693.16,Other,125% New York Medicaid APG,554.53,7216,
Treat fracture radius/ulna,25605,CPT,,,,,,,,both,,,34409.3,25462.88,74,,25462.88,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15484.19,45,,15484.19,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,17032.6,49.5,,17032.6,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,1031.43,,,1031.43,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,3578,,"100% primary, 0% secondary procedures",3578,Other,MagnaCare ASC Grouper,24086.51,70,,24086.51,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,554.53,,,554.53,Other,New York Medicaid APG methodology,554.53,,,554.53,Other,100% New York Medicaid APG,554.53,,,554.53,Other,100% New York Medicaid APG,554.53,,,554.53,Other,100% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,848.43,,,848.43,Other,153% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,776.34,,,776.34,Other,140% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,1441.78,,,1441.78,Other,260% New York Medicaid APG,1796.68,,,1796.68,Other,324% New York Medicaid APG,1192.24,,,1192.24,Other,215% New York Medicaid APG,1192.24,,,1192.24,Other,215% New York Medicaid APG,693.16,,,693.16,Other,125% New York Medicaid APG,554.53,25462.88,
Treat fx distal radial,25606,CPT,,,,,,,,both,,,36026.77,26659.81,74,,26659.81,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,16212.05,45,,16212.05,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,17833.25,49.5,,17833.25,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5092.5,,,5092.5,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,25218.74,70,,25218.74,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,2737.91,,,2737.91,Other,New York Medicaid APG methodology,2737.91,,,2737.91,Other,100% New York Medicaid APG,2737.91,,,2737.91,Other,100% New York Medicaid APG,2737.91,,,2737.91,Other,100% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,4189,,,4189,Other,153% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,3833.07,,,3833.07,Other,140% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,7118.55,,,7118.55,Other,260% New York Medicaid APG,8870.81,,,8870.81,Other,324% New York Medicaid APG,5886.5,,,5886.5,Other,215% New York Medicaid APG,5886.5,,,5886.5,Other,215% New York Medicaid APG,3422.38,,,3422.38,Other,125% New York Medicaid APG,2737.91,26659.81,
Treat fx rad extra-articul,25607,CPT,,,,,,,,both,,,99538.86,73658.76,74,,73658.76,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,44792.49,45,,44792.49,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,49271.74,49.5,,49271.74,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5092.5,,,5092.5,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,69677.2,70,,69677.2,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,2737.91,,,2737.91,Other,New York Medicaid APG methodology,2737.91,,,2737.91,Other,100% New York Medicaid APG,2737.91,,,2737.91,Other,100% New York Medicaid APG,2737.91,,,2737.91,Other,100% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,4189,,,4189,Other,153% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,3833.07,,,3833.07,Other,140% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,7118.55,,,7118.55,Other,260% New York Medicaid APG,8870.81,,,8870.81,Other,324% New York Medicaid APG,5886.5,,,5886.5,Other,215% New York Medicaid APG,5886.5,,,5886.5,Other,215% New York Medicaid APG,3422.38,,,3422.38,Other,125% New York Medicaid APG,2737.91,73658.76,
Treat fx rad intra-articul,25608,CPT,,,,,,,,both,,,62978.56,46604.13,74,,46604.13,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,28340.35,45,,28340.35,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,31174.39,49.5,,31174.39,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5092.5,,,5092.5,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,44084.99,70,,44084.99,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,2737.91,,,2737.91,Other,New York Medicaid APG methodology,2737.91,,,2737.91,Other,100% New York Medicaid APG,2737.91,,,2737.91,Other,100% New York Medicaid APG,2737.91,,,2737.91,Other,100% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,4189,,,4189,Other,153% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,3833.07,,,3833.07,Other,140% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,7118.55,,,7118.55,Other,260% New York Medicaid APG,8870.81,,,8870.81,Other,324% New York Medicaid APG,5886.5,,,5886.5,Other,215% New York Medicaid APG,5886.5,,,5886.5,Other,215% New York Medicaid APG,3422.38,,,3422.38,Other,125% New York Medicaid APG,2737.91,46604.13,
Treat fx radial 3+ frag,25609,CPT,,,,,,,,both,,,74400.22,55056.16,74,,55056.16,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,33480.1,45,,33480.1,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,36828.11,49.5,,36828.11,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5092.5,,,5092.5,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,52080.15,70,,52080.15,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,2737.91,,,2737.91,Other,New York Medicaid APG methodology,2737.91,,,2737.91,Other,100% New York Medicaid APG,2737.91,,,2737.91,Other,100% New York Medicaid APG,2737.91,,,2737.91,Other,100% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,4189,,,4189,Other,153% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,3833.07,,,3833.07,Other,140% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,7118.55,,,7118.55,Other,260% New York Medicaid APG,8870.81,,,8870.81,Other,324% New York Medicaid APG,5886.5,,,5886.5,Other,215% New York Medicaid APG,5886.5,,,5886.5,Other,215% New York Medicaid APG,3422.38,,,3422.38,Other,125% New York Medicaid APG,2737.91,55056.16,
Treat wrist bone fracture,25622,CPT,,,,,,,,both,,,4960.23,3670.57,74,,3670.57,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,2232.1,45,,2232.1,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,2455.31,49.5,,2455.31,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,1031.43,,,1031.43,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,3472.16,70,,3472.16,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,554.53,,,554.53,Other,New York Medicaid APG methodology,554.53,,,554.53,Other,100% New York Medicaid APG,554.53,,,554.53,Other,100% New York Medicaid APG,554.53,,,554.53,Other,100% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,848.43,,,848.43,Other,153% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,776.34,,,776.34,Other,140% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,1441.78,,,1441.78,Other,260% New York Medicaid APG,1796.68,,,1796.68,Other,324% New York Medicaid APG,1192.24,,,1192.24,Other,215% New York Medicaid APG,1192.24,,,1192.24,Other,215% New York Medicaid APG,693.16,,,693.16,Other,125% New York Medicaid APG,554.53,9473,
Treat wrist bone fracture,25624,CPT,,,,,,,,both,,,33805.49,25016.06,74,,25016.06,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15212.47,45,,15212.47,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,16733.72,49.5,,16733.72,percent of total billed charges,110% of Medicare,22987.73,68,,22987.73,percent of total billed charges,,1031.43,,,1031.43,Other,186% of Medicaid,27044.39,80,,27044.39,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,27044.39,80,,27044.39,percent of total billed charges,,7216,,,7216,Case Rate,,3578,,"100% primary, 0% secondary procedures",3578,Other,MagnaCare ASC Grouper,23663.84,70,,23663.84,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,554.53,,,554.53,Other,New York Medicaid APG methodology,554.53,,,554.53,Other,100% New York Medicaid APG,554.53,,,554.53,Other,100% New York Medicaid APG,554.53,,,554.53,Other,100% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,848.43,,,848.43,Other,153% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,776.34,,,776.34,Other,140% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,1441.78,,,1441.78,Other,260% New York Medicaid APG,1796.68,,,1796.68,Other,324% New York Medicaid APG,1192.24,,,1192.24,Other,215% New York Medicaid APG,1192.24,,,1192.24,Other,215% New York Medicaid APG,693.16,,,693.16,Other,125% New York Medicaid APG,554.53,27044.39,
Treat wrist bone fracture,25628,CPT,,,,,,,,both,,,66045.92,48873.98,74,,48873.98,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,29720.66,45,,29720.66,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,32692.73,49.5,,32692.73,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5092.5,,,5092.5,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,46232.14,70,,46232.14,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,2737.91,,,2737.91,Other,New York Medicaid APG methodology,2737.91,,,2737.91,Other,100% New York Medicaid APG,2737.91,,,2737.91,Other,100% New York Medicaid APG,2737.91,,,2737.91,Other,100% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,4189,,,4189,Other,153% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,3833.07,,,3833.07,Other,140% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,7118.55,,,7118.55,Other,260% New York Medicaid APG,8870.81,,,8870.81,Other,324% New York Medicaid APG,5886.5,,,5886.5,Other,215% New York Medicaid APG,5886.5,,,5886.5,Other,215% New York Medicaid APG,3422.38,,,3422.38,Other,125% New York Medicaid APG,2737.91,48873.98,
Treat wrist bone fracture,25630,CPT,,,,,,,,both,,,4960.23,3670.57,74,,3670.57,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,2232.1,45,,2232.1,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,2455.31,49.5,,2455.31,percent of total billed charges,110% of Medicare,3372.96,68,,3372.96,percent of total billed charges,,1031.43,,,1031.43,Other,186% of Medicaid,3968.18,80,,3968.18,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,3968.18,80,,3968.18,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,3472.16,70,,3472.16,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,554.53,,,554.53,Other,New York Medicaid APG methodology,554.53,,,554.53,Other,100% New York Medicaid APG,554.53,,,554.53,Other,100% New York Medicaid APG,554.53,,,554.53,Other,100% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,848.43,,,848.43,Other,153% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,776.34,,,776.34,Other,140% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,1441.78,,,1441.78,Other,260% New York Medicaid APG,1796.68,,,1796.68,Other,324% New York Medicaid APG,1192.24,,,1192.24,Other,215% New York Medicaid APG,1192.24,,,1192.24,Other,215% New York Medicaid APG,693.16,,,693.16,Other,125% New York Medicaid APG,554.53,7216,
Treat wrist bone fracture,25635,CPT,,,,,,,,both,,,33805.49,25016.06,74,,25016.06,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15212.47,45,,15212.47,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,16733.72,49.5,,16733.72,percent of total billed charges,110% of Medicare,22987.73,68,,22987.73,percent of total billed charges,,1031.43,,,1031.43,Other,186% of Medicaid,27044.39,80,,27044.39,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,27044.39,80,,27044.39,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,23663.84,70,,23663.84,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,554.53,,,554.53,Other,New York Medicaid APG methodology,554.53,,,554.53,Other,100% New York Medicaid APG,554.53,,,554.53,Other,100% New York Medicaid APG,554.53,,,554.53,Other,100% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,848.43,,,848.43,Other,153% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,776.34,,,776.34,Other,140% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,1441.78,,,1441.78,Other,260% New York Medicaid APG,1796.68,,,1796.68,Other,324% New York Medicaid APG,1192.24,,,1192.24,Other,215% New York Medicaid APG,1192.24,,,1192.24,Other,215% New York Medicaid APG,693.16,,,693.16,Other,125% New York Medicaid APG,554.53,27044.39,
Treat wrist bone fracture,25645,CPT,,,,,,,,both,,,68082.75,50381.24,74,,50381.24,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30637.24,45,,30637.24,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33700.96,49.5,,33700.96,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5092.5,,,5092.5,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,47657.93,70,,47657.93,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,2737.91,,,2737.91,Other,New York Medicaid APG methodology,2737.91,,,2737.91,Other,100% New York Medicaid APG,2737.91,,,2737.91,Other,100% New York Medicaid APG,2737.91,,,2737.91,Other,100% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,4189,,,4189,Other,153% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,3833.07,,,3833.07,Other,140% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,7118.55,,,7118.55,Other,260% New York Medicaid APG,8870.81,,,8870.81,Other,324% New York Medicaid APG,5886.5,,,5886.5,Other,215% New York Medicaid APG,5886.5,,,5886.5,Other,215% New York Medicaid APG,3422.38,,,3422.38,Other,125% New York Medicaid APG,2737.91,50381.24,
Treat wrist bone fracture,25650,CPT,,,,,,,,both,,,4960.23,3670.57,74,,3670.57,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,2232.1,45,,2232.1,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,2455.31,49.5,,2455.31,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,1031.43,,,1031.43,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,3472.16,70,,3472.16,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,554.53,,,554.53,Other,New York Medicaid APG methodology,554.53,,,554.53,Other,100% New York Medicaid APG,554.53,,,554.53,Other,100% New York Medicaid APG,554.53,,,554.53,Other,100% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,848.43,,,848.43,Other,153% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,776.34,,,776.34,Other,140% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,1441.78,,,1441.78,Other,260% New York Medicaid APG,1796.68,,,1796.68,Other,324% New York Medicaid APG,1192.24,,,1192.24,Other,215% New York Medicaid APG,1192.24,,,1192.24,Other,215% New York Medicaid APG,693.16,,,693.16,Other,125% New York Medicaid APG,554.53,9473,
Pin ulnar styloid fracture,25651,CPT,,,,,,,,both,,,68082.75,50381.24,74,,50381.24,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30637.24,45,,30637.24,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33700.96,49.5,,33700.96,percent of total billed charges,110% of Medicare,46296.27,68,,46296.27,percent of total billed charges,,5092.5,,,5092.5,Other,186% of Medicaid,54466.2,80,,54466.2,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,54466.2,80,,54466.2,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,47657.93,70,,47657.93,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,2737.91,,,2737.91,Other,New York Medicaid APG methodology,2737.91,,,2737.91,Other,100% New York Medicaid APG,2737.91,,,2737.91,Other,100% New York Medicaid APG,2737.91,,,2737.91,Other,100% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,4189,,,4189,Other,153% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,3833.07,,,3833.07,Other,140% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,7118.55,,,7118.55,Other,260% New York Medicaid APG,8870.81,,,8870.81,Other,324% New York Medicaid APG,5886.5,,,5886.5,Other,215% New York Medicaid APG,5886.5,,,5886.5,Other,215% New York Medicaid APG,3422.38,,,3422.38,Other,125% New York Medicaid APG,2053,54466.2,
Treat fracture ulnar styloid,25652,CPT,,,,,,,,both,,,150476.65,111352.72,74,,111352.72,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,67714.49,45,,67714.49,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,74485.94,49.5,,74485.94,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5092.5,,,5092.5,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,105333.66,70,,105333.66,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,2737.91,,,2737.91,Other,New York Medicaid APG methodology,2737.91,,,2737.91,Other,100% New York Medicaid APG,2737.91,,,2737.91,Other,100% New York Medicaid APG,2737.91,,,2737.91,Other,100% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,4189,,,4189,Other,153% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,3833.07,,,3833.07,Other,140% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,7118.55,,,7118.55,Other,260% New York Medicaid APG,8870.81,,,8870.81,Other,324% New York Medicaid APG,5886.5,,,5886.5,Other,215% New York Medicaid APG,5886.5,,,5886.5,Other,215% New York Medicaid APG,3422.38,,,3422.38,Other,125% New York Medicaid APG,2737.91,111352.72,
Treat wrist dislocation,25660,CPT,,,,,,,,both,,,4960.23,3670.57,74,,3670.57,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,2232.1,45,,2232.1,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,2455.31,49.5,,2455.31,percent of total billed charges,110% of Medicare,3372.96,68,,3372.96,percent of total billed charges,,1031.43,,,1031.43,Other,186% of Medicaid,3968.18,80,,3968.18,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,3968.18,80,,3968.18,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,3472.16,70,,3472.16,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,554.53,,,554.53,Other,New York Medicaid APG methodology,554.53,,,554.53,Other,100% New York Medicaid APG,554.53,,,554.53,Other,100% New York Medicaid APG,554.53,,,554.53,Other,100% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,848.43,,,848.43,Other,153% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,776.34,,,776.34,Other,140% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,1441.78,,,1441.78,Other,260% New York Medicaid APG,1796.68,,,1796.68,Other,324% New York Medicaid APG,1192.24,,,1192.24,Other,215% New York Medicaid APG,1192.24,,,1192.24,Other,215% New York Medicaid APG,693.16,,,693.16,Other,125% New York Medicaid APG,554.53,7216,
Treat wrist dislocation,25670,CPT,,,,,,,,both,,,150476.65,111352.72,74,,111352.72,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,67714.49,45,,67714.49,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,74485.94,49.5,,74485.94,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5092.5,,,5092.5,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,105333.66,70,,105333.66,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,2737.91,,,2737.91,Other,New York Medicaid APG methodology,2737.91,,,2737.91,Other,100% New York Medicaid APG,2737.91,,,2737.91,Other,100% New York Medicaid APG,2737.91,,,2737.91,Other,100% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,4189,,,4189,Other,153% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,3833.07,,,3833.07,Other,140% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,7118.55,,,7118.55,Other,260% New York Medicaid APG,8870.81,,,8870.81,Other,324% New York Medicaid APG,5886.5,,,5886.5,Other,215% New York Medicaid APG,5886.5,,,5886.5,Other,215% New York Medicaid APG,3422.38,,,3422.38,Other,125% New York Medicaid APG,2737.91,111352.72,
Pin radioulnar dislocation,25671,CPT,,,,,,,,both,,,68082.75,50381.24,74,,50381.24,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30637.24,45,,30637.24,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33700.96,49.5,,33700.96,percent of total billed charges,110% of Medicare,46296.27,68,,46296.27,percent of total billed charges,,5092.5,,,5092.5,Other,186% of Medicaid,54466.2,80,,54466.2,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,54466.2,80,,54466.2,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,47657.93,70,,47657.93,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,2737.91,,,2737.91,Other,New York Medicaid APG methodology,2737.91,,,2737.91,Other,100% New York Medicaid APG,2737.91,,,2737.91,Other,100% New York Medicaid APG,2737.91,,,2737.91,Other,100% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,4189,,,4189,Other,153% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,3833.07,,,3833.07,Other,140% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,7118.55,,,7118.55,Other,260% New York Medicaid APG,8870.81,,,8870.81,Other,324% New York Medicaid APG,5886.5,,,5886.5,Other,215% New York Medicaid APG,5886.5,,,5886.5,Other,215% New York Medicaid APG,3422.38,,,3422.38,Other,125% New York Medicaid APG,2053,54466.2,
Treat wrist dislocation,25675,CPT,,,,,,,,both,,,4960.23,3670.57,74,,3670.57,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,2232.1,45,,2232.1,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,2455.31,49.5,,2455.31,percent of total billed charges,110% of Medicare,3372.96,68,,3372.96,percent of total billed charges,,1031.43,,,1031.43,Other,186% of Medicaid,3968.18,80,,3968.18,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,3968.18,80,,3968.18,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,3472.16,70,,3472.16,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,554.53,,,554.53,Other,New York Medicaid APG methodology,554.53,,,554.53,Other,100% New York Medicaid APG,554.53,,,554.53,Other,100% New York Medicaid APG,554.53,,,554.53,Other,100% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,848.43,,,848.43,Other,153% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,776.34,,,776.34,Other,140% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,1441.78,,,1441.78,Other,260% New York Medicaid APG,1796.68,,,1796.68,Other,324% New York Medicaid APG,1192.24,,,1192.24,Other,215% New York Medicaid APG,1192.24,,,1192.24,Other,215% New York Medicaid APG,693.16,,,693.16,Other,125% New York Medicaid APG,554.53,7216,
Treat wrist dislocation,25676,CPT,,,,,,,,both,,,150476.65,111352.72,74,,111352.72,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,67714.49,45,,67714.49,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,74485.94,49.5,,74485.94,percent of total billed charges,110% of Medicare,102324.12,68,,102324.12,percent of total billed charges,,5092.5,,,5092.5,Other,186% of Medicaid,120381.32,80,,120381.32,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,120381.32,80,,120381.32,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,105333.66,70,,105333.66,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,2737.91,,,2737.91,Other,New York Medicaid APG methodology,2737.91,,,2737.91,Other,100% New York Medicaid APG,2737.91,,,2737.91,Other,100% New York Medicaid APG,2737.91,,,2737.91,Other,100% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,4189,,,4189,Other,153% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,3833.07,,,3833.07,Other,140% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,7118.55,,,7118.55,Other,260% New York Medicaid APG,8870.81,,,8870.81,Other,324% New York Medicaid APG,5886.5,,,5886.5,Other,215% New York Medicaid APG,5886.5,,,5886.5,Other,215% New York Medicaid APG,3422.38,,,3422.38,Other,125% New York Medicaid APG,2232,120381.32,
Treat wrist fracture,25680,CPT,,,,,,,,both,,,4960.23,3670.57,74,,3670.57,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,2232.1,45,,2232.1,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,2455.31,49.5,,2455.31,percent of total billed charges,110% of Medicare,3372.96,68,,3372.96,percent of total billed charges,,1031.43,,,1031.43,Other,186% of Medicaid,3968.18,80,,3968.18,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,3968.18,80,,3968.18,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,3472.16,70,,3472.16,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,554.53,,,554.53,Other,New York Medicaid APG methodology,554.53,,,554.53,Other,100% New York Medicaid APG,554.53,,,554.53,Other,100% New York Medicaid APG,554.53,,,554.53,Other,100% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,848.43,,,848.43,Other,153% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,776.34,,,776.34,Other,140% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,1441.78,,,1441.78,Other,260% New York Medicaid APG,1796.68,,,1796.68,Other,324% New York Medicaid APG,1192.24,,,1192.24,Other,215% New York Medicaid APG,1192.24,,,1192.24,Other,215% New York Medicaid APG,693.16,,,693.16,Other,125% New York Medicaid APG,554.53,7216,
Treat wrist fracture,25685,CPT,,,,,,,,both,,,150476.65,111352.72,74,,111352.72,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,67714.49,45,,67714.49,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,74485.94,49.5,,74485.94,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5092.5,,,5092.5,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,105333.66,70,,105333.66,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,2737.91,,,2737.91,Other,New York Medicaid APG methodology,2737.91,,,2737.91,Other,100% New York Medicaid APG,2737.91,,,2737.91,Other,100% New York Medicaid APG,2737.91,,,2737.91,Other,100% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,4189,,,4189,Other,153% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,3833.07,,,3833.07,Other,140% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,7118.55,,,7118.55,Other,260% New York Medicaid APG,8870.81,,,8870.81,Other,324% New York Medicaid APG,5886.5,,,5886.5,Other,215% New York Medicaid APG,5886.5,,,5886.5,Other,215% New York Medicaid APG,3422.38,,,3422.38,Other,125% New York Medicaid APG,2737.91,111352.72,
Treat wrist dislocation,25690,CPT,,,,,,,,both,,,33805.49,25016.06,74,,25016.06,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15212.47,45,,15212.47,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,16733.72,49.5,,16733.72,percent of total billed charges,110% of Medicare,22987.73,68,,22987.73,percent of total billed charges,,1031.43,,,1031.43,Other,186% of Medicaid,27044.39,80,,27044.39,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,27044.39,80,,27044.39,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,23663.84,70,,23663.84,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,554.53,,,554.53,Other,New York Medicaid APG methodology,554.53,,,554.53,Other,100% New York Medicaid APG,554.53,,,554.53,Other,100% New York Medicaid APG,554.53,,,554.53,Other,100% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,848.43,,,848.43,Other,153% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,776.34,,,776.34,Other,140% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,1441.78,,,1441.78,Other,260% New York Medicaid APG,1796.68,,,1796.68,Other,324% New York Medicaid APG,1192.24,,,1192.24,Other,215% New York Medicaid APG,1192.24,,,1192.24,Other,215% New York Medicaid APG,693.16,,,693.16,Other,125% New York Medicaid APG,554.53,27044.39,
Treat wrist dislocation,25695,CPT,,,,,,,,both,,,150476.65,111352.72,74,,111352.72,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,67714.49,45,,67714.49,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,74485.94,49.5,,74485.94,percent of total billed charges,110% of Medicare,102324.12,68,,102324.12,percent of total billed charges,,5092.5,,,5092.5,Other,186% of Medicaid,120381.32,80,,120381.32,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,120381.32,80,,120381.32,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,105333.66,70,,105333.66,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,2737.91,,,2737.91,Other,New York Medicaid APG methodology,2737.91,,,2737.91,Other,100% New York Medicaid APG,2737.91,,,2737.91,Other,100% New York Medicaid APG,2737.91,,,2737.91,Other,100% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,4189,,,4189,Other,153% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,3833.07,,,3833.07,Other,140% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,7118.55,,,7118.55,Other,260% New York Medicaid APG,8870.81,,,8870.81,Other,324% New York Medicaid APG,5886.5,,,5886.5,Other,215% New York Medicaid APG,5886.5,,,5886.5,Other,215% New York Medicaid APG,3422.38,,,3422.38,Other,125% New York Medicaid APG,2232,120381.32,
Fusion of wrist joint,25800,CPT,,,,,,,,both,,,150476.65,111352.72,74,,111352.72,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,67714.49,45,,67714.49,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,74485.94,49.5,,74485.94,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3937.21,,,3937.21,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,105333.66,70,,105333.66,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,2116.78,,,2116.78,Other,New York Medicaid APG methodology,2116.78,,,2116.78,Other,100% New York Medicaid APG,2116.78,,,2116.78,Other,100% New York Medicaid APG,2116.78,,,2116.78,Other,100% New York Medicaid APG,4762.75,,,4762.75,Other,225% New York Medicaid APG,3238.67,,,3238.67,Other,153% New York Medicaid APG,4762.75,,,4762.75,Other,225% New York Medicaid APG,2963.49,,,2963.49,Other,140% New York Medicaid APG,4762.75,,,4762.75,Other,225% New York Medicaid APG,5503.62,,,5503.62,Other,260% New York Medicaid APG,6858.36,,,6858.36,Other,324% New York Medicaid APG,4551.07,,,4551.07,Other,215% New York Medicaid APG,4551.07,,,4551.07,Other,215% New York Medicaid APG,2645.97,,,2645.97,Other,125% New York Medicaid APG,2116.78,111352.72,
Fusion/graft of wrist joint,25805,CPT,,,,,,,,both,,,150476.65,111352.72,74,,111352.72,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,67714.49,45,,67714.49,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,74485.94,49.5,,74485.94,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3937.21,,,3937.21,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,105333.66,70,,105333.66,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,2116.78,,,2116.78,Other,New York Medicaid APG methodology,2116.78,,,2116.78,Other,100% New York Medicaid APG,2116.78,,,2116.78,Other,100% New York Medicaid APG,2116.78,,,2116.78,Other,100% New York Medicaid APG,4762.75,,,4762.75,Other,225% New York Medicaid APG,3238.67,,,3238.67,Other,153% New York Medicaid APG,4762.75,,,4762.75,Other,225% New York Medicaid APG,2963.49,,,2963.49,Other,140% New York Medicaid APG,4762.75,,,4762.75,Other,225% New York Medicaid APG,5503.62,,,5503.62,Other,260% New York Medicaid APG,6858.36,,,6858.36,Other,324% New York Medicaid APG,4551.07,,,4551.07,Other,215% New York Medicaid APG,4551.07,,,4551.07,Other,215% New York Medicaid APG,2645.97,,,2645.97,Other,125% New York Medicaid APG,2116.78,111352.72,
Fusion/graft of wrist joint,25810,CPT,,,,,,,,both,,,56204.17,41591.09,74,,41591.09,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,25291.88,45,,25291.88,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,27821.06,49.5,,27821.06,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3937.21,,,3937.21,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,39342.92,70,,39342.92,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,2116.78,,,2116.78,Other,New York Medicaid APG methodology,2116.78,,,2116.78,Other,100% New York Medicaid APG,2116.78,,,2116.78,Other,100% New York Medicaid APG,2116.78,,,2116.78,Other,100% New York Medicaid APG,4762.75,,,4762.75,Other,225% New York Medicaid APG,3238.67,,,3238.67,Other,153% New York Medicaid APG,4762.75,,,4762.75,Other,225% New York Medicaid APG,2963.49,,,2963.49,Other,140% New York Medicaid APG,4762.75,,,4762.75,Other,225% New York Medicaid APG,5503.62,,,5503.62,Other,260% New York Medicaid APG,6858.36,,,6858.36,Other,324% New York Medicaid APG,4551.07,,,4551.07,Other,215% New York Medicaid APG,4551.07,,,4551.07,Other,215% New York Medicaid APG,2645.97,,,2645.97,Other,125% New York Medicaid APG,2116.78,41591.09,
Fusion of hand bones,25820,CPT,,,,,,,,both,,,150476.65,111352.72,74,,111352.72,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,67714.49,45,,67714.49,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,74485.94,49.5,,74485.94,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3654.9,,,3654.9,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,105333.66,70,,105333.66,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,1965,,,1965,Other,New York Medicaid APG methodology,1965,,,1965,Other,100% New York Medicaid APG,1965,,,1965,Other,100% New York Medicaid APG,1965,,,1965,Other,100% New York Medicaid APG,4421.25,,,4421.25,Other,225% New York Medicaid APG,3006.45,,,3006.45,Other,153% New York Medicaid APG,4421.25,,,4421.25,Other,225% New York Medicaid APG,2751,,,2751,Other,140% New York Medicaid APG,4421.25,,,4421.25,Other,225% New York Medicaid APG,5109,,,5109,Other,260% New York Medicaid APG,6366.6,,,6366.6,Other,324% New York Medicaid APG,4224.75,,,4224.75,Other,215% New York Medicaid APG,4224.75,,,4224.75,Other,215% New York Medicaid APG,2456.25,,,2456.25,Other,125% New York Medicaid APG,1965,111352.72,
Fuse hand bones with graft,25825,CPT,,,,,,,,both,,,71599.92,52983.94,74,,52983.94,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,32219.96,45,,32219.96,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,35441.96,49.5,,35441.96,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3654.9,,,3654.9,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,50119.94,70,,50119.94,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,1965,,,1965,Other,New York Medicaid APG methodology,1965,,,1965,Other,100% New York Medicaid APG,1965,,,1965,Other,100% New York Medicaid APG,1965,,,1965,Other,100% New York Medicaid APG,4421.25,,,4421.25,Other,225% New York Medicaid APG,3006.45,,,3006.45,Other,153% New York Medicaid APG,4421.25,,,4421.25,Other,225% New York Medicaid APG,2751,,,2751,Other,140% New York Medicaid APG,4421.25,,,4421.25,Other,225% New York Medicaid APG,5109,,,5109,Other,260% New York Medicaid APG,6366.6,,,6366.6,Other,324% New York Medicaid APG,4224.75,,,4224.75,Other,215% New York Medicaid APG,4224.75,,,4224.75,Other,215% New York Medicaid APG,2456.25,,,2456.25,Other,125% New York Medicaid APG,1965,52983.94,
Fusion radioulnar jnt/ulna,25830,CPT,,,,,,,,both,,,150476.65,111352.72,74,,111352.72,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,67714.49,45,,67714.49,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,74485.94,49.5,,74485.94,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3937.21,,,3937.21,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,105333.66,70,,105333.66,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,2116.78,,,2116.78,Other,New York Medicaid APG methodology,2116.78,,,2116.78,Other,100% New York Medicaid APG,2116.78,,,2116.78,Other,100% New York Medicaid APG,2116.78,,,2116.78,Other,100% New York Medicaid APG,4762.75,,,4762.75,Other,225% New York Medicaid APG,3238.67,,,3238.67,Other,153% New York Medicaid APG,4762.75,,,4762.75,Other,225% New York Medicaid APG,2963.49,,,2963.49,Other,140% New York Medicaid APG,4762.75,,,4762.75,Other,225% New York Medicaid APG,5503.62,,,5503.62,Other,260% New York Medicaid APG,6858.36,,,6858.36,Other,324% New York Medicaid APG,4551.07,,,4551.07,Other,215% New York Medicaid APG,4551.07,,,4551.07,Other,215% New York Medicaid APG,2645.97,,,2645.97,Other,125% New York Medicaid APG,2116.78,111352.72,
Amputation follow-up surgery,25907,CPT,,,,,,,,both,,,68082.75,50381.24,74,,50381.24,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30637.24,45,,30637.24,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33700.96,49.5,,33700.96,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3479.6,,,3479.6,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,47657.93,70,,47657.93,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1870.75,,,1870.75,Other,New York Medicaid APG methodology,1870.75,,,1870.75,Other,100% New York Medicaid APG,1870.75,,,1870.75,Other,100% New York Medicaid APG,1870.75,,,1870.75,Other,100% New York Medicaid APG,4209.2,,,4209.2,Other,225% New York Medicaid APG,2862.25,,,2862.25,Other,153% New York Medicaid APG,4209.2,,,4209.2,Other,225% New York Medicaid APG,2619.06,,,2619.06,Other,140% New York Medicaid APG,4209.2,,,4209.2,Other,225% New York Medicaid APG,4863.96,,,4863.96,Other,260% New York Medicaid APG,6061.24,,,6061.24,Other,324% New York Medicaid APG,4022.12,,,4022.12,Other,215% New York Medicaid APG,4022.12,,,4022.12,Other,215% New York Medicaid APG,2338.44,,,2338.44,Other,125% New York Medicaid APG,1870.75,50381.24,
Amputation follow-up surgery,25909,CPT,,,,,,,,both,,,150476.65,111352.72,74,,111352.72,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,67714.49,45,,67714.49,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,74485.94,49.5,,74485.94,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3937.21,,,3937.21,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,105333.66,70,,105333.66,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,2116.78,,,2116.78,Other,New York Medicaid APG methodology,2116.78,,,2116.78,Other,100% New York Medicaid APG,2116.78,,,2116.78,Other,100% New York Medicaid APG,2116.78,,,2116.78,Other,100% New York Medicaid APG,4762.75,,,4762.75,Other,225% New York Medicaid APG,3238.67,,,3238.67,Other,153% New York Medicaid APG,4762.75,,,4762.75,Other,225% New York Medicaid APG,2963.49,,,2963.49,Other,140% New York Medicaid APG,4762.75,,,4762.75,Other,225% New York Medicaid APG,5503.62,,,5503.62,Other,260% New York Medicaid APG,6858.36,,,6858.36,Other,324% New York Medicaid APG,4551.07,,,4551.07,Other,215% New York Medicaid APG,4551.07,,,4551.07,Other,215% New York Medicaid APG,2645.97,,,2645.97,Other,125% New York Medicaid APG,2116.78,111352.72,
Amputate hand at wrist,25922,CPT,,,,,,,,both,,,33805.49,25016.06,74,,25016.06,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15212.47,45,,15212.47,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,16733.72,49.5,,16733.72,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3479.6,,,3479.6,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,23663.84,70,,23663.84,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1870.75,,,1870.75,Other,New York Medicaid APG methodology,1870.75,,,1870.75,Other,100% New York Medicaid APG,1870.75,,,1870.75,Other,100% New York Medicaid APG,1870.75,,,1870.75,Other,100% New York Medicaid APG,4209.2,,,4209.2,Other,225% New York Medicaid APG,2862.25,,,2862.25,Other,153% New York Medicaid APG,4209.2,,,4209.2,Other,225% New York Medicaid APG,2619.06,,,2619.06,Other,140% New York Medicaid APG,4209.2,,,4209.2,Other,225% New York Medicaid APG,4863.96,,,4863.96,Other,260% New York Medicaid APG,6061.24,,,6061.24,Other,324% New York Medicaid APG,4022.12,,,4022.12,Other,215% New York Medicaid APG,4022.12,,,4022.12,Other,215% New York Medicaid APG,2338.44,,,2338.44,Other,125% New York Medicaid APG,1870.75,25016.06,
Amputation follow-up surgery,25929,CPT,,,,,,,,both,,,38357.55,28384.59,74,,28384.59,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,17260.9,45,,17260.9,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,18986.99,49.5,,18986.99,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2289.65,,,2289.65,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,26850.29,70,,26850.29,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1231,,,1231,Other,New York Medicaid APG methodology,1231,,,1231,Other,100% New York Medicaid APG,1231,,,1231,Other,100% New York Medicaid APG,1231,,,1231,Other,100% New York Medicaid APG,2769.74,,,2769.74,Other,225% New York Medicaid APG,1883.42,,,1883.42,Other,153% New York Medicaid APG,2769.74,,,2769.74,Other,225% New York Medicaid APG,1723.39,,,1723.39,Other,140% New York Medicaid APG,2769.74,,,2769.74,Other,225% New York Medicaid APG,3200.59,,,3200.59,Other,260% New York Medicaid APG,3988.42,,,3988.42,Other,324% New York Medicaid APG,2646.64,,,2646.64,Other,215% New York Medicaid APG,2646.64,,,2646.64,Other,215% New York Medicaid APG,1538.74,,,1538.74,Other,125% New York Medicaid APG,1231,28384.59,
Amputation follow-up surgery,25931,CPT,,,,,,,,both,,,68082.75,50381.24,74,,50381.24,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30637.24,45,,30637.24,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33700.96,49.5,,33700.96,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3479.6,,,3479.6,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,47657.93,70,,47657.93,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1870.75,,,1870.75,Other,New York Medicaid APG methodology,1870.75,,,1870.75,Other,100% New York Medicaid APG,1870.75,,,1870.75,Other,100% New York Medicaid APG,1870.75,,,1870.75,Other,100% New York Medicaid APG,4209.2,,,4209.2,Other,225% New York Medicaid APG,2862.25,,,2862.25,Other,153% New York Medicaid APG,4209.2,,,4209.2,Other,225% New York Medicaid APG,2619.06,,,2619.06,Other,140% New York Medicaid APG,4209.2,,,4209.2,Other,225% New York Medicaid APG,4863.96,,,4863.96,Other,260% New York Medicaid APG,6061.24,,,6061.24,Other,324% New York Medicaid APG,4022.12,,,4022.12,Other,215% New York Medicaid APG,4022.12,,,4022.12,Other,215% New York Medicaid APG,2338.44,,,2338.44,Other,125% New York Medicaid APG,1870.75,50381.24,
Drainage of finger abscess,26010,CPT,,,,,,,,both,,,4210.98,3116.13,74,,3116.13,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,1894.94,45,,1894.94,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,2084.44,49.5,,2084.44,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,733.11,,,733.11,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,2947.69,70,,2947.69,percent of total billed charges,,697,,,697,Fee Schedule,,590.75,,,590.75,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,394.14,,,394.14,Other,New York Medicaid APG methodology,394.14,,,394.14,Other,100% New York Medicaid APG,394.14,,,394.14,Other,100% New York Medicaid APG,394.14,,,394.14,Other,100% New York Medicaid APG,886.83,,,886.83,Other,225% New York Medicaid APG,603.04,,,603.04,Other,153% New York Medicaid APG,886.83,,,886.83,Other,225% New York Medicaid APG,551.8,,,551.8,Other,140% New York Medicaid APG,886.83,,,886.83,Other,225% New York Medicaid APG,1024.78,,,1024.78,Other,260% New York Medicaid APG,1277.03,,,1277.03,Other,324% New York Medicaid APG,847.41,,,847.41,Other,215% New York Medicaid APG,847.41,,,847.41,Other,215% New York Medicaid APG,492.68,,,492.68,Other,125% New York Medicaid APG,394.14,9473,
Drainage of finger abscess,26011,CPT,,,,,,,,both,,,34101.75,25235.3,74,,25235.3,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15345.79,45,,15345.79,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,16880.37,49.5,,16880.37,percent of total billed charges,110% of Medicare,23189.19,68,,23189.19,percent of total billed charges,,1207.1,,,1207.1,Other,186% of Medicaid,27281.4,80,,27281.4,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,27281.4,80,,27281.4,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,23871.23,70,,23871.23,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,648.98,,,648.98,Other,New York Medicaid APG methodology,648.98,,,648.98,Other,100% New York Medicaid APG,648.98,,,648.98,Other,100% New York Medicaid APG,648.98,,,648.98,Other,100% New York Medicaid APG,1460.2,,,1460.2,Other,225% New York Medicaid APG,992.94,,,992.94,Other,153% New York Medicaid APG,1460.2,,,1460.2,Other,225% New York Medicaid APG,908.57,,,908.57,Other,140% New York Medicaid APG,1460.2,,,1460.2,Other,225% New York Medicaid APG,1687.34,,,1687.34,Other,260% New York Medicaid APG,2102.69,,,2102.69,Other,324% New York Medicaid APG,1395.3,,,1395.3,Other,215% New York Medicaid APG,1395.3,,,1395.3,Other,215% New York Medicaid APG,811.22,,,811.22,Other,125% New York Medicaid APG,648.98,27281.4,
Drain hand tendon sheath,26020,CPT,,,,,,,,both,,,68082.75,50381.24,74,,50381.24,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30637.24,45,,30637.24,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33700.96,49.5,,33700.96,percent of total billed charges,110% of Medicare,46296.27,68,,46296.27,percent of total billed charges,,2289.65,,,2289.65,Other,186% of Medicaid,54466.2,80,,54466.2,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,54466.2,80,,54466.2,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,47657.93,70,,47657.93,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1231,,,1231,Other,New York Medicaid APG methodology,1231,,,1231,Other,100% New York Medicaid APG,1231,,,1231,Other,100% New York Medicaid APG,1231,,,1231,Other,100% New York Medicaid APG,2769.74,,,2769.74,Other,225% New York Medicaid APG,1883.42,,,1883.42,Other,153% New York Medicaid APG,2769.74,,,2769.74,Other,225% New York Medicaid APG,1723.39,,,1723.39,Other,140% New York Medicaid APG,2769.74,,,2769.74,Other,225% New York Medicaid APG,3200.59,,,3200.59,Other,260% New York Medicaid APG,3988.42,,,3988.42,Other,324% New York Medicaid APG,2646.64,,,2646.64,Other,215% New York Medicaid APG,2646.64,,,2646.64,Other,215% New York Medicaid APG,1538.74,,,1538.74,Other,125% New York Medicaid APG,1231,54466.2,
Drainage of palm bursa,26025,CPT,,,,,,,,both,,,68082.75,50381.24,74,,50381.24,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30637.24,45,,30637.24,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33700.96,49.5,,33700.96,percent of total billed charges,110% of Medicare,46296.27,68,,46296.27,percent of total billed charges,,2289.65,,,2289.65,Other,186% of Medicaid,54466.2,80,,54466.2,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,54466.2,80,,54466.2,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,47657.93,70,,47657.93,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1231,,,1231,Other,New York Medicaid APG methodology,1231,,,1231,Other,100% New York Medicaid APG,1231,,,1231,Other,100% New York Medicaid APG,1231,,,1231,Other,100% New York Medicaid APG,2769.74,,,2769.74,Other,225% New York Medicaid APG,1883.42,,,1883.42,Other,153% New York Medicaid APG,2769.74,,,2769.74,Other,225% New York Medicaid APG,1723.39,,,1723.39,Other,140% New York Medicaid APG,2769.74,,,2769.74,Other,225% New York Medicaid APG,3200.59,,,3200.59,Other,260% New York Medicaid APG,3988.42,,,3988.42,Other,324% New York Medicaid APG,2646.64,,,2646.64,Other,215% New York Medicaid APG,2646.64,,,2646.64,Other,215% New York Medicaid APG,1538.74,,,1538.74,Other,125% New York Medicaid APG,1231,54466.2,
Drainage of palm bursas,26030,CPT,,,,,,,,both,,,68082.75,50381.24,74,,50381.24,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30637.24,45,,30637.24,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33700.96,49.5,,33700.96,percent of total billed charges,110% of Medicare,46296.27,68,,46296.27,percent of total billed charges,,2289.65,,,2289.65,Other,186% of Medicaid,54466.2,80,,54466.2,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,54466.2,80,,54466.2,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,47657.93,70,,47657.93,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1231,,,1231,Other,New York Medicaid APG methodology,1231,,,1231,Other,100% New York Medicaid APG,1231,,,1231,Other,100% New York Medicaid APG,1231,,,1231,Other,100% New York Medicaid APG,2769.74,,,2769.74,Other,225% New York Medicaid APG,1883.42,,,1883.42,Other,153% New York Medicaid APG,2769.74,,,2769.74,Other,225% New York Medicaid APG,1723.39,,,1723.39,Other,140% New York Medicaid APG,2769.74,,,2769.74,Other,225% New York Medicaid APG,3200.59,,,3200.59,Other,260% New York Medicaid APG,3988.42,,,3988.42,Other,324% New York Medicaid APG,2646.64,,,2646.64,Other,215% New York Medicaid APG,2646.64,,,2646.64,Other,215% New York Medicaid APG,1538.74,,,1538.74,Other,125% New York Medicaid APG,1231,54466.2,
Treat hand bone lesion,26034,CPT,,,,,,,,both,,,33805.49,25016.06,74,,25016.06,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15212.47,45,,15212.47,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,16733.72,49.5,,16733.72,percent of total billed charges,110% of Medicare,22987.73,68,,22987.73,percent of total billed charges,,2289.65,,,2289.65,Other,186% of Medicaid,27044.39,80,,27044.39,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,27044.39,80,,27044.39,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,23663.84,70,,23663.84,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1231,,,1231,Other,New York Medicaid APG methodology,1231,,,1231,Other,100% New York Medicaid APG,1231,,,1231,Other,100% New York Medicaid APG,1231,,,1231,Other,100% New York Medicaid APG,2769.74,,,2769.74,Other,225% New York Medicaid APG,1883.42,,,1883.42,Other,153% New York Medicaid APG,2769.74,,,2769.74,Other,225% New York Medicaid APG,1723.39,,,1723.39,Other,140% New York Medicaid APG,2769.74,,,2769.74,Other,225% New York Medicaid APG,3200.59,,,3200.59,Other,260% New York Medicaid APG,3988.42,,,3988.42,Other,324% New York Medicaid APG,2646.64,,,2646.64,Other,215% New York Medicaid APG,2646.64,,,2646.64,Other,215% New York Medicaid APG,1538.74,,,1538.74,Other,125% New York Medicaid APG,1231,27044.39,
Decompress fingers/hand,26035,CPT,,,,,,,,both,,,68082.75,50381.24,74,,50381.24,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30637.24,45,,30637.24,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33700.96,49.5,,33700.96,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3654.9,,,3654.9,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,47657.93,70,,47657.93,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1965,,,1965,Other,New York Medicaid APG methodology,1965,,,1965,Other,100% New York Medicaid APG,1965,,,1965,Other,100% New York Medicaid APG,1965,,,1965,Other,100% New York Medicaid APG,4421.25,,,4421.25,Other,225% New York Medicaid APG,3006.45,,,3006.45,Other,153% New York Medicaid APG,4421.25,,,4421.25,Other,225% New York Medicaid APG,2751,,,2751,Other,140% New York Medicaid APG,4421.25,,,4421.25,Other,225% New York Medicaid APG,5109,,,5109,Other,260% New York Medicaid APG,6366.6,,,6366.6,Other,324% New York Medicaid APG,4224.75,,,4224.75,Other,215% New York Medicaid APG,4224.75,,,4224.75,Other,215% New York Medicaid APG,2456.25,,,2456.25,Other,125% New York Medicaid APG,1965,50381.24,
Decompress fingers/hand,26037,CPT,,,,,,,,both,,,68082.75,50381.24,74,,50381.24,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30637.24,45,,30637.24,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33700.96,49.5,,33700.96,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3654.9,,,3654.9,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,47657.93,70,,47657.93,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1965,,,1965,Other,New York Medicaid APG methodology,1965,,,1965,Other,100% New York Medicaid APG,1965,,,1965,Other,100% New York Medicaid APG,1965,,,1965,Other,100% New York Medicaid APG,4421.25,,,4421.25,Other,225% New York Medicaid APG,3006.45,,,3006.45,Other,153% New York Medicaid APG,4421.25,,,4421.25,Other,225% New York Medicaid APG,2751,,,2751,Other,140% New York Medicaid APG,4421.25,,,4421.25,Other,225% New York Medicaid APG,5109,,,5109,Other,260% New York Medicaid APG,6366.6,,,6366.6,Other,324% New York Medicaid APG,4224.75,,,4224.75,Other,215% New York Medicaid APG,4224.75,,,4224.75,Other,215% New York Medicaid APG,2456.25,,,2456.25,Other,125% New York Medicaid APG,1965,50381.24,
Release palm contracture,26040,CPT,,,,,,,,both,,,33805.49,25016.06,74,,25016.06,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15212.47,45,,15212.47,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,16733.72,49.5,,16733.72,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2289.65,,,2289.65,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,23663.84,70,,23663.84,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1231,,,1231,Other,New York Medicaid APG methodology,1231,,,1231,Other,100% New York Medicaid APG,1231,,,1231,Other,100% New York Medicaid APG,1231,,,1231,Other,100% New York Medicaid APG,2769.74,,,2769.74,Other,225% New York Medicaid APG,1883.42,,,1883.42,Other,153% New York Medicaid APG,2769.74,,,2769.74,Other,225% New York Medicaid APG,1723.39,,,1723.39,Other,140% New York Medicaid APG,2769.74,,,2769.74,Other,225% New York Medicaid APG,3200.59,,,3200.59,Other,260% New York Medicaid APG,3988.42,,,3988.42,Other,324% New York Medicaid APG,2646.64,,,2646.64,Other,215% New York Medicaid APG,2646.64,,,2646.64,Other,215% New York Medicaid APG,1538.74,,,1538.74,Other,125% New York Medicaid APG,1231,25016.06,
Release palm contracture,26045,CPT,,,,,,,,both,,,68082.75,50381.24,74,,50381.24,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30637.24,45,,30637.24,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33700.96,49.5,,33700.96,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2289.65,,,2289.65,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,47657.93,70,,47657.93,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1231,,,1231,Other,New York Medicaid APG methodology,1231,,,1231,Other,100% New York Medicaid APG,1231,,,1231,Other,100% New York Medicaid APG,1231,,,1231,Other,100% New York Medicaid APG,2769.74,,,2769.74,Other,225% New York Medicaid APG,1883.42,,,1883.42,Other,153% New York Medicaid APG,2769.74,,,2769.74,Other,225% New York Medicaid APG,1723.39,,,1723.39,Other,140% New York Medicaid APG,2769.74,,,2769.74,Other,225% New York Medicaid APG,3200.59,,,3200.59,Other,260% New York Medicaid APG,3988.42,,,3988.42,Other,324% New York Medicaid APG,2646.64,,,2646.64,Other,215% New York Medicaid APG,2646.64,,,2646.64,Other,215% New York Medicaid APG,1538.74,,,1538.74,Other,125% New York Medicaid APG,1231,50381.24,
Incise finger tendon sheath,26055,CPT,,,,,,,,both,,,33711.03,24946.16,74,,24946.16,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15169.96,45,,15169.96,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,16686.96,49.5,,16686.96,percent of total billed charges,110% of Medicare,22923.5,68,,22923.5,percent of total billed charges,,2289.65,,,2289.65,Other,186% of Medicaid,26968.82,80,,26968.82,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,26968.82,80,,26968.82,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,23597.72,70,,23597.72,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1231,,,1231,Other,New York Medicaid APG methodology,1231,,,1231,Other,100% New York Medicaid APG,1231,,,1231,Other,100% New York Medicaid APG,1231,,,1231,Other,100% New York Medicaid APG,2769.74,,,2769.74,Other,225% New York Medicaid APG,1883.42,,,1883.42,Other,153% New York Medicaid APG,2769.74,,,2769.74,Other,225% New York Medicaid APG,1723.39,,,1723.39,Other,140% New York Medicaid APG,2769.74,,,2769.74,Other,225% New York Medicaid APG,3200.59,,,3200.59,Other,260% New York Medicaid APG,3988.42,,,3988.42,Other,324% New York Medicaid APG,2646.64,,,2646.64,Other,215% New York Medicaid APG,2646.64,,,2646.64,Other,215% New York Medicaid APG,1538.74,,,1538.74,Other,125% New York Medicaid APG,1231,26968.82,
Incision of finger tendon,26060,CPT,,,,,,,,both,,,33805.49,25016.06,74,,25016.06,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15212.47,45,,15212.47,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,16733.72,49.5,,16733.72,percent of total billed charges,110% of Medicare,22987.73,68,,22987.73,percent of total billed charges,,2289.65,,,2289.65,Other,186% of Medicaid,27044.39,80,,27044.39,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,27044.39,80,,27044.39,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,23663.84,70,,23663.84,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1231,,,1231,Other,New York Medicaid APG methodology,1231,,,1231,Other,100% New York Medicaid APG,1231,,,1231,Other,100% New York Medicaid APG,1231,,,1231,Other,100% New York Medicaid APG,2769.74,,,2769.74,Other,225% New York Medicaid APG,1883.42,,,1883.42,Other,153% New York Medicaid APG,2769.74,,,2769.74,Other,225% New York Medicaid APG,1723.39,,,1723.39,Other,140% New York Medicaid APG,2769.74,,,2769.74,Other,225% New York Medicaid APG,3200.59,,,3200.59,Other,260% New York Medicaid APG,3988.42,,,3988.42,Other,324% New York Medicaid APG,2646.64,,,2646.64,Other,215% New York Medicaid APG,2646.64,,,2646.64,Other,215% New York Medicaid APG,1538.74,,,1538.74,Other,125% New York Medicaid APG,1231,27044.39,
Explore/treat hand joint,26070,CPT,,,,,,,,both,,,33805.49,25016.06,74,,25016.06,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15212.47,45,,15212.47,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,16733.72,49.5,,16733.72,percent of total billed charges,110% of Medicare,22987.73,68,,22987.73,percent of total billed charges,,2289.65,,,2289.65,Other,186% of Medicaid,27044.39,80,,27044.39,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,27044.39,80,,27044.39,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,23663.84,70,,23663.84,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1231,,,1231,Other,New York Medicaid APG methodology,1231,,,1231,Other,100% New York Medicaid APG,1231,,,1231,Other,100% New York Medicaid APG,1231,,,1231,Other,100% New York Medicaid APG,2769.74,,,2769.74,Other,225% New York Medicaid APG,1883.42,,,1883.42,Other,153% New York Medicaid APG,2769.74,,,2769.74,Other,225% New York Medicaid APG,1723.39,,,1723.39,Other,140% New York Medicaid APG,2769.74,,,2769.74,Other,225% New York Medicaid APG,3200.59,,,3200.59,Other,260% New York Medicaid APG,3988.42,,,3988.42,Other,324% New York Medicaid APG,2646.64,,,2646.64,Other,215% New York Medicaid APG,2646.64,,,2646.64,Other,215% New York Medicaid APG,1538.74,,,1538.74,Other,125% New York Medicaid APG,1231,27044.39,
Explore/treat finger joint,26075,CPT,,,,,,,,both,,,68082.75,50381.24,74,,50381.24,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30637.24,45,,30637.24,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33700.96,49.5,,33700.96,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2289.65,,,2289.65,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,47657.93,70,,47657.93,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1231,,,1231,Other,New York Medicaid APG methodology,1231,,,1231,Other,100% New York Medicaid APG,1231,,,1231,Other,100% New York Medicaid APG,1231,,,1231,Other,100% New York Medicaid APG,2769.74,,,2769.74,Other,225% New York Medicaid APG,1883.42,,,1883.42,Other,153% New York Medicaid APG,2769.74,,,2769.74,Other,225% New York Medicaid APG,1723.39,,,1723.39,Other,140% New York Medicaid APG,2769.74,,,2769.74,Other,225% New York Medicaid APG,3200.59,,,3200.59,Other,260% New York Medicaid APG,3988.42,,,3988.42,Other,324% New York Medicaid APG,2646.64,,,2646.64,Other,215% New York Medicaid APG,2646.64,,,2646.64,Other,215% New York Medicaid APG,1538.74,,,1538.74,Other,125% New York Medicaid APG,1231,50381.24,
Explore/treat finger joint,26080,CPT,,,,,,,,both,,,33671.19,24916.68,74,,24916.68,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15152.04,45,,15152.04,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,16667.24,49.5,,16667.24,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2289.65,,,2289.65,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,23569.83,70,,23569.83,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1231,,,1231,Other,New York Medicaid APG methodology,1231,,,1231,Other,100% New York Medicaid APG,1231,,,1231,Other,100% New York Medicaid APG,1231,,,1231,Other,100% New York Medicaid APG,2769.74,,,2769.74,Other,225% New York Medicaid APG,1883.42,,,1883.42,Other,153% New York Medicaid APG,2769.74,,,2769.74,Other,225% New York Medicaid APG,1723.39,,,1723.39,Other,140% New York Medicaid APG,2769.74,,,2769.74,Other,225% New York Medicaid APG,3200.59,,,3200.59,Other,260% New York Medicaid APG,3988.42,,,3988.42,Other,324% New York Medicaid APG,2646.64,,,2646.64,Other,215% New York Medicaid APG,2646.64,,,2646.64,Other,215% New York Medicaid APG,1538.74,,,1538.74,Other,125% New York Medicaid APG,1231,24916.68,
Biopsy hand joint lining,26100,CPT,,,,,,,,both,,,68082.75,50381.24,74,,50381.24,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30637.24,45,,30637.24,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33700.96,49.5,,33700.96,percent of total billed charges,110% of Medicare,46296.27,68,,46296.27,percent of total billed charges,,2289.65,,,2289.65,Other,186% of Medicaid,54466.2,80,,54466.2,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,54466.2,80,,54466.2,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,47657.93,70,,47657.93,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1231,,,1231,Other,New York Medicaid APG methodology,1231,,,1231,Other,100% New York Medicaid APG,1231,,,1231,Other,100% New York Medicaid APG,1231,,,1231,Other,100% New York Medicaid APG,2769.74,,,2769.74,Other,225% New York Medicaid APG,1883.42,,,1883.42,Other,153% New York Medicaid APG,2769.74,,,2769.74,Other,225% New York Medicaid APG,1723.39,,,1723.39,Other,140% New York Medicaid APG,2769.74,,,2769.74,Other,225% New York Medicaid APG,3200.59,,,3200.59,Other,260% New York Medicaid APG,3988.42,,,3988.42,Other,324% New York Medicaid APG,2646.64,,,2646.64,Other,215% New York Medicaid APG,2646.64,,,2646.64,Other,215% New York Medicaid APG,1538.74,,,1538.74,Other,125% New York Medicaid APG,1231,54466.2,
Biopsy finger joint lining,26105,CPT,,,,,,,,both,,,68082.75,50381.24,74,,50381.24,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30637.24,45,,30637.24,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33700.96,49.5,,33700.96,percent of total billed charges,110% of Medicare,46296.27,68,,46296.27,percent of total billed charges,,2289.65,,,2289.65,Other,186% of Medicaid,54466.2,80,,54466.2,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,54466.2,80,,54466.2,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,47657.93,70,,47657.93,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1231,,,1231,Other,New York Medicaid APG methodology,1231,,,1231,Other,100% New York Medicaid APG,1231,,,1231,Other,100% New York Medicaid APG,1231,,,1231,Other,100% New York Medicaid APG,2769.74,,,2769.74,Other,225% New York Medicaid APG,1883.42,,,1883.42,Other,153% New York Medicaid APG,2769.74,,,2769.74,Other,225% New York Medicaid APG,1723.39,,,1723.39,Other,140% New York Medicaid APG,2769.74,,,2769.74,Other,225% New York Medicaid APG,3200.59,,,3200.59,Other,260% New York Medicaid APG,3988.42,,,3988.42,Other,324% New York Medicaid APG,2646.64,,,2646.64,Other,215% New York Medicaid APG,2646.64,,,2646.64,Other,215% New York Medicaid APG,1538.74,,,1538.74,Other,125% New York Medicaid APG,1231,54466.2,
Biopsy finger joint lining,26110,CPT,,,,,,,,both,,,33805.49,25016.06,74,,25016.06,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15212.47,45,,15212.47,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,16733.72,49.5,,16733.72,percent of total billed charges,110% of Medicare,22987.73,68,,22987.73,percent of total billed charges,,2289.65,,,2289.65,Other,186% of Medicaid,27044.39,80,,27044.39,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,27044.39,80,,27044.39,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,23663.84,70,,23663.84,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1231,,,1231,Other,New York Medicaid APG methodology,1231,,,1231,Other,100% New York Medicaid APG,1231,,,1231,Other,100% New York Medicaid APG,1231,,,1231,Other,100% New York Medicaid APG,2769.74,,,2769.74,Other,225% New York Medicaid APG,1883.42,,,1883.42,Other,153% New York Medicaid APG,2769.74,,,2769.74,Other,225% New York Medicaid APG,1723.39,,,1723.39,Other,140% New York Medicaid APG,2769.74,,,2769.74,Other,225% New York Medicaid APG,3200.59,,,3200.59,Other,260% New York Medicaid APG,3988.42,,,3988.42,Other,324% New York Medicaid APG,2646.64,,,2646.64,Other,215% New York Medicaid APG,2646.64,,,2646.64,Other,215% New York Medicaid APG,1538.74,,,1538.74,Other,125% New York Medicaid APG,1231,27044.39,
Exc hand les sc 1.5 cm/>,26111,CPT,,,,,,,,both,,,35595.01,26340.31,74,,26340.31,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,16017.75,45,,16017.75,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,17619.53,49.5,,17619.53,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2289.65,,,2289.65,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,24916.51,70,,24916.51,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1231,,,1231,Other,New York Medicaid APG methodology,1231,,,1231,Other,100% New York Medicaid APG,1231,,,1231,Other,100% New York Medicaid APG,1231,,,1231,Other,100% New York Medicaid APG,2769.74,,,2769.74,Other,225% New York Medicaid APG,1883.42,,,1883.42,Other,153% New York Medicaid APG,2769.74,,,2769.74,Other,225% New York Medicaid APG,1723.39,,,1723.39,Other,140% New York Medicaid APG,2769.74,,,2769.74,Other,225% New York Medicaid APG,3200.59,,,3200.59,Other,260% New York Medicaid APG,3988.42,,,3988.42,Other,324% New York Medicaid APG,2646.64,,,2646.64,Other,215% New York Medicaid APG,2646.64,,,2646.64,Other,215% New York Medicaid APG,1538.74,,,1538.74,Other,125% New York Medicaid APG,1231,26340.31,
Exc hand tum deep 1.5 cm/>,26113,CPT,,,,,,,,both,,,34101.75,25235.3,74,,25235.3,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15345.79,45,,15345.79,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,16880.37,49.5,,16880.37,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2289.65,,,2289.65,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,23871.23,70,,23871.23,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1231,,,1231,Other,New York Medicaid APG methodology,1231,,,1231,Other,100% New York Medicaid APG,1231,,,1231,Other,100% New York Medicaid APG,1231,,,1231,Other,100% New York Medicaid APG,2769.74,,,2769.74,Other,225% New York Medicaid APG,1883.42,,,1883.42,Other,153% New York Medicaid APG,2769.74,,,2769.74,Other,225% New York Medicaid APG,1723.39,,,1723.39,Other,140% New York Medicaid APG,2769.74,,,2769.74,Other,225% New York Medicaid APG,3200.59,,,3200.59,Other,260% New York Medicaid APG,3988.42,,,3988.42,Other,324% New York Medicaid APG,2646.64,,,2646.64,Other,215% New York Medicaid APG,2646.64,,,2646.64,Other,215% New York Medicaid APG,1538.74,,,1538.74,Other,125% New York Medicaid APG,1231,25235.3,
Exc hand les sc < 1.5 cm,26115,CPT,,,,,,,,both,,,33585.72,24853.43,74,,24853.43,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15113.57,45,,15113.57,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,16624.93,49.5,,16624.93,percent of total billed charges,110% of Medicare,22838.29,68,,22838.29,percent of total billed charges,,2289.65,,,2289.65,Other,186% of Medicaid,26868.58,80,,26868.58,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,26868.58,80,,26868.58,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,23510,70,,23510,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1231,,,1231,Other,New York Medicaid APG methodology,1231,,,1231,Other,100% New York Medicaid APG,1231,,,1231,Other,100% New York Medicaid APG,1231,,,1231,Other,100% New York Medicaid APG,2769.74,,,2769.74,Other,225% New York Medicaid APG,1883.42,,,1883.42,Other,153% New York Medicaid APG,2769.74,,,2769.74,Other,225% New York Medicaid APG,1723.39,,,1723.39,Other,140% New York Medicaid APG,2769.74,,,2769.74,Other,225% New York Medicaid APG,3200.59,,,3200.59,Other,260% New York Medicaid APG,3988.42,,,3988.42,Other,324% New York Medicaid APG,2646.64,,,2646.64,Other,215% New York Medicaid APG,2646.64,,,2646.64,Other,215% New York Medicaid APG,1538.74,,,1538.74,Other,125% New York Medicaid APG,1231,26868.58,
Exc hand tum deep < 1.5 cm,26116,CPT,,,,,,,,both,,,34505.64,25534.17,74,,25534.17,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15527.54,45,,15527.54,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,17080.29,49.5,,17080.29,percent of total billed charges,110% of Medicare,23463.84,68,,23463.84,percent of total billed charges,,2289.65,,,2289.65,Other,186% of Medicaid,27604.51,80,,27604.51,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,27604.51,80,,27604.51,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,24153.95,70,,24153.95,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1231,,,1231,Other,New York Medicaid APG methodology,1231,,,1231,Other,100% New York Medicaid APG,1231,,,1231,Other,100% New York Medicaid APG,1231,,,1231,Other,100% New York Medicaid APG,2769.74,,,2769.74,Other,225% New York Medicaid APG,1883.42,,,1883.42,Other,153% New York Medicaid APG,2769.74,,,2769.74,Other,225% New York Medicaid APG,1723.39,,,1723.39,Other,140% New York Medicaid APG,2769.74,,,2769.74,Other,225% New York Medicaid APG,3200.59,,,3200.59,Other,260% New York Medicaid APG,3988.42,,,3988.42,Other,324% New York Medicaid APG,2646.64,,,2646.64,Other,215% New York Medicaid APG,2646.64,,,2646.64,Other,215% New York Medicaid APG,1538.74,,,1538.74,Other,125% New York Medicaid APG,1231,27604.51,
Rad resect hand tumor < 3 cm,26117,CPT,,,,,,,,both,,,59767.2,44227.73,74,,44227.73,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,26895.24,45,,26895.24,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,29584.76,49.5,,29584.76,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3654.9,,,3654.9,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,41837.04,70,,41837.04,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1965,,,1965,Other,New York Medicaid APG methodology,1965,,,1965,Other,100% New York Medicaid APG,1965,,,1965,Other,100% New York Medicaid APG,1965,,,1965,Other,100% New York Medicaid APG,4421.25,,,4421.25,Other,225% New York Medicaid APG,3006.45,,,3006.45,Other,153% New York Medicaid APG,4421.25,,,4421.25,Other,225% New York Medicaid APG,2751,,,2751,Other,140% New York Medicaid APG,4421.25,,,4421.25,Other,225% New York Medicaid APG,5109,,,5109,Other,260% New York Medicaid APG,6366.6,,,6366.6,Other,324% New York Medicaid APG,4224.75,,,4224.75,Other,215% New York Medicaid APG,4224.75,,,4224.75,Other,215% New York Medicaid APG,2456.25,,,2456.25,Other,125% New York Medicaid APG,1965,44227.73,
Rad resect hand tumor 3 cm/>,26118,CPT,,,,,,,,both,,,59767.2,44227.73,74,,44227.73,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,26895.24,45,,26895.24,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,29584.76,49.5,,29584.76,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3654.9,,,3654.9,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,41837.04,70,,41837.04,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1965,,,1965,Other,New York Medicaid APG methodology,1965,,,1965,Other,100% New York Medicaid APG,1965,,,1965,Other,100% New York Medicaid APG,1965,,,1965,Other,100% New York Medicaid APG,4421.25,,,4421.25,Other,225% New York Medicaid APG,3006.45,,,3006.45,Other,153% New York Medicaid APG,4421.25,,,4421.25,Other,225% New York Medicaid APG,2751,,,2751,Other,140% New York Medicaid APG,4421.25,,,4421.25,Other,225% New York Medicaid APG,5109,,,5109,Other,260% New York Medicaid APG,6366.6,,,6366.6,Other,324% New York Medicaid APG,4224.75,,,4224.75,Other,215% New York Medicaid APG,4224.75,,,4224.75,Other,215% New York Medicaid APG,2456.25,,,2456.25,Other,125% New York Medicaid APG,1965,44227.73,
Release palm contracture,26121,CPT,,,,,,,,both,,,35559.44,26313.99,74,,26313.99,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,16001.75,45,,16001.75,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,17601.92,49.5,,17601.92,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3654.9,,,3654.9,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,24891.61,70,,24891.61,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1965,,,1965,Other,New York Medicaid APG methodology,1965,,,1965,Other,100% New York Medicaid APG,1965,,,1965,Other,100% New York Medicaid APG,1965,,,1965,Other,100% New York Medicaid APG,4421.25,,,4421.25,Other,225% New York Medicaid APG,3006.45,,,3006.45,Other,153% New York Medicaid APG,4421.25,,,4421.25,Other,225% New York Medicaid APG,2751,,,2751,Other,140% New York Medicaid APG,4421.25,,,4421.25,Other,225% New York Medicaid APG,5109,,,5109,Other,260% New York Medicaid APG,6366.6,,,6366.6,Other,324% New York Medicaid APG,4224.75,,,4224.75,Other,215% New York Medicaid APG,4224.75,,,4224.75,Other,215% New York Medicaid APG,2456.25,,,2456.25,Other,125% New York Medicaid APG,1965,26313.99,
Release palm contracture,26123,CPT,,,,,,,,both,,,35036.5,25927.01,74,,25927.01,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15766.43,45,,15766.43,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,17343.07,49.5,,17343.07,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3654.9,,,3654.9,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,24525.55,70,,24525.55,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1965,,,1965,Other,New York Medicaid APG methodology,1965,,,1965,Other,100% New York Medicaid APG,1965,,,1965,Other,100% New York Medicaid APG,1965,,,1965,Other,100% New York Medicaid APG,4421.25,,,4421.25,Other,225% New York Medicaid APG,3006.45,,,3006.45,Other,153% New York Medicaid APG,4421.25,,,4421.25,Other,225% New York Medicaid APG,2751,,,2751,Other,140% New York Medicaid APG,4421.25,,,4421.25,Other,225% New York Medicaid APG,5109,,,5109,Other,260% New York Medicaid APG,6366.6,,,6366.6,Other,324% New York Medicaid APG,4224.75,,,4224.75,Other,215% New York Medicaid APG,4224.75,,,4224.75,Other,215% New York Medicaid APG,2456.25,,,2456.25,Other,125% New York Medicaid APG,1965,25927.01,
Release palm contracture,26125,CPT,,,,,,,,both,,,83504,61792.96,74,,61792.96,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,37576.8,45,,37576.8,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,41334.48,49.5,,41334.48,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3654.9,,,3654.9,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,58452.8,70,,58452.8,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,1965,,,1965,Other,New York Medicaid APG methodology,1965,,,1965,Other,100% New York Medicaid APG,1965,,,1965,Other,100% New York Medicaid APG,1965,,,1965,Other,100% New York Medicaid APG,4421.25,,,4421.25,Other,225% New York Medicaid APG,3006.45,,,3006.45,Other,153% New York Medicaid APG,4421.25,,,4421.25,Other,225% New York Medicaid APG,2751,,,2751,Other,140% New York Medicaid APG,4421.25,,,4421.25,Other,225% New York Medicaid APG,5109,,,5109,Other,260% New York Medicaid APG,6366.6,,,6366.6,Other,324% New York Medicaid APG,4224.75,,,4224.75,Other,215% New York Medicaid APG,4224.75,,,4224.75,Other,215% New York Medicaid APG,2456.25,,,2456.25,Other,125% New York Medicaid APG,1965,61792.96,
Remove wrist joint lining,26130,CPT,,,,,,,,both,,,68082.75,50381.24,74,,50381.24,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30637.24,45,,30637.24,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33700.96,49.5,,33700.96,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2289.65,,,2289.65,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,47657.93,70,,47657.93,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1231,,,1231,Other,New York Medicaid APG methodology,1231,,,1231,Other,100% New York Medicaid APG,1231,,,1231,Other,100% New York Medicaid APG,1231,,,1231,Other,100% New York Medicaid APG,2769.74,,,2769.74,Other,225% New York Medicaid APG,1883.42,,,1883.42,Other,153% New York Medicaid APG,2769.74,,,2769.74,Other,225% New York Medicaid APG,1723.39,,,1723.39,Other,140% New York Medicaid APG,2769.74,,,2769.74,Other,225% New York Medicaid APG,3200.59,,,3200.59,Other,260% New York Medicaid APG,3988.42,,,3988.42,Other,324% New York Medicaid APG,2646.64,,,2646.64,Other,215% New York Medicaid APG,2646.64,,,2646.64,Other,215% New York Medicaid APG,1538.74,,,1538.74,Other,125% New York Medicaid APG,1231,50381.24,
Revise finger joint each,26135,CPT,,,,,,,,both,,,68082.75,50381.24,74,,50381.24,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30637.24,45,,30637.24,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33700.96,49.5,,33700.96,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3654.9,,,3654.9,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,47657.93,70,,47657.93,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1965,,,1965,Other,New York Medicaid APG methodology,1965,,,1965,Other,100% New York Medicaid APG,1965,,,1965,Other,100% New York Medicaid APG,1965,,,1965,Other,100% New York Medicaid APG,4421.25,,,4421.25,Other,225% New York Medicaid APG,3006.45,,,3006.45,Other,153% New York Medicaid APG,4421.25,,,4421.25,Other,225% New York Medicaid APG,2751,,,2751,Other,140% New York Medicaid APG,4421.25,,,4421.25,Other,225% New York Medicaid APG,5109,,,5109,Other,260% New York Medicaid APG,6366.6,,,6366.6,Other,324% New York Medicaid APG,4224.75,,,4224.75,Other,215% New York Medicaid APG,4224.75,,,4224.75,Other,215% New York Medicaid APG,2456.25,,,2456.25,Other,125% New York Medicaid APG,1965,50381.24,
Revise finger joint each,26140,CPT,,,,,,,,both,,,33805.49,25016.06,74,,25016.06,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15212.47,45,,15212.47,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,16733.72,49.5,,16733.72,percent of total billed charges,110% of Medicare,22987.73,68,,22987.73,percent of total billed charges,,2289.65,,,2289.65,Other,186% of Medicaid,27044.39,80,,27044.39,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,27044.39,80,,27044.39,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,23663.84,70,,23663.84,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1231,,,1231,Other,New York Medicaid APG methodology,1231,,,1231,Other,100% New York Medicaid APG,1231,,,1231,Other,100% New York Medicaid APG,1231,,,1231,Other,100% New York Medicaid APG,2769.74,,,2769.74,Other,225% New York Medicaid APG,1883.42,,,1883.42,Other,153% New York Medicaid APG,2769.74,,,2769.74,Other,225% New York Medicaid APG,1723.39,,,1723.39,Other,140% New York Medicaid APG,2769.74,,,2769.74,Other,225% New York Medicaid APG,3200.59,,,3200.59,Other,260% New York Medicaid APG,3988.42,,,3988.42,Other,324% New York Medicaid APG,2646.64,,,2646.64,Other,215% New York Medicaid APG,2646.64,,,2646.64,Other,215% New York Medicaid APG,1538.74,,,1538.74,Other,125% New York Medicaid APG,1231,27044.39,
Tendon excision palm/finger,26145,CPT,,,,,,,,both,,,33317,24654.58,74,,24654.58,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,14992.65,45,,14992.65,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,16491.92,49.5,,16491.92,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3654.9,,,3654.9,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,23321.9,70,,23321.9,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1965,,,1965,Other,New York Medicaid APG methodology,1965,,,1965,Other,100% New York Medicaid APG,1965,,,1965,Other,100% New York Medicaid APG,1965,,,1965,Other,100% New York Medicaid APG,4421.25,,,4421.25,Other,225% New York Medicaid APG,3006.45,,,3006.45,Other,153% New York Medicaid APG,4421.25,,,4421.25,Other,225% New York Medicaid APG,2751,,,2751,Other,140% New York Medicaid APG,4421.25,,,4421.25,Other,225% New York Medicaid APG,5109,,,5109,Other,260% New York Medicaid APG,6366.6,,,6366.6,Other,324% New York Medicaid APG,4224.75,,,4224.75,Other,215% New York Medicaid APG,4224.75,,,4224.75,Other,215% New York Medicaid APG,2456.25,,,2456.25,Other,125% New York Medicaid APG,1965,24654.58,
Remove tendon sheath lesion,26160,CPT,,,,,,,,both,,,33778.34,24995.97,74,,24995.97,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15200.25,45,,15200.25,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,16720.28,49.5,,16720.28,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2289.65,,,2289.65,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,23644.84,70,,23644.84,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1231,,,1231,Other,New York Medicaid APG methodology,1231,,,1231,Other,100% New York Medicaid APG,1231,,,1231,Other,100% New York Medicaid APG,1231,,,1231,Other,100% New York Medicaid APG,2769.74,,,2769.74,Other,225% New York Medicaid APG,1883.42,,,1883.42,Other,153% New York Medicaid APG,2769.74,,,2769.74,Other,225% New York Medicaid APG,1723.39,,,1723.39,Other,140% New York Medicaid APG,2769.74,,,2769.74,Other,225% New York Medicaid APG,3200.59,,,3200.59,Other,260% New York Medicaid APG,3988.42,,,3988.42,Other,324% New York Medicaid APG,2646.64,,,2646.64,Other,215% New York Medicaid APG,2646.64,,,2646.64,Other,215% New York Medicaid APG,1538.74,,,1538.74,Other,125% New York Medicaid APG,1231,24995.97,
Removal of palm tendon each,26170,CPT,,,,,,,,both,,,33805.49,25016.06,74,,25016.06,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15212.47,45,,15212.47,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,16733.72,49.5,,16733.72,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2289.65,,,2289.65,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,23663.84,70,,23663.84,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1231,,,1231,Other,New York Medicaid APG methodology,1231,,,1231,Other,100% New York Medicaid APG,1231,,,1231,Other,100% New York Medicaid APG,1231,,,1231,Other,100% New York Medicaid APG,2769.74,,,2769.74,Other,225% New York Medicaid APG,1883.42,,,1883.42,Other,153% New York Medicaid APG,2769.74,,,2769.74,Other,225% New York Medicaid APG,1723.39,,,1723.39,Other,140% New York Medicaid APG,2769.74,,,2769.74,Other,225% New York Medicaid APG,3200.59,,,3200.59,Other,260% New York Medicaid APG,3988.42,,,3988.42,Other,324% New York Medicaid APG,2646.64,,,2646.64,Other,215% New York Medicaid APG,2646.64,,,2646.64,Other,215% New York Medicaid APG,1538.74,,,1538.74,Other,125% New York Medicaid APG,1231,25016.06,
Removal of finger tendon,26180,CPT,,,,,,,,both,,,33805.49,25016.06,74,,25016.06,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15212.47,45,,15212.47,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,16733.72,49.5,,16733.72,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2289.65,,,2289.65,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,23663.84,70,,23663.84,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1231,,,1231,Other,New York Medicaid APG methodology,1231,,,1231,Other,100% New York Medicaid APG,1231,,,1231,Other,100% New York Medicaid APG,1231,,,1231,Other,100% New York Medicaid APG,2769.74,,,2769.74,Other,225% New York Medicaid APG,1883.42,,,1883.42,Other,153% New York Medicaid APG,2769.74,,,2769.74,Other,225% New York Medicaid APG,1723.39,,,1723.39,Other,140% New York Medicaid APG,2769.74,,,2769.74,Other,225% New York Medicaid APG,3200.59,,,3200.59,Other,260% New York Medicaid APG,3988.42,,,3988.42,Other,324% New York Medicaid APG,2646.64,,,2646.64,Other,215% New York Medicaid APG,2646.64,,,2646.64,Other,215% New York Medicaid APG,1538.74,,,1538.74,Other,125% New York Medicaid APG,1231,25016.06,
Remove finger bone,26185,CPT,,,,,,,,both,,,33805.49,25016.06,74,,25016.06,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15212.47,45,,15212.47,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,16733.72,49.5,,16733.72,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2289.65,,,2289.65,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,23663.84,70,,23663.84,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1231,,,1231,Other,New York Medicaid APG methodology,1231,,,1231,Other,100% New York Medicaid APG,1231,,,1231,Other,100% New York Medicaid APG,1231,,,1231,Other,100% New York Medicaid APG,2769.74,,,2769.74,Other,225% New York Medicaid APG,1883.42,,,1883.42,Other,153% New York Medicaid APG,2769.74,,,2769.74,Other,225% New York Medicaid APG,1723.39,,,1723.39,Other,140% New York Medicaid APG,2769.74,,,2769.74,Other,225% New York Medicaid APG,3200.59,,,3200.59,Other,260% New York Medicaid APG,3988.42,,,3988.42,Other,324% New York Medicaid APG,2646.64,,,2646.64,Other,215% New York Medicaid APG,2646.64,,,2646.64,Other,215% New York Medicaid APG,1538.74,,,1538.74,Other,125% New York Medicaid APG,1231,25016.06,
Remove hand bone lesion,26200,CPT,,,,,,,,both,,,41803.66,30934.71,74,,30934.71,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,18811.65,45,,18811.65,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,20692.81,49.5,,20692.81,percent of total billed charges,110% of Medicare,28426.49,68,,28426.49,percent of total billed charges,,2289.65,,,2289.65,Other,186% of Medicaid,33442.93,80,,33442.93,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,33442.93,80,,33442.93,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,29262.56,70,,29262.56,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1231,,,1231,Other,New York Medicaid APG methodology,1231,,,1231,Other,100% New York Medicaid APG,1231,,,1231,Other,100% New York Medicaid APG,1231,,,1231,Other,100% New York Medicaid APG,2769.74,,,2769.74,Other,225% New York Medicaid APG,1883.42,,,1883.42,Other,153% New York Medicaid APG,2769.74,,,2769.74,Other,225% New York Medicaid APG,1723.39,,,1723.39,Other,140% New York Medicaid APG,2769.74,,,2769.74,Other,225% New York Medicaid APG,3200.59,,,3200.59,Other,260% New York Medicaid APG,3988.42,,,3988.42,Other,324% New York Medicaid APG,2646.64,,,2646.64,Other,215% New York Medicaid APG,2646.64,,,2646.64,Other,215% New York Medicaid APG,1538.74,,,1538.74,Other,125% New York Medicaid APG,1231,33442.93,
Remove/graft bone lesion,26205,CPT,,,,,,,,both,,,150476.65,111352.72,74,,111352.72,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,67714.49,45,,67714.49,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,74485.94,49.5,,74485.94,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3654.9,,,3654.9,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,105333.66,70,,105333.66,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1965,,,1965,Other,New York Medicaid APG methodology,1965,,,1965,Other,100% New York Medicaid APG,1965,,,1965,Other,100% New York Medicaid APG,1965,,,1965,Other,100% New York Medicaid APG,4421.25,,,4421.25,Other,225% New York Medicaid APG,3006.45,,,3006.45,Other,153% New York Medicaid APG,4421.25,,,4421.25,Other,225% New York Medicaid APG,2751,,,2751,Other,140% New York Medicaid APG,4421.25,,,4421.25,Other,225% New York Medicaid APG,5109,,,5109,Other,260% New York Medicaid APG,6366.6,,,6366.6,Other,324% New York Medicaid APG,4224.75,,,4224.75,Other,215% New York Medicaid APG,4224.75,,,4224.75,Other,215% New York Medicaid APG,2456.25,,,2456.25,Other,125% New York Medicaid APG,1965,111352.72,
Removal of finger lesion,26210,CPT,,,,,,,,both,,,33805.49,25016.06,74,,25016.06,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15212.47,45,,15212.47,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,16733.72,49.5,,16733.72,percent of total billed charges,110% of Medicare,22987.73,68,,22987.73,percent of total billed charges,,2289.65,,,2289.65,Other,186% of Medicaid,27044.39,80,,27044.39,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,27044.39,80,,27044.39,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,23663.84,70,,23663.84,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1231,,,1231,Other,New York Medicaid APG methodology,1231,,,1231,Other,100% New York Medicaid APG,1231,,,1231,Other,100% New York Medicaid APG,1231,,,1231,Other,100% New York Medicaid APG,2769.74,,,2769.74,Other,225% New York Medicaid APG,1883.42,,,1883.42,Other,153% New York Medicaid APG,2769.74,,,2769.74,Other,225% New York Medicaid APG,1723.39,,,1723.39,Other,140% New York Medicaid APG,2769.74,,,2769.74,Other,225% New York Medicaid APG,3200.59,,,3200.59,Other,260% New York Medicaid APG,3988.42,,,3988.42,Other,324% New York Medicaid APG,2646.64,,,2646.64,Other,215% New York Medicaid APG,2646.64,,,2646.64,Other,215% New York Medicaid APG,1538.74,,,1538.74,Other,125% New York Medicaid APG,1231,27044.39,
Remove/graft finger lesion,26215,CPT,,,,,,,,both,,,68082.75,50381.24,74,,50381.24,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30637.24,45,,30637.24,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33700.96,49.5,,33700.96,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3654.9,,,3654.9,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,47657.93,70,,47657.93,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1965,,,1965,Other,New York Medicaid APG methodology,1965,,,1965,Other,100% New York Medicaid APG,1965,,,1965,Other,100% New York Medicaid APG,1965,,,1965,Other,100% New York Medicaid APG,4421.25,,,4421.25,Other,225% New York Medicaid APG,3006.45,,,3006.45,Other,153% New York Medicaid APG,4421.25,,,4421.25,Other,225% New York Medicaid APG,2751,,,2751,Other,140% New York Medicaid APG,4421.25,,,4421.25,Other,225% New York Medicaid APG,5109,,,5109,Other,260% New York Medicaid APG,6366.6,,,6366.6,Other,324% New York Medicaid APG,4224.75,,,4224.75,Other,215% New York Medicaid APG,4224.75,,,4224.75,Other,215% New York Medicaid APG,2456.25,,,2456.25,Other,125% New York Medicaid APG,1965,50381.24,
Partial removal of hand bone,26230,CPT,,,,,,,,both,,,39242.3,29039.3,74,,29039.3,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,17659.04,45,,17659.04,percent of total billed charges,Medicare Ratio of cost to charges,5954,,"100% primary, 50% supplemental procedure",5954,Other,Aetna ASC Grouper,5359,,"100% primary, 50% supplemental procedure",5359,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,19424.94,49.5,,19424.94,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3654.9,,,3654.9,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,27469.61,70,,27469.61,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1965,,,1965,Other,New York Medicaid APG methodology,1965,,,1965,Other,100% New York Medicaid APG,1965,,,1965,Other,100% New York Medicaid APG,1965,,,1965,Other,100% New York Medicaid APG,4421.25,,,4421.25,Other,225% New York Medicaid APG,3006.45,,,3006.45,Other,153% New York Medicaid APG,4421.25,,,4421.25,Other,225% New York Medicaid APG,2751,,,2751,Other,140% New York Medicaid APG,4421.25,,,4421.25,Other,225% New York Medicaid APG,5109,,,5109,Other,260% New York Medicaid APG,6366.6,,,6366.6,Other,324% New York Medicaid APG,4224.75,,,4224.75,Other,215% New York Medicaid APG,4224.75,,,4224.75,Other,215% New York Medicaid APG,2456.25,,,2456.25,Other,125% New York Medicaid APG,1965,29039.3,
Partial removal finger bone,26235,CPT,,,,,,,,both,,,33805.49,25016.06,74,,25016.06,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15212.47,45,,15212.47,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,16733.72,49.5,,16733.72,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3654.9,,,3654.9,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,23663.84,70,,23663.84,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1965,,,1965,Other,New York Medicaid APG methodology,1965,,,1965,Other,100% New York Medicaid APG,1965,,,1965,Other,100% New York Medicaid APG,1965,,,1965,Other,100% New York Medicaid APG,4421.25,,,4421.25,Other,225% New York Medicaid APG,3006.45,,,3006.45,Other,153% New York Medicaid APG,4421.25,,,4421.25,Other,225% New York Medicaid APG,2751,,,2751,Other,140% New York Medicaid APG,4421.25,,,4421.25,Other,225% New York Medicaid APG,5109,,,5109,Other,260% New York Medicaid APG,6366.6,,,6366.6,Other,324% New York Medicaid APG,4224.75,,,4224.75,Other,215% New York Medicaid APG,4224.75,,,4224.75,Other,215% New York Medicaid APG,2456.25,,,2456.25,Other,125% New York Medicaid APG,1965,25016.06,
Partial removal finger bone,26236,CPT,,,,,,,,both,,,33805.49,25016.06,74,,25016.06,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15212.47,45,,15212.47,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,16733.72,49.5,,16733.72,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2289.65,,,2289.65,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,23663.84,70,,23663.84,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1231,,,1231,Other,New York Medicaid APG methodology,1231,,,1231,Other,100% New York Medicaid APG,1231,,,1231,Other,100% New York Medicaid APG,1231,,,1231,Other,100% New York Medicaid APG,2769.74,,,2769.74,Other,225% New York Medicaid APG,1883.42,,,1883.42,Other,153% New York Medicaid APG,2769.74,,,2769.74,Other,225% New York Medicaid APG,1723.39,,,1723.39,Other,140% New York Medicaid APG,2769.74,,,2769.74,Other,225% New York Medicaid APG,3200.59,,,3200.59,Other,260% New York Medicaid APG,3988.42,,,3988.42,Other,324% New York Medicaid APG,2646.64,,,2646.64,Other,215% New York Medicaid APG,2646.64,,,2646.64,Other,215% New York Medicaid APG,1538.74,,,1538.74,Other,125% New York Medicaid APG,1231,25016.06,
Extensive hand surgery,26250,CPT,,,,,,,,both,,,68082.75,50381.24,74,,50381.24,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30637.24,45,,30637.24,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33700.96,49.5,,33700.96,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2289.65,,,2289.65,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,47657.93,70,,47657.93,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1231,,,1231,Other,New York Medicaid APG methodology,1231,,,1231,Other,100% New York Medicaid APG,1231,,,1231,Other,100% New York Medicaid APG,1231,,,1231,Other,100% New York Medicaid APG,2769.74,,,2769.74,Other,225% New York Medicaid APG,1883.42,,,1883.42,Other,153% New York Medicaid APG,2769.74,,,2769.74,Other,225% New York Medicaid APG,1723.39,,,1723.39,Other,140% New York Medicaid APG,2769.74,,,2769.74,Other,225% New York Medicaid APG,3200.59,,,3200.59,Other,260% New York Medicaid APG,3988.42,,,3988.42,Other,324% New York Medicaid APG,2646.64,,,2646.64,Other,215% New York Medicaid APG,2646.64,,,2646.64,Other,215% New York Medicaid APG,1538.74,,,1538.74,Other,125% New York Medicaid APG,1231,50381.24,
Resect prox finger tumor,26260,CPT,,,,,,,,both,,,41609.73,30791.2,74,,30791.2,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,18724.38,45,,18724.38,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,20596.82,49.5,,20596.82,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3654.9,,,3654.9,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,29126.81,70,,29126.81,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1965,,,1965,Other,New York Medicaid APG methodology,1965,,,1965,Other,100% New York Medicaid APG,1965,,,1965,Other,100% New York Medicaid APG,1965,,,1965,Other,100% New York Medicaid APG,4421.25,,,4421.25,Other,225% New York Medicaid APG,3006.45,,,3006.45,Other,153% New York Medicaid APG,4421.25,,,4421.25,Other,225% New York Medicaid APG,2751,,,2751,Other,140% New York Medicaid APG,4421.25,,,4421.25,Other,225% New York Medicaid APG,5109,,,5109,Other,260% New York Medicaid APG,6366.6,,,6366.6,Other,324% New York Medicaid APG,4224.75,,,4224.75,Other,215% New York Medicaid APG,4224.75,,,4224.75,Other,215% New York Medicaid APG,2456.25,,,2456.25,Other,125% New York Medicaid APG,1965,30791.2,
Resect distal finger tumor,26262,CPT,,,,,,,,both,,,33805.49,25016.06,74,,25016.06,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15212.47,45,,15212.47,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,16733.72,49.5,,16733.72,percent of total billed charges,110% of Medicare,22987.73,68,,22987.73,percent of total billed charges,,2289.65,,,2289.65,Other,186% of Medicaid,27044.39,80,,27044.39,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,27044.39,80,,27044.39,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,23663.84,70,,23663.84,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1231,,,1231,Other,New York Medicaid APG methodology,1231,,,1231,Other,100% New York Medicaid APG,1231,,,1231,Other,100% New York Medicaid APG,1231,,,1231,Other,100% New York Medicaid APG,2769.74,,,2769.74,Other,225% New York Medicaid APG,1883.42,,,1883.42,Other,153% New York Medicaid APG,2769.74,,,2769.74,Other,225% New York Medicaid APG,1723.39,,,1723.39,Other,140% New York Medicaid APG,2769.74,,,2769.74,Other,225% New York Medicaid APG,3200.59,,,3200.59,Other,260% New York Medicaid APG,3988.42,,,3988.42,Other,324% New York Medicaid APG,2646.64,,,2646.64,Other,215% New York Medicaid APG,2646.64,,,2646.64,Other,215% New York Medicaid APG,1538.74,,,1538.74,Other,125% New York Medicaid APG,1231,27044.39,
Removal of implant from hand,26320,CPT,,,,,,,,both,,,35678.49,26402.08,74,,26402.08,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,16055.32,45,,16055.32,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,17660.85,49.5,,17660.85,percent of total billed charges,110% of Medicare,24261.37,68,,24261.37,percent of total billed charges,,2289.65,,,2289.65,Other,186% of Medicaid,28542.79,80,,28542.79,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,28542.79,80,,28542.79,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,24974.94,70,,24974.94,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1231,,,1231,Other,New York Medicaid APG methodology,1231,,,1231,Other,100% New York Medicaid APG,1231,,,1231,Other,100% New York Medicaid APG,1231,,,1231,Other,100% New York Medicaid APG,2769.74,,,2769.74,Other,225% New York Medicaid APG,1883.42,,,1883.42,Other,153% New York Medicaid APG,2769.74,,,2769.74,Other,225% New York Medicaid APG,1723.39,,,1723.39,Other,140% New York Medicaid APG,2769.74,,,2769.74,Other,225% New York Medicaid APG,3200.59,,,3200.59,Other,260% New York Medicaid APG,3988.42,,,3988.42,Other,324% New York Medicaid APG,2646.64,,,2646.64,Other,215% New York Medicaid APG,2646.64,,,2646.64,Other,215% New York Medicaid APG,1538.74,,,1538.74,Other,125% New York Medicaid APG,1231,28542.79,
Manipulate finger w/anesth,26340,CPT,,,,,,,,both,,,33748.75,24974.08,74,,24974.08,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15186.94,45,,15186.94,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,16705.63,49.5,,16705.63,percent of total billed charges,110% of Medicare,22949.15,68,,22949.15,percent of total billed charges,,1730.38,,,1730.38,Other,186% of Medicaid,26999,80,,26999,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,26999,80,,26999,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,23624.13,70,,23624.13,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,930.31,,,930.31,Other,New York Medicaid APG methodology,930.31,,,930.31,Other,100% New York Medicaid APG,930.31,,,930.31,Other,100% New York Medicaid APG,930.31,,,930.31,Other,100% New York Medicaid APG,2093.21,,,2093.21,Other,225% New York Medicaid APG,1423.38,,,1423.38,Other,153% New York Medicaid APG,2093.21,,,2093.21,Other,225% New York Medicaid APG,1302.44,,,1302.44,Other,140% New York Medicaid APG,2093.21,,,2093.21,Other,225% New York Medicaid APG,2418.82,,,2418.82,Other,260% New York Medicaid APG,3014.22,,,3014.22,Other,324% New York Medicaid APG,2000.18,,,2000.18,Other,215% New York Medicaid APG,2000.18,,,2000.18,Other,215% New York Medicaid APG,1162.89,,,1162.89,Other,125% New York Medicaid APG,930.31,26999,
Manipulat palm cord post inj,26341,CPT,,,,,,,,both,,,4960.23,3670.57,74,,3670.57,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,2232.1,45,,2232.1,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,2455.31,49.5,,2455.31,percent of total billed charges,110% of Medicare,3372.96,68,,3372.96,percent of total billed charges,,1031.43,,,1031.43,Other,186% of Medicaid,3968.18,80,,3968.18,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,3968.18,80,,3968.18,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,3472.16,70,,3472.16,percent of total billed charges,,387.04,,,387.04,Fee Schedule,,328.04,,,328.04,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,554.53,,,554.53,Other,New York Medicaid APG methodology,554.53,,,554.53,Other,100% New York Medicaid APG,554.53,,,554.53,Other,100% New York Medicaid APG,554.53,,,554.53,Other,100% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,848.43,,,848.43,Other,153% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,776.34,,,776.34,Other,140% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,1441.78,,,1441.78,Other,260% New York Medicaid APG,1796.68,,,1796.68,Other,324% New York Medicaid APG,1192.24,,,1192.24,Other,215% New York Medicaid APG,1192.24,,,1192.24,Other,215% New York Medicaid APG,693.16,,,693.16,Other,125% New York Medicaid APG,328.04,7216,
Repair finger/hand tendon,26350,CPT,,,,,,,,both,,,33832.37,25035.95,74,,25035.95,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15224.57,45,,15224.57,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,16747.02,49.5,,16747.02,percent of total billed charges,110% of Medicare,23006.01,68,,23006.01,percent of total billed charges,,2289.65,,,2289.65,Other,186% of Medicaid,27065.9,80,,27065.9,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,27065.9,80,,27065.9,percent of total billed charges,,7216,,,7216,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,23682.66,70,,23682.66,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1231,,,1231,Other,New York Medicaid APG methodology,1231,,,1231,Other,100% New York Medicaid APG,1231,,,1231,Other,100% New York Medicaid APG,1231,,,1231,Other,100% New York Medicaid APG,2769.74,,,2769.74,Other,225% New York Medicaid APG,1883.42,,,1883.42,Other,153% New York Medicaid APG,2769.74,,,2769.74,Other,225% New York Medicaid APG,1723.39,,,1723.39,Other,140% New York Medicaid APG,2769.74,,,2769.74,Other,225% New York Medicaid APG,3200.59,,,3200.59,Other,260% New York Medicaid APG,3988.42,,,3988.42,Other,324% New York Medicaid APG,2646.64,,,2646.64,Other,215% New York Medicaid APG,2646.64,,,2646.64,Other,215% New York Medicaid APG,1538.74,,,1538.74,Other,125% New York Medicaid APG,1231,27065.9,
Repair/graft hand tendon,26352,CPT,,,,,,,,both,,,150476.65,111352.72,74,,111352.72,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,67714.49,45,,67714.49,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,74485.94,49.5,,74485.94,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3654.9,,,3654.9,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,105333.66,70,,105333.66,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1965,,,1965,Other,New York Medicaid APG methodology,1965,,,1965,Other,100% New York Medicaid APG,1965,,,1965,Other,100% New York Medicaid APG,1965,,,1965,Other,100% New York Medicaid APG,4421.25,,,4421.25,Other,225% New York Medicaid APG,3006.45,,,3006.45,Other,153% New York Medicaid APG,4421.25,,,4421.25,Other,225% New York Medicaid APG,2751,,,2751,Other,140% New York Medicaid APG,4421.25,,,4421.25,Other,225% New York Medicaid APG,5109,,,5109,Other,260% New York Medicaid APG,6366.6,,,6366.6,Other,324% New York Medicaid APG,4224.75,,,4224.75,Other,215% New York Medicaid APG,4224.75,,,4224.75,Other,215% New York Medicaid APG,2456.25,,,2456.25,Other,125% New York Medicaid APG,1965,111352.72,
Repair finger/hand tendon,26356,CPT,,,,,,,,both,,,40034.5,29625.53,74,,29625.53,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,18015.53,45,,18015.53,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,19817.08,49.5,,19817.08,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3654.9,,,3654.9,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,28024.15,70,,28024.15,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1965,,,1965,Other,New York Medicaid APG methodology,1965,,,1965,Other,100% New York Medicaid APG,1965,,,1965,Other,100% New York Medicaid APG,1965,,,1965,Other,100% New York Medicaid APG,4421.25,,,4421.25,Other,225% New York Medicaid APG,3006.45,,,3006.45,Other,153% New York Medicaid APG,4421.25,,,4421.25,Other,225% New York Medicaid APG,2751,,,2751,Other,140% New York Medicaid APG,4421.25,,,4421.25,Other,225% New York Medicaid APG,5109,,,5109,Other,260% New York Medicaid APG,6366.6,,,6366.6,Other,324% New York Medicaid APG,4224.75,,,4224.75,Other,215% New York Medicaid APG,4224.75,,,4224.75,Other,215% New York Medicaid APG,2456.25,,,2456.25,Other,125% New York Medicaid APG,1965,29625.53,
Repair finger/hand tendon,26357,CPT,,,,,,,,both,,,68082.75,50381.24,74,,50381.24,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30637.24,45,,30637.24,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33700.96,49.5,,33700.96,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3654.9,,,3654.9,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,47657.93,70,,47657.93,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1965,,,1965,Other,New York Medicaid APG methodology,1965,,,1965,Other,100% New York Medicaid APG,1965,,,1965,Other,100% New York Medicaid APG,1965,,,1965,Other,100% New York Medicaid APG,4421.25,,,4421.25,Other,225% New York Medicaid APG,3006.45,,,3006.45,Other,153% New York Medicaid APG,4421.25,,,4421.25,Other,225% New York Medicaid APG,2751,,,2751,Other,140% New York Medicaid APG,4421.25,,,4421.25,Other,225% New York Medicaid APG,5109,,,5109,Other,260% New York Medicaid APG,6366.6,,,6366.6,Other,324% New York Medicaid APG,4224.75,,,4224.75,Other,215% New York Medicaid APG,4224.75,,,4224.75,Other,215% New York Medicaid APG,2456.25,,,2456.25,Other,125% New York Medicaid APG,1965,50381.24,
Repair/graft hand tendon,26358,CPT,,,,,,,,both,,,54507.34,40335.43,74,,40335.43,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,24528.3,45,,24528.3,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,26981.13,49.5,,26981.13,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3654.9,,,3654.9,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,38155.14,70,,38155.14,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1965,,,1965,Other,New York Medicaid APG methodology,1965,,,1965,Other,100% New York Medicaid APG,1965,,,1965,Other,100% New York Medicaid APG,1965,,,1965,Other,100% New York Medicaid APG,4421.25,,,4421.25,Other,225% New York Medicaid APG,3006.45,,,3006.45,Other,153% New York Medicaid APG,4421.25,,,4421.25,Other,225% New York Medicaid APG,2751,,,2751,Other,140% New York Medicaid APG,4421.25,,,4421.25,Other,225% New York Medicaid APG,5109,,,5109,Other,260% New York Medicaid APG,6366.6,,,6366.6,Other,324% New York Medicaid APG,4224.75,,,4224.75,Other,215% New York Medicaid APG,4224.75,,,4224.75,Other,215% New York Medicaid APG,2456.25,,,2456.25,Other,125% New York Medicaid APG,1965,40335.43,
Repair finger/hand tendon,26370,CPT,,,,,,,,both,,,37850.35,28009.26,74,,28009.26,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,17032.66,45,,17032.66,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,18735.92,49.5,,18735.92,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3654.9,,,3654.9,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,26495.25,70,,26495.25,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1965,,,1965,Other,New York Medicaid APG methodology,1965,,,1965,Other,100% New York Medicaid APG,1965,,,1965,Other,100% New York Medicaid APG,1965,,,1965,Other,100% New York Medicaid APG,4421.25,,,4421.25,Other,225% New York Medicaid APG,3006.45,,,3006.45,Other,153% New York Medicaid APG,4421.25,,,4421.25,Other,225% New York Medicaid APG,2751,,,2751,Other,140% New York Medicaid APG,4421.25,,,4421.25,Other,225% New York Medicaid APG,5109,,,5109,Other,260% New York Medicaid APG,6366.6,,,6366.6,Other,324% New York Medicaid APG,4224.75,,,4224.75,Other,215% New York Medicaid APG,4224.75,,,4224.75,Other,215% New York Medicaid APG,2456.25,,,2456.25,Other,125% New York Medicaid APG,1965,28009.26,
Repair/graft hand tendon,26372,CPT,,,,,,,,both,,,150476.65,111352.72,74,,111352.72,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,67714.49,45,,67714.49,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,74485.94,49.5,,74485.94,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3654.9,,,3654.9,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,105333.66,70,,105333.66,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1965,,,1965,Other,New York Medicaid APG methodology,1965,,,1965,Other,100% New York Medicaid APG,1965,,,1965,Other,100% New York Medicaid APG,1965,,,1965,Other,100% New York Medicaid APG,4421.25,,,4421.25,Other,225% New York Medicaid APG,3006.45,,,3006.45,Other,153% New York Medicaid APG,4421.25,,,4421.25,Other,225% New York Medicaid APG,2751,,,2751,Other,140% New York Medicaid APG,4421.25,,,4421.25,Other,225% New York Medicaid APG,5109,,,5109,Other,260% New York Medicaid APG,6366.6,,,6366.6,Other,324% New York Medicaid APG,4224.75,,,4224.75,Other,215% New York Medicaid APG,4224.75,,,4224.75,Other,215% New York Medicaid APG,2456.25,,,2456.25,Other,125% New York Medicaid APG,1965,111352.72,
Repair finger/hand tendon,26373,CPT,,,,,,,,both,,,68082.75,50381.24,74,,50381.24,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30637.24,45,,30637.24,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33700.96,49.5,,33700.96,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3654.9,,,3654.9,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,47657.93,70,,47657.93,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1965,,,1965,Other,New York Medicaid APG methodology,1965,,,1965,Other,100% New York Medicaid APG,1965,,,1965,Other,100% New York Medicaid APG,1965,,,1965,Other,100% New York Medicaid APG,4421.25,,,4421.25,Other,225% New York Medicaid APG,3006.45,,,3006.45,Other,153% New York Medicaid APG,4421.25,,,4421.25,Other,225% New York Medicaid APG,2751,,,2751,Other,140% New York Medicaid APG,4421.25,,,4421.25,Other,225% New York Medicaid APG,5109,,,5109,Other,260% New York Medicaid APG,6366.6,,,6366.6,Other,324% New York Medicaid APG,4224.75,,,4224.75,Other,215% New York Medicaid APG,4224.75,,,4224.75,Other,215% New York Medicaid APG,2456.25,,,2456.25,Other,125% New York Medicaid APG,1965,50381.24,
Revise hand/finger tendon,26390,CPT,,,,,,,,both,,,37645.65,27857.78,74,,27857.78,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,16940.54,45,,16940.54,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,18634.6,49.5,,18634.6,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3654.9,,,3654.9,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,26351.96,70,,26351.96,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1965,,,1965,Other,New York Medicaid APG methodology,1965,,,1965,Other,100% New York Medicaid APG,1965,,,1965,Other,100% New York Medicaid APG,1965,,,1965,Other,100% New York Medicaid APG,4421.25,,,4421.25,Other,225% New York Medicaid APG,3006.45,,,3006.45,Other,153% New York Medicaid APG,4421.25,,,4421.25,Other,225% New York Medicaid APG,2751,,,2751,Other,140% New York Medicaid APG,4421.25,,,4421.25,Other,225% New York Medicaid APG,5109,,,5109,Other,260% New York Medicaid APG,6366.6,,,6366.6,Other,324% New York Medicaid APG,4224.75,,,4224.75,Other,215% New York Medicaid APG,4224.75,,,4224.75,Other,215% New York Medicaid APG,2456.25,,,2456.25,Other,125% New York Medicaid APG,1965,27857.78,
Repair/graft hand tendon,26392,CPT,,,,,,,,both,,,56888.22,42097.28,74,,42097.28,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,25599.7,45,,25599.7,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,28159.67,49.5,,28159.67,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3654.9,,,3654.9,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,39821.75,70,,39821.75,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1965,,,1965,Other,New York Medicaid APG methodology,1965,,,1965,Other,100% New York Medicaid APG,1965,,,1965,Other,100% New York Medicaid APG,1965,,,1965,Other,100% New York Medicaid APG,4421.25,,,4421.25,Other,225% New York Medicaid APG,3006.45,,,3006.45,Other,153% New York Medicaid APG,4421.25,,,4421.25,Other,225% New York Medicaid APG,2751,,,2751,Other,140% New York Medicaid APG,4421.25,,,4421.25,Other,225% New York Medicaid APG,5109,,,5109,Other,260% New York Medicaid APG,6366.6,,,6366.6,Other,324% New York Medicaid APG,4224.75,,,4224.75,Other,215% New York Medicaid APG,4224.75,,,4224.75,Other,215% New York Medicaid APG,2456.25,,,2456.25,Other,125% New York Medicaid APG,1965,42097.28,
Repair hand tendon,26410,CPT,,,,,,,,both,,,32157.65,23796.66,74,,23796.66,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,14470.94,45,,14470.94,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,15918.04,49.5,,15918.04,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2289.65,,,2289.65,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,22510.36,70,,22510.36,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1231,,,1231,Other,New York Medicaid APG methodology,1231,,,1231,Other,100% New York Medicaid APG,1231,,,1231,Other,100% New York Medicaid APG,1231,,,1231,Other,100% New York Medicaid APG,2769.74,,,2769.74,Other,225% New York Medicaid APG,1883.42,,,1883.42,Other,153% New York Medicaid APG,2769.74,,,2769.74,Other,225% New York Medicaid APG,1723.39,,,1723.39,Other,140% New York Medicaid APG,2769.74,,,2769.74,Other,225% New York Medicaid APG,3200.59,,,3200.59,Other,260% New York Medicaid APG,3988.42,,,3988.42,Other,324% New York Medicaid APG,2646.64,,,2646.64,Other,215% New York Medicaid APG,2646.64,,,2646.64,Other,215% New York Medicaid APG,1538.74,,,1538.74,Other,125% New York Medicaid APG,1231,23796.66,
Repair/graft hand tendon,26412,CPT,,,,,,,,both,,,68082.75,50381.24,74,,50381.24,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30637.24,45,,30637.24,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33700.96,49.5,,33700.96,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3654.9,,,3654.9,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,47657.93,70,,47657.93,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1965,,,1965,Other,New York Medicaid APG methodology,1965,,,1965,Other,100% New York Medicaid APG,1965,,,1965,Other,100% New York Medicaid APG,1965,,,1965,Other,100% New York Medicaid APG,4421.25,,,4421.25,Other,225% New York Medicaid APG,3006.45,,,3006.45,Other,153% New York Medicaid APG,4421.25,,,4421.25,Other,225% New York Medicaid APG,2751,,,2751,Other,140% New York Medicaid APG,4421.25,,,4421.25,Other,225% New York Medicaid APG,5109,,,5109,Other,260% New York Medicaid APG,6366.6,,,6366.6,Other,324% New York Medicaid APG,4224.75,,,4224.75,Other,215% New York Medicaid APG,4224.75,,,4224.75,Other,215% New York Medicaid APG,2456.25,,,2456.25,Other,125% New York Medicaid APG,1965,50381.24,
Excision hand/finger tendon,26415,CPT,,,,,,,,both,,,68082.75,50381.24,74,,50381.24,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30637.24,45,,30637.24,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33700.96,49.5,,33700.96,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3654.9,,,3654.9,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,47657.93,70,,47657.93,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1965,,,1965,Other,New York Medicaid APG methodology,1965,,,1965,Other,100% New York Medicaid APG,1965,,,1965,Other,100% New York Medicaid APG,1965,,,1965,Other,100% New York Medicaid APG,4421.25,,,4421.25,Other,225% New York Medicaid APG,3006.45,,,3006.45,Other,153% New York Medicaid APG,4421.25,,,4421.25,Other,225% New York Medicaid APG,2751,,,2751,Other,140% New York Medicaid APG,4421.25,,,4421.25,Other,225% New York Medicaid APG,5109,,,5109,Other,260% New York Medicaid APG,6366.6,,,6366.6,Other,324% New York Medicaid APG,4224.75,,,4224.75,Other,215% New York Medicaid APG,4224.75,,,4224.75,Other,215% New York Medicaid APG,2456.25,,,2456.25,Other,125% New York Medicaid APG,1965,50381.24,
Graft hand or finger tendon,26416,CPT,,,,,,,,both,,,68082.75,50381.24,74,,50381.24,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30637.24,45,,30637.24,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33700.96,49.5,,33700.96,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3654.9,,,3654.9,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,47657.93,70,,47657.93,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1965,,,1965,Other,New York Medicaid APG methodology,1965,,,1965,Other,100% New York Medicaid APG,1965,,,1965,Other,100% New York Medicaid APG,1965,,,1965,Other,100% New York Medicaid APG,4421.25,,,4421.25,Other,225% New York Medicaid APG,3006.45,,,3006.45,Other,153% New York Medicaid APG,4421.25,,,4421.25,Other,225% New York Medicaid APG,2751,,,2751,Other,140% New York Medicaid APG,4421.25,,,4421.25,Other,225% New York Medicaid APG,5109,,,5109,Other,260% New York Medicaid APG,6366.6,,,6366.6,Other,324% New York Medicaid APG,4224.75,,,4224.75,Other,215% New York Medicaid APG,4224.75,,,4224.75,Other,215% New York Medicaid APG,2456.25,,,2456.25,Other,125% New York Medicaid APG,1965,50381.24,
Repair finger tendon,26418,CPT,,,,,,,,both,,,34562.54,25576.28,74,,25576.28,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15553.14,45,,15553.14,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,17108.46,49.5,,17108.46,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2289.65,,,2289.65,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,24193.78,70,,24193.78,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1231,,,1231,Other,New York Medicaid APG methodology,1231,,,1231,Other,100% New York Medicaid APG,1231,,,1231,Other,100% New York Medicaid APG,1231,,,1231,Other,100% New York Medicaid APG,2769.74,,,2769.74,Other,225% New York Medicaid APG,1883.42,,,1883.42,Other,153% New York Medicaid APG,2769.74,,,2769.74,Other,225% New York Medicaid APG,1723.39,,,1723.39,Other,140% New York Medicaid APG,2769.74,,,2769.74,Other,225% New York Medicaid APG,3200.59,,,3200.59,Other,260% New York Medicaid APG,3988.42,,,3988.42,Other,324% New York Medicaid APG,2646.64,,,2646.64,Other,215% New York Medicaid APG,2646.64,,,2646.64,Other,215% New York Medicaid APG,1538.74,,,1538.74,Other,125% New York Medicaid APG,1231,25576.28,
Repair/graft finger tendon,26420,CPT,,,,,,,,both,,,61393.55,45431.23,74,,45431.23,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,27627.1,45,,27627.1,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,30389.81,49.5,,30389.81,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3654.9,,,3654.9,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,42975.49,70,,42975.49,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1965,,,1965,Other,New York Medicaid APG methodology,1965,,,1965,Other,100% New York Medicaid APG,1965,,,1965,Other,100% New York Medicaid APG,1965,,,1965,Other,100% New York Medicaid APG,4421.25,,,4421.25,Other,225% New York Medicaid APG,3006.45,,,3006.45,Other,153% New York Medicaid APG,4421.25,,,4421.25,Other,225% New York Medicaid APG,2751,,,2751,Other,140% New York Medicaid APG,4421.25,,,4421.25,Other,225% New York Medicaid APG,5109,,,5109,Other,260% New York Medicaid APG,6366.6,,,6366.6,Other,324% New York Medicaid APG,4224.75,,,4224.75,Other,215% New York Medicaid APG,4224.75,,,4224.75,Other,215% New York Medicaid APG,2456.25,,,2456.25,Other,125% New York Medicaid APG,1965,45431.23,
Repair finger/hand tendon,26426,CPT,,,,,,,,both,,,35216.28,26060.05,74,,26060.05,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15847.33,45,,15847.33,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,17432.06,49.5,,17432.06,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3654.9,,,3654.9,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,24651.4,70,,24651.4,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1965,,,1965,Other,New York Medicaid APG methodology,1965,,,1965,Other,100% New York Medicaid APG,1965,,,1965,Other,100% New York Medicaid APG,1965,,,1965,Other,100% New York Medicaid APG,4421.25,,,4421.25,Other,225% New York Medicaid APG,3006.45,,,3006.45,Other,153% New York Medicaid APG,4421.25,,,4421.25,Other,225% New York Medicaid APG,2751,,,2751,Other,140% New York Medicaid APG,4421.25,,,4421.25,Other,225% New York Medicaid APG,5109,,,5109,Other,260% New York Medicaid APG,6366.6,,,6366.6,Other,324% New York Medicaid APG,4224.75,,,4224.75,Other,215% New York Medicaid APG,4224.75,,,4224.75,Other,215% New York Medicaid APG,2456.25,,,2456.25,Other,125% New York Medicaid APG,1965,26060.05,
Repair/graft finger tendon,26428,CPT,,,,,,,,both,,,68082.75,50381.24,74,,50381.24,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30637.24,45,,30637.24,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33700.96,49.5,,33700.96,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3654.9,,,3654.9,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,47657.93,70,,47657.93,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1965,,,1965,Other,New York Medicaid APG methodology,1965,,,1965,Other,100% New York Medicaid APG,1965,,,1965,Other,100% New York Medicaid APG,1965,,,1965,Other,100% New York Medicaid APG,4421.25,,,4421.25,Other,225% New York Medicaid APG,3006.45,,,3006.45,Other,153% New York Medicaid APG,4421.25,,,4421.25,Other,225% New York Medicaid APG,2751,,,2751,Other,140% New York Medicaid APG,4421.25,,,4421.25,Other,225% New York Medicaid APG,5109,,,5109,Other,260% New York Medicaid APG,6366.6,,,6366.6,Other,324% New York Medicaid APG,4224.75,,,4224.75,Other,215% New York Medicaid APG,4224.75,,,4224.75,Other,215% New York Medicaid APG,2456.25,,,2456.25,Other,125% New York Medicaid APG,1965,50381.24,
Repair finger tendon,26432,CPT,,,,,,,,both,,,33805.49,25016.06,74,,25016.06,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15212.47,45,,15212.47,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,16733.72,49.5,,16733.72,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2289.65,,,2289.65,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,23663.84,70,,23663.84,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1231,,,1231,Other,New York Medicaid APG methodology,1231,,,1231,Other,100% New York Medicaid APG,1231,,,1231,Other,100% New York Medicaid APG,1231,,,1231,Other,100% New York Medicaid APG,2769.74,,,2769.74,Other,225% New York Medicaid APG,1883.42,,,1883.42,Other,153% New York Medicaid APG,2769.74,,,2769.74,Other,225% New York Medicaid APG,1723.39,,,1723.39,Other,140% New York Medicaid APG,2769.74,,,2769.74,Other,225% New York Medicaid APG,3200.59,,,3200.59,Other,260% New York Medicaid APG,3988.42,,,3988.42,Other,324% New York Medicaid APG,2646.64,,,2646.64,Other,215% New York Medicaid APG,2646.64,,,2646.64,Other,215% New York Medicaid APG,1538.74,,,1538.74,Other,125% New York Medicaid APG,1231,25016.06,
Repair finger tendon,26433,CPT,,,,,,,,both,,,68082.75,50381.24,74,,50381.24,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30637.24,45,,30637.24,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33700.96,49.5,,33700.96,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2289.65,,,2289.65,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,47657.93,70,,47657.93,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1231,,,1231,Other,New York Medicaid APG methodology,1231,,,1231,Other,100% New York Medicaid APG,1231,,,1231,Other,100% New York Medicaid APG,1231,,,1231,Other,100% New York Medicaid APG,2769.74,,,2769.74,Other,225% New York Medicaid APG,1883.42,,,1883.42,Other,153% New York Medicaid APG,2769.74,,,2769.74,Other,225% New York Medicaid APG,1723.39,,,1723.39,Other,140% New York Medicaid APG,2769.74,,,2769.74,Other,225% New York Medicaid APG,3200.59,,,3200.59,Other,260% New York Medicaid APG,3988.42,,,3988.42,Other,324% New York Medicaid APG,2646.64,,,2646.64,Other,215% New York Medicaid APG,2646.64,,,2646.64,Other,215% New York Medicaid APG,1538.74,,,1538.74,Other,125% New York Medicaid APG,1231,50381.24,
Repair/graft finger tendon,26434,CPT,,,,,,,,both,,,68082.75,50381.24,74,,50381.24,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30637.24,45,,30637.24,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33700.96,49.5,,33700.96,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3654.9,,,3654.9,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,47657.93,70,,47657.93,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1965,,,1965,Other,New York Medicaid APG methodology,1965,,,1965,Other,100% New York Medicaid APG,1965,,,1965,Other,100% New York Medicaid APG,1965,,,1965,Other,100% New York Medicaid APG,4421.25,,,4421.25,Other,225% New York Medicaid APG,3006.45,,,3006.45,Other,153% New York Medicaid APG,4421.25,,,4421.25,Other,225% New York Medicaid APG,2751,,,2751,Other,140% New York Medicaid APG,4421.25,,,4421.25,Other,225% New York Medicaid APG,5109,,,5109,Other,260% New York Medicaid APG,6366.6,,,6366.6,Other,324% New York Medicaid APG,4224.75,,,4224.75,Other,215% New York Medicaid APG,4224.75,,,4224.75,Other,215% New York Medicaid APG,2456.25,,,2456.25,Other,125% New York Medicaid APG,1965,50381.24,
Realignment of tendons,26437,CPT,,,,,,,,both,,,68082.75,50381.24,74,,50381.24,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30637.24,45,,30637.24,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33700.96,49.5,,33700.96,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2289.65,,,2289.65,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,47657.93,70,,47657.93,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1231,,,1231,Other,New York Medicaid APG methodology,1231,,,1231,Other,100% New York Medicaid APG,1231,,,1231,Other,100% New York Medicaid APG,1231,,,1231,Other,100% New York Medicaid APG,2769.74,,,2769.74,Other,225% New York Medicaid APG,1883.42,,,1883.42,Other,153% New York Medicaid APG,2769.74,,,2769.74,Other,225% New York Medicaid APG,1723.39,,,1723.39,Other,140% New York Medicaid APG,2769.74,,,2769.74,Other,225% New York Medicaid APG,3200.59,,,3200.59,Other,260% New York Medicaid APG,3988.42,,,3988.42,Other,324% New York Medicaid APG,2646.64,,,2646.64,Other,215% New York Medicaid APG,2646.64,,,2646.64,Other,215% New York Medicaid APG,1538.74,,,1538.74,Other,125% New York Medicaid APG,1231,50381.24,
Release palm/finger tendon,26440,CPT,,,,,,,,both,,,38676.66,28620.73,74,,28620.73,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,17404.5,45,,17404.5,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,19144.95,49.5,,19144.95,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2289.65,,,2289.65,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,27073.66,70,,27073.66,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1231,,,1231,Other,New York Medicaid APG methodology,1231,,,1231,Other,100% New York Medicaid APG,1231,,,1231,Other,100% New York Medicaid APG,1231,,,1231,Other,100% New York Medicaid APG,2769.74,,,2769.74,Other,225% New York Medicaid APG,1883.42,,,1883.42,Other,153% New York Medicaid APG,2769.74,,,2769.74,Other,225% New York Medicaid APG,1723.39,,,1723.39,Other,140% New York Medicaid APG,2769.74,,,2769.74,Other,225% New York Medicaid APG,3200.59,,,3200.59,Other,260% New York Medicaid APG,3988.42,,,3988.42,Other,324% New York Medicaid APG,2646.64,,,2646.64,Other,215% New York Medicaid APG,2646.64,,,2646.64,Other,215% New York Medicaid APG,1538.74,,,1538.74,Other,125% New York Medicaid APG,1231,28620.73,
Release palm & finger tendon,26442,CPT,,,,,,,,both,,,42387.74,31366.93,74,,31366.93,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,19074.48,45,,19074.48,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,20981.93,49.5,,20981.93,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3654.9,,,3654.9,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,29671.42,70,,29671.42,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1965,,,1965,Other,New York Medicaid APG methodology,1965,,,1965,Other,100% New York Medicaid APG,1965,,,1965,Other,100% New York Medicaid APG,1965,,,1965,Other,100% New York Medicaid APG,4421.25,,,4421.25,Other,225% New York Medicaid APG,3006.45,,,3006.45,Other,153% New York Medicaid APG,4421.25,,,4421.25,Other,225% New York Medicaid APG,2751,,,2751,Other,140% New York Medicaid APG,4421.25,,,4421.25,Other,225% New York Medicaid APG,5109,,,5109,Other,260% New York Medicaid APG,6366.6,,,6366.6,Other,324% New York Medicaid APG,4224.75,,,4224.75,Other,215% New York Medicaid APG,4224.75,,,4224.75,Other,215% New York Medicaid APG,2456.25,,,2456.25,Other,125% New York Medicaid APG,1965,31366.93,
Release hand/finger tendon,26445,CPT,,,,,,,,both,,,34927.48,25846.34,74,,25846.34,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15717.37,45,,15717.37,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,17289.1,49.5,,17289.1,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2289.65,,,2289.65,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,24449.24,70,,24449.24,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1231,,,1231,Other,New York Medicaid APG methodology,1231,,,1231,Other,100% New York Medicaid APG,1231,,,1231,Other,100% New York Medicaid APG,1231,,,1231,Other,100% New York Medicaid APG,2769.74,,,2769.74,Other,225% New York Medicaid APG,1883.42,,,1883.42,Other,153% New York Medicaid APG,2769.74,,,2769.74,Other,225% New York Medicaid APG,1723.39,,,1723.39,Other,140% New York Medicaid APG,2769.74,,,2769.74,Other,225% New York Medicaid APG,3200.59,,,3200.59,Other,260% New York Medicaid APG,3988.42,,,3988.42,Other,324% New York Medicaid APG,2646.64,,,2646.64,Other,215% New York Medicaid APG,2646.64,,,2646.64,Other,215% New York Medicaid APG,1538.74,,,1538.74,Other,125% New York Medicaid APG,1231,25846.34,
Release forearm/hand tendon,26449,CPT,,,,,,,,both,,,68082.75,50381.24,74,,50381.24,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30637.24,45,,30637.24,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33700.96,49.5,,33700.96,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2289.65,,,2289.65,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,47657.93,70,,47657.93,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1231,,,1231,Other,New York Medicaid APG methodology,1231,,,1231,Other,100% New York Medicaid APG,1231,,,1231,Other,100% New York Medicaid APG,1231,,,1231,Other,100% New York Medicaid APG,2769.74,,,2769.74,Other,225% New York Medicaid APG,1883.42,,,1883.42,Other,153% New York Medicaid APG,2769.74,,,2769.74,Other,225% New York Medicaid APG,1723.39,,,1723.39,Other,140% New York Medicaid APG,2769.74,,,2769.74,Other,225% New York Medicaid APG,3200.59,,,3200.59,Other,260% New York Medicaid APG,3988.42,,,3988.42,Other,324% New York Medicaid APG,2646.64,,,2646.64,Other,215% New York Medicaid APG,2646.64,,,2646.64,Other,215% New York Medicaid APG,1538.74,,,1538.74,Other,125% New York Medicaid APG,1231,50381.24,
Incision of palm tendon,26450,CPT,,,,,,,,both,,,68082.75,50381.24,74,,50381.24,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30637.24,45,,30637.24,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33700.96,49.5,,33700.96,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2289.65,,,2289.65,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,47657.93,70,,47657.93,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1231,,,1231,Other,New York Medicaid APG methodology,1231,,,1231,Other,100% New York Medicaid APG,1231,,,1231,Other,100% New York Medicaid APG,1231,,,1231,Other,100% New York Medicaid APG,2769.74,,,2769.74,Other,225% New York Medicaid APG,1883.42,,,1883.42,Other,153% New York Medicaid APG,2769.74,,,2769.74,Other,225% New York Medicaid APG,1723.39,,,1723.39,Other,140% New York Medicaid APG,2769.74,,,2769.74,Other,225% New York Medicaid APG,3200.59,,,3200.59,Other,260% New York Medicaid APG,3988.42,,,3988.42,Other,324% New York Medicaid APG,2646.64,,,2646.64,Other,215% New York Medicaid APG,2646.64,,,2646.64,Other,215% New York Medicaid APG,1538.74,,,1538.74,Other,125% New York Medicaid APG,1231,50381.24,
Incision of finger tendon,26455,CPT,,,,,,,,both,,,33805.49,25016.06,74,,25016.06,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15212.47,45,,15212.47,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,16733.72,49.5,,16733.72,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2289.65,,,2289.65,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,23663.84,70,,23663.84,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1231,,,1231,Other,New York Medicaid APG methodology,1231,,,1231,Other,100% New York Medicaid APG,1231,,,1231,Other,100% New York Medicaid APG,1231,,,1231,Other,100% New York Medicaid APG,2769.74,,,2769.74,Other,225% New York Medicaid APG,1883.42,,,1883.42,Other,153% New York Medicaid APG,2769.74,,,2769.74,Other,225% New York Medicaid APG,1723.39,,,1723.39,Other,140% New York Medicaid APG,2769.74,,,2769.74,Other,225% New York Medicaid APG,3200.59,,,3200.59,Other,260% New York Medicaid APG,3988.42,,,3988.42,Other,324% New York Medicaid APG,2646.64,,,2646.64,Other,215% New York Medicaid APG,2646.64,,,2646.64,Other,215% New York Medicaid APG,1538.74,,,1538.74,Other,125% New York Medicaid APG,1231,25016.06,
Incise hand/finger tendon,26460,CPT,,,,,,,,both,,,51889.91,38398.53,74,,38398.53,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,23350.46,45,,23350.46,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,25685.51,49.5,,25685.51,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2289.65,,,2289.65,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,36322.94,70,,36322.94,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1231,,,1231,Other,New York Medicaid APG methodology,1231,,,1231,Other,100% New York Medicaid APG,1231,,,1231,Other,100% New York Medicaid APG,1231,,,1231,Other,100% New York Medicaid APG,2769.74,,,2769.74,Other,225% New York Medicaid APG,1883.42,,,1883.42,Other,153% New York Medicaid APG,2769.74,,,2769.74,Other,225% New York Medicaid APG,1723.39,,,1723.39,Other,140% New York Medicaid APG,2769.74,,,2769.74,Other,225% New York Medicaid APG,3200.59,,,3200.59,Other,260% New York Medicaid APG,3988.42,,,3988.42,Other,324% New York Medicaid APG,2646.64,,,2646.64,Other,215% New York Medicaid APG,2646.64,,,2646.64,Other,215% New York Medicaid APG,1538.74,,,1538.74,Other,125% New York Medicaid APG,1231,38398.53,
Fusion of finger tendons,26471,CPT,,,,,,,,both,,,68082.75,50381.24,74,,50381.24,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30637.24,45,,30637.24,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33700.96,49.5,,33700.96,percent of total billed charges,110% of Medicare,46296.27,68,,46296.27,percent of total billed charges,,2289.65,,,2289.65,Other,186% of Medicaid,54466.2,80,,54466.2,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,54466.2,80,,54466.2,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,47657.93,70,,47657.93,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1231,,,1231,Other,New York Medicaid APG methodology,1231,,,1231,Other,100% New York Medicaid APG,1231,,,1231,Other,100% New York Medicaid APG,1231,,,1231,Other,100% New York Medicaid APG,2769.74,,,2769.74,Other,225% New York Medicaid APG,1883.42,,,1883.42,Other,153% New York Medicaid APG,2769.74,,,2769.74,Other,225% New York Medicaid APG,1723.39,,,1723.39,Other,140% New York Medicaid APG,2769.74,,,2769.74,Other,225% New York Medicaid APG,3200.59,,,3200.59,Other,260% New York Medicaid APG,3988.42,,,3988.42,Other,324% New York Medicaid APG,2646.64,,,2646.64,Other,215% New York Medicaid APG,2646.64,,,2646.64,Other,215% New York Medicaid APG,1538.74,,,1538.74,Other,125% New York Medicaid APG,1231,54466.2,
Fusion of finger tendons,26474,CPT,,,,,,,,both,,,33805.49,25016.06,74,,25016.06,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15212.47,45,,15212.47,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,16733.72,49.5,,16733.72,percent of total billed charges,110% of Medicare,22987.73,68,,22987.73,percent of total billed charges,,2289.65,,,2289.65,Other,186% of Medicaid,27044.39,80,,27044.39,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,27044.39,80,,27044.39,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,23663.84,70,,23663.84,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1231,,,1231,Other,New York Medicaid APG methodology,1231,,,1231,Other,100% New York Medicaid APG,1231,,,1231,Other,100% New York Medicaid APG,1231,,,1231,Other,100% New York Medicaid APG,2769.74,,,2769.74,Other,225% New York Medicaid APG,1883.42,,,1883.42,Other,153% New York Medicaid APG,2769.74,,,2769.74,Other,225% New York Medicaid APG,1723.39,,,1723.39,Other,140% New York Medicaid APG,2769.74,,,2769.74,Other,225% New York Medicaid APG,3200.59,,,3200.59,Other,260% New York Medicaid APG,3988.42,,,3988.42,Other,324% New York Medicaid APG,2646.64,,,2646.64,Other,215% New York Medicaid APG,2646.64,,,2646.64,Other,215% New York Medicaid APG,1538.74,,,1538.74,Other,125% New York Medicaid APG,1231,27044.39,
Tendon lengthening,26476,CPT,,,,,,,,both,,,68082.75,50381.24,74,,50381.24,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30637.24,45,,30637.24,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33700.96,49.5,,33700.96,percent of total billed charges,110% of Medicare,46296.27,68,,46296.27,percent of total billed charges,,2289.65,,,2289.65,Other,186% of Medicaid,54466.2,80,,54466.2,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,54466.2,80,,54466.2,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,47657.93,70,,47657.93,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1231,,,1231,Other,New York Medicaid APG methodology,1231,,,1231,Other,100% New York Medicaid APG,1231,,,1231,Other,100% New York Medicaid APG,1231,,,1231,Other,100% New York Medicaid APG,2769.74,,,2769.74,Other,225% New York Medicaid APG,1883.42,,,1883.42,Other,153% New York Medicaid APG,2769.74,,,2769.74,Other,225% New York Medicaid APG,1723.39,,,1723.39,Other,140% New York Medicaid APG,2769.74,,,2769.74,Other,225% New York Medicaid APG,3200.59,,,3200.59,Other,260% New York Medicaid APG,3988.42,,,3988.42,Other,324% New York Medicaid APG,2646.64,,,2646.64,Other,215% New York Medicaid APG,2646.64,,,2646.64,Other,215% New York Medicaid APG,1538.74,,,1538.74,Other,125% New York Medicaid APG,1231,54466.2,
Tendon shortening,26477,CPT,,,,,,,,both,,,68082.75,50381.24,74,,50381.24,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30637.24,45,,30637.24,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33700.96,49.5,,33700.96,percent of total billed charges,110% of Medicare,46296.27,68,,46296.27,percent of total billed charges,,2289.65,,,2289.65,Other,186% of Medicaid,54466.2,80,,54466.2,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,54466.2,80,,54466.2,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,47657.93,70,,47657.93,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1231,,,1231,Other,New York Medicaid APG methodology,1231,,,1231,Other,100% New York Medicaid APG,1231,,,1231,Other,100% New York Medicaid APG,1231,,,1231,Other,100% New York Medicaid APG,2769.74,,,2769.74,Other,225% New York Medicaid APG,1883.42,,,1883.42,Other,153% New York Medicaid APG,2769.74,,,2769.74,Other,225% New York Medicaid APG,1723.39,,,1723.39,Other,140% New York Medicaid APG,2769.74,,,2769.74,Other,225% New York Medicaid APG,3200.59,,,3200.59,Other,260% New York Medicaid APG,3988.42,,,3988.42,Other,324% New York Medicaid APG,2646.64,,,2646.64,Other,215% New York Medicaid APG,2646.64,,,2646.64,Other,215% New York Medicaid APG,1538.74,,,1538.74,Other,125% New York Medicaid APG,1231,54466.2,
Lengthening of hand tendon,26478,CPT,,,,,,,,both,,,68082.75,50381.24,74,,50381.24,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30637.24,45,,30637.24,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33700.96,49.5,,33700.96,percent of total billed charges,110% of Medicare,46296.27,68,,46296.27,percent of total billed charges,,2289.65,,,2289.65,Other,186% of Medicaid,54466.2,80,,54466.2,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,54466.2,80,,54466.2,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,47657.93,70,,47657.93,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1231,,,1231,Other,New York Medicaid APG methodology,1231,,,1231,Other,100% New York Medicaid APG,1231,,,1231,Other,100% New York Medicaid APG,1231,,,1231,Other,100% New York Medicaid APG,2769.74,,,2769.74,Other,225% New York Medicaid APG,1883.42,,,1883.42,Other,153% New York Medicaid APG,2769.74,,,2769.74,Other,225% New York Medicaid APG,1723.39,,,1723.39,Other,140% New York Medicaid APG,2769.74,,,2769.74,Other,225% New York Medicaid APG,3200.59,,,3200.59,Other,260% New York Medicaid APG,3988.42,,,3988.42,Other,324% New York Medicaid APG,2646.64,,,2646.64,Other,215% New York Medicaid APG,2646.64,,,2646.64,Other,215% New York Medicaid APG,1538.74,,,1538.74,Other,125% New York Medicaid APG,1231,54466.2,
Shortening of hand tendon,26479,CPT,,,,,,,,both,,,68082.75,50381.24,74,,50381.24,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30637.24,45,,30637.24,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33700.96,49.5,,33700.96,percent of total billed charges,110% of Medicare,46296.27,68,,46296.27,percent of total billed charges,,2289.65,,,2289.65,Other,186% of Medicaid,54466.2,80,,54466.2,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,54466.2,80,,54466.2,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,47657.93,70,,47657.93,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1231,,,1231,Other,New York Medicaid APG methodology,1231,,,1231,Other,100% New York Medicaid APG,1231,,,1231,Other,100% New York Medicaid APG,1231,,,1231,Other,100% New York Medicaid APG,2769.74,,,2769.74,Other,225% New York Medicaid APG,1883.42,,,1883.42,Other,153% New York Medicaid APG,2769.74,,,2769.74,Other,225% New York Medicaid APG,1723.39,,,1723.39,Other,140% New York Medicaid APG,2769.74,,,2769.74,Other,225% New York Medicaid APG,3200.59,,,3200.59,Other,260% New York Medicaid APG,3988.42,,,3988.42,Other,324% New York Medicaid APG,2646.64,,,2646.64,Other,215% New York Medicaid APG,2646.64,,,2646.64,Other,215% New York Medicaid APG,1538.74,,,1538.74,Other,125% New York Medicaid APG,1231,54466.2,
Transplant hand tendon,26480,CPT,,,,,,,,both,,,41084.27,30402.36,74,,30402.36,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,18487.92,45,,18487.92,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,20336.71,49.5,,20336.71,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3654.9,,,3654.9,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,28758.99,70,,28758.99,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1965,,,1965,Other,New York Medicaid APG methodology,1965,,,1965,Other,100% New York Medicaid APG,1965,,,1965,Other,100% New York Medicaid APG,1965,,,1965,Other,100% New York Medicaid APG,4421.25,,,4421.25,Other,225% New York Medicaid APG,3006.45,,,3006.45,Other,153% New York Medicaid APG,4421.25,,,4421.25,Other,225% New York Medicaid APG,2751,,,2751,Other,140% New York Medicaid APG,4421.25,,,4421.25,Other,225% New York Medicaid APG,5109,,,5109,Other,260% New York Medicaid APG,6366.6,,,6366.6,Other,324% New York Medicaid APG,4224.75,,,4224.75,Other,215% New York Medicaid APG,4224.75,,,4224.75,Other,215% New York Medicaid APG,2456.25,,,2456.25,Other,125% New York Medicaid APG,1965,30402.36,
Transplant/graft hand tendon,26483,CPT,,,,,,,,both,,,68082.75,50381.24,74,,50381.24,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30637.24,45,,30637.24,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33700.96,49.5,,33700.96,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3654.9,,,3654.9,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,47657.93,70,,47657.93,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1965,,,1965,Other,New York Medicaid APG methodology,1965,,,1965,Other,100% New York Medicaid APG,1965,,,1965,Other,100% New York Medicaid APG,1965,,,1965,Other,100% New York Medicaid APG,4421.25,,,4421.25,Other,225% New York Medicaid APG,3006.45,,,3006.45,Other,153% New York Medicaid APG,4421.25,,,4421.25,Other,225% New York Medicaid APG,2751,,,2751,Other,140% New York Medicaid APG,4421.25,,,4421.25,Other,225% New York Medicaid APG,5109,,,5109,Other,260% New York Medicaid APG,6366.6,,,6366.6,Other,324% New York Medicaid APG,4224.75,,,4224.75,Other,215% New York Medicaid APG,4224.75,,,4224.75,Other,215% New York Medicaid APG,2456.25,,,2456.25,Other,125% New York Medicaid APG,1965,50381.24,
Transplant palm tendon,26485,CPT,,,,,,,,both,,,68082.75,50381.24,74,,50381.24,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30637.24,45,,30637.24,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33700.96,49.5,,33700.96,percent of total billed charges,110% of Medicare,46296.27,68,,46296.27,percent of total billed charges,,3654.9,,,3654.9,Other,186% of Medicaid,54466.2,80,,54466.2,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,54466.2,80,,54466.2,percent of total billed charges,,7216,,,7216,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,47657.93,70,,47657.93,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1965,,,1965,Other,New York Medicaid APG methodology,1965,,,1965,Other,100% New York Medicaid APG,1965,,,1965,Other,100% New York Medicaid APG,1965,,,1965,Other,100% New York Medicaid APG,4421.25,,,4421.25,Other,225% New York Medicaid APG,3006.45,,,3006.45,Other,153% New York Medicaid APG,4421.25,,,4421.25,Other,225% New York Medicaid APG,2751,,,2751,Other,140% New York Medicaid APG,4421.25,,,4421.25,Other,225% New York Medicaid APG,5109,,,5109,Other,260% New York Medicaid APG,6366.6,,,6366.6,Other,324% New York Medicaid APG,4224.75,,,4224.75,Other,215% New York Medicaid APG,4224.75,,,4224.75,Other,215% New York Medicaid APG,2456.25,,,2456.25,Other,125% New York Medicaid APG,1965,54466.2,
Transplant/graft palm tendon,26489,CPT,,,,,,,,both,,,68082.75,50381.24,74,,50381.24,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30637.24,45,,30637.24,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33700.96,49.5,,33700.96,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3654.9,,,3654.9,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,47657.93,70,,47657.93,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1965,,,1965,Other,New York Medicaid APG methodology,1965,,,1965,Other,100% New York Medicaid APG,1965,,,1965,Other,100% New York Medicaid APG,1965,,,1965,Other,100% New York Medicaid APG,4421.25,,,4421.25,Other,225% New York Medicaid APG,3006.45,,,3006.45,Other,153% New York Medicaid APG,4421.25,,,4421.25,Other,225% New York Medicaid APG,2751,,,2751,Other,140% New York Medicaid APG,4421.25,,,4421.25,Other,225% New York Medicaid APG,5109,,,5109,Other,260% New York Medicaid APG,6366.6,,,6366.6,Other,324% New York Medicaid APG,4224.75,,,4224.75,Other,215% New York Medicaid APG,4224.75,,,4224.75,Other,215% New York Medicaid APG,2456.25,,,2456.25,Other,125% New York Medicaid APG,1965,50381.24,
Revise thumb tendon,26490,CPT,,,,,,,,both,,,68082.75,50381.24,74,,50381.24,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30637.24,45,,30637.24,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33700.96,49.5,,33700.96,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3654.9,,,3654.9,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,47657.93,70,,47657.93,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1965,,,1965,Other,New York Medicaid APG methodology,1965,,,1965,Other,100% New York Medicaid APG,1965,,,1965,Other,100% New York Medicaid APG,1965,,,1965,Other,100% New York Medicaid APG,4421.25,,,4421.25,Other,225% New York Medicaid APG,3006.45,,,3006.45,Other,153% New York Medicaid APG,4421.25,,,4421.25,Other,225% New York Medicaid APG,2751,,,2751,Other,140% New York Medicaid APG,4421.25,,,4421.25,Other,225% New York Medicaid APG,5109,,,5109,Other,260% New York Medicaid APG,6366.6,,,6366.6,Other,324% New York Medicaid APG,4224.75,,,4224.75,Other,215% New York Medicaid APG,4224.75,,,4224.75,Other,215% New York Medicaid APG,2456.25,,,2456.25,Other,125% New York Medicaid APG,1965,50381.24,
Tendon transfer with graft,26492,CPT,,,,,,,,both,,,32843,24303.82,74,,24303.82,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,14779.35,45,,14779.35,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,16257.29,49.5,,16257.29,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3654.9,,,3654.9,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,22990.1,70,,22990.1,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1965,,,1965,Other,New York Medicaid APG methodology,1965,,,1965,Other,100% New York Medicaid APG,1965,,,1965,Other,100% New York Medicaid APG,1965,,,1965,Other,100% New York Medicaid APG,4421.25,,,4421.25,Other,225% New York Medicaid APG,3006.45,,,3006.45,Other,153% New York Medicaid APG,4421.25,,,4421.25,Other,225% New York Medicaid APG,2751,,,2751,Other,140% New York Medicaid APG,4421.25,,,4421.25,Other,225% New York Medicaid APG,5109,,,5109,Other,260% New York Medicaid APG,6366.6,,,6366.6,Other,324% New York Medicaid APG,4224.75,,,4224.75,Other,215% New York Medicaid APG,4224.75,,,4224.75,Other,215% New York Medicaid APG,2456.25,,,2456.25,Other,125% New York Medicaid APG,1965,24303.82,
Hand tendon/muscle transfer,26494,CPT,,,,,,,,both,,,68082.75,50381.24,74,,50381.24,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30637.24,45,,30637.24,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33700.96,49.5,,33700.96,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3654.9,,,3654.9,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,47657.93,70,,47657.93,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1965,,,1965,Other,New York Medicaid APG methodology,1965,,,1965,Other,100% New York Medicaid APG,1965,,,1965,Other,100% New York Medicaid APG,1965,,,1965,Other,100% New York Medicaid APG,4421.25,,,4421.25,Other,225% New York Medicaid APG,3006.45,,,3006.45,Other,153% New York Medicaid APG,4421.25,,,4421.25,Other,225% New York Medicaid APG,2751,,,2751,Other,140% New York Medicaid APG,4421.25,,,4421.25,Other,225% New York Medicaid APG,5109,,,5109,Other,260% New York Medicaid APG,6366.6,,,6366.6,Other,324% New York Medicaid APG,4224.75,,,4224.75,Other,215% New York Medicaid APG,4224.75,,,4224.75,Other,215% New York Medicaid APG,2456.25,,,2456.25,Other,125% New York Medicaid APG,1965,50381.24,
Revise thumb tendon,26496,CPT,,,,,,,,both,,,68082.75,50381.24,74,,50381.24,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30637.24,45,,30637.24,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33700.96,49.5,,33700.96,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3654.9,,,3654.9,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,47657.93,70,,47657.93,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1965,,,1965,Other,New York Medicaid APG methodology,1965,,,1965,Other,100% New York Medicaid APG,1965,,,1965,Other,100% New York Medicaid APG,1965,,,1965,Other,100% New York Medicaid APG,4421.25,,,4421.25,Other,225% New York Medicaid APG,3006.45,,,3006.45,Other,153% New York Medicaid APG,4421.25,,,4421.25,Other,225% New York Medicaid APG,2751,,,2751,Other,140% New York Medicaid APG,4421.25,,,4421.25,Other,225% New York Medicaid APG,5109,,,5109,Other,260% New York Medicaid APG,6366.6,,,6366.6,Other,324% New York Medicaid APG,4224.75,,,4224.75,Other,215% New York Medicaid APG,4224.75,,,4224.75,Other,215% New York Medicaid APG,2456.25,,,2456.25,Other,125% New York Medicaid APG,1965,50381.24,
Finger tendon transfer,26497,CPT,,,,,,,,both,,,56674.81,41939.36,74,,41939.36,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,25503.66,45,,25503.66,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,28054.03,49.5,,28054.03,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3654.9,,,3654.9,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,39672.37,70,,39672.37,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1965,,,1965,Other,New York Medicaid APG methodology,1965,,,1965,Other,100% New York Medicaid APG,1965,,,1965,Other,100% New York Medicaid APG,1965,,,1965,Other,100% New York Medicaid APG,4421.25,,,4421.25,Other,225% New York Medicaid APG,3006.45,,,3006.45,Other,153% New York Medicaid APG,4421.25,,,4421.25,Other,225% New York Medicaid APG,2751,,,2751,Other,140% New York Medicaid APG,4421.25,,,4421.25,Other,225% New York Medicaid APG,5109,,,5109,Other,260% New York Medicaid APG,6366.6,,,6366.6,Other,324% New York Medicaid APG,4224.75,,,4224.75,Other,215% New York Medicaid APG,4224.75,,,4224.75,Other,215% New York Medicaid APG,2456.25,,,2456.25,Other,125% New York Medicaid APG,1965,41939.36,
Finger tendon transfer,26498,CPT,,,,,,,,both,,,68082.75,50381.24,74,,50381.24,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30637.24,45,,30637.24,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33700.96,49.5,,33700.96,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3654.9,,,3654.9,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,47657.93,70,,47657.93,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1965,,,1965,Other,New York Medicaid APG methodology,1965,,,1965,Other,100% New York Medicaid APG,1965,,,1965,Other,100% New York Medicaid APG,1965,,,1965,Other,100% New York Medicaid APG,4421.25,,,4421.25,Other,225% New York Medicaid APG,3006.45,,,3006.45,Other,153% New York Medicaid APG,4421.25,,,4421.25,Other,225% New York Medicaid APG,2751,,,2751,Other,140% New York Medicaid APG,4421.25,,,4421.25,Other,225% New York Medicaid APG,5109,,,5109,Other,260% New York Medicaid APG,6366.6,,,6366.6,Other,324% New York Medicaid APG,4224.75,,,4224.75,Other,215% New York Medicaid APG,4224.75,,,4224.75,Other,215% New York Medicaid APG,2456.25,,,2456.25,Other,125% New York Medicaid APG,1965,50381.24,
Revision of finger,26499,CPT,,,,,,,,both,,,34322.65,25398.76,74,,25398.76,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15445.19,45,,15445.19,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,16989.71,49.5,,16989.71,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3654.9,,,3654.9,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,24025.86,70,,24025.86,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1965,,,1965,Other,New York Medicaid APG methodology,1965,,,1965,Other,100% New York Medicaid APG,1965,,,1965,Other,100% New York Medicaid APG,1965,,,1965,Other,100% New York Medicaid APG,4421.25,,,4421.25,Other,225% New York Medicaid APG,3006.45,,,3006.45,Other,153% New York Medicaid APG,4421.25,,,4421.25,Other,225% New York Medicaid APG,2751,,,2751,Other,140% New York Medicaid APG,4421.25,,,4421.25,Other,225% New York Medicaid APG,5109,,,5109,Other,260% New York Medicaid APG,6366.6,,,6366.6,Other,324% New York Medicaid APG,4224.75,,,4224.75,Other,215% New York Medicaid APG,4224.75,,,4224.75,Other,215% New York Medicaid APG,2456.25,,,2456.25,Other,125% New York Medicaid APG,1965,25398.76,
Hand tendon reconstruction,26500,CPT,,,,,,,,both,,,150476.65,111352.72,74,,111352.72,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,67714.49,45,,67714.49,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,74485.94,49.5,,74485.94,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3654.9,,,3654.9,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,105333.66,70,,105333.66,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1965,,,1965,Other,New York Medicaid APG methodology,1965,,,1965,Other,100% New York Medicaid APG,1965,,,1965,Other,100% New York Medicaid APG,1965,,,1965,Other,100% New York Medicaid APG,4421.25,,,4421.25,Other,225% New York Medicaid APG,3006.45,,,3006.45,Other,153% New York Medicaid APG,4421.25,,,4421.25,Other,225% New York Medicaid APG,2751,,,2751,Other,140% New York Medicaid APG,4421.25,,,4421.25,Other,225% New York Medicaid APG,5109,,,5109,Other,260% New York Medicaid APG,6366.6,,,6366.6,Other,324% New York Medicaid APG,4224.75,,,4224.75,Other,215% New York Medicaid APG,4224.75,,,4224.75,Other,215% New York Medicaid APG,2456.25,,,2456.25,Other,125% New York Medicaid APG,1965,111352.72,
Hand tendon reconstruction,26502,CPT,,,,,,,,both,,,39162.16,28980,74,,28980,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,17622.97,45,,17622.97,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,19385.27,49.5,,19385.27,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3654.9,,,3654.9,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,27413.51,70,,27413.51,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1965,,,1965,Other,New York Medicaid APG methodology,1965,,,1965,Other,100% New York Medicaid APG,1965,,,1965,Other,100% New York Medicaid APG,1965,,,1965,Other,100% New York Medicaid APG,4421.25,,,4421.25,Other,225% New York Medicaid APG,3006.45,,,3006.45,Other,153% New York Medicaid APG,4421.25,,,4421.25,Other,225% New York Medicaid APG,2751,,,2751,Other,140% New York Medicaid APG,4421.25,,,4421.25,Other,225% New York Medicaid APG,5109,,,5109,Other,260% New York Medicaid APG,6366.6,,,6366.6,Other,324% New York Medicaid APG,4224.75,,,4224.75,Other,215% New York Medicaid APG,4224.75,,,4224.75,Other,215% New York Medicaid APG,2456.25,,,2456.25,Other,125% New York Medicaid APG,1965,28980,
Release thumb contracture,26508,CPT,,,,,,,,both,,,68082.75,50381.24,74,,50381.24,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30637.24,45,,30637.24,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33700.96,49.5,,33700.96,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2289.65,,,2289.65,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,47657.93,70,,47657.93,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1231,,,1231,Other,New York Medicaid APG methodology,1231,,,1231,Other,100% New York Medicaid APG,1231,,,1231,Other,100% New York Medicaid APG,1231,,,1231,Other,100% New York Medicaid APG,2769.74,,,2769.74,Other,225% New York Medicaid APG,1883.42,,,1883.42,Other,153% New York Medicaid APG,2769.74,,,2769.74,Other,225% New York Medicaid APG,1723.39,,,1723.39,Other,140% New York Medicaid APG,2769.74,,,2769.74,Other,225% New York Medicaid APG,3200.59,,,3200.59,Other,260% New York Medicaid APG,3988.42,,,3988.42,Other,324% New York Medicaid APG,2646.64,,,2646.64,Other,215% New York Medicaid APG,2646.64,,,2646.64,Other,215% New York Medicaid APG,1538.74,,,1538.74,Other,125% New York Medicaid APG,1231,50381.24,
Thumb tendon transfer,26510,CPT,,,,,,,,both,,,68082.75,50381.24,74,,50381.24,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30637.24,45,,30637.24,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33700.96,49.5,,33700.96,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3654.9,,,3654.9,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,47657.93,70,,47657.93,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1965,,,1965,Other,New York Medicaid APG methodology,1965,,,1965,Other,100% New York Medicaid APG,1965,,,1965,Other,100% New York Medicaid APG,1965,,,1965,Other,100% New York Medicaid APG,4421.25,,,4421.25,Other,225% New York Medicaid APG,3006.45,,,3006.45,Other,153% New York Medicaid APG,4421.25,,,4421.25,Other,225% New York Medicaid APG,2751,,,2751,Other,140% New York Medicaid APG,4421.25,,,4421.25,Other,225% New York Medicaid APG,5109,,,5109,Other,260% New York Medicaid APG,6366.6,,,6366.6,Other,324% New York Medicaid APG,4224.75,,,4224.75,Other,215% New York Medicaid APG,4224.75,,,4224.75,Other,215% New York Medicaid APG,2456.25,,,2456.25,Other,125% New York Medicaid APG,1965,50381.24,
Fusion of knuckle joint,26516,CPT,,,,,,,,both,,,68082.75,50381.24,74,,50381.24,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30637.24,45,,30637.24,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33700.96,49.5,,33700.96,percent of total billed charges,110% of Medicare,46296.27,68,,46296.27,percent of total billed charges,,2289.65,,,2289.65,Other,186% of Medicaid,54466.2,80,,54466.2,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,54466.2,80,,54466.2,percent of total billed charges,,7216,,,7216,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,47657.93,70,,47657.93,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1231,,,1231,Other,New York Medicaid APG methodology,1231,,,1231,Other,100% New York Medicaid APG,1231,,,1231,Other,100% New York Medicaid APG,1231,,,1231,Other,100% New York Medicaid APG,2769.74,,,2769.74,Other,225% New York Medicaid APG,1883.42,,,1883.42,Other,153% New York Medicaid APG,2769.74,,,2769.74,Other,225% New York Medicaid APG,1723.39,,,1723.39,Other,140% New York Medicaid APG,2769.74,,,2769.74,Other,225% New York Medicaid APG,3200.59,,,3200.59,Other,260% New York Medicaid APG,3988.42,,,3988.42,Other,324% New York Medicaid APG,2646.64,,,2646.64,Other,215% New York Medicaid APG,2646.64,,,2646.64,Other,215% New York Medicaid APG,1538.74,,,1538.74,Other,125% New York Medicaid APG,1231,54466.2,
Fusion of knuckle joints,26517,CPT,,,,,,,,both,,,68082.75,50381.24,74,,50381.24,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30637.24,45,,30637.24,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33700.96,49.5,,33700.96,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2289.65,,,2289.65,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,47657.93,70,,47657.93,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1231,,,1231,Other,New York Medicaid APG methodology,1231,,,1231,Other,100% New York Medicaid APG,1231,,,1231,Other,100% New York Medicaid APG,1231,,,1231,Other,100% New York Medicaid APG,2769.74,,,2769.74,Other,225% New York Medicaid APG,1883.42,,,1883.42,Other,153% New York Medicaid APG,2769.74,,,2769.74,Other,225% New York Medicaid APG,1723.39,,,1723.39,Other,140% New York Medicaid APG,2769.74,,,2769.74,Other,225% New York Medicaid APG,3200.59,,,3200.59,Other,260% New York Medicaid APG,3988.42,,,3988.42,Other,324% New York Medicaid APG,2646.64,,,2646.64,Other,215% New York Medicaid APG,2646.64,,,2646.64,Other,215% New York Medicaid APG,1538.74,,,1538.74,Other,125% New York Medicaid APG,1231,50381.24,
Fusion of knuckle joints,26518,CPT,,,,,,,,both,,,150476.65,111352.72,74,,111352.72,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,67714.49,45,,67714.49,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,74485.94,49.5,,74485.94,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3654.9,,,3654.9,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,105333.66,70,,105333.66,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1965,,,1965,Other,New York Medicaid APG methodology,1965,,,1965,Other,100% New York Medicaid APG,1965,,,1965,Other,100% New York Medicaid APG,1965,,,1965,Other,100% New York Medicaid APG,4421.25,,,4421.25,Other,225% New York Medicaid APG,3006.45,,,3006.45,Other,153% New York Medicaid APG,4421.25,,,4421.25,Other,225% New York Medicaid APG,2751,,,2751,Other,140% New York Medicaid APG,4421.25,,,4421.25,Other,225% New York Medicaid APG,5109,,,5109,Other,260% New York Medicaid APG,6366.6,,,6366.6,Other,324% New York Medicaid APG,4224.75,,,4224.75,Other,215% New York Medicaid APG,4224.75,,,4224.75,Other,215% New York Medicaid APG,2456.25,,,2456.25,Other,125% New York Medicaid APG,1965,111352.72,
Release knuckle contracture,26520,CPT,,,,,,,,both,,,36530.43,27032.52,74,,27032.52,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,16438.69,45,,16438.69,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,18082.56,49.5,,18082.56,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2289.65,,,2289.65,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,25571.3,70,,25571.3,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1231,,,1231,Other,New York Medicaid APG methodology,1231,,,1231,Other,100% New York Medicaid APG,1231,,,1231,Other,100% New York Medicaid APG,1231,,,1231,Other,100% New York Medicaid APG,2769.74,,,2769.74,Other,225% New York Medicaid APG,1883.42,,,1883.42,Other,153% New York Medicaid APG,2769.74,,,2769.74,Other,225% New York Medicaid APG,1723.39,,,1723.39,Other,140% New York Medicaid APG,2769.74,,,2769.74,Other,225% New York Medicaid APG,3200.59,,,3200.59,Other,260% New York Medicaid APG,3988.42,,,3988.42,Other,324% New York Medicaid APG,2646.64,,,2646.64,Other,215% New York Medicaid APG,2646.64,,,2646.64,Other,215% New York Medicaid APG,1538.74,,,1538.74,Other,125% New York Medicaid APG,1231,27032.52,
Release finger contracture,26525,CPT,,,,,,,,both,,,36510.01,27017.41,74,,27017.41,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,16429.5,45,,16429.5,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,18072.45,49.5,,18072.45,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2289.65,,,2289.65,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,25557.01,70,,25557.01,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1231,,,1231,Other,New York Medicaid APG methodology,1231,,,1231,Other,100% New York Medicaid APG,1231,,,1231,Other,100% New York Medicaid APG,1231,,,1231,Other,100% New York Medicaid APG,2769.74,,,2769.74,Other,225% New York Medicaid APG,1883.42,,,1883.42,Other,153% New York Medicaid APG,2769.74,,,2769.74,Other,225% New York Medicaid APG,1723.39,,,1723.39,Other,140% New York Medicaid APG,2769.74,,,2769.74,Other,225% New York Medicaid APG,3200.59,,,3200.59,Other,260% New York Medicaid APG,3988.42,,,3988.42,Other,324% New York Medicaid APG,2646.64,,,2646.64,Other,215% New York Medicaid APG,2646.64,,,2646.64,Other,215% New York Medicaid APG,1538.74,,,1538.74,Other,125% New York Medicaid APG,1231,27017.41,
Revise knuckle joint,26530,CPT,,,,,,,,both,,,37234.15,27553.27,74,,27553.27,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,16755.37,45,,16755.37,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,18430.9,49.5,,18430.9,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5218.57,,,5218.57,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,26063.91,70,,26063.91,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,2805.68,,,2805.68,Other,New York Medicaid APG methodology,2805.68,,,2805.68,Other,100% New York Medicaid APG,2805.68,,,2805.68,Other,100% New York Medicaid APG,2805.68,,,2805.68,Other,100% New York Medicaid APG,6312.79,,,6312.79,Other,225% New York Medicaid APG,4292.7,,,4292.7,Other,153% New York Medicaid APG,6312.79,,,6312.79,Other,225% New York Medicaid APG,3927.96,,,3927.96,Other,140% New York Medicaid APG,6312.79,,,6312.79,Other,225% New York Medicaid APG,7294.78,,,7294.78,Other,260% New York Medicaid APG,9090.42,,,9090.42,Other,324% New York Medicaid APG,6032.22,,,6032.22,Other,215% New York Medicaid APG,6032.22,,,6032.22,Other,215% New York Medicaid APG,3507.11,,,3507.11,Other,125% New York Medicaid APG,2805.68,27553.27,
Revise knuckle with implant,26531,CPT,,,,,,,,both,,,50570.66,37422.29,74,,37422.29,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,22756.8,45,,22756.8,percent of total billed charges,Medicare Ratio of cost to charges,5954,,"100% primary, 50% supplemental procedure",5954,Other,Aetna ASC Grouper,5359,,"100% primary, 50% supplemental procedure",5359,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,25032.48,49.5,,25032.48,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5218.57,,,5218.57,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,35399.46,70,,35399.46,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,2805.68,,,2805.68,Other,New York Medicaid APG methodology,2805.68,,,2805.68,Other,100% New York Medicaid APG,2805.68,,,2805.68,Other,100% New York Medicaid APG,2805.68,,,2805.68,Other,100% New York Medicaid APG,6312.79,,,6312.79,Other,225% New York Medicaid APG,4292.7,,,4292.7,Other,153% New York Medicaid APG,6312.79,,,6312.79,Other,225% New York Medicaid APG,3927.96,,,3927.96,Other,140% New York Medicaid APG,6312.79,,,6312.79,Other,225% New York Medicaid APG,7294.78,,,7294.78,Other,260% New York Medicaid APG,9090.42,,,9090.42,Other,324% New York Medicaid APG,6032.22,,,6032.22,Other,215% New York Medicaid APG,6032.22,,,6032.22,Other,215% New York Medicaid APG,3507.11,,,3507.11,Other,125% New York Medicaid APG,2805.68,37422.29,
Revise finger joint,26535,CPT,,,,,,,,both,,,68082.75,50381.24,74,,50381.24,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30637.24,45,,30637.24,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33700.96,49.5,,33700.96,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5218.57,,,5218.57,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,47657.93,70,,47657.93,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,2805.68,,,2805.68,Other,New York Medicaid APG methodology,2805.68,,,2805.68,Other,100% New York Medicaid APG,2805.68,,,2805.68,Other,100% New York Medicaid APG,2805.68,,,2805.68,Other,100% New York Medicaid APG,6312.79,,,6312.79,Other,225% New York Medicaid APG,4292.7,,,4292.7,Other,153% New York Medicaid APG,6312.79,,,6312.79,Other,225% New York Medicaid APG,3927.96,,,3927.96,Other,140% New York Medicaid APG,6312.79,,,6312.79,Other,225% New York Medicaid APG,7294.78,,,7294.78,Other,260% New York Medicaid APG,9090.42,,,9090.42,Other,324% New York Medicaid APG,6032.22,,,6032.22,Other,215% New York Medicaid APG,6032.22,,,6032.22,Other,215% New York Medicaid APG,3507.11,,,3507.11,Other,125% New York Medicaid APG,2805.68,50381.24,
Revise/implant finger joint,26536,CPT,,,,,,,,both,,,150476.65,111352.72,74,,111352.72,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,67714.49,45,,67714.49,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,74485.94,49.5,,74485.94,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5218.57,,,5218.57,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,105333.66,70,,105333.66,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,2805.68,,,2805.68,Other,New York Medicaid APG methodology,2805.68,,,2805.68,Other,100% New York Medicaid APG,2805.68,,,2805.68,Other,100% New York Medicaid APG,2805.68,,,2805.68,Other,100% New York Medicaid APG,6312.79,,,6312.79,Other,225% New York Medicaid APG,4292.7,,,4292.7,Other,153% New York Medicaid APG,6312.79,,,6312.79,Other,225% New York Medicaid APG,3927.96,,,3927.96,Other,140% New York Medicaid APG,6312.79,,,6312.79,Other,225% New York Medicaid APG,7294.78,,,7294.78,Other,260% New York Medicaid APG,9090.42,,,9090.42,Other,324% New York Medicaid APG,6032.22,,,6032.22,Other,215% New York Medicaid APG,6032.22,,,6032.22,Other,215% New York Medicaid APG,3507.11,,,3507.11,Other,125% New York Medicaid APG,2805.68,111352.72,
Repair hand joint,26540,CPT,,,,,,,,both,,,47774.16,35352.88,74,,35352.88,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,21498.37,45,,21498.37,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,23648.21,49.5,,23648.21,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2289.65,,,2289.65,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,33441.91,70,,33441.91,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1231,,,1231,Other,New York Medicaid APG methodology,1231,,,1231,Other,100% New York Medicaid APG,1231,,,1231,Other,100% New York Medicaid APG,1231,,,1231,Other,100% New York Medicaid APG,2769.74,,,2769.74,Other,225% New York Medicaid APG,1883.42,,,1883.42,Other,153% New York Medicaid APG,2769.74,,,2769.74,Other,225% New York Medicaid APG,1723.39,,,1723.39,Other,140% New York Medicaid APG,2769.74,,,2769.74,Other,225% New York Medicaid APG,3200.59,,,3200.59,Other,260% New York Medicaid APG,3988.42,,,3988.42,Other,324% New York Medicaid APG,2646.64,,,2646.64,Other,215% New York Medicaid APG,2646.64,,,2646.64,Other,215% New York Medicaid APG,1538.74,,,1538.74,Other,125% New York Medicaid APG,1231,35352.88,
Repair hand joint with graft,26541,CPT,,,,,,,,both,,,51006.86,37745.08,74,,37745.08,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,22953.09,45,,22953.09,percent of total billed charges,Medicare Ratio of cost to charges,5954,,"100% primary, 50% supplemental procedure",5954,Other,Aetna ASC Grouper,5359,,"100% primary, 50% supplemental procedure",5359,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,25248.4,49.5,,25248.4,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3654.9,,,3654.9,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,35704.8,70,,35704.8,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1965,,,1965,Other,New York Medicaid APG methodology,1965,,,1965,Other,100% New York Medicaid APG,1965,,,1965,Other,100% New York Medicaid APG,1965,,,1965,Other,100% New York Medicaid APG,4421.25,,,4421.25,Other,225% New York Medicaid APG,3006.45,,,3006.45,Other,153% New York Medicaid APG,4421.25,,,4421.25,Other,225% New York Medicaid APG,2751,,,2751,Other,140% New York Medicaid APG,4421.25,,,4421.25,Other,225% New York Medicaid APG,5109,,,5109,Other,260% New York Medicaid APG,6366.6,,,6366.6,Other,324% New York Medicaid APG,4224.75,,,4224.75,Other,215% New York Medicaid APG,4224.75,,,4224.75,Other,215% New York Medicaid APG,2456.25,,,2456.25,Other,125% New York Medicaid APG,1965,37745.08,
Repair hand joint with graft,26542,CPT,,,,,,,,both,,,68082.75,50381.24,74,,50381.24,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30637.24,45,,30637.24,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33700.96,49.5,,33700.96,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3654.9,,,3654.9,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,47657.93,70,,47657.93,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1965,,,1965,Other,New York Medicaid APG methodology,1965,,,1965,Other,100% New York Medicaid APG,1965,,,1965,Other,100% New York Medicaid APG,1965,,,1965,Other,100% New York Medicaid APG,4421.25,,,4421.25,Other,225% New York Medicaid APG,3006.45,,,3006.45,Other,153% New York Medicaid APG,4421.25,,,4421.25,Other,225% New York Medicaid APG,2751,,,2751,Other,140% New York Medicaid APG,4421.25,,,4421.25,Other,225% New York Medicaid APG,5109,,,5109,Other,260% New York Medicaid APG,6366.6,,,6366.6,Other,324% New York Medicaid APG,4224.75,,,4224.75,Other,215% New York Medicaid APG,4224.75,,,4224.75,Other,215% New York Medicaid APG,2456.25,,,2456.25,Other,125% New York Medicaid APG,1965,50381.24,
Reconstruct finger joint,26545,CPT,,,,,,,,both,,,42409.65,31383.14,74,,31383.14,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,19084.34,45,,19084.34,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,20992.78,49.5,,20992.78,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3654.9,,,3654.9,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,29686.76,70,,29686.76,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1965,,,1965,Other,New York Medicaid APG methodology,1965,,,1965,Other,100% New York Medicaid APG,1965,,,1965,Other,100% New York Medicaid APG,1965,,,1965,Other,100% New York Medicaid APG,4421.25,,,4421.25,Other,225% New York Medicaid APG,3006.45,,,3006.45,Other,153% New York Medicaid APG,4421.25,,,4421.25,Other,225% New York Medicaid APG,2751,,,2751,Other,140% New York Medicaid APG,4421.25,,,4421.25,Other,225% New York Medicaid APG,5109,,,5109,Other,260% New York Medicaid APG,6366.6,,,6366.6,Other,324% New York Medicaid APG,4224.75,,,4224.75,Other,215% New York Medicaid APG,4224.75,,,4224.75,Other,215% New York Medicaid APG,2456.25,,,2456.25,Other,125% New York Medicaid APG,1965,31383.14,
Repair nonunion hand,26546,CPT,,,,,,,,both,,,150476.65,111352.72,74,,111352.72,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,67714.49,45,,67714.49,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,74485.94,49.5,,74485.94,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3654.9,,,3654.9,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,105333.66,70,,105333.66,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1965,,,1965,Other,New York Medicaid APG methodology,1965,,,1965,Other,100% New York Medicaid APG,1965,,,1965,Other,100% New York Medicaid APG,1965,,,1965,Other,100% New York Medicaid APG,4421.25,,,4421.25,Other,225% New York Medicaid APG,3006.45,,,3006.45,Other,153% New York Medicaid APG,4421.25,,,4421.25,Other,225% New York Medicaid APG,2751,,,2751,Other,140% New York Medicaid APG,4421.25,,,4421.25,Other,225% New York Medicaid APG,5109,,,5109,Other,260% New York Medicaid APG,6366.6,,,6366.6,Other,324% New York Medicaid APG,4224.75,,,4224.75,Other,215% New York Medicaid APG,4224.75,,,4224.75,Other,215% New York Medicaid APG,2456.25,,,2456.25,Other,125% New York Medicaid APG,1965,111352.72,
Reconstruct finger joint,26548,CPT,,,,,,,,both,,,39006.65,28864.92,74,,28864.92,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,17552.99,45,,17552.99,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,19308.29,49.5,,19308.29,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3654.9,,,3654.9,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,27304.66,70,,27304.66,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1965,,,1965,Other,New York Medicaid APG methodology,1965,,,1965,Other,100% New York Medicaid APG,1965,,,1965,Other,100% New York Medicaid APG,1965,,,1965,Other,100% New York Medicaid APG,4421.25,,,4421.25,Other,225% New York Medicaid APG,3006.45,,,3006.45,Other,153% New York Medicaid APG,4421.25,,,4421.25,Other,225% New York Medicaid APG,2751,,,2751,Other,140% New York Medicaid APG,4421.25,,,4421.25,Other,225% New York Medicaid APG,5109,,,5109,Other,260% New York Medicaid APG,6366.6,,,6366.6,Other,324% New York Medicaid APG,4224.75,,,4224.75,Other,215% New York Medicaid APG,4224.75,,,4224.75,Other,215% New York Medicaid APG,2456.25,,,2456.25,Other,125% New York Medicaid APG,1965,28864.92,
Construct thumb replacement,26550,CPT,,,,,,,,both,,,68082.75,50381.24,74,,50381.24,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30637.24,45,,30637.24,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33700.96,49.5,,33700.96,percent of total billed charges,110% of Medicare,46296.27,68,,46296.27,percent of total billed charges,,3654.9,,,3654.9,Other,186% of Medicaid,54466.2,80,,54466.2,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,54466.2,80,,54466.2,percent of total billed charges,,7216,,,7216,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,47657.93,70,,47657.93,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1965,,,1965,Other,New York Medicaid APG methodology,1965,,,1965,Other,100% New York Medicaid APG,1965,,,1965,Other,100% New York Medicaid APG,1965,,,1965,Other,100% New York Medicaid APG,4421.25,,,4421.25,Other,225% New York Medicaid APG,3006.45,,,3006.45,Other,153% New York Medicaid APG,4421.25,,,4421.25,Other,225% New York Medicaid APG,2751,,,2751,Other,140% New York Medicaid APG,4421.25,,,4421.25,Other,225% New York Medicaid APG,5109,,,5109,Other,260% New York Medicaid APG,6366.6,,,6366.6,Other,324% New York Medicaid APG,4224.75,,,4224.75,Other,215% New York Medicaid APG,4224.75,,,4224.75,Other,215% New York Medicaid APG,2456.25,,,2456.25,Other,125% New York Medicaid APG,1965,54466.2,
Positional change of finger,26555,CPT,,,,,,,,both,,,150476.65,111352.72,74,,111352.72,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,67714.49,45,,67714.49,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,74485.94,49.5,,74485.94,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3654.9,,,3654.9,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,105333.66,70,,105333.66,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1965,,,1965,Other,New York Medicaid APG methodology,1965,,,1965,Other,100% New York Medicaid APG,1965,,,1965,Other,100% New York Medicaid APG,1965,,,1965,Other,100% New York Medicaid APG,4421.25,,,4421.25,Other,225% New York Medicaid APG,3006.45,,,3006.45,Other,153% New York Medicaid APG,4421.25,,,4421.25,Other,225% New York Medicaid APG,2751,,,2751,Other,140% New York Medicaid APG,4421.25,,,4421.25,Other,225% New York Medicaid APG,5109,,,5109,Other,260% New York Medicaid APG,6366.6,,,6366.6,Other,324% New York Medicaid APG,4224.75,,,4224.75,Other,215% New York Medicaid APG,4224.75,,,4224.75,Other,215% New York Medicaid APG,2456.25,,,2456.25,Other,125% New York Medicaid APG,1965,111352.72,
Repair of web finger,26560,CPT,,,,,,,,both,,,33805.49,25016.06,74,,25016.06,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15212.47,45,,15212.47,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,16733.72,49.5,,16733.72,percent of total billed charges,110% of Medicare,22987.73,68,,22987.73,percent of total billed charges,,3654.9,,,3654.9,Other,186% of Medicaid,27044.39,80,,27044.39,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,27044.39,80,,27044.39,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,23663.84,70,,23663.84,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1965,,,1965,Other,New York Medicaid APG methodology,1965,,,1965,Other,100% New York Medicaid APG,1965,,,1965,Other,100% New York Medicaid APG,1965,,,1965,Other,100% New York Medicaid APG,4421.25,,,4421.25,Other,225% New York Medicaid APG,3006.45,,,3006.45,Other,153% New York Medicaid APG,4421.25,,,4421.25,Other,225% New York Medicaid APG,2751,,,2751,Other,140% New York Medicaid APG,4421.25,,,4421.25,Other,225% New York Medicaid APG,5109,,,5109,Other,260% New York Medicaid APG,6366.6,,,6366.6,Other,324% New York Medicaid APG,4224.75,,,4224.75,Other,215% New York Medicaid APG,4224.75,,,4224.75,Other,215% New York Medicaid APG,2456.25,,,2456.25,Other,125% New York Medicaid APG,1965,27044.39,
Repair of web finger,26561,CPT,,,,,,,,both,,,41047.15,30374.89,74,,30374.89,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,18471.22,45,,18471.22,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,20318.34,49.5,,20318.34,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3654.9,,,3654.9,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,28733.01,70,,28733.01,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1965,,,1965,Other,New York Medicaid APG methodology,1965,,,1965,Other,100% New York Medicaid APG,1965,,,1965,Other,100% New York Medicaid APG,1965,,,1965,Other,100% New York Medicaid APG,4421.25,,,4421.25,Other,225% New York Medicaid APG,3006.45,,,3006.45,Other,153% New York Medicaid APG,4421.25,,,4421.25,Other,225% New York Medicaid APG,2751,,,2751,Other,140% New York Medicaid APG,4421.25,,,4421.25,Other,225% New York Medicaid APG,5109,,,5109,Other,260% New York Medicaid APG,6366.6,,,6366.6,Other,324% New York Medicaid APG,4224.75,,,4224.75,Other,215% New York Medicaid APG,4224.75,,,4224.75,Other,215% New York Medicaid APG,2456.25,,,2456.25,Other,125% New York Medicaid APG,1965,30374.89,
Repair of web finger,26562,CPT,,,,,,,,both,,,68082.75,50381.24,74,,50381.24,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30637.24,45,,30637.24,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33700.96,49.5,,33700.96,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3654.9,,,3654.9,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,47657.93,70,,47657.93,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1965,,,1965,Other,New York Medicaid APG methodology,1965,,,1965,Other,100% New York Medicaid APG,1965,,,1965,Other,100% New York Medicaid APG,1965,,,1965,Other,100% New York Medicaid APG,4421.25,,,4421.25,Other,225% New York Medicaid APG,3006.45,,,3006.45,Other,153% New York Medicaid APG,4421.25,,,4421.25,Other,225% New York Medicaid APG,2751,,,2751,Other,140% New York Medicaid APG,4421.25,,,4421.25,Other,225% New York Medicaid APG,5109,,,5109,Other,260% New York Medicaid APG,6366.6,,,6366.6,Other,324% New York Medicaid APG,4224.75,,,4224.75,Other,215% New York Medicaid APG,4224.75,,,4224.75,Other,215% New York Medicaid APG,2456.25,,,2456.25,Other,125% New York Medicaid APG,1965,50381.24,
Correct metacarpal flaw,26565,CPT,,,,,,,,both,,,55334.13,40947.26,74,,40947.26,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,24900.36,45,,24900.36,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,27390.39,49.5,,27390.39,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3654.9,,,3654.9,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,38733.89,70,,38733.89,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1965,,,1965,Other,New York Medicaid APG methodology,1965,,,1965,Other,100% New York Medicaid APG,1965,,,1965,Other,100% New York Medicaid APG,1965,,,1965,Other,100% New York Medicaid APG,4421.25,,,4421.25,Other,225% New York Medicaid APG,3006.45,,,3006.45,Other,153% New York Medicaid APG,4421.25,,,4421.25,Other,225% New York Medicaid APG,2751,,,2751,Other,140% New York Medicaid APG,4421.25,,,4421.25,Other,225% New York Medicaid APG,5109,,,5109,Other,260% New York Medicaid APG,6366.6,,,6366.6,Other,324% New York Medicaid APG,4224.75,,,4224.75,Other,215% New York Medicaid APG,4224.75,,,4224.75,Other,215% New York Medicaid APG,2456.25,,,2456.25,Other,125% New York Medicaid APG,1965,40947.26,
Correct finger deformity,26567,CPT,,,,,,,,both,,,49243.45,36440.15,74,,36440.15,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,22159.55,45,,22159.55,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,24375.51,49.5,,24375.51,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3654.9,,,3654.9,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,34470.42,70,,34470.42,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1965,,,1965,Other,New York Medicaid APG methodology,1965,,,1965,Other,100% New York Medicaid APG,1965,,,1965,Other,100% New York Medicaid APG,1965,,,1965,Other,100% New York Medicaid APG,4421.25,,,4421.25,Other,225% New York Medicaid APG,3006.45,,,3006.45,Other,153% New York Medicaid APG,4421.25,,,4421.25,Other,225% New York Medicaid APG,2751,,,2751,Other,140% New York Medicaid APG,4421.25,,,4421.25,Other,225% New York Medicaid APG,5109,,,5109,Other,260% New York Medicaid APG,6366.6,,,6366.6,Other,324% New York Medicaid APG,4224.75,,,4224.75,Other,215% New York Medicaid APG,4224.75,,,4224.75,Other,215% New York Medicaid APG,2456.25,,,2456.25,Other,125% New York Medicaid APG,1965,36440.15,
Lengthen metacarpal/finger,26568,CPT,,,,,,,,both,,,150476.65,111352.72,74,,111352.72,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,67714.49,45,,67714.49,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,74485.94,49.5,,74485.94,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3654.9,,,3654.9,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,105333.66,70,,105333.66,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1965,,,1965,Other,New York Medicaid APG methodology,1965,,,1965,Other,100% New York Medicaid APG,1965,,,1965,Other,100% New York Medicaid APG,1965,,,1965,Other,100% New York Medicaid APG,4421.25,,,4421.25,Other,225% New York Medicaid APG,3006.45,,,3006.45,Other,153% New York Medicaid APG,4421.25,,,4421.25,Other,225% New York Medicaid APG,2751,,,2751,Other,140% New York Medicaid APG,4421.25,,,4421.25,Other,225% New York Medicaid APG,5109,,,5109,Other,260% New York Medicaid APG,6366.6,,,6366.6,Other,324% New York Medicaid APG,4224.75,,,4224.75,Other,215% New York Medicaid APG,4224.75,,,4224.75,Other,215% New York Medicaid APG,2456.25,,,2456.25,Other,125% New York Medicaid APG,1965,111352.72,
Repair hand deformity,26580,CPT,,,,,,,,both,,,68082.75,50381.24,74,,50381.24,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30637.24,45,,30637.24,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33700.96,49.5,,33700.96,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3654.9,,,3654.9,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,47657.93,70,,47657.93,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1965,,,1965,Other,New York Medicaid APG methodology,1965,,,1965,Other,100% New York Medicaid APG,1965,,,1965,Other,100% New York Medicaid APG,1965,,,1965,Other,100% New York Medicaid APG,4421.25,,,4421.25,Other,225% New York Medicaid APG,3006.45,,,3006.45,Other,153% New York Medicaid APG,4421.25,,,4421.25,Other,225% New York Medicaid APG,2751,,,2751,Other,140% New York Medicaid APG,4421.25,,,4421.25,Other,225% New York Medicaid APG,5109,,,5109,Other,260% New York Medicaid APG,6366.6,,,6366.6,Other,324% New York Medicaid APG,4224.75,,,4224.75,Other,215% New York Medicaid APG,4224.75,,,4224.75,Other,215% New York Medicaid APG,2456.25,,,2456.25,Other,125% New York Medicaid APG,1965,50381.24,
Reconstruct extra finger,26587,CPT,,,,,,,,both,,,34877.63,25809.45,74,,25809.45,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15694.93,45,,15694.93,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,17264.43,49.5,,17264.43,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3654.9,,,3654.9,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,24414.34,70,,24414.34,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1965,,,1965,Other,New York Medicaid APG methodology,1965,,,1965,Other,100% New York Medicaid APG,1965,,,1965,Other,100% New York Medicaid APG,1965,,,1965,Other,100% New York Medicaid APG,4421.25,,,4421.25,Other,225% New York Medicaid APG,3006.45,,,3006.45,Other,153% New York Medicaid APG,4421.25,,,4421.25,Other,225% New York Medicaid APG,2751,,,2751,Other,140% New York Medicaid APG,4421.25,,,4421.25,Other,225% New York Medicaid APG,5109,,,5109,Other,260% New York Medicaid APG,6366.6,,,6366.6,Other,324% New York Medicaid APG,4224.75,,,4224.75,Other,215% New York Medicaid APG,4224.75,,,4224.75,Other,215% New York Medicaid APG,2456.25,,,2456.25,Other,125% New York Medicaid APG,1965,25809.45,
Repair finger deformity,26590,CPT,,,,,,,,both,,,33805.49,25016.06,74,,25016.06,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15212.47,45,,15212.47,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,16733.72,49.5,,16733.72,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3654.9,,,3654.9,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,23663.84,70,,23663.84,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1965,,,1965,Other,New York Medicaid APG methodology,1965,,,1965,Other,100% New York Medicaid APG,1965,,,1965,Other,100% New York Medicaid APG,1965,,,1965,Other,100% New York Medicaid APG,4421.25,,,4421.25,Other,225% New York Medicaid APG,3006.45,,,3006.45,Other,153% New York Medicaid APG,4421.25,,,4421.25,Other,225% New York Medicaid APG,2751,,,2751,Other,140% New York Medicaid APG,4421.25,,,4421.25,Other,225% New York Medicaid APG,5109,,,5109,Other,260% New York Medicaid APG,6366.6,,,6366.6,Other,324% New York Medicaid APG,4224.75,,,4224.75,Other,215% New York Medicaid APG,4224.75,,,4224.75,Other,215% New York Medicaid APG,2456.25,,,2456.25,Other,125% New York Medicaid APG,1965,25016.06,
Repair muscles of hand,26591,CPT,,,,,,,,both,,,68082.75,50381.24,74,,50381.24,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30637.24,45,,30637.24,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33700.96,49.5,,33700.96,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3654.9,,,3654.9,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,47657.93,70,,47657.93,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1965,,,1965,Other,New York Medicaid APG methodology,1965,,,1965,Other,100% New York Medicaid APG,1965,,,1965,Other,100% New York Medicaid APG,1965,,,1965,Other,100% New York Medicaid APG,4421.25,,,4421.25,Other,225% New York Medicaid APG,3006.45,,,3006.45,Other,153% New York Medicaid APG,4421.25,,,4421.25,Other,225% New York Medicaid APG,2751,,,2751,Other,140% New York Medicaid APG,4421.25,,,4421.25,Other,225% New York Medicaid APG,5109,,,5109,Other,260% New York Medicaid APG,6366.6,,,6366.6,Other,324% New York Medicaid APG,4224.75,,,4224.75,Other,215% New York Medicaid APG,4224.75,,,4224.75,Other,215% New York Medicaid APG,2456.25,,,2456.25,Other,125% New York Medicaid APG,1965,50381.24,
Release muscles of hand,26593,CPT,,,,,,,,both,,,68082.75,50381.24,74,,50381.24,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30637.24,45,,30637.24,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33700.96,49.5,,33700.96,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2289.65,,,2289.65,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,47657.93,70,,47657.93,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1231,,,1231,Other,New York Medicaid APG methodology,1231,,,1231,Other,100% New York Medicaid APG,1231,,,1231,Other,100% New York Medicaid APG,1231,,,1231,Other,100% New York Medicaid APG,2769.74,,,2769.74,Other,225% New York Medicaid APG,1883.42,,,1883.42,Other,153% New York Medicaid APG,2769.74,,,2769.74,Other,225% New York Medicaid APG,1723.39,,,1723.39,Other,140% New York Medicaid APG,2769.74,,,2769.74,Other,225% New York Medicaid APG,3200.59,,,3200.59,Other,260% New York Medicaid APG,3988.42,,,3988.42,Other,324% New York Medicaid APG,2646.64,,,2646.64,Other,215% New York Medicaid APG,2646.64,,,2646.64,Other,215% New York Medicaid APG,1538.74,,,1538.74,Other,125% New York Medicaid APG,1231,50381.24,
Excision constricting tissue,26596,CPT,,,,,,,,both,,,68082.75,50381.24,74,,50381.24,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30637.24,45,,30637.24,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33700.96,49.5,,33700.96,percent of total billed charges,110% of Medicare,46296.27,68,,46296.27,percent of total billed charges,,3654.9,,,3654.9,Other,186% of Medicaid,54466.2,80,,54466.2,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,54466.2,80,,54466.2,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,47657.93,70,,47657.93,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1965,,,1965,Other,New York Medicaid APG methodology,1965,,,1965,Other,100% New York Medicaid APG,1965,,,1965,Other,100% New York Medicaid APG,1965,,,1965,Other,100% New York Medicaid APG,4421.25,,,4421.25,Other,225% New York Medicaid APG,3006.45,,,3006.45,Other,153% New York Medicaid APG,4421.25,,,4421.25,Other,225% New York Medicaid APG,2751,,,2751,Other,140% New York Medicaid APG,4421.25,,,4421.25,Other,225% New York Medicaid APG,5109,,,5109,Other,260% New York Medicaid APG,6366.6,,,6366.6,Other,324% New York Medicaid APG,4224.75,,,4224.75,Other,215% New York Medicaid APG,4224.75,,,4224.75,Other,215% New York Medicaid APG,2456.25,,,2456.25,Other,125% New York Medicaid APG,1965,54466.2,
Treat metacarpal fracture,26600,CPT,,,,,,,,both,,,4960.23,3670.57,74,,3670.57,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,2232.1,45,,2232.1,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,2455.31,49.5,,2455.31,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,1031.43,,,1031.43,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,3472.16,70,,3472.16,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,554.53,,,554.53,Other,New York Medicaid APG methodology,554.53,,,554.53,Other,100% New York Medicaid APG,554.53,,,554.53,Other,100% New York Medicaid APG,554.53,,,554.53,Other,100% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,848.43,,,848.43,Other,153% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,776.34,,,776.34,Other,140% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,1441.78,,,1441.78,Other,260% New York Medicaid APG,1796.68,,,1796.68,Other,324% New York Medicaid APG,1192.24,,,1192.24,Other,215% New York Medicaid APG,1192.24,,,1192.24,Other,215% New York Medicaid APG,693.16,,,693.16,Other,125% New York Medicaid APG,554.53,9473,
Treat metacarpal fracture,26605,CPT,,,,,,,,both,,,4960.23,3670.57,74,,3670.57,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,2232.1,45,,2232.1,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,2455.31,49.5,,2455.31,percent of total billed charges,110% of Medicare,3372.96,68,,3372.96,percent of total billed charges,,1031.43,,,1031.43,Other,186% of Medicaid,3968.18,80,,3968.18,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,3968.18,80,,3968.18,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,3472.16,70,,3472.16,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,554.53,,,554.53,Other,New York Medicaid APG methodology,554.53,,,554.53,Other,100% New York Medicaid APG,554.53,,,554.53,Other,100% New York Medicaid APG,554.53,,,554.53,Other,100% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,848.43,,,848.43,Other,153% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,776.34,,,776.34,Other,140% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,1441.78,,,1441.78,Other,260% New York Medicaid APG,1796.68,,,1796.68,Other,324% New York Medicaid APG,1192.24,,,1192.24,Other,215% New York Medicaid APG,1192.24,,,1192.24,Other,215% New York Medicaid APG,693.16,,,693.16,Other,125% New York Medicaid APG,554.53,7216,
Treat metacarpal fracture,26607,CPT,,,,,,,,both,,,68082.75,50381.24,74,,50381.24,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30637.24,45,,30637.24,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33700.96,49.5,,33700.96,percent of total billed charges,110% of Medicare,46296.27,68,,46296.27,percent of total billed charges,,1031.43,,,1031.43,Other,186% of Medicaid,54466.2,80,,54466.2,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,54466.2,80,,54466.2,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,47657.93,70,,47657.93,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,554.53,,,554.53,Other,New York Medicaid APG methodology,554.53,,,554.53,Other,100% New York Medicaid APG,554.53,,,554.53,Other,100% New York Medicaid APG,554.53,,,554.53,Other,100% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,848.43,,,848.43,Other,153% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,776.34,,,776.34,Other,140% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,1441.78,,,1441.78,Other,260% New York Medicaid APG,1796.68,,,1796.68,Other,324% New York Medicaid APG,1192.24,,,1192.24,Other,215% New York Medicaid APG,1192.24,,,1192.24,Other,215% New York Medicaid APG,693.16,,,693.16,Other,125% New York Medicaid APG,554.53,54466.2,
Treat metacarpal fracture,26608,CPT,,,,,,,,both,,,33165.32,24542.34,74,,24542.34,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,14924.39,45,,14924.39,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,16416.83,49.5,,16416.83,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5092.5,,,5092.5,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,23215.72,70,,23215.72,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,2737.91,,,2737.91,Other,New York Medicaid APG methodology,2737.91,,,2737.91,Other,100% New York Medicaid APG,2737.91,,,2737.91,Other,100% New York Medicaid APG,2737.91,,,2737.91,Other,100% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,4189,,,4189,Other,153% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,3833.07,,,3833.07,Other,140% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,7118.55,,,7118.55,Other,260% New York Medicaid APG,8870.81,,,8870.81,Other,324% New York Medicaid APG,5886.5,,,5886.5,Other,215% New York Medicaid APG,5886.5,,,5886.5,Other,215% New York Medicaid APG,3422.38,,,3422.38,Other,125% New York Medicaid APG,2737.91,24542.34,
Treat metacarpal fracture,26615,CPT,,,,,,,,both,,,54008.81,39966.52,74,,39966.52,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,24303.96,45,,24303.96,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,26734.36,49.5,,26734.36,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5092.5,,,5092.5,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,37806.17,70,,37806.17,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,2737.91,,,2737.91,Other,New York Medicaid APG methodology,2737.91,,,2737.91,Other,100% New York Medicaid APG,2737.91,,,2737.91,Other,100% New York Medicaid APG,2737.91,,,2737.91,Other,100% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,4189,,,4189,Other,153% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,3833.07,,,3833.07,Other,140% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,7118.55,,,7118.55,Other,260% New York Medicaid APG,8870.81,,,8870.81,Other,324% New York Medicaid APG,5886.5,,,5886.5,Other,215% New York Medicaid APG,5886.5,,,5886.5,Other,215% New York Medicaid APG,3422.38,,,3422.38,Other,125% New York Medicaid APG,2737.91,39966.52,
Treat thumb dislocation,26641,CPT,,,,,,,,both,,,4960.23,3670.57,74,,3670.57,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,2232.1,45,,2232.1,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,2455.31,49.5,,2455.31,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,1031.43,,,1031.43,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,3472.16,70,,3472.16,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,554.53,,,554.53,Other,New York Medicaid APG methodology,554.53,,,554.53,Other,100% New York Medicaid APG,554.53,,,554.53,Other,100% New York Medicaid APG,554.53,,,554.53,Other,100% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,848.43,,,848.43,Other,153% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,776.34,,,776.34,Other,140% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,1441.78,,,1441.78,Other,260% New York Medicaid APG,1796.68,,,1796.68,Other,324% New York Medicaid APG,1192.24,,,1192.24,Other,215% New York Medicaid APG,1192.24,,,1192.24,Other,215% New York Medicaid APG,693.16,,,693.16,Other,125% New York Medicaid APG,554.53,9473,
Treat thumb fracture,26645,CPT,,,,,,,,both,,,33805.49,25016.06,74,,25016.06,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15212.47,45,,15212.47,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,16733.72,49.5,,16733.72,percent of total billed charges,110% of Medicare,22987.73,68,,22987.73,percent of total billed charges,,1031.43,,,1031.43,Other,186% of Medicaid,27044.39,80,,27044.39,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,27044.39,80,,27044.39,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,23663.84,70,,23663.84,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,554.53,,,554.53,Other,New York Medicaid APG methodology,554.53,,,554.53,Other,100% New York Medicaid APG,554.53,,,554.53,Other,100% New York Medicaid APG,554.53,,,554.53,Other,100% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,848.43,,,848.43,Other,153% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,776.34,,,776.34,Other,140% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,1441.78,,,1441.78,Other,260% New York Medicaid APG,1796.68,,,1796.68,Other,324% New York Medicaid APG,1192.24,,,1192.24,Other,215% New York Medicaid APG,1192.24,,,1192.24,Other,215% New York Medicaid APG,693.16,,,693.16,Other,125% New York Medicaid APG,554.53,27044.39,
Treat thumb fracture,26650,CPT,,,,,,,,both,,,73072.3,54073.5,74,,54073.5,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,32882.54,45,,32882.54,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,36170.79,49.5,,36170.79,percent of total billed charges,110% of Medicare,49689.16,68,,49689.16,percent of total billed charges,,5092.5,,,5092.5,Other,186% of Medicaid,58457.84,80,,58457.84,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,58457.84,80,,58457.84,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,51150.61,70,,51150.61,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,2737.91,,,2737.91,Other,New York Medicaid APG methodology,2737.91,,,2737.91,Other,100% New York Medicaid APG,2737.91,,,2737.91,Other,100% New York Medicaid APG,2737.91,,,2737.91,Other,100% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,4189,,,4189,Other,153% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,3833.07,,,3833.07,Other,140% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,7118.55,,,7118.55,Other,260% New York Medicaid APG,8870.81,,,8870.81,Other,324% New York Medicaid APG,5886.5,,,5886.5,Other,215% New York Medicaid APG,5886.5,,,5886.5,Other,215% New York Medicaid APG,3422.38,,,3422.38,Other,125% New York Medicaid APG,2232,58457.84,
Treat thumb fracture,26665,CPT,,,,,,,,both,,,38014.32,28130.6,74,,28130.6,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,17106.44,45,,17106.44,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,18817.09,49.5,,18817.09,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5092.5,,,5092.5,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,26610.02,70,,26610.02,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,2737.91,,,2737.91,Other,New York Medicaid APG methodology,2737.91,,,2737.91,Other,100% New York Medicaid APG,2737.91,,,2737.91,Other,100% New York Medicaid APG,2737.91,,,2737.91,Other,100% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,4189,,,4189,Other,153% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,3833.07,,,3833.07,Other,140% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,7118.55,,,7118.55,Other,260% New York Medicaid APG,8870.81,,,8870.81,Other,324% New York Medicaid APG,5886.5,,,5886.5,Other,215% New York Medicaid APG,5886.5,,,5886.5,Other,215% New York Medicaid APG,3422.38,,,3422.38,Other,125% New York Medicaid APG,2737.91,28130.6,
Treat hand dislocation,26670,CPT,,,,,,,,both,,,4960.23,3670.57,74,,3670.57,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,2232.1,45,,2232.1,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,2455.31,49.5,,2455.31,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,1031.43,,,1031.43,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,3472.16,70,,3472.16,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,554.53,,,554.53,Other,New York Medicaid APG methodology,554.53,,,554.53,Other,100% New York Medicaid APG,554.53,,,554.53,Other,100% New York Medicaid APG,554.53,,,554.53,Other,100% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,848.43,,,848.43,Other,153% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,776.34,,,776.34,Other,140% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,1441.78,,,1441.78,Other,260% New York Medicaid APG,1796.68,,,1796.68,Other,324% New York Medicaid APG,1192.24,,,1192.24,Other,215% New York Medicaid APG,1192.24,,,1192.24,Other,215% New York Medicaid APG,693.16,,,693.16,Other,125% New York Medicaid APG,554.53,9473,
Treat hand dislocation,26675,CPT,,,,,,,,both,,,33805.49,25016.06,74,,25016.06,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15212.47,45,,15212.47,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,16733.72,49.5,,16733.72,percent of total billed charges,110% of Medicare,22987.73,68,,22987.73,percent of total billed charges,,1730.38,,,1730.38,Other,186% of Medicaid,27044.39,80,,27044.39,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,27044.39,80,,27044.39,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,23663.84,70,,23663.84,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,930.31,,,930.31,Other,New York Medicaid APG methodology,930.31,,,930.31,Other,100% New York Medicaid APG,930.31,,,930.31,Other,100% New York Medicaid APG,930.31,,,930.31,Other,100% New York Medicaid APG,2093.21,,,2093.21,Other,225% New York Medicaid APG,1423.38,,,1423.38,Other,153% New York Medicaid APG,2093.21,,,2093.21,Other,225% New York Medicaid APG,1302.44,,,1302.44,Other,140% New York Medicaid APG,2093.21,,,2093.21,Other,225% New York Medicaid APG,2418.82,,,2418.82,Other,260% New York Medicaid APG,3014.22,,,3014.22,Other,324% New York Medicaid APG,2000.18,,,2000.18,Other,215% New York Medicaid APG,2000.18,,,2000.18,Other,215% New York Medicaid APG,1162.89,,,1162.89,Other,125% New York Medicaid APG,930.31,27044.39,
Pin hand dislocation,26676,CPT,,,,,,,,both,,,68082.75,50381.24,74,,50381.24,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30637.24,45,,30637.24,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33700.96,49.5,,33700.96,percent of total billed charges,110% of Medicare,46296.27,68,,46296.27,percent of total billed charges,,5092.5,,,5092.5,Other,186% of Medicaid,54466.2,80,,54466.2,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,54466.2,80,,54466.2,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,47657.93,70,,47657.93,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,2737.91,,,2737.91,Other,New York Medicaid APG methodology,2737.91,,,2737.91,Other,100% New York Medicaid APG,2737.91,,,2737.91,Other,100% New York Medicaid APG,2737.91,,,2737.91,Other,100% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,4189,,,4189,Other,153% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,3833.07,,,3833.07,Other,140% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,7118.55,,,7118.55,Other,260% New York Medicaid APG,8870.81,,,8870.81,Other,324% New York Medicaid APG,5886.5,,,5886.5,Other,215% New York Medicaid APG,5886.5,,,5886.5,Other,215% New York Medicaid APG,3422.38,,,3422.38,Other,125% New York Medicaid APG,2232,54466.2,
Treat hand dislocation,26685,CPT,,,,,,,,both,,,45313.25,33531.81,74,,33531.81,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,20390.96,45,,20390.96,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,22430.06,49.5,,22430.06,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5092.5,,,5092.5,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,31719.28,70,,31719.28,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,2737.91,,,2737.91,Other,New York Medicaid APG methodology,2737.91,,,2737.91,Other,100% New York Medicaid APG,2737.91,,,2737.91,Other,100% New York Medicaid APG,2737.91,,,2737.91,Other,100% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,4189,,,4189,Other,153% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,3833.07,,,3833.07,Other,140% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,7118.55,,,7118.55,Other,260% New York Medicaid APG,8870.81,,,8870.81,Other,324% New York Medicaid APG,5886.5,,,5886.5,Other,215% New York Medicaid APG,5886.5,,,5886.5,Other,215% New York Medicaid APG,3422.38,,,3422.38,Other,125% New York Medicaid APG,2737.91,33531.81,
Treat hand dislocation,26686,CPT,,,,,,,,both,,,68082.75,50381.24,74,,50381.24,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30637.24,45,,30637.24,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33700.96,49.5,,33700.96,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5092.5,,,5092.5,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,47657.93,70,,47657.93,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,2737.91,,,2737.91,Other,New York Medicaid APG methodology,2737.91,,,2737.91,Other,100% New York Medicaid APG,2737.91,,,2737.91,Other,100% New York Medicaid APG,2737.91,,,2737.91,Other,100% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,4189,,,4189,Other,153% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,3833.07,,,3833.07,Other,140% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,7118.55,,,7118.55,Other,260% New York Medicaid APG,8870.81,,,8870.81,Other,324% New York Medicaid APG,5886.5,,,5886.5,Other,215% New York Medicaid APG,5886.5,,,5886.5,Other,215% New York Medicaid APG,3422.38,,,3422.38,Other,125% New York Medicaid APG,2737.91,50381.24,
Treat knuckle dislocation,26700,CPT,,,,,,,,both,,,4960.23,3670.57,74,,3670.57,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,2232.1,45,,2232.1,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,2455.31,49.5,,2455.31,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,1031.43,,,1031.43,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,3472.16,70,,3472.16,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,554.53,,,554.53,Other,New York Medicaid APG methodology,554.53,,,554.53,Other,100% New York Medicaid APG,554.53,,,554.53,Other,100% New York Medicaid APG,554.53,,,554.53,Other,100% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,848.43,,,848.43,Other,153% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,776.34,,,776.34,Other,140% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,1441.78,,,1441.78,Other,260% New York Medicaid APG,1796.68,,,1796.68,Other,324% New York Medicaid APG,1192.24,,,1192.24,Other,215% New York Medicaid APG,1192.24,,,1192.24,Other,215% New York Medicaid APG,693.16,,,693.16,Other,125% New York Medicaid APG,554.53,9473,
Treat knuckle dislocation,26705,CPT,,,,,,,,both,,,33805.49,25016.06,74,,25016.06,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15212.47,45,,15212.47,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,16733.72,49.5,,16733.72,percent of total billed charges,110% of Medicare,22987.73,68,,22987.73,percent of total billed charges,,1730.38,,,1730.38,Other,186% of Medicaid,27044.39,80,,27044.39,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,27044.39,80,,27044.39,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,23663.84,70,,23663.84,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,930.31,,,930.31,Other,New York Medicaid APG methodology,930.31,,,930.31,Other,100% New York Medicaid APG,930.31,,,930.31,Other,100% New York Medicaid APG,930.31,,,930.31,Other,100% New York Medicaid APG,2093.21,,,2093.21,Other,225% New York Medicaid APG,1423.38,,,1423.38,Other,153% New York Medicaid APG,2093.21,,,2093.21,Other,225% New York Medicaid APG,1302.44,,,1302.44,Other,140% New York Medicaid APG,2093.21,,,2093.21,Other,225% New York Medicaid APG,2418.82,,,2418.82,Other,260% New York Medicaid APG,3014.22,,,3014.22,Other,324% New York Medicaid APG,2000.18,,,2000.18,Other,215% New York Medicaid APG,2000.18,,,2000.18,Other,215% New York Medicaid APG,1162.89,,,1162.89,Other,125% New York Medicaid APG,930.31,27044.39,
Pin knuckle dislocation,26706,CPT,,,,,,,,both,,,68082.75,50381.24,74,,50381.24,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30637.24,45,,30637.24,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33700.96,49.5,,33700.96,percent of total billed charges,110% of Medicare,46296.27,68,,46296.27,percent of total billed charges,,5092.5,,,5092.5,Other,186% of Medicaid,54466.2,80,,54466.2,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,54466.2,80,,54466.2,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,47657.93,70,,47657.93,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,2737.91,,,2737.91,Other,New York Medicaid APG methodology,2737.91,,,2737.91,Other,100% New York Medicaid APG,2737.91,,,2737.91,Other,100% New York Medicaid APG,2737.91,,,2737.91,Other,100% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,4189,,,4189,Other,153% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,3833.07,,,3833.07,Other,140% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,7118.55,,,7118.55,Other,260% New York Medicaid APG,8870.81,,,8870.81,Other,324% New York Medicaid APG,5886.5,,,5886.5,Other,215% New York Medicaid APG,5886.5,,,5886.5,Other,215% New York Medicaid APG,3422.38,,,3422.38,Other,125% New York Medicaid APG,2232,54466.2,
Treat knuckle dislocation,26715,CPT,,,,,,,,both,,,68082.75,50381.24,74,,50381.24,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30637.24,45,,30637.24,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33700.96,49.5,,33700.96,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5092.5,,,5092.5,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,47657.93,70,,47657.93,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,2737.91,,,2737.91,Other,New York Medicaid APG methodology,2737.91,,,2737.91,Other,100% New York Medicaid APG,2737.91,,,2737.91,Other,100% New York Medicaid APG,2737.91,,,2737.91,Other,100% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,4189,,,4189,Other,153% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,3833.07,,,3833.07,Other,140% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,7118.55,,,7118.55,Other,260% New York Medicaid APG,8870.81,,,8870.81,Other,324% New York Medicaid APG,5886.5,,,5886.5,Other,215% New York Medicaid APG,5886.5,,,5886.5,Other,215% New York Medicaid APG,3422.38,,,3422.38,Other,125% New York Medicaid APG,2737.91,50381.24,
Treat finger fracture each,26720,CPT,,,,,,,,both,,,33713.65,24948.1,74,,24948.1,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15171.14,45,,15171.14,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,16688.26,49.5,,16688.26,percent of total billed charges,110% of Medicare,22925.28,68,,22925.28,percent of total billed charges,,1031.43,,,1031.43,Other,186% of Medicaid,26970.92,80,,26970.92,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,26970.92,80,,26970.92,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,23599.56,70,,23599.56,percent of total billed charges,,956.12,,,956.12,Fee Schedule,,810.37,,,810.37,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,554.53,,,554.53,Other,New York Medicaid APG methodology,554.53,,,554.53,Other,100% New York Medicaid APG,554.53,,,554.53,Other,100% New York Medicaid APG,554.53,,,554.53,Other,100% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,848.43,,,848.43,Other,153% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,776.34,,,776.34,Other,140% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,1441.78,,,1441.78,Other,260% New York Medicaid APG,1796.68,,,1796.68,Other,324% New York Medicaid APG,1192.24,,,1192.24,Other,215% New York Medicaid APG,1192.24,,,1192.24,Other,215% New York Medicaid APG,693.16,,,693.16,Other,125% New York Medicaid APG,554.53,26970.92,
Treat finger fracture each,26725,CPT,,,,,,,,both,,,4960.23,3670.57,74,,3670.57,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,2232.1,45,,2232.1,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,2455.31,49.5,,2455.31,percent of total billed charges,110% of Medicare,3372.96,68,,3372.96,percent of total billed charges,,1031.43,,,1031.43,Other,186% of Medicaid,3968.18,80,,3968.18,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,3968.18,80,,3968.18,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,3472.16,70,,3472.16,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,554.53,,,554.53,Other,New York Medicaid APG methodology,554.53,,,554.53,Other,100% New York Medicaid APG,554.53,,,554.53,Other,100% New York Medicaid APG,554.53,,,554.53,Other,100% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,848.43,,,848.43,Other,153% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,776.34,,,776.34,Other,140% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,1441.78,,,1441.78,Other,260% New York Medicaid APG,1796.68,,,1796.68,Other,324% New York Medicaid APG,1192.24,,,1192.24,Other,215% New York Medicaid APG,1192.24,,,1192.24,Other,215% New York Medicaid APG,693.16,,,693.16,Other,125% New York Medicaid APG,554.53,7216,
Treat finger fracture each,26727,CPT,,,,,,,,both,,,36735.79,27184.48,74,,27184.48,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,16531.11,45,,16531.11,percent of total billed charges,Medicare Ratio of cost to charges,5954,,"100% primary, 50% supplemental procedure",5954,Other,Aetna ASC Grouper,5359,,"100% primary, 50% supplemental procedure",5359,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,18184.22,49.5,,18184.22,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5092.5,,,5092.5,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,25715.05,70,,25715.05,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,2737.91,,,2737.91,Other,New York Medicaid APG methodology,2737.91,,,2737.91,Other,100% New York Medicaid APG,2737.91,,,2737.91,Other,100% New York Medicaid APG,2737.91,,,2737.91,Other,100% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,4189,,,4189,Other,153% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,3833.07,,,3833.07,Other,140% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,7118.55,,,7118.55,Other,260% New York Medicaid APG,8870.81,,,8870.81,Other,324% New York Medicaid APG,5886.5,,,5886.5,Other,215% New York Medicaid APG,5886.5,,,5886.5,Other,215% New York Medicaid APG,3422.38,,,3422.38,Other,125% New York Medicaid APG,2737.91,27184.48,
Treat finger fracture each,26735,CPT,,,,,,,,both,,,53414.96,39527.07,74,,39527.07,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,24036.73,45,,24036.73,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,26440.41,49.5,,26440.41,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5092.5,,,5092.5,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,37390.47,70,,37390.47,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,2737.91,,,2737.91,Other,New York Medicaid APG methodology,2737.91,,,2737.91,Other,100% New York Medicaid APG,2737.91,,,2737.91,Other,100% New York Medicaid APG,2737.91,,,2737.91,Other,100% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,4189,,,4189,Other,153% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,3833.07,,,3833.07,Other,140% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,7118.55,,,7118.55,Other,260% New York Medicaid APG,8870.81,,,8870.81,Other,324% New York Medicaid APG,5886.5,,,5886.5,Other,215% New York Medicaid APG,5886.5,,,5886.5,Other,215% New York Medicaid APG,3422.38,,,3422.38,Other,125% New York Medicaid APG,2737.91,39527.07,
Treat finger fracture each,26740,CPT,,,,,,,,both,,,4960.23,3670.57,74,,3670.57,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,2232.1,45,,2232.1,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,2455.31,49.5,,2455.31,percent of total billed charges,110% of Medicare,3372.96,68,,3372.96,percent of total billed charges,,1031.43,,,1031.43,Other,186% of Medicaid,3968.18,80,,3968.18,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,3968.18,80,,3968.18,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,3472.16,70,,3472.16,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,554.53,,,554.53,Other,New York Medicaid APG methodology,554.53,,,554.53,Other,100% New York Medicaid APG,554.53,,,554.53,Other,100% New York Medicaid APG,554.53,,,554.53,Other,100% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,848.43,,,848.43,Other,153% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,776.34,,,776.34,Other,140% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,1441.78,,,1441.78,Other,260% New York Medicaid APG,1796.68,,,1796.68,Other,324% New York Medicaid APG,1192.24,,,1192.24,Other,215% New York Medicaid APG,1192.24,,,1192.24,Other,215% New York Medicaid APG,693.16,,,693.16,Other,125% New York Medicaid APG,554.53,7216,
Treat finger fracture each,26742,CPT,,,,,,,,both,,,33805.49,25016.06,74,,25016.06,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15212.47,45,,15212.47,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,16733.72,49.5,,16733.72,percent of total billed charges,110% of Medicare,22987.73,68,,22987.73,percent of total billed charges,,1031.43,,,1031.43,Other,186% of Medicaid,27044.39,80,,27044.39,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,27044.39,80,,27044.39,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,23663.84,70,,23663.84,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,554.53,,,554.53,Other,New York Medicaid APG methodology,554.53,,,554.53,Other,100% New York Medicaid APG,554.53,,,554.53,Other,100% New York Medicaid APG,554.53,,,554.53,Other,100% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,848.43,,,848.43,Other,153% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,776.34,,,776.34,Other,140% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,1441.78,,,1441.78,Other,260% New York Medicaid APG,1796.68,,,1796.68,Other,324% New York Medicaid APG,1192.24,,,1192.24,Other,215% New York Medicaid APG,1192.24,,,1192.24,Other,215% New York Medicaid APG,693.16,,,693.16,Other,125% New York Medicaid APG,554.53,27044.39,
Treat finger fracture each,26746,CPT,,,,,,,,both,,,44085.92,32623.58,74,,32623.58,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,19838.66,45,,19838.66,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,21822.53,49.5,,21822.53,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5092.5,,,5092.5,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,30860.14,70,,30860.14,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,2737.91,,,2737.91,Other,New York Medicaid APG methodology,2737.91,,,2737.91,Other,100% New York Medicaid APG,2737.91,,,2737.91,Other,100% New York Medicaid APG,2737.91,,,2737.91,Other,100% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,4189,,,4189,Other,153% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,3833.07,,,3833.07,Other,140% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,7118.55,,,7118.55,Other,260% New York Medicaid APG,8870.81,,,8870.81,Other,324% New York Medicaid APG,5886.5,,,5886.5,Other,215% New York Medicaid APG,5886.5,,,5886.5,Other,215% New York Medicaid APG,3422.38,,,3422.38,Other,125% New York Medicaid APG,2737.91,32623.58,
Treat finger fracture each,26750,CPT,,,,,,,,both,,,4960.23,3670.57,74,,3670.57,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,2232.1,45,,2232.1,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,2455.31,49.5,,2455.31,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,1031.43,,,1031.43,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,3472.16,70,,3472.16,percent of total billed charges,,961.04,,,961.04,Fee Schedule,,814.54,,,814.54,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,554.53,,,554.53,Other,New York Medicaid APG methodology,554.53,,,554.53,Other,100% New York Medicaid APG,554.53,,,554.53,Other,100% New York Medicaid APG,554.53,,,554.53,Other,100% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,848.43,,,848.43,Other,153% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,776.34,,,776.34,Other,140% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,1441.78,,,1441.78,Other,260% New York Medicaid APG,1796.68,,,1796.68,Other,324% New York Medicaid APG,1192.24,,,1192.24,Other,215% New York Medicaid APG,1192.24,,,1192.24,Other,215% New York Medicaid APG,693.16,,,693.16,Other,125% New York Medicaid APG,554.53,9473,
Treat finger fracture each,26755,CPT,,,,,,,,both,,,4960.23,3670.57,74,,3670.57,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,2232.1,45,,2232.1,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,2455.31,49.5,,2455.31,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,1031.43,,,1031.43,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,3472.16,70,,3472.16,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,554.53,,,554.53,Other,New York Medicaid APG methodology,554.53,,,554.53,Other,100% New York Medicaid APG,554.53,,,554.53,Other,100% New York Medicaid APG,554.53,,,554.53,Other,100% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,848.43,,,848.43,Other,153% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,776.34,,,776.34,Other,140% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,1441.78,,,1441.78,Other,260% New York Medicaid APG,1796.68,,,1796.68,Other,324% New York Medicaid APG,1192.24,,,1192.24,Other,215% New York Medicaid APG,1192.24,,,1192.24,Other,215% New York Medicaid APG,693.16,,,693.16,Other,125% New York Medicaid APG,554.53,9473,
Pin finger fracture each,26756,CPT,,,,,,,,both,,,68082.75,50381.24,74,,50381.24,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30637.24,45,,30637.24,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33700.96,49.5,,33700.96,percent of total billed charges,110% of Medicare,46296.27,68,,46296.27,percent of total billed charges,,5092.5,,,5092.5,Other,186% of Medicaid,54466.2,80,,54466.2,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,54466.2,80,,54466.2,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,47657.93,70,,47657.93,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,2737.91,,,2737.91,Other,New York Medicaid APG methodology,2737.91,,,2737.91,Other,100% New York Medicaid APG,2737.91,,,2737.91,Other,100% New York Medicaid APG,2737.91,,,2737.91,Other,100% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,4189,,,4189,Other,153% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,3833.07,,,3833.07,Other,140% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,7118.55,,,7118.55,Other,260% New York Medicaid APG,8870.81,,,8870.81,Other,324% New York Medicaid APG,5886.5,,,5886.5,Other,215% New York Medicaid APG,5886.5,,,5886.5,Other,215% New York Medicaid APG,3422.38,,,3422.38,Other,125% New York Medicaid APG,2232,54466.2,
Treat finger fracture each,26765,CPT,,,,,,,,both,,,42356.52,31343.82,74,,31343.82,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,19060.43,45,,19060.43,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,20966.48,49.5,,20966.48,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5092.5,,,5092.5,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,29649.56,70,,29649.56,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,2737.91,,,2737.91,Other,New York Medicaid APG methodology,2737.91,,,2737.91,Other,100% New York Medicaid APG,2737.91,,,2737.91,Other,100% New York Medicaid APG,2737.91,,,2737.91,Other,100% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,4189,,,4189,Other,153% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,3833.07,,,3833.07,Other,140% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,7118.55,,,7118.55,Other,260% New York Medicaid APG,8870.81,,,8870.81,Other,324% New York Medicaid APG,5886.5,,,5886.5,Other,215% New York Medicaid APG,5886.5,,,5886.5,Other,215% New York Medicaid APG,3422.38,,,3422.38,Other,125% New York Medicaid APG,2737.91,31343.82,
Treat finger dislocation,26770,CPT,,,,,,,,both,,,4960.23,3670.57,74,,3670.57,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,2232.1,45,,2232.1,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,2455.31,49.5,,2455.31,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,1031.43,,,1031.43,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,3472.16,70,,3472.16,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,554.53,,,554.53,Other,New York Medicaid APG methodology,554.53,,,554.53,Other,100% New York Medicaid APG,554.53,,,554.53,Other,100% New York Medicaid APG,554.53,,,554.53,Other,100% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,848.43,,,848.43,Other,153% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,776.34,,,776.34,Other,140% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,1441.78,,,1441.78,Other,260% New York Medicaid APG,1796.68,,,1796.68,Other,324% New York Medicaid APG,1192.24,,,1192.24,Other,215% New York Medicaid APG,1192.24,,,1192.24,Other,215% New York Medicaid APG,693.16,,,693.16,Other,125% New York Medicaid APG,554.53,9473,
Treat finger dislocation,26775,CPT,,,,,,,,both,,,5648.78,4180.1,74,,4180.1,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,2541.95,45,,2541.95,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,2796.15,49.5,,2796.15,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,1730.38,,,1730.38,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,3954.15,70,,3954.15,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,930.31,,,930.31,Other,New York Medicaid APG methodology,930.31,,,930.31,Other,100% New York Medicaid APG,930.31,,,930.31,Other,100% New York Medicaid APG,930.31,,,930.31,Other,100% New York Medicaid APG,2093.21,,,2093.21,Other,225% New York Medicaid APG,1423.38,,,1423.38,Other,153% New York Medicaid APG,2093.21,,,2093.21,Other,225% New York Medicaid APG,1302.44,,,1302.44,Other,140% New York Medicaid APG,2093.21,,,2093.21,Other,225% New York Medicaid APG,2418.82,,,2418.82,Other,260% New York Medicaid APG,3014.22,,,3014.22,Other,324% New York Medicaid APG,2000.18,,,2000.18,Other,215% New York Medicaid APG,2000.18,,,2000.18,Other,215% New York Medicaid APG,1162.89,,,1162.89,Other,125% New York Medicaid APG,930.31,9473,
Pin finger dislocation,26776,CPT,,,,,,,,both,,,68082.75,50381.24,74,,50381.24,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30637.24,45,,30637.24,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33700.96,49.5,,33700.96,percent of total billed charges,110% of Medicare,46296.27,68,,46296.27,percent of total billed charges,,5092.5,,,5092.5,Other,186% of Medicaid,54466.2,80,,54466.2,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,54466.2,80,,54466.2,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,47657.93,70,,47657.93,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,2737.91,,,2737.91,Other,New York Medicaid APG methodology,2737.91,,,2737.91,Other,100% New York Medicaid APG,2737.91,,,2737.91,Other,100% New York Medicaid APG,2737.91,,,2737.91,Other,100% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,4189,,,4189,Other,153% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,3833.07,,,3833.07,Other,140% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,7118.55,,,7118.55,Other,260% New York Medicaid APG,8870.81,,,8870.81,Other,324% New York Medicaid APG,5886.5,,,5886.5,Other,215% New York Medicaid APG,5886.5,,,5886.5,Other,215% New York Medicaid APG,3422.38,,,3422.38,Other,125% New York Medicaid APG,2232,54466.2,
Treat finger dislocation,26785,CPT,,,,,,,,both,,,37112.76,27463.44,74,,27463.44,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,16700.74,45,,16700.74,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,18370.82,49.5,,18370.82,percent of total billed charges,110% of Medicare,25236.68,68,,25236.68,percent of total billed charges,,5092.5,,,5092.5,Other,186% of Medicaid,29690.21,80,,29690.21,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,29690.21,80,,29690.21,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,25978.93,70,,25978.93,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,2737.91,,,2737.91,Other,New York Medicaid APG methodology,2737.91,,,2737.91,Other,100% New York Medicaid APG,2737.91,,,2737.91,Other,100% New York Medicaid APG,2737.91,,,2737.91,Other,100% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,4189,,,4189,Other,153% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,3833.07,,,3833.07,Other,140% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,7118.55,,,7118.55,Other,260% New York Medicaid APG,8870.81,,,8870.81,Other,324% New York Medicaid APG,5886.5,,,5886.5,Other,215% New York Medicaid APG,5886.5,,,5886.5,Other,215% New York Medicaid APG,3422.38,,,3422.38,Other,125% New York Medicaid APG,2232,29690.21,
Thumb fusion with graft,26820,CPT,,,,,,,,both,,,150476.65,111352.72,74,,111352.72,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,67714.49,45,,67714.49,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,74485.94,49.5,,74485.94,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3654.9,,,3654.9,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,105333.66,70,,105333.66,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1965,,,1965,Other,New York Medicaid APG methodology,1965,,,1965,Other,100% New York Medicaid APG,1965,,,1965,Other,100% New York Medicaid APG,1965,,,1965,Other,100% New York Medicaid APG,4421.25,,,4421.25,Other,225% New York Medicaid APG,3006.45,,,3006.45,Other,153% New York Medicaid APG,4421.25,,,4421.25,Other,225% New York Medicaid APG,2751,,,2751,Other,140% New York Medicaid APG,4421.25,,,4421.25,Other,225% New York Medicaid APG,5109,,,5109,Other,260% New York Medicaid APG,6366.6,,,6366.6,Other,324% New York Medicaid APG,4224.75,,,4224.75,Other,215% New York Medicaid APG,4224.75,,,4224.75,Other,215% New York Medicaid APG,2456.25,,,2456.25,Other,125% New York Medicaid APG,1965,111352.72,
Fusion of thumb,26841,CPT,,,,,,,,both,,,150476.65,111352.72,74,,111352.72,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,67714.49,45,,67714.49,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,74485.94,49.5,,74485.94,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3654.9,,,3654.9,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,105333.66,70,,105333.66,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1965,,,1965,Other,New York Medicaid APG methodology,1965,,,1965,Other,100% New York Medicaid APG,1965,,,1965,Other,100% New York Medicaid APG,1965,,,1965,Other,100% New York Medicaid APG,4421.25,,,4421.25,Other,225% New York Medicaid APG,3006.45,,,3006.45,Other,153% New York Medicaid APG,4421.25,,,4421.25,Other,225% New York Medicaid APG,2751,,,2751,Other,140% New York Medicaid APG,4421.25,,,4421.25,Other,225% New York Medicaid APG,5109,,,5109,Other,260% New York Medicaid APG,6366.6,,,6366.6,Other,324% New York Medicaid APG,4224.75,,,4224.75,Other,215% New York Medicaid APG,4224.75,,,4224.75,Other,215% New York Medicaid APG,2456.25,,,2456.25,Other,125% New York Medicaid APG,1965,111352.72,
Thumb fusion with graft,26842,CPT,,,,,,,,both,,,81392.29,60230.29,74,,60230.29,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,36626.53,45,,36626.53,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,40289.18,49.5,,40289.18,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3654.9,,,3654.9,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,56974.6,70,,56974.6,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1965,,,1965,Other,New York Medicaid APG methodology,1965,,,1965,Other,100% New York Medicaid APG,1965,,,1965,Other,100% New York Medicaid APG,1965,,,1965,Other,100% New York Medicaid APG,4421.25,,,4421.25,Other,225% New York Medicaid APG,3006.45,,,3006.45,Other,153% New York Medicaid APG,4421.25,,,4421.25,Other,225% New York Medicaid APG,2751,,,2751,Other,140% New York Medicaid APG,4421.25,,,4421.25,Other,225% New York Medicaid APG,5109,,,5109,Other,260% New York Medicaid APG,6366.6,,,6366.6,Other,324% New York Medicaid APG,4224.75,,,4224.75,Other,215% New York Medicaid APG,4224.75,,,4224.75,Other,215% New York Medicaid APG,2456.25,,,2456.25,Other,125% New York Medicaid APG,1965,60230.29,
Fusion of hand joint,26843,CPT,,,,,,,,both,,,150476.65,111352.72,74,,111352.72,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,67714.49,45,,67714.49,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,74485.94,49.5,,74485.94,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2289.65,,,2289.65,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,105333.66,70,,105333.66,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1231,,,1231,Other,New York Medicaid APG methodology,1231,,,1231,Other,100% New York Medicaid APG,1231,,,1231,Other,100% New York Medicaid APG,1231,,,1231,Other,100% New York Medicaid APG,2769.74,,,2769.74,Other,225% New York Medicaid APG,1883.42,,,1883.42,Other,153% New York Medicaid APG,2769.74,,,2769.74,Other,225% New York Medicaid APG,1723.39,,,1723.39,Other,140% New York Medicaid APG,2769.74,,,2769.74,Other,225% New York Medicaid APG,3200.59,,,3200.59,Other,260% New York Medicaid APG,3988.42,,,3988.42,Other,324% New York Medicaid APG,2646.64,,,2646.64,Other,215% New York Medicaid APG,2646.64,,,2646.64,Other,215% New York Medicaid APG,1538.74,,,1538.74,Other,125% New York Medicaid APG,1231,111352.72,
Fusion/graft of hand joint,26844,CPT,,,,,,,,both,,,150476.65,111352.72,74,,111352.72,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,67714.49,45,,67714.49,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,74485.94,49.5,,74485.94,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3654.9,,,3654.9,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,105333.66,70,,105333.66,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1965,,,1965,Other,New York Medicaid APG methodology,1965,,,1965,Other,100% New York Medicaid APG,1965,,,1965,Other,100% New York Medicaid APG,1965,,,1965,Other,100% New York Medicaid APG,4421.25,,,4421.25,Other,225% New York Medicaid APG,3006.45,,,3006.45,Other,153% New York Medicaid APG,4421.25,,,4421.25,Other,225% New York Medicaid APG,2751,,,2751,Other,140% New York Medicaid APG,4421.25,,,4421.25,Other,225% New York Medicaid APG,5109,,,5109,Other,260% New York Medicaid APG,6366.6,,,6366.6,Other,324% New York Medicaid APG,4224.75,,,4224.75,Other,215% New York Medicaid APG,4224.75,,,4224.75,Other,215% New York Medicaid APG,2456.25,,,2456.25,Other,125% New York Medicaid APG,1965,111352.72,
Fusion of knuckle,26850,CPT,,,,,,,,both,,,59284.06,43870.2,74,,43870.2,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,26677.83,45,,26677.83,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,29345.61,49.5,,29345.61,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3654.9,,,3654.9,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,41498.84,70,,41498.84,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1965,,,1965,Other,New York Medicaid APG methodology,1965,,,1965,Other,100% New York Medicaid APG,1965,,,1965,Other,100% New York Medicaid APG,1965,,,1965,Other,100% New York Medicaid APG,4421.25,,,4421.25,Other,225% New York Medicaid APG,3006.45,,,3006.45,Other,153% New York Medicaid APG,4421.25,,,4421.25,Other,225% New York Medicaid APG,2751,,,2751,Other,140% New York Medicaid APG,4421.25,,,4421.25,Other,225% New York Medicaid APG,5109,,,5109,Other,260% New York Medicaid APG,6366.6,,,6366.6,Other,324% New York Medicaid APG,4224.75,,,4224.75,Other,215% New York Medicaid APG,4224.75,,,4224.75,Other,215% New York Medicaid APG,2456.25,,,2456.25,Other,125% New York Medicaid APG,1965,43870.2,
Fusion of knuckle with graft,26852,CPT,,,,,,,,both,,,150476.65,111352.72,74,,111352.72,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,67714.49,45,,67714.49,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,74485.94,49.5,,74485.94,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3654.9,,,3654.9,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,105333.66,70,,105333.66,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1965,,,1965,Other,New York Medicaid APG methodology,1965,,,1965,Other,100% New York Medicaid APG,1965,,,1965,Other,100% New York Medicaid APG,1965,,,1965,Other,100% New York Medicaid APG,4421.25,,,4421.25,Other,225% New York Medicaid APG,3006.45,,,3006.45,Other,153% New York Medicaid APG,4421.25,,,4421.25,Other,225% New York Medicaid APG,2751,,,2751,Other,140% New York Medicaid APG,4421.25,,,4421.25,Other,225% New York Medicaid APG,5109,,,5109,Other,260% New York Medicaid APG,6366.6,,,6366.6,Other,324% New York Medicaid APG,4224.75,,,4224.75,Other,215% New York Medicaid APG,4224.75,,,4224.75,Other,215% New York Medicaid APG,2456.25,,,2456.25,Other,125% New York Medicaid APG,1965,111352.72,
Fusion of finger joint,26860,CPT,,,,,,,,both,,,41021.1,30355.61,74,,30355.61,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,18459.5,45,,18459.5,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,20305.44,49.5,,20305.44,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2289.65,,,2289.65,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,28714.77,70,,28714.77,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1231,,,1231,Other,New York Medicaid APG methodology,1231,,,1231,Other,100% New York Medicaid APG,1231,,,1231,Other,100% New York Medicaid APG,1231,,,1231,Other,100% New York Medicaid APG,2769.74,,,2769.74,Other,225% New York Medicaid APG,1883.42,,,1883.42,Other,153% New York Medicaid APG,2769.74,,,2769.74,Other,225% New York Medicaid APG,1723.39,,,1723.39,Other,140% New York Medicaid APG,2769.74,,,2769.74,Other,225% New York Medicaid APG,3200.59,,,3200.59,Other,260% New York Medicaid APG,3988.42,,,3988.42,Other,324% New York Medicaid APG,2646.64,,,2646.64,Other,215% New York Medicaid APG,2646.64,,,2646.64,Other,215% New York Medicaid APG,1538.74,,,1538.74,Other,125% New York Medicaid APG,1231,30355.61,
Fusion of finger jnt add-on,26861,CPT,,,,,,,,both,,,51572.04,38163.31,74,,38163.31,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,23207.42,45,,23207.42,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,25528.16,49.5,,25528.16,percent of total billed charges,110% of Medicare,35068.99,68,,35068.99,percent of total billed charges,,2289.65,,,2289.65,Other,186% of Medicaid,41257.63,80,,41257.63,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,41257.63,80,,41257.63,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,36100.43,70,,36100.43,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,1231,,,1231,Other,New York Medicaid APG methodology,1231,,,1231,Other,100% New York Medicaid APG,1231,,,1231,Other,100% New York Medicaid APG,1231,,,1231,Other,100% New York Medicaid APG,2769.74,,,2769.74,Other,225% New York Medicaid APG,1883.42,,,1883.42,Other,153% New York Medicaid APG,2769.74,,,2769.74,Other,225% New York Medicaid APG,1723.39,,,1723.39,Other,140% New York Medicaid APG,2769.74,,,2769.74,Other,225% New York Medicaid APG,3200.59,,,3200.59,Other,260% New York Medicaid APG,3988.42,,,3988.42,Other,324% New York Medicaid APG,2646.64,,,2646.64,Other,215% New York Medicaid APG,2646.64,,,2646.64,Other,215% New York Medicaid APG,1538.74,,,1538.74,Other,125% New York Medicaid APG,1231,41257.63,
Fusion/graft of finger joint,26862,CPT,,,,,,,,both,,,32178.46,23812.06,74,,23812.06,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,14480.31,45,,14480.31,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,15928.34,49.5,,15928.34,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2289.65,,,2289.65,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,22524.92,70,,22524.92,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1231,,,1231,Other,New York Medicaid APG methodology,1231,,,1231,Other,100% New York Medicaid APG,1231,,,1231,Other,100% New York Medicaid APG,1231,,,1231,Other,100% New York Medicaid APG,2769.74,,,2769.74,Other,225% New York Medicaid APG,1883.42,,,1883.42,Other,153% New York Medicaid APG,2769.74,,,2769.74,Other,225% New York Medicaid APG,1723.39,,,1723.39,Other,140% New York Medicaid APG,2769.74,,,2769.74,Other,225% New York Medicaid APG,3200.59,,,3200.59,Other,260% New York Medicaid APG,3988.42,,,3988.42,Other,324% New York Medicaid APG,2646.64,,,2646.64,Other,215% New York Medicaid APG,2646.64,,,2646.64,Other,215% New York Medicaid APG,1538.74,,,1538.74,Other,125% New York Medicaid APG,1231,23812.06,
Fuse/graft added joint,26863,CPT,,,,,,,,both,,,64479.48,47714.82,74,,47714.82,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,29015.77,45,,29015.77,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,31917.34,49.5,,31917.34,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2289.65,,,2289.65,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,45135.64,70,,45135.64,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,1231,,,1231,Other,New York Medicaid APG methodology,1231,,,1231,Other,100% New York Medicaid APG,1231,,,1231,Other,100% New York Medicaid APG,1231,,,1231,Other,100% New York Medicaid APG,2769.74,,,2769.74,Other,225% New York Medicaid APG,1883.42,,,1883.42,Other,153% New York Medicaid APG,2769.74,,,2769.74,Other,225% New York Medicaid APG,1723.39,,,1723.39,Other,140% New York Medicaid APG,2769.74,,,2769.74,Other,225% New York Medicaid APG,3200.59,,,3200.59,Other,260% New York Medicaid APG,3988.42,,,3988.42,Other,324% New York Medicaid APG,2646.64,,,2646.64,Other,215% New York Medicaid APG,2646.64,,,2646.64,Other,215% New York Medicaid APG,1538.74,,,1538.74,Other,125% New York Medicaid APG,1231,47714.82,
Amputate metacarpal bone,26910,CPT,,,,,,,,both,,,68082.75,50381.24,74,,50381.24,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30637.24,45,,30637.24,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33700.96,49.5,,33700.96,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3654.9,,,3654.9,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,47657.93,70,,47657.93,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1965,,,1965,Other,New York Medicaid APG methodology,1965,,,1965,Other,100% New York Medicaid APG,1965,,,1965,Other,100% New York Medicaid APG,1965,,,1965,Other,100% New York Medicaid APG,4421.25,,,4421.25,Other,225% New York Medicaid APG,3006.45,,,3006.45,Other,153% New York Medicaid APG,4421.25,,,4421.25,Other,225% New York Medicaid APG,2751,,,2751,Other,140% New York Medicaid APG,4421.25,,,4421.25,Other,225% New York Medicaid APG,5109,,,5109,Other,260% New York Medicaid APG,6366.6,,,6366.6,Other,324% New York Medicaid APG,4224.75,,,4224.75,Other,215% New York Medicaid APG,4224.75,,,4224.75,Other,215% New York Medicaid APG,2456.25,,,2456.25,Other,125% New York Medicaid APG,1965,50381.24,
Amputation of finger/thumb,26951,CPT,,,,,,,,both,,,37728.36,27918.99,74,,27918.99,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,16977.76,45,,16977.76,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,18675.54,49.5,,18675.54,percent of total billed charges,110% of Medicare,25655.28,68,,25655.28,percent of total billed charges,,2289.65,,,2289.65,Other,186% of Medicaid,30182.69,80,,30182.69,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,30182.69,80,,30182.69,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,26409.85,70,,26409.85,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1231,,,1231,Other,New York Medicaid APG methodology,1231,,,1231,Other,100% New York Medicaid APG,1231,,,1231,Other,100% New York Medicaid APG,1231,,,1231,Other,100% New York Medicaid APG,2769.74,,,2769.74,Other,225% New York Medicaid APG,1883.42,,,1883.42,Other,153% New York Medicaid APG,2769.74,,,2769.74,Other,225% New York Medicaid APG,1723.39,,,1723.39,Other,140% New York Medicaid APG,2769.74,,,2769.74,Other,225% New York Medicaid APG,3200.59,,,3200.59,Other,260% New York Medicaid APG,3988.42,,,3988.42,Other,324% New York Medicaid APG,2646.64,,,2646.64,Other,215% New York Medicaid APG,2646.64,,,2646.64,Other,215% New York Medicaid APG,1538.74,,,1538.74,Other,125% New York Medicaid APG,1231,30182.69,
Amputation of finger/thumb,26952,CPT,,,,,,,,both,,,34439.27,25485.06,74,,25485.06,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15497.67,45,,15497.67,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,17047.44,49.5,,17047.44,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3654.9,,,3654.9,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,24107.49,70,,24107.49,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1965,,,1965,Other,New York Medicaid APG methodology,1965,,,1965,Other,100% New York Medicaid APG,1965,,,1965,Other,100% New York Medicaid APG,1965,,,1965,Other,100% New York Medicaid APG,4421.25,,,4421.25,Other,225% New York Medicaid APG,3006.45,,,3006.45,Other,153% New York Medicaid APG,4421.25,,,4421.25,Other,225% New York Medicaid APG,2751,,,2751,Other,140% New York Medicaid APG,4421.25,,,4421.25,Other,225% New York Medicaid APG,5109,,,5109,Other,260% New York Medicaid APG,6366.6,,,6366.6,Other,324% New York Medicaid APG,4224.75,,,4224.75,Other,215% New York Medicaid APG,4224.75,,,4224.75,Other,215% New York Medicaid APG,2456.25,,,2456.25,Other,125% New York Medicaid APG,1965,25485.06,
Drainage of pelvis lesion,26990,CPT,,,,,,,,both,,,68082.75,50381.24,74,,50381.24,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30637.24,45,,30637.24,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33700.96,49.5,,33700.96,percent of total billed charges,110% of Medicare,46296.27,68,,46296.27,percent of total billed charges,,3817.83,,,3817.83,Other,186% of Medicaid,54466.2,80,,54466.2,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,54466.2,80,,54466.2,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,47657.93,70,,47657.93,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,2052.6,,,2052.6,Other,New York Medicaid APG methodology,2052.6,,,2052.6,Other,100% New York Medicaid APG,2052.6,,,2052.6,Other,100% New York Medicaid APG,2052.6,,,2052.6,Other,100% New York Medicaid APG,4618.35,,,4618.35,Other,225% New York Medicaid APG,3140.47,,,3140.47,Other,153% New York Medicaid APG,4618.35,,,4618.35,Other,225% New York Medicaid APG,2873.64,,,2873.64,Other,140% New York Medicaid APG,4618.35,,,4618.35,Other,225% New York Medicaid APG,5336.75,,,5336.75,Other,260% New York Medicaid APG,6650.42,,,6650.42,Other,324% New York Medicaid APG,4413.09,,,4413.09,Other,215% New York Medicaid APG,4413.09,,,4413.09,Other,215% New York Medicaid APG,2565.75,,,2565.75,Other,125% New York Medicaid APG,2052.6,54466.2,
Drainage of pelvis bursa,26991,CPT,,,,,,,,both,,,33805.49,25016.06,74,,25016.06,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15212.47,45,,15212.47,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,16733.72,49.5,,16733.72,percent of total billed charges,110% of Medicare,22987.73,68,,22987.73,percent of total billed charges,,1973.06,,,1973.06,Other,186% of Medicaid,27044.39,80,,27044.39,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,27044.39,80,,27044.39,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,23663.84,70,,23663.84,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1060.79,,,1060.79,Other,New York Medicaid APG methodology,1060.79,,,1060.79,Other,100% New York Medicaid APG,1060.79,,,1060.79,Other,100% New York Medicaid APG,1060.79,,,1060.79,Other,100% New York Medicaid APG,2386.77,,,2386.77,Other,225% New York Medicaid APG,1623,,,1623,Other,153% New York Medicaid APG,2386.77,,,2386.77,Other,225% New York Medicaid APG,1485.1,,,1485.1,Other,140% New York Medicaid APG,2386.77,,,2386.77,Other,225% New York Medicaid APG,2758.05,,,2758.05,Other,260% New York Medicaid APG,3436.95,,,3436.95,Other,324% New York Medicaid APG,2280.69,,,2280.69,Other,215% New York Medicaid APG,2280.69,,,2280.69,Other,215% New York Medicaid APG,1325.98,,,1325.98,Other,125% New York Medicaid APG,1060.79,27044.39,
Incision of hip tendon,27000,CPT,,,,,,,,both,,,33805.49,25016.06,74,,25016.06,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15212.47,45,,15212.47,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,16733.72,49.5,,16733.72,percent of total billed charges,110% of Medicare,22987.73,68,,22987.73,percent of total billed charges,,3817.83,,,3817.83,Other,186% of Medicaid,27044.39,80,,27044.39,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,27044.39,80,,27044.39,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,23663.84,70,,23663.84,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,2052.6,,,2052.6,Other,New York Medicaid APG methodology,2052.6,,,2052.6,Other,100% New York Medicaid APG,2052.6,,,2052.6,Other,100% New York Medicaid APG,2052.6,,,2052.6,Other,100% New York Medicaid APG,4618.35,,,4618.35,Other,225% New York Medicaid APG,3140.47,,,3140.47,Other,153% New York Medicaid APG,4618.35,,,4618.35,Other,225% New York Medicaid APG,2873.64,,,2873.64,Other,140% New York Medicaid APG,4618.35,,,4618.35,Other,225% New York Medicaid APG,5336.75,,,5336.75,Other,260% New York Medicaid APG,6650.42,,,6650.42,Other,324% New York Medicaid APG,4413.09,,,4413.09,Other,215% New York Medicaid APG,4413.09,,,4413.09,Other,215% New York Medicaid APG,2565.75,,,2565.75,Other,125% New York Medicaid APG,2052.6,27044.39,
Incision of hip tendon,27001,CPT,,,,,,,,both,,,68082.75,50381.24,74,,50381.24,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30637.24,45,,30637.24,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33700.96,49.5,,33700.96,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3817.83,,,3817.83,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,47657.93,70,,47657.93,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,2052.6,,,2052.6,Other,New York Medicaid APG methodology,2052.6,,,2052.6,Other,100% New York Medicaid APG,2052.6,,,2052.6,Other,100% New York Medicaid APG,2052.6,,,2052.6,Other,100% New York Medicaid APG,4618.35,,,4618.35,Other,225% New York Medicaid APG,3140.47,,,3140.47,Other,153% New York Medicaid APG,4618.35,,,4618.35,Other,225% New York Medicaid APG,2873.64,,,2873.64,Other,140% New York Medicaid APG,4618.35,,,4618.35,Other,225% New York Medicaid APG,5336.75,,,5336.75,Other,260% New York Medicaid APG,6650.42,,,6650.42,Other,324% New York Medicaid APG,4413.09,,,4413.09,Other,215% New York Medicaid APG,4413.09,,,4413.09,Other,215% New York Medicaid APG,2565.75,,,2565.75,Other,125% New York Medicaid APG,2052.6,50381.24,
Incision of hip tendon,27003,CPT,,,,,,,,both,,,150476.65,111352.72,74,,111352.72,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,67714.49,45,,67714.49,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,74485.94,49.5,,74485.94,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3817.83,,,3817.83,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,105333.66,70,,105333.66,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,2052.6,,,2052.6,Other,New York Medicaid APG methodology,2052.6,,,2052.6,Other,100% New York Medicaid APG,2052.6,,,2052.6,Other,100% New York Medicaid APG,2052.6,,,2052.6,Other,100% New York Medicaid APG,4618.35,,,4618.35,Other,225% New York Medicaid APG,3140.47,,,3140.47,Other,153% New York Medicaid APG,4618.35,,,4618.35,Other,225% New York Medicaid APG,2873.64,,,2873.64,Other,140% New York Medicaid APG,4618.35,,,4618.35,Other,225% New York Medicaid APG,5336.75,,,5336.75,Other,260% New York Medicaid APG,6650.42,,,6650.42,Other,324% New York Medicaid APG,4413.09,,,4413.09,Other,215% New York Medicaid APG,4413.09,,,4413.09,Other,215% New York Medicaid APG,2565.75,,,2565.75,Other,125% New York Medicaid APG,2052.6,111352.72,
Incision of hip tendons,27006,CPT,,,,,,,,both,,,68082.75,50381.24,74,,50381.24,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30637.24,45,,30637.24,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33700.96,49.5,,33700.96,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3817.83,,,3817.83,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,47657.93,70,,47657.93,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,2052.6,,,2052.6,Other,New York Medicaid APG methodology,2052.6,,,2052.6,Other,100% New York Medicaid APG,2052.6,,,2052.6,Other,100% New York Medicaid APG,2052.6,,,2052.6,Other,100% New York Medicaid APG,4618.35,,,4618.35,Other,225% New York Medicaid APG,3140.47,,,3140.47,Other,153% New York Medicaid APG,4618.35,,,4618.35,Other,225% New York Medicaid APG,2873.64,,,2873.64,Other,140% New York Medicaid APG,4618.35,,,4618.35,Other,225% New York Medicaid APG,5336.75,,,5336.75,Other,260% New York Medicaid APG,6650.42,,,6650.42,Other,324% New York Medicaid APG,4413.09,,,4413.09,Other,215% New York Medicaid APG,4413.09,,,4413.09,Other,215% New York Medicaid APG,2565.75,,,2565.75,Other,125% New York Medicaid APG,2052.6,50381.24,
Buttock fasciotomy,27027,CPT,,,,,,,,both,,,150476.65,111352.72,74,,111352.72,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,67714.49,45,,67714.49,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,74485.94,49.5,,74485.94,percent of total billed charges,110% of Medicare,102324.12,68,,102324.12,percent of total billed charges,,3817.83,,,3817.83,Other,186% of Medicaid,120381.32,80,,120381.32,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,120381.32,80,,120381.32,percent of total billed charges,,7216,,,7216,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,105333.66,70,,105333.66,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,2052.6,,,2052.6,Other,New York Medicaid APG methodology,2052.6,,,2052.6,Other,100% New York Medicaid APG,2052.6,,,2052.6,Other,100% New York Medicaid APG,2052.6,,,2052.6,Other,100% New York Medicaid APG,4618.35,,,4618.35,Other,225% New York Medicaid APG,3140.47,,,3140.47,Other,153% New York Medicaid APG,4618.35,,,4618.35,Other,225% New York Medicaid APG,2873.64,,,2873.64,Other,140% New York Medicaid APG,4618.35,,,4618.35,Other,225% New York Medicaid APG,5336.75,,,5336.75,Other,260% New York Medicaid APG,6650.42,,,6650.42,Other,324% New York Medicaid APG,4413.09,,,4413.09,Other,215% New York Medicaid APG,4413.09,,,4413.09,Other,215% New York Medicaid APG,2565.75,,,2565.75,Other,125% New York Medicaid APG,2052.6,120381.32,
Exploration of hip joint,27033,CPT,,,,,,,,both,,,150476.65,111352.72,74,,111352.72,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,67714.49,45,,67714.49,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,74485.94,49.5,,74485.94,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3817.83,,,3817.83,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,105333.66,70,,105333.66,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,2052.6,,,2052.6,Other,New York Medicaid APG methodology,2052.6,,,2052.6,Other,100% New York Medicaid APG,2052.6,,,2052.6,Other,100% New York Medicaid APG,2052.6,,,2052.6,Other,100% New York Medicaid APG,4618.35,,,4618.35,Other,225% New York Medicaid APG,3140.47,,,3140.47,Other,153% New York Medicaid APG,4618.35,,,4618.35,Other,225% New York Medicaid APG,2873.64,,,2873.64,Other,140% New York Medicaid APG,4618.35,,,4618.35,Other,225% New York Medicaid APG,5336.75,,,5336.75,Other,260% New York Medicaid APG,6650.42,,,6650.42,Other,324% New York Medicaid APG,4413.09,,,4413.09,Other,215% New York Medicaid APG,4413.09,,,4413.09,Other,215% New York Medicaid APG,2565.75,,,2565.75,Other,125% New York Medicaid APG,2052.6,111352.72,
Denervation of hip joint,27035,CPT,,,,,,,,both,,,68082.75,50381.24,74,,50381.24,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30637.24,45,,30637.24,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33700.96,49.5,,33700.96,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3817.83,,,3817.83,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,47657.93,70,,47657.93,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,2052.6,,,2052.6,Other,New York Medicaid APG methodology,2052.6,,,2052.6,Other,100% New York Medicaid APG,2052.6,,,2052.6,Other,100% New York Medicaid APG,2052.6,,,2052.6,Other,100% New York Medicaid APG,4618.35,,,4618.35,Other,225% New York Medicaid APG,3140.47,,,3140.47,Other,153% New York Medicaid APG,4618.35,,,4618.35,Other,225% New York Medicaid APG,2873.64,,,2873.64,Other,140% New York Medicaid APG,4618.35,,,4618.35,Other,225% New York Medicaid APG,5336.75,,,5336.75,Other,260% New York Medicaid APG,6650.42,,,6650.42,Other,324% New York Medicaid APG,4413.09,,,4413.09,Other,215% New York Medicaid APG,4413.09,,,4413.09,Other,215% New York Medicaid APG,2565.75,,,2565.75,Other,125% New York Medicaid APG,2052.6,50381.24,
Biopsy of soft tissues,27040,CPT,,,,,,,,both,,,34101.75,25235.3,74,,25235.3,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15345.79,45,,15345.79,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,16880.37,49.5,,16880.37,percent of total billed charges,110% of Medicare,23189.19,68,,23189.19,percent of total billed charges,,1973.06,,,1973.06,Other,186% of Medicaid,27281.4,80,,27281.4,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,27281.4,80,,27281.4,percent of total billed charges,,7216,,,7216,Case Rate,,3578,,"100% primary, 0% secondary procedures",3578,Other,MagnaCare ASC Grouper,23871.23,70,,23871.23,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,1060.79,,,1060.79,Other,New York Medicaid APG methodology,1060.79,,,1060.79,Other,100% New York Medicaid APG,1060.79,,,1060.79,Other,100% New York Medicaid APG,1060.79,,,1060.79,Other,100% New York Medicaid APG,2386.77,,,2386.77,Other,225% New York Medicaid APG,1623,,,1623,Other,153% New York Medicaid APG,2386.77,,,2386.77,Other,225% New York Medicaid APG,1485.1,,,1485.1,Other,140% New York Medicaid APG,2386.77,,,2386.77,Other,225% New York Medicaid APG,2758.05,,,2758.05,Other,260% New York Medicaid APG,3436.95,,,3436.95,Other,324% New York Medicaid APG,2280.69,,,2280.69,Other,215% New York Medicaid APG,2280.69,,,2280.69,Other,215% New York Medicaid APG,1325.98,,,1325.98,Other,125% New York Medicaid APG,1060.79,27281.4,
Biopsy of soft tissues,27041,CPT,,,,,,,,both,,,34101.75,25235.3,74,,25235.3,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15345.79,45,,15345.79,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,16880.37,49.5,,16880.37,percent of total billed charges,110% of Medicare,23189.19,68,,23189.19,percent of total billed charges,,1973.06,,,1973.06,Other,186% of Medicaid,27281.4,80,,27281.4,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,27281.4,80,,27281.4,percent of total billed charges,,7216,,,7216,Case Rate,,3578,,"100% primary, 0% secondary procedures",3578,Other,MagnaCare ASC Grouper,23871.23,70,,23871.23,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,1060.79,,,1060.79,Other,New York Medicaid APG methodology,1060.79,,,1060.79,Other,100% New York Medicaid APG,1060.79,,,1060.79,Other,100% New York Medicaid APG,1060.79,,,1060.79,Other,100% New York Medicaid APG,2386.77,,,2386.77,Other,225% New York Medicaid APG,1623,,,1623,Other,153% New York Medicaid APG,2386.77,,,2386.77,Other,225% New York Medicaid APG,1485.1,,,1485.1,Other,140% New York Medicaid APG,2386.77,,,2386.77,Other,225% New York Medicaid APG,2758.05,,,2758.05,Other,260% New York Medicaid APG,3436.95,,,3436.95,Other,324% New York Medicaid APG,2280.69,,,2280.69,Other,215% New York Medicaid APG,2280.69,,,2280.69,Other,215% New York Medicaid APG,1325.98,,,1325.98,Other,125% New York Medicaid APG,1060.79,27281.4,
Exc hip pelvis les sc 3 cm/>,27043,CPT,,,,,,,,both,,,37916.56,28058.25,74,,28058.25,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,17062.45,45,,17062.45,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,18768.7,49.5,,18768.7,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,1973.06,,,1973.06,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,26541.59,70,,26541.59,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1060.79,,,1060.79,Other,New York Medicaid APG methodology,1060.79,,,1060.79,Other,100% New York Medicaid APG,1060.79,,,1060.79,Other,100% New York Medicaid APG,1060.79,,,1060.79,Other,100% New York Medicaid APG,2386.77,,,2386.77,Other,225% New York Medicaid APG,1623,,,1623,Other,153% New York Medicaid APG,2386.77,,,2386.77,Other,225% New York Medicaid APG,1485.1,,,1485.1,Other,140% New York Medicaid APG,2386.77,,,2386.77,Other,225% New York Medicaid APG,2758.05,,,2758.05,Other,260% New York Medicaid APG,3436.95,,,3436.95,Other,324% New York Medicaid APG,2280.69,,,2280.69,Other,215% New York Medicaid APG,2280.69,,,2280.69,Other,215% New York Medicaid APG,1325.98,,,1325.98,Other,125% New York Medicaid APG,1060.79,28058.25,
Exc hip/pelv tum deep 5 cm/>,27045,CPT,,,,,,,,both,,,59767.2,44227.73,74,,44227.73,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,26895.24,45,,26895.24,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,29584.76,49.5,,29584.76,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,1973.06,,,1973.06,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,41837.04,70,,41837.04,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1060.79,,,1060.79,Other,New York Medicaid APG methodology,1060.79,,,1060.79,Other,100% New York Medicaid APG,1060.79,,,1060.79,Other,100% New York Medicaid APG,1060.79,,,1060.79,Other,100% New York Medicaid APG,2386.77,,,2386.77,Other,225% New York Medicaid APG,1623,,,1623,Other,153% New York Medicaid APG,2386.77,,,2386.77,Other,225% New York Medicaid APG,1485.1,,,1485.1,Other,140% New York Medicaid APG,2386.77,,,2386.77,Other,225% New York Medicaid APG,2758.05,,,2758.05,Other,260% New York Medicaid APG,3436.95,,,3436.95,Other,324% New York Medicaid APG,2280.69,,,2280.69,Other,215% New York Medicaid APG,2280.69,,,2280.69,Other,215% New York Medicaid APG,1325.98,,,1325.98,Other,125% New York Medicaid APG,1060.79,44227.73,
Exc hip/pelvis les sc < 3 cm,27047,CPT,,,,,,,,both,,,59767.2,44227.73,74,,44227.73,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,26895.24,45,,26895.24,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,29584.76,49.5,,29584.76,percent of total billed charges,110% of Medicare,40641.7,68,,40641.7,percent of total billed charges,,1973.06,,,1973.06,Other,186% of Medicaid,47813.76,80,,47813.76,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,47813.76,80,,47813.76,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,41837.04,70,,41837.04,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1060.79,,,1060.79,Other,New York Medicaid APG methodology,1060.79,,,1060.79,Other,100% New York Medicaid APG,1060.79,,,1060.79,Other,100% New York Medicaid APG,1060.79,,,1060.79,Other,100% New York Medicaid APG,2386.77,,,2386.77,Other,225% New York Medicaid APG,1623,,,1623,Other,153% New York Medicaid APG,2386.77,,,2386.77,Other,225% New York Medicaid APG,1485.1,,,1485.1,Other,140% New York Medicaid APG,2386.77,,,2386.77,Other,225% New York Medicaid APG,2758.05,,,2758.05,Other,260% New York Medicaid APG,3436.95,,,3436.95,Other,324% New York Medicaid APG,2280.69,,,2280.69,Other,215% New York Medicaid APG,2280.69,,,2280.69,Other,215% New York Medicaid APG,1325.98,,,1325.98,Other,125% New York Medicaid APG,1060.79,47813.76,
Exc hip/pelv tum deep < 5 cm,27048,CPT,,,,,,,,both,,,72101.84,53355.36,74,,53355.36,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,32445.83,45,,32445.83,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,35690.41,49.5,,35690.41,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,1973.06,,,1973.06,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,50471.29,70,,50471.29,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1060.79,,,1060.79,Other,New York Medicaid APG methodology,1060.79,,,1060.79,Other,100% New York Medicaid APG,1060.79,,,1060.79,Other,100% New York Medicaid APG,1060.79,,,1060.79,Other,100% New York Medicaid APG,2386.77,,,2386.77,Other,225% New York Medicaid APG,1623,,,1623,Other,153% New York Medicaid APG,2386.77,,,2386.77,Other,225% New York Medicaid APG,1485.1,,,1485.1,Other,140% New York Medicaid APG,2386.77,,,2386.77,Other,225% New York Medicaid APG,2758.05,,,2758.05,Other,260% New York Medicaid APG,3436.95,,,3436.95,Other,324% New York Medicaid APG,2280.69,,,2280.69,Other,215% New York Medicaid APG,2280.69,,,2280.69,Other,215% New York Medicaid APG,1325.98,,,1325.98,Other,125% New York Medicaid APG,1060.79,53355.36,
Resect hip/pelv tum < 5 cm,27049,CPT,,,,,,,,both,,,59767.2,44227.73,74,,44227.73,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,26895.24,45,,26895.24,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,29584.76,49.5,,29584.76,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3817.83,,,3817.83,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,41837.04,70,,41837.04,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,2052.6,,,2052.6,Other,New York Medicaid APG methodology,2052.6,,,2052.6,Other,100% New York Medicaid APG,2052.6,,,2052.6,Other,100% New York Medicaid APG,2052.6,,,2052.6,Other,100% New York Medicaid APG,4618.35,,,4618.35,Other,225% New York Medicaid APG,3140.47,,,3140.47,Other,153% New York Medicaid APG,4618.35,,,4618.35,Other,225% New York Medicaid APG,2873.64,,,2873.64,Other,140% New York Medicaid APG,4618.35,,,4618.35,Other,225% New York Medicaid APG,5336.75,,,5336.75,Other,260% New York Medicaid APG,6650.42,,,6650.42,Other,324% New York Medicaid APG,4413.09,,,4413.09,Other,215% New York Medicaid APG,4413.09,,,4413.09,Other,215% New York Medicaid APG,2565.75,,,2565.75,Other,125% New York Medicaid APG,2052.6,44227.73,
Biopsy of sacroiliac joint,27050,CPT,,,,,,,,both,,,33805.49,25016.06,74,,25016.06,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15212.47,45,,15212.47,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,16733.72,49.5,,16733.72,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3817.83,,,3817.83,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,23663.84,70,,23663.84,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,2052.6,,,2052.6,Other,New York Medicaid APG methodology,2052.6,,,2052.6,Other,100% New York Medicaid APG,2052.6,,,2052.6,Other,100% New York Medicaid APG,2052.6,,,2052.6,Other,100% New York Medicaid APG,4618.35,,,4618.35,Other,225% New York Medicaid APG,3140.47,,,3140.47,Other,153% New York Medicaid APG,4618.35,,,4618.35,Other,225% New York Medicaid APG,2873.64,,,2873.64,Other,140% New York Medicaid APG,4618.35,,,4618.35,Other,225% New York Medicaid APG,5336.75,,,5336.75,Other,260% New York Medicaid APG,6650.42,,,6650.42,Other,324% New York Medicaid APG,4413.09,,,4413.09,Other,215% New York Medicaid APG,4413.09,,,4413.09,Other,215% New York Medicaid APG,2565.75,,,2565.75,Other,125% New York Medicaid APG,2052.6,25016.06,
Biopsy of hip joint,27052,CPT,,,,,,,,both,,,33805.49,25016.06,74,,25016.06,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15212.47,45,,15212.47,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,16733.72,49.5,,16733.72,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3817.83,,,3817.83,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,23663.84,70,,23663.84,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,2052.6,,,2052.6,Other,New York Medicaid APG methodology,2052.6,,,2052.6,Other,100% New York Medicaid APG,2052.6,,,2052.6,Other,100% New York Medicaid APG,2052.6,,,2052.6,Other,100% New York Medicaid APG,4618.35,,,4618.35,Other,225% New York Medicaid APG,3140.47,,,3140.47,Other,153% New York Medicaid APG,4618.35,,,4618.35,Other,225% New York Medicaid APG,2873.64,,,2873.64,Other,140% New York Medicaid APG,4618.35,,,4618.35,Other,225% New York Medicaid APG,5336.75,,,5336.75,Other,260% New York Medicaid APG,6650.42,,,6650.42,Other,324% New York Medicaid APG,4413.09,,,4413.09,Other,215% New York Medicaid APG,4413.09,,,4413.09,Other,215% New York Medicaid APG,2565.75,,,2565.75,Other,125% New York Medicaid APG,2052.6,25016.06,
Buttock fasciotomy w/dbrdmt,27057,CPT,,,,,,,,both,,,33805.49,25016.06,74,,25016.06,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15212.47,45,,15212.47,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,16733.72,49.5,,16733.72,percent of total billed charges,110% of Medicare,22987.73,68,,22987.73,percent of total billed charges,,3817.83,,,3817.83,Other,186% of Medicaid,27044.39,80,,27044.39,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,27044.39,80,,27044.39,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,23663.84,70,,23663.84,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,2052.6,,,2052.6,Other,New York Medicaid APG methodology,2052.6,,,2052.6,Other,100% New York Medicaid APG,2052.6,,,2052.6,Other,100% New York Medicaid APG,2052.6,,,2052.6,Other,100% New York Medicaid APG,4618.35,,,4618.35,Other,225% New York Medicaid APG,3140.47,,,3140.47,Other,153% New York Medicaid APG,4618.35,,,4618.35,Other,225% New York Medicaid APG,2873.64,,,2873.64,Other,140% New York Medicaid APG,4618.35,,,4618.35,Other,225% New York Medicaid APG,5336.75,,,5336.75,Other,260% New York Medicaid APG,6650.42,,,6650.42,Other,324% New York Medicaid APG,4413.09,,,4413.09,Other,215% New York Medicaid APG,4413.09,,,4413.09,Other,215% New York Medicaid APG,2565.75,,,2565.75,Other,125% New York Medicaid APG,2052.6,27044.39,
Resect hip/pelv tum 5 cm/>,27059,CPT,,,,,,,,both,,,59767.2,44227.73,74,,44227.73,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,26895.24,45,,26895.24,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,29584.76,49.5,,29584.76,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3817.83,,,3817.83,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,41837.04,70,,41837.04,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,2052.6,,,2052.6,Other,New York Medicaid APG methodology,2052.6,,,2052.6,Other,100% New York Medicaid APG,2052.6,,,2052.6,Other,100% New York Medicaid APG,2052.6,,,2052.6,Other,100% New York Medicaid APG,4618.35,,,4618.35,Other,225% New York Medicaid APG,3140.47,,,3140.47,Other,153% New York Medicaid APG,4618.35,,,4618.35,Other,225% New York Medicaid APG,2873.64,,,2873.64,Other,140% New York Medicaid APG,4618.35,,,4618.35,Other,225% New York Medicaid APG,5336.75,,,5336.75,Other,260% New York Medicaid APG,6650.42,,,6650.42,Other,324% New York Medicaid APG,4413.09,,,4413.09,Other,215% New York Medicaid APG,4413.09,,,4413.09,Other,215% New York Medicaid APG,2565.75,,,2565.75,Other,125% New York Medicaid APG,2052.6,44227.73,
Removal of ischial bursa,27060,CPT,,,,,,,,both,,,150476.65,111352.72,74,,111352.72,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,67714.49,45,,67714.49,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,74485.94,49.5,,74485.94,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3817.83,,,3817.83,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,105333.66,70,,105333.66,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,2052.6,,,2052.6,Other,New York Medicaid APG methodology,2052.6,,,2052.6,Other,100% New York Medicaid APG,2052.6,,,2052.6,Other,100% New York Medicaid APG,2052.6,,,2052.6,Other,100% New York Medicaid APG,4618.35,,,4618.35,Other,225% New York Medicaid APG,3140.47,,,3140.47,Other,153% New York Medicaid APG,4618.35,,,4618.35,Other,225% New York Medicaid APG,2873.64,,,2873.64,Other,140% New York Medicaid APG,4618.35,,,4618.35,Other,225% New York Medicaid APG,5336.75,,,5336.75,Other,260% New York Medicaid APG,6650.42,,,6650.42,Other,324% New York Medicaid APG,4413.09,,,4413.09,Other,215% New York Medicaid APG,4413.09,,,4413.09,Other,215% New York Medicaid APG,2565.75,,,2565.75,Other,125% New York Medicaid APG,2052.6,111352.72,
Remove femur lesion/bursa,27062,CPT,,,,,,,,both,,,51263.95,37935.32,74,,37935.32,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,23068.78,45,,23068.78,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,25375.66,49.5,,25375.66,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3817.83,,,3817.83,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,35884.77,70,,35884.77,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,2052.6,,,2052.6,Other,New York Medicaid APG methodology,2052.6,,,2052.6,Other,100% New York Medicaid APG,2052.6,,,2052.6,Other,100% New York Medicaid APG,2052.6,,,2052.6,Other,100% New York Medicaid APG,4618.35,,,4618.35,Other,225% New York Medicaid APG,3140.47,,,3140.47,Other,153% New York Medicaid APG,4618.35,,,4618.35,Other,225% New York Medicaid APG,2873.64,,,2873.64,Other,140% New York Medicaid APG,4618.35,,,4618.35,Other,225% New York Medicaid APG,5336.75,,,5336.75,Other,260% New York Medicaid APG,6650.42,,,6650.42,Other,324% New York Medicaid APG,4413.09,,,4413.09,Other,215% New York Medicaid APG,4413.09,,,4413.09,Other,215% New York Medicaid APG,2565.75,,,2565.75,Other,125% New York Medicaid APG,2052.6,37935.32,
Remove hip bone les super,27065,CPT,,,,,,,,both,,,38551,28527.74,74,,28527.74,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,17347.95,45,,17347.95,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,19082.75,49.5,,19082.75,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3817.83,,,3817.83,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,26985.7,70,,26985.7,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,2052.6,,,2052.6,Other,New York Medicaid APG methodology,2052.6,,,2052.6,Other,100% New York Medicaid APG,2052.6,,,2052.6,Other,100% New York Medicaid APG,2052.6,,,2052.6,Other,100% New York Medicaid APG,4618.35,,,4618.35,Other,225% New York Medicaid APG,3140.47,,,3140.47,Other,153% New York Medicaid APG,4618.35,,,4618.35,Other,225% New York Medicaid APG,2873.64,,,2873.64,Other,140% New York Medicaid APG,4618.35,,,4618.35,Other,225% New York Medicaid APG,5336.75,,,5336.75,Other,260% New York Medicaid APG,6650.42,,,6650.42,Other,324% New York Medicaid APG,4413.09,,,4413.09,Other,215% New York Medicaid APG,4413.09,,,4413.09,Other,215% New York Medicaid APG,2565.75,,,2565.75,Other,125% New York Medicaid APG,2052.6,28527.74,
Remove hip bone les deep,27066,CPT,,,,,,,,both,,,68082.75,50381.24,74,,50381.24,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30637.24,45,,30637.24,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33700.96,49.5,,33700.96,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3817.83,,,3817.83,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,47657.93,70,,47657.93,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,2052.6,,,2052.6,Other,New York Medicaid APG methodology,2052.6,,,2052.6,Other,100% New York Medicaid APG,2052.6,,,2052.6,Other,100% New York Medicaid APG,2052.6,,,2052.6,Other,100% New York Medicaid APG,4618.35,,,4618.35,Other,225% New York Medicaid APG,3140.47,,,3140.47,Other,153% New York Medicaid APG,4618.35,,,4618.35,Other,225% New York Medicaid APG,2873.64,,,2873.64,Other,140% New York Medicaid APG,4618.35,,,4618.35,Other,225% New York Medicaid APG,5336.75,,,5336.75,Other,260% New York Medicaid APG,6650.42,,,6650.42,Other,324% New York Medicaid APG,4413.09,,,4413.09,Other,215% New York Medicaid APG,4413.09,,,4413.09,Other,215% New York Medicaid APG,2565.75,,,2565.75,Other,125% New York Medicaid APG,2052.6,50381.24,
Remove/graft hip bone lesion,27067,CPT,,,,,,,,both,,,150476.65,111352.72,74,,111352.72,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,67714.49,45,,67714.49,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,74485.94,49.5,,74485.94,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3817.83,,,3817.83,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,105333.66,70,,105333.66,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,2052.6,,,2052.6,Other,New York Medicaid APG methodology,2052.6,,,2052.6,Other,100% New York Medicaid APG,2052.6,,,2052.6,Other,100% New York Medicaid APG,2052.6,,,2052.6,Other,100% New York Medicaid APG,4618.35,,,4618.35,Other,225% New York Medicaid APG,3140.47,,,3140.47,Other,153% New York Medicaid APG,4618.35,,,4618.35,Other,225% New York Medicaid APG,2873.64,,,2873.64,Other,140% New York Medicaid APG,4618.35,,,4618.35,Other,225% New York Medicaid APG,5336.75,,,5336.75,Other,260% New York Medicaid APG,6650.42,,,6650.42,Other,324% New York Medicaid APG,4413.09,,,4413.09,Other,215% New York Medicaid APG,4413.09,,,4413.09,Other,215% New York Medicaid APG,2565.75,,,2565.75,Other,125% New York Medicaid APG,2052.6,111352.72,
Removal of tail bone,27080,CPT,,,,,,,,both,,,53815.49,39823.46,74,,39823.46,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,24216.97,45,,24216.97,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,26638.67,49.5,,26638.67,percent of total billed charges,110% of Medicare,36594.53,68,,36594.53,percent of total billed charges,,3817.83,,,3817.83,Other,186% of Medicaid,43052.39,80,,43052.39,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,43052.39,80,,43052.39,percent of total billed charges,,7216,,,7216,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,37670.84,70,,37670.84,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,2052.6,,,2052.6,Other,New York Medicaid APG methodology,2052.6,,,2052.6,Other,100% New York Medicaid APG,2052.6,,,2052.6,Other,100% New York Medicaid APG,2052.6,,,2052.6,Other,100% New York Medicaid APG,4618.35,,,4618.35,Other,225% New York Medicaid APG,3140.47,,,3140.47,Other,153% New York Medicaid APG,4618.35,,,4618.35,Other,225% New York Medicaid APG,2873.64,,,2873.64,Other,140% New York Medicaid APG,4618.35,,,4618.35,Other,225% New York Medicaid APG,5336.75,,,5336.75,Other,260% New York Medicaid APG,6650.42,,,6650.42,Other,324% New York Medicaid APG,4413.09,,,4413.09,Other,215% New York Medicaid APG,4413.09,,,4413.09,Other,215% New York Medicaid APG,2565.75,,,2565.75,Other,125% New York Medicaid APG,2052.6,43052.39,
Remove hip foreign body,27086,CPT,,,,,,,,both,,,59767.2,44227.73,74,,44227.73,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,26895.24,45,,26895.24,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,29584.76,49.5,,29584.76,percent of total billed charges,110% of Medicare,40641.7,68,,40641.7,percent of total billed charges,,1973.06,,,1973.06,Other,186% of Medicaid,47813.76,80,,47813.76,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,47813.76,80,,47813.76,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,41837.04,70,,41837.04,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1060.79,,,1060.79,Other,New York Medicaid APG methodology,1060.79,,,1060.79,Other,100% New York Medicaid APG,1060.79,,,1060.79,Other,100% New York Medicaid APG,1060.79,,,1060.79,Other,100% New York Medicaid APG,2386.77,,,2386.77,Other,225% New York Medicaid APG,1623,,,1623,Other,153% New York Medicaid APG,2386.77,,,2386.77,Other,225% New York Medicaid APG,1485.1,,,1485.1,Other,140% New York Medicaid APG,2386.77,,,2386.77,Other,225% New York Medicaid APG,2758.05,,,2758.05,Other,260% New York Medicaid APG,3436.95,,,3436.95,Other,324% New York Medicaid APG,2280.69,,,2280.69,Other,215% New York Medicaid APG,2280.69,,,2280.69,Other,215% New York Medicaid APG,1325.98,,,1325.98,Other,125% New York Medicaid APG,1060.79,47813.76,
Remove hip foreign body,27087,CPT,,,,,,,,both,,,68082.75,50381.24,74,,50381.24,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30637.24,45,,30637.24,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33700.96,49.5,,33700.96,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3817.83,,,3817.83,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,47657.93,70,,47657.93,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,2052.6,,,2052.6,Other,New York Medicaid APG methodology,2052.6,,,2052.6,Other,100% New York Medicaid APG,2052.6,,,2052.6,Other,100% New York Medicaid APG,2052.6,,,2052.6,Other,100% New York Medicaid APG,4618.35,,,4618.35,Other,225% New York Medicaid APG,3140.47,,,3140.47,Other,153% New York Medicaid APG,4618.35,,,4618.35,Other,225% New York Medicaid APG,2873.64,,,2873.64,Other,140% New York Medicaid APG,4618.35,,,4618.35,Other,225% New York Medicaid APG,5336.75,,,5336.75,Other,260% New York Medicaid APG,6650.42,,,6650.42,Other,324% New York Medicaid APG,4413.09,,,4413.09,Other,215% New York Medicaid APG,4413.09,,,4413.09,Other,215% New York Medicaid APG,2565.75,,,2565.75,Other,125% New York Medicaid APG,2052.6,50381.24,
Injection for hip x-ray,27093,CPT,,,,,,,,both,,,13750.07,10175.05,74,,10175.05,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,6187.53,45,,6187.53,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,6806.28,49.5,,6806.28,percent of total billed charges,110% of Medicare,9350.05,68,,9350.05,percent of total billed charges,,966.93,,,966.93,Other,186% of Medicaid,11000.06,80,,11000.06,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,11000.06,80,,11000.06,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,9625.05,70,,9625.05,percent of total billed charges,,332.92,,,332.92,Fee Schedule,,282.17,,,282.17,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,519.86,,,519.86,Other,New York Medicaid APG methodology,519.86,,,519.86,Other,100% New York Medicaid APG,519.86,,,519.86,Other,100% New York Medicaid APG,519.86,,,519.86,Other,100% New York Medicaid APG,1169.68,,,1169.68,Other,225% New York Medicaid APG,795.38,,,795.38,Other,153% New York Medicaid APG,1169.68,,,1169.68,Other,225% New York Medicaid APG,727.8,,,727.8,Other,140% New York Medicaid APG,1169.68,,,1169.68,Other,225% New York Medicaid APG,1351.62,,,1351.62,Other,260% New York Medicaid APG,1684.33,,,1684.33,Other,324% New York Medicaid APG,1117.69,,,1117.69,Other,215% New York Medicaid APG,1117.69,,,1117.69,Other,215% New York Medicaid APG,649.82,,,649.82,Other,125% New York Medicaid APG,282.17,11000.06,
Injection for hip x-ray,27095,CPT,,,,,,,,both,,,32432.1,23999.75,74,,23999.75,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,14594.45,45,,14594.45,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,16053.89,49.5,,16053.89,percent of total billed charges,110% of Medicare,22053.83,68,,22053.83,percent of total billed charges,,966.93,,,966.93,Other,186% of Medicaid,25945.68,80,,25945.68,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,25945.68,80,,25945.68,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,22702.47,70,,22702.47,percent of total billed charges,,398.52,,,398.52,Fee Schedule,,337.77,,,337.77,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,519.86,,,519.86,Other,New York Medicaid APG methodology,519.86,,,519.86,Other,100% New York Medicaid APG,519.86,,,519.86,Other,100% New York Medicaid APG,519.86,,,519.86,Other,100% New York Medicaid APG,1169.68,,,1169.68,Other,225% New York Medicaid APG,795.38,,,795.38,Other,153% New York Medicaid APG,1169.68,,,1169.68,Other,225% New York Medicaid APG,727.8,,,727.8,Other,140% New York Medicaid APG,1169.68,,,1169.68,Other,225% New York Medicaid APG,1351.62,,,1351.62,Other,260% New York Medicaid APG,1684.33,,,1684.33,Other,324% New York Medicaid APG,1117.69,,,1117.69,Other,215% New York Medicaid APG,1117.69,,,1117.69,Other,215% New York Medicaid APG,649.82,,,649.82,Other,125% New York Medicaid APG,337.77,25945.68,
Revision of hip tendon,27097,CPT,,,,,,,,both,,,68082.75,50381.24,74,,50381.24,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30637.24,45,,30637.24,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33700.96,49.5,,33700.96,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3817.83,,,3817.83,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,47657.93,70,,47657.93,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,2052.6,,,2052.6,Other,New York Medicaid APG methodology,2052.6,,,2052.6,Other,100% New York Medicaid APG,2052.6,,,2052.6,Other,100% New York Medicaid APG,2052.6,,,2052.6,Other,100% New York Medicaid APG,4618.35,,,4618.35,Other,225% New York Medicaid APG,3140.47,,,3140.47,Other,153% New York Medicaid APG,4618.35,,,4618.35,Other,225% New York Medicaid APG,2873.64,,,2873.64,Other,140% New York Medicaid APG,4618.35,,,4618.35,Other,225% New York Medicaid APG,5336.75,,,5336.75,Other,260% New York Medicaid APG,6650.42,,,6650.42,Other,324% New York Medicaid APG,4413.09,,,4413.09,Other,215% New York Medicaid APG,4413.09,,,4413.09,Other,215% New York Medicaid APG,2565.75,,,2565.75,Other,125% New York Medicaid APG,2052.6,50381.24,
Transfer tendon to pelvis,27098,CPT,,,,,,,,both,,,68082.75,50381.24,74,,50381.24,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30637.24,45,,30637.24,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33700.96,49.5,,33700.96,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3817.83,,,3817.83,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,47657.93,70,,47657.93,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,2052.6,,,2052.6,Other,New York Medicaid APG methodology,2052.6,,,2052.6,Other,100% New York Medicaid APG,2052.6,,,2052.6,Other,100% New York Medicaid APG,2052.6,,,2052.6,Other,100% New York Medicaid APG,4618.35,,,4618.35,Other,225% New York Medicaid APG,3140.47,,,3140.47,Other,153% New York Medicaid APG,4618.35,,,4618.35,Other,225% New York Medicaid APG,2873.64,,,2873.64,Other,140% New York Medicaid APG,4618.35,,,4618.35,Other,225% New York Medicaid APG,5336.75,,,5336.75,Other,260% New York Medicaid APG,6650.42,,,6650.42,Other,324% New York Medicaid APG,4413.09,,,4413.09,Other,215% New York Medicaid APG,4413.09,,,4413.09,Other,215% New York Medicaid APG,2565.75,,,2565.75,Other,125% New York Medicaid APG,2052.6,50381.24,
Transfer of abdominal muscle,27100,CPT,,,,,,,,both,,,150476.65,111352.72,74,,111352.72,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,67714.49,45,,67714.49,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,74485.94,49.5,,74485.94,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3817.83,,,3817.83,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,105333.66,70,,105333.66,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,2052.6,,,2052.6,Other,New York Medicaid APG methodology,2052.6,,,2052.6,Other,100% New York Medicaid APG,2052.6,,,2052.6,Other,100% New York Medicaid APG,2052.6,,,2052.6,Other,100% New York Medicaid APG,4618.35,,,4618.35,Other,225% New York Medicaid APG,3140.47,,,3140.47,Other,153% New York Medicaid APG,4618.35,,,4618.35,Other,225% New York Medicaid APG,2873.64,,,2873.64,Other,140% New York Medicaid APG,4618.35,,,4618.35,Other,225% New York Medicaid APG,5336.75,,,5336.75,Other,260% New York Medicaid APG,6650.42,,,6650.42,Other,324% New York Medicaid APG,4413.09,,,4413.09,Other,215% New York Medicaid APG,4413.09,,,4413.09,Other,215% New York Medicaid APG,2565.75,,,2565.75,Other,125% New York Medicaid APG,2052.6,111352.72,
Transfer of spinal muscle,27105,CPT,,,,,,,,both,,,68082.75,50381.24,74,,50381.24,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30637.24,45,,30637.24,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33700.96,49.5,,33700.96,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3817.83,,,3817.83,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,47657.93,70,,47657.93,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,2052.6,,,2052.6,Other,New York Medicaid APG methodology,2052.6,,,2052.6,Other,100% New York Medicaid APG,2052.6,,,2052.6,Other,100% New York Medicaid APG,2052.6,,,2052.6,Other,100% New York Medicaid APG,4618.35,,,4618.35,Other,225% New York Medicaid APG,3140.47,,,3140.47,Other,153% New York Medicaid APG,4618.35,,,4618.35,Other,225% New York Medicaid APG,2873.64,,,2873.64,Other,140% New York Medicaid APG,4618.35,,,4618.35,Other,225% New York Medicaid APG,5336.75,,,5336.75,Other,260% New York Medicaid APG,6650.42,,,6650.42,Other,324% New York Medicaid APG,4413.09,,,4413.09,Other,215% New York Medicaid APG,4413.09,,,4413.09,Other,215% New York Medicaid APG,2565.75,,,2565.75,Other,125% New York Medicaid APG,2052.6,50381.24,
Transfer of iliopsoas muscle,27110,CPT,,,,,,,,both,,,150476.65,111352.72,74,,111352.72,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,67714.49,45,,67714.49,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,74485.94,49.5,,74485.94,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3817.83,,,3817.83,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,105333.66,70,,105333.66,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,2052.6,,,2052.6,Other,New York Medicaid APG methodology,2052.6,,,2052.6,Other,100% New York Medicaid APG,2052.6,,,2052.6,Other,100% New York Medicaid APG,2052.6,,,2052.6,Other,100% New York Medicaid APG,4618.35,,,4618.35,Other,225% New York Medicaid APG,3140.47,,,3140.47,Other,153% New York Medicaid APG,4618.35,,,4618.35,Other,225% New York Medicaid APG,2873.64,,,2873.64,Other,140% New York Medicaid APG,4618.35,,,4618.35,Other,225% New York Medicaid APG,5336.75,,,5336.75,Other,260% New York Medicaid APG,6650.42,,,6650.42,Other,324% New York Medicaid APG,4413.09,,,4413.09,Other,215% New York Medicaid APG,4413.09,,,4413.09,Other,215% New York Medicaid APG,2565.75,,,2565.75,Other,125% New York Medicaid APG,2052.6,111352.72,
Transfer of iliopsoas muscle,27111,CPT,,,,,,,,both,,,68082.75,50381.24,74,,50381.24,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30637.24,45,,30637.24,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33700.96,49.5,,33700.96,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3817.83,,,3817.83,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,47657.93,70,,47657.93,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,2052.6,,,2052.6,Other,New York Medicaid APG methodology,2052.6,,,2052.6,Other,100% New York Medicaid APG,2052.6,,,2052.6,Other,100% New York Medicaid APG,2052.6,,,2052.6,Other,100% New York Medicaid APG,4618.35,,,4618.35,Other,225% New York Medicaid APG,3140.47,,,3140.47,Other,153% New York Medicaid APG,4618.35,,,4618.35,Other,225% New York Medicaid APG,2873.64,,,2873.64,Other,140% New York Medicaid APG,4618.35,,,4618.35,Other,225% New York Medicaid APG,5336.75,,,5336.75,Other,260% New York Medicaid APG,6650.42,,,6650.42,Other,324% New York Medicaid APG,4413.09,,,4413.09,Other,215% New York Medicaid APG,4413.09,,,4413.09,Other,215% New York Medicaid APG,2565.75,,,2565.75,Other,125% New York Medicaid APG,2052.6,50381.24,
Total hip arthroplasty,27130,CPT,,,,,,,,both,,,95245.67,70481.8,74,,70481.8,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,42860.55,45,,42860.55,percent of total billed charges,Medicare Ratio of cost to charges,5459,,"100% primary, 50% supplemental procedure",5459,Other,Aetna ASC Grouper,4913,,"100% primary, 50% supplemental procedure",4913,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,47146.61,49.5,,47146.61,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5965.25,,,5965.25,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9196,,"100% primary, 0% secondary procedures",9196,Other,MagnaCare ASC Grouper,66671.97,70,,66671.97,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6956,,"100% primary, 50% secondary, 25% tertiary procedure",6956,Other,United Healthcare ASC Grouper,6261,,"100% primary, 50% secondary, 25% tertiary procedure",6261,Other,United Healthcare ASC Grouper,6956,,"100% primary, 50% secondary, 25% tertiary procedure",6956,Other,United Healthcare ASC Grouper,5913,,"100% primary, 50% secondary, 25% tertiary procedure",5913,Other,United Healthcare ASC Grouper,3207.13,,,3207.13,Other,New York Medicaid APG methodology,3207.13,,,3207.13,Other,100% New York Medicaid APG,3207.13,,,3207.13,Other,100% New York Medicaid APG,3207.13,,,3207.13,Other,100% New York Medicaid APG,7216.03,,,7216.03,Other,225% New York Medicaid APG,4906.9,,,4906.9,Other,153% New York Medicaid APG,7216.03,,,7216.03,Other,225% New York Medicaid APG,4489.98,,,4489.98,Other,140% New York Medicaid APG,7216.03,,,7216.03,Other,225% New York Medicaid APG,8338.53,,,8338.53,Other,260% New York Medicaid APG,10391.09,,,10391.09,Other,324% New York Medicaid APG,6895.32,,,6895.32,Other,215% New York Medicaid APG,6895.32,,,6895.32,Other,215% New York Medicaid APG,4008.91,,,4008.91,Other,125% New York Medicaid APG,3207.13,70481.8,
Revise head/neck of femur,27179,CPT,,,,,,,,both,,,150476.65,111352.72,74,,111352.72,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,67714.49,45,,67714.49,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,74485.94,49.5,,74485.94,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3817.83,,,3817.83,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,105333.66,70,,105333.66,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,2052.6,,,2052.6,Other,New York Medicaid APG methodology,2052.6,,,2052.6,Other,100% New York Medicaid APG,2052.6,,,2052.6,Other,100% New York Medicaid APG,2052.6,,,2052.6,Other,100% New York Medicaid APG,4618.35,,,4618.35,Other,225% New York Medicaid APG,3140.47,,,3140.47,Other,153% New York Medicaid APG,4618.35,,,4618.35,Other,225% New York Medicaid APG,2873.64,,,2873.64,Other,140% New York Medicaid APG,4618.35,,,4618.35,Other,225% New York Medicaid APG,5336.75,,,5336.75,Other,260% New York Medicaid APG,6650.42,,,6650.42,Other,324% New York Medicaid APG,4413.09,,,4413.09,Other,215% New York Medicaid APG,4413.09,,,4413.09,Other,215% New York Medicaid APG,2565.75,,,2565.75,Other,125% New York Medicaid APG,2052.6,111352.72,
Clsd tx pelvic ring fx,27197,CPT,,,,,,,,both,,,4960.23,3670.57,74,,3670.57,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,2232.1,45,,2232.1,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,2455.31,49.5,,2455.31,percent of total billed charges,110% of Medicare,3372.96,68,,3372.96,percent of total billed charges,,1031.43,,,1031.43,Other,186% of Medicaid,3968.18,80,,3968.18,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,3968.18,80,,3968.18,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,3472.16,70,,3472.16,percent of total billed charges,,659.28,,,659.28,Fee Schedule,,558.78,,,558.78,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,554.53,,,554.53,Other,New York Medicaid APG methodology,554.53,,,554.53,Other,100% New York Medicaid APG,554.53,,,554.53,Other,100% New York Medicaid APG,554.53,,,554.53,Other,100% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,848.43,,,848.43,Other,153% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,776.34,,,776.34,Other,140% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,1441.78,,,1441.78,Other,260% New York Medicaid APG,1796.68,,,1796.68,Other,324% New York Medicaid APG,1192.24,,,1192.24,Other,215% New York Medicaid APG,1192.24,,,1192.24,Other,215% New York Medicaid APG,693.16,,,693.16,Other,125% New York Medicaid APG,554.53,7216,
Clsd tx pelvic ring fx,27198,CPT,,,,,,,,both,,,4960.23,3670.57,74,,3670.57,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,2232.1,45,,2232.1,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,2455.31,49.5,,2455.31,percent of total billed charges,110% of Medicare,3372.96,68,,3372.96,percent of total billed charges,,1031.43,,,1031.43,Other,186% of Medicaid,3968.18,80,,3968.18,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,3968.18,80,,3968.18,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,3472.16,70,,3472.16,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,554.53,,,554.53,Other,New York Medicaid APG methodology,554.53,,,554.53,Other,100% New York Medicaid APG,554.53,,,554.53,Other,100% New York Medicaid APG,554.53,,,554.53,Other,100% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,848.43,,,848.43,Other,153% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,776.34,,,776.34,Other,140% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,1441.78,,,1441.78,Other,260% New York Medicaid APG,1796.68,,,1796.68,Other,324% New York Medicaid APG,1192.24,,,1192.24,Other,215% New York Medicaid APG,1192.24,,,1192.24,Other,215% New York Medicaid APG,693.16,,,693.16,Other,125% New York Medicaid APG,554.53,7216,
Treat tail bone fracture,27200,CPT,,,,,,,,both,,,4960.23,3670.57,74,,3670.57,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,2232.1,45,,2232.1,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,2455.31,49.5,,2455.31,percent of total billed charges,110% of Medicare,3372.96,68,,3372.96,percent of total billed charges,,1031.43,,,1031.43,Other,186% of Medicaid,3968.18,80,,3968.18,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,3968.18,80,,3968.18,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,3472.16,70,,3472.16,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,554.53,,,554.53,Other,New York Medicaid APG methodology,554.53,,,554.53,Other,100% New York Medicaid APG,554.53,,,554.53,Other,100% New York Medicaid APG,554.53,,,554.53,Other,100% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,848.43,,,848.43,Other,153% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,776.34,,,776.34,Other,140% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,1441.78,,,1441.78,Other,260% New York Medicaid APG,1796.68,,,1796.68,Other,324% New York Medicaid APG,1192.24,,,1192.24,Other,215% New York Medicaid APG,1192.24,,,1192.24,Other,215% New York Medicaid APG,693.16,,,693.16,Other,125% New York Medicaid APG,554.53,7216,
Treat tail bone fracture,27202,CPT,,,,,,,,both,,,68082.75,50381.24,74,,50381.24,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30637.24,45,,30637.24,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33700.96,49.5,,33700.96,percent of total billed charges,110% of Medicare,46296.27,68,,46296.27,percent of total billed charges,,5092.5,,,5092.5,Other,186% of Medicaid,54466.2,80,,54466.2,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,54466.2,80,,54466.2,percent of total billed charges,,7216,,,7216,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,47657.93,70,,47657.93,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,2737.91,,,2737.91,Other,New York Medicaid APG methodology,2737.91,,,2737.91,Other,100% New York Medicaid APG,2737.91,,,2737.91,Other,100% New York Medicaid APG,2737.91,,,2737.91,Other,100% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,4189,,,4189,Other,153% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,3833.07,,,3833.07,Other,140% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,7118.55,,,7118.55,Other,260% New York Medicaid APG,8870.81,,,8870.81,Other,324% New York Medicaid APG,5886.5,,,5886.5,Other,215% New York Medicaid APG,5886.5,,,5886.5,Other,215% New York Medicaid APG,3422.38,,,3422.38,Other,125% New York Medicaid APG,2232,54466.2,
Treat hip socket fracture,27220,CPT,,,,,,,,both,,,4960.23,3670.57,74,,3670.57,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,2232.1,45,,2232.1,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,2455.31,49.5,,2455.31,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,1031.43,,,1031.43,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,3472.16,70,,3472.16,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,554.53,,,554.53,Other,New York Medicaid APG methodology,554.53,,,554.53,Other,100% New York Medicaid APG,554.53,,,554.53,Other,100% New York Medicaid APG,554.53,,,554.53,Other,100% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,848.43,,,848.43,Other,153% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,776.34,,,776.34,Other,140% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,1441.78,,,1441.78,Other,260% New York Medicaid APG,1796.68,,,1796.68,Other,324% New York Medicaid APG,1192.24,,,1192.24,Other,215% New York Medicaid APG,1192.24,,,1192.24,Other,215% New York Medicaid APG,693.16,,,693.16,Other,125% New York Medicaid APG,554.53,9473,
Treat thigh fracture,27230,CPT,,,,,,,,both,,,4960.23,3670.57,74,,3670.57,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,2232.1,45,,2232.1,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,2455.31,49.5,,2455.31,percent of total billed charges,110% of Medicare,3372.96,68,,3372.96,percent of total billed charges,,1031.43,,,1031.43,Other,186% of Medicaid,3968.18,80,,3968.18,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,3968.18,80,,3968.18,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,3472.16,70,,3472.16,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,554.53,,,554.53,Other,New York Medicaid APG methodology,554.53,,,554.53,Other,100% New York Medicaid APG,554.53,,,554.53,Other,100% New York Medicaid APG,554.53,,,554.53,Other,100% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,848.43,,,848.43,Other,153% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,776.34,,,776.34,Other,140% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,1441.78,,,1441.78,Other,260% New York Medicaid APG,1796.68,,,1796.68,Other,324% New York Medicaid APG,1192.24,,,1192.24,Other,215% New York Medicaid APG,1192.24,,,1192.24,Other,215% New York Medicaid APG,693.16,,,693.16,Other,125% New York Medicaid APG,554.53,7216,
Treat thigh fracture,27235,CPT,,,,,,,,both,,,150476.65,111352.72,74,,111352.72,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,67714.49,45,,67714.49,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,74485.94,49.5,,74485.94,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5092.5,,,5092.5,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,105333.66,70,,105333.66,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,2737.91,,,2737.91,Other,New York Medicaid APG methodology,2737.91,,,2737.91,Other,100% New York Medicaid APG,2737.91,,,2737.91,Other,100% New York Medicaid APG,2737.91,,,2737.91,Other,100% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,4189,,,4189,Other,153% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,3833.07,,,3833.07,Other,140% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,7118.55,,,7118.55,Other,260% New York Medicaid APG,8870.81,,,8870.81,Other,324% New York Medicaid APG,5886.5,,,5886.5,Other,215% New York Medicaid APG,5886.5,,,5886.5,Other,215% New York Medicaid APG,3422.38,,,3422.38,Other,125% New York Medicaid APG,2737.91,111352.72,
Treat thigh fracture,27238,CPT,,,,,,,,both,,,33805.49,25016.06,74,,25016.06,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15212.47,45,,15212.47,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,16733.72,49.5,,16733.72,percent of total billed charges,110% of Medicare,22987.73,68,,22987.73,percent of total billed charges,,1031.43,,,1031.43,Other,186% of Medicaid,27044.39,80,,27044.39,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,27044.39,80,,27044.39,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,23663.84,70,,23663.84,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,554.53,,,554.53,Other,New York Medicaid APG methodology,554.53,,,554.53,Other,100% New York Medicaid APG,554.53,,,554.53,Other,100% New York Medicaid APG,554.53,,,554.53,Other,100% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,848.43,,,848.43,Other,153% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,776.34,,,776.34,Other,140% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,1441.78,,,1441.78,Other,260% New York Medicaid APG,1796.68,,,1796.68,Other,324% New York Medicaid APG,1192.24,,,1192.24,Other,215% New York Medicaid APG,1192.24,,,1192.24,Other,215% New York Medicaid APG,693.16,,,693.16,Other,125% New York Medicaid APG,554.53,27044.39,
Treat thigh fracture,27246,CPT,,,,,,,,both,,,4960.23,3670.57,74,,3670.57,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,2232.1,45,,2232.1,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,2455.31,49.5,,2455.31,percent of total billed charges,110% of Medicare,3372.96,68,,3372.96,percent of total billed charges,,1031.43,,,1031.43,Other,186% of Medicaid,3968.18,80,,3968.18,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,3968.18,80,,3968.18,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,3472.16,70,,3472.16,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,554.53,,,554.53,Other,New York Medicaid APG methodology,554.53,,,554.53,Other,100% New York Medicaid APG,554.53,,,554.53,Other,100% New York Medicaid APG,554.53,,,554.53,Other,100% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,848.43,,,848.43,Other,153% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,776.34,,,776.34,Other,140% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,1441.78,,,1441.78,Other,260% New York Medicaid APG,1796.68,,,1796.68,Other,324% New York Medicaid APG,1192.24,,,1192.24,Other,215% New York Medicaid APG,1192.24,,,1192.24,Other,215% New York Medicaid APG,693.16,,,693.16,Other,125% New York Medicaid APG,554.53,7216,
Treat hip dislocation,27250,CPT,,,,,,,,both,,,4960.23,3670.57,74,,3670.57,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,2232.1,45,,2232.1,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,2455.31,49.5,,2455.31,percent of total billed charges,110% of Medicare,3372.96,68,,3372.96,percent of total billed charges,,1031.43,,,1031.43,Other,186% of Medicaid,3968.18,80,,3968.18,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,3968.18,80,,3968.18,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,3472.16,70,,3472.16,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,554.53,,,554.53,Other,New York Medicaid APG methodology,554.53,,,554.53,Other,100% New York Medicaid APG,554.53,,,554.53,Other,100% New York Medicaid APG,554.53,,,554.53,Other,100% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,848.43,,,848.43,Other,153% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,776.34,,,776.34,Other,140% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,1441.78,,,1441.78,Other,260% New York Medicaid APG,1796.68,,,1796.68,Other,324% New York Medicaid APG,1192.24,,,1192.24,Other,215% New York Medicaid APG,1192.24,,,1192.24,Other,215% New York Medicaid APG,693.16,,,693.16,Other,125% New York Medicaid APG,554.53,7216,
Treat hip dislocation,27252,CPT,,,,,,,,both,,,33805.49,25016.06,74,,25016.06,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15212.47,45,,15212.47,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,16733.72,49.5,,16733.72,percent of total billed charges,110% of Medicare,22987.73,68,,22987.73,percent of total billed charges,,1730.38,,,1730.38,Other,186% of Medicaid,27044.39,80,,27044.39,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,27044.39,80,,27044.39,percent of total billed charges,,7216,,,7216,Case Rate,,3578,,"100% primary, 0% secondary procedures",3578,Other,MagnaCare ASC Grouper,23663.84,70,,23663.84,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,930.31,,,930.31,Other,New York Medicaid APG methodology,930.31,,,930.31,Other,100% New York Medicaid APG,930.31,,,930.31,Other,100% New York Medicaid APG,930.31,,,930.31,Other,100% New York Medicaid APG,2093.21,,,2093.21,Other,225% New York Medicaid APG,1423.38,,,1423.38,Other,153% New York Medicaid APG,2093.21,,,2093.21,Other,225% New York Medicaid APG,1302.44,,,1302.44,Other,140% New York Medicaid APG,2093.21,,,2093.21,Other,225% New York Medicaid APG,2418.82,,,2418.82,Other,260% New York Medicaid APG,3014.22,,,3014.22,Other,324% New York Medicaid APG,2000.18,,,2000.18,Other,215% New York Medicaid APG,2000.18,,,2000.18,Other,215% New York Medicaid APG,1162.89,,,1162.89,Other,125% New York Medicaid APG,930.31,27044.39,
Treat hip dislocation,27256,CPT,,,,,,,,both,,,4960.23,3670.57,74,,3670.57,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,2232.1,45,,2232.1,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,2455.31,49.5,,2455.31,percent of total billed charges,110% of Medicare,3372.96,68,,3372.96,percent of total billed charges,,1031.43,,,1031.43,Other,186% of Medicaid,3968.18,80,,3968.18,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,3968.18,80,,3968.18,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,3472.16,70,,3472.16,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,554.53,,,554.53,Other,New York Medicaid APG methodology,554.53,,,554.53,Other,100% New York Medicaid APG,554.53,,,554.53,Other,100% New York Medicaid APG,554.53,,,554.53,Other,100% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,848.43,,,848.43,Other,153% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,776.34,,,776.34,Other,140% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,1441.78,,,1441.78,Other,260% New York Medicaid APG,1796.68,,,1796.68,Other,324% New York Medicaid APG,1192.24,,,1192.24,Other,215% New York Medicaid APG,1192.24,,,1192.24,Other,215% New York Medicaid APG,693.16,,,693.16,Other,125% New York Medicaid APG,554.53,7216,
Treat hip dislocation,27257,CPT,,,,,,,,both,,,48847.39,36147.07,74,,36147.07,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,21981.33,45,,21981.33,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,24179.46,49.5,,24179.46,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,1730.38,,,1730.38,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,3578,,"100% primary, 0% secondary procedures",3578,Other,MagnaCare ASC Grouper,34193.17,70,,34193.17,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,930.31,,,930.31,Other,New York Medicaid APG methodology,930.31,,,930.31,Other,100% New York Medicaid APG,930.31,,,930.31,Other,100% New York Medicaid APG,930.31,,,930.31,Other,100% New York Medicaid APG,2093.21,,,2093.21,Other,225% New York Medicaid APG,1423.38,,,1423.38,Other,153% New York Medicaid APG,2093.21,,,2093.21,Other,225% New York Medicaid APG,1302.44,,,1302.44,Other,140% New York Medicaid APG,2093.21,,,2093.21,Other,225% New York Medicaid APG,2418.82,,,2418.82,Other,260% New York Medicaid APG,3014.22,,,3014.22,Other,324% New York Medicaid APG,2000.18,,,2000.18,Other,215% New York Medicaid APG,2000.18,,,2000.18,Other,215% New York Medicaid APG,1162.89,,,1162.89,Other,125% New York Medicaid APG,930.31,36147.07,
Treat hip dislocation,27265,CPT,,,,,,,,both,,,4960.23,3670.57,74,,3670.57,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,2232.1,45,,2232.1,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,2455.31,49.5,,2455.31,percent of total billed charges,110% of Medicare,3372.96,68,,3372.96,percent of total billed charges,,1031.43,,,1031.43,Other,186% of Medicaid,3968.18,80,,3968.18,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,3968.18,80,,3968.18,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,3472.16,70,,3472.16,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,554.53,,,554.53,Other,New York Medicaid APG methodology,554.53,,,554.53,Other,100% New York Medicaid APG,554.53,,,554.53,Other,100% New York Medicaid APG,554.53,,,554.53,Other,100% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,848.43,,,848.43,Other,153% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,776.34,,,776.34,Other,140% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,1441.78,,,1441.78,Other,260% New York Medicaid APG,1796.68,,,1796.68,Other,324% New York Medicaid APG,1192.24,,,1192.24,Other,215% New York Medicaid APG,1192.24,,,1192.24,Other,215% New York Medicaid APG,693.16,,,693.16,Other,125% New York Medicaid APG,554.53,7216,
Treat hip dislocation,27266,CPT,,,,,,,,both,,,33805.49,25016.06,74,,25016.06,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15212.47,45,,15212.47,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,16733.72,49.5,,16733.72,percent of total billed charges,110% of Medicare,22987.73,68,,22987.73,percent of total billed charges,,1730.38,,,1730.38,Other,186% of Medicaid,27044.39,80,,27044.39,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,27044.39,80,,27044.39,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,23663.84,70,,23663.84,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,930.31,,,930.31,Other,New York Medicaid APG methodology,930.31,,,930.31,Other,100% New York Medicaid APG,930.31,,,930.31,Other,100% New York Medicaid APG,930.31,,,930.31,Other,100% New York Medicaid APG,2093.21,,,2093.21,Other,225% New York Medicaid APG,1423.38,,,1423.38,Other,153% New York Medicaid APG,2093.21,,,2093.21,Other,225% New York Medicaid APG,1302.44,,,1302.44,Other,140% New York Medicaid APG,2093.21,,,2093.21,Other,225% New York Medicaid APG,2418.82,,,2418.82,Other,260% New York Medicaid APG,3014.22,,,3014.22,Other,324% New York Medicaid APG,2000.18,,,2000.18,Other,215% New York Medicaid APG,2000.18,,,2000.18,Other,215% New York Medicaid APG,1162.89,,,1162.89,Other,125% New York Medicaid APG,930.31,27044.39,
Cltx thigh fx,27267,CPT,,,,,,,,both,,,68082.75,50381.24,74,,50381.24,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30637.24,45,,30637.24,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33700.96,49.5,,33700.96,percent of total billed charges,110% of Medicare,46296.27,68,,46296.27,percent of total billed charges,,1031.43,,,1031.43,Other,186% of Medicaid,54466.2,80,,54466.2,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,54466.2,80,,54466.2,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,47657.93,70,,47657.93,percent of total billed charges,,2194.32,,,2194.32,Fee Schedule,,1859.82,,,1859.82,Fee Schedule,,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,554.53,,,554.53,Other,New York Medicaid APG methodology,554.53,,,554.53,Other,100% New York Medicaid APG,554.53,,,554.53,Other,100% New York Medicaid APG,554.53,,,554.53,Other,100% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,848.43,,,848.43,Other,153% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,776.34,,,776.34,Other,140% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,1441.78,,,1441.78,Other,260% New York Medicaid APG,1796.68,,,1796.68,Other,324% New York Medicaid APG,1192.24,,,1192.24,Other,215% New York Medicaid APG,1192.24,,,1192.24,Other,215% New York Medicaid APG,693.16,,,693.16,Other,125% New York Medicaid APG,554.53,54466.2,
Manipulation of hip joint,27275,CPT,,,,,,,,both,,,33805.49,25016.06,74,,25016.06,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15212.47,45,,15212.47,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,16733.72,49.5,,16733.72,percent of total billed charges,110% of Medicare,22987.73,68,,22987.73,percent of total billed charges,,1730.38,,,1730.38,Other,186% of Medicaid,27044.39,80,,27044.39,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,27044.39,80,,27044.39,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,23663.84,70,,23663.84,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,930.31,,,930.31,Other,New York Medicaid APG methodology,930.31,,,930.31,Other,100% New York Medicaid APG,930.31,,,930.31,Other,100% New York Medicaid APG,930.31,,,930.31,Other,100% New York Medicaid APG,2093.21,,,2093.21,Other,225% New York Medicaid APG,1423.38,,,1423.38,Other,153% New York Medicaid APG,2093.21,,,2093.21,Other,225% New York Medicaid APG,1302.44,,,1302.44,Other,140% New York Medicaid APG,2093.21,,,2093.21,Other,225% New York Medicaid APG,2418.82,,,2418.82,Other,260% New York Medicaid APG,3014.22,,,3014.22,Other,324% New York Medicaid APG,2000.18,,,2000.18,Other,215% New York Medicaid APG,2000.18,,,2000.18,Other,215% New York Medicaid APG,1162.89,,,1162.89,Other,125% New York Medicaid APG,930.31,27044.39,
Arthrodesis sacroiliac joint,27279,CPT,,,,,,,,both,,,117408.93,86882.61,74,,86882.61,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,52834.02,45,,52834.02,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,58117.42,49.5,,58117.42,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3817.83,,,3817.83,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9196,,"100% primary, 0% secondary procedures",9196,Other,MagnaCare ASC Grouper,82186.25,70,,82186.25,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6956,,"100% primary, 50% secondary, 25% tertiary procedure",6956,Other,United Healthcare ASC Grouper,6261,,"100% primary, 50% secondary, 25% tertiary procedure",6261,Other,United Healthcare ASC Grouper,6956,,"100% primary, 50% secondary, 25% tertiary procedure",6956,Other,United Healthcare ASC Grouper,5913,,"100% primary, 50% secondary, 25% tertiary procedure",5913,Other,United Healthcare ASC Grouper,2052.6,,,2052.6,Other,New York Medicaid APG methodology,2052.6,,,2052.6,Other,100% New York Medicaid APG,2052.6,,,2052.6,Other,100% New York Medicaid APG,2052.6,,,2052.6,Other,100% New York Medicaid APG,4618.35,,,4618.35,Other,225% New York Medicaid APG,3140.47,,,3140.47,Other,153% New York Medicaid APG,4618.35,,,4618.35,Other,225% New York Medicaid APG,2873.64,,,2873.64,Other,140% New York Medicaid APG,4618.35,,,4618.35,Other,225% New York Medicaid APG,5336.75,,,5336.75,Other,260% New York Medicaid APG,6650.42,,,6650.42,Other,324% New York Medicaid APG,4413.09,,,4413.09,Other,215% New York Medicaid APG,4413.09,,,4413.09,Other,215% New York Medicaid APG,2565.75,,,2565.75,Other,125% New York Medicaid APG,2052.6,86882.61,
Drain thigh/knee lesion,27301,CPT,,,,,,,,both,,,59767.2,44227.73,74,,44227.73,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,26895.24,45,,26895.24,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,29584.76,49.5,,29584.76,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,1973.06,,,1973.06,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,41837.04,70,,41837.04,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1060.79,,,1060.79,Other,New York Medicaid APG methodology,1060.79,,,1060.79,Other,100% New York Medicaid APG,1060.79,,,1060.79,Other,100% New York Medicaid APG,1060.79,,,1060.79,Other,100% New York Medicaid APG,2386.77,,,2386.77,Other,225% New York Medicaid APG,1623,,,1623,Other,153% New York Medicaid APG,2386.77,,,2386.77,Other,225% New York Medicaid APG,1485.1,,,1485.1,Other,140% New York Medicaid APG,2386.77,,,2386.77,Other,225% New York Medicaid APG,2758.05,,,2758.05,Other,260% New York Medicaid APG,3436.95,,,3436.95,Other,324% New York Medicaid APG,2280.69,,,2280.69,Other,215% New York Medicaid APG,2280.69,,,2280.69,Other,215% New York Medicaid APG,1325.98,,,1325.98,Other,125% New York Medicaid APG,1060.79,44227.73,
Incise thigh tendon & fascia,27305,CPT,,,,,,,,both,,,68082.75,50381.24,74,,50381.24,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30637.24,45,,30637.24,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33700.96,49.5,,33700.96,percent of total billed charges,110% of Medicare,46296.27,68,,46296.27,percent of total billed charges,,3817.83,,,3817.83,Other,186% of Medicaid,54466.2,80,,54466.2,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,54466.2,80,,54466.2,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,47657.93,70,,47657.93,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,2052.6,,,2052.6,Other,New York Medicaid APG methodology,2052.6,,,2052.6,Other,100% New York Medicaid APG,2052.6,,,2052.6,Other,100% New York Medicaid APG,2052.6,,,2052.6,Other,100% New York Medicaid APG,4618.35,,,4618.35,Other,225% New York Medicaid APG,3140.47,,,3140.47,Other,153% New York Medicaid APG,4618.35,,,4618.35,Other,225% New York Medicaid APG,2873.64,,,2873.64,Other,140% New York Medicaid APG,4618.35,,,4618.35,Other,225% New York Medicaid APG,5336.75,,,5336.75,Other,260% New York Medicaid APG,6650.42,,,6650.42,Other,324% New York Medicaid APG,4413.09,,,4413.09,Other,215% New York Medicaid APG,4413.09,,,4413.09,Other,215% New York Medicaid APG,2565.75,,,2565.75,Other,125% New York Medicaid APG,2052.6,54466.2,
Incision of thigh tendon,27306,CPT,,,,,,,,both,,,68082.75,50381.24,74,,50381.24,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30637.24,45,,30637.24,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33700.96,49.5,,33700.96,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3817.83,,,3817.83,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,47657.93,70,,47657.93,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,2052.6,,,2052.6,Other,New York Medicaid APG methodology,2052.6,,,2052.6,Other,100% New York Medicaid APG,2052.6,,,2052.6,Other,100% New York Medicaid APG,2052.6,,,2052.6,Other,100% New York Medicaid APG,4618.35,,,4618.35,Other,225% New York Medicaid APG,3140.47,,,3140.47,Other,153% New York Medicaid APG,4618.35,,,4618.35,Other,225% New York Medicaid APG,2873.64,,,2873.64,Other,140% New York Medicaid APG,4618.35,,,4618.35,Other,225% New York Medicaid APG,5336.75,,,5336.75,Other,260% New York Medicaid APG,6650.42,,,6650.42,Other,324% New York Medicaid APG,4413.09,,,4413.09,Other,215% New York Medicaid APG,4413.09,,,4413.09,Other,215% New York Medicaid APG,2565.75,,,2565.75,Other,125% New York Medicaid APG,2052.6,50381.24,
Incision of thigh tendons,27307,CPT,,,,,,,,both,,,68082.75,50381.24,74,,50381.24,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30637.24,45,,30637.24,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33700.96,49.5,,33700.96,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3817.83,,,3817.83,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,47657.93,70,,47657.93,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,2052.6,,,2052.6,Other,New York Medicaid APG methodology,2052.6,,,2052.6,Other,100% New York Medicaid APG,2052.6,,,2052.6,Other,100% New York Medicaid APG,2052.6,,,2052.6,Other,100% New York Medicaid APG,4618.35,,,4618.35,Other,225% New York Medicaid APG,3140.47,,,3140.47,Other,153% New York Medicaid APG,4618.35,,,4618.35,Other,225% New York Medicaid APG,2873.64,,,2873.64,Other,140% New York Medicaid APG,4618.35,,,4618.35,Other,225% New York Medicaid APG,5336.75,,,5336.75,Other,260% New York Medicaid APG,6650.42,,,6650.42,Other,324% New York Medicaid APG,4413.09,,,4413.09,Other,215% New York Medicaid APG,4413.09,,,4413.09,Other,215% New York Medicaid APG,2565.75,,,2565.75,Other,125% New York Medicaid APG,2052.6,50381.24,
Exploration of knee joint,27310,CPT,,,,,,,,both,,,68082.75,50381.24,74,,50381.24,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30637.24,45,,30637.24,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33700.96,49.5,,33700.96,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3097.27,,,3097.27,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,47657.93,70,,47657.93,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1665.2,,,1665.2,Other,New York Medicaid APG methodology,1665.2,,,1665.2,Other,100% New York Medicaid APG,1665.2,,,1665.2,Other,100% New York Medicaid APG,1665.2,,,1665.2,Other,100% New York Medicaid APG,3746.7,,,3746.7,Other,225% New York Medicaid APG,2547.75,,,2547.75,Other,153% New York Medicaid APG,3746.7,,,3746.7,Other,225% New York Medicaid APG,2331.28,,,2331.28,Other,140% New York Medicaid APG,3746.7,,,3746.7,Other,225% New York Medicaid APG,4329.52,,,4329.52,Other,260% New York Medicaid APG,5395.24,,,5395.24,Other,324% New York Medicaid APG,3580.18,,,3580.18,Other,215% New York Medicaid APG,3580.18,,,3580.18,Other,215% New York Medicaid APG,2081.5,,,2081.5,Other,125% New York Medicaid APG,1665.2,50381.24,
Biopsy thigh soft tissues,27323,CPT,,,,,,,,both,,,34101.75,25235.3,74,,25235.3,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15345.79,45,,15345.79,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,16880.37,49.5,,16880.37,percent of total billed charges,110% of Medicare,23189.19,68,,23189.19,percent of total billed charges,,1973.06,,,1973.06,Other,186% of Medicaid,27281.4,80,,27281.4,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,27281.4,80,,27281.4,percent of total billed charges,,7216,,,7216,Case Rate,,3578,,"100% primary, 0% secondary procedures",3578,Other,MagnaCare ASC Grouper,23871.23,70,,23871.23,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,1060.79,,,1060.79,Other,New York Medicaid APG methodology,1060.79,,,1060.79,Other,100% New York Medicaid APG,1060.79,,,1060.79,Other,100% New York Medicaid APG,1060.79,,,1060.79,Other,100% New York Medicaid APG,2386.77,,,2386.77,Other,225% New York Medicaid APG,1623,,,1623,Other,153% New York Medicaid APG,2386.77,,,2386.77,Other,225% New York Medicaid APG,1485.1,,,1485.1,Other,140% New York Medicaid APG,2386.77,,,2386.77,Other,225% New York Medicaid APG,2758.05,,,2758.05,Other,260% New York Medicaid APG,3436.95,,,3436.95,Other,324% New York Medicaid APG,2280.69,,,2280.69,Other,215% New York Medicaid APG,2280.69,,,2280.69,Other,215% New York Medicaid APG,1325.98,,,1325.98,Other,125% New York Medicaid APG,1060.79,27281.4,
Biopsy thigh soft tissues,27324,CPT,,,,,,,,both,,,71152.91,52653.15,74,,52653.15,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,32018.81,45,,32018.81,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,35220.69,49.5,,35220.69,percent of total billed charges,110% of Medicare,48383.98,68,,48383.98,percent of total billed charges,,1973.06,,,1973.06,Other,186% of Medicaid,56922.33,80,,56922.33,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,56922.33,80,,56922.33,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,49807.04,70,,49807.04,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1060.79,,,1060.79,Other,New York Medicaid APG methodology,1060.79,,,1060.79,Other,100% New York Medicaid APG,1060.79,,,1060.79,Other,100% New York Medicaid APG,1060.79,,,1060.79,Other,100% New York Medicaid APG,2386.77,,,2386.77,Other,225% New York Medicaid APG,1623,,,1623,Other,153% New York Medicaid APG,2386.77,,,2386.77,Other,225% New York Medicaid APG,1485.1,,,1485.1,Other,140% New York Medicaid APG,2386.77,,,2386.77,Other,225% New York Medicaid APG,2758.05,,,2758.05,Other,260% New York Medicaid APG,3436.95,,,3436.95,Other,324% New York Medicaid APG,2280.69,,,2280.69,Other,215% New York Medicaid APG,2280.69,,,2280.69,Other,215% New York Medicaid APG,1325.98,,,1325.98,Other,125% New York Medicaid APG,1060.79,56922.33,
Neurectomy hamstring,27325,CPT,,,,,,,,both,,,40611.5,30052.51,74,,30052.51,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,18275.18,45,,18275.18,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,20102.69,49.5,,20102.69,percent of total billed charges,110% of Medicare,27615.82,68,,27615.82,percent of total billed charges,,3817.83,,,3817.83,Other,186% of Medicaid,32489.2,80,,32489.2,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,32489.2,80,,32489.2,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,28428.05,70,,28428.05,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,2052.6,,,2052.6,Other,New York Medicaid APG methodology,2052.6,,,2052.6,Other,100% New York Medicaid APG,2052.6,,,2052.6,Other,100% New York Medicaid APG,2052.6,,,2052.6,Other,100% New York Medicaid APG,4618.35,,,4618.35,Other,225% New York Medicaid APG,3140.47,,,3140.47,Other,153% New York Medicaid APG,4618.35,,,4618.35,Other,225% New York Medicaid APG,2873.64,,,2873.64,Other,140% New York Medicaid APG,4618.35,,,4618.35,Other,225% New York Medicaid APG,5336.75,,,5336.75,Other,260% New York Medicaid APG,6650.42,,,6650.42,Other,324% New York Medicaid APG,4413.09,,,4413.09,Other,215% New York Medicaid APG,4413.09,,,4413.09,Other,215% New York Medicaid APG,2565.75,,,2565.75,Other,125% New York Medicaid APG,2052.6,32489.2,
Neurectomy popliteal,27326,CPT,,,,,,,,both,,,40611.5,30052.51,74,,30052.51,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,18275.18,45,,18275.18,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,20102.69,49.5,,20102.69,percent of total billed charges,110% of Medicare,27615.82,68,,27615.82,percent of total billed charges,,3097.27,,,3097.27,Other,186% of Medicaid,32489.2,80,,32489.2,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,32489.2,80,,32489.2,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,28428.05,70,,28428.05,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1665.2,,,1665.2,Other,New York Medicaid APG methodology,1665.2,,,1665.2,Other,100% New York Medicaid APG,1665.2,,,1665.2,Other,100% New York Medicaid APG,1665.2,,,1665.2,Other,100% New York Medicaid APG,3746.7,,,3746.7,Other,225% New York Medicaid APG,2547.75,,,2547.75,Other,153% New York Medicaid APG,3746.7,,,3746.7,Other,225% New York Medicaid APG,2331.28,,,2331.28,Other,140% New York Medicaid APG,3746.7,,,3746.7,Other,225% New York Medicaid APG,4329.52,,,4329.52,Other,260% New York Medicaid APG,5395.24,,,5395.24,Other,324% New York Medicaid APG,3580.18,,,3580.18,Other,215% New York Medicaid APG,3580.18,,,3580.18,Other,215% New York Medicaid APG,2081.5,,,2081.5,Other,125% New York Medicaid APG,1665.2,32489.2,
Exc thigh/knee les sc < 3 cm,27327,CPT,,,,,,,,both,,,35232.08,26071.74,74,,26071.74,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15854.44,45,,15854.44,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,17439.88,49.5,,17439.88,percent of total billed charges,110% of Medicare,23957.81,68,,23957.81,percent of total billed charges,,1973.06,,,1973.06,Other,186% of Medicaid,28185.66,80,,28185.66,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,28185.66,80,,28185.66,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,24662.46,70,,24662.46,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1060.79,,,1060.79,Other,New York Medicaid APG methodology,1060.79,,,1060.79,Other,100% New York Medicaid APG,1060.79,,,1060.79,Other,100% New York Medicaid APG,1060.79,,,1060.79,Other,100% New York Medicaid APG,2386.77,,,2386.77,Other,225% New York Medicaid APG,1623,,,1623,Other,153% New York Medicaid APG,2386.77,,,2386.77,Other,225% New York Medicaid APG,1485.1,,,1485.1,Other,140% New York Medicaid APG,2386.77,,,2386.77,Other,225% New York Medicaid APG,2758.05,,,2758.05,Other,260% New York Medicaid APG,3436.95,,,3436.95,Other,324% New York Medicaid APG,2280.69,,,2280.69,Other,215% New York Medicaid APG,2280.69,,,2280.69,Other,215% New York Medicaid APG,1325.98,,,1325.98,Other,125% New York Medicaid APG,1060.79,28185.66,
Exc thigh/knee tum deep <5cm,27328,CPT,,,,,,,,both,,,39215.98,29019.83,74,,29019.83,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,17647.19,45,,17647.19,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,19411.91,49.5,,19411.91,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,1973.06,,,1973.06,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,27451.19,70,,27451.19,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1060.79,,,1060.79,Other,New York Medicaid APG methodology,1060.79,,,1060.79,Other,100% New York Medicaid APG,1060.79,,,1060.79,Other,100% New York Medicaid APG,1060.79,,,1060.79,Other,100% New York Medicaid APG,2386.77,,,2386.77,Other,225% New York Medicaid APG,1623,,,1623,Other,153% New York Medicaid APG,2386.77,,,2386.77,Other,225% New York Medicaid APG,1485.1,,,1485.1,Other,140% New York Medicaid APG,2386.77,,,2386.77,Other,225% New York Medicaid APG,2758.05,,,2758.05,Other,260% New York Medicaid APG,3436.95,,,3436.95,Other,324% New York Medicaid APG,2280.69,,,2280.69,Other,215% New York Medicaid APG,2280.69,,,2280.69,Other,215% New York Medicaid APG,1325.98,,,1325.98,Other,125% New York Medicaid APG,1060.79,29019.83,
Resect thigh/knee tum < 5 cm,27329,CPT,,,,,,,,both,,,59767.2,44227.73,74,,44227.73,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,26895.24,45,,26895.24,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,29584.76,49.5,,29584.76,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3097.27,,,3097.27,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,41837.04,70,,41837.04,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1665.2,,,1665.2,Other,New York Medicaid APG methodology,1665.2,,,1665.2,Other,100% New York Medicaid APG,1665.2,,,1665.2,Other,100% New York Medicaid APG,1665.2,,,1665.2,Other,100% New York Medicaid APG,3746.7,,,3746.7,Other,225% New York Medicaid APG,2547.75,,,2547.75,Other,153% New York Medicaid APG,3746.7,,,3746.7,Other,225% New York Medicaid APG,2331.28,,,2331.28,Other,140% New York Medicaid APG,3746.7,,,3746.7,Other,225% New York Medicaid APG,4329.52,,,4329.52,Other,260% New York Medicaid APG,5395.24,,,5395.24,Other,324% New York Medicaid APG,3580.18,,,3580.18,Other,215% New York Medicaid APG,3580.18,,,3580.18,Other,215% New York Medicaid APG,2081.5,,,2081.5,Other,125% New York Medicaid APG,1665.2,44227.73,
Biopsy knee joint lining,27330,CPT,,,,,,,,both,,,68082.75,50381.24,74,,50381.24,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30637.24,45,,30637.24,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33700.96,49.5,,33700.96,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3097.27,,,3097.27,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,47657.93,70,,47657.93,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1665.2,,,1665.2,Other,New York Medicaid APG methodology,1665.2,,,1665.2,Other,100% New York Medicaid APG,1665.2,,,1665.2,Other,100% New York Medicaid APG,1665.2,,,1665.2,Other,100% New York Medicaid APG,3746.7,,,3746.7,Other,225% New York Medicaid APG,2547.75,,,2547.75,Other,153% New York Medicaid APG,3746.7,,,3746.7,Other,225% New York Medicaid APG,2331.28,,,2331.28,Other,140% New York Medicaid APG,3746.7,,,3746.7,Other,225% New York Medicaid APG,4329.52,,,4329.52,Other,260% New York Medicaid APG,5395.24,,,5395.24,Other,324% New York Medicaid APG,3580.18,,,3580.18,Other,215% New York Medicaid APG,3580.18,,,3580.18,Other,215% New York Medicaid APG,2081.5,,,2081.5,Other,125% New York Medicaid APG,1665.2,50381.24,
Explore/treat knee joint,27331,CPT,,,,,,,,both,,,68082.75,50381.24,74,,50381.24,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30637.24,45,,30637.24,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33700.96,49.5,,33700.96,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3097.27,,,3097.27,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,47657.93,70,,47657.93,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1665.2,,,1665.2,Other,New York Medicaid APG methodology,1665.2,,,1665.2,Other,100% New York Medicaid APG,1665.2,,,1665.2,Other,100% New York Medicaid APG,1665.2,,,1665.2,Other,100% New York Medicaid APG,3746.7,,,3746.7,Other,225% New York Medicaid APG,2547.75,,,2547.75,Other,153% New York Medicaid APG,3746.7,,,3746.7,Other,225% New York Medicaid APG,2331.28,,,2331.28,Other,140% New York Medicaid APG,3746.7,,,3746.7,Other,225% New York Medicaid APG,4329.52,,,4329.52,Other,260% New York Medicaid APG,5395.24,,,5395.24,Other,324% New York Medicaid APG,3580.18,,,3580.18,Other,215% New York Medicaid APG,3580.18,,,3580.18,Other,215% New York Medicaid APG,2081.5,,,2081.5,Other,125% New York Medicaid APG,1665.2,50381.24,
Removal of knee cartilage,27332,CPT,,,,,,,,both,,,68082.75,50381.24,74,,50381.24,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30637.24,45,,30637.24,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33700.96,49.5,,33700.96,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3097.27,,,3097.27,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,47657.93,70,,47657.93,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1665.2,,,1665.2,Other,New York Medicaid APG methodology,1665.2,,,1665.2,Other,100% New York Medicaid APG,1665.2,,,1665.2,Other,100% New York Medicaid APG,1665.2,,,1665.2,Other,100% New York Medicaid APG,3746.7,,,3746.7,Other,225% New York Medicaid APG,2547.75,,,2547.75,Other,153% New York Medicaid APG,3746.7,,,3746.7,Other,225% New York Medicaid APG,2331.28,,,2331.28,Other,140% New York Medicaid APG,3746.7,,,3746.7,Other,225% New York Medicaid APG,4329.52,,,4329.52,Other,260% New York Medicaid APG,5395.24,,,5395.24,Other,324% New York Medicaid APG,3580.18,,,3580.18,Other,215% New York Medicaid APG,3580.18,,,3580.18,Other,215% New York Medicaid APG,2081.5,,,2081.5,Other,125% New York Medicaid APG,1665.2,50381.24,
Removal of knee cartilage,27333,CPT,,,,,,,,both,,,68082.75,50381.24,74,,50381.24,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30637.24,45,,30637.24,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33700.96,49.5,,33700.96,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3097.27,,,3097.27,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,47657.93,70,,47657.93,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1665.2,,,1665.2,Other,New York Medicaid APG methodology,1665.2,,,1665.2,Other,100% New York Medicaid APG,1665.2,,,1665.2,Other,100% New York Medicaid APG,1665.2,,,1665.2,Other,100% New York Medicaid APG,3746.7,,,3746.7,Other,225% New York Medicaid APG,2547.75,,,2547.75,Other,153% New York Medicaid APG,3746.7,,,3746.7,Other,225% New York Medicaid APG,2331.28,,,2331.28,Other,140% New York Medicaid APG,3746.7,,,3746.7,Other,225% New York Medicaid APG,4329.52,,,4329.52,Other,260% New York Medicaid APG,5395.24,,,5395.24,Other,324% New York Medicaid APG,3580.18,,,3580.18,Other,215% New York Medicaid APG,3580.18,,,3580.18,Other,215% New York Medicaid APG,2081.5,,,2081.5,Other,125% New York Medicaid APG,1665.2,50381.24,
Remove knee joint lining,27334,CPT,,,,,,,,both,,,68082.75,50381.24,74,,50381.24,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30637.24,45,,30637.24,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33700.96,49.5,,33700.96,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3097.27,,,3097.27,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,47657.93,70,,47657.93,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1665.2,,,1665.2,Other,New York Medicaid APG methodology,1665.2,,,1665.2,Other,100% New York Medicaid APG,1665.2,,,1665.2,Other,100% New York Medicaid APG,1665.2,,,1665.2,Other,100% New York Medicaid APG,3746.7,,,3746.7,Other,225% New York Medicaid APG,2547.75,,,2547.75,Other,153% New York Medicaid APG,3746.7,,,3746.7,Other,225% New York Medicaid APG,2331.28,,,2331.28,Other,140% New York Medicaid APG,3746.7,,,3746.7,Other,225% New York Medicaid APG,4329.52,,,4329.52,Other,260% New York Medicaid APG,5395.24,,,5395.24,Other,324% New York Medicaid APG,3580.18,,,3580.18,Other,215% New York Medicaid APG,3580.18,,,3580.18,Other,215% New York Medicaid APG,2081.5,,,2081.5,Other,125% New York Medicaid APG,1665.2,50381.24,
Remove knee joint lining,27335,CPT,,,,,,,,both,,,150476.65,111352.72,74,,111352.72,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,67714.49,45,,67714.49,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,74485.94,49.5,,74485.94,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3502.03,,,3502.03,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,105333.66,70,,105333.66,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1882.81,,,1882.81,Other,New York Medicaid APG methodology,1882.81,,,1882.81,Other,100% New York Medicaid APG,1882.81,,,1882.81,Other,100% New York Medicaid APG,1882.81,,,1882.81,Other,100% New York Medicaid APG,4236.33,,,4236.33,Other,225% New York Medicaid APG,2880.7,,,2880.7,Other,153% New York Medicaid APG,4236.33,,,4236.33,Other,225% New York Medicaid APG,2635.94,,,2635.94,Other,140% New York Medicaid APG,4236.33,,,4236.33,Other,225% New York Medicaid APG,4895.31,,,4895.31,Other,260% New York Medicaid APG,6100.32,,,6100.32,Other,324% New York Medicaid APG,4048.05,,,4048.05,Other,215% New York Medicaid APG,4048.05,,,4048.05,Other,215% New York Medicaid APG,2353.52,,,2353.52,Other,125% New York Medicaid APG,1882.81,111352.72,
Exc thigh/knee les sc 3 cm/>,27337,CPT,,,,,,,,both,,,35216.67,26060.34,74,,26060.34,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15847.5,45,,15847.5,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,17432.25,49.5,,17432.25,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,1973.06,,,1973.06,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,24651.67,70,,24651.67,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1060.79,,,1060.79,Other,New York Medicaid APG methodology,1060.79,,,1060.79,Other,100% New York Medicaid APG,1060.79,,,1060.79,Other,100% New York Medicaid APG,1060.79,,,1060.79,Other,100% New York Medicaid APG,2386.77,,,2386.77,Other,225% New York Medicaid APG,1623,,,1623,Other,153% New York Medicaid APG,2386.77,,,2386.77,Other,225% New York Medicaid APG,1485.1,,,1485.1,Other,140% New York Medicaid APG,2386.77,,,2386.77,Other,225% New York Medicaid APG,2758.05,,,2758.05,Other,260% New York Medicaid APG,3436.95,,,3436.95,Other,324% New York Medicaid APG,2280.69,,,2280.69,Other,215% New York Medicaid APG,2280.69,,,2280.69,Other,215% New York Medicaid APG,1325.98,,,1325.98,Other,125% New York Medicaid APG,1060.79,26060.34,
Exc thigh/knee tum dep 5cm/>,27339,CPT,,,,,,,,both,,,39221.15,29023.65,74,,29023.65,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,17649.52,45,,17649.52,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,19414.47,49.5,,19414.47,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,1973.06,,,1973.06,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,27454.81,70,,27454.81,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1060.79,,,1060.79,Other,New York Medicaid APG methodology,1060.79,,,1060.79,Other,100% New York Medicaid APG,1060.79,,,1060.79,Other,100% New York Medicaid APG,1060.79,,,1060.79,Other,100% New York Medicaid APG,2386.77,,,2386.77,Other,225% New York Medicaid APG,1623,,,1623,Other,153% New York Medicaid APG,2386.77,,,2386.77,Other,225% New York Medicaid APG,1485.1,,,1485.1,Other,140% New York Medicaid APG,2386.77,,,2386.77,Other,225% New York Medicaid APG,2758.05,,,2758.05,Other,260% New York Medicaid APG,3436.95,,,3436.95,Other,324% New York Medicaid APG,2280.69,,,2280.69,Other,215% New York Medicaid APG,2280.69,,,2280.69,Other,215% New York Medicaid APG,1325.98,,,1325.98,Other,125% New York Medicaid APG,1060.79,29023.65,
Removal of kneecap bursa,27340,CPT,,,,,,,,both,,,68082.75,50381.24,74,,50381.24,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30637.24,45,,30637.24,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33700.96,49.5,,33700.96,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3097.27,,,3097.27,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,47657.93,70,,47657.93,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1665.2,,,1665.2,Other,New York Medicaid APG methodology,1665.2,,,1665.2,Other,100% New York Medicaid APG,1665.2,,,1665.2,Other,100% New York Medicaid APG,1665.2,,,1665.2,Other,100% New York Medicaid APG,3746.7,,,3746.7,Other,225% New York Medicaid APG,2547.75,,,2547.75,Other,153% New York Medicaid APG,3746.7,,,3746.7,Other,225% New York Medicaid APG,2331.28,,,2331.28,Other,140% New York Medicaid APG,3746.7,,,3746.7,Other,225% New York Medicaid APG,4329.52,,,4329.52,Other,260% New York Medicaid APG,5395.24,,,5395.24,Other,324% New York Medicaid APG,3580.18,,,3580.18,Other,215% New York Medicaid APG,3580.18,,,3580.18,Other,215% New York Medicaid APG,2081.5,,,2081.5,Other,125% New York Medicaid APG,1665.2,50381.24,
Removal of knee cyst,27345,CPT,,,,,,,,both,,,68082.75,50381.24,74,,50381.24,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30637.24,45,,30637.24,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33700.96,49.5,,33700.96,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3097.27,,,3097.27,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,47657.93,70,,47657.93,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1665.2,,,1665.2,Other,New York Medicaid APG methodology,1665.2,,,1665.2,Other,100% New York Medicaid APG,1665.2,,,1665.2,Other,100% New York Medicaid APG,1665.2,,,1665.2,Other,100% New York Medicaid APG,3746.7,,,3746.7,Other,225% New York Medicaid APG,2547.75,,,2547.75,Other,153% New York Medicaid APG,3746.7,,,3746.7,Other,225% New York Medicaid APG,2331.28,,,2331.28,Other,140% New York Medicaid APG,3746.7,,,3746.7,Other,225% New York Medicaid APG,4329.52,,,4329.52,Other,260% New York Medicaid APG,5395.24,,,5395.24,Other,324% New York Medicaid APG,3580.18,,,3580.18,Other,215% New York Medicaid APG,3580.18,,,3580.18,Other,215% New York Medicaid APG,2081.5,,,2081.5,Other,125% New York Medicaid APG,1665.2,50381.24,
Remove knee cyst,27347,CPT,,,,,,,,both,,,68082.75,50381.24,74,,50381.24,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30637.24,45,,30637.24,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33700.96,49.5,,33700.96,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3097.27,,,3097.27,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,47657.93,70,,47657.93,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1665.2,,,1665.2,Other,New York Medicaid APG methodology,1665.2,,,1665.2,Other,100% New York Medicaid APG,1665.2,,,1665.2,Other,100% New York Medicaid APG,1665.2,,,1665.2,Other,100% New York Medicaid APG,3746.7,,,3746.7,Other,225% New York Medicaid APG,2547.75,,,2547.75,Other,153% New York Medicaid APG,3746.7,,,3746.7,Other,225% New York Medicaid APG,2331.28,,,2331.28,Other,140% New York Medicaid APG,3746.7,,,3746.7,Other,225% New York Medicaid APG,4329.52,,,4329.52,Other,260% New York Medicaid APG,5395.24,,,5395.24,Other,324% New York Medicaid APG,3580.18,,,3580.18,Other,215% New York Medicaid APG,3580.18,,,3580.18,Other,215% New York Medicaid APG,2081.5,,,2081.5,Other,125% New York Medicaid APG,1665.2,50381.24,
Removal of kneecap,27350,CPT,,,,,,,,both,,,150476.65,111352.72,74,,111352.72,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,67714.49,45,,67714.49,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,74485.94,49.5,,74485.94,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3097.27,,,3097.27,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,105333.66,70,,105333.66,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1665.2,,,1665.2,Other,New York Medicaid APG methodology,1665.2,,,1665.2,Other,100% New York Medicaid APG,1665.2,,,1665.2,Other,100% New York Medicaid APG,1665.2,,,1665.2,Other,100% New York Medicaid APG,3746.7,,,3746.7,Other,225% New York Medicaid APG,2547.75,,,2547.75,Other,153% New York Medicaid APG,3746.7,,,3746.7,Other,225% New York Medicaid APG,2331.28,,,2331.28,Other,140% New York Medicaid APG,3746.7,,,3746.7,Other,225% New York Medicaid APG,4329.52,,,4329.52,Other,260% New York Medicaid APG,5395.24,,,5395.24,Other,324% New York Medicaid APG,3580.18,,,3580.18,Other,215% New York Medicaid APG,3580.18,,,3580.18,Other,215% New York Medicaid APG,2081.5,,,2081.5,Other,125% New York Medicaid APG,1665.2,111352.72,
Remove femur lesion,27355,CPT,,,,,,,,both,,,37524.27,27767.96,74,,27767.96,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,16885.92,45,,16885.92,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,18574.51,49.5,,18574.51,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3817.83,,,3817.83,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,26266.99,70,,26266.99,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,2052.6,,,2052.6,Other,New York Medicaid APG methodology,2052.6,,,2052.6,Other,100% New York Medicaid APG,2052.6,,,2052.6,Other,100% New York Medicaid APG,2052.6,,,2052.6,Other,100% New York Medicaid APG,4618.35,,,4618.35,Other,225% New York Medicaid APG,3140.47,,,3140.47,Other,153% New York Medicaid APG,4618.35,,,4618.35,Other,225% New York Medicaid APG,2873.64,,,2873.64,Other,140% New York Medicaid APG,4618.35,,,4618.35,Other,225% New York Medicaid APG,5336.75,,,5336.75,Other,260% New York Medicaid APG,6650.42,,,6650.42,Other,324% New York Medicaid APG,4413.09,,,4413.09,Other,215% New York Medicaid APG,4413.09,,,4413.09,Other,215% New York Medicaid APG,2565.75,,,2565.75,Other,125% New York Medicaid APG,2052.6,27767.96,
Remove femur lesion/graft,27356,CPT,,,,,,,,both,,,276827.87,204852.62,74,,204852.62,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,124572.54,45,,124572.54,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,137029.8,49.5,,137029.8,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3817.83,,,3817.83,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,193779.51,70,,193779.51,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,2052.6,,,2052.6,Other,New York Medicaid APG methodology,2052.6,,,2052.6,Other,100% New York Medicaid APG,2052.6,,,2052.6,Other,100% New York Medicaid APG,2052.6,,,2052.6,Other,100% New York Medicaid APG,4618.35,,,4618.35,Other,225% New York Medicaid APG,3140.47,,,3140.47,Other,153% New York Medicaid APG,4618.35,,,4618.35,Other,225% New York Medicaid APG,2873.64,,,2873.64,Other,140% New York Medicaid APG,4618.35,,,4618.35,Other,225% New York Medicaid APG,5336.75,,,5336.75,Other,260% New York Medicaid APG,6650.42,,,6650.42,Other,324% New York Medicaid APG,4413.09,,,4413.09,Other,215% New York Medicaid APG,4413.09,,,4413.09,Other,215% New York Medicaid APG,2565.75,,,2565.75,Other,125% New York Medicaid APG,2052.6,204852.62,
Remove femur lesion/graft,27357,CPT,,,,,,,,both,,,49274.1,36462.83,74,,36462.83,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,22173.35,45,,22173.35,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,24390.68,49.5,,24390.68,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3817.83,,,3817.83,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,34491.87,70,,34491.87,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,2052.6,,,2052.6,Other,New York Medicaid APG methodology,2052.6,,,2052.6,Other,100% New York Medicaid APG,2052.6,,,2052.6,Other,100% New York Medicaid APG,2052.6,,,2052.6,Other,100% New York Medicaid APG,4618.35,,,4618.35,Other,225% New York Medicaid APG,3140.47,,,3140.47,Other,153% New York Medicaid APG,4618.35,,,4618.35,Other,225% New York Medicaid APG,2873.64,,,2873.64,Other,140% New York Medicaid APG,4618.35,,,4618.35,Other,225% New York Medicaid APG,5336.75,,,5336.75,Other,260% New York Medicaid APG,6650.42,,,6650.42,Other,324% New York Medicaid APG,4413.09,,,4413.09,Other,215% New York Medicaid APG,4413.09,,,4413.09,Other,215% New York Medicaid APG,2565.75,,,2565.75,Other,125% New York Medicaid APG,2052.6,36462.83,
Remove femur lesion/fixation,27358,CPT,,,,,,,,both,,,86591.4,64077.64,74,,64077.64,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,38966.13,45,,38966.13,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,6125,,"100% primary, 50% secondary, 25% supplemental procedure",6125,Other,Blue Cross ASC Grouper,5513,,"100% primary, 50% secondary, 25% supplemental procedure",5513,Other,Blue Cross ASC Grouper,5206,,"100% primary, 50% secondary, 25% supplemental procedure",5206,Other,Blue Cross ASC Grouper,42862.74,49.5,,42862.74,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3817.83,,,3817.83,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,60613.98,70,,60613.98,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,2052.6,,,2052.6,Other,New York Medicaid APG methodology,2052.6,,,2052.6,Other,100% New York Medicaid APG,2052.6,,,2052.6,Other,100% New York Medicaid APG,2052.6,,,2052.6,Other,100% New York Medicaid APG,4618.35,,,4618.35,Other,225% New York Medicaid APG,3140.47,,,3140.47,Other,153% New York Medicaid APG,4618.35,,,4618.35,Other,225% New York Medicaid APG,2873.64,,,2873.64,Other,140% New York Medicaid APG,4618.35,,,4618.35,Other,225% New York Medicaid APG,5336.75,,,5336.75,Other,260% New York Medicaid APG,6650.42,,,6650.42,Other,324% New York Medicaid APG,4413.09,,,4413.09,Other,215% New York Medicaid APG,4413.09,,,4413.09,Other,215% New York Medicaid APG,2565.75,,,2565.75,Other,125% New York Medicaid APG,2052.6,64077.64,
Partial removal leg bone(s),27360,CPT,,,,,,,,both,,,68082.75,50381.24,74,,50381.24,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30637.24,45,,30637.24,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33700.96,49.5,,33700.96,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3097.27,,,3097.27,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,47657.93,70,,47657.93,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1665.2,,,1665.2,Other,New York Medicaid APG methodology,1665.2,,,1665.2,Other,100% New York Medicaid APG,1665.2,,,1665.2,Other,100% New York Medicaid APG,1665.2,,,1665.2,Other,100% New York Medicaid APG,3746.7,,,3746.7,Other,225% New York Medicaid APG,2547.75,,,2547.75,Other,153% New York Medicaid APG,3746.7,,,3746.7,Other,225% New York Medicaid APG,2331.28,,,2331.28,Other,140% New York Medicaid APG,3746.7,,,3746.7,Other,225% New York Medicaid APG,4329.52,,,4329.52,Other,260% New York Medicaid APG,5395.24,,,5395.24,Other,324% New York Medicaid APG,3580.18,,,3580.18,Other,215% New York Medicaid APG,3580.18,,,3580.18,Other,215% New York Medicaid APG,2081.5,,,2081.5,Other,125% New York Medicaid APG,1665.2,50381.24,
Resect thigh/knee tum 5 cm/>,27364,CPT,,,,,,,,both,,,59767.2,44227.73,74,,44227.73,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,26895.24,45,,26895.24,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,29584.76,49.5,,29584.76,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3097.27,,,3097.27,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,41837.04,70,,41837.04,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1665.2,,,1665.2,Other,New York Medicaid APG methodology,1665.2,,,1665.2,Other,100% New York Medicaid APG,1665.2,,,1665.2,Other,100% New York Medicaid APG,1665.2,,,1665.2,Other,100% New York Medicaid APG,3746.7,,,3746.7,Other,225% New York Medicaid APG,2547.75,,,2547.75,Other,153% New York Medicaid APG,3746.7,,,3746.7,Other,225% New York Medicaid APG,2331.28,,,2331.28,Other,140% New York Medicaid APG,3746.7,,,3746.7,Other,225% New York Medicaid APG,4329.52,,,4329.52,Other,260% New York Medicaid APG,5395.24,,,5395.24,Other,324% New York Medicaid APG,3580.18,,,3580.18,Other,215% New York Medicaid APG,3580.18,,,3580.18,Other,215% New York Medicaid APG,2081.5,,,2081.5,Other,125% New York Medicaid APG,1665.2,44227.73,
Njx cntrst kne arthg/ct/mri,27369,CPT,,,,,,,,both,,,32432.1,23999.75,74,,23999.75,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,14594.45,45,,14594.45,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,16053.89,49.5,,16053.89,percent of total billed charges,110% of Medicare,22053.83,68,,22053.83,percent of total billed charges,,966.93,,,966.93,Other,186% of Medicaid,25945.68,80,,25945.68,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,25945.68,80,,25945.68,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,22702.47,70,,22702.47,percent of total billed charges,,196.8,,,196.8,Fee Schedule,,166.8,,,166.8,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,519.86,,,519.86,Other,New York Medicaid APG methodology,519.86,,,519.86,Other,100% New York Medicaid APG,519.86,,,519.86,Other,100% New York Medicaid APG,519.86,,,519.86,Other,100% New York Medicaid APG,1169.68,,,1169.68,Other,225% New York Medicaid APG,795.38,,,795.38,Other,153% New York Medicaid APG,1169.68,,,1169.68,Other,225% New York Medicaid APG,727.8,,,727.8,Other,140% New York Medicaid APG,1169.68,,,1169.68,Other,225% New York Medicaid APG,1351.62,,,1351.62,Other,260% New York Medicaid APG,1684.33,,,1684.33,Other,324% New York Medicaid APG,1117.69,,,1117.69,Other,215% New York Medicaid APG,1117.69,,,1117.69,Other,215% New York Medicaid APG,649.82,,,649.82,Other,125% New York Medicaid APG,166.8,25945.68,
Removal of foreign body,27372,CPT,,,,,,,,both,,,59767.2,44227.73,74,,44227.73,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,26895.24,45,,26895.24,percent of total billed charges,Medicare Ratio of cost to charges,5954,,"100% primary, 50% supplemental procedure",5954,Other,Aetna ASC Grouper,5359,,"100% primary, 50% supplemental procedure",5359,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,29584.76,49.5,,29584.76,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,1973.06,,,1973.06,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,41837.04,70,,41837.04,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1060.79,,,1060.79,Other,New York Medicaid APG methodology,1060.79,,,1060.79,Other,100% New York Medicaid APG,1060.79,,,1060.79,Other,100% New York Medicaid APG,1060.79,,,1060.79,Other,100% New York Medicaid APG,2386.77,,,2386.77,Other,225% New York Medicaid APG,1623,,,1623,Other,153% New York Medicaid APG,2386.77,,,2386.77,Other,225% New York Medicaid APG,1485.1,,,1485.1,Other,140% New York Medicaid APG,2386.77,,,2386.77,Other,225% New York Medicaid APG,2758.05,,,2758.05,Other,260% New York Medicaid APG,3436.95,,,3436.95,Other,324% New York Medicaid APG,2280.69,,,2280.69,Other,215% New York Medicaid APG,2280.69,,,2280.69,Other,215% New York Medicaid APG,1325.98,,,1325.98,Other,125% New York Medicaid APG,1060.79,44227.73,
Repair of kneecap tendon,27380,CPT,,,,,,,,both,,,38422.81,28432.88,74,,28432.88,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,17290.26,45,,17290.26,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,19019.29,49.5,,19019.29,percent of total billed charges,110% of Medicare,26127.51,68,,26127.51,percent of total billed charges,,3097.27,,,3097.27,Other,186% of Medicaid,30738.25,80,,30738.25,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,30738.25,80,,30738.25,percent of total billed charges,,7216,,,7216,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,26895.97,70,,26895.97,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1665.2,,,1665.2,Other,New York Medicaid APG methodology,1665.2,,,1665.2,Other,100% New York Medicaid APG,1665.2,,,1665.2,Other,100% New York Medicaid APG,1665.2,,,1665.2,Other,100% New York Medicaid APG,3746.7,,,3746.7,Other,225% New York Medicaid APG,2547.75,,,2547.75,Other,153% New York Medicaid APG,3746.7,,,3746.7,Other,225% New York Medicaid APG,2331.28,,,2331.28,Other,140% New York Medicaid APG,3746.7,,,3746.7,Other,225% New York Medicaid APG,4329.52,,,4329.52,Other,260% New York Medicaid APG,5395.24,,,5395.24,Other,324% New York Medicaid APG,3580.18,,,3580.18,Other,215% New York Medicaid APG,3580.18,,,3580.18,Other,215% New York Medicaid APG,2081.5,,,2081.5,Other,125% New York Medicaid APG,1665.2,30738.25,
Repair/graft kneecap tendon,27381,CPT,,,,,,,,both,,,93520.15,69204.91,74,,69204.91,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,42084.07,45,,42084.07,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,46292.47,49.5,,46292.47,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3502.03,,,3502.03,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,65464.11,70,,65464.11,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1882.81,,,1882.81,Other,New York Medicaid APG methodology,1882.81,,,1882.81,Other,100% New York Medicaid APG,1882.81,,,1882.81,Other,100% New York Medicaid APG,1882.81,,,1882.81,Other,100% New York Medicaid APG,4236.33,,,4236.33,Other,225% New York Medicaid APG,2880.7,,,2880.7,Other,153% New York Medicaid APG,4236.33,,,4236.33,Other,225% New York Medicaid APG,2635.94,,,2635.94,Other,140% New York Medicaid APG,4236.33,,,4236.33,Other,225% New York Medicaid APG,4895.31,,,4895.31,Other,260% New York Medicaid APG,6100.32,,,6100.32,Other,324% New York Medicaid APG,4048.05,,,4048.05,Other,215% New York Medicaid APG,4048.05,,,4048.05,Other,215% New York Medicaid APG,2353.52,,,2353.52,Other,125% New York Medicaid APG,1882.81,69204.91,
Repair of thigh muscle,27385,CPT,,,,,,,,both,,,44183.39,32695.71,74,,32695.71,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,19882.53,45,,19882.53,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,21870.78,49.5,,21870.78,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3817.83,,,3817.83,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,30928.37,70,,30928.37,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,2052.6,,,2052.6,Other,New York Medicaid APG methodology,2052.6,,,2052.6,Other,100% New York Medicaid APG,2052.6,,,2052.6,Other,100% New York Medicaid APG,2052.6,,,2052.6,Other,100% New York Medicaid APG,4618.35,,,4618.35,Other,225% New York Medicaid APG,3140.47,,,3140.47,Other,153% New York Medicaid APG,4618.35,,,4618.35,Other,225% New York Medicaid APG,2873.64,,,2873.64,Other,140% New York Medicaid APG,4618.35,,,4618.35,Other,225% New York Medicaid APG,5336.75,,,5336.75,Other,260% New York Medicaid APG,6650.42,,,6650.42,Other,324% New York Medicaid APG,4413.09,,,4413.09,Other,215% New York Medicaid APG,4413.09,,,4413.09,Other,215% New York Medicaid APG,2565.75,,,2565.75,Other,125% New York Medicaid APG,2052.6,32695.71,
Repair/graft of thigh muscle,27386,CPT,,,,,,,,both,,,66941.66,49536.83,74,,49536.83,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30123.75,45,,30123.75,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,33136.12,49.5,,33136.12,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3817.83,,,3817.83,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,46859.16,70,,46859.16,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,2052.6,,,2052.6,Other,New York Medicaid APG methodology,2052.6,,,2052.6,Other,100% New York Medicaid APG,2052.6,,,2052.6,Other,100% New York Medicaid APG,2052.6,,,2052.6,Other,100% New York Medicaid APG,4618.35,,,4618.35,Other,225% New York Medicaid APG,3140.47,,,3140.47,Other,153% New York Medicaid APG,4618.35,,,4618.35,Other,225% New York Medicaid APG,2873.64,,,2873.64,Other,140% New York Medicaid APG,4618.35,,,4618.35,Other,225% New York Medicaid APG,5336.75,,,5336.75,Other,260% New York Medicaid APG,6650.42,,,6650.42,Other,324% New York Medicaid APG,4413.09,,,4413.09,Other,215% New York Medicaid APG,4413.09,,,4413.09,Other,215% New York Medicaid APG,2565.75,,,2565.75,Other,125% New York Medicaid APG,2052.6,49536.83,
Incision of thigh tendon,27390,CPT,,,,,,,,both,,,68082.75,50381.24,74,,50381.24,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30637.24,45,,30637.24,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33700.96,49.5,,33700.96,percent of total billed charges,110% of Medicare,46296.27,68,,46296.27,percent of total billed charges,,3817.83,,,3817.83,Other,186% of Medicaid,54466.2,80,,54466.2,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,54466.2,80,,54466.2,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,47657.93,70,,47657.93,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,2052.6,,,2052.6,Other,New York Medicaid APG methodology,2052.6,,,2052.6,Other,100% New York Medicaid APG,2052.6,,,2052.6,Other,100% New York Medicaid APG,2052.6,,,2052.6,Other,100% New York Medicaid APG,4618.35,,,4618.35,Other,225% New York Medicaid APG,3140.47,,,3140.47,Other,153% New York Medicaid APG,4618.35,,,4618.35,Other,225% New York Medicaid APG,2873.64,,,2873.64,Other,140% New York Medicaid APG,4618.35,,,4618.35,Other,225% New York Medicaid APG,5336.75,,,5336.75,Other,260% New York Medicaid APG,6650.42,,,6650.42,Other,324% New York Medicaid APG,4413.09,,,4413.09,Other,215% New York Medicaid APG,4413.09,,,4413.09,Other,215% New York Medicaid APG,2565.75,,,2565.75,Other,125% New York Medicaid APG,2052.6,54466.2,
Incision of thigh tendons,27391,CPT,,,,,,,,both,,,68082.75,50381.24,74,,50381.24,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30637.24,45,,30637.24,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33700.96,49.5,,33700.96,percent of total billed charges,110% of Medicare,46296.27,68,,46296.27,percent of total billed charges,,3817.83,,,3817.83,Other,186% of Medicaid,54466.2,80,,54466.2,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,54466.2,80,,54466.2,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,47657.93,70,,47657.93,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,2052.6,,,2052.6,Other,New York Medicaid APG methodology,2052.6,,,2052.6,Other,100% New York Medicaid APG,2052.6,,,2052.6,Other,100% New York Medicaid APG,2052.6,,,2052.6,Other,100% New York Medicaid APG,4618.35,,,4618.35,Other,225% New York Medicaid APG,3140.47,,,3140.47,Other,153% New York Medicaid APG,4618.35,,,4618.35,Other,225% New York Medicaid APG,2873.64,,,2873.64,Other,140% New York Medicaid APG,4618.35,,,4618.35,Other,225% New York Medicaid APG,5336.75,,,5336.75,Other,260% New York Medicaid APG,6650.42,,,6650.42,Other,324% New York Medicaid APG,4413.09,,,4413.09,Other,215% New York Medicaid APG,4413.09,,,4413.09,Other,215% New York Medicaid APG,2565.75,,,2565.75,Other,125% New York Medicaid APG,2052.6,54466.2,
Incision of thigh tendons,27392,CPT,,,,,,,,both,,,68082.75,50381.24,74,,50381.24,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30637.24,45,,30637.24,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33700.96,49.5,,33700.96,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3817.83,,,3817.83,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,47657.93,70,,47657.93,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,2052.6,,,2052.6,Other,New York Medicaid APG methodology,2052.6,,,2052.6,Other,100% New York Medicaid APG,2052.6,,,2052.6,Other,100% New York Medicaid APG,2052.6,,,2052.6,Other,100% New York Medicaid APG,4618.35,,,4618.35,Other,225% New York Medicaid APG,3140.47,,,3140.47,Other,153% New York Medicaid APG,4618.35,,,4618.35,Other,225% New York Medicaid APG,2873.64,,,2873.64,Other,140% New York Medicaid APG,4618.35,,,4618.35,Other,225% New York Medicaid APG,5336.75,,,5336.75,Other,260% New York Medicaid APG,6650.42,,,6650.42,Other,324% New York Medicaid APG,4413.09,,,4413.09,Other,215% New York Medicaid APG,4413.09,,,4413.09,Other,215% New York Medicaid APG,2565.75,,,2565.75,Other,125% New York Medicaid APG,2052.6,50381.24,
Lengthening of thigh tendon,27393,CPT,,,,,,,,both,,,150476.65,111352.72,74,,111352.72,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,67714.49,45,,67714.49,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,74485.94,49.5,,74485.94,percent of total billed charges,110% of Medicare,102324.12,68,,102324.12,percent of total billed charges,,3817.83,,,3817.83,Other,186% of Medicaid,120381.32,80,,120381.32,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,120381.32,80,,120381.32,percent of total billed charges,,7216,,,7216,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,105333.66,70,,105333.66,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,2052.6,,,2052.6,Other,New York Medicaid APG methodology,2052.6,,,2052.6,Other,100% New York Medicaid APG,2052.6,,,2052.6,Other,100% New York Medicaid APG,2052.6,,,2052.6,Other,100% New York Medicaid APG,4618.35,,,4618.35,Other,225% New York Medicaid APG,3140.47,,,3140.47,Other,153% New York Medicaid APG,4618.35,,,4618.35,Other,225% New York Medicaid APG,2873.64,,,2873.64,Other,140% New York Medicaid APG,4618.35,,,4618.35,Other,225% New York Medicaid APG,5336.75,,,5336.75,Other,260% New York Medicaid APG,6650.42,,,6650.42,Other,324% New York Medicaid APG,4413.09,,,4413.09,Other,215% New York Medicaid APG,4413.09,,,4413.09,Other,215% New York Medicaid APG,2565.75,,,2565.75,Other,125% New York Medicaid APG,2052.6,120381.32,
Lengthening of thigh tendons,27394,CPT,,,,,,,,both,,,51096.05,37811.08,74,,37811.08,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,22993.22,45,,22993.22,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,25292.54,49.5,,25292.54,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3817.83,,,3817.83,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,35767.24,70,,35767.24,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,2052.6,,,2052.6,Other,New York Medicaid APG methodology,2052.6,,,2052.6,Other,100% New York Medicaid APG,2052.6,,,2052.6,Other,100% New York Medicaid APG,2052.6,,,2052.6,Other,100% New York Medicaid APG,4618.35,,,4618.35,Other,225% New York Medicaid APG,3140.47,,,3140.47,Other,153% New York Medicaid APG,4618.35,,,4618.35,Other,225% New York Medicaid APG,2873.64,,,2873.64,Other,140% New York Medicaid APG,4618.35,,,4618.35,Other,225% New York Medicaid APG,5336.75,,,5336.75,Other,260% New York Medicaid APG,6650.42,,,6650.42,Other,324% New York Medicaid APG,4413.09,,,4413.09,Other,215% New York Medicaid APG,4413.09,,,4413.09,Other,215% New York Medicaid APG,2565.75,,,2565.75,Other,125% New York Medicaid APG,2052.6,37811.08,
Lengthening of thigh tendons,27395,CPT,,,,,,,,both,,,68082.75,50381.24,74,,50381.24,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30637.24,45,,30637.24,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33700.96,49.5,,33700.96,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3817.83,,,3817.83,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,47657.93,70,,47657.93,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,2052.6,,,2052.6,Other,New York Medicaid APG methodology,2052.6,,,2052.6,Other,100% New York Medicaid APG,2052.6,,,2052.6,Other,100% New York Medicaid APG,2052.6,,,2052.6,Other,100% New York Medicaid APG,4618.35,,,4618.35,Other,225% New York Medicaid APG,3140.47,,,3140.47,Other,153% New York Medicaid APG,4618.35,,,4618.35,Other,225% New York Medicaid APG,2873.64,,,2873.64,Other,140% New York Medicaid APG,4618.35,,,4618.35,Other,225% New York Medicaid APG,5336.75,,,5336.75,Other,260% New York Medicaid APG,6650.42,,,6650.42,Other,324% New York Medicaid APG,4413.09,,,4413.09,Other,215% New York Medicaid APG,4413.09,,,4413.09,Other,215% New York Medicaid APG,2565.75,,,2565.75,Other,125% New York Medicaid APG,2052.6,50381.24,
Transplant of thigh tendon,27396,CPT,,,,,,,,both,,,150476.65,111352.72,74,,111352.72,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,67714.49,45,,67714.49,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,74485.94,49.5,,74485.94,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3817.83,,,3817.83,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,105333.66,70,,105333.66,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,2052.6,,,2052.6,Other,New York Medicaid APG methodology,2052.6,,,2052.6,Other,100% New York Medicaid APG,2052.6,,,2052.6,Other,100% New York Medicaid APG,2052.6,,,2052.6,Other,100% New York Medicaid APG,4618.35,,,4618.35,Other,225% New York Medicaid APG,3140.47,,,3140.47,Other,153% New York Medicaid APG,4618.35,,,4618.35,Other,225% New York Medicaid APG,2873.64,,,2873.64,Other,140% New York Medicaid APG,4618.35,,,4618.35,Other,225% New York Medicaid APG,5336.75,,,5336.75,Other,260% New York Medicaid APG,6650.42,,,6650.42,Other,324% New York Medicaid APG,4413.09,,,4413.09,Other,215% New York Medicaid APG,4413.09,,,4413.09,Other,215% New York Medicaid APG,2565.75,,,2565.75,Other,125% New York Medicaid APG,2052.6,111352.72,
Transplants of thigh tendons,27397,CPT,,,,,,,,both,,,150476.65,111352.72,74,,111352.72,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,67714.49,45,,67714.49,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,74485.94,49.5,,74485.94,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3817.83,,,3817.83,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,105333.66,70,,105333.66,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,2052.6,,,2052.6,Other,New York Medicaid APG methodology,2052.6,,,2052.6,Other,100% New York Medicaid APG,2052.6,,,2052.6,Other,100% New York Medicaid APG,2052.6,,,2052.6,Other,100% New York Medicaid APG,4618.35,,,4618.35,Other,225% New York Medicaid APG,3140.47,,,3140.47,Other,153% New York Medicaid APG,4618.35,,,4618.35,Other,225% New York Medicaid APG,2873.64,,,2873.64,Other,140% New York Medicaid APG,4618.35,,,4618.35,Other,225% New York Medicaid APG,5336.75,,,5336.75,Other,260% New York Medicaid APG,6650.42,,,6650.42,Other,324% New York Medicaid APG,4413.09,,,4413.09,Other,215% New York Medicaid APG,4413.09,,,4413.09,Other,215% New York Medicaid APG,2565.75,,,2565.75,Other,125% New York Medicaid APG,2052.6,111352.72,
Revise thigh muscles/tendons,27400,CPT,,,,,,,,both,,,150476.65,111352.72,74,,111352.72,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,67714.49,45,,67714.49,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,74485.94,49.5,,74485.94,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3817.83,,,3817.83,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,105333.66,70,,105333.66,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,2052.6,,,2052.6,Other,New York Medicaid APG methodology,2052.6,,,2052.6,Other,100% New York Medicaid APG,2052.6,,,2052.6,Other,100% New York Medicaid APG,2052.6,,,2052.6,Other,100% New York Medicaid APG,4618.35,,,4618.35,Other,225% New York Medicaid APG,3140.47,,,3140.47,Other,153% New York Medicaid APG,4618.35,,,4618.35,Other,225% New York Medicaid APG,2873.64,,,2873.64,Other,140% New York Medicaid APG,4618.35,,,4618.35,Other,225% New York Medicaid APG,5336.75,,,5336.75,Other,260% New York Medicaid APG,6650.42,,,6650.42,Other,324% New York Medicaid APG,4413.09,,,4413.09,Other,215% New York Medicaid APG,4413.09,,,4413.09,Other,215% New York Medicaid APG,2565.75,,,2565.75,Other,125% New York Medicaid APG,2052.6,111352.72,
Repair of knee cartilage,27403,CPT,,,,,,,,both,,,150476.65,111352.72,74,,111352.72,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,67714.49,45,,67714.49,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,74485.94,49.5,,74485.94,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3097.27,,,3097.27,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,105333.66,70,,105333.66,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1665.2,,,1665.2,Other,New York Medicaid APG methodology,1665.2,,,1665.2,Other,100% New York Medicaid APG,1665.2,,,1665.2,Other,100% New York Medicaid APG,1665.2,,,1665.2,Other,100% New York Medicaid APG,3746.7,,,3746.7,Other,225% New York Medicaid APG,2547.75,,,2547.75,Other,153% New York Medicaid APG,3746.7,,,3746.7,Other,225% New York Medicaid APG,2331.28,,,2331.28,Other,140% New York Medicaid APG,3746.7,,,3746.7,Other,225% New York Medicaid APG,4329.52,,,4329.52,Other,260% New York Medicaid APG,5395.24,,,5395.24,Other,324% New York Medicaid APG,3580.18,,,3580.18,Other,215% New York Medicaid APG,3580.18,,,3580.18,Other,215% New York Medicaid APG,2081.5,,,2081.5,Other,125% New York Medicaid APG,1665.2,111352.72,
Repair of knee ligament,27405,CPT,,,,,,,,both,,,150476.65,111352.72,74,,111352.72,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,67714.49,45,,67714.49,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,74485.94,49.5,,74485.94,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3502.03,,,3502.03,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,105333.66,70,,105333.66,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,1882.81,,,1882.81,Other,New York Medicaid APG methodology,1882.81,,,1882.81,Other,100% New York Medicaid APG,1882.81,,,1882.81,Other,100% New York Medicaid APG,1882.81,,,1882.81,Other,100% New York Medicaid APG,4236.33,,,4236.33,Other,225% New York Medicaid APG,2880.7,,,2880.7,Other,153% New York Medicaid APG,4236.33,,,4236.33,Other,225% New York Medicaid APG,2635.94,,,2635.94,Other,140% New York Medicaid APG,4236.33,,,4236.33,Other,225% New York Medicaid APG,4895.31,,,4895.31,Other,260% New York Medicaid APG,6100.32,,,6100.32,Other,324% New York Medicaid APG,4048.05,,,4048.05,Other,215% New York Medicaid APG,4048.05,,,4048.05,Other,215% New York Medicaid APG,2353.52,,,2353.52,Other,125% New York Medicaid APG,1882.81,111352.72,
Repair of knee ligament,27407,CPT,,,,,,,,both,,,150476.65,111352.72,74,,111352.72,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,67714.49,45,,67714.49,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,74485.94,49.5,,74485.94,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3502.03,,,3502.03,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,105333.66,70,,105333.66,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,1882.81,,,1882.81,Other,New York Medicaid APG methodology,1882.81,,,1882.81,Other,100% New York Medicaid APG,1882.81,,,1882.81,Other,100% New York Medicaid APG,1882.81,,,1882.81,Other,100% New York Medicaid APG,4236.33,,,4236.33,Other,225% New York Medicaid APG,2880.7,,,2880.7,Other,153% New York Medicaid APG,4236.33,,,4236.33,Other,225% New York Medicaid APG,2635.94,,,2635.94,Other,140% New York Medicaid APG,4236.33,,,4236.33,Other,225% New York Medicaid APG,4895.31,,,4895.31,Other,260% New York Medicaid APG,6100.32,,,6100.32,Other,324% New York Medicaid APG,4048.05,,,4048.05,Other,215% New York Medicaid APG,4048.05,,,4048.05,Other,215% New York Medicaid APG,2353.52,,,2353.52,Other,125% New York Medicaid APG,1882.81,111352.72,
Repair of knee ligaments,27409,CPT,,,,,,,,both,,,150476.65,111352.72,74,,111352.72,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,67714.49,45,,67714.49,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,74485.94,49.5,,74485.94,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3502.03,,,3502.03,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,105333.66,70,,105333.66,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,1882.81,,,1882.81,Other,New York Medicaid APG methodology,1882.81,,,1882.81,Other,100% New York Medicaid APG,1882.81,,,1882.81,Other,100% New York Medicaid APG,1882.81,,,1882.81,Other,100% New York Medicaid APG,4236.33,,,4236.33,Other,225% New York Medicaid APG,2880.7,,,2880.7,Other,153% New York Medicaid APG,4236.33,,,4236.33,Other,225% New York Medicaid APG,2635.94,,,2635.94,Other,140% New York Medicaid APG,4236.33,,,4236.33,Other,225% New York Medicaid APG,4895.31,,,4895.31,Other,260% New York Medicaid APG,6100.32,,,6100.32,Other,324% New York Medicaid APG,4048.05,,,4048.05,Other,215% New York Medicaid APG,4048.05,,,4048.05,Other,215% New York Medicaid APG,2353.52,,,2353.52,Other,125% New York Medicaid APG,1882.81,111352.72,
Autochondrocyte implant knee,27412,CPT,,,,,,,,both,,,150476.65,111352.72,74,,111352.72,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,67714.49,45,,67714.49,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,74485.94,49.5,,74485.94,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5918.58,,,5918.58,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,105333.66,70,,105333.66,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,3182.03,,,3182.03,Other,New York Medicaid APG methodology,3182.03,,,3182.03,Other,100% New York Medicaid APG,3182.03,,,3182.03,Other,100% New York Medicaid APG,3182.03,,,3182.03,Other,100% New York Medicaid APG,7159.57,,,7159.57,Other,225% New York Medicaid APG,4868.51,,,4868.51,Other,153% New York Medicaid APG,7159.57,,,7159.57,Other,225% New York Medicaid APG,4454.84,,,4454.84,Other,140% New York Medicaid APG,7159.57,,,7159.57,Other,225% New York Medicaid APG,8273.28,,,8273.28,Other,260% New York Medicaid APG,10309.78,,,10309.78,Other,324% New York Medicaid APG,6841.37,,,6841.37,Other,215% New York Medicaid APG,6841.37,,,6841.37,Other,215% New York Medicaid APG,3977.54,,,3977.54,Other,125% New York Medicaid APG,3126,111352.72,
Osteochondral knee allograft,27415,CPT,,,,,,,,both,,,276827.87,204852.62,74,,204852.62,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,124572.54,45,,124572.54,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,137029.8,49.5,,137029.8,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5918.58,,,5918.58,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,193779.51,70,,193779.51,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,3182.03,,,3182.03,Other,New York Medicaid APG methodology,3182.03,,,3182.03,Other,100% New York Medicaid APG,3182.03,,,3182.03,Other,100% New York Medicaid APG,3182.03,,,3182.03,Other,100% New York Medicaid APG,7159.57,,,7159.57,Other,225% New York Medicaid APG,4868.51,,,4868.51,Other,153% New York Medicaid APG,7159.57,,,7159.57,Other,225% New York Medicaid APG,4454.84,,,4454.84,Other,140% New York Medicaid APG,7159.57,,,7159.57,Other,225% New York Medicaid APG,8273.28,,,8273.28,Other,260% New York Medicaid APG,10309.78,,,10309.78,Other,324% New York Medicaid APG,6841.37,,,6841.37,Other,215% New York Medicaid APG,6841.37,,,6841.37,Other,215% New York Medicaid APG,3977.54,,,3977.54,Other,125% New York Medicaid APG,3126,204852.62,
Osteochondral knee autograft,27416,CPT,,,,,,,,both,,,150476.65,111352.72,74,,111352.72,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,67714.49,45,,67714.49,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,74485.94,49.5,,74485.94,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3502.03,,,3502.03,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,105333.66,70,,105333.66,percent of total billed charges,,4824.88,,,4824.88,Fee Schedule,,4089.38,,,4089.38,Fee Schedule,,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,1882.81,,,1882.81,Other,New York Medicaid APG methodology,1882.81,,,1882.81,Other,100% New York Medicaid APG,1882.81,,,1882.81,Other,100% New York Medicaid APG,1882.81,,,1882.81,Other,100% New York Medicaid APG,4236.33,,,4236.33,Other,225% New York Medicaid APG,2880.7,,,2880.7,Other,153% New York Medicaid APG,4236.33,,,4236.33,Other,225% New York Medicaid APG,2635.94,,,2635.94,Other,140% New York Medicaid APG,4236.33,,,4236.33,Other,225% New York Medicaid APG,4895.31,,,4895.31,Other,260% New York Medicaid APG,6100.32,,,6100.32,Other,324% New York Medicaid APG,4048.05,,,4048.05,Other,215% New York Medicaid APG,4048.05,,,4048.05,Other,215% New York Medicaid APG,2353.52,,,2353.52,Other,125% New York Medicaid APG,1882.81,111352.72,
Repair degenerated kneecap,27418,CPT,,,,,,,,both,,,68506.97,50695.16,74,,50695.16,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30828.14,45,,30828.14,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,33910.95,49.5,,33910.95,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3502.03,,,3502.03,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,47954.88,70,,47954.88,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,1882.81,,,1882.81,Other,New York Medicaid APG methodology,1882.81,,,1882.81,Other,100% New York Medicaid APG,1882.81,,,1882.81,Other,100% New York Medicaid APG,1882.81,,,1882.81,Other,100% New York Medicaid APG,4236.33,,,4236.33,Other,225% New York Medicaid APG,2880.7,,,2880.7,Other,153% New York Medicaid APG,4236.33,,,4236.33,Other,225% New York Medicaid APG,2635.94,,,2635.94,Other,140% New York Medicaid APG,4236.33,,,4236.33,Other,225% New York Medicaid APG,4895.31,,,4895.31,Other,260% New York Medicaid APG,6100.32,,,6100.32,Other,324% New York Medicaid APG,4048.05,,,4048.05,Other,215% New York Medicaid APG,4048.05,,,4048.05,Other,215% New York Medicaid APG,2353.52,,,2353.52,Other,125% New York Medicaid APG,1882.81,50695.16,
Revision of unstable kneecap,27420,CPT,,,,,,,,both,,,150476.65,111352.72,74,,111352.72,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,67714.49,45,,67714.49,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,74485.94,49.5,,74485.94,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3502.03,,,3502.03,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,105333.66,70,,105333.66,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,1882.81,,,1882.81,Other,New York Medicaid APG methodology,1882.81,,,1882.81,Other,100% New York Medicaid APG,1882.81,,,1882.81,Other,100% New York Medicaid APG,1882.81,,,1882.81,Other,100% New York Medicaid APG,4236.33,,,4236.33,Other,225% New York Medicaid APG,2880.7,,,2880.7,Other,153% New York Medicaid APG,4236.33,,,4236.33,Other,225% New York Medicaid APG,2635.94,,,2635.94,Other,140% New York Medicaid APG,4236.33,,,4236.33,Other,225% New York Medicaid APG,4895.31,,,4895.31,Other,260% New York Medicaid APG,6100.32,,,6100.32,Other,324% New York Medicaid APG,4048.05,,,4048.05,Other,215% New York Medicaid APG,4048.05,,,4048.05,Other,215% New York Medicaid APG,2353.52,,,2353.52,Other,125% New York Medicaid APG,1882.81,111352.72,
Revision of unstable kneecap,27422,CPT,,,,,,,,both,,,70807.26,52397.37,74,,52397.37,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,31863.27,45,,31863.27,percent of total billed charges,Medicare Ratio of cost to charges,5954,,"100% primary, 50% supplemental procedure",5954,Other,Aetna ASC Grouper,5359,,"100% primary, 50% supplemental procedure",5359,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,35049.59,49.5,,35049.59,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3502.03,,,3502.03,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,49565.08,70,,49565.08,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,1882.81,,,1882.81,Other,New York Medicaid APG methodology,1882.81,,,1882.81,Other,100% New York Medicaid APG,1882.81,,,1882.81,Other,100% New York Medicaid APG,1882.81,,,1882.81,Other,100% New York Medicaid APG,4236.33,,,4236.33,Other,225% New York Medicaid APG,2880.7,,,2880.7,Other,153% New York Medicaid APG,4236.33,,,4236.33,Other,225% New York Medicaid APG,2635.94,,,2635.94,Other,140% New York Medicaid APG,4236.33,,,4236.33,Other,225% New York Medicaid APG,4895.31,,,4895.31,Other,260% New York Medicaid APG,6100.32,,,6100.32,Other,324% New York Medicaid APG,4048.05,,,4048.05,Other,215% New York Medicaid APG,4048.05,,,4048.05,Other,215% New York Medicaid APG,2353.52,,,2353.52,Other,125% New York Medicaid APG,1882.81,52397.37,
Revision/removal of kneecap,27424,CPT,,,,,,,,both,,,50657.5,37486.55,74,,37486.55,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,22795.88,45,,22795.88,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,25075.46,49.5,,25075.46,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3502.03,,,3502.03,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,35460.25,70,,35460.25,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,1882.81,,,1882.81,Other,New York Medicaid APG methodology,1882.81,,,1882.81,Other,100% New York Medicaid APG,1882.81,,,1882.81,Other,100% New York Medicaid APG,1882.81,,,1882.81,Other,100% New York Medicaid APG,4236.33,,,4236.33,Other,225% New York Medicaid APG,2880.7,,,2880.7,Other,153% New York Medicaid APG,4236.33,,,4236.33,Other,225% New York Medicaid APG,2635.94,,,2635.94,Other,140% New York Medicaid APG,4236.33,,,4236.33,Other,225% New York Medicaid APG,4895.31,,,4895.31,Other,260% New York Medicaid APG,6100.32,,,6100.32,Other,324% New York Medicaid APG,4048.05,,,4048.05,Other,215% New York Medicaid APG,4048.05,,,4048.05,Other,215% New York Medicaid APG,2353.52,,,2353.52,Other,125% New York Medicaid APG,1882.81,37486.55,
Lat retinacular release open,27425,CPT,,,,,,,,both,,,68082.75,50381.24,74,,50381.24,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30637.24,45,,30637.24,percent of total billed charges,Medicare Ratio of cost to charges,5954,,"100% primary, 50% supplemental procedure",5954,Other,Aetna ASC Grouper,5359,,"100% primary, 50% supplemental procedure",5359,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33700.96,49.5,,33700.96,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3097.27,,,3097.27,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,47657.93,70,,47657.93,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1665.2,,,1665.2,Other,New York Medicaid APG methodology,1665.2,,,1665.2,Other,100% New York Medicaid APG,1665.2,,,1665.2,Other,100% New York Medicaid APG,1665.2,,,1665.2,Other,100% New York Medicaid APG,3746.7,,,3746.7,Other,225% New York Medicaid APG,2547.75,,,2547.75,Other,153% New York Medicaid APG,3746.7,,,3746.7,Other,225% New York Medicaid APG,2331.28,,,2331.28,Other,140% New York Medicaid APG,3746.7,,,3746.7,Other,225% New York Medicaid APG,4329.52,,,4329.52,Other,260% New York Medicaid APG,5395.24,,,5395.24,Other,324% New York Medicaid APG,3580.18,,,3580.18,Other,215% New York Medicaid APG,3580.18,,,3580.18,Other,215% New York Medicaid APG,2081.5,,,2081.5,Other,125% New York Medicaid APG,1665.2,50381.24,
Reconstruction knee,27427,CPT,,,,,,,,both,,,100972.69,74719.79,74,,74719.79,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,45437.71,45,,45437.71,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,49981.48,49.5,,49981.48,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3502.03,,,3502.03,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,70680.88,70,,70680.88,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,1882.81,,,1882.81,Other,New York Medicaid APG methodology,1882.81,,,1882.81,Other,100% New York Medicaid APG,1882.81,,,1882.81,Other,100% New York Medicaid APG,1882.81,,,1882.81,Other,100% New York Medicaid APG,4236.33,,,4236.33,Other,225% New York Medicaid APG,2880.7,,,2880.7,Other,153% New York Medicaid APG,4236.33,,,4236.33,Other,225% New York Medicaid APG,2635.94,,,2635.94,Other,140% New York Medicaid APG,4236.33,,,4236.33,Other,225% New York Medicaid APG,4895.31,,,4895.31,Other,260% New York Medicaid APG,6100.32,,,6100.32,Other,324% New York Medicaid APG,4048.05,,,4048.05,Other,215% New York Medicaid APG,4048.05,,,4048.05,Other,215% New York Medicaid APG,2353.52,,,2353.52,Other,125% New York Medicaid APG,1882.81,74719.79,
Reconstruction knee,27428,CPT,,,,,,,,both,,,276827.87,204852.62,74,,204852.62,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,124572.54,45,,124572.54,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,137029.8,49.5,,137029.8,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3502.03,,,3502.03,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,193779.51,70,,193779.51,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,1882.81,,,1882.81,Other,New York Medicaid APG methodology,1882.81,,,1882.81,Other,100% New York Medicaid APG,1882.81,,,1882.81,Other,100% New York Medicaid APG,1882.81,,,1882.81,Other,100% New York Medicaid APG,4236.33,,,4236.33,Other,225% New York Medicaid APG,2880.7,,,2880.7,Other,153% New York Medicaid APG,4236.33,,,4236.33,Other,225% New York Medicaid APG,2635.94,,,2635.94,Other,140% New York Medicaid APG,4236.33,,,4236.33,Other,225% New York Medicaid APG,4895.31,,,4895.31,Other,260% New York Medicaid APG,6100.32,,,6100.32,Other,324% New York Medicaid APG,4048.05,,,4048.05,Other,215% New York Medicaid APG,4048.05,,,4048.05,Other,215% New York Medicaid APG,2353.52,,,2353.52,Other,125% New York Medicaid APG,1882.81,204852.62,
Reconstruction knee,27429,CPT,,,,,,,,both,,,276827.87,204852.62,74,,204852.62,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,124572.54,45,,124572.54,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,137029.8,49.5,,137029.8,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3502.03,,,3502.03,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,193779.51,70,,193779.51,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,1882.81,,,1882.81,Other,New York Medicaid APG methodology,1882.81,,,1882.81,Other,100% New York Medicaid APG,1882.81,,,1882.81,Other,100% New York Medicaid APG,1882.81,,,1882.81,Other,100% New York Medicaid APG,4236.33,,,4236.33,Other,225% New York Medicaid APG,2880.7,,,2880.7,Other,153% New York Medicaid APG,4236.33,,,4236.33,Other,225% New York Medicaid APG,2635.94,,,2635.94,Other,140% New York Medicaid APG,4236.33,,,4236.33,Other,225% New York Medicaid APG,4895.31,,,4895.31,Other,260% New York Medicaid APG,6100.32,,,6100.32,Other,324% New York Medicaid APG,4048.05,,,4048.05,Other,215% New York Medicaid APG,4048.05,,,4048.05,Other,215% New York Medicaid APG,2353.52,,,2353.52,Other,125% New York Medicaid APG,1882.81,204852.62,
Revision of thigh muscles,27430,CPT,,,,,,,,both,,,150476.65,111352.72,74,,111352.72,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,67714.49,45,,67714.49,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,74485.94,49.5,,74485.94,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3817.83,,,3817.83,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,105333.66,70,,105333.66,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,2052.6,,,2052.6,Other,New York Medicaid APG methodology,2052.6,,,2052.6,Other,100% New York Medicaid APG,2052.6,,,2052.6,Other,100% New York Medicaid APG,2052.6,,,2052.6,Other,100% New York Medicaid APG,4618.35,,,4618.35,Other,225% New York Medicaid APG,3140.47,,,3140.47,Other,153% New York Medicaid APG,4618.35,,,4618.35,Other,225% New York Medicaid APG,2873.64,,,2873.64,Other,140% New York Medicaid APG,4618.35,,,4618.35,Other,225% New York Medicaid APG,5336.75,,,5336.75,Other,260% New York Medicaid APG,6650.42,,,6650.42,Other,324% New York Medicaid APG,4413.09,,,4413.09,Other,215% New York Medicaid APG,4413.09,,,4413.09,Other,215% New York Medicaid APG,2565.75,,,2565.75,Other,125% New York Medicaid APG,2052.6,111352.72,
Incision of knee joint,27435,CPT,,,,,,,,both,,,68082.75,50381.24,74,,50381.24,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30637.24,45,,30637.24,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33700.96,49.5,,33700.96,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3097.27,,,3097.27,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,47657.93,70,,47657.93,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1665.2,,,1665.2,Other,New York Medicaid APG methodology,1665.2,,,1665.2,Other,100% New York Medicaid APG,1665.2,,,1665.2,Other,100% New York Medicaid APG,1665.2,,,1665.2,Other,100% New York Medicaid APG,3746.7,,,3746.7,Other,225% New York Medicaid APG,2547.75,,,2547.75,Other,153% New York Medicaid APG,3746.7,,,3746.7,Other,225% New York Medicaid APG,2331.28,,,2331.28,Other,140% New York Medicaid APG,3746.7,,,3746.7,Other,225% New York Medicaid APG,4329.52,,,4329.52,Other,260% New York Medicaid APG,5395.24,,,5395.24,Other,324% New York Medicaid APG,3580.18,,,3580.18,Other,215% New York Medicaid APG,3580.18,,,3580.18,Other,215% New York Medicaid APG,2081.5,,,2081.5,Other,125% New York Medicaid APG,1665.2,50381.24,
Revise kneecap,27437,CPT,,,,,,,,both,,,150476.65,111352.72,74,,111352.72,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,67714.49,45,,67714.49,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,74485.94,49.5,,74485.94,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5218.57,,,5218.57,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,105333.66,70,,105333.66,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,2805.68,,,2805.68,Other,New York Medicaid APG methodology,2805.68,,,2805.68,Other,100% New York Medicaid APG,2805.68,,,2805.68,Other,100% New York Medicaid APG,2805.68,,,2805.68,Other,100% New York Medicaid APG,6312.79,,,6312.79,Other,225% New York Medicaid APG,4292.7,,,4292.7,Other,153% New York Medicaid APG,6312.79,,,6312.79,Other,225% New York Medicaid APG,3927.96,,,3927.96,Other,140% New York Medicaid APG,6312.79,,,6312.79,Other,225% New York Medicaid APG,7294.78,,,7294.78,Other,260% New York Medicaid APG,9090.42,,,9090.42,Other,324% New York Medicaid APG,6032.22,,,6032.22,Other,215% New York Medicaid APG,6032.22,,,6032.22,Other,215% New York Medicaid APG,3507.11,,,3507.11,Other,125% New York Medicaid APG,2805.68,111352.72,
Revise kneecap with implant,27438,CPT,,,,,,,,both,,,46878.57,34690.14,74,,34690.14,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,21095.36,45,,21095.36,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,23204.89,49.5,,23204.89,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5965.25,,,5965.25,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,32815,70,,32815,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,3207.13,,,3207.13,Other,New York Medicaid APG methodology,3207.13,,,3207.13,Other,100% New York Medicaid APG,3207.13,,,3207.13,Other,100% New York Medicaid APG,3207.13,,,3207.13,Other,100% New York Medicaid APG,7216.03,,,7216.03,Other,225% New York Medicaid APG,4906.9,,,4906.9,Other,153% New York Medicaid APG,7216.03,,,7216.03,Other,225% New York Medicaid APG,4489.98,,,4489.98,Other,140% New York Medicaid APG,7216.03,,,7216.03,Other,225% New York Medicaid APG,8338.53,,,8338.53,Other,260% New York Medicaid APG,10391.09,,,10391.09,Other,324% New York Medicaid APG,6895.32,,,6895.32,Other,215% New York Medicaid APG,6895.32,,,6895.32,Other,215% New York Medicaid APG,4008.91,,,4008.91,Other,125% New York Medicaid APG,3207.13,34690.14,
Revision of knee joint,27440,CPT,,,,,,,,both,,,276827.87,204852.62,74,,204852.62,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,124572.54,45,,124572.54,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,137029.8,49.5,,137029.8,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5965.25,,,5965.25,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,193779.51,70,,193779.51,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,3207.13,,,3207.13,Other,New York Medicaid APG methodology,3207.13,,,3207.13,Other,100% New York Medicaid APG,3207.13,,,3207.13,Other,100% New York Medicaid APG,3207.13,,,3207.13,Other,100% New York Medicaid APG,7216.03,,,7216.03,Other,225% New York Medicaid APG,4906.9,,,4906.9,Other,153% New York Medicaid APG,7216.03,,,7216.03,Other,225% New York Medicaid APG,4489.98,,,4489.98,Other,140% New York Medicaid APG,7216.03,,,7216.03,Other,225% New York Medicaid APG,8338.53,,,8338.53,Other,260% New York Medicaid APG,10391.09,,,10391.09,Other,324% New York Medicaid APG,6895.32,,,6895.32,Other,215% New York Medicaid APG,6895.32,,,6895.32,Other,215% New York Medicaid APG,4008.91,,,4008.91,Other,125% New York Medicaid APG,3207.13,204852.62,
Revision of knee joint,27441,CPT,,,,,,,,both,,,276827.87,204852.62,74,,204852.62,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,124572.54,45,,124572.54,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,137029.8,49.5,,137029.8,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5965.25,,,5965.25,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,193779.51,70,,193779.51,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,3207.13,,,3207.13,Other,New York Medicaid APG methodology,3207.13,,,3207.13,Other,100% New York Medicaid APG,3207.13,,,3207.13,Other,100% New York Medicaid APG,3207.13,,,3207.13,Other,100% New York Medicaid APG,7216.03,,,7216.03,Other,225% New York Medicaid APG,4906.9,,,4906.9,Other,153% New York Medicaid APG,7216.03,,,7216.03,Other,225% New York Medicaid APG,4489.98,,,4489.98,Other,140% New York Medicaid APG,7216.03,,,7216.03,Other,225% New York Medicaid APG,8338.53,,,8338.53,Other,260% New York Medicaid APG,10391.09,,,10391.09,Other,324% New York Medicaid APG,6895.32,,,6895.32,Other,215% New York Medicaid APG,6895.32,,,6895.32,Other,215% New York Medicaid APG,4008.91,,,4008.91,Other,125% New York Medicaid APG,3207.13,204852.62,
Revision of knee joint,27442,CPT,,,,,,,,both,,,276827.87,204852.62,74,,204852.62,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,124572.54,45,,124572.54,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,137029.8,49.5,,137029.8,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5965.25,,,5965.25,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,193779.51,70,,193779.51,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,3207.13,,,3207.13,Other,New York Medicaid APG methodology,3207.13,,,3207.13,Other,100% New York Medicaid APG,3207.13,,,3207.13,Other,100% New York Medicaid APG,3207.13,,,3207.13,Other,100% New York Medicaid APG,7216.03,,,7216.03,Other,225% New York Medicaid APG,4906.9,,,4906.9,Other,153% New York Medicaid APG,7216.03,,,7216.03,Other,225% New York Medicaid APG,4489.98,,,4489.98,Other,140% New York Medicaid APG,7216.03,,,7216.03,Other,225% New York Medicaid APG,8338.53,,,8338.53,Other,260% New York Medicaid APG,10391.09,,,10391.09,Other,324% New York Medicaid APG,6895.32,,,6895.32,Other,215% New York Medicaid APG,6895.32,,,6895.32,Other,215% New York Medicaid APG,4008.91,,,4008.91,Other,125% New York Medicaid APG,3207.13,204852.62,
Revision of knee joint,27443,CPT,,,,,,,,both,,,276827.87,204852.62,74,,204852.62,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,124572.54,45,,124572.54,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,137029.8,49.5,,137029.8,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5965.25,,,5965.25,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,193779.51,70,,193779.51,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,3207.13,,,3207.13,Other,New York Medicaid APG methodology,3207.13,,,3207.13,Other,100% New York Medicaid APG,3207.13,,,3207.13,Other,100% New York Medicaid APG,3207.13,,,3207.13,Other,100% New York Medicaid APG,7216.03,,,7216.03,Other,225% New York Medicaid APG,4906.9,,,4906.9,Other,153% New York Medicaid APG,7216.03,,,7216.03,Other,225% New York Medicaid APG,4489.98,,,4489.98,Other,140% New York Medicaid APG,7216.03,,,7216.03,Other,225% New York Medicaid APG,8338.53,,,8338.53,Other,260% New York Medicaid APG,10391.09,,,10391.09,Other,324% New York Medicaid APG,6895.32,,,6895.32,Other,215% New York Medicaid APG,6895.32,,,6895.32,Other,215% New York Medicaid APG,4008.91,,,4008.91,Other,125% New York Medicaid APG,3207.13,204852.62,
Revision of knee joint,27446,CPT,,,,,,,,both,,,77786.36,57561.91,74,,57561.91,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,35003.86,45,,35003.86,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,38504.25,49.5,,38504.25,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5965.25,,,5965.25,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9196,,"100% primary, 0% secondary procedures",9196,Other,MagnaCare ASC Grouper,54450.45,70,,54450.45,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6956,,"100% primary, 50% secondary, 25% tertiary procedure",6956,Other,United Healthcare ASC Grouper,6261,,"100% primary, 50% secondary, 25% tertiary procedure",6261,Other,United Healthcare ASC Grouper,6956,,"100% primary, 50% secondary, 25% tertiary procedure",6956,Other,United Healthcare ASC Grouper,5913,,"100% primary, 50% secondary, 25% tertiary procedure",5913,Other,United Healthcare ASC Grouper,3207.13,,,3207.13,Other,New York Medicaid APG methodology,3207.13,,,3207.13,Other,100% New York Medicaid APG,3207.13,,,3207.13,Other,100% New York Medicaid APG,3207.13,,,3207.13,Other,100% New York Medicaid APG,7216.03,,,7216.03,Other,225% New York Medicaid APG,4906.9,,,4906.9,Other,153% New York Medicaid APG,7216.03,,,7216.03,Other,225% New York Medicaid APG,4489.98,,,4489.98,Other,140% New York Medicaid APG,7216.03,,,7216.03,Other,225% New York Medicaid APG,8338.53,,,8338.53,Other,260% New York Medicaid APG,10391.09,,,10391.09,Other,324% New York Medicaid APG,6895.32,,,6895.32,Other,215% New York Medicaid APG,6895.32,,,6895.32,Other,215% New York Medicaid APG,4008.91,,,4008.91,Other,125% New York Medicaid APG,3207.13,57561.91,
Total knee arthroplasty,27447,CPT,,,,,,,,both,,,86226.6,63807.68,74,,63807.68,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,38801.97,45,,38801.97,percent of total billed charges,Medicare Ratio of cost to charges,5459,,"100% primary, 50% supplemental procedure",5459,Other,Aetna ASC Grouper,4913,,"100% primary, 50% supplemental procedure",4913,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,42682.17,49.5,,42682.17,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5965.25,,,5965.25,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9196,,"100% primary, 0% secondary procedures",9196,Other,MagnaCare ASC Grouper,60358.62,70,,60358.62,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6956,,"100% primary, 50% secondary, 25% tertiary procedure",6956,Other,United Healthcare ASC Grouper,6261,,"100% primary, 50% secondary, 25% tertiary procedure",6261,Other,United Healthcare ASC Grouper,6956,,"100% primary, 50% secondary, 25% tertiary procedure",6956,Other,United Healthcare ASC Grouper,5913,,"100% primary, 50% secondary, 25% tertiary procedure",5913,Other,United Healthcare ASC Grouper,3207.13,,,3207.13,Other,New York Medicaid APG methodology,3207.13,,,3207.13,Other,100% New York Medicaid APG,3207.13,,,3207.13,Other,100% New York Medicaid APG,3207.13,,,3207.13,Other,100% New York Medicaid APG,7216.03,,,7216.03,Other,225% New York Medicaid APG,4906.9,,,4906.9,Other,153% New York Medicaid APG,7216.03,,,7216.03,Other,225% New York Medicaid APG,4489.98,,,4489.98,Other,140% New York Medicaid APG,7216.03,,,7216.03,Other,225% New York Medicaid APG,8338.53,,,8338.53,Other,260% New York Medicaid APG,10391.09,,,10391.09,Other,324% New York Medicaid APG,6895.32,,,6895.32,Other,215% New York Medicaid APG,6895.32,,,6895.32,Other,215% New York Medicaid APG,4008.91,,,4008.91,Other,125% New York Medicaid APG,3207.13,63807.68,
Surgery to stop leg growth,27475,CPT,,,,,,,,both,,,38859.59,28756.1,74,,28756.1,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,17486.82,45,,17486.82,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,19235.5,49.5,,19235.5,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3817.83,,,3817.83,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,27201.71,70,,27201.71,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,2052.6,,,2052.6,Other,New York Medicaid APG methodology,2052.6,,,2052.6,Other,100% New York Medicaid APG,2052.6,,,2052.6,Other,100% New York Medicaid APG,2052.6,,,2052.6,Other,100% New York Medicaid APG,4618.35,,,4618.35,Other,225% New York Medicaid APG,3140.47,,,3140.47,Other,153% New York Medicaid APG,4618.35,,,4618.35,Other,225% New York Medicaid APG,2873.64,,,2873.64,Other,140% New York Medicaid APG,4618.35,,,4618.35,Other,225% New York Medicaid APG,5336.75,,,5336.75,Other,260% New York Medicaid APG,6650.42,,,6650.42,Other,324% New York Medicaid APG,4413.09,,,4413.09,Other,215% New York Medicaid APG,4413.09,,,4413.09,Other,215% New York Medicaid APG,2565.75,,,2565.75,Other,125% New York Medicaid APG,2052.6,28756.1,
Surgery to stop leg growth,27477,CPT,,,,,,,,both,,,150476.65,111352.72,74,,111352.72,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,67714.49,45,,67714.49,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,74485.94,49.5,,74485.94,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3097.27,,,3097.27,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,105333.66,70,,105333.66,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1665.2,,,1665.2,Other,New York Medicaid APG methodology,1665.2,,,1665.2,Other,100% New York Medicaid APG,1665.2,,,1665.2,Other,100% New York Medicaid APG,1665.2,,,1665.2,Other,100% New York Medicaid APG,3746.7,,,3746.7,Other,225% New York Medicaid APG,2547.75,,,2547.75,Other,153% New York Medicaid APG,3746.7,,,3746.7,Other,225% New York Medicaid APG,2331.28,,,2331.28,Other,140% New York Medicaid APG,3746.7,,,3746.7,Other,225% New York Medicaid APG,4329.52,,,4329.52,Other,260% New York Medicaid APG,5395.24,,,5395.24,Other,324% New York Medicaid APG,3580.18,,,3580.18,Other,215% New York Medicaid APG,3580.18,,,3580.18,Other,215% New York Medicaid APG,2081.5,,,2081.5,Other,125% New York Medicaid APG,1665.2,111352.72,
Surgery to stop leg growth,27479,CPT,,,,,,,,both,,,39487.52,29220.76,74,,29220.76,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,17769.38,45,,17769.38,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,19546.32,49.5,,19546.32,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3502.03,,,3502.03,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,27641.26,70,,27641.26,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1882.81,,,1882.81,Other,New York Medicaid APG methodology,1882.81,,,1882.81,Other,100% New York Medicaid APG,1882.81,,,1882.81,Other,100% New York Medicaid APG,1882.81,,,1882.81,Other,100% New York Medicaid APG,4236.33,,,4236.33,Other,225% New York Medicaid APG,2880.7,,,2880.7,Other,153% New York Medicaid APG,4236.33,,,4236.33,Other,225% New York Medicaid APG,2635.94,,,2635.94,Other,140% New York Medicaid APG,4236.33,,,4236.33,Other,225% New York Medicaid APG,4895.31,,,4895.31,Other,260% New York Medicaid APG,6100.32,,,6100.32,Other,324% New York Medicaid APG,4048.05,,,4048.05,Other,215% New York Medicaid APG,4048.05,,,4048.05,Other,215% New York Medicaid APG,2353.52,,,2353.52,Other,125% New York Medicaid APG,1882.81,29220.76,
Surgery to stop leg growth,27485,CPT,,,,,,,,both,,,63947.43,47321.1,74,,47321.1,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,28776.34,45,,28776.34,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,31653.98,49.5,,31653.98,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3097.27,,,3097.27,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,44763.2,70,,44763.2,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1665.2,,,1665.2,Other,New York Medicaid APG methodology,1665.2,,,1665.2,Other,100% New York Medicaid APG,1665.2,,,1665.2,Other,100% New York Medicaid APG,1665.2,,,1665.2,Other,100% New York Medicaid APG,3746.7,,,3746.7,Other,225% New York Medicaid APG,2547.75,,,2547.75,Other,153% New York Medicaid APG,3746.7,,,3746.7,Other,225% New York Medicaid APG,2331.28,,,2331.28,Other,140% New York Medicaid APG,3746.7,,,3746.7,Other,225% New York Medicaid APG,4329.52,,,4329.52,Other,260% New York Medicaid APG,5395.24,,,5395.24,Other,324% New York Medicaid APG,3580.18,,,3580.18,Other,215% New York Medicaid APG,3580.18,,,3580.18,Other,215% New York Medicaid APG,2081.5,,,2081.5,Other,125% New York Medicaid APG,1665.2,47321.1,
Decompression of thigh/knee,27496,CPT,,,,,,,,both,,,68082.75,50381.24,74,,50381.24,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30637.24,45,,30637.24,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33700.96,49.5,,33700.96,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3817.83,,,3817.83,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,47657.93,70,,47657.93,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,2052.6,,,2052.6,Other,New York Medicaid APG methodology,2052.6,,,2052.6,Other,100% New York Medicaid APG,2052.6,,,2052.6,Other,100% New York Medicaid APG,2052.6,,,2052.6,Other,100% New York Medicaid APG,4618.35,,,4618.35,Other,225% New York Medicaid APG,3140.47,,,3140.47,Other,153% New York Medicaid APG,4618.35,,,4618.35,Other,225% New York Medicaid APG,2873.64,,,2873.64,Other,140% New York Medicaid APG,4618.35,,,4618.35,Other,225% New York Medicaid APG,5336.75,,,5336.75,Other,260% New York Medicaid APG,6650.42,,,6650.42,Other,324% New York Medicaid APG,4413.09,,,4413.09,Other,215% New York Medicaid APG,4413.09,,,4413.09,Other,215% New York Medicaid APG,2565.75,,,2565.75,Other,125% New York Medicaid APG,2052.6,50381.24,
Decompression of thigh/knee,27497,CPT,,,,,,,,both,,,68082.75,50381.24,74,,50381.24,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30637.24,45,,30637.24,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33700.96,49.5,,33700.96,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3097.27,,,3097.27,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,47657.93,70,,47657.93,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1665.2,,,1665.2,Other,New York Medicaid APG methodology,1665.2,,,1665.2,Other,100% New York Medicaid APG,1665.2,,,1665.2,Other,100% New York Medicaid APG,1665.2,,,1665.2,Other,100% New York Medicaid APG,3746.7,,,3746.7,Other,225% New York Medicaid APG,2547.75,,,2547.75,Other,153% New York Medicaid APG,3746.7,,,3746.7,Other,225% New York Medicaid APG,2331.28,,,2331.28,Other,140% New York Medicaid APG,3746.7,,,3746.7,Other,225% New York Medicaid APG,4329.52,,,4329.52,Other,260% New York Medicaid APG,5395.24,,,5395.24,Other,324% New York Medicaid APG,3580.18,,,3580.18,Other,215% New York Medicaid APG,3580.18,,,3580.18,Other,215% New York Medicaid APG,2081.5,,,2081.5,Other,125% New York Medicaid APG,1665.2,50381.24,
Decompression of thigh/knee,27498,CPT,,,,,,,,both,,,33805.49,25016.06,74,,25016.06,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15212.47,45,,15212.47,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,16733.72,49.5,,16733.72,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3097.27,,,3097.27,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,23663.84,70,,23663.84,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1665.2,,,1665.2,Other,New York Medicaid APG methodology,1665.2,,,1665.2,Other,100% New York Medicaid APG,1665.2,,,1665.2,Other,100% New York Medicaid APG,1665.2,,,1665.2,Other,100% New York Medicaid APG,3746.7,,,3746.7,Other,225% New York Medicaid APG,2547.75,,,2547.75,Other,153% New York Medicaid APG,3746.7,,,3746.7,Other,225% New York Medicaid APG,2331.28,,,2331.28,Other,140% New York Medicaid APG,3746.7,,,3746.7,Other,225% New York Medicaid APG,4329.52,,,4329.52,Other,260% New York Medicaid APG,5395.24,,,5395.24,Other,324% New York Medicaid APG,3580.18,,,3580.18,Other,215% New York Medicaid APG,3580.18,,,3580.18,Other,215% New York Medicaid APG,2081.5,,,2081.5,Other,125% New York Medicaid APG,1665.2,25016.06,
Decompression of thigh/knee,27499,CPT,,,,,,,,both,,,150476.65,111352.72,74,,111352.72,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,67714.49,45,,67714.49,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,74485.94,49.5,,74485.94,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3097.27,,,3097.27,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,105333.66,70,,105333.66,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1665.2,,,1665.2,Other,New York Medicaid APG methodology,1665.2,,,1665.2,Other,100% New York Medicaid APG,1665.2,,,1665.2,Other,100% New York Medicaid APG,1665.2,,,1665.2,Other,100% New York Medicaid APG,3746.7,,,3746.7,Other,225% New York Medicaid APG,2547.75,,,2547.75,Other,153% New York Medicaid APG,3746.7,,,3746.7,Other,225% New York Medicaid APG,2331.28,,,2331.28,Other,140% New York Medicaid APG,3746.7,,,3746.7,Other,225% New York Medicaid APG,4329.52,,,4329.52,Other,260% New York Medicaid APG,5395.24,,,5395.24,Other,324% New York Medicaid APG,3580.18,,,3580.18,Other,215% New York Medicaid APG,3580.18,,,3580.18,Other,215% New York Medicaid APG,2081.5,,,2081.5,Other,125% New York Medicaid APG,1665.2,111352.72,
Treatment of thigh fracture,27500,CPT,,,,,,,,both,,,4960.23,3670.57,74,,3670.57,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,2232.1,45,,2232.1,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,2455.31,49.5,,2455.31,percent of total billed charges,110% of Medicare,3372.96,68,,3372.96,percent of total billed charges,,1031.43,,,1031.43,Other,186% of Medicaid,3968.18,80,,3968.18,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,3968.18,80,,3968.18,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,3472.16,70,,3472.16,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,554.53,,,554.53,Other,New York Medicaid APG methodology,554.53,,,554.53,Other,100% New York Medicaid APG,554.53,,,554.53,Other,100% New York Medicaid APG,554.53,,,554.53,Other,100% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,848.43,,,848.43,Other,153% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,776.34,,,776.34,Other,140% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,1441.78,,,1441.78,Other,260% New York Medicaid APG,1796.68,,,1796.68,Other,324% New York Medicaid APG,1192.24,,,1192.24,Other,215% New York Medicaid APG,1192.24,,,1192.24,Other,215% New York Medicaid APG,693.16,,,693.16,Other,125% New York Medicaid APG,554.53,7216,
Treatment of thigh fracture,27501,CPT,,,,,,,,both,,,4960.23,3670.57,74,,3670.57,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,2232.1,45,,2232.1,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,2455.31,49.5,,2455.31,percent of total billed charges,110% of Medicare,3372.96,68,,3372.96,percent of total billed charges,,1031.43,,,1031.43,Other,186% of Medicaid,3968.18,80,,3968.18,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,3968.18,80,,3968.18,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,3472.16,70,,3472.16,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,554.53,,,554.53,Other,New York Medicaid APG methodology,554.53,,,554.53,Other,100% New York Medicaid APG,554.53,,,554.53,Other,100% New York Medicaid APG,554.53,,,554.53,Other,100% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,848.43,,,848.43,Other,153% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,776.34,,,776.34,Other,140% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,1441.78,,,1441.78,Other,260% New York Medicaid APG,1796.68,,,1796.68,Other,324% New York Medicaid APG,1192.24,,,1192.24,Other,215% New York Medicaid APG,1192.24,,,1192.24,Other,215% New York Medicaid APG,693.16,,,693.16,Other,125% New York Medicaid APG,554.53,7216,
Treatment of thigh fracture,27502,CPT,,,,,,,,both,,,35094.81,25970.16,74,,25970.16,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15792.66,45,,15792.66,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,17371.93,49.5,,17371.93,percent of total billed charges,110% of Medicare,23864.47,68,,23864.47,percent of total billed charges,,1031.43,,,1031.43,Other,186% of Medicaid,28075.85,80,,28075.85,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,28075.85,80,,28075.85,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,24566.37,70,,24566.37,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,554.53,,,554.53,Other,New York Medicaid APG methodology,554.53,,,554.53,Other,100% New York Medicaid APG,554.53,,,554.53,Other,100% New York Medicaid APG,554.53,,,554.53,Other,100% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,848.43,,,848.43,Other,153% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,776.34,,,776.34,Other,140% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,1441.78,,,1441.78,Other,260% New York Medicaid APG,1796.68,,,1796.68,Other,324% New York Medicaid APG,1192.24,,,1192.24,Other,215% New York Medicaid APG,1192.24,,,1192.24,Other,215% New York Medicaid APG,693.16,,,693.16,Other,125% New York Medicaid APG,554.53,28075.85,
Treatment of thigh fracture,27503,CPT,,,,,,,,both,,,33805.49,25016.06,74,,25016.06,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15212.47,45,,15212.47,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,16733.72,49.5,,16733.72,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,1031.43,,,1031.43,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,23663.84,70,,23663.84,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,554.53,,,554.53,Other,New York Medicaid APG methodology,554.53,,,554.53,Other,100% New York Medicaid APG,554.53,,,554.53,Other,100% New York Medicaid APG,554.53,,,554.53,Other,100% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,848.43,,,848.43,Other,153% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,776.34,,,776.34,Other,140% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,1441.78,,,1441.78,Other,260% New York Medicaid APG,1796.68,,,1796.68,Other,324% New York Medicaid APG,1192.24,,,1192.24,Other,215% New York Medicaid APG,1192.24,,,1192.24,Other,215% New York Medicaid APG,693.16,,,693.16,Other,125% New York Medicaid APG,554.53,25016.06,
Treatment of thigh fracture,27508,CPT,,,,,,,,both,,,4960.23,3670.57,74,,3670.57,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,2232.1,45,,2232.1,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,2455.31,49.5,,2455.31,percent of total billed charges,110% of Medicare,3372.96,68,,3372.96,percent of total billed charges,,1031.43,,,1031.43,Other,186% of Medicaid,3968.18,80,,3968.18,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,3968.18,80,,3968.18,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,3472.16,70,,3472.16,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,554.53,,,554.53,Other,New York Medicaid APG methodology,554.53,,,554.53,Other,100% New York Medicaid APG,554.53,,,554.53,Other,100% New York Medicaid APG,554.53,,,554.53,Other,100% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,848.43,,,848.43,Other,153% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,776.34,,,776.34,Other,140% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,1441.78,,,1441.78,Other,260% New York Medicaid APG,1796.68,,,1796.68,Other,324% New York Medicaid APG,1192.24,,,1192.24,Other,215% New York Medicaid APG,1192.24,,,1192.24,Other,215% New York Medicaid APG,693.16,,,693.16,Other,125% New York Medicaid APG,554.53,7216,
Treatment of thigh fracture,27509,CPT,,,,,,,,both,,,150476.65,111352.72,74,,111352.72,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,67714.49,45,,67714.49,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,74485.94,49.5,,74485.94,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5092.5,,,5092.5,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,105333.66,70,,105333.66,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,2737.91,,,2737.91,Other,New York Medicaid APG methodology,2737.91,,,2737.91,Other,100% New York Medicaid APG,2737.91,,,2737.91,Other,100% New York Medicaid APG,2737.91,,,2737.91,Other,100% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,4189,,,4189,Other,153% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,3833.07,,,3833.07,Other,140% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,7118.55,,,7118.55,Other,260% New York Medicaid APG,8870.81,,,8870.81,Other,324% New York Medicaid APG,5886.5,,,5886.5,Other,215% New York Medicaid APG,5886.5,,,5886.5,Other,215% New York Medicaid APG,3422.38,,,3422.38,Other,125% New York Medicaid APG,2737.91,111352.72,
Treatment of thigh fracture,27510,CPT,,,,,,,,both,,,33805.49,25016.06,74,,25016.06,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15212.47,45,,15212.47,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,16733.72,49.5,,16733.72,percent of total billed charges,110% of Medicare,22987.73,68,,22987.73,percent of total billed charges,,1031.43,,,1031.43,Other,186% of Medicaid,27044.39,80,,27044.39,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,27044.39,80,,27044.39,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,23663.84,70,,23663.84,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,554.53,,,554.53,Other,New York Medicaid APG methodology,554.53,,,554.53,Other,100% New York Medicaid APG,554.53,,,554.53,Other,100% New York Medicaid APG,554.53,,,554.53,Other,100% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,848.43,,,848.43,Other,153% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,776.34,,,776.34,Other,140% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,1441.78,,,1441.78,Other,260% New York Medicaid APG,1796.68,,,1796.68,Other,324% New York Medicaid APG,1192.24,,,1192.24,Other,215% New York Medicaid APG,1192.24,,,1192.24,Other,215% New York Medicaid APG,693.16,,,693.16,Other,125% New York Medicaid APG,554.53,27044.39,
Treat thigh fx growth plate,27516,CPT,,,,,,,,both,,,4960.23,3670.57,74,,3670.57,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,2232.1,45,,2232.1,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,2455.31,49.5,,2455.31,percent of total billed charges,110% of Medicare,3372.96,68,,3372.96,percent of total billed charges,,1031.43,,,1031.43,Other,186% of Medicaid,3968.18,80,,3968.18,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,3968.18,80,,3968.18,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,3472.16,70,,3472.16,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,554.53,,,554.53,Other,New York Medicaid APG methodology,554.53,,,554.53,Other,100% New York Medicaid APG,554.53,,,554.53,Other,100% New York Medicaid APG,554.53,,,554.53,Other,100% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,848.43,,,848.43,Other,153% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,776.34,,,776.34,Other,140% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,1441.78,,,1441.78,Other,260% New York Medicaid APG,1796.68,,,1796.68,Other,324% New York Medicaid APG,1192.24,,,1192.24,Other,215% New York Medicaid APG,1192.24,,,1192.24,Other,215% New York Medicaid APG,693.16,,,693.16,Other,125% New York Medicaid APG,554.53,7216,
Treat thigh fx growth plate,27517,CPT,,,,,,,,both,,,33805.49,25016.06,74,,25016.06,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15212.47,45,,15212.47,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,16733.72,49.5,,16733.72,percent of total billed charges,110% of Medicare,22987.73,68,,22987.73,percent of total billed charges,,1031.43,,,1031.43,Other,186% of Medicaid,27044.39,80,,27044.39,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,27044.39,80,,27044.39,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,23663.84,70,,23663.84,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,554.53,,,554.53,Other,New York Medicaid APG methodology,554.53,,,554.53,Other,100% New York Medicaid APG,554.53,,,554.53,Other,100% New York Medicaid APG,554.53,,,554.53,Other,100% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,848.43,,,848.43,Other,153% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,776.34,,,776.34,Other,140% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,1441.78,,,1441.78,Other,260% New York Medicaid APG,1796.68,,,1796.68,Other,324% New York Medicaid APG,1192.24,,,1192.24,Other,215% New York Medicaid APG,1192.24,,,1192.24,Other,215% New York Medicaid APG,693.16,,,693.16,Other,125% New York Medicaid APG,554.53,27044.39,
Treat kneecap fracture,27520,CPT,,,,,,,,both,,,4960.23,3670.57,74,,3670.57,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,2232.1,45,,2232.1,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,2455.31,49.5,,2455.31,percent of total billed charges,110% of Medicare,3372.96,68,,3372.96,percent of total billed charges,,1031.43,,,1031.43,Other,186% of Medicaid,3968.18,80,,3968.18,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,3968.18,80,,3968.18,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,3472.16,70,,3472.16,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,554.53,,,554.53,Other,New York Medicaid APG methodology,554.53,,,554.53,Other,100% New York Medicaid APG,554.53,,,554.53,Other,100% New York Medicaid APG,554.53,,,554.53,Other,100% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,848.43,,,848.43,Other,153% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,776.34,,,776.34,Other,140% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,1441.78,,,1441.78,Other,260% New York Medicaid APG,1796.68,,,1796.68,Other,324% New York Medicaid APG,1192.24,,,1192.24,Other,215% New York Medicaid APG,1192.24,,,1192.24,Other,215% New York Medicaid APG,693.16,,,693.16,Other,125% New York Medicaid APG,554.53,7216,
Treat kneecap fracture,27524,CPT,,,,,,,,both,,,78201.22,57868.9,74,,57868.9,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,35190.55,45,,35190.55,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,38709.6,49.5,,38709.6,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5092.5,,,5092.5,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,54740.85,70,,54740.85,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,2737.91,,,2737.91,Other,New York Medicaid APG methodology,2737.91,,,2737.91,Other,100% New York Medicaid APG,2737.91,,,2737.91,Other,100% New York Medicaid APG,2737.91,,,2737.91,Other,100% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,4189,,,4189,Other,153% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,3833.07,,,3833.07,Other,140% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,7118.55,,,7118.55,Other,260% New York Medicaid APG,8870.81,,,8870.81,Other,324% New York Medicaid APG,5886.5,,,5886.5,Other,215% New York Medicaid APG,5886.5,,,5886.5,Other,215% New York Medicaid APG,3422.38,,,3422.38,Other,125% New York Medicaid APG,2737.91,57868.9,
Treat knee fracture,27530,CPT,,,,,,,,both,,,4960.23,3670.57,74,,3670.57,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,2232.1,45,,2232.1,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,2455.31,49.5,,2455.31,percent of total billed charges,110% of Medicare,3372.96,68,,3372.96,percent of total billed charges,,1031.43,,,1031.43,Other,186% of Medicaid,3968.18,80,,3968.18,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,3968.18,80,,3968.18,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,3472.16,70,,3472.16,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,554.53,,,554.53,Other,New York Medicaid APG methodology,554.53,,,554.53,Other,100% New York Medicaid APG,554.53,,,554.53,Other,100% New York Medicaid APG,554.53,,,554.53,Other,100% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,848.43,,,848.43,Other,153% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,776.34,,,776.34,Other,140% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,1441.78,,,1441.78,Other,260% New York Medicaid APG,1796.68,,,1796.68,Other,324% New York Medicaid APG,1192.24,,,1192.24,Other,215% New York Medicaid APG,1192.24,,,1192.24,Other,215% New York Medicaid APG,693.16,,,693.16,Other,125% New York Medicaid APG,554.53,7216,
Treat knee fracture,27532,CPT,,,,,,,,both,,,39345.83,29115.91,74,,29115.91,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,17705.62,45,,17705.62,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,19476.19,49.5,,19476.19,percent of total billed charges,110% of Medicare,26755.16,68,,26755.16,percent of total billed charges,,1031.43,,,1031.43,Other,186% of Medicaid,31476.66,80,,31476.66,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,31476.66,80,,31476.66,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,27542.08,70,,27542.08,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,554.53,,,554.53,Other,New York Medicaid APG methodology,554.53,,,554.53,Other,100% New York Medicaid APG,554.53,,,554.53,Other,100% New York Medicaid APG,554.53,,,554.53,Other,100% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,848.43,,,848.43,Other,153% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,776.34,,,776.34,Other,140% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,1441.78,,,1441.78,Other,260% New York Medicaid APG,1796.68,,,1796.68,Other,324% New York Medicaid APG,1192.24,,,1192.24,Other,215% New York Medicaid APG,1192.24,,,1192.24,Other,215% New York Medicaid APG,693.16,,,693.16,Other,125% New York Medicaid APG,554.53,31476.66,
Treat knee fracture(s),27538,CPT,,,,,,,,both,,,4960.23,3670.57,74,,3670.57,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,2232.1,45,,2232.1,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,2455.31,49.5,,2455.31,percent of total billed charges,110% of Medicare,3372.96,68,,3372.96,percent of total billed charges,,1031.43,,,1031.43,Other,186% of Medicaid,3968.18,80,,3968.18,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,3968.18,80,,3968.18,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,3472.16,70,,3472.16,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,554.53,,,554.53,Other,New York Medicaid APG methodology,554.53,,,554.53,Other,100% New York Medicaid APG,554.53,,,554.53,Other,100% New York Medicaid APG,554.53,,,554.53,Other,100% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,848.43,,,848.43,Other,153% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,776.34,,,776.34,Other,140% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,1441.78,,,1441.78,Other,260% New York Medicaid APG,1796.68,,,1796.68,Other,324% New York Medicaid APG,1192.24,,,1192.24,Other,215% New York Medicaid APG,1192.24,,,1192.24,Other,215% New York Medicaid APG,693.16,,,693.16,Other,125% New York Medicaid APG,554.53,7216,
Treat knee dislocation,27550,CPT,,,,,,,,both,,,4960.23,3670.57,74,,3670.57,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,2232.1,45,,2232.1,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,2455.31,49.5,,2455.31,percent of total billed charges,110% of Medicare,3372.96,68,,3372.96,percent of total billed charges,,1031.43,,,1031.43,Other,186% of Medicaid,3968.18,80,,3968.18,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,3968.18,80,,3968.18,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,3472.16,70,,3472.16,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,554.53,,,554.53,Other,New York Medicaid APG methodology,554.53,,,554.53,Other,100% New York Medicaid APG,554.53,,,554.53,Other,100% New York Medicaid APG,554.53,,,554.53,Other,100% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,848.43,,,848.43,Other,153% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,776.34,,,776.34,Other,140% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,1441.78,,,1441.78,Other,260% New York Medicaid APG,1796.68,,,1796.68,Other,324% New York Medicaid APG,1192.24,,,1192.24,Other,215% New York Medicaid APG,1192.24,,,1192.24,Other,215% New York Medicaid APG,693.16,,,693.16,Other,125% New York Medicaid APG,554.53,7216,
Treat knee dislocation,27552,CPT,,,,,,,,both,,,33805.49,25016.06,74,,25016.06,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15212.47,45,,15212.47,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,16733.72,49.5,,16733.72,percent of total billed charges,110% of Medicare,22987.73,68,,22987.73,percent of total billed charges,,1730.38,,,1730.38,Other,186% of Medicaid,27044.39,80,,27044.39,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,27044.39,80,,27044.39,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,23663.84,70,,23663.84,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,930.31,,,930.31,Other,New York Medicaid APG methodology,930.31,,,930.31,Other,100% New York Medicaid APG,930.31,,,930.31,Other,100% New York Medicaid APG,930.31,,,930.31,Other,100% New York Medicaid APG,2093.21,,,2093.21,Other,225% New York Medicaid APG,1423.38,,,1423.38,Other,153% New York Medicaid APG,2093.21,,,2093.21,Other,225% New York Medicaid APG,1302.44,,,1302.44,Other,140% New York Medicaid APG,2093.21,,,2093.21,Other,225% New York Medicaid APG,2418.82,,,2418.82,Other,260% New York Medicaid APG,3014.22,,,3014.22,Other,324% New York Medicaid APG,2000.18,,,2000.18,Other,215% New York Medicaid APG,2000.18,,,2000.18,Other,215% New York Medicaid APG,1162.89,,,1162.89,Other,125% New York Medicaid APG,930.31,27044.39,
Treat kneecap dislocation,27560,CPT,,,,,,,,both,,,4960.23,3670.57,74,,3670.57,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,2232.1,45,,2232.1,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,2455.31,49.5,,2455.31,percent of total billed charges,110% of Medicare,3372.96,68,,3372.96,percent of total billed charges,,1031.43,,,1031.43,Other,186% of Medicaid,3968.18,80,,3968.18,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,3968.18,80,,3968.18,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,3472.16,70,,3472.16,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,554.53,,,554.53,Other,New York Medicaid APG methodology,554.53,,,554.53,Other,100% New York Medicaid APG,554.53,,,554.53,Other,100% New York Medicaid APG,554.53,,,554.53,Other,100% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,848.43,,,848.43,Other,153% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,776.34,,,776.34,Other,140% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,1441.78,,,1441.78,Other,260% New York Medicaid APG,1796.68,,,1796.68,Other,324% New York Medicaid APG,1192.24,,,1192.24,Other,215% New York Medicaid APG,1192.24,,,1192.24,Other,215% New York Medicaid APG,693.16,,,693.16,Other,125% New York Medicaid APG,554.53,7216,
Treat kneecap dislocation,27562,CPT,,,,,,,,both,,,4960.23,3670.57,74,,3670.57,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,2232.1,45,,2232.1,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,2455.31,49.5,,2455.31,percent of total billed charges,110% of Medicare,3372.96,68,,3372.96,percent of total billed charges,,1730.38,,,1730.38,Other,186% of Medicaid,3968.18,80,,3968.18,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,3968.18,80,,3968.18,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,3472.16,70,,3472.16,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,930.31,,,930.31,Other,New York Medicaid APG methodology,930.31,,,930.31,Other,100% New York Medicaid APG,930.31,,,930.31,Other,100% New York Medicaid APG,930.31,,,930.31,Other,100% New York Medicaid APG,2093.21,,,2093.21,Other,225% New York Medicaid APG,1423.38,,,1423.38,Other,153% New York Medicaid APG,2093.21,,,2093.21,Other,225% New York Medicaid APG,1302.44,,,1302.44,Other,140% New York Medicaid APG,2093.21,,,2093.21,Other,225% New York Medicaid APG,2418.82,,,2418.82,Other,260% New York Medicaid APG,3014.22,,,3014.22,Other,324% New York Medicaid APG,2000.18,,,2000.18,Other,215% New York Medicaid APG,2000.18,,,2000.18,Other,215% New York Medicaid APG,1162.89,,,1162.89,Other,125% New York Medicaid APG,930.31,7216,
Treat kneecap dislocation,27566,CPT,,,,,,,,both,,,150476.65,111352.72,74,,111352.72,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,67714.49,45,,67714.49,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,74485.94,49.5,,74485.94,percent of total billed charges,110% of Medicare,102324.12,68,,102324.12,percent of total billed charges,,5092.5,,,5092.5,Other,186% of Medicaid,120381.32,80,,120381.32,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,120381.32,80,,120381.32,percent of total billed charges,,7216,,,7216,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,105333.66,70,,105333.66,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,2737.91,,,2737.91,Other,New York Medicaid APG methodology,2737.91,,,2737.91,Other,100% New York Medicaid APG,2737.91,,,2737.91,Other,100% New York Medicaid APG,2737.91,,,2737.91,Other,100% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,4189,,,4189,Other,153% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,3833.07,,,3833.07,Other,140% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,7118.55,,,7118.55,Other,260% New York Medicaid APG,8870.81,,,8870.81,Other,324% New York Medicaid APG,5886.5,,,5886.5,Other,215% New York Medicaid APG,5886.5,,,5886.5,Other,215% New York Medicaid APG,3422.38,,,3422.38,Other,125% New York Medicaid APG,2232,120381.32,
Fixation of knee joint,27570,CPT,,,,,,,,both,,,44434.54,32881.56,74,,32881.56,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,19995.54,45,,19995.54,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,21995.1,49.5,,21995.1,percent of total billed charges,110% of Medicare,30215.49,68,,30215.49,percent of total billed charges,,1730.38,,,1730.38,Other,186% of Medicaid,35547.63,80,,35547.63,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,35547.63,80,,35547.63,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,31104.18,70,,31104.18,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,930.31,,,930.31,Other,New York Medicaid APG methodology,930.31,,,930.31,Other,100% New York Medicaid APG,930.31,,,930.31,Other,100% New York Medicaid APG,930.31,,,930.31,Other,100% New York Medicaid APG,2093.21,,,2093.21,Other,225% New York Medicaid APG,1423.38,,,1423.38,Other,153% New York Medicaid APG,2093.21,,,2093.21,Other,225% New York Medicaid APG,1302.44,,,1302.44,Other,140% New York Medicaid APG,2093.21,,,2093.21,Other,225% New York Medicaid APG,2418.82,,,2418.82,Other,260% New York Medicaid APG,3014.22,,,3014.22,Other,324% New York Medicaid APG,2000.18,,,2000.18,Other,215% New York Medicaid APG,2000.18,,,2000.18,Other,215% New York Medicaid APG,1162.89,,,1162.89,Other,125% New York Medicaid APG,930.31,35547.63,
Amputation follow-up surgery,27594,CPT,,,,,,,,both,,,68082.75,50381.24,74,,50381.24,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30637.24,45,,30637.24,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33700.96,49.5,,33700.96,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3817.83,,,3817.83,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,47657.93,70,,47657.93,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,2052.6,,,2052.6,Other,New York Medicaid APG methodology,2052.6,,,2052.6,Other,100% New York Medicaid APG,2052.6,,,2052.6,Other,100% New York Medicaid APG,2052.6,,,2052.6,Other,100% New York Medicaid APG,4618.35,,,4618.35,Other,225% New York Medicaid APG,3140.47,,,3140.47,Other,153% New York Medicaid APG,4618.35,,,4618.35,Other,225% New York Medicaid APG,2873.64,,,2873.64,Other,140% New York Medicaid APG,4618.35,,,4618.35,Other,225% New York Medicaid APG,5336.75,,,5336.75,Other,260% New York Medicaid APG,6650.42,,,6650.42,Other,324% New York Medicaid APG,4413.09,,,4413.09,Other,215% New York Medicaid APG,4413.09,,,4413.09,Other,215% New York Medicaid APG,2565.75,,,2565.75,Other,125% New York Medicaid APG,2052.6,50381.24,
Decompression of lower leg,27600,CPT,,,,,,,,both,,,68082.75,50381.24,74,,50381.24,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30637.24,45,,30637.24,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33700.96,49.5,,33700.96,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3097.27,,,3097.27,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,47657.93,70,,47657.93,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1665.2,,,1665.2,Other,New York Medicaid APG methodology,1665.2,,,1665.2,Other,100% New York Medicaid APG,1665.2,,,1665.2,Other,100% New York Medicaid APG,1665.2,,,1665.2,Other,100% New York Medicaid APG,3746.7,,,3746.7,Other,225% New York Medicaid APG,2547.75,,,2547.75,Other,153% New York Medicaid APG,3746.7,,,3746.7,Other,225% New York Medicaid APG,2331.28,,,2331.28,Other,140% New York Medicaid APG,3746.7,,,3746.7,Other,225% New York Medicaid APG,4329.52,,,4329.52,Other,260% New York Medicaid APG,5395.24,,,5395.24,Other,324% New York Medicaid APG,3580.18,,,3580.18,Other,215% New York Medicaid APG,3580.18,,,3580.18,Other,215% New York Medicaid APG,2081.5,,,2081.5,Other,125% New York Medicaid APG,1665.2,50381.24,
Decompression of lower leg,27601,CPT,,,,,,,,both,,,68082.75,50381.24,74,,50381.24,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30637.24,45,,30637.24,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33700.96,49.5,,33700.96,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3097.27,,,3097.27,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,47657.93,70,,47657.93,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1665.2,,,1665.2,Other,New York Medicaid APG methodology,1665.2,,,1665.2,Other,100% New York Medicaid APG,1665.2,,,1665.2,Other,100% New York Medicaid APG,1665.2,,,1665.2,Other,100% New York Medicaid APG,3746.7,,,3746.7,Other,225% New York Medicaid APG,2547.75,,,2547.75,Other,153% New York Medicaid APG,3746.7,,,3746.7,Other,225% New York Medicaid APG,2331.28,,,2331.28,Other,140% New York Medicaid APG,3746.7,,,3746.7,Other,225% New York Medicaid APG,4329.52,,,4329.52,Other,260% New York Medicaid APG,5395.24,,,5395.24,Other,324% New York Medicaid APG,3580.18,,,3580.18,Other,215% New York Medicaid APG,3580.18,,,3580.18,Other,215% New York Medicaid APG,2081.5,,,2081.5,Other,125% New York Medicaid APG,1665.2,50381.24,
Decompression of lower leg,27602,CPT,,,,,,,,both,,,38724.79,28656.34,74,,28656.34,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,17426.16,45,,17426.16,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,19168.77,49.5,,19168.77,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3097.27,,,3097.27,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,27107.35,70,,27107.35,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1665.2,,,1665.2,Other,New York Medicaid APG methodology,1665.2,,,1665.2,Other,100% New York Medicaid APG,1665.2,,,1665.2,Other,100% New York Medicaid APG,1665.2,,,1665.2,Other,100% New York Medicaid APG,3746.7,,,3746.7,Other,225% New York Medicaid APG,2547.75,,,2547.75,Other,153% New York Medicaid APG,3746.7,,,3746.7,Other,225% New York Medicaid APG,2331.28,,,2331.28,Other,140% New York Medicaid APG,3746.7,,,3746.7,Other,225% New York Medicaid APG,4329.52,,,4329.52,Other,260% New York Medicaid APG,5395.24,,,5395.24,Other,324% New York Medicaid APG,3580.18,,,3580.18,Other,215% New York Medicaid APG,3580.18,,,3580.18,Other,215% New York Medicaid APG,2081.5,,,2081.5,Other,125% New York Medicaid APG,1665.2,28656.34,
Drain lower leg lesion,27603,CPT,,,,,,,,both,,,59767.2,44227.73,74,,44227.73,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,26895.24,45,,26895.24,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,29584.76,49.5,,29584.76,percent of total billed charges,110% of Medicare,40641.7,68,,40641.7,percent of total billed charges,,1973.06,,,1973.06,Other,186% of Medicaid,47813.76,80,,47813.76,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,47813.76,80,,47813.76,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,41837.04,70,,41837.04,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1060.79,,,1060.79,Other,New York Medicaid APG methodology,1060.79,,,1060.79,Other,100% New York Medicaid APG,1060.79,,,1060.79,Other,100% New York Medicaid APG,1060.79,,,1060.79,Other,100% New York Medicaid APG,2386.77,,,2386.77,Other,225% New York Medicaid APG,1623,,,1623,Other,153% New York Medicaid APG,2386.77,,,2386.77,Other,225% New York Medicaid APG,1485.1,,,1485.1,Other,140% New York Medicaid APG,2386.77,,,2386.77,Other,225% New York Medicaid APG,2758.05,,,2758.05,Other,260% New York Medicaid APG,3436.95,,,3436.95,Other,324% New York Medicaid APG,2280.69,,,2280.69,Other,215% New York Medicaid APG,2280.69,,,2280.69,Other,215% New York Medicaid APG,1325.98,,,1325.98,Other,125% New York Medicaid APG,1060.79,47813.76,
Drain lower leg bursa,27604,CPT,,,,,,,,both,,,68082.75,50381.24,74,,50381.24,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30637.24,45,,30637.24,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33700.96,49.5,,33700.96,percent of total billed charges,110% of Medicare,46296.27,68,,46296.27,percent of total billed charges,,3097.27,,,3097.27,Other,186% of Medicaid,54466.2,80,,54466.2,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,54466.2,80,,54466.2,percent of total billed charges,,7216,,,7216,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,47657.93,70,,47657.93,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1665.2,,,1665.2,Other,New York Medicaid APG methodology,1665.2,,,1665.2,Other,100% New York Medicaid APG,1665.2,,,1665.2,Other,100% New York Medicaid APG,1665.2,,,1665.2,Other,100% New York Medicaid APG,3746.7,,,3746.7,Other,225% New York Medicaid APG,2547.75,,,2547.75,Other,153% New York Medicaid APG,3746.7,,,3746.7,Other,225% New York Medicaid APG,2331.28,,,2331.28,Other,140% New York Medicaid APG,3746.7,,,3746.7,Other,225% New York Medicaid APG,4329.52,,,4329.52,Other,260% New York Medicaid APG,5395.24,,,5395.24,Other,324% New York Medicaid APG,3580.18,,,3580.18,Other,215% New York Medicaid APG,3580.18,,,3580.18,Other,215% New York Medicaid APG,2081.5,,,2081.5,Other,125% New York Medicaid APG,1665.2,54466.2,
Incision of achilles tendon,27605,CPT,,,,,,,,both,,,33805.49,25016.06,74,,25016.06,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15212.47,45,,15212.47,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,16733.72,49.5,,16733.72,percent of total billed charges,110% of Medicare,22987.73,68,,22987.73,percent of total billed charges,,2891.15,,,2891.15,Other,186% of Medicaid,27044.39,80,,27044.39,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,27044.39,80,,27044.39,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,23663.84,70,,23663.84,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1554.38,,,1554.38,Other,New York Medicaid APG methodology,1554.38,,,1554.38,Other,100% New York Medicaid APG,1554.38,,,1554.38,Other,100% New York Medicaid APG,1554.38,,,1554.38,Other,100% New York Medicaid APG,3497.36,,,3497.36,Other,225% New York Medicaid APG,2378.21,,,2378.21,Other,153% New York Medicaid APG,3497.36,,,3497.36,Other,225% New York Medicaid APG,2176.14,,,2176.14,Other,140% New York Medicaid APG,3497.36,,,3497.36,Other,225% New York Medicaid APG,4041.4,,,4041.4,Other,260% New York Medicaid APG,5036.2,,,5036.2,Other,324% New York Medicaid APG,3341.93,,,3341.93,Other,215% New York Medicaid APG,3341.93,,,3341.93,Other,215% New York Medicaid APG,1942.98,,,1942.98,Other,125% New York Medicaid APG,1554.38,27044.39,
Incision of achilles tendon,27606,CPT,,,,,,,,both,,,33463.8,24763.21,74,,24763.21,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15058.71,45,,15058.71,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,16564.58,49.5,,16564.58,percent of total billed charges,110% of Medicare,22755.38,68,,22755.38,percent of total billed charges,,3097.27,,,3097.27,Other,186% of Medicaid,26771.04,80,,26771.04,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,26771.04,80,,26771.04,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,23424.66,70,,23424.66,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1665.2,,,1665.2,Other,New York Medicaid APG methodology,1665.2,,,1665.2,Other,100% New York Medicaid APG,1665.2,,,1665.2,Other,100% New York Medicaid APG,1665.2,,,1665.2,Other,100% New York Medicaid APG,3746.7,,,3746.7,Other,225% New York Medicaid APG,2547.75,,,2547.75,Other,153% New York Medicaid APG,3746.7,,,3746.7,Other,225% New York Medicaid APG,2331.28,,,2331.28,Other,140% New York Medicaid APG,3746.7,,,3746.7,Other,225% New York Medicaid APG,4329.52,,,4329.52,Other,260% New York Medicaid APG,5395.24,,,5395.24,Other,324% New York Medicaid APG,3580.18,,,3580.18,Other,215% New York Medicaid APG,3580.18,,,3580.18,Other,215% New York Medicaid APG,2081.5,,,2081.5,Other,125% New York Medicaid APG,1665.2,26771.04,
Treat lower leg bone lesion,27607,CPT,,,,,,,,both,,,68082.75,50381.24,74,,50381.24,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30637.24,45,,30637.24,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33700.96,49.5,,33700.96,percent of total billed charges,110% of Medicare,46296.27,68,,46296.27,percent of total billed charges,,3097.27,,,3097.27,Other,186% of Medicaid,54466.2,80,,54466.2,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,54466.2,80,,54466.2,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,47657.93,70,,47657.93,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1665.2,,,1665.2,Other,New York Medicaid APG methodology,1665.2,,,1665.2,Other,100% New York Medicaid APG,1665.2,,,1665.2,Other,100% New York Medicaid APG,1665.2,,,1665.2,Other,100% New York Medicaid APG,3746.7,,,3746.7,Other,225% New York Medicaid APG,2547.75,,,2547.75,Other,153% New York Medicaid APG,3746.7,,,3746.7,Other,225% New York Medicaid APG,2331.28,,,2331.28,Other,140% New York Medicaid APG,3746.7,,,3746.7,Other,225% New York Medicaid APG,4329.52,,,4329.52,Other,260% New York Medicaid APG,5395.24,,,5395.24,Other,324% New York Medicaid APG,3580.18,,,3580.18,Other,215% New York Medicaid APG,3580.18,,,3580.18,Other,215% New York Medicaid APG,2081.5,,,2081.5,Other,125% New York Medicaid APG,1665.2,54466.2,
Explore/treat ankle joint,27610,CPT,,,,,,,,both,,,68082.75,50381.24,74,,50381.24,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30637.24,45,,30637.24,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33700.96,49.5,,33700.96,percent of total billed charges,110% of Medicare,46296.27,68,,46296.27,percent of total billed charges,,3097.27,,,3097.27,Other,186% of Medicaid,54466.2,80,,54466.2,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,54466.2,80,,54466.2,percent of total billed charges,,7216,,,7216,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,47657.93,70,,47657.93,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1665.2,,,1665.2,Other,New York Medicaid APG methodology,1665.2,,,1665.2,Other,100% New York Medicaid APG,1665.2,,,1665.2,Other,100% New York Medicaid APG,1665.2,,,1665.2,Other,100% New York Medicaid APG,3746.7,,,3746.7,Other,225% New York Medicaid APG,2547.75,,,2547.75,Other,153% New York Medicaid APG,3746.7,,,3746.7,Other,225% New York Medicaid APG,2331.28,,,2331.28,Other,140% New York Medicaid APG,3746.7,,,3746.7,Other,225% New York Medicaid APG,4329.52,,,4329.52,Other,260% New York Medicaid APG,5395.24,,,5395.24,Other,324% New York Medicaid APG,3580.18,,,3580.18,Other,215% New York Medicaid APG,3580.18,,,3580.18,Other,215% New York Medicaid APG,2081.5,,,2081.5,Other,125% New York Medicaid APG,1665.2,54466.2,
Exploration of ankle joint,27612,CPT,,,,,,,,both,,,69465.45,51404.43,74,,51404.43,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,31259.45,45,,31259.45,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,34385.4,49.5,,34385.4,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3097.27,,,3097.27,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,48625.82,70,,48625.82,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1665.2,,,1665.2,Other,New York Medicaid APG methodology,1665.2,,,1665.2,Other,100% New York Medicaid APG,1665.2,,,1665.2,Other,100% New York Medicaid APG,1665.2,,,1665.2,Other,100% New York Medicaid APG,3746.7,,,3746.7,Other,225% New York Medicaid APG,2547.75,,,2547.75,Other,153% New York Medicaid APG,3746.7,,,3746.7,Other,225% New York Medicaid APG,2331.28,,,2331.28,Other,140% New York Medicaid APG,3746.7,,,3746.7,Other,225% New York Medicaid APG,4329.52,,,4329.52,Other,260% New York Medicaid APG,5395.24,,,5395.24,Other,324% New York Medicaid APG,3580.18,,,3580.18,Other,215% New York Medicaid APG,3580.18,,,3580.18,Other,215% New York Medicaid APG,2081.5,,,2081.5,Other,125% New York Medicaid APG,1665.2,51404.43,
Biopsy lower leg soft tissue,27613,CPT,,,,,,,,both,,,34101.75,25235.3,74,,25235.3,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15345.79,45,,15345.79,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,16880.37,49.5,,16880.37,percent of total billed charges,110% of Medicare,23189.19,68,,23189.19,percent of total billed charges,,1973.06,,,1973.06,Other,186% of Medicaid,27281.4,80,,27281.4,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,27281.4,80,,27281.4,percent of total billed charges,,7216,,,7216,Case Rate,,3578,,"100% primary, 0% secondary procedures",3578,Other,MagnaCare ASC Grouper,23871.23,70,,23871.23,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,1060.79,,,1060.79,Other,New York Medicaid APG methodology,1060.79,,,1060.79,Other,100% New York Medicaid APG,1060.79,,,1060.79,Other,100% New York Medicaid APG,1060.79,,,1060.79,Other,100% New York Medicaid APG,2386.77,,,2386.77,Other,225% New York Medicaid APG,1623,,,1623,Other,153% New York Medicaid APG,2386.77,,,2386.77,Other,225% New York Medicaid APG,1485.1,,,1485.1,Other,140% New York Medicaid APG,2386.77,,,2386.77,Other,225% New York Medicaid APG,2758.05,,,2758.05,Other,260% New York Medicaid APG,3436.95,,,3436.95,Other,324% New York Medicaid APG,2280.69,,,2280.69,Other,215% New York Medicaid APG,2280.69,,,2280.69,Other,215% New York Medicaid APG,1325.98,,,1325.98,Other,125% New York Medicaid APG,1060.79,27281.4,
Biopsy lower leg soft tissue,27614,CPT,,,,,,,,both,,,59767.2,44227.73,74,,44227.73,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,26895.24,45,,26895.24,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,29584.76,49.5,,29584.76,percent of total billed charges,110% of Medicare,40641.7,68,,40641.7,percent of total billed charges,,1973.06,,,1973.06,Other,186% of Medicaid,47813.76,80,,47813.76,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,47813.76,80,,47813.76,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,41837.04,70,,41837.04,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1060.79,,,1060.79,Other,New York Medicaid APG methodology,1060.79,,,1060.79,Other,100% New York Medicaid APG,1060.79,,,1060.79,Other,100% New York Medicaid APG,1060.79,,,1060.79,Other,100% New York Medicaid APG,2386.77,,,2386.77,Other,225% New York Medicaid APG,1623,,,1623,Other,153% New York Medicaid APG,2386.77,,,2386.77,Other,225% New York Medicaid APG,1485.1,,,1485.1,Other,140% New York Medicaid APG,2386.77,,,2386.77,Other,225% New York Medicaid APG,2758.05,,,2758.05,Other,260% New York Medicaid APG,3436.95,,,3436.95,Other,324% New York Medicaid APG,2280.69,,,2280.69,Other,215% New York Medicaid APG,2280.69,,,2280.69,Other,215% New York Medicaid APG,1325.98,,,1325.98,Other,125% New York Medicaid APG,1060.79,47813.76,
Resect leg/ankle tum < 5 cm,27615,CPT,,,,,,,,both,,,59767.2,44227.73,74,,44227.73,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,26895.24,45,,26895.24,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,29584.76,49.5,,29584.76,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,1973.06,,,1973.06,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,41837.04,70,,41837.04,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1060.79,,,1060.79,Other,New York Medicaid APG methodology,1060.79,,,1060.79,Other,100% New York Medicaid APG,1060.79,,,1060.79,Other,100% New York Medicaid APG,1060.79,,,1060.79,Other,100% New York Medicaid APG,2386.77,,,2386.77,Other,225% New York Medicaid APG,1623,,,1623,Other,153% New York Medicaid APG,2386.77,,,2386.77,Other,225% New York Medicaid APG,1485.1,,,1485.1,Other,140% New York Medicaid APG,2386.77,,,2386.77,Other,225% New York Medicaid APG,2758.05,,,2758.05,Other,260% New York Medicaid APG,3436.95,,,3436.95,Other,324% New York Medicaid APG,2280.69,,,2280.69,Other,215% New York Medicaid APG,2280.69,,,2280.69,Other,215% New York Medicaid APG,1325.98,,,1325.98,Other,125% New York Medicaid APG,1060.79,44227.73,
Resect leg/ankle tum 5 cm/>,27616,CPT,,,,,,,,both,,,59767.2,44227.73,74,,44227.73,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,26895.24,45,,26895.24,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,29584.76,49.5,,29584.76,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,1973.06,,,1973.06,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,41837.04,70,,41837.04,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1060.79,,,1060.79,Other,New York Medicaid APG methodology,1060.79,,,1060.79,Other,100% New York Medicaid APG,1060.79,,,1060.79,Other,100% New York Medicaid APG,1060.79,,,1060.79,Other,100% New York Medicaid APG,2386.77,,,2386.77,Other,225% New York Medicaid APG,1623,,,1623,Other,153% New York Medicaid APG,2386.77,,,2386.77,Other,225% New York Medicaid APG,1485.1,,,1485.1,Other,140% New York Medicaid APG,2386.77,,,2386.77,Other,225% New York Medicaid APG,2758.05,,,2758.05,Other,260% New York Medicaid APG,3436.95,,,3436.95,Other,324% New York Medicaid APG,2280.69,,,2280.69,Other,215% New York Medicaid APG,2280.69,,,2280.69,Other,215% New York Medicaid APG,1325.98,,,1325.98,Other,125% New York Medicaid APG,1060.79,44227.73,
Exc leg/ankle tum < 3 cm,27618,CPT,,,,,,,,both,,,34747.3,25713,74,,25713,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15636.29,45,,15636.29,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,17199.91,49.5,,17199.91,percent of total billed charges,110% of Medicare,23628.16,68,,23628.16,percent of total billed charges,,1973.06,,,1973.06,Other,186% of Medicaid,27797.84,80,,27797.84,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,27797.84,80,,27797.84,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,24323.11,70,,24323.11,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1060.79,,,1060.79,Other,New York Medicaid APG methodology,1060.79,,,1060.79,Other,100% New York Medicaid APG,1060.79,,,1060.79,Other,100% New York Medicaid APG,1060.79,,,1060.79,Other,100% New York Medicaid APG,2386.77,,,2386.77,Other,225% New York Medicaid APG,1623,,,1623,Other,153% New York Medicaid APG,2386.77,,,2386.77,Other,225% New York Medicaid APG,1485.1,,,1485.1,Other,140% New York Medicaid APG,2386.77,,,2386.77,Other,225% New York Medicaid APG,2758.05,,,2758.05,Other,260% New York Medicaid APG,3436.95,,,3436.95,Other,324% New York Medicaid APG,2280.69,,,2280.69,Other,215% New York Medicaid APG,2280.69,,,2280.69,Other,215% New York Medicaid APG,1325.98,,,1325.98,Other,125% New York Medicaid APG,1060.79,27797.84,
Exc leg/ankle tum deep <5 cm,27619,CPT,,,,,,,,both,,,42722.51,31614.66,74,,31614.66,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,19225.13,45,,19225.13,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,21147.64,49.5,,21147.64,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,1973.06,,,1973.06,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,29905.76,70,,29905.76,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1060.79,,,1060.79,Other,New York Medicaid APG methodology,1060.79,,,1060.79,Other,100% New York Medicaid APG,1060.79,,,1060.79,Other,100% New York Medicaid APG,1060.79,,,1060.79,Other,100% New York Medicaid APG,2386.77,,,2386.77,Other,225% New York Medicaid APG,1623,,,1623,Other,153% New York Medicaid APG,2386.77,,,2386.77,Other,225% New York Medicaid APG,1485.1,,,1485.1,Other,140% New York Medicaid APG,2386.77,,,2386.77,Other,225% New York Medicaid APG,2758.05,,,2758.05,Other,260% New York Medicaid APG,3436.95,,,3436.95,Other,324% New York Medicaid APG,2280.69,,,2280.69,Other,215% New York Medicaid APG,2280.69,,,2280.69,Other,215% New York Medicaid APG,1325.98,,,1325.98,Other,125% New York Medicaid APG,1060.79,31614.66,
Explore/treat ankle joint,27620,CPT,,,,,,,,both,,,68082.75,50381.24,74,,50381.24,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30637.24,45,,30637.24,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33700.96,49.5,,33700.96,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3097.27,,,3097.27,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,47657.93,70,,47657.93,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1665.2,,,1665.2,Other,New York Medicaid APG methodology,1665.2,,,1665.2,Other,100% New York Medicaid APG,1665.2,,,1665.2,Other,100% New York Medicaid APG,1665.2,,,1665.2,Other,100% New York Medicaid APG,3746.7,,,3746.7,Other,225% New York Medicaid APG,2547.75,,,2547.75,Other,153% New York Medicaid APG,3746.7,,,3746.7,Other,225% New York Medicaid APG,2331.28,,,2331.28,Other,140% New York Medicaid APG,3746.7,,,3746.7,Other,225% New York Medicaid APG,4329.52,,,4329.52,Other,260% New York Medicaid APG,5395.24,,,5395.24,Other,324% New York Medicaid APG,3580.18,,,3580.18,Other,215% New York Medicaid APG,3580.18,,,3580.18,Other,215% New York Medicaid APG,2081.5,,,2081.5,Other,125% New York Medicaid APG,1665.2,50381.24,
Remove ankle joint lining,27625,CPT,,,,,,,,both,,,121665.15,90032.21,74,,90032.21,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,54749.32,45,,54749.32,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,60224.25,49.5,,60224.25,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3097.27,,,3097.27,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,85165.61,70,,85165.61,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1665.2,,,1665.2,Other,New York Medicaid APG methodology,1665.2,,,1665.2,Other,100% New York Medicaid APG,1665.2,,,1665.2,Other,100% New York Medicaid APG,1665.2,,,1665.2,Other,100% New York Medicaid APG,3746.7,,,3746.7,Other,225% New York Medicaid APG,2547.75,,,2547.75,Other,153% New York Medicaid APG,3746.7,,,3746.7,Other,225% New York Medicaid APG,2331.28,,,2331.28,Other,140% New York Medicaid APG,3746.7,,,3746.7,Other,225% New York Medicaid APG,4329.52,,,4329.52,Other,260% New York Medicaid APG,5395.24,,,5395.24,Other,324% New York Medicaid APG,3580.18,,,3580.18,Other,215% New York Medicaid APG,3580.18,,,3580.18,Other,215% New York Medicaid APG,2081.5,,,2081.5,Other,125% New York Medicaid APG,1665.2,90032.21,
Remove ankle joint lining,27626,CPT,,,,,,,,both,,,68082.75,50381.24,74,,50381.24,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30637.24,45,,30637.24,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33700.96,49.5,,33700.96,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3097.27,,,3097.27,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,47657.93,70,,47657.93,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1665.2,,,1665.2,Other,New York Medicaid APG methodology,1665.2,,,1665.2,Other,100% New York Medicaid APG,1665.2,,,1665.2,Other,100% New York Medicaid APG,1665.2,,,1665.2,Other,100% New York Medicaid APG,3746.7,,,3746.7,Other,225% New York Medicaid APG,2547.75,,,2547.75,Other,153% New York Medicaid APG,3746.7,,,3746.7,Other,225% New York Medicaid APG,2331.28,,,2331.28,Other,140% New York Medicaid APG,3746.7,,,3746.7,Other,225% New York Medicaid APG,4329.52,,,4329.52,Other,260% New York Medicaid APG,5395.24,,,5395.24,Other,324% New York Medicaid APG,3580.18,,,3580.18,Other,215% New York Medicaid APG,3580.18,,,3580.18,Other,215% New York Medicaid APG,2081.5,,,2081.5,Other,125% New York Medicaid APG,1665.2,50381.24,
Removal of tendon lesion,27630,CPT,,,,,,,,both,,,35493.32,26265.06,74,,26265.06,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15971.99,45,,15971.99,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,17569.19,49.5,,17569.19,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3097.27,,,3097.27,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,24845.32,70,,24845.32,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1665.2,,,1665.2,Other,New York Medicaid APG methodology,1665.2,,,1665.2,Other,100% New York Medicaid APG,1665.2,,,1665.2,Other,100% New York Medicaid APG,1665.2,,,1665.2,Other,100% New York Medicaid APG,3746.7,,,3746.7,Other,225% New York Medicaid APG,2547.75,,,2547.75,Other,153% New York Medicaid APG,3746.7,,,3746.7,Other,225% New York Medicaid APG,2331.28,,,2331.28,Other,140% New York Medicaid APG,3746.7,,,3746.7,Other,225% New York Medicaid APG,4329.52,,,4329.52,Other,260% New York Medicaid APG,5395.24,,,5395.24,Other,324% New York Medicaid APG,3580.18,,,3580.18,Other,215% New York Medicaid APG,3580.18,,,3580.18,Other,215% New York Medicaid APG,2081.5,,,2081.5,Other,125% New York Medicaid APG,1665.2,26265.06,
Exc leg/ankle les sc 3 cm/>,27632,CPT,,,,,,,,both,,,59767.2,44227.73,74,,44227.73,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,26895.24,45,,26895.24,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,29584.76,49.5,,29584.76,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3097.27,,,3097.27,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,41837.04,70,,41837.04,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1665.2,,,1665.2,Other,New York Medicaid APG methodology,1665.2,,,1665.2,Other,100% New York Medicaid APG,1665.2,,,1665.2,Other,100% New York Medicaid APG,1665.2,,,1665.2,Other,100% New York Medicaid APG,3746.7,,,3746.7,Other,225% New York Medicaid APG,2547.75,,,2547.75,Other,153% New York Medicaid APG,3746.7,,,3746.7,Other,225% New York Medicaid APG,2331.28,,,2331.28,Other,140% New York Medicaid APG,3746.7,,,3746.7,Other,225% New York Medicaid APG,4329.52,,,4329.52,Other,260% New York Medicaid APG,5395.24,,,5395.24,Other,324% New York Medicaid APG,3580.18,,,3580.18,Other,215% New York Medicaid APG,3580.18,,,3580.18,Other,215% New York Medicaid APG,2081.5,,,2081.5,Other,125% New York Medicaid APG,1665.2,44227.73,
Exc leg/ankle tum dep 5 cm/>,27634,CPT,,,,,,,,both,,,59767.2,44227.73,74,,44227.73,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,26895.24,45,,26895.24,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,29584.76,49.5,,29584.76,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3097.27,,,3097.27,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,41837.04,70,,41837.04,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1665.2,,,1665.2,Other,New York Medicaid APG methodology,1665.2,,,1665.2,Other,100% New York Medicaid APG,1665.2,,,1665.2,Other,100% New York Medicaid APG,1665.2,,,1665.2,Other,100% New York Medicaid APG,3746.7,,,3746.7,Other,225% New York Medicaid APG,2547.75,,,2547.75,Other,153% New York Medicaid APG,3746.7,,,3746.7,Other,225% New York Medicaid APG,2331.28,,,2331.28,Other,140% New York Medicaid APG,3746.7,,,3746.7,Other,225% New York Medicaid APG,4329.52,,,4329.52,Other,260% New York Medicaid APG,5395.24,,,5395.24,Other,324% New York Medicaid APG,3580.18,,,3580.18,Other,215% New York Medicaid APG,3580.18,,,3580.18,Other,215% New York Medicaid APG,2081.5,,,2081.5,Other,125% New York Medicaid APG,1665.2,44227.73,
Remove lower leg bone lesion,27635,CPT,,,,,,,,both,,,68082.75,50381.24,74,,50381.24,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30637.24,45,,30637.24,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33700.96,49.5,,33700.96,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3097.27,,,3097.27,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,47657.93,70,,47657.93,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1665.2,,,1665.2,Other,New York Medicaid APG methodology,1665.2,,,1665.2,Other,100% New York Medicaid APG,1665.2,,,1665.2,Other,100% New York Medicaid APG,1665.2,,,1665.2,Other,100% New York Medicaid APG,3746.7,,,3746.7,Other,225% New York Medicaid APG,2547.75,,,2547.75,Other,153% New York Medicaid APG,3746.7,,,3746.7,Other,225% New York Medicaid APG,2331.28,,,2331.28,Other,140% New York Medicaid APG,3746.7,,,3746.7,Other,225% New York Medicaid APG,4329.52,,,4329.52,Other,260% New York Medicaid APG,5395.24,,,5395.24,Other,324% New York Medicaid APG,3580.18,,,3580.18,Other,215% New York Medicaid APG,3580.18,,,3580.18,Other,215% New York Medicaid APG,2081.5,,,2081.5,Other,125% New York Medicaid APG,1665.2,50381.24,
Remove/graft leg bone lesion,27637,CPT,,,,,,,,both,,,161949.55,119842.67,74,,119842.67,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,72877.3,45,,72877.3,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,80165.03,49.5,,80165.03,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3502.03,,,3502.03,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,113364.69,70,,113364.69,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1882.81,,,1882.81,Other,New York Medicaid APG methodology,1882.81,,,1882.81,Other,100% New York Medicaid APG,1882.81,,,1882.81,Other,100% New York Medicaid APG,1882.81,,,1882.81,Other,100% New York Medicaid APG,4236.33,,,4236.33,Other,225% New York Medicaid APG,2880.7,,,2880.7,Other,153% New York Medicaid APG,4236.33,,,4236.33,Other,225% New York Medicaid APG,2635.94,,,2635.94,Other,140% New York Medicaid APG,4236.33,,,4236.33,Other,225% New York Medicaid APG,4895.31,,,4895.31,Other,260% New York Medicaid APG,6100.32,,,6100.32,Other,324% New York Medicaid APG,4048.05,,,4048.05,Other,215% New York Medicaid APG,4048.05,,,4048.05,Other,215% New York Medicaid APG,2353.52,,,2353.52,Other,125% New York Medicaid APG,1882.81,119842.67,
Remove/graft leg bone lesion,27638,CPT,,,,,,,,both,,,39228.79,29029.3,74,,29029.3,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,17652.96,45,,17652.96,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,19418.25,49.5,,19418.25,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3502.03,,,3502.03,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,27460.15,70,,27460.15,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1882.81,,,1882.81,Other,New York Medicaid APG methodology,1882.81,,,1882.81,Other,100% New York Medicaid APG,1882.81,,,1882.81,Other,100% New York Medicaid APG,1882.81,,,1882.81,Other,100% New York Medicaid APG,4236.33,,,4236.33,Other,225% New York Medicaid APG,2880.7,,,2880.7,Other,153% New York Medicaid APG,4236.33,,,4236.33,Other,225% New York Medicaid APG,2635.94,,,2635.94,Other,140% New York Medicaid APG,4236.33,,,4236.33,Other,225% New York Medicaid APG,4895.31,,,4895.31,Other,260% New York Medicaid APG,6100.32,,,6100.32,Other,324% New York Medicaid APG,4048.05,,,4048.05,Other,215% New York Medicaid APG,4048.05,,,4048.05,Other,215% New York Medicaid APG,2353.52,,,2353.52,Other,125% New York Medicaid APG,1882.81,29029.3,
Partial removal of tibia,27640,CPT,,,,,,,,both,,,43528.56,32211.13,74,,32211.13,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,19587.85,45,,19587.85,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,21546.64,49.5,,21546.64,percent of total billed charges,110% of Medicare,29599.42,68,,29599.42,percent of total billed charges,,3502.03,,,3502.03,Other,186% of Medicaid,34822.85,80,,34822.85,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,34822.85,80,,34822.85,percent of total billed charges,,7216,,,7216,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,30469.99,70,,30469.99,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1882.81,,,1882.81,Other,New York Medicaid APG methodology,1882.81,,,1882.81,Other,100% New York Medicaid APG,1882.81,,,1882.81,Other,100% New York Medicaid APG,1882.81,,,1882.81,Other,100% New York Medicaid APG,4236.33,,,4236.33,Other,225% New York Medicaid APG,2880.7,,,2880.7,Other,153% New York Medicaid APG,4236.33,,,4236.33,Other,225% New York Medicaid APG,2635.94,,,2635.94,Other,140% New York Medicaid APG,4236.33,,,4236.33,Other,225% New York Medicaid APG,4895.31,,,4895.31,Other,260% New York Medicaid APG,6100.32,,,6100.32,Other,324% New York Medicaid APG,4048.05,,,4048.05,Other,215% New York Medicaid APG,4048.05,,,4048.05,Other,215% New York Medicaid APG,2353.52,,,2353.52,Other,125% New York Medicaid APG,1882.81,34822.85,
Partial removal of fibula,27641,CPT,,,,,,,,both,,,68082.75,50381.24,74,,50381.24,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30637.24,45,,30637.24,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33700.96,49.5,,33700.96,percent of total billed charges,110% of Medicare,46296.27,68,,46296.27,percent of total billed charges,,3097.27,,,3097.27,Other,186% of Medicaid,54466.2,80,,54466.2,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,54466.2,80,,54466.2,percent of total billed charges,,7216,,,7216,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,47657.93,70,,47657.93,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1665.2,,,1665.2,Other,New York Medicaid APG methodology,1665.2,,,1665.2,Other,100% New York Medicaid APG,1665.2,,,1665.2,Other,100% New York Medicaid APG,1665.2,,,1665.2,Other,100% New York Medicaid APG,3746.7,,,3746.7,Other,225% New York Medicaid APG,2547.75,,,2547.75,Other,153% New York Medicaid APG,3746.7,,,3746.7,Other,225% New York Medicaid APG,2331.28,,,2331.28,Other,140% New York Medicaid APG,3746.7,,,3746.7,Other,225% New York Medicaid APG,4329.52,,,4329.52,Other,260% New York Medicaid APG,5395.24,,,5395.24,Other,324% New York Medicaid APG,3580.18,,,3580.18,Other,215% New York Medicaid APG,3580.18,,,3580.18,Other,215% New York Medicaid APG,2081.5,,,2081.5,Other,125% New York Medicaid APG,1665.2,54466.2,
Resect talus/calcaneus tum,27647,CPT,,,,,,,,both,,,68082.75,50381.24,74,,50381.24,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30637.24,45,,30637.24,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33700.96,49.5,,33700.96,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3502.03,,,3502.03,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,47657.93,70,,47657.93,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1882.81,,,1882.81,Other,New York Medicaid APG methodology,1882.81,,,1882.81,Other,100% New York Medicaid APG,1882.81,,,1882.81,Other,100% New York Medicaid APG,1882.81,,,1882.81,Other,100% New York Medicaid APG,4236.33,,,4236.33,Other,225% New York Medicaid APG,2880.7,,,2880.7,Other,153% New York Medicaid APG,4236.33,,,4236.33,Other,225% New York Medicaid APG,2635.94,,,2635.94,Other,140% New York Medicaid APG,4236.33,,,4236.33,Other,225% New York Medicaid APG,4895.31,,,4895.31,Other,260% New York Medicaid APG,6100.32,,,6100.32,Other,324% New York Medicaid APG,4048.05,,,4048.05,Other,215% New York Medicaid APG,4048.05,,,4048.05,Other,215% New York Medicaid APG,2353.52,,,2353.52,Other,125% New York Medicaid APG,1882.81,50381.24,
Injection for ankle x-ray,27648,CPT,,,,,,,,both,,,32432.1,23999.75,74,,23999.75,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,14594.45,45,,14594.45,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,16053.89,49.5,,16053.89,percent of total billed charges,110% of Medicare,22053.83,68,,22053.83,percent of total billed charges,,966.93,,,966.93,Other,186% of Medicaid,25945.68,80,,25945.68,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,25945.68,80,,25945.68,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,22702.47,70,,22702.47,percent of total billed charges,,247.64,,,247.64,Fee Schedule,,209.89,,,209.89,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,519.86,,,519.86,Other,New York Medicaid APG methodology,519.86,,,519.86,Other,100% New York Medicaid APG,519.86,,,519.86,Other,100% New York Medicaid APG,519.86,,,519.86,Other,100% New York Medicaid APG,1169.68,,,1169.68,Other,225% New York Medicaid APG,795.38,,,795.38,Other,153% New York Medicaid APG,1169.68,,,1169.68,Other,225% New York Medicaid APG,727.8,,,727.8,Other,140% New York Medicaid APG,1169.68,,,1169.68,Other,225% New York Medicaid APG,1351.62,,,1351.62,Other,260% New York Medicaid APG,1684.33,,,1684.33,Other,324% New York Medicaid APG,1117.69,,,1117.69,Other,215% New York Medicaid APG,1117.69,,,1117.69,Other,215% New York Medicaid APG,649.82,,,649.82,Other,125% New York Medicaid APG,209.89,25945.68,
Repair achilles tendon,27650,CPT,,,,,,,,both,,,65373.37,48376.29,74,,48376.29,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,29418.02,45,,29418.02,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,32359.82,49.5,,32359.82,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3097.27,,,3097.27,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,45761.36,70,,45761.36,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,1665.2,,,1665.2,Other,New York Medicaid APG methodology,1665.2,,,1665.2,Other,100% New York Medicaid APG,1665.2,,,1665.2,Other,100% New York Medicaid APG,1665.2,,,1665.2,Other,100% New York Medicaid APG,3746.7,,,3746.7,Other,225% New York Medicaid APG,2547.75,,,2547.75,Other,153% New York Medicaid APG,3746.7,,,3746.7,Other,225% New York Medicaid APG,2331.28,,,2331.28,Other,140% New York Medicaid APG,3746.7,,,3746.7,Other,225% New York Medicaid APG,4329.52,,,4329.52,Other,260% New York Medicaid APG,5395.24,,,5395.24,Other,324% New York Medicaid APG,3580.18,,,3580.18,Other,215% New York Medicaid APG,3580.18,,,3580.18,Other,215% New York Medicaid APG,2081.5,,,2081.5,Other,125% New York Medicaid APG,1665.2,48376.29,
Repair/graft achilles tendon,27652,CPT,,,,,,,,both,,,56945.95,42140,74,,42140,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,25625.68,45,,25625.68,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,28188.25,49.5,,28188.25,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3502.03,,,3502.03,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,39862.17,70,,39862.17,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,1882.81,,,1882.81,Other,New York Medicaid APG methodology,1882.81,,,1882.81,Other,100% New York Medicaid APG,1882.81,,,1882.81,Other,100% New York Medicaid APG,1882.81,,,1882.81,Other,100% New York Medicaid APG,4236.33,,,4236.33,Other,225% New York Medicaid APG,2880.7,,,2880.7,Other,153% New York Medicaid APG,4236.33,,,4236.33,Other,225% New York Medicaid APG,2635.94,,,2635.94,Other,140% New York Medicaid APG,4236.33,,,4236.33,Other,225% New York Medicaid APG,4895.31,,,4895.31,Other,260% New York Medicaid APG,6100.32,,,6100.32,Other,324% New York Medicaid APG,4048.05,,,4048.05,Other,215% New York Medicaid APG,4048.05,,,4048.05,Other,215% New York Medicaid APG,2353.52,,,2353.52,Other,125% New York Medicaid APG,1882.81,42140,
Repair of achilles tendon,27654,CPT,,,,,,,,both,,,84319.85,62396.69,74,,62396.69,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,37943.93,45,,37943.93,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,41738.33,49.5,,41738.33,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3502.03,,,3502.03,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,59023.9,70,,59023.9,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,1882.81,,,1882.81,Other,New York Medicaid APG methodology,1882.81,,,1882.81,Other,100% New York Medicaid APG,1882.81,,,1882.81,Other,100% New York Medicaid APG,1882.81,,,1882.81,Other,100% New York Medicaid APG,4236.33,,,4236.33,Other,225% New York Medicaid APG,2880.7,,,2880.7,Other,153% New York Medicaid APG,4236.33,,,4236.33,Other,225% New York Medicaid APG,2635.94,,,2635.94,Other,140% New York Medicaid APG,4236.33,,,4236.33,Other,225% New York Medicaid APG,4895.31,,,4895.31,Other,260% New York Medicaid APG,6100.32,,,6100.32,Other,324% New York Medicaid APG,4048.05,,,4048.05,Other,215% New York Medicaid APG,4048.05,,,4048.05,Other,215% New York Medicaid APG,2353.52,,,2353.52,Other,125% New York Medicaid APG,1882.81,62396.69,
Repair leg fascia defect,27656,CPT,,,,,,,,both,,,68082.75,50381.24,74,,50381.24,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30637.24,45,,30637.24,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33700.96,49.5,,33700.96,percent of total billed charges,110% of Medicare,46296.27,68,,46296.27,percent of total billed charges,,3817.83,,,3817.83,Other,186% of Medicaid,54466.2,80,,54466.2,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,54466.2,80,,54466.2,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,47657.93,70,,47657.93,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,2052.6,,,2052.6,Other,New York Medicaid APG methodology,2052.6,,,2052.6,Other,100% New York Medicaid APG,2052.6,,,2052.6,Other,100% New York Medicaid APG,2052.6,,,2052.6,Other,100% New York Medicaid APG,4618.35,,,4618.35,Other,225% New York Medicaid APG,3140.47,,,3140.47,Other,153% New York Medicaid APG,4618.35,,,4618.35,Other,225% New York Medicaid APG,2873.64,,,2873.64,Other,140% New York Medicaid APG,4618.35,,,4618.35,Other,225% New York Medicaid APG,5336.75,,,5336.75,Other,260% New York Medicaid APG,6650.42,,,6650.42,Other,324% New York Medicaid APG,4413.09,,,4413.09,Other,215% New York Medicaid APG,4413.09,,,4413.09,Other,215% New York Medicaid APG,2565.75,,,2565.75,Other,125% New York Medicaid APG,2052.6,54466.2,
Repair of leg tendon each,27658,CPT,,,,,,,,both,,,87326.11,64621.32,74,,64621.32,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,39296.75,45,,39296.75,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,43226.42,49.5,,43226.42,percent of total billed charges,110% of Medicare,59381.75,68,,59381.75,percent of total billed charges,,3097.27,,,3097.27,Other,186% of Medicaid,69860.89,80,,69860.89,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,69860.89,80,,69860.89,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,61128.28,70,,61128.28,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1665.2,,,1665.2,Other,New York Medicaid APG methodology,1665.2,,,1665.2,Other,100% New York Medicaid APG,1665.2,,,1665.2,Other,100% New York Medicaid APG,1665.2,,,1665.2,Other,100% New York Medicaid APG,3746.7,,,3746.7,Other,225% New York Medicaid APG,2547.75,,,2547.75,Other,153% New York Medicaid APG,3746.7,,,3746.7,Other,225% New York Medicaid APG,2331.28,,,2331.28,Other,140% New York Medicaid APG,3746.7,,,3746.7,Other,225% New York Medicaid APG,4329.52,,,4329.52,Other,260% New York Medicaid APG,5395.24,,,5395.24,Other,324% New York Medicaid APG,3580.18,,,3580.18,Other,215% New York Medicaid APG,3580.18,,,3580.18,Other,215% New York Medicaid APG,2081.5,,,2081.5,Other,125% New York Medicaid APG,1665.2,69860.89,
Repair of leg tendon each,27659,CPT,,,,,,,,both,,,61576.68,45566.74,74,,45566.74,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,27709.51,45,,27709.51,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,30480.46,49.5,,30480.46,percent of total billed charges,110% of Medicare,41872.14,68,,41872.14,percent of total billed charges,,3502.03,,,3502.03,Other,186% of Medicaid,49261.34,80,,49261.34,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,49261.34,80,,49261.34,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,43103.68,70,,43103.68,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1882.81,,,1882.81,Other,New York Medicaid APG methodology,1882.81,,,1882.81,Other,100% New York Medicaid APG,1882.81,,,1882.81,Other,100% New York Medicaid APG,1882.81,,,1882.81,Other,100% New York Medicaid APG,4236.33,,,4236.33,Other,225% New York Medicaid APG,2880.7,,,2880.7,Other,153% New York Medicaid APG,4236.33,,,4236.33,Other,225% New York Medicaid APG,2635.94,,,2635.94,Other,140% New York Medicaid APG,4236.33,,,4236.33,Other,225% New York Medicaid APG,4895.31,,,4895.31,Other,260% New York Medicaid APG,6100.32,,,6100.32,Other,324% New York Medicaid APG,4048.05,,,4048.05,Other,215% New York Medicaid APG,4048.05,,,4048.05,Other,215% New York Medicaid APG,2353.52,,,2353.52,Other,125% New York Medicaid APG,1882.81,49261.34,
Repair of leg tendon each,27664,CPT,,,,,,,,both,,,45470.79,33648.38,74,,33648.38,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,20461.86,45,,20461.86,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,22508.04,49.5,,22508.04,percent of total billed charges,110% of Medicare,30920.14,68,,30920.14,percent of total billed charges,,3097.27,,,3097.27,Other,186% of Medicaid,36376.63,80,,36376.63,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,36376.63,80,,36376.63,percent of total billed charges,,7216,,,7216,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,31829.55,70,,31829.55,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1665.2,,,1665.2,Other,New York Medicaid APG methodology,1665.2,,,1665.2,Other,100% New York Medicaid APG,1665.2,,,1665.2,Other,100% New York Medicaid APG,1665.2,,,1665.2,Other,100% New York Medicaid APG,3746.7,,,3746.7,Other,225% New York Medicaid APG,2547.75,,,2547.75,Other,153% New York Medicaid APG,3746.7,,,3746.7,Other,225% New York Medicaid APG,2331.28,,,2331.28,Other,140% New York Medicaid APG,3746.7,,,3746.7,Other,225% New York Medicaid APG,4329.52,,,4329.52,Other,260% New York Medicaid APG,5395.24,,,5395.24,Other,324% New York Medicaid APG,3580.18,,,3580.18,Other,215% New York Medicaid APG,3580.18,,,3580.18,Other,215% New York Medicaid APG,2081.5,,,2081.5,Other,125% New York Medicaid APG,1665.2,36376.63,
Repair of leg tendon each,27665,CPT,,,,,,,,both,,,150476.65,111352.72,74,,111352.72,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,67714.49,45,,67714.49,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,74485.94,49.5,,74485.94,percent of total billed charges,110% of Medicare,102324.12,68,,102324.12,percent of total billed charges,,3502.03,,,3502.03,Other,186% of Medicaid,120381.32,80,,120381.32,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,120381.32,80,,120381.32,percent of total billed charges,,7216,,,7216,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,105333.66,70,,105333.66,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1882.81,,,1882.81,Other,New York Medicaid APG methodology,1882.81,,,1882.81,Other,100% New York Medicaid APG,1882.81,,,1882.81,Other,100% New York Medicaid APG,1882.81,,,1882.81,Other,100% New York Medicaid APG,4236.33,,,4236.33,Other,225% New York Medicaid APG,2880.7,,,2880.7,Other,153% New York Medicaid APG,4236.33,,,4236.33,Other,225% New York Medicaid APG,2635.94,,,2635.94,Other,140% New York Medicaid APG,4236.33,,,4236.33,Other,225% New York Medicaid APG,4895.31,,,4895.31,Other,260% New York Medicaid APG,6100.32,,,6100.32,Other,324% New York Medicaid APG,4048.05,,,4048.05,Other,215% New York Medicaid APG,4048.05,,,4048.05,Other,215% New York Medicaid APG,2353.52,,,2353.52,Other,125% New York Medicaid APG,1882.81,120381.32,
Repair lower leg tendons,27675,CPT,,,,,,,,both,,,68082.75,50381.24,74,,50381.24,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30637.24,45,,30637.24,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33700.96,49.5,,33700.96,percent of total billed charges,110% of Medicare,46296.27,68,,46296.27,percent of total billed charges,,3097.27,,,3097.27,Other,186% of Medicaid,54466.2,80,,54466.2,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,54466.2,80,,54466.2,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,47657.93,70,,47657.93,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1665.2,,,1665.2,Other,New York Medicaid APG methodology,1665.2,,,1665.2,Other,100% New York Medicaid APG,1665.2,,,1665.2,Other,100% New York Medicaid APG,1665.2,,,1665.2,Other,100% New York Medicaid APG,3746.7,,,3746.7,Other,225% New York Medicaid APG,2547.75,,,2547.75,Other,153% New York Medicaid APG,3746.7,,,3746.7,Other,225% New York Medicaid APG,2331.28,,,2331.28,Other,140% New York Medicaid APG,3746.7,,,3746.7,Other,225% New York Medicaid APG,4329.52,,,4329.52,Other,260% New York Medicaid APG,5395.24,,,5395.24,Other,324% New York Medicaid APG,3580.18,,,3580.18,Other,215% New York Medicaid APG,3580.18,,,3580.18,Other,215% New York Medicaid APG,2081.5,,,2081.5,Other,125% New York Medicaid APG,1665.2,54466.2,
Repair lower leg tendons,27676,CPT,,,,,,,,both,,,150476.65,111352.72,74,,111352.72,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,67714.49,45,,67714.49,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,74485.94,49.5,,74485.94,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3502.03,,,3502.03,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,105333.66,70,,105333.66,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1882.81,,,1882.81,Other,New York Medicaid APG methodology,1882.81,,,1882.81,Other,100% New York Medicaid APG,1882.81,,,1882.81,Other,100% New York Medicaid APG,1882.81,,,1882.81,Other,100% New York Medicaid APG,4236.33,,,4236.33,Other,225% New York Medicaid APG,2880.7,,,2880.7,Other,153% New York Medicaid APG,4236.33,,,4236.33,Other,225% New York Medicaid APG,2635.94,,,2635.94,Other,140% New York Medicaid APG,4236.33,,,4236.33,Other,225% New York Medicaid APG,4895.31,,,4895.31,Other,260% New York Medicaid APG,6100.32,,,6100.32,Other,324% New York Medicaid APG,4048.05,,,4048.05,Other,215% New York Medicaid APG,4048.05,,,4048.05,Other,215% New York Medicaid APG,2353.52,,,2353.52,Other,125% New York Medicaid APG,1882.81,111352.72,
Release of lower leg tendon,27680,CPT,,,,,,,,both,,,59649.87,44140.9,74,,44140.9,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,26842.44,45,,26842.44,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,29526.69,49.5,,29526.69,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3097.27,,,3097.27,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,41754.91,70,,41754.91,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1665.2,,,1665.2,Other,New York Medicaid APG methodology,1665.2,,,1665.2,Other,100% New York Medicaid APG,1665.2,,,1665.2,Other,100% New York Medicaid APG,1665.2,,,1665.2,Other,100% New York Medicaid APG,3746.7,,,3746.7,Other,225% New York Medicaid APG,2547.75,,,2547.75,Other,153% New York Medicaid APG,3746.7,,,3746.7,Other,225% New York Medicaid APG,2331.28,,,2331.28,Other,140% New York Medicaid APG,3746.7,,,3746.7,Other,225% New York Medicaid APG,4329.52,,,4329.52,Other,260% New York Medicaid APG,5395.24,,,5395.24,Other,324% New York Medicaid APG,3580.18,,,3580.18,Other,215% New York Medicaid APG,3580.18,,,3580.18,Other,215% New York Medicaid APG,2081.5,,,2081.5,Other,125% New York Medicaid APG,1665.2,44140.9,
Release of lower leg tendons,27681,CPT,,,,,,,,both,,,68082.75,50381.24,74,,50381.24,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30637.24,45,,30637.24,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33700.96,49.5,,33700.96,percent of total billed charges,110% of Medicare,46296.27,68,,46296.27,percent of total billed charges,,3097.27,,,3097.27,Other,186% of Medicaid,54466.2,80,,54466.2,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,54466.2,80,,54466.2,percent of total billed charges,,7216,,,7216,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,47657.93,70,,47657.93,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1665.2,,,1665.2,Other,New York Medicaid APG methodology,1665.2,,,1665.2,Other,100% New York Medicaid APG,1665.2,,,1665.2,Other,100% New York Medicaid APG,1665.2,,,1665.2,Other,100% New York Medicaid APG,3746.7,,,3746.7,Other,225% New York Medicaid APG,2547.75,,,2547.75,Other,153% New York Medicaid APG,3746.7,,,3746.7,Other,225% New York Medicaid APG,2331.28,,,2331.28,Other,140% New York Medicaid APG,3746.7,,,3746.7,Other,225% New York Medicaid APG,4329.52,,,4329.52,Other,260% New York Medicaid APG,5395.24,,,5395.24,Other,324% New York Medicaid APG,3580.18,,,3580.18,Other,215% New York Medicaid APG,3580.18,,,3580.18,Other,215% New York Medicaid APG,2081.5,,,2081.5,Other,125% New York Medicaid APG,1665.2,54466.2,
Revision of lower leg tendon,27685,CPT,,,,,,,,both,,,40974.55,30321.17,74,,30321.17,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,18438.55,45,,18438.55,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,20282.4,49.5,,20282.4,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3097.27,,,3097.27,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,28682.19,70,,28682.19,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1665.2,,,1665.2,Other,New York Medicaid APG methodology,1665.2,,,1665.2,Other,100% New York Medicaid APG,1665.2,,,1665.2,Other,100% New York Medicaid APG,1665.2,,,1665.2,Other,100% New York Medicaid APG,3746.7,,,3746.7,Other,225% New York Medicaid APG,2547.75,,,2547.75,Other,153% New York Medicaid APG,3746.7,,,3746.7,Other,225% New York Medicaid APG,2331.28,,,2331.28,Other,140% New York Medicaid APG,3746.7,,,3746.7,Other,225% New York Medicaid APG,4329.52,,,4329.52,Other,260% New York Medicaid APG,5395.24,,,5395.24,Other,324% New York Medicaid APG,3580.18,,,3580.18,Other,215% New York Medicaid APG,3580.18,,,3580.18,Other,215% New York Medicaid APG,2081.5,,,2081.5,Other,125% New York Medicaid APG,1665.2,30321.17,
Revise lower leg tendons,27686,CPT,,,,,,,,both,,,68082.75,50381.24,74,,50381.24,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30637.24,45,,30637.24,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33700.96,49.5,,33700.96,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3097.27,,,3097.27,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,47657.93,70,,47657.93,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1665.2,,,1665.2,Other,New York Medicaid APG methodology,1665.2,,,1665.2,Other,100% New York Medicaid APG,1665.2,,,1665.2,Other,100% New York Medicaid APG,1665.2,,,1665.2,Other,100% New York Medicaid APG,3746.7,,,3746.7,Other,225% New York Medicaid APG,2547.75,,,2547.75,Other,153% New York Medicaid APG,3746.7,,,3746.7,Other,225% New York Medicaid APG,2331.28,,,2331.28,Other,140% New York Medicaid APG,3746.7,,,3746.7,Other,225% New York Medicaid APG,4329.52,,,4329.52,Other,260% New York Medicaid APG,5395.24,,,5395.24,Other,324% New York Medicaid APG,3580.18,,,3580.18,Other,215% New York Medicaid APG,3580.18,,,3580.18,Other,215% New York Medicaid APG,2081.5,,,2081.5,Other,125% New York Medicaid APG,1665.2,50381.24,
Revision of calf tendon,27687,CPT,,,,,,,,both,,,46751.12,34595.83,74,,34595.83,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,21038,45,,21038,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,23141.8,49.5,,23141.8,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3097.27,,,3097.27,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,32725.78,70,,32725.78,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1665.2,,,1665.2,Other,New York Medicaid APG methodology,1665.2,,,1665.2,Other,100% New York Medicaid APG,1665.2,,,1665.2,Other,100% New York Medicaid APG,1665.2,,,1665.2,Other,100% New York Medicaid APG,3746.7,,,3746.7,Other,225% New York Medicaid APG,2547.75,,,2547.75,Other,153% New York Medicaid APG,3746.7,,,3746.7,Other,225% New York Medicaid APG,2331.28,,,2331.28,Other,140% New York Medicaid APG,3746.7,,,3746.7,Other,225% New York Medicaid APG,4329.52,,,4329.52,Other,260% New York Medicaid APG,5395.24,,,5395.24,Other,324% New York Medicaid APG,3580.18,,,3580.18,Other,215% New York Medicaid APG,3580.18,,,3580.18,Other,215% New York Medicaid APG,2081.5,,,2081.5,Other,125% New York Medicaid APG,1665.2,34595.83,
Revise lower leg tendon,27690,CPT,,,,,,,,both,,,150476.65,111352.72,74,,111352.72,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,67714.49,45,,67714.49,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,74485.94,49.5,,74485.94,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3502.03,,,3502.03,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,105333.66,70,,105333.66,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,1882.81,,,1882.81,Other,New York Medicaid APG methodology,1882.81,,,1882.81,Other,100% New York Medicaid APG,1882.81,,,1882.81,Other,100% New York Medicaid APG,1882.81,,,1882.81,Other,100% New York Medicaid APG,4236.33,,,4236.33,Other,225% New York Medicaid APG,2880.7,,,2880.7,Other,153% New York Medicaid APG,4236.33,,,4236.33,Other,225% New York Medicaid APG,2635.94,,,2635.94,Other,140% New York Medicaid APG,4236.33,,,4236.33,Other,225% New York Medicaid APG,4895.31,,,4895.31,Other,260% New York Medicaid APG,6100.32,,,6100.32,Other,324% New York Medicaid APG,4048.05,,,4048.05,Other,215% New York Medicaid APG,4048.05,,,4048.05,Other,215% New York Medicaid APG,2353.52,,,2353.52,Other,125% New York Medicaid APG,1882.81,111352.72,
Revise lower leg tendon,27691,CPT,,,,,,,,both,,,97738.58,72326.55,74,,72326.55,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,43982.36,45,,43982.36,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,48380.6,49.5,,48380.6,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3502.03,,,3502.03,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,68417.01,70,,68417.01,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,1882.81,,,1882.81,Other,New York Medicaid APG methodology,1882.81,,,1882.81,Other,100% New York Medicaid APG,1882.81,,,1882.81,Other,100% New York Medicaid APG,1882.81,,,1882.81,Other,100% New York Medicaid APG,4236.33,,,4236.33,Other,225% New York Medicaid APG,2880.7,,,2880.7,Other,153% New York Medicaid APG,4236.33,,,4236.33,Other,225% New York Medicaid APG,2635.94,,,2635.94,Other,140% New York Medicaid APG,4236.33,,,4236.33,Other,225% New York Medicaid APG,4895.31,,,4895.31,Other,260% New York Medicaid APG,6100.32,,,6100.32,Other,324% New York Medicaid APG,4048.05,,,4048.05,Other,215% New York Medicaid APG,4048.05,,,4048.05,Other,215% New York Medicaid APG,2353.52,,,2353.52,Other,125% New York Medicaid APG,1882.81,72326.55,
Revise additional leg tendon,27692,CPT,,,,,,,,both,,,64479.48,47714.82,74,,47714.82,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,29015.77,45,,29015.77,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,31917.34,49.5,,31917.34,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3502.03,,,3502.03,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,45135.64,70,,45135.64,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,1882.81,,,1882.81,Other,New York Medicaid APG methodology,1882.81,,,1882.81,Other,100% New York Medicaid APG,1882.81,,,1882.81,Other,100% New York Medicaid APG,1882.81,,,1882.81,Other,100% New York Medicaid APG,4236.33,,,4236.33,Other,225% New York Medicaid APG,2880.7,,,2880.7,Other,153% New York Medicaid APG,4236.33,,,4236.33,Other,225% New York Medicaid APG,2635.94,,,2635.94,Other,140% New York Medicaid APG,4236.33,,,4236.33,Other,225% New York Medicaid APG,4895.31,,,4895.31,Other,260% New York Medicaid APG,6100.32,,,6100.32,Other,324% New York Medicaid APG,4048.05,,,4048.05,Other,215% New York Medicaid APG,4048.05,,,4048.05,Other,215% New York Medicaid APG,2353.52,,,2353.52,Other,125% New York Medicaid APG,1882.81,47714.82,
Repair of ankle ligament,27695,CPT,,,,,,,,both,,,100988.85,74731.75,74,,74731.75,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,45444.98,45,,45444.98,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,49989.48,49.5,,49989.48,percent of total billed charges,110% of Medicare,68672.42,68,,68672.42,percent of total billed charges,,3502.03,,,3502.03,Other,186% of Medicaid,80791.08,80,,80791.08,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,80791.08,80,,80791.08,percent of total billed charges,,7216,,,7216,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,70692.2,70,,70692.2,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1882.81,,,1882.81,Other,New York Medicaid APG methodology,1882.81,,,1882.81,Other,100% New York Medicaid APG,1882.81,,,1882.81,Other,100% New York Medicaid APG,1882.81,,,1882.81,Other,100% New York Medicaid APG,4236.33,,,4236.33,Other,225% New York Medicaid APG,2880.7,,,2880.7,Other,153% New York Medicaid APG,4236.33,,,4236.33,Other,225% New York Medicaid APG,2635.94,,,2635.94,Other,140% New York Medicaid APG,4236.33,,,4236.33,Other,225% New York Medicaid APG,4895.31,,,4895.31,Other,260% New York Medicaid APG,6100.32,,,6100.32,Other,324% New York Medicaid APG,4048.05,,,4048.05,Other,215% New York Medicaid APG,4048.05,,,4048.05,Other,215% New York Medicaid APG,2353.52,,,2353.52,Other,125% New York Medicaid APG,1882.81,80791.08,
Repair of ankle ligaments,27696,CPT,,,,,,,,both,,,150476.65,111352.72,74,,111352.72,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,67714.49,45,,67714.49,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,74485.94,49.5,,74485.94,percent of total billed charges,110% of Medicare,102324.12,68,,102324.12,percent of total billed charges,,3502.03,,,3502.03,Other,186% of Medicaid,120381.32,80,,120381.32,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,120381.32,80,,120381.32,percent of total billed charges,,7216,,,7216,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,105333.66,70,,105333.66,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1882.81,,,1882.81,Other,New York Medicaid APG methodology,1882.81,,,1882.81,Other,100% New York Medicaid APG,1882.81,,,1882.81,Other,100% New York Medicaid APG,1882.81,,,1882.81,Other,100% New York Medicaid APG,4236.33,,,4236.33,Other,225% New York Medicaid APG,2880.7,,,2880.7,Other,153% New York Medicaid APG,4236.33,,,4236.33,Other,225% New York Medicaid APG,2635.94,,,2635.94,Other,140% New York Medicaid APG,4236.33,,,4236.33,Other,225% New York Medicaid APG,4895.31,,,4895.31,Other,260% New York Medicaid APG,6100.32,,,6100.32,Other,324% New York Medicaid APG,4048.05,,,4048.05,Other,215% New York Medicaid APG,4048.05,,,4048.05,Other,215% New York Medicaid APG,2353.52,,,2353.52,Other,125% New York Medicaid APG,1882.81,120381.32,
Repair of ankle ligament,27698,CPT,,,,,,,,both,,,79440.32,58785.84,74,,58785.84,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,35748.14,45,,35748.14,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,39322.96,49.5,,39322.96,percent of total billed charges,110% of Medicare,54019.42,68,,54019.42,percent of total billed charges,,3502.03,,,3502.03,Other,186% of Medicaid,63552.26,80,,63552.26,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,63552.26,80,,63552.26,percent of total billed charges,,7216,,,7216,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,55608.22,70,,55608.22,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1882.81,,,1882.81,Other,New York Medicaid APG methodology,1882.81,,,1882.81,Other,100% New York Medicaid APG,1882.81,,,1882.81,Other,100% New York Medicaid APG,1882.81,,,1882.81,Other,100% New York Medicaid APG,4236.33,,,4236.33,Other,225% New York Medicaid APG,2880.7,,,2880.7,Other,153% New York Medicaid APG,4236.33,,,4236.33,Other,225% New York Medicaid APG,2635.94,,,2635.94,Other,140% New York Medicaid APG,4236.33,,,4236.33,Other,225% New York Medicaid APG,4895.31,,,4895.31,Other,260% New York Medicaid APG,6100.32,,,6100.32,Other,324% New York Medicaid APG,4048.05,,,4048.05,Other,215% New York Medicaid APG,4048.05,,,4048.05,Other,215% New York Medicaid APG,2353.52,,,2353.52,Other,125% New York Medicaid APG,1882.81,63552.26,
Revision of ankle joint,27700,CPT,,,,,,,,both,,,150476.65,111352.72,74,,111352.72,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,67714.49,45,,67714.49,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,74485.94,49.5,,74485.94,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5218.57,,,5218.57,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,105333.66,70,,105333.66,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,2805.68,,,2805.68,Other,New York Medicaid APG methodology,2805.68,,,2805.68,Other,100% New York Medicaid APG,2805.68,,,2805.68,Other,100% New York Medicaid APG,2805.68,,,2805.68,Other,100% New York Medicaid APG,6312.79,,,6312.79,Other,225% New York Medicaid APG,4292.7,,,4292.7,Other,153% New York Medicaid APG,6312.79,,,6312.79,Other,225% New York Medicaid APG,3927.96,,,3927.96,Other,140% New York Medicaid APG,6312.79,,,6312.79,Other,225% New York Medicaid APG,7294.78,,,7294.78,Other,260% New York Medicaid APG,9090.42,,,9090.42,Other,324% New York Medicaid APG,6032.22,,,6032.22,Other,215% New York Medicaid APG,6032.22,,,6032.22,Other,215% New York Medicaid APG,3507.11,,,3507.11,Other,125% New York Medicaid APG,2805.68,111352.72,
Removal of ankle implant,27704,CPT,,,,,,,,both,,,68082.75,50381.24,74,,50381.24,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30637.24,45,,30637.24,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33700.96,49.5,,33700.96,percent of total billed charges,110% of Medicare,46296.27,68,,46296.27,percent of total billed charges,,3097.27,,,3097.27,Other,186% of Medicaid,54466.2,80,,54466.2,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,54466.2,80,,54466.2,percent of total billed charges,,7216,,,7216,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,47657.93,70,,47657.93,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1665.2,,,1665.2,Other,New York Medicaid APG methodology,1665.2,,,1665.2,Other,100% New York Medicaid APG,1665.2,,,1665.2,Other,100% New York Medicaid APG,1665.2,,,1665.2,Other,100% New York Medicaid APG,3746.7,,,3746.7,Other,225% New York Medicaid APG,2547.75,,,2547.75,Other,153% New York Medicaid APG,3746.7,,,3746.7,Other,225% New York Medicaid APG,2331.28,,,2331.28,Other,140% New York Medicaid APG,3746.7,,,3746.7,Other,225% New York Medicaid APG,4329.52,,,4329.52,Other,260% New York Medicaid APG,5395.24,,,5395.24,Other,324% New York Medicaid APG,3580.18,,,3580.18,Other,215% New York Medicaid APG,3580.18,,,3580.18,Other,215% New York Medicaid APG,2081.5,,,2081.5,Other,125% New York Medicaid APG,1665.2,54466.2,
Incision of tibia,27705,CPT,,,,,,,,both,,,48338.46,35770.46,74,,35770.46,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,21752.31,45,,21752.31,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,23927.54,49.5,,23927.54,percent of total billed charges,110% of Medicare,32870.15,68,,32870.15,percent of total billed charges,,3502.03,,,3502.03,Other,186% of Medicaid,38670.77,80,,38670.77,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,38670.77,80,,38670.77,percent of total billed charges,,7216,,,7216,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,33836.92,70,,33836.92,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,1882.81,,,1882.81,Other,New York Medicaid APG methodology,1882.81,,,1882.81,Other,100% New York Medicaid APG,1882.81,,,1882.81,Other,100% New York Medicaid APG,1882.81,,,1882.81,Other,100% New York Medicaid APG,4236.33,,,4236.33,Other,225% New York Medicaid APG,2880.7,,,2880.7,Other,153% New York Medicaid APG,4236.33,,,4236.33,Other,225% New York Medicaid APG,2635.94,,,2635.94,Other,140% New York Medicaid APG,4236.33,,,4236.33,Other,225% New York Medicaid APG,4895.31,,,4895.31,Other,260% New York Medicaid APG,6100.32,,,6100.32,Other,324% New York Medicaid APG,4048.05,,,4048.05,Other,215% New York Medicaid APG,4048.05,,,4048.05,Other,215% New York Medicaid APG,2353.52,,,2353.52,Other,125% New York Medicaid APG,1882.81,38670.77,
Incision of fibula,27707,CPT,,,,,,,,both,,,68082.75,50381.24,74,,50381.24,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30637.24,45,,30637.24,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33700.96,49.5,,33700.96,percent of total billed charges,110% of Medicare,46296.27,68,,46296.27,percent of total billed charges,,3502.03,,,3502.03,Other,186% of Medicaid,54466.2,80,,54466.2,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,54466.2,80,,54466.2,percent of total billed charges,,7216,,,7216,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,47657.93,70,,47657.93,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1882.81,,,1882.81,Other,New York Medicaid APG methodology,1882.81,,,1882.81,Other,100% New York Medicaid APG,1882.81,,,1882.81,Other,100% New York Medicaid APG,1882.81,,,1882.81,Other,100% New York Medicaid APG,4236.33,,,4236.33,Other,225% New York Medicaid APG,2880.7,,,2880.7,Other,153% New York Medicaid APG,4236.33,,,4236.33,Other,225% New York Medicaid APG,2635.94,,,2635.94,Other,140% New York Medicaid APG,4236.33,,,4236.33,Other,225% New York Medicaid APG,4895.31,,,4895.31,Other,260% New York Medicaid APG,6100.32,,,6100.32,Other,324% New York Medicaid APG,4048.05,,,4048.05,Other,215% New York Medicaid APG,4048.05,,,4048.05,Other,215% New York Medicaid APG,2353.52,,,2353.52,Other,125% New York Medicaid APG,1882.81,54466.2,
Incision of tibia & fibula,27709,CPT,,,,,,,,both,,,110739.67,81947.36,74,,81947.36,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,49832.85,45,,49832.85,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,54816.14,49.5,,54816.14,percent of total billed charges,110% of Medicare,75302.98,68,,75302.98,percent of total billed charges,,3502.03,,,3502.03,Other,186% of Medicaid,88591.74,80,,88591.74,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,88591.74,80,,88591.74,percent of total billed charges,,7216,,,7216,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,77517.77,70,,77517.77,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1882.81,,,1882.81,Other,New York Medicaid APG methodology,1882.81,,,1882.81,Other,100% New York Medicaid APG,1882.81,,,1882.81,Other,100% New York Medicaid APG,1882.81,,,1882.81,Other,100% New York Medicaid APG,4236.33,,,4236.33,Other,225% New York Medicaid APG,2880.7,,,2880.7,Other,153% New York Medicaid APG,4236.33,,,4236.33,Other,225% New York Medicaid APG,2635.94,,,2635.94,Other,140% New York Medicaid APG,4236.33,,,4236.33,Other,225% New York Medicaid APG,4895.31,,,4895.31,Other,260% New York Medicaid APG,6100.32,,,6100.32,Other,324% New York Medicaid APG,4048.05,,,4048.05,Other,215% New York Medicaid APG,4048.05,,,4048.05,Other,215% New York Medicaid APG,2353.52,,,2353.52,Other,125% New York Medicaid APG,1882.81,88591.74,
Repair of tibia,27720,CPT,,,,,,,,both,,,75013.17,55509.75,74,,55509.75,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,33755.93,45,,33755.93,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,37131.52,49.5,,37131.52,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5092.5,,,5092.5,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,52509.22,70,,52509.22,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,2737.91,,,2737.91,Other,New York Medicaid APG methodology,2737.91,,,2737.91,Other,100% New York Medicaid APG,2737.91,,,2737.91,Other,100% New York Medicaid APG,2737.91,,,2737.91,Other,100% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,4189,,,4189,Other,153% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,3833.07,,,3833.07,Other,140% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,7118.55,,,7118.55,Other,260% New York Medicaid APG,8870.81,,,8870.81,Other,324% New York Medicaid APG,5886.5,,,5886.5,Other,215% New York Medicaid APG,5886.5,,,5886.5,Other,215% New York Medicaid APG,3422.38,,,3422.38,Other,125% New York Medicaid APG,2737.91,55509.75,
Repair/graft of tibia,27722,CPT,,,,,,,,both,,,150476.65,111352.72,74,,111352.72,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,67714.49,45,,67714.49,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,74485.94,49.5,,74485.94,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5092.5,,,5092.5,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,105333.66,70,,105333.66,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,2737.91,,,2737.91,Other,New York Medicaid APG methodology,2737.91,,,2737.91,Other,100% New York Medicaid APG,2737.91,,,2737.91,Other,100% New York Medicaid APG,2737.91,,,2737.91,Other,100% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,4189,,,4189,Other,153% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,3833.07,,,3833.07,Other,140% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,7118.55,,,7118.55,Other,260% New York Medicaid APG,8870.81,,,8870.81,Other,324% New York Medicaid APG,5886.5,,,5886.5,Other,215% New York Medicaid APG,5886.5,,,5886.5,Other,215% New York Medicaid APG,3422.38,,,3422.38,Other,125% New York Medicaid APG,2737.91,111352.72,
Repair fibula nonunion,27726,CPT,,,,,,,,both,,,102271.53,75680.93,74,,75680.93,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,46022.19,45,,46022.19,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,50624.41,49.5,,50624.41,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5092.5,,,5092.5,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,71590.07,70,,71590.07,percent of total billed charges,,4710.08,,,4710.08,Fee Schedule,,3992.08,,,3992.08,Fee Schedule,,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,2737.91,,,2737.91,Other,New York Medicaid APG methodology,2737.91,,,2737.91,Other,100% New York Medicaid APG,2737.91,,,2737.91,Other,100% New York Medicaid APG,2737.91,,,2737.91,Other,100% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,4189,,,4189,Other,153% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,3833.07,,,3833.07,Other,140% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,7118.55,,,7118.55,Other,260% New York Medicaid APG,8870.81,,,8870.81,Other,324% New York Medicaid APG,5886.5,,,5886.5,Other,215% New York Medicaid APG,5886.5,,,5886.5,Other,215% New York Medicaid APG,3422.38,,,3422.38,Other,125% New York Medicaid APG,2737.91,75680.93,
Repair of tibia epiphysis,27730,CPT,,,,,,,,both,,,34131.15,25257.05,74,,25257.05,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15359.02,45,,15359.02,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,16894.92,49.5,,16894.92,percent of total billed charges,110% of Medicare,23209.18,68,,23209.18,percent of total billed charges,,3097.27,,,3097.27,Other,186% of Medicaid,27304.92,80,,27304.92,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,27304.92,80,,27304.92,percent of total billed charges,,7216,,,7216,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,23891.81,70,,23891.81,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1665.2,,,1665.2,Other,New York Medicaid APG methodology,1665.2,,,1665.2,Other,100% New York Medicaid APG,1665.2,,,1665.2,Other,100% New York Medicaid APG,1665.2,,,1665.2,Other,100% New York Medicaid APG,3746.7,,,3746.7,Other,225% New York Medicaid APG,2547.75,,,2547.75,Other,153% New York Medicaid APG,3746.7,,,3746.7,Other,225% New York Medicaid APG,2331.28,,,2331.28,Other,140% New York Medicaid APG,3746.7,,,3746.7,Other,225% New York Medicaid APG,4329.52,,,4329.52,Other,260% New York Medicaid APG,5395.24,,,5395.24,Other,324% New York Medicaid APG,3580.18,,,3580.18,Other,215% New York Medicaid APG,3580.18,,,3580.18,Other,215% New York Medicaid APG,2081.5,,,2081.5,Other,125% New York Medicaid APG,1665.2,27304.92,
Repair of fibula epiphysis,27732,CPT,,,,,,,,both,,,68082.75,50381.24,74,,50381.24,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30637.24,45,,30637.24,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33700.96,49.5,,33700.96,percent of total billed charges,110% of Medicare,46296.27,68,,46296.27,percent of total billed charges,,3097.27,,,3097.27,Other,186% of Medicaid,54466.2,80,,54466.2,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,54466.2,80,,54466.2,percent of total billed charges,,7216,,,7216,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,47657.93,70,,47657.93,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1665.2,,,1665.2,Other,New York Medicaid APG methodology,1665.2,,,1665.2,Other,100% New York Medicaid APG,1665.2,,,1665.2,Other,100% New York Medicaid APG,1665.2,,,1665.2,Other,100% New York Medicaid APG,3746.7,,,3746.7,Other,225% New York Medicaid APG,2547.75,,,2547.75,Other,153% New York Medicaid APG,3746.7,,,3746.7,Other,225% New York Medicaid APG,2331.28,,,2331.28,Other,140% New York Medicaid APG,3746.7,,,3746.7,Other,225% New York Medicaid APG,4329.52,,,4329.52,Other,260% New York Medicaid APG,5395.24,,,5395.24,Other,324% New York Medicaid APG,3580.18,,,3580.18,Other,215% New York Medicaid APG,3580.18,,,3580.18,Other,215% New York Medicaid APG,2081.5,,,2081.5,Other,125% New York Medicaid APG,1665.2,54466.2,
Repair lower leg epiphyses,27734,CPT,,,,,,,,both,,,68082.75,50381.24,74,,50381.24,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30637.24,45,,30637.24,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33700.96,49.5,,33700.96,percent of total billed charges,110% of Medicare,46296.27,68,,46296.27,percent of total billed charges,,3097.27,,,3097.27,Other,186% of Medicaid,54466.2,80,,54466.2,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,54466.2,80,,54466.2,percent of total billed charges,,7216,,,7216,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,47657.93,70,,47657.93,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1665.2,,,1665.2,Other,New York Medicaid APG methodology,1665.2,,,1665.2,Other,100% New York Medicaid APG,1665.2,,,1665.2,Other,100% New York Medicaid APG,1665.2,,,1665.2,Other,100% New York Medicaid APG,3746.7,,,3746.7,Other,225% New York Medicaid APG,2547.75,,,2547.75,Other,153% New York Medicaid APG,3746.7,,,3746.7,Other,225% New York Medicaid APG,2331.28,,,2331.28,Other,140% New York Medicaid APG,3746.7,,,3746.7,Other,225% New York Medicaid APG,4329.52,,,4329.52,Other,260% New York Medicaid APG,5395.24,,,5395.24,Other,324% New York Medicaid APG,3580.18,,,3580.18,Other,215% New York Medicaid APG,3580.18,,,3580.18,Other,215% New York Medicaid APG,2081.5,,,2081.5,Other,125% New York Medicaid APG,1665.2,54466.2,
Repair of leg epiphyses,27740,CPT,,,,,,,,both,,,68082.75,50381.24,74,,50381.24,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30637.24,45,,30637.24,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33700.96,49.5,,33700.96,percent of total billed charges,110% of Medicare,46296.27,68,,46296.27,percent of total billed charges,,3097.27,,,3097.27,Other,186% of Medicaid,54466.2,80,,54466.2,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,54466.2,80,,54466.2,percent of total billed charges,,7216,,,7216,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,47657.93,70,,47657.93,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1665.2,,,1665.2,Other,New York Medicaid APG methodology,1665.2,,,1665.2,Other,100% New York Medicaid APG,1665.2,,,1665.2,Other,100% New York Medicaid APG,1665.2,,,1665.2,Other,100% New York Medicaid APG,3746.7,,,3746.7,Other,225% New York Medicaid APG,2547.75,,,2547.75,Other,153% New York Medicaid APG,3746.7,,,3746.7,Other,225% New York Medicaid APG,2331.28,,,2331.28,Other,140% New York Medicaid APG,3746.7,,,3746.7,Other,225% New York Medicaid APG,4329.52,,,4329.52,Other,260% New York Medicaid APG,5395.24,,,5395.24,Other,324% New York Medicaid APG,3580.18,,,3580.18,Other,215% New York Medicaid APG,3580.18,,,3580.18,Other,215% New York Medicaid APG,2081.5,,,2081.5,Other,125% New York Medicaid APG,1665.2,54466.2,
Repair of leg epiphyses,27742,CPT,,,,,,,,both,,,68082.75,50381.24,74,,50381.24,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30637.24,45,,30637.24,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33700.96,49.5,,33700.96,percent of total billed charges,110% of Medicare,46296.27,68,,46296.27,percent of total billed charges,,3097.27,,,3097.27,Other,186% of Medicaid,54466.2,80,,54466.2,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,54466.2,80,,54466.2,percent of total billed charges,,7216,,,7216,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,47657.93,70,,47657.93,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,1665.2,,,1665.2,Other,New York Medicaid APG methodology,1665.2,,,1665.2,Other,100% New York Medicaid APG,1665.2,,,1665.2,Other,100% New York Medicaid APG,1665.2,,,1665.2,Other,100% New York Medicaid APG,3746.7,,,3746.7,Other,225% New York Medicaid APG,2547.75,,,2547.75,Other,153% New York Medicaid APG,3746.7,,,3746.7,Other,225% New York Medicaid APG,2331.28,,,2331.28,Other,140% New York Medicaid APG,3746.7,,,3746.7,Other,225% New York Medicaid APG,4329.52,,,4329.52,Other,260% New York Medicaid APG,5395.24,,,5395.24,Other,324% New York Medicaid APG,3580.18,,,3580.18,Other,215% New York Medicaid APG,3580.18,,,3580.18,Other,215% New York Medicaid APG,2081.5,,,2081.5,Other,125% New York Medicaid APG,1665.2,54466.2,
Reinforce tibia,27745,CPT,,,,,,,,both,,,150476.65,111352.72,74,,111352.72,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,67714.49,45,,67714.49,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,74485.94,49.5,,74485.94,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3502.03,,,3502.03,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,105333.66,70,,105333.66,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,1882.81,,,1882.81,Other,New York Medicaid APG methodology,1882.81,,,1882.81,Other,100% New York Medicaid APG,1882.81,,,1882.81,Other,100% New York Medicaid APG,1882.81,,,1882.81,Other,100% New York Medicaid APG,4236.33,,,4236.33,Other,225% New York Medicaid APG,2880.7,,,2880.7,Other,153% New York Medicaid APG,4236.33,,,4236.33,Other,225% New York Medicaid APG,2635.94,,,2635.94,Other,140% New York Medicaid APG,4236.33,,,4236.33,Other,225% New York Medicaid APG,4895.31,,,4895.31,Other,260% New York Medicaid APG,6100.32,,,6100.32,Other,324% New York Medicaid APG,4048.05,,,4048.05,Other,215% New York Medicaid APG,4048.05,,,4048.05,Other,215% New York Medicaid APG,2353.52,,,2353.52,Other,125% New York Medicaid APG,1882.81,111352.72,
Treatment of tibia fracture,27750,CPT,,,,,,,,both,,,4960.23,3670.57,74,,3670.57,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,2232.1,45,,2232.1,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,2455.31,49.5,,2455.31,percent of total billed charges,110% of Medicare,3372.96,68,,3372.96,percent of total billed charges,,1031.43,,,1031.43,Other,186% of Medicaid,3968.18,80,,3968.18,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,3968.18,80,,3968.18,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,3472.16,70,,3472.16,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,554.53,,,554.53,Other,New York Medicaid APG methodology,554.53,,,554.53,Other,100% New York Medicaid APG,554.53,,,554.53,Other,100% New York Medicaid APG,554.53,,,554.53,Other,100% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,848.43,,,848.43,Other,153% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,776.34,,,776.34,Other,140% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,1441.78,,,1441.78,Other,260% New York Medicaid APG,1796.68,,,1796.68,Other,324% New York Medicaid APG,1192.24,,,1192.24,Other,215% New York Medicaid APG,1192.24,,,1192.24,Other,215% New York Medicaid APG,693.16,,,693.16,Other,125% New York Medicaid APG,554.53,7216,
Treatment of tibia fracture,27752,CPT,,,,,,,,both,,,33805.49,25016.06,74,,25016.06,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15212.47,45,,15212.47,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,16733.72,49.5,,16733.72,percent of total billed charges,110% of Medicare,22987.73,68,,22987.73,percent of total billed charges,,1031.43,,,1031.43,Other,186% of Medicaid,27044.39,80,,27044.39,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,27044.39,80,,27044.39,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,23663.84,70,,23663.84,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,554.53,,,554.53,Other,New York Medicaid APG methodology,554.53,,,554.53,Other,100% New York Medicaid APG,554.53,,,554.53,Other,100% New York Medicaid APG,554.53,,,554.53,Other,100% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,848.43,,,848.43,Other,153% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,776.34,,,776.34,Other,140% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,1441.78,,,1441.78,Other,260% New York Medicaid APG,1796.68,,,1796.68,Other,324% New York Medicaid APG,1192.24,,,1192.24,Other,215% New York Medicaid APG,1192.24,,,1192.24,Other,215% New York Medicaid APG,693.16,,,693.16,Other,125% New York Medicaid APG,554.53,27044.39,
Treatment of tibia fracture,27756,CPT,,,,,,,,both,,,150476.65,111352.72,74,,111352.72,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,67714.49,45,,67714.49,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,74485.94,49.5,,74485.94,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5092.5,,,5092.5,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,105333.66,70,,105333.66,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,2737.91,,,2737.91,Other,New York Medicaid APG methodology,2737.91,,,2737.91,Other,100% New York Medicaid APG,2737.91,,,2737.91,Other,100% New York Medicaid APG,2737.91,,,2737.91,Other,100% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,4189,,,4189,Other,153% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,3833.07,,,3833.07,Other,140% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,7118.55,,,7118.55,Other,260% New York Medicaid APG,8870.81,,,8870.81,Other,324% New York Medicaid APG,5886.5,,,5886.5,Other,215% New York Medicaid APG,5886.5,,,5886.5,Other,215% New York Medicaid APG,3422.38,,,3422.38,Other,125% New York Medicaid APG,2737.91,111352.72,
Treatment of tibia fracture,27758,CPT,,,,,,,,both,,,170284.2,126010.31,74,,126010.31,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,76627.89,45,,76627.89,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,84290.68,49.5,,84290.68,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5092.5,,,5092.5,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,119198.94,70,,119198.94,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,2737.91,,,2737.91,Other,New York Medicaid APG methodology,2737.91,,,2737.91,Other,100% New York Medicaid APG,2737.91,,,2737.91,Other,100% New York Medicaid APG,2737.91,,,2737.91,Other,100% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,4189,,,4189,Other,153% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,3833.07,,,3833.07,Other,140% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,7118.55,,,7118.55,Other,260% New York Medicaid APG,8870.81,,,8870.81,Other,324% New York Medicaid APG,5886.5,,,5886.5,Other,215% New York Medicaid APG,5886.5,,,5886.5,Other,215% New York Medicaid APG,3422.38,,,3422.38,Other,125% New York Medicaid APG,2737.91,126010.31,
Treatment of tibia fracture,27759,CPT,,,,,,,,both,,,80308.42,59428.23,74,,59428.23,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,36138.79,45,,36138.79,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,39752.67,49.5,,39752.67,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5092.5,,,5092.5,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,56215.89,70,,56215.89,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,2737.91,,,2737.91,Other,New York Medicaid APG methodology,2737.91,,,2737.91,Other,100% New York Medicaid APG,2737.91,,,2737.91,Other,100% New York Medicaid APG,2737.91,,,2737.91,Other,100% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,4189,,,4189,Other,153% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,3833.07,,,3833.07,Other,140% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,7118.55,,,7118.55,Other,260% New York Medicaid APG,8870.81,,,8870.81,Other,324% New York Medicaid APG,5886.5,,,5886.5,Other,215% New York Medicaid APG,5886.5,,,5886.5,Other,215% New York Medicaid APG,3422.38,,,3422.38,Other,125% New York Medicaid APG,2737.91,59428.23,
Cltx medial ankle fx,27760,CPT,,,,,,,,both,,,4960.23,3670.57,74,,3670.57,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,2232.1,45,,2232.1,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,2455.31,49.5,,2455.31,percent of total billed charges,110% of Medicare,3372.96,68,,3372.96,percent of total billed charges,,1031.43,,,1031.43,Other,186% of Medicaid,3968.18,80,,3968.18,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,3968.18,80,,3968.18,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,3472.16,70,,3472.16,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,554.53,,,554.53,Other,New York Medicaid APG methodology,554.53,,,554.53,Other,100% New York Medicaid APG,554.53,,,554.53,Other,100% New York Medicaid APG,554.53,,,554.53,Other,100% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,848.43,,,848.43,Other,153% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,776.34,,,776.34,Other,140% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,1441.78,,,1441.78,Other,260% New York Medicaid APG,1796.68,,,1796.68,Other,324% New York Medicaid APG,1192.24,,,1192.24,Other,215% New York Medicaid APG,1192.24,,,1192.24,Other,215% New York Medicaid APG,693.16,,,693.16,Other,125% New York Medicaid APG,554.53,7216,
Cltx med ankle fx w/mnpj,27762,CPT,,,,,,,,both,,,33805.49,25016.06,74,,25016.06,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15212.47,45,,15212.47,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,16733.72,49.5,,16733.72,percent of total billed charges,110% of Medicare,22987.73,68,,22987.73,percent of total billed charges,,1031.43,,,1031.43,Other,186% of Medicaid,27044.39,80,,27044.39,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,27044.39,80,,27044.39,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,23663.84,70,,23663.84,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,554.53,,,554.53,Other,New York Medicaid APG methodology,554.53,,,554.53,Other,100% New York Medicaid APG,554.53,,,554.53,Other,100% New York Medicaid APG,554.53,,,554.53,Other,100% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,848.43,,,848.43,Other,153% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,776.34,,,776.34,Other,140% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,1441.78,,,1441.78,Other,260% New York Medicaid APG,1796.68,,,1796.68,Other,324% New York Medicaid APG,1192.24,,,1192.24,Other,215% New York Medicaid APG,1192.24,,,1192.24,Other,215% New York Medicaid APG,693.16,,,693.16,Other,125% New York Medicaid APG,554.53,27044.39,
Optx medial ankle fx,27766,CPT,,,,,,,,both,,,50346.88,37256.69,74,,37256.69,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,22656.1,45,,22656.1,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,24921.71,49.5,,24921.71,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5092.5,,,5092.5,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,35242.82,70,,35242.82,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,2737.91,,,2737.91,Other,New York Medicaid APG methodology,2737.91,,,2737.91,Other,100% New York Medicaid APG,2737.91,,,2737.91,Other,100% New York Medicaid APG,2737.91,,,2737.91,Other,100% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,4189,,,4189,Other,153% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,3833.07,,,3833.07,Other,140% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,7118.55,,,7118.55,Other,260% New York Medicaid APG,8870.81,,,8870.81,Other,324% New York Medicaid APG,5886.5,,,5886.5,Other,215% New York Medicaid APG,5886.5,,,5886.5,Other,215% New York Medicaid APG,3422.38,,,3422.38,Other,125% New York Medicaid APG,2737.91,37256.69,
Cltx post ankle fx,27767,CPT,,,,,,,,both,,,4960.23,3670.57,74,,3670.57,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,2232.1,45,,2232.1,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,2455.31,49.5,,2455.31,percent of total billed charges,110% of Medicare,3372.96,68,,3372.96,percent of total billed charges,,1031.43,,,1031.43,Other,186% of Medicaid,3968.18,80,,3968.18,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,3968.18,80,,3968.18,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,3472.16,70,,3472.16,percent of total billed charges,,1464.52,,,1464.52,Fee Schedule,,1241.27,,,1241.27,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,554.53,,,554.53,Other,New York Medicaid APG methodology,554.53,,,554.53,Other,100% New York Medicaid APG,554.53,,,554.53,Other,100% New York Medicaid APG,554.53,,,554.53,Other,100% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,848.43,,,848.43,Other,153% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,776.34,,,776.34,Other,140% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,1441.78,,,1441.78,Other,260% New York Medicaid APG,1796.68,,,1796.68,Other,324% New York Medicaid APG,1192.24,,,1192.24,Other,215% New York Medicaid APG,1192.24,,,1192.24,Other,215% New York Medicaid APG,693.16,,,693.16,Other,125% New York Medicaid APG,554.53,7216,
Cltx post ankle fx w/mnpj,27768,CPT,,,,,,,,both,,,33805.49,25016.06,74,,25016.06,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15212.47,45,,15212.47,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,16733.72,49.5,,16733.72,percent of total billed charges,110% of Medicare,22987.73,68,,22987.73,percent of total billed charges,,1031.43,,,1031.43,Other,186% of Medicaid,27044.39,80,,27044.39,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,27044.39,80,,27044.39,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,23663.84,70,,23663.84,percent of total billed charges,,2240.24,,,2240.24,Fee Schedule,,1898.74,,,1898.74,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,554.53,,,554.53,Other,New York Medicaid APG methodology,554.53,,,554.53,Other,100% New York Medicaid APG,554.53,,,554.53,Other,100% New York Medicaid APG,554.53,,,554.53,Other,100% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,848.43,,,848.43,Other,153% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,776.34,,,776.34,Other,140% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,1441.78,,,1441.78,Other,260% New York Medicaid APG,1796.68,,,1796.68,Other,324% New York Medicaid APG,1192.24,,,1192.24,Other,215% New York Medicaid APG,1192.24,,,1192.24,Other,215% New York Medicaid APG,693.16,,,693.16,Other,125% New York Medicaid APG,554.53,27044.39,
Optx post ankle fx,27769,CPT,,,,,,,,both,,,150476.65,111352.72,74,,111352.72,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,67714.49,45,,67714.49,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,74485.94,49.5,,74485.94,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5092.5,,,5092.5,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,105333.66,70,,105333.66,percent of total billed charges,,3588.32,,,3588.32,Fee Schedule,,3041.32,,,3041.32,Fee Schedule,,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,2737.91,,,2737.91,Other,New York Medicaid APG methodology,2737.91,,,2737.91,Other,100% New York Medicaid APG,2737.91,,,2737.91,Other,100% New York Medicaid APG,2737.91,,,2737.91,Other,100% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,4189,,,4189,Other,153% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,3833.07,,,3833.07,Other,140% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,7118.55,,,7118.55,Other,260% New York Medicaid APG,8870.81,,,8870.81,Other,324% New York Medicaid APG,5886.5,,,5886.5,Other,215% New York Medicaid APG,5886.5,,,5886.5,Other,215% New York Medicaid APG,3422.38,,,3422.38,Other,125% New York Medicaid APG,2737.91,111352.72,
Treatment of fibula fracture,27780,CPT,,,,,,,,both,,,4960.23,3670.57,74,,3670.57,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,2232.1,45,,2232.1,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,2455.31,49.5,,2455.31,percent of total billed charges,110% of Medicare,3372.96,68,,3372.96,percent of total billed charges,,1031.43,,,1031.43,Other,186% of Medicaid,3968.18,80,,3968.18,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,3968.18,80,,3968.18,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,3472.16,70,,3472.16,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,554.53,,,554.53,Other,New York Medicaid APG methodology,554.53,,,554.53,Other,100% New York Medicaid APG,554.53,,,554.53,Other,100% New York Medicaid APG,554.53,,,554.53,Other,100% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,848.43,,,848.43,Other,153% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,776.34,,,776.34,Other,140% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,1441.78,,,1441.78,Other,260% New York Medicaid APG,1796.68,,,1796.68,Other,324% New York Medicaid APG,1192.24,,,1192.24,Other,215% New York Medicaid APG,1192.24,,,1192.24,Other,215% New York Medicaid APG,693.16,,,693.16,Other,125% New York Medicaid APG,554.53,7216,
Treatment of fibula fracture,27781,CPT,,,,,,,,both,,,33805.49,25016.06,74,,25016.06,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15212.47,45,,15212.47,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,16733.72,49.5,,16733.72,percent of total billed charges,110% of Medicare,22987.73,68,,22987.73,percent of total billed charges,,1031.43,,,1031.43,Other,186% of Medicaid,27044.39,80,,27044.39,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,27044.39,80,,27044.39,percent of total billed charges,,7216,,,7216,Case Rate,,3578,,"100% primary, 0% secondary procedures",3578,Other,MagnaCare ASC Grouper,23663.84,70,,23663.84,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,554.53,,,554.53,Other,New York Medicaid APG methodology,554.53,,,554.53,Other,100% New York Medicaid APG,554.53,,,554.53,Other,100% New York Medicaid APG,554.53,,,554.53,Other,100% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,848.43,,,848.43,Other,153% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,776.34,,,776.34,Other,140% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,1441.78,,,1441.78,Other,260% New York Medicaid APG,1796.68,,,1796.68,Other,324% New York Medicaid APG,1192.24,,,1192.24,Other,215% New York Medicaid APG,1192.24,,,1192.24,Other,215% New York Medicaid APG,693.16,,,693.16,Other,125% New York Medicaid APG,554.53,27044.39,
Treatment of fibula fracture,27784,CPT,,,,,,,,both,,,150476.65,111352.72,74,,111352.72,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,67714.49,45,,67714.49,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,74485.94,49.5,,74485.94,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5092.5,,,5092.5,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,105333.66,70,,105333.66,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,2737.91,,,2737.91,Other,New York Medicaid APG methodology,2737.91,,,2737.91,Other,100% New York Medicaid APG,2737.91,,,2737.91,Other,100% New York Medicaid APG,2737.91,,,2737.91,Other,100% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,4189,,,4189,Other,153% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,3833.07,,,3833.07,Other,140% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,7118.55,,,7118.55,Other,260% New York Medicaid APG,8870.81,,,8870.81,Other,324% New York Medicaid APG,5886.5,,,5886.5,Other,215% New York Medicaid APG,5886.5,,,5886.5,Other,215% New York Medicaid APG,3422.38,,,3422.38,Other,125% New York Medicaid APG,2737.91,111352.72,
Treatment of ankle fracture,27786,CPT,,,,,,,,both,,,4960.23,3670.57,74,,3670.57,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,2232.1,45,,2232.1,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,2455.31,49.5,,2455.31,percent of total billed charges,110% of Medicare,3372.96,68,,3372.96,percent of total billed charges,,1031.43,,,1031.43,Other,186% of Medicaid,3968.18,80,,3968.18,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,3968.18,80,,3968.18,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,3472.16,70,,3472.16,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,554.53,,,554.53,Other,New York Medicaid APG methodology,554.53,,,554.53,Other,100% New York Medicaid APG,554.53,,,554.53,Other,100% New York Medicaid APG,554.53,,,554.53,Other,100% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,848.43,,,848.43,Other,153% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,776.34,,,776.34,Other,140% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,1441.78,,,1441.78,Other,260% New York Medicaid APG,1796.68,,,1796.68,Other,324% New York Medicaid APG,1192.24,,,1192.24,Other,215% New York Medicaid APG,1192.24,,,1192.24,Other,215% New York Medicaid APG,693.16,,,693.16,Other,125% New York Medicaid APG,554.53,7216,
Treatment of ankle fracture,27788,CPT,,,,,,,,both,,,4960.23,3670.57,74,,3670.57,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,2232.1,45,,2232.1,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,2455.31,49.5,,2455.31,percent of total billed charges,110% of Medicare,3372.96,68,,3372.96,percent of total billed charges,,1031.43,,,1031.43,Other,186% of Medicaid,3968.18,80,,3968.18,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,3968.18,80,,3968.18,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,3472.16,70,,3472.16,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,554.53,,,554.53,Other,New York Medicaid APG methodology,554.53,,,554.53,Other,100% New York Medicaid APG,554.53,,,554.53,Other,100% New York Medicaid APG,554.53,,,554.53,Other,100% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,848.43,,,848.43,Other,153% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,776.34,,,776.34,Other,140% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,1441.78,,,1441.78,Other,260% New York Medicaid APG,1796.68,,,1796.68,Other,324% New York Medicaid APG,1192.24,,,1192.24,Other,215% New York Medicaid APG,1192.24,,,1192.24,Other,215% New York Medicaid APG,693.16,,,693.16,Other,125% New York Medicaid APG,554.53,7216,
Treatment of ankle fracture,27792,CPT,,,,,,,,both,,,82253.84,60867.84,74,,60867.84,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,37014.23,45,,37014.23,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,40715.65,49.5,,40715.65,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5092.5,,,5092.5,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,57577.69,70,,57577.69,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,2737.91,,,2737.91,Other,New York Medicaid APG methodology,2737.91,,,2737.91,Other,100% New York Medicaid APG,2737.91,,,2737.91,Other,100% New York Medicaid APG,2737.91,,,2737.91,Other,100% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,4189,,,4189,Other,153% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,3833.07,,,3833.07,Other,140% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,7118.55,,,7118.55,Other,260% New York Medicaid APG,8870.81,,,8870.81,Other,324% New York Medicaid APG,5886.5,,,5886.5,Other,215% New York Medicaid APG,5886.5,,,5886.5,Other,215% New York Medicaid APG,3422.38,,,3422.38,Other,125% New York Medicaid APG,2737.91,60867.84,
Treatment of ankle fracture,27808,CPT,,,,,,,,both,,,4960.23,3670.57,74,,3670.57,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,2232.1,45,,2232.1,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,2455.31,49.5,,2455.31,percent of total billed charges,110% of Medicare,3372.96,68,,3372.96,percent of total billed charges,,1031.43,,,1031.43,Other,186% of Medicaid,3968.18,80,,3968.18,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,3968.18,80,,3968.18,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,3472.16,70,,3472.16,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,554.53,,,554.53,Other,New York Medicaid APG methodology,554.53,,,554.53,Other,100% New York Medicaid APG,554.53,,,554.53,Other,100% New York Medicaid APG,554.53,,,554.53,Other,100% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,848.43,,,848.43,Other,153% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,776.34,,,776.34,Other,140% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,1441.78,,,1441.78,Other,260% New York Medicaid APG,1796.68,,,1796.68,Other,324% New York Medicaid APG,1192.24,,,1192.24,Other,215% New York Medicaid APG,1192.24,,,1192.24,Other,215% New York Medicaid APG,693.16,,,693.16,Other,125% New York Medicaid APG,554.53,7216,
Treatment of ankle fracture,27810,CPT,,,,,,,,both,,,33805.49,25016.06,74,,25016.06,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15212.47,45,,15212.47,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,16733.72,49.5,,16733.72,percent of total billed charges,110% of Medicare,22987.73,68,,22987.73,percent of total billed charges,,1031.43,,,1031.43,Other,186% of Medicaid,27044.39,80,,27044.39,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,27044.39,80,,27044.39,percent of total billed charges,,7216,,,7216,Case Rate,,3578,,"100% primary, 0% secondary procedures",3578,Other,MagnaCare ASC Grouper,23663.84,70,,23663.84,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,554.53,,,554.53,Other,New York Medicaid APG methodology,554.53,,,554.53,Other,100% New York Medicaid APG,554.53,,,554.53,Other,100% New York Medicaid APG,554.53,,,554.53,Other,100% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,848.43,,,848.43,Other,153% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,776.34,,,776.34,Other,140% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,1441.78,,,1441.78,Other,260% New York Medicaid APG,1796.68,,,1796.68,Other,324% New York Medicaid APG,1192.24,,,1192.24,Other,215% New York Medicaid APG,1192.24,,,1192.24,Other,215% New York Medicaid APG,693.16,,,693.16,Other,125% New York Medicaid APG,554.53,27044.39,
Treatment of ankle fracture,27814,CPT,,,,,,,,both,,,101018.81,74753.92,74,,74753.92,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,45458.46,45,,45458.46,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,50004.31,49.5,,50004.31,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5092.5,,,5092.5,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,70713.17,70,,70713.17,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,2737.91,,,2737.91,Other,New York Medicaid APG methodology,2737.91,,,2737.91,Other,100% New York Medicaid APG,2737.91,,,2737.91,Other,100% New York Medicaid APG,2737.91,,,2737.91,Other,100% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,4189,,,4189,Other,153% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,3833.07,,,3833.07,Other,140% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,7118.55,,,7118.55,Other,260% New York Medicaid APG,8870.81,,,8870.81,Other,324% New York Medicaid APG,5886.5,,,5886.5,Other,215% New York Medicaid APG,5886.5,,,5886.5,Other,215% New York Medicaid APG,3422.38,,,3422.38,Other,125% New York Medicaid APG,2737.91,74753.92,
Treatment of ankle fracture,27816,CPT,,,,,,,,both,,,4960.23,3670.57,74,,3670.57,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,2232.1,45,,2232.1,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,2455.31,49.5,,2455.31,percent of total billed charges,110% of Medicare,3372.96,68,,3372.96,percent of total billed charges,,1031.43,,,1031.43,Other,186% of Medicaid,3968.18,80,,3968.18,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,3968.18,80,,3968.18,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,3472.16,70,,3472.16,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,554.53,,,554.53,Other,New York Medicaid APG methodology,554.53,,,554.53,Other,100% New York Medicaid APG,554.53,,,554.53,Other,100% New York Medicaid APG,554.53,,,554.53,Other,100% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,848.43,,,848.43,Other,153% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,776.34,,,776.34,Other,140% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,1441.78,,,1441.78,Other,260% New York Medicaid APG,1796.68,,,1796.68,Other,324% New York Medicaid APG,1192.24,,,1192.24,Other,215% New York Medicaid APG,1192.24,,,1192.24,Other,215% New York Medicaid APG,693.16,,,693.16,Other,125% New York Medicaid APG,554.53,7216,
Treatment of ankle fracture,27818,CPT,,,,,,,,both,,,33805.49,25016.06,74,,25016.06,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15212.47,45,,15212.47,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,16733.72,49.5,,16733.72,percent of total billed charges,110% of Medicare,22987.73,68,,22987.73,percent of total billed charges,,1031.43,,,1031.43,Other,186% of Medicaid,27044.39,80,,27044.39,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,27044.39,80,,27044.39,percent of total billed charges,,7216,,,7216,Case Rate,,3578,,"100% primary, 0% secondary procedures",3578,Other,MagnaCare ASC Grouper,23663.84,70,,23663.84,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,554.53,,,554.53,Other,New York Medicaid APG methodology,554.53,,,554.53,Other,100% New York Medicaid APG,554.53,,,554.53,Other,100% New York Medicaid APG,554.53,,,554.53,Other,100% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,848.43,,,848.43,Other,153% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,776.34,,,776.34,Other,140% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,1441.78,,,1441.78,Other,260% New York Medicaid APG,1796.68,,,1796.68,Other,324% New York Medicaid APG,1192.24,,,1192.24,Other,215% New York Medicaid APG,1192.24,,,1192.24,Other,215% New York Medicaid APG,693.16,,,693.16,Other,125% New York Medicaid APG,554.53,27044.39,
Treatment of ankle fracture,27822,CPT,,,,,,,,both,,,110876.23,82048.41,74,,82048.41,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,49894.3,45,,49894.3,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,54883.73,49.5,,54883.73,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5092.5,,,5092.5,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,77613.36,70,,77613.36,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,2737.91,,,2737.91,Other,New York Medicaid APG methodology,2737.91,,,2737.91,Other,100% New York Medicaid APG,2737.91,,,2737.91,Other,100% New York Medicaid APG,2737.91,,,2737.91,Other,100% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,4189,,,4189,Other,153% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,3833.07,,,3833.07,Other,140% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,7118.55,,,7118.55,Other,260% New York Medicaid APG,8870.81,,,8870.81,Other,324% New York Medicaid APG,5886.5,,,5886.5,Other,215% New York Medicaid APG,5886.5,,,5886.5,Other,215% New York Medicaid APG,3422.38,,,3422.38,Other,125% New York Medicaid APG,2737.91,82048.41,
Treatment of ankle fracture,27823,CPT,,,,,,,,both,,,118330,87564.2,74,,87564.2,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,53248.5,45,,53248.5,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,58573.35,49.5,,58573.35,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5092.5,,,5092.5,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,82831,70,,82831,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,2737.91,,,2737.91,Other,New York Medicaid APG methodology,2737.91,,,2737.91,Other,100% New York Medicaid APG,2737.91,,,2737.91,Other,100% New York Medicaid APG,2737.91,,,2737.91,Other,100% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,4189,,,4189,Other,153% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,3833.07,,,3833.07,Other,140% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,7118.55,,,7118.55,Other,260% New York Medicaid APG,8870.81,,,8870.81,Other,324% New York Medicaid APG,5886.5,,,5886.5,Other,215% New York Medicaid APG,5886.5,,,5886.5,Other,215% New York Medicaid APG,3422.38,,,3422.38,Other,125% New York Medicaid APG,2737.91,87564.2,
Treat lower leg fracture,27824,CPT,,,,,,,,both,,,4960.23,3670.57,74,,3670.57,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,2232.1,45,,2232.1,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,2455.31,49.5,,2455.31,percent of total billed charges,110% of Medicare,3372.96,68,,3372.96,percent of total billed charges,,1031.43,,,1031.43,Other,186% of Medicaid,3968.18,80,,3968.18,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,3968.18,80,,3968.18,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,3472.16,70,,3472.16,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,554.53,,,554.53,Other,New York Medicaid APG methodology,554.53,,,554.53,Other,100% New York Medicaid APG,554.53,,,554.53,Other,100% New York Medicaid APG,554.53,,,554.53,Other,100% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,848.43,,,848.43,Other,153% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,776.34,,,776.34,Other,140% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,1441.78,,,1441.78,Other,260% New York Medicaid APG,1796.68,,,1796.68,Other,324% New York Medicaid APG,1192.24,,,1192.24,Other,215% New York Medicaid APG,1192.24,,,1192.24,Other,215% New York Medicaid APG,693.16,,,693.16,Other,125% New York Medicaid APG,554.53,7216,
Treat lower leg fracture,27825,CPT,,,,,,,,both,,,33805.49,25016.06,74,,25016.06,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15212.47,45,,15212.47,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,16733.72,49.5,,16733.72,percent of total billed charges,110% of Medicare,22987.73,68,,22987.73,percent of total billed charges,,1031.43,,,1031.43,Other,186% of Medicaid,27044.39,80,,27044.39,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,27044.39,80,,27044.39,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,23663.84,70,,23663.84,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,554.53,,,554.53,Other,New York Medicaid APG methodology,554.53,,,554.53,Other,100% New York Medicaid APG,554.53,,,554.53,Other,100% New York Medicaid APG,554.53,,,554.53,Other,100% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,848.43,,,848.43,Other,153% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,776.34,,,776.34,Other,140% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,1441.78,,,1441.78,Other,260% New York Medicaid APG,1796.68,,,1796.68,Other,324% New York Medicaid APG,1192.24,,,1192.24,Other,215% New York Medicaid APG,1192.24,,,1192.24,Other,215% New York Medicaid APG,693.16,,,693.16,Other,125% New York Medicaid APG,554.53,27044.39,
Treat lower leg fracture,27826,CPT,,,,,,,,both,,,150476.65,111352.72,74,,111352.72,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,67714.49,45,,67714.49,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,74485.94,49.5,,74485.94,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5092.5,,,5092.5,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,105333.66,70,,105333.66,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,2737.91,,,2737.91,Other,New York Medicaid APG methodology,2737.91,,,2737.91,Other,100% New York Medicaid APG,2737.91,,,2737.91,Other,100% New York Medicaid APG,2737.91,,,2737.91,Other,100% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,4189,,,4189,Other,153% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,3833.07,,,3833.07,Other,140% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,7118.55,,,7118.55,Other,260% New York Medicaid APG,8870.81,,,8870.81,Other,324% New York Medicaid APG,5886.5,,,5886.5,Other,215% New York Medicaid APG,5886.5,,,5886.5,Other,215% New York Medicaid APG,3422.38,,,3422.38,Other,125% New York Medicaid APG,2737.91,111352.72,
Treat lower leg fracture,27827,CPT,,,,,,,,both,,,66604.04,49286.99,74,,49286.99,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,29971.82,45,,29971.82,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,32969,49.5,,32969,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5092.5,,,5092.5,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,46622.83,70,,46622.83,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,2737.91,,,2737.91,Other,New York Medicaid APG methodology,2737.91,,,2737.91,Other,100% New York Medicaid APG,2737.91,,,2737.91,Other,100% New York Medicaid APG,2737.91,,,2737.91,Other,100% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,4189,,,4189,Other,153% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,3833.07,,,3833.07,Other,140% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,7118.55,,,7118.55,Other,260% New York Medicaid APG,8870.81,,,8870.81,Other,324% New York Medicaid APG,5886.5,,,5886.5,Other,215% New York Medicaid APG,5886.5,,,5886.5,Other,215% New York Medicaid APG,3422.38,,,3422.38,Other,125% New York Medicaid APG,2737.91,49286.99,
Treat lower leg fracture,27828,CPT,,,,,,,,both,,,276827.87,204852.62,74,,204852.62,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,124572.54,45,,124572.54,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,137029.8,49.5,,137029.8,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5092.5,,,5092.5,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,193779.51,70,,193779.51,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,2737.91,,,2737.91,Other,New York Medicaid APG methodology,2737.91,,,2737.91,Other,100% New York Medicaid APG,2737.91,,,2737.91,Other,100% New York Medicaid APG,2737.91,,,2737.91,Other,100% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,4189,,,4189,Other,153% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,3833.07,,,3833.07,Other,140% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,7118.55,,,7118.55,Other,260% New York Medicaid APG,8870.81,,,8870.81,Other,324% New York Medicaid APG,5886.5,,,5886.5,Other,215% New York Medicaid APG,5886.5,,,5886.5,Other,215% New York Medicaid APG,3422.38,,,3422.38,Other,125% New York Medicaid APG,2737.91,204852.62,
Treat lower leg joint,27829,CPT,,,,,,,,both,,,52382.9,38763.35,74,,38763.35,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,23572.31,45,,23572.31,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,25929.54,49.5,,25929.54,percent of total billed charges,110% of Medicare,35620.37,68,,35620.37,percent of total billed charges,,5092.5,,,5092.5,Other,186% of Medicaid,41906.32,80,,41906.32,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,41906.32,80,,41906.32,percent of total billed charges,,7216,,,7216,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,36668.03,70,,36668.03,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,2737.91,,,2737.91,Other,New York Medicaid APG methodology,2737.91,,,2737.91,Other,100% New York Medicaid APG,2737.91,,,2737.91,Other,100% New York Medicaid APG,2737.91,,,2737.91,Other,100% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,4189,,,4189,Other,153% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,3833.07,,,3833.07,Other,140% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,7118.55,,,7118.55,Other,260% New York Medicaid APG,8870.81,,,8870.81,Other,324% New York Medicaid APG,5886.5,,,5886.5,Other,215% New York Medicaid APG,5886.5,,,5886.5,Other,215% New York Medicaid APG,3422.38,,,3422.38,Other,125% New York Medicaid APG,2232,41906.32,
Treat lower leg dislocation,27830,CPT,,,,,,,,both,,,4960.23,3670.57,74,,3670.57,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,2232.1,45,,2232.1,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,2455.31,49.5,,2455.31,percent of total billed charges,110% of Medicare,3372.96,68,,3372.96,percent of total billed charges,,1031.43,,,1031.43,Other,186% of Medicaid,3968.18,80,,3968.18,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,3968.18,80,,3968.18,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,3472.16,70,,3472.16,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,554.53,,,554.53,Other,New York Medicaid APG methodology,554.53,,,554.53,Other,100% New York Medicaid APG,554.53,,,554.53,Other,100% New York Medicaid APG,554.53,,,554.53,Other,100% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,848.43,,,848.43,Other,153% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,776.34,,,776.34,Other,140% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,1441.78,,,1441.78,Other,260% New York Medicaid APG,1796.68,,,1796.68,Other,324% New York Medicaid APG,1192.24,,,1192.24,Other,215% New York Medicaid APG,1192.24,,,1192.24,Other,215% New York Medicaid APG,693.16,,,693.16,Other,125% New York Medicaid APG,554.53,7216,
Treat lower leg dislocation,27831,CPT,,,,,,,,both,,,68082.75,50381.24,74,,50381.24,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30637.24,45,,30637.24,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33700.96,49.5,,33700.96,percent of total billed charges,110% of Medicare,46296.27,68,,46296.27,percent of total billed charges,,1031.43,,,1031.43,Other,186% of Medicaid,54466.2,80,,54466.2,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,54466.2,80,,54466.2,percent of total billed charges,,7216,,,7216,Case Rate,,3578,,"100% primary, 0% secondary procedures",3578,Other,MagnaCare ASC Grouper,47657.93,70,,47657.93,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,554.53,,,554.53,Other,New York Medicaid APG methodology,554.53,,,554.53,Other,100% New York Medicaid APG,554.53,,,554.53,Other,100% New York Medicaid APG,554.53,,,554.53,Other,100% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,848.43,,,848.43,Other,153% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,776.34,,,776.34,Other,140% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,1441.78,,,1441.78,Other,260% New York Medicaid APG,1796.68,,,1796.68,Other,324% New York Medicaid APG,1192.24,,,1192.24,Other,215% New York Medicaid APG,1192.24,,,1192.24,Other,215% New York Medicaid APG,693.16,,,693.16,Other,125% New York Medicaid APG,554.53,54466.2,
Treat lower leg dislocation,27832,CPT,,,,,,,,both,,,150476.65,111352.72,74,,111352.72,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,67714.49,45,,67714.49,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,74485.94,49.5,,74485.94,percent of total billed charges,110% of Medicare,102324.12,68,,102324.12,percent of total billed charges,,5092.5,,,5092.5,Other,186% of Medicaid,120381.32,80,,120381.32,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,120381.32,80,,120381.32,percent of total billed charges,,7216,,,7216,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,105333.66,70,,105333.66,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,2737.91,,,2737.91,Other,New York Medicaid APG methodology,2737.91,,,2737.91,Other,100% New York Medicaid APG,2737.91,,,2737.91,Other,100% New York Medicaid APG,2737.91,,,2737.91,Other,100% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,4189,,,4189,Other,153% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,3833.07,,,3833.07,Other,140% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,7118.55,,,7118.55,Other,260% New York Medicaid APG,8870.81,,,8870.81,Other,324% New York Medicaid APG,5886.5,,,5886.5,Other,215% New York Medicaid APG,5886.5,,,5886.5,Other,215% New York Medicaid APG,3422.38,,,3422.38,Other,125% New York Medicaid APG,2232,120381.32,
Treat ankle dislocation,27840,CPT,,,,,,,,both,,,4960.23,3670.57,74,,3670.57,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,2232.1,45,,2232.1,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,2455.31,49.5,,2455.31,percent of total billed charges,110% of Medicare,3372.96,68,,3372.96,percent of total billed charges,,1031.43,,,1031.43,Other,186% of Medicaid,3968.18,80,,3968.18,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,3968.18,80,,3968.18,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,3472.16,70,,3472.16,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,554.53,,,554.53,Other,New York Medicaid APG methodology,554.53,,,554.53,Other,100% New York Medicaid APG,554.53,,,554.53,Other,100% New York Medicaid APG,554.53,,,554.53,Other,100% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,848.43,,,848.43,Other,153% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,776.34,,,776.34,Other,140% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,1441.78,,,1441.78,Other,260% New York Medicaid APG,1796.68,,,1796.68,Other,324% New York Medicaid APG,1192.24,,,1192.24,Other,215% New York Medicaid APG,1192.24,,,1192.24,Other,215% New York Medicaid APG,693.16,,,693.16,Other,125% New York Medicaid APG,554.53,7216,
Treat ankle dislocation,27842,CPT,,,,,,,,both,,,33805.49,25016.06,74,,25016.06,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15212.47,45,,15212.47,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,16733.72,49.5,,16733.72,percent of total billed charges,110% of Medicare,22987.73,68,,22987.73,percent of total billed charges,,1730.38,,,1730.38,Other,186% of Medicaid,27044.39,80,,27044.39,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,27044.39,80,,27044.39,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,23663.84,70,,23663.84,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,930.31,,,930.31,Other,New York Medicaid APG methodology,930.31,,,930.31,Other,100% New York Medicaid APG,930.31,,,930.31,Other,100% New York Medicaid APG,930.31,,,930.31,Other,100% New York Medicaid APG,2093.21,,,2093.21,Other,225% New York Medicaid APG,1423.38,,,1423.38,Other,153% New York Medicaid APG,2093.21,,,2093.21,Other,225% New York Medicaid APG,1302.44,,,1302.44,Other,140% New York Medicaid APG,2093.21,,,2093.21,Other,225% New York Medicaid APG,2418.82,,,2418.82,Other,260% New York Medicaid APG,3014.22,,,3014.22,Other,324% New York Medicaid APG,2000.18,,,2000.18,Other,215% New York Medicaid APG,2000.18,,,2000.18,Other,215% New York Medicaid APG,1162.89,,,1162.89,Other,125% New York Medicaid APG,930.31,27044.39,
Treat ankle dislocation,27846,CPT,,,,,,,,both,,,150476.65,111352.72,74,,111352.72,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,67714.49,45,,67714.49,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,74485.94,49.5,,74485.94,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5092.5,,,5092.5,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,105333.66,70,,105333.66,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,2737.91,,,2737.91,Other,New York Medicaid APG methodology,2737.91,,,2737.91,Other,100% New York Medicaid APG,2737.91,,,2737.91,Other,100% New York Medicaid APG,2737.91,,,2737.91,Other,100% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,4189,,,4189,Other,153% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,3833.07,,,3833.07,Other,140% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,7118.55,,,7118.55,Other,260% New York Medicaid APG,8870.81,,,8870.81,Other,324% New York Medicaid APG,5886.5,,,5886.5,Other,215% New York Medicaid APG,5886.5,,,5886.5,Other,215% New York Medicaid APG,3422.38,,,3422.38,Other,125% New York Medicaid APG,2737.91,111352.72,
Treat ankle dislocation,27848,CPT,,,,,,,,both,,,150476.65,111352.72,74,,111352.72,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,67714.49,45,,67714.49,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,74485.94,49.5,,74485.94,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5092.5,,,5092.5,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,105333.66,70,,105333.66,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,2737.91,,,2737.91,Other,New York Medicaid APG methodology,2737.91,,,2737.91,Other,100% New York Medicaid APG,2737.91,,,2737.91,Other,100% New York Medicaid APG,2737.91,,,2737.91,Other,100% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,4189,,,4189,Other,153% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,3833.07,,,3833.07,Other,140% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,7118.55,,,7118.55,Other,260% New York Medicaid APG,8870.81,,,8870.81,Other,324% New York Medicaid APG,5886.5,,,5886.5,Other,215% New York Medicaid APG,5886.5,,,5886.5,Other,215% New York Medicaid APG,3422.38,,,3422.38,Other,125% New York Medicaid APG,2737.91,111352.72,
Fixation of ankle joint,27860,CPT,,,,,,,,both,,,68082.75,50381.24,74,,50381.24,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30637.24,45,,30637.24,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33700.96,49.5,,33700.96,percent of total billed charges,110% of Medicare,46296.27,68,,46296.27,percent of total billed charges,,1730.38,,,1730.38,Other,186% of Medicaid,54466.2,80,,54466.2,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,54466.2,80,,54466.2,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,47657.93,70,,47657.93,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,930.31,,,930.31,Other,New York Medicaid APG methodology,930.31,,,930.31,Other,100% New York Medicaid APG,930.31,,,930.31,Other,100% New York Medicaid APG,930.31,,,930.31,Other,100% New York Medicaid APG,2093.21,,,2093.21,Other,225% New York Medicaid APG,1423.38,,,1423.38,Other,153% New York Medicaid APG,2093.21,,,2093.21,Other,225% New York Medicaid APG,1302.44,,,1302.44,Other,140% New York Medicaid APG,2093.21,,,2093.21,Other,225% New York Medicaid APG,2418.82,,,2418.82,Other,260% New York Medicaid APG,3014.22,,,3014.22,Other,324% New York Medicaid APG,2000.18,,,2000.18,Other,215% New York Medicaid APG,2000.18,,,2000.18,Other,215% New York Medicaid APG,1162.89,,,1162.89,Other,125% New York Medicaid APG,930.31,54466.2,
Fusion of ankle joint open,27870,CPT,,,,,,,,both,,,124203.23,91910.39,74,,91910.39,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,55891.45,45,,55891.45,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,61480.6,49.5,,61480.6,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3502.03,,,3502.03,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,86942.26,70,,86942.26,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,1882.81,,,1882.81,Other,New York Medicaid APG methodology,1882.81,,,1882.81,Other,100% New York Medicaid APG,1882.81,,,1882.81,Other,100% New York Medicaid APG,1882.81,,,1882.81,Other,100% New York Medicaid APG,4236.33,,,4236.33,Other,225% New York Medicaid APG,2880.7,,,2880.7,Other,153% New York Medicaid APG,4236.33,,,4236.33,Other,225% New York Medicaid APG,2635.94,,,2635.94,Other,140% New York Medicaid APG,4236.33,,,4236.33,Other,225% New York Medicaid APG,4895.31,,,4895.31,Other,260% New York Medicaid APG,6100.32,,,6100.32,Other,324% New York Medicaid APG,4048.05,,,4048.05,Other,215% New York Medicaid APG,4048.05,,,4048.05,Other,215% New York Medicaid APG,2353.52,,,2353.52,Other,125% New York Medicaid APG,1882.81,91910.39,
Fusion of tibiofibular joint,27871,CPT,,,,,,,,both,,,276827.87,204852.62,74,,204852.62,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,124572.54,45,,124572.54,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,137029.8,49.5,,137029.8,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3502.03,,,3502.03,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,193779.51,70,,193779.51,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,1882.81,,,1882.81,Other,New York Medicaid APG methodology,1882.81,,,1882.81,Other,100% New York Medicaid APG,1882.81,,,1882.81,Other,100% New York Medicaid APG,1882.81,,,1882.81,Other,100% New York Medicaid APG,4236.33,,,4236.33,Other,225% New York Medicaid APG,2880.7,,,2880.7,Other,153% New York Medicaid APG,4236.33,,,4236.33,Other,225% New York Medicaid APG,2635.94,,,2635.94,Other,140% New York Medicaid APG,4236.33,,,4236.33,Other,225% New York Medicaid APG,4895.31,,,4895.31,Other,260% New York Medicaid APG,6100.32,,,6100.32,Other,324% New York Medicaid APG,4048.05,,,4048.05,Other,215% New York Medicaid APG,4048.05,,,4048.05,Other,215% New York Medicaid APG,2353.52,,,2353.52,Other,125% New York Medicaid APG,1882.81,204852.62,
Amputation follow-up surgery,27884,CPT,,,,,,,,both,,,38158.9,28237.59,74,,28237.59,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,17171.51,45,,17171.51,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,18888.66,49.5,,18888.66,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3097.27,,,3097.27,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,26711.23,70,,26711.23,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1665.2,,,1665.2,Other,New York Medicaid APG methodology,1665.2,,,1665.2,Other,100% New York Medicaid APG,1665.2,,,1665.2,Other,100% New York Medicaid APG,1665.2,,,1665.2,Other,100% New York Medicaid APG,3746.7,,,3746.7,Other,225% New York Medicaid APG,2547.75,,,2547.75,Other,153% New York Medicaid APG,3746.7,,,3746.7,Other,225% New York Medicaid APG,2331.28,,,2331.28,Other,140% New York Medicaid APG,3746.7,,,3746.7,Other,225% New York Medicaid APG,4329.52,,,4329.52,Other,260% New York Medicaid APG,5395.24,,,5395.24,Other,324% New York Medicaid APG,3580.18,,,3580.18,Other,215% New York Medicaid APG,3580.18,,,3580.18,Other,215% New York Medicaid APG,2081.5,,,2081.5,Other,125% New York Medicaid APG,1665.2,28237.59,
Amputation of foot at ankle,27889,CPT,,,,,,,,both,,,150476.65,111352.72,74,,111352.72,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,67714.49,45,,67714.49,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,74485.94,49.5,,74485.94,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3502.03,,,3502.03,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,105333.66,70,,105333.66,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1882.81,,,1882.81,Other,New York Medicaid APG methodology,1882.81,,,1882.81,Other,100% New York Medicaid APG,1882.81,,,1882.81,Other,100% New York Medicaid APG,1882.81,,,1882.81,Other,100% New York Medicaid APG,4236.33,,,4236.33,Other,225% New York Medicaid APG,2880.7,,,2880.7,Other,153% New York Medicaid APG,4236.33,,,4236.33,Other,225% New York Medicaid APG,2635.94,,,2635.94,Other,140% New York Medicaid APG,4236.33,,,4236.33,Other,225% New York Medicaid APG,4895.31,,,4895.31,Other,260% New York Medicaid APG,6100.32,,,6100.32,Other,324% New York Medicaid APG,4048.05,,,4048.05,Other,215% New York Medicaid APG,4048.05,,,4048.05,Other,215% New York Medicaid APG,2353.52,,,2353.52,Other,125% New York Medicaid APG,1882.81,111352.72,
Decompression of leg,27892,CPT,,,,,,,,both,,,68082.75,50381.24,74,,50381.24,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30637.24,45,,30637.24,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33700.96,49.5,,33700.96,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3817.83,,,3817.83,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,47657.93,70,,47657.93,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,2052.6,,,2052.6,Other,New York Medicaid APG methodology,2052.6,,,2052.6,Other,100% New York Medicaid APG,2052.6,,,2052.6,Other,100% New York Medicaid APG,2052.6,,,2052.6,Other,100% New York Medicaid APG,4618.35,,,4618.35,Other,225% New York Medicaid APG,3140.47,,,3140.47,Other,153% New York Medicaid APG,4618.35,,,4618.35,Other,225% New York Medicaid APG,2873.64,,,2873.64,Other,140% New York Medicaid APG,4618.35,,,4618.35,Other,225% New York Medicaid APG,5336.75,,,5336.75,Other,260% New York Medicaid APG,6650.42,,,6650.42,Other,324% New York Medicaid APG,4413.09,,,4413.09,Other,215% New York Medicaid APG,4413.09,,,4413.09,Other,215% New York Medicaid APG,2565.75,,,2565.75,Other,125% New York Medicaid APG,2052.6,50381.24,
Decompression of leg,27893,CPT,,,,,,,,both,,,150476.65,111352.72,74,,111352.72,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,67714.49,45,,67714.49,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,74485.94,49.5,,74485.94,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3817.83,,,3817.83,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,105333.66,70,,105333.66,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,2052.6,,,2052.6,Other,New York Medicaid APG methodology,2052.6,,,2052.6,Other,100% New York Medicaid APG,2052.6,,,2052.6,Other,100% New York Medicaid APG,2052.6,,,2052.6,Other,100% New York Medicaid APG,4618.35,,,4618.35,Other,225% New York Medicaid APG,3140.47,,,3140.47,Other,153% New York Medicaid APG,4618.35,,,4618.35,Other,225% New York Medicaid APG,2873.64,,,2873.64,Other,140% New York Medicaid APG,4618.35,,,4618.35,Other,225% New York Medicaid APG,5336.75,,,5336.75,Other,260% New York Medicaid APG,6650.42,,,6650.42,Other,324% New York Medicaid APG,4413.09,,,4413.09,Other,215% New York Medicaid APG,4413.09,,,4413.09,Other,215% New York Medicaid APG,2565.75,,,2565.75,Other,125% New York Medicaid APG,2052.6,111352.72,
Decompression of leg,27894,CPT,,,,,,,,both,,,68082.75,50381.24,74,,50381.24,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30637.24,45,,30637.24,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33700.96,49.5,,33700.96,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3817.83,,,3817.83,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,47657.93,70,,47657.93,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,2052.6,,,2052.6,Other,New York Medicaid APG methodology,2052.6,,,2052.6,Other,100% New York Medicaid APG,2052.6,,,2052.6,Other,100% New York Medicaid APG,2052.6,,,2052.6,Other,100% New York Medicaid APG,4618.35,,,4618.35,Other,225% New York Medicaid APG,3140.47,,,3140.47,Other,153% New York Medicaid APG,4618.35,,,4618.35,Other,225% New York Medicaid APG,2873.64,,,2873.64,Other,140% New York Medicaid APG,4618.35,,,4618.35,Other,225% New York Medicaid APG,5336.75,,,5336.75,Other,260% New York Medicaid APG,6650.42,,,6650.42,Other,324% New York Medicaid APG,4413.09,,,4413.09,Other,215% New York Medicaid APG,4413.09,,,4413.09,Other,215% New York Medicaid APG,2565.75,,,2565.75,Other,125% New York Medicaid APG,2052.6,50381.24,
Drainage of bursa of foot,28001,CPT,,,,,,,,both,,,34101.75,25235.3,74,,25235.3,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15345.79,45,,15345.79,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,16880.37,49.5,,16880.37,percent of total billed charges,110% of Medicare,23189.19,68,,23189.19,percent of total billed charges,,2891.15,,,2891.15,Other,186% of Medicaid,27281.4,80,,27281.4,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,27281.4,80,,27281.4,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,23871.23,70,,23871.23,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1554.38,,,1554.38,Other,New York Medicaid APG methodology,1554.38,,,1554.38,Other,100% New York Medicaid APG,1554.38,,,1554.38,Other,100% New York Medicaid APG,1554.38,,,1554.38,Other,100% New York Medicaid APG,3497.36,,,3497.36,Other,225% New York Medicaid APG,2378.21,,,2378.21,Other,153% New York Medicaid APG,3497.36,,,3497.36,Other,225% New York Medicaid APG,2176.14,,,2176.14,Other,140% New York Medicaid APG,3497.36,,,3497.36,Other,225% New York Medicaid APG,4041.4,,,4041.4,Other,260% New York Medicaid APG,5036.2,,,5036.2,Other,324% New York Medicaid APG,3341.93,,,3341.93,Other,215% New York Medicaid APG,3341.93,,,3341.93,Other,215% New York Medicaid APG,1942.98,,,1942.98,Other,125% New York Medicaid APG,1554.38,27281.4,
Treatment of foot infection,28002,CPT,,,,,,,,both,,,33805.49,25016.06,74,,25016.06,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15212.47,45,,15212.47,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,16733.72,49.5,,16733.72,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2891.15,,,2891.15,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,23663.84,70,,23663.84,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1554.38,,,1554.38,Other,New York Medicaid APG methodology,1554.38,,,1554.38,Other,100% New York Medicaid APG,1554.38,,,1554.38,Other,100% New York Medicaid APG,1554.38,,,1554.38,Other,100% New York Medicaid APG,3497.36,,,3497.36,Other,225% New York Medicaid APG,2378.21,,,2378.21,Other,153% New York Medicaid APG,3497.36,,,3497.36,Other,225% New York Medicaid APG,2176.14,,,2176.14,Other,140% New York Medicaid APG,3497.36,,,3497.36,Other,225% New York Medicaid APG,4041.4,,,4041.4,Other,260% New York Medicaid APG,5036.2,,,5036.2,Other,324% New York Medicaid APG,3341.93,,,3341.93,Other,215% New York Medicaid APG,3341.93,,,3341.93,Other,215% New York Medicaid APG,1942.98,,,1942.98,Other,125% New York Medicaid APG,1554.38,25016.06,
Treatment of foot infection,28003,CPT,,,,,,,,both,,,68082.75,50381.24,74,,50381.24,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30637.24,45,,30637.24,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33700.96,49.5,,33700.96,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,1973.06,,,1973.06,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,47657.93,70,,47657.93,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1060.79,,,1060.79,Other,New York Medicaid APG methodology,1060.79,,,1060.79,Other,100% New York Medicaid APG,1060.79,,,1060.79,Other,100% New York Medicaid APG,1060.79,,,1060.79,Other,100% New York Medicaid APG,2386.77,,,2386.77,Other,225% New York Medicaid APG,1623,,,1623,Other,153% New York Medicaid APG,2386.77,,,2386.77,Other,225% New York Medicaid APG,1485.1,,,1485.1,Other,140% New York Medicaid APG,2386.77,,,2386.77,Other,225% New York Medicaid APG,2758.05,,,2758.05,Other,260% New York Medicaid APG,3436.95,,,3436.95,Other,324% New York Medicaid APG,2280.69,,,2280.69,Other,215% New York Medicaid APG,2280.69,,,2280.69,Other,215% New York Medicaid APG,1325.98,,,1325.98,Other,125% New York Medicaid APG,1060.79,50381.24,
Treat foot bone lesion,28005,CPT,,,,,,,,both,,,68082.75,50381.24,74,,50381.24,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30637.24,45,,30637.24,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33700.96,49.5,,33700.96,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3642.86,,,3642.86,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,47657.93,70,,47657.93,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1958.52,,,1958.52,Other,New York Medicaid APG methodology,1958.52,,,1958.52,Other,100% New York Medicaid APG,1958.52,,,1958.52,Other,100% New York Medicaid APG,1958.52,,,1958.52,Other,100% New York Medicaid APG,4406.68,,,4406.68,Other,225% New York Medicaid APG,2996.54,,,2996.54,Other,153% New York Medicaid APG,4406.68,,,4406.68,Other,225% New York Medicaid APG,2741.93,,,2741.93,Other,140% New York Medicaid APG,4406.68,,,4406.68,Other,225% New York Medicaid APG,5092.16,,,5092.16,Other,260% New York Medicaid APG,6345.62,,,6345.62,Other,324% New York Medicaid APG,4210.83,,,4210.83,Other,215% New York Medicaid APG,4210.83,,,4210.83,Other,215% New York Medicaid APG,2448.16,,,2448.16,Other,125% New York Medicaid APG,1958.52,50381.24,
Incision of foot fascia,28008,CPT,,,,,,,,both,,,39365.75,29130.66,74,,29130.66,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,17714.59,45,,17714.59,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,19486.05,49.5,,19486.05,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2891.15,,,2891.15,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,27556.03,70,,27556.03,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1554.38,,,1554.38,Other,New York Medicaid APG methodology,1554.38,,,1554.38,Other,100% New York Medicaid APG,1554.38,,,1554.38,Other,100% New York Medicaid APG,1554.38,,,1554.38,Other,100% New York Medicaid APG,3497.36,,,3497.36,Other,225% New York Medicaid APG,2378.21,,,2378.21,Other,153% New York Medicaid APG,3497.36,,,3497.36,Other,225% New York Medicaid APG,2176.14,,,2176.14,Other,140% New York Medicaid APG,3497.36,,,3497.36,Other,225% New York Medicaid APG,4041.4,,,4041.4,Other,260% New York Medicaid APG,5036.2,,,5036.2,Other,324% New York Medicaid APG,3341.93,,,3341.93,Other,215% New York Medicaid APG,3341.93,,,3341.93,Other,215% New York Medicaid APG,1942.98,,,1942.98,Other,125% New York Medicaid APG,1554.38,29130.66,
Incision of toe tendon,28010,CPT,,,,,,,,both,,,33805.49,25016.06,74,,25016.06,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15212.47,45,,15212.47,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,16733.72,49.5,,16733.72,percent of total billed charges,110% of Medicare,22987.73,68,,22987.73,percent of total billed charges,,2891.15,,,2891.15,Other,186% of Medicaid,27044.39,80,,27044.39,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,27044.39,80,,27044.39,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,23663.84,70,,23663.84,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1554.38,,,1554.38,Other,New York Medicaid APG methodology,1554.38,,,1554.38,Other,100% New York Medicaid APG,1554.38,,,1554.38,Other,100% New York Medicaid APG,1554.38,,,1554.38,Other,100% New York Medicaid APG,3497.36,,,3497.36,Other,225% New York Medicaid APG,2378.21,,,2378.21,Other,153% New York Medicaid APG,3497.36,,,3497.36,Other,225% New York Medicaid APG,2176.14,,,2176.14,Other,140% New York Medicaid APG,3497.36,,,3497.36,Other,225% New York Medicaid APG,4041.4,,,4041.4,Other,260% New York Medicaid APG,5036.2,,,5036.2,Other,324% New York Medicaid APG,3341.93,,,3341.93,Other,215% New York Medicaid APG,3341.93,,,3341.93,Other,215% New York Medicaid APG,1942.98,,,1942.98,Other,125% New York Medicaid APG,1554.38,27044.39,
Incision of toe tendons,28011,CPT,,,,,,,,both,,,33805.49,25016.06,74,,25016.06,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15212.47,45,,15212.47,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,16733.72,49.5,,16733.72,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2891.15,,,2891.15,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,23663.84,70,,23663.84,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1554.38,,,1554.38,Other,New York Medicaid APG methodology,1554.38,,,1554.38,Other,100% New York Medicaid APG,1554.38,,,1554.38,Other,100% New York Medicaid APG,1554.38,,,1554.38,Other,100% New York Medicaid APG,3497.36,,,3497.36,Other,225% New York Medicaid APG,2378.21,,,2378.21,Other,153% New York Medicaid APG,3497.36,,,3497.36,Other,225% New York Medicaid APG,2176.14,,,2176.14,Other,140% New York Medicaid APG,3497.36,,,3497.36,Other,225% New York Medicaid APG,4041.4,,,4041.4,Other,260% New York Medicaid APG,5036.2,,,5036.2,Other,324% New York Medicaid APG,3341.93,,,3341.93,Other,215% New York Medicaid APG,3341.93,,,3341.93,Other,215% New York Medicaid APG,1942.98,,,1942.98,Other,125% New York Medicaid APG,1554.38,25016.06,
Exploration of foot joint,28020,CPT,,,,,,,,both,,,68082.75,50381.24,74,,50381.24,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30637.24,45,,30637.24,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33700.96,49.5,,33700.96,percent of total billed charges,110% of Medicare,46296.27,68,,46296.27,percent of total billed charges,,2891.15,,,2891.15,Other,186% of Medicaid,54466.2,80,,54466.2,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,54466.2,80,,54466.2,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,47657.93,70,,47657.93,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1554.38,,,1554.38,Other,New York Medicaid APG methodology,1554.38,,,1554.38,Other,100% New York Medicaid APG,1554.38,,,1554.38,Other,100% New York Medicaid APG,1554.38,,,1554.38,Other,100% New York Medicaid APG,3497.36,,,3497.36,Other,225% New York Medicaid APG,2378.21,,,2378.21,Other,153% New York Medicaid APG,3497.36,,,3497.36,Other,225% New York Medicaid APG,2176.14,,,2176.14,Other,140% New York Medicaid APG,3497.36,,,3497.36,Other,225% New York Medicaid APG,4041.4,,,4041.4,Other,260% New York Medicaid APG,5036.2,,,5036.2,Other,324% New York Medicaid APG,3341.93,,,3341.93,Other,215% New York Medicaid APG,3341.93,,,3341.93,Other,215% New York Medicaid APG,1942.98,,,1942.98,Other,125% New York Medicaid APG,1554.38,54466.2,
Exploration of foot joint,28022,CPT,,,,,,,,both,,,68082.75,50381.24,74,,50381.24,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30637.24,45,,30637.24,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33700.96,49.5,,33700.96,percent of total billed charges,110% of Medicare,46296.27,68,,46296.27,percent of total billed charges,,2891.15,,,2891.15,Other,186% of Medicaid,54466.2,80,,54466.2,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,54466.2,80,,54466.2,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,47657.93,70,,47657.93,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1554.38,,,1554.38,Other,New York Medicaid APG methodology,1554.38,,,1554.38,Other,100% New York Medicaid APG,1554.38,,,1554.38,Other,100% New York Medicaid APG,1554.38,,,1554.38,Other,100% New York Medicaid APG,3497.36,,,3497.36,Other,225% New York Medicaid APG,2378.21,,,2378.21,Other,153% New York Medicaid APG,3497.36,,,3497.36,Other,225% New York Medicaid APG,2176.14,,,2176.14,Other,140% New York Medicaid APG,3497.36,,,3497.36,Other,225% New York Medicaid APG,4041.4,,,4041.4,Other,260% New York Medicaid APG,5036.2,,,5036.2,Other,324% New York Medicaid APG,3341.93,,,3341.93,Other,215% New York Medicaid APG,3341.93,,,3341.93,Other,215% New York Medicaid APG,1942.98,,,1942.98,Other,125% New York Medicaid APG,1554.38,54466.2,
Exploration of toe joint,28024,CPT,,,,,,,,both,,,33805.49,25016.06,74,,25016.06,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15212.47,45,,15212.47,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,16733.72,49.5,,16733.72,percent of total billed charges,110% of Medicare,22987.73,68,,22987.73,percent of total billed charges,,2891.15,,,2891.15,Other,186% of Medicaid,27044.39,80,,27044.39,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,27044.39,80,,27044.39,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,23663.84,70,,23663.84,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1554.38,,,1554.38,Other,New York Medicaid APG methodology,1554.38,,,1554.38,Other,100% New York Medicaid APG,1554.38,,,1554.38,Other,100% New York Medicaid APG,1554.38,,,1554.38,Other,100% New York Medicaid APG,3497.36,,,3497.36,Other,225% New York Medicaid APG,2378.21,,,2378.21,Other,153% New York Medicaid APG,3497.36,,,3497.36,Other,225% New York Medicaid APG,2176.14,,,2176.14,Other,140% New York Medicaid APG,3497.36,,,3497.36,Other,225% New York Medicaid APG,4041.4,,,4041.4,Other,260% New York Medicaid APG,5036.2,,,5036.2,Other,324% New York Medicaid APG,3341.93,,,3341.93,Other,215% New York Medicaid APG,3341.93,,,3341.93,Other,215% New York Medicaid APG,1942.98,,,1942.98,Other,125% New York Medicaid APG,1554.38,27044.39,
Decompression of tibia nerve,28035,CPT,,,,,,,,both,,,40611.5,30052.51,74,,30052.51,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,18275.18,45,,18275.18,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,20102.69,49.5,,20102.69,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3097.27,,,3097.27,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,28428.05,70,,28428.05,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1665.2,,,1665.2,Other,New York Medicaid APG methodology,1665.2,,,1665.2,Other,100% New York Medicaid APG,1665.2,,,1665.2,Other,100% New York Medicaid APG,1665.2,,,1665.2,Other,100% New York Medicaid APG,3746.7,,,3746.7,Other,225% New York Medicaid APG,2547.75,,,2547.75,Other,153% New York Medicaid APG,3746.7,,,3746.7,Other,225% New York Medicaid APG,2331.28,,,2331.28,Other,140% New York Medicaid APG,3746.7,,,3746.7,Other,225% New York Medicaid APG,4329.52,,,4329.52,Other,260% New York Medicaid APG,5395.24,,,5395.24,Other,324% New York Medicaid APG,3580.18,,,3580.18,Other,215% New York Medicaid APG,3580.18,,,3580.18,Other,215% New York Medicaid APG,2081.5,,,2081.5,Other,125% New York Medicaid APG,1665.2,30052.51,
Exc foot/toe tum sc 1.5 cm/>,28039,CPT,,,,,,,,both,,,41783.13,30919.52,74,,30919.52,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,18802.41,45,,18802.41,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,20682.65,49.5,,20682.65,percent of total billed charges,110% of Medicare,28412.53,68,,28412.53,percent of total billed charges,,2891.15,,,2891.15,Other,186% of Medicaid,33426.5,80,,33426.5,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,33426.5,80,,33426.5,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,29248.19,70,,29248.19,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1554.38,,,1554.38,Other,New York Medicaid APG methodology,1554.38,,,1554.38,Other,100% New York Medicaid APG,1554.38,,,1554.38,Other,100% New York Medicaid APG,1554.38,,,1554.38,Other,100% New York Medicaid APG,3497.36,,,3497.36,Other,225% New York Medicaid APG,2378.21,,,2378.21,Other,153% New York Medicaid APG,3497.36,,,3497.36,Other,225% New York Medicaid APG,2176.14,,,2176.14,Other,140% New York Medicaid APG,3497.36,,,3497.36,Other,225% New York Medicaid APG,4041.4,,,4041.4,Other,260% New York Medicaid APG,5036.2,,,5036.2,Other,324% New York Medicaid APG,3341.93,,,3341.93,Other,215% New York Medicaid APG,3341.93,,,3341.93,Other,215% New York Medicaid APG,1942.98,,,1942.98,Other,125% New York Medicaid APG,1554.38,33426.5,
Exc foot/toe tum dep 1.5cm/>,28041,CPT,,,,,,,,both,,,58093.92,42989.5,74,,42989.5,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,26142.26,45,,26142.26,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,28756.49,49.5,,28756.49,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2891.15,,,2891.15,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,40665.74,70,,40665.74,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1554.38,,,1554.38,Other,New York Medicaid APG methodology,1554.38,,,1554.38,Other,100% New York Medicaid APG,1554.38,,,1554.38,Other,100% New York Medicaid APG,1554.38,,,1554.38,Other,100% New York Medicaid APG,3497.36,,,3497.36,Other,225% New York Medicaid APG,2378.21,,,2378.21,Other,153% New York Medicaid APG,3497.36,,,3497.36,Other,225% New York Medicaid APG,2176.14,,,2176.14,Other,140% New York Medicaid APG,3497.36,,,3497.36,Other,225% New York Medicaid APG,4041.4,,,4041.4,Other,260% New York Medicaid APG,5036.2,,,5036.2,Other,324% New York Medicaid APG,3341.93,,,3341.93,Other,215% New York Medicaid APG,3341.93,,,3341.93,Other,215% New York Medicaid APG,1942.98,,,1942.98,Other,125% New York Medicaid APG,1554.38,42989.5,
Exc foot/toe tum sc < 1.5 cm,28043,CPT,,,,,,,,both,,,36382.58,26923.11,74,,26923.11,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,16372.16,45,,16372.16,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,18009.38,49.5,,18009.38,percent of total billed charges,110% of Medicare,24740.15,68,,24740.15,percent of total billed charges,,1973.06,,,1973.06,Other,186% of Medicaid,29106.06,80,,29106.06,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,29106.06,80,,29106.06,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,25467.81,70,,25467.81,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1060.79,,,1060.79,Other,New York Medicaid APG methodology,1060.79,,,1060.79,Other,100% New York Medicaid APG,1060.79,,,1060.79,Other,100% New York Medicaid APG,1060.79,,,1060.79,Other,100% New York Medicaid APG,2386.77,,,2386.77,Other,225% New York Medicaid APG,1623,,,1623,Other,153% New York Medicaid APG,2386.77,,,2386.77,Other,225% New York Medicaid APG,1485.1,,,1485.1,Other,140% New York Medicaid APG,2386.77,,,2386.77,Other,225% New York Medicaid APG,2758.05,,,2758.05,Other,260% New York Medicaid APG,3436.95,,,3436.95,Other,324% New York Medicaid APG,2280.69,,,2280.69,Other,215% New York Medicaid APG,2280.69,,,2280.69,Other,215% New York Medicaid APG,1325.98,,,1325.98,Other,125% New York Medicaid APG,1060.79,29106.06,
Exc foot/toe tum deep <1.5cm,28045,CPT,,,,,,,,both,,,59767.2,44227.73,74,,44227.73,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,26895.24,45,,26895.24,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,29584.76,49.5,,29584.76,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2891.15,,,2891.15,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,41837.04,70,,41837.04,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1554.38,,,1554.38,Other,New York Medicaid APG methodology,1554.38,,,1554.38,Other,100% New York Medicaid APG,1554.38,,,1554.38,Other,100% New York Medicaid APG,1554.38,,,1554.38,Other,100% New York Medicaid APG,3497.36,,,3497.36,Other,225% New York Medicaid APG,2378.21,,,2378.21,Other,153% New York Medicaid APG,3497.36,,,3497.36,Other,225% New York Medicaid APG,2176.14,,,2176.14,Other,140% New York Medicaid APG,3497.36,,,3497.36,Other,225% New York Medicaid APG,4041.4,,,4041.4,Other,260% New York Medicaid APG,5036.2,,,5036.2,Other,324% New York Medicaid APG,3341.93,,,3341.93,Other,215% New York Medicaid APG,3341.93,,,3341.93,Other,215% New York Medicaid APG,1942.98,,,1942.98,Other,125% New York Medicaid APG,1554.38,44227.73,
Resect foot/toe tumor < 3 cm,28046,CPT,,,,,,,,both,,,59767.2,44227.73,74,,44227.73,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,26895.24,45,,26895.24,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,29584.76,49.5,,29584.76,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3642.86,,,3642.86,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,41837.04,70,,41837.04,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1958.52,,,1958.52,Other,New York Medicaid APG methodology,1958.52,,,1958.52,Other,100% New York Medicaid APG,1958.52,,,1958.52,Other,100% New York Medicaid APG,1958.52,,,1958.52,Other,100% New York Medicaid APG,4406.68,,,4406.68,Other,225% New York Medicaid APG,2996.54,,,2996.54,Other,153% New York Medicaid APG,4406.68,,,4406.68,Other,225% New York Medicaid APG,2741.93,,,2741.93,Other,140% New York Medicaid APG,4406.68,,,4406.68,Other,225% New York Medicaid APG,5092.16,,,5092.16,Other,260% New York Medicaid APG,6345.62,,,6345.62,Other,324% New York Medicaid APG,4210.83,,,4210.83,Other,215% New York Medicaid APG,4210.83,,,4210.83,Other,215% New York Medicaid APG,2448.16,,,2448.16,Other,125% New York Medicaid APG,1958.52,44227.73,
Resect foot/toe tumor 3 cm/>,28047,CPT,,,,,,,,both,,,35622.92,26360.96,74,,26360.96,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,16030.31,45,,16030.31,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,17633.35,49.5,,17633.35,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3642.86,,,3642.86,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,24936.04,70,,24936.04,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1958.52,,,1958.52,Other,New York Medicaid APG methodology,1958.52,,,1958.52,Other,100% New York Medicaid APG,1958.52,,,1958.52,Other,100% New York Medicaid APG,1958.52,,,1958.52,Other,100% New York Medicaid APG,4406.68,,,4406.68,Other,225% New York Medicaid APG,2996.54,,,2996.54,Other,153% New York Medicaid APG,4406.68,,,4406.68,Other,225% New York Medicaid APG,2741.93,,,2741.93,Other,140% New York Medicaid APG,4406.68,,,4406.68,Other,225% New York Medicaid APG,5092.16,,,5092.16,Other,260% New York Medicaid APG,6345.62,,,6345.62,Other,324% New York Medicaid APG,4210.83,,,4210.83,Other,215% New York Medicaid APG,4210.83,,,4210.83,Other,215% New York Medicaid APG,2448.16,,,2448.16,Other,125% New York Medicaid APG,1958.52,26360.96,
Biopsy of foot joint lining,28050,CPT,,,,,,,,both,,,68082.75,50381.24,74,,50381.24,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30637.24,45,,30637.24,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33700.96,49.5,,33700.96,percent of total billed charges,110% of Medicare,46296.27,68,,46296.27,percent of total billed charges,,2891.15,,,2891.15,Other,186% of Medicaid,54466.2,80,,54466.2,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,54466.2,80,,54466.2,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,47657.93,70,,47657.93,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1554.38,,,1554.38,Other,New York Medicaid APG methodology,1554.38,,,1554.38,Other,100% New York Medicaid APG,1554.38,,,1554.38,Other,100% New York Medicaid APG,1554.38,,,1554.38,Other,100% New York Medicaid APG,3497.36,,,3497.36,Other,225% New York Medicaid APG,2378.21,,,2378.21,Other,153% New York Medicaid APG,3497.36,,,3497.36,Other,225% New York Medicaid APG,2176.14,,,2176.14,Other,140% New York Medicaid APG,3497.36,,,3497.36,Other,225% New York Medicaid APG,4041.4,,,4041.4,Other,260% New York Medicaid APG,5036.2,,,5036.2,Other,324% New York Medicaid APG,3341.93,,,3341.93,Other,215% New York Medicaid APG,3341.93,,,3341.93,Other,215% New York Medicaid APG,1942.98,,,1942.98,Other,125% New York Medicaid APG,1554.38,54466.2,
Biopsy of foot joint lining,28052,CPT,,,,,,,,both,,,68082.75,50381.24,74,,50381.24,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30637.24,45,,30637.24,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33700.96,49.5,,33700.96,percent of total billed charges,110% of Medicare,46296.27,68,,46296.27,percent of total billed charges,,2891.15,,,2891.15,Other,186% of Medicaid,54466.2,80,,54466.2,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,54466.2,80,,54466.2,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,47657.93,70,,47657.93,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1554.38,,,1554.38,Other,New York Medicaid APG methodology,1554.38,,,1554.38,Other,100% New York Medicaid APG,1554.38,,,1554.38,Other,100% New York Medicaid APG,1554.38,,,1554.38,Other,100% New York Medicaid APG,3497.36,,,3497.36,Other,225% New York Medicaid APG,2378.21,,,2378.21,Other,153% New York Medicaid APG,3497.36,,,3497.36,Other,225% New York Medicaid APG,2176.14,,,2176.14,Other,140% New York Medicaid APG,3497.36,,,3497.36,Other,225% New York Medicaid APG,4041.4,,,4041.4,Other,260% New York Medicaid APG,5036.2,,,5036.2,Other,324% New York Medicaid APG,3341.93,,,3341.93,Other,215% New York Medicaid APG,3341.93,,,3341.93,Other,215% New York Medicaid APG,1942.98,,,1942.98,Other,125% New York Medicaid APG,1554.38,54466.2,
Biopsy of toe joint lining,28054,CPT,,,,,,,,both,,,68082.75,50381.24,74,,50381.24,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30637.24,45,,30637.24,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33700.96,49.5,,33700.96,percent of total billed charges,110% of Medicare,46296.27,68,,46296.27,percent of total billed charges,,2891.15,,,2891.15,Other,186% of Medicaid,54466.2,80,,54466.2,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,54466.2,80,,54466.2,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,47657.93,70,,47657.93,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1554.38,,,1554.38,Other,New York Medicaid APG methodology,1554.38,,,1554.38,Other,100% New York Medicaid APG,1554.38,,,1554.38,Other,100% New York Medicaid APG,1554.38,,,1554.38,Other,100% New York Medicaid APG,3497.36,,,3497.36,Other,225% New York Medicaid APG,2378.21,,,2378.21,Other,153% New York Medicaid APG,3497.36,,,3497.36,Other,225% New York Medicaid APG,2176.14,,,2176.14,Other,140% New York Medicaid APG,3497.36,,,3497.36,Other,225% New York Medicaid APG,4041.4,,,4041.4,Other,260% New York Medicaid APG,5036.2,,,5036.2,Other,324% New York Medicaid APG,3341.93,,,3341.93,Other,215% New York Medicaid APG,3341.93,,,3341.93,Other,215% New York Medicaid APG,1942.98,,,1942.98,Other,125% New York Medicaid APG,1554.38,54466.2,
Neurectomy foot,28055,CPT,,,,,,,,both,,,40611.5,30052.51,74,,30052.51,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,18275.18,45,,18275.18,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,20102.69,49.5,,20102.69,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3642.86,,,3642.86,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,28428.05,70,,28428.05,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1958.52,,,1958.52,Other,New York Medicaid APG methodology,1958.52,,,1958.52,Other,100% New York Medicaid APG,1958.52,,,1958.52,Other,100% New York Medicaid APG,1958.52,,,1958.52,Other,100% New York Medicaid APG,4406.68,,,4406.68,Other,225% New York Medicaid APG,2996.54,,,2996.54,Other,153% New York Medicaid APG,4406.68,,,4406.68,Other,225% New York Medicaid APG,2741.93,,,2741.93,Other,140% New York Medicaid APG,4406.68,,,4406.68,Other,225% New York Medicaid APG,5092.16,,,5092.16,Other,260% New York Medicaid APG,6345.62,,,6345.62,Other,324% New York Medicaid APG,4210.83,,,4210.83,Other,215% New York Medicaid APG,4210.83,,,4210.83,Other,215% New York Medicaid APG,2448.16,,,2448.16,Other,125% New York Medicaid APG,1958.52,30052.51,
Partial removal foot fascia,28060,CPT,,,,,,,,both,,,35068.64,25950.79,74,,25950.79,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15780.89,45,,15780.89,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,17358.98,49.5,,17358.98,percent of total billed charges,110% of Medicare,23846.68,68,,23846.68,percent of total billed charges,,2891.15,,,2891.15,Other,186% of Medicaid,28054.91,80,,28054.91,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,28054.91,80,,28054.91,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,24548.05,70,,24548.05,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1554.38,,,1554.38,Other,New York Medicaid APG methodology,1554.38,,,1554.38,Other,100% New York Medicaid APG,1554.38,,,1554.38,Other,100% New York Medicaid APG,1554.38,,,1554.38,Other,100% New York Medicaid APG,3497.36,,,3497.36,Other,225% New York Medicaid APG,2378.21,,,2378.21,Other,153% New York Medicaid APG,3497.36,,,3497.36,Other,225% New York Medicaid APG,2176.14,,,2176.14,Other,140% New York Medicaid APG,3497.36,,,3497.36,Other,225% New York Medicaid APG,4041.4,,,4041.4,Other,260% New York Medicaid APG,5036.2,,,5036.2,Other,324% New York Medicaid APG,3341.93,,,3341.93,Other,215% New York Medicaid APG,3341.93,,,3341.93,Other,215% New York Medicaid APG,1942.98,,,1942.98,Other,125% New York Medicaid APG,1554.38,28054.91,
Removal of foot fascia,28062,CPT,,,,,,,,both,,,51449.55,38072.67,74,,38072.67,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,23152.3,45,,23152.3,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,25467.53,49.5,,25467.53,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2891.15,,,2891.15,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,36014.69,70,,36014.69,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1554.38,,,1554.38,Other,New York Medicaid APG methodology,1554.38,,,1554.38,Other,100% New York Medicaid APG,1554.38,,,1554.38,Other,100% New York Medicaid APG,1554.38,,,1554.38,Other,100% New York Medicaid APG,3497.36,,,3497.36,Other,225% New York Medicaid APG,2378.21,,,2378.21,Other,153% New York Medicaid APG,3497.36,,,3497.36,Other,225% New York Medicaid APG,2176.14,,,2176.14,Other,140% New York Medicaid APG,3497.36,,,3497.36,Other,225% New York Medicaid APG,4041.4,,,4041.4,Other,260% New York Medicaid APG,5036.2,,,5036.2,Other,324% New York Medicaid APG,3341.93,,,3341.93,Other,215% New York Medicaid APG,3341.93,,,3341.93,Other,215% New York Medicaid APG,1942.98,,,1942.98,Other,125% New York Medicaid APG,1554.38,38072.67,
Removal of foot joint lining,28070,CPT,,,,,,,,both,,,37759.44,27941.99,74,,27941.99,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,16991.75,45,,16991.75,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,18690.92,49.5,,18690.92,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2891.15,,,2891.15,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,26431.61,70,,26431.61,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1554.38,,,1554.38,Other,New York Medicaid APG methodology,1554.38,,,1554.38,Other,100% New York Medicaid APG,1554.38,,,1554.38,Other,100% New York Medicaid APG,1554.38,,,1554.38,Other,100% New York Medicaid APG,3497.36,,,3497.36,Other,225% New York Medicaid APG,2378.21,,,2378.21,Other,153% New York Medicaid APG,3497.36,,,3497.36,Other,225% New York Medicaid APG,2176.14,,,2176.14,Other,140% New York Medicaid APG,3497.36,,,3497.36,Other,225% New York Medicaid APG,4041.4,,,4041.4,Other,260% New York Medicaid APG,5036.2,,,5036.2,Other,324% New York Medicaid APG,3341.93,,,3341.93,Other,215% New York Medicaid APG,3341.93,,,3341.93,Other,215% New York Medicaid APG,1942.98,,,1942.98,Other,125% New York Medicaid APG,1554.38,27941.99,
Removal of foot joint lining,28072,CPT,,,,,,,,both,,,68082.75,50381.24,74,,50381.24,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30637.24,45,,30637.24,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33700.96,49.5,,33700.96,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2891.15,,,2891.15,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,47657.93,70,,47657.93,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1554.38,,,1554.38,Other,New York Medicaid APG methodology,1554.38,,,1554.38,Other,100% New York Medicaid APG,1554.38,,,1554.38,Other,100% New York Medicaid APG,1554.38,,,1554.38,Other,100% New York Medicaid APG,3497.36,,,3497.36,Other,225% New York Medicaid APG,2378.21,,,2378.21,Other,153% New York Medicaid APG,3497.36,,,3497.36,Other,225% New York Medicaid APG,2176.14,,,2176.14,Other,140% New York Medicaid APG,3497.36,,,3497.36,Other,225% New York Medicaid APG,4041.4,,,4041.4,Other,260% New York Medicaid APG,5036.2,,,5036.2,Other,324% New York Medicaid APG,3341.93,,,3341.93,Other,215% New York Medicaid APG,3341.93,,,3341.93,Other,215% New York Medicaid APG,1942.98,,,1942.98,Other,125% New York Medicaid APG,1554.38,50381.24,
Removal of foot lesion,28080,CPT,,,,,,,,both,,,34738.77,25706.69,74,,25706.69,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15632.45,45,,15632.45,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,17195.69,49.5,,17195.69,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2891.15,,,2891.15,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,24317.14,70,,24317.14,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1554.38,,,1554.38,Other,New York Medicaid APG methodology,1554.38,,,1554.38,Other,100% New York Medicaid APG,1554.38,,,1554.38,Other,100% New York Medicaid APG,1554.38,,,1554.38,Other,100% New York Medicaid APG,3497.36,,,3497.36,Other,225% New York Medicaid APG,2378.21,,,2378.21,Other,153% New York Medicaid APG,3497.36,,,3497.36,Other,225% New York Medicaid APG,2176.14,,,2176.14,Other,140% New York Medicaid APG,3497.36,,,3497.36,Other,225% New York Medicaid APG,4041.4,,,4041.4,Other,260% New York Medicaid APG,5036.2,,,5036.2,Other,324% New York Medicaid APG,3341.93,,,3341.93,Other,215% New York Medicaid APG,3341.93,,,3341.93,Other,215% New York Medicaid APG,1942.98,,,1942.98,Other,125% New York Medicaid APG,1554.38,25706.69,
Excise foot tendon sheath,28086,CPT,,,,,,,,both,,,68082.75,50381.24,74,,50381.24,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30637.24,45,,30637.24,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33700.96,49.5,,33700.96,percent of total billed charges,110% of Medicare,46296.27,68,,46296.27,percent of total billed charges,,2891.15,,,2891.15,Other,186% of Medicaid,54466.2,80,,54466.2,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,54466.2,80,,54466.2,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,47657.93,70,,47657.93,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1554.38,,,1554.38,Other,New York Medicaid APG methodology,1554.38,,,1554.38,Other,100% New York Medicaid APG,1554.38,,,1554.38,Other,100% New York Medicaid APG,1554.38,,,1554.38,Other,100% New York Medicaid APG,3497.36,,,3497.36,Other,225% New York Medicaid APG,2378.21,,,2378.21,Other,153% New York Medicaid APG,3497.36,,,3497.36,Other,225% New York Medicaid APG,2176.14,,,2176.14,Other,140% New York Medicaid APG,3497.36,,,3497.36,Other,225% New York Medicaid APG,4041.4,,,4041.4,Other,260% New York Medicaid APG,5036.2,,,5036.2,Other,324% New York Medicaid APG,3341.93,,,3341.93,Other,215% New York Medicaid APG,3341.93,,,3341.93,Other,215% New York Medicaid APG,1942.98,,,1942.98,Other,125% New York Medicaid APG,1554.38,54466.2,
Excise foot tendon sheath,28088,CPT,,,,,,,,both,,,68082.75,50381.24,74,,50381.24,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30637.24,45,,30637.24,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33700.96,49.5,,33700.96,percent of total billed charges,110% of Medicare,46296.27,68,,46296.27,percent of total billed charges,,2891.15,,,2891.15,Other,186% of Medicaid,54466.2,80,,54466.2,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,54466.2,80,,54466.2,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,47657.93,70,,47657.93,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1554.38,,,1554.38,Other,New York Medicaid APG methodology,1554.38,,,1554.38,Other,100% New York Medicaid APG,1554.38,,,1554.38,Other,100% New York Medicaid APG,1554.38,,,1554.38,Other,100% New York Medicaid APG,3497.36,,,3497.36,Other,225% New York Medicaid APG,2378.21,,,2378.21,Other,153% New York Medicaid APG,3497.36,,,3497.36,Other,225% New York Medicaid APG,2176.14,,,2176.14,Other,140% New York Medicaid APG,3497.36,,,3497.36,Other,225% New York Medicaid APG,4041.4,,,4041.4,Other,260% New York Medicaid APG,5036.2,,,5036.2,Other,324% New York Medicaid APG,3341.93,,,3341.93,Other,215% New York Medicaid APG,3341.93,,,3341.93,Other,215% New York Medicaid APG,1942.98,,,1942.98,Other,125% New York Medicaid APG,1554.38,54466.2,
Removal of foot lesion,28090,CPT,,,,,,,,both,,,33789.97,25004.58,74,,25004.58,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15205.49,45,,15205.49,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,16726.04,49.5,,16726.04,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2891.15,,,2891.15,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,23652.98,70,,23652.98,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1554.38,,,1554.38,Other,New York Medicaid APG methodology,1554.38,,,1554.38,Other,100% New York Medicaid APG,1554.38,,,1554.38,Other,100% New York Medicaid APG,1554.38,,,1554.38,Other,100% New York Medicaid APG,3497.36,,,3497.36,Other,225% New York Medicaid APG,2378.21,,,2378.21,Other,153% New York Medicaid APG,3497.36,,,3497.36,Other,225% New York Medicaid APG,2176.14,,,2176.14,Other,140% New York Medicaid APG,3497.36,,,3497.36,Other,225% New York Medicaid APG,4041.4,,,4041.4,Other,260% New York Medicaid APG,5036.2,,,5036.2,Other,324% New York Medicaid APG,3341.93,,,3341.93,Other,215% New York Medicaid APG,3341.93,,,3341.93,Other,215% New York Medicaid APG,1942.98,,,1942.98,Other,125% New York Medicaid APG,1554.38,25004.58,
Removal of toe lesions,28092,CPT,,,,,,,,both,,,33805.49,25016.06,74,,25016.06,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15212.47,45,,15212.47,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,16733.72,49.5,,16733.72,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2891.15,,,2891.15,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,23663.84,70,,23663.84,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1554.38,,,1554.38,Other,New York Medicaid APG methodology,1554.38,,,1554.38,Other,100% New York Medicaid APG,1554.38,,,1554.38,Other,100% New York Medicaid APG,1554.38,,,1554.38,Other,100% New York Medicaid APG,3497.36,,,3497.36,Other,225% New York Medicaid APG,2378.21,,,2378.21,Other,153% New York Medicaid APG,3497.36,,,3497.36,Other,225% New York Medicaid APG,2176.14,,,2176.14,Other,140% New York Medicaid APG,3497.36,,,3497.36,Other,225% New York Medicaid APG,4041.4,,,4041.4,Other,260% New York Medicaid APG,5036.2,,,5036.2,Other,324% New York Medicaid APG,3341.93,,,3341.93,Other,215% New York Medicaid APG,3341.93,,,3341.93,Other,215% New York Medicaid APG,1942.98,,,1942.98,Other,125% New York Medicaid APG,1554.38,25016.06,
Removal of ankle/heel lesion,28100,CPT,,,,,,,,both,,,68082.75,50381.24,74,,50381.24,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30637.24,45,,30637.24,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33700.96,49.5,,33700.96,percent of total billed charges,110% of Medicare,46296.27,68,,46296.27,percent of total billed charges,,3642.86,,,3642.86,Other,186% of Medicaid,54466.2,80,,54466.2,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,54466.2,80,,54466.2,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,47657.93,70,,47657.93,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1958.52,,,1958.52,Other,New York Medicaid APG methodology,1958.52,,,1958.52,Other,100% New York Medicaid APG,1958.52,,,1958.52,Other,100% New York Medicaid APG,1958.52,,,1958.52,Other,100% New York Medicaid APG,4406.68,,,4406.68,Other,225% New York Medicaid APG,2996.54,,,2996.54,Other,153% New York Medicaid APG,4406.68,,,4406.68,Other,225% New York Medicaid APG,2741.93,,,2741.93,Other,140% New York Medicaid APG,4406.68,,,4406.68,Other,225% New York Medicaid APG,5092.16,,,5092.16,Other,260% New York Medicaid APG,6345.62,,,6345.62,Other,324% New York Medicaid APG,4210.83,,,4210.83,Other,215% New York Medicaid APG,4210.83,,,4210.83,Other,215% New York Medicaid APG,2448.16,,,2448.16,Other,125% New York Medicaid APG,1958.52,54466.2,
Remove/graft foot lesion,28102,CPT,,,,,,,,both,,,150476.65,111352.72,74,,111352.72,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,67714.49,45,,67714.49,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,74485.94,49.5,,74485.94,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3642.86,,,3642.86,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,105333.66,70,,105333.66,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,1958.52,,,1958.52,Other,New York Medicaid APG methodology,1958.52,,,1958.52,Other,100% New York Medicaid APG,1958.52,,,1958.52,Other,100% New York Medicaid APG,1958.52,,,1958.52,Other,100% New York Medicaid APG,4406.68,,,4406.68,Other,225% New York Medicaid APG,2996.54,,,2996.54,Other,153% New York Medicaid APG,4406.68,,,4406.68,Other,225% New York Medicaid APG,2741.93,,,2741.93,Other,140% New York Medicaid APG,4406.68,,,4406.68,Other,225% New York Medicaid APG,5092.16,,,5092.16,Other,260% New York Medicaid APG,6345.62,,,6345.62,Other,324% New York Medicaid APG,4210.83,,,4210.83,Other,215% New York Medicaid APG,4210.83,,,4210.83,Other,215% New York Medicaid APG,2448.16,,,2448.16,Other,125% New York Medicaid APG,1958.52,111352.72,
Remove/graft foot lesion,28103,CPT,,,,,,,,both,,,150476.65,111352.72,74,,111352.72,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,67714.49,45,,67714.49,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,74485.94,49.5,,74485.94,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3642.86,,,3642.86,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,105333.66,70,,105333.66,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,1958.52,,,1958.52,Other,New York Medicaid APG methodology,1958.52,,,1958.52,Other,100% New York Medicaid APG,1958.52,,,1958.52,Other,100% New York Medicaid APG,1958.52,,,1958.52,Other,100% New York Medicaid APG,4406.68,,,4406.68,Other,225% New York Medicaid APG,2996.54,,,2996.54,Other,153% New York Medicaid APG,4406.68,,,4406.68,Other,225% New York Medicaid APG,2741.93,,,2741.93,Other,140% New York Medicaid APG,4406.68,,,4406.68,Other,225% New York Medicaid APG,5092.16,,,5092.16,Other,260% New York Medicaid APG,6345.62,,,6345.62,Other,324% New York Medicaid APG,4210.83,,,4210.83,Other,215% New York Medicaid APG,4210.83,,,4210.83,Other,215% New York Medicaid APG,2448.16,,,2448.16,Other,125% New York Medicaid APG,1958.52,111352.72,
Removal of foot lesion,28104,CPT,,,,,,,,both,,,35913.38,26575.9,74,,26575.9,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,16161.02,45,,16161.02,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,17777.12,49.5,,17777.12,percent of total billed charges,110% of Medicare,24421.1,68,,24421.1,percent of total billed charges,,2891.15,,,2891.15,Other,186% of Medicaid,28730.7,80,,28730.7,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,28730.7,80,,28730.7,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,25139.37,70,,25139.37,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1554.38,,,1554.38,Other,New York Medicaid APG methodology,1554.38,,,1554.38,Other,100% New York Medicaid APG,1554.38,,,1554.38,Other,100% New York Medicaid APG,1554.38,,,1554.38,Other,100% New York Medicaid APG,3497.36,,,3497.36,Other,225% New York Medicaid APG,2378.21,,,2378.21,Other,153% New York Medicaid APG,3497.36,,,3497.36,Other,225% New York Medicaid APG,2176.14,,,2176.14,Other,140% New York Medicaid APG,3497.36,,,3497.36,Other,225% New York Medicaid APG,4041.4,,,4041.4,Other,260% New York Medicaid APG,5036.2,,,5036.2,Other,324% New York Medicaid APG,3341.93,,,3341.93,Other,215% New York Medicaid APG,3341.93,,,3341.93,Other,215% New York Medicaid APG,1942.98,,,1942.98,Other,125% New York Medicaid APG,1554.38,28730.7,
Remove/graft foot lesion,28106,CPT,,,,,,,,both,,,150476.65,111352.72,74,,111352.72,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,67714.49,45,,67714.49,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,74485.94,49.5,,74485.94,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3642.86,,,3642.86,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,105333.66,70,,105333.66,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,1958.52,,,1958.52,Other,New York Medicaid APG methodology,1958.52,,,1958.52,Other,100% New York Medicaid APG,1958.52,,,1958.52,Other,100% New York Medicaid APG,1958.52,,,1958.52,Other,100% New York Medicaid APG,4406.68,,,4406.68,Other,225% New York Medicaid APG,2996.54,,,2996.54,Other,153% New York Medicaid APG,4406.68,,,4406.68,Other,225% New York Medicaid APG,2741.93,,,2741.93,Other,140% New York Medicaid APG,4406.68,,,4406.68,Other,225% New York Medicaid APG,5092.16,,,5092.16,Other,260% New York Medicaid APG,6345.62,,,6345.62,Other,324% New York Medicaid APG,4210.83,,,4210.83,Other,215% New York Medicaid APG,4210.83,,,4210.83,Other,215% New York Medicaid APG,2448.16,,,2448.16,Other,125% New York Medicaid APG,1958.52,111352.72,
Remove/graft foot lesion,28107,CPT,,,,,,,,both,,,150476.65,111352.72,74,,111352.72,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,67714.49,45,,67714.49,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,74485.94,49.5,,74485.94,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3642.86,,,3642.86,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,105333.66,70,,105333.66,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,1958.52,,,1958.52,Other,New York Medicaid APG methodology,1958.52,,,1958.52,Other,100% New York Medicaid APG,1958.52,,,1958.52,Other,100% New York Medicaid APG,1958.52,,,1958.52,Other,100% New York Medicaid APG,4406.68,,,4406.68,Other,225% New York Medicaid APG,2996.54,,,2996.54,Other,153% New York Medicaid APG,4406.68,,,4406.68,Other,225% New York Medicaid APG,2741.93,,,2741.93,Other,140% New York Medicaid APG,4406.68,,,4406.68,Other,225% New York Medicaid APG,5092.16,,,5092.16,Other,260% New York Medicaid APG,6345.62,,,6345.62,Other,324% New York Medicaid APG,4210.83,,,4210.83,Other,215% New York Medicaid APG,4210.83,,,4210.83,Other,215% New York Medicaid APG,2448.16,,,2448.16,Other,125% New York Medicaid APG,1958.52,111352.72,
Removal of toe lesions,28108,CPT,,,,,,,,both,,,33805.49,25016.06,74,,25016.06,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15212.47,45,,15212.47,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,16733.72,49.5,,16733.72,percent of total billed charges,110% of Medicare,22987.73,68,,22987.73,percent of total billed charges,,2891.15,,,2891.15,Other,186% of Medicaid,27044.39,80,,27044.39,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,27044.39,80,,27044.39,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,23663.84,70,,23663.84,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1554.38,,,1554.38,Other,New York Medicaid APG methodology,1554.38,,,1554.38,Other,100% New York Medicaid APG,1554.38,,,1554.38,Other,100% New York Medicaid APG,1554.38,,,1554.38,Other,100% New York Medicaid APG,3497.36,,,3497.36,Other,225% New York Medicaid APG,2378.21,,,2378.21,Other,153% New York Medicaid APG,3497.36,,,3497.36,Other,225% New York Medicaid APG,2176.14,,,2176.14,Other,140% New York Medicaid APG,3497.36,,,3497.36,Other,225% New York Medicaid APG,4041.4,,,4041.4,Other,260% New York Medicaid APG,5036.2,,,5036.2,Other,324% New York Medicaid APG,3341.93,,,3341.93,Other,215% New York Medicaid APG,3341.93,,,3341.93,Other,215% New York Medicaid APG,1942.98,,,1942.98,Other,125% New York Medicaid APG,1554.38,27044.39,
Part removal of metatarsal,28110,CPT,,,,,,,,both,,,44380.59,32841.64,74,,32841.64,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,19971.27,45,,19971.27,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,21968.39,49.5,,21968.39,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3642.86,,,3642.86,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,31066.41,70,,31066.41,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1958.52,,,1958.52,Other,New York Medicaid APG methodology,1958.52,,,1958.52,Other,100% New York Medicaid APG,1958.52,,,1958.52,Other,100% New York Medicaid APG,1958.52,,,1958.52,Other,100% New York Medicaid APG,4406.68,,,4406.68,Other,225% New York Medicaid APG,2996.54,,,2996.54,Other,153% New York Medicaid APG,4406.68,,,4406.68,Other,225% New York Medicaid APG,2741.93,,,2741.93,Other,140% New York Medicaid APG,4406.68,,,4406.68,Other,225% New York Medicaid APG,5092.16,,,5092.16,Other,260% New York Medicaid APG,6345.62,,,6345.62,Other,324% New York Medicaid APG,4210.83,,,4210.83,Other,215% New York Medicaid APG,4210.83,,,4210.83,Other,215% New York Medicaid APG,2448.16,,,2448.16,Other,125% New York Medicaid APG,1958.52,32841.64,
Part removal of metatarsal,28111,CPT,,,,,,,,both,,,68082.75,50381.24,74,,50381.24,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30637.24,45,,30637.24,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33700.96,49.5,,33700.96,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2891.15,,,2891.15,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,47657.93,70,,47657.93,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1554.38,,,1554.38,Other,New York Medicaid APG methodology,1554.38,,,1554.38,Other,100% New York Medicaid APG,1554.38,,,1554.38,Other,100% New York Medicaid APG,1554.38,,,1554.38,Other,100% New York Medicaid APG,3497.36,,,3497.36,Other,225% New York Medicaid APG,2378.21,,,2378.21,Other,153% New York Medicaid APG,3497.36,,,3497.36,Other,225% New York Medicaid APG,2176.14,,,2176.14,Other,140% New York Medicaid APG,3497.36,,,3497.36,Other,225% New York Medicaid APG,4041.4,,,4041.4,Other,260% New York Medicaid APG,5036.2,,,5036.2,Other,324% New York Medicaid APG,3341.93,,,3341.93,Other,215% New York Medicaid APG,3341.93,,,3341.93,Other,215% New York Medicaid APG,1942.98,,,1942.98,Other,125% New York Medicaid APG,1554.38,50381.24,
Part removal of metatarsal,28112,CPT,,,,,,,,both,,,34923.41,25843.32,74,,25843.32,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15715.53,45,,15715.53,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,17287.09,49.5,,17287.09,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2891.15,,,2891.15,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,24446.39,70,,24446.39,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1554.38,,,1554.38,Other,New York Medicaid APG methodology,1554.38,,,1554.38,Other,100% New York Medicaid APG,1554.38,,,1554.38,Other,100% New York Medicaid APG,1554.38,,,1554.38,Other,100% New York Medicaid APG,3497.36,,,3497.36,Other,225% New York Medicaid APG,2378.21,,,2378.21,Other,153% New York Medicaid APG,3497.36,,,3497.36,Other,225% New York Medicaid APG,2176.14,,,2176.14,Other,140% New York Medicaid APG,3497.36,,,3497.36,Other,225% New York Medicaid APG,4041.4,,,4041.4,Other,260% New York Medicaid APG,5036.2,,,5036.2,Other,324% New York Medicaid APG,3341.93,,,3341.93,Other,215% New York Medicaid APG,3341.93,,,3341.93,Other,215% New York Medicaid APG,1942.98,,,1942.98,Other,125% New York Medicaid APG,1554.38,25843.32,
Part removal of metatarsal,28113,CPT,,,,,,,,both,,,34840.86,25782.24,74,,25782.24,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15678.39,45,,15678.39,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,17246.23,49.5,,17246.23,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2891.15,,,2891.15,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,24388.6,70,,24388.6,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1554.38,,,1554.38,Other,New York Medicaid APG methodology,1554.38,,,1554.38,Other,100% New York Medicaid APG,1554.38,,,1554.38,Other,100% New York Medicaid APG,1554.38,,,1554.38,Other,100% New York Medicaid APG,3497.36,,,3497.36,Other,225% New York Medicaid APG,2378.21,,,2378.21,Other,153% New York Medicaid APG,3497.36,,,3497.36,Other,225% New York Medicaid APG,2176.14,,,2176.14,Other,140% New York Medicaid APG,3497.36,,,3497.36,Other,225% New York Medicaid APG,4041.4,,,4041.4,Other,260% New York Medicaid APG,5036.2,,,5036.2,Other,324% New York Medicaid APG,3341.93,,,3341.93,Other,215% New York Medicaid APG,3341.93,,,3341.93,Other,215% New York Medicaid APG,1942.98,,,1942.98,Other,125% New York Medicaid APG,1554.38,25782.24,
Removal of metatarsal heads,28114,CPT,,,,,,,,both,,,68082.75,50381.24,74,,50381.24,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30637.24,45,,30637.24,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33700.96,49.5,,33700.96,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3642.86,,,3642.86,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,47657.93,70,,47657.93,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1958.52,,,1958.52,Other,New York Medicaid APG methodology,1958.52,,,1958.52,Other,100% New York Medicaid APG,1958.52,,,1958.52,Other,100% New York Medicaid APG,1958.52,,,1958.52,Other,100% New York Medicaid APG,4406.68,,,4406.68,Other,225% New York Medicaid APG,2996.54,,,2996.54,Other,153% New York Medicaid APG,4406.68,,,4406.68,Other,225% New York Medicaid APG,2741.93,,,2741.93,Other,140% New York Medicaid APG,4406.68,,,4406.68,Other,225% New York Medicaid APG,5092.16,,,5092.16,Other,260% New York Medicaid APG,6345.62,,,6345.62,Other,324% New York Medicaid APG,4210.83,,,4210.83,Other,215% New York Medicaid APG,4210.83,,,4210.83,Other,215% New York Medicaid APG,2448.16,,,2448.16,Other,125% New York Medicaid APG,1958.52,50381.24,
Revision of foot,28116,CPT,,,,,,,,both,,,67355.24,49842.88,74,,49842.88,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30309.86,45,,30309.86,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33340.84,49.5,,33340.84,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2891.15,,,2891.15,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,47148.67,70,,47148.67,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1554.38,,,1554.38,Other,New York Medicaid APG methodology,1554.38,,,1554.38,Other,100% New York Medicaid APG,1554.38,,,1554.38,Other,100% New York Medicaid APG,1554.38,,,1554.38,Other,100% New York Medicaid APG,3497.36,,,3497.36,Other,225% New York Medicaid APG,2378.21,,,2378.21,Other,153% New York Medicaid APG,3497.36,,,3497.36,Other,225% New York Medicaid APG,2176.14,,,2176.14,Other,140% New York Medicaid APG,3497.36,,,3497.36,Other,225% New York Medicaid APG,4041.4,,,4041.4,Other,260% New York Medicaid APG,5036.2,,,5036.2,Other,324% New York Medicaid APG,3341.93,,,3341.93,Other,215% New York Medicaid APG,3341.93,,,3341.93,Other,215% New York Medicaid APG,1942.98,,,1942.98,Other,125% New York Medicaid APG,1554.38,49842.88,
Removal of heel bone,28118,CPT,,,,,,,,both,,,68082.75,50381.24,74,,50381.24,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30637.24,45,,30637.24,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33700.96,49.5,,33700.96,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2891.15,,,2891.15,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,47657.93,70,,47657.93,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1554.38,,,1554.38,Other,New York Medicaid APG methodology,1554.38,,,1554.38,Other,100% New York Medicaid APG,1554.38,,,1554.38,Other,100% New York Medicaid APG,1554.38,,,1554.38,Other,100% New York Medicaid APG,3497.36,,,3497.36,Other,225% New York Medicaid APG,2378.21,,,2378.21,Other,153% New York Medicaid APG,3497.36,,,3497.36,Other,225% New York Medicaid APG,2176.14,,,2176.14,Other,140% New York Medicaid APG,3497.36,,,3497.36,Other,225% New York Medicaid APG,4041.4,,,4041.4,Other,260% New York Medicaid APG,5036.2,,,5036.2,Other,324% New York Medicaid APG,3341.93,,,3341.93,Other,215% New York Medicaid APG,3341.93,,,3341.93,Other,215% New York Medicaid APG,1942.98,,,1942.98,Other,125% New York Medicaid APG,1554.38,50381.24,
Removal of heel spur,28119,CPT,,,,,,,,both,,,42571.64,31503.01,74,,31503.01,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,19157.24,45,,19157.24,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,21072.96,49.5,,21072.96,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2891.15,,,2891.15,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,29800.15,70,,29800.15,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1554.38,,,1554.38,Other,New York Medicaid APG methodology,1554.38,,,1554.38,Other,100% New York Medicaid APG,1554.38,,,1554.38,Other,100% New York Medicaid APG,1554.38,,,1554.38,Other,100% New York Medicaid APG,3497.36,,,3497.36,Other,225% New York Medicaid APG,2378.21,,,2378.21,Other,153% New York Medicaid APG,3497.36,,,3497.36,Other,225% New York Medicaid APG,2176.14,,,2176.14,Other,140% New York Medicaid APG,3497.36,,,3497.36,Other,225% New York Medicaid APG,4041.4,,,4041.4,Other,260% New York Medicaid APG,5036.2,,,5036.2,Other,324% New York Medicaid APG,3341.93,,,3341.93,Other,215% New York Medicaid APG,3341.93,,,3341.93,Other,215% New York Medicaid APG,1942.98,,,1942.98,Other,125% New York Medicaid APG,1554.38,31503.01,
Part removal of ankle/heel,28120,CPT,,,,,,,,both,,,36961.26,27351.33,74,,27351.33,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,16632.57,45,,16632.57,percent of total billed charges,Medicare Ratio of cost to charges,5954,,"100% primary, 50% supplemental procedure",5954,Other,Aetna ASC Grouper,5359,,"100% primary, 50% supplemental procedure",5359,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,18295.82,49.5,,18295.82,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2891.15,,,2891.15,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,25872.88,70,,25872.88,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1554.38,,,1554.38,Other,New York Medicaid APG methodology,1554.38,,,1554.38,Other,100% New York Medicaid APG,1554.38,,,1554.38,Other,100% New York Medicaid APG,1554.38,,,1554.38,Other,100% New York Medicaid APG,3497.36,,,3497.36,Other,225% New York Medicaid APG,2378.21,,,2378.21,Other,153% New York Medicaid APG,3497.36,,,3497.36,Other,225% New York Medicaid APG,2176.14,,,2176.14,Other,140% New York Medicaid APG,3497.36,,,3497.36,Other,225% New York Medicaid APG,4041.4,,,4041.4,Other,260% New York Medicaid APG,5036.2,,,5036.2,Other,324% New York Medicaid APG,3341.93,,,3341.93,Other,215% New York Medicaid APG,3341.93,,,3341.93,Other,215% New York Medicaid APG,1942.98,,,1942.98,Other,125% New York Medicaid APG,1554.38,27351.33,
Partial removal of foot bone,28122,CPT,,,,,,,,both,,,39159.77,28978.23,74,,28978.23,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,17621.9,45,,17621.9,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,19384.09,49.5,,19384.09,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3642.86,,,3642.86,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,27411.84,70,,27411.84,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1958.52,,,1958.52,Other,New York Medicaid APG methodology,1958.52,,,1958.52,Other,100% New York Medicaid APG,1958.52,,,1958.52,Other,100% New York Medicaid APG,1958.52,,,1958.52,Other,100% New York Medicaid APG,4406.68,,,4406.68,Other,225% New York Medicaid APG,2996.54,,,2996.54,Other,153% New York Medicaid APG,4406.68,,,4406.68,Other,225% New York Medicaid APG,2741.93,,,2741.93,Other,140% New York Medicaid APG,4406.68,,,4406.68,Other,225% New York Medicaid APG,5092.16,,,5092.16,Other,260% New York Medicaid APG,6345.62,,,6345.62,Other,324% New York Medicaid APG,4210.83,,,4210.83,Other,215% New York Medicaid APG,4210.83,,,4210.83,Other,215% New York Medicaid APG,2448.16,,,2448.16,Other,125% New York Medicaid APG,1958.52,28978.23,
Partial removal of toe,28124,CPT,,,,,,,,both,,,33224.17,24585.89,74,,24585.89,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,14950.88,45,,14950.88,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,16445.96,49.5,,16445.96,percent of total billed charges,110% of Medicare,22592.44,68,,22592.44,percent of total billed charges,,2891.15,,,2891.15,Other,186% of Medicaid,26579.34,80,,26579.34,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,26579.34,80,,26579.34,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,23256.92,70,,23256.92,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1554.38,,,1554.38,Other,New York Medicaid APG methodology,1554.38,,,1554.38,Other,100% New York Medicaid APG,1554.38,,,1554.38,Other,100% New York Medicaid APG,1554.38,,,1554.38,Other,100% New York Medicaid APG,3497.36,,,3497.36,Other,225% New York Medicaid APG,2378.21,,,2378.21,Other,153% New York Medicaid APG,3497.36,,,3497.36,Other,225% New York Medicaid APG,2176.14,,,2176.14,Other,140% New York Medicaid APG,3497.36,,,3497.36,Other,225% New York Medicaid APG,4041.4,,,4041.4,Other,260% New York Medicaid APG,5036.2,,,5036.2,Other,324% New York Medicaid APG,3341.93,,,3341.93,Other,215% New York Medicaid APG,3341.93,,,3341.93,Other,215% New York Medicaid APG,1942.98,,,1942.98,Other,125% New York Medicaid APG,1554.38,26579.34,
Partial removal of toe,28126,CPT,,,,,,,,both,,,68082.75,50381.24,74,,50381.24,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30637.24,45,,30637.24,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33700.96,49.5,,33700.96,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2891.15,,,2891.15,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,47657.93,70,,47657.93,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1554.38,,,1554.38,Other,New York Medicaid APG methodology,1554.38,,,1554.38,Other,100% New York Medicaid APG,1554.38,,,1554.38,Other,100% New York Medicaid APG,1554.38,,,1554.38,Other,100% New York Medicaid APG,3497.36,,,3497.36,Other,225% New York Medicaid APG,2378.21,,,2378.21,Other,153% New York Medicaid APG,3497.36,,,3497.36,Other,225% New York Medicaid APG,2176.14,,,2176.14,Other,140% New York Medicaid APG,3497.36,,,3497.36,Other,225% New York Medicaid APG,4041.4,,,4041.4,Other,260% New York Medicaid APG,5036.2,,,5036.2,Other,324% New York Medicaid APG,3341.93,,,3341.93,Other,215% New York Medicaid APG,3341.93,,,3341.93,Other,215% New York Medicaid APG,1942.98,,,1942.98,Other,125% New York Medicaid APG,1554.38,50381.24,
Removal of ankle bone,28130,CPT,,,,,,,,both,,,150476.65,111352.72,74,,111352.72,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,67714.49,45,,67714.49,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,74485.94,49.5,,74485.94,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3642.86,,,3642.86,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,105333.66,70,,105333.66,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1958.52,,,1958.52,Other,New York Medicaid APG methodology,1958.52,,,1958.52,Other,100% New York Medicaid APG,1958.52,,,1958.52,Other,100% New York Medicaid APG,1958.52,,,1958.52,Other,100% New York Medicaid APG,4406.68,,,4406.68,Other,225% New York Medicaid APG,2996.54,,,2996.54,Other,153% New York Medicaid APG,4406.68,,,4406.68,Other,225% New York Medicaid APG,2741.93,,,2741.93,Other,140% New York Medicaid APG,4406.68,,,4406.68,Other,225% New York Medicaid APG,5092.16,,,5092.16,Other,260% New York Medicaid APG,6345.62,,,6345.62,Other,324% New York Medicaid APG,4210.83,,,4210.83,Other,215% New York Medicaid APG,4210.83,,,4210.83,Other,215% New York Medicaid APG,2448.16,,,2448.16,Other,125% New York Medicaid APG,1958.52,111352.72,
Removal of metatarsal,28140,CPT,,,,,,,,both,,,68082.75,50381.24,74,,50381.24,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30637.24,45,,30637.24,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33700.96,49.5,,33700.96,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2891.15,,,2891.15,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,47657.93,70,,47657.93,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1554.38,,,1554.38,Other,New York Medicaid APG methodology,1554.38,,,1554.38,Other,100% New York Medicaid APG,1554.38,,,1554.38,Other,100% New York Medicaid APG,1554.38,,,1554.38,Other,100% New York Medicaid APG,3497.36,,,3497.36,Other,225% New York Medicaid APG,2378.21,,,2378.21,Other,153% New York Medicaid APG,3497.36,,,3497.36,Other,225% New York Medicaid APG,2176.14,,,2176.14,Other,140% New York Medicaid APG,3497.36,,,3497.36,Other,225% New York Medicaid APG,4041.4,,,4041.4,Other,260% New York Medicaid APG,5036.2,,,5036.2,Other,324% New York Medicaid APG,3341.93,,,3341.93,Other,215% New York Medicaid APG,3341.93,,,3341.93,Other,215% New York Medicaid APG,1942.98,,,1942.98,Other,125% New York Medicaid APG,1554.38,50381.24,
Removal of toe,28150,CPT,,,,,,,,both,,,68082.75,50381.24,74,,50381.24,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30637.24,45,,30637.24,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33700.96,49.5,,33700.96,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2891.15,,,2891.15,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,47657.93,70,,47657.93,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1554.38,,,1554.38,Other,New York Medicaid APG methodology,1554.38,,,1554.38,Other,100% New York Medicaid APG,1554.38,,,1554.38,Other,100% New York Medicaid APG,1554.38,,,1554.38,Other,100% New York Medicaid APG,3497.36,,,3497.36,Other,225% New York Medicaid APG,2378.21,,,2378.21,Other,153% New York Medicaid APG,3497.36,,,3497.36,Other,225% New York Medicaid APG,2176.14,,,2176.14,Other,140% New York Medicaid APG,3497.36,,,3497.36,Other,225% New York Medicaid APG,4041.4,,,4041.4,Other,260% New York Medicaid APG,5036.2,,,5036.2,Other,324% New York Medicaid APG,3341.93,,,3341.93,Other,215% New York Medicaid APG,3341.93,,,3341.93,Other,215% New York Medicaid APG,1942.98,,,1942.98,Other,125% New York Medicaid APG,1554.38,50381.24,
Partial removal of toe,28153,CPT,,,,,,,,both,,,68082.75,50381.24,74,,50381.24,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30637.24,45,,30637.24,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33700.96,49.5,,33700.96,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2891.15,,,2891.15,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,47657.93,70,,47657.93,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1554.38,,,1554.38,Other,New York Medicaid APG methodology,1554.38,,,1554.38,Other,100% New York Medicaid APG,1554.38,,,1554.38,Other,100% New York Medicaid APG,1554.38,,,1554.38,Other,100% New York Medicaid APG,3497.36,,,3497.36,Other,225% New York Medicaid APG,2378.21,,,2378.21,Other,153% New York Medicaid APG,3497.36,,,3497.36,Other,225% New York Medicaid APG,2176.14,,,2176.14,Other,140% New York Medicaid APG,3497.36,,,3497.36,Other,225% New York Medicaid APG,4041.4,,,4041.4,Other,260% New York Medicaid APG,5036.2,,,5036.2,Other,324% New York Medicaid APG,3341.93,,,3341.93,Other,215% New York Medicaid APG,3341.93,,,3341.93,Other,215% New York Medicaid APG,1942.98,,,1942.98,Other,125% New York Medicaid APG,1554.38,50381.24,
Partial removal of toe,28160,CPT,,,,,,,,both,,,45697.03,33815.8,74,,33815.8,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,20563.66,45,,20563.66,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,22620.03,49.5,,22620.03,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2891.15,,,2891.15,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,31987.92,70,,31987.92,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1554.38,,,1554.38,Other,New York Medicaid APG methodology,1554.38,,,1554.38,Other,100% New York Medicaid APG,1554.38,,,1554.38,Other,100% New York Medicaid APG,1554.38,,,1554.38,Other,100% New York Medicaid APG,3497.36,,,3497.36,Other,225% New York Medicaid APG,2378.21,,,2378.21,Other,153% New York Medicaid APG,3497.36,,,3497.36,Other,225% New York Medicaid APG,2176.14,,,2176.14,Other,140% New York Medicaid APG,3497.36,,,3497.36,Other,225% New York Medicaid APG,4041.4,,,4041.4,Other,260% New York Medicaid APG,5036.2,,,5036.2,Other,324% New York Medicaid APG,3341.93,,,3341.93,Other,215% New York Medicaid APG,3341.93,,,3341.93,Other,215% New York Medicaid APG,1942.98,,,1942.98,Other,125% New York Medicaid APG,1554.38,33815.8,
Resect tarsal tumor,28171,CPT,,,,,,,,both,,,68082.75,50381.24,74,,50381.24,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30637.24,45,,30637.24,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33700.96,49.5,,33700.96,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3642.86,,,3642.86,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,47657.93,70,,47657.93,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1958.52,,,1958.52,Other,New York Medicaid APG methodology,1958.52,,,1958.52,Other,100% New York Medicaid APG,1958.52,,,1958.52,Other,100% New York Medicaid APG,1958.52,,,1958.52,Other,100% New York Medicaid APG,4406.68,,,4406.68,Other,225% New York Medicaid APG,2996.54,,,2996.54,Other,153% New York Medicaid APG,4406.68,,,4406.68,Other,225% New York Medicaid APG,2741.93,,,2741.93,Other,140% New York Medicaid APG,4406.68,,,4406.68,Other,225% New York Medicaid APG,5092.16,,,5092.16,Other,260% New York Medicaid APG,6345.62,,,6345.62,Other,324% New York Medicaid APG,4210.83,,,4210.83,Other,215% New York Medicaid APG,4210.83,,,4210.83,Other,215% New York Medicaid APG,2448.16,,,2448.16,Other,125% New York Medicaid APG,1958.52,50381.24,
Resect metatarsal tumor,28173,CPT,,,,,,,,both,,,68082.75,50381.24,74,,50381.24,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30637.24,45,,30637.24,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33700.96,49.5,,33700.96,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3642.86,,,3642.86,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,47657.93,70,,47657.93,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1958.52,,,1958.52,Other,New York Medicaid APG methodology,1958.52,,,1958.52,Other,100% New York Medicaid APG,1958.52,,,1958.52,Other,100% New York Medicaid APG,1958.52,,,1958.52,Other,100% New York Medicaid APG,4406.68,,,4406.68,Other,225% New York Medicaid APG,2996.54,,,2996.54,Other,153% New York Medicaid APG,4406.68,,,4406.68,Other,225% New York Medicaid APG,2741.93,,,2741.93,Other,140% New York Medicaid APG,4406.68,,,4406.68,Other,225% New York Medicaid APG,5092.16,,,5092.16,Other,260% New York Medicaid APG,6345.62,,,6345.62,Other,324% New York Medicaid APG,4210.83,,,4210.83,Other,215% New York Medicaid APG,4210.83,,,4210.83,Other,215% New York Medicaid APG,2448.16,,,2448.16,Other,125% New York Medicaid APG,1958.52,50381.24,
Resect phalanx of toe tumor,28175,CPT,,,,,,,,both,,,33805.49,25016.06,74,,25016.06,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15212.47,45,,15212.47,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,16733.72,49.5,,16733.72,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2891.15,,,2891.15,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,23663.84,70,,23663.84,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1554.38,,,1554.38,Other,New York Medicaid APG methodology,1554.38,,,1554.38,Other,100% New York Medicaid APG,1554.38,,,1554.38,Other,100% New York Medicaid APG,1554.38,,,1554.38,Other,100% New York Medicaid APG,3497.36,,,3497.36,Other,225% New York Medicaid APG,2378.21,,,2378.21,Other,153% New York Medicaid APG,3497.36,,,3497.36,Other,225% New York Medicaid APG,2176.14,,,2176.14,Other,140% New York Medicaid APG,3497.36,,,3497.36,Other,225% New York Medicaid APG,4041.4,,,4041.4,Other,260% New York Medicaid APG,5036.2,,,5036.2,Other,324% New York Medicaid APG,3341.93,,,3341.93,Other,215% New York Medicaid APG,3341.93,,,3341.93,Other,215% New York Medicaid APG,1942.98,,,1942.98,Other,125% New York Medicaid APG,1554.38,25016.06,
Removal of foot foreign body,28190,CPT,,,,,,,,both,,,34116.99,25246.57,74,,25246.57,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15352.65,45,,15352.65,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,16887.91,49.5,,16887.91,percent of total billed charges,110% of Medicare,23199.55,68,,23199.55,percent of total billed charges,,1240.83,,,1240.83,Other,186% of Medicaid,27293.59,80,,27293.59,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,27293.59,80,,27293.59,percent of total billed charges,,7216,,,7216,Case Rate,,3578,,"100% primary, 0% secondary procedures",3578,Other,MagnaCare ASC Grouper,23881.89,70,,23881.89,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,667.11,,,667.11,Other,New York Medicaid APG methodology,667.11,,,667.11,Other,100% New York Medicaid APG,667.11,,,667.11,Other,100% New York Medicaid APG,667.11,,,667.11,Other,100% New York Medicaid APG,1501,,,1501,Other,225% New York Medicaid APG,1020.68,,,1020.68,Other,153% New York Medicaid APG,1501,,,1501,Other,225% New York Medicaid APG,933.96,,,933.96,Other,140% New York Medicaid APG,1501,,,1501,Other,225% New York Medicaid APG,1734.49,,,1734.49,Other,260% New York Medicaid APG,2161.44,,,2161.44,Other,324% New York Medicaid APG,1434.29,,,1434.29,Other,215% New York Medicaid APG,1434.29,,,1434.29,Other,215% New York Medicaid APG,833.89,,,833.89,Other,125% New York Medicaid APG,667.11,27293.59,
Removal of foot foreign body,28192,CPT,,,,,,,,both,,,35216.74,26060.39,74,,26060.39,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15847.53,45,,15847.53,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,17432.29,49.5,,17432.29,percent of total billed charges,110% of Medicare,23947.38,68,,23947.38,percent of total billed charges,,1973.06,,,1973.06,Other,186% of Medicaid,28173.39,80,,28173.39,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,28173.39,80,,28173.39,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,24651.72,70,,24651.72,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1060.79,,,1060.79,Other,New York Medicaid APG methodology,1060.79,,,1060.79,Other,100% New York Medicaid APG,1060.79,,,1060.79,Other,100% New York Medicaid APG,1060.79,,,1060.79,Other,100% New York Medicaid APG,2386.77,,,2386.77,Other,225% New York Medicaid APG,1623,,,1623,Other,153% New York Medicaid APG,2386.77,,,2386.77,Other,225% New York Medicaid APG,1485.1,,,1485.1,Other,140% New York Medicaid APG,2386.77,,,2386.77,Other,225% New York Medicaid APG,2758.05,,,2758.05,Other,260% New York Medicaid APG,3436.95,,,3436.95,Other,324% New York Medicaid APG,2280.69,,,2280.69,Other,215% New York Medicaid APG,2280.69,,,2280.69,Other,215% New York Medicaid APG,1325.98,,,1325.98,Other,125% New York Medicaid APG,1060.79,28173.39,
Removal of foot foreign body,28193,CPT,,,,,,,,both,,,34101.75,25235.3,74,,25235.3,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15345.79,45,,15345.79,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,16880.37,49.5,,16880.37,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2891.15,,,2891.15,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,3578,,"100% primary, 0% secondary procedures",3578,Other,MagnaCare ASC Grouper,23871.23,70,,23871.23,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,1554.38,,,1554.38,Other,New York Medicaid APG methodology,1554.38,,,1554.38,Other,100% New York Medicaid APG,1554.38,,,1554.38,Other,100% New York Medicaid APG,1554.38,,,1554.38,Other,100% New York Medicaid APG,3497.36,,,3497.36,Other,225% New York Medicaid APG,2378.21,,,2378.21,Other,153% New York Medicaid APG,3497.36,,,3497.36,Other,225% New York Medicaid APG,2176.14,,,2176.14,Other,140% New York Medicaid APG,3497.36,,,3497.36,Other,225% New York Medicaid APG,4041.4,,,4041.4,Other,260% New York Medicaid APG,5036.2,,,5036.2,Other,324% New York Medicaid APG,3341.93,,,3341.93,Other,215% New York Medicaid APG,3341.93,,,3341.93,Other,215% New York Medicaid APG,1942.98,,,1942.98,Other,125% New York Medicaid APG,1554.38,25235.3,
Repair of foot tendon,28200,CPT,,,,,,,,both,,,66385.42,49125.21,74,,49125.21,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,29873.44,45,,29873.44,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,32860.78,49.5,,32860.78,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2891.15,,,2891.15,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,46469.79,70,,46469.79,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1554.38,,,1554.38,Other,New York Medicaid APG methodology,1554.38,,,1554.38,Other,100% New York Medicaid APG,1554.38,,,1554.38,Other,100% New York Medicaid APG,1554.38,,,1554.38,Other,100% New York Medicaid APG,3497.36,,,3497.36,Other,225% New York Medicaid APG,2378.21,,,2378.21,Other,153% New York Medicaid APG,3497.36,,,3497.36,Other,225% New York Medicaid APG,2176.14,,,2176.14,Other,140% New York Medicaid APG,3497.36,,,3497.36,Other,225% New York Medicaid APG,4041.4,,,4041.4,Other,260% New York Medicaid APG,5036.2,,,5036.2,Other,324% New York Medicaid APG,3341.93,,,3341.93,Other,215% New York Medicaid APG,3341.93,,,3341.93,Other,215% New York Medicaid APG,1942.98,,,1942.98,Other,125% New York Medicaid APG,1554.38,49125.21,
Repair/graft of foot tendon,28202,CPT,,,,,,,,both,,,58632.75,43388.24,74,,43388.24,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,26384.74,45,,26384.74,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,29023.21,49.5,,29023.21,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3642.86,,,3642.86,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,41042.93,70,,41042.93,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1958.52,,,1958.52,Other,New York Medicaid APG methodology,1958.52,,,1958.52,Other,100% New York Medicaid APG,1958.52,,,1958.52,Other,100% New York Medicaid APG,1958.52,,,1958.52,Other,100% New York Medicaid APG,4406.68,,,4406.68,Other,225% New York Medicaid APG,2996.54,,,2996.54,Other,153% New York Medicaid APG,4406.68,,,4406.68,Other,225% New York Medicaid APG,2741.93,,,2741.93,Other,140% New York Medicaid APG,4406.68,,,4406.68,Other,225% New York Medicaid APG,5092.16,,,5092.16,Other,260% New York Medicaid APG,6345.62,,,6345.62,Other,324% New York Medicaid APG,4210.83,,,4210.83,Other,215% New York Medicaid APG,4210.83,,,4210.83,Other,215% New York Medicaid APG,2448.16,,,2448.16,Other,125% New York Medicaid APG,1958.52,43388.24,
Repair of foot tendon,28208,CPT,,,,,,,,both,,,33901.61,25087.19,74,,25087.19,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15255.72,45,,15255.72,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,16781.3,49.5,,16781.3,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2891.15,,,2891.15,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,23731.13,70,,23731.13,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1554.38,,,1554.38,Other,New York Medicaid APG methodology,1554.38,,,1554.38,Other,100% New York Medicaid APG,1554.38,,,1554.38,Other,100% New York Medicaid APG,1554.38,,,1554.38,Other,100% New York Medicaid APG,3497.36,,,3497.36,Other,225% New York Medicaid APG,2378.21,,,2378.21,Other,153% New York Medicaid APG,3497.36,,,3497.36,Other,225% New York Medicaid APG,2176.14,,,2176.14,Other,140% New York Medicaid APG,3497.36,,,3497.36,Other,225% New York Medicaid APG,4041.4,,,4041.4,Other,260% New York Medicaid APG,5036.2,,,5036.2,Other,324% New York Medicaid APG,3341.93,,,3341.93,Other,215% New York Medicaid APG,3341.93,,,3341.93,Other,215% New York Medicaid APG,1942.98,,,1942.98,Other,125% New York Medicaid APG,1554.38,25087.19,
Repair/graft of foot tendon,28210,CPT,,,,,,,,both,,,150476.65,111352.72,74,,111352.72,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,67714.49,45,,67714.49,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,74485.94,49.5,,74485.94,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3642.86,,,3642.86,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,105333.66,70,,105333.66,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,1958.52,,,1958.52,Other,New York Medicaid APG methodology,1958.52,,,1958.52,Other,100% New York Medicaid APG,1958.52,,,1958.52,Other,100% New York Medicaid APG,1958.52,,,1958.52,Other,100% New York Medicaid APG,4406.68,,,4406.68,Other,225% New York Medicaid APG,2996.54,,,2996.54,Other,153% New York Medicaid APG,4406.68,,,4406.68,Other,225% New York Medicaid APG,2741.93,,,2741.93,Other,140% New York Medicaid APG,4406.68,,,4406.68,Other,225% New York Medicaid APG,5092.16,,,5092.16,Other,260% New York Medicaid APG,6345.62,,,6345.62,Other,324% New York Medicaid APG,4210.83,,,4210.83,Other,215% New York Medicaid APG,4210.83,,,4210.83,Other,215% New York Medicaid APG,2448.16,,,2448.16,Other,125% New York Medicaid APG,1958.52,111352.72,
Release of foot tendon,28220,CPT,,,,,,,,both,,,33805.49,25016.06,74,,25016.06,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15212.47,45,,15212.47,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,16733.72,49.5,,16733.72,percent of total billed charges,110% of Medicare,22987.73,68,,22987.73,percent of total billed charges,,2891.15,,,2891.15,Other,186% of Medicaid,27044.39,80,,27044.39,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,27044.39,80,,27044.39,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,23663.84,70,,23663.84,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1554.38,,,1554.38,Other,New York Medicaid APG methodology,1554.38,,,1554.38,Other,100% New York Medicaid APG,1554.38,,,1554.38,Other,100% New York Medicaid APG,1554.38,,,1554.38,Other,100% New York Medicaid APG,3497.36,,,3497.36,Other,225% New York Medicaid APG,2378.21,,,2378.21,Other,153% New York Medicaid APG,3497.36,,,3497.36,Other,225% New York Medicaid APG,2176.14,,,2176.14,Other,140% New York Medicaid APG,3497.36,,,3497.36,Other,225% New York Medicaid APG,4041.4,,,4041.4,Other,260% New York Medicaid APG,5036.2,,,5036.2,Other,324% New York Medicaid APG,3341.93,,,3341.93,Other,215% New York Medicaid APG,3341.93,,,3341.93,Other,215% New York Medicaid APG,1942.98,,,1942.98,Other,125% New York Medicaid APG,1554.38,27044.39,
Release of foot tendons,28222,CPT,,,,,,,,both,,,68082.75,50381.24,74,,50381.24,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30637.24,45,,30637.24,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33700.96,49.5,,33700.96,percent of total billed charges,110% of Medicare,46296.27,68,,46296.27,percent of total billed charges,,2891.15,,,2891.15,Other,186% of Medicaid,54466.2,80,,54466.2,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,54466.2,80,,54466.2,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,47657.93,70,,47657.93,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1554.38,,,1554.38,Other,New York Medicaid APG methodology,1554.38,,,1554.38,Other,100% New York Medicaid APG,1554.38,,,1554.38,Other,100% New York Medicaid APG,1554.38,,,1554.38,Other,100% New York Medicaid APG,3497.36,,,3497.36,Other,225% New York Medicaid APG,2378.21,,,2378.21,Other,153% New York Medicaid APG,3497.36,,,3497.36,Other,225% New York Medicaid APG,2176.14,,,2176.14,Other,140% New York Medicaid APG,3497.36,,,3497.36,Other,225% New York Medicaid APG,4041.4,,,4041.4,Other,260% New York Medicaid APG,5036.2,,,5036.2,Other,324% New York Medicaid APG,3341.93,,,3341.93,Other,215% New York Medicaid APG,3341.93,,,3341.93,Other,215% New York Medicaid APG,1942.98,,,1942.98,Other,125% New York Medicaid APG,1554.38,54466.2,
Release of foot tendon,28225,CPT,,,,,,,,both,,,68082.75,50381.24,74,,50381.24,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30637.24,45,,30637.24,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33700.96,49.5,,33700.96,percent of total billed charges,110% of Medicare,46296.27,68,,46296.27,percent of total billed charges,,2891.15,,,2891.15,Other,186% of Medicaid,54466.2,80,,54466.2,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,54466.2,80,,54466.2,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,47657.93,70,,47657.93,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1554.38,,,1554.38,Other,New York Medicaid APG methodology,1554.38,,,1554.38,Other,100% New York Medicaid APG,1554.38,,,1554.38,Other,100% New York Medicaid APG,1554.38,,,1554.38,Other,100% New York Medicaid APG,3497.36,,,3497.36,Other,225% New York Medicaid APG,2378.21,,,2378.21,Other,153% New York Medicaid APG,3497.36,,,3497.36,Other,225% New York Medicaid APG,2176.14,,,2176.14,Other,140% New York Medicaid APG,3497.36,,,3497.36,Other,225% New York Medicaid APG,4041.4,,,4041.4,Other,260% New York Medicaid APG,5036.2,,,5036.2,Other,324% New York Medicaid APG,3341.93,,,3341.93,Other,215% New York Medicaid APG,3341.93,,,3341.93,Other,215% New York Medicaid APG,1942.98,,,1942.98,Other,125% New York Medicaid APG,1554.38,54466.2,
Release of foot tendons,28226,CPT,,,,,,,,both,,,68082.75,50381.24,74,,50381.24,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30637.24,45,,30637.24,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33700.96,49.5,,33700.96,percent of total billed charges,110% of Medicare,46296.27,68,,46296.27,percent of total billed charges,,2891.15,,,2891.15,Other,186% of Medicaid,54466.2,80,,54466.2,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,54466.2,80,,54466.2,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,47657.93,70,,47657.93,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1554.38,,,1554.38,Other,New York Medicaid APG methodology,1554.38,,,1554.38,Other,100% New York Medicaid APG,1554.38,,,1554.38,Other,100% New York Medicaid APG,1554.38,,,1554.38,Other,100% New York Medicaid APG,3497.36,,,3497.36,Other,225% New York Medicaid APG,2378.21,,,2378.21,Other,153% New York Medicaid APG,3497.36,,,3497.36,Other,225% New York Medicaid APG,2176.14,,,2176.14,Other,140% New York Medicaid APG,3497.36,,,3497.36,Other,225% New York Medicaid APG,4041.4,,,4041.4,Other,260% New York Medicaid APG,5036.2,,,5036.2,Other,324% New York Medicaid APG,3341.93,,,3341.93,Other,215% New York Medicaid APG,3341.93,,,3341.93,Other,215% New York Medicaid APG,1942.98,,,1942.98,Other,125% New York Medicaid APG,1554.38,54466.2,
Incision of foot tendon(s),28230,CPT,,,,,,,,both,,,33805.49,25016.06,74,,25016.06,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15212.47,45,,15212.47,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,16733.72,49.5,,16733.72,percent of total billed charges,110% of Medicare,22987.73,68,,22987.73,percent of total billed charges,,2891.15,,,2891.15,Other,186% of Medicaid,27044.39,80,,27044.39,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,27044.39,80,,27044.39,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,23663.84,70,,23663.84,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1554.38,,,1554.38,Other,New York Medicaid APG methodology,1554.38,,,1554.38,Other,100% New York Medicaid APG,1554.38,,,1554.38,Other,100% New York Medicaid APG,1554.38,,,1554.38,Other,100% New York Medicaid APG,3497.36,,,3497.36,Other,225% New York Medicaid APG,2378.21,,,2378.21,Other,153% New York Medicaid APG,3497.36,,,3497.36,Other,225% New York Medicaid APG,2176.14,,,2176.14,Other,140% New York Medicaid APG,3497.36,,,3497.36,Other,225% New York Medicaid APG,4041.4,,,4041.4,Other,260% New York Medicaid APG,5036.2,,,5036.2,Other,324% New York Medicaid APG,3341.93,,,3341.93,Other,215% New York Medicaid APG,3341.93,,,3341.93,Other,215% New York Medicaid APG,1942.98,,,1942.98,Other,125% New York Medicaid APG,1554.38,27044.39,
Incision of toe tendon,28232,CPT,,,,,,,,both,,,36409.48,26943.02,74,,26943.02,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,16384.27,45,,16384.27,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,18022.69,49.5,,18022.69,percent of total billed charges,110% of Medicare,24758.45,68,,24758.45,percent of total billed charges,,2891.15,,,2891.15,Other,186% of Medicaid,29127.58,80,,29127.58,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,29127.58,80,,29127.58,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,25486.64,70,,25486.64,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1554.38,,,1554.38,Other,New York Medicaid APG methodology,1554.38,,,1554.38,Other,100% New York Medicaid APG,1554.38,,,1554.38,Other,100% New York Medicaid APG,1554.38,,,1554.38,Other,100% New York Medicaid APG,3497.36,,,3497.36,Other,225% New York Medicaid APG,2378.21,,,2378.21,Other,153% New York Medicaid APG,3497.36,,,3497.36,Other,225% New York Medicaid APG,2176.14,,,2176.14,Other,140% New York Medicaid APG,3497.36,,,3497.36,Other,225% New York Medicaid APG,4041.4,,,4041.4,Other,260% New York Medicaid APG,5036.2,,,5036.2,Other,324% New York Medicaid APG,3341.93,,,3341.93,Other,215% New York Medicaid APG,3341.93,,,3341.93,Other,215% New York Medicaid APG,1942.98,,,1942.98,Other,125% New York Medicaid APG,1554.38,29127.58,
Incision of foot tendon,28234,CPT,,,,,,,,both,,,33805.49,25016.06,74,,25016.06,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15212.47,45,,15212.47,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,16733.72,49.5,,16733.72,percent of total billed charges,110% of Medicare,22987.73,68,,22987.73,percent of total billed charges,,2891.15,,,2891.15,Other,186% of Medicaid,27044.39,80,,27044.39,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,27044.39,80,,27044.39,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,23663.84,70,,23663.84,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1554.38,,,1554.38,Other,New York Medicaid APG methodology,1554.38,,,1554.38,Other,100% New York Medicaid APG,1554.38,,,1554.38,Other,100% New York Medicaid APG,1554.38,,,1554.38,Other,100% New York Medicaid APG,3497.36,,,3497.36,Other,225% New York Medicaid APG,2378.21,,,2378.21,Other,153% New York Medicaid APG,3497.36,,,3497.36,Other,225% New York Medicaid APG,2176.14,,,2176.14,Other,140% New York Medicaid APG,3497.36,,,3497.36,Other,225% New York Medicaid APG,4041.4,,,4041.4,Other,260% New York Medicaid APG,5036.2,,,5036.2,Other,324% New York Medicaid APG,3341.93,,,3341.93,Other,215% New York Medicaid APG,3341.93,,,3341.93,Other,215% New York Medicaid APG,1942.98,,,1942.98,Other,125% New York Medicaid APG,1554.38,27044.39,
Revision of foot tendon,28238,CPT,,,,,,,,both,,,74342.65,55013.56,74,,55013.56,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,33454.19,45,,33454.19,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,36799.61,49.5,,36799.61,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3642.86,,,3642.86,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,52039.86,70,,52039.86,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,1958.52,,,1958.52,Other,New York Medicaid APG methodology,1958.52,,,1958.52,Other,100% New York Medicaid APG,1958.52,,,1958.52,Other,100% New York Medicaid APG,1958.52,,,1958.52,Other,100% New York Medicaid APG,4406.68,,,4406.68,Other,225% New York Medicaid APG,2996.54,,,2996.54,Other,153% New York Medicaid APG,4406.68,,,4406.68,Other,225% New York Medicaid APG,2741.93,,,2741.93,Other,140% New York Medicaid APG,4406.68,,,4406.68,Other,225% New York Medicaid APG,5092.16,,,5092.16,Other,260% New York Medicaid APG,6345.62,,,6345.62,Other,324% New York Medicaid APG,4210.83,,,4210.83,Other,215% New York Medicaid APG,4210.83,,,4210.83,Other,215% New York Medicaid APG,2448.16,,,2448.16,Other,125% New York Medicaid APG,1958.52,55013.56,
Release of big toe,28240,CPT,,,,,,,,both,,,68082.75,50381.24,74,,50381.24,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30637.24,45,,30637.24,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33700.96,49.5,,33700.96,percent of total billed charges,110% of Medicare,46296.27,68,,46296.27,percent of total billed charges,,2891.15,,,2891.15,Other,186% of Medicaid,54466.2,80,,54466.2,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,54466.2,80,,54466.2,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,47657.93,70,,47657.93,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1554.38,,,1554.38,Other,New York Medicaid APG methodology,1554.38,,,1554.38,Other,100% New York Medicaid APG,1554.38,,,1554.38,Other,100% New York Medicaid APG,1554.38,,,1554.38,Other,100% New York Medicaid APG,3497.36,,,3497.36,Other,225% New York Medicaid APG,2378.21,,,2378.21,Other,153% New York Medicaid APG,3497.36,,,3497.36,Other,225% New York Medicaid APG,2176.14,,,2176.14,Other,140% New York Medicaid APG,3497.36,,,3497.36,Other,225% New York Medicaid APG,4041.4,,,4041.4,Other,260% New York Medicaid APG,5036.2,,,5036.2,Other,324% New York Medicaid APG,3341.93,,,3341.93,Other,215% New York Medicaid APG,3341.93,,,3341.93,Other,215% New York Medicaid APG,1942.98,,,1942.98,Other,125% New York Medicaid APG,1554.38,54466.2,
Revision of foot fascia,28250,CPT,,,,,,,,both,,,68082.75,50381.24,74,,50381.24,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30637.24,45,,30637.24,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33700.96,49.5,,33700.96,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2891.15,,,2891.15,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,47657.93,70,,47657.93,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1554.38,,,1554.38,Other,New York Medicaid APG methodology,1554.38,,,1554.38,Other,100% New York Medicaid APG,1554.38,,,1554.38,Other,100% New York Medicaid APG,1554.38,,,1554.38,Other,100% New York Medicaid APG,3497.36,,,3497.36,Other,225% New York Medicaid APG,2378.21,,,2378.21,Other,153% New York Medicaid APG,3497.36,,,3497.36,Other,225% New York Medicaid APG,2176.14,,,2176.14,Other,140% New York Medicaid APG,3497.36,,,3497.36,Other,225% New York Medicaid APG,4041.4,,,4041.4,Other,260% New York Medicaid APG,5036.2,,,5036.2,Other,324% New York Medicaid APG,3341.93,,,3341.93,Other,215% New York Medicaid APG,3341.93,,,3341.93,Other,215% New York Medicaid APG,1942.98,,,1942.98,Other,125% New York Medicaid APG,1554.38,50381.24,
Release of midfoot joint,28260,CPT,,,,,,,,both,,,68082.75,50381.24,74,,50381.24,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30637.24,45,,30637.24,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33700.96,49.5,,33700.96,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3642.86,,,3642.86,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,47657.93,70,,47657.93,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1958.52,,,1958.52,Other,New York Medicaid APG methodology,1958.52,,,1958.52,Other,100% New York Medicaid APG,1958.52,,,1958.52,Other,100% New York Medicaid APG,1958.52,,,1958.52,Other,100% New York Medicaid APG,4406.68,,,4406.68,Other,225% New York Medicaid APG,2996.54,,,2996.54,Other,153% New York Medicaid APG,4406.68,,,4406.68,Other,225% New York Medicaid APG,2741.93,,,2741.93,Other,140% New York Medicaid APG,4406.68,,,4406.68,Other,225% New York Medicaid APG,5092.16,,,5092.16,Other,260% New York Medicaid APG,6345.62,,,6345.62,Other,324% New York Medicaid APG,4210.83,,,4210.83,Other,215% New York Medicaid APG,4210.83,,,4210.83,Other,215% New York Medicaid APG,2448.16,,,2448.16,Other,125% New York Medicaid APG,1958.52,50381.24,
Revision of foot tendon,28261,CPT,,,,,,,,both,,,57176.73,42310.78,74,,42310.78,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,25729.53,45,,25729.53,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,28302.48,49.5,,28302.48,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3642.86,,,3642.86,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,40023.71,70,,40023.71,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1958.52,,,1958.52,Other,New York Medicaid APG methodology,1958.52,,,1958.52,Other,100% New York Medicaid APG,1958.52,,,1958.52,Other,100% New York Medicaid APG,1958.52,,,1958.52,Other,100% New York Medicaid APG,4406.68,,,4406.68,Other,225% New York Medicaid APG,2996.54,,,2996.54,Other,153% New York Medicaid APG,4406.68,,,4406.68,Other,225% New York Medicaid APG,2741.93,,,2741.93,Other,140% New York Medicaid APG,4406.68,,,4406.68,Other,225% New York Medicaid APG,5092.16,,,5092.16,Other,260% New York Medicaid APG,6345.62,,,6345.62,Other,324% New York Medicaid APG,4210.83,,,4210.83,Other,215% New York Medicaid APG,4210.83,,,4210.83,Other,215% New York Medicaid APG,2448.16,,,2448.16,Other,125% New York Medicaid APG,1958.52,42310.78,
Revision of foot and ankle,28262,CPT,,,,,,,,both,,,93565.48,69238.46,74,,69238.46,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,42104.47,45,,42104.47,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,46314.91,49.5,,46314.91,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3642.86,,,3642.86,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,65495.84,70,,65495.84,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1958.52,,,1958.52,Other,New York Medicaid APG methodology,1958.52,,,1958.52,Other,100% New York Medicaid APG,1958.52,,,1958.52,Other,100% New York Medicaid APG,1958.52,,,1958.52,Other,100% New York Medicaid APG,4406.68,,,4406.68,Other,225% New York Medicaid APG,2996.54,,,2996.54,Other,153% New York Medicaid APG,4406.68,,,4406.68,Other,225% New York Medicaid APG,2741.93,,,2741.93,Other,140% New York Medicaid APG,4406.68,,,4406.68,Other,225% New York Medicaid APG,5092.16,,,5092.16,Other,260% New York Medicaid APG,6345.62,,,6345.62,Other,324% New York Medicaid APG,4210.83,,,4210.83,Other,215% New York Medicaid APG,4210.83,,,4210.83,Other,215% New York Medicaid APG,2448.16,,,2448.16,Other,125% New York Medicaid APG,1958.52,69238.46,
Release of midfoot joint,28264,CPT,,,,,,,,both,,,33805.49,25016.06,74,,25016.06,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15212.47,45,,15212.47,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,16733.72,49.5,,16733.72,percent of total billed charges,110% of Medicare,22987.73,68,,22987.73,percent of total billed charges,,3642.86,,,3642.86,Other,186% of Medicaid,27044.39,80,,27044.39,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,27044.39,80,,27044.39,percent of total billed charges,,7216,,,7216,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,23663.84,70,,23663.84,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,1958.52,,,1958.52,Other,New York Medicaid APG methodology,1958.52,,,1958.52,Other,100% New York Medicaid APG,1958.52,,,1958.52,Other,100% New York Medicaid APG,1958.52,,,1958.52,Other,100% New York Medicaid APG,4406.68,,,4406.68,Other,225% New York Medicaid APG,2996.54,,,2996.54,Other,153% New York Medicaid APG,4406.68,,,4406.68,Other,225% New York Medicaid APG,2741.93,,,2741.93,Other,140% New York Medicaid APG,4406.68,,,4406.68,Other,225% New York Medicaid APG,5092.16,,,5092.16,Other,260% New York Medicaid APG,6345.62,,,6345.62,Other,324% New York Medicaid APG,4210.83,,,4210.83,Other,215% New York Medicaid APG,4210.83,,,4210.83,Other,215% New York Medicaid APG,2448.16,,,2448.16,Other,125% New York Medicaid APG,1958.52,27044.39,
Release of foot contracture,28270,CPT,,,,,,,,both,,,68082.75,50381.24,74,,50381.24,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30637.24,45,,30637.24,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33700.96,49.5,,33700.96,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2891.15,,,2891.15,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,47657.93,70,,47657.93,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1554.38,,,1554.38,Other,New York Medicaid APG methodology,1554.38,,,1554.38,Other,100% New York Medicaid APG,1554.38,,,1554.38,Other,100% New York Medicaid APG,1554.38,,,1554.38,Other,100% New York Medicaid APG,3497.36,,,3497.36,Other,225% New York Medicaid APG,2378.21,,,2378.21,Other,153% New York Medicaid APG,3497.36,,,3497.36,Other,225% New York Medicaid APG,2176.14,,,2176.14,Other,140% New York Medicaid APG,3497.36,,,3497.36,Other,225% New York Medicaid APG,4041.4,,,4041.4,Other,260% New York Medicaid APG,5036.2,,,5036.2,Other,324% New York Medicaid APG,3341.93,,,3341.93,Other,215% New York Medicaid APG,3341.93,,,3341.93,Other,215% New York Medicaid APG,1942.98,,,1942.98,Other,125% New York Medicaid APG,1554.38,50381.24,
Release of toe joint each,28272,CPT,,,,,,,,both,,,33805.49,25016.06,74,,25016.06,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15212.47,45,,15212.47,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,16733.72,49.5,,16733.72,percent of total billed charges,110% of Medicare,22987.73,68,,22987.73,percent of total billed charges,,2891.15,,,2891.15,Other,186% of Medicaid,27044.39,80,,27044.39,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,27044.39,80,,27044.39,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,23663.84,70,,23663.84,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1554.38,,,1554.38,Other,New York Medicaid APG methodology,1554.38,,,1554.38,Other,100% New York Medicaid APG,1554.38,,,1554.38,Other,100% New York Medicaid APG,1554.38,,,1554.38,Other,100% New York Medicaid APG,3497.36,,,3497.36,Other,225% New York Medicaid APG,2378.21,,,2378.21,Other,153% New York Medicaid APG,3497.36,,,3497.36,Other,225% New York Medicaid APG,2176.14,,,2176.14,Other,140% New York Medicaid APG,3497.36,,,3497.36,Other,225% New York Medicaid APG,4041.4,,,4041.4,Other,260% New York Medicaid APG,5036.2,,,5036.2,Other,324% New York Medicaid APG,3341.93,,,3341.93,Other,215% New York Medicaid APG,3341.93,,,3341.93,Other,215% New York Medicaid APG,1942.98,,,1942.98,Other,125% New York Medicaid APG,1554.38,27044.39,
Fusion of toes,28280,CPT,,,,,,,,both,,,68082.75,50381.24,74,,50381.24,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30637.24,45,,30637.24,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33700.96,49.5,,33700.96,percent of total billed charges,110% of Medicare,46296.27,68,,46296.27,percent of total billed charges,,2891.15,,,2891.15,Other,186% of Medicaid,54466.2,80,,54466.2,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,54466.2,80,,54466.2,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,47657.93,70,,47657.93,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1554.38,,,1554.38,Other,New York Medicaid APG methodology,1554.38,,,1554.38,Other,100% New York Medicaid APG,1554.38,,,1554.38,Other,100% New York Medicaid APG,1554.38,,,1554.38,Other,100% New York Medicaid APG,3497.36,,,3497.36,Other,225% New York Medicaid APG,2378.21,,,2378.21,Other,153% New York Medicaid APG,3497.36,,,3497.36,Other,225% New York Medicaid APG,2176.14,,,2176.14,Other,140% New York Medicaid APG,3497.36,,,3497.36,Other,225% New York Medicaid APG,4041.4,,,4041.4,Other,260% New York Medicaid APG,5036.2,,,5036.2,Other,324% New York Medicaid APG,3341.93,,,3341.93,Other,215% New York Medicaid APG,3341.93,,,3341.93,Other,215% New York Medicaid APG,1942.98,,,1942.98,Other,125% New York Medicaid APG,1554.38,54466.2,
Repair of hammertoe,28285,CPT,,,,,,,,both,,,39003.16,28862.34,74,,28862.34,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,17551.42,45,,17551.42,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,19306.56,49.5,,19306.56,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2891.15,,,2891.15,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,27302.21,70,,27302.21,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1554.38,,,1554.38,Other,New York Medicaid APG methodology,1554.38,,,1554.38,Other,100% New York Medicaid APG,1554.38,,,1554.38,Other,100% New York Medicaid APG,1554.38,,,1554.38,Other,100% New York Medicaid APG,3497.36,,,3497.36,Other,225% New York Medicaid APG,2378.21,,,2378.21,Other,153% New York Medicaid APG,3497.36,,,3497.36,Other,225% New York Medicaid APG,2176.14,,,2176.14,Other,140% New York Medicaid APG,3497.36,,,3497.36,Other,225% New York Medicaid APG,4041.4,,,4041.4,Other,260% New York Medicaid APG,5036.2,,,5036.2,Other,324% New York Medicaid APG,3341.93,,,3341.93,Other,215% New York Medicaid APG,3341.93,,,3341.93,Other,215% New York Medicaid APG,1942.98,,,1942.98,Other,125% New York Medicaid APG,1554.38,28862.34,
Repair of hammertoe,28286,CPT,,,,,,,,both,,,68082.75,50381.24,74,,50381.24,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30637.24,45,,30637.24,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33700.96,49.5,,33700.96,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2891.15,,,2891.15,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,47657.93,70,,47657.93,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1554.38,,,1554.38,Other,New York Medicaid APG methodology,1554.38,,,1554.38,Other,100% New York Medicaid APG,1554.38,,,1554.38,Other,100% New York Medicaid APG,1554.38,,,1554.38,Other,100% New York Medicaid APG,3497.36,,,3497.36,Other,225% New York Medicaid APG,2378.21,,,2378.21,Other,153% New York Medicaid APG,3497.36,,,3497.36,Other,225% New York Medicaid APG,2176.14,,,2176.14,Other,140% New York Medicaid APG,3497.36,,,3497.36,Other,225% New York Medicaid APG,4041.4,,,4041.4,Other,260% New York Medicaid APG,5036.2,,,5036.2,Other,324% New York Medicaid APG,3341.93,,,3341.93,Other,215% New York Medicaid APG,3341.93,,,3341.93,Other,215% New York Medicaid APG,1942.98,,,1942.98,Other,125% New York Medicaid APG,1554.38,50381.24,
Partial removal of foot bone,28288,CPT,,,,,,,,both,,,34275.11,25363.58,74,,25363.58,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15423.8,45,,15423.8,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,16966.18,49.5,,16966.18,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2891.15,,,2891.15,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,23992.58,70,,23992.58,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1554.38,,,1554.38,Other,New York Medicaid APG methodology,1554.38,,,1554.38,Other,100% New York Medicaid APG,1554.38,,,1554.38,Other,100% New York Medicaid APG,1554.38,,,1554.38,Other,100% New York Medicaid APG,3497.36,,,3497.36,Other,225% New York Medicaid APG,2378.21,,,2378.21,Other,153% New York Medicaid APG,3497.36,,,3497.36,Other,225% New York Medicaid APG,2176.14,,,2176.14,Other,140% New York Medicaid APG,3497.36,,,3497.36,Other,225% New York Medicaid APG,4041.4,,,4041.4,Other,260% New York Medicaid APG,5036.2,,,5036.2,Other,324% New York Medicaid APG,3341.93,,,3341.93,Other,215% New York Medicaid APG,3341.93,,,3341.93,Other,215% New York Medicaid APG,1942.98,,,1942.98,Other,125% New York Medicaid APG,1554.38,25363.58,
Corrj halux rigdus w/o implt,28289,CPT,,,,,,,,both,,,34937.05,25853.42,74,,25853.42,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15721.67,45,,15721.67,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,17293.84,49.5,,17293.84,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3642.86,,,3642.86,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,24455.94,70,,24455.94,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1958.52,,,1958.52,Other,New York Medicaid APG methodology,1958.52,,,1958.52,Other,100% New York Medicaid APG,1958.52,,,1958.52,Other,100% New York Medicaid APG,1958.52,,,1958.52,Other,100% New York Medicaid APG,4406.68,,,4406.68,Other,225% New York Medicaid APG,2996.54,,,2996.54,Other,153% New York Medicaid APG,4406.68,,,4406.68,Other,225% New York Medicaid APG,2741.93,,,2741.93,Other,140% New York Medicaid APG,4406.68,,,4406.68,Other,225% New York Medicaid APG,5092.16,,,5092.16,Other,260% New York Medicaid APG,6345.62,,,6345.62,Other,324% New York Medicaid APG,4210.83,,,4210.83,Other,215% New York Medicaid APG,4210.83,,,4210.83,Other,215% New York Medicaid APG,2448.16,,,2448.16,Other,125% New York Medicaid APG,1958.52,25853.42,
Corrj halux rigdus w/implt,28291,CPT,,,,,,,,both,,,74358.15,55025.03,74,,55025.03,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,33461.17,45,,33461.17,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,36807.28,49.5,,36807.28,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3642.86,,,3642.86,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,52050.71,70,,52050.71,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,1958.52,,,1958.52,Other,New York Medicaid APG methodology,1958.52,,,1958.52,Other,100% New York Medicaid APG,1958.52,,,1958.52,Other,100% New York Medicaid APG,1958.52,,,1958.52,Other,100% New York Medicaid APG,4406.68,,,4406.68,Other,225% New York Medicaid APG,2996.54,,,2996.54,Other,153% New York Medicaid APG,4406.68,,,4406.68,Other,225% New York Medicaid APG,2741.93,,,2741.93,Other,140% New York Medicaid APG,4406.68,,,4406.68,Other,225% New York Medicaid APG,5092.16,,,5092.16,Other,260% New York Medicaid APG,6345.62,,,6345.62,Other,324% New York Medicaid APG,4210.83,,,4210.83,Other,215% New York Medicaid APG,4210.83,,,4210.83,Other,215% New York Medicaid APG,2448.16,,,2448.16,Other,125% New York Medicaid APG,1958.52,55025.03,
Correction hallux valgus,28292,CPT,,,,,,,,both,,,40898.42,30264.83,74,,30264.83,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,18404.29,45,,18404.29,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,20244.72,49.5,,20244.72,percent of total billed charges,110% of Medicare,27810.93,68,,27810.93,percent of total billed charges,,3642.86,,,3642.86,Other,186% of Medicaid,32718.74,80,,32718.74,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,32718.74,80,,32718.74,percent of total billed charges,,7216,,,7216,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,28628.89,70,,28628.89,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1958.52,,,1958.52,Other,New York Medicaid APG methodology,1958.52,,,1958.52,Other,100% New York Medicaid APG,1958.52,,,1958.52,Other,100% New York Medicaid APG,1958.52,,,1958.52,Other,100% New York Medicaid APG,4406.68,,,4406.68,Other,225% New York Medicaid APG,2996.54,,,2996.54,Other,153% New York Medicaid APG,4406.68,,,4406.68,Other,225% New York Medicaid APG,2741.93,,,2741.93,Other,140% New York Medicaid APG,4406.68,,,4406.68,Other,225% New York Medicaid APG,5092.16,,,5092.16,Other,260% New York Medicaid APG,6345.62,,,6345.62,Other,324% New York Medicaid APG,4210.83,,,4210.83,Other,215% New York Medicaid APG,4210.83,,,4210.83,Other,215% New York Medicaid APG,2448.16,,,2448.16,Other,125% New York Medicaid APG,1958.52,32718.74,
Correction hallux valgus,28295,CPT,,,,,,,,both,,,68082.75,50381.24,74,,50381.24,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30637.24,45,,30637.24,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33700.96,49.5,,33700.96,percent of total billed charges,110% of Medicare,46296.27,68,,46296.27,percent of total billed charges,,3642.86,,,3642.86,Other,186% of Medicaid,54466.2,80,,54466.2,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,54466.2,80,,54466.2,percent of total billed charges,,7216,,,7216,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,47657.93,70,,47657.93,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1958.52,,,1958.52,Other,New York Medicaid APG methodology,1958.52,,,1958.52,Other,100% New York Medicaid APG,1958.52,,,1958.52,Other,100% New York Medicaid APG,1958.52,,,1958.52,Other,100% New York Medicaid APG,4406.68,,,4406.68,Other,225% New York Medicaid APG,2996.54,,,2996.54,Other,153% New York Medicaid APG,4406.68,,,4406.68,Other,225% New York Medicaid APG,2741.93,,,2741.93,Other,140% New York Medicaid APG,4406.68,,,4406.68,Other,225% New York Medicaid APG,5092.16,,,5092.16,Other,260% New York Medicaid APG,6345.62,,,6345.62,Other,324% New York Medicaid APG,4210.83,,,4210.83,Other,215% New York Medicaid APG,4210.83,,,4210.83,Other,215% New York Medicaid APG,2448.16,,,2448.16,Other,125% New York Medicaid APG,1958.52,54466.2,
Correction hallux valgus,28296,CPT,,,,,,,,both,,,37862.65,28018.36,74,,28018.36,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,17038.19,45,,17038.19,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,18742.01,49.5,,18742.01,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3642.86,,,3642.86,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,26503.86,70,,26503.86,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1958.52,,,1958.52,Other,New York Medicaid APG methodology,1958.52,,,1958.52,Other,100% New York Medicaid APG,1958.52,,,1958.52,Other,100% New York Medicaid APG,1958.52,,,1958.52,Other,100% New York Medicaid APG,4406.68,,,4406.68,Other,225% New York Medicaid APG,2996.54,,,2996.54,Other,153% New York Medicaid APG,4406.68,,,4406.68,Other,225% New York Medicaid APG,2741.93,,,2741.93,Other,140% New York Medicaid APG,4406.68,,,4406.68,Other,225% New York Medicaid APG,5092.16,,,5092.16,Other,260% New York Medicaid APG,6345.62,,,6345.62,Other,324% New York Medicaid APG,4210.83,,,4210.83,Other,215% New York Medicaid APG,4210.83,,,4210.83,Other,215% New York Medicaid APG,2448.16,,,2448.16,Other,125% New York Medicaid APG,1958.52,28018.36,
Correction hallux valgus,28297,CPT,,,,,,,,both,,,150476.65,111352.72,74,,111352.72,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,67714.49,45,,67714.49,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,74485.94,49.5,,74485.94,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3642.86,,,3642.86,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,105333.66,70,,105333.66,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1958.52,,,1958.52,Other,New York Medicaid APG methodology,1958.52,,,1958.52,Other,100% New York Medicaid APG,1958.52,,,1958.52,Other,100% New York Medicaid APG,1958.52,,,1958.52,Other,100% New York Medicaid APG,4406.68,,,4406.68,Other,225% New York Medicaid APG,2996.54,,,2996.54,Other,153% New York Medicaid APG,4406.68,,,4406.68,Other,225% New York Medicaid APG,2741.93,,,2741.93,Other,140% New York Medicaid APG,4406.68,,,4406.68,Other,225% New York Medicaid APG,5092.16,,,5092.16,Other,260% New York Medicaid APG,6345.62,,,6345.62,Other,324% New York Medicaid APG,4210.83,,,4210.83,Other,215% New York Medicaid APG,4210.83,,,4210.83,Other,215% New York Medicaid APG,2448.16,,,2448.16,Other,125% New York Medicaid APG,1958.52,111352.72,
Correction hallux valgus,28298,CPT,,,,,,,,both,,,38569.2,28541.21,74,,28541.21,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,17356.14,45,,17356.14,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,19091.75,49.5,,19091.75,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3642.86,,,3642.86,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,26998.44,70,,26998.44,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1958.52,,,1958.52,Other,New York Medicaid APG methodology,1958.52,,,1958.52,Other,100% New York Medicaid APG,1958.52,,,1958.52,Other,100% New York Medicaid APG,1958.52,,,1958.52,Other,100% New York Medicaid APG,4406.68,,,4406.68,Other,225% New York Medicaid APG,2996.54,,,2996.54,Other,153% New York Medicaid APG,4406.68,,,4406.68,Other,225% New York Medicaid APG,2741.93,,,2741.93,Other,140% New York Medicaid APG,4406.68,,,4406.68,Other,225% New York Medicaid APG,5092.16,,,5092.16,Other,260% New York Medicaid APG,6345.62,,,6345.62,Other,324% New York Medicaid APG,4210.83,,,4210.83,Other,215% New York Medicaid APG,4210.83,,,4210.83,Other,215% New York Medicaid APG,2448.16,,,2448.16,Other,125% New York Medicaid APG,1958.52,28541.21,
Correction hallux valgus,28299,CPT,,,,,,,,both,,,53511.09,39598.21,74,,39598.21,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,24079.99,45,,24079.99,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,6125,,"100% primary, 50% secondary, 25% supplemental procedure",6125,Other,Blue Cross ASC Grouper,5513,,"100% primary, 50% secondary, 25% supplemental procedure",5513,Other,Blue Cross ASC Grouper,5206,,"100% primary, 50% secondary, 25% supplemental procedure",5206,Other,Blue Cross ASC Grouper,26487.99,49.5,,26487.99,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3642.86,,,3642.86,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,37457.76,70,,37457.76,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1958.52,,,1958.52,Other,New York Medicaid APG methodology,1958.52,,,1958.52,Other,100% New York Medicaid APG,1958.52,,,1958.52,Other,100% New York Medicaid APG,1958.52,,,1958.52,Other,100% New York Medicaid APG,4406.68,,,4406.68,Other,225% New York Medicaid APG,2996.54,,,2996.54,Other,153% New York Medicaid APG,4406.68,,,4406.68,Other,225% New York Medicaid APG,2741.93,,,2741.93,Other,140% New York Medicaid APG,4406.68,,,4406.68,Other,225% New York Medicaid APG,5092.16,,,5092.16,Other,260% New York Medicaid APG,6345.62,,,6345.62,Other,324% New York Medicaid APG,4210.83,,,4210.83,Other,215% New York Medicaid APG,4210.83,,,4210.83,Other,215% New York Medicaid APG,2448.16,,,2448.16,Other,125% New York Medicaid APG,1958.52,39598.21,
Incision of heel bone,28300,CPT,,,,,,,,both,,,116501.74,86211.29,74,,86211.29,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,52425.78,45,,52425.78,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,57668.36,49.5,,57668.36,percent of total billed charges,110% of Medicare,79221.18,68,,79221.18,percent of total billed charges,,3642.86,,,3642.86,Other,186% of Medicaid,93201.39,80,,93201.39,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,93201.39,80,,93201.39,percent of total billed charges,,7216,,,7216,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,81551.22,70,,81551.22,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,1958.52,,,1958.52,Other,New York Medicaid APG methodology,1958.52,,,1958.52,Other,100% New York Medicaid APG,1958.52,,,1958.52,Other,100% New York Medicaid APG,1958.52,,,1958.52,Other,100% New York Medicaid APG,4406.68,,,4406.68,Other,225% New York Medicaid APG,2996.54,,,2996.54,Other,153% New York Medicaid APG,4406.68,,,4406.68,Other,225% New York Medicaid APG,2741.93,,,2741.93,Other,140% New York Medicaid APG,4406.68,,,4406.68,Other,225% New York Medicaid APG,5092.16,,,5092.16,Other,260% New York Medicaid APG,6345.62,,,6345.62,Other,324% New York Medicaid APG,4210.83,,,4210.83,Other,215% New York Medicaid APG,4210.83,,,4210.83,Other,215% New York Medicaid APG,2448.16,,,2448.16,Other,125% New York Medicaid APG,1958.52,93201.39,
Incision of ankle bone,28302,CPT,,,,,,,,both,,,150476.65,111352.72,74,,111352.72,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,67714.49,45,,67714.49,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,74485.94,49.5,,74485.94,percent of total billed charges,110% of Medicare,102324.12,68,,102324.12,percent of total billed charges,,3642.86,,,3642.86,Other,186% of Medicaid,120381.32,80,,120381.32,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,120381.32,80,,120381.32,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,105333.66,70,,105333.66,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1958.52,,,1958.52,Other,New York Medicaid APG methodology,1958.52,,,1958.52,Other,100% New York Medicaid APG,1958.52,,,1958.52,Other,100% New York Medicaid APG,1958.52,,,1958.52,Other,100% New York Medicaid APG,4406.68,,,4406.68,Other,225% New York Medicaid APG,2996.54,,,2996.54,Other,153% New York Medicaid APG,4406.68,,,4406.68,Other,225% New York Medicaid APG,2741.93,,,2741.93,Other,140% New York Medicaid APG,4406.68,,,4406.68,Other,225% New York Medicaid APG,5092.16,,,5092.16,Other,260% New York Medicaid APG,6345.62,,,6345.62,Other,324% New York Medicaid APG,4210.83,,,4210.83,Other,215% New York Medicaid APG,4210.83,,,4210.83,Other,215% New York Medicaid APG,2448.16,,,2448.16,Other,125% New York Medicaid APG,1958.52,120381.32,
Incision of midfoot bones,28304,CPT,,,,,,,,both,,,150476.65,111352.72,74,,111352.72,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,67714.49,45,,67714.49,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,74485.94,49.5,,74485.94,percent of total billed charges,110% of Medicare,102324.12,68,,102324.12,percent of total billed charges,,3642.86,,,3642.86,Other,186% of Medicaid,120381.32,80,,120381.32,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,120381.32,80,,120381.32,percent of total billed charges,,7216,,,7216,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,105333.66,70,,105333.66,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,1958.52,,,1958.52,Other,New York Medicaid APG methodology,1958.52,,,1958.52,Other,100% New York Medicaid APG,1958.52,,,1958.52,Other,100% New York Medicaid APG,1958.52,,,1958.52,Other,100% New York Medicaid APG,4406.68,,,4406.68,Other,225% New York Medicaid APG,2996.54,,,2996.54,Other,153% New York Medicaid APG,4406.68,,,4406.68,Other,225% New York Medicaid APG,2741.93,,,2741.93,Other,140% New York Medicaid APG,4406.68,,,4406.68,Other,225% New York Medicaid APG,5092.16,,,5092.16,Other,260% New York Medicaid APG,6345.62,,,6345.62,Other,324% New York Medicaid APG,4210.83,,,4210.83,Other,215% New York Medicaid APG,4210.83,,,4210.83,Other,215% New York Medicaid APG,2448.16,,,2448.16,Other,125% New York Medicaid APG,1958.52,120381.32,
Incise/graft midfoot bones,28305,CPT,,,,,,,,both,,,99047.96,73295.49,74,,73295.49,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,44571.58,45,,44571.58,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,49028.74,49.5,,49028.74,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3642.86,,,3642.86,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,69333.57,70,,69333.57,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,1958.52,,,1958.52,Other,New York Medicaid APG methodology,1958.52,,,1958.52,Other,100% New York Medicaid APG,1958.52,,,1958.52,Other,100% New York Medicaid APG,1958.52,,,1958.52,Other,100% New York Medicaid APG,4406.68,,,4406.68,Other,225% New York Medicaid APG,2996.54,,,2996.54,Other,153% New York Medicaid APG,4406.68,,,4406.68,Other,225% New York Medicaid APG,2741.93,,,2741.93,Other,140% New York Medicaid APG,4406.68,,,4406.68,Other,225% New York Medicaid APG,5092.16,,,5092.16,Other,260% New York Medicaid APG,6345.62,,,6345.62,Other,324% New York Medicaid APG,4210.83,,,4210.83,Other,215% New York Medicaid APG,4210.83,,,4210.83,Other,215% New York Medicaid APG,2448.16,,,2448.16,Other,125% New York Medicaid APG,1958.52,73295.49,
Incision of metatarsal,28306,CPT,,,,,,,,both,,,33438.04,24744.15,74,,24744.15,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15047.12,45,,15047.12,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,16551.83,49.5,,16551.83,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2891.15,,,2891.15,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,23406.63,70,,23406.63,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1554.38,,,1554.38,Other,New York Medicaid APG methodology,1554.38,,,1554.38,Other,100% New York Medicaid APG,1554.38,,,1554.38,Other,100% New York Medicaid APG,1554.38,,,1554.38,Other,100% New York Medicaid APG,3497.36,,,3497.36,Other,225% New York Medicaid APG,2378.21,,,2378.21,Other,153% New York Medicaid APG,3497.36,,,3497.36,Other,225% New York Medicaid APG,2176.14,,,2176.14,Other,140% New York Medicaid APG,3497.36,,,3497.36,Other,225% New York Medicaid APG,4041.4,,,4041.4,Other,260% New York Medicaid APG,5036.2,,,5036.2,Other,324% New York Medicaid APG,3341.93,,,3341.93,Other,215% New York Medicaid APG,3341.93,,,3341.93,Other,215% New York Medicaid APG,1942.98,,,1942.98,Other,125% New York Medicaid APG,1554.38,24744.15,
Incision of metatarsal,28307,CPT,,,,,,,,both,,,150476.65,111352.72,74,,111352.72,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,67714.49,45,,67714.49,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,74485.94,49.5,,74485.94,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3642.86,,,3642.86,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,105333.66,70,,105333.66,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1958.52,,,1958.52,Other,New York Medicaid APG methodology,1958.52,,,1958.52,Other,100% New York Medicaid APG,1958.52,,,1958.52,Other,100% New York Medicaid APG,1958.52,,,1958.52,Other,100% New York Medicaid APG,4406.68,,,4406.68,Other,225% New York Medicaid APG,2996.54,,,2996.54,Other,153% New York Medicaid APG,4406.68,,,4406.68,Other,225% New York Medicaid APG,2741.93,,,2741.93,Other,140% New York Medicaid APG,4406.68,,,4406.68,Other,225% New York Medicaid APG,5092.16,,,5092.16,Other,260% New York Medicaid APG,6345.62,,,6345.62,Other,324% New York Medicaid APG,4210.83,,,4210.83,Other,215% New York Medicaid APG,4210.83,,,4210.83,Other,215% New York Medicaid APG,2448.16,,,2448.16,Other,125% New York Medicaid APG,1958.52,111352.72,
Incision of metatarsal,28308,CPT,,,,,,,,both,,,50631.12,37467.03,74,,37467.03,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,22784,45,,22784,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,25062.4,49.5,,25062.4,percent of total billed charges,110% of Medicare,34429.16,68,,34429.16,percent of total billed charges,,2891.15,,,2891.15,Other,186% of Medicaid,40504.9,80,,40504.9,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,40504.9,80,,40504.9,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,35441.78,70,,35441.78,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1554.38,,,1554.38,Other,New York Medicaid APG methodology,1554.38,,,1554.38,Other,100% New York Medicaid APG,1554.38,,,1554.38,Other,100% New York Medicaid APG,1554.38,,,1554.38,Other,100% New York Medicaid APG,3497.36,,,3497.36,Other,225% New York Medicaid APG,2378.21,,,2378.21,Other,153% New York Medicaid APG,3497.36,,,3497.36,Other,225% New York Medicaid APG,2176.14,,,2176.14,Other,140% New York Medicaid APG,3497.36,,,3497.36,Other,225% New York Medicaid APG,4041.4,,,4041.4,Other,260% New York Medicaid APG,5036.2,,,5036.2,Other,324% New York Medicaid APG,3341.93,,,3341.93,Other,215% New York Medicaid APG,3341.93,,,3341.93,Other,215% New York Medicaid APG,1942.98,,,1942.98,Other,125% New York Medicaid APG,1554.38,40504.9,
Incision of metatarsals,28309,CPT,,,,,,,,both,,,150476.65,111352.72,74,,111352.72,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,67714.49,45,,67714.49,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,74485.94,49.5,,74485.94,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3642.86,,,3642.86,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,105333.66,70,,105333.66,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,1958.52,,,1958.52,Other,New York Medicaid APG methodology,1958.52,,,1958.52,Other,100% New York Medicaid APG,1958.52,,,1958.52,Other,100% New York Medicaid APG,1958.52,,,1958.52,Other,100% New York Medicaid APG,4406.68,,,4406.68,Other,225% New York Medicaid APG,2996.54,,,2996.54,Other,153% New York Medicaid APG,4406.68,,,4406.68,Other,225% New York Medicaid APG,2741.93,,,2741.93,Other,140% New York Medicaid APG,4406.68,,,4406.68,Other,225% New York Medicaid APG,5092.16,,,5092.16,Other,260% New York Medicaid APG,6345.62,,,6345.62,Other,324% New York Medicaid APG,4210.83,,,4210.83,Other,215% New York Medicaid APG,4210.83,,,4210.83,Other,215% New York Medicaid APG,2448.16,,,2448.16,Other,125% New York Medicaid APG,1958.52,111352.72,
Revision of big toe,28310,CPT,,,,,,,,both,,,150476.65,111352.72,74,,111352.72,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,67714.49,45,,67714.49,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,74485.94,49.5,,74485.94,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2891.15,,,2891.15,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,105333.66,70,,105333.66,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1554.38,,,1554.38,Other,New York Medicaid APG methodology,1554.38,,,1554.38,Other,100% New York Medicaid APG,1554.38,,,1554.38,Other,100% New York Medicaid APG,1554.38,,,1554.38,Other,100% New York Medicaid APG,3497.36,,,3497.36,Other,225% New York Medicaid APG,2378.21,,,2378.21,Other,153% New York Medicaid APG,3497.36,,,3497.36,Other,225% New York Medicaid APG,2176.14,,,2176.14,Other,140% New York Medicaid APG,3497.36,,,3497.36,Other,225% New York Medicaid APG,4041.4,,,4041.4,Other,260% New York Medicaid APG,5036.2,,,5036.2,Other,324% New York Medicaid APG,3341.93,,,3341.93,Other,215% New York Medicaid APG,3341.93,,,3341.93,Other,215% New York Medicaid APG,1942.98,,,1942.98,Other,125% New York Medicaid APG,1554.38,111352.72,
Revision of toe,28312,CPT,,,,,,,,both,,,68082.75,50381.24,74,,50381.24,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30637.24,45,,30637.24,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33700.96,49.5,,33700.96,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2891.15,,,2891.15,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,47657.93,70,,47657.93,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1554.38,,,1554.38,Other,New York Medicaid APG methodology,1554.38,,,1554.38,Other,100% New York Medicaid APG,1554.38,,,1554.38,Other,100% New York Medicaid APG,1554.38,,,1554.38,Other,100% New York Medicaid APG,3497.36,,,3497.36,Other,225% New York Medicaid APG,2378.21,,,2378.21,Other,153% New York Medicaid APG,3497.36,,,3497.36,Other,225% New York Medicaid APG,2176.14,,,2176.14,Other,140% New York Medicaid APG,3497.36,,,3497.36,Other,225% New York Medicaid APG,4041.4,,,4041.4,Other,260% New York Medicaid APG,5036.2,,,5036.2,Other,324% New York Medicaid APG,3341.93,,,3341.93,Other,215% New York Medicaid APG,3341.93,,,3341.93,Other,215% New York Medicaid APG,1942.98,,,1942.98,Other,125% New York Medicaid APG,1554.38,50381.24,
Repair deformity of toe,28313,CPT,,,,,,,,both,,,68082.75,50381.24,74,,50381.24,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30637.24,45,,30637.24,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33700.96,49.5,,33700.96,percent of total billed charges,110% of Medicare,46296.27,68,,46296.27,percent of total billed charges,,2891.15,,,2891.15,Other,186% of Medicaid,54466.2,80,,54466.2,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,54466.2,80,,54466.2,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,47657.93,70,,47657.93,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1554.38,,,1554.38,Other,New York Medicaid APG methodology,1554.38,,,1554.38,Other,100% New York Medicaid APG,1554.38,,,1554.38,Other,100% New York Medicaid APG,1554.38,,,1554.38,Other,100% New York Medicaid APG,3497.36,,,3497.36,Other,225% New York Medicaid APG,2378.21,,,2378.21,Other,153% New York Medicaid APG,3497.36,,,3497.36,Other,225% New York Medicaid APG,2176.14,,,2176.14,Other,140% New York Medicaid APG,3497.36,,,3497.36,Other,225% New York Medicaid APG,4041.4,,,4041.4,Other,260% New York Medicaid APG,5036.2,,,5036.2,Other,324% New York Medicaid APG,3341.93,,,3341.93,Other,215% New York Medicaid APG,3341.93,,,3341.93,Other,215% New York Medicaid APG,1942.98,,,1942.98,Other,125% New York Medicaid APG,1554.38,54466.2,
Removal of sesamoid bone,28315,CPT,,,,,,,,both,,,33217,24580.58,74,,24580.58,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,14947.65,45,,14947.65,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,16442.42,49.5,,16442.42,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2891.15,,,2891.15,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,23251.9,70,,23251.9,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1554.38,,,1554.38,Other,New York Medicaid APG methodology,1554.38,,,1554.38,Other,100% New York Medicaid APG,1554.38,,,1554.38,Other,100% New York Medicaid APG,1554.38,,,1554.38,Other,100% New York Medicaid APG,3497.36,,,3497.36,Other,225% New York Medicaid APG,2378.21,,,2378.21,Other,153% New York Medicaid APG,3497.36,,,3497.36,Other,225% New York Medicaid APG,2176.14,,,2176.14,Other,140% New York Medicaid APG,3497.36,,,3497.36,Other,225% New York Medicaid APG,4041.4,,,4041.4,Other,260% New York Medicaid APG,5036.2,,,5036.2,Other,324% New York Medicaid APG,3341.93,,,3341.93,Other,215% New York Medicaid APG,3341.93,,,3341.93,Other,215% New York Medicaid APG,1942.98,,,1942.98,Other,125% New York Medicaid APG,1554.38,24580.58,
Repair of foot bones,28320,CPT,,,,,,,,both,,,276827.87,204852.62,74,,204852.62,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,124572.54,45,,124572.54,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,137029.8,49.5,,137029.8,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3642.86,,,3642.86,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,193779.51,70,,193779.51,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,1958.52,,,1958.52,Other,New York Medicaid APG methodology,1958.52,,,1958.52,Other,100% New York Medicaid APG,1958.52,,,1958.52,Other,100% New York Medicaid APG,1958.52,,,1958.52,Other,100% New York Medicaid APG,4406.68,,,4406.68,Other,225% New York Medicaid APG,2996.54,,,2996.54,Other,153% New York Medicaid APG,4406.68,,,4406.68,Other,225% New York Medicaid APG,2741.93,,,2741.93,Other,140% New York Medicaid APG,4406.68,,,4406.68,Other,225% New York Medicaid APG,5092.16,,,5092.16,Other,260% New York Medicaid APG,6345.62,,,6345.62,Other,324% New York Medicaid APG,4210.83,,,4210.83,Other,215% New York Medicaid APG,4210.83,,,4210.83,Other,215% New York Medicaid APG,2448.16,,,2448.16,Other,125% New York Medicaid APG,1958.52,204852.62,
Repair of metatarsals,28322,CPT,,,,,,,,both,,,78188.55,57859.53,74,,57859.53,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,35184.85,45,,35184.85,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,38703.33,49.5,,38703.33,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3642.86,,,3642.86,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,54731.99,70,,54731.99,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1958.52,,,1958.52,Other,New York Medicaid APG methodology,1958.52,,,1958.52,Other,100% New York Medicaid APG,1958.52,,,1958.52,Other,100% New York Medicaid APG,1958.52,,,1958.52,Other,100% New York Medicaid APG,4406.68,,,4406.68,Other,225% New York Medicaid APG,2996.54,,,2996.54,Other,153% New York Medicaid APG,4406.68,,,4406.68,Other,225% New York Medicaid APG,2741.93,,,2741.93,Other,140% New York Medicaid APG,4406.68,,,4406.68,Other,225% New York Medicaid APG,5092.16,,,5092.16,Other,260% New York Medicaid APG,6345.62,,,6345.62,Other,324% New York Medicaid APG,4210.83,,,4210.83,Other,215% New York Medicaid APG,4210.83,,,4210.83,Other,215% New York Medicaid APG,2448.16,,,2448.16,Other,125% New York Medicaid APG,1958.52,57859.53,
Resect enlarged toe tissue,28340,CPT,,,,,,,,both,,,68082.75,50381.24,74,,50381.24,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30637.24,45,,30637.24,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33700.96,49.5,,33700.96,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2891.15,,,2891.15,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,47657.93,70,,47657.93,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1554.38,,,1554.38,Other,New York Medicaid APG methodology,1554.38,,,1554.38,Other,100% New York Medicaid APG,1554.38,,,1554.38,Other,100% New York Medicaid APG,1554.38,,,1554.38,Other,100% New York Medicaid APG,3497.36,,,3497.36,Other,225% New York Medicaid APG,2378.21,,,2378.21,Other,153% New York Medicaid APG,3497.36,,,3497.36,Other,225% New York Medicaid APG,2176.14,,,2176.14,Other,140% New York Medicaid APG,3497.36,,,3497.36,Other,225% New York Medicaid APG,4041.4,,,4041.4,Other,260% New York Medicaid APG,5036.2,,,5036.2,Other,324% New York Medicaid APG,3341.93,,,3341.93,Other,215% New York Medicaid APG,3341.93,,,3341.93,Other,215% New York Medicaid APG,1942.98,,,1942.98,Other,125% New York Medicaid APG,1554.38,50381.24,
Resect enlarged toe,28341,CPT,,,,,,,,both,,,68082.75,50381.24,74,,50381.24,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30637.24,45,,30637.24,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33700.96,49.5,,33700.96,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3642.86,,,3642.86,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,47657.93,70,,47657.93,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1958.52,,,1958.52,Other,New York Medicaid APG methodology,1958.52,,,1958.52,Other,100% New York Medicaid APG,1958.52,,,1958.52,Other,100% New York Medicaid APG,1958.52,,,1958.52,Other,100% New York Medicaid APG,4406.68,,,4406.68,Other,225% New York Medicaid APG,2996.54,,,2996.54,Other,153% New York Medicaid APG,4406.68,,,4406.68,Other,225% New York Medicaid APG,2741.93,,,2741.93,Other,140% New York Medicaid APG,4406.68,,,4406.68,Other,225% New York Medicaid APG,5092.16,,,5092.16,Other,260% New York Medicaid APG,6345.62,,,6345.62,Other,324% New York Medicaid APG,4210.83,,,4210.83,Other,215% New York Medicaid APG,4210.83,,,4210.83,Other,215% New York Medicaid APG,2448.16,,,2448.16,Other,125% New York Medicaid APG,1958.52,50381.24,
Repair extra toe(s),28344,CPT,,,,,,,,both,,,38069.18,28171.19,74,,28171.19,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,17131.13,45,,17131.13,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,18844.24,49.5,,18844.24,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2891.15,,,2891.15,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,26648.43,70,,26648.43,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1554.38,,,1554.38,Other,New York Medicaid APG methodology,1554.38,,,1554.38,Other,100% New York Medicaid APG,1554.38,,,1554.38,Other,100% New York Medicaid APG,1554.38,,,1554.38,Other,100% New York Medicaid APG,3497.36,,,3497.36,Other,225% New York Medicaid APG,2378.21,,,2378.21,Other,153% New York Medicaid APG,3497.36,,,3497.36,Other,225% New York Medicaid APG,2176.14,,,2176.14,Other,140% New York Medicaid APG,3497.36,,,3497.36,Other,225% New York Medicaid APG,4041.4,,,4041.4,Other,260% New York Medicaid APG,5036.2,,,5036.2,Other,324% New York Medicaid APG,3341.93,,,3341.93,Other,215% New York Medicaid APG,3341.93,,,3341.93,Other,215% New York Medicaid APG,1942.98,,,1942.98,Other,125% New York Medicaid APG,1554.38,28171.19,
Repair webbed toe(s),28345,CPT,,,,,,,,both,,,51736.25,38284.83,74,,38284.83,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,23281.31,45,,23281.31,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,25609.44,49.5,,25609.44,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2891.15,,,2891.15,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,36215.38,70,,36215.38,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1554.38,,,1554.38,Other,New York Medicaid APG methodology,1554.38,,,1554.38,Other,100% New York Medicaid APG,1554.38,,,1554.38,Other,100% New York Medicaid APG,1554.38,,,1554.38,Other,100% New York Medicaid APG,3497.36,,,3497.36,Other,225% New York Medicaid APG,2378.21,,,2378.21,Other,153% New York Medicaid APG,3497.36,,,3497.36,Other,225% New York Medicaid APG,2176.14,,,2176.14,Other,140% New York Medicaid APG,3497.36,,,3497.36,Other,225% New York Medicaid APG,4041.4,,,4041.4,Other,260% New York Medicaid APG,5036.2,,,5036.2,Other,324% New York Medicaid APG,3341.93,,,3341.93,Other,215% New York Medicaid APG,3341.93,,,3341.93,Other,215% New York Medicaid APG,1942.98,,,1942.98,Other,125% New York Medicaid APG,1554.38,38284.83,
Reconstruct cleft foot,28360,CPT,,,,,,,,both,,,150476.65,111352.72,74,,111352.72,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,67714.49,45,,67714.49,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,74485.94,49.5,,74485.94,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3642.86,,,3642.86,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,105333.66,70,,105333.66,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,1958.52,,,1958.52,Other,New York Medicaid APG methodology,1958.52,,,1958.52,Other,100% New York Medicaid APG,1958.52,,,1958.52,Other,100% New York Medicaid APG,1958.52,,,1958.52,Other,100% New York Medicaid APG,4406.68,,,4406.68,Other,225% New York Medicaid APG,2996.54,,,2996.54,Other,153% New York Medicaid APG,4406.68,,,4406.68,Other,225% New York Medicaid APG,2741.93,,,2741.93,Other,140% New York Medicaid APG,4406.68,,,4406.68,Other,225% New York Medicaid APG,5092.16,,,5092.16,Other,260% New York Medicaid APG,6345.62,,,6345.62,Other,324% New York Medicaid APG,4210.83,,,4210.83,Other,215% New York Medicaid APG,4210.83,,,4210.83,Other,215% New York Medicaid APG,2448.16,,,2448.16,Other,125% New York Medicaid APG,1958.52,111352.72,
Treatment of heel fracture,28400,CPT,,,,,,,,both,,,4960.23,3670.57,74,,3670.57,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,2232.1,45,,2232.1,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,2455.31,49.5,,2455.31,percent of total billed charges,110% of Medicare,3372.96,68,,3372.96,percent of total billed charges,,1031.43,,,1031.43,Other,186% of Medicaid,3968.18,80,,3968.18,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,3968.18,80,,3968.18,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,3472.16,70,,3472.16,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,554.53,,,554.53,Other,New York Medicaid APG methodology,554.53,,,554.53,Other,100% New York Medicaid APG,554.53,,,554.53,Other,100% New York Medicaid APG,554.53,,,554.53,Other,100% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,848.43,,,848.43,Other,153% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,776.34,,,776.34,Other,140% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,1441.78,,,1441.78,Other,260% New York Medicaid APG,1796.68,,,1796.68,Other,324% New York Medicaid APG,1192.24,,,1192.24,Other,215% New York Medicaid APG,1192.24,,,1192.24,Other,215% New York Medicaid APG,693.16,,,693.16,Other,125% New York Medicaid APG,554.53,7216,
Treatment of heel fracture,28405,CPT,,,,,,,,both,,,4960.23,3670.57,74,,3670.57,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,2232.1,45,,2232.1,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,2455.31,49.5,,2455.31,percent of total billed charges,110% of Medicare,3372.96,68,,3372.96,percent of total billed charges,,1031.43,,,1031.43,Other,186% of Medicaid,3968.18,80,,3968.18,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,3968.18,80,,3968.18,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,3472.16,70,,3472.16,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,554.53,,,554.53,Other,New York Medicaid APG methodology,554.53,,,554.53,Other,100% New York Medicaid APG,554.53,,,554.53,Other,100% New York Medicaid APG,554.53,,,554.53,Other,100% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,848.43,,,848.43,Other,153% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,776.34,,,776.34,Other,140% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,1441.78,,,1441.78,Other,260% New York Medicaid APG,1796.68,,,1796.68,Other,324% New York Medicaid APG,1192.24,,,1192.24,Other,215% New York Medicaid APG,1192.24,,,1192.24,Other,215% New York Medicaid APG,693.16,,,693.16,Other,125% New York Medicaid APG,554.53,7216,
Treatment of heel fracture,28406,CPT,,,,,,,,both,,,150476.65,111352.72,74,,111352.72,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,67714.49,45,,67714.49,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,74485.94,49.5,,74485.94,percent of total billed charges,110% of Medicare,102324.12,68,,102324.12,percent of total billed charges,,5092.5,,,5092.5,Other,186% of Medicaid,120381.32,80,,120381.32,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,120381.32,80,,120381.32,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,105333.66,70,,105333.66,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,2737.91,,,2737.91,Other,New York Medicaid APG methodology,2737.91,,,2737.91,Other,100% New York Medicaid APG,2737.91,,,2737.91,Other,100% New York Medicaid APG,2737.91,,,2737.91,Other,100% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,4189,,,4189,Other,153% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,3833.07,,,3833.07,Other,140% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,7118.55,,,7118.55,Other,260% New York Medicaid APG,8870.81,,,8870.81,Other,324% New York Medicaid APG,5886.5,,,5886.5,Other,215% New York Medicaid APG,5886.5,,,5886.5,Other,215% New York Medicaid APG,3422.38,,,3422.38,Other,125% New York Medicaid APG,2232,120381.32,
Treat heel fracture,28415,CPT,,,,,,,,both,,,150476.65,111352.72,74,,111352.72,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,67714.49,45,,67714.49,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,74485.94,49.5,,74485.94,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5092.5,,,5092.5,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,105333.66,70,,105333.66,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,2737.91,,,2737.91,Other,New York Medicaid APG methodology,2737.91,,,2737.91,Other,100% New York Medicaid APG,2737.91,,,2737.91,Other,100% New York Medicaid APG,2737.91,,,2737.91,Other,100% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,4189,,,4189,Other,153% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,3833.07,,,3833.07,Other,140% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,7118.55,,,7118.55,Other,260% New York Medicaid APG,8870.81,,,8870.81,Other,324% New York Medicaid APG,5886.5,,,5886.5,Other,215% New York Medicaid APG,5886.5,,,5886.5,Other,215% New York Medicaid APG,3422.38,,,3422.38,Other,125% New York Medicaid APG,2737.91,111352.72,
Treat/graft heel fracture,28420,CPT,,,,,,,,both,,,276827.87,204852.62,74,,204852.62,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,124572.54,45,,124572.54,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,137029.8,49.5,,137029.8,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5092.5,,,5092.5,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,193779.51,70,,193779.51,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,2737.91,,,2737.91,Other,New York Medicaid APG methodology,2737.91,,,2737.91,Other,100% New York Medicaid APG,2737.91,,,2737.91,Other,100% New York Medicaid APG,2737.91,,,2737.91,Other,100% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,4189,,,4189,Other,153% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,3833.07,,,3833.07,Other,140% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,7118.55,,,7118.55,Other,260% New York Medicaid APG,8870.81,,,8870.81,Other,324% New York Medicaid APG,5886.5,,,5886.5,Other,215% New York Medicaid APG,5886.5,,,5886.5,Other,215% New York Medicaid APG,3422.38,,,3422.38,Other,125% New York Medicaid APG,2737.91,204852.62,
Treatment of ankle fracture,28430,CPT,,,,,,,,both,,,4960.23,3670.57,74,,3670.57,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,2232.1,45,,2232.1,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,2455.31,49.5,,2455.31,percent of total billed charges,110% of Medicare,3372.96,68,,3372.96,percent of total billed charges,,1031.43,,,1031.43,Other,186% of Medicaid,3968.18,80,,3968.18,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,3968.18,80,,3968.18,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,3472.16,70,,3472.16,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,554.53,,,554.53,Other,New York Medicaid APG methodology,554.53,,,554.53,Other,100% New York Medicaid APG,554.53,,,554.53,Other,100% New York Medicaid APG,554.53,,,554.53,Other,100% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,848.43,,,848.43,Other,153% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,776.34,,,776.34,Other,140% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,1441.78,,,1441.78,Other,260% New York Medicaid APG,1796.68,,,1796.68,Other,324% New York Medicaid APG,1192.24,,,1192.24,Other,215% New York Medicaid APG,1192.24,,,1192.24,Other,215% New York Medicaid APG,693.16,,,693.16,Other,125% New York Medicaid APG,554.53,7216,
Treatment of ankle fracture,28435,CPT,,,,,,,,both,,,33805.49,25016.06,74,,25016.06,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15212.47,45,,15212.47,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,16733.72,49.5,,16733.72,percent of total billed charges,110% of Medicare,22987.73,68,,22987.73,percent of total billed charges,,1031.43,,,1031.43,Other,186% of Medicaid,27044.39,80,,27044.39,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,27044.39,80,,27044.39,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,23663.84,70,,23663.84,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,554.53,,,554.53,Other,New York Medicaid APG methodology,554.53,,,554.53,Other,100% New York Medicaid APG,554.53,,,554.53,Other,100% New York Medicaid APG,554.53,,,554.53,Other,100% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,848.43,,,848.43,Other,153% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,776.34,,,776.34,Other,140% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,1441.78,,,1441.78,Other,260% New York Medicaid APG,1796.68,,,1796.68,Other,324% New York Medicaid APG,1192.24,,,1192.24,Other,215% New York Medicaid APG,1192.24,,,1192.24,Other,215% New York Medicaid APG,693.16,,,693.16,Other,125% New York Medicaid APG,554.53,27044.39,
Treatment of ankle fracture,28436,CPT,,,,,,,,both,,,150476.65,111352.72,74,,111352.72,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,67714.49,45,,67714.49,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,74485.94,49.5,,74485.94,percent of total billed charges,110% of Medicare,102324.12,68,,102324.12,percent of total billed charges,,5092.5,,,5092.5,Other,186% of Medicaid,120381.32,80,,120381.32,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,120381.32,80,,120381.32,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,105333.66,70,,105333.66,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,2737.91,,,2737.91,Other,New York Medicaid APG methodology,2737.91,,,2737.91,Other,100% New York Medicaid APG,2737.91,,,2737.91,Other,100% New York Medicaid APG,2737.91,,,2737.91,Other,100% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,4189,,,4189,Other,153% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,3833.07,,,3833.07,Other,140% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,7118.55,,,7118.55,Other,260% New York Medicaid APG,8870.81,,,8870.81,Other,324% New York Medicaid APG,5886.5,,,5886.5,Other,215% New York Medicaid APG,5886.5,,,5886.5,Other,215% New York Medicaid APG,3422.38,,,3422.38,Other,125% New York Medicaid APG,2232,120381.32,
Treat ankle fracture,28445,CPT,,,,,,,,both,,,137108.27,101460.12,74,,101460.12,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,61698.72,45,,61698.72,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,67868.59,49.5,,67868.59,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5092.5,,,5092.5,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,95975.79,70,,95975.79,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,2737.91,,,2737.91,Other,New York Medicaid APG methodology,2737.91,,,2737.91,Other,100% New York Medicaid APG,2737.91,,,2737.91,Other,100% New York Medicaid APG,2737.91,,,2737.91,Other,100% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,4189,,,4189,Other,153% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,3833.07,,,3833.07,Other,140% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,7118.55,,,7118.55,Other,260% New York Medicaid APG,8870.81,,,8870.81,Other,324% New York Medicaid APG,5886.5,,,5886.5,Other,215% New York Medicaid APG,5886.5,,,5886.5,Other,215% New York Medicaid APG,3422.38,,,3422.38,Other,125% New York Medicaid APG,2737.91,101460.12,
Osteochondral talus autogrft,28446,CPT,,,,,,,,both,,,150476.65,111352.72,74,,111352.72,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,67714.49,45,,67714.49,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,74485.94,49.5,,74485.94,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3642.86,,,3642.86,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,105333.66,70,,105333.66,percent of total billed charges,,6018.8,,,6018.8,Fee Schedule,,5101.3,,,5101.3,Fee Schedule,,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,1958.52,,,1958.52,Other,New York Medicaid APG methodology,1958.52,,,1958.52,Other,100% New York Medicaid APG,1958.52,,,1958.52,Other,100% New York Medicaid APG,1958.52,,,1958.52,Other,100% New York Medicaid APG,4406.68,,,4406.68,Other,225% New York Medicaid APG,2996.54,,,2996.54,Other,153% New York Medicaid APG,4406.68,,,4406.68,Other,225% New York Medicaid APG,2741.93,,,2741.93,Other,140% New York Medicaid APG,4406.68,,,4406.68,Other,225% New York Medicaid APG,5092.16,,,5092.16,Other,260% New York Medicaid APG,6345.62,,,6345.62,Other,324% New York Medicaid APG,4210.83,,,4210.83,Other,215% New York Medicaid APG,4210.83,,,4210.83,Other,215% New York Medicaid APG,2448.16,,,2448.16,Other,125% New York Medicaid APG,1958.52,111352.72,
Treat midfoot fracture each,28450,CPT,,,,,,,,both,,,4960.23,3670.57,74,,3670.57,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,2232.1,45,,2232.1,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,2455.31,49.5,,2455.31,percent of total billed charges,110% of Medicare,3372.96,68,,3372.96,percent of total billed charges,,1031.43,,,1031.43,Other,186% of Medicaid,3968.18,80,,3968.18,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,3968.18,80,,3968.18,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,3472.16,70,,3472.16,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,554.53,,,554.53,Other,New York Medicaid APG methodology,554.53,,,554.53,Other,100% New York Medicaid APG,554.53,,,554.53,Other,100% New York Medicaid APG,554.53,,,554.53,Other,100% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,848.43,,,848.43,Other,153% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,776.34,,,776.34,Other,140% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,1441.78,,,1441.78,Other,260% New York Medicaid APG,1796.68,,,1796.68,Other,324% New York Medicaid APG,1192.24,,,1192.24,Other,215% New York Medicaid APG,1192.24,,,1192.24,Other,215% New York Medicaid APG,693.16,,,693.16,Other,125% New York Medicaid APG,554.53,7216,
Treat midfoot fracture each,28455,CPT,,,,,,,,both,,,33805.49,25016.06,74,,25016.06,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15212.47,45,,15212.47,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,16733.72,49.5,,16733.72,percent of total billed charges,110% of Medicare,22987.73,68,,22987.73,percent of total billed charges,,1031.43,,,1031.43,Other,186% of Medicaid,27044.39,80,,27044.39,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,27044.39,80,,27044.39,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,23663.84,70,,23663.84,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,554.53,,,554.53,Other,New York Medicaid APG methodology,554.53,,,554.53,Other,100% New York Medicaid APG,554.53,,,554.53,Other,100% New York Medicaid APG,554.53,,,554.53,Other,100% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,848.43,,,848.43,Other,153% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,776.34,,,776.34,Other,140% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,1441.78,,,1441.78,Other,260% New York Medicaid APG,1796.68,,,1796.68,Other,324% New York Medicaid APG,1192.24,,,1192.24,Other,215% New York Medicaid APG,1192.24,,,1192.24,Other,215% New York Medicaid APG,693.16,,,693.16,Other,125% New York Medicaid APG,554.53,27044.39,
Treat midfoot fracture,28456,CPT,,,,,,,,both,,,150476.65,111352.72,74,,111352.72,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,67714.49,45,,67714.49,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,74485.94,49.5,,74485.94,percent of total billed charges,110% of Medicare,102324.12,68,,102324.12,percent of total billed charges,,5092.5,,,5092.5,Other,186% of Medicaid,120381.32,80,,120381.32,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,120381.32,80,,120381.32,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,105333.66,70,,105333.66,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,2737.91,,,2737.91,Other,New York Medicaid APG methodology,2737.91,,,2737.91,Other,100% New York Medicaid APG,2737.91,,,2737.91,Other,100% New York Medicaid APG,2737.91,,,2737.91,Other,100% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,4189,,,4189,Other,153% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,3833.07,,,3833.07,Other,140% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,7118.55,,,7118.55,Other,260% New York Medicaid APG,8870.81,,,8870.81,Other,324% New York Medicaid APG,5886.5,,,5886.5,Other,215% New York Medicaid APG,5886.5,,,5886.5,Other,215% New York Medicaid APG,3422.38,,,3422.38,Other,125% New York Medicaid APG,2232,120381.32,
Treat midfoot fracture each,28465,CPT,,,,,,,,both,,,150476.65,111352.72,74,,111352.72,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,67714.49,45,,67714.49,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,74485.94,49.5,,74485.94,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5092.5,,,5092.5,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,105333.66,70,,105333.66,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,2737.91,,,2737.91,Other,New York Medicaid APG methodology,2737.91,,,2737.91,Other,100% New York Medicaid APG,2737.91,,,2737.91,Other,100% New York Medicaid APG,2737.91,,,2737.91,Other,100% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,4189,,,4189,Other,153% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,3833.07,,,3833.07,Other,140% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,7118.55,,,7118.55,Other,260% New York Medicaid APG,8870.81,,,8870.81,Other,324% New York Medicaid APG,5886.5,,,5886.5,Other,215% New York Medicaid APG,5886.5,,,5886.5,Other,215% New York Medicaid APG,3422.38,,,3422.38,Other,125% New York Medicaid APG,2737.91,111352.72,
Treat metatarsal fracture,28470,CPT,,,,,,,,both,,,4960.23,3670.57,74,,3670.57,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,2232.1,45,,2232.1,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,2455.31,49.5,,2455.31,percent of total billed charges,110% of Medicare,3372.96,68,,3372.96,percent of total billed charges,,1031.43,,,1031.43,Other,186% of Medicaid,3968.18,80,,3968.18,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,3968.18,80,,3968.18,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,3472.16,70,,3472.16,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,554.53,,,554.53,Other,New York Medicaid APG methodology,554.53,,,554.53,Other,100% New York Medicaid APG,554.53,,,554.53,Other,100% New York Medicaid APG,554.53,,,554.53,Other,100% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,848.43,,,848.43,Other,153% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,776.34,,,776.34,Other,140% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,1441.78,,,1441.78,Other,260% New York Medicaid APG,1796.68,,,1796.68,Other,324% New York Medicaid APG,1192.24,,,1192.24,Other,215% New York Medicaid APG,1192.24,,,1192.24,Other,215% New York Medicaid APG,693.16,,,693.16,Other,125% New York Medicaid APG,554.53,7216,
Treat metatarsal fracture,28475,CPT,,,,,,,,both,,,4960.23,3670.57,74,,3670.57,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,2232.1,45,,2232.1,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,2455.31,49.5,,2455.31,percent of total billed charges,110% of Medicare,3372.96,68,,3372.96,percent of total billed charges,,1031.43,,,1031.43,Other,186% of Medicaid,3968.18,80,,3968.18,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,3968.18,80,,3968.18,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,3472.16,70,,3472.16,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,554.53,,,554.53,Other,New York Medicaid APG methodology,554.53,,,554.53,Other,100% New York Medicaid APG,554.53,,,554.53,Other,100% New York Medicaid APG,554.53,,,554.53,Other,100% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,848.43,,,848.43,Other,153% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,776.34,,,776.34,Other,140% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,1441.78,,,1441.78,Other,260% New York Medicaid APG,1796.68,,,1796.68,Other,324% New York Medicaid APG,1192.24,,,1192.24,Other,215% New York Medicaid APG,1192.24,,,1192.24,Other,215% New York Medicaid APG,693.16,,,693.16,Other,125% New York Medicaid APG,554.53,7216,
Treat metatarsal fracture,28476,CPT,,,,,,,,both,,,36963.26,27352.81,74,,27352.81,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,16633.47,45,,16633.47,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,18296.81,49.5,,18296.81,percent of total billed charges,110% of Medicare,25135.02,68,,25135.02,percent of total billed charges,,5092.5,,,5092.5,Other,186% of Medicaid,29570.61,80,,29570.61,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,29570.61,80,,29570.61,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,25874.28,70,,25874.28,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,2737.91,,,2737.91,Other,New York Medicaid APG methodology,2737.91,,,2737.91,Other,100% New York Medicaid APG,2737.91,,,2737.91,Other,100% New York Medicaid APG,2737.91,,,2737.91,Other,100% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,4189,,,4189,Other,153% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,3833.07,,,3833.07,Other,140% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,7118.55,,,7118.55,Other,260% New York Medicaid APG,8870.81,,,8870.81,Other,324% New York Medicaid APG,5886.5,,,5886.5,Other,215% New York Medicaid APG,5886.5,,,5886.5,Other,215% New York Medicaid APG,3422.38,,,3422.38,Other,125% New York Medicaid APG,2232,29570.61,
Treat metatarsal fracture,28485,CPT,,,,,,,,both,,,77830.44,57594.53,74,,57594.53,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,35023.7,45,,35023.7,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,38526.07,49.5,,38526.07,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5092.5,,,5092.5,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,54481.31,70,,54481.31,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,2737.91,,,2737.91,Other,New York Medicaid APG methodology,2737.91,,,2737.91,Other,100% New York Medicaid APG,2737.91,,,2737.91,Other,100% New York Medicaid APG,2737.91,,,2737.91,Other,100% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,4189,,,4189,Other,153% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,3833.07,,,3833.07,Other,140% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,7118.55,,,7118.55,Other,260% New York Medicaid APG,8870.81,,,8870.81,Other,324% New York Medicaid APG,5886.5,,,5886.5,Other,215% New York Medicaid APG,5886.5,,,5886.5,Other,215% New York Medicaid APG,3422.38,,,3422.38,Other,125% New York Medicaid APG,2737.91,57594.53,
Treat big toe fracture,28490,CPT,,,,,,,,both,,,4960.23,3670.57,74,,3670.57,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,2232.1,45,,2232.1,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,2455.31,49.5,,2455.31,percent of total billed charges,110% of Medicare,3372.96,68,,3372.96,percent of total billed charges,,1031.43,,,1031.43,Other,186% of Medicaid,3968.18,80,,3968.18,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,3968.18,80,,3968.18,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,3472.16,70,,3472.16,percent of total billed charges,,623.2,,,623.2,Fee Schedule,,528.2,,,528.2,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,554.53,,,554.53,Other,New York Medicaid APG methodology,554.53,,,554.53,Other,100% New York Medicaid APG,554.53,,,554.53,Other,100% New York Medicaid APG,554.53,,,554.53,Other,100% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,848.43,,,848.43,Other,153% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,776.34,,,776.34,Other,140% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,1441.78,,,1441.78,Other,260% New York Medicaid APG,1796.68,,,1796.68,Other,324% New York Medicaid APG,1192.24,,,1192.24,Other,215% New York Medicaid APG,1192.24,,,1192.24,Other,215% New York Medicaid APG,693.16,,,693.16,Other,125% New York Medicaid APG,528.2,7216,
Treat big toe fracture,28495,CPT,,,,,,,,both,,,4960.23,3670.57,74,,3670.57,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,2232.1,45,,2232.1,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,2455.31,49.5,,2455.31,percent of total billed charges,110% of Medicare,3372.96,68,,3372.96,percent of total billed charges,,1031.43,,,1031.43,Other,186% of Medicaid,3968.18,80,,3968.18,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,3968.18,80,,3968.18,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,3472.16,70,,3472.16,percent of total billed charges,,738,,,738,Fee Schedule,,625.5,,,625.5,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,554.53,,,554.53,Other,New York Medicaid APG methodology,554.53,,,554.53,Other,100% New York Medicaid APG,554.53,,,554.53,Other,100% New York Medicaid APG,554.53,,,554.53,Other,100% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,848.43,,,848.43,Other,153% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,776.34,,,776.34,Other,140% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,1441.78,,,1441.78,Other,260% New York Medicaid APG,1796.68,,,1796.68,Other,324% New York Medicaid APG,1192.24,,,1192.24,Other,215% New York Medicaid APG,1192.24,,,1192.24,Other,215% New York Medicaid APG,693.16,,,693.16,Other,125% New York Medicaid APG,554.53,7216,
Treat big toe fracture,28496,CPT,,,,,,,,both,,,68082.75,50381.24,74,,50381.24,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30637.24,45,,30637.24,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33700.96,49.5,,33700.96,percent of total billed charges,110% of Medicare,46296.27,68,,46296.27,percent of total billed charges,,5092.5,,,5092.5,Other,186% of Medicaid,54466.2,80,,54466.2,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,54466.2,80,,54466.2,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,47657.93,70,,47657.93,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,2737.91,,,2737.91,Other,New York Medicaid APG methodology,2737.91,,,2737.91,Other,100% New York Medicaid APG,2737.91,,,2737.91,Other,100% New York Medicaid APG,2737.91,,,2737.91,Other,100% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,4189,,,4189,Other,153% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,3833.07,,,3833.07,Other,140% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,7118.55,,,7118.55,Other,260% New York Medicaid APG,8870.81,,,8870.81,Other,324% New York Medicaid APG,5886.5,,,5886.5,Other,215% New York Medicaid APG,5886.5,,,5886.5,Other,215% New York Medicaid APG,3422.38,,,3422.38,Other,125% New York Medicaid APG,2232,54466.2,
Treat big toe fracture,28505,CPT,,,,,,,,both,,,64933,48050.42,74,,48050.42,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,29219.85,45,,29219.85,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,32141.84,49.5,,32141.84,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5092.5,,,5092.5,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,45453.1,70,,45453.1,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,2737.91,,,2737.91,Other,New York Medicaid APG methodology,2737.91,,,2737.91,Other,100% New York Medicaid APG,2737.91,,,2737.91,Other,100% New York Medicaid APG,2737.91,,,2737.91,Other,100% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,4189,,,4189,Other,153% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,3833.07,,,3833.07,Other,140% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,7118.55,,,7118.55,Other,260% New York Medicaid APG,8870.81,,,8870.81,Other,324% New York Medicaid APG,5886.5,,,5886.5,Other,215% New York Medicaid APG,5886.5,,,5886.5,Other,215% New York Medicaid APG,3422.38,,,3422.38,Other,125% New York Medicaid APG,2737.91,48050.42,
Treatment of toe fracture,28510,CPT,,,,,,,,both,,,4960.23,3670.57,74,,3670.57,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,2232.1,45,,2232.1,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,2455.31,49.5,,2455.31,percent of total billed charges,110% of Medicare,3372.96,68,,3372.96,percent of total billed charges,,1031.43,,,1031.43,Other,186% of Medicaid,3968.18,80,,3968.18,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,3968.18,80,,3968.18,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,3472.16,70,,3472.16,percent of total billed charges,,598.6,,,598.6,Fee Schedule,,507.35,,,507.35,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,554.53,,,554.53,Other,New York Medicaid APG methodology,554.53,,,554.53,Other,100% New York Medicaid APG,554.53,,,554.53,Other,100% New York Medicaid APG,554.53,,,554.53,Other,100% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,848.43,,,848.43,Other,153% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,776.34,,,776.34,Other,140% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,1441.78,,,1441.78,Other,260% New York Medicaid APG,1796.68,,,1796.68,Other,324% New York Medicaid APG,1192.24,,,1192.24,Other,215% New York Medicaid APG,1192.24,,,1192.24,Other,215% New York Medicaid APG,693.16,,,693.16,Other,125% New York Medicaid APG,507.35,7216,
Treatment of toe fracture,28515,CPT,,,,,,,,both,,,4960.23,3670.57,74,,3670.57,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,2232.1,45,,2232.1,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,2455.31,49.5,,2455.31,percent of total billed charges,110% of Medicare,3372.96,68,,3372.96,percent of total billed charges,,1031.43,,,1031.43,Other,186% of Medicaid,3968.18,80,,3968.18,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,3968.18,80,,3968.18,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,3472.16,70,,3472.16,percent of total billed charges,,711.76,,,711.76,Fee Schedule,,603.26,,,603.26,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,554.53,,,554.53,Other,New York Medicaid APG methodology,554.53,,,554.53,Other,100% New York Medicaid APG,554.53,,,554.53,Other,100% New York Medicaid APG,554.53,,,554.53,Other,100% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,848.43,,,848.43,Other,153% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,776.34,,,776.34,Other,140% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,1441.78,,,1441.78,Other,260% New York Medicaid APG,1796.68,,,1796.68,Other,324% New York Medicaid APG,1192.24,,,1192.24,Other,215% New York Medicaid APG,1192.24,,,1192.24,Other,215% New York Medicaid APG,693.16,,,693.16,Other,125% New York Medicaid APG,554.53,7216,
Treat toe fracture,28525,CPT,,,,,,,,both,,,52709.62,39005.12,74,,39005.12,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,23719.33,45,,23719.33,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,26091.26,49.5,,26091.26,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5092.5,,,5092.5,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,36896.73,70,,36896.73,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,2737.91,,,2737.91,Other,New York Medicaid APG methodology,2737.91,,,2737.91,Other,100% New York Medicaid APG,2737.91,,,2737.91,Other,100% New York Medicaid APG,2737.91,,,2737.91,Other,100% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,4189,,,4189,Other,153% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,3833.07,,,3833.07,Other,140% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,7118.55,,,7118.55,Other,260% New York Medicaid APG,8870.81,,,8870.81,Other,324% New York Medicaid APG,5886.5,,,5886.5,Other,215% New York Medicaid APG,5886.5,,,5886.5,Other,215% New York Medicaid APG,3422.38,,,3422.38,Other,125% New York Medicaid APG,2737.91,39005.12,
Treat sesamoid bone fracture,28530,CPT,,,,,,,,both,,,4960.23,3670.57,74,,3670.57,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,2232.1,45,,2232.1,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,2455.31,49.5,,2455.31,percent of total billed charges,110% of Medicare,3372.96,68,,3372.96,percent of total billed charges,,1031.43,,,1031.43,Other,186% of Medicaid,3968.18,80,,3968.18,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,3968.18,80,,3968.18,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,3472.16,70,,3472.16,percent of total billed charges,,498.56,,,498.56,Fee Schedule,,422.56,,,422.56,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,554.53,,,554.53,Other,New York Medicaid APG methodology,554.53,,,554.53,Other,100% New York Medicaid APG,554.53,,,554.53,Other,100% New York Medicaid APG,554.53,,,554.53,Other,100% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,848.43,,,848.43,Other,153% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,776.34,,,776.34,Other,140% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,1441.78,,,1441.78,Other,260% New York Medicaid APG,1796.68,,,1796.68,Other,324% New York Medicaid APG,1192.24,,,1192.24,Other,215% New York Medicaid APG,1192.24,,,1192.24,Other,215% New York Medicaid APG,693.16,,,693.16,Other,125% New York Medicaid APG,422.56,7216,
Treat sesamoid bone fracture,28531,CPT,,,,,,,,both,,,150476.65,111352.72,74,,111352.72,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,67714.49,45,,67714.49,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,74485.94,49.5,,74485.94,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5092.5,,,5092.5,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,105333.66,70,,105333.66,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,2737.91,,,2737.91,Other,New York Medicaid APG methodology,2737.91,,,2737.91,Other,100% New York Medicaid APG,2737.91,,,2737.91,Other,100% New York Medicaid APG,2737.91,,,2737.91,Other,100% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,4189,,,4189,Other,153% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,3833.07,,,3833.07,Other,140% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,7118.55,,,7118.55,Other,260% New York Medicaid APG,8870.81,,,8870.81,Other,324% New York Medicaid APG,5886.5,,,5886.5,Other,215% New York Medicaid APG,5886.5,,,5886.5,Other,215% New York Medicaid APG,3422.38,,,3422.38,Other,125% New York Medicaid APG,2737.91,111352.72,
Treat foot dislocation,28540,CPT,,,,,,,,both,,,4960.23,3670.57,74,,3670.57,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,2232.1,45,,2232.1,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,2455.31,49.5,,2455.31,percent of total billed charges,110% of Medicare,3372.96,68,,3372.96,percent of total billed charges,,1031.43,,,1031.43,Other,186% of Medicaid,3968.18,80,,3968.18,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,3968.18,80,,3968.18,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,3472.16,70,,3472.16,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,554.53,,,554.53,Other,New York Medicaid APG methodology,554.53,,,554.53,Other,100% New York Medicaid APG,554.53,,,554.53,Other,100% New York Medicaid APG,554.53,,,554.53,Other,100% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,848.43,,,848.43,Other,153% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,776.34,,,776.34,Other,140% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,1441.78,,,1441.78,Other,260% New York Medicaid APG,1796.68,,,1796.68,Other,324% New York Medicaid APG,1192.24,,,1192.24,Other,215% New York Medicaid APG,1192.24,,,1192.24,Other,215% New York Medicaid APG,693.16,,,693.16,Other,125% New York Medicaid APG,554.53,7216,
Treat foot dislocation,28545,CPT,,,,,,,,both,,,68082.75,50381.24,74,,50381.24,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30637.24,45,,30637.24,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33700.96,49.5,,33700.96,percent of total billed charges,110% of Medicare,46296.27,68,,46296.27,percent of total billed charges,,1730.38,,,1730.38,Other,186% of Medicaid,54466.2,80,,54466.2,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,54466.2,80,,54466.2,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,47657.93,70,,47657.93,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,930.31,,,930.31,Other,New York Medicaid APG methodology,930.31,,,930.31,Other,100% New York Medicaid APG,930.31,,,930.31,Other,100% New York Medicaid APG,930.31,,,930.31,Other,100% New York Medicaid APG,2093.21,,,2093.21,Other,225% New York Medicaid APG,1423.38,,,1423.38,Other,153% New York Medicaid APG,2093.21,,,2093.21,Other,225% New York Medicaid APG,1302.44,,,1302.44,Other,140% New York Medicaid APG,2093.21,,,2093.21,Other,225% New York Medicaid APG,2418.82,,,2418.82,Other,260% New York Medicaid APG,3014.22,,,3014.22,Other,324% New York Medicaid APG,2000.18,,,2000.18,Other,215% New York Medicaid APG,2000.18,,,2000.18,Other,215% New York Medicaid APG,1162.89,,,1162.89,Other,125% New York Medicaid APG,930.31,54466.2,
Treat foot dislocation,28546,CPT,,,,,,,,both,,,33805.49,25016.06,74,,25016.06,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15212.47,45,,15212.47,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,16733.72,49.5,,16733.72,percent of total billed charges,110% of Medicare,22987.73,68,,22987.73,percent of total billed charges,,5092.5,,,5092.5,Other,186% of Medicaid,27044.39,80,,27044.39,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,27044.39,80,,27044.39,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,23663.84,70,,23663.84,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,2737.91,,,2737.91,Other,New York Medicaid APG methodology,2737.91,,,2737.91,Other,100% New York Medicaid APG,2737.91,,,2737.91,Other,100% New York Medicaid APG,2737.91,,,2737.91,Other,100% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,4189,,,4189,Other,153% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,3833.07,,,3833.07,Other,140% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,7118.55,,,7118.55,Other,260% New York Medicaid APG,8870.81,,,8870.81,Other,324% New York Medicaid APG,5886.5,,,5886.5,Other,215% New York Medicaid APG,5886.5,,,5886.5,Other,215% New York Medicaid APG,3422.38,,,3422.38,Other,125% New York Medicaid APG,2232,27044.39,
Repair foot dislocation,28555,CPT,,,,,,,,both,,,150476.65,111352.72,74,,111352.72,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,67714.49,45,,67714.49,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,74485.94,49.5,,74485.94,percent of total billed charges,110% of Medicare,102324.12,68,,102324.12,percent of total billed charges,,5092.5,,,5092.5,Other,186% of Medicaid,120381.32,80,,120381.32,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,120381.32,80,,120381.32,percent of total billed charges,,7216,,,7216,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,105333.66,70,,105333.66,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,2737.91,,,2737.91,Other,New York Medicaid APG methodology,2737.91,,,2737.91,Other,100% New York Medicaid APG,2737.91,,,2737.91,Other,100% New York Medicaid APG,2737.91,,,2737.91,Other,100% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,4189,,,4189,Other,153% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,3833.07,,,3833.07,Other,140% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,7118.55,,,7118.55,Other,260% New York Medicaid APG,8870.81,,,8870.81,Other,324% New York Medicaid APG,5886.5,,,5886.5,Other,215% New York Medicaid APG,5886.5,,,5886.5,Other,215% New York Medicaid APG,3422.38,,,3422.38,Other,125% New York Medicaid APG,2232,120381.32,
Treat foot dislocation,28570,CPT,,,,,,,,both,,,4960.23,3670.57,74,,3670.57,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,2232.1,45,,2232.1,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,2455.31,49.5,,2455.31,percent of total billed charges,110% of Medicare,3372.96,68,,3372.96,percent of total billed charges,,1031.43,,,1031.43,Other,186% of Medicaid,3968.18,80,,3968.18,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,3968.18,80,,3968.18,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,3472.16,70,,3472.16,percent of total billed charges,,987.28,,,987.28,Fee Schedule,,836.78,,,836.78,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,554.53,,,554.53,Other,New York Medicaid APG methodology,554.53,,,554.53,Other,100% New York Medicaid APG,554.53,,,554.53,Other,100% New York Medicaid APG,554.53,,,554.53,Other,100% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,848.43,,,848.43,Other,153% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,776.34,,,776.34,Other,140% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,1441.78,,,1441.78,Other,260% New York Medicaid APG,1796.68,,,1796.68,Other,324% New York Medicaid APG,1192.24,,,1192.24,Other,215% New York Medicaid APG,1192.24,,,1192.24,Other,215% New York Medicaid APG,693.16,,,693.16,Other,125% New York Medicaid APG,554.53,7216,
Treat foot dislocation,28575,CPT,,,,,,,,both,,,68082.75,50381.24,74,,50381.24,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30637.24,45,,30637.24,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33700.96,49.5,,33700.96,percent of total billed charges,110% of Medicare,46296.27,68,,46296.27,percent of total billed charges,,1730.38,,,1730.38,Other,186% of Medicaid,54466.2,80,,54466.2,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,54466.2,80,,54466.2,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,47657.93,70,,47657.93,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,930.31,,,930.31,Other,New York Medicaid APG methodology,930.31,,,930.31,Other,100% New York Medicaid APG,930.31,,,930.31,Other,100% New York Medicaid APG,930.31,,,930.31,Other,100% New York Medicaid APG,2093.21,,,2093.21,Other,225% New York Medicaid APG,1423.38,,,1423.38,Other,153% New York Medicaid APG,2093.21,,,2093.21,Other,225% New York Medicaid APG,1302.44,,,1302.44,Other,140% New York Medicaid APG,2093.21,,,2093.21,Other,225% New York Medicaid APG,2418.82,,,2418.82,Other,260% New York Medicaid APG,3014.22,,,3014.22,Other,324% New York Medicaid APG,2000.18,,,2000.18,Other,215% New York Medicaid APG,2000.18,,,2000.18,Other,215% New York Medicaid APG,1162.89,,,1162.89,Other,125% New York Medicaid APG,930.31,54466.2,
Treat foot dislocation,28576,CPT,,,,,,,,both,,,36779.05,27216.5,74,,27216.5,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,16550.57,45,,16550.57,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,18205.63,49.5,,18205.63,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5092.5,,,5092.5,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,25745.34,70,,25745.34,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,2737.91,,,2737.91,Other,New York Medicaid APG methodology,2737.91,,,2737.91,Other,100% New York Medicaid APG,2737.91,,,2737.91,Other,100% New York Medicaid APG,2737.91,,,2737.91,Other,100% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,4189,,,4189,Other,153% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,3833.07,,,3833.07,Other,140% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,7118.55,,,7118.55,Other,260% New York Medicaid APG,8870.81,,,8870.81,Other,324% New York Medicaid APG,5886.5,,,5886.5,Other,215% New York Medicaid APG,5886.5,,,5886.5,Other,215% New York Medicaid APG,3422.38,,,3422.38,Other,125% New York Medicaid APG,2737.91,27216.5,
Repair foot dislocation,28585,CPT,,,,,,,,both,,,150476.65,111352.72,74,,111352.72,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,67714.49,45,,67714.49,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,74485.94,49.5,,74485.94,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5092.5,,,5092.5,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,105333.66,70,,105333.66,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,2737.91,,,2737.91,Other,New York Medicaid APG methodology,2737.91,,,2737.91,Other,100% New York Medicaid APG,2737.91,,,2737.91,Other,100% New York Medicaid APG,2737.91,,,2737.91,Other,100% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,4189,,,4189,Other,153% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,3833.07,,,3833.07,Other,140% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,7118.55,,,7118.55,Other,260% New York Medicaid APG,8870.81,,,8870.81,Other,324% New York Medicaid APG,5886.5,,,5886.5,Other,215% New York Medicaid APG,5886.5,,,5886.5,Other,215% New York Medicaid APG,3422.38,,,3422.38,Other,125% New York Medicaid APG,2737.91,111352.72,
Treat foot dislocation,28600,CPT,,,,,,,,both,,,4960.23,3670.57,74,,3670.57,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,2232.1,45,,2232.1,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,2455.31,49.5,,2455.31,percent of total billed charges,110% of Medicare,3372.96,68,,3372.96,percent of total billed charges,,1031.43,,,1031.43,Other,186% of Medicaid,3968.18,80,,3968.18,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,3968.18,80,,3968.18,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,3472.16,70,,3472.16,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,554.53,,,554.53,Other,New York Medicaid APG methodology,554.53,,,554.53,Other,100% New York Medicaid APG,554.53,,,554.53,Other,100% New York Medicaid APG,554.53,,,554.53,Other,100% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,848.43,,,848.43,Other,153% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,776.34,,,776.34,Other,140% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,1441.78,,,1441.78,Other,260% New York Medicaid APG,1796.68,,,1796.68,Other,324% New York Medicaid APG,1192.24,,,1192.24,Other,215% New York Medicaid APG,1192.24,,,1192.24,Other,215% New York Medicaid APG,693.16,,,693.16,Other,125% New York Medicaid APG,554.53,7216,
Treat foot dislocation,28605,CPT,,,,,,,,both,,,4960.23,3670.57,74,,3670.57,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,2232.1,45,,2232.1,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,2455.31,49.5,,2455.31,percent of total billed charges,110% of Medicare,3372.96,68,,3372.96,percent of total billed charges,,1730.38,,,1730.38,Other,186% of Medicaid,3968.18,80,,3968.18,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,3968.18,80,,3968.18,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,3472.16,70,,3472.16,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,930.31,,,930.31,Other,New York Medicaid APG methodology,930.31,,,930.31,Other,100% New York Medicaid APG,930.31,,,930.31,Other,100% New York Medicaid APG,930.31,,,930.31,Other,100% New York Medicaid APG,2093.21,,,2093.21,Other,225% New York Medicaid APG,1423.38,,,1423.38,Other,153% New York Medicaid APG,2093.21,,,2093.21,Other,225% New York Medicaid APG,1302.44,,,1302.44,Other,140% New York Medicaid APG,2093.21,,,2093.21,Other,225% New York Medicaid APG,2418.82,,,2418.82,Other,260% New York Medicaid APG,3014.22,,,3014.22,Other,324% New York Medicaid APG,2000.18,,,2000.18,Other,215% New York Medicaid APG,2000.18,,,2000.18,Other,215% New York Medicaid APG,1162.89,,,1162.89,Other,125% New York Medicaid APG,930.31,7216,
Treat foot dislocation,28606,CPT,,,,,,,,both,,,68082.75,50381.24,74,,50381.24,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30637.24,45,,30637.24,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33700.96,49.5,,33700.96,percent of total billed charges,110% of Medicare,46296.27,68,,46296.27,percent of total billed charges,,5092.5,,,5092.5,Other,186% of Medicaid,54466.2,80,,54466.2,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,54466.2,80,,54466.2,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,47657.93,70,,47657.93,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,2737.91,,,2737.91,Other,New York Medicaid APG methodology,2737.91,,,2737.91,Other,100% New York Medicaid APG,2737.91,,,2737.91,Other,100% New York Medicaid APG,2737.91,,,2737.91,Other,100% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,4189,,,4189,Other,153% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,3833.07,,,3833.07,Other,140% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,7118.55,,,7118.55,Other,260% New York Medicaid APG,8870.81,,,8870.81,Other,324% New York Medicaid APG,5886.5,,,5886.5,Other,215% New York Medicaid APG,5886.5,,,5886.5,Other,215% New York Medicaid APG,3422.38,,,3422.38,Other,125% New York Medicaid APG,2232,54466.2,
Repair foot dislocation,28615,CPT,,,,,,,,both,,,150476.65,111352.72,74,,111352.72,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,67714.49,45,,67714.49,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,74485.94,49.5,,74485.94,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5092.5,,,5092.5,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,105333.66,70,,105333.66,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,2737.91,,,2737.91,Other,New York Medicaid APG methodology,2737.91,,,2737.91,Other,100% New York Medicaid APG,2737.91,,,2737.91,Other,100% New York Medicaid APG,2737.91,,,2737.91,Other,100% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,4189,,,4189,Other,153% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,3833.07,,,3833.07,Other,140% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,7118.55,,,7118.55,Other,260% New York Medicaid APG,8870.81,,,8870.81,Other,324% New York Medicaid APG,5886.5,,,5886.5,Other,215% New York Medicaid APG,5886.5,,,5886.5,Other,215% New York Medicaid APG,3422.38,,,3422.38,Other,125% New York Medicaid APG,2737.91,111352.72,
Treat toe dislocation,28630,CPT,,,,,,,,both,,,4960.23,3670.57,74,,3670.57,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,2232.1,45,,2232.1,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,2455.31,49.5,,2455.31,percent of total billed charges,110% of Medicare,3372.96,68,,3372.96,percent of total billed charges,,1031.43,,,1031.43,Other,186% of Medicaid,3968.18,80,,3968.18,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,3968.18,80,,3968.18,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,3472.16,70,,3472.16,percent of total billed charges,,544.48,,,544.48,Fee Schedule,,461.48,,,461.48,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,554.53,,,554.53,Other,New York Medicaid APG methodology,554.53,,,554.53,Other,100% New York Medicaid APG,554.53,,,554.53,Other,100% New York Medicaid APG,554.53,,,554.53,Other,100% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,848.43,,,848.43,Other,153% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,776.34,,,776.34,Other,140% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,1441.78,,,1441.78,Other,260% New York Medicaid APG,1796.68,,,1796.68,Other,324% New York Medicaid APG,1192.24,,,1192.24,Other,215% New York Medicaid APG,1192.24,,,1192.24,Other,215% New York Medicaid APG,693.16,,,693.16,Other,125% New York Medicaid APG,461.48,7216,
Treat toe dislocation,28635,CPT,,,,,,,,both,,,33805.49,25016.06,74,,25016.06,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15212.47,45,,15212.47,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,16733.72,49.5,,16733.72,percent of total billed charges,110% of Medicare,22987.73,68,,22987.73,percent of total billed charges,,1730.38,,,1730.38,Other,186% of Medicaid,27044.39,80,,27044.39,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,27044.39,80,,27044.39,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,23663.84,70,,23663.84,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,930.31,,,930.31,Other,New York Medicaid APG methodology,930.31,,,930.31,Other,100% New York Medicaid APG,930.31,,,930.31,Other,100% New York Medicaid APG,930.31,,,930.31,Other,100% New York Medicaid APG,2093.21,,,2093.21,Other,225% New York Medicaid APG,1423.38,,,1423.38,Other,153% New York Medicaid APG,2093.21,,,2093.21,Other,225% New York Medicaid APG,1302.44,,,1302.44,Other,140% New York Medicaid APG,2093.21,,,2093.21,Other,225% New York Medicaid APG,2418.82,,,2418.82,Other,260% New York Medicaid APG,3014.22,,,3014.22,Other,324% New York Medicaid APG,2000.18,,,2000.18,Other,215% New York Medicaid APG,2000.18,,,2000.18,Other,215% New York Medicaid APG,1162.89,,,1162.89,Other,125% New York Medicaid APG,930.31,27044.39,
Treat toe dislocation,28636,CPT,,,,,,,,both,,,68082.75,50381.24,74,,50381.24,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30637.24,45,,30637.24,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33700.96,49.5,,33700.96,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5092.5,,,5092.5,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,47657.93,70,,47657.93,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,2737.91,,,2737.91,Other,New York Medicaid APG methodology,2737.91,,,2737.91,Other,100% New York Medicaid APG,2737.91,,,2737.91,Other,100% New York Medicaid APG,2737.91,,,2737.91,Other,100% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,4189,,,4189,Other,153% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,3833.07,,,3833.07,Other,140% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,7118.55,,,7118.55,Other,260% New York Medicaid APG,8870.81,,,8870.81,Other,324% New York Medicaid APG,5886.5,,,5886.5,Other,215% New York Medicaid APG,5886.5,,,5886.5,Other,215% New York Medicaid APG,3422.38,,,3422.38,Other,125% New York Medicaid APG,2737.91,50381.24,
Repair toe dislocation,28645,CPT,,,,,,,,both,,,68082.75,50381.24,74,,50381.24,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30637.24,45,,30637.24,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33700.96,49.5,,33700.96,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5092.5,,,5092.5,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,47657.93,70,,47657.93,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,2737.91,,,2737.91,Other,New York Medicaid APG methodology,2737.91,,,2737.91,Other,100% New York Medicaid APG,2737.91,,,2737.91,Other,100% New York Medicaid APG,2737.91,,,2737.91,Other,100% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,4189,,,4189,Other,153% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,3833.07,,,3833.07,Other,140% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,7118.55,,,7118.55,Other,260% New York Medicaid APG,8870.81,,,8870.81,Other,324% New York Medicaid APG,5886.5,,,5886.5,Other,215% New York Medicaid APG,5886.5,,,5886.5,Other,215% New York Medicaid APG,3422.38,,,3422.38,Other,125% New York Medicaid APG,2737.91,50381.24,
Treat toe dislocation,28660,CPT,,,,,,,,both,,,4960.23,3670.57,74,,3670.57,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,2232.1,45,,2232.1,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,2455.31,49.5,,2455.31,percent of total billed charges,110% of Medicare,3372.96,68,,3372.96,percent of total billed charges,,1031.43,,,1031.43,Other,186% of Medicaid,3968.18,80,,3968.18,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,3968.18,80,,3968.18,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,3472.16,70,,3472.16,percent of total billed charges,,459.2,,,459.2,Fee Schedule,,389.2,,,389.2,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,554.53,,,554.53,Other,New York Medicaid APG methodology,554.53,,,554.53,Other,100% New York Medicaid APG,554.53,,,554.53,Other,100% New York Medicaid APG,554.53,,,554.53,Other,100% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,848.43,,,848.43,Other,153% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,776.34,,,776.34,Other,140% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,1441.78,,,1441.78,Other,260% New York Medicaid APG,1796.68,,,1796.68,Other,324% New York Medicaid APG,1192.24,,,1192.24,Other,215% New York Medicaid APG,1192.24,,,1192.24,Other,215% New York Medicaid APG,693.16,,,693.16,Other,125% New York Medicaid APG,389.2,7216,
Treat toe dislocation,28665,CPT,,,,,,,,both,,,5648.78,4180.1,74,,4180.1,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,2541.95,45,,2541.95,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,2796.15,49.5,,2796.15,percent of total billed charges,110% of Medicare,3841.17,68,,3841.17,percent of total billed charges,,1730.38,,,1730.38,Other,186% of Medicaid,4519.02,80,,4519.02,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,4519.02,80,,4519.02,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,3954.15,70,,3954.15,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,930.31,,,930.31,Other,New York Medicaid APG methodology,930.31,,,930.31,Other,100% New York Medicaid APG,930.31,,,930.31,Other,100% New York Medicaid APG,930.31,,,930.31,Other,100% New York Medicaid APG,2093.21,,,2093.21,Other,225% New York Medicaid APG,1423.38,,,1423.38,Other,153% New York Medicaid APG,2093.21,,,2093.21,Other,225% New York Medicaid APG,1302.44,,,1302.44,Other,140% New York Medicaid APG,2093.21,,,2093.21,Other,225% New York Medicaid APG,2418.82,,,2418.82,Other,260% New York Medicaid APG,3014.22,,,3014.22,Other,324% New York Medicaid APG,2000.18,,,2000.18,Other,215% New York Medicaid APG,2000.18,,,2000.18,Other,215% New York Medicaid APG,1162.89,,,1162.89,Other,125% New York Medicaid APG,930.31,7216,
Treat toe dislocation,28666,CPT,,,,,,,,both,,,68082.75,50381.24,74,,50381.24,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30637.24,45,,30637.24,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33700.96,49.5,,33700.96,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5092.5,,,5092.5,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,47657.93,70,,47657.93,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,2737.91,,,2737.91,Other,New York Medicaid APG methodology,2737.91,,,2737.91,Other,100% New York Medicaid APG,2737.91,,,2737.91,Other,100% New York Medicaid APG,2737.91,,,2737.91,Other,100% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,4189,,,4189,Other,153% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,3833.07,,,3833.07,Other,140% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,7118.55,,,7118.55,Other,260% New York Medicaid APG,8870.81,,,8870.81,Other,324% New York Medicaid APG,5886.5,,,5886.5,Other,215% New York Medicaid APG,5886.5,,,5886.5,Other,215% New York Medicaid APG,3422.38,,,3422.38,Other,125% New York Medicaid APG,2737.91,50381.24,
Repair of toe dislocation,28675,CPT,,,,,,,,both,,,41462.4,30682.18,74,,30682.18,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,18658.08,45,,18658.08,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,20523.89,49.5,,20523.89,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5092.5,,,5092.5,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,29023.68,70,,29023.68,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,2737.91,,,2737.91,Other,New York Medicaid APG methodology,2737.91,,,2737.91,Other,100% New York Medicaid APG,2737.91,,,2737.91,Other,100% New York Medicaid APG,2737.91,,,2737.91,Other,100% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,4189,,,4189,Other,153% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,3833.07,,,3833.07,Other,140% New York Medicaid APG,6160.29,,,6160.29,Other,225% New York Medicaid APG,7118.55,,,7118.55,Other,260% New York Medicaid APG,8870.81,,,8870.81,Other,324% New York Medicaid APG,5886.5,,,5886.5,Other,215% New York Medicaid APG,5886.5,,,5886.5,Other,215% New York Medicaid APG,3422.38,,,3422.38,Other,125% New York Medicaid APG,2737.91,30682.18,
Fusion of foot bones,28705,CPT,,,,,,,,both,,,391985.94,290069.6,74,,290069.6,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,176393.67,45,,176393.67,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,194033.04,49.5,,194033.04,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3642.86,,,3642.86,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,274390.16,70,,274390.16,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,1958.52,,,1958.52,Other,New York Medicaid APG methodology,1958.52,,,1958.52,Other,100% New York Medicaid APG,1958.52,,,1958.52,Other,100% New York Medicaid APG,1958.52,,,1958.52,Other,100% New York Medicaid APG,4406.68,,,4406.68,Other,225% New York Medicaid APG,2996.54,,,2996.54,Other,153% New York Medicaid APG,4406.68,,,4406.68,Other,225% New York Medicaid APG,2741.93,,,2741.93,Other,140% New York Medicaid APG,4406.68,,,4406.68,Other,225% New York Medicaid APG,5092.16,,,5092.16,Other,260% New York Medicaid APG,6345.62,,,6345.62,Other,324% New York Medicaid APG,4210.83,,,4210.83,Other,215% New York Medicaid APG,4210.83,,,4210.83,Other,215% New York Medicaid APG,2448.16,,,2448.16,Other,125% New York Medicaid APG,1958.52,290069.6,
Fusion of foot bones,28715,CPT,,,,,,,,both,,,276827.87,204852.62,74,,204852.62,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,124572.54,45,,124572.54,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,137029.8,49.5,,137029.8,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3642.86,,,3642.86,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,193779.51,70,,193779.51,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,1958.52,,,1958.52,Other,New York Medicaid APG methodology,1958.52,,,1958.52,Other,100% New York Medicaid APG,1958.52,,,1958.52,Other,100% New York Medicaid APG,1958.52,,,1958.52,Other,100% New York Medicaid APG,4406.68,,,4406.68,Other,225% New York Medicaid APG,2996.54,,,2996.54,Other,153% New York Medicaid APG,4406.68,,,4406.68,Other,225% New York Medicaid APG,2741.93,,,2741.93,Other,140% New York Medicaid APG,4406.68,,,4406.68,Other,225% New York Medicaid APG,5092.16,,,5092.16,Other,260% New York Medicaid APG,6345.62,,,6345.62,Other,324% New York Medicaid APG,4210.83,,,4210.83,Other,215% New York Medicaid APG,4210.83,,,4210.83,Other,215% New York Medicaid APG,2448.16,,,2448.16,Other,125% New York Medicaid APG,1958.52,204852.62,
Fusion of foot bones,28725,CPT,,,,,,,,both,,,111393.97,82431.54,74,,82431.54,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,50127.29,45,,50127.29,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,55140.02,49.5,,55140.02,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3642.86,,,3642.86,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,77975.78,70,,77975.78,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,1958.52,,,1958.52,Other,New York Medicaid APG methodology,1958.52,,,1958.52,Other,100% New York Medicaid APG,1958.52,,,1958.52,Other,100% New York Medicaid APG,1958.52,,,1958.52,Other,100% New York Medicaid APG,4406.68,,,4406.68,Other,225% New York Medicaid APG,2996.54,,,2996.54,Other,153% New York Medicaid APG,4406.68,,,4406.68,Other,225% New York Medicaid APG,2741.93,,,2741.93,Other,140% New York Medicaid APG,4406.68,,,4406.68,Other,225% New York Medicaid APG,5092.16,,,5092.16,Other,260% New York Medicaid APG,6345.62,,,6345.62,Other,324% New York Medicaid APG,4210.83,,,4210.83,Other,215% New York Medicaid APG,4210.83,,,4210.83,Other,215% New York Medicaid APG,2448.16,,,2448.16,Other,125% New York Medicaid APG,1958.52,82431.54,
Fusion of foot bones,28730,CPT,,,,,,,,both,,,121482.05,89896.72,74,,89896.72,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,54666.92,45,,54666.92,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,60133.61,49.5,,60133.61,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3642.86,,,3642.86,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,85037.44,70,,85037.44,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,1958.52,,,1958.52,Other,New York Medicaid APG methodology,1958.52,,,1958.52,Other,100% New York Medicaid APG,1958.52,,,1958.52,Other,100% New York Medicaid APG,1958.52,,,1958.52,Other,100% New York Medicaid APG,4406.68,,,4406.68,Other,225% New York Medicaid APG,2996.54,,,2996.54,Other,153% New York Medicaid APG,4406.68,,,4406.68,Other,225% New York Medicaid APG,2741.93,,,2741.93,Other,140% New York Medicaid APG,4406.68,,,4406.68,Other,225% New York Medicaid APG,5092.16,,,5092.16,Other,260% New York Medicaid APG,6345.62,,,6345.62,Other,324% New York Medicaid APG,4210.83,,,4210.83,Other,215% New York Medicaid APG,4210.83,,,4210.83,Other,215% New York Medicaid APG,2448.16,,,2448.16,Other,125% New York Medicaid APG,1958.52,89896.72,
Fusion of foot bones,28735,CPT,,,,,,,,both,,,276827.87,204852.62,74,,204852.62,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,124572.54,45,,124572.54,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,137029.8,49.5,,137029.8,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3642.86,,,3642.86,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,193779.51,70,,193779.51,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,1958.52,,,1958.52,Other,New York Medicaid APG methodology,1958.52,,,1958.52,Other,100% New York Medicaid APG,1958.52,,,1958.52,Other,100% New York Medicaid APG,1958.52,,,1958.52,Other,100% New York Medicaid APG,4406.68,,,4406.68,Other,225% New York Medicaid APG,2996.54,,,2996.54,Other,153% New York Medicaid APG,4406.68,,,4406.68,Other,225% New York Medicaid APG,2741.93,,,2741.93,Other,140% New York Medicaid APG,4406.68,,,4406.68,Other,225% New York Medicaid APG,5092.16,,,5092.16,Other,260% New York Medicaid APG,6345.62,,,6345.62,Other,324% New York Medicaid APG,4210.83,,,4210.83,Other,215% New York Medicaid APG,4210.83,,,4210.83,Other,215% New York Medicaid APG,2448.16,,,2448.16,Other,125% New York Medicaid APG,1958.52,204852.62,
Revision of foot bones,28737,CPT,,,,,,,,both,,,276827.87,204852.62,74,,204852.62,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,124572.54,45,,124572.54,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,137029.8,49.5,,137029.8,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3642.86,,,3642.86,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,193779.51,70,,193779.51,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,1958.52,,,1958.52,Other,New York Medicaid APG methodology,1958.52,,,1958.52,Other,100% New York Medicaid APG,1958.52,,,1958.52,Other,100% New York Medicaid APG,1958.52,,,1958.52,Other,100% New York Medicaid APG,4406.68,,,4406.68,Other,225% New York Medicaid APG,2996.54,,,2996.54,Other,153% New York Medicaid APG,4406.68,,,4406.68,Other,225% New York Medicaid APG,2741.93,,,2741.93,Other,140% New York Medicaid APG,4406.68,,,4406.68,Other,225% New York Medicaid APG,5092.16,,,5092.16,Other,260% New York Medicaid APG,6345.62,,,6345.62,Other,324% New York Medicaid APG,4210.83,,,4210.83,Other,215% New York Medicaid APG,4210.83,,,4210.83,Other,215% New York Medicaid APG,2448.16,,,2448.16,Other,125% New York Medicaid APG,1958.52,204852.62,
Fusion of foot bones,28740,CPT,,,,,,,,both,,,128635.84,95190.52,74,,95190.52,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,57886.13,45,,57886.13,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,63674.74,49.5,,63674.74,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3642.86,,,3642.86,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,90045.09,70,,90045.09,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,1958.52,,,1958.52,Other,New York Medicaid APG methodology,1958.52,,,1958.52,Other,100% New York Medicaid APG,1958.52,,,1958.52,Other,100% New York Medicaid APG,1958.52,,,1958.52,Other,100% New York Medicaid APG,4406.68,,,4406.68,Other,225% New York Medicaid APG,2996.54,,,2996.54,Other,153% New York Medicaid APG,4406.68,,,4406.68,Other,225% New York Medicaid APG,2741.93,,,2741.93,Other,140% New York Medicaid APG,4406.68,,,4406.68,Other,225% New York Medicaid APG,5092.16,,,5092.16,Other,260% New York Medicaid APG,6345.62,,,6345.62,Other,324% New York Medicaid APG,4210.83,,,4210.83,Other,215% New York Medicaid APG,4210.83,,,4210.83,Other,215% New York Medicaid APG,2448.16,,,2448.16,Other,125% New York Medicaid APG,1958.52,95190.52,
Fusion of big toe joint,28750,CPT,,,,,,,,both,,,83667.26,61913.77,74,,61913.77,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,37650.27,45,,37650.27,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,41415.29,49.5,,41415.29,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3642.86,,,3642.86,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,58567.08,70,,58567.08,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,1958.52,,,1958.52,Other,New York Medicaid APG methodology,1958.52,,,1958.52,Other,100% New York Medicaid APG,1958.52,,,1958.52,Other,100% New York Medicaid APG,1958.52,,,1958.52,Other,100% New York Medicaid APG,4406.68,,,4406.68,Other,225% New York Medicaid APG,2996.54,,,2996.54,Other,153% New York Medicaid APG,4406.68,,,4406.68,Other,225% New York Medicaid APG,2741.93,,,2741.93,Other,140% New York Medicaid APG,4406.68,,,4406.68,Other,225% New York Medicaid APG,5092.16,,,5092.16,Other,260% New York Medicaid APG,6345.62,,,6345.62,Other,324% New York Medicaid APG,4210.83,,,4210.83,Other,215% New York Medicaid APG,4210.83,,,4210.83,Other,215% New York Medicaid APG,2448.16,,,2448.16,Other,125% New York Medicaid APG,1958.52,61913.77,
Fusion of big toe joint,28755,CPT,,,,,,,,both,,,150476.65,111352.72,74,,111352.72,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,67714.49,45,,67714.49,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,74485.94,49.5,,74485.94,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2891.15,,,2891.15,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,105333.66,70,,105333.66,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1554.38,,,1554.38,Other,New York Medicaid APG methodology,1554.38,,,1554.38,Other,100% New York Medicaid APG,1554.38,,,1554.38,Other,100% New York Medicaid APG,1554.38,,,1554.38,Other,100% New York Medicaid APG,3497.36,,,3497.36,Other,225% New York Medicaid APG,2378.21,,,2378.21,Other,153% New York Medicaid APG,3497.36,,,3497.36,Other,225% New York Medicaid APG,2176.14,,,2176.14,Other,140% New York Medicaid APG,3497.36,,,3497.36,Other,225% New York Medicaid APG,4041.4,,,4041.4,Other,260% New York Medicaid APG,5036.2,,,5036.2,Other,324% New York Medicaid APG,3341.93,,,3341.93,Other,215% New York Medicaid APG,3341.93,,,3341.93,Other,215% New York Medicaid APG,1942.98,,,1942.98,Other,125% New York Medicaid APG,1554.38,111352.72,
Fusion of big toe joint,28760,CPT,,,,,,,,both,,,150476.65,111352.72,74,,111352.72,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,67714.49,45,,67714.49,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,74485.94,49.5,,74485.94,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3642.86,,,3642.86,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,105333.66,70,,105333.66,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,1958.52,,,1958.52,Other,New York Medicaid APG methodology,1958.52,,,1958.52,Other,100% New York Medicaid APG,1958.52,,,1958.52,Other,100% New York Medicaid APG,1958.52,,,1958.52,Other,100% New York Medicaid APG,4406.68,,,4406.68,Other,225% New York Medicaid APG,2996.54,,,2996.54,Other,153% New York Medicaid APG,4406.68,,,4406.68,Other,225% New York Medicaid APG,2741.93,,,2741.93,Other,140% New York Medicaid APG,4406.68,,,4406.68,Other,225% New York Medicaid APG,5092.16,,,5092.16,Other,260% New York Medicaid APG,6345.62,,,6345.62,Other,324% New York Medicaid APG,4210.83,,,4210.83,Other,215% New York Medicaid APG,4210.83,,,4210.83,Other,215% New York Medicaid APG,2448.16,,,2448.16,Other,125% New York Medicaid APG,1958.52,111352.72,
Amputation thru metatarsal,28805,CPT,,,,,,,,both,,,38333.33,28366.66,74,,28366.66,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,17250,45,,17250,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,18975,49.5,,18975,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3642.86,,,3642.86,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,26833.33,70,,26833.33,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1958.52,,,1958.52,Other,New York Medicaid APG methodology,1958.52,,,1958.52,Other,100% New York Medicaid APG,1958.52,,,1958.52,Other,100% New York Medicaid APG,1958.52,,,1958.52,Other,100% New York Medicaid APG,4406.68,,,4406.68,Other,225% New York Medicaid APG,2996.54,,,2996.54,Other,153% New York Medicaid APG,4406.68,,,4406.68,Other,225% New York Medicaid APG,2741.93,,,2741.93,Other,140% New York Medicaid APG,4406.68,,,4406.68,Other,225% New York Medicaid APG,5092.16,,,5092.16,Other,260% New York Medicaid APG,6345.62,,,6345.62,Other,324% New York Medicaid APG,4210.83,,,4210.83,Other,215% New York Medicaid APG,4210.83,,,4210.83,Other,215% New York Medicaid APG,2448.16,,,2448.16,Other,125% New York Medicaid APG,1958.52,28366.66,
Amputation toe & metatarsal,28810,CPT,,,,,,,,both,,,48080.72,35579.73,74,,35579.73,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,21636.32,45,,21636.32,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,23799.96,49.5,,23799.96,percent of total billed charges,110% of Medicare,32694.89,68,,32694.89,percent of total billed charges,,3642.86,,,3642.86,Other,186% of Medicaid,38464.58,80,,38464.58,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,38464.58,80,,38464.58,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,33656.5,70,,33656.5,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1958.52,,,1958.52,Other,New York Medicaid APG methodology,1958.52,,,1958.52,Other,100% New York Medicaid APG,1958.52,,,1958.52,Other,100% New York Medicaid APG,1958.52,,,1958.52,Other,100% New York Medicaid APG,4406.68,,,4406.68,Other,225% New York Medicaid APG,2996.54,,,2996.54,Other,153% New York Medicaid APG,4406.68,,,4406.68,Other,225% New York Medicaid APG,2741.93,,,2741.93,Other,140% New York Medicaid APG,4406.68,,,4406.68,Other,225% New York Medicaid APG,5092.16,,,5092.16,Other,260% New York Medicaid APG,6345.62,,,6345.62,Other,324% New York Medicaid APG,4210.83,,,4210.83,Other,215% New York Medicaid APG,4210.83,,,4210.83,Other,215% New York Medicaid APG,2448.16,,,2448.16,Other,125% New York Medicaid APG,1958.52,38464.58,
Amputation of toe,28820,CPT,,,,,,,,both,,,35523.77,26287.59,74,,26287.59,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15985.7,45,,15985.7,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,17584.27,49.5,,17584.27,percent of total billed charges,110% of Medicare,24156.16,68,,24156.16,percent of total billed charges,,2891.15,,,2891.15,Other,186% of Medicaid,28419.02,80,,28419.02,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,28419.02,80,,28419.02,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,24866.64,70,,24866.64,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1554.38,,,1554.38,Other,New York Medicaid APG methodology,1554.38,,,1554.38,Other,100% New York Medicaid APG,1554.38,,,1554.38,Other,100% New York Medicaid APG,1554.38,,,1554.38,Other,100% New York Medicaid APG,3497.36,,,3497.36,Other,225% New York Medicaid APG,2378.21,,,2378.21,Other,153% New York Medicaid APG,3497.36,,,3497.36,Other,225% New York Medicaid APG,2176.14,,,2176.14,Other,140% New York Medicaid APG,3497.36,,,3497.36,Other,225% New York Medicaid APG,4041.4,,,4041.4,Other,260% New York Medicaid APG,5036.2,,,5036.2,Other,324% New York Medicaid APG,3341.93,,,3341.93,Other,215% New York Medicaid APG,3341.93,,,3341.93,Other,215% New York Medicaid APG,1942.98,,,1942.98,Other,125% New York Medicaid APG,1554.38,28419.02,
Partial amputation of toe,28825,CPT,,,,,,,,both,,,36834.32,27257.4,74,,27257.4,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,16575.44,45,,16575.44,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,18232.99,49.5,,18232.99,percent of total billed charges,110% of Medicare,25047.34,68,,25047.34,percent of total billed charges,,2891.15,,,2891.15,Other,186% of Medicaid,29467.46,80,,29467.46,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,29467.46,80,,29467.46,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,25784.02,70,,25784.02,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1554.38,,,1554.38,Other,New York Medicaid APG methodology,1554.38,,,1554.38,Other,100% New York Medicaid APG,1554.38,,,1554.38,Other,100% New York Medicaid APG,1554.38,,,1554.38,Other,100% New York Medicaid APG,3497.36,,,3497.36,Other,225% New York Medicaid APG,2378.21,,,2378.21,Other,153% New York Medicaid APG,3497.36,,,3497.36,Other,225% New York Medicaid APG,2176.14,,,2176.14,Other,140% New York Medicaid APG,3497.36,,,3497.36,Other,225% New York Medicaid APG,4041.4,,,4041.4,Other,260% New York Medicaid APG,5036.2,,,5036.2,Other,324% New York Medicaid APG,3341.93,,,3341.93,Other,215% New York Medicaid APG,3341.93,,,3341.93,Other,215% New York Medicaid APG,1942.98,,,1942.98,Other,125% New York Medicaid APG,1554.38,29467.46,
Hi enrgy eswt plantar fascia,28890,CPT,,,,,,,,both,,,33805.49,25016.06,74,,25016.06,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15212.47,45,,15212.47,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,16733.72,49.5,,16733.72,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2891.15,,,2891.15,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,23663.84,70,,23663.84,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1554.38,,,1554.38,Other,New York Medicaid APG methodology,1554.38,,,1554.38,Other,100% New York Medicaid APG,1554.38,,,1554.38,Other,100% New York Medicaid APG,1554.38,,,1554.38,Other,100% New York Medicaid APG,3497.36,,,3497.36,Other,225% New York Medicaid APG,2378.21,,,2378.21,Other,153% New York Medicaid APG,3497.36,,,3497.36,Other,225% New York Medicaid APG,2176.14,,,2176.14,Other,140% New York Medicaid APG,3497.36,,,3497.36,Other,225% New York Medicaid APG,4041.4,,,4041.4,Other,260% New York Medicaid APG,5036.2,,,5036.2,Other,324% New York Medicaid APG,3341.93,,,3341.93,Other,215% New York Medicaid APG,3341.93,,,3341.93,Other,215% New York Medicaid APG,1942.98,,,1942.98,Other,125% New York Medicaid APG,1554.38,25016.06,
Application of body cast,29000,CPT,,,,,,,,both,,,5648.78,4180.1,74,,4180.1,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,2541.95,45,,2541.95,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,2796.15,49.5,,2796.15,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,680.21,,,680.21,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,3954.15,70,,3954.15,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,365.71,,,365.71,Other,New York Medicaid APG methodology,365.71,,,365.71,Other,100% New York Medicaid APG,365.71,,,365.71,Other,100% New York Medicaid APG,365.71,,,365.71,Other,100% New York Medicaid APG,822.84,,,822.84,Other,225% New York Medicaid APG,559.53,,,559.53,Other,153% New York Medicaid APG,822.84,,,822.84,Other,225% New York Medicaid APG,511.99,,,511.99,Other,140% New York Medicaid APG,822.84,,,822.84,Other,225% New York Medicaid APG,950.84,,,950.84,Other,260% New York Medicaid APG,1184.89,,,1184.89,Other,324% New York Medicaid APG,786.27,,,786.27,Other,215% New York Medicaid APG,786.27,,,786.27,Other,215% New York Medicaid APG,457.13,,,457.13,Other,125% New York Medicaid APG,365.71,9473,
Application of body cast,29010,CPT,,,,,,,,both,,,5648.78,4180.1,74,,4180.1,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,2541.95,45,,2541.95,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,2796.15,49.5,,2796.15,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,680.21,,,680.21,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,3954.15,70,,3954.15,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,365.71,,,365.71,Other,New York Medicaid APG methodology,365.71,,,365.71,Other,100% New York Medicaid APG,365.71,,,365.71,Other,100% New York Medicaid APG,365.71,,,365.71,Other,100% New York Medicaid APG,822.84,,,822.84,Other,225% New York Medicaid APG,559.53,,,559.53,Other,153% New York Medicaid APG,822.84,,,822.84,Other,225% New York Medicaid APG,511.99,,,511.99,Other,140% New York Medicaid APG,822.84,,,822.84,Other,225% New York Medicaid APG,950.84,,,950.84,Other,260% New York Medicaid APG,1184.89,,,1184.89,Other,324% New York Medicaid APG,786.27,,,786.27,Other,215% New York Medicaid APG,786.27,,,786.27,Other,215% New York Medicaid APG,457.13,,,457.13,Other,125% New York Medicaid APG,365.71,9473,
Application of body cast,29015,CPT,,,,,,,,both,,,5648.78,4180.1,74,,4180.1,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,2541.95,45,,2541.95,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,2796.15,49.5,,2796.15,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,680.21,,,680.21,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,3954.15,70,,3954.15,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,365.71,,,365.71,Other,New York Medicaid APG methodology,365.71,,,365.71,Other,100% New York Medicaid APG,365.71,,,365.71,Other,100% New York Medicaid APG,365.71,,,365.71,Other,100% New York Medicaid APG,822.84,,,822.84,Other,225% New York Medicaid APG,559.53,,,559.53,Other,153% New York Medicaid APG,822.84,,,822.84,Other,225% New York Medicaid APG,511.99,,,511.99,Other,140% New York Medicaid APG,822.84,,,822.84,Other,225% New York Medicaid APG,950.84,,,950.84,Other,260% New York Medicaid APG,1184.89,,,1184.89,Other,324% New York Medicaid APG,786.27,,,786.27,Other,215% New York Medicaid APG,786.27,,,786.27,Other,215% New York Medicaid APG,457.13,,,457.13,Other,125% New York Medicaid APG,365.71,9473,
Application of body cast,29035,CPT,,,,,,,,both,,,5648.78,4180.1,74,,4180.1,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,2541.95,45,,2541.95,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,2796.15,49.5,,2796.15,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,680.21,,,680.21,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,3954.15,70,,3954.15,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,365.71,,,365.71,Other,New York Medicaid APG methodology,365.71,,,365.71,Other,100% New York Medicaid APG,365.71,,,365.71,Other,100% New York Medicaid APG,365.71,,,365.71,Other,100% New York Medicaid APG,822.84,,,822.84,Other,225% New York Medicaid APG,559.53,,,559.53,Other,153% New York Medicaid APG,822.84,,,822.84,Other,225% New York Medicaid APG,511.99,,,511.99,Other,140% New York Medicaid APG,822.84,,,822.84,Other,225% New York Medicaid APG,950.84,,,950.84,Other,260% New York Medicaid APG,1184.89,,,1184.89,Other,324% New York Medicaid APG,786.27,,,786.27,Other,215% New York Medicaid APG,786.27,,,786.27,Other,215% New York Medicaid APG,457.13,,,457.13,Other,125% New York Medicaid APG,365.71,9473,
Application of body cast,29040,CPT,,,,,,,,both,,,5648.78,4180.1,74,,4180.1,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,2541.95,45,,2541.95,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,2796.15,49.5,,2796.15,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,680.21,,,680.21,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,3954.15,70,,3954.15,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,365.71,,,365.71,Other,New York Medicaid APG methodology,365.71,,,365.71,Other,100% New York Medicaid APG,365.71,,,365.71,Other,100% New York Medicaid APG,365.71,,,365.71,Other,100% New York Medicaid APG,822.84,,,822.84,Other,225% New York Medicaid APG,559.53,,,559.53,Other,153% New York Medicaid APG,822.84,,,822.84,Other,225% New York Medicaid APG,511.99,,,511.99,Other,140% New York Medicaid APG,822.84,,,822.84,Other,225% New York Medicaid APG,950.84,,,950.84,Other,260% New York Medicaid APG,1184.89,,,1184.89,Other,324% New York Medicaid APG,786.27,,,786.27,Other,215% New York Medicaid APG,786.27,,,786.27,Other,215% New York Medicaid APG,457.13,,,457.13,Other,125% New York Medicaid APG,365.71,9473,
Application of body cast,29044,CPT,,,,,,,,both,,,3314.26,2452.55,74,,2452.55,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,1491.42,45,,1491.42,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,1640.56,49.5,,1640.56,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,680.21,,,680.21,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,2319.98,70,,2319.98,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,365.71,,,365.71,Other,New York Medicaid APG methodology,365.71,,,365.71,Other,100% New York Medicaid APG,365.71,,,365.71,Other,100% New York Medicaid APG,365.71,,,365.71,Other,100% New York Medicaid APG,822.84,,,822.84,Other,225% New York Medicaid APG,559.53,,,559.53,Other,153% New York Medicaid APG,822.84,,,822.84,Other,225% New York Medicaid APG,511.99,,,511.99,Other,140% New York Medicaid APG,822.84,,,822.84,Other,225% New York Medicaid APG,950.84,,,950.84,Other,260% New York Medicaid APG,1184.89,,,1184.89,Other,324% New York Medicaid APG,786.27,,,786.27,Other,215% New York Medicaid APG,786.27,,,786.27,Other,215% New York Medicaid APG,457.13,,,457.13,Other,125% New York Medicaid APG,365.71,9473,
Application of body cast,29046,CPT,,,,,,,,both,,,5648.78,4180.1,74,,4180.1,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,2541.95,45,,2541.95,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,2796.15,49.5,,2796.15,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,680.21,,,680.21,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,3954.15,70,,3954.15,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,365.71,,,365.71,Other,New York Medicaid APG methodology,365.71,,,365.71,Other,100% New York Medicaid APG,365.71,,,365.71,Other,100% New York Medicaid APG,365.71,,,365.71,Other,100% New York Medicaid APG,822.84,,,822.84,Other,225% New York Medicaid APG,559.53,,,559.53,Other,153% New York Medicaid APG,822.84,,,822.84,Other,225% New York Medicaid APG,511.99,,,511.99,Other,140% New York Medicaid APG,822.84,,,822.84,Other,225% New York Medicaid APG,950.84,,,950.84,Other,260% New York Medicaid APG,1184.89,,,1184.89,Other,324% New York Medicaid APG,786.27,,,786.27,Other,215% New York Medicaid APG,786.27,,,786.27,Other,215% New York Medicaid APG,457.13,,,457.13,Other,125% New York Medicaid APG,365.71,9473,
Application of figure eight,29049,CPT,,,,,,,,both,,,5648.78,4180.1,74,,4180.1,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,2541.95,45,,2541.95,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,2796.15,49.5,,2796.15,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,680.21,,,680.21,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,3954.15,70,,3954.15,percent of total billed charges,,339.48,,,339.48,Fee Schedule,,287.73,,,287.73,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,365.71,,,365.71,Other,New York Medicaid APG methodology,365.71,,,365.71,Other,100% New York Medicaid APG,365.71,,,365.71,Other,100% New York Medicaid APG,365.71,,,365.71,Other,100% New York Medicaid APG,822.84,,,822.84,Other,225% New York Medicaid APG,559.53,,,559.53,Other,153% New York Medicaid APG,822.84,,,822.84,Other,225% New York Medicaid APG,511.99,,,511.99,Other,140% New York Medicaid APG,822.84,,,822.84,Other,225% New York Medicaid APG,950.84,,,950.84,Other,260% New York Medicaid APG,1184.89,,,1184.89,Other,324% New York Medicaid APG,786.27,,,786.27,Other,215% New York Medicaid APG,786.27,,,786.27,Other,215% New York Medicaid APG,457.13,,,457.13,Other,125% New York Medicaid APG,287.73,9473,
Application of shoulder cast,29055,CPT,,,,,,,,both,,,5648.78,4180.1,74,,4180.1,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,2541.95,45,,2541.95,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,2796.15,49.5,,2796.15,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,680.21,,,680.21,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,3954.15,70,,3954.15,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,365.71,,,365.71,Other,New York Medicaid APG methodology,365.71,,,365.71,Other,100% New York Medicaid APG,365.71,,,365.71,Other,100% New York Medicaid APG,365.71,,,365.71,Other,100% New York Medicaid APG,822.84,,,822.84,Other,225% New York Medicaid APG,559.53,,,559.53,Other,153% New York Medicaid APG,822.84,,,822.84,Other,225% New York Medicaid APG,511.99,,,511.99,Other,140% New York Medicaid APG,822.84,,,822.84,Other,225% New York Medicaid APG,950.84,,,950.84,Other,260% New York Medicaid APG,1184.89,,,1184.89,Other,324% New York Medicaid APG,786.27,,,786.27,Other,215% New York Medicaid APG,786.27,,,786.27,Other,215% New York Medicaid APG,457.13,,,457.13,Other,125% New York Medicaid APG,365.71,9473,
Application of shoulder cast,29058,CPT,,,,,,,,both,,,5648.78,4180.1,74,,4180.1,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,2541.95,45,,2541.95,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,2796.15,49.5,,2796.15,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,680.21,,,680.21,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,3954.15,70,,3954.15,percent of total billed charges,,457.56,,,457.56,Fee Schedule,,387.81,,,387.81,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,365.71,,,365.71,Other,New York Medicaid APG methodology,365.71,,,365.71,Other,100% New York Medicaid APG,365.71,,,365.71,Other,100% New York Medicaid APG,365.71,,,365.71,Other,100% New York Medicaid APG,822.84,,,822.84,Other,225% New York Medicaid APG,559.53,,,559.53,Other,153% New York Medicaid APG,822.84,,,822.84,Other,225% New York Medicaid APG,511.99,,,511.99,Other,140% New York Medicaid APG,822.84,,,822.84,Other,225% New York Medicaid APG,950.84,,,950.84,Other,260% New York Medicaid APG,1184.89,,,1184.89,Other,324% New York Medicaid APG,786.27,,,786.27,Other,215% New York Medicaid APG,786.27,,,786.27,Other,215% New York Medicaid APG,457.13,,,457.13,Other,125% New York Medicaid APG,365.71,9473,
Application of long arm cast,29065,CPT,,,,,,,,both,,,5648.78,4180.1,74,,4180.1,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,2541.95,45,,2541.95,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,2796.15,49.5,,2796.15,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,680.21,,,680.21,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,3954.15,70,,3954.15,percent of total billed charges,,334.56,,,334.56,Fee Schedule,,283.56,,,283.56,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,365.71,,,365.71,Other,New York Medicaid APG methodology,365.71,,,365.71,Other,100% New York Medicaid APG,365.71,,,365.71,Other,100% New York Medicaid APG,365.71,,,365.71,Other,100% New York Medicaid APG,822.84,,,822.84,Other,225% New York Medicaid APG,559.53,,,559.53,Other,153% New York Medicaid APG,822.84,,,822.84,Other,225% New York Medicaid APG,511.99,,,511.99,Other,140% New York Medicaid APG,822.84,,,822.84,Other,225% New York Medicaid APG,950.84,,,950.84,Other,260% New York Medicaid APG,1184.89,,,1184.89,Other,324% New York Medicaid APG,786.27,,,786.27,Other,215% New York Medicaid APG,786.27,,,786.27,Other,215% New York Medicaid APG,457.13,,,457.13,Other,125% New York Medicaid APG,283.56,9473,
Application of forearm cast,29075,CPT,,,,,,,,both,,,5648.78,4180.1,74,,4180.1,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,2541.95,45,,2541.95,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,2796.15,49.5,,2796.15,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,680.21,,,680.21,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,3954.15,70,,3954.15,percent of total billed charges,,308.32,,,308.32,Fee Schedule,,261.32,,,261.32,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,365.71,,,365.71,Other,New York Medicaid APG methodology,365.71,,,365.71,Other,100% New York Medicaid APG,365.71,,,365.71,Other,100% New York Medicaid APG,365.71,,,365.71,Other,100% New York Medicaid APG,822.84,,,822.84,Other,225% New York Medicaid APG,559.53,,,559.53,Other,153% New York Medicaid APG,822.84,,,822.84,Other,225% New York Medicaid APG,511.99,,,511.99,Other,140% New York Medicaid APG,822.84,,,822.84,Other,225% New York Medicaid APG,950.84,,,950.84,Other,260% New York Medicaid APG,1184.89,,,1184.89,Other,324% New York Medicaid APG,786.27,,,786.27,Other,215% New York Medicaid APG,786.27,,,786.27,Other,215% New York Medicaid APG,457.13,,,457.13,Other,125% New York Medicaid APG,261.32,9473,
Apply hand/wrist cast,29085,CPT,,,,,,,,both,,,3314.26,2452.55,74,,2452.55,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,1491.42,45,,1491.42,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,1640.56,49.5,,1640.56,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,680.21,,,680.21,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,2319.98,70,,2319.98,percent of total billed charges,,329.64,,,329.64,Fee Schedule,,279.39,,,279.39,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,365.71,,,365.71,Other,New York Medicaid APG methodology,365.71,,,365.71,Other,100% New York Medicaid APG,365.71,,,365.71,Other,100% New York Medicaid APG,365.71,,,365.71,Other,100% New York Medicaid APG,822.84,,,822.84,Other,225% New York Medicaid APG,559.53,,,559.53,Other,153% New York Medicaid APG,822.84,,,822.84,Other,225% New York Medicaid APG,511.99,,,511.99,Other,140% New York Medicaid APG,822.84,,,822.84,Other,225% New York Medicaid APG,950.84,,,950.84,Other,260% New York Medicaid APG,1184.89,,,1184.89,Other,324% New York Medicaid APG,786.27,,,786.27,Other,215% New York Medicaid APG,786.27,,,786.27,Other,215% New York Medicaid APG,457.13,,,457.13,Other,125% New York Medicaid APG,279.39,9473,
Apply finger cast,29086,CPT,,,,,,,,both,,,3314.26,2452.55,74,,2452.55,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,1491.42,45,,1491.42,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,1640.56,49.5,,1640.56,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,680.21,,,680.21,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,2319.98,70,,2319.98,percent of total billed charges,,241.08,,,241.08,Fee Schedule,,204.33,,,204.33,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,365.71,,,365.71,Other,New York Medicaid APG methodology,365.71,,,365.71,Other,100% New York Medicaid APG,365.71,,,365.71,Other,100% New York Medicaid APG,365.71,,,365.71,Other,100% New York Medicaid APG,822.84,,,822.84,Other,225% New York Medicaid APG,559.53,,,559.53,Other,153% New York Medicaid APG,822.84,,,822.84,Other,225% New York Medicaid APG,511.99,,,511.99,Other,140% New York Medicaid APG,822.84,,,822.84,Other,225% New York Medicaid APG,950.84,,,950.84,Other,260% New York Medicaid APG,1184.89,,,1184.89,Other,324% New York Medicaid APG,786.27,,,786.27,Other,215% New York Medicaid APG,786.27,,,786.27,Other,215% New York Medicaid APG,457.13,,,457.13,Other,125% New York Medicaid APG,204.33,9473,
Apply long arm splint,29105,CPT,,,,,,,,both,,,3314.26,2452.55,74,,2452.55,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,1491.42,45,,1491.42,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,1640.56,49.5,,1640.56,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,551.94,,,551.94,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,2319.98,70,,2319.98,percent of total billed charges,,206.64,,,206.64,Fee Schedule,,175.14,,,175.14,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,296.74,,,296.74,Other,New York Medicaid APG methodology,296.74,,,296.74,Other,100% New York Medicaid APG,296.74,,,296.74,Other,100% New York Medicaid APG,296.74,,,296.74,Other,100% New York Medicaid APG,667.67,,,667.67,Other,225% New York Medicaid APG,454.02,,,454.02,Other,153% New York Medicaid APG,667.67,,,667.67,Other,225% New York Medicaid APG,415.44,,,415.44,Other,140% New York Medicaid APG,667.67,,,667.67,Other,225% New York Medicaid APG,771.53,,,771.53,Other,260% New York Medicaid APG,961.45,,,961.45,Other,324% New York Medicaid APG,638,,,638,Other,215% New York Medicaid APG,638,,,638,Other,215% New York Medicaid APG,370.93,,,370.93,Other,125% New York Medicaid APG,175.14,9473,
Apply forearm splint,29125,CPT,,,,,,,,both,,,2686.86,1988.28,74,,1988.28,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,1209.09,45,,1209.09,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,1330,49.5,,1330,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,551.94,,,551.94,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,1880.8,70,,1880.8,percent of total billed charges,,198.44,,,198.44,Fee Schedule,,168.19,,,168.19,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,296.74,,,296.74,Other,New York Medicaid APG methodology,296.74,,,296.74,Other,100% New York Medicaid APG,296.74,,,296.74,Other,100% New York Medicaid APG,296.74,,,296.74,Other,100% New York Medicaid APG,667.67,,,667.67,Other,225% New York Medicaid APG,454.02,,,454.02,Other,153% New York Medicaid APG,667.67,,,667.67,Other,225% New York Medicaid APG,415.44,,,415.44,Other,140% New York Medicaid APG,667.67,,,667.67,Other,225% New York Medicaid APG,771.53,,,771.53,Other,260% New York Medicaid APG,961.45,,,961.45,Other,324% New York Medicaid APG,638,,,638,Other,215% New York Medicaid APG,638,,,638,Other,215% New York Medicaid APG,370.93,,,370.93,Other,125% New York Medicaid APG,168.19,9473,
Apply forearm splint,29126,CPT,,,,,,,,both,,,2686.86,1988.28,74,,1988.28,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,1209.09,45,,1209.09,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,1330,49.5,,1330,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,551.94,,,551.94,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,1880.8,70,,1880.8,percent of total billed charges,,241.08,,,241.08,Fee Schedule,,204.33,,,204.33,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,296.74,,,296.74,Other,New York Medicaid APG methodology,296.74,,,296.74,Other,100% New York Medicaid APG,296.74,,,296.74,Other,100% New York Medicaid APG,296.74,,,296.74,Other,100% New York Medicaid APG,667.67,,,667.67,Other,225% New York Medicaid APG,454.02,,,454.02,Other,153% New York Medicaid APG,667.67,,,667.67,Other,225% New York Medicaid APG,415.44,,,415.44,Other,140% New York Medicaid APG,667.67,,,667.67,Other,225% New York Medicaid APG,771.53,,,771.53,Other,260% New York Medicaid APG,961.45,,,961.45,Other,324% New York Medicaid APG,638,,,638,Other,215% New York Medicaid APG,638,,,638,Other,215% New York Medicaid APG,370.93,,,370.93,Other,125% New York Medicaid APG,204.33,9473,
Application of finger splint,29130,CPT,,,,,,,,both,,,2686.86,1988.28,74,,1988.28,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,1209.09,45,,1209.09,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,1330,49.5,,1330,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,551.94,,,551.94,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,1880.8,70,,1880.8,percent of total billed charges,,144.32,,,144.32,Fee Schedule,,122.32,,,122.32,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,296.74,,,296.74,Other,New York Medicaid APG methodology,296.74,,,296.74,Other,100% New York Medicaid APG,296.74,,,296.74,Other,100% New York Medicaid APG,296.74,,,296.74,Other,100% New York Medicaid APG,667.67,,,667.67,Other,225% New York Medicaid APG,454.02,,,454.02,Other,153% New York Medicaid APG,667.67,,,667.67,Other,225% New York Medicaid APG,415.44,,,415.44,Other,140% New York Medicaid APG,667.67,,,667.67,Other,225% New York Medicaid APG,771.53,,,771.53,Other,260% New York Medicaid APG,961.45,,,961.45,Other,324% New York Medicaid APG,638,,,638,Other,215% New York Medicaid APG,638,,,638,Other,215% New York Medicaid APG,370.93,,,370.93,Other,125% New York Medicaid APG,122.32,9473,
Application of finger splint,29131,CPT,,,,,,,,both,,,1286.58,952.07,74,,952.07,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,578.96,45,,578.96,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,636.86,49.5,,636.86,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,551.94,,,551.94,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,900.61,70,,900.61,percent of total billed charges,,170.56,,,170.56,Fee Schedule,,144.56,,,144.56,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,296.74,,,296.74,Other,New York Medicaid APG methodology,296.74,,,296.74,Other,100% New York Medicaid APG,296.74,,,296.74,Other,100% New York Medicaid APG,296.74,,,296.74,Other,100% New York Medicaid APG,667.67,,,667.67,Other,225% New York Medicaid APG,454.02,,,454.02,Other,153% New York Medicaid APG,667.67,,,667.67,Other,225% New York Medicaid APG,415.44,,,415.44,Other,140% New York Medicaid APG,667.67,,,667.67,Other,225% New York Medicaid APG,771.53,,,771.53,Other,260% New York Medicaid APG,961.45,,,961.45,Other,324% New York Medicaid APG,638,,,638,Other,215% New York Medicaid APG,638,,,638,Other,215% New York Medicaid APG,370.93,,,370.93,Other,125% New York Medicaid APG,144.56,9473,
Strapping of chest,29200,CPT,,,,,,,,both,,,3314.26,2452.55,74,,2452.55,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,1491.42,45,,1491.42,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,1640.56,49.5,,1640.56,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,551.94,,,551.94,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,2319.98,70,,2319.98,percent of total billed charges,,90.2,,,90.2,Fee Schedule,,76.45,,,76.45,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,296.74,,,296.74,Other,New York Medicaid APG methodology,296.74,,,296.74,Other,100% New York Medicaid APG,296.74,,,296.74,Other,100% New York Medicaid APG,296.74,,,296.74,Other,100% New York Medicaid APG,667.67,,,667.67,Other,225% New York Medicaid APG,454.02,,,454.02,Other,153% New York Medicaid APG,667.67,,,667.67,Other,225% New York Medicaid APG,415.44,,,415.44,Other,140% New York Medicaid APG,667.67,,,667.67,Other,225% New York Medicaid APG,771.53,,,771.53,Other,260% New York Medicaid APG,961.45,,,961.45,Other,324% New York Medicaid APG,638,,,638,Other,215% New York Medicaid APG,638,,,638,Other,215% New York Medicaid APG,370.93,,,370.93,Other,125% New York Medicaid APG,76.45,9473,
Strapping of shoulder,29240,CPT,,,,,,,,both,,,2686.86,1988.28,74,,1988.28,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,1209.09,45,,1209.09,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,1330,49.5,,1330,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,551.94,,,551.94,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,1880.8,70,,1880.8,percent of total billed charges,,88.56,,,88.56,Fee Schedule,,75.06,,,75.06,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,296.74,,,296.74,Other,New York Medicaid APG methodology,296.74,,,296.74,Other,100% New York Medicaid APG,296.74,,,296.74,Other,100% New York Medicaid APG,296.74,,,296.74,Other,100% New York Medicaid APG,667.67,,,667.67,Other,225% New York Medicaid APG,454.02,,,454.02,Other,153% New York Medicaid APG,667.67,,,667.67,Other,225% New York Medicaid APG,415.44,,,415.44,Other,140% New York Medicaid APG,667.67,,,667.67,Other,225% New York Medicaid APG,771.53,,,771.53,Other,260% New York Medicaid APG,961.45,,,961.45,Other,324% New York Medicaid APG,638,,,638,Other,215% New York Medicaid APG,638,,,638,Other,215% New York Medicaid APG,370.93,,,370.93,Other,125% New York Medicaid APG,75.06,9473,
Strapping of elbow or wrist,29260,CPT,,,,,,,,both,,,1286.58,952.07,74,,952.07,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,578.96,45,,578.96,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,636.86,49.5,,636.86,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,551.94,,,551.94,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,900.61,70,,900.61,percent of total billed charges,,93.48,,,93.48,Fee Schedule,,79.23,,,79.23,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,296.74,,,296.74,Other,New York Medicaid APG methodology,296.74,,,296.74,Other,100% New York Medicaid APG,296.74,,,296.74,Other,100% New York Medicaid APG,296.74,,,296.74,Other,100% New York Medicaid APG,667.67,,,667.67,Other,225% New York Medicaid APG,454.02,,,454.02,Other,153% New York Medicaid APG,667.67,,,667.67,Other,225% New York Medicaid APG,415.44,,,415.44,Other,140% New York Medicaid APG,667.67,,,667.67,Other,225% New York Medicaid APG,771.53,,,771.53,Other,260% New York Medicaid APG,961.45,,,961.45,Other,324% New York Medicaid APG,638,,,638,Other,215% New York Medicaid APG,638,,,638,Other,215% New York Medicaid APG,370.93,,,370.93,Other,125% New York Medicaid APG,79.23,9473,
Strapping of hand or finger,29280,CPT,,,,,,,,both,,,1286.58,952.07,74,,952.07,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,578.96,45,,578.96,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,636.86,49.5,,636.86,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,551.94,,,551.94,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,900.61,70,,900.61,percent of total billed charges,,96.76,,,96.76,Fee Schedule,,82.01,,,82.01,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,296.74,,,296.74,Other,New York Medicaid APG methodology,296.74,,,296.74,Other,100% New York Medicaid APG,296.74,,,296.74,Other,100% New York Medicaid APG,296.74,,,296.74,Other,100% New York Medicaid APG,667.67,,,667.67,Other,225% New York Medicaid APG,454.02,,,454.02,Other,153% New York Medicaid APG,667.67,,,667.67,Other,225% New York Medicaid APG,415.44,,,415.44,Other,140% New York Medicaid APG,667.67,,,667.67,Other,225% New York Medicaid APG,771.53,,,771.53,Other,260% New York Medicaid APG,961.45,,,961.45,Other,324% New York Medicaid APG,638,,,638,Other,215% New York Medicaid APG,638,,,638,Other,215% New York Medicaid APG,370.93,,,370.93,Other,125% New York Medicaid APG,82.01,9473,
Application of hip cast,29305,CPT,,,,,,,,both,,,5648.78,4180.1,74,,4180.1,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,2541.95,45,,2541.95,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,2796.15,49.5,,2796.15,percent of total billed charges,110% of Medicare,3841.17,68,,3841.17,percent of total billed charges,,680.21,,,680.21,Other,186% of Medicaid,4519.02,80,,4519.02,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,4519.02,80,,4519.02,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,3954.15,70,,3954.15,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,365.71,,,365.71,Other,New York Medicaid APG methodology,365.71,,,365.71,Other,100% New York Medicaid APG,365.71,,,365.71,Other,100% New York Medicaid APG,365.71,,,365.71,Other,100% New York Medicaid APG,822.84,,,822.84,Other,225% New York Medicaid APG,559.53,,,559.53,Other,153% New York Medicaid APG,822.84,,,822.84,Other,225% New York Medicaid APG,511.99,,,511.99,Other,140% New York Medicaid APG,822.84,,,822.84,Other,225% New York Medicaid APG,950.84,,,950.84,Other,260% New York Medicaid APG,1184.89,,,1184.89,Other,324% New York Medicaid APG,786.27,,,786.27,Other,215% New York Medicaid APG,786.27,,,786.27,Other,215% New York Medicaid APG,457.13,,,457.13,Other,125% New York Medicaid APG,365.71,7216,
Application of hip casts,29325,CPT,,,,,,,,both,,,50856.25,37633.63,74,,37633.63,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,22885.31,45,,22885.31,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,25173.84,49.5,,25173.84,percent of total billed charges,110% of Medicare,34582.25,68,,34582.25,percent of total billed charges,,680.21,,,680.21,Other,186% of Medicaid,40685,80,,40685,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,40685,80,,40685,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,35599.38,70,,35599.38,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,365.71,,,365.71,Other,New York Medicaid APG methodology,365.71,,,365.71,Other,100% New York Medicaid APG,365.71,,,365.71,Other,100% New York Medicaid APG,365.71,,,365.71,Other,100% New York Medicaid APG,822.84,,,822.84,Other,225% New York Medicaid APG,559.53,,,559.53,Other,153% New York Medicaid APG,822.84,,,822.84,Other,225% New York Medicaid APG,511.99,,,511.99,Other,140% New York Medicaid APG,822.84,,,822.84,Other,225% New York Medicaid APG,950.84,,,950.84,Other,260% New York Medicaid APG,1184.89,,,1184.89,Other,324% New York Medicaid APG,786.27,,,786.27,Other,215% New York Medicaid APG,786.27,,,786.27,Other,215% New York Medicaid APG,457.13,,,457.13,Other,125% New York Medicaid APG,365.71,40685,
Application of long leg cast,29345,CPT,,,,,,,,both,,,5648.78,4180.1,74,,4180.1,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,2541.95,45,,2541.95,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,2796.15,49.5,,2796.15,percent of total billed charges,110% of Medicare,3841.17,68,,3841.17,percent of total billed charges,,680.21,,,680.21,Other,186% of Medicaid,4519.02,80,,4519.02,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,4519.02,80,,4519.02,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,3954.15,70,,3954.15,percent of total billed charges,,487.08,,,487.08,Fee Schedule,,412.83,,,412.83,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,365.71,,,365.71,Other,New York Medicaid APG methodology,365.71,,,365.71,Other,100% New York Medicaid APG,365.71,,,365.71,Other,100% New York Medicaid APG,365.71,,,365.71,Other,100% New York Medicaid APG,822.84,,,822.84,Other,225% New York Medicaid APG,559.53,,,559.53,Other,153% New York Medicaid APG,822.84,,,822.84,Other,225% New York Medicaid APG,511.99,,,511.99,Other,140% New York Medicaid APG,822.84,,,822.84,Other,225% New York Medicaid APG,950.84,,,950.84,Other,260% New York Medicaid APG,1184.89,,,1184.89,Other,324% New York Medicaid APG,786.27,,,786.27,Other,215% New York Medicaid APG,786.27,,,786.27,Other,215% New York Medicaid APG,457.13,,,457.13,Other,125% New York Medicaid APG,365.71,7216,
Application of long leg cast,29355,CPT,,,,,,,,both,,,5648.78,4180.1,74,,4180.1,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,2541.95,45,,2541.95,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,2796.15,49.5,,2796.15,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,680.21,,,680.21,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,3954.15,70,,3954.15,percent of total billed charges,,519.88,,,519.88,Fee Schedule,,440.63,,,440.63,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,365.71,,,365.71,Other,New York Medicaid APG methodology,365.71,,,365.71,Other,100% New York Medicaid APG,365.71,,,365.71,Other,100% New York Medicaid APG,365.71,,,365.71,Other,100% New York Medicaid APG,822.84,,,822.84,Other,225% New York Medicaid APG,559.53,,,559.53,Other,153% New York Medicaid APG,822.84,,,822.84,Other,225% New York Medicaid APG,511.99,,,511.99,Other,140% New York Medicaid APG,822.84,,,822.84,Other,225% New York Medicaid APG,950.84,,,950.84,Other,260% New York Medicaid APG,1184.89,,,1184.89,Other,324% New York Medicaid APG,786.27,,,786.27,Other,215% New York Medicaid APG,786.27,,,786.27,Other,215% New York Medicaid APG,457.13,,,457.13,Other,125% New York Medicaid APG,365.71,9473,
Apply long leg cast brace,29358,CPT,,,,,,,,both,,,5648.78,4180.1,74,,4180.1,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,2541.95,45,,2541.95,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,2796.15,49.5,,2796.15,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,680.21,,,680.21,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,3954.15,70,,3954.15,percent of total billed charges,,503.48,,,503.48,Fee Schedule,,426.73,,,426.73,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,365.71,,,365.71,Other,New York Medicaid APG methodology,365.71,,,365.71,Other,100% New York Medicaid APG,365.71,,,365.71,Other,100% New York Medicaid APG,365.71,,,365.71,Other,100% New York Medicaid APG,822.84,,,822.84,Other,225% New York Medicaid APG,559.53,,,559.53,Other,153% New York Medicaid APG,822.84,,,822.84,Other,225% New York Medicaid APG,511.99,,,511.99,Other,140% New York Medicaid APG,822.84,,,822.84,Other,225% New York Medicaid APG,950.84,,,950.84,Other,260% New York Medicaid APG,1184.89,,,1184.89,Other,324% New York Medicaid APG,786.27,,,786.27,Other,215% New York Medicaid APG,786.27,,,786.27,Other,215% New York Medicaid APG,457.13,,,457.13,Other,125% New York Medicaid APG,365.71,9473,
Application of long leg cast,29365,CPT,,,,,,,,both,,,5648.78,4180.1,74,,4180.1,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,2541.95,45,,2541.95,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,2796.15,49.5,,2796.15,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,680.21,,,680.21,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,3954.15,70,,3954.15,percent of total billed charges,,426.4,,,426.4,Fee Schedule,,361.4,,,361.4,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,365.71,,,365.71,Other,New York Medicaid APG methodology,365.71,,,365.71,Other,100% New York Medicaid APG,365.71,,,365.71,Other,100% New York Medicaid APG,365.71,,,365.71,Other,100% New York Medicaid APG,822.84,,,822.84,Other,225% New York Medicaid APG,559.53,,,559.53,Other,153% New York Medicaid APG,822.84,,,822.84,Other,225% New York Medicaid APG,511.99,,,511.99,Other,140% New York Medicaid APG,822.84,,,822.84,Other,225% New York Medicaid APG,950.84,,,950.84,Other,260% New York Medicaid APG,1184.89,,,1184.89,Other,324% New York Medicaid APG,786.27,,,786.27,Other,215% New York Medicaid APG,786.27,,,786.27,Other,215% New York Medicaid APG,457.13,,,457.13,Other,125% New York Medicaid APG,361.4,9473,
Apply short leg cast,29405,CPT,,,,,,,,both,,,5648.78,4180.1,74,,4180.1,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,2541.95,45,,2541.95,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,2796.15,49.5,,2796.15,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,680.21,,,680.21,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,3954.15,70,,3954.15,percent of total billed charges,,285.36,,,285.36,Fee Schedule,,241.86,,,241.86,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,365.71,,,365.71,Other,New York Medicaid APG methodology,365.71,,,365.71,Other,100% New York Medicaid APG,365.71,,,365.71,Other,100% New York Medicaid APG,365.71,,,365.71,Other,100% New York Medicaid APG,822.84,,,822.84,Other,225% New York Medicaid APG,559.53,,,559.53,Other,153% New York Medicaid APG,822.84,,,822.84,Other,225% New York Medicaid APG,511.99,,,511.99,Other,140% New York Medicaid APG,822.84,,,822.84,Other,225% New York Medicaid APG,950.84,,,950.84,Other,260% New York Medicaid APG,1184.89,,,1184.89,Other,324% New York Medicaid APG,786.27,,,786.27,Other,215% New York Medicaid APG,786.27,,,786.27,Other,215% New York Medicaid APG,457.13,,,457.13,Other,125% New York Medicaid APG,241.86,9473,
Apply short leg cast,29425,CPT,,,,,,,,both,,,5648.78,4180.1,74,,4180.1,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,2541.95,45,,2541.95,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,2796.15,49.5,,2796.15,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,680.21,,,680.21,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,3954.15,70,,3954.15,percent of total billed charges,,264.04,,,264.04,Fee Schedule,,223.79,,,223.79,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,365.71,,,365.71,Other,New York Medicaid APG methodology,365.71,,,365.71,Other,100% New York Medicaid APG,365.71,,,365.71,Other,100% New York Medicaid APG,365.71,,,365.71,Other,100% New York Medicaid APG,822.84,,,822.84,Other,225% New York Medicaid APG,559.53,,,559.53,Other,153% New York Medicaid APG,822.84,,,822.84,Other,225% New York Medicaid APG,511.99,,,511.99,Other,140% New York Medicaid APG,822.84,,,822.84,Other,225% New York Medicaid APG,950.84,,,950.84,Other,260% New York Medicaid APG,1184.89,,,1184.89,Other,324% New York Medicaid APG,786.27,,,786.27,Other,215% New York Medicaid APG,786.27,,,786.27,Other,215% New York Medicaid APG,457.13,,,457.13,Other,125% New York Medicaid APG,223.79,9473,
Apply short leg cast,29435,CPT,,,,,,,,both,,,5648.78,4180.1,74,,4180.1,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,2541.95,45,,2541.95,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,2796.15,49.5,,2796.15,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,680.21,,,680.21,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,3954.15,70,,3954.15,percent of total billed charges,,395.24,,,395.24,Fee Schedule,,334.99,,,334.99,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,365.71,,,365.71,Other,New York Medicaid APG methodology,365.71,,,365.71,Other,100% New York Medicaid APG,365.71,,,365.71,Other,100% New York Medicaid APG,365.71,,,365.71,Other,100% New York Medicaid APG,822.84,,,822.84,Other,225% New York Medicaid APG,559.53,,,559.53,Other,153% New York Medicaid APG,822.84,,,822.84,Other,225% New York Medicaid APG,511.99,,,511.99,Other,140% New York Medicaid APG,822.84,,,822.84,Other,225% New York Medicaid APG,950.84,,,950.84,Other,260% New York Medicaid APG,1184.89,,,1184.89,Other,324% New York Medicaid APG,786.27,,,786.27,Other,215% New York Medicaid APG,786.27,,,786.27,Other,215% New York Medicaid APG,457.13,,,457.13,Other,125% New York Medicaid APG,334.99,9473,
Addition of walker to cast,29440,CPT,,,,,,,,both,,,3314.26,2452.55,74,,2452.55,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,1491.42,45,,1491.42,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,1640.56,49.5,,1640.56,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,680.21,,,680.21,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,2319.98,70,,2319.98,percent of total billed charges,,134.48,,,134.48,Fee Schedule,,113.98,,,113.98,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,365.71,,,365.71,Other,New York Medicaid APG methodology,365.71,,,365.71,Other,100% New York Medicaid APG,365.71,,,365.71,Other,100% New York Medicaid APG,365.71,,,365.71,Other,100% New York Medicaid APG,822.84,,,822.84,Other,225% New York Medicaid APG,559.53,,,559.53,Other,153% New York Medicaid APG,822.84,,,822.84,Other,225% New York Medicaid APG,511.99,,,511.99,Other,140% New York Medicaid APG,822.84,,,822.84,Other,225% New York Medicaid APG,950.84,,,950.84,Other,260% New York Medicaid APG,1184.89,,,1184.89,Other,324% New York Medicaid APG,786.27,,,786.27,Other,215% New York Medicaid APG,786.27,,,786.27,Other,215% New York Medicaid APG,457.13,,,457.13,Other,125% New York Medicaid APG,113.98,9473,
Apply rigid leg cast,29445,CPT,,,,,,,,both,,,5648.78,4180.1,74,,4180.1,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,2541.95,45,,2541.95,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,2796.15,49.5,,2796.15,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,680.21,,,680.21,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,3954.15,70,,3954.15,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,365.71,,,365.71,Other,New York Medicaid APG methodology,365.71,,,365.71,Other,100% New York Medicaid APG,365.71,,,365.71,Other,100% New York Medicaid APG,365.71,,,365.71,Other,100% New York Medicaid APG,822.84,,,822.84,Other,225% New York Medicaid APG,559.53,,,559.53,Other,153% New York Medicaid APG,822.84,,,822.84,Other,225% New York Medicaid APG,511.99,,,511.99,Other,140% New York Medicaid APG,822.84,,,822.84,Other,225% New York Medicaid APG,950.84,,,950.84,Other,260% New York Medicaid APG,1184.89,,,1184.89,Other,324% New York Medicaid APG,786.27,,,786.27,Other,215% New York Medicaid APG,786.27,,,786.27,Other,215% New York Medicaid APG,457.13,,,457.13,Other,125% New York Medicaid APG,365.71,9473,
Application of leg cast,29450,CPT,,,,,,,,both,,,3314.26,2452.55,74,,2452.55,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,1491.42,45,,1491.42,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,1640.56,49.5,,1640.56,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,680.21,,,680.21,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,2319.98,70,,2319.98,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,365.71,,,365.71,Other,New York Medicaid APG methodology,365.71,,,365.71,Other,100% New York Medicaid APG,365.71,,,365.71,Other,100% New York Medicaid APG,365.71,,,365.71,Other,100% New York Medicaid APG,822.84,,,822.84,Other,225% New York Medicaid APG,559.53,,,559.53,Other,153% New York Medicaid APG,822.84,,,822.84,Other,225% New York Medicaid APG,511.99,,,511.99,Other,140% New York Medicaid APG,822.84,,,822.84,Other,225% New York Medicaid APG,950.84,,,950.84,Other,260% New York Medicaid APG,1184.89,,,1184.89,Other,324% New York Medicaid APG,786.27,,,786.27,Other,215% New York Medicaid APG,786.27,,,786.27,Other,215% New York Medicaid APG,457.13,,,457.13,Other,125% New York Medicaid APG,365.71,9473,
Application long leg splint,29505,CPT,,,,,,,,both,,,3314.26,2452.55,74,,2452.55,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,1491.42,45,,1491.42,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,1640.56,49.5,,1640.56,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,551.94,,,551.94,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,2319.98,70,,2319.98,percent of total billed charges,,254.2,,,254.2,Fee Schedule,,215.45,,,215.45,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,296.74,,,296.74,Other,New York Medicaid APG methodology,296.74,,,296.74,Other,100% New York Medicaid APG,296.74,,,296.74,Other,100% New York Medicaid APG,296.74,,,296.74,Other,100% New York Medicaid APG,667.67,,,667.67,Other,225% New York Medicaid APG,454.02,,,454.02,Other,153% New York Medicaid APG,667.67,,,667.67,Other,225% New York Medicaid APG,415.44,,,415.44,Other,140% New York Medicaid APG,667.67,,,667.67,Other,225% New York Medicaid APG,771.53,,,771.53,Other,260% New York Medicaid APG,961.45,,,961.45,Other,324% New York Medicaid APG,638,,,638,Other,215% New York Medicaid APG,638,,,638,Other,215% New York Medicaid APG,370.93,,,370.93,Other,125% New York Medicaid APG,215.45,9473,
Application lower leg splint,29515,CPT,,,,,,,,both,,,3314.26,2452.55,74,,2452.55,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,1491.42,45,,1491.42,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,1640.56,49.5,,1640.56,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,551.94,,,551.94,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,2319.98,70,,2319.98,percent of total billed charges,,241.08,,,241.08,Fee Schedule,,204.33,,,204.33,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,296.74,,,296.74,Other,New York Medicaid APG methodology,296.74,,,296.74,Other,100% New York Medicaid APG,296.74,,,296.74,Other,100% New York Medicaid APG,296.74,,,296.74,Other,100% New York Medicaid APG,667.67,,,667.67,Other,225% New York Medicaid APG,454.02,,,454.02,Other,153% New York Medicaid APG,667.67,,,667.67,Other,225% New York Medicaid APG,415.44,,,415.44,Other,140% New York Medicaid APG,667.67,,,667.67,Other,225% New York Medicaid APG,771.53,,,771.53,Other,260% New York Medicaid APG,961.45,,,961.45,Other,324% New York Medicaid APG,638,,,638,Other,215% New York Medicaid APG,638,,,638,Other,215% New York Medicaid APG,370.93,,,370.93,Other,125% New York Medicaid APG,204.33,9473,
Strapping of hip,29520,CPT,,,,,,,,both,,,2686.86,1988.28,74,,1988.28,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,1209.09,45,,1209.09,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,1330,49.5,,1330,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,551.94,,,551.94,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,1880.8,70,,1880.8,percent of total billed charges,,88.56,,,88.56,Fee Schedule,,75.06,,,75.06,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,296.74,,,296.74,Other,New York Medicaid APG methodology,296.74,,,296.74,Other,100% New York Medicaid APG,296.74,,,296.74,Other,100% New York Medicaid APG,296.74,,,296.74,Other,100% New York Medicaid APG,667.67,,,667.67,Other,225% New York Medicaid APG,454.02,,,454.02,Other,153% New York Medicaid APG,667.67,,,667.67,Other,225% New York Medicaid APG,415.44,,,415.44,Other,140% New York Medicaid APG,667.67,,,667.67,Other,225% New York Medicaid APG,771.53,,,771.53,Other,260% New York Medicaid APG,961.45,,,961.45,Other,324% New York Medicaid APG,638,,,638,Other,215% New York Medicaid APG,638,,,638,Other,215% New York Medicaid APG,370.93,,,370.93,Other,125% New York Medicaid APG,75.06,9473,
Strapping of knee,29530,CPT,,,,,,,,both,,,2686.86,1988.28,74,,1988.28,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,1209.09,45,,1209.09,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,1330,49.5,,1330,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,551.94,,,551.94,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,1880.8,70,,1880.8,percent of total billed charges,,88.56,,,88.56,Fee Schedule,,75.06,,,75.06,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,296.74,,,296.74,Other,New York Medicaid APG methodology,296.74,,,296.74,Other,100% New York Medicaid APG,296.74,,,296.74,Other,100% New York Medicaid APG,296.74,,,296.74,Other,100% New York Medicaid APG,667.67,,,667.67,Other,225% New York Medicaid APG,454.02,,,454.02,Other,153% New York Medicaid APG,667.67,,,667.67,Other,225% New York Medicaid APG,415.44,,,415.44,Other,140% New York Medicaid APG,667.67,,,667.67,Other,225% New York Medicaid APG,771.53,,,771.53,Other,260% New York Medicaid APG,961.45,,,961.45,Other,324% New York Medicaid APG,638,,,638,Other,215% New York Medicaid APG,638,,,638,Other,215% New York Medicaid APG,370.93,,,370.93,Other,125% New York Medicaid APG,75.06,9473,
Strapping of ankle and/or ft,29540,CPT,,,,,,,,both,,,3314.26,2452.55,74,,2452.55,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,1491.42,45,,1491.42,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,1640.56,49.5,,1640.56,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,551.94,,,551.94,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,2319.98,70,,2319.98,percent of total billed charges,,85.28,,,85.28,Fee Schedule,,72.28,,,72.28,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,296.74,,,296.74,Other,New York Medicaid APG methodology,296.74,,,296.74,Other,100% New York Medicaid APG,296.74,,,296.74,Other,100% New York Medicaid APG,296.74,,,296.74,Other,100% New York Medicaid APG,667.67,,,667.67,Other,225% New York Medicaid APG,454.02,,,454.02,Other,153% New York Medicaid APG,667.67,,,667.67,Other,225% New York Medicaid APG,415.44,,,415.44,Other,140% New York Medicaid APG,667.67,,,667.67,Other,225% New York Medicaid APG,771.53,,,771.53,Other,260% New York Medicaid APG,961.45,,,961.45,Other,324% New York Medicaid APG,638,,,638,Other,215% New York Medicaid APG,638,,,638,Other,215% New York Medicaid APG,370.93,,,370.93,Other,125% New York Medicaid APG,72.28,9473,
Strapping of toes,29550,CPT,,,,,,,,both,,,1286.58,952.07,74,,952.07,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,578.96,45,,578.96,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,636.86,49.5,,636.86,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,551.94,,,551.94,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,900.61,70,,900.61,percent of total billed charges,,54.12,,,54.12,Fee Schedule,,45.87,,,45.87,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,296.74,,,296.74,Other,New York Medicaid APG methodology,296.74,,,296.74,Other,100% New York Medicaid APG,296.74,,,296.74,Other,100% New York Medicaid APG,296.74,,,296.74,Other,100% New York Medicaid APG,667.67,,,667.67,Other,225% New York Medicaid APG,454.02,,,454.02,Other,153% New York Medicaid APG,667.67,,,667.67,Other,225% New York Medicaid APG,415.44,,,415.44,Other,140% New York Medicaid APG,667.67,,,667.67,Other,225% New York Medicaid APG,771.53,,,771.53,Other,260% New York Medicaid APG,961.45,,,961.45,Other,324% New York Medicaid APG,638,,,638,Other,215% New York Medicaid APG,638,,,638,Other,215% New York Medicaid APG,370.93,,,370.93,Other,125% New York Medicaid APG,45.87,9473,
Application of paste boot,29580,CPT,,,,,,,,both,,,3314.26,2452.55,74,,2452.55,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,1491.42,45,,1491.42,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,1640.56,49.5,,1640.56,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,680.21,,,680.21,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,2319.98,70,,2319.98,percent of total billed charges,,127.92,,,127.92,Fee Schedule,,108.42,,,108.42,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,365.71,,,365.71,Other,New York Medicaid APG methodology,365.71,,,365.71,Other,100% New York Medicaid APG,365.71,,,365.71,Other,100% New York Medicaid APG,365.71,,,365.71,Other,100% New York Medicaid APG,822.84,,,822.84,Other,225% New York Medicaid APG,559.53,,,559.53,Other,153% New York Medicaid APG,822.84,,,822.84,Other,225% New York Medicaid APG,511.99,,,511.99,Other,140% New York Medicaid APG,822.84,,,822.84,Other,225% New York Medicaid APG,950.84,,,950.84,Other,260% New York Medicaid APG,1184.89,,,1184.89,Other,324% New York Medicaid APG,786.27,,,786.27,Other,215% New York Medicaid APG,786.27,,,786.27,Other,215% New York Medicaid APG,457.13,,,457.13,Other,125% New York Medicaid APG,108.42,9473,
Apply multlay comprs lwr leg,29581,CPT,,,,,,,,both,,,3314.26,2452.55,74,,2452.55,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,1491.42,45,,1491.42,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,1640.56,49.5,,1640.56,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,680.21,,,680.21,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,2319.98,70,,2319.98,percent of total billed charges,,129.56,,,129.56,Fee Schedule,,109.81,,,109.81,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,365.71,,,365.71,Other,New York Medicaid APG methodology,365.71,,,365.71,Other,100% New York Medicaid APG,365.71,,,365.71,Other,100% New York Medicaid APG,365.71,,,365.71,Other,100% New York Medicaid APG,822.84,,,822.84,Other,225% New York Medicaid APG,559.53,,,559.53,Other,153% New York Medicaid APG,822.84,,,822.84,Other,225% New York Medicaid APG,511.99,,,511.99,Other,140% New York Medicaid APG,822.84,,,822.84,Other,225% New York Medicaid APG,950.84,,,950.84,Other,260% New York Medicaid APG,1184.89,,,1184.89,Other,324% New York Medicaid APG,786.27,,,786.27,Other,215% New York Medicaid APG,786.27,,,786.27,Other,215% New York Medicaid APG,457.13,,,457.13,Other,125% New York Medicaid APG,109.81,9473,
Appl multlay comprs arm/hand,29584,CPT,,,,,,,,both,,,3314.26,2452.55,74,,2452.55,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,1491.42,45,,1491.42,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,1640.56,49.5,,1640.56,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,551.94,,,551.94,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,2319.98,70,,2319.98,percent of total billed charges,,77.08,,,77.08,Fee Schedule,,65.33,,,65.33,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,296.74,,,296.74,Other,New York Medicaid APG methodology,296.74,,,296.74,Other,100% New York Medicaid APG,296.74,,,296.74,Other,100% New York Medicaid APG,296.74,,,296.74,Other,100% New York Medicaid APG,667.67,,,667.67,Other,225% New York Medicaid APG,454.02,,,454.02,Other,153% New York Medicaid APG,667.67,,,667.67,Other,225% New York Medicaid APG,415.44,,,415.44,Other,140% New York Medicaid APG,667.67,,,667.67,Other,225% New York Medicaid APG,771.53,,,771.53,Other,260% New York Medicaid APG,961.45,,,961.45,Other,324% New York Medicaid APG,638,,,638,Other,215% New York Medicaid APG,638,,,638,Other,215% New York Medicaid APG,370.93,,,370.93,Other,125% New York Medicaid APG,65.33,9473,
Removal/revision of cast,29700,CPT,,,,,,,,both,,,5648.78,4180.1,74,,4180.1,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,2541.95,45,,2541.95,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,2796.15,49.5,,2796.15,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,680.21,,,680.21,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,3954.15,70,,3954.15,percent of total billed charges,,160.72,,,160.72,Fee Schedule,,136.22,,,136.22,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,365.71,,,365.71,Other,New York Medicaid APG methodology,365.71,,,365.71,Other,100% New York Medicaid APG,365.71,,,365.71,Other,100% New York Medicaid APG,365.71,,,365.71,Other,100% New York Medicaid APG,822.84,,,822.84,Other,225% New York Medicaid APG,559.53,,,559.53,Other,153% New York Medicaid APG,822.84,,,822.84,Other,225% New York Medicaid APG,511.99,,,511.99,Other,140% New York Medicaid APG,822.84,,,822.84,Other,225% New York Medicaid APG,950.84,,,950.84,Other,260% New York Medicaid APG,1184.89,,,1184.89,Other,324% New York Medicaid APG,786.27,,,786.27,Other,215% New York Medicaid APG,786.27,,,786.27,Other,215% New York Medicaid APG,457.13,,,457.13,Other,125% New York Medicaid APG,136.22,9473,
Removal/revision of cast,29705,CPT,,,,,,,,both,,,5648.78,4180.1,74,,4180.1,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,2541.95,45,,2541.95,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,2796.15,49.5,,2796.15,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,680.21,,,680.21,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,3954.15,70,,3954.15,percent of total billed charges,,218.12,,,218.12,Fee Schedule,,184.87,,,184.87,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,365.71,,,365.71,Other,New York Medicaid APG methodology,365.71,,,365.71,Other,100% New York Medicaid APG,365.71,,,365.71,Other,100% New York Medicaid APG,365.71,,,365.71,Other,100% New York Medicaid APG,822.84,,,822.84,Other,225% New York Medicaid APG,559.53,,,559.53,Other,153% New York Medicaid APG,822.84,,,822.84,Other,225% New York Medicaid APG,511.99,,,511.99,Other,140% New York Medicaid APG,822.84,,,822.84,Other,225% New York Medicaid APG,950.84,,,950.84,Other,260% New York Medicaid APG,1184.89,,,1184.89,Other,324% New York Medicaid APG,786.27,,,786.27,Other,215% New York Medicaid APG,786.27,,,786.27,Other,215% New York Medicaid APG,457.13,,,457.13,Other,125% New York Medicaid APG,184.87,9473,
Removal/revision of cast,29710,CPT,,,,,,,,both,,,5648.78,4180.1,74,,4180.1,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,2541.95,45,,2541.95,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,2796.15,49.5,,2796.15,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,680.21,,,680.21,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,3954.15,70,,3954.15,percent of total billed charges,,401.8,,,401.8,Fee Schedule,,340.55,,,340.55,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,365.71,,,365.71,Other,New York Medicaid APG methodology,365.71,,,365.71,Other,100% New York Medicaid APG,365.71,,,365.71,Other,100% New York Medicaid APG,365.71,,,365.71,Other,100% New York Medicaid APG,822.84,,,822.84,Other,225% New York Medicaid APG,559.53,,,559.53,Other,153% New York Medicaid APG,822.84,,,822.84,Other,225% New York Medicaid APG,511.99,,,511.99,Other,140% New York Medicaid APG,822.84,,,822.84,Other,225% New York Medicaid APG,950.84,,,950.84,Other,260% New York Medicaid APG,1184.89,,,1184.89,Other,324% New York Medicaid APG,786.27,,,786.27,Other,215% New York Medicaid APG,786.27,,,786.27,Other,215% New York Medicaid APG,457.13,,,457.13,Other,125% New York Medicaid APG,340.55,9473,
Repair of body cast,29720,CPT,,,,,,,,both,,,3314.26,2452.55,74,,2452.55,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,1491.42,45,,1491.42,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,1640.56,49.5,,1640.56,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,680.21,,,680.21,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,2319.98,70,,2319.98,percent of total billed charges,,213.2,,,213.2,Fee Schedule,,180.7,,,180.7,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,365.71,,,365.71,Other,New York Medicaid APG methodology,365.71,,,365.71,Other,100% New York Medicaid APG,365.71,,,365.71,Other,100% New York Medicaid APG,365.71,,,365.71,Other,100% New York Medicaid APG,822.84,,,822.84,Other,225% New York Medicaid APG,559.53,,,559.53,Other,153% New York Medicaid APG,822.84,,,822.84,Other,225% New York Medicaid APG,511.99,,,511.99,Other,140% New York Medicaid APG,822.84,,,822.84,Other,225% New York Medicaid APG,950.84,,,950.84,Other,260% New York Medicaid APG,1184.89,,,1184.89,Other,324% New York Medicaid APG,786.27,,,786.27,Other,215% New York Medicaid APG,786.27,,,786.27,Other,215% New York Medicaid APG,457.13,,,457.13,Other,125% New York Medicaid APG,180.7,9473,
Windowing of cast,29730,CPT,,,,,,,,both,,,3314.26,2452.55,74,,2452.55,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,1491.42,45,,1491.42,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,1640.56,49.5,,1640.56,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,680.21,,,680.21,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,2319.98,70,,2319.98,percent of total billed charges,,216.48,,,216.48,Fee Schedule,,183.48,,,183.48,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,365.71,,,365.71,Other,New York Medicaid APG methodology,365.71,,,365.71,Other,100% New York Medicaid APG,365.71,,,365.71,Other,100% New York Medicaid APG,365.71,,,365.71,Other,100% New York Medicaid APG,822.84,,,822.84,Other,225% New York Medicaid APG,559.53,,,559.53,Other,153% New York Medicaid APG,822.84,,,822.84,Other,225% New York Medicaid APG,511.99,,,511.99,Other,140% New York Medicaid APG,822.84,,,822.84,Other,225% New York Medicaid APG,950.84,,,950.84,Other,260% New York Medicaid APG,1184.89,,,1184.89,Other,324% New York Medicaid APG,786.27,,,786.27,Other,215% New York Medicaid APG,786.27,,,786.27,Other,215% New York Medicaid APG,457.13,,,457.13,Other,125% New York Medicaid APG,183.48,9473,
Wedging of cast,29740,CPT,,,,,,,,both,,,5648.78,4180.1,74,,4180.1,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,2541.95,45,,2541.95,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,2796.15,49.5,,2796.15,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,680.21,,,680.21,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,3954.15,70,,3954.15,percent of total billed charges,,336.2,,,336.2,Fee Schedule,,284.95,,,284.95,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,365.71,,,365.71,Other,New York Medicaid APG methodology,365.71,,,365.71,Other,100% New York Medicaid APG,365.71,,,365.71,Other,100% New York Medicaid APG,365.71,,,365.71,Other,100% New York Medicaid APG,822.84,,,822.84,Other,225% New York Medicaid APG,559.53,,,559.53,Other,153% New York Medicaid APG,822.84,,,822.84,Other,225% New York Medicaid APG,511.99,,,511.99,Other,140% New York Medicaid APG,822.84,,,822.84,Other,225% New York Medicaid APG,950.84,,,950.84,Other,260% New York Medicaid APG,1184.89,,,1184.89,Other,324% New York Medicaid APG,786.27,,,786.27,Other,215% New York Medicaid APG,786.27,,,786.27,Other,215% New York Medicaid APG,457.13,,,457.13,Other,125% New York Medicaid APG,284.95,9473,
Wedging of clubfoot cast,29750,CPT,,,,,,,,both,,,5648.78,4180.1,74,,4180.1,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,2541.95,45,,2541.95,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,2796.15,49.5,,2796.15,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,680.21,,,680.21,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,3954.15,70,,3954.15,percent of total billed charges,,375.56,,,375.56,Fee Schedule,,318.31,,,318.31,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,365.71,,,365.71,Other,New York Medicaid APG methodology,365.71,,,365.71,Other,100% New York Medicaid APG,365.71,,,365.71,Other,100% New York Medicaid APG,365.71,,,365.71,Other,100% New York Medicaid APG,822.84,,,822.84,Other,225% New York Medicaid APG,559.53,,,559.53,Other,153% New York Medicaid APG,822.84,,,822.84,Other,225% New York Medicaid APG,511.99,,,511.99,Other,140% New York Medicaid APG,822.84,,,822.84,Other,225% New York Medicaid APG,950.84,,,950.84,Other,260% New York Medicaid APG,1184.89,,,1184.89,Other,324% New York Medicaid APG,786.27,,,786.27,Other,215% New York Medicaid APG,786.27,,,786.27,Other,215% New York Medicaid APG,457.13,,,457.13,Other,125% New York Medicaid APG,318.31,9473,
Jaw arthroscopy/surgery,29800,CPT,,,,,,,,both,,,68082.75,50381.24,74,,50381.24,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30637.24,45,,30637.24,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33700.96,49.5,,33700.96,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3210.17,,,3210.17,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,47657.93,70,,47657.93,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1725.9,,,1725.9,Other,New York Medicaid APG methodology,1725.9,,,1725.9,Other,100% New York Medicaid APG,1725.9,,,1725.9,Other,100% New York Medicaid APG,1725.9,,,1725.9,Other,100% New York Medicaid APG,3883.27,,,3883.27,Other,225% New York Medicaid APG,2640.62,,,2640.62,Other,153% New York Medicaid APG,3883.27,,,3883.27,Other,225% New York Medicaid APG,2416.26,,,2416.26,Other,140% New York Medicaid APG,3883.27,,,3883.27,Other,225% New York Medicaid APG,4487.33,,,4487.33,Other,260% New York Medicaid APG,5591.91,,,5591.91,Other,324% New York Medicaid APG,3710.68,,,3710.68,Other,215% New York Medicaid APG,3710.68,,,3710.68,Other,215% New York Medicaid APG,2157.37,,,2157.37,Other,125% New York Medicaid APG,1725.9,50381.24,
Jaw arthroscopy/surgery,29804,CPT,,,,,,,,both,,,68082.75,50381.24,74,,50381.24,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30637.24,45,,30637.24,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33700.96,49.5,,33700.96,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3210.17,,,3210.17,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,47657.93,70,,47657.93,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1725.9,,,1725.9,Other,New York Medicaid APG methodology,1725.9,,,1725.9,Other,100% New York Medicaid APG,1725.9,,,1725.9,Other,100% New York Medicaid APG,1725.9,,,1725.9,Other,100% New York Medicaid APG,3883.27,,,3883.27,Other,225% New York Medicaid APG,2640.62,,,2640.62,Other,153% New York Medicaid APG,3883.27,,,3883.27,Other,225% New York Medicaid APG,2416.26,,,2416.26,Other,140% New York Medicaid APG,3883.27,,,3883.27,Other,225% New York Medicaid APG,4487.33,,,4487.33,Other,260% New York Medicaid APG,5591.91,,,5591.91,Other,324% New York Medicaid APG,3710.68,,,3710.68,Other,215% New York Medicaid APG,3710.68,,,3710.68,Other,215% New York Medicaid APG,2157.37,,,2157.37,Other,125% New York Medicaid APG,1725.9,50381.24,
Sho arthrs dx +- synovial bx,29805,CPT,,,,,,,,both,,,68082.75,50381.24,74,,50381.24,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30637.24,45,,30637.24,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33700.96,49.5,,33700.96,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3210.17,,,3210.17,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,47657.93,70,,47657.93,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1725.9,,,1725.9,Other,New York Medicaid APG methodology,1725.9,,,1725.9,Other,100% New York Medicaid APG,1725.9,,,1725.9,Other,100% New York Medicaid APG,1725.9,,,1725.9,Other,100% New York Medicaid APG,3883.27,,,3883.27,Other,225% New York Medicaid APG,2640.62,,,2640.62,Other,153% New York Medicaid APG,3883.27,,,3883.27,Other,225% New York Medicaid APG,2416.26,,,2416.26,Other,140% New York Medicaid APG,3883.27,,,3883.27,Other,225% New York Medicaid APG,4487.33,,,4487.33,Other,260% New York Medicaid APG,5591.91,,,5591.91,Other,324% New York Medicaid APG,3710.68,,,3710.68,Other,215% New York Medicaid APG,3710.68,,,3710.68,Other,215% New York Medicaid APG,2157.37,,,2157.37,Other,125% New York Medicaid APG,1725.9,50381.24,
Sho arthrs srg capsulorpaphy,29806,CPT,,,,,,,,both,,,74747.75,55313.34,74,,55313.34,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,33636.49,45,,33636.49,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,37000.14,49.5,,37000.14,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5918.58,,,5918.58,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,52323.43,70,,52323.43,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,3182.03,,,3182.03,Other,New York Medicaid APG methodology,3182.03,,,3182.03,Other,100% New York Medicaid APG,3182.03,,,3182.03,Other,100% New York Medicaid APG,3182.03,,,3182.03,Other,100% New York Medicaid APG,7159.57,,,7159.57,Other,225% New York Medicaid APG,4868.51,,,4868.51,Other,153% New York Medicaid APG,7159.57,,,7159.57,Other,225% New York Medicaid APG,4454.84,,,4454.84,Other,140% New York Medicaid APG,7159.57,,,7159.57,Other,225% New York Medicaid APG,8273.28,,,8273.28,Other,260% New York Medicaid APG,10309.78,,,10309.78,Other,324% New York Medicaid APG,6841.37,,,6841.37,Other,215% New York Medicaid APG,6841.37,,,6841.37,Other,215% New York Medicaid APG,3977.54,,,3977.54,Other,125% New York Medicaid APG,3126,55313.34,
Sho arthrs srg rpr slap les,29807,CPT,,,,,,,,both,,,62418.33,46189.56,74,,46189.56,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,28088.25,45,,28088.25,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,30897.07,49.5,,30897.07,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5918.58,,,5918.58,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,43692.83,70,,43692.83,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,3182.03,,,3182.03,Other,New York Medicaid APG methodology,3182.03,,,3182.03,Other,100% New York Medicaid APG,3182.03,,,3182.03,Other,100% New York Medicaid APG,3182.03,,,3182.03,Other,100% New York Medicaid APG,7159.57,,,7159.57,Other,225% New York Medicaid APG,4868.51,,,4868.51,Other,153% New York Medicaid APG,7159.57,,,7159.57,Other,225% New York Medicaid APG,4454.84,,,4454.84,Other,140% New York Medicaid APG,7159.57,,,7159.57,Other,225% New York Medicaid APG,8273.28,,,8273.28,Other,260% New York Medicaid APG,10309.78,,,10309.78,Other,324% New York Medicaid APG,6841.37,,,6841.37,Other,215% New York Medicaid APG,6841.37,,,6841.37,Other,215% New York Medicaid APG,3977.54,,,3977.54,Other,125% New York Medicaid APG,3126,46189.56,
Sho arthrs srg rmvl loose/fb,29819,CPT,,,,,,,,both,,,68082.75,50381.24,74,,50381.24,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30637.24,45,,30637.24,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33700.96,49.5,,33700.96,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3210.17,,,3210.17,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,47657.93,70,,47657.93,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,1725.9,,,1725.9,Other,New York Medicaid APG methodology,1725.9,,,1725.9,Other,100% New York Medicaid APG,1725.9,,,1725.9,Other,100% New York Medicaid APG,1725.9,,,1725.9,Other,100% New York Medicaid APG,3883.27,,,3883.27,Other,225% New York Medicaid APG,2640.62,,,2640.62,Other,153% New York Medicaid APG,3883.27,,,3883.27,Other,225% New York Medicaid APG,2416.26,,,2416.26,Other,140% New York Medicaid APG,3883.27,,,3883.27,Other,225% New York Medicaid APG,4487.33,,,4487.33,Other,260% New York Medicaid APG,5591.91,,,5591.91,Other,324% New York Medicaid APG,3710.68,,,3710.68,Other,215% New York Medicaid APG,3710.68,,,3710.68,Other,215% New York Medicaid APG,2157.37,,,2157.37,Other,125% New York Medicaid APG,1725.9,50381.24,
Sho arthrs srg prtl synvct,29820,CPT,,,,,,,,both,,,64371.33,47634.78,74,,47634.78,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,28967.1,45,,28967.1,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,31863.81,49.5,,31863.81,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3210.17,,,3210.17,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,45059.93,70,,45059.93,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,1725.9,,,1725.9,Other,New York Medicaid APG methodology,1725.9,,,1725.9,Other,100% New York Medicaid APG,1725.9,,,1725.9,Other,100% New York Medicaid APG,1725.9,,,1725.9,Other,100% New York Medicaid APG,3883.27,,,3883.27,Other,225% New York Medicaid APG,2640.62,,,2640.62,Other,153% New York Medicaid APG,3883.27,,,3883.27,Other,225% New York Medicaid APG,2416.26,,,2416.26,Other,140% New York Medicaid APG,3883.27,,,3883.27,Other,225% New York Medicaid APG,4487.33,,,4487.33,Other,260% New York Medicaid APG,5591.91,,,5591.91,Other,324% New York Medicaid APG,3710.68,,,3710.68,Other,215% New York Medicaid APG,3710.68,,,3710.68,Other,215% New York Medicaid APG,2157.37,,,2157.37,Other,125% New York Medicaid APG,1725.9,47634.78,
Sho arthrs srg compl synvct,29821,CPT,,,,,,,,both,,,68082.75,50381.24,74,,50381.24,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30637.24,45,,30637.24,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33700.96,49.5,,33700.96,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5918.58,,,5918.58,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,47657.93,70,,47657.93,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,3182.03,,,3182.03,Other,New York Medicaid APG methodology,3182.03,,,3182.03,Other,100% New York Medicaid APG,3182.03,,,3182.03,Other,100% New York Medicaid APG,3182.03,,,3182.03,Other,100% New York Medicaid APG,7159.57,,,7159.57,Other,225% New York Medicaid APG,4868.51,,,4868.51,Other,153% New York Medicaid APG,7159.57,,,7159.57,Other,225% New York Medicaid APG,4454.84,,,4454.84,Other,140% New York Medicaid APG,7159.57,,,7159.57,Other,225% New York Medicaid APG,8273.28,,,8273.28,Other,260% New York Medicaid APG,10309.78,,,10309.78,Other,324% New York Medicaid APG,6841.37,,,6841.37,Other,215% New York Medicaid APG,6841.37,,,6841.37,Other,215% New York Medicaid APG,3977.54,,,3977.54,Other,125% New York Medicaid APG,3126,50381.24,
Sho arthrs srg lmtd dbrdmt,29822,CPT,,,,,,,,both,,,55898.02,41364.53,74,,41364.53,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,25154.11,45,,25154.11,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,27669.52,49.5,,27669.52,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3210.17,,,3210.17,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,39128.61,70,,39128.61,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1725.9,,,1725.9,Other,New York Medicaid APG methodology,1725.9,,,1725.9,Other,100% New York Medicaid APG,1725.9,,,1725.9,Other,100% New York Medicaid APG,1725.9,,,1725.9,Other,100% New York Medicaid APG,3883.27,,,3883.27,Other,225% New York Medicaid APG,2640.62,,,2640.62,Other,153% New York Medicaid APG,3883.27,,,3883.27,Other,225% New York Medicaid APG,2416.26,,,2416.26,Other,140% New York Medicaid APG,3883.27,,,3883.27,Other,225% New York Medicaid APG,4487.33,,,4487.33,Other,260% New York Medicaid APG,5591.91,,,5591.91,Other,324% New York Medicaid APG,3710.68,,,3710.68,Other,215% New York Medicaid APG,3710.68,,,3710.68,Other,215% New York Medicaid APG,2157.37,,,2157.37,Other,125% New York Medicaid APG,1725.9,41364.53,
Sho arthrs srg xtnsv dbrdmt,29823,CPT,,,,,,,,both,,,43934.41,32511.46,74,,32511.46,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,19770.48,45,,19770.48,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,21747.53,49.5,,21747.53,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3210.17,,,3210.17,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,30754.09,70,,30754.09,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,1725.9,,,1725.9,Other,New York Medicaid APG methodology,1725.9,,,1725.9,Other,100% New York Medicaid APG,1725.9,,,1725.9,Other,100% New York Medicaid APG,1725.9,,,1725.9,Other,100% New York Medicaid APG,3883.27,,,3883.27,Other,225% New York Medicaid APG,2640.62,,,2640.62,Other,153% New York Medicaid APG,3883.27,,,3883.27,Other,225% New York Medicaid APG,2416.26,,,2416.26,Other,140% New York Medicaid APG,3883.27,,,3883.27,Other,225% New York Medicaid APG,4487.33,,,4487.33,Other,260% New York Medicaid APG,5591.91,,,5591.91,Other,324% New York Medicaid APG,3710.68,,,3710.68,Other,215% New York Medicaid APG,3710.68,,,3710.68,Other,215% New York Medicaid APG,2157.37,,,2157.37,Other,125% New York Medicaid APG,1725.9,32511.46,
Sho arthrs srg dstl claviclc,29824,CPT,,,,,,,,both,,,52694.18,38993.69,74,,38993.69,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,23712.38,45,,23712.38,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,26083.62,49.5,,26083.62,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3210.17,,,3210.17,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,36885.93,70,,36885.93,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,1725.9,,,1725.9,Other,New York Medicaid APG methodology,1725.9,,,1725.9,Other,100% New York Medicaid APG,1725.9,,,1725.9,Other,100% New York Medicaid APG,1725.9,,,1725.9,Other,100% New York Medicaid APG,3883.27,,,3883.27,Other,225% New York Medicaid APG,2640.62,,,2640.62,Other,153% New York Medicaid APG,3883.27,,,3883.27,Other,225% New York Medicaid APG,2416.26,,,2416.26,Other,140% New York Medicaid APG,3883.27,,,3883.27,Other,225% New York Medicaid APG,4487.33,,,4487.33,Other,260% New York Medicaid APG,5591.91,,,5591.91,Other,324% New York Medicaid APG,3710.68,,,3710.68,Other,215% New York Medicaid APG,3710.68,,,3710.68,Other,215% New York Medicaid APG,2157.37,,,2157.37,Other,125% New York Medicaid APG,1725.9,38993.69,
Sho arthrs srg lss&rescj ads,29825,CPT,,,,,,,,both,,,68082.75,50381.24,74,,50381.24,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30637.24,45,,30637.24,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33700.96,49.5,,33700.96,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3210.17,,,3210.17,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,47657.93,70,,47657.93,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,1725.9,,,1725.9,Other,New York Medicaid APG methodology,1725.9,,,1725.9,Other,100% New York Medicaid APG,1725.9,,,1725.9,Other,100% New York Medicaid APG,1725.9,,,1725.9,Other,100% New York Medicaid APG,3883.27,,,3883.27,Other,225% New York Medicaid APG,2640.62,,,2640.62,Other,153% New York Medicaid APG,3883.27,,,3883.27,Other,225% New York Medicaid APG,2416.26,,,2416.26,Other,140% New York Medicaid APG,3883.27,,,3883.27,Other,225% New York Medicaid APG,4487.33,,,4487.33,Other,260% New York Medicaid APG,5591.91,,,5591.91,Other,324% New York Medicaid APG,3710.68,,,3710.68,Other,215% New York Medicaid APG,3710.68,,,3710.68,Other,215% New York Medicaid APG,2157.37,,,2157.37,Other,125% New York Medicaid APG,1725.9,50381.24,
Sho arthrs srg decompression,29826,CPT,,,,,,,,both,,,64222.15,47524.39,74,,47524.39,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,28899.97,45,,28899.97,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,31789.96,49.5,,31789.96,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3210.17,,,3210.17,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,44955.51,70,,44955.51,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,1725.9,,,1725.9,Other,New York Medicaid APG methodology,1725.9,,,1725.9,Other,100% New York Medicaid APG,1725.9,,,1725.9,Other,100% New York Medicaid APG,1725.9,,,1725.9,Other,100% New York Medicaid APG,3883.27,,,3883.27,Other,225% New York Medicaid APG,2640.62,,,2640.62,Other,153% New York Medicaid APG,3883.27,,,3883.27,Other,225% New York Medicaid APG,2416.26,,,2416.26,Other,140% New York Medicaid APG,3883.27,,,3883.27,Other,225% New York Medicaid APG,4487.33,,,4487.33,Other,260% New York Medicaid APG,5591.91,,,5591.91,Other,324% New York Medicaid APG,3710.68,,,3710.68,Other,215% New York Medicaid APG,3710.68,,,3710.68,Other,215% New York Medicaid APG,2157.37,,,2157.37,Other,125% New York Medicaid APG,1725.9,47524.39,
Sho arthrs srg rt8tr cuf rpr,29827,CPT,,,,,,,,both,,,88593.2,65558.97,74,,65558.97,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,39866.94,45,,39866.94,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,43853.63,49.5,,43853.63,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5918.58,,,5918.58,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,62015.24,70,,62015.24,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,3182.03,,,3182.03,Other,New York Medicaid APG methodology,3182.03,,,3182.03,Other,100% New York Medicaid APG,3182.03,,,3182.03,Other,100% New York Medicaid APG,3182.03,,,3182.03,Other,100% New York Medicaid APG,7159.57,,,7159.57,Other,225% New York Medicaid APG,4868.51,,,4868.51,Other,153% New York Medicaid APG,7159.57,,,7159.57,Other,225% New York Medicaid APG,4454.84,,,4454.84,Other,140% New York Medicaid APG,7159.57,,,7159.57,Other,225% New York Medicaid APG,8273.28,,,8273.28,Other,260% New York Medicaid APG,10309.78,,,10309.78,Other,324% New York Medicaid APG,6841.37,,,6841.37,Other,215% New York Medicaid APG,6841.37,,,6841.37,Other,215% New York Medicaid APG,3977.54,,,3977.54,Other,125% New York Medicaid APG,3182.03,65558.97,
Sho arthrs srg bicp tenodsis,29828,CPT,,,,,,,,both,,,65898.99,48765.25,74,,48765.25,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,29654.55,45,,29654.55,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,32620,49.5,,32620,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5918.58,,,5918.58,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,46129.29,70,,46129.29,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,3182.03,,,3182.03,Other,New York Medicaid APG methodology,3182.03,,,3182.03,Other,100% New York Medicaid APG,3182.03,,,3182.03,Other,100% New York Medicaid APG,3182.03,,,3182.03,Other,100% New York Medicaid APG,7159.57,,,7159.57,Other,225% New York Medicaid APG,4868.51,,,4868.51,Other,153% New York Medicaid APG,7159.57,,,7159.57,Other,225% New York Medicaid APG,4454.84,,,4454.84,Other,140% New York Medicaid APG,7159.57,,,7159.57,Other,225% New York Medicaid APG,8273.28,,,8273.28,Other,260% New York Medicaid APG,10309.78,,,10309.78,Other,324% New York Medicaid APG,6841.37,,,6841.37,Other,215% New York Medicaid APG,6841.37,,,6841.37,Other,215% New York Medicaid APG,3977.54,,,3977.54,Other,125% New York Medicaid APG,2879,48765.25,
Elbow arthroscopy,29830,CPT,,,,,,,,both,,,68082.75,50381.24,74,,50381.24,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30637.24,45,,30637.24,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33700.96,49.5,,33700.96,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3210.17,,,3210.17,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,47657.93,70,,47657.93,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,1725.9,,,1725.9,Other,New York Medicaid APG methodology,1725.9,,,1725.9,Other,100% New York Medicaid APG,1725.9,,,1725.9,Other,100% New York Medicaid APG,1725.9,,,1725.9,Other,100% New York Medicaid APG,3883.27,,,3883.27,Other,225% New York Medicaid APG,2640.62,,,2640.62,Other,153% New York Medicaid APG,3883.27,,,3883.27,Other,225% New York Medicaid APG,2416.26,,,2416.26,Other,140% New York Medicaid APG,3883.27,,,3883.27,Other,225% New York Medicaid APG,4487.33,,,4487.33,Other,260% New York Medicaid APG,5591.91,,,5591.91,Other,324% New York Medicaid APG,3710.68,,,3710.68,Other,215% New York Medicaid APG,3710.68,,,3710.68,Other,215% New York Medicaid APG,2157.37,,,2157.37,Other,125% New York Medicaid APG,1725.9,50381.24,
Elbow arthroscopy/surgery,29834,CPT,,,,,,,,both,,,68082.75,50381.24,74,,50381.24,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30637.24,45,,30637.24,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33700.96,49.5,,33700.96,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3210.17,,,3210.17,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,47657.93,70,,47657.93,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1725.9,,,1725.9,Other,New York Medicaid APG methodology,1725.9,,,1725.9,Other,100% New York Medicaid APG,1725.9,,,1725.9,Other,100% New York Medicaid APG,1725.9,,,1725.9,Other,100% New York Medicaid APG,3883.27,,,3883.27,Other,225% New York Medicaid APG,2640.62,,,2640.62,Other,153% New York Medicaid APG,3883.27,,,3883.27,Other,225% New York Medicaid APG,2416.26,,,2416.26,Other,140% New York Medicaid APG,3883.27,,,3883.27,Other,225% New York Medicaid APG,4487.33,,,4487.33,Other,260% New York Medicaid APG,5591.91,,,5591.91,Other,324% New York Medicaid APG,3710.68,,,3710.68,Other,215% New York Medicaid APG,3710.68,,,3710.68,Other,215% New York Medicaid APG,2157.37,,,2157.37,Other,125% New York Medicaid APG,1725.9,50381.24,
Elbow arthroscopy/surgery,29835,CPT,,,,,,,,both,,,68082.75,50381.24,74,,50381.24,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30637.24,45,,30637.24,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33700.96,49.5,,33700.96,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3210.17,,,3210.17,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,47657.93,70,,47657.93,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,1725.9,,,1725.9,Other,New York Medicaid APG methodology,1725.9,,,1725.9,Other,100% New York Medicaid APG,1725.9,,,1725.9,Other,100% New York Medicaid APG,1725.9,,,1725.9,Other,100% New York Medicaid APG,3883.27,,,3883.27,Other,225% New York Medicaid APG,2640.62,,,2640.62,Other,153% New York Medicaid APG,3883.27,,,3883.27,Other,225% New York Medicaid APG,2416.26,,,2416.26,Other,140% New York Medicaid APG,3883.27,,,3883.27,Other,225% New York Medicaid APG,4487.33,,,4487.33,Other,260% New York Medicaid APG,5591.91,,,5591.91,Other,324% New York Medicaid APG,3710.68,,,3710.68,Other,215% New York Medicaid APG,3710.68,,,3710.68,Other,215% New York Medicaid APG,2157.37,,,2157.37,Other,125% New York Medicaid APG,1725.9,50381.24,
Elbow arthroscopy/surgery,29836,CPT,,,,,,,,both,,,150476.65,111352.72,74,,111352.72,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,67714.49,45,,67714.49,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,74485.94,49.5,,74485.94,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5918.58,,,5918.58,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,105333.66,70,,105333.66,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,3182.03,,,3182.03,Other,New York Medicaid APG methodology,3182.03,,,3182.03,Other,100% New York Medicaid APG,3182.03,,,3182.03,Other,100% New York Medicaid APG,3182.03,,,3182.03,Other,100% New York Medicaid APG,7159.57,,,7159.57,Other,225% New York Medicaid APG,4868.51,,,4868.51,Other,153% New York Medicaid APG,7159.57,,,7159.57,Other,225% New York Medicaid APG,4454.84,,,4454.84,Other,140% New York Medicaid APG,7159.57,,,7159.57,Other,225% New York Medicaid APG,8273.28,,,8273.28,Other,260% New York Medicaid APG,10309.78,,,10309.78,Other,324% New York Medicaid APG,6841.37,,,6841.37,Other,215% New York Medicaid APG,6841.37,,,6841.37,Other,215% New York Medicaid APG,3977.54,,,3977.54,Other,125% New York Medicaid APG,3126,111352.72,
Elbow arthroscopy/surgery,29837,CPT,,,,,,,,both,,,42892.81,31740.68,74,,31740.68,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,19301.76,45,,19301.76,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,21231.94,49.5,,21231.94,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3210.17,,,3210.17,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,30024.97,70,,30024.97,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1725.9,,,1725.9,Other,New York Medicaid APG methodology,1725.9,,,1725.9,Other,100% New York Medicaid APG,1725.9,,,1725.9,Other,100% New York Medicaid APG,1725.9,,,1725.9,Other,100% New York Medicaid APG,3883.27,,,3883.27,Other,225% New York Medicaid APG,2640.62,,,2640.62,Other,153% New York Medicaid APG,3883.27,,,3883.27,Other,225% New York Medicaid APG,2416.26,,,2416.26,Other,140% New York Medicaid APG,3883.27,,,3883.27,Other,225% New York Medicaid APG,4487.33,,,4487.33,Other,260% New York Medicaid APG,5591.91,,,5591.91,Other,324% New York Medicaid APG,3710.68,,,3710.68,Other,215% New York Medicaid APG,3710.68,,,3710.68,Other,215% New York Medicaid APG,2157.37,,,2157.37,Other,125% New York Medicaid APG,1725.9,31740.68,
Elbow arthroscopy/surgery,29838,CPT,,,,,,,,both,,,68082.75,50381.24,74,,50381.24,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30637.24,45,,30637.24,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33700.96,49.5,,33700.96,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3210.17,,,3210.17,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,47657.93,70,,47657.93,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1725.9,,,1725.9,Other,New York Medicaid APG methodology,1725.9,,,1725.9,Other,100% New York Medicaid APG,1725.9,,,1725.9,Other,100% New York Medicaid APG,1725.9,,,1725.9,Other,100% New York Medicaid APG,3883.27,,,3883.27,Other,225% New York Medicaid APG,2640.62,,,2640.62,Other,153% New York Medicaid APG,3883.27,,,3883.27,Other,225% New York Medicaid APG,2416.26,,,2416.26,Other,140% New York Medicaid APG,3883.27,,,3883.27,Other,225% New York Medicaid APG,4487.33,,,4487.33,Other,260% New York Medicaid APG,5591.91,,,5591.91,Other,324% New York Medicaid APG,3710.68,,,3710.68,Other,215% New York Medicaid APG,3710.68,,,3710.68,Other,215% New York Medicaid APG,2157.37,,,2157.37,Other,125% New York Medicaid APG,1725.9,50381.24,
Wrist arthroscopy,29840,CPT,,,,,,,,both,,,68082.75,50381.24,74,,50381.24,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30637.24,45,,30637.24,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33700.96,49.5,,33700.96,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3210.17,,,3210.17,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,47657.93,70,,47657.93,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1725.9,,,1725.9,Other,New York Medicaid APG methodology,1725.9,,,1725.9,Other,100% New York Medicaid APG,1725.9,,,1725.9,Other,100% New York Medicaid APG,1725.9,,,1725.9,Other,100% New York Medicaid APG,3883.27,,,3883.27,Other,225% New York Medicaid APG,2640.62,,,2640.62,Other,153% New York Medicaid APG,3883.27,,,3883.27,Other,225% New York Medicaid APG,2416.26,,,2416.26,Other,140% New York Medicaid APG,3883.27,,,3883.27,Other,225% New York Medicaid APG,4487.33,,,4487.33,Other,260% New York Medicaid APG,5591.91,,,5591.91,Other,324% New York Medicaid APG,3710.68,,,3710.68,Other,215% New York Medicaid APG,3710.68,,,3710.68,Other,215% New York Medicaid APG,2157.37,,,2157.37,Other,125% New York Medicaid APG,1725.9,50381.24,
Wrist arthroscopy/surgery,29843,CPT,,,,,,,,both,,,68082.75,50381.24,74,,50381.24,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30637.24,45,,30637.24,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33700.96,49.5,,33700.96,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3210.17,,,3210.17,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,47657.93,70,,47657.93,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1725.9,,,1725.9,Other,New York Medicaid APG methodology,1725.9,,,1725.9,Other,100% New York Medicaid APG,1725.9,,,1725.9,Other,100% New York Medicaid APG,1725.9,,,1725.9,Other,100% New York Medicaid APG,3883.27,,,3883.27,Other,225% New York Medicaid APG,2640.62,,,2640.62,Other,153% New York Medicaid APG,3883.27,,,3883.27,Other,225% New York Medicaid APG,2416.26,,,2416.26,Other,140% New York Medicaid APG,3883.27,,,3883.27,Other,225% New York Medicaid APG,4487.33,,,4487.33,Other,260% New York Medicaid APG,5591.91,,,5591.91,Other,324% New York Medicaid APG,3710.68,,,3710.68,Other,215% New York Medicaid APG,3710.68,,,3710.68,Other,215% New York Medicaid APG,2157.37,,,2157.37,Other,125% New York Medicaid APG,1725.9,50381.24,
Wrist arthroscopy/surgery,29844,CPT,,,,,,,,both,,,68082.75,50381.24,74,,50381.24,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30637.24,45,,30637.24,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33700.96,49.5,,33700.96,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3210.17,,,3210.17,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,47657.93,70,,47657.93,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1725.9,,,1725.9,Other,New York Medicaid APG methodology,1725.9,,,1725.9,Other,100% New York Medicaid APG,1725.9,,,1725.9,Other,100% New York Medicaid APG,1725.9,,,1725.9,Other,100% New York Medicaid APG,3883.27,,,3883.27,Other,225% New York Medicaid APG,2640.62,,,2640.62,Other,153% New York Medicaid APG,3883.27,,,3883.27,Other,225% New York Medicaid APG,2416.26,,,2416.26,Other,140% New York Medicaid APG,3883.27,,,3883.27,Other,225% New York Medicaid APG,4487.33,,,4487.33,Other,260% New York Medicaid APG,5591.91,,,5591.91,Other,324% New York Medicaid APG,3710.68,,,3710.68,Other,215% New York Medicaid APG,3710.68,,,3710.68,Other,215% New York Medicaid APG,2157.37,,,2157.37,Other,125% New York Medicaid APG,1725.9,50381.24,
Wrist arthroscopy/surgery,29845,CPT,,,,,,,,both,,,68082.75,50381.24,74,,50381.24,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30637.24,45,,30637.24,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33700.96,49.5,,33700.96,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3210.17,,,3210.17,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,47657.93,70,,47657.93,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1725.9,,,1725.9,Other,New York Medicaid APG methodology,1725.9,,,1725.9,Other,100% New York Medicaid APG,1725.9,,,1725.9,Other,100% New York Medicaid APG,1725.9,,,1725.9,Other,100% New York Medicaid APG,3883.27,,,3883.27,Other,225% New York Medicaid APG,2640.62,,,2640.62,Other,153% New York Medicaid APG,3883.27,,,3883.27,Other,225% New York Medicaid APG,2416.26,,,2416.26,Other,140% New York Medicaid APG,3883.27,,,3883.27,Other,225% New York Medicaid APG,4487.33,,,4487.33,Other,260% New York Medicaid APG,5591.91,,,5591.91,Other,324% New York Medicaid APG,3710.68,,,3710.68,Other,215% New York Medicaid APG,3710.68,,,3710.68,Other,215% New York Medicaid APG,2157.37,,,2157.37,Other,125% New York Medicaid APG,1725.9,50381.24,
Wrist arthroscopy/surgery,29846,CPT,,,,,,,,both,,,48604.71,35967.49,74,,35967.49,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,21872.12,45,,21872.12,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,24059.33,49.5,,24059.33,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3210.17,,,3210.17,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,34023.3,70,,34023.3,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1725.9,,,1725.9,Other,New York Medicaid APG methodology,1725.9,,,1725.9,Other,100% New York Medicaid APG,1725.9,,,1725.9,Other,100% New York Medicaid APG,1725.9,,,1725.9,Other,100% New York Medicaid APG,3883.27,,,3883.27,Other,225% New York Medicaid APG,2640.62,,,2640.62,Other,153% New York Medicaid APG,3883.27,,,3883.27,Other,225% New York Medicaid APG,2416.26,,,2416.26,Other,140% New York Medicaid APG,3883.27,,,3883.27,Other,225% New York Medicaid APG,4487.33,,,4487.33,Other,260% New York Medicaid APG,5591.91,,,5591.91,Other,324% New York Medicaid APG,3710.68,,,3710.68,Other,215% New York Medicaid APG,3710.68,,,3710.68,Other,215% New York Medicaid APG,2157.37,,,2157.37,Other,125% New York Medicaid APG,1725.9,35967.49,
Wrist arthroscopy/surgery,29847,CPT,,,,,,,,both,,,150476.65,111352.72,74,,111352.72,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,67714.49,45,,67714.49,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,74485.94,49.5,,74485.94,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5918.58,,,5918.58,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,105333.66,70,,105333.66,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,3182.03,,,3182.03,Other,New York Medicaid APG methodology,3182.03,,,3182.03,Other,100% New York Medicaid APG,3182.03,,,3182.03,Other,100% New York Medicaid APG,3182.03,,,3182.03,Other,100% New York Medicaid APG,7159.57,,,7159.57,Other,225% New York Medicaid APG,4868.51,,,4868.51,Other,153% New York Medicaid APG,7159.57,,,7159.57,Other,225% New York Medicaid APG,4454.84,,,4454.84,Other,140% New York Medicaid APG,7159.57,,,7159.57,Other,225% New York Medicaid APG,8273.28,,,8273.28,Other,260% New York Medicaid APG,10309.78,,,10309.78,Other,324% New York Medicaid APG,6841.37,,,6841.37,Other,215% New York Medicaid APG,6841.37,,,6841.37,Other,215% New York Medicaid APG,3977.54,,,3977.54,Other,125% New York Medicaid APG,3126,111352.72,
Wrist endoscopy/surgery,29848,CPT,,,,,,,,both,,,32256.3,23869.66,74,,23869.66,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,14515.34,45,,14515.34,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,15966.87,49.5,,15966.87,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3210.17,,,3210.17,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,22579.41,70,,22579.41,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1725.9,,,1725.9,Other,New York Medicaid APG methodology,1725.9,,,1725.9,Other,100% New York Medicaid APG,1725.9,,,1725.9,Other,100% New York Medicaid APG,1725.9,,,1725.9,Other,100% New York Medicaid APG,3883.27,,,3883.27,Other,225% New York Medicaid APG,2640.62,,,2640.62,Other,153% New York Medicaid APG,3883.27,,,3883.27,Other,225% New York Medicaid APG,2416.26,,,2416.26,Other,140% New York Medicaid APG,3883.27,,,3883.27,Other,225% New York Medicaid APG,4487.33,,,4487.33,Other,260% New York Medicaid APG,5591.91,,,5591.91,Other,324% New York Medicaid APG,3710.68,,,3710.68,Other,215% New York Medicaid APG,3710.68,,,3710.68,Other,215% New York Medicaid APG,2157.37,,,2157.37,Other,125% New York Medicaid APG,1725.9,23869.66,
Knee arthroscopy/surgery,29850,CPT,,,,,,,,both,,,33805.49,25016.06,74,,25016.06,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15212.47,45,,15212.47,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,16733.72,49.5,,16733.72,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3210.17,,,3210.17,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,23663.84,70,,23663.84,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1725.9,,,1725.9,Other,New York Medicaid APG methodology,1725.9,,,1725.9,Other,100% New York Medicaid APG,1725.9,,,1725.9,Other,100% New York Medicaid APG,1725.9,,,1725.9,Other,100% New York Medicaid APG,3883.27,,,3883.27,Other,225% New York Medicaid APG,2640.62,,,2640.62,Other,153% New York Medicaid APG,3883.27,,,3883.27,Other,225% New York Medicaid APG,2416.26,,,2416.26,Other,140% New York Medicaid APG,3883.27,,,3883.27,Other,225% New York Medicaid APG,4487.33,,,4487.33,Other,260% New York Medicaid APG,5591.91,,,5591.91,Other,324% New York Medicaid APG,3710.68,,,3710.68,Other,215% New York Medicaid APG,3710.68,,,3710.68,Other,215% New York Medicaid APG,2157.37,,,2157.37,Other,125% New York Medicaid APG,1725.9,25016.06,
Knee arthroscopy/surgery,29851,CPT,,,,,,,,both,,,33805.49,25016.06,74,,25016.06,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15212.47,45,,15212.47,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,16733.72,49.5,,16733.72,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3210.17,,,3210.17,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,23663.84,70,,23663.84,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,1725.9,,,1725.9,Other,New York Medicaid APG methodology,1725.9,,,1725.9,Other,100% New York Medicaid APG,1725.9,,,1725.9,Other,100% New York Medicaid APG,1725.9,,,1725.9,Other,100% New York Medicaid APG,3883.27,,,3883.27,Other,225% New York Medicaid APG,2640.62,,,2640.62,Other,153% New York Medicaid APG,3883.27,,,3883.27,Other,225% New York Medicaid APG,2416.26,,,2416.26,Other,140% New York Medicaid APG,3883.27,,,3883.27,Other,225% New York Medicaid APG,4487.33,,,4487.33,Other,260% New York Medicaid APG,5591.91,,,5591.91,Other,324% New York Medicaid APG,3710.68,,,3710.68,Other,215% New York Medicaid APG,3710.68,,,3710.68,Other,215% New York Medicaid APG,2157.37,,,2157.37,Other,125% New York Medicaid APG,1725.9,25016.06,
Tibial arthroscopy/surgery,29855,CPT,,,,,,,,both,,,150476.65,111352.72,74,,111352.72,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,67714.49,45,,67714.49,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,74485.94,49.5,,74485.94,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5918.58,,,5918.58,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,105333.66,70,,105333.66,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,3182.03,,,3182.03,Other,New York Medicaid APG methodology,3182.03,,,3182.03,Other,100% New York Medicaid APG,3182.03,,,3182.03,Other,100% New York Medicaid APG,3182.03,,,3182.03,Other,100% New York Medicaid APG,7159.57,,,7159.57,Other,225% New York Medicaid APG,4868.51,,,4868.51,Other,153% New York Medicaid APG,7159.57,,,7159.57,Other,225% New York Medicaid APG,4454.84,,,4454.84,Other,140% New York Medicaid APG,7159.57,,,7159.57,Other,225% New York Medicaid APG,8273.28,,,8273.28,Other,260% New York Medicaid APG,10309.78,,,10309.78,Other,324% New York Medicaid APG,6841.37,,,6841.37,Other,215% New York Medicaid APG,6841.37,,,6841.37,Other,215% New York Medicaid APG,3977.54,,,3977.54,Other,125% New York Medicaid APG,3182.03,111352.72,
Tibial arthroscopy/surgery,29856,CPT,,,,,,,,both,,,276827.87,204852.62,74,,204852.62,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,124572.54,45,,124572.54,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,137029.8,49.5,,137029.8,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5918.58,,,5918.58,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,193779.51,70,,193779.51,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,3182.03,,,3182.03,Other,New York Medicaid APG methodology,3182.03,,,3182.03,Other,100% New York Medicaid APG,3182.03,,,3182.03,Other,100% New York Medicaid APG,3182.03,,,3182.03,Other,100% New York Medicaid APG,7159.57,,,7159.57,Other,225% New York Medicaid APG,4868.51,,,4868.51,Other,153% New York Medicaid APG,7159.57,,,7159.57,Other,225% New York Medicaid APG,4454.84,,,4454.84,Other,140% New York Medicaid APG,7159.57,,,7159.57,Other,225% New York Medicaid APG,8273.28,,,8273.28,Other,260% New York Medicaid APG,10309.78,,,10309.78,Other,324% New York Medicaid APG,6841.37,,,6841.37,Other,215% New York Medicaid APG,6841.37,,,6841.37,Other,215% New York Medicaid APG,3977.54,,,3977.54,Other,125% New York Medicaid APG,3182.03,204852.62,
Hip arthroscopy dx,29860,CPT,,,,,,,,both,,,150476.65,111352.72,74,,111352.72,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,67714.49,45,,67714.49,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,74485.94,49.5,,74485.94,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5918.58,,,5918.58,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,105333.66,70,,105333.66,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,3182.03,,,3182.03,Other,New York Medicaid APG methodology,3182.03,,,3182.03,Other,100% New York Medicaid APG,3182.03,,,3182.03,Other,100% New York Medicaid APG,3182.03,,,3182.03,Other,100% New York Medicaid APG,7159.57,,,7159.57,Other,225% New York Medicaid APG,4868.51,,,4868.51,Other,153% New York Medicaid APG,7159.57,,,7159.57,Other,225% New York Medicaid APG,4454.84,,,4454.84,Other,140% New York Medicaid APG,7159.57,,,7159.57,Other,225% New York Medicaid APG,8273.28,,,8273.28,Other,260% New York Medicaid APG,10309.78,,,10309.78,Other,324% New York Medicaid APG,6841.37,,,6841.37,Other,215% New York Medicaid APG,6841.37,,,6841.37,Other,215% New York Medicaid APG,3977.54,,,3977.54,Other,125% New York Medicaid APG,3182.03,111352.72,
Hip arthro w/fb removal,29861,CPT,,,,,,,,both,,,150476.65,111352.72,74,,111352.72,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,67714.49,45,,67714.49,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,74485.94,49.5,,74485.94,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3210.17,,,3210.17,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,105333.66,70,,105333.66,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,1725.9,,,1725.9,Other,New York Medicaid APG methodology,1725.9,,,1725.9,Other,100% New York Medicaid APG,1725.9,,,1725.9,Other,100% New York Medicaid APG,1725.9,,,1725.9,Other,100% New York Medicaid APG,3883.27,,,3883.27,Other,225% New York Medicaid APG,2640.62,,,2640.62,Other,153% New York Medicaid APG,3883.27,,,3883.27,Other,225% New York Medicaid APG,2416.26,,,2416.26,Other,140% New York Medicaid APG,3883.27,,,3883.27,Other,225% New York Medicaid APG,4487.33,,,4487.33,Other,260% New York Medicaid APG,5591.91,,,5591.91,Other,324% New York Medicaid APG,3710.68,,,3710.68,Other,215% New York Medicaid APG,3710.68,,,3710.68,Other,215% New York Medicaid APG,2157.37,,,2157.37,Other,125% New York Medicaid APG,1725.9,111352.72,
Hip arthr0 w/debridement,29862,CPT,,,,,,,,both,,,150476.65,111352.72,74,,111352.72,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,67714.49,45,,67714.49,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,74485.94,49.5,,74485.94,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5918.58,,,5918.58,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,105333.66,70,,105333.66,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,3182.03,,,3182.03,Other,New York Medicaid APG methodology,3182.03,,,3182.03,Other,100% New York Medicaid APG,3182.03,,,3182.03,Other,100% New York Medicaid APG,3182.03,,,3182.03,Other,100% New York Medicaid APG,7159.57,,,7159.57,Other,225% New York Medicaid APG,4868.51,,,4868.51,Other,153% New York Medicaid APG,7159.57,,,7159.57,Other,225% New York Medicaid APG,4454.84,,,4454.84,Other,140% New York Medicaid APG,7159.57,,,7159.57,Other,225% New York Medicaid APG,8273.28,,,8273.28,Other,260% New York Medicaid APG,10309.78,,,10309.78,Other,324% New York Medicaid APG,6841.37,,,6841.37,Other,215% New York Medicaid APG,6841.37,,,6841.37,Other,215% New York Medicaid APG,3977.54,,,3977.54,Other,125% New York Medicaid APG,3182.03,111352.72,
Hip arthr0 w/synovectomy,29863,CPT,,,,,,,,both,,,68082.75,50381.24,74,,50381.24,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30637.24,45,,30637.24,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33700.96,49.5,,33700.96,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3210.17,,,3210.17,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,47657.93,70,,47657.93,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,1725.9,,,1725.9,Other,New York Medicaid APG methodology,1725.9,,,1725.9,Other,100% New York Medicaid APG,1725.9,,,1725.9,Other,100% New York Medicaid APG,1725.9,,,1725.9,Other,100% New York Medicaid APG,3883.27,,,3883.27,Other,225% New York Medicaid APG,2640.62,,,2640.62,Other,153% New York Medicaid APG,3883.27,,,3883.27,Other,225% New York Medicaid APG,2416.26,,,2416.26,Other,140% New York Medicaid APG,3883.27,,,3883.27,Other,225% New York Medicaid APG,4487.33,,,4487.33,Other,260% New York Medicaid APG,5591.91,,,5591.91,Other,324% New York Medicaid APG,3710.68,,,3710.68,Other,215% New York Medicaid APG,3710.68,,,3710.68,Other,215% New York Medicaid APG,2157.37,,,2157.37,Other,125% New York Medicaid APG,1725.9,50381.24,
Autgrft implnt knee w/scope,29866,CPT,,,,,,,,both,,,150476.65,111352.72,74,,111352.72,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,67714.49,45,,67714.49,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,74485.94,49.5,,74485.94,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5918.58,,,5918.58,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,105333.66,70,,105333.66,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,3182.03,,,3182.03,Other,New York Medicaid APG methodology,3182.03,,,3182.03,Other,100% New York Medicaid APG,3182.03,,,3182.03,Other,100% New York Medicaid APG,3182.03,,,3182.03,Other,100% New York Medicaid APG,7159.57,,,7159.57,Other,225% New York Medicaid APG,4868.51,,,4868.51,Other,153% New York Medicaid APG,7159.57,,,7159.57,Other,225% New York Medicaid APG,4454.84,,,4454.84,Other,140% New York Medicaid APG,7159.57,,,7159.57,Other,225% New York Medicaid APG,8273.28,,,8273.28,Other,260% New York Medicaid APG,10309.78,,,10309.78,Other,324% New York Medicaid APG,6841.37,,,6841.37,Other,215% New York Medicaid APG,6841.37,,,6841.37,Other,215% New York Medicaid APG,3977.54,,,3977.54,Other,125% New York Medicaid APG,3126,111352.72,
Allgrft implnt knee w/scope,29867,CPT,,,,,,,,both,,,276827.87,204852.62,74,,204852.62,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,124572.54,45,,124572.54,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,137029.8,49.5,,137029.8,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5918.58,,,5918.58,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,193779.51,70,,193779.51,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,3182.03,,,3182.03,Other,New York Medicaid APG methodology,3182.03,,,3182.03,Other,100% New York Medicaid APG,3182.03,,,3182.03,Other,100% New York Medicaid APG,3182.03,,,3182.03,Other,100% New York Medicaid APG,7159.57,,,7159.57,Other,225% New York Medicaid APG,4868.51,,,4868.51,Other,153% New York Medicaid APG,7159.57,,,7159.57,Other,225% New York Medicaid APG,4454.84,,,4454.84,Other,140% New York Medicaid APG,7159.57,,,7159.57,Other,225% New York Medicaid APG,8273.28,,,8273.28,Other,260% New York Medicaid APG,10309.78,,,10309.78,Other,324% New York Medicaid APG,6841.37,,,6841.37,Other,215% New York Medicaid APG,6841.37,,,6841.37,Other,215% New York Medicaid APG,3977.54,,,3977.54,Other,125% New York Medicaid APG,3126,204852.62,
Meniscal trnspl knee w/scpe,29868,CPT,,,,,,,,both,,,150476.65,111352.72,74,,111352.72,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,67714.49,45,,67714.49,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,74485.94,49.5,,74485.94,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5918.58,,,5918.58,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,105333.66,70,,105333.66,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,3182.03,,,3182.03,Other,New York Medicaid APG methodology,3182.03,,,3182.03,Other,100% New York Medicaid APG,3182.03,,,3182.03,Other,100% New York Medicaid APG,3182.03,,,3182.03,Other,100% New York Medicaid APG,7159.57,,,7159.57,Other,225% New York Medicaid APG,4868.51,,,4868.51,Other,153% New York Medicaid APG,7159.57,,,7159.57,Other,225% New York Medicaid APG,4454.84,,,4454.84,Other,140% New York Medicaid APG,7159.57,,,7159.57,Other,225% New York Medicaid APG,8273.28,,,8273.28,Other,260% New York Medicaid APG,10309.78,,,10309.78,Other,324% New York Medicaid APG,6841.37,,,6841.37,Other,215% New York Medicaid APG,6841.37,,,6841.37,Other,215% New York Medicaid APG,3977.54,,,3977.54,Other,125% New York Medicaid APG,3126,111352.72,
Knee arthroscopy dx,29870,CPT,,,,,,,,both,,,68082.75,50381.24,74,,50381.24,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30637.24,45,,30637.24,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33700.96,49.5,,33700.96,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3210.17,,,3210.17,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,47657.93,70,,47657.93,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1725.9,,,1725.9,Other,New York Medicaid APG methodology,1725.9,,,1725.9,Other,100% New York Medicaid APG,1725.9,,,1725.9,Other,100% New York Medicaid APG,1725.9,,,1725.9,Other,100% New York Medicaid APG,3883.27,,,3883.27,Other,225% New York Medicaid APG,2640.62,,,2640.62,Other,153% New York Medicaid APG,3883.27,,,3883.27,Other,225% New York Medicaid APG,2416.26,,,2416.26,Other,140% New York Medicaid APG,3883.27,,,3883.27,Other,225% New York Medicaid APG,4487.33,,,4487.33,Other,260% New York Medicaid APG,5591.91,,,5591.91,Other,324% New York Medicaid APG,3710.68,,,3710.68,Other,215% New York Medicaid APG,3710.68,,,3710.68,Other,215% New York Medicaid APG,2157.37,,,2157.37,Other,125% New York Medicaid APG,1725.9,50381.24,
Knee arthroscopy/drainage,29871,CPT,,,,,,,,both,,,68082.75,50381.24,74,,50381.24,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30637.24,45,,30637.24,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33700.96,49.5,,33700.96,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3210.17,,,3210.17,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,47657.93,70,,47657.93,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1725.9,,,1725.9,Other,New York Medicaid APG methodology,1725.9,,,1725.9,Other,100% New York Medicaid APG,1725.9,,,1725.9,Other,100% New York Medicaid APG,1725.9,,,1725.9,Other,100% New York Medicaid APG,3883.27,,,3883.27,Other,225% New York Medicaid APG,2640.62,,,2640.62,Other,153% New York Medicaid APG,3883.27,,,3883.27,Other,225% New York Medicaid APG,2416.26,,,2416.26,Other,140% New York Medicaid APG,3883.27,,,3883.27,Other,225% New York Medicaid APG,4487.33,,,4487.33,Other,260% New York Medicaid APG,5591.91,,,5591.91,Other,324% New York Medicaid APG,3710.68,,,3710.68,Other,215% New York Medicaid APG,3710.68,,,3710.68,Other,215% New York Medicaid APG,2157.37,,,2157.37,Other,125% New York Medicaid APG,1725.9,50381.24,
Knee arthroscopy/surgery,29873,CPT,,,,,,,,both,,,35991.34,26633.59,74,,26633.59,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,16196.1,45,,16196.1,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,17815.71,49.5,,17815.71,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3210.17,,,3210.17,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,25193.94,70,,25193.94,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1725.9,,,1725.9,Other,New York Medicaid APG methodology,1725.9,,,1725.9,Other,100% New York Medicaid APG,1725.9,,,1725.9,Other,100% New York Medicaid APG,1725.9,,,1725.9,Other,100% New York Medicaid APG,3883.27,,,3883.27,Other,225% New York Medicaid APG,2640.62,,,2640.62,Other,153% New York Medicaid APG,3883.27,,,3883.27,Other,225% New York Medicaid APG,2416.26,,,2416.26,Other,140% New York Medicaid APG,3883.27,,,3883.27,Other,225% New York Medicaid APG,4487.33,,,4487.33,Other,260% New York Medicaid APG,5591.91,,,5591.91,Other,324% New York Medicaid APG,3710.68,,,3710.68,Other,215% New York Medicaid APG,3710.68,,,3710.68,Other,215% New York Medicaid APG,2157.37,,,2157.37,Other,125% New York Medicaid APG,1725.9,26633.59,
Knee arthroscopy/surgery,29874,CPT,,,,,,,,both,,,68082.75,50381.24,74,,50381.24,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30637.24,45,,30637.24,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33700.96,49.5,,33700.96,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3210.17,,,3210.17,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,47657.93,70,,47657.93,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1725.9,,,1725.9,Other,New York Medicaid APG methodology,1725.9,,,1725.9,Other,100% New York Medicaid APG,1725.9,,,1725.9,Other,100% New York Medicaid APG,1725.9,,,1725.9,Other,100% New York Medicaid APG,3883.27,,,3883.27,Other,225% New York Medicaid APG,2640.62,,,2640.62,Other,153% New York Medicaid APG,3883.27,,,3883.27,Other,225% New York Medicaid APG,2416.26,,,2416.26,Other,140% New York Medicaid APG,3883.27,,,3883.27,Other,225% New York Medicaid APG,4487.33,,,4487.33,Other,260% New York Medicaid APG,5591.91,,,5591.91,Other,324% New York Medicaid APG,3710.68,,,3710.68,Other,215% New York Medicaid APG,3710.68,,,3710.68,Other,215% New York Medicaid APG,2157.37,,,2157.37,Other,125% New York Medicaid APG,1725.9,50381.24,
Knee arthroscopy/surgery,29875,CPT,,,,,,,,both,,,39883.71,29513.95,74,,29513.95,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,17947.67,45,,17947.67,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,19742.44,49.5,,19742.44,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3210.17,,,3210.17,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,27918.6,70,,27918.6,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1725.9,,,1725.9,Other,New York Medicaid APG methodology,1725.9,,,1725.9,Other,100% New York Medicaid APG,1725.9,,,1725.9,Other,100% New York Medicaid APG,1725.9,,,1725.9,Other,100% New York Medicaid APG,3883.27,,,3883.27,Other,225% New York Medicaid APG,2640.62,,,2640.62,Other,153% New York Medicaid APG,3883.27,,,3883.27,Other,225% New York Medicaid APG,2416.26,,,2416.26,Other,140% New York Medicaid APG,3883.27,,,3883.27,Other,225% New York Medicaid APG,4487.33,,,4487.33,Other,260% New York Medicaid APG,5591.91,,,5591.91,Other,324% New York Medicaid APG,3710.68,,,3710.68,Other,215% New York Medicaid APG,3710.68,,,3710.68,Other,215% New York Medicaid APG,2157.37,,,2157.37,Other,125% New York Medicaid APG,1725.9,29513.95,
Knee arthroscopy/surgery,29876,CPT,,,,,,,,both,,,38574.18,28544.89,74,,28544.89,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,17358.38,45,,17358.38,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,19094.22,49.5,,19094.22,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3210.17,,,3210.17,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,27001.93,70,,27001.93,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1725.9,,,1725.9,Other,New York Medicaid APG methodology,1725.9,,,1725.9,Other,100% New York Medicaid APG,1725.9,,,1725.9,Other,100% New York Medicaid APG,1725.9,,,1725.9,Other,100% New York Medicaid APG,3883.27,,,3883.27,Other,225% New York Medicaid APG,2640.62,,,2640.62,Other,153% New York Medicaid APG,3883.27,,,3883.27,Other,225% New York Medicaid APG,2416.26,,,2416.26,Other,140% New York Medicaid APG,3883.27,,,3883.27,Other,225% New York Medicaid APG,4487.33,,,4487.33,Other,260% New York Medicaid APG,5591.91,,,5591.91,Other,324% New York Medicaid APG,3710.68,,,3710.68,Other,215% New York Medicaid APG,3710.68,,,3710.68,Other,215% New York Medicaid APG,2157.37,,,2157.37,Other,125% New York Medicaid APG,1725.9,28544.89,
Knee arthroscopy/surgery,29877,CPT,,,,,,,,both,,,40524.95,29988.46,74,,29988.46,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,18236.23,45,,18236.23,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,20059.85,49.5,,20059.85,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3210.17,,,3210.17,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,28367.47,70,,28367.47,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1725.9,,,1725.9,Other,New York Medicaid APG methodology,1725.9,,,1725.9,Other,100% New York Medicaid APG,1725.9,,,1725.9,Other,100% New York Medicaid APG,1725.9,,,1725.9,Other,100% New York Medicaid APG,3883.27,,,3883.27,Other,225% New York Medicaid APG,2640.62,,,2640.62,Other,153% New York Medicaid APG,3883.27,,,3883.27,Other,225% New York Medicaid APG,2416.26,,,2416.26,Other,140% New York Medicaid APG,3883.27,,,3883.27,Other,225% New York Medicaid APG,4487.33,,,4487.33,Other,260% New York Medicaid APG,5591.91,,,5591.91,Other,324% New York Medicaid APG,3710.68,,,3710.68,Other,215% New York Medicaid APG,3710.68,,,3710.68,Other,215% New York Medicaid APG,2157.37,,,2157.37,Other,125% New York Medicaid APG,1725.9,29988.46,
Knee arthroscopy/surgery,29879,CPT,,,,,,,,both,,,39316.75,29094.4,74,,29094.4,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,17692.54,45,,17692.54,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,19461.79,49.5,,19461.79,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3210.17,,,3210.17,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,27521.73,70,,27521.73,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1725.9,,,1725.9,Other,New York Medicaid APG methodology,1725.9,,,1725.9,Other,100% New York Medicaid APG,1725.9,,,1725.9,Other,100% New York Medicaid APG,1725.9,,,1725.9,Other,100% New York Medicaid APG,3883.27,,,3883.27,Other,225% New York Medicaid APG,2640.62,,,2640.62,Other,153% New York Medicaid APG,3883.27,,,3883.27,Other,225% New York Medicaid APG,2416.26,,,2416.26,Other,140% New York Medicaid APG,3883.27,,,3883.27,Other,225% New York Medicaid APG,4487.33,,,4487.33,Other,260% New York Medicaid APG,5591.91,,,5591.91,Other,324% New York Medicaid APG,3710.68,,,3710.68,Other,215% New York Medicaid APG,3710.68,,,3710.68,Other,215% New York Medicaid APG,2157.37,,,2157.37,Other,125% New York Medicaid APG,1725.9,29094.4,
Knee arthroscopy/surgery,29880,CPT,,,,,,,,both,,,40879.28,30250.67,74,,30250.67,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,18395.68,45,,18395.68,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,20235.24,49.5,,20235.24,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3210.17,,,3210.17,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,28615.5,70,,28615.5,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1725.9,,,1725.9,Other,New York Medicaid APG methodology,1725.9,,,1725.9,Other,100% New York Medicaid APG,1725.9,,,1725.9,Other,100% New York Medicaid APG,1725.9,,,1725.9,Other,100% New York Medicaid APG,3883.27,,,3883.27,Other,225% New York Medicaid APG,2640.62,,,2640.62,Other,153% New York Medicaid APG,3883.27,,,3883.27,Other,225% New York Medicaid APG,2416.26,,,2416.26,Other,140% New York Medicaid APG,3883.27,,,3883.27,Other,225% New York Medicaid APG,4487.33,,,4487.33,Other,260% New York Medicaid APG,5591.91,,,5591.91,Other,324% New York Medicaid APG,3710.68,,,3710.68,Other,215% New York Medicaid APG,3710.68,,,3710.68,Other,215% New York Medicaid APG,2157.37,,,2157.37,Other,125% New York Medicaid APG,1725.9,30250.67,
Knee arthroscopy/surgery,29881,CPT,,,,,,,,both,,,38920.36,28801.07,74,,28801.07,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,17514.16,45,,17514.16,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,19265.58,49.5,,19265.58,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3210.17,,,3210.17,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,27244.25,70,,27244.25,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1725.9,,,1725.9,Other,New York Medicaid APG methodology,1725.9,,,1725.9,Other,100% New York Medicaid APG,1725.9,,,1725.9,Other,100% New York Medicaid APG,1725.9,,,1725.9,Other,100% New York Medicaid APG,3883.27,,,3883.27,Other,225% New York Medicaid APG,2640.62,,,2640.62,Other,153% New York Medicaid APG,3883.27,,,3883.27,Other,225% New York Medicaid APG,2416.26,,,2416.26,Other,140% New York Medicaid APG,3883.27,,,3883.27,Other,225% New York Medicaid APG,4487.33,,,4487.33,Other,260% New York Medicaid APG,5591.91,,,5591.91,Other,324% New York Medicaid APG,3710.68,,,3710.68,Other,215% New York Medicaid APG,3710.68,,,3710.68,Other,215% New York Medicaid APG,2157.37,,,2157.37,Other,125% New York Medicaid APG,1725.9,28801.07,
Knee arthroscopy/surgery,29882,CPT,,,,,,,,both,,,58881.06,43571.98,74,,43571.98,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,26496.48,45,,26496.48,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,29146.12,49.5,,29146.12,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3210.17,,,3210.17,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,41216.74,70,,41216.74,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1725.9,,,1725.9,Other,New York Medicaid APG methodology,1725.9,,,1725.9,Other,100% New York Medicaid APG,1725.9,,,1725.9,Other,100% New York Medicaid APG,1725.9,,,1725.9,Other,100% New York Medicaid APG,3883.27,,,3883.27,Other,225% New York Medicaid APG,2640.62,,,2640.62,Other,153% New York Medicaid APG,3883.27,,,3883.27,Other,225% New York Medicaid APG,2416.26,,,2416.26,Other,140% New York Medicaid APG,3883.27,,,3883.27,Other,225% New York Medicaid APG,4487.33,,,4487.33,Other,260% New York Medicaid APG,5591.91,,,5591.91,Other,324% New York Medicaid APG,3710.68,,,3710.68,Other,215% New York Medicaid APG,3710.68,,,3710.68,Other,215% New York Medicaid APG,2157.37,,,2157.37,Other,125% New York Medicaid APG,1725.9,43571.98,
Knee arthroscopy/surgery,29883,CPT,,,,,,,,both,,,59564.36,44077.63,74,,44077.63,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,26803.96,45,,26803.96,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,29484.36,49.5,,29484.36,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3210.17,,,3210.17,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,41695.05,70,,41695.05,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1725.9,,,1725.9,Other,New York Medicaid APG methodology,1725.9,,,1725.9,Other,100% New York Medicaid APG,1725.9,,,1725.9,Other,100% New York Medicaid APG,1725.9,,,1725.9,Other,100% New York Medicaid APG,3883.27,,,3883.27,Other,225% New York Medicaid APG,2640.62,,,2640.62,Other,153% New York Medicaid APG,3883.27,,,3883.27,Other,225% New York Medicaid APG,2416.26,,,2416.26,Other,140% New York Medicaid APG,3883.27,,,3883.27,Other,225% New York Medicaid APG,4487.33,,,4487.33,Other,260% New York Medicaid APG,5591.91,,,5591.91,Other,324% New York Medicaid APG,3710.68,,,3710.68,Other,215% New York Medicaid APG,3710.68,,,3710.68,Other,215% New York Medicaid APG,2157.37,,,2157.37,Other,125% New York Medicaid APG,1725.9,44077.63,
Knee arthroscopy/surgery,29884,CPT,,,,,,,,both,,,40094.07,29669.61,74,,29669.61,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,18042.33,45,,18042.33,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,19846.56,49.5,,19846.56,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3210.17,,,3210.17,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,28065.85,70,,28065.85,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1725.9,,,1725.9,Other,New York Medicaid APG methodology,1725.9,,,1725.9,Other,100% New York Medicaid APG,1725.9,,,1725.9,Other,100% New York Medicaid APG,1725.9,,,1725.9,Other,100% New York Medicaid APG,3883.27,,,3883.27,Other,225% New York Medicaid APG,2640.62,,,2640.62,Other,153% New York Medicaid APG,3883.27,,,3883.27,Other,225% New York Medicaid APG,2416.26,,,2416.26,Other,140% New York Medicaid APG,3883.27,,,3883.27,Other,225% New York Medicaid APG,4487.33,,,4487.33,Other,260% New York Medicaid APG,5591.91,,,5591.91,Other,324% New York Medicaid APG,3710.68,,,3710.68,Other,215% New York Medicaid APG,3710.68,,,3710.68,Other,215% New York Medicaid APG,2157.37,,,2157.37,Other,125% New York Medicaid APG,1725.9,29669.61,
Knee arthroscopy/surgery,29885,CPT,,,,,,,,both,,,150476.65,111352.72,74,,111352.72,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,67714.49,45,,67714.49,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,74485.94,49.5,,74485.94,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5918.58,,,5918.58,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,105333.66,70,,105333.66,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,3182.03,,,3182.03,Other,New York Medicaid APG methodology,3182.03,,,3182.03,Other,100% New York Medicaid APG,3182.03,,,3182.03,Other,100% New York Medicaid APG,3182.03,,,3182.03,Other,100% New York Medicaid APG,7159.57,,,7159.57,Other,225% New York Medicaid APG,4868.51,,,4868.51,Other,153% New York Medicaid APG,7159.57,,,7159.57,Other,225% New York Medicaid APG,4454.84,,,4454.84,Other,140% New York Medicaid APG,7159.57,,,7159.57,Other,225% New York Medicaid APG,8273.28,,,8273.28,Other,260% New York Medicaid APG,10309.78,,,10309.78,Other,324% New York Medicaid APG,6841.37,,,6841.37,Other,215% New York Medicaid APG,6841.37,,,6841.37,Other,215% New York Medicaid APG,3977.54,,,3977.54,Other,125% New York Medicaid APG,3126,111352.72,
Knee arthroscopy/surgery,29886,CPT,,,,,,,,both,,,48477.88,35873.63,74,,35873.63,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,21815.05,45,,21815.05,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,23996.55,49.5,,23996.55,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3210.17,,,3210.17,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,33934.52,70,,33934.52,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1725.9,,,1725.9,Other,New York Medicaid APG methodology,1725.9,,,1725.9,Other,100% New York Medicaid APG,1725.9,,,1725.9,Other,100% New York Medicaid APG,1725.9,,,1725.9,Other,100% New York Medicaid APG,3883.27,,,3883.27,Other,225% New York Medicaid APG,2640.62,,,2640.62,Other,153% New York Medicaid APG,3883.27,,,3883.27,Other,225% New York Medicaid APG,2416.26,,,2416.26,Other,140% New York Medicaid APG,3883.27,,,3883.27,Other,225% New York Medicaid APG,4487.33,,,4487.33,Other,260% New York Medicaid APG,5591.91,,,5591.91,Other,324% New York Medicaid APG,3710.68,,,3710.68,Other,215% New York Medicaid APG,3710.68,,,3710.68,Other,215% New York Medicaid APG,2157.37,,,2157.37,Other,125% New York Medicaid APG,1725.9,35873.63,
Knee arthroscopy/surgery,29887,CPT,,,,,,,,both,,,49933.99,36951.15,74,,36951.15,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,22470.3,45,,22470.3,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,24717.33,49.5,,24717.33,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5918.58,,,5918.58,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,34953.79,70,,34953.79,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,3182.03,,,3182.03,Other,New York Medicaid APG methodology,3182.03,,,3182.03,Other,100% New York Medicaid APG,3182.03,,,3182.03,Other,100% New York Medicaid APG,3182.03,,,3182.03,Other,100% New York Medicaid APG,7159.57,,,7159.57,Other,225% New York Medicaid APG,4868.51,,,4868.51,Other,153% New York Medicaid APG,7159.57,,,7159.57,Other,225% New York Medicaid APG,4454.84,,,4454.84,Other,140% New York Medicaid APG,7159.57,,,7159.57,Other,225% New York Medicaid APG,8273.28,,,8273.28,Other,260% New York Medicaid APG,10309.78,,,10309.78,Other,324% New York Medicaid APG,6841.37,,,6841.37,Other,215% New York Medicaid APG,6841.37,,,6841.37,Other,215% New York Medicaid APG,3977.54,,,3977.54,Other,125% New York Medicaid APG,3126,36951.15,
Knee arthroscopy/surgery,29888,CPT,,,,,,,,both,,,91694.76,67854.12,74,,67854.12,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,41262.64,45,,41262.64,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,45388.91,49.5,,45388.91,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5918.58,,,5918.58,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,64186.33,70,,64186.33,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,3182.03,,,3182.03,Other,New York Medicaid APG methodology,3182.03,,,3182.03,Other,100% New York Medicaid APG,3182.03,,,3182.03,Other,100% New York Medicaid APG,3182.03,,,3182.03,Other,100% New York Medicaid APG,7159.57,,,7159.57,Other,225% New York Medicaid APG,4868.51,,,4868.51,Other,153% New York Medicaid APG,7159.57,,,7159.57,Other,225% New York Medicaid APG,4454.84,,,4454.84,Other,140% New York Medicaid APG,7159.57,,,7159.57,Other,225% New York Medicaid APG,8273.28,,,8273.28,Other,260% New York Medicaid APG,10309.78,,,10309.78,Other,324% New York Medicaid APG,6841.37,,,6841.37,Other,215% New York Medicaid APG,6841.37,,,6841.37,Other,215% New York Medicaid APG,3977.54,,,3977.54,Other,125% New York Medicaid APG,3126,67854.12,
Knee arthroscopy/surgery,29889,CPT,,,,,,,,both,,,134126.7,99253.76,74,,99253.76,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,60357.02,45,,60357.02,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,66392.72,49.5,,66392.72,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5918.58,,,5918.58,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,93888.69,70,,93888.69,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,3182.03,,,3182.03,Other,New York Medicaid APG methodology,3182.03,,,3182.03,Other,100% New York Medicaid APG,3182.03,,,3182.03,Other,100% New York Medicaid APG,3182.03,,,3182.03,Other,100% New York Medicaid APG,7159.57,,,7159.57,Other,225% New York Medicaid APG,4868.51,,,4868.51,Other,153% New York Medicaid APG,7159.57,,,7159.57,Other,225% New York Medicaid APG,4454.84,,,4454.84,Other,140% New York Medicaid APG,7159.57,,,7159.57,Other,225% New York Medicaid APG,8273.28,,,8273.28,Other,260% New York Medicaid APG,10309.78,,,10309.78,Other,324% New York Medicaid APG,6841.37,,,6841.37,Other,215% New York Medicaid APG,6841.37,,,6841.37,Other,215% New York Medicaid APG,3977.54,,,3977.54,Other,125% New York Medicaid APG,3126,99253.76,
Ankle arthroscopy/surgery,29891,CPT,,,,,,,,both,,,33768.9,24988.99,74,,24988.99,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15196.01,45,,15196.01,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,16715.61,49.5,,16715.61,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3210.17,,,3210.17,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,23638.23,70,,23638.23,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,1725.9,,,1725.9,Other,New York Medicaid APG methodology,1725.9,,,1725.9,Other,100% New York Medicaid APG,1725.9,,,1725.9,Other,100% New York Medicaid APG,1725.9,,,1725.9,Other,100% New York Medicaid APG,3883.27,,,3883.27,Other,225% New York Medicaid APG,2640.62,,,2640.62,Other,153% New York Medicaid APG,3883.27,,,3883.27,Other,225% New York Medicaid APG,2416.26,,,2416.26,Other,140% New York Medicaid APG,3883.27,,,3883.27,Other,225% New York Medicaid APG,4487.33,,,4487.33,Other,260% New York Medicaid APG,5591.91,,,5591.91,Other,324% New York Medicaid APG,3710.68,,,3710.68,Other,215% New York Medicaid APG,3710.68,,,3710.68,Other,215% New York Medicaid APG,2157.37,,,2157.37,Other,125% New York Medicaid APG,1725.9,24988.99,
Ankle arthroscopy/surgery,29892,CPT,,,,,,,,both,,,104708.88,77484.57,74,,77484.57,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,47119,45,,47119,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,51830.9,49.5,,51830.9,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5918.58,,,5918.58,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,73296.22,70,,73296.22,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,3182.03,,,3182.03,Other,New York Medicaid APG methodology,3182.03,,,3182.03,Other,100% New York Medicaid APG,3182.03,,,3182.03,Other,100% New York Medicaid APG,3182.03,,,3182.03,Other,100% New York Medicaid APG,7159.57,,,7159.57,Other,225% New York Medicaid APG,4868.51,,,4868.51,Other,153% New York Medicaid APG,7159.57,,,7159.57,Other,225% New York Medicaid APG,4454.84,,,4454.84,Other,140% New York Medicaid APG,7159.57,,,7159.57,Other,225% New York Medicaid APG,8273.28,,,8273.28,Other,260% New York Medicaid APG,10309.78,,,10309.78,Other,324% New York Medicaid APG,6841.37,,,6841.37,Other,215% New York Medicaid APG,6841.37,,,6841.37,Other,215% New York Medicaid APG,3977.54,,,3977.54,Other,125% New York Medicaid APG,3126,77484.57,
Scope plantar fasciotomy,29893,CPT,,,,,,,,both,,,41676.94,30840.94,74,,30840.94,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,18754.62,45,,18754.62,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,20630.09,49.5,,20630.09,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2891.15,,,2891.15,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,29173.86,70,,29173.86,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1554.38,,,1554.38,Other,New York Medicaid APG methodology,1554.38,,,1554.38,Other,100% New York Medicaid APG,1554.38,,,1554.38,Other,100% New York Medicaid APG,1554.38,,,1554.38,Other,100% New York Medicaid APG,3497.36,,,3497.36,Other,225% New York Medicaid APG,2378.21,,,2378.21,Other,153% New York Medicaid APG,3497.36,,,3497.36,Other,225% New York Medicaid APG,2176.14,,,2176.14,Other,140% New York Medicaid APG,3497.36,,,3497.36,Other,225% New York Medicaid APG,4041.4,,,4041.4,Other,260% New York Medicaid APG,5036.2,,,5036.2,Other,324% New York Medicaid APG,3341.93,,,3341.93,Other,215% New York Medicaid APG,3341.93,,,3341.93,Other,215% New York Medicaid APG,1942.98,,,1942.98,Other,125% New York Medicaid APG,1554.38,30840.94,
Ankle arthroscopy/surgery,29894,CPT,,,,,,,,both,,,68082.75,50381.24,74,,50381.24,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30637.24,45,,30637.24,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33700.96,49.5,,33700.96,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3210.17,,,3210.17,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,47657.93,70,,47657.93,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1725.9,,,1725.9,Other,New York Medicaid APG methodology,1725.9,,,1725.9,Other,100% New York Medicaid APG,1725.9,,,1725.9,Other,100% New York Medicaid APG,1725.9,,,1725.9,Other,100% New York Medicaid APG,3883.27,,,3883.27,Other,225% New York Medicaid APG,2640.62,,,2640.62,Other,153% New York Medicaid APG,3883.27,,,3883.27,Other,225% New York Medicaid APG,2416.26,,,2416.26,Other,140% New York Medicaid APG,3883.27,,,3883.27,Other,225% New York Medicaid APG,4487.33,,,4487.33,Other,260% New York Medicaid APG,5591.91,,,5591.91,Other,324% New York Medicaid APG,3710.68,,,3710.68,Other,215% New York Medicaid APG,3710.68,,,3710.68,Other,215% New York Medicaid APG,2157.37,,,2157.37,Other,125% New York Medicaid APG,1725.9,50381.24,
Ankle arthroscopy/surgery,29895,CPT,,,,,,,,both,,,58681.23,43424.11,74,,43424.11,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,26406.55,45,,26406.55,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,29047.21,49.5,,29047.21,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3210.17,,,3210.17,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,41076.86,70,,41076.86,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1725.9,,,1725.9,Other,New York Medicaid APG methodology,1725.9,,,1725.9,Other,100% New York Medicaid APG,1725.9,,,1725.9,Other,100% New York Medicaid APG,1725.9,,,1725.9,Other,100% New York Medicaid APG,3883.27,,,3883.27,Other,225% New York Medicaid APG,2640.62,,,2640.62,Other,153% New York Medicaid APG,3883.27,,,3883.27,Other,225% New York Medicaid APG,2416.26,,,2416.26,Other,140% New York Medicaid APG,3883.27,,,3883.27,Other,225% New York Medicaid APG,4487.33,,,4487.33,Other,260% New York Medicaid APG,5591.91,,,5591.91,Other,324% New York Medicaid APG,3710.68,,,3710.68,Other,215% New York Medicaid APG,3710.68,,,3710.68,Other,215% New York Medicaid APG,2157.37,,,2157.37,Other,125% New York Medicaid APG,1725.9,43424.11,
Ankle arthroscopy/surgery,29897,CPT,,,,,,,,both,,,39196.19,29005.18,74,,29005.18,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,17638.29,45,,17638.29,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,19402.11,49.5,,19402.11,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3210.17,,,3210.17,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,27437.33,70,,27437.33,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1725.9,,,1725.9,Other,New York Medicaid APG methodology,1725.9,,,1725.9,Other,100% New York Medicaid APG,1725.9,,,1725.9,Other,100% New York Medicaid APG,1725.9,,,1725.9,Other,100% New York Medicaid APG,3883.27,,,3883.27,Other,225% New York Medicaid APG,2640.62,,,2640.62,Other,153% New York Medicaid APG,3883.27,,,3883.27,Other,225% New York Medicaid APG,2416.26,,,2416.26,Other,140% New York Medicaid APG,3883.27,,,3883.27,Other,225% New York Medicaid APG,4487.33,,,4487.33,Other,260% New York Medicaid APG,5591.91,,,5591.91,Other,324% New York Medicaid APG,3710.68,,,3710.68,Other,215% New York Medicaid APG,3710.68,,,3710.68,Other,215% New York Medicaid APG,2157.37,,,2157.37,Other,125% New York Medicaid APG,1725.9,29005.18,
Ankle arthroscopy/surgery,29898,CPT,,,,,,,,both,,,101597.45,75182.11,74,,75182.11,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,45718.85,45,,45718.85,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,50290.74,49.5,,50290.74,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3210.17,,,3210.17,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,71118.22,70,,71118.22,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1725.9,,,1725.9,Other,New York Medicaid APG methodology,1725.9,,,1725.9,Other,100% New York Medicaid APG,1725.9,,,1725.9,Other,100% New York Medicaid APG,1725.9,,,1725.9,Other,100% New York Medicaid APG,3883.27,,,3883.27,Other,225% New York Medicaid APG,2640.62,,,2640.62,Other,153% New York Medicaid APG,3883.27,,,3883.27,Other,225% New York Medicaid APG,2416.26,,,2416.26,Other,140% New York Medicaid APG,3883.27,,,3883.27,Other,225% New York Medicaid APG,4487.33,,,4487.33,Other,260% New York Medicaid APG,5591.91,,,5591.91,Other,324% New York Medicaid APG,3710.68,,,3710.68,Other,215% New York Medicaid APG,3710.68,,,3710.68,Other,215% New York Medicaid APG,2157.37,,,2157.37,Other,125% New York Medicaid APG,1725.9,75182.11,
Ankle arthroscopy/surgery,29899,CPT,,,,,,,,both,,,150476.65,111352.72,74,,111352.72,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,67714.49,45,,67714.49,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,74485.94,49.5,,74485.94,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5918.58,,,5918.58,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,105333.66,70,,105333.66,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,3182.03,,,3182.03,Other,New York Medicaid APG methodology,3182.03,,,3182.03,Other,100% New York Medicaid APG,3182.03,,,3182.03,Other,100% New York Medicaid APG,3182.03,,,3182.03,Other,100% New York Medicaid APG,7159.57,,,7159.57,Other,225% New York Medicaid APG,4868.51,,,4868.51,Other,153% New York Medicaid APG,7159.57,,,7159.57,Other,225% New York Medicaid APG,4454.84,,,4454.84,Other,140% New York Medicaid APG,7159.57,,,7159.57,Other,225% New York Medicaid APG,8273.28,,,8273.28,Other,260% New York Medicaid APG,10309.78,,,10309.78,Other,324% New York Medicaid APG,6841.37,,,6841.37,Other,215% New York Medicaid APG,6841.37,,,6841.37,Other,215% New York Medicaid APG,3977.54,,,3977.54,Other,125% New York Medicaid APG,3126,111352.72,
Mcp joint arthroscopy dx,29900,CPT,,,,,,,,both,,,68082.75,50381.24,74,,50381.24,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30637.24,45,,30637.24,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33700.96,49.5,,33700.96,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3210.17,,,3210.17,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,47657.93,70,,47657.93,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1725.9,,,1725.9,Other,New York Medicaid APG methodology,1725.9,,,1725.9,Other,100% New York Medicaid APG,1725.9,,,1725.9,Other,100% New York Medicaid APG,1725.9,,,1725.9,Other,100% New York Medicaid APG,3883.27,,,3883.27,Other,225% New York Medicaid APG,2640.62,,,2640.62,Other,153% New York Medicaid APG,3883.27,,,3883.27,Other,225% New York Medicaid APG,2416.26,,,2416.26,Other,140% New York Medicaid APG,3883.27,,,3883.27,Other,225% New York Medicaid APG,4487.33,,,4487.33,Other,260% New York Medicaid APG,5591.91,,,5591.91,Other,324% New York Medicaid APG,3710.68,,,3710.68,Other,215% New York Medicaid APG,3710.68,,,3710.68,Other,215% New York Medicaid APG,2157.37,,,2157.37,Other,125% New York Medicaid APG,1725.9,50381.24,
Mcp joint arthroscopy surg,29901,CPT,,,,,,,,both,,,68082.75,50381.24,74,,50381.24,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30637.24,45,,30637.24,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33700.96,49.5,,33700.96,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3210.17,,,3210.17,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,47657.93,70,,47657.93,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,1725.9,,,1725.9,Other,New York Medicaid APG methodology,1725.9,,,1725.9,Other,100% New York Medicaid APG,1725.9,,,1725.9,Other,100% New York Medicaid APG,1725.9,,,1725.9,Other,100% New York Medicaid APG,3883.27,,,3883.27,Other,225% New York Medicaid APG,2640.62,,,2640.62,Other,153% New York Medicaid APG,3883.27,,,3883.27,Other,225% New York Medicaid APG,2416.26,,,2416.26,Other,140% New York Medicaid APG,3883.27,,,3883.27,Other,225% New York Medicaid APG,4487.33,,,4487.33,Other,260% New York Medicaid APG,5591.91,,,5591.91,Other,324% New York Medicaid APG,3710.68,,,3710.68,Other,215% New York Medicaid APG,3710.68,,,3710.68,Other,215% New York Medicaid APG,2157.37,,,2157.37,Other,125% New York Medicaid APG,1725.9,50381.24,
Mcp joint arthroscopy surg,29902,CPT,,,,,,,,both,,,33805.49,25016.06,74,,25016.06,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15212.47,45,,15212.47,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,16733.72,49.5,,16733.72,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3210.17,,,3210.17,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,23663.84,70,,23663.84,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1725.9,,,1725.9,Other,New York Medicaid APG methodology,1725.9,,,1725.9,Other,100% New York Medicaid APG,1725.9,,,1725.9,Other,100% New York Medicaid APG,1725.9,,,1725.9,Other,100% New York Medicaid APG,3883.27,,,3883.27,Other,225% New York Medicaid APG,2640.62,,,2640.62,Other,153% New York Medicaid APG,3883.27,,,3883.27,Other,225% New York Medicaid APG,2416.26,,,2416.26,Other,140% New York Medicaid APG,3883.27,,,3883.27,Other,225% New York Medicaid APG,4487.33,,,4487.33,Other,260% New York Medicaid APG,5591.91,,,5591.91,Other,324% New York Medicaid APG,3710.68,,,3710.68,Other,215% New York Medicaid APG,3710.68,,,3710.68,Other,215% New York Medicaid APG,2157.37,,,2157.37,Other,125% New York Medicaid APG,1725.9,25016.06,
Subtalar arthro w/fb rmvl,29904,CPT,,,,,,,,both,,,68082.75,50381.24,74,,50381.24,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30637.24,45,,30637.24,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33700.96,49.5,,33700.96,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3210.17,,,3210.17,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,47657.93,70,,47657.93,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1725.9,,,1725.9,Other,New York Medicaid APG methodology,1725.9,,,1725.9,Other,100% New York Medicaid APG,1725.9,,,1725.9,Other,100% New York Medicaid APG,1725.9,,,1725.9,Other,100% New York Medicaid APG,3883.27,,,3883.27,Other,225% New York Medicaid APG,2640.62,,,2640.62,Other,153% New York Medicaid APG,3883.27,,,3883.27,Other,225% New York Medicaid APG,2416.26,,,2416.26,Other,140% New York Medicaid APG,3883.27,,,3883.27,Other,225% New York Medicaid APG,4487.33,,,4487.33,Other,260% New York Medicaid APG,5591.91,,,5591.91,Other,324% New York Medicaid APG,3710.68,,,3710.68,Other,215% New York Medicaid APG,3710.68,,,3710.68,Other,215% New York Medicaid APG,2157.37,,,2157.37,Other,125% New York Medicaid APG,1725.9,50381.24,
Subtalar arthro w/exc,29905,CPT,,,,,,,,both,,,150476.65,111352.72,74,,111352.72,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,67714.49,45,,67714.49,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,74485.94,49.5,,74485.94,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3210.17,,,3210.17,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,105333.66,70,,105333.66,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1725.9,,,1725.9,Other,New York Medicaid APG methodology,1725.9,,,1725.9,Other,100% New York Medicaid APG,1725.9,,,1725.9,Other,100% New York Medicaid APG,1725.9,,,1725.9,Other,100% New York Medicaid APG,3883.27,,,3883.27,Other,225% New York Medicaid APG,2640.62,,,2640.62,Other,153% New York Medicaid APG,3883.27,,,3883.27,Other,225% New York Medicaid APG,2416.26,,,2416.26,Other,140% New York Medicaid APG,3883.27,,,3883.27,Other,225% New York Medicaid APG,4487.33,,,4487.33,Other,260% New York Medicaid APG,5591.91,,,5591.91,Other,324% New York Medicaid APG,3710.68,,,3710.68,Other,215% New York Medicaid APG,3710.68,,,3710.68,Other,215% New York Medicaid APG,2157.37,,,2157.37,Other,125% New York Medicaid APG,1725.9,111352.72,
Subtalar arthro w/deb,29906,CPT,,,,,,,,both,,,68082.75,50381.24,74,,50381.24,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30637.24,45,,30637.24,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33700.96,49.5,,33700.96,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3210.17,,,3210.17,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,47657.93,70,,47657.93,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1725.9,,,1725.9,Other,New York Medicaid APG methodology,1725.9,,,1725.9,Other,100% New York Medicaid APG,1725.9,,,1725.9,Other,100% New York Medicaid APG,1725.9,,,1725.9,Other,100% New York Medicaid APG,3883.27,,,3883.27,Other,225% New York Medicaid APG,2640.62,,,2640.62,Other,153% New York Medicaid APG,3883.27,,,3883.27,Other,225% New York Medicaid APG,2416.26,,,2416.26,Other,140% New York Medicaid APG,3883.27,,,3883.27,Other,225% New York Medicaid APG,4487.33,,,4487.33,Other,260% New York Medicaid APG,5591.91,,,5591.91,Other,324% New York Medicaid APG,3710.68,,,3710.68,Other,215% New York Medicaid APG,3710.68,,,3710.68,Other,215% New York Medicaid APG,2157.37,,,2157.37,Other,125% New York Medicaid APG,1725.9,50381.24,
Subtalar arthro w/fusion,29907,CPT,,,,,,,,both,,,276827.87,204852.62,74,,204852.62,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,124572.54,45,,124572.54,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,137029.8,49.5,,137029.8,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5918.58,,,5918.58,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,193779.51,70,,193779.51,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,3182.03,,,3182.03,Other,New York Medicaid APG methodology,3182.03,,,3182.03,Other,100% New York Medicaid APG,3182.03,,,3182.03,Other,100% New York Medicaid APG,3182.03,,,3182.03,Other,100% New York Medicaid APG,7159.57,,,7159.57,Other,225% New York Medicaid APG,4868.51,,,4868.51,Other,153% New York Medicaid APG,7159.57,,,7159.57,Other,225% New York Medicaid APG,4454.84,,,4454.84,Other,140% New York Medicaid APG,7159.57,,,7159.57,Other,225% New York Medicaid APG,8273.28,,,8273.28,Other,260% New York Medicaid APG,10309.78,,,10309.78,Other,324% New York Medicaid APG,6841.37,,,6841.37,Other,215% New York Medicaid APG,6841.37,,,6841.37,Other,215% New York Medicaid APG,3977.54,,,3977.54,Other,125% New York Medicaid APG,2879,204852.62,
Hip arthro w/femoroplasty,29914,CPT,,,,,,,,both,,,93714.83,69348.97,74,,69348.97,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,42171.67,45,,42171.67,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,46388.84,49.5,,46388.84,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5918.58,,,5918.58,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,65600.38,70,,65600.38,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,3182.03,,,3182.03,Other,New York Medicaid APG methodology,3182.03,,,3182.03,Other,100% New York Medicaid APG,3182.03,,,3182.03,Other,100% New York Medicaid APG,3182.03,,,3182.03,Other,100% New York Medicaid APG,7159.57,,,7159.57,Other,225% New York Medicaid APG,4868.51,,,4868.51,Other,153% New York Medicaid APG,7159.57,,,7159.57,Other,225% New York Medicaid APG,4454.84,,,4454.84,Other,140% New York Medicaid APG,7159.57,,,7159.57,Other,225% New York Medicaid APG,8273.28,,,8273.28,Other,260% New York Medicaid APG,10309.78,,,10309.78,Other,324% New York Medicaid APG,6841.37,,,6841.37,Other,215% New York Medicaid APG,6841.37,,,6841.37,Other,215% New York Medicaid APG,3977.54,,,3977.54,Other,125% New York Medicaid APG,3182.03,69348.97,
Hip arthro acetabuloplasty,29915,CPT,,,,,,,,both,,,150476.65,111352.72,74,,111352.72,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,67714.49,45,,67714.49,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,74485.94,49.5,,74485.94,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5918.58,,,5918.58,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,105333.66,70,,105333.66,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,3182.03,,,3182.03,Other,New York Medicaid APG methodology,3182.03,,,3182.03,Other,100% New York Medicaid APG,3182.03,,,3182.03,Other,100% New York Medicaid APG,3182.03,,,3182.03,Other,100% New York Medicaid APG,7159.57,,,7159.57,Other,225% New York Medicaid APG,4868.51,,,4868.51,Other,153% New York Medicaid APG,7159.57,,,7159.57,Other,225% New York Medicaid APG,4454.84,,,4454.84,Other,140% New York Medicaid APG,7159.57,,,7159.57,Other,225% New York Medicaid APG,8273.28,,,8273.28,Other,260% New York Medicaid APG,10309.78,,,10309.78,Other,324% New York Medicaid APG,6841.37,,,6841.37,Other,215% New York Medicaid APG,6841.37,,,6841.37,Other,215% New York Medicaid APG,3977.54,,,3977.54,Other,125% New York Medicaid APG,3182.03,111352.72,
Hip arthro w/labral repair,29916,CPT,,,,,,,,both,,,104264.25,77155.55,74,,77155.55,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,46918.91,45,,46918.91,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,51610.8,49.5,,51610.8,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5918.58,,,5918.58,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,72984.98,70,,72984.98,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,3182.03,,,3182.03,Other,New York Medicaid APG methodology,3182.03,,,3182.03,Other,100% New York Medicaid APG,3182.03,,,3182.03,Other,100% New York Medicaid APG,3182.03,,,3182.03,Other,100% New York Medicaid APG,7159.57,,,7159.57,Other,225% New York Medicaid APG,4868.51,,,4868.51,Other,153% New York Medicaid APG,7159.57,,,7159.57,Other,225% New York Medicaid APG,4454.84,,,4454.84,Other,140% New York Medicaid APG,7159.57,,,7159.57,Other,225% New York Medicaid APG,8273.28,,,8273.28,Other,260% New York Medicaid APG,10309.78,,,10309.78,Other,324% New York Medicaid APG,6841.37,,,6841.37,Other,215% New York Medicaid APG,6841.37,,,6841.37,Other,215% New York Medicaid APG,3977.54,,,3977.54,Other,125% New York Medicaid APG,3182.03,77155.55,
Drainage of nose lesion,30000,CPT,,,,,,,,both,,,5137.73,3801.92,74,,3801.92,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,2311.98,45,,2311.98,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,2543.18,49.5,,2543.18,percent of total billed charges,110% of Medicare,3493.66,68,,3493.66,percent of total billed charges,,423.06,,,423.06,Other,186% of Medicaid,4110.18,80,,4110.18,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,4110.18,80,,4110.18,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,3596.41,70,,3596.41,percent of total billed charges,,598.6,,,598.6,Fee Schedule,,507.35,,,507.35,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,227.45,,,227.45,Other,New York Medicaid APG methodology,227.45,,,227.45,Other,100% New York Medicaid APG,227.45,,,227.45,Other,100% New York Medicaid APG,227.45,,,227.45,Other,100% New York Medicaid APG,511.76,,,511.76,Other,225% New York Medicaid APG,348,,,348,Other,153% New York Medicaid APG,511.76,,,511.76,Other,225% New York Medicaid APG,318.43,,,318.43,Other,140% New York Medicaid APG,511.76,,,511.76,Other,225% New York Medicaid APG,591.37,,,591.37,Other,260% New York Medicaid APG,736.94,,,736.94,Other,324% New York Medicaid APG,489.02,,,489.02,Other,215% New York Medicaid APG,489.02,,,489.02,Other,215% New York Medicaid APG,284.31,,,284.31,Other,125% New York Medicaid APG,227.45,7216,
Drainage of nose lesion,30020,CPT,,,,,,,,both,,,11572.85,8563.91,74,,8563.91,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,5207.78,45,,5207.78,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,5728.56,49.5,,5728.56,percent of total billed charges,110% of Medicare,7869.54,68,,7869.54,percent of total billed charges,,2256.57,,,2256.57,Other,186% of Medicaid,9258.28,80,,9258.28,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,9258.28,80,,9258.28,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,8101,70,,8101,percent of total billed charges,,603.52,,,603.52,Fee Schedule,,511.52,,,511.52,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,1213.21,,,1213.21,Other,New York Medicaid APG methodology,1213.21,,,1213.21,Other,100% New York Medicaid APG,1213.21,,,1213.21,Other,100% New York Medicaid APG,1213.21,,,1213.21,Other,100% New York Medicaid APG,2729.72,,,2729.72,Other,225% New York Medicaid APG,1856.21,,,1856.21,Other,153% New York Medicaid APG,2729.72,,,2729.72,Other,225% New York Medicaid APG,1698.49,,,1698.49,Other,140% New York Medicaid APG,2729.72,,,2729.72,Other,225% New York Medicaid APG,3154.34,,,3154.34,Other,260% New York Medicaid APG,3930.79,,,3930.79,Other,324% New York Medicaid APG,2608.4,,,2608.4,Other,215% New York Medicaid APG,2608.4,,,2608.4,Other,215% New York Medicaid APG,1516.51,,,1516.51,Other,125% New York Medicaid APG,511.52,9258.28,
Intranasal biopsy,30100,CPT,,,,,,,,both,,,32077.39,23737.27,74,,23737.27,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,14434.83,45,,14434.83,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,15878.31,49.5,,15878.31,percent of total billed charges,110% of Medicare,21812.63,68,,21812.63,percent of total billed charges,,2256.57,,,2256.57,Other,186% of Medicaid,25661.91,80,,25661.91,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,25661.91,80,,25661.91,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,22454.17,70,,22454.17,percent of total billed charges,,331.28,,,331.28,Fee Schedule,,280.78,,,280.78,Fee Schedule,,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1213.21,,,1213.21,Other,New York Medicaid APG methodology,1213.21,,,1213.21,Other,100% New York Medicaid APG,1213.21,,,1213.21,Other,100% New York Medicaid APG,1213.21,,,1213.21,Other,100% New York Medicaid APG,2729.72,,,2729.72,Other,225% New York Medicaid APG,1856.21,,,1856.21,Other,153% New York Medicaid APG,2729.72,,,2729.72,Other,225% New York Medicaid APG,1698.49,,,1698.49,Other,140% New York Medicaid APG,2729.72,,,2729.72,Other,225% New York Medicaid APG,3154.34,,,3154.34,Other,260% New York Medicaid APG,3930.79,,,3930.79,Other,324% New York Medicaid APG,2608.4,,,2608.4,Other,215% New York Medicaid APG,2608.4,,,2608.4,Other,215% New York Medicaid APG,1516.51,,,1516.51,Other,125% New York Medicaid APG,280.78,25661.91,
Removal of nose polyp(s),30110,CPT,,,,,,,,both,,,32077.39,23737.27,74,,23737.27,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,14434.83,45,,14434.83,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,15878.31,49.5,,15878.31,percent of total billed charges,110% of Medicare,21812.63,68,,21812.63,percent of total billed charges,,2256.57,,,2256.57,Other,186% of Medicaid,25661.91,80,,25661.91,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,25661.91,80,,25661.91,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,22454.17,70,,22454.17,percent of total billed charges,,652.72,,,652.72,Fee Schedule,,553.22,,,553.22,Fee Schedule,,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1213.21,,,1213.21,Other,New York Medicaid APG methodology,1213.21,,,1213.21,Other,100% New York Medicaid APG,1213.21,,,1213.21,Other,100% New York Medicaid APG,1213.21,,,1213.21,Other,100% New York Medicaid APG,2729.72,,,2729.72,Other,225% New York Medicaid APG,1856.21,,,1856.21,Other,153% New York Medicaid APG,2729.72,,,2729.72,Other,225% New York Medicaid APG,1698.49,,,1698.49,Other,140% New York Medicaid APG,2729.72,,,2729.72,Other,225% New York Medicaid APG,3154.34,,,3154.34,Other,260% New York Medicaid APG,3930.79,,,3930.79,Other,324% New York Medicaid APG,2608.4,,,2608.4,Other,215% New York Medicaid APG,2608.4,,,2608.4,Other,215% New York Medicaid APG,1516.51,,,1516.51,Other,125% New York Medicaid APG,553.22,25661.91,
Removal of nose polyp(s),30115,CPT,,,,,,,,both,,,67720.49,50113.16,74,,50113.16,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30474.22,45,,30474.22,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,33521.64,49.5,,33521.64,percent of total billed charges,110% of Medicare,46049.93,68,,46049.93,percent of total billed charges,,2256.57,,,2256.57,Other,186% of Medicaid,54176.39,80,,54176.39,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,54176.39,80,,54176.39,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,47404.34,70,,47404.34,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1213.21,,,1213.21,Other,New York Medicaid APG methodology,1213.21,,,1213.21,Other,100% New York Medicaid APG,1213.21,,,1213.21,Other,100% New York Medicaid APG,1213.21,,,1213.21,Other,100% New York Medicaid APG,2729.72,,,2729.72,Other,225% New York Medicaid APG,1856.21,,,1856.21,Other,153% New York Medicaid APG,2729.72,,,2729.72,Other,225% New York Medicaid APG,1698.49,,,1698.49,Other,140% New York Medicaid APG,2729.72,,,2729.72,Other,225% New York Medicaid APG,3154.34,,,3154.34,Other,260% New York Medicaid APG,3930.79,,,3930.79,Other,324% New York Medicaid APG,2608.4,,,2608.4,Other,215% New York Medicaid APG,2608.4,,,2608.4,Other,215% New York Medicaid APG,1516.51,,,1516.51,Other,125% New York Medicaid APG,1213.21,54176.39,
Removal of intranasal lesion,30117,CPT,,,,,,,,both,,,35951.86,26604.38,74,,26604.38,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,16178.34,45,,16178.34,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,17796.17,49.5,,17796.17,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2965.83,,,2965.83,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,25166.3,70,,25166.3,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1594.53,,,1594.53,Other,New York Medicaid APG methodology,1594.53,,,1594.53,Other,100% New York Medicaid APG,1594.53,,,1594.53,Other,100% New York Medicaid APG,1594.53,,,1594.53,Other,100% New York Medicaid APG,3587.7,,,3587.7,Other,225% New York Medicaid APG,2439.64,,,2439.64,Other,153% New York Medicaid APG,3587.7,,,3587.7,Other,225% New York Medicaid APG,2232.35,,,2232.35,Other,140% New York Medicaid APG,3587.7,,,3587.7,Other,225% New York Medicaid APG,4145.78,,,4145.78,Other,260% New York Medicaid APG,5166.29,,,5166.29,Other,324% New York Medicaid APG,3428.25,,,3428.25,Other,215% New York Medicaid APG,3428.25,,,3428.25,Other,215% New York Medicaid APG,1993.17,,,1993.17,Other,125% New York Medicaid APG,1594.53,26604.38,
Removal of intranasal lesion,30118,CPT,,,,,,,,both,,,67720.49,50113.16,74,,50113.16,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30474.22,45,,30474.22,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,33521.64,49.5,,33521.64,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2965.83,,,2965.83,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,47404.34,70,,47404.34,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1594.53,,,1594.53,Other,New York Medicaid APG methodology,1594.53,,,1594.53,Other,100% New York Medicaid APG,1594.53,,,1594.53,Other,100% New York Medicaid APG,1594.53,,,1594.53,Other,100% New York Medicaid APG,3587.7,,,3587.7,Other,225% New York Medicaid APG,2439.64,,,2439.64,Other,153% New York Medicaid APG,3587.7,,,3587.7,Other,225% New York Medicaid APG,2232.35,,,2232.35,Other,140% New York Medicaid APG,3587.7,,,3587.7,Other,225% New York Medicaid APG,4145.78,,,4145.78,Other,260% New York Medicaid APG,5166.29,,,5166.29,Other,324% New York Medicaid APG,3428.25,,,3428.25,Other,215% New York Medicaid APG,3428.25,,,3428.25,Other,215% New York Medicaid APG,1993.17,,,1993.17,Other,125% New York Medicaid APG,1594.53,50113.16,
Revision of nose,30120,CPT,,,,,,,,both,,,35129.63,25995.93,74,,25995.93,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15808.33,45,,15808.33,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,17389.17,49.5,,17389.17,percent of total billed charges,110% of Medicare,23888.15,68,,23888.15,percent of total billed charges,,2965.83,,,2965.83,Other,186% of Medicaid,28103.7,80,,28103.7,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,28103.7,80,,28103.7,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,24590.74,70,,24590.74,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1594.53,,,1594.53,Other,New York Medicaid APG methodology,1594.53,,,1594.53,Other,100% New York Medicaid APG,1594.53,,,1594.53,Other,100% New York Medicaid APG,1594.53,,,1594.53,Other,100% New York Medicaid APG,3587.7,,,3587.7,Other,225% New York Medicaid APG,2439.64,,,2439.64,Other,153% New York Medicaid APG,3587.7,,,3587.7,Other,225% New York Medicaid APG,2232.35,,,2232.35,Other,140% New York Medicaid APG,3587.7,,,3587.7,Other,225% New York Medicaid APG,4145.78,,,4145.78,Other,260% New York Medicaid APG,5166.29,,,5166.29,Other,324% New York Medicaid APG,3428.25,,,3428.25,Other,215% New York Medicaid APG,3428.25,,,3428.25,Other,215% New York Medicaid APG,1993.17,,,1993.17,Other,125% New York Medicaid APG,1594.53,28103.7,
Removal of nose lesion,30124,CPT,,,,,,,,both,,,32077.39,23737.27,74,,23737.27,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,14434.83,45,,14434.83,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,15878.31,49.5,,15878.31,percent of total billed charges,110% of Medicare,21812.63,68,,21812.63,percent of total billed charges,,2256.57,,,2256.57,Other,186% of Medicaid,25661.91,80,,25661.91,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,25661.91,80,,25661.91,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,22454.17,70,,22454.17,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1213.21,,,1213.21,Other,New York Medicaid APG methodology,1213.21,,,1213.21,Other,100% New York Medicaid APG,1213.21,,,1213.21,Other,100% New York Medicaid APG,1213.21,,,1213.21,Other,100% New York Medicaid APG,2729.72,,,2729.72,Other,225% New York Medicaid APG,1856.21,,,1856.21,Other,153% New York Medicaid APG,2729.72,,,2729.72,Other,225% New York Medicaid APG,1698.49,,,1698.49,Other,140% New York Medicaid APG,2729.72,,,2729.72,Other,225% New York Medicaid APG,3154.34,,,3154.34,Other,260% New York Medicaid APG,3930.79,,,3930.79,Other,324% New York Medicaid APG,2608.4,,,2608.4,Other,215% New York Medicaid APG,2608.4,,,2608.4,Other,215% New York Medicaid APG,1516.51,,,1516.51,Other,125% New York Medicaid APG,1213.21,25661.91,
Removal of nose lesion,30125,CPT,,,,,,,,both,,,51239.1,37916.93,74,,37916.93,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,23057.6,45,,23057.6,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,25363.35,49.5,,25363.35,percent of total billed charges,110% of Medicare,34842.59,68,,34842.59,percent of total billed charges,,2256.57,,,2256.57,Other,186% of Medicaid,40991.28,80,,40991.28,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,40991.28,80,,40991.28,percent of total billed charges,,7216,,,7216,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,35867.37,70,,35867.37,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,1213.21,,,1213.21,Other,New York Medicaid APG methodology,1213.21,,,1213.21,Other,100% New York Medicaid APG,1213.21,,,1213.21,Other,100% New York Medicaid APG,1213.21,,,1213.21,Other,100% New York Medicaid APG,2729.72,,,2729.72,Other,225% New York Medicaid APG,1856.21,,,1856.21,Other,153% New York Medicaid APG,2729.72,,,2729.72,Other,225% New York Medicaid APG,1698.49,,,1698.49,Other,140% New York Medicaid APG,2729.72,,,2729.72,Other,225% New York Medicaid APG,3154.34,,,3154.34,Other,260% New York Medicaid APG,3930.79,,,3930.79,Other,324% New York Medicaid APG,2608.4,,,2608.4,Other,215% New York Medicaid APG,2608.4,,,2608.4,Other,215% New York Medicaid APG,1516.51,,,1516.51,Other,125% New York Medicaid APG,1213.21,40991.28,
Excise inferior turbinate,30130,CPT,,,,,,,,both,,,67720.49,50113.16,74,,50113.16,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30474.22,45,,30474.22,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,33521.64,49.5,,33521.64,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,4398.22,,,4398.22,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,47404.34,70,,47404.34,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,2364.64,,,2364.64,Other,New York Medicaid APG methodology,2364.64,,,2364.64,Other,100% New York Medicaid APG,2364.64,,,2364.64,Other,100% New York Medicaid APG,2364.64,,,2364.64,Other,100% New York Medicaid APG,5320.43,,,5320.43,Other,225% New York Medicaid APG,3617.89,,,3617.89,Other,153% New York Medicaid APG,5320.43,,,5320.43,Other,225% New York Medicaid APG,3310.49,,,3310.49,Other,140% New York Medicaid APG,5320.43,,,5320.43,Other,225% New York Medicaid APG,6148.05,,,6148.05,Other,260% New York Medicaid APG,7661.42,,,7661.42,Other,324% New York Medicaid APG,5083.97,,,5083.97,Other,215% New York Medicaid APG,5083.97,,,5083.97,Other,215% New York Medicaid APG,2955.8,,,2955.8,Other,125% New York Medicaid APG,2364.64,50113.16,
Resect inferior turbinate,30140,CPT,,,,,,,,both,,,35888.55,26557.53,74,,26557.53,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,16149.85,45,,16149.85,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,17764.83,49.5,,17764.83,percent of total billed charges,110% of Medicare,24404.21,68,,24404.21,percent of total billed charges,,4398.22,,,4398.22,Other,186% of Medicaid,28710.84,80,,28710.84,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,28710.84,80,,28710.84,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,25121.99,70,,25121.99,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,2364.64,,,2364.64,Other,New York Medicaid APG methodology,2364.64,,,2364.64,Other,100% New York Medicaid APG,2364.64,,,2364.64,Other,100% New York Medicaid APG,2364.64,,,2364.64,Other,100% New York Medicaid APG,5320.43,,,5320.43,Other,225% New York Medicaid APG,3617.89,,,3617.89,Other,153% New York Medicaid APG,5320.43,,,5320.43,Other,225% New York Medicaid APG,3310.49,,,3310.49,Other,140% New York Medicaid APG,5320.43,,,5320.43,Other,225% New York Medicaid APG,6148.05,,,6148.05,Other,260% New York Medicaid APG,7661.42,,,7661.42,Other,324% New York Medicaid APG,5083.97,,,5083.97,Other,215% New York Medicaid APG,5083.97,,,5083.97,Other,215% New York Medicaid APG,2955.8,,,2955.8,Other,125% New York Medicaid APG,2232,28710.84,
Partial removal of nose,30150,CPT,,,,,,,,both,,,123177.14,91151.08,74,,91151.08,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,55429.71,45,,55429.71,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,60972.68,49.5,,60972.68,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5482.74,,,5482.74,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,86224,70,,86224,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,2947.71,,,2947.71,Other,New York Medicaid APG methodology,2947.71,,,2947.71,Other,100% New York Medicaid APG,2947.71,,,2947.71,Other,100% New York Medicaid APG,2947.71,,,2947.71,Other,100% New York Medicaid APG,6632.35,,,6632.35,Other,225% New York Medicaid APG,4510,,,4510,Other,153% New York Medicaid APG,6632.35,,,6632.35,Other,225% New York Medicaid APG,4126.79,,,4126.79,Other,140% New York Medicaid APG,6632.35,,,6632.35,Other,225% New York Medicaid APG,7664.04,,,7664.04,Other,260% New York Medicaid APG,9550.58,,,9550.58,Other,324% New York Medicaid APG,6337.58,,,6337.58,Other,215% New York Medicaid APG,6337.58,,,6337.58,Other,215% New York Medicaid APG,3684.64,,,3684.64,Other,125% New York Medicaid APG,2947.71,91151.08,
Removal of nose,30160,CPT,,,,,,,,both,,,123177.14,91151.08,74,,91151.08,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,55429.71,45,,55429.71,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,60972.68,49.5,,60972.68,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5482.74,,,5482.74,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,86224,70,,86224,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,2947.71,,,2947.71,Other,New York Medicaid APG methodology,2947.71,,,2947.71,Other,100% New York Medicaid APG,2947.71,,,2947.71,Other,100% New York Medicaid APG,2947.71,,,2947.71,Other,100% New York Medicaid APG,6632.35,,,6632.35,Other,225% New York Medicaid APG,4510,,,4510,Other,153% New York Medicaid APG,6632.35,,,6632.35,Other,225% New York Medicaid APG,4126.79,,,4126.79,Other,140% New York Medicaid APG,6632.35,,,6632.35,Other,225% New York Medicaid APG,7664.04,,,7664.04,Other,260% New York Medicaid APG,9550.58,,,9550.58,Other,324% New York Medicaid APG,6337.58,,,6337.58,Other,215% New York Medicaid APG,6337.58,,,6337.58,Other,215% New York Medicaid APG,3684.64,,,3684.64,Other,125% New York Medicaid APG,2947.71,91151.08,
Injection treatment of nose,30200,CPT,,,,,,,,both,,,11572.85,8563.91,74,,8563.91,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,5207.78,45,,5207.78,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,5728.56,49.5,,5728.56,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,423.06,,,423.06,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,8101,70,,8101,percent of total billed charges,,291.92,,,291.92,Fee Schedule,,247.42,,,247.42,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,227.45,,,227.45,Other,New York Medicaid APG methodology,227.45,,,227.45,Other,100% New York Medicaid APG,227.45,,,227.45,Other,100% New York Medicaid APG,227.45,,,227.45,Other,100% New York Medicaid APG,511.76,,,511.76,Other,225% New York Medicaid APG,348,,,348,Other,153% New York Medicaid APG,511.76,,,511.76,Other,225% New York Medicaid APG,318.43,,,318.43,Other,140% New York Medicaid APG,511.76,,,511.76,Other,225% New York Medicaid APG,591.37,,,591.37,Other,260% New York Medicaid APG,736.94,,,736.94,Other,324% New York Medicaid APG,489.02,,,489.02,Other,215% New York Medicaid APG,489.02,,,489.02,Other,215% New York Medicaid APG,284.31,,,284.31,Other,125% New York Medicaid APG,227.45,9473,
Nasal sinus therapy,30210,CPT,,,,,,,,both,,,32077.39,23737.27,74,,23737.27,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,14434.83,45,,14434.83,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,15878.31,49.5,,15878.31,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,423.06,,,423.06,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,22454.17,70,,22454.17,percent of total billed charges,,508.4,,,508.4,Fee Schedule,,430.9,,,430.9,Fee Schedule,,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,227.45,,,227.45,Other,New York Medicaid APG methodology,227.45,,,227.45,Other,100% New York Medicaid APG,227.45,,,227.45,Other,100% New York Medicaid APG,227.45,,,227.45,Other,100% New York Medicaid APG,511.76,,,511.76,Other,225% New York Medicaid APG,348,,,348,Other,153% New York Medicaid APG,511.76,,,511.76,Other,225% New York Medicaid APG,318.43,,,318.43,Other,140% New York Medicaid APG,511.76,,,511.76,Other,225% New York Medicaid APG,591.37,,,591.37,Other,260% New York Medicaid APG,736.94,,,736.94,Other,324% New York Medicaid APG,489.02,,,489.02,Other,215% New York Medicaid APG,489.02,,,489.02,Other,215% New York Medicaid APG,284.31,,,284.31,Other,125% New York Medicaid APG,227.45,23737.27,
Insert nasal septal button,30220,CPT,,,,,,,,both,,,32077.39,23737.27,74,,23737.27,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,14434.83,45,,14434.83,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,15878.31,49.5,,15878.31,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2256.57,,,2256.57,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,22454.17,70,,22454.17,percent of total billed charges,,629.76,,,629.76,Fee Schedule,,533.76,,,533.76,Fee Schedule,,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1213.21,,,1213.21,Other,New York Medicaid APG methodology,1213.21,,,1213.21,Other,100% New York Medicaid APG,1213.21,,,1213.21,Other,100% New York Medicaid APG,1213.21,,,1213.21,Other,100% New York Medicaid APG,2729.72,,,2729.72,Other,225% New York Medicaid APG,1856.21,,,1856.21,Other,153% New York Medicaid APG,2729.72,,,2729.72,Other,225% New York Medicaid APG,1698.49,,,1698.49,Other,140% New York Medicaid APG,2729.72,,,2729.72,Other,225% New York Medicaid APG,3154.34,,,3154.34,Other,260% New York Medicaid APG,3930.79,,,3930.79,Other,324% New York Medicaid APG,2608.4,,,2608.4,Other,215% New York Medicaid APG,2608.4,,,2608.4,Other,215% New York Medicaid APG,1516.51,,,1516.51,Other,125% New York Medicaid APG,533.76,23737.27,
Remove nasal foreign body,30300,CPT,,,,,,,,both,,,2686.86,1988.28,74,,1988.28,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,1209.09,45,,1209.09,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,1330,49.5,,1330,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,423.06,,,423.06,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,1880.8,70,,1880.8,percent of total billed charges,,615,,,615,Fee Schedule,,521.25,,,521.25,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,227.45,,,227.45,Other,New York Medicaid APG methodology,227.45,,,227.45,Other,100% New York Medicaid APG,227.45,,,227.45,Other,100% New York Medicaid APG,227.45,,,227.45,Other,100% New York Medicaid APG,511.76,,,511.76,Other,225% New York Medicaid APG,348,,,348,Other,153% New York Medicaid APG,511.76,,,511.76,Other,225% New York Medicaid APG,318.43,,,318.43,Other,140% New York Medicaid APG,511.76,,,511.76,Other,225% New York Medicaid APG,591.37,,,591.37,Other,260% New York Medicaid APG,736.94,,,736.94,Other,324% New York Medicaid APG,489.02,,,489.02,Other,215% New York Medicaid APG,489.02,,,489.02,Other,215% New York Medicaid APG,284.31,,,284.31,Other,125% New York Medicaid APG,227.45,9473,
Remove nasal foreign body,30310,CPT,,,,,,,,both,,,35579.78,26329.04,74,,26329.04,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,16010.9,45,,16010.9,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,17611.99,49.5,,17611.99,percent of total billed charges,110% of Medicare,24194.25,68,,24194.25,percent of total billed charges,,2256.57,,,2256.57,Other,186% of Medicaid,28463.82,80,,28463.82,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,28463.82,80,,28463.82,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,24905.85,70,,24905.85,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1213.21,,,1213.21,Other,New York Medicaid APG methodology,1213.21,,,1213.21,Other,100% New York Medicaid APG,1213.21,,,1213.21,Other,100% New York Medicaid APG,1213.21,,,1213.21,Other,100% New York Medicaid APG,2729.72,,,2729.72,Other,225% New York Medicaid APG,1856.21,,,1856.21,Other,153% New York Medicaid APG,2729.72,,,2729.72,Other,225% New York Medicaid APG,1698.49,,,1698.49,Other,140% New York Medicaid APG,2729.72,,,2729.72,Other,225% New York Medicaid APG,3154.34,,,3154.34,Other,260% New York Medicaid APG,3930.79,,,3930.79,Other,324% New York Medicaid APG,2608.4,,,2608.4,Other,215% New York Medicaid APG,2608.4,,,2608.4,Other,215% New York Medicaid APG,1516.51,,,1516.51,Other,125% New York Medicaid APG,1213.21,28463.82,
Remove nasal foreign body,30320,CPT,,,,,,,,both,,,32077.39,23737.27,74,,23737.27,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,14434.83,45,,14434.83,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,15878.31,49.5,,15878.31,percent of total billed charges,110% of Medicare,21812.63,68,,21812.63,percent of total billed charges,,2256.57,,,2256.57,Other,186% of Medicaid,25661.91,80,,25661.91,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,25661.91,80,,25661.91,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,22454.17,70,,22454.17,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1213.21,,,1213.21,Other,New York Medicaid APG methodology,1213.21,,,1213.21,Other,100% New York Medicaid APG,1213.21,,,1213.21,Other,100% New York Medicaid APG,1213.21,,,1213.21,Other,100% New York Medicaid APG,2729.72,,,2729.72,Other,225% New York Medicaid APG,1856.21,,,1856.21,Other,153% New York Medicaid APG,2729.72,,,2729.72,Other,225% New York Medicaid APG,1698.49,,,1698.49,Other,140% New York Medicaid APG,2729.72,,,2729.72,Other,225% New York Medicaid APG,3154.34,,,3154.34,Other,260% New York Medicaid APG,3930.79,,,3930.79,Other,324% New York Medicaid APG,2608.4,,,2608.4,Other,215% New York Medicaid APG,2608.4,,,2608.4,Other,215% New York Medicaid APG,1516.51,,,1516.51,Other,125% New York Medicaid APG,1213.21,25661.91,
Reconstruction of nose,30400,CPT,,,,,,,,both,,,123177.14,91151.08,74,,91151.08,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,55429.71,45,,55429.71,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,60972.68,49.5,,60972.68,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,4398.22,,,4398.22,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,86224,70,,86224,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,2364.64,,,2364.64,Other,New York Medicaid APG methodology,2364.64,,,2364.64,Other,100% New York Medicaid APG,2364.64,,,2364.64,Other,100% New York Medicaid APG,2364.64,,,2364.64,Other,100% New York Medicaid APG,5320.43,,,5320.43,Other,225% New York Medicaid APG,3617.89,,,3617.89,Other,153% New York Medicaid APG,5320.43,,,5320.43,Other,225% New York Medicaid APG,3310.49,,,3310.49,Other,140% New York Medicaid APG,5320.43,,,5320.43,Other,225% New York Medicaid APG,6148.05,,,6148.05,Other,260% New York Medicaid APG,7661.42,,,7661.42,Other,324% New York Medicaid APG,5083.97,,,5083.97,Other,215% New York Medicaid APG,5083.97,,,5083.97,Other,215% New York Medicaid APG,2955.8,,,2955.8,Other,125% New York Medicaid APG,2364.64,91151.08,
Reconstruction of nose,30410,CPT,,,,,,,,both,,,56761.14,42003.24,74,,42003.24,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,25542.51,45,,25542.51,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,28096.76,49.5,,28096.76,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5482.74,,,5482.74,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,39732.8,70,,39732.8,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,2947.71,,,2947.71,Other,New York Medicaid APG methodology,2947.71,,,2947.71,Other,100% New York Medicaid APG,2947.71,,,2947.71,Other,100% New York Medicaid APG,2947.71,,,2947.71,Other,100% New York Medicaid APG,6632.35,,,6632.35,Other,225% New York Medicaid APG,4510,,,4510,Other,153% New York Medicaid APG,6632.35,,,6632.35,Other,225% New York Medicaid APG,4126.79,,,4126.79,Other,140% New York Medicaid APG,6632.35,,,6632.35,Other,225% New York Medicaid APG,7664.04,,,7664.04,Other,260% New York Medicaid APG,9550.58,,,9550.58,Other,324% New York Medicaid APG,6337.58,,,6337.58,Other,215% New York Medicaid APG,6337.58,,,6337.58,Other,215% New York Medicaid APG,3684.64,,,3684.64,Other,125% New York Medicaid APG,2947.71,42003.24,
Reconstruction of nose,30420,CPT,,,,,,,,both,,,55638.22,41172.28,74,,41172.28,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,25037.2,45,,25037.2,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,27540.92,49.5,,27540.92,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5482.74,,,5482.74,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,38946.75,70,,38946.75,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,2947.71,,,2947.71,Other,New York Medicaid APG methodology,2947.71,,,2947.71,Other,100% New York Medicaid APG,2947.71,,,2947.71,Other,100% New York Medicaid APG,2947.71,,,2947.71,Other,100% New York Medicaid APG,6632.35,,,6632.35,Other,225% New York Medicaid APG,4510,,,4510,Other,153% New York Medicaid APG,6632.35,,,6632.35,Other,225% New York Medicaid APG,4126.79,,,4126.79,Other,140% New York Medicaid APG,6632.35,,,6632.35,Other,225% New York Medicaid APG,7664.04,,,7664.04,Other,260% New York Medicaid APG,9550.58,,,9550.58,Other,324% New York Medicaid APG,6337.58,,,6337.58,Other,215% New York Medicaid APG,6337.58,,,6337.58,Other,215% New York Medicaid APG,3684.64,,,3684.64,Other,125% New York Medicaid APG,2947.71,41172.28,
Revision of nose,30430,CPT,,,,,,,,both,,,44143.84,32666.44,74,,32666.44,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,19864.73,45,,19864.73,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,21851.2,49.5,,21851.2,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2965.83,,,2965.83,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,30900.69,70,,30900.69,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1594.53,,,1594.53,Other,New York Medicaid APG methodology,1594.53,,,1594.53,Other,100% New York Medicaid APG,1594.53,,,1594.53,Other,100% New York Medicaid APG,1594.53,,,1594.53,Other,100% New York Medicaid APG,3587.7,,,3587.7,Other,225% New York Medicaid APG,2439.64,,,2439.64,Other,153% New York Medicaid APG,3587.7,,,3587.7,Other,225% New York Medicaid APG,2232.35,,,2232.35,Other,140% New York Medicaid APG,3587.7,,,3587.7,Other,225% New York Medicaid APG,4145.78,,,4145.78,Other,260% New York Medicaid APG,5166.29,,,5166.29,Other,324% New York Medicaid APG,3428.25,,,3428.25,Other,215% New York Medicaid APG,3428.25,,,3428.25,Other,215% New York Medicaid APG,1993.17,,,1993.17,Other,125% New York Medicaid APG,1594.53,32666.44,
Revision of nose,30435,CPT,,,,,,,,both,,,123177.14,91151.08,74,,91151.08,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,55429.71,45,,55429.71,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,60972.68,49.5,,60972.68,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5482.74,,,5482.74,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,86224,70,,86224,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,2947.71,,,2947.71,Other,New York Medicaid APG methodology,2947.71,,,2947.71,Other,100% New York Medicaid APG,2947.71,,,2947.71,Other,100% New York Medicaid APG,2947.71,,,2947.71,Other,100% New York Medicaid APG,6632.35,,,6632.35,Other,225% New York Medicaid APG,4510,,,4510,Other,153% New York Medicaid APG,6632.35,,,6632.35,Other,225% New York Medicaid APG,4126.79,,,4126.79,Other,140% New York Medicaid APG,6632.35,,,6632.35,Other,225% New York Medicaid APG,7664.04,,,7664.04,Other,260% New York Medicaid APG,9550.58,,,9550.58,Other,324% New York Medicaid APG,6337.58,,,6337.58,Other,215% New York Medicaid APG,6337.58,,,6337.58,Other,215% New York Medicaid APG,3684.64,,,3684.64,Other,125% New York Medicaid APG,2947.71,91151.08,
Revision of nose,30450,CPT,,,,,,,,both,,,82062.41,60726.18,74,,60726.18,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,36928.08,45,,36928.08,percent of total billed charges,Medicare Ratio of cost to charges,5954,,"100% primary, 50% supplemental procedure",5954,Other,Aetna ASC Grouper,5359,,"100% primary, 50% supplemental procedure",5359,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,40620.89,49.5,,40620.89,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5482.74,,,5482.74,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,57443.69,70,,57443.69,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,2947.71,,,2947.71,Other,New York Medicaid APG methodology,2947.71,,,2947.71,Other,100% New York Medicaid APG,2947.71,,,2947.71,Other,100% New York Medicaid APG,2947.71,,,2947.71,Other,100% New York Medicaid APG,6632.35,,,6632.35,Other,225% New York Medicaid APG,4510,,,4510,Other,153% New York Medicaid APG,6632.35,,,6632.35,Other,225% New York Medicaid APG,4126.79,,,4126.79,Other,140% New York Medicaid APG,6632.35,,,6632.35,Other,225% New York Medicaid APG,7664.04,,,7664.04,Other,260% New York Medicaid APG,9550.58,,,9550.58,Other,324% New York Medicaid APG,6337.58,,,6337.58,Other,215% New York Medicaid APG,6337.58,,,6337.58,Other,215% New York Medicaid APG,3684.64,,,3684.64,Other,125% New York Medicaid APG,2947.71,60726.18,
Revision of nose,30460,CPT,,,,,,,,both,,,123177.14,91151.08,74,,91151.08,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,55429.71,45,,55429.71,percent of total billed charges,Medicare Ratio of cost to charges,5954,,"100% primary, 50% supplemental procedure",5954,Other,Aetna ASC Grouper,5359,,"100% primary, 50% supplemental procedure",5359,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,60972.68,49.5,,60972.68,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5482.74,,,5482.74,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,86224,70,,86224,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,2947.71,,,2947.71,Other,New York Medicaid APG methodology,2947.71,,,2947.71,Other,100% New York Medicaid APG,2947.71,,,2947.71,Other,100% New York Medicaid APG,2947.71,,,2947.71,Other,100% New York Medicaid APG,6632.35,,,6632.35,Other,225% New York Medicaid APG,4510,,,4510,Other,153% New York Medicaid APG,6632.35,,,6632.35,Other,225% New York Medicaid APG,4126.79,,,4126.79,Other,140% New York Medicaid APG,6632.35,,,6632.35,Other,225% New York Medicaid APG,7664.04,,,7664.04,Other,260% New York Medicaid APG,9550.58,,,9550.58,Other,324% New York Medicaid APG,6337.58,,,6337.58,Other,215% New York Medicaid APG,6337.58,,,6337.58,Other,215% New York Medicaid APG,3684.64,,,3684.64,Other,125% New York Medicaid APG,2947.71,91151.08,
Revision of nose,30462,CPT,,,,,,,,both,,,123177.14,91151.08,74,,91151.08,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,55429.71,45,,55429.71,percent of total billed charges,Medicare Ratio of cost to charges,5954,,"100% primary, 50% supplemental procedure",5954,Other,Aetna ASC Grouper,5359,,"100% primary, 50% supplemental procedure",5359,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,60972.68,49.5,,60972.68,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5482.74,,,5482.74,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,86224,70,,86224,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,2947.71,,,2947.71,Other,New York Medicaid APG methodology,2947.71,,,2947.71,Other,100% New York Medicaid APG,2947.71,,,2947.71,Other,100% New York Medicaid APG,2947.71,,,2947.71,Other,100% New York Medicaid APG,6632.35,,,6632.35,Other,225% New York Medicaid APG,4510,,,4510,Other,153% New York Medicaid APG,6632.35,,,6632.35,Other,225% New York Medicaid APG,4126.79,,,4126.79,Other,140% New York Medicaid APG,6632.35,,,6632.35,Other,225% New York Medicaid APG,7664.04,,,7664.04,Other,260% New York Medicaid APG,9550.58,,,9550.58,Other,324% New York Medicaid APG,6337.58,,,6337.58,Other,215% New York Medicaid APG,6337.58,,,6337.58,Other,215% New York Medicaid APG,3684.64,,,3684.64,Other,125% New York Medicaid APG,2947.71,91151.08,
Repair nasal stenosis,30465,CPT,,,,,,,,both,,,46270.96,34240.51,74,,34240.51,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,20821.93,45,,20821.93,percent of total billed charges,Medicare Ratio of cost to charges,5954,,"100% primary, 50% supplemental procedure",5954,Other,Aetna ASC Grouper,5359,,"100% primary, 50% supplemental procedure",5359,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,22904.13,49.5,,22904.13,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2965.83,,,2965.83,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,32389.67,70,,32389.67,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,1594.53,,,1594.53,Other,New York Medicaid APG methodology,1594.53,,,1594.53,Other,100% New York Medicaid APG,1594.53,,,1594.53,Other,100% New York Medicaid APG,1594.53,,,1594.53,Other,100% New York Medicaid APG,3587.7,,,3587.7,Other,225% New York Medicaid APG,2439.64,,,2439.64,Other,153% New York Medicaid APG,3587.7,,,3587.7,Other,225% New York Medicaid APG,2232.35,,,2232.35,Other,140% New York Medicaid APG,3587.7,,,3587.7,Other,225% New York Medicaid APG,4145.78,,,4145.78,Other,260% New York Medicaid APG,5166.29,,,5166.29,Other,324% New York Medicaid APG,3428.25,,,3428.25,Other,215% New York Medicaid APG,3428.25,,,3428.25,Other,215% New York Medicaid APG,1993.17,,,1993.17,Other,125% New York Medicaid APG,1594.53,34240.51,
Rpr nsl vlv collapse w/implt,30468,CPT,,,,,,,,both,,,36572.73,27063.82,74,,27063.82,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,16457.73,45,,16457.73,percent of total billed charges,Medicare Ratio of cost to charges,5954,,"100% primary, 50% supplemental procedure",5954,Other,Aetna ASC Grouper,5359,,"100% primary, 50% supplemental procedure",5359,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,18103.5,49.5,,18103.5,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,4119.28,,,4119.28,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,29258.18,80,,29258.18,percent of total billed charges,,25600.91,70,,25600.91,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,2214.67,,,2214.67,Other,New York Medicaid APG methodology,2214.67,,,2214.67,Other,100% New York Medicaid APG,2214.67,,,2214.67,Other,100% New York Medicaid APG,2214.67,,,2214.67,Other,100% New York Medicaid APG,4983,,,4983,Other,225% New York Medicaid APG,3388.44,,,3388.44,Other,153% New York Medicaid APG,4983,,,4983,Other,225% New York Medicaid APG,3100.53,,,3100.53,Other,140% New York Medicaid APG,4983,,,4983,Other,225% New York Medicaid APG,5758.13,,,5758.13,Other,260% New York Medicaid APG,7175.52,,,7175.52,Other,324% New York Medicaid APG,4761.53,,,4761.53,Other,215% New York Medicaid APG,4761.53,,,4761.53,Other,215% New York Medicaid APG,2768.33,,,2768.33,Other,125% New York Medicaid APG,2214.67,29258.18,
Repair of nasal septum,30520,CPT,,,,,,,,both,,,39526.16,29249.36,74,,29249.36,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,17786.77,45,,17786.77,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,19565.45,49.5,,19565.45,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,4398.22,,,4398.22,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,27668.31,70,,27668.31,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,2364.64,,,2364.64,Other,New York Medicaid APG methodology,2364.64,,,2364.64,Other,100% New York Medicaid APG,2364.64,,,2364.64,Other,100% New York Medicaid APG,2364.64,,,2364.64,Other,100% New York Medicaid APG,5320.43,,,5320.43,Other,225% New York Medicaid APG,3617.89,,,3617.89,Other,153% New York Medicaid APG,5320.43,,,5320.43,Other,225% New York Medicaid APG,3310.49,,,3310.49,Other,140% New York Medicaid APG,5320.43,,,5320.43,Other,225% New York Medicaid APG,6148.05,,,6148.05,Other,260% New York Medicaid APG,7661.42,,,7661.42,Other,324% New York Medicaid APG,5083.97,,,5083.97,Other,215% New York Medicaid APG,5083.97,,,5083.97,Other,215% New York Medicaid APG,2955.8,,,2955.8,Other,125% New York Medicaid APG,2364.64,29249.36,
Repair nasal defect,30540,CPT,,,,,,,,both,,,123177.14,91151.08,74,,91151.08,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,55429.71,45,,55429.71,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,60972.68,49.5,,60972.68,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,4119.28,,,4119.28,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,86224,70,,86224,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,2214.67,,,2214.67,Other,New York Medicaid APG methodology,2214.67,,,2214.67,Other,100% New York Medicaid APG,2214.67,,,2214.67,Other,100% New York Medicaid APG,2214.67,,,2214.67,Other,100% New York Medicaid APG,4983,,,4983,Other,225% New York Medicaid APG,3388.44,,,3388.44,Other,153% New York Medicaid APG,4983,,,4983,Other,225% New York Medicaid APG,3100.53,,,3100.53,Other,140% New York Medicaid APG,4983,,,4983,Other,225% New York Medicaid APG,5758.13,,,5758.13,Other,260% New York Medicaid APG,7175.52,,,7175.52,Other,324% New York Medicaid APG,4761.53,,,4761.53,Other,215% New York Medicaid APG,4761.53,,,4761.53,Other,215% New York Medicaid APG,2768.33,,,2768.33,Other,125% New York Medicaid APG,2214.67,91151.08,
Repair nasal defect,30545,CPT,,,,,,,,both,,,123177.14,91151.08,74,,91151.08,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,55429.71,45,,55429.71,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,60972.68,49.5,,60972.68,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5266.94,,,5266.94,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,86224,70,,86224,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,2831.69,,,2831.69,Other,New York Medicaid APG methodology,2831.69,,,2831.69,Other,100% New York Medicaid APG,2831.69,,,2831.69,Other,100% New York Medicaid APG,2831.69,,,2831.69,Other,100% New York Medicaid APG,6371.29,,,6371.29,Other,225% New York Medicaid APG,4332.48,,,4332.48,Other,153% New York Medicaid APG,6371.29,,,6371.29,Other,225% New York Medicaid APG,3964.36,,,3964.36,Other,140% New York Medicaid APG,6371.29,,,6371.29,Other,225% New York Medicaid APG,7362.38,,,7362.38,Other,260% New York Medicaid APG,9174.66,,,9174.66,Other,324% New York Medicaid APG,6088.13,,,6088.13,Other,215% New York Medicaid APG,6088.13,,,6088.13,Other,215% New York Medicaid APG,3539.61,,,3539.61,Other,125% New York Medicaid APG,2831.69,91151.08,
Release of nasal adhesions,30560,CPT,,,,,,,,both,,,11572.85,8563.91,74,,8563.91,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,5207.78,45,,5207.78,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,5728.56,49.5,,5728.56,percent of total billed charges,110% of Medicare,7869.54,68,,7869.54,percent of total billed charges,,2256.57,,,2256.57,Other,186% of Medicaid,9258.28,80,,9258.28,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,9258.28,80,,9258.28,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,8101,70,,8101,percent of total billed charges,,746.2,,,746.2,Fee Schedule,,632.45,,,632.45,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,1213.21,,,1213.21,Other,New York Medicaid APG methodology,1213.21,,,1213.21,Other,100% New York Medicaid APG,1213.21,,,1213.21,Other,100% New York Medicaid APG,1213.21,,,1213.21,Other,100% New York Medicaid APG,2729.72,,,2729.72,Other,225% New York Medicaid APG,1856.21,,,1856.21,Other,153% New York Medicaid APG,2729.72,,,2729.72,Other,225% New York Medicaid APG,1698.49,,,1698.49,Other,140% New York Medicaid APG,2729.72,,,2729.72,Other,225% New York Medicaid APG,3154.34,,,3154.34,Other,260% New York Medicaid APG,3930.79,,,3930.79,Other,324% New York Medicaid APG,2608.4,,,2608.4,Other,215% New York Medicaid APG,2608.4,,,2608.4,Other,215% New York Medicaid APG,1516.51,,,1516.51,Other,125% New York Medicaid APG,632.45,9258.28,
Repair upper jaw fistula,30580,CPT,,,,,,,,both,,,44575.28,32985.71,74,,32985.71,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,20058.88,45,,20058.88,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,22064.76,49.5,,22064.76,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,4119.28,,,4119.28,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,31202.7,70,,31202.7,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,2214.67,,,2214.67,Other,New York Medicaid APG methodology,2214.67,,,2214.67,Other,100% New York Medicaid APG,2214.67,,,2214.67,Other,100% New York Medicaid APG,2214.67,,,2214.67,Other,100% New York Medicaid APG,4983,,,4983,Other,225% New York Medicaid APG,3388.44,,,3388.44,Other,153% New York Medicaid APG,4983,,,4983,Other,225% New York Medicaid APG,3100.53,,,3100.53,Other,140% New York Medicaid APG,4983,,,4983,Other,225% New York Medicaid APG,5758.13,,,5758.13,Other,260% New York Medicaid APG,7175.52,,,7175.52,Other,324% New York Medicaid APG,4761.53,,,4761.53,Other,215% New York Medicaid APG,4761.53,,,4761.53,Other,215% New York Medicaid APG,2768.33,,,2768.33,Other,125% New York Medicaid APG,2214.67,32985.71,
Repair mouth/nose fistula,30600,CPT,,,,,,,,both,,,123177.14,91151.08,74,,91151.08,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,55429.71,45,,55429.71,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,60972.68,49.5,,60972.68,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,4119.28,,,4119.28,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,86224,70,,86224,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,2214.67,,,2214.67,Other,New York Medicaid APG methodology,2214.67,,,2214.67,Other,100% New York Medicaid APG,2214.67,,,2214.67,Other,100% New York Medicaid APG,2214.67,,,2214.67,Other,100% New York Medicaid APG,4983,,,4983,Other,225% New York Medicaid APG,3388.44,,,3388.44,Other,153% New York Medicaid APG,4983,,,4983,Other,225% New York Medicaid APG,3100.53,,,3100.53,Other,140% New York Medicaid APG,4983,,,4983,Other,225% New York Medicaid APG,5758.13,,,5758.13,Other,260% New York Medicaid APG,7175.52,,,7175.52,Other,324% New York Medicaid APG,4761.53,,,4761.53,Other,215% New York Medicaid APG,4761.53,,,4761.53,Other,215% New York Medicaid APG,2768.33,,,2768.33,Other,125% New York Medicaid APG,2214.67,91151.08,
Intranasal reconstruction,30620,CPT,,,,,,,,both,,,78477.05,58073.02,74,,58073.02,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,35314.67,45,,35314.67,percent of total billed charges,Medicare Ratio of cost to charges,5954,,"100% primary, 50% supplemental procedure",5954,Other,Aetna ASC Grouper,5359,,"100% primary, 50% supplemental procedure",5359,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,38846.14,49.5,,38846.14,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,4119.28,,,4119.28,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,54933.94,70,,54933.94,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,2214.67,,,2214.67,Other,New York Medicaid APG methodology,2214.67,,,2214.67,Other,100% New York Medicaid APG,2214.67,,,2214.67,Other,100% New York Medicaid APG,2214.67,,,2214.67,Other,100% New York Medicaid APG,4983,,,4983,Other,225% New York Medicaid APG,3388.44,,,3388.44,Other,153% New York Medicaid APG,4983,,,4983,Other,225% New York Medicaid APG,3100.53,,,3100.53,Other,140% New York Medicaid APG,4983,,,4983,Other,225% New York Medicaid APG,5758.13,,,5758.13,Other,260% New York Medicaid APG,7175.52,,,7175.52,Other,324% New York Medicaid APG,4761.53,,,4761.53,Other,215% New York Medicaid APG,4761.53,,,4761.53,Other,215% New York Medicaid APG,2768.33,,,2768.33,Other,125% New York Medicaid APG,2214.67,58073.02,
Repair nasal septum defect,30630,CPT,,,,,,,,both,,,67720.49,50113.16,74,,50113.16,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30474.22,45,,30474.22,percent of total billed charges,Medicare Ratio of cost to charges,5954,,"100% primary, 50% supplemental procedure",5954,Other,Aetna ASC Grouper,5359,,"100% primary, 50% supplemental procedure",5359,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,33521.64,49.5,,33521.64,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,4119.28,,,4119.28,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,47404.34,70,,47404.34,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,2214.67,,,2214.67,Other,New York Medicaid APG methodology,2214.67,,,2214.67,Other,100% New York Medicaid APG,2214.67,,,2214.67,Other,100% New York Medicaid APG,2214.67,,,2214.67,Other,100% New York Medicaid APG,4983,,,4983,Other,225% New York Medicaid APG,3388.44,,,3388.44,Other,153% New York Medicaid APG,4983,,,4983,Other,225% New York Medicaid APG,3100.53,,,3100.53,Other,140% New York Medicaid APG,4983,,,4983,Other,225% New York Medicaid APG,5758.13,,,5758.13,Other,260% New York Medicaid APG,7175.52,,,7175.52,Other,324% New York Medicaid APG,4761.53,,,4761.53,Other,215% New York Medicaid APG,4761.53,,,4761.53,Other,215% New York Medicaid APG,2768.33,,,2768.33,Other,125% New York Medicaid APG,2214.67,50113.16,
Ablate inf turbinate superf,30801,CPT,,,,,,,,both,,,32077.39,23737.27,74,,23737.27,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,14434.83,45,,14434.83,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,15878.31,49.5,,15878.31,percent of total billed charges,110% of Medicare,21812.63,68,,21812.63,percent of total billed charges,,2256.57,,,2256.57,Other,186% of Medicaid,25661.91,80,,25661.91,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,25661.91,80,,25661.91,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,22454.17,70,,22454.17,percent of total billed charges,,757.68,,,757.68,Fee Schedule,,642.18,,,642.18,Fee Schedule,,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1213.21,,,1213.21,Other,New York Medicaid APG methodology,1213.21,,,1213.21,Other,100% New York Medicaid APG,1213.21,,,1213.21,Other,100% New York Medicaid APG,1213.21,,,1213.21,Other,100% New York Medicaid APG,2729.72,,,2729.72,Other,225% New York Medicaid APG,1856.21,,,1856.21,Other,153% New York Medicaid APG,2729.72,,,2729.72,Other,225% New York Medicaid APG,1698.49,,,1698.49,Other,140% New York Medicaid APG,2729.72,,,2729.72,Other,225% New York Medicaid APG,3154.34,,,3154.34,Other,260% New York Medicaid APG,3930.79,,,3930.79,Other,324% New York Medicaid APG,2608.4,,,2608.4,Other,215% New York Medicaid APG,2608.4,,,2608.4,Other,215% New York Medicaid APG,1516.51,,,1516.51,Other,125% New York Medicaid APG,642.18,25661.91,
Ablate inf turbinate submuc,30802,CPT,,,,,,,,both,,,35088.16,25965.24,74,,25965.24,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15789.67,45,,15789.67,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,17368.64,49.5,,17368.64,percent of total billed charges,110% of Medicare,23859.95,68,,23859.95,percent of total billed charges,,4398.22,,,4398.22,Other,186% of Medicaid,28070.53,80,,28070.53,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,28070.53,80,,28070.53,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,24561.71,70,,24561.71,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,2364.64,,,2364.64,Other,New York Medicaid APG methodology,2364.64,,,2364.64,Other,100% New York Medicaid APG,2364.64,,,2364.64,Other,100% New York Medicaid APG,2364.64,,,2364.64,Other,100% New York Medicaid APG,5320.43,,,5320.43,Other,225% New York Medicaid APG,3617.89,,,3617.89,Other,153% New York Medicaid APG,5320.43,,,5320.43,Other,225% New York Medicaid APG,3310.49,,,3310.49,Other,140% New York Medicaid APG,5320.43,,,5320.43,Other,225% New York Medicaid APG,6148.05,,,6148.05,Other,260% New York Medicaid APG,7661.42,,,7661.42,Other,324% New York Medicaid APG,5083.97,,,5083.97,Other,215% New York Medicaid APG,5083.97,,,5083.97,Other,215% New York Medicaid APG,2955.8,,,2955.8,Other,125% New York Medicaid APG,2053,28070.53,
Control of nosebleed,30901,CPT,,,,,,,,both,,,11865.24,8780.28,74,,8780.28,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,5339.36,45,,5339.36,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,5873.29,49.5,,5873.29,percent of total billed charges,110% of Medicare,8068.36,68,,8068.36,percent of total billed charges,,423.06,,,423.06,Other,186% of Medicaid,9492.19,80,,9492.19,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,9492.19,80,,9492.19,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,8305.67,70,,8305.67,percent of total billed charges,,277.16,,,277.16,Fee Schedule,,234.91,,,234.91,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,227.45,,,227.45,Other,New York Medicaid APG methodology,227.45,,,227.45,Other,100% New York Medicaid APG,227.45,,,227.45,Other,100% New York Medicaid APG,227.45,,,227.45,Other,100% New York Medicaid APG,511.76,,,511.76,Other,225% New York Medicaid APG,348,,,348,Other,153% New York Medicaid APG,511.76,,,511.76,Other,225% New York Medicaid APG,318.43,,,318.43,Other,140% New York Medicaid APG,511.76,,,511.76,Other,225% New York Medicaid APG,591.37,,,591.37,Other,260% New York Medicaid APG,736.94,,,736.94,Other,324% New York Medicaid APG,489.02,,,489.02,Other,215% New York Medicaid APG,489.02,,,489.02,Other,215% New York Medicaid APG,284.31,,,284.31,Other,125% New York Medicaid APG,227.45,9492.19,
Control of nosebleed,30903,CPT,,,,,,,,both,,,2686.86,1988.28,74,,1988.28,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,1209.09,45,,1209.09,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,1330,49.5,,1330,percent of total billed charges,110% of Medicare,1827.06,68,,1827.06,percent of total billed charges,,423.06,,,423.06,Other,186% of Medicaid,2149.49,80,,2149.49,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,2149.49,80,,2149.49,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,1880.8,70,,1880.8,percent of total billed charges,,378.84,,,378.84,Fee Schedule,,321.09,,,321.09,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,227.45,,,227.45,Other,New York Medicaid APG methodology,227.45,,,227.45,Other,100% New York Medicaid APG,227.45,,,227.45,Other,100% New York Medicaid APG,227.45,,,227.45,Other,100% New York Medicaid APG,511.76,,,511.76,Other,225% New York Medicaid APG,348,,,348,Other,153% New York Medicaid APG,511.76,,,511.76,Other,225% New York Medicaid APG,318.43,,,318.43,Other,140% New York Medicaid APG,511.76,,,511.76,Other,225% New York Medicaid APG,591.37,,,591.37,Other,260% New York Medicaid APG,736.94,,,736.94,Other,324% New York Medicaid APG,489.02,,,489.02,Other,215% New York Medicaid APG,489.02,,,489.02,Other,215% New York Medicaid APG,284.31,,,284.31,Other,125% New York Medicaid APG,227.45,7216,
Control of nosebleed,30905,CPT,,,,,,,,both,,,2686.86,1988.28,74,,1988.28,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,1209.09,45,,1209.09,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,1330,49.5,,1330,percent of total billed charges,110% of Medicare,1827.06,68,,1827.06,percent of total billed charges,,423.06,,,423.06,Other,186% of Medicaid,2149.49,80,,2149.49,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,2149.49,80,,2149.49,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,1880.8,70,,1880.8,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,227.45,,,227.45,Other,New York Medicaid APG methodology,227.45,,,227.45,Other,100% New York Medicaid APG,227.45,,,227.45,Other,100% New York Medicaid APG,227.45,,,227.45,Other,100% New York Medicaid APG,511.76,,,511.76,Other,225% New York Medicaid APG,348,,,348,Other,153% New York Medicaid APG,511.76,,,511.76,Other,225% New York Medicaid APG,318.43,,,318.43,Other,140% New York Medicaid APG,511.76,,,511.76,Other,225% New York Medicaid APG,591.37,,,591.37,Other,260% New York Medicaid APG,736.94,,,736.94,Other,324% New York Medicaid APG,489.02,,,489.02,Other,215% New York Medicaid APG,489.02,,,489.02,Other,215% New York Medicaid APG,284.31,,,284.31,Other,125% New York Medicaid APG,227.45,7216,
Repeat control of nosebleed,30906,CPT,,,,,,,,both,,,5137.73,3801.92,74,,3801.92,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,2311.98,45,,2311.98,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,2543.18,49.5,,2543.18,percent of total billed charges,110% of Medicare,3493.66,68,,3493.66,percent of total billed charges,,423.06,,,423.06,Other,186% of Medicaid,4110.18,80,,4110.18,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,4110.18,80,,4110.18,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,3596.41,70,,3596.41,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,227.45,,,227.45,Other,New York Medicaid APG methodology,227.45,,,227.45,Other,100% New York Medicaid APG,227.45,,,227.45,Other,100% New York Medicaid APG,227.45,,,227.45,Other,100% New York Medicaid APG,511.76,,,511.76,Other,225% New York Medicaid APG,348,,,348,Other,153% New York Medicaid APG,511.76,,,511.76,Other,225% New York Medicaid APG,318.43,,,318.43,Other,140% New York Medicaid APG,511.76,,,511.76,Other,225% New York Medicaid APG,591.37,,,591.37,Other,260% New York Medicaid APG,736.94,,,736.94,Other,324% New York Medicaid APG,489.02,,,489.02,Other,215% New York Medicaid APG,489.02,,,489.02,Other,215% New York Medicaid APG,284.31,,,284.31,Other,125% New York Medicaid APG,227.45,7216,
Ligation nasal sinus artery,30915,CPT,,,,,,,,both,,,67044.74,49613.11,74,,49613.11,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30170.13,45,,30170.13,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33187.15,49.5,,33187.15,percent of total billed charges,110% of Medicare,45590.42,68,,45590.42,percent of total billed charges,,4418.36,,,4418.36,Other,186% of Medicaid,53635.79,80,,53635.79,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,53635.79,80,,53635.79,percent of total billed charges,,7216,,,7216,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,46931.32,70,,46931.32,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,2375.46,,,2375.46,Other,New York Medicaid APG methodology,2375.46,,,2375.46,Other,100% New York Medicaid APG,2375.46,,,2375.46,Other,100% New York Medicaid APG,2375.46,,,2375.46,Other,100% New York Medicaid APG,5344.79,,,5344.79,Other,225% New York Medicaid APG,3634.45,,,3634.45,Other,153% New York Medicaid APG,5344.79,,,5344.79,Other,225% New York Medicaid APG,3325.64,,,3325.64,Other,140% New York Medicaid APG,5344.79,,,5344.79,Other,225% New York Medicaid APG,6176.2,,,6176.2,Other,260% New York Medicaid APG,7696.49,,,7696.49,Other,324% New York Medicaid APG,5107.24,,,5107.24,Other,215% New York Medicaid APG,5107.24,,,5107.24,Other,215% New York Medicaid APG,2969.33,,,2969.33,Other,125% New York Medicaid APG,2232,53635.79,
Ligation upper jaw artery,30920,CPT,,,,,,,,both,,,67044.74,49613.11,74,,49613.11,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30170.13,45,,30170.13,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33187.15,49.5,,33187.15,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,4418.36,,,4418.36,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,46931.32,70,,46931.32,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,2375.46,,,2375.46,Other,New York Medicaid APG methodology,2375.46,,,2375.46,Other,100% New York Medicaid APG,2375.46,,,2375.46,Other,100% New York Medicaid APG,2375.46,,,2375.46,Other,100% New York Medicaid APG,5344.79,,,5344.79,Other,225% New York Medicaid APG,3634.45,,,3634.45,Other,153% New York Medicaid APG,5344.79,,,5344.79,Other,225% New York Medicaid APG,3325.64,,,3325.64,Other,140% New York Medicaid APG,5344.79,,,5344.79,Other,225% New York Medicaid APG,6176.2,,,6176.2,Other,260% New York Medicaid APG,7696.49,,,7696.49,Other,324% New York Medicaid APG,5107.24,,,5107.24,Other,215% New York Medicaid APG,5107.24,,,5107.24,Other,215% New York Medicaid APG,2969.33,,,2969.33,Other,125% New York Medicaid APG,2375.46,49613.11,
Ther fx nasal inf turbinate,30930,CPT,,,,,,,,both,,,36197.05,26785.82,74,,26785.82,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,16288.67,45,,16288.67,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,17917.54,49.5,,17917.54,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,4398.22,,,4398.22,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,25337.94,70,,25337.94,percent of total billed charges,,582.2,,,582.2,Fee Schedule,,493.45,,,493.45,Fee Schedule,,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,2364.64,,,2364.64,Other,New York Medicaid APG methodology,2364.64,,,2364.64,Other,100% New York Medicaid APG,2364.64,,,2364.64,Other,100% New York Medicaid APG,2364.64,,,2364.64,Other,100% New York Medicaid APG,5320.43,,,5320.43,Other,225% New York Medicaid APG,3617.89,,,3617.89,Other,153% New York Medicaid APG,5320.43,,,5320.43,Other,225% New York Medicaid APG,3310.49,,,3310.49,Other,140% New York Medicaid APG,5320.43,,,5320.43,Other,225% New York Medicaid APG,6148.05,,,6148.05,Other,260% New York Medicaid APG,7661.42,,,7661.42,Other,324% New York Medicaid APG,5083.97,,,5083.97,Other,215% New York Medicaid APG,5083.97,,,5083.97,Other,215% New York Medicaid APG,2955.8,,,2955.8,Other,125% New York Medicaid APG,493.45,26785.82,
Irrigation maxillary sinus,31000,CPT,,,,,,,,both,,,5137.73,3801.92,74,,3801.92,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,2311.98,45,,2311.98,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,2543.18,49.5,,2543.18,percent of total billed charges,110% of Medicare,3493.66,68,,3493.66,percent of total billed charges,,2256.57,,,2256.57,Other,186% of Medicaid,4110.18,80,,4110.18,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,4110.18,80,,4110.18,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,3596.41,70,,3596.41,percent of total billed charges,,544.48,,,544.48,Fee Schedule,,461.48,,,461.48,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,1213.21,,,1213.21,Other,New York Medicaid APG methodology,1213.21,,,1213.21,Other,100% New York Medicaid APG,1213.21,,,1213.21,Other,100% New York Medicaid APG,1213.21,,,1213.21,Other,100% New York Medicaid APG,2729.72,,,2729.72,Other,225% New York Medicaid APG,1856.21,,,1856.21,Other,153% New York Medicaid APG,2729.72,,,2729.72,Other,225% New York Medicaid APG,1698.49,,,1698.49,Other,140% New York Medicaid APG,2729.72,,,2729.72,Other,225% New York Medicaid APG,3154.34,,,3154.34,Other,260% New York Medicaid APG,3930.79,,,3930.79,Other,324% New York Medicaid APG,2608.4,,,2608.4,Other,215% New York Medicaid APG,2608.4,,,2608.4,Other,215% New York Medicaid APG,1516.51,,,1516.51,Other,125% New York Medicaid APG,461.48,7216,
Irrigation sphenoid sinus,31002,CPT,,,,,,,,both,,,32077.39,23737.27,74,,23737.27,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,14434.83,45,,14434.83,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,15878.31,49.5,,15878.31,percent of total billed charges,110% of Medicare,21812.63,68,,21812.63,percent of total billed charges,,423.06,,,423.06,Other,186% of Medicaid,25661.91,80,,25661.91,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,25661.91,80,,25661.91,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,22454.17,70,,22454.17,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,227.45,,,227.45,Other,New York Medicaid APG methodology,227.45,,,227.45,Other,100% New York Medicaid APG,227.45,,,227.45,Other,100% New York Medicaid APG,227.45,,,227.45,Other,100% New York Medicaid APG,511.76,,,511.76,Other,225% New York Medicaid APG,348,,,348,Other,153% New York Medicaid APG,511.76,,,511.76,Other,225% New York Medicaid APG,318.43,,,318.43,Other,140% New York Medicaid APG,511.76,,,511.76,Other,225% New York Medicaid APG,591.37,,,591.37,Other,260% New York Medicaid APG,736.94,,,736.94,Other,324% New York Medicaid APG,489.02,,,489.02,Other,215% New York Medicaid APG,489.02,,,489.02,Other,215% New York Medicaid APG,284.31,,,284.31,Other,125% New York Medicaid APG,227.45,25661.91,
Exploration maxillary sinus,31020,CPT,,,,,,,,both,,,67720.49,50113.16,74,,50113.16,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30474.22,45,,30474.22,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,33521.64,49.5,,33521.64,percent of total billed charges,110% of Medicare,46049.93,68,,46049.93,percent of total billed charges,,2256.57,,,2256.57,Other,186% of Medicaid,54176.39,80,,54176.39,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,54176.39,80,,54176.39,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,47404.34,70,,47404.34,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1213.21,,,1213.21,Other,New York Medicaid APG methodology,1213.21,,,1213.21,Other,100% New York Medicaid APG,1213.21,,,1213.21,Other,100% New York Medicaid APG,1213.21,,,1213.21,Other,100% New York Medicaid APG,2729.72,,,2729.72,Other,225% New York Medicaid APG,1856.21,,,1856.21,Other,153% New York Medicaid APG,2729.72,,,2729.72,Other,225% New York Medicaid APG,1698.49,,,1698.49,Other,140% New York Medicaid APG,2729.72,,,2729.72,Other,225% New York Medicaid APG,3154.34,,,3154.34,Other,260% New York Medicaid APG,3930.79,,,3930.79,Other,324% New York Medicaid APG,2608.4,,,2608.4,Other,215% New York Medicaid APG,2608.4,,,2608.4,Other,215% New York Medicaid APG,1516.51,,,1516.51,Other,125% New York Medicaid APG,1213.21,54176.39,
Exploration maxillary sinus,31030,CPT,,,,,,,,both,,,123177.14,91151.08,74,,91151.08,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,55429.71,45,,55429.71,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,60972.68,49.5,,60972.68,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,4119.28,,,4119.28,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,86224,70,,86224,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,2214.67,,,2214.67,Other,New York Medicaid APG methodology,2214.67,,,2214.67,Other,100% New York Medicaid APG,2214.67,,,2214.67,Other,100% New York Medicaid APG,2214.67,,,2214.67,Other,100% New York Medicaid APG,4983,,,4983,Other,225% New York Medicaid APG,3388.44,,,3388.44,Other,153% New York Medicaid APG,4983,,,4983,Other,225% New York Medicaid APG,3100.53,,,3100.53,Other,140% New York Medicaid APG,4983,,,4983,Other,225% New York Medicaid APG,5758.13,,,5758.13,Other,260% New York Medicaid APG,7175.52,,,7175.52,Other,324% New York Medicaid APG,4761.53,,,4761.53,Other,215% New York Medicaid APG,4761.53,,,4761.53,Other,215% New York Medicaid APG,2768.33,,,2768.33,Other,125% New York Medicaid APG,2214.67,91151.08,
Explore sinus remove polyps,31032,CPT,,,,,,,,both,,,123177.14,91151.08,74,,91151.08,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,55429.71,45,,55429.71,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,60972.68,49.5,,60972.68,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,4119.28,,,4119.28,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,86224,70,,86224,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,2214.67,,,2214.67,Other,New York Medicaid APG methodology,2214.67,,,2214.67,Other,100% New York Medicaid APG,2214.67,,,2214.67,Other,100% New York Medicaid APG,2214.67,,,2214.67,Other,100% New York Medicaid APG,4983,,,4983,Other,225% New York Medicaid APG,3388.44,,,3388.44,Other,153% New York Medicaid APG,4983,,,4983,Other,225% New York Medicaid APG,3100.53,,,3100.53,Other,140% New York Medicaid APG,4983,,,4983,Other,225% New York Medicaid APG,5758.13,,,5758.13,Other,260% New York Medicaid APG,7175.52,,,7175.52,Other,324% New York Medicaid APG,4761.53,,,4761.53,Other,215% New York Medicaid APG,4761.53,,,4761.53,Other,215% New York Medicaid APG,2768.33,,,2768.33,Other,125% New York Medicaid APG,2214.67,91151.08,
Exploration behind upper jaw,31040,CPT,,,,,,,,both,,,123177.14,91151.08,74,,91151.08,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,55429.71,45,,55429.71,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,60972.68,49.5,,60972.68,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5482.74,,,5482.74,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,86224,70,,86224,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,2947.71,,,2947.71,Other,New York Medicaid APG methodology,2947.71,,,2947.71,Other,100% New York Medicaid APG,2947.71,,,2947.71,Other,100% New York Medicaid APG,2947.71,,,2947.71,Other,100% New York Medicaid APG,6632.35,,,6632.35,Other,225% New York Medicaid APG,4510,,,4510,Other,153% New York Medicaid APG,6632.35,,,6632.35,Other,225% New York Medicaid APG,4126.79,,,4126.79,Other,140% New York Medicaid APG,6632.35,,,6632.35,Other,225% New York Medicaid APG,7664.04,,,7664.04,Other,260% New York Medicaid APG,9550.58,,,9550.58,Other,324% New York Medicaid APG,6337.58,,,6337.58,Other,215% New York Medicaid APG,6337.58,,,6337.58,Other,215% New York Medicaid APG,3684.64,,,3684.64,Other,125% New York Medicaid APG,2947.71,91151.08,
Exploration sphenoid sinus,31050,CPT,,,,,,,,both,,,123177.14,91151.08,74,,91151.08,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,55429.71,45,,55429.71,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,60972.68,49.5,,60972.68,percent of total billed charges,110% of Medicare,83760.46,68,,83760.46,percent of total billed charges,,4119.28,,,4119.28,Other,186% of Medicaid,98541.71,80,,98541.71,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,98541.71,80,,98541.71,percent of total billed charges,,7216,,,7216,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,86224,70,,86224,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,2214.67,,,2214.67,Other,New York Medicaid APG methodology,2214.67,,,2214.67,Other,100% New York Medicaid APG,2214.67,,,2214.67,Other,100% New York Medicaid APG,2214.67,,,2214.67,Other,100% New York Medicaid APG,4983,,,4983,Other,225% New York Medicaid APG,3388.44,,,3388.44,Other,153% New York Medicaid APG,4983,,,4983,Other,225% New York Medicaid APG,3100.53,,,3100.53,Other,140% New York Medicaid APG,4983,,,4983,Other,225% New York Medicaid APG,5758.13,,,5758.13,Other,260% New York Medicaid APG,7175.52,,,7175.52,Other,324% New York Medicaid APG,4761.53,,,4761.53,Other,215% New York Medicaid APG,4761.53,,,4761.53,Other,215% New York Medicaid APG,2768.33,,,2768.33,Other,125% New York Medicaid APG,2214.67,98541.71,
Sphenoid sinus surgery,31051,CPT,,,,,,,,both,,,123177.14,91151.08,74,,91151.08,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,55429.71,45,,55429.71,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,60972.68,49.5,,60972.68,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,4119.28,,,4119.28,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,86224,70,,86224,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,2214.67,,,2214.67,Other,New York Medicaid APG methodology,2214.67,,,2214.67,Other,100% New York Medicaid APG,2214.67,,,2214.67,Other,100% New York Medicaid APG,2214.67,,,2214.67,Other,100% New York Medicaid APG,4983,,,4983,Other,225% New York Medicaid APG,3388.44,,,3388.44,Other,153% New York Medicaid APG,4983,,,4983,Other,225% New York Medicaid APG,3100.53,,,3100.53,Other,140% New York Medicaid APG,4983,,,4983,Other,225% New York Medicaid APG,5758.13,,,5758.13,Other,260% New York Medicaid APG,7175.52,,,7175.52,Other,324% New York Medicaid APG,4761.53,,,4761.53,Other,215% New York Medicaid APG,4761.53,,,4761.53,Other,215% New York Medicaid APG,2768.33,,,2768.33,Other,125% New York Medicaid APG,2214.67,91151.08,
Exploration of frontal sinus,31070,CPT,,,,,,,,both,,,123177.14,91151.08,74,,91151.08,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,55429.71,45,,55429.71,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,60972.68,49.5,,60972.68,percent of total billed charges,110% of Medicare,83760.46,68,,83760.46,percent of total billed charges,,4119.28,,,4119.28,Other,186% of Medicaid,98541.71,80,,98541.71,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,98541.71,80,,98541.71,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,86224,70,,86224,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,2214.67,,,2214.67,Other,New York Medicaid APG methodology,2214.67,,,2214.67,Other,100% New York Medicaid APG,2214.67,,,2214.67,Other,100% New York Medicaid APG,2214.67,,,2214.67,Other,100% New York Medicaid APG,4983,,,4983,Other,225% New York Medicaid APG,3388.44,,,3388.44,Other,153% New York Medicaid APG,4983,,,4983,Other,225% New York Medicaid APG,3100.53,,,3100.53,Other,140% New York Medicaid APG,4983,,,4983,Other,225% New York Medicaid APG,5758.13,,,5758.13,Other,260% New York Medicaid APG,7175.52,,,7175.52,Other,324% New York Medicaid APG,4761.53,,,4761.53,Other,215% New York Medicaid APG,4761.53,,,4761.53,Other,215% New York Medicaid APG,2768.33,,,2768.33,Other,125% New York Medicaid APG,2214.67,98541.71,
Exploration of frontal sinus,31075,CPT,,,,,,,,both,,,123177.14,91151.08,74,,91151.08,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,55429.71,45,,55429.71,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,60972.68,49.5,,60972.68,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,4119.28,,,4119.28,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,86224,70,,86224,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,2214.67,,,2214.67,Other,New York Medicaid APG methodology,2214.67,,,2214.67,Other,100% New York Medicaid APG,2214.67,,,2214.67,Other,100% New York Medicaid APG,2214.67,,,2214.67,Other,100% New York Medicaid APG,4983,,,4983,Other,225% New York Medicaid APG,3388.44,,,3388.44,Other,153% New York Medicaid APG,4983,,,4983,Other,225% New York Medicaid APG,3100.53,,,3100.53,Other,140% New York Medicaid APG,4983,,,4983,Other,225% New York Medicaid APG,5758.13,,,5758.13,Other,260% New York Medicaid APG,7175.52,,,7175.52,Other,324% New York Medicaid APG,4761.53,,,4761.53,Other,215% New York Medicaid APG,4761.53,,,4761.53,Other,215% New York Medicaid APG,2768.33,,,2768.33,Other,125% New York Medicaid APG,2214.67,91151.08,
Removal of frontal sinus,31080,CPT,,,,,,,,both,,,123177.14,91151.08,74,,91151.08,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,55429.71,45,,55429.71,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,60972.68,49.5,,60972.68,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5841.74,,,5841.74,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,86224,70,,86224,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,3140.72,,,3140.72,Other,New York Medicaid APG methodology,3140.72,,,3140.72,Other,100% New York Medicaid APG,3140.72,,,3140.72,Other,100% New York Medicaid APG,3140.72,,,3140.72,Other,100% New York Medicaid APG,7066.62,,,7066.62,Other,225% New York Medicaid APG,4805.3,,,4805.3,Other,153% New York Medicaid APG,7066.62,,,7066.62,Other,225% New York Medicaid APG,4397.01,,,4397.01,Other,140% New York Medicaid APG,7066.62,,,7066.62,Other,225% New York Medicaid APG,8165.87,,,8165.87,Other,260% New York Medicaid APG,10175.93,,,10175.93,Other,324% New York Medicaid APG,6752.54,,,6752.54,Other,215% New York Medicaid APG,6752.54,,,6752.54,Other,215% New York Medicaid APG,3925.9,,,3925.9,Other,125% New York Medicaid APG,3140.72,91151.08,
Removal of frontal sinus,31081,CPT,,,,,,,,both,,,123177.14,91151.08,74,,91151.08,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,55429.71,45,,55429.71,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,60972.68,49.5,,60972.68,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5482.74,,,5482.74,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,86224,70,,86224,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,2947.71,,,2947.71,Other,New York Medicaid APG methodology,2947.71,,,2947.71,Other,100% New York Medicaid APG,2947.71,,,2947.71,Other,100% New York Medicaid APG,2947.71,,,2947.71,Other,100% New York Medicaid APG,6632.35,,,6632.35,Other,225% New York Medicaid APG,4510,,,4510,Other,153% New York Medicaid APG,6632.35,,,6632.35,Other,225% New York Medicaid APG,4126.79,,,4126.79,Other,140% New York Medicaid APG,6632.35,,,6632.35,Other,225% New York Medicaid APG,7664.04,,,7664.04,Other,260% New York Medicaid APG,9550.58,,,9550.58,Other,324% New York Medicaid APG,6337.58,,,6337.58,Other,215% New York Medicaid APG,6337.58,,,6337.58,Other,215% New York Medicaid APG,3684.64,,,3684.64,Other,125% New York Medicaid APG,2947.71,91151.08,
Removal of frontal sinus,31084,CPT,,,,,,,,both,,,123177.14,91151.08,74,,91151.08,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,55429.71,45,,55429.71,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,60972.68,49.5,,60972.68,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,4119.28,,,4119.28,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,86224,70,,86224,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,2214.67,,,2214.67,Other,New York Medicaid APG methodology,2214.67,,,2214.67,Other,100% New York Medicaid APG,2214.67,,,2214.67,Other,100% New York Medicaid APG,2214.67,,,2214.67,Other,100% New York Medicaid APG,4983,,,4983,Other,225% New York Medicaid APG,3388.44,,,3388.44,Other,153% New York Medicaid APG,4983,,,4983,Other,225% New York Medicaid APG,3100.53,,,3100.53,Other,140% New York Medicaid APG,4983,,,4983,Other,225% New York Medicaid APG,5758.13,,,5758.13,Other,260% New York Medicaid APG,7175.52,,,7175.52,Other,324% New York Medicaid APG,4761.53,,,4761.53,Other,215% New York Medicaid APG,4761.53,,,4761.53,Other,215% New York Medicaid APG,2768.33,,,2768.33,Other,125% New York Medicaid APG,2214.67,91151.08,
Removal of frontal sinus,31085,CPT,,,,,,,,both,,,123177.14,91151.08,74,,91151.08,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,55429.71,45,,55429.71,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,60972.68,49.5,,60972.68,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5841.74,,,5841.74,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,86224,70,,86224,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,3140.72,,,3140.72,Other,New York Medicaid APG methodology,3140.72,,,3140.72,Other,100% New York Medicaid APG,3140.72,,,3140.72,Other,100% New York Medicaid APG,3140.72,,,3140.72,Other,100% New York Medicaid APG,7066.62,,,7066.62,Other,225% New York Medicaid APG,4805.3,,,4805.3,Other,153% New York Medicaid APG,7066.62,,,7066.62,Other,225% New York Medicaid APG,4397.01,,,4397.01,Other,140% New York Medicaid APG,7066.62,,,7066.62,Other,225% New York Medicaid APG,8165.87,,,8165.87,Other,260% New York Medicaid APG,10175.93,,,10175.93,Other,324% New York Medicaid APG,6752.54,,,6752.54,Other,215% New York Medicaid APG,6752.54,,,6752.54,Other,215% New York Medicaid APG,3925.9,,,3925.9,Other,125% New York Medicaid APG,3140.72,91151.08,
Removal of frontal sinus,31086,CPT,,,,,,,,both,,,123177.14,91151.08,74,,91151.08,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,55429.71,45,,55429.71,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,60972.68,49.5,,60972.68,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5841.74,,,5841.74,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,86224,70,,86224,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,3140.72,,,3140.72,Other,New York Medicaid APG methodology,3140.72,,,3140.72,Other,100% New York Medicaid APG,3140.72,,,3140.72,Other,100% New York Medicaid APG,3140.72,,,3140.72,Other,100% New York Medicaid APG,7066.62,,,7066.62,Other,225% New York Medicaid APG,4805.3,,,4805.3,Other,153% New York Medicaid APG,7066.62,,,7066.62,Other,225% New York Medicaid APG,4397.01,,,4397.01,Other,140% New York Medicaid APG,7066.62,,,7066.62,Other,225% New York Medicaid APG,8165.87,,,8165.87,Other,260% New York Medicaid APG,10175.93,,,10175.93,Other,324% New York Medicaid APG,6752.54,,,6752.54,Other,215% New York Medicaid APG,6752.54,,,6752.54,Other,215% New York Medicaid APG,3925.9,,,3925.9,Other,125% New York Medicaid APG,3140.72,91151.08,
Removal of frontal sinus,31087,CPT,,,,,,,,both,,,123177.14,91151.08,74,,91151.08,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,55429.71,45,,55429.71,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,60972.68,49.5,,60972.68,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,4119.28,,,4119.28,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,86224,70,,86224,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,2214.67,,,2214.67,Other,New York Medicaid APG methodology,2214.67,,,2214.67,Other,100% New York Medicaid APG,2214.67,,,2214.67,Other,100% New York Medicaid APG,2214.67,,,2214.67,Other,100% New York Medicaid APG,4983,,,4983,Other,225% New York Medicaid APG,3388.44,,,3388.44,Other,153% New York Medicaid APG,4983,,,4983,Other,225% New York Medicaid APG,3100.53,,,3100.53,Other,140% New York Medicaid APG,4983,,,4983,Other,225% New York Medicaid APG,5758.13,,,5758.13,Other,260% New York Medicaid APG,7175.52,,,7175.52,Other,324% New York Medicaid APG,4761.53,,,4761.53,Other,215% New York Medicaid APG,4761.53,,,4761.53,Other,215% New York Medicaid APG,2768.33,,,2768.33,Other,125% New York Medicaid APG,2214.67,91151.08,
Exploration of sinuses,31090,CPT,,,,,,,,both,,,123177.14,91151.08,74,,91151.08,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,55429.71,45,,55429.71,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,60972.68,49.5,,60972.68,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,4119.28,,,4119.28,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,86224,70,,86224,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,2214.67,,,2214.67,Other,New York Medicaid APG methodology,2214.67,,,2214.67,Other,100% New York Medicaid APG,2214.67,,,2214.67,Other,100% New York Medicaid APG,2214.67,,,2214.67,Other,100% New York Medicaid APG,4983,,,4983,Other,225% New York Medicaid APG,3388.44,,,3388.44,Other,153% New York Medicaid APG,4983,,,4983,Other,225% New York Medicaid APG,3100.53,,,3100.53,Other,140% New York Medicaid APG,4983,,,4983,Other,225% New York Medicaid APG,5758.13,,,5758.13,Other,260% New York Medicaid APG,7175.52,,,7175.52,Other,324% New York Medicaid APG,4761.53,,,4761.53,Other,215% New York Medicaid APG,4761.53,,,4761.53,Other,215% New York Medicaid APG,2768.33,,,2768.33,Other,125% New York Medicaid APG,2214.67,91151.08,
Removal of ethmoid sinus,31200,CPT,,,,,,,,both,,,123177.14,91151.08,74,,91151.08,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,55429.71,45,,55429.71,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,60972.68,49.5,,60972.68,percent of total billed charges,110% of Medicare,83760.46,68,,83760.46,percent of total billed charges,,4119.28,,,4119.28,Other,186% of Medicaid,98541.71,80,,98541.71,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,98541.71,80,,98541.71,percent of total billed charges,,7216,,,7216,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,86224,70,,86224,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,2214.67,,,2214.67,Other,New York Medicaid APG methodology,2214.67,,,2214.67,Other,100% New York Medicaid APG,2214.67,,,2214.67,Other,100% New York Medicaid APG,2214.67,,,2214.67,Other,100% New York Medicaid APG,4983,,,4983,Other,225% New York Medicaid APG,3388.44,,,3388.44,Other,153% New York Medicaid APG,4983,,,4983,Other,225% New York Medicaid APG,3100.53,,,3100.53,Other,140% New York Medicaid APG,4983,,,4983,Other,225% New York Medicaid APG,5758.13,,,5758.13,Other,260% New York Medicaid APG,7175.52,,,7175.52,Other,324% New York Medicaid APG,4761.53,,,4761.53,Other,215% New York Medicaid APG,4761.53,,,4761.53,Other,215% New York Medicaid APG,2768.33,,,2768.33,Other,125% New York Medicaid APG,2214.67,98541.71,
Removal of ethmoid sinus,31201,CPT,,,,,,,,both,,,32077.39,23737.27,74,,23737.27,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,14434.83,45,,14434.83,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,15878.31,49.5,,15878.31,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2965.83,,,2965.83,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,22454.17,70,,22454.17,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1594.53,,,1594.53,Other,New York Medicaid APG methodology,1594.53,,,1594.53,Other,100% New York Medicaid APG,1594.53,,,1594.53,Other,100% New York Medicaid APG,1594.53,,,1594.53,Other,100% New York Medicaid APG,3587.7,,,3587.7,Other,225% New York Medicaid APG,2439.64,,,2439.64,Other,153% New York Medicaid APG,3587.7,,,3587.7,Other,225% New York Medicaid APG,2232.35,,,2232.35,Other,140% New York Medicaid APG,3587.7,,,3587.7,Other,225% New York Medicaid APG,4145.78,,,4145.78,Other,260% New York Medicaid APG,5166.29,,,5166.29,Other,324% New York Medicaid APG,3428.25,,,3428.25,Other,215% New York Medicaid APG,3428.25,,,3428.25,Other,215% New York Medicaid APG,1993.17,,,1993.17,Other,125% New York Medicaid APG,1594.53,23737.27,
Removal of ethmoid sinus,31205,CPT,,,,,,,,both,,,67720.49,50113.16,74,,50113.16,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30474.22,45,,30474.22,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,33521.64,49.5,,33521.64,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2965.83,,,2965.83,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,47404.34,70,,47404.34,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1594.53,,,1594.53,Other,New York Medicaid APG methodology,1594.53,,,1594.53,Other,100% New York Medicaid APG,1594.53,,,1594.53,Other,100% New York Medicaid APG,1594.53,,,1594.53,Other,100% New York Medicaid APG,3587.7,,,3587.7,Other,225% New York Medicaid APG,2439.64,,,2439.64,Other,153% New York Medicaid APG,3587.7,,,3587.7,Other,225% New York Medicaid APG,2232.35,,,2232.35,Other,140% New York Medicaid APG,3587.7,,,3587.7,Other,225% New York Medicaid APG,4145.78,,,4145.78,Other,260% New York Medicaid APG,5166.29,,,5166.29,Other,324% New York Medicaid APG,3428.25,,,3428.25,Other,215% New York Medicaid APG,3428.25,,,3428.25,Other,215% New York Medicaid APG,1993.17,,,1993.17,Other,125% New York Medicaid APG,1594.53,50113.16,
Nasal endoscopy dx,31231,CPT,,,,,,,,both,,,35228.49,26069.08,74,,26069.08,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15852.82,45,,15852.82,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,17438.1,49.5,,17438.1,percent of total billed charges,110% of Medicare,23955.37,68,,23955.37,percent of total billed charges,,423.06,,,423.06,Other,186% of Medicaid,28182.79,80,,28182.79,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,28182.79,80,,28182.79,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,24659.94,70,,24659.94,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,227.45,,,227.45,Other,New York Medicaid APG methodology,227.45,,,227.45,Other,100% New York Medicaid APG,227.45,,,227.45,Other,100% New York Medicaid APG,227.45,,,227.45,Other,100% New York Medicaid APG,511.76,,,511.76,Other,225% New York Medicaid APG,348,,,348,Other,153% New York Medicaid APG,511.76,,,511.76,Other,225% New York Medicaid APG,318.43,,,318.43,Other,140% New York Medicaid APG,511.76,,,511.76,Other,225% New York Medicaid APG,591.37,,,591.37,Other,260% New York Medicaid APG,736.94,,,736.94,Other,324% New York Medicaid APG,489.02,,,489.02,Other,215% New York Medicaid APG,489.02,,,489.02,Other,215% New York Medicaid APG,284.31,,,284.31,Other,125% New York Medicaid APG,227.45,28182.79,
Nsl/sins ndsc dx max sinusc,31233,CPT,,,,,,,,both,,,8588.63,6355.59,74,,6355.59,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,3864.88,45,,3864.88,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,4251.37,49.5,,4251.37,percent of total billed charges,110% of Medicare,5840.27,68,,5840.27,percent of total billed charges,,831.59,,,831.59,Other,186% of Medicaid,6870.9,80,,6870.9,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,6870.9,80,,6870.9,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,6012.04,70,,6012.04,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,447.09,,,447.09,Other,New York Medicaid APG methodology,447.09,,,447.09,Other,100% New York Medicaid APG,447.09,,,447.09,Other,100% New York Medicaid APG,447.09,,,447.09,Other,100% New York Medicaid APG,1005.95,,,1005.95,Other,225% New York Medicaid APG,684.05,,,684.05,Other,153% New York Medicaid APG,1005.95,,,1005.95,Other,225% New York Medicaid APG,625.92,,,625.92,Other,140% New York Medicaid APG,1005.95,,,1005.95,Other,225% New York Medicaid APG,1162.43,,,1162.43,Other,260% New York Medicaid APG,1448.57,,,1448.57,Other,324% New York Medicaid APG,961.24,,,961.24,Other,215% New York Medicaid APG,961.24,,,961.24,Other,215% New York Medicaid APG,558.86,,,558.86,Other,125% New York Medicaid APG,447.09,7216,
Nsl/sins ndsc dx sphn sinusc,31235,CPT,,,,,,,,both,,,35699.83,26417.87,74,,26417.87,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,16064.92,45,,16064.92,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,17671.42,49.5,,17671.42,percent of total billed charges,110% of Medicare,24275.88,68,,24275.88,percent of total billed charges,,2982.31,,,2982.31,Other,186% of Medicaid,28559.86,80,,28559.86,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,28559.86,80,,28559.86,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,24989.88,70,,24989.88,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1603.39,,,1603.39,Other,New York Medicaid APG methodology,1603.39,,,1603.39,Other,100% New York Medicaid APG,1603.39,,,1603.39,Other,100% New York Medicaid APG,1603.39,,,1603.39,Other,100% New York Medicaid APG,3607.64,,,3607.64,Other,225% New York Medicaid APG,2453.19,,,2453.19,Other,153% New York Medicaid APG,3607.64,,,3607.64,Other,225% New York Medicaid APG,2244.75,,,2244.75,Other,140% New York Medicaid APG,3607.64,,,3607.64,Other,225% New York Medicaid APG,4168.82,,,4168.82,Other,260% New York Medicaid APG,5195,,,5195,Other,324% New York Medicaid APG,3447.3,,,3447.3,Other,215% New York Medicaid APG,3447.3,,,3447.3,Other,215% New York Medicaid APG,2004.24,,,2004.24,Other,125% New York Medicaid APG,1603.39,28559.86,
Nasal/sinus endoscopy surg,31237,CPT,,,,,,,,both,,,38391.34,28409.59,74,,28409.59,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,17276.1,45,,17276.1,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,19003.71,49.5,,19003.71,percent of total billed charges,110% of Medicare,26106.11,68,,26106.11,percent of total billed charges,,2982.31,,,2982.31,Other,186% of Medicaid,30713.07,80,,30713.07,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,30713.07,80,,30713.07,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,26873.94,70,,26873.94,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1603.39,,,1603.39,Other,New York Medicaid APG methodology,1603.39,,,1603.39,Other,100% New York Medicaid APG,1603.39,,,1603.39,Other,100% New York Medicaid APG,1603.39,,,1603.39,Other,100% New York Medicaid APG,3607.64,,,3607.64,Other,225% New York Medicaid APG,2453.19,,,2453.19,Other,153% New York Medicaid APG,3607.64,,,3607.64,Other,225% New York Medicaid APG,2244.75,,,2244.75,Other,140% New York Medicaid APG,3607.64,,,3607.64,Other,225% New York Medicaid APG,4168.82,,,4168.82,Other,260% New York Medicaid APG,5195,,,5195,Other,324% New York Medicaid APG,3447.3,,,3447.3,Other,215% New York Medicaid APG,3447.3,,,3447.3,Other,215% New York Medicaid APG,2004.24,,,2004.24,Other,125% New York Medicaid APG,1603.39,30713.07,
Nasal/sinus endoscopy surg,31238,CPT,,,,,,,,both,,,37288.61,27593.57,74,,27593.57,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,16779.87,45,,16779.87,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,18457.86,49.5,,18457.86,percent of total billed charges,110% of Medicare,25356.25,68,,25356.25,percent of total billed charges,,2982.31,,,2982.31,Other,186% of Medicaid,29830.89,80,,29830.89,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,29830.89,80,,29830.89,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,26102.03,70,,26102.03,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1603.39,,,1603.39,Other,New York Medicaid APG methodology,1603.39,,,1603.39,Other,100% New York Medicaid APG,1603.39,,,1603.39,Other,100% New York Medicaid APG,1603.39,,,1603.39,Other,100% New York Medicaid APG,3607.64,,,3607.64,Other,225% New York Medicaid APG,2453.19,,,2453.19,Other,153% New York Medicaid APG,3607.64,,,3607.64,Other,225% New York Medicaid APG,2244.75,,,2244.75,Other,140% New York Medicaid APG,3607.64,,,3607.64,Other,225% New York Medicaid APG,4168.82,,,4168.82,Other,260% New York Medicaid APG,5195,,,5195,Other,324% New York Medicaid APG,3447.3,,,3447.3,Other,215% New York Medicaid APG,3447.3,,,3447.3,Other,215% New York Medicaid APG,2004.24,,,2004.24,Other,125% New York Medicaid APG,1603.39,29830.89,
Nasal/sinus endoscopy surg,31239,CPT,,,,,,,,both,,,78767.93,58288.27,74,,58288.27,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,35445.57,45,,35445.57,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,38990.13,49.5,,38990.13,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2982.31,,,2982.31,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,55137.55,70,,55137.55,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1603.39,,,1603.39,Other,New York Medicaid APG methodology,1603.39,,,1603.39,Other,100% New York Medicaid APG,1603.39,,,1603.39,Other,100% New York Medicaid APG,1603.39,,,1603.39,Other,100% New York Medicaid APG,3607.64,,,3607.64,Other,225% New York Medicaid APG,2453.19,,,2453.19,Other,153% New York Medicaid APG,3607.64,,,3607.64,Other,225% New York Medicaid APG,2244.75,,,2244.75,Other,140% New York Medicaid APG,3607.64,,,3607.64,Other,225% New York Medicaid APG,4168.82,,,4168.82,Other,260% New York Medicaid APG,5195,,,5195,Other,324% New York Medicaid APG,3447.3,,,3447.3,Other,215% New York Medicaid APG,3447.3,,,3447.3,Other,215% New York Medicaid APG,2004.24,,,2004.24,Other,125% New York Medicaid APG,1603.39,58288.27,
Nasal/sinus endoscopy surg,31240,CPT,,,,,,,,both,,,35699.83,26417.87,74,,26417.87,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,16064.92,45,,16064.92,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,17671.42,49.5,,17671.42,percent of total billed charges,110% of Medicare,24275.88,68,,24275.88,percent of total billed charges,,831.59,,,831.59,Other,186% of Medicaid,28559.86,80,,28559.86,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,28559.86,80,,28559.86,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,24989.88,70,,24989.88,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,447.09,,,447.09,Other,New York Medicaid APG methodology,447.09,,,447.09,Other,100% New York Medicaid APG,447.09,,,447.09,Other,100% New York Medicaid APG,447.09,,,447.09,Other,100% New York Medicaid APG,1005.95,,,1005.95,Other,225% New York Medicaid APG,684.05,,,684.05,Other,153% New York Medicaid APG,1005.95,,,1005.95,Other,225% New York Medicaid APG,625.92,,,625.92,Other,140% New York Medicaid APG,1005.95,,,1005.95,Other,225% New York Medicaid APG,1162.43,,,1162.43,Other,260% New York Medicaid APG,1448.57,,,1448.57,Other,324% New York Medicaid APG,961.24,,,961.24,Other,215% New York Medicaid APG,961.24,,,961.24,Other,215% New York Medicaid APG,558.86,,,558.86,Other,125% New York Medicaid APG,447.09,28559.86,
Nsl/sins ndsc w/artery lig,31241,CPT,,,,,,,,both,,,35699.83,26417.87,74,,26417.87,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,16064.92,45,,16064.92,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,17671.42,49.5,,17671.42,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2982.31,,,2982.31,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,28559.86,80,,28559.86,percent of total billed charges,,24989.88,70,,24989.88,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1603.39,,,1603.39,Other,New York Medicaid APG methodology,1603.39,,,1603.39,Other,100% New York Medicaid APG,1603.39,,,1603.39,Other,100% New York Medicaid APG,1603.39,,,1603.39,Other,100% New York Medicaid APG,3607.64,,,3607.64,Other,225% New York Medicaid APG,2453.19,,,2453.19,Other,153% New York Medicaid APG,3607.64,,,3607.64,Other,225% New York Medicaid APG,2244.75,,,2244.75,Other,140% New York Medicaid APG,3607.64,,,3607.64,Other,225% New York Medicaid APG,4168.82,,,4168.82,Other,260% New York Medicaid APG,5195,,,5195,Other,324% New York Medicaid APG,3447.3,,,3447.3,Other,215% New York Medicaid APG,3447.3,,,3447.3,Other,215% New York Medicaid APG,2004.24,,,2004.24,Other,125% New York Medicaid APG,1603.39,28559.86,
Nsl/sins ndsc total,31253,CPT,,,,,,,,both,,,39119.74,28948.61,74,,28948.61,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,17603.88,45,,17603.88,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,7266,,"100% primary, 50% secondary, 25% supplemental procedure",7266,Other,Blue Cross ASC Grouper,6539,,"100% primary, 50% secondary, 25% supplemental procedure",6539,Other,Blue Cross ASC Grouper,6176,,"100% primary, 50% secondary, 25% supplemental procedure",6176,Other,Blue Cross ASC Grouper,19364.27,49.5,,19364.27,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5841.74,,,5841.74,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,27383.82,70,,27383.82,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,3140.72,,,3140.72,Other,New York Medicaid APG methodology,3140.72,,,3140.72,Other,100% New York Medicaid APG,3140.72,,,3140.72,Other,100% New York Medicaid APG,3140.72,,,3140.72,Other,100% New York Medicaid APG,7066.62,,,7066.62,Other,225% New York Medicaid APG,4805.3,,,4805.3,Other,153% New York Medicaid APG,7066.62,,,7066.62,Other,225% New York Medicaid APG,4397.01,,,4397.01,Other,140% New York Medicaid APG,7066.62,,,7066.62,Other,225% New York Medicaid APG,8165.87,,,8165.87,Other,260% New York Medicaid APG,10175.93,,,10175.93,Other,324% New York Medicaid APG,6752.54,,,6752.54,Other,215% New York Medicaid APG,6752.54,,,6752.54,Other,215% New York Medicaid APG,3925.9,,,3925.9,Other,125% New York Medicaid APG,3140.72,28948.61,
Nsl/sins ndsc w/prtl ethmdct,31254,CPT,,,,,,,,both,,,38226.57,28287.66,74,,28287.66,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,17201.96,45,,17201.96,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,7266,,"100% primary, 50% secondary, 25% supplemental procedure",7266,Other,Blue Cross ASC Grouper,6539,,"100% primary, 50% secondary, 25% supplemental procedure",6539,Other,Blue Cross ASC Grouper,6176,,"100% primary, 50% secondary, 25% supplemental procedure",6176,Other,Blue Cross ASC Grouper,18922.15,49.5,,18922.15,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2965.83,,,2965.83,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,26758.6,70,,26758.6,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1594.53,,,1594.53,Other,New York Medicaid APG methodology,1594.53,,,1594.53,Other,100% New York Medicaid APG,1594.53,,,1594.53,Other,100% New York Medicaid APG,1594.53,,,1594.53,Other,100% New York Medicaid APG,3587.7,,,3587.7,Other,225% New York Medicaid APG,2439.64,,,2439.64,Other,153% New York Medicaid APG,3587.7,,,3587.7,Other,225% New York Medicaid APG,2232.35,,,2232.35,Other,140% New York Medicaid APG,3587.7,,,3587.7,Other,225% New York Medicaid APG,4145.78,,,4145.78,Other,260% New York Medicaid APG,5166.29,,,5166.29,Other,324% New York Medicaid APG,3428.25,,,3428.25,Other,215% New York Medicaid APG,3428.25,,,3428.25,Other,215% New York Medicaid APG,1993.17,,,1993.17,Other,125% New York Medicaid APG,1594.53,28287.66,
Nsl/sins ndsc w/tot ethmdct,31255,CPT,,,,,,,,both,,,46439.9,34365.53,74,,34365.53,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,20897.96,45,,20897.96,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,7266,,"100% primary, 50% secondary, 25% supplemental procedure",7266,Other,Blue Cross ASC Grouper,6539,,"100% primary, 50% secondary, 25% supplemental procedure",6539,Other,Blue Cross ASC Grouper,6176,,"100% primary, 50% secondary, 25% supplemental procedure",6176,Other,Blue Cross ASC Grouper,22987.75,49.5,,22987.75,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5841.74,,,5841.74,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,32507.93,70,,32507.93,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,3140.72,,,3140.72,Other,New York Medicaid APG methodology,3140.72,,,3140.72,Other,100% New York Medicaid APG,3140.72,,,3140.72,Other,100% New York Medicaid APG,3140.72,,,3140.72,Other,100% New York Medicaid APG,7066.62,,,7066.62,Other,225% New York Medicaid APG,4805.3,,,4805.3,Other,153% New York Medicaid APG,7066.62,,,7066.62,Other,225% New York Medicaid APG,4397.01,,,4397.01,Other,140% New York Medicaid APG,7066.62,,,7066.62,Other,225% New York Medicaid APG,8165.87,,,8165.87,Other,260% New York Medicaid APG,10175.93,,,10175.93,Other,324% New York Medicaid APG,6752.54,,,6752.54,Other,215% New York Medicaid APG,6752.54,,,6752.54,Other,215% New York Medicaid APG,3925.9,,,3925.9,Other,125% New York Medicaid APG,2879,34365.53,
Exploration maxillary sinus,31256,CPT,,,,,,,,both,,,41549.37,30746.53,74,,30746.53,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,18697.22,45,,18697.22,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,20566.94,49.5,,20566.94,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2965.83,,,2965.83,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,29084.56,70,,29084.56,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1594.53,,,1594.53,Other,New York Medicaid APG methodology,1594.53,,,1594.53,Other,100% New York Medicaid APG,1594.53,,,1594.53,Other,100% New York Medicaid APG,1594.53,,,1594.53,Other,100% New York Medicaid APG,3587.7,,,3587.7,Other,225% New York Medicaid APG,2439.64,,,2439.64,Other,153% New York Medicaid APG,3587.7,,,3587.7,Other,225% New York Medicaid APG,2232.35,,,2232.35,Other,140% New York Medicaid APG,3587.7,,,3587.7,Other,225% New York Medicaid APG,4145.78,,,4145.78,Other,260% New York Medicaid APG,5166.29,,,5166.29,Other,324% New York Medicaid APG,3428.25,,,3428.25,Other,215% New York Medicaid APG,3428.25,,,3428.25,Other,215% New York Medicaid APG,1993.17,,,1993.17,Other,125% New York Medicaid APG,1594.53,30746.53,
Nsl/sins ndsc tot w/sphendt,31257,CPT,,,,,,,,both,,,40828.4,30213.02,74,,30213.02,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,18372.78,45,,18372.78,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,7266,,"100% primary, 50% secondary, 25% supplemental procedure",7266,Other,Blue Cross ASC Grouper,6539,,"100% primary, 50% secondary, 25% supplemental procedure",6539,Other,Blue Cross ASC Grouper,6176,,"100% primary, 50% secondary, 25% supplemental procedure",6176,Other,Blue Cross ASC Grouper,20210.06,49.5,,20210.06,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5841.74,,,5841.74,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,28579.88,70,,28579.88,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,3140.72,,,3140.72,Other,New York Medicaid APG methodology,3140.72,,,3140.72,Other,100% New York Medicaid APG,3140.72,,,3140.72,Other,100% New York Medicaid APG,3140.72,,,3140.72,Other,100% New York Medicaid APG,7066.62,,,7066.62,Other,225% New York Medicaid APG,4805.3,,,4805.3,Other,153% New York Medicaid APG,7066.62,,,7066.62,Other,225% New York Medicaid APG,4397.01,,,4397.01,Other,140% New York Medicaid APG,7066.62,,,7066.62,Other,225% New York Medicaid APG,8165.87,,,8165.87,Other,260% New York Medicaid APG,10175.93,,,10175.93,Other,324% New York Medicaid APG,6752.54,,,6752.54,Other,215% New York Medicaid APG,6752.54,,,6752.54,Other,215% New York Medicaid APG,3925.9,,,3925.9,Other,125% New York Medicaid APG,3140.72,30213.02,
Nsl/sins ndsc sphn tiss rmvl,31259,CPT,,,,,,,,both,,,64583.51,47791.8,74,,47791.8,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,29062.58,45,,29062.58,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,7266,,"100% primary, 50% secondary, 25% supplemental procedure",7266,Other,Blue Cross ASC Grouper,6539,,"100% primary, 50% secondary, 25% supplemental procedure",6539,Other,Blue Cross ASC Grouper,6176,,"100% primary, 50% secondary, 25% supplemental procedure",6176,Other,Blue Cross ASC Grouper,31968.84,49.5,,31968.84,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5841.74,,,5841.74,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,45208.46,70,,45208.46,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,3140.72,,,3140.72,Other,New York Medicaid APG methodology,3140.72,,,3140.72,Other,100% New York Medicaid APG,3140.72,,,3140.72,Other,100% New York Medicaid APG,3140.72,,,3140.72,Other,100% New York Medicaid APG,7066.62,,,7066.62,Other,225% New York Medicaid APG,4805.3,,,4805.3,Other,153% New York Medicaid APG,7066.62,,,7066.62,Other,225% New York Medicaid APG,4397.01,,,4397.01,Other,140% New York Medicaid APG,7066.62,,,7066.62,Other,225% New York Medicaid APG,8165.87,,,8165.87,Other,260% New York Medicaid APG,10175.93,,,10175.93,Other,324% New York Medicaid APG,6752.54,,,6752.54,Other,215% New York Medicaid APG,6752.54,,,6752.54,Other,215% New York Medicaid APG,3925.9,,,3925.9,Other,125% New York Medicaid APG,3140.72,47791.8,
Endoscopy maxillary sinus,31267,CPT,,,,,,,,both,,,41890.73,30999.14,74,,30999.14,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,18850.83,45,,18850.83,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,7266,,"100% primary, 50% secondary, 25% supplemental procedure",7266,Other,Blue Cross ASC Grouper,6539,,"100% primary, 50% secondary, 25% supplemental procedure",6539,Other,Blue Cross ASC Grouper,6176,,"100% primary, 50% secondary, 25% supplemental procedure",6176,Other,Blue Cross ASC Grouper,20735.91,49.5,,20735.91,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,831.59,,,831.59,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,29323.51,70,,29323.51,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,447.09,,,447.09,Other,New York Medicaid APG methodology,447.09,,,447.09,Other,100% New York Medicaid APG,447.09,,,447.09,Other,100% New York Medicaid APG,447.09,,,447.09,Other,100% New York Medicaid APG,1005.95,,,1005.95,Other,225% New York Medicaid APG,684.05,,,684.05,Other,153% New York Medicaid APG,1005.95,,,1005.95,Other,225% New York Medicaid APG,625.92,,,625.92,Other,140% New York Medicaid APG,1005.95,,,1005.95,Other,225% New York Medicaid APG,1162.43,,,1162.43,Other,260% New York Medicaid APG,1448.57,,,1448.57,Other,324% New York Medicaid APG,961.24,,,961.24,Other,215% New York Medicaid APG,961.24,,,961.24,Other,215% New York Medicaid APG,558.86,,,558.86,Other,125% New York Medicaid APG,447.09,30999.14,
Nsl/sins ndsc frnt tiss rmvl,31276,CPT,,,,,,,,both,,,51273.89,37942.68,74,,37942.68,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,23073.25,45,,23073.25,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,7266,,"100% primary, 50% secondary, 25% supplemental procedure",7266,Other,Blue Cross ASC Grouper,6539,,"100% primary, 50% secondary, 25% supplemental procedure",6539,Other,Blue Cross ASC Grouper,6176,,"100% primary, 50% secondary, 25% supplemental procedure",6176,Other,Blue Cross ASC Grouper,25380.58,49.5,,25380.58,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,831.59,,,831.59,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,35891.72,70,,35891.72,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,447.09,,,447.09,Other,New York Medicaid APG methodology,447.09,,,447.09,Other,100% New York Medicaid APG,447.09,,,447.09,Other,100% New York Medicaid APG,447.09,,,447.09,Other,100% New York Medicaid APG,1005.95,,,1005.95,Other,225% New York Medicaid APG,684.05,,,684.05,Other,153% New York Medicaid APG,1005.95,,,1005.95,Other,225% New York Medicaid APG,625.92,,,625.92,Other,140% New York Medicaid APG,1005.95,,,1005.95,Other,225% New York Medicaid APG,1162.43,,,1162.43,Other,260% New York Medicaid APG,1448.57,,,1448.57,Other,324% New York Medicaid APG,961.24,,,961.24,Other,215% New York Medicaid APG,961.24,,,961.24,Other,215% New York Medicaid APG,558.86,,,558.86,Other,125% New York Medicaid APG,447.09,37942.68,
Nasal/sinus endoscopy surg,31287,CPT,,,,,,,,both,,,143961.17,106531.27,74,,106531.27,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,64782.53,45,,64782.53,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,7266,,"100% primary, 50% secondary, 25% supplemental procedure",7266,Other,Blue Cross ASC Grouper,6539,,"100% primary, 50% secondary, 25% supplemental procedure",6539,Other,Blue Cross ASC Grouper,6176,,"100% primary, 50% secondary, 25% supplemental procedure",6176,Other,Blue Cross ASC Grouper,71260.78,49.5,,71260.78,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,831.59,,,831.59,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,100772.82,70,,100772.82,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,447.09,,,447.09,Other,New York Medicaid APG methodology,447.09,,,447.09,Other,100% New York Medicaid APG,447.09,,,447.09,Other,100% New York Medicaid APG,447.09,,,447.09,Other,100% New York Medicaid APG,1005.95,,,1005.95,Other,225% New York Medicaid APG,684.05,,,684.05,Other,153% New York Medicaid APG,1005.95,,,1005.95,Other,225% New York Medicaid APG,625.92,,,625.92,Other,140% New York Medicaid APG,1005.95,,,1005.95,Other,225% New York Medicaid APG,1162.43,,,1162.43,Other,260% New York Medicaid APG,1448.57,,,1448.57,Other,324% New York Medicaid APG,961.24,,,961.24,Other,215% New York Medicaid APG,961.24,,,961.24,Other,215% New York Medicaid APG,558.86,,,558.86,Other,125% New York Medicaid APG,447.09,106531.27,
Nasal/sinus endoscopy surg,31288,CPT,,,,,,,,both,,,143961.17,106531.27,74,,106531.27,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,64782.53,45,,64782.53,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,7266,,"100% primary, 50% secondary, 25% supplemental procedure",7266,Other,Blue Cross ASC Grouper,6539,,"100% primary, 50% secondary, 25% supplemental procedure",6539,Other,Blue Cross ASC Grouper,6176,,"100% primary, 50% secondary, 25% supplemental procedure",6176,Other,Blue Cross ASC Grouper,71260.78,49.5,,71260.78,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,831.59,,,831.59,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,100772.82,70,,100772.82,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,447.09,,,447.09,Other,New York Medicaid APG methodology,447.09,,,447.09,Other,100% New York Medicaid APG,447.09,,,447.09,Other,100% New York Medicaid APG,447.09,,,447.09,Other,100% New York Medicaid APG,1005.95,,,1005.95,Other,225% New York Medicaid APG,684.05,,,684.05,Other,153% New York Medicaid APG,1005.95,,,1005.95,Other,225% New York Medicaid APG,625.92,,,625.92,Other,140% New York Medicaid APG,1005.95,,,1005.95,Other,225% New York Medicaid APG,1162.43,,,1162.43,Other,260% New York Medicaid APG,1448.57,,,1448.57,Other,324% New York Medicaid APG,961.24,,,961.24,Other,215% New York Medicaid APG,961.24,,,961.24,Other,215% New York Medicaid APG,558.86,,,558.86,Other,125% New York Medicaid APG,447.09,106531.27,
Nsl/sins ndsc med/inf dcmprn,31292,CPT,,,,,,,,both,,,64741.66,47908.83,74,,47908.83,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,29133.75,45,,29133.75,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,7266,,"100% primary, 50% secondary, 25% supplemental procedure",7266,Other,Blue Cross ASC Grouper,6539,,"100% primary, 50% secondary, 25% supplemental procedure",6539,Other,Blue Cross ASC Grouper,6176,,"100% primary, 50% secondary, 25% supplemental procedure",6176,Other,Blue Cross ASC Grouper,32047.12,49.5,,32047.12,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2982.31,,,2982.31,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,45319.16,70,,45319.16,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1603.39,,,1603.39,Other,New York Medicaid APG methodology,1603.39,,,1603.39,Other,100% New York Medicaid APG,1603.39,,,1603.39,Other,100% New York Medicaid APG,1603.39,,,1603.39,Other,100% New York Medicaid APG,3607.64,,,3607.64,Other,225% New York Medicaid APG,2453.19,,,2453.19,Other,153% New York Medicaid APG,3607.64,,,3607.64,Other,225% New York Medicaid APG,2244.75,,,2244.75,Other,140% New York Medicaid APG,3607.64,,,3607.64,Other,225% New York Medicaid APG,4168.82,,,4168.82,Other,260% New York Medicaid APG,5195,,,5195,Other,324% New York Medicaid APG,3447.3,,,3447.3,Other,215% New York Medicaid APG,3447.3,,,3447.3,Other,215% New York Medicaid APG,2004.24,,,2004.24,Other,125% New York Medicaid APG,1603.39,47908.83,
Nsl/sins ndsc med&inf dcmprn,31293,CPT,,,,,,,,both,,,143961.17,106531.27,74,,106531.27,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,64782.53,45,,64782.53,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,7266,,"100% primary, 50% secondary, 25% supplemental procedure",7266,Other,Blue Cross ASC Grouper,6539,,"100% primary, 50% secondary, 25% supplemental procedure",6539,Other,Blue Cross ASC Grouper,6176,,"100% primary, 50% secondary, 25% supplemental procedure",6176,Other,Blue Cross ASC Grouper,71260.78,49.5,,71260.78,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2982.31,,,2982.31,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,100772.82,70,,100772.82,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1603.39,,,1603.39,Other,New York Medicaid APG methodology,1603.39,,,1603.39,Other,100% New York Medicaid APG,1603.39,,,1603.39,Other,100% New York Medicaid APG,1603.39,,,1603.39,Other,100% New York Medicaid APG,3607.64,,,3607.64,Other,225% New York Medicaid APG,2453.19,,,2453.19,Other,153% New York Medicaid APG,3607.64,,,3607.64,Other,225% New York Medicaid APG,2244.75,,,2244.75,Other,140% New York Medicaid APG,3607.64,,,3607.64,Other,225% New York Medicaid APG,4168.82,,,4168.82,Other,260% New York Medicaid APG,5195,,,5195,Other,324% New York Medicaid APG,3447.3,,,3447.3,Other,215% New York Medicaid APG,3447.3,,,3447.3,Other,215% New York Medicaid APG,2004.24,,,2004.24,Other,125% New York Medicaid APG,1603.39,106531.27,
Nsl/sins ndsc surg on dcmprn,31294,CPT,,,,,,,,both,,,143961.17,106531.27,74,,106531.27,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,64782.53,45,,64782.53,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,7266,,"100% primary, 50% secondary, 25% supplemental procedure",7266,Other,Blue Cross ASC Grouper,6539,,"100% primary, 50% secondary, 25% supplemental procedure",6539,Other,Blue Cross ASC Grouper,6176,,"100% primary, 50% secondary, 25% supplemental procedure",6176,Other,Blue Cross ASC Grouper,71260.78,49.5,,71260.78,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2982.31,,,2982.31,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,100772.82,70,,100772.82,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1603.39,,,1603.39,Other,New York Medicaid APG methodology,1603.39,,,1603.39,Other,100% New York Medicaid APG,1603.39,,,1603.39,Other,100% New York Medicaid APG,1603.39,,,1603.39,Other,100% New York Medicaid APG,3607.64,,,3607.64,Other,225% New York Medicaid APG,2453.19,,,2453.19,Other,153% New York Medicaid APG,3607.64,,,3607.64,Other,225% New York Medicaid APG,2244.75,,,2244.75,Other,140% New York Medicaid APG,3607.64,,,3607.64,Other,225% New York Medicaid APG,4168.82,,,4168.82,Other,260% New York Medicaid APG,5195,,,5195,Other,324% New York Medicaid APG,3447.3,,,3447.3,Other,215% New York Medicaid APG,3447.3,,,3447.3,Other,215% New York Medicaid APG,2004.24,,,2004.24,Other,125% New York Medicaid APG,1603.39,106531.27,
Nsl/sins ndsc surg max sins,31295,CPT,,,,,,,,both,,,143961.17,106531.27,74,,106531.27,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,64782.53,45,,64782.53,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,71260.78,49.5,,71260.78,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2982.31,,,2982.31,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,100772.82,70,,100772.82,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1603.39,,,1603.39,Other,New York Medicaid APG methodology,1603.39,,,1603.39,Other,100% New York Medicaid APG,1603.39,,,1603.39,Other,100% New York Medicaid APG,1603.39,,,1603.39,Other,100% New York Medicaid APG,3607.64,,,3607.64,Other,225% New York Medicaid APG,2453.19,,,2453.19,Other,153% New York Medicaid APG,3607.64,,,3607.64,Other,225% New York Medicaid APG,2244.75,,,2244.75,Other,140% New York Medicaid APG,3607.64,,,3607.64,Other,225% New York Medicaid APG,4168.82,,,4168.82,Other,260% New York Medicaid APG,5195,,,5195,Other,324% New York Medicaid APG,3447.3,,,3447.3,Other,215% New York Medicaid APG,3447.3,,,3447.3,Other,215% New York Medicaid APG,2004.24,,,2004.24,Other,125% New York Medicaid APG,1603.39,106531.27,
Nsl/sins ndsc surg frnt sins,31296,CPT,,,,,,,,both,,,143961.17,106531.27,74,,106531.27,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,64782.53,45,,64782.53,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,71260.78,49.5,,71260.78,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,831.59,,,831.59,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,100772.82,70,,100772.82,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,447.09,,,447.09,Other,New York Medicaid APG methodology,447.09,,,447.09,Other,100% New York Medicaid APG,447.09,,,447.09,Other,100% New York Medicaid APG,447.09,,,447.09,Other,100% New York Medicaid APG,1005.95,,,1005.95,Other,225% New York Medicaid APG,684.05,,,684.05,Other,153% New York Medicaid APG,1005.95,,,1005.95,Other,225% New York Medicaid APG,625.92,,,625.92,Other,140% New York Medicaid APG,1005.95,,,1005.95,Other,225% New York Medicaid APG,1162.43,,,1162.43,Other,260% New York Medicaid APG,1448.57,,,1448.57,Other,324% New York Medicaid APG,961.24,,,961.24,Other,215% New York Medicaid APG,961.24,,,961.24,Other,215% New York Medicaid APG,558.86,,,558.86,Other,125% New York Medicaid APG,447.09,106531.27,
Nsl/sins ndsc surg sphn sins,31297,CPT,,,,,,,,both,,,143961.17,106531.27,74,,106531.27,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,64782.53,45,,64782.53,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,71260.78,49.5,,71260.78,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,831.59,,,831.59,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,100772.82,70,,100772.82,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,447.09,,,447.09,Other,New York Medicaid APG methodology,447.09,,,447.09,Other,100% New York Medicaid APG,447.09,,,447.09,Other,100% New York Medicaid APG,447.09,,,447.09,Other,100% New York Medicaid APG,1005.95,,,1005.95,Other,225% New York Medicaid APG,684.05,,,684.05,Other,153% New York Medicaid APG,1005.95,,,1005.95,Other,225% New York Medicaid APG,625.92,,,625.92,Other,140% New York Medicaid APG,1005.95,,,1005.95,Other,225% New York Medicaid APG,1162.43,,,1162.43,Other,260% New York Medicaid APG,1448.57,,,1448.57,Other,324% New York Medicaid APG,961.24,,,961.24,Other,215% New York Medicaid APG,961.24,,,961.24,Other,215% New York Medicaid APG,558.86,,,558.86,Other,125% New York Medicaid APG,447.09,106531.27,
Nsl/sins ndsc surg frnt&sphn,31298,CPT,,,,,,,,both,,,143961.17,106531.27,74,,106531.27,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,64782.53,45,,64782.53,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,7266,,"100% primary, 50% secondary, 25% supplemental procedure",7266,Other,Blue Cross ASC Grouper,6539,,"100% primary, 50% secondary, 25% supplemental procedure",6539,Other,Blue Cross ASC Grouper,6176,,"100% primary, 50% secondary, 25% supplemental procedure",6176,Other,Blue Cross ASC Grouper,71260.78,49.5,,71260.78,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,831.59,,,831.59,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,100772.82,70,,100772.82,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,447.09,,,447.09,Other,New York Medicaid APG methodology,447.09,,,447.09,Other,100% New York Medicaid APG,447.09,,,447.09,Other,100% New York Medicaid APG,447.09,,,447.09,Other,100% New York Medicaid APG,1005.95,,,1005.95,Other,225% New York Medicaid APG,684.05,,,684.05,Other,153% New York Medicaid APG,1005.95,,,1005.95,Other,225% New York Medicaid APG,625.92,,,625.92,Other,140% New York Medicaid APG,1005.95,,,1005.95,Other,225% New York Medicaid APG,1162.43,,,1162.43,Other,260% New York Medicaid APG,1448.57,,,1448.57,Other,324% New York Medicaid APG,961.24,,,961.24,Other,215% New York Medicaid APG,961.24,,,961.24,Other,215% New York Medicaid APG,558.86,,,558.86,Other,125% New York Medicaid APG,447.09,106531.27,
Removal of larynx lesion,31300,CPT,,,,,,,,both,,,67720.49,50113.16,74,,50113.16,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30474.22,45,,30474.22,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,33521.64,49.5,,33521.64,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2965.83,,,2965.83,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,47404.34,70,,47404.34,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1594.53,,,1594.53,Other,New York Medicaid APG methodology,1594.53,,,1594.53,Other,100% New York Medicaid APG,1594.53,,,1594.53,Other,100% New York Medicaid APG,1594.53,,,1594.53,Other,100% New York Medicaid APG,3587.7,,,3587.7,Other,225% New York Medicaid APG,2439.64,,,2439.64,Other,153% New York Medicaid APG,3587.7,,,3587.7,Other,225% New York Medicaid APG,2232.35,,,2232.35,Other,140% New York Medicaid APG,3587.7,,,3587.7,Other,225% New York Medicaid APG,4145.78,,,4145.78,Other,260% New York Medicaid APG,5166.29,,,5166.29,Other,324% New York Medicaid APG,3428.25,,,3428.25,Other,215% New York Medicaid APG,3428.25,,,3428.25,Other,215% New York Medicaid APG,1993.17,,,1993.17,Other,125% New York Medicaid APG,1594.53,50113.16,
Revision of larynx,31400,CPT,,,,,,,,both,,,42086.37,31143.91,74,,31143.91,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,18938.87,45,,18938.87,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,20832.75,49.5,,20832.75,percent of total billed charges,110% of Medicare,28618.73,68,,28618.73,percent of total billed charges,,5841.74,,,5841.74,Other,186% of Medicaid,33669.1,80,,33669.1,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,33669.1,80,,33669.1,percent of total billed charges,,7216,,,7216,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,29460.46,70,,29460.46,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,3140.72,,,3140.72,Other,New York Medicaid APG methodology,3140.72,,,3140.72,Other,100% New York Medicaid APG,3140.72,,,3140.72,Other,100% New York Medicaid APG,3140.72,,,3140.72,Other,100% New York Medicaid APG,7066.62,,,7066.62,Other,225% New York Medicaid APG,4805.3,,,4805.3,Other,153% New York Medicaid APG,7066.62,,,7066.62,Other,225% New York Medicaid APG,4397.01,,,4397.01,Other,140% New York Medicaid APG,7066.62,,,7066.62,Other,225% New York Medicaid APG,8165.87,,,8165.87,Other,260% New York Medicaid APG,10175.93,,,10175.93,Other,324% New York Medicaid APG,6752.54,,,6752.54,Other,215% New York Medicaid APG,6752.54,,,6752.54,Other,215% New York Medicaid APG,3925.9,,,3925.9,Other,125% New York Medicaid APG,2232,33669.1,
Removal of epiglottis,31420,CPT,,,,,,,,both,,,123177.14,91151.08,74,,91151.08,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,55429.71,45,,55429.71,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,60972.68,49.5,,60972.68,percent of total billed charges,110% of Medicare,83760.46,68,,83760.46,percent of total billed charges,,5841.74,,,5841.74,Other,186% of Medicaid,98541.71,80,,98541.71,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,98541.71,80,,98541.71,percent of total billed charges,,7216,,,7216,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,86224,70,,86224,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,3140.72,,,3140.72,Other,New York Medicaid APG methodology,3140.72,,,3140.72,Other,100% New York Medicaid APG,3140.72,,,3140.72,Other,100% New York Medicaid APG,3140.72,,,3140.72,Other,100% New York Medicaid APG,7066.62,,,7066.62,Other,225% New York Medicaid APG,4805.3,,,4805.3,Other,153% New York Medicaid APG,7066.62,,,7066.62,Other,225% New York Medicaid APG,4397.01,,,4397.01,Other,140% New York Medicaid APG,7066.62,,,7066.62,Other,225% New York Medicaid APG,8165.87,,,8165.87,Other,260% New York Medicaid APG,10175.93,,,10175.93,Other,324% New York Medicaid APG,6752.54,,,6752.54,Other,215% New York Medicaid APG,6752.54,,,6752.54,Other,215% New York Medicaid APG,3925.9,,,3925.9,Other,125% New York Medicaid APG,2232,98541.71,
Insert emergency airway,31500,CPT,,,,,,,,both,,,5137.73,3801.92,74,,3801.92,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,2311.98,45,,2311.98,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,2543.18,49.5,,2543.18,percent of total billed charges,110% of Medicare,3493.66,68,,3493.66,percent of total billed charges,,1147.86,,,1147.86,Other,186% of Medicaid,4110.18,80,,4110.18,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,4110.18,80,,4110.18,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,3596.41,70,,3596.41,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,617.13,,,617.13,Other,New York Medicaid APG methodology,617.13,,,617.13,Other,100% New York Medicaid APG,617.13,,,617.13,Other,100% New York Medicaid APG,617.13,,,617.13,Other,100% New York Medicaid APG,1388.54,,,1388.54,Other,225% New York Medicaid APG,944.21,,,944.21,Other,153% New York Medicaid APG,1388.54,,,1388.54,Other,225% New York Medicaid APG,863.98,,,863.98,Other,140% New York Medicaid APG,1388.54,,,1388.54,Other,225% New York Medicaid APG,1604.54,,,1604.54,Other,260% New York Medicaid APG,1999.5,,,1999.5,Other,324% New York Medicaid APG,1326.83,,,1326.83,Other,215% New York Medicaid APG,1326.83,,,1326.83,Other,215% New York Medicaid APG,771.41,,,771.41,Other,125% New York Medicaid APG,617.13,7216,
Change of windpipe airway,31502,CPT,,,,,,,,both,,,28281.42,20928.25,74,,20928.25,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,12726.64,45,,12726.64,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,13999.3,49.5,,13999.3,percent of total billed charges,110% of Medicare,19231.37,68,,19231.37,percent of total billed charges,,423.06,,,423.06,Other,186% of Medicaid,22625.14,80,,22625.14,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,22625.14,80,,22625.14,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,19796.99,70,,19796.99,percent of total billed charges,,170.56,,,170.56,Fee Schedule,,144.56,,,144.56,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,227.45,,,227.45,Other,New York Medicaid APG methodology,227.45,,,227.45,Other,100% New York Medicaid APG,227.45,,,227.45,Other,100% New York Medicaid APG,227.45,,,227.45,Other,100% New York Medicaid APG,511.76,,,511.76,Other,225% New York Medicaid APG,348,,,348,Other,153% New York Medicaid APG,511.76,,,511.76,Other,225% New York Medicaid APG,318.43,,,318.43,Other,140% New York Medicaid APG,511.76,,,511.76,Other,225% New York Medicaid APG,591.37,,,591.37,Other,260% New York Medicaid APG,736.94,,,736.94,Other,324% New York Medicaid APG,489.02,,,489.02,Other,215% New York Medicaid APG,489.02,,,489.02,Other,215% New York Medicaid APG,284.31,,,284.31,Other,125% New York Medicaid APG,144.56,22625.14,
Diagnostic laryngoscopy,31505,CPT,,,,,,,,both,,,4166.39,3083.13,74,,3083.13,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,1874.88,45,,1874.88,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,2062.36,49.5,,2062.36,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,423.06,,,423.06,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,2916.47,70,,2916.47,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,227.45,,,227.45,Other,New York Medicaid APG methodology,227.45,,,227.45,Other,100% New York Medicaid APG,227.45,,,227.45,Other,100% New York Medicaid APG,227.45,,,227.45,Other,100% New York Medicaid APG,511.76,,,511.76,Other,225% New York Medicaid APG,348,,,348,Other,153% New York Medicaid APG,511.76,,,511.76,Other,225% New York Medicaid APG,318.43,,,318.43,Other,140% New York Medicaid APG,511.76,,,511.76,Other,225% New York Medicaid APG,591.37,,,591.37,Other,260% New York Medicaid APG,736.94,,,736.94,Other,324% New York Medicaid APG,489.02,,,489.02,Other,215% New York Medicaid APG,489.02,,,489.02,Other,215% New York Medicaid APG,284.31,,,284.31,Other,125% New York Medicaid APG,227.45,9473,
Laryngoscopy with biopsy,31510,CPT,,,,,,,,both,,,78767.93,58288.27,74,,58288.27,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,35445.57,45,,35445.57,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,38990.13,49.5,,38990.13,percent of total billed charges,110% of Medicare,53562.19,68,,53562.19,percent of total billed charges,,2982.31,,,2982.31,Other,186% of Medicaid,63014.34,80,,63014.34,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,63014.34,80,,63014.34,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,55137.55,70,,55137.55,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1603.39,,,1603.39,Other,New York Medicaid APG methodology,1603.39,,,1603.39,Other,100% New York Medicaid APG,1603.39,,,1603.39,Other,100% New York Medicaid APG,1603.39,,,1603.39,Other,100% New York Medicaid APG,3607.64,,,3607.64,Other,225% New York Medicaid APG,2453.19,,,2453.19,Other,153% New York Medicaid APG,3607.64,,,3607.64,Other,225% New York Medicaid APG,2244.75,,,2244.75,Other,140% New York Medicaid APG,3607.64,,,3607.64,Other,225% New York Medicaid APG,4168.82,,,4168.82,Other,260% New York Medicaid APG,5195,,,5195,Other,324% New York Medicaid APG,3447.3,,,3447.3,Other,215% New York Medicaid APG,3447.3,,,3447.3,Other,215% New York Medicaid APG,2004.24,,,2004.24,Other,125% New York Medicaid APG,1603.39,63014.34,
Remove foreign body larynx,31511,CPT,,,,,,,,both,,,4166.39,3083.13,74,,3083.13,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,1874.88,45,,1874.88,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,2062.36,49.5,,2062.36,percent of total billed charges,110% of Medicare,2833.15,68,,2833.15,percent of total billed charges,,423.06,,,423.06,Other,186% of Medicaid,3333.11,80,,3333.11,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,3333.11,80,,3333.11,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,2916.47,70,,2916.47,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,227.45,,,227.45,Other,New York Medicaid APG methodology,227.45,,,227.45,Other,100% New York Medicaid APG,227.45,,,227.45,Other,100% New York Medicaid APG,227.45,,,227.45,Other,100% New York Medicaid APG,511.76,,,511.76,Other,225% New York Medicaid APG,348,,,348,Other,153% New York Medicaid APG,511.76,,,511.76,Other,225% New York Medicaid APG,318.43,,,318.43,Other,140% New York Medicaid APG,511.76,,,511.76,Other,225% New York Medicaid APG,591.37,,,591.37,Other,260% New York Medicaid APG,736.94,,,736.94,Other,324% New York Medicaid APG,489.02,,,489.02,Other,215% New York Medicaid APG,489.02,,,489.02,Other,215% New York Medicaid APG,284.31,,,284.31,Other,125% New York Medicaid APG,227.45,7216,
Removal of larynx lesion,31512,CPT,,,,,,,,both,,,78767.93,58288.27,74,,58288.27,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,35445.57,45,,35445.57,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,38990.13,49.5,,38990.13,percent of total billed charges,110% of Medicare,53562.19,68,,53562.19,percent of total billed charges,,2982.31,,,2982.31,Other,186% of Medicaid,63014.34,80,,63014.34,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,63014.34,80,,63014.34,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,55137.55,70,,55137.55,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1603.39,,,1603.39,Other,New York Medicaid APG methodology,1603.39,,,1603.39,Other,100% New York Medicaid APG,1603.39,,,1603.39,Other,100% New York Medicaid APG,1603.39,,,1603.39,Other,100% New York Medicaid APG,3607.64,,,3607.64,Other,225% New York Medicaid APG,2453.19,,,2453.19,Other,153% New York Medicaid APG,3607.64,,,3607.64,Other,225% New York Medicaid APG,2244.75,,,2244.75,Other,140% New York Medicaid APG,3607.64,,,3607.64,Other,225% New York Medicaid APG,4168.82,,,4168.82,Other,260% New York Medicaid APG,5195,,,5195,Other,324% New York Medicaid APG,3447.3,,,3447.3,Other,215% New York Medicaid APG,3447.3,,,3447.3,Other,215% New York Medicaid APG,2004.24,,,2004.24,Other,125% New York Medicaid APG,1603.39,63014.34,
Injection into vocal cord,31513,CPT,,,,,,,,both,,,8588.63,6355.59,74,,6355.59,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,3864.88,45,,3864.88,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,4251.37,49.5,,4251.37,percent of total billed charges,110% of Medicare,5840.27,68,,5840.27,percent of total billed charges,,831.59,,,831.59,Other,186% of Medicaid,6870.9,80,,6870.9,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,6870.9,80,,6870.9,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,6012.04,70,,6012.04,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,447.09,,,447.09,Other,New York Medicaid APG methodology,447.09,,,447.09,Other,100% New York Medicaid APG,447.09,,,447.09,Other,100% New York Medicaid APG,447.09,,,447.09,Other,100% New York Medicaid APG,1005.95,,,1005.95,Other,225% New York Medicaid APG,684.05,,,684.05,Other,153% New York Medicaid APG,1005.95,,,1005.95,Other,225% New York Medicaid APG,625.92,,,625.92,Other,140% New York Medicaid APG,1005.95,,,1005.95,Other,225% New York Medicaid APG,1162.43,,,1162.43,Other,260% New York Medicaid APG,1448.57,,,1448.57,Other,324% New York Medicaid APG,961.24,,,961.24,Other,215% New York Medicaid APG,961.24,,,961.24,Other,215% New York Medicaid APG,558.86,,,558.86,Other,125% New York Medicaid APG,447.09,7216,
Laryngoscopy for aspiration,31515,CPT,,,,,,,,both,,,8588.63,6355.59,74,,6355.59,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,3864.88,45,,3864.88,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,4251.37,49.5,,4251.37,percent of total billed charges,110% of Medicare,5840.27,68,,5840.27,percent of total billed charges,,831.59,,,831.59,Other,186% of Medicaid,6870.9,80,,6870.9,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,6870.9,80,,6870.9,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,6012.04,70,,6012.04,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,447.09,,,447.09,Other,New York Medicaid APG methodology,447.09,,,447.09,Other,100% New York Medicaid APG,447.09,,,447.09,Other,100% New York Medicaid APG,447.09,,,447.09,Other,100% New York Medicaid APG,1005.95,,,1005.95,Other,225% New York Medicaid APG,684.05,,,684.05,Other,153% New York Medicaid APG,1005.95,,,1005.95,Other,225% New York Medicaid APG,625.92,,,625.92,Other,140% New York Medicaid APG,1005.95,,,1005.95,Other,225% New York Medicaid APG,1162.43,,,1162.43,Other,260% New York Medicaid APG,1448.57,,,1448.57,Other,324% New York Medicaid APG,961.24,,,961.24,Other,215% New York Medicaid APG,961.24,,,961.24,Other,215% New York Medicaid APG,558.86,,,558.86,Other,125% New York Medicaid APG,447.09,7216,
Dx laryngoscopy newborn,31520,CPT,,,,,,,,both,,,8588.63,6355.59,74,,6355.59,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,3864.88,45,,3864.88,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,4251.37,49.5,,4251.37,percent of total billed charges,110% of Medicare,5840.27,68,,5840.27,percent of total billed charges,,831.59,,,831.59,Other,186% of Medicaid,6870.9,80,,6870.9,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,6870.9,80,,6870.9,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,6012.04,70,,6012.04,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,447.09,,,447.09,Other,New York Medicaid APG methodology,447.09,,,447.09,Other,100% New York Medicaid APG,447.09,,,447.09,Other,100% New York Medicaid APG,447.09,,,447.09,Other,100% New York Medicaid APG,1005.95,,,1005.95,Other,225% New York Medicaid APG,684.05,,,684.05,Other,153% New York Medicaid APG,1005.95,,,1005.95,Other,225% New York Medicaid APG,625.92,,,625.92,Other,140% New York Medicaid APG,1005.95,,,1005.95,Other,225% New York Medicaid APG,1162.43,,,1162.43,Other,260% New York Medicaid APG,1448.57,,,1448.57,Other,324% New York Medicaid APG,961.24,,,961.24,Other,215% New York Medicaid APG,961.24,,,961.24,Other,215% New York Medicaid APG,558.86,,,558.86,Other,125% New York Medicaid APG,447.09,7216,
Dx laryngoscopy excl nb,31525,CPT,,,,,,,,both,,,34333.7,25406.94,74,,25406.94,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15450.17,45,,15450.17,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,16995.18,49.5,,16995.18,percent of total billed charges,110% of Medicare,23346.92,68,,23346.92,percent of total billed charges,,831.59,,,831.59,Other,186% of Medicaid,27466.96,80,,27466.96,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,27466.96,80,,27466.96,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,24033.59,70,,24033.59,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,447.09,,,447.09,Other,New York Medicaid APG methodology,447.09,,,447.09,Other,100% New York Medicaid APG,447.09,,,447.09,Other,100% New York Medicaid APG,447.09,,,447.09,Other,100% New York Medicaid APG,1005.95,,,1005.95,Other,225% New York Medicaid APG,684.05,,,684.05,Other,153% New York Medicaid APG,1005.95,,,1005.95,Other,225% New York Medicaid APG,625.92,,,625.92,Other,140% New York Medicaid APG,1005.95,,,1005.95,Other,225% New York Medicaid APG,1162.43,,,1162.43,Other,260% New York Medicaid APG,1448.57,,,1448.57,Other,324% New York Medicaid APG,961.24,,,961.24,Other,215% New York Medicaid APG,961.24,,,961.24,Other,215% New York Medicaid APG,558.86,,,558.86,Other,125% New York Medicaid APG,447.09,27466.96,
Dx laryngoscopy w/oper scope,31526,CPT,,,,,,,,both,,,38383.39,28403.71,74,,28403.71,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,17272.53,45,,17272.53,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,18999.78,49.5,,18999.78,percent of total billed charges,110% of Medicare,26100.71,68,,26100.71,percent of total billed charges,,831.59,,,831.59,Other,186% of Medicaid,30706.71,80,,30706.71,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,30706.71,80,,30706.71,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,26868.37,70,,26868.37,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,447.09,,,447.09,Other,New York Medicaid APG methodology,447.09,,,447.09,Other,100% New York Medicaid APG,447.09,,,447.09,Other,100% New York Medicaid APG,447.09,,,447.09,Other,100% New York Medicaid APG,1005.95,,,1005.95,Other,225% New York Medicaid APG,684.05,,,684.05,Other,153% New York Medicaid APG,1005.95,,,1005.95,Other,225% New York Medicaid APG,625.92,,,625.92,Other,140% New York Medicaid APG,1005.95,,,1005.95,Other,225% New York Medicaid APG,1162.43,,,1162.43,Other,260% New York Medicaid APG,1448.57,,,1448.57,Other,324% New York Medicaid APG,961.24,,,961.24,Other,215% New York Medicaid APG,961.24,,,961.24,Other,215% New York Medicaid APG,558.86,,,558.86,Other,125% New York Medicaid APG,447.09,30706.71,
Laryngoscopy for treatment,31527,CPT,,,,,,,,both,,,78767.93,58288.27,74,,58288.27,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,35445.57,45,,35445.57,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,38990.13,49.5,,38990.13,percent of total billed charges,110% of Medicare,53562.19,68,,53562.19,percent of total billed charges,,2982.31,,,2982.31,Other,186% of Medicaid,63014.34,80,,63014.34,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,63014.34,80,,63014.34,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,55137.55,70,,55137.55,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1603.39,,,1603.39,Other,New York Medicaid APG methodology,1603.39,,,1603.39,Other,100% New York Medicaid APG,1603.39,,,1603.39,Other,100% New York Medicaid APG,1603.39,,,1603.39,Other,100% New York Medicaid APG,3607.64,,,3607.64,Other,225% New York Medicaid APG,2453.19,,,2453.19,Other,153% New York Medicaid APG,3607.64,,,3607.64,Other,225% New York Medicaid APG,2244.75,,,2244.75,Other,140% New York Medicaid APG,3607.64,,,3607.64,Other,225% New York Medicaid APG,4168.82,,,4168.82,Other,260% New York Medicaid APG,5195,,,5195,Other,324% New York Medicaid APG,3447.3,,,3447.3,Other,215% New York Medicaid APG,3447.3,,,3447.3,Other,215% New York Medicaid APG,2004.24,,,2004.24,Other,125% New York Medicaid APG,1603.39,63014.34,
Laryngoscopy and dilation,31528,CPT,,,,,,,,both,,,39598.13,29302.62,74,,29302.62,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,17819.16,45,,17819.16,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,19601.07,49.5,,19601.07,percent of total billed charges,110% of Medicare,26926.73,68,,26926.73,percent of total billed charges,,2982.31,,,2982.31,Other,186% of Medicaid,31678.5,80,,31678.5,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,31678.5,80,,31678.5,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,27718.69,70,,27718.69,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1603.39,,,1603.39,Other,New York Medicaid APG methodology,1603.39,,,1603.39,Other,100% New York Medicaid APG,1603.39,,,1603.39,Other,100% New York Medicaid APG,1603.39,,,1603.39,Other,100% New York Medicaid APG,3607.64,,,3607.64,Other,225% New York Medicaid APG,2453.19,,,2453.19,Other,153% New York Medicaid APG,3607.64,,,3607.64,Other,225% New York Medicaid APG,2244.75,,,2244.75,Other,140% New York Medicaid APG,3607.64,,,3607.64,Other,225% New York Medicaid APG,4168.82,,,4168.82,Other,260% New York Medicaid APG,5195,,,5195,Other,324% New York Medicaid APG,3447.3,,,3447.3,Other,215% New York Medicaid APG,3447.3,,,3447.3,Other,215% New York Medicaid APG,2004.24,,,2004.24,Other,125% New York Medicaid APG,1603.39,31678.5,
Laryngoscopy and dilation,31529,CPT,,,,,,,,both,,,38922.21,28802.44,74,,28802.44,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,17514.99,45,,17514.99,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,19266.49,49.5,,19266.49,percent of total billed charges,110% of Medicare,26467.1,68,,26467.1,percent of total billed charges,,2982.31,,,2982.31,Other,186% of Medicaid,31137.77,80,,31137.77,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,31137.77,80,,31137.77,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,27245.55,70,,27245.55,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1603.39,,,1603.39,Other,New York Medicaid APG methodology,1603.39,,,1603.39,Other,100% New York Medicaid APG,1603.39,,,1603.39,Other,100% New York Medicaid APG,1603.39,,,1603.39,Other,100% New York Medicaid APG,3607.64,,,3607.64,Other,225% New York Medicaid APG,2453.19,,,2453.19,Other,153% New York Medicaid APG,3607.64,,,3607.64,Other,225% New York Medicaid APG,2244.75,,,2244.75,Other,140% New York Medicaid APG,3607.64,,,3607.64,Other,225% New York Medicaid APG,4168.82,,,4168.82,Other,260% New York Medicaid APG,5195,,,5195,Other,324% New York Medicaid APG,3447.3,,,3447.3,Other,215% New York Medicaid APG,3447.3,,,3447.3,Other,215% New York Medicaid APG,2004.24,,,2004.24,Other,125% New York Medicaid APG,1603.39,31137.77,
Laryngoscopy w/fb removal,31530,CPT,,,,,,,,both,,,35699.83,26417.87,74,,26417.87,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,16064.92,45,,16064.92,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,17671.42,49.5,,17671.42,percent of total billed charges,110% of Medicare,24275.88,68,,24275.88,percent of total billed charges,,831.59,,,831.59,Other,186% of Medicaid,28559.86,80,,28559.86,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,28559.86,80,,28559.86,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,24989.88,70,,24989.88,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,447.09,,,447.09,Other,New York Medicaid APG methodology,447.09,,,447.09,Other,100% New York Medicaid APG,447.09,,,447.09,Other,100% New York Medicaid APG,447.09,,,447.09,Other,100% New York Medicaid APG,1005.95,,,1005.95,Other,225% New York Medicaid APG,684.05,,,684.05,Other,153% New York Medicaid APG,1005.95,,,1005.95,Other,225% New York Medicaid APG,625.92,,,625.92,Other,140% New York Medicaid APG,1005.95,,,1005.95,Other,225% New York Medicaid APG,1162.43,,,1162.43,Other,260% New York Medicaid APG,1448.57,,,1448.57,Other,324% New York Medicaid APG,961.24,,,961.24,Other,215% New York Medicaid APG,961.24,,,961.24,Other,215% New York Medicaid APG,558.86,,,558.86,Other,125% New York Medicaid APG,447.09,28559.86,
Laryngoscopy w/fb & op scope,31531,CPT,,,,,,,,both,,,35300,26122,74,,26122,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15885,45,,15885,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,17473.5,49.5,,17473.5,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2982.31,,,2982.31,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,24710,70,,24710,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1603.39,,,1603.39,Other,New York Medicaid APG methodology,1603.39,,,1603.39,Other,100% New York Medicaid APG,1603.39,,,1603.39,Other,100% New York Medicaid APG,1603.39,,,1603.39,Other,100% New York Medicaid APG,3607.64,,,3607.64,Other,225% New York Medicaid APG,2453.19,,,2453.19,Other,153% New York Medicaid APG,3607.64,,,3607.64,Other,225% New York Medicaid APG,2244.75,,,2244.75,Other,140% New York Medicaid APG,3607.64,,,3607.64,Other,225% New York Medicaid APG,4168.82,,,4168.82,Other,260% New York Medicaid APG,5195,,,5195,Other,324% New York Medicaid APG,3447.3,,,3447.3,Other,215% New York Medicaid APG,3447.3,,,3447.3,Other,215% New York Medicaid APG,2004.24,,,2004.24,Other,125% New York Medicaid APG,1603.39,26122,
Laryngoscopy w/biopsy,31535,CPT,,,,,,,,both,,,40730.91,30140.87,74,,30140.87,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,18328.91,45,,18328.91,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,20161.8,49.5,,20161.8,percent of total billed charges,110% of Medicare,27697.02,68,,27697.02,percent of total billed charges,,2982.31,,,2982.31,Other,186% of Medicaid,32584.73,80,,32584.73,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,32584.73,80,,32584.73,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,28511.64,70,,28511.64,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1603.39,,,1603.39,Other,New York Medicaid APG methodology,1603.39,,,1603.39,Other,100% New York Medicaid APG,1603.39,,,1603.39,Other,100% New York Medicaid APG,1603.39,,,1603.39,Other,100% New York Medicaid APG,3607.64,,,3607.64,Other,225% New York Medicaid APG,2453.19,,,2453.19,Other,153% New York Medicaid APG,3607.64,,,3607.64,Other,225% New York Medicaid APG,2244.75,,,2244.75,Other,140% New York Medicaid APG,3607.64,,,3607.64,Other,225% New York Medicaid APG,4168.82,,,4168.82,Other,260% New York Medicaid APG,5195,,,5195,Other,324% New York Medicaid APG,3447.3,,,3447.3,Other,215% New York Medicaid APG,3447.3,,,3447.3,Other,215% New York Medicaid APG,2004.24,,,2004.24,Other,125% New York Medicaid APG,1603.39,32584.73,
Laryngoscopy w/bx & op scope,31536,CPT,,,,,,,,both,,,38456,28457.44,74,,28457.44,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,17305.2,45,,17305.2,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,19035.72,49.5,,19035.72,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2982.31,,,2982.31,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,26919.2,70,,26919.2,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1603.39,,,1603.39,Other,New York Medicaid APG methodology,1603.39,,,1603.39,Other,100% New York Medicaid APG,1603.39,,,1603.39,Other,100% New York Medicaid APG,1603.39,,,1603.39,Other,100% New York Medicaid APG,3607.64,,,3607.64,Other,225% New York Medicaid APG,2453.19,,,2453.19,Other,153% New York Medicaid APG,3607.64,,,3607.64,Other,225% New York Medicaid APG,2244.75,,,2244.75,Other,140% New York Medicaid APG,3607.64,,,3607.64,Other,225% New York Medicaid APG,4168.82,,,4168.82,Other,260% New York Medicaid APG,5195,,,5195,Other,324% New York Medicaid APG,3447.3,,,3447.3,Other,215% New York Medicaid APG,3447.3,,,3447.3,Other,215% New York Medicaid APG,2004.24,,,2004.24,Other,125% New York Medicaid APG,1603.39,28457.44,
Laryngoscopy w/exc of tumor,31540,CPT,,,,,,,,both,,,78767.93,58288.27,74,,58288.27,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,35445.57,45,,35445.57,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,38990.13,49.5,,38990.13,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2982.31,,,2982.31,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,55137.55,70,,55137.55,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1603.39,,,1603.39,Other,New York Medicaid APG methodology,1603.39,,,1603.39,Other,100% New York Medicaid APG,1603.39,,,1603.39,Other,100% New York Medicaid APG,1603.39,,,1603.39,Other,100% New York Medicaid APG,3607.64,,,3607.64,Other,225% New York Medicaid APG,2453.19,,,2453.19,Other,153% New York Medicaid APG,3607.64,,,3607.64,Other,225% New York Medicaid APG,2244.75,,,2244.75,Other,140% New York Medicaid APG,3607.64,,,3607.64,Other,225% New York Medicaid APG,4168.82,,,4168.82,Other,260% New York Medicaid APG,5195,,,5195,Other,324% New York Medicaid APG,3447.3,,,3447.3,Other,215% New York Medicaid APG,3447.3,,,3447.3,Other,215% New York Medicaid APG,2004.24,,,2004.24,Other,125% New York Medicaid APG,1603.39,58288.27,
Larynscop w/tumr exc + scope,31541,CPT,,,,,,,,both,,,39879.43,29510.78,74,,29510.78,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,17945.74,45,,17945.74,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,19740.32,49.5,,19740.32,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2982.31,,,2982.31,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,27915.6,70,,27915.6,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1603.39,,,1603.39,Other,New York Medicaid APG methodology,1603.39,,,1603.39,Other,100% New York Medicaid APG,1603.39,,,1603.39,Other,100% New York Medicaid APG,1603.39,,,1603.39,Other,100% New York Medicaid APG,3607.64,,,3607.64,Other,225% New York Medicaid APG,2453.19,,,2453.19,Other,153% New York Medicaid APG,3607.64,,,3607.64,Other,225% New York Medicaid APG,2244.75,,,2244.75,Other,140% New York Medicaid APG,3607.64,,,3607.64,Other,225% New York Medicaid APG,4168.82,,,4168.82,Other,260% New York Medicaid APG,5195,,,5195,Other,324% New York Medicaid APG,3447.3,,,3447.3,Other,215% New York Medicaid APG,3447.3,,,3447.3,Other,215% New York Medicaid APG,2004.24,,,2004.24,Other,125% New York Medicaid APG,1603.39,29510.78,
Remove vc lesion w/scope,31545,CPT,,,,,,,,both,,,36077,26696.98,74,,26696.98,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,16234.65,45,,16234.65,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,17858.12,49.5,,17858.12,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2982.31,,,2982.31,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,25253.9,70,,25253.9,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1603.39,,,1603.39,Other,New York Medicaid APG methodology,1603.39,,,1603.39,Other,100% New York Medicaid APG,1603.39,,,1603.39,Other,100% New York Medicaid APG,1603.39,,,1603.39,Other,100% New York Medicaid APG,3607.64,,,3607.64,Other,225% New York Medicaid APG,2453.19,,,2453.19,Other,153% New York Medicaid APG,3607.64,,,3607.64,Other,225% New York Medicaid APG,2244.75,,,2244.75,Other,140% New York Medicaid APG,3607.64,,,3607.64,Other,225% New York Medicaid APG,4168.82,,,4168.82,Other,260% New York Medicaid APG,5195,,,5195,Other,324% New York Medicaid APG,3447.3,,,3447.3,Other,215% New York Medicaid APG,3447.3,,,3447.3,Other,215% New York Medicaid APG,2004.24,,,2004.24,Other,125% New York Medicaid APG,1603.39,26696.98,
Remove vc lesion scope/graft,31546,CPT,,,,,,,,both,,,143961.17,106531.27,74,,106531.27,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,64782.53,45,,64782.53,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,7266,,"100% primary, 50% secondary, 25% supplemental procedure",7266,Other,Blue Cross ASC Grouper,6539,,"100% primary, 50% secondary, 25% supplemental procedure",6539,Other,Blue Cross ASC Grouper,6176,,"100% primary, 50% secondary, 25% supplemental procedure",6176,Other,Blue Cross ASC Grouper,71260.78,49.5,,71260.78,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2982.31,,,2982.31,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,100772.82,70,,100772.82,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1603.39,,,1603.39,Other,New York Medicaid APG methodology,1603.39,,,1603.39,Other,100% New York Medicaid APG,1603.39,,,1603.39,Other,100% New York Medicaid APG,1603.39,,,1603.39,Other,100% New York Medicaid APG,3607.64,,,3607.64,Other,225% New York Medicaid APG,2453.19,,,2453.19,Other,153% New York Medicaid APG,3607.64,,,3607.64,Other,225% New York Medicaid APG,2244.75,,,2244.75,Other,140% New York Medicaid APG,3607.64,,,3607.64,Other,225% New York Medicaid APG,4168.82,,,4168.82,Other,260% New York Medicaid APG,5195,,,5195,Other,324% New York Medicaid APG,3447.3,,,3447.3,Other,215% New York Medicaid APG,3447.3,,,3447.3,Other,215% New York Medicaid APG,2004.24,,,2004.24,Other,125% New York Medicaid APG,1603.39,106531.27,
Laryngoplasty laryngeal sten,31551,CPT,,,,,,,,both,,,123177.14,91151.08,74,,91151.08,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,55429.71,45,,55429.71,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,60972.68,49.5,,60972.68,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5841.74,,,5841.74,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,86224,70,,86224,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,3140.72,,,3140.72,Other,New York Medicaid APG methodology,3140.72,,,3140.72,Other,100% New York Medicaid APG,3140.72,,,3140.72,Other,100% New York Medicaid APG,3140.72,,,3140.72,Other,100% New York Medicaid APG,7066.62,,,7066.62,Other,225% New York Medicaid APG,4805.3,,,4805.3,Other,153% New York Medicaid APG,7066.62,,,7066.62,Other,225% New York Medicaid APG,4397.01,,,4397.01,Other,140% New York Medicaid APG,7066.62,,,7066.62,Other,225% New York Medicaid APG,8165.87,,,8165.87,Other,260% New York Medicaid APG,10175.93,,,10175.93,Other,324% New York Medicaid APG,6752.54,,,6752.54,Other,215% New York Medicaid APG,6752.54,,,6752.54,Other,215% New York Medicaid APG,3925.9,,,3925.9,Other,125% New York Medicaid APG,3140.72,91151.08,
Laryngoplasty laryngeal sten,31552,CPT,,,,,,,,both,,,123177.14,91151.08,74,,91151.08,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,55429.71,45,,55429.71,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,60972.68,49.5,,60972.68,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,4119.28,,,4119.28,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,86224,70,,86224,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,2214.67,,,2214.67,Other,New York Medicaid APG methodology,2214.67,,,2214.67,Other,100% New York Medicaid APG,2214.67,,,2214.67,Other,100% New York Medicaid APG,2214.67,,,2214.67,Other,100% New York Medicaid APG,4983,,,4983,Other,225% New York Medicaid APG,3388.44,,,3388.44,Other,153% New York Medicaid APG,4983,,,4983,Other,225% New York Medicaid APG,3100.53,,,3100.53,Other,140% New York Medicaid APG,4983,,,4983,Other,225% New York Medicaid APG,5758.13,,,5758.13,Other,260% New York Medicaid APG,7175.52,,,7175.52,Other,324% New York Medicaid APG,4761.53,,,4761.53,Other,215% New York Medicaid APG,4761.53,,,4761.53,Other,215% New York Medicaid APG,2768.33,,,2768.33,Other,125% New York Medicaid APG,2214.67,91151.08,
Laryngoplasty laryngeal sten,31553,CPT,,,,,,,,both,,,123177.14,91151.08,74,,91151.08,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,55429.71,45,,55429.71,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,60972.68,49.5,,60972.68,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5841.74,,,5841.74,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,86224,70,,86224,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,3140.72,,,3140.72,Other,New York Medicaid APG methodology,3140.72,,,3140.72,Other,100% New York Medicaid APG,3140.72,,,3140.72,Other,100% New York Medicaid APG,3140.72,,,3140.72,Other,100% New York Medicaid APG,7066.62,,,7066.62,Other,225% New York Medicaid APG,4805.3,,,4805.3,Other,153% New York Medicaid APG,7066.62,,,7066.62,Other,225% New York Medicaid APG,4397.01,,,4397.01,Other,140% New York Medicaid APG,7066.62,,,7066.62,Other,225% New York Medicaid APG,8165.87,,,8165.87,Other,260% New York Medicaid APG,10175.93,,,10175.93,Other,324% New York Medicaid APG,6752.54,,,6752.54,Other,215% New York Medicaid APG,6752.54,,,6752.54,Other,215% New York Medicaid APG,3925.9,,,3925.9,Other,125% New York Medicaid APG,3140.72,91151.08,
Laryngoplasty laryngeal sten,31554,CPT,,,,,,,,both,,,123177.14,91151.08,74,,91151.08,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,55429.71,45,,55429.71,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,60972.68,49.5,,60972.68,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,4119.28,,,4119.28,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,86224,70,,86224,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,2214.67,,,2214.67,Other,New York Medicaid APG methodology,2214.67,,,2214.67,Other,100% New York Medicaid APG,2214.67,,,2214.67,Other,100% New York Medicaid APG,2214.67,,,2214.67,Other,100% New York Medicaid APG,4983,,,4983,Other,225% New York Medicaid APG,3388.44,,,3388.44,Other,153% New York Medicaid APG,4983,,,4983,Other,225% New York Medicaid APG,3100.53,,,3100.53,Other,140% New York Medicaid APG,4983,,,4983,Other,225% New York Medicaid APG,5758.13,,,5758.13,Other,260% New York Medicaid APG,7175.52,,,7175.52,Other,324% New York Medicaid APG,4761.53,,,4761.53,Other,215% New York Medicaid APG,4761.53,,,4761.53,Other,215% New York Medicaid APG,2768.33,,,2768.33,Other,125% New York Medicaid APG,2214.67,91151.08,
Laryngoscop w/arytenoidectom,31560,CPT,,,,,,,,both,,,36585.05,27072.94,74,,27072.94,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,16463.27,45,,16463.27,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,7266,,"100% primary, 50% secondary, 25% supplemental procedure",7266,Other,Blue Cross ASC Grouper,6539,,"100% primary, 50% secondary, 25% supplemental procedure",6539,Other,Blue Cross ASC Grouper,6176,,"100% primary, 50% secondary, 25% supplemental procedure",6176,Other,Blue Cross ASC Grouper,18109.6,49.5,,18109.6,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2982.31,,,2982.31,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,25609.54,70,,25609.54,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1603.39,,,1603.39,Other,New York Medicaid APG methodology,1603.39,,,1603.39,Other,100% New York Medicaid APG,1603.39,,,1603.39,Other,100% New York Medicaid APG,1603.39,,,1603.39,Other,100% New York Medicaid APG,3607.64,,,3607.64,Other,225% New York Medicaid APG,2453.19,,,2453.19,Other,153% New York Medicaid APG,3607.64,,,3607.64,Other,225% New York Medicaid APG,2244.75,,,2244.75,Other,140% New York Medicaid APG,3607.64,,,3607.64,Other,225% New York Medicaid APG,4168.82,,,4168.82,Other,260% New York Medicaid APG,5195,,,5195,Other,324% New York Medicaid APG,3447.3,,,3447.3,Other,215% New York Medicaid APG,3447.3,,,3447.3,Other,215% New York Medicaid APG,2004.24,,,2004.24,Other,125% New York Medicaid APG,1603.39,27072.94,
Larynscop remve cart + scop,31561,CPT,,,,,,,,both,,,38171.03,28246.56,74,,28246.56,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,17176.96,45,,17176.96,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,7266,,"100% primary, 50% secondary, 25% supplemental procedure",7266,Other,Blue Cross ASC Grouper,6539,,"100% primary, 50% secondary, 25% supplemental procedure",6539,Other,Blue Cross ASC Grouper,6176,,"100% primary, 50% secondary, 25% supplemental procedure",6176,Other,Blue Cross ASC Grouper,18894.66,49.5,,18894.66,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2982.31,,,2982.31,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,26719.72,70,,26719.72,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1603.39,,,1603.39,Other,New York Medicaid APG methodology,1603.39,,,1603.39,Other,100% New York Medicaid APG,1603.39,,,1603.39,Other,100% New York Medicaid APG,1603.39,,,1603.39,Other,100% New York Medicaid APG,3607.64,,,3607.64,Other,225% New York Medicaid APG,2453.19,,,2453.19,Other,153% New York Medicaid APG,3607.64,,,3607.64,Other,225% New York Medicaid APG,2244.75,,,2244.75,Other,140% New York Medicaid APG,3607.64,,,3607.64,Other,225% New York Medicaid APG,4168.82,,,4168.82,Other,260% New York Medicaid APG,5195,,,5195,Other,324% New York Medicaid APG,3447.3,,,3447.3,Other,215% New York Medicaid APG,3447.3,,,3447.3,Other,215% New York Medicaid APG,2004.24,,,2004.24,Other,125% New York Medicaid APG,1603.39,28246.56,
Laryngoscope w/vc inj,31570,CPT,,,,,,,,both,,,37684.84,27886.78,74,,27886.78,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,16958.18,45,,16958.18,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,18654,49.5,,18654,percent of total billed charges,110% of Medicare,25625.69,68,,25625.69,percent of total billed charges,,2982.31,,,2982.31,Other,186% of Medicaid,30147.87,80,,30147.87,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,30147.87,80,,30147.87,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,26379.39,70,,26379.39,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1603.39,,,1603.39,Other,New York Medicaid APG methodology,1603.39,,,1603.39,Other,100% New York Medicaid APG,1603.39,,,1603.39,Other,100% New York Medicaid APG,1603.39,,,1603.39,Other,100% New York Medicaid APG,3607.64,,,3607.64,Other,225% New York Medicaid APG,2453.19,,,2453.19,Other,153% New York Medicaid APG,3607.64,,,3607.64,Other,225% New York Medicaid APG,2244.75,,,2244.75,Other,140% New York Medicaid APG,3607.64,,,3607.64,Other,225% New York Medicaid APG,4168.82,,,4168.82,Other,260% New York Medicaid APG,5195,,,5195,Other,324% New York Medicaid APG,3447.3,,,3447.3,Other,215% New York Medicaid APG,3447.3,,,3447.3,Other,215% New York Medicaid APG,2004.24,,,2004.24,Other,125% New York Medicaid APG,1603.39,30147.87,
Laryngoscop w/vc inj + scope,31571,CPT,,,,,,,,both,,,38146.33,28228.28,74,,28228.28,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,17165.85,45,,17165.85,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,18882.43,49.5,,18882.43,percent of total billed charges,110% of Medicare,25939.5,68,,25939.5,percent of total billed charges,,2982.31,,,2982.31,Other,186% of Medicaid,30517.06,80,,30517.06,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,30517.06,80,,30517.06,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,26702.43,70,,26702.43,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1603.39,,,1603.39,Other,New York Medicaid APG methodology,1603.39,,,1603.39,Other,100% New York Medicaid APG,1603.39,,,1603.39,Other,100% New York Medicaid APG,1603.39,,,1603.39,Other,100% New York Medicaid APG,3607.64,,,3607.64,Other,225% New York Medicaid APG,2453.19,,,2453.19,Other,153% New York Medicaid APG,3607.64,,,3607.64,Other,225% New York Medicaid APG,2244.75,,,2244.75,Other,140% New York Medicaid APG,3607.64,,,3607.64,Other,225% New York Medicaid APG,4168.82,,,4168.82,Other,260% New York Medicaid APG,5195,,,5195,Other,324% New York Medicaid APG,3447.3,,,3447.3,Other,215% New York Medicaid APG,3447.3,,,3447.3,Other,215% New York Medicaid APG,2004.24,,,2004.24,Other,125% New York Medicaid APG,1603.39,30517.06,
Largsc w/laser dstrj les,31572,CPT,,,,,,,,both,,,35485.78,26259.48,74,,26259.48,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15968.6,45,,15968.6,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,17565.46,49.5,,17565.46,percent of total billed charges,110% of Medicare,24130.33,68,,24130.33,percent of total billed charges,,2982.31,,,2982.31,Other,186% of Medicaid,28388.62,80,,28388.62,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,28388.62,80,,28388.62,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,24840.05,70,,24840.05,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1603.39,,,1603.39,Other,New York Medicaid APG methodology,1603.39,,,1603.39,Other,100% New York Medicaid APG,1603.39,,,1603.39,Other,100% New York Medicaid APG,1603.39,,,1603.39,Other,100% New York Medicaid APG,3607.64,,,3607.64,Other,225% New York Medicaid APG,2453.19,,,2453.19,Other,153% New York Medicaid APG,3607.64,,,3607.64,Other,225% New York Medicaid APG,2244.75,,,2244.75,Other,140% New York Medicaid APG,3607.64,,,3607.64,Other,225% New York Medicaid APG,4168.82,,,4168.82,Other,260% New York Medicaid APG,5195,,,5195,Other,324% New York Medicaid APG,3447.3,,,3447.3,Other,215% New York Medicaid APG,3447.3,,,3447.3,Other,215% New York Medicaid APG,2004.24,,,2004.24,Other,125% New York Medicaid APG,1603.39,28388.62,
Largsc w/ther injection,31573,CPT,,,,,,,,both,,,35699.83,26417.87,74,,26417.87,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,16064.92,45,,16064.92,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,17671.42,49.5,,17671.42,percent of total billed charges,110% of Medicare,24275.88,68,,24275.88,percent of total billed charges,,2982.31,,,2982.31,Other,186% of Medicaid,28559.86,80,,28559.86,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,28559.86,80,,28559.86,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,24989.88,70,,24989.88,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1603.39,,,1603.39,Other,New York Medicaid APG methodology,1603.39,,,1603.39,Other,100% New York Medicaid APG,1603.39,,,1603.39,Other,100% New York Medicaid APG,1603.39,,,1603.39,Other,100% New York Medicaid APG,3607.64,,,3607.64,Other,225% New York Medicaid APG,2453.19,,,2453.19,Other,153% New York Medicaid APG,3607.64,,,3607.64,Other,225% New York Medicaid APG,2244.75,,,2244.75,Other,140% New York Medicaid APG,3607.64,,,3607.64,Other,225% New York Medicaid APG,4168.82,,,4168.82,Other,260% New York Medicaid APG,5195,,,5195,Other,324% New York Medicaid APG,3447.3,,,3447.3,Other,215% New York Medicaid APG,3447.3,,,3447.3,Other,215% New York Medicaid APG,2004.24,,,2004.24,Other,125% New York Medicaid APG,1603.39,28559.86,
Largsc w/njx augmentation,31574,CPT,,,,,,,,both,,,35276,26104.24,74,,26104.24,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15874.2,45,,15874.2,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,17461.62,49.5,,17461.62,percent of total billed charges,110% of Medicare,23987.68,68,,23987.68,percent of total billed charges,,2982.31,,,2982.31,Other,186% of Medicaid,28220.8,80,,28220.8,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,28220.8,80,,28220.8,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,24693.2,70,,24693.2,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1603.39,,,1603.39,Other,New York Medicaid APG methodology,1603.39,,,1603.39,Other,100% New York Medicaid APG,1603.39,,,1603.39,Other,100% New York Medicaid APG,1603.39,,,1603.39,Other,100% New York Medicaid APG,3607.64,,,3607.64,Other,225% New York Medicaid APG,2453.19,,,2453.19,Other,153% New York Medicaid APG,3607.64,,,3607.64,Other,225% New York Medicaid APG,2244.75,,,2244.75,Other,140% New York Medicaid APG,3607.64,,,3607.64,Other,225% New York Medicaid APG,4168.82,,,4168.82,Other,260% New York Medicaid APG,5195,,,5195,Other,324% New York Medicaid APG,3447.3,,,3447.3,Other,215% New York Medicaid APG,3447.3,,,3447.3,Other,215% New York Medicaid APG,2004.24,,,2004.24,Other,125% New York Medicaid APG,1603.39,28220.8,
Diagnostic laryngoscopy,31575,CPT,,,,,,,,both,,,4166.39,3083.13,74,,3083.13,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,1874.88,45,,1874.88,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,2062.36,49.5,,2062.36,percent of total billed charges,110% of Medicare,2833.15,68,,2833.15,percent of total billed charges,,423.06,,,423.06,Other,186% of Medicaid,3333.11,80,,3333.11,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,3333.11,80,,3333.11,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,2916.47,70,,2916.47,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,227.45,,,227.45,Other,New York Medicaid APG methodology,227.45,,,227.45,Other,100% New York Medicaid APG,227.45,,,227.45,Other,100% New York Medicaid APG,227.45,,,227.45,Other,100% New York Medicaid APG,511.76,,,511.76,Other,225% New York Medicaid APG,348,,,348,Other,153% New York Medicaid APG,511.76,,,511.76,Other,225% New York Medicaid APG,318.43,,,318.43,Other,140% New York Medicaid APG,511.76,,,511.76,Other,225% New York Medicaid APG,591.37,,,591.37,Other,260% New York Medicaid APG,736.94,,,736.94,Other,324% New York Medicaid APG,489.02,,,489.02,Other,215% New York Medicaid APG,489.02,,,489.02,Other,215% New York Medicaid APG,284.31,,,284.31,Other,125% New York Medicaid APG,227.45,7216,
Laryngoscopy with biopsy,31576,CPT,,,,,,,,both,,,35699.83,26417.87,74,,26417.87,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,16064.92,45,,16064.92,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,17671.42,49.5,,17671.42,percent of total billed charges,110% of Medicare,24275.88,68,,24275.88,percent of total billed charges,,2982.31,,,2982.31,Other,186% of Medicaid,28559.86,80,,28559.86,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,28559.86,80,,28559.86,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,24989.88,70,,24989.88,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1603.39,,,1603.39,Other,New York Medicaid APG methodology,1603.39,,,1603.39,Other,100% New York Medicaid APG,1603.39,,,1603.39,Other,100% New York Medicaid APG,1603.39,,,1603.39,Other,100% New York Medicaid APG,3607.64,,,3607.64,Other,225% New York Medicaid APG,2453.19,,,2453.19,Other,153% New York Medicaid APG,3607.64,,,3607.64,Other,225% New York Medicaid APG,2244.75,,,2244.75,Other,140% New York Medicaid APG,3607.64,,,3607.64,Other,225% New York Medicaid APG,4168.82,,,4168.82,Other,260% New York Medicaid APG,5195,,,5195,Other,324% New York Medicaid APG,3447.3,,,3447.3,Other,215% New York Medicaid APG,3447.3,,,3447.3,Other,215% New York Medicaid APG,2004.24,,,2004.24,Other,125% New York Medicaid APG,1603.39,28559.86,
Largsc w/rmvl foreign bdy(s),31577,CPT,,,,,,,,both,,,8588.63,6355.59,74,,6355.59,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,3864.88,45,,3864.88,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,4251.37,49.5,,4251.37,percent of total billed charges,110% of Medicare,5840.27,68,,5840.27,percent of total billed charges,,831.59,,,831.59,Other,186% of Medicaid,6870.9,80,,6870.9,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,6870.9,80,,6870.9,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,6012.04,70,,6012.04,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,447.09,,,447.09,Other,New York Medicaid APG methodology,447.09,,,447.09,Other,100% New York Medicaid APG,447.09,,,447.09,Other,100% New York Medicaid APG,447.09,,,447.09,Other,100% New York Medicaid APG,1005.95,,,1005.95,Other,225% New York Medicaid APG,684.05,,,684.05,Other,153% New York Medicaid APG,1005.95,,,1005.95,Other,225% New York Medicaid APG,625.92,,,625.92,Other,140% New York Medicaid APG,1005.95,,,1005.95,Other,225% New York Medicaid APG,1162.43,,,1162.43,Other,260% New York Medicaid APG,1448.57,,,1448.57,Other,324% New York Medicaid APG,961.24,,,961.24,Other,215% New York Medicaid APG,961.24,,,961.24,Other,215% New York Medicaid APG,558.86,,,558.86,Other,125% New York Medicaid APG,447.09,7216,
Largsc w/removal lesion,31578,CPT,,,,,,,,both,,,175702.48,130019.84,74,,130019.84,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,79066.12,45,,79066.12,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,86972.73,49.5,,86972.73,percent of total billed charges,110% of Medicare,119477.69,68,,119477.69,percent of total billed charges,,2982.31,,,2982.31,Other,186% of Medicaid,140561.98,80,,140561.98,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,140561.98,80,,140561.98,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,122991.74,70,,122991.74,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1603.39,,,1603.39,Other,New York Medicaid APG methodology,1603.39,,,1603.39,Other,100% New York Medicaid APG,1603.39,,,1603.39,Other,100% New York Medicaid APG,1603.39,,,1603.39,Other,100% New York Medicaid APG,3607.64,,,3607.64,Other,225% New York Medicaid APG,2453.19,,,2453.19,Other,153% New York Medicaid APG,3607.64,,,3607.64,Other,225% New York Medicaid APG,2244.75,,,2244.75,Other,140% New York Medicaid APG,3607.64,,,3607.64,Other,225% New York Medicaid APG,4168.82,,,4168.82,Other,260% New York Medicaid APG,5195,,,5195,Other,324% New York Medicaid APG,3447.3,,,3447.3,Other,215% New York Medicaid APG,3447.3,,,3447.3,Other,215% New York Medicaid APG,2004.24,,,2004.24,Other,125% New York Medicaid APG,1603.39,140561.98,
Laryngoscopy telescopic,31579,CPT,,,,,,,,both,,,8588.63,6355.59,74,,6355.59,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,3864.88,45,,3864.88,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,4251.37,49.5,,4251.37,percent of total billed charges,110% of Medicare,5840.27,68,,5840.27,percent of total billed charges,,831.59,,,831.59,Other,186% of Medicaid,6870.9,80,,6870.9,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,6870.9,80,,6870.9,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,6012.04,70,,6012.04,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,447.09,,,447.09,Other,New York Medicaid APG methodology,447.09,,,447.09,Other,100% New York Medicaid APG,447.09,,,447.09,Other,100% New York Medicaid APG,447.09,,,447.09,Other,100% New York Medicaid APG,1005.95,,,1005.95,Other,225% New York Medicaid APG,684.05,,,684.05,Other,153% New York Medicaid APG,1005.95,,,1005.95,Other,225% New York Medicaid APG,625.92,,,625.92,Other,140% New York Medicaid APG,1005.95,,,1005.95,Other,225% New York Medicaid APG,1162.43,,,1162.43,Other,260% New York Medicaid APG,1448.57,,,1448.57,Other,324% New York Medicaid APG,961.24,,,961.24,Other,215% New York Medicaid APG,961.24,,,961.24,Other,215% New York Medicaid APG,558.86,,,558.86,Other,125% New York Medicaid APG,447.09,7216,
Laryngoplasty laryngeal web,31580,CPT,,,,,,,,both,,,123177.14,91151.08,74,,91151.08,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,55429.71,45,,55429.71,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,60972.68,49.5,,60972.68,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,4119.28,,,4119.28,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,86224,70,,86224,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,2214.67,,,2214.67,Other,New York Medicaid APG methodology,2214.67,,,2214.67,Other,100% New York Medicaid APG,2214.67,,,2214.67,Other,100% New York Medicaid APG,2214.67,,,2214.67,Other,100% New York Medicaid APG,4983,,,4983,Other,225% New York Medicaid APG,3388.44,,,3388.44,Other,153% New York Medicaid APG,4983,,,4983,Other,225% New York Medicaid APG,3100.53,,,3100.53,Other,140% New York Medicaid APG,4983,,,4983,Other,225% New York Medicaid APG,5758.13,,,5758.13,Other,260% New York Medicaid APG,7175.52,,,7175.52,Other,324% New York Medicaid APG,4761.53,,,4761.53,Other,215% New York Medicaid APG,4761.53,,,4761.53,Other,215% New York Medicaid APG,2768.33,,,2768.33,Other,125% New York Medicaid APG,2214.67,91151.08,
Laryngoplasty fx rdctj fixj,31584,CPT,,,,,,,,both,,,123177.14,91151.08,74,,91151.08,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,55429.71,45,,55429.71,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,60972.68,49.5,,60972.68,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,4119.28,,,4119.28,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,86224,70,,86224,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,2214.67,,,2214.67,Other,New York Medicaid APG methodology,2214.67,,,2214.67,Other,100% New York Medicaid APG,2214.67,,,2214.67,Other,100% New York Medicaid APG,2214.67,,,2214.67,Other,100% New York Medicaid APG,4983,,,4983,Other,225% New York Medicaid APG,3388.44,,,3388.44,Other,153% New York Medicaid APG,4983,,,4983,Other,225% New York Medicaid APG,3100.53,,,3100.53,Other,140% New York Medicaid APG,4983,,,4983,Other,225% New York Medicaid APG,5758.13,,,5758.13,Other,260% New York Medicaid APG,7175.52,,,7175.52,Other,324% New York Medicaid APG,4761.53,,,4761.53,Other,215% New York Medicaid APG,4761.53,,,4761.53,Other,215% New York Medicaid APG,2768.33,,,2768.33,Other,125% New York Medicaid APG,2214.67,91151.08,
Laryngoplasty cricoid split,31587,CPT,,,,,,,,both,,,123177.14,91151.08,74,,91151.08,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,55429.71,45,,55429.71,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,60972.68,49.5,,60972.68,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5841.74,,,5841.74,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,86224,70,,86224,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,3140.72,,,3140.72,Other,New York Medicaid APG methodology,3140.72,,,3140.72,Other,100% New York Medicaid APG,3140.72,,,3140.72,Other,100% New York Medicaid APG,3140.72,,,3140.72,Other,100% New York Medicaid APG,7066.62,,,7066.62,Other,225% New York Medicaid APG,4805.3,,,4805.3,Other,153% New York Medicaid APG,7066.62,,,7066.62,Other,225% New York Medicaid APG,4397.01,,,4397.01,Other,140% New York Medicaid APG,7066.62,,,7066.62,Other,225% New York Medicaid APG,8165.87,,,8165.87,Other,260% New York Medicaid APG,10175.93,,,10175.93,Other,324% New York Medicaid APG,6752.54,,,6752.54,Other,215% New York Medicaid APG,6752.54,,,6752.54,Other,215% New York Medicaid APG,3925.9,,,3925.9,Other,125% New York Medicaid APG,3140.72,91151.08,
Reinnervate larynx,31590,CPT,,,,,,,,both,,,55388,40987.12,74,,40987.12,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,24924.6,45,,24924.6,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,27417.06,49.5,,27417.06,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5841.74,,,5841.74,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,38771.6,70,,38771.6,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,3140.72,,,3140.72,Other,New York Medicaid APG methodology,3140.72,,,3140.72,Other,100% New York Medicaid APG,3140.72,,,3140.72,Other,100% New York Medicaid APG,3140.72,,,3140.72,Other,100% New York Medicaid APG,7066.62,,,7066.62,Other,225% New York Medicaid APG,4805.3,,,4805.3,Other,153% New York Medicaid APG,7066.62,,,7066.62,Other,225% New York Medicaid APG,4397.01,,,4397.01,Other,140% New York Medicaid APG,7066.62,,,7066.62,Other,225% New York Medicaid APG,8165.87,,,8165.87,Other,260% New York Medicaid APG,10175.93,,,10175.93,Other,324% New York Medicaid APG,6752.54,,,6752.54,Other,215% New York Medicaid APG,6752.54,,,6752.54,Other,215% New York Medicaid APG,3925.9,,,3925.9,Other,125% New York Medicaid APG,3140.72,40987.12,
Laryngoplasty medialization,31591,CPT,,,,,,,,both,,,34997.18,25897.91,74,,25897.91,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15748.73,45,,15748.73,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,17323.6,49.5,,17323.6,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,4119.28,,,4119.28,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,24498.03,70,,24498.03,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,2214.67,,,2214.67,Other,New York Medicaid APG methodology,2214.67,,,2214.67,Other,100% New York Medicaid APG,2214.67,,,2214.67,Other,100% New York Medicaid APG,2214.67,,,2214.67,Other,100% New York Medicaid APG,4983,,,4983,Other,225% New York Medicaid APG,3388.44,,,3388.44,Other,153% New York Medicaid APG,4983,,,4983,Other,225% New York Medicaid APG,3100.53,,,3100.53,Other,140% New York Medicaid APG,4983,,,4983,Other,225% New York Medicaid APG,5758.13,,,5758.13,Other,260% New York Medicaid APG,7175.52,,,7175.52,Other,324% New York Medicaid APG,4761.53,,,4761.53,Other,215% New York Medicaid APG,4761.53,,,4761.53,Other,215% New York Medicaid APG,2768.33,,,2768.33,Other,125% New York Medicaid APG,2214.67,25897.91,
Cricotracheal resection,31592,CPT,,,,,,,,both,,,123177.14,91151.08,74,,91151.08,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,55429.71,45,,55429.71,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,60972.68,49.5,,60972.68,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,4046.72,,,4046.72,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,86224,70,,86224,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,2175.66,,,2175.66,Other,New York Medicaid APG methodology,2175.66,,,2175.66,Other,100% New York Medicaid APG,2175.66,,,2175.66,Other,100% New York Medicaid APG,2175.66,,,2175.66,Other,100% New York Medicaid APG,4895.23,,,4895.23,Other,225% New York Medicaid APG,3328.76,,,3328.76,Other,153% New York Medicaid APG,4895.23,,,4895.23,Other,225% New York Medicaid APG,3045.92,,,3045.92,Other,140% New York Medicaid APG,4895.23,,,4895.23,Other,225% New York Medicaid APG,5656.71,,,5656.71,Other,260% New York Medicaid APG,7049.13,,,7049.13,Other,324% New York Medicaid APG,4677.66,,,4677.66,Other,215% New York Medicaid APG,4677.66,,,4677.66,Other,215% New York Medicaid APG,2719.57,,,2719.57,Other,125% New York Medicaid APG,2175.66,91151.08,
Incision of windpipe,31600,CPT,,,,,,,,both,,,67720.49,50113.16,74,,50113.16,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30474.22,45,,30474.22,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,33521.64,49.5,,33521.64,percent of total billed charges,110% of Medicare,46049.93,68,,46049.93,percent of total billed charges,,3493.72,,,3493.72,Other,186% of Medicaid,54176.39,80,,54176.39,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,54176.39,80,,54176.39,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,47404.34,70,,47404.34,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1878.34,,,1878.34,Other,New York Medicaid APG methodology,1878.34,,,1878.34,Other,100% New York Medicaid APG,1878.34,,,1878.34,Other,100% New York Medicaid APG,1878.34,,,1878.34,Other,100% New York Medicaid APG,4226.27,,,4226.27,Other,225% New York Medicaid APG,2873.87,,,2873.87,Other,153% New York Medicaid APG,4226.27,,,4226.27,Other,225% New York Medicaid APG,2629.68,,,2629.68,Other,140% New York Medicaid APG,4226.27,,,4226.27,Other,225% New York Medicaid APG,4883.69,,,4883.69,Other,260% New York Medicaid APG,6085.83,,,6085.83,Other,324% New York Medicaid APG,4038.44,,,4038.44,Other,215% New York Medicaid APG,4038.44,,,4038.44,Other,215% New York Medicaid APG,2347.93,,,2347.93,Other,125% New York Medicaid APG,1878.34,54176.39,
Incision of windpipe,31601,CPT,,,,,,,,both,,,123177.14,91151.08,74,,91151.08,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,55429.71,45,,55429.71,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,60972.68,49.5,,60972.68,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3493.72,,,3493.72,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,86224,70,,86224,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1878.34,,,1878.34,Other,New York Medicaid APG methodology,1878.34,,,1878.34,Other,100% New York Medicaid APG,1878.34,,,1878.34,Other,100% New York Medicaid APG,1878.34,,,1878.34,Other,100% New York Medicaid APG,4226.27,,,4226.27,Other,225% New York Medicaid APG,2873.87,,,2873.87,Other,153% New York Medicaid APG,4226.27,,,4226.27,Other,225% New York Medicaid APG,2629.68,,,2629.68,Other,140% New York Medicaid APG,4226.27,,,4226.27,Other,225% New York Medicaid APG,4883.69,,,4883.69,Other,260% New York Medicaid APG,6085.83,,,6085.83,Other,324% New York Medicaid APG,4038.44,,,4038.44,Other,215% New York Medicaid APG,4038.44,,,4038.44,Other,215% New York Medicaid APG,2347.93,,,2347.93,Other,125% New York Medicaid APG,1878.34,91151.08,
Incision of windpipe,31603,CPT,,,,,,,,both,,,32077.39,23737.27,74,,23737.27,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,14434.83,45,,14434.83,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,15878.31,49.5,,15878.31,percent of total billed charges,110% of Medicare,21812.63,68,,21812.63,percent of total billed charges,,3493.72,,,3493.72,Other,186% of Medicaid,25661.91,80,,25661.91,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,25661.91,80,,25661.91,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,22454.17,70,,22454.17,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1878.34,,,1878.34,Other,New York Medicaid APG methodology,1878.34,,,1878.34,Other,100% New York Medicaid APG,1878.34,,,1878.34,Other,100% New York Medicaid APG,1878.34,,,1878.34,Other,100% New York Medicaid APG,4226.27,,,4226.27,Other,225% New York Medicaid APG,2873.87,,,2873.87,Other,153% New York Medicaid APG,4226.27,,,4226.27,Other,225% New York Medicaid APG,2629.68,,,2629.68,Other,140% New York Medicaid APG,4226.27,,,4226.27,Other,225% New York Medicaid APG,4883.69,,,4883.69,Other,260% New York Medicaid APG,6085.83,,,6085.83,Other,324% New York Medicaid APG,4038.44,,,4038.44,Other,215% New York Medicaid APG,4038.44,,,4038.44,Other,215% New York Medicaid APG,2347.93,,,2347.93,Other,125% New York Medicaid APG,1878.34,25661.91,
Incision of windpipe,31605,CPT,,,,,,,,both,,,5137.73,3801.92,74,,3801.92,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,2311.98,45,,2311.98,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,2543.18,49.5,,2543.18,percent of total billed charges,110% of Medicare,3493.66,68,,3493.66,percent of total billed charges,,3493.72,,,3493.72,Other,186% of Medicaid,4110.18,80,,4110.18,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,4110.18,80,,4110.18,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,3596.41,70,,3596.41,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,1878.34,,,1878.34,Other,New York Medicaid APG methodology,1878.34,,,1878.34,Other,100% New York Medicaid APG,1878.34,,,1878.34,Other,100% New York Medicaid APG,1878.34,,,1878.34,Other,100% New York Medicaid APG,4226.27,,,4226.27,Other,225% New York Medicaid APG,2873.87,,,2873.87,Other,153% New York Medicaid APG,4226.27,,,4226.27,Other,225% New York Medicaid APG,2629.68,,,2629.68,Other,140% New York Medicaid APG,4226.27,,,4226.27,Other,225% New York Medicaid APG,4883.69,,,4883.69,Other,260% New York Medicaid APG,6085.83,,,6085.83,Other,324% New York Medicaid APG,4038.44,,,4038.44,Other,215% New York Medicaid APG,4038.44,,,4038.44,Other,215% New York Medicaid APG,2347.93,,,2347.93,Other,125% New York Medicaid APG,1878.34,7216,
Incision of windpipe,31610,CPT,,,,,,,,both,,,123177.14,91151.08,74,,91151.08,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,55429.71,45,,55429.71,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,60972.68,49.5,,60972.68,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3493.72,,,3493.72,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,86224,70,,86224,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1878.34,,,1878.34,Other,New York Medicaid APG methodology,1878.34,,,1878.34,Other,100% New York Medicaid APG,1878.34,,,1878.34,Other,100% New York Medicaid APG,1878.34,,,1878.34,Other,100% New York Medicaid APG,4226.27,,,4226.27,Other,225% New York Medicaid APG,2873.87,,,2873.87,Other,153% New York Medicaid APG,4226.27,,,4226.27,Other,225% New York Medicaid APG,2629.68,,,2629.68,Other,140% New York Medicaid APG,4226.27,,,4226.27,Other,225% New York Medicaid APG,4883.69,,,4883.69,Other,260% New York Medicaid APG,6085.83,,,6085.83,Other,324% New York Medicaid APG,4038.44,,,4038.44,Other,215% New York Medicaid APG,4038.44,,,4038.44,Other,215% New York Medicaid APG,2347.93,,,2347.93,Other,125% New York Medicaid APG,1878.34,91151.08,
Surgery/speech prosthesis,31611,CPT,,,,,,,,both,,,39071.66,28913.03,74,,28913.03,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,17582.25,45,,17582.25,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,19340.47,49.5,,19340.47,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3493.72,,,3493.72,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,27350.16,70,,27350.16,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1878.34,,,1878.34,Other,New York Medicaid APG methodology,1878.34,,,1878.34,Other,100% New York Medicaid APG,1878.34,,,1878.34,Other,100% New York Medicaid APG,1878.34,,,1878.34,Other,100% New York Medicaid APG,4226.27,,,4226.27,Other,225% New York Medicaid APG,2873.87,,,2873.87,Other,153% New York Medicaid APG,4226.27,,,4226.27,Other,225% New York Medicaid APG,2629.68,,,2629.68,Other,140% New York Medicaid APG,4226.27,,,4226.27,Other,225% New York Medicaid APG,4883.69,,,4883.69,Other,260% New York Medicaid APG,6085.83,,,6085.83,Other,324% New York Medicaid APG,4038.44,,,4038.44,Other,215% New York Medicaid APG,4038.44,,,4038.44,Other,215% New York Medicaid APG,2347.93,,,2347.93,Other,125% New York Medicaid APG,1878.34,28913.03,
Puncture/clear windpipe,31612,CPT,,,,,,,,both,,,67720.49,50113.16,74,,50113.16,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30474.22,45,,30474.22,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,33521.64,49.5,,33521.64,percent of total billed charges,110% of Medicare,46049.93,68,,46049.93,percent of total billed charges,,1196.64,,,1196.64,Other,186% of Medicaid,54176.39,80,,54176.39,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,54176.39,80,,54176.39,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,47404.34,70,,47404.34,percent of total billed charges,,237.8,,,237.8,Fee Schedule,,201.55,,,201.55,Fee Schedule,,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,643.35,,,643.35,Other,New York Medicaid APG methodology,643.35,,,643.35,Other,100% New York Medicaid APG,643.35,,,643.35,Other,100% New York Medicaid APG,643.35,,,643.35,Other,100% New York Medicaid APG,1447.55,,,1447.55,Other,225% New York Medicaid APG,984.33,,,984.33,Other,153% New York Medicaid APG,1447.55,,,1447.55,Other,225% New York Medicaid APG,900.7,,,900.7,Other,140% New York Medicaid APG,1447.55,,,1447.55,Other,225% New York Medicaid APG,1672.72,,,1672.72,Other,260% New York Medicaid APG,2084.47,,,2084.47,Other,324% New York Medicaid APG,1383.21,,,1383.21,Other,215% New York Medicaid APG,1383.21,,,1383.21,Other,215% New York Medicaid APG,804.19,,,804.19,Other,125% New York Medicaid APG,201.55,54176.39,
Repair windpipe opening,31613,CPT,,,,,,,,both,,,36827.53,27252.37,74,,27252.37,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,16572.39,45,,16572.39,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,18229.63,49.5,,18229.63,percent of total billed charges,110% of Medicare,25042.72,68,,25042.72,percent of total billed charges,,3493.72,,,3493.72,Other,186% of Medicaid,29462.02,80,,29462.02,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,29462.02,80,,29462.02,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,25779.27,70,,25779.27,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1878.34,,,1878.34,Other,New York Medicaid APG methodology,1878.34,,,1878.34,Other,100% New York Medicaid APG,1878.34,,,1878.34,Other,100% New York Medicaid APG,1878.34,,,1878.34,Other,100% New York Medicaid APG,4226.27,,,4226.27,Other,225% New York Medicaid APG,2873.87,,,2873.87,Other,153% New York Medicaid APG,4226.27,,,4226.27,Other,225% New York Medicaid APG,2629.68,,,2629.68,Other,140% New York Medicaid APG,4226.27,,,4226.27,Other,225% New York Medicaid APG,4883.69,,,4883.69,Other,260% New York Medicaid APG,6085.83,,,6085.83,Other,324% New York Medicaid APG,4038.44,,,4038.44,Other,215% New York Medicaid APG,4038.44,,,4038.44,Other,215% New York Medicaid APG,2347.93,,,2347.93,Other,125% New York Medicaid APG,1878.34,29462.02,
Repair windpipe opening,31614,CPT,,,,,,,,both,,,46626.08,34503.3,74,,34503.3,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,20981.74,45,,20981.74,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,23079.91,49.5,,23079.91,percent of total billed charges,110% of Medicare,31705.73,68,,31705.73,percent of total billed charges,,3493.72,,,3493.72,Other,186% of Medicaid,37300.86,80,,37300.86,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,37300.86,80,,37300.86,percent of total billed charges,,7216,,,7216,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,32638.26,70,,32638.26,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,1878.34,,,1878.34,Other,New York Medicaid APG methodology,1878.34,,,1878.34,Other,100% New York Medicaid APG,1878.34,,,1878.34,Other,100% New York Medicaid APG,1878.34,,,1878.34,Other,100% New York Medicaid APG,4226.27,,,4226.27,Other,225% New York Medicaid APG,2873.87,,,2873.87,Other,153% New York Medicaid APG,4226.27,,,4226.27,Other,225% New York Medicaid APG,2629.68,,,2629.68,Other,140% New York Medicaid APG,4226.27,,,4226.27,Other,225% New York Medicaid APG,4883.69,,,4883.69,Other,260% New York Medicaid APG,6085.83,,,6085.83,Other,324% New York Medicaid APG,4038.44,,,4038.44,Other,215% New York Medicaid APG,4038.44,,,4038.44,Other,215% New York Medicaid APG,2347.93,,,2347.93,Other,125% New York Medicaid APG,1878.34,37300.86,
Visualization of windpipe,31615,CPT,,,,,,,,both,,,11572.85,8563.91,74,,8563.91,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,5207.78,45,,5207.78,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,5728.56,49.5,,5728.56,percent of total billed charges,110% of Medicare,7869.54,68,,7869.54,percent of total billed charges,,2135.15,,,2135.15,Other,186% of Medicaid,9258.28,80,,9258.28,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,9258.28,80,,9258.28,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,8101,70,,8101,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,1147.93,,,1147.93,Other,New York Medicaid APG methodology,1147.93,,,1147.93,Other,100% New York Medicaid APG,1147.93,,,1147.93,Other,100% New York Medicaid APG,1147.93,,,1147.93,Other,100% New York Medicaid APG,2582.84,,,2582.84,Other,225% New York Medicaid APG,1756.33,,,1756.33,Other,153% New York Medicaid APG,2582.84,,,2582.84,Other,225% New York Medicaid APG,1607.1,,,1607.1,Other,140% New York Medicaid APG,2582.84,,,2582.84,Other,225% New York Medicaid APG,2984.62,,,2984.62,Other,260% New York Medicaid APG,3719.29,,,3719.29,Other,324% New York Medicaid APG,2468.05,,,2468.05,Other,215% New York Medicaid APG,2468.05,,,2468.05,Other,215% New York Medicaid APG,1434.91,,,1434.91,Other,125% New York Medicaid APG,1147.93,9258.28,
Dx bronchoscope/wash,31622,CPT,,,,,,,,both,,,37079.01,27438.47,74,,27438.47,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,16685.55,45,,16685.55,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,18354.11,49.5,,18354.11,percent of total billed charges,110% of Medicare,25213.73,68,,25213.73,percent of total billed charges,,2135.15,,,2135.15,Other,186% of Medicaid,29663.21,80,,29663.21,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,29663.21,80,,29663.21,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,25955.31,70,,25955.31,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1147.93,,,1147.93,Other,New York Medicaid APG methodology,1147.93,,,1147.93,Other,100% New York Medicaid APG,1147.93,,,1147.93,Other,100% New York Medicaid APG,1147.93,,,1147.93,Other,100% New York Medicaid APG,2582.84,,,2582.84,Other,225% New York Medicaid APG,1756.33,,,1756.33,Other,153% New York Medicaid APG,2582.84,,,2582.84,Other,225% New York Medicaid APG,1607.1,,,1607.1,Other,140% New York Medicaid APG,2582.84,,,2582.84,Other,225% New York Medicaid APG,2984.62,,,2984.62,Other,260% New York Medicaid APG,3719.29,,,3719.29,Other,324% New York Medicaid APG,2468.05,,,2468.05,Other,215% New York Medicaid APG,2468.05,,,2468.05,Other,215% New York Medicaid APG,1434.91,,,1434.91,Other,125% New York Medicaid APG,1147.93,29663.21,
Dx bronchoscope/brush,31623,CPT,,,,,,,,both,,,43100.6,31894.44,74,,31894.44,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,19395.27,45,,19395.27,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,21334.8,49.5,,21334.8,percent of total billed charges,110% of Medicare,29308.41,68,,29308.41,percent of total billed charges,,2135.15,,,2135.15,Other,186% of Medicaid,34480.48,80,,34480.48,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,34480.48,80,,34480.48,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,30170.42,70,,30170.42,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1147.93,,,1147.93,Other,New York Medicaid APG methodology,1147.93,,,1147.93,Other,100% New York Medicaid APG,1147.93,,,1147.93,Other,100% New York Medicaid APG,1147.93,,,1147.93,Other,100% New York Medicaid APG,2582.84,,,2582.84,Other,225% New York Medicaid APG,1756.33,,,1756.33,Other,153% New York Medicaid APG,2582.84,,,2582.84,Other,225% New York Medicaid APG,1607.1,,,1607.1,Other,140% New York Medicaid APG,2582.84,,,2582.84,Other,225% New York Medicaid APG,2984.62,,,2984.62,Other,260% New York Medicaid APG,3719.29,,,3719.29,Other,324% New York Medicaid APG,2468.05,,,2468.05,Other,215% New York Medicaid APG,2468.05,,,2468.05,Other,215% New York Medicaid APG,1434.91,,,1434.91,Other,125% New York Medicaid APG,1147.93,34480.48,
Dx bronchoscope/lavage,31624,CPT,,,,,,,,both,,,39238.97,29036.84,74,,29036.84,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,17657.54,45,,17657.54,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,19423.29,49.5,,19423.29,percent of total billed charges,110% of Medicare,26682.5,68,,26682.5,percent of total billed charges,,2135.15,,,2135.15,Other,186% of Medicaid,31391.18,80,,31391.18,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,31391.18,80,,31391.18,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,27467.28,70,,27467.28,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1147.93,,,1147.93,Other,New York Medicaid APG methodology,1147.93,,,1147.93,Other,100% New York Medicaid APG,1147.93,,,1147.93,Other,100% New York Medicaid APG,1147.93,,,1147.93,Other,100% New York Medicaid APG,2582.84,,,2582.84,Other,225% New York Medicaid APG,1756.33,,,1756.33,Other,153% New York Medicaid APG,2582.84,,,2582.84,Other,225% New York Medicaid APG,1607.1,,,1607.1,Other,140% New York Medicaid APG,2582.84,,,2582.84,Other,225% New York Medicaid APG,2984.62,,,2984.62,Other,260% New York Medicaid APG,3719.29,,,3719.29,Other,324% New York Medicaid APG,2468.05,,,2468.05,Other,215% New York Medicaid APG,2468.05,,,2468.05,Other,215% New York Medicaid APG,1434.91,,,1434.91,Other,125% New York Medicaid APG,1147.93,31391.18,
Bronchoscopy w/biopsy(s),31625,CPT,,,,,,,,both,,,45889.33,33958.1,74,,33958.1,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,20650.2,45,,20650.2,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,22715.22,49.5,,22715.22,percent of total billed charges,110% of Medicare,31204.74,68,,31204.74,percent of total billed charges,,2135.15,,,2135.15,Other,186% of Medicaid,36711.46,80,,36711.46,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,36711.46,80,,36711.46,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,32122.53,70,,32122.53,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1147.93,,,1147.93,Other,New York Medicaid APG methodology,1147.93,,,1147.93,Other,100% New York Medicaid APG,1147.93,,,1147.93,Other,100% New York Medicaid APG,1147.93,,,1147.93,Other,100% New York Medicaid APG,2582.84,,,2582.84,Other,225% New York Medicaid APG,1756.33,,,1756.33,Other,153% New York Medicaid APG,2582.84,,,2582.84,Other,225% New York Medicaid APG,1607.1,,,1607.1,Other,140% New York Medicaid APG,2582.84,,,2582.84,Other,225% New York Medicaid APG,2984.62,,,2984.62,Other,260% New York Medicaid APG,3719.29,,,3719.29,Other,324% New York Medicaid APG,2468.05,,,2468.05,Other,215% New York Medicaid APG,2468.05,,,2468.05,Other,215% New York Medicaid APG,1434.91,,,1434.91,Other,125% New York Medicaid APG,1147.93,36711.46,
Bronchoscopy w/markers,31626,CPT,,,,,,,,both,,,143961.17,106531.27,74,,106531.27,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,64782.53,45,,64782.53,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,7266,,"100% primary, 50% secondary, 25% supplemental procedure",7266,Other,Blue Cross ASC Grouper,6539,,"100% primary, 50% secondary, 25% supplemental procedure",6539,Other,Blue Cross ASC Grouper,6176,,"100% primary, 50% secondary, 25% supplemental procedure",6176,Other,Blue Cross ASC Grouper,71260.78,49.5,,71260.78,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2135.15,,,2135.15,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,100772.82,70,,100772.82,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1147.93,,,1147.93,Other,New York Medicaid APG methodology,1147.93,,,1147.93,Other,100% New York Medicaid APG,1147.93,,,1147.93,Other,100% New York Medicaid APG,1147.93,,,1147.93,Other,100% New York Medicaid APG,2582.84,,,2582.84,Other,225% New York Medicaid APG,1756.33,,,1756.33,Other,153% New York Medicaid APG,2582.84,,,2582.84,Other,225% New York Medicaid APG,1607.1,,,1607.1,Other,140% New York Medicaid APG,2582.84,,,2582.84,Other,225% New York Medicaid APG,2984.62,,,2984.62,Other,260% New York Medicaid APG,3719.29,,,3719.29,Other,324% New York Medicaid APG,2468.05,,,2468.05,Other,215% New York Medicaid APG,2468.05,,,2468.05,Other,215% New York Medicaid APG,1434.91,,,1434.91,Other,125% New York Medicaid APG,1147.93,106531.27,
Navigational bronchoscopy,31627,CPT,,,,,,,,both,,,59722.25,44194.47,74,,44194.47,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,26875.01,45,,26875.01,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,35833.35,60,,35833.35,percent of total billed charges,,33444.46,56,,33444.46,percent of total billed charges,,32250.02,54,,32250.02,percent of total billed charges,,29562.51,49.5,,29562.51,percent of total billed charges,110% of Medicare,40611.13,68,,40611.13,percent of total billed charges,,3002.5,,,3002.5,Other,186% of Medicaid,47777.8,80,,47777.8,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,47777.8,80,,47777.8,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,41805.58,70,,41805.58,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,1614.25,,,1614.25,Other,New York Medicaid APG methodology,1614.25,,,1614.25,Other,100% New York Medicaid APG,1614.25,,,1614.25,Other,100% New York Medicaid APG,1614.25,,,1614.25,Other,100% New York Medicaid APG,3632.06,,,3632.06,Other,225% New York Medicaid APG,2469.8,,,2469.8,Other,153% New York Medicaid APG,3632.06,,,3632.06,Other,225% New York Medicaid APG,2259.95,,,2259.95,Other,140% New York Medicaid APG,3632.06,,,3632.06,Other,225% New York Medicaid APG,4197.05,,,4197.05,Other,260% New York Medicaid APG,5230.17,,,5230.17,Other,324% New York Medicaid APG,3470.64,,,3470.64,Other,215% New York Medicaid APG,3470.64,,,3470.64,Other,215% New York Medicaid APG,2017.81,,,2017.81,Other,125% New York Medicaid APG,1614.25,47777.8,
Bronchoscopy/lung bx each,31628,CPT,,,,,,,,both,,,56748.72,41994.05,74,,41994.05,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,25536.92,45,,25536.92,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,28090.62,49.5,,28090.62,percent of total billed charges,110% of Medicare,38589.13,68,,38589.13,percent of total billed charges,,2135.15,,,2135.15,Other,186% of Medicaid,45398.98,80,,45398.98,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,45398.98,80,,45398.98,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,39724.1,70,,39724.1,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1147.93,,,1147.93,Other,New York Medicaid APG methodology,1147.93,,,1147.93,Other,100% New York Medicaid APG,1147.93,,,1147.93,Other,100% New York Medicaid APG,1147.93,,,1147.93,Other,100% New York Medicaid APG,2582.84,,,2582.84,Other,225% New York Medicaid APG,1756.33,,,1756.33,Other,153% New York Medicaid APG,2582.84,,,2582.84,Other,225% New York Medicaid APG,1607.1,,,1607.1,Other,140% New York Medicaid APG,2582.84,,,2582.84,Other,225% New York Medicaid APG,2984.62,,,2984.62,Other,260% New York Medicaid APG,3719.29,,,3719.29,Other,324% New York Medicaid APG,2468.05,,,2468.05,Other,215% New York Medicaid APG,2468.05,,,2468.05,Other,215% New York Medicaid APG,1434.91,,,1434.91,Other,125% New York Medicaid APG,1147.93,45398.98,
Bronchoscopy/needle bx each,31629,CPT,,,,,,,,both,,,68153.41,50433.52,74,,50433.52,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30669.03,45,,30669.03,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33735.94,49.5,,33735.94,percent of total billed charges,110% of Medicare,46344.32,68,,46344.32,percent of total billed charges,,2135.15,,,2135.15,Other,186% of Medicaid,54522.73,80,,54522.73,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,54522.73,80,,54522.73,percent of total billed charges,,7216,,,7216,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,47707.39,70,,47707.39,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1147.93,,,1147.93,Other,New York Medicaid APG methodology,1147.93,,,1147.93,Other,100% New York Medicaid APG,1147.93,,,1147.93,Other,100% New York Medicaid APG,1147.93,,,1147.93,Other,100% New York Medicaid APG,2582.84,,,2582.84,Other,225% New York Medicaid APG,1756.33,,,1756.33,Other,153% New York Medicaid APG,2582.84,,,2582.84,Other,225% New York Medicaid APG,1607.1,,,1607.1,Other,140% New York Medicaid APG,2582.84,,,2582.84,Other,225% New York Medicaid APG,2984.62,,,2984.62,Other,260% New York Medicaid APG,3719.29,,,3719.29,Other,324% New York Medicaid APG,2468.05,,,2468.05,Other,215% New York Medicaid APG,2468.05,,,2468.05,Other,215% New York Medicaid APG,1434.91,,,1434.91,Other,125% New York Medicaid APG,1147.93,54522.73,
Bronchoscopy dilate/fx repr,31630,CPT,,,,,,,,both,,,37547.22,27784.94,74,,27784.94,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,16896.25,45,,16896.25,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,18585.87,49.5,,18585.87,percent of total billed charges,110% of Medicare,25532.11,68,,25532.11,percent of total billed charges,,2328.45,,,2328.45,Other,186% of Medicaid,30037.78,80,,30037.78,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,30037.78,80,,30037.78,percent of total billed charges,,7216,,,7216,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,26283.05,70,,26283.05,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1251.86,,,1251.86,Other,New York Medicaid APG methodology,1251.86,,,1251.86,Other,100% New York Medicaid APG,1251.86,,,1251.86,Other,100% New York Medicaid APG,1251.86,,,1251.86,Other,100% New York Medicaid APG,2816.67,,,2816.67,Other,225% New York Medicaid APG,1915.34,,,1915.34,Other,153% New York Medicaid APG,2816.67,,,2816.67,Other,225% New York Medicaid APG,1752.6,,,1752.6,Other,140% New York Medicaid APG,2816.67,,,2816.67,Other,225% New York Medicaid APG,3254.82,,,3254.82,Other,260% New York Medicaid APG,4056.01,,,4056.01,Other,324% New York Medicaid APG,2691.49,,,2691.49,Other,215% New York Medicaid APG,2691.49,,,2691.49,Other,215% New York Medicaid APG,1564.82,,,1564.82,Other,125% New York Medicaid APG,1251.86,30037.78,
Bronchoscopy dilate w/stent,31631,CPT,,,,,,,,both,,,143961.17,106531.27,74,,106531.27,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,64782.53,45,,64782.53,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,7266,,"100% primary, 50% secondary, 25% supplemental procedure",7266,Other,Blue Cross ASC Grouper,6539,,"100% primary, 50% secondary, 25% supplemental procedure",6539,Other,Blue Cross ASC Grouper,6176,,"100% primary, 50% secondary, 25% supplemental procedure",6176,Other,Blue Cross ASC Grouper,71260.78,49.5,,71260.78,percent of total billed charges,110% of Medicare,97893.6,68,,97893.6,percent of total billed charges,,2328.45,,,2328.45,Other,186% of Medicaid,115168.94,80,,115168.94,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,115168.94,80,,115168.94,percent of total billed charges,,7216,,,7216,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,100772.82,70,,100772.82,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1251.86,,,1251.86,Other,New York Medicaid APG methodology,1251.86,,,1251.86,Other,100% New York Medicaid APG,1251.86,,,1251.86,Other,100% New York Medicaid APG,1251.86,,,1251.86,Other,100% New York Medicaid APG,2816.67,,,2816.67,Other,225% New York Medicaid APG,1915.34,,,1915.34,Other,153% New York Medicaid APG,2816.67,,,2816.67,Other,225% New York Medicaid APG,1752.6,,,1752.6,Other,140% New York Medicaid APG,2816.67,,,2816.67,Other,225% New York Medicaid APG,3254.82,,,3254.82,Other,260% New York Medicaid APG,4056.01,,,4056.01,Other,324% New York Medicaid APG,2691.49,,,2691.49,Other,215% New York Medicaid APG,2691.49,,,2691.49,Other,215% New York Medicaid APG,1564.82,,,1564.82,Other,125% New York Medicaid APG,1251.86,115168.94,
Bronchoscopy/lung bx addl,31632,CPT,,,,,,,,both,,,51572.04,38163.31,74,,38163.31,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,23207.42,45,,23207.42,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,25528.16,49.5,,25528.16,percent of total billed charges,110% of Medicare,35068.99,68,,35068.99,percent of total billed charges,,2135.15,,,2135.15,Other,186% of Medicaid,41257.63,80,,41257.63,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,41257.63,80,,41257.63,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,36100.43,70,,36100.43,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,1147.93,,,1147.93,Other,New York Medicaid APG methodology,1147.93,,,1147.93,Other,100% New York Medicaid APG,1147.93,,,1147.93,Other,100% New York Medicaid APG,1147.93,,,1147.93,Other,100% New York Medicaid APG,2582.84,,,2582.84,Other,225% New York Medicaid APG,1756.33,,,1756.33,Other,153% New York Medicaid APG,2582.84,,,2582.84,Other,225% New York Medicaid APG,1607.1,,,1607.1,Other,140% New York Medicaid APG,2582.84,,,2582.84,Other,225% New York Medicaid APG,2984.62,,,2984.62,Other,260% New York Medicaid APG,3719.29,,,3719.29,Other,324% New York Medicaid APG,2468.05,,,2468.05,Other,215% New York Medicaid APG,2468.05,,,2468.05,Other,215% New York Medicaid APG,1434.91,,,1434.91,Other,125% New York Medicaid APG,1147.93,41257.63,
Bronchoscopy/needle bx addl,31633,CPT,,,,,,,,both,,,51572.04,38163.31,74,,38163.31,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,23207.42,45,,23207.42,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,25528.16,49.5,,25528.16,percent of total billed charges,110% of Medicare,35068.99,68,,35068.99,percent of total billed charges,,2135.15,,,2135.15,Other,186% of Medicaid,41257.63,80,,41257.63,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,41257.63,80,,41257.63,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,36100.43,70,,36100.43,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,1147.93,,,1147.93,Other,New York Medicaid APG methodology,1147.93,,,1147.93,Other,100% New York Medicaid APG,1147.93,,,1147.93,Other,100% New York Medicaid APG,1147.93,,,1147.93,Other,100% New York Medicaid APG,2582.84,,,2582.84,Other,225% New York Medicaid APG,1756.33,,,1756.33,Other,153% New York Medicaid APG,2582.84,,,2582.84,Other,225% New York Medicaid APG,1607.1,,,1607.1,Other,140% New York Medicaid APG,2582.84,,,2582.84,Other,225% New York Medicaid APG,2984.62,,,2984.62,Other,260% New York Medicaid APG,3719.29,,,3719.29,Other,324% New York Medicaid APG,2468.05,,,2468.05,Other,215% New York Medicaid APG,2468.05,,,2468.05,Other,215% New York Medicaid APG,1434.91,,,1434.91,Other,125% New York Medicaid APG,1147.93,41257.63,
Bronch w/balloon occlusion,31634,CPT,,,,,,,,both,,,143961.17,106531.27,74,,106531.27,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,64782.53,45,,64782.53,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,7266,,"100% primary, 50% secondary, 25% supplemental procedure",7266,Other,Blue Cross ASC Grouper,6539,,"100% primary, 50% secondary, 25% supplemental procedure",6539,Other,Blue Cross ASC Grouper,6176,,"100% primary, 50% secondary, 25% supplemental procedure",6176,Other,Blue Cross ASC Grouper,71260.78,49.5,,71260.78,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2328.45,,,2328.45,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,100772.82,70,,100772.82,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1251.86,,,1251.86,Other,New York Medicaid APG methodology,1251.86,,,1251.86,Other,100% New York Medicaid APG,1251.86,,,1251.86,Other,100% New York Medicaid APG,1251.86,,,1251.86,Other,100% New York Medicaid APG,2816.67,,,2816.67,Other,225% New York Medicaid APG,1915.34,,,1915.34,Other,153% New York Medicaid APG,2816.67,,,2816.67,Other,225% New York Medicaid APG,1752.6,,,1752.6,Other,140% New York Medicaid APG,2816.67,,,2816.67,Other,225% New York Medicaid APG,3254.82,,,3254.82,Other,260% New York Medicaid APG,4056.01,,,4056.01,Other,324% New York Medicaid APG,2691.49,,,2691.49,Other,215% New York Medicaid APG,2691.49,,,2691.49,Other,215% New York Medicaid APG,1564.82,,,1564.82,Other,125% New York Medicaid APG,1251.86,106531.27,
Bronchoscopy w/fb removal,31635,CPT,,,,,,,,both,,,35553.87,26309.86,74,,26309.86,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15999.24,45,,15999.24,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,17599.17,49.5,,17599.17,percent of total billed charges,110% of Medicare,24176.63,68,,24176.63,percent of total billed charges,,2135.15,,,2135.15,Other,186% of Medicaid,28443.1,80,,28443.1,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,28443.1,80,,28443.1,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,24887.71,70,,24887.71,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1147.93,,,1147.93,Other,New York Medicaid APG methodology,1147.93,,,1147.93,Other,100% New York Medicaid APG,1147.93,,,1147.93,Other,100% New York Medicaid APG,1147.93,,,1147.93,Other,100% New York Medicaid APG,2582.84,,,2582.84,Other,225% New York Medicaid APG,1756.33,,,1756.33,Other,153% New York Medicaid APG,2582.84,,,2582.84,Other,225% New York Medicaid APG,1607.1,,,1607.1,Other,140% New York Medicaid APG,2582.84,,,2582.84,Other,225% New York Medicaid APG,2984.62,,,2984.62,Other,260% New York Medicaid APG,3719.29,,,3719.29,Other,324% New York Medicaid APG,2468.05,,,2468.05,Other,215% New York Medicaid APG,2468.05,,,2468.05,Other,215% New York Medicaid APG,1434.91,,,1434.91,Other,125% New York Medicaid APG,1147.93,28443.1,
Bronchoscopy bronch stents,31636,CPT,,,,,,,,both,,,44965.28,33274.31,74,,33274.31,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,20234.38,45,,20234.38,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,7266,,"100% primary, 50% secondary, 25% supplemental procedure",7266,Other,Blue Cross ASC Grouper,6539,,"100% primary, 50% secondary, 25% supplemental procedure",6539,Other,Blue Cross ASC Grouper,6176,,"100% primary, 50% secondary, 25% supplemental procedure",6176,Other,Blue Cross ASC Grouper,22257.81,49.5,,22257.81,percent of total billed charges,110% of Medicare,30576.39,68,,30576.39,percent of total billed charges,,2328.45,,,2328.45,Other,186% of Medicaid,35972.22,80,,35972.22,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,35972.22,80,,35972.22,percent of total billed charges,,7216,,,7216,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,31475.7,70,,31475.7,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1251.86,,,1251.86,Other,New York Medicaid APG methodology,1251.86,,,1251.86,Other,100% New York Medicaid APG,1251.86,,,1251.86,Other,100% New York Medicaid APG,1251.86,,,1251.86,Other,100% New York Medicaid APG,2816.67,,,2816.67,Other,225% New York Medicaid APG,1915.34,,,1915.34,Other,153% New York Medicaid APG,2816.67,,,2816.67,Other,225% New York Medicaid APG,1752.6,,,1752.6,Other,140% New York Medicaid APG,2816.67,,,2816.67,Other,225% New York Medicaid APG,3254.82,,,3254.82,Other,260% New York Medicaid APG,4056.01,,,4056.01,Other,324% New York Medicaid APG,2691.49,,,2691.49,Other,215% New York Medicaid APG,2691.49,,,2691.49,Other,215% New York Medicaid APG,1564.82,,,1564.82,Other,125% New York Medicaid APG,1251.86,35972.22,
Bronchoscopy stent add-on,31637,CPT,,,,,,,,both,,,32432.1,23999.75,74,,23999.75,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,14594.45,45,,14594.45,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,16053.89,49.5,,16053.89,percent of total billed charges,110% of Medicare,22053.83,68,,22053.83,percent of total billed charges,,2328.45,,,2328.45,Other,186% of Medicaid,25945.68,80,,25945.68,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,25945.68,80,,25945.68,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,22702.47,70,,22702.47,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,1251.86,,,1251.86,Other,New York Medicaid APG methodology,1251.86,,,1251.86,Other,100% New York Medicaid APG,1251.86,,,1251.86,Other,100% New York Medicaid APG,1251.86,,,1251.86,Other,100% New York Medicaid APG,2816.67,,,2816.67,Other,225% New York Medicaid APG,1915.34,,,1915.34,Other,153% New York Medicaid APG,2816.67,,,2816.67,Other,225% New York Medicaid APG,1752.6,,,1752.6,Other,140% New York Medicaid APG,2816.67,,,2816.67,Other,225% New York Medicaid APG,3254.82,,,3254.82,Other,260% New York Medicaid APG,4056.01,,,4056.01,Other,324% New York Medicaid APG,2691.49,,,2691.49,Other,215% New York Medicaid APG,2691.49,,,2691.49,Other,215% New York Medicaid APG,1564.82,,,1564.82,Other,125% New York Medicaid APG,1251.86,25945.68,
Bronchoscopy revise stent,31638,CPT,,,,,,,,both,,,38273,28322.02,74,,28322.02,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,17222.85,45,,17222.85,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,7266,,"100% primary, 50% secondary, 25% supplemental procedure",7266,Other,Blue Cross ASC Grouper,6539,,"100% primary, 50% secondary, 25% supplemental procedure",6539,Other,Blue Cross ASC Grouper,6176,,"100% primary, 50% secondary, 25% supplemental procedure",6176,Other,Blue Cross ASC Grouper,18945.14,49.5,,18945.14,percent of total billed charges,110% of Medicare,26025.64,68,,26025.64,percent of total billed charges,,2328.45,,,2328.45,Other,186% of Medicaid,30618.4,80,,30618.4,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,30618.4,80,,30618.4,percent of total billed charges,,7216,,,7216,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,26791.1,70,,26791.1,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1251.86,,,1251.86,Other,New York Medicaid APG methodology,1251.86,,,1251.86,Other,100% New York Medicaid APG,1251.86,,,1251.86,Other,100% New York Medicaid APG,1251.86,,,1251.86,Other,100% New York Medicaid APG,2816.67,,,2816.67,Other,225% New York Medicaid APG,1915.34,,,1915.34,Other,153% New York Medicaid APG,2816.67,,,2816.67,Other,225% New York Medicaid APG,1752.6,,,1752.6,Other,140% New York Medicaid APG,2816.67,,,2816.67,Other,225% New York Medicaid APG,3254.82,,,3254.82,Other,260% New York Medicaid APG,4056.01,,,4056.01,Other,324% New York Medicaid APG,2691.49,,,2691.49,Other,215% New York Medicaid APG,2691.49,,,2691.49,Other,215% New York Medicaid APG,1564.82,,,1564.82,Other,125% New York Medicaid APG,1251.86,30618.4,
Bronchoscopy w/tumor excise,31640,CPT,,,,,,,,both,,,46256.93,34230.13,74,,34230.13,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,20815.62,45,,20815.62,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,22897.18,49.5,,22897.18,percent of total billed charges,110% of Medicare,31454.71,68,,31454.71,percent of total billed charges,,2328.45,,,2328.45,Other,186% of Medicaid,37005.54,80,,37005.54,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,37005.54,80,,37005.54,percent of total billed charges,,7216,,,7216,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,32379.85,70,,32379.85,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1251.86,,,1251.86,Other,New York Medicaid APG methodology,1251.86,,,1251.86,Other,100% New York Medicaid APG,1251.86,,,1251.86,Other,100% New York Medicaid APG,1251.86,,,1251.86,Other,100% New York Medicaid APG,2816.67,,,2816.67,Other,225% New York Medicaid APG,1915.34,,,1915.34,Other,153% New York Medicaid APG,2816.67,,,2816.67,Other,225% New York Medicaid APG,1752.6,,,1752.6,Other,140% New York Medicaid APG,2816.67,,,2816.67,Other,225% New York Medicaid APG,3254.82,,,3254.82,Other,260% New York Medicaid APG,4056.01,,,4056.01,Other,324% New York Medicaid APG,2691.49,,,2691.49,Other,215% New York Medicaid APG,2691.49,,,2691.49,Other,215% New York Medicaid APG,1564.82,,,1564.82,Other,125% New York Medicaid APG,1251.86,37005.54,
Bronchoscopy treat blockage,31641,CPT,,,,,,,,both,,,37178.25,27511.91,74,,27511.91,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,16730.21,45,,16730.21,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,18403.23,49.5,,18403.23,percent of total billed charges,110% of Medicare,25281.21,68,,25281.21,percent of total billed charges,,2328.45,,,2328.45,Other,186% of Medicaid,29742.6,80,,29742.6,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,29742.6,80,,29742.6,percent of total billed charges,,7216,,,7216,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,26024.78,70,,26024.78,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1251.86,,,1251.86,Other,New York Medicaid APG methodology,1251.86,,,1251.86,Other,100% New York Medicaid APG,1251.86,,,1251.86,Other,100% New York Medicaid APG,1251.86,,,1251.86,Other,100% New York Medicaid APG,2816.67,,,2816.67,Other,225% New York Medicaid APG,1915.34,,,1915.34,Other,153% New York Medicaid APG,2816.67,,,2816.67,Other,225% New York Medicaid APG,1752.6,,,1752.6,Other,140% New York Medicaid APG,2816.67,,,2816.67,Other,225% New York Medicaid APG,3254.82,,,3254.82,Other,260% New York Medicaid APG,4056.01,,,4056.01,Other,324% New York Medicaid APG,2691.49,,,2691.49,Other,215% New York Medicaid APG,2691.49,,,2691.49,Other,215% New York Medicaid APG,1564.82,,,1564.82,Other,125% New York Medicaid APG,1251.86,29742.6,
Diag bronchoscope/catheter,31643,CPT,,,,,,,,both,,,35699.83,26417.87,74,,26417.87,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,16064.92,45,,16064.92,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,17671.42,49.5,,17671.42,percent of total billed charges,110% of Medicare,24275.88,68,,24275.88,percent of total billed charges,,2135.15,,,2135.15,Other,186% of Medicaid,28559.86,80,,28559.86,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,28559.86,80,,28559.86,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,24989.88,70,,24989.88,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1147.93,,,1147.93,Other,New York Medicaid APG methodology,1147.93,,,1147.93,Other,100% New York Medicaid APG,1147.93,,,1147.93,Other,100% New York Medicaid APG,1147.93,,,1147.93,Other,100% New York Medicaid APG,2582.84,,,2582.84,Other,225% New York Medicaid APG,1756.33,,,1756.33,Other,153% New York Medicaid APG,2582.84,,,2582.84,Other,225% New York Medicaid APG,1607.1,,,1607.1,Other,140% New York Medicaid APG,2582.84,,,2582.84,Other,225% New York Medicaid APG,2984.62,,,2984.62,Other,260% New York Medicaid APG,3719.29,,,3719.29,Other,324% New York Medicaid APG,2468.05,,,2468.05,Other,215% New York Medicaid APG,2468.05,,,2468.05,Other,215% New York Medicaid APG,1434.91,,,1434.91,Other,125% New York Medicaid APG,1147.93,28559.86,
Brnchsc w/ther aspir 1st,31645,CPT,,,,,,,,both,,,36693.03,27152.84,74,,27152.84,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,16511.86,45,,16511.86,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,18163.05,49.5,,18163.05,percent of total billed charges,110% of Medicare,24951.26,68,,24951.26,percent of total billed charges,,2135.15,,,2135.15,Other,186% of Medicaid,29354.42,80,,29354.42,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,29354.42,80,,29354.42,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,25685.12,70,,25685.12,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1147.93,,,1147.93,Other,New York Medicaid APG methodology,1147.93,,,1147.93,Other,100% New York Medicaid APG,1147.93,,,1147.93,Other,100% New York Medicaid APG,1147.93,,,1147.93,Other,100% New York Medicaid APG,2582.84,,,2582.84,Other,225% New York Medicaid APG,1756.33,,,1756.33,Other,153% New York Medicaid APG,2582.84,,,2582.84,Other,225% New York Medicaid APG,1607.1,,,1607.1,Other,140% New York Medicaid APG,2582.84,,,2582.84,Other,225% New York Medicaid APG,2984.62,,,2984.62,Other,260% New York Medicaid APG,3719.29,,,3719.29,Other,324% New York Medicaid APG,2468.05,,,2468.05,Other,215% New York Medicaid APG,2468.05,,,2468.05,Other,215% New York Medicaid APG,1434.91,,,1434.91,Other,125% New York Medicaid APG,1147.93,29354.42,
Brnchsc w/ther aspir sbsq,31646,CPT,,,,,,,,both,,,8588.63,6355.59,74,,6355.59,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,3864.88,45,,3864.88,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,4251.37,49.5,,4251.37,percent of total billed charges,110% of Medicare,5840.27,68,,5840.27,percent of total billed charges,,2135.15,,,2135.15,Other,186% of Medicaid,6870.9,80,,6870.9,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,6870.9,80,,6870.9,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,6012.04,70,,6012.04,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,1147.93,,,1147.93,Other,New York Medicaid APG methodology,1147.93,,,1147.93,Other,100% New York Medicaid APG,1147.93,,,1147.93,Other,100% New York Medicaid APG,1147.93,,,1147.93,Other,100% New York Medicaid APG,2582.84,,,2582.84,Other,225% New York Medicaid APG,1756.33,,,1756.33,Other,153% New York Medicaid APG,2582.84,,,2582.84,Other,225% New York Medicaid APG,1607.1,,,1607.1,Other,140% New York Medicaid APG,2582.84,,,2582.84,Other,225% New York Medicaid APG,2984.62,,,2984.62,Other,260% New York Medicaid APG,3719.29,,,3719.29,Other,324% New York Medicaid APG,2468.05,,,2468.05,Other,215% New York Medicaid APG,2468.05,,,2468.05,Other,215% New York Medicaid APG,1434.91,,,1434.91,Other,125% New York Medicaid APG,1147.93,7216,
Bronchial valve init insert,31647,CPT,,,,,,,,both,,,143961.17,106531.27,74,,106531.27,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,64782.53,45,,64782.53,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,7266,,"100% primary, 50% secondary, 25% supplemental procedure",7266,Other,Blue Cross ASC Grouper,6539,,"100% primary, 50% secondary, 25% supplemental procedure",6539,Other,Blue Cross ASC Grouper,6176,,"100% primary, 50% secondary, 25% supplemental procedure",6176,Other,Blue Cross ASC Grouper,71260.78,49.5,,71260.78,percent of total billed charges,110% of Medicare,97893.6,68,,97893.6,percent of total billed charges,,2328.45,,,2328.45,Other,186% of Medicaid,115168.94,80,,115168.94,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,115168.94,80,,115168.94,percent of total billed charges,,7216,,,7216,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,100772.82,70,,100772.82,percent of total billed charges,,980.72,,,980.72,Fee Schedule,,831.22,,,831.22,Fee Schedule,,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1251.86,,,1251.86,Other,New York Medicaid APG methodology,1251.86,,,1251.86,Other,100% New York Medicaid APG,1251.86,,,1251.86,Other,100% New York Medicaid APG,1251.86,,,1251.86,Other,100% New York Medicaid APG,2816.67,,,2816.67,Other,225% New York Medicaid APG,1915.34,,,1915.34,Other,153% New York Medicaid APG,2816.67,,,2816.67,Other,225% New York Medicaid APG,1752.6,,,1752.6,Other,140% New York Medicaid APG,2816.67,,,2816.67,Other,225% New York Medicaid APG,3254.82,,,3254.82,Other,260% New York Medicaid APG,4056.01,,,4056.01,Other,324% New York Medicaid APG,2691.49,,,2691.49,Other,215% New York Medicaid APG,2691.49,,,2691.49,Other,215% New York Medicaid APG,1564.82,,,1564.82,Other,125% New York Medicaid APG,831.22,115168.94,
Bronchial valve remov init,31648,CPT,,,,,,,,both,,,38917.96,28799.29,74,,28799.29,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,17513.08,45,,17513.08,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,19264.39,49.5,,19264.39,percent of total billed charges,110% of Medicare,26464.21,68,,26464.21,percent of total billed charges,,2328.45,,,2328.45,Other,186% of Medicaid,31134.37,80,,31134.37,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,31134.37,80,,31134.37,percent of total billed charges,,7216,,,7216,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,27242.57,70,,27242.57,percent of total billed charges,,939.72,,,939.72,Fee Schedule,,796.47,,,796.47,Fee Schedule,,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1251.86,,,1251.86,Other,New York Medicaid APG methodology,1251.86,,,1251.86,Other,100% New York Medicaid APG,1251.86,,,1251.86,Other,100% New York Medicaid APG,1251.86,,,1251.86,Other,100% New York Medicaid APG,2816.67,,,2816.67,Other,225% New York Medicaid APG,1915.34,,,1915.34,Other,153% New York Medicaid APG,2816.67,,,2816.67,Other,225% New York Medicaid APG,1752.6,,,1752.6,Other,140% New York Medicaid APG,2816.67,,,2816.67,Other,225% New York Medicaid APG,3254.82,,,3254.82,Other,260% New York Medicaid APG,4056.01,,,4056.01,Other,324% New York Medicaid APG,2691.49,,,2691.49,Other,215% New York Medicaid APG,2691.49,,,2691.49,Other,215% New York Medicaid APG,1564.82,,,1564.82,Other,125% New York Medicaid APG,796.47,31134.37,
Bronchial valve remov addl,31649,CPT,,,,,,,,both,,,35699.83,26417.87,74,,26417.87,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,16064.92,45,,16064.92,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,17671.42,49.5,,17671.42,percent of total billed charges,110% of Medicare,24275.88,68,,24275.88,percent of total billed charges,,2328.45,,,2328.45,Other,186% of Medicaid,28559.86,80,,28559.86,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,28559.86,80,,28559.86,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,24989.88,70,,24989.88,percent of total billed charges,,319.8,,,319.8,Fee Schedule,,271.05,,,271.05,Fee Schedule,,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1251.86,,,1251.86,Other,New York Medicaid APG methodology,1251.86,,,1251.86,Other,100% New York Medicaid APG,1251.86,,,1251.86,Other,100% New York Medicaid APG,1251.86,,,1251.86,Other,100% New York Medicaid APG,2816.67,,,2816.67,Other,225% New York Medicaid APG,1915.34,,,1915.34,Other,153% New York Medicaid APG,2816.67,,,2816.67,Other,225% New York Medicaid APG,1752.6,,,1752.6,Other,140% New York Medicaid APG,2816.67,,,2816.67,Other,225% New York Medicaid APG,3254.82,,,3254.82,Other,260% New York Medicaid APG,4056.01,,,4056.01,Other,324% New York Medicaid APG,2691.49,,,2691.49,Other,215% New York Medicaid APG,2691.49,,,2691.49,Other,215% New York Medicaid APG,1564.82,,,1564.82,Other,125% New York Medicaid APG,271.05,28559.86,
Bronchial valve addl insert,31651,CPT,,,,,,,,both,,,36356.27,26903.64,74,,26903.64,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,16360.32,45,,16360.32,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,21813.76,60,,21813.76,percent of total billed charges,,20359.51,56,,20359.51,percent of total billed charges,,19632.39,54,,19632.39,percent of total billed charges,,17996.35,49.5,,17996.35,percent of total billed charges,110% of Medicare,24722.26,68,,24722.26,percent of total billed charges,,2328.45,,,2328.45,Other,186% of Medicaid,29085.02,80,,29085.02,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,29085.02,80,,29085.02,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,25449.39,70,,25449.39,percent of total billed charges,,367.36,,,367.36,Fee Schedule,,311.36,,,311.36,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,1251.86,,,1251.86,Other,New York Medicaid APG methodology,1251.86,,,1251.86,Other,100% New York Medicaid APG,1251.86,,,1251.86,Other,100% New York Medicaid APG,1251.86,,,1251.86,Other,100% New York Medicaid APG,2816.67,,,2816.67,Other,225% New York Medicaid APG,1915.34,,,1915.34,Other,153% New York Medicaid APG,2816.67,,,2816.67,Other,225% New York Medicaid APG,1752.6,,,1752.6,Other,140% New York Medicaid APG,2816.67,,,2816.67,Other,225% New York Medicaid APG,3254.82,,,3254.82,Other,260% New York Medicaid APG,4056.01,,,4056.01,Other,324% New York Medicaid APG,2691.49,,,2691.49,Other,215% New York Medicaid APG,2691.49,,,2691.49,Other,215% New York Medicaid APG,1564.82,,,1564.82,Other,125% New York Medicaid APG,311.36,29085.02,
Bronch ebus samplng 1/2 node,31652,CPT,,,,,,,,both,,,57482.41,42536.98,74,,42536.98,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,25867.08,45,,25867.08,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,28453.79,49.5,,28453.79,percent of total billed charges,110% of Medicare,39088.04,68,,39088.04,percent of total billed charges,,2328.45,,,2328.45,Other,186% of Medicaid,45985.93,80,,45985.93,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,45985.93,80,,45985.93,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,40237.69,70,,40237.69,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1251.86,,,1251.86,Other,New York Medicaid APG methodology,1251.86,,,1251.86,Other,100% New York Medicaid APG,1251.86,,,1251.86,Other,100% New York Medicaid APG,1251.86,,,1251.86,Other,100% New York Medicaid APG,2816.67,,,2816.67,Other,225% New York Medicaid APG,1915.34,,,1915.34,Other,153% New York Medicaid APG,2816.67,,,2816.67,Other,225% New York Medicaid APG,1752.6,,,1752.6,Other,140% New York Medicaid APG,2816.67,,,2816.67,Other,225% New York Medicaid APG,3254.82,,,3254.82,Other,260% New York Medicaid APG,4056.01,,,4056.01,Other,324% New York Medicaid APG,2691.49,,,2691.49,Other,215% New York Medicaid APG,2691.49,,,2691.49,Other,215% New York Medicaid APG,1564.82,,,1564.82,Other,125% New York Medicaid APG,1251.86,45985.93,
Bronch ebus samplng 3/> node,31653,CPT,,,,,,,,both,,,61306.09,45366.51,74,,45366.51,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,27587.74,45,,27587.74,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,30346.51,49.5,,30346.51,percent of total billed charges,110% of Medicare,41688.14,68,,41688.14,percent of total billed charges,,2328.45,,,2328.45,Other,186% of Medicaid,49044.87,80,,49044.87,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,49044.87,80,,49044.87,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,42914.26,70,,42914.26,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1251.86,,,1251.86,Other,New York Medicaid APG methodology,1251.86,,,1251.86,Other,100% New York Medicaid APG,1251.86,,,1251.86,Other,100% New York Medicaid APG,1251.86,,,1251.86,Other,100% New York Medicaid APG,2816.67,,,2816.67,Other,225% New York Medicaid APG,1915.34,,,1915.34,Other,153% New York Medicaid APG,2816.67,,,2816.67,Other,225% New York Medicaid APG,1752.6,,,1752.6,Other,140% New York Medicaid APG,2816.67,,,2816.67,Other,225% New York Medicaid APG,3254.82,,,3254.82,Other,260% New York Medicaid APG,4056.01,,,4056.01,Other,324% New York Medicaid APG,2691.49,,,2691.49,Other,215% New York Medicaid APG,2691.49,,,2691.49,Other,215% New York Medicaid APG,1564.82,,,1564.82,Other,125% New York Medicaid APG,1251.86,49044.87,
Bronch ebus ivntj perph les,31654,CPT,,,,,,,,both,,,71595.02,52980.31,74,,52980.31,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,32217.76,45,,32217.76,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,35439.53,49.5,,35439.53,percent of total billed charges,110% of Medicare,48684.61,68,,48684.61,percent of total billed charges,,2328.45,,,2328.45,Other,186% of Medicaid,57276.02,80,,57276.02,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,57276.02,80,,57276.02,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,50116.51,70,,50116.51,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,1251.86,,,1251.86,Other,New York Medicaid APG methodology,1251.86,,,1251.86,Other,100% New York Medicaid APG,1251.86,,,1251.86,Other,100% New York Medicaid APG,1251.86,,,1251.86,Other,100% New York Medicaid APG,2816.67,,,2816.67,Other,225% New York Medicaid APG,1915.34,,,1915.34,Other,153% New York Medicaid APG,2816.67,,,2816.67,Other,225% New York Medicaid APG,1752.6,,,1752.6,Other,140% New York Medicaid APG,2816.67,,,2816.67,Other,225% New York Medicaid APG,3254.82,,,3254.82,Other,260% New York Medicaid APG,4056.01,,,4056.01,Other,324% New York Medicaid APG,2691.49,,,2691.49,Other,215% New York Medicaid APG,2691.49,,,2691.49,Other,215% New York Medicaid APG,1564.82,,,1564.82,Other,125% New York Medicaid APG,1251.86,57276.02,
Bronch thermoplsty 1 lobe,31660,CPT,,,,,,,,both,,,143961.17,106531.27,74,,106531.27,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,64782.53,45,,64782.53,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,7266,,"100% primary, 50% secondary, 25% supplemental procedure",7266,Other,Blue Cross ASC Grouper,6539,,"100% primary, 50% secondary, 25% supplemental procedure",6539,Other,Blue Cross ASC Grouper,6176,,"100% primary, 50% secondary, 25% supplemental procedure",6176,Other,Blue Cross ASC Grouper,71260.78,49.5,,71260.78,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2328.45,,,2328.45,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,100772.82,70,,100772.82,percent of total billed charges,,946.28,,,946.28,Fee Schedule,,802.03,,,802.03,Fee Schedule,,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1251.86,,,1251.86,Other,New York Medicaid APG methodology,1251.86,,,1251.86,Other,100% New York Medicaid APG,1251.86,,,1251.86,Other,100% New York Medicaid APG,1251.86,,,1251.86,Other,100% New York Medicaid APG,2816.67,,,2816.67,Other,225% New York Medicaid APG,1915.34,,,1915.34,Other,153% New York Medicaid APG,2816.67,,,2816.67,Other,225% New York Medicaid APG,1752.6,,,1752.6,Other,140% New York Medicaid APG,2816.67,,,2816.67,Other,225% New York Medicaid APG,3254.82,,,3254.82,Other,260% New York Medicaid APG,4056.01,,,4056.01,Other,324% New York Medicaid APG,2691.49,,,2691.49,Other,215% New York Medicaid APG,2691.49,,,2691.49,Other,215% New York Medicaid APG,1564.82,,,1564.82,Other,125% New York Medicaid APG,802.03,106531.27,
Bronch thermoplsty 2/> lobes,31661,CPT,,,,,,,,both,,,143961.17,106531.27,74,,106531.27,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,64782.53,45,,64782.53,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,7266,,"100% primary, 50% secondary, 25% supplemental procedure",7266,Other,Blue Cross ASC Grouper,6539,,"100% primary, 50% secondary, 25% supplemental procedure",6539,Other,Blue Cross ASC Grouper,6176,,"100% primary, 50% secondary, 25% supplemental procedure",6176,Other,Blue Cross ASC Grouper,71260.78,49.5,,71260.78,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2328.45,,,2328.45,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,100772.82,70,,100772.82,percent of total billed charges,,957.76,,,957.76,Fee Schedule,,811.76,,,811.76,Fee Schedule,,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1251.86,,,1251.86,Other,New York Medicaid APG methodology,1251.86,,,1251.86,Other,100% New York Medicaid APG,1251.86,,,1251.86,Other,100% New York Medicaid APG,1251.86,,,1251.86,Other,100% New York Medicaid APG,2816.67,,,2816.67,Other,225% New York Medicaid APG,1915.34,,,1915.34,Other,153% New York Medicaid APG,2816.67,,,2816.67,Other,225% New York Medicaid APG,1752.6,,,1752.6,Other,140% New York Medicaid APG,2816.67,,,2816.67,Other,225% New York Medicaid APG,3254.82,,,3254.82,Other,260% New York Medicaid APG,4056.01,,,4056.01,Other,324% New York Medicaid APG,2691.49,,,2691.49,Other,215% New York Medicaid APG,2691.49,,,2691.49,Other,215% New York Medicaid APG,1564.82,,,1564.82,Other,125% New York Medicaid APG,811.76,106531.27,
Bronchial brush biopsy,31717,CPT,,,,,,,,both,,,8588.63,6355.59,74,,6355.59,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,3864.88,45,,3864.88,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,4251.37,49.5,,4251.37,percent of total billed charges,110% of Medicare,5840.27,68,,5840.27,percent of total billed charges,,2328.45,,,2328.45,Other,186% of Medicaid,6870.9,80,,6870.9,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,6870.9,80,,6870.9,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,6012.04,70,,6012.04,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,1251.86,,,1251.86,Other,New York Medicaid APG methodology,1251.86,,,1251.86,Other,100% New York Medicaid APG,1251.86,,,1251.86,Other,100% New York Medicaid APG,1251.86,,,1251.86,Other,100% New York Medicaid APG,2816.67,,,2816.67,Other,225% New York Medicaid APG,1915.34,,,1915.34,Other,153% New York Medicaid APG,2816.67,,,2816.67,Other,225% New York Medicaid APG,1752.6,,,1752.6,Other,140% New York Medicaid APG,2816.67,,,2816.67,Other,225% New York Medicaid APG,3254.82,,,3254.82,Other,260% New York Medicaid APG,4056.01,,,4056.01,Other,324% New York Medicaid APG,2691.49,,,2691.49,Other,215% New York Medicaid APG,2691.49,,,2691.49,Other,215% New York Medicaid APG,1564.82,,,1564.82,Other,125% New York Medicaid APG,1251.86,7216,
Clearance of airways,31720,CPT,,,,,,,,both,,,4486.27,3319.84,74,,3319.84,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,2018.82,45,,2018.82,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,2220.7,49.5,,2220.7,percent of total billed charges,110% of Medicare,3050.66,68,,3050.66,percent of total billed charges,,324.12,,,324.12,Other,186% of Medicaid,3589.02,80,,3589.02,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,3589.02,80,,3589.02,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,3140.39,70,,3140.39,percent of total billed charges,,234.52,,,234.52,Fee Schedule,,198.77,,,198.77,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,174.26,,,174.26,Other,New York Medicaid APG methodology,174.26,,,174.26,Other,100% New York Medicaid APG,174.26,,,174.26,Other,100% New York Medicaid APG,174.26,,,174.26,Other,100% New York Medicaid APG,392.08,,,392.08,Other,225% New York Medicaid APG,266.62,,,266.62,Other,153% New York Medicaid APG,392.08,,,392.08,Other,225% New York Medicaid APG,243.96,,,243.96,Other,140% New York Medicaid APG,392.08,,,392.08,Other,225% New York Medicaid APG,453.07,,,453.07,Other,260% New York Medicaid APG,564.6,,,564.6,Other,324% New York Medicaid APG,374.66,,,374.66,Other,215% New York Medicaid APG,374.66,,,374.66,Other,215% New York Medicaid APG,217.82,,,217.82,Other,125% New York Medicaid APG,174.26,7216,
Intro windpipe wire/tube,31730,CPT,,,,,,,,both,,,35699.83,26417.87,74,,26417.87,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,16064.92,45,,16064.92,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,17671.42,49.5,,17671.42,percent of total billed charges,110% of Medicare,24275.88,68,,24275.88,percent of total billed charges,,3493.72,,,3493.72,Other,186% of Medicaid,28559.86,80,,28559.86,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,28559.86,80,,28559.86,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,24989.88,70,,24989.88,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1878.34,,,1878.34,Other,New York Medicaid APG methodology,1878.34,,,1878.34,Other,100% New York Medicaid APG,1878.34,,,1878.34,Other,100% New York Medicaid APG,1878.34,,,1878.34,Other,100% New York Medicaid APG,4226.27,,,4226.27,Other,225% New York Medicaid APG,2873.87,,,2873.87,Other,153% New York Medicaid APG,4226.27,,,4226.27,Other,225% New York Medicaid APG,2629.68,,,2629.68,Other,140% New York Medicaid APG,4226.27,,,4226.27,Other,225% New York Medicaid APG,4883.69,,,4883.69,Other,260% New York Medicaid APG,6085.83,,,6085.83,Other,324% New York Medicaid APG,4038.44,,,4038.44,Other,215% New York Medicaid APG,4038.44,,,4038.44,Other,215% New York Medicaid APG,2347.93,,,2347.93,Other,125% New York Medicaid APG,1878.34,28559.86,
Repair of windpipe,31750,CPT,,,,,,,,both,,,123177.14,91151.08,74,,91151.08,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,55429.71,45,,55429.71,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,60972.68,49.5,,60972.68,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3493.72,,,3493.72,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,86224,70,,86224,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,1878.34,,,1878.34,Other,New York Medicaid APG methodology,1878.34,,,1878.34,Other,100% New York Medicaid APG,1878.34,,,1878.34,Other,100% New York Medicaid APG,1878.34,,,1878.34,Other,100% New York Medicaid APG,4226.27,,,4226.27,Other,225% New York Medicaid APG,2873.87,,,2873.87,Other,153% New York Medicaid APG,4226.27,,,4226.27,Other,225% New York Medicaid APG,2629.68,,,2629.68,Other,140% New York Medicaid APG,4226.27,,,4226.27,Other,225% New York Medicaid APG,4883.69,,,4883.69,Other,260% New York Medicaid APG,6085.83,,,6085.83,Other,324% New York Medicaid APG,4038.44,,,4038.44,Other,215% New York Medicaid APG,4038.44,,,4038.44,Other,215% New York Medicaid APG,2347.93,,,2347.93,Other,125% New York Medicaid APG,1878.34,91151.08,
Repair of windpipe,31755,CPT,,,,,,,,both,,,123177.14,91151.08,74,,91151.08,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,55429.71,45,,55429.71,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,60972.68,49.5,,60972.68,percent of total billed charges,110% of Medicare,83760.46,68,,83760.46,percent of total billed charges,,3493.72,,,3493.72,Other,186% of Medicaid,98541.71,80,,98541.71,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,98541.71,80,,98541.71,percent of total billed charges,,7216,,,7216,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,86224,70,,86224,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,1878.34,,,1878.34,Other,New York Medicaid APG methodology,1878.34,,,1878.34,Other,100% New York Medicaid APG,1878.34,,,1878.34,Other,100% New York Medicaid APG,1878.34,,,1878.34,Other,100% New York Medicaid APG,4226.27,,,4226.27,Other,225% New York Medicaid APG,2873.87,,,2873.87,Other,153% New York Medicaid APG,4226.27,,,4226.27,Other,225% New York Medicaid APG,2629.68,,,2629.68,Other,140% New York Medicaid APG,4226.27,,,4226.27,Other,225% New York Medicaid APG,4883.69,,,4883.69,Other,260% New York Medicaid APG,6085.83,,,6085.83,Other,324% New York Medicaid APG,4038.44,,,4038.44,Other,215% New York Medicaid APG,4038.44,,,4038.44,Other,215% New York Medicaid APG,2347.93,,,2347.93,Other,125% New York Medicaid APG,1878.34,98541.71,
Remove windpipe lesion,31785,CPT,,,,,,,,both,,,123177.14,91151.08,74,,91151.08,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,55429.71,45,,55429.71,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,60972.68,49.5,,60972.68,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3493.72,,,3493.72,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,86224,70,,86224,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1878.34,,,1878.34,Other,New York Medicaid APG methodology,1878.34,,,1878.34,Other,100% New York Medicaid APG,1878.34,,,1878.34,Other,100% New York Medicaid APG,1878.34,,,1878.34,Other,100% New York Medicaid APG,4226.27,,,4226.27,Other,225% New York Medicaid APG,2873.87,,,2873.87,Other,153% New York Medicaid APG,4226.27,,,4226.27,Other,225% New York Medicaid APG,2629.68,,,2629.68,Other,140% New York Medicaid APG,4226.27,,,4226.27,Other,225% New York Medicaid APG,4883.69,,,4883.69,Other,260% New York Medicaid APG,6085.83,,,6085.83,Other,324% New York Medicaid APG,4038.44,,,4038.44,Other,215% New York Medicaid APG,4038.44,,,4038.44,Other,215% New York Medicaid APG,2347.93,,,2347.93,Other,125% New York Medicaid APG,1878.34,91151.08,
Closure of windpipe lesion,31820,CPT,,,,,,,,both,,,36971.74,27359.09,74,,27359.09,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,16637.28,45,,16637.28,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,18301.01,49.5,,18301.01,percent of total billed charges,110% of Medicare,25140.78,68,,25140.78,percent of total billed charges,,3493.72,,,3493.72,Other,186% of Medicaid,29577.39,80,,29577.39,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,29577.39,80,,29577.39,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,25880.22,70,,25880.22,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1878.34,,,1878.34,Other,New York Medicaid APG methodology,1878.34,,,1878.34,Other,100% New York Medicaid APG,1878.34,,,1878.34,Other,100% New York Medicaid APG,1878.34,,,1878.34,Other,100% New York Medicaid APG,4226.27,,,4226.27,Other,225% New York Medicaid APG,2873.87,,,2873.87,Other,153% New York Medicaid APG,4226.27,,,4226.27,Other,225% New York Medicaid APG,2629.68,,,2629.68,Other,140% New York Medicaid APG,4226.27,,,4226.27,Other,225% New York Medicaid APG,4883.69,,,4883.69,Other,260% New York Medicaid APG,6085.83,,,6085.83,Other,324% New York Medicaid APG,4038.44,,,4038.44,Other,215% New York Medicaid APG,4038.44,,,4038.44,Other,215% New York Medicaid APG,2347.93,,,2347.93,Other,125% New York Medicaid APG,1878.34,29577.39,
Repair of windpipe defect,31825,CPT,,,,,,,,both,,,67720.49,50113.16,74,,50113.16,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30474.22,45,,30474.22,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,33521.64,49.5,,33521.64,percent of total billed charges,110% of Medicare,46049.93,68,,46049.93,percent of total billed charges,,3493.72,,,3493.72,Other,186% of Medicaid,54176.39,80,,54176.39,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,54176.39,80,,54176.39,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,47404.34,70,,47404.34,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1878.34,,,1878.34,Other,New York Medicaid APG methodology,1878.34,,,1878.34,Other,100% New York Medicaid APG,1878.34,,,1878.34,Other,100% New York Medicaid APG,1878.34,,,1878.34,Other,100% New York Medicaid APG,4226.27,,,4226.27,Other,225% New York Medicaid APG,2873.87,,,2873.87,Other,153% New York Medicaid APG,4226.27,,,4226.27,Other,225% New York Medicaid APG,2629.68,,,2629.68,Other,140% New York Medicaid APG,4226.27,,,4226.27,Other,225% New York Medicaid APG,4883.69,,,4883.69,Other,260% New York Medicaid APG,6085.83,,,6085.83,Other,324% New York Medicaid APG,4038.44,,,4038.44,Other,215% New York Medicaid APG,4038.44,,,4038.44,Other,215% New York Medicaid APG,2347.93,,,2347.93,Other,125% New York Medicaid APG,1878.34,54176.39,
Revise windpipe scar,31830,CPT,,,,,,,,both,,,67720.49,50113.16,74,,50113.16,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30474.22,45,,30474.22,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,33521.64,49.5,,33521.64,percent of total billed charges,110% of Medicare,46049.93,68,,46049.93,percent of total billed charges,,3493.72,,,3493.72,Other,186% of Medicaid,54176.39,80,,54176.39,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,54176.39,80,,54176.39,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,47404.34,70,,47404.34,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1878.34,,,1878.34,Other,New York Medicaid APG methodology,1878.34,,,1878.34,Other,100% New York Medicaid APG,1878.34,,,1878.34,Other,100% New York Medicaid APG,1878.34,,,1878.34,Other,100% New York Medicaid APG,4226.27,,,4226.27,Other,225% New York Medicaid APG,2873.87,,,2873.87,Other,153% New York Medicaid APG,4226.27,,,4226.27,Other,225% New York Medicaid APG,2629.68,,,2629.68,Other,140% New York Medicaid APG,4226.27,,,4226.27,Other,225% New York Medicaid APG,4883.69,,,4883.69,Other,260% New York Medicaid APG,6085.83,,,6085.83,Other,324% New York Medicaid APG,4038.44,,,4038.44,Other,215% New York Medicaid APG,4038.44,,,4038.44,Other,215% New York Medicaid APG,2347.93,,,2347.93,Other,125% New York Medicaid APG,1878.34,54176.39,
Needle biopsy chest lining,32400,CPT,,,,,,,,both,,,50166.38,37123.12,74,,37123.12,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,22574.87,45,,22574.87,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,24832.36,49.5,,24832.36,percent of total billed charges,110% of Medicare,34113.14,68,,34113.14,percent of total billed charges,,1196.64,,,1196.64,Other,186% of Medicaid,40133.1,80,,40133.1,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,40133.1,80,,40133.1,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,35116.47,70,,35116.47,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,643.35,,,643.35,Other,New York Medicaid APG methodology,643.35,,,643.35,Other,100% New York Medicaid APG,643.35,,,643.35,Other,100% New York Medicaid APG,643.35,,,643.35,Other,100% New York Medicaid APG,1447.55,,,1447.55,Other,225% New York Medicaid APG,984.33,,,984.33,Other,153% New York Medicaid APG,1447.55,,,1447.55,Other,225% New York Medicaid APG,900.7,,,900.7,Other,140% New York Medicaid APG,1447.55,,,1447.55,Other,225% New York Medicaid APG,1672.72,,,1672.72,Other,260% New York Medicaid APG,2084.47,,,2084.47,Other,324% New York Medicaid APG,1383.21,,,1383.21,Other,215% New York Medicaid APG,1383.21,,,1383.21,Other,215% New York Medicaid APG,804.19,,,804.19,Other,125% New York Medicaid APG,643.35,40133.1,
Core ndl bx lng/med perq,32408,CPT,,,,,,,,both,,,48462.88,35862.53,74,,35862.53,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,21808.3,45,,21808.3,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,23989.13,49.5,,23989.13,percent of total billed charges,110% of Medicare,32954.76,68,,32954.76,percent of total billed charges,,1196.64,,,1196.64,Other,186% of Medicaid,38770.3,80,,38770.3,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,38770.3,80,,38770.3,percent of total billed charges,,7216,,,7216,Case Rate,,38770.3,80,,38770.3,percent of total billed charges,,33924.02,70,,33924.02,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,643.35,,,643.35,Other,New York Medicaid APG methodology,643.35,,,643.35,Other,100% New York Medicaid APG,643.35,,,643.35,Other,100% New York Medicaid APG,643.35,,,643.35,Other,100% New York Medicaid APG,1447.55,,,1447.55,Other,225% New York Medicaid APG,984.33,,,984.33,Other,153% New York Medicaid APG,1447.55,,,1447.55,Other,225% New York Medicaid APG,900.7,,,900.7,Other,140% New York Medicaid APG,1447.55,,,1447.55,Other,225% New York Medicaid APG,1672.72,,,1672.72,Other,260% New York Medicaid APG,2084.47,,,2084.47,Other,324% New York Medicaid APG,1383.21,,,1383.21,Other,215% New York Medicaid APG,1383.21,,,1383.21,Other,215% New York Medicaid APG,804.19,,,804.19,Other,125% New York Medicaid APG,643.35,38770.3,
Insert pleural cath,32550,CPT,,,,,,,,both,,,34976,25882.24,74,,25882.24,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15739.2,45,,15739.2,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,17313.12,49.5,,17313.12,percent of total billed charges,110% of Medicare,23783.68,68,,23783.68,percent of total billed charges,,1196.64,,,1196.64,Other,186% of Medicaid,27980.8,80,,27980.8,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,27980.8,80,,27980.8,percent of total billed charges,,7216,,,7216,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,24483.2,70,,24483.2,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,643.35,,,643.35,Other,New York Medicaid APG methodology,643.35,,,643.35,Other,100% New York Medicaid APG,643.35,,,643.35,Other,100% New York Medicaid APG,643.35,,,643.35,Other,100% New York Medicaid APG,1447.55,,,1447.55,Other,225% New York Medicaid APG,984.33,,,984.33,Other,153% New York Medicaid APG,1447.55,,,1447.55,Other,225% New York Medicaid APG,900.7,,,900.7,Other,140% New York Medicaid APG,1447.55,,,1447.55,Other,225% New York Medicaid APG,1672.72,,,1672.72,Other,260% New York Medicaid APG,2084.47,,,2084.47,Other,324% New York Medicaid APG,1383.21,,,1383.21,Other,215% New York Medicaid APG,1383.21,,,1383.21,Other,215% New York Medicaid APG,804.19,,,804.19,Other,125% New York Medicaid APG,643.35,27980.8,
Insertion of chest tube,32551,CPT,,,,,,,,both,,,33686.28,24927.85,74,,24927.85,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15158.83,45,,15158.83,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,16674.71,49.5,,16674.71,percent of total billed charges,110% of Medicare,22906.67,68,,22906.67,percent of total billed charges,,1196.64,,,1196.64,Other,186% of Medicaid,26949.02,80,,26949.02,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,26949.02,80,,26949.02,percent of total billed charges,,7216,,,7216,Case Rate,,3578,,"100% primary, 0% secondary procedures",3578,Other,MagnaCare ASC Grouper,23580.4,70,,23580.4,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,643.35,,,643.35,Other,New York Medicaid APG methodology,643.35,,,643.35,Other,100% New York Medicaid APG,643.35,,,643.35,Other,100% New York Medicaid APG,643.35,,,643.35,Other,100% New York Medicaid APG,1447.55,,,1447.55,Other,225% New York Medicaid APG,984.33,,,984.33,Other,153% New York Medicaid APG,1447.55,,,1447.55,Other,225% New York Medicaid APG,900.7,,,900.7,Other,140% New York Medicaid APG,1447.55,,,1447.55,Other,225% New York Medicaid APG,1672.72,,,1672.72,Other,260% New York Medicaid APG,2084.47,,,2084.47,Other,324% New York Medicaid APG,1383.21,,,1383.21,Other,215% New York Medicaid APG,1383.21,,,1383.21,Other,215% New York Medicaid APG,804.19,,,804.19,Other,125% New York Medicaid APG,643.35,26949.02,
Remove lung catheter,32552,CPT,,,,,,,,both,,,33893,25080.82,74,,25080.82,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15251.85,45,,15251.85,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,16777.04,49.5,,16777.04,percent of total billed charges,110% of Medicare,23047.24,68,,23047.24,percent of total billed charges,,1196.64,,,1196.64,Other,186% of Medicaid,27114.4,80,,27114.4,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,27114.4,80,,27114.4,percent of total billed charges,,7216,,,7216,Case Rate,,3578,,"100% primary, 0% secondary procedures",3578,Other,MagnaCare ASC Grouper,23725.1,70,,23725.1,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,643.35,,,643.35,Other,New York Medicaid APG methodology,643.35,,,643.35,Other,100% New York Medicaid APG,643.35,,,643.35,Other,100% New York Medicaid APG,643.35,,,643.35,Other,100% New York Medicaid APG,1447.55,,,1447.55,Other,225% New York Medicaid APG,984.33,,,984.33,Other,153% New York Medicaid APG,1447.55,,,1447.55,Other,225% New York Medicaid APG,900.7,,,900.7,Other,140% New York Medicaid APG,1447.55,,,1447.55,Other,225% New York Medicaid APG,1672.72,,,1672.72,Other,260% New York Medicaid APG,2084.47,,,2084.47,Other,324% New York Medicaid APG,1383.21,,,1383.21,Other,215% New York Medicaid APG,1383.21,,,1383.21,Other,215% New York Medicaid APG,804.19,,,804.19,Other,125% New York Medicaid APG,643.35,27114.4,
Ins mark thor for rt perq,32553,CPT,,,,,,,,both,,,29144.83,21567.17,74,,21567.17,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,13115.17,45,,13115.17,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,14426.69,49.5,,14426.69,percent of total billed charges,110% of Medicare,19818.48,68,,19818.48,percent of total billed charges,,479.66,,,479.66,Other,186% of Medicaid,23315.86,80,,23315.86,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,23315.86,80,,23315.86,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,20401.38,70,,20401.38,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,257.88,,,257.88,Other,New York Medicaid APG methodology,257.88,,,257.88,Other,100% New York Medicaid APG,257.88,,,257.88,Other,100% New York Medicaid APG,257.88,,,257.88,Other,100% New York Medicaid APG,580.23,,,580.23,Other,225% New York Medicaid APG,394.56,,,394.56,Other,153% New York Medicaid APG,580.23,,,580.23,Other,225% New York Medicaid APG,361.03,,,361.03,Other,140% New York Medicaid APG,580.23,,,580.23,Other,225% New York Medicaid APG,670.49,,,670.49,Other,260% New York Medicaid APG,835.53,,,835.53,Other,324% New York Medicaid APG,554.44,,,554.44,Other,215% New York Medicaid APG,554.44,,,554.44,Other,215% New York Medicaid APG,322.35,,,322.35,Other,125% New York Medicaid APG,257.88,23315.86,
Aspirate pleura w/o imaging,32554,CPT,,,,,,,,both,,,13213.53,9778.01,74,,9778.01,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,5946.09,45,,5946.09,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,6540.7,49.5,,6540.7,percent of total billed charges,110% of Medicare,8985.2,68,,8985.2,percent of total billed charges,,1196.64,,,1196.64,Other,186% of Medicaid,10570.82,80,,10570.82,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,10570.82,80,,10570.82,percent of total billed charges,,7216,,,7216,Case Rate,,3578,,"100% primary, 0% secondary procedures",3578,Other,MagnaCare ASC Grouper,9249.47,70,,9249.47,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,643.35,,,643.35,Other,New York Medicaid APG methodology,643.35,,,643.35,Other,100% New York Medicaid APG,643.35,,,643.35,Other,100% New York Medicaid APG,643.35,,,643.35,Other,100% New York Medicaid APG,1447.55,,,1447.55,Other,225% New York Medicaid APG,984.33,,,984.33,Other,153% New York Medicaid APG,1447.55,,,1447.55,Other,225% New York Medicaid APG,900.7,,,900.7,Other,140% New York Medicaid APG,1447.55,,,1447.55,Other,225% New York Medicaid APG,1672.72,,,1672.72,Other,260% New York Medicaid APG,2084.47,,,2084.47,Other,324% New York Medicaid APG,1383.21,,,1383.21,Other,215% New York Medicaid APG,1383.21,,,1383.21,Other,215% New York Medicaid APG,804.19,,,804.19,Other,125% New York Medicaid APG,643.35,10570.82,
Aspirate pleura w/ imaging,32555,CPT,,,,,,,,both,,,24290.55,17975.01,74,,17975.01,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,10930.75,45,,10930.75,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,12023.82,49.5,,12023.82,percent of total billed charges,110% of Medicare,16517.57,68,,16517.57,percent of total billed charges,,1196.64,,,1196.64,Other,186% of Medicaid,19432.44,80,,19432.44,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,19432.44,80,,19432.44,percent of total billed charges,,7216,,,7216,Case Rate,,3578,,"100% primary, 0% secondary procedures",3578,Other,MagnaCare ASC Grouper,17003.39,70,,17003.39,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,643.35,,,643.35,Other,New York Medicaid APG methodology,643.35,,,643.35,Other,100% New York Medicaid APG,643.35,,,643.35,Other,100% New York Medicaid APG,643.35,,,643.35,Other,100% New York Medicaid APG,1447.55,,,1447.55,Other,225% New York Medicaid APG,984.33,,,984.33,Other,153% New York Medicaid APG,1447.55,,,1447.55,Other,225% New York Medicaid APG,900.7,,,900.7,Other,140% New York Medicaid APG,1447.55,,,1447.55,Other,225% New York Medicaid APG,1672.72,,,1672.72,Other,260% New York Medicaid APG,2084.47,,,2084.47,Other,324% New York Medicaid APG,1383.21,,,1383.21,Other,215% New York Medicaid APG,1383.21,,,1383.21,Other,215% New York Medicaid APG,804.19,,,804.19,Other,125% New York Medicaid APG,643.35,19432.44,
Insert cath pleura w/o image,32556,CPT,,,,,,,,both,,,38003,28122.22,74,,28122.22,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,17101.35,45,,17101.35,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,18811.49,49.5,,18811.49,percent of total billed charges,110% of Medicare,25842.04,68,,25842.04,percent of total billed charges,,1196.64,,,1196.64,Other,186% of Medicaid,30402.4,80,,30402.4,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,30402.4,80,,30402.4,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,26602.1,70,,26602.1,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,643.35,,,643.35,Other,New York Medicaid APG methodology,643.35,,,643.35,Other,100% New York Medicaid APG,643.35,,,643.35,Other,100% New York Medicaid APG,643.35,,,643.35,Other,100% New York Medicaid APG,1447.55,,,1447.55,Other,225% New York Medicaid APG,984.33,,,984.33,Other,153% New York Medicaid APG,1447.55,,,1447.55,Other,225% New York Medicaid APG,900.7,,,900.7,Other,140% New York Medicaid APG,1447.55,,,1447.55,Other,225% New York Medicaid APG,1672.72,,,1672.72,Other,260% New York Medicaid APG,2084.47,,,2084.47,Other,324% New York Medicaid APG,1383.21,,,1383.21,Other,215% New York Medicaid APG,1383.21,,,1383.21,Other,215% New York Medicaid APG,804.19,,,804.19,Other,125% New York Medicaid APG,643.35,30402.4,
Insert cath pleura w/ image,32557,CPT,,,,,,,,both,,,33686.28,24927.85,74,,24927.85,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15158.83,45,,15158.83,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,16674.71,49.5,,16674.71,percent of total billed charges,110% of Medicare,22906.67,68,,22906.67,percent of total billed charges,,1196.64,,,1196.64,Other,186% of Medicaid,26949.02,80,,26949.02,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,26949.02,80,,26949.02,percent of total billed charges,,7216,,,7216,Case Rate,,3578,,"100% primary, 0% secondary procedures",3578,Other,MagnaCare ASC Grouper,23580.4,70,,23580.4,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,643.35,,,643.35,Other,New York Medicaid APG methodology,643.35,,,643.35,Other,100% New York Medicaid APG,643.35,,,643.35,Other,100% New York Medicaid APG,643.35,,,643.35,Other,100% New York Medicaid APG,1447.55,,,1447.55,Other,225% New York Medicaid APG,984.33,,,984.33,Other,153% New York Medicaid APG,1447.55,,,1447.55,Other,225% New York Medicaid APG,900.7,,,900.7,Other,140% New York Medicaid APG,1447.55,,,1447.55,Other,225% New York Medicaid APG,1672.72,,,1672.72,Other,260% New York Medicaid APG,2084.47,,,2084.47,Other,324% New York Medicaid APG,1383.21,,,1383.21,Other,215% New York Medicaid APG,1383.21,,,1383.21,Other,215% New York Medicaid APG,804.19,,,804.19,Other,125% New York Medicaid APG,643.35,26949.02,
Treat pleurodesis w/agent,32560,CPT,,,,,,,,both,,,13213.53,9778.01,74,,9778.01,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,5946.09,45,,5946.09,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,6540.7,49.5,,6540.7,percent of total billed charges,110% of Medicare,8985.2,68,,8985.2,percent of total billed charges,,1196.64,,,1196.64,Other,186% of Medicaid,10570.82,80,,10570.82,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,10570.82,80,,10570.82,percent of total billed charges,,7216,,,7216,Case Rate,,3578,,"100% primary, 0% secondary procedures",3578,Other,MagnaCare ASC Grouper,9249.47,70,,9249.47,percent of total billed charges,,365.72,,,365.72,Fee Schedule,,309.97,,,309.97,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,643.35,,,643.35,Other,New York Medicaid APG methodology,643.35,,,643.35,Other,100% New York Medicaid APG,643.35,,,643.35,Other,100% New York Medicaid APG,643.35,,,643.35,Other,100% New York Medicaid APG,1447.55,,,1447.55,Other,225% New York Medicaid APG,984.33,,,984.33,Other,153% New York Medicaid APG,1447.55,,,1447.55,Other,225% New York Medicaid APG,900.7,,,900.7,Other,140% New York Medicaid APG,1447.55,,,1447.55,Other,225% New York Medicaid APG,1672.72,,,1672.72,Other,260% New York Medicaid APG,2084.47,,,2084.47,Other,324% New York Medicaid APG,1383.21,,,1383.21,Other,215% New York Medicaid APG,1383.21,,,1383.21,Other,215% New York Medicaid APG,804.19,,,804.19,Other,125% New York Medicaid APG,309.97,10570.82,
Lyse chest fibrin init day,32561,CPT,,,,,,,,both,,,13213.53,9778.01,74,,9778.01,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,5946.09,45,,5946.09,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,6540.7,49.5,,6540.7,percent of total billed charges,110% of Medicare,8985.2,68,,8985.2,percent of total billed charges,,1196.64,,,1196.64,Other,186% of Medicaid,10570.82,80,,10570.82,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,10570.82,80,,10570.82,percent of total billed charges,,7216,,,7216,Case Rate,,3578,,"100% primary, 0% secondary procedures",3578,Other,MagnaCare ASC Grouper,9249.47,70,,9249.47,percent of total billed charges,,326.36,,,326.36,Fee Schedule,,276.61,,,276.61,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,643.35,,,643.35,Other,New York Medicaid APG methodology,643.35,,,643.35,Other,100% New York Medicaid APG,643.35,,,643.35,Other,100% New York Medicaid APG,643.35,,,643.35,Other,100% New York Medicaid APG,1447.55,,,1447.55,Other,225% New York Medicaid APG,984.33,,,984.33,Other,153% New York Medicaid APG,1447.55,,,1447.55,Other,225% New York Medicaid APG,900.7,,,900.7,Other,140% New York Medicaid APG,1447.55,,,1447.55,Other,225% New York Medicaid APG,1672.72,,,1672.72,Other,260% New York Medicaid APG,2084.47,,,2084.47,Other,324% New York Medicaid APG,1383.21,,,1383.21,Other,215% New York Medicaid APG,1383.21,,,1383.21,Other,215% New York Medicaid APG,804.19,,,804.19,Other,125% New York Medicaid APG,276.61,10570.82,
Lyse chest fibrin subq day,32562,CPT,,,,,,,,both,,,13213.53,9778.01,74,,9778.01,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,5946.09,45,,5946.09,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,6540.7,49.5,,6540.7,percent of total billed charges,110% of Medicare,8985.2,68,,8985.2,percent of total billed charges,,1196.64,,,1196.64,Other,186% of Medicaid,10570.82,80,,10570.82,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,10570.82,80,,10570.82,percent of total billed charges,,7216,,,7216,Case Rate,,3578,,"100% primary, 0% secondary procedures",3578,Other,MagnaCare ASC Grouper,9249.47,70,,9249.47,percent of total billed charges,,290.28,,,290.28,Fee Schedule,,246.03,,,246.03,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,643.35,,,643.35,Other,New York Medicaid APG methodology,643.35,,,643.35,Other,100% New York Medicaid APG,643.35,,,643.35,Other,100% New York Medicaid APG,643.35,,,643.35,Other,100% New York Medicaid APG,1447.55,,,1447.55,Other,225% New York Medicaid APG,984.33,,,984.33,Other,153% New York Medicaid APG,1447.55,,,1447.55,Other,225% New York Medicaid APG,900.7,,,900.7,Other,140% New York Medicaid APG,1447.55,,,1447.55,Other,225% New York Medicaid APG,1672.72,,,1672.72,Other,260% New York Medicaid APG,2084.47,,,2084.47,Other,324% New York Medicaid APG,1383.21,,,1383.21,Other,215% New York Medicaid APG,1383.21,,,1383.21,Other,215% New York Medicaid APG,804.19,,,804.19,Other,125% New York Medicaid APG,246.03,10570.82,
Thoracoscopy diagnostic,32601,CPT,,,,,,,,both,,,121364.27,89809.56,74,,89809.56,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,54613.92,45,,54613.92,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,6125,,"100% primary, 50% secondary, 25% supplemental procedure",6125,Other,Blue Cross ASC Grouper,5513,,"100% primary, 50% secondary, 25% supplemental procedure",5513,Other,Blue Cross ASC Grouper,5206,,"100% primary, 50% secondary, 25% supplemental procedure",5206,Other,Blue Cross ASC Grouper,60075.31,49.5,,60075.31,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,4046.72,,,4046.72,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,84954.99,70,,84954.99,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,2175.66,,,2175.66,Other,New York Medicaid APG methodology,2175.66,,,2175.66,Other,100% New York Medicaid APG,2175.66,,,2175.66,Other,100% New York Medicaid APG,2175.66,,,2175.66,Other,100% New York Medicaid APG,4895.23,,,4895.23,Other,225% New York Medicaid APG,3328.76,,,3328.76,Other,153% New York Medicaid APG,4895.23,,,4895.23,Other,225% New York Medicaid APG,3045.92,,,3045.92,Other,140% New York Medicaid APG,4895.23,,,4895.23,Other,225% New York Medicaid APG,5656.71,,,5656.71,Other,260% New York Medicaid APG,7049.13,,,7049.13,Other,324% New York Medicaid APG,4677.66,,,4677.66,Other,215% New York Medicaid APG,4677.66,,,4677.66,Other,215% New York Medicaid APG,2719.57,,,2719.57,Other,125% New York Medicaid APG,2175.66,89809.56,
Thoracoscopy wbx sac,32604,CPT,,,,,,,,both,,,216515.17,160221.23,74,,160221.23,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,97431.83,45,,97431.83,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,6125,,"100% primary, 50% secondary, 25% supplemental procedure",6125,Other,Blue Cross ASC Grouper,5513,,"100% primary, 50% secondary, 25% supplemental procedure",5513,Other,Blue Cross ASC Grouper,5206,,"100% primary, 50% secondary, 25% supplemental procedure",5206,Other,Blue Cross ASC Grouper,107175.01,49.5,,107175.01,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3164.53,,,3164.53,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,151560.62,70,,151560.62,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,1701.36,,,1701.36,Other,New York Medicaid APG methodology,1701.36,,,1701.36,Other,100% New York Medicaid APG,1701.36,,,1701.36,Other,100% New York Medicaid APG,1701.36,,,1701.36,Other,100% New York Medicaid APG,3828.06,,,3828.06,Other,225% New York Medicaid APG,2603.08,,,2603.08,Other,153% New York Medicaid APG,3828.06,,,3828.06,Other,225% New York Medicaid APG,2381.9,,,2381.9,Other,140% New York Medicaid APG,3828.06,,,3828.06,Other,225% New York Medicaid APG,4423.54,,,4423.54,Other,260% New York Medicaid APG,5512.41,,,5512.41,Other,324% New York Medicaid APG,3657.92,,,3657.92,Other,215% New York Medicaid APG,3657.92,,,3657.92,Other,215% New York Medicaid APG,2126.7,,,2126.7,Other,125% New York Medicaid APG,1701.36,160221.23,
Thoracoscopy w/bx med space,32606,CPT,,,,,,,,both,,,115664.62,85591.82,74,,85591.82,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,52049.08,45,,52049.08,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,6125,,"100% primary, 50% secondary, 25% supplemental procedure",6125,Other,Blue Cross ASC Grouper,5513,,"100% primary, 50% secondary, 25% supplemental procedure",5513,Other,Blue Cross ASC Grouper,5206,,"100% primary, 50% secondary, 25% supplemental procedure",5206,Other,Blue Cross ASC Grouper,57253.99,49.5,,57253.99,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,4046.72,,,4046.72,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,80965.23,70,,80965.23,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,2175.66,,,2175.66,Other,New York Medicaid APG methodology,2175.66,,,2175.66,Other,100% New York Medicaid APG,2175.66,,,2175.66,Other,100% New York Medicaid APG,2175.66,,,2175.66,Other,100% New York Medicaid APG,4895.23,,,4895.23,Other,225% New York Medicaid APG,3328.76,,,3328.76,Other,153% New York Medicaid APG,4895.23,,,4895.23,Other,225% New York Medicaid APG,3045.92,,,3045.92,Other,140% New York Medicaid APG,4895.23,,,4895.23,Other,225% New York Medicaid APG,5656.71,,,5656.71,Other,260% New York Medicaid APG,7049.13,,,7049.13,Other,324% New York Medicaid APG,4677.66,,,4677.66,Other,215% New York Medicaid APG,4677.66,,,4677.66,Other,215% New York Medicaid APG,2719.57,,,2719.57,Other,125% New York Medicaid APG,2175.66,85591.82,
Thoracoscopy w/bx infiltrate,32607,CPT,,,,,,,,both,,,216515.17,160221.23,74,,160221.23,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,97431.83,45,,97431.83,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,6125,,"100% primary, 50% secondary, 25% supplemental procedure",6125,Other,Blue Cross ASC Grouper,5513,,"100% primary, 50% secondary, 25% supplemental procedure",5513,Other,Blue Cross ASC Grouper,5206,,"100% primary, 50% secondary, 25% supplemental procedure",5206,Other,Blue Cross ASC Grouper,107175.01,49.5,,107175.01,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,4046.72,,,4046.72,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,151560.62,70,,151560.62,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,2175.66,,,2175.66,Other,New York Medicaid APG methodology,2175.66,,,2175.66,Other,100% New York Medicaid APG,2175.66,,,2175.66,Other,100% New York Medicaid APG,2175.66,,,2175.66,Other,100% New York Medicaid APG,4895.23,,,4895.23,Other,225% New York Medicaid APG,3328.76,,,3328.76,Other,153% New York Medicaid APG,4895.23,,,4895.23,Other,225% New York Medicaid APG,3045.92,,,3045.92,Other,140% New York Medicaid APG,4895.23,,,4895.23,Other,225% New York Medicaid APG,5656.71,,,5656.71,Other,260% New York Medicaid APG,7049.13,,,7049.13,Other,324% New York Medicaid APG,4677.66,,,4677.66,Other,215% New York Medicaid APG,4677.66,,,4677.66,Other,215% New York Medicaid APG,2719.57,,,2719.57,Other,125% New York Medicaid APG,2175.66,160221.23,
Thoracoscopy w/bx nodule,32608,CPT,,,,,,,,both,,,216515.17,160221.23,74,,160221.23,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,97431.83,45,,97431.83,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,6125,,"100% primary, 50% secondary, 25% supplemental procedure",6125,Other,Blue Cross ASC Grouper,5513,,"100% primary, 50% secondary, 25% supplemental procedure",5513,Other,Blue Cross ASC Grouper,5206,,"100% primary, 50% secondary, 25% supplemental procedure",5206,Other,Blue Cross ASC Grouper,107175.01,49.5,,107175.01,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,4046.72,,,4046.72,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,151560.62,70,,151560.62,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,2175.66,,,2175.66,Other,New York Medicaid APG methodology,2175.66,,,2175.66,Other,100% New York Medicaid APG,2175.66,,,2175.66,Other,100% New York Medicaid APG,2175.66,,,2175.66,Other,100% New York Medicaid APG,4895.23,,,4895.23,Other,225% New York Medicaid APG,3328.76,,,3328.76,Other,153% New York Medicaid APG,4895.23,,,4895.23,Other,225% New York Medicaid APG,3045.92,,,3045.92,Other,140% New York Medicaid APG,4895.23,,,4895.23,Other,225% New York Medicaid APG,5656.71,,,5656.71,Other,260% New York Medicaid APG,7049.13,,,7049.13,Other,324% New York Medicaid APG,4677.66,,,4677.66,Other,215% New York Medicaid APG,4677.66,,,4677.66,Other,215% New York Medicaid APG,2719.57,,,2719.57,Other,125% New York Medicaid APG,2175.66,160221.23,
Thoracoscopy w/bx pleura,32609,CPT,,,,,,,,both,,,121364.27,89809.56,74,,89809.56,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,54613.92,45,,54613.92,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,6125,,"100% primary, 50% secondary, 25% supplemental procedure",6125,Other,Blue Cross ASC Grouper,5513,,"100% primary, 50% secondary, 25% supplemental procedure",5513,Other,Blue Cross ASC Grouper,5206,,"100% primary, 50% secondary, 25% supplemental procedure",5206,Other,Blue Cross ASC Grouper,60075.31,49.5,,60075.31,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3164.53,,,3164.53,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,84954.99,70,,84954.99,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,1701.36,,,1701.36,Other,New York Medicaid APG methodology,1701.36,,,1701.36,Other,100% New York Medicaid APG,1701.36,,,1701.36,Other,100% New York Medicaid APG,1701.36,,,1701.36,Other,100% New York Medicaid APG,3828.06,,,3828.06,Other,225% New York Medicaid APG,2603.08,,,2603.08,Other,153% New York Medicaid APG,3828.06,,,3828.06,Other,225% New York Medicaid APG,2381.9,,,2381.9,Other,140% New York Medicaid APG,3828.06,,,3828.06,Other,225% New York Medicaid APG,4423.54,,,4423.54,Other,260% New York Medicaid APG,5512.41,,,5512.41,Other,324% New York Medicaid APG,3657.92,,,3657.92,Other,215% New York Medicaid APG,3657.92,,,3657.92,Other,215% New York Medicaid APG,2126.7,,,2126.7,Other,125% New York Medicaid APG,1701.36,89809.56,
Therapeutic pneumothorax,32960,CPT,,,,,,,,both,,,13213.53,9778.01,74,,9778.01,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,5946.09,45,,5946.09,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,6540.7,49.5,,6540.7,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,1196.64,,,1196.64,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,3578,,"100% primary, 0% secondary procedures",3578,Other,MagnaCare ASC Grouper,9249.47,70,,9249.47,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,643.35,,,643.35,Other,New York Medicaid APG methodology,643.35,,,643.35,Other,100% New York Medicaid APG,643.35,,,643.35,Other,100% New York Medicaid APG,643.35,,,643.35,Other,100% New York Medicaid APG,1447.55,,,1447.55,Other,225% New York Medicaid APG,984.33,,,984.33,Other,153% New York Medicaid APG,1447.55,,,1447.55,Other,225% New York Medicaid APG,900.7,,,900.7,Other,140% New York Medicaid APG,1447.55,,,1447.55,Other,225% New York Medicaid APG,1672.72,,,1672.72,Other,260% New York Medicaid APG,2084.47,,,2084.47,Other,324% New York Medicaid APG,1383.21,,,1383.21,Other,215% New York Medicaid APG,1383.21,,,1383.21,Other,215% New York Medicaid APG,804.19,,,804.19,Other,125% New York Medicaid APG,643.35,9778.01,
Ablate pulm tumor perq crybl,32994,CPT,,,,,,,,both,,,216515.17,160221.23,74,,160221.23,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,97431.83,45,,97431.83,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,6125,,"100% primary, 50% secondary, 25% supplemental procedure",6125,Other,Blue Cross ASC Grouper,5513,,"100% primary, 50% secondary, 25% supplemental procedure",5513,Other,Blue Cross ASC Grouper,5206,,"100% primary, 50% secondary, 25% supplemental procedure",5206,Other,Blue Cross ASC Grouper,107175.01,49.5,,107175.01,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,4046.72,,,4046.72,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,151560.62,70,,151560.62,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,2175.66,,,2175.66,Other,New York Medicaid APG methodology,2175.66,,,2175.66,Other,100% New York Medicaid APG,2175.66,,,2175.66,Other,100% New York Medicaid APG,2175.66,,,2175.66,Other,100% New York Medicaid APG,4895.23,,,4895.23,Other,225% New York Medicaid APG,3328.76,,,3328.76,Other,153% New York Medicaid APG,4895.23,,,4895.23,Other,225% New York Medicaid APG,3045.92,,,3045.92,Other,140% New York Medicaid APG,4895.23,,,4895.23,Other,225% New York Medicaid APG,5656.71,,,5656.71,Other,260% New York Medicaid APG,7049.13,,,7049.13,Other,324% New York Medicaid APG,4677.66,,,4677.66,Other,215% New York Medicaid APG,4677.66,,,4677.66,Other,215% New York Medicaid APG,2719.57,,,2719.57,Other,125% New York Medicaid APG,2175.66,160221.23,
Ablate pulm tumor perq rf,32998,CPT,,,,,,,,both,,,121364.27,89809.56,74,,89809.56,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,54613.92,45,,54613.92,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,6125,,"100% primary, 50% secondary, 25% supplemental procedure",6125,Other,Blue Cross ASC Grouper,5513,,"100% primary, 50% secondary, 25% supplemental procedure",5513,Other,Blue Cross ASC Grouper,5206,,"100% primary, 50% secondary, 25% supplemental procedure",5206,Other,Blue Cross ASC Grouper,60075.31,49.5,,60075.31,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,4046.72,,,4046.72,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,84954.99,70,,84954.99,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,2175.66,,,2175.66,Other,New York Medicaid APG methodology,2175.66,,,2175.66,Other,100% New York Medicaid APG,2175.66,,,2175.66,Other,100% New York Medicaid APG,2175.66,,,2175.66,Other,100% New York Medicaid APG,4895.23,,,4895.23,Other,225% New York Medicaid APG,3328.76,,,3328.76,Other,153% New York Medicaid APG,4895.23,,,4895.23,Other,225% New York Medicaid APG,3045.92,,,3045.92,Other,140% New York Medicaid APG,4895.23,,,4895.23,Other,225% New York Medicaid APG,5656.71,,,5656.71,Other,260% New York Medicaid APG,7049.13,,,7049.13,Other,324% New York Medicaid APG,4677.66,,,4677.66,Other,215% New York Medicaid APG,4677.66,,,4677.66,Other,215% New York Medicaid APG,2719.57,,,2719.57,Other,125% New York Medicaid APG,2175.66,89809.56,
Pericardiocentesis w/imaging,33016,CPT,,,,,,,,both,,,33686.28,24927.85,74,,24927.85,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15158.83,45,,15158.83,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,16674.71,49.5,,16674.71,percent of total billed charges,110% of Medicare,22906.67,68,,22906.67,percent of total billed charges,,1196.64,,,1196.64,Other,186% of Medicaid,26949.02,80,,26949.02,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,26949.02,80,,26949.02,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,23580.4,70,,23580.4,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,643.35,,,643.35,Other,New York Medicaid APG methodology,643.35,,,643.35,Other,100% New York Medicaid APG,643.35,,,643.35,Other,100% New York Medicaid APG,643.35,,,643.35,Other,100% New York Medicaid APG,1447.55,,,1447.55,Other,225% New York Medicaid APG,984.33,,,984.33,Other,153% New York Medicaid APG,1447.55,,,1447.55,Other,225% New York Medicaid APG,900.7,,,900.7,Other,140% New York Medicaid APG,1447.55,,,1447.55,Other,225% New York Medicaid APG,1672.72,,,1672.72,Other,260% New York Medicaid APG,2084.47,,,2084.47,Other,324% New York Medicaid APG,1383.21,,,1383.21,Other,215% New York Medicaid APG,1383.21,,,1383.21,Other,215% New York Medicaid APG,804.19,,,804.19,Other,125% New York Medicaid APG,643.35,26949.02,
Insert heart pm atrial,33206,CPT,,,,,,,,both,,,155525,115088.5,74,,115088.5,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,69986.25,45,,69986.25,percent of total billed charges,Medicare Ratio of cost to charges,5954,,"100% primary, 50% supplemental procedure",5954,Other,Aetna ASC Grouper,5359,,"100% primary, 50% supplemental procedure",5359,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,76984.88,49.5,,76984.88,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,10683.75,,,10683.75,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9196,,"100% primary, 0% secondary procedures",9196,Other,MagnaCare ASC Grouper,108867.5,70,,108867.5,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6956,,"100% primary, 50% secondary, 25% tertiary procedure",6956,Other,United Healthcare ASC Grouper,6261,,"100% primary, 50% secondary, 25% tertiary procedure",6261,Other,United Healthcare ASC Grouper,6956,,"100% primary, 50% secondary, 25% tertiary procedure",6956,Other,United Healthcare ASC Grouper,5913,,"100% primary, 50% secondary, 25% tertiary procedure",5913,Other,United Healthcare ASC Grouper,5743.95,,,5743.95,Other,New York Medicaid APG methodology,5743.95,,,5743.95,Other,100% New York Medicaid APG,5743.95,,,5743.95,Other,100% New York Medicaid APG,5743.95,,,5743.95,Other,100% New York Medicaid APG,12923.9,,,12923.9,Other,225% New York Medicaid APG,8788.25,,,8788.25,Other,153% New York Medicaid APG,12923.9,,,12923.9,Other,225% New York Medicaid APG,8041.54,,,8041.54,Other,140% New York Medicaid APG,12923.9,,,12923.9,Other,225% New York Medicaid APG,14934.28,,,14934.28,Other,260% New York Medicaid APG,18610.41,,,18610.41,Other,324% New York Medicaid APG,12349.5,,,12349.5,Other,215% New York Medicaid APG,12349.5,,,12349.5,Other,215% New York Medicaid APG,7179.94,,,7179.94,Other,125% New York Medicaid APG,3343,115088.5,
Insert heart pm ventricular,33207,CPT,,,,,,,,both,,,224603.78,166206.8,74,,166206.8,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,101071.7,45,,101071.7,percent of total billed charges,Medicare Ratio of cost to charges,5954,,"100% primary, 50% supplemental procedure",5954,Other,Aetna ASC Grouper,5359,,"100% primary, 50% supplemental procedure",5359,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,111178.87,49.5,,111178.87,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,10683.75,,,10683.75,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9196,,"100% primary, 0% secondary procedures",9196,Other,MagnaCare ASC Grouper,157222.65,70,,157222.65,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6956,,"100% primary, 50% secondary, 25% tertiary procedure",6956,Other,United Healthcare ASC Grouper,6261,,"100% primary, 50% secondary, 25% tertiary procedure",6261,Other,United Healthcare ASC Grouper,6956,,"100% primary, 50% secondary, 25% tertiary procedure",6956,Other,United Healthcare ASC Grouper,5913,,"100% primary, 50% secondary, 25% tertiary procedure",5913,Other,United Healthcare ASC Grouper,5743.95,,,5743.95,Other,New York Medicaid APG methodology,5743.95,,,5743.95,Other,100% New York Medicaid APG,5743.95,,,5743.95,Other,100% New York Medicaid APG,5743.95,,,5743.95,Other,100% New York Medicaid APG,12923.9,,,12923.9,Other,225% New York Medicaid APG,8788.25,,,8788.25,Other,153% New York Medicaid APG,12923.9,,,12923.9,Other,225% New York Medicaid APG,8041.54,,,8041.54,Other,140% New York Medicaid APG,12923.9,,,12923.9,Other,225% New York Medicaid APG,14934.28,,,14934.28,Other,260% New York Medicaid APG,18610.41,,,18610.41,Other,324% New York Medicaid APG,12349.5,,,12349.5,Other,215% New York Medicaid APG,12349.5,,,12349.5,Other,215% New York Medicaid APG,7179.94,,,7179.94,Other,125% New York Medicaid APG,3343,166206.8,
Insrt heart pm atrial & vent,33208,CPT,,,,,,,,both,,,119138.84,88162.74,74,,88162.74,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,53612.48,45,,53612.48,percent of total billed charges,Medicare Ratio of cost to charges,5954,,"100% primary, 50% supplemental procedure",5954,Other,Aetna ASC Grouper,5359,,"100% primary, 50% supplemental procedure",5359,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,58973.73,49.5,,58973.73,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,10683.75,,,10683.75,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9196,,"100% primary, 0% secondary procedures",9196,Other,MagnaCare ASC Grouper,83397.19,70,,83397.19,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,7364,,"100% primary, 50% secondary, 25% tertiary procedure",7364,Other,United Healthcare ASC Grouper,6628,,"100% primary, 50% secondary, 25% tertiary procedure",6628,Other,United Healthcare ASC Grouper,7364,,"100% primary, 50% secondary, 25% tertiary procedure",7364,Other,United Healthcare ASC Grouper,6260,,"100% primary, 50% secondary, 25% tertiary procedure",6260,Other,United Healthcare ASC Grouper,5743.95,,,5743.95,Other,New York Medicaid APG methodology,5743.95,,,5743.95,Other,100% New York Medicaid APG,5743.95,,,5743.95,Other,100% New York Medicaid APG,5743.95,,,5743.95,Other,100% New York Medicaid APG,12923.9,,,12923.9,Other,225% New York Medicaid APG,8788.25,,,8788.25,Other,153% New York Medicaid APG,12923.9,,,12923.9,Other,225% New York Medicaid APG,8041.54,,,8041.54,Other,140% New York Medicaid APG,12923.9,,,12923.9,Other,225% New York Medicaid APG,14934.28,,,14934.28,Other,260% New York Medicaid APG,18610.41,,,18610.41,Other,324% New York Medicaid APG,12349.5,,,12349.5,Other,215% New York Medicaid APG,12349.5,,,12349.5,Other,215% New York Medicaid APG,7179.94,,,7179.94,Other,125% New York Medicaid APG,3343,88162.74,
Insert electrd/pm cath sngl,33210,CPT,,,,,,,,both,,,52092,38548.08,74,,38548.08,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,23441.4,45,,23441.4,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,25785.54,49.5,,25785.54,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,4536.91,,,4536.91,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,36464.4,70,,36464.4,percent of total billed charges,,777.36,,,777.36,Fee Schedule,,658.86,,,658.86,Fee Schedule,,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,2439.2,,,2439.2,Other,New York Medicaid APG methodology,2439.2,,,2439.2,Other,100% New York Medicaid APG,2439.2,,,2439.2,Other,100% New York Medicaid APG,2439.2,,,2439.2,Other,100% New York Medicaid APG,5488.2,,,5488.2,Other,225% New York Medicaid APG,3731.98,,,3731.98,Other,153% New York Medicaid APG,5488.2,,,5488.2,Other,225% New York Medicaid APG,3414.88,,,3414.88,Other,140% New York Medicaid APG,5488.2,,,5488.2,Other,225% New York Medicaid APG,6341.92,,,6341.92,Other,260% New York Medicaid APG,7903.01,,,7903.01,Other,324% New York Medicaid APG,5244.28,,,5244.28,Other,215% New York Medicaid APG,5244.28,,,5244.28,Other,215% New York Medicaid APG,3049,,,3049,Other,125% New York Medicaid APG,658.86,38548.08,
Insert card electrodes dual,33211,CPT,,,,,,,,both,,,178695.84,132234.92,74,,132234.92,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,80413.13,45,,80413.13,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,88454.44,49.5,,88454.44,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,4536.91,,,4536.91,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,125087.09,70,,125087.09,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,2439.2,,,2439.2,Other,New York Medicaid APG methodology,2439.2,,,2439.2,Other,100% New York Medicaid APG,2439.2,,,2439.2,Other,100% New York Medicaid APG,2439.2,,,2439.2,Other,100% New York Medicaid APG,5488.2,,,5488.2,Other,225% New York Medicaid APG,3731.98,,,3731.98,Other,153% New York Medicaid APG,5488.2,,,5488.2,Other,225% New York Medicaid APG,3414.88,,,3414.88,Other,140% New York Medicaid APG,5488.2,,,5488.2,Other,225% New York Medicaid APG,6341.92,,,6341.92,Other,260% New York Medicaid APG,7903.01,,,7903.01,Other,324% New York Medicaid APG,5244.28,,,5244.28,Other,215% New York Medicaid APG,5244.28,,,5244.28,Other,215% New York Medicaid APG,3049,,,3049,Other,125% New York Medicaid APG,2439.2,132234.92,
Insert pulse gen sngl lead,33212,CPT,,,,,,,,both,,,178695.84,132234.92,74,,132234.92,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,80413.13,45,,80413.13,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,88454.44,49.5,,88454.44,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,10683.75,,,10683.75,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9196,,"100% primary, 0% secondary procedures",9196,Other,MagnaCare ASC Grouper,125087.09,70,,125087.09,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6956,,"100% primary, 50% secondary, 25% tertiary procedure",6956,Other,United Healthcare ASC Grouper,6261,,"100% primary, 50% secondary, 25% tertiary procedure",6261,Other,United Healthcare ASC Grouper,6956,,"100% primary, 50% secondary, 25% tertiary procedure",6956,Other,United Healthcare ASC Grouper,5913,,"100% primary, 50% secondary, 25% tertiary procedure",5913,Other,United Healthcare ASC Grouper,5743.95,,,5743.95,Other,New York Medicaid APG methodology,5743.95,,,5743.95,Other,100% New York Medicaid APG,5743.95,,,5743.95,Other,100% New York Medicaid APG,5743.95,,,5743.95,Other,100% New York Medicaid APG,12923.9,,,12923.9,Other,225% New York Medicaid APG,8788.25,,,8788.25,Other,153% New York Medicaid APG,12923.9,,,12923.9,Other,225% New York Medicaid APG,8041.54,,,8041.54,Other,140% New York Medicaid APG,12923.9,,,12923.9,Other,225% New York Medicaid APG,14934.28,,,14934.28,Other,260% New York Medicaid APG,18610.41,,,18610.41,Other,324% New York Medicaid APG,12349.5,,,12349.5,Other,215% New York Medicaid APG,12349.5,,,12349.5,Other,215% New York Medicaid APG,7179.94,,,7179.94,Other,125% New York Medicaid APG,3126,132234.92,
Insert pulse gen dual leads,33213,CPT,,,,,,,,both,,,224603.78,166206.8,74,,166206.8,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,101071.7,45,,101071.7,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,111178.87,49.5,,111178.87,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,10683.75,,,10683.75,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9196,,"100% primary, 0% secondary procedures",9196,Other,MagnaCare ASC Grouper,157222.65,70,,157222.65,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6956,,"100% primary, 50% secondary, 25% tertiary procedure",6956,Other,United Healthcare ASC Grouper,6261,,"100% primary, 50% secondary, 25% tertiary procedure",6261,Other,United Healthcare ASC Grouper,6956,,"100% primary, 50% secondary, 25% tertiary procedure",6956,Other,United Healthcare ASC Grouper,5913,,"100% primary, 50% secondary, 25% tertiary procedure",5913,Other,United Healthcare ASC Grouper,5743.95,,,5743.95,Other,New York Medicaid APG methodology,5743.95,,,5743.95,Other,100% New York Medicaid APG,5743.95,,,5743.95,Other,100% New York Medicaid APG,5743.95,,,5743.95,Other,100% New York Medicaid APG,12923.9,,,12923.9,Other,225% New York Medicaid APG,8788.25,,,8788.25,Other,153% New York Medicaid APG,12923.9,,,12923.9,Other,225% New York Medicaid APG,8041.54,,,8041.54,Other,140% New York Medicaid APG,12923.9,,,12923.9,Other,225% New York Medicaid APG,14934.28,,,14934.28,Other,260% New York Medicaid APG,18610.41,,,18610.41,Other,324% New York Medicaid APG,12349.5,,,12349.5,Other,215% New York Medicaid APG,12349.5,,,12349.5,Other,215% New York Medicaid APG,7179.94,,,7179.94,Other,125% New York Medicaid APG,3126,166206.8,
Upgrade of pacemaker system,33214,CPT,,,,,,,,both,,,224603.78,166206.8,74,,166206.8,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,101071.7,45,,101071.7,percent of total billed charges,Medicare Ratio of cost to charges,5954,,"100% primary, 50% supplemental procedure",5954,Other,Aetna ASC Grouper,5359,,"100% primary, 50% supplemental procedure",5359,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,111178.87,49.5,,111178.87,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,10683.75,,,10683.75,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9196,,"100% primary, 0% secondary procedures",9196,Other,MagnaCare ASC Grouper,157222.65,70,,157222.65,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,7364,,"100% primary, 50% secondary, 25% tertiary procedure",7364,Other,United Healthcare ASC Grouper,6628,,"100% primary, 50% secondary, 25% tertiary procedure",6628,Other,United Healthcare ASC Grouper,7364,,"100% primary, 50% secondary, 25% tertiary procedure",7364,Other,United Healthcare ASC Grouper,6260,,"100% primary, 50% secondary, 25% tertiary procedure",6260,Other,United Healthcare ASC Grouper,5743.95,,,5743.95,Other,New York Medicaid APG methodology,5743.95,,,5743.95,Other,100% New York Medicaid APG,5743.95,,,5743.95,Other,100% New York Medicaid APG,5743.95,,,5743.95,Other,100% New York Medicaid APG,12923.9,,,12923.9,Other,225% New York Medicaid APG,8788.25,,,8788.25,Other,153% New York Medicaid APG,12923.9,,,12923.9,Other,225% New York Medicaid APG,8041.54,,,8041.54,Other,140% New York Medicaid APG,12923.9,,,12923.9,Other,225% New York Medicaid APG,14934.28,,,14934.28,Other,260% New York Medicaid APG,18610.41,,,18610.41,Other,324% New York Medicaid APG,12349.5,,,12349.5,Other,215% New York Medicaid APG,12349.5,,,12349.5,Other,215% New York Medicaid APG,7179.94,,,7179.94,Other,125% New York Medicaid APG,3343,166206.8,
Reposition pacing-defib lead,33215,CPT,,,,,,,,both,,,67044.74,49613.11,74,,49613.11,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30170.13,45,,30170.13,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33187.15,49.5,,33187.15,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,4536.91,,,4536.91,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,46931.32,70,,46931.32,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,2439.2,,,2439.2,Other,New York Medicaid APG methodology,2439.2,,,2439.2,Other,100% New York Medicaid APG,2439.2,,,2439.2,Other,100% New York Medicaid APG,2439.2,,,2439.2,Other,100% New York Medicaid APG,5488.2,,,5488.2,Other,225% New York Medicaid APG,3731.98,,,3731.98,Other,153% New York Medicaid APG,5488.2,,,5488.2,Other,225% New York Medicaid APG,3414.88,,,3414.88,Other,140% New York Medicaid APG,5488.2,,,5488.2,Other,225% New York Medicaid APG,6341.92,,,6341.92,Other,260% New York Medicaid APG,7903.01,,,7903.01,Other,324% New York Medicaid APG,5244.28,,,5244.28,Other,215% New York Medicaid APG,5244.28,,,5244.28,Other,215% New York Medicaid APG,3049,,,3049,Other,125% New York Medicaid APG,2439.2,49613.11,
Insert 1 electrode pm-defib,33216,CPT,,,,,,,,both,,,122462.33,90622.12,74,,90622.12,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,55108.05,45,,55108.05,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,60618.85,49.5,,60618.85,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,4536.91,,,4536.91,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,85723.63,70,,85723.63,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,2439.2,,,2439.2,Other,New York Medicaid APG methodology,2439.2,,,2439.2,Other,100% New York Medicaid APG,2439.2,,,2439.2,Other,100% New York Medicaid APG,2439.2,,,2439.2,Other,100% New York Medicaid APG,5488.2,,,5488.2,Other,225% New York Medicaid APG,3731.98,,,3731.98,Other,153% New York Medicaid APG,5488.2,,,5488.2,Other,225% New York Medicaid APG,3414.88,,,3414.88,Other,140% New York Medicaid APG,5488.2,,,5488.2,Other,225% New York Medicaid APG,6341.92,,,6341.92,Other,260% New York Medicaid APG,7903.01,,,7903.01,Other,324% New York Medicaid APG,5244.28,,,5244.28,Other,215% New York Medicaid APG,5244.28,,,5244.28,Other,215% New York Medicaid APG,3049,,,3049,Other,125% New York Medicaid APG,2439.2,90622.12,
Insert 2 electrode pm-defib,33217,CPT,,,,,,,,both,,,178695.84,132234.92,74,,132234.92,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,80413.13,45,,80413.13,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,88454.44,49.5,,88454.44,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,4536.91,,,4536.91,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,125087.09,70,,125087.09,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,2439.2,,,2439.2,Other,New York Medicaid APG methodology,2439.2,,,2439.2,Other,100% New York Medicaid APG,2439.2,,,2439.2,Other,100% New York Medicaid APG,2439.2,,,2439.2,Other,100% New York Medicaid APG,5488.2,,,5488.2,Other,225% New York Medicaid APG,3731.98,,,3731.98,Other,153% New York Medicaid APG,5488.2,,,5488.2,Other,225% New York Medicaid APG,3414.88,,,3414.88,Other,140% New York Medicaid APG,5488.2,,,5488.2,Other,225% New York Medicaid APG,6341.92,,,6341.92,Other,260% New York Medicaid APG,7903.01,,,7903.01,Other,324% New York Medicaid APG,5244.28,,,5244.28,Other,215% New York Medicaid APG,5244.28,,,5244.28,Other,215% New York Medicaid APG,3049,,,3049,Other,125% New York Medicaid APG,2439.2,132234.92,
Repair lead pace-defib one,33218,CPT,,,,,,,,both,,,115106,85178.44,74,,85178.44,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,51797.7,45,,51797.7,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,56977.47,49.5,,56977.47,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,4536.91,,,4536.91,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,80574.2,70,,80574.2,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,2439.2,,,2439.2,Other,New York Medicaid APG methodology,2439.2,,,2439.2,Other,100% New York Medicaid APG,2439.2,,,2439.2,Other,100% New York Medicaid APG,2439.2,,,2439.2,Other,100% New York Medicaid APG,5488.2,,,5488.2,Other,225% New York Medicaid APG,3731.98,,,3731.98,Other,153% New York Medicaid APG,5488.2,,,5488.2,Other,225% New York Medicaid APG,3414.88,,,3414.88,Other,140% New York Medicaid APG,5488.2,,,5488.2,Other,225% New York Medicaid APG,6341.92,,,6341.92,Other,260% New York Medicaid APG,7903.01,,,7903.01,Other,324% New York Medicaid APG,5244.28,,,5244.28,Other,215% New York Medicaid APG,5244.28,,,5244.28,Other,215% New York Medicaid APG,3049,,,3049,Other,125% New York Medicaid APG,2439.2,85178.44,
Repair lead pace-defib dual,33220,CPT,,,,,,,,both,,,82599.65,61123.74,74,,61123.74,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,37169.84,45,,37169.84,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,40886.83,49.5,,40886.83,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,4536.91,,,4536.91,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,57819.76,70,,57819.76,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,2439.2,,,2439.2,Other,New York Medicaid APG methodology,2439.2,,,2439.2,Other,100% New York Medicaid APG,2439.2,,,2439.2,Other,100% New York Medicaid APG,2439.2,,,2439.2,Other,100% New York Medicaid APG,5488.2,,,5488.2,Other,225% New York Medicaid APG,3731.98,,,3731.98,Other,153% New York Medicaid APG,5488.2,,,5488.2,Other,225% New York Medicaid APG,3414.88,,,3414.88,Other,140% New York Medicaid APG,5488.2,,,5488.2,Other,225% New York Medicaid APG,6341.92,,,6341.92,Other,260% New York Medicaid APG,7903.01,,,7903.01,Other,324% New York Medicaid APG,5244.28,,,5244.28,Other,215% New York Medicaid APG,5244.28,,,5244.28,Other,215% New York Medicaid APG,3049,,,3049,Other,125% New York Medicaid APG,2439.2,61123.74,
Insert pulse gen mult leads,33221,CPT,,,,,,,,both,,,409846.89,303286.7,74,,303286.7,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,184431.1,45,,184431.1,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,202874.21,49.5,,202874.21,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,10683.75,,,10683.75,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9196,,"100% primary, 0% secondary procedures",9196,Other,MagnaCare ASC Grouper,286892.82,70,,286892.82,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6956,,"100% primary, 50% secondary, 25% tertiary procedure",6956,Other,United Healthcare ASC Grouper,6261,,"100% primary, 50% secondary, 25% tertiary procedure",6261,Other,United Healthcare ASC Grouper,6956,,"100% primary, 50% secondary, 25% tertiary procedure",6956,Other,United Healthcare ASC Grouper,5913,,"100% primary, 50% secondary, 25% tertiary procedure",5913,Other,United Healthcare ASC Grouper,5743.95,,,5743.95,Other,New York Medicaid APG methodology,5743.95,,,5743.95,Other,100% New York Medicaid APG,5743.95,,,5743.95,Other,100% New York Medicaid APG,5743.95,,,5743.95,Other,100% New York Medicaid APG,12923.9,,,12923.9,Other,225% New York Medicaid APG,8788.25,,,8788.25,Other,153% New York Medicaid APG,12923.9,,,12923.9,Other,225% New York Medicaid APG,8041.54,,,8041.54,Other,140% New York Medicaid APG,12923.9,,,12923.9,Other,225% New York Medicaid APG,14934.28,,,14934.28,Other,260% New York Medicaid APG,18610.41,,,18610.41,Other,324% New York Medicaid APG,12349.5,,,12349.5,Other,215% New York Medicaid APG,12349.5,,,12349.5,Other,215% New York Medicaid APG,7179.94,,,7179.94,Other,125% New York Medicaid APG,3126,303286.7,
Relocation pocket pacemaker,33222,CPT,,,,,,,,both,,,72120,53368.8,74,,53368.8,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,32454,45,,32454,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,35699.4,49.5,,35699.4,percent of total billed charges,110% of Medicare,49041.6,68,,49041.6,percent of total billed charges,,4536.91,,,4536.91,Other,186% of Medicaid,57696,80,,57696,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,57696,80,,57696,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,50484,70,,50484,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,2439.2,,,2439.2,Other,New York Medicaid APG methodology,2439.2,,,2439.2,Other,100% New York Medicaid APG,2439.2,,,2439.2,Other,100% New York Medicaid APG,2439.2,,,2439.2,Other,100% New York Medicaid APG,5488.2,,,5488.2,Other,225% New York Medicaid APG,3731.98,,,3731.98,Other,153% New York Medicaid APG,5488.2,,,5488.2,Other,225% New York Medicaid APG,3414.88,,,3414.88,Other,140% New York Medicaid APG,5488.2,,,5488.2,Other,225% New York Medicaid APG,6341.92,,,6341.92,Other,260% New York Medicaid APG,7903.01,,,7903.01,Other,324% New York Medicaid APG,5244.28,,,5244.28,Other,215% New York Medicaid APG,5244.28,,,5244.28,Other,215% New York Medicaid APG,3049,,,3049,Other,125% New York Medicaid APG,2232,57696,
Relocate pocket for defib,33223,CPT,,,,,,,,both,,,107123.53,79271.41,74,,79271.41,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,48205.59,45,,48205.59,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,53026.15,49.5,,53026.15,percent of total billed charges,110% of Medicare,72844,68,,72844,percent of total billed charges,,4536.91,,,4536.91,Other,186% of Medicaid,85698.82,80,,85698.82,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,85698.82,80,,85698.82,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,74986.47,70,,74986.47,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,2439.2,,,2439.2,Other,New York Medicaid APG methodology,2439.2,,,2439.2,Other,100% New York Medicaid APG,2439.2,,,2439.2,Other,100% New York Medicaid APG,2439.2,,,2439.2,Other,100% New York Medicaid APG,5488.2,,,5488.2,Other,225% New York Medicaid APG,3731.98,,,3731.98,Other,153% New York Medicaid APG,5488.2,,,5488.2,Other,225% New York Medicaid APG,3414.88,,,3414.88,Other,140% New York Medicaid APG,5488.2,,,5488.2,Other,225% New York Medicaid APG,6341.92,,,6341.92,Other,260% New York Medicaid APG,7903.01,,,7903.01,Other,324% New York Medicaid APG,5244.28,,,5244.28,Other,215% New York Medicaid APG,5244.28,,,5244.28,Other,215% New York Medicaid APG,3049,,,3049,Other,125% New York Medicaid APG,2232,85698.82,
Insert pacing lead & connect,33224,CPT,,,,,,,,both,,,127078,94037.72,74,,94037.72,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,57185.1,45,,57185.1,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,62903.61,49.5,,62903.61,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,10683.75,,,10683.75,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9196,,"100% primary, 0% secondary procedures",9196,Other,MagnaCare ASC Grouper,88954.6,70,,88954.6,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,7364,,"100% primary, 50% secondary, 25% tertiary procedure",7364,Other,United Healthcare ASC Grouper,6628,,"100% primary, 50% secondary, 25% tertiary procedure",6628,Other,United Healthcare ASC Grouper,7364,,"100% primary, 50% secondary, 25% tertiary procedure",7364,Other,United Healthcare ASC Grouper,6260,,"100% primary, 50% secondary, 25% tertiary procedure",6260,Other,United Healthcare ASC Grouper,5743.95,,,5743.95,Other,New York Medicaid APG methodology,5743.95,,,5743.95,Other,100% New York Medicaid APG,5743.95,,,5743.95,Other,100% New York Medicaid APG,5743.95,,,5743.95,Other,100% New York Medicaid APG,12923.9,,,12923.9,Other,225% New York Medicaid APG,8788.25,,,8788.25,Other,153% New York Medicaid APG,12923.9,,,12923.9,Other,225% New York Medicaid APG,8041.54,,,8041.54,Other,140% New York Medicaid APG,12923.9,,,12923.9,Other,225% New York Medicaid APG,14934.28,,,14934.28,Other,260% New York Medicaid APG,18610.41,,,18610.41,Other,324% New York Medicaid APG,12349.5,,,12349.5,Other,215% New York Medicaid APG,12349.5,,,12349.5,Other,215% New York Medicaid APG,7179.94,,,7179.94,Other,125% New York Medicaid APG,3126,94037.72,
L ventric pacing lead add-on,33225,CPT,,,,,,,,both,,,51572.04,38163.31,74,,38163.31,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,23207.42,45,,23207.42,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,25528.16,49.5,,25528.16,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,10683.75,,,10683.75,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9196,,"100% primary, 0% secondary procedures",9196,Other,MagnaCare ASC Grouper,36100.43,70,,36100.43,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,7364,,"100% primary, 50% secondary, 25% tertiary procedure",7364,Other,United Healthcare ASC Grouper,6628,,"100% primary, 50% secondary, 25% tertiary procedure",6628,Other,United Healthcare ASC Grouper,7364,,"100% primary, 50% secondary, 25% tertiary procedure",7364,Other,United Healthcare ASC Grouper,6260,,"100% primary, 50% secondary, 25% tertiary procedure",6260,Other,United Healthcare ASC Grouper,5743.95,,,5743.95,Other,New York Medicaid APG methodology,5743.95,,,5743.95,Other,100% New York Medicaid APG,5743.95,,,5743.95,Other,100% New York Medicaid APG,5743.95,,,5743.95,Other,100% New York Medicaid APG,12923.9,,,12923.9,Other,225% New York Medicaid APG,8788.25,,,8788.25,Other,153% New York Medicaid APG,12923.9,,,12923.9,Other,225% New York Medicaid APG,8041.54,,,8041.54,Other,140% New York Medicaid APG,12923.9,,,12923.9,Other,225% New York Medicaid APG,14934.28,,,14934.28,Other,260% New York Medicaid APG,18610.41,,,18610.41,Other,324% New York Medicaid APG,12349.5,,,12349.5,Other,215% New York Medicaid APG,12349.5,,,12349.5,Other,215% New York Medicaid APG,7179.94,,,7179.94,Other,125% New York Medicaid APG,3310,38163.31,
Reposition l ventric lead,33226,CPT,,,,,,,,both,,,67044.74,49613.11,74,,49613.11,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30170.13,45,,30170.13,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33187.15,49.5,,33187.15,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3946.83,,,3946.83,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,46931.32,70,,46931.32,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,2121.95,,,2121.95,Other,New York Medicaid APG methodology,2121.95,,,2121.95,Other,100% New York Medicaid APG,2121.95,,,2121.95,Other,100% New York Medicaid APG,2121.95,,,2121.95,Other,100% New York Medicaid APG,4774.4,,,4774.4,Other,225% New York Medicaid APG,3246.59,,,3246.59,Other,153% New York Medicaid APG,4774.4,,,4774.4,Other,225% New York Medicaid APG,2970.74,,,2970.74,Other,140% New York Medicaid APG,4774.4,,,4774.4,Other,225% New York Medicaid APG,5517.08,,,5517.08,Other,260% New York Medicaid APG,6875.13,,,6875.13,Other,324% New York Medicaid APG,4562.2,,,4562.2,Other,215% New York Medicaid APG,4562.2,,,4562.2,Other,215% New York Medicaid APG,2652.44,,,2652.44,Other,125% New York Medicaid APG,2121.95,49613.11,
Remove&replace pm gen singl,33227,CPT,,,,,,,,both,,,80557,59612.18,74,,59612.18,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,36250.65,45,,36250.65,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,39875.72,49.5,,39875.72,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,10683.75,,,10683.75,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9196,,"100% primary, 0% secondary procedures",9196,Other,MagnaCare ASC Grouper,56389.9,70,,56389.9,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6956,,"100% primary, 50% secondary, 25% tertiary procedure",6956,Other,United Healthcare ASC Grouper,6261,,"100% primary, 50% secondary, 25% tertiary procedure",6261,Other,United Healthcare ASC Grouper,6956,,"100% primary, 50% secondary, 25% tertiary procedure",6956,Other,United Healthcare ASC Grouper,5913,,"100% primary, 50% secondary, 25% tertiary procedure",5913,Other,United Healthcare ASC Grouper,5743.95,,,5743.95,Other,New York Medicaid APG methodology,5743.95,,,5743.95,Other,100% New York Medicaid APG,5743.95,,,5743.95,Other,100% New York Medicaid APG,5743.95,,,5743.95,Other,100% New York Medicaid APG,12923.9,,,12923.9,Other,225% New York Medicaid APG,8788.25,,,8788.25,Other,153% New York Medicaid APG,12923.9,,,12923.9,Other,225% New York Medicaid APG,8041.54,,,8041.54,Other,140% New York Medicaid APG,12923.9,,,12923.9,Other,225% New York Medicaid APG,14934.28,,,14934.28,Other,260% New York Medicaid APG,18610.41,,,18610.41,Other,324% New York Medicaid APG,12349.5,,,12349.5,Other,215% New York Medicaid APG,12349.5,,,12349.5,Other,215% New York Medicaid APG,7179.94,,,7179.94,Other,125% New York Medicaid APG,3126,59612.18,
Remv&replc pm gen dual lead,33228,CPT,,,,,,,,both,,,90306.48,66826.8,74,,66826.8,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,40637.92,45,,40637.92,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,44701.71,49.5,,44701.71,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,10683.75,,,10683.75,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9196,,"100% primary, 0% secondary procedures",9196,Other,MagnaCare ASC Grouper,63214.54,70,,63214.54,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6956,,"100% primary, 50% secondary, 25% tertiary procedure",6956,Other,United Healthcare ASC Grouper,6261,,"100% primary, 50% secondary, 25% tertiary procedure",6261,Other,United Healthcare ASC Grouper,6956,,"100% primary, 50% secondary, 25% tertiary procedure",6956,Other,United Healthcare ASC Grouper,5913,,"100% primary, 50% secondary, 25% tertiary procedure",5913,Other,United Healthcare ASC Grouper,5743.95,,,5743.95,Other,New York Medicaid APG methodology,5743.95,,,5743.95,Other,100% New York Medicaid APG,5743.95,,,5743.95,Other,100% New York Medicaid APG,5743.95,,,5743.95,Other,100% New York Medicaid APG,12923.9,,,12923.9,Other,225% New York Medicaid APG,8788.25,,,8788.25,Other,153% New York Medicaid APG,12923.9,,,12923.9,Other,225% New York Medicaid APG,8041.54,,,8041.54,Other,140% New York Medicaid APG,12923.9,,,12923.9,Other,225% New York Medicaid APG,14934.28,,,14934.28,Other,260% New York Medicaid APG,18610.41,,,18610.41,Other,324% New York Medicaid APG,12349.5,,,12349.5,Other,215% New York Medicaid APG,12349.5,,,12349.5,Other,215% New York Medicaid APG,7179.94,,,7179.94,Other,125% New York Medicaid APG,3126,66826.8,
Remv&replc pm gen mult leads,33229,CPT,,,,,,,,both,,,162903.47,120548.57,74,,120548.57,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,73306.56,45,,73306.56,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,80637.22,49.5,,80637.22,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,10683.75,,,10683.75,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9196,,"100% primary, 0% secondary procedures",9196,Other,MagnaCare ASC Grouper,114032.43,70,,114032.43,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6956,,"100% primary, 50% secondary, 25% tertiary procedure",6956,Other,United Healthcare ASC Grouper,6261,,"100% primary, 50% secondary, 25% tertiary procedure",6261,Other,United Healthcare ASC Grouper,6956,,"100% primary, 50% secondary, 25% tertiary procedure",6956,Other,United Healthcare ASC Grouper,5913,,"100% primary, 50% secondary, 25% tertiary procedure",5913,Other,United Healthcare ASC Grouper,5743.95,,,5743.95,Other,New York Medicaid APG methodology,5743.95,,,5743.95,Other,100% New York Medicaid APG,5743.95,,,5743.95,Other,100% New York Medicaid APG,5743.95,,,5743.95,Other,100% New York Medicaid APG,12923.9,,,12923.9,Other,225% New York Medicaid APG,8788.25,,,8788.25,Other,153% New York Medicaid APG,12923.9,,,12923.9,Other,225% New York Medicaid APG,8041.54,,,8041.54,Other,140% New York Medicaid APG,12923.9,,,12923.9,Other,225% New York Medicaid APG,14934.28,,,14934.28,Other,260% New York Medicaid APG,18610.41,,,18610.41,Other,324% New York Medicaid APG,12349.5,,,12349.5,Other,215% New York Medicaid APG,12349.5,,,12349.5,Other,215% New York Medicaid APG,7179.94,,,7179.94,Other,125% New York Medicaid APG,3126,120548.57,
Insrt pulse gen w/dual leads,33230,CPT,,,,,,,,both,,,495795.01,366888.31,74,,366888.31,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,223107.75,45,,223107.75,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,245418.53,49.5,,245418.53,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,25102.82,,,25102.82,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9196,,"100% primary, 0% secondary procedures",9196,Other,MagnaCare ASC Grouper,347056.51,70,,347056.51,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,15267,,"100% primary, 50% secondary, 25% tertiary procedure",15267,Other,United Healthcare ASC Grouper,13740,,"100% primary, 50% secondary, 25% tertiary procedure",13740,Other,United Healthcare ASC Grouper,15267,,"100% primary, 50% secondary, 25% tertiary procedure",15267,Other,United Healthcare ASC Grouper,12977,,"100% primary, 50% secondary, 25% tertiary procedure",12977,Other,United Healthcare ASC Grouper,13496.14,,,13496.14,Other,New York Medicaid APG methodology,13496.14,,,13496.14,Other,100% New York Medicaid APG,13496.14,,,13496.14,Other,100% New York Medicaid APG,13496.14,,,13496.14,Other,100% New York Medicaid APG,30366.31,,,30366.31,Other,225% New York Medicaid APG,20649.09,,,20649.09,Other,153% New York Medicaid APG,30366.31,,,30366.31,Other,225% New York Medicaid APG,18894.6,,,18894.6,Other,140% New York Medicaid APG,30366.31,,,30366.31,Other,225% New York Medicaid APG,35089.96,,,35089.96,Other,260% New York Medicaid APG,43727.49,,,43727.49,Other,324% New York Medicaid APG,29016.7,,,29016.7,Other,215% New York Medicaid APG,29016.7,,,29016.7,Other,215% New York Medicaid APG,16870.17,,,16870.17,Other,125% New York Medicaid APG,3126,366888.31,
Insrt pulse gen w/mult leads,33231,CPT,,,,,,,,both,,,691990.86,512073.24,74,,512073.24,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,311395.89,45,,311395.89,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,342535.48,49.5,,342535.48,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,25102.82,,,25102.82,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9196,,"100% primary, 0% secondary procedures",9196,Other,MagnaCare ASC Grouper,484393.6,70,,484393.6,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,15267,,"100% primary, 50% secondary, 25% tertiary procedure",15267,Other,United Healthcare ASC Grouper,13740,,"100% primary, 50% secondary, 25% tertiary procedure",13740,Other,United Healthcare ASC Grouper,15267,,"100% primary, 50% secondary, 25% tertiary procedure",15267,Other,United Healthcare ASC Grouper,12977,,"100% primary, 50% secondary, 25% tertiary procedure",12977,Other,United Healthcare ASC Grouper,13496.14,,,13496.14,Other,New York Medicaid APG methodology,13496.14,,,13496.14,Other,100% New York Medicaid APG,13496.14,,,13496.14,Other,100% New York Medicaid APG,13496.14,,,13496.14,Other,100% New York Medicaid APG,30366.31,,,30366.31,Other,225% New York Medicaid APG,20649.09,,,20649.09,Other,153% New York Medicaid APG,30366.31,,,30366.31,Other,225% New York Medicaid APG,18894.6,,,18894.6,Other,140% New York Medicaid APG,30366.31,,,30366.31,Other,225% New York Medicaid APG,35089.96,,,35089.96,Other,260% New York Medicaid APG,43727.49,,,43727.49,Other,324% New York Medicaid APG,29016.7,,,29016.7,Other,215% New York Medicaid APG,29016.7,,,29016.7,Other,215% New York Medicaid APG,16870.17,,,16870.17,Other,125% New York Medicaid APG,3126,512073.24,
Removal of pm generator,33233,CPT,,,,,,,,both,,,178695.84,132234.92,74,,132234.92,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,80413.13,45,,80413.13,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,88454.44,49.5,,88454.44,percent of total billed charges,110% of Medicare,121513.17,68,,121513.17,percent of total billed charges,,3946.83,,,3946.83,Other,186% of Medicaid,142956.67,80,,142956.67,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,142956.67,80,,142956.67,percent of total billed charges,,7216,,,7216,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,125087.09,70,,125087.09,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,2121.95,,,2121.95,Other,New York Medicaid APG methodology,2121.95,,,2121.95,Other,100% New York Medicaid APG,2121.95,,,2121.95,Other,100% New York Medicaid APG,2121.95,,,2121.95,Other,100% New York Medicaid APG,4774.4,,,4774.4,Other,225% New York Medicaid APG,3246.59,,,3246.59,Other,153% New York Medicaid APG,4774.4,,,4774.4,Other,225% New York Medicaid APG,2970.74,,,2970.74,Other,140% New York Medicaid APG,4774.4,,,4774.4,Other,225% New York Medicaid APG,5517.08,,,5517.08,Other,260% New York Medicaid APG,6875.13,,,6875.13,Other,324% New York Medicaid APG,4562.2,,,4562.2,Other,215% New York Medicaid APG,4562.2,,,4562.2,Other,215% New York Medicaid APG,2652.44,,,2652.44,Other,125% New York Medicaid APG,2121.95,142956.67,
Removal of pacemaker system,33234,CPT,,,,,,,,both,,,82599.65,61123.74,74,,61123.74,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,37169.84,45,,37169.84,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,40886.83,49.5,,40886.83,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,4536.91,,,4536.91,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,57819.76,70,,57819.76,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,2439.2,,,2439.2,Other,New York Medicaid APG methodology,2439.2,,,2439.2,Other,100% New York Medicaid APG,2439.2,,,2439.2,Other,100% New York Medicaid APG,2439.2,,,2439.2,Other,100% New York Medicaid APG,5488.2,,,5488.2,Other,225% New York Medicaid APG,3731.98,,,3731.98,Other,153% New York Medicaid APG,5488.2,,,5488.2,Other,225% New York Medicaid APG,3414.88,,,3414.88,Other,140% New York Medicaid APG,5488.2,,,5488.2,Other,225% New York Medicaid APG,6341.92,,,6341.92,Other,260% New York Medicaid APG,7903.01,,,7903.01,Other,324% New York Medicaid APG,5244.28,,,5244.28,Other,215% New York Medicaid APG,5244.28,,,5244.28,Other,215% New York Medicaid APG,3049,,,3049,Other,125% New York Medicaid APG,2439.2,61123.74,
Removal pacemaker electrode,33235,CPT,,,,,,,,both,,,82599.65,61123.74,74,,61123.74,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,37169.84,45,,37169.84,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,40886.83,49.5,,40886.83,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,4536.91,,,4536.91,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,57819.76,70,,57819.76,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,2439.2,,,2439.2,Other,New York Medicaid APG methodology,2439.2,,,2439.2,Other,100% New York Medicaid APG,2439.2,,,2439.2,Other,100% New York Medicaid APG,2439.2,,,2439.2,Other,100% New York Medicaid APG,5488.2,,,5488.2,Other,225% New York Medicaid APG,3731.98,,,3731.98,Other,153% New York Medicaid APG,5488.2,,,5488.2,Other,225% New York Medicaid APG,3414.88,,,3414.88,Other,140% New York Medicaid APG,5488.2,,,5488.2,Other,225% New York Medicaid APG,6341.92,,,6341.92,Other,260% New York Medicaid APG,7903.01,,,7903.01,Other,324% New York Medicaid APG,5244.28,,,5244.28,Other,215% New York Medicaid APG,5244.28,,,5244.28,Other,215% New York Medicaid APG,3049,,,3049,Other,125% New York Medicaid APG,2439.2,61123.74,
Insrt pulse gen w/singl lead,33240,CPT,,,,,,,,both,,,495795.01,366888.31,74,,366888.31,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,223107.75,45,,223107.75,percent of total billed charges,Medicare Ratio of cost to charges,5954,,"100% primary, 50% supplemental procedure",5954,Other,Aetna ASC Grouper,5359,,"100% primary, 50% supplemental procedure",5359,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,245418.53,49.5,,245418.53,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,25102.82,,,25102.82,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9196,,"100% primary, 0% secondary procedures",9196,Other,MagnaCare ASC Grouper,347056.51,70,,347056.51,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,15267,,"100% primary, 50% secondary, 25% tertiary procedure",15267,Other,United Healthcare ASC Grouper,13740,,"100% primary, 50% secondary, 25% tertiary procedure",13740,Other,United Healthcare ASC Grouper,15267,,"100% primary, 50% secondary, 25% tertiary procedure",15267,Other,United Healthcare ASC Grouper,12977,,"100% primary, 50% secondary, 25% tertiary procedure",12977,Other,United Healthcare ASC Grouper,13496.14,,,13496.14,Other,New York Medicaid APG methodology,13496.14,,,13496.14,Other,100% New York Medicaid APG,13496.14,,,13496.14,Other,100% New York Medicaid APG,13496.14,,,13496.14,Other,100% New York Medicaid APG,30366.31,,,30366.31,Other,225% New York Medicaid APG,20649.09,,,20649.09,Other,153% New York Medicaid APG,30366.31,,,30366.31,Other,225% New York Medicaid APG,18894.6,,,18894.6,Other,140% New York Medicaid APG,30366.31,,,30366.31,Other,225% New York Medicaid APG,35089.96,,,35089.96,Other,260% New York Medicaid APG,43727.49,,,43727.49,Other,324% New York Medicaid APG,29016.7,,,29016.7,Other,215% New York Medicaid APG,29016.7,,,29016.7,Other,215% New York Medicaid APG,16870.17,,,16870.17,Other,125% New York Medicaid APG,3343,366888.31,
Remove pulse generator,33241,CPT,,,,,,,,both,,,82599.65,61123.74,74,,61123.74,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,37169.84,45,,37169.84,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,40886.83,49.5,,40886.83,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3946.83,,,3946.83,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,57819.76,70,,57819.76,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,2121.95,,,2121.95,Other,New York Medicaid APG methodology,2121.95,,,2121.95,Other,100% New York Medicaid APG,2121.95,,,2121.95,Other,100% New York Medicaid APG,2121.95,,,2121.95,Other,100% New York Medicaid APG,4774.4,,,4774.4,Other,225% New York Medicaid APG,3246.59,,,3246.59,Other,153% New York Medicaid APG,4774.4,,,4774.4,Other,225% New York Medicaid APG,2970.74,,,2970.74,Other,140% New York Medicaid APG,4774.4,,,4774.4,Other,225% New York Medicaid APG,5517.08,,,5517.08,Other,260% New York Medicaid APG,6875.13,,,6875.13,Other,324% New York Medicaid APG,4562.2,,,4562.2,Other,215% New York Medicaid APG,4562.2,,,4562.2,Other,215% New York Medicaid APG,2652.44,,,2652.44,Other,125% New York Medicaid APG,2121.95,61123.74,
Remove elctrd transvenously,33244,CPT,,,,,,,,both,,,273034.86,202045.8,74,,202045.8,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,122865.69,45,,122865.69,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,135152.26,49.5,,135152.26,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,4536.91,,,4536.91,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,191124.4,70,,191124.4,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,2439.2,,,2439.2,Other,New York Medicaid APG methodology,2439.2,,,2439.2,Other,100% New York Medicaid APG,2439.2,,,2439.2,Other,100% New York Medicaid APG,2439.2,,,2439.2,Other,100% New York Medicaid APG,5488.2,,,5488.2,Other,225% New York Medicaid APG,3731.98,,,3731.98,Other,153% New York Medicaid APG,5488.2,,,5488.2,Other,225% New York Medicaid APG,3414.88,,,3414.88,Other,140% New York Medicaid APG,5488.2,,,5488.2,Other,225% New York Medicaid APG,6341.92,,,6341.92,Other,260% New York Medicaid APG,7903.01,,,7903.01,Other,324% New York Medicaid APG,5244.28,,,5244.28,Other,215% New York Medicaid APG,5244.28,,,5244.28,Other,215% New York Medicaid APG,3049,,,3049,Other,125% New York Medicaid APG,2439.2,202045.8,
Insj/rplcmt defib w/lead(s),33249,CPT,,,,,,,,both,,,169009.67,125067.16,74,,125067.16,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,76054.35,45,,76054.35,percent of total billed charges,Medicare Ratio of cost to charges,5954,,"100% primary, 50% supplemental procedure",5954,Other,Aetna ASC Grouper,5359,,"100% primary, 50% supplemental procedure",5359,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,83659.79,49.5,,83659.79,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,25102.82,,,25102.82,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9196,,"100% primary, 0% secondary procedures",9196,Other,MagnaCare ASC Grouper,118306.77,70,,118306.77,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,15267,,"100% primary, 50% secondary, 25% tertiary procedure",15267,Other,United Healthcare ASC Grouper,13740,,"100% primary, 50% secondary, 25% tertiary procedure",13740,Other,United Healthcare ASC Grouper,15267,,"100% primary, 50% secondary, 25% tertiary procedure",15267,Other,United Healthcare ASC Grouper,12977,,"100% primary, 50% secondary, 25% tertiary procedure",12977,Other,United Healthcare ASC Grouper,13496.14,,,13496.14,Other,New York Medicaid APG methodology,13496.14,,,13496.14,Other,100% New York Medicaid APG,13496.14,,,13496.14,Other,100% New York Medicaid APG,13496.14,,,13496.14,Other,100% New York Medicaid APG,30366.31,,,30366.31,Other,225% New York Medicaid APG,20649.09,,,20649.09,Other,153% New York Medicaid APG,30366.31,,,30366.31,Other,225% New York Medicaid APG,18894.6,,,18894.6,Other,140% New York Medicaid APG,30366.31,,,30366.31,Other,225% New York Medicaid APG,35089.96,,,35089.96,Other,260% New York Medicaid APG,43727.49,,,43727.49,Other,324% New York Medicaid APG,29016.7,,,29016.7,Other,215% New York Medicaid APG,29016.7,,,29016.7,Other,215% New York Medicaid APG,16870.17,,,16870.17,Other,125% New York Medicaid APG,3343,125067.16,
Rmvl& replc pulse gen 1 lead,33262,CPT,,,,,,,,both,,,128383.53,95003.81,74,,95003.81,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,57772.59,45,,57772.59,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,63549.85,49.5,,63549.85,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,25102.82,,,25102.82,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9196,,"100% primary, 0% secondary procedures",9196,Other,MagnaCare ASC Grouper,89868.47,70,,89868.47,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,15267,,"100% primary, 50% secondary, 25% tertiary procedure",15267,Other,United Healthcare ASC Grouper,13740,,"100% primary, 50% secondary, 25% tertiary procedure",13740,Other,United Healthcare ASC Grouper,15267,,"100% primary, 50% secondary, 25% tertiary procedure",15267,Other,United Healthcare ASC Grouper,12977,,"100% primary, 50% secondary, 25% tertiary procedure",12977,Other,United Healthcare ASC Grouper,13496.14,,,13496.14,Other,New York Medicaid APG methodology,13496.14,,,13496.14,Other,100% New York Medicaid APG,13496.14,,,13496.14,Other,100% New York Medicaid APG,13496.14,,,13496.14,Other,100% New York Medicaid APG,30366.31,,,30366.31,Other,225% New York Medicaid APG,20649.09,,,20649.09,Other,153% New York Medicaid APG,30366.31,,,30366.31,Other,225% New York Medicaid APG,18894.6,,,18894.6,Other,140% New York Medicaid APG,30366.31,,,30366.31,Other,225% New York Medicaid APG,35089.96,,,35089.96,Other,260% New York Medicaid APG,43727.49,,,43727.49,Other,324% New York Medicaid APG,29016.7,,,29016.7,Other,215% New York Medicaid APG,29016.7,,,29016.7,Other,215% New York Medicaid APG,16870.17,,,16870.17,Other,125% New York Medicaid APG,3126,95003.81,
Rmvl & rplcmt dfb gen 2 lead,33263,CPT,,,,,,,,both,,,135571.71,100323.07,74,,100323.07,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,61007.27,45,,61007.27,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,67108,49.5,,67108,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,25102.82,,,25102.82,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9196,,"100% primary, 0% secondary procedures",9196,Other,MagnaCare ASC Grouper,94900.2,70,,94900.2,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,15267,,"100% primary, 50% secondary, 25% tertiary procedure",15267,Other,United Healthcare ASC Grouper,13740,,"100% primary, 50% secondary, 25% tertiary procedure",13740,Other,United Healthcare ASC Grouper,15267,,"100% primary, 50% secondary, 25% tertiary procedure",15267,Other,United Healthcare ASC Grouper,12977,,"100% primary, 50% secondary, 25% tertiary procedure",12977,Other,United Healthcare ASC Grouper,13496.14,,,13496.14,Other,New York Medicaid APG methodology,13496.14,,,13496.14,Other,100% New York Medicaid APG,13496.14,,,13496.14,Other,100% New York Medicaid APG,13496.14,,,13496.14,Other,100% New York Medicaid APG,30366.31,,,30366.31,Other,225% New York Medicaid APG,20649.09,,,20649.09,Other,153% New York Medicaid APG,30366.31,,,30366.31,Other,225% New York Medicaid APG,18894.6,,,18894.6,Other,140% New York Medicaid APG,30366.31,,,30366.31,Other,225% New York Medicaid APG,35089.96,,,35089.96,Other,260% New York Medicaid APG,43727.49,,,43727.49,Other,324% New York Medicaid APG,29016.7,,,29016.7,Other,215% New York Medicaid APG,29016.7,,,29016.7,Other,215% New York Medicaid APG,16870.17,,,16870.17,Other,125% New York Medicaid APG,3126,100323.07,
Rmvl & rplcmt dfb gen mlt ld,33264,CPT,,,,,,,,both,,,153330.86,113464.84,74,,113464.84,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,68998.89,45,,68998.89,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,75898.78,49.5,,75898.78,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,25102.82,,,25102.82,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9196,,"100% primary, 0% secondary procedures",9196,Other,MagnaCare ASC Grouper,107331.6,70,,107331.6,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,15267,,"100% primary, 50% secondary, 25% tertiary procedure",15267,Other,United Healthcare ASC Grouper,13740,,"100% primary, 50% secondary, 25% tertiary procedure",13740,Other,United Healthcare ASC Grouper,15267,,"100% primary, 50% secondary, 25% tertiary procedure",15267,Other,United Healthcare ASC Grouper,12977,,"100% primary, 50% secondary, 25% tertiary procedure",12977,Other,United Healthcare ASC Grouper,13496.14,,,13496.14,Other,New York Medicaid APG methodology,13496.14,,,13496.14,Other,100% New York Medicaid APG,13496.14,,,13496.14,Other,100% New York Medicaid APG,13496.14,,,13496.14,Other,100% New York Medicaid APG,30366.31,,,30366.31,Other,225% New York Medicaid APG,20649.09,,,20649.09,Other,153% New York Medicaid APG,30366.31,,,30366.31,Other,225% New York Medicaid APG,18894.6,,,18894.6,Other,140% New York Medicaid APG,30366.31,,,30366.31,Other,225% New York Medicaid APG,35089.96,,,35089.96,Other,260% New York Medicaid APG,43727.49,,,43727.49,Other,324% New York Medicaid APG,29016.7,,,29016.7,Other,215% New York Medicaid APG,29016.7,,,29016.7,Other,215% New York Medicaid APG,16870.17,,,16870.17,Other,125% New York Medicaid APG,3126,113464.84,
Ins/rep subq defibrillator,33270,CPT,,,,,,,,both,,,209767.75,155228.14,74,,155228.14,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,94395.49,45,,94395.49,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,103835.04,49.5,,103835.04,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,25102.82,,,25102.82,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9196,,"100% primary, 0% secondary procedures",9196,Other,MagnaCare ASC Grouper,146837.43,70,,146837.43,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,15267,,"100% primary, 50% secondary, 25% tertiary procedure",15267,Other,United Healthcare ASC Grouper,13740,,"100% primary, 50% secondary, 25% tertiary procedure",13740,Other,United Healthcare ASC Grouper,15267,,"100% primary, 50% secondary, 25% tertiary procedure",15267,Other,United Healthcare ASC Grouper,12977,,"100% primary, 50% secondary, 25% tertiary procedure",12977,Other,United Healthcare ASC Grouper,13496.14,,,13496.14,Other,New York Medicaid APG methodology,13496.14,,,13496.14,Other,100% New York Medicaid APG,13496.14,,,13496.14,Other,100% New York Medicaid APG,13496.14,,,13496.14,Other,100% New York Medicaid APG,30366.31,,,30366.31,Other,225% New York Medicaid APG,20649.09,,,20649.09,Other,153% New York Medicaid APG,30366.31,,,30366.31,Other,225% New York Medicaid APG,18894.6,,,18894.6,Other,140% New York Medicaid APG,30366.31,,,30366.31,Other,225% New York Medicaid APG,35089.96,,,35089.96,Other,260% New York Medicaid APG,43727.49,,,43727.49,Other,324% New York Medicaid APG,29016.7,,,29016.7,Other,215% New York Medicaid APG,29016.7,,,29016.7,Other,215% New York Medicaid APG,16870.17,,,16870.17,Other,125% New York Medicaid APG,3126,155228.14,
Insj subq impltbl dfb elctrd,33271,CPT,,,,,,,,both,,,178695.84,132234.92,74,,132234.92,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,80413.13,45,,80413.13,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,88454.44,49.5,,88454.44,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,4536.91,,,4536.91,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9196,,"100% primary, 0% secondary procedures",9196,Other,MagnaCare ASC Grouper,125087.09,70,,125087.09,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6956,,"100% primary, 50% secondary, 25% tertiary procedure",6956,Other,United Healthcare ASC Grouper,6261,,"100% primary, 50% secondary, 25% tertiary procedure",6261,Other,United Healthcare ASC Grouper,6956,,"100% primary, 50% secondary, 25% tertiary procedure",6956,Other,United Healthcare ASC Grouper,5913,,"100% primary, 50% secondary, 25% tertiary procedure",5913,Other,United Healthcare ASC Grouper,2439.2,,,2439.2,Other,New York Medicaid APG methodology,2439.2,,,2439.2,Other,100% New York Medicaid APG,2439.2,,,2439.2,Other,100% New York Medicaid APG,2439.2,,,2439.2,Other,100% New York Medicaid APG,5488.2,,,5488.2,Other,225% New York Medicaid APG,3731.98,,,3731.98,Other,153% New York Medicaid APG,5488.2,,,5488.2,Other,225% New York Medicaid APG,3414.88,,,3414.88,Other,140% New York Medicaid APG,5488.2,,,5488.2,Other,225% New York Medicaid APG,6341.92,,,6341.92,Other,260% New York Medicaid APG,7903.01,,,7903.01,Other,324% New York Medicaid APG,5244.28,,,5244.28,Other,215% New York Medicaid APG,5244.28,,,5244.28,Other,215% New York Medicaid APG,3049,,,3049,Other,125% New York Medicaid APG,2439.2,132234.92,
Rmvl of subq defibrillator,33272,CPT,,,,,,,,both,,,82599.65,61123.74,74,,61123.74,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,37169.84,45,,37169.84,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,40886.83,49.5,,40886.83,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,4536.91,,,4536.91,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,57819.76,70,,57819.76,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,2439.2,,,2439.2,Other,New York Medicaid APG methodology,2439.2,,,2439.2,Other,100% New York Medicaid APG,2439.2,,,2439.2,Other,100% New York Medicaid APG,2439.2,,,2439.2,Other,100% New York Medicaid APG,5488.2,,,5488.2,Other,225% New York Medicaid APG,3731.98,,,3731.98,Other,153% New York Medicaid APG,5488.2,,,5488.2,Other,225% New York Medicaid APG,3414.88,,,3414.88,Other,140% New York Medicaid APG,5488.2,,,5488.2,Other,225% New York Medicaid APG,6341.92,,,6341.92,Other,260% New York Medicaid APG,7903.01,,,7903.01,Other,324% New York Medicaid APG,5244.28,,,5244.28,Other,215% New York Medicaid APG,5244.28,,,5244.28,Other,215% New York Medicaid APG,3049,,,3049,Other,125% New York Medicaid APG,2439.2,61123.74,
Repos prev impltbl subq dfb,33273,CPT,,,,,,,,both,,,82599.65,61123.74,74,,61123.74,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,37169.84,45,,37169.84,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,40886.83,49.5,,40886.83,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,4536.91,,,4536.91,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,57819.76,70,,57819.76,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,2439.2,,,2439.2,Other,New York Medicaid APG methodology,2439.2,,,2439.2,Other,100% New York Medicaid APG,2439.2,,,2439.2,Other,100% New York Medicaid APG,2439.2,,,2439.2,Other,100% New York Medicaid APG,5488.2,,,5488.2,Other,225% New York Medicaid APG,3731.98,,,3731.98,Other,153% New York Medicaid APG,5488.2,,,5488.2,Other,225% New York Medicaid APG,3414.88,,,3414.88,Other,140% New York Medicaid APG,5488.2,,,5488.2,Other,225% New York Medicaid APG,6341.92,,,6341.92,Other,260% New York Medicaid APG,7903.01,,,7903.01,Other,324% New York Medicaid APG,5244.28,,,5244.28,Other,215% New York Medicaid APG,5244.28,,,5244.28,Other,215% New York Medicaid APG,3049,,,3049,Other,125% New York Medicaid APG,2439.2,61123.74,
Tcat insj/rpl perm ldls pm,33274,CPT,,,,,,,,both,,,111843.5,82764.19,74,,82764.19,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,50329.58,45,,50329.58,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,55362.53,49.5,,55362.53,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,10683.75,,,10683.75,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,78290.45,70,,78290.45,percent of total billed charges,,2325.52,,,2325.52,Fee Schedule,,1971.02,,,1971.02,Fee Schedule,,8589,,"100% primary, 50% secondary, 25% tertiary procedure",8589,Other,United Healthcare ASC Grouper,7730,,"100% primary, 50% secondary, 25% tertiary procedure",7730,Other,United Healthcare ASC Grouper,8589,,"100% primary, 50% secondary, 25% tertiary procedure",8589,Other,United Healthcare ASC Grouper,7301,,"100% primary, 50% secondary, 25% tertiary procedure",7301,Other,United Healthcare ASC Grouper,5743.95,,,5743.95,Other,New York Medicaid APG methodology,5743.95,,,5743.95,Other,100% New York Medicaid APG,5743.95,,,5743.95,Other,100% New York Medicaid APG,5743.95,,,5743.95,Other,100% New York Medicaid APG,12923.9,,,12923.9,Other,225% New York Medicaid APG,8788.25,,,8788.25,Other,153% New York Medicaid APG,12923.9,,,12923.9,Other,225% New York Medicaid APG,8041.54,,,8041.54,Other,140% New York Medicaid APG,12923.9,,,12923.9,Other,225% New York Medicaid APG,14934.28,,,14934.28,Other,260% New York Medicaid APG,18610.41,,,18610.41,Other,324% New York Medicaid APG,12349.5,,,12349.5,Other,215% New York Medicaid APG,12349.5,,,12349.5,Other,215% New York Medicaid APG,7179.94,,,7179.94,Other,125% New York Medicaid APG,1971.02,82764.19,
Tcat rmvl perm ldls pm w/img,33275,CPT,,,,,,,,both,,,67044.74,49613.11,74,,49613.11,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30170.13,45,,30170.13,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33187.15,49.5,,33187.15,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3946.83,,,3946.83,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,46931.32,70,,46931.32,percent of total billed charges,,2425.56,,,2425.56,Fee Schedule,,2055.81,,,2055.81,Fee Schedule,,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,2121.95,,,2121.95,Other,New York Medicaid APG methodology,2121.95,,,2121.95,Other,100% New York Medicaid APG,2121.95,,,2121.95,Other,100% New York Medicaid APG,2121.95,,,2121.95,Other,100% New York Medicaid APG,4774.4,,,4774.4,Other,225% New York Medicaid APG,3246.59,,,3246.59,Other,153% New York Medicaid APG,4774.4,,,4774.4,Other,225% New York Medicaid APG,2970.74,,,2970.74,Other,140% New York Medicaid APG,4774.4,,,4774.4,Other,225% New York Medicaid APG,5517.08,,,5517.08,Other,260% New York Medicaid APG,6875.13,,,6875.13,Other,324% New York Medicaid APG,4562.2,,,4562.2,Other,215% New York Medicaid APG,4562.2,,,4562.2,Other,215% New York Medicaid APG,2652.44,,,2652.44,Other,125% New York Medicaid APG,2055.81,49613.11,
Insj subq car rhythm mntr,33285,CPT,,,,,,,,both,,,63517.36,47002.85,74,,47002.85,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,28582.81,45,,28582.81,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,31441.09,49.5,,31441.09,percent of total billed charges,110% of Medicare,43191.8,68,,43191.8,percent of total billed charges,,10683.75,,,10683.75,Other,186% of Medicaid,50813.89,80,,50813.89,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,50813.89,80,,50813.89,percent of total billed charges,,7216,,,7216,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,44462.15,70,,44462.15,percent of total billed charges,,424.76,,,424.76,Fee Schedule,,360.01,,,360.01,Fee Schedule,,6956,,"100% primary, 50% secondary, 25% tertiary procedure",6956,Other,United Healthcare ASC Grouper,6261,,"100% primary, 50% secondary, 25% tertiary procedure",6261,Other,United Healthcare ASC Grouper,6956,,"100% primary, 50% secondary, 25% tertiary procedure",6956,Other,United Healthcare ASC Grouper,5913,,"100% primary, 50% secondary, 25% tertiary procedure",5913,Other,United Healthcare ASC Grouper,5743.95,,,5743.95,Other,New York Medicaid APG methodology,5743.95,,,5743.95,Other,100% New York Medicaid APG,5743.95,,,5743.95,Other,100% New York Medicaid APG,5743.95,,,5743.95,Other,100% New York Medicaid APG,12923.9,,,12923.9,Other,225% New York Medicaid APG,8788.25,,,8788.25,Other,153% New York Medicaid APG,12923.9,,,12923.9,Other,225% New York Medicaid APG,8041.54,,,8041.54,Other,140% New York Medicaid APG,12923.9,,,12923.9,Other,225% New York Medicaid APG,14934.28,,,14934.28,Other,260% New York Medicaid APG,18610.41,,,18610.41,Other,324% New York Medicaid APG,12349.5,,,12349.5,Other,215% New York Medicaid APG,12349.5,,,12349.5,Other,215% New York Medicaid APG,7179.94,,,7179.94,Other,125% New York Medicaid APG,360.01,50813.89,
Rmvl subq car rhythm mntr,33286,CPT,,,,,,,,both,,,49862.63,36898.35,74,,36898.35,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,22438.18,45,,22438.18,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,24682,49.5,,24682,percent of total billed charges,110% of Medicare,33906.59,68,,33906.59,percent of total billed charges,,4536.91,,,4536.91,Other,186% of Medicaid,39890.1,80,,39890.1,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,39890.1,80,,39890.1,percent of total billed charges,,7216,,,7216,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,34903.84,70,,34903.84,percent of total billed charges,,418.2,,,418.2,Fee Schedule,,354.45,,,354.45,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,2439.2,,,2439.2,Other,New York Medicaid APG methodology,2439.2,,,2439.2,Other,100% New York Medicaid APG,2439.2,,,2439.2,Other,100% New York Medicaid APG,2439.2,,,2439.2,Other,100% New York Medicaid APG,5488.2,,,5488.2,Other,225% New York Medicaid APG,3731.98,,,3731.98,Other,153% New York Medicaid APG,5488.2,,,5488.2,Other,225% New York Medicaid APG,3414.88,,,3414.88,Other,140% New York Medicaid APG,5488.2,,,5488.2,Other,225% New York Medicaid APG,6341.92,,,6341.92,Other,260% New York Medicaid APG,7903.01,,,7903.01,Other,324% New York Medicaid APG,5244.28,,,5244.28,Other,215% New York Medicaid APG,5244.28,,,5244.28,Other,215% New York Medicaid APG,3049,,,3049,Other,125% New York Medicaid APG,354.45,39890.1,
Repair tcat mitral valve,33419,CPT,,,,,,,,both,,,87274.28,64582.97,74,,64582.97,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,39273.43,45,,39273.43,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,52364.57,60,,52364.57,percent of total billed charges,,48873.6,56,,48873.6,percent of total billed charges,,47128.11,54,,47128.11,percent of total billed charges,,43200.77,49.5,,43200.77,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,4727.53,,,4727.53,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,61092,70,,61092,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,2541.68,,,2541.68,Other,New York Medicaid APG methodology,2541.68,,,2541.68,Other,100% New York Medicaid APG,2541.68,,,2541.68,Other,100% New York Medicaid APG,2541.68,,,2541.68,Other,100% New York Medicaid APG,5718.79,,,5718.79,Other,225% New York Medicaid APG,3888.77,,,3888.77,Other,153% New York Medicaid APG,5718.79,,,5718.79,Other,225% New York Medicaid APG,3558.36,,,3558.36,Other,140% New York Medicaid APG,5718.79,,,5718.79,Other,225% New York Medicaid APG,6608.37,,,6608.37,Other,260% New York Medicaid APG,8235.05,,,8235.05,Other,324% New York Medicaid APG,5464.62,,,5464.62,Other,215% New York Medicaid APG,5464.62,,,5464.62,Other,215% New York Medicaid APG,3177.1,,,3177.1,Other,125% New York Medicaid APG,2541.68,64582.97,
Endoscopic vein harvest,33508,CPT,,,,,,,,both,,,32432.1,23999.75,74,,23999.75,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,14594.45,45,,14594.45,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,16053.89,49.5,,16053.89,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,0.02,,,0.02,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,22702.47,70,,22702.47,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% New York Medicaid APG,0.01,,,0.01,Other,100% New York Medicaid APG,0.01,,,0.01,Other,100% New York Medicaid APG,0.02,,,0.02,Other,225% New York Medicaid APG,0.02,,,0.02,Other,153% New York Medicaid APG,0.02,,,0.02,Other,225% New York Medicaid APG,0.01,,,0.01,Other,140% New York Medicaid APG,0.02,,,0.02,Other,225% New York Medicaid APG,0.03,,,0.03,Other,260% New York Medicaid APG,0.03,,,0.03,Other,324% New York Medicaid APG,0.02,,,0.02,Other,215% New York Medicaid APG,0.02,,,0.02,Other,215% New York Medicaid APG,0.01,,,0.01,Other,125% New York Medicaid APG,0.01,23999.75,
Aortic hemiarch graft,33866,CPT,,,,,,,,both,,,86591.4,64077.64,74,,64077.64,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,38966.13,45,,38966.13,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,6125,,"100% primary, 50% secondary, 25% supplemental procedure",6125,Other,Blue Cross ASC Grouper,5513,,"100% primary, 50% secondary, 25% supplemental procedure",5513,Other,Blue Cross ASC Grouper,5206,,"100% primary, 50% secondary, 25% supplemental procedure",5206,Other,Blue Cross ASC Grouper,42862.74,49.5,,42862.74,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,4418.36,,,4418.36,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,60613.98,70,,60613.98,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,2375.46,,,2375.46,Other,New York Medicaid APG methodology,2375.46,,,2375.46,Other,100% New York Medicaid APG,2375.46,,,2375.46,Other,100% New York Medicaid APG,2375.46,,,2375.46,Other,100% New York Medicaid APG,5344.79,,,5344.79,Other,225% New York Medicaid APG,3634.45,,,3634.45,Other,153% New York Medicaid APG,5344.79,,,5344.79,Other,225% New York Medicaid APG,3325.64,,,3325.64,Other,140% New York Medicaid APG,5344.79,,,5344.79,Other,225% New York Medicaid APG,6176.2,,,6176.2,Other,260% New York Medicaid APG,7696.49,,,7696.49,Other,324% New York Medicaid APG,5107.24,,,5107.24,Other,215% New York Medicaid APG,5107.24,,,5107.24,Other,215% New York Medicaid APG,2969.33,,,2969.33,Other,125% New York Medicaid APG,2375.46,64077.64,
Removal of artery clot,34101,CPT,,,,,,,,both,,,115587.67,85534.88,74,,85534.88,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,52014.45,45,,52014.45,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,57215.9,49.5,,57215.9,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,4418.36,,,4418.36,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,80911.37,70,,80911.37,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,2375.46,,,2375.46,Other,New York Medicaid APG methodology,2375.46,,,2375.46,Other,100% New York Medicaid APG,2375.46,,,2375.46,Other,100% New York Medicaid APG,2375.46,,,2375.46,Other,100% New York Medicaid APG,5344.79,,,5344.79,Other,225% New York Medicaid APG,3634.46,,,3634.46,Other,153% New York Medicaid APG,5344.79,,,5344.79,Other,225% New York Medicaid APG,3325.65,,,3325.65,Other,140% New York Medicaid APG,5344.79,,,5344.79,Other,225% New York Medicaid APG,6176.2,,,6176.2,Other,260% New York Medicaid APG,7696.49,,,7696.49,Other,324% New York Medicaid APG,5107.24,,,5107.24,Other,215% New York Medicaid APG,5107.24,,,5107.24,Other,215% New York Medicaid APG,2969.33,,,2969.33,Other,125% New York Medicaid APG,2375.46,85534.88,
Removal of arm artery clot,34111,CPT,,,,,,,,both,,,115587.67,85534.88,74,,85534.88,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,52014.45,45,,52014.45,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,57215.9,49.5,,57215.9,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,4418.36,,,4418.36,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,80911.37,70,,80911.37,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,2375.46,,,2375.46,Other,New York Medicaid APG methodology,2375.46,,,2375.46,Other,100% New York Medicaid APG,2375.46,,,2375.46,Other,100% New York Medicaid APG,2375.46,,,2375.46,Other,100% New York Medicaid APG,5344.79,,,5344.79,Other,225% New York Medicaid APG,3634.46,,,3634.46,Other,153% New York Medicaid APG,5344.79,,,5344.79,Other,225% New York Medicaid APG,3325.65,,,3325.65,Other,140% New York Medicaid APG,5344.79,,,5344.79,Other,225% New York Medicaid APG,6176.2,,,6176.2,Other,260% New York Medicaid APG,7696.49,,,7696.49,Other,324% New York Medicaid APG,5107.24,,,5107.24,Other,215% New York Medicaid APG,5107.24,,,5107.24,Other,215% New York Medicaid APG,2969.33,,,2969.33,Other,125% New York Medicaid APG,2375.46,85534.88,
Removal of artery clot,34201,CPT,,,,,,,,both,,,115587.67,85534.88,74,,85534.88,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,52014.45,45,,52014.45,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,57215.9,49.5,,57215.9,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,4418.36,,,4418.36,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,80911.37,70,,80911.37,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,2375.46,,,2375.46,Other,New York Medicaid APG methodology,2375.46,,,2375.46,Other,100% New York Medicaid APG,2375.46,,,2375.46,Other,100% New York Medicaid APG,2375.46,,,2375.46,Other,100% New York Medicaid APG,5344.79,,,5344.79,Other,225% New York Medicaid APG,3634.46,,,3634.46,Other,153% New York Medicaid APG,5344.79,,,5344.79,Other,225% New York Medicaid APG,3325.65,,,3325.65,Other,140% New York Medicaid APG,5344.79,,,5344.79,Other,225% New York Medicaid APG,6176.2,,,6176.2,Other,260% New York Medicaid APG,7696.49,,,7696.49,Other,324% New York Medicaid APG,5107.24,,,5107.24,Other,215% New York Medicaid APG,5107.24,,,5107.24,Other,215% New York Medicaid APG,2969.33,,,2969.33,Other,125% New York Medicaid APG,2375.46,85534.88,
Removal of leg artery clot,34203,CPT,,,,,,,,both,,,115587.67,85534.88,74,,85534.88,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,52014.45,45,,52014.45,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,57215.9,49.5,,57215.9,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,4418.36,,,4418.36,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,80911.37,70,,80911.37,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,2375.46,,,2375.46,Other,New York Medicaid APG methodology,2375.46,,,2375.46,Other,100% New York Medicaid APG,2375.46,,,2375.46,Other,100% New York Medicaid APG,2375.46,,,2375.46,Other,100% New York Medicaid APG,5344.79,,,5344.79,Other,225% New York Medicaid APG,3634.46,,,3634.46,Other,153% New York Medicaid APG,5344.79,,,5344.79,Other,225% New York Medicaid APG,3325.65,,,3325.65,Other,140% New York Medicaid APG,5344.79,,,5344.79,Other,225% New York Medicaid APG,6176.2,,,6176.2,Other,260% New York Medicaid APG,7696.49,,,7696.49,Other,324% New York Medicaid APG,5107.24,,,5107.24,Other,215% New York Medicaid APG,5107.24,,,5107.24,Other,215% New York Medicaid APG,2969.33,,,2969.33,Other,125% New York Medicaid APG,2375.46,85534.88,
Removal of vein clot,34421,CPT,,,,,,,,both,,,67044.74,49613.11,74,,49613.11,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30170.13,45,,30170.13,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33187.15,49.5,,33187.15,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,4418.36,,,4418.36,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,46931.32,70,,46931.32,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,2375.46,,,2375.46,Other,New York Medicaid APG methodology,2375.46,,,2375.46,Other,100% New York Medicaid APG,2375.46,,,2375.46,Other,100% New York Medicaid APG,2375.46,,,2375.46,Other,100% New York Medicaid APG,5344.79,,,5344.79,Other,225% New York Medicaid APG,3634.46,,,3634.46,Other,153% New York Medicaid APG,5344.79,,,5344.79,Other,225% New York Medicaid APG,3325.65,,,3325.65,Other,140% New York Medicaid APG,5344.79,,,5344.79,Other,225% New York Medicaid APG,6176.2,,,6176.2,Other,260% New York Medicaid APG,7696.49,,,7696.49,Other,324% New York Medicaid APG,5107.24,,,5107.24,Other,215% New York Medicaid APG,5107.24,,,5107.24,Other,215% New York Medicaid APG,2969.33,,,2969.33,Other,125% New York Medicaid APG,2375.46,49613.11,
Removal of vein clot,34471,CPT,,,,,,,,both,,,13213.53,9778.01,74,,9778.01,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,5946.09,45,,5946.09,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,6540.7,49.5,,6540.7,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,4418.36,,,4418.36,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,3578,,"100% primary, 0% secondary procedures",3578,Other,MagnaCare ASC Grouper,9249.47,70,,9249.47,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,2375.46,,,2375.46,Other,New York Medicaid APG methodology,2375.46,,,2375.46,Other,100% New York Medicaid APG,2375.46,,,2375.46,Other,100% New York Medicaid APG,2375.46,,,2375.46,Other,100% New York Medicaid APG,5344.79,,,5344.79,Other,225% New York Medicaid APG,3634.46,,,3634.46,Other,153% New York Medicaid APG,5344.79,,,5344.79,Other,225% New York Medicaid APG,3325.65,,,3325.65,Other,140% New York Medicaid APG,5344.79,,,5344.79,Other,225% New York Medicaid APG,6176.2,,,6176.2,Other,260% New York Medicaid APG,7696.49,,,7696.49,Other,324% New York Medicaid APG,5107.24,,,5107.24,Other,215% New York Medicaid APG,5107.24,,,5107.24,Other,215% New York Medicaid APG,2969.33,,,2969.33,Other,125% New York Medicaid APG,2375.46,9778.01,
Removal of vein clot,34490,CPT,,,,,,,,both,,,67044.74,49613.11,74,,49613.11,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30170.13,45,,30170.13,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33187.15,49.5,,33187.15,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,4418.36,,,4418.36,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,46931.32,70,,46931.32,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,2375.46,,,2375.46,Other,New York Medicaid APG methodology,2375.46,,,2375.46,Other,100% New York Medicaid APG,2375.46,,,2375.46,Other,100% New York Medicaid APG,2375.46,,,2375.46,Other,100% New York Medicaid APG,5344.79,,,5344.79,Other,225% New York Medicaid APG,3634.46,,,3634.46,Other,153% New York Medicaid APG,5344.79,,,5344.79,Other,225% New York Medicaid APG,3325.65,,,3325.65,Other,140% New York Medicaid APG,5344.79,,,5344.79,Other,225% New York Medicaid APG,6176.2,,,6176.2,Other,260% New York Medicaid APG,7696.49,,,7696.49,Other,324% New York Medicaid APG,5107.24,,,5107.24,Other,215% New York Medicaid APG,5107.24,,,5107.24,Other,215% New York Medicaid APG,2969.33,,,2969.33,Other,125% New York Medicaid APG,2375.46,49613.11,
Repair valve femoral vein,34501,CPT,,,,,,,,both,,,115587.67,85534.88,74,,85534.88,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,52014.45,45,,52014.45,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,57215.9,49.5,,57215.9,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,4418.36,,,4418.36,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,80911.37,70,,80911.37,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,2375.46,,,2375.46,Other,New York Medicaid APG methodology,2375.46,,,2375.46,Other,100% New York Medicaid APG,2375.46,,,2375.46,Other,100% New York Medicaid APG,2375.46,,,2375.46,Other,100% New York Medicaid APG,5344.79,,,5344.79,Other,225% New York Medicaid APG,3634.46,,,3634.46,Other,153% New York Medicaid APG,5344.79,,,5344.79,Other,225% New York Medicaid APG,3325.65,,,3325.65,Other,140% New York Medicaid APG,5344.79,,,5344.79,Other,225% New York Medicaid APG,6176.2,,,6176.2,Other,260% New York Medicaid APG,7696.49,,,7696.49,Other,324% New York Medicaid APG,5107.24,,,5107.24,Other,215% New York Medicaid APG,5107.24,,,5107.24,Other,215% New York Medicaid APG,2969.33,,,2969.33,Other,125% New York Medicaid APG,2375.46,85534.88,
Transposition of vein valve,34510,CPT,,,,,,,,both,,,115587.67,85534.88,74,,85534.88,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,52014.45,45,,52014.45,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,57215.9,49.5,,57215.9,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,4418.36,,,4418.36,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,80911.37,70,,80911.37,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,2375.46,,,2375.46,Other,New York Medicaid APG methodology,2375.46,,,2375.46,Other,100% New York Medicaid APG,2375.46,,,2375.46,Other,100% New York Medicaid APG,2375.46,,,2375.46,Other,100% New York Medicaid APG,5344.79,,,5344.79,Other,225% New York Medicaid APG,3634.46,,,3634.46,Other,153% New York Medicaid APG,5344.79,,,5344.79,Other,225% New York Medicaid APG,3325.65,,,3325.65,Other,140% New York Medicaid APG,5344.79,,,5344.79,Other,225% New York Medicaid APG,6176.2,,,6176.2,Other,260% New York Medicaid APG,7696.49,,,7696.49,Other,324% New York Medicaid APG,5107.24,,,5107.24,Other,215% New York Medicaid APG,5107.24,,,5107.24,Other,215% New York Medicaid APG,2969.33,,,2969.33,Other,125% New York Medicaid APG,2375.46,85534.88,
Cross-over vein graft,34520,CPT,,,,,,,,both,,,115587.67,85534.88,74,,85534.88,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,52014.45,45,,52014.45,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,57215.9,49.5,,57215.9,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,4418.36,,,4418.36,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,80911.37,70,,80911.37,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,2375.46,,,2375.46,Other,New York Medicaid APG methodology,2375.46,,,2375.46,Other,100% New York Medicaid APG,2375.46,,,2375.46,Other,100% New York Medicaid APG,2375.46,,,2375.46,Other,100% New York Medicaid APG,5344.79,,,5344.79,Other,225% New York Medicaid APG,3634.46,,,3634.46,Other,153% New York Medicaid APG,5344.79,,,5344.79,Other,225% New York Medicaid APG,3325.65,,,3325.65,Other,140% New York Medicaid APG,5344.79,,,5344.79,Other,225% New York Medicaid APG,6176.2,,,6176.2,Other,260% New York Medicaid APG,7696.49,,,7696.49,Other,324% New York Medicaid APG,5107.24,,,5107.24,Other,215% New York Medicaid APG,5107.24,,,5107.24,Other,215% New York Medicaid APG,2969.33,,,2969.33,Other,125% New York Medicaid APG,2375.46,85534.88,
Leg vein fusion,34530,CPT,,,,,,,,both,,,67044.74,49613.11,74,,49613.11,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30170.13,45,,30170.13,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33187.15,49.5,,33187.15,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,4418.36,,,4418.36,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,46931.32,70,,46931.32,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,2375.46,,,2375.46,Other,New York Medicaid APG methodology,2375.46,,,2375.46,Other,100% New York Medicaid APG,2375.46,,,2375.46,Other,100% New York Medicaid APG,2375.46,,,2375.46,Other,100% New York Medicaid APG,5344.79,,,5344.79,Other,225% New York Medicaid APG,3634.46,,,3634.46,Other,153% New York Medicaid APG,5344.79,,,5344.79,Other,225% New York Medicaid APG,3325.65,,,3325.65,Other,140% New York Medicaid APG,5344.79,,,5344.79,Other,225% New York Medicaid APG,6176.2,,,6176.2,Other,260% New York Medicaid APG,7696.49,,,7696.49,Other,324% New York Medicaid APG,5107.24,,,5107.24,Other,215% New York Medicaid APG,5107.24,,,5107.24,Other,215% New York Medicaid APG,2969.33,,,2969.33,Other,125% New York Medicaid APG,2375.46,49613.11,
Perq access & clsr fem art,34713,CPT,,,,,,,,both,,,98219.64,72682.53,74,,72682.53,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,44198.84,45,,44198.84,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,48618.72,49.5,,48618.72,percent of total billed charges,110% of Medicare,66789.36,68,,66789.36,percent of total billed charges,,2757.95,,,2757.95,Other,186% of Medicaid,78575.71,80,,78575.71,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,78575.71,80,,78575.71,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,68753.75,70,,68753.75,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,1482.77,,,1482.77,Other,New York Medicaid APG methodology,1482.77,,,1482.77,Other,100% New York Medicaid APG,1482.77,,,1482.77,Other,100% New York Medicaid APG,1482.77,,,1482.77,Other,100% New York Medicaid APG,3336.23,,,3336.23,Other,225% New York Medicaid APG,2268.64,,,2268.64,Other,153% New York Medicaid APG,3336.23,,,3336.23,Other,225% New York Medicaid APG,2075.88,,,2075.88,Other,140% New York Medicaid APG,3336.23,,,3336.23,Other,225% New York Medicaid APG,3855.2,,,3855.2,Other,260% New York Medicaid APG,4804.18,,,4804.18,Other,324% New York Medicaid APG,3187.96,,,3187.96,Other,215% New York Medicaid APG,3187.96,,,3187.96,Other,215% New York Medicaid APG,1853.46,,,1853.46,Other,125% New York Medicaid APG,1482.77,78575.71,
Opn fem art expos cndt crtj,34714,CPT,,,,,,,,both,,,83504,61792.96,74,,61792.96,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,37576.8,45,,37576.8,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,41334.48,49.5,,41334.48,percent of total billed charges,110% of Medicare,56782.72,68,,56782.72,percent of total billed charges,,3002.5,,,3002.5,Other,186% of Medicaid,66803.2,80,,66803.2,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,66803.2,80,,66803.2,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,58452.8,70,,58452.8,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,1614.25,,,1614.25,Other,New York Medicaid APG methodology,1614.25,,,1614.25,Other,100% New York Medicaid APG,1614.25,,,1614.25,Other,100% New York Medicaid APG,1614.25,,,1614.25,Other,100% New York Medicaid APG,3632.06,,,3632.06,Other,225% New York Medicaid APG,2469.8,,,2469.8,Other,153% New York Medicaid APG,3632.06,,,3632.06,Other,225% New York Medicaid APG,2259.95,,,2259.95,Other,140% New York Medicaid APG,3632.06,,,3632.06,Other,225% New York Medicaid APG,4197.05,,,4197.05,Other,260% New York Medicaid APG,5230.17,,,5230.17,Other,324% New York Medicaid APG,3470.64,,,3470.64,Other,215% New York Medicaid APG,3470.64,,,3470.64,Other,215% New York Medicaid APG,2017.81,,,2017.81,Other,125% New York Medicaid APG,1614.25,66803.2,
Opn ax/subcla art expos,34715,CPT,,,,,,,,both,,,83504,61792.96,74,,61792.96,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,37576.8,45,,37576.8,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,41334.48,49.5,,41334.48,percent of total billed charges,110% of Medicare,56782.72,68,,56782.72,percent of total billed charges,,4418.36,,,4418.36,Other,186% of Medicaid,66803.2,80,,66803.2,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,66803.2,80,,66803.2,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,58452.8,70,,58452.8,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,2375.46,,,2375.46,Other,New York Medicaid APG methodology,2375.46,,,2375.46,Other,100% New York Medicaid APG,2375.46,,,2375.46,Other,100% New York Medicaid APG,2375.46,,,2375.46,Other,100% New York Medicaid APG,5344.79,,,5344.79,Other,225% New York Medicaid APG,3634.46,,,3634.46,Other,153% New York Medicaid APG,5344.79,,,5344.79,Other,225% New York Medicaid APG,3325.65,,,3325.65,Other,140% New York Medicaid APG,5344.79,,,5344.79,Other,225% New York Medicaid APG,6176.2,,,6176.2,Other,260% New York Medicaid APG,7696.49,,,7696.49,Other,324% New York Medicaid APG,5107.24,,,5107.24,Other,215% New York Medicaid APG,5107.24,,,5107.24,Other,215% New York Medicaid APG,2969.33,,,2969.33,Other,125% New York Medicaid APG,2053,66803.2,
Opn ax/subcla art expos cndt,34716,CPT,,,,,,,,both,,,83504,61792.96,74,,61792.96,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,37576.8,45,,37576.8,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,41334.48,49.5,,41334.48,percent of total billed charges,110% of Medicare,56782.72,68,,56782.72,percent of total billed charges,,3002.5,,,3002.5,Other,186% of Medicaid,66803.2,80,,66803.2,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,66803.2,80,,66803.2,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,58452.8,70,,58452.8,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,1614.25,,,1614.25,Other,New York Medicaid APG methodology,1614.25,,,1614.25,Other,100% New York Medicaid APG,1614.25,,,1614.25,Other,100% New York Medicaid APG,1614.25,,,1614.25,Other,100% New York Medicaid APG,3632.06,,,3632.06,Other,225% New York Medicaid APG,2469.8,,,2469.8,Other,153% New York Medicaid APG,3632.06,,,3632.06,Other,225% New York Medicaid APG,2259.95,,,2259.95,Other,140% New York Medicaid APG,3632.06,,,3632.06,Other,225% New York Medicaid APG,4197.05,,,4197.05,Other,260% New York Medicaid APG,5230.17,,,5230.17,Other,324% New York Medicaid APG,3470.64,,,3470.64,Other,215% New York Medicaid APG,3470.64,,,3470.64,Other,215% New York Medicaid APG,2017.81,,,2017.81,Other,125% New York Medicaid APG,1614.25,66803.2,
Repair defect of artery,35011,CPT,,,,,,,,both,,,115587.67,85534.88,74,,85534.88,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,52014.45,45,,52014.45,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,57215.9,49.5,,57215.9,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,4418.36,,,4418.36,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,80911.37,70,,80911.37,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,2375.46,,,2375.46,Other,New York Medicaid APG methodology,2375.46,,,2375.46,Other,100% New York Medicaid APG,2375.46,,,2375.46,Other,100% New York Medicaid APG,2375.46,,,2375.46,Other,100% New York Medicaid APG,5344.79,,,5344.79,Other,225% New York Medicaid APG,3634.46,,,3634.46,Other,153% New York Medicaid APG,5344.79,,,5344.79,Other,225% New York Medicaid APG,3325.65,,,3325.65,Other,140% New York Medicaid APG,5344.79,,,5344.79,Other,225% New York Medicaid APG,6176.2,,,6176.2,Other,260% New York Medicaid APG,7696.49,,,7696.49,Other,324% New York Medicaid APG,5107.24,,,5107.24,Other,215% New York Medicaid APG,5107.24,,,5107.24,Other,215% New York Medicaid APG,2969.33,,,2969.33,Other,125% New York Medicaid APG,2375.46,85534.88,
Repair defect of arm artery,35045,CPT,,,,,,,,both,,,32847.72,24307.31,74,,24307.31,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,14781.47,45,,14781.47,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,16259.62,49.5,,16259.62,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,4418.36,,,4418.36,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,22993.4,70,,22993.4,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,2375.46,,,2375.46,Other,New York Medicaid APG methodology,2375.46,,,2375.46,Other,100% New York Medicaid APG,2375.46,,,2375.46,Other,100% New York Medicaid APG,2375.46,,,2375.46,Other,100% New York Medicaid APG,5344.79,,,5344.79,Other,225% New York Medicaid APG,3634.46,,,3634.46,Other,153% New York Medicaid APG,5344.79,,,5344.79,Other,225% New York Medicaid APG,3325.65,,,3325.65,Other,140% New York Medicaid APG,5344.79,,,5344.79,Other,225% New York Medicaid APG,6176.2,,,6176.2,Other,260% New York Medicaid APG,7696.49,,,7696.49,Other,324% New York Medicaid APG,5107.24,,,5107.24,Other,215% New York Medicaid APG,5107.24,,,5107.24,Other,215% New York Medicaid APG,2969.33,,,2969.33,Other,125% New York Medicaid APG,2375.46,24307.31,
Repair blood vessel lesion,35180,CPT,,,,,,,,both,,,33686.28,24927.85,74,,24927.85,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15158.83,45,,15158.83,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,16674.71,49.5,,16674.71,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,4418.36,,,4418.36,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,3578,,"100% primary, 0% secondary procedures",3578,Other,MagnaCare ASC Grouper,23580.4,70,,23580.4,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,2375.46,,,2375.46,Other,New York Medicaid APG methodology,2375.46,,,2375.46,Other,100% New York Medicaid APG,2375.46,,,2375.46,Other,100% New York Medicaid APG,2375.46,,,2375.46,Other,100% New York Medicaid APG,5344.79,,,5344.79,Other,225% New York Medicaid APG,3634.45,,,3634.45,Other,153% New York Medicaid APG,5344.79,,,5344.79,Other,225% New York Medicaid APG,3325.64,,,3325.64,Other,140% New York Medicaid APG,5344.79,,,5344.79,Other,225% New York Medicaid APG,6176.2,,,6176.2,Other,260% New York Medicaid APG,7696.49,,,7696.49,Other,324% New York Medicaid APG,5107.24,,,5107.24,Other,215% New York Medicaid APG,5107.24,,,5107.24,Other,215% New York Medicaid APG,2969.33,,,2969.33,Other,125% New York Medicaid APG,2375.46,24927.85,
Repair blood vessel lesion,35184,CPT,,,,,,,,both,,,67044.74,49613.11,74,,49613.11,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30170.13,45,,30170.13,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33187.15,49.5,,33187.15,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,4418.36,,,4418.36,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,46931.32,70,,46931.32,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,2375.46,,,2375.46,Other,New York Medicaid APG methodology,2375.46,,,2375.46,Other,100% New York Medicaid APG,2375.46,,,2375.46,Other,100% New York Medicaid APG,2375.46,,,2375.46,Other,100% New York Medicaid APG,5344.79,,,5344.79,Other,225% New York Medicaid APG,3634.45,,,3634.45,Other,153% New York Medicaid APG,5344.79,,,5344.79,Other,225% New York Medicaid APG,3325.64,,,3325.64,Other,140% New York Medicaid APG,5344.79,,,5344.79,Other,225% New York Medicaid APG,6176.2,,,6176.2,Other,260% New York Medicaid APG,7696.49,,,7696.49,Other,324% New York Medicaid APG,5107.24,,,5107.24,Other,215% New York Medicaid APG,5107.24,,,5107.24,Other,215% New York Medicaid APG,2969.33,,,2969.33,Other,125% New York Medicaid APG,2375.46,49613.11,
Repair blood vessel lesion,35188,CPT,,,,,,,,both,,,115587.67,85534.88,74,,85534.88,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,52014.45,45,,52014.45,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,57215.9,49.5,,57215.9,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,4418.36,,,4418.36,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,80911.37,70,,80911.37,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,2375.46,,,2375.46,Other,New York Medicaid APG methodology,2375.46,,,2375.46,Other,100% New York Medicaid APG,2375.46,,,2375.46,Other,100% New York Medicaid APG,2375.46,,,2375.46,Other,100% New York Medicaid APG,5344.79,,,5344.79,Other,225% New York Medicaid APG,3634.45,,,3634.45,Other,153% New York Medicaid APG,5344.79,,,5344.79,Other,225% New York Medicaid APG,3325.64,,,3325.64,Other,140% New York Medicaid APG,5344.79,,,5344.79,Other,225% New York Medicaid APG,6176.2,,,6176.2,Other,260% New York Medicaid APG,7696.49,,,7696.49,Other,324% New York Medicaid APG,5107.24,,,5107.24,Other,215% New York Medicaid APG,5107.24,,,5107.24,Other,215% New York Medicaid APG,2969.33,,,2969.33,Other,125% New York Medicaid APG,2375.46,85534.88,
Repair blood vessel lesion,35190,CPT,,,,,,,,both,,,115587.67,85534.88,74,,85534.88,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,52014.45,45,,52014.45,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,57215.9,49.5,,57215.9,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,4418.36,,,4418.36,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,80911.37,70,,80911.37,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,2375.46,,,2375.46,Other,New York Medicaid APG methodology,2375.46,,,2375.46,Other,100% New York Medicaid APG,2375.46,,,2375.46,Other,100% New York Medicaid APG,2375.46,,,2375.46,Other,100% New York Medicaid APG,5344.79,,,5344.79,Other,225% New York Medicaid APG,3634.45,,,3634.45,Other,153% New York Medicaid APG,5344.79,,,5344.79,Other,225% New York Medicaid APG,3325.64,,,3325.64,Other,140% New York Medicaid APG,5344.79,,,5344.79,Other,225% New York Medicaid APG,6176.2,,,6176.2,Other,260% New York Medicaid APG,7696.49,,,7696.49,Other,324% New York Medicaid APG,5107.24,,,5107.24,Other,215% New York Medicaid APG,5107.24,,,5107.24,Other,215% New York Medicaid APG,2969.33,,,2969.33,Other,125% New York Medicaid APG,2375.46,85534.88,
Repair blood vessel lesion,35201,CPT,,,,,,,,both,,,115587.67,85534.88,74,,85534.88,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,52014.45,45,,52014.45,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,57215.9,49.5,,57215.9,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,4418.36,,,4418.36,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,80911.37,70,,80911.37,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,2375.46,,,2375.46,Other,New York Medicaid APG methodology,2375.46,,,2375.46,Other,100% New York Medicaid APG,2375.46,,,2375.46,Other,100% New York Medicaid APG,2375.46,,,2375.46,Other,100% New York Medicaid APG,5344.79,,,5344.79,Other,225% New York Medicaid APG,3634.45,,,3634.45,Other,153% New York Medicaid APG,5344.79,,,5344.79,Other,225% New York Medicaid APG,3325.64,,,3325.64,Other,140% New York Medicaid APG,5344.79,,,5344.79,Other,225% New York Medicaid APG,6176.2,,,6176.2,Other,260% New York Medicaid APG,7696.49,,,7696.49,Other,324% New York Medicaid APG,5107.24,,,5107.24,Other,215% New York Medicaid APG,5107.24,,,5107.24,Other,215% New York Medicaid APG,2969.33,,,2969.33,Other,125% New York Medicaid APG,2375.46,85534.88,
Repair blood vessel lesion,35206,CPT,,,,,,,,both,,,67044.74,49613.11,74,,49613.11,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30170.13,45,,30170.13,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33187.15,49.5,,33187.15,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,4418.36,,,4418.36,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,46931.32,70,,46931.32,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,2375.46,,,2375.46,Other,New York Medicaid APG methodology,2375.46,,,2375.46,Other,100% New York Medicaid APG,2375.46,,,2375.46,Other,100% New York Medicaid APG,2375.46,,,2375.46,Other,100% New York Medicaid APG,5344.79,,,5344.79,Other,225% New York Medicaid APG,3634.45,,,3634.45,Other,153% New York Medicaid APG,5344.79,,,5344.79,Other,225% New York Medicaid APG,3325.64,,,3325.64,Other,140% New York Medicaid APG,5344.79,,,5344.79,Other,225% New York Medicaid APG,6176.2,,,6176.2,Other,260% New York Medicaid APG,7696.49,,,7696.49,Other,324% New York Medicaid APG,5107.24,,,5107.24,Other,215% New York Medicaid APG,5107.24,,,5107.24,Other,215% New York Medicaid APG,2969.33,,,2969.33,Other,125% New York Medicaid APG,2375.46,49613.11,
Repair blood vessel lesion,35207,CPT,,,,,,,,both,,,67044.74,49613.11,74,,49613.11,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30170.13,45,,30170.13,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33187.15,49.5,,33187.15,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,4418.36,,,4418.36,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,46931.32,70,,46931.32,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,2375.46,,,2375.46,Other,New York Medicaid APG methodology,2375.46,,,2375.46,Other,100% New York Medicaid APG,2375.46,,,2375.46,Other,100% New York Medicaid APG,2375.46,,,2375.46,Other,100% New York Medicaid APG,5344.79,,,5344.79,Other,225% New York Medicaid APG,3634.45,,,3634.45,Other,153% New York Medicaid APG,5344.79,,,5344.79,Other,225% New York Medicaid APG,3325.64,,,3325.64,Other,140% New York Medicaid APG,5344.79,,,5344.79,Other,225% New York Medicaid APG,6176.2,,,6176.2,Other,260% New York Medicaid APG,7696.49,,,7696.49,Other,324% New York Medicaid APG,5107.24,,,5107.24,Other,215% New York Medicaid APG,5107.24,,,5107.24,Other,215% New York Medicaid APG,2969.33,,,2969.33,Other,125% New York Medicaid APG,2375.46,49613.11,
Repair blood vessel lesion,35226,CPT,,,,,,,,both,,,14798.8,10951.11,74,,10951.11,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,6659.46,45,,6659.46,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,7325.41,49.5,,7325.41,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,4418.36,,,4418.36,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,3578,,"100% primary, 0% secondary procedures",3578,Other,MagnaCare ASC Grouper,10359.16,70,,10359.16,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,2375.46,,,2375.46,Other,New York Medicaid APG methodology,2375.46,,,2375.46,Other,100% New York Medicaid APG,2375.46,,,2375.46,Other,100% New York Medicaid APG,2375.46,,,2375.46,Other,100% New York Medicaid APG,5344.79,,,5344.79,Other,225% New York Medicaid APG,3634.45,,,3634.45,Other,153% New York Medicaid APG,5344.79,,,5344.79,Other,225% New York Medicaid APG,3325.64,,,3325.64,Other,140% New York Medicaid APG,5344.79,,,5344.79,Other,225% New York Medicaid APG,6176.2,,,6176.2,Other,260% New York Medicaid APG,7696.49,,,7696.49,Other,324% New York Medicaid APG,5107.24,,,5107.24,Other,215% New York Medicaid APG,5107.24,,,5107.24,Other,215% New York Medicaid APG,2969.33,,,2969.33,Other,125% New York Medicaid APG,2375.46,10951.11,
Repair blood vessel lesion,35231,CPT,,,,,,,,both,,,67044.74,49613.11,74,,49613.11,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30170.13,45,,30170.13,percent of total billed charges,Medicare Ratio of cost to charges,5459,,"100% primary, 50% supplemental procedure",5459,Other,Aetna ASC Grouper,4913,,"100% primary, 50% supplemental procedure",4913,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33187.15,49.5,,33187.15,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,4418.36,,,4418.36,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,46931.32,70,,46931.32,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,2375.46,,,2375.46,Other,New York Medicaid APG methodology,2375.46,,,2375.46,Other,100% New York Medicaid APG,2375.46,,,2375.46,Other,100% New York Medicaid APG,2375.46,,,2375.46,Other,100% New York Medicaid APG,5344.79,,,5344.79,Other,225% New York Medicaid APG,3634.45,,,3634.45,Other,153% New York Medicaid APG,5344.79,,,5344.79,Other,225% New York Medicaid APG,3325.64,,,3325.64,Other,140% New York Medicaid APG,5344.79,,,5344.79,Other,225% New York Medicaid APG,6176.2,,,6176.2,Other,260% New York Medicaid APG,7696.49,,,7696.49,Other,324% New York Medicaid APG,5107.24,,,5107.24,Other,215% New York Medicaid APG,5107.24,,,5107.24,Other,215% New York Medicaid APG,2969.33,,,2969.33,Other,125% New York Medicaid APG,2375.46,49613.11,
Repair blood vessel lesion,35236,CPT,,,,,,,,both,,,115587.67,85534.88,74,,85534.88,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,52014.45,45,,52014.45,percent of total billed charges,Medicare Ratio of cost to charges,5459,,"100% primary, 50% supplemental procedure",5459,Other,Aetna ASC Grouper,4913,,"100% primary, 50% supplemental procedure",4913,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,57215.9,49.5,,57215.9,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,4418.36,,,4418.36,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,80911.37,70,,80911.37,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,2375.46,,,2375.46,Other,New York Medicaid APG methodology,2375.46,,,2375.46,Other,100% New York Medicaid APG,2375.46,,,2375.46,Other,100% New York Medicaid APG,2375.46,,,2375.46,Other,100% New York Medicaid APG,5344.79,,,5344.79,Other,225% New York Medicaid APG,3634.45,,,3634.45,Other,153% New York Medicaid APG,5344.79,,,5344.79,Other,225% New York Medicaid APG,3325.64,,,3325.64,Other,140% New York Medicaid APG,5344.79,,,5344.79,Other,225% New York Medicaid APG,6176.2,,,6176.2,Other,260% New York Medicaid APG,7696.49,,,7696.49,Other,324% New York Medicaid APG,5107.24,,,5107.24,Other,215% New York Medicaid APG,5107.24,,,5107.24,Other,215% New York Medicaid APG,2969.33,,,2969.33,Other,125% New York Medicaid APG,2375.46,85534.88,
Repair blood vessel lesion,35256,CPT,,,,,,,,both,,,115587.67,85534.88,74,,85534.88,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,52014.45,45,,52014.45,percent of total billed charges,Medicare Ratio of cost to charges,5459,,"100% primary, 50% supplemental procedure",5459,Other,Aetna ASC Grouper,4913,,"100% primary, 50% supplemental procedure",4913,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,57215.9,49.5,,57215.9,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,4418.36,,,4418.36,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,80911.37,70,,80911.37,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,2375.46,,,2375.46,Other,New York Medicaid APG methodology,2375.46,,,2375.46,Other,100% New York Medicaid APG,2375.46,,,2375.46,Other,100% New York Medicaid APG,2375.46,,,2375.46,Other,100% New York Medicaid APG,5344.79,,,5344.79,Other,225% New York Medicaid APG,3634.46,,,3634.46,Other,153% New York Medicaid APG,5344.79,,,5344.79,Other,225% New York Medicaid APG,3325.65,,,3325.65,Other,140% New York Medicaid APG,5344.79,,,5344.79,Other,225% New York Medicaid APG,6176.2,,,6176.2,Other,260% New York Medicaid APG,7696.49,,,7696.49,Other,324% New York Medicaid APG,5107.24,,,5107.24,Other,215% New York Medicaid APG,5107.24,,,5107.24,Other,215% New York Medicaid APG,2969.33,,,2969.33,Other,125% New York Medicaid APG,2375.46,85534.88,
Repair blood vessel lesion,35261,CPT,,,,,,,,both,,,67044.74,49613.11,74,,49613.11,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30170.13,45,,30170.13,percent of total billed charges,Medicare Ratio of cost to charges,5459,,"100% primary, 50% supplemental procedure",5459,Other,Aetna ASC Grouper,4913,,"100% primary, 50% supplemental procedure",4913,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33187.15,49.5,,33187.15,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,4418.36,,,4418.36,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,46931.32,70,,46931.32,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,2375.46,,,2375.46,Other,New York Medicaid APG methodology,2375.46,,,2375.46,Other,100% New York Medicaid APG,2375.46,,,2375.46,Other,100% New York Medicaid APG,2375.46,,,2375.46,Other,100% New York Medicaid APG,5344.79,,,5344.79,Other,225% New York Medicaid APG,3634.46,,,3634.46,Other,153% New York Medicaid APG,5344.79,,,5344.79,Other,225% New York Medicaid APG,3325.65,,,3325.65,Other,140% New York Medicaid APG,5344.79,,,5344.79,Other,225% New York Medicaid APG,6176.2,,,6176.2,Other,260% New York Medicaid APG,7696.49,,,7696.49,Other,324% New York Medicaid APG,5107.24,,,5107.24,Other,215% New York Medicaid APG,5107.24,,,5107.24,Other,215% New York Medicaid APG,2969.33,,,2969.33,Other,125% New York Medicaid APG,2375.46,49613.11,
Repair blood vessel lesion,35266,CPT,,,,,,,,both,,,115587.67,85534.88,74,,85534.88,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,52014.45,45,,52014.45,percent of total billed charges,Medicare Ratio of cost to charges,5459,,"100% primary, 50% supplemental procedure",5459,Other,Aetna ASC Grouper,4913,,"100% primary, 50% supplemental procedure",4913,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,57215.9,49.5,,57215.9,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,4418.36,,,4418.36,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,80911.37,70,,80911.37,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,2375.46,,,2375.46,Other,New York Medicaid APG methodology,2375.46,,,2375.46,Other,100% New York Medicaid APG,2375.46,,,2375.46,Other,100% New York Medicaid APG,2375.46,,,2375.46,Other,100% New York Medicaid APG,5344.79,,,5344.79,Other,225% New York Medicaid APG,3634.45,,,3634.45,Other,153% New York Medicaid APG,5344.79,,,5344.79,Other,225% New York Medicaid APG,3325.64,,,3325.64,Other,140% New York Medicaid APG,5344.79,,,5344.79,Other,225% New York Medicaid APG,6176.2,,,6176.2,Other,260% New York Medicaid APG,7696.49,,,7696.49,Other,324% New York Medicaid APG,5107.24,,,5107.24,Other,215% New York Medicaid APG,5107.24,,,5107.24,Other,215% New York Medicaid APG,2969.33,,,2969.33,Other,125% New York Medicaid APG,2375.46,85534.88,
Repair blood vessel lesion,35286,CPT,,,,,,,,both,,,115587.67,85534.88,74,,85534.88,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,52014.45,45,,52014.45,percent of total billed charges,Medicare Ratio of cost to charges,5459,,"100% primary, 50% supplemental procedure",5459,Other,Aetna ASC Grouper,4913,,"100% primary, 50% supplemental procedure",4913,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,57215.9,49.5,,57215.9,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,4076.5,,,4076.5,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,80911.37,70,,80911.37,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,2191.67,,,2191.67,Other,New York Medicaid APG methodology,2191.67,,,2191.67,Other,100% New York Medicaid APG,2191.67,,,2191.67,Other,100% New York Medicaid APG,2191.67,,,2191.67,Other,100% New York Medicaid APG,4931.25,,,4931.25,Other,225% New York Medicaid APG,3353.25,,,3353.25,Other,153% New York Medicaid APG,4931.25,,,4931.25,Other,225% New York Medicaid APG,3068.33,,,3068.33,Other,140% New York Medicaid APG,4931.25,,,4931.25,Other,225% New York Medicaid APG,5698.33,,,5698.33,Other,260% New York Medicaid APG,7101,,,7101,Other,324% New York Medicaid APG,4712.08,,,4712.08,Other,215% New York Medicaid APG,4712.08,,,4712.08,Other,215% New York Medicaid APG,2739.58,,,2739.58,Other,125% New York Medicaid APG,2191.67,85534.88,
Rechanneling of artery,35321,CPT,,,,,,,,both,,,115587.67,85534.88,74,,85534.88,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,52014.45,45,,52014.45,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,57215.9,49.5,,57215.9,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,4418.36,,,4418.36,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,80911.37,70,,80911.37,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,2375.46,,,2375.46,Other,New York Medicaid APG methodology,2375.46,,,2375.46,Other,100% New York Medicaid APG,2375.46,,,2375.46,Other,100% New York Medicaid APG,2375.46,,,2375.46,Other,100% New York Medicaid APG,5344.79,,,5344.79,Other,225% New York Medicaid APG,3634.46,,,3634.46,Other,153% New York Medicaid APG,5344.79,,,5344.79,Other,225% New York Medicaid APG,3325.65,,,3325.65,Other,140% New York Medicaid APG,5344.79,,,5344.79,Other,225% New York Medicaid APG,6176.2,,,6176.2,Other,260% New York Medicaid APG,7696.49,,,7696.49,Other,324% New York Medicaid APG,5107.24,,,5107.24,Other,215% New York Medicaid APG,5107.24,,,5107.24,Other,215% New York Medicaid APG,2969.33,,,2969.33,Other,125% New York Medicaid APG,2375.46,85534.88,
Harvest femoropopliteal vein,35572,CPT,,,,,,,,both,,,51572.04,38163.31,74,,38163.31,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,23207.42,45,,23207.42,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,25528.16,49.5,,25528.16,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,4076.5,,,4076.5,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,36100.43,70,,36100.43,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,2191.67,,,2191.67,Other,New York Medicaid APG methodology,2191.67,,,2191.67,Other,100% New York Medicaid APG,2191.67,,,2191.67,Other,100% New York Medicaid APG,2191.67,,,2191.67,Other,100% New York Medicaid APG,4931.25,,,4931.25,Other,225% New York Medicaid APG,3353.25,,,3353.25,Other,153% New York Medicaid APG,4931.25,,,4931.25,Other,225% New York Medicaid APG,3068.33,,,3068.33,Other,140% New York Medicaid APG,4931.25,,,4931.25,Other,225% New York Medicaid APG,5698.33,,,5698.33,Other,260% New York Medicaid APG,7101,,,7101,Other,324% New York Medicaid APG,4712.08,,,4712.08,Other,215% New York Medicaid APG,4712.08,,,4712.08,Other,215% New York Medicaid APG,2739.58,,,2739.58,Other,125% New York Medicaid APG,2191.67,38163.31,
Explore limb vessels,35860,CPT,,,,,,,,both,,,67044.74,49613.11,74,,49613.11,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30170.13,45,,30170.13,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33187.15,49.5,,33187.15,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,4418.36,,,4418.36,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,46931.32,70,,46931.32,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,2375.46,,,2375.46,Other,New York Medicaid APG methodology,2375.46,,,2375.46,Other,100% New York Medicaid APG,2375.46,,,2375.46,Other,100% New York Medicaid APG,2375.46,,,2375.46,Other,100% New York Medicaid APG,5344.79,,,5344.79,Other,225% New York Medicaid APG,3634.46,,,3634.46,Other,153% New York Medicaid APG,5344.79,,,5344.79,Other,225% New York Medicaid APG,3325.65,,,3325.65,Other,140% New York Medicaid APG,5344.79,,,5344.79,Other,225% New York Medicaid APG,6176.2,,,6176.2,Other,260% New York Medicaid APG,7696.49,,,7696.49,Other,324% New York Medicaid APG,5107.24,,,5107.24,Other,215% New York Medicaid APG,5107.24,,,5107.24,Other,215% New York Medicaid APG,2969.33,,,2969.33,Other,125% New York Medicaid APG,2375.46,49613.11,
Removal of clot in graft,35875,CPT,,,,,,,,both,,,115587.67,85534.88,74,,85534.88,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,52014.45,45,,52014.45,percent of total billed charges,Medicare Ratio of cost to charges,5954,,"100% primary, 50% supplemental procedure",5954,Other,Aetna ASC Grouper,5359,,"100% primary, 50% supplemental procedure",5359,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,57215.9,49.5,,57215.9,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,4418.36,,,4418.36,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,80911.37,70,,80911.37,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,2375.46,,,2375.46,Other,New York Medicaid APG methodology,2375.46,,,2375.46,Other,100% New York Medicaid APG,2375.46,,,2375.46,Other,100% New York Medicaid APG,2375.46,,,2375.46,Other,100% New York Medicaid APG,5344.79,,,5344.79,Other,225% New York Medicaid APG,3634.46,,,3634.46,Other,153% New York Medicaid APG,5344.79,,,5344.79,Other,225% New York Medicaid APG,3325.65,,,3325.65,Other,140% New York Medicaid APG,5344.79,,,5344.79,Other,225% New York Medicaid APG,6176.2,,,6176.2,Other,260% New York Medicaid APG,7696.49,,,7696.49,Other,324% New York Medicaid APG,5107.24,,,5107.24,Other,215% New York Medicaid APG,5107.24,,,5107.24,Other,215% New York Medicaid APG,2969.33,,,2969.33,Other,125% New York Medicaid APG,2375.46,85534.88,
Removal of clot in graft,35876,CPT,,,,,,,,both,,,115587.67,85534.88,74,,85534.88,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,52014.45,45,,52014.45,percent of total billed charges,Medicare Ratio of cost to charges,5954,,"100% primary, 50% supplemental procedure",5954,Other,Aetna ASC Grouper,5359,,"100% primary, 50% supplemental procedure",5359,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,57215.9,49.5,,57215.9,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,4418.36,,,4418.36,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,80911.37,70,,80911.37,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,2375.46,,,2375.46,Other,New York Medicaid APG methodology,2375.46,,,2375.46,Other,100% New York Medicaid APG,2375.46,,,2375.46,Other,100% New York Medicaid APG,2375.46,,,2375.46,Other,100% New York Medicaid APG,5344.79,,,5344.79,Other,225% New York Medicaid APG,3634.46,,,3634.46,Other,153% New York Medicaid APG,5344.79,,,5344.79,Other,225% New York Medicaid APG,3325.65,,,3325.65,Other,140% New York Medicaid APG,5344.79,,,5344.79,Other,225% New York Medicaid APG,6176.2,,,6176.2,Other,260% New York Medicaid APG,7696.49,,,7696.49,Other,324% New York Medicaid APG,5107.24,,,5107.24,Other,215% New York Medicaid APG,5107.24,,,5107.24,Other,215% New York Medicaid APG,2969.33,,,2969.33,Other,125% New York Medicaid APG,2375.46,85534.88,
Revise graft w/vein,35879,CPT,,,,,,,,both,,,115587.67,85534.88,74,,85534.88,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,52014.45,45,,52014.45,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,57215.9,49.5,,57215.9,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,4076.5,,,4076.5,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,80911.37,70,,80911.37,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,2191.67,,,2191.67,Other,New York Medicaid APG methodology,2191.67,,,2191.67,Other,100% New York Medicaid APG,2191.67,,,2191.67,Other,100% New York Medicaid APG,2191.67,,,2191.67,Other,100% New York Medicaid APG,4931.25,,,4931.25,Other,225% New York Medicaid APG,3353.25,,,3353.25,Other,153% New York Medicaid APG,4931.25,,,4931.25,Other,225% New York Medicaid APG,3068.33,,,3068.33,Other,140% New York Medicaid APG,4931.25,,,4931.25,Other,225% New York Medicaid APG,5698.33,,,5698.33,Other,260% New York Medicaid APG,7101,,,7101,Other,324% New York Medicaid APG,4712.08,,,4712.08,Other,215% New York Medicaid APG,4712.08,,,4712.08,Other,215% New York Medicaid APG,2739.58,,,2739.58,Other,125% New York Medicaid APG,2191.67,85534.88,
Revise graft w/vein,35881,CPT,,,,,,,,both,,,115587.67,85534.88,74,,85534.88,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,52014.45,45,,52014.45,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,57215.9,49.5,,57215.9,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,4076.5,,,4076.5,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,80911.37,70,,80911.37,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,2191.67,,,2191.67,Other,New York Medicaid APG methodology,2191.67,,,2191.67,Other,100% New York Medicaid APG,2191.67,,,2191.67,Other,100% New York Medicaid APG,2191.67,,,2191.67,Other,100% New York Medicaid APG,4931.25,,,4931.25,Other,225% New York Medicaid APG,3353.25,,,3353.25,Other,153% New York Medicaid APG,4931.25,,,4931.25,Other,225% New York Medicaid APG,3068.33,,,3068.33,Other,140% New York Medicaid APG,4931.25,,,4931.25,Other,225% New York Medicaid APG,5698.33,,,5698.33,Other,260% New York Medicaid APG,7101,,,7101,Other,324% New York Medicaid APG,4712.08,,,4712.08,Other,215% New York Medicaid APG,4712.08,,,4712.08,Other,215% New York Medicaid APG,2739.58,,,2739.58,Other,125% New York Medicaid APG,2191.67,85534.88,
Revise graft w/nonauto graft,35883,CPT,,,,,,,,both,,,115587.67,85534.88,74,,85534.88,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,52014.45,45,,52014.45,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,57215.9,49.5,,57215.9,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,4076.5,,,4076.5,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,80911.37,70,,80911.37,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,2191.67,,,2191.67,Other,New York Medicaid APG methodology,2191.67,,,2191.67,Other,100% New York Medicaid APG,2191.67,,,2191.67,Other,100% New York Medicaid APG,2191.67,,,2191.67,Other,100% New York Medicaid APG,4931.25,,,4931.25,Other,225% New York Medicaid APG,3353.25,,,3353.25,Other,153% New York Medicaid APG,4931.25,,,4931.25,Other,225% New York Medicaid APG,3068.33,,,3068.33,Other,140% New York Medicaid APG,4931.25,,,4931.25,Other,225% New York Medicaid APG,5698.33,,,5698.33,Other,260% New York Medicaid APG,7101,,,7101,Other,324% New York Medicaid APG,4712.08,,,4712.08,Other,215% New York Medicaid APG,4712.08,,,4712.08,Other,215% New York Medicaid APG,2739.58,,,2739.58,Other,125% New York Medicaid APG,2191.67,85534.88,
Revise graft w/vein,35884,CPT,,,,,,,,both,,,115587.67,85534.88,74,,85534.88,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,52014.45,45,,52014.45,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,57215.9,49.5,,57215.9,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,4076.5,,,4076.5,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,80911.37,70,,80911.37,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,2191.67,,,2191.67,Other,New York Medicaid APG methodology,2191.67,,,2191.67,Other,100% New York Medicaid APG,2191.67,,,2191.67,Other,100% New York Medicaid APG,2191.67,,,2191.67,Other,100% New York Medicaid APG,4931.25,,,4931.25,Other,225% New York Medicaid APG,3353.25,,,3353.25,Other,153% New York Medicaid APG,4931.25,,,4931.25,Other,225% New York Medicaid APG,3068.33,,,3068.33,Other,140% New York Medicaid APG,4931.25,,,4931.25,Other,225% New York Medicaid APG,5698.33,,,5698.33,Other,260% New York Medicaid APG,7101,,,7101,Other,324% New York Medicaid APG,4712.08,,,4712.08,Other,215% New York Medicaid APG,4712.08,,,4712.08,Other,215% New York Medicaid APG,2739.58,,,2739.58,Other,125% New York Medicaid APG,2191.67,85534.88,
Excision graft extremity,35903,CPT,,,,,,,,both,,,67044.74,49613.11,74,,49613.11,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30170.13,45,,30170.13,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33187.15,49.5,,33187.15,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,4418.36,,,4418.36,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,46931.32,70,,46931.32,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,2375.46,,,2375.46,Other,New York Medicaid APG methodology,2375.46,,,2375.46,Other,100% New York Medicaid APG,2375.46,,,2375.46,Other,100% New York Medicaid APG,2375.46,,,2375.46,Other,100% New York Medicaid APG,5344.79,,,5344.79,Other,225% New York Medicaid APG,3634.45,,,3634.45,Other,153% New York Medicaid APG,5344.79,,,5344.79,Other,225% New York Medicaid APG,3325.64,,,3325.64,Other,140% New York Medicaid APG,5344.79,,,5344.79,Other,225% New York Medicaid APG,6176.2,,,6176.2,Other,260% New York Medicaid APG,7696.49,,,7696.49,Other,324% New York Medicaid APG,5107.24,,,5107.24,Other,215% New York Medicaid APG,5107.24,,,5107.24,Other,215% New York Medicaid APG,2969.33,,,2969.33,Other,125% New York Medicaid APG,2375.46,49613.11,
Place needle in vein,36000,CPT,,,,,,,,both,,,32432.1,23999.75,74,,23999.75,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,14594.45,45,,14594.45,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,16053.89,49.5,,16053.89,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,254.86,,,254.86,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,22702.47,70,,22702.47,percent of total billed charges,,44.28,,,44.28,Fee Schedule,,37.53,,,37.53,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,137.02,,,137.02,Other,New York Medicaid APG methodology,137.02,,,137.02,Other,100% New York Medicaid APG,137.02,,,137.02,Other,100% New York Medicaid APG,137.02,,,137.02,Other,100% New York Medicaid APG,308.3,,,308.3,Other,225% New York Medicaid APG,209.65,,,209.65,Other,153% New York Medicaid APG,308.3,,,308.3,Other,225% New York Medicaid APG,191.83,,,191.83,Other,140% New York Medicaid APG,308.3,,,308.3,Other,225% New York Medicaid APG,356.26,,,356.26,Other,260% New York Medicaid APG,443.96,,,443.96,Other,324% New York Medicaid APG,294.6,,,294.6,Other,215% New York Medicaid APG,294.6,,,294.6,Other,215% New York Medicaid APG,171.28,,,171.28,Other,125% New York Medicaid APG,37.53,23999.75,
Pseudoaneurysm injection trt,36002,CPT,,,,,,,,both,,,13213.53,9778.01,74,,9778.01,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,5946.09,45,,5946.09,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,6540.7,49.5,,6540.7,percent of total billed charges,110% of Medicare,8985.2,68,,8985.2,percent of total billed charges,,728.47,,,728.47,Other,186% of Medicaid,10570.82,80,,10570.82,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,10570.82,80,,10570.82,percent of total billed charges,,7216,,,7216,Case Rate,,3578,,"100% primary, 0% secondary procedures",3578,Other,MagnaCare ASC Grouper,9249.47,70,,9249.47,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,391.65,,,391.65,Other,New York Medicaid APG methodology,391.65,,,391.65,Other,100% New York Medicaid APG,391.65,,,391.65,Other,100% New York Medicaid APG,391.65,,,391.65,Other,100% New York Medicaid APG,881.21,,,881.21,Other,225% New York Medicaid APG,599.22,,,599.22,Other,153% New York Medicaid APG,881.21,,,881.21,Other,225% New York Medicaid APG,548.31,,,548.31,Other,140% New York Medicaid APG,881.21,,,881.21,Other,225% New York Medicaid APG,1018.29,,,1018.29,Other,260% New York Medicaid APG,1268.95,,,1268.95,Other,324% New York Medicaid APG,842.05,,,842.05,Other,215% New York Medicaid APG,842.05,,,842.05,Other,215% New York Medicaid APG,489.56,,,489.56,Other,125% New York Medicaid APG,391.65,10570.82,
Injection ext venography,36005,CPT,,,,,,,,both,,,32432.1,23999.75,74,,23999.75,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,14594.45,45,,14594.45,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,16053.89,49.5,,16053.89,percent of total billed charges,110% of Medicare,22053.83,68,,22053.83,percent of total billed charges,,516.02,,,516.02,Other,186% of Medicaid,25945.68,80,,25945.68,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,25945.68,80,,25945.68,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,22702.47,70,,22702.47,percent of total billed charges,,231.24,,,231.24,Fee Schedule,,195.99,,,195.99,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,277.43,,,277.43,Other,New York Medicaid APG methodology,277.43,,,277.43,Other,100% New York Medicaid APG,277.43,,,277.43,Other,100% New York Medicaid APG,277.43,,,277.43,Other,100% New York Medicaid APG,624.21,,,624.21,Other,225% New York Medicaid APG,424.47,,,424.47,Other,153% New York Medicaid APG,624.21,,,624.21,Other,225% New York Medicaid APG,388.4,,,388.4,Other,140% New York Medicaid APG,624.21,,,624.21,Other,225% New York Medicaid APG,721.31,,,721.31,Other,260% New York Medicaid APG,898.87,,,898.87,Other,324% New York Medicaid APG,596.47,,,596.47,Other,215% New York Medicaid APG,596.47,,,596.47,Other,215% New York Medicaid APG,346.79,,,346.79,Other,125% New York Medicaid APG,195.99,25945.68,
Place catheter in vein,36010,CPT,,,,,,,,both,,,70032,51823.68,74,,51823.68,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,31514.4,45,,31514.4,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,34665.84,49.5,,34665.84,percent of total billed charges,110% of Medicare,47621.76,68,,47621.76,percent of total billed charges,,516.02,,,516.02,Other,186% of Medicaid,56025.6,80,,56025.6,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,56025.6,80,,56025.6,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,49022.4,70,,49022.4,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,277.43,,,277.43,Other,New York Medicaid APG methodology,277.43,,,277.43,Other,100% New York Medicaid APG,277.43,,,277.43,Other,100% New York Medicaid APG,277.43,,,277.43,Other,100% New York Medicaid APG,624.21,,,624.21,Other,225% New York Medicaid APG,424.47,,,424.47,Other,153% New York Medicaid APG,624.21,,,624.21,Other,225% New York Medicaid APG,388.4,,,388.4,Other,140% New York Medicaid APG,624.21,,,624.21,Other,225% New York Medicaid APG,721.31,,,721.31,Other,260% New York Medicaid APG,898.87,,,898.87,Other,324% New York Medicaid APG,596.47,,,596.47,Other,215% New York Medicaid APG,596.47,,,596.47,Other,215% New York Medicaid APG,346.79,,,346.79,Other,125% New York Medicaid APG,277.43,56025.6,
Place catheter in vein,36011,CPT,,,,,,,,both,,,71652,53022.48,74,,53022.48,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,32243.4,45,,32243.4,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,35467.74,49.5,,35467.74,percent of total billed charges,110% of Medicare,48723.36,68,,48723.36,percent of total billed charges,,516.02,,,516.02,Other,186% of Medicaid,57321.6,80,,57321.6,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,57321.6,80,,57321.6,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,50156.4,70,,50156.4,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,277.43,,,277.43,Other,New York Medicaid APG methodology,277.43,,,277.43,Other,100% New York Medicaid APG,277.43,,,277.43,Other,100% New York Medicaid APG,277.43,,,277.43,Other,100% New York Medicaid APG,624.21,,,624.21,Other,225% New York Medicaid APG,424.47,,,424.47,Other,153% New York Medicaid APG,624.21,,,624.21,Other,225% New York Medicaid APG,388.4,,,388.4,Other,140% New York Medicaid APG,624.21,,,624.21,Other,225% New York Medicaid APG,721.31,,,721.31,Other,260% New York Medicaid APG,898.87,,,898.87,Other,324% New York Medicaid APG,596.47,,,596.47,Other,215% New York Medicaid APG,596.47,,,596.47,Other,215% New York Medicaid APG,346.79,,,346.79,Other,125% New York Medicaid APG,277.43,57321.6,
Place catheter in vein,36012,CPT,,,,,,,,both,,,35764.36,26465.63,74,,26465.63,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,16093.96,45,,16093.96,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,17703.36,49.5,,17703.36,percent of total billed charges,110% of Medicare,24319.76,68,,24319.76,percent of total billed charges,,516.02,,,516.02,Other,186% of Medicaid,28611.49,80,,28611.49,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,28611.49,80,,28611.49,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,25035.05,70,,25035.05,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,277.43,,,277.43,Other,New York Medicaid APG methodology,277.43,,,277.43,Other,100% New York Medicaid APG,277.43,,,277.43,Other,100% New York Medicaid APG,277.43,,,277.43,Other,100% New York Medicaid APG,624.21,,,624.21,Other,225% New York Medicaid APG,424.47,,,424.47,Other,153% New York Medicaid APG,624.21,,,624.21,Other,225% New York Medicaid APG,388.4,,,388.4,Other,140% New York Medicaid APG,624.21,,,624.21,Other,225% New York Medicaid APG,721.31,,,721.31,Other,260% New York Medicaid APG,898.87,,,898.87,Other,324% New York Medicaid APG,596.47,,,596.47,Other,215% New York Medicaid APG,596.47,,,596.47,Other,215% New York Medicaid APG,346.79,,,346.79,Other,125% New York Medicaid APG,277.43,28611.49,
Place catheter in artery,36013,CPT,,,,,,,,both,,,83504,61792.96,74,,61792.96,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,37576.8,45,,37576.8,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,41334.48,49.5,,41334.48,percent of total billed charges,110% of Medicare,56782.72,68,,56782.72,percent of total billed charges,,516.02,,,516.02,Other,186% of Medicaid,66803.2,80,,66803.2,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,66803.2,80,,66803.2,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,58452.8,70,,58452.8,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,277.43,,,277.43,Other,New York Medicaid APG methodology,277.43,,,277.43,Other,100% New York Medicaid APG,277.43,,,277.43,Other,100% New York Medicaid APG,277.43,,,277.43,Other,100% New York Medicaid APG,624.21,,,624.21,Other,225% New York Medicaid APG,424.47,,,424.47,Other,153% New York Medicaid APG,624.21,,,624.21,Other,225% New York Medicaid APG,388.4,,,388.4,Other,140% New York Medicaid APG,624.21,,,624.21,Other,225% New York Medicaid APG,721.31,,,721.31,Other,260% New York Medicaid APG,898.87,,,898.87,Other,324% New York Medicaid APG,596.47,,,596.47,Other,215% New York Medicaid APG,596.47,,,596.47,Other,215% New York Medicaid APG,346.79,,,346.79,Other,125% New York Medicaid APG,277.43,66803.2,
Place catheter in artery,36014,CPT,,,,,,,,both,,,83504,61792.96,74,,61792.96,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,37576.8,45,,37576.8,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,41334.48,49.5,,41334.48,percent of total billed charges,110% of Medicare,56782.72,68,,56782.72,percent of total billed charges,,516.02,,,516.02,Other,186% of Medicaid,66803.2,80,,66803.2,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,66803.2,80,,66803.2,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,58452.8,70,,58452.8,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,277.43,,,277.43,Other,New York Medicaid APG methodology,277.43,,,277.43,Other,100% New York Medicaid APG,277.43,,,277.43,Other,100% New York Medicaid APG,277.43,,,277.43,Other,100% New York Medicaid APG,624.21,,,624.21,Other,225% New York Medicaid APG,424.47,,,424.47,Other,153% New York Medicaid APG,624.21,,,624.21,Other,225% New York Medicaid APG,388.4,,,388.4,Other,140% New York Medicaid APG,624.21,,,624.21,Other,225% New York Medicaid APG,721.31,,,721.31,Other,260% New York Medicaid APG,898.87,,,898.87,Other,324% New York Medicaid APG,596.47,,,596.47,Other,215% New York Medicaid APG,596.47,,,596.47,Other,215% New York Medicaid APG,346.79,,,346.79,Other,125% New York Medicaid APG,277.43,66803.2,
Place catheter in artery,36015,CPT,,,,,,,,both,,,83504,61792.96,74,,61792.96,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,37576.8,45,,37576.8,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,41334.48,49.5,,41334.48,percent of total billed charges,110% of Medicare,56782.72,68,,56782.72,percent of total billed charges,,516.02,,,516.02,Other,186% of Medicaid,66803.2,80,,66803.2,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,66803.2,80,,66803.2,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,58452.8,70,,58452.8,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,277.43,,,277.43,Other,New York Medicaid APG methodology,277.43,,,277.43,Other,100% New York Medicaid APG,277.43,,,277.43,Other,100% New York Medicaid APG,277.43,,,277.43,Other,100% New York Medicaid APG,624.21,,,624.21,Other,225% New York Medicaid APG,424.47,,,424.47,Other,153% New York Medicaid APG,624.21,,,624.21,Other,225% New York Medicaid APG,388.4,,,388.4,Other,140% New York Medicaid APG,624.21,,,624.21,Other,225% New York Medicaid APG,721.31,,,721.31,Other,260% New York Medicaid APG,898.87,,,898.87,Other,324% New York Medicaid APG,596.47,,,596.47,Other,215% New York Medicaid APG,596.47,,,596.47,Other,215% New York Medicaid APG,346.79,,,346.79,Other,125% New York Medicaid APG,277.43,66803.2,
Establish access to artery,36100,CPT,,,,,,,,both,,,32432.1,23999.75,74,,23999.75,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,14594.45,45,,14594.45,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,16053.89,49.5,,16053.89,percent of total billed charges,110% of Medicare,22053.83,68,,22053.83,percent of total billed charges,,516.02,,,516.02,Other,186% of Medicaid,25945.68,80,,25945.68,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,25945.68,80,,25945.68,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,22702.47,70,,22702.47,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,277.43,,,277.43,Other,New York Medicaid APG methodology,277.43,,,277.43,Other,100% New York Medicaid APG,277.43,,,277.43,Other,100% New York Medicaid APG,277.43,,,277.43,Other,100% New York Medicaid APG,624.21,,,624.21,Other,225% New York Medicaid APG,424.47,,,424.47,Other,153% New York Medicaid APG,624.21,,,624.21,Other,225% New York Medicaid APG,388.4,,,388.4,Other,140% New York Medicaid APG,624.21,,,624.21,Other,225% New York Medicaid APG,721.31,,,721.31,Other,260% New York Medicaid APG,898.87,,,898.87,Other,324% New York Medicaid APG,596.47,,,596.47,Other,215% New York Medicaid APG,596.47,,,596.47,Other,215% New York Medicaid APG,346.79,,,346.79,Other,125% New York Medicaid APG,277.43,25945.68,
Intro ndl icath upr/lxtr art,36140,CPT,,,,,,,,both,,,82502.75,61052.04,74,,61052.04,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,37126.24,45,,37126.24,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,40838.86,49.5,,40838.86,percent of total billed charges,110% of Medicare,56101.87,68,,56101.87,percent of total billed charges,,516.02,,,516.02,Other,186% of Medicaid,66002.2,80,,66002.2,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,66002.2,80,,66002.2,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,57751.93,70,,57751.93,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,277.43,,,277.43,Other,New York Medicaid APG methodology,277.43,,,277.43,Other,100% New York Medicaid APG,277.43,,,277.43,Other,100% New York Medicaid APG,277.43,,,277.43,Other,100% New York Medicaid APG,624.21,,,624.21,Other,225% New York Medicaid APG,424.47,,,424.47,Other,153% New York Medicaid APG,624.21,,,624.21,Other,225% New York Medicaid APG,388.4,,,388.4,Other,140% New York Medicaid APG,624.21,,,624.21,Other,225% New York Medicaid APG,721.31,,,721.31,Other,260% New York Medicaid APG,898.87,,,898.87,Other,324% New York Medicaid APG,596.47,,,596.47,Other,215% New York Medicaid APG,596.47,,,596.47,Other,215% New York Medicaid APG,346.79,,,346.79,Other,125% New York Medicaid APG,277.43,66002.2,
Establish access to aorta,36160,CPT,,,,,,,,both,,,51572.04,38163.31,74,,38163.31,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,23207.42,45,,23207.42,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,25528.16,49.5,,25528.16,percent of total billed charges,110% of Medicare,35068.99,68,,35068.99,percent of total billed charges,,516.02,,,516.02,Other,186% of Medicaid,41257.63,80,,41257.63,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,41257.63,80,,41257.63,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,36100.43,70,,36100.43,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,277.43,,,277.43,Other,New York Medicaid APG methodology,277.43,,,277.43,Other,100% New York Medicaid APG,277.43,,,277.43,Other,100% New York Medicaid APG,277.43,,,277.43,Other,100% New York Medicaid APG,624.21,,,624.21,Other,225% New York Medicaid APG,424.47,,,424.47,Other,153% New York Medicaid APG,624.21,,,624.21,Other,225% New York Medicaid APG,388.4,,,388.4,Other,140% New York Medicaid APG,624.21,,,624.21,Other,225% New York Medicaid APG,721.31,,,721.31,Other,260% New York Medicaid APG,898.87,,,898.87,Other,324% New York Medicaid APG,596.47,,,596.47,Other,215% New York Medicaid APG,596.47,,,596.47,Other,215% New York Medicaid APG,346.79,,,346.79,Other,125% New York Medicaid APG,277.43,41257.63,
Place catheter in aorta,36200,CPT,,,,,,,,both,,,32242.94,23859.78,74,,23859.78,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,14509.32,45,,14509.32,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,15960.26,49.5,,15960.26,percent of total billed charges,110% of Medicare,21925.2,68,,21925.2,percent of total billed charges,,516.02,,,516.02,Other,186% of Medicaid,25794.35,80,,25794.35,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,25794.35,80,,25794.35,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,22570.06,70,,22570.06,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,277.43,,,277.43,Other,New York Medicaid APG methodology,277.43,,,277.43,Other,100% New York Medicaid APG,277.43,,,277.43,Other,100% New York Medicaid APG,277.43,,,277.43,Other,100% New York Medicaid APG,624.21,,,624.21,Other,225% New York Medicaid APG,424.47,,,424.47,Other,153% New York Medicaid APG,624.21,,,624.21,Other,225% New York Medicaid APG,388.4,,,388.4,Other,140% New York Medicaid APG,624.21,,,624.21,Other,225% New York Medicaid APG,721.31,,,721.31,Other,260% New York Medicaid APG,898.87,,,898.87,Other,324% New York Medicaid APG,596.47,,,596.47,Other,215% New York Medicaid APG,596.47,,,596.47,Other,215% New York Medicaid APG,346.79,,,346.79,Other,125% New York Medicaid APG,277.43,25794.35,
Place catheter in artery,36215,CPT,,,,,,,,both,,,64479.48,47714.82,74,,47714.82,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,29015.77,45,,29015.77,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,31917.34,49.5,,31917.34,percent of total billed charges,110% of Medicare,43846.05,68,,43846.05,percent of total billed charges,,516.02,,,516.02,Other,186% of Medicaid,51583.58,80,,51583.58,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,51583.58,80,,51583.58,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,45135.64,70,,45135.64,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,277.43,,,277.43,Other,New York Medicaid APG methodology,277.43,,,277.43,Other,100% New York Medicaid APG,277.43,,,277.43,Other,100% New York Medicaid APG,277.43,,,277.43,Other,100% New York Medicaid APG,624.21,,,624.21,Other,225% New York Medicaid APG,424.47,,,424.47,Other,153% New York Medicaid APG,624.21,,,624.21,Other,225% New York Medicaid APG,388.4,,,388.4,Other,140% New York Medicaid APG,624.21,,,624.21,Other,225% New York Medicaid APG,721.31,,,721.31,Other,260% New York Medicaid APG,898.87,,,898.87,Other,324% New York Medicaid APG,596.47,,,596.47,Other,215% New York Medicaid APG,596.47,,,596.47,Other,215% New York Medicaid APG,346.79,,,346.79,Other,125% New York Medicaid APG,277.43,51583.58,
Place catheter in artery,36216,CPT,,,,,,,,both,,,64479.48,47714.82,74,,47714.82,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,29015.77,45,,29015.77,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,31917.34,49.5,,31917.34,percent of total billed charges,110% of Medicare,43846.05,68,,43846.05,percent of total billed charges,,516.02,,,516.02,Other,186% of Medicaid,51583.58,80,,51583.58,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,51583.58,80,,51583.58,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,45135.64,70,,45135.64,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,277.43,,,277.43,Other,New York Medicaid APG methodology,277.43,,,277.43,Other,100% New York Medicaid APG,277.43,,,277.43,Other,100% New York Medicaid APG,277.43,,,277.43,Other,100% New York Medicaid APG,624.21,,,624.21,Other,225% New York Medicaid APG,424.47,,,424.47,Other,153% New York Medicaid APG,624.21,,,624.21,Other,225% New York Medicaid APG,388.4,,,388.4,Other,140% New York Medicaid APG,624.21,,,624.21,Other,225% New York Medicaid APG,721.31,,,721.31,Other,260% New York Medicaid APG,898.87,,,898.87,Other,324% New York Medicaid APG,596.47,,,596.47,Other,215% New York Medicaid APG,596.47,,,596.47,Other,215% New York Medicaid APG,346.79,,,346.79,Other,125% New York Medicaid APG,277.43,51583.58,
Place catheter in artery,36217,CPT,,,,,,,,both,,,64479.48,47714.82,74,,47714.82,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,29015.77,45,,29015.77,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,31917.34,49.5,,31917.34,percent of total billed charges,110% of Medicare,43846.05,68,,43846.05,percent of total billed charges,,516.02,,,516.02,Other,186% of Medicaid,51583.58,80,,51583.58,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,51583.58,80,,51583.58,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,45135.64,70,,45135.64,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,277.43,,,277.43,Other,New York Medicaid APG methodology,277.43,,,277.43,Other,100% New York Medicaid APG,277.43,,,277.43,Other,100% New York Medicaid APG,277.43,,,277.43,Other,100% New York Medicaid APG,624.21,,,624.21,Other,225% New York Medicaid APG,424.47,,,424.47,Other,153% New York Medicaid APG,624.21,,,624.21,Other,225% New York Medicaid APG,388.4,,,388.4,Other,140% New York Medicaid APG,624.21,,,624.21,Other,225% New York Medicaid APG,721.31,,,721.31,Other,260% New York Medicaid APG,898.87,,,898.87,Other,324% New York Medicaid APG,596.47,,,596.47,Other,215% New York Medicaid APG,596.47,,,596.47,Other,215% New York Medicaid APG,346.79,,,346.79,Other,125% New York Medicaid APG,277.43,51583.58,
Place catheter in artery,36218,CPT,,,,,,,,both,,,64479.48,47714.82,74,,47714.82,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,29015.77,45,,29015.77,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,31917.34,49.5,,31917.34,percent of total billed charges,110% of Medicare,43846.05,68,,43846.05,percent of total billed charges,,516.02,,,516.02,Other,186% of Medicaid,51583.58,80,,51583.58,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,51583.58,80,,51583.58,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,45135.64,70,,45135.64,percent of total billed charges,,249.28,,,249.28,Fee Schedule,,211.28,,,211.28,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,277.43,,,277.43,Other,New York Medicaid APG methodology,277.43,,,277.43,Other,100% New York Medicaid APG,277.43,,,277.43,Other,100% New York Medicaid APG,277.43,,,277.43,Other,100% New York Medicaid APG,624.21,,,624.21,Other,225% New York Medicaid APG,424.47,,,424.47,Other,153% New York Medicaid APG,624.21,,,624.21,Other,225% New York Medicaid APG,388.4,,,388.4,Other,140% New York Medicaid APG,624.21,,,624.21,Other,225% New York Medicaid APG,721.31,,,721.31,Other,260% New York Medicaid APG,898.87,,,898.87,Other,324% New York Medicaid APG,596.47,,,596.47,Other,215% New York Medicaid APG,596.47,,,596.47,Other,215% New York Medicaid APG,346.79,,,346.79,Other,125% New York Medicaid APG,211.28,51583.58,
Place cath thoracic aorta,36221,CPT,,,,,,,,both,,,67044.74,49613.11,74,,49613.11,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30170.13,45,,30170.13,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33187.15,49.5,,33187.15,percent of total billed charges,110% of Medicare,45590.42,68,,45590.42,percent of total billed charges,,1729.46,,,1729.46,Other,186% of Medicaid,53635.79,80,,53635.79,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,53635.79,80,,53635.79,percent of total billed charges,,7216,,,7216,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,46931.32,70,,46931.32,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,929.82,,,929.82,Other,New York Medicaid APG methodology,929.82,,,929.82,Other,100% New York Medicaid APG,929.82,,,929.82,Other,100% New York Medicaid APG,929.82,,,929.82,Other,100% New York Medicaid APG,2092.09,,,2092.09,Other,225% New York Medicaid APG,1422.62,,,1422.62,Other,153% New York Medicaid APG,2092.09,,,2092.09,Other,225% New York Medicaid APG,1301.75,,,1301.75,Other,140% New York Medicaid APG,2092.09,,,2092.09,Other,225% New York Medicaid APG,2417.53,,,2417.53,Other,260% New York Medicaid APG,3012.61,,,3012.61,Other,324% New York Medicaid APG,1999.11,,,1999.11,Other,215% New York Medicaid APG,1999.11,,,1999.11,Other,215% New York Medicaid APG,1162.27,,,1162.27,Other,125% New York Medicaid APG,929.82,53635.79,
Place cath carotid/inom art,36222,CPT,,,,,,,,both,,,23345,17275.3,74,,17275.3,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,10505.25,45,,10505.25,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,11555.78,49.5,,11555.78,percent of total billed charges,110% of Medicare,15874.6,68,,15874.6,percent of total billed charges,,1729.46,,,1729.46,Other,186% of Medicaid,18676,80,,18676,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,18676,80,,18676,percent of total billed charges,,7216,,,7216,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,16341.5,70,,16341.5,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,929.82,,,929.82,Other,New York Medicaid APG methodology,929.82,,,929.82,Other,100% New York Medicaid APG,929.82,,,929.82,Other,100% New York Medicaid APG,929.82,,,929.82,Other,100% New York Medicaid APG,2092.09,,,2092.09,Other,225% New York Medicaid APG,1422.62,,,1422.62,Other,153% New York Medicaid APG,2092.09,,,2092.09,Other,225% New York Medicaid APG,1301.75,,,1301.75,Other,140% New York Medicaid APG,2092.09,,,2092.09,Other,225% New York Medicaid APG,2417.53,,,2417.53,Other,260% New York Medicaid APG,3012.61,,,3012.61,Other,324% New York Medicaid APG,1999.11,,,1999.11,Other,215% New York Medicaid APG,1999.11,,,1999.11,Other,215% New York Medicaid APG,1162.27,,,1162.27,Other,125% New York Medicaid APG,929.82,18676,
Place cath carotid/inom art,36223,CPT,,,,,,,,both,,,25923.2,19183.17,74,,19183.17,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,11665.44,45,,11665.44,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,12831.98,49.5,,12831.98,percent of total billed charges,110% of Medicare,17627.78,68,,17627.78,percent of total billed charges,,1729.46,,,1729.46,Other,186% of Medicaid,20738.56,80,,20738.56,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,20738.56,80,,20738.56,percent of total billed charges,,7216,,,7216,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,18146.24,70,,18146.24,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,929.82,,,929.82,Other,New York Medicaid APG methodology,929.82,,,929.82,Other,100% New York Medicaid APG,929.82,,,929.82,Other,100% New York Medicaid APG,929.82,,,929.82,Other,100% New York Medicaid APG,2092.09,,,2092.09,Other,225% New York Medicaid APG,1422.62,,,1422.62,Other,153% New York Medicaid APG,2092.09,,,2092.09,Other,225% New York Medicaid APG,1301.75,,,1301.75,Other,140% New York Medicaid APG,2092.09,,,2092.09,Other,225% New York Medicaid APG,2417.53,,,2417.53,Other,260% New York Medicaid APG,3012.61,,,3012.61,Other,324% New York Medicaid APG,1999.11,,,1999.11,Other,215% New York Medicaid APG,1999.11,,,1999.11,Other,215% New York Medicaid APG,1162.27,,,1162.27,Other,125% New York Medicaid APG,929.82,20738.56,
Place cath carotd art,36224,CPT,,,,,,,,both,,,28636.41,21190.94,74,,21190.94,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,12886.38,45,,12886.38,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,14175.02,49.5,,14175.02,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,1729.46,,,1729.46,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,20045.49,70,,20045.49,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,929.82,,,929.82,Other,New York Medicaid APG methodology,929.82,,,929.82,Other,100% New York Medicaid APG,929.82,,,929.82,Other,100% New York Medicaid APG,929.82,,,929.82,Other,100% New York Medicaid APG,2092.09,,,2092.09,Other,225% New York Medicaid APG,1422.62,,,1422.62,Other,153% New York Medicaid APG,2092.09,,,2092.09,Other,225% New York Medicaid APG,1301.75,,,1301.75,Other,140% New York Medicaid APG,2092.09,,,2092.09,Other,225% New York Medicaid APG,2417.53,,,2417.53,Other,260% New York Medicaid APG,3012.61,,,3012.61,Other,324% New York Medicaid APG,1999.11,,,1999.11,Other,215% New York Medicaid APG,1999.11,,,1999.11,Other,215% New York Medicaid APG,1162.27,,,1162.27,Other,125% New York Medicaid APG,929.82,21190.94,
Place cath subclavian art,36225,CPT,,,,,,,,both,,,29080.31,21519.43,74,,21519.43,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,13086.14,45,,13086.14,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,14394.75,49.5,,14394.75,percent of total billed charges,110% of Medicare,19774.61,68,,19774.61,percent of total billed charges,,1729.46,,,1729.46,Other,186% of Medicaid,23264.25,80,,23264.25,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,23264.25,80,,23264.25,percent of total billed charges,,7216,,,7216,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,20356.22,70,,20356.22,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,929.82,,,929.82,Other,New York Medicaid APG methodology,929.82,,,929.82,Other,100% New York Medicaid APG,929.82,,,929.82,Other,100% New York Medicaid APG,929.82,,,929.82,Other,100% New York Medicaid APG,2092.09,,,2092.09,Other,225% New York Medicaid APG,1422.62,,,1422.62,Other,153% New York Medicaid APG,2092.09,,,2092.09,Other,225% New York Medicaid APG,1301.75,,,1301.75,Other,140% New York Medicaid APG,2092.09,,,2092.09,Other,225% New York Medicaid APG,2417.53,,,2417.53,Other,260% New York Medicaid APG,3012.61,,,3012.61,Other,324% New York Medicaid APG,1999.11,,,1999.11,Other,215% New York Medicaid APG,1999.11,,,1999.11,Other,215% New York Medicaid APG,1162.27,,,1162.27,Other,125% New York Medicaid APG,929.82,23264.25,
Place cath vertebral art,36226,CPT,,,,,,,,both,,,29146.36,21568.31,74,,21568.31,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,13115.86,45,,13115.86,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,14427.45,49.5,,14427.45,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,1729.46,,,1729.46,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,20402.45,70,,20402.45,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,929.82,,,929.82,Other,New York Medicaid APG methodology,929.82,,,929.82,Other,100% New York Medicaid APG,929.82,,,929.82,Other,100% New York Medicaid APG,929.82,,,929.82,Other,100% New York Medicaid APG,2092.09,,,2092.09,Other,225% New York Medicaid APG,1422.62,,,1422.62,Other,153% New York Medicaid APG,2092.09,,,2092.09,Other,225% New York Medicaid APG,1301.75,,,1301.75,Other,140% New York Medicaid APG,2092.09,,,2092.09,Other,225% New York Medicaid APG,2417.53,,,2417.53,Other,260% New York Medicaid APG,3012.61,,,3012.61,Other,324% New York Medicaid APG,1999.11,,,1999.11,Other,215% New York Medicaid APG,1999.11,,,1999.11,Other,215% New York Medicaid APG,1162.27,,,1162.27,Other,125% New York Medicaid APG,929.82,21568.31,
Place cath xtrnl carotid,36227,CPT,,,,,,,,both,,,64479.48,47714.82,74,,47714.82,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,29015.77,45,,29015.77,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,31917.34,49.5,,31917.34,percent of total billed charges,110% of Medicare,43846.05,68,,43846.05,percent of total billed charges,,1729.46,,,1729.46,Other,186% of Medicaid,51583.58,80,,51583.58,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,51583.58,80,,51583.58,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,45135.64,70,,45135.64,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,929.82,,,929.82,Other,New York Medicaid APG methodology,929.82,,,929.82,Other,100% New York Medicaid APG,929.82,,,929.82,Other,100% New York Medicaid APG,929.82,,,929.82,Other,100% New York Medicaid APG,2092.09,,,2092.09,Other,225% New York Medicaid APG,1422.62,,,1422.62,Other,153% New York Medicaid APG,2092.09,,,2092.09,Other,225% New York Medicaid APG,1301.75,,,1301.75,Other,140% New York Medicaid APG,2092.09,,,2092.09,Other,225% New York Medicaid APG,2417.53,,,2417.53,Other,260% New York Medicaid APG,3012.61,,,3012.61,Other,324% New York Medicaid APG,1999.11,,,1999.11,Other,215% New York Medicaid APG,1999.11,,,1999.11,Other,215% New York Medicaid APG,1162.27,,,1162.27,Other,125% New York Medicaid APG,929.82,51583.58,
Place cath intracranial art,36228,CPT,,,,,,,,both,,,64479.48,47714.82,74,,47714.82,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,29015.77,45,,29015.77,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,31917.34,49.5,,31917.34,percent of total billed charges,110% of Medicare,43846.05,68,,43846.05,percent of total billed charges,,1729.46,,,1729.46,Other,186% of Medicaid,51583.58,80,,51583.58,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,51583.58,80,,51583.58,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,45135.64,70,,45135.64,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,929.82,,,929.82,Other,New York Medicaid APG methodology,929.82,,,929.82,Other,100% New York Medicaid APG,929.82,,,929.82,Other,100% New York Medicaid APG,929.82,,,929.82,Other,100% New York Medicaid APG,2092.09,,,2092.09,Other,225% New York Medicaid APG,1422.62,,,1422.62,Other,153% New York Medicaid APG,2092.09,,,2092.09,Other,225% New York Medicaid APG,1301.75,,,1301.75,Other,140% New York Medicaid APG,2092.09,,,2092.09,Other,225% New York Medicaid APG,2417.53,,,2417.53,Other,260% New York Medicaid APG,3012.61,,,3012.61,Other,324% New York Medicaid APG,1999.11,,,1999.11,Other,215% New York Medicaid APG,1999.11,,,1999.11,Other,215% New York Medicaid APG,1162.27,,,1162.27,Other,125% New York Medicaid APG,929.82,51583.58,
Ins cath abd/l-ext art 1st,36245,CPT,,,,,,,,both,,,50737.16,37545.5,74,,37545.5,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,22831.72,45,,22831.72,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,25114.89,49.5,,25114.89,percent of total billed charges,110% of Medicare,34501.27,68,,34501.27,percent of total billed charges,,516.02,,,516.02,Other,186% of Medicaid,40589.73,80,,40589.73,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,40589.73,80,,40589.73,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,35516.01,70,,35516.01,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,277.43,,,277.43,Other,New York Medicaid APG methodology,277.43,,,277.43,Other,100% New York Medicaid APG,277.43,,,277.43,Other,100% New York Medicaid APG,277.43,,,277.43,Other,100% New York Medicaid APG,624.21,,,624.21,Other,225% New York Medicaid APG,424.47,,,424.47,Other,153% New York Medicaid APG,624.21,,,624.21,Other,225% New York Medicaid APG,388.4,,,388.4,Other,140% New York Medicaid APG,624.21,,,624.21,Other,225% New York Medicaid APG,721.31,,,721.31,Other,260% New York Medicaid APG,898.87,,,898.87,Other,324% New York Medicaid APG,596.47,,,596.47,Other,215% New York Medicaid APG,596.47,,,596.47,Other,215% New York Medicaid APG,346.79,,,346.79,Other,125% New York Medicaid APG,277.43,40589.73,
Ins cath abd/l-ext art 2nd,36246,CPT,,,,,,,,both,,,68028.63,50341.19,74,,50341.19,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30612.88,45,,30612.88,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,33674.17,49.5,,33674.17,percent of total billed charges,110% of Medicare,46259.47,68,,46259.47,percent of total billed charges,,516.02,,,516.02,Other,186% of Medicaid,54422.9,80,,54422.9,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,54422.9,80,,54422.9,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,47620.04,70,,47620.04,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,277.43,,,277.43,Other,New York Medicaid APG methodology,277.43,,,277.43,Other,100% New York Medicaid APG,277.43,,,277.43,Other,100% New York Medicaid APG,277.43,,,277.43,Other,100% New York Medicaid APG,624.21,,,624.21,Other,225% New York Medicaid APG,424.47,,,424.47,Other,153% New York Medicaid APG,624.21,,,624.21,Other,225% New York Medicaid APG,388.4,,,388.4,Other,140% New York Medicaid APG,624.21,,,624.21,Other,225% New York Medicaid APG,721.31,,,721.31,Other,260% New York Medicaid APG,898.87,,,898.87,Other,324% New York Medicaid APG,596.47,,,596.47,Other,215% New York Medicaid APG,596.47,,,596.47,Other,215% New York Medicaid APG,346.79,,,346.79,Other,125% New York Medicaid APG,277.43,54422.9,
Ins cath abd/l-ext art 3rd,36247,CPT,,,,,,,,both,,,81571.9,60363.21,74,,60363.21,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,36707.36,45,,36707.36,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,40378.09,49.5,,40378.09,percent of total billed charges,110% of Medicare,55468.89,68,,55468.89,percent of total billed charges,,516.02,,,516.02,Other,186% of Medicaid,65257.52,80,,65257.52,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,65257.52,80,,65257.52,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,57100.33,70,,57100.33,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,277.43,,,277.43,Other,New York Medicaid APG methodology,277.43,,,277.43,Other,100% New York Medicaid APG,277.43,,,277.43,Other,100% New York Medicaid APG,277.43,,,277.43,Other,100% New York Medicaid APG,624.21,,,624.21,Other,225% New York Medicaid APG,424.47,,,424.47,Other,153% New York Medicaid APG,624.21,,,624.21,Other,225% New York Medicaid APG,388.4,,,388.4,Other,140% New York Medicaid APG,624.21,,,624.21,Other,225% New York Medicaid APG,721.31,,,721.31,Other,260% New York Medicaid APG,898.87,,,898.87,Other,324% New York Medicaid APG,596.47,,,596.47,Other,215% New York Medicaid APG,596.47,,,596.47,Other,215% New York Medicaid APG,346.79,,,346.79,Other,125% New York Medicaid APG,277.43,65257.52,
Ins cath abd/l-ext art addl,36248,CPT,,,,,,,,both,,,50142.2,37105.23,74,,37105.23,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,22563.99,45,,22563.99,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,24820.39,49.5,,24820.39,percent of total billed charges,110% of Medicare,34096.7,68,,34096.7,percent of total billed charges,,516.02,,,516.02,Other,186% of Medicaid,40113.76,80,,40113.76,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,40113.76,80,,40113.76,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,35099.54,70,,35099.54,percent of total billed charges,,231.24,,,231.24,Fee Schedule,,195.99,,,195.99,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,277.43,,,277.43,Other,New York Medicaid APG methodology,277.43,,,277.43,Other,100% New York Medicaid APG,277.43,,,277.43,Other,100% New York Medicaid APG,277.43,,,277.43,Other,100% New York Medicaid APG,624.21,,,624.21,Other,225% New York Medicaid APG,424.47,,,424.47,Other,153% New York Medicaid APG,624.21,,,624.21,Other,225% New York Medicaid APG,388.4,,,388.4,Other,140% New York Medicaid APG,624.21,,,624.21,Other,225% New York Medicaid APG,721.31,,,721.31,Other,260% New York Medicaid APG,898.87,,,898.87,Other,324% New York Medicaid APG,596.47,,,596.47,Other,215% New York Medicaid APG,596.47,,,596.47,Other,215% New York Medicaid APG,346.79,,,346.79,Other,125% New York Medicaid APG,195.99,40113.76,
Ins cath ren art 1st unilat,36251,CPT,,,,,,,,both,,,67044.74,49613.11,74,,49613.11,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30170.13,45,,30170.13,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33187.15,49.5,,33187.15,percent of total billed charges,110% of Medicare,45590.42,68,,45590.42,percent of total billed charges,,1729.46,,,1729.46,Other,186% of Medicaid,53635.79,80,,53635.79,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,53635.79,80,,53635.79,percent of total billed charges,,7216,,,7216,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,46931.32,70,,46931.32,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,929.82,,,929.82,Other,New York Medicaid APG methodology,929.82,,,929.82,Other,100% New York Medicaid APG,929.82,,,929.82,Other,100% New York Medicaid APG,929.82,,,929.82,Other,100% New York Medicaid APG,2092.09,,,2092.09,Other,225% New York Medicaid APG,1422.62,,,1422.62,Other,153% New York Medicaid APG,2092.09,,,2092.09,Other,225% New York Medicaid APG,1301.75,,,1301.75,Other,140% New York Medicaid APG,2092.09,,,2092.09,Other,225% New York Medicaid APG,2417.53,,,2417.53,Other,260% New York Medicaid APG,3012.61,,,3012.61,Other,324% New York Medicaid APG,1999.11,,,1999.11,Other,215% New York Medicaid APG,1999.11,,,1999.11,Other,215% New York Medicaid APG,1162.27,,,1162.27,Other,125% New York Medicaid APG,929.82,53635.79,
Ins cath ren art 1st bilat,36252,CPT,,,,,,,,both,,,67044.74,49613.11,74,,49613.11,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30170.13,45,,30170.13,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33187.15,49.5,,33187.15,percent of total billed charges,110% of Medicare,45590.42,68,,45590.42,percent of total billed charges,,1729.46,,,1729.46,Other,186% of Medicaid,53635.79,80,,53635.79,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,53635.79,80,,53635.79,percent of total billed charges,,7216,,,7216,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,46931.32,70,,46931.32,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,929.82,,,929.82,Other,New York Medicaid APG methodology,929.82,,,929.82,Other,100% New York Medicaid APG,929.82,,,929.82,Other,100% New York Medicaid APG,929.82,,,929.82,Other,100% New York Medicaid APG,2092.09,,,2092.09,Other,225% New York Medicaid APG,1422.62,,,1422.62,Other,153% New York Medicaid APG,2092.09,,,2092.09,Other,225% New York Medicaid APG,1301.75,,,1301.75,Other,140% New York Medicaid APG,2092.09,,,2092.09,Other,225% New York Medicaid APG,2417.53,,,2417.53,Other,260% New York Medicaid APG,3012.61,,,3012.61,Other,324% New York Medicaid APG,1999.11,,,1999.11,Other,215% New York Medicaid APG,1999.11,,,1999.11,Other,215% New York Medicaid APG,1162.27,,,1162.27,Other,125% New York Medicaid APG,929.82,53635.79,
Ins cath ren art 2nd+ unilat,36253,CPT,,,,,,,,both,,,115587.67,85534.88,74,,85534.88,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,52014.45,45,,52014.45,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,57215.9,49.5,,57215.9,percent of total billed charges,110% of Medicare,78599.62,68,,78599.62,percent of total billed charges,,1729.46,,,1729.46,Other,186% of Medicaid,92470.14,80,,92470.14,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,92470.14,80,,92470.14,percent of total billed charges,,7216,,,7216,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,80911.37,70,,80911.37,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,929.82,,,929.82,Other,New York Medicaid APG methodology,929.82,,,929.82,Other,100% New York Medicaid APG,929.82,,,929.82,Other,100% New York Medicaid APG,929.82,,,929.82,Other,100% New York Medicaid APG,2092.09,,,2092.09,Other,225% New York Medicaid APG,1422.62,,,1422.62,Other,153% New York Medicaid APG,2092.09,,,2092.09,Other,225% New York Medicaid APG,1301.75,,,1301.75,Other,140% New York Medicaid APG,2092.09,,,2092.09,Other,225% New York Medicaid APG,2417.53,,,2417.53,Other,260% New York Medicaid APG,3012.61,,,3012.61,Other,324% New York Medicaid APG,1999.11,,,1999.11,Other,215% New York Medicaid APG,1999.11,,,1999.11,Other,215% New York Medicaid APG,1162.27,,,1162.27,Other,125% New York Medicaid APG,929.82,92470.14,
Ins cath ren art 2nd+ bilat,36254,CPT,,,,,,,,both,,,67044.74,49613.11,74,,49613.11,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30170.13,45,,30170.13,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33187.15,49.5,,33187.15,percent of total billed charges,110% of Medicare,45590.42,68,,45590.42,percent of total billed charges,,1729.46,,,1729.46,Other,186% of Medicaid,53635.79,80,,53635.79,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,53635.79,80,,53635.79,percent of total billed charges,,7216,,,7216,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,46931.32,70,,46931.32,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,929.82,,,929.82,Other,New York Medicaid APG methodology,929.82,,,929.82,Other,100% New York Medicaid APG,929.82,,,929.82,Other,100% New York Medicaid APG,929.82,,,929.82,Other,100% New York Medicaid APG,2092.09,,,2092.09,Other,225% New York Medicaid APG,1422.62,,,1422.62,Other,153% New York Medicaid APG,2092.09,,,2092.09,Other,225% New York Medicaid APG,1301.75,,,1301.75,Other,140% New York Medicaid APG,2092.09,,,2092.09,Other,225% New York Medicaid APG,2417.53,,,2417.53,Other,260% New York Medicaid APG,3012.61,,,3012.61,Other,324% New York Medicaid APG,1999.11,,,1999.11,Other,215% New York Medicaid APG,1999.11,,,1999.11,Other,215% New York Medicaid APG,1162.27,,,1162.27,Other,125% New York Medicaid APG,929.82,53635.79,
Insertion of infusion pump,36260,CPT,,,,,,,,both,,,115587.67,85534.88,74,,85534.88,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,52014.45,45,,52014.45,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,57215.9,49.5,,57215.9,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,10683.75,,,10683.75,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,80911.37,70,,80911.37,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,5743.95,,,5743.95,Other,New York Medicaid APG methodology,5743.95,,,5743.95,Other,100% New York Medicaid APG,5743.95,,,5743.95,Other,100% New York Medicaid APG,5743.95,,,5743.95,Other,100% New York Medicaid APG,12923.9,,,12923.9,Other,225% New York Medicaid APG,8788.25,,,8788.25,Other,153% New York Medicaid APG,12923.9,,,12923.9,Other,225% New York Medicaid APG,8041.54,,,8041.54,Other,140% New York Medicaid APG,12923.9,,,12923.9,Other,225% New York Medicaid APG,14934.28,,,14934.28,Other,260% New York Medicaid APG,18610.41,,,18610.41,Other,324% New York Medicaid APG,12349.5,,,12349.5,Other,215% New York Medicaid APG,12349.5,,,12349.5,Other,215% New York Medicaid APG,7179.94,,,7179.94,Other,125% New York Medicaid APG,3126,85534.88,
Revision of infusion pump,36261,CPT,,,,,,,,both,,,82599.65,61123.74,74,,61123.74,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,37169.84,45,,37169.84,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,40886.83,49.5,,40886.83,percent of total billed charges,110% of Medicare,56167.76,68,,56167.76,percent of total billed charges,,4536.91,,,4536.91,Other,186% of Medicaid,66079.72,80,,66079.72,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,66079.72,80,,66079.72,percent of total billed charges,,7216,,,7216,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,57819.76,70,,57819.76,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,2439.2,,,2439.2,Other,New York Medicaid APG methodology,2439.2,,,2439.2,Other,100% New York Medicaid APG,2439.2,,,2439.2,Other,100% New York Medicaid APG,2439.2,,,2439.2,Other,100% New York Medicaid APG,5488.2,,,5488.2,Other,225% New York Medicaid APG,3731.98,,,3731.98,Other,153% New York Medicaid APG,5488.2,,,5488.2,Other,225% New York Medicaid APG,3414.88,,,3414.88,Other,140% New York Medicaid APG,5488.2,,,5488.2,Other,225% New York Medicaid APG,6341.92,,,6341.92,Other,260% New York Medicaid APG,7903.01,,,7903.01,Other,324% New York Medicaid APG,5244.28,,,5244.28,Other,215% New York Medicaid APG,5244.28,,,5244.28,Other,215% New York Medicaid APG,3049,,,3049,Other,125% New York Medicaid APG,2232,66079.72,
Removal of infusion pump,36262,CPT,,,,,,,,both,,,82599.65,61123.74,74,,61123.74,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,37169.84,45,,37169.84,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,40886.83,49.5,,40886.83,percent of total billed charges,110% of Medicare,56167.76,68,,56167.76,percent of total billed charges,,4536.91,,,4536.91,Other,186% of Medicaid,66079.72,80,,66079.72,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,66079.72,80,,66079.72,percent of total billed charges,,7216,,,7216,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,57819.76,70,,57819.76,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,2439.2,,,2439.2,Other,New York Medicaid APG methodology,2439.2,,,2439.2,Other,100% New York Medicaid APG,2439.2,,,2439.2,Other,100% New York Medicaid APG,2439.2,,,2439.2,Other,100% New York Medicaid APG,5488.2,,,5488.2,Other,225% New York Medicaid APG,3731.98,,,3731.98,Other,153% New York Medicaid APG,5488.2,,,5488.2,Other,225% New York Medicaid APG,3414.88,,,3414.88,Other,140% New York Medicaid APG,5488.2,,,5488.2,Other,225% New York Medicaid APG,6341.92,,,6341.92,Other,260% New York Medicaid APG,7903.01,,,7903.01,Other,324% New York Medicaid APG,5244.28,,,5244.28,Other,215% New York Medicaid APG,5244.28,,,5244.28,Other,215% New York Medicaid APG,3049,,,3049,Other,125% New York Medicaid APG,2053,66079.72,
Bl draw < 3 yrs fem/jugular,36400,CPT,,,,,,,,both,,,32432.1,23999.75,74,,23999.75,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,14594.45,45,,14594.45,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,16053.89,49.5,,16053.89,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,267.8,,,267.8,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,25945.68,80,,25945.68,percent of total billed charges,,22702.47,70,,22702.47,percent of total billed charges,,91.84,,,91.84,Fee Schedule,,77.84,,,77.84,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,143.98,,,143.98,Other,New York Medicaid APG methodology,143.98,,,143.98,Other,100% New York Medicaid APG,143.98,,,143.98,Other,100% New York Medicaid APG,143.98,,,143.98,Other,100% New York Medicaid APG,323.95,,,323.95,Other,225% New York Medicaid APG,220.29,,,220.29,Other,153% New York Medicaid APG,323.95,,,323.95,Other,225% New York Medicaid APG,201.57,,,201.57,Other,140% New York Medicaid APG,323.95,,,323.95,Other,225% New York Medicaid APG,374.35,,,374.35,Other,260% New York Medicaid APG,466.49,,,466.49,Other,324% New York Medicaid APG,309.56,,,309.56,Other,215% New York Medicaid APG,309.56,,,309.56,Other,215% New York Medicaid APG,179.97,,,179.97,Other,125% New York Medicaid APG,77.84,25945.68,
Bl draw <3 yrs scalp vein,36405,CPT,,,,,,,,both,,,32432.1,23999.75,74,,23999.75,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,14594.45,45,,14594.45,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,16053.89,49.5,,16053.89,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,267.8,,,267.8,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,25945.68,80,,25945.68,percent of total billed charges,,22702.47,70,,22702.47,percent of total billed charges,,72.16,,,72.16,Fee Schedule,,61.16,,,61.16,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,143.98,,,143.98,Other,New York Medicaid APG methodology,143.98,,,143.98,Other,100% New York Medicaid APG,143.98,,,143.98,Other,100% New York Medicaid APG,143.98,,,143.98,Other,100% New York Medicaid APG,323.95,,,323.95,Other,225% New York Medicaid APG,220.29,,,220.29,Other,153% New York Medicaid APG,323.95,,,323.95,Other,225% New York Medicaid APG,201.57,,,201.57,Other,140% New York Medicaid APG,323.95,,,323.95,Other,225% New York Medicaid APG,374.35,,,374.35,Other,260% New York Medicaid APG,466.49,,,466.49,Other,324% New York Medicaid APG,309.56,,,309.56,Other,215% New York Medicaid APG,309.56,,,309.56,Other,215% New York Medicaid APG,179.97,,,179.97,Other,125% New York Medicaid APG,61.16,25945.68,
Bl draw <3 yrs other vein,36406,CPT,,,,,,,,both,,,32432.1,23999.75,74,,23999.75,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,14594.45,45,,14594.45,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,16053.89,49.5,,16053.89,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,267.8,,,267.8,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,25945.68,80,,25945.68,percent of total billed charges,,22702.47,70,,22702.47,percent of total billed charges,,42.64,,,42.64,Fee Schedule,,36.14,,,36.14,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,143.98,,,143.98,Other,New York Medicaid APG methodology,143.98,,,143.98,Other,100% New York Medicaid APG,143.98,,,143.98,Other,100% New York Medicaid APG,143.98,,,143.98,Other,100% New York Medicaid APG,323.95,,,323.95,Other,225% New York Medicaid APG,220.29,,,220.29,Other,153% New York Medicaid APG,323.95,,,323.95,Other,225% New York Medicaid APG,201.57,,,201.57,Other,140% New York Medicaid APG,323.95,,,323.95,Other,225% New York Medicaid APG,374.35,,,374.35,Other,260% New York Medicaid APG,466.49,,,466.49,Other,324% New York Medicaid APG,309.56,,,309.56,Other,215% New York Medicaid APG,309.56,,,309.56,Other,215% New York Medicaid APG,179.97,,,179.97,Other,125% New York Medicaid APG,36.14,25945.68,
Non-routine bl draw 3/> yrs,36410,CPT,,,,,,,,both,,,35243,26079.82,74,,26079.82,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15859.35,45,,15859.35,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,116.52,,,116.52,Fee Schedule,,104.8,,,104.8,Fee Schedule,,99.05,,,99.05,Fee Schedule,,17445.29,49.5,,17445.29,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,254.86,,,254.86,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,28194.4,80,,28194.4,percent of total billed charges,,24670.1,70,,24670.1,percent of total billed charges,,44.28,,,44.28,Fee Schedule,,37.53,,,37.53,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,137.02,,,137.02,Other,New York Medicaid APG methodology,137.02,,,137.02,Other,100% New York Medicaid APG,137.02,,,137.02,Other,100% New York Medicaid APG,137.02,,,137.02,Other,100% New York Medicaid APG,308.3,,,308.3,Other,225% New York Medicaid APG,209.65,,,209.65,Other,153% New York Medicaid APG,308.3,,,308.3,Other,225% New York Medicaid APG,191.83,,,191.83,Other,140% New York Medicaid APG,308.3,,,308.3,Other,225% New York Medicaid APG,356.26,,,356.26,Other,260% New York Medicaid APG,443.96,,,443.96,Other,324% New York Medicaid APG,294.6,,,294.6,Other,215% New York Medicaid APG,294.6,,,294.6,Other,215% New York Medicaid APG,171.28,,,171.28,Other,125% New York Medicaid APG,37.53,28194.4,
Capillary blood draw,36416,CPT,,,,,,,,both,,,11.73,8.68,74,,8.68,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,5.28,45,,5.28,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,1.22,,,1.22,Fee Schedule,,1.22,,,1.22,Fee Schedule,,1.22,,,1.22,Fee Schedule,,5.81,49.5,,5.81,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,267.8,,,267.8,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9.38,80,,9.38,percent of total billed charges,,8.21,70,,8.21,percent of total billed charges,,7.62,65,,7.62,percent of total billed charges,,7.62,65,,7.62,percent of total billed charges,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,143.98,,,143.98,Other,New York Medicaid APG methodology,143.98,,,143.98,Other,100% New York Medicaid APG,143.98,,,143.98,Other,100% New York Medicaid APG,143.98,,,143.98,Other,100% New York Medicaid APG,323.95,,,323.95,Other,225% New York Medicaid APG,220.29,,,220.29,Other,153% New York Medicaid APG,323.95,,,323.95,Other,225% New York Medicaid APG,201.57,,,201.57,Other,140% New York Medicaid APG,323.95,,,323.95,Other,225% New York Medicaid APG,374.35,,,374.35,Other,260% New York Medicaid APG,466.49,,,466.49,Other,324% New York Medicaid APG,309.56,,,309.56,Other,215% New York Medicaid APG,309.56,,,309.56,Other,215% New York Medicaid APG,179.97,,,179.97,Other,125% New York Medicaid APG,1.22,9473,
Vein access cutdown < 1 yr,36420,CPT,,,,,,,,both,,,2686.86,1988.28,74,,1988.28,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,1209.09,45,,1209.09,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,1330,49.5,,1330,percent of total billed charges,110% of Medicare,1827.06,68,,1827.06,percent of total billed charges,,254.86,,,254.86,Other,186% of Medicaid,2149.49,80,,2149.49,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,2149.49,80,,2149.49,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,1880.8,70,,1880.8,percent of total billed charges,,231.24,,,231.24,Fee Schedule,,195.99,,,195.99,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,137.02,,,137.02,Other,New York Medicaid APG methodology,137.02,,,137.02,Other,100% New York Medicaid APG,137.02,,,137.02,Other,100% New York Medicaid APG,137.02,,,137.02,Other,100% New York Medicaid APG,308.3,,,308.3,Other,225% New York Medicaid APG,209.65,,,209.65,Other,153% New York Medicaid APG,308.3,,,308.3,Other,225% New York Medicaid APG,191.83,,,191.83,Other,140% New York Medicaid APG,308.3,,,308.3,Other,225% New York Medicaid APG,356.26,,,356.26,Other,260% New York Medicaid APG,443.96,,,443.96,Other,324% New York Medicaid APG,294.6,,,294.6,Other,215% New York Medicaid APG,294.6,,,294.6,Other,215% New York Medicaid APG,171.28,,,171.28,Other,125% New York Medicaid APG,137.02,7216,
Vein access cutdown > 1 yr,36425,CPT,,,,,,,,both,,,8380.68,6201.7,74,,6201.7,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,3771.31,45,,3771.31,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,4148.44,49.5,,4148.44,percent of total billed charges,110% of Medicare,5698.86,68,,5698.86,percent of total billed charges,,254.86,,,254.86,Other,186% of Medicaid,6704.54,80,,6704.54,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,6704.54,80,,6704.54,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,5866.48,70,,5866.48,percent of total billed charges,,191.88,,,191.88,Fee Schedule,,162.63,,,162.63,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,137.02,,,137.02,Other,New York Medicaid APG methodology,137.02,,,137.02,Other,100% New York Medicaid APG,137.02,,,137.02,Other,100% New York Medicaid APG,137.02,,,137.02,Other,100% New York Medicaid APG,308.3,,,308.3,Other,225% New York Medicaid APG,209.65,,,209.65,Other,153% New York Medicaid APG,308.3,,,308.3,Other,225% New York Medicaid APG,191.83,,,191.83,Other,140% New York Medicaid APG,308.3,,,308.3,Other,225% New York Medicaid APG,356.26,,,356.26,Other,260% New York Medicaid APG,443.96,,,443.96,Other,324% New York Medicaid APG,294.6,,,294.6,Other,215% New York Medicaid APG,294.6,,,294.6,Other,215% New York Medicaid APG,171.28,,,171.28,Other,125% New York Medicaid APG,137.02,7216,
Blood transfusion service,36430,CPT,,,,,,,,both,,,11735,8683.9,74,,8683.9,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,5280.75,45,,5280.75,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,5808.83,49.5,,5808.83,percent of total billed charges,110% of Medicare,7979.8,68,,7979.8,percent of total billed charges,,1096.85,,,1096.85,Other,186% of Medicaid,9388,80,,9388,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,9388,80,,9388,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,8214.5,70,,8214.5,percent of total billed charges,,191.88,,,191.88,Fee Schedule,,162.63,,,162.63,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,589.7,,,589.7,Other,New York Medicaid APG methodology,589.7,,,589.7,Other,100% New York Medicaid APG,589.7,,,589.7,Other,100% New York Medicaid APG,589.7,,,589.7,Other,100% New York Medicaid APG,1326.83,,,1326.83,Other,225% New York Medicaid APG,902.24,,,902.24,Other,153% New York Medicaid APG,1326.83,,,1326.83,Other,225% New York Medicaid APG,825.58,,,825.58,Other,140% New York Medicaid APG,1326.83,,,1326.83,Other,225% New York Medicaid APG,1533.23,,,1533.23,Other,260% New York Medicaid APG,1910.63,,,1910.63,Other,324% New York Medicaid APG,1267.86,,,1267.86,Other,215% New York Medicaid APG,1267.86,,,1267.86,Other,215% New York Medicaid APG,737.13,,,737.13,Other,125% New York Medicaid APG,162.63,9388,
Bl push transfuse 2 yr/<,36440,CPT,,,,,,,,both,,,9130.81,6756.8,74,,6756.8,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,4108.86,45,,4108.86,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,4519.75,49.5,,4519.75,percent of total billed charges,110% of Medicare,6208.95,68,,6208.95,percent of total billed charges,,1096.85,,,1096.85,Other,186% of Medicaid,7304.65,80,,7304.65,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,7304.65,80,,7304.65,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,6391.57,70,,6391.57,percent of total billed charges,,242.72,,,242.72,Fee Schedule,,205.72,,,205.72,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,589.7,,,589.7,Other,New York Medicaid APG methodology,589.7,,,589.7,Other,100% New York Medicaid APG,589.7,,,589.7,Other,100% New York Medicaid APG,589.7,,,589.7,Other,100% New York Medicaid APG,1326.83,,,1326.83,Other,225% New York Medicaid APG,902.24,,,902.24,Other,153% New York Medicaid APG,1326.83,,,1326.83,Other,225% New York Medicaid APG,825.58,,,825.58,Other,140% New York Medicaid APG,1326.83,,,1326.83,Other,225% New York Medicaid APG,1533.23,,,1533.23,Other,260% New York Medicaid APG,1910.63,,,1910.63,Other,324% New York Medicaid APG,1267.86,,,1267.86,Other,215% New York Medicaid APG,1267.86,,,1267.86,Other,215% New York Medicaid APG,737.13,,,737.13,Other,125% New York Medicaid APG,205.72,7304.65,
Bl exchange/transfuse nb,36450,CPT,,,,,,,,both,,,9130.81,6756.8,74,,6756.8,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,4108.86,45,,4108.86,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,4519.75,49.5,,4519.75,percent of total billed charges,110% of Medicare,6208.95,68,,6208.95,percent of total billed charges,,1096.85,,,1096.85,Other,186% of Medicaid,7304.65,80,,7304.65,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,7304.65,80,,7304.65,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,6391.57,70,,6391.57,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,589.7,,,589.7,Other,New York Medicaid APG methodology,589.7,,,589.7,Other,100% New York Medicaid APG,589.7,,,589.7,Other,100% New York Medicaid APG,589.7,,,589.7,Other,100% New York Medicaid APG,1326.83,,,1326.83,Other,225% New York Medicaid APG,902.24,,,902.24,Other,153% New York Medicaid APG,1326.83,,,1326.83,Other,225% New York Medicaid APG,825.58,,,825.58,Other,140% New York Medicaid APG,1326.83,,,1326.83,Other,225% New York Medicaid APG,1533.23,,,1533.23,Other,260% New York Medicaid APG,1910.63,,,1910.63,Other,324% New York Medicaid APG,1267.86,,,1267.86,Other,215% New York Medicaid APG,1267.86,,,1267.86,Other,215% New York Medicaid APG,737.13,,,737.13,Other,125% New York Medicaid APG,589.7,7304.65,
Bl exchange/transfuse non-nb,36455,CPT,,,,,,,,both,,,9130.81,6756.8,74,,6756.8,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,4108.86,45,,4108.86,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,4519.75,49.5,,4519.75,percent of total billed charges,110% of Medicare,6208.95,68,,6208.95,percent of total billed charges,,1096.85,,,1096.85,Other,186% of Medicaid,7304.65,80,,7304.65,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,7304.65,80,,7304.65,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,6391.57,70,,6391.57,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,589.7,,,589.7,Other,New York Medicaid APG methodology,589.7,,,589.7,Other,100% New York Medicaid APG,589.7,,,589.7,Other,100% New York Medicaid APG,589.7,,,589.7,Other,100% New York Medicaid APG,1326.83,,,1326.83,Other,225% New York Medicaid APG,902.24,,,902.24,Other,153% New York Medicaid APG,1326.83,,,1326.83,Other,225% New York Medicaid APG,825.58,,,825.58,Other,140% New York Medicaid APG,1326.83,,,1326.83,Other,225% New York Medicaid APG,1533.23,,,1533.23,Other,260% New York Medicaid APG,1910.63,,,1910.63,Other,324% New York Medicaid APG,1267.86,,,1267.86,Other,215% New York Medicaid APG,1267.86,,,1267.86,Other,215% New York Medicaid APG,737.13,,,737.13,Other,125% New York Medicaid APG,589.7,7304.65,
Transfusion service fetal,36460,CPT,,,,,,,,both,,,9130.81,6756.8,74,,6756.8,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,4108.86,45,,4108.86,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,4519.75,49.5,,4519.75,percent of total billed charges,110% of Medicare,6208.95,68,,6208.95,percent of total billed charges,,1096.85,,,1096.85,Other,186% of Medicaid,7304.65,80,,7304.65,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,7304.65,80,,7304.65,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,6391.57,70,,6391.57,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,589.7,,,589.7,Other,New York Medicaid APG methodology,589.7,,,589.7,Other,100% New York Medicaid APG,589.7,,,589.7,Other,100% New York Medicaid APG,589.7,,,589.7,Other,100% New York Medicaid APG,1326.83,,,1326.83,Other,225% New York Medicaid APG,902.24,,,902.24,Other,153% New York Medicaid APG,1326.83,,,1326.83,Other,225% New York Medicaid APG,825.58,,,825.58,Other,140% New York Medicaid APG,1326.83,,,1326.83,Other,225% New York Medicaid APG,1533.23,,,1533.23,Other,260% New York Medicaid APG,1910.63,,,1910.63,Other,324% New York Medicaid APG,1267.86,,,1267.86,Other,215% New York Medicaid APG,1267.86,,,1267.86,Other,215% New York Medicaid APG,737.13,,,737.13,Other,125% New York Medicaid APG,589.7,7304.65,
Njx noncmpnd sclrsnt 1 vein,36465,CPT,,,,,,,,both,,,32059.3,23723.88,74,,23723.88,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,14426.69,45,,14426.69,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,15869.35,49.5,,15869.35,percent of total billed charges,110% of Medicare,21800.32,68,,21800.32,percent of total billed charges,,1930.23,,,1930.23,Other,186% of Medicaid,25647.44,80,,25647.44,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,25647.44,80,,25647.44,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,22441.51,70,,22441.51,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1037.76,,,1037.76,Other,New York Medicaid APG methodology,1037.76,,,1037.76,Other,100% New York Medicaid APG,1037.76,,,1037.76,Other,100% New York Medicaid APG,1037.76,,,1037.76,Other,100% New York Medicaid APG,2334.95,,,2334.95,Other,225% New York Medicaid APG,1587.77,,,1587.77,Other,153% New York Medicaid APG,2334.95,,,2334.95,Other,225% New York Medicaid APG,1452.86,,,1452.86,Other,140% New York Medicaid APG,2334.95,,,2334.95,Other,225% New York Medicaid APG,2698.17,,,2698.17,Other,260% New York Medicaid APG,3362.33,,,3362.33,Other,324% New York Medicaid APG,2231.18,,,2231.18,Other,215% New York Medicaid APG,2231.18,,,2231.18,Other,215% New York Medicaid APG,1297.2,,,1297.2,Other,125% New York Medicaid APG,1037.76,25647.44,
Njx noncmpnd sclrsnt mlt vn,36466,CPT,,,,,,,,both,,,38357.55,28384.59,74,,28384.59,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,17260.9,45,,17260.9,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,18986.99,49.5,,18986.99,percent of total billed charges,110% of Medicare,26083.13,68,,26083.13,percent of total billed charges,,1930.23,,,1930.23,Other,186% of Medicaid,30686.04,80,,30686.04,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,30686.04,80,,30686.04,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,26850.29,70,,26850.29,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1037.76,,,1037.76,Other,New York Medicaid APG methodology,1037.76,,,1037.76,Other,100% New York Medicaid APG,1037.76,,,1037.76,Other,100% New York Medicaid APG,1037.76,,,1037.76,Other,100% New York Medicaid APG,2334.95,,,2334.95,Other,225% New York Medicaid APG,1587.77,,,1587.77,Other,153% New York Medicaid APG,2334.95,,,2334.95,Other,225% New York Medicaid APG,1452.86,,,1452.86,Other,140% New York Medicaid APG,2334.95,,,2334.95,Other,225% New York Medicaid APG,2698.17,,,2698.17,Other,260% New York Medicaid APG,3362.33,,,3362.33,Other,324% New York Medicaid APG,2231.18,,,2231.18,Other,215% New York Medicaid APG,2231.18,,,2231.18,Other,215% New York Medicaid APG,1297.2,,,1297.2,Other,125% New York Medicaid APG,1037.76,30686.04,
Njx sclrsnt spider veins,36468,CPT,,,,,,,,both,,,8387.08,6206.44,74,,6206.44,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,3774.19,45,,3774.19,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,4151.6,49.5,,4151.6,percent of total billed charges,110% of Medicare,5703.21,68,,5703.21,percent of total billed charges,,1930.23,,,1930.23,Other,186% of Medicaid,6709.66,80,,6709.66,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,6709.66,80,,6709.66,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,5870.96,70,,5870.96,percent of total billed charges,,5451.6,65,,5451.6,percent of total billed charges,,5451.6,65,,5451.6,percent of total billed charges,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,1037.76,,,1037.76,Other,New York Medicaid APG methodology,1037.76,,,1037.76,Other,100% New York Medicaid APG,1037.76,,,1037.76,Other,100% New York Medicaid APG,1037.76,,,1037.76,Other,100% New York Medicaid APG,2334.95,,,2334.95,Other,225% New York Medicaid APG,1587.77,,,1587.77,Other,153% New York Medicaid APG,2334.95,,,2334.95,Other,225% New York Medicaid APG,1452.86,,,1452.86,Other,140% New York Medicaid APG,2334.95,,,2334.95,Other,225% New York Medicaid APG,2698.17,,,2698.17,Other,260% New York Medicaid APG,3362.33,,,3362.33,Other,324% New York Medicaid APG,2231.18,,,2231.18,Other,215% New York Medicaid APG,2231.18,,,2231.18,Other,215% New York Medicaid APG,1297.2,,,1297.2,Other,125% New York Medicaid APG,1037.76,7216,
Njx sclrsnt 1 incmptnt vein,36470,CPT,,,,,,,,both,,,8387.08,6206.44,74,,6206.44,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,3774.19,45,,3774.19,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,4151.6,49.5,,4151.6,percent of total billed charges,110% of Medicare,5703.21,68,,5703.21,percent of total billed charges,,1930.23,,,1930.23,Other,186% of Medicaid,6709.66,80,,6709.66,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,6709.66,80,,6709.66,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,5870.96,70,,5870.96,percent of total billed charges,,186.96,,,186.96,Fee Schedule,,158.46,,,158.46,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,1037.76,,,1037.76,Other,New York Medicaid APG methodology,1037.76,,,1037.76,Other,100% New York Medicaid APG,1037.76,,,1037.76,Other,100% New York Medicaid APG,1037.76,,,1037.76,Other,100% New York Medicaid APG,2334.95,,,2334.95,Other,225% New York Medicaid APG,1587.77,,,1587.77,Other,153% New York Medicaid APG,2334.95,,,2334.95,Other,225% New York Medicaid APG,1452.86,,,1452.86,Other,140% New York Medicaid APG,2334.95,,,2334.95,Other,225% New York Medicaid APG,2698.17,,,2698.17,Other,260% New York Medicaid APG,3362.33,,,3362.33,Other,324% New York Medicaid APG,2231.18,,,2231.18,Other,215% New York Medicaid APG,2231.18,,,2231.18,Other,215% New York Medicaid APG,1297.2,,,1297.2,Other,125% New York Medicaid APG,158.46,7216,
Njx sclrsnt mlt incmptnt vn,36471,CPT,,,,,,,,both,,,8387.08,6206.44,74,,6206.44,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,3774.19,45,,3774.19,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,4151.6,49.5,,4151.6,percent of total billed charges,110% of Medicare,5703.21,68,,5703.21,percent of total billed charges,,1930.23,,,1930.23,Other,186% of Medicaid,6709.66,80,,6709.66,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,6709.66,80,,6709.66,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,5870.96,70,,5870.96,percent of total billed charges,,365.72,,,365.72,Fee Schedule,,309.97,,,309.97,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,1037.76,,,1037.76,Other,New York Medicaid APG methodology,1037.76,,,1037.76,Other,100% New York Medicaid APG,1037.76,,,1037.76,Other,100% New York Medicaid APG,1037.76,,,1037.76,Other,100% New York Medicaid APG,2334.95,,,2334.95,Other,225% New York Medicaid APG,1587.77,,,1587.77,Other,153% New York Medicaid APG,2334.95,,,2334.95,Other,225% New York Medicaid APG,1452.86,,,1452.86,Other,140% New York Medicaid APG,2334.95,,,2334.95,Other,225% New York Medicaid APG,2698.17,,,2698.17,Other,260% New York Medicaid APG,3362.33,,,3362.33,Other,324% New York Medicaid APG,2231.18,,,2231.18,Other,215% New York Medicaid APG,2231.18,,,2231.18,Other,215% New York Medicaid APG,1297.2,,,1297.2,Other,125% New York Medicaid APG,309.97,7216,
Endovenous mchnchem 1st vein,36473,CPT,,,,,,,,both,,,67044.74,49613.11,74,,49613.11,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30170.13,45,,30170.13,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33187.15,49.5,,33187.15,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,4156.45,,,4156.45,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,46931.32,70,,46931.32,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,2234.65,,,2234.65,Other,New York Medicaid APG methodology,2234.65,,,2234.65,Other,100% New York Medicaid APG,2234.65,,,2234.65,Other,100% New York Medicaid APG,2234.65,,,2234.65,Other,100% New York Medicaid APG,5027.97,,,5027.97,Other,225% New York Medicaid APG,3419.02,,,3419.02,Other,153% New York Medicaid APG,5027.97,,,5027.97,Other,225% New York Medicaid APG,3128.51,,,3128.51,Other,140% New York Medicaid APG,5027.97,,,5027.97,Other,225% New York Medicaid APG,5810.1,,,5810.1,Other,260% New York Medicaid APG,7240.28,,,7240.28,Other,324% New York Medicaid APG,4804.5,,,4804.5,Other,215% New York Medicaid APG,4804.5,,,4804.5,Other,215% New York Medicaid APG,2793.32,,,2793.32,Other,125% New York Medicaid APG,2234.65,49613.11,
Endovenous mchnchem add-on,36474,CPT,,,,,,,,both,,,64479.48,47714.82,74,,47714.82,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,29015.77,45,,29015.77,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,31917.34,49.5,,31917.34,percent of total billed charges,110% of Medicare,43846.05,68,,43846.05,percent of total billed charges,,4156.45,,,4156.45,Other,186% of Medicaid,51583.58,80,,51583.58,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,51583.58,80,,51583.58,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,45135.64,70,,45135.64,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,2234.65,,,2234.65,Other,New York Medicaid APG methodology,2234.65,,,2234.65,Other,100% New York Medicaid APG,2234.65,,,2234.65,Other,100% New York Medicaid APG,2234.65,,,2234.65,Other,100% New York Medicaid APG,5027.97,,,5027.97,Other,225% New York Medicaid APG,3419.02,,,3419.02,Other,153% New York Medicaid APG,5027.97,,,5027.97,Other,225% New York Medicaid APG,3128.51,,,3128.51,Other,140% New York Medicaid APG,5027.97,,,5027.97,Other,225% New York Medicaid APG,5810.1,,,5810.1,Other,260% New York Medicaid APG,7240.28,,,7240.28,Other,324% New York Medicaid APG,4804.5,,,4804.5,Other,215% New York Medicaid APG,4804.5,,,4804.5,Other,215% New York Medicaid APG,2793.32,,,2793.32,Other,125% New York Medicaid APG,2053,51583.58,
Endovenous rf 1st vein,36475,CPT,,,,,,,,both,,,35971.87,26619.18,74,,26619.18,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,16187.34,45,,16187.34,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,17806.08,49.5,,17806.08,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,4156.45,,,4156.45,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,25180.31,70,,25180.31,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,2234.65,,,2234.65,Other,New York Medicaid APG methodology,2234.65,,,2234.65,Other,100% New York Medicaid APG,2234.65,,,2234.65,Other,100% New York Medicaid APG,2234.65,,,2234.65,Other,100% New York Medicaid APG,5027.97,,,5027.97,Other,225% New York Medicaid APG,3419.02,,,3419.02,Other,153% New York Medicaid APG,5027.97,,,5027.97,Other,225% New York Medicaid APG,3128.51,,,3128.51,Other,140% New York Medicaid APG,5027.97,,,5027.97,Other,225% New York Medicaid APG,5810.1,,,5810.1,Other,260% New York Medicaid APG,7240.28,,,7240.28,Other,324% New York Medicaid APG,4804.5,,,4804.5,Other,215% New York Medicaid APG,4804.5,,,4804.5,Other,215% New York Medicaid APG,2793.32,,,2793.32,Other,125% New York Medicaid APG,2234.65,26619.18,
Endovenous rf vein add-on,36476,CPT,,,,,,,,both,,,64479.48,47714.82,74,,47714.82,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,29015.77,45,,29015.77,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,31917.34,49.5,,31917.34,percent of total billed charges,110% of Medicare,43846.05,68,,43846.05,percent of total billed charges,,4156.45,,,4156.45,Other,186% of Medicaid,51583.58,80,,51583.58,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,51583.58,80,,51583.58,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,45135.64,70,,45135.64,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,2234.65,,,2234.65,Other,New York Medicaid APG methodology,2234.65,,,2234.65,Other,100% New York Medicaid APG,2234.65,,,2234.65,Other,100% New York Medicaid APG,2234.65,,,2234.65,Other,100% New York Medicaid APG,5027.97,,,5027.97,Other,225% New York Medicaid APG,3419.02,,,3419.02,Other,153% New York Medicaid APG,5027.97,,,5027.97,Other,225% New York Medicaid APG,3128.51,,,3128.51,Other,140% New York Medicaid APG,5027.97,,,5027.97,Other,225% New York Medicaid APG,5810.1,,,5810.1,Other,260% New York Medicaid APG,7240.28,,,7240.28,Other,324% New York Medicaid APG,4804.5,,,4804.5,Other,215% New York Medicaid APG,4804.5,,,4804.5,Other,215% New York Medicaid APG,2793.32,,,2793.32,Other,125% New York Medicaid APG,2053,51583.58,
Endovenous laser 1st vein,36478,CPT,,,,,,,,both,,,67044.74,49613.11,74,,49613.11,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30170.13,45,,30170.13,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33187.15,49.5,,33187.15,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,4156.45,,,4156.45,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,46931.32,70,,46931.32,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,2234.65,,,2234.65,Other,New York Medicaid APG methodology,2234.65,,,2234.65,Other,100% New York Medicaid APG,2234.65,,,2234.65,Other,100% New York Medicaid APG,2234.65,,,2234.65,Other,100% New York Medicaid APG,5027.97,,,5027.97,Other,225% New York Medicaid APG,3419.02,,,3419.02,Other,153% New York Medicaid APG,5027.97,,,5027.97,Other,225% New York Medicaid APG,3128.51,,,3128.51,Other,140% New York Medicaid APG,5027.97,,,5027.97,Other,225% New York Medicaid APG,5810.1,,,5810.1,Other,260% New York Medicaid APG,7240.28,,,7240.28,Other,324% New York Medicaid APG,4804.5,,,4804.5,Other,215% New York Medicaid APG,4804.5,,,4804.5,Other,215% New York Medicaid APG,2793.32,,,2793.32,Other,125% New York Medicaid APG,2234.65,49613.11,
Endovenous laser vein addon,36479,CPT,,,,,,,,both,,,64479.48,47714.82,74,,47714.82,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,29015.77,45,,29015.77,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,31917.34,49.5,,31917.34,percent of total billed charges,110% of Medicare,43846.05,68,,43846.05,percent of total billed charges,,4156.45,,,4156.45,Other,186% of Medicaid,51583.58,80,,51583.58,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,51583.58,80,,51583.58,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,45135.64,70,,45135.64,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,2234.65,,,2234.65,Other,New York Medicaid APG methodology,2234.65,,,2234.65,Other,100% New York Medicaid APG,2234.65,,,2234.65,Other,100% New York Medicaid APG,2234.65,,,2234.65,Other,100% New York Medicaid APG,5027.97,,,5027.97,Other,225% New York Medicaid APG,3419.02,,,3419.02,Other,153% New York Medicaid APG,5027.97,,,5027.97,Other,225% New York Medicaid APG,3128.51,,,3128.51,Other,140% New York Medicaid APG,5027.97,,,5027.97,Other,225% New York Medicaid APG,5810.1,,,5810.1,Other,260% New York Medicaid APG,7240.28,,,7240.28,Other,324% New York Medicaid APG,4804.5,,,4804.5,Other,215% New York Medicaid APG,4804.5,,,4804.5,Other,215% New York Medicaid APG,2793.32,,,2793.32,Other,125% New York Medicaid APG,2053,51583.58,
Insertion of catheter vein,36481,CPT,,,,,,,,both,,,32432.1,23999.75,74,,23999.75,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,14594.45,45,,14594.45,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,16053.89,49.5,,16053.89,percent of total billed charges,110% of Medicare,22053.83,68,,22053.83,percent of total billed charges,,516.02,,,516.02,Other,186% of Medicaid,25945.68,80,,25945.68,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,25945.68,80,,25945.68,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,22702.47,70,,22702.47,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,277.43,,,277.43,Other,New York Medicaid APG methodology,277.43,,,277.43,Other,100% New York Medicaid APG,277.43,,,277.43,Other,100% New York Medicaid APG,277.43,,,277.43,Other,100% New York Medicaid APG,624.21,,,624.21,Other,225% New York Medicaid APG,424.47,,,424.47,Other,153% New York Medicaid APG,624.21,,,624.21,Other,225% New York Medicaid APG,388.4,,,388.4,Other,140% New York Medicaid APG,624.21,,,624.21,Other,225% New York Medicaid APG,721.31,,,721.31,Other,260% New York Medicaid APG,898.87,,,898.87,Other,324% New York Medicaid APG,596.47,,,596.47,Other,215% New York Medicaid APG,596.47,,,596.47,Other,215% New York Medicaid APG,346.79,,,346.79,Other,125% New York Medicaid APG,277.43,25945.68,
Endoven ther chem adhes 1st,36482,CPT,,,,,,,,both,,,115587.67,85534.88,74,,85534.88,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,52014.45,45,,52014.45,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,57215.9,49.5,,57215.9,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,4156.45,,,4156.45,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,80911.37,70,,80911.37,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,2234.65,,,2234.65,Other,New York Medicaid APG methodology,2234.65,,,2234.65,Other,100% New York Medicaid APG,2234.65,,,2234.65,Other,100% New York Medicaid APG,2234.65,,,2234.65,Other,100% New York Medicaid APG,5027.97,,,5027.97,Other,225% New York Medicaid APG,3419.02,,,3419.02,Other,153% New York Medicaid APG,5027.97,,,5027.97,Other,225% New York Medicaid APG,3128.51,,,3128.51,Other,140% New York Medicaid APG,5027.97,,,5027.97,Other,225% New York Medicaid APG,5810.1,,,5810.1,Other,260% New York Medicaid APG,7240.28,,,7240.28,Other,324% New York Medicaid APG,4804.5,,,4804.5,Other,215% New York Medicaid APG,4804.5,,,4804.5,Other,215% New York Medicaid APG,2793.32,,,2793.32,Other,125% New York Medicaid APG,2234.65,85534.88,
Endoven ther chem adhes sbsq,36483,CPT,,,,,,,,both,,,64479.48,47714.82,74,,47714.82,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,29015.77,45,,29015.77,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,31917.34,49.5,,31917.34,percent of total billed charges,110% of Medicare,43846.05,68,,43846.05,percent of total billed charges,,4156.45,,,4156.45,Other,186% of Medicaid,51583.58,80,,51583.58,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,51583.58,80,,51583.58,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,45135.64,70,,45135.64,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,2234.65,,,2234.65,Other,New York Medicaid APG methodology,2234.65,,,2234.65,Other,100% New York Medicaid APG,2234.65,,,2234.65,Other,100% New York Medicaid APG,2234.65,,,2234.65,Other,100% New York Medicaid APG,5027.97,,,5027.97,Other,225% New York Medicaid APG,3419.02,,,3419.02,Other,153% New York Medicaid APG,5027.97,,,5027.97,Other,225% New York Medicaid APG,3128.51,,,3128.51,Other,140% New York Medicaid APG,5027.97,,,5027.97,Other,225% New York Medicaid APG,5810.1,,,5810.1,Other,260% New York Medicaid APG,7240.28,,,7240.28,Other,324% New York Medicaid APG,4804.5,,,4804.5,Other,215% New York Medicaid APG,4804.5,,,4804.5,Other,215% New York Medicaid APG,2793.32,,,2793.32,Other,125% New York Medicaid APG,2053,51583.58,
Insertion of catheter vein,36500,CPT,,,,,,,,both,,,32432.1,23999.75,74,,23999.75,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,14594.45,45,,14594.45,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,16053.89,49.5,,16053.89,percent of total billed charges,110% of Medicare,22053.83,68,,22053.83,percent of total billed charges,,516.02,,,516.02,Other,186% of Medicaid,25945.68,80,,25945.68,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,25945.68,80,,25945.68,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,22702.47,70,,22702.47,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,277.43,,,277.43,Other,New York Medicaid APG methodology,277.43,,,277.43,Other,100% New York Medicaid APG,277.43,,,277.43,Other,100% New York Medicaid APG,277.43,,,277.43,Other,100% New York Medicaid APG,624.21,,,624.21,Other,225% New York Medicaid APG,424.47,,,424.47,Other,153% New York Medicaid APG,624.21,,,624.21,Other,225% New York Medicaid APG,388.4,,,388.4,Other,140% New York Medicaid APG,624.21,,,624.21,Other,225% New York Medicaid APG,721.31,,,721.31,Other,260% New York Medicaid APG,898.87,,,898.87,Other,324% New York Medicaid APG,596.47,,,596.47,Other,215% New York Medicaid APG,596.47,,,596.47,Other,215% New York Medicaid APG,346.79,,,346.79,Other,125% New York Medicaid APG,277.43,25945.68,
Insertion of catheter vein,36510,CPT,,,,,,,,both,,,32432.1,23999.75,74,,23999.75,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,14594.45,45,,14594.45,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,16053.89,49.5,,16053.89,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,254.86,,,254.86,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,22702.47,70,,22702.47,percent of total billed charges,,257.48,,,257.48,Fee Schedule,,218.23,,,218.23,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,137.02,,,137.02,Other,New York Medicaid APG methodology,137.02,,,137.02,Other,100% New York Medicaid APG,137.02,,,137.02,Other,100% New York Medicaid APG,137.02,,,137.02,Other,100% New York Medicaid APG,308.3,,,308.3,Other,225% New York Medicaid APG,209.65,,,209.65,Other,153% New York Medicaid APG,308.3,,,308.3,Other,225% New York Medicaid APG,191.83,,,191.83,Other,140% New York Medicaid APG,308.3,,,308.3,Other,225% New York Medicaid APG,356.26,,,356.26,Other,260% New York Medicaid APG,443.96,,,443.96,Other,324% New York Medicaid APG,294.6,,,294.6,Other,215% New York Medicaid APG,294.6,,,294.6,Other,215% New York Medicaid APG,171.28,,,171.28,Other,125% New York Medicaid APG,137.02,23999.75,
Apheresis wbc,36511,CPT,,,,,,,,both,,,32272.54,23881.68,74,,23881.68,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,14522.64,45,,14522.64,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,15974.91,49.5,,15974.91,percent of total billed charges,110% of Medicare,21945.33,68,,21945.33,percent of total billed charges,,3573.86,,,3573.86,Other,186% of Medicaid,25818.03,80,,25818.03,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,25818.03,80,,25818.03,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,22590.78,70,,22590.78,percent of total billed charges,,528.08,,,528.08,Fee Schedule,,447.58,,,447.58,Fee Schedule,,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1921.43,,,1921.43,Other,New York Medicaid APG methodology,1921.43,,,1921.43,Other,100% New York Medicaid APG,1921.43,,,1921.43,Other,100% New York Medicaid APG,1921.43,,,1921.43,Other,100% New York Medicaid APG,4323.22,,,4323.22,Other,225% New York Medicaid APG,2939.79,,,2939.79,Other,153% New York Medicaid APG,4323.22,,,4323.22,Other,225% New York Medicaid APG,2690.01,,,2690.01,Other,140% New York Medicaid APG,4323.22,,,4323.22,Other,225% New York Medicaid APG,4995.72,,,4995.72,Other,260% New York Medicaid APG,6225.44,,,6225.44,Other,324% New York Medicaid APG,4131.08,,,4131.08,Other,215% New York Medicaid APG,4131.08,,,4131.08,Other,215% New York Medicaid APG,2401.79,,,2401.79,Other,125% New York Medicaid APG,447.58,25818.03,
Apheresis rbc,36512,CPT,,,,,,,,both,,,32272.54,23881.68,74,,23881.68,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,14522.64,45,,14522.64,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,15974.91,49.5,,15974.91,percent of total billed charges,110% of Medicare,21945.33,68,,21945.33,percent of total billed charges,,3573.86,,,3573.86,Other,186% of Medicaid,25818.03,80,,25818.03,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,25818.03,80,,25818.03,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,22590.78,70,,22590.78,percent of total billed charges,,513.32,,,513.32,Fee Schedule,,435.07,,,435.07,Fee Schedule,,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1921.43,,,1921.43,Other,New York Medicaid APG methodology,1921.43,,,1921.43,Other,100% New York Medicaid APG,1921.43,,,1921.43,Other,100% New York Medicaid APG,1921.43,,,1921.43,Other,100% New York Medicaid APG,4323.22,,,4323.22,Other,225% New York Medicaid APG,2939.79,,,2939.79,Other,153% New York Medicaid APG,4323.22,,,4323.22,Other,225% New York Medicaid APG,2690.01,,,2690.01,Other,140% New York Medicaid APG,4323.22,,,4323.22,Other,225% New York Medicaid APG,4995.72,,,4995.72,Other,260% New York Medicaid APG,6225.44,,,6225.44,Other,324% New York Medicaid APG,4131.08,,,4131.08,Other,215% New York Medicaid APG,4131.08,,,4131.08,Other,215% New York Medicaid APG,2401.79,,,2401.79,Other,125% New York Medicaid APG,435.07,25818.03,
Apheresis platelets,36513,CPT,,,,,,,,both,,,9130.81,6756.8,74,,6756.8,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,4108.86,45,,4108.86,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,4519.75,49.5,,4519.75,percent of total billed charges,110% of Medicare,6208.95,68,,6208.95,percent of total billed charges,,3573.86,,,3573.86,Other,186% of Medicaid,7304.65,80,,7304.65,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,7304.65,80,,7304.65,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,6391.57,70,,6391.57,percent of total billed charges,,511.68,,,511.68,Fee Schedule,,433.68,,,433.68,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,1921.43,,,1921.43,Other,New York Medicaid APG methodology,1921.43,,,1921.43,Other,100% New York Medicaid APG,1921.43,,,1921.43,Other,100% New York Medicaid APG,1921.43,,,1921.43,Other,100% New York Medicaid APG,4323.22,,,4323.22,Other,225% New York Medicaid APG,2939.79,,,2939.79,Other,153% New York Medicaid APG,4323.22,,,4323.22,Other,225% New York Medicaid APG,2690.01,,,2690.01,Other,140% New York Medicaid APG,4323.22,,,4323.22,Other,225% New York Medicaid APG,4995.72,,,4995.72,Other,260% New York Medicaid APG,6225.44,,,6225.44,Other,324% New York Medicaid APG,4131.08,,,4131.08,Other,215% New York Medicaid APG,4131.08,,,4131.08,Other,215% New York Medicaid APG,2401.79,,,2401.79,Other,125% New York Medicaid APG,433.68,7304.65,
Apheresis plasma,36514,CPT,,,,,,,,both,,,32272.54,23881.68,74,,23881.68,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,14522.64,45,,14522.64,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,15974.91,49.5,,15974.91,percent of total billed charges,110% of Medicare,21945.33,68,,21945.33,percent of total billed charges,,3573.86,,,3573.86,Other,186% of Medicaid,25818.03,80,,25818.03,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,25818.03,80,,25818.03,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,22590.78,70,,22590.78,percent of total billed charges,,449.36,,,449.36,Fee Schedule,,380.86,,,380.86,Fee Schedule,,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1921.43,,,1921.43,Other,New York Medicaid APG methodology,1921.43,,,1921.43,Other,100% New York Medicaid APG,1921.43,,,1921.43,Other,100% New York Medicaid APG,1921.43,,,1921.43,Other,100% New York Medicaid APG,4323.22,,,4323.22,Other,225% New York Medicaid APG,2939.79,,,2939.79,Other,153% New York Medicaid APG,4323.22,,,4323.22,Other,225% New York Medicaid APG,2690.01,,,2690.01,Other,140% New York Medicaid APG,4323.22,,,4323.22,Other,225% New York Medicaid APG,4995.72,,,4995.72,Other,260% New York Medicaid APG,6225.44,,,6225.44,Other,324% New York Medicaid APG,4131.08,,,4131.08,Other,215% New York Medicaid APG,4131.08,,,4131.08,Other,215% New York Medicaid APG,2401.79,,,2401.79,Other,125% New York Medicaid APG,380.86,25818.03,
Apheresis immunoads slctv,36516,CPT,,,,,,,,both,,,97340.17,72031.73,74,,72031.73,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,43803.08,45,,43803.08,percent of total billed charges,Medicare Ratio of cost to charges,5954,,"100% primary, 50% supplemental procedure",5954,Other,Aetna ASC Grouper,5359,,"100% primary, 50% supplemental procedure",5359,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,48183.38,49.5,,48183.38,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3573.86,,,3573.86,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,68138.12,70,,68138.12,percent of total billed charges,,411.64,,,411.64,Fee Schedule,,348.89,,,348.89,Fee Schedule,,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,1921.43,,,1921.43,Other,New York Medicaid APG methodology,1921.43,,,1921.43,Other,100% New York Medicaid APG,1921.43,,,1921.43,Other,100% New York Medicaid APG,1921.43,,,1921.43,Other,100% New York Medicaid APG,4323.21,,,4323.21,Other,225% New York Medicaid APG,2939.78,,,2939.78,Other,153% New York Medicaid APG,4323.21,,,4323.21,Other,225% New York Medicaid APG,2690,,,2690,Other,140% New York Medicaid APG,4323.21,,,4323.21,Other,225% New York Medicaid APG,4995.71,,,4995.71,Other,260% New York Medicaid APG,6225.43,,,6225.43,Other,324% New York Medicaid APG,4131.07,,,4131.07,Other,215% New York Medicaid APG,4131.07,,,4131.07,Other,215% New York Medicaid APG,2401.79,,,2401.79,Other,125% New York Medicaid APG,348.89,72031.73,
Photopheresis,36522,CPT,,,,,,,,both,,,97340.17,72031.73,74,,72031.73,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,43803.08,45,,43803.08,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,48183.38,49.5,,48183.38,percent of total billed charges,110% of Medicare,66191.32,68,,66191.32,percent of total billed charges,,3573.86,,,3573.86,Other,186% of Medicaid,77872.14,80,,77872.14,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,77872.14,80,,77872.14,percent of total billed charges,,7216,,,7216,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,68138.12,70,,68138.12,percent of total billed charges,,464.12,,,464.12,Fee Schedule,,393.37,,,393.37,Fee Schedule,,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,1921.43,,,1921.43,Other,New York Medicaid APG methodology,1921.43,,,1921.43,Other,100% New York Medicaid APG,1921.43,,,1921.43,Other,100% New York Medicaid APG,1921.43,,,1921.43,Other,100% New York Medicaid APG,4323.21,,,4323.21,Other,225% New York Medicaid APG,2939.78,,,2939.78,Other,153% New York Medicaid APG,4323.21,,,4323.21,Other,225% New York Medicaid APG,2690,,,2690,Other,140% New York Medicaid APG,4323.21,,,4323.21,Other,225% New York Medicaid APG,4995.71,,,4995.71,Other,260% New York Medicaid APG,6225.43,,,6225.43,Other,324% New York Medicaid APG,4131.07,,,4131.07,Other,215% New York Medicaid APG,4131.07,,,4131.07,Other,215% New York Medicaid APG,2401.79,,,2401.79,Other,125% New York Medicaid APG,393.37,77872.14,
Insert non-tunnel cv cath,36555,CPT,,,,,,,,both,,,67044.74,49613.11,74,,49613.11,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30170.13,45,,30170.13,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,33187.15,49.5,,33187.15,percent of total billed charges,110% of Medicare,45590.42,68,,45590.42,percent of total billed charges,,586.68,,,586.68,Other,186% of Medicaid,53635.79,80,,53635.79,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,53635.79,80,,53635.79,percent of total billed charges,,7216,,,7216,Case Rate,,3578,,"100% primary, 0% secondary procedures",3578,Other,MagnaCare ASC Grouper,46931.32,70,,46931.32,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,315.42,,,315.42,Other,New York Medicaid APG methodology,315.42,,,315.42,Other,100% New York Medicaid APG,315.42,,,315.42,Other,100% New York Medicaid APG,315.42,,,315.42,Other,100% New York Medicaid APG,709.7,,,709.7,Other,225% New York Medicaid APG,482.6,,,482.6,Other,153% New York Medicaid APG,709.7,,,709.7,Other,225% New York Medicaid APG,441.59,,,441.59,Other,140% New York Medicaid APG,709.7,,,709.7,Other,225% New York Medicaid APG,820.1,,,820.1,Other,260% New York Medicaid APG,1021.97,,,1021.97,Other,324% New York Medicaid APG,678.16,,,678.16,Other,215% New York Medicaid APG,678.16,,,678.16,Other,215% New York Medicaid APG,394.28,,,394.28,Other,125% New York Medicaid APG,315.42,53635.79,
Insert non-tunnel cv cath,36556,CPT,,,,,,,,both,,,24711.85,18286.77,74,,18286.77,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,11120.33,45,,11120.33,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,12232.37,49.5,,12232.37,percent of total billed charges,110% of Medicare,16804.06,68,,16804.06,percent of total billed charges,,586.68,,,586.68,Other,186% of Medicaid,19769.48,80,,19769.48,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,19769.48,80,,19769.48,percent of total billed charges,,7216,,,7216,Case Rate,,3578,,"100% primary, 0% secondary procedures",3578,Other,MagnaCare ASC Grouper,17298.3,70,,17298.3,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,315.42,,,315.42,Other,New York Medicaid APG methodology,315.42,,,315.42,Other,100% New York Medicaid APG,315.42,,,315.42,Other,100% New York Medicaid APG,315.42,,,315.42,Other,100% New York Medicaid APG,709.7,,,709.7,Other,225% New York Medicaid APG,482.6,,,482.6,Other,153% New York Medicaid APG,709.7,,,709.7,Other,225% New York Medicaid APG,441.59,,,441.59,Other,140% New York Medicaid APG,709.7,,,709.7,Other,225% New York Medicaid APG,820.1,,,820.1,Other,260% New York Medicaid APG,1021.97,,,1021.97,Other,324% New York Medicaid APG,678.16,,,678.16,Other,215% New York Medicaid APG,678.16,,,678.16,Other,215% New York Medicaid APG,394.28,,,394.28,Other,125% New York Medicaid APG,315.42,19769.48,
Insert tunneled cv cath,36557,CPT,,,,,,,,both,,,48529.02,35911.47,74,,35911.47,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,21838.06,45,,21838.06,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,24021.86,49.5,,24021.86,percent of total billed charges,110% of Medicare,32999.73,68,,32999.73,percent of total billed charges,,2490.15,,,2490.15,Other,186% of Medicaid,38823.22,80,,38823.22,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,38823.22,80,,38823.22,percent of total billed charges,,7216,,,7216,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,33970.31,70,,33970.31,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,1338.79,,,1338.79,Other,New York Medicaid APG methodology,1338.79,,,1338.79,Other,100% New York Medicaid APG,1338.79,,,1338.79,Other,100% New York Medicaid APG,1338.79,,,1338.79,Other,100% New York Medicaid APG,3012.28,,,3012.28,Other,225% New York Medicaid APG,2048.35,,,2048.35,Other,153% New York Medicaid APG,3012.28,,,3012.28,Other,225% New York Medicaid APG,1874.31,,,1874.31,Other,140% New York Medicaid APG,3012.28,,,3012.28,Other,225% New York Medicaid APG,3480.85,,,3480.85,Other,260% New York Medicaid APG,4337.68,,,4337.68,Other,324% New York Medicaid APG,2878.4,,,2878.4,Other,215% New York Medicaid APG,2878.4,,,2878.4,Other,215% New York Medicaid APG,1673.49,,,1673.49,Other,125% New York Medicaid APG,1338.79,38823.22,
Insert tunneled cv cath,36558,CPT,,,,,,,,both,,,24444.27,18088.76,74,,18088.76,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,10999.92,45,,10999.92,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,12099.91,49.5,,12099.91,percent of total billed charges,110% of Medicare,16622.1,68,,16622.1,percent of total billed charges,,2490.15,,,2490.15,Other,186% of Medicaid,19555.42,80,,19555.42,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,19555.42,80,,19555.42,percent of total billed charges,,7216,,,7216,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,17110.99,70,,17110.99,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1338.79,,,1338.79,Other,New York Medicaid APG methodology,1338.79,,,1338.79,Other,100% New York Medicaid APG,1338.79,,,1338.79,Other,100% New York Medicaid APG,1338.79,,,1338.79,Other,100% New York Medicaid APG,3012.28,,,3012.28,Other,225% New York Medicaid APG,2048.35,,,2048.35,Other,153% New York Medicaid APG,3012.28,,,3012.28,Other,225% New York Medicaid APG,1874.31,,,1874.31,Other,140% New York Medicaid APG,3012.28,,,3012.28,Other,225% New York Medicaid APG,3480.85,,,3480.85,Other,260% New York Medicaid APG,4337.68,,,4337.68,Other,324% New York Medicaid APG,2878.4,,,2878.4,Other,215% New York Medicaid APG,2878.4,,,2878.4,Other,215% New York Medicaid APG,1673.49,,,1673.49,Other,125% New York Medicaid APG,1338.79,19555.42,
Insert tunneled cv cath,36560,CPT,,,,,,,,both,,,37353.29,27641.43,74,,27641.43,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,16808.98,45,,16808.98,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,18489.88,49.5,,18489.88,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2490.15,,,2490.15,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,26147.3,70,,26147.3,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1338.79,,,1338.79,Other,New York Medicaid APG methodology,1338.79,,,1338.79,Other,100% New York Medicaid APG,1338.79,,,1338.79,Other,100% New York Medicaid APG,1338.79,,,1338.79,Other,100% New York Medicaid APG,3012.28,,,3012.28,Other,225% New York Medicaid APG,2048.35,,,2048.35,Other,153% New York Medicaid APG,3012.28,,,3012.28,Other,225% New York Medicaid APG,1874.31,,,1874.31,Other,140% New York Medicaid APG,3012.28,,,3012.28,Other,225% New York Medicaid APG,3480.85,,,3480.85,Other,260% New York Medicaid APG,4337.68,,,4337.68,Other,324% New York Medicaid APG,2878.4,,,2878.4,Other,215% New York Medicaid APG,2878.4,,,2878.4,Other,215% New York Medicaid APG,1673.49,,,1673.49,Other,125% New York Medicaid APG,1338.79,27641.43,
Insert tunneled cv cath,36561,CPT,,,,,,,,both,,,26377.3,19519.2,74,,19519.2,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,11869.79,45,,11869.79,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,13056.76,49.5,,13056.76,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2490.15,,,2490.15,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,18464.11,70,,18464.11,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1338.79,,,1338.79,Other,New York Medicaid APG methodology,1338.79,,,1338.79,Other,100% New York Medicaid APG,1338.79,,,1338.79,Other,100% New York Medicaid APG,1338.79,,,1338.79,Other,100% New York Medicaid APG,3012.28,,,3012.28,Other,225% New York Medicaid APG,2048.35,,,2048.35,Other,153% New York Medicaid APG,3012.28,,,3012.28,Other,225% New York Medicaid APG,1874.31,,,1874.31,Other,140% New York Medicaid APG,3012.28,,,3012.28,Other,225% New York Medicaid APG,3480.85,,,3480.85,Other,260% New York Medicaid APG,4337.68,,,4337.68,Other,324% New York Medicaid APG,2878.4,,,2878.4,Other,215% New York Medicaid APG,2878.4,,,2878.4,Other,215% New York Medicaid APG,1673.49,,,1673.49,Other,125% New York Medicaid APG,1338.79,19519.2,
Insert tunneled cv cath,36563,CPT,,,,,,,,both,,,115587.67,85534.88,74,,85534.88,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,52014.45,45,,52014.45,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,57215.9,49.5,,57215.9,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2490.15,,,2490.15,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,80911.37,70,,80911.37,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,1338.79,,,1338.79,Other,New York Medicaid APG methodology,1338.79,,,1338.79,Other,100% New York Medicaid APG,1338.79,,,1338.79,Other,100% New York Medicaid APG,1338.79,,,1338.79,Other,100% New York Medicaid APG,3012.28,,,3012.28,Other,225% New York Medicaid APG,2048.35,,,2048.35,Other,153% New York Medicaid APG,3012.28,,,3012.28,Other,225% New York Medicaid APG,1874.31,,,1874.31,Other,140% New York Medicaid APG,3012.28,,,3012.28,Other,225% New York Medicaid APG,3480.85,,,3480.85,Other,260% New York Medicaid APG,4337.68,,,4337.68,Other,324% New York Medicaid APG,2878.4,,,2878.4,Other,215% New York Medicaid APG,2878.4,,,2878.4,Other,215% New York Medicaid APG,1673.49,,,1673.49,Other,125% New York Medicaid APG,1338.79,85534.88,
Insert tunneled cv cath,36565,CPT,,,,,,,,both,,,67044.74,49613.11,74,,49613.11,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30170.13,45,,30170.13,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33187.15,49.5,,33187.15,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2490.15,,,2490.15,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,46931.32,70,,46931.32,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1338.79,,,1338.79,Other,New York Medicaid APG methodology,1338.79,,,1338.79,Other,100% New York Medicaid APG,1338.79,,,1338.79,Other,100% New York Medicaid APG,1338.79,,,1338.79,Other,100% New York Medicaid APG,3012.28,,,3012.28,Other,225% New York Medicaid APG,2048.35,,,2048.35,Other,153% New York Medicaid APG,3012.28,,,3012.28,Other,225% New York Medicaid APG,1874.31,,,1874.31,Other,140% New York Medicaid APG,3012.28,,,3012.28,Other,225% New York Medicaid APG,3480.85,,,3480.85,Other,260% New York Medicaid APG,4337.68,,,4337.68,Other,324% New York Medicaid APG,2878.4,,,2878.4,Other,215% New York Medicaid APG,2878.4,,,2878.4,Other,215% New York Medicaid APG,1673.49,,,1673.49,Other,125% New York Medicaid APG,1338.79,49613.11,
Insert tunneled cv cath,36566,CPT,,,,,,,,both,,,115587.67,85534.88,74,,85534.88,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,52014.45,45,,52014.45,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,57215.9,49.5,,57215.9,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2490.15,,,2490.15,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,80911.37,70,,80911.37,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,1338.79,,,1338.79,Other,New York Medicaid APG methodology,1338.79,,,1338.79,Other,100% New York Medicaid APG,1338.79,,,1338.79,Other,100% New York Medicaid APG,1338.79,,,1338.79,Other,100% New York Medicaid APG,3012.28,,,3012.28,Other,225% New York Medicaid APG,2048.35,,,2048.35,Other,153% New York Medicaid APG,3012.28,,,3012.28,Other,225% New York Medicaid APG,1874.31,,,1874.31,Other,140% New York Medicaid APG,3012.28,,,3012.28,Other,225% New York Medicaid APG,3480.85,,,3480.85,Other,260% New York Medicaid APG,4337.68,,,4337.68,Other,324% New York Medicaid APG,2878.4,,,2878.4,Other,215% New York Medicaid APG,2878.4,,,2878.4,Other,215% New York Medicaid APG,1673.49,,,1673.49,Other,125% New York Medicaid APG,1338.79,85534.88,
Insj picc <5 yr w/o imaging,36568,CPT,,,,,,,,both,,,33686.28,24927.85,74,,24927.85,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15158.83,45,,15158.83,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,16674.71,49.5,,16674.71,percent of total billed charges,110% of Medicare,22906.67,68,,22906.67,percent of total billed charges,,586.68,,,586.68,Other,186% of Medicaid,26949.02,80,,26949.02,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,26949.02,80,,26949.02,percent of total billed charges,,7216,,,7216,Case Rate,,3578,,"100% primary, 0% secondary procedures",3578,Other,MagnaCare ASC Grouper,23580.4,70,,23580.4,percent of total billed charges,,444.44,,,444.44,Fee Schedule,,376.69,,,376.69,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,315.42,,,315.42,Other,New York Medicaid APG methodology,315.42,,,315.42,Other,100% New York Medicaid APG,315.42,,,315.42,Other,100% New York Medicaid APG,315.42,,,315.42,Other,100% New York Medicaid APG,709.7,,,709.7,Other,225% New York Medicaid APG,482.6,,,482.6,Other,153% New York Medicaid APG,709.7,,,709.7,Other,225% New York Medicaid APG,441.59,,,441.59,Other,140% New York Medicaid APG,709.7,,,709.7,Other,225% New York Medicaid APG,820.1,,,820.1,Other,260% New York Medicaid APG,1021.97,,,1021.97,Other,324% New York Medicaid APG,678.16,,,678.16,Other,215% New York Medicaid APG,678.16,,,678.16,Other,215% New York Medicaid APG,394.28,,,394.28,Other,125% New York Medicaid APG,315.42,26949.02,
Insj picc 5 yr+ w/o imaging,36569,CPT,,,,,,,,both,,,33686.28,24927.85,74,,24927.85,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15158.83,45,,15158.83,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,16674.71,49.5,,16674.71,percent of total billed charges,110% of Medicare,22906.67,68,,22906.67,percent of total billed charges,,586.68,,,586.68,Other,186% of Medicaid,26949.02,80,,26949.02,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,26949.02,80,,26949.02,percent of total billed charges,,7216,,,7216,Case Rate,,3578,,"100% primary, 0% secondary procedures",3578,Other,MagnaCare ASC Grouper,23580.4,70,,23580.4,percent of total billed charges,,451,,,451,Fee Schedule,,382.25,,,382.25,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,315.42,,,315.42,Other,New York Medicaid APG methodology,315.42,,,315.42,Other,100% New York Medicaid APG,315.42,,,315.42,Other,100% New York Medicaid APG,315.42,,,315.42,Other,100% New York Medicaid APG,709.7,,,709.7,Other,225% New York Medicaid APG,482.6,,,482.6,Other,153% New York Medicaid APG,709.7,,,709.7,Other,225% New York Medicaid APG,441.59,,,441.59,Other,140% New York Medicaid APG,709.7,,,709.7,Other,225% New York Medicaid APG,820.1,,,820.1,Other,260% New York Medicaid APG,1021.97,,,1021.97,Other,324% New York Medicaid APG,678.16,,,678.16,Other,215% New York Medicaid APG,678.16,,,678.16,Other,215% New York Medicaid APG,394.28,,,394.28,Other,125% New York Medicaid APG,315.42,26949.02,
Insert picvad cath,36570,CPT,,,,,,,,both,,,67044.74,49613.11,74,,49613.11,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30170.13,45,,30170.13,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33187.15,49.5,,33187.15,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,586.68,,,586.68,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,46931.32,70,,46931.32,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,315.42,,,315.42,Other,New York Medicaid APG methodology,315.42,,,315.42,Other,100% New York Medicaid APG,315.42,,,315.42,Other,100% New York Medicaid APG,315.42,,,315.42,Other,100% New York Medicaid APG,709.7,,,709.7,Other,225% New York Medicaid APG,482.6,,,482.6,Other,153% New York Medicaid APG,709.7,,,709.7,Other,225% New York Medicaid APG,441.59,,,441.59,Other,140% New York Medicaid APG,709.7,,,709.7,Other,225% New York Medicaid APG,820.1,,,820.1,Other,260% New York Medicaid APG,1021.97,,,1021.97,Other,324% New York Medicaid APG,678.16,,,678.16,Other,215% New York Medicaid APG,678.16,,,678.16,Other,215% New York Medicaid APG,394.28,,,394.28,Other,125% New York Medicaid APG,315.42,49613.11,
Insert picvad cath,36571,CPT,,,,,,,,both,,,67044.74,49613.11,74,,49613.11,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30170.13,45,,30170.13,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33187.15,49.5,,33187.15,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,586.68,,,586.68,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,46931.32,70,,46931.32,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,315.42,,,315.42,Other,New York Medicaid APG methodology,315.42,,,315.42,Other,100% New York Medicaid APG,315.42,,,315.42,Other,100% New York Medicaid APG,315.42,,,315.42,Other,100% New York Medicaid APG,709.7,,,709.7,Other,225% New York Medicaid APG,482.6,,,482.6,Other,153% New York Medicaid APG,709.7,,,709.7,Other,225% New York Medicaid APG,441.59,,,441.59,Other,140% New York Medicaid APG,709.7,,,709.7,Other,225% New York Medicaid APG,820.1,,,820.1,Other,260% New York Medicaid APG,1021.97,,,1021.97,Other,324% New York Medicaid APG,678.16,,,678.16,Other,215% New York Medicaid APG,678.16,,,678.16,Other,215% New York Medicaid APG,394.28,,,394.28,Other,125% New York Medicaid APG,315.42,49613.11,
Insj picc rs&i <5 yr,36572,CPT,,,,,,,,both,,,13213.53,9778.01,74,,9778.01,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,5946.09,45,,5946.09,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,6540.7,49.5,,6540.7,percent of total billed charges,110% of Medicare,8985.2,68,,8985.2,percent of total billed charges,,586.68,,,586.68,Other,186% of Medicaid,10570.82,80,,10570.82,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,10570.82,80,,10570.82,percent of total billed charges,,7216,,,7216,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,9249.47,70,,9249.47,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,315.42,,,315.42,Other,New York Medicaid APG methodology,315.42,,,315.42,Other,100% New York Medicaid APG,315.42,,,315.42,Other,100% New York Medicaid APG,315.42,,,315.42,Other,100% New York Medicaid APG,709.7,,,709.7,Other,225% New York Medicaid APG,482.6,,,482.6,Other,153% New York Medicaid APG,709.7,,,709.7,Other,225% New York Medicaid APG,441.59,,,441.59,Other,140% New York Medicaid APG,709.7,,,709.7,Other,225% New York Medicaid APG,820.1,,,820.1,Other,260% New York Medicaid APG,1021.97,,,1021.97,Other,324% New York Medicaid APG,678.16,,,678.16,Other,215% New York Medicaid APG,678.16,,,678.16,Other,215% New York Medicaid APG,394.28,,,394.28,Other,125% New York Medicaid APG,315.42,10570.82,
Insj picc rs&i 5 yr+,36573,CPT,,,,,,,,both,,,15068.01,11150.33,74,,11150.33,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,6780.6,45,,6780.6,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,7458.66,49.5,,7458.66,percent of total billed charges,110% of Medicare,10246.25,68,,10246.25,percent of total billed charges,,586.68,,,586.68,Other,186% of Medicaid,12054.41,80,,12054.41,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,12054.41,80,,12054.41,percent of total billed charges,,7216,,,7216,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,10547.61,70,,10547.61,percent of total billed charges,,405.08,,,405.08,Fee Schedule,,343.33,,,343.33,Fee Schedule,,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,315.42,,,315.42,Other,New York Medicaid APG methodology,315.42,,,315.42,Other,100% New York Medicaid APG,315.42,,,315.42,Other,100% New York Medicaid APG,315.42,,,315.42,Other,100% New York Medicaid APG,709.7,,,709.7,Other,225% New York Medicaid APG,482.6,,,482.6,Other,153% New York Medicaid APG,709.7,,,709.7,Other,225% New York Medicaid APG,441.59,,,441.59,Other,140% New York Medicaid APG,709.7,,,709.7,Other,225% New York Medicaid APG,820.1,,,820.1,Other,260% New York Medicaid APG,1021.97,,,1021.97,Other,324% New York Medicaid APG,678.16,,,678.16,Other,215% New York Medicaid APG,678.16,,,678.16,Other,215% New York Medicaid APG,394.28,,,394.28,Other,125% New York Medicaid APG,315.42,12054.41,
Repair tunneled cv cath,36575,CPT,,,,,,,,both,,,13213.53,9778.01,74,,9778.01,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,5946.09,45,,5946.09,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,6540.7,49.5,,6540.7,percent of total billed charges,110% of Medicare,8985.2,68,,8985.2,percent of total billed charges,,1556.72,,,1556.72,Other,186% of Medicaid,10570.82,80,,10570.82,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,10570.82,80,,10570.82,percent of total billed charges,,7216,,,7216,Case Rate,,3578,,"100% primary, 0% secondary procedures",3578,Other,MagnaCare ASC Grouper,9249.47,70,,9249.47,percent of total billed charges,,160.72,,,160.72,Fee Schedule,,136.22,,,136.22,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,836.95,,,836.95,Other,New York Medicaid APG methodology,836.95,,,836.95,Other,100% New York Medicaid APG,836.95,,,836.95,Other,100% New York Medicaid APG,836.95,,,836.95,Other,100% New York Medicaid APG,1883.13,,,1883.13,Other,225% New York Medicaid APG,1280.53,,,1280.53,Other,153% New York Medicaid APG,1883.13,,,1883.13,Other,225% New York Medicaid APG,1171.73,,,1171.73,Other,140% New York Medicaid APG,1883.13,,,1883.13,Other,225% New York Medicaid APG,2176.07,,,2176.07,Other,260% New York Medicaid APG,2711.71,,,2711.71,Other,324% New York Medicaid APG,1799.44,,,1799.44,Other,215% New York Medicaid APG,1799.44,,,1799.44,Other,215% New York Medicaid APG,1046.19,,,1046.19,Other,125% New York Medicaid APG,136.22,10570.82,
Repair tunneled cv cath,36576,CPT,,,,,,,,both,,,33686.28,24927.85,74,,24927.85,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15158.83,45,,15158.83,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,16674.71,49.5,,16674.71,percent of total billed charges,110% of Medicare,22906.67,68,,22906.67,percent of total billed charges,,1556.72,,,1556.72,Other,186% of Medicaid,26949.02,80,,26949.02,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,26949.02,80,,26949.02,percent of total billed charges,,7216,,,7216,Case Rate,,3578,,"100% primary, 0% secondary procedures",3578,Other,MagnaCare ASC Grouper,23580.4,70,,23580.4,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,836.95,,,836.95,Other,New York Medicaid APG methodology,836.95,,,836.95,Other,100% New York Medicaid APG,836.95,,,836.95,Other,100% New York Medicaid APG,836.95,,,836.95,Other,100% New York Medicaid APG,1883.13,,,1883.13,Other,225% New York Medicaid APG,1280.53,,,1280.53,Other,153% New York Medicaid APG,1883.13,,,1883.13,Other,225% New York Medicaid APG,1171.73,,,1171.73,Other,140% New York Medicaid APG,1883.13,,,1883.13,Other,225% New York Medicaid APG,2176.07,,,2176.07,Other,260% New York Medicaid APG,2711.71,,,2711.71,Other,324% New York Medicaid APG,1799.44,,,1799.44,Other,215% New York Medicaid APG,1799.44,,,1799.44,Other,215% New York Medicaid APG,1046.19,,,1046.19,Other,125% New York Medicaid APG,836.95,26949.02,
Replace tunneled cv cath,36578,CPT,,,,,,,,both,,,67044.74,49613.11,74,,49613.11,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30170.13,45,,30170.13,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33187.15,49.5,,33187.15,percent of total billed charges,110% of Medicare,45590.42,68,,45590.42,percent of total billed charges,,1556.72,,,1556.72,Other,186% of Medicaid,53635.79,80,,53635.79,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,53635.79,80,,53635.79,percent of total billed charges,,7216,,,7216,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,46931.32,70,,46931.32,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,836.95,,,836.95,Other,New York Medicaid APG methodology,836.95,,,836.95,Other,100% New York Medicaid APG,836.95,,,836.95,Other,100% New York Medicaid APG,836.95,,,836.95,Other,100% New York Medicaid APG,1883.13,,,1883.13,Other,225% New York Medicaid APG,1280.53,,,1280.53,Other,153% New York Medicaid APG,1883.13,,,1883.13,Other,225% New York Medicaid APG,1171.73,,,1171.73,Other,140% New York Medicaid APG,1883.13,,,1883.13,Other,225% New York Medicaid APG,2176.07,,,2176.07,Other,260% New York Medicaid APG,2711.71,,,2711.71,Other,324% New York Medicaid APG,1799.44,,,1799.44,Other,215% New York Medicaid APG,1799.44,,,1799.44,Other,215% New York Medicaid APG,1046.19,,,1046.19,Other,125% New York Medicaid APG,836.95,53635.79,
Replace cvad cath,36580,CPT,,,,,,,,both,,,14619,10818.06,74,,10818.06,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,6578.55,45,,6578.55,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,7236.41,49.5,,7236.41,percent of total billed charges,110% of Medicare,9940.92,68,,9940.92,percent of total billed charges,,586.68,,,586.68,Other,186% of Medicaid,11695.2,80,,11695.2,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,11695.2,80,,11695.2,percent of total billed charges,,7216,,,7216,Case Rate,,3578,,"100% primary, 0% secondary procedures",3578,Other,MagnaCare ASC Grouper,10233.3,70,,10233.3,percent of total billed charges,,316.52,,,316.52,Fee Schedule,,268.27,,,268.27,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,315.42,,,315.42,Other,New York Medicaid APG methodology,315.42,,,315.42,Other,100% New York Medicaid APG,315.42,,,315.42,Other,100% New York Medicaid APG,315.42,,,315.42,Other,100% New York Medicaid APG,709.7,,,709.7,Other,225% New York Medicaid APG,482.6,,,482.6,Other,153% New York Medicaid APG,709.7,,,709.7,Other,225% New York Medicaid APG,441.59,,,441.59,Other,140% New York Medicaid APG,709.7,,,709.7,Other,225% New York Medicaid APG,820.1,,,820.1,Other,260% New York Medicaid APG,1021.97,,,1021.97,Other,324% New York Medicaid APG,678.16,,,678.16,Other,215% New York Medicaid APG,678.16,,,678.16,Other,215% New York Medicaid APG,394.28,,,394.28,Other,125% New York Medicaid APG,268.27,11695.2,
Replace tunneled cv cath,36581,CPT,,,,,,,,both,,,21192.57,15682.5,74,,15682.5,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,9536.66,45,,9536.66,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,10490.32,49.5,,10490.32,percent of total billed charges,110% of Medicare,14410.95,68,,14410.95,percent of total billed charges,,2490.15,,,2490.15,Other,186% of Medicaid,16954.06,80,,16954.06,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,16954.06,80,,16954.06,percent of total billed charges,,7216,,,7216,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,14834.8,70,,14834.8,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1338.79,,,1338.79,Other,New York Medicaid APG methodology,1338.79,,,1338.79,Other,100% New York Medicaid APG,1338.79,,,1338.79,Other,100% New York Medicaid APG,1338.79,,,1338.79,Other,100% New York Medicaid APG,3012.28,,,3012.28,Other,225% New York Medicaid APG,2048.35,,,2048.35,Other,153% New York Medicaid APG,3012.28,,,3012.28,Other,225% New York Medicaid APG,1874.31,,,1874.31,Other,140% New York Medicaid APG,3012.28,,,3012.28,Other,225% New York Medicaid APG,3480.85,,,3480.85,Other,260% New York Medicaid APG,4337.68,,,4337.68,Other,324% New York Medicaid APG,2878.4,,,2878.4,Other,215% New York Medicaid APG,2878.4,,,2878.4,Other,215% New York Medicaid APG,1673.49,,,1673.49,Other,125% New York Medicaid APG,1338.79,16954.06,
Replace tunneled cv cath,36582,CPT,,,,,,,,both,,,67044.74,49613.11,74,,49613.11,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30170.13,45,,30170.13,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33187.15,49.5,,33187.15,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2490.15,,,2490.15,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,46931.32,70,,46931.32,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1338.79,,,1338.79,Other,New York Medicaid APG methodology,1338.79,,,1338.79,Other,100% New York Medicaid APG,1338.79,,,1338.79,Other,100% New York Medicaid APG,1338.79,,,1338.79,Other,100% New York Medicaid APG,3012.28,,,3012.28,Other,225% New York Medicaid APG,2048.35,,,2048.35,Other,153% New York Medicaid APG,3012.28,,,3012.28,Other,225% New York Medicaid APG,1874.31,,,1874.31,Other,140% New York Medicaid APG,3012.28,,,3012.28,Other,225% New York Medicaid APG,3480.85,,,3480.85,Other,260% New York Medicaid APG,4337.68,,,4337.68,Other,324% New York Medicaid APG,2878.4,,,2878.4,Other,215% New York Medicaid APG,2878.4,,,2878.4,Other,215% New York Medicaid APG,1673.49,,,1673.49,Other,125% New York Medicaid APG,1338.79,49613.11,
Replace tunneled cv cath,36583,CPT,,,,,,,,both,,,115587.67,85534.88,74,,85534.88,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,52014.45,45,,52014.45,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,57215.9,49.5,,57215.9,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2490.15,,,2490.15,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,80911.37,70,,80911.37,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,1338.79,,,1338.79,Other,New York Medicaid APG methodology,1338.79,,,1338.79,Other,100% New York Medicaid APG,1338.79,,,1338.79,Other,100% New York Medicaid APG,1338.79,,,1338.79,Other,100% New York Medicaid APG,3012.28,,,3012.28,Other,225% New York Medicaid APG,2048.35,,,2048.35,Other,153% New York Medicaid APG,3012.28,,,3012.28,Other,225% New York Medicaid APG,1874.31,,,1874.31,Other,140% New York Medicaid APG,3012.28,,,3012.28,Other,225% New York Medicaid APG,3480.85,,,3480.85,Other,260% New York Medicaid APG,4337.68,,,4337.68,Other,324% New York Medicaid APG,2878.4,,,2878.4,Other,215% New York Medicaid APG,2878.4,,,2878.4,Other,215% New York Medicaid APG,1673.49,,,1673.49,Other,125% New York Medicaid APG,1338.79,85534.88,
Compl rplcmt picc rs&i,36584,CPT,,,,,,,,both,,,33686.28,24927.85,74,,24927.85,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15158.83,45,,15158.83,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,16674.71,49.5,,16674.71,percent of total billed charges,110% of Medicare,22906.67,68,,22906.67,percent of total billed charges,,586.68,,,586.68,Other,186% of Medicaid,26949.02,80,,26949.02,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,26949.02,80,,26949.02,percent of total billed charges,,7216,,,7216,Case Rate,,3578,,"100% primary, 0% secondary procedures",3578,Other,MagnaCare ASC Grouper,23580.4,70,,23580.4,percent of total billed charges,,282.08,,,282.08,Fee Schedule,,239.08,,,239.08,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,315.42,,,315.42,Other,New York Medicaid APG methodology,315.42,,,315.42,Other,100% New York Medicaid APG,315.42,,,315.42,Other,100% New York Medicaid APG,315.42,,,315.42,Other,100% New York Medicaid APG,709.7,,,709.7,Other,225% New York Medicaid APG,482.6,,,482.6,Other,153% New York Medicaid APG,709.7,,,709.7,Other,225% New York Medicaid APG,441.59,,,441.59,Other,140% New York Medicaid APG,709.7,,,709.7,Other,225% New York Medicaid APG,820.1,,,820.1,Other,260% New York Medicaid APG,1021.97,,,1021.97,Other,324% New York Medicaid APG,678.16,,,678.16,Other,215% New York Medicaid APG,678.16,,,678.16,Other,215% New York Medicaid APG,394.28,,,394.28,Other,125% New York Medicaid APG,239.08,26949.02,
Replace picvad cath,36585,CPT,,,,,,,,both,,,67044.74,49613.11,74,,49613.11,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30170.13,45,,30170.13,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33187.15,49.5,,33187.15,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,586.68,,,586.68,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,46931.32,70,,46931.32,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,315.42,,,315.42,Other,New York Medicaid APG methodology,315.42,,,315.42,Other,100% New York Medicaid APG,315.42,,,315.42,Other,100% New York Medicaid APG,315.42,,,315.42,Other,100% New York Medicaid APG,709.7,,,709.7,Other,225% New York Medicaid APG,482.6,,,482.6,Other,153% New York Medicaid APG,709.7,,,709.7,Other,225% New York Medicaid APG,441.59,,,441.59,Other,140% New York Medicaid APG,709.7,,,709.7,Other,225% New York Medicaid APG,820.1,,,820.1,Other,260% New York Medicaid APG,1021.97,,,1021.97,Other,324% New York Medicaid APG,678.16,,,678.16,Other,215% New York Medicaid APG,678.16,,,678.16,Other,215% New York Medicaid APG,394.28,,,394.28,Other,125% New York Medicaid APG,315.42,49613.11,
Removal tunneled cv cath,36589,CPT,,,,,,,,both,,,35837.87,26520.02,74,,26520.02,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,16127.04,45,,16127.04,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,17739.75,49.5,,17739.75,percent of total billed charges,110% of Medicare,24369.75,68,,24369.75,percent of total billed charges,,1556.72,,,1556.72,Other,186% of Medicaid,28670.3,80,,28670.3,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,28670.3,80,,28670.3,percent of total billed charges,,7216,,,7216,Case Rate,,3578,,"100% primary, 0% secondary procedures",3578,Other,MagnaCare ASC Grouper,25086.51,70,,25086.51,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,836.95,,,836.95,Other,New York Medicaid APG methodology,836.95,,,836.95,Other,100% New York Medicaid APG,836.95,,,836.95,Other,100% New York Medicaid APG,836.95,,,836.95,Other,100% New York Medicaid APG,1883.13,,,1883.13,Other,225% New York Medicaid APG,1280.53,,,1280.53,Other,153% New York Medicaid APG,1883.13,,,1883.13,Other,225% New York Medicaid APG,1171.73,,,1171.73,Other,140% New York Medicaid APG,1883.13,,,1883.13,Other,225% New York Medicaid APG,2176.07,,,2176.07,Other,260% New York Medicaid APG,2711.71,,,2711.71,Other,324% New York Medicaid APG,1799.44,,,1799.44,Other,215% New York Medicaid APG,1799.44,,,1799.44,Other,215% New York Medicaid APG,1046.19,,,1046.19,Other,125% New York Medicaid APG,836.95,28670.3,
Removal tunneled cv cath,36590,CPT,,,,,,,,both,,,26044.81,19273.16,74,,19273.16,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,11720.16,45,,11720.16,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,12892.18,49.5,,12892.18,percent of total billed charges,110% of Medicare,17710.47,68,,17710.47,percent of total billed charges,,1556.72,,,1556.72,Other,186% of Medicaid,20835.85,80,,20835.85,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,20835.85,80,,20835.85,percent of total billed charges,,7216,,,7216,Case Rate,,3578,,"100% primary, 0% secondary procedures",3578,Other,MagnaCare ASC Grouper,18231.37,70,,18231.37,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,836.95,,,836.95,Other,New York Medicaid APG methodology,836.95,,,836.95,Other,100% New York Medicaid APG,836.95,,,836.95,Other,100% New York Medicaid APG,836.95,,,836.95,Other,100% New York Medicaid APG,1883.13,,,1883.13,Other,225% New York Medicaid APG,1280.53,,,1280.53,Other,153% New York Medicaid APG,1883.13,,,1883.13,Other,225% New York Medicaid APG,1171.73,,,1171.73,Other,140% New York Medicaid APG,1883.13,,,1883.13,Other,225% New York Medicaid APG,2176.07,,,2176.07,Other,260% New York Medicaid APG,2711.71,,,2711.71,Other,324% New York Medicaid APG,1799.44,,,1799.44,Other,215% New York Medicaid APG,1799.44,,,1799.44,Other,215% New York Medicaid APG,1046.19,,,1046.19,Other,125% New York Medicaid APG,836.95,20835.85,
Draw blood off venous device,36591,CPT,,,,,,,,both,,,2686.86,1988.28,74,,1988.28,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,1209.09,45,,1209.09,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,155.73,,,155.73,Fee Schedule,,140.07,,,140.07,Fee Schedule,,132.38,,,132.38,Fee Schedule,,1330,49.5,,1330,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,254.86,,,254.86,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,1880.8,70,,1880.8,percent of total billed charges,,131.2,,,131.2,Fee Schedule,,111.2,,,111.2,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,137.02,,,137.02,Other,New York Medicaid APG methodology,137.02,,,137.02,Other,100% New York Medicaid APG,137.02,,,137.02,Other,100% New York Medicaid APG,137.02,,,137.02,Other,100% New York Medicaid APG,308.3,,,308.3,Other,225% New York Medicaid APG,209.65,,,209.65,Other,153% New York Medicaid APG,308.3,,,308.3,Other,225% New York Medicaid APG,191.83,,,191.83,Other,140% New York Medicaid APG,308.3,,,308.3,Other,225% New York Medicaid APG,356.26,,,356.26,Other,260% New York Medicaid APG,443.96,,,443.96,Other,324% New York Medicaid APG,294.6,,,294.6,Other,215% New York Medicaid APG,294.6,,,294.6,Other,215% New York Medicaid APG,171.28,,,171.28,Other,125% New York Medicaid APG,111.2,9473,
Collect blood from picc,36592,CPT,,,,,,,,both,,,2686.86,1988.28,74,,1988.28,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,1209.09,45,,1209.09,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,174.02,,,174.02,Fee Schedule,,156.51,,,156.51,Fee Schedule,,147.93,,,147.93,Fee Schedule,,1330,49.5,,1330,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,254.86,,,254.86,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,1880.8,70,,1880.8,percent of total billed charges,,142.68,,,142.68,Fee Schedule,,120.93,,,120.93,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,137.02,,,137.02,Other,New York Medicaid APG methodology,137.02,,,137.02,Other,100% New York Medicaid APG,137.02,,,137.02,Other,100% New York Medicaid APG,137.02,,,137.02,Other,100% New York Medicaid APG,308.3,,,308.3,Other,225% New York Medicaid APG,209.65,,,209.65,Other,153% New York Medicaid APG,308.3,,,308.3,Other,225% New York Medicaid APG,191.83,,,191.83,Other,140% New York Medicaid APG,308.3,,,308.3,Other,225% New York Medicaid APG,356.26,,,356.26,Other,260% New York Medicaid APG,443.96,,,443.96,Other,324% New York Medicaid APG,294.6,,,294.6,Other,215% New York Medicaid APG,294.6,,,294.6,Other,215% New York Medicaid APG,171.28,,,171.28,Other,125% New York Medicaid APG,120.93,9473,
Declot vascular device,36593,CPT,,,,,,,,both,,,41600.5,30784.37,74,,30784.37,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,18720.23,45,,18720.23,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,20592.25,49.5,,20592.25,percent of total billed charges,110% of Medicare,28288.34,68,,28288.34,percent of total billed charges,,644.22,,,644.22,Other,186% of Medicaid,33280.4,80,,33280.4,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,33280.4,80,,33280.4,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,29120.35,70,,29120.35,percent of total billed charges,,162.36,,,162.36,Fee Schedule,,137.61,,,137.61,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,346.35,,,346.35,Other,New York Medicaid APG methodology,346.35,,,346.35,Other,100% New York Medicaid APG,346.35,,,346.35,Other,100% New York Medicaid APG,346.35,,,346.35,Other,100% New York Medicaid APG,779.3,,,779.3,Other,225% New York Medicaid APG,529.92,,,529.92,Other,153% New York Medicaid APG,779.3,,,779.3,Other,225% New York Medicaid APG,484.9,,,484.9,Other,140% New York Medicaid APG,779.3,,,779.3,Other,225% New York Medicaid APG,900.52,,,900.52,Other,260% New York Medicaid APG,1122.19,,,1122.19,Other,324% New York Medicaid APG,744.66,,,744.66,Other,215% New York Medicaid APG,744.66,,,744.66,Other,215% New York Medicaid APG,432.94,,,432.94,Other,125% New York Medicaid APG,137.61,33280.4,
Mech remov tunneled cv cath,36595,CPT,,,,,,,,both,,,67044.74,49613.11,74,,49613.11,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30170.13,45,,30170.13,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33187.15,49.5,,33187.15,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,1556.72,,,1556.72,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,46931.32,70,,46931.32,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,836.95,,,836.95,Other,New York Medicaid APG methodology,836.95,,,836.95,Other,100% New York Medicaid APG,836.95,,,836.95,Other,100% New York Medicaid APG,836.95,,,836.95,Other,100% New York Medicaid APG,1883.13,,,1883.13,Other,225% New York Medicaid APG,1280.53,,,1280.53,Other,153% New York Medicaid APG,1883.13,,,1883.13,Other,225% New York Medicaid APG,1171.73,,,1171.73,Other,140% New York Medicaid APG,1883.13,,,1883.13,Other,225% New York Medicaid APG,2176.07,,,2176.07,Other,260% New York Medicaid APG,2711.71,,,2711.71,Other,324% New York Medicaid APG,1799.44,,,1799.44,Other,215% New York Medicaid APG,1799.44,,,1799.44,Other,215% New York Medicaid APG,1046.19,,,1046.19,Other,125% New York Medicaid APG,836.95,49613.11,
Mech remov tunneled cv cath,36596,CPT,,,,,,,,both,,,33686.28,24927.85,74,,24927.85,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15158.83,45,,15158.83,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,16674.71,49.5,,16674.71,percent of total billed charges,110% of Medicare,22906.67,68,,22906.67,percent of total billed charges,,1556.72,,,1556.72,Other,186% of Medicaid,26949.02,80,,26949.02,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,26949.02,80,,26949.02,percent of total billed charges,,7216,,,7216,Case Rate,,3578,,"100% primary, 0% secondary procedures",3578,Other,MagnaCare ASC Grouper,23580.4,70,,23580.4,percent of total billed charges,,213.2,,,213.2,Fee Schedule,,180.7,,,180.7,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,836.95,,,836.95,Other,New York Medicaid APG methodology,836.95,,,836.95,Other,100% New York Medicaid APG,836.95,,,836.95,Other,100% New York Medicaid APG,836.95,,,836.95,Other,100% New York Medicaid APG,1883.13,,,1883.13,Other,225% New York Medicaid APG,1280.53,,,1280.53,Other,153% New York Medicaid APG,1883.13,,,1883.13,Other,225% New York Medicaid APG,1171.73,,,1171.73,Other,140% New York Medicaid APG,1883.13,,,1883.13,Other,225% New York Medicaid APG,2176.07,,,2176.07,Other,260% New York Medicaid APG,2711.71,,,2711.71,Other,324% New York Medicaid APG,1799.44,,,1799.44,Other,215% New York Medicaid APG,1799.44,,,1799.44,Other,215% New York Medicaid APG,1046.19,,,1046.19,Other,125% New York Medicaid APG,180.7,26949.02,
Reposition venous catheter,36597,CPT,,,,,,,,both,,,33686.28,24927.85,74,,24927.85,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15158.83,45,,15158.83,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,16674.71,49.5,,16674.71,percent of total billed charges,110% of Medicare,22906.67,68,,22906.67,percent of total billed charges,,1556.72,,,1556.72,Other,186% of Medicaid,26949.02,80,,26949.02,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,26949.02,80,,26949.02,percent of total billed charges,,7216,,,7216,Case Rate,,3578,,"100% primary, 0% secondary procedures",3578,Other,MagnaCare ASC Grouper,23580.4,70,,23580.4,percent of total billed charges,,293.56,,,293.56,Fee Schedule,,248.81,,,248.81,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,836.95,,,836.95,Other,New York Medicaid APG methodology,836.95,,,836.95,Other,100% New York Medicaid APG,836.95,,,836.95,Other,100% New York Medicaid APG,836.95,,,836.95,Other,100% New York Medicaid APG,1883.13,,,1883.13,Other,225% New York Medicaid APG,1280.53,,,1280.53,Other,153% New York Medicaid APG,1883.13,,,1883.13,Other,225% New York Medicaid APG,1171.73,,,1171.73,Other,140% New York Medicaid APG,1883.13,,,1883.13,Other,225% New York Medicaid APG,2176.07,,,2176.07,Other,260% New York Medicaid APG,2711.71,,,2711.71,Other,324% New York Medicaid APG,1799.44,,,1799.44,Other,215% New York Medicaid APG,1799.44,,,1799.44,Other,215% New York Medicaid APG,1046.19,,,1046.19,Other,125% New York Medicaid APG,248.81,26949.02,
Inj w/fluor eval cv device,36598,CPT,,,,,,,,both,,,13047.71,9655.31,74,,9655.31,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,5871.47,45,,5871.47,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,6458.62,49.5,,6458.62,percent of total billed charges,110% of Medicare,8872.44,68,,8872.44,percent of total billed charges,,966.93,,,966.93,Other,186% of Medicaid,10438.17,80,,10438.17,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,10438.17,80,,10438.17,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,9133.4,70,,9133.4,percent of total billed charges,,172.2,,,172.2,Fee Schedule,,145.95,,,145.95,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,519.86,,,519.86,Other,New York Medicaid APG methodology,519.86,,,519.86,Other,100% New York Medicaid APG,519.86,,,519.86,Other,100% New York Medicaid APG,519.86,,,519.86,Other,100% New York Medicaid APG,1169.68,,,1169.68,Other,225% New York Medicaid APG,795.38,,,795.38,Other,153% New York Medicaid APG,1169.68,,,1169.68,Other,225% New York Medicaid APG,727.8,,,727.8,Other,140% New York Medicaid APG,1169.68,,,1169.68,Other,225% New York Medicaid APG,1351.62,,,1351.62,Other,260% New York Medicaid APG,1684.33,,,1684.33,Other,324% New York Medicaid APG,1117.69,,,1117.69,Other,215% New York Medicaid APG,1117.69,,,1117.69,Other,215% New York Medicaid APG,649.82,,,649.82,Other,125% New York Medicaid APG,145.95,10438.17,
Withdrawal of arterial blood,36600,CPT,,,,,,,,both,,,2686.86,1988.28,74,,1988.28,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,1209.09,45,,1209.09,percent of total billed charges,Medicare Ratio of cost to charges,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Aetna ASC Grouper,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,1330,49.5,,1330,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,254.86,,,254.86,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,1880.8,70,,1880.8,percent of total billed charges,,72.16,,,72.16,Fee Schedule,,61.16,,,61.16,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,137.02,,,137.02,Other,New York Medicaid APG methodology,137.02,,,137.02,Other,100% New York Medicaid APG,137.02,,,137.02,Other,100% New York Medicaid APG,137.02,,,137.02,Other,100% New York Medicaid APG,308.3,,,308.3,Other,225% New York Medicaid APG,209.65,,,209.65,Other,153% New York Medicaid APG,308.3,,,308.3,Other,225% New York Medicaid APG,191.83,,,191.83,Other,140% New York Medicaid APG,308.3,,,308.3,Other,225% New York Medicaid APG,356.26,,,356.26,Other,260% New York Medicaid APG,443.96,,,443.96,Other,324% New York Medicaid APG,294.6,,,294.6,Other,215% New York Medicaid APG,294.6,,,294.6,Other,215% New York Medicaid APG,171.28,,,171.28,Other,125% New York Medicaid APG,0.01,9473,
Insertion catheter artery,36620,CPT,,,,,,,,both,,,32432.1,23999.75,74,,23999.75,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,14594.45,45,,14594.45,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,16053.89,49.5,,16053.89,percent of total billed charges,110% of Medicare,22053.83,68,,22053.83,percent of total billed charges,,516.02,,,516.02,Other,186% of Medicaid,25945.68,80,,25945.68,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,25945.68,80,,25945.68,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,22702.47,70,,22702.47,percent of total billed charges,,214.84,,,214.84,Fee Schedule,,182.09,,,182.09,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,277.43,,,277.43,Other,New York Medicaid APG methodology,277.43,,,277.43,Other,100% New York Medicaid APG,277.43,,,277.43,Other,100% New York Medicaid APG,277.43,,,277.43,Other,100% New York Medicaid APG,624.21,,,624.21,Other,225% New York Medicaid APG,424.47,,,424.47,Other,153% New York Medicaid APG,624.21,,,624.21,Other,225% New York Medicaid APG,388.4,,,388.4,Other,140% New York Medicaid APG,624.21,,,624.21,Other,225% New York Medicaid APG,721.31,,,721.31,Other,260% New York Medicaid APG,898.87,,,898.87,Other,324% New York Medicaid APG,596.47,,,596.47,Other,215% New York Medicaid APG,596.47,,,596.47,Other,215% New York Medicaid APG,346.79,,,346.79,Other,125% New York Medicaid APG,182.09,25945.68,
Insertion catheter artery,36625,CPT,,,,,,,,both,,,32432.1,23999.75,74,,23999.75,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,14594.45,45,,14594.45,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,16053.89,49.5,,16053.89,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,516.02,,,516.02,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,22702.47,70,,22702.47,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,277.43,,,277.43,Other,New York Medicaid APG methodology,277.43,,,277.43,Other,100% New York Medicaid APG,277.43,,,277.43,Other,100% New York Medicaid APG,277.43,,,277.43,Other,100% New York Medicaid APG,624.21,,,624.21,Other,225% New York Medicaid APG,424.47,,,424.47,Other,153% New York Medicaid APG,624.21,,,624.21,Other,225% New York Medicaid APG,388.4,,,388.4,Other,140% New York Medicaid APG,624.21,,,624.21,Other,225% New York Medicaid APG,721.31,,,721.31,Other,260% New York Medicaid APG,898.87,,,898.87,Other,324% New York Medicaid APG,596.47,,,596.47,Other,215% New York Medicaid APG,596.47,,,596.47,Other,215% New York Medicaid APG,346.79,,,346.79,Other,125% New York Medicaid APG,277.43,23999.75,
Insertion catheter artery,36640,CPT,,,,,,,,both,,,67044.74,49613.11,74,,49613.11,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30170.13,45,,30170.13,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33187.15,49.5,,33187.15,percent of total billed charges,110% of Medicare,45590.42,68,,45590.42,percent of total billed charges,,1729.46,,,1729.46,Other,186% of Medicaid,53635.79,80,,53635.79,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,53635.79,80,,53635.79,percent of total billed charges,,7216,,,7216,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,46931.32,70,,46931.32,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,929.82,,,929.82,Other,New York Medicaid APG methodology,929.82,,,929.82,Other,100% New York Medicaid APG,929.82,,,929.82,Other,100% New York Medicaid APG,929.82,,,929.82,Other,100% New York Medicaid APG,2092.09,,,2092.09,Other,225% New York Medicaid APG,1422.62,,,1422.62,Other,153% New York Medicaid APG,2092.09,,,2092.09,Other,225% New York Medicaid APG,1301.75,,,1301.75,Other,140% New York Medicaid APG,2092.09,,,2092.09,Other,225% New York Medicaid APG,2417.53,,,2417.53,Other,260% New York Medicaid APG,3012.61,,,3012.61,Other,324% New York Medicaid APG,1999.11,,,1999.11,Other,215% New York Medicaid APG,1999.11,,,1999.11,Other,215% New York Medicaid APG,1162.27,,,1162.27,Other,125% New York Medicaid APG,929.82,53635.79,
Insert needle bone cavity,36680,CPT,,,,,,,,both,,,8380.68,6201.7,74,,6201.7,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,3771.31,45,,3771.31,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,4148.44,49.5,,4148.44,percent of total billed charges,110% of Medicare,5698.86,68,,5698.86,percent of total billed charges,,685.67,,,685.67,Other,186% of Medicaid,6704.54,80,,6704.54,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,6704.54,80,,6704.54,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,5866.48,70,,5866.48,percent of total billed charges,,288.64,,,288.64,Fee Schedule,,244.64,,,244.64,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,368.64,,,368.64,Other,New York Medicaid APG methodology,368.64,,,368.64,Other,100% New York Medicaid APG,368.64,,,368.64,Other,100% New York Medicaid APG,368.64,,,368.64,Other,100% New York Medicaid APG,829.44,,,829.44,Other,225% New York Medicaid APG,564.02,,,564.02,Other,153% New York Medicaid APG,829.44,,,829.44,Other,225% New York Medicaid APG,516.1,,,516.1,Other,140% New York Medicaid APG,829.44,,,829.44,Other,225% New York Medicaid APG,958.46,,,958.46,Other,260% New York Medicaid APG,1194.39,,,1194.39,Other,324% New York Medicaid APG,792.58,,,792.58,Other,215% New York Medicaid APG,792.58,,,792.58,Other,215% New York Medicaid APG,460.8,,,460.8,Other,125% New York Medicaid APG,244.64,7216,
Insertion of cannula,36800,CPT,,,,,,,,both,,,115587.67,85534.88,74,,85534.88,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,52014.45,45,,52014.45,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,57215.9,49.5,,57215.9,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2490.15,,,2490.15,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,80911.37,70,,80911.37,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,1338.79,,,1338.79,Other,New York Medicaid APG methodology,1338.79,,,1338.79,Other,100% New York Medicaid APG,1338.79,,,1338.79,Other,100% New York Medicaid APG,1338.79,,,1338.79,Other,100% New York Medicaid APG,3012.28,,,3012.28,Other,225% New York Medicaid APG,2048.35,,,2048.35,Other,153% New York Medicaid APG,3012.28,,,3012.28,Other,225% New York Medicaid APG,1874.31,,,1874.31,Other,140% New York Medicaid APG,3012.28,,,3012.28,Other,225% New York Medicaid APG,3480.85,,,3480.85,Other,260% New York Medicaid APG,4337.68,,,4337.68,Other,324% New York Medicaid APG,2878.4,,,2878.4,Other,215% New York Medicaid APG,2878.4,,,2878.4,Other,215% New York Medicaid APG,1673.49,,,1673.49,Other,125% New York Medicaid APG,1338.79,85534.88,
Insertion of cannula,36810,CPT,,,,,,,,both,,,67044.74,49613.11,74,,49613.11,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30170.13,45,,30170.13,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33187.15,49.5,,33187.15,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2490.15,,,2490.15,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,46931.32,70,,46931.32,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1338.79,,,1338.79,Other,New York Medicaid APG methodology,1338.79,,,1338.79,Other,100% New York Medicaid APG,1338.79,,,1338.79,Other,100% New York Medicaid APG,1338.79,,,1338.79,Other,100% New York Medicaid APG,3012.28,,,3012.28,Other,225% New York Medicaid APG,2048.35,,,2048.35,Other,153% New York Medicaid APG,3012.28,,,3012.28,Other,225% New York Medicaid APG,1874.31,,,1874.31,Other,140% New York Medicaid APG,3012.28,,,3012.28,Other,225% New York Medicaid APG,3480.85,,,3480.85,Other,260% New York Medicaid APG,4337.68,,,4337.68,Other,324% New York Medicaid APG,2878.4,,,2878.4,Other,215% New York Medicaid APG,2878.4,,,2878.4,Other,215% New York Medicaid APG,1673.49,,,1673.49,Other,125% New York Medicaid APG,1338.79,49613.11,
Insertion of cannula,36815,CPT,,,,,,,,both,,,115587.67,85534.88,74,,85534.88,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,52014.45,45,,52014.45,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,57215.9,49.5,,57215.9,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2490.15,,,2490.15,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,80911.37,70,,80911.37,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,1338.79,,,1338.79,Other,New York Medicaid APG methodology,1338.79,,,1338.79,Other,100% New York Medicaid APG,1338.79,,,1338.79,Other,100% New York Medicaid APG,1338.79,,,1338.79,Other,100% New York Medicaid APG,3012.28,,,3012.28,Other,225% New York Medicaid APG,2048.35,,,2048.35,Other,153% New York Medicaid APG,3012.28,,,3012.28,Other,225% New York Medicaid APG,1874.31,,,1874.31,Other,140% New York Medicaid APG,3012.28,,,3012.28,Other,225% New York Medicaid APG,3480.85,,,3480.85,Other,260% New York Medicaid APG,4337.68,,,4337.68,Other,324% New York Medicaid APG,2878.4,,,2878.4,Other,215% New York Medicaid APG,2878.4,,,2878.4,Other,215% New York Medicaid APG,1673.49,,,1673.49,Other,125% New York Medicaid APG,1338.79,85534.88,
Av fuse uppr arm cephalic,36818,CPT,,,,,,,,both,,,46108.27,34120.12,74,,34120.12,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,20748.72,45,,20748.72,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,22823.59,49.5,,22823.59,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,4389.52,,,4389.52,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,32275.79,70,,32275.79,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,2359.96,,,2359.96,Other,New York Medicaid APG methodology,2359.96,,,2359.96,Other,100% New York Medicaid APG,2359.96,,,2359.96,Other,100% New York Medicaid APG,2359.96,,,2359.96,Other,100% New York Medicaid APG,5309.9,,,5309.9,Other,225% New York Medicaid APG,3610.73,,,3610.73,Other,153% New York Medicaid APG,5309.9,,,5309.9,Other,225% New York Medicaid APG,3303.94,,,3303.94,Other,140% New York Medicaid APG,5309.9,,,5309.9,Other,225% New York Medicaid APG,6135.89,,,6135.89,Other,260% New York Medicaid APG,7646.26,,,7646.26,Other,324% New York Medicaid APG,5073.9,,,5073.9,Other,215% New York Medicaid APG,5073.9,,,5073.9,Other,215% New York Medicaid APG,2949.94,,,2949.94,Other,125% New York Medicaid APG,2359.96,34120.12,
Av fuse uppr arm basilic,36819,CPT,,,,,,,,both,,,39936.33,29552.88,74,,29552.88,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,17971.35,45,,17971.35,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,19768.48,49.5,,19768.48,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,4389.52,,,4389.52,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,27955.43,70,,27955.43,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,2359.96,,,2359.96,Other,New York Medicaid APG methodology,2359.96,,,2359.96,Other,100% New York Medicaid APG,2359.96,,,2359.96,Other,100% New York Medicaid APG,2359.96,,,2359.96,Other,100% New York Medicaid APG,5309.9,,,5309.9,Other,225% New York Medicaid APG,3610.73,,,3610.73,Other,153% New York Medicaid APG,5309.9,,,5309.9,Other,225% New York Medicaid APG,3303.94,,,3303.94,Other,140% New York Medicaid APG,5309.9,,,5309.9,Other,225% New York Medicaid APG,6135.89,,,6135.89,Other,260% New York Medicaid APG,7646.26,,,7646.26,Other,324% New York Medicaid APG,5073.9,,,5073.9,Other,215% New York Medicaid APG,5073.9,,,5073.9,Other,215% New York Medicaid APG,2949.94,,,2949.94,Other,125% New York Medicaid APG,2359.96,29552.88,
Av fusion/forearm vein,36820,CPT,,,,,,,,both,,,115587.67,85534.88,74,,85534.88,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,52014.45,45,,52014.45,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,57215.9,49.5,,57215.9,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,4389.52,,,4389.52,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,80911.37,70,,80911.37,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,2359.96,,,2359.96,Other,New York Medicaid APG methodology,2359.96,,,2359.96,Other,100% New York Medicaid APG,2359.96,,,2359.96,Other,100% New York Medicaid APG,2359.96,,,2359.96,Other,100% New York Medicaid APG,5309.9,,,5309.9,Other,225% New York Medicaid APG,3610.73,,,3610.73,Other,153% New York Medicaid APG,5309.9,,,5309.9,Other,225% New York Medicaid APG,3303.94,,,3303.94,Other,140% New York Medicaid APG,5309.9,,,5309.9,Other,225% New York Medicaid APG,6135.89,,,6135.89,Other,260% New York Medicaid APG,7646.26,,,7646.26,Other,324% New York Medicaid APG,5073.9,,,5073.9,Other,215% New York Medicaid APG,5073.9,,,5073.9,Other,215% New York Medicaid APG,2949.94,,,2949.94,Other,125% New York Medicaid APG,2359.96,85534.88,
Av fusion direct any site,36821,CPT,,,,,,,,both,,,40013.59,29610.06,74,,29610.06,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,18006.12,45,,18006.12,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,19806.73,49.5,,19806.73,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,4389.52,,,4389.52,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,28009.51,70,,28009.51,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,2359.96,,,2359.96,Other,New York Medicaid APG methodology,2359.96,,,2359.96,Other,100% New York Medicaid APG,2359.96,,,2359.96,Other,100% New York Medicaid APG,2359.96,,,2359.96,Other,100% New York Medicaid APG,5309.9,,,5309.9,Other,225% New York Medicaid APG,3610.73,,,3610.73,Other,153% New York Medicaid APG,5309.9,,,5309.9,Other,225% New York Medicaid APG,3303.94,,,3303.94,Other,140% New York Medicaid APG,5309.9,,,5309.9,Other,225% New York Medicaid APG,6135.89,,,6135.89,Other,260% New York Medicaid APG,7646.26,,,7646.26,Other,324% New York Medicaid APG,5073.9,,,5073.9,Other,215% New York Medicaid APG,5073.9,,,5073.9,Other,215% New York Medicaid APG,2949.94,,,2949.94,Other,125% New York Medicaid APG,2359.96,29610.06,
Artery-vein autograft,36825,CPT,,,,,,,,both,,,115587.67,85534.88,74,,85534.88,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,52014.45,45,,52014.45,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,57215.9,49.5,,57215.9,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,4389.52,,,4389.52,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,80911.37,70,,80911.37,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,2359.96,,,2359.96,Other,New York Medicaid APG methodology,2359.96,,,2359.96,Other,100% New York Medicaid APG,2359.96,,,2359.96,Other,100% New York Medicaid APG,2359.96,,,2359.96,Other,100% New York Medicaid APG,5309.9,,,5309.9,Other,225% New York Medicaid APG,3610.73,,,3610.73,Other,153% New York Medicaid APG,5309.9,,,5309.9,Other,225% New York Medicaid APG,3303.94,,,3303.94,Other,140% New York Medicaid APG,5309.9,,,5309.9,Other,225% New York Medicaid APG,6135.89,,,6135.89,Other,260% New York Medicaid APG,7646.26,,,7646.26,Other,324% New York Medicaid APG,5073.9,,,5073.9,Other,215% New York Medicaid APG,5073.9,,,5073.9,Other,215% New York Medicaid APG,2949.94,,,2949.94,Other,125% New York Medicaid APG,2359.96,85534.88,
Artery-vein nonautograft,36830,CPT,,,,,,,,both,,,47662.49,35270.24,74,,35270.24,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,21448.12,45,,21448.12,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,23592.93,49.5,,23592.93,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,4389.52,,,4389.52,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,33363.74,70,,33363.74,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,2359.96,,,2359.96,Other,New York Medicaid APG methodology,2359.96,,,2359.96,Other,100% New York Medicaid APG,2359.96,,,2359.96,Other,100% New York Medicaid APG,2359.96,,,2359.96,Other,100% New York Medicaid APG,5309.9,,,5309.9,Other,225% New York Medicaid APG,3610.73,,,3610.73,Other,153% New York Medicaid APG,5309.9,,,5309.9,Other,225% New York Medicaid APG,3303.94,,,3303.94,Other,140% New York Medicaid APG,5309.9,,,5309.9,Other,225% New York Medicaid APG,6135.89,,,6135.89,Other,260% New York Medicaid APG,7646.26,,,7646.26,Other,324% New York Medicaid APG,5073.9,,,5073.9,Other,215% New York Medicaid APG,5073.9,,,5073.9,Other,215% New York Medicaid APG,2949.94,,,2949.94,Other,125% New York Medicaid APG,2359.96,35270.24,
Open thrombect av fistula,36831,CPT,,,,,,,,both,,,115587.67,85534.88,74,,85534.88,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,52014.45,45,,52014.45,percent of total billed charges,Medicare Ratio of cost to charges,5954,,"100% primary, 50% supplemental procedure",5954,Other,Aetna ASC Grouper,5359,,"100% primary, 50% supplemental procedure",5359,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,57215.9,49.5,,57215.9,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,4389.52,,,4389.52,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,80911.37,70,,80911.37,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,2359.96,,,2359.96,Other,New York Medicaid APG methodology,2359.96,,,2359.96,Other,100% New York Medicaid APG,2359.96,,,2359.96,Other,100% New York Medicaid APG,2359.96,,,2359.96,Other,100% New York Medicaid APG,5309.9,,,5309.9,Other,225% New York Medicaid APG,3610.73,,,3610.73,Other,153% New York Medicaid APG,5309.9,,,5309.9,Other,225% New York Medicaid APG,3303.94,,,3303.94,Other,140% New York Medicaid APG,5309.9,,,5309.9,Other,225% New York Medicaid APG,6135.89,,,6135.89,Other,260% New York Medicaid APG,7646.26,,,7646.26,Other,324% New York Medicaid APG,5073.9,,,5073.9,Other,215% New York Medicaid APG,5073.9,,,5073.9,Other,215% New York Medicaid APG,2949.94,,,2949.94,Other,125% New York Medicaid APG,2359.96,85534.88,
Av fistula revision open,36832,CPT,,,,,,,,both,,,46489.03,34401.88,74,,34401.88,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,20920.06,45,,20920.06,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,23012.07,49.5,,23012.07,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,4389.52,,,4389.52,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,32542.32,70,,32542.32,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,2359.96,,,2359.96,Other,New York Medicaid APG methodology,2359.96,,,2359.96,Other,100% New York Medicaid APG,2359.96,,,2359.96,Other,100% New York Medicaid APG,2359.96,,,2359.96,Other,100% New York Medicaid APG,5309.9,,,5309.9,Other,225% New York Medicaid APG,3610.73,,,3610.73,Other,153% New York Medicaid APG,5309.9,,,5309.9,Other,225% New York Medicaid APG,3303.94,,,3303.94,Other,140% New York Medicaid APG,5309.9,,,5309.9,Other,225% New York Medicaid APG,6135.89,,,6135.89,Other,260% New York Medicaid APG,7646.26,,,7646.26,Other,324% New York Medicaid APG,5073.9,,,5073.9,Other,215% New York Medicaid APG,5073.9,,,5073.9,Other,215% New York Medicaid APG,2949.94,,,2949.94,Other,125% New York Medicaid APG,2359.96,34401.88,
Av fistula revision,36833,CPT,,,,,,,,both,,,48927.34,36206.23,74,,36206.23,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,22017.3,45,,22017.3,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,24219.03,49.5,,24219.03,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,4389.52,,,4389.52,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,34249.14,70,,34249.14,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,2359.96,,,2359.96,Other,New York Medicaid APG methodology,2359.96,,,2359.96,Other,100% New York Medicaid APG,2359.96,,,2359.96,Other,100% New York Medicaid APG,2359.96,,,2359.96,Other,100% New York Medicaid APG,5309.9,,,5309.9,Other,225% New York Medicaid APG,3610.73,,,3610.73,Other,153% New York Medicaid APG,5309.9,,,5309.9,Other,225% New York Medicaid APG,3303.94,,,3303.94,Other,140% New York Medicaid APG,5309.9,,,5309.9,Other,225% New York Medicaid APG,6135.89,,,6135.89,Other,260% New York Medicaid APG,7646.26,,,7646.26,Other,324% New York Medicaid APG,5073.9,,,5073.9,Other,215% New York Medicaid APG,5073.9,,,5073.9,Other,215% New York Medicaid APG,2949.94,,,2949.94,Other,125% New York Medicaid APG,2359.96,36206.23,
Artery to vein shunt,36835,CPT,,,,,,,,both,,,67044.74,49613.11,74,,49613.11,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30170.13,45,,30170.13,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33187.15,49.5,,33187.15,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,4389.52,,,4389.52,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,46931.32,70,,46931.32,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,2359.96,,,2359.96,Other,New York Medicaid APG methodology,2359.96,,,2359.96,Other,100% New York Medicaid APG,2359.96,,,2359.96,Other,100% New York Medicaid APG,2359.96,,,2359.96,Other,100% New York Medicaid APG,5309.9,,,5309.9,Other,225% New York Medicaid APG,3610.73,,,3610.73,Other,153% New York Medicaid APG,5309.9,,,5309.9,Other,225% New York Medicaid APG,3303.94,,,3303.94,Other,140% New York Medicaid APG,5309.9,,,5309.9,Other,225% New York Medicaid APG,6135.89,,,6135.89,Other,260% New York Medicaid APG,7646.26,,,7646.26,Other,324% New York Medicaid APG,5073.9,,,5073.9,Other,215% New York Medicaid APG,5073.9,,,5073.9,Other,215% New York Medicaid APG,2949.94,,,2949.94,Other,125% New York Medicaid APG,2359.96,49613.11,
Dist revas ligation hemo,36838,CPT,,,,,,,,both,,,71342.33,52793.32,74,,52793.32,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,32104.05,45,,32104.05,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,35314.45,49.5,,35314.45,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,4389.52,,,4389.52,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,49939.63,70,,49939.63,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,2359.96,,,2359.96,Other,New York Medicaid APG methodology,2359.96,,,2359.96,Other,100% New York Medicaid APG,2359.96,,,2359.96,Other,100% New York Medicaid APG,2359.96,,,2359.96,Other,100% New York Medicaid APG,5309.9,,,5309.9,Other,225% New York Medicaid APG,3610.73,,,3610.73,Other,153% New York Medicaid APG,5309.9,,,5309.9,Other,225% New York Medicaid APG,3303.94,,,3303.94,Other,140% New York Medicaid APG,5309.9,,,5309.9,Other,225% New York Medicaid APG,6135.89,,,6135.89,Other,260% New York Medicaid APG,7646.26,,,7646.26,Other,324% New York Medicaid APG,5073.9,,,5073.9,Other,215% New York Medicaid APG,5073.9,,,5073.9,Other,215% New York Medicaid APG,2949.94,,,2949.94,Other,125% New York Medicaid APG,2359.96,52793.32,
External cannula declotting,36860,CPT,,,,,,,,both,,,33686.28,24927.85,74,,24927.85,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15158.83,45,,15158.83,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,16674.71,49.5,,16674.71,percent of total billed charges,110% of Medicare,22906.67,68,,22906.67,percent of total billed charges,,644.22,,,644.22,Other,186% of Medicaid,26949.02,80,,26949.02,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,26949.02,80,,26949.02,percent of total billed charges,,7216,,,7216,Case Rate,,3578,,"100% primary, 0% secondary procedures",3578,Other,MagnaCare ASC Grouper,23580.4,70,,23580.4,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,346.35,,,346.35,Other,New York Medicaid APG methodology,346.35,,,346.35,Other,100% New York Medicaid APG,346.35,,,346.35,Other,100% New York Medicaid APG,346.35,,,346.35,Other,100% New York Medicaid APG,779.3,,,779.3,Other,225% New York Medicaid APG,529.92,,,529.92,Other,153% New York Medicaid APG,779.3,,,779.3,Other,225% New York Medicaid APG,484.9,,,484.9,Other,140% New York Medicaid APG,779.3,,,779.3,Other,225% New York Medicaid APG,900.52,,,900.52,Other,260% New York Medicaid APG,1122.19,,,1122.19,Other,324% New York Medicaid APG,744.66,,,744.66,Other,215% New York Medicaid APG,744.66,,,744.66,Other,215% New York Medicaid APG,432.94,,,432.94,Other,125% New York Medicaid APG,346.35,26949.02,
Cannula declotting,36861,CPT,,,,,,,,both,,,115587.67,85534.88,74,,85534.88,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,52014.45,45,,52014.45,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,57215.9,49.5,,57215.9,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3853.44,,,3853.44,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,80911.37,70,,80911.37,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,2071.74,,,2071.74,Other,New York Medicaid APG methodology,2071.74,,,2071.74,Other,100% New York Medicaid APG,2071.74,,,2071.74,Other,100% New York Medicaid APG,2071.74,,,2071.74,Other,100% New York Medicaid APG,4661.42,,,4661.42,Other,225% New York Medicaid APG,3169.77,,,3169.77,Other,153% New York Medicaid APG,4661.42,,,4661.42,Other,225% New York Medicaid APG,2900.44,,,2900.44,Other,140% New York Medicaid APG,4661.42,,,4661.42,Other,225% New York Medicaid APG,5386.53,,,5386.53,Other,260% New York Medicaid APG,6712.45,,,6712.45,Other,324% New York Medicaid APG,4454.25,,,4454.25,Other,215% New York Medicaid APG,4454.25,,,4454.25,Other,215% New York Medicaid APG,2589.68,,,2589.68,Other,125% New York Medicaid APG,2071.74,85534.88,
Intro cath dialysis circuit,36901,CPT,,,,,,,,both,,,45783.33,33879.66,74,,33879.66,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,20602.5,45,,20602.5,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,22662.75,49.5,,22662.75,percent of total billed charges,110% of Medicare,31132.66,68,,31132.66,percent of total billed charges,,786.95,,,786.95,Other,186% of Medicaid,36626.66,80,,36626.66,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,36626.66,80,,36626.66,percent of total billed charges,,7216,,,7216,Case Rate,,3578,,"100% primary, 0% secondary procedures",3578,Other,MagnaCare ASC Grouper,32048.33,70,,32048.33,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,423.09,,,423.09,Other,New York Medicaid APG methodology,423.09,,,423.09,Other,100% New York Medicaid APG,423.09,,,423.09,Other,100% New York Medicaid APG,423.09,,,423.09,Other,100% New York Medicaid APG,951.96,,,951.96,Other,225% New York Medicaid APG,647.33,,,647.33,Other,153% New York Medicaid APG,951.96,,,951.96,Other,225% New York Medicaid APG,592.33,,,592.33,Other,140% New York Medicaid APG,951.96,,,951.96,Other,225% New York Medicaid APG,1100.04,,,1100.04,Other,260% New York Medicaid APG,1370.82,,,1370.82,Other,324% New York Medicaid APG,909.65,,,909.65,Other,215% New York Medicaid APG,909.65,,,909.65,Other,215% New York Medicaid APG,528.86,,,528.86,Other,125% New York Medicaid APG,423.09,36626.66,
Intro cath dialysis circuit,36902,CPT,,,,,,,,both,,,59916.11,44337.92,74,,44337.92,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,26962.25,45,,26962.25,percent of total billed charges,Medicare Ratio of cost to charges,5954,,"100% primary, 50% supplemental procedure",5954,Other,Aetna ASC Grouper,5359,,"100% primary, 50% supplemental procedure",5359,Other,Aetna ASC Grouper,7266,,"100% primary, 50% secondary, 25% supplemental procedure",7266,Other,Blue Cross ASC Grouper,6539,,"100% primary, 50% secondary, 25% supplemental procedure",6539,Other,Blue Cross ASC Grouper,6176,,"100% primary, 50% secondary, 25% supplemental procedure",6176,Other,Blue Cross ASC Grouper,29658.47,49.5,,29658.47,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3853.44,,,3853.44,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,41941.28,70,,41941.28,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,2071.74,,,2071.74,Other,New York Medicaid APG methodology,2071.74,,,2071.74,Other,100% New York Medicaid APG,2071.74,,,2071.74,Other,100% New York Medicaid APG,2071.74,,,2071.74,Other,100% New York Medicaid APG,4661.42,,,4661.42,Other,225% New York Medicaid APG,3169.77,,,3169.77,Other,153% New York Medicaid APG,4661.42,,,4661.42,Other,225% New York Medicaid APG,2900.44,,,2900.44,Other,140% New York Medicaid APG,4661.42,,,4661.42,Other,225% New York Medicaid APG,5386.53,,,5386.53,Other,260% New York Medicaid APG,6712.45,,,6712.45,Other,324% New York Medicaid APG,4454.25,,,4454.25,Other,215% New York Medicaid APG,4454.25,,,4454.25,Other,215% New York Medicaid APG,2589.68,,,2589.68,Other,125% New York Medicaid APG,2071.74,44337.92,
Intro cath dialysis circuit,36903,CPT,,,,,,,,both,,,84539,62558.86,74,,62558.86,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,38042.55,45,,38042.55,percent of total billed charges,Medicare Ratio of cost to charges,5954,,"100% primary, 50% supplemental procedure",5954,Other,Aetna ASC Grouper,5359,,"100% primary, 50% supplemental procedure",5359,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,41846.81,49.5,,41846.81,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,4605.54,,,4605.54,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9196,,"100% primary, 0% secondary procedures",9196,Other,MagnaCare ASC Grouper,59177.3,70,,59177.3,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6956,,"100% primary, 50% secondary, 25% tertiary procedure",6956,Other,United Healthcare ASC Grouper,6261,,"100% primary, 50% secondary, 25% tertiary procedure",6261,Other,United Healthcare ASC Grouper,6956,,"100% primary, 50% secondary, 25% tertiary procedure",6956,Other,United Healthcare ASC Grouper,5913,,"100% primary, 50% secondary, 25% tertiary procedure",5913,Other,United Healthcare ASC Grouper,2476.1,,,2476.1,Other,New York Medicaid APG methodology,2476.1,,,2476.1,Other,100% New York Medicaid APG,2476.1,,,2476.1,Other,100% New York Medicaid APG,2476.1,,,2476.1,Other,100% New York Medicaid APG,5571.22,,,5571.22,Other,225% New York Medicaid APG,3788.43,,,3788.43,Other,153% New York Medicaid APG,5571.22,,,5571.22,Other,225% New York Medicaid APG,3466.54,,,3466.54,Other,140% New York Medicaid APG,5571.22,,,5571.22,Other,225% New York Medicaid APG,6437.85,,,6437.85,Other,260% New York Medicaid APG,8022.56,,,8022.56,Other,324% New York Medicaid APG,5323.61,,,5323.61,Other,215% New York Medicaid APG,5323.61,,,5323.61,Other,215% New York Medicaid APG,3095.12,,,3095.12,Other,125% New York Medicaid APG,2476.1,62558.86,
Thrmbc/nfs dialysis circuit,36904,CPT,,,,,,,,both,,,120221.84,88964.16,74,,88964.16,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,54099.83,45,,54099.83,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,7266,,"100% primary, 50% secondary, 25% supplemental procedure",7266,Other,Blue Cross ASC Grouper,6539,,"100% primary, 50% secondary, 25% supplemental procedure",6539,Other,Blue Cross ASC Grouper,6176,,"100% primary, 50% secondary, 25% supplemental procedure",6176,Other,Blue Cross ASC Grouper,59509.81,49.5,,59509.81,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3853.44,,,3853.44,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,84155.29,70,,84155.29,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,2071.74,,,2071.74,Other,New York Medicaid APG methodology,2071.74,,,2071.74,Other,100% New York Medicaid APG,2071.74,,,2071.74,Other,100% New York Medicaid APG,2071.74,,,2071.74,Other,100% New York Medicaid APG,4661.42,,,4661.42,Other,225% New York Medicaid APG,3169.77,,,3169.77,Other,153% New York Medicaid APG,4661.42,,,4661.42,Other,225% New York Medicaid APG,2900.44,,,2900.44,Other,140% New York Medicaid APG,4661.42,,,4661.42,Other,225% New York Medicaid APG,5386.53,,,5386.53,Other,260% New York Medicaid APG,6712.45,,,6712.45,Other,324% New York Medicaid APG,4454.25,,,4454.25,Other,215% New York Medicaid APG,4454.25,,,4454.25,Other,215% New York Medicaid APG,2589.68,,,2589.68,Other,125% New York Medicaid APG,2071.74,88964.16,
Thrmbc/nfs dialysis circuit,36905,CPT,,,,,,,,both,,,33272.33,24621.52,74,,24621.52,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,14972.55,45,,14972.55,percent of total billed charges,Medicare Ratio of cost to charges,5954,,"100% primary, 50% supplemental procedure",5954,Other,Aetna ASC Grouper,5359,,"100% primary, 50% supplemental procedure",5359,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,16469.8,49.5,,16469.8,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,4605.53,,,4605.53,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9196,,"100% primary, 0% secondary procedures",9196,Other,MagnaCare ASC Grouper,23290.63,70,,23290.63,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6956,,"100% primary, 50% secondary, 25% tertiary procedure",6956,Other,United Healthcare ASC Grouper,6261,,"100% primary, 50% secondary, 25% tertiary procedure",6261,Other,United Healthcare ASC Grouper,6956,,"100% primary, 50% secondary, 25% tertiary procedure",6956,Other,United Healthcare ASC Grouper,5913,,"100% primary, 50% secondary, 25% tertiary procedure",5913,Other,United Healthcare ASC Grouper,2476.09,,,2476.09,Other,New York Medicaid APG methodology,2476.09,,,2476.09,Other,100% New York Medicaid APG,2476.09,,,2476.09,Other,100% New York Medicaid APG,2476.09,,,2476.09,Other,100% New York Medicaid APG,5571.21,,,5571.21,Other,225% New York Medicaid APG,3788.42,,,3788.42,Other,153% New York Medicaid APG,5571.21,,,5571.21,Other,225% New York Medicaid APG,3466.53,,,3466.53,Other,140% New York Medicaid APG,5571.21,,,5571.21,Other,225% New York Medicaid APG,6437.84,,,6437.84,Other,260% New York Medicaid APG,8022.54,,,8022.54,Other,324% New York Medicaid APG,5323.6,,,5323.6,Other,215% New York Medicaid APG,5323.6,,,5323.6,Other,215% New York Medicaid APG,3095.12,,,3095.12,Other,125% New York Medicaid APG,2476.09,24621.52,
Thrmbc/nfs dialysis circuit,36906,CPT,,,,,,,,both,,,37210,27535.4,74,,27535.4,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,16744.5,45,,16744.5,percent of total billed charges,Medicare Ratio of cost to charges,5954,,"100% primary, 50% supplemental procedure",5954,Other,Aetna ASC Grouper,5359,,"100% primary, 50% supplemental procedure",5359,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,18418.95,49.5,,18418.95,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,4605.54,,,4605.54,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9196,,"100% primary, 0% secondary procedures",9196,Other,MagnaCare ASC Grouper,26047,70,,26047,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,8589,,"100% primary, 50% secondary, 25% tertiary procedure",8589,Other,United Healthcare ASC Grouper,7730,,"100% primary, 50% secondary, 25% tertiary procedure",7730,Other,United Healthcare ASC Grouper,8589,,"100% primary, 50% secondary, 25% tertiary procedure",8589,Other,United Healthcare ASC Grouper,7301,,"100% primary, 50% secondary, 25% tertiary procedure",7301,Other,United Healthcare ASC Grouper,2476.1,,,2476.1,Other,New York Medicaid APG methodology,2476.1,,,2476.1,Other,100% New York Medicaid APG,2476.1,,,2476.1,Other,100% New York Medicaid APG,2476.1,,,2476.1,Other,100% New York Medicaid APG,5571.22,,,5571.22,Other,225% New York Medicaid APG,3788.43,,,3788.43,Other,153% New York Medicaid APG,5571.22,,,5571.22,Other,225% New York Medicaid APG,3466.54,,,3466.54,Other,140% New York Medicaid APG,5571.22,,,5571.22,Other,225% New York Medicaid APG,6437.85,,,6437.85,Other,260% New York Medicaid APG,8022.56,,,8022.56,Other,324% New York Medicaid APG,5323.61,,,5323.61,Other,215% New York Medicaid APG,5323.61,,,5323.61,Other,215% New York Medicaid APG,3095.12,,,3095.12,Other,125% New York Medicaid APG,2476.1,27535.4,
Balo angiop ctr dialysis seg,36907,CPT,,,,,,,,both,,,86591.4,64077.64,74,,64077.64,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,38966.13,45,,38966.13,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,6125,,"100% primary, 50% secondary, 25% supplemental procedure",6125,Other,Blue Cross ASC Grouper,5513,,"100% primary, 50% secondary, 25% supplemental procedure",5513,Other,Blue Cross ASC Grouper,5206,,"100% primary, 50% secondary, 25% supplemental procedure",5206,Other,Blue Cross ASC Grouper,42862.74,49.5,,42862.74,percent of total billed charges,110% of Medicare,58882.15,68,,58882.15,percent of total billed charges,,4605.53,,,4605.53,Other,186% of Medicaid,69273.12,80,,69273.12,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,69273.12,80,,69273.12,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,60613.98,70,,60613.98,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,2476.09,,,2476.09,Other,New York Medicaid APG methodology,2476.09,,,2476.09,Other,100% New York Medicaid APG,2476.09,,,2476.09,Other,100% New York Medicaid APG,2476.09,,,2476.09,Other,100% New York Medicaid APG,5571.21,,,5571.21,Other,225% New York Medicaid APG,3788.42,,,3788.42,Other,153% New York Medicaid APG,5571.21,,,5571.21,Other,225% New York Medicaid APG,3466.53,,,3466.53,Other,140% New York Medicaid APG,5571.21,,,5571.21,Other,225% New York Medicaid APG,6437.84,,,6437.84,Other,260% New York Medicaid APG,8022.54,,,8022.54,Other,324% New York Medicaid APG,5323.6,,,5323.6,Other,215% New York Medicaid APG,5323.6,,,5323.6,Other,215% New York Medicaid APG,3095.12,,,3095.12,Other,125% New York Medicaid APG,2053,69273.12,
Stent plmt ctr dialysis seg,36908,CPT,,,,,,,,both,,,83504,61792.96,74,,61792.96,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,37576.8,45,,37576.8,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,41334.48,49.5,,41334.48,percent of total billed charges,110% of Medicare,56782.72,68,,56782.72,percent of total billed charges,,4605.53,,,4605.53,Other,186% of Medicaid,66803.2,80,,66803.2,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,66803.2,80,,66803.2,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,58452.8,70,,58452.8,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,2476.09,,,2476.09,Other,New York Medicaid APG methodology,2476.09,,,2476.09,Other,100% New York Medicaid APG,2476.09,,,2476.09,Other,100% New York Medicaid APG,2476.09,,,2476.09,Other,100% New York Medicaid APG,5571.21,,,5571.21,Other,225% New York Medicaid APG,3788.42,,,3788.42,Other,153% New York Medicaid APG,5571.21,,,5571.21,Other,225% New York Medicaid APG,3466.53,,,3466.53,Other,140% New York Medicaid APG,5571.21,,,5571.21,Other,225% New York Medicaid APG,6437.84,,,6437.84,Other,260% New York Medicaid APG,8022.54,,,8022.54,Other,324% New York Medicaid APG,5323.6,,,5323.6,Other,215% New York Medicaid APG,5323.6,,,5323.6,Other,215% New York Medicaid APG,3095.12,,,3095.12,Other,125% New York Medicaid APG,2053,66803.2,
Dialysis circuit embolj,36909,CPT,,,,,,,,both,,,64479.48,47714.82,74,,47714.82,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,29015.77,45,,29015.77,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,31917.34,49.5,,31917.34,percent of total billed charges,110% of Medicare,43846.05,68,,43846.05,percent of total billed charges,,4605.54,,,4605.54,Other,186% of Medicaid,51583.58,80,,51583.58,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,51583.58,80,,51583.58,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,45135.64,70,,45135.64,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,2476.1,,,2476.1,Other,New York Medicaid APG methodology,2476.1,,,2476.1,Other,100% New York Medicaid APG,2476.1,,,2476.1,Other,100% New York Medicaid APG,2476.1,,,2476.1,Other,100% New York Medicaid APG,5571.22,,,5571.22,Other,225% New York Medicaid APG,3788.43,,,3788.43,Other,153% New York Medicaid APG,5571.22,,,5571.22,Other,225% New York Medicaid APG,3466.54,,,3466.54,Other,140% New York Medicaid APG,5571.22,,,5571.22,Other,225% New York Medicaid APG,6437.85,,,6437.85,Other,260% New York Medicaid APG,8022.56,,,8022.56,Other,324% New York Medicaid APG,5323.61,,,5323.61,Other,215% New York Medicaid APG,5323.61,,,5323.61,Other,215% New York Medicaid APG,3095.12,,,3095.12,Other,125% New York Medicaid APG,2053,51583.58,
Remove hepatic shunt (tips),37183,CPT,,,,,,,,both,,,53851.78,39850.32,74,,39850.32,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,24233.3,45,,24233.3,percent of total billed charges,Medicare Ratio of cost to charges,7938,,"100% primary, 50% supplemental procedure",7938,Other,Aetna ASC Grouper,7144,,"100% primary, 50% supplemental procedure",7144,Other,Aetna ASC Grouper,7266,,"100% primary, 50% secondary, 25% supplemental procedure",7266,Other,Blue Cross ASC Grouper,6539,,"100% primary, 50% secondary, 25% supplemental procedure",6539,Other,Blue Cross ASC Grouper,6176,,"100% primary, 50% secondary, 25% supplemental procedure",6176,Other,Blue Cross ASC Grouper,26656.63,49.5,,26656.63,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,4605.53,,,4605.53,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9196,,"100% primary, 0% secondary procedures",9196,Other,MagnaCare ASC Grouper,37696.25,70,,37696.25,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6956,,"100% primary, 50% secondary, 25% tertiary procedure",6956,Other,United Healthcare ASC Grouper,6261,,"100% primary, 50% secondary, 25% tertiary procedure",6261,Other,United Healthcare ASC Grouper,6956,,"100% primary, 50% secondary, 25% tertiary procedure",6956,Other,United Healthcare ASC Grouper,5913,,"100% primary, 50% secondary, 25% tertiary procedure",5913,Other,United Healthcare ASC Grouper,2476.09,,,2476.09,Other,New York Medicaid APG methodology,2476.09,,,2476.09,Other,100% New York Medicaid APG,2476.09,,,2476.09,Other,100% New York Medicaid APG,2476.09,,,2476.09,Other,100% New York Medicaid APG,5571.21,,,5571.21,Other,225% New York Medicaid APG,3788.42,,,3788.42,Other,153% New York Medicaid APG,5571.21,,,5571.21,Other,225% New York Medicaid APG,3466.53,,,3466.53,Other,140% New York Medicaid APG,5571.21,,,5571.21,Other,225% New York Medicaid APG,6437.84,,,6437.84,Other,260% New York Medicaid APG,8022.54,,,8022.54,Other,324% New York Medicaid APG,5323.6,,,5323.6,Other,215% New York Medicaid APG,5323.6,,,5323.6,Other,215% New York Medicaid APG,3095.12,,,3095.12,Other,125% New York Medicaid APG,2476.09,39850.32,
Prim art m-thrmbc 1st vsl,37184,CPT,,,,,,,,both,,,150309.5,111229.03,74,,111229.03,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,67639.28,45,,67639.28,percent of total billed charges,Medicare Ratio of cost to charges,7938,,"100% primary, 50% supplemental procedure",7938,Other,Aetna ASC Grouper,7144,,"100% primary, 50% supplemental procedure",7144,Other,Aetna ASC Grouper,7266,,"100% primary, 50% secondary, 25% supplemental procedure",7266,Other,Blue Cross ASC Grouper,6539,,"100% primary, 50% secondary, 25% supplemental procedure",6539,Other,Blue Cross ASC Grouper,6176,,"100% primary, 50% secondary, 25% supplemental procedure",6176,Other,Blue Cross ASC Grouper,74403.2,49.5,,74403.2,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,4605.53,,,4605.53,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,105216.65,70,,105216.65,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,2476.09,,,2476.09,Other,New York Medicaid APG methodology,2476.09,,,2476.09,Other,100% New York Medicaid APG,2476.09,,,2476.09,Other,100% New York Medicaid APG,2476.09,,,2476.09,Other,100% New York Medicaid APG,5571.21,,,5571.21,Other,225% New York Medicaid APG,3788.42,,,3788.42,Other,153% New York Medicaid APG,5571.21,,,5571.21,Other,225% New York Medicaid APG,3466.53,,,3466.53,Other,140% New York Medicaid APG,5571.21,,,5571.21,Other,225% New York Medicaid APG,6437.84,,,6437.84,Other,260% New York Medicaid APG,8022.54,,,8022.54,Other,324% New York Medicaid APG,5323.6,,,5323.6,Other,215% New York Medicaid APG,5323.6,,,5323.6,Other,215% New York Medicaid APG,3095.12,,,3095.12,Other,125% New York Medicaid APG,2476.09,111229.03,
Prim art m-thrmbc sbsq vsl,37185,CPT,,,,,,,,both,,,64479.48,47714.82,74,,47714.82,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,29015.77,45,,29015.77,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,31917.34,49.5,,31917.34,percent of total billed charges,110% of Medicare,43846.05,68,,43846.05,percent of total billed charges,,4605.53,,,4605.53,Other,186% of Medicaid,51583.58,80,,51583.58,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,51583.58,80,,51583.58,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,45135.64,70,,45135.64,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,2476.09,,,2476.09,Other,New York Medicaid APG methodology,2476.09,,,2476.09,Other,100% New York Medicaid APG,2476.09,,,2476.09,Other,100% New York Medicaid APG,2476.09,,,2476.09,Other,100% New York Medicaid APG,5571.21,,,5571.21,Other,225% New York Medicaid APG,3788.42,,,3788.42,Other,153% New York Medicaid APG,5571.21,,,5571.21,Other,225% New York Medicaid APG,3466.53,,,3466.53,Other,140% New York Medicaid APG,5571.21,,,5571.21,Other,225% New York Medicaid APG,6437.84,,,6437.84,Other,260% New York Medicaid APG,8022.54,,,8022.54,Other,324% New York Medicaid APG,5323.6,,,5323.6,Other,215% New York Medicaid APG,5323.6,,,5323.6,Other,215% New York Medicaid APG,3095.12,,,3095.12,Other,125% New York Medicaid APG,2232,51583.58,
Sec art thrombectomy add-on,37186,CPT,,,,,,,,both,,,64479.48,47714.82,74,,47714.82,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,29015.77,45,,29015.77,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,31917.34,49.5,,31917.34,percent of total billed charges,110% of Medicare,43846.05,68,,43846.05,percent of total billed charges,,4605.54,,,4605.54,Other,186% of Medicaid,51583.58,80,,51583.58,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,51583.58,80,,51583.58,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,45135.64,70,,45135.64,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,2476.1,,,2476.1,Other,New York Medicaid APG methodology,2476.1,,,2476.1,Other,100% New York Medicaid APG,2476.1,,,2476.1,Other,100% New York Medicaid APG,2476.1,,,2476.1,Other,100% New York Medicaid APG,5571.22,,,5571.22,Other,225% New York Medicaid APG,3788.43,,,3788.43,Other,153% New York Medicaid APG,5571.22,,,5571.22,Other,225% New York Medicaid APG,3466.54,,,3466.54,Other,140% New York Medicaid APG,5571.22,,,5571.22,Other,225% New York Medicaid APG,6437.85,,,6437.85,Other,260% New York Medicaid APG,8022.56,,,8022.56,Other,324% New York Medicaid APG,5323.61,,,5323.61,Other,215% New York Medicaid APG,5323.61,,,5323.61,Other,215% New York Medicaid APG,3095.12,,,3095.12,Other,125% New York Medicaid APG,2053,51583.58,
Venous mech thrombectomy,37187,CPT,,,,,,,,both,,,126314.5,93472.73,74,,93472.73,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,56841.53,45,,56841.53,percent of total billed charges,Medicare Ratio of cost to charges,7938,,"100% primary, 50% supplemental procedure",7938,Other,Aetna ASC Grouper,7144,,"100% primary, 50% supplemental procedure",7144,Other,Aetna ASC Grouper,7266,,"100% primary, 50% secondary, 25% supplemental procedure",7266,Other,Blue Cross ASC Grouper,6539,,"100% primary, 50% secondary, 25% supplemental procedure",6539,Other,Blue Cross ASC Grouper,6176,,"100% primary, 50% secondary, 25% supplemental procedure",6176,Other,Blue Cross ASC Grouper,62525.68,49.5,,62525.68,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3853.44,,,3853.44,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,88420.15,70,,88420.15,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,2071.74,,,2071.74,Other,New York Medicaid APG methodology,2071.74,,,2071.74,Other,100% New York Medicaid APG,2071.74,,,2071.74,Other,100% New York Medicaid APG,2071.74,,,2071.74,Other,100% New York Medicaid APG,4661.42,,,4661.42,Other,225% New York Medicaid APG,3169.77,,,3169.77,Other,153% New York Medicaid APG,4661.42,,,4661.42,Other,225% New York Medicaid APG,2900.44,,,2900.44,Other,140% New York Medicaid APG,4661.42,,,4661.42,Other,225% New York Medicaid APG,5386.53,,,5386.53,Other,260% New York Medicaid APG,6712.45,,,6712.45,Other,324% New York Medicaid APG,4454.25,,,4454.25,Other,215% New York Medicaid APG,4454.25,,,4454.25,Other,215% New York Medicaid APG,2589.68,,,2589.68,Other,125% New York Medicaid APG,2071.74,93472.73,
Ven mechnl thrmbc repeat tx,37188,CPT,,,,,,,,both,,,67044.74,49613.11,74,,49613.11,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30170.13,45,,30170.13,percent of total billed charges,Medicare Ratio of cost to charges,7938,,"100% primary, 50% supplemental procedure",7938,Other,Aetna ASC Grouper,7144,,"100% primary, 50% supplemental procedure",7144,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33187.15,49.5,,33187.15,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3853.44,,,3853.44,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,46931.32,70,,46931.32,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,2071.74,,,2071.74,Other,New York Medicaid APG methodology,2071.74,,,2071.74,Other,100% New York Medicaid APG,2071.74,,,2071.74,Other,100% New York Medicaid APG,2071.74,,,2071.74,Other,100% New York Medicaid APG,4661.42,,,4661.42,Other,225% New York Medicaid APG,3169.77,,,3169.77,Other,153% New York Medicaid APG,4661.42,,,4661.42,Other,225% New York Medicaid APG,2900.44,,,2900.44,Other,140% New York Medicaid APG,4661.42,,,4661.42,Other,225% New York Medicaid APG,5386.53,,,5386.53,Other,260% New York Medicaid APG,6712.45,,,6712.45,Other,324% New York Medicaid APG,4454.25,,,4454.25,Other,215% New York Medicaid APG,4454.25,,,4454.25,Other,215% New York Medicaid APG,2589.68,,,2589.68,Other,125% New York Medicaid APG,2071.74,49613.11,
Ins endovas vena cava filtr,37191,CPT,,,,,,,,both,,,20501.41,15171.04,74,,15171.04,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,9225.63,45,,9225.63,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,10148.2,49.5,,10148.2,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3853.44,,,3853.44,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,14350.99,70,,14350.99,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,2071.74,,,2071.74,Other,New York Medicaid APG methodology,2071.74,,,2071.74,Other,100% New York Medicaid APG,2071.74,,,2071.74,Other,100% New York Medicaid APG,2071.74,,,2071.74,Other,100% New York Medicaid APG,4661.42,,,4661.42,Other,225% New York Medicaid APG,3169.77,,,3169.77,Other,153% New York Medicaid APG,4661.42,,,4661.42,Other,225% New York Medicaid APG,2900.44,,,2900.44,Other,140% New York Medicaid APG,4661.42,,,4661.42,Other,225% New York Medicaid APG,5386.53,,,5386.53,Other,260% New York Medicaid APG,6712.45,,,6712.45,Other,324% New York Medicaid APG,4454.25,,,4454.25,Other,215% New York Medicaid APG,4454.25,,,4454.25,Other,215% New York Medicaid APG,2589.68,,,2589.68,Other,125% New York Medicaid APG,2071.74,15171.04,
Redo endovas vena cava filtr,37192,CPT,,,,,,,,both,,,67044.74,49613.11,74,,49613.11,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30170.13,45,,30170.13,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33187.15,49.5,,33187.15,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3853.44,,,3853.44,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,46931.32,70,,46931.32,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,2071.74,,,2071.74,Other,New York Medicaid APG methodology,2071.74,,,2071.74,Other,100% New York Medicaid APG,2071.74,,,2071.74,Other,100% New York Medicaid APG,2071.74,,,2071.74,Other,100% New York Medicaid APG,4661.42,,,4661.42,Other,225% New York Medicaid APG,3169.77,,,3169.77,Other,153% New York Medicaid APG,4661.42,,,4661.42,Other,225% New York Medicaid APG,2900.44,,,2900.44,Other,140% New York Medicaid APG,4661.42,,,4661.42,Other,225% New York Medicaid APG,5386.53,,,5386.53,Other,260% New York Medicaid APG,6712.45,,,6712.45,Other,324% New York Medicaid APG,4454.25,,,4454.25,Other,215% New York Medicaid APG,4454.25,,,4454.25,Other,215% New York Medicaid APG,2589.68,,,2589.68,Other,125% New York Medicaid APG,2071.74,49613.11,
Rem endovas vena cava filter,37193,CPT,,,,,,,,both,,,41084.31,30402.39,74,,30402.39,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,18487.94,45,,18487.94,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,20336.73,49.5,,20336.73,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3853.44,,,3853.44,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,28759.02,70,,28759.02,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,2071.74,,,2071.74,Other,New York Medicaid APG methodology,2071.74,,,2071.74,Other,100% New York Medicaid APG,2071.74,,,2071.74,Other,100% New York Medicaid APG,2071.74,,,2071.74,Other,100% New York Medicaid APG,4661.42,,,4661.42,Other,225% New York Medicaid APG,3169.77,,,3169.77,Other,153% New York Medicaid APG,4661.42,,,4661.42,Other,225% New York Medicaid APG,2900.44,,,2900.44,Other,140% New York Medicaid APG,4661.42,,,4661.42,Other,225% New York Medicaid APG,5386.53,,,5386.53,Other,260% New York Medicaid APG,6712.45,,,6712.45,Other,324% New York Medicaid APG,4454.25,,,4454.25,Other,215% New York Medicaid APG,4454.25,,,4454.25,Other,215% New York Medicaid APG,2589.68,,,2589.68,Other,125% New York Medicaid APG,2071.74,30402.39,
Thrombolytic therapy stroke,37195,CPT,,,,,,,,both,,,7123.45,5271.35,74,,5271.35,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,3205.55,45,,3205.55,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,3526.11,49.5,,3526.11,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,644.22,,,644.22,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,4986.42,70,,4986.42,percent of total billed charges,,4630.24,65,,4630.24,percent of total billed charges,,4630.24,65,,4630.24,percent of total billed charges,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,346.35,,,346.35,Other,New York Medicaid APG methodology,346.35,,,346.35,Other,100% New York Medicaid APG,346.35,,,346.35,Other,100% New York Medicaid APG,346.35,,,346.35,Other,100% New York Medicaid APG,779.3,,,779.3,Other,225% New York Medicaid APG,529.92,,,529.92,Other,153% New York Medicaid APG,779.3,,,779.3,Other,225% New York Medicaid APG,484.9,,,484.9,Other,140% New York Medicaid APG,779.3,,,779.3,Other,225% New York Medicaid APG,900.52,,,900.52,Other,260% New York Medicaid APG,1122.19,,,1122.19,Other,324% New York Medicaid APG,744.66,,,744.66,Other,215% New York Medicaid APG,744.66,,,744.66,Other,215% New York Medicaid APG,432.94,,,432.94,Other,125% New York Medicaid APG,346.35,9473,
Remove intrvas foreign body,37197,CPT,,,,,,,,both,,,67044.74,49613.11,74,,49613.11,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30170.13,45,,30170.13,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33187.15,49.5,,33187.15,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3853.44,,,3853.44,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,46931.32,70,,46931.32,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,2071.74,,,2071.74,Other,New York Medicaid APG methodology,2071.74,,,2071.74,Other,100% New York Medicaid APG,2071.74,,,2071.74,Other,100% New York Medicaid APG,2071.74,,,2071.74,Other,100% New York Medicaid APG,4661.42,,,4661.42,Other,225% New York Medicaid APG,3169.77,,,3169.77,Other,153% New York Medicaid APG,4661.42,,,4661.42,Other,225% New York Medicaid APG,2900.44,,,2900.44,Other,140% New York Medicaid APG,4661.42,,,4661.42,Other,225% New York Medicaid APG,5386.53,,,5386.53,Other,260% New York Medicaid APG,6712.45,,,6712.45,Other,324% New York Medicaid APG,4454.25,,,4454.25,Other,215% New York Medicaid APG,4454.25,,,4454.25,Other,215% New York Medicaid APG,2589.68,,,2589.68,Other,125% New York Medicaid APG,2071.74,49613.11,
Transcatheter biopsy,37200,CPT,,,,,,,,both,,,27909.7,20653.18,74,,20653.18,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,12559.37,45,,12559.37,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,13815.3,49.5,,13815.3,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3853.44,,,3853.44,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,19536.79,70,,19536.79,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,2071.74,,,2071.74,Other,New York Medicaid APG methodology,2071.74,,,2071.74,Other,100% New York Medicaid APG,2071.74,,,2071.74,Other,100% New York Medicaid APG,2071.74,,,2071.74,Other,100% New York Medicaid APG,4661.42,,,4661.42,Other,225% New York Medicaid APG,3169.77,,,3169.77,Other,153% New York Medicaid APG,4661.42,,,4661.42,Other,225% New York Medicaid APG,2900.44,,,2900.44,Other,140% New York Medicaid APG,4661.42,,,4661.42,Other,225% New York Medicaid APG,5386.53,,,5386.53,Other,260% New York Medicaid APG,6712.45,,,6712.45,Other,324% New York Medicaid APG,4454.25,,,4454.25,Other,215% New York Medicaid APG,4454.25,,,4454.25,Other,215% New York Medicaid APG,2589.68,,,2589.68,Other,125% New York Medicaid APG,2071.74,20653.18,
Thrombolytic art therapy,37211,CPT,,,,,,,,both,,,115587.67,85534.88,74,,85534.88,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,52014.45,45,,52014.45,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,57215.9,49.5,,57215.9,percent of total billed charges,110% of Medicare,78599.62,68,,78599.62,percent of total billed charges,,3853.44,,,3853.44,Other,186% of Medicaid,92470.14,80,,92470.14,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,92470.14,80,,92470.14,percent of total billed charges,,7216,,,7216,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,80911.37,70,,80911.37,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,2071.74,,,2071.74,Other,New York Medicaid APG methodology,2071.74,,,2071.74,Other,100% New York Medicaid APG,2071.74,,,2071.74,Other,100% New York Medicaid APG,2071.74,,,2071.74,Other,100% New York Medicaid APG,4661.42,,,4661.42,Other,225% New York Medicaid APG,3169.77,,,3169.77,Other,153% New York Medicaid APG,4661.42,,,4661.42,Other,225% New York Medicaid APG,2900.44,,,2900.44,Other,140% New York Medicaid APG,4661.42,,,4661.42,Other,225% New York Medicaid APG,5386.53,,,5386.53,Other,260% New York Medicaid APG,6712.45,,,6712.45,Other,324% New York Medicaid APG,4454.25,,,4454.25,Other,215% New York Medicaid APG,4454.25,,,4454.25,Other,215% New York Medicaid APG,2589.68,,,2589.68,Other,125% New York Medicaid APG,2053,92470.14,
Thrombolytic venous therapy,37212,CPT,,,,,,,,both,,,67044.74,49613.11,74,,49613.11,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30170.13,45,,30170.13,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33187.15,49.5,,33187.15,percent of total billed charges,110% of Medicare,45590.42,68,,45590.42,percent of total billed charges,,3853.44,,,3853.44,Other,186% of Medicaid,53635.79,80,,53635.79,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,53635.79,80,,53635.79,percent of total billed charges,,7216,,,7216,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,46931.32,70,,46931.32,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,2071.74,,,2071.74,Other,New York Medicaid APG methodology,2071.74,,,2071.74,Other,100% New York Medicaid APG,2071.74,,,2071.74,Other,100% New York Medicaid APG,2071.74,,,2071.74,Other,100% New York Medicaid APG,4661.42,,,4661.42,Other,225% New York Medicaid APG,3169.77,,,3169.77,Other,153% New York Medicaid APG,4661.42,,,4661.42,Other,225% New York Medicaid APG,2900.44,,,2900.44,Other,140% New York Medicaid APG,4661.42,,,4661.42,Other,225% New York Medicaid APG,5386.53,,,5386.53,Other,260% New York Medicaid APG,6712.45,,,6712.45,Other,324% New York Medicaid APG,4454.25,,,4454.25,Other,215% New York Medicaid APG,4454.25,,,4454.25,Other,215% New York Medicaid APG,2589.68,,,2589.68,Other,125% New York Medicaid APG,2053,53635.79,
Thromblytic art/ven therapy,37213,CPT,,,,,,,,both,,,67044.74,49613.11,74,,49613.11,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30170.13,45,,30170.13,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,33187.15,49.5,,33187.15,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3853.44,,,3853.44,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,3578,,"100% primary, 0% secondary procedures",3578,Other,MagnaCare ASC Grouper,46931.32,70,,46931.32,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,2071.74,,,2071.74,Other,New York Medicaid APG methodology,2071.74,,,2071.74,Other,100% New York Medicaid APG,2071.74,,,2071.74,Other,100% New York Medicaid APG,2071.74,,,2071.74,Other,100% New York Medicaid APG,4661.42,,,4661.42,Other,225% New York Medicaid APG,3169.77,,,3169.77,Other,153% New York Medicaid APG,4661.42,,,4661.42,Other,225% New York Medicaid APG,2900.44,,,2900.44,Other,140% New York Medicaid APG,4661.42,,,4661.42,Other,225% New York Medicaid APG,5386.53,,,5386.53,Other,260% New York Medicaid APG,6712.45,,,6712.45,Other,324% New York Medicaid APG,4454.25,,,4454.25,Other,215% New York Medicaid APG,4454.25,,,4454.25,Other,215% New York Medicaid APG,2589.68,,,2589.68,Other,125% New York Medicaid APG,2071.74,49613.11,
Cessj therapy cath removal,37214,CPT,,,,,,,,both,,,67044.74,49613.11,74,,49613.11,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30170.13,45,,30170.13,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,33187.15,49.5,,33187.15,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3853.44,,,3853.44,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,3578,,"100% primary, 0% secondary procedures",3578,Other,MagnaCare ASC Grouper,46931.32,70,,46931.32,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,2071.74,,,2071.74,Other,New York Medicaid APG methodology,2071.74,,,2071.74,Other,100% New York Medicaid APG,2071.74,,,2071.74,Other,100% New York Medicaid APG,2071.74,,,2071.74,Other,100% New York Medicaid APG,4661.42,,,4661.42,Other,225% New York Medicaid APG,3169.77,,,3169.77,Other,153% New York Medicaid APG,4661.42,,,4661.42,Other,225% New York Medicaid APG,2900.44,,,2900.44,Other,140% New York Medicaid APG,4661.42,,,4661.42,Other,225% New York Medicaid APG,5386.53,,,5386.53,Other,260% New York Medicaid APG,6712.45,,,6712.45,Other,324% New York Medicaid APG,4454.25,,,4454.25,Other,215% New York Medicaid APG,4454.25,,,4454.25,Other,215% New York Medicaid APG,2589.68,,,2589.68,Other,125% New York Medicaid APG,2071.74,49613.11,
Iliac revasc,37220,CPT,,,,,,,,both,,,27747,20532.78,74,,20532.78,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,12486.15,45,,12486.15,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,7266,,"100% primary, 50% secondary, 25% supplemental procedure",7266,Other,Blue Cross ASC Grouper,6539,,"100% primary, 50% secondary, 25% supplemental procedure",6539,Other,Blue Cross ASC Grouper,6176,,"100% primary, 50% secondary, 25% supplemental procedure",6176,Other,Blue Cross ASC Grouper,13734.77,49.5,,13734.77,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,4605.53,,,4605.53,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,19422.9,70,,19422.9,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,2476.09,,,2476.09,Other,New York Medicaid APG methodology,2476.09,,,2476.09,Other,100% New York Medicaid APG,2476.09,,,2476.09,Other,100% New York Medicaid APG,2476.09,,,2476.09,Other,100% New York Medicaid APG,5571.21,,,5571.21,Other,225% New York Medicaid APG,3788.42,,,3788.42,Other,153% New York Medicaid APG,5571.21,,,5571.21,Other,225% New York Medicaid APG,3466.53,,,3466.53,Other,140% New York Medicaid APG,5571.21,,,5571.21,Other,225% New York Medicaid APG,6437.84,,,6437.84,Other,260% New York Medicaid APG,8022.54,,,8022.54,Other,324% New York Medicaid APG,5323.6,,,5323.6,Other,215% New York Medicaid APG,5323.6,,,5323.6,Other,215% New York Medicaid APG,3095.12,,,3095.12,Other,125% New York Medicaid APG,2476.09,20532.78,
Iliac revasc w/stent,37221,CPT,,,,,,,,both,,,147449.05,109112.3,74,,109112.3,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,66352.07,45,,66352.07,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,72987.28,49.5,,72987.28,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,4605.54,,,4605.54,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9196,,"100% primary, 0% secondary procedures",9196,Other,MagnaCare ASC Grouper,103214.34,70,,103214.34,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6956,,"100% primary, 50% secondary, 25% tertiary procedure",6956,Other,United Healthcare ASC Grouper,6261,,"100% primary, 50% secondary, 25% tertiary procedure",6261,Other,United Healthcare ASC Grouper,6956,,"100% primary, 50% secondary, 25% tertiary procedure",6956,Other,United Healthcare ASC Grouper,5913,,"100% primary, 50% secondary, 25% tertiary procedure",5913,Other,United Healthcare ASC Grouper,2476.1,,,2476.1,Other,New York Medicaid APG methodology,2476.1,,,2476.1,Other,100% New York Medicaid APG,2476.1,,,2476.1,Other,100% New York Medicaid APG,2476.1,,,2476.1,Other,100% New York Medicaid APG,5571.22,,,5571.22,Other,225% New York Medicaid APG,3788.43,,,3788.43,Other,153% New York Medicaid APG,5571.22,,,5571.22,Other,225% New York Medicaid APG,3466.54,,,3466.54,Other,140% New York Medicaid APG,5571.22,,,5571.22,Other,225% New York Medicaid APG,6437.85,,,6437.85,Other,260% New York Medicaid APG,8022.56,,,8022.56,Other,324% New York Medicaid APG,5323.61,,,5323.61,Other,215% New York Medicaid APG,5323.61,,,5323.61,Other,215% New York Medicaid APG,3095.12,,,3095.12,Other,125% New York Medicaid APG,2476.1,109112.3,
Iliac revasc add-on,37222,CPT,,,,,,,,both,,,98219.64,72682.53,74,,72682.53,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,44198.84,45,,44198.84,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,48618.72,49.5,,48618.72,percent of total billed charges,110% of Medicare,66789.36,68,,66789.36,percent of total billed charges,,4605.54,,,4605.54,Other,186% of Medicaid,78575.71,80,,78575.71,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,78575.71,80,,78575.71,percent of total billed charges,,7216,,,7216,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,68753.75,70,,68753.75,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,2476.1,,,2476.1,Other,New York Medicaid APG methodology,2476.1,,,2476.1,Other,100% New York Medicaid APG,2476.1,,,2476.1,Other,100% New York Medicaid APG,2476.1,,,2476.1,Other,100% New York Medicaid APG,5571.22,,,5571.22,Other,225% New York Medicaid APG,3788.43,,,3788.43,Other,153% New York Medicaid APG,5571.22,,,5571.22,Other,225% New York Medicaid APG,3466.54,,,3466.54,Other,140% New York Medicaid APG,5571.22,,,5571.22,Other,225% New York Medicaid APG,6437.85,,,6437.85,Other,260% New York Medicaid APG,8022.56,,,8022.56,Other,324% New York Medicaid APG,5323.61,,,5323.61,Other,215% New York Medicaid APG,5323.61,,,5323.61,Other,215% New York Medicaid APG,3095.12,,,3095.12,Other,125% New York Medicaid APG,2053,78575.71,
Iliac revasc w/stent add-on,37223,CPT,,,,,,,,both,,,98219.64,72682.53,74,,72682.53,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,44198.84,45,,44198.84,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,48618.72,49.5,,48618.72,percent of total billed charges,110% of Medicare,66789.36,68,,66789.36,percent of total billed charges,,4605.54,,,4605.54,Other,186% of Medicaid,78575.71,80,,78575.71,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,78575.71,80,,78575.71,percent of total billed charges,,7216,,,7216,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,68753.75,70,,68753.75,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,2476.1,,,2476.1,Other,New York Medicaid APG methodology,2476.1,,,2476.1,Other,100% New York Medicaid APG,2476.1,,,2476.1,Other,100% New York Medicaid APG,2476.1,,,2476.1,Other,100% New York Medicaid APG,5571.22,,,5571.22,Other,225% New York Medicaid APG,3788.43,,,3788.43,Other,153% New York Medicaid APG,5571.22,,,5571.22,Other,225% New York Medicaid APG,3466.54,,,3466.54,Other,140% New York Medicaid APG,5571.22,,,5571.22,Other,225% New York Medicaid APG,6437.85,,,6437.85,Other,260% New York Medicaid APG,8022.56,,,8022.56,Other,324% New York Medicaid APG,5323.61,,,5323.61,Other,215% New York Medicaid APG,5323.61,,,5323.61,Other,215% New York Medicaid APG,3095.12,,,3095.12,Other,125% New York Medicaid APG,2053,78575.71,
Fem/popl revas w/tla,37224,CPT,,,,,,,,both,,,93611,69272.14,74,,69272.14,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,42124.95,45,,42124.95,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,7266,,"100% primary, 50% secondary, 25% supplemental procedure",7266,Other,Blue Cross ASC Grouper,6539,,"100% primary, 50% secondary, 25% supplemental procedure",6539,Other,Blue Cross ASC Grouper,6176,,"100% primary, 50% secondary, 25% supplemental procedure",6176,Other,Blue Cross ASC Grouper,46337.45,49.5,,46337.45,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,4605.53,,,4605.53,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,65527.7,70,,65527.7,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,2476.09,,,2476.09,Other,New York Medicaid APG methodology,2476.09,,,2476.09,Other,100% New York Medicaid APG,2476.09,,,2476.09,Other,100% New York Medicaid APG,2476.09,,,2476.09,Other,100% New York Medicaid APG,5571.21,,,5571.21,Other,225% New York Medicaid APG,3788.42,,,3788.42,Other,153% New York Medicaid APG,5571.21,,,5571.21,Other,225% New York Medicaid APG,3466.53,,,3466.53,Other,140% New York Medicaid APG,5571.21,,,5571.21,Other,225% New York Medicaid APG,6437.84,,,6437.84,Other,260% New York Medicaid APG,8022.54,,,8022.54,Other,324% New York Medicaid APG,5323.6,,,5323.6,Other,215% New York Medicaid APG,5323.6,,,5323.6,Other,215% New York Medicaid APG,3095.12,,,3095.12,Other,125% New York Medicaid APG,2476.09,69272.14,
Fem/popl revas w/ather,37225,CPT,,,,,,,,both,,,368828.98,272933.45,74,,272933.45,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,165973.04,45,,165973.04,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,182570.35,49.5,,182570.35,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,4605.54,,,4605.54,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9196,,"100% primary, 0% secondary procedures",9196,Other,MagnaCare ASC Grouper,258180.29,70,,258180.29,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6956,,"100% primary, 50% secondary, 25% tertiary procedure",6956,Other,United Healthcare ASC Grouper,6261,,"100% primary, 50% secondary, 25% tertiary procedure",6261,Other,United Healthcare ASC Grouper,6956,,"100% primary, 50% secondary, 25% tertiary procedure",6956,Other,United Healthcare ASC Grouper,5913,,"100% primary, 50% secondary, 25% tertiary procedure",5913,Other,United Healthcare ASC Grouper,2476.1,,,2476.1,Other,New York Medicaid APG methodology,2476.1,,,2476.1,Other,100% New York Medicaid APG,2476.1,,,2476.1,Other,100% New York Medicaid APG,2476.1,,,2476.1,Other,100% New York Medicaid APG,5571.22,,,5571.22,Other,225% New York Medicaid APG,3788.43,,,3788.43,Other,153% New York Medicaid APG,5571.22,,,5571.22,Other,225% New York Medicaid APG,3466.54,,,3466.54,Other,140% New York Medicaid APG,5571.22,,,5571.22,Other,225% New York Medicaid APG,6437.85,,,6437.85,Other,260% New York Medicaid APG,8022.56,,,8022.56,Other,324% New York Medicaid APG,5323.61,,,5323.61,Other,215% New York Medicaid APG,5323.61,,,5323.61,Other,215% New York Medicaid APG,3095.12,,,3095.12,Other,125% New York Medicaid APG,2476.1,272933.45,
Fem/popl revasc w/stent,37226,CPT,,,,,,,,both,,,108112.64,80003.35,74,,80003.35,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,48650.69,45,,48650.69,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,53515.76,49.5,,53515.76,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,4605.54,,,4605.54,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9196,,"100% primary, 0% secondary procedures",9196,Other,MagnaCare ASC Grouper,75678.85,70,,75678.85,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6956,,"100% primary, 50% secondary, 25% tertiary procedure",6956,Other,United Healthcare ASC Grouper,6261,,"100% primary, 50% secondary, 25% tertiary procedure",6261,Other,United Healthcare ASC Grouper,6956,,"100% primary, 50% secondary, 25% tertiary procedure",6956,Other,United Healthcare ASC Grouper,5913,,"100% primary, 50% secondary, 25% tertiary procedure",5913,Other,United Healthcare ASC Grouper,2476.1,,,2476.1,Other,New York Medicaid APG methodology,2476.1,,,2476.1,Other,100% New York Medicaid APG,2476.1,,,2476.1,Other,100% New York Medicaid APG,2476.1,,,2476.1,Other,100% New York Medicaid APG,5571.22,,,5571.22,Other,225% New York Medicaid APG,3788.43,,,3788.43,Other,153% New York Medicaid APG,5571.22,,,5571.22,Other,225% New York Medicaid APG,3466.54,,,3466.54,Other,140% New York Medicaid APG,5571.22,,,5571.22,Other,225% New York Medicaid APG,6437.85,,,6437.85,Other,260% New York Medicaid APG,8022.56,,,8022.56,Other,324% New York Medicaid APG,5323.61,,,5323.61,Other,215% New York Medicaid APG,5323.61,,,5323.61,Other,215% New York Medicaid APG,3095.12,,,3095.12,Other,125% New York Medicaid APG,2476.1,80003.35,
Fem/popl revasc stnt & ather,37227,CPT,,,,,,,,both,,,368828.98,272933.45,74,,272933.45,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,165973.04,45,,165973.04,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,182570.35,49.5,,182570.35,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,4605.54,,,4605.54,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9196,,"100% primary, 0% secondary procedures",9196,Other,MagnaCare ASC Grouper,258180.29,70,,258180.29,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,8589,,"100% primary, 50% secondary, 25% tertiary procedure",8589,Other,United Healthcare ASC Grouper,7730,,"100% primary, 50% secondary, 25% tertiary procedure",7730,Other,United Healthcare ASC Grouper,8589,,"100% primary, 50% secondary, 25% tertiary procedure",8589,Other,United Healthcare ASC Grouper,7301,,"100% primary, 50% secondary, 25% tertiary procedure",7301,Other,United Healthcare ASC Grouper,2476.1,,,2476.1,Other,New York Medicaid APG methodology,2476.1,,,2476.1,Other,100% New York Medicaid APG,2476.1,,,2476.1,Other,100% New York Medicaid APG,2476.1,,,2476.1,Other,100% New York Medicaid APG,5571.22,,,5571.22,Other,225% New York Medicaid APG,3788.43,,,3788.43,Other,153% New York Medicaid APG,5571.22,,,5571.22,Other,225% New York Medicaid APG,3466.54,,,3466.54,Other,140% New York Medicaid APG,5571.22,,,5571.22,Other,225% New York Medicaid APG,6437.85,,,6437.85,Other,260% New York Medicaid APG,8022.56,,,8022.56,Other,324% New York Medicaid APG,5323.61,,,5323.61,Other,215% New York Medicaid APG,5323.61,,,5323.61,Other,215% New York Medicaid APG,3095.12,,,3095.12,Other,125% New York Medicaid APG,2476.1,272933.45,
Tib/per revasc w/tla,37228,CPT,,,,,,,,both,,,148904.54,110189.36,74,,110189.36,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,67007.04,45,,67007.04,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,73707.75,49.5,,73707.75,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,4605.53,,,4605.53,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,104233.18,70,,104233.18,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,2476.09,,,2476.09,Other,New York Medicaid APG methodology,2476.09,,,2476.09,Other,100% New York Medicaid APG,2476.09,,,2476.09,Other,100% New York Medicaid APG,2476.09,,,2476.09,Other,100% New York Medicaid APG,5571.21,,,5571.21,Other,225% New York Medicaid APG,3788.42,,,3788.42,Other,153% New York Medicaid APG,5571.21,,,5571.21,Other,225% New York Medicaid APG,3466.53,,,3466.53,Other,140% New York Medicaid APG,5571.21,,,5571.21,Other,225% New York Medicaid APG,6437.84,,,6437.84,Other,260% New York Medicaid APG,8022.54,,,8022.54,Other,324% New York Medicaid APG,5323.6,,,5323.6,Other,215% New York Medicaid APG,5323.6,,,5323.6,Other,215% New York Medicaid APG,3095.12,,,3095.12,Other,125% New York Medicaid APG,2476.09,110189.36,
Tib/per revasc w/ather,37229,CPT,,,,,,,,both,,,368828.98,272933.45,74,,272933.45,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,165973.04,45,,165973.04,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,182570.35,49.5,,182570.35,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,4605.54,,,4605.54,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9196,,"100% primary, 0% secondary procedures",9196,Other,MagnaCare ASC Grouper,258180.29,70,,258180.29,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6956,,"100% primary, 50% secondary, 25% tertiary procedure",6956,Other,United Healthcare ASC Grouper,6261,,"100% primary, 50% secondary, 25% tertiary procedure",6261,Other,United Healthcare ASC Grouper,6956,,"100% primary, 50% secondary, 25% tertiary procedure",6956,Other,United Healthcare ASC Grouper,5913,,"100% primary, 50% secondary, 25% tertiary procedure",5913,Other,United Healthcare ASC Grouper,2476.1,,,2476.1,Other,New York Medicaid APG methodology,2476.1,,,2476.1,Other,100% New York Medicaid APG,2476.1,,,2476.1,Other,100% New York Medicaid APG,2476.1,,,2476.1,Other,100% New York Medicaid APG,5571.22,,,5571.22,Other,225% New York Medicaid APG,3788.43,,,3788.43,Other,153% New York Medicaid APG,5571.22,,,5571.22,Other,225% New York Medicaid APG,3466.54,,,3466.54,Other,140% New York Medicaid APG,5571.22,,,5571.22,Other,225% New York Medicaid APG,6437.85,,,6437.85,Other,260% New York Medicaid APG,8022.56,,,8022.56,Other,324% New York Medicaid APG,5323.61,,,5323.61,Other,215% New York Medicaid APG,5323.61,,,5323.61,Other,215% New York Medicaid APG,3095.12,,,3095.12,Other,125% New York Medicaid APG,2476.1,272933.45,
Tib/per revasc w/stent,37230,CPT,,,,,,,,both,,,368828.98,272933.45,74,,272933.45,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,165973.04,45,,165973.04,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,182570.35,49.5,,182570.35,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,4605.54,,,4605.54,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9196,,"100% primary, 0% secondary procedures",9196,Other,MagnaCare ASC Grouper,258180.29,70,,258180.29,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6956,,"100% primary, 50% secondary, 25% tertiary procedure",6956,Other,United Healthcare ASC Grouper,6261,,"100% primary, 50% secondary, 25% tertiary procedure",6261,Other,United Healthcare ASC Grouper,6956,,"100% primary, 50% secondary, 25% tertiary procedure",6956,Other,United Healthcare ASC Grouper,5913,,"100% primary, 50% secondary, 25% tertiary procedure",5913,Other,United Healthcare ASC Grouper,2476.1,,,2476.1,Other,New York Medicaid APG methodology,2476.1,,,2476.1,Other,100% New York Medicaid APG,2476.1,,,2476.1,Other,100% New York Medicaid APG,2476.1,,,2476.1,Other,100% New York Medicaid APG,5571.22,,,5571.22,Other,225% New York Medicaid APG,3788.43,,,3788.43,Other,153% New York Medicaid APG,5571.22,,,5571.22,Other,225% New York Medicaid APG,3466.54,,,3466.54,Other,140% New York Medicaid APG,5571.22,,,5571.22,Other,225% New York Medicaid APG,6437.85,,,6437.85,Other,260% New York Medicaid APG,8022.56,,,8022.56,Other,324% New York Medicaid APG,5323.61,,,5323.61,Other,215% New York Medicaid APG,5323.61,,,5323.61,Other,215% New York Medicaid APG,3095.12,,,3095.12,Other,125% New York Medicaid APG,2476.1,272933.45,
Tib/per revasc stent & ather,37231,CPT,,,,,,,,both,,,368828.98,272933.45,74,,272933.45,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,165973.04,45,,165973.04,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,182570.35,49.5,,182570.35,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,4605.54,,,4605.54,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9196,,"100% primary, 0% secondary procedures",9196,Other,MagnaCare ASC Grouper,258180.29,70,,258180.29,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,8589,,"100% primary, 50% secondary, 25% tertiary procedure",8589,Other,United Healthcare ASC Grouper,7730,,"100% primary, 50% secondary, 25% tertiary procedure",7730,Other,United Healthcare ASC Grouper,8589,,"100% primary, 50% secondary, 25% tertiary procedure",8589,Other,United Healthcare ASC Grouper,7301,,"100% primary, 50% secondary, 25% tertiary procedure",7301,Other,United Healthcare ASC Grouper,2476.1,,,2476.1,Other,New York Medicaid APG methodology,2476.1,,,2476.1,Other,100% New York Medicaid APG,2476.1,,,2476.1,Other,100% New York Medicaid APG,2476.1,,,2476.1,Other,100% New York Medicaid APG,5571.22,,,5571.22,Other,225% New York Medicaid APG,3788.43,,,3788.43,Other,153% New York Medicaid APG,5571.22,,,5571.22,Other,225% New York Medicaid APG,3466.54,,,3466.54,Other,140% New York Medicaid APG,5571.22,,,5571.22,Other,225% New York Medicaid APG,6437.85,,,6437.85,Other,260% New York Medicaid APG,8022.56,,,8022.56,Other,324% New York Medicaid APG,5323.61,,,5323.61,Other,215% New York Medicaid APG,5323.61,,,5323.61,Other,215% New York Medicaid APG,3095.12,,,3095.12,Other,125% New York Medicaid APG,2476.1,272933.45,
Tib/per revasc add-on,37232,CPT,,,,,,,,both,,,86591.4,64077.64,74,,64077.64,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,38966.13,45,,38966.13,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,6125,,"100% primary, 50% secondary, 25% supplemental procedure",6125,Other,Blue Cross ASC Grouper,5513,,"100% primary, 50% secondary, 25% supplemental procedure",5513,Other,Blue Cross ASC Grouper,5206,,"100% primary, 50% secondary, 25% supplemental procedure",5206,Other,Blue Cross ASC Grouper,42862.74,49.5,,42862.74,percent of total billed charges,110% of Medicare,58882.15,68,,58882.15,percent of total billed charges,,4605.54,,,4605.54,Other,186% of Medicaid,69273.12,80,,69273.12,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,69273.12,80,,69273.12,percent of total billed charges,,7216,,,7216,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,60613.98,70,,60613.98,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,2476.1,,,2476.1,Other,New York Medicaid APG methodology,2476.1,,,2476.1,Other,100% New York Medicaid APG,2476.1,,,2476.1,Other,100% New York Medicaid APG,2476.1,,,2476.1,Other,100% New York Medicaid APG,5571.22,,,5571.22,Other,225% New York Medicaid APG,3788.43,,,3788.43,Other,153% New York Medicaid APG,5571.22,,,5571.22,Other,225% New York Medicaid APG,3466.54,,,3466.54,Other,140% New York Medicaid APG,5571.22,,,5571.22,Other,225% New York Medicaid APG,6437.85,,,6437.85,Other,260% New York Medicaid APG,8022.56,,,8022.56,Other,324% New York Medicaid APG,5323.61,,,5323.61,Other,215% New York Medicaid APG,5323.61,,,5323.61,Other,215% New York Medicaid APG,3095.12,,,3095.12,Other,125% New York Medicaid APG,2053,69273.12,
Tibper revasc w/ather add-on,37233,CPT,,,,,,,,both,,,86591.4,64077.64,74,,64077.64,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,38966.13,45,,38966.13,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,6125,,"100% primary, 50% secondary, 25% supplemental procedure",6125,Other,Blue Cross ASC Grouper,5513,,"100% primary, 50% secondary, 25% supplemental procedure",5513,Other,Blue Cross ASC Grouper,5206,,"100% primary, 50% secondary, 25% supplemental procedure",5206,Other,Blue Cross ASC Grouper,42862.74,49.5,,42862.74,percent of total billed charges,110% of Medicare,58882.15,68,,58882.15,percent of total billed charges,,4605.54,,,4605.54,Other,186% of Medicaid,69273.12,80,,69273.12,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,69273.12,80,,69273.12,percent of total billed charges,,7216,,,7216,Case Rate,,9196,,"100% primary, 0% secondary procedures",9196,Other,MagnaCare ASC Grouper,60613.98,70,,60613.98,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6956,,"100% primary, 50% secondary, 25% tertiary procedure",6956,Other,United Healthcare ASC Grouper,6261,,"100% primary, 50% secondary, 25% tertiary procedure",6261,Other,United Healthcare ASC Grouper,6956,,"100% primary, 50% secondary, 25% tertiary procedure",6956,Other,United Healthcare ASC Grouper,5913,,"100% primary, 50% secondary, 25% tertiary procedure",5913,Other,United Healthcare ASC Grouper,2476.1,,,2476.1,Other,New York Medicaid APG methodology,2476.1,,,2476.1,Other,100% New York Medicaid APG,2476.1,,,2476.1,Other,100% New York Medicaid APG,2476.1,,,2476.1,Other,100% New York Medicaid APG,5571.22,,,5571.22,Other,225% New York Medicaid APG,3788.43,,,3788.43,Other,153% New York Medicaid APG,5571.22,,,5571.22,Other,225% New York Medicaid APG,3466.54,,,3466.54,Other,140% New York Medicaid APG,5571.22,,,5571.22,Other,225% New York Medicaid APG,6437.85,,,6437.85,Other,260% New York Medicaid APG,8022.56,,,8022.56,Other,324% New York Medicaid APG,5323.61,,,5323.61,Other,215% New York Medicaid APG,5323.61,,,5323.61,Other,215% New York Medicaid APG,3095.12,,,3095.12,Other,125% New York Medicaid APG,2053,69273.12,
Revsc opn/prq tib/pero stent,37234,CPT,,,,,,,,both,,,86591.4,64077.64,74,,64077.64,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,38966.13,45,,38966.13,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,6125,,"100% primary, 50% secondary, 25% supplemental procedure",6125,Other,Blue Cross ASC Grouper,5513,,"100% primary, 50% secondary, 25% supplemental procedure",5513,Other,Blue Cross ASC Grouper,5206,,"100% primary, 50% secondary, 25% supplemental procedure",5206,Other,Blue Cross ASC Grouper,42862.74,49.5,,42862.74,percent of total billed charges,110% of Medicare,58882.15,68,,58882.15,percent of total billed charges,,4605.54,,,4605.54,Other,186% of Medicaid,69273.12,80,,69273.12,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,69273.12,80,,69273.12,percent of total billed charges,,7216,,,7216,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,60613.98,70,,60613.98,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,2476.1,,,2476.1,Other,New York Medicaid APG methodology,2476.1,,,2476.1,Other,100% New York Medicaid APG,2476.1,,,2476.1,Other,100% New York Medicaid APG,2476.1,,,2476.1,Other,100% New York Medicaid APG,5571.22,,,5571.22,Other,225% New York Medicaid APG,3788.43,,,3788.43,Other,153% New York Medicaid APG,5571.22,,,5571.22,Other,225% New York Medicaid APG,3466.54,,,3466.54,Other,140% New York Medicaid APG,5571.22,,,5571.22,Other,225% New York Medicaid APG,6437.85,,,6437.85,Other,260% New York Medicaid APG,8022.56,,,8022.56,Other,324% New York Medicaid APG,5323.61,,,5323.61,Other,215% New York Medicaid APG,5323.61,,,5323.61,Other,215% New York Medicaid APG,3095.12,,,3095.12,Other,125% New York Medicaid APG,2053,69273.12,
Tib/per revasc stnt & ather,37235,CPT,,,,,,,,both,,,86591.4,64077.64,74,,64077.64,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,38966.13,45,,38966.13,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,6125,,"100% primary, 50% secondary, 25% supplemental procedure",6125,Other,Blue Cross ASC Grouper,5513,,"100% primary, 50% secondary, 25% supplemental procedure",5513,Other,Blue Cross ASC Grouper,5206,,"100% primary, 50% secondary, 25% supplemental procedure",5206,Other,Blue Cross ASC Grouper,42862.74,49.5,,42862.74,percent of total billed charges,110% of Medicare,58882.15,68,,58882.15,percent of total billed charges,,4605.54,,,4605.54,Other,186% of Medicaid,69273.12,80,,69273.12,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,69273.12,80,,69273.12,percent of total billed charges,,7216,,,7216,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,60613.98,70,,60613.98,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,2476.1,,,2476.1,Other,New York Medicaid APG methodology,2476.1,,,2476.1,Other,100% New York Medicaid APG,2476.1,,,2476.1,Other,100% New York Medicaid APG,2476.1,,,2476.1,Other,100% New York Medicaid APG,5571.22,,,5571.22,Other,225% New York Medicaid APG,3788.43,,,3788.43,Other,153% New York Medicaid APG,5571.22,,,5571.22,Other,225% New York Medicaid APG,3466.54,,,3466.54,Other,140% New York Medicaid APG,5571.22,,,5571.22,Other,225% New York Medicaid APG,6437.85,,,6437.85,Other,260% New York Medicaid APG,8022.56,,,8022.56,Other,324% New York Medicaid APG,5323.61,,,5323.61,Other,215% New York Medicaid APG,5323.61,,,5323.61,Other,215% New York Medicaid APG,3095.12,,,3095.12,Other,125% New York Medicaid APG,2053,69273.12,
Open/perq place stent 1st,37236,CPT,,,,,,,,both,,,128514,95100.36,74,,95100.36,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,57831.3,45,,57831.3,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,63614.43,49.5,,63614.43,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,4605.54,,,4605.54,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9196,,"100% primary, 0% secondary procedures",9196,Other,MagnaCare ASC Grouper,89959.8,70,,89959.8,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6956,,"100% primary, 50% secondary, 25% tertiary procedure",6956,Other,United Healthcare ASC Grouper,6261,,"100% primary, 50% secondary, 25% tertiary procedure",6261,Other,United Healthcare ASC Grouper,6956,,"100% primary, 50% secondary, 25% tertiary procedure",6956,Other,United Healthcare ASC Grouper,5913,,"100% primary, 50% secondary, 25% tertiary procedure",5913,Other,United Healthcare ASC Grouper,2476.1,,,2476.1,Other,New York Medicaid APG methodology,2476.1,,,2476.1,Other,100% New York Medicaid APG,2476.1,,,2476.1,Other,100% New York Medicaid APG,2476.1,,,2476.1,Other,100% New York Medicaid APG,5571.22,,,5571.22,Other,225% New York Medicaid APG,3788.43,,,3788.43,Other,153% New York Medicaid APG,5571.22,,,5571.22,Other,225% New York Medicaid APG,3466.54,,,3466.54,Other,140% New York Medicaid APG,5571.22,,,5571.22,Other,225% New York Medicaid APG,6437.85,,,6437.85,Other,260% New York Medicaid APG,8022.56,,,8022.56,Other,324% New York Medicaid APG,5323.61,,,5323.61,Other,215% New York Medicaid APG,5323.61,,,5323.61,Other,215% New York Medicaid APG,3095.12,,,3095.12,Other,125% New York Medicaid APG,2476.1,95100.36,
Open/perq place stent ea add,37237,CPT,,,,,,,,both,,,51572.04,38163.31,74,,38163.31,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,23207.42,45,,23207.42,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,25528.16,49.5,,25528.16,percent of total billed charges,110% of Medicare,35068.99,68,,35068.99,percent of total billed charges,,4605.54,,,4605.54,Other,186% of Medicaid,41257.63,80,,41257.63,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,41257.63,80,,41257.63,percent of total billed charges,,7216,,,7216,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,36100.43,70,,36100.43,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,2476.1,,,2476.1,Other,New York Medicaid APG methodology,2476.1,,,2476.1,Other,100% New York Medicaid APG,2476.1,,,2476.1,Other,100% New York Medicaid APG,2476.1,,,2476.1,Other,100% New York Medicaid APG,5571.22,,,5571.22,Other,225% New York Medicaid APG,3788.43,,,3788.43,Other,153% New York Medicaid APG,5571.22,,,5571.22,Other,225% New York Medicaid APG,3466.54,,,3466.54,Other,140% New York Medicaid APG,5571.22,,,5571.22,Other,225% New York Medicaid APG,6437.85,,,6437.85,Other,260% New York Medicaid APG,8022.56,,,8022.56,Other,324% New York Medicaid APG,5323.61,,,5323.61,Other,215% New York Medicaid APG,5323.61,,,5323.61,Other,215% New York Medicaid APG,3095.12,,,3095.12,Other,125% New York Medicaid APG,2053,41257.63,
Open/perq place stent same,37238,CPT,,,,,,,,both,,,99592.33,73698.32,74,,73698.32,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,44816.55,45,,44816.55,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,49298.2,49.5,,49298.2,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,4605.54,,,4605.54,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9196,,"100% primary, 0% secondary procedures",9196,Other,MagnaCare ASC Grouper,69714.63,70,,69714.63,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6956,,"100% primary, 50% secondary, 25% tertiary procedure",6956,Other,United Healthcare ASC Grouper,6261,,"100% primary, 50% secondary, 25% tertiary procedure",6261,Other,United Healthcare ASC Grouper,6956,,"100% primary, 50% secondary, 25% tertiary procedure",6956,Other,United Healthcare ASC Grouper,5913,,"100% primary, 50% secondary, 25% tertiary procedure",5913,Other,United Healthcare ASC Grouper,2476.1,,,2476.1,Other,New York Medicaid APG methodology,2476.1,,,2476.1,Other,100% New York Medicaid APG,2476.1,,,2476.1,Other,100% New York Medicaid APG,2476.1,,,2476.1,Other,100% New York Medicaid APG,5571.22,,,5571.22,Other,225% New York Medicaid APG,3788.43,,,3788.43,Other,153% New York Medicaid APG,5571.22,,,5571.22,Other,225% New York Medicaid APG,3466.54,,,3466.54,Other,140% New York Medicaid APG,5571.22,,,5571.22,Other,225% New York Medicaid APG,6437.85,,,6437.85,Other,260% New York Medicaid APG,8022.56,,,8022.56,Other,324% New York Medicaid APG,5323.61,,,5323.61,Other,215% New York Medicaid APG,5323.61,,,5323.61,Other,215% New York Medicaid APG,3095.12,,,3095.12,Other,125% New York Medicaid APG,2476.1,73698.32,
Open/perq place stent ea add,37239,CPT,,,,,,,,both,,,51572.04,38163.31,74,,38163.31,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,23207.42,45,,23207.42,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,25528.16,49.5,,25528.16,percent of total billed charges,110% of Medicare,35068.99,68,,35068.99,percent of total billed charges,,4605.54,,,4605.54,Other,186% of Medicaid,41257.63,80,,41257.63,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,41257.63,80,,41257.63,percent of total billed charges,,7216,,,7216,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,36100.43,70,,36100.43,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,2476.1,,,2476.1,Other,New York Medicaid APG methodology,2476.1,,,2476.1,Other,100% New York Medicaid APG,2476.1,,,2476.1,Other,100% New York Medicaid APG,2476.1,,,2476.1,Other,100% New York Medicaid APG,5571.22,,,5571.22,Other,225% New York Medicaid APG,3788.43,,,3788.43,Other,153% New York Medicaid APG,5571.22,,,5571.22,Other,225% New York Medicaid APG,3466.54,,,3466.54,Other,140% New York Medicaid APG,5571.22,,,5571.22,Other,225% New York Medicaid APG,6437.85,,,6437.85,Other,260% New York Medicaid APG,8022.56,,,8022.56,Other,324% New York Medicaid APG,5323.61,,,5323.61,Other,215% New York Medicaid APG,5323.61,,,5323.61,Other,215% New York Medicaid APG,3095.12,,,3095.12,Other,125% New York Medicaid APG,2053,41257.63,
Vasc embolize/occlude venous,37241,CPT,,,,,,,,both,,,71391.01,52829.35,74,,52829.35,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,32125.95,45,,32125.95,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,35338.55,49.5,,35338.55,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,4605.54,,,4605.54,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9196,,"100% primary, 0% secondary procedures",9196,Other,MagnaCare ASC Grouper,49973.71,70,,49973.71,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6956,,"100% primary, 50% secondary, 25% tertiary procedure",6956,Other,United Healthcare ASC Grouper,6261,,"100% primary, 50% secondary, 25% tertiary procedure",6261,Other,United Healthcare ASC Grouper,6956,,"100% primary, 50% secondary, 25% tertiary procedure",6956,Other,United Healthcare ASC Grouper,5913,,"100% primary, 50% secondary, 25% tertiary procedure",5913,Other,United Healthcare ASC Grouper,2476.1,,,2476.1,Other,New York Medicaid APG methodology,2476.1,,,2476.1,Other,100% New York Medicaid APG,2476.1,,,2476.1,Other,100% New York Medicaid APG,2476.1,,,2476.1,Other,100% New York Medicaid APG,5571.22,,,5571.22,Other,225% New York Medicaid APG,3788.43,,,3788.43,Other,153% New York Medicaid APG,5571.22,,,5571.22,Other,225% New York Medicaid APG,3466.54,,,3466.54,Other,140% New York Medicaid APG,5571.22,,,5571.22,Other,225% New York Medicaid APG,6437.85,,,6437.85,Other,260% New York Medicaid APG,8022.56,,,8022.56,Other,324% New York Medicaid APG,5323.61,,,5323.61,Other,215% New York Medicaid APG,5323.61,,,5323.61,Other,215% New York Medicaid APG,3095.12,,,3095.12,Other,125% New York Medicaid APG,2476.1,52829.35,
Vasc embolize/occlude artery,37242,CPT,,,,,,,,both,,,58008,42925.92,74,,42925.92,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,26103.6,45,,26103.6,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,28713.96,49.5,,28713.96,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,4605.54,,,4605.54,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9196,,"100% primary, 0% secondary procedures",9196,Other,MagnaCare ASC Grouper,40605.6,70,,40605.6,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6956,,"100% primary, 50% secondary, 25% tertiary procedure",6956,Other,United Healthcare ASC Grouper,6261,,"100% primary, 50% secondary, 25% tertiary procedure",6261,Other,United Healthcare ASC Grouper,6956,,"100% primary, 50% secondary, 25% tertiary procedure",6956,Other,United Healthcare ASC Grouper,5913,,"100% primary, 50% secondary, 25% tertiary procedure",5913,Other,United Healthcare ASC Grouper,2476.1,,,2476.1,Other,New York Medicaid APG methodology,2476.1,,,2476.1,Other,100% New York Medicaid APG,2476.1,,,2476.1,Other,100% New York Medicaid APG,2476.1,,,2476.1,Other,100% New York Medicaid APG,5571.22,,,5571.22,Other,225% New York Medicaid APG,3788.43,,,3788.43,Other,153% New York Medicaid APG,5571.22,,,5571.22,Other,225% New York Medicaid APG,3466.54,,,3466.54,Other,140% New York Medicaid APG,5571.22,,,5571.22,Other,225% New York Medicaid APG,6437.85,,,6437.85,Other,260% New York Medicaid APG,8022.56,,,8022.56,Other,324% New York Medicaid APG,5323.61,,,5323.61,Other,215% New York Medicaid APG,5323.61,,,5323.61,Other,215% New York Medicaid APG,3095.12,,,3095.12,Other,125% New York Medicaid APG,2476.1,42925.92,
Vasc embolize/occlude organ,37243,CPT,,,,,,,,both,,,105190.95,77841.3,74,,77841.3,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,47335.93,45,,47335.93,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,52069.52,49.5,,52069.52,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,4605.54,,,4605.54,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9196,,"100% primary, 0% secondary procedures",9196,Other,MagnaCare ASC Grouper,73633.67,70,,73633.67,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6956,,"100% primary, 50% secondary, 25% tertiary procedure",6956,Other,United Healthcare ASC Grouper,6261,,"100% primary, 50% secondary, 25% tertiary procedure",6261,Other,United Healthcare ASC Grouper,6956,,"100% primary, 50% secondary, 25% tertiary procedure",6956,Other,United Healthcare ASC Grouper,5913,,"100% primary, 50% secondary, 25% tertiary procedure",5913,Other,United Healthcare ASC Grouper,2476.1,,,2476.1,Other,New York Medicaid APG methodology,2476.1,,,2476.1,Other,100% New York Medicaid APG,2476.1,,,2476.1,Other,100% New York Medicaid APG,2476.1,,,2476.1,Other,100% New York Medicaid APG,5571.22,,,5571.22,Other,225% New York Medicaid APG,3788.43,,,3788.43,Other,153% New York Medicaid APG,5571.22,,,5571.22,Other,225% New York Medicaid APG,3466.54,,,3466.54,Other,140% New York Medicaid APG,5571.22,,,5571.22,Other,225% New York Medicaid APG,6437.85,,,6437.85,Other,260% New York Medicaid APG,8022.56,,,8022.56,Other,324% New York Medicaid APG,5323.61,,,5323.61,Other,215% New York Medicaid APG,5323.61,,,5323.61,Other,215% New York Medicaid APG,3095.12,,,3095.12,Other,125% New York Medicaid APG,2476.1,77841.3,
Vasc embolize/occlude bleed,37244,CPT,,,,,,,,both,,,59963.33,44372.86,74,,44372.86,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,26983.5,45,,26983.5,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,29681.85,49.5,,29681.85,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,4605.54,,,4605.54,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9196,,"100% primary, 0% secondary procedures",9196,Other,MagnaCare ASC Grouper,41974.33,70,,41974.33,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6956,,"100% primary, 50% secondary, 25% tertiary procedure",6956,Other,United Healthcare ASC Grouper,6261,,"100% primary, 50% secondary, 25% tertiary procedure",6261,Other,United Healthcare ASC Grouper,6956,,"100% primary, 50% secondary, 25% tertiary procedure",6956,Other,United Healthcare ASC Grouper,5913,,"100% primary, 50% secondary, 25% tertiary procedure",5913,Other,United Healthcare ASC Grouper,2476.1,,,2476.1,Other,New York Medicaid APG methodology,2476.1,,,2476.1,Other,100% New York Medicaid APG,2476.1,,,2476.1,Other,100% New York Medicaid APG,2476.1,,,2476.1,Other,100% New York Medicaid APG,5571.22,,,5571.22,Other,225% New York Medicaid APG,3788.43,,,3788.43,Other,153% New York Medicaid APG,5571.22,,,5571.22,Other,225% New York Medicaid APG,3466.54,,,3466.54,Other,140% New York Medicaid APG,5571.22,,,5571.22,Other,225% New York Medicaid APG,6437.85,,,6437.85,Other,260% New York Medicaid APG,8022.56,,,8022.56,Other,324% New York Medicaid APG,5323.61,,,5323.61,Other,215% New York Medicaid APG,5323.61,,,5323.61,Other,215% New York Medicaid APG,3095.12,,,3095.12,Other,125% New York Medicaid APG,2476.1,44372.86,
Trluml balo angiop 1st art,37246,CPT,,,,,,,,both,,,120221.84,88964.16,74,,88964.16,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,54099.83,45,,54099.83,percent of total billed charges,Medicare Ratio of cost to charges,5954,,"100% primary, 50% supplemental procedure",5954,Other,Aetna ASC Grouper,5359,,"100% primary, 50% supplemental procedure",5359,Other,Aetna ASC Grouper,7266,,"100% primary, 50% secondary, 25% supplemental procedure",7266,Other,Blue Cross ASC Grouper,6539,,"100% primary, 50% secondary, 25% supplemental procedure",6539,Other,Blue Cross ASC Grouper,6176,,"100% primary, 50% secondary, 25% supplemental procedure",6176,Other,Blue Cross ASC Grouper,59509.81,49.5,,59509.81,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3853.44,,,3853.44,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,84155.29,70,,84155.29,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,2071.74,,,2071.74,Other,New York Medicaid APG methodology,2071.74,,,2071.74,Other,100% New York Medicaid APG,2071.74,,,2071.74,Other,100% New York Medicaid APG,2071.74,,,2071.74,Other,100% New York Medicaid APG,4661.42,,,4661.42,Other,225% New York Medicaid APG,3169.77,,,3169.77,Other,153% New York Medicaid APG,4661.42,,,4661.42,Other,225% New York Medicaid APG,2900.44,,,2900.44,Other,140% New York Medicaid APG,4661.42,,,4661.42,Other,225% New York Medicaid APG,5386.53,,,5386.53,Other,260% New York Medicaid APG,6712.45,,,6712.45,Other,324% New York Medicaid APG,4454.25,,,4454.25,Other,215% New York Medicaid APG,4454.25,,,4454.25,Other,215% New York Medicaid APG,2589.68,,,2589.68,Other,125% New York Medicaid APG,2071.74,88964.16,
Trluml balo angiop addl art,37247,CPT,,,,,,,,both,,,83504,61792.96,74,,61792.96,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,37576.8,45,,37576.8,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,41334.48,49.5,,41334.48,percent of total billed charges,110% of Medicare,56782.72,68,,56782.72,percent of total billed charges,,4605.53,,,4605.53,Other,186% of Medicaid,66803.2,80,,66803.2,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,66803.2,80,,66803.2,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,58452.8,70,,58452.8,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,2476.09,,,2476.09,Other,New York Medicaid APG methodology,2476.09,,,2476.09,Other,100% New York Medicaid APG,2476.09,,,2476.09,Other,100% New York Medicaid APG,2476.09,,,2476.09,Other,100% New York Medicaid APG,5571.21,,,5571.21,Other,225% New York Medicaid APG,3788.42,,,3788.42,Other,153% New York Medicaid APG,5571.21,,,5571.21,Other,225% New York Medicaid APG,3466.53,,,3466.53,Other,140% New York Medicaid APG,5571.21,,,5571.21,Other,225% New York Medicaid APG,6437.84,,,6437.84,Other,260% New York Medicaid APG,8022.54,,,8022.54,Other,324% New York Medicaid APG,5323.6,,,5323.6,Other,215% New York Medicaid APG,5323.6,,,5323.6,Other,215% New York Medicaid APG,3095.12,,,3095.12,Other,125% New York Medicaid APG,2053,66803.2,
Trluml balo angiop 1st vein,37248,CPT,,,,,,,,both,,,76655,56724.7,74,,56724.7,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,34494.75,45,,34494.75,percent of total billed charges,Medicare Ratio of cost to charges,5954,,"100% primary, 50% supplemental procedure",5954,Other,Aetna ASC Grouper,5359,,"100% primary, 50% supplemental procedure",5359,Other,Aetna ASC Grouper,7266,,"100% primary, 50% secondary, 25% supplemental procedure",7266,Other,Blue Cross ASC Grouper,6539,,"100% primary, 50% secondary, 25% supplemental procedure",6539,Other,Blue Cross ASC Grouper,6176,,"100% primary, 50% secondary, 25% supplemental procedure",6176,Other,Blue Cross ASC Grouper,37944.23,49.5,,37944.23,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3853.44,,,3853.44,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,53658.5,70,,53658.5,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,2071.74,,,2071.74,Other,New York Medicaid APG methodology,2071.74,,,2071.74,Other,100% New York Medicaid APG,2071.74,,,2071.74,Other,100% New York Medicaid APG,2071.74,,,2071.74,Other,100% New York Medicaid APG,4661.42,,,4661.42,Other,225% New York Medicaid APG,3169.77,,,3169.77,Other,153% New York Medicaid APG,4661.42,,,4661.42,Other,225% New York Medicaid APG,2900.44,,,2900.44,Other,140% New York Medicaid APG,4661.42,,,4661.42,Other,225% New York Medicaid APG,5386.53,,,5386.53,Other,260% New York Medicaid APG,6712.45,,,6712.45,Other,324% New York Medicaid APG,4454.25,,,4454.25,Other,215% New York Medicaid APG,4454.25,,,4454.25,Other,215% New York Medicaid APG,2589.68,,,2589.68,Other,125% New York Medicaid APG,2071.74,56724.7,
Trluml balo angiop addl vein,37249,CPT,,,,,,,,both,,,83504,61792.96,74,,61792.96,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,37576.8,45,,37576.8,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,41334.48,49.5,,41334.48,percent of total billed charges,110% of Medicare,56782.72,68,,56782.72,percent of total billed charges,,4605.53,,,4605.53,Other,186% of Medicaid,66803.2,80,,66803.2,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,66803.2,80,,66803.2,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,58452.8,70,,58452.8,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,2476.09,,,2476.09,Other,New York Medicaid APG methodology,2476.09,,,2476.09,Other,100% New York Medicaid APG,2476.09,,,2476.09,Other,100% New York Medicaid APG,2476.09,,,2476.09,Other,100% New York Medicaid APG,5571.21,,,5571.21,Other,225% New York Medicaid APG,3788.42,,,3788.42,Other,153% New York Medicaid APG,5571.21,,,5571.21,Other,225% New York Medicaid APG,3466.53,,,3466.53,Other,140% New York Medicaid APG,5571.21,,,5571.21,Other,225% New York Medicaid APG,6437.84,,,6437.84,Other,260% New York Medicaid APG,8022.54,,,8022.54,Other,324% New York Medicaid APG,5323.6,,,5323.6,Other,215% New York Medicaid APG,5323.6,,,5323.6,Other,215% New York Medicaid APG,3095.12,,,3095.12,Other,125% New York Medicaid APG,2053,66803.2,
Intrvasc us noncoronary 1st,37252,CPT,,,,,,,,both,,,32432.1,23999.75,74,,23999.75,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,14594.45,45,,14594.45,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,16053.89,49.5,,16053.89,percent of total billed charges,110% of Medicare,22053.83,68,,22053.83,percent of total billed charges,,3002.5,,,3002.5,Other,186% of Medicaid,25945.68,80,,25945.68,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,25945.68,80,,25945.68,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,22702.47,70,,22702.47,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,1614.25,,,1614.25,Other,New York Medicaid APG methodology,1614.25,,,1614.25,Other,100% New York Medicaid APG,1614.25,,,1614.25,Other,100% New York Medicaid APG,1614.25,,,1614.25,Other,100% New York Medicaid APG,3632.06,,,3632.06,Other,225% New York Medicaid APG,2469.8,,,2469.8,Other,153% New York Medicaid APG,3632.06,,,3632.06,Other,225% New York Medicaid APG,2259.95,,,2259.95,Other,140% New York Medicaid APG,3632.06,,,3632.06,Other,225% New York Medicaid APG,4197.05,,,4197.05,Other,260% New York Medicaid APG,5230.17,,,5230.17,Other,324% New York Medicaid APG,3470.64,,,3470.64,Other,215% New York Medicaid APG,3470.64,,,3470.64,Other,215% New York Medicaid APG,2017.81,,,2017.81,Other,125% New York Medicaid APG,1614.25,25945.68,
Intrvasc us noncoronary addl,37253,CPT,,,,,,,,both,,,32432.1,23999.75,74,,23999.75,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,14594.45,45,,14594.45,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,16053.89,49.5,,16053.89,percent of total billed charges,110% of Medicare,22053.83,68,,22053.83,percent of total billed charges,,3002.5,,,3002.5,Other,186% of Medicaid,25945.68,80,,25945.68,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,25945.68,80,,25945.68,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,22702.47,70,,22702.47,percent of total billed charges,,337.84,,,337.84,Fee Schedule,,286.34,,,286.34,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,1614.25,,,1614.25,Other,New York Medicaid APG methodology,1614.25,,,1614.25,Other,100% New York Medicaid APG,1614.25,,,1614.25,Other,100% New York Medicaid APG,1614.25,,,1614.25,Other,100% New York Medicaid APG,3632.06,,,3632.06,Other,225% New York Medicaid APG,2469.8,,,2469.8,Other,153% New York Medicaid APG,3632.06,,,3632.06,Other,225% New York Medicaid APG,2259.95,,,2259.95,Other,140% New York Medicaid APG,3632.06,,,3632.06,Other,225% New York Medicaid APG,4197.05,,,4197.05,Other,260% New York Medicaid APG,5230.17,,,5230.17,Other,324% New York Medicaid APG,3470.64,,,3470.64,Other,215% New York Medicaid APG,3470.64,,,3470.64,Other,215% New York Medicaid APG,2017.81,,,2017.81,Other,125% New York Medicaid APG,286.34,25945.68,
Endoscopy ligate perf veins,37500,CPT,,,,,,,,both,,,115587.67,85534.88,74,,85534.88,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,52014.45,45,,52014.45,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,57215.9,49.5,,57215.9,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,4418.36,,,4418.36,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,80911.37,70,,80911.37,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,2375.46,,,2375.46,Other,New York Medicaid APG methodology,2375.46,,,2375.46,Other,100% New York Medicaid APG,2375.46,,,2375.46,Other,100% New York Medicaid APG,2375.46,,,2375.46,Other,100% New York Medicaid APG,5344.79,,,5344.79,Other,225% New York Medicaid APG,3634.46,,,3634.46,Other,153% New York Medicaid APG,5344.79,,,5344.79,Other,225% New York Medicaid APG,3325.65,,,3325.65,Other,140% New York Medicaid APG,5344.79,,,5344.79,Other,225% New York Medicaid APG,6176.2,,,6176.2,Other,260% New York Medicaid APG,7696.49,,,7696.49,Other,324% New York Medicaid APG,5107.24,,,5107.24,Other,215% New York Medicaid APG,5107.24,,,5107.24,Other,215% New York Medicaid APG,2969.33,,,2969.33,Other,125% New York Medicaid APG,2375.46,85534.88,
Ligation of neck vein,37565,CPT,,,,,,,,both,,,67044.74,49613.11,74,,49613.11,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30170.13,45,,30170.13,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,33187.15,49.5,,33187.15,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,4418.36,,,4418.36,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,3578,,"100% primary, 0% secondary procedures",3578,Other,MagnaCare ASC Grouper,46931.32,70,,46931.32,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,2375.46,,,2375.46,Other,New York Medicaid APG methodology,2375.46,,,2375.46,Other,100% New York Medicaid APG,2375.46,,,2375.46,Other,100% New York Medicaid APG,2375.46,,,2375.46,Other,100% New York Medicaid APG,5344.79,,,5344.79,Other,225% New York Medicaid APG,3634.45,,,3634.45,Other,153% New York Medicaid APG,5344.79,,,5344.79,Other,225% New York Medicaid APG,3325.64,,,3325.64,Other,140% New York Medicaid APG,5344.79,,,5344.79,Other,225% New York Medicaid APG,6176.2,,,6176.2,Other,260% New York Medicaid APG,7696.49,,,7696.49,Other,324% New York Medicaid APG,5107.24,,,5107.24,Other,215% New York Medicaid APG,5107.24,,,5107.24,Other,215% New York Medicaid APG,2969.33,,,2969.33,Other,125% New York Medicaid APG,2375.46,49613.11,
Ligation of neck artery,37600,CPT,,,,,,,,both,,,67044.74,49613.11,74,,49613.11,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30170.13,45,,30170.13,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33187.15,49.5,,33187.15,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,4349.98,,,4349.98,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,46931.32,70,,46931.32,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,2338.7,,,2338.7,Other,New York Medicaid APG methodology,2338.7,,,2338.7,Other,100% New York Medicaid APG,2338.7,,,2338.7,Other,100% New York Medicaid APG,2338.7,,,2338.7,Other,100% New York Medicaid APG,5262.07,,,5262.07,Other,225% New York Medicaid APG,3578.21,,,3578.21,Other,153% New York Medicaid APG,5262.07,,,5262.07,Other,225% New York Medicaid APG,3274.18,,,3274.18,Other,140% New York Medicaid APG,5262.07,,,5262.07,Other,225% New York Medicaid APG,6080.62,,,6080.62,Other,260% New York Medicaid APG,7577.38,,,7577.38,Other,324% New York Medicaid APG,5028.2,,,5028.2,Other,215% New York Medicaid APG,5028.2,,,5028.2,Other,215% New York Medicaid APG,2923.37,,,2923.37,Other,125% New York Medicaid APG,2338.7,49613.11,
Ligation of neck artery,37605,CPT,,,,,,,,both,,,67044.74,49613.11,74,,49613.11,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30170.13,45,,30170.13,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33187.15,49.5,,33187.15,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,4349.98,,,4349.98,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,46931.32,70,,46931.32,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,2338.7,,,2338.7,Other,New York Medicaid APG methodology,2338.7,,,2338.7,Other,100% New York Medicaid APG,2338.7,,,2338.7,Other,100% New York Medicaid APG,2338.7,,,2338.7,Other,100% New York Medicaid APG,5262.07,,,5262.07,Other,225% New York Medicaid APG,3578.21,,,3578.21,Other,153% New York Medicaid APG,5262.07,,,5262.07,Other,225% New York Medicaid APG,3274.18,,,3274.18,Other,140% New York Medicaid APG,5262.07,,,5262.07,Other,225% New York Medicaid APG,6080.62,,,6080.62,Other,260% New York Medicaid APG,7577.38,,,7577.38,Other,324% New York Medicaid APG,5028.2,,,5028.2,Other,215% New York Medicaid APG,5028.2,,,5028.2,Other,215% New York Medicaid APG,2923.37,,,2923.37,Other,125% New York Medicaid APG,2338.7,49613.11,
Ligation of neck artery,37606,CPT,,,,,,,,both,,,67044.74,49613.11,74,,49613.11,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30170.13,45,,30170.13,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33187.15,49.5,,33187.15,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,4349.98,,,4349.98,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,46931.32,70,,46931.32,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,2338.7,,,2338.7,Other,New York Medicaid APG methodology,2338.7,,,2338.7,Other,100% New York Medicaid APG,2338.7,,,2338.7,Other,100% New York Medicaid APG,2338.7,,,2338.7,Other,100% New York Medicaid APG,5262.07,,,5262.07,Other,225% New York Medicaid APG,3578.21,,,3578.21,Other,153% New York Medicaid APG,5262.07,,,5262.07,Other,225% New York Medicaid APG,3274.18,,,3274.18,Other,140% New York Medicaid APG,5262.07,,,5262.07,Other,225% New York Medicaid APG,6080.62,,,6080.62,Other,260% New York Medicaid APG,7577.38,,,7577.38,Other,324% New York Medicaid APG,5028.2,,,5028.2,Other,215% New York Medicaid APG,5028.2,,,5028.2,Other,215% New York Medicaid APG,2923.37,,,2923.37,Other,125% New York Medicaid APG,2338.7,49613.11,
Ligation of a-v fistula,37607,CPT,,,,,,,,both,,,37131.52,27477.32,74,,27477.32,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,16709.18,45,,16709.18,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,18380.1,49.5,,18380.1,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,4418.36,,,4418.36,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,25992.06,70,,25992.06,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,2375.46,,,2375.46,Other,New York Medicaid APG methodology,2375.46,,,2375.46,Other,100% New York Medicaid APG,2375.46,,,2375.46,Other,100% New York Medicaid APG,2375.46,,,2375.46,Other,100% New York Medicaid APG,5344.79,,,5344.79,Other,225% New York Medicaid APG,3634.45,,,3634.45,Other,153% New York Medicaid APG,5344.79,,,5344.79,Other,225% New York Medicaid APG,3325.64,,,3325.64,Other,140% New York Medicaid APG,5344.79,,,5344.79,Other,225% New York Medicaid APG,6176.2,,,6176.2,Other,260% New York Medicaid APG,7696.49,,,7696.49,Other,324% New York Medicaid APG,5107.24,,,5107.24,Other,215% New York Medicaid APG,5107.24,,,5107.24,Other,215% New York Medicaid APG,2969.33,,,2969.33,Other,125% New York Medicaid APG,2375.46,27477.32,
Temporal artery procedure,37609,CPT,,,,,,,,both,,,34281.79,25368.52,74,,25368.52,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15426.81,45,,15426.81,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,16969.49,49.5,,16969.49,percent of total billed charges,110% of Medicare,23311.62,68,,23311.62,percent of total billed charges,,4418.36,,,4418.36,Other,186% of Medicaid,27425.43,80,,27425.43,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,27425.43,80,,27425.43,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,23997.25,70,,23997.25,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,2375.46,,,2375.46,Other,New York Medicaid APG methodology,2375.46,,,2375.46,Other,100% New York Medicaid APG,2375.46,,,2375.46,Other,100% New York Medicaid APG,2375.46,,,2375.46,Other,100% New York Medicaid APG,5344.79,,,5344.79,Other,225% New York Medicaid APG,3634.45,,,3634.45,Other,153% New York Medicaid APG,5344.79,,,5344.79,Other,225% New York Medicaid APG,3325.64,,,3325.64,Other,140% New York Medicaid APG,5344.79,,,5344.79,Other,225% New York Medicaid APG,6176.2,,,6176.2,Other,260% New York Medicaid APG,7696.49,,,7696.49,Other,324% New York Medicaid APG,5107.24,,,5107.24,Other,215% New York Medicaid APG,5107.24,,,5107.24,Other,215% New York Medicaid APG,2969.33,,,2969.33,Other,125% New York Medicaid APG,2232,27425.43,
Ligation of neck artery,37615,CPT,,,,,,,,both,,,67044.74,49613.11,74,,49613.11,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30170.13,45,,30170.13,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,33187.15,49.5,,33187.15,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,4418.36,,,4418.36,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,3578,,"100% primary, 0% secondary procedures",3578,Other,MagnaCare ASC Grouper,46931.32,70,,46931.32,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,2375.46,,,2375.46,Other,New York Medicaid APG methodology,2375.46,,,2375.46,Other,100% New York Medicaid APG,2375.46,,,2375.46,Other,100% New York Medicaid APG,2375.46,,,2375.46,Other,100% New York Medicaid APG,5344.79,,,5344.79,Other,225% New York Medicaid APG,3634.45,,,3634.45,Other,153% New York Medicaid APG,5344.79,,,5344.79,Other,225% New York Medicaid APG,3325.64,,,3325.64,Other,140% New York Medicaid APG,5344.79,,,5344.79,Other,225% New York Medicaid APG,6176.2,,,6176.2,Other,260% New York Medicaid APG,7696.49,,,7696.49,Other,324% New York Medicaid APG,5107.24,,,5107.24,Other,215% New York Medicaid APG,5107.24,,,5107.24,Other,215% New York Medicaid APG,2969.33,,,2969.33,Other,125% New York Medicaid APG,2375.46,49613.11,
Ligation of inf vena cava,37619,CPT,,,,,,,,both,,,115587.67,85534.88,74,,85534.88,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,52014.45,45,,52014.45,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,57215.9,49.5,,57215.9,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,4418.36,,,4418.36,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,80911.37,70,,80911.37,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,2375.46,,,2375.46,Other,New York Medicaid APG methodology,2375.46,,,2375.46,Other,100% New York Medicaid APG,2375.46,,,2375.46,Other,100% New York Medicaid APG,2375.46,,,2375.46,Other,100% New York Medicaid APG,5344.79,,,5344.79,Other,225% New York Medicaid APG,3634.46,,,3634.46,Other,153% New York Medicaid APG,5344.79,,,5344.79,Other,225% New York Medicaid APG,3325.65,,,3325.65,Other,140% New York Medicaid APG,5344.79,,,5344.79,Other,225% New York Medicaid APG,6176.2,,,6176.2,Other,260% New York Medicaid APG,7696.49,,,7696.49,Other,324% New York Medicaid APG,5107.24,,,5107.24,Other,215% New York Medicaid APG,5107.24,,,5107.24,Other,215% New York Medicaid APG,2969.33,,,2969.33,Other,125% New York Medicaid APG,2375.46,85534.88,
Revision of major vein,37650,CPT,,,,,,,,both,,,67044.74,49613.11,74,,49613.11,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30170.13,45,,30170.13,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33187.15,49.5,,33187.15,percent of total billed charges,110% of Medicare,45590.42,68,,45590.42,percent of total billed charges,,4418.36,,,4418.36,Other,186% of Medicaid,53635.79,80,,53635.79,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,53635.79,80,,53635.79,percent of total billed charges,,7216,,,7216,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,46931.32,70,,46931.32,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,2375.46,,,2375.46,Other,New York Medicaid APG methodology,2375.46,,,2375.46,Other,100% New York Medicaid APG,2375.46,,,2375.46,Other,100% New York Medicaid APG,2375.46,,,2375.46,Other,100% New York Medicaid APG,5344.79,,,5344.79,Other,225% New York Medicaid APG,3634.45,,,3634.45,Other,153% New York Medicaid APG,5344.79,,,5344.79,Other,225% New York Medicaid APG,3325.64,,,3325.64,Other,140% New York Medicaid APG,5344.79,,,5344.79,Other,225% New York Medicaid APG,6176.2,,,6176.2,Other,260% New York Medicaid APG,7696.49,,,7696.49,Other,324% New York Medicaid APG,5107.24,,,5107.24,Other,215% New York Medicaid APG,5107.24,,,5107.24,Other,215% New York Medicaid APG,2969.33,,,2969.33,Other,125% New York Medicaid APG,2232,53635.79,
Revise leg vein,37700,CPT,,,,,,,,both,,,41492.11,30704.16,74,,30704.16,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,18671.45,45,,18671.45,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,20538.59,49.5,,20538.59,percent of total billed charges,110% of Medicare,28214.63,68,,28214.63,percent of total billed charges,,4156.45,,,4156.45,Other,186% of Medicaid,33193.69,80,,33193.69,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,33193.69,80,,33193.69,percent of total billed charges,,7216,,,7216,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,29044.48,70,,29044.48,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,2234.65,,,2234.65,Other,New York Medicaid APG methodology,2234.65,,,2234.65,Other,100% New York Medicaid APG,2234.65,,,2234.65,Other,100% New York Medicaid APG,2234.65,,,2234.65,Other,100% New York Medicaid APG,5027.97,,,5027.97,Other,225% New York Medicaid APG,3419.02,,,3419.02,Other,153% New York Medicaid APG,5027.97,,,5027.97,Other,225% New York Medicaid APG,3128.51,,,3128.51,Other,140% New York Medicaid APG,5027.97,,,5027.97,Other,225% New York Medicaid APG,5810.1,,,5810.1,Other,260% New York Medicaid APG,7240.28,,,7240.28,Other,324% New York Medicaid APG,4804.5,,,4804.5,Other,215% New York Medicaid APG,4804.5,,,4804.5,Other,215% New York Medicaid APG,2793.32,,,2793.32,Other,125% New York Medicaid APG,2232,33193.69,
Ligate/strip short leg vein,37718,CPT,,,,,,,,both,,,67044.74,49613.11,74,,49613.11,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30170.13,45,,30170.13,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33187.15,49.5,,33187.15,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,4156.45,,,4156.45,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,46931.32,70,,46931.32,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,2234.65,,,2234.65,Other,New York Medicaid APG methodology,2234.65,,,2234.65,Other,100% New York Medicaid APG,2234.65,,,2234.65,Other,100% New York Medicaid APG,2234.65,,,2234.65,Other,100% New York Medicaid APG,5027.97,,,5027.97,Other,225% New York Medicaid APG,3419.02,,,3419.02,Other,153% New York Medicaid APG,5027.97,,,5027.97,Other,225% New York Medicaid APG,3128.51,,,3128.51,Other,140% New York Medicaid APG,5027.97,,,5027.97,Other,225% New York Medicaid APG,5810.1,,,5810.1,Other,260% New York Medicaid APG,7240.28,,,7240.28,Other,324% New York Medicaid APG,4804.5,,,4804.5,Other,215% New York Medicaid APG,4804.5,,,4804.5,Other,215% New York Medicaid APG,2793.32,,,2793.32,Other,125% New York Medicaid APG,2234.65,49613.11,
Ligate/strip long leg vein,37722,CPT,,,,,,,,both,,,44299.77,32781.83,74,,32781.83,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,19934.9,45,,19934.9,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,21928.39,49.5,,21928.39,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,4156.45,,,4156.45,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,31009.84,70,,31009.84,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,2234.65,,,2234.65,Other,New York Medicaid APG methodology,2234.65,,,2234.65,Other,100% New York Medicaid APG,2234.65,,,2234.65,Other,100% New York Medicaid APG,2234.65,,,2234.65,Other,100% New York Medicaid APG,5027.97,,,5027.97,Other,225% New York Medicaid APG,3419.02,,,3419.02,Other,153% New York Medicaid APG,5027.97,,,5027.97,Other,225% New York Medicaid APG,3128.51,,,3128.51,Other,140% New York Medicaid APG,5027.97,,,5027.97,Other,225% New York Medicaid APG,5810.1,,,5810.1,Other,260% New York Medicaid APG,7240.28,,,7240.28,Other,324% New York Medicaid APG,4804.5,,,4804.5,Other,215% New York Medicaid APG,4804.5,,,4804.5,Other,215% New York Medicaid APG,2793.32,,,2793.32,Other,125% New York Medicaid APG,2234.65,32781.83,
Removal of leg veins/lesion,37735,CPT,,,,,,,,both,,,67044.74,49613.11,74,,49613.11,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30170.13,45,,30170.13,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33187.15,49.5,,33187.15,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,4156.45,,,4156.45,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,46931.32,70,,46931.32,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,2234.65,,,2234.65,Other,New York Medicaid APG methodology,2234.65,,,2234.65,Other,100% New York Medicaid APG,2234.65,,,2234.65,Other,100% New York Medicaid APG,2234.65,,,2234.65,Other,100% New York Medicaid APG,5027.97,,,5027.97,Other,225% New York Medicaid APG,3419.02,,,3419.02,Other,153% New York Medicaid APG,5027.97,,,5027.97,Other,225% New York Medicaid APG,3128.51,,,3128.51,Other,140% New York Medicaid APG,5027.97,,,5027.97,Other,225% New York Medicaid APG,5810.1,,,5810.1,Other,260% New York Medicaid APG,7240.28,,,7240.28,Other,324% New York Medicaid APG,4804.5,,,4804.5,Other,215% New York Medicaid APG,4804.5,,,4804.5,Other,215% New York Medicaid APG,2793.32,,,2793.32,Other,125% New York Medicaid APG,2234.65,49613.11,
Ligate leg veins radical,37760,CPT,,,,,,,,both,,,67044.74,49613.11,74,,49613.11,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30170.13,45,,30170.13,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33187.15,49.5,,33187.15,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,4156.45,,,4156.45,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,46931.32,70,,46931.32,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,2234.65,,,2234.65,Other,New York Medicaid APG methodology,2234.65,,,2234.65,Other,100% New York Medicaid APG,2234.65,,,2234.65,Other,100% New York Medicaid APG,2234.65,,,2234.65,Other,100% New York Medicaid APG,5027.97,,,5027.97,Other,225% New York Medicaid APG,3419.02,,,3419.02,Other,153% New York Medicaid APG,5027.97,,,5027.97,Other,225% New York Medicaid APG,3128.51,,,3128.51,Other,140% New York Medicaid APG,5027.97,,,5027.97,Other,225% New York Medicaid APG,5810.1,,,5810.1,Other,260% New York Medicaid APG,7240.28,,,7240.28,Other,324% New York Medicaid APG,4804.5,,,4804.5,Other,215% New York Medicaid APG,4804.5,,,4804.5,Other,215% New York Medicaid APG,2793.32,,,2793.32,Other,125% New York Medicaid APG,2234.65,49613.11,
Ligate leg veins open,37761,CPT,,,,,,,,both,,,67044.74,49613.11,74,,49613.11,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30170.13,45,,30170.13,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,33187.15,49.5,,33187.15,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,4156.45,,,4156.45,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,3578,,"100% primary, 0% secondary procedures",3578,Other,MagnaCare ASC Grouper,46931.32,70,,46931.32,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,2234.65,,,2234.65,Other,New York Medicaid APG methodology,2234.65,,,2234.65,Other,100% New York Medicaid APG,2234.65,,,2234.65,Other,100% New York Medicaid APG,2234.65,,,2234.65,Other,100% New York Medicaid APG,5027.97,,,5027.97,Other,225% New York Medicaid APG,3419.02,,,3419.02,Other,153% New York Medicaid APG,5027.97,,,5027.97,Other,225% New York Medicaid APG,3128.51,,,3128.51,Other,140% New York Medicaid APG,5027.97,,,5027.97,Other,225% New York Medicaid APG,5810.1,,,5810.1,Other,260% New York Medicaid APG,7240.28,,,7240.28,Other,324% New York Medicaid APG,4804.5,,,4804.5,Other,215% New York Medicaid APG,4804.5,,,4804.5,Other,215% New York Medicaid APG,2793.32,,,2793.32,Other,125% New York Medicaid APG,2234.65,49613.11,
Stab phleb veins xtr 10-20,37765,CPT,,,,,,,,both,,,38028.55,28141.13,74,,28141.13,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,17112.85,45,,17112.85,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,18824.13,49.5,,18824.13,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,4156.45,,,4156.45,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,26619.99,70,,26619.99,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,2234.65,,,2234.65,Other,New York Medicaid APG methodology,2234.65,,,2234.65,Other,100% New York Medicaid APG,2234.65,,,2234.65,Other,100% New York Medicaid APG,2234.65,,,2234.65,Other,100% New York Medicaid APG,5027.97,,,5027.97,Other,225% New York Medicaid APG,3419.02,,,3419.02,Other,153% New York Medicaid APG,5027.97,,,5027.97,Other,225% New York Medicaid APG,3128.51,,,3128.51,Other,140% New York Medicaid APG,5027.97,,,5027.97,Other,225% New York Medicaid APG,5810.1,,,5810.1,Other,260% New York Medicaid APG,7240.28,,,7240.28,Other,324% New York Medicaid APG,4804.5,,,4804.5,Other,215% New York Medicaid APG,4804.5,,,4804.5,Other,215% New York Medicaid APG,2793.32,,,2793.32,Other,125% New York Medicaid APG,2234.65,28141.13,
Phleb veins - extrem 20+,37766,CPT,,,,,,,,both,,,52151.56,38592.15,74,,38592.15,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,23468.2,45,,23468.2,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,25815.02,49.5,,25815.02,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,4156.45,,,4156.45,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,36506.09,70,,36506.09,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,2234.65,,,2234.65,Other,New York Medicaid APG methodology,2234.65,,,2234.65,Other,100% New York Medicaid APG,2234.65,,,2234.65,Other,100% New York Medicaid APG,2234.65,,,2234.65,Other,100% New York Medicaid APG,5027.97,,,5027.97,Other,225% New York Medicaid APG,3419.02,,,3419.02,Other,153% New York Medicaid APG,5027.97,,,5027.97,Other,225% New York Medicaid APG,3128.51,,,3128.51,Other,140% New York Medicaid APG,5027.97,,,5027.97,Other,225% New York Medicaid APG,5810.1,,,5810.1,Other,260% New York Medicaid APG,7240.28,,,7240.28,Other,324% New York Medicaid APG,4804.5,,,4804.5,Other,215% New York Medicaid APG,4804.5,,,4804.5,Other,215% New York Medicaid APG,2793.32,,,2793.32,Other,125% New York Medicaid APG,2234.65,38592.15,
Revision of leg vein,37780,CPT,,,,,,,,both,,,67044.74,49613.11,74,,49613.11,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30170.13,45,,30170.13,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,33187.15,49.5,,33187.15,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,4156.45,,,4156.45,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,3578,,"100% primary, 0% secondary procedures",3578,Other,MagnaCare ASC Grouper,46931.32,70,,46931.32,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,2234.65,,,2234.65,Other,New York Medicaid APG methodology,2234.65,,,2234.65,Other,100% New York Medicaid APG,2234.65,,,2234.65,Other,100% New York Medicaid APG,2234.65,,,2234.65,Other,100% New York Medicaid APG,5027.97,,,5027.97,Other,225% New York Medicaid APG,3419.02,,,3419.02,Other,153% New York Medicaid APG,5027.97,,,5027.97,Other,225% New York Medicaid APG,3128.51,,,3128.51,Other,140% New York Medicaid APG,5027.97,,,5027.97,Other,225% New York Medicaid APG,5810.1,,,5810.1,Other,260% New York Medicaid APG,7240.28,,,7240.28,Other,324% New York Medicaid APG,4804.5,,,4804.5,Other,215% New York Medicaid APG,4804.5,,,4804.5,Other,215% New York Medicaid APG,2793.32,,,2793.32,Other,125% New York Medicaid APG,2234.65,49613.11,
Ligate/divide/excise vein,37785,CPT,,,,,,,,both,,,67044.74,49613.11,74,,49613.11,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30170.13,45,,30170.13,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33187.15,49.5,,33187.15,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,4156.45,,,4156.45,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,46931.32,70,,46931.32,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,2234.65,,,2234.65,Other,New York Medicaid APG methodology,2234.65,,,2234.65,Other,100% New York Medicaid APG,2234.65,,,2234.65,Other,100% New York Medicaid APG,2234.65,,,2234.65,Other,100% New York Medicaid APG,5027.97,,,5027.97,Other,225% New York Medicaid APG,3419.02,,,3419.02,Other,153% New York Medicaid APG,5027.97,,,5027.97,Other,225% New York Medicaid APG,3128.51,,,3128.51,Other,140% New York Medicaid APG,5027.97,,,5027.97,Other,225% New York Medicaid APG,5810.1,,,5810.1,Other,260% New York Medicaid APG,7240.28,,,7240.28,Other,324% New York Medicaid APG,4804.5,,,4804.5,Other,215% New York Medicaid APG,4804.5,,,4804.5,Other,215% New York Medicaid APG,2793.32,,,2793.32,Other,125% New York Medicaid APG,2234.65,49613.11,
Penile venous occlusion,37790,CPT,,,,,,,,both,,,73326.88,54261.89,74,,54261.89,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,32997.1,45,,32997.1,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,36296.81,49.5,,36296.81,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,1762.47,,,1762.47,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,51328.82,70,,51328.82,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,947.56,,,947.56,Other,New York Medicaid APG methodology,947.56,,,947.56,Other,100% New York Medicaid APG,947.56,,,947.56,Other,100% New York Medicaid APG,947.56,,,947.56,Other,100% New York Medicaid APG,2132.02,,,2132.02,Other,225% New York Medicaid APG,1449.77,,,1449.77,Other,153% New York Medicaid APG,2132.02,,,2132.02,Other,225% New York Medicaid APG,1326.59,,,1326.59,Other,140% New York Medicaid APG,2132.02,,,2132.02,Other,225% New York Medicaid APG,2463.67,,,2463.67,Other,260% New York Medicaid APG,3070.11,,,3070.11,Other,324% New York Medicaid APG,2037.26,,,2037.26,Other,215% New York Medicaid APG,2037.26,,,2037.26,Other,215% New York Medicaid APG,1184.46,,,1184.46,Other,125% New York Medicaid APG,947.56,54261.89,
Laparoscopy splenectomy,38120,CPT,,,,,,,,both,,,44931.54,33249.34,74,,33249.34,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,20219.19,45,,20219.19,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,22241.11,49.5,,22241.11,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3632.62,,,3632.62,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,31452.08,70,,31452.08,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,1953.02,,,1953.02,Other,New York Medicaid APG methodology,1953.02,,,1953.02,Other,100% New York Medicaid APG,1953.02,,,1953.02,Other,100% New York Medicaid APG,1953.02,,,1953.02,Other,100% New York Medicaid APG,4394.3,,,4394.3,Other,225% New York Medicaid APG,2988.12,,,2988.12,Other,153% New York Medicaid APG,4394.3,,,4394.3,Other,225% New York Medicaid APG,2734.23,,,2734.23,Other,140% New York Medicaid APG,4394.3,,,4394.3,Other,225% New York Medicaid APG,5077.86,,,5077.86,Other,260% New York Medicaid APG,6327.79,,,6327.79,Other,324% New York Medicaid APG,4199,,,4199,Other,215% New York Medicaid APG,4199,,,4199,Other,215% New York Medicaid APG,2441.28,,,2441.28,Other,125% New York Medicaid APG,1953.02,33249.34,
Injection for spleen x-ray,38200,CPT,,,,,,,,both,,,32432.1,23999.75,74,,23999.75,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,14594.45,45,,14594.45,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,16053.89,49.5,,16053.89,percent of total billed charges,110% of Medicare,22053.83,68,,22053.83,percent of total billed charges,,966.93,,,966.93,Other,186% of Medicaid,25945.68,80,,25945.68,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,25945.68,80,,25945.68,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,22702.47,70,,22702.47,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,519.86,,,519.86,Other,New York Medicaid APG methodology,519.86,,,519.86,Other,100% New York Medicaid APG,519.86,,,519.86,Other,100% New York Medicaid APG,519.86,,,519.86,Other,100% New York Medicaid APG,1169.68,,,1169.68,Other,225% New York Medicaid APG,795.38,,,795.38,Other,153% New York Medicaid APG,1169.68,,,1169.68,Other,225% New York Medicaid APG,727.8,,,727.8,Other,140% New York Medicaid APG,1169.68,,,1169.68,Other,225% New York Medicaid APG,1351.62,,,1351.62,Other,260% New York Medicaid APG,1684.33,,,1684.33,Other,324% New York Medicaid APG,1117.69,,,1117.69,Other,215% New York Medicaid APG,1117.69,,,1117.69,Other,215% New York Medicaid APG,649.82,,,649.82,Other,125% New York Medicaid APG,519.86,25945.68,
Bl donor search management,38204,CPT,,,,,,,,both,,,87274.28,64582.97,74,,64582.97,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,39273.43,45,,39273.43,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,52364.57,60,,52364.57,percent of total billed charges,,48873.6,56,,48873.6,percent of total billed charges,,47128.11,54,,47128.11,percent of total billed charges,,43200.77,49.5,,43200.77,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,0.02,,,0.02,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,69819.42,80,,69819.42,percent of total billed charges,,61092,70,,61092,percent of total billed charges,,487.08,,,487.08,Fee Schedule,,412.83,,,412.83,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% New York Medicaid APG,0.01,,,0.01,Other,100% New York Medicaid APG,0.01,,,0.01,Other,100% New York Medicaid APG,0.02,,,0.02,Other,225% New York Medicaid APG,0.02,,,0.02,Other,153% New York Medicaid APG,0.02,,,0.02,Other,225% New York Medicaid APG,0.01,,,0.01,Other,140% New York Medicaid APG,0.02,,,0.02,Other,225% New York Medicaid APG,0.03,,,0.03,Other,260% New York Medicaid APG,0.03,,,0.03,Other,324% New York Medicaid APG,0.02,,,0.02,Other,215% New York Medicaid APG,0.02,,,0.02,Other,215% New York Medicaid APG,0.01,,,0.01,Other,125% New York Medicaid APG,0.01,69819.42,
Harvest auto stem cells,38206,CPT,,,,,,,,both,,,32272.54,23881.68,74,,23881.68,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,14522.64,45,,14522.64,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,15974.91,49.5,,15974.91,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3573.86,,,3573.86,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,22590.78,70,,22590.78,percent of total billed charges,,403.44,,,403.44,Fee Schedule,,341.94,,,341.94,Fee Schedule,,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1921.43,,,1921.43,Other,New York Medicaid APG methodology,1921.43,,,1921.43,Other,100% New York Medicaid APG,1921.43,,,1921.43,Other,100% New York Medicaid APG,1921.43,,,1921.43,Other,100% New York Medicaid APG,4323.22,,,4323.22,Other,225% New York Medicaid APG,2939.79,,,2939.79,Other,153% New York Medicaid APG,4323.22,,,4323.22,Other,225% New York Medicaid APG,2690.01,,,2690.01,Other,140% New York Medicaid APG,4323.22,,,4323.22,Other,225% New York Medicaid APG,4995.72,,,4995.72,Other,260% New York Medicaid APG,6225.44,,,6225.44,Other,324% New York Medicaid APG,4131.08,,,4131.08,Other,215% New York Medicaid APG,4131.08,,,4131.08,Other,215% New York Medicaid APG,2401.79,,,2401.79,Other,125% New York Medicaid APG,341.94,23881.68,
Cryopreserve stem cells,38207,CPT,,,,,,,,both,,,9130.81,6756.8,74,,6756.8,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,4108.86,45,,4108.86,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,4519.75,49.5,,4519.75,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3573.86,,,3573.86,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,6391.57,70,,6391.57,percent of total billed charges,,218.12,,,218.12,Fee Schedule,,184.87,,,184.87,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,1921.43,,,1921.43,Other,New York Medicaid APG methodology,1921.43,,,1921.43,Other,100% New York Medicaid APG,1921.43,,,1921.43,Other,100% New York Medicaid APG,1921.43,,,1921.43,Other,100% New York Medicaid APG,4323.22,,,4323.22,Other,225% New York Medicaid APG,2939.79,,,2939.79,Other,153% New York Medicaid APG,4323.22,,,4323.22,Other,225% New York Medicaid APG,2690.01,,,2690.01,Other,140% New York Medicaid APG,4323.22,,,4323.22,Other,225% New York Medicaid APG,4995.72,,,4995.72,Other,260% New York Medicaid APG,6225.44,,,6225.44,Other,324% New York Medicaid APG,4131.08,,,4131.08,Other,215% New York Medicaid APG,4131.08,,,4131.08,Other,215% New York Medicaid APG,2401.79,,,2401.79,Other,125% New York Medicaid APG,184.87,9473,
Thaw preserved stem cells,38208,CPT,,,,,,,,both,,,9130.81,6756.8,74,,6756.8,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,4108.86,45,,4108.86,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,4519.75,49.5,,4519.75,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3573.86,,,3573.86,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,6391.57,70,,6391.57,percent of total billed charges,,137.76,,,137.76,Fee Schedule,,116.76,,,116.76,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,1921.43,,,1921.43,Other,New York Medicaid APG methodology,1921.43,,,1921.43,Other,100% New York Medicaid APG,1921.43,,,1921.43,Other,100% New York Medicaid APG,1921.43,,,1921.43,Other,100% New York Medicaid APG,4323.22,,,4323.22,Other,225% New York Medicaid APG,2939.79,,,2939.79,Other,153% New York Medicaid APG,4323.22,,,4323.22,Other,225% New York Medicaid APG,2690.01,,,2690.01,Other,140% New York Medicaid APG,4323.22,,,4323.22,Other,225% New York Medicaid APG,4995.72,,,4995.72,Other,260% New York Medicaid APG,6225.44,,,6225.44,Other,324% New York Medicaid APG,4131.08,,,4131.08,Other,215% New York Medicaid APG,4131.08,,,4131.08,Other,215% New York Medicaid APG,2401.79,,,2401.79,Other,125% New York Medicaid APG,116.76,9473,
Wash harvest stem cells,38209,CPT,,,,,,,,both,,,9130.81,6756.8,74,,6756.8,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,4108.86,45,,4108.86,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,5478.49,60,,5478.49,percent of total billed charges,,5113.25,56,,5113.25,percent of total billed charges,,4930.64,54,,4930.64,percent of total billed charges,,4519.75,49.5,,4519.75,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3573.86,,,3573.86,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,6391.57,70,,6391.57,percent of total billed charges,,57.4,,,57.4,Fee Schedule,,48.65,,,48.65,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,1921.43,,,1921.43,Other,New York Medicaid APG methodology,1921.43,,,1921.43,Other,100% New York Medicaid APG,1921.43,,,1921.43,Other,100% New York Medicaid APG,1921.43,,,1921.43,Other,100% New York Medicaid APG,4323.22,,,4323.22,Other,225% New York Medicaid APG,2939.79,,,2939.79,Other,153% New York Medicaid APG,4323.22,,,4323.22,Other,225% New York Medicaid APG,2690.01,,,2690.01,Other,140% New York Medicaid APG,4323.22,,,4323.22,Other,225% New York Medicaid APG,4995.72,,,4995.72,Other,260% New York Medicaid APG,6225.44,,,6225.44,Other,324% New York Medicaid APG,4131.08,,,4131.08,Other,215% New York Medicaid APG,4131.08,,,4131.08,Other,215% New York Medicaid APG,2401.79,,,2401.79,Other,125% New York Medicaid APG,48.65,9473,
T-cell depletion of harvest,38210,CPT,,,,,,,,both,,,9130.81,6756.8,74,,6756.8,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,4108.86,45,,4108.86,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,5478.49,60,,5478.49,percent of total billed charges,,5113.25,56,,5113.25,percent of total billed charges,,4930.64,54,,4930.64,percent of total billed charges,,4519.75,49.5,,4519.75,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3573.86,,,3573.86,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,6391.57,70,,6391.57,percent of total billed charges,,385.4,,,385.4,Fee Schedule,,326.65,,,326.65,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,1921.43,,,1921.43,Other,New York Medicaid APG methodology,1921.43,,,1921.43,Other,100% New York Medicaid APG,1921.43,,,1921.43,Other,100% New York Medicaid APG,1921.43,,,1921.43,Other,100% New York Medicaid APG,4323.22,,,4323.22,Other,225% New York Medicaid APG,2939.79,,,2939.79,Other,153% New York Medicaid APG,4323.22,,,4323.22,Other,225% New York Medicaid APG,2690.01,,,2690.01,Other,140% New York Medicaid APG,4323.22,,,4323.22,Other,225% New York Medicaid APG,4995.72,,,4995.72,Other,260% New York Medicaid APG,6225.44,,,6225.44,Other,324% New York Medicaid APG,4131.08,,,4131.08,Other,215% New York Medicaid APG,4131.08,,,4131.08,Other,215% New York Medicaid APG,2401.79,,,2401.79,Other,125% New York Medicaid APG,326.65,9473,
Tumor cell deplete of harvst,38211,CPT,,,,,,,,both,,,9130.81,6756.8,74,,6756.8,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,4108.86,45,,4108.86,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,5478.49,60,,5478.49,percent of total billed charges,,5113.25,56,,5113.25,percent of total billed charges,,4930.64,54,,4930.64,percent of total billed charges,,4519.75,49.5,,4519.75,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3573.86,,,3573.86,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,6391.57,70,,6391.57,percent of total billed charges,,350.96,,,350.96,Fee Schedule,,297.46,,,297.46,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,1921.43,,,1921.43,Other,New York Medicaid APG methodology,1921.43,,,1921.43,Other,100% New York Medicaid APG,1921.43,,,1921.43,Other,100% New York Medicaid APG,1921.43,,,1921.43,Other,100% New York Medicaid APG,4323.22,,,4323.22,Other,225% New York Medicaid APG,2939.79,,,2939.79,Other,153% New York Medicaid APG,4323.22,,,4323.22,Other,225% New York Medicaid APG,2690.01,,,2690.01,Other,140% New York Medicaid APG,4323.22,,,4323.22,Other,225% New York Medicaid APG,4995.72,,,4995.72,Other,260% New York Medicaid APG,6225.44,,,6225.44,Other,324% New York Medicaid APG,4131.08,,,4131.08,Other,215% New York Medicaid APG,4131.08,,,4131.08,Other,215% New York Medicaid APG,2401.79,,,2401.79,Other,125% New York Medicaid APG,297.46,9473,
Rbc depletion of harvest,38212,CPT,,,,,,,,both,,,9130.81,6756.8,74,,6756.8,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,4108.86,45,,4108.86,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,4519.75,49.5,,4519.75,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,1096.85,,,1096.85,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,6391.57,70,,6391.57,percent of total billed charges,,229.6,,,229.6,Fee Schedule,,194.6,,,194.6,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,589.7,,,589.7,Other,New York Medicaid APG methodology,589.7,,,589.7,Other,100% New York Medicaid APG,589.7,,,589.7,Other,100% New York Medicaid APG,589.7,,,589.7,Other,100% New York Medicaid APG,1326.83,,,1326.83,Other,225% New York Medicaid APG,902.24,,,902.24,Other,153% New York Medicaid APG,1326.83,,,1326.83,Other,225% New York Medicaid APG,825.58,,,825.58,Other,140% New York Medicaid APG,1326.83,,,1326.83,Other,225% New York Medicaid APG,1533.23,,,1533.23,Other,260% New York Medicaid APG,1910.63,,,1910.63,Other,324% New York Medicaid APG,1267.86,,,1267.86,Other,215% New York Medicaid APG,1267.86,,,1267.86,Other,215% New York Medicaid APG,737.13,,,737.13,Other,125% New York Medicaid APG,194.6,9473,
Platelet deplete of harvest,38213,CPT,,,,,,,,both,,,9130.81,6756.8,74,,6756.8,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,4108.86,45,,4108.86,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,4519.75,49.5,,4519.75,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3573.86,,,3573.86,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,6391.57,70,,6391.57,percent of total billed charges,,57.4,,,57.4,Fee Schedule,,48.65,,,48.65,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,1921.43,,,1921.43,Other,New York Medicaid APG methodology,1921.43,,,1921.43,Other,100% New York Medicaid APG,1921.43,,,1921.43,Other,100% New York Medicaid APG,1921.43,,,1921.43,Other,100% New York Medicaid APG,4323.22,,,4323.22,Other,225% New York Medicaid APG,2939.79,,,2939.79,Other,153% New York Medicaid APG,4323.22,,,4323.22,Other,225% New York Medicaid APG,2690.01,,,2690.01,Other,140% New York Medicaid APG,4323.22,,,4323.22,Other,225% New York Medicaid APG,4995.72,,,4995.72,Other,260% New York Medicaid APG,6225.44,,,6225.44,Other,324% New York Medicaid APG,4131.08,,,4131.08,Other,215% New York Medicaid APG,4131.08,,,4131.08,Other,215% New York Medicaid APG,2401.79,,,2401.79,Other,125% New York Medicaid APG,48.65,9473,
Volume deplete of harvest,38214,CPT,,,,,,,,both,,,9130.81,6756.8,74,,6756.8,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,4108.86,45,,4108.86,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,4519.75,49.5,,4519.75,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3573.86,,,3573.86,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,6391.57,70,,6391.57,percent of total billed charges,,196.8,,,196.8,Fee Schedule,,166.8,,,166.8,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,1921.43,,,1921.43,Other,New York Medicaid APG methodology,1921.43,,,1921.43,Other,100% New York Medicaid APG,1921.43,,,1921.43,Other,100% New York Medicaid APG,1921.43,,,1921.43,Other,100% New York Medicaid APG,4323.22,,,4323.22,Other,225% New York Medicaid APG,2939.79,,,2939.79,Other,153% New York Medicaid APG,4323.22,,,4323.22,Other,225% New York Medicaid APG,2690.01,,,2690.01,Other,140% New York Medicaid APG,4323.22,,,4323.22,Other,225% New York Medicaid APG,4995.72,,,4995.72,Other,260% New York Medicaid APG,6225.44,,,6225.44,Other,324% New York Medicaid APG,4131.08,,,4131.08,Other,215% New York Medicaid APG,4131.08,,,4131.08,Other,215% New York Medicaid APG,2401.79,,,2401.79,Other,125% New York Medicaid APG,166.8,9473,
Harvest stem cell concentrte,38215,CPT,,,,,,,,both,,,9130.81,6756.8,74,,6756.8,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,4108.86,45,,4108.86,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,4519.75,49.5,,4519.75,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3573.86,,,3573.86,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,6391.57,70,,6391.57,percent of total billed charges,,229.6,,,229.6,Fee Schedule,,194.6,,,194.6,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,1921.43,,,1921.43,Other,New York Medicaid APG methodology,1921.43,,,1921.43,Other,100% New York Medicaid APG,1921.43,,,1921.43,Other,100% New York Medicaid APG,1921.43,,,1921.43,Other,100% New York Medicaid APG,4323.22,,,4323.22,Other,225% New York Medicaid APG,2939.79,,,2939.79,Other,153% New York Medicaid APG,4323.22,,,4323.22,Other,225% New York Medicaid APG,2690.01,,,2690.01,Other,140% New York Medicaid APG,4323.22,,,4323.22,Other,225% New York Medicaid APG,4995.72,,,4995.72,Other,260% New York Medicaid APG,6225.44,,,6225.44,Other,324% New York Medicaid APG,4131.08,,,4131.08,Other,215% New York Medicaid APG,4131.08,,,4131.08,Other,215% New York Medicaid APG,2401.79,,,2401.79,Other,125% New York Medicaid APG,194.6,9473,
Dx bone marrow aspirations,38220,CPT,,,,,,,,both,,,55779.91,41277.13,74,,41277.13,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,25100.96,45,,25100.96,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,27611.06,49.5,,27611.06,percent of total billed charges,110% of Medicare,37930.34,68,,37930.34,percent of total billed charges,,1037.55,,,1037.55,Other,186% of Medicaid,44623.93,80,,44623.93,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,44623.93,80,,44623.93,percent of total billed charges,,7216,,,7216,Case Rate,,3578,,"100% primary, 0% secondary procedures",3578,Other,MagnaCare ASC Grouper,39045.94,70,,39045.94,percent of total billed charges,,328,,,328,Fee Schedule,,278,,,278,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,557.82,,,557.82,Other,New York Medicaid APG methodology,557.82,,,557.82,Other,100% New York Medicaid APG,557.82,,,557.82,Other,100% New York Medicaid APG,557.82,,,557.82,Other,100% New York Medicaid APG,1255.1,,,1255.1,Other,225% New York Medicaid APG,853.47,,,853.47,Other,153% New York Medicaid APG,1255.1,,,1255.1,Other,225% New York Medicaid APG,780.95,,,780.95,Other,140% New York Medicaid APG,1255.1,,,1255.1,Other,225% New York Medicaid APG,1450.33,,,1450.33,Other,260% New York Medicaid APG,1807.34,,,1807.34,Other,324% New York Medicaid APG,1199.31,,,1199.31,Other,215% New York Medicaid APG,1199.31,,,1199.31,Other,215% New York Medicaid APG,697.28,,,697.28,Other,125% New York Medicaid APG,278,44623.93,
Dx bone marrow biopsies,38221,CPT,,,,,,,,both,,,71841.53,53162.73,74,,53162.73,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,32328.69,45,,32328.69,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,35561.56,49.5,,35561.56,percent of total billed charges,110% of Medicare,48852.24,68,,48852.24,percent of total billed charges,,1037.55,,,1037.55,Other,186% of Medicaid,57473.22,80,,57473.22,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,57473.22,80,,57473.22,percent of total billed charges,,7216,,,7216,Case Rate,,3578,,"100% primary, 0% secondary procedures",3578,Other,MagnaCare ASC Grouper,50289.07,70,,50289.07,percent of total billed charges,,339.48,,,339.48,Fee Schedule,,287.73,,,287.73,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,557.82,,,557.82,Other,New York Medicaid APG methodology,557.82,,,557.82,Other,100% New York Medicaid APG,557.82,,,557.82,Other,100% New York Medicaid APG,557.82,,,557.82,Other,100% New York Medicaid APG,1255.1,,,1255.1,Other,225% New York Medicaid APG,853.47,,,853.47,Other,153% New York Medicaid APG,1255.1,,,1255.1,Other,225% New York Medicaid APG,780.95,,,780.95,Other,140% New York Medicaid APG,1255.1,,,1255.1,Other,225% New York Medicaid APG,1450.33,,,1450.33,Other,260% New York Medicaid APG,1807.34,,,1807.34,Other,324% New York Medicaid APG,1199.31,,,1199.31,Other,215% New York Medicaid APG,1199.31,,,1199.31,Other,215% New York Medicaid APG,697.28,,,697.28,Other,125% New York Medicaid APG,287.73,57473.22,
Dx bone marrow bx & aspir,38222,CPT,,,,,,,,both,,,65070.68,48152.3,74,,48152.3,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,29281.81,45,,29281.81,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,32209.99,49.5,,32209.99,percent of total billed charges,110% of Medicare,44248.06,68,,44248.06,percent of total billed charges,,1037.55,,,1037.55,Other,186% of Medicaid,52056.54,80,,52056.54,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,52056.54,80,,52056.54,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,45549.48,70,,45549.48,percent of total billed charges,,365.72,,,365.72,Fee Schedule,,309.97,,,309.97,Fee Schedule,,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,557.82,,,557.82,Other,New York Medicaid APG methodology,557.82,,,557.82,Other,100% New York Medicaid APG,557.82,,,557.82,Other,100% New York Medicaid APG,557.82,,,557.82,Other,100% New York Medicaid APG,1255.1,,,1255.1,Other,225% New York Medicaid APG,853.47,,,853.47,Other,153% New York Medicaid APG,1255.1,,,1255.1,Other,225% New York Medicaid APG,780.95,,,780.95,Other,140% New York Medicaid APG,1255.1,,,1255.1,Other,225% New York Medicaid APG,1450.33,,,1450.33,Other,260% New York Medicaid APG,1807.34,,,1807.34,Other,324% New York Medicaid APG,1199.31,,,1199.31,Other,215% New York Medicaid APG,1199.31,,,1199.31,Other,215% New York Medicaid APG,697.28,,,697.28,Other,125% New York Medicaid APG,309.97,52056.54,
Bone marrow harvest allogen,38230,CPT,,,,,,,,both,,,45489.38,33662.14,74,,33662.14,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,20470.22,45,,20470.22,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,22517.24,49.5,,22517.24,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3573.86,,,3573.86,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,31842.57,70,,31842.57,percent of total billed charges,,988.92,,,988.92,Fee Schedule,,838.17,,,838.17,Fee Schedule,,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1921.43,,,1921.43,Other,New York Medicaid APG methodology,1921.43,,,1921.43,Other,100% New York Medicaid APG,1921.43,,,1921.43,Other,100% New York Medicaid APG,1921.43,,,1921.43,Other,100% New York Medicaid APG,4323.22,,,4323.22,Other,225% New York Medicaid APG,2939.79,,,2939.79,Other,153% New York Medicaid APG,4323.22,,,4323.22,Other,225% New York Medicaid APG,2690.01,,,2690.01,Other,140% New York Medicaid APG,4323.22,,,4323.22,Other,225% New York Medicaid APG,4995.72,,,4995.72,Other,260% New York Medicaid APG,6225.44,,,6225.44,Other,324% New York Medicaid APG,4131.08,,,4131.08,Other,215% New York Medicaid APG,4131.08,,,4131.08,Other,215% New York Medicaid APG,2401.79,,,2401.79,Other,125% New York Medicaid APG,838.17,33662.14,
Bone marrow harvest autolog,38232,CPT,,,,,,,,both,,,97340.17,72031.73,74,,72031.73,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,43803.08,45,,43803.08,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,48183.38,49.5,,48183.38,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3573.86,,,3573.86,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,68138.12,70,,68138.12,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,1921.43,,,1921.43,Other,New York Medicaid APG methodology,1921.43,,,1921.43,Other,100% New York Medicaid APG,1921.43,,,1921.43,Other,100% New York Medicaid APG,1921.43,,,1921.43,Other,100% New York Medicaid APG,4323.22,,,4323.22,Other,225% New York Medicaid APG,2939.79,,,2939.79,Other,153% New York Medicaid APG,4323.22,,,4323.22,Other,225% New York Medicaid APG,2690.01,,,2690.01,Other,140% New York Medicaid APG,4323.22,,,4323.22,Other,225% New York Medicaid APG,4995.72,,,4995.72,Other,260% New York Medicaid APG,6225.44,,,6225.44,Other,324% New York Medicaid APG,4131.08,,,4131.08,Other,215% New York Medicaid APG,4131.08,,,4131.08,Other,215% New York Medicaid APG,2401.79,,,2401.79,Other,125% New York Medicaid APG,1921.43,72031.73,
Transplt allo hct/donor,38240,CPT,,,,,,,,both,,,50891.17,37659.47,74,,37659.47,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,22901.03,45,,22901.03,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,25191.13,49.5,,25191.13,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3573.86,,,3573.86,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,35623.82,70,,35623.82,percent of total billed charges,,1159.48,,,1159.48,Fee Schedule,,982.73,,,982.73,Fee Schedule,,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,1921.43,,,1921.43,Other,New York Medicaid APG methodology,1921.43,,,1921.43,Other,100% New York Medicaid APG,1921.43,,,1921.43,Other,100% New York Medicaid APG,1921.43,,,1921.43,Other,100% New York Medicaid APG,4323.21,,,4323.21,Other,225% New York Medicaid APG,2939.78,,,2939.78,Other,153% New York Medicaid APG,4323.21,,,4323.21,Other,225% New York Medicaid APG,2690,,,2690,Other,140% New York Medicaid APG,4323.21,,,4323.21,Other,225% New York Medicaid APG,4995.71,,,4995.71,Other,260% New York Medicaid APG,6225.43,,,6225.43,Other,324% New York Medicaid APG,4131.07,,,4131.07,Other,215% New York Medicaid APG,4131.07,,,4131.07,Other,215% New York Medicaid APG,2401.79,,,2401.79,Other,125% New York Medicaid APG,982.73,37659.47,
Transplt autol hct/donor,38241,CPT,,,,,,,,both,,,32272.54,23881.68,74,,23881.68,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,14522.64,45,,14522.64,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,15974.91,49.5,,15974.91,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3573.86,,,3573.86,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,22590.78,70,,22590.78,percent of total billed charges,,856.08,,,856.08,Fee Schedule,,725.58,,,725.58,Fee Schedule,,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1921.43,,,1921.43,Other,New York Medicaid APG methodology,1921.43,,,1921.43,Other,100% New York Medicaid APG,1921.43,,,1921.43,Other,100% New York Medicaid APG,1921.43,,,1921.43,Other,100% New York Medicaid APG,4323.22,,,4323.22,Other,225% New York Medicaid APG,2939.79,,,2939.79,Other,153% New York Medicaid APG,4323.22,,,4323.22,Other,225% New York Medicaid APG,2690.01,,,2690.01,Other,140% New York Medicaid APG,4323.22,,,4323.22,Other,225% New York Medicaid APG,4995.72,,,4995.72,Other,260% New York Medicaid APG,6225.44,,,6225.44,Other,324% New York Medicaid APG,4131.08,,,4131.08,Other,215% New York Medicaid APG,4131.08,,,4131.08,Other,215% New York Medicaid APG,2401.79,,,2401.79,Other,125% New York Medicaid APG,725.58,23881.68,
Transplt allo lymphocytes,38242,CPT,,,,,,,,both,,,32272.54,23881.68,74,,23881.68,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,14522.64,45,,14522.64,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,15974.91,49.5,,15974.91,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3573.86,,,3573.86,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,22590.78,70,,22590.78,percent of total billed charges,,606.8,,,606.8,Fee Schedule,,514.3,,,514.3,Fee Schedule,,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1921.43,,,1921.43,Other,New York Medicaid APG methodology,1921.43,,,1921.43,Other,100% New York Medicaid APG,1921.43,,,1921.43,Other,100% New York Medicaid APG,1921.43,,,1921.43,Other,100% New York Medicaid APG,4323.22,,,4323.22,Other,225% New York Medicaid APG,2939.79,,,2939.79,Other,153% New York Medicaid APG,4323.22,,,4323.22,Other,225% New York Medicaid APG,2690.01,,,2690.01,Other,140% New York Medicaid APG,4323.22,,,4323.22,Other,225% New York Medicaid APG,4995.72,,,4995.72,Other,260% New York Medicaid APG,6225.44,,,6225.44,Other,324% New York Medicaid APG,4131.08,,,4131.08,Other,215% New York Medicaid APG,4131.08,,,4131.08,Other,215% New York Medicaid APG,2401.79,,,2401.79,Other,125% New York Medicaid APG,514.3,23881.68,
Transplj hematopoietic boost,38243,CPT,,,,,,,,both,,,32272.54,23881.68,74,,23881.68,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,14522.64,45,,14522.64,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,15974.91,49.5,,15974.91,percent of total billed charges,110% of Medicare,21945.33,68,,21945.33,percent of total billed charges,,3573.86,,,3573.86,Other,186% of Medicaid,25818.03,80,,25818.03,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,25818.03,80,,25818.03,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,22590.78,70,,22590.78,percent of total billed charges,,593.68,,,593.68,Fee Schedule,,503.18,,,503.18,Fee Schedule,,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1921.43,,,1921.43,Other,New York Medicaid APG methodology,1921.43,,,1921.43,Other,100% New York Medicaid APG,1921.43,,,1921.43,Other,100% New York Medicaid APG,1921.43,,,1921.43,Other,100% New York Medicaid APG,4323.22,,,4323.22,Other,225% New York Medicaid APG,2939.79,,,2939.79,Other,153% New York Medicaid APG,4323.22,,,4323.22,Other,225% New York Medicaid APG,2690.01,,,2690.01,Other,140% New York Medicaid APG,4323.22,,,4323.22,Other,225% New York Medicaid APG,4995.72,,,4995.72,Other,260% New York Medicaid APG,6225.44,,,6225.44,Other,324% New York Medicaid APG,4131.08,,,4131.08,Other,215% New York Medicaid APG,4131.08,,,4131.08,Other,215% New York Medicaid APG,2401.79,,,2401.79,Other,125% New York Medicaid APG,503.18,25818.03,
Drainage lymph node lesion,38300,CPT,,,,,,,,both,,,59767.2,44227.73,74,,44227.73,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,26895.24,45,,26895.24,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,29584.76,49.5,,29584.76,percent of total billed charges,110% of Medicare,40641.7,68,,40641.7,percent of total billed charges,,2572.54,,,2572.54,Other,186% of Medicaid,47813.76,80,,47813.76,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,47813.76,80,,47813.76,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,41837.04,70,,41837.04,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1383.09,,,1383.09,Other,New York Medicaid APG methodology,1383.09,,,1383.09,Other,100% New York Medicaid APG,1383.09,,,1383.09,Other,100% New York Medicaid APG,1383.09,,,1383.09,Other,100% New York Medicaid APG,3111.95,,,3111.95,Other,225% New York Medicaid APG,2116.12,,,2116.12,Other,153% New York Medicaid APG,3111.95,,,3111.95,Other,225% New York Medicaid APG,1936.32,,,1936.32,Other,140% New York Medicaid APG,3111.95,,,3111.95,Other,225% New York Medicaid APG,3596.03,,,3596.03,Other,260% New York Medicaid APG,4481.21,,,4481.21,Other,324% New York Medicaid APG,2973.64,,,2973.64,Other,215% New York Medicaid APG,2973.64,,,2973.64,Other,215% New York Medicaid APG,1728.86,,,1728.86,Other,125% New York Medicaid APG,1383.09,47813.76,
Drainage lymph node lesion,38305,CPT,,,,,,,,both,,,59767.2,44227.73,74,,44227.73,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,26895.24,45,,26895.24,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,29584.76,49.5,,29584.76,percent of total billed charges,110% of Medicare,40641.7,68,,40641.7,percent of total billed charges,,2572.54,,,2572.54,Other,186% of Medicaid,47813.76,80,,47813.76,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,47813.76,80,,47813.76,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,41837.04,70,,41837.04,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1383.09,,,1383.09,Other,New York Medicaid APG methodology,1383.09,,,1383.09,Other,100% New York Medicaid APG,1383.09,,,1383.09,Other,100% New York Medicaid APG,1383.09,,,1383.09,Other,100% New York Medicaid APG,3111.95,,,3111.95,Other,225% New York Medicaid APG,2116.12,,,2116.12,Other,153% New York Medicaid APG,3111.95,,,3111.95,Other,225% New York Medicaid APG,1936.32,,,1936.32,Other,140% New York Medicaid APG,3111.95,,,3111.95,Other,225% New York Medicaid APG,3596.03,,,3596.03,Other,260% New York Medicaid APG,4481.21,,,4481.21,Other,324% New York Medicaid APG,2973.64,,,2973.64,Other,215% New York Medicaid APG,2973.64,,,2973.64,Other,215% New York Medicaid APG,1728.86,,,1728.86,Other,125% New York Medicaid APG,1383.09,47813.76,
Incision of lymph channels,38308,CPT,,,,,,,,both,,,80175.05,59329.54,74,,59329.54,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,36078.77,45,,36078.77,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,39686.65,49.5,,39686.65,percent of total billed charges,110% of Medicare,54519.03,68,,54519.03,percent of total billed charges,,2572.54,,,2572.54,Other,186% of Medicaid,64140.04,80,,64140.04,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,64140.04,80,,64140.04,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,56122.54,70,,56122.54,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1383.09,,,1383.09,Other,New York Medicaid APG methodology,1383.09,,,1383.09,Other,100% New York Medicaid APG,1383.09,,,1383.09,Other,100% New York Medicaid APG,1383.09,,,1383.09,Other,100% New York Medicaid APG,3111.95,,,3111.95,Other,225% New York Medicaid APG,2116.12,,,2116.12,Other,153% New York Medicaid APG,3111.95,,,3111.95,Other,225% New York Medicaid APG,1936.32,,,1936.32,Other,140% New York Medicaid APG,3111.95,,,3111.95,Other,225% New York Medicaid APG,3596.03,,,3596.03,Other,260% New York Medicaid APG,4481.21,,,4481.21,Other,324% New York Medicaid APG,2973.64,,,2973.64,Other,215% New York Medicaid APG,2973.64,,,2973.64,Other,215% New York Medicaid APG,1728.86,,,1728.86,Other,125% New York Medicaid APG,1383.09,64140.04,
Biopsy/removal lymph nodes,38500,CPT,,,,,,,,both,,,80175.05,59329.54,74,,59329.54,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,36078.77,45,,36078.77,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,39686.65,49.5,,39686.65,percent of total billed charges,110% of Medicare,54519.03,68,,54519.03,percent of total billed charges,,2572.54,,,2572.54,Other,186% of Medicaid,64140.04,80,,64140.04,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,64140.04,80,,64140.04,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,56122.54,70,,56122.54,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1383.09,,,1383.09,Other,New York Medicaid APG methodology,1383.09,,,1383.09,Other,100% New York Medicaid APG,1383.09,,,1383.09,Other,100% New York Medicaid APG,1383.09,,,1383.09,Other,100% New York Medicaid APG,3111.95,,,3111.95,Other,225% New York Medicaid APG,2116.12,,,2116.12,Other,153% New York Medicaid APG,3111.95,,,3111.95,Other,225% New York Medicaid APG,1936.32,,,1936.32,Other,140% New York Medicaid APG,3111.95,,,3111.95,Other,225% New York Medicaid APG,3596.03,,,3596.03,Other,260% New York Medicaid APG,4481.21,,,4481.21,Other,324% New York Medicaid APG,2973.64,,,2973.64,Other,215% New York Medicaid APG,2973.64,,,2973.64,Other,215% New York Medicaid APG,1728.86,,,1728.86,Other,125% New York Medicaid APG,1383.09,64140.04,
Needle biopsy lymph nodes,38505,CPT,,,,,,,,both,,,47084.53,34842.55,74,,34842.55,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,21188.04,45,,21188.04,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,23306.84,49.5,,23306.84,percent of total billed charges,110% of Medicare,32017.48,68,,32017.48,percent of total billed charges,,2241.85,,,2241.85,Other,186% of Medicaid,37667.62,80,,37667.62,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,37667.62,80,,37667.62,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,32959.17,70,,32959.17,percent of total billed charges,,416.56,,,416.56,Fee Schedule,,353.06,,,353.06,Fee Schedule,,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1205.3,,,1205.3,Other,New York Medicaid APG methodology,1205.3,,,1205.3,Other,100% New York Medicaid APG,1205.3,,,1205.3,Other,100% New York Medicaid APG,1205.3,,,1205.3,Other,100% New York Medicaid APG,2711.92,,,2711.92,Other,225% New York Medicaid APG,1844.1,,,1844.1,Other,153% New York Medicaid APG,2711.92,,,2711.92,Other,225% New York Medicaid APG,1687.41,,,1687.41,Other,140% New York Medicaid APG,2711.92,,,2711.92,Other,225% New York Medicaid APG,3133.77,,,3133.77,Other,260% New York Medicaid APG,3905.16,,,3905.16,Other,324% New York Medicaid APG,2591.39,,,2591.39,Other,215% New York Medicaid APG,2591.39,,,2591.39,Other,215% New York Medicaid APG,1506.62,,,1506.62,Other,125% New York Medicaid APG,353.06,37667.62,
Biopsy/removal lymph nodes,38510,CPT,,,,,,,,both,,,54121.87,40050.18,74,,40050.18,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,24354.84,45,,24354.84,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,26790.33,49.5,,26790.33,percent of total billed charges,110% of Medicare,36802.87,68,,36802.87,percent of total billed charges,,2572.54,,,2572.54,Other,186% of Medicaid,43297.5,80,,43297.5,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,43297.5,80,,43297.5,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,37885.31,70,,37885.31,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1383.09,,,1383.09,Other,New York Medicaid APG methodology,1383.09,,,1383.09,Other,100% New York Medicaid APG,1383.09,,,1383.09,Other,100% New York Medicaid APG,1383.09,,,1383.09,Other,100% New York Medicaid APG,3111.95,,,3111.95,Other,225% New York Medicaid APG,2116.12,,,2116.12,Other,153% New York Medicaid APG,3111.95,,,3111.95,Other,225% New York Medicaid APG,1936.32,,,1936.32,Other,140% New York Medicaid APG,3111.95,,,3111.95,Other,225% New York Medicaid APG,3596.03,,,3596.03,Other,260% New York Medicaid APG,4481.21,,,4481.21,Other,324% New York Medicaid APG,2973.64,,,2973.64,Other,215% New York Medicaid APG,2973.64,,,2973.64,Other,215% New York Medicaid APG,1728.86,,,1728.86,Other,125% New York Medicaid APG,1383.09,43297.5,
Biopsy/removal lymph nodes,38520,CPT,,,,,,,,both,,,80175.05,59329.54,74,,59329.54,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,36078.77,45,,36078.77,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,39686.65,49.5,,39686.65,percent of total billed charges,110% of Medicare,54519.03,68,,54519.03,percent of total billed charges,,2572.54,,,2572.54,Other,186% of Medicaid,64140.04,80,,64140.04,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,64140.04,80,,64140.04,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,56122.54,70,,56122.54,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1383.09,,,1383.09,Other,New York Medicaid APG methodology,1383.09,,,1383.09,Other,100% New York Medicaid APG,1383.09,,,1383.09,Other,100% New York Medicaid APG,1383.09,,,1383.09,Other,100% New York Medicaid APG,3111.95,,,3111.95,Other,225% New York Medicaid APG,2116.12,,,2116.12,Other,153% New York Medicaid APG,3111.95,,,3111.95,Other,225% New York Medicaid APG,1936.32,,,1936.32,Other,140% New York Medicaid APG,3111.95,,,3111.95,Other,225% New York Medicaid APG,3596.03,,,3596.03,Other,260% New York Medicaid APG,4481.21,,,4481.21,Other,324% New York Medicaid APG,2973.64,,,2973.64,Other,215% New York Medicaid APG,2973.64,,,2973.64,Other,215% New York Medicaid APG,1728.86,,,1728.86,Other,125% New York Medicaid APG,1383.09,64140.04,
Biopsy/removal lymph nodes,38525,CPT,,,,,,,,both,,,80175.05,59329.54,74,,59329.54,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,36078.77,45,,36078.77,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,39686.65,49.5,,39686.65,percent of total billed charges,110% of Medicare,54519.03,68,,54519.03,percent of total billed charges,,2572.54,,,2572.54,Other,186% of Medicaid,64140.04,80,,64140.04,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,64140.04,80,,64140.04,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,56122.54,70,,56122.54,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1383.09,,,1383.09,Other,New York Medicaid APG methodology,1383.09,,,1383.09,Other,100% New York Medicaid APG,1383.09,,,1383.09,Other,100% New York Medicaid APG,1383.09,,,1383.09,Other,100% New York Medicaid APG,3111.95,,,3111.95,Other,225% New York Medicaid APG,2116.12,,,2116.12,Other,153% New York Medicaid APG,3111.95,,,3111.95,Other,225% New York Medicaid APG,1936.32,,,1936.32,Other,140% New York Medicaid APG,3111.95,,,3111.95,Other,225% New York Medicaid APG,3596.03,,,3596.03,Other,260% New York Medicaid APG,4481.21,,,4481.21,Other,324% New York Medicaid APG,2973.64,,,2973.64,Other,215% New York Medicaid APG,2973.64,,,2973.64,Other,215% New York Medicaid APG,1728.86,,,1728.86,Other,125% New York Medicaid APG,1383.09,64140.04,
Biopsy/removal lymph nodes,38530,CPT,,,,,,,,both,,,80175.05,59329.54,74,,59329.54,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,36078.77,45,,36078.77,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,39686.65,49.5,,39686.65,percent of total billed charges,110% of Medicare,54519.03,68,,54519.03,percent of total billed charges,,2572.54,,,2572.54,Other,186% of Medicaid,64140.04,80,,64140.04,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,64140.04,80,,64140.04,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,56122.54,70,,56122.54,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1383.09,,,1383.09,Other,New York Medicaid APG methodology,1383.09,,,1383.09,Other,100% New York Medicaid APG,1383.09,,,1383.09,Other,100% New York Medicaid APG,1383.09,,,1383.09,Other,100% New York Medicaid APG,3111.95,,,3111.95,Other,225% New York Medicaid APG,2116.12,,,2116.12,Other,153% New York Medicaid APG,3111.95,,,3111.95,Other,225% New York Medicaid APG,1936.32,,,1936.32,Other,140% New York Medicaid APG,3111.95,,,3111.95,Other,225% New York Medicaid APG,3596.03,,,3596.03,Other,260% New York Medicaid APG,4481.21,,,4481.21,Other,324% New York Medicaid APG,2973.64,,,2973.64,Other,215% New York Medicaid APG,2973.64,,,2973.64,Other,215% New York Medicaid APG,1728.86,,,1728.86,Other,125% New York Medicaid APG,1383.09,64140.04,
Open bx/exc inguinofem nodes,38531,CPT,,,,,,,,both,,,49445.29,36589.51,74,,36589.51,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,22250.38,45,,22250.38,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,24475.42,49.5,,24475.42,percent of total billed charges,110% of Medicare,33622.8,68,,33622.8,percent of total billed charges,,2572.54,,,2572.54,Other,186% of Medicaid,39556.23,80,,39556.23,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,39556.23,80,,39556.23,percent of total billed charges,,7216,,,7216,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,34611.7,70,,34611.7,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1383.09,,,1383.09,Other,New York Medicaid APG methodology,1383.09,,,1383.09,Other,100% New York Medicaid APG,1383.09,,,1383.09,Other,100% New York Medicaid APG,1383.09,,,1383.09,Other,100% New York Medicaid APG,3111.95,,,3111.95,Other,225% New York Medicaid APG,2116.12,,,2116.12,Other,153% New York Medicaid APG,3111.95,,,3111.95,Other,225% New York Medicaid APG,1936.32,,,1936.32,Other,140% New York Medicaid APG,3111.95,,,3111.95,Other,225% New York Medicaid APG,3596.03,,,3596.03,Other,260% New York Medicaid APG,4481.21,,,4481.21,Other,324% New York Medicaid APG,2973.64,,,2973.64,Other,215% New York Medicaid APG,2973.64,,,2973.64,Other,215% New York Medicaid APG,1728.86,,,1728.86,Other,125% New York Medicaid APG,1383.09,39556.23,
Explore deep node(s) neck,38542,CPT,,,,,,,,both,,,121364.27,89809.56,74,,89809.56,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,54613.92,45,,54613.92,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,6125,,"100% primary, 50% secondary, 25% supplemental procedure",6125,Other,Blue Cross ASC Grouper,5513,,"100% primary, 50% secondary, 25% supplemental procedure",5513,Other,Blue Cross ASC Grouper,5206,,"100% primary, 50% secondary, 25% supplemental procedure",5206,Other,Blue Cross ASC Grouper,60075.31,49.5,,60075.31,percent of total billed charges,110% of Medicare,82527.7,68,,82527.7,percent of total billed charges,,2572.54,,,2572.54,Other,186% of Medicaid,97091.42,80,,97091.42,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,97091.42,80,,97091.42,percent of total billed charges,,7216,,,7216,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,84954.99,70,,84954.99,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,1383.09,,,1383.09,Other,New York Medicaid APG methodology,1383.09,,,1383.09,Other,100% New York Medicaid APG,1383.09,,,1383.09,Other,100% New York Medicaid APG,1383.09,,,1383.09,Other,100% New York Medicaid APG,3111.95,,,3111.95,Other,225% New York Medicaid APG,2116.12,,,2116.12,Other,153% New York Medicaid APG,3111.95,,,3111.95,Other,225% New York Medicaid APG,1936.32,,,1936.32,Other,140% New York Medicaid APG,3111.95,,,3111.95,Other,225% New York Medicaid APG,3596.03,,,3596.03,Other,260% New York Medicaid APG,4481.21,,,4481.21,Other,324% New York Medicaid APG,2973.64,,,2973.64,Other,215% New York Medicaid APG,2973.64,,,2973.64,Other,215% New York Medicaid APG,1728.86,,,1728.86,Other,125% New York Medicaid APG,1383.09,97091.42,
Removal neck/armpit lesion,38550,CPT,,,,,,,,both,,,80175.05,59329.54,74,,59329.54,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,36078.77,45,,36078.77,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,39686.65,49.5,,39686.65,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2572.54,,,2572.54,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,56122.54,70,,56122.54,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1383.09,,,1383.09,Other,New York Medicaid APG methodology,1383.09,,,1383.09,Other,100% New York Medicaid APG,1383.09,,,1383.09,Other,100% New York Medicaid APG,1383.09,,,1383.09,Other,100% New York Medicaid APG,3111.95,,,3111.95,Other,225% New York Medicaid APG,2116.12,,,2116.12,Other,153% New York Medicaid APG,3111.95,,,3111.95,Other,225% New York Medicaid APG,1936.32,,,1936.32,Other,140% New York Medicaid APG,3111.95,,,3111.95,Other,225% New York Medicaid APG,3596.03,,,3596.03,Other,260% New York Medicaid APG,4481.21,,,4481.21,Other,324% New York Medicaid APG,2973.64,,,2973.64,Other,215% New York Medicaid APG,2973.64,,,2973.64,Other,215% New York Medicaid APG,1728.86,,,1728.86,Other,125% New York Medicaid APG,1383.09,59329.54,
Removal neck/armpit lesion,38555,CPT,,,,,,,,both,,,137162.89,101500.54,74,,101500.54,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,61723.3,45,,61723.3,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,7266,,"100% primary, 50% secondary, 25% supplemental procedure",7266,Other,Blue Cross ASC Grouper,6539,,"100% primary, 50% secondary, 25% supplemental procedure",6539,Other,Blue Cross ASC Grouper,6176,,"100% primary, 50% secondary, 25% supplemental procedure",6176,Other,Blue Cross ASC Grouper,67895.63,49.5,,67895.63,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2572.54,,,2572.54,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,96014.02,70,,96014.02,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1383.09,,,1383.09,Other,New York Medicaid APG methodology,1383.09,,,1383.09,Other,100% New York Medicaid APG,1383.09,,,1383.09,Other,100% New York Medicaid APG,1383.09,,,1383.09,Other,100% New York Medicaid APG,3111.95,,,3111.95,Other,225% New York Medicaid APG,2116.12,,,2116.12,Other,153% New York Medicaid APG,3111.95,,,3111.95,Other,225% New York Medicaid APG,1936.32,,,1936.32,Other,140% New York Medicaid APG,3111.95,,,3111.95,Other,225% New York Medicaid APG,3596.03,,,3596.03,Other,260% New York Medicaid APG,4481.21,,,4481.21,Other,324% New York Medicaid APG,2973.64,,,2973.64,Other,215% New York Medicaid APG,2973.64,,,2973.64,Other,215% New York Medicaid APG,1728.86,,,1728.86,Other,125% New York Medicaid APG,1383.09,101500.54,
Laparoscopy lymph node biop,38570,CPT,,,,,,,,both,,,64506.8,47735.03,74,,47735.03,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,29028.06,45,,29028.06,percent of total billed charges,Medicare Ratio of cost to charges,5459,,"100% primary, 50% supplemental procedure",5459,Other,Aetna ASC Grouper,4913,,"100% primary, 50% supplemental procedure",4913,Other,Aetna ASC Grouper,6125,,"100% primary, 50% secondary, 25% supplemental procedure",6125,Other,Blue Cross ASC Grouper,5513,,"100% primary, 50% secondary, 25% supplemental procedure",5513,Other,Blue Cross ASC Grouper,5206,,"100% primary, 50% secondary, 25% supplemental procedure",5206,Other,Blue Cross ASC Grouper,31930.87,49.5,,31930.87,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3632.62,,,3632.62,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,45154.76,70,,45154.76,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,1953.02,,,1953.02,Other,New York Medicaid APG methodology,1953.02,,,1953.02,Other,100% New York Medicaid APG,1953.02,,,1953.02,Other,100% New York Medicaid APG,1953.02,,,1953.02,Other,100% New York Medicaid APG,4394.3,,,4394.3,Other,225% New York Medicaid APG,2988.12,,,2988.12,Other,153% New York Medicaid APG,4394.3,,,4394.3,Other,225% New York Medicaid APG,2734.23,,,2734.23,Other,140% New York Medicaid APG,4394.3,,,4394.3,Other,225% New York Medicaid APG,5077.86,,,5077.86,Other,260% New York Medicaid APG,6327.79,,,6327.79,Other,324% New York Medicaid APG,4199,,,4199,Other,215% New York Medicaid APG,4199,,,4199,Other,215% New York Medicaid APG,2441.28,,,2441.28,Other,125% New York Medicaid APG,1953.02,47735.03,
Laparoscopy lymphadenectomy,38571,CPT,,,,,,,,both,,,76185.64,56377.37,74,,56377.37,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,34283.54,45,,34283.54,percent of total billed charges,Medicare Ratio of cost to charges,7938,,"100% primary, 50% supplemental procedure",7938,Other,Aetna ASC Grouper,7144,,"100% primary, 50% supplemental procedure",7144,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,37711.89,49.5,,37711.89,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3632.62,,,3632.62,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,53329.95,70,,53329.95,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,1953.02,,,1953.02,Other,New York Medicaid APG methodology,1953.02,,,1953.02,Other,100% New York Medicaid APG,1953.02,,,1953.02,Other,100% New York Medicaid APG,1953.02,,,1953.02,Other,100% New York Medicaid APG,4394.3,,,4394.3,Other,225% New York Medicaid APG,2988.12,,,2988.12,Other,153% New York Medicaid APG,4394.3,,,4394.3,Other,225% New York Medicaid APG,2734.23,,,2734.23,Other,140% New York Medicaid APG,4394.3,,,4394.3,Other,225% New York Medicaid APG,5077.86,,,5077.86,Other,260% New York Medicaid APG,6327.79,,,6327.79,Other,324% New York Medicaid APG,4199,,,4199,Other,215% New York Medicaid APG,4199,,,4199,Other,215% New York Medicaid APG,2441.28,,,2441.28,Other,125% New York Medicaid APG,1953.02,56377.37,
Laparoscopy lymphadenectomy,38572,CPT,,,,,,,,both,,,216515.17,160221.23,74,,160221.23,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,97431.83,45,,97431.83,percent of total billed charges,Medicare Ratio of cost to charges,7938,,"100% primary, 50% supplemental procedure",7938,Other,Aetna ASC Grouper,7144,,"100% primary, 50% supplemental procedure",7144,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,107175.01,49.5,,107175.01,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3632.62,,,3632.62,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,151560.62,70,,151560.62,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,1953.02,,,1953.02,Other,New York Medicaid APG methodology,1953.02,,,1953.02,Other,100% New York Medicaid APG,1953.02,,,1953.02,Other,100% New York Medicaid APG,1953.02,,,1953.02,Other,100% New York Medicaid APG,4394.3,,,4394.3,Other,225% New York Medicaid APG,2988.12,,,2988.12,Other,153% New York Medicaid APG,4394.3,,,4394.3,Other,225% New York Medicaid APG,2734.23,,,2734.23,Other,140% New York Medicaid APG,4394.3,,,4394.3,Other,225% New York Medicaid APG,5077.86,,,5077.86,Other,260% New York Medicaid APG,6327.79,,,6327.79,Other,324% New York Medicaid APG,4199,,,4199,Other,215% New York Medicaid APG,4199,,,4199,Other,215% New York Medicaid APG,2441.28,,,2441.28,Other,125% New York Medicaid APG,1953.02,160221.23,
Laps pelvic lymphadec,38573,CPT,,,,,,,,both,,,216515.17,160221.23,74,,160221.23,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,97431.83,45,,97431.83,percent of total billed charges,Medicare Ratio of cost to charges,5459,,"100% primary, 50% supplemental procedure",5459,Other,Aetna ASC Grouper,4913,,"100% primary, 50% supplemental procedure",4913,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,107175.01,49.5,,107175.01,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3632.62,,,3632.62,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,151560.62,70,,151560.62,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,1953.02,,,1953.02,Other,New York Medicaid APG methodology,1953.02,,,1953.02,Other,100% New York Medicaid APG,1953.02,,,1953.02,Other,100% New York Medicaid APG,1953.02,,,1953.02,Other,100% New York Medicaid APG,4394.3,,,4394.3,Other,225% New York Medicaid APG,2988.12,,,2988.12,Other,153% New York Medicaid APG,4394.3,,,4394.3,Other,225% New York Medicaid APG,2734.23,,,2734.23,Other,140% New York Medicaid APG,4394.3,,,4394.3,Other,225% New York Medicaid APG,5077.86,,,5077.86,Other,260% New York Medicaid APG,6327.79,,,6327.79,Other,324% New York Medicaid APG,4199,,,4199,Other,215% New York Medicaid APG,4199,,,4199,Other,215% New York Medicaid APG,2441.28,,,2441.28,Other,125% New York Medicaid APG,1953.02,160221.23,
Removal of lymph nodes neck,38700,CPT,,,,,,,,both,,,137162.89,101500.54,74,,101500.54,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,61723.3,45,,61723.3,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,7266,,"100% primary, 50% secondary, 25% supplemental procedure",7266,Other,Blue Cross ASC Grouper,6539,,"100% primary, 50% secondary, 25% supplemental procedure",6539,Other,Blue Cross ASC Grouper,6176,,"100% primary, 50% secondary, 25% supplemental procedure",6176,Other,Blue Cross ASC Grouper,67895.63,49.5,,67895.63,percent of total billed charges,110% of Medicare,93270.77,68,,93270.77,percent of total billed charges,,2572.54,,,2572.54,Other,186% of Medicaid,109730.31,80,,109730.31,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,109730.31,80,,109730.31,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,96014.02,70,,96014.02,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1383.09,,,1383.09,Other,New York Medicaid APG methodology,1383.09,,,1383.09,Other,100% New York Medicaid APG,1383.09,,,1383.09,Other,100% New York Medicaid APG,1383.09,,,1383.09,Other,100% New York Medicaid APG,3111.95,,,3111.95,Other,225% New York Medicaid APG,2116.12,,,2116.12,Other,153% New York Medicaid APG,3111.95,,,3111.95,Other,225% New York Medicaid APG,1936.32,,,1936.32,Other,140% New York Medicaid APG,3111.95,,,3111.95,Other,225% New York Medicaid APG,3596.03,,,3596.03,Other,260% New York Medicaid APG,4481.21,,,4481.21,Other,324% New York Medicaid APG,2973.64,,,2973.64,Other,215% New York Medicaid APG,2973.64,,,2973.64,Other,215% New York Medicaid APG,1728.86,,,1728.86,Other,125% New York Medicaid APG,1383.09,109730.31,
Removal of lymph nodes neck,38720,CPT,,,,,,,,both,,,137162.89,101500.54,74,,101500.54,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,61723.3,45,,61723.3,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,67895.63,49.5,,67895.63,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2572.54,,,2572.54,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,96014.02,70,,96014.02,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1383.09,,,1383.09,Other,New York Medicaid APG methodology,1383.09,,,1383.09,Other,100% New York Medicaid APG,1383.09,,,1383.09,Other,100% New York Medicaid APG,1383.09,,,1383.09,Other,100% New York Medicaid APG,3111.95,,,3111.95,Other,225% New York Medicaid APG,2116.12,,,2116.12,Other,153% New York Medicaid APG,3111.95,,,3111.95,Other,225% New York Medicaid APG,1936.32,,,1936.32,Other,140% New York Medicaid APG,3111.95,,,3111.95,Other,225% New York Medicaid APG,3596.03,,,3596.03,Other,260% New York Medicaid APG,4481.21,,,4481.21,Other,324% New York Medicaid APG,2973.64,,,2973.64,Other,215% New York Medicaid APG,2973.64,,,2973.64,Other,215% New York Medicaid APG,1728.86,,,1728.86,Other,125% New York Medicaid APG,1383.09,101500.54,
Remove armpit lymph nodes,38740,CPT,,,,,,,,both,,,121364.27,89809.56,74,,89809.56,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,54613.92,45,,54613.92,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,6125,,"100% primary, 50% secondary, 25% supplemental procedure",6125,Other,Blue Cross ASC Grouper,5513,,"100% primary, 50% secondary, 25% supplemental procedure",5513,Other,Blue Cross ASC Grouper,5206,,"100% primary, 50% secondary, 25% supplemental procedure",5206,Other,Blue Cross ASC Grouper,60075.31,49.5,,60075.31,percent of total billed charges,110% of Medicare,82527.7,68,,82527.7,percent of total billed charges,,3621.77,,,3621.77,Other,186% of Medicaid,97091.42,80,,97091.42,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,97091.42,80,,97091.42,percent of total billed charges,,7216,,,7216,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,84954.99,70,,84954.99,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,1947.19,,,1947.19,Other,New York Medicaid APG methodology,1947.19,,,1947.19,Other,100% New York Medicaid APG,1947.19,,,1947.19,Other,100% New York Medicaid APG,1947.19,,,1947.19,Other,100% New York Medicaid APG,4381.17,,,4381.17,Other,225% New York Medicaid APG,2979.2,,,2979.2,Other,153% New York Medicaid APG,4381.17,,,4381.17,Other,225% New York Medicaid APG,2726.06,,,2726.06,Other,140% New York Medicaid APG,4381.17,,,4381.17,Other,225% New York Medicaid APG,5062.69,,,5062.69,Other,260% New York Medicaid APG,6308.89,,,6308.89,Other,324% New York Medicaid APG,4186.45,,,4186.45,Other,215% New York Medicaid APG,4186.45,,,4186.45,Other,215% New York Medicaid APG,2433.99,,,2433.99,Other,125% New York Medicaid APG,1947.19,97091.42,
Remove armpit lymph nodes,38745,CPT,,,,,,,,both,,,121364.27,89809.56,74,,89809.56,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,54613.92,45,,54613.92,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,6125,,"100% primary, 50% secondary, 25% supplemental procedure",6125,Other,Blue Cross ASC Grouper,5513,,"100% primary, 50% secondary, 25% supplemental procedure",5513,Other,Blue Cross ASC Grouper,5206,,"100% primary, 50% secondary, 25% supplemental procedure",5206,Other,Blue Cross ASC Grouper,60075.31,49.5,,60075.31,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3621.77,,,3621.77,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,84954.99,70,,84954.99,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,1947.19,,,1947.19,Other,New York Medicaid APG methodology,1947.19,,,1947.19,Other,100% New York Medicaid APG,1947.19,,,1947.19,Other,100% New York Medicaid APG,1947.19,,,1947.19,Other,100% New York Medicaid APG,4381.17,,,4381.17,Other,225% New York Medicaid APG,2979.2,,,2979.2,Other,153% New York Medicaid APG,4381.17,,,4381.17,Other,225% New York Medicaid APG,2726.06,,,2726.06,Other,140% New York Medicaid APG,4381.17,,,4381.17,Other,225% New York Medicaid APG,5062.69,,,5062.69,Other,260% New York Medicaid APG,6308.89,,,6308.89,Other,324% New York Medicaid APG,4186.45,,,4186.45,Other,215% New York Medicaid APG,4186.45,,,4186.45,Other,215% New York Medicaid APG,2433.99,,,2433.99,Other,125% New York Medicaid APG,1947.19,89809.56,
Remove groin lymph nodes,38760,CPT,,,,,,,,both,,,137162.89,101500.54,74,,101500.54,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,61723.3,45,,61723.3,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,7266,,"100% primary, 50% secondary, 25% supplemental procedure",7266,Other,Blue Cross ASC Grouper,6539,,"100% primary, 50% secondary, 25% supplemental procedure",6539,Other,Blue Cross ASC Grouper,6176,,"100% primary, 50% secondary, 25% supplemental procedure",6176,Other,Blue Cross ASC Grouper,67895.63,49.5,,67895.63,percent of total billed charges,110% of Medicare,93270.77,68,,93270.77,percent of total billed charges,,2572.54,,,2572.54,Other,186% of Medicaid,109730.31,80,,109730.31,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,109730.31,80,,109730.31,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,96014.02,70,,96014.02,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1383.09,,,1383.09,Other,New York Medicaid APG methodology,1383.09,,,1383.09,Other,100% New York Medicaid APG,1383.09,,,1383.09,Other,100% New York Medicaid APG,1383.09,,,1383.09,Other,100% New York Medicaid APG,3111.95,,,3111.95,Other,225% New York Medicaid APG,2116.12,,,2116.12,Other,153% New York Medicaid APG,3111.95,,,3111.95,Other,225% New York Medicaid APG,1936.32,,,1936.32,Other,140% New York Medicaid APG,3111.95,,,3111.95,Other,225% New York Medicaid APG,3596.03,,,3596.03,Other,260% New York Medicaid APG,4481.21,,,4481.21,Other,324% New York Medicaid APG,2973.64,,,2973.64,Other,215% New York Medicaid APG,2973.64,,,2973.64,Other,215% New York Medicaid APG,1728.86,,,1728.86,Other,125% New York Medicaid APG,1383.09,109730.31,
Inject for lymphatic x-ray,38790,CPT,,,,,,,,both,,,31549.03,23346.28,74,,23346.28,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,14197.06,45,,14197.06,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,15616.77,49.5,,15616.77,percent of total billed charges,110% of Medicare,21453.34,68,,21453.34,percent of total billed charges,,966.93,,,966.93,Other,186% of Medicaid,25239.22,80,,25239.22,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,25239.22,80,,25239.22,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,22084.32,70,,22084.32,percent of total billed charges,,398.52,,,398.52,Fee Schedule,,337.77,,,337.77,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,519.86,,,519.86,Other,New York Medicaid APG methodology,519.86,,,519.86,Other,100% New York Medicaid APG,519.86,,,519.86,Other,100% New York Medicaid APG,519.86,,,519.86,Other,100% New York Medicaid APG,1169.68,,,1169.68,Other,225% New York Medicaid APG,795.38,,,795.38,Other,153% New York Medicaid APG,1169.68,,,1169.68,Other,225% New York Medicaid APG,727.8,,,727.8,Other,140% New York Medicaid APG,1169.68,,,1169.68,Other,225% New York Medicaid APG,1351.62,,,1351.62,Other,260% New York Medicaid APG,1684.33,,,1684.33,Other,324% New York Medicaid APG,1117.69,,,1117.69,Other,215% New York Medicaid APG,1117.69,,,1117.69,Other,215% New York Medicaid APG,649.82,,,649.82,Other,125% New York Medicaid APG,337.77,25239.22,
Ra tracer id of sentinl node,38792,CPT,,,,,,,,both,,,8675.17,6419.63,74,,6419.63,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,3903.83,45,,3903.83,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,4294.21,49.5,,4294.21,percent of total billed charges,110% of Medicare,5899.12,68,,5899.12,percent of total billed charges,,765.84,,,765.84,Other,186% of Medicaid,6940.14,80,,6940.14,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,6940.14,80,,6940.14,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,6072.62,70,,6072.62,percent of total billed charges,,157.44,,,157.44,Fee Schedule,,133.44,,,133.44,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,411.74,,,411.74,Other,New York Medicaid APG methodology,411.74,,,411.74,Other,100% New York Medicaid APG,411.74,,,411.74,Other,100% New York Medicaid APG,411.74,,,411.74,Other,100% New York Medicaid APG,926.42,,,926.42,Other,225% New York Medicaid APG,629.97,,,629.97,Other,153% New York Medicaid APG,926.42,,,926.42,Other,225% New York Medicaid APG,576.44,,,576.44,Other,140% New York Medicaid APG,926.42,,,926.42,Other,225% New York Medicaid APG,1070.53,,,1070.53,Other,260% New York Medicaid APG,1334.05,,,1334.05,Other,324% New York Medicaid APG,885.25,,,885.25,Other,215% New York Medicaid APG,885.25,,,885.25,Other,215% New York Medicaid APG,514.68,,,514.68,Other,125% New York Medicaid APG,133.44,7216,
Access thoracic lymph duct,38794,CPT,,,,,,,,both,,,51572.04,38163.31,74,,38163.31,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,23207.42,45,,23207.42,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,25528.16,49.5,,25528.16,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,516.02,,,516.02,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,36100.43,70,,36100.43,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,277.43,,,277.43,Other,New York Medicaid APG methodology,277.43,,,277.43,Other,100% New York Medicaid APG,277.43,,,277.43,Other,100% New York Medicaid APG,277.43,,,277.43,Other,100% New York Medicaid APG,624.21,,,624.21,Other,225% New York Medicaid APG,424.47,,,424.47,Other,153% New York Medicaid APG,624.21,,,624.21,Other,225% New York Medicaid APG,388.4,,,388.4,Other,140% New York Medicaid APG,624.21,,,624.21,Other,225% New York Medicaid APG,721.31,,,721.31,Other,260% New York Medicaid APG,898.87,,,898.87,Other,324% New York Medicaid APG,596.47,,,596.47,Other,215% New York Medicaid APG,596.47,,,596.47,Other,215% New York Medicaid APG,346.79,,,346.79,Other,125% New York Medicaid APG,277.43,38163.31,
Io map of sent lymph node,38900,CPT,,,,,,,,both,,,32432.1,23999.75,74,,23999.75,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,14594.45,45,,14594.45,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,16053.89,49.5,,16053.89,percent of total billed charges,110% of Medicare,22053.83,68,,22053.83,percent of total billed charges,,966.93,,,966.93,Other,186% of Medicaid,25945.68,80,,25945.68,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,25945.68,80,,25945.68,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,22702.47,70,,22702.47,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,519.86,,,519.86,Other,New York Medicaid APG methodology,519.86,,,519.86,Other,100% New York Medicaid APG,519.86,,,519.86,Other,100% New York Medicaid APG,519.86,,,519.86,Other,100% New York Medicaid APG,1169.68,,,1169.68,Other,225% New York Medicaid APG,795.38,,,795.38,Other,153% New York Medicaid APG,1169.68,,,1169.68,Other,225% New York Medicaid APG,727.8,,,727.8,Other,140% New York Medicaid APG,1169.68,,,1169.68,Other,225% New York Medicaid APG,1351.62,,,1351.62,Other,260% New York Medicaid APG,1684.33,,,1684.33,Other,324% New York Medicaid APG,1117.69,,,1117.69,Other,215% New York Medicaid APG,1117.69,,,1117.69,Other,215% New York Medicaid APG,649.82,,,649.82,Other,125% New York Medicaid APG,519.86,25945.68,
Mediastinoscpy w/medstnl bx,39401,CPT,,,,,,,,both,,,121364.27,89809.56,74,,89809.56,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,54613.92,45,,54613.92,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,6125,,"100% primary, 50% secondary, 25% supplemental procedure",6125,Other,Blue Cross ASC Grouper,5513,,"100% primary, 50% secondary, 25% supplemental procedure",5513,Other,Blue Cross ASC Grouper,5206,,"100% primary, 50% secondary, 25% supplemental procedure",5206,Other,Blue Cross ASC Grouper,60075.31,49.5,,60075.31,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3164.53,,,3164.53,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,84954.99,70,,84954.99,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,1701.36,,,1701.36,Other,New York Medicaid APG methodology,1701.36,,,1701.36,Other,100% New York Medicaid APG,1701.36,,,1701.36,Other,100% New York Medicaid APG,1701.36,,,1701.36,Other,100% New York Medicaid APG,3828.06,,,3828.06,Other,225% New York Medicaid APG,2603.08,,,2603.08,Other,153% New York Medicaid APG,3828.06,,,3828.06,Other,225% New York Medicaid APG,2381.9,,,2381.9,Other,140% New York Medicaid APG,3828.06,,,3828.06,Other,225% New York Medicaid APG,4423.54,,,4423.54,Other,260% New York Medicaid APG,5512.41,,,5512.41,Other,324% New York Medicaid APG,3657.92,,,3657.92,Other,215% New York Medicaid APG,3657.92,,,3657.92,Other,215% New York Medicaid APG,2126.7,,,2126.7,Other,125% New York Medicaid APG,1701.36,89809.56,
Mediastinoscpy w/lmph nod bx,39402,CPT,,,,,,,,both,,,121364.27,89809.56,74,,89809.56,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,54613.92,45,,54613.92,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,6125,,"100% primary, 50% secondary, 25% supplemental procedure",6125,Other,Blue Cross ASC Grouper,5513,,"100% primary, 50% secondary, 25% supplemental procedure",5513,Other,Blue Cross ASC Grouper,5206,,"100% primary, 50% secondary, 25% supplemental procedure",5206,Other,Blue Cross ASC Grouper,60075.31,49.5,,60075.31,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3164.53,,,3164.53,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,84954.99,70,,84954.99,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,1701.36,,,1701.36,Other,New York Medicaid APG methodology,1701.36,,,1701.36,Other,100% New York Medicaid APG,1701.36,,,1701.36,Other,100% New York Medicaid APG,1701.36,,,1701.36,Other,100% New York Medicaid APG,3828.06,,,3828.06,Other,225% New York Medicaid APG,2603.08,,,2603.08,Other,153% New York Medicaid APG,3828.06,,,3828.06,Other,225% New York Medicaid APG,2381.9,,,2381.9,Other,140% New York Medicaid APG,3828.06,,,3828.06,Other,225% New York Medicaid APG,4423.54,,,4423.54,Other,260% New York Medicaid APG,5512.41,,,5512.41,Other,324% New York Medicaid APG,3657.92,,,3657.92,Other,215% New York Medicaid APG,3657.92,,,3657.92,Other,215% New York Medicaid APG,2126.7,,,2126.7,Other,125% New York Medicaid APG,1701.36,89809.56,
Biopsy of lip,40490,CPT,,,,,,,,both,,,34446.73,25490.58,74,,25490.58,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15501.03,45,,15501.03,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,17051.13,49.5,,17051.13,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,423.06,,,423.06,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,24112.71,70,,24112.71,percent of total billed charges,,336.2,,,336.2,Fee Schedule,,284.95,,,284.95,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,227.45,,,227.45,Other,New York Medicaid APG methodology,227.45,,,227.45,Other,100% New York Medicaid APG,227.45,,,227.45,Other,100% New York Medicaid APG,227.45,,,227.45,Other,100% New York Medicaid APG,511.76,,,511.76,Other,225% New York Medicaid APG,348,,,348,Other,153% New York Medicaid APG,511.76,,,511.76,Other,225% New York Medicaid APG,318.43,,,318.43,Other,140% New York Medicaid APG,511.76,,,511.76,Other,225% New York Medicaid APG,591.37,,,591.37,Other,260% New York Medicaid APG,736.94,,,736.94,Other,324% New York Medicaid APG,489.02,,,489.02,Other,215% New York Medicaid APG,489.02,,,489.02,Other,215% New York Medicaid APG,284.31,,,284.31,Other,125% New York Medicaid APG,227.45,25490.58,
Partial excision of lip,40500,CPT,,,,,,,,both,,,67720.49,50113.16,74,,50113.16,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30474.22,45,,30474.22,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,33521.64,49.5,,33521.64,percent of total billed charges,110% of Medicare,46049.93,68,,46049.93,percent of total billed charges,,2256.57,,,2256.57,Other,186% of Medicaid,54176.39,80,,54176.39,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,54176.39,80,,54176.39,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,47404.34,70,,47404.34,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1213.21,,,1213.21,Other,New York Medicaid APG methodology,1213.21,,,1213.21,Other,100% New York Medicaid APG,1213.21,,,1213.21,Other,100% New York Medicaid APG,1213.21,,,1213.21,Other,100% New York Medicaid APG,2729.72,,,2729.72,Other,225% New York Medicaid APG,1856.21,,,1856.21,Other,153% New York Medicaid APG,2729.72,,,2729.72,Other,225% New York Medicaid APG,1698.49,,,1698.49,Other,140% New York Medicaid APG,2729.72,,,2729.72,Other,225% New York Medicaid APG,3154.34,,,3154.34,Other,260% New York Medicaid APG,3930.79,,,3930.79,Other,324% New York Medicaid APG,2608.4,,,2608.4,Other,215% New York Medicaid APG,2608.4,,,2608.4,Other,215% New York Medicaid APG,1516.51,,,1516.51,Other,125% New York Medicaid APG,1213.21,54176.39,
Partial excision of lip,40510,CPT,,,,,,,,both,,,67720.49,50113.16,74,,50113.16,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30474.22,45,,30474.22,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,33521.64,49.5,,33521.64,percent of total billed charges,110% of Medicare,46049.93,68,,46049.93,percent of total billed charges,,2965.83,,,2965.83,Other,186% of Medicaid,54176.39,80,,54176.39,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,54176.39,80,,54176.39,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,47404.34,70,,47404.34,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1594.53,,,1594.53,Other,New York Medicaid APG methodology,1594.53,,,1594.53,Other,100% New York Medicaid APG,1594.53,,,1594.53,Other,100% New York Medicaid APG,1594.53,,,1594.53,Other,100% New York Medicaid APG,3587.7,,,3587.7,Other,225% New York Medicaid APG,2439.64,,,2439.64,Other,153% New York Medicaid APG,3587.7,,,3587.7,Other,225% New York Medicaid APG,2232.35,,,2232.35,Other,140% New York Medicaid APG,3587.7,,,3587.7,Other,225% New York Medicaid APG,4145.78,,,4145.78,Other,260% New York Medicaid APG,5166.29,,,5166.29,Other,324% New York Medicaid APG,3428.25,,,3428.25,Other,215% New York Medicaid APG,3428.25,,,3428.25,Other,215% New York Medicaid APG,1993.17,,,1993.17,Other,125% New York Medicaid APG,1594.53,54176.39,
Partial excision of lip,40520,CPT,,,,,,,,both,,,35222.09,26064.35,74,,26064.35,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15849.94,45,,15849.94,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,17434.93,49.5,,17434.93,percent of total billed charges,110% of Medicare,23951.02,68,,23951.02,percent of total billed charges,,2256.57,,,2256.57,Other,186% of Medicaid,28177.67,80,,28177.67,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,28177.67,80,,28177.67,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,24655.46,70,,24655.46,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1213.21,,,1213.21,Other,New York Medicaid APG methodology,1213.21,,,1213.21,Other,100% New York Medicaid APG,1213.21,,,1213.21,Other,100% New York Medicaid APG,1213.21,,,1213.21,Other,100% New York Medicaid APG,2729.72,,,2729.72,Other,225% New York Medicaid APG,1856.21,,,1856.21,Other,153% New York Medicaid APG,2729.72,,,2729.72,Other,225% New York Medicaid APG,1698.49,,,1698.49,Other,140% New York Medicaid APG,2729.72,,,2729.72,Other,225% New York Medicaid APG,3154.34,,,3154.34,Other,260% New York Medicaid APG,3930.79,,,3930.79,Other,324% New York Medicaid APG,2608.4,,,2608.4,Other,215% New York Medicaid APG,2608.4,,,2608.4,Other,215% New York Medicaid APG,1516.51,,,1516.51,Other,125% New York Medicaid APG,1213.21,28177.67,
Reconstruct lip with flap,40525,CPT,,,,,,,,both,,,60680.73,44903.74,74,,44903.74,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,27306.33,45,,27306.33,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,30036.96,49.5,,30036.96,percent of total billed charges,110% of Medicare,41262.9,68,,41262.9,percent of total billed charges,,2965.83,,,2965.83,Other,186% of Medicaid,48544.58,80,,48544.58,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,48544.58,80,,48544.58,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,42476.51,70,,42476.51,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1594.53,,,1594.53,Other,New York Medicaid APG methodology,1594.53,,,1594.53,Other,100% New York Medicaid APG,1594.53,,,1594.53,Other,100% New York Medicaid APG,1594.53,,,1594.53,Other,100% New York Medicaid APG,3587.7,,,3587.7,Other,225% New York Medicaid APG,2439.64,,,2439.64,Other,153% New York Medicaid APG,3587.7,,,3587.7,Other,225% New York Medicaid APG,2232.35,,,2232.35,Other,140% New York Medicaid APG,3587.7,,,3587.7,Other,225% New York Medicaid APG,4145.78,,,4145.78,Other,260% New York Medicaid APG,5166.29,,,5166.29,Other,324% New York Medicaid APG,3428.25,,,3428.25,Other,215% New York Medicaid APG,3428.25,,,3428.25,Other,215% New York Medicaid APG,1993.17,,,1993.17,Other,125% New York Medicaid APG,1594.53,48544.58,
Reconstruct lip with flap,40527,CPT,,,,,,,,both,,,123177.14,91151.08,74,,91151.08,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,55429.71,45,,55429.71,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,60972.68,49.5,,60972.68,percent of total billed charges,110% of Medicare,83760.46,68,,83760.46,percent of total billed charges,,4119.28,,,4119.28,Other,186% of Medicaid,98541.71,80,,98541.71,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,98541.71,80,,98541.71,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,86224,70,,86224,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,2214.67,,,2214.67,Other,New York Medicaid APG methodology,2214.67,,,2214.67,Other,100% New York Medicaid APG,2214.67,,,2214.67,Other,100% New York Medicaid APG,2214.67,,,2214.67,Other,100% New York Medicaid APG,4983,,,4983,Other,225% New York Medicaid APG,3388.44,,,3388.44,Other,153% New York Medicaid APG,4983,,,4983,Other,225% New York Medicaid APG,3100.53,,,3100.53,Other,140% New York Medicaid APG,4983,,,4983,Other,225% New York Medicaid APG,5758.13,,,5758.13,Other,260% New York Medicaid APG,7175.52,,,7175.52,Other,324% New York Medicaid APG,4761.53,,,4761.53,Other,215% New York Medicaid APG,4761.53,,,4761.53,Other,215% New York Medicaid APG,2768.33,,,2768.33,Other,125% New York Medicaid APG,2214.67,98541.71,
Partial removal of lip,40530,CPT,,,,,,,,both,,,36028.54,26661.12,74,,26661.12,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,16212.84,45,,16212.84,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,17834.13,49.5,,17834.13,percent of total billed charges,110% of Medicare,24499.41,68,,24499.41,percent of total billed charges,,2965.83,,,2965.83,Other,186% of Medicaid,28822.83,80,,28822.83,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,28822.83,80,,28822.83,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,25219.98,70,,25219.98,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1594.53,,,1594.53,Other,New York Medicaid APG methodology,1594.53,,,1594.53,Other,100% New York Medicaid APG,1594.53,,,1594.53,Other,100% New York Medicaid APG,1594.53,,,1594.53,Other,100% New York Medicaid APG,3587.7,,,3587.7,Other,225% New York Medicaid APG,2439.64,,,2439.64,Other,153% New York Medicaid APG,3587.7,,,3587.7,Other,225% New York Medicaid APG,2232.35,,,2232.35,Other,140% New York Medicaid APG,3587.7,,,3587.7,Other,225% New York Medicaid APG,4145.78,,,4145.78,Other,260% New York Medicaid APG,5166.29,,,5166.29,Other,324% New York Medicaid APG,3428.25,,,3428.25,Other,215% New York Medicaid APG,3428.25,,,3428.25,Other,215% New York Medicaid APG,1993.17,,,1993.17,Other,125% New York Medicaid APG,1594.53,28822.83,
Repair lip,40650,CPT,,,,,,,,both,,,11572.85,8563.91,74,,8563.91,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,5207.78,45,,5207.78,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,5728.56,49.5,,5728.56,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,423.06,,,423.06,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,8101,70,,8101,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,227.45,,,227.45,Other,New York Medicaid APG methodology,227.45,,,227.45,Other,100% New York Medicaid APG,227.45,,,227.45,Other,100% New York Medicaid APG,227.45,,,227.45,Other,100% New York Medicaid APG,511.76,,,511.76,Other,225% New York Medicaid APG,348,,,348,Other,153% New York Medicaid APG,511.76,,,511.76,Other,225% New York Medicaid APG,318.43,,,318.43,Other,140% New York Medicaid APG,511.76,,,511.76,Other,225% New York Medicaid APG,591.37,,,591.37,Other,260% New York Medicaid APG,736.94,,,736.94,Other,324% New York Medicaid APG,489.02,,,489.02,Other,215% New York Medicaid APG,489.02,,,489.02,Other,215% New York Medicaid APG,284.31,,,284.31,Other,125% New York Medicaid APG,227.45,9473,
Repair lip,40652,CPT,,,,,,,,both,,,11572.85,8563.91,74,,8563.91,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,5207.78,45,,5207.78,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,5728.56,49.5,,5728.56,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,423.06,,,423.06,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,8101,70,,8101,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,227.45,,,227.45,Other,New York Medicaid APG methodology,227.45,,,227.45,Other,100% New York Medicaid APG,227.45,,,227.45,Other,100% New York Medicaid APG,227.45,,,227.45,Other,100% New York Medicaid APG,511.76,,,511.76,Other,225% New York Medicaid APG,348,,,348,Other,153% New York Medicaid APG,511.76,,,511.76,Other,225% New York Medicaid APG,318.43,,,318.43,Other,140% New York Medicaid APG,511.76,,,511.76,Other,225% New York Medicaid APG,591.37,,,591.37,Other,260% New York Medicaid APG,736.94,,,736.94,Other,324% New York Medicaid APG,489.02,,,489.02,Other,215% New York Medicaid APG,489.02,,,489.02,Other,215% New York Medicaid APG,284.31,,,284.31,Other,125% New York Medicaid APG,227.45,9473,
Repair lip,40654,CPT,,,,,,,,both,,,32077.39,23737.27,74,,23737.27,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,14434.83,45,,14434.83,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,15878.31,49.5,,15878.31,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2256.57,,,2256.57,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,22454.17,70,,22454.17,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1213.21,,,1213.21,Other,New York Medicaid APG methodology,1213.21,,,1213.21,Other,100% New York Medicaid APG,1213.21,,,1213.21,Other,100% New York Medicaid APG,1213.21,,,1213.21,Other,100% New York Medicaid APG,2729.72,,,2729.72,Other,225% New York Medicaid APG,1856.21,,,1856.21,Other,153% New York Medicaid APG,2729.72,,,2729.72,Other,225% New York Medicaid APG,1698.49,,,1698.49,Other,140% New York Medicaid APG,2729.72,,,2729.72,Other,225% New York Medicaid APG,3154.34,,,3154.34,Other,260% New York Medicaid APG,3930.79,,,3930.79,Other,324% New York Medicaid APG,2608.4,,,2608.4,Other,215% New York Medicaid APG,2608.4,,,2608.4,Other,215% New York Medicaid APG,1516.51,,,1516.51,Other,125% New York Medicaid APG,1213.21,23737.27,
Repair cleft lip/nasal,40700,CPT,,,,,,,,both,,,37061.46,27425.48,74,,27425.48,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,16677.66,45,,16677.66,percent of total billed charges,Medicare Ratio of cost to charges,5954,,"100% primary, 50% supplemental procedure",5954,Other,Aetna ASC Grouper,5359,,"100% primary, 50% supplemental procedure",5359,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,18345.42,49.5,,18345.42,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5266.94,,,5266.94,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,25943.02,70,,25943.02,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,2831.69,,,2831.69,Other,New York Medicaid APG methodology,2831.69,,,2831.69,Other,100% New York Medicaid APG,2831.69,,,2831.69,Other,100% New York Medicaid APG,2831.69,,,2831.69,Other,100% New York Medicaid APG,6371.29,,,6371.29,Other,225% New York Medicaid APG,4332.48,,,4332.48,Other,153% New York Medicaid APG,6371.29,,,6371.29,Other,225% New York Medicaid APG,3964.36,,,3964.36,Other,140% New York Medicaid APG,6371.29,,,6371.29,Other,225% New York Medicaid APG,7362.38,,,7362.38,Other,260% New York Medicaid APG,9174.66,,,9174.66,Other,324% New York Medicaid APG,6088.13,,,6088.13,Other,215% New York Medicaid APG,6088.13,,,6088.13,Other,215% New York Medicaid APG,3539.61,,,3539.61,Other,125% New York Medicaid APG,2831.69,27425.48,
Repair cleft lip/nasal,40701,CPT,,,,,,,,both,,,123177.14,91151.08,74,,91151.08,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,55429.71,45,,55429.71,percent of total billed charges,Medicare Ratio of cost to charges,5954,,"100% primary, 50% supplemental procedure",5954,Other,Aetna ASC Grouper,5359,,"100% primary, 50% supplemental procedure",5359,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,60972.68,49.5,,60972.68,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5266.94,,,5266.94,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,86224,70,,86224,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,2831.69,,,2831.69,Other,New York Medicaid APG methodology,2831.69,,,2831.69,Other,100% New York Medicaid APG,2831.69,,,2831.69,Other,100% New York Medicaid APG,2831.69,,,2831.69,Other,100% New York Medicaid APG,6371.29,,,6371.29,Other,225% New York Medicaid APG,4332.48,,,4332.48,Other,153% New York Medicaid APG,6371.29,,,6371.29,Other,225% New York Medicaid APG,3964.36,,,3964.36,Other,140% New York Medicaid APG,6371.29,,,6371.29,Other,225% New York Medicaid APG,7362.38,,,7362.38,Other,260% New York Medicaid APG,9174.66,,,9174.66,Other,324% New York Medicaid APG,6088.13,,,6088.13,Other,215% New York Medicaid APG,6088.13,,,6088.13,Other,215% New York Medicaid APG,3539.61,,,3539.61,Other,125% New York Medicaid APG,2831.69,91151.08,
Repair cleft lip/nasal,40702,CPT,,,,,,,,both,,,37204.04,27530.99,74,,27530.99,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,16741.82,45,,16741.82,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,18416,49.5,,18416,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5266.94,,,5266.94,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,26042.83,70,,26042.83,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,2831.69,,,2831.69,Other,New York Medicaid APG methodology,2831.69,,,2831.69,Other,100% New York Medicaid APG,2831.69,,,2831.69,Other,100% New York Medicaid APG,2831.69,,,2831.69,Other,100% New York Medicaid APG,6371.29,,,6371.29,Other,225% New York Medicaid APG,4332.48,,,4332.48,Other,153% New York Medicaid APG,6371.29,,,6371.29,Other,225% New York Medicaid APG,3964.36,,,3964.36,Other,140% New York Medicaid APG,6371.29,,,6371.29,Other,225% New York Medicaid APG,7362.38,,,7362.38,Other,260% New York Medicaid APG,9174.66,,,9174.66,Other,324% New York Medicaid APG,6088.13,,,6088.13,Other,215% New York Medicaid APG,6088.13,,,6088.13,Other,215% New York Medicaid APG,3539.61,,,3539.61,Other,125% New York Medicaid APG,2831.69,27530.99,
Repair cleft lip/nasal,40720,CPT,,,,,,,,both,,,46637.53,34511.77,74,,34511.77,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,20986.89,45,,20986.89,percent of total billed charges,Medicare Ratio of cost to charges,5954,,"100% primary, 50% supplemental procedure",5954,Other,Aetna ASC Grouper,5359,,"100% primary, 50% supplemental procedure",5359,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,23085.58,49.5,,23085.58,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5266.94,,,5266.94,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,32646.27,70,,32646.27,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,2831.69,,,2831.69,Other,New York Medicaid APG methodology,2831.69,,,2831.69,Other,100% New York Medicaid APG,2831.69,,,2831.69,Other,100% New York Medicaid APG,2831.69,,,2831.69,Other,100% New York Medicaid APG,6371.29,,,6371.29,Other,225% New York Medicaid APG,4332.48,,,4332.48,Other,153% New York Medicaid APG,6371.29,,,6371.29,Other,225% New York Medicaid APG,3964.36,,,3964.36,Other,140% New York Medicaid APG,6371.29,,,6371.29,Other,225% New York Medicaid APG,7362.38,,,7362.38,Other,260% New York Medicaid APG,9174.66,,,9174.66,Other,324% New York Medicaid APG,6088.13,,,6088.13,Other,215% New York Medicaid APG,6088.13,,,6088.13,Other,215% New York Medicaid APG,3539.61,,,3539.61,Other,125% New York Medicaid APG,2831.69,34511.77,
Repair cleft lip/nasal,40761,CPT,,,,,,,,both,,,123177.14,91151.08,74,,91151.08,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,55429.71,45,,55429.71,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,60972.68,49.5,,60972.68,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5266.94,,,5266.94,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,86224,70,,86224,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,2831.69,,,2831.69,Other,New York Medicaid APG methodology,2831.69,,,2831.69,Other,100% New York Medicaid APG,2831.69,,,2831.69,Other,100% New York Medicaid APG,2831.69,,,2831.69,Other,100% New York Medicaid APG,6371.29,,,6371.29,Other,225% New York Medicaid APG,4332.48,,,4332.48,Other,153% New York Medicaid APG,6371.29,,,6371.29,Other,225% New York Medicaid APG,3964.36,,,3964.36,Other,140% New York Medicaid APG,6371.29,,,6371.29,Other,225% New York Medicaid APG,7362.38,,,7362.38,Other,260% New York Medicaid APG,9174.66,,,9174.66,Other,324% New York Medicaid APG,6088.13,,,6088.13,Other,215% New York Medicaid APG,6088.13,,,6088.13,Other,215% New York Medicaid APG,3539.61,,,3539.61,Other,125% New York Medicaid APG,2831.69,91151.08,
Drainage of mouth lesion,40800,CPT,,,,,,,,both,,,14798.8,10951.11,74,,10951.11,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,6659.46,45,,6659.46,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,7325.41,49.5,,7325.41,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,428.6,,,428.6,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,3578,,"100% primary, 0% secondary procedures",3578,Other,MagnaCare ASC Grouper,10359.16,70,,10359.16,percent of total billed charges,,580.56,,,580.56,Fee Schedule,,492.06,,,492.06,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,230.43,,,230.43,Other,New York Medicaid APG methodology,230.43,,,230.43,Other,100% New York Medicaid APG,230.43,,,230.43,Other,100% New York Medicaid APG,230.43,,,230.43,Other,100% New York Medicaid APG,518.46,,,518.46,Other,225% New York Medicaid APG,352.55,,,352.55,Other,153% New York Medicaid APG,518.46,,,518.46,Other,225% New York Medicaid APG,322.6,,,322.6,Other,140% New York Medicaid APG,518.46,,,518.46,Other,225% New York Medicaid APG,599.11,,,599.11,Other,260% New York Medicaid APG,746.59,,,746.59,Other,324% New York Medicaid APG,495.42,,,495.42,Other,215% New York Medicaid APG,495.42,,,495.42,Other,215% New York Medicaid APG,288.03,,,288.03,Other,125% New York Medicaid APG,230.43,10951.11,
Drainage of mouth lesion,40801,CPT,,,,,,,,both,,,11572.85,8563.91,74,,8563.91,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,5207.78,45,,5207.78,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,5728.56,49.5,,5728.56,percent of total billed charges,110% of Medicare,7869.54,68,,7869.54,percent of total billed charges,,428.6,,,428.6,Other,186% of Medicaid,9258.28,80,,9258.28,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,9258.28,80,,9258.28,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,8101,70,,8101,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,230.43,,,230.43,Other,New York Medicaid APG methodology,230.43,,,230.43,Other,100% New York Medicaid APG,230.43,,,230.43,Other,100% New York Medicaid APG,230.43,,,230.43,Other,100% New York Medicaid APG,518.46,,,518.46,Other,225% New York Medicaid APG,352.55,,,352.55,Other,153% New York Medicaid APG,518.46,,,518.46,Other,225% New York Medicaid APG,322.6,,,322.6,Other,140% New York Medicaid APG,518.46,,,518.46,Other,225% New York Medicaid APG,599.11,,,599.11,Other,260% New York Medicaid APG,746.59,,,746.59,Other,324% New York Medicaid APG,495.42,,,495.42,Other,215% New York Medicaid APG,495.42,,,495.42,Other,215% New York Medicaid APG,288.03,,,288.03,Other,125% New York Medicaid APG,230.43,9258.28,
Removal foreign body mouth,40804,CPT,,,,,,,,both,,,19066.74,14109.39,74,,14109.39,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,8580.03,45,,8580.03,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,9438.04,49.5,,9438.04,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,428.6,,,428.6,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,13346.72,70,,13346.72,percent of total billed charges,,554.32,,,554.32,Fee Schedule,,469.82,,,469.82,Fee Schedule,,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,230.43,,,230.43,Other,New York Medicaid APG methodology,230.43,,,230.43,Other,100% New York Medicaid APG,230.43,,,230.43,Other,100% New York Medicaid APG,230.43,,,230.43,Other,100% New York Medicaid APG,518.46,,,518.46,Other,225% New York Medicaid APG,352.55,,,352.55,Other,153% New York Medicaid APG,518.46,,,518.46,Other,225% New York Medicaid APG,322.6,,,322.6,Other,140% New York Medicaid APG,518.46,,,518.46,Other,225% New York Medicaid APG,599.11,,,599.11,Other,260% New York Medicaid APG,746.59,,,746.59,Other,324% New York Medicaid APG,495.42,,,495.42,Other,215% New York Medicaid APG,495.42,,,495.42,Other,215% New York Medicaid APG,288.03,,,288.03,Other,125% New York Medicaid APG,230.43,14109.39,
Removal foreign body mouth,40805,CPT,,,,,,,,both,,,11572.85,8563.91,74,,8563.91,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,5207.78,45,,5207.78,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,5728.56,49.5,,5728.56,percent of total billed charges,110% of Medicare,7869.54,68,,7869.54,percent of total billed charges,,428.6,,,428.6,Other,186% of Medicaid,9258.28,80,,9258.28,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,9258.28,80,,9258.28,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,8101,70,,8101,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,230.43,,,230.43,Other,New York Medicaid APG methodology,230.43,,,230.43,Other,100% New York Medicaid APG,230.43,,,230.43,Other,100% New York Medicaid APG,230.43,,,230.43,Other,100% New York Medicaid APG,518.46,,,518.46,Other,225% New York Medicaid APG,352.55,,,352.55,Other,153% New York Medicaid APG,518.46,,,518.46,Other,225% New York Medicaid APG,322.6,,,322.6,Other,140% New York Medicaid APG,518.46,,,518.46,Other,225% New York Medicaid APG,599.11,,,599.11,Other,260% New York Medicaid APG,746.59,,,746.59,Other,324% New York Medicaid APG,495.42,,,495.42,Other,215% New York Medicaid APG,495.42,,,495.42,Other,215% New York Medicaid APG,288.03,,,288.03,Other,125% New York Medicaid APG,230.43,9258.28,
Incision of lip fold,40806,CPT,,,,,,,,both,,,11572.85,8563.91,74,,8563.91,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,5207.78,45,,5207.78,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,5728.56,49.5,,5728.56,percent of total billed charges,110% of Medicare,7869.54,68,,7869.54,percent of total billed charges,,2256.57,,,2256.57,Other,186% of Medicaid,9258.28,80,,9258.28,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,9258.28,80,,9258.28,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,8101,70,,8101,percent of total billed charges,,141.04,,,141.04,Fee Schedule,,119.54,,,119.54,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,1213.21,,,1213.21,Other,New York Medicaid APG methodology,1213.21,,,1213.21,Other,100% New York Medicaid APG,1213.21,,,1213.21,Other,100% New York Medicaid APG,1213.21,,,1213.21,Other,100% New York Medicaid APG,2729.72,,,2729.72,Other,225% New York Medicaid APG,1856.21,,,1856.21,Other,153% New York Medicaid APG,2729.72,,,2729.72,Other,225% New York Medicaid APG,1698.49,,,1698.49,Other,140% New York Medicaid APG,2729.72,,,2729.72,Other,225% New York Medicaid APG,3154.34,,,3154.34,Other,260% New York Medicaid APG,3930.79,,,3930.79,Other,324% New York Medicaid APG,2608.4,,,2608.4,Other,215% New York Medicaid APG,2608.4,,,2608.4,Other,215% New York Medicaid APG,1516.51,,,1516.51,Other,125% New York Medicaid APG,119.54,9258.28,
Biopsy of mouth lesion,40808,CPT,,,,,,,,both,,,11572.85,8563.91,74,,8563.91,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,5207.78,45,,5207.78,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,5728.56,49.5,,5728.56,percent of total billed charges,110% of Medicare,7869.54,68,,7869.54,percent of total billed charges,,428.6,,,428.6,Other,186% of Medicaid,9258.28,80,,9258.28,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,9258.28,80,,9258.28,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,8101,70,,8101,percent of total billed charges,,434.6,,,434.6,Fee Schedule,,368.35,,,368.35,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,230.43,,,230.43,Other,New York Medicaid APG methodology,230.43,,,230.43,Other,100% New York Medicaid APG,230.43,,,230.43,Other,100% New York Medicaid APG,230.43,,,230.43,Other,100% New York Medicaid APG,518.46,,,518.46,Other,225% New York Medicaid APG,352.55,,,352.55,Other,153% New York Medicaid APG,518.46,,,518.46,Other,225% New York Medicaid APG,322.6,,,322.6,Other,140% New York Medicaid APG,518.46,,,518.46,Other,225% New York Medicaid APG,599.11,,,599.11,Other,260% New York Medicaid APG,746.59,,,746.59,Other,324% New York Medicaid APG,495.42,,,495.42,Other,215% New York Medicaid APG,495.42,,,495.42,Other,215% New York Medicaid APG,288.03,,,288.03,Other,125% New York Medicaid APG,230.43,9258.28,
Excision of mouth lesion,40810,CPT,,,,,,,,both,,,36908.56,27312.33,74,,27312.33,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,16608.85,45,,16608.85,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,18269.74,49.5,,18269.74,percent of total billed charges,110% of Medicare,25097.82,68,,25097.82,percent of total billed charges,,829.41,,,829.41,Other,186% of Medicaid,29526.85,80,,29526.85,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,29526.85,80,,29526.85,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,25835.99,70,,25835.99,percent of total billed charges,,605.16,,,605.16,Fee Schedule,,512.91,,,512.91,Fee Schedule,,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,445.92,,,445.92,Other,New York Medicaid APG methodology,445.92,,,445.92,Other,100% New York Medicaid APG,445.92,,,445.92,Other,100% New York Medicaid APG,445.92,,,445.92,Other,100% New York Medicaid APG,1003.32,,,1003.32,Other,225% New York Medicaid APG,682.26,,,682.26,Other,153% New York Medicaid APG,1003.32,,,1003.32,Other,225% New York Medicaid APG,624.29,,,624.29,Other,140% New York Medicaid APG,1003.32,,,1003.32,Other,225% New York Medicaid APG,1159.39,,,1159.39,Other,260% New York Medicaid APG,1444.78,,,1444.78,Other,324% New York Medicaid APG,958.72,,,958.72,Other,215% New York Medicaid APG,958.72,,,958.72,Other,215% New York Medicaid APG,557.4,,,557.4,Other,125% New York Medicaid APG,445.92,29526.85,
Excise/repair mouth lesion,40812,CPT,,,,,,,,both,,,35262.79,26094.46,74,,26094.46,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15868.26,45,,15868.26,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,17455.08,49.5,,17455.08,percent of total billed charges,110% of Medicare,23978.7,68,,23978.7,percent of total billed charges,,829.41,,,829.41,Other,186% of Medicaid,28210.23,80,,28210.23,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,28210.23,80,,28210.23,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,24683.95,70,,24683.95,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,445.92,,,445.92,Other,New York Medicaid APG methodology,445.92,,,445.92,Other,100% New York Medicaid APG,445.92,,,445.92,Other,100% New York Medicaid APG,445.92,,,445.92,Other,100% New York Medicaid APG,1003.32,,,1003.32,Other,225% New York Medicaid APG,682.26,,,682.26,Other,153% New York Medicaid APG,1003.32,,,1003.32,Other,225% New York Medicaid APG,624.29,,,624.29,Other,140% New York Medicaid APG,1003.32,,,1003.32,Other,225% New York Medicaid APG,1159.39,,,1159.39,Other,260% New York Medicaid APG,1444.78,,,1444.78,Other,324% New York Medicaid APG,958.72,,,958.72,Other,215% New York Medicaid APG,958.72,,,958.72,Other,215% New York Medicaid APG,557.4,,,557.4,Other,125% New York Medicaid APG,445.92,28210.23,
Excise/repair mouth lesion,40814,CPT,,,,,,,,both,,,67720.49,50113.16,74,,50113.16,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30474.22,45,,30474.22,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,33521.64,49.5,,33521.64,percent of total billed charges,110% of Medicare,46049.93,68,,46049.93,percent of total billed charges,,829.41,,,829.41,Other,186% of Medicaid,54176.39,80,,54176.39,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,54176.39,80,,54176.39,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,47404.34,70,,47404.34,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,445.92,,,445.92,Other,New York Medicaid APG methodology,445.92,,,445.92,Other,100% New York Medicaid APG,445.92,,,445.92,Other,100% New York Medicaid APG,445.92,,,445.92,Other,100% New York Medicaid APG,1003.32,,,1003.32,Other,225% New York Medicaid APG,682.26,,,682.26,Other,153% New York Medicaid APG,1003.32,,,1003.32,Other,225% New York Medicaid APG,624.29,,,624.29,Other,140% New York Medicaid APG,1003.32,,,1003.32,Other,225% New York Medicaid APG,1159.39,,,1159.39,Other,260% New York Medicaid APG,1444.78,,,1444.78,Other,324% New York Medicaid APG,958.72,,,958.72,Other,215% New York Medicaid APG,958.72,,,958.72,Other,215% New York Medicaid APG,557.4,,,557.4,Other,125% New York Medicaid APG,445.92,54176.39,
Excision of mouth lesion,40816,CPT,,,,,,,,both,,,67720.49,50113.16,74,,50113.16,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30474.22,45,,30474.22,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,33521.64,49.5,,33521.64,percent of total billed charges,110% of Medicare,46049.93,68,,46049.93,percent of total billed charges,,829.41,,,829.41,Other,186% of Medicaid,54176.39,80,,54176.39,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,54176.39,80,,54176.39,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,47404.34,70,,47404.34,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,445.92,,,445.92,Other,New York Medicaid APG methodology,445.92,,,445.92,Other,100% New York Medicaid APG,445.92,,,445.92,Other,100% New York Medicaid APG,445.92,,,445.92,Other,100% New York Medicaid APG,1003.32,,,1003.32,Other,225% New York Medicaid APG,682.26,,,682.26,Other,153% New York Medicaid APG,1003.32,,,1003.32,Other,225% New York Medicaid APG,624.29,,,624.29,Other,140% New York Medicaid APG,1003.32,,,1003.32,Other,225% New York Medicaid APG,1159.39,,,1159.39,Other,260% New York Medicaid APG,1444.78,,,1444.78,Other,324% New York Medicaid APG,958.72,,,958.72,Other,215% New York Medicaid APG,958.72,,,958.72,Other,215% New York Medicaid APG,557.4,,,557.4,Other,125% New York Medicaid APG,445.92,54176.39,
Excise oral mucosa for graft,40818,CPT,,,,,,,,both,,,11572.85,8563.91,74,,8563.91,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,5207.78,45,,5207.78,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,5728.56,49.5,,5728.56,percent of total billed charges,110% of Medicare,7869.54,68,,7869.54,percent of total billed charges,,829.41,,,829.41,Other,186% of Medicaid,9258.28,80,,9258.28,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,9258.28,80,,9258.28,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,8101,70,,8101,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,445.92,,,445.92,Other,New York Medicaid APG methodology,445.92,,,445.92,Other,100% New York Medicaid APG,445.92,,,445.92,Other,100% New York Medicaid APG,445.92,,,445.92,Other,100% New York Medicaid APG,1003.32,,,1003.32,Other,225% New York Medicaid APG,682.26,,,682.26,Other,153% New York Medicaid APG,1003.32,,,1003.32,Other,225% New York Medicaid APG,624.29,,,624.29,Other,140% New York Medicaid APG,1003.32,,,1003.32,Other,225% New York Medicaid APG,1159.39,,,1159.39,Other,260% New York Medicaid APG,1444.78,,,1444.78,Other,324% New York Medicaid APG,958.72,,,958.72,Other,215% New York Medicaid APG,958.72,,,958.72,Other,215% New York Medicaid APG,557.4,,,557.4,Other,125% New York Medicaid APG,445.92,9258.28,
Excise lip or cheek fold,40819,CPT,,,,,,,,both,,,32077.39,23737.27,74,,23737.27,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,14434.83,45,,14434.83,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,15878.31,49.5,,15878.31,percent of total billed charges,110% of Medicare,21812.63,68,,21812.63,percent of total billed charges,,2256.57,,,2256.57,Other,186% of Medicaid,25661.91,80,,25661.91,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,25661.91,80,,25661.91,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,22454.17,70,,22454.17,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1213.21,,,1213.21,Other,New York Medicaid APG methodology,1213.21,,,1213.21,Other,100% New York Medicaid APG,1213.21,,,1213.21,Other,100% New York Medicaid APG,1213.21,,,1213.21,Other,100% New York Medicaid APG,2729.72,,,2729.72,Other,225% New York Medicaid APG,1856.21,,,1856.21,Other,153% New York Medicaid APG,2729.72,,,2729.72,Other,225% New York Medicaid APG,1698.49,,,1698.49,Other,140% New York Medicaid APG,2729.72,,,2729.72,Other,225% New York Medicaid APG,3154.34,,,3154.34,Other,260% New York Medicaid APG,3930.79,,,3930.79,Other,324% New York Medicaid APG,2608.4,,,2608.4,Other,215% New York Medicaid APG,2608.4,,,2608.4,Other,215% New York Medicaid APG,1516.51,,,1516.51,Other,125% New York Medicaid APG,1213.21,25661.91,
Treatment of mouth lesion,40820,CPT,,,,,,,,both,,,67720.49,50113.16,74,,50113.16,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30474.22,45,,30474.22,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,33521.64,49.5,,33521.64,percent of total billed charges,110% of Medicare,46049.93,68,,46049.93,percent of total billed charges,,829.41,,,829.41,Other,186% of Medicaid,54176.39,80,,54176.39,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,54176.39,80,,54176.39,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,47404.34,70,,47404.34,percent of total billed charges,,816.72,,,816.72,Fee Schedule,,692.22,,,692.22,Fee Schedule,,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,445.92,,,445.92,Other,New York Medicaid APG methodology,445.92,,,445.92,Other,100% New York Medicaid APG,445.92,,,445.92,Other,100% New York Medicaid APG,445.92,,,445.92,Other,100% New York Medicaid APG,1003.32,,,1003.32,Other,225% New York Medicaid APG,682.26,,,682.26,Other,153% New York Medicaid APG,1003.32,,,1003.32,Other,225% New York Medicaid APG,624.29,,,624.29,Other,140% New York Medicaid APG,1003.32,,,1003.32,Other,225% New York Medicaid APG,1159.39,,,1159.39,Other,260% New York Medicaid APG,1444.78,,,1444.78,Other,324% New York Medicaid APG,958.72,,,958.72,Other,215% New York Medicaid APG,958.72,,,958.72,Other,215% New York Medicaid APG,557.4,,,557.4,Other,125% New York Medicaid APG,445.92,54176.39,
Repair mouth laceration,40830,CPT,,,,,,,,both,,,5137.73,3801.92,74,,3801.92,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,2311.98,45,,2311.98,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,2543.18,49.5,,2543.18,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,423.06,,,423.06,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,3596.41,70,,3596.41,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,227.45,,,227.45,Other,New York Medicaid APG methodology,227.45,,,227.45,Other,100% New York Medicaid APG,227.45,,,227.45,Other,100% New York Medicaid APG,227.45,,,227.45,Other,100% New York Medicaid APG,511.76,,,511.76,Other,225% New York Medicaid APG,348,,,348,Other,153% New York Medicaid APG,511.76,,,511.76,Other,225% New York Medicaid APG,318.43,,,318.43,Other,140% New York Medicaid APG,511.76,,,511.76,Other,225% New York Medicaid APG,591.37,,,591.37,Other,260% New York Medicaid APG,736.94,,,736.94,Other,324% New York Medicaid APG,489.02,,,489.02,Other,215% New York Medicaid APG,489.02,,,489.02,Other,215% New York Medicaid APG,284.31,,,284.31,Other,125% New York Medicaid APG,227.45,9473,
Repair mouth laceration,40831,CPT,,,,,,,,both,,,11572.85,8563.91,74,,8563.91,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,5207.78,45,,5207.78,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,5728.56,49.5,,5728.56,percent of total billed charges,110% of Medicare,7869.54,68,,7869.54,percent of total billed charges,,428.6,,,428.6,Other,186% of Medicaid,9258.28,80,,9258.28,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,9258.28,80,,9258.28,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,8101,70,,8101,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,230.43,,,230.43,Other,New York Medicaid APG methodology,230.43,,,230.43,Other,100% New York Medicaid APG,230.43,,,230.43,Other,100% New York Medicaid APG,230.43,,,230.43,Other,100% New York Medicaid APG,518.46,,,518.46,Other,225% New York Medicaid APG,352.55,,,352.55,Other,153% New York Medicaid APG,518.46,,,518.46,Other,225% New York Medicaid APG,322.6,,,322.6,Other,140% New York Medicaid APG,518.46,,,518.46,Other,225% New York Medicaid APG,599.11,,,599.11,Other,260% New York Medicaid APG,746.59,,,746.59,Other,324% New York Medicaid APG,495.42,,,495.42,Other,215% New York Medicaid APG,495.42,,,495.42,Other,215% New York Medicaid APG,288.03,,,288.03,Other,125% New York Medicaid APG,230.43,9258.28,
Reconstruction of mouth,40840,CPT,,,,,,,,both,,,123177.14,91151.08,74,,91151.08,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,55429.71,45,,55429.71,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,60972.68,49.5,,60972.68,percent of total billed charges,110% of Medicare,83760.46,68,,83760.46,percent of total billed charges,,829.41,,,829.41,Other,186% of Medicaid,98541.71,80,,98541.71,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,98541.71,80,,98541.71,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,86224,70,,86224,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,445.92,,,445.92,Other,New York Medicaid APG methodology,445.92,,,445.92,Other,100% New York Medicaid APG,445.92,,,445.92,Other,100% New York Medicaid APG,445.92,,,445.92,Other,100% New York Medicaid APG,1003.32,,,1003.32,Other,225% New York Medicaid APG,682.26,,,682.26,Other,153% New York Medicaid APG,1003.32,,,1003.32,Other,225% New York Medicaid APG,624.29,,,624.29,Other,140% New York Medicaid APG,1003.32,,,1003.32,Other,225% New York Medicaid APG,1159.39,,,1159.39,Other,260% New York Medicaid APG,1444.78,,,1444.78,Other,324% New York Medicaid APG,958.72,,,958.72,Other,215% New York Medicaid APG,958.72,,,958.72,Other,215% New York Medicaid APG,557.4,,,557.4,Other,125% New York Medicaid APG,445.92,98541.71,
Reconstruction of mouth,40842,CPT,,,,,,,,both,,,123177.14,91151.08,74,,91151.08,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,55429.71,45,,55429.71,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,60972.68,49.5,,60972.68,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,829.41,,,829.41,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,86224,70,,86224,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,445.92,,,445.92,Other,New York Medicaid APG methodology,445.92,,,445.92,Other,100% New York Medicaid APG,445.92,,,445.92,Other,100% New York Medicaid APG,445.92,,,445.92,Other,100% New York Medicaid APG,1003.32,,,1003.32,Other,225% New York Medicaid APG,682.26,,,682.26,Other,153% New York Medicaid APG,1003.32,,,1003.32,Other,225% New York Medicaid APG,624.29,,,624.29,Other,140% New York Medicaid APG,1003.32,,,1003.32,Other,225% New York Medicaid APG,1159.39,,,1159.39,Other,260% New York Medicaid APG,1444.78,,,1444.78,Other,324% New York Medicaid APG,958.72,,,958.72,Other,215% New York Medicaid APG,958.72,,,958.72,Other,215% New York Medicaid APG,557.4,,,557.4,Other,125% New York Medicaid APG,445.92,91151.08,
Reconstruction of mouth,40843,CPT,,,,,,,,both,,,123177.14,91151.08,74,,91151.08,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,55429.71,45,,55429.71,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,60972.68,49.5,,60972.68,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,829.41,,,829.41,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,86224,70,,86224,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,445.92,,,445.92,Other,New York Medicaid APG methodology,445.92,,,445.92,Other,100% New York Medicaid APG,445.92,,,445.92,Other,100% New York Medicaid APG,445.92,,,445.92,Other,100% New York Medicaid APG,1003.32,,,1003.32,Other,225% New York Medicaid APG,682.26,,,682.26,Other,153% New York Medicaid APG,1003.32,,,1003.32,Other,225% New York Medicaid APG,624.29,,,624.29,Other,140% New York Medicaid APG,1003.32,,,1003.32,Other,225% New York Medicaid APG,1159.39,,,1159.39,Other,260% New York Medicaid APG,1444.78,,,1444.78,Other,324% New York Medicaid APG,958.72,,,958.72,Other,215% New York Medicaid APG,958.72,,,958.72,Other,215% New York Medicaid APG,557.4,,,557.4,Other,125% New York Medicaid APG,445.92,91151.08,
Reconstruction of mouth,40844,CPT,,,,,,,,both,,,123177.14,91151.08,74,,91151.08,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,55429.71,45,,55429.71,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,60972.68,49.5,,60972.68,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,829.41,,,829.41,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,86224,70,,86224,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,445.92,,,445.92,Other,New York Medicaid APG methodology,445.92,,,445.92,Other,100% New York Medicaid APG,445.92,,,445.92,Other,100% New York Medicaid APG,445.92,,,445.92,Other,100% New York Medicaid APG,1003.32,,,1003.32,Other,225% New York Medicaid APG,682.26,,,682.26,Other,153% New York Medicaid APG,1003.32,,,1003.32,Other,225% New York Medicaid APG,624.29,,,624.29,Other,140% New York Medicaid APG,1003.32,,,1003.32,Other,225% New York Medicaid APG,1159.39,,,1159.39,Other,260% New York Medicaid APG,1444.78,,,1444.78,Other,324% New York Medicaid APG,958.72,,,958.72,Other,215% New York Medicaid APG,958.72,,,958.72,Other,215% New York Medicaid APG,557.4,,,557.4,Other,125% New York Medicaid APG,445.92,91151.08,
Reconstruction of mouth,40845,CPT,,,,,,,,both,,,123177.14,91151.08,74,,91151.08,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,55429.71,45,,55429.71,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,60972.68,49.5,,60972.68,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,829.41,,,829.41,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,86224,70,,86224,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,445.92,,,445.92,Other,New York Medicaid APG methodology,445.92,,,445.92,Other,100% New York Medicaid APG,445.92,,,445.92,Other,100% New York Medicaid APG,445.92,,,445.92,Other,100% New York Medicaid APG,1003.32,,,1003.32,Other,225% New York Medicaid APG,682.26,,,682.26,Other,153% New York Medicaid APG,1003.32,,,1003.32,Other,225% New York Medicaid APG,624.29,,,624.29,Other,140% New York Medicaid APG,1003.32,,,1003.32,Other,225% New York Medicaid APG,1159.39,,,1159.39,Other,260% New York Medicaid APG,1444.78,,,1444.78,Other,324% New York Medicaid APG,958.72,,,958.72,Other,215% New York Medicaid APG,958.72,,,958.72,Other,215% New York Medicaid APG,557.4,,,557.4,Other,125% New York Medicaid APG,445.92,91151.08,
Drainage of mouth lesion,41000,CPT,,,,,,,,both,,,11572.85,8563.91,74,,8563.91,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,5207.78,45,,5207.78,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,5728.56,49.5,,5728.56,percent of total billed charges,110% of Medicare,7869.54,68,,7869.54,percent of total billed charges,,2256.57,,,2256.57,Other,186% of Medicaid,9258.28,80,,9258.28,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,9258.28,80,,9258.28,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,8101,70,,8101,percent of total billed charges,,518.24,,,518.24,Fee Schedule,,439.24,,,439.24,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,1213.21,,,1213.21,Other,New York Medicaid APG methodology,1213.21,,,1213.21,Other,100% New York Medicaid APG,1213.21,,,1213.21,Other,100% New York Medicaid APG,1213.21,,,1213.21,Other,100% New York Medicaid APG,2729.72,,,2729.72,Other,225% New York Medicaid APG,1856.21,,,1856.21,Other,153% New York Medicaid APG,2729.72,,,2729.72,Other,225% New York Medicaid APG,1698.49,,,1698.49,Other,140% New York Medicaid APG,2729.72,,,2729.72,Other,225% New York Medicaid APG,3154.34,,,3154.34,Other,260% New York Medicaid APG,3930.79,,,3930.79,Other,324% New York Medicaid APG,2608.4,,,2608.4,Other,215% New York Medicaid APG,2608.4,,,2608.4,Other,215% New York Medicaid APG,1516.51,,,1516.51,Other,125% New York Medicaid APG,439.24,9258.28,
Drainage of mouth lesion,41005,CPT,,,,,,,,both,,,5137.73,3801.92,74,,3801.92,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,2311.98,45,,2311.98,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,2543.18,49.5,,2543.18,percent of total billed charges,110% of Medicare,3493.66,68,,3493.66,percent of total billed charges,,423.06,,,423.06,Other,186% of Medicaid,4110.18,80,,4110.18,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,4110.18,80,,4110.18,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,3596.41,70,,3596.41,percent of total billed charges,,588.76,,,588.76,Fee Schedule,,499.01,,,499.01,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,227.45,,,227.45,Other,New York Medicaid APG methodology,227.45,,,227.45,Other,100% New York Medicaid APG,227.45,,,227.45,Other,100% New York Medicaid APG,227.45,,,227.45,Other,100% New York Medicaid APG,511.76,,,511.76,Other,225% New York Medicaid APG,348,,,348,Other,153% New York Medicaid APG,511.76,,,511.76,Other,225% New York Medicaid APG,318.43,,,318.43,Other,140% New York Medicaid APG,511.76,,,511.76,Other,225% New York Medicaid APG,591.37,,,591.37,Other,260% New York Medicaid APG,736.94,,,736.94,Other,324% New York Medicaid APG,489.02,,,489.02,Other,215% New York Medicaid APG,489.02,,,489.02,Other,215% New York Medicaid APG,284.31,,,284.31,Other,125% New York Medicaid APG,227.45,7216,
Drainage of mouth lesion,41006,CPT,,,,,,,,both,,,32077.39,23737.27,74,,23737.27,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,14434.83,45,,14434.83,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,15878.31,49.5,,15878.31,percent of total billed charges,110% of Medicare,21812.63,68,,21812.63,percent of total billed charges,,2256.57,,,2256.57,Other,186% of Medicaid,25661.91,80,,25661.91,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,25661.91,80,,25661.91,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,22454.17,70,,22454.17,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1213.21,,,1213.21,Other,New York Medicaid APG methodology,1213.21,,,1213.21,Other,100% New York Medicaid APG,1213.21,,,1213.21,Other,100% New York Medicaid APG,1213.21,,,1213.21,Other,100% New York Medicaid APG,2729.72,,,2729.72,Other,225% New York Medicaid APG,1856.21,,,1856.21,Other,153% New York Medicaid APG,2729.72,,,2729.72,Other,225% New York Medicaid APG,1698.49,,,1698.49,Other,140% New York Medicaid APG,2729.72,,,2729.72,Other,225% New York Medicaid APG,3154.34,,,3154.34,Other,260% New York Medicaid APG,3930.79,,,3930.79,Other,324% New York Medicaid APG,2608.4,,,2608.4,Other,215% New York Medicaid APG,2608.4,,,2608.4,Other,215% New York Medicaid APG,1516.51,,,1516.51,Other,125% New York Medicaid APG,1213.21,25661.91,
Drainage of mouth lesion,41007,CPT,,,,,,,,both,,,32077.39,23737.27,74,,23737.27,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,14434.83,45,,14434.83,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,15878.31,49.5,,15878.31,percent of total billed charges,110% of Medicare,21812.63,68,,21812.63,percent of total billed charges,,2256.57,,,2256.57,Other,186% of Medicaid,25661.91,80,,25661.91,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,25661.91,80,,25661.91,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,22454.17,70,,22454.17,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1213.21,,,1213.21,Other,New York Medicaid APG methodology,1213.21,,,1213.21,Other,100% New York Medicaid APG,1213.21,,,1213.21,Other,100% New York Medicaid APG,1213.21,,,1213.21,Other,100% New York Medicaid APG,2729.72,,,2729.72,Other,225% New York Medicaid APG,1856.21,,,1856.21,Other,153% New York Medicaid APG,2729.72,,,2729.72,Other,225% New York Medicaid APG,1698.49,,,1698.49,Other,140% New York Medicaid APG,2729.72,,,2729.72,Other,225% New York Medicaid APG,3154.34,,,3154.34,Other,260% New York Medicaid APG,3930.79,,,3930.79,Other,324% New York Medicaid APG,2608.4,,,2608.4,Other,215% New York Medicaid APG,2608.4,,,2608.4,Other,215% New York Medicaid APG,1516.51,,,1516.51,Other,125% New York Medicaid APG,1213.21,25661.91,
Drainage of mouth lesion,41008,CPT,,,,,,,,both,,,67720.49,50113.16,74,,50113.16,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30474.22,45,,30474.22,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,33521.64,49.5,,33521.64,percent of total billed charges,110% of Medicare,46049.93,68,,46049.93,percent of total billed charges,,2256.57,,,2256.57,Other,186% of Medicaid,54176.39,80,,54176.39,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,54176.39,80,,54176.39,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,47404.34,70,,47404.34,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1213.21,,,1213.21,Other,New York Medicaid APG methodology,1213.21,,,1213.21,Other,100% New York Medicaid APG,1213.21,,,1213.21,Other,100% New York Medicaid APG,1213.21,,,1213.21,Other,100% New York Medicaid APG,2729.72,,,2729.72,Other,225% New York Medicaid APG,1856.21,,,1856.21,Other,153% New York Medicaid APG,2729.72,,,2729.72,Other,225% New York Medicaid APG,1698.49,,,1698.49,Other,140% New York Medicaid APG,2729.72,,,2729.72,Other,225% New York Medicaid APG,3154.34,,,3154.34,Other,260% New York Medicaid APG,3930.79,,,3930.79,Other,324% New York Medicaid APG,2608.4,,,2608.4,Other,215% New York Medicaid APG,2608.4,,,2608.4,Other,215% New York Medicaid APG,1516.51,,,1516.51,Other,125% New York Medicaid APG,1213.21,54176.39,
Drainage of mouth lesion,41009,CPT,,,,,,,,both,,,11572.85,8563.91,74,,8563.91,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,5207.78,45,,5207.78,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,5728.56,49.5,,5728.56,percent of total billed charges,110% of Medicare,7869.54,68,,7869.54,percent of total billed charges,,2256.57,,,2256.57,Other,186% of Medicaid,9258.28,80,,9258.28,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,9258.28,80,,9258.28,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,8101,70,,8101,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,1213.21,,,1213.21,Other,New York Medicaid APG methodology,1213.21,,,1213.21,Other,100% New York Medicaid APG,1213.21,,,1213.21,Other,100% New York Medicaid APG,1213.21,,,1213.21,Other,100% New York Medicaid APG,2729.72,,,2729.72,Other,225% New York Medicaid APG,1856.21,,,1856.21,Other,153% New York Medicaid APG,2729.72,,,2729.72,Other,225% New York Medicaid APG,1698.49,,,1698.49,Other,140% New York Medicaid APG,2729.72,,,2729.72,Other,225% New York Medicaid APG,3154.34,,,3154.34,Other,260% New York Medicaid APG,3930.79,,,3930.79,Other,324% New York Medicaid APG,2608.4,,,2608.4,Other,215% New York Medicaid APG,2608.4,,,2608.4,Other,215% New York Medicaid APG,1516.51,,,1516.51,Other,125% New York Medicaid APG,1213.21,9258.28,
Incision of tongue fold,41010,CPT,,,,,,,,both,,,33613.92,24874.3,74,,24874.3,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15126.26,45,,15126.26,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,16638.89,49.5,,16638.89,percent of total billed charges,110% of Medicare,22857.47,68,,22857.47,percent of total billed charges,,2256.57,,,2256.57,Other,186% of Medicaid,26891.14,80,,26891.14,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,26891.14,80,,26891.14,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,23529.74,70,,23529.74,percent of total billed charges,,544.48,,,544.48,Fee Schedule,,461.48,,,461.48,Fee Schedule,,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1213.21,,,1213.21,Other,New York Medicaid APG methodology,1213.21,,,1213.21,Other,100% New York Medicaid APG,1213.21,,,1213.21,Other,100% New York Medicaid APG,1213.21,,,1213.21,Other,100% New York Medicaid APG,2729.72,,,2729.72,Other,225% New York Medicaid APG,1856.21,,,1856.21,Other,153% New York Medicaid APG,2729.72,,,2729.72,Other,225% New York Medicaid APG,1698.49,,,1698.49,Other,140% New York Medicaid APG,2729.72,,,2729.72,Other,225% New York Medicaid APG,3154.34,,,3154.34,Other,260% New York Medicaid APG,3930.79,,,3930.79,Other,324% New York Medicaid APG,2608.4,,,2608.4,Other,215% New York Medicaid APG,2608.4,,,2608.4,Other,215% New York Medicaid APG,1516.51,,,1516.51,Other,125% New York Medicaid APG,461.48,26891.14,
Drainage of mouth lesion,41015,CPT,,,,,,,,both,,,11572.85,8563.91,74,,8563.91,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,5207.78,45,,5207.78,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,5728.56,49.5,,5728.56,percent of total billed charges,110% of Medicare,7869.54,68,,7869.54,percent of total billed charges,,428.6,,,428.6,Other,186% of Medicaid,9258.28,80,,9258.28,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,9258.28,80,,9258.28,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,8101,70,,8101,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,230.43,,,230.43,Other,New York Medicaid APG methodology,230.43,,,230.43,Other,100% New York Medicaid APG,230.43,,,230.43,Other,100% New York Medicaid APG,230.43,,,230.43,Other,100% New York Medicaid APG,518.46,,,518.46,Other,225% New York Medicaid APG,352.55,,,352.55,Other,153% New York Medicaid APG,518.46,,,518.46,Other,225% New York Medicaid APG,322.6,,,322.6,Other,140% New York Medicaid APG,518.46,,,518.46,Other,225% New York Medicaid APG,599.11,,,599.11,Other,260% New York Medicaid APG,746.59,,,746.59,Other,324% New York Medicaid APG,495.42,,,495.42,Other,215% New York Medicaid APG,495.42,,,495.42,Other,215% New York Medicaid APG,288.03,,,288.03,Other,125% New York Medicaid APG,230.43,9258.28,
Drainage of mouth lesion,41016,CPT,,,,,,,,both,,,123177.14,91151.08,74,,91151.08,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,55429.71,45,,55429.71,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,60972.68,49.5,,60972.68,percent of total billed charges,110% of Medicare,83760.46,68,,83760.46,percent of total billed charges,,829.41,,,829.41,Other,186% of Medicaid,98541.71,80,,98541.71,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,98541.71,80,,98541.71,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,86224,70,,86224,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,445.92,,,445.92,Other,New York Medicaid APG methodology,445.92,,,445.92,Other,100% New York Medicaid APG,445.92,,,445.92,Other,100% New York Medicaid APG,445.92,,,445.92,Other,100% New York Medicaid APG,1003.32,,,1003.32,Other,225% New York Medicaid APG,682.26,,,682.26,Other,153% New York Medicaid APG,1003.32,,,1003.32,Other,225% New York Medicaid APG,624.29,,,624.29,Other,140% New York Medicaid APG,1003.32,,,1003.32,Other,225% New York Medicaid APG,1159.39,,,1159.39,Other,260% New York Medicaid APG,1444.78,,,1444.78,Other,324% New York Medicaid APG,958.72,,,958.72,Other,215% New York Medicaid APG,958.72,,,958.72,Other,215% New York Medicaid APG,557.4,,,557.4,Other,125% New York Medicaid APG,445.92,98541.71,
Drainage of mouth lesion,41017,CPT,,,,,,,,both,,,67720.49,50113.16,74,,50113.16,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30474.22,45,,30474.22,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,33521.64,49.5,,33521.64,percent of total billed charges,110% of Medicare,46049.93,68,,46049.93,percent of total billed charges,,829.41,,,829.41,Other,186% of Medicaid,54176.39,80,,54176.39,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,54176.39,80,,54176.39,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,47404.34,70,,47404.34,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,445.92,,,445.92,Other,New York Medicaid APG methodology,445.92,,,445.92,Other,100% New York Medicaid APG,445.92,,,445.92,Other,100% New York Medicaid APG,445.92,,,445.92,Other,100% New York Medicaid APG,1003.32,,,1003.32,Other,225% New York Medicaid APG,682.26,,,682.26,Other,153% New York Medicaid APG,1003.32,,,1003.32,Other,225% New York Medicaid APG,624.29,,,624.29,Other,140% New York Medicaid APG,1003.32,,,1003.32,Other,225% New York Medicaid APG,1159.39,,,1159.39,Other,260% New York Medicaid APG,1444.78,,,1444.78,Other,324% New York Medicaid APG,958.72,,,958.72,Other,215% New York Medicaid APG,958.72,,,958.72,Other,215% New York Medicaid APG,557.4,,,557.4,Other,125% New York Medicaid APG,445.92,54176.39,
Drainage of mouth lesion,41018,CPT,,,,,,,,both,,,32077.39,23737.27,74,,23737.27,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,14434.83,45,,14434.83,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,15878.31,49.5,,15878.31,percent of total billed charges,110% of Medicare,21812.63,68,,21812.63,percent of total billed charges,,829.41,,,829.41,Other,186% of Medicaid,25661.91,80,,25661.91,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,25661.91,80,,25661.91,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,22454.17,70,,22454.17,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,445.92,,,445.92,Other,New York Medicaid APG methodology,445.92,,,445.92,Other,100% New York Medicaid APG,445.92,,,445.92,Other,100% New York Medicaid APG,445.92,,,445.92,Other,100% New York Medicaid APG,1003.32,,,1003.32,Other,225% New York Medicaid APG,682.26,,,682.26,Other,153% New York Medicaid APG,1003.32,,,1003.32,Other,225% New York Medicaid APG,624.29,,,624.29,Other,140% New York Medicaid APG,1003.32,,,1003.32,Other,225% New York Medicaid APG,1159.39,,,1159.39,Other,260% New York Medicaid APG,1444.78,,,1444.78,Other,324% New York Medicaid APG,958.72,,,958.72,Other,215% New York Medicaid APG,958.72,,,958.72,Other,215% New York Medicaid APG,557.4,,,557.4,Other,125% New York Medicaid APG,445.92,25661.91,
Place needles h&n for rt,41019,CPT,,,,,,,,both,,,39024.79,28878.34,74,,28878.34,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,17561.16,45,,17561.16,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,19317.27,49.5,,19317.27,percent of total billed charges,110% of Medicare,26536.86,68,,26536.86,percent of total billed charges,,5841.74,,,5841.74,Other,186% of Medicaid,31219.83,80,,31219.83,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,31219.83,80,,31219.83,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,27317.35,70,,27317.35,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,3140.72,,,3140.72,Other,New York Medicaid APG methodology,3140.72,,,3140.72,Other,100% New York Medicaid APG,3140.72,,,3140.72,Other,100% New York Medicaid APG,3140.72,,,3140.72,Other,100% New York Medicaid APG,7066.62,,,7066.62,Other,225% New York Medicaid APG,4805.3,,,4805.3,Other,153% New York Medicaid APG,7066.62,,,7066.62,Other,225% New York Medicaid APG,4397.01,,,4397.01,Other,140% New York Medicaid APG,7066.62,,,7066.62,Other,225% New York Medicaid APG,8165.87,,,8165.87,Other,260% New York Medicaid APG,10175.93,,,10175.93,Other,324% New York Medicaid APG,6752.54,,,6752.54,Other,215% New York Medicaid APG,6752.54,,,6752.54,Other,215% New York Medicaid APG,3925.9,,,3925.9,Other,125% New York Medicaid APG,2053,31219.83,
Biopsy of tongue,41100,CPT,,,,,,,,both,,,11572.85,8563.91,74,,8563.91,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,5207.78,45,,5207.78,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,5728.56,49.5,,5728.56,percent of total billed charges,110% of Medicare,7869.54,68,,7869.54,percent of total billed charges,,423.06,,,423.06,Other,186% of Medicaid,9258.28,80,,9258.28,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,9258.28,80,,9258.28,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,8101,70,,8101,percent of total billed charges,,528.08,,,528.08,Fee Schedule,,447.58,,,447.58,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,227.45,,,227.45,Other,New York Medicaid APG methodology,227.45,,,227.45,Other,100% New York Medicaid APG,227.45,,,227.45,Other,100% New York Medicaid APG,227.45,,,227.45,Other,100% New York Medicaid APG,511.76,,,511.76,Other,225% New York Medicaid APG,348,,,348,Other,153% New York Medicaid APG,511.76,,,511.76,Other,225% New York Medicaid APG,318.43,,,318.43,Other,140% New York Medicaid APG,511.76,,,511.76,Other,225% New York Medicaid APG,591.37,,,591.37,Other,260% New York Medicaid APG,736.94,,,736.94,Other,324% New York Medicaid APG,489.02,,,489.02,Other,215% New York Medicaid APG,489.02,,,489.02,Other,215% New York Medicaid APG,284.31,,,284.31,Other,125% New York Medicaid APG,227.45,9258.28,
Biopsy of tongue,41105,CPT,,,,,,,,both,,,67720.49,50113.16,74,,50113.16,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30474.22,45,,30474.22,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,33521.64,49.5,,33521.64,percent of total billed charges,110% of Medicare,46049.93,68,,46049.93,percent of total billed charges,,2256.57,,,2256.57,Other,186% of Medicaid,54176.39,80,,54176.39,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,54176.39,80,,54176.39,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,47404.34,70,,47404.34,percent of total billed charges,,541.2,,,541.2,Fee Schedule,,458.7,,,458.7,Fee Schedule,,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1213.21,,,1213.21,Other,New York Medicaid APG methodology,1213.21,,,1213.21,Other,100% New York Medicaid APG,1213.21,,,1213.21,Other,100% New York Medicaid APG,1213.21,,,1213.21,Other,100% New York Medicaid APG,2729.72,,,2729.72,Other,225% New York Medicaid APG,1856.21,,,1856.21,Other,153% New York Medicaid APG,2729.72,,,2729.72,Other,225% New York Medicaid APG,1698.49,,,1698.49,Other,140% New York Medicaid APG,2729.72,,,2729.72,Other,225% New York Medicaid APG,3154.34,,,3154.34,Other,260% New York Medicaid APG,3930.79,,,3930.79,Other,324% New York Medicaid APG,2608.4,,,2608.4,Other,215% New York Medicaid APG,2608.4,,,2608.4,Other,215% New York Medicaid APG,1516.51,,,1516.51,Other,125% New York Medicaid APG,458.7,54176.39,
Biopsy of floor of mouth,41108,CPT,,,,,,,,both,,,34101.75,25235.3,74,,25235.3,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15345.79,45,,15345.79,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,16880.37,49.5,,16880.37,percent of total billed charges,110% of Medicare,23189.19,68,,23189.19,percent of total billed charges,,2256.57,,,2256.57,Other,186% of Medicaid,27281.4,80,,27281.4,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,27281.4,80,,27281.4,percent of total billed charges,,7216,,,7216,Case Rate,,3578,,"100% primary, 0% secondary procedures",3578,Other,MagnaCare ASC Grouper,23871.23,70,,23871.23,percent of total billed charges,,451,,,451,Fee Schedule,,382.25,,,382.25,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,1213.21,,,1213.21,Other,New York Medicaid APG methodology,1213.21,,,1213.21,Other,100% New York Medicaid APG,1213.21,,,1213.21,Other,100% New York Medicaid APG,1213.21,,,1213.21,Other,100% New York Medicaid APG,2729.72,,,2729.72,Other,225% New York Medicaid APG,1856.21,,,1856.21,Other,153% New York Medicaid APG,2729.72,,,2729.72,Other,225% New York Medicaid APG,1698.49,,,1698.49,Other,140% New York Medicaid APG,2729.72,,,2729.72,Other,225% New York Medicaid APG,3154.34,,,3154.34,Other,260% New York Medicaid APG,3930.79,,,3930.79,Other,324% New York Medicaid APG,2608.4,,,2608.4,Other,215% New York Medicaid APG,2608.4,,,2608.4,Other,215% New York Medicaid APG,1516.51,,,1516.51,Other,125% New York Medicaid APG,382.25,27281.4,
Excision of tongue lesion,41110,CPT,,,,,,,,both,,,67720.49,50113.16,74,,50113.16,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30474.22,45,,30474.22,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,33521.64,49.5,,33521.64,percent of total billed charges,110% of Medicare,46049.93,68,,46049.93,percent of total billed charges,,2256.57,,,2256.57,Other,186% of Medicaid,54176.39,80,,54176.39,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,54176.39,80,,54176.39,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,47404.34,70,,47404.34,percent of total billed charges,,641.24,,,641.24,Fee Schedule,,543.49,,,543.49,Fee Schedule,,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1213.21,,,1213.21,Other,New York Medicaid APG methodology,1213.21,,,1213.21,Other,100% New York Medicaid APG,1213.21,,,1213.21,Other,100% New York Medicaid APG,1213.21,,,1213.21,Other,100% New York Medicaid APG,2729.72,,,2729.72,Other,225% New York Medicaid APG,1856.21,,,1856.21,Other,153% New York Medicaid APG,2729.72,,,2729.72,Other,225% New York Medicaid APG,1698.49,,,1698.49,Other,140% New York Medicaid APG,2729.72,,,2729.72,Other,225% New York Medicaid APG,3154.34,,,3154.34,Other,260% New York Medicaid APG,3930.79,,,3930.79,Other,324% New York Medicaid APG,2608.4,,,2608.4,Other,215% New York Medicaid APG,2608.4,,,2608.4,Other,215% New York Medicaid APG,1516.51,,,1516.51,Other,125% New York Medicaid APG,543.49,54176.39,
Excision of tongue lesion,41112,CPT,,,,,,,,both,,,48875.01,36167.51,74,,36167.51,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,21993.75,45,,21993.75,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,24193.13,49.5,,24193.13,percent of total billed charges,110% of Medicare,33235.01,68,,33235.01,percent of total billed charges,,2256.57,,,2256.57,Other,186% of Medicaid,39100.01,80,,39100.01,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,39100.01,80,,39100.01,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,34212.51,70,,34212.51,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1213.21,,,1213.21,Other,New York Medicaid APG methodology,1213.21,,,1213.21,Other,100% New York Medicaid APG,1213.21,,,1213.21,Other,100% New York Medicaid APG,1213.21,,,1213.21,Other,100% New York Medicaid APG,2729.72,,,2729.72,Other,225% New York Medicaid APG,1856.21,,,1856.21,Other,153% New York Medicaid APG,2729.72,,,2729.72,Other,225% New York Medicaid APG,1698.49,,,1698.49,Other,140% New York Medicaid APG,2729.72,,,2729.72,Other,225% New York Medicaid APG,3154.34,,,3154.34,Other,260% New York Medicaid APG,3930.79,,,3930.79,Other,324% New York Medicaid APG,2608.4,,,2608.4,Other,215% New York Medicaid APG,2608.4,,,2608.4,Other,215% New York Medicaid APG,1516.51,,,1516.51,Other,125% New York Medicaid APG,1213.21,39100.01,
Excision of tongue lesion,41113,CPT,,,,,,,,both,,,34482.73,25517.22,74,,25517.22,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15517.23,45,,15517.23,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,17068.95,49.5,,17068.95,percent of total billed charges,110% of Medicare,23448.26,68,,23448.26,percent of total billed charges,,2256.57,,,2256.57,Other,186% of Medicaid,27586.18,80,,27586.18,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,27586.18,80,,27586.18,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,24137.91,70,,24137.91,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1213.21,,,1213.21,Other,New York Medicaid APG methodology,1213.21,,,1213.21,Other,100% New York Medicaid APG,1213.21,,,1213.21,Other,100% New York Medicaid APG,1213.21,,,1213.21,Other,100% New York Medicaid APG,2729.72,,,2729.72,Other,225% New York Medicaid APG,1856.21,,,1856.21,Other,153% New York Medicaid APG,2729.72,,,2729.72,Other,225% New York Medicaid APG,1698.49,,,1698.49,Other,140% New York Medicaid APG,2729.72,,,2729.72,Other,225% New York Medicaid APG,3154.34,,,3154.34,Other,260% New York Medicaid APG,3930.79,,,3930.79,Other,324% New York Medicaid APG,2608.4,,,2608.4,Other,215% New York Medicaid APG,2608.4,,,2608.4,Other,215% New York Medicaid APG,1516.51,,,1516.51,Other,125% New York Medicaid APG,1213.21,27586.18,
Excision of tongue lesion,41114,CPT,,,,,,,,both,,,67720.49,50113.16,74,,50113.16,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30474.22,45,,30474.22,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,33521.64,49.5,,33521.64,percent of total billed charges,110% of Medicare,46049.93,68,,46049.93,percent of total billed charges,,2965.83,,,2965.83,Other,186% of Medicaid,54176.39,80,,54176.39,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,54176.39,80,,54176.39,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,47404.34,70,,47404.34,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1594.53,,,1594.53,Other,New York Medicaid APG methodology,1594.53,,,1594.53,Other,100% New York Medicaid APG,1594.53,,,1594.53,Other,100% New York Medicaid APG,1594.53,,,1594.53,Other,100% New York Medicaid APG,3587.7,,,3587.7,Other,225% New York Medicaid APG,2439.64,,,2439.64,Other,153% New York Medicaid APG,3587.7,,,3587.7,Other,225% New York Medicaid APG,2232.35,,,2232.35,Other,140% New York Medicaid APG,3587.7,,,3587.7,Other,225% New York Medicaid APG,4145.78,,,4145.78,Other,260% New York Medicaid APG,5166.29,,,5166.29,Other,324% New York Medicaid APG,3428.25,,,3428.25,Other,215% New York Medicaid APG,3428.25,,,3428.25,Other,215% New York Medicaid APG,1993.17,,,1993.17,Other,125% New York Medicaid APG,1594.53,54176.39,
Excision of tongue fold,41115,CPT,,,,,,,,both,,,34373.25,25436.21,74,,25436.21,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15467.96,45,,15467.96,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,17014.76,49.5,,17014.76,percent of total billed charges,110% of Medicare,23373.81,68,,23373.81,percent of total billed charges,,2256.57,,,2256.57,Other,186% of Medicaid,27498.6,80,,27498.6,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,27498.6,80,,27498.6,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,24061.28,70,,24061.28,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1213.21,,,1213.21,Other,New York Medicaid APG methodology,1213.21,,,1213.21,Other,100% New York Medicaid APG,1213.21,,,1213.21,Other,100% New York Medicaid APG,1213.21,,,1213.21,Other,100% New York Medicaid APG,2729.72,,,2729.72,Other,225% New York Medicaid APG,1856.21,,,1856.21,Other,153% New York Medicaid APG,2729.72,,,2729.72,Other,225% New York Medicaid APG,1698.49,,,1698.49,Other,140% New York Medicaid APG,2729.72,,,2729.72,Other,225% New York Medicaid APG,3154.34,,,3154.34,Other,260% New York Medicaid APG,3930.79,,,3930.79,Other,324% New York Medicaid APG,2608.4,,,2608.4,Other,215% New York Medicaid APG,2608.4,,,2608.4,Other,215% New York Medicaid APG,1516.51,,,1516.51,Other,125% New York Medicaid APG,1213.21,27498.6,
Excision of mouth lesion,41116,CPT,,,,,,,,both,,,67720.49,50113.16,74,,50113.16,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30474.22,45,,30474.22,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,33521.64,49.5,,33521.64,percent of total billed charges,110% of Medicare,46049.93,68,,46049.93,percent of total billed charges,,829.41,,,829.41,Other,186% of Medicaid,54176.39,80,,54176.39,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,54176.39,80,,54176.39,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,47404.34,70,,47404.34,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,445.92,,,445.92,Other,New York Medicaid APG methodology,445.92,,,445.92,Other,100% New York Medicaid APG,445.92,,,445.92,Other,100% New York Medicaid APG,445.92,,,445.92,Other,100% New York Medicaid APG,1003.32,,,1003.32,Other,225% New York Medicaid APG,682.26,,,682.26,Other,153% New York Medicaid APG,1003.32,,,1003.32,Other,225% New York Medicaid APG,624.29,,,624.29,Other,140% New York Medicaid APG,1003.32,,,1003.32,Other,225% New York Medicaid APG,1159.39,,,1159.39,Other,260% New York Medicaid APG,1444.78,,,1444.78,Other,324% New York Medicaid APG,958.72,,,958.72,Other,215% New York Medicaid APG,958.72,,,958.72,Other,215% New York Medicaid APG,557.4,,,557.4,Other,125% New York Medicaid APG,445.92,54176.39,
Partial removal of tongue,41120,CPT,,,,,,,,both,,,50582.73,37431.22,74,,37431.22,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,22762.23,45,,22762.23,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,25038.45,49.5,,25038.45,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,4119.28,,,4119.28,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,35407.91,70,,35407.91,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,2214.67,,,2214.67,Other,New York Medicaid APG methodology,2214.67,,,2214.67,Other,100% New York Medicaid APG,2214.67,,,2214.67,Other,100% New York Medicaid APG,2214.67,,,2214.67,Other,100% New York Medicaid APG,4983,,,4983,Other,225% New York Medicaid APG,3388.44,,,3388.44,Other,153% New York Medicaid APG,4983,,,4983,Other,225% New York Medicaid APG,3100.53,,,3100.53,Other,140% New York Medicaid APG,4983,,,4983,Other,225% New York Medicaid APG,5758.13,,,5758.13,Other,260% New York Medicaid APG,7175.52,,,7175.52,Other,324% New York Medicaid APG,4761.53,,,4761.53,Other,215% New York Medicaid APG,4761.53,,,4761.53,Other,215% New York Medicaid APG,2768.33,,,2768.33,Other,125% New York Medicaid APG,2214.67,37431.22,
Repair tongue laceration,41250,CPT,,,,,,,,both,,,8380.68,6201.7,74,,6201.7,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,3771.31,45,,3771.31,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,4148.44,49.5,,4148.44,percent of total billed charges,110% of Medicare,5698.86,68,,5698.86,percent of total billed charges,,423.06,,,423.06,Other,186% of Medicaid,6704.54,80,,6704.54,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,6704.54,80,,6704.54,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,5866.48,70,,5866.48,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,227.45,,,227.45,Other,New York Medicaid APG methodology,227.45,,,227.45,Other,100% New York Medicaid APG,227.45,,,227.45,Other,100% New York Medicaid APG,227.45,,,227.45,Other,100% New York Medicaid APG,511.76,,,511.76,Other,225% New York Medicaid APG,348,,,348,Other,153% New York Medicaid APG,511.76,,,511.76,Other,225% New York Medicaid APG,318.43,,,318.43,Other,140% New York Medicaid APG,511.76,,,511.76,Other,225% New York Medicaid APG,591.37,,,591.37,Other,260% New York Medicaid APG,736.94,,,736.94,Other,324% New York Medicaid APG,489.02,,,489.02,Other,215% New York Medicaid APG,489.02,,,489.02,Other,215% New York Medicaid APG,284.31,,,284.31,Other,125% New York Medicaid APG,227.45,7216,
Repair tongue laceration,41251,CPT,,,,,,,,both,,,5137.73,3801.92,74,,3801.92,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,2311.98,45,,2311.98,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,2543.18,49.5,,2543.18,percent of total billed charges,110% of Medicare,3493.66,68,,3493.66,percent of total billed charges,,423.06,,,423.06,Other,186% of Medicaid,4110.18,80,,4110.18,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,4110.18,80,,4110.18,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,3596.41,70,,3596.41,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,227.45,,,227.45,Other,New York Medicaid APG methodology,227.45,,,227.45,Other,100% New York Medicaid APG,227.45,,,227.45,Other,100% New York Medicaid APG,227.45,,,227.45,Other,100% New York Medicaid APG,511.76,,,511.76,Other,225% New York Medicaid APG,348,,,348,Other,153% New York Medicaid APG,511.76,,,511.76,Other,225% New York Medicaid APG,318.43,,,318.43,Other,140% New York Medicaid APG,511.76,,,511.76,Other,225% New York Medicaid APG,591.37,,,591.37,Other,260% New York Medicaid APG,736.94,,,736.94,Other,324% New York Medicaid APG,489.02,,,489.02,Other,215% New York Medicaid APG,489.02,,,489.02,Other,215% New York Medicaid APG,284.31,,,284.31,Other,125% New York Medicaid APG,227.45,7216,
Repair tongue laceration,41252,CPT,,,,,,,,both,,,5137.73,3801.92,74,,3801.92,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,2311.98,45,,2311.98,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,2543.18,49.5,,2543.18,percent of total billed charges,110% of Medicare,3493.66,68,,3493.66,percent of total billed charges,,423.06,,,423.06,Other,186% of Medicaid,4110.18,80,,4110.18,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,4110.18,80,,4110.18,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,3596.41,70,,3596.41,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,227.45,,,227.45,Other,New York Medicaid APG methodology,227.45,,,227.45,Other,100% New York Medicaid APG,227.45,,,227.45,Other,100% New York Medicaid APG,227.45,,,227.45,Other,100% New York Medicaid APG,511.76,,,511.76,Other,225% New York Medicaid APG,348,,,348,Other,153% New York Medicaid APG,511.76,,,511.76,Other,225% New York Medicaid APG,318.43,,,318.43,Other,140% New York Medicaid APG,511.76,,,511.76,Other,225% New York Medicaid APG,591.37,,,591.37,Other,260% New York Medicaid APG,736.94,,,736.94,Other,324% New York Medicaid APG,489.02,,,489.02,Other,215% New York Medicaid APG,489.02,,,489.02,Other,215% New York Medicaid APG,284.31,,,284.31,Other,125% New York Medicaid APG,227.45,7216,
Tongue to lip surgery,41510,CPT,,,,,,,,both,,,67720.49,50113.16,74,,50113.16,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30474.22,45,,30474.22,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,33521.64,49.5,,33521.64,percent of total billed charges,110% of Medicare,46049.93,68,,46049.93,percent of total billed charges,,2256.57,,,2256.57,Other,186% of Medicaid,54176.39,80,,54176.39,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,54176.39,80,,54176.39,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,47404.34,70,,47404.34,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1213.21,,,1213.21,Other,New York Medicaid APG methodology,1213.21,,,1213.21,Other,100% New York Medicaid APG,1213.21,,,1213.21,Other,100% New York Medicaid APG,1213.21,,,1213.21,Other,100% New York Medicaid APG,2729.72,,,2729.72,Other,225% New York Medicaid APG,1856.21,,,1856.21,Other,153% New York Medicaid APG,2729.72,,,2729.72,Other,225% New York Medicaid APG,1698.49,,,1698.49,Other,140% New York Medicaid APG,2729.72,,,2729.72,Other,225% New York Medicaid APG,3154.34,,,3154.34,Other,260% New York Medicaid APG,3930.79,,,3930.79,Other,324% New York Medicaid APG,2608.4,,,2608.4,Other,215% New York Medicaid APG,2608.4,,,2608.4,Other,215% New York Medicaid APG,1516.51,,,1516.51,Other,125% New York Medicaid APG,1213.21,54176.39,
Tongue suspension,41512,CPT,,,,,,,,both,,,123177.14,91151.08,74,,91151.08,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,55429.71,45,,55429.71,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,60972.68,49.5,,60972.68,percent of total billed charges,110% of Medicare,83760.46,68,,83760.46,percent of total billed charges,,5841.74,,,5841.74,Other,186% of Medicaid,98541.71,80,,98541.71,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,98541.71,80,,98541.71,percent of total billed charges,,7216,,,7216,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,86224,70,,86224,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,3140.72,,,3140.72,Other,New York Medicaid APG methodology,3140.72,,,3140.72,Other,100% New York Medicaid APG,3140.72,,,3140.72,Other,100% New York Medicaid APG,3140.72,,,3140.72,Other,100% New York Medicaid APG,7066.62,,,7066.62,Other,225% New York Medicaid APG,4805.3,,,4805.3,Other,153% New York Medicaid APG,7066.62,,,7066.62,Other,225% New York Medicaid APG,4397.01,,,4397.01,Other,140% New York Medicaid APG,7066.62,,,7066.62,Other,225% New York Medicaid APG,8165.87,,,8165.87,Other,260% New York Medicaid APG,10175.93,,,10175.93,Other,324% New York Medicaid APG,6752.54,,,6752.54,Other,215% New York Medicaid APG,6752.54,,,6752.54,Other,215% New York Medicaid APG,3925.9,,,3925.9,Other,125% New York Medicaid APG,2232,98541.71,
Reconstruction tongue fold,41520,CPT,,,,,,,,both,,,34094.95,25230.26,74,,25230.26,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15342.73,45,,15342.73,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,16877,49.5,,16877,percent of total billed charges,110% of Medicare,23184.57,68,,23184.57,percent of total billed charges,,4119.28,,,4119.28,Other,186% of Medicaid,27275.96,80,,27275.96,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,27275.96,80,,27275.96,percent of total billed charges,,7216,,,7216,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,23866.47,70,,23866.47,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,2214.67,,,2214.67,Other,New York Medicaid APG methodology,2214.67,,,2214.67,Other,100% New York Medicaid APG,2214.67,,,2214.67,Other,100% New York Medicaid APG,2214.67,,,2214.67,Other,100% New York Medicaid APG,4983,,,4983,Other,225% New York Medicaid APG,3388.44,,,3388.44,Other,153% New York Medicaid APG,4983,,,4983,Other,225% New York Medicaid APG,3100.53,,,3100.53,Other,140% New York Medicaid APG,4983,,,4983,Other,225% New York Medicaid APG,5758.13,,,5758.13,Other,260% New York Medicaid APG,7175.52,,,7175.52,Other,324% New York Medicaid APG,4761.53,,,4761.53,Other,215% New York Medicaid APG,4761.53,,,4761.53,Other,215% New York Medicaid APG,2768.33,,,2768.33,Other,125% New York Medicaid APG,2214.67,27275.96,
Tongue base vol reduction,41530,CPT,,,,,,,,both,,,67720.49,50113.16,74,,50113.16,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30474.22,45,,30474.22,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,33521.64,49.5,,33521.64,percent of total billed charges,110% of Medicare,46049.93,68,,46049.93,percent of total billed charges,,2965.83,,,2965.83,Other,186% of Medicaid,54176.39,80,,54176.39,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,54176.39,80,,54176.39,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,47404.34,70,,47404.34,percent of total billed charges,,1866.32,,,1866.32,Fee Schedule,,1581.82,,,1581.82,Fee Schedule,,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1594.53,,,1594.53,Other,New York Medicaid APG methodology,1594.53,,,1594.53,Other,100% New York Medicaid APG,1594.53,,,1594.53,Other,100% New York Medicaid APG,1594.53,,,1594.53,Other,100% New York Medicaid APG,3587.7,,,3587.7,Other,225% New York Medicaid APG,2439.64,,,2439.64,Other,153% New York Medicaid APG,3587.7,,,3587.7,Other,225% New York Medicaid APG,2232.35,,,2232.35,Other,140% New York Medicaid APG,3587.7,,,3587.7,Other,225% New York Medicaid APG,4145.78,,,4145.78,Other,260% New York Medicaid APG,5166.29,,,5166.29,Other,324% New York Medicaid APG,3428.25,,,3428.25,Other,215% New York Medicaid APG,3428.25,,,3428.25,Other,215% New York Medicaid APG,1993.17,,,1993.17,Other,125% New York Medicaid APG,1581.82,54176.39,
Drainage of gum lesion,41800,CPT,,,,,,,,both,,,2686.86,1988.28,74,,1988.28,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,1209.09,45,,1209.09,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,1330,49.5,,1330,percent of total billed charges,110% of Medicare,1827.06,68,,1827.06,percent of total billed charges,,423.06,,,423.06,Other,186% of Medicaid,2149.49,80,,2149.49,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,2149.49,80,,2149.49,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,1880.8,70,,1880.8,percent of total billed charges,,757.68,,,757.68,Fee Schedule,,642.18,,,642.18,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,227.45,,,227.45,Other,New York Medicaid APG methodology,227.45,,,227.45,Other,100% New York Medicaid APG,227.45,,,227.45,Other,100% New York Medicaid APG,227.45,,,227.45,Other,100% New York Medicaid APG,511.76,,,511.76,Other,225% New York Medicaid APG,348,,,348,Other,153% New York Medicaid APG,511.76,,,511.76,Other,225% New York Medicaid APG,318.43,,,318.43,Other,140% New York Medicaid APG,511.76,,,511.76,Other,225% New York Medicaid APG,591.37,,,591.37,Other,260% New York Medicaid APG,736.94,,,736.94,Other,324% New York Medicaid APG,489.02,,,489.02,Other,215% New York Medicaid APG,489.02,,,489.02,Other,215% New York Medicaid APG,284.31,,,284.31,Other,125% New York Medicaid APG,227.45,7216,
Removal foreign body gum,41805,CPT,,,,,,,,both,,,32077.39,23737.27,74,,23737.27,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,14434.83,45,,14434.83,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,15878.31,49.5,,15878.31,percent of total billed charges,110% of Medicare,21812.63,68,,21812.63,percent of total billed charges,,428.6,,,428.6,Other,186% of Medicaid,25661.91,80,,25661.91,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,25661.91,80,,25661.91,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,22454.17,70,,22454.17,percent of total billed charges,,972.52,,,972.52,Fee Schedule,,824.27,,,824.27,Fee Schedule,,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,230.43,,,230.43,Other,New York Medicaid APG methodology,230.43,,,230.43,Other,100% New York Medicaid APG,230.43,,,230.43,Other,100% New York Medicaid APG,230.43,,,230.43,Other,100% New York Medicaid APG,518.46,,,518.46,Other,225% New York Medicaid APG,352.55,,,352.55,Other,153% New York Medicaid APG,518.46,,,518.46,Other,225% New York Medicaid APG,322.6,,,322.6,Other,140% New York Medicaid APG,518.46,,,518.46,Other,225% New York Medicaid APG,599.11,,,599.11,Other,260% New York Medicaid APG,746.59,,,746.59,Other,324% New York Medicaid APG,495.42,,,495.42,Other,215% New York Medicaid APG,495.42,,,495.42,Other,215% New York Medicaid APG,288.03,,,288.03,Other,125% New York Medicaid APG,230.43,25661.91,
Removal foreign body jawbone,41806,CPT,,,,,,,,both,,,32077.39,23737.27,74,,23737.27,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,14434.83,45,,14434.83,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,15878.31,49.5,,15878.31,percent of total billed charges,110% of Medicare,21812.63,68,,21812.63,percent of total billed charges,,829.41,,,829.41,Other,186% of Medicaid,25661.91,80,,25661.91,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,25661.91,80,,25661.91,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,22454.17,70,,22454.17,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,445.92,,,445.92,Other,New York Medicaid APG methodology,445.92,,,445.92,Other,100% New York Medicaid APG,445.92,,,445.92,Other,100% New York Medicaid APG,445.92,,,445.92,Other,100% New York Medicaid APG,1003.32,,,1003.32,Other,225% New York Medicaid APG,682.26,,,682.26,Other,153% New York Medicaid APG,1003.32,,,1003.32,Other,225% New York Medicaid APG,624.29,,,624.29,Other,140% New York Medicaid APG,1003.32,,,1003.32,Other,225% New York Medicaid APG,1159.39,,,1159.39,Other,260% New York Medicaid APG,1444.78,,,1444.78,Other,324% New York Medicaid APG,958.72,,,958.72,Other,215% New York Medicaid APG,958.72,,,958.72,Other,215% New York Medicaid APG,557.4,,,557.4,Other,125% New York Medicaid APG,445.92,25661.91,
Excision gum each quadrant,41820,CPT,,,,,,,,both,,,11190,8280.6,74,,8280.6,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,5035.5,45,,5035.5,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,5539.05,49.5,,5539.05,percent of total billed charges,110% of Medicare,7609.2,68,,7609.2,percent of total billed charges,,0.02,,,0.02,Other,186% of Medicaid,8952,80,,8952,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,8952,80,,8952,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,7833,70,,7833,percent of total billed charges,,7273.5,65,,7273.5,percent of total billed charges,,7273.5,65,,7273.5,percent of total billed charges,,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% New York Medicaid APG,0.01,,,0.01,Other,100% New York Medicaid APG,0.01,,,0.01,Other,100% New York Medicaid APG,0.02,,,0.02,Other,225% New York Medicaid APG,0.02,,,0.02,Other,153% New York Medicaid APG,0.02,,,0.02,Other,225% New York Medicaid APG,0.01,,,0.01,Other,140% New York Medicaid APG,0.02,,,0.02,Other,225% New York Medicaid APG,0.03,,,0.03,Other,260% New York Medicaid APG,0.03,,,0.03,Other,324% New York Medicaid APG,0.02,,,0.02,Other,215% New York Medicaid APG,0.02,,,0.02,Other,215% New York Medicaid APG,0.01,,,0.01,Other,125% New York Medicaid APG,0.01,8952,
Excision of gum flap,41821,CPT,,,,,,,,both,,,32077.39,23737.27,74,,23737.27,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,14434.83,45,,14434.83,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,15878.31,49.5,,15878.31,percent of total billed charges,110% of Medicare,21812.63,68,,21812.63,percent of total billed charges,,342.38,,,342.38,Other,186% of Medicaid,25661.91,80,,25661.91,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,25661.91,80,,25661.91,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,22454.17,70,,22454.17,percent of total billed charges,,20850.3,65,,20850.3,percent of total billed charges,,20850.3,65,,20850.3,percent of total billed charges,,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,184.07,,,184.07,Other,New York Medicaid APG methodology,184.07,,,184.07,Other,100% New York Medicaid APG,184.07,,,184.07,Other,100% New York Medicaid APG,184.07,,,184.07,Other,100% New York Medicaid APG,414.17,,,414.17,Other,225% New York Medicaid APG,281.63,,,281.63,Other,153% New York Medicaid APG,414.17,,,414.17,Other,225% New York Medicaid APG,257.7,,,257.7,Other,140% New York Medicaid APG,414.17,,,414.17,Other,225% New York Medicaid APG,478.59,,,478.59,Other,260% New York Medicaid APG,596.4,,,596.4,Other,324% New York Medicaid APG,395.76,,,395.76,Other,215% New York Medicaid APG,395.76,,,395.76,Other,215% New York Medicaid APG,230.09,,,230.09,Other,125% New York Medicaid APG,184.07,25661.91,
Excision of gum lesion,41822,CPT,,,,,,,,both,,,32077.39,23737.27,74,,23737.27,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,14434.83,45,,14434.83,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,15878.31,49.5,,15878.31,percent of total billed charges,110% of Medicare,21812.63,68,,21812.63,percent of total billed charges,,829.41,,,829.41,Other,186% of Medicaid,25661.91,80,,25661.91,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,25661.91,80,,25661.91,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,22454.17,70,,22454.17,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,445.92,,,445.92,Other,New York Medicaid APG methodology,445.92,,,445.92,Other,100% New York Medicaid APG,445.92,,,445.92,Other,100% New York Medicaid APG,445.92,,,445.92,Other,100% New York Medicaid APG,1003.32,,,1003.32,Other,225% New York Medicaid APG,682.26,,,682.26,Other,153% New York Medicaid APG,1003.32,,,1003.32,Other,225% New York Medicaid APG,624.29,,,624.29,Other,140% New York Medicaid APG,1003.32,,,1003.32,Other,225% New York Medicaid APG,1159.39,,,1159.39,Other,260% New York Medicaid APG,1444.78,,,1444.78,Other,324% New York Medicaid APG,958.72,,,958.72,Other,215% New York Medicaid APG,958.72,,,958.72,Other,215% New York Medicaid APG,557.4,,,557.4,Other,125% New York Medicaid APG,445.92,25661.91,
Excision of gum lesion,41823,CPT,,,,,,,,both,,,123177.14,91151.08,74,,91151.08,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,55429.71,45,,55429.71,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,60972.68,49.5,,60972.68,percent of total billed charges,110% of Medicare,83760.46,68,,83760.46,percent of total billed charges,,829.41,,,829.41,Other,186% of Medicaid,98541.71,80,,98541.71,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,98541.71,80,,98541.71,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,86224,70,,86224,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,445.92,,,445.92,Other,New York Medicaid APG methodology,445.92,,,445.92,Other,100% New York Medicaid APG,445.92,,,445.92,Other,100% New York Medicaid APG,445.92,,,445.92,Other,100% New York Medicaid APG,1003.32,,,1003.32,Other,225% New York Medicaid APG,682.26,,,682.26,Other,153% New York Medicaid APG,1003.32,,,1003.32,Other,225% New York Medicaid APG,624.29,,,624.29,Other,140% New York Medicaid APG,1003.32,,,1003.32,Other,225% New York Medicaid APG,1159.39,,,1159.39,Other,260% New York Medicaid APG,1444.78,,,1444.78,Other,324% New York Medicaid APG,958.72,,,958.72,Other,215% New York Medicaid APG,958.72,,,958.72,Other,215% New York Medicaid APG,557.4,,,557.4,Other,125% New York Medicaid APG,445.92,98541.71,
Excision of gum lesion,41825,CPT,,,,,,,,both,,,67720.49,50113.16,74,,50113.16,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30474.22,45,,30474.22,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,33521.64,49.5,,33521.64,percent of total billed charges,110% of Medicare,46049.93,68,,46049.93,percent of total billed charges,,829.41,,,829.41,Other,186% of Medicaid,54176.39,80,,54176.39,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,54176.39,80,,54176.39,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,47404.34,70,,47404.34,percent of total billed charges,,595.32,,,595.32,Fee Schedule,,504.57,,,504.57,Fee Schedule,,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,445.92,,,445.92,Other,New York Medicaid APG methodology,445.92,,,445.92,Other,100% New York Medicaid APG,445.92,,,445.92,Other,100% New York Medicaid APG,445.92,,,445.92,Other,100% New York Medicaid APG,1003.32,,,1003.32,Other,225% New York Medicaid APG,682.26,,,682.26,Other,153% New York Medicaid APG,1003.32,,,1003.32,Other,225% New York Medicaid APG,624.29,,,624.29,Other,140% New York Medicaid APG,1003.32,,,1003.32,Other,225% New York Medicaid APG,1159.39,,,1159.39,Other,260% New York Medicaid APG,1444.78,,,1444.78,Other,324% New York Medicaid APG,958.72,,,958.72,Other,215% New York Medicaid APG,958.72,,,958.72,Other,215% New York Medicaid APG,557.4,,,557.4,Other,125% New York Medicaid APG,445.92,54176.39,
Excision of gum lesion,41826,CPT,,,,,,,,both,,,33723,24955.02,74,,24955.02,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15175.35,45,,15175.35,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,16692.89,49.5,,16692.89,percent of total billed charges,110% of Medicare,22931.64,68,,22931.64,percent of total billed charges,,829.41,,,829.41,Other,186% of Medicaid,26978.4,80,,26978.4,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,26978.4,80,,26978.4,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,23606.1,70,,23606.1,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,445.92,,,445.92,Other,New York Medicaid APG methodology,445.92,,,445.92,Other,100% New York Medicaid APG,445.92,,,445.92,Other,100% New York Medicaid APG,445.92,,,445.92,Other,100% New York Medicaid APG,1003.32,,,1003.32,Other,225% New York Medicaid APG,682.26,,,682.26,Other,153% New York Medicaid APG,1003.32,,,1003.32,Other,225% New York Medicaid APG,624.29,,,624.29,Other,140% New York Medicaid APG,1003.32,,,1003.32,Other,225% New York Medicaid APG,1159.39,,,1159.39,Other,260% New York Medicaid APG,1444.78,,,1444.78,Other,324% New York Medicaid APG,958.72,,,958.72,Other,215% New York Medicaid APG,958.72,,,958.72,Other,215% New York Medicaid APG,557.4,,,557.4,Other,125% New York Medicaid APG,445.92,26978.4,
Excision of gum lesion,41827,CPT,,,,,,,,both,,,123177.14,91151.08,74,,91151.08,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,55429.71,45,,55429.71,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,60972.68,49.5,,60972.68,percent of total billed charges,110% of Medicare,83760.46,68,,83760.46,percent of total billed charges,,829.41,,,829.41,Other,186% of Medicaid,98541.71,80,,98541.71,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,98541.71,80,,98541.71,percent of total billed charges,,7216,,,7216,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,86224,70,,86224,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,445.92,,,445.92,Other,New York Medicaid APG methodology,445.92,,,445.92,Other,100% New York Medicaid APG,445.92,,,445.92,Other,100% New York Medicaid APG,445.92,,,445.92,Other,100% New York Medicaid APG,1003.32,,,1003.32,Other,225% New York Medicaid APG,682.26,,,682.26,Other,153% New York Medicaid APG,1003.32,,,1003.32,Other,225% New York Medicaid APG,624.29,,,624.29,Other,140% New York Medicaid APG,1003.32,,,1003.32,Other,225% New York Medicaid APG,1159.39,,,1159.39,Other,260% New York Medicaid APG,1444.78,,,1444.78,Other,324% New York Medicaid APG,958.72,,,958.72,Other,215% New York Medicaid APG,958.72,,,958.72,Other,215% New York Medicaid APG,557.4,,,557.4,Other,125% New York Medicaid APG,445.92,98541.71,
Excision of gum lesion,41828,CPT,,,,,,,,both,,,32077.39,23737.27,74,,23737.27,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,14434.83,45,,14434.83,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,15878.31,49.5,,15878.31,percent of total billed charges,110% of Medicare,21812.63,68,,21812.63,percent of total billed charges,,829.41,,,829.41,Other,186% of Medicaid,25661.91,80,,25661.91,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,25661.91,80,,25661.91,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,22454.17,70,,22454.17,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,445.92,,,445.92,Other,New York Medicaid APG methodology,445.92,,,445.92,Other,100% New York Medicaid APG,445.92,,,445.92,Other,100% New York Medicaid APG,445.92,,,445.92,Other,100% New York Medicaid APG,1003.32,,,1003.32,Other,225% New York Medicaid APG,682.26,,,682.26,Other,153% New York Medicaid APG,1003.32,,,1003.32,Other,225% New York Medicaid APG,624.29,,,624.29,Other,140% New York Medicaid APG,1003.32,,,1003.32,Other,225% New York Medicaid APG,1159.39,,,1159.39,Other,260% New York Medicaid APG,1444.78,,,1444.78,Other,324% New York Medicaid APG,958.72,,,958.72,Other,215% New York Medicaid APG,958.72,,,958.72,Other,215% New York Medicaid APG,557.4,,,557.4,Other,125% New York Medicaid APG,445.92,25661.91,
Removal of gum tissue,41830,CPT,,,,,,,,both,,,67720.49,50113.16,74,,50113.16,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30474.22,45,,30474.22,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,33521.64,49.5,,33521.64,percent of total billed charges,110% of Medicare,46049.93,68,,46049.93,percent of total billed charges,,829.41,,,829.41,Other,186% of Medicaid,54176.39,80,,54176.39,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,54176.39,80,,54176.39,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,47404.34,70,,47404.34,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,445.92,,,445.92,Other,New York Medicaid APG methodology,445.92,,,445.92,Other,100% New York Medicaid APG,445.92,,,445.92,Other,100% New York Medicaid APG,445.92,,,445.92,Other,100% New York Medicaid APG,1003.32,,,1003.32,Other,225% New York Medicaid APG,682.26,,,682.26,Other,153% New York Medicaid APG,1003.32,,,1003.32,Other,225% New York Medicaid APG,624.29,,,624.29,Other,140% New York Medicaid APG,1003.32,,,1003.32,Other,225% New York Medicaid APG,1159.39,,,1159.39,Other,260% New York Medicaid APG,1444.78,,,1444.78,Other,324% New York Medicaid APG,958.72,,,958.72,Other,215% New York Medicaid APG,958.72,,,958.72,Other,215% New York Medicaid APG,557.4,,,557.4,Other,125% New York Medicaid APG,445.92,54176.39,
Treatment of gum lesion,41850,CPT,,,,,,,,both,,,32077.39,23737.27,74,,23737.27,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,14434.83,45,,14434.83,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,15878.31,49.5,,15878.31,percent of total billed charges,110% of Medicare,21812.63,68,,21812.63,percent of total billed charges,,829.41,,,829.41,Other,186% of Medicaid,25661.91,80,,25661.91,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,25661.91,80,,25661.91,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,22454.17,70,,22454.17,percent of total billed charges,,20850.3,65,,20850.3,percent of total billed charges,,20850.3,65,,20850.3,percent of total billed charges,,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,445.92,,,445.92,Other,New York Medicaid APG methodology,445.92,,,445.92,Other,100% New York Medicaid APG,445.92,,,445.92,Other,100% New York Medicaid APG,445.92,,,445.92,Other,100% New York Medicaid APG,1003.32,,,1003.32,Other,225% New York Medicaid APG,682.26,,,682.26,Other,153% New York Medicaid APG,1003.32,,,1003.32,Other,225% New York Medicaid APG,624.29,,,624.29,Other,140% New York Medicaid APG,1003.32,,,1003.32,Other,225% New York Medicaid APG,1159.39,,,1159.39,Other,260% New York Medicaid APG,1444.78,,,1444.78,Other,324% New York Medicaid APG,958.72,,,958.72,Other,215% New York Medicaid APG,958.72,,,958.72,Other,215% New York Medicaid APG,557.4,,,557.4,Other,125% New York Medicaid APG,445.92,25661.91,
Gum graft,41870,CPT,,,,,,,,both,,,32077.39,23737.27,74,,23737.27,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,14434.83,45,,14434.83,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,15878.31,49.5,,15878.31,percent of total billed charges,110% of Medicare,21812.63,68,,21812.63,percent of total billed charges,,0.02,,,0.02,Other,186% of Medicaid,25661.91,80,,25661.91,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,25661.91,80,,25661.91,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,22454.17,70,,22454.17,percent of total billed charges,,20850.3,65,,20850.3,percent of total billed charges,,20850.3,65,,20850.3,percent of total billed charges,,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% New York Medicaid APG,0.01,,,0.01,Other,100% New York Medicaid APG,0.01,,,0.01,Other,100% New York Medicaid APG,0.02,,,0.02,Other,225% New York Medicaid APG,0.02,,,0.02,Other,153% New York Medicaid APG,0.02,,,0.02,Other,225% New York Medicaid APG,0.01,,,0.01,Other,140% New York Medicaid APG,0.02,,,0.02,Other,225% New York Medicaid APG,0.03,,,0.03,Other,260% New York Medicaid APG,0.03,,,0.03,Other,324% New York Medicaid APG,0.02,,,0.02,Other,215% New York Medicaid APG,0.02,,,0.02,Other,215% New York Medicaid APG,0.01,,,0.01,Other,125% New York Medicaid APG,0.01,25661.91,
Repair gum,41872,CPT,,,,,,,,both,,,67720.49,50113.16,74,,50113.16,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30474.22,45,,30474.22,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,33521.64,49.5,,33521.64,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,0.02,,,0.02,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,47404.34,70,,47404.34,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% New York Medicaid APG,0.01,,,0.01,Other,100% New York Medicaid APG,0.01,,,0.01,Other,100% New York Medicaid APG,0.02,,,0.02,Other,225% New York Medicaid APG,0.02,,,0.02,Other,153% New York Medicaid APG,0.02,,,0.02,Other,225% New York Medicaid APG,0.01,,,0.01,Other,140% New York Medicaid APG,0.02,,,0.02,Other,225% New York Medicaid APG,0.03,,,0.03,Other,260% New York Medicaid APG,0.03,,,0.03,Other,324% New York Medicaid APG,0.02,,,0.02,Other,215% New York Medicaid APG,0.02,,,0.02,Other,215% New York Medicaid APG,0.01,,,0.01,Other,125% New York Medicaid APG,0.01,50113.16,
Repair tooth socket,41874,CPT,,,,,,,,both,,,12102.9,8956.15,74,,8956.15,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,5446.31,45,,5446.31,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,5990.94,49.5,,5990.94,percent of total billed charges,110% of Medicare,8229.97,68,,8229.97,percent of total billed charges,,829.41,,,829.41,Other,186% of Medicaid,9682.32,80,,9682.32,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,9682.32,80,,9682.32,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,8472.03,70,,8472.03,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,445.92,,,445.92,Other,New York Medicaid APG methodology,445.92,,,445.92,Other,100% New York Medicaid APG,445.92,,,445.92,Other,100% New York Medicaid APG,445.92,,,445.92,Other,100% New York Medicaid APG,1003.32,,,1003.32,Other,225% New York Medicaid APG,682.26,,,682.26,Other,153% New York Medicaid APG,1003.32,,,1003.32,Other,225% New York Medicaid APG,624.29,,,624.29,Other,140% New York Medicaid APG,1003.32,,,1003.32,Other,225% New York Medicaid APG,1159.39,,,1159.39,Other,260% New York Medicaid APG,1444.78,,,1444.78,Other,324% New York Medicaid APG,958.72,,,958.72,Other,215% New York Medicaid APG,958.72,,,958.72,Other,215% New York Medicaid APG,557.4,,,557.4,Other,125% New York Medicaid APG,445.92,9682.32,
Drainage mouth roof lesion,42000,CPT,,,,,,,,both,,,5137.73,3801.92,74,,3801.92,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,2311.98,45,,2311.98,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,2543.18,49.5,,2543.18,percent of total billed charges,110% of Medicare,3493.66,68,,3493.66,percent of total billed charges,,423.06,,,423.06,Other,186% of Medicaid,4110.18,80,,4110.18,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,4110.18,80,,4110.18,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,3596.41,70,,3596.41,percent of total billed charges,,536.28,,,536.28,Fee Schedule,,454.53,,,454.53,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,227.45,,,227.45,Other,New York Medicaid APG methodology,227.45,,,227.45,Other,100% New York Medicaid APG,227.45,,,227.45,Other,100% New York Medicaid APG,227.45,,,227.45,Other,100% New York Medicaid APG,511.76,,,511.76,Other,225% New York Medicaid APG,348,,,348,Other,153% New York Medicaid APG,511.76,,,511.76,Other,225% New York Medicaid APG,318.43,,,318.43,Other,140% New York Medicaid APG,511.76,,,511.76,Other,225% New York Medicaid APG,591.37,,,591.37,Other,260% New York Medicaid APG,736.94,,,736.94,Other,324% New York Medicaid APG,489.02,,,489.02,Other,215% New York Medicaid APG,489.02,,,489.02,Other,215% New York Medicaid APG,284.31,,,284.31,Other,125% New York Medicaid APG,227.45,7216,
Biopsy roof of mouth,42100,CPT,,,,,,,,both,,,32077.39,23737.27,74,,23737.27,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,14434.83,45,,14434.83,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,15878.31,49.5,,15878.31,percent of total billed charges,110% of Medicare,21812.63,68,,21812.63,percent of total billed charges,,2256.57,,,2256.57,Other,186% of Medicaid,25661.91,80,,25661.91,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,25661.91,80,,25661.91,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,22454.17,70,,22454.17,percent of total billed charges,,541.2,,,541.2,Fee Schedule,,458.7,,,458.7,Fee Schedule,,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1213.21,,,1213.21,Other,New York Medicaid APG methodology,1213.21,,,1213.21,Other,100% New York Medicaid APG,1213.21,,,1213.21,Other,100% New York Medicaid APG,1213.21,,,1213.21,Other,100% New York Medicaid APG,2729.72,,,2729.72,Other,225% New York Medicaid APG,1856.21,,,1856.21,Other,153% New York Medicaid APG,2729.72,,,2729.72,Other,225% New York Medicaid APG,1698.49,,,1698.49,Other,140% New York Medicaid APG,2729.72,,,2729.72,Other,225% New York Medicaid APG,3154.34,,,3154.34,Other,260% New York Medicaid APG,3930.79,,,3930.79,Other,324% New York Medicaid APG,2608.4,,,2608.4,Other,215% New York Medicaid APG,2608.4,,,2608.4,Other,215% New York Medicaid APG,1516.51,,,1516.51,Other,125% New York Medicaid APG,458.7,25661.91,
Excision lesion mouth roof,42104,CPT,,,,,,,,both,,,32876,24328.24,74,,24328.24,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,14794.2,45,,14794.2,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,16273.62,49.5,,16273.62,percent of total billed charges,110% of Medicare,22355.68,68,,22355.68,percent of total billed charges,,2965.83,,,2965.83,Other,186% of Medicaid,26300.8,80,,26300.8,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,26300.8,80,,26300.8,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,23013.2,70,,23013.2,percent of total billed charges,,662.56,,,662.56,Fee Schedule,,561.56,,,561.56,Fee Schedule,,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1594.53,,,1594.53,Other,New York Medicaid APG methodology,1594.53,,,1594.53,Other,100% New York Medicaid APG,1594.53,,,1594.53,Other,100% New York Medicaid APG,1594.53,,,1594.53,Other,100% New York Medicaid APG,3587.7,,,3587.7,Other,225% New York Medicaid APG,2439.64,,,2439.64,Other,153% New York Medicaid APG,3587.7,,,3587.7,Other,225% New York Medicaid APG,2232.35,,,2232.35,Other,140% New York Medicaid APG,3587.7,,,3587.7,Other,225% New York Medicaid APG,4145.78,,,4145.78,Other,260% New York Medicaid APG,5166.29,,,5166.29,Other,324% New York Medicaid APG,3428.25,,,3428.25,Other,215% New York Medicaid APG,3428.25,,,3428.25,Other,215% New York Medicaid APG,1993.17,,,1993.17,Other,125% New York Medicaid APG,561.56,26300.8,
Excision lesion mouth roof,42106,CPT,,,,,,,,both,,,67720.49,50113.16,74,,50113.16,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30474.22,45,,30474.22,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,33521.64,49.5,,33521.64,percent of total billed charges,110% of Medicare,46049.93,68,,46049.93,percent of total billed charges,,2965.83,,,2965.83,Other,186% of Medicaid,54176.39,80,,54176.39,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,54176.39,80,,54176.39,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,47404.34,70,,47404.34,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1594.53,,,1594.53,Other,New York Medicaid APG methodology,1594.53,,,1594.53,Other,100% New York Medicaid APG,1594.53,,,1594.53,Other,100% New York Medicaid APG,1594.53,,,1594.53,Other,100% New York Medicaid APG,3587.7,,,3587.7,Other,225% New York Medicaid APG,2439.64,,,2439.64,Other,153% New York Medicaid APG,3587.7,,,3587.7,Other,225% New York Medicaid APG,2232.35,,,2232.35,Other,140% New York Medicaid APG,3587.7,,,3587.7,Other,225% New York Medicaid APG,4145.78,,,4145.78,Other,260% New York Medicaid APG,5166.29,,,5166.29,Other,324% New York Medicaid APG,3428.25,,,3428.25,Other,215% New York Medicaid APG,3428.25,,,3428.25,Other,215% New York Medicaid APG,1993.17,,,1993.17,Other,125% New York Medicaid APG,1594.53,54176.39,
Excision lesion mouth roof,42107,CPT,,,,,,,,both,,,45847.43,33927.1,74,,33927.1,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,20631.34,45,,20631.34,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,22694.48,49.5,,22694.48,percent of total billed charges,110% of Medicare,31176.25,68,,31176.25,percent of total billed charges,,2965.83,,,2965.83,Other,186% of Medicaid,36677.94,80,,36677.94,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,36677.94,80,,36677.94,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,32093.2,70,,32093.2,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1594.53,,,1594.53,Other,New York Medicaid APG methodology,1594.53,,,1594.53,Other,100% New York Medicaid APG,1594.53,,,1594.53,Other,100% New York Medicaid APG,1594.53,,,1594.53,Other,100% New York Medicaid APG,3587.7,,,3587.7,Other,225% New York Medicaid APG,2439.64,,,2439.64,Other,153% New York Medicaid APG,3587.7,,,3587.7,Other,225% New York Medicaid APG,2232.35,,,2232.35,Other,140% New York Medicaid APG,3587.7,,,3587.7,Other,225% New York Medicaid APG,4145.78,,,4145.78,Other,260% New York Medicaid APG,5166.29,,,5166.29,Other,324% New York Medicaid APG,3428.25,,,3428.25,Other,215% New York Medicaid APG,3428.25,,,3428.25,Other,215% New York Medicaid APG,1993.17,,,1993.17,Other,125% New York Medicaid APG,1594.53,36677.94,
Remove palate/lesion,42120,CPT,,,,,,,,both,,,123177.14,91151.08,74,,91151.08,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,55429.71,45,,55429.71,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,60972.68,49.5,,60972.68,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,829.41,,,829.41,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,86224,70,,86224,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,445.92,,,445.92,Other,New York Medicaid APG methodology,445.92,,,445.92,Other,100% New York Medicaid APG,445.92,,,445.92,Other,100% New York Medicaid APG,445.92,,,445.92,Other,100% New York Medicaid APG,1003.32,,,1003.32,Other,225% New York Medicaid APG,682.26,,,682.26,Other,153% New York Medicaid APG,1003.32,,,1003.32,Other,225% New York Medicaid APG,624.29,,,624.29,Other,140% New York Medicaid APG,1003.32,,,1003.32,Other,225% New York Medicaid APG,1159.39,,,1159.39,Other,260% New York Medicaid APG,1444.78,,,1444.78,Other,324% New York Medicaid APG,958.72,,,958.72,Other,215% New York Medicaid APG,958.72,,,958.72,Other,215% New York Medicaid APG,557.4,,,557.4,Other,125% New York Medicaid APG,445.92,91151.08,
Excision of uvula,42140,CPT,,,,,,,,both,,,67720.49,50113.16,74,,50113.16,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30474.22,45,,30474.22,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,33521.64,49.5,,33521.64,percent of total billed charges,110% of Medicare,46049.93,68,,46049.93,percent of total billed charges,,2965.83,,,2965.83,Other,186% of Medicaid,54176.39,80,,54176.39,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,54176.39,80,,54176.39,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,47404.34,70,,47404.34,percent of total billed charges,,800.32,,,800.32,Fee Schedule,,678.32,,,678.32,Fee Schedule,,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1594.53,,,1594.53,Other,New York Medicaid APG methodology,1594.53,,,1594.53,Other,100% New York Medicaid APG,1594.53,,,1594.53,Other,100% New York Medicaid APG,1594.53,,,1594.53,Other,100% New York Medicaid APG,3587.7,,,3587.7,Other,225% New York Medicaid APG,2439.64,,,2439.64,Other,153% New York Medicaid APG,3587.7,,,3587.7,Other,225% New York Medicaid APG,2232.35,,,2232.35,Other,140% New York Medicaid APG,3587.7,,,3587.7,Other,225% New York Medicaid APG,4145.78,,,4145.78,Other,260% New York Medicaid APG,5166.29,,,5166.29,Other,324% New York Medicaid APG,3428.25,,,3428.25,Other,215% New York Medicaid APG,3428.25,,,3428.25,Other,215% New York Medicaid APG,1993.17,,,1993.17,Other,125% New York Medicaid APG,678.32,54176.39,
Repair palate pharynx/uvula,42145,CPT,,,,,,,,both,,,40196.92,29745.72,74,,29745.72,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,18088.61,45,,18088.61,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,19897.48,49.5,,19897.48,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5266.94,,,5266.94,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,28137.84,70,,28137.84,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,2831.69,,,2831.69,Other,New York Medicaid APG methodology,2831.69,,,2831.69,Other,100% New York Medicaid APG,2831.69,,,2831.69,Other,100% New York Medicaid APG,2831.69,,,2831.69,Other,100% New York Medicaid APG,6371.29,,,6371.29,Other,225% New York Medicaid APG,4332.48,,,4332.48,Other,153% New York Medicaid APG,6371.29,,,6371.29,Other,225% New York Medicaid APG,3964.36,,,3964.36,Other,140% New York Medicaid APG,6371.29,,,6371.29,Other,225% New York Medicaid APG,7362.38,,,7362.38,Other,260% New York Medicaid APG,9174.66,,,9174.66,Other,324% New York Medicaid APG,6088.13,,,6088.13,Other,215% New York Medicaid APG,6088.13,,,6088.13,Other,215% New York Medicaid APG,3539.61,,,3539.61,Other,125% New York Medicaid APG,2831.69,29745.72,
Treatment mouth roof lesion,42160,CPT,,,,,,,,both,,,67720.49,50113.16,74,,50113.16,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30474.22,45,,30474.22,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,33521.64,49.5,,33521.64,percent of total billed charges,110% of Medicare,46049.93,68,,46049.93,percent of total billed charges,,2965.83,,,2965.83,Other,186% of Medicaid,54176.39,80,,54176.39,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,54176.39,80,,54176.39,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,47404.34,70,,47404.34,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1594.53,,,1594.53,Other,New York Medicaid APG methodology,1594.53,,,1594.53,Other,100% New York Medicaid APG,1594.53,,,1594.53,Other,100% New York Medicaid APG,1594.53,,,1594.53,Other,100% New York Medicaid APG,3587.7,,,3587.7,Other,225% New York Medicaid APG,2439.64,,,2439.64,Other,153% New York Medicaid APG,3587.7,,,3587.7,Other,225% New York Medicaid APG,2232.35,,,2232.35,Other,140% New York Medicaid APG,3587.7,,,3587.7,Other,225% New York Medicaid APG,4145.78,,,4145.78,Other,260% New York Medicaid APG,5166.29,,,5166.29,Other,324% New York Medicaid APG,3428.25,,,3428.25,Other,215% New York Medicaid APG,3428.25,,,3428.25,Other,215% New York Medicaid APG,1993.17,,,1993.17,Other,125% New York Medicaid APG,1594.53,54176.39,
Repair palate,42180,CPT,,,,,,,,both,,,11572.85,8563.91,74,,8563.91,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,5207.78,45,,5207.78,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,5728.56,49.5,,5728.56,percent of total billed charges,110% of Medicare,7869.54,68,,7869.54,percent of total billed charges,,428.6,,,428.6,Other,186% of Medicaid,9258.28,80,,9258.28,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,9258.28,80,,9258.28,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,8101,70,,8101,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,230.43,,,230.43,Other,New York Medicaid APG methodology,230.43,,,230.43,Other,100% New York Medicaid APG,230.43,,,230.43,Other,100% New York Medicaid APG,230.43,,,230.43,Other,100% New York Medicaid APG,518.46,,,518.46,Other,225% New York Medicaid APG,352.55,,,352.55,Other,153% New York Medicaid APG,518.46,,,518.46,Other,225% New York Medicaid APG,322.6,,,322.6,Other,140% New York Medicaid APG,518.46,,,518.46,Other,225% New York Medicaid APG,599.11,,,599.11,Other,260% New York Medicaid APG,746.59,,,746.59,Other,324% New York Medicaid APG,495.42,,,495.42,Other,215% New York Medicaid APG,495.42,,,495.42,Other,215% New York Medicaid APG,288.03,,,288.03,Other,125% New York Medicaid APG,230.43,9258.28,
Repair palate,42182,CPT,,,,,,,,both,,,123177.14,91151.08,74,,91151.08,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,55429.71,45,,55429.71,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,60972.68,49.5,,60972.68,percent of total billed charges,110% of Medicare,83760.46,68,,83760.46,percent of total billed charges,,829.41,,,829.41,Other,186% of Medicaid,98541.71,80,,98541.71,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,98541.71,80,,98541.71,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,86224,70,,86224,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,445.92,,,445.92,Other,New York Medicaid APG methodology,445.92,,,445.92,Other,100% New York Medicaid APG,445.92,,,445.92,Other,100% New York Medicaid APG,445.92,,,445.92,Other,100% New York Medicaid APG,1003.32,,,1003.32,Other,225% New York Medicaid APG,682.26,,,682.26,Other,153% New York Medicaid APG,1003.32,,,1003.32,Other,225% New York Medicaid APG,624.29,,,624.29,Other,140% New York Medicaid APG,1003.32,,,1003.32,Other,225% New York Medicaid APG,1159.39,,,1159.39,Other,260% New York Medicaid APG,1444.78,,,1444.78,Other,324% New York Medicaid APG,958.72,,,958.72,Other,215% New York Medicaid APG,958.72,,,958.72,Other,215% New York Medicaid APG,557.4,,,557.4,Other,125% New York Medicaid APG,445.92,98541.71,
Reconstruct cleft palate,42200,CPT,,,,,,,,both,,,57820.07,42786.85,74,,42786.85,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,26019.03,45,,26019.03,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,28620.93,49.5,,28620.93,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5266.94,,,5266.94,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,40474.05,70,,40474.05,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,2831.69,,,2831.69,Other,New York Medicaid APG methodology,2831.69,,,2831.69,Other,100% New York Medicaid APG,2831.69,,,2831.69,Other,100% New York Medicaid APG,2831.69,,,2831.69,Other,100% New York Medicaid APG,6371.29,,,6371.29,Other,225% New York Medicaid APG,4332.48,,,4332.48,Other,153% New York Medicaid APG,6371.29,,,6371.29,Other,225% New York Medicaid APG,3964.36,,,3964.36,Other,140% New York Medicaid APG,6371.29,,,6371.29,Other,225% New York Medicaid APG,7362.38,,,7362.38,Other,260% New York Medicaid APG,9174.66,,,9174.66,Other,324% New York Medicaid APG,6088.13,,,6088.13,Other,215% New York Medicaid APG,6088.13,,,6088.13,Other,215% New York Medicaid APG,3539.61,,,3539.61,Other,125% New York Medicaid APG,2831.69,42786.85,
Reconstruct cleft palate,42205,CPT,,,,,,,,both,,,49217.65,36421.06,74,,36421.06,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,22147.94,45,,22147.94,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,24362.74,49.5,,24362.74,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5266.94,,,5266.94,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,34452.36,70,,34452.36,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,2831.69,,,2831.69,Other,New York Medicaid APG methodology,2831.69,,,2831.69,Other,100% New York Medicaid APG,2831.69,,,2831.69,Other,100% New York Medicaid APG,2831.69,,,2831.69,Other,100% New York Medicaid APG,6371.29,,,6371.29,Other,225% New York Medicaid APG,4332.48,,,4332.48,Other,153% New York Medicaid APG,6371.29,,,6371.29,Other,225% New York Medicaid APG,3964.36,,,3964.36,Other,140% New York Medicaid APG,6371.29,,,6371.29,Other,225% New York Medicaid APG,7362.38,,,7362.38,Other,260% New York Medicaid APG,9174.66,,,9174.66,Other,324% New York Medicaid APG,6088.13,,,6088.13,Other,215% New York Medicaid APG,6088.13,,,6088.13,Other,215% New York Medicaid APG,3539.61,,,3539.61,Other,125% New York Medicaid APG,2831.69,36421.06,
Reconstruct cleft palate,42210,CPT,,,,,,,,both,,,34416.87,25468.48,74,,25468.48,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15487.59,45,,15487.59,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,17036.35,49.5,,17036.35,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5266.94,,,5266.94,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,24091.81,70,,24091.81,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,2831.69,,,2831.69,Other,New York Medicaid APG methodology,2831.69,,,2831.69,Other,100% New York Medicaid APG,2831.69,,,2831.69,Other,100% New York Medicaid APG,2831.69,,,2831.69,Other,100% New York Medicaid APG,6371.29,,,6371.29,Other,225% New York Medicaid APG,4332.48,,,4332.48,Other,153% New York Medicaid APG,6371.29,,,6371.29,Other,225% New York Medicaid APG,3964.36,,,3964.36,Other,140% New York Medicaid APG,6371.29,,,6371.29,Other,225% New York Medicaid APG,7362.38,,,7362.38,Other,260% New York Medicaid APG,9174.66,,,9174.66,Other,324% New York Medicaid APG,6088.13,,,6088.13,Other,215% New York Medicaid APG,6088.13,,,6088.13,Other,215% New York Medicaid APG,3539.61,,,3539.61,Other,125% New York Medicaid APG,2831.69,25468.48,
Reconstruct cleft palate,42215,CPT,,,,,,,,both,,,36696.4,27155.34,74,,27155.34,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,16513.38,45,,16513.38,percent of total billed charges,Medicare Ratio of cost to charges,5954,,"100% primary, 50% supplemental procedure",5954,Other,Aetna ASC Grouper,5359,,"100% primary, 50% supplemental procedure",5359,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,18164.72,49.5,,18164.72,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5266.94,,,5266.94,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,25687.48,70,,25687.48,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,2831.69,,,2831.69,Other,New York Medicaid APG methodology,2831.69,,,2831.69,Other,100% New York Medicaid APG,2831.69,,,2831.69,Other,100% New York Medicaid APG,2831.69,,,2831.69,Other,100% New York Medicaid APG,6371.29,,,6371.29,Other,225% New York Medicaid APG,4332.48,,,4332.48,Other,153% New York Medicaid APG,6371.29,,,6371.29,Other,225% New York Medicaid APG,3964.36,,,3964.36,Other,140% New York Medicaid APG,6371.29,,,6371.29,Other,225% New York Medicaid APG,7362.38,,,7362.38,Other,260% New York Medicaid APG,9174.66,,,9174.66,Other,324% New York Medicaid APG,6088.13,,,6088.13,Other,215% New York Medicaid APG,6088.13,,,6088.13,Other,215% New York Medicaid APG,3539.61,,,3539.61,Other,125% New York Medicaid APG,2831.69,27155.34,
Reconstruct cleft palate,42220,CPT,,,,,,,,both,,,37009.4,27386.96,74,,27386.96,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,16654.23,45,,16654.23,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,18319.65,49.5,,18319.65,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5266.94,,,5266.94,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,25906.58,70,,25906.58,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,2831.69,,,2831.69,Other,New York Medicaid APG methodology,2831.69,,,2831.69,Other,100% New York Medicaid APG,2831.69,,,2831.69,Other,100% New York Medicaid APG,2831.69,,,2831.69,Other,100% New York Medicaid APG,6371.29,,,6371.29,Other,225% New York Medicaid APG,4332.48,,,4332.48,Other,153% New York Medicaid APG,6371.29,,,6371.29,Other,225% New York Medicaid APG,3964.36,,,3964.36,Other,140% New York Medicaid APG,6371.29,,,6371.29,Other,225% New York Medicaid APG,7362.38,,,7362.38,Other,260% New York Medicaid APG,9174.66,,,9174.66,Other,324% New York Medicaid APG,6088.13,,,6088.13,Other,215% New York Medicaid APG,6088.13,,,6088.13,Other,215% New York Medicaid APG,3539.61,,,3539.61,Other,125% New York Medicaid APG,2831.69,27386.96,
Reconstruct cleft palate,42225,CPT,,,,,,,,both,,,36570.71,27062.33,74,,27062.33,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,16456.82,45,,16456.82,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,18102.5,49.5,,18102.5,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5266.94,,,5266.94,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,25599.5,70,,25599.5,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,2831.69,,,2831.69,Other,New York Medicaid APG methodology,2831.69,,,2831.69,Other,100% New York Medicaid APG,2831.69,,,2831.69,Other,100% New York Medicaid APG,2831.69,,,2831.69,Other,100% New York Medicaid APG,6371.29,,,6371.29,Other,225% New York Medicaid APG,4332.48,,,4332.48,Other,153% New York Medicaid APG,6371.29,,,6371.29,Other,225% New York Medicaid APG,3964.36,,,3964.36,Other,140% New York Medicaid APG,6371.29,,,6371.29,Other,225% New York Medicaid APG,7362.38,,,7362.38,Other,260% New York Medicaid APG,9174.66,,,9174.66,Other,324% New York Medicaid APG,6088.13,,,6088.13,Other,215% New York Medicaid APG,6088.13,,,6088.13,Other,215% New York Medicaid APG,3539.61,,,3539.61,Other,125% New York Medicaid APG,2831.69,27062.33,
Lengthening of palate,42226,CPT,,,,,,,,both,,,123177.14,91151.08,74,,91151.08,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,55429.71,45,,55429.71,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,60972.68,49.5,,60972.68,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5266.94,,,5266.94,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,86224,70,,86224,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,2831.69,,,2831.69,Other,New York Medicaid APG methodology,2831.69,,,2831.69,Other,100% New York Medicaid APG,2831.69,,,2831.69,Other,100% New York Medicaid APG,2831.69,,,2831.69,Other,100% New York Medicaid APG,6371.29,,,6371.29,Other,225% New York Medicaid APG,4332.48,,,4332.48,Other,153% New York Medicaid APG,6371.29,,,6371.29,Other,225% New York Medicaid APG,3964.36,,,3964.36,Other,140% New York Medicaid APG,6371.29,,,6371.29,Other,225% New York Medicaid APG,7362.38,,,7362.38,Other,260% New York Medicaid APG,9174.66,,,9174.66,Other,324% New York Medicaid APG,6088.13,,,6088.13,Other,215% New York Medicaid APG,6088.13,,,6088.13,Other,215% New York Medicaid APG,3539.61,,,3539.61,Other,125% New York Medicaid APG,2831.69,91151.08,
Lengthening of palate,42227,CPT,,,,,,,,both,,,123177.14,91151.08,74,,91151.08,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,55429.71,45,,55429.71,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,60972.68,49.5,,60972.68,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5266.94,,,5266.94,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,86224,70,,86224,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,2831.69,,,2831.69,Other,New York Medicaid APG methodology,2831.69,,,2831.69,Other,100% New York Medicaid APG,2831.69,,,2831.69,Other,100% New York Medicaid APG,2831.69,,,2831.69,Other,100% New York Medicaid APG,6371.29,,,6371.29,Other,225% New York Medicaid APG,4332.48,,,4332.48,Other,153% New York Medicaid APG,6371.29,,,6371.29,Other,225% New York Medicaid APG,3964.36,,,3964.36,Other,140% New York Medicaid APG,6371.29,,,6371.29,Other,225% New York Medicaid APG,7362.38,,,7362.38,Other,260% New York Medicaid APG,9174.66,,,9174.66,Other,324% New York Medicaid APG,6088.13,,,6088.13,Other,215% New York Medicaid APG,6088.13,,,6088.13,Other,215% New York Medicaid APG,3539.61,,,3539.61,Other,125% New York Medicaid APG,2831.69,91151.08,
Repair palate,42235,CPT,,,,,,,,both,,,33741.06,24968.38,74,,24968.38,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15183.48,45,,15183.48,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,16701.82,49.5,,16701.82,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5266.94,,,5266.94,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,23618.74,70,,23618.74,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,2831.69,,,2831.69,Other,New York Medicaid APG methodology,2831.69,,,2831.69,Other,100% New York Medicaid APG,2831.69,,,2831.69,Other,100% New York Medicaid APG,2831.69,,,2831.69,Other,100% New York Medicaid APG,6371.29,,,6371.29,Other,225% New York Medicaid APG,4332.48,,,4332.48,Other,153% New York Medicaid APG,6371.29,,,6371.29,Other,225% New York Medicaid APG,3964.36,,,3964.36,Other,140% New York Medicaid APG,6371.29,,,6371.29,Other,225% New York Medicaid APG,7362.38,,,7362.38,Other,260% New York Medicaid APG,9174.66,,,9174.66,Other,324% New York Medicaid APG,6088.13,,,6088.13,Other,215% New York Medicaid APG,6088.13,,,6088.13,Other,215% New York Medicaid APG,3539.61,,,3539.61,Other,125% New York Medicaid APG,2831.69,24968.38,
Repair nose to lip fistula,42260,CPT,,,,,,,,both,,,123177.14,91151.08,74,,91151.08,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,55429.71,45,,55429.71,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,60972.68,49.5,,60972.68,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,4119.28,,,4119.28,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,86224,70,,86224,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,2214.67,,,2214.67,Other,New York Medicaid APG methodology,2214.67,,,2214.67,Other,100% New York Medicaid APG,2214.67,,,2214.67,Other,100% New York Medicaid APG,2214.67,,,2214.67,Other,100% New York Medicaid APG,4983,,,4983,Other,225% New York Medicaid APG,3388.44,,,3388.44,Other,153% New York Medicaid APG,4983,,,4983,Other,225% New York Medicaid APG,3100.53,,,3100.53,Other,140% New York Medicaid APG,4983,,,4983,Other,225% New York Medicaid APG,5758.13,,,5758.13,Other,260% New York Medicaid APG,7175.52,,,7175.52,Other,324% New York Medicaid APG,4761.53,,,4761.53,Other,215% New York Medicaid APG,4761.53,,,4761.53,Other,215% New York Medicaid APG,2768.33,,,2768.33,Other,125% New York Medicaid APG,2214.67,91151.08,
Preparation palate mold,42280,CPT,,,,,,,,both,,,11572.85,8563.91,74,,8563.91,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,5207.78,45,,5207.78,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,5728.56,49.5,,5728.56,percent of total billed charges,110% of Medicare,7869.54,68,,7869.54,percent of total billed charges,,279.58,,,279.58,Other,186% of Medicaid,9258.28,80,,9258.28,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,9258.28,80,,9258.28,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,8101,70,,8101,percent of total billed charges,,536.28,,,536.28,Fee Schedule,,454.53,,,454.53,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,150.31,,,150.31,Other,New York Medicaid APG methodology,150.31,,,150.31,Other,100% New York Medicaid APG,150.31,,,150.31,Other,100% New York Medicaid APG,150.31,,,150.31,Other,100% New York Medicaid APG,338.21,,,338.21,Other,225% New York Medicaid APG,229.98,,,229.98,Other,153% New York Medicaid APG,338.21,,,338.21,Other,225% New York Medicaid APG,210.44,,,210.44,Other,140% New York Medicaid APG,338.21,,,338.21,Other,225% New York Medicaid APG,390.81,,,390.81,Other,260% New York Medicaid APG,487.02,,,487.02,Other,324% New York Medicaid APG,323.17,,,323.17,Other,215% New York Medicaid APG,323.17,,,323.17,Other,215% New York Medicaid APG,187.89,,,187.89,Other,125% New York Medicaid APG,150.31,9258.28,
Insertion palate prosthesis,42281,CPT,,,,,,,,both,,,123177.14,91151.08,74,,91151.08,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,55429.71,45,,55429.71,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,60972.68,49.5,,60972.68,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,829.41,,,829.41,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,86224,70,,86224,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,445.92,,,445.92,Other,New York Medicaid APG methodology,445.92,,,445.92,Other,100% New York Medicaid APG,445.92,,,445.92,Other,100% New York Medicaid APG,445.92,,,445.92,Other,100% New York Medicaid APG,1003.32,,,1003.32,Other,225% New York Medicaid APG,682.26,,,682.26,Other,153% New York Medicaid APG,1003.32,,,1003.32,Other,225% New York Medicaid APG,624.29,,,624.29,Other,140% New York Medicaid APG,1003.32,,,1003.32,Other,225% New York Medicaid APG,1159.39,,,1159.39,Other,260% New York Medicaid APG,1444.78,,,1444.78,Other,324% New York Medicaid APG,958.72,,,958.72,Other,215% New York Medicaid APG,958.72,,,958.72,Other,215% New York Medicaid APG,557.4,,,557.4,Other,125% New York Medicaid APG,445.92,91151.08,
Drainage of salivary gland,42300,CPT,,,,,,,,both,,,32077.39,23737.27,74,,23737.27,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,14434.83,45,,14434.83,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,15878.31,49.5,,15878.31,percent of total billed charges,110% of Medicare,21812.63,68,,21812.63,percent of total billed charges,,428.6,,,428.6,Other,186% of Medicaid,25661.91,80,,25661.91,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,25661.91,80,,25661.91,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,22454.17,70,,22454.17,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,230.43,,,230.43,Other,New York Medicaid APG methodology,230.43,,,230.43,Other,100% New York Medicaid APG,230.43,,,230.43,Other,100% New York Medicaid APG,230.43,,,230.43,Other,100% New York Medicaid APG,518.46,,,518.46,Other,225% New York Medicaid APG,352.55,,,352.55,Other,153% New York Medicaid APG,518.46,,,518.46,Other,225% New York Medicaid APG,322.6,,,322.6,Other,140% New York Medicaid APG,518.46,,,518.46,Other,225% New York Medicaid APG,599.11,,,599.11,Other,260% New York Medicaid APG,746.59,,,746.59,Other,324% New York Medicaid APG,495.42,,,495.42,Other,215% New York Medicaid APG,495.42,,,495.42,Other,215% New York Medicaid APG,288.03,,,288.03,Other,125% New York Medicaid APG,230.43,25661.91,
Drainage of salivary gland,42305,CPT,,,,,,,,both,,,67720.49,50113.16,74,,50113.16,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30474.22,45,,30474.22,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,33521.64,49.5,,33521.64,percent of total billed charges,110% of Medicare,46049.93,68,,46049.93,percent of total billed charges,,2965.83,,,2965.83,Other,186% of Medicaid,54176.39,80,,54176.39,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,54176.39,80,,54176.39,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,47404.34,70,,47404.34,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1594.53,,,1594.53,Other,New York Medicaid APG methodology,1594.53,,,1594.53,Other,100% New York Medicaid APG,1594.53,,,1594.53,Other,100% New York Medicaid APG,1594.53,,,1594.53,Other,100% New York Medicaid APG,3587.7,,,3587.7,Other,225% New York Medicaid APG,2439.64,,,2439.64,Other,153% New York Medicaid APG,3587.7,,,3587.7,Other,225% New York Medicaid APG,2232.35,,,2232.35,Other,140% New York Medicaid APG,3587.7,,,3587.7,Other,225% New York Medicaid APG,4145.78,,,4145.78,Other,260% New York Medicaid APG,5166.29,,,5166.29,Other,324% New York Medicaid APG,3428.25,,,3428.25,Other,215% New York Medicaid APG,3428.25,,,3428.25,Other,215% New York Medicaid APG,1993.17,,,1993.17,Other,125% New York Medicaid APG,1594.53,54176.39,
Drainage of salivary gland,42310,CPT,,,,,,,,both,,,11572.85,8563.91,74,,8563.91,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,5207.78,45,,5207.78,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,5728.56,49.5,,5728.56,percent of total billed charges,110% of Medicare,7869.54,68,,7869.54,percent of total billed charges,,428.6,,,428.6,Other,186% of Medicaid,9258.28,80,,9258.28,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,9258.28,80,,9258.28,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,8101,70,,8101,percent of total billed charges,,665.84,,,665.84,Fee Schedule,,564.34,,,564.34,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,230.43,,,230.43,Other,New York Medicaid APG methodology,230.43,,,230.43,Other,100% New York Medicaid APG,230.43,,,230.43,Other,100% New York Medicaid APG,230.43,,,230.43,Other,100% New York Medicaid APG,518.46,,,518.46,Other,225% New York Medicaid APG,352.55,,,352.55,Other,153% New York Medicaid APG,518.46,,,518.46,Other,225% New York Medicaid APG,322.6,,,322.6,Other,140% New York Medicaid APG,518.46,,,518.46,Other,225% New York Medicaid APG,599.11,,,599.11,Other,260% New York Medicaid APG,746.59,,,746.59,Other,324% New York Medicaid APG,495.42,,,495.42,Other,215% New York Medicaid APG,495.42,,,495.42,Other,215% New York Medicaid APG,288.03,,,288.03,Other,125% New York Medicaid APG,230.43,9258.28,
Drainage of salivary gland,42320,CPT,,,,,,,,both,,,11572.85,8563.91,74,,8563.91,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,5207.78,45,,5207.78,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,5728.56,49.5,,5728.56,percent of total billed charges,110% of Medicare,7869.54,68,,7869.54,percent of total billed charges,,428.6,,,428.6,Other,186% of Medicaid,9258.28,80,,9258.28,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,9258.28,80,,9258.28,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,8101,70,,8101,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,230.43,,,230.43,Other,New York Medicaid APG methodology,230.43,,,230.43,Other,100% New York Medicaid APG,230.43,,,230.43,Other,100% New York Medicaid APG,230.43,,,230.43,Other,100% New York Medicaid APG,518.46,,,518.46,Other,225% New York Medicaid APG,352.55,,,352.55,Other,153% New York Medicaid APG,518.46,,,518.46,Other,225% New York Medicaid APG,322.6,,,322.6,Other,140% New York Medicaid APG,518.46,,,518.46,Other,225% New York Medicaid APG,599.11,,,599.11,Other,260% New York Medicaid APG,746.59,,,746.59,Other,324% New York Medicaid APG,495.42,,,495.42,Other,215% New York Medicaid APG,495.42,,,495.42,Other,215% New York Medicaid APG,288.03,,,288.03,Other,125% New York Medicaid APG,230.43,9258.28,
Removal of salivary stone,42330,CPT,,,,,,,,both,,,19986.89,14790.3,74,,14790.3,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,8994.1,45,,8994.1,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,9893.51,49.5,,9893.51,percent of total billed charges,110% of Medicare,13591.09,68,,13591.09,percent of total billed charges,,829.41,,,829.41,Other,186% of Medicaid,15989.51,80,,15989.51,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,15989.51,80,,15989.51,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,13990.82,70,,13990.82,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,445.92,,,445.92,Other,New York Medicaid APG methodology,445.92,,,445.92,Other,100% New York Medicaid APG,445.92,,,445.92,Other,100% New York Medicaid APG,445.92,,,445.92,Other,100% New York Medicaid APG,1003.32,,,1003.32,Other,225% New York Medicaid APG,682.26,,,682.26,Other,153% New York Medicaid APG,1003.32,,,1003.32,Other,225% New York Medicaid APG,624.29,,,624.29,Other,140% New York Medicaid APG,1003.32,,,1003.32,Other,225% New York Medicaid APG,1159.39,,,1159.39,Other,260% New York Medicaid APG,1444.78,,,1444.78,Other,324% New York Medicaid APG,958.72,,,958.72,Other,215% New York Medicaid APG,958.72,,,958.72,Other,215% New York Medicaid APG,557.4,,,557.4,Other,125% New York Medicaid APG,445.92,15989.51,
Removal of salivary stone,42335,CPT,,,,,,,,both,,,67720.49,50113.16,74,,50113.16,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30474.22,45,,30474.22,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,33521.64,49.5,,33521.64,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,829.41,,,829.41,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,47404.34,70,,47404.34,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,445.92,,,445.92,Other,New York Medicaid APG methodology,445.92,,,445.92,Other,100% New York Medicaid APG,445.92,,,445.92,Other,100% New York Medicaid APG,445.92,,,445.92,Other,100% New York Medicaid APG,1003.32,,,1003.32,Other,225% New York Medicaid APG,682.26,,,682.26,Other,153% New York Medicaid APG,1003.32,,,1003.32,Other,225% New York Medicaid APG,624.29,,,624.29,Other,140% New York Medicaid APG,1003.32,,,1003.32,Other,225% New York Medicaid APG,1159.39,,,1159.39,Other,260% New York Medicaid APG,1444.78,,,1444.78,Other,324% New York Medicaid APG,958.72,,,958.72,Other,215% New York Medicaid APG,958.72,,,958.72,Other,215% New York Medicaid APG,557.4,,,557.4,Other,125% New York Medicaid APG,445.92,50113.16,
Removal of salivary stone,42340,CPT,,,,,,,,both,,,67720.49,50113.16,74,,50113.16,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30474.22,45,,30474.22,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,33521.64,49.5,,33521.64,percent of total billed charges,110% of Medicare,46049.93,68,,46049.93,percent of total billed charges,,829.41,,,829.41,Other,186% of Medicaid,54176.39,80,,54176.39,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,54176.39,80,,54176.39,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,47404.34,70,,47404.34,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,445.92,,,445.92,Other,New York Medicaid APG methodology,445.92,,,445.92,Other,100% New York Medicaid APG,445.92,,,445.92,Other,100% New York Medicaid APG,445.92,,,445.92,Other,100% New York Medicaid APG,1003.32,,,1003.32,Other,225% New York Medicaid APG,682.26,,,682.26,Other,153% New York Medicaid APG,1003.32,,,1003.32,Other,225% New York Medicaid APG,624.29,,,624.29,Other,140% New York Medicaid APG,1003.32,,,1003.32,Other,225% New York Medicaid APG,1159.39,,,1159.39,Other,260% New York Medicaid APG,1444.78,,,1444.78,Other,324% New York Medicaid APG,958.72,,,958.72,Other,215% New York Medicaid APG,958.72,,,958.72,Other,215% New York Medicaid APG,557.4,,,557.4,Other,125% New York Medicaid APG,445.92,54176.39,
Biopsy of salivary gland,42400,CPT,,,,,,,,both,,,14798.8,10951.11,74,,10951.11,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,6659.46,45,,6659.46,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,7325.41,49.5,,7325.41,percent of total billed charges,110% of Medicare,10063.18,68,,10063.18,percent of total billed charges,,428.6,,,428.6,Other,186% of Medicaid,11839.04,80,,11839.04,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,11839.04,80,,11839.04,percent of total billed charges,,7216,,,7216,Case Rate,,3578,,"100% primary, 0% secondary procedures",3578,Other,MagnaCare ASC Grouper,10359.16,70,,10359.16,percent of total billed charges,,257.48,,,257.48,Fee Schedule,,218.23,,,218.23,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,230.43,,,230.43,Other,New York Medicaid APG methodology,230.43,,,230.43,Other,100% New York Medicaid APG,230.43,,,230.43,Other,100% New York Medicaid APG,230.43,,,230.43,Other,100% New York Medicaid APG,518.46,,,518.46,Other,225% New York Medicaid APG,352.55,,,352.55,Other,153% New York Medicaid APG,518.46,,,518.46,Other,225% New York Medicaid APG,322.6,,,322.6,Other,140% New York Medicaid APG,518.46,,,518.46,Other,225% New York Medicaid APG,599.11,,,599.11,Other,260% New York Medicaid APG,746.59,,,746.59,Other,324% New York Medicaid APG,495.42,,,495.42,Other,215% New York Medicaid APG,495.42,,,495.42,Other,215% New York Medicaid APG,288.03,,,288.03,Other,125% New York Medicaid APG,218.23,11839.04,
Biopsy of salivary gland,42405,CPT,,,,,,,,both,,,40860,30236.4,74,,30236.4,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,18387,45,,18387,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,20225.7,49.5,,20225.7,percent of total billed charges,110% of Medicare,27784.8,68,,27784.8,percent of total billed charges,,829.41,,,829.41,Other,186% of Medicaid,32688,80,,32688,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,32688,80,,32688,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,28602,70,,28602,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,445.92,,,445.92,Other,New York Medicaid APG methodology,445.92,,,445.92,Other,100% New York Medicaid APG,445.92,,,445.92,Other,100% New York Medicaid APG,445.92,,,445.92,Other,100% New York Medicaid APG,1003.32,,,1003.32,Other,225% New York Medicaid APG,682.26,,,682.26,Other,153% New York Medicaid APG,1003.32,,,1003.32,Other,225% New York Medicaid APG,624.29,,,624.29,Other,140% New York Medicaid APG,1003.32,,,1003.32,Other,225% New York Medicaid APG,1159.39,,,1159.39,Other,260% New York Medicaid APG,1444.78,,,1444.78,Other,324% New York Medicaid APG,958.72,,,958.72,Other,215% New York Medicaid APG,958.72,,,958.72,Other,215% New York Medicaid APG,557.4,,,557.4,Other,125% New York Medicaid APG,445.92,32688,
Excision of salivary cyst,42408,CPT,,,,,,,,both,,,42114.67,31164.86,74,,31164.86,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,18951.6,45,,18951.6,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,20846.76,49.5,,20846.76,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,829.41,,,829.41,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,29480.27,70,,29480.27,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,445.92,,,445.92,Other,New York Medicaid APG methodology,445.92,,,445.92,Other,100% New York Medicaid APG,445.92,,,445.92,Other,100% New York Medicaid APG,445.92,,,445.92,Other,100% New York Medicaid APG,1003.32,,,1003.32,Other,225% New York Medicaid APG,682.26,,,682.26,Other,153% New York Medicaid APG,1003.32,,,1003.32,Other,225% New York Medicaid APG,624.29,,,624.29,Other,140% New York Medicaid APG,1003.32,,,1003.32,Other,225% New York Medicaid APG,1159.39,,,1159.39,Other,260% New York Medicaid APG,1444.78,,,1444.78,Other,324% New York Medicaid APG,958.72,,,958.72,Other,215% New York Medicaid APG,958.72,,,958.72,Other,215% New York Medicaid APG,557.4,,,557.4,Other,125% New York Medicaid APG,445.92,31164.86,
Drainage of salivary cyst,42409,CPT,,,,,,,,both,,,36553.88,27049.87,74,,27049.87,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,16449.25,45,,16449.25,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,18094.17,49.5,,18094.17,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,829.41,,,829.41,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,25587.72,70,,25587.72,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,445.92,,,445.92,Other,New York Medicaid APG methodology,445.92,,,445.92,Other,100% New York Medicaid APG,445.92,,,445.92,Other,100% New York Medicaid APG,445.92,,,445.92,Other,100% New York Medicaid APG,1003.32,,,1003.32,Other,225% New York Medicaid APG,682.26,,,682.26,Other,153% New York Medicaid APG,1003.32,,,1003.32,Other,225% New York Medicaid APG,624.29,,,624.29,Other,140% New York Medicaid APG,1003.32,,,1003.32,Other,225% New York Medicaid APG,1159.39,,,1159.39,Other,260% New York Medicaid APG,1444.78,,,1444.78,Other,324% New York Medicaid APG,958.72,,,958.72,Other,215% New York Medicaid APG,958.72,,,958.72,Other,215% New York Medicaid APG,557.4,,,557.4,Other,125% New York Medicaid APG,445.92,27049.87,
Excise parotid gland/lesion,42410,CPT,,,,,,,,both,,,52234.44,38653.49,74,,38653.49,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,23505.5,45,,23505.5,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,25856.05,49.5,,25856.05,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,4119.28,,,4119.28,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,36564.11,70,,36564.11,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,2214.67,,,2214.67,Other,New York Medicaid APG methodology,2214.67,,,2214.67,Other,100% New York Medicaid APG,2214.67,,,2214.67,Other,100% New York Medicaid APG,2214.67,,,2214.67,Other,100% New York Medicaid APG,4983,,,4983,Other,225% New York Medicaid APG,3388.44,,,3388.44,Other,153% New York Medicaid APG,4983,,,4983,Other,225% New York Medicaid APG,3100.53,,,3100.53,Other,140% New York Medicaid APG,4983,,,4983,Other,225% New York Medicaid APG,5758.13,,,5758.13,Other,260% New York Medicaid APG,7175.52,,,7175.52,Other,324% New York Medicaid APG,4761.53,,,4761.53,Other,215% New York Medicaid APG,4761.53,,,4761.53,Other,215% New York Medicaid APG,2768.33,,,2768.33,Other,125% New York Medicaid APG,2214.67,38653.49,
Excise parotid gland/lesion,42415,CPT,,,,,,,,both,,,47640.68,35254.1,74,,35254.1,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,21438.31,45,,21438.31,percent of total billed charges,Medicare Ratio of cost to charges,5954,,"100% primary, 50% supplemental procedure",5954,Other,Aetna ASC Grouper,5359,,"100% primary, 50% supplemental procedure",5359,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,23582.14,49.5,,23582.14,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5841.74,,,5841.74,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,33348.48,70,,33348.48,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,3140.72,,,3140.72,Other,New York Medicaid APG methodology,3140.72,,,3140.72,Other,100% New York Medicaid APG,3140.72,,,3140.72,Other,100% New York Medicaid APG,3140.72,,,3140.72,Other,100% New York Medicaid APG,7066.62,,,7066.62,Other,225% New York Medicaid APG,4805.3,,,4805.3,Other,153% New York Medicaid APG,7066.62,,,7066.62,Other,225% New York Medicaid APG,4397.01,,,4397.01,Other,140% New York Medicaid APG,7066.62,,,7066.62,Other,225% New York Medicaid APG,8165.87,,,8165.87,Other,260% New York Medicaid APG,10175.93,,,10175.93,Other,324% New York Medicaid APG,6752.54,,,6752.54,Other,215% New York Medicaid APG,6752.54,,,6752.54,Other,215% New York Medicaid APG,3925.9,,,3925.9,Other,125% New York Medicaid APG,3140.72,35254.1,
Excise parotid gland/lesion,42420,CPT,,,,,,,,both,,,105173.42,77828.33,74,,77828.33,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,47328.04,45,,47328.04,percent of total billed charges,Medicare Ratio of cost to charges,5954,,"100% primary, 50% supplemental procedure",5954,Other,Aetna ASC Grouper,5359,,"100% primary, 50% supplemental procedure",5359,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,52060.84,49.5,,52060.84,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5841.74,,,5841.74,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,73621.39,70,,73621.39,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,3140.72,,,3140.72,Other,New York Medicaid APG methodology,3140.72,,,3140.72,Other,100% New York Medicaid APG,3140.72,,,3140.72,Other,100% New York Medicaid APG,3140.72,,,3140.72,Other,100% New York Medicaid APG,7066.62,,,7066.62,Other,225% New York Medicaid APG,4805.3,,,4805.3,Other,153% New York Medicaid APG,7066.62,,,7066.62,Other,225% New York Medicaid APG,4397.01,,,4397.01,Other,140% New York Medicaid APG,7066.62,,,7066.62,Other,225% New York Medicaid APG,8165.87,,,8165.87,Other,260% New York Medicaid APG,10175.93,,,10175.93,Other,324% New York Medicaid APG,6752.54,,,6752.54,Other,215% New York Medicaid APG,6752.54,,,6752.54,Other,215% New York Medicaid APG,3925.9,,,3925.9,Other,125% New York Medicaid APG,3140.72,77828.33,
Excise parotid gland/lesion,42425,CPT,,,,,,,,both,,,123177.14,91151.08,74,,91151.08,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,55429.71,45,,55429.71,percent of total billed charges,Medicare Ratio of cost to charges,5954,,"100% primary, 50% supplemental procedure",5954,Other,Aetna ASC Grouper,5359,,"100% primary, 50% supplemental procedure",5359,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,60972.68,49.5,,60972.68,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5841.74,,,5841.74,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,86224,70,,86224,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,3140.72,,,3140.72,Other,New York Medicaid APG methodology,3140.72,,,3140.72,Other,100% New York Medicaid APG,3140.72,,,3140.72,Other,100% New York Medicaid APG,3140.72,,,3140.72,Other,100% New York Medicaid APG,7066.62,,,7066.62,Other,225% New York Medicaid APG,4805.3,,,4805.3,Other,153% New York Medicaid APG,7066.62,,,7066.62,Other,225% New York Medicaid APG,4397.01,,,4397.01,Other,140% New York Medicaid APG,7066.62,,,7066.62,Other,225% New York Medicaid APG,8165.87,,,8165.87,Other,260% New York Medicaid APG,10175.93,,,10175.93,Other,324% New York Medicaid APG,6752.54,,,6752.54,Other,215% New York Medicaid APG,6752.54,,,6752.54,Other,215% New York Medicaid APG,3925.9,,,3925.9,Other,125% New York Medicaid APG,3140.72,91151.08,
Excise submaxillary gland,42440,CPT,,,,,,,,both,,,46934.86,34731.8,74,,34731.8,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,21120.69,45,,21120.69,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,23232.76,49.5,,23232.76,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,4119.28,,,4119.28,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,32854.4,70,,32854.4,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,2214.67,,,2214.67,Other,New York Medicaid APG methodology,2214.67,,,2214.67,Other,100% New York Medicaid APG,2214.67,,,2214.67,Other,100% New York Medicaid APG,2214.67,,,2214.67,Other,100% New York Medicaid APG,4983,,,4983,Other,225% New York Medicaid APG,3388.44,,,3388.44,Other,153% New York Medicaid APG,4983,,,4983,Other,225% New York Medicaid APG,3100.53,,,3100.53,Other,140% New York Medicaid APG,4983,,,4983,Other,225% New York Medicaid APG,5758.13,,,5758.13,Other,260% New York Medicaid APG,7175.52,,,7175.52,Other,324% New York Medicaid APG,4761.53,,,4761.53,Other,215% New York Medicaid APG,4761.53,,,4761.53,Other,215% New York Medicaid APG,2768.33,,,2768.33,Other,125% New York Medicaid APG,2214.67,34731.8,
Excise sublingual gland,42450,CPT,,,,,,,,both,,,41640.28,30813.81,74,,30813.81,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,18738.13,45,,18738.13,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,20611.94,49.5,,20611.94,percent of total billed charges,110% of Medicare,28315.39,68,,28315.39,percent of total billed charges,,4119.28,,,4119.28,Other,186% of Medicaid,33312.22,80,,33312.22,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,33312.22,80,,33312.22,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,29148.2,70,,29148.2,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,2214.67,,,2214.67,Other,New York Medicaid APG methodology,2214.67,,,2214.67,Other,100% New York Medicaid APG,2214.67,,,2214.67,Other,100% New York Medicaid APG,2214.67,,,2214.67,Other,100% New York Medicaid APG,4983,,,4983,Other,225% New York Medicaid APG,3388.44,,,3388.44,Other,153% New York Medicaid APG,4983,,,4983,Other,225% New York Medicaid APG,3100.53,,,3100.53,Other,140% New York Medicaid APG,4983,,,4983,Other,225% New York Medicaid APG,5758.13,,,5758.13,Other,260% New York Medicaid APG,7175.52,,,7175.52,Other,324% New York Medicaid APG,4761.53,,,4761.53,Other,215% New York Medicaid APG,4761.53,,,4761.53,Other,215% New York Medicaid APG,2768.33,,,2768.33,Other,125% New York Medicaid APG,2214.67,33312.22,
Repair salivary duct,42500,CPT,,,,,,,,both,,,35276.6,26104.68,74,,26104.68,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15874.47,45,,15874.47,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,17461.92,49.5,,17461.92,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,829.41,,,829.41,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,24693.62,70,,24693.62,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,445.92,,,445.92,Other,New York Medicaid APG methodology,445.92,,,445.92,Other,100% New York Medicaid APG,445.92,,,445.92,Other,100% New York Medicaid APG,445.92,,,445.92,Other,100% New York Medicaid APG,1003.32,,,1003.32,Other,225% New York Medicaid APG,682.26,,,682.26,Other,153% New York Medicaid APG,1003.32,,,1003.32,Other,225% New York Medicaid APG,624.29,,,624.29,Other,140% New York Medicaid APG,1003.32,,,1003.32,Other,225% New York Medicaid APG,1159.39,,,1159.39,Other,260% New York Medicaid APG,1444.78,,,1444.78,Other,324% New York Medicaid APG,958.72,,,958.72,Other,215% New York Medicaid APG,958.72,,,958.72,Other,215% New York Medicaid APG,557.4,,,557.4,Other,125% New York Medicaid APG,445.92,26104.68,
Repair salivary duct,42505,CPT,,,,,,,,both,,,34960,25870.4,74,,25870.4,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15732,45,,15732,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,17305.2,49.5,,17305.2,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,829.41,,,829.41,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,24472,70,,24472,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,445.92,,,445.92,Other,New York Medicaid APG methodology,445.92,,,445.92,Other,100% New York Medicaid APG,445.92,,,445.92,Other,100% New York Medicaid APG,445.92,,,445.92,Other,100% New York Medicaid APG,1003.32,,,1003.32,Other,225% New York Medicaid APG,682.26,,,682.26,Other,153% New York Medicaid APG,1003.32,,,1003.32,Other,225% New York Medicaid APG,624.29,,,624.29,Other,140% New York Medicaid APG,1003.32,,,1003.32,Other,225% New York Medicaid APG,1159.39,,,1159.39,Other,260% New York Medicaid APG,1444.78,,,1444.78,Other,324% New York Medicaid APG,958.72,,,958.72,Other,215% New York Medicaid APG,958.72,,,958.72,Other,215% New York Medicaid APG,557.4,,,557.4,Other,125% New York Medicaid APG,445.92,25870.4,
Parotid duct diversion,42507,CPT,,,,,,,,both,,,123177.14,91151.08,74,,91151.08,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,55429.71,45,,55429.71,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,60972.68,49.5,,60972.68,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,4119.28,,,4119.28,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,86224,70,,86224,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,2214.67,,,2214.67,Other,New York Medicaid APG methodology,2214.67,,,2214.67,Other,100% New York Medicaid APG,2214.67,,,2214.67,Other,100% New York Medicaid APG,2214.67,,,2214.67,Other,100% New York Medicaid APG,4983,,,4983,Other,225% New York Medicaid APG,3388.44,,,3388.44,Other,153% New York Medicaid APG,4983,,,4983,Other,225% New York Medicaid APG,3100.53,,,3100.53,Other,140% New York Medicaid APG,4983,,,4983,Other,225% New York Medicaid APG,5758.13,,,5758.13,Other,260% New York Medicaid APG,7175.52,,,7175.52,Other,324% New York Medicaid APG,4761.53,,,4761.53,Other,215% New York Medicaid APG,4761.53,,,4761.53,Other,215% New York Medicaid APG,2768.33,,,2768.33,Other,125% New York Medicaid APG,2214.67,91151.08,
Parotid duct diversion,42509,CPT,,,,,,,,both,,,123177.14,91151.08,74,,91151.08,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,55429.71,45,,55429.71,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,60972.68,49.5,,60972.68,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5841.74,,,5841.74,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,86224,70,,86224,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,3140.72,,,3140.72,Other,New York Medicaid APG methodology,3140.72,,,3140.72,Other,100% New York Medicaid APG,3140.72,,,3140.72,Other,100% New York Medicaid APG,3140.72,,,3140.72,Other,100% New York Medicaid APG,7066.62,,,7066.62,Other,225% New York Medicaid APG,4805.3,,,4805.3,Other,153% New York Medicaid APG,7066.62,,,7066.62,Other,225% New York Medicaid APG,4397.01,,,4397.01,Other,140% New York Medicaid APG,7066.62,,,7066.62,Other,225% New York Medicaid APG,8165.87,,,8165.87,Other,260% New York Medicaid APG,10175.93,,,10175.93,Other,324% New York Medicaid APG,6752.54,,,6752.54,Other,215% New York Medicaid APG,6752.54,,,6752.54,Other,215% New York Medicaid APG,3925.9,,,3925.9,Other,125% New York Medicaid APG,3140.72,91151.08,
Parotid duct diversion,42510,CPT,,,,,,,,both,,,67720.49,50113.16,74,,50113.16,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30474.22,45,,30474.22,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,33521.64,49.5,,33521.64,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,4119.28,,,4119.28,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,47404.34,70,,47404.34,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,2214.67,,,2214.67,Other,New York Medicaid APG methodology,2214.67,,,2214.67,Other,100% New York Medicaid APG,2214.67,,,2214.67,Other,100% New York Medicaid APG,2214.67,,,2214.67,Other,100% New York Medicaid APG,4983,,,4983,Other,225% New York Medicaid APG,3388.44,,,3388.44,Other,153% New York Medicaid APG,4983,,,4983,Other,225% New York Medicaid APG,3100.53,,,3100.53,Other,140% New York Medicaid APG,4983,,,4983,Other,225% New York Medicaid APG,5758.13,,,5758.13,Other,260% New York Medicaid APG,7175.52,,,7175.52,Other,324% New York Medicaid APG,4761.53,,,4761.53,Other,215% New York Medicaid APG,4761.53,,,4761.53,Other,215% New York Medicaid APG,2768.33,,,2768.33,Other,125% New York Medicaid APG,2214.67,50113.16,
Injection for salivary x-ray,42550,CPT,,,,,,,,both,,,32432.1,23999.75,74,,23999.75,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,14594.45,45,,14594.45,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,16053.89,49.5,,16053.89,percent of total billed charges,110% of Medicare,22053.83,68,,22053.83,percent of total billed charges,,966.93,,,966.93,Other,186% of Medicaid,25945.68,80,,25945.68,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,25945.68,80,,25945.68,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,22702.47,70,,22702.47,percent of total billed charges,,298.48,,,298.48,Fee Schedule,,252.98,,,252.98,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,519.86,,,519.86,Other,New York Medicaid APG methodology,519.86,,,519.86,Other,100% New York Medicaid APG,519.86,,,519.86,Other,100% New York Medicaid APG,519.86,,,519.86,Other,100% New York Medicaid APG,1169.68,,,1169.68,Other,225% New York Medicaid APG,795.38,,,795.38,Other,153% New York Medicaid APG,1169.68,,,1169.68,Other,225% New York Medicaid APG,727.8,,,727.8,Other,140% New York Medicaid APG,1169.68,,,1169.68,Other,225% New York Medicaid APG,1351.62,,,1351.62,Other,260% New York Medicaid APG,1684.33,,,1684.33,Other,324% New York Medicaid APG,1117.69,,,1117.69,Other,215% New York Medicaid APG,1117.69,,,1117.69,Other,215% New York Medicaid APG,649.82,,,649.82,Other,125% New York Medicaid APG,252.98,25945.68,
Closure of salivary fistula,42600,CPT,,,,,,,,both,,,67720.49,50113.16,74,,50113.16,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30474.22,45,,30474.22,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,33521.64,49.5,,33521.64,percent of total billed charges,110% of Medicare,46049.93,68,,46049.93,percent of total billed charges,,4119.28,,,4119.28,Other,186% of Medicaid,54176.39,80,,54176.39,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,54176.39,80,,54176.39,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,47404.34,70,,47404.34,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,2214.67,,,2214.67,Other,New York Medicaid APG methodology,2214.67,,,2214.67,Other,100% New York Medicaid APG,2214.67,,,2214.67,Other,100% New York Medicaid APG,2214.67,,,2214.67,Other,100% New York Medicaid APG,4983,,,4983,Other,225% New York Medicaid APG,3388.44,,,3388.44,Other,153% New York Medicaid APG,4983,,,4983,Other,225% New York Medicaid APG,3100.53,,,3100.53,Other,140% New York Medicaid APG,4983,,,4983,Other,225% New York Medicaid APG,5758.13,,,5758.13,Other,260% New York Medicaid APG,7175.52,,,7175.52,Other,324% New York Medicaid APG,4761.53,,,4761.53,Other,215% New York Medicaid APG,4761.53,,,4761.53,Other,215% New York Medicaid APG,2768.33,,,2768.33,Other,125% New York Medicaid APG,2053,54176.39,
Dilation of salivary duct,42650,CPT,,,,,,,,both,,,32077.39,23737.27,74,,23737.27,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,14434.83,45,,14434.83,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,15878.31,49.5,,15878.31,percent of total billed charges,110% of Medicare,21812.63,68,,21812.63,percent of total billed charges,,829.41,,,829.41,Other,186% of Medicaid,25661.91,80,,25661.91,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,25661.91,80,,25661.91,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,22454.17,70,,22454.17,percent of total billed charges,,288.64,,,288.64,Fee Schedule,,244.64,,,244.64,Fee Schedule,,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,445.92,,,445.92,Other,New York Medicaid APG methodology,445.92,,,445.92,Other,100% New York Medicaid APG,445.92,,,445.92,Other,100% New York Medicaid APG,445.92,,,445.92,Other,100% New York Medicaid APG,1003.32,,,1003.32,Other,225% New York Medicaid APG,682.26,,,682.26,Other,153% New York Medicaid APG,1003.32,,,1003.32,Other,225% New York Medicaid APG,624.29,,,624.29,Other,140% New York Medicaid APG,1003.32,,,1003.32,Other,225% New York Medicaid APG,1159.39,,,1159.39,Other,260% New York Medicaid APG,1444.78,,,1444.78,Other,324% New York Medicaid APG,958.72,,,958.72,Other,215% New York Medicaid APG,958.72,,,958.72,Other,215% New York Medicaid APG,557.4,,,557.4,Other,125% New York Medicaid APG,244.64,25661.91,
Dilation of salivary duct,42660,CPT,,,,,,,,both,,,33480.3,24775.42,74,,24775.42,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15066.14,45,,15066.14,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,16572.75,49.5,,16572.75,percent of total billed charges,110% of Medicare,22766.6,68,,22766.6,percent of total billed charges,,829.41,,,829.41,Other,186% of Medicaid,26784.24,80,,26784.24,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,26784.24,80,,26784.24,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,23436.21,70,,23436.21,percent of total billed charges,,434.6,,,434.6,Fee Schedule,,368.35,,,368.35,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,445.92,,,445.92,Other,New York Medicaid APG methodology,445.92,,,445.92,Other,100% New York Medicaid APG,445.92,,,445.92,Other,100% New York Medicaid APG,445.92,,,445.92,Other,100% New York Medicaid APG,1003.32,,,1003.32,Other,225% New York Medicaid APG,682.26,,,682.26,Other,153% New York Medicaid APG,1003.32,,,1003.32,Other,225% New York Medicaid APG,624.29,,,624.29,Other,140% New York Medicaid APG,1003.32,,,1003.32,Other,225% New York Medicaid APG,1159.39,,,1159.39,Other,260% New York Medicaid APG,1444.78,,,1444.78,Other,324% New York Medicaid APG,958.72,,,958.72,Other,215% New York Medicaid APG,958.72,,,958.72,Other,215% New York Medicaid APG,557.4,,,557.4,Other,125% New York Medicaid APG,368.35,26784.24,
Ligation of salivary duct,42665,CPT,,,,,,,,both,,,67720.49,50113.16,74,,50113.16,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30474.22,45,,30474.22,percent of total billed charges,Medicare Ratio of cost to charges,5954,,"100% primary, 50% supplemental procedure",5954,Other,Aetna ASC Grouper,5359,,"100% primary, 50% supplemental procedure",5359,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,33521.64,49.5,,33521.64,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,428.6,,,428.6,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,47404.34,70,,47404.34,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,230.43,,,230.43,Other,New York Medicaid APG methodology,230.43,,,230.43,Other,100% New York Medicaid APG,230.43,,,230.43,Other,100% New York Medicaid APG,230.43,,,230.43,Other,100% New York Medicaid APG,518.46,,,518.46,Other,225% New York Medicaid APG,352.55,,,352.55,Other,153% New York Medicaid APG,518.46,,,518.46,Other,225% New York Medicaid APG,322.6,,,322.6,Other,140% New York Medicaid APG,518.46,,,518.46,Other,225% New York Medicaid APG,599.11,,,599.11,Other,260% New York Medicaid APG,746.59,,,746.59,Other,324% New York Medicaid APG,495.42,,,495.42,Other,215% New York Medicaid APG,495.42,,,495.42,Other,215% New York Medicaid APG,288.03,,,288.03,Other,125% New York Medicaid APG,230.43,50113.16,
Drainage of tonsil abscess,42700,CPT,,,,,,,,both,,,5137.73,3801.92,74,,3801.92,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,2311.98,45,,2311.98,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,2543.18,49.5,,2543.18,percent of total billed charges,110% of Medicare,3493.66,68,,3493.66,percent of total billed charges,,423.06,,,423.06,Other,186% of Medicaid,4110.18,80,,4110.18,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,4110.18,80,,4110.18,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,3596.41,70,,3596.41,percent of total billed charges,,670.76,,,670.76,Fee Schedule,,568.51,,,568.51,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,227.45,,,227.45,Other,New York Medicaid APG methodology,227.45,,,227.45,Other,100% New York Medicaid APG,227.45,,,227.45,Other,100% New York Medicaid APG,227.45,,,227.45,Other,100% New York Medicaid APG,511.76,,,511.76,Other,225% New York Medicaid APG,348,,,348,Other,153% New York Medicaid APG,511.76,,,511.76,Other,225% New York Medicaid APG,318.43,,,318.43,Other,140% New York Medicaid APG,511.76,,,511.76,Other,225% New York Medicaid APG,591.37,,,591.37,Other,260% New York Medicaid APG,736.94,,,736.94,Other,324% New York Medicaid APG,489.02,,,489.02,Other,215% New York Medicaid APG,489.02,,,489.02,Other,215% New York Medicaid APG,284.31,,,284.31,Other,125% New York Medicaid APG,227.45,7216,
Drainage of throat abscess,42720,CPT,,,,,,,,both,,,67720.49,50113.16,74,,50113.16,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30474.22,45,,30474.22,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,33521.64,49.5,,33521.64,percent of total billed charges,110% of Medicare,46049.93,68,,46049.93,percent of total billed charges,,2256.57,,,2256.57,Other,186% of Medicaid,54176.39,80,,54176.39,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,54176.39,80,,54176.39,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,47404.34,70,,47404.34,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1213.21,,,1213.21,Other,New York Medicaid APG methodology,1213.21,,,1213.21,Other,100% New York Medicaid APG,1213.21,,,1213.21,Other,100% New York Medicaid APG,1213.21,,,1213.21,Other,100% New York Medicaid APG,2729.72,,,2729.72,Other,225% New York Medicaid APG,1856.21,,,1856.21,Other,153% New York Medicaid APG,2729.72,,,2729.72,Other,225% New York Medicaid APG,1698.49,,,1698.49,Other,140% New York Medicaid APG,2729.72,,,2729.72,Other,225% New York Medicaid APG,3154.34,,,3154.34,Other,260% New York Medicaid APG,3930.79,,,3930.79,Other,324% New York Medicaid APG,2608.4,,,2608.4,Other,215% New York Medicaid APG,2608.4,,,2608.4,Other,215% New York Medicaid APG,1516.51,,,1516.51,Other,125% New York Medicaid APG,1213.21,54176.39,
Drainage of throat abscess,42725,CPT,,,,,,,,both,,,123177.14,91151.08,74,,91151.08,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,55429.71,45,,55429.71,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,60972.68,49.5,,60972.68,percent of total billed charges,110% of Medicare,83760.46,68,,83760.46,percent of total billed charges,,2256.57,,,2256.57,Other,186% of Medicaid,98541.71,80,,98541.71,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,98541.71,80,,98541.71,percent of total billed charges,,7216,,,7216,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,86224,70,,86224,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,1213.21,,,1213.21,Other,New York Medicaid APG methodology,1213.21,,,1213.21,Other,100% New York Medicaid APG,1213.21,,,1213.21,Other,100% New York Medicaid APG,1213.21,,,1213.21,Other,100% New York Medicaid APG,2729.72,,,2729.72,Other,225% New York Medicaid APG,1856.21,,,1856.21,Other,153% New York Medicaid APG,2729.72,,,2729.72,Other,225% New York Medicaid APG,1698.49,,,1698.49,Other,140% New York Medicaid APG,2729.72,,,2729.72,Other,225% New York Medicaid APG,3154.34,,,3154.34,Other,260% New York Medicaid APG,3930.79,,,3930.79,Other,324% New York Medicaid APG,2608.4,,,2608.4,Other,215% New York Medicaid APG,2608.4,,,2608.4,Other,215% New York Medicaid APG,1516.51,,,1516.51,Other,125% New York Medicaid APG,1213.21,98541.71,
Biopsy of throat,42800,CPT,,,,,,,,both,,,32077.39,23737.27,74,,23737.27,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,14434.83,45,,14434.83,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,15878.31,49.5,,15878.31,percent of total billed charges,110% of Medicare,21812.63,68,,21812.63,percent of total billed charges,,2256.57,,,2256.57,Other,186% of Medicaid,25661.91,80,,25661.91,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,25661.91,80,,25661.91,percent of total billed charges,,7216,,,7216,Case Rate,,3578,,"100% primary, 0% secondary procedures",3578,Other,MagnaCare ASC Grouper,22454.17,70,,22454.17,percent of total billed charges,,574,,,574,Fee Schedule,,486.5,,,486.5,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,1213.21,,,1213.21,Other,New York Medicaid APG methodology,1213.21,,,1213.21,Other,100% New York Medicaid APG,1213.21,,,1213.21,Other,100% New York Medicaid APG,1213.21,,,1213.21,Other,100% New York Medicaid APG,2729.72,,,2729.72,Other,225% New York Medicaid APG,1856.21,,,1856.21,Other,153% New York Medicaid APG,2729.72,,,2729.72,Other,225% New York Medicaid APG,1698.49,,,1698.49,Other,140% New York Medicaid APG,2729.72,,,2729.72,Other,225% New York Medicaid APG,3154.34,,,3154.34,Other,260% New York Medicaid APG,3930.79,,,3930.79,Other,324% New York Medicaid APG,2608.4,,,2608.4,Other,215% New York Medicaid APG,2608.4,,,2608.4,Other,215% New York Medicaid APG,1516.51,,,1516.51,Other,125% New York Medicaid APG,486.5,25661.91,
Biopsy of upper nose/throat,42804,CPT,,,,,,,,both,,,67720.49,50113.16,74,,50113.16,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30474.22,45,,30474.22,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,33521.64,49.5,,33521.64,percent of total billed charges,110% of Medicare,46049.93,68,,46049.93,percent of total billed charges,,2256.57,,,2256.57,Other,186% of Medicaid,54176.39,80,,54176.39,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,54176.39,80,,54176.39,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,47404.34,70,,47404.34,percent of total billed charges,,606.8,,,606.8,Fee Schedule,,514.3,,,514.3,Fee Schedule,,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1213.21,,,1213.21,Other,New York Medicaid APG methodology,1213.21,,,1213.21,Other,100% New York Medicaid APG,1213.21,,,1213.21,Other,100% New York Medicaid APG,1213.21,,,1213.21,Other,100% New York Medicaid APG,2729.72,,,2729.72,Other,225% New York Medicaid APG,1856.21,,,1856.21,Other,153% New York Medicaid APG,2729.72,,,2729.72,Other,225% New York Medicaid APG,1698.49,,,1698.49,Other,140% New York Medicaid APG,2729.72,,,2729.72,Other,225% New York Medicaid APG,3154.34,,,3154.34,Other,260% New York Medicaid APG,3930.79,,,3930.79,Other,324% New York Medicaid APG,2608.4,,,2608.4,Other,215% New York Medicaid APG,2608.4,,,2608.4,Other,215% New York Medicaid APG,1516.51,,,1516.51,Other,125% New York Medicaid APG,514.3,54176.39,
Biopsy of upper nose/throat,42806,CPT,,,,,,,,both,,,67720.49,50113.16,74,,50113.16,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30474.22,45,,30474.22,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,33521.64,49.5,,33521.64,percent of total billed charges,110% of Medicare,46049.93,68,,46049.93,percent of total billed charges,,2256.57,,,2256.57,Other,186% of Medicaid,54176.39,80,,54176.39,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,54176.39,80,,54176.39,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,47404.34,70,,47404.34,percent of total billed charges,,697,,,697,Fee Schedule,,590.75,,,590.75,Fee Schedule,,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1213.21,,,1213.21,Other,New York Medicaid APG methodology,1213.21,,,1213.21,Other,100% New York Medicaid APG,1213.21,,,1213.21,Other,100% New York Medicaid APG,1213.21,,,1213.21,Other,100% New York Medicaid APG,2729.72,,,2729.72,Other,225% New York Medicaid APG,1856.21,,,1856.21,Other,153% New York Medicaid APG,2729.72,,,2729.72,Other,225% New York Medicaid APG,1698.49,,,1698.49,Other,140% New York Medicaid APG,2729.72,,,2729.72,Other,225% New York Medicaid APG,3154.34,,,3154.34,Other,260% New York Medicaid APG,3930.79,,,3930.79,Other,324% New York Medicaid APG,2608.4,,,2608.4,Other,215% New York Medicaid APG,2608.4,,,2608.4,Other,215% New York Medicaid APG,1516.51,,,1516.51,Other,125% New York Medicaid APG,590.75,54176.39,
Excise pharynx lesion,42808,CPT,,,,,,,,both,,,99331.66,73505.43,74,,73505.43,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,44699.25,45,,44699.25,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,49169.17,49.5,,49169.17,percent of total billed charges,110% of Medicare,67545.53,68,,67545.53,percent of total billed charges,,2965.83,,,2965.83,Other,186% of Medicaid,79465.33,80,,79465.33,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,79465.33,80,,79465.33,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,69532.16,70,,69532.16,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1594.53,,,1594.53,Other,New York Medicaid APG methodology,1594.53,,,1594.53,Other,100% New York Medicaid APG,1594.53,,,1594.53,Other,100% New York Medicaid APG,1594.53,,,1594.53,Other,100% New York Medicaid APG,3587.7,,,3587.7,Other,225% New York Medicaid APG,2439.64,,,2439.64,Other,153% New York Medicaid APG,3587.7,,,3587.7,Other,225% New York Medicaid APG,2232.35,,,2232.35,Other,140% New York Medicaid APG,3587.7,,,3587.7,Other,225% New York Medicaid APG,4145.78,,,4145.78,Other,260% New York Medicaid APG,5166.29,,,5166.29,Other,324% New York Medicaid APG,3428.25,,,3428.25,Other,215% New York Medicaid APG,3428.25,,,3428.25,Other,215% New York Medicaid APG,1993.17,,,1993.17,Other,125% New York Medicaid APG,1594.53,79465.33,
Remove pharynx foreign body,42809,CPT,,,,,,,,both,,,8380.68,6201.7,74,,6201.7,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,3771.31,45,,3771.31,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,4148.44,49.5,,4148.44,percent of total billed charges,110% of Medicare,5698.86,68,,5698.86,percent of total billed charges,,423.06,,,423.06,Other,186% of Medicaid,6704.54,80,,6704.54,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,6704.54,80,,6704.54,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,5866.48,70,,5866.48,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,227.45,,,227.45,Other,New York Medicaid APG methodology,227.45,,,227.45,Other,100% New York Medicaid APG,227.45,,,227.45,Other,100% New York Medicaid APG,227.45,,,227.45,Other,100% New York Medicaid APG,511.76,,,511.76,Other,225% New York Medicaid APG,348,,,348,Other,153% New York Medicaid APG,511.76,,,511.76,Other,225% New York Medicaid APG,318.43,,,318.43,Other,140% New York Medicaid APG,511.76,,,511.76,Other,225% New York Medicaid APG,591.37,,,591.37,Other,260% New York Medicaid APG,736.94,,,736.94,Other,324% New York Medicaid APG,489.02,,,489.02,Other,215% New York Medicaid APG,489.02,,,489.02,Other,215% New York Medicaid APG,284.31,,,284.31,Other,125% New York Medicaid APG,227.45,7216,
Excision of neck cyst,42810,CPT,,,,,,,,both,,,36766.28,27207.05,74,,27207.05,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,16544.83,45,,16544.83,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,18199.31,49.5,,18199.31,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2256.57,,,2256.57,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,25736.4,70,,25736.4,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1213.21,,,1213.21,Other,New York Medicaid APG methodology,1213.21,,,1213.21,Other,100% New York Medicaid APG,1213.21,,,1213.21,Other,100% New York Medicaid APG,1213.21,,,1213.21,Other,100% New York Medicaid APG,2729.72,,,2729.72,Other,225% New York Medicaid APG,1856.21,,,1856.21,Other,153% New York Medicaid APG,2729.72,,,2729.72,Other,225% New York Medicaid APG,1698.49,,,1698.49,Other,140% New York Medicaid APG,2729.72,,,2729.72,Other,225% New York Medicaid APG,3154.34,,,3154.34,Other,260% New York Medicaid APG,3930.79,,,3930.79,Other,324% New York Medicaid APG,2608.4,,,2608.4,Other,215% New York Medicaid APG,2608.4,,,2608.4,Other,215% New York Medicaid APG,1516.51,,,1516.51,Other,125% New York Medicaid APG,1213.21,27207.05,
Excision of neck cyst,42815,CPT,,,,,,,,both,,,36519.76,27024.62,74,,27024.62,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,16433.89,45,,16433.89,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,18077.28,49.5,,18077.28,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,4119.28,,,4119.28,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,25563.83,70,,25563.83,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,2214.67,,,2214.67,Other,New York Medicaid APG methodology,2214.67,,,2214.67,Other,100% New York Medicaid APG,2214.67,,,2214.67,Other,100% New York Medicaid APG,2214.67,,,2214.67,Other,100% New York Medicaid APG,4983,,,4983,Other,225% New York Medicaid APG,3388.44,,,3388.44,Other,153% New York Medicaid APG,4983,,,4983,Other,225% New York Medicaid APG,3100.53,,,3100.53,Other,140% New York Medicaid APG,4983,,,4983,Other,225% New York Medicaid APG,5758.13,,,5758.13,Other,260% New York Medicaid APG,7175.52,,,7175.52,Other,324% New York Medicaid APG,4761.53,,,4761.53,Other,215% New York Medicaid APG,4761.53,,,4761.53,Other,215% New York Medicaid APG,2768.33,,,2768.33,Other,125% New York Medicaid APG,2214.67,27024.62,
Remove tonsils and adenoids,42820,CPT,,,,,,,,both,,,35805.32,26495.94,74,,26495.94,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,16112.39,45,,16112.39,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,17723.63,49.5,,17723.63,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2581.6,,,2581.6,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,25063.72,70,,25063.72,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1387.96,,,1387.96,Other,New York Medicaid APG methodology,1387.96,,,1387.96,Other,100% New York Medicaid APG,1387.96,,,1387.96,Other,100% New York Medicaid APG,1387.96,,,1387.96,Other,100% New York Medicaid APG,3122.9,,,3122.9,Other,225% New York Medicaid APG,2123.57,,,2123.57,Other,153% New York Medicaid APG,3122.9,,,3122.9,Other,225% New York Medicaid APG,1943.14,,,1943.14,Other,140% New York Medicaid APG,3122.9,,,3122.9,Other,225% New York Medicaid APG,3608.69,,,3608.69,Other,260% New York Medicaid APG,4496.98,,,4496.98,Other,324% New York Medicaid APG,2984.11,,,2984.11,Other,215% New York Medicaid APG,2984.11,,,2984.11,Other,215% New York Medicaid APG,1734.95,,,1734.95,Other,125% New York Medicaid APG,1387.96,26495.94,
Remove tonsils and adenoids,42821,CPT,,,,,,,,both,,,36490.36,27002.87,74,,27002.87,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,16420.66,45,,16420.66,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,18062.73,49.5,,18062.73,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2581.6,,,2581.6,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,25543.25,70,,25543.25,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1387.96,,,1387.96,Other,New York Medicaid APG methodology,1387.96,,,1387.96,Other,100% New York Medicaid APG,1387.96,,,1387.96,Other,100% New York Medicaid APG,1387.96,,,1387.96,Other,100% New York Medicaid APG,3122.9,,,3122.9,Other,225% New York Medicaid APG,2123.57,,,2123.57,Other,153% New York Medicaid APG,3122.9,,,3122.9,Other,225% New York Medicaid APG,1943.14,,,1943.14,Other,140% New York Medicaid APG,3122.9,,,3122.9,Other,225% New York Medicaid APG,3608.69,,,3608.69,Other,260% New York Medicaid APG,4496.98,,,4496.98,Other,324% New York Medicaid APG,2984.11,,,2984.11,Other,215% New York Medicaid APG,2984.11,,,2984.11,Other,215% New York Medicaid APG,1734.95,,,1734.95,Other,125% New York Medicaid APG,1387.96,27002.87,
Removal of tonsils,42825,CPT,,,,,,,,both,,,36380.39,26921.49,74,,26921.49,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,16371.18,45,,16371.18,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,18008.29,49.5,,18008.29,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2581.6,,,2581.6,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,25466.27,70,,25466.27,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1387.96,,,1387.96,Other,New York Medicaid APG methodology,1387.96,,,1387.96,Other,100% New York Medicaid APG,1387.96,,,1387.96,Other,100% New York Medicaid APG,1387.96,,,1387.96,Other,100% New York Medicaid APG,3122.9,,,3122.9,Other,225% New York Medicaid APG,2123.57,,,2123.57,Other,153% New York Medicaid APG,3122.9,,,3122.9,Other,225% New York Medicaid APG,1943.14,,,1943.14,Other,140% New York Medicaid APG,3122.9,,,3122.9,Other,225% New York Medicaid APG,3608.69,,,3608.69,Other,260% New York Medicaid APG,4496.98,,,4496.98,Other,324% New York Medicaid APG,2984.11,,,2984.11,Other,215% New York Medicaid APG,2984.11,,,2984.11,Other,215% New York Medicaid APG,1734.95,,,1734.95,Other,125% New York Medicaid APG,1387.96,26921.49,
Removal of tonsils,42826,CPT,,,,,,,,both,,,38466.62,28465.3,74,,28465.3,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,17309.98,45,,17309.98,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,19040.98,49.5,,19040.98,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2581.6,,,2581.6,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,26926.63,70,,26926.63,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1387.96,,,1387.96,Other,New York Medicaid APG methodology,1387.96,,,1387.96,Other,100% New York Medicaid APG,1387.96,,,1387.96,Other,100% New York Medicaid APG,1387.96,,,1387.96,Other,100% New York Medicaid APG,3122.9,,,3122.9,Other,225% New York Medicaid APG,2123.57,,,2123.57,Other,153% New York Medicaid APG,3122.9,,,3122.9,Other,225% New York Medicaid APG,1943.14,,,1943.14,Other,140% New York Medicaid APG,3122.9,,,3122.9,Other,225% New York Medicaid APG,3608.69,,,3608.69,Other,260% New York Medicaid APG,4496.98,,,4496.98,Other,324% New York Medicaid APG,2984.11,,,2984.11,Other,215% New York Medicaid APG,2984.11,,,2984.11,Other,215% New York Medicaid APG,1734.95,,,1734.95,Other,125% New York Medicaid APG,1387.96,28465.3,
Removal of adenoids,42830,CPT,,,,,,,,both,,,34982.02,25886.69,74,,25886.69,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15741.91,45,,15741.91,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,17316.1,49.5,,17316.1,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2581.6,,,2581.6,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,24487.41,70,,24487.41,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1387.96,,,1387.96,Other,New York Medicaid APG methodology,1387.96,,,1387.96,Other,100% New York Medicaid APG,1387.96,,,1387.96,Other,100% New York Medicaid APG,1387.96,,,1387.96,Other,100% New York Medicaid APG,3122.9,,,3122.9,Other,225% New York Medicaid APG,2123.57,,,2123.57,Other,153% New York Medicaid APG,3122.9,,,3122.9,Other,225% New York Medicaid APG,1943.14,,,1943.14,Other,140% New York Medicaid APG,3122.9,,,3122.9,Other,225% New York Medicaid APG,3608.69,,,3608.69,Other,260% New York Medicaid APG,4496.98,,,4496.98,Other,324% New York Medicaid APG,2984.11,,,2984.11,Other,215% New York Medicaid APG,2984.11,,,2984.11,Other,215% New York Medicaid APG,1734.95,,,1734.95,Other,125% New York Medicaid APG,1387.96,25886.69,
Removal of adenoids,42831,CPT,,,,,,,,both,,,34792.95,25746.78,74,,25746.78,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15656.83,45,,15656.83,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,17222.51,49.5,,17222.51,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2581.6,,,2581.6,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,24355.07,70,,24355.07,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1387.96,,,1387.96,Other,New York Medicaid APG methodology,1387.96,,,1387.96,Other,100% New York Medicaid APG,1387.96,,,1387.96,Other,100% New York Medicaid APG,1387.96,,,1387.96,Other,100% New York Medicaid APG,3122.9,,,3122.9,Other,225% New York Medicaid APG,2123.57,,,2123.57,Other,153% New York Medicaid APG,3122.9,,,3122.9,Other,225% New York Medicaid APG,1943.14,,,1943.14,Other,140% New York Medicaid APG,3122.9,,,3122.9,Other,225% New York Medicaid APG,3608.69,,,3608.69,Other,260% New York Medicaid APG,4496.98,,,4496.98,Other,324% New York Medicaid APG,2984.11,,,2984.11,Other,215% New York Medicaid APG,2984.11,,,2984.11,Other,215% New York Medicaid APG,1734.95,,,1734.95,Other,125% New York Medicaid APG,1387.96,25746.78,
Removal of adenoids,42835,CPT,,,,,,,,both,,,35678.62,26402.18,74,,26402.18,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,16055.38,45,,16055.38,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,17660.92,49.5,,17660.92,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2581.6,,,2581.6,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,24975.03,70,,24975.03,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1387.96,,,1387.96,Other,New York Medicaid APG methodology,1387.96,,,1387.96,Other,100% New York Medicaid APG,1387.96,,,1387.96,Other,100% New York Medicaid APG,1387.96,,,1387.96,Other,100% New York Medicaid APG,3122.9,,,3122.9,Other,225% New York Medicaid APG,2123.57,,,2123.57,Other,153% New York Medicaid APG,3122.9,,,3122.9,Other,225% New York Medicaid APG,1943.14,,,1943.14,Other,140% New York Medicaid APG,3122.9,,,3122.9,Other,225% New York Medicaid APG,3608.69,,,3608.69,Other,260% New York Medicaid APG,4496.98,,,4496.98,Other,324% New York Medicaid APG,2984.11,,,2984.11,Other,215% New York Medicaid APG,2984.11,,,2984.11,Other,215% New York Medicaid APG,1734.95,,,1734.95,Other,125% New York Medicaid APG,1387.96,26402.18,
Removal of adenoids,42836,CPT,,,,,,,,both,,,67720.49,50113.16,74,,50113.16,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30474.22,45,,30474.22,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,33521.64,49.5,,33521.64,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2581.6,,,2581.6,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,47404.34,70,,47404.34,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1387.96,,,1387.96,Other,New York Medicaid APG methodology,1387.96,,,1387.96,Other,100% New York Medicaid APG,1387.96,,,1387.96,Other,100% New York Medicaid APG,1387.96,,,1387.96,Other,100% New York Medicaid APG,3122.9,,,3122.9,Other,225% New York Medicaid APG,2123.57,,,2123.57,Other,153% New York Medicaid APG,3122.9,,,3122.9,Other,225% New York Medicaid APG,1943.14,,,1943.14,Other,140% New York Medicaid APG,3122.9,,,3122.9,Other,225% New York Medicaid APG,3608.69,,,3608.69,Other,260% New York Medicaid APG,4496.98,,,4496.98,Other,324% New York Medicaid APG,2984.11,,,2984.11,Other,215% New York Medicaid APG,2984.11,,,2984.11,Other,215% New York Medicaid APG,1734.95,,,1734.95,Other,125% New York Medicaid APG,1387.96,50113.16,
Extensive surgery of throat,42842,CPT,,,,,,,,both,,,123177.14,91151.08,74,,91151.08,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,55429.71,45,,55429.71,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,60972.68,49.5,,60972.68,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2581.6,,,2581.6,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,86224,70,,86224,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1387.96,,,1387.96,Other,New York Medicaid APG methodology,1387.96,,,1387.96,Other,100% New York Medicaid APG,1387.96,,,1387.96,Other,100% New York Medicaid APG,1387.96,,,1387.96,Other,100% New York Medicaid APG,3122.9,,,3122.9,Other,225% New York Medicaid APG,2123.57,,,2123.57,Other,153% New York Medicaid APG,3122.9,,,3122.9,Other,225% New York Medicaid APG,1943.14,,,1943.14,Other,140% New York Medicaid APG,3122.9,,,3122.9,Other,225% New York Medicaid APG,3608.69,,,3608.69,Other,260% New York Medicaid APG,4496.98,,,4496.98,Other,324% New York Medicaid APG,2984.11,,,2984.11,Other,215% New York Medicaid APG,2984.11,,,2984.11,Other,215% New York Medicaid APG,1734.95,,,1734.95,Other,125% New York Medicaid APG,1387.96,91151.08,
Extensive surgery of throat,42844,CPT,,,,,,,,both,,,123177.14,91151.08,74,,91151.08,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,55429.71,45,,55429.71,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,60972.68,49.5,,60972.68,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2581.6,,,2581.6,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,86224,70,,86224,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,1387.96,,,1387.96,Other,New York Medicaid APG methodology,1387.96,,,1387.96,Other,100% New York Medicaid APG,1387.96,,,1387.96,Other,100% New York Medicaid APG,1387.96,,,1387.96,Other,100% New York Medicaid APG,3122.9,,,3122.9,Other,225% New York Medicaid APG,2123.57,,,2123.57,Other,153% New York Medicaid APG,3122.9,,,3122.9,Other,225% New York Medicaid APG,1943.14,,,1943.14,Other,140% New York Medicaid APG,3122.9,,,3122.9,Other,225% New York Medicaid APG,3608.69,,,3608.69,Other,260% New York Medicaid APG,4496.98,,,4496.98,Other,324% New York Medicaid APG,2984.11,,,2984.11,Other,215% New York Medicaid APG,2984.11,,,2984.11,Other,215% New York Medicaid APG,1734.95,,,1734.95,Other,125% New York Medicaid APG,1387.96,91151.08,
Excision of tonsil tags,42860,CPT,,,,,,,,both,,,67720.49,50113.16,74,,50113.16,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30474.22,45,,30474.22,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,33521.64,49.5,,33521.64,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2581.6,,,2581.6,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,47404.34,70,,47404.34,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1387.96,,,1387.96,Other,New York Medicaid APG methodology,1387.96,,,1387.96,Other,100% New York Medicaid APG,1387.96,,,1387.96,Other,100% New York Medicaid APG,1387.96,,,1387.96,Other,100% New York Medicaid APG,3122.9,,,3122.9,Other,225% New York Medicaid APG,2123.57,,,2123.57,Other,153% New York Medicaid APG,3122.9,,,3122.9,Other,225% New York Medicaid APG,1943.14,,,1943.14,Other,140% New York Medicaid APG,3122.9,,,3122.9,Other,225% New York Medicaid APG,3608.69,,,3608.69,Other,260% New York Medicaid APG,4496.98,,,4496.98,Other,324% New York Medicaid APG,2984.11,,,2984.11,Other,215% New York Medicaid APG,2984.11,,,2984.11,Other,215% New York Medicaid APG,1734.95,,,1734.95,Other,125% New York Medicaid APG,1387.96,50113.16,
Excision of lingual tonsil,42870,CPT,,,,,,,,both,,,123177.14,91151.08,74,,91151.08,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,55429.71,45,,55429.71,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,60972.68,49.5,,60972.68,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2581.6,,,2581.6,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,86224,70,,86224,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1387.96,,,1387.96,Other,New York Medicaid APG methodology,1387.96,,,1387.96,Other,100% New York Medicaid APG,1387.96,,,1387.96,Other,100% New York Medicaid APG,1387.96,,,1387.96,Other,100% New York Medicaid APG,3122.9,,,3122.9,Other,225% New York Medicaid APG,2123.57,,,2123.57,Other,153% New York Medicaid APG,3122.9,,,3122.9,Other,225% New York Medicaid APG,1943.14,,,1943.14,Other,140% New York Medicaid APG,3122.9,,,3122.9,Other,225% New York Medicaid APG,3608.69,,,3608.69,Other,260% New York Medicaid APG,4496.98,,,4496.98,Other,324% New York Medicaid APG,2984.11,,,2984.11,Other,215% New York Medicaid APG,2984.11,,,2984.11,Other,215% New York Medicaid APG,1734.95,,,1734.95,Other,125% New York Medicaid APG,1387.96,91151.08,
Partial removal of pharynx,42890,CPT,,,,,,,,both,,,123177.14,91151.08,74,,91151.08,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,55429.71,45,,55429.71,percent of total billed charges,Medicare Ratio of cost to charges,5954,,"100% primary, 50% supplemental procedure",5954,Other,Aetna ASC Grouper,5359,,"100% primary, 50% supplemental procedure",5359,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,60972.68,49.5,,60972.68,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,4119.28,,,4119.28,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,86224,70,,86224,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,2214.67,,,2214.67,Other,New York Medicaid APG methodology,2214.67,,,2214.67,Other,100% New York Medicaid APG,2214.67,,,2214.67,Other,100% New York Medicaid APG,2214.67,,,2214.67,Other,100% New York Medicaid APG,4983,,,4983,Other,225% New York Medicaid APG,3388.44,,,3388.44,Other,153% New York Medicaid APG,4983,,,4983,Other,225% New York Medicaid APG,3100.53,,,3100.53,Other,140% New York Medicaid APG,4983,,,4983,Other,225% New York Medicaid APG,5758.13,,,5758.13,Other,260% New York Medicaid APG,7175.52,,,7175.52,Other,324% New York Medicaid APG,4761.53,,,4761.53,Other,215% New York Medicaid APG,4761.53,,,4761.53,Other,215% New York Medicaid APG,2768.33,,,2768.33,Other,125% New York Medicaid APG,2214.67,91151.08,
Revision of pharyngeal walls,42892,CPT,,,,,,,,both,,,123177.14,91151.08,74,,91151.08,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,55429.71,45,,55429.71,percent of total billed charges,Medicare Ratio of cost to charges,5954,,"100% primary, 50% supplemental procedure",5954,Other,Aetna ASC Grouper,5359,,"100% primary, 50% supplemental procedure",5359,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,60972.68,49.5,,60972.68,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,4119.28,,,4119.28,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,86224,70,,86224,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,2214.67,,,2214.67,Other,New York Medicaid APG methodology,2214.67,,,2214.67,Other,100% New York Medicaid APG,2214.67,,,2214.67,Other,100% New York Medicaid APG,2214.67,,,2214.67,Other,100% New York Medicaid APG,4983,,,4983,Other,225% New York Medicaid APG,3388.44,,,3388.44,Other,153% New York Medicaid APG,4983,,,4983,Other,225% New York Medicaid APG,3100.53,,,3100.53,Other,140% New York Medicaid APG,4983,,,4983,Other,225% New York Medicaid APG,5758.13,,,5758.13,Other,260% New York Medicaid APG,7175.52,,,7175.52,Other,324% New York Medicaid APG,4761.53,,,4761.53,Other,215% New York Medicaid APG,4761.53,,,4761.53,Other,215% New York Medicaid APG,2768.33,,,2768.33,Other,125% New York Medicaid APG,2214.67,91151.08,
Repair throat wound,42900,CPT,,,,,,,,both,,,32077.39,23737.27,74,,23737.27,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,14434.83,45,,14434.83,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,15878.31,49.5,,15878.31,percent of total billed charges,110% of Medicare,21812.63,68,,21812.63,percent of total billed charges,,2256.57,,,2256.57,Other,186% of Medicaid,25661.91,80,,25661.91,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,25661.91,80,,25661.91,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,22454.17,70,,22454.17,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1213.21,,,1213.21,Other,New York Medicaid APG methodology,1213.21,,,1213.21,Other,100% New York Medicaid APG,1213.21,,,1213.21,Other,100% New York Medicaid APG,1213.21,,,1213.21,Other,100% New York Medicaid APG,2729.72,,,2729.72,Other,225% New York Medicaid APG,1856.21,,,1856.21,Other,153% New York Medicaid APG,2729.72,,,2729.72,Other,225% New York Medicaid APG,1698.49,,,1698.49,Other,140% New York Medicaid APG,2729.72,,,2729.72,Other,225% New York Medicaid APG,3154.34,,,3154.34,Other,260% New York Medicaid APG,3930.79,,,3930.79,Other,324% New York Medicaid APG,2608.4,,,2608.4,Other,215% New York Medicaid APG,2608.4,,,2608.4,Other,215% New York Medicaid APG,1516.51,,,1516.51,Other,125% New York Medicaid APG,1213.21,25661.91,
Reconstruction of throat,42950,CPT,,,,,,,,both,,,35704.71,26421.49,74,,26421.49,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,16067.12,45,,16067.12,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,17673.83,49.5,,17673.83,percent of total billed charges,110% of Medicare,24279.2,68,,24279.2,percent of total billed charges,,4119.28,,,4119.28,Other,186% of Medicaid,28563.77,80,,28563.77,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,28563.77,80,,28563.77,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,24993.3,70,,24993.3,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,2214.67,,,2214.67,Other,New York Medicaid APG methodology,2214.67,,,2214.67,Other,100% New York Medicaid APG,2214.67,,,2214.67,Other,100% New York Medicaid APG,2214.67,,,2214.67,Other,100% New York Medicaid APG,4983,,,4983,Other,225% New York Medicaid APG,3388.44,,,3388.44,Other,153% New York Medicaid APG,4983,,,4983,Other,225% New York Medicaid APG,3100.53,,,3100.53,Other,140% New York Medicaid APG,4983,,,4983,Other,225% New York Medicaid APG,5758.13,,,5758.13,Other,260% New York Medicaid APG,7175.52,,,7175.52,Other,324% New York Medicaid APG,4761.53,,,4761.53,Other,215% New York Medicaid APG,4761.53,,,4761.53,Other,215% New York Medicaid APG,2768.33,,,2768.33,Other,125% New York Medicaid APG,2214.67,28563.77,
Surgical opening of throat,42955,CPT,,,,,,,,both,,,32077.39,23737.27,74,,23737.27,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,14434.83,45,,14434.83,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,15878.31,49.5,,15878.31,percent of total billed charges,110% of Medicare,21812.63,68,,21812.63,percent of total billed charges,,2256.57,,,2256.57,Other,186% of Medicaid,25661.91,80,,25661.91,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,25661.91,80,,25661.91,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,22454.17,70,,22454.17,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1213.21,,,1213.21,Other,New York Medicaid APG methodology,1213.21,,,1213.21,Other,100% New York Medicaid APG,1213.21,,,1213.21,Other,100% New York Medicaid APG,1213.21,,,1213.21,Other,100% New York Medicaid APG,2729.72,,,2729.72,Other,225% New York Medicaid APG,1856.21,,,1856.21,Other,153% New York Medicaid APG,2729.72,,,2729.72,Other,225% New York Medicaid APG,1698.49,,,1698.49,Other,140% New York Medicaid APG,2729.72,,,2729.72,Other,225% New York Medicaid APG,3154.34,,,3154.34,Other,260% New York Medicaid APG,3930.79,,,3930.79,Other,324% New York Medicaid APG,2608.4,,,2608.4,Other,215% New York Medicaid APG,2608.4,,,2608.4,Other,215% New York Medicaid APG,1516.51,,,1516.51,Other,125% New York Medicaid APG,1213.21,25661.91,
Control throat bleeding,42960,CPT,,,,,,,,both,,,11572.85,8563.91,74,,8563.91,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,5207.78,45,,5207.78,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,5728.56,49.5,,5728.56,percent of total billed charges,110% of Medicare,7869.54,68,,7869.54,percent of total billed charges,,2256.57,,,2256.57,Other,186% of Medicaid,9258.28,80,,9258.28,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,9258.28,80,,9258.28,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,8101,70,,8101,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,1213.21,,,1213.21,Other,New York Medicaid APG methodology,1213.21,,,1213.21,Other,100% New York Medicaid APG,1213.21,,,1213.21,Other,100% New York Medicaid APG,1213.21,,,1213.21,Other,100% New York Medicaid APG,2729.72,,,2729.72,Other,225% New York Medicaid APG,1856.21,,,1856.21,Other,153% New York Medicaid APG,2729.72,,,2729.72,Other,225% New York Medicaid APG,1698.49,,,1698.49,Other,140% New York Medicaid APG,2729.72,,,2729.72,Other,225% New York Medicaid APG,3154.34,,,3154.34,Other,260% New York Medicaid APG,3930.79,,,3930.79,Other,324% New York Medicaid APG,2608.4,,,2608.4,Other,215% New York Medicaid APG,2608.4,,,2608.4,Other,215% New York Medicaid APG,1516.51,,,1516.51,Other,125% New York Medicaid APG,1213.21,9258.28,
Control throat bleeding,42962,CPT,,,,,,,,both,,,67720.49,50113.16,74,,50113.16,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30474.22,45,,30474.22,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,33521.64,49.5,,33521.64,percent of total billed charges,110% of Medicare,46049.93,68,,46049.93,percent of total billed charges,,2256.57,,,2256.57,Other,186% of Medicaid,54176.39,80,,54176.39,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,54176.39,80,,54176.39,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,47404.34,70,,47404.34,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1213.21,,,1213.21,Other,New York Medicaid APG methodology,1213.21,,,1213.21,Other,100% New York Medicaid APG,1213.21,,,1213.21,Other,100% New York Medicaid APG,1213.21,,,1213.21,Other,100% New York Medicaid APG,2729.72,,,2729.72,Other,225% New York Medicaid APG,1856.21,,,1856.21,Other,153% New York Medicaid APG,2729.72,,,2729.72,Other,225% New York Medicaid APG,1698.49,,,1698.49,Other,140% New York Medicaid APG,2729.72,,,2729.72,Other,225% New York Medicaid APG,3154.34,,,3154.34,Other,260% New York Medicaid APG,3930.79,,,3930.79,Other,324% New York Medicaid APG,2608.4,,,2608.4,Other,215% New York Medicaid APG,2608.4,,,2608.4,Other,215% New York Medicaid APG,1516.51,,,1516.51,Other,125% New York Medicaid APG,1213.21,54176.39,
Control nose/throat bleeding,42970,CPT,,,,,,,,both,,,5137.73,3801.92,74,,3801.92,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,2311.98,45,,2311.98,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,2543.18,49.5,,2543.18,percent of total billed charges,110% of Medicare,3493.66,68,,3493.66,percent of total billed charges,,423.06,,,423.06,Other,186% of Medicaid,4110.18,80,,4110.18,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,4110.18,80,,4110.18,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,3596.41,70,,3596.41,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,227.45,,,227.45,Other,New York Medicaid APG methodology,227.45,,,227.45,Other,100% New York Medicaid APG,227.45,,,227.45,Other,100% New York Medicaid APG,227.45,,,227.45,Other,100% New York Medicaid APG,511.76,,,511.76,Other,225% New York Medicaid APG,348,,,348,Other,153% New York Medicaid APG,511.76,,,511.76,Other,225% New York Medicaid APG,318.43,,,318.43,Other,140% New York Medicaid APG,511.76,,,511.76,Other,225% New York Medicaid APG,591.37,,,591.37,Other,260% New York Medicaid APG,736.94,,,736.94,Other,324% New York Medicaid APG,489.02,,,489.02,Other,215% New York Medicaid APG,489.02,,,489.02,Other,215% New York Medicaid APG,284.31,,,284.31,Other,125% New York Medicaid APG,227.45,7216,
Control nose/throat bleeding,42972,CPT,,,,,,,,both,,,67720.49,50113.16,74,,50113.16,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30474.22,45,,30474.22,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,33521.64,49.5,,33521.64,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2256.57,,,2256.57,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,47404.34,70,,47404.34,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1213.21,,,1213.21,Other,New York Medicaid APG methodology,1213.21,,,1213.21,Other,100% New York Medicaid APG,1213.21,,,1213.21,Other,100% New York Medicaid APG,1213.21,,,1213.21,Other,100% New York Medicaid APG,2729.72,,,2729.72,Other,225% New York Medicaid APG,1856.21,,,1856.21,Other,153% New York Medicaid APG,2729.72,,,2729.72,Other,225% New York Medicaid APG,1698.49,,,1698.49,Other,140% New York Medicaid APG,2729.72,,,2729.72,Other,225% New York Medicaid APG,3154.34,,,3154.34,Other,260% New York Medicaid APG,3930.79,,,3930.79,Other,324% New York Medicaid APG,2608.4,,,2608.4,Other,215% New York Medicaid APG,2608.4,,,2608.4,Other,215% New York Medicaid APG,1516.51,,,1516.51,Other,125% New York Medicaid APG,1213.21,50113.16,
Incision of esophagus,43020,CPT,,,,,,,,both,,,32077.39,23737.27,74,,23737.27,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,14434.83,45,,14434.83,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,15878.31,49.5,,15878.31,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2256.57,,,2256.57,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,22454.17,70,,22454.17,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1213.21,,,1213.21,Other,New York Medicaid APG methodology,1213.21,,,1213.21,Other,100% New York Medicaid APG,1213.21,,,1213.21,Other,100% New York Medicaid APG,1213.21,,,1213.21,Other,100% New York Medicaid APG,2729.72,,,2729.72,Other,225% New York Medicaid APG,1856.21,,,1856.21,Other,153% New York Medicaid APG,2729.72,,,2729.72,Other,225% New York Medicaid APG,1698.49,,,1698.49,Other,140% New York Medicaid APG,2729.72,,,2729.72,Other,225% New York Medicaid APG,3154.34,,,3154.34,Other,260% New York Medicaid APG,3930.79,,,3930.79,Other,324% New York Medicaid APG,2608.4,,,2608.4,Other,215% New York Medicaid APG,2608.4,,,2608.4,Other,215% New York Medicaid APG,1516.51,,,1516.51,Other,125% New York Medicaid APG,1213.21,23737.27,
Throat muscle surgery,43030,CPT,,,,,,,,both,,,123177.14,91151.08,74,,91151.08,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,55429.71,45,,55429.71,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,60972.68,49.5,,60972.68,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,4119.28,,,4119.28,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,86224,70,,86224,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,2214.67,,,2214.67,Other,New York Medicaid APG methodology,2214.67,,,2214.67,Other,100% New York Medicaid APG,2214.67,,,2214.67,Other,100% New York Medicaid APG,2214.67,,,2214.67,Other,100% New York Medicaid APG,4983,,,4983,Other,225% New York Medicaid APG,3388.44,,,3388.44,Other,153% New York Medicaid APG,4983,,,4983,Other,225% New York Medicaid APG,3100.53,,,3100.53,Other,140% New York Medicaid APG,4983,,,4983,Other,225% New York Medicaid APG,5758.13,,,5758.13,Other,260% New York Medicaid APG,7175.52,,,7175.52,Other,324% New York Medicaid APG,4761.53,,,4761.53,Other,215% New York Medicaid APG,4761.53,,,4761.53,Other,215% New York Medicaid APG,2768.33,,,2768.33,Other,125% New York Medicaid APG,2214.67,91151.08,
Removal of esophagus pouch,43130,CPT,,,,,,,,both,,,35116.91,25986.51,74,,25986.51,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15802.61,45,,15802.61,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,17382.87,49.5,,17382.87,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,4162.5,,,4162.5,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,24581.84,70,,24581.84,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,2237.9,,,2237.9,Other,New York Medicaid APG methodology,2237.9,,,2237.9,Other,100% New York Medicaid APG,2237.9,,,2237.9,Other,100% New York Medicaid APG,2237.9,,,2237.9,Other,100% New York Medicaid APG,5035.28,,,5035.28,Other,225% New York Medicaid APG,3423.99,,,3423.99,Other,153% New York Medicaid APG,5035.28,,,5035.28,Other,225% New York Medicaid APG,3133.06,,,3133.06,Other,140% New York Medicaid APG,5035.28,,,5035.28,Other,225% New York Medicaid APG,5818.55,,,5818.55,Other,260% New York Medicaid APG,7250.81,,,7250.81,Other,324% New York Medicaid APG,4811.49,,,4811.49,Other,215% New York Medicaid APG,4811.49,,,4811.49,Other,215% New York Medicaid APG,2797.38,,,2797.38,Other,125% New York Medicaid APG,2237.9,25986.51,
Esophagoscopy rigid trnso,43180,CPT,,,,,,,,both,,,123177.14,91151.08,74,,91151.08,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,55429.71,45,,55429.71,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,60972.68,49.5,,60972.68,percent of total billed charges,110% of Medicare,83760.46,68,,83760.46,percent of total billed charges,,1813.82,,,1813.82,Other,186% of Medicaid,98541.71,80,,98541.71,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,98541.71,80,,98541.71,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,86224,70,,86224,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,975.17,,,975.17,Other,New York Medicaid APG methodology,975.17,,,975.17,Other,100% New York Medicaid APG,975.17,,,975.17,Other,100% New York Medicaid APG,975.17,,,975.17,Other,100% New York Medicaid APG,2194.14,,,2194.14,Other,225% New York Medicaid APG,1492.01,,,1492.01,Other,153% New York Medicaid APG,2194.14,,,2194.14,Other,225% New York Medicaid APG,1365.24,,,1365.24,Other,140% New York Medicaid APG,2194.14,,,2194.14,Other,225% New York Medicaid APG,2535.45,,,2535.45,Other,260% New York Medicaid APG,3159.56,,,3159.56,Other,324% New York Medicaid APG,2096.62,,,2096.62,Other,215% New York Medicaid APG,2096.62,,,2096.62,Other,215% New York Medicaid APG,1218.96,,,1218.96,Other,125% New York Medicaid APG,975.17,98541.71,
Esophagoscopy rigid trnso dx,43191,CPT,,,,,,,,both,,,40023.39,29617.31,74,,29617.31,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,18010.53,45,,18010.53,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,19811.58,49.5,,19811.58,percent of total billed charges,110% of Medicare,27215.91,68,,27215.91,percent of total billed charges,,1721.88,,,1721.88,Other,186% of Medicaid,32018.71,80,,32018.71,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,32018.71,80,,32018.71,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,28016.37,70,,28016.37,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,925.74,,,925.74,Other,New York Medicaid APG methodology,925.74,,,925.74,Other,100% New York Medicaid APG,925.74,,,925.74,Other,100% New York Medicaid APG,925.74,,,925.74,Other,100% New York Medicaid APG,2082.92,,,2082.92,Other,225% New York Medicaid APG,1416.38,,,1416.38,Other,153% New York Medicaid APG,2082.92,,,2082.92,Other,225% New York Medicaid APG,1296.04,,,1296.04,Other,140% New York Medicaid APG,2082.92,,,2082.92,Other,225% New York Medicaid APG,2406.92,,,2406.92,Other,260% New York Medicaid APG,2999.4,,,2999.4,Other,324% New York Medicaid APG,1990.34,,,1990.34,Other,215% New York Medicaid APG,1990.34,,,1990.34,Other,215% New York Medicaid APG,1157.18,,,1157.18,Other,125% New York Medicaid APG,925.74,32018.71,
Esophagoscp rig trnso inject,43192,CPT,,,,,,,,both,,,34010.82,25168.01,74,,25168.01,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15304.87,45,,15304.87,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,16835.36,49.5,,16835.36,percent of total billed charges,110% of Medicare,23127.36,68,,23127.36,percent of total billed charges,,1721.88,,,1721.88,Other,186% of Medicaid,27208.66,80,,27208.66,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,27208.66,80,,27208.66,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,23807.57,70,,23807.57,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,925.74,,,925.74,Other,New York Medicaid APG methodology,925.74,,,925.74,Other,100% New York Medicaid APG,925.74,,,925.74,Other,100% New York Medicaid APG,925.74,,,925.74,Other,100% New York Medicaid APG,2082.92,,,2082.92,Other,225% New York Medicaid APG,1416.38,,,1416.38,Other,153% New York Medicaid APG,2082.92,,,2082.92,Other,225% New York Medicaid APG,1296.04,,,1296.04,Other,140% New York Medicaid APG,2082.92,,,2082.92,Other,225% New York Medicaid APG,2406.92,,,2406.92,Other,260% New York Medicaid APG,2999.4,,,2999.4,Other,324% New York Medicaid APG,1990.34,,,1990.34,Other,215% New York Medicaid APG,1990.34,,,1990.34,Other,215% New York Medicaid APG,1157.18,,,1157.18,Other,125% New York Medicaid APG,925.74,27208.66,
Esophagoscp rig trnso biopsy,43193,CPT,,,,,,,,both,,,40023.39,29617.31,74,,29617.31,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,18010.53,45,,18010.53,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,19811.58,49.5,,19811.58,percent of total billed charges,110% of Medicare,27215.91,68,,27215.91,percent of total billed charges,,1721.88,,,1721.88,Other,186% of Medicaid,32018.71,80,,32018.71,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,32018.71,80,,32018.71,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,28016.37,70,,28016.37,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,925.74,,,925.74,Other,New York Medicaid APG methodology,925.74,,,925.74,Other,100% New York Medicaid APG,925.74,,,925.74,Other,100% New York Medicaid APG,925.74,,,925.74,Other,100% New York Medicaid APG,2082.92,,,2082.92,Other,225% New York Medicaid APG,1416.38,,,1416.38,Other,153% New York Medicaid APG,2082.92,,,2082.92,Other,225% New York Medicaid APG,1296.04,,,1296.04,Other,140% New York Medicaid APG,2082.92,,,2082.92,Other,225% New York Medicaid APG,2406.92,,,2406.92,Other,260% New York Medicaid APG,2999.4,,,2999.4,Other,324% New York Medicaid APG,1990.34,,,1990.34,Other,215% New York Medicaid APG,1990.34,,,1990.34,Other,215% New York Medicaid APG,1157.18,,,1157.18,Other,125% New York Medicaid APG,925.74,32018.71,
Esophagoscp rig trnso rem fb,43194,CPT,,,,,,,,both,,,40023.39,29617.31,74,,29617.31,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,18010.53,45,,18010.53,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,19811.58,49.5,,19811.58,percent of total billed charges,110% of Medicare,27215.91,68,,27215.91,percent of total billed charges,,1721.88,,,1721.88,Other,186% of Medicaid,32018.71,80,,32018.71,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,32018.71,80,,32018.71,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,28016.37,70,,28016.37,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,925.74,,,925.74,Other,New York Medicaid APG methodology,925.74,,,925.74,Other,100% New York Medicaid APG,925.74,,,925.74,Other,100% New York Medicaid APG,925.74,,,925.74,Other,100% New York Medicaid APG,2082.92,,,2082.92,Other,225% New York Medicaid APG,1416.38,,,1416.38,Other,153% New York Medicaid APG,2082.92,,,2082.92,Other,225% New York Medicaid APG,1296.04,,,1296.04,Other,140% New York Medicaid APG,2082.92,,,2082.92,Other,225% New York Medicaid APG,2406.92,,,2406.92,Other,260% New York Medicaid APG,2999.4,,,2999.4,Other,324% New York Medicaid APG,1990.34,,,1990.34,Other,215% New York Medicaid APG,1990.34,,,1990.34,Other,215% New York Medicaid APG,1157.18,,,1157.18,Other,125% New York Medicaid APG,925.74,32018.71,
Esophagoscopy rigid balloon,43195,CPT,,,,,,,,both,,,37422.98,27693.01,74,,27693.01,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,16840.34,45,,16840.34,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,18524.38,49.5,,18524.38,percent of total billed charges,110% of Medicare,25447.63,68,,25447.63,percent of total billed charges,,1813.82,,,1813.82,Other,186% of Medicaid,29938.38,80,,29938.38,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,29938.38,80,,29938.38,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,26196.09,70,,26196.09,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,975.17,,,975.17,Other,New York Medicaid APG methodology,975.17,,,975.17,Other,100% New York Medicaid APG,975.17,,,975.17,Other,100% New York Medicaid APG,975.17,,,975.17,Other,100% New York Medicaid APG,2194.14,,,2194.14,Other,225% New York Medicaid APG,1492.01,,,1492.01,Other,153% New York Medicaid APG,2194.14,,,2194.14,Other,225% New York Medicaid APG,1365.24,,,1365.24,Other,140% New York Medicaid APG,2194.14,,,2194.14,Other,225% New York Medicaid APG,2535.45,,,2535.45,Other,260% New York Medicaid APG,3159.56,,,3159.56,Other,324% New York Medicaid APG,2096.62,,,2096.62,Other,215% New York Medicaid APG,2096.62,,,2096.62,Other,215% New York Medicaid APG,1218.96,,,1218.96,Other,125% New York Medicaid APG,975.17,29938.38,
Esophagoscp guide wire dilat,43196,CPT,,,,,,,,both,,,40023.39,29617.31,74,,29617.31,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,18010.53,45,,18010.53,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,19811.58,49.5,,19811.58,percent of total billed charges,110% of Medicare,27215.91,68,,27215.91,percent of total billed charges,,1721.88,,,1721.88,Other,186% of Medicaid,32018.71,80,,32018.71,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,32018.71,80,,32018.71,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,28016.37,70,,28016.37,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,925.74,,,925.74,Other,New York Medicaid APG methodology,925.74,,,925.74,Other,100% New York Medicaid APG,925.74,,,925.74,Other,100% New York Medicaid APG,925.74,,,925.74,Other,100% New York Medicaid APG,2082.92,,,2082.92,Other,225% New York Medicaid APG,1416.38,,,1416.38,Other,153% New York Medicaid APG,2082.92,,,2082.92,Other,225% New York Medicaid APG,1296.04,,,1296.04,Other,140% New York Medicaid APG,2082.92,,,2082.92,Other,225% New York Medicaid APG,2406.92,,,2406.92,Other,260% New York Medicaid APG,2999.4,,,2999.4,Other,324% New York Medicaid APG,1990.34,,,1990.34,Other,215% New York Medicaid APG,1990.34,,,1990.34,Other,215% New York Medicaid APG,1157.18,,,1157.18,Other,125% New York Medicaid APG,925.74,32018.71,
Esophagoscopy flex dx brush,43197,CPT,,,,,,,,both,,,19066.74,14109.39,74,,14109.39,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,8580.03,45,,8580.03,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,9438.04,49.5,,9438.04,percent of total billed charges,110% of Medicare,12965.38,68,,12965.38,percent of total billed charges,,1530.86,,,1530.86,Other,186% of Medicaid,15253.39,80,,15253.39,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,15253.39,80,,15253.39,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,13346.72,70,,13346.72,percent of total billed charges,,398.52,,,398.52,Fee Schedule,,337.77,,,337.77,Fee Schedule,,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,823.04,,,823.04,Other,New York Medicaid APG methodology,823.04,,,823.04,Other,100% New York Medicaid APG,823.04,,,823.04,Other,100% New York Medicaid APG,823.04,,,823.04,Other,100% New York Medicaid APG,1851.85,,,1851.85,Other,225% New York Medicaid APG,1259.26,,,1259.26,Other,153% New York Medicaid APG,1851.85,,,1851.85,Other,225% New York Medicaid APG,1152.26,,,1152.26,Other,140% New York Medicaid APG,1851.85,,,1851.85,Other,225% New York Medicaid APG,2139.92,,,2139.92,Other,260% New York Medicaid APG,2666.66,,,2666.66,Other,324% New York Medicaid APG,1769.55,,,1769.55,Other,215% New York Medicaid APG,1769.55,,,1769.55,Other,215% New York Medicaid APG,1028.81,,,1028.81,Other,125% New York Medicaid APG,337.77,15253.39,
Esophagosc flex trnsn biopsy,43198,CPT,,,,,,,,both,,,19066.74,14109.39,74,,14109.39,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,8580.03,45,,8580.03,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,9438.04,49.5,,9438.04,percent of total billed charges,110% of Medicare,12965.38,68,,12965.38,percent of total billed charges,,1530.86,,,1530.86,Other,186% of Medicaid,15253.39,80,,15253.39,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,15253.39,80,,15253.39,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,13346.72,70,,13346.72,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,823.04,,,823.04,Other,New York Medicaid APG methodology,823.04,,,823.04,Other,100% New York Medicaid APG,823.04,,,823.04,Other,100% New York Medicaid APG,823.04,,,823.04,Other,100% New York Medicaid APG,1851.85,,,1851.85,Other,225% New York Medicaid APG,1259.26,,,1259.26,Other,153% New York Medicaid APG,1851.85,,,1851.85,Other,225% New York Medicaid APG,1152.26,,,1152.26,Other,140% New York Medicaid APG,1851.85,,,1851.85,Other,225% New York Medicaid APG,2139.92,,,2139.92,Other,260% New York Medicaid APG,2666.66,,,2666.66,Other,324% New York Medicaid APG,1769.55,,,1769.55,Other,215% New York Medicaid APG,1769.55,,,1769.55,Other,215% New York Medicaid APG,1028.81,,,1028.81,Other,125% New York Medicaid APG,823.04,15253.39,
Esophagoscopy flexible brush,43200,CPT,,,,,,,,both,,,19066.74,14109.39,74,,14109.39,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,8580.03,45,,8580.03,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,9438.04,49.5,,9438.04,percent of total billed charges,110% of Medicare,12965.38,68,,12965.38,percent of total billed charges,,1530.86,,,1530.86,Other,186% of Medicaid,15253.39,80,,15253.39,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,15253.39,80,,15253.39,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,13346.72,70,,13346.72,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,823.04,,,823.04,Other,New York Medicaid APG methodology,823.04,,,823.04,Other,100% New York Medicaid APG,823.04,,,823.04,Other,100% New York Medicaid APG,823.04,,,823.04,Other,100% New York Medicaid APG,1851.85,,,1851.85,Other,225% New York Medicaid APG,1259.26,,,1259.26,Other,153% New York Medicaid APG,1851.85,,,1851.85,Other,225% New York Medicaid APG,1152.26,,,1152.26,Other,140% New York Medicaid APG,1851.85,,,1851.85,Other,225% New York Medicaid APG,2139.92,,,2139.92,Other,260% New York Medicaid APG,2666.66,,,2666.66,Other,324% New York Medicaid APG,1769.55,,,1769.55,Other,215% New York Medicaid APG,1769.55,,,1769.55,Other,215% New York Medicaid APG,1028.81,,,1028.81,Other,125% New York Medicaid APG,823.04,15253.39,
Esoph scope w/submucous inj,43201,CPT,,,,,,,,both,,,40023.39,29617.31,74,,29617.31,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,18010.53,45,,18010.53,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,19811.58,49.5,,19811.58,percent of total billed charges,110% of Medicare,27215.91,68,,27215.91,percent of total billed charges,,1530.86,,,1530.86,Other,186% of Medicaid,32018.71,80,,32018.71,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,32018.71,80,,32018.71,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,28016.37,70,,28016.37,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,823.04,,,823.04,Other,New York Medicaid APG methodology,823.04,,,823.04,Other,100% New York Medicaid APG,823.04,,,823.04,Other,100% New York Medicaid APG,823.04,,,823.04,Other,100% New York Medicaid APG,1851.85,,,1851.85,Other,225% New York Medicaid APG,1259.26,,,1259.26,Other,153% New York Medicaid APG,1851.85,,,1851.85,Other,225% New York Medicaid APG,1152.26,,,1152.26,Other,140% New York Medicaid APG,1851.85,,,1851.85,Other,225% New York Medicaid APG,2139.92,,,2139.92,Other,260% New York Medicaid APG,2666.66,,,2666.66,Other,324% New York Medicaid APG,1769.55,,,1769.55,Other,215% New York Medicaid APG,1769.55,,,1769.55,Other,215% New York Medicaid APG,1028.81,,,1028.81,Other,125% New York Medicaid APG,823.04,32018.71,
Esophagoscopy flex biopsy,43202,CPT,,,,,,,,both,,,37898,28044.52,74,,28044.52,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,17054.1,45,,17054.1,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,18759.51,49.5,,18759.51,percent of total billed charges,110% of Medicare,25770.64,68,,25770.64,percent of total billed charges,,1530.86,,,1530.86,Other,186% of Medicaid,30318.4,80,,30318.4,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,30318.4,80,,30318.4,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,26528.6,70,,26528.6,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,823.04,,,823.04,Other,New York Medicaid APG methodology,823.04,,,823.04,Other,100% New York Medicaid APG,823.04,,,823.04,Other,100% New York Medicaid APG,823.04,,,823.04,Other,100% New York Medicaid APG,1851.85,,,1851.85,Other,225% New York Medicaid APG,1259.26,,,1259.26,Other,153% New York Medicaid APG,1851.85,,,1851.85,Other,225% New York Medicaid APG,1152.26,,,1152.26,Other,140% New York Medicaid APG,1851.85,,,1851.85,Other,225% New York Medicaid APG,2139.92,,,2139.92,Other,260% New York Medicaid APG,2666.66,,,2666.66,Other,324% New York Medicaid APG,1769.55,,,1769.55,Other,215% New York Medicaid APG,1769.55,,,1769.55,Other,215% New York Medicaid APG,1028.81,,,1028.81,Other,125% New York Medicaid APG,823.04,30318.4,
Esoph scope w/sclerosis inj,43204,CPT,,,,,,,,both,,,40023.39,29617.31,74,,29617.31,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,18010.53,45,,18010.53,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,19811.58,49.5,,19811.58,percent of total billed charges,110% of Medicare,27215.91,68,,27215.91,percent of total billed charges,,1530.86,,,1530.86,Other,186% of Medicaid,32018.71,80,,32018.71,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,32018.71,80,,32018.71,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,28016.37,70,,28016.37,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,823.04,,,823.04,Other,New York Medicaid APG methodology,823.04,,,823.04,Other,100% New York Medicaid APG,823.04,,,823.04,Other,100% New York Medicaid APG,823.04,,,823.04,Other,100% New York Medicaid APG,1851.85,,,1851.85,Other,225% New York Medicaid APG,1259.26,,,1259.26,Other,153% New York Medicaid APG,1851.85,,,1851.85,Other,225% New York Medicaid APG,1152.26,,,1152.26,Other,140% New York Medicaid APG,1851.85,,,1851.85,Other,225% New York Medicaid APG,2139.92,,,2139.92,Other,260% New York Medicaid APG,2666.66,,,2666.66,Other,324% New York Medicaid APG,1769.55,,,1769.55,Other,215% New York Medicaid APG,1769.55,,,1769.55,Other,215% New York Medicaid APG,1028.81,,,1028.81,Other,125% New York Medicaid APG,823.04,32018.71,
Esophagus endoscopy/ligation,43205,CPT,,,,,,,,both,,,40023.39,29617.31,74,,29617.31,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,18010.53,45,,18010.53,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,19811.58,49.5,,19811.58,percent of total billed charges,110% of Medicare,27215.91,68,,27215.91,percent of total billed charges,,1530.86,,,1530.86,Other,186% of Medicaid,32018.71,80,,32018.71,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,32018.71,80,,32018.71,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,28016.37,70,,28016.37,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,823.04,,,823.04,Other,New York Medicaid APG methodology,823.04,,,823.04,Other,100% New York Medicaid APG,823.04,,,823.04,Other,100% New York Medicaid APG,823.04,,,823.04,Other,100% New York Medicaid APG,1851.85,,,1851.85,Other,225% New York Medicaid APG,1259.26,,,1259.26,Other,153% New York Medicaid APG,1851.85,,,1851.85,Other,225% New York Medicaid APG,1152.26,,,1152.26,Other,140% New York Medicaid APG,1851.85,,,1851.85,Other,225% New York Medicaid APG,2139.92,,,2139.92,Other,260% New York Medicaid APG,2666.66,,,2666.66,Other,324% New York Medicaid APG,1769.55,,,1769.55,Other,215% New York Medicaid APG,1769.55,,,1769.55,Other,215% New York Medicaid APG,1028.81,,,1028.81,Other,125% New York Medicaid APG,823.04,32018.71,
Esoph optical endomicroscopy,43206,CPT,,,,,,,,both,,,40023.39,29617.31,74,,29617.31,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,18010.53,45,,18010.53,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,19811.58,49.5,,19811.58,percent of total billed charges,110% of Medicare,27215.91,68,,27215.91,percent of total billed charges,,1721.88,,,1721.88,Other,186% of Medicaid,32018.71,80,,32018.71,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,32018.71,80,,32018.71,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,28016.37,70,,28016.37,percent of total billed charges,,639.6,,,639.6,Fee Schedule,,542.1,,,542.1,Fee Schedule,,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,925.74,,,925.74,Other,New York Medicaid APG methodology,925.74,,,925.74,Other,100% New York Medicaid APG,925.74,,,925.74,Other,100% New York Medicaid APG,925.74,,,925.74,Other,100% New York Medicaid APG,2082.92,,,2082.92,Other,225% New York Medicaid APG,1416.38,,,1416.38,Other,153% New York Medicaid APG,2082.92,,,2082.92,Other,225% New York Medicaid APG,1296.04,,,1296.04,Other,140% New York Medicaid APG,2082.92,,,2082.92,Other,225% New York Medicaid APG,2406.92,,,2406.92,Other,260% New York Medicaid APG,2999.4,,,2999.4,Other,324% New York Medicaid APG,1990.34,,,1990.34,Other,215% New York Medicaid APG,1990.34,,,1990.34,Other,215% New York Medicaid APG,1157.18,,,1157.18,Other,125% New York Medicaid APG,542.1,32018.71,
Egd esophagogastrc fndoplsty,43210,CPT,,,,,,,,both,,,216515.17,160221.23,74,,160221.23,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,97431.83,45,,97431.83,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,107175.01,49.5,,107175.01,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,1813.82,,,1813.82,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,151560.62,70,,151560.62,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,975.17,,,975.17,Other,New York Medicaid APG methodology,975.17,,,975.17,Other,100% New York Medicaid APG,975.17,,,975.17,Other,100% New York Medicaid APG,975.17,,,975.17,Other,100% New York Medicaid APG,2194.14,,,2194.14,Other,225% New York Medicaid APG,1492.01,,,1492.01,Other,153% New York Medicaid APG,2194.14,,,2194.14,Other,225% New York Medicaid APG,1365.24,,,1365.24,Other,140% New York Medicaid APG,2194.14,,,2194.14,Other,225% New York Medicaid APG,2535.45,,,2535.45,Other,260% New York Medicaid APG,3159.56,,,3159.56,Other,324% New York Medicaid APG,2096.62,,,2096.62,Other,215% New York Medicaid APG,2096.62,,,2096.62,Other,215% New York Medicaid APG,1218.96,,,1218.96,Other,125% New York Medicaid APG,975.17,160221.23,
Esophagoscop mucosal resect,43211,CPT,,,,,,,,both,,,40023.39,29617.31,74,,29617.31,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,18010.53,45,,18010.53,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,19811.58,49.5,,19811.58,percent of total billed charges,110% of Medicare,27215.91,68,,27215.91,percent of total billed charges,,1530.86,,,1530.86,Other,186% of Medicaid,32018.71,80,,32018.71,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,32018.71,80,,32018.71,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,28016.37,70,,28016.37,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,823.04,,,823.04,Other,New York Medicaid APG methodology,823.04,,,823.04,Other,100% New York Medicaid APG,823.04,,,823.04,Other,100% New York Medicaid APG,823.04,,,823.04,Other,100% New York Medicaid APG,1851.85,,,1851.85,Other,225% New York Medicaid APG,1259.26,,,1259.26,Other,153% New York Medicaid APG,1851.85,,,1851.85,Other,225% New York Medicaid APG,1152.26,,,1152.26,Other,140% New York Medicaid APG,1851.85,,,1851.85,Other,225% New York Medicaid APG,2139.92,,,2139.92,Other,260% New York Medicaid APG,2666.66,,,2666.66,Other,324% New York Medicaid APG,1769.55,,,1769.55,Other,215% New York Medicaid APG,1769.55,,,1769.55,Other,215% New York Medicaid APG,1028.81,,,1028.81,Other,125% New York Medicaid APG,823.04,32018.71,
Esophagoscop stent placement,43212,CPT,,,,,,,,both,,,119876.35,88708.5,74,,88708.5,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,53944.36,45,,53944.36,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,59338.79,49.5,,59338.79,percent of total billed charges,110% of Medicare,81515.92,68,,81515.92,percent of total billed charges,,1813.82,,,1813.82,Other,186% of Medicaid,95901.08,80,,95901.08,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,95901.08,80,,95901.08,percent of total billed charges,,7216,,,7216,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,83913.45,70,,83913.45,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,975.17,,,975.17,Other,New York Medicaid APG methodology,975.17,,,975.17,Other,100% New York Medicaid APG,975.17,,,975.17,Other,100% New York Medicaid APG,975.17,,,975.17,Other,100% New York Medicaid APG,2194.14,,,2194.14,Other,225% New York Medicaid APG,1492.01,,,1492.01,Other,153% New York Medicaid APG,2194.14,,,2194.14,Other,225% New York Medicaid APG,1365.24,,,1365.24,Other,140% New York Medicaid APG,2194.14,,,2194.14,Other,225% New York Medicaid APG,2535.45,,,2535.45,Other,260% New York Medicaid APG,3159.56,,,3159.56,Other,324% New York Medicaid APG,2096.62,,,2096.62,Other,215% New York Medicaid APG,2096.62,,,2096.62,Other,215% New York Medicaid APG,1218.96,,,1218.96,Other,125% New York Medicaid APG,975.17,95901.08,
Esophagoscopy retro balloon,43213,CPT,,,,,,,,both,,,40023.39,29617.31,74,,29617.31,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,18010.53,45,,18010.53,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,19811.58,49.5,,19811.58,percent of total billed charges,110% of Medicare,27215.91,68,,27215.91,percent of total billed charges,,1530.86,,,1530.86,Other,186% of Medicaid,32018.71,80,,32018.71,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,32018.71,80,,32018.71,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,28016.37,70,,28016.37,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,823.04,,,823.04,Other,New York Medicaid APG methodology,823.04,,,823.04,Other,100% New York Medicaid APG,823.04,,,823.04,Other,100% New York Medicaid APG,823.04,,,823.04,Other,100% New York Medicaid APG,1851.85,,,1851.85,Other,225% New York Medicaid APG,1259.26,,,1259.26,Other,153% New York Medicaid APG,1851.85,,,1851.85,Other,225% New York Medicaid APG,1152.26,,,1152.26,Other,140% New York Medicaid APG,1851.85,,,1851.85,Other,225% New York Medicaid APG,2139.92,,,2139.92,Other,260% New York Medicaid APG,2666.66,,,2666.66,Other,324% New York Medicaid APG,1769.55,,,1769.55,Other,215% New York Medicaid APG,1769.55,,,1769.55,Other,215% New York Medicaid APG,1028.81,,,1028.81,Other,125% New York Medicaid APG,823.04,32018.71,
Esophagosc dilate balloon 30,43214,CPT,,,,,,,,both,,,40023.39,29617.31,74,,29617.31,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,18010.53,45,,18010.53,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,19811.58,49.5,,19811.58,percent of total billed charges,110% of Medicare,27215.91,68,,27215.91,percent of total billed charges,,1721.88,,,1721.88,Other,186% of Medicaid,32018.71,80,,32018.71,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,32018.71,80,,32018.71,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,28016.37,70,,28016.37,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,925.74,,,925.74,Other,New York Medicaid APG methodology,925.74,,,925.74,Other,100% New York Medicaid APG,925.74,,,925.74,Other,100% New York Medicaid APG,925.74,,,925.74,Other,100% New York Medicaid APG,2082.92,,,2082.92,Other,225% New York Medicaid APG,1416.38,,,1416.38,Other,153% New York Medicaid APG,2082.92,,,2082.92,Other,225% New York Medicaid APG,1296.04,,,1296.04,Other,140% New York Medicaid APG,2082.92,,,2082.92,Other,225% New York Medicaid APG,2406.92,,,2406.92,Other,260% New York Medicaid APG,2999.4,,,2999.4,Other,324% New York Medicaid APG,1990.34,,,1990.34,Other,215% New York Medicaid APG,1990.34,,,1990.34,Other,215% New York Medicaid APG,1157.18,,,1157.18,Other,125% New York Medicaid APG,925.74,32018.71,
Esophagoscopy flex remove fb,43215,CPT,,,,,,,,both,,,40023.39,29617.31,74,,29617.31,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,18010.53,45,,18010.53,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,19811.58,49.5,,19811.58,percent of total billed charges,110% of Medicare,27215.91,68,,27215.91,percent of total billed charges,,1530.86,,,1530.86,Other,186% of Medicaid,32018.71,80,,32018.71,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,32018.71,80,,32018.71,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,28016.37,70,,28016.37,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,823.04,,,823.04,Other,New York Medicaid APG methodology,823.04,,,823.04,Other,100% New York Medicaid APG,823.04,,,823.04,Other,100% New York Medicaid APG,823.04,,,823.04,Other,100% New York Medicaid APG,1851.85,,,1851.85,Other,225% New York Medicaid APG,1259.26,,,1259.26,Other,153% New York Medicaid APG,1851.85,,,1851.85,Other,225% New York Medicaid APG,1152.26,,,1152.26,Other,140% New York Medicaid APG,1851.85,,,1851.85,Other,225% New York Medicaid APG,2139.92,,,2139.92,Other,260% New York Medicaid APG,2666.66,,,2666.66,Other,324% New York Medicaid APG,1769.55,,,1769.55,Other,215% New York Medicaid APG,1769.55,,,1769.55,Other,215% New York Medicaid APG,1028.81,,,1028.81,Other,125% New York Medicaid APG,823.04,32018.71,
Esophagoscopy lesion removal,43216,CPT,,,,,,,,both,,,40023.39,29617.31,74,,29617.31,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,18010.53,45,,18010.53,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,19811.58,49.5,,19811.58,percent of total billed charges,110% of Medicare,27215.91,68,,27215.91,percent of total billed charges,,1530.86,,,1530.86,Other,186% of Medicaid,32018.71,80,,32018.71,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,32018.71,80,,32018.71,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,28016.37,70,,28016.37,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,823.04,,,823.04,Other,New York Medicaid APG methodology,823.04,,,823.04,Other,100% New York Medicaid APG,823.04,,,823.04,Other,100% New York Medicaid APG,823.04,,,823.04,Other,100% New York Medicaid APG,1851.85,,,1851.85,Other,225% New York Medicaid APG,1259.26,,,1259.26,Other,153% New York Medicaid APG,1851.85,,,1851.85,Other,225% New York Medicaid APG,1152.26,,,1152.26,Other,140% New York Medicaid APG,1851.85,,,1851.85,Other,225% New York Medicaid APG,2139.92,,,2139.92,Other,260% New York Medicaid APG,2666.66,,,2666.66,Other,324% New York Medicaid APG,1769.55,,,1769.55,Other,215% New York Medicaid APG,1769.55,,,1769.55,Other,215% New York Medicaid APG,1028.81,,,1028.81,Other,125% New York Medicaid APG,823.04,32018.71,
Esophagoscopy snare les remv,43217,CPT,,,,,,,,both,,,40023.39,29617.31,74,,29617.31,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,18010.53,45,,18010.53,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,19811.58,49.5,,19811.58,percent of total billed charges,110% of Medicare,27215.91,68,,27215.91,percent of total billed charges,,1530.86,,,1530.86,Other,186% of Medicaid,32018.71,80,,32018.71,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,32018.71,80,,32018.71,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,28016.37,70,,28016.37,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,823.04,,,823.04,Other,New York Medicaid APG methodology,823.04,,,823.04,Other,100% New York Medicaid APG,823.04,,,823.04,Other,100% New York Medicaid APG,823.04,,,823.04,Other,100% New York Medicaid APG,1851.85,,,1851.85,Other,225% New York Medicaid APG,1259.26,,,1259.26,Other,153% New York Medicaid APG,1851.85,,,1851.85,Other,225% New York Medicaid APG,1152.26,,,1152.26,Other,140% New York Medicaid APG,1851.85,,,1851.85,Other,225% New York Medicaid APG,2139.92,,,2139.92,Other,260% New York Medicaid APG,2666.66,,,2666.66,Other,324% New York Medicaid APG,1769.55,,,1769.55,Other,215% New York Medicaid APG,1769.55,,,1769.55,Other,215% New York Medicaid APG,1028.81,,,1028.81,Other,125% New York Medicaid APG,823.04,32018.71,
Esophagoscopy balloon <30mm,43220,CPT,,,,,,,,both,,,31351.03,23199.76,74,,23199.76,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,14107.96,45,,14107.96,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,15518.76,49.5,,15518.76,percent of total billed charges,110% of Medicare,21318.7,68,,21318.7,percent of total billed charges,,1530.86,,,1530.86,Other,186% of Medicaid,25080.82,80,,25080.82,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,25080.82,80,,25080.82,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,21945.72,70,,21945.72,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,823.04,,,823.04,Other,New York Medicaid APG methodology,823.04,,,823.04,Other,100% New York Medicaid APG,823.04,,,823.04,Other,100% New York Medicaid APG,823.04,,,823.04,Other,100% New York Medicaid APG,1851.85,,,1851.85,Other,225% New York Medicaid APG,1259.26,,,1259.26,Other,153% New York Medicaid APG,1851.85,,,1851.85,Other,225% New York Medicaid APG,1152.26,,,1152.26,Other,140% New York Medicaid APG,1851.85,,,1851.85,Other,225% New York Medicaid APG,2139.92,,,2139.92,Other,260% New York Medicaid APG,2666.66,,,2666.66,Other,324% New York Medicaid APG,1769.55,,,1769.55,Other,215% New York Medicaid APG,1769.55,,,1769.55,Other,215% New York Medicaid APG,1028.81,,,1028.81,Other,125% New York Medicaid APG,823.04,25080.82,
Esoph endoscopy dilation,43226,CPT,,,,,,,,both,,,36025,26658.5,74,,26658.5,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,16211.25,45,,16211.25,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,17832.38,49.5,,17832.38,percent of total billed charges,110% of Medicare,24497,68,,24497,percent of total billed charges,,1530.86,,,1530.86,Other,186% of Medicaid,28820,80,,28820,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,28820,80,,28820,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,25217.5,70,,25217.5,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,823.04,,,823.04,Other,New York Medicaid APG methodology,823.04,,,823.04,Other,100% New York Medicaid APG,823.04,,,823.04,Other,100% New York Medicaid APG,823.04,,,823.04,Other,100% New York Medicaid APG,1851.85,,,1851.85,Other,225% New York Medicaid APG,1259.26,,,1259.26,Other,153% New York Medicaid APG,1851.85,,,1851.85,Other,225% New York Medicaid APG,1152.26,,,1152.26,Other,140% New York Medicaid APG,1851.85,,,1851.85,Other,225% New York Medicaid APG,2139.92,,,2139.92,Other,260% New York Medicaid APG,2666.66,,,2666.66,Other,324% New York Medicaid APG,1769.55,,,1769.55,Other,215% New York Medicaid APG,1769.55,,,1769.55,Other,215% New York Medicaid APG,1028.81,,,1028.81,Other,125% New York Medicaid APG,823.04,28820,
Esophagoscopy control bleed,43227,CPT,,,,,,,,both,,,40023.39,29617.31,74,,29617.31,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,18010.53,45,,18010.53,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,19811.58,49.5,,19811.58,percent of total billed charges,110% of Medicare,27215.91,68,,27215.91,percent of total billed charges,,1530.86,,,1530.86,Other,186% of Medicaid,32018.71,80,,32018.71,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,32018.71,80,,32018.71,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,28016.37,70,,28016.37,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,823.04,,,823.04,Other,New York Medicaid APG methodology,823.04,,,823.04,Other,100% New York Medicaid APG,823.04,,,823.04,Other,100% New York Medicaid APG,823.04,,,823.04,Other,100% New York Medicaid APG,1851.85,,,1851.85,Other,225% New York Medicaid APG,1259.26,,,1259.26,Other,153% New York Medicaid APG,1851.85,,,1851.85,Other,225% New York Medicaid APG,1152.26,,,1152.26,Other,140% New York Medicaid APG,1851.85,,,1851.85,Other,225% New York Medicaid APG,2139.92,,,2139.92,Other,260% New York Medicaid APG,2666.66,,,2666.66,Other,324% New York Medicaid APG,1769.55,,,1769.55,Other,215% New York Medicaid APG,1769.55,,,1769.55,Other,215% New York Medicaid APG,1028.81,,,1028.81,Other,125% New York Medicaid APG,823.04,32018.71,
Esophagoscopy lesion ablate,43229,CPT,,,,,,,,both,,,80554.09,59610.03,74,,59610.03,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,36249.34,45,,36249.34,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,39874.27,49.5,,39874.27,percent of total billed charges,110% of Medicare,54776.78,68,,54776.78,percent of total billed charges,,1721.88,,,1721.88,Other,186% of Medicaid,64443.27,80,,64443.27,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,64443.27,80,,64443.27,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,56387.86,70,,56387.86,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,925.74,,,925.74,Other,New York Medicaid APG methodology,925.74,,,925.74,Other,100% New York Medicaid APG,925.74,,,925.74,Other,100% New York Medicaid APG,925.74,,,925.74,Other,100% New York Medicaid APG,2082.92,,,2082.92,Other,225% New York Medicaid APG,1416.38,,,1416.38,Other,153% New York Medicaid APG,2082.92,,,2082.92,Other,225% New York Medicaid APG,1296.04,,,1296.04,Other,140% New York Medicaid APG,2082.92,,,2082.92,Other,225% New York Medicaid APG,2406.92,,,2406.92,Other,260% New York Medicaid APG,2999.4,,,2999.4,Other,324% New York Medicaid APG,1990.34,,,1990.34,Other,215% New York Medicaid APG,1990.34,,,1990.34,Other,215% New York Medicaid APG,1157.18,,,1157.18,Other,125% New York Medicaid APG,925.74,64443.27,
Esophagoscop ultrasound exam,43231,CPT,,,,,,,,both,,,12293.8,9097.41,74,,9097.41,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,5532.21,45,,5532.21,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,6085.43,49.5,,6085.43,percent of total billed charges,110% of Medicare,8359.78,68,,8359.78,percent of total billed charges,,1530.86,,,1530.86,Other,186% of Medicaid,9835.04,80,,9835.04,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,9835.04,80,,9835.04,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,8605.66,70,,8605.66,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,823.04,,,823.04,Other,New York Medicaid APG methodology,823.04,,,823.04,Other,100% New York Medicaid APG,823.04,,,823.04,Other,100% New York Medicaid APG,823.04,,,823.04,Other,100% New York Medicaid APG,1851.85,,,1851.85,Other,225% New York Medicaid APG,1259.26,,,1259.26,Other,153% New York Medicaid APG,1851.85,,,1851.85,Other,225% New York Medicaid APG,1152.26,,,1152.26,Other,140% New York Medicaid APG,1851.85,,,1851.85,Other,225% New York Medicaid APG,2139.92,,,2139.92,Other,260% New York Medicaid APG,2666.66,,,2666.66,Other,324% New York Medicaid APG,1769.55,,,1769.55,Other,215% New York Medicaid APG,1769.55,,,1769.55,Other,215% New York Medicaid APG,1028.81,,,1028.81,Other,125% New York Medicaid APG,823.04,9835.04,
Esophagoscopy w/us needle bx,43232,CPT,,,,,,,,both,,,40023.39,29617.31,74,,29617.31,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,18010.53,45,,18010.53,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,19811.58,49.5,,19811.58,percent of total billed charges,110% of Medicare,27215.91,68,,27215.91,percent of total billed charges,,1530.86,,,1530.86,Other,186% of Medicaid,32018.71,80,,32018.71,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,32018.71,80,,32018.71,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,28016.37,70,,28016.37,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,823.04,,,823.04,Other,New York Medicaid APG methodology,823.04,,,823.04,Other,100% New York Medicaid APG,823.04,,,823.04,Other,100% New York Medicaid APG,823.04,,,823.04,Other,100% New York Medicaid APG,1851.85,,,1851.85,Other,225% New York Medicaid APG,1259.26,,,1259.26,Other,153% New York Medicaid APG,1851.85,,,1851.85,Other,225% New York Medicaid APG,1152.26,,,1152.26,Other,140% New York Medicaid APG,1851.85,,,1851.85,Other,225% New York Medicaid APG,2139.92,,,2139.92,Other,260% New York Medicaid APG,2666.66,,,2666.66,Other,324% New York Medicaid APG,1769.55,,,1769.55,Other,215% New York Medicaid APG,1769.55,,,1769.55,Other,215% New York Medicaid APG,1028.81,,,1028.81,Other,125% New York Medicaid APG,823.04,32018.71,
Egd balloon dil esoph30 mm/>,43233,CPT,,,,,,,,both,,,31175.65,23069.98,74,,23069.98,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,14029.04,45,,14029.04,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,15431.95,49.5,,15431.95,percent of total billed charges,110% of Medicare,21199.44,68,,21199.44,percent of total billed charges,,1530.86,,,1530.86,Other,186% of Medicaid,24940.52,80,,24940.52,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,24940.52,80,,24940.52,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,21822.96,70,,21822.96,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,823.04,,,823.04,Other,New York Medicaid APG methodology,823.04,,,823.04,Other,100% New York Medicaid APG,823.04,,,823.04,Other,100% New York Medicaid APG,823.04,,,823.04,Other,100% New York Medicaid APG,1851.85,,,1851.85,Other,225% New York Medicaid APG,1259.26,,,1259.26,Other,153% New York Medicaid APG,1851.85,,,1851.85,Other,225% New York Medicaid APG,1152.26,,,1152.26,Other,140% New York Medicaid APG,1851.85,,,1851.85,Other,225% New York Medicaid APG,2139.92,,,2139.92,Other,260% New York Medicaid APG,2666.66,,,2666.66,Other,324% New York Medicaid APG,1769.55,,,1769.55,Other,215% New York Medicaid APG,1769.55,,,1769.55,Other,215% New York Medicaid APG,1028.81,,,1028.81,Other,125% New York Medicaid APG,823.04,24940.52,
Egd diagnostic brush wash,43235,CPT,,,,,,,,both,,,13363.62,9889.08,74,,9889.08,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,6013.63,45,,6013.63,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,6614.99,49.5,,6614.99,percent of total billed charges,110% of Medicare,9087.26,68,,9087.26,percent of total billed charges,,1530.86,,,1530.86,Other,186% of Medicaid,10690.9,80,,10690.9,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,10690.9,80,,10690.9,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,9354.53,70,,9354.53,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,823.04,,,823.04,Other,New York Medicaid APG methodology,823.04,,,823.04,Other,100% New York Medicaid APG,823.04,,,823.04,Other,100% New York Medicaid APG,823.04,,,823.04,Other,100% New York Medicaid APG,1851.85,,,1851.85,Other,225% New York Medicaid APG,1259.26,,,1259.26,Other,153% New York Medicaid APG,1851.85,,,1851.85,Other,225% New York Medicaid APG,1152.26,,,1152.26,Other,140% New York Medicaid APG,1851.85,,,1851.85,Other,225% New York Medicaid APG,2139.92,,,2139.92,Other,260% New York Medicaid APG,2666.66,,,2666.66,Other,324% New York Medicaid APG,1769.55,,,1769.55,Other,215% New York Medicaid APG,1769.55,,,1769.55,Other,215% New York Medicaid APG,1028.81,,,1028.81,Other,125% New York Medicaid APG,823.04,10690.9,
Uppr gi scope w/submuc inj,43236,CPT,,,,,,,,both,,,16160.18,11958.53,74,,11958.53,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,7272.08,45,,7272.08,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,7999.29,49.5,,7999.29,percent of total billed charges,110% of Medicare,10988.92,68,,10988.92,percent of total billed charges,,1530.86,,,1530.86,Other,186% of Medicaid,12928.14,80,,12928.14,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,12928.14,80,,12928.14,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,11312.13,70,,11312.13,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,823.04,,,823.04,Other,New York Medicaid APG methodology,823.04,,,823.04,Other,100% New York Medicaid APG,823.04,,,823.04,Other,100% New York Medicaid APG,823.04,,,823.04,Other,100% New York Medicaid APG,1851.85,,,1851.85,Other,225% New York Medicaid APG,1259.26,,,1259.26,Other,153% New York Medicaid APG,1851.85,,,1851.85,Other,225% New York Medicaid APG,1152.26,,,1152.26,Other,140% New York Medicaid APG,1851.85,,,1851.85,Other,225% New York Medicaid APG,2139.92,,,2139.92,Other,260% New York Medicaid APG,2666.66,,,2666.66,Other,324% New York Medicaid APG,1769.55,,,1769.55,Other,215% New York Medicaid APG,1769.55,,,1769.55,Other,215% New York Medicaid APG,1028.81,,,1028.81,Other,125% New York Medicaid APG,823.04,12928.14,
Endoscopic us exam esoph,43237,CPT,,,,,,,,both,,,17728.21,13118.88,74,,13118.88,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,7977.69,45,,7977.69,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,8775.46,49.5,,8775.46,percent of total billed charges,110% of Medicare,12055.18,68,,12055.18,percent of total billed charges,,1530.86,,,1530.86,Other,186% of Medicaid,14182.57,80,,14182.57,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,14182.57,80,,14182.57,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,12409.75,70,,12409.75,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,823.04,,,823.04,Other,New York Medicaid APG methodology,823.04,,,823.04,Other,100% New York Medicaid APG,823.04,,,823.04,Other,100% New York Medicaid APG,823.04,,,823.04,Other,100% New York Medicaid APG,1851.85,,,1851.85,Other,225% New York Medicaid APG,1259.26,,,1259.26,Other,153% New York Medicaid APG,1851.85,,,1851.85,Other,225% New York Medicaid APG,1152.26,,,1152.26,Other,140% New York Medicaid APG,1851.85,,,1851.85,Other,225% New York Medicaid APG,2139.92,,,2139.92,Other,260% New York Medicaid APG,2666.66,,,2666.66,Other,324% New York Medicaid APG,1769.55,,,1769.55,Other,215% New York Medicaid APG,1769.55,,,1769.55,Other,215% New York Medicaid APG,1028.81,,,1028.81,Other,125% New York Medicaid APG,823.04,14182.57,
Egd us fine needle bx/aspir,43238,CPT,,,,,,,,both,,,29340.91,21712.27,74,,21712.27,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,13203.41,45,,13203.41,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,14523.75,49.5,,14523.75,percent of total billed charges,110% of Medicare,19951.82,68,,19951.82,percent of total billed charges,,1530.86,,,1530.86,Other,186% of Medicaid,23472.73,80,,23472.73,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,23472.73,80,,23472.73,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,20538.64,70,,20538.64,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,823.04,,,823.04,Other,New York Medicaid APG methodology,823.04,,,823.04,Other,100% New York Medicaid APG,823.04,,,823.04,Other,100% New York Medicaid APG,823.04,,,823.04,Other,100% New York Medicaid APG,1851.85,,,1851.85,Other,225% New York Medicaid APG,1259.26,,,1259.26,Other,153% New York Medicaid APG,1851.85,,,1851.85,Other,225% New York Medicaid APG,1152.26,,,1152.26,Other,140% New York Medicaid APG,1851.85,,,1851.85,Other,225% New York Medicaid APG,2139.92,,,2139.92,Other,260% New York Medicaid APG,2666.66,,,2666.66,Other,324% New York Medicaid APG,1769.55,,,1769.55,Other,215% New York Medicaid APG,1769.55,,,1769.55,Other,215% New York Medicaid APG,1028.81,,,1028.81,Other,125% New York Medicaid APG,823.04,23472.73,
Egd biopsy single/multiple,43239,CPT,,,,,,,,both,,,23634.5,17489.53,74,,17489.53,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,10635.53,45,,10635.53,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,11699.08,49.5,,11699.08,percent of total billed charges,110% of Medicare,16071.46,68,,16071.46,percent of total billed charges,,1530.86,,,1530.86,Other,186% of Medicaid,18907.6,80,,18907.6,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,18907.6,80,,18907.6,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,16544.15,70,,16544.15,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,823.04,,,823.04,Other,New York Medicaid APG methodology,823.04,,,823.04,Other,100% New York Medicaid APG,823.04,,,823.04,Other,100% New York Medicaid APG,823.04,,,823.04,Other,100% New York Medicaid APG,1851.85,,,1851.85,Other,225% New York Medicaid APG,1259.26,,,1259.26,Other,153% New York Medicaid APG,1851.85,,,1851.85,Other,225% New York Medicaid APG,1152.26,,,1152.26,Other,140% New York Medicaid APG,1851.85,,,1851.85,Other,225% New York Medicaid APG,2139.92,,,2139.92,Other,260% New York Medicaid APG,2666.66,,,2666.66,Other,324% New York Medicaid APG,1769.55,,,1769.55,Other,215% New York Medicaid APG,1769.55,,,1769.55,Other,215% New York Medicaid APG,1028.81,,,1028.81,Other,125% New York Medicaid APG,823.04,18907.6,
Egd w/transmural drain cyst,43240,CPT,,,,,,,,both,,,119876.35,88708.5,74,,88708.5,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,53944.36,45,,53944.36,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,59338.79,49.5,,59338.79,percent of total billed charges,110% of Medicare,81515.92,68,,81515.92,percent of total billed charges,,1813.82,,,1813.82,Other,186% of Medicaid,95901.08,80,,95901.08,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,95901.08,80,,95901.08,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,83913.45,70,,83913.45,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,975.17,,,975.17,Other,New York Medicaid APG methodology,975.17,,,975.17,Other,100% New York Medicaid APG,975.17,,,975.17,Other,100% New York Medicaid APG,975.17,,,975.17,Other,100% New York Medicaid APG,2194.14,,,2194.14,Other,225% New York Medicaid APG,1492.01,,,1492.01,Other,153% New York Medicaid APG,2194.14,,,2194.14,Other,225% New York Medicaid APG,1365.24,,,1365.24,Other,140% New York Medicaid APG,2194.14,,,2194.14,Other,225% New York Medicaid APG,2535.45,,,2535.45,Other,260% New York Medicaid APG,3159.56,,,3159.56,Other,324% New York Medicaid APG,2096.62,,,2096.62,Other,215% New York Medicaid APG,2096.62,,,2096.62,Other,215% New York Medicaid APG,1218.96,,,1218.96,Other,125% New York Medicaid APG,975.17,95901.08,
Egd tube/cath insertion,43241,CPT,,,,,,,,both,,,44542.16,32961.2,74,,32961.2,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,20043.97,45,,20043.97,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,22048.37,49.5,,22048.37,percent of total billed charges,110% of Medicare,30288.67,68,,30288.67,percent of total billed charges,,1530.86,,,1530.86,Other,186% of Medicaid,35633.73,80,,35633.73,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,35633.73,80,,35633.73,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,31179.51,70,,31179.51,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,823.04,,,823.04,Other,New York Medicaid APG methodology,823.04,,,823.04,Other,100% New York Medicaid APG,823.04,,,823.04,Other,100% New York Medicaid APG,823.04,,,823.04,Other,100% New York Medicaid APG,1851.85,,,1851.85,Other,225% New York Medicaid APG,1259.26,,,1259.26,Other,153% New York Medicaid APG,1851.85,,,1851.85,Other,225% New York Medicaid APG,1152.26,,,1152.26,Other,140% New York Medicaid APG,1851.85,,,1851.85,Other,225% New York Medicaid APG,2139.92,,,2139.92,Other,260% New York Medicaid APG,2666.66,,,2666.66,Other,324% New York Medicaid APG,1769.55,,,1769.55,Other,215% New York Medicaid APG,1769.55,,,1769.55,Other,215% New York Medicaid APG,1028.81,,,1028.81,Other,125% New York Medicaid APG,823.04,35633.73,
Egd us fine needle bx/aspir,43242,CPT,,,,,,,,both,,,29434.97,21781.88,74,,21781.88,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,13245.74,45,,13245.74,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,14570.31,49.5,,14570.31,percent of total billed charges,110% of Medicare,20015.78,68,,20015.78,percent of total billed charges,,1530.86,,,1530.86,Other,186% of Medicaid,23547.98,80,,23547.98,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,23547.98,80,,23547.98,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,20604.48,70,,20604.48,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,823.04,,,823.04,Other,New York Medicaid APG methodology,823.04,,,823.04,Other,100% New York Medicaid APG,823.04,,,823.04,Other,100% New York Medicaid APG,823.04,,,823.04,Other,100% New York Medicaid APG,1851.85,,,1851.85,Other,225% New York Medicaid APG,1259.26,,,1259.26,Other,153% New York Medicaid APG,1851.85,,,1851.85,Other,225% New York Medicaid APG,1152.26,,,1152.26,Other,140% New York Medicaid APG,1851.85,,,1851.85,Other,225% New York Medicaid APG,2139.92,,,2139.92,Other,260% New York Medicaid APG,2666.66,,,2666.66,Other,324% New York Medicaid APG,1769.55,,,1769.55,Other,215% New York Medicaid APG,1769.55,,,1769.55,Other,215% New York Medicaid APG,1028.81,,,1028.81,Other,125% New York Medicaid APG,823.04,23547.98,
Egd injection varices,43243,CPT,,,,,,,,both,,,40023.39,29617.31,74,,29617.31,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,18010.53,45,,18010.53,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,19811.58,49.5,,19811.58,percent of total billed charges,110% of Medicare,27215.91,68,,27215.91,percent of total billed charges,,1530.86,,,1530.86,Other,186% of Medicaid,32018.71,80,,32018.71,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,32018.71,80,,32018.71,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,28016.37,70,,28016.37,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,823.04,,,823.04,Other,New York Medicaid APG methodology,823.04,,,823.04,Other,100% New York Medicaid APG,823.04,,,823.04,Other,100% New York Medicaid APG,823.04,,,823.04,Other,100% New York Medicaid APG,1851.85,,,1851.85,Other,225% New York Medicaid APG,1259.26,,,1259.26,Other,153% New York Medicaid APG,1851.85,,,1851.85,Other,225% New York Medicaid APG,1152.26,,,1152.26,Other,140% New York Medicaid APG,1851.85,,,1851.85,Other,225% New York Medicaid APG,2139.92,,,2139.92,Other,260% New York Medicaid APG,2666.66,,,2666.66,Other,324% New York Medicaid APG,1769.55,,,1769.55,Other,215% New York Medicaid APG,1769.55,,,1769.55,Other,215% New York Medicaid APG,1028.81,,,1028.81,Other,125% New York Medicaid APG,823.04,32018.71,
Egd varices ligation,43244,CPT,,,,,,,,both,,,15264.53,11295.75,74,,11295.75,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,6869.04,45,,6869.04,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,7555.94,49.5,,7555.94,percent of total billed charges,110% of Medicare,10379.88,68,,10379.88,percent of total billed charges,,1530.86,,,1530.86,Other,186% of Medicaid,12211.62,80,,12211.62,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,12211.62,80,,12211.62,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,10685.17,70,,10685.17,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,823.04,,,823.04,Other,New York Medicaid APG methodology,823.04,,,823.04,Other,100% New York Medicaid APG,823.04,,,823.04,Other,100% New York Medicaid APG,823.04,,,823.04,Other,100% New York Medicaid APG,1851.85,,,1851.85,Other,225% New York Medicaid APG,1259.26,,,1259.26,Other,153% New York Medicaid APG,1851.85,,,1851.85,Other,225% New York Medicaid APG,1152.26,,,1152.26,Other,140% New York Medicaid APG,1851.85,,,1851.85,Other,225% New York Medicaid APG,2139.92,,,2139.92,Other,260% New York Medicaid APG,2666.66,,,2666.66,Other,324% New York Medicaid APG,1769.55,,,1769.55,Other,215% New York Medicaid APG,1769.55,,,1769.55,Other,215% New York Medicaid APG,1028.81,,,1028.81,Other,125% New York Medicaid APG,823.04,12211.62,
Egd dilate stricture,43245,CPT,,,,,,,,both,,,21612.12,15992.97,74,,15992.97,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,9725.45,45,,9725.45,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,10698,49.5,,10698,percent of total billed charges,110% of Medicare,14696.24,68,,14696.24,percent of total billed charges,,1530.86,,,1530.86,Other,186% of Medicaid,17289.7,80,,17289.7,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,17289.7,80,,17289.7,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,15128.48,70,,15128.48,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,823.04,,,823.04,Other,New York Medicaid APG methodology,823.04,,,823.04,Other,100% New York Medicaid APG,823.04,,,823.04,Other,100% New York Medicaid APG,823.04,,,823.04,Other,100% New York Medicaid APG,1851.85,,,1851.85,Other,225% New York Medicaid APG,1259.26,,,1259.26,Other,153% New York Medicaid APG,1851.85,,,1851.85,Other,225% New York Medicaid APG,1152.26,,,1152.26,Other,140% New York Medicaid APG,1851.85,,,1851.85,Other,225% New York Medicaid APG,2139.92,,,2139.92,Other,260% New York Medicaid APG,2666.66,,,2666.66,Other,324% New York Medicaid APG,1769.55,,,1769.55,Other,215% New York Medicaid APG,1769.55,,,1769.55,Other,215% New York Medicaid APG,1028.81,,,1028.81,Other,125% New York Medicaid APG,823.04,17289.7,
Egd place gastrostomy tube,43246,CPT,,,,,,,,both,,,25442.5,18827.45,74,,18827.45,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,11449.13,45,,11449.13,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,12594.04,49.5,,12594.04,percent of total billed charges,110% of Medicare,17300.9,68,,17300.9,percent of total billed charges,,1530.86,,,1530.86,Other,186% of Medicaid,20354,80,,20354,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,20354,80,,20354,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,17809.75,70,,17809.75,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,823.04,,,823.04,Other,New York Medicaid APG methodology,823.04,,,823.04,Other,100% New York Medicaid APG,823.04,,,823.04,Other,100% New York Medicaid APG,823.04,,,823.04,Other,100% New York Medicaid APG,1851.85,,,1851.85,Other,225% New York Medicaid APG,1259.26,,,1259.26,Other,153% New York Medicaid APG,1851.85,,,1851.85,Other,225% New York Medicaid APG,1152.26,,,1152.26,Other,140% New York Medicaid APG,1851.85,,,1851.85,Other,225% New York Medicaid APG,2139.92,,,2139.92,Other,260% New York Medicaid APG,2666.66,,,2666.66,Other,324% New York Medicaid APG,1769.55,,,1769.55,Other,215% New York Medicaid APG,1769.55,,,1769.55,Other,215% New York Medicaid APG,1028.81,,,1028.81,Other,125% New York Medicaid APG,823.04,20354,
Egd remove foreign body,43247,CPT,,,,,,,,both,,,22283.81,16490.02,74,,16490.02,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,10027.71,45,,10027.71,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,11030.49,49.5,,11030.49,percent of total billed charges,110% of Medicare,15152.99,68,,15152.99,percent of total billed charges,,1530.86,,,1530.86,Other,186% of Medicaid,17827.05,80,,17827.05,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,17827.05,80,,17827.05,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,15598.67,70,,15598.67,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,823.04,,,823.04,Other,New York Medicaid APG methodology,823.04,,,823.04,Other,100% New York Medicaid APG,823.04,,,823.04,Other,100% New York Medicaid APG,823.04,,,823.04,Other,100% New York Medicaid APG,1851.85,,,1851.85,Other,225% New York Medicaid APG,1259.26,,,1259.26,Other,153% New York Medicaid APG,1851.85,,,1851.85,Other,225% New York Medicaid APG,1152.26,,,1152.26,Other,140% New York Medicaid APG,1851.85,,,1851.85,Other,225% New York Medicaid APG,2139.92,,,2139.92,Other,260% New York Medicaid APG,2666.66,,,2666.66,Other,324% New York Medicaid APG,1769.55,,,1769.55,Other,215% New York Medicaid APG,1769.55,,,1769.55,Other,215% New York Medicaid APG,1028.81,,,1028.81,Other,125% New York Medicaid APG,823.04,17827.05,
Egd guide wire insertion,43248,CPT,,,,,,,,both,,,19066.74,14109.39,74,,14109.39,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,8580.03,45,,8580.03,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,9438.04,49.5,,9438.04,percent of total billed charges,110% of Medicare,12965.38,68,,12965.38,percent of total billed charges,,1530.86,,,1530.86,Other,186% of Medicaid,15253.39,80,,15253.39,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,15253.39,80,,15253.39,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,13346.72,70,,13346.72,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,823.04,,,823.04,Other,New York Medicaid APG methodology,823.04,,,823.04,Other,100% New York Medicaid APG,823.04,,,823.04,Other,100% New York Medicaid APG,823.04,,,823.04,Other,100% New York Medicaid APG,1851.85,,,1851.85,Other,225% New York Medicaid APG,1259.26,,,1259.26,Other,153% New York Medicaid APG,1851.85,,,1851.85,Other,225% New York Medicaid APG,1152.26,,,1152.26,Other,140% New York Medicaid APG,1851.85,,,1851.85,Other,225% New York Medicaid APG,2139.92,,,2139.92,Other,260% New York Medicaid APG,2666.66,,,2666.66,Other,324% New York Medicaid APG,1769.55,,,1769.55,Other,215% New York Medicaid APG,1769.55,,,1769.55,Other,215% New York Medicaid APG,1028.81,,,1028.81,Other,125% New York Medicaid APG,823.04,15253.39,
Esoph egd dilation <30 mm,43249,CPT,,,,,,,,both,,,20422.88,15112.93,74,,15112.93,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,9190.3,45,,9190.3,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,10109.33,49.5,,10109.33,percent of total billed charges,110% of Medicare,13887.56,68,,13887.56,percent of total billed charges,,1530.86,,,1530.86,Other,186% of Medicaid,16338.3,80,,16338.3,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,16338.3,80,,16338.3,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,14296.02,70,,14296.02,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,823.04,,,823.04,Other,New York Medicaid APG methodology,823.04,,,823.04,Other,100% New York Medicaid APG,823.04,,,823.04,Other,100% New York Medicaid APG,823.04,,,823.04,Other,100% New York Medicaid APG,1851.85,,,1851.85,Other,225% New York Medicaid APG,1259.26,,,1259.26,Other,153% New York Medicaid APG,1851.85,,,1851.85,Other,225% New York Medicaid APG,1152.26,,,1152.26,Other,140% New York Medicaid APG,1851.85,,,1851.85,Other,225% New York Medicaid APG,2139.92,,,2139.92,Other,260% New York Medicaid APG,2666.66,,,2666.66,Other,324% New York Medicaid APG,1769.55,,,1769.55,Other,215% New York Medicaid APG,1769.55,,,1769.55,Other,215% New York Medicaid APG,1028.81,,,1028.81,Other,125% New York Medicaid APG,823.04,16338.3,
Egd cautery tumor polyp,43250,CPT,,,,,,,,both,,,40023.39,29617.31,74,,29617.31,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,18010.53,45,,18010.53,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,19811.58,49.5,,19811.58,percent of total billed charges,110% of Medicare,27215.91,68,,27215.91,percent of total billed charges,,1530.86,,,1530.86,Other,186% of Medicaid,32018.71,80,,32018.71,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,32018.71,80,,32018.71,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,28016.37,70,,28016.37,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,823.04,,,823.04,Other,New York Medicaid APG methodology,823.04,,,823.04,Other,100% New York Medicaid APG,823.04,,,823.04,Other,100% New York Medicaid APG,823.04,,,823.04,Other,100% New York Medicaid APG,1851.85,,,1851.85,Other,225% New York Medicaid APG,1259.26,,,1259.26,Other,153% New York Medicaid APG,1851.85,,,1851.85,Other,225% New York Medicaid APG,1152.26,,,1152.26,Other,140% New York Medicaid APG,1851.85,,,1851.85,Other,225% New York Medicaid APG,2139.92,,,2139.92,Other,260% New York Medicaid APG,2666.66,,,2666.66,Other,324% New York Medicaid APG,1769.55,,,1769.55,Other,215% New York Medicaid APG,1769.55,,,1769.55,Other,215% New York Medicaid APG,1028.81,,,1028.81,Other,125% New York Medicaid APG,823.04,32018.71,
Egd remove lesion snare,43251,CPT,,,,,,,,both,,,23659.1,17507.73,74,,17507.73,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,10646.6,45,,10646.6,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,11711.25,49.5,,11711.25,percent of total billed charges,110% of Medicare,16088.19,68,,16088.19,percent of total billed charges,,1530.86,,,1530.86,Other,186% of Medicaid,18927.28,80,,18927.28,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,18927.28,80,,18927.28,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,16561.37,70,,16561.37,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,823.04,,,823.04,Other,New York Medicaid APG methodology,823.04,,,823.04,Other,100% New York Medicaid APG,823.04,,,823.04,Other,100% New York Medicaid APG,823.04,,,823.04,Other,100% New York Medicaid APG,1851.85,,,1851.85,Other,225% New York Medicaid APG,1259.26,,,1259.26,Other,153% New York Medicaid APG,1851.85,,,1851.85,Other,225% New York Medicaid APG,1152.26,,,1152.26,Other,140% New York Medicaid APG,1851.85,,,1851.85,Other,225% New York Medicaid APG,2139.92,,,2139.92,Other,260% New York Medicaid APG,2666.66,,,2666.66,Other,324% New York Medicaid APG,1769.55,,,1769.55,Other,215% New York Medicaid APG,1769.55,,,1769.55,Other,215% New York Medicaid APG,1028.81,,,1028.81,Other,125% New York Medicaid APG,823.04,18927.28,
Egd optical endomicroscopy,43252,CPT,,,,,,,,both,,,40023.39,29617.31,74,,29617.31,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,18010.53,45,,18010.53,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,19811.58,49.5,,19811.58,percent of total billed charges,110% of Medicare,27215.91,68,,27215.91,percent of total billed charges,,1813.82,,,1813.82,Other,186% of Medicaid,32018.71,80,,32018.71,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,32018.71,80,,32018.71,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,28016.37,70,,28016.37,percent of total billed charges,,808.52,,,808.52,Fee Schedule,,685.27,,,685.27,Fee Schedule,,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,975.17,,,975.17,Other,New York Medicaid APG methodology,975.17,,,975.17,Other,100% New York Medicaid APG,975.17,,,975.17,Other,100% New York Medicaid APG,975.17,,,975.17,Other,100% New York Medicaid APG,2194.14,,,2194.14,Other,225% New York Medicaid APG,1492.01,,,1492.01,Other,153% New York Medicaid APG,2194.14,,,2194.14,Other,225% New York Medicaid APG,1365.24,,,1365.24,Other,140% New York Medicaid APG,2194.14,,,2194.14,Other,225% New York Medicaid APG,2535.45,,,2535.45,Other,260% New York Medicaid APG,3159.56,,,3159.56,Other,324% New York Medicaid APG,2096.62,,,2096.62,Other,215% New York Medicaid APG,2096.62,,,2096.62,Other,215% New York Medicaid APG,1218.96,,,1218.96,Other,125% New York Medicaid APG,685.27,32018.71,
Egd us transmural injxn/mark,43253,CPT,,,,,,,,both,,,28190.73,20861.14,74,,20861.14,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,12685.83,45,,12685.83,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,13954.41,49.5,,13954.41,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,1530.86,,,1530.86,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,19733.51,70,,19733.51,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,823.04,,,823.04,Other,New York Medicaid APG methodology,823.04,,,823.04,Other,100% New York Medicaid APG,823.04,,,823.04,Other,100% New York Medicaid APG,823.04,,,823.04,Other,100% New York Medicaid APG,1851.85,,,1851.85,Other,225% New York Medicaid APG,1259.26,,,1259.26,Other,153% New York Medicaid APG,1851.85,,,1851.85,Other,225% New York Medicaid APG,1152.26,,,1152.26,Other,140% New York Medicaid APG,1851.85,,,1851.85,Other,225% New York Medicaid APG,2139.92,,,2139.92,Other,260% New York Medicaid APG,2666.66,,,2666.66,Other,324% New York Medicaid APG,1769.55,,,1769.55,Other,215% New York Medicaid APG,1769.55,,,1769.55,Other,215% New York Medicaid APG,1028.81,,,1028.81,Other,125% New York Medicaid APG,823.04,20861.14,
Egd endo mucosal resection,43254,CPT,,,,,,,,both,,,28195.3,20864.52,74,,20864.52,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,12687.89,45,,12687.89,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,13956.67,49.5,,13956.67,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,1721.88,,,1721.88,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,19736.71,70,,19736.71,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,925.74,,,925.74,Other,New York Medicaid APG methodology,925.74,,,925.74,Other,100% New York Medicaid APG,925.74,,,925.74,Other,100% New York Medicaid APG,925.74,,,925.74,Other,100% New York Medicaid APG,2082.92,,,2082.92,Other,225% New York Medicaid APG,1416.38,,,1416.38,Other,153% New York Medicaid APG,2082.92,,,2082.92,Other,225% New York Medicaid APG,1296.04,,,1296.04,Other,140% New York Medicaid APG,2082.92,,,2082.92,Other,225% New York Medicaid APG,2406.92,,,2406.92,Other,260% New York Medicaid APG,2999.4,,,2999.4,Other,324% New York Medicaid APG,1990.34,,,1990.34,Other,215% New York Medicaid APG,1990.34,,,1990.34,Other,215% New York Medicaid APG,1157.18,,,1157.18,Other,125% New York Medicaid APG,925.74,20864.52,
Egd control bleeding any,43255,CPT,,,,,,,,both,,,14839.33,10981.1,74,,10981.1,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,6677.7,45,,6677.7,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,7345.47,49.5,,7345.47,percent of total billed charges,110% of Medicare,10090.74,68,,10090.74,percent of total billed charges,,1530.86,,,1530.86,Other,186% of Medicaid,11871.46,80,,11871.46,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,11871.46,80,,11871.46,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,10387.53,70,,10387.53,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,823.04,,,823.04,Other,New York Medicaid APG methodology,823.04,,,823.04,Other,100% New York Medicaid APG,823.04,,,823.04,Other,100% New York Medicaid APG,823.04,,,823.04,Other,100% New York Medicaid APG,1851.85,,,1851.85,Other,225% New York Medicaid APG,1259.26,,,1259.26,Other,153% New York Medicaid APG,1851.85,,,1851.85,Other,225% New York Medicaid APG,1152.26,,,1152.26,Other,140% New York Medicaid APG,1851.85,,,1851.85,Other,225% New York Medicaid APG,2139.92,,,2139.92,Other,260% New York Medicaid APG,2666.66,,,2666.66,Other,324% New York Medicaid APG,1769.55,,,1769.55,Other,215% New York Medicaid APG,1769.55,,,1769.55,Other,215% New York Medicaid APG,1028.81,,,1028.81,Other,125% New York Medicaid APG,823.04,11871.46,
Egd w/thrml txmnt gerd,43257,CPT,,,,,,,,both,,,80554.09,59610.03,74,,59610.03,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,36249.34,45,,36249.34,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,39874.27,49.5,,39874.27,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,1721.88,,,1721.88,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,56387.86,70,,56387.86,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,925.74,,,925.74,Other,New York Medicaid APG methodology,925.74,,,925.74,Other,100% New York Medicaid APG,925.74,,,925.74,Other,100% New York Medicaid APG,925.74,,,925.74,Other,100% New York Medicaid APG,2082.92,,,2082.92,Other,225% New York Medicaid APG,1416.38,,,1416.38,Other,153% New York Medicaid APG,2082.92,,,2082.92,Other,225% New York Medicaid APG,1296.04,,,1296.04,Other,140% New York Medicaid APG,2082.92,,,2082.92,Other,225% New York Medicaid APG,2406.92,,,2406.92,Other,260% New York Medicaid APG,2999.4,,,2999.4,Other,324% New York Medicaid APG,1990.34,,,1990.34,Other,215% New York Medicaid APG,1990.34,,,1990.34,Other,215% New York Medicaid APG,1157.18,,,1157.18,Other,125% New York Medicaid APG,925.74,59610.03,
Egd us exam duodenum/jejunum,43259,CPT,,,,,,,,both,,,16503.83,12212.83,74,,12212.83,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,7426.72,45,,7426.72,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,8169.4,49.5,,8169.4,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,1530.86,,,1530.86,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,11552.68,70,,11552.68,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,823.04,,,823.04,Other,New York Medicaid APG methodology,823.04,,,823.04,Other,100% New York Medicaid APG,823.04,,,823.04,Other,100% New York Medicaid APG,823.04,,,823.04,Other,100% New York Medicaid APG,1851.85,,,1851.85,Other,225% New York Medicaid APG,1259.26,,,1259.26,Other,153% New York Medicaid APG,1851.85,,,1851.85,Other,225% New York Medicaid APG,1152.26,,,1152.26,Other,140% New York Medicaid APG,1851.85,,,1851.85,Other,225% New York Medicaid APG,2139.92,,,2139.92,Other,260% New York Medicaid APG,2666.66,,,2666.66,Other,324% New York Medicaid APG,1769.55,,,1769.55,Other,215% New York Medicaid APG,1769.55,,,1769.55,Other,215% New York Medicaid APG,1028.81,,,1028.81,Other,125% New York Medicaid APG,823.04,12212.83,
Ercp w/specimen collection,43260,CPT,,,,,,,,both,,,44600.39,33004.29,74,,33004.29,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,20070.18,45,,20070.18,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,22077.19,49.5,,22077.19,percent of total billed charges,110% of Medicare,30328.27,68,,30328.27,percent of total billed charges,,2349.18,,,2349.18,Other,186% of Medicaid,35680.31,80,,35680.31,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,35680.31,80,,35680.31,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,31220.27,70,,31220.27,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1263,,,1263,Other,New York Medicaid APG methodology,1263,,,1263,Other,100% New York Medicaid APG,1263,,,1263,Other,100% New York Medicaid APG,1263,,,1263,Other,100% New York Medicaid APG,2841.76,,,2841.76,Other,225% New York Medicaid APG,1932.39,,,1932.39,Other,153% New York Medicaid APG,2841.76,,,2841.76,Other,225% New York Medicaid APG,1768.2,,,1768.2,Other,140% New York Medicaid APG,2841.76,,,2841.76,Other,225% New York Medicaid APG,3283.81,,,3283.81,Other,260% New York Medicaid APG,4092.13,,,4092.13,Other,324% New York Medicaid APG,2715.46,,,2715.46,Other,215% New York Medicaid APG,2715.46,,,2715.46,Other,215% New York Medicaid APG,1578.75,,,1578.75,Other,125% New York Medicaid APG,1263,35680.31,
Endo cholangiopancreatograph,43261,CPT,,,,,,,,both,,,48894.68,36182.06,74,,36182.06,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,22002.61,45,,22002.61,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,24202.87,49.5,,24202.87,percent of total billed charges,110% of Medicare,33248.38,68,,33248.38,percent of total billed charges,,2349.18,,,2349.18,Other,186% of Medicaid,39115.74,80,,39115.74,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,39115.74,80,,39115.74,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,34226.28,70,,34226.28,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1263,,,1263,Other,New York Medicaid APG methodology,1263,,,1263,Other,100% New York Medicaid APG,1263,,,1263,Other,100% New York Medicaid APG,1263,,,1263,Other,100% New York Medicaid APG,2841.76,,,2841.76,Other,225% New York Medicaid APG,1932.39,,,1932.39,Other,153% New York Medicaid APG,2841.76,,,2841.76,Other,225% New York Medicaid APG,1768.2,,,1768.2,Other,140% New York Medicaid APG,2841.76,,,2841.76,Other,225% New York Medicaid APG,3283.81,,,3283.81,Other,260% New York Medicaid APG,4092.13,,,4092.13,Other,324% New York Medicaid APG,2715.46,,,2715.46,Other,215% New York Medicaid APG,2715.46,,,2715.46,Other,215% New York Medicaid APG,1578.75,,,1578.75,Other,125% New York Medicaid APG,1263,39115.74,
Endo cholangiopancreatograph,43262,CPT,,,,,,,,both,,,35727.6,26438.42,74,,26438.42,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,16077.42,45,,16077.42,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,17685.16,49.5,,17685.16,percent of total billed charges,110% of Medicare,24294.77,68,,24294.77,percent of total billed charges,,2349.18,,,2349.18,Other,186% of Medicaid,28582.08,80,,28582.08,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,28582.08,80,,28582.08,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,25009.32,70,,25009.32,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1263,,,1263,Other,New York Medicaid APG methodology,1263,,,1263,Other,100% New York Medicaid APG,1263,,,1263,Other,100% New York Medicaid APG,1263,,,1263,Other,100% New York Medicaid APG,2841.76,,,2841.76,Other,225% New York Medicaid APG,1932.39,,,1932.39,Other,153% New York Medicaid APG,2841.76,,,2841.76,Other,225% New York Medicaid APG,1768.2,,,1768.2,Other,140% New York Medicaid APG,2841.76,,,2841.76,Other,225% New York Medicaid APG,3283.81,,,3283.81,Other,260% New York Medicaid APG,4092.13,,,4092.13,Other,324% New York Medicaid APG,2715.46,,,2715.46,Other,215% New York Medicaid APG,2715.46,,,2715.46,Other,215% New York Medicaid APG,1578.75,,,1578.75,Other,125% New York Medicaid APG,1263,28582.08,
Ercp sphincter pressure meas,43263,CPT,,,,,,,,both,,,40023.39,29617.31,74,,29617.31,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,18010.53,45,,18010.53,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,19811.58,49.5,,19811.58,percent of total billed charges,110% of Medicare,27215.91,68,,27215.91,percent of total billed charges,,2349.18,,,2349.18,Other,186% of Medicaid,32018.71,80,,32018.71,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,32018.71,80,,32018.71,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,28016.37,70,,28016.37,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1263,,,1263,Other,New York Medicaid APG methodology,1263,,,1263,Other,100% New York Medicaid APG,1263,,,1263,Other,100% New York Medicaid APG,1263,,,1263,Other,100% New York Medicaid APG,2841.76,,,2841.76,Other,225% New York Medicaid APG,1932.39,,,1932.39,Other,153% New York Medicaid APG,2841.76,,,2841.76,Other,225% New York Medicaid APG,1768.2,,,1768.2,Other,140% New York Medicaid APG,2841.76,,,2841.76,Other,225% New York Medicaid APG,3283.81,,,3283.81,Other,260% New York Medicaid APG,4092.13,,,4092.13,Other,324% New York Medicaid APG,2715.46,,,2715.46,Other,215% New York Medicaid APG,2715.46,,,2715.46,Other,215% New York Medicaid APG,1578.75,,,1578.75,Other,125% New York Medicaid APG,1263,32018.71,
Ercp remove duct calculi,43264,CPT,,,,,,,,both,,,32360.33,23946.64,74,,23946.64,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,14562.15,45,,14562.15,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,16018.36,49.5,,16018.36,percent of total billed charges,110% of Medicare,22005.02,68,,22005.02,percent of total billed charges,,2349.18,,,2349.18,Other,186% of Medicaid,25888.26,80,,25888.26,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,25888.26,80,,25888.26,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,22652.23,70,,22652.23,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1263,,,1263,Other,New York Medicaid APG methodology,1263,,,1263,Other,100% New York Medicaid APG,1263,,,1263,Other,100% New York Medicaid APG,1263,,,1263,Other,100% New York Medicaid APG,2841.76,,,2841.76,Other,225% New York Medicaid APG,1932.39,,,1932.39,Other,153% New York Medicaid APG,2841.76,,,2841.76,Other,225% New York Medicaid APG,1768.2,,,1768.2,Other,140% New York Medicaid APG,2841.76,,,2841.76,Other,225% New York Medicaid APG,3283.81,,,3283.81,Other,260% New York Medicaid APG,4092.13,,,4092.13,Other,324% New York Medicaid APG,2715.46,,,2715.46,Other,215% New York Medicaid APG,2715.46,,,2715.46,Other,215% New York Medicaid APG,1578.75,,,1578.75,Other,125% New York Medicaid APG,1263,25888.26,
Ercp lithotripsy calculi,43265,CPT,,,,,,,,both,,,119876.35,88708.5,74,,88708.5,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,53944.36,45,,53944.36,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,59338.79,49.5,,59338.79,percent of total billed charges,110% of Medicare,81515.92,68,,81515.92,percent of total billed charges,,2563.88,,,2563.88,Other,186% of Medicaid,95901.08,80,,95901.08,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,95901.08,80,,95901.08,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,83913.45,70,,83913.45,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1378.43,,,1378.43,Other,New York Medicaid APG methodology,1378.43,,,1378.43,Other,100% New York Medicaid APG,1378.43,,,1378.43,Other,100% New York Medicaid APG,1378.43,,,1378.43,Other,100% New York Medicaid APG,3101.47,,,3101.47,Other,225% New York Medicaid APG,2109,,,2109,Other,153% New York Medicaid APG,3101.47,,,3101.47,Other,225% New York Medicaid APG,1929.81,,,1929.81,Other,140% New York Medicaid APG,3101.47,,,3101.47,Other,225% New York Medicaid APG,3583.92,,,3583.92,Other,260% New York Medicaid APG,4466.12,,,4466.12,Other,324% New York Medicaid APG,2963.63,,,2963.63,Other,215% New York Medicaid APG,2963.63,,,2963.63,Other,215% New York Medicaid APG,1723.04,,,1723.04,Other,125% New York Medicaid APG,1378.43,95901.08,
Egd endoscopic stent place,43266,CPT,,,,,,,,both,,,29477.85,21813.61,74,,21813.61,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,13265.03,45,,13265.03,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,14591.54,49.5,,14591.54,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,1813.82,,,1813.82,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,20634.5,70,,20634.5,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,975.17,,,975.17,Other,New York Medicaid APG methodology,975.17,,,975.17,Other,100% New York Medicaid APG,975.17,,,975.17,Other,100% New York Medicaid APG,975.17,,,975.17,Other,100% New York Medicaid APG,2194.14,,,2194.14,Other,225% New York Medicaid APG,1492.01,,,1492.01,Other,153% New York Medicaid APG,2194.14,,,2194.14,Other,225% New York Medicaid APG,1365.24,,,1365.24,Other,140% New York Medicaid APG,2194.14,,,2194.14,Other,225% New York Medicaid APG,2535.45,,,2535.45,Other,260% New York Medicaid APG,3159.56,,,3159.56,Other,324% New York Medicaid APG,2096.62,,,2096.62,Other,215% New York Medicaid APG,2096.62,,,2096.62,Other,215% New York Medicaid APG,1218.96,,,1218.96,Other,125% New York Medicaid APG,975.17,21813.61,
Egd lesion ablation,43270,CPT,,,,,,,,both,,,20371.8,15075.13,74,,15075.13,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,9167.31,45,,9167.31,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,10084.04,49.5,,10084.04,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,1721.88,,,1721.88,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,14260.26,70,,14260.26,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,925.74,,,925.74,Other,New York Medicaid APG methodology,925.74,,,925.74,Other,100% New York Medicaid APG,925.74,,,925.74,Other,100% New York Medicaid APG,925.74,,,925.74,Other,100% New York Medicaid APG,2082.92,,,2082.92,Other,225% New York Medicaid APG,1416.38,,,1416.38,Other,153% New York Medicaid APG,2082.92,,,2082.92,Other,225% New York Medicaid APG,1296.04,,,1296.04,Other,140% New York Medicaid APG,2082.92,,,2082.92,Other,225% New York Medicaid APG,2406.92,,,2406.92,Other,260% New York Medicaid APG,2999.4,,,2999.4,Other,324% New York Medicaid APG,1990.34,,,1990.34,Other,215% New York Medicaid APG,1990.34,,,1990.34,Other,215% New York Medicaid APG,1157.18,,,1157.18,Other,125% New York Medicaid APG,925.74,15075.13,
Endoscopic pancreatoscopy,43273,CPT,,,,,,,,both,,,25918.71,19179.85,74,,19179.85,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,11663.42,45,,11663.42,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,12829.76,49.5,,12829.76,percent of total billed charges,110% of Medicare,17624.72,68,,17624.72,percent of total billed charges,,2563.88,,,2563.88,Other,186% of Medicaid,20734.97,80,,20734.97,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,20734.97,80,,20734.97,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,18143.1,70,,18143.1,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,1378.43,,,1378.43,Other,New York Medicaid APG methodology,1378.43,,,1378.43,Other,100% New York Medicaid APG,1378.43,,,1378.43,Other,100% New York Medicaid APG,1378.43,,,1378.43,Other,100% New York Medicaid APG,3101.47,,,3101.47,Other,225% New York Medicaid APG,2109,,,2109,Other,153% New York Medicaid APG,3101.47,,,3101.47,Other,225% New York Medicaid APG,1929.81,,,1929.81,Other,140% New York Medicaid APG,3101.47,,,3101.47,Other,225% New York Medicaid APG,3583.92,,,3583.92,Other,260% New York Medicaid APG,4466.12,,,4466.12,Other,324% New York Medicaid APG,2963.63,,,2963.63,Other,215% New York Medicaid APG,2963.63,,,2963.63,Other,215% New York Medicaid APG,1723.04,,,1723.04,Other,125% New York Medicaid APG,1378.43,20734.97,
Ercp duct stent placement,43274,CPT,,,,,,,,both,,,44985.34,33289.15,74,,33289.15,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,20243.4,45,,20243.4,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,22267.74,49.5,,22267.74,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2563.88,,,2563.88,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,31489.74,70,,31489.74,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1378.43,,,1378.43,Other,New York Medicaid APG methodology,1378.43,,,1378.43,Other,100% New York Medicaid APG,1378.43,,,1378.43,Other,100% New York Medicaid APG,1378.43,,,1378.43,Other,100% New York Medicaid APG,3101.47,,,3101.47,Other,225% New York Medicaid APG,2109,,,2109,Other,153% New York Medicaid APG,3101.47,,,3101.47,Other,225% New York Medicaid APG,1929.81,,,1929.81,Other,140% New York Medicaid APG,3101.47,,,3101.47,Other,225% New York Medicaid APG,3583.92,,,3583.92,Other,260% New York Medicaid APG,4466.12,,,4466.12,Other,324% New York Medicaid APG,2963.63,,,2963.63,Other,215% New York Medicaid APG,2963.63,,,2963.63,Other,215% New York Medicaid APG,1723.04,,,1723.04,Other,125% New York Medicaid APG,1378.43,33289.15,
Ercp remove forgn body duct,43275,CPT,,,,,,,,both,,,29252.14,21646.58,74,,21646.58,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,13163.46,45,,13163.46,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,14479.81,49.5,,14479.81,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2349.18,,,2349.18,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,20476.5,70,,20476.5,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1263,,,1263,Other,New York Medicaid APG methodology,1263,,,1263,Other,100% New York Medicaid APG,1263,,,1263,Other,100% New York Medicaid APG,1263,,,1263,Other,100% New York Medicaid APG,2841.76,,,2841.76,Other,225% New York Medicaid APG,1932.39,,,1932.39,Other,153% New York Medicaid APG,2841.76,,,2841.76,Other,225% New York Medicaid APG,1768.2,,,1768.2,Other,140% New York Medicaid APG,2841.76,,,2841.76,Other,225% New York Medicaid APG,3283.81,,,3283.81,Other,260% New York Medicaid APG,4092.13,,,4092.13,Other,324% New York Medicaid APG,2715.46,,,2715.46,Other,215% New York Medicaid APG,2715.46,,,2715.46,Other,215% New York Medicaid APG,1578.75,,,1578.75,Other,125% New York Medicaid APG,1263,21646.58,
Ercp stent exchange w/dilate,43276,CPT,,,,,,,,both,,,37978.7,28104.24,74,,28104.24,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,17090.42,45,,17090.42,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,18799.46,49.5,,18799.46,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2563.88,,,2563.88,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,26585.09,70,,26585.09,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1378.43,,,1378.43,Other,New York Medicaid APG methodology,1378.43,,,1378.43,Other,100% New York Medicaid APG,1378.43,,,1378.43,Other,100% New York Medicaid APG,1378.43,,,1378.43,Other,100% New York Medicaid APG,3101.47,,,3101.47,Other,225% New York Medicaid APG,2109,,,2109,Other,153% New York Medicaid APG,3101.47,,,3101.47,Other,225% New York Medicaid APG,1929.81,,,1929.81,Other,140% New York Medicaid APG,3101.47,,,3101.47,Other,225% New York Medicaid APG,3583.92,,,3583.92,Other,260% New York Medicaid APG,4466.12,,,4466.12,Other,324% New York Medicaid APG,2963.63,,,2963.63,Other,215% New York Medicaid APG,2963.63,,,2963.63,Other,215% New York Medicaid APG,1723.04,,,1723.04,Other,125% New York Medicaid APG,1378.43,28104.24,
Ercp ea duct/ampulla dilate,43277,CPT,,,,,,,,both,,,22214.78,16438.94,74,,16438.94,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,9996.65,45,,9996.65,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,10996.32,49.5,,10996.32,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2563.88,,,2563.88,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,15550.35,70,,15550.35,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1378.43,,,1378.43,Other,New York Medicaid APG methodology,1378.43,,,1378.43,Other,100% New York Medicaid APG,1378.43,,,1378.43,Other,100% New York Medicaid APG,1378.43,,,1378.43,Other,100% New York Medicaid APG,3101.47,,,3101.47,Other,225% New York Medicaid APG,2109,,,2109,Other,153% New York Medicaid APG,3101.47,,,3101.47,Other,225% New York Medicaid APG,1929.81,,,1929.81,Other,140% New York Medicaid APG,3101.47,,,3101.47,Other,225% New York Medicaid APG,3583.92,,,3583.92,Other,260% New York Medicaid APG,4466.12,,,4466.12,Other,324% New York Medicaid APG,2963.63,,,2963.63,Other,215% New York Medicaid APG,2963.63,,,2963.63,Other,215% New York Medicaid APG,1723.04,,,1723.04,Other,125% New York Medicaid APG,1378.43,16438.94,
Ercp lesion ablate w/dilate,43278,CPT,,,,,,,,both,,,33649.33,24900.5,74,,24900.5,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15142.2,45,,15142.2,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,16656.42,49.5,,16656.42,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2563.88,,,2563.88,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,23554.53,70,,23554.53,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1378.43,,,1378.43,Other,New York Medicaid APG methodology,1378.43,,,1378.43,Other,100% New York Medicaid APG,1378.43,,,1378.43,Other,100% New York Medicaid APG,1378.43,,,1378.43,Other,100% New York Medicaid APG,3101.47,,,3101.47,Other,225% New York Medicaid APG,2109,,,2109,Other,153% New York Medicaid APG,3101.47,,,3101.47,Other,225% New York Medicaid APG,1929.81,,,1929.81,Other,140% New York Medicaid APG,3101.47,,,3101.47,Other,225% New York Medicaid APG,3583.92,,,3583.92,Other,260% New York Medicaid APG,4466.12,,,4466.12,Other,324% New York Medicaid APG,2963.63,,,2963.63,Other,215% New York Medicaid APG,2963.63,,,2963.63,Other,215% New York Medicaid APG,1723.04,,,1723.04,Other,125% New York Medicaid APG,1378.43,24900.5,
Laparoscopy fundoplasty,43280,CPT,,,,,,,,both,,,68977.61,51043.43,74,,51043.43,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,31039.92,45,,31039.92,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,34143.92,49.5,,34143.92,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,4367.06,,,4367.06,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,48284.33,70,,48284.33,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,2347.88,,,2347.88,Other,New York Medicaid APG methodology,2347.88,,,2347.88,Other,100% New York Medicaid APG,2347.88,,,2347.88,Other,100% New York Medicaid APG,2347.88,,,2347.88,Other,100% New York Medicaid APG,5282.73,,,5282.73,Other,225% New York Medicaid APG,3592.26,,,3592.26,Other,153% New York Medicaid APG,5282.73,,,5282.73,Other,225% New York Medicaid APG,3287.03,,,3287.03,Other,140% New York Medicaid APG,5282.73,,,5282.73,Other,225% New York Medicaid APG,6104.49,,,6104.49,Other,260% New York Medicaid APG,7607.13,,,7607.13,Other,324% New York Medicaid APG,5047.94,,,5047.94,Other,215% New York Medicaid APG,5047.94,,,5047.94,Other,215% New York Medicaid APG,2934.85,,,2934.85,Other,125% New York Medicaid APG,2347.88,51043.43,
Lap paraesophag hern repair,43281,CPT,,,,,,,,both,,,51978.93,38464.41,74,,38464.41,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,23390.52,45,,23390.52,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,25729.57,49.5,,25729.57,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,4034.06,,,4034.06,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,36385.25,70,,36385.25,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,2168.85,,,2168.85,Other,New York Medicaid APG methodology,2168.85,,,2168.85,Other,100% New York Medicaid APG,2168.85,,,2168.85,Other,100% New York Medicaid APG,2168.85,,,2168.85,Other,100% New York Medicaid APG,4879.91,,,4879.91,Other,225% New York Medicaid APG,3318.34,,,3318.34,Other,153% New York Medicaid APG,4879.91,,,4879.91,Other,225% New York Medicaid APG,3036.39,,,3036.39,Other,140% New York Medicaid APG,4879.91,,,4879.91,Other,225% New York Medicaid APG,5639.01,,,5639.01,Other,260% New York Medicaid APG,7027.07,,,7027.07,Other,324% New York Medicaid APG,4663.02,,,4663.02,Other,215% New York Medicaid APG,4663.02,,,4663.02,Other,215% New York Medicaid APG,2711.06,,,2711.06,Other,125% New York Medicaid APG,2168.85,38464.41,
Lap paraesoph her rpr w/mesh,43282,CPT,,,,,,,,both,,,50030.79,37022.78,74,,37022.78,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,22513.86,45,,22513.86,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,24765.24,49.5,,24765.24,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,4034.06,,,4034.06,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,35021.55,70,,35021.55,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,2168.85,,,2168.85,Other,New York Medicaid APG methodology,2168.85,,,2168.85,Other,100% New York Medicaid APG,2168.85,,,2168.85,Other,100% New York Medicaid APG,2168.85,,,2168.85,Other,100% New York Medicaid APG,4879.91,,,4879.91,Other,225% New York Medicaid APG,3318.34,,,3318.34,Other,153% New York Medicaid APG,4879.91,,,4879.91,Other,225% New York Medicaid APG,3036.39,,,3036.39,Other,140% New York Medicaid APG,4879.91,,,4879.91,Other,225% New York Medicaid APG,5639.01,,,5639.01,Other,260% New York Medicaid APG,7027.07,,,7027.07,Other,324% New York Medicaid APG,4663.02,,,4663.02,Other,215% New York Medicaid APG,4663.02,,,4663.02,Other,215% New York Medicaid APG,2711.06,,,2711.06,Other,125% New York Medicaid APG,2168.85,37022.78,
Laps esophgl sphnctr agmntj,43284,CPT,,,,,,,,both,,,216515.17,160221.23,74,,160221.23,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,97431.83,45,,97431.83,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,107175.01,49.5,,107175.01,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,4367.06,,,4367.06,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,151560.62,70,,151560.62,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,2347.88,,,2347.88,Other,New York Medicaid APG methodology,2347.88,,,2347.88,Other,100% New York Medicaid APG,2347.88,,,2347.88,Other,100% New York Medicaid APG,2347.88,,,2347.88,Other,100% New York Medicaid APG,5282.73,,,5282.73,Other,225% New York Medicaid APG,3592.26,,,3592.26,Other,153% New York Medicaid APG,5282.73,,,5282.73,Other,225% New York Medicaid APG,3287.03,,,3287.03,Other,140% New York Medicaid APG,5282.73,,,5282.73,Other,225% New York Medicaid APG,6104.49,,,6104.49,Other,260% New York Medicaid APG,7607.13,,,7607.13,Other,324% New York Medicaid APG,5047.94,,,5047.94,Other,215% New York Medicaid APG,5047.94,,,5047.94,Other,215% New York Medicaid APG,2934.85,,,2934.85,Other,125% New York Medicaid APG,2347.88,160221.23,
Rmvl esophgl sphnctr dev,43285,CPT,,,,,,,,both,,,121364.27,89809.56,74,,89809.56,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,54613.92,45,,54613.92,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,6125,,"100% primary, 50% secondary, 25% supplemental procedure",6125,Other,Blue Cross ASC Grouper,5513,,"100% primary, 50% secondary, 25% supplemental procedure",5513,Other,Blue Cross ASC Grouper,5206,,"100% primary, 50% secondary, 25% supplemental procedure",5206,Other,Blue Cross ASC Grouper,60075.31,49.5,,60075.31,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,4367.06,,,4367.06,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,84954.99,70,,84954.99,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,2347.88,,,2347.88,Other,New York Medicaid APG methodology,2347.88,,,2347.88,Other,100% New York Medicaid APG,2347.88,,,2347.88,Other,100% New York Medicaid APG,2347.88,,,2347.88,Other,100% New York Medicaid APG,5282.73,,,5282.73,Other,225% New York Medicaid APG,3592.26,,,3592.26,Other,153% New York Medicaid APG,5282.73,,,5282.73,Other,225% New York Medicaid APG,3287.03,,,3287.03,Other,140% New York Medicaid APG,5282.73,,,5282.73,Other,225% New York Medicaid APG,6104.49,,,6104.49,Other,260% New York Medicaid APG,7607.13,,,7607.13,Other,324% New York Medicaid APG,5047.94,,,5047.94,Other,215% New York Medicaid APG,5047.94,,,5047.94,Other,215% New York Medicaid APG,2934.85,,,2934.85,Other,125% New York Medicaid APG,2347.88,89809.56,
Repair esophagus opening,43420,CPT,,,,,,,,both,,,67720.49,50113.16,74,,50113.16,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30474.22,45,,30474.22,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,33521.64,49.5,,33521.64,percent of total billed charges,110% of Medicare,46049.93,68,,46049.93,percent of total billed charges,,4162.5,,,4162.5,Other,186% of Medicaid,54176.39,80,,54176.39,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,54176.39,80,,54176.39,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,47404.34,70,,47404.34,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,2237.9,,,2237.9,Other,New York Medicaid APG methodology,2237.9,,,2237.9,Other,100% New York Medicaid APG,2237.9,,,2237.9,Other,100% New York Medicaid APG,2237.9,,,2237.9,Other,100% New York Medicaid APG,5035.28,,,5035.28,Other,225% New York Medicaid APG,3423.99,,,3423.99,Other,153% New York Medicaid APG,5035.28,,,5035.28,Other,225% New York Medicaid APG,3133.06,,,3133.06,Other,140% New York Medicaid APG,5035.28,,,5035.28,Other,225% New York Medicaid APG,5818.55,,,5818.55,Other,260% New York Medicaid APG,7250.81,,,7250.81,Other,324% New York Medicaid APG,4811.49,,,4811.49,Other,215% New York Medicaid APG,4811.49,,,4811.49,Other,215% New York Medicaid APG,2797.38,,,2797.38,Other,125% New York Medicaid APG,2232,54176.39,
Dilate esophagus 1/mult pass,43450,CPT,,,,,,,,both,,,19066.74,14109.39,74,,14109.39,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,8580.03,45,,8580.03,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,9438.04,49.5,,9438.04,percent of total billed charges,110% of Medicare,12965.38,68,,12965.38,percent of total billed charges,,1030.37,,,1030.37,Other,186% of Medicaid,15253.39,80,,15253.39,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,15253.39,80,,15253.39,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,13346.72,70,,13346.72,percent of total billed charges,,387.04,,,387.04,Fee Schedule,,328.04,,,328.04,Fee Schedule,,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,553.96,,,553.96,Other,New York Medicaid APG methodology,553.96,,,553.96,Other,100% New York Medicaid APG,553.96,,,553.96,Other,100% New York Medicaid APG,553.96,,,553.96,Other,100% New York Medicaid APG,1246.41,,,1246.41,Other,225% New York Medicaid APG,847.56,,,847.56,Other,153% New York Medicaid APG,1246.41,,,1246.41,Other,225% New York Medicaid APG,775.55,,,775.55,Other,140% New York Medicaid APG,1246.41,,,1246.41,Other,225% New York Medicaid APG,1440.3,,,1440.3,Other,260% New York Medicaid APG,1794.83,,,1794.83,Other,324% New York Medicaid APG,1191.02,,,1191.02,Other,215% New York Medicaid APG,1191.02,,,1191.02,Other,215% New York Medicaid APG,692.45,,,692.45,Other,125% New York Medicaid APG,328.04,15253.39,
Dilate esophagus,43453,CPT,,,,,,,,both,,,40023.39,29617.31,74,,29617.31,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,18010.53,45,,18010.53,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,19811.58,49.5,,19811.58,percent of total billed charges,110% of Medicare,27215.91,68,,27215.91,percent of total billed charges,,1030.37,,,1030.37,Other,186% of Medicaid,32018.71,80,,32018.71,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,32018.71,80,,32018.71,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,28016.37,70,,28016.37,percent of total billed charges,,418.2,,,418.2,Fee Schedule,,354.45,,,354.45,Fee Schedule,,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,553.96,,,553.96,Other,New York Medicaid APG methodology,553.96,,,553.96,Other,100% New York Medicaid APG,553.96,,,553.96,Other,100% New York Medicaid APG,553.96,,,553.96,Other,100% New York Medicaid APG,1246.41,,,1246.41,Other,225% New York Medicaid APG,847.56,,,847.56,Other,153% New York Medicaid APG,1246.41,,,1246.41,Other,225% New York Medicaid APG,775.55,,,775.55,Other,140% New York Medicaid APG,1246.41,,,1246.41,Other,225% New York Medicaid APG,1440.3,,,1440.3,Other,260% New York Medicaid APG,1794.83,,,1794.83,Other,324% New York Medicaid APG,1191.02,,,1191.02,Other,215% New York Medicaid APG,1191.02,,,1191.02,Other,215% New York Medicaid APG,692.45,,,692.45,Other,125% New York Medicaid APG,354.45,32018.71,
Surgical opening of stomach,43510,CPT,,,,,,,,both,,,19066.74,14109.39,74,,14109.39,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,8580.03,45,,8580.03,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,9438.04,49.5,,9438.04,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,4162.5,,,4162.5,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,13346.72,70,,13346.72,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,2237.9,,,2237.9,Other,New York Medicaid APG methodology,2237.9,,,2237.9,Other,100% New York Medicaid APG,2237.9,,,2237.9,Other,100% New York Medicaid APG,2237.9,,,2237.9,Other,100% New York Medicaid APG,5035.28,,,5035.28,Other,225% New York Medicaid APG,3423.99,,,3423.99,Other,153% New York Medicaid APG,5035.28,,,5035.28,Other,225% New York Medicaid APG,3133.06,,,3133.06,Other,140% New York Medicaid APG,5035.28,,,5035.28,Other,225% New York Medicaid APG,5818.55,,,5818.55,Other,260% New York Medicaid APG,7250.81,,,7250.81,Other,324% New York Medicaid APG,4811.49,,,4811.49,Other,215% New York Medicaid APG,4811.49,,,4811.49,Other,215% New York Medicaid APG,2797.38,,,2797.38,Other,125% New York Medicaid APG,2237.9,14109.39,
Lap impl electrode antrum,43647,CPT,,,,,,,,both,,,71765.7,53106.62,74,,53106.62,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,32294.57,45,,32294.57,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,35524.02,49.5,,35524.02,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3632.62,,,3632.62,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9196,,"100% primary, 0% secondary procedures",9196,Other,MagnaCare ASC Grouper,50235.99,70,,50235.99,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6956,,"100% primary, 50% secondary, 25% tertiary procedure",6956,Other,United Healthcare ASC Grouper,6261,,"100% primary, 50% secondary, 25% tertiary procedure",6261,Other,United Healthcare ASC Grouper,6956,,"100% primary, 50% secondary, 25% tertiary procedure",6956,Other,United Healthcare ASC Grouper,5913,,"100% primary, 50% secondary, 25% tertiary procedure",5913,Other,United Healthcare ASC Grouper,1953.02,,,1953.02,Other,New York Medicaid APG methodology,1953.02,,,1953.02,Other,100% New York Medicaid APG,1953.02,,,1953.02,Other,100% New York Medicaid APG,1953.02,,,1953.02,Other,100% New York Medicaid APG,4394.3,,,4394.3,Other,225% New York Medicaid APG,2988.12,,,2988.12,Other,153% New York Medicaid APG,4394.3,,,4394.3,Other,225% New York Medicaid APG,2734.23,,,2734.23,Other,140% New York Medicaid APG,4394.3,,,4394.3,Other,225% New York Medicaid APG,5077.86,,,5077.86,Other,260% New York Medicaid APG,6327.79,,,6327.79,Other,324% New York Medicaid APG,4199,,,4199,Other,215% New York Medicaid APG,4199,,,4199,Other,215% New York Medicaid APG,2441.28,,,2441.28,Other,125% New York Medicaid APG,1953.02,53106.62,
Lap revise/remv eltrd antrum,43648,CPT,,,,,,,,both,,,38857.5,28754.55,74,,28754.55,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,17485.88,45,,17485.88,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,6125,,"100% primary, 50% secondary, 25% supplemental procedure",6125,Other,Blue Cross ASC Grouper,5513,,"100% primary, 50% secondary, 25% supplemental procedure",5513,Other,Blue Cross ASC Grouper,5206,,"100% primary, 50% secondary, 25% supplemental procedure",5206,Other,Blue Cross ASC Grouper,19234.46,49.5,,19234.46,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3632.62,,,3632.62,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,27200.25,70,,27200.25,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,1953.02,,,1953.02,Other,New York Medicaid APG methodology,1953.02,,,1953.02,Other,100% New York Medicaid APG,1953.02,,,1953.02,Other,100% New York Medicaid APG,1953.02,,,1953.02,Other,100% New York Medicaid APG,4394.3,,,4394.3,Other,225% New York Medicaid APG,2988.12,,,2988.12,Other,153% New York Medicaid APG,4394.3,,,4394.3,Other,225% New York Medicaid APG,2734.23,,,2734.23,Other,140% New York Medicaid APG,4394.3,,,4394.3,Other,225% New York Medicaid APG,5077.86,,,5077.86,Other,260% New York Medicaid APG,6327.79,,,6327.79,Other,324% New York Medicaid APG,4199,,,4199,Other,215% New York Medicaid APG,4199,,,4199,Other,215% New York Medicaid APG,2441.28,,,2441.28,Other,125% New York Medicaid APG,1953.02,28754.55,
Laparoscopy vagus nerve,43651,CPT,,,,,,,,both,,,121364.27,89809.56,74,,89809.56,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,54613.92,45,,54613.92,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,6125,,"100% primary, 50% secondary, 25% supplemental procedure",6125,Other,Blue Cross ASC Grouper,5513,,"100% primary, 50% secondary, 25% supplemental procedure",5513,Other,Blue Cross ASC Grouper,5206,,"100% primary, 50% secondary, 25% supplemental procedure",5206,Other,Blue Cross ASC Grouper,60075.31,49.5,,60075.31,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3632.62,,,3632.62,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,84954.99,70,,84954.99,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,1953.02,,,1953.02,Other,New York Medicaid APG methodology,1953.02,,,1953.02,Other,100% New York Medicaid APG,1953.02,,,1953.02,Other,100% New York Medicaid APG,1953.02,,,1953.02,Other,100% New York Medicaid APG,4394.3,,,4394.3,Other,225% New York Medicaid APG,2988.12,,,2988.12,Other,153% New York Medicaid APG,4394.3,,,4394.3,Other,225% New York Medicaid APG,2734.23,,,2734.23,Other,140% New York Medicaid APG,4394.3,,,4394.3,Other,225% New York Medicaid APG,5077.86,,,5077.86,Other,260% New York Medicaid APG,6327.79,,,6327.79,Other,324% New York Medicaid APG,4199,,,4199,Other,215% New York Medicaid APG,4199,,,4199,Other,215% New York Medicaid APG,2441.28,,,2441.28,Other,125% New York Medicaid APG,1953.02,89809.56,
Laparoscopy vagus nerve,43652,CPT,,,,,,,,both,,,121364.27,89809.56,74,,89809.56,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,54613.92,45,,54613.92,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,6125,,"100% primary, 50% secondary, 25% supplemental procedure",6125,Other,Blue Cross ASC Grouper,5513,,"100% primary, 50% secondary, 25% supplemental procedure",5513,Other,Blue Cross ASC Grouper,5206,,"100% primary, 50% secondary, 25% supplemental procedure",5206,Other,Blue Cross ASC Grouper,60075.31,49.5,,60075.31,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3632.62,,,3632.62,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,84954.99,70,,84954.99,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,1953.02,,,1953.02,Other,New York Medicaid APG methodology,1953.02,,,1953.02,Other,100% New York Medicaid APG,1953.02,,,1953.02,Other,100% New York Medicaid APG,1953.02,,,1953.02,Other,100% New York Medicaid APG,4394.3,,,4394.3,Other,225% New York Medicaid APG,2988.12,,,2988.12,Other,153% New York Medicaid APG,4394.3,,,4394.3,Other,225% New York Medicaid APG,2734.23,,,2734.23,Other,140% New York Medicaid APG,4394.3,,,4394.3,Other,225% New York Medicaid APG,5077.86,,,5077.86,Other,260% New York Medicaid APG,6327.79,,,6327.79,Other,324% New York Medicaid APG,4199,,,4199,Other,215% New York Medicaid APG,4199,,,4199,Other,215% New York Medicaid APG,2441.28,,,2441.28,Other,125% New York Medicaid APG,1953.02,89809.56,
Laparoscopy gastrostomy,43653,CPT,,,,,,,,both,,,40291.87,29815.98,74,,29815.98,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,18131.34,45,,18131.34,percent of total billed charges,Medicare Ratio of cost to charges,5459,,"100% primary, 50% supplemental procedure",5459,Other,Aetna ASC Grouper,4913,,"100% primary, 50% supplemental procedure",4913,Other,Aetna ASC Grouper,6125,,"100% primary, 50% secondary, 25% supplemental procedure",6125,Other,Blue Cross ASC Grouper,5513,,"100% primary, 50% secondary, 25% supplemental procedure",5513,Other,Blue Cross ASC Grouper,5206,,"100% primary, 50% secondary, 25% supplemental procedure",5206,Other,Blue Cross ASC Grouper,19944.48,49.5,,19944.48,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,4162.5,,,4162.5,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,28204.31,70,,28204.31,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,2237.9,,,2237.9,Other,New York Medicaid APG methodology,2237.9,,,2237.9,Other,100% New York Medicaid APG,2237.9,,,2237.9,Other,100% New York Medicaid APG,2237.9,,,2237.9,Other,100% New York Medicaid APG,5035.28,,,5035.28,Other,225% New York Medicaid APG,3423.99,,,3423.99,Other,153% New York Medicaid APG,5035.28,,,5035.28,Other,225% New York Medicaid APG,3133.06,,,3133.06,Other,140% New York Medicaid APG,5035.28,,,5035.28,Other,225% New York Medicaid APG,5818.55,,,5818.55,Other,260% New York Medicaid APG,7250.81,,,7250.81,Other,324% New York Medicaid APG,4811.49,,,4811.49,Other,215% New York Medicaid APG,4811.49,,,4811.49,Other,215% New York Medicaid APG,2797.38,,,2797.38,Other,125% New York Medicaid APG,2237.9,29815.98,
Nasal/orogastric w/tube plmt,43752,CPT,,,,,,,,both,,,8380.68,6201.7,74,,6201.7,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,3771.31,45,,3771.31,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,4148.44,49.5,,4148.44,percent of total billed charges,110% of Medicare,5698.86,68,,5698.86,percent of total billed charges,,1030.37,,,1030.37,Other,186% of Medicaid,6704.54,80,,6704.54,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,6704.54,80,,6704.54,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,5866.48,70,,5866.48,percent of total billed charges,,195.16,,,195.16,Fee Schedule,,165.41,,,165.41,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,553.96,,,553.96,Other,New York Medicaid APG methodology,553.96,,,553.96,Other,100% New York Medicaid APG,553.96,,,553.96,Other,100% New York Medicaid APG,553.96,,,553.96,Other,100% New York Medicaid APG,1246.41,,,1246.41,Other,225% New York Medicaid APG,847.56,,,847.56,Other,153% New York Medicaid APG,1246.41,,,1246.41,Other,225% New York Medicaid APG,775.55,,,775.55,Other,140% New York Medicaid APG,1246.41,,,1246.41,Other,225% New York Medicaid APG,1440.3,,,1440.3,Other,260% New York Medicaid APG,1794.83,,,1794.83,Other,324% New York Medicaid APG,1191.02,,,1191.02,Other,215% New York Medicaid APG,1191.02,,,1191.02,Other,215% New York Medicaid APG,692.45,,,692.45,Other,125% New York Medicaid APG,165.41,7216,
Tx gastro intub w/asp,43753,CPT,,,,,,,,both,,,6602.02,4885.49,74,,4885.49,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,2970.91,45,,2970.91,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,3268,49.5,,3268,percent of total billed charges,110% of Medicare,4489.37,68,,4489.37,percent of total billed charges,,0.02,,,0.02,Other,186% of Medicaid,5281.62,80,,5281.62,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,5281.62,80,,5281.62,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,4621.41,70,,4621.41,percent of total billed charges,,104.96,,,104.96,Fee Schedule,,88.96,,,88.96,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% New York Medicaid APG,0.01,,,0.01,Other,100% New York Medicaid APG,0.01,,,0.01,Other,100% New York Medicaid APG,0.02,,,0.02,Other,225% New York Medicaid APG,0.02,,,0.02,Other,153% New York Medicaid APG,0.02,,,0.02,Other,225% New York Medicaid APG,0.01,,,0.01,Other,140% New York Medicaid APG,0.02,,,0.02,Other,225% New York Medicaid APG,0.03,,,0.03,Other,260% New York Medicaid APG,0.03,,,0.03,Other,324% New York Medicaid APG,0.02,,,0.02,Other,215% New York Medicaid APG,0.02,,,0.02,Other,215% New York Medicaid APG,0.01,,,0.01,Other,125% New York Medicaid APG,0.01,7216,
Dx gastr intub w/asp spec,43754,CPT,,,,,,,,both,,,6602.02,4885.49,74,,4885.49,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,2970.91,45,,2970.91,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,3268,49.5,,3268,percent of total billed charges,110% of Medicare,4489.37,68,,4489.37,percent of total billed charges,,0.02,,,0.02,Other,186% of Medicaid,5281.62,80,,5281.62,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,5281.62,80,,5281.62,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,4621.41,70,,4621.41,percent of total billed charges,,183.68,,,183.68,Fee Schedule,,155.68,,,155.68,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% New York Medicaid APG,0.01,,,0.01,Other,100% New York Medicaid APG,0.01,,,0.01,Other,100% New York Medicaid APG,0.02,,,0.02,Other,225% New York Medicaid APG,0.02,,,0.02,Other,153% New York Medicaid APG,0.02,,,0.02,Other,225% New York Medicaid APG,0.01,,,0.01,Other,140% New York Medicaid APG,0.02,,,0.02,Other,225% New York Medicaid APG,0.03,,,0.03,Other,260% New York Medicaid APG,0.03,,,0.03,Other,324% New York Medicaid APG,0.02,,,0.02,Other,215% New York Medicaid APG,0.02,,,0.02,Other,215% New York Medicaid APG,0.01,,,0.01,Other,125% New York Medicaid APG,0.01,7216,
Dx gastr intub w/asp specs,43755,CPT,,,,,,,,both,,,3285.56,2431.31,74,,2431.31,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,1478.5,45,,1478.5,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,1626.35,49.5,,1626.35,percent of total billed charges,110% of Medicare,2234.18,68,,2234.18,percent of total billed charges,,1030.37,,,1030.37,Other,186% of Medicaid,2628.45,80,,2628.45,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,2628.45,80,,2628.45,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,2299.89,70,,2299.89,percent of total billed charges,,288.64,,,288.64,Fee Schedule,,244.64,,,244.64,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,553.96,,,553.96,Other,New York Medicaid APG methodology,553.96,,,553.96,Other,100% New York Medicaid APG,553.96,,,553.96,Other,100% New York Medicaid APG,553.96,,,553.96,Other,100% New York Medicaid APG,1246.41,,,1246.41,Other,225% New York Medicaid APG,847.56,,,847.56,Other,153% New York Medicaid APG,1246.41,,,1246.41,Other,225% New York Medicaid APG,775.55,,,775.55,Other,140% New York Medicaid APG,1246.41,,,1246.41,Other,225% New York Medicaid APG,1440.3,,,1440.3,Other,260% New York Medicaid APG,1794.83,,,1794.83,Other,324% New York Medicaid APG,1191.02,,,1191.02,Other,215% New York Medicaid APG,1191.02,,,1191.02,Other,215% New York Medicaid APG,692.45,,,692.45,Other,125% New York Medicaid APG,244.64,7216,
Dx duod intub w/asp spec,43756,CPT,,,,,,,,both,,,19066.74,14109.39,74,,14109.39,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,8580.03,45,,8580.03,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,9438.04,49.5,,9438.04,percent of total billed charges,110% of Medicare,12965.38,68,,12965.38,percent of total billed charges,,1030.37,,,1030.37,Other,186% of Medicaid,15253.39,80,,15253.39,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,15253.39,80,,15253.39,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,13346.72,70,,13346.72,percent of total billed charges,,247.64,,,247.64,Fee Schedule,,209.89,,,209.89,Fee Schedule,,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,553.96,,,553.96,Other,New York Medicaid APG methodology,553.96,,,553.96,Other,100% New York Medicaid APG,553.96,,,553.96,Other,100% New York Medicaid APG,553.96,,,553.96,Other,100% New York Medicaid APG,1246.41,,,1246.41,Other,225% New York Medicaid APG,847.56,,,847.56,Other,153% New York Medicaid APG,1246.41,,,1246.41,Other,225% New York Medicaid APG,775.55,,,775.55,Other,140% New York Medicaid APG,1246.41,,,1246.41,Other,225% New York Medicaid APG,1440.3,,,1440.3,Other,260% New York Medicaid APG,1794.83,,,1794.83,Other,324% New York Medicaid APG,1191.02,,,1191.02,Other,215% New York Medicaid APG,1191.02,,,1191.02,Other,215% New York Medicaid APG,692.45,,,692.45,Other,125% New York Medicaid APG,209.89,15253.39,
Dx duod intub w/asp specs,43757,CPT,,,,,,,,both,,,19066.74,14109.39,74,,14109.39,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,8580.03,45,,8580.03,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,9438.04,49.5,,9438.04,percent of total billed charges,110% of Medicare,12965.38,68,,12965.38,percent of total billed charges,,1030.37,,,1030.37,Other,186% of Medicaid,15253.39,80,,15253.39,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,15253.39,80,,15253.39,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,13346.72,70,,13346.72,percent of total billed charges,,373.92,,,373.92,Fee Schedule,,316.92,,,316.92,Fee Schedule,,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,553.96,,,553.96,Other,New York Medicaid APG methodology,553.96,,,553.96,Other,100% New York Medicaid APG,553.96,,,553.96,Other,100% New York Medicaid APG,553.96,,,553.96,Other,100% New York Medicaid APG,1246.41,,,1246.41,Other,225% New York Medicaid APG,847.56,,,847.56,Other,153% New York Medicaid APG,1246.41,,,1246.41,Other,225% New York Medicaid APG,775.55,,,775.55,Other,140% New York Medicaid APG,1246.41,,,1246.41,Other,225% New York Medicaid APG,1440.3,,,1440.3,Other,260% New York Medicaid APG,1794.83,,,1794.83,Other,324% New York Medicaid APG,1191.02,,,1191.02,Other,215% New York Medicaid APG,1191.02,,,1191.02,Other,215% New York Medicaid APG,692.45,,,692.45,Other,125% New York Medicaid APG,316.92,15253.39,
Reposition gastrostomy tube,43761,CPT,,,,,,,,both,,,5198.43,3846.84,74,,3846.84,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,2339.29,45,,2339.29,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,2573.22,49.5,,2573.22,percent of total billed charges,110% of Medicare,3534.93,68,,3534.93,percent of total billed charges,,1030.37,,,1030.37,Other,186% of Medicaid,4158.74,80,,4158.74,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,4158.74,80,,4158.74,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,3638.9,70,,3638.9,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,553.96,,,553.96,Other,New York Medicaid APG methodology,553.96,,,553.96,Other,100% New York Medicaid APG,553.96,,,553.96,Other,100% New York Medicaid APG,553.96,,,553.96,Other,100% New York Medicaid APG,1246.41,,,1246.41,Other,225% New York Medicaid APG,847.56,,,847.56,Other,153% New York Medicaid APG,1246.41,,,1246.41,Other,225% New York Medicaid APG,775.55,,,775.55,Other,140% New York Medicaid APG,1246.41,,,1246.41,Other,225% New York Medicaid APG,1440.3,,,1440.3,Other,260% New York Medicaid APG,1794.83,,,1794.83,Other,324% New York Medicaid APG,1191.02,,,1191.02,Other,215% New York Medicaid APG,1191.02,,,1191.02,Other,215% New York Medicaid APG,692.45,,,692.45,Other,125% New York Medicaid APG,553.96,7216,
Rplc gtube no revj trc,43762,CPT,,,,,,,,both,,,34227.74,25328.53,74,,25328.53,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15402.48,45,,15402.48,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,16942.73,49.5,,16942.73,percent of total billed charges,110% of Medicare,23274.86,68,,23274.86,percent of total billed charges,,1030.37,,,1030.37,Other,186% of Medicaid,27382.19,80,,27382.19,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,27382.19,80,,27382.19,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,23959.42,70,,23959.42,percent of total billed charges,,178.76,,,178.76,Fee Schedule,,151.51,,,151.51,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,553.96,,,553.96,Other,New York Medicaid APG methodology,553.96,,,553.96,Other,100% New York Medicaid APG,553.96,,,553.96,Other,100% New York Medicaid APG,553.96,,,553.96,Other,100% New York Medicaid APG,1246.41,,,1246.41,Other,225% New York Medicaid APG,847.56,,,847.56,Other,153% New York Medicaid APG,1246.41,,,1246.41,Other,225% New York Medicaid APG,775.55,,,775.55,Other,140% New York Medicaid APG,1246.41,,,1246.41,Other,225% New York Medicaid APG,1440.3,,,1440.3,Other,260% New York Medicaid APG,1794.83,,,1794.83,Other,324% New York Medicaid APG,1191.02,,,1191.02,Other,215% New York Medicaid APG,1191.02,,,1191.02,Other,215% New York Medicaid APG,692.45,,,692.45,Other,125% New York Medicaid APG,151.51,27382.19,
Rplc gtube revj gstrst trc,43763,CPT,,,,,,,,both,,,5198.43,3846.84,74,,3846.84,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,2339.29,45,,2339.29,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,2573.22,49.5,,2573.22,percent of total billed charges,110% of Medicare,3534.93,68,,3534.93,percent of total billed charges,,1030.37,,,1030.37,Other,186% of Medicaid,4158.74,80,,4158.74,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,4158.74,80,,4158.74,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,3638.9,70,,3638.9,percent of total billed charges,,424.76,,,424.76,Fee Schedule,,360.01,,,360.01,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,553.96,,,553.96,Other,New York Medicaid APG methodology,553.96,,,553.96,Other,100% New York Medicaid APG,553.96,,,553.96,Other,100% New York Medicaid APG,553.96,,,553.96,Other,100% New York Medicaid APG,1246.41,,,1246.41,Other,225% New York Medicaid APG,847.56,,,847.56,Other,153% New York Medicaid APG,1246.41,,,1246.41,Other,225% New York Medicaid APG,775.55,,,775.55,Other,140% New York Medicaid APG,1246.41,,,1246.41,Other,225% New York Medicaid APG,1440.3,,,1440.3,Other,260% New York Medicaid APG,1794.83,,,1794.83,Other,324% New York Medicaid APG,1191.02,,,1191.02,Other,215% New York Medicaid APG,1191.02,,,1191.02,Other,215% New York Medicaid APG,692.45,,,692.45,Other,125% New York Medicaid APG,360.01,7216,
Lap place gastr adj device,43770,CPT,,,,,,,,both,,,216515.17,160221.23,74,,160221.23,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,97431.83,45,,97431.83,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,107175.01,49.5,,107175.01,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,4367.06,,,4367.06,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,151560.62,70,,151560.62,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,2347.88,,,2347.88,Other,New York Medicaid APG methodology,2347.88,,,2347.88,Other,100% New York Medicaid APG,2347.88,,,2347.88,Other,100% New York Medicaid APG,2347.88,,,2347.88,Other,100% New York Medicaid APG,5282.73,,,5282.73,Other,225% New York Medicaid APG,3592.26,,,3592.26,Other,153% New York Medicaid APG,5282.73,,,5282.73,Other,225% New York Medicaid APG,3287.03,,,3287.03,Other,140% New York Medicaid APG,5282.73,,,5282.73,Other,225% New York Medicaid APG,6104.49,,,6104.49,Other,260% New York Medicaid APG,7607.13,,,7607.13,Other,324% New York Medicaid APG,5047.94,,,5047.94,Other,215% New York Medicaid APG,5047.94,,,5047.94,Other,215% New York Medicaid APG,2934.85,,,2934.85,Other,125% New York Medicaid APG,2347.88,160221.23,
Lap rmvl gastr adj device,43772,CPT,,,,,,,,both,,,80554.09,59610.03,74,,59610.03,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,36249.34,45,,36249.34,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,39874.27,49.5,,39874.27,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,4367.06,,,4367.06,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,56387.86,70,,56387.86,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,2347.88,,,2347.88,Other,New York Medicaid APG methodology,2347.88,,,2347.88,Other,100% New York Medicaid APG,2347.88,,,2347.88,Other,100% New York Medicaid APG,2347.88,,,2347.88,Other,100% New York Medicaid APG,5282.73,,,5282.73,Other,225% New York Medicaid APG,3592.26,,,3592.26,Other,153% New York Medicaid APG,5282.73,,,5282.73,Other,225% New York Medicaid APG,3287.03,,,3287.03,Other,140% New York Medicaid APG,5282.73,,,5282.73,Other,225% New York Medicaid APG,6104.49,,,6104.49,Other,260% New York Medicaid APG,7607.13,,,7607.13,Other,324% New York Medicaid APG,5047.94,,,5047.94,Other,215% New York Medicaid APG,5047.94,,,5047.94,Other,215% New York Medicaid APG,2934.85,,,2934.85,Other,125% New York Medicaid APG,2347.88,59610.03,
Lap replace gastr adj device,43773,CPT,,,,,,,,both,,,121364.27,89809.56,74,,89809.56,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,54613.92,45,,54613.92,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,6125,,"100% primary, 50% secondary, 25% supplemental procedure",6125,Other,Blue Cross ASC Grouper,5513,,"100% primary, 50% secondary, 25% supplemental procedure",5513,Other,Blue Cross ASC Grouper,5206,,"100% primary, 50% secondary, 25% supplemental procedure",5206,Other,Blue Cross ASC Grouper,60075.31,49.5,,60075.31,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,4367.06,,,4367.06,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,84954.99,70,,84954.99,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,2347.88,,,2347.88,Other,New York Medicaid APG methodology,2347.88,,,2347.88,Other,100% New York Medicaid APG,2347.88,,,2347.88,Other,100% New York Medicaid APG,2347.88,,,2347.88,Other,100% New York Medicaid APG,5282.73,,,5282.73,Other,225% New York Medicaid APG,3592.26,,,3592.26,Other,153% New York Medicaid APG,5282.73,,,5282.73,Other,225% New York Medicaid APG,3287.03,,,3287.03,Other,140% New York Medicaid APG,5282.73,,,5282.73,Other,225% New York Medicaid APG,6104.49,,,6104.49,Other,260% New York Medicaid APG,7607.13,,,7607.13,Other,324% New York Medicaid APG,5047.94,,,5047.94,Other,215% New York Medicaid APG,5047.94,,,5047.94,Other,215% New York Medicaid APG,2934.85,,,2934.85,Other,125% New York Medicaid APG,2347.88,89809.56,
Lap rmvl gastr adj all parts,43774,CPT,,,,,,,,both,,,43538.66,32218.61,74,,32218.61,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,19592.4,45,,19592.4,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,21551.64,49.5,,21551.64,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,4367.06,,,4367.06,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9196,,"100% primary, 0% secondary procedures",9196,Other,MagnaCare ASC Grouper,30477.06,70,,30477.06,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6956,,"100% primary, 50% secondary, 25% tertiary procedure",6956,Other,United Healthcare ASC Grouper,6261,,"100% primary, 50% secondary, 25% tertiary procedure",6261,Other,United Healthcare ASC Grouper,6956,,"100% primary, 50% secondary, 25% tertiary procedure",6956,Other,United Healthcare ASC Grouper,5913,,"100% primary, 50% secondary, 25% tertiary procedure",5913,Other,United Healthcare ASC Grouper,2347.88,,,2347.88,Other,New York Medicaid APG methodology,2347.88,,,2347.88,Other,100% New York Medicaid APG,2347.88,,,2347.88,Other,100% New York Medicaid APG,2347.88,,,2347.88,Other,100% New York Medicaid APG,5282.73,,,5282.73,Other,225% New York Medicaid APG,3592.26,,,3592.26,Other,153% New York Medicaid APG,5282.73,,,5282.73,Other,225% New York Medicaid APG,3287.03,,,3287.03,Other,140% New York Medicaid APG,5282.73,,,5282.73,Other,225% New York Medicaid APG,6104.49,,,6104.49,Other,260% New York Medicaid APG,7607.13,,,7607.13,Other,324% New York Medicaid APG,5047.94,,,5047.94,Other,215% New York Medicaid APG,5047.94,,,5047.94,Other,215% New York Medicaid APG,2934.85,,,2934.85,Other,125% New York Medicaid APG,2347.88,32218.61,
Place gastrostomy tube,43830,CPT,,,,,,,,both,,,40023.39,29617.31,74,,29617.31,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,18010.53,45,,18010.53,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,19811.58,49.5,,19811.58,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3157.33,,,3157.33,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,28016.37,70,,28016.37,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1697.49,,,1697.49,Other,New York Medicaid APG methodology,1697.49,,,1697.49,Other,100% New York Medicaid APG,1697.49,,,1697.49,Other,100% New York Medicaid APG,1697.49,,,1697.49,Other,100% New York Medicaid APG,3819.36,,,3819.36,Other,225% New York Medicaid APG,2597.16,,,2597.16,Other,153% New York Medicaid APG,3819.36,,,3819.36,Other,225% New York Medicaid APG,2376.49,,,2376.49,Other,140% New York Medicaid APG,3819.36,,,3819.36,Other,225% New York Medicaid APG,4413.48,,,4413.48,Other,260% New York Medicaid APG,5499.87,,,5499.87,Other,324% New York Medicaid APG,3649.61,,,3649.61,Other,215% New York Medicaid APG,3649.61,,,3649.61,Other,215% New York Medicaid APG,2121.86,,,2121.86,Other,125% New York Medicaid APG,1697.49,29617.31,
Place gastrostomy tube,43831,CPT,,,,,,,,both,,,19066.74,14109.39,74,,14109.39,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,8580.03,45,,8580.03,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,9438.04,49.5,,9438.04,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3157.33,,,3157.33,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,13346.72,70,,13346.72,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1697.49,,,1697.49,Other,New York Medicaid APG methodology,1697.49,,,1697.49,Other,100% New York Medicaid APG,1697.49,,,1697.49,Other,100% New York Medicaid APG,1697.49,,,1697.49,Other,100% New York Medicaid APG,3819.36,,,3819.36,Other,225% New York Medicaid APG,2597.16,,,2597.16,Other,153% New York Medicaid APG,3819.36,,,3819.36,Other,225% New York Medicaid APG,2376.49,,,2376.49,Other,140% New York Medicaid APG,3819.36,,,3819.36,Other,225% New York Medicaid APG,4413.48,,,4413.48,Other,260% New York Medicaid APG,5499.87,,,5499.87,Other,324% New York Medicaid APG,3649.61,,,3649.61,Other,215% New York Medicaid APG,3649.61,,,3649.61,Other,215% New York Medicaid APG,2121.86,,,2121.86,Other,125% New York Medicaid APG,1697.49,14109.39,
Repair stomach opening,43870,CPT,,,,,,,,both,,,35558.33,26313.16,74,,26313.16,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,16001.25,45,,16001.25,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,17601.37,49.5,,17601.37,percent of total billed charges,110% of Medicare,24179.66,68,,24179.66,percent of total billed charges,,3157.33,,,3157.33,Other,186% of Medicaid,28446.66,80,,28446.66,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,28446.66,80,,28446.66,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,24890.83,70,,24890.83,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1697.49,,,1697.49,Other,New York Medicaid APG methodology,1697.49,,,1697.49,Other,100% New York Medicaid APG,1697.49,,,1697.49,Other,100% New York Medicaid APG,1697.49,,,1697.49,Other,100% New York Medicaid APG,3819.36,,,3819.36,Other,225% New York Medicaid APG,2597.16,,,2597.16,Other,153% New York Medicaid APG,3819.36,,,3819.36,Other,225% New York Medicaid APG,2376.49,,,2376.49,Other,140% New York Medicaid APG,3819.36,,,3819.36,Other,225% New York Medicaid APG,4413.48,,,4413.48,Other,260% New York Medicaid APG,5499.87,,,5499.87,Other,324% New York Medicaid APG,3649.61,,,3649.61,Other,215% New York Medicaid APG,3649.61,,,3649.61,Other,215% New York Medicaid APG,2121.86,,,2121.86,Other,125% New York Medicaid APG,1697.49,28446.66,
Revise gastric port open,43886,CPT,,,,,,,,both,,,75461.18,55841.27,74,,55841.27,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,33957.53,45,,33957.53,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,37353.28,49.5,,37353.28,percent of total billed charges,110% of Medicare,51313.6,68,,51313.6,percent of total billed charges,,3157.33,,,3157.33,Other,186% of Medicaid,60368.94,80,,60368.94,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,60368.94,80,,60368.94,percent of total billed charges,,7216,,,7216,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,52822.83,70,,52822.83,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1697.49,,,1697.49,Other,New York Medicaid APG methodology,1697.49,,,1697.49,Other,100% New York Medicaid APG,1697.49,,,1697.49,Other,100% New York Medicaid APG,1697.49,,,1697.49,Other,100% New York Medicaid APG,3819.36,,,3819.36,Other,225% New York Medicaid APG,2597.16,,,2597.16,Other,153% New York Medicaid APG,3819.36,,,3819.36,Other,225% New York Medicaid APG,2376.49,,,2376.49,Other,140% New York Medicaid APG,3819.36,,,3819.36,Other,225% New York Medicaid APG,4413.48,,,4413.48,Other,260% New York Medicaid APG,5499.87,,,5499.87,Other,324% New York Medicaid APG,3649.61,,,3649.61,Other,215% New York Medicaid APG,3649.61,,,3649.61,Other,215% New York Medicaid APG,2121.86,,,2121.86,Other,125% New York Medicaid APG,1697.49,60368.94,
Remove gastric port open,43887,CPT,,,,,,,,both,,,38357.55,28384.59,74,,28384.59,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,17260.9,45,,17260.9,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,18986.99,49.5,,18986.99,percent of total billed charges,110% of Medicare,26083.13,68,,26083.13,percent of total billed charges,,3157.33,,,3157.33,Other,186% of Medicaid,30686.04,80,,30686.04,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,30686.04,80,,30686.04,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,26850.29,70,,26850.29,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1697.49,,,1697.49,Other,New York Medicaid APG methodology,1697.49,,,1697.49,Other,100% New York Medicaid APG,1697.49,,,1697.49,Other,100% New York Medicaid APG,1697.49,,,1697.49,Other,100% New York Medicaid APG,3819.36,,,3819.36,Other,225% New York Medicaid APG,2597.16,,,2597.16,Other,153% New York Medicaid APG,3819.36,,,3819.36,Other,225% New York Medicaid APG,2376.49,,,2376.49,Other,140% New York Medicaid APG,3819.36,,,3819.36,Other,225% New York Medicaid APG,4413.48,,,4413.48,Other,260% New York Medicaid APG,5499.87,,,5499.87,Other,324% New York Medicaid APG,3649.61,,,3649.61,Other,215% New York Medicaid APG,3649.61,,,3649.61,Other,215% New York Medicaid APG,2121.86,,,2121.86,Other,125% New York Medicaid APG,1697.49,30686.04,
Change gastric port open,43888,CPT,,,,,,,,both,,,75461.18,55841.27,74,,55841.27,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,33957.53,45,,33957.53,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,37353.28,49.5,,37353.28,percent of total billed charges,110% of Medicare,51313.6,68,,51313.6,percent of total billed charges,,4367.06,,,4367.06,Other,186% of Medicaid,60368.94,80,,60368.94,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,60368.94,80,,60368.94,percent of total billed charges,,7216,,,7216,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,52822.83,70,,52822.83,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,2347.88,,,2347.88,Other,New York Medicaid APG methodology,2347.88,,,2347.88,Other,100% New York Medicaid APG,2347.88,,,2347.88,Other,100% New York Medicaid APG,2347.88,,,2347.88,Other,100% New York Medicaid APG,5282.73,,,5282.73,Other,225% New York Medicaid APG,3592.26,,,3592.26,Other,153% New York Medicaid APG,5282.73,,,5282.73,Other,225% New York Medicaid APG,3287.03,,,3287.03,Other,140% New York Medicaid APG,5282.73,,,5282.73,Other,225% New York Medicaid APG,6104.49,,,6104.49,Other,260% New York Medicaid APG,7607.13,,,7607.13,Other,324% New York Medicaid APG,5047.94,,,5047.94,Other,215% New York Medicaid APG,5047.94,,,5047.94,Other,215% New York Medicaid APG,2934.85,,,2934.85,Other,125% New York Medicaid APG,2232,60368.94,
Biopsy of bowel,44100,CPT,,,,,,,,both,,,19066.74,14109.39,74,,14109.39,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,8580.03,45,,8580.03,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,9438.04,49.5,,9438.04,percent of total billed charges,110% of Medicare,12965.38,68,,12965.38,percent of total billed charges,,1478.54,,,1478.54,Other,186% of Medicaid,15253.39,80,,15253.39,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,15253.39,80,,15253.39,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,13346.72,70,,13346.72,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,794.91,,,794.91,Other,New York Medicaid APG methodology,794.91,,,794.91,Other,100% New York Medicaid APG,794.91,,,794.91,Other,100% New York Medicaid APG,794.91,,,794.91,Other,100% New York Medicaid APG,1788.55,,,1788.55,Other,225% New York Medicaid APG,1216.22,,,1216.22,Other,153% New York Medicaid APG,1788.55,,,1788.55,Other,225% New York Medicaid APG,1112.88,,,1112.88,Other,140% New York Medicaid APG,1788.55,,,1788.55,Other,225% New York Medicaid APG,2066.77,,,2066.77,Other,260% New York Medicaid APG,2575.52,,,2575.52,Other,324% New York Medicaid APG,1709.06,,,1709.06,Other,215% New York Medicaid APG,1709.06,,,1709.06,Other,215% New York Medicaid APG,993.64,,,993.64,Other,125% New York Medicaid APG,794.91,15253.39,
Lap enterolysis,44180,CPT,,,,,,,,both,,,36727.13,27178.08,74,,27178.08,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,16527.21,45,,16527.21,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,6125,,"100% primary, 50% secondary, 25% supplemental procedure",6125,Other,Blue Cross ASC Grouper,5513,,"100% primary, 50% secondary, 25% supplemental procedure",5513,Other,Blue Cross ASC Grouper,5206,,"100% primary, 50% secondary, 25% supplemental procedure",5206,Other,Blue Cross ASC Grouper,18179.93,49.5,,18179.93,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,4362.86,,,4362.86,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,25708.99,70,,25708.99,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,2345.62,,,2345.62,Other,New York Medicaid APG methodology,2345.62,,,2345.62,Other,100% New York Medicaid APG,2345.62,,,2345.62,Other,100% New York Medicaid APG,2345.62,,,2345.62,Other,100% New York Medicaid APG,5277.65,,,5277.65,Other,225% New York Medicaid APG,3588.8,,,3588.8,Other,153% New York Medicaid APG,5277.65,,,5277.65,Other,225% New York Medicaid APG,3283.87,,,3283.87,Other,140% New York Medicaid APG,5277.65,,,5277.65,Other,225% New York Medicaid APG,6098.62,,,6098.62,Other,260% New York Medicaid APG,7599.81,,,7599.81,Other,324% New York Medicaid APG,5043.09,,,5043.09,Other,215% New York Medicaid APG,5043.09,,,5043.09,Other,215% New York Medicaid APG,2932.03,,,2932.03,Other,125% New York Medicaid APG,2345.62,27178.08,
Lap jejunostomy,44186,CPT,,,,,,,,both,,,121364.27,89809.56,74,,89809.56,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,54613.92,45,,54613.92,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,6125,,"100% primary, 50% secondary, 25% supplemental procedure",6125,Other,Blue Cross ASC Grouper,5513,,"100% primary, 50% secondary, 25% supplemental procedure",5513,Other,Blue Cross ASC Grouper,5206,,"100% primary, 50% secondary, 25% supplemental procedure",5206,Other,Blue Cross ASC Grouper,60075.31,49.5,,60075.31,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,4362.86,,,4362.86,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,84954.99,70,,84954.99,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,2345.62,,,2345.62,Other,New York Medicaid APG methodology,2345.62,,,2345.62,Other,100% New York Medicaid APG,2345.62,,,2345.62,Other,100% New York Medicaid APG,2345.62,,,2345.62,Other,100% New York Medicaid APG,5277.65,,,5277.65,Other,225% New York Medicaid APG,3588.8,,,3588.8,Other,153% New York Medicaid APG,5277.65,,,5277.65,Other,225% New York Medicaid APG,3283.87,,,3283.87,Other,140% New York Medicaid APG,5277.65,,,5277.65,Other,225% New York Medicaid APG,6098.62,,,6098.62,Other,260% New York Medicaid APG,7599.81,,,7599.81,Other,324% New York Medicaid APG,5043.09,,,5043.09,Other,215% New York Medicaid APG,5043.09,,,5043.09,Other,215% New York Medicaid APG,2932.03,,,2932.03,Other,125% New York Medicaid APG,2345.62,89809.56,
Revision of ileostomy,44312,CPT,,,,,,,,both,,,75461.18,55841.27,74,,55841.27,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,33957.53,45,,33957.53,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,37353.28,49.5,,37353.28,percent of total billed charges,110% of Medicare,51313.6,68,,51313.6,percent of total billed charges,,3995.12,,,3995.12,Other,186% of Medicaid,60368.94,80,,60368.94,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,60368.94,80,,60368.94,percent of total billed charges,,7216,,,7216,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,52822.83,70,,52822.83,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,2147.92,,,2147.92,Other,New York Medicaid APG methodology,2147.92,,,2147.92,Other,100% New York Medicaid APG,2147.92,,,2147.92,Other,100% New York Medicaid APG,2147.92,,,2147.92,Other,100% New York Medicaid APG,4832.81,,,4832.81,Other,225% New York Medicaid APG,3286.31,,,3286.31,Other,153% New York Medicaid APG,4832.81,,,4832.81,Other,225% New York Medicaid APG,3007.08,,,3007.08,Other,140% New York Medicaid APG,4832.81,,,4832.81,Other,225% New York Medicaid APG,5584.58,,,5584.58,Other,260% New York Medicaid APG,6959.25,,,6959.25,Other,324% New York Medicaid APG,4618.02,,,4618.02,Other,215% New York Medicaid APG,4618.02,,,4618.02,Other,215% New York Medicaid APG,2684.89,,,2684.89,Other,125% New York Medicaid APG,2053,60368.94,
Revision of colostomy,44340,CPT,,,,,,,,both,,,75461.18,55841.27,74,,55841.27,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,33957.53,45,,33957.53,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,37353.28,49.5,,37353.28,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3995.12,,,3995.12,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,52822.83,70,,52822.83,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,2147.92,,,2147.92,Other,New York Medicaid APG methodology,2147.92,,,2147.92,Other,100% New York Medicaid APG,2147.92,,,2147.92,Other,100% New York Medicaid APG,2147.92,,,2147.92,Other,100% New York Medicaid APG,4832.81,,,4832.81,Other,225% New York Medicaid APG,3286.31,,,3286.31,Other,153% New York Medicaid APG,4832.81,,,4832.81,Other,225% New York Medicaid APG,3007.08,,,3007.08,Other,140% New York Medicaid APG,4832.81,,,4832.81,Other,225% New York Medicaid APG,5584.58,,,5584.58,Other,260% New York Medicaid APG,6959.25,,,6959.25,Other,324% New York Medicaid APG,4618.02,,,4618.02,Other,215% New York Medicaid APG,4618.02,,,4618.02,Other,215% New York Medicaid APG,2684.89,,,2684.89,Other,125% New York Medicaid APG,2147.92,55841.27,
Small bowel endoscopy,44360,CPT,,,,,,,,both,,,12741.73,9428.88,74,,9428.88,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,5733.78,45,,5733.78,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,6307.16,49.5,,6307.16,percent of total billed charges,110% of Medicare,8664.38,68,,8664.38,percent of total billed charges,,1530.86,,,1530.86,Other,186% of Medicaid,10193.38,80,,10193.38,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,10193.38,80,,10193.38,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,8919.21,70,,8919.21,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,823.04,,,823.04,Other,New York Medicaid APG methodology,823.04,,,823.04,Other,100% New York Medicaid APG,823.04,,,823.04,Other,100% New York Medicaid APG,823.04,,,823.04,Other,100% New York Medicaid APG,1851.85,,,1851.85,Other,225% New York Medicaid APG,1259.26,,,1259.26,Other,153% New York Medicaid APG,1851.85,,,1851.85,Other,225% New York Medicaid APG,1152.26,,,1152.26,Other,140% New York Medicaid APG,1851.85,,,1851.85,Other,225% New York Medicaid APG,2139.92,,,2139.92,Other,260% New York Medicaid APG,2666.66,,,2666.66,Other,324% New York Medicaid APG,1769.55,,,1769.55,Other,215% New York Medicaid APG,1769.55,,,1769.55,Other,215% New York Medicaid APG,1028.81,,,1028.81,Other,125% New York Medicaid APG,823.04,10193.38,
Small bowel endoscopy/biopsy,44361,CPT,,,,,,,,both,,,18601.74,13765.29,74,,13765.29,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,8370.78,45,,8370.78,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,9207.86,49.5,,9207.86,percent of total billed charges,110% of Medicare,12649.18,68,,12649.18,percent of total billed charges,,1530.86,,,1530.86,Other,186% of Medicaid,14881.39,80,,14881.39,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,14881.39,80,,14881.39,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,13021.22,70,,13021.22,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,823.04,,,823.04,Other,New York Medicaid APG methodology,823.04,,,823.04,Other,100% New York Medicaid APG,823.04,,,823.04,Other,100% New York Medicaid APG,823.04,,,823.04,Other,100% New York Medicaid APG,1851.85,,,1851.85,Other,225% New York Medicaid APG,1259.26,,,1259.26,Other,153% New York Medicaid APG,1851.85,,,1851.85,Other,225% New York Medicaid APG,1152.26,,,1152.26,Other,140% New York Medicaid APG,1851.85,,,1851.85,Other,225% New York Medicaid APG,2139.92,,,2139.92,Other,260% New York Medicaid APG,2666.66,,,2666.66,Other,324% New York Medicaid APG,1769.55,,,1769.55,Other,215% New York Medicaid APG,1769.55,,,1769.55,Other,215% New York Medicaid APG,1028.81,,,1028.81,Other,125% New York Medicaid APG,823.04,14881.39,
Small bowel endoscopy,44363,CPT,,,,,,,,both,,,40023.39,29617.31,74,,29617.31,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,18010.53,45,,18010.53,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,19811.58,49.5,,19811.58,percent of total billed charges,110% of Medicare,27215.91,68,,27215.91,percent of total billed charges,,1721.88,,,1721.88,Other,186% of Medicaid,32018.71,80,,32018.71,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,32018.71,80,,32018.71,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,28016.37,70,,28016.37,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,925.74,,,925.74,Other,New York Medicaid APG methodology,925.74,,,925.74,Other,100% New York Medicaid APG,925.74,,,925.74,Other,100% New York Medicaid APG,925.74,,,925.74,Other,100% New York Medicaid APG,2082.92,,,2082.92,Other,225% New York Medicaid APG,1416.38,,,1416.38,Other,153% New York Medicaid APG,2082.92,,,2082.92,Other,225% New York Medicaid APG,1296.04,,,1296.04,Other,140% New York Medicaid APG,2082.92,,,2082.92,Other,225% New York Medicaid APG,2406.92,,,2406.92,Other,260% New York Medicaid APG,2999.4,,,2999.4,Other,324% New York Medicaid APG,1990.34,,,1990.34,Other,215% New York Medicaid APG,1990.34,,,1990.34,Other,215% New York Medicaid APG,1157.18,,,1157.18,Other,125% New York Medicaid APG,925.74,32018.71,
Small bowel endoscopy,44364,CPT,,,,,,,,both,,,20520,15184.8,74,,15184.8,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,9234,45,,9234,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,10157.4,49.5,,10157.4,percent of total billed charges,110% of Medicare,13953.6,68,,13953.6,percent of total billed charges,,1721.88,,,1721.88,Other,186% of Medicaid,16416,80,,16416,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,16416,80,,16416,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,14364,70,,14364,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,925.74,,,925.74,Other,New York Medicaid APG methodology,925.74,,,925.74,Other,100% New York Medicaid APG,925.74,,,925.74,Other,100% New York Medicaid APG,925.74,,,925.74,Other,100% New York Medicaid APG,2082.92,,,2082.92,Other,225% New York Medicaid APG,1416.38,,,1416.38,Other,153% New York Medicaid APG,2082.92,,,2082.92,Other,225% New York Medicaid APG,1296.04,,,1296.04,Other,140% New York Medicaid APG,2082.92,,,2082.92,Other,225% New York Medicaid APG,2406.92,,,2406.92,Other,260% New York Medicaid APG,2999.4,,,2999.4,Other,324% New York Medicaid APG,1990.34,,,1990.34,Other,215% New York Medicaid APG,1990.34,,,1990.34,Other,215% New York Medicaid APG,1157.18,,,1157.18,Other,125% New York Medicaid APG,925.74,16416,
Small bowel endoscopy,44365,CPT,,,,,,,,both,,,40023.39,29617.31,74,,29617.31,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,18010.53,45,,18010.53,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,19811.58,49.5,,19811.58,percent of total billed charges,110% of Medicare,27215.91,68,,27215.91,percent of total billed charges,,1721.88,,,1721.88,Other,186% of Medicaid,32018.71,80,,32018.71,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,32018.71,80,,32018.71,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,28016.37,70,,28016.37,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,925.74,,,925.74,Other,New York Medicaid APG methodology,925.74,,,925.74,Other,100% New York Medicaid APG,925.74,,,925.74,Other,100% New York Medicaid APG,925.74,,,925.74,Other,100% New York Medicaid APG,2082.92,,,2082.92,Other,225% New York Medicaid APG,1416.38,,,1416.38,Other,153% New York Medicaid APG,2082.92,,,2082.92,Other,225% New York Medicaid APG,1296.04,,,1296.04,Other,140% New York Medicaid APG,2082.92,,,2082.92,Other,225% New York Medicaid APG,2406.92,,,2406.92,Other,260% New York Medicaid APG,2999.4,,,2999.4,Other,324% New York Medicaid APG,1990.34,,,1990.34,Other,215% New York Medicaid APG,1990.34,,,1990.34,Other,215% New York Medicaid APG,1157.18,,,1157.18,Other,125% New York Medicaid APG,925.74,32018.71,
Small bowel endoscopy,44366,CPT,,,,,,,,both,,,13853.17,10251.35,74,,10251.35,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,6233.93,45,,6233.93,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,6857.32,49.5,,6857.32,percent of total billed charges,110% of Medicare,9420.16,68,,9420.16,percent of total billed charges,,1721.88,,,1721.88,Other,186% of Medicaid,11082.54,80,,11082.54,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,11082.54,80,,11082.54,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,9697.22,70,,9697.22,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,925.74,,,925.74,Other,New York Medicaid APG methodology,925.74,,,925.74,Other,100% New York Medicaid APG,925.74,,,925.74,Other,100% New York Medicaid APG,925.74,,,925.74,Other,100% New York Medicaid APG,2082.92,,,2082.92,Other,225% New York Medicaid APG,1416.38,,,1416.38,Other,153% New York Medicaid APG,2082.92,,,2082.92,Other,225% New York Medicaid APG,1296.04,,,1296.04,Other,140% New York Medicaid APG,2082.92,,,2082.92,Other,225% New York Medicaid APG,2406.92,,,2406.92,Other,260% New York Medicaid APG,2999.4,,,2999.4,Other,324% New York Medicaid APG,1990.34,,,1990.34,Other,215% New York Medicaid APG,1990.34,,,1990.34,Other,215% New York Medicaid APG,1157.18,,,1157.18,Other,125% New York Medicaid APG,925.74,11082.54,
Small bowel endoscopy,44369,CPT,,,,,,,,both,,,21770.89,16110.46,74,,16110.46,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,9796.9,45,,9796.9,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,10776.59,49.5,,10776.59,percent of total billed charges,110% of Medicare,14804.21,68,,14804.21,percent of total billed charges,,1530.86,,,1530.86,Other,186% of Medicaid,17416.71,80,,17416.71,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,17416.71,80,,17416.71,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,15239.62,70,,15239.62,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,823.04,,,823.04,Other,New York Medicaid APG methodology,823.04,,,823.04,Other,100% New York Medicaid APG,823.04,,,823.04,Other,100% New York Medicaid APG,823.04,,,823.04,Other,100% New York Medicaid APG,1851.85,,,1851.85,Other,225% New York Medicaid APG,1259.26,,,1259.26,Other,153% New York Medicaid APG,1851.85,,,1851.85,Other,225% New York Medicaid APG,1152.26,,,1152.26,Other,140% New York Medicaid APG,1851.85,,,1851.85,Other,225% New York Medicaid APG,2139.92,,,2139.92,Other,260% New York Medicaid APG,2666.66,,,2666.66,Other,324% New York Medicaid APG,1769.55,,,1769.55,Other,215% New York Medicaid APG,1769.55,,,1769.55,Other,215% New York Medicaid APG,1028.81,,,1028.81,Other,125% New York Medicaid APG,823.04,17416.71,
Small bowel endoscopy/stent,44370,CPT,,,,,,,,both,,,119876.35,88708.5,74,,88708.5,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,53944.36,45,,53944.36,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,59338.79,49.5,,59338.79,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,1721.88,,,1721.88,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,83913.45,70,,83913.45,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,925.74,,,925.74,Other,New York Medicaid APG methodology,925.74,,,925.74,Other,100% New York Medicaid APG,925.74,,,925.74,Other,100% New York Medicaid APG,925.74,,,925.74,Other,100% New York Medicaid APG,2082.92,,,2082.92,Other,225% New York Medicaid APG,1416.38,,,1416.38,Other,153% New York Medicaid APG,2082.92,,,2082.92,Other,225% New York Medicaid APG,1296.04,,,1296.04,Other,140% New York Medicaid APG,2082.92,,,2082.92,Other,225% New York Medicaid APG,2406.92,,,2406.92,Other,260% New York Medicaid APG,2999.4,,,2999.4,Other,324% New York Medicaid APG,1990.34,,,1990.34,Other,215% New York Medicaid APG,1990.34,,,1990.34,Other,215% New York Medicaid APG,1157.18,,,1157.18,Other,125% New York Medicaid APG,925.74,88708.5,
Small bowel endoscopy,44372,CPT,,,,,,,,both,,,40023.39,29617.31,74,,29617.31,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,18010.53,45,,18010.53,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,19811.58,49.5,,19811.58,percent of total billed charges,110% of Medicare,27215.91,68,,27215.91,percent of total billed charges,,1530.86,,,1530.86,Other,186% of Medicaid,32018.71,80,,32018.71,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,32018.71,80,,32018.71,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,28016.37,70,,28016.37,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,823.04,,,823.04,Other,New York Medicaid APG methodology,823.04,,,823.04,Other,100% New York Medicaid APG,823.04,,,823.04,Other,100% New York Medicaid APG,823.04,,,823.04,Other,100% New York Medicaid APG,1851.85,,,1851.85,Other,225% New York Medicaid APG,1259.26,,,1259.26,Other,153% New York Medicaid APG,1851.85,,,1851.85,Other,225% New York Medicaid APG,1152.26,,,1152.26,Other,140% New York Medicaid APG,1851.85,,,1851.85,Other,225% New York Medicaid APG,2139.92,,,2139.92,Other,260% New York Medicaid APG,2666.66,,,2666.66,Other,324% New York Medicaid APG,1769.55,,,1769.55,Other,215% New York Medicaid APG,1769.55,,,1769.55,Other,215% New York Medicaid APG,1028.81,,,1028.81,Other,125% New York Medicaid APG,823.04,32018.71,
Small bowel endoscopy,44373,CPT,,,,,,,,both,,,14298,10580.52,74,,10580.52,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,6434.1,45,,6434.1,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,7077.51,49.5,,7077.51,percent of total billed charges,110% of Medicare,9722.64,68,,9722.64,percent of total billed charges,,1530.86,,,1530.86,Other,186% of Medicaid,11438.4,80,,11438.4,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,11438.4,80,,11438.4,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,10008.6,70,,10008.6,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,823.04,,,823.04,Other,New York Medicaid APG methodology,823.04,,,823.04,Other,100% New York Medicaid APG,823.04,,,823.04,Other,100% New York Medicaid APG,823.04,,,823.04,Other,100% New York Medicaid APG,1851.85,,,1851.85,Other,225% New York Medicaid APG,1259.26,,,1259.26,Other,153% New York Medicaid APG,1851.85,,,1851.85,Other,225% New York Medicaid APG,1152.26,,,1152.26,Other,140% New York Medicaid APG,1851.85,,,1851.85,Other,225% New York Medicaid APG,2139.92,,,2139.92,Other,260% New York Medicaid APG,2666.66,,,2666.66,Other,324% New York Medicaid APG,1769.55,,,1769.55,Other,215% New York Medicaid APG,1769.55,,,1769.55,Other,215% New York Medicaid APG,1028.81,,,1028.81,Other,125% New York Medicaid APG,823.04,11438.4,
Small bowel endoscopy,44376,CPT,,,,,,,,both,,,40023.39,29617.31,74,,29617.31,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,18010.53,45,,18010.53,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,19811.58,49.5,,19811.58,percent of total billed charges,110% of Medicare,27215.91,68,,27215.91,percent of total billed charges,,1530.86,,,1530.86,Other,186% of Medicaid,32018.71,80,,32018.71,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,32018.71,80,,32018.71,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,28016.37,70,,28016.37,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,823.04,,,823.04,Other,New York Medicaid APG methodology,823.04,,,823.04,Other,100% New York Medicaid APG,823.04,,,823.04,Other,100% New York Medicaid APG,823.04,,,823.04,Other,100% New York Medicaid APG,1851.85,,,1851.85,Other,225% New York Medicaid APG,1259.26,,,1259.26,Other,153% New York Medicaid APG,1851.85,,,1851.85,Other,225% New York Medicaid APG,1152.26,,,1152.26,Other,140% New York Medicaid APG,1851.85,,,1851.85,Other,225% New York Medicaid APG,2139.92,,,2139.92,Other,260% New York Medicaid APG,2666.66,,,2666.66,Other,324% New York Medicaid APG,1769.55,,,1769.55,Other,215% New York Medicaid APG,1769.55,,,1769.55,Other,215% New York Medicaid APG,1028.81,,,1028.81,Other,125% New York Medicaid APG,823.04,32018.71,
Small bowel endoscopy/biopsy,44377,CPT,,,,,,,,both,,,40023.39,29617.31,74,,29617.31,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,18010.53,45,,18010.53,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,19811.58,49.5,,19811.58,percent of total billed charges,110% of Medicare,27215.91,68,,27215.91,percent of total billed charges,,1530.86,,,1530.86,Other,186% of Medicaid,32018.71,80,,32018.71,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,32018.71,80,,32018.71,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,28016.37,70,,28016.37,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,823.04,,,823.04,Other,New York Medicaid APG methodology,823.04,,,823.04,Other,100% New York Medicaid APG,823.04,,,823.04,Other,100% New York Medicaid APG,823.04,,,823.04,Other,100% New York Medicaid APG,1851.85,,,1851.85,Other,225% New York Medicaid APG,1259.26,,,1259.26,Other,153% New York Medicaid APG,1851.85,,,1851.85,Other,225% New York Medicaid APG,1152.26,,,1152.26,Other,140% New York Medicaid APG,1851.85,,,1851.85,Other,225% New York Medicaid APG,2139.92,,,2139.92,Other,260% New York Medicaid APG,2666.66,,,2666.66,Other,324% New York Medicaid APG,1769.55,,,1769.55,Other,215% New York Medicaid APG,1769.55,,,1769.55,Other,215% New York Medicaid APG,1028.81,,,1028.81,Other,125% New York Medicaid APG,823.04,32018.71,
Small bowel endoscopy,44378,CPT,,,,,,,,both,,,40023.39,29617.31,74,,29617.31,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,18010.53,45,,18010.53,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,19811.58,49.5,,19811.58,percent of total billed charges,110% of Medicare,27215.91,68,,27215.91,percent of total billed charges,,1721.88,,,1721.88,Other,186% of Medicaid,32018.71,80,,32018.71,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,32018.71,80,,32018.71,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,28016.37,70,,28016.37,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,925.74,,,925.74,Other,New York Medicaid APG methodology,925.74,,,925.74,Other,100% New York Medicaid APG,925.74,,,925.74,Other,100% New York Medicaid APG,925.74,,,925.74,Other,100% New York Medicaid APG,2082.92,,,2082.92,Other,225% New York Medicaid APG,1416.38,,,1416.38,Other,153% New York Medicaid APG,2082.92,,,2082.92,Other,225% New York Medicaid APG,1296.04,,,1296.04,Other,140% New York Medicaid APG,2082.92,,,2082.92,Other,225% New York Medicaid APG,2406.92,,,2406.92,Other,260% New York Medicaid APG,2999.4,,,2999.4,Other,324% New York Medicaid APG,1990.34,,,1990.34,Other,215% New York Medicaid APG,1990.34,,,1990.34,Other,215% New York Medicaid APG,1157.18,,,1157.18,Other,125% New York Medicaid APG,925.74,32018.71,
S bowel endoscope w/stent,44379,CPT,,,,,,,,both,,,119876.35,88708.5,74,,88708.5,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,53944.36,45,,53944.36,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,59338.79,49.5,,59338.79,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,1721.88,,,1721.88,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,83913.45,70,,83913.45,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,925.74,,,925.74,Other,New York Medicaid APG methodology,925.74,,,925.74,Other,100% New York Medicaid APG,925.74,,,925.74,Other,100% New York Medicaid APG,925.74,,,925.74,Other,100% New York Medicaid APG,2082.92,,,2082.92,Other,225% New York Medicaid APG,1416.38,,,1416.38,Other,153% New York Medicaid APG,2082.92,,,2082.92,Other,225% New York Medicaid APG,1296.04,,,1296.04,Other,140% New York Medicaid APG,2082.92,,,2082.92,Other,225% New York Medicaid APG,2406.92,,,2406.92,Other,260% New York Medicaid APG,2999.4,,,2999.4,Other,324% New York Medicaid APG,1990.34,,,1990.34,Other,215% New York Medicaid APG,1990.34,,,1990.34,Other,215% New York Medicaid APG,1157.18,,,1157.18,Other,125% New York Medicaid APG,925.74,88708.5,
Small bowel endoscopy br/wa,44380,CPT,,,,,,,,both,,,19066.74,14109.39,74,,14109.39,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,8580.03,45,,8580.03,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,9438.04,49.5,,9438.04,percent of total billed charges,110% of Medicare,12965.38,68,,12965.38,percent of total billed charges,,1478.54,,,1478.54,Other,186% of Medicaid,15253.39,80,,15253.39,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,15253.39,80,,15253.39,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,13346.72,70,,13346.72,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,794.91,,,794.91,Other,New York Medicaid APG methodology,794.91,,,794.91,Other,100% New York Medicaid APG,794.91,,,794.91,Other,100% New York Medicaid APG,794.91,,,794.91,Other,100% New York Medicaid APG,1788.55,,,1788.55,Other,225% New York Medicaid APG,1216.22,,,1216.22,Other,153% New York Medicaid APG,1788.55,,,1788.55,Other,225% New York Medicaid APG,1112.88,,,1112.88,Other,140% New York Medicaid APG,1788.55,,,1788.55,Other,225% New York Medicaid APG,2066.77,,,2066.77,Other,260% New York Medicaid APG,2575.52,,,2575.52,Other,324% New York Medicaid APG,1709.06,,,1709.06,Other,215% New York Medicaid APG,1709.06,,,1709.06,Other,215% New York Medicaid APG,993.64,,,993.64,Other,125% New York Medicaid APG,794.91,15253.39,
Small bowel endoscopy br/wa,44381,CPT,,,,,,,,both,,,40023.39,29617.31,74,,29617.31,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,18010.53,45,,18010.53,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,19811.58,49.5,,19811.58,percent of total billed charges,110% of Medicare,27215.91,68,,27215.91,percent of total billed charges,,1478.54,,,1478.54,Other,186% of Medicaid,32018.71,80,,32018.71,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,32018.71,80,,32018.71,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,28016.37,70,,28016.37,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,794.91,,,794.91,Other,New York Medicaid APG methodology,794.91,,,794.91,Other,100% New York Medicaid APG,794.91,,,794.91,Other,100% New York Medicaid APG,794.91,,,794.91,Other,100% New York Medicaid APG,1788.55,,,1788.55,Other,225% New York Medicaid APG,1216.22,,,1216.22,Other,153% New York Medicaid APG,1788.55,,,1788.55,Other,225% New York Medicaid APG,1112.88,,,1112.88,Other,140% New York Medicaid APG,1788.55,,,1788.55,Other,225% New York Medicaid APG,2066.77,,,2066.77,Other,260% New York Medicaid APG,2575.52,,,2575.52,Other,324% New York Medicaid APG,1709.06,,,1709.06,Other,215% New York Medicaid APG,1709.06,,,1709.06,Other,215% New York Medicaid APG,993.64,,,993.64,Other,125% New York Medicaid APG,794.91,32018.71,
Small bowel endoscopy,44382,CPT,,,,,,,,both,,,14892,11020.08,74,,11020.08,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,6701.4,45,,6701.4,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,7371.54,49.5,,7371.54,percent of total billed charges,110% of Medicare,10126.56,68,,10126.56,percent of total billed charges,,1478.54,,,1478.54,Other,186% of Medicaid,11913.6,80,,11913.6,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,11913.6,80,,11913.6,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,10424.4,70,,10424.4,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,794.91,,,794.91,Other,New York Medicaid APG methodology,794.91,,,794.91,Other,100% New York Medicaid APG,794.91,,,794.91,Other,100% New York Medicaid APG,794.91,,,794.91,Other,100% New York Medicaid APG,1788.55,,,1788.55,Other,225% New York Medicaid APG,1216.22,,,1216.22,Other,153% New York Medicaid APG,1788.55,,,1788.55,Other,225% New York Medicaid APG,1112.88,,,1112.88,Other,140% New York Medicaid APG,1788.55,,,1788.55,Other,225% New York Medicaid APG,2066.77,,,2066.77,Other,260% New York Medicaid APG,2575.52,,,2575.52,Other,324% New York Medicaid APG,1709.06,,,1709.06,Other,215% New York Medicaid APG,1709.06,,,1709.06,Other,215% New York Medicaid APG,993.64,,,993.64,Other,125% New York Medicaid APG,794.91,11913.6,
Small bowel endoscopy,44384,CPT,,,,,,,,both,,,40023.39,29617.31,74,,29617.31,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,18010.53,45,,18010.53,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,19811.58,49.5,,19811.58,percent of total billed charges,110% of Medicare,27215.91,68,,27215.91,percent of total billed charges,,1648.24,,,1648.24,Other,186% of Medicaid,32018.71,80,,32018.71,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,32018.71,80,,32018.71,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,28016.37,70,,28016.37,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,886.15,,,886.15,Other,New York Medicaid APG methodology,886.15,,,886.15,Other,100% New York Medicaid APG,886.15,,,886.15,Other,100% New York Medicaid APG,886.15,,,886.15,Other,100% New York Medicaid APG,1993.84,,,1993.84,Other,225% New York Medicaid APG,1355.81,,,1355.81,Other,153% New York Medicaid APG,1993.84,,,1993.84,Other,225% New York Medicaid APG,1240.61,,,1240.61,Other,140% New York Medicaid APG,1993.84,,,1993.84,Other,225% New York Medicaid APG,2303.99,,,2303.99,Other,260% New York Medicaid APG,2871.13,,,2871.13,Other,324% New York Medicaid APG,1905.23,,,1905.23,Other,215% New York Medicaid APG,1905.23,,,1905.23,Other,215% New York Medicaid APG,1107.69,,,1107.69,Other,125% New York Medicaid APG,886.15,32018.71,
Endoscopy of bowel pouch,44385,CPT,,,,,,,,both,,,11038,8168.12,74,,8168.12,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,4967.1,45,,4967.1,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,5463.81,49.5,,5463.81,percent of total billed charges,110% of Medicare,7505.84,68,,7505.84,percent of total billed charges,,1478.54,,,1478.54,Other,186% of Medicaid,8830.4,80,,8830.4,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,8830.4,80,,8830.4,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,7726.6,70,,7726.6,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,794.91,,,794.91,Other,New York Medicaid APG methodology,794.91,,,794.91,Other,100% New York Medicaid APG,794.91,,,794.91,Other,100% New York Medicaid APG,794.91,,,794.91,Other,100% New York Medicaid APG,1788.55,,,1788.55,Other,225% New York Medicaid APG,1216.22,,,1216.22,Other,153% New York Medicaid APG,1788.55,,,1788.55,Other,225% New York Medicaid APG,1112.88,,,1112.88,Other,140% New York Medicaid APG,1788.55,,,1788.55,Other,225% New York Medicaid APG,2066.77,,,2066.77,Other,260% New York Medicaid APG,2575.52,,,2575.52,Other,324% New York Medicaid APG,1709.06,,,1709.06,Other,215% New York Medicaid APG,1709.06,,,1709.06,Other,215% New York Medicaid APG,993.64,,,993.64,Other,125% New York Medicaid APG,794.91,8830.4,
Endoscopy bowel pouch/biop,44386,CPT,,,,,,,,both,,,15400,11396,74,,11396,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,6930,45,,6930,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,7623,49.5,,7623,percent of total billed charges,110% of Medicare,10472,68,,10472,percent of total billed charges,,1478.54,,,1478.54,Other,186% of Medicaid,12320,80,,12320,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,12320,80,,12320,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,10780,70,,10780,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,794.91,,,794.91,Other,New York Medicaid APG methodology,794.91,,,794.91,Other,100% New York Medicaid APG,794.91,,,794.91,Other,100% New York Medicaid APG,794.91,,,794.91,Other,100% New York Medicaid APG,1788.55,,,1788.55,Other,225% New York Medicaid APG,1216.22,,,1216.22,Other,153% New York Medicaid APG,1788.55,,,1788.55,Other,225% New York Medicaid APG,1112.88,,,1112.88,Other,140% New York Medicaid APG,1788.55,,,1788.55,Other,225% New York Medicaid APG,2066.77,,,2066.77,Other,260% New York Medicaid APG,2575.52,,,2575.52,Other,324% New York Medicaid APG,1709.06,,,1709.06,Other,215% New York Medicaid APG,1709.06,,,1709.06,Other,215% New York Medicaid APG,993.64,,,993.64,Other,125% New York Medicaid APG,794.91,12320,
Colonoscopy thru stoma spx,44388,CPT,,,,,,,,both,,,17317.69,12815.09,74,,12815.09,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,7792.96,45,,7792.96,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,8572.26,49.5,,8572.26,percent of total billed charges,110% of Medicare,11776.03,68,,11776.03,percent of total billed charges,,1478.54,,,1478.54,Other,186% of Medicaid,13854.15,80,,13854.15,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,13854.15,80,,13854.15,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,12122.38,70,,12122.38,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,794.91,,,794.91,Other,New York Medicaid APG methodology,794.91,,,794.91,Other,100% New York Medicaid APG,794.91,,,794.91,Other,100% New York Medicaid APG,794.91,,,794.91,Other,100% New York Medicaid APG,1788.55,,,1788.55,Other,225% New York Medicaid APG,1216.22,,,1216.22,Other,153% New York Medicaid APG,1788.55,,,1788.55,Other,225% New York Medicaid APG,1112.88,,,1112.88,Other,140% New York Medicaid APG,1788.55,,,1788.55,Other,225% New York Medicaid APG,2066.77,,,2066.77,Other,260% New York Medicaid APG,2575.52,,,2575.52,Other,324% New York Medicaid APG,1709.06,,,1709.06,Other,215% New York Medicaid APG,1709.06,,,1709.06,Other,215% New York Medicaid APG,993.64,,,993.64,Other,125% New York Medicaid APG,794.91,13854.15,
Colonoscopy with biopsy,44389,CPT,,,,,,,,both,,,22258.28,16471.13,74,,16471.13,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,10016.23,45,,10016.23,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,11017.85,49.5,,11017.85,percent of total billed charges,110% of Medicare,15135.63,68,,15135.63,percent of total billed charges,,1478.54,,,1478.54,Other,186% of Medicaid,17806.62,80,,17806.62,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,17806.62,80,,17806.62,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,15580.8,70,,15580.8,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,794.91,,,794.91,Other,New York Medicaid APG methodology,794.91,,,794.91,Other,100% New York Medicaid APG,794.91,,,794.91,Other,100% New York Medicaid APG,794.91,,,794.91,Other,100% New York Medicaid APG,1788.55,,,1788.55,Other,225% New York Medicaid APG,1216.22,,,1216.22,Other,153% New York Medicaid APG,1788.55,,,1788.55,Other,225% New York Medicaid APG,1112.88,,,1112.88,Other,140% New York Medicaid APG,1788.55,,,1788.55,Other,225% New York Medicaid APG,2066.77,,,2066.77,Other,260% New York Medicaid APG,2575.52,,,2575.52,Other,324% New York Medicaid APG,1709.06,,,1709.06,Other,215% New York Medicaid APG,1709.06,,,1709.06,Other,215% New York Medicaid APG,993.64,,,993.64,Other,125% New York Medicaid APG,794.91,17806.62,
Colonoscopy for foreign body,44390,CPT,,,,,,,,both,,,19223.92,14225.7,74,,14225.7,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,8650.76,45,,8650.76,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,9515.84,49.5,,9515.84,percent of total billed charges,110% of Medicare,13072.27,68,,13072.27,percent of total billed charges,,1478.54,,,1478.54,Other,186% of Medicaid,15379.14,80,,15379.14,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,15379.14,80,,15379.14,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,13456.74,70,,13456.74,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,794.91,,,794.91,Other,New York Medicaid APG methodology,794.91,,,794.91,Other,100% New York Medicaid APG,794.91,,,794.91,Other,100% New York Medicaid APG,794.91,,,794.91,Other,100% New York Medicaid APG,1788.55,,,1788.55,Other,225% New York Medicaid APG,1216.22,,,1216.22,Other,153% New York Medicaid APG,1788.55,,,1788.55,Other,225% New York Medicaid APG,1112.88,,,1112.88,Other,140% New York Medicaid APG,1788.55,,,1788.55,Other,225% New York Medicaid APG,2066.77,,,2066.77,Other,260% New York Medicaid APG,2575.52,,,2575.52,Other,324% New York Medicaid APG,1709.06,,,1709.06,Other,215% New York Medicaid APG,1709.06,,,1709.06,Other,215% New York Medicaid APG,993.64,,,993.64,Other,125% New York Medicaid APG,794.91,15379.14,
Colonoscopy for bleeding,44391,CPT,,,,,,,,both,,,24821.26,18367.73,74,,18367.73,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,11169.57,45,,11169.57,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,12286.52,49.5,,12286.52,percent of total billed charges,110% of Medicare,16878.46,68,,16878.46,percent of total billed charges,,1478.54,,,1478.54,Other,186% of Medicaid,19857.01,80,,19857.01,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,19857.01,80,,19857.01,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,17374.88,70,,17374.88,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,794.91,,,794.91,Other,New York Medicaid APG methodology,794.91,,,794.91,Other,100% New York Medicaid APG,794.91,,,794.91,Other,100% New York Medicaid APG,794.91,,,794.91,Other,100% New York Medicaid APG,1788.55,,,1788.55,Other,225% New York Medicaid APG,1216.22,,,1216.22,Other,153% New York Medicaid APG,1788.55,,,1788.55,Other,225% New York Medicaid APG,1112.88,,,1112.88,Other,140% New York Medicaid APG,1788.55,,,1788.55,Other,225% New York Medicaid APG,2066.77,,,2066.77,Other,260% New York Medicaid APG,2575.52,,,2575.52,Other,324% New York Medicaid APG,1709.06,,,1709.06,Other,215% New York Medicaid APG,1709.06,,,1709.06,Other,215% New York Medicaid APG,993.64,,,993.64,Other,125% New York Medicaid APG,794.91,19857.01,
Colonoscopy & polypectomy,44392,CPT,,,,,,,,both,,,24821.26,18367.73,74,,18367.73,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,11169.57,45,,11169.57,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,12286.52,49.5,,12286.52,percent of total billed charges,110% of Medicare,16878.46,68,,16878.46,percent of total billed charges,,1478.54,,,1478.54,Other,186% of Medicaid,19857.01,80,,19857.01,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,19857.01,80,,19857.01,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,17374.88,70,,17374.88,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,794.91,,,794.91,Other,New York Medicaid APG methodology,794.91,,,794.91,Other,100% New York Medicaid APG,794.91,,,794.91,Other,100% New York Medicaid APG,794.91,,,794.91,Other,100% New York Medicaid APG,1788.55,,,1788.55,Other,225% New York Medicaid APG,1216.22,,,1216.22,Other,153% New York Medicaid APG,1788.55,,,1788.55,Other,225% New York Medicaid APG,1112.88,,,1112.88,Other,140% New York Medicaid APG,1788.55,,,1788.55,Other,225% New York Medicaid APG,2066.77,,,2066.77,Other,260% New York Medicaid APG,2575.52,,,2575.52,Other,324% New York Medicaid APG,1709.06,,,1709.06,Other,215% New York Medicaid APG,1709.06,,,1709.06,Other,215% New York Medicaid APG,993.64,,,993.64,Other,125% New York Medicaid APG,794.91,19857.01,
Colonoscopy w/snare,44394,CPT,,,,,,,,both,,,23738.78,17566.7,74,,17566.7,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,10682.45,45,,10682.45,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,11750.7,49.5,,11750.7,percent of total billed charges,110% of Medicare,16142.37,68,,16142.37,percent of total billed charges,,1478.54,,,1478.54,Other,186% of Medicaid,18991.02,80,,18991.02,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,18991.02,80,,18991.02,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,16617.15,70,,16617.15,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,794.91,,,794.91,Other,New York Medicaid APG methodology,794.91,,,794.91,Other,100% New York Medicaid APG,794.91,,,794.91,Other,100% New York Medicaid APG,794.91,,,794.91,Other,100% New York Medicaid APG,1788.55,,,1788.55,Other,225% New York Medicaid APG,1216.22,,,1216.22,Other,153% New York Medicaid APG,1788.55,,,1788.55,Other,225% New York Medicaid APG,1112.88,,,1112.88,Other,140% New York Medicaid APG,1788.55,,,1788.55,Other,225% New York Medicaid APG,2066.77,,,2066.77,Other,260% New York Medicaid APG,2575.52,,,2575.52,Other,324% New York Medicaid APG,1709.06,,,1709.06,Other,215% New York Medicaid APG,1709.06,,,1709.06,Other,215% New York Medicaid APG,993.64,,,993.64,Other,125% New York Medicaid APG,794.91,18991.02,
Colonoscopy with ablation,44401,CPT,,,,,,,,both,,,24821.26,18367.73,74,,18367.73,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,11169.57,45,,11169.57,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,12286.52,49.5,,12286.52,percent of total billed charges,110% of Medicare,16878.46,68,,16878.46,percent of total billed charges,,1478.54,,,1478.54,Other,186% of Medicaid,19857.01,80,,19857.01,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,19857.01,80,,19857.01,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,17374.88,70,,17374.88,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,794.91,,,794.91,Other,New York Medicaid APG methodology,794.91,,,794.91,Other,100% New York Medicaid APG,794.91,,,794.91,Other,100% New York Medicaid APG,794.91,,,794.91,Other,100% New York Medicaid APG,1788.55,,,1788.55,Other,225% New York Medicaid APG,1216.22,,,1216.22,Other,153% New York Medicaid APG,1788.55,,,1788.55,Other,225% New York Medicaid APG,1112.88,,,1112.88,Other,140% New York Medicaid APG,1788.55,,,1788.55,Other,225% New York Medicaid APG,2066.77,,,2066.77,Other,260% New York Medicaid APG,2575.52,,,2575.52,Other,324% New York Medicaid APG,1709.06,,,1709.06,Other,215% New York Medicaid APG,1709.06,,,1709.06,Other,215% New York Medicaid APG,993.64,,,993.64,Other,125% New York Medicaid APG,794.91,19857.01,
Colonoscopy w/stent plcmt,44402,CPT,,,,,,,,both,,,119876.35,88708.5,74,,88708.5,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,53944.36,45,,53944.36,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,59338.79,49.5,,59338.79,percent of total billed charges,110% of Medicare,81515.92,68,,81515.92,percent of total billed charges,,1648.24,,,1648.24,Other,186% of Medicaid,95901.08,80,,95901.08,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,95901.08,80,,95901.08,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,83913.45,70,,83913.45,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,886.15,,,886.15,Other,New York Medicaid APG methodology,886.15,,,886.15,Other,100% New York Medicaid APG,886.15,,,886.15,Other,100% New York Medicaid APG,886.15,,,886.15,Other,100% New York Medicaid APG,1993.84,,,1993.84,Other,225% New York Medicaid APG,1355.81,,,1355.81,Other,153% New York Medicaid APG,1993.84,,,1993.84,Other,225% New York Medicaid APG,1240.61,,,1240.61,Other,140% New York Medicaid APG,1993.84,,,1993.84,Other,225% New York Medicaid APG,2303.99,,,2303.99,Other,260% New York Medicaid APG,2871.13,,,2871.13,Other,324% New York Medicaid APG,1905.23,,,1905.23,Other,215% New York Medicaid APG,1905.23,,,1905.23,Other,215% New York Medicaid APG,1107.69,,,1107.69,Other,125% New York Medicaid APG,886.15,95901.08,
Colonoscopy w/resection,44403,CPT,,,,,,,,both,,,24821.26,18367.73,74,,18367.73,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,11169.57,45,,11169.57,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,12286.52,49.5,,12286.52,percent of total billed charges,110% of Medicare,16878.46,68,,16878.46,percent of total billed charges,,1478.54,,,1478.54,Other,186% of Medicaid,19857.01,80,,19857.01,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,19857.01,80,,19857.01,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,17374.88,70,,17374.88,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,794.91,,,794.91,Other,New York Medicaid APG methodology,794.91,,,794.91,Other,100% New York Medicaid APG,794.91,,,794.91,Other,100% New York Medicaid APG,794.91,,,794.91,Other,100% New York Medicaid APG,1788.55,,,1788.55,Other,225% New York Medicaid APG,1216.22,,,1216.22,Other,153% New York Medicaid APG,1788.55,,,1788.55,Other,225% New York Medicaid APG,1112.88,,,1112.88,Other,140% New York Medicaid APG,1788.55,,,1788.55,Other,225% New York Medicaid APG,2066.77,,,2066.77,Other,260% New York Medicaid APG,2575.52,,,2575.52,Other,324% New York Medicaid APG,1709.06,,,1709.06,Other,215% New York Medicaid APG,1709.06,,,1709.06,Other,215% New York Medicaid APG,993.64,,,993.64,Other,125% New York Medicaid APG,794.91,19857.01,
Colonoscopy w/injection,44404,CPT,,,,,,,,both,,,24821.26,18367.73,74,,18367.73,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,11169.57,45,,11169.57,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,12286.52,49.5,,12286.52,percent of total billed charges,110% of Medicare,16878.46,68,,16878.46,percent of total billed charges,,1478.54,,,1478.54,Other,186% of Medicaid,19857.01,80,,19857.01,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,19857.01,80,,19857.01,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,17374.88,70,,17374.88,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,794.91,,,794.91,Other,New York Medicaid APG methodology,794.91,,,794.91,Other,100% New York Medicaid APG,794.91,,,794.91,Other,100% New York Medicaid APG,794.91,,,794.91,Other,100% New York Medicaid APG,1788.55,,,1788.55,Other,225% New York Medicaid APG,1216.22,,,1216.22,Other,153% New York Medicaid APG,1788.55,,,1788.55,Other,225% New York Medicaid APG,1112.88,,,1112.88,Other,140% New York Medicaid APG,1788.55,,,1788.55,Other,225% New York Medicaid APG,2066.77,,,2066.77,Other,260% New York Medicaid APG,2575.52,,,2575.52,Other,324% New York Medicaid APG,1709.06,,,1709.06,Other,215% New York Medicaid APG,1709.06,,,1709.06,Other,215% New York Medicaid APG,993.64,,,993.64,Other,125% New York Medicaid APG,794.91,19857.01,
Colonoscopy w/dilation,44405,CPT,,,,,,,,both,,,24821.26,18367.73,74,,18367.73,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,11169.57,45,,11169.57,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,12286.52,49.5,,12286.52,percent of total billed charges,110% of Medicare,16878.46,68,,16878.46,percent of total billed charges,,1478.54,,,1478.54,Other,186% of Medicaid,19857.01,80,,19857.01,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,19857.01,80,,19857.01,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,17374.88,70,,17374.88,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,794.91,,,794.91,Other,New York Medicaid APG methodology,794.91,,,794.91,Other,100% New York Medicaid APG,794.91,,,794.91,Other,100% New York Medicaid APG,794.91,,,794.91,Other,100% New York Medicaid APG,1788.55,,,1788.55,Other,225% New York Medicaid APG,1216.22,,,1216.22,Other,153% New York Medicaid APG,1788.55,,,1788.55,Other,225% New York Medicaid APG,1112.88,,,1112.88,Other,140% New York Medicaid APG,1788.55,,,1788.55,Other,225% New York Medicaid APG,2066.77,,,2066.77,Other,260% New York Medicaid APG,2575.52,,,2575.52,Other,324% New York Medicaid APG,1709.06,,,1709.06,Other,215% New York Medicaid APG,1709.06,,,1709.06,Other,215% New York Medicaid APG,993.64,,,993.64,Other,125% New York Medicaid APG,794.91,19857.01,
Colonoscopy w/ultrasound,44406,CPT,,,,,,,,both,,,24821.26,18367.73,74,,18367.73,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,11169.57,45,,11169.57,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,12286.52,49.5,,12286.52,percent of total billed charges,110% of Medicare,16878.46,68,,16878.46,percent of total billed charges,,1478.54,,,1478.54,Other,186% of Medicaid,19857.01,80,,19857.01,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,19857.01,80,,19857.01,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,17374.88,70,,17374.88,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,794.91,,,794.91,Other,New York Medicaid APG methodology,794.91,,,794.91,Other,100% New York Medicaid APG,794.91,,,794.91,Other,100% New York Medicaid APG,794.91,,,794.91,Other,100% New York Medicaid APG,1788.55,,,1788.55,Other,225% New York Medicaid APG,1216.22,,,1216.22,Other,153% New York Medicaid APG,1788.55,,,1788.55,Other,225% New York Medicaid APG,1112.88,,,1112.88,Other,140% New York Medicaid APG,1788.55,,,1788.55,Other,225% New York Medicaid APG,2066.77,,,2066.77,Other,260% New York Medicaid APG,2575.52,,,2575.52,Other,324% New York Medicaid APG,1709.06,,,1709.06,Other,215% New York Medicaid APG,1709.06,,,1709.06,Other,215% New York Medicaid APG,993.64,,,993.64,Other,125% New York Medicaid APG,794.91,19857.01,
Colonoscopy w/ndl aspir/bx,44407,CPT,,,,,,,,both,,,24821.26,18367.73,74,,18367.73,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,11169.57,45,,11169.57,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,12286.52,49.5,,12286.52,percent of total billed charges,110% of Medicare,16878.46,68,,16878.46,percent of total billed charges,,1478.54,,,1478.54,Other,186% of Medicaid,19857.01,80,,19857.01,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,19857.01,80,,19857.01,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,17374.88,70,,17374.88,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,794.91,,,794.91,Other,New York Medicaid APG methodology,794.91,,,794.91,Other,100% New York Medicaid APG,794.91,,,794.91,Other,100% New York Medicaid APG,794.91,,,794.91,Other,100% New York Medicaid APG,1788.55,,,1788.55,Other,225% New York Medicaid APG,1216.22,,,1216.22,Other,153% New York Medicaid APG,1788.55,,,1788.55,Other,225% New York Medicaid APG,1112.88,,,1112.88,Other,140% New York Medicaid APG,1788.55,,,1788.55,Other,225% New York Medicaid APG,2066.77,,,2066.77,Other,260% New York Medicaid APG,2575.52,,,2575.52,Other,324% New York Medicaid APG,1709.06,,,1709.06,Other,215% New York Medicaid APG,1709.06,,,1709.06,Other,215% New York Medicaid APG,993.64,,,993.64,Other,125% New York Medicaid APG,794.91,19857.01,
Colonoscopy w/decompression,44408,CPT,,,,,,,,both,,,19223.92,14225.7,74,,14225.7,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,8650.76,45,,8650.76,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,9515.84,49.5,,9515.84,percent of total billed charges,110% of Medicare,13072.27,68,,13072.27,percent of total billed charges,,1478.54,,,1478.54,Other,186% of Medicaid,15379.14,80,,15379.14,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,15379.14,80,,15379.14,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,13456.74,70,,13456.74,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,794.91,,,794.91,Other,New York Medicaid APG methodology,794.91,,,794.91,Other,100% New York Medicaid APG,794.91,,,794.91,Other,100% New York Medicaid APG,794.91,,,794.91,Other,100% New York Medicaid APG,1788.55,,,1788.55,Other,225% New York Medicaid APG,1216.22,,,1216.22,Other,153% New York Medicaid APG,1788.55,,,1788.55,Other,225% New York Medicaid APG,1112.88,,,1112.88,Other,140% New York Medicaid APG,1788.55,,,1788.55,Other,225% New York Medicaid APG,2066.77,,,2066.77,Other,260% New York Medicaid APG,2575.52,,,2575.52,Other,324% New York Medicaid APG,1709.06,,,1709.06,Other,215% New York Medicaid APG,1709.06,,,1709.06,Other,215% New York Medicaid APG,993.64,,,993.64,Other,125% New York Medicaid APG,794.91,15379.14,
Intro gastrointestinal tube,44500,CPT,,,,,,,,both,,,19066.74,14109.39,74,,14109.39,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,8580.03,45,,8580.03,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,9438.04,49.5,,9438.04,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,1030.37,,,1030.37,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,13346.72,70,,13346.72,percent of total billed charges,,93.48,,,93.48,Fee Schedule,,79.23,,,79.23,Fee Schedule,,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,553.96,,,553.96,Other,New York Medicaid APG methodology,553.96,,,553.96,Other,100% New York Medicaid APG,553.96,,,553.96,Other,100% New York Medicaid APG,553.96,,,553.96,Other,100% New York Medicaid APG,1246.41,,,1246.41,Other,225% New York Medicaid APG,847.56,,,847.56,Other,153% New York Medicaid APG,1246.41,,,1246.41,Other,225% New York Medicaid APG,775.55,,,775.55,Other,140% New York Medicaid APG,1246.41,,,1246.41,Other,225% New York Medicaid APG,1440.3,,,1440.3,Other,260% New York Medicaid APG,1794.83,,,1794.83,Other,324% New York Medicaid APG,1191.02,,,1191.02,Other,215% New York Medicaid APG,1191.02,,,1191.02,Other,215% New York Medicaid APG,692.45,,,692.45,Other,125% New York Medicaid APG,79.23,14109.39,
Intraop colon lavage add-on,44701,CPT,,,,,,,,both,,,32432.1,23999.75,74,,23999.75,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,14594.45,45,,14594.45,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,16053.89,49.5,,16053.89,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,4362.86,,,4362.86,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,22702.47,70,,22702.47,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,2345.62,,,2345.62,Other,New York Medicaid APG methodology,2345.62,,,2345.62,Other,100% New York Medicaid APG,2345.62,,,2345.62,Other,100% New York Medicaid APG,2345.62,,,2345.62,Other,100% New York Medicaid APG,5277.65,,,5277.65,Other,225% New York Medicaid APG,3588.8,,,3588.8,Other,153% New York Medicaid APG,5277.65,,,5277.65,Other,225% New York Medicaid APG,3283.87,,,3283.87,Other,140% New York Medicaid APG,5277.65,,,5277.65,Other,225% New York Medicaid APG,6098.62,,,6098.62,Other,260% New York Medicaid APG,7599.81,,,7599.81,Other,324% New York Medicaid APG,5043.09,,,5043.09,Other,215% New York Medicaid APG,5043.09,,,5043.09,Other,215% New York Medicaid APG,2932.03,,,2932.03,Other,125% New York Medicaid APG,2345.62,23999.75,
Appendectomy,44950,CPT,,,,,,,,both,,,40609.56,30051.07,74,,30051.07,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,18274.3,45,,18274.3,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,20101.73,49.5,,20101.73,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,4362.86,,,4362.86,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,28426.69,70,,28426.69,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,2345.62,,,2345.62,Other,New York Medicaid APG methodology,2345.62,,,2345.62,Other,100% New York Medicaid APG,2345.62,,,2345.62,Other,100% New York Medicaid APG,2345.62,,,2345.62,Other,100% New York Medicaid APG,5277.65,,,5277.65,Other,225% New York Medicaid APG,3588.8,,,3588.8,Other,153% New York Medicaid APG,5277.65,,,5277.65,Other,225% New York Medicaid APG,3283.87,,,3283.87,Other,140% New York Medicaid APG,5277.65,,,5277.65,Other,225% New York Medicaid APG,6098.62,,,6098.62,Other,260% New York Medicaid APG,7599.81,,,7599.81,Other,324% New York Medicaid APG,5043.09,,,5043.09,Other,215% New York Medicaid APG,5043.09,,,5043.09,Other,215% New York Medicaid APG,2932.03,,,2932.03,Other,125% New York Medicaid APG,2345.62,30051.07,
Appendectomy add-on,44955,CPT,,,,,,,,both,,,86591.4,64077.64,74,,64077.64,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,38966.13,45,,38966.13,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,6125,,"100% primary, 50% secondary, 25% supplemental procedure",6125,Other,Blue Cross ASC Grouper,5513,,"100% primary, 50% secondary, 25% supplemental procedure",5513,Other,Blue Cross ASC Grouper,5206,,"100% primary, 50% secondary, 25% supplemental procedure",5206,Other,Blue Cross ASC Grouper,42862.74,49.5,,42862.74,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3632.62,,,3632.62,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,60613.98,70,,60613.98,percent of total billed charges,,406.72,,,406.72,Fee Schedule,,344.72,,,344.72,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,1953.02,,,1953.02,Other,New York Medicaid APG methodology,1953.02,,,1953.02,Other,100% New York Medicaid APG,1953.02,,,1953.02,Other,100% New York Medicaid APG,1953.02,,,1953.02,Other,100% New York Medicaid APG,4394.3,,,4394.3,Other,225% New York Medicaid APG,2988.12,,,2988.12,Other,153% New York Medicaid APG,4394.3,,,4394.3,Other,225% New York Medicaid APG,2734.23,,,2734.23,Other,140% New York Medicaid APG,4394.3,,,4394.3,Other,225% New York Medicaid APG,5077.86,,,5077.86,Other,260% New York Medicaid APG,6327.79,,,6327.79,Other,324% New York Medicaid APG,4199,,,4199,Other,215% New York Medicaid APG,4199,,,4199,Other,215% New York Medicaid APG,2441.28,,,2441.28,Other,125% New York Medicaid APG,344.72,64077.64,
Laparoscopy appendectomy,44970,CPT,,,,,,,,both,,,44035.36,32586.17,74,,32586.17,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,19815.91,45,,19815.91,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,6125,,"100% primary, 50% secondary, 25% supplemental procedure",6125,Other,Blue Cross ASC Grouper,5513,,"100% primary, 50% secondary, 25% supplemental procedure",5513,Other,Blue Cross ASC Grouper,5206,,"100% primary, 50% secondary, 25% supplemental procedure",5206,Other,Blue Cross ASC Grouper,21797.5,49.5,,21797.5,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,4362.86,,,4362.86,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,30824.75,70,,30824.75,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,2345.62,,,2345.62,Other,New York Medicaid APG methodology,2345.62,,,2345.62,Other,100% New York Medicaid APG,2345.62,,,2345.62,Other,100% New York Medicaid APG,2345.62,,,2345.62,Other,100% New York Medicaid APG,5277.65,,,5277.65,Other,225% New York Medicaid APG,3588.8,,,3588.8,Other,153% New York Medicaid APG,5277.65,,,5277.65,Other,225% New York Medicaid APG,3283.87,,,3283.87,Other,140% New York Medicaid APG,5277.65,,,5277.65,Other,225% New York Medicaid APG,6098.62,,,6098.62,Other,260% New York Medicaid APG,7599.81,,,7599.81,Other,324% New York Medicaid APG,5043.09,,,5043.09,Other,215% New York Medicaid APG,5043.09,,,5043.09,Other,215% New York Medicaid APG,2932.03,,,2932.03,Other,125% New York Medicaid APG,2345.62,32586.17,
Drainage of pelvic abscess,45000,CPT,,,,,,,,both,,,24821.26,18367.73,74,,18367.73,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,11169.57,45,,11169.57,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,12286.52,49.5,,12286.52,percent of total billed charges,110% of Medicare,16878.46,68,,16878.46,percent of total billed charges,,2732.76,,,2732.76,Other,186% of Medicaid,19857.01,80,,19857.01,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,19857.01,80,,19857.01,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,17374.88,70,,17374.88,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1469.23,,,1469.23,Other,New York Medicaid APG methodology,1469.23,,,1469.23,Other,100% New York Medicaid APG,1469.23,,,1469.23,Other,100% New York Medicaid APG,1469.23,,,1469.23,Other,100% New York Medicaid APG,3305.76,,,3305.76,Other,225% New York Medicaid APG,2247.91,,,2247.91,Other,153% New York Medicaid APG,3305.76,,,3305.76,Other,225% New York Medicaid APG,2056.92,,,2056.92,Other,140% New York Medicaid APG,3305.76,,,3305.76,Other,225% New York Medicaid APG,3819.99,,,3819.99,Other,260% New York Medicaid APG,4760.29,,,4760.29,Other,324% New York Medicaid APG,3158.83,,,3158.83,Other,215% New York Medicaid APG,3158.83,,,3158.83,Other,215% New York Medicaid APG,1836.53,,,1836.53,Other,125% New York Medicaid APG,1469.23,19857.01,
Drainage of rectal abscess,45005,CPT,,,,,,,,both,,,24821.26,18367.73,74,,18367.73,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,11169.57,45,,11169.57,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,12286.52,49.5,,12286.52,percent of total billed charges,110% of Medicare,16878.46,68,,16878.46,percent of total billed charges,,2000.16,,,2000.16,Other,186% of Medicaid,19857.01,80,,19857.01,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,19857.01,80,,19857.01,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,17374.88,70,,17374.88,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1075.35,,,1075.35,Other,New York Medicaid APG methodology,1075.35,,,1075.35,Other,100% New York Medicaid APG,1075.35,,,1075.35,Other,100% New York Medicaid APG,1075.35,,,1075.35,Other,100% New York Medicaid APG,2419.55,,,2419.55,Other,225% New York Medicaid APG,1645.29,,,1645.29,Other,153% New York Medicaid APG,2419.55,,,2419.55,Other,225% New York Medicaid APG,1505.5,,,1505.5,Other,140% New York Medicaid APG,2419.55,,,2419.55,Other,225% New York Medicaid APG,2795.92,,,2795.92,Other,260% New York Medicaid APG,3484.15,,,3484.15,Other,324% New York Medicaid APG,2312.01,,,2312.01,Other,215% New York Medicaid APG,2312.01,,,2312.01,Other,215% New York Medicaid APG,1344.19,,,1344.19,Other,125% New York Medicaid APG,1075.35,19857.01,
Drainage of rectal abscess,45020,CPT,,,,,,,,both,,,59058.34,43703.17,74,,43703.17,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,26576.25,45,,26576.25,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,29233.88,49.5,,29233.88,percent of total billed charges,110% of Medicare,40159.67,68,,40159.67,percent of total billed charges,,2732.76,,,2732.76,Other,186% of Medicaid,47246.67,80,,47246.67,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,47246.67,80,,47246.67,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,41340.84,70,,41340.84,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1469.23,,,1469.23,Other,New York Medicaid APG methodology,1469.23,,,1469.23,Other,100% New York Medicaid APG,1469.23,,,1469.23,Other,100% New York Medicaid APG,1469.23,,,1469.23,Other,100% New York Medicaid APG,3305.76,,,3305.76,Other,225% New York Medicaid APG,2247.91,,,2247.91,Other,153% New York Medicaid APG,3305.76,,,3305.76,Other,225% New York Medicaid APG,2056.92,,,2056.92,Other,140% New York Medicaid APG,3305.76,,,3305.76,Other,225% New York Medicaid APG,3819.99,,,3819.99,Other,260% New York Medicaid APG,4760.29,,,4760.29,Other,324% New York Medicaid APG,3158.83,,,3158.83,Other,215% New York Medicaid APG,3158.83,,,3158.83,Other,215% New York Medicaid APG,1836.53,,,1836.53,Other,125% New York Medicaid APG,1469.23,47246.67,
Biopsy of rectum,45100,CPT,,,,,,,,both,,,37185.79,27517.48,74,,27517.48,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,16733.61,45,,16733.61,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,18406.97,49.5,,18406.97,percent of total billed charges,110% of Medicare,25286.34,68,,25286.34,percent of total billed charges,,2000.16,,,2000.16,Other,186% of Medicaid,29748.63,80,,29748.63,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,29748.63,80,,29748.63,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,26030.05,70,,26030.05,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1075.35,,,1075.35,Other,New York Medicaid APG methodology,1075.35,,,1075.35,Other,100% New York Medicaid APG,1075.35,,,1075.35,Other,100% New York Medicaid APG,1075.35,,,1075.35,Other,100% New York Medicaid APG,2419.55,,,2419.55,Other,225% New York Medicaid APG,1645.29,,,1645.29,Other,153% New York Medicaid APG,2419.55,,,2419.55,Other,225% New York Medicaid APG,1505.5,,,1505.5,Other,140% New York Medicaid APG,2419.55,,,2419.55,Other,225% New York Medicaid APG,2795.92,,,2795.92,Other,260% New York Medicaid APG,3484.15,,,3484.15,Other,324% New York Medicaid APG,2312.01,,,2312.01,Other,215% New York Medicaid APG,2312.01,,,2312.01,Other,215% New York Medicaid APG,1344.19,,,1344.19,Other,125% New York Medicaid APG,1075.35,29748.63,
Removal of anorectal lesion,45108,CPT,,,,,,,,both,,,59058.34,43703.17,74,,43703.17,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,26576.25,45,,26576.25,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,29233.88,49.5,,29233.88,percent of total billed charges,110% of Medicare,40159.67,68,,40159.67,percent of total billed charges,,2732.76,,,2732.76,Other,186% of Medicaid,47246.67,80,,47246.67,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,47246.67,80,,47246.67,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,41340.84,70,,41340.84,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1469.23,,,1469.23,Other,New York Medicaid APG methodology,1469.23,,,1469.23,Other,100% New York Medicaid APG,1469.23,,,1469.23,Other,100% New York Medicaid APG,1469.23,,,1469.23,Other,100% New York Medicaid APG,3305.76,,,3305.76,Other,225% New York Medicaid APG,2247.91,,,2247.91,Other,153% New York Medicaid APG,3305.76,,,3305.76,Other,225% New York Medicaid APG,2056.92,,,2056.92,Other,140% New York Medicaid APG,3305.76,,,3305.76,Other,225% New York Medicaid APG,3819.99,,,3819.99,Other,260% New York Medicaid APG,4760.29,,,4760.29,Other,324% New York Medicaid APG,3158.83,,,3158.83,Other,215% New York Medicaid APG,3158.83,,,3158.83,Other,215% New York Medicaid APG,1836.53,,,1836.53,Other,125% New York Medicaid APG,1469.23,47246.67,
Excision of rectal stricture,45150,CPT,,,,,,,,both,,,24821.26,18367.73,74,,18367.73,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,11169.57,45,,11169.57,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,12286.52,49.5,,12286.52,percent of total billed charges,110% of Medicare,16878.46,68,,16878.46,percent of total billed charges,,2732.76,,,2732.76,Other,186% of Medicaid,19857.01,80,,19857.01,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,19857.01,80,,19857.01,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,17374.88,70,,17374.88,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1469.23,,,1469.23,Other,New York Medicaid APG methodology,1469.23,,,1469.23,Other,100% New York Medicaid APG,1469.23,,,1469.23,Other,100% New York Medicaid APG,1469.23,,,1469.23,Other,100% New York Medicaid APG,3305.76,,,3305.76,Other,225% New York Medicaid APG,2247.91,,,2247.91,Other,153% New York Medicaid APG,3305.76,,,3305.76,Other,225% New York Medicaid APG,2056.92,,,2056.92,Other,140% New York Medicaid APG,3305.76,,,3305.76,Other,225% New York Medicaid APG,3819.99,,,3819.99,Other,260% New York Medicaid APG,4760.29,,,4760.29,Other,324% New York Medicaid APG,3158.83,,,3158.83,Other,215% New York Medicaid APG,3158.83,,,3158.83,Other,215% New York Medicaid APG,1836.53,,,1836.53,Other,125% New York Medicaid APG,1469.23,19857.01,
Excision of rectal lesion,45160,CPT,,,,,,,,both,,,59058.34,43703.17,74,,43703.17,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,26576.25,45,,26576.25,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,29233.88,49.5,,29233.88,percent of total billed charges,110% of Medicare,40159.67,68,,40159.67,percent of total billed charges,,2732.76,,,2732.76,Other,186% of Medicaid,47246.67,80,,47246.67,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,47246.67,80,,47246.67,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,41340.84,70,,41340.84,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1469.23,,,1469.23,Other,New York Medicaid APG methodology,1469.23,,,1469.23,Other,100% New York Medicaid APG,1469.23,,,1469.23,Other,100% New York Medicaid APG,1469.23,,,1469.23,Other,100% New York Medicaid APG,3305.76,,,3305.76,Other,225% New York Medicaid APG,2247.91,,,2247.91,Other,153% New York Medicaid APG,3305.76,,,3305.76,Other,225% New York Medicaid APG,2056.92,,,2056.92,Other,140% New York Medicaid APG,3305.76,,,3305.76,Other,225% New York Medicaid APG,3819.99,,,3819.99,Other,260% New York Medicaid APG,4760.29,,,4760.29,Other,324% New York Medicaid APG,3158.83,,,3158.83,Other,215% New York Medicaid APG,3158.83,,,3158.83,Other,215% New York Medicaid APG,1836.53,,,1836.53,Other,125% New York Medicaid APG,1469.23,47246.67,
Exc rect tum transanal part,45171,CPT,,,,,,,,both,,,35248.2,26083.67,74,,26083.67,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15861.69,45,,15861.69,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,17447.86,49.5,,17447.86,percent of total billed charges,110% of Medicare,23968.78,68,,23968.78,percent of total billed charges,,2732.76,,,2732.76,Other,186% of Medicaid,28198.56,80,,28198.56,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,28198.56,80,,28198.56,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,24673.74,70,,24673.74,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1469.23,,,1469.23,Other,New York Medicaid APG methodology,1469.23,,,1469.23,Other,100% New York Medicaid APG,1469.23,,,1469.23,Other,100% New York Medicaid APG,1469.23,,,1469.23,Other,100% New York Medicaid APG,3305.76,,,3305.76,Other,225% New York Medicaid APG,2247.91,,,2247.91,Other,153% New York Medicaid APG,3305.76,,,3305.76,Other,225% New York Medicaid APG,2056.92,,,2056.92,Other,140% New York Medicaid APG,3305.76,,,3305.76,Other,225% New York Medicaid APG,3819.99,,,3819.99,Other,260% New York Medicaid APG,4760.29,,,4760.29,Other,324% New York Medicaid APG,3158.83,,,3158.83,Other,215% New York Medicaid APG,3158.83,,,3158.83,Other,215% New York Medicaid APG,1836.53,,,1836.53,Other,125% New York Medicaid APG,1469.23,28198.56,
Exc rect tum transanal full,45172,CPT,,,,,,,,both,,,59058.34,43703.17,74,,43703.17,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,26576.25,45,,26576.25,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,29233.88,49.5,,29233.88,percent of total billed charges,110% of Medicare,40159.67,68,,40159.67,percent of total billed charges,,2732.76,,,2732.76,Other,186% of Medicaid,47246.67,80,,47246.67,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,47246.67,80,,47246.67,percent of total billed charges,,7216,,,7216,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,41340.84,70,,41340.84,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1469.23,,,1469.23,Other,New York Medicaid APG methodology,1469.23,,,1469.23,Other,100% New York Medicaid APG,1469.23,,,1469.23,Other,100% New York Medicaid APG,1469.23,,,1469.23,Other,100% New York Medicaid APG,3305.76,,,3305.76,Other,225% New York Medicaid APG,2247.91,,,2247.91,Other,153% New York Medicaid APG,3305.76,,,3305.76,Other,225% New York Medicaid APG,2056.92,,,2056.92,Other,140% New York Medicaid APG,3305.76,,,3305.76,Other,225% New York Medicaid APG,3819.99,,,3819.99,Other,260% New York Medicaid APG,4760.29,,,4760.29,Other,324% New York Medicaid APG,3158.83,,,3158.83,Other,215% New York Medicaid APG,3158.83,,,3158.83,Other,215% New York Medicaid APG,1836.53,,,1836.53,Other,125% New York Medicaid APG,1469.23,47246.67,
Destruction rectal tumor,45190,CPT,,,,,,,,both,,,59058.34,43703.17,74,,43703.17,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,26576.25,45,,26576.25,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,29233.88,49.5,,29233.88,percent of total billed charges,110% of Medicare,40159.67,68,,40159.67,percent of total billed charges,,2732.76,,,2732.76,Other,186% of Medicaid,47246.67,80,,47246.67,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,47246.67,80,,47246.67,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,41340.84,70,,41340.84,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1469.23,,,1469.23,Other,New York Medicaid APG methodology,1469.23,,,1469.23,Other,100% New York Medicaid APG,1469.23,,,1469.23,Other,100% New York Medicaid APG,1469.23,,,1469.23,Other,100% New York Medicaid APG,3305.76,,,3305.76,Other,225% New York Medicaid APG,2247.91,,,2247.91,Other,153% New York Medicaid APG,3305.76,,,3305.76,Other,225% New York Medicaid APG,2056.92,,,2056.92,Other,140% New York Medicaid APG,3305.76,,,3305.76,Other,225% New York Medicaid APG,3819.99,,,3819.99,Other,260% New York Medicaid APG,4760.29,,,4760.29,Other,324% New York Medicaid APG,3158.83,,,3158.83,Other,215% New York Medicaid APG,3158.83,,,3158.83,Other,215% New York Medicaid APG,1836.53,,,1836.53,Other,125% New York Medicaid APG,1469.23,47246.67,
Proctosigmoidoscopy dx,45300,CPT,,,,,,,,both,,,19223.92,14225.7,74,,14225.7,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,8650.76,45,,8650.76,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,9515.84,49.5,,9515.84,percent of total billed charges,110% of Medicare,13072.27,68,,13072.27,percent of total billed charges,,1478.54,,,1478.54,Other,186% of Medicaid,15379.14,80,,15379.14,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,15379.14,80,,15379.14,percent of total billed charges,,7216,,,7216,Case Rate,,3578,,"100% primary, 0% secondary procedures",3578,Other,MagnaCare ASC Grouper,13456.74,70,,13456.74,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,794.91,,,794.91,Other,New York Medicaid APG methodology,794.91,,,794.91,Other,100% New York Medicaid APG,794.91,,,794.91,Other,100% New York Medicaid APG,794.91,,,794.91,Other,100% New York Medicaid APG,1788.55,,,1788.55,Other,225% New York Medicaid APG,1216.22,,,1216.22,Other,153% New York Medicaid APG,1788.55,,,1788.55,Other,225% New York Medicaid APG,1112.88,,,1112.88,Other,140% New York Medicaid APG,1788.55,,,1788.55,Other,225% New York Medicaid APG,2066.77,,,2066.77,Other,260% New York Medicaid APG,2575.52,,,2575.52,Other,324% New York Medicaid APG,1709.06,,,1709.06,Other,215% New York Medicaid APG,1709.06,,,1709.06,Other,215% New York Medicaid APG,993.64,,,993.64,Other,125% New York Medicaid APG,794.91,15379.14,
Proctosigmoidoscopy dilate,45303,CPT,,,,,,,,both,,,24821.26,18367.73,74,,18367.73,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,11169.57,45,,11169.57,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,12286.52,49.5,,12286.52,percent of total billed charges,110% of Medicare,16878.46,68,,16878.46,percent of total billed charges,,1648.24,,,1648.24,Other,186% of Medicaid,19857.01,80,,19857.01,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,19857.01,80,,19857.01,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,17374.88,70,,17374.88,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,886.15,,,886.15,Other,New York Medicaid APG methodology,886.15,,,886.15,Other,100% New York Medicaid APG,886.15,,,886.15,Other,100% New York Medicaid APG,886.15,,,886.15,Other,100% New York Medicaid APG,1993.84,,,1993.84,Other,225% New York Medicaid APG,1355.81,,,1355.81,Other,153% New York Medicaid APG,1993.84,,,1993.84,Other,225% New York Medicaid APG,1240.61,,,1240.61,Other,140% New York Medicaid APG,1993.84,,,1993.84,Other,225% New York Medicaid APG,2303.99,,,2303.99,Other,260% New York Medicaid APG,2871.13,,,2871.13,Other,324% New York Medicaid APG,1905.23,,,1905.23,Other,215% New York Medicaid APG,1905.23,,,1905.23,Other,215% New York Medicaid APG,1107.69,,,1107.69,Other,125% New York Medicaid APG,886.15,19857.01,
Proctosigmoidoscopy w/bx,45305,CPT,,,,,,,,both,,,24821.26,18367.73,74,,18367.73,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,11169.57,45,,11169.57,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,12286.52,49.5,,12286.52,percent of total billed charges,110% of Medicare,16878.46,68,,16878.46,percent of total billed charges,,1478.54,,,1478.54,Other,186% of Medicaid,19857.01,80,,19857.01,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,19857.01,80,,19857.01,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,17374.88,70,,17374.88,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,794.91,,,794.91,Other,New York Medicaid APG methodology,794.91,,,794.91,Other,100% New York Medicaid APG,794.91,,,794.91,Other,100% New York Medicaid APG,794.91,,,794.91,Other,100% New York Medicaid APG,1788.55,,,1788.55,Other,225% New York Medicaid APG,1216.22,,,1216.22,Other,153% New York Medicaid APG,1788.55,,,1788.55,Other,225% New York Medicaid APG,1112.88,,,1112.88,Other,140% New York Medicaid APG,1788.55,,,1788.55,Other,225% New York Medicaid APG,2066.77,,,2066.77,Other,260% New York Medicaid APG,2575.52,,,2575.52,Other,324% New York Medicaid APG,1709.06,,,1709.06,Other,215% New York Medicaid APG,1709.06,,,1709.06,Other,215% New York Medicaid APG,993.64,,,993.64,Other,125% New York Medicaid APG,794.91,19857.01,
Proctosigmoidoscopy fb,45307,CPT,,,,,,,,both,,,59058.34,43703.17,74,,43703.17,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,26576.25,45,,26576.25,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,29233.88,49.5,,29233.88,percent of total billed charges,110% of Medicare,40159.67,68,,40159.67,percent of total billed charges,,1478.54,,,1478.54,Other,186% of Medicaid,47246.67,80,,47246.67,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,47246.67,80,,47246.67,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,41340.84,70,,41340.84,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,794.91,,,794.91,Other,New York Medicaid APG methodology,794.91,,,794.91,Other,100% New York Medicaid APG,794.91,,,794.91,Other,100% New York Medicaid APG,794.91,,,794.91,Other,100% New York Medicaid APG,1788.55,,,1788.55,Other,225% New York Medicaid APG,1216.22,,,1216.22,Other,153% New York Medicaid APG,1788.55,,,1788.55,Other,225% New York Medicaid APG,1112.88,,,1112.88,Other,140% New York Medicaid APG,1788.55,,,1788.55,Other,225% New York Medicaid APG,2066.77,,,2066.77,Other,260% New York Medicaid APG,2575.52,,,2575.52,Other,324% New York Medicaid APG,1709.06,,,1709.06,Other,215% New York Medicaid APG,1709.06,,,1709.06,Other,215% New York Medicaid APG,993.64,,,993.64,Other,125% New York Medicaid APG,794.91,47246.67,
Proctosigmoidoscopy removal,45308,CPT,,,,,,,,both,,,59058.34,43703.17,74,,43703.17,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,26576.25,45,,26576.25,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,29233.88,49.5,,29233.88,percent of total billed charges,110% of Medicare,40159.67,68,,40159.67,percent of total billed charges,,1648.24,,,1648.24,Other,186% of Medicaid,47246.67,80,,47246.67,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,47246.67,80,,47246.67,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,41340.84,70,,41340.84,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,886.15,,,886.15,Other,New York Medicaid APG methodology,886.15,,,886.15,Other,100% New York Medicaid APG,886.15,,,886.15,Other,100% New York Medicaid APG,886.15,,,886.15,Other,100% New York Medicaid APG,1993.84,,,1993.84,Other,225% New York Medicaid APG,1355.81,,,1355.81,Other,153% New York Medicaid APG,1993.84,,,1993.84,Other,225% New York Medicaid APG,1240.61,,,1240.61,Other,140% New York Medicaid APG,1993.84,,,1993.84,Other,225% New York Medicaid APG,2303.99,,,2303.99,Other,260% New York Medicaid APG,2871.13,,,2871.13,Other,324% New York Medicaid APG,1905.23,,,1905.23,Other,215% New York Medicaid APG,1905.23,,,1905.23,Other,215% New York Medicaid APG,1107.69,,,1107.69,Other,125% New York Medicaid APG,886.15,47246.67,
Proctosigmoidoscopy removal,45309,CPT,,,,,,,,both,,,24821.26,18367.73,74,,18367.73,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,11169.57,45,,11169.57,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,12286.52,49.5,,12286.52,percent of total billed charges,110% of Medicare,16878.46,68,,16878.46,percent of total billed charges,,1478.54,,,1478.54,Other,186% of Medicaid,19857.01,80,,19857.01,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,19857.01,80,,19857.01,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,17374.88,70,,17374.88,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,794.91,,,794.91,Other,New York Medicaid APG methodology,794.91,,,794.91,Other,100% New York Medicaid APG,794.91,,,794.91,Other,100% New York Medicaid APG,794.91,,,794.91,Other,100% New York Medicaid APG,1788.55,,,1788.55,Other,225% New York Medicaid APG,1216.22,,,1216.22,Other,153% New York Medicaid APG,1788.55,,,1788.55,Other,225% New York Medicaid APG,1112.88,,,1112.88,Other,140% New York Medicaid APG,1788.55,,,1788.55,Other,225% New York Medicaid APG,2066.77,,,2066.77,Other,260% New York Medicaid APG,2575.52,,,2575.52,Other,324% New York Medicaid APG,1709.06,,,1709.06,Other,215% New York Medicaid APG,1709.06,,,1709.06,Other,215% New York Medicaid APG,993.64,,,993.64,Other,125% New York Medicaid APG,794.91,19857.01,
Proctosigmoidoscopy removal,45315,CPT,,,,,,,,both,,,24821.26,18367.73,74,,18367.73,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,11169.57,45,,11169.57,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,12286.52,49.5,,12286.52,percent of total billed charges,110% of Medicare,16878.46,68,,16878.46,percent of total billed charges,,1478.54,,,1478.54,Other,186% of Medicaid,19857.01,80,,19857.01,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,19857.01,80,,19857.01,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,17374.88,70,,17374.88,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,794.91,,,794.91,Other,New York Medicaid APG methodology,794.91,,,794.91,Other,100% New York Medicaid APG,794.91,,,794.91,Other,100% New York Medicaid APG,794.91,,,794.91,Other,100% New York Medicaid APG,1788.55,,,1788.55,Other,225% New York Medicaid APG,1216.22,,,1216.22,Other,153% New York Medicaid APG,1788.55,,,1788.55,Other,225% New York Medicaid APG,1112.88,,,1112.88,Other,140% New York Medicaid APG,1788.55,,,1788.55,Other,225% New York Medicaid APG,2066.77,,,2066.77,Other,260% New York Medicaid APG,2575.52,,,2575.52,Other,324% New York Medicaid APG,1709.06,,,1709.06,Other,215% New York Medicaid APG,1709.06,,,1709.06,Other,215% New York Medicaid APG,993.64,,,993.64,Other,125% New York Medicaid APG,794.91,19857.01,
Proctosigmoidoscopy bleed,45317,CPT,,,,,,,,both,,,24821.26,18367.73,74,,18367.73,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,11169.57,45,,11169.57,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,12286.52,49.5,,12286.52,percent of total billed charges,110% of Medicare,16878.46,68,,16878.46,percent of total billed charges,,1648.24,,,1648.24,Other,186% of Medicaid,19857.01,80,,19857.01,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,19857.01,80,,19857.01,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,17374.88,70,,17374.88,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,886.15,,,886.15,Other,New York Medicaid APG methodology,886.15,,,886.15,Other,100% New York Medicaid APG,886.15,,,886.15,Other,100% New York Medicaid APG,886.15,,,886.15,Other,100% New York Medicaid APG,1993.84,,,1993.84,Other,225% New York Medicaid APG,1355.81,,,1355.81,Other,153% New York Medicaid APG,1993.84,,,1993.84,Other,225% New York Medicaid APG,1240.61,,,1240.61,Other,140% New York Medicaid APG,1993.84,,,1993.84,Other,225% New York Medicaid APG,2303.99,,,2303.99,Other,260% New York Medicaid APG,2871.13,,,2871.13,Other,324% New York Medicaid APG,1905.23,,,1905.23,Other,215% New York Medicaid APG,1905.23,,,1905.23,Other,215% New York Medicaid APG,1107.69,,,1107.69,Other,125% New York Medicaid APG,886.15,19857.01,
Proctosigmoidoscopy ablate,45320,CPT,,,,,,,,both,,,59058.34,43703.17,74,,43703.17,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,26576.25,45,,26576.25,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,29233.88,49.5,,29233.88,percent of total billed charges,110% of Medicare,40159.67,68,,40159.67,percent of total billed charges,,1648.24,,,1648.24,Other,186% of Medicaid,47246.67,80,,47246.67,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,47246.67,80,,47246.67,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,41340.84,70,,41340.84,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,886.15,,,886.15,Other,New York Medicaid APG methodology,886.15,,,886.15,Other,100% New York Medicaid APG,886.15,,,886.15,Other,100% New York Medicaid APG,886.15,,,886.15,Other,100% New York Medicaid APG,1993.84,,,1993.84,Other,225% New York Medicaid APG,1355.81,,,1355.81,Other,153% New York Medicaid APG,1993.84,,,1993.84,Other,225% New York Medicaid APG,1240.61,,,1240.61,Other,140% New York Medicaid APG,1993.84,,,1993.84,Other,225% New York Medicaid APG,2303.99,,,2303.99,Other,260% New York Medicaid APG,2871.13,,,2871.13,Other,324% New York Medicaid APG,1905.23,,,1905.23,Other,215% New York Medicaid APG,1905.23,,,1905.23,Other,215% New York Medicaid APG,1107.69,,,1107.69,Other,125% New York Medicaid APG,886.15,47246.67,
Proctosigmoidoscopy volvul,45321,CPT,,,,,,,,both,,,59058.34,43703.17,74,,43703.17,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,26576.25,45,,26576.25,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,29233.88,49.5,,29233.88,percent of total billed charges,110% of Medicare,40159.67,68,,40159.67,percent of total billed charges,,1648.24,,,1648.24,Other,186% of Medicaid,47246.67,80,,47246.67,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,47246.67,80,,47246.67,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,41340.84,70,,41340.84,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,886.15,,,886.15,Other,New York Medicaid APG methodology,886.15,,,886.15,Other,100% New York Medicaid APG,886.15,,,886.15,Other,100% New York Medicaid APG,886.15,,,886.15,Other,100% New York Medicaid APG,1993.84,,,1993.84,Other,225% New York Medicaid APG,1355.81,,,1355.81,Other,153% New York Medicaid APG,1993.84,,,1993.84,Other,225% New York Medicaid APG,1240.61,,,1240.61,Other,140% New York Medicaid APG,1993.84,,,1993.84,Other,225% New York Medicaid APG,2303.99,,,2303.99,Other,260% New York Medicaid APG,2871.13,,,2871.13,Other,324% New York Medicaid APG,1905.23,,,1905.23,Other,215% New York Medicaid APG,1905.23,,,1905.23,Other,215% New York Medicaid APG,1107.69,,,1107.69,Other,125% New York Medicaid APG,886.15,47246.67,
Proctosigmoidoscopy w/stent,45327,CPT,,,,,,,,both,,,119876.35,88708.5,74,,88708.5,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,53944.36,45,,53944.36,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,59338.79,49.5,,59338.79,percent of total billed charges,110% of Medicare,81515.92,68,,81515.92,percent of total billed charges,,1648.24,,,1648.24,Other,186% of Medicaid,95901.08,80,,95901.08,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,95901.08,80,,95901.08,percent of total billed charges,,7216,,,7216,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,83913.45,70,,83913.45,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,886.15,,,886.15,Other,New York Medicaid APG methodology,886.15,,,886.15,Other,100% New York Medicaid APG,886.15,,,886.15,Other,100% New York Medicaid APG,886.15,,,886.15,Other,100% New York Medicaid APG,1993.84,,,1993.84,Other,225% New York Medicaid APG,1355.81,,,1355.81,Other,153% New York Medicaid APG,1993.84,,,1993.84,Other,225% New York Medicaid APG,1240.61,,,1240.61,Other,140% New York Medicaid APG,1993.84,,,1993.84,Other,225% New York Medicaid APG,2303.99,,,2303.99,Other,260% New York Medicaid APG,2871.13,,,2871.13,Other,324% New York Medicaid APG,1905.23,,,1905.23,Other,215% New York Medicaid APG,1905.23,,,1905.23,Other,215% New York Medicaid APG,1107.69,,,1107.69,Other,125% New York Medicaid APG,886.15,95901.08,
Diagnostic sigmoidoscopy,45330,CPT,,,,,,,,both,,,12997.89,9618.44,74,,9618.44,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,5849.05,45,,5849.05,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,6433.96,49.5,,6433.96,percent of total billed charges,110% of Medicare,8838.57,68,,8838.57,percent of total billed charges,,1478.54,,,1478.54,Other,186% of Medicaid,10398.31,80,,10398.31,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,10398.31,80,,10398.31,percent of total billed charges,,7216,,,7216,Case Rate,,3578,,"100% primary, 0% secondary procedures",3578,Other,MagnaCare ASC Grouper,9098.52,70,,9098.52,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,794.91,,,794.91,Other,New York Medicaid APG methodology,794.91,,,794.91,Other,100% New York Medicaid APG,794.91,,,794.91,Other,100% New York Medicaid APG,794.91,,,794.91,Other,100% New York Medicaid APG,1788.55,,,1788.55,Other,225% New York Medicaid APG,1216.22,,,1216.22,Other,153% New York Medicaid APG,1788.55,,,1788.55,Other,225% New York Medicaid APG,1112.88,,,1112.88,Other,140% New York Medicaid APG,1788.55,,,1788.55,Other,225% New York Medicaid APG,2066.77,,,2066.77,Other,260% New York Medicaid APG,2575.52,,,2575.52,Other,324% New York Medicaid APG,1709.06,,,1709.06,Other,215% New York Medicaid APG,1709.06,,,1709.06,Other,215% New York Medicaid APG,993.64,,,993.64,Other,125% New York Medicaid APG,794.91,10398.31,
Sigmoidoscopy and biopsy,45331,CPT,,,,,,,,both,,,17108.6,12660.36,74,,12660.36,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,7698.87,45,,7698.87,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,8468.76,49.5,,8468.76,percent of total billed charges,110% of Medicare,11633.85,68,,11633.85,percent of total billed charges,,1478.54,,,1478.54,Other,186% of Medicaid,13686.88,80,,13686.88,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,13686.88,80,,13686.88,percent of total billed charges,,7216,,,7216,Case Rate,,3578,,"100% primary, 0% secondary procedures",3578,Other,MagnaCare ASC Grouper,11976.02,70,,11976.02,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,794.91,,,794.91,Other,New York Medicaid APG methodology,794.91,,,794.91,Other,100% New York Medicaid APG,794.91,,,794.91,Other,100% New York Medicaid APG,794.91,,,794.91,Other,100% New York Medicaid APG,1788.55,,,1788.55,Other,225% New York Medicaid APG,1216.22,,,1216.22,Other,153% New York Medicaid APG,1788.55,,,1788.55,Other,225% New York Medicaid APG,1112.88,,,1112.88,Other,140% New York Medicaid APG,1788.55,,,1788.55,Other,225% New York Medicaid APG,2066.77,,,2066.77,Other,260% New York Medicaid APG,2575.52,,,2575.52,Other,324% New York Medicaid APG,1709.06,,,1709.06,Other,215% New York Medicaid APG,1709.06,,,1709.06,Other,215% New York Medicaid APG,993.64,,,993.64,Other,125% New York Medicaid APG,794.91,13686.88,
Sigmoidoscopy w/fb removal,45332,CPT,,,,,,,,both,,,24821.26,18367.73,74,,18367.73,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,11169.57,45,,11169.57,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,12286.52,49.5,,12286.52,percent of total billed charges,110% of Medicare,16878.46,68,,16878.46,percent of total billed charges,,1478.54,,,1478.54,Other,186% of Medicaid,19857.01,80,,19857.01,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,19857.01,80,,19857.01,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,17374.88,70,,17374.88,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,794.91,,,794.91,Other,New York Medicaid APG methodology,794.91,,,794.91,Other,100% New York Medicaid APG,794.91,,,794.91,Other,100% New York Medicaid APG,794.91,,,794.91,Other,100% New York Medicaid APG,1788.55,,,1788.55,Other,225% New York Medicaid APG,1216.22,,,1216.22,Other,153% New York Medicaid APG,1788.55,,,1788.55,Other,225% New York Medicaid APG,1112.88,,,1112.88,Other,140% New York Medicaid APG,1788.55,,,1788.55,Other,225% New York Medicaid APG,2066.77,,,2066.77,Other,260% New York Medicaid APG,2575.52,,,2575.52,Other,324% New York Medicaid APG,1709.06,,,1709.06,Other,215% New York Medicaid APG,1709.06,,,1709.06,Other,215% New York Medicaid APG,993.64,,,993.64,Other,125% New York Medicaid APG,794.91,19857.01,
Sigmoidoscopy & polypectomy,45333,CPT,,,,,,,,both,,,19223.92,14225.7,74,,14225.7,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,8650.76,45,,8650.76,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,9515.84,49.5,,9515.84,percent of total billed charges,110% of Medicare,13072.27,68,,13072.27,percent of total billed charges,,1478.54,,,1478.54,Other,186% of Medicaid,15379.14,80,,15379.14,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,15379.14,80,,15379.14,percent of total billed charges,,7216,,,7216,Case Rate,,3578,,"100% primary, 0% secondary procedures",3578,Other,MagnaCare ASC Grouper,13456.74,70,,13456.74,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,794.91,,,794.91,Other,New York Medicaid APG methodology,794.91,,,794.91,Other,100% New York Medicaid APG,794.91,,,794.91,Other,100% New York Medicaid APG,794.91,,,794.91,Other,100% New York Medicaid APG,1788.55,,,1788.55,Other,225% New York Medicaid APG,1216.22,,,1216.22,Other,153% New York Medicaid APG,1788.55,,,1788.55,Other,225% New York Medicaid APG,1112.88,,,1112.88,Other,140% New York Medicaid APG,1788.55,,,1788.55,Other,225% New York Medicaid APG,2066.77,,,2066.77,Other,260% New York Medicaid APG,2575.52,,,2575.52,Other,324% New York Medicaid APG,1709.06,,,1709.06,Other,215% New York Medicaid APG,1709.06,,,1709.06,Other,215% New York Medicaid APG,993.64,,,993.64,Other,125% New York Medicaid APG,794.91,15379.14,
Sigmoidoscopy for bleeding,45334,CPT,,,,,,,,both,,,24821.26,18367.73,74,,18367.73,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,11169.57,45,,11169.57,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,12286.52,49.5,,12286.52,percent of total billed charges,110% of Medicare,16878.46,68,,16878.46,percent of total billed charges,,1478.54,,,1478.54,Other,186% of Medicaid,19857.01,80,,19857.01,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,19857.01,80,,19857.01,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,17374.88,70,,17374.88,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,794.91,,,794.91,Other,New York Medicaid APG methodology,794.91,,,794.91,Other,100% New York Medicaid APG,794.91,,,794.91,Other,100% New York Medicaid APG,794.91,,,794.91,Other,100% New York Medicaid APG,1788.55,,,1788.55,Other,225% New York Medicaid APG,1216.22,,,1216.22,Other,153% New York Medicaid APG,1788.55,,,1788.55,Other,225% New York Medicaid APG,1112.88,,,1112.88,Other,140% New York Medicaid APG,1788.55,,,1788.55,Other,225% New York Medicaid APG,2066.77,,,2066.77,Other,260% New York Medicaid APG,2575.52,,,2575.52,Other,324% New York Medicaid APG,1709.06,,,1709.06,Other,215% New York Medicaid APG,1709.06,,,1709.06,Other,215% New York Medicaid APG,993.64,,,993.64,Other,125% New York Medicaid APG,794.91,19857.01,
Sigmoidoscopy w/submuc inj,45335,CPT,,,,,,,,both,,,13730.67,10160.7,74,,10160.7,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,6178.8,45,,6178.8,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,6796.68,49.5,,6796.68,percent of total billed charges,110% of Medicare,9336.86,68,,9336.86,percent of total billed charges,,1478.54,,,1478.54,Other,186% of Medicaid,10984.54,80,,10984.54,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,10984.54,80,,10984.54,percent of total billed charges,,7216,,,7216,Case Rate,,3578,,"100% primary, 0% secondary procedures",3578,Other,MagnaCare ASC Grouper,9611.47,70,,9611.47,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,794.91,,,794.91,Other,New York Medicaid APG methodology,794.91,,,794.91,Other,100% New York Medicaid APG,794.91,,,794.91,Other,100% New York Medicaid APG,794.91,,,794.91,Other,100% New York Medicaid APG,1788.55,,,1788.55,Other,225% New York Medicaid APG,1216.22,,,1216.22,Other,153% New York Medicaid APG,1788.55,,,1788.55,Other,225% New York Medicaid APG,1112.88,,,1112.88,Other,140% New York Medicaid APG,1788.55,,,1788.55,Other,225% New York Medicaid APG,2066.77,,,2066.77,Other,260% New York Medicaid APG,2575.52,,,2575.52,Other,324% New York Medicaid APG,1709.06,,,1709.06,Other,215% New York Medicaid APG,1709.06,,,1709.06,Other,215% New York Medicaid APG,993.64,,,993.64,Other,125% New York Medicaid APG,794.91,10984.54,
Sigmoidoscopy & decompress,45337,CPT,,,,,,,,both,,,19223.92,14225.7,74,,14225.7,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,8650.76,45,,8650.76,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,9515.84,49.5,,9515.84,percent of total billed charges,110% of Medicare,13072.27,68,,13072.27,percent of total billed charges,,1478.54,,,1478.54,Other,186% of Medicaid,15379.14,80,,15379.14,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,15379.14,80,,15379.14,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,13456.74,70,,13456.74,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,794.91,,,794.91,Other,New York Medicaid APG methodology,794.91,,,794.91,Other,100% New York Medicaid APG,794.91,,,794.91,Other,100% New York Medicaid APG,794.91,,,794.91,Other,100% New York Medicaid APG,1788.55,,,1788.55,Other,225% New York Medicaid APG,1216.22,,,1216.22,Other,153% New York Medicaid APG,1788.55,,,1788.55,Other,225% New York Medicaid APG,1112.88,,,1112.88,Other,140% New York Medicaid APG,1788.55,,,1788.55,Other,225% New York Medicaid APG,2066.77,,,2066.77,Other,260% New York Medicaid APG,2575.52,,,2575.52,Other,324% New York Medicaid APG,1709.06,,,1709.06,Other,215% New York Medicaid APG,1709.06,,,1709.06,Other,215% New York Medicaid APG,993.64,,,993.64,Other,125% New York Medicaid APG,794.91,15379.14,
Sigmoidoscopy w/tumr remove,45338,CPT,,,,,,,,both,,,20445.33,15129.54,74,,15129.54,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,9200.4,45,,9200.4,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,10120.44,49.5,,10120.44,percent of total billed charges,110% of Medicare,13902.82,68,,13902.82,percent of total billed charges,,1478.54,,,1478.54,Other,186% of Medicaid,16356.26,80,,16356.26,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,16356.26,80,,16356.26,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,14311.73,70,,14311.73,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,794.91,,,794.91,Other,New York Medicaid APG methodology,794.91,,,794.91,Other,100% New York Medicaid APG,794.91,,,794.91,Other,100% New York Medicaid APG,794.91,,,794.91,Other,100% New York Medicaid APG,1788.55,,,1788.55,Other,225% New York Medicaid APG,1216.22,,,1216.22,Other,153% New York Medicaid APG,1788.55,,,1788.55,Other,225% New York Medicaid APG,1112.88,,,1112.88,Other,140% New York Medicaid APG,1788.55,,,1788.55,Other,225% New York Medicaid APG,2066.77,,,2066.77,Other,260% New York Medicaid APG,2575.52,,,2575.52,Other,324% New York Medicaid APG,1709.06,,,1709.06,Other,215% New York Medicaid APG,1709.06,,,1709.06,Other,215% New York Medicaid APG,993.64,,,993.64,Other,125% New York Medicaid APG,794.91,16356.26,
Sig w/tndsc balloon dilation,45340,CPT,,,,,,,,both,,,20062.56,14846.29,74,,14846.29,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,9028.15,45,,9028.15,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,9930.97,49.5,,9930.97,percent of total billed charges,110% of Medicare,13642.54,68,,13642.54,percent of total billed charges,,1478.54,,,1478.54,Other,186% of Medicaid,16050.05,80,,16050.05,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,16050.05,80,,16050.05,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,14043.79,70,,14043.79,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,794.91,,,794.91,Other,New York Medicaid APG methodology,794.91,,,794.91,Other,100% New York Medicaid APG,794.91,,,794.91,Other,100% New York Medicaid APG,794.91,,,794.91,Other,100% New York Medicaid APG,1788.55,,,1788.55,Other,225% New York Medicaid APG,1216.22,,,1216.22,Other,153% New York Medicaid APG,1788.55,,,1788.55,Other,225% New York Medicaid APG,1112.88,,,1112.88,Other,140% New York Medicaid APG,1788.55,,,1788.55,Other,225% New York Medicaid APG,2066.77,,,2066.77,Other,260% New York Medicaid APG,2575.52,,,2575.52,Other,324% New York Medicaid APG,1709.06,,,1709.06,Other,215% New York Medicaid APG,1709.06,,,1709.06,Other,215% New York Medicaid APG,993.64,,,993.64,Other,125% New York Medicaid APG,794.91,16050.05,
Sigmoidoscopy w/ultrasound,45341,CPT,,,,,,,,both,,,12269.31,9079.29,74,,9079.29,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,5521.19,45,,5521.19,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,6073.31,49.5,,6073.31,percent of total billed charges,110% of Medicare,8343.13,68,,8343.13,percent of total billed charges,,1478.54,,,1478.54,Other,186% of Medicaid,9815.45,80,,9815.45,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,9815.45,80,,9815.45,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,8588.52,70,,8588.52,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,794.91,,,794.91,Other,New York Medicaid APG methodology,794.91,,,794.91,Other,100% New York Medicaid APG,794.91,,,794.91,Other,100% New York Medicaid APG,794.91,,,794.91,Other,100% New York Medicaid APG,1788.55,,,1788.55,Other,225% New York Medicaid APG,1216.22,,,1216.22,Other,153% New York Medicaid APG,1788.55,,,1788.55,Other,225% New York Medicaid APG,1112.88,,,1112.88,Other,140% New York Medicaid APG,1788.55,,,1788.55,Other,225% New York Medicaid APG,2066.77,,,2066.77,Other,260% New York Medicaid APG,2575.52,,,2575.52,Other,324% New York Medicaid APG,1709.06,,,1709.06,Other,215% New York Medicaid APG,1709.06,,,1709.06,Other,215% New York Medicaid APG,993.64,,,993.64,Other,125% New York Medicaid APG,794.91,9815.45,
Sigmoidoscopy w/us guide bx,45342,CPT,,,,,,,,both,,,29003,21462.22,74,,21462.22,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,13051.35,45,,13051.35,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,14356.49,49.5,,14356.49,percent of total billed charges,110% of Medicare,19722.04,68,,19722.04,percent of total billed charges,,1478.54,,,1478.54,Other,186% of Medicaid,23202.4,80,,23202.4,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,23202.4,80,,23202.4,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,20302.1,70,,20302.1,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,794.91,,,794.91,Other,New York Medicaid APG methodology,794.91,,,794.91,Other,100% New York Medicaid APG,794.91,,,794.91,Other,100% New York Medicaid APG,794.91,,,794.91,Other,100% New York Medicaid APG,1788.55,,,1788.55,Other,225% New York Medicaid APG,1216.22,,,1216.22,Other,153% New York Medicaid APG,1788.55,,,1788.55,Other,225% New York Medicaid APG,1112.88,,,1112.88,Other,140% New York Medicaid APG,1788.55,,,1788.55,Other,225% New York Medicaid APG,2066.77,,,2066.77,Other,260% New York Medicaid APG,2575.52,,,2575.52,Other,324% New York Medicaid APG,1709.06,,,1709.06,Other,215% New York Medicaid APG,1709.06,,,1709.06,Other,215% New York Medicaid APG,993.64,,,993.64,Other,125% New York Medicaid APG,794.91,23202.4,
Sigmoidoscopy w/ablation,45346,CPT,,,,,,,,both,,,11592,8578.08,74,,8578.08,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,5216.4,45,,5216.4,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,5738.04,49.5,,5738.04,percent of total billed charges,110% of Medicare,7882.56,68,,7882.56,percent of total billed charges,,1478.54,,,1478.54,Other,186% of Medicaid,9273.6,80,,9273.6,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,9273.6,80,,9273.6,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,8114.4,70,,8114.4,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,794.91,,,794.91,Other,New York Medicaid APG methodology,794.91,,,794.91,Other,100% New York Medicaid APG,794.91,,,794.91,Other,100% New York Medicaid APG,794.91,,,794.91,Other,100% New York Medicaid APG,1788.55,,,1788.55,Other,225% New York Medicaid APG,1216.22,,,1216.22,Other,153% New York Medicaid APG,1788.55,,,1788.55,Other,225% New York Medicaid APG,1112.88,,,1112.88,Other,140% New York Medicaid APG,1788.55,,,1788.55,Other,225% New York Medicaid APG,2066.77,,,2066.77,Other,260% New York Medicaid APG,2575.52,,,2575.52,Other,324% New York Medicaid APG,1709.06,,,1709.06,Other,215% New York Medicaid APG,1709.06,,,1709.06,Other,215% New York Medicaid APG,993.64,,,993.64,Other,125% New York Medicaid APG,794.91,9273.6,
Sigmoidoscopy w/plcmt stent,45347,CPT,,,,,,,,both,,,36950.9,27343.67,74,,27343.67,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,16627.91,45,,16627.91,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,18290.7,49.5,,18290.7,percent of total billed charges,110% of Medicare,25126.61,68,,25126.61,percent of total billed charges,,1648.24,,,1648.24,Other,186% of Medicaid,29560.72,80,,29560.72,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,29560.72,80,,29560.72,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,25865.63,70,,25865.63,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,886.15,,,886.15,Other,New York Medicaid APG methodology,886.15,,,886.15,Other,100% New York Medicaid APG,886.15,,,886.15,Other,100% New York Medicaid APG,886.15,,,886.15,Other,100% New York Medicaid APG,1993.84,,,1993.84,Other,225% New York Medicaid APG,1355.81,,,1355.81,Other,153% New York Medicaid APG,1993.84,,,1993.84,Other,225% New York Medicaid APG,1240.61,,,1240.61,Other,140% New York Medicaid APG,1993.84,,,1993.84,Other,225% New York Medicaid APG,2303.99,,,2303.99,Other,260% New York Medicaid APG,2871.13,,,2871.13,Other,324% New York Medicaid APG,1905.23,,,1905.23,Other,215% New York Medicaid APG,1905.23,,,1905.23,Other,215% New York Medicaid APG,1107.69,,,1107.69,Other,125% New York Medicaid APG,886.15,29560.72,
Sigmoidoscopy w/resection,45349,CPT,,,,,,,,both,,,26478,19593.72,74,,19593.72,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,11915.1,45,,11915.1,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,13106.61,49.5,,13106.61,percent of total billed charges,110% of Medicare,18005.04,68,,18005.04,percent of total billed charges,,1648.24,,,1648.24,Other,186% of Medicaid,21182.4,80,,21182.4,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,21182.4,80,,21182.4,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,18534.6,70,,18534.6,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,886.15,,,886.15,Other,New York Medicaid APG methodology,886.15,,,886.15,Other,100% New York Medicaid APG,886.15,,,886.15,Other,100% New York Medicaid APG,886.15,,,886.15,Other,100% New York Medicaid APG,1993.84,,,1993.84,Other,225% New York Medicaid APG,1355.81,,,1355.81,Other,153% New York Medicaid APG,1993.84,,,1993.84,Other,225% New York Medicaid APG,1240.61,,,1240.61,Other,140% New York Medicaid APG,1993.84,,,1993.84,Other,225% New York Medicaid APG,2303.99,,,2303.99,Other,260% New York Medicaid APG,2871.13,,,2871.13,Other,324% New York Medicaid APG,1905.23,,,1905.23,Other,215% New York Medicaid APG,1905.23,,,1905.23,Other,215% New York Medicaid APG,1107.69,,,1107.69,Other,125% New York Medicaid APG,886.15,21182.4,
Sgmdsc w/band ligation,45350,CPT,,,,,,,,both,,,21132,15637.68,74,,15637.68,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,9509.4,45,,9509.4,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,10460.34,49.5,,10460.34,percent of total billed charges,110% of Medicare,14369.76,68,,14369.76,percent of total billed charges,,1478.54,,,1478.54,Other,186% of Medicaid,16905.6,80,,16905.6,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,16905.6,80,,16905.6,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,14792.4,70,,14792.4,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,794.91,,,794.91,Other,New York Medicaid APG methodology,794.91,,,794.91,Other,100% New York Medicaid APG,794.91,,,794.91,Other,100% New York Medicaid APG,794.91,,,794.91,Other,100% New York Medicaid APG,1788.55,,,1788.55,Other,225% New York Medicaid APG,1216.22,,,1216.22,Other,153% New York Medicaid APG,1788.55,,,1788.55,Other,225% New York Medicaid APG,1112.88,,,1112.88,Other,140% New York Medicaid APG,1788.55,,,1788.55,Other,225% New York Medicaid APG,2066.77,,,2066.77,Other,260% New York Medicaid APG,2575.52,,,2575.52,Other,324% New York Medicaid APG,1709.06,,,1709.06,Other,215% New York Medicaid APG,1709.06,,,1709.06,Other,215% New York Medicaid APG,993.64,,,993.64,Other,125% New York Medicaid APG,794.91,16905.6,
Diagnostic colonoscopy,45378,CPT,,,,,,,,both,,,18300.47,13542.35,74,,13542.35,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,8235.21,45,,8235.21,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,9058.73,49.5,,9058.73,percent of total billed charges,110% of Medicare,12444.32,68,,12444.32,percent of total billed charges,,1478.54,,,1478.54,Other,186% of Medicaid,14640.38,80,,14640.38,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,14640.38,80,,14640.38,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,12810.33,70,,12810.33,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,794.91,,,794.91,Other,New York Medicaid APG methodology,794.91,,,794.91,Other,100% New York Medicaid APG,794.91,,,794.91,Other,100% New York Medicaid APG,794.91,,,794.91,Other,100% New York Medicaid APG,1788.55,,,1788.55,Other,225% New York Medicaid APG,1216.22,,,1216.22,Other,153% New York Medicaid APG,1788.55,,,1788.55,Other,225% New York Medicaid APG,1112.88,,,1112.88,Other,140% New York Medicaid APG,1788.55,,,1788.55,Other,225% New York Medicaid APG,2066.77,,,2066.77,Other,260% New York Medicaid APG,2575.52,,,2575.52,Other,324% New York Medicaid APG,1709.06,,,1709.06,Other,215% New York Medicaid APG,1709.06,,,1709.06,Other,215% New York Medicaid APG,993.64,,,993.64,Other,125% New York Medicaid APG,794.91,14640.38,
Colonoscopy w/fb removal,45379,CPT,,,,,,,,both,,,15782.42,11678.99,74,,11678.99,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,7102.09,45,,7102.09,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,7812.3,49.5,,7812.3,percent of total billed charges,110% of Medicare,10732.05,68,,10732.05,percent of total billed charges,,1478.54,,,1478.54,Other,186% of Medicaid,12625.94,80,,12625.94,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,12625.94,80,,12625.94,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,11047.69,70,,11047.69,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,794.91,,,794.91,Other,New York Medicaid APG methodology,794.91,,,794.91,Other,100% New York Medicaid APG,794.91,,,794.91,Other,100% New York Medicaid APG,794.91,,,794.91,Other,100% New York Medicaid APG,1788.55,,,1788.55,Other,225% New York Medicaid APG,1216.22,,,1216.22,Other,153% New York Medicaid APG,1788.55,,,1788.55,Other,225% New York Medicaid APG,1112.88,,,1112.88,Other,140% New York Medicaid APG,1788.55,,,1788.55,Other,225% New York Medicaid APG,2066.77,,,2066.77,Other,260% New York Medicaid APG,2575.52,,,2575.52,Other,324% New York Medicaid APG,1709.06,,,1709.06,Other,215% New York Medicaid APG,1709.06,,,1709.06,Other,215% New York Medicaid APG,993.64,,,993.64,Other,125% New York Medicaid APG,794.91,12625.94,
Colonoscopy and biopsy,45380,CPT,,,,,,,,both,,,25392.05,18790.12,74,,18790.12,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,11426.42,45,,11426.42,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,12569.06,49.5,,12569.06,percent of total billed charges,110% of Medicare,17266.59,68,,17266.59,percent of total billed charges,,1478.54,,,1478.54,Other,186% of Medicaid,20313.64,80,,20313.64,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,20313.64,80,,20313.64,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,17774.44,70,,17774.44,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,794.91,,,794.91,Other,New York Medicaid APG methodology,794.91,,,794.91,Other,100% New York Medicaid APG,794.91,,,794.91,Other,100% New York Medicaid APG,794.91,,,794.91,Other,100% New York Medicaid APG,1788.55,,,1788.55,Other,225% New York Medicaid APG,1216.22,,,1216.22,Other,153% New York Medicaid APG,1788.55,,,1788.55,Other,225% New York Medicaid APG,1112.88,,,1112.88,Other,140% New York Medicaid APG,1788.55,,,1788.55,Other,225% New York Medicaid APG,2066.77,,,2066.77,Other,260% New York Medicaid APG,2575.52,,,2575.52,Other,324% New York Medicaid APG,1709.06,,,1709.06,Other,215% New York Medicaid APG,1709.06,,,1709.06,Other,215% New York Medicaid APG,993.64,,,993.64,Other,125% New York Medicaid APG,794.91,20313.64,
Colonoscopy submucous njx,45381,CPT,,,,,,,,both,,,30844.27,22824.76,74,,22824.76,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,13879.92,45,,13879.92,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,15267.91,49.5,,15267.91,percent of total billed charges,110% of Medicare,20974.1,68,,20974.1,percent of total billed charges,,1478.54,,,1478.54,Other,186% of Medicaid,24675.42,80,,24675.42,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,24675.42,80,,24675.42,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,21590.99,70,,21590.99,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,794.91,,,794.91,Other,New York Medicaid APG methodology,794.91,,,794.91,Other,100% New York Medicaid APG,794.91,,,794.91,Other,100% New York Medicaid APG,794.91,,,794.91,Other,100% New York Medicaid APG,1788.55,,,1788.55,Other,225% New York Medicaid APG,1216.22,,,1216.22,Other,153% New York Medicaid APG,1788.55,,,1788.55,Other,225% New York Medicaid APG,1112.88,,,1112.88,Other,140% New York Medicaid APG,1788.55,,,1788.55,Other,225% New York Medicaid APG,2066.77,,,2066.77,Other,260% New York Medicaid APG,2575.52,,,2575.52,Other,324% New York Medicaid APG,1709.06,,,1709.06,Other,215% New York Medicaid APG,1709.06,,,1709.06,Other,215% New York Medicaid APG,993.64,,,993.64,Other,125% New York Medicaid APG,794.91,24675.42,
Colonoscopy w/control bleed,45382,CPT,,,,,,,,both,,,12868.66,9522.81,74,,9522.81,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,5790.9,45,,5790.9,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,6369.99,49.5,,6369.99,percent of total billed charges,110% of Medicare,8750.69,68,,8750.69,percent of total billed charges,,1478.54,,,1478.54,Other,186% of Medicaid,10294.93,80,,10294.93,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,10294.93,80,,10294.93,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,9008.06,70,,9008.06,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,794.91,,,794.91,Other,New York Medicaid APG methodology,794.91,,,794.91,Other,100% New York Medicaid APG,794.91,,,794.91,Other,100% New York Medicaid APG,794.91,,,794.91,Other,100% New York Medicaid APG,1788.55,,,1788.55,Other,225% New York Medicaid APG,1216.22,,,1216.22,Other,153% New York Medicaid APG,1788.55,,,1788.55,Other,225% New York Medicaid APG,1112.88,,,1112.88,Other,140% New York Medicaid APG,1788.55,,,1788.55,Other,225% New York Medicaid APG,2066.77,,,2066.77,Other,260% New York Medicaid APG,2575.52,,,2575.52,Other,324% New York Medicaid APG,1709.06,,,1709.06,Other,215% New York Medicaid APG,1709.06,,,1709.06,Other,215% New York Medicaid APG,993.64,,,993.64,Other,125% New York Medicaid APG,794.91,10294.93,
Colonoscopy w/lesion removal,45384,CPT,,,,,,,,both,,,17656,13065.44,74,,13065.44,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,7945.2,45,,7945.2,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,8739.72,49.5,,8739.72,percent of total billed charges,110% of Medicare,12006.08,68,,12006.08,percent of total billed charges,,1478.54,,,1478.54,Other,186% of Medicaid,14124.8,80,,14124.8,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,14124.8,80,,14124.8,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,12359.2,70,,12359.2,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,794.91,,,794.91,Other,New York Medicaid APG methodology,794.91,,,794.91,Other,100% New York Medicaid APG,794.91,,,794.91,Other,100% New York Medicaid APG,794.91,,,794.91,Other,100% New York Medicaid APG,1788.55,,,1788.55,Other,225% New York Medicaid APG,1216.22,,,1216.22,Other,153% New York Medicaid APG,1788.55,,,1788.55,Other,225% New York Medicaid APG,1112.88,,,1112.88,Other,140% New York Medicaid APG,1788.55,,,1788.55,Other,225% New York Medicaid APG,2066.77,,,2066.77,Other,260% New York Medicaid APG,2575.52,,,2575.52,Other,324% New York Medicaid APG,1709.06,,,1709.06,Other,215% New York Medicaid APG,1709.06,,,1709.06,Other,215% New York Medicaid APG,993.64,,,993.64,Other,125% New York Medicaid APG,794.91,14124.8,
Colonoscopy w/lesion removal,45385,CPT,,,,,,,,both,,,23753.5,17577.59,74,,17577.59,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,10689.08,45,,10689.08,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,11757.98,49.5,,11757.98,percent of total billed charges,110% of Medicare,16152.38,68,,16152.38,percent of total billed charges,,1478.54,,,1478.54,Other,186% of Medicaid,19002.8,80,,19002.8,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,19002.8,80,,19002.8,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,16627.45,70,,16627.45,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,794.91,,,794.91,Other,New York Medicaid APG methodology,794.91,,,794.91,Other,100% New York Medicaid APG,794.91,,,794.91,Other,100% New York Medicaid APG,794.91,,,794.91,Other,100% New York Medicaid APG,1788.55,,,1788.55,Other,225% New York Medicaid APG,1216.22,,,1216.22,Other,153% New York Medicaid APG,1788.55,,,1788.55,Other,225% New York Medicaid APG,1112.88,,,1112.88,Other,140% New York Medicaid APG,1788.55,,,1788.55,Other,225% New York Medicaid APG,2066.77,,,2066.77,Other,260% New York Medicaid APG,2575.52,,,2575.52,Other,324% New York Medicaid APG,1709.06,,,1709.06,Other,215% New York Medicaid APG,1709.06,,,1709.06,Other,215% New York Medicaid APG,993.64,,,993.64,Other,125% New York Medicaid APG,794.91,19002.8,
Colonoscopy w/balloon dilat,45386,CPT,,,,,,,,both,,,32175.67,23810,74,,23810,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,14479.05,45,,14479.05,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,15926.96,49.5,,15926.96,percent of total billed charges,110% of Medicare,21879.46,68,,21879.46,percent of total billed charges,,1478.54,,,1478.54,Other,186% of Medicaid,25740.54,80,,25740.54,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,25740.54,80,,25740.54,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,22522.97,70,,22522.97,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,794.91,,,794.91,Other,New York Medicaid APG methodology,794.91,,,794.91,Other,100% New York Medicaid APG,794.91,,,794.91,Other,100% New York Medicaid APG,794.91,,,794.91,Other,100% New York Medicaid APG,1788.55,,,1788.55,Other,225% New York Medicaid APG,1216.22,,,1216.22,Other,153% New York Medicaid APG,1788.55,,,1788.55,Other,225% New York Medicaid APG,1112.88,,,1112.88,Other,140% New York Medicaid APG,1788.55,,,1788.55,Other,225% New York Medicaid APG,2066.77,,,2066.77,Other,260% New York Medicaid APG,2575.52,,,2575.52,Other,324% New York Medicaid APG,1709.06,,,1709.06,Other,215% New York Medicaid APG,1709.06,,,1709.06,Other,215% New York Medicaid APG,993.64,,,993.64,Other,125% New York Medicaid APG,794.91,25740.54,
Colonoscopy w/ablation,45388,CPT,,,,,,,,both,,,24635.95,18230.6,74,,18230.6,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,11086.18,45,,11086.18,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,12194.8,49.5,,12194.8,percent of total billed charges,110% of Medicare,16752.45,68,,16752.45,percent of total billed charges,,1478.54,,,1478.54,Other,186% of Medicaid,19708.76,80,,19708.76,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,19708.76,80,,19708.76,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,17245.17,70,,17245.17,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,794.91,,,794.91,Other,New York Medicaid APG methodology,794.91,,,794.91,Other,100% New York Medicaid APG,794.91,,,794.91,Other,100% New York Medicaid APG,794.91,,,794.91,Other,100% New York Medicaid APG,1788.55,,,1788.55,Other,225% New York Medicaid APG,1216.22,,,1216.22,Other,153% New York Medicaid APG,1788.55,,,1788.55,Other,225% New York Medicaid APG,1112.88,,,1112.88,Other,140% New York Medicaid APG,1788.55,,,1788.55,Other,225% New York Medicaid APG,2066.77,,,2066.77,Other,260% New York Medicaid APG,2575.52,,,2575.52,Other,324% New York Medicaid APG,1709.06,,,1709.06,Other,215% New York Medicaid APG,1709.06,,,1709.06,Other,215% New York Medicaid APG,993.64,,,993.64,Other,125% New York Medicaid APG,794.91,19708.76,
Colonoscopy w/stent plcmt,45389,CPT,,,,,,,,both,,,119876.35,88708.5,74,,88708.5,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,53944.36,45,,53944.36,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,59338.79,49.5,,59338.79,percent of total billed charges,110% of Medicare,81515.92,68,,81515.92,percent of total billed charges,,1648.24,,,1648.24,Other,186% of Medicaid,95901.08,80,,95901.08,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,95901.08,80,,95901.08,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,83913.45,70,,83913.45,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,886.15,,,886.15,Other,New York Medicaid APG methodology,886.15,,,886.15,Other,100% New York Medicaid APG,886.15,,,886.15,Other,100% New York Medicaid APG,886.15,,,886.15,Other,100% New York Medicaid APG,1993.84,,,1993.84,Other,225% New York Medicaid APG,1355.81,,,1355.81,Other,153% New York Medicaid APG,1993.84,,,1993.84,Other,225% New York Medicaid APG,1240.61,,,1240.61,Other,140% New York Medicaid APG,1993.84,,,1993.84,Other,225% New York Medicaid APG,2303.99,,,2303.99,Other,260% New York Medicaid APG,2871.13,,,2871.13,Other,324% New York Medicaid APG,1905.23,,,1905.23,Other,215% New York Medicaid APG,1905.23,,,1905.23,Other,215% New York Medicaid APG,1107.69,,,1107.69,Other,125% New York Medicaid APG,886.15,95901.08,
Colonoscopy w/resection,45390,CPT,,,,,,,,both,,,32260.86,23873.04,74,,23873.04,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,14517.39,45,,14517.39,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,15969.13,49.5,,15969.13,percent of total billed charges,110% of Medicare,21937.38,68,,21937.38,percent of total billed charges,,1648.24,,,1648.24,Other,186% of Medicaid,25808.69,80,,25808.69,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,25808.69,80,,25808.69,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,22582.6,70,,22582.6,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,886.15,,,886.15,Other,New York Medicaid APG methodology,886.15,,,886.15,Other,100% New York Medicaid APG,886.15,,,886.15,Other,100% New York Medicaid APG,886.15,,,886.15,Other,100% New York Medicaid APG,1993.84,,,1993.84,Other,225% New York Medicaid APG,1355.81,,,1355.81,Other,153% New York Medicaid APG,1993.84,,,1993.84,Other,225% New York Medicaid APG,1240.61,,,1240.61,Other,140% New York Medicaid APG,1993.84,,,1993.84,Other,225% New York Medicaid APG,2303.99,,,2303.99,Other,260% New York Medicaid APG,2871.13,,,2871.13,Other,324% New York Medicaid APG,1905.23,,,1905.23,Other,215% New York Medicaid APG,1905.23,,,1905.23,Other,215% New York Medicaid APG,1107.69,,,1107.69,Other,125% New York Medicaid APG,886.15,25808.69,
Colonoscopy w/endoscope us,45391,CPT,,,,,,,,both,,,14789.75,10944.42,74,,10944.42,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,6655.39,45,,6655.39,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,7320.93,49.5,,7320.93,percent of total billed charges,110% of Medicare,10057.03,68,,10057.03,percent of total billed charges,,1478.54,,,1478.54,Other,186% of Medicaid,11831.8,80,,11831.8,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,11831.8,80,,11831.8,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,10352.83,70,,10352.83,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,794.91,,,794.91,Other,New York Medicaid APG methodology,794.91,,,794.91,Other,100% New York Medicaid APG,794.91,,,794.91,Other,100% New York Medicaid APG,794.91,,,794.91,Other,100% New York Medicaid APG,1788.55,,,1788.55,Other,225% New York Medicaid APG,1216.22,,,1216.22,Other,153% New York Medicaid APG,1788.55,,,1788.55,Other,225% New York Medicaid APG,1112.88,,,1112.88,Other,140% New York Medicaid APG,1788.55,,,1788.55,Other,225% New York Medicaid APG,2066.77,,,2066.77,Other,260% New York Medicaid APG,2575.52,,,2575.52,Other,324% New York Medicaid APG,1709.06,,,1709.06,Other,215% New York Medicaid APG,1709.06,,,1709.06,Other,215% New York Medicaid APG,993.64,,,993.64,Other,125% New York Medicaid APG,794.91,11831.8,
Colonoscopy w/endoscopic fnb,45392,CPT,,,,,,,,both,,,25125,18592.5,74,,18592.5,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,11306.25,45,,11306.25,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,12436.88,49.5,,12436.88,percent of total billed charges,110% of Medicare,17085,68,,17085,percent of total billed charges,,1648.24,,,1648.24,Other,186% of Medicaid,20100,80,,20100,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,20100,80,,20100,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,17587.5,70,,17587.5,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,886.15,,,886.15,Other,New York Medicaid APG methodology,886.15,,,886.15,Other,100% New York Medicaid APG,886.15,,,886.15,Other,100% New York Medicaid APG,886.15,,,886.15,Other,100% New York Medicaid APG,1993.84,,,1993.84,Other,225% New York Medicaid APG,1355.81,,,1355.81,Other,153% New York Medicaid APG,1993.84,,,1993.84,Other,225% New York Medicaid APG,1240.61,,,1240.61,Other,140% New York Medicaid APG,1993.84,,,1993.84,Other,225% New York Medicaid APG,2303.99,,,2303.99,Other,260% New York Medicaid APG,2871.13,,,2871.13,Other,324% New York Medicaid APG,1905.23,,,1905.23,Other,215% New York Medicaid APG,1905.23,,,1905.23,Other,215% New York Medicaid APG,1107.69,,,1107.69,Other,125% New York Medicaid APG,886.15,20100,
Colonoscopy w/decompression,45393,CPT,,,,,,,,both,,,24821.26,18367.73,74,,18367.73,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,11169.57,45,,11169.57,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,12286.52,49.5,,12286.52,percent of total billed charges,110% of Medicare,16878.46,68,,16878.46,percent of total billed charges,,1478.54,,,1478.54,Other,186% of Medicaid,19857.01,80,,19857.01,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,19857.01,80,,19857.01,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,17374.88,70,,17374.88,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,794.91,,,794.91,Other,New York Medicaid APG methodology,794.91,,,794.91,Other,100% New York Medicaid APG,794.91,,,794.91,Other,100% New York Medicaid APG,794.91,,,794.91,Other,100% New York Medicaid APG,1788.55,,,1788.55,Other,225% New York Medicaid APG,1216.22,,,1216.22,Other,153% New York Medicaid APG,1788.55,,,1788.55,Other,225% New York Medicaid APG,1112.88,,,1112.88,Other,140% New York Medicaid APG,1788.55,,,1788.55,Other,225% New York Medicaid APG,2066.77,,,2066.77,Other,260% New York Medicaid APG,2575.52,,,2575.52,Other,324% New York Medicaid APG,1709.06,,,1709.06,Other,215% New York Medicaid APG,1709.06,,,1709.06,Other,215% New York Medicaid APG,993.64,,,993.64,Other,125% New York Medicaid APG,794.91,19857.01,
Colonoscopy w/band ligation,45398,CPT,,,,,,,,both,,,20872.6,15445.72,74,,15445.72,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,9392.67,45,,9392.67,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,10331.94,49.5,,10331.94,percent of total billed charges,110% of Medicare,14193.37,68,,14193.37,percent of total billed charges,,1478.54,,,1478.54,Other,186% of Medicaid,16698.08,80,,16698.08,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,16698.08,80,,16698.08,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,14610.82,70,,14610.82,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,794.91,,,794.91,Other,New York Medicaid APG methodology,794.91,,,794.91,Other,100% New York Medicaid APG,794.91,,,794.91,Other,100% New York Medicaid APG,794.91,,,794.91,Other,100% New York Medicaid APG,1788.55,,,1788.55,Other,225% New York Medicaid APG,1216.22,,,1216.22,Other,153% New York Medicaid APG,1788.55,,,1788.55,Other,225% New York Medicaid APG,1112.88,,,1112.88,Other,140% New York Medicaid APG,1788.55,,,1788.55,Other,225% New York Medicaid APG,2066.77,,,2066.77,Other,260% New York Medicaid APG,2575.52,,,2575.52,Other,324% New York Medicaid APG,1709.06,,,1709.06,Other,215% New York Medicaid APG,1709.06,,,1709.06,Other,215% New York Medicaid APG,993.64,,,993.64,Other,125% New York Medicaid APG,794.91,16698.08,
Repair of rectum,45500,CPT,,,,,,,,both,,,59058.34,43703.17,74,,43703.17,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,26576.25,45,,26576.25,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,29233.88,49.5,,29233.88,percent of total billed charges,110% of Medicare,40159.67,68,,40159.67,percent of total billed charges,,2732.76,,,2732.76,Other,186% of Medicaid,47246.67,80,,47246.67,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,47246.67,80,,47246.67,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,41340.84,70,,41340.84,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1469.23,,,1469.23,Other,New York Medicaid APG methodology,1469.23,,,1469.23,Other,100% New York Medicaid APG,1469.23,,,1469.23,Other,100% New York Medicaid APG,1469.23,,,1469.23,Other,100% New York Medicaid APG,3305.76,,,3305.76,Other,225% New York Medicaid APG,2247.91,,,2247.91,Other,153% New York Medicaid APG,3305.76,,,3305.76,Other,225% New York Medicaid APG,2056.92,,,2056.92,Other,140% New York Medicaid APG,3305.76,,,3305.76,Other,225% New York Medicaid APG,3819.99,,,3819.99,Other,260% New York Medicaid APG,4760.29,,,4760.29,Other,324% New York Medicaid APG,3158.83,,,3158.83,Other,215% New York Medicaid APG,3158.83,,,3158.83,Other,215% New York Medicaid APG,1836.53,,,1836.53,Other,125% New York Medicaid APG,1469.23,47246.67,
Repair of rectum,45505,CPT,,,,,,,,both,,,34496.71,25527.57,74,,25527.57,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15523.52,45,,15523.52,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,17075.87,49.5,,17075.87,percent of total billed charges,110% of Medicare,23457.76,68,,23457.76,percent of total billed charges,,2732.76,,,2732.76,Other,186% of Medicaid,27597.37,80,,27597.37,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,27597.37,80,,27597.37,percent of total billed charges,,7216,,,7216,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,24147.7,70,,24147.7,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1469.23,,,1469.23,Other,New York Medicaid APG methodology,1469.23,,,1469.23,Other,100% New York Medicaid APG,1469.23,,,1469.23,Other,100% New York Medicaid APG,1469.23,,,1469.23,Other,100% New York Medicaid APG,3305.76,,,3305.76,Other,225% New York Medicaid APG,2247.91,,,2247.91,Other,153% New York Medicaid APG,3305.76,,,3305.76,Other,225% New York Medicaid APG,2056.92,,,2056.92,Other,140% New York Medicaid APG,3305.76,,,3305.76,Other,225% New York Medicaid APG,3819.99,,,3819.99,Other,260% New York Medicaid APG,4760.29,,,4760.29,Other,324% New York Medicaid APG,3158.83,,,3158.83,Other,215% New York Medicaid APG,3158.83,,,3158.83,Other,215% New York Medicaid APG,1836.53,,,1836.53,Other,125% New York Medicaid APG,1469.23,27597.37,
Treatment of rectal prolapse,45520,CPT,,,,,,,,both,,,19223.92,14225.7,74,,14225.7,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,8650.76,45,,8650.76,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,9515.84,49.5,,9515.84,percent of total billed charges,110% of Medicare,13072.27,68,,13072.27,percent of total billed charges,,2000.16,,,2000.16,Other,186% of Medicaid,15379.14,80,,15379.14,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,15379.14,80,,15379.14,percent of total billed charges,,7216,,,7216,Case Rate,,3578,,"100% primary, 0% secondary procedures",3578,Other,MagnaCare ASC Grouper,13456.74,70,,13456.74,percent of total billed charges,,196.8,,,196.8,Fee Schedule,,166.8,,,166.8,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,1075.35,,,1075.35,Other,New York Medicaid APG methodology,1075.35,,,1075.35,Other,100% New York Medicaid APG,1075.35,,,1075.35,Other,100% New York Medicaid APG,1075.35,,,1075.35,Other,100% New York Medicaid APG,2419.55,,,2419.55,Other,225% New York Medicaid APG,1645.29,,,1645.29,Other,153% New York Medicaid APG,2419.55,,,2419.55,Other,225% New York Medicaid APG,1505.5,,,1505.5,Other,140% New York Medicaid APG,2419.55,,,2419.55,Other,225% New York Medicaid APG,2795.92,,,2795.92,Other,260% New York Medicaid APG,3484.15,,,3484.15,Other,324% New York Medicaid APG,2312.01,,,2312.01,Other,215% New York Medicaid APG,2312.01,,,2312.01,Other,215% New York Medicaid APG,1344.19,,,1344.19,Other,125% New York Medicaid APG,166.8,15379.14,
Correct rectal prolapse,45541,CPT,,,,,,,,both,,,59058.34,43703.17,74,,43703.17,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,26576.25,45,,26576.25,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,29233.88,49.5,,29233.88,percent of total billed charges,110% of Medicare,40159.67,68,,40159.67,percent of total billed charges,,2732.76,,,2732.76,Other,186% of Medicaid,47246.67,80,,47246.67,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,47246.67,80,,47246.67,percent of total billed charges,,7216,,,7216,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,41340.84,70,,41340.84,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1469.23,,,1469.23,Other,New York Medicaid APG methodology,1469.23,,,1469.23,Other,100% New York Medicaid APG,1469.23,,,1469.23,Other,100% New York Medicaid APG,1469.23,,,1469.23,Other,100% New York Medicaid APG,3305.76,,,3305.76,Other,225% New York Medicaid APG,2247.91,,,2247.91,Other,153% New York Medicaid APG,3305.76,,,3305.76,Other,225% New York Medicaid APG,2056.92,,,2056.92,Other,140% New York Medicaid APG,3305.76,,,3305.76,Other,225% New York Medicaid APG,3819.99,,,3819.99,Other,260% New York Medicaid APG,4760.29,,,4760.29,Other,324% New York Medicaid APG,3158.83,,,3158.83,Other,215% New York Medicaid APG,3158.83,,,3158.83,Other,215% New York Medicaid APG,1836.53,,,1836.53,Other,125% New York Medicaid APG,1469.23,47246.67,
Repair of rectocele,45560,CPT,,,,,,,,both,,,59058.34,43703.17,74,,43703.17,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,26576.25,45,,26576.25,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,29233.88,49.5,,29233.88,percent of total billed charges,110% of Medicare,40159.67,68,,40159.67,percent of total billed charges,,2732.76,,,2732.76,Other,186% of Medicaid,47246.67,80,,47246.67,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,47246.67,80,,47246.67,percent of total billed charges,,7216,,,7216,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,41340.84,70,,41340.84,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1469.23,,,1469.23,Other,New York Medicaid APG methodology,1469.23,,,1469.23,Other,100% New York Medicaid APG,1469.23,,,1469.23,Other,100% New York Medicaid APG,1469.23,,,1469.23,Other,100% New York Medicaid APG,3305.76,,,3305.76,Other,225% New York Medicaid APG,2247.91,,,2247.91,Other,153% New York Medicaid APG,3305.76,,,3305.76,Other,225% New York Medicaid APG,2056.92,,,2056.92,Other,140% New York Medicaid APG,3305.76,,,3305.76,Other,225% New York Medicaid APG,3819.99,,,3819.99,Other,260% New York Medicaid APG,4760.29,,,4760.29,Other,324% New York Medicaid APG,3158.83,,,3158.83,Other,215% New York Medicaid APG,3158.83,,,3158.83,Other,215% New York Medicaid APG,1836.53,,,1836.53,Other,125% New York Medicaid APG,1469.23,47246.67,
Reduction of rectal prolapse,45900,CPT,,,,,,,,both,,,19223.92,14225.7,74,,14225.7,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,8650.76,45,,8650.76,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,9515.84,49.5,,9515.84,percent of total billed charges,110% of Medicare,13072.27,68,,13072.27,percent of total billed charges,,2000.16,,,2000.16,Other,186% of Medicaid,15379.14,80,,15379.14,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,15379.14,80,,15379.14,percent of total billed charges,,7216,,,7216,Case Rate,,3578,,"100% primary, 0% secondary procedures",3578,Other,MagnaCare ASC Grouper,13456.74,70,,13456.74,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,1075.35,,,1075.35,Other,New York Medicaid APG methodology,1075.35,,,1075.35,Other,100% New York Medicaid APG,1075.35,,,1075.35,Other,100% New York Medicaid APG,1075.35,,,1075.35,Other,100% New York Medicaid APG,2419.55,,,2419.55,Other,225% New York Medicaid APG,1645.29,,,1645.29,Other,153% New York Medicaid APG,2419.55,,,2419.55,Other,225% New York Medicaid APG,1505.5,,,1505.5,Other,140% New York Medicaid APG,2419.55,,,2419.55,Other,225% New York Medicaid APG,2795.92,,,2795.92,Other,260% New York Medicaid APG,3484.15,,,3484.15,Other,324% New York Medicaid APG,2312.01,,,2312.01,Other,215% New York Medicaid APG,2312.01,,,2312.01,Other,215% New York Medicaid APG,1344.19,,,1344.19,Other,125% New York Medicaid APG,1075.35,15379.14,
Dilation of anal sphincter,45905,CPT,,,,,,,,both,,,34516.73,25542.38,74,,25542.38,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15532.53,45,,15532.53,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,17085.78,49.5,,17085.78,percent of total billed charges,110% of Medicare,23471.38,68,,23471.38,percent of total billed charges,,2000.16,,,2000.16,Other,186% of Medicaid,27613.38,80,,27613.38,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,27613.38,80,,27613.38,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,24161.71,70,,24161.71,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1075.35,,,1075.35,Other,New York Medicaid APG methodology,1075.35,,,1075.35,Other,100% New York Medicaid APG,1075.35,,,1075.35,Other,100% New York Medicaid APG,1075.35,,,1075.35,Other,100% New York Medicaid APG,2419.55,,,2419.55,Other,225% New York Medicaid APG,1645.29,,,1645.29,Other,153% New York Medicaid APG,2419.55,,,2419.55,Other,225% New York Medicaid APG,1505.5,,,1505.5,Other,140% New York Medicaid APG,2419.55,,,2419.55,Other,225% New York Medicaid APG,2795.92,,,2795.92,Other,260% New York Medicaid APG,3484.15,,,3484.15,Other,324% New York Medicaid APG,2312.01,,,2312.01,Other,215% New York Medicaid APG,2312.01,,,2312.01,Other,215% New York Medicaid APG,1344.19,,,1344.19,Other,125% New York Medicaid APG,1075.35,27613.38,
Dilation of rectal narrowing,45910,CPT,,,,,,,,both,,,19172.43,14187.6,74,,14187.6,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,8627.59,45,,8627.59,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,9490.35,49.5,,9490.35,percent of total billed charges,110% of Medicare,13037.25,68,,13037.25,percent of total billed charges,,2000.16,,,2000.16,Other,186% of Medicaid,15337.94,80,,15337.94,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,15337.94,80,,15337.94,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,13420.7,70,,13420.7,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1075.35,,,1075.35,Other,New York Medicaid APG methodology,1075.35,,,1075.35,Other,100% New York Medicaid APG,1075.35,,,1075.35,Other,100% New York Medicaid APG,1075.35,,,1075.35,Other,100% New York Medicaid APG,2419.55,,,2419.55,Other,225% New York Medicaid APG,1645.29,,,1645.29,Other,153% New York Medicaid APG,2419.55,,,2419.55,Other,225% New York Medicaid APG,1505.5,,,1505.5,Other,140% New York Medicaid APG,2419.55,,,2419.55,Other,225% New York Medicaid APG,2795.92,,,2795.92,Other,260% New York Medicaid APG,3484.15,,,3484.15,Other,324% New York Medicaid APG,2312.01,,,2312.01,Other,215% New York Medicaid APG,2312.01,,,2312.01,Other,215% New York Medicaid APG,1344.19,,,1344.19,Other,125% New York Medicaid APG,1075.35,15337.94,
Remove rectal obstruction,45915,CPT,,,,,,,,both,,,24821.26,18367.73,74,,18367.73,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,11169.57,45,,11169.57,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,12286.52,49.5,,12286.52,percent of total billed charges,110% of Medicare,16878.46,68,,16878.46,percent of total billed charges,,2000.16,,,2000.16,Other,186% of Medicaid,19857.01,80,,19857.01,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,19857.01,80,,19857.01,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,17374.88,70,,17374.88,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1075.35,,,1075.35,Other,New York Medicaid APG methodology,1075.35,,,1075.35,Other,100% New York Medicaid APG,1075.35,,,1075.35,Other,100% New York Medicaid APG,1075.35,,,1075.35,Other,100% New York Medicaid APG,2419.55,,,2419.55,Other,225% New York Medicaid APG,1645.29,,,1645.29,Other,153% New York Medicaid APG,2419.55,,,2419.55,Other,225% New York Medicaid APG,1505.5,,,1505.5,Other,140% New York Medicaid APG,2419.55,,,2419.55,Other,225% New York Medicaid APG,2795.92,,,2795.92,Other,260% New York Medicaid APG,3484.15,,,3484.15,Other,324% New York Medicaid APG,2312.01,,,2312.01,Other,215% New York Medicaid APG,2312.01,,,2312.01,Other,215% New York Medicaid APG,1344.19,,,1344.19,Other,125% New York Medicaid APG,1075.35,19857.01,
Surg dx exam anorectal,45990,CPT,,,,,,,,both,,,34896.01,25823.05,74,,25823.05,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15703.2,45,,15703.2,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,17273.52,49.5,,17273.52,percent of total billed charges,110% of Medicare,23729.29,68,,23729.29,percent of total billed charges,,2000.16,,,2000.16,Other,186% of Medicaid,27916.81,80,,27916.81,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,27916.81,80,,27916.81,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,24427.21,70,,24427.21,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1075.35,,,1075.35,Other,New York Medicaid APG methodology,1075.35,,,1075.35,Other,100% New York Medicaid APG,1075.35,,,1075.35,Other,100% New York Medicaid APG,1075.35,,,1075.35,Other,100% New York Medicaid APG,2419.55,,,2419.55,Other,225% New York Medicaid APG,1645.29,,,1645.29,Other,153% New York Medicaid APG,2419.55,,,2419.55,Other,225% New York Medicaid APG,1505.5,,,1505.5,Other,140% New York Medicaid APG,2419.55,,,2419.55,Other,225% New York Medicaid APG,2795.92,,,2795.92,Other,260% New York Medicaid APG,3484.15,,,3484.15,Other,324% New York Medicaid APG,2312.01,,,2312.01,Other,215% New York Medicaid APG,2312.01,,,2312.01,Other,215% New York Medicaid APG,1344.19,,,1344.19,Other,125% New York Medicaid APG,1075.35,27916.81,
Placement of seton,46020,CPT,,,,,,,,both,,,36040.94,26670.3,74,,26670.3,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,16218.42,45,,16218.42,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,17840.27,49.5,,17840.27,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2000.16,,,2000.16,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,25228.66,70,,25228.66,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1075.35,,,1075.35,Other,New York Medicaid APG methodology,1075.35,,,1075.35,Other,100% New York Medicaid APG,1075.35,,,1075.35,Other,100% New York Medicaid APG,1075.35,,,1075.35,Other,100% New York Medicaid APG,2419.55,,,2419.55,Other,225% New York Medicaid APG,1645.29,,,1645.29,Other,153% New York Medicaid APG,2419.55,,,2419.55,Other,225% New York Medicaid APG,1505.5,,,1505.5,Other,140% New York Medicaid APG,2419.55,,,2419.55,Other,225% New York Medicaid APG,2795.92,,,2795.92,Other,260% New York Medicaid APG,3484.15,,,3484.15,Other,324% New York Medicaid APG,2312.01,,,2312.01,Other,215% New York Medicaid APG,2312.01,,,2312.01,Other,215% New York Medicaid APG,1344.19,,,1344.19,Other,125% New York Medicaid APG,1075.35,26670.3,
Removal of rectal marker,46030,CPT,,,,,,,,both,,,24821.26,18367.73,74,,18367.73,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,11169.57,45,,11169.57,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,12286.52,49.5,,12286.52,percent of total billed charges,110% of Medicare,16878.46,68,,16878.46,percent of total billed charges,,2000.16,,,2000.16,Other,186% of Medicaid,19857.01,80,,19857.01,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,19857.01,80,,19857.01,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,17374.88,70,,17374.88,percent of total billed charges,,424.76,,,424.76,Fee Schedule,,360.01,,,360.01,Fee Schedule,,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1075.35,,,1075.35,Other,New York Medicaid APG methodology,1075.35,,,1075.35,Other,100% New York Medicaid APG,1075.35,,,1075.35,Other,100% New York Medicaid APG,1075.35,,,1075.35,Other,100% New York Medicaid APG,2419.55,,,2419.55,Other,225% New York Medicaid APG,1645.29,,,1645.29,Other,153% New York Medicaid APG,2419.55,,,2419.55,Other,225% New York Medicaid APG,1505.5,,,1505.5,Other,140% New York Medicaid APG,2419.55,,,2419.55,Other,225% New York Medicaid APG,2795.92,,,2795.92,Other,260% New York Medicaid APG,3484.15,,,3484.15,Other,324% New York Medicaid APG,2312.01,,,2312.01,Other,215% New York Medicaid APG,2312.01,,,2312.01,Other,215% New York Medicaid APG,1344.19,,,1344.19,Other,125% New York Medicaid APG,360.01,19857.01,
Incision of rectal abscess,46040,CPT,,,,,,,,both,,,33065.33,24468.34,74,,24468.34,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,14879.4,45,,14879.4,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,16367.34,49.5,,16367.34,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2000.16,,,2000.16,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,23145.73,70,,23145.73,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1075.35,,,1075.35,Other,New York Medicaid APG methodology,1075.35,,,1075.35,Other,100% New York Medicaid APG,1075.35,,,1075.35,Other,100% New York Medicaid APG,1075.35,,,1075.35,Other,100% New York Medicaid APG,2419.55,,,2419.55,Other,225% New York Medicaid APG,1645.29,,,1645.29,Other,153% New York Medicaid APG,2419.55,,,2419.55,Other,225% New York Medicaid APG,1505.5,,,1505.5,Other,140% New York Medicaid APG,2419.55,,,2419.55,Other,225% New York Medicaid APG,2795.92,,,2795.92,Other,260% New York Medicaid APG,3484.15,,,3484.15,Other,324% New York Medicaid APG,2312.01,,,2312.01,Other,215% New York Medicaid APG,2312.01,,,2312.01,Other,215% New York Medicaid APG,1344.19,,,1344.19,Other,125% New York Medicaid APG,1075.35,24468.34,
Incision of rectal abscess,46045,CPT,,,,,,,,both,,,59058.34,43703.17,74,,43703.17,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,26576.25,45,,26576.25,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,29233.88,49.5,,29233.88,percent of total billed charges,110% of Medicare,40159.67,68,,40159.67,percent of total billed charges,,2732.76,,,2732.76,Other,186% of Medicaid,47246.67,80,,47246.67,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,47246.67,80,,47246.67,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,41340.84,70,,41340.84,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1469.23,,,1469.23,Other,New York Medicaid APG methodology,1469.23,,,1469.23,Other,100% New York Medicaid APG,1469.23,,,1469.23,Other,100% New York Medicaid APG,1469.23,,,1469.23,Other,100% New York Medicaid APG,3305.76,,,3305.76,Other,225% New York Medicaid APG,2247.91,,,2247.91,Other,153% New York Medicaid APG,3305.76,,,3305.76,Other,225% New York Medicaid APG,2056.92,,,2056.92,Other,140% New York Medicaid APG,3305.76,,,3305.76,Other,225% New York Medicaid APG,3819.99,,,3819.99,Other,260% New York Medicaid APG,4760.29,,,4760.29,Other,324% New York Medicaid APG,3158.83,,,3158.83,Other,215% New York Medicaid APG,3158.83,,,3158.83,Other,215% New York Medicaid APG,1836.53,,,1836.53,Other,125% New York Medicaid APG,1469.23,47246.67,
Incision of anal abscess,46050,CPT,,,,,,,,both,,,19223.92,14225.7,74,,14225.7,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,8650.76,45,,8650.76,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,9515.84,49.5,,9515.84,percent of total billed charges,110% of Medicare,13072.27,68,,13072.27,percent of total billed charges,,2000.16,,,2000.16,Other,186% of Medicaid,15379.14,80,,15379.14,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,15379.14,80,,15379.14,percent of total billed charges,,7216,,,7216,Case Rate,,3578,,"100% primary, 0% secondary procedures",3578,Other,MagnaCare ASC Grouper,13456.74,70,,13456.74,percent of total billed charges,,498.56,,,498.56,Fee Schedule,,422.56,,,422.56,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,1075.35,,,1075.35,Other,New York Medicaid APG methodology,1075.35,,,1075.35,Other,100% New York Medicaid APG,1075.35,,,1075.35,Other,100% New York Medicaid APG,1075.35,,,1075.35,Other,100% New York Medicaid APG,2419.55,,,2419.55,Other,225% New York Medicaid APG,1645.29,,,1645.29,Other,153% New York Medicaid APG,2419.55,,,2419.55,Other,225% New York Medicaid APG,1505.5,,,1505.5,Other,140% New York Medicaid APG,2419.55,,,2419.55,Other,225% New York Medicaid APG,2795.92,,,2795.92,Other,260% New York Medicaid APG,3484.15,,,3484.15,Other,324% New York Medicaid APG,2312.01,,,2312.01,Other,215% New York Medicaid APG,2312.01,,,2312.01,Other,215% New York Medicaid APG,1344.19,,,1344.19,Other,125% New York Medicaid APG,422.56,15379.14,
Incision of rectal abscess,46060,CPT,,,,,,,,both,,,59058.34,43703.17,74,,43703.17,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,26576.25,45,,26576.25,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,29233.88,49.5,,29233.88,percent of total billed charges,110% of Medicare,40159.67,68,,40159.67,percent of total billed charges,,2732.76,,,2732.76,Other,186% of Medicaid,47246.67,80,,47246.67,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,47246.67,80,,47246.67,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,41340.84,70,,41340.84,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1469.23,,,1469.23,Other,New York Medicaid APG methodology,1469.23,,,1469.23,Other,100% New York Medicaid APG,1469.23,,,1469.23,Other,100% New York Medicaid APG,1469.23,,,1469.23,Other,100% New York Medicaid APG,3305.76,,,3305.76,Other,225% New York Medicaid APG,2247.91,,,2247.91,Other,153% New York Medicaid APG,3305.76,,,3305.76,Other,225% New York Medicaid APG,2056.92,,,2056.92,Other,140% New York Medicaid APG,3305.76,,,3305.76,Other,225% New York Medicaid APG,3819.99,,,3819.99,Other,260% New York Medicaid APG,4760.29,,,4760.29,Other,324% New York Medicaid APG,3158.83,,,3158.83,Other,215% New York Medicaid APG,3158.83,,,3158.83,Other,215% New York Medicaid APG,1836.53,,,1836.53,Other,125% New York Medicaid APG,1469.23,47246.67,
Incision of anal septum,46070,CPT,,,,,,,,both,,,59058.34,43703.17,74,,43703.17,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,26576.25,45,,26576.25,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,29233.88,49.5,,29233.88,percent of total billed charges,110% of Medicare,40159.67,68,,40159.67,percent of total billed charges,,2000.16,,,2000.16,Other,186% of Medicaid,47246.67,80,,47246.67,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,47246.67,80,,47246.67,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,41340.84,70,,41340.84,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1075.35,,,1075.35,Other,New York Medicaid APG methodology,1075.35,,,1075.35,Other,100% New York Medicaid APG,1075.35,,,1075.35,Other,100% New York Medicaid APG,1075.35,,,1075.35,Other,100% New York Medicaid APG,2419.55,,,2419.55,Other,225% New York Medicaid APG,1645.29,,,1645.29,Other,153% New York Medicaid APG,2419.55,,,2419.55,Other,225% New York Medicaid APG,1505.5,,,1505.5,Other,140% New York Medicaid APG,2419.55,,,2419.55,Other,225% New York Medicaid APG,2795.92,,,2795.92,Other,260% New York Medicaid APG,3484.15,,,3484.15,Other,324% New York Medicaid APG,2312.01,,,2312.01,Other,215% New York Medicaid APG,2312.01,,,2312.01,Other,215% New York Medicaid APG,1344.19,,,1344.19,Other,125% New York Medicaid APG,1075.35,47246.67,
Incision of anal sphincter,46080,CPT,,,,,,,,both,,,34783.06,25739.46,74,,25739.46,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15652.38,45,,15652.38,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,17217.61,49.5,,17217.61,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2000.16,,,2000.16,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,24348.14,70,,24348.14,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1075.35,,,1075.35,Other,New York Medicaid APG methodology,1075.35,,,1075.35,Other,100% New York Medicaid APG,1075.35,,,1075.35,Other,100% New York Medicaid APG,1075.35,,,1075.35,Other,100% New York Medicaid APG,2419.55,,,2419.55,Other,225% New York Medicaid APG,1645.29,,,1645.29,Other,153% New York Medicaid APG,2419.55,,,2419.55,Other,225% New York Medicaid APG,1505.5,,,1505.5,Other,140% New York Medicaid APG,2419.55,,,2419.55,Other,225% New York Medicaid APG,2795.92,,,2795.92,Other,260% New York Medicaid APG,3484.15,,,3484.15,Other,324% New York Medicaid APG,2312.01,,,2312.01,Other,215% New York Medicaid APG,2312.01,,,2312.01,Other,215% New York Medicaid APG,1344.19,,,1344.19,Other,125% New York Medicaid APG,1075.35,25739.46,
Incise external hemorrhoid,46083,CPT,,,,,,,,both,,,5198.43,3846.84,74,,3846.84,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,2339.29,45,,2339.29,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,2573.22,49.5,,2573.22,percent of total billed charges,110% of Medicare,3534.93,68,,3534.93,percent of total billed charges,,2000.16,,,2000.16,Other,186% of Medicaid,4158.74,80,,4158.74,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,4158.74,80,,4158.74,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,3638.9,70,,3638.9,percent of total billed charges,,539.56,,,539.56,Fee Schedule,,457.31,,,457.31,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,1075.35,,,1075.35,Other,New York Medicaid APG methodology,1075.35,,,1075.35,Other,100% New York Medicaid APG,1075.35,,,1075.35,Other,100% New York Medicaid APG,1075.35,,,1075.35,Other,100% New York Medicaid APG,2419.55,,,2419.55,Other,225% New York Medicaid APG,1645.29,,,1645.29,Other,153% New York Medicaid APG,2419.55,,,2419.55,Other,225% New York Medicaid APG,1505.5,,,1505.5,Other,140% New York Medicaid APG,2419.55,,,2419.55,Other,225% New York Medicaid APG,2795.92,,,2795.92,Other,260% New York Medicaid APG,3484.15,,,3484.15,Other,324% New York Medicaid APG,2312.01,,,2312.01,Other,215% New York Medicaid APG,2312.01,,,2312.01,Other,215% New York Medicaid APG,1344.19,,,1344.19,Other,125% New York Medicaid APG,457.31,7216,
Removal of anal fissure,46200,CPT,,,,,,,,both,,,36254.69,26828.47,74,,26828.47,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,16314.61,45,,16314.61,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,17946.07,49.5,,17946.07,percent of total billed charges,110% of Medicare,24653.19,68,,24653.19,percent of total billed charges,,2000.16,,,2000.16,Other,186% of Medicaid,29003.75,80,,29003.75,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,29003.75,80,,29003.75,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,25378.28,70,,25378.28,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1075.35,,,1075.35,Other,New York Medicaid APG methodology,1075.35,,,1075.35,Other,100% New York Medicaid APG,1075.35,,,1075.35,Other,100% New York Medicaid APG,1075.35,,,1075.35,Other,100% New York Medicaid APG,2419.55,,,2419.55,Other,225% New York Medicaid APG,1645.29,,,1645.29,Other,153% New York Medicaid APG,2419.55,,,2419.55,Other,225% New York Medicaid APG,1505.5,,,1505.5,Other,140% New York Medicaid APG,2419.55,,,2419.55,Other,225% New York Medicaid APG,2795.92,,,2795.92,Other,260% New York Medicaid APG,3484.15,,,3484.15,Other,324% New York Medicaid APG,2312.01,,,2312.01,Other,215% New York Medicaid APG,2312.01,,,2312.01,Other,215% New York Medicaid APG,1344.19,,,1344.19,Other,125% New York Medicaid APG,1075.35,29003.75,
Excise anal ext tag/papilla,46220,CPT,,,,,,,,both,,,24821.26,18367.73,74,,18367.73,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,11169.57,45,,11169.57,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,12286.52,49.5,,12286.52,percent of total billed charges,110% of Medicare,16878.46,68,,16878.46,percent of total billed charges,,2000.16,,,2000.16,Other,186% of Medicaid,19857.01,80,,19857.01,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,19857.01,80,,19857.01,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,17374.88,70,,17374.88,percent of total billed charges,,596.96,,,596.96,Fee Schedule,,505.96,,,505.96,Fee Schedule,,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1075.35,,,1075.35,Other,New York Medicaid APG methodology,1075.35,,,1075.35,Other,100% New York Medicaid APG,1075.35,,,1075.35,Other,100% New York Medicaid APG,1075.35,,,1075.35,Other,100% New York Medicaid APG,2419.55,,,2419.55,Other,225% New York Medicaid APG,1645.29,,,1645.29,Other,153% New York Medicaid APG,2419.55,,,2419.55,Other,225% New York Medicaid APG,1505.5,,,1505.5,Other,140% New York Medicaid APG,2419.55,,,2419.55,Other,225% New York Medicaid APG,2795.92,,,2795.92,Other,260% New York Medicaid APG,3484.15,,,3484.15,Other,324% New York Medicaid APG,2312.01,,,2312.01,Other,215% New York Medicaid APG,2312.01,,,2312.01,Other,215% New York Medicaid APG,1344.19,,,1344.19,Other,125% New York Medicaid APG,505.96,19857.01,
Ligation of hemorrhoid(s),46221,CPT,,,,,,,,both,,,19223.92,14225.7,74,,14225.7,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,8650.76,45,,8650.76,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,9515.84,49.5,,9515.84,percent of total billed charges,110% of Medicare,13072.27,68,,13072.27,percent of total billed charges,,2000.16,,,2000.16,Other,186% of Medicaid,15379.14,80,,15379.14,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,15379.14,80,,15379.14,percent of total billed charges,,7216,,,7216,Case Rate,,3578,,"100% primary, 0% secondary procedures",3578,Other,MagnaCare ASC Grouper,13456.74,70,,13456.74,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,1075.35,,,1075.35,Other,New York Medicaid APG methodology,1075.35,,,1075.35,Other,100% New York Medicaid APG,1075.35,,,1075.35,Other,100% New York Medicaid APG,1075.35,,,1075.35,Other,100% New York Medicaid APG,2419.55,,,2419.55,Other,225% New York Medicaid APG,1645.29,,,1645.29,Other,153% New York Medicaid APG,2419.55,,,2419.55,Other,225% New York Medicaid APG,1505.5,,,1505.5,Other,140% New York Medicaid APG,2419.55,,,2419.55,Other,225% New York Medicaid APG,2795.92,,,2795.92,Other,260% New York Medicaid APG,3484.15,,,3484.15,Other,324% New York Medicaid APG,2312.01,,,2312.01,Other,215% New York Medicaid APG,2312.01,,,2312.01,Other,215% New York Medicaid APG,1344.19,,,1344.19,Other,125% New York Medicaid APG,1075.35,15379.14,
Removal of anal tags,46230,CPT,,,,,,,,both,,,34206.69,25312.95,74,,25312.95,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15393.01,45,,15393.01,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,16932.31,49.5,,16932.31,percent of total billed charges,110% of Medicare,23260.55,68,,23260.55,percent of total billed charges,,2000.16,,,2000.16,Other,186% of Medicaid,27365.35,80,,27365.35,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,27365.35,80,,27365.35,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,23944.68,70,,23944.68,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1075.35,,,1075.35,Other,New York Medicaid APG methodology,1075.35,,,1075.35,Other,100% New York Medicaid APG,1075.35,,,1075.35,Other,100% New York Medicaid APG,1075.35,,,1075.35,Other,100% New York Medicaid APG,2419.55,,,2419.55,Other,225% New York Medicaid APG,1645.29,,,1645.29,Other,153% New York Medicaid APG,2419.55,,,2419.55,Other,225% New York Medicaid APG,1505.5,,,1505.5,Other,140% New York Medicaid APG,2419.55,,,2419.55,Other,225% New York Medicaid APG,2795.92,,,2795.92,Other,260% New York Medicaid APG,3484.15,,,3484.15,Other,324% New York Medicaid APG,2312.01,,,2312.01,Other,215% New York Medicaid APG,2312.01,,,2312.01,Other,215% New York Medicaid APG,1344.19,,,1344.19,Other,125% New York Medicaid APG,1075.35,27365.35,
Remove ext hem groups 2+,46250,CPT,,,,,,,,both,,,36111.37,26722.41,74,,26722.41,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,16250.12,45,,16250.12,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,17875.13,49.5,,17875.13,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2732.76,,,2732.76,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,25277.96,70,,25277.96,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1469.23,,,1469.23,Other,New York Medicaid APG methodology,1469.23,,,1469.23,Other,100% New York Medicaid APG,1469.23,,,1469.23,Other,100% New York Medicaid APG,1469.23,,,1469.23,Other,100% New York Medicaid APG,3305.76,,,3305.76,Other,225% New York Medicaid APG,2247.91,,,2247.91,Other,153% New York Medicaid APG,3305.76,,,3305.76,Other,225% New York Medicaid APG,2056.92,,,2056.92,Other,140% New York Medicaid APG,3305.76,,,3305.76,Other,225% New York Medicaid APG,3819.99,,,3819.99,Other,260% New York Medicaid APG,4760.29,,,4760.29,Other,324% New York Medicaid APG,3158.83,,,3158.83,Other,215% New York Medicaid APG,3158.83,,,3158.83,Other,215% New York Medicaid APG,1836.53,,,1836.53,Other,125% New York Medicaid APG,1469.23,26722.41,
Remove int/ext hem 1 group,46255,CPT,,,,,,,,both,,,30279.6,22406.9,74,,22406.9,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,13625.82,45,,13625.82,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,14988.4,49.5,,14988.4,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2732.76,,,2732.76,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,21195.72,70,,21195.72,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1469.23,,,1469.23,Other,New York Medicaid APG methodology,1469.23,,,1469.23,Other,100% New York Medicaid APG,1469.23,,,1469.23,Other,100% New York Medicaid APG,1469.23,,,1469.23,Other,100% New York Medicaid APG,3305.76,,,3305.76,Other,225% New York Medicaid APG,2247.91,,,2247.91,Other,153% New York Medicaid APG,3305.76,,,3305.76,Other,225% New York Medicaid APG,2056.92,,,2056.92,Other,140% New York Medicaid APG,3305.76,,,3305.76,Other,225% New York Medicaid APG,3819.99,,,3819.99,Other,260% New York Medicaid APG,4760.29,,,4760.29,Other,324% New York Medicaid APG,3158.83,,,3158.83,Other,215% New York Medicaid APG,3158.83,,,3158.83,Other,215% New York Medicaid APG,1836.53,,,1836.53,Other,125% New York Medicaid APG,1469.23,22406.9,
Remove in/ex hem grp & fiss,46257,CPT,,,,,,,,both,,,59058.34,43703.17,74,,43703.17,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,26576.25,45,,26576.25,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,29233.88,49.5,,29233.88,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2732.76,,,2732.76,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,41340.84,70,,41340.84,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1469.23,,,1469.23,Other,New York Medicaid APG methodology,1469.23,,,1469.23,Other,100% New York Medicaid APG,1469.23,,,1469.23,Other,100% New York Medicaid APG,1469.23,,,1469.23,Other,100% New York Medicaid APG,3305.76,,,3305.76,Other,225% New York Medicaid APG,2247.91,,,2247.91,Other,153% New York Medicaid APG,3305.76,,,3305.76,Other,225% New York Medicaid APG,2056.92,,,2056.92,Other,140% New York Medicaid APG,3305.76,,,3305.76,Other,225% New York Medicaid APG,3819.99,,,3819.99,Other,260% New York Medicaid APG,4760.29,,,4760.29,Other,324% New York Medicaid APG,3158.83,,,3158.83,Other,215% New York Medicaid APG,3158.83,,,3158.83,Other,215% New York Medicaid APG,1836.53,,,1836.53,Other,125% New York Medicaid APG,1469.23,43703.17,
Remove in/ex hem grp w/fistu,46258,CPT,,,,,,,,both,,,59058.34,43703.17,74,,43703.17,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,26576.25,45,,26576.25,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,29233.88,49.5,,29233.88,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2732.76,,,2732.76,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,41340.84,70,,41340.84,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1469.23,,,1469.23,Other,New York Medicaid APG methodology,1469.23,,,1469.23,Other,100% New York Medicaid APG,1469.23,,,1469.23,Other,100% New York Medicaid APG,1469.23,,,1469.23,Other,100% New York Medicaid APG,3305.76,,,3305.76,Other,225% New York Medicaid APG,2247.91,,,2247.91,Other,153% New York Medicaid APG,3305.76,,,3305.76,Other,225% New York Medicaid APG,2056.92,,,2056.92,Other,140% New York Medicaid APG,3305.76,,,3305.76,Other,225% New York Medicaid APG,3819.99,,,3819.99,Other,260% New York Medicaid APG,4760.29,,,4760.29,Other,324% New York Medicaid APG,3158.83,,,3158.83,Other,215% New York Medicaid APG,3158.83,,,3158.83,Other,215% New York Medicaid APG,1836.53,,,1836.53,Other,125% New York Medicaid APG,1469.23,43703.17,
Remove in/ex hem groups 2+,46260,CPT,,,,,,,,both,,,37527.47,27770.33,74,,27770.33,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,16887.36,45,,16887.36,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,18576.1,49.5,,18576.1,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2732.76,,,2732.76,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,26269.23,70,,26269.23,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1469.23,,,1469.23,Other,New York Medicaid APG methodology,1469.23,,,1469.23,Other,100% New York Medicaid APG,1469.23,,,1469.23,Other,100% New York Medicaid APG,1469.23,,,1469.23,Other,100% New York Medicaid APG,3305.76,,,3305.76,Other,225% New York Medicaid APG,2247.91,,,2247.91,Other,153% New York Medicaid APG,3305.76,,,3305.76,Other,225% New York Medicaid APG,2056.92,,,2056.92,Other,140% New York Medicaid APG,3305.76,,,3305.76,Other,225% New York Medicaid APG,3819.99,,,3819.99,Other,260% New York Medicaid APG,4760.29,,,4760.29,Other,324% New York Medicaid APG,3158.83,,,3158.83,Other,215% New York Medicaid APG,3158.83,,,3158.83,Other,215% New York Medicaid APG,1836.53,,,1836.53,Other,125% New York Medicaid APG,1469.23,27770.33,
Remove in/ex hem grps & fiss,46261,CPT,,,,,,,,both,,,38923.23,28803.19,74,,28803.19,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,17515.45,45,,17515.45,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,19267,49.5,,19267,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2732.76,,,2732.76,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,27246.26,70,,27246.26,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1469.23,,,1469.23,Other,New York Medicaid APG methodology,1469.23,,,1469.23,Other,100% New York Medicaid APG,1469.23,,,1469.23,Other,100% New York Medicaid APG,1469.23,,,1469.23,Other,100% New York Medicaid APG,3305.76,,,3305.76,Other,225% New York Medicaid APG,2247.91,,,2247.91,Other,153% New York Medicaid APG,3305.76,,,3305.76,Other,225% New York Medicaid APG,2056.92,,,2056.92,Other,140% New York Medicaid APG,3305.76,,,3305.76,Other,225% New York Medicaid APG,3819.99,,,3819.99,Other,260% New York Medicaid APG,4760.29,,,4760.29,Other,324% New York Medicaid APG,3158.83,,,3158.83,Other,215% New York Medicaid APG,3158.83,,,3158.83,Other,215% New York Medicaid APG,1836.53,,,1836.53,Other,125% New York Medicaid APG,1469.23,28803.19,
Remove in/ex hem grps w/fist,46262,CPT,,,,,,,,both,,,59058.34,43703.17,74,,43703.17,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,26576.25,45,,26576.25,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,29233.88,49.5,,29233.88,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2732.76,,,2732.76,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,41340.84,70,,41340.84,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1469.23,,,1469.23,Other,New York Medicaid APG methodology,1469.23,,,1469.23,Other,100% New York Medicaid APG,1469.23,,,1469.23,Other,100% New York Medicaid APG,1469.23,,,1469.23,Other,100% New York Medicaid APG,3305.76,,,3305.76,Other,225% New York Medicaid APG,2247.91,,,2247.91,Other,153% New York Medicaid APG,3305.76,,,3305.76,Other,225% New York Medicaid APG,2056.92,,,2056.92,Other,140% New York Medicaid APG,3305.76,,,3305.76,Other,225% New York Medicaid APG,3819.99,,,3819.99,Other,260% New York Medicaid APG,4760.29,,,4760.29,Other,324% New York Medicaid APG,3158.83,,,3158.83,Other,215% New York Medicaid APG,3158.83,,,3158.83,Other,215% New York Medicaid APG,1836.53,,,1836.53,Other,125% New York Medicaid APG,1469.23,43703.17,
Remove anal fist subq,46270,CPT,,,,,,,,both,,,34672.13,25657.38,74,,25657.38,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15602.46,45,,15602.46,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,17162.7,49.5,,17162.7,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2732.76,,,2732.76,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,24270.49,70,,24270.49,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1469.23,,,1469.23,Other,New York Medicaid APG methodology,1469.23,,,1469.23,Other,100% New York Medicaid APG,1469.23,,,1469.23,Other,100% New York Medicaid APG,1469.23,,,1469.23,Other,100% New York Medicaid APG,3305.76,,,3305.76,Other,225% New York Medicaid APG,2247.91,,,2247.91,Other,153% New York Medicaid APG,3305.76,,,3305.76,Other,225% New York Medicaid APG,2056.92,,,2056.92,Other,140% New York Medicaid APG,3305.76,,,3305.76,Other,225% New York Medicaid APG,3819.99,,,3819.99,Other,260% New York Medicaid APG,4760.29,,,4760.29,Other,324% New York Medicaid APG,3158.83,,,3158.83,Other,215% New York Medicaid APG,3158.83,,,3158.83,Other,215% New York Medicaid APG,1836.53,,,1836.53,Other,125% New York Medicaid APG,1469.23,25657.38,
Remove anal fist inter,46275,CPT,,,,,,,,both,,,35748.17,26453.65,74,,26453.65,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,16086.68,45,,16086.68,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,17695.34,49.5,,17695.34,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2732.76,,,2732.76,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,25023.72,70,,25023.72,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1469.23,,,1469.23,Other,New York Medicaid APG methodology,1469.23,,,1469.23,Other,100% New York Medicaid APG,1469.23,,,1469.23,Other,100% New York Medicaid APG,1469.23,,,1469.23,Other,100% New York Medicaid APG,3305.76,,,3305.76,Other,225% New York Medicaid APG,2247.91,,,2247.91,Other,153% New York Medicaid APG,3305.76,,,3305.76,Other,225% New York Medicaid APG,2056.92,,,2056.92,Other,140% New York Medicaid APG,3305.76,,,3305.76,Other,225% New York Medicaid APG,3819.99,,,3819.99,Other,260% New York Medicaid APG,4760.29,,,4760.29,Other,324% New York Medicaid APG,3158.83,,,3158.83,Other,215% New York Medicaid APG,3158.83,,,3158.83,Other,215% New York Medicaid APG,1836.53,,,1836.53,Other,125% New York Medicaid APG,1469.23,26453.65,
Remove anal fist complex,46280,CPT,,,,,,,,both,,,36371.95,26915.24,74,,26915.24,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,16367.38,45,,16367.38,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,18004.12,49.5,,18004.12,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2732.76,,,2732.76,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,25460.37,70,,25460.37,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1469.23,,,1469.23,Other,New York Medicaid APG methodology,1469.23,,,1469.23,Other,100% New York Medicaid APG,1469.23,,,1469.23,Other,100% New York Medicaid APG,1469.23,,,1469.23,Other,100% New York Medicaid APG,3305.76,,,3305.76,Other,225% New York Medicaid APG,2247.91,,,2247.91,Other,153% New York Medicaid APG,3305.76,,,3305.76,Other,225% New York Medicaid APG,2056.92,,,2056.92,Other,140% New York Medicaid APG,3305.76,,,3305.76,Other,225% New York Medicaid APG,3819.99,,,3819.99,Other,260% New York Medicaid APG,4760.29,,,4760.29,Other,324% New York Medicaid APG,3158.83,,,3158.83,Other,215% New York Medicaid APG,3158.83,,,3158.83,Other,215% New York Medicaid APG,1836.53,,,1836.53,Other,125% New York Medicaid APG,1469.23,26915.24,
Remove anal fist 2 stage,46285,CPT,,,,,,,,both,,,32112.66,23763.37,74,,23763.37,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,14450.7,45,,14450.7,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,15895.77,49.5,,15895.77,percent of total billed charges,110% of Medicare,21836.61,68,,21836.61,percent of total billed charges,,2000.16,,,2000.16,Other,186% of Medicaid,25690.13,80,,25690.13,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,25690.13,80,,25690.13,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,22478.86,70,,22478.86,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1075.35,,,1075.35,Other,New York Medicaid APG methodology,1075.35,,,1075.35,Other,100% New York Medicaid APG,1075.35,,,1075.35,Other,100% New York Medicaid APG,1075.35,,,1075.35,Other,100% New York Medicaid APG,2419.55,,,2419.55,Other,225% New York Medicaid APG,1645.29,,,1645.29,Other,153% New York Medicaid APG,2419.55,,,2419.55,Other,225% New York Medicaid APG,1505.5,,,1505.5,Other,140% New York Medicaid APG,2419.55,,,2419.55,Other,225% New York Medicaid APG,2795.92,,,2795.92,Other,260% New York Medicaid APG,3484.15,,,3484.15,Other,324% New York Medicaid APG,2312.01,,,2312.01,Other,215% New York Medicaid APG,2312.01,,,2312.01,Other,215% New York Medicaid APG,1344.19,,,1344.19,Other,125% New York Medicaid APG,1075.35,25690.13,
Repair anal fistula,46288,CPT,,,,,,,,both,,,35532.32,26293.92,74,,26293.92,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15989.54,45,,15989.54,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,17588.5,49.5,,17588.5,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2732.76,,,2732.76,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,24872.62,70,,24872.62,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1469.23,,,1469.23,Other,New York Medicaid APG methodology,1469.23,,,1469.23,Other,100% New York Medicaid APG,1469.23,,,1469.23,Other,100% New York Medicaid APG,1469.23,,,1469.23,Other,100% New York Medicaid APG,3305.76,,,3305.76,Other,225% New York Medicaid APG,2247.91,,,2247.91,Other,153% New York Medicaid APG,3305.76,,,3305.76,Other,225% New York Medicaid APG,2056.92,,,2056.92,Other,140% New York Medicaid APG,3305.76,,,3305.76,Other,225% New York Medicaid APG,3819.99,,,3819.99,Other,260% New York Medicaid APG,4760.29,,,4760.29,Other,324% New York Medicaid APG,3158.83,,,3158.83,Other,215% New York Medicaid APG,3158.83,,,3158.83,Other,215% New York Medicaid APG,1836.53,,,1836.53,Other,125% New York Medicaid APG,1469.23,26293.92,
Removal of hemorrhoid clot,46320,CPT,,,,,,,,both,,,34261.11,25353.22,74,,25353.22,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15417.5,45,,15417.5,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,16959.25,49.5,,16959.25,percent of total billed charges,110% of Medicare,23297.55,68,,23297.55,percent of total billed charges,,2000.16,,,2000.16,Other,186% of Medicaid,27408.89,80,,27408.89,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,27408.89,80,,27408.89,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,23982.78,70,,23982.78,percent of total billed charges,,554.32,,,554.32,Fee Schedule,,469.82,,,469.82,Fee Schedule,,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1075.35,,,1075.35,Other,New York Medicaid APG methodology,1075.35,,,1075.35,Other,100% New York Medicaid APG,1075.35,,,1075.35,Other,100% New York Medicaid APG,1075.35,,,1075.35,Other,100% New York Medicaid APG,2419.55,,,2419.55,Other,225% New York Medicaid APG,1645.29,,,1645.29,Other,153% New York Medicaid APG,2419.55,,,2419.55,Other,225% New York Medicaid APG,1505.5,,,1505.5,Other,140% New York Medicaid APG,2419.55,,,2419.55,Other,225% New York Medicaid APG,2795.92,,,2795.92,Other,260% New York Medicaid APG,3484.15,,,3484.15,Other,324% New York Medicaid APG,2312.01,,,2312.01,Other,215% New York Medicaid APG,2312.01,,,2312.01,Other,215% New York Medicaid APG,1344.19,,,1344.19,Other,125% New York Medicaid APG,469.82,27408.89,
Injection into hemorrhoid(s),46500,CPT,,,,,,,,both,,,19223.92,14225.7,74,,14225.7,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,8650.76,45,,8650.76,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,9515.84,49.5,,9515.84,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2000.16,,,2000.16,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,3578,,"100% primary, 0% secondary procedures",3578,Other,MagnaCare ASC Grouper,13456.74,70,,13456.74,percent of total billed charges,,910.2,,,910.2,Fee Schedule,,771.45,,,771.45,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,1075.35,,,1075.35,Other,New York Medicaid APG methodology,1075.35,,,1075.35,Other,100% New York Medicaid APG,1075.35,,,1075.35,Other,100% New York Medicaid APG,1075.35,,,1075.35,Other,100% New York Medicaid APG,2419.55,,,2419.55,Other,225% New York Medicaid APG,1645.29,,,1645.29,Other,153% New York Medicaid APG,2419.55,,,2419.55,Other,225% New York Medicaid APG,1505.5,,,1505.5,Other,140% New York Medicaid APG,2419.55,,,2419.55,Other,225% New York Medicaid APG,2795.92,,,2795.92,Other,260% New York Medicaid APG,3484.15,,,3484.15,Other,324% New York Medicaid APG,2312.01,,,2312.01,Other,215% New York Medicaid APG,2312.01,,,2312.01,Other,215% New York Medicaid APG,1344.19,,,1344.19,Other,125% New York Medicaid APG,771.45,14225.7,
Chemodenervation anal musc,46505,CPT,,,,,,,,both,,,25418.06,18809.36,74,,18809.36,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,11438.13,45,,11438.13,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,12581.94,49.5,,12581.94,percent of total billed charges,110% of Medicare,17284.28,68,,17284.28,percent of total billed charges,,2000.16,,,2000.16,Other,186% of Medicaid,20334.45,80,,20334.45,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,20334.45,80,,20334.45,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,17792.64,70,,17792.64,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1075.35,,,1075.35,Other,New York Medicaid APG methodology,1075.35,,,1075.35,Other,100% New York Medicaid APG,1075.35,,,1075.35,Other,100% New York Medicaid APG,1075.35,,,1075.35,Other,100% New York Medicaid APG,2419.55,,,2419.55,Other,225% New York Medicaid APG,1645.29,,,1645.29,Other,153% New York Medicaid APG,2419.55,,,2419.55,Other,225% New York Medicaid APG,1505.5,,,1505.5,Other,140% New York Medicaid APG,2419.55,,,2419.55,Other,225% New York Medicaid APG,2795.92,,,2795.92,Other,260% New York Medicaid APG,3484.15,,,3484.15,Other,324% New York Medicaid APG,2312.01,,,2312.01,Other,215% New York Medicaid APG,2312.01,,,2312.01,Other,215% New York Medicaid APG,1344.19,,,1344.19,Other,125% New York Medicaid APG,1075.35,20334.45,
Diagnostic anoscopy spx,46600,CPT,,,,,,,,both,,,38102.91,28196.15,74,,28196.15,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,17146.31,45,,17146.31,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,18860.94,49.5,,18860.94,percent of total billed charges,110% of Medicare,25909.98,68,,25909.98,percent of total billed charges,,1030.37,,,1030.37,Other,186% of Medicaid,30482.33,80,,30482.33,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,30482.33,80,,30482.33,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,26672.04,70,,26672.04,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,553.96,,,553.96,Other,New York Medicaid APG methodology,553.96,,,553.96,Other,100% New York Medicaid APG,553.96,,,553.96,Other,100% New York Medicaid APG,553.96,,,553.96,Other,100% New York Medicaid APG,1246.41,,,1246.41,Other,225% New York Medicaid APG,847.56,,,847.56,Other,153% New York Medicaid APG,1246.41,,,1246.41,Other,225% New York Medicaid APG,775.55,,,775.55,Other,140% New York Medicaid APG,1246.41,,,1246.41,Other,225% New York Medicaid APG,1440.3,,,1440.3,Other,260% New York Medicaid APG,1794.83,,,1794.83,Other,324% New York Medicaid APG,1191.02,,,1191.02,Other,215% New York Medicaid APG,1191.02,,,1191.02,Other,215% New York Medicaid APG,692.45,,,692.45,Other,125% New York Medicaid APG,553.96,30482.33,
Diagnostic anoscopy,46601,CPT,,,,,,,,both,,,2686.86,1988.28,74,,1988.28,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,1209.09,45,,1209.09,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,1330,49.5,,1330,percent of total billed charges,110% of Medicare,1827.06,68,,1827.06,percent of total billed charges,,1030.37,,,1030.37,Other,186% of Medicaid,2149.49,80,,2149.49,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,2149.49,80,,2149.49,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,1880.8,70,,1880.8,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,553.96,,,553.96,Other,New York Medicaid APG methodology,553.96,,,553.96,Other,100% New York Medicaid APG,553.96,,,553.96,Other,100% New York Medicaid APG,553.96,,,553.96,Other,100% New York Medicaid APG,1246.41,,,1246.41,Other,225% New York Medicaid APG,847.56,,,847.56,Other,153% New York Medicaid APG,1246.41,,,1246.41,Other,225% New York Medicaid APG,775.55,,,775.55,Other,140% New York Medicaid APG,1246.41,,,1246.41,Other,225% New York Medicaid APG,1440.3,,,1440.3,Other,260% New York Medicaid APG,1794.83,,,1794.83,Other,324% New York Medicaid APG,1191.02,,,1191.02,Other,215% New York Medicaid APG,1191.02,,,1191.02,Other,215% New York Medicaid APG,692.45,,,692.45,Other,125% New York Medicaid APG,553.96,7216,
Anoscopy and dilation,46604,CPT,,,,,,,,both,,,24821.26,18367.73,74,,18367.73,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,11169.57,45,,11169.57,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,12286.52,49.5,,12286.52,percent of total billed charges,110% of Medicare,16878.46,68,,16878.46,percent of total billed charges,,1478.54,,,1478.54,Other,186% of Medicaid,19857.01,80,,19857.01,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,19857.01,80,,19857.01,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,17374.88,70,,17374.88,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,794.91,,,794.91,Other,New York Medicaid APG methodology,794.91,,,794.91,Other,100% New York Medicaid APG,794.91,,,794.91,Other,100% New York Medicaid APG,794.91,,,794.91,Other,100% New York Medicaid APG,1788.55,,,1788.55,Other,225% New York Medicaid APG,1216.22,,,1216.22,Other,153% New York Medicaid APG,1788.55,,,1788.55,Other,225% New York Medicaid APG,1112.88,,,1112.88,Other,140% New York Medicaid APG,1788.55,,,1788.55,Other,225% New York Medicaid APG,2066.77,,,2066.77,Other,260% New York Medicaid APG,2575.52,,,2575.52,Other,324% New York Medicaid APG,1709.06,,,1709.06,Other,215% New York Medicaid APG,1709.06,,,1709.06,Other,215% New York Medicaid APG,993.64,,,993.64,Other,125% New York Medicaid APG,794.91,19857.01,
Anoscopy and biopsy,46606,CPT,,,,,,,,both,,,42463.29,31422.83,74,,31422.83,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,19108.48,45,,19108.48,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,21019.33,49.5,,21019.33,percent of total billed charges,110% of Medicare,28875.04,68,,28875.04,percent of total billed charges,,1478.54,,,1478.54,Other,186% of Medicaid,33970.63,80,,33970.63,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,33970.63,80,,33970.63,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,29724.3,70,,29724.3,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,794.91,,,794.91,Other,New York Medicaid APG methodology,794.91,,,794.91,Other,100% New York Medicaid APG,794.91,,,794.91,Other,100% New York Medicaid APG,794.91,,,794.91,Other,100% New York Medicaid APG,1788.55,,,1788.55,Other,225% New York Medicaid APG,1216.22,,,1216.22,Other,153% New York Medicaid APG,1788.55,,,1788.55,Other,225% New York Medicaid APG,1112.88,,,1112.88,Other,140% New York Medicaid APG,1788.55,,,1788.55,Other,225% New York Medicaid APG,2066.77,,,2066.77,Other,260% New York Medicaid APG,2575.52,,,2575.52,Other,324% New York Medicaid APG,1709.06,,,1709.06,Other,215% New York Medicaid APG,1709.06,,,1709.06,Other,215% New York Medicaid APG,993.64,,,993.64,Other,125% New York Medicaid APG,794.91,33970.63,
Diagnostic anoscopy & biopsy,46607,CPT,,,,,,,,both,,,24821.26,18367.73,74,,18367.73,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,11169.57,45,,11169.57,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,12286.52,49.5,,12286.52,percent of total billed charges,110% of Medicare,16878.46,68,,16878.46,percent of total billed charges,,1478.54,,,1478.54,Other,186% of Medicaid,19857.01,80,,19857.01,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,19857.01,80,,19857.01,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,17374.88,70,,17374.88,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,794.91,,,794.91,Other,New York Medicaid APG methodology,794.91,,,794.91,Other,100% New York Medicaid APG,794.91,,,794.91,Other,100% New York Medicaid APG,794.91,,,794.91,Other,100% New York Medicaid APG,1788.55,,,1788.55,Other,225% New York Medicaid APG,1216.22,,,1216.22,Other,153% New York Medicaid APG,1788.55,,,1788.55,Other,225% New York Medicaid APG,1112.88,,,1112.88,Other,140% New York Medicaid APG,1788.55,,,1788.55,Other,225% New York Medicaid APG,2066.77,,,2066.77,Other,260% New York Medicaid APG,2575.52,,,2575.52,Other,324% New York Medicaid APG,1709.06,,,1709.06,Other,215% New York Medicaid APG,1709.06,,,1709.06,Other,215% New York Medicaid APG,993.64,,,993.64,Other,125% New York Medicaid APG,794.91,19857.01,
Anoscopy remove for body,46608,CPT,,,,,,,,both,,,19223.92,14225.7,74,,14225.7,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,8650.76,45,,8650.76,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,9515.84,49.5,,9515.84,percent of total billed charges,110% of Medicare,13072.27,68,,13072.27,percent of total billed charges,,1478.54,,,1478.54,Other,186% of Medicaid,15379.14,80,,15379.14,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,15379.14,80,,15379.14,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,13456.74,70,,13456.74,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,794.91,,,794.91,Other,New York Medicaid APG methodology,794.91,,,794.91,Other,100% New York Medicaid APG,794.91,,,794.91,Other,100% New York Medicaid APG,794.91,,,794.91,Other,100% New York Medicaid APG,1788.55,,,1788.55,Other,225% New York Medicaid APG,1216.22,,,1216.22,Other,153% New York Medicaid APG,1788.55,,,1788.55,Other,225% New York Medicaid APG,1112.88,,,1112.88,Other,140% New York Medicaid APG,1788.55,,,1788.55,Other,225% New York Medicaid APG,2066.77,,,2066.77,Other,260% New York Medicaid APG,2575.52,,,2575.52,Other,324% New York Medicaid APG,1709.06,,,1709.06,Other,215% New York Medicaid APG,1709.06,,,1709.06,Other,215% New York Medicaid APG,993.64,,,993.64,Other,125% New York Medicaid APG,794.91,15379.14,
Anoscopy remove lesion,46610,CPT,,,,,,,,both,,,59058.34,43703.17,74,,43703.17,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,26576.25,45,,26576.25,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,29233.88,49.5,,29233.88,percent of total billed charges,110% of Medicare,40159.67,68,,40159.67,percent of total billed charges,,1648.24,,,1648.24,Other,186% of Medicaid,47246.67,80,,47246.67,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,47246.67,80,,47246.67,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,41340.84,70,,41340.84,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,886.15,,,886.15,Other,New York Medicaid APG methodology,886.15,,,886.15,Other,100% New York Medicaid APG,886.15,,,886.15,Other,100% New York Medicaid APG,886.15,,,886.15,Other,100% New York Medicaid APG,1993.84,,,1993.84,Other,225% New York Medicaid APG,1355.81,,,1355.81,Other,153% New York Medicaid APG,1993.84,,,1993.84,Other,225% New York Medicaid APG,1240.61,,,1240.61,Other,140% New York Medicaid APG,1993.84,,,1993.84,Other,225% New York Medicaid APG,2303.99,,,2303.99,Other,260% New York Medicaid APG,2871.13,,,2871.13,Other,324% New York Medicaid APG,1905.23,,,1905.23,Other,215% New York Medicaid APG,1905.23,,,1905.23,Other,215% New York Medicaid APG,1107.69,,,1107.69,Other,125% New York Medicaid APG,886.15,47246.67,
Anoscopy,46611,CPT,,,,,,,,both,,,19223.92,14225.7,74,,14225.7,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,8650.76,45,,8650.76,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,9515.84,49.5,,9515.84,percent of total billed charges,110% of Medicare,13072.27,68,,13072.27,percent of total billed charges,,1478.54,,,1478.54,Other,186% of Medicaid,15379.14,80,,15379.14,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,15379.14,80,,15379.14,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,13456.74,70,,13456.74,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,794.91,,,794.91,Other,New York Medicaid APG methodology,794.91,,,794.91,Other,100% New York Medicaid APG,794.91,,,794.91,Other,100% New York Medicaid APG,794.91,,,794.91,Other,100% New York Medicaid APG,1788.55,,,1788.55,Other,225% New York Medicaid APG,1216.22,,,1216.22,Other,153% New York Medicaid APG,1788.55,,,1788.55,Other,225% New York Medicaid APG,1112.88,,,1112.88,Other,140% New York Medicaid APG,1788.55,,,1788.55,Other,225% New York Medicaid APG,2066.77,,,2066.77,Other,260% New York Medicaid APG,2575.52,,,2575.52,Other,324% New York Medicaid APG,1709.06,,,1709.06,Other,215% New York Medicaid APG,1709.06,,,1709.06,Other,215% New York Medicaid APG,993.64,,,993.64,Other,125% New York Medicaid APG,794.91,15379.14,
Anoscopy remove lesions,46612,CPT,,,,,,,,both,,,59058.34,43703.17,74,,43703.17,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,26576.25,45,,26576.25,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,29233.88,49.5,,29233.88,percent of total billed charges,110% of Medicare,40159.67,68,,40159.67,percent of total billed charges,,1648.24,,,1648.24,Other,186% of Medicaid,47246.67,80,,47246.67,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,47246.67,80,,47246.67,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,41340.84,70,,41340.84,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,886.15,,,886.15,Other,New York Medicaid APG methodology,886.15,,,886.15,Other,100% New York Medicaid APG,886.15,,,886.15,Other,100% New York Medicaid APG,886.15,,,886.15,Other,100% New York Medicaid APG,1993.84,,,1993.84,Other,225% New York Medicaid APG,1355.81,,,1355.81,Other,153% New York Medicaid APG,1993.84,,,1993.84,Other,225% New York Medicaid APG,1240.61,,,1240.61,Other,140% New York Medicaid APG,1993.84,,,1993.84,Other,225% New York Medicaid APG,2303.99,,,2303.99,Other,260% New York Medicaid APG,2871.13,,,2871.13,Other,324% New York Medicaid APG,1905.23,,,1905.23,Other,215% New York Medicaid APG,1905.23,,,1905.23,Other,215% New York Medicaid APG,1107.69,,,1107.69,Other,125% New York Medicaid APG,886.15,47246.67,
Anoscopy control bleeding,46614,CPT,,,,,,,,both,,,25806,19096.44,74,,19096.44,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,11612.7,45,,11612.7,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,12773.97,49.5,,12773.97,percent of total billed charges,110% of Medicare,17548.08,68,,17548.08,percent of total billed charges,,1478.54,,,1478.54,Other,186% of Medicaid,20644.8,80,,20644.8,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,20644.8,80,,20644.8,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,18064.2,70,,18064.2,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,794.91,,,794.91,Other,New York Medicaid APG methodology,794.91,,,794.91,Other,100% New York Medicaid APG,794.91,,,794.91,Other,100% New York Medicaid APG,794.91,,,794.91,Other,100% New York Medicaid APG,1788.55,,,1788.55,Other,225% New York Medicaid APG,1216.22,,,1216.22,Other,153% New York Medicaid APG,1788.55,,,1788.55,Other,225% New York Medicaid APG,1112.88,,,1112.88,Other,140% New York Medicaid APG,1788.55,,,1788.55,Other,225% New York Medicaid APG,2066.77,,,2066.77,Other,260% New York Medicaid APG,2575.52,,,2575.52,Other,324% New York Medicaid APG,1709.06,,,1709.06,Other,215% New York Medicaid APG,1709.06,,,1709.06,Other,215% New York Medicaid APG,993.64,,,993.64,Other,125% New York Medicaid APG,794.91,20644.8,
Anoscopy,46615,CPT,,,,,,,,both,,,33680.29,24923.41,74,,24923.41,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15156.13,45,,15156.13,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,16671.74,49.5,,16671.74,percent of total billed charges,110% of Medicare,22902.6,68,,22902.6,percent of total billed charges,,1648.24,,,1648.24,Other,186% of Medicaid,26944.23,80,,26944.23,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,26944.23,80,,26944.23,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,23576.2,70,,23576.2,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,886.15,,,886.15,Other,New York Medicaid APG methodology,886.15,,,886.15,Other,100% New York Medicaid APG,886.15,,,886.15,Other,100% New York Medicaid APG,886.15,,,886.15,Other,100% New York Medicaid APG,1993.84,,,1993.84,Other,225% New York Medicaid APG,1355.81,,,1355.81,Other,153% New York Medicaid APG,1993.84,,,1993.84,Other,225% New York Medicaid APG,1240.61,,,1240.61,Other,140% New York Medicaid APG,1993.84,,,1993.84,Other,225% New York Medicaid APG,2303.99,,,2303.99,Other,260% New York Medicaid APG,2871.13,,,2871.13,Other,324% New York Medicaid APG,1905.23,,,1905.23,Other,215% New York Medicaid APG,1905.23,,,1905.23,Other,215% New York Medicaid APG,1107.69,,,1107.69,Other,125% New York Medicaid APG,886.15,26944.23,
Repair of anal stricture,46700,CPT,,,,,,,,both,,,59058.34,43703.17,74,,43703.17,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,26576.25,45,,26576.25,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,29233.88,49.5,,29233.88,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2732.76,,,2732.76,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,41340.84,70,,41340.84,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1469.23,,,1469.23,Other,New York Medicaid APG methodology,1469.23,,,1469.23,Other,100% New York Medicaid APG,1469.23,,,1469.23,Other,100% New York Medicaid APG,1469.23,,,1469.23,Other,100% New York Medicaid APG,3305.76,,,3305.76,Other,225% New York Medicaid APG,2247.91,,,2247.91,Other,153% New York Medicaid APG,3305.76,,,3305.76,Other,225% New York Medicaid APG,2056.92,,,2056.92,Other,140% New York Medicaid APG,3305.76,,,3305.76,Other,225% New York Medicaid APG,3819.99,,,3819.99,Other,260% New York Medicaid APG,4760.29,,,4760.29,Other,324% New York Medicaid APG,3158.83,,,3158.83,Other,215% New York Medicaid APG,3158.83,,,3158.83,Other,215% New York Medicaid APG,1836.53,,,1836.53,Other,125% New York Medicaid APG,1469.23,43703.17,
Repr of anal fistula w/glue,46706,CPT,,,,,,,,both,,,59058.34,43703.17,74,,43703.17,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,26576.25,45,,26576.25,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,29233.88,49.5,,29233.88,percent of total billed charges,110% of Medicare,40159.67,68,,40159.67,percent of total billed charges,,2000.16,,,2000.16,Other,186% of Medicaid,47246.67,80,,47246.67,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,47246.67,80,,47246.67,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,41340.84,70,,41340.84,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1075.35,,,1075.35,Other,New York Medicaid APG methodology,1075.35,,,1075.35,Other,100% New York Medicaid APG,1075.35,,,1075.35,Other,100% New York Medicaid APG,1075.35,,,1075.35,Other,100% New York Medicaid APG,2419.55,,,2419.55,Other,225% New York Medicaid APG,1645.29,,,1645.29,Other,153% New York Medicaid APG,2419.55,,,2419.55,Other,225% New York Medicaid APG,1505.5,,,1505.5,Other,140% New York Medicaid APG,2419.55,,,2419.55,Other,225% New York Medicaid APG,2795.92,,,2795.92,Other,260% New York Medicaid APG,3484.15,,,3484.15,Other,324% New York Medicaid APG,2312.01,,,2312.01,Other,215% New York Medicaid APG,2312.01,,,2312.01,Other,215% New York Medicaid APG,1344.19,,,1344.19,Other,125% New York Medicaid APG,1075.35,47246.67,
Repair anorectal fist w/plug,46707,CPT,,,,,,,,both,,,59058.34,43703.17,74,,43703.17,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,26576.25,45,,26576.25,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,29233.88,49.5,,29233.88,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2000.16,,,2000.16,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,41340.84,70,,41340.84,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1075.35,,,1075.35,Other,New York Medicaid APG methodology,1075.35,,,1075.35,Other,100% New York Medicaid APG,1075.35,,,1075.35,Other,100% New York Medicaid APG,1075.35,,,1075.35,Other,100% New York Medicaid APG,2419.55,,,2419.55,Other,225% New York Medicaid APG,1645.29,,,1645.29,Other,153% New York Medicaid APG,2419.55,,,2419.55,Other,225% New York Medicaid APG,1505.5,,,1505.5,Other,140% New York Medicaid APG,2419.55,,,2419.55,Other,225% New York Medicaid APG,2795.92,,,2795.92,Other,260% New York Medicaid APG,3484.15,,,3484.15,Other,324% New York Medicaid APG,2312.01,,,2312.01,Other,215% New York Medicaid APG,2312.01,,,2312.01,Other,215% New York Medicaid APG,1344.19,,,1344.19,Other,125% New York Medicaid APG,1075.35,43703.17,
Repair of anal sphincter,46750,CPT,,,,,,,,both,,,59058.34,43703.17,74,,43703.17,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,26576.25,45,,26576.25,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,29233.88,49.5,,29233.88,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2732.76,,,2732.76,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,41340.84,70,,41340.84,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1469.23,,,1469.23,Other,New York Medicaid APG methodology,1469.23,,,1469.23,Other,100% New York Medicaid APG,1469.23,,,1469.23,Other,100% New York Medicaid APG,1469.23,,,1469.23,Other,100% New York Medicaid APG,3305.76,,,3305.76,Other,225% New York Medicaid APG,2247.91,,,2247.91,Other,153% New York Medicaid APG,3305.76,,,3305.76,Other,225% New York Medicaid APG,2056.92,,,2056.92,Other,140% New York Medicaid APG,3305.76,,,3305.76,Other,225% New York Medicaid APG,3819.99,,,3819.99,Other,260% New York Medicaid APG,4760.29,,,4760.29,Other,324% New York Medicaid APG,3158.83,,,3158.83,Other,215% New York Medicaid APG,3158.83,,,3158.83,Other,215% New York Medicaid APG,1836.53,,,1836.53,Other,125% New York Medicaid APG,1469.23,43703.17,
Reconstruction of anus,46753,CPT,,,,,,,,both,,,59058.34,43703.17,74,,43703.17,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,26576.25,45,,26576.25,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,29233.88,49.5,,29233.88,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2732.76,,,2732.76,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,41340.84,70,,41340.84,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1469.23,,,1469.23,Other,New York Medicaid APG methodology,1469.23,,,1469.23,Other,100% New York Medicaid APG,1469.23,,,1469.23,Other,100% New York Medicaid APG,1469.23,,,1469.23,Other,100% New York Medicaid APG,3305.76,,,3305.76,Other,225% New York Medicaid APG,2247.91,,,2247.91,Other,153% New York Medicaid APG,3305.76,,,3305.76,Other,225% New York Medicaid APG,2056.92,,,2056.92,Other,140% New York Medicaid APG,3305.76,,,3305.76,Other,225% New York Medicaid APG,3819.99,,,3819.99,Other,260% New York Medicaid APG,4760.29,,,4760.29,Other,324% New York Medicaid APG,3158.83,,,3158.83,Other,215% New York Medicaid APG,3158.83,,,3158.83,Other,215% New York Medicaid APG,1836.53,,,1836.53,Other,125% New York Medicaid APG,1469.23,43703.17,
Removal of suture from anus,46754,CPT,,,,,,,,both,,,59058.34,43703.17,74,,43703.17,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,26576.25,45,,26576.25,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,29233.88,49.5,,29233.88,percent of total billed charges,110% of Medicare,40159.67,68,,40159.67,percent of total billed charges,,2000.16,,,2000.16,Other,186% of Medicaid,47246.67,80,,47246.67,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,47246.67,80,,47246.67,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,41340.84,70,,41340.84,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1075.35,,,1075.35,Other,New York Medicaid APG methodology,1075.35,,,1075.35,Other,100% New York Medicaid APG,1075.35,,,1075.35,Other,100% New York Medicaid APG,1075.35,,,1075.35,Other,100% New York Medicaid APG,2419.55,,,2419.55,Other,225% New York Medicaid APG,1645.29,,,1645.29,Other,153% New York Medicaid APG,2419.55,,,2419.55,Other,225% New York Medicaid APG,1505.5,,,1505.5,Other,140% New York Medicaid APG,2419.55,,,2419.55,Other,225% New York Medicaid APG,2795.92,,,2795.92,Other,260% New York Medicaid APG,3484.15,,,3484.15,Other,324% New York Medicaid APG,2312.01,,,2312.01,Other,215% New York Medicaid APG,2312.01,,,2312.01,Other,215% New York Medicaid APG,1344.19,,,1344.19,Other,125% New York Medicaid APG,1075.35,47246.67,
Repair of anal sphincter,46760,CPT,,,,,,,,both,,,59058.34,43703.17,74,,43703.17,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,26576.25,45,,26576.25,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,29233.88,49.5,,29233.88,percent of total billed charges,110% of Medicare,40159.67,68,,40159.67,percent of total billed charges,,2732.76,,,2732.76,Other,186% of Medicaid,47246.67,80,,47246.67,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,47246.67,80,,47246.67,percent of total billed charges,,7216,,,7216,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,41340.84,70,,41340.84,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1469.23,,,1469.23,Other,New York Medicaid APG methodology,1469.23,,,1469.23,Other,100% New York Medicaid APG,1469.23,,,1469.23,Other,100% New York Medicaid APG,1469.23,,,1469.23,Other,100% New York Medicaid APG,3305.76,,,3305.76,Other,225% New York Medicaid APG,2247.91,,,2247.91,Other,153% New York Medicaid APG,3305.76,,,3305.76,Other,225% New York Medicaid APG,2056.92,,,2056.92,Other,140% New York Medicaid APG,3305.76,,,3305.76,Other,225% New York Medicaid APG,3819.99,,,3819.99,Other,260% New York Medicaid APG,4760.29,,,4760.29,Other,324% New York Medicaid APG,3158.83,,,3158.83,Other,215% New York Medicaid APG,3158.83,,,3158.83,Other,215% New York Medicaid APG,1836.53,,,1836.53,Other,125% New York Medicaid APG,1469.23,47246.67,
Repair of anal sphincter,46761,CPT,,,,,,,,both,,,59058.34,43703.17,74,,43703.17,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,26576.25,45,,26576.25,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,29233.88,49.5,,29233.88,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2732.76,,,2732.76,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,41340.84,70,,41340.84,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1469.23,,,1469.23,Other,New York Medicaid APG methodology,1469.23,,,1469.23,Other,100% New York Medicaid APG,1469.23,,,1469.23,Other,100% New York Medicaid APG,1469.23,,,1469.23,Other,100% New York Medicaid APG,3305.76,,,3305.76,Other,225% New York Medicaid APG,2247.91,,,2247.91,Other,153% New York Medicaid APG,3305.76,,,3305.76,Other,225% New York Medicaid APG,2056.92,,,2056.92,Other,140% New York Medicaid APG,3305.76,,,3305.76,Other,225% New York Medicaid APG,3819.99,,,3819.99,Other,260% New York Medicaid APG,4760.29,,,4760.29,Other,324% New York Medicaid APG,3158.83,,,3158.83,Other,215% New York Medicaid APG,3158.83,,,3158.83,Other,215% New York Medicaid APG,1836.53,,,1836.53,Other,125% New York Medicaid APG,1469.23,43703.17,
Destruction anal lesion(s),46900,CPT,,,,,,,,both,,,8387.08,6206.44,74,,6206.44,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,3774.19,45,,3774.19,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,4151.6,49.5,,4151.6,percent of total billed charges,110% of Medicare,5703.21,68,,5703.21,percent of total billed charges,,2000.16,,,2000.16,Other,186% of Medicaid,6709.66,80,,6709.66,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,6709.66,80,,6709.66,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,5870.96,70,,5870.96,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,1075.35,,,1075.35,Other,New York Medicaid APG methodology,1075.35,,,1075.35,Other,100% New York Medicaid APG,1075.35,,,1075.35,Other,100% New York Medicaid APG,1075.35,,,1075.35,Other,100% New York Medicaid APG,2419.55,,,2419.55,Other,225% New York Medicaid APG,1645.29,,,1645.29,Other,153% New York Medicaid APG,2419.55,,,2419.55,Other,225% New York Medicaid APG,1505.5,,,1505.5,Other,140% New York Medicaid APG,2419.55,,,2419.55,Other,225% New York Medicaid APG,2795.92,,,2795.92,Other,260% New York Medicaid APG,3484.15,,,3484.15,Other,324% New York Medicaid APG,2312.01,,,2312.01,Other,215% New York Medicaid APG,2312.01,,,2312.01,Other,215% New York Medicaid APG,1344.19,,,1344.19,Other,125% New York Medicaid APG,1075.35,7216,
Destruction anal lesion(s),46910,CPT,,,,,,,,both,,,38456.29,28457.65,74,,28457.65,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,17305.33,45,,17305.33,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,19035.86,49.5,,19035.86,percent of total billed charges,110% of Medicare,26150.28,68,,26150.28,percent of total billed charges,,2000.16,,,2000.16,Other,186% of Medicaid,30765.03,80,,30765.03,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,30765.03,80,,30765.03,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,26919.4,70,,26919.4,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1075.35,,,1075.35,Other,New York Medicaid APG methodology,1075.35,,,1075.35,Other,100% New York Medicaid APG,1075.35,,,1075.35,Other,100% New York Medicaid APG,1075.35,,,1075.35,Other,100% New York Medicaid APG,2419.55,,,2419.55,Other,225% New York Medicaid APG,1645.29,,,1645.29,Other,153% New York Medicaid APG,2419.55,,,2419.55,Other,225% New York Medicaid APG,1505.5,,,1505.5,Other,140% New York Medicaid APG,2419.55,,,2419.55,Other,225% New York Medicaid APG,2795.92,,,2795.92,Other,260% New York Medicaid APG,3484.15,,,3484.15,Other,324% New York Medicaid APG,2312.01,,,2312.01,Other,215% New York Medicaid APG,2312.01,,,2312.01,Other,215% New York Medicaid APG,1344.19,,,1344.19,Other,125% New York Medicaid APG,1075.35,30765.03,
Cryosurgery anal lesion(s),46916,CPT,,,,,,,,both,,,4210.98,3116.13,74,,3116.13,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,1894.94,45,,1894.94,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,2084.44,49.5,,2084.44,percent of total billed charges,110% of Medicare,2863.47,68,,2863.47,percent of total billed charges,,2000.16,,,2000.16,Other,186% of Medicaid,3368.78,80,,3368.78,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,3368.78,80,,3368.78,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,2947.69,70,,2947.69,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,1075.35,,,1075.35,Other,New York Medicaid APG methodology,1075.35,,,1075.35,Other,100% New York Medicaid APG,1075.35,,,1075.35,Other,100% New York Medicaid APG,1075.35,,,1075.35,Other,100% New York Medicaid APG,2419.55,,,2419.55,Other,225% New York Medicaid APG,1645.29,,,1645.29,Other,153% New York Medicaid APG,2419.55,,,2419.55,Other,225% New York Medicaid APG,1505.5,,,1505.5,Other,140% New York Medicaid APG,2419.55,,,2419.55,Other,225% New York Medicaid APG,2795.92,,,2795.92,Other,260% New York Medicaid APG,3484.15,,,3484.15,Other,324% New York Medicaid APG,2312.01,,,2312.01,Other,215% New York Medicaid APG,2312.01,,,2312.01,Other,215% New York Medicaid APG,1344.19,,,1344.19,Other,125% New York Medicaid APG,1075.35,7216,
Laser surgery anal lesions,46917,CPT,,,,,,,,both,,,44593.69,32999.33,74,,32999.33,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,20067.16,45,,20067.16,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,22073.88,49.5,,22073.88,percent of total billed charges,110% of Medicare,30323.71,68,,30323.71,percent of total billed charges,,2000.16,,,2000.16,Other,186% of Medicaid,35674.95,80,,35674.95,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,35674.95,80,,35674.95,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,31215.58,70,,31215.58,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1075.35,,,1075.35,Other,New York Medicaid APG methodology,1075.35,,,1075.35,Other,100% New York Medicaid APG,1075.35,,,1075.35,Other,100% New York Medicaid APG,1075.35,,,1075.35,Other,100% New York Medicaid APG,2419.55,,,2419.55,Other,225% New York Medicaid APG,1645.29,,,1645.29,Other,153% New York Medicaid APG,2419.55,,,2419.55,Other,225% New York Medicaid APG,1505.5,,,1505.5,Other,140% New York Medicaid APG,2419.55,,,2419.55,Other,225% New York Medicaid APG,2795.92,,,2795.92,Other,260% New York Medicaid APG,3484.15,,,3484.15,Other,324% New York Medicaid APG,2312.01,,,2312.01,Other,215% New York Medicaid APG,2312.01,,,2312.01,Other,215% New York Medicaid APG,1344.19,,,1344.19,Other,125% New York Medicaid APG,1075.35,35674.95,
Excision of anal lesion(s),46922,CPT,,,,,,,,both,,,35119.53,25988.45,74,,25988.45,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15803.79,45,,15803.79,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,17384.17,49.5,,17384.17,percent of total billed charges,110% of Medicare,23881.28,68,,23881.28,percent of total billed charges,,2000.16,,,2000.16,Other,186% of Medicaid,28095.62,80,,28095.62,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,28095.62,80,,28095.62,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,24583.67,70,,24583.67,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1075.35,,,1075.35,Other,New York Medicaid APG methodology,1075.35,,,1075.35,Other,100% New York Medicaid APG,1075.35,,,1075.35,Other,100% New York Medicaid APG,1075.35,,,1075.35,Other,100% New York Medicaid APG,2419.55,,,2419.55,Other,225% New York Medicaid APG,1645.29,,,1645.29,Other,153% New York Medicaid APG,2419.55,,,2419.55,Other,225% New York Medicaid APG,1505.5,,,1505.5,Other,140% New York Medicaid APG,2419.55,,,2419.55,Other,225% New York Medicaid APG,2795.92,,,2795.92,Other,260% New York Medicaid APG,3484.15,,,3484.15,Other,324% New York Medicaid APG,2312.01,,,2312.01,Other,215% New York Medicaid APG,2312.01,,,2312.01,Other,215% New York Medicaid APG,1344.19,,,1344.19,Other,125% New York Medicaid APG,1075.35,28095.62,
Destruction anal lesion(s),46924,CPT,,,,,,,,both,,,40608.23,30050.09,74,,30050.09,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,18273.7,45,,18273.7,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,20101.07,49.5,,20101.07,percent of total billed charges,110% of Medicare,27613.6,68,,27613.6,percent of total billed charges,,2000.16,,,2000.16,Other,186% of Medicaid,32486.58,80,,32486.58,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,32486.58,80,,32486.58,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,28425.76,70,,28425.76,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1075.35,,,1075.35,Other,New York Medicaid APG methodology,1075.35,,,1075.35,Other,100% New York Medicaid APG,1075.35,,,1075.35,Other,100% New York Medicaid APG,1075.35,,,1075.35,Other,100% New York Medicaid APG,2419.55,,,2419.55,Other,225% New York Medicaid APG,1645.29,,,1645.29,Other,153% New York Medicaid APG,2419.55,,,2419.55,Other,225% New York Medicaid APG,1505.5,,,1505.5,Other,140% New York Medicaid APG,2419.55,,,2419.55,Other,225% New York Medicaid APG,2795.92,,,2795.92,Other,260% New York Medicaid APG,3484.15,,,3484.15,Other,324% New York Medicaid APG,2312.01,,,2312.01,Other,215% New York Medicaid APG,2312.01,,,2312.01,Other,215% New York Medicaid APG,1344.19,,,1344.19,Other,125% New York Medicaid APG,1075.35,32486.58,
Destroy internal hemorrhoids,46930,CPT,,,,,,,,both,,,24821.26,18367.73,74,,18367.73,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,11169.57,45,,11169.57,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,12286.52,49.5,,12286.52,percent of total billed charges,110% of Medicare,16878.46,68,,16878.46,percent of total billed charges,,2000.16,,,2000.16,Other,186% of Medicaid,19857.01,80,,19857.01,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,19857.01,80,,19857.01,percent of total billed charges,,7216,,,7216,Case Rate,,3578,,"100% primary, 0% secondary procedures",3578,Other,MagnaCare ASC Grouper,17374.88,70,,17374.88,percent of total billed charges,,744.56,,,744.56,Fee Schedule,,631.06,,,631.06,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,1075.35,,,1075.35,Other,New York Medicaid APG methodology,1075.35,,,1075.35,Other,100% New York Medicaid APG,1075.35,,,1075.35,Other,100% New York Medicaid APG,1075.35,,,1075.35,Other,100% New York Medicaid APG,2419.55,,,2419.55,Other,225% New York Medicaid APG,1645.29,,,1645.29,Other,153% New York Medicaid APG,2419.55,,,2419.55,Other,225% New York Medicaid APG,1505.5,,,1505.5,Other,140% New York Medicaid APG,2419.55,,,2419.55,Other,225% New York Medicaid APG,2795.92,,,2795.92,Other,260% New York Medicaid APG,3484.15,,,3484.15,Other,324% New York Medicaid APG,2312.01,,,2312.01,Other,215% New York Medicaid APG,2312.01,,,2312.01,Other,215% New York Medicaid APG,1344.19,,,1344.19,Other,125% New York Medicaid APG,631.06,19857.01,
Treatment of anal fissure,46940,CPT,,,,,,,,both,,,59058.34,43703.17,74,,43703.17,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,26576.25,45,,26576.25,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,29233.88,49.5,,29233.88,percent of total billed charges,110% of Medicare,40159.67,68,,40159.67,percent of total billed charges,,2000.16,,,2000.16,Other,186% of Medicaid,47246.67,80,,47246.67,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,47246.67,80,,47246.67,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,41340.84,70,,41340.84,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1075.35,,,1075.35,Other,New York Medicaid APG methodology,1075.35,,,1075.35,Other,100% New York Medicaid APG,1075.35,,,1075.35,Other,100% New York Medicaid APG,1075.35,,,1075.35,Other,100% New York Medicaid APG,2419.55,,,2419.55,Other,225% New York Medicaid APG,1645.29,,,1645.29,Other,153% New York Medicaid APG,2419.55,,,2419.55,Other,225% New York Medicaid APG,1505.5,,,1505.5,Other,140% New York Medicaid APG,2419.55,,,2419.55,Other,225% New York Medicaid APG,2795.92,,,2795.92,Other,260% New York Medicaid APG,3484.15,,,3484.15,Other,324% New York Medicaid APG,2312.01,,,2312.01,Other,215% New York Medicaid APG,2312.01,,,2312.01,Other,215% New York Medicaid APG,1344.19,,,1344.19,Other,125% New York Medicaid APG,1075.35,47246.67,
Treatment of anal fissure,46942,CPT,,,,,,,,both,,,19223.92,14225.7,74,,14225.7,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,8650.76,45,,8650.76,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,9515.84,49.5,,9515.84,percent of total billed charges,110% of Medicare,13072.27,68,,13072.27,percent of total billed charges,,2000.16,,,2000.16,Other,186% of Medicaid,15379.14,80,,15379.14,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,15379.14,80,,15379.14,percent of total billed charges,,7216,,,7216,Case Rate,,3578,,"100% primary, 0% secondary procedures",3578,Other,MagnaCare ASC Grouper,13456.74,70,,13456.74,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,1075.35,,,1075.35,Other,New York Medicaid APG methodology,1075.35,,,1075.35,Other,100% New York Medicaid APG,1075.35,,,1075.35,Other,100% New York Medicaid APG,1075.35,,,1075.35,Other,100% New York Medicaid APG,2419.55,,,2419.55,Other,225% New York Medicaid APG,1645.29,,,1645.29,Other,153% New York Medicaid APG,2419.55,,,2419.55,Other,225% New York Medicaid APG,1505.5,,,1505.5,Other,140% New York Medicaid APG,2419.55,,,2419.55,Other,225% New York Medicaid APG,2795.92,,,2795.92,Other,260% New York Medicaid APG,3484.15,,,3484.15,Other,324% New York Medicaid APG,2312.01,,,2312.01,Other,215% New York Medicaid APG,2312.01,,,2312.01,Other,215% New York Medicaid APG,1344.19,,,1344.19,Other,125% New York Medicaid APG,1075.35,15379.14,
Int hrhc lig 1 hroid w/o img,46945,CPT,,,,,,,,both,,,31715.04,23469.13,74,,23469.13,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,14271.77,45,,14271.77,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,15698.94,49.5,,15698.94,percent of total billed charges,110% of Medicare,21566.23,68,,21566.23,percent of total billed charges,,2000.16,,,2000.16,Other,186% of Medicaid,25372.03,80,,25372.03,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,25372.03,80,,25372.03,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,22200.53,70,,22200.53,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1075.35,,,1075.35,Other,New York Medicaid APG methodology,1075.35,,,1075.35,Other,100% New York Medicaid APG,1075.35,,,1075.35,Other,100% New York Medicaid APG,1075.35,,,1075.35,Other,100% New York Medicaid APG,2419.55,,,2419.55,Other,225% New York Medicaid APG,1645.29,,,1645.29,Other,153% New York Medicaid APG,2419.55,,,2419.55,Other,225% New York Medicaid APG,1505.5,,,1505.5,Other,140% New York Medicaid APG,2419.55,,,2419.55,Other,225% New York Medicaid APG,2795.92,,,2795.92,Other,260% New York Medicaid APG,3484.15,,,3484.15,Other,324% New York Medicaid APG,2312.01,,,2312.01,Other,215% New York Medicaid APG,2312.01,,,2312.01,Other,215% New York Medicaid APG,1344.19,,,1344.19,Other,125% New York Medicaid APG,1075.35,25372.03,
Int hrhc lig 2+hroid w/o img,46946,CPT,,,,,,,,both,,,34725.26,25696.69,74,,25696.69,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15626.37,45,,15626.37,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,17189,49.5,,17189,percent of total billed charges,110% of Medicare,23613.18,68,,23613.18,percent of total billed charges,,2000.16,,,2000.16,Other,186% of Medicaid,27780.21,80,,27780.21,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,27780.21,80,,27780.21,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,24307.68,70,,24307.68,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1075.35,,,1075.35,Other,New York Medicaid APG methodology,1075.35,,,1075.35,Other,100% New York Medicaid APG,1075.35,,,1075.35,Other,100% New York Medicaid APG,1075.35,,,1075.35,Other,100% New York Medicaid APG,2419.55,,,2419.55,Other,225% New York Medicaid APG,1645.29,,,1645.29,Other,153% New York Medicaid APG,2419.55,,,2419.55,Other,225% New York Medicaid APG,1505.5,,,1505.5,Other,140% New York Medicaid APG,2419.55,,,2419.55,Other,225% New York Medicaid APG,2795.92,,,2795.92,Other,260% New York Medicaid APG,3484.15,,,3484.15,Other,324% New York Medicaid APG,2312.01,,,2312.01,Other,215% New York Medicaid APG,2312.01,,,2312.01,Other,215% New York Medicaid APG,1344.19,,,1344.19,Other,125% New York Medicaid APG,1075.35,27780.21,
Hemorrhoidopexy by stapling,46947,CPT,,,,,,,,both,,,59058.34,43703.17,74,,43703.17,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,26576.25,45,,26576.25,percent of total billed charges,Medicare Ratio of cost to charges,5954,,"100% primary, 50% supplemental procedure",5954,Other,Aetna ASC Grouper,5359,,"100% primary, 50% supplemental procedure",5359,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,29233.88,49.5,,29233.88,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2732.76,,,2732.76,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,41340.84,70,,41340.84,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1469.23,,,1469.23,Other,New York Medicaid APG methodology,1469.23,,,1469.23,Other,100% New York Medicaid APG,1469.23,,,1469.23,Other,100% New York Medicaid APG,1469.23,,,1469.23,Other,100% New York Medicaid APG,3305.76,,,3305.76,Other,225% New York Medicaid APG,2247.91,,,2247.91,Other,153% New York Medicaid APG,3305.76,,,3305.76,Other,225% New York Medicaid APG,2056.92,,,2056.92,Other,140% New York Medicaid APG,3305.76,,,3305.76,Other,225% New York Medicaid APG,3819.99,,,3819.99,Other,260% New York Medicaid APG,4760.29,,,4760.29,Other,324% New York Medicaid APG,3158.83,,,3158.83,Other,215% New York Medicaid APG,3158.83,,,3158.83,Other,215% New York Medicaid APG,1836.53,,,1836.53,Other,125% New York Medicaid APG,1469.23,43703.17,
Int hrhc tranal dartlzj 2+,46948,CPT,,,,,,,,both,,,39511.68,29238.64,74,,29238.64,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,17780.26,45,,17780.26,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,19558.28,49.5,,19558.28,percent of total billed charges,110% of Medicare,26867.94,68,,26867.94,percent of total billed charges,,2732.76,,,2732.76,Other,186% of Medicaid,31609.34,80,,31609.34,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,31609.34,80,,31609.34,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,27658.18,70,,27658.18,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1469.23,,,1469.23,Other,New York Medicaid APG methodology,1469.23,,,1469.23,Other,100% New York Medicaid APG,1469.23,,,1469.23,Other,100% New York Medicaid APG,1469.23,,,1469.23,Other,100% New York Medicaid APG,3305.76,,,3305.76,Other,225% New York Medicaid APG,2247.91,,,2247.91,Other,153% New York Medicaid APG,3305.76,,,3305.76,Other,225% New York Medicaid APG,2056.92,,,2056.92,Other,140% New York Medicaid APG,3305.76,,,3305.76,Other,225% New York Medicaid APG,3819.99,,,3819.99,Other,260% New York Medicaid APG,4760.29,,,4760.29,Other,324% New York Medicaid APG,3158.83,,,3158.83,Other,215% New York Medicaid APG,3158.83,,,3158.83,Other,215% New York Medicaid APG,1836.53,,,1836.53,Other,125% New York Medicaid APG,1469.23,31609.34,
Needle biopsy of liver,47000,CPT,,,,,,,,both,,,29488.87,21821.76,74,,21821.76,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,13269.99,45,,13269.99,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,14596.99,49.5,,14596.99,percent of total billed charges,110% of Medicare,20052.43,68,,20052.43,percent of total billed charges,,1196.64,,,1196.64,Other,186% of Medicaid,23591.1,80,,23591.1,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,23591.1,80,,23591.1,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,20642.21,70,,20642.21,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,643.35,,,643.35,Other,New York Medicaid APG methodology,643.35,,,643.35,Other,100% New York Medicaid APG,643.35,,,643.35,Other,100% New York Medicaid APG,643.35,,,643.35,Other,100% New York Medicaid APG,1447.55,,,1447.55,Other,225% New York Medicaid APG,984.33,,,984.33,Other,153% New York Medicaid APG,1447.55,,,1447.55,Other,225% New York Medicaid APG,900.7,,,900.7,Other,140% New York Medicaid APG,1447.55,,,1447.55,Other,225% New York Medicaid APG,1672.72,,,1672.72,Other,260% New York Medicaid APG,2084.47,,,2084.47,Other,324% New York Medicaid APG,1383.21,,,1383.21,Other,215% New York Medicaid APG,1383.21,,,1383.21,Other,215% New York Medicaid APG,804.19,,,804.19,Other,125% New York Medicaid APG,643.35,23591.1,
Needle biopsy liver add-on,47001,CPT,,,,,,,,both,,,32432.1,23999.75,74,,23999.75,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,14594.45,45,,14594.45,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,16053.89,49.5,,16053.89,percent of total billed charges,110% of Medicare,22053.83,68,,22053.83,percent of total billed charges,,1196.64,,,1196.64,Other,186% of Medicaid,25945.68,80,,25945.68,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,25945.68,80,,25945.68,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,22702.47,70,,22702.47,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,643.35,,,643.35,Other,New York Medicaid APG methodology,643.35,,,643.35,Other,100% New York Medicaid APG,643.35,,,643.35,Other,100% New York Medicaid APG,643.35,,,643.35,Other,100% New York Medicaid APG,1447.55,,,1447.55,Other,225% New York Medicaid APG,984.33,,,984.33,Other,153% New York Medicaid APG,1447.55,,,1447.55,Other,225% New York Medicaid APG,900.7,,,900.7,Other,140% New York Medicaid APG,1447.55,,,1447.55,Other,225% New York Medicaid APG,1672.72,,,1672.72,Other,260% New York Medicaid APG,2084.47,,,2084.47,Other,324% New York Medicaid APG,1383.21,,,1383.21,Other,215% New York Medicaid APG,1383.21,,,1383.21,Other,215% New York Medicaid APG,804.19,,,804.19,Other,125% New York Medicaid APG,643.35,25945.68,
Laparo ablate liver tumor rf,47370,CPT,,,,,,,,both,,,216515.17,160221.23,74,,160221.23,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,97431.83,45,,97431.83,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,107175.01,49.5,,107175.01,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3989.38,,,3989.38,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9196,,"100% primary, 0% secondary procedures",9196,Other,MagnaCare ASC Grouper,151560.62,70,,151560.62,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6956,,"100% primary, 50% secondary, 25% tertiary procedure",6956,Other,United Healthcare ASC Grouper,6261,,"100% primary, 50% secondary, 25% tertiary procedure",6261,Other,United Healthcare ASC Grouper,6956,,"100% primary, 50% secondary, 25% tertiary procedure",6956,Other,United Healthcare ASC Grouper,5913,,"100% primary, 50% secondary, 25% tertiary procedure",5913,Other,United Healthcare ASC Grouper,2144.83,,,2144.83,Other,New York Medicaid APG methodology,2144.83,,,2144.83,Other,100% New York Medicaid APG,2144.83,,,2144.83,Other,100% New York Medicaid APG,2144.83,,,2144.83,Other,100% New York Medicaid APG,4825.86,,,4825.86,Other,225% New York Medicaid APG,3281.59,,,3281.59,Other,153% New York Medicaid APG,4825.86,,,4825.86,Other,225% New York Medicaid APG,3002.76,,,3002.76,Other,140% New York Medicaid APG,4825.86,,,4825.86,Other,225% New York Medicaid APG,5576.55,,,5576.55,Other,260% New York Medicaid APG,6949.24,,,6949.24,Other,324% New York Medicaid APG,4611.38,,,4611.38,Other,215% New York Medicaid APG,4611.38,,,4611.38,Other,215% New York Medicaid APG,2681.04,,,2681.04,Other,125% New York Medicaid APG,2144.83,160221.23,
Laparo ablate liver cryosurg,47371,CPT,,,,,,,,both,,,216515.17,160221.23,74,,160221.23,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,97431.83,45,,97431.83,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,107175.01,49.5,,107175.01,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3989.38,,,3989.38,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9196,,"100% primary, 0% secondary procedures",9196,Other,MagnaCare ASC Grouper,151560.62,70,,151560.62,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6956,,"100% primary, 50% secondary, 25% tertiary procedure",6956,Other,United Healthcare ASC Grouper,6261,,"100% primary, 50% secondary, 25% tertiary procedure",6261,Other,United Healthcare ASC Grouper,6956,,"100% primary, 50% secondary, 25% tertiary procedure",6956,Other,United Healthcare ASC Grouper,5913,,"100% primary, 50% secondary, 25% tertiary procedure",5913,Other,United Healthcare ASC Grouper,2144.83,,,2144.83,Other,New York Medicaid APG methodology,2144.83,,,2144.83,Other,100% New York Medicaid APG,2144.83,,,2144.83,Other,100% New York Medicaid APG,2144.83,,,2144.83,Other,100% New York Medicaid APG,4825.86,,,4825.86,Other,225% New York Medicaid APG,3281.59,,,3281.59,Other,153% New York Medicaid APG,4825.86,,,4825.86,Other,225% New York Medicaid APG,3002.76,,,3002.76,Other,140% New York Medicaid APG,4825.86,,,4825.86,Other,225% New York Medicaid APG,5576.55,,,5576.55,Other,260% New York Medicaid APG,6949.24,,,6949.24,Other,324% New York Medicaid APG,4611.38,,,4611.38,Other,215% New York Medicaid APG,4611.38,,,4611.38,Other,215% New York Medicaid APG,2681.04,,,2681.04,Other,125% New York Medicaid APG,2144.83,160221.23,
Percut ablate liver rf,47382,CPT,,,,,,,,both,,,49249.91,36444.93,74,,36444.93,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,22162.46,45,,22162.46,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,6125,,"100% primary, 50% secondary, 25% supplemental procedure",6125,Other,Blue Cross ASC Grouper,5513,,"100% primary, 50% secondary, 25% supplemental procedure",5513,Other,Blue Cross ASC Grouper,5206,,"100% primary, 50% secondary, 25% supplemental procedure",5206,Other,Blue Cross ASC Grouper,24378.71,49.5,,24378.71,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3989.38,,,3989.38,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,34474.94,70,,34474.94,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,2144.83,,,2144.83,Other,New York Medicaid APG methodology,2144.83,,,2144.83,Other,100% New York Medicaid APG,2144.83,,,2144.83,Other,100% New York Medicaid APG,2144.83,,,2144.83,Other,100% New York Medicaid APG,4825.86,,,4825.86,Other,225% New York Medicaid APG,3281.59,,,3281.59,Other,153% New York Medicaid APG,4825.86,,,4825.86,Other,225% New York Medicaid APG,3002.76,,,3002.76,Other,140% New York Medicaid APG,4825.86,,,4825.86,Other,225% New York Medicaid APG,5576.55,,,5576.55,Other,260% New York Medicaid APG,6949.24,,,6949.24,Other,324% New York Medicaid APG,4611.38,,,4611.38,Other,215% New York Medicaid APG,4611.38,,,4611.38,Other,215% New York Medicaid APG,2681.04,,,2681.04,Other,125% New York Medicaid APG,2144.83,36444.93,
Perq abltj lvr cryoablation,47383,CPT,,,,,,,,both,,,216515.17,160221.23,74,,160221.23,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,97431.83,45,,97431.83,percent of total billed charges,Medicare Ratio of cost to charges,7938,,"100% primary, 50% supplemental procedure",7938,Other,Aetna ASC Grouper,7144,,"100% primary, 50% supplemental procedure",7144,Other,Aetna ASC Grouper,6125,,"100% primary, 50% secondary, 25% supplemental procedure",6125,Other,Blue Cross ASC Grouper,5513,,"100% primary, 50% secondary, 25% supplemental procedure",5513,Other,Blue Cross ASC Grouper,5206,,"100% primary, 50% secondary, 25% supplemental procedure",5206,Other,Blue Cross ASC Grouper,107175.01,49.5,,107175.01,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3989.38,,,3989.38,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,151560.62,70,,151560.62,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,2144.83,,,2144.83,Other,New York Medicaid APG methodology,2144.83,,,2144.83,Other,100% New York Medicaid APG,2144.83,,,2144.83,Other,100% New York Medicaid APG,2144.83,,,2144.83,Other,100% New York Medicaid APG,4825.86,,,4825.86,Other,225% New York Medicaid APG,3281.59,,,3281.59,Other,153% New York Medicaid APG,4825.86,,,4825.86,Other,225% New York Medicaid APG,3002.76,,,3002.76,Other,140% New York Medicaid APG,4825.86,,,4825.86,Other,225% New York Medicaid APG,5576.55,,,5576.55,Other,260% New York Medicaid APG,6949.24,,,6949.24,Other,324% New York Medicaid APG,4611.38,,,4611.38,Other,215% New York Medicaid APG,4611.38,,,4611.38,Other,215% New York Medicaid APG,2681.04,,,2681.04,Other,125% New York Medicaid APG,2144.83,160221.23,
Incision of gallbladder,47490,CPT,,,,,,,,both,,,72769.69,53849.57,74,,53849.57,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,32746.36,45,,32746.36,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,36021,49.5,,36021,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2588.91,,,2588.91,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,50938.78,70,,50938.78,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1391.89,,,1391.89,Other,New York Medicaid APG methodology,1391.89,,,1391.89,Other,100% New York Medicaid APG,1391.89,,,1391.89,Other,100% New York Medicaid APG,1391.89,,,1391.89,Other,100% New York Medicaid APG,3131.75,,,3131.75,Other,225% New York Medicaid APG,2129.59,,,2129.59,Other,153% New York Medicaid APG,3131.75,,,3131.75,Other,225% New York Medicaid APG,1948.64,,,1948.64,Other,140% New York Medicaid APG,3131.75,,,3131.75,Other,225% New York Medicaid APG,3618.91,,,3618.91,Other,260% New York Medicaid APG,4509.72,,,4509.72,Other,324% New York Medicaid APG,2992.56,,,2992.56,Other,215% New York Medicaid APG,2992.56,,,2992.56,Other,215% New York Medicaid APG,1739.86,,,1739.86,Other,125% New York Medicaid APG,1391.89,53849.57,
Injection for cholangiogram,47531,CPT,,,,,,,,both,,,17151.17,12691.87,74,,12691.87,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,7718.03,45,,7718.03,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,8489.83,49.5,,8489.83,percent of total billed charges,110% of Medicare,11662.8,68,,11662.8,percent of total billed charges,,786.95,,,786.95,Other,186% of Medicaid,13720.94,80,,13720.94,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,13720.94,80,,13720.94,percent of total billed charges,,7216,,,7216,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,12005.82,70,,12005.82,percent of total billed charges,,336.2,,,336.2,Fee Schedule,,284.95,,,284.95,Fee Schedule,,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,423.09,,,423.09,Other,New York Medicaid APG methodology,423.09,,,423.09,Other,100% New York Medicaid APG,423.09,,,423.09,Other,100% New York Medicaid APG,423.09,,,423.09,Other,100% New York Medicaid APG,951.96,,,951.96,Other,225% New York Medicaid APG,647.33,,,647.33,Other,153% New York Medicaid APG,951.96,,,951.96,Other,225% New York Medicaid APG,592.33,,,592.33,Other,140% New York Medicaid APG,951.96,,,951.96,Other,225% New York Medicaid APG,1100.04,,,1100.04,Other,260% New York Medicaid APG,1370.82,,,1370.82,Other,324% New York Medicaid APG,909.65,,,909.65,Other,215% New York Medicaid APG,909.65,,,909.65,Other,215% New York Medicaid APG,528.86,,,528.86,Other,125% New York Medicaid APG,284.95,13720.94,
Injection for cholangiogram,47532,CPT,,,,,,,,both,,,72769.69,53849.57,74,,53849.57,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,32746.36,45,,32746.36,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,36021,49.5,,36021,percent of total billed charges,110% of Medicare,49483.39,68,,49483.39,percent of total billed charges,,786.95,,,786.95,Other,186% of Medicaid,58215.75,80,,58215.75,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,58215.75,80,,58215.75,percent of total billed charges,,7216,,,7216,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,50938.78,70,,50938.78,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,423.09,,,423.09,Other,New York Medicaid APG methodology,423.09,,,423.09,Other,100% New York Medicaid APG,423.09,,,423.09,Other,100% New York Medicaid APG,423.09,,,423.09,Other,100% New York Medicaid APG,951.96,,,951.96,Other,225% New York Medicaid APG,647.33,,,647.33,Other,153% New York Medicaid APG,951.96,,,951.96,Other,225% New York Medicaid APG,592.33,,,592.33,Other,140% New York Medicaid APG,951.96,,,951.96,Other,225% New York Medicaid APG,1100.04,,,1100.04,Other,260% New York Medicaid APG,1370.82,,,1370.82,Other,324% New York Medicaid APG,909.65,,,909.65,Other,215% New York Medicaid APG,909.65,,,909.65,Other,215% New York Medicaid APG,528.86,,,528.86,Other,125% New York Medicaid APG,423.09,58215.75,
Plmt biliary drainage cath,47533,CPT,,,,,,,,both,,,72769.69,53849.57,74,,53849.57,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,32746.36,45,,32746.36,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,36021,49.5,,36021,percent of total billed charges,110% of Medicare,49483.39,68,,49483.39,percent of total billed charges,,2588.91,,,2588.91,Other,186% of Medicaid,58215.75,80,,58215.75,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,58215.75,80,,58215.75,percent of total billed charges,,7216,,,7216,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,50938.78,70,,50938.78,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1391.89,,,1391.89,Other,New York Medicaid APG methodology,1391.89,,,1391.89,Other,100% New York Medicaid APG,1391.89,,,1391.89,Other,100% New York Medicaid APG,1391.89,,,1391.89,Other,100% New York Medicaid APG,3131.75,,,3131.75,Other,225% New York Medicaid APG,2129.59,,,2129.59,Other,153% New York Medicaid APG,3131.75,,,3131.75,Other,225% New York Medicaid APG,1948.64,,,1948.64,Other,140% New York Medicaid APG,3131.75,,,3131.75,Other,225% New York Medicaid APG,3618.91,,,3618.91,Other,260% New York Medicaid APG,4509.72,,,4509.72,Other,324% New York Medicaid APG,2992.56,,,2992.56,Other,215% New York Medicaid APG,2992.56,,,2992.56,Other,215% New York Medicaid APG,1739.86,,,1739.86,Other,125% New York Medicaid APG,1391.89,58215.75,
Plmt biliary drainage cath,47534,CPT,,,,,,,,both,,,45203,33450.22,74,,33450.22,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,20341.35,45,,20341.35,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,22375.49,49.5,,22375.49,percent of total billed charges,110% of Medicare,30738.04,68,,30738.04,percent of total billed charges,,2588.91,,,2588.91,Other,186% of Medicaid,36162.4,80,,36162.4,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,36162.4,80,,36162.4,percent of total billed charges,,7216,,,7216,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,31642.1,70,,31642.1,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1391.89,,,1391.89,Other,New York Medicaid APG methodology,1391.89,,,1391.89,Other,100% New York Medicaid APG,1391.89,,,1391.89,Other,100% New York Medicaid APG,1391.89,,,1391.89,Other,100% New York Medicaid APG,3131.75,,,3131.75,Other,225% New York Medicaid APG,2129.59,,,2129.59,Other,153% New York Medicaid APG,3131.75,,,3131.75,Other,225% New York Medicaid APG,1948.64,,,1948.64,Other,140% New York Medicaid APG,3131.75,,,3131.75,Other,225% New York Medicaid APG,3618.91,,,3618.91,Other,260% New York Medicaid APG,4509.72,,,4509.72,Other,324% New York Medicaid APG,2992.56,,,2992.56,Other,215% New York Medicaid APG,2992.56,,,2992.56,Other,215% New York Medicaid APG,1739.86,,,1739.86,Other,125% New York Medicaid APG,1391.89,36162.4,
Conversion ext bil drg cath,47535,CPT,,,,,,,,both,,,72769.69,53849.57,74,,53849.57,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,32746.36,45,,32746.36,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,36021,49.5,,36021,percent of total billed charges,110% of Medicare,49483.39,68,,49483.39,percent of total billed charges,,2588.91,,,2588.91,Other,186% of Medicaid,58215.75,80,,58215.75,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,58215.75,80,,58215.75,percent of total billed charges,,7216,,,7216,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,50938.78,70,,50938.78,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1391.89,,,1391.89,Other,New York Medicaid APG methodology,1391.89,,,1391.89,Other,100% New York Medicaid APG,1391.89,,,1391.89,Other,100% New York Medicaid APG,1391.89,,,1391.89,Other,100% New York Medicaid APG,3131.75,,,3131.75,Other,225% New York Medicaid APG,2129.59,,,2129.59,Other,153% New York Medicaid APG,3131.75,,,3131.75,Other,225% New York Medicaid APG,1948.64,,,1948.64,Other,140% New York Medicaid APG,3131.75,,,3131.75,Other,225% New York Medicaid APG,3618.91,,,3618.91,Other,260% New York Medicaid APG,4509.72,,,4509.72,Other,324% New York Medicaid APG,2992.56,,,2992.56,Other,215% New York Medicaid APG,2992.56,,,2992.56,Other,215% New York Medicaid APG,1739.86,,,1739.86,Other,125% New York Medicaid APG,1391.89,58215.75,
Exchange biliary drg cath,47536,CPT,,,,,,,,both,,,22519.57,16664.48,74,,16664.48,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,10133.81,45,,10133.81,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,11147.19,49.5,,11147.19,percent of total billed charges,110% of Medicare,15313.31,68,,15313.31,percent of total billed charges,,2588.91,,,2588.91,Other,186% of Medicaid,18015.66,80,,18015.66,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,18015.66,80,,18015.66,percent of total billed charges,,7216,,,7216,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,15763.7,70,,15763.7,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1391.89,,,1391.89,Other,New York Medicaid APG methodology,1391.89,,,1391.89,Other,100% New York Medicaid APG,1391.89,,,1391.89,Other,100% New York Medicaid APG,1391.89,,,1391.89,Other,100% New York Medicaid APG,3131.75,,,3131.75,Other,225% New York Medicaid APG,2129.59,,,2129.59,Other,153% New York Medicaid APG,3131.75,,,3131.75,Other,225% New York Medicaid APG,1948.64,,,1948.64,Other,140% New York Medicaid APG,3131.75,,,3131.75,Other,225% New York Medicaid APG,3618.91,,,3618.91,Other,260% New York Medicaid APG,4509.72,,,4509.72,Other,324% New York Medicaid APG,2992.56,,,2992.56,Other,215% New York Medicaid APG,2992.56,,,2992.56,Other,215% New York Medicaid APG,1739.86,,,1739.86,Other,125% New York Medicaid APG,1391.89,18015.66,
Removal biliary drg cath,47537,CPT,,,,,,,,both,,,16182.01,11974.69,74,,11974.69,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,7281.9,45,,7281.9,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,8010.09,49.5,,8010.09,percent of total billed charges,110% of Medicare,11003.77,68,,11003.77,percent of total billed charges,,1030.37,,,1030.37,Other,186% of Medicaid,12945.61,80,,12945.61,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,12945.61,80,,12945.61,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,11327.41,70,,11327.41,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,553.96,,,553.96,Other,New York Medicaid APG methodology,553.96,,,553.96,Other,100% New York Medicaid APG,553.96,,,553.96,Other,100% New York Medicaid APG,553.96,,,553.96,Other,100% New York Medicaid APG,1246.41,,,1246.41,Other,225% New York Medicaid APG,847.56,,,847.56,Other,153% New York Medicaid APG,1246.41,,,1246.41,Other,225% New York Medicaid APG,775.55,,,775.55,Other,140% New York Medicaid APG,1246.41,,,1246.41,Other,225% New York Medicaid APG,1440.3,,,1440.3,Other,260% New York Medicaid APG,1794.83,,,1794.83,Other,324% New York Medicaid APG,1191.02,,,1191.02,Other,215% New York Medicaid APG,1191.02,,,1191.02,Other,215% New York Medicaid APG,692.45,,,692.45,Other,125% New York Medicaid APG,553.96,12945.61,
Perq plmt bile duct stent,47538,CPT,,,,,,,,both,,,121364.27,89809.56,74,,89809.56,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,54613.92,45,,54613.92,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,6125,,"100% primary, 50% secondary, 25% supplemental procedure",6125,Other,Blue Cross ASC Grouper,5513,,"100% primary, 50% secondary, 25% supplemental procedure",5513,Other,Blue Cross ASC Grouper,5206,,"100% primary, 50% secondary, 25% supplemental procedure",5206,Other,Blue Cross ASC Grouper,60075.31,49.5,,60075.31,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2588.91,,,2588.91,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,84954.99,70,,84954.99,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,1391.89,,,1391.89,Other,New York Medicaid APG methodology,1391.89,,,1391.89,Other,100% New York Medicaid APG,1391.89,,,1391.89,Other,100% New York Medicaid APG,1391.89,,,1391.89,Other,100% New York Medicaid APG,3131.75,,,3131.75,Other,225% New York Medicaid APG,2129.59,,,2129.59,Other,153% New York Medicaid APG,3131.75,,,3131.75,Other,225% New York Medicaid APG,1948.64,,,1948.64,Other,140% New York Medicaid APG,3131.75,,,3131.75,Other,225% New York Medicaid APG,3618.91,,,3618.91,Other,260% New York Medicaid APG,4509.72,,,4509.72,Other,324% New York Medicaid APG,2992.56,,,2992.56,Other,215% New York Medicaid APG,2992.56,,,2992.56,Other,215% New York Medicaid APG,1739.86,,,1739.86,Other,125% New York Medicaid APG,1391.89,89809.56,
Perq plmt bile duct stent,47539,CPT,,,,,,,,both,,,121364.27,89809.56,74,,89809.56,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,54613.92,45,,54613.92,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,6125,,"100% primary, 50% secondary, 25% supplemental procedure",6125,Other,Blue Cross ASC Grouper,5513,,"100% primary, 50% secondary, 25% supplemental procedure",5513,Other,Blue Cross ASC Grouper,5206,,"100% primary, 50% secondary, 25% supplemental procedure",5206,Other,Blue Cross ASC Grouper,60075.31,49.5,,60075.31,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2588.91,,,2588.91,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,84954.99,70,,84954.99,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,1391.89,,,1391.89,Other,New York Medicaid APG methodology,1391.89,,,1391.89,Other,100% New York Medicaid APG,1391.89,,,1391.89,Other,100% New York Medicaid APG,1391.89,,,1391.89,Other,100% New York Medicaid APG,3131.75,,,3131.75,Other,225% New York Medicaid APG,2129.59,,,2129.59,Other,153% New York Medicaid APG,3131.75,,,3131.75,Other,225% New York Medicaid APG,1948.64,,,1948.64,Other,140% New York Medicaid APG,3131.75,,,3131.75,Other,225% New York Medicaid APG,3618.91,,,3618.91,Other,260% New York Medicaid APG,4509.72,,,4509.72,Other,324% New York Medicaid APG,2992.56,,,2992.56,Other,215% New York Medicaid APG,2992.56,,,2992.56,Other,215% New York Medicaid APG,1739.86,,,1739.86,Other,125% New York Medicaid APG,1391.89,89809.56,
Perq plmt bile duct stent,47540,CPT,,,,,,,,both,,,121364.27,89809.56,74,,89809.56,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,54613.92,45,,54613.92,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,6125,,"100% primary, 50% secondary, 25% supplemental procedure",6125,Other,Blue Cross ASC Grouper,5513,,"100% primary, 50% secondary, 25% supplemental procedure",5513,Other,Blue Cross ASC Grouper,5206,,"100% primary, 50% secondary, 25% supplemental procedure",5206,Other,Blue Cross ASC Grouper,60075.31,49.5,,60075.31,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3989.38,,,3989.38,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,84954.99,70,,84954.99,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,2144.83,,,2144.83,Other,New York Medicaid APG methodology,2144.83,,,2144.83,Other,100% New York Medicaid APG,2144.83,,,2144.83,Other,100% New York Medicaid APG,2144.83,,,2144.83,Other,100% New York Medicaid APG,4825.86,,,4825.86,Other,225% New York Medicaid APG,3281.59,,,3281.59,Other,153% New York Medicaid APG,4825.86,,,4825.86,Other,225% New York Medicaid APG,3002.76,,,3002.76,Other,140% New York Medicaid APG,4825.86,,,4825.86,Other,225% New York Medicaid APG,5576.55,,,5576.55,Other,260% New York Medicaid APG,6949.24,,,6949.24,Other,324% New York Medicaid APG,4611.38,,,4611.38,Other,215% New York Medicaid APG,4611.38,,,4611.38,Other,215% New York Medicaid APG,2681.04,,,2681.04,Other,125% New York Medicaid APG,2144.83,89809.56,
Plmt access bil tree sm bwl,47541,CPT,,,,,,,,both,,,159132.17,117757.81,74,,117757.81,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,71609.48,45,,71609.48,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,78770.42,49.5,,78770.42,percent of total billed charges,110% of Medicare,108209.88,68,,108209.88,percent of total billed charges,,3989.38,,,3989.38,Other,186% of Medicaid,127305.74,80,,127305.74,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,127305.74,80,,127305.74,percent of total billed charges,,7216,,,7216,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,111392.52,70,,111392.52,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,2144.83,,,2144.83,Other,New York Medicaid APG methodology,2144.83,,,2144.83,Other,100% New York Medicaid APG,2144.83,,,2144.83,Other,100% New York Medicaid APG,2144.83,,,2144.83,Other,100% New York Medicaid APG,4825.86,,,4825.86,Other,225% New York Medicaid APG,3281.59,,,3281.59,Other,153% New York Medicaid APG,4825.86,,,4825.86,Other,225% New York Medicaid APG,3002.76,,,3002.76,Other,140% New York Medicaid APG,4825.86,,,4825.86,Other,225% New York Medicaid APG,5576.55,,,5576.55,Other,260% New York Medicaid APG,6949.24,,,6949.24,Other,324% New York Medicaid APG,4611.38,,,4611.38,Other,215% New York Medicaid APG,4611.38,,,4611.38,Other,215% New York Medicaid APG,2681.04,,,2681.04,Other,125% New York Medicaid APG,2144.83,127305.74,
Dilate biliary duct/ampulla,47542,CPT,,,,,,,,both,,,51572.04,38163.31,74,,38163.31,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,23207.42,45,,23207.42,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,25528.16,49.5,,25528.16,percent of total billed charges,110% of Medicare,35068.99,68,,35068.99,percent of total billed charges,,3989.38,,,3989.38,Other,186% of Medicaid,41257.63,80,,41257.63,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,41257.63,80,,41257.63,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,36100.43,70,,36100.43,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,2144.83,,,2144.83,Other,New York Medicaid APG methodology,2144.83,,,2144.83,Other,100% New York Medicaid APG,2144.83,,,2144.83,Other,100% New York Medicaid APG,2144.83,,,2144.83,Other,100% New York Medicaid APG,4825.86,,,4825.86,Other,225% New York Medicaid APG,3281.59,,,3281.59,Other,153% New York Medicaid APG,4825.86,,,4825.86,Other,225% New York Medicaid APG,3002.76,,,3002.76,Other,140% New York Medicaid APG,4825.86,,,4825.86,Other,225% New York Medicaid APG,5576.55,,,5576.55,Other,260% New York Medicaid APG,6949.24,,,6949.24,Other,324% New York Medicaid APG,4611.38,,,4611.38,Other,215% New York Medicaid APG,4611.38,,,4611.38,Other,215% New York Medicaid APG,2681.04,,,2681.04,Other,125% New York Medicaid APG,2053,41257.63,
Endoluminal bx biliary tree,47543,CPT,,,,,,,,both,,,51572.04,38163.31,74,,38163.31,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,23207.42,45,,23207.42,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,25528.16,49.5,,25528.16,percent of total billed charges,110% of Medicare,35068.99,68,,35068.99,percent of total billed charges,,3989.38,,,3989.38,Other,186% of Medicaid,41257.63,80,,41257.63,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,41257.63,80,,41257.63,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,36100.43,70,,36100.43,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,2144.83,,,2144.83,Other,New York Medicaid APG methodology,2144.83,,,2144.83,Other,100% New York Medicaid APG,2144.83,,,2144.83,Other,100% New York Medicaid APG,2144.83,,,2144.83,Other,100% New York Medicaid APG,4825.86,,,4825.86,Other,225% New York Medicaid APG,3281.59,,,3281.59,Other,153% New York Medicaid APG,4825.86,,,4825.86,Other,225% New York Medicaid APG,3002.76,,,3002.76,Other,140% New York Medicaid APG,4825.86,,,4825.86,Other,225% New York Medicaid APG,5576.55,,,5576.55,Other,260% New York Medicaid APG,6949.24,,,6949.24,Other,324% New York Medicaid APG,4611.38,,,4611.38,Other,215% New York Medicaid APG,4611.38,,,4611.38,Other,215% New York Medicaid APG,2681.04,,,2681.04,Other,125% New York Medicaid APG,2053,41257.63,
Removal duct glbldr calculi,47544,CPT,,,,,,,,both,,,51572.04,38163.31,74,,38163.31,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,23207.42,45,,23207.42,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,25528.16,49.5,,25528.16,percent of total billed charges,110% of Medicare,35068.99,68,,35068.99,percent of total billed charges,,3989.38,,,3989.38,Other,186% of Medicaid,41257.63,80,,41257.63,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,41257.63,80,,41257.63,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,36100.43,70,,36100.43,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,2144.83,,,2144.83,Other,New York Medicaid APG methodology,2144.83,,,2144.83,Other,100% New York Medicaid APG,2144.83,,,2144.83,Other,100% New York Medicaid APG,2144.83,,,2144.83,Other,100% New York Medicaid APG,4825.86,,,4825.86,Other,225% New York Medicaid APG,3281.59,,,3281.59,Other,153% New York Medicaid APG,4825.86,,,4825.86,Other,225% New York Medicaid APG,3002.76,,,3002.76,Other,140% New York Medicaid APG,4825.86,,,4825.86,Other,225% New York Medicaid APG,5576.55,,,5576.55,Other,260% New York Medicaid APG,6949.24,,,6949.24,Other,324% New York Medicaid APG,4611.38,,,4611.38,Other,215% New York Medicaid APG,4611.38,,,4611.38,Other,215% New York Medicaid APG,2681.04,,,2681.04,Other,125% New York Medicaid APG,2053,41257.63,
Biliary endo perq dx w/speci,47552,CPT,,,,,,,,both,,,159132.17,117757.81,74,,117757.81,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,71609.48,45,,71609.48,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,78770.42,49.5,,78770.42,percent of total billed charges,110% of Medicare,108209.88,68,,108209.88,percent of total billed charges,,2563.88,,,2563.88,Other,186% of Medicaid,127305.74,80,,127305.74,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,127305.74,80,,127305.74,percent of total billed charges,,7216,,,7216,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,111392.52,70,,111392.52,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1378.43,,,1378.43,Other,New York Medicaid APG methodology,1378.43,,,1378.43,Other,100% New York Medicaid APG,1378.43,,,1378.43,Other,100% New York Medicaid APG,1378.43,,,1378.43,Other,100% New York Medicaid APG,3101.47,,,3101.47,Other,225% New York Medicaid APG,2109,,,2109,Other,153% New York Medicaid APG,3101.47,,,3101.47,Other,225% New York Medicaid APG,1929.81,,,1929.81,Other,140% New York Medicaid APG,3101.47,,,3101.47,Other,225% New York Medicaid APG,3583.92,,,3583.92,Other,260% New York Medicaid APG,4466.12,,,4466.12,Other,324% New York Medicaid APG,2963.63,,,2963.63,Other,215% New York Medicaid APG,2963.63,,,2963.63,Other,215% New York Medicaid APG,1723.04,,,1723.04,Other,125% New York Medicaid APG,1378.43,127305.74,
Biliary endoscopy thru skin,47553,CPT,,,,,,,,both,,,159132.17,117757.81,74,,117757.81,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,71609.48,45,,71609.48,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,78770.42,49.5,,78770.42,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2563.88,,,2563.88,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,111392.52,70,,111392.52,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,1378.43,,,1378.43,Other,New York Medicaid APG methodology,1378.43,,,1378.43,Other,100% New York Medicaid APG,1378.43,,,1378.43,Other,100% New York Medicaid APG,1378.43,,,1378.43,Other,100% New York Medicaid APG,3101.47,,,3101.47,Other,225% New York Medicaid APG,2109,,,2109,Other,153% New York Medicaid APG,3101.47,,,3101.47,Other,225% New York Medicaid APG,1929.81,,,1929.81,Other,140% New York Medicaid APG,3101.47,,,3101.47,Other,225% New York Medicaid APG,3583.92,,,3583.92,Other,260% New York Medicaid APG,4466.12,,,4466.12,Other,324% New York Medicaid APG,2963.63,,,2963.63,Other,215% New York Medicaid APG,2963.63,,,2963.63,Other,215% New York Medicaid APG,1723.04,,,1723.04,Other,125% New York Medicaid APG,1378.43,117757.81,
Biliary endoscopy thru skin,47554,CPT,,,,,,,,both,,,216515.17,160221.23,74,,160221.23,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,97431.83,45,,97431.83,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,6125,,"100% primary, 50% secondary, 25% supplemental procedure",6125,Other,Blue Cross ASC Grouper,5513,,"100% primary, 50% secondary, 25% supplemental procedure",5513,Other,Blue Cross ASC Grouper,5206,,"100% primary, 50% secondary, 25% supplemental procedure",5206,Other,Blue Cross ASC Grouper,107175.01,49.5,,107175.01,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2563.88,,,2563.88,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,151560.62,70,,151560.62,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,1378.43,,,1378.43,Other,New York Medicaid APG methodology,1378.43,,,1378.43,Other,100% New York Medicaid APG,1378.43,,,1378.43,Other,100% New York Medicaid APG,1378.43,,,1378.43,Other,100% New York Medicaid APG,3101.47,,,3101.47,Other,225% New York Medicaid APG,2109,,,2109,Other,153% New York Medicaid APG,3101.47,,,3101.47,Other,225% New York Medicaid APG,1929.81,,,1929.81,Other,140% New York Medicaid APG,3101.47,,,3101.47,Other,225% New York Medicaid APG,3583.92,,,3583.92,Other,260% New York Medicaid APG,4466.12,,,4466.12,Other,324% New York Medicaid APG,2963.63,,,2963.63,Other,215% New York Medicaid APG,2963.63,,,2963.63,Other,215% New York Medicaid APG,1723.04,,,1723.04,Other,125% New York Medicaid APG,1378.43,160221.23,
Biliary endoscopy thru skin,47555,CPT,,,,,,,,both,,,72769.69,53849.57,74,,53849.57,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,32746.36,45,,32746.36,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,36021,49.5,,36021,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2563.88,,,2563.88,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,50938.78,70,,50938.78,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1378.43,,,1378.43,Other,New York Medicaid APG methodology,1378.43,,,1378.43,Other,100% New York Medicaid APG,1378.43,,,1378.43,Other,100% New York Medicaid APG,1378.43,,,1378.43,Other,100% New York Medicaid APG,3101.47,,,3101.47,Other,225% New York Medicaid APG,2109,,,2109,Other,153% New York Medicaid APG,3101.47,,,3101.47,Other,225% New York Medicaid APG,1929.81,,,1929.81,Other,140% New York Medicaid APG,3101.47,,,3101.47,Other,225% New York Medicaid APG,3583.92,,,3583.92,Other,260% New York Medicaid APG,4466.12,,,4466.12,Other,324% New York Medicaid APG,2963.63,,,2963.63,Other,215% New York Medicaid APG,2963.63,,,2963.63,Other,215% New York Medicaid APG,1723.04,,,1723.04,Other,125% New York Medicaid APG,1378.43,53849.57,
Biliary endoscopy thru skin,47556,CPT,,,,,,,,both,,,216515.17,160221.23,74,,160221.23,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,97431.83,45,,97431.83,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,6125,,"100% primary, 50% secondary, 25% supplemental procedure",6125,Other,Blue Cross ASC Grouper,5513,,"100% primary, 50% secondary, 25% supplemental procedure",5513,Other,Blue Cross ASC Grouper,5206,,"100% primary, 50% secondary, 25% supplemental procedure",5206,Other,Blue Cross ASC Grouper,107175.01,49.5,,107175.01,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2563.88,,,2563.88,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,151560.62,70,,151560.62,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,1378.43,,,1378.43,Other,New York Medicaid APG methodology,1378.43,,,1378.43,Other,100% New York Medicaid APG,1378.43,,,1378.43,Other,100% New York Medicaid APG,1378.43,,,1378.43,Other,100% New York Medicaid APG,3101.47,,,3101.47,Other,225% New York Medicaid APG,2109,,,2109,Other,153% New York Medicaid APG,3101.47,,,3101.47,Other,225% New York Medicaid APG,1929.81,,,1929.81,Other,140% New York Medicaid APG,3101.47,,,3101.47,Other,225% New York Medicaid APG,3583.92,,,3583.92,Other,260% New York Medicaid APG,4466.12,,,4466.12,Other,324% New York Medicaid APG,2963.63,,,2963.63,Other,215% New York Medicaid APG,2963.63,,,2963.63,Other,215% New York Medicaid APG,1723.04,,,1723.04,Other,125% New York Medicaid APG,1378.43,160221.23,
Laparoscopic cholecystectomy,47562,CPT,,,,,,,,both,,,39561.06,29275.18,74,,29275.18,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,17802.48,45,,17802.48,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,6125,,"100% primary, 50% secondary, 25% supplemental procedure",6125,Other,Blue Cross ASC Grouper,5513,,"100% primary, 50% secondary, 25% supplemental procedure",5513,Other,Blue Cross ASC Grouper,5206,,"100% primary, 50% secondary, 25% supplemental procedure",5206,Other,Blue Cross ASC Grouper,19582.72,49.5,,19582.72,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,4648.82,,,4648.82,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,27692.74,70,,27692.74,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,2499.37,,,2499.37,Other,New York Medicaid APG methodology,2499.37,,,2499.37,Other,100% New York Medicaid APG,2499.37,,,2499.37,Other,100% New York Medicaid APG,2499.37,,,2499.37,Other,100% New York Medicaid APG,5623.57,,,5623.57,Other,225% New York Medicaid APG,3824.03,,,3824.03,Other,153% New York Medicaid APG,5623.57,,,5623.57,Other,225% New York Medicaid APG,3499.11,,,3499.11,Other,140% New York Medicaid APG,5623.57,,,5623.57,Other,225% New York Medicaid APG,6498.35,,,6498.35,Other,260% New York Medicaid APG,8097.94,,,8097.94,Other,324% New York Medicaid APG,5373.64,,,5373.64,Other,215% New York Medicaid APG,5373.64,,,5373.64,Other,215% New York Medicaid APG,3124.21,,,3124.21,Other,125% New York Medicaid APG,2499.37,29275.18,
Laparo cholecystectomy/graph,47563,CPT,,,,,,,,both,,,39396.88,29153.69,74,,29153.69,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,17728.6,45,,17728.6,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,6125,,"100% primary, 50% secondary, 25% supplemental procedure",6125,Other,Blue Cross ASC Grouper,5513,,"100% primary, 50% secondary, 25% supplemental procedure",5513,Other,Blue Cross ASC Grouper,5206,,"100% primary, 50% secondary, 25% supplemental procedure",5206,Other,Blue Cross ASC Grouper,19501.46,49.5,,19501.46,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,4648.82,,,4648.82,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,27577.82,70,,27577.82,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,2499.37,,,2499.37,Other,New York Medicaid APG methodology,2499.37,,,2499.37,Other,100% New York Medicaid APG,2499.37,,,2499.37,Other,100% New York Medicaid APG,2499.37,,,2499.37,Other,100% New York Medicaid APG,5623.57,,,5623.57,Other,225% New York Medicaid APG,3824.03,,,3824.03,Other,153% New York Medicaid APG,5623.57,,,5623.57,Other,225% New York Medicaid APG,3499.11,,,3499.11,Other,140% New York Medicaid APG,5623.57,,,5623.57,Other,225% New York Medicaid APG,6498.35,,,6498.35,Other,260% New York Medicaid APG,8097.94,,,8097.94,Other,324% New York Medicaid APG,5373.64,,,5373.64,Other,215% New York Medicaid APG,5373.64,,,5373.64,Other,215% New York Medicaid APG,3124.21,,,3124.21,Other,125% New York Medicaid APG,2499.37,29153.69,
Laparo cholecystectomy/explr,47564,CPT,,,,,,,,both,,,216515.17,160221.23,74,,160221.23,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,97431.83,45,,97431.83,percent of total billed charges,Medicare Ratio of cost to charges,5954,,"100% primary, 50% supplemental procedure",5954,Other,Aetna ASC Grouper,5359,,"100% primary, 50% supplemental procedure",5359,Other,Aetna ASC Grouper,6125,,"100% primary, 50% secondary, 25% supplemental procedure",6125,Other,Blue Cross ASC Grouper,5513,,"100% primary, 50% secondary, 25% supplemental procedure",5513,Other,Blue Cross ASC Grouper,5206,,"100% primary, 50% secondary, 25% supplemental procedure",5206,Other,Blue Cross ASC Grouper,107175.01,49.5,,107175.01,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,4648.82,,,4648.82,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,151560.62,70,,151560.62,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,2499.37,,,2499.37,Other,New York Medicaid APG methodology,2499.37,,,2499.37,Other,100% New York Medicaid APG,2499.37,,,2499.37,Other,100% New York Medicaid APG,2499.37,,,2499.37,Other,100% New York Medicaid APG,5623.57,,,5623.57,Other,225% New York Medicaid APG,3824.03,,,3824.03,Other,153% New York Medicaid APG,5623.57,,,5623.57,Other,225% New York Medicaid APG,3499.11,,,3499.11,Other,140% New York Medicaid APG,5623.57,,,5623.57,Other,225% New York Medicaid APG,6498.35,,,6498.35,Other,260% New York Medicaid APG,8097.94,,,8097.94,Other,324% New York Medicaid APG,5373.64,,,5373.64,Other,215% New York Medicaid APG,5373.64,,,5373.64,Other,215% New York Medicaid APG,3124.21,,,3124.21,Other,125% New York Medicaid APG,2499.37,160221.23,
Needle biopsy pancreas,48102,CPT,,,,,,,,both,,,34101.75,25235.3,74,,25235.3,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15345.79,45,,15345.79,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,16880.37,49.5,,16880.37,percent of total billed charges,110% of Medicare,23189.19,68,,23189.19,percent of total billed charges,,1196.64,,,1196.64,Other,186% of Medicaid,27281.4,80,,27281.4,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,27281.4,80,,27281.4,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,23871.23,70,,23871.23,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,643.35,,,643.35,Other,New York Medicaid APG methodology,643.35,,,643.35,Other,100% New York Medicaid APG,643.35,,,643.35,Other,100% New York Medicaid APG,643.35,,,643.35,Other,100% New York Medicaid APG,1447.55,,,1447.55,Other,225% New York Medicaid APG,984.33,,,984.33,Other,153% New York Medicaid APG,1447.55,,,1447.55,Other,225% New York Medicaid APG,900.7,,,900.7,Other,140% New York Medicaid APG,1447.55,,,1447.55,Other,225% New York Medicaid APG,1672.72,,,1672.72,Other,260% New York Medicaid APG,2084.47,,,2084.47,Other,324% New York Medicaid APG,1383.21,,,1383.21,Other,215% New York Medicaid APG,1383.21,,,1383.21,Other,215% New York Medicaid APG,804.19,,,804.19,Other,125% New York Medicaid APG,643.35,27281.4,
Abd paracentesis,49082,CPT,,,,,,,,both,,,19066.74,14109.39,74,,14109.39,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,8580.03,45,,8580.03,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,9438.04,49.5,,9438.04,percent of total billed charges,110% of Medicare,12965.38,68,,12965.38,percent of total billed charges,,1196.64,,,1196.64,Other,186% of Medicaid,15253.39,80,,15253.39,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,15253.39,80,,15253.39,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,13346.72,70,,13346.72,percent of total billed charges,,354.24,,,354.24,Fee Schedule,,300.24,,,300.24,Fee Schedule,,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,643.35,,,643.35,Other,New York Medicaid APG methodology,643.35,,,643.35,Other,100% New York Medicaid APG,643.35,,,643.35,Other,100% New York Medicaid APG,643.35,,,643.35,Other,100% New York Medicaid APG,1447.55,,,1447.55,Other,225% New York Medicaid APG,984.33,,,984.33,Other,153% New York Medicaid APG,1447.55,,,1447.55,Other,225% New York Medicaid APG,900.7,,,900.7,Other,140% New York Medicaid APG,1447.55,,,1447.55,Other,225% New York Medicaid APG,1672.72,,,1672.72,Other,260% New York Medicaid APG,2084.47,,,2084.47,Other,324% New York Medicaid APG,1383.21,,,1383.21,Other,215% New York Medicaid APG,1383.21,,,1383.21,Other,215% New York Medicaid APG,804.19,,,804.19,Other,125% New York Medicaid APG,300.24,15253.39,
Abd paracentesis w/imaging,49083,CPT,,,,,,,,both,,,22401.51,16577.12,74,,16577.12,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,10080.68,45,,10080.68,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,11088.75,49.5,,11088.75,percent of total billed charges,110% of Medicare,15233.03,68,,15233.03,percent of total billed charges,,1196.64,,,1196.64,Other,186% of Medicaid,17921.21,80,,17921.21,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,17921.21,80,,17921.21,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,15681.06,70,,15681.06,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,643.35,,,643.35,Other,New York Medicaid APG methodology,643.35,,,643.35,Other,100% New York Medicaid APG,643.35,,,643.35,Other,100% New York Medicaid APG,643.35,,,643.35,Other,100% New York Medicaid APG,1447.55,,,1447.55,Other,225% New York Medicaid APG,984.33,,,984.33,Other,153% New York Medicaid APG,1447.55,,,1447.55,Other,225% New York Medicaid APG,900.7,,,900.7,Other,140% New York Medicaid APG,1447.55,,,1447.55,Other,225% New York Medicaid APG,1672.72,,,1672.72,Other,260% New York Medicaid APG,2084.47,,,2084.47,Other,324% New York Medicaid APG,1383.21,,,1383.21,Other,215% New York Medicaid APG,1383.21,,,1383.21,Other,215% New York Medicaid APG,804.19,,,804.19,Other,125% New York Medicaid APG,643.35,17921.21,
Peritoneal lavage,49084,CPT,,,,,,,,both,,,19066.74,14109.39,74,,14109.39,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,8580.03,45,,8580.03,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,9438.04,49.5,,9438.04,percent of total billed charges,110% of Medicare,12965.38,68,,12965.38,percent of total billed charges,,1196.64,,,1196.64,Other,186% of Medicaid,15253.39,80,,15253.39,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,15253.39,80,,15253.39,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,13346.72,70,,13346.72,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,643.35,,,643.35,Other,New York Medicaid APG methodology,643.35,,,643.35,Other,100% New York Medicaid APG,643.35,,,643.35,Other,100% New York Medicaid APG,643.35,,,643.35,Other,100% New York Medicaid APG,1447.55,,,1447.55,Other,225% New York Medicaid APG,984.33,,,984.33,Other,153% New York Medicaid APG,1447.55,,,1447.55,Other,225% New York Medicaid APG,900.7,,,900.7,Other,140% New York Medicaid APG,1447.55,,,1447.55,Other,225% New York Medicaid APG,1672.72,,,1672.72,Other,260% New York Medicaid APG,2084.47,,,2084.47,Other,324% New York Medicaid APG,1383.21,,,1383.21,Other,215% New York Medicaid APG,1383.21,,,1383.21,Other,215% New York Medicaid APG,804.19,,,804.19,Other,125% New York Medicaid APG,643.35,15253.39,
Biopsy abdominal mass,49180,CPT,,,,,,,,both,,,39815.4,29463.4,74,,29463.4,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,17916.93,45,,17916.93,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,19708.62,49.5,,19708.62,percent of total billed charges,110% of Medicare,27074.47,68,,27074.47,percent of total billed charges,,1196.64,,,1196.64,Other,186% of Medicaid,31852.32,80,,31852.32,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,31852.32,80,,31852.32,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,27870.78,70,,27870.78,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,643.35,,,643.35,Other,New York Medicaid APG methodology,643.35,,,643.35,Other,100% New York Medicaid APG,643.35,,,643.35,Other,100% New York Medicaid APG,643.35,,,643.35,Other,100% New York Medicaid APG,1447.55,,,1447.55,Other,225% New York Medicaid APG,984.33,,,984.33,Other,153% New York Medicaid APG,1447.55,,,1447.55,Other,225% New York Medicaid APG,900.7,,,900.7,Other,140% New York Medicaid APG,1447.55,,,1447.55,Other,225% New York Medicaid APG,1672.72,,,1672.72,Other,260% New York Medicaid APG,2084.47,,,2084.47,Other,324% New York Medicaid APG,1383.21,,,1383.21,Other,215% New York Medicaid APG,1383.21,,,1383.21,Other,215% New York Medicaid APG,804.19,,,804.19,Other,125% New York Medicaid APG,643.35,31852.32,
Sclerotx fluid collection,49185,CPT,,,,,,,,both,,,36148.51,26749.9,74,,26749.9,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,16266.83,45,,16266.83,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,17893.51,49.5,,17893.51,percent of total billed charges,110% of Medicare,24580.99,68,,24580.99,percent of total billed charges,,1196.64,,,1196.64,Other,186% of Medicaid,28918.81,80,,28918.81,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,28918.81,80,,28918.81,percent of total billed charges,,7216,,,7216,Case Rate,,3578,,"100% primary, 0% secondary procedures",3578,Other,MagnaCare ASC Grouper,25303.96,70,,25303.96,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,643.35,,,643.35,Other,New York Medicaid APG methodology,643.35,,,643.35,Other,100% New York Medicaid APG,643.35,,,643.35,Other,100% New York Medicaid APG,643.35,,,643.35,Other,100% New York Medicaid APG,1447.55,,,1447.55,Other,225% New York Medicaid APG,984.33,,,984.33,Other,153% New York Medicaid APG,1447.55,,,1447.55,Other,225% New York Medicaid APG,900.7,,,900.7,Other,140% New York Medicaid APG,1447.55,,,1447.55,Other,225% New York Medicaid APG,1672.72,,,1672.72,Other,260% New York Medicaid APG,2084.47,,,2084.47,Other,324% New York Medicaid APG,1383.21,,,1383.21,Other,215% New York Medicaid APG,1383.21,,,1383.21,Other,215% New York Medicaid APG,804.19,,,804.19,Other,125% New York Medicaid APG,643.35,28918.81,
Excision of umbilicus,49250,CPT,,,,,,,,both,,,35159.27,26017.86,74,,26017.86,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15821.67,45,,15821.67,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,17403.84,49.5,,17403.84,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3639.33,,,3639.33,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,24611.49,70,,24611.49,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1956.63,,,1956.63,Other,New York Medicaid APG methodology,1956.63,,,1956.63,Other,100% New York Medicaid APG,1956.63,,,1956.63,Other,100% New York Medicaid APG,1956.63,,,1956.63,Other,100% New York Medicaid APG,4402.42,,,4402.42,Other,225% New York Medicaid APG,2993.64,,,2993.64,Other,153% New York Medicaid APG,4402.42,,,4402.42,Other,225% New York Medicaid APG,2739.28,,,2739.28,Other,140% New York Medicaid APG,4402.42,,,4402.42,Other,225% New York Medicaid APG,5087.24,,,5087.24,Other,260% New York Medicaid APG,6339.48,,,6339.48,Other,324% New York Medicaid APG,4206.75,,,4206.75,Other,215% New York Medicaid APG,4206.75,,,4206.75,Other,215% New York Medicaid APG,2445.79,,,2445.79,Other,125% New York Medicaid APG,1956.63,26017.86,
Diag laparo separate proc,49320,CPT,,,,,,,,both,,,41980.23,31065.37,74,,31065.37,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,18891.1,45,,18891.1,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,6125,,"100% primary, 50% secondary, 25% supplemental procedure",6125,Other,Blue Cross ASC Grouper,5513,,"100% primary, 50% secondary, 25% supplemental procedure",5513,Other,Blue Cross ASC Grouper,5206,,"100% primary, 50% secondary, 25% supplemental procedure",5206,Other,Blue Cross ASC Grouper,20780.21,49.5,,20780.21,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3632.62,,,3632.62,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,29386.16,70,,29386.16,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,1953.02,,,1953.02,Other,New York Medicaid APG methodology,1953.02,,,1953.02,Other,100% New York Medicaid APG,1953.02,,,1953.02,Other,100% New York Medicaid APG,1953.02,,,1953.02,Other,100% New York Medicaid APG,4394.3,,,4394.3,Other,225% New York Medicaid APG,2988.12,,,2988.12,Other,153% New York Medicaid APG,4394.3,,,4394.3,Other,225% New York Medicaid APG,2734.23,,,2734.23,Other,140% New York Medicaid APG,4394.3,,,4394.3,Other,225% New York Medicaid APG,5077.86,,,5077.86,Other,260% New York Medicaid APG,6327.79,,,6327.79,Other,324% New York Medicaid APG,4199,,,4199,Other,215% New York Medicaid APG,4199,,,4199,Other,215% New York Medicaid APG,2441.28,,,2441.28,Other,125% New York Medicaid APG,1953.02,31065.37,
Laparoscopy biopsy,49321,CPT,,,,,,,,both,,,47480.52,35135.58,74,,35135.58,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,21366.23,45,,21366.23,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,6125,,"100% primary, 50% secondary, 25% supplemental procedure",6125,Other,Blue Cross ASC Grouper,5513,,"100% primary, 50% secondary, 25% supplemental procedure",5513,Other,Blue Cross ASC Grouper,5206,,"100% primary, 50% secondary, 25% supplemental procedure",5206,Other,Blue Cross ASC Grouper,23502.86,49.5,,23502.86,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3632.62,,,3632.62,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,33236.36,70,,33236.36,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,1953.02,,,1953.02,Other,New York Medicaid APG methodology,1953.02,,,1953.02,Other,100% New York Medicaid APG,1953.02,,,1953.02,Other,100% New York Medicaid APG,1953.02,,,1953.02,Other,100% New York Medicaid APG,4394.3,,,4394.3,Other,225% New York Medicaid APG,2988.12,,,2988.12,Other,153% New York Medicaid APG,4394.3,,,4394.3,Other,225% New York Medicaid APG,2734.23,,,2734.23,Other,140% New York Medicaid APG,4394.3,,,4394.3,Other,225% New York Medicaid APG,5077.86,,,5077.86,Other,260% New York Medicaid APG,6327.79,,,6327.79,Other,324% New York Medicaid APG,4199,,,4199,Other,215% New York Medicaid APG,4199,,,4199,Other,215% New York Medicaid APG,2441.28,,,2441.28,Other,125% New York Medicaid APG,1953.02,35135.58,
Laparoscopy aspiration,49322,CPT,,,,,,,,both,,,121364.27,89809.56,74,,89809.56,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,54613.92,45,,54613.92,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,6125,,"100% primary, 50% secondary, 25% supplemental procedure",6125,Other,Blue Cross ASC Grouper,5513,,"100% primary, 50% secondary, 25% supplemental procedure",5513,Other,Blue Cross ASC Grouper,5206,,"100% primary, 50% secondary, 25% supplemental procedure",5206,Other,Blue Cross ASC Grouper,60075.31,49.5,,60075.31,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3632.62,,,3632.62,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,84954.99,70,,84954.99,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,1953.02,,,1953.02,Other,New York Medicaid APG methodology,1953.02,,,1953.02,Other,100% New York Medicaid APG,1953.02,,,1953.02,Other,100% New York Medicaid APG,1953.02,,,1953.02,Other,100% New York Medicaid APG,4394.3,,,4394.3,Other,225% New York Medicaid APG,2988.12,,,2988.12,Other,153% New York Medicaid APG,4394.3,,,4394.3,Other,225% New York Medicaid APG,2734.23,,,2734.23,Other,140% New York Medicaid APG,4394.3,,,4394.3,Other,225% New York Medicaid APG,5077.86,,,5077.86,Other,260% New York Medicaid APG,6327.79,,,6327.79,Other,324% New York Medicaid APG,4199,,,4199,Other,215% New York Medicaid APG,4199,,,4199,Other,215% New York Medicaid APG,2441.28,,,2441.28,Other,125% New York Medicaid APG,1953.02,89809.56,
Laparo drain lymphocele,49323,CPT,,,,,,,,both,,,121364.27,89809.56,74,,89809.56,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,54613.92,45,,54613.92,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,6125,,"100% primary, 50% secondary, 25% supplemental procedure",6125,Other,Blue Cross ASC Grouper,5513,,"100% primary, 50% secondary, 25% supplemental procedure",5513,Other,Blue Cross ASC Grouper,5206,,"100% primary, 50% secondary, 25% supplemental procedure",5206,Other,Blue Cross ASC Grouper,60075.31,49.5,,60075.31,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3632.62,,,3632.62,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,84954.99,70,,84954.99,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,1953.02,,,1953.02,Other,New York Medicaid APG methodology,1953.02,,,1953.02,Other,100% New York Medicaid APG,1953.02,,,1953.02,Other,100% New York Medicaid APG,1953.02,,,1953.02,Other,100% New York Medicaid APG,4394.3,,,4394.3,Other,225% New York Medicaid APG,2988.12,,,2988.12,Other,153% New York Medicaid APG,4394.3,,,4394.3,Other,225% New York Medicaid APG,2734.23,,,2734.23,Other,140% New York Medicaid APG,4394.3,,,4394.3,Other,225% New York Medicaid APG,5077.86,,,5077.86,Other,260% New York Medicaid APG,6327.79,,,6327.79,Other,324% New York Medicaid APG,4199,,,4199,Other,215% New York Medicaid APG,4199,,,4199,Other,215% New York Medicaid APG,2441.28,,,2441.28,Other,125% New York Medicaid APG,1953.02,89809.56,
Lap insert tunnel ip cath,49324,CPT,,,,,,,,both,,,40853.43,30231.54,74,,30231.54,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,18384.04,45,,18384.04,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,6125,,"100% primary, 50% secondary, 25% supplemental procedure",6125,Other,Blue Cross ASC Grouper,5513,,"100% primary, 50% secondary, 25% supplemental procedure",5513,Other,Blue Cross ASC Grouper,5206,,"100% primary, 50% secondary, 25% supplemental procedure",5206,Other,Blue Cross ASC Grouper,20222.45,49.5,,20222.45,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3632.62,,,3632.62,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,28597.4,70,,28597.4,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,1953.02,,,1953.02,Other,New York Medicaid APG methodology,1953.02,,,1953.02,Other,100% New York Medicaid APG,1953.02,,,1953.02,Other,100% New York Medicaid APG,1953.02,,,1953.02,Other,100% New York Medicaid APG,4394.3,,,4394.3,Other,225% New York Medicaid APG,2988.12,,,2988.12,Other,153% New York Medicaid APG,4394.3,,,4394.3,Other,225% New York Medicaid APG,2734.23,,,2734.23,Other,140% New York Medicaid APG,4394.3,,,4394.3,Other,225% New York Medicaid APG,5077.86,,,5077.86,Other,260% New York Medicaid APG,6327.79,,,6327.79,Other,324% New York Medicaid APG,4199,,,4199,Other,215% New York Medicaid APG,4199,,,4199,Other,215% New York Medicaid APG,2441.28,,,2441.28,Other,125% New York Medicaid APG,1953.02,30231.54,
Lap revision perm ip cath,49325,CPT,,,,,,,,both,,,121364.27,89809.56,74,,89809.56,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,54613.92,45,,54613.92,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,6125,,"100% primary, 50% secondary, 25% supplemental procedure",6125,Other,Blue Cross ASC Grouper,5513,,"100% primary, 50% secondary, 25% supplemental procedure",5513,Other,Blue Cross ASC Grouper,5206,,"100% primary, 50% secondary, 25% supplemental procedure",5206,Other,Blue Cross ASC Grouper,60075.31,49.5,,60075.31,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3632.62,,,3632.62,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,84954.99,70,,84954.99,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,1953.02,,,1953.02,Other,New York Medicaid APG methodology,1953.02,,,1953.02,Other,100% New York Medicaid APG,1953.02,,,1953.02,Other,100% New York Medicaid APG,1953.02,,,1953.02,Other,100% New York Medicaid APG,4394.3,,,4394.3,Other,225% New York Medicaid APG,2988.12,,,2988.12,Other,153% New York Medicaid APG,4394.3,,,4394.3,Other,225% New York Medicaid APG,2734.23,,,2734.23,Other,140% New York Medicaid APG,4394.3,,,4394.3,Other,225% New York Medicaid APG,5077.86,,,5077.86,Other,260% New York Medicaid APG,6327.79,,,6327.79,Other,324% New York Medicaid APG,4199,,,4199,Other,215% New York Medicaid APG,4199,,,4199,Other,215% New York Medicaid APG,2441.28,,,2441.28,Other,125% New York Medicaid APG,1953.02,89809.56,
Lap w/omentopexy add-on,49326,CPT,,,,,,,,both,,,83504,61792.96,74,,61792.96,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,37576.8,45,,37576.8,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,41334.48,49.5,,41334.48,percent of total billed charges,110% of Medicare,56782.72,68,,56782.72,percent of total billed charges,,3632.62,,,3632.62,Other,186% of Medicaid,66803.2,80,,66803.2,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,66803.2,80,,66803.2,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,58452.8,70,,58452.8,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,1953.02,,,1953.02,Other,New York Medicaid APG methodology,1953.02,,,1953.02,Other,100% New York Medicaid APG,1953.02,,,1953.02,Other,100% New York Medicaid APG,1953.02,,,1953.02,Other,100% New York Medicaid APG,4394.3,,,4394.3,Other,225% New York Medicaid APG,2988.12,,,2988.12,Other,153% New York Medicaid APG,4394.3,,,4394.3,Other,225% New York Medicaid APG,2734.23,,,2734.23,Other,140% New York Medicaid APG,4394.3,,,4394.3,Other,225% New York Medicaid APG,5077.86,,,5077.86,Other,260% New York Medicaid APG,6327.79,,,6327.79,Other,324% New York Medicaid APG,4199,,,4199,Other,215% New York Medicaid APG,4199,,,4199,Other,215% New York Medicaid APG,2441.28,,,2441.28,Other,125% New York Medicaid APG,1953.02,66803.2,
Lap ins device for rt,49327,CPT,,,,,,,,both,,,98219.64,72682.53,74,,72682.53,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,44198.84,45,,44198.84,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,48618.72,49.5,,48618.72,percent of total billed charges,110% of Medicare,66789.36,68,,66789.36,percent of total billed charges,,0.02,,,0.02,Other,186% of Medicaid,78575.71,80,,78575.71,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,78575.71,80,,78575.71,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,68753.75,70,,68753.75,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% New York Medicaid APG,0.01,,,0.01,Other,100% New York Medicaid APG,0.01,,,0.01,Other,100% New York Medicaid APG,0.02,,,0.02,Other,225% New York Medicaid APG,0.02,,,0.02,Other,153% New York Medicaid APG,0.02,,,0.02,Other,225% New York Medicaid APG,0.01,,,0.01,Other,140% New York Medicaid APG,0.02,,,0.02,Other,225% New York Medicaid APG,0.03,,,0.03,Other,260% New York Medicaid APG,0.03,,,0.03,Other,324% New York Medicaid APG,0.02,,,0.02,Other,215% New York Medicaid APG,0.02,,,0.02,Other,215% New York Medicaid APG,0.01,,,0.01,Other,125% New York Medicaid APG,0.01,78575.71,
Air injection into abdomen,49400,CPT,,,,,,,,both,,,32432.1,23999.75,74,,23999.75,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,14594.45,45,,14594.45,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,16053.89,49.5,,16053.89,percent of total billed charges,110% of Medicare,22053.83,68,,22053.83,percent of total billed charges,,966.93,,,966.93,Other,186% of Medicaid,25945.68,80,,25945.68,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,25945.68,80,,25945.68,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,22702.47,70,,22702.47,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,519.86,,,519.86,Other,New York Medicaid APG methodology,519.86,,,519.86,Other,100% New York Medicaid APG,519.86,,,519.86,Other,100% New York Medicaid APG,519.86,,,519.86,Other,100% New York Medicaid APG,1169.68,,,1169.68,Other,225% New York Medicaid APG,795.38,,,795.38,Other,153% New York Medicaid APG,1169.68,,,1169.68,Other,225% New York Medicaid APG,727.8,,,727.8,Other,140% New York Medicaid APG,1169.68,,,1169.68,Other,225% New York Medicaid APG,1351.62,,,1351.62,Other,260% New York Medicaid APG,1684.33,,,1684.33,Other,324% New York Medicaid APG,1117.69,,,1117.69,Other,215% New York Medicaid APG,1117.69,,,1117.69,Other,215% New York Medicaid APG,649.82,,,649.82,Other,125% New York Medicaid APG,519.86,25945.68,
Remove foreign body adbomen,49402,CPT,,,,,,,,both,,,72769.69,53849.57,74,,53849.57,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,32746.36,45,,32746.36,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,36021,49.5,,36021,percent of total billed charges,110% of Medicare,49483.39,68,,49483.39,percent of total billed charges,,3632.62,,,3632.62,Other,186% of Medicaid,58215.75,80,,58215.75,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,58215.75,80,,58215.75,percent of total billed charges,,7216,,,7216,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,50938.78,70,,50938.78,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1953.02,,,1953.02,Other,New York Medicaid APG methodology,1953.02,,,1953.02,Other,100% New York Medicaid APG,1953.02,,,1953.02,Other,100% New York Medicaid APG,1953.02,,,1953.02,Other,100% New York Medicaid APG,4394.3,,,4394.3,Other,225% New York Medicaid APG,2988.12,,,2988.12,Other,153% New York Medicaid APG,4394.3,,,4394.3,Other,225% New York Medicaid APG,2734.23,,,2734.23,Other,140% New York Medicaid APG,4394.3,,,4394.3,Other,225% New York Medicaid APG,5077.86,,,5077.86,Other,260% New York Medicaid APG,6327.79,,,6327.79,Other,324% New York Medicaid APG,4199,,,4199,Other,215% New York Medicaid APG,4199,,,4199,Other,215% New York Medicaid APG,2441.28,,,2441.28,Other,125% New York Medicaid APG,1953.02,58215.75,
Image cath fluid colxn visc,49405,CPT,,,,,,,,both,,,12479.89,9235.12,74,,9235.12,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,5615.95,45,,5615.95,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,6177.55,49.5,,6177.55,percent of total billed charges,110% of Medicare,8486.33,68,,8486.33,percent of total billed charges,,1196.64,,,1196.64,Other,186% of Medicaid,9983.91,80,,9983.91,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,9983.91,80,,9983.91,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,8735.92,70,,8735.92,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,643.35,,,643.35,Other,New York Medicaid APG methodology,643.35,,,643.35,Other,100% New York Medicaid APG,643.35,,,643.35,Other,100% New York Medicaid APG,643.35,,,643.35,Other,100% New York Medicaid APG,1447.55,,,1447.55,Other,225% New York Medicaid APG,984.33,,,984.33,Other,153% New York Medicaid APG,1447.55,,,1447.55,Other,225% New York Medicaid APG,900.7,,,900.7,Other,140% New York Medicaid APG,1447.55,,,1447.55,Other,225% New York Medicaid APG,1672.72,,,1672.72,Other,260% New York Medicaid APG,2084.47,,,2084.47,Other,324% New York Medicaid APG,1383.21,,,1383.21,Other,215% New York Medicaid APG,1383.21,,,1383.21,Other,215% New York Medicaid APG,804.19,,,804.19,Other,125% New York Medicaid APG,643.35,9983.91,
Image cath fluid peri/retro,49406,CPT,,,,,,,,both,,,13910.07,10293.45,74,,10293.45,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,6259.53,45,,6259.53,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,6885.48,49.5,,6885.48,percent of total billed charges,110% of Medicare,9458.85,68,,9458.85,percent of total billed charges,,1196.64,,,1196.64,Other,186% of Medicaid,11128.06,80,,11128.06,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,11128.06,80,,11128.06,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,9737.05,70,,9737.05,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,643.35,,,643.35,Other,New York Medicaid APG methodology,643.35,,,643.35,Other,100% New York Medicaid APG,643.35,,,643.35,Other,100% New York Medicaid APG,643.35,,,643.35,Other,100% New York Medicaid APG,1447.55,,,1447.55,Other,225% New York Medicaid APG,984.33,,,984.33,Other,153% New York Medicaid APG,1447.55,,,1447.55,Other,225% New York Medicaid APG,900.7,,,900.7,Other,140% New York Medicaid APG,1447.55,,,1447.55,Other,225% New York Medicaid APG,1672.72,,,1672.72,Other,260% New York Medicaid APG,2084.47,,,2084.47,Other,324% New York Medicaid APG,1383.21,,,1383.21,Other,215% New York Medicaid APG,1383.21,,,1383.21,Other,215% New York Medicaid APG,804.19,,,804.19,Other,125% New York Medicaid APG,643.35,11128.06,
Image cath fluid trns/vgnl,49407,CPT,,,,,,,,both,,,34101.75,25235.3,74,,25235.3,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15345.79,45,,15345.79,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,16880.37,49.5,,16880.37,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,1196.64,,,1196.64,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,23871.23,70,,23871.23,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,643.35,,,643.35,Other,New York Medicaid APG methodology,643.35,,,643.35,Other,100% New York Medicaid APG,643.35,,,643.35,Other,100% New York Medicaid APG,643.35,,,643.35,Other,100% New York Medicaid APG,1447.55,,,1447.55,Other,225% New York Medicaid APG,984.33,,,984.33,Other,153% New York Medicaid APG,1447.55,,,1447.55,Other,225% New York Medicaid APG,900.7,,,900.7,Other,140% New York Medicaid APG,1447.55,,,1447.55,Other,225% New York Medicaid APG,1672.72,,,1672.72,Other,260% New York Medicaid APG,2084.47,,,2084.47,Other,324% New York Medicaid APG,1383.21,,,1383.21,Other,215% New York Medicaid APG,1383.21,,,1383.21,Other,215% New York Medicaid APG,804.19,,,804.19,Other,125% New York Medicaid APG,643.35,25235.3,
Ins mark abd/pel for rt perq,49411,CPT,,,,,,,,both,,,29144.83,21567.17,74,,21567.17,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,13115.17,45,,13115.17,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,14426.69,49.5,,14426.69,percent of total billed charges,110% of Medicare,19818.48,68,,19818.48,percent of total billed charges,,479.66,,,479.66,Other,186% of Medicaid,23315.86,80,,23315.86,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,23315.86,80,,23315.86,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,20401.38,70,,20401.38,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,257.88,,,257.88,Other,New York Medicaid APG methodology,257.88,,,257.88,Other,100% New York Medicaid APG,257.88,,,257.88,Other,100% New York Medicaid APG,257.88,,,257.88,Other,100% New York Medicaid APG,580.23,,,580.23,Other,225% New York Medicaid APG,394.56,,,394.56,Other,153% New York Medicaid APG,580.23,,,580.23,Other,225% New York Medicaid APG,361.03,,,361.03,Other,140% New York Medicaid APG,580.23,,,580.23,Other,225% New York Medicaid APG,670.49,,,670.49,Other,260% New York Medicaid APG,835.53,,,835.53,Other,324% New York Medicaid APG,554.44,,,554.44,Other,215% New York Medicaid APG,554.44,,,554.44,Other,215% New York Medicaid APG,322.35,,,322.35,Other,125% New York Medicaid APG,257.88,23315.86,
Insert tun ip cath perc,49418,CPT,,,,,,,,both,,,26173,19368.02,74,,19368.02,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,11777.85,45,,11777.85,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,12955.64,49.5,,12955.64,percent of total billed charges,110% of Medicare,17797.64,68,,17797.64,percent of total billed charges,,3632.62,,,3632.62,Other,186% of Medicaid,20938.4,80,,20938.4,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,20938.4,80,,20938.4,percent of total billed charges,,7216,,,7216,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,18321.1,70,,18321.1,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1953.02,,,1953.02,Other,New York Medicaid APG methodology,1953.02,,,1953.02,Other,100% New York Medicaid APG,1953.02,,,1953.02,Other,100% New York Medicaid APG,1953.02,,,1953.02,Other,100% New York Medicaid APG,4394.3,,,4394.3,Other,225% New York Medicaid APG,2988.12,,,2988.12,Other,153% New York Medicaid APG,4394.3,,,4394.3,Other,225% New York Medicaid APG,2734.23,,,2734.23,Other,140% New York Medicaid APG,4394.3,,,4394.3,Other,225% New York Medicaid APG,5077.86,,,5077.86,Other,260% New York Medicaid APG,6327.79,,,6327.79,Other,324% New York Medicaid APG,4199,,,4199,Other,215% New York Medicaid APG,4199,,,4199,Other,215% New York Medicaid APG,2441.28,,,2441.28,Other,125% New York Medicaid APG,1953.02,20938.4,
Insert tun ip cath w/port,49419,CPT,,,,,,,,both,,,115587.67,85534.88,74,,85534.88,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,52014.45,45,,52014.45,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,57215.9,49.5,,57215.9,percent of total billed charges,110% of Medicare,78599.62,68,,78599.62,percent of total billed charges,,3632.62,,,3632.62,Other,186% of Medicaid,92470.14,80,,92470.14,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,92470.14,80,,92470.14,percent of total billed charges,,7216,,,7216,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,80911.37,70,,80911.37,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,1953.02,,,1953.02,Other,New York Medicaid APG methodology,1953.02,,,1953.02,Other,100% New York Medicaid APG,1953.02,,,1953.02,Other,100% New York Medicaid APG,1953.02,,,1953.02,Other,100% New York Medicaid APG,4394.3,,,4394.3,Other,225% New York Medicaid APG,2988.12,,,2988.12,Other,153% New York Medicaid APG,4394.3,,,4394.3,Other,225% New York Medicaid APG,2734.23,,,2734.23,Other,140% New York Medicaid APG,4394.3,,,4394.3,Other,225% New York Medicaid APG,5077.86,,,5077.86,Other,260% New York Medicaid APG,6327.79,,,6327.79,Other,324% New York Medicaid APG,4199,,,4199,Other,215% New York Medicaid APG,4199,,,4199,Other,215% New York Medicaid APG,2441.28,,,2441.28,Other,125% New York Medicaid APG,1953.02,92470.14,
Ins tun ip cath for dial opn,49421,CPT,,,,,,,,both,,,72769.69,53849.57,74,,53849.57,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,32746.36,45,,32746.36,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,36021,49.5,,36021,percent of total billed charges,110% of Medicare,49483.39,68,,49483.39,percent of total billed charges,,3632.62,,,3632.62,Other,186% of Medicaid,58215.75,80,,58215.75,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,58215.75,80,,58215.75,percent of total billed charges,,7216,,,7216,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,50938.78,70,,50938.78,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1953.02,,,1953.02,Other,New York Medicaid APG methodology,1953.02,,,1953.02,Other,100% New York Medicaid APG,1953.02,,,1953.02,Other,100% New York Medicaid APG,1953.02,,,1953.02,Other,100% New York Medicaid APG,4394.3,,,4394.3,Other,225% New York Medicaid APG,2988.12,,,2988.12,Other,153% New York Medicaid APG,4394.3,,,4394.3,Other,225% New York Medicaid APG,2734.23,,,2734.23,Other,140% New York Medicaid APG,4394.3,,,4394.3,Other,225% New York Medicaid APG,5077.86,,,5077.86,Other,260% New York Medicaid APG,6327.79,,,6327.79,Other,324% New York Medicaid APG,4199,,,4199,Other,215% New York Medicaid APG,4199,,,4199,Other,215% New York Medicaid APG,2441.28,,,2441.28,Other,125% New York Medicaid APG,1953.02,58215.75,
Remove tunneled ip cath,49422,CPT,,,,,,,,both,,,34083.58,25221.85,74,,25221.85,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15337.61,45,,15337.61,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,16871.37,49.5,,16871.37,percent of total billed charges,110% of Medicare,23176.83,68,,23176.83,percent of total billed charges,,1196.64,,,1196.64,Other,186% of Medicaid,27266.86,80,,27266.86,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,27266.86,80,,27266.86,percent of total billed charges,,7216,,,7216,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,23858.51,70,,23858.51,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,643.35,,,643.35,Other,New York Medicaid APG methodology,643.35,,,643.35,Other,100% New York Medicaid APG,643.35,,,643.35,Other,100% New York Medicaid APG,643.35,,,643.35,Other,100% New York Medicaid APG,1447.55,,,1447.55,Other,225% New York Medicaid APG,984.33,,,984.33,Other,153% New York Medicaid APG,1447.55,,,1447.55,Other,225% New York Medicaid APG,900.7,,,900.7,Other,140% New York Medicaid APG,1447.55,,,1447.55,Other,225% New York Medicaid APG,1672.72,,,1672.72,Other,260% New York Medicaid APG,2084.47,,,2084.47,Other,324% New York Medicaid APG,1383.21,,,1383.21,Other,215% New York Medicaid APG,1383.21,,,1383.21,Other,215% New York Medicaid APG,804.19,,,804.19,Other,125% New York Medicaid APG,643.35,27266.86,
Exchange drainage catheter,49423,CPT,,,,,,,,both,,,20387,15086.38,74,,15086.38,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,9174.15,45,,9174.15,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,10091.57,49.5,,10091.57,percent of total billed charges,110% of Medicare,13863.16,68,,13863.16,percent of total billed charges,,1196.64,,,1196.64,Other,186% of Medicaid,16309.6,80,,16309.6,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,16309.6,80,,16309.6,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,14270.9,70,,14270.9,percent of total billed charges,,341.12,,,341.12,Fee Schedule,,289.12,,,289.12,Fee Schedule,,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,643.35,,,643.35,Other,New York Medicaid APG methodology,643.35,,,643.35,Other,100% New York Medicaid APG,643.35,,,643.35,Other,100% New York Medicaid APG,643.35,,,643.35,Other,100% New York Medicaid APG,1447.55,,,1447.55,Other,225% New York Medicaid APG,984.33,,,984.33,Other,153% New York Medicaid APG,1447.55,,,1447.55,Other,225% New York Medicaid APG,900.7,,,900.7,Other,140% New York Medicaid APG,1447.55,,,1447.55,Other,225% New York Medicaid APG,1672.72,,,1672.72,Other,260% New York Medicaid APG,2084.47,,,2084.47,Other,324% New York Medicaid APG,1383.21,,,1383.21,Other,215% New York Medicaid APG,1383.21,,,1383.21,Other,215% New York Medicaid APG,804.19,,,804.19,Other,125% New York Medicaid APG,289.12,16309.6,
Assess cyst contrast inject,49424,CPT,,,,,,,,both,,,12706.39,9402.73,74,,9402.73,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,5717.88,45,,5717.88,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,6289.66,49.5,,6289.66,percent of total billed charges,110% of Medicare,8640.35,68,,8640.35,percent of total billed charges,,966.93,,,966.93,Other,186% of Medicaid,10165.11,80,,10165.11,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,10165.11,80,,10165.11,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,8894.47,70,,8894.47,percent of total billed charges,,180.4,,,180.4,Fee Schedule,,152.9,,,152.9,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,519.86,,,519.86,Other,New York Medicaid APG methodology,519.86,,,519.86,Other,100% New York Medicaid APG,519.86,,,519.86,Other,100% New York Medicaid APG,519.86,,,519.86,Other,100% New York Medicaid APG,1169.68,,,1169.68,Other,225% New York Medicaid APG,795.38,,,795.38,Other,153% New York Medicaid APG,1169.68,,,1169.68,Other,225% New York Medicaid APG,727.8,,,727.8,Other,140% New York Medicaid APG,1169.68,,,1169.68,Other,225% New York Medicaid APG,1351.62,,,1351.62,Other,260% New York Medicaid APG,1684.33,,,1684.33,Other,324% New York Medicaid APG,1117.69,,,1117.69,Other,215% New York Medicaid APG,1117.69,,,1117.69,Other,215% New York Medicaid APG,649.82,,,649.82,Other,125% New York Medicaid APG,152.9,10165.11,
Revise abdomen-venous shunt,49426,CPT,,,,,,,,both,,,72769.69,53849.57,74,,53849.57,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,32746.36,45,,32746.36,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,36021,49.5,,36021,percent of total billed charges,110% of Medicare,49483.39,68,,49483.39,percent of total billed charges,,3632.62,,,3632.62,Other,186% of Medicaid,58215.75,80,,58215.75,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,58215.75,80,,58215.75,percent of total billed charges,,7216,,,7216,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,50938.78,70,,50938.78,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1953.02,,,1953.02,Other,New York Medicaid APG methodology,1953.02,,,1953.02,Other,100% New York Medicaid APG,1953.02,,,1953.02,Other,100% New York Medicaid APG,1953.02,,,1953.02,Other,100% New York Medicaid APG,4394.3,,,4394.3,Other,225% New York Medicaid APG,2988.12,,,2988.12,Other,153% New York Medicaid APG,4394.3,,,4394.3,Other,225% New York Medicaid APG,2734.23,,,2734.23,Other,140% New York Medicaid APG,4394.3,,,4394.3,Other,225% New York Medicaid APG,5077.86,,,5077.86,Other,260% New York Medicaid APG,6327.79,,,6327.79,Other,324% New York Medicaid APG,4199,,,4199,Other,215% New York Medicaid APG,4199,,,4199,Other,215% New York Medicaid APG,2441.28,,,2441.28,Other,125% New York Medicaid APG,1953.02,58215.75,
Injection abdominal shunt,49427,CPT,,,,,,,,both,,,32432.1,23999.75,74,,23999.75,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,14594.45,45,,14594.45,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,16053.89,49.5,,16053.89,percent of total billed charges,110% of Medicare,22053.83,68,,22053.83,percent of total billed charges,,966.93,,,966.93,Other,186% of Medicaid,25945.68,80,,25945.68,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,25945.68,80,,25945.68,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,22702.47,70,,22702.47,percent of total billed charges,,188.6,,,188.6,Fee Schedule,,159.85,,,159.85,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,519.86,,,519.86,Other,New York Medicaid APG methodology,519.86,,,519.86,Other,100% New York Medicaid APG,519.86,,,519.86,Other,100% New York Medicaid APG,519.86,,,519.86,Other,100% New York Medicaid APG,1169.68,,,1169.68,Other,225% New York Medicaid APG,795.38,,,795.38,Other,153% New York Medicaid APG,1169.68,,,1169.68,Other,225% New York Medicaid APG,727.8,,,727.8,Other,140% New York Medicaid APG,1169.68,,,1169.68,Other,225% New York Medicaid APG,1351.62,,,1351.62,Other,260% New York Medicaid APG,1684.33,,,1684.33,Other,324% New York Medicaid APG,1117.69,,,1117.69,Other,215% New York Medicaid APG,1117.69,,,1117.69,Other,215% New York Medicaid APG,649.82,,,649.82,Other,125% New York Medicaid APG,159.85,25945.68,
Removal of shunt,49429,CPT,,,,,,,,both,,,67044.74,49613.11,74,,49613.11,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30170.13,45,,30170.13,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33187.15,49.5,,33187.15,percent of total billed charges,110% of Medicare,45590.42,68,,45590.42,percent of total billed charges,,3632.62,,,3632.62,Other,186% of Medicaid,53635.79,80,,53635.79,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,53635.79,80,,53635.79,percent of total billed charges,,7216,,,7216,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,46931.32,70,,46931.32,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1953.02,,,1953.02,Other,New York Medicaid APG methodology,1953.02,,,1953.02,Other,100% New York Medicaid APG,1953.02,,,1953.02,Other,100% New York Medicaid APG,1953.02,,,1953.02,Other,100% New York Medicaid APG,4394.3,,,4394.3,Other,225% New York Medicaid APG,2988.12,,,2988.12,Other,153% New York Medicaid APG,4394.3,,,4394.3,Other,225% New York Medicaid APG,2734.23,,,2734.23,Other,140% New York Medicaid APG,4394.3,,,4394.3,Other,225% New York Medicaid APG,5077.86,,,5077.86,Other,260% New York Medicaid APG,6327.79,,,6327.79,Other,324% New York Medicaid APG,4199,,,4199,Other,215% New York Medicaid APG,4199,,,4199,Other,215% New York Medicaid APG,2441.28,,,2441.28,Other,125% New York Medicaid APG,1953.02,53635.79,
Insert subq exten to ip cath,49435,CPT,,,,,,,,both,,,86591.4,64077.64,74,,64077.64,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,38966.13,45,,38966.13,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,6125,,"100% primary, 50% secondary, 25% supplemental procedure",6125,Other,Blue Cross ASC Grouper,5513,,"100% primary, 50% secondary, 25% supplemental procedure",5513,Other,Blue Cross ASC Grouper,5206,,"100% primary, 50% secondary, 25% supplemental procedure",5206,Other,Blue Cross ASC Grouper,42862.74,49.5,,42862.74,percent of total billed charges,110% of Medicare,58882.15,68,,58882.15,percent of total billed charges,,1196.64,,,1196.64,Other,186% of Medicaid,69273.12,80,,69273.12,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,69273.12,80,,69273.12,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,60613.98,70,,60613.98,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,643.35,,,643.35,Other,New York Medicaid APG methodology,643.35,,,643.35,Other,100% New York Medicaid APG,643.35,,,643.35,Other,100% New York Medicaid APG,643.35,,,643.35,Other,100% New York Medicaid APG,1447.55,,,1447.55,Other,225% New York Medicaid APG,984.33,,,984.33,Other,153% New York Medicaid APG,1447.55,,,1447.55,Other,225% New York Medicaid APG,900.7,,,900.7,Other,140% New York Medicaid APG,1447.55,,,1447.55,Other,225% New York Medicaid APG,1672.72,,,1672.72,Other,260% New York Medicaid APG,2084.47,,,2084.47,Other,324% New York Medicaid APG,1383.21,,,1383.21,Other,215% New York Medicaid APG,1383.21,,,1383.21,Other,215% New York Medicaid APG,804.19,,,804.19,Other,125% New York Medicaid APG,643.35,69273.12,
Embedded ip cath exit-site,49436,CPT,,,,,,,,both,,,40023.39,29617.31,74,,29617.31,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,18010.53,45,,18010.53,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,19811.58,49.5,,19811.58,percent of total billed charges,110% of Medicare,27215.91,68,,27215.91,percent of total billed charges,,1196.64,,,1196.64,Other,186% of Medicaid,32018.71,80,,32018.71,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,32018.71,80,,32018.71,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,28016.37,70,,28016.37,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,643.35,,,643.35,Other,New York Medicaid APG methodology,643.35,,,643.35,Other,100% New York Medicaid APG,643.35,,,643.35,Other,100% New York Medicaid APG,643.35,,,643.35,Other,100% New York Medicaid APG,1447.55,,,1447.55,Other,225% New York Medicaid APG,984.33,,,984.33,Other,153% New York Medicaid APG,1447.55,,,1447.55,Other,225% New York Medicaid APG,900.7,,,900.7,Other,140% New York Medicaid APG,1447.55,,,1447.55,Other,225% New York Medicaid APG,1672.72,,,1672.72,Other,260% New York Medicaid APG,2084.47,,,2084.47,Other,324% New York Medicaid APG,1383.21,,,1383.21,Other,215% New York Medicaid APG,1383.21,,,1383.21,Other,215% New York Medicaid APG,804.19,,,804.19,Other,125% New York Medicaid APG,643.35,32018.71,
Place gastrostomy tube perc,49440,CPT,,,,,,,,both,,,40023.39,29617.31,74,,29617.31,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,18010.53,45,,18010.53,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,19811.58,49.5,,19811.58,percent of total billed charges,110% of Medicare,27215.91,68,,27215.91,percent of total billed charges,,1030.37,,,1030.37,Other,186% of Medicaid,32018.71,80,,32018.71,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,32018.71,80,,32018.71,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,28016.37,70,,28016.37,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,553.96,,,553.96,Other,New York Medicaid APG methodology,553.96,,,553.96,Other,100% New York Medicaid APG,553.96,,,553.96,Other,100% New York Medicaid APG,553.96,,,553.96,Other,100% New York Medicaid APG,1246.41,,,1246.41,Other,225% New York Medicaid APG,847.56,,,847.56,Other,153% New York Medicaid APG,1246.41,,,1246.41,Other,225% New York Medicaid APG,775.55,,,775.55,Other,140% New York Medicaid APG,1246.41,,,1246.41,Other,225% New York Medicaid APG,1440.3,,,1440.3,Other,260% New York Medicaid APG,1794.83,,,1794.83,Other,324% New York Medicaid APG,1191.02,,,1191.02,Other,215% New York Medicaid APG,1191.02,,,1191.02,Other,215% New York Medicaid APG,692.45,,,692.45,Other,125% New York Medicaid APG,553.96,32018.71,
Place duod/jej tube perc,49441,CPT,,,,,,,,both,,,40023.39,29617.31,74,,29617.31,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,18010.53,45,,18010.53,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,19811.58,49.5,,19811.58,percent of total billed charges,110% of Medicare,27215.91,68,,27215.91,percent of total billed charges,,1030.37,,,1030.37,Other,186% of Medicaid,32018.71,80,,32018.71,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,32018.71,80,,32018.71,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,28016.37,70,,28016.37,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,553.96,,,553.96,Other,New York Medicaid APG methodology,553.96,,,553.96,Other,100% New York Medicaid APG,553.96,,,553.96,Other,100% New York Medicaid APG,553.96,,,553.96,Other,100% New York Medicaid APG,1246.41,,,1246.41,Other,225% New York Medicaid APG,847.56,,,847.56,Other,153% New York Medicaid APG,1246.41,,,1246.41,Other,225% New York Medicaid APG,775.55,,,775.55,Other,140% New York Medicaid APG,1246.41,,,1246.41,Other,225% New York Medicaid APG,1440.3,,,1440.3,Other,260% New York Medicaid APG,1794.83,,,1794.83,Other,324% New York Medicaid APG,1191.02,,,1191.02,Other,215% New York Medicaid APG,1191.02,,,1191.02,Other,215% New York Medicaid APG,692.45,,,692.45,Other,125% New York Medicaid APG,553.96,32018.71,
Place cecostomy tube perc,49442,CPT,,,,,,,,both,,,24821.26,18367.73,74,,18367.73,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,11169.57,45,,11169.57,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,12286.52,49.5,,12286.52,percent of total billed charges,110% of Medicare,16878.46,68,,16878.46,percent of total billed charges,,2732.76,,,2732.76,Other,186% of Medicaid,19857.01,80,,19857.01,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,19857.01,80,,19857.01,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,17374.88,70,,17374.88,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1469.23,,,1469.23,Other,New York Medicaid APG methodology,1469.23,,,1469.23,Other,100% New York Medicaid APG,1469.23,,,1469.23,Other,100% New York Medicaid APG,1469.23,,,1469.23,Other,100% New York Medicaid APG,3305.76,,,3305.76,Other,225% New York Medicaid APG,2247.91,,,2247.91,Other,153% New York Medicaid APG,3305.76,,,3305.76,Other,225% New York Medicaid APG,2056.92,,,2056.92,Other,140% New York Medicaid APG,3305.76,,,3305.76,Other,225% New York Medicaid APG,3819.99,,,3819.99,Other,260% New York Medicaid APG,4760.29,,,4760.29,Other,324% New York Medicaid APG,3158.83,,,3158.83,Other,215% New York Medicaid APG,3158.83,,,3158.83,Other,215% New York Medicaid APG,1836.53,,,1836.53,Other,125% New York Medicaid APG,1469.23,19857.01,
Change g-tube to g-j perc,49446,CPT,,,,,,,,both,,,40023.39,29617.31,74,,29617.31,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,18010.53,45,,18010.53,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,19811.58,49.5,,19811.58,percent of total billed charges,110% of Medicare,27215.91,68,,27215.91,percent of total billed charges,,1030.37,,,1030.37,Other,186% of Medicaid,32018.71,80,,32018.71,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,32018.71,80,,32018.71,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,28016.37,70,,28016.37,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,553.96,,,553.96,Other,New York Medicaid APG methodology,553.96,,,553.96,Other,100% New York Medicaid APG,553.96,,,553.96,Other,100% New York Medicaid APG,553.96,,,553.96,Other,100% New York Medicaid APG,1246.41,,,1246.41,Other,225% New York Medicaid APG,847.56,,,847.56,Other,153% New York Medicaid APG,1246.41,,,1246.41,Other,225% New York Medicaid APG,775.55,,,775.55,Other,140% New York Medicaid APG,1246.41,,,1246.41,Other,225% New York Medicaid APG,1440.3,,,1440.3,Other,260% New York Medicaid APG,1794.83,,,1794.83,Other,324% New York Medicaid APG,1191.02,,,1191.02,Other,215% New York Medicaid APG,1191.02,,,1191.02,Other,215% New York Medicaid APG,692.45,,,692.45,Other,125% New York Medicaid APG,553.96,32018.71,
Replace g/c tube perc,49450,CPT,,,,,,,,both,,,32413.64,23986.09,74,,23986.09,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,14586.14,45,,14586.14,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,16044.75,49.5,,16044.75,percent of total billed charges,110% of Medicare,22041.28,68,,22041.28,percent of total billed charges,,1030.37,,,1030.37,Other,186% of Medicaid,25930.91,80,,25930.91,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,25930.91,80,,25930.91,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,22689.55,70,,22689.55,percent of total billed charges,,319.8,,,319.8,Fee Schedule,,271.05,,,271.05,Fee Schedule,,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,553.96,,,553.96,Other,New York Medicaid APG methodology,553.96,,,553.96,Other,100% New York Medicaid APG,553.96,,,553.96,Other,100% New York Medicaid APG,553.96,,,553.96,Other,100% New York Medicaid APG,1246.41,,,1246.41,Other,225% New York Medicaid APG,847.56,,,847.56,Other,153% New York Medicaid APG,1246.41,,,1246.41,Other,225% New York Medicaid APG,775.55,,,775.55,Other,140% New York Medicaid APG,1246.41,,,1246.41,Other,225% New York Medicaid APG,1440.3,,,1440.3,Other,260% New York Medicaid APG,1794.83,,,1794.83,Other,324% New York Medicaid APG,1191.02,,,1191.02,Other,215% New York Medicaid APG,1191.02,,,1191.02,Other,215% New York Medicaid APG,692.45,,,692.45,Other,125% New York Medicaid APG,271.05,25930.91,
Replace duod/jej tube perc,49451,CPT,,,,,,,,both,,,19066.74,14109.39,74,,14109.39,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,8580.03,45,,8580.03,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,9438.04,49.5,,9438.04,percent of total billed charges,110% of Medicare,12965.38,68,,12965.38,percent of total billed charges,,1030.37,,,1030.37,Other,186% of Medicaid,15253.39,80,,15253.39,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,15253.39,80,,15253.39,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,13346.72,70,,13346.72,percent of total billed charges,,423.12,,,423.12,Fee Schedule,,358.62,,,358.62,Fee Schedule,,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,553.96,,,553.96,Other,New York Medicaid APG methodology,553.96,,,553.96,Other,100% New York Medicaid APG,553.96,,,553.96,Other,100% New York Medicaid APG,553.96,,,553.96,Other,100% New York Medicaid APG,1246.41,,,1246.41,Other,225% New York Medicaid APG,847.56,,,847.56,Other,153% New York Medicaid APG,1246.41,,,1246.41,Other,225% New York Medicaid APG,775.55,,,775.55,Other,140% New York Medicaid APG,1246.41,,,1246.41,Other,225% New York Medicaid APG,1440.3,,,1440.3,Other,260% New York Medicaid APG,1794.83,,,1794.83,Other,324% New York Medicaid APG,1191.02,,,1191.02,Other,215% New York Medicaid APG,1191.02,,,1191.02,Other,215% New York Medicaid APG,692.45,,,692.45,Other,125% New York Medicaid APG,358.62,15253.39,
Replace g-j tube perc,49452,CPT,,,,,,,,both,,,19066.74,14109.39,74,,14109.39,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,8580.03,45,,8580.03,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,9438.04,49.5,,9438.04,percent of total billed charges,110% of Medicare,12965.38,68,,12965.38,percent of total billed charges,,1030.37,,,1030.37,Other,186% of Medicaid,15253.39,80,,15253.39,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,15253.39,80,,15253.39,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,13346.72,70,,13346.72,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,553.96,,,553.96,Other,New York Medicaid APG methodology,553.96,,,553.96,Other,100% New York Medicaid APG,553.96,,,553.96,Other,100% New York Medicaid APG,553.96,,,553.96,Other,100% New York Medicaid APG,1246.41,,,1246.41,Other,225% New York Medicaid APG,847.56,,,847.56,Other,153% New York Medicaid APG,1246.41,,,1246.41,Other,225% New York Medicaid APG,775.55,,,775.55,Other,140% New York Medicaid APG,1246.41,,,1246.41,Other,225% New York Medicaid APG,1440.3,,,1440.3,Other,260% New York Medicaid APG,1794.83,,,1794.83,Other,324% New York Medicaid APG,1191.02,,,1191.02,Other,215% New York Medicaid APG,1191.02,,,1191.02,Other,215% New York Medicaid APG,692.45,,,692.45,Other,125% New York Medicaid APG,553.96,15253.39,
Fix g/colon tube w/device,49460,CPT,,,,,,,,both,,,19066.74,14109.39,74,,14109.39,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,8580.03,45,,8580.03,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,9438.04,49.5,,9438.04,percent of total billed charges,110% of Medicare,12965.38,68,,12965.38,percent of total billed charges,,1030.37,,,1030.37,Other,186% of Medicaid,15253.39,80,,15253.39,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,15253.39,80,,15253.39,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,13346.72,70,,13346.72,percent of total billed charges,,239.44,,,239.44,Fee Schedule,,202.94,,,202.94,Fee Schedule,,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,553.96,,,553.96,Other,New York Medicaid APG methodology,553.96,,,553.96,Other,100% New York Medicaid APG,553.96,,,553.96,Other,100% New York Medicaid APG,553.96,,,553.96,Other,100% New York Medicaid APG,1246.41,,,1246.41,Other,225% New York Medicaid APG,847.56,,,847.56,Other,153% New York Medicaid APG,1246.41,,,1246.41,Other,225% New York Medicaid APG,775.55,,,775.55,Other,140% New York Medicaid APG,1246.41,,,1246.41,Other,225% New York Medicaid APG,1440.3,,,1440.3,Other,260% New York Medicaid APG,1794.83,,,1794.83,Other,324% New York Medicaid APG,1191.02,,,1191.02,Other,215% New York Medicaid APG,1191.02,,,1191.02,Other,215% New York Medicaid APG,692.45,,,692.45,Other,125% New York Medicaid APG,202.94,15253.39,
Fluoro exam of g/colon tube,49465,CPT,,,,,,,,both,,,5154.06,3814,74,,3814,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,2319.33,45,,2319.33,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,2551.26,49.5,,2551.26,percent of total billed charges,110% of Medicare,3504.76,68,,3504.76,percent of total billed charges,,623.23,,,623.23,Other,186% of Medicaid,4123.25,80,,4123.25,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,4123.25,80,,4123.25,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,3607.84,70,,3607.84,percent of total billed charges,,147.6,,,147.6,Fee Schedule,,125.1,,,125.1,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,335.07,,,335.07,Other,New York Medicaid APG methodology,335.07,,,335.07,Other,100% New York Medicaid APG,335.07,,,335.07,Other,100% New York Medicaid APG,335.07,,,335.07,Other,100% New York Medicaid APG,753.91,,,753.91,Other,225% New York Medicaid APG,512.66,,,512.66,Other,153% New York Medicaid APG,753.91,,,753.91,Other,225% New York Medicaid APG,469.1,,,469.1,Other,140% New York Medicaid APG,753.91,,,753.91,Other,225% New York Medicaid APG,871.18,,,871.18,Other,260% New York Medicaid APG,1085.63,,,1085.63,Other,324% New York Medicaid APG,720.4,,,720.4,Other,215% New York Medicaid APG,720.4,,,720.4,Other,215% New York Medicaid APG,418.84,,,418.84,Other,125% New York Medicaid APG,125.1,7216,
Rpr hern preemie reduc,49491,CPT,,,,,,,,both,,,36476.2,26992.39,74,,26992.39,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,16414.29,45,,16414.29,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,6125,,"100% primary, 50% secondary, 25% supplemental procedure",6125,Other,Blue Cross ASC Grouper,5513,,"100% primary, 50% secondary, 25% supplemental procedure",5513,Other,Blue Cross ASC Grouper,5206,,"100% primary, 50% secondary, 25% supplemental procedure",5206,Other,Blue Cross ASC Grouper,18055.72,49.5,,18055.72,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3639.33,,,3639.33,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,25533.34,70,,25533.34,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1956.63,,,1956.63,Other,New York Medicaid APG methodology,1956.63,,,1956.63,Other,100% New York Medicaid APG,1956.63,,,1956.63,Other,100% New York Medicaid APG,1956.63,,,1956.63,Other,100% New York Medicaid APG,4402.42,,,4402.42,Other,225% New York Medicaid APG,2993.64,,,2993.64,Other,153% New York Medicaid APG,4402.42,,,4402.42,Other,225% New York Medicaid APG,2739.28,,,2739.28,Other,140% New York Medicaid APG,4402.42,,,4402.42,Other,225% New York Medicaid APG,5087.24,,,5087.24,Other,260% New York Medicaid APG,6339.48,,,6339.48,Other,324% New York Medicaid APG,4206.75,,,4206.75,Other,215% New York Medicaid APG,4206.75,,,4206.75,Other,215% New York Medicaid APG,2445.79,,,2445.79,Other,125% New York Medicaid APG,1956.63,26992.39,
Rpr ing hern premie blocked,49492,CPT,,,,,,,,both,,,72769.69,53849.57,74,,53849.57,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,32746.36,45,,32746.36,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,36021,49.5,,36021,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3639.33,,,3639.33,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,50938.78,70,,50938.78,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1956.63,,,1956.63,Other,New York Medicaid APG methodology,1956.63,,,1956.63,Other,100% New York Medicaid APG,1956.63,,,1956.63,Other,100% New York Medicaid APG,1956.63,,,1956.63,Other,100% New York Medicaid APG,4402.42,,,4402.42,Other,225% New York Medicaid APG,2993.64,,,2993.64,Other,153% New York Medicaid APG,4402.42,,,4402.42,Other,225% New York Medicaid APG,2739.28,,,2739.28,Other,140% New York Medicaid APG,4402.42,,,4402.42,Other,225% New York Medicaid APG,5087.24,,,5087.24,Other,260% New York Medicaid APG,6339.48,,,6339.48,Other,324% New York Medicaid APG,4206.75,,,4206.75,Other,215% New York Medicaid APG,4206.75,,,4206.75,Other,215% New York Medicaid APG,2445.79,,,2445.79,Other,125% New York Medicaid APG,1956.63,53849.57,
Rpr ing hernia baby reduc,49495,CPT,,,,,,,,both,,,34971.91,25879.21,74,,25879.21,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15737.36,45,,15737.36,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,17311.1,49.5,,17311.1,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3639.33,,,3639.33,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,24480.34,70,,24480.34,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1956.63,,,1956.63,Other,New York Medicaid APG methodology,1956.63,,,1956.63,Other,100% New York Medicaid APG,1956.63,,,1956.63,Other,100% New York Medicaid APG,1956.63,,,1956.63,Other,100% New York Medicaid APG,4402.42,,,4402.42,Other,225% New York Medicaid APG,2993.64,,,2993.64,Other,153% New York Medicaid APG,4402.42,,,4402.42,Other,225% New York Medicaid APG,2739.28,,,2739.28,Other,140% New York Medicaid APG,4402.42,,,4402.42,Other,225% New York Medicaid APG,5087.24,,,5087.24,Other,260% New York Medicaid APG,6339.48,,,6339.48,Other,324% New York Medicaid APG,4206.75,,,4206.75,Other,215% New York Medicaid APG,4206.75,,,4206.75,Other,215% New York Medicaid APG,2445.79,,,2445.79,Other,125% New York Medicaid APG,1956.63,25879.21,
Rpr ing hernia baby blocked,49496,CPT,,,,,,,,both,,,72769.69,53849.57,74,,53849.57,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,32746.36,45,,32746.36,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,36021,49.5,,36021,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3639.33,,,3639.33,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,50938.78,70,,50938.78,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1956.63,,,1956.63,Other,New York Medicaid APG methodology,1956.63,,,1956.63,Other,100% New York Medicaid APG,1956.63,,,1956.63,Other,100% New York Medicaid APG,1956.63,,,1956.63,Other,100% New York Medicaid APG,4402.42,,,4402.42,Other,225% New York Medicaid APG,2993.64,,,2993.64,Other,153% New York Medicaid APG,4402.42,,,4402.42,Other,225% New York Medicaid APG,2739.28,,,2739.28,Other,140% New York Medicaid APG,4402.42,,,4402.42,Other,225% New York Medicaid APG,5087.24,,,5087.24,Other,260% New York Medicaid APG,6339.48,,,6339.48,Other,324% New York Medicaid APG,4206.75,,,4206.75,Other,215% New York Medicaid APG,4206.75,,,4206.75,Other,215% New York Medicaid APG,2445.79,,,2445.79,Other,125% New York Medicaid APG,1956.63,53849.57,
Rpr ing hernia init reduce,49500,CPT,,,,,,,,both,,,35650.88,26381.65,74,,26381.65,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,16042.9,45,,16042.9,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,17647.19,49.5,,17647.19,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3639.33,,,3639.33,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,24955.62,70,,24955.62,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1956.63,,,1956.63,Other,New York Medicaid APG methodology,1956.63,,,1956.63,Other,100% New York Medicaid APG,1956.63,,,1956.63,Other,100% New York Medicaid APG,1956.63,,,1956.63,Other,100% New York Medicaid APG,4402.42,,,4402.42,Other,225% New York Medicaid APG,2993.64,,,2993.64,Other,153% New York Medicaid APG,4402.42,,,4402.42,Other,225% New York Medicaid APG,2739.28,,,2739.28,Other,140% New York Medicaid APG,4402.42,,,4402.42,Other,225% New York Medicaid APG,5087.24,,,5087.24,Other,260% New York Medicaid APG,6339.48,,,6339.48,Other,324% New York Medicaid APG,4206.75,,,4206.75,Other,215% New York Medicaid APG,4206.75,,,4206.75,Other,215% New York Medicaid APG,2445.79,,,2445.79,Other,125% New York Medicaid APG,1956.63,26381.65,
Rpr ing hernia init blocked,49501,CPT,,,,,,,,both,,,72769.69,53849.57,74,,53849.57,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,32746.36,45,,32746.36,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,36021,49.5,,36021,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3639.33,,,3639.33,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,50938.78,70,,50938.78,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1956.63,,,1956.63,Other,New York Medicaid APG methodology,1956.63,,,1956.63,Other,100% New York Medicaid APG,1956.63,,,1956.63,Other,100% New York Medicaid APG,1956.63,,,1956.63,Other,100% New York Medicaid APG,4402.42,,,4402.42,Other,225% New York Medicaid APG,2993.64,,,2993.64,Other,153% New York Medicaid APG,4402.42,,,4402.42,Other,225% New York Medicaid APG,2739.28,,,2739.28,Other,140% New York Medicaid APG,4402.42,,,4402.42,Other,225% New York Medicaid APG,5087.24,,,5087.24,Other,260% New York Medicaid APG,6339.48,,,6339.48,Other,324% New York Medicaid APG,4206.75,,,4206.75,Other,215% New York Medicaid APG,4206.75,,,4206.75,Other,215% New York Medicaid APG,2445.79,,,2445.79,Other,125% New York Medicaid APG,1956.63,53849.57,
Prp i/hern init reduc >5 yr,49505,CPT,,,,,,,,both,,,37203.27,27530.42,74,,27530.42,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,16741.47,45,,16741.47,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,18415.62,49.5,,18415.62,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3639.33,,,3639.33,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,26042.29,70,,26042.29,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1956.63,,,1956.63,Other,New York Medicaid APG methodology,1956.63,,,1956.63,Other,100% New York Medicaid APG,1956.63,,,1956.63,Other,100% New York Medicaid APG,1956.63,,,1956.63,Other,100% New York Medicaid APG,4402.42,,,4402.42,Other,225% New York Medicaid APG,2993.64,,,2993.64,Other,153% New York Medicaid APG,4402.42,,,4402.42,Other,225% New York Medicaid APG,2739.28,,,2739.28,Other,140% New York Medicaid APG,4402.42,,,4402.42,Other,225% New York Medicaid APG,5087.24,,,5087.24,Other,260% New York Medicaid APG,6339.48,,,6339.48,Other,324% New York Medicaid APG,4206.75,,,4206.75,Other,215% New York Medicaid APG,4206.75,,,4206.75,Other,215% New York Medicaid APG,2445.79,,,2445.79,Other,125% New York Medicaid APG,1956.63,27530.42,
Prp i/hern init block >5 yr,49507,CPT,,,,,,,,both,,,44660.6,33048.84,74,,33048.84,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,20097.27,45,,20097.27,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,22107,49.5,,22107,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3639.33,,,3639.33,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,31262.42,70,,31262.42,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1956.63,,,1956.63,Other,New York Medicaid APG methodology,1956.63,,,1956.63,Other,100% New York Medicaid APG,1956.63,,,1956.63,Other,100% New York Medicaid APG,1956.63,,,1956.63,Other,100% New York Medicaid APG,4402.42,,,4402.42,Other,225% New York Medicaid APG,2993.64,,,2993.64,Other,153% New York Medicaid APG,4402.42,,,4402.42,Other,225% New York Medicaid APG,2739.28,,,2739.28,Other,140% New York Medicaid APG,4402.42,,,4402.42,Other,225% New York Medicaid APG,5087.24,,,5087.24,Other,260% New York Medicaid APG,6339.48,,,6339.48,Other,324% New York Medicaid APG,4206.75,,,4206.75,Other,215% New York Medicaid APG,4206.75,,,4206.75,Other,215% New York Medicaid APG,2445.79,,,2445.79,Other,125% New York Medicaid APG,1956.63,33048.84,
Rerepair ing hernia reduce,49520,CPT,,,,,,,,both,,,40414.17,29906.49,74,,29906.49,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,18186.38,45,,18186.38,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,20005.01,49.5,,20005.01,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3639.33,,,3639.33,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,28289.92,70,,28289.92,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1956.63,,,1956.63,Other,New York Medicaid APG methodology,1956.63,,,1956.63,Other,100% New York Medicaid APG,1956.63,,,1956.63,Other,100% New York Medicaid APG,1956.63,,,1956.63,Other,100% New York Medicaid APG,4402.42,,,4402.42,Other,225% New York Medicaid APG,2993.64,,,2993.64,Other,153% New York Medicaid APG,4402.42,,,4402.42,Other,225% New York Medicaid APG,2739.28,,,2739.28,Other,140% New York Medicaid APG,4402.42,,,4402.42,Other,225% New York Medicaid APG,5087.24,,,5087.24,Other,260% New York Medicaid APG,6339.48,,,6339.48,Other,324% New York Medicaid APG,4206.75,,,4206.75,Other,215% New York Medicaid APG,4206.75,,,4206.75,Other,215% New York Medicaid APG,2445.79,,,2445.79,Other,125% New York Medicaid APG,1956.63,29906.49,
Rerepair ing hernia blocked,49521,CPT,,,,,,,,both,,,37127.91,27474.65,74,,27474.65,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,16707.56,45,,16707.56,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,18378.32,49.5,,18378.32,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3639.33,,,3639.33,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,25989.54,70,,25989.54,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1956.63,,,1956.63,Other,New York Medicaid APG methodology,1956.63,,,1956.63,Other,100% New York Medicaid APG,1956.63,,,1956.63,Other,100% New York Medicaid APG,1956.63,,,1956.63,Other,100% New York Medicaid APG,4402.42,,,4402.42,Other,225% New York Medicaid APG,2993.64,,,2993.64,Other,153% New York Medicaid APG,4402.42,,,4402.42,Other,225% New York Medicaid APG,2739.28,,,2739.28,Other,140% New York Medicaid APG,4402.42,,,4402.42,Other,225% New York Medicaid APG,5087.24,,,5087.24,Other,260% New York Medicaid APG,6339.48,,,6339.48,Other,324% New York Medicaid APG,4206.75,,,4206.75,Other,215% New York Medicaid APG,4206.75,,,4206.75,Other,215% New York Medicaid APG,2445.79,,,2445.79,Other,125% New York Medicaid APG,1956.63,27474.65,
Repair ing hernia sliding,49525,CPT,,,,,,,,both,,,43308.47,32048.27,74,,32048.27,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,19488.81,45,,19488.81,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,21437.69,49.5,,21437.69,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3639.33,,,3639.33,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,30315.93,70,,30315.93,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1956.63,,,1956.63,Other,New York Medicaid APG methodology,1956.63,,,1956.63,Other,100% New York Medicaid APG,1956.63,,,1956.63,Other,100% New York Medicaid APG,1956.63,,,1956.63,Other,100% New York Medicaid APG,4402.42,,,4402.42,Other,225% New York Medicaid APG,2993.64,,,2993.64,Other,153% New York Medicaid APG,4402.42,,,4402.42,Other,225% New York Medicaid APG,2739.28,,,2739.28,Other,140% New York Medicaid APG,4402.42,,,4402.42,Other,225% New York Medicaid APG,5087.24,,,5087.24,Other,260% New York Medicaid APG,6339.48,,,6339.48,Other,324% New York Medicaid APG,4206.75,,,4206.75,Other,215% New York Medicaid APG,4206.75,,,4206.75,Other,215% New York Medicaid APG,2445.79,,,2445.79,Other,125% New York Medicaid APG,1956.63,32048.27,
Repair lumbar hernia,49540,CPT,,,,,,,,both,,,121364.27,89809.56,74,,89809.56,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,54613.92,45,,54613.92,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,6125,,"100% primary, 50% secondary, 25% supplemental procedure",6125,Other,Blue Cross ASC Grouper,5513,,"100% primary, 50% secondary, 25% supplemental procedure",5513,Other,Blue Cross ASC Grouper,5206,,"100% primary, 50% secondary, 25% supplemental procedure",5206,Other,Blue Cross ASC Grouper,60075.31,49.5,,60075.31,percent of total billed charges,110% of Medicare,82527.7,68,,82527.7,percent of total billed charges,,3791.71,,,3791.71,Other,186% of Medicaid,97091.42,80,,97091.42,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,97091.42,80,,97091.42,percent of total billed charges,,7216,,,7216,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,84954.99,70,,84954.99,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,2038.56,,,2038.56,Other,New York Medicaid APG methodology,2038.56,,,2038.56,Other,100% New York Medicaid APG,2038.56,,,2038.56,Other,100% New York Medicaid APG,2038.56,,,2038.56,Other,100% New York Medicaid APG,4586.75,,,4586.75,Other,225% New York Medicaid APG,3118.99,,,3118.99,Other,153% New York Medicaid APG,4586.75,,,4586.75,Other,225% New York Medicaid APG,2853.98,,,2853.98,Other,140% New York Medicaid APG,4586.75,,,4586.75,Other,225% New York Medicaid APG,5300.25,,,5300.25,Other,260% New York Medicaid APG,6604.92,,,6604.92,Other,324% New York Medicaid APG,4382.9,,,4382.9,Other,215% New York Medicaid APG,4382.9,,,4382.9,Other,215% New York Medicaid APG,2548.2,,,2548.2,Other,125% New York Medicaid APG,2038.56,97091.42,
Rpr rem hernia init reduce,49550,CPT,,,,,,,,both,,,72769.69,53849.57,74,,53849.57,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,32746.36,45,,32746.36,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,36021,49.5,,36021,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3639.33,,,3639.33,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,50938.78,70,,50938.78,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1956.63,,,1956.63,Other,New York Medicaid APG methodology,1956.63,,,1956.63,Other,100% New York Medicaid APG,1956.63,,,1956.63,Other,100% New York Medicaid APG,1956.63,,,1956.63,Other,100% New York Medicaid APG,4402.42,,,4402.42,Other,225% New York Medicaid APG,2993.64,,,2993.64,Other,153% New York Medicaid APG,4402.42,,,4402.42,Other,225% New York Medicaid APG,2739.28,,,2739.28,Other,140% New York Medicaid APG,4402.42,,,4402.42,Other,225% New York Medicaid APG,5087.24,,,5087.24,Other,260% New York Medicaid APG,6339.48,,,6339.48,Other,324% New York Medicaid APG,4206.75,,,4206.75,Other,215% New York Medicaid APG,4206.75,,,4206.75,Other,215% New York Medicaid APG,2445.79,,,2445.79,Other,125% New York Medicaid APG,1956.63,53849.57,
Rpr fem hernia init blocked,49553,CPT,,,,,,,,both,,,61084.35,45202.42,74,,45202.42,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,27487.96,45,,27487.96,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,30236.75,49.5,,30236.75,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3639.33,,,3639.33,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,42759.05,70,,42759.05,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1956.63,,,1956.63,Other,New York Medicaid APG methodology,1956.63,,,1956.63,Other,100% New York Medicaid APG,1956.63,,,1956.63,Other,100% New York Medicaid APG,1956.63,,,1956.63,Other,100% New York Medicaid APG,4402.42,,,4402.42,Other,225% New York Medicaid APG,2993.64,,,2993.64,Other,153% New York Medicaid APG,4402.42,,,4402.42,Other,225% New York Medicaid APG,2739.28,,,2739.28,Other,140% New York Medicaid APG,4402.42,,,4402.42,Other,225% New York Medicaid APG,5087.24,,,5087.24,Other,260% New York Medicaid APG,6339.48,,,6339.48,Other,324% New York Medicaid APG,4206.75,,,4206.75,Other,215% New York Medicaid APG,4206.75,,,4206.75,Other,215% New York Medicaid APG,2445.79,,,2445.79,Other,125% New York Medicaid APG,1956.63,45202.42,
Rerepair fem hernia reduce,49555,CPT,,,,,,,,both,,,72769.69,53849.57,74,,53849.57,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,32746.36,45,,32746.36,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,36021,49.5,,36021,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3639.33,,,3639.33,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,50938.78,70,,50938.78,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1956.63,,,1956.63,Other,New York Medicaid APG methodology,1956.63,,,1956.63,Other,100% New York Medicaid APG,1956.63,,,1956.63,Other,100% New York Medicaid APG,1956.63,,,1956.63,Other,100% New York Medicaid APG,4402.42,,,4402.42,Other,225% New York Medicaid APG,2993.64,,,2993.64,Other,153% New York Medicaid APG,4402.42,,,4402.42,Other,225% New York Medicaid APG,2739.28,,,2739.28,Other,140% New York Medicaid APG,4402.42,,,4402.42,Other,225% New York Medicaid APG,5087.24,,,5087.24,Other,260% New York Medicaid APG,6339.48,,,6339.48,Other,324% New York Medicaid APG,4206.75,,,4206.75,Other,215% New York Medicaid APG,4206.75,,,4206.75,Other,215% New York Medicaid APG,2445.79,,,2445.79,Other,125% New York Medicaid APG,1956.63,53849.57,
Rerepair fem hernia blocked,49557,CPT,,,,,,,,both,,,72769.69,53849.57,74,,53849.57,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,32746.36,45,,32746.36,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,36021,49.5,,36021,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3639.33,,,3639.33,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,50938.78,70,,50938.78,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1956.63,,,1956.63,Other,New York Medicaid APG methodology,1956.63,,,1956.63,Other,100% New York Medicaid APG,1956.63,,,1956.63,Other,100% New York Medicaid APG,1956.63,,,1956.63,Other,100% New York Medicaid APG,4402.42,,,4402.42,Other,225% New York Medicaid APG,2993.64,,,2993.64,Other,153% New York Medicaid APG,4402.42,,,4402.42,Other,225% New York Medicaid APG,2739.28,,,2739.28,Other,140% New York Medicaid APG,4402.42,,,4402.42,Other,225% New York Medicaid APG,5087.24,,,5087.24,Other,260% New York Medicaid APG,6339.48,,,6339.48,Other,324% New York Medicaid APG,4206.75,,,4206.75,Other,215% New York Medicaid APG,4206.75,,,4206.75,Other,215% New York Medicaid APG,2445.79,,,2445.79,Other,125% New York Medicaid APG,1956.63,53849.57,
Repair umbilical lesion,49600,CPT,,,,,,,,both,,,39921.1,29541.61,74,,29541.61,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,17964.5,45,,17964.5,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,19760.94,49.5,,19760.94,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3791.71,,,3791.71,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,27944.77,70,,27944.77,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,2038.56,,,2038.56,Other,New York Medicaid APG methodology,2038.56,,,2038.56,Other,100% New York Medicaid APG,2038.56,,,2038.56,Other,100% New York Medicaid APG,2038.56,,,2038.56,Other,100% New York Medicaid APG,4586.75,,,4586.75,Other,225% New York Medicaid APG,3118.99,,,3118.99,Other,153% New York Medicaid APG,4586.75,,,4586.75,Other,225% New York Medicaid APG,2853.98,,,2853.98,Other,140% New York Medicaid APG,4586.75,,,4586.75,Other,225% New York Medicaid APG,5300.25,,,5300.25,Other,260% New York Medicaid APG,6604.92,,,6604.92,Other,324% New York Medicaid APG,4382.9,,,4382.9,Other,215% New York Medicaid APG,4382.9,,,4382.9,Other,215% New York Medicaid APG,2548.2,,,2548.2,Other,125% New York Medicaid APG,2038.56,29541.61,
Lap ing hernia repair init,49650,CPT,,,,,,,,both,,,42549.81,31486.86,74,,31486.86,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,19147.41,45,,19147.41,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,6125,,"100% primary, 50% secondary, 25% supplemental procedure",6125,Other,Blue Cross ASC Grouper,5513,,"100% primary, 50% secondary, 25% supplemental procedure",5513,Other,Blue Cross ASC Grouper,5206,,"100% primary, 50% secondary, 25% supplemental procedure",5206,Other,Blue Cross ASC Grouper,21062.16,49.5,,21062.16,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3639.33,,,3639.33,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,29784.87,70,,29784.87,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,1956.63,,,1956.63,Other,New York Medicaid APG methodology,1956.63,,,1956.63,Other,100% New York Medicaid APG,1956.63,,,1956.63,Other,100% New York Medicaid APG,1956.63,,,1956.63,Other,100% New York Medicaid APG,4402.42,,,4402.42,Other,225% New York Medicaid APG,2993.64,,,2993.64,Other,153% New York Medicaid APG,4402.42,,,4402.42,Other,225% New York Medicaid APG,2739.28,,,2739.28,Other,140% New York Medicaid APG,4402.42,,,4402.42,Other,225% New York Medicaid APG,5087.24,,,5087.24,Other,260% New York Medicaid APG,6339.48,,,6339.48,Other,324% New York Medicaid APG,4206.75,,,4206.75,Other,215% New York Medicaid APG,4206.75,,,4206.75,Other,215% New York Medicaid APG,2445.79,,,2445.79,Other,125% New York Medicaid APG,1956.63,31486.86,
Lap ing hernia repair recur,49651,CPT,,,,,,,,both,,,46480.03,34395.22,74,,34395.22,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,20916.01,45,,20916.01,percent of total billed charges,Medicare Ratio of cost to charges,5954,,"100% primary, 50% supplemental procedure",5954,Other,Aetna ASC Grouper,5359,,"100% primary, 50% supplemental procedure",5359,Other,Aetna ASC Grouper,6125,,"100% primary, 50% secondary, 25% supplemental procedure",6125,Other,Blue Cross ASC Grouper,5513,,"100% primary, 50% secondary, 25% supplemental procedure",5513,Other,Blue Cross ASC Grouper,5206,,"100% primary, 50% secondary, 25% supplemental procedure",5206,Other,Blue Cross ASC Grouper,23007.61,49.5,,23007.61,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3639.33,,,3639.33,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,32536.02,70,,32536.02,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,1956.63,,,1956.63,Other,New York Medicaid APG methodology,1956.63,,,1956.63,Other,100% New York Medicaid APG,1956.63,,,1956.63,Other,100% New York Medicaid APG,1956.63,,,1956.63,Other,100% New York Medicaid APG,4402.42,,,4402.42,Other,225% New York Medicaid APG,2993.64,,,2993.64,Other,153% New York Medicaid APG,4402.42,,,4402.42,Other,225% New York Medicaid APG,2739.28,,,2739.28,Other,140% New York Medicaid APG,4402.42,,,4402.42,Other,225% New York Medicaid APG,5087.24,,,5087.24,Other,260% New York Medicaid APG,6339.48,,,6339.48,Other,324% New York Medicaid APG,4206.75,,,4206.75,Other,215% New York Medicaid APG,4206.75,,,4206.75,Other,215% New York Medicaid APG,2445.79,,,2445.79,Other,125% New York Medicaid APG,1956.63,34395.22,
Renal abscess open drain,50020,CPT,,,,,,,,both,,,42841.82,31702.95,74,,31702.95,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,19278.82,45,,19278.82,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,21206.7,49.5,,21206.7,percent of total billed charges,110% of Medicare,29132.44,68,,29132.44,percent of total billed charges,,3435.71,,,3435.71,Other,186% of Medicaid,34273.46,80,,34273.46,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,34273.46,80,,34273.46,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,29989.27,70,,29989.27,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1847.16,,,1847.16,Other,New York Medicaid APG methodology,1847.16,,,1847.16,Other,100% New York Medicaid APG,1847.16,,,1847.16,Other,100% New York Medicaid APG,1847.16,,,1847.16,Other,100% New York Medicaid APG,4156.1,,,4156.1,Other,225% New York Medicaid APG,2826.15,,,2826.15,Other,153% New York Medicaid APG,4156.1,,,4156.1,Other,225% New York Medicaid APG,2586.02,,,2586.02,Other,140% New York Medicaid APG,4156.1,,,4156.1,Other,225% New York Medicaid APG,4802.61,,,4802.61,Other,260% New York Medicaid APG,5984.79,,,5984.79,Other,324% New York Medicaid APG,3971.39,,,3971.39,Other,215% New York Medicaid APG,3971.39,,,3971.39,Other,215% New York Medicaid APG,2308.95,,,2308.95,Other,125% New York Medicaid APG,1847.16,34273.46,
Removal of kidney stone,50080,CPT,,,,,,,,both,,,43674.9,32319.43,74,,32319.43,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,19653.71,45,,19653.71,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,21619.08,49.5,,21619.08,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3435.71,,,3435.71,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,30572.43,70,,30572.43,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,1847.16,,,1847.16,Other,New York Medicaid APG methodology,1847.16,,,1847.16,Other,100% New York Medicaid APG,1847.16,,,1847.16,Other,100% New York Medicaid APG,1847.16,,,1847.16,Other,100% New York Medicaid APG,4156.1,,,4156.1,Other,225% New York Medicaid APG,2826.15,,,2826.15,Other,153% New York Medicaid APG,4156.1,,,4156.1,Other,225% New York Medicaid APG,2586.02,,,2586.02,Other,140% New York Medicaid APG,4156.1,,,4156.1,Other,225% New York Medicaid APG,4802.61,,,4802.61,Other,260% New York Medicaid APG,5984.79,,,5984.79,Other,324% New York Medicaid APG,3971.39,,,3971.39,Other,215% New York Medicaid APG,3971.39,,,3971.39,Other,215% New York Medicaid APG,2308.95,,,2308.95,Other,125% New York Medicaid APG,1847.16,32319.43,
Removal of kidney stone,50081,CPT,,,,,,,,both,,,45007.64,33305.65,74,,33305.65,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,20253.44,45,,20253.44,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,22278.78,49.5,,22278.78,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3435.71,,,3435.71,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,31505.35,70,,31505.35,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,1847.16,,,1847.16,Other,New York Medicaid APG methodology,1847.16,,,1847.16,Other,100% New York Medicaid APG,1847.16,,,1847.16,Other,100% New York Medicaid APG,1847.16,,,1847.16,Other,100% New York Medicaid APG,4156.1,,,4156.1,Other,225% New York Medicaid APG,2826.15,,,2826.15,Other,153% New York Medicaid APG,4156.1,,,4156.1,Other,225% New York Medicaid APG,2586.02,,,2586.02,Other,140% New York Medicaid APG,4156.1,,,4156.1,Other,225% New York Medicaid APG,4802.61,,,4802.61,Other,260% New York Medicaid APG,5984.79,,,5984.79,Other,324% New York Medicaid APG,3971.39,,,3971.39,Other,215% New York Medicaid APG,3971.39,,,3971.39,Other,215% New York Medicaid APG,2308.95,,,2308.95,Other,125% New York Medicaid APG,1847.16,33305.65,
Renal biopsy perq,50200,CPT,,,,,,,,both,,,31170.32,23066.04,74,,23066.04,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,14026.64,45,,14026.64,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,15429.31,49.5,,15429.31,percent of total billed charges,110% of Medicare,21195.82,68,,21195.82,percent of total billed charges,,2011.18,,,2011.18,Other,186% of Medicaid,24936.26,80,,24936.26,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,24936.26,80,,24936.26,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,21819.22,70,,21819.22,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1081.28,,,1081.28,Other,New York Medicaid APG methodology,1081.28,,,1081.28,Other,100% New York Medicaid APG,1081.28,,,1081.28,Other,100% New York Medicaid APG,1081.28,,,1081.28,Other,100% New York Medicaid APG,2432.88,,,2432.88,Other,225% New York Medicaid APG,1654.36,,,1654.36,Other,153% New York Medicaid APG,2432.88,,,2432.88,Other,225% New York Medicaid APG,1513.79,,,1513.79,Other,140% New York Medicaid APG,2432.88,,,2432.88,Other,225% New York Medicaid APG,2811.33,,,2811.33,Other,260% New York Medicaid APG,3503.35,,,3503.35,Other,324% New York Medicaid APG,2324.75,,,2324.75,Other,215% New York Medicaid APG,2324.75,,,2324.75,Other,215% New York Medicaid APG,1351.6,,,1351.6,Other,125% New York Medicaid APG,1081.28,24936.26,
Change ureter stent percut,50382,CPT,,,,,,,,both,,,42841.82,31702.95,74,,31702.95,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,19278.82,45,,19278.82,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,21206.7,49.5,,21206.7,percent of total billed charges,110% of Medicare,29132.44,68,,29132.44,percent of total billed charges,,2011.18,,,2011.18,Other,186% of Medicaid,34273.46,80,,34273.46,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,34273.46,80,,34273.46,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,29989.27,70,,29989.27,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1081.28,,,1081.28,Other,New York Medicaid APG methodology,1081.28,,,1081.28,Other,100% New York Medicaid APG,1081.28,,,1081.28,Other,100% New York Medicaid APG,1081.28,,,1081.28,Other,100% New York Medicaid APG,2432.88,,,2432.88,Other,225% New York Medicaid APG,1654.36,,,1654.36,Other,153% New York Medicaid APG,2432.88,,,2432.88,Other,225% New York Medicaid APG,1513.79,,,1513.79,Other,140% New York Medicaid APG,2432.88,,,2432.88,Other,225% New York Medicaid APG,2811.33,,,2811.33,Other,260% New York Medicaid APG,3503.35,,,3503.35,Other,324% New York Medicaid APG,2324.75,,,2324.75,Other,215% New York Medicaid APG,2324.75,,,2324.75,Other,215% New York Medicaid APG,1351.6,,,1351.6,Other,125% New York Medicaid APG,1081.28,34273.46,
Remove ureter stent percut,50384,CPT,,,,,,,,both,,,42841.82,31702.95,74,,31702.95,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,19278.82,45,,19278.82,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,21206.7,49.5,,21206.7,percent of total billed charges,110% of Medicare,29132.44,68,,29132.44,percent of total billed charges,,2011.18,,,2011.18,Other,186% of Medicaid,34273.46,80,,34273.46,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,34273.46,80,,34273.46,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,29989.27,70,,29989.27,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1081.28,,,1081.28,Other,New York Medicaid APG methodology,1081.28,,,1081.28,Other,100% New York Medicaid APG,1081.28,,,1081.28,Other,100% New York Medicaid APG,1081.28,,,1081.28,Other,100% New York Medicaid APG,2432.88,,,2432.88,Other,225% New York Medicaid APG,1654.36,,,1654.36,Other,153% New York Medicaid APG,2432.88,,,2432.88,Other,225% New York Medicaid APG,1513.79,,,1513.79,Other,140% New York Medicaid APG,2432.88,,,2432.88,Other,225% New York Medicaid APG,2811.33,,,2811.33,Other,260% New York Medicaid APG,3503.35,,,3503.35,Other,324% New York Medicaid APG,2324.75,,,2324.75,Other,215% New York Medicaid APG,2324.75,,,2324.75,Other,215% New York Medicaid APG,1351.6,,,1351.6,Other,125% New York Medicaid APG,1081.28,34273.46,
Change stent via transureth,50385,CPT,,,,,,,,both,,,42841.82,31702.95,74,,31702.95,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,19278.82,45,,19278.82,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,21206.7,49.5,,21206.7,percent of total billed charges,110% of Medicare,29132.44,68,,29132.44,percent of total billed charges,,2011.18,,,2011.18,Other,186% of Medicaid,34273.46,80,,34273.46,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,34273.46,80,,34273.46,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,29989.27,70,,29989.27,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1081.28,,,1081.28,Other,New York Medicaid APG methodology,1081.28,,,1081.28,Other,100% New York Medicaid APG,1081.28,,,1081.28,Other,100% New York Medicaid APG,1081.28,,,1081.28,Other,100% New York Medicaid APG,2432.88,,,2432.88,Other,225% New York Medicaid APG,1654.36,,,1654.36,Other,153% New York Medicaid APG,2432.88,,,2432.88,Other,225% New York Medicaid APG,1513.79,,,1513.79,Other,140% New York Medicaid APG,2432.88,,,2432.88,Other,225% New York Medicaid APG,2811.33,,,2811.33,Other,260% New York Medicaid APG,3503.35,,,3503.35,Other,324% New York Medicaid APG,2324.75,,,2324.75,Other,215% New York Medicaid APG,2324.75,,,2324.75,Other,215% New York Medicaid APG,1351.6,,,1351.6,Other,125% New York Medicaid APG,1081.28,34273.46,
Remove stent via transureth,50386,CPT,,,,,,,,both,,,42841.82,31702.95,74,,31702.95,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,19278.82,45,,19278.82,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,21206.7,49.5,,21206.7,percent of total billed charges,110% of Medicare,29132.44,68,,29132.44,percent of total billed charges,,2011.18,,,2011.18,Other,186% of Medicaid,34273.46,80,,34273.46,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,34273.46,80,,34273.46,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,29989.27,70,,29989.27,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1081.28,,,1081.28,Other,New York Medicaid APG methodology,1081.28,,,1081.28,Other,100% New York Medicaid APG,1081.28,,,1081.28,Other,100% New York Medicaid APG,1081.28,,,1081.28,Other,100% New York Medicaid APG,2432.88,,,2432.88,Other,225% New York Medicaid APG,1654.36,,,1654.36,Other,153% New York Medicaid APG,2432.88,,,2432.88,Other,225% New York Medicaid APG,1513.79,,,1513.79,Other,140% New York Medicaid APG,2432.88,,,2432.88,Other,225% New York Medicaid APG,2811.33,,,2811.33,Other,260% New York Medicaid APG,3503.35,,,3503.35,Other,324% New York Medicaid APG,2324.75,,,2324.75,Other,215% New York Medicaid APG,2324.75,,,2324.75,Other,215% New York Medicaid APG,1351.6,,,1351.6,Other,125% New York Medicaid APG,1081.28,34273.46,
Change nephroureteral cath,50387,CPT,,,,,,,,both,,,26629,19705.46,74,,19705.46,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,11983.05,45,,11983.05,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,13181.36,49.5,,13181.36,percent of total billed charges,110% of Medicare,18107.72,68,,18107.72,percent of total billed charges,,2011.18,,,2011.18,Other,186% of Medicaid,21303.2,80,,21303.2,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,21303.2,80,,21303.2,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,18640.3,70,,18640.3,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1081.28,,,1081.28,Other,New York Medicaid APG methodology,1081.28,,,1081.28,Other,100% New York Medicaid APG,1081.28,,,1081.28,Other,100% New York Medicaid APG,1081.28,,,1081.28,Other,100% New York Medicaid APG,2432.88,,,2432.88,Other,225% New York Medicaid APG,1654.36,,,1654.36,Other,153% New York Medicaid APG,2432.88,,,2432.88,Other,225% New York Medicaid APG,1513.79,,,1513.79,Other,140% New York Medicaid APG,2432.88,,,2432.88,Other,225% New York Medicaid APG,2811.33,,,2811.33,Other,260% New York Medicaid APG,3503.35,,,3503.35,Other,324% New York Medicaid APG,2324.75,,,2324.75,Other,215% New York Medicaid APG,2324.75,,,2324.75,Other,215% New York Medicaid APG,1351.6,,,1351.6,Other,125% New York Medicaid APG,1081.28,21303.2,
Remove renal tube w/fluoro,50389,CPT,,,,,,,,both,,,10806,7996.44,74,,7996.44,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,4862.7,45,,4862.7,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,5348.97,49.5,,5348.97,percent of total billed charges,110% of Medicare,7348.08,68,,7348.08,percent of total billed charges,,903.43,,,903.43,Other,186% of Medicaid,8644.8,80,,8644.8,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,8644.8,80,,8644.8,percent of total billed charges,,7216,,,7216,Case Rate,,3578,,"100% primary, 0% secondary procedures",3578,Other,MagnaCare ASC Grouper,7564.2,70,,7564.2,percent of total billed charges,,255.84,,,255.84,Fee Schedule,,216.84,,,216.84,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,485.72,,,485.72,Other,New York Medicaid APG methodology,485.72,,,485.72,Other,100% New York Medicaid APG,485.72,,,485.72,Other,100% New York Medicaid APG,485.72,,,485.72,Other,100% New York Medicaid APG,1092.86,,,1092.86,Other,225% New York Medicaid APG,743.14,,,743.14,Other,153% New York Medicaid APG,1092.86,,,1092.86,Other,225% New York Medicaid APG,680,,,680,Other,140% New York Medicaid APG,1092.86,,,1092.86,Other,225% New York Medicaid APG,1262.86,,,1262.86,Other,260% New York Medicaid APG,1573.72,,,1573.72,Other,324% New York Medicaid APG,1044.29,,,1044.29,Other,215% New York Medicaid APG,1044.29,,,1044.29,Other,215% New York Medicaid APG,607.14,,,607.14,Other,125% New York Medicaid APG,216.84,8644.8,
Drainage of kidney lesion,50390,CPT,,,,,,,,both,,,28765,21286.1,74,,21286.1,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,12944.25,45,,12944.25,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,14238.68,49.5,,14238.68,percent of total billed charges,110% of Medicare,19560.2,68,,19560.2,percent of total billed charges,,903.43,,,903.43,Other,186% of Medicaid,23012,80,,23012,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,23012,80,,23012,percent of total billed charges,,7216,,,7216,Case Rate,,3578,,"100% primary, 0% secondary procedures",3578,Other,MagnaCare ASC Grouper,20135.5,70,,20135.5,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,485.72,,,485.72,Other,New York Medicaid APG methodology,485.72,,,485.72,Other,100% New York Medicaid APG,485.72,,,485.72,Other,100% New York Medicaid APG,485.72,,,485.72,Other,100% New York Medicaid APG,1092.86,,,1092.86,Other,225% New York Medicaid APG,743.14,,,743.14,Other,153% New York Medicaid APG,1092.86,,,1092.86,Other,225% New York Medicaid APG,680,,,680,Other,140% New York Medicaid APG,1092.86,,,1092.86,Other,225% New York Medicaid APG,1262.86,,,1262.86,Other,260% New York Medicaid APG,1573.72,,,1573.72,Other,324% New York Medicaid APG,1044.29,,,1044.29,Other,215% New York Medicaid APG,1044.29,,,1044.29,Other,215% New York Medicaid APG,607.14,,,607.14,Other,125% New York Medicaid APG,485.72,23012,
Instll rx agnt into rnal tub,50391,CPT,,,,,,,,both,,,35086.55,25964.05,74,,25964.05,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15788.95,45,,15788.95,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,17367.84,49.5,,17367.84,percent of total billed charges,110% of Medicare,23858.85,68,,23858.85,percent of total billed charges,,903.43,,,903.43,Other,186% of Medicaid,28069.24,80,,28069.24,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,28069.24,80,,28069.24,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,24560.59,70,,24560.59,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,485.72,,,485.72,Other,New York Medicaid APG methodology,485.72,,,485.72,Other,100% New York Medicaid APG,485.72,,,485.72,Other,100% New York Medicaid APG,485.72,,,485.72,Other,100% New York Medicaid APG,1092.86,,,1092.86,Other,225% New York Medicaid APG,743.14,,,743.14,Other,153% New York Medicaid APG,1092.86,,,1092.86,Other,225% New York Medicaid APG,680,,,680,Other,140% New York Medicaid APG,1092.86,,,1092.86,Other,225% New York Medicaid APG,1262.86,,,1262.86,Other,260% New York Medicaid APG,1573.72,,,1573.72,Other,324% New York Medicaid APG,1044.29,,,1044.29,Other,215% New York Medicaid APG,1044.29,,,1044.29,Other,215% New York Medicaid APG,607.14,,,607.14,Other,125% New York Medicaid APG,485.72,28069.24,
Measure kidney pressure,50396,CPT,,,,,,,,both,,,14368.32,10632.56,74,,10632.56,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,6465.74,45,,6465.74,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,7112.32,49.5,,7112.32,percent of total billed charges,110% of Medicare,9770.46,68,,9770.46,percent of total billed charges,,903.43,,,903.43,Other,186% of Medicaid,11494.66,80,,11494.66,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,11494.66,80,,11494.66,percent of total billed charges,,7216,,,7216,Case Rate,,3578,,"100% primary, 0% secondary procedures",3578,Other,MagnaCare ASC Grouper,10057.82,70,,10057.82,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,485.72,,,485.72,Other,New York Medicaid APG methodology,485.72,,,485.72,Other,100% New York Medicaid APG,485.72,,,485.72,Other,100% New York Medicaid APG,485.72,,,485.72,Other,100% New York Medicaid APG,1092.86,,,1092.86,Other,225% New York Medicaid APG,743.14,,,743.14,Other,153% New York Medicaid APG,1092.86,,,1092.86,Other,225% New York Medicaid APG,680,,,680,Other,140% New York Medicaid APG,1092.86,,,1092.86,Other,225% New York Medicaid APG,1262.86,,,1262.86,Other,260% New York Medicaid APG,1573.72,,,1573.72,Other,324% New York Medicaid APG,1044.29,,,1044.29,Other,215% New York Medicaid APG,1044.29,,,1044.29,Other,215% New York Medicaid APG,607.14,,,607.14,Other,125% New York Medicaid APG,485.72,11494.66,
Njx px nfrosgrm &/urtrgrm,50430,CPT,,,,,,,,both,,,14368.32,10632.56,74,,10632.56,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,6465.74,45,,6465.74,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,7112.32,49.5,,7112.32,percent of total billed charges,110% of Medicare,9770.46,68,,9770.46,percent of total billed charges,,903.43,,,903.43,Other,186% of Medicaid,11494.66,80,,11494.66,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,11494.66,80,,11494.66,percent of total billed charges,,7216,,,7216,Case Rate,,3578,,"100% primary, 0% secondary procedures",3578,Other,MagnaCare ASC Grouper,10057.82,70,,10057.82,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,485.72,,,485.72,Other,New York Medicaid APG methodology,485.72,,,485.72,Other,100% New York Medicaid APG,485.72,,,485.72,Other,100% New York Medicaid APG,485.72,,,485.72,Other,100% New York Medicaid APG,1092.86,,,1092.86,Other,225% New York Medicaid APG,743.14,,,743.14,Other,153% New York Medicaid APG,1092.86,,,1092.86,Other,225% New York Medicaid APG,680,,,680,Other,140% New York Medicaid APG,1092.86,,,1092.86,Other,225% New York Medicaid APG,1262.86,,,1262.86,Other,260% New York Medicaid APG,1573.72,,,1573.72,Other,324% New York Medicaid APG,1044.29,,,1044.29,Other,215% New York Medicaid APG,1044.29,,,1044.29,Other,215% New York Medicaid APG,607.14,,,607.14,Other,125% New York Medicaid APG,485.72,11494.66,
Njx px nfrosgrm &/urtrgrm,50431,CPT,,,,,,,,both,,,14368.32,10632.56,74,,10632.56,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,6465.74,45,,6465.74,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,7112.32,49.5,,7112.32,percent of total billed charges,110% of Medicare,9770.46,68,,9770.46,percent of total billed charges,,903.43,,,903.43,Other,186% of Medicaid,11494.66,80,,11494.66,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,11494.66,80,,11494.66,percent of total billed charges,,7216,,,7216,Case Rate,,3578,,"100% primary, 0% secondary procedures",3578,Other,MagnaCare ASC Grouper,10057.82,70,,10057.82,percent of total billed charges,,316.52,,,316.52,Fee Schedule,,268.27,,,268.27,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,485.72,,,485.72,Other,New York Medicaid APG methodology,485.72,,,485.72,Other,100% New York Medicaid APG,485.72,,,485.72,Other,100% New York Medicaid APG,485.72,,,485.72,Other,100% New York Medicaid APG,1092.86,,,1092.86,Other,225% New York Medicaid APG,743.14,,,743.14,Other,153% New York Medicaid APG,1092.86,,,1092.86,Other,225% New York Medicaid APG,680,,,680,Other,140% New York Medicaid APG,1092.86,,,1092.86,Other,225% New York Medicaid APG,1262.86,,,1262.86,Other,260% New York Medicaid APG,1573.72,,,1573.72,Other,324% New York Medicaid APG,1044.29,,,1044.29,Other,215% New York Medicaid APG,1044.29,,,1044.29,Other,215% New York Medicaid APG,607.14,,,607.14,Other,125% New York Medicaid APG,268.27,11494.66,
Plmt nephrostomy catheter,50432,CPT,,,,,,,,both,,,18708.67,13844.42,74,,13844.42,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,8418.9,45,,8418.9,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,9260.79,49.5,,9260.79,percent of total billed charges,110% of Medicare,12721.9,68,,12721.9,percent of total billed charges,,2011.18,,,2011.18,Other,186% of Medicaid,14966.94,80,,14966.94,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,14966.94,80,,14966.94,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,13096.07,70,,13096.07,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1081.28,,,1081.28,Other,New York Medicaid APG methodology,1081.28,,,1081.28,Other,100% New York Medicaid APG,1081.28,,,1081.28,Other,100% New York Medicaid APG,1081.28,,,1081.28,Other,100% New York Medicaid APG,2432.88,,,2432.88,Other,225% New York Medicaid APG,1654.36,,,1654.36,Other,153% New York Medicaid APG,2432.88,,,2432.88,Other,225% New York Medicaid APG,1513.79,,,1513.79,Other,140% New York Medicaid APG,2432.88,,,2432.88,Other,225% New York Medicaid APG,2811.33,,,2811.33,Other,260% New York Medicaid APG,3503.35,,,3503.35,Other,324% New York Medicaid APG,2324.75,,,2324.75,Other,215% New York Medicaid APG,2324.75,,,2324.75,Other,215% New York Medicaid APG,1351.6,,,1351.6,Other,125% New York Medicaid APG,1081.28,14966.94,
Plmt nephroureteral catheter,50433,CPT,,,,,,,,both,,,31502,23311.48,74,,23311.48,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,14175.9,45,,14175.9,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,15593.49,49.5,,15593.49,percent of total billed charges,110% of Medicare,21421.36,68,,21421.36,percent of total billed charges,,2586.25,,,2586.25,Other,186% of Medicaid,25201.6,80,,25201.6,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,25201.6,80,,25201.6,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,22051.4,70,,22051.4,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1390.46,,,1390.46,Other,New York Medicaid APG methodology,1390.46,,,1390.46,Other,100% New York Medicaid APG,1390.46,,,1390.46,Other,100% New York Medicaid APG,1390.46,,,1390.46,Other,100% New York Medicaid APG,3128.53,,,3128.53,Other,225% New York Medicaid APG,2127.4,,,2127.4,Other,153% New York Medicaid APG,3128.53,,,3128.53,Other,225% New York Medicaid APG,1946.64,,,1946.64,Other,140% New York Medicaid APG,3128.53,,,3128.53,Other,225% New York Medicaid APG,3615.19,,,3615.19,Other,260% New York Medicaid APG,4505.09,,,4505.09,Other,324% New York Medicaid APG,2989.49,,,2989.49,Other,215% New York Medicaid APG,2989.49,,,2989.49,Other,215% New York Medicaid APG,1738.07,,,1738.07,Other,125% New York Medicaid APG,1390.46,25201.6,
Convert nephrostomy catheter,50434,CPT,,,,,,,,both,,,42841.82,31702.95,74,,31702.95,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,19278.82,45,,19278.82,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,21206.7,49.5,,21206.7,percent of total billed charges,110% of Medicare,29132.44,68,,29132.44,percent of total billed charges,,2011.18,,,2011.18,Other,186% of Medicaid,34273.46,80,,34273.46,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,34273.46,80,,34273.46,percent of total billed charges,,7216,,,7216,Case Rate,,3578,,"100% primary, 0% secondary procedures",3578,Other,MagnaCare ASC Grouper,29989.27,70,,29989.27,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,1081.28,,,1081.28,Other,New York Medicaid APG methodology,1081.28,,,1081.28,Other,100% New York Medicaid APG,1081.28,,,1081.28,Other,100% New York Medicaid APG,1081.28,,,1081.28,Other,100% New York Medicaid APG,2432.88,,,2432.88,Other,225% New York Medicaid APG,1654.36,,,1654.36,Other,153% New York Medicaid APG,2432.88,,,2432.88,Other,225% New York Medicaid APG,1513.79,,,1513.79,Other,140% New York Medicaid APG,2432.88,,,2432.88,Other,225% New York Medicaid APG,2811.33,,,2811.33,Other,260% New York Medicaid APG,3503.35,,,3503.35,Other,324% New York Medicaid APG,2324.75,,,2324.75,Other,215% New York Medicaid APG,2324.75,,,2324.75,Other,215% New York Medicaid APG,1351.6,,,1351.6,Other,125% New York Medicaid APG,1081.28,34273.46,
Exchange nephrostomy cath,50435,CPT,,,,,,,,both,,,21380.09,15821.27,74,,15821.27,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,9621.04,45,,9621.04,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,10583.14,49.5,,10583.14,percent of total billed charges,110% of Medicare,14538.46,68,,14538.46,percent of total billed charges,,2011.18,,,2011.18,Other,186% of Medicaid,17104.07,80,,17104.07,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,17104.07,80,,17104.07,percent of total billed charges,,7216,,,7216,Case Rate,,3578,,"100% primary, 0% secondary procedures",3578,Other,MagnaCare ASC Grouper,14966.06,70,,14966.06,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,1081.28,,,1081.28,Other,New York Medicaid APG methodology,1081.28,,,1081.28,Other,100% New York Medicaid APG,1081.28,,,1081.28,Other,100% New York Medicaid APG,1081.28,,,1081.28,Other,100% New York Medicaid APG,2432.88,,,2432.88,Other,225% New York Medicaid APG,1654.36,,,1654.36,Other,153% New York Medicaid APG,2432.88,,,2432.88,Other,225% New York Medicaid APG,1513.79,,,1513.79,Other,140% New York Medicaid APG,2432.88,,,2432.88,Other,225% New York Medicaid APG,2811.33,,,2811.33,Other,260% New York Medicaid APG,3503.35,,,3503.35,Other,324% New York Medicaid APG,2324.75,,,2324.75,Other,215% New York Medicaid APG,2324.75,,,2324.75,Other,215% New York Medicaid APG,1351.6,,,1351.6,Other,125% New York Medicaid APG,1081.28,17104.07,
Dilat xst trc ndurlgc px,50436,CPT,,,,,,,,both,,,48568.73,35940.86,74,,35940.86,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,21855.93,45,,21855.93,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,24041.52,49.5,,24041.52,percent of total billed charges,110% of Medicare,33026.74,68,,33026.74,percent of total billed charges,,2011.18,,,2011.18,Other,186% of Medicaid,38854.98,80,,38854.98,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,38854.98,80,,38854.98,percent of total billed charges,,7216,,,7216,Case Rate,,3578,,"100% primary, 0% secondary procedures",3578,Other,MagnaCare ASC Grouper,33998.11,70,,33998.11,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1081.28,,,1081.28,Other,New York Medicaid APG methodology,1081.28,,,1081.28,Other,100% New York Medicaid APG,1081.28,,,1081.28,Other,100% New York Medicaid APG,1081.28,,,1081.28,Other,100% New York Medicaid APG,2432.88,,,2432.88,Other,225% New York Medicaid APG,1654.36,,,1654.36,Other,153% New York Medicaid APG,2432.88,,,2432.88,Other,225% New York Medicaid APG,1513.79,,,1513.79,Other,140% New York Medicaid APG,2432.88,,,2432.88,Other,225% New York Medicaid APG,2811.33,,,2811.33,Other,260% New York Medicaid APG,3503.35,,,3503.35,Other,324% New York Medicaid APG,2324.75,,,2324.75,Other,215% New York Medicaid APG,2324.75,,,2324.75,Other,215% New York Medicaid APG,1351.6,,,1351.6,Other,125% New York Medicaid APG,1081.28,38854.98,
Dilat xst trc new access rcs,50437,CPT,,,,,,,,both,,,73326.88,54261.89,74,,54261.89,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,32997.1,45,,32997.1,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,36296.81,49.5,,36296.81,percent of total billed charges,110% of Medicare,49862.28,68,,49862.28,percent of total billed charges,,2011.18,,,2011.18,Other,186% of Medicaid,58661.5,80,,58661.5,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,58661.5,80,,58661.5,percent of total billed charges,,7216,,,7216,Case Rate,,3578,,"100% primary, 0% secondary procedures",3578,Other,MagnaCare ASC Grouper,51328.82,70,,51328.82,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1081.28,,,1081.28,Other,New York Medicaid APG methodology,1081.28,,,1081.28,Other,100% New York Medicaid APG,1081.28,,,1081.28,Other,100% New York Medicaid APG,1081.28,,,1081.28,Other,100% New York Medicaid APG,2432.88,,,2432.88,Other,225% New York Medicaid APG,1654.36,,,1654.36,Other,153% New York Medicaid APG,2432.88,,,2432.88,Other,225% New York Medicaid APG,1513.79,,,1513.79,Other,140% New York Medicaid APG,2432.88,,,2432.88,Other,225% New York Medicaid APG,2811.33,,,2811.33,Other,260% New York Medicaid APG,3503.35,,,3503.35,Other,324% New York Medicaid APG,2324.75,,,2324.75,Other,215% New York Medicaid APG,2324.75,,,2324.75,Other,215% New York Medicaid APG,1351.6,,,1351.6,Other,125% New York Medicaid APG,1081.28,58661.5,
Laparo ablate renal cyst,50541,CPT,,,,,,,,both,,,43179.12,31952.55,74,,31952.55,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,19430.6,45,,19430.6,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,6125,,"100% primary, 50% secondary, 25% supplemental procedure",6125,Other,Blue Cross ASC Grouper,5513,,"100% primary, 50% secondary, 25% supplemental procedure",5513,Other,Blue Cross ASC Grouper,5206,,"100% primary, 50% secondary, 25% supplemental procedure",5206,Other,Blue Cross ASC Grouper,21373.66,49.5,,21373.66,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2586.25,,,2586.25,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,30225.38,70,,30225.38,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,1390.46,,,1390.46,Other,New York Medicaid APG methodology,1390.46,,,1390.46,Other,100% New York Medicaid APG,1390.46,,,1390.46,Other,100% New York Medicaid APG,1390.46,,,1390.46,Other,100% New York Medicaid APG,3128.53,,,3128.53,Other,225% New York Medicaid APG,2127.4,,,2127.4,Other,153% New York Medicaid APG,3128.53,,,3128.53,Other,225% New York Medicaid APG,1946.64,,,1946.64,Other,140% New York Medicaid APG,3128.53,,,3128.53,Other,225% New York Medicaid APG,3615.19,,,3615.19,Other,260% New York Medicaid APG,4505.09,,,4505.09,Other,324% New York Medicaid APG,2989.49,,,2989.49,Other,215% New York Medicaid APG,2989.49,,,2989.49,Other,215% New York Medicaid APG,1738.07,,,1738.07,Other,125% New York Medicaid APG,1390.46,31952.55,
Laparo ablate renal mass,50542,CPT,,,,,,,,both,,,216515.17,160221.23,74,,160221.23,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,97431.83,45,,97431.83,percent of total billed charges,Medicare Ratio of cost to charges,5954,,"100% primary, 50% supplemental procedure",5954,Other,Aetna ASC Grouper,5359,,"100% primary, 50% supplemental procedure",5359,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,107175.01,49.5,,107175.01,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3435.71,,,3435.71,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9196,,"100% primary, 0% secondary procedures",9196,Other,MagnaCare ASC Grouper,151560.62,70,,151560.62,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6956,,"100% primary, 50% secondary, 25% tertiary procedure",6956,Other,United Healthcare ASC Grouper,6261,,"100% primary, 50% secondary, 25% tertiary procedure",6261,Other,United Healthcare ASC Grouper,6956,,"100% primary, 50% secondary, 25% tertiary procedure",6956,Other,United Healthcare ASC Grouper,5913,,"100% primary, 50% secondary, 25% tertiary procedure",5913,Other,United Healthcare ASC Grouper,1847.16,,,1847.16,Other,New York Medicaid APG methodology,1847.16,,,1847.16,Other,100% New York Medicaid APG,1847.16,,,1847.16,Other,100% New York Medicaid APG,1847.16,,,1847.16,Other,100% New York Medicaid APG,4156.1,,,4156.1,Other,225% New York Medicaid APG,2826.15,,,2826.15,Other,153% New York Medicaid APG,4156.1,,,4156.1,Other,225% New York Medicaid APG,2586.02,,,2586.02,Other,140% New York Medicaid APG,4156.1,,,4156.1,Other,225% New York Medicaid APG,4802.61,,,4802.61,Other,260% New York Medicaid APG,5984.79,,,5984.79,Other,324% New York Medicaid APG,3971.39,,,3971.39,Other,215% New York Medicaid APG,3971.39,,,3971.39,Other,215% New York Medicaid APG,2308.95,,,2308.95,Other,125% New York Medicaid APG,1847.16,160221.23,
Laparo partial nephrectomy,50543,CPT,,,,,,,,both,,,53399.3,39515.48,74,,39515.48,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,24029.69,45,,24029.69,percent of total billed charges,Medicare Ratio of cost to charges,5954,,"100% primary, 50% supplemental procedure",5954,Other,Aetna ASC Grouper,5359,,"100% primary, 50% supplemental procedure",5359,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,26432.65,49.5,,26432.65,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3435.71,,,3435.71,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,37379.51,70,,37379.51,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,1847.16,,,1847.16,Other,New York Medicaid APG methodology,1847.16,,,1847.16,Other,100% New York Medicaid APG,1847.16,,,1847.16,Other,100% New York Medicaid APG,1847.16,,,1847.16,Other,100% New York Medicaid APG,4156.1,,,4156.1,Other,225% New York Medicaid APG,2826.15,,,2826.15,Other,153% New York Medicaid APG,4156.1,,,4156.1,Other,225% New York Medicaid APG,2586.02,,,2586.02,Other,140% New York Medicaid APG,4156.1,,,4156.1,Other,225% New York Medicaid APG,4802.61,,,4802.61,Other,260% New York Medicaid APG,5984.79,,,5984.79,Other,324% New York Medicaid APG,3971.39,,,3971.39,Other,215% New York Medicaid APG,3971.39,,,3971.39,Other,215% New York Medicaid APG,2308.95,,,2308.95,Other,125% New York Medicaid APG,1847.16,39515.48,
Laparoscopy pyeloplasty,50544,CPT,,,,,,,,both,,,44766.15,33126.95,74,,33126.95,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,20144.77,45,,20144.77,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,22159.24,49.5,,22159.24,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3435.71,,,3435.71,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,31336.31,70,,31336.31,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,1847.16,,,1847.16,Other,New York Medicaid APG methodology,1847.16,,,1847.16,Other,100% New York Medicaid APG,1847.16,,,1847.16,Other,100% New York Medicaid APG,1847.16,,,1847.16,Other,100% New York Medicaid APG,4156.1,,,4156.1,Other,225% New York Medicaid APG,2826.15,,,2826.15,Other,153% New York Medicaid APG,4156.1,,,4156.1,Other,225% New York Medicaid APG,2586.02,,,2586.02,Other,140% New York Medicaid APG,4156.1,,,4156.1,Other,225% New York Medicaid APG,4802.61,,,4802.61,Other,260% New York Medicaid APG,5984.79,,,5984.79,Other,324% New York Medicaid APG,3971.39,,,3971.39,Other,215% New York Medicaid APG,3971.39,,,3971.39,Other,215% New York Medicaid APG,2308.95,,,2308.95,Other,125% New York Medicaid APG,1847.16,33126.95,
Kidney endoscopy,50551,CPT,,,,,,,,both,,,108835.97,80538.62,74,,80538.62,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,48976.19,45,,48976.19,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,53873.81,49.5,,53873.81,percent of total billed charges,110% of Medicare,74008.46,68,,74008.46,percent of total billed charges,,2586.25,,,2586.25,Other,186% of Medicaid,87068.78,80,,87068.78,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,87068.78,80,,87068.78,percent of total billed charges,,7216,,,7216,Case Rate,,3578,,"100% primary, 0% secondary procedures",3578,Other,MagnaCare ASC Grouper,76185.18,70,,76185.18,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1390.46,,,1390.46,Other,New York Medicaid APG methodology,1390.46,,,1390.46,Other,100% New York Medicaid APG,1390.46,,,1390.46,Other,100% New York Medicaid APG,1390.46,,,1390.46,Other,100% New York Medicaid APG,3128.53,,,3128.53,Other,225% New York Medicaid APG,2127.4,,,2127.4,Other,153% New York Medicaid APG,3128.53,,,3128.53,Other,225% New York Medicaid APG,1946.64,,,1946.64,Other,140% New York Medicaid APG,3128.53,,,3128.53,Other,225% New York Medicaid APG,3615.19,,,3615.19,Other,260% New York Medicaid APG,4505.09,,,4505.09,Other,324% New York Medicaid APG,2989.49,,,2989.49,Other,215% New York Medicaid APG,2989.49,,,2989.49,Other,215% New York Medicaid APG,1738.07,,,1738.07,Other,125% New York Medicaid APG,1390.46,87068.78,
Kidney endoscopy,50553,CPT,,,,,,,,both,,,36540,27039.6,74,,27039.6,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,16443,45,,16443,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,18087.3,49.5,,18087.3,percent of total billed charges,110% of Medicare,24847.2,68,,24847.2,percent of total billed charges,,2586.25,,,2586.25,Other,186% of Medicaid,29232,80,,29232,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,29232,80,,29232,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,25578,70,,25578,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1390.46,,,1390.46,Other,New York Medicaid APG methodology,1390.46,,,1390.46,Other,100% New York Medicaid APG,1390.46,,,1390.46,Other,100% New York Medicaid APG,1390.46,,,1390.46,Other,100% New York Medicaid APG,3128.53,,,3128.53,Other,225% New York Medicaid APG,2127.4,,,2127.4,Other,153% New York Medicaid APG,3128.53,,,3128.53,Other,225% New York Medicaid APG,1946.64,,,1946.64,Other,140% New York Medicaid APG,3128.53,,,3128.53,Other,225% New York Medicaid APG,3615.19,,,3615.19,Other,260% New York Medicaid APG,4505.09,,,4505.09,Other,324% New York Medicaid APG,2989.49,,,2989.49,Other,215% New York Medicaid APG,2989.49,,,2989.49,Other,215% New York Medicaid APG,1738.07,,,1738.07,Other,125% New York Medicaid APG,1390.46,29232,
Kidney endoscopy & biopsy,50555,CPT,,,,,,,,both,,,193769.26,143389.25,74,,143389.25,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,87196.17,45,,87196.17,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,95915.78,49.5,,95915.78,percent of total billed charges,110% of Medicare,131763.1,68,,131763.1,percent of total billed charges,,2586.25,,,2586.25,Other,186% of Medicaid,155015.41,80,,155015.41,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,155015.41,80,,155015.41,percent of total billed charges,,7216,,,7216,Case Rate,,3578,,"100% primary, 0% secondary procedures",3578,Other,MagnaCare ASC Grouper,135638.48,70,,135638.48,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1390.46,,,1390.46,Other,New York Medicaid APG methodology,1390.46,,,1390.46,Other,100% New York Medicaid APG,1390.46,,,1390.46,Other,100% New York Medicaid APG,1390.46,,,1390.46,Other,100% New York Medicaid APG,3128.53,,,3128.53,Other,225% New York Medicaid APG,2127.4,,,2127.4,Other,153% New York Medicaid APG,3128.53,,,3128.53,Other,225% New York Medicaid APG,1946.64,,,1946.64,Other,140% New York Medicaid APG,3128.53,,,3128.53,Other,225% New York Medicaid APG,3615.19,,,3615.19,Other,260% New York Medicaid APG,4505.09,,,4505.09,Other,324% New York Medicaid APG,2989.49,,,2989.49,Other,215% New York Medicaid APG,2989.49,,,2989.49,Other,215% New York Medicaid APG,1738.07,,,1738.07,Other,125% New York Medicaid APG,1390.46,155015.41,
Kidney endoscopy & treatment,50557,CPT,,,,,,,,both,,,57942.78,42877.66,74,,42877.66,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,26074.25,45,,26074.25,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,28681.68,49.5,,28681.68,percent of total billed charges,110% of Medicare,39401.09,68,,39401.09,percent of total billed charges,,2586.25,,,2586.25,Other,186% of Medicaid,46354.22,80,,46354.22,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,46354.22,80,,46354.22,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,40559.95,70,,40559.95,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1390.46,,,1390.46,Other,New York Medicaid APG methodology,1390.46,,,1390.46,Other,100% New York Medicaid APG,1390.46,,,1390.46,Other,100% New York Medicaid APG,1390.46,,,1390.46,Other,100% New York Medicaid APG,3128.53,,,3128.53,Other,225% New York Medicaid APG,2127.4,,,2127.4,Other,153% New York Medicaid APG,3128.53,,,3128.53,Other,225% New York Medicaid APG,1946.64,,,1946.64,Other,140% New York Medicaid APG,3128.53,,,3128.53,Other,225% New York Medicaid APG,3615.19,,,3615.19,Other,260% New York Medicaid APG,4505.09,,,4505.09,Other,324% New York Medicaid APG,2989.49,,,2989.49,Other,215% New York Medicaid APG,2989.49,,,2989.49,Other,215% New York Medicaid APG,1738.07,,,1738.07,Other,125% New York Medicaid APG,1390.46,46354.22,
Kidney endoscopy & treatment,50561,CPT,,,,,,,,both,,,108835.97,80538.62,74,,80538.62,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,48976.19,45,,48976.19,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,53873.81,49.5,,53873.81,percent of total billed charges,110% of Medicare,74008.46,68,,74008.46,percent of total billed charges,,2586.25,,,2586.25,Other,186% of Medicaid,87068.78,80,,87068.78,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,87068.78,80,,87068.78,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,76185.18,70,,76185.18,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1390.46,,,1390.46,Other,New York Medicaid APG methodology,1390.46,,,1390.46,Other,100% New York Medicaid APG,1390.46,,,1390.46,Other,100% New York Medicaid APG,1390.46,,,1390.46,Other,100% New York Medicaid APG,3128.53,,,3128.53,Other,225% New York Medicaid APG,2127.4,,,2127.4,Other,153% New York Medicaid APG,3128.53,,,3128.53,Other,225% New York Medicaid APG,1946.64,,,1946.64,Other,140% New York Medicaid APG,3128.53,,,3128.53,Other,225% New York Medicaid APG,3615.19,,,3615.19,Other,260% New York Medicaid APG,4505.09,,,4505.09,Other,324% New York Medicaid APG,2989.49,,,2989.49,Other,215% New York Medicaid APG,2989.49,,,2989.49,Other,215% New York Medicaid APG,1738.07,,,1738.07,Other,125% New York Medicaid APG,1390.46,87068.78,
Renal scope w/tumor resect,50562,CPT,,,,,,,,both,,,193769.26,143389.25,74,,143389.25,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,87196.17,45,,87196.17,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,95915.78,49.5,,95915.78,percent of total billed charges,110% of Medicare,131763.1,68,,131763.1,percent of total billed charges,,2586.25,,,2586.25,Other,186% of Medicaid,155015.41,80,,155015.41,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,155015.41,80,,155015.41,percent of total billed charges,,7216,,,7216,Case Rate,,3578,,"100% primary, 0% secondary procedures",3578,Other,MagnaCare ASC Grouper,135638.48,70,,135638.48,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,1390.46,,,1390.46,Other,New York Medicaid APG methodology,1390.46,,,1390.46,Other,100% New York Medicaid APG,1390.46,,,1390.46,Other,100% New York Medicaid APG,1390.46,,,1390.46,Other,100% New York Medicaid APG,3128.53,,,3128.53,Other,225% New York Medicaid APG,2127.4,,,2127.4,Other,153% New York Medicaid APG,3128.53,,,3128.53,Other,225% New York Medicaid APG,1946.64,,,1946.64,Other,140% New York Medicaid APG,3128.53,,,3128.53,Other,225% New York Medicaid APG,3615.19,,,3615.19,Other,260% New York Medicaid APG,4505.09,,,4505.09,Other,324% New York Medicaid APG,2989.49,,,2989.49,Other,215% New York Medicaid APG,2989.49,,,2989.49,Other,215% New York Medicaid APG,1738.07,,,1738.07,Other,125% New York Medicaid APG,1390.46,155015.41,
Kidney endoscopy,50570,CPT,,,,,,,,both,,,73326.88,54261.89,74,,54261.89,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,32997.1,45,,32997.1,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,36296.81,49.5,,36296.81,percent of total billed charges,110% of Medicare,49862.28,68,,49862.28,percent of total billed charges,,2586.25,,,2586.25,Other,186% of Medicaid,58661.5,80,,58661.5,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,58661.5,80,,58661.5,percent of total billed charges,,7216,,,7216,Case Rate,,3578,,"100% primary, 0% secondary procedures",3578,Other,MagnaCare ASC Grouper,51328.82,70,,51328.82,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,1390.46,,,1390.46,Other,New York Medicaid APG methodology,1390.46,,,1390.46,Other,100% New York Medicaid APG,1390.46,,,1390.46,Other,100% New York Medicaid APG,1390.46,,,1390.46,Other,100% New York Medicaid APG,3128.53,,,3128.53,Other,225% New York Medicaid APG,2127.4,,,2127.4,Other,153% New York Medicaid APG,3128.53,,,3128.53,Other,225% New York Medicaid APG,1946.64,,,1946.64,Other,140% New York Medicaid APG,3128.53,,,3128.53,Other,225% New York Medicaid APG,3615.19,,,3615.19,Other,260% New York Medicaid APG,4505.09,,,4505.09,Other,324% New York Medicaid APG,2989.49,,,2989.49,Other,215% New York Medicaid APG,2989.49,,,2989.49,Other,215% New York Medicaid APG,1738.07,,,1738.07,Other,125% New York Medicaid APG,1390.46,58661.5,
Kidney endoscopy,50572,CPT,,,,,,,,both,,,14368.32,10632.56,74,,10632.56,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,6465.74,45,,6465.74,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,7112.32,49.5,,7112.32,percent of total billed charges,110% of Medicare,9770.46,68,,9770.46,percent of total billed charges,,2011.18,,,2011.18,Other,186% of Medicaid,11494.66,80,,11494.66,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,11494.66,80,,11494.66,percent of total billed charges,,7216,,,7216,Case Rate,,3578,,"100% primary, 0% secondary procedures",3578,Other,MagnaCare ASC Grouper,10057.82,70,,10057.82,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,1081.28,,,1081.28,Other,New York Medicaid APG methodology,1081.28,,,1081.28,Other,100% New York Medicaid APG,1081.28,,,1081.28,Other,100% New York Medicaid APG,1081.28,,,1081.28,Other,100% New York Medicaid APG,2432.88,,,2432.88,Other,225% New York Medicaid APG,1654.36,,,1654.36,Other,153% New York Medicaid APG,2432.88,,,2432.88,Other,225% New York Medicaid APG,1513.79,,,1513.79,Other,140% New York Medicaid APG,2432.88,,,2432.88,Other,225% New York Medicaid APG,2811.33,,,2811.33,Other,260% New York Medicaid APG,3503.35,,,3503.35,Other,324% New York Medicaid APG,2324.75,,,2324.75,Other,215% New York Medicaid APG,2324.75,,,2324.75,Other,215% New York Medicaid APG,1351.6,,,1351.6,Other,125% New York Medicaid APG,1081.28,11494.66,
Kidney endoscopy & biopsy,50574,CPT,,,,,,,,both,,,73326.88,54261.89,74,,54261.89,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,32997.1,45,,32997.1,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,36296.81,49.5,,36296.81,percent of total billed charges,110% of Medicare,49862.28,68,,49862.28,percent of total billed charges,,2586.25,,,2586.25,Other,186% of Medicaid,58661.5,80,,58661.5,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,58661.5,80,,58661.5,percent of total billed charges,,7216,,,7216,Case Rate,,3578,,"100% primary, 0% secondary procedures",3578,Other,MagnaCare ASC Grouper,51328.82,70,,51328.82,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,1390.46,,,1390.46,Other,New York Medicaid APG methodology,1390.46,,,1390.46,Other,100% New York Medicaid APG,1390.46,,,1390.46,Other,100% New York Medicaid APG,1390.46,,,1390.46,Other,100% New York Medicaid APG,3128.53,,,3128.53,Other,225% New York Medicaid APG,2127.4,,,2127.4,Other,153% New York Medicaid APG,3128.53,,,3128.53,Other,225% New York Medicaid APG,1946.64,,,1946.64,Other,140% New York Medicaid APG,3128.53,,,3128.53,Other,225% New York Medicaid APG,3615.19,,,3615.19,Other,260% New York Medicaid APG,4505.09,,,4505.09,Other,324% New York Medicaid APG,2989.49,,,2989.49,Other,215% New York Medicaid APG,2989.49,,,2989.49,Other,215% New York Medicaid APG,1738.07,,,1738.07,Other,125% New York Medicaid APG,1390.46,58661.5,
Kidney endoscopy,50575,CPT,,,,,,,,both,,,108835.97,80538.62,74,,80538.62,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,48976.19,45,,48976.19,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,53873.81,49.5,,53873.81,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2586.25,,,2586.25,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,76185.18,70,,76185.18,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,1390.46,,,1390.46,Other,New York Medicaid APG methodology,1390.46,,,1390.46,Other,100% New York Medicaid APG,1390.46,,,1390.46,Other,100% New York Medicaid APG,1390.46,,,1390.46,Other,100% New York Medicaid APG,3128.53,,,3128.53,Other,225% New York Medicaid APG,2127.4,,,2127.4,Other,153% New York Medicaid APG,3128.53,,,3128.53,Other,225% New York Medicaid APG,1946.64,,,1946.64,Other,140% New York Medicaid APG,3128.53,,,3128.53,Other,225% New York Medicaid APG,3615.19,,,3615.19,Other,260% New York Medicaid APG,4505.09,,,4505.09,Other,324% New York Medicaid APG,2989.49,,,2989.49,Other,215% New York Medicaid APG,2989.49,,,2989.49,Other,215% New York Medicaid APG,1738.07,,,1738.07,Other,125% New York Medicaid APG,1390.46,80538.62,
Kidney endoscopy & treatment,50576,CPT,,,,,,,,both,,,193769.26,143389.25,74,,143389.25,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,87196.17,45,,87196.17,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,95915.78,49.5,,95915.78,percent of total billed charges,110% of Medicare,131763.1,68,,131763.1,percent of total billed charges,,2586.25,,,2586.25,Other,186% of Medicaid,155015.41,80,,155015.41,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,155015.41,80,,155015.41,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,135638.48,70,,135638.48,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1390.46,,,1390.46,Other,New York Medicaid APG methodology,1390.46,,,1390.46,Other,100% New York Medicaid APG,1390.46,,,1390.46,Other,100% New York Medicaid APG,1390.46,,,1390.46,Other,100% New York Medicaid APG,3128.53,,,3128.53,Other,225% New York Medicaid APG,2127.4,,,2127.4,Other,153% New York Medicaid APG,3128.53,,,3128.53,Other,225% New York Medicaid APG,1946.64,,,1946.64,Other,140% New York Medicaid APG,3128.53,,,3128.53,Other,225% New York Medicaid APG,3615.19,,,3615.19,Other,260% New York Medicaid APG,4505.09,,,4505.09,Other,324% New York Medicaid APG,2989.49,,,2989.49,Other,215% New York Medicaid APG,2989.49,,,2989.49,Other,215% New York Medicaid APG,1738.07,,,1738.07,Other,125% New York Medicaid APG,1390.46,155015.41,
Kidney endoscopy & treatment,50580,CPT,,,,,,,,both,,,108835.97,80538.62,74,,80538.62,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,48976.19,45,,48976.19,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,53873.81,49.5,,53873.81,percent of total billed charges,110% of Medicare,74008.46,68,,74008.46,percent of total billed charges,,2586.25,,,2586.25,Other,186% of Medicaid,87068.78,80,,87068.78,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,87068.78,80,,87068.78,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,76185.18,70,,76185.18,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1390.46,,,1390.46,Other,New York Medicaid APG methodology,1390.46,,,1390.46,Other,100% New York Medicaid APG,1390.46,,,1390.46,Other,100% New York Medicaid APG,1390.46,,,1390.46,Other,100% New York Medicaid APG,3128.53,,,3128.53,Other,225% New York Medicaid APG,2127.4,,,2127.4,Other,153% New York Medicaid APG,3128.53,,,3128.53,Other,225% New York Medicaid APG,1946.64,,,1946.64,Other,140% New York Medicaid APG,3128.53,,,3128.53,Other,225% New York Medicaid APG,3615.19,,,3615.19,Other,260% New York Medicaid APG,4505.09,,,4505.09,Other,324% New York Medicaid APG,2989.49,,,2989.49,Other,215% New York Medicaid APG,2989.49,,,2989.49,Other,215% New York Medicaid APG,1738.07,,,1738.07,Other,125% New York Medicaid APG,1390.46,87068.78,
Fragmenting of kidney stone,50590,CPT,,,,,,,,both,,,33416.74,24728.39,74,,24728.39,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15037.53,45,,15037.53,percent of total billed charges,Medicare Ratio of cost to charges,7938,,"100% primary, 50% supplemental procedure",7938,Other,Aetna ASC Grouper,7144,,"100% primary, 50% supplemental procedure",7144,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,16541.29,49.5,,16541.29,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2586.25,,,2586.25,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,23391.72,70,,23391.72,percent of total billed charges,,2769.96,,,2769.96,Fee Schedule,,2347.71,,,2347.71,Fee Schedule,,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,1390.46,,,1390.46,Other,New York Medicaid APG methodology,1390.46,,,1390.46,Other,100% New York Medicaid APG,1390.46,,,1390.46,Other,100% New York Medicaid APG,1390.46,,,1390.46,Other,100% New York Medicaid APG,3128.53,,,3128.53,Other,225% New York Medicaid APG,2127.4,,,2127.4,Other,153% New York Medicaid APG,3128.53,,,3128.53,Other,225% New York Medicaid APG,1946.64,,,1946.64,Other,140% New York Medicaid APG,3128.53,,,3128.53,Other,225% New York Medicaid APG,3615.19,,,3615.19,Other,260% New York Medicaid APG,4505.09,,,4505.09,Other,324% New York Medicaid APG,2989.49,,,2989.49,Other,215% New York Medicaid APG,2989.49,,,2989.49,Other,215% New York Medicaid APG,1738.07,,,1738.07,Other,125% New York Medicaid APG,1390.46,24728.39,
Perc rf ablate renal tumor,50592,CPT,,,,,,,,both,,,39799.33,29451.5,74,,29451.5,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,17909.7,45,,17909.7,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,6125,,"100% primary, 50% secondary, 25% supplemental procedure",6125,Other,Blue Cross ASC Grouper,5513,,"100% primary, 50% secondary, 25% supplemental procedure",5513,Other,Blue Cross ASC Grouper,5206,,"100% primary, 50% secondary, 25% supplemental procedure",5206,Other,Blue Cross ASC Grouper,19700.67,49.5,,19700.67,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2586.25,,,2586.25,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,27859.53,70,,27859.53,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,1390.46,,,1390.46,Other,New York Medicaid APG methodology,1390.46,,,1390.46,Other,100% New York Medicaid APG,1390.46,,,1390.46,Other,100% New York Medicaid APG,1390.46,,,1390.46,Other,100% New York Medicaid APG,3128.53,,,3128.53,Other,225% New York Medicaid APG,2127.4,,,2127.4,Other,153% New York Medicaid APG,3128.53,,,3128.53,Other,225% New York Medicaid APG,1946.64,,,1946.64,Other,140% New York Medicaid APG,3128.53,,,3128.53,Other,225% New York Medicaid APG,3615.19,,,3615.19,Other,260% New York Medicaid APG,4505.09,,,4505.09,Other,324% New York Medicaid APG,2989.49,,,2989.49,Other,215% New York Medicaid APG,2989.49,,,2989.49,Other,215% New York Medicaid APG,1738.07,,,1738.07,Other,125% New York Medicaid APG,1390.46,29451.5,
Perc cryo ablate renal tum,50593,CPT,,,,,,,,both,,,216515.17,160221.23,74,,160221.23,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,97431.83,45,,97431.83,percent of total billed charges,Medicare Ratio of cost to charges,7938,,"100% primary, 50% supplemental procedure",7938,Other,Aetna ASC Grouper,7144,,"100% primary, 50% supplemental procedure",7144,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,107175.01,49.5,,107175.01,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3435.71,,,3435.71,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,151560.62,70,,151560.62,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,1847.16,,,1847.16,Other,New York Medicaid APG methodology,1847.16,,,1847.16,Other,100% New York Medicaid APG,1847.16,,,1847.16,Other,100% New York Medicaid APG,1847.16,,,1847.16,Other,100% New York Medicaid APG,4156.1,,,4156.1,Other,225% New York Medicaid APG,2826.15,,,2826.15,Other,153% New York Medicaid APG,4156.1,,,4156.1,Other,225% New York Medicaid APG,2586.02,,,2586.02,Other,140% New York Medicaid APG,4156.1,,,4156.1,Other,225% New York Medicaid APG,4802.61,,,4802.61,Other,260% New York Medicaid APG,5984.79,,,5984.79,Other,324% New York Medicaid APG,3971.39,,,3971.39,Other,215% New York Medicaid APG,3971.39,,,3971.39,Other,215% New York Medicaid APG,2308.95,,,2308.95,Other,125% New York Medicaid APG,1847.16,160221.23,
Endoluminal bx urtr rnl plvs,50606,CPT,,,,,,,,both,,,32432.1,23999.75,74,,23999.75,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,14594.45,45,,14594.45,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,16053.89,49.5,,16053.89,percent of total billed charges,110% of Medicare,22053.83,68,,22053.83,percent of total billed charges,,3435.71,,,3435.71,Other,186% of Medicaid,25945.68,80,,25945.68,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,25945.68,80,,25945.68,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,22702.47,70,,22702.47,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,1847.16,,,1847.16,Other,New York Medicaid APG methodology,1847.16,,,1847.16,Other,100% New York Medicaid APG,1847.16,,,1847.16,Other,100% New York Medicaid APG,1847.16,,,1847.16,Other,100% New York Medicaid APG,4156.1,,,4156.1,Other,225% New York Medicaid APG,2826.15,,,2826.15,Other,153% New York Medicaid APG,4156.1,,,4156.1,Other,225% New York Medicaid APG,2586.02,,,2586.02,Other,140% New York Medicaid APG,4156.1,,,4156.1,Other,225% New York Medicaid APG,4802.61,,,4802.61,Other,260% New York Medicaid APG,5984.79,,,5984.79,Other,324% New York Medicaid APG,3971.39,,,3971.39,Other,215% New York Medicaid APG,3971.39,,,3971.39,Other,215% New York Medicaid APG,2308.95,,,2308.95,Other,125% New York Medicaid APG,1847.16,25945.68,
Injection for ureter x-ray,50684,CPT,,,,,,,,both,,,32432.1,23999.75,74,,23999.75,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,14594.45,45,,14594.45,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,16053.89,49.5,,16053.89,percent of total billed charges,110% of Medicare,22053.83,68,,22053.83,percent of total billed charges,,966.93,,,966.93,Other,186% of Medicaid,25945.68,80,,25945.68,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,25945.68,80,,25945.68,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,22702.47,70,,22702.47,percent of total billed charges,,246,,,246,Fee Schedule,,208.5,,,208.5,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,519.86,,,519.86,Other,New York Medicaid APG methodology,519.86,,,519.86,Other,100% New York Medicaid APG,519.86,,,519.86,Other,100% New York Medicaid APG,519.86,,,519.86,Other,100% New York Medicaid APG,1169.68,,,1169.68,Other,225% New York Medicaid APG,795.38,,,795.38,Other,153% New York Medicaid APG,1169.68,,,1169.68,Other,225% New York Medicaid APG,727.8,,,727.8,Other,140% New York Medicaid APG,1169.68,,,1169.68,Other,225% New York Medicaid APG,1351.62,,,1351.62,Other,260% New York Medicaid APG,1684.33,,,1684.33,Other,324% New York Medicaid APG,1117.69,,,1117.69,Other,215% New York Medicaid APG,1117.69,,,1117.69,Other,215% New York Medicaid APG,649.82,,,649.82,Other,125% New York Medicaid APG,208.5,25945.68,
Measure ureter pressure,50686,CPT,,,,,,,,both,,,3285.56,2431.31,74,,2431.31,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,1478.5,45,,1478.5,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,1626.35,49.5,,1626.35,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,847.8,,,847.8,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,2299.89,70,,2299.89,percent of total billed charges,,424.76,,,424.76,Fee Schedule,,360.01,,,360.01,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,455.81,,,455.81,Other,New York Medicaid APG methodology,455.81,,,455.81,Other,100% New York Medicaid APG,455.81,,,455.81,Other,100% New York Medicaid APG,455.81,,,455.81,Other,100% New York Medicaid APG,1025.56,,,1025.56,Other,225% New York Medicaid APG,697.38,,,697.38,Other,153% New York Medicaid APG,1025.56,,,1025.56,Other,225% New York Medicaid APG,638.13,,,638.13,Other,140% New York Medicaid APG,1025.56,,,1025.56,Other,225% New York Medicaid APG,1185.1,,,1185.1,Other,260% New York Medicaid APG,1476.81,,,1476.81,Other,324% New York Medicaid APG,979.98,,,979.98,Other,215% New York Medicaid APG,979.98,,,979.98,Other,215% New York Medicaid APG,569.76,,,569.76,Other,125% New York Medicaid APG,360.01,9473,
Change of ureter tube/stent,50688,CPT,,,,,,,,both,,,42841.82,31702.95,74,,31702.95,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,19278.82,45,,19278.82,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,21206.7,49.5,,21206.7,percent of total billed charges,110% of Medicare,29132.44,68,,29132.44,percent of total billed charges,,2011.18,,,2011.18,Other,186% of Medicaid,34273.46,80,,34273.46,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,34273.46,80,,34273.46,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,29989.27,70,,29989.27,percent of total billed charges,,373.92,,,373.92,Fee Schedule,,316.92,,,316.92,Fee Schedule,,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1081.28,,,1081.28,Other,New York Medicaid APG methodology,1081.28,,,1081.28,Other,100% New York Medicaid APG,1081.28,,,1081.28,Other,100% New York Medicaid APG,1081.28,,,1081.28,Other,100% New York Medicaid APG,2432.88,,,2432.88,Other,225% New York Medicaid APG,1654.36,,,1654.36,Other,153% New York Medicaid APG,2432.88,,,2432.88,Other,225% New York Medicaid APG,1513.79,,,1513.79,Other,140% New York Medicaid APG,2432.88,,,2432.88,Other,225% New York Medicaid APG,2811.33,,,2811.33,Other,260% New York Medicaid APG,3503.35,,,3503.35,Other,324% New York Medicaid APG,2324.75,,,2324.75,Other,215% New York Medicaid APG,2324.75,,,2324.75,Other,215% New York Medicaid APG,1351.6,,,1351.6,Other,125% New York Medicaid APG,316.92,34273.46,
Injection for ureter x-ray,50690,CPT,,,,,,,,both,,,32432.1,23999.75,74,,23999.75,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,14594.45,45,,14594.45,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,16053.89,49.5,,16053.89,percent of total billed charges,110% of Medicare,22053.83,68,,22053.83,percent of total billed charges,,966.93,,,966.93,Other,186% of Medicaid,25945.68,80,,25945.68,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,25945.68,80,,25945.68,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,22702.47,70,,22702.47,percent of total billed charges,,337.84,,,337.84,Fee Schedule,,286.34,,,286.34,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,519.86,,,519.86,Other,New York Medicaid APG methodology,519.86,,,519.86,Other,100% New York Medicaid APG,519.86,,,519.86,Other,100% New York Medicaid APG,519.86,,,519.86,Other,100% New York Medicaid APG,1169.68,,,1169.68,Other,225% New York Medicaid APG,795.38,,,795.38,Other,153% New York Medicaid APG,1169.68,,,1169.68,Other,225% New York Medicaid APG,727.8,,,727.8,Other,140% New York Medicaid APG,1169.68,,,1169.68,Other,225% New York Medicaid APG,1351.62,,,1351.62,Other,260% New York Medicaid APG,1684.33,,,1684.33,Other,324% New York Medicaid APG,1117.69,,,1117.69,Other,215% New York Medicaid APG,1117.69,,,1117.69,Other,215% New York Medicaid APG,649.82,,,649.82,Other,125% New York Medicaid APG,286.34,25945.68,
Plmt ureteral stent prq,50693,CPT,,,,,,,,both,,,73326.88,54261.89,74,,54261.89,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,32997.1,45,,32997.1,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,36296.81,49.5,,36296.81,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2586.25,,,2586.25,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,51328.82,70,,51328.82,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1390.46,,,1390.46,Other,New York Medicaid APG methodology,1390.46,,,1390.46,Other,100% New York Medicaid APG,1390.46,,,1390.46,Other,100% New York Medicaid APG,1390.46,,,1390.46,Other,100% New York Medicaid APG,3128.53,,,3128.53,Other,225% New York Medicaid APG,2127.4,,,2127.4,Other,153% New York Medicaid APG,3128.53,,,3128.53,Other,225% New York Medicaid APG,1946.64,,,1946.64,Other,140% New York Medicaid APG,3128.53,,,3128.53,Other,225% New York Medicaid APG,3615.19,,,3615.19,Other,260% New York Medicaid APG,4505.09,,,4505.09,Other,324% New York Medicaid APG,2989.49,,,2989.49,Other,215% New York Medicaid APG,2989.49,,,2989.49,Other,215% New York Medicaid APG,1738.07,,,1738.07,Other,125% New York Medicaid APG,1390.46,54261.89,
Plmt ureteral stent prq,50694,CPT,,,,,,,,both,,,73326.88,54261.89,74,,54261.89,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,32997.1,45,,32997.1,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,36296.81,49.5,,36296.81,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2586.25,,,2586.25,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,51328.82,70,,51328.82,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1390.46,,,1390.46,Other,New York Medicaid APG methodology,1390.46,,,1390.46,Other,100% New York Medicaid APG,1390.46,,,1390.46,Other,100% New York Medicaid APG,1390.46,,,1390.46,Other,100% New York Medicaid APG,3128.53,,,3128.53,Other,225% New York Medicaid APG,2127.4,,,2127.4,Other,153% New York Medicaid APG,3128.53,,,3128.53,Other,225% New York Medicaid APG,1946.64,,,1946.64,Other,140% New York Medicaid APG,3128.53,,,3128.53,Other,225% New York Medicaid APG,3615.19,,,3615.19,Other,260% New York Medicaid APG,4505.09,,,4505.09,Other,324% New York Medicaid APG,2989.49,,,2989.49,Other,215% New York Medicaid APG,2989.49,,,2989.49,Other,215% New York Medicaid APG,1738.07,,,1738.07,Other,125% New York Medicaid APG,1390.46,54261.89,
Plmt ureteral stent prq,50695,CPT,,,,,,,,both,,,73326.88,54261.89,74,,54261.89,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,32997.1,45,,32997.1,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,36296.81,49.5,,36296.81,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2586.25,,,2586.25,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,51328.82,70,,51328.82,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1390.46,,,1390.46,Other,New York Medicaid APG methodology,1390.46,,,1390.46,Other,100% New York Medicaid APG,1390.46,,,1390.46,Other,100% New York Medicaid APG,1390.46,,,1390.46,Other,100% New York Medicaid APG,3128.53,,,3128.53,Other,225% New York Medicaid APG,2127.4,,,2127.4,Other,153% New York Medicaid APG,3128.53,,,3128.53,Other,225% New York Medicaid APG,1946.64,,,1946.64,Other,140% New York Medicaid APG,3128.53,,,3128.53,Other,225% New York Medicaid APG,3615.19,,,3615.19,Other,260% New York Medicaid APG,4505.09,,,4505.09,Other,324% New York Medicaid APG,2989.49,,,2989.49,Other,215% New York Medicaid APG,2989.49,,,2989.49,Other,215% New York Medicaid APG,1738.07,,,1738.07,Other,125% New York Medicaid APG,1390.46,54261.89,
Ureteral embolization/occl,50705,CPT,,,,,,,,both,,,64479.48,47714.82,74,,47714.82,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,29015.77,45,,29015.77,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,31917.34,49.5,,31917.34,percent of total billed charges,110% of Medicare,43846.05,68,,43846.05,percent of total billed charges,,3435.71,,,3435.71,Other,186% of Medicaid,51583.58,80,,51583.58,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,51583.58,80,,51583.58,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,45135.64,70,,45135.64,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,1847.16,,,1847.16,Other,New York Medicaid APG methodology,1847.16,,,1847.16,Other,100% New York Medicaid APG,1847.16,,,1847.16,Other,100% New York Medicaid APG,1847.16,,,1847.16,Other,100% New York Medicaid APG,4156.1,,,4156.1,Other,225% New York Medicaid APG,2826.15,,,2826.15,Other,153% New York Medicaid APG,4156.1,,,4156.1,Other,225% New York Medicaid APG,2586.02,,,2586.02,Other,140% New York Medicaid APG,4156.1,,,4156.1,Other,225% New York Medicaid APG,4802.61,,,4802.61,Other,260% New York Medicaid APG,5984.79,,,5984.79,Other,324% New York Medicaid APG,3971.39,,,3971.39,Other,215% New York Medicaid APG,3971.39,,,3971.39,Other,215% New York Medicaid APG,2308.95,,,2308.95,Other,125% New York Medicaid APG,1847.16,51583.58,
Balloon dilate urtrl strix,50706,CPT,,,,,,,,both,,,64479.48,47714.82,74,,47714.82,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,29015.77,45,,29015.77,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,31917.34,49.5,,31917.34,percent of total billed charges,110% of Medicare,43846.05,68,,43846.05,percent of total billed charges,,3435.71,,,3435.71,Other,186% of Medicaid,51583.58,80,,51583.58,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,51583.58,80,,51583.58,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,45135.64,70,,45135.64,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,1847.16,,,1847.16,Other,New York Medicaid APG methodology,1847.16,,,1847.16,Other,100% New York Medicaid APG,1847.16,,,1847.16,Other,100% New York Medicaid APG,1847.16,,,1847.16,Other,100% New York Medicaid APG,4156.1,,,4156.1,Other,225% New York Medicaid APG,2826.15,,,2826.15,Other,153% New York Medicaid APG,4156.1,,,4156.1,Other,225% New York Medicaid APG,2586.02,,,2586.02,Other,140% New York Medicaid APG,4156.1,,,4156.1,Other,225% New York Medicaid APG,4802.61,,,4802.61,Other,260% New York Medicaid APG,5984.79,,,5984.79,Other,324% New York Medicaid APG,3971.39,,,3971.39,Other,215% New York Medicaid APG,3971.39,,,3971.39,Other,215% New York Medicaid APG,2308.95,,,2308.95,Other,125% New York Medicaid APG,1847.16,51583.58,
Revise ureter,50727,CPT,,,,,,,,both,,,73326.88,54261.89,74,,54261.89,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,32997.1,45,,32997.1,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,36296.81,49.5,,36296.81,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2876.72,,,2876.72,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,51328.82,70,,51328.82,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1546.62,,,1546.62,Other,New York Medicaid APG methodology,1546.62,,,1546.62,Other,100% New York Medicaid APG,1546.62,,,1546.62,Other,100% New York Medicaid APG,1546.62,,,1546.62,Other,100% New York Medicaid APG,3479.91,,,3479.91,Other,225% New York Medicaid APG,2366.34,,,2366.34,Other,153% New York Medicaid APG,3479.91,,,3479.91,Other,225% New York Medicaid APG,2165.27,,,2165.27,Other,140% New York Medicaid APG,3479.91,,,3479.91,Other,225% New York Medicaid APG,4021.22,,,4021.22,Other,260% New York Medicaid APG,5011.06,,,5011.06,Other,324% New York Medicaid APG,3325.24,,,3325.24,Other,215% New York Medicaid APG,3325.24,,,3325.24,Other,215% New York Medicaid APG,1933.28,,,1933.28,Other,125% New York Medicaid APG,1546.62,54261.89,
Laparoscopy ureterolithotomy,50945,CPT,,,,,,,,both,,,121364.27,89809.56,74,,89809.56,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,54613.92,45,,54613.92,percent of total billed charges,Medicare Ratio of cost to charges,5459,,"100% primary, 50% supplemental procedure",5459,Other,Aetna ASC Grouper,4913,,"100% primary, 50% supplemental procedure",4913,Other,Aetna ASC Grouper,6125,,"100% primary, 50% secondary, 25% supplemental procedure",6125,Other,Blue Cross ASC Grouper,5513,,"100% primary, 50% secondary, 25% supplemental procedure",5513,Other,Blue Cross ASC Grouper,5206,,"100% primary, 50% secondary, 25% supplemental procedure",5206,Other,Blue Cross ASC Grouper,60075.31,49.5,,60075.31,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2586.25,,,2586.25,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,84954.99,70,,84954.99,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,1390.46,,,1390.46,Other,New York Medicaid APG methodology,1390.46,,,1390.46,Other,100% New York Medicaid APG,1390.46,,,1390.46,Other,100% New York Medicaid APG,1390.46,,,1390.46,Other,100% New York Medicaid APG,3128.53,,,3128.53,Other,225% New York Medicaid APG,2127.4,,,2127.4,Other,153% New York Medicaid APG,3128.53,,,3128.53,Other,225% New York Medicaid APG,1946.64,,,1946.64,Other,140% New York Medicaid APG,3128.53,,,3128.53,Other,225% New York Medicaid APG,3615.19,,,3615.19,Other,260% New York Medicaid APG,4505.09,,,4505.09,Other,324% New York Medicaid APG,2989.49,,,2989.49,Other,215% New York Medicaid APG,2989.49,,,2989.49,Other,215% New York Medicaid APG,1738.07,,,1738.07,Other,125% New York Medicaid APG,1390.46,89809.56,
Laparo new ureter/bladder,50947,CPT,,,,,,,,both,,,216515.17,160221.23,74,,160221.23,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,97431.83,45,,97431.83,percent of total billed charges,Medicare Ratio of cost to charges,5459,,"100% primary, 50% supplemental procedure",5459,Other,Aetna ASC Grouper,4913,,"100% primary, 50% supplemental procedure",4913,Other,Aetna ASC Grouper,6125,,"100% primary, 50% secondary, 25% supplemental procedure",6125,Other,Blue Cross ASC Grouper,5513,,"100% primary, 50% secondary, 25% supplemental procedure",5513,Other,Blue Cross ASC Grouper,5206,,"100% primary, 50% secondary, 25% supplemental procedure",5206,Other,Blue Cross ASC Grouper,107175.01,49.5,,107175.01,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3435.71,,,3435.71,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,151560.62,70,,151560.62,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,1847.16,,,1847.16,Other,New York Medicaid APG methodology,1847.16,,,1847.16,Other,100% New York Medicaid APG,1847.16,,,1847.16,Other,100% New York Medicaid APG,1847.16,,,1847.16,Other,100% New York Medicaid APG,4156.1,,,4156.1,Other,225% New York Medicaid APG,2826.15,,,2826.15,Other,153% New York Medicaid APG,4156.1,,,4156.1,Other,225% New York Medicaid APG,2586.02,,,2586.02,Other,140% New York Medicaid APG,4156.1,,,4156.1,Other,225% New York Medicaid APG,4802.61,,,4802.61,Other,260% New York Medicaid APG,5984.79,,,5984.79,Other,324% New York Medicaid APG,3971.39,,,3971.39,Other,215% New York Medicaid APG,3971.39,,,3971.39,Other,215% New York Medicaid APG,2308.95,,,2308.95,Other,125% New York Medicaid APG,1847.16,160221.23,
Laparo new ureter/bladder,50948,CPT,,,,,,,,both,,,216515.17,160221.23,74,,160221.23,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,97431.83,45,,97431.83,percent of total billed charges,Medicare Ratio of cost to charges,5459,,"100% primary, 50% supplemental procedure",5459,Other,Aetna ASC Grouper,4913,,"100% primary, 50% supplemental procedure",4913,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,107175.01,49.5,,107175.01,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2586.25,,,2586.25,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,151560.62,70,,151560.62,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,1390.46,,,1390.46,Other,New York Medicaid APG methodology,1390.46,,,1390.46,Other,100% New York Medicaid APG,1390.46,,,1390.46,Other,100% New York Medicaid APG,1390.46,,,1390.46,Other,100% New York Medicaid APG,3128.53,,,3128.53,Other,225% New York Medicaid APG,2127.4,,,2127.4,Other,153% New York Medicaid APG,3128.53,,,3128.53,Other,225% New York Medicaid APG,1946.64,,,1946.64,Other,140% New York Medicaid APG,3128.53,,,3128.53,Other,225% New York Medicaid APG,3615.19,,,3615.19,Other,260% New York Medicaid APG,4505.09,,,4505.09,Other,324% New York Medicaid APG,2989.49,,,2989.49,Other,215% New York Medicaid APG,2989.49,,,2989.49,Other,215% New York Medicaid APG,1738.07,,,1738.07,Other,125% New York Medicaid APG,1390.46,160221.23,
Endoscopy of ureter,50951,CPT,,,,,,,,both,,,73326.88,54261.89,74,,54261.89,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,32997.1,45,,32997.1,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,36296.81,49.5,,36296.81,percent of total billed charges,110% of Medicare,49862.28,68,,49862.28,percent of total billed charges,,2011.18,,,2011.18,Other,186% of Medicaid,58661.5,80,,58661.5,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,58661.5,80,,58661.5,percent of total billed charges,,7216,,,7216,Case Rate,,3578,,"100% primary, 0% secondary procedures",3578,Other,MagnaCare ASC Grouper,51328.82,70,,51328.82,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,1081.28,,,1081.28,Other,New York Medicaid APG methodology,1081.28,,,1081.28,Other,100% New York Medicaid APG,1081.28,,,1081.28,Other,100% New York Medicaid APG,1081.28,,,1081.28,Other,100% New York Medicaid APG,2432.88,,,2432.88,Other,225% New York Medicaid APG,1654.36,,,1654.36,Other,153% New York Medicaid APG,2432.88,,,2432.88,Other,225% New York Medicaid APG,1513.79,,,1513.79,Other,140% New York Medicaid APG,2432.88,,,2432.88,Other,225% New York Medicaid APG,2811.33,,,2811.33,Other,260% New York Medicaid APG,3503.35,,,3503.35,Other,324% New York Medicaid APG,2324.75,,,2324.75,Other,215% New York Medicaid APG,2324.75,,,2324.75,Other,215% New York Medicaid APG,1351.6,,,1351.6,Other,125% New York Medicaid APG,1081.28,58661.5,
Endoscopy of ureter,50953,CPT,,,,,,,,both,,,73326.88,54261.89,74,,54261.89,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,32997.1,45,,32997.1,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,36296.81,49.5,,36296.81,percent of total billed charges,110% of Medicare,49862.28,68,,49862.28,percent of total billed charges,,2011.18,,,2011.18,Other,186% of Medicaid,58661.5,80,,58661.5,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,58661.5,80,,58661.5,percent of total billed charges,,7216,,,7216,Case Rate,,3578,,"100% primary, 0% secondary procedures",3578,Other,MagnaCare ASC Grouper,51328.82,70,,51328.82,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1081.28,,,1081.28,Other,New York Medicaid APG methodology,1081.28,,,1081.28,Other,100% New York Medicaid APG,1081.28,,,1081.28,Other,100% New York Medicaid APG,1081.28,,,1081.28,Other,100% New York Medicaid APG,2432.88,,,2432.88,Other,225% New York Medicaid APG,1654.36,,,1654.36,Other,153% New York Medicaid APG,2432.88,,,2432.88,Other,225% New York Medicaid APG,1513.79,,,1513.79,Other,140% New York Medicaid APG,2432.88,,,2432.88,Other,225% New York Medicaid APG,2811.33,,,2811.33,Other,260% New York Medicaid APG,3503.35,,,3503.35,Other,324% New York Medicaid APG,2324.75,,,2324.75,Other,215% New York Medicaid APG,2324.75,,,2324.75,Other,215% New York Medicaid APG,1351.6,,,1351.6,Other,125% New York Medicaid APG,1081.28,58661.5,
Ureter endoscopy & biopsy,50955,CPT,,,,,,,,both,,,108835.97,80538.62,74,,80538.62,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,48976.19,45,,48976.19,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,53873.81,49.5,,53873.81,percent of total billed charges,110% of Medicare,74008.46,68,,74008.46,percent of total billed charges,,2586.25,,,2586.25,Other,186% of Medicaid,87068.78,80,,87068.78,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,87068.78,80,,87068.78,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,76185.18,70,,76185.18,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1390.46,,,1390.46,Other,New York Medicaid APG methodology,1390.46,,,1390.46,Other,100% New York Medicaid APG,1390.46,,,1390.46,Other,100% New York Medicaid APG,1390.46,,,1390.46,Other,100% New York Medicaid APG,3128.53,,,3128.53,Other,225% New York Medicaid APG,2127.4,,,2127.4,Other,153% New York Medicaid APG,3128.53,,,3128.53,Other,225% New York Medicaid APG,1946.64,,,1946.64,Other,140% New York Medicaid APG,3128.53,,,3128.53,Other,225% New York Medicaid APG,3615.19,,,3615.19,Other,260% New York Medicaid APG,4505.09,,,4505.09,Other,324% New York Medicaid APG,2989.49,,,2989.49,Other,215% New York Medicaid APG,2989.49,,,2989.49,Other,215% New York Medicaid APG,1738.07,,,1738.07,Other,125% New York Medicaid APG,1390.46,87068.78,
Ureter endoscopy & treatment,50957,CPT,,,,,,,,both,,,108835.97,80538.62,74,,80538.62,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,48976.19,45,,48976.19,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,53873.81,49.5,,53873.81,percent of total billed charges,110% of Medicare,74008.46,68,,74008.46,percent of total billed charges,,2586.25,,,2586.25,Other,186% of Medicaid,87068.78,80,,87068.78,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,87068.78,80,,87068.78,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,76185.18,70,,76185.18,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1390.46,,,1390.46,Other,New York Medicaid APG methodology,1390.46,,,1390.46,Other,100% New York Medicaid APG,1390.46,,,1390.46,Other,100% New York Medicaid APG,1390.46,,,1390.46,Other,100% New York Medicaid APG,3128.53,,,3128.53,Other,225% New York Medicaid APG,2127.4,,,2127.4,Other,153% New York Medicaid APG,3128.53,,,3128.53,Other,225% New York Medicaid APG,1946.64,,,1946.64,Other,140% New York Medicaid APG,3128.53,,,3128.53,Other,225% New York Medicaid APG,3615.19,,,3615.19,Other,260% New York Medicaid APG,4505.09,,,4505.09,Other,324% New York Medicaid APG,2989.49,,,2989.49,Other,215% New York Medicaid APG,2989.49,,,2989.49,Other,215% New York Medicaid APG,1738.07,,,1738.07,Other,125% New York Medicaid APG,1390.46,87068.78,
Ureter endoscopy & treatment,50961,CPT,,,,,,,,both,,,108835.97,80538.62,74,,80538.62,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,48976.19,45,,48976.19,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,53873.81,49.5,,53873.81,percent of total billed charges,110% of Medicare,74008.46,68,,74008.46,percent of total billed charges,,2586.25,,,2586.25,Other,186% of Medicaid,87068.78,80,,87068.78,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,87068.78,80,,87068.78,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,76185.18,70,,76185.18,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1390.46,,,1390.46,Other,New York Medicaid APG methodology,1390.46,,,1390.46,Other,100% New York Medicaid APG,1390.46,,,1390.46,Other,100% New York Medicaid APG,1390.46,,,1390.46,Other,100% New York Medicaid APG,3128.53,,,3128.53,Other,225% New York Medicaid APG,2127.4,,,2127.4,Other,153% New York Medicaid APG,3128.53,,,3128.53,Other,225% New York Medicaid APG,1946.64,,,1946.64,Other,140% New York Medicaid APG,3128.53,,,3128.53,Other,225% New York Medicaid APG,3615.19,,,3615.19,Other,260% New York Medicaid APG,4505.09,,,4505.09,Other,324% New York Medicaid APG,2989.49,,,2989.49,Other,215% New York Medicaid APG,2989.49,,,2989.49,Other,215% New York Medicaid APG,1738.07,,,1738.07,Other,125% New York Medicaid APG,1390.46,87068.78,
Ureter endoscopy,50970,CPT,,,,,,,,both,,,73326.88,54261.89,74,,54261.89,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,32997.1,45,,32997.1,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,36296.81,49.5,,36296.81,percent of total billed charges,110% of Medicare,49862.28,68,,49862.28,percent of total billed charges,,2011.18,,,2011.18,Other,186% of Medicaid,58661.5,80,,58661.5,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,58661.5,80,,58661.5,percent of total billed charges,,7216,,,7216,Case Rate,,3578,,"100% primary, 0% secondary procedures",3578,Other,MagnaCare ASC Grouper,51328.82,70,,51328.82,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,1081.28,,,1081.28,Other,New York Medicaid APG methodology,1081.28,,,1081.28,Other,100% New York Medicaid APG,1081.28,,,1081.28,Other,100% New York Medicaid APG,1081.28,,,1081.28,Other,100% New York Medicaid APG,2432.88,,,2432.88,Other,225% New York Medicaid APG,1654.36,,,1654.36,Other,153% New York Medicaid APG,2432.88,,,2432.88,Other,225% New York Medicaid APG,1513.79,,,1513.79,Other,140% New York Medicaid APG,2432.88,,,2432.88,Other,225% New York Medicaid APG,2811.33,,,2811.33,Other,260% New York Medicaid APG,3503.35,,,3503.35,Other,324% New York Medicaid APG,2324.75,,,2324.75,Other,215% New York Medicaid APG,2324.75,,,2324.75,Other,215% New York Medicaid APG,1351.6,,,1351.6,Other,125% New York Medicaid APG,1081.28,58661.5,
Ureter endoscopy & catheter,50972,CPT,,,,,,,,both,,,73326.88,54261.89,74,,54261.89,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,32997.1,45,,32997.1,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,36296.81,49.5,,36296.81,percent of total billed charges,110% of Medicare,49862.28,68,,49862.28,percent of total billed charges,,2011.18,,,2011.18,Other,186% of Medicaid,58661.5,80,,58661.5,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,58661.5,80,,58661.5,percent of total billed charges,,7216,,,7216,Case Rate,,3578,,"100% primary, 0% secondary procedures",3578,Other,MagnaCare ASC Grouper,51328.82,70,,51328.82,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,1081.28,,,1081.28,Other,New York Medicaid APG methodology,1081.28,,,1081.28,Other,100% New York Medicaid APG,1081.28,,,1081.28,Other,100% New York Medicaid APG,1081.28,,,1081.28,Other,100% New York Medicaid APG,2432.88,,,2432.88,Other,225% New York Medicaid APG,1654.36,,,1654.36,Other,153% New York Medicaid APG,2432.88,,,2432.88,Other,225% New York Medicaid APG,1513.79,,,1513.79,Other,140% New York Medicaid APG,2432.88,,,2432.88,Other,225% New York Medicaid APG,2811.33,,,2811.33,Other,260% New York Medicaid APG,3503.35,,,3503.35,Other,324% New York Medicaid APG,2324.75,,,2324.75,Other,215% New York Medicaid APG,2324.75,,,2324.75,Other,215% New York Medicaid APG,1351.6,,,1351.6,Other,125% New York Medicaid APG,1081.28,58661.5,
Ureter endoscopy & biopsy,50974,CPT,,,,,,,,both,,,108835.97,80538.62,74,,80538.62,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,48976.19,45,,48976.19,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,53873.81,49.5,,53873.81,percent of total billed charges,110% of Medicare,74008.46,68,,74008.46,percent of total billed charges,,2586.25,,,2586.25,Other,186% of Medicaid,87068.78,80,,87068.78,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,87068.78,80,,87068.78,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,76185.18,70,,76185.18,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1390.46,,,1390.46,Other,New York Medicaid APG methodology,1390.46,,,1390.46,Other,100% New York Medicaid APG,1390.46,,,1390.46,Other,100% New York Medicaid APG,1390.46,,,1390.46,Other,100% New York Medicaid APG,3128.53,,,3128.53,Other,225% New York Medicaid APG,2127.4,,,2127.4,Other,153% New York Medicaid APG,3128.53,,,3128.53,Other,225% New York Medicaid APG,1946.64,,,1946.64,Other,140% New York Medicaid APG,3128.53,,,3128.53,Other,225% New York Medicaid APG,3615.19,,,3615.19,Other,260% New York Medicaid APG,4505.09,,,4505.09,Other,324% New York Medicaid APG,2989.49,,,2989.49,Other,215% New York Medicaid APG,2989.49,,,2989.49,Other,215% New York Medicaid APG,1738.07,,,1738.07,Other,125% New York Medicaid APG,1390.46,87068.78,
Ureter endoscopy & treatment,50976,CPT,,,,,,,,both,,,108835.97,80538.62,74,,80538.62,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,48976.19,45,,48976.19,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,53873.81,49.5,,53873.81,percent of total billed charges,110% of Medicare,74008.46,68,,74008.46,percent of total billed charges,,2586.25,,,2586.25,Other,186% of Medicaid,87068.78,80,,87068.78,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,87068.78,80,,87068.78,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,76185.18,70,,76185.18,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1390.46,,,1390.46,Other,New York Medicaid APG methodology,1390.46,,,1390.46,Other,100% New York Medicaid APG,1390.46,,,1390.46,Other,100% New York Medicaid APG,1390.46,,,1390.46,Other,100% New York Medicaid APG,3128.53,,,3128.53,Other,225% New York Medicaid APG,2127.4,,,2127.4,Other,153% New York Medicaid APG,3128.53,,,3128.53,Other,225% New York Medicaid APG,1946.64,,,1946.64,Other,140% New York Medicaid APG,3128.53,,,3128.53,Other,225% New York Medicaid APG,3615.19,,,3615.19,Other,260% New York Medicaid APG,4505.09,,,4505.09,Other,324% New York Medicaid APG,2989.49,,,2989.49,Other,215% New York Medicaid APG,2989.49,,,2989.49,Other,215% New York Medicaid APG,1738.07,,,1738.07,Other,125% New York Medicaid APG,1390.46,87068.78,
Ureter endoscopy & treatment,50980,CPT,,,,,,,,both,,,108835.97,80538.62,74,,80538.62,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,48976.19,45,,48976.19,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,53873.81,49.5,,53873.81,percent of total billed charges,110% of Medicare,74008.46,68,,74008.46,percent of total billed charges,,2586.25,,,2586.25,Other,186% of Medicaid,87068.78,80,,87068.78,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,87068.78,80,,87068.78,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,76185.18,70,,76185.18,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1390.46,,,1390.46,Other,New York Medicaid APG methodology,1390.46,,,1390.46,Other,100% New York Medicaid APG,1390.46,,,1390.46,Other,100% New York Medicaid APG,1390.46,,,1390.46,Other,100% New York Medicaid APG,3128.53,,,3128.53,Other,225% New York Medicaid APG,2127.4,,,2127.4,Other,153% New York Medicaid APG,3128.53,,,3128.53,Other,225% New York Medicaid APG,1946.64,,,1946.64,Other,140% New York Medicaid APG,3128.53,,,3128.53,Other,225% New York Medicaid APG,3615.19,,,3615.19,Other,260% New York Medicaid APG,4505.09,,,4505.09,Other,324% New York Medicaid APG,2989.49,,,2989.49,Other,215% New York Medicaid APG,2989.49,,,2989.49,Other,215% New York Medicaid APG,1738.07,,,1738.07,Other,125% New York Medicaid APG,1390.46,87068.78,
Incise & treat bladder,51020,CPT,,,,,,,,both,,,73326.88,54261.89,74,,54261.89,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,32997.1,45,,32997.1,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,36296.81,49.5,,36296.81,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2876.72,,,2876.72,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,51328.82,70,,51328.82,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1546.62,,,1546.62,Other,New York Medicaid APG methodology,1546.62,,,1546.62,Other,100% New York Medicaid APG,1546.62,,,1546.62,Other,100% New York Medicaid APG,1546.62,,,1546.62,Other,100% New York Medicaid APG,3479.91,,,3479.91,Other,225% New York Medicaid APG,2366.34,,,2366.34,Other,153% New York Medicaid APG,3479.91,,,3479.91,Other,225% New York Medicaid APG,2165.27,,,2165.27,Other,140% New York Medicaid APG,3479.91,,,3479.91,Other,225% New York Medicaid APG,4021.22,,,4021.22,Other,260% New York Medicaid APG,5011.06,,,5011.06,Other,324% New York Medicaid APG,3325.24,,,3325.24,Other,215% New York Medicaid APG,3325.24,,,3325.24,Other,215% New York Medicaid APG,1933.28,,,1933.28,Other,125% New York Medicaid APG,1546.62,54261.89,
Incise & treat bladder,51030,CPT,,,,,,,,both,,,73326.88,54261.89,74,,54261.89,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,32997.1,45,,32997.1,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,36296.81,49.5,,36296.81,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2876.72,,,2876.72,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,51328.82,70,,51328.82,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1546.62,,,1546.62,Other,New York Medicaid APG methodology,1546.62,,,1546.62,Other,100% New York Medicaid APG,1546.62,,,1546.62,Other,100% New York Medicaid APG,1546.62,,,1546.62,Other,100% New York Medicaid APG,3479.91,,,3479.91,Other,225% New York Medicaid APG,2366.34,,,2366.34,Other,153% New York Medicaid APG,3479.91,,,3479.91,Other,225% New York Medicaid APG,2165.27,,,2165.27,Other,140% New York Medicaid APG,3479.91,,,3479.91,Other,225% New York Medicaid APG,4021.22,,,4021.22,Other,260% New York Medicaid APG,5011.06,,,5011.06,Other,324% New York Medicaid APG,3325.24,,,3325.24,Other,215% New York Medicaid APG,3325.24,,,3325.24,Other,215% New York Medicaid APG,1933.28,,,1933.28,Other,125% New York Medicaid APG,1546.62,54261.89,
Incise & drain bladder,51040,CPT,,,,,,,,both,,,31647.7,23419.3,74,,23419.3,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,14241.47,45,,14241.47,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,15665.61,49.5,,15665.61,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2876.72,,,2876.72,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,22153.39,70,,22153.39,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1546.62,,,1546.62,Other,New York Medicaid APG methodology,1546.62,,,1546.62,Other,100% New York Medicaid APG,1546.62,,,1546.62,Other,100% New York Medicaid APG,1546.62,,,1546.62,Other,100% New York Medicaid APG,3479.91,,,3479.91,Other,225% New York Medicaid APG,2366.34,,,2366.34,Other,153% New York Medicaid APG,3479.91,,,3479.91,Other,225% New York Medicaid APG,2165.27,,,2165.27,Other,140% New York Medicaid APG,3479.91,,,3479.91,Other,225% New York Medicaid APG,4021.22,,,4021.22,Other,260% New York Medicaid APG,5011.06,,,5011.06,Other,324% New York Medicaid APG,3325.24,,,3325.24,Other,215% New York Medicaid APG,3325.24,,,3325.24,Other,215% New York Medicaid APG,1933.28,,,1933.28,Other,125% New York Medicaid APG,1546.62,23419.3,
Incise bladder/drain ureter,51045,CPT,,,,,,,,both,,,42841.82,31702.95,74,,31702.95,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,19278.82,45,,19278.82,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,21206.7,49.5,,21206.7,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2876.72,,,2876.72,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,3578,,"100% primary, 0% secondary procedures",3578,Other,MagnaCare ASC Grouper,29989.27,70,,29989.27,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,1546.62,,,1546.62,Other,New York Medicaid APG methodology,1546.62,,,1546.62,Other,100% New York Medicaid APG,1546.62,,,1546.62,Other,100% New York Medicaid APG,1546.62,,,1546.62,Other,100% New York Medicaid APG,3479.91,,,3479.91,Other,225% New York Medicaid APG,2366.34,,,2366.34,Other,153% New York Medicaid APG,3479.91,,,3479.91,Other,225% New York Medicaid APG,2165.27,,,2165.27,Other,140% New York Medicaid APG,3479.91,,,3479.91,Other,225% New York Medicaid APG,4021.22,,,4021.22,Other,260% New York Medicaid APG,5011.06,,,5011.06,Other,324% New York Medicaid APG,3325.24,,,3325.24,Other,215% New York Medicaid APG,3325.24,,,3325.24,Other,215% New York Medicaid APG,1933.28,,,1933.28,Other,125% New York Medicaid APG,1546.62,31702.95,
Removal of bladder stone,51050,CPT,,,,,,,,both,,,35106.99,25979.17,74,,25979.17,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15798.15,45,,15798.15,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,17377.96,49.5,,17377.96,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3412.13,,,3412.13,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,24574.89,70,,24574.89,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1834.48,,,1834.48,Other,New York Medicaid APG methodology,1834.48,,,1834.48,Other,100% New York Medicaid APG,1834.48,,,1834.48,Other,100% New York Medicaid APG,1834.48,,,1834.48,Other,100% New York Medicaid APG,4127.58,,,4127.58,Other,225% New York Medicaid APG,2806.75,,,2806.75,Other,153% New York Medicaid APG,4127.58,,,4127.58,Other,225% New York Medicaid APG,2568.27,,,2568.27,Other,140% New York Medicaid APG,4127.58,,,4127.58,Other,225% New York Medicaid APG,4769.65,,,4769.65,Other,260% New York Medicaid APG,5943.71,,,5943.71,Other,324% New York Medicaid APG,3944.13,,,3944.13,Other,215% New York Medicaid APG,3944.13,,,3944.13,Other,215% New York Medicaid APG,2293.1,,,2293.1,Other,125% New York Medicaid APG,1834.48,25979.17,
Removal of ureter stone,51060,CPT,,,,,,,,both,,,42841.82,31702.95,74,,31702.95,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,19278.82,45,,19278.82,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,21206.7,49.5,,21206.7,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2011.18,,,2011.18,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,29989.27,70,,29989.27,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,1081.28,,,1081.28,Other,New York Medicaid APG methodology,1081.28,,,1081.28,Other,100% New York Medicaid APG,1081.28,,,1081.28,Other,100% New York Medicaid APG,1081.28,,,1081.28,Other,100% New York Medicaid APG,2432.88,,,2432.88,Other,225% New York Medicaid APG,1654.36,,,1654.36,Other,153% New York Medicaid APG,2432.88,,,2432.88,Other,225% New York Medicaid APG,1513.79,,,1513.79,Other,140% New York Medicaid APG,2432.88,,,2432.88,Other,225% New York Medicaid APG,2811.33,,,2811.33,Other,260% New York Medicaid APG,3503.35,,,3503.35,Other,324% New York Medicaid APG,2324.75,,,2324.75,Other,215% New York Medicaid APG,2324.75,,,2324.75,Other,215% New York Medicaid APG,1351.6,,,1351.6,Other,125% New York Medicaid APG,1081.28,31702.95,
Remove ureter calculus,51065,CPT,,,,,,,,both,,,73326.88,54261.89,74,,54261.89,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,32997.1,45,,32997.1,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,36296.81,49.5,,36296.81,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2876.72,,,2876.72,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,51328.82,70,,51328.82,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1546.62,,,1546.62,Other,New York Medicaid APG methodology,1546.62,,,1546.62,Other,100% New York Medicaid APG,1546.62,,,1546.62,Other,100% New York Medicaid APG,1546.62,,,1546.62,Other,100% New York Medicaid APG,3479.91,,,3479.91,Other,225% New York Medicaid APG,2366.34,,,2366.34,Other,153% New York Medicaid APG,3479.91,,,3479.91,Other,225% New York Medicaid APG,2165.27,,,2165.27,Other,140% New York Medicaid APG,3479.91,,,3479.91,Other,225% New York Medicaid APG,4021.22,,,4021.22,Other,260% New York Medicaid APG,5011.06,,,5011.06,Other,324% New York Medicaid APG,3325.24,,,3325.24,Other,215% New York Medicaid APG,3325.24,,,3325.24,Other,215% New York Medicaid APG,1933.28,,,1933.28,Other,125% New York Medicaid APG,1546.62,54261.89,
Drainage of bladder abscess,51080,CPT,,,,,,,,both,,,59767.2,44227.73,74,,44227.73,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,26895.24,45,,26895.24,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,29584.76,49.5,,29584.76,percent of total billed charges,110% of Medicare,40641.7,68,,40641.7,percent of total billed charges,,2876.72,,,2876.72,Other,186% of Medicaid,47813.76,80,,47813.76,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,47813.76,80,,47813.76,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,41837.04,70,,41837.04,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1546.62,,,1546.62,Other,New York Medicaid APG methodology,1546.62,,,1546.62,Other,100% New York Medicaid APG,1546.62,,,1546.62,Other,100% New York Medicaid APG,1546.62,,,1546.62,Other,100% New York Medicaid APG,3479.91,,,3479.91,Other,225% New York Medicaid APG,2366.34,,,2366.34,Other,153% New York Medicaid APG,3479.91,,,3479.91,Other,225% New York Medicaid APG,2165.27,,,2165.27,Other,140% New York Medicaid APG,3479.91,,,3479.91,Other,225% New York Medicaid APG,4021.22,,,4021.22,Other,260% New York Medicaid APG,5011.06,,,5011.06,Other,324% New York Medicaid APG,3325.24,,,3325.24,Other,215% New York Medicaid APG,3325.24,,,3325.24,Other,215% New York Medicaid APG,1933.28,,,1933.28,Other,125% New York Medicaid APG,1546.62,47813.76,
Drain bladder by needle,51100,CPT,,,,,,,,both,,,5198.43,3846.84,74,,3846.84,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,2339.29,45,,2339.29,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,2573.22,49.5,,2573.22,percent of total billed charges,110% of Medicare,3534.93,68,,3534.93,percent of total billed charges,,903.43,,,903.43,Other,186% of Medicaid,4158.74,80,,4158.74,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,4158.74,80,,4158.74,percent of total billed charges,,7216,,,7216,Case Rate,,3578,,"100% primary, 0% secondary procedures",3578,Other,MagnaCare ASC Grouper,3638.9,70,,3638.9,percent of total billed charges,,188.6,,,188.6,Fee Schedule,,159.85,,,159.85,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,485.72,,,485.72,Other,New York Medicaid APG methodology,485.72,,,485.72,Other,100% New York Medicaid APG,485.72,,,485.72,Other,100% New York Medicaid APG,485.72,,,485.72,Other,100% New York Medicaid APG,1092.86,,,1092.86,Other,225% New York Medicaid APG,743.14,,,743.14,Other,153% New York Medicaid APG,1092.86,,,1092.86,Other,225% New York Medicaid APG,680,,,680,Other,140% New York Medicaid APG,1092.86,,,1092.86,Other,225% New York Medicaid APG,1262.86,,,1262.86,Other,260% New York Medicaid APG,1573.72,,,1573.72,Other,324% New York Medicaid APG,1044.29,,,1044.29,Other,215% New York Medicaid APG,1044.29,,,1044.29,Other,215% New York Medicaid APG,607.14,,,607.14,Other,125% New York Medicaid APG,159.85,7216,
Drain bladder by trocar/cath,51101,CPT,,,,,,,,both,,,21991.57,16273.76,74,,16273.76,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,9896.21,45,,9896.21,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,10885.83,49.5,,10885.83,percent of total billed charges,110% of Medicare,14954.27,68,,14954.27,percent of total billed charges,,903.43,,,903.43,Other,186% of Medicaid,17593.26,80,,17593.26,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,17593.26,80,,17593.26,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,15394.1,70,,15394.1,percent of total billed charges,,244.36,,,244.36,Fee Schedule,,207.11,,,207.11,Fee Schedule,,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,485.72,,,485.72,Other,New York Medicaid APG methodology,485.72,,,485.72,Other,100% New York Medicaid APG,485.72,,,485.72,Other,100% New York Medicaid APG,485.72,,,485.72,Other,100% New York Medicaid APG,1092.86,,,1092.86,Other,225% New York Medicaid APG,743.14,,,743.14,Other,153% New York Medicaid APG,1092.86,,,1092.86,Other,225% New York Medicaid APG,680,,,680,Other,140% New York Medicaid APG,1092.86,,,1092.86,Other,225% New York Medicaid APG,1262.86,,,1262.86,Other,260% New York Medicaid APG,1573.72,,,1573.72,Other,324% New York Medicaid APG,1044.29,,,1044.29,Other,215% New York Medicaid APG,1044.29,,,1044.29,Other,215% New York Medicaid APG,607.14,,,607.14,Other,125% New York Medicaid APG,207.11,17593.26,
Drain bl w/cath insertion,51102,CPT,,,,,,,,both,,,24721.94,18294.24,74,,18294.24,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,11124.87,45,,11124.87,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,12237.36,49.5,,12237.36,percent of total billed charges,110% of Medicare,16810.92,68,,16810.92,percent of total billed charges,,2876.72,,,2876.72,Other,186% of Medicaid,19777.55,80,,19777.55,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,19777.55,80,,19777.55,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,17305.36,70,,17305.36,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1546.62,,,1546.62,Other,New York Medicaid APG methodology,1546.62,,,1546.62,Other,100% New York Medicaid APG,1546.62,,,1546.62,Other,100% New York Medicaid APG,1546.62,,,1546.62,Other,100% New York Medicaid APG,3479.91,,,3479.91,Other,225% New York Medicaid APG,2366.34,,,2366.34,Other,153% New York Medicaid APG,3479.91,,,3479.91,Other,225% New York Medicaid APG,2165.27,,,2165.27,Other,140% New York Medicaid APG,3479.91,,,3479.91,Other,225% New York Medicaid APG,4021.22,,,4021.22,Other,260% New York Medicaid APG,5011.06,,,5011.06,Other,324% New York Medicaid APG,3325.24,,,3325.24,Other,215% New York Medicaid APG,3325.24,,,3325.24,Other,215% New York Medicaid APG,1933.28,,,1933.28,Other,125% New York Medicaid APG,1546.62,19777.55,
Removal of bladder cyst,51500,CPT,,,,,,,,both,,,121364.27,89809.56,74,,89809.56,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,54613.92,45,,54613.92,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,6125,,"100% primary, 50% secondary, 25% supplemental procedure",6125,Other,Blue Cross ASC Grouper,5513,,"100% primary, 50% secondary, 25% supplemental procedure",5513,Other,Blue Cross ASC Grouper,5206,,"100% primary, 50% secondary, 25% supplemental procedure",5206,Other,Blue Cross ASC Grouper,60075.31,49.5,,60075.31,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3639.33,,,3639.33,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,84954.99,70,,84954.99,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1956.63,,,1956.63,Other,New York Medicaid APG methodology,1956.63,,,1956.63,Other,100% New York Medicaid APG,1956.63,,,1956.63,Other,100% New York Medicaid APG,1956.63,,,1956.63,Other,100% New York Medicaid APG,4402.42,,,4402.42,Other,225% New York Medicaid APG,2993.64,,,2993.64,Other,153% New York Medicaid APG,4402.42,,,4402.42,Other,225% New York Medicaid APG,2739.28,,,2739.28,Other,140% New York Medicaid APG,4402.42,,,4402.42,Other,225% New York Medicaid APG,5087.24,,,5087.24,Other,260% New York Medicaid APG,6339.48,,,6339.48,Other,324% New York Medicaid APG,4206.75,,,4206.75,Other,215% New York Medicaid APG,4206.75,,,4206.75,Other,215% New York Medicaid APG,2445.79,,,2445.79,Other,125% New York Medicaid APG,1956.63,89809.56,
Removal of bladder lesion,51520,CPT,,,,,,,,both,,,73326.88,54261.89,74,,54261.89,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,32997.1,45,,32997.1,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,36296.81,49.5,,36296.81,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2876.72,,,2876.72,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,51328.82,70,,51328.82,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1546.62,,,1546.62,Other,New York Medicaid APG methodology,1546.62,,,1546.62,Other,100% New York Medicaid APG,1546.62,,,1546.62,Other,100% New York Medicaid APG,1546.62,,,1546.62,Other,100% New York Medicaid APG,3479.91,,,3479.91,Other,225% New York Medicaid APG,2366.34,,,2366.34,Other,153% New York Medicaid APG,3479.91,,,3479.91,Other,225% New York Medicaid APG,2165.27,,,2165.27,Other,140% New York Medicaid APG,3479.91,,,3479.91,Other,225% New York Medicaid APG,4021.22,,,4021.22,Other,260% New York Medicaid APG,5011.06,,,5011.06,Other,324% New York Medicaid APG,3325.24,,,3325.24,Other,215% New York Medicaid APG,3325.24,,,3325.24,Other,215% New York Medicaid APG,1933.28,,,1933.28,Other,125% New York Medicaid APG,1546.62,54261.89,
Repair of ureter lesion,51535,CPT,,,,,,,,both,,,73326.88,54261.89,74,,54261.89,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,32997.1,45,,32997.1,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,36296.81,49.5,,36296.81,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2876.72,,,2876.72,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,51328.82,70,,51328.82,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1546.62,,,1546.62,Other,New York Medicaid APG methodology,1546.62,,,1546.62,Other,100% New York Medicaid APG,1546.62,,,1546.62,Other,100% New York Medicaid APG,1546.62,,,1546.62,Other,100% New York Medicaid APG,3479.91,,,3479.91,Other,225% New York Medicaid APG,2366.34,,,2366.34,Other,153% New York Medicaid APG,3479.91,,,3479.91,Other,225% New York Medicaid APG,2165.27,,,2165.27,Other,140% New York Medicaid APG,3479.91,,,3479.91,Other,225% New York Medicaid APG,4021.22,,,4021.22,Other,260% New York Medicaid APG,5011.06,,,5011.06,Other,324% New York Medicaid APG,3325.24,,,3325.24,Other,215% New York Medicaid APG,3325.24,,,3325.24,Other,215% New York Medicaid APG,1933.28,,,1933.28,Other,125% New York Medicaid APG,1546.62,54261.89,
Injection for bladder x-ray,51600,CPT,,,,,,,,both,,,11088.61,8205.57,74,,8205.57,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,4989.87,45,,4989.87,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,5488.86,49.5,,5488.86,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,966.93,,,966.93,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,7762.03,70,,7762.03,percent of total billed charges,,211.56,,,211.56,Fee Schedule,,179.31,,,179.31,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,519.86,,,519.86,Other,New York Medicaid APG methodology,519.86,,,519.86,Other,100% New York Medicaid APG,519.86,,,519.86,Other,100% New York Medicaid APG,519.86,,,519.86,Other,100% New York Medicaid APG,1169.68,,,1169.68,Other,225% New York Medicaid APG,795.38,,,795.38,Other,153% New York Medicaid APG,1169.68,,,1169.68,Other,225% New York Medicaid APG,727.8,,,727.8,Other,140% New York Medicaid APG,1169.68,,,1169.68,Other,225% New York Medicaid APG,1351.62,,,1351.62,Other,260% New York Medicaid APG,1684.33,,,1684.33,Other,324% New York Medicaid APG,1117.69,,,1117.69,Other,215% New York Medicaid APG,1117.69,,,1117.69,Other,215% New York Medicaid APG,649.82,,,649.82,Other,125% New York Medicaid APG,179.31,9473,
Preparation for bladder xray,51605,CPT,,,,,,,,both,,,32432.1,23999.75,74,,23999.75,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,14594.45,45,,14594.45,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,16053.89,49.5,,16053.89,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,966.93,,,966.93,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,22702.47,70,,22702.47,percent of total billed charges,,185.32,,,185.32,Fee Schedule,,157.07,,,157.07,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,519.86,,,519.86,Other,New York Medicaid APG methodology,519.86,,,519.86,Other,100% New York Medicaid APG,519.86,,,519.86,Other,100% New York Medicaid APG,519.86,,,519.86,Other,100% New York Medicaid APG,1169.68,,,1169.68,Other,225% New York Medicaid APG,795.38,,,795.38,Other,153% New York Medicaid APG,1169.68,,,1169.68,Other,225% New York Medicaid APG,727.8,,,727.8,Other,140% New York Medicaid APG,1169.68,,,1169.68,Other,225% New York Medicaid APG,1351.62,,,1351.62,Other,260% New York Medicaid APG,1684.33,,,1684.33,Other,324% New York Medicaid APG,1117.69,,,1117.69,Other,215% New York Medicaid APG,1117.69,,,1117.69,Other,215% New York Medicaid APG,649.82,,,649.82,Other,125% New York Medicaid APG,157.07,23999.75,
Injection for bladder x-ray,51610,CPT,,,,,,,,both,,,13768.75,10188.88,74,,10188.88,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,6195.94,45,,6195.94,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,6815.53,49.5,,6815.53,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,966.93,,,966.93,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,9638.13,70,,9638.13,percent of total billed charges,,309.96,,,309.96,Fee Schedule,,262.71,,,262.71,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,519.86,,,519.86,Other,New York Medicaid APG methodology,519.86,,,519.86,Other,100% New York Medicaid APG,519.86,,,519.86,Other,100% New York Medicaid APG,519.86,,,519.86,Other,100% New York Medicaid APG,1169.68,,,1169.68,Other,225% New York Medicaid APG,795.38,,,795.38,Other,153% New York Medicaid APG,1169.68,,,1169.68,Other,225% New York Medicaid APG,727.8,,,727.8,Other,140% New York Medicaid APG,1169.68,,,1169.68,Other,225% New York Medicaid APG,1351.62,,,1351.62,Other,260% New York Medicaid APG,1684.33,,,1684.33,Other,324% New York Medicaid APG,1117.69,,,1117.69,Other,215% New York Medicaid APG,1117.69,,,1117.69,Other,215% New York Medicaid APG,649.82,,,649.82,Other,125% New York Medicaid APG,262.71,10188.88,
Irrigation of bladder,51700,CPT,,,,,,,,both,,,31905.96,23610.41,74,,23610.41,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,14357.68,45,,14357.68,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,15793.45,49.5,,15793.45,percent of total billed charges,110% of Medicare,21696.05,68,,21696.05,percent of total billed charges,,847.8,,,847.8,Other,186% of Medicaid,25524.77,80,,25524.77,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,25524.77,80,,25524.77,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,22334.17,70,,22334.17,percent of total billed charges,,145.96,,,145.96,Fee Schedule,,123.71,,,123.71,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,455.81,,,455.81,Other,New York Medicaid APG methodology,455.81,,,455.81,Other,100% New York Medicaid APG,455.81,,,455.81,Other,100% New York Medicaid APG,455.81,,,455.81,Other,100% New York Medicaid APG,1025.56,,,1025.56,Other,225% New York Medicaid APG,697.38,,,697.38,Other,153% New York Medicaid APG,1025.56,,,1025.56,Other,225% New York Medicaid APG,638.13,,,638.13,Other,140% New York Medicaid APG,1025.56,,,1025.56,Other,225% New York Medicaid APG,1185.1,,,1185.1,Other,260% New York Medicaid APG,1476.81,,,1476.81,Other,324% New York Medicaid APG,979.98,,,979.98,Other,215% New York Medicaid APG,979.98,,,979.98,Other,215% New York Medicaid APG,569.76,,,569.76,Other,125% New York Medicaid APG,123.71,25524.77,
Insert bladder catheter,51701,CPT,,,,,,,,both,,,35280.75,26107.76,74,,26107.76,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15876.34,45,,15876.34,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,17463.97,49.5,,17463.97,percent of total billed charges,110% of Medicare,23990.91,68,,23990.91,percent of total billed charges,,847.8,,,847.8,Other,186% of Medicaid,28224.6,80,,28224.6,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,28224.6,80,,28224.6,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,24696.53,70,,24696.53,percent of total billed charges,,123,,,123,Fee Schedule,,104.25,,,104.25,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,455.81,,,455.81,Other,New York Medicaid APG methodology,455.81,,,455.81,Other,100% New York Medicaid APG,455.81,,,455.81,Other,100% New York Medicaid APG,455.81,,,455.81,Other,100% New York Medicaid APG,1025.56,,,1025.56,Other,225% New York Medicaid APG,697.38,,,697.38,Other,153% New York Medicaid APG,1025.56,,,1025.56,Other,225% New York Medicaid APG,638.13,,,638.13,Other,140% New York Medicaid APG,1025.56,,,1025.56,Other,225% New York Medicaid APG,1185.1,,,1185.1,Other,260% New York Medicaid APG,1476.81,,,1476.81,Other,324% New York Medicaid APG,979.98,,,979.98,Other,215% New York Medicaid APG,979.98,,,979.98,Other,215% New York Medicaid APG,569.76,,,569.76,Other,125% New York Medicaid APG,104.25,28224.6,
Insert temp bladder cath,51702,CPT,,,,,,,,both,,,2686.86,1988.28,74,,1988.28,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,1209.09,45,,1209.09,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,1330,49.5,,1330,percent of total billed charges,110% of Medicare,1827.06,68,,1827.06,percent of total billed charges,,847.8,,,847.8,Other,186% of Medicaid,2149.49,80,,2149.49,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,2149.49,80,,2149.49,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,1880.8,70,,1880.8,percent of total billed charges,,121.36,,,121.36,Fee Schedule,,102.86,,,102.86,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,455.81,,,455.81,Other,New York Medicaid APG methodology,455.81,,,455.81,Other,100% New York Medicaid APG,455.81,,,455.81,Other,100% New York Medicaid APG,455.81,,,455.81,Other,100% New York Medicaid APG,1025.56,,,1025.56,Other,225% New York Medicaid APG,697.38,,,697.38,Other,153% New York Medicaid APG,1025.56,,,1025.56,Other,225% New York Medicaid APG,638.13,,,638.13,Other,140% New York Medicaid APG,1025.56,,,1025.56,Other,225% New York Medicaid APG,1185.1,,,1185.1,Other,260% New York Medicaid APG,1476.81,,,1476.81,Other,324% New York Medicaid APG,979.98,,,979.98,Other,215% New York Medicaid APG,979.98,,,979.98,Other,215% New York Medicaid APG,569.76,,,569.76,Other,125% New York Medicaid APG,102.86,7216,
Insert bladder cath complex,51703,CPT,,,,,,,,both,,,3285.56,2431.31,74,,2431.31,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,1478.5,45,,1478.5,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,1626.35,49.5,,1626.35,percent of total billed charges,110% of Medicare,2234.18,68,,2234.18,percent of total billed charges,,847.8,,,847.8,Other,186% of Medicaid,2628.45,80,,2628.45,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,2628.45,80,,2628.45,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,2299.89,70,,2299.89,percent of total billed charges,,369,,,369,Fee Schedule,,312.75,,,312.75,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,455.81,,,455.81,Other,New York Medicaid APG methodology,455.81,,,455.81,Other,100% New York Medicaid APG,455.81,,,455.81,Other,100% New York Medicaid APG,455.81,,,455.81,Other,100% New York Medicaid APG,1025.56,,,1025.56,Other,225% New York Medicaid APG,697.38,,,697.38,Other,153% New York Medicaid APG,1025.56,,,1025.56,Other,225% New York Medicaid APG,638.13,,,638.13,Other,140% New York Medicaid APG,1025.56,,,1025.56,Other,225% New York Medicaid APG,1185.1,,,1185.1,Other,260% New York Medicaid APG,1476.81,,,1476.81,Other,324% New York Medicaid APG,979.98,,,979.98,Other,215% New York Medicaid APG,979.98,,,979.98,Other,215% New York Medicaid APG,569.76,,,569.76,Other,125% New York Medicaid APG,312.75,7216,
Change of bladder tube,51705,CPT,,,,,,,,both,,,17435.51,12902.28,74,,12902.28,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,7845.98,45,,7845.98,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,8630.58,49.5,,8630.58,percent of total billed charges,110% of Medicare,11856.15,68,,11856.15,percent of total billed charges,,847.8,,,847.8,Other,186% of Medicaid,13948.41,80,,13948.41,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,13948.41,80,,13948.41,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,12204.86,70,,12204.86,percent of total billed charges,,249.28,,,249.28,Fee Schedule,,211.28,,,211.28,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,455.81,,,455.81,Other,New York Medicaid APG methodology,455.81,,,455.81,Other,100% New York Medicaid APG,455.81,,,455.81,Other,100% New York Medicaid APG,455.81,,,455.81,Other,100% New York Medicaid APG,1025.56,,,1025.56,Other,225% New York Medicaid APG,697.38,,,697.38,Other,153% New York Medicaid APG,1025.56,,,1025.56,Other,225% New York Medicaid APG,638.13,,,638.13,Other,140% New York Medicaid APG,1025.56,,,1025.56,Other,225% New York Medicaid APG,1185.1,,,1185.1,Other,260% New York Medicaid APG,1476.81,,,1476.81,Other,324% New York Medicaid APG,979.98,,,979.98,Other,215% New York Medicaid APG,979.98,,,979.98,Other,215% New York Medicaid APG,569.76,,,569.76,Other,125% New York Medicaid APG,211.28,13948.41,
Change of bladder tube,51710,CPT,,,,,,,,both,,,35147.83,26009.39,74,,26009.39,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15816.52,45,,15816.52,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,17398.18,49.5,,17398.18,percent of total billed charges,110% of Medicare,23900.52,68,,23900.52,percent of total billed charges,,903.43,,,903.43,Other,186% of Medicaid,28118.26,80,,28118.26,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,28118.26,80,,28118.26,percent of total billed charges,,7216,,,7216,Case Rate,,3578,,"100% primary, 0% secondary procedures",3578,Other,MagnaCare ASC Grouper,24603.48,70,,24603.48,percent of total billed charges,,387.04,,,387.04,Fee Schedule,,328.04,,,328.04,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,485.72,,,485.72,Other,New York Medicaid APG methodology,485.72,,,485.72,Other,100% New York Medicaid APG,485.72,,,485.72,Other,100% New York Medicaid APG,485.72,,,485.72,Other,100% New York Medicaid APG,1092.86,,,1092.86,Other,225% New York Medicaid APG,743.14,,,743.14,Other,153% New York Medicaid APG,1092.86,,,1092.86,Other,225% New York Medicaid APG,680,,,680,Other,140% New York Medicaid APG,1092.86,,,1092.86,Other,225% New York Medicaid APG,1262.86,,,1262.86,Other,260% New York Medicaid APG,1573.72,,,1573.72,Other,324% New York Medicaid APG,1044.29,,,1044.29,Other,215% New York Medicaid APG,1044.29,,,1044.29,Other,215% New York Medicaid APG,607.14,,,607.14,Other,125% New York Medicaid APG,328.04,28118.26,
Endoscopic injection/implant,51715,CPT,,,,,,,,both,,,32444.16,24008.68,74,,24008.68,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,14599.87,45,,14599.87,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,16059.86,49.5,,16059.86,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,1857.5,,,1857.5,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,22710.91,70,,22710.91,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,998.66,,,998.66,Other,New York Medicaid APG methodology,998.66,,,998.66,Other,100% New York Medicaid APG,998.66,,,998.66,Other,100% New York Medicaid APG,998.66,,,998.66,Other,100% New York Medicaid APG,2246.97,,,2246.97,Other,225% New York Medicaid APG,1527.94,,,1527.94,Other,153% New York Medicaid APG,2246.97,,,2246.97,Other,225% New York Medicaid APG,1398.12,,,1398.12,Other,140% New York Medicaid APG,2246.97,,,2246.97,Other,225% New York Medicaid APG,2596.5,,,2596.5,Other,260% New York Medicaid APG,3235.64,,,3235.64,Other,324% New York Medicaid APG,2147.11,,,2147.11,Other,215% New York Medicaid APG,2147.11,,,2147.11,Other,215% New York Medicaid APG,1248.32,,,1248.32,Other,125% New York Medicaid APG,998.66,24008.68,
Treatment of bladder lesion,51720,CPT,,,,,,,,both,,,98730.7,73060.72,74,,73060.72,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,44428.82,45,,44428.82,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,48871.7,49.5,,48871.7,percent of total billed charges,110% of Medicare,67136.88,68,,67136.88,percent of total billed charges,,903.43,,,903.43,Other,186% of Medicaid,78984.56,80,,78984.56,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,78984.56,80,,78984.56,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,69111.49,70,,69111.49,percent of total billed charges,,211.56,,,211.56,Fee Schedule,,179.31,,,179.31,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,485.72,,,485.72,Other,New York Medicaid APG methodology,485.72,,,485.72,Other,100% New York Medicaid APG,485.72,,,485.72,Other,100% New York Medicaid APG,485.72,,,485.72,Other,100% New York Medicaid APG,1092.86,,,1092.86,Other,225% New York Medicaid APG,743.14,,,743.14,Other,153% New York Medicaid APG,1092.86,,,1092.86,Other,225% New York Medicaid APG,680,,,680,Other,140% New York Medicaid APG,1092.86,,,1092.86,Other,225% New York Medicaid APG,1262.86,,,1262.86,Other,260% New York Medicaid APG,1573.72,,,1573.72,Other,324% New York Medicaid APG,1044.29,,,1044.29,Other,215% New York Medicaid APG,1044.29,,,1044.29,Other,215% New York Medicaid APG,607.14,,,607.14,Other,125% New York Medicaid APG,179.31,78984.56,
Simple cystometrogram,51725,CPT,,,,,,,,both,,,5198.43,3846.84,74,,3846.84,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,2339.29,45,,2339.29,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,897.11,,,897.11,Fee Schedule,,806.89,,,806.89,Fee Schedule,,762.63,,,762.63,Fee Schedule,,2573.22,49.5,,2573.22,percent of total billed charges,110% of Medicare,3534.93,68,,3534.93,percent of total billed charges,,903.43,,,903.43,Other,186% of Medicaid,4158.74,80,,4158.74,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,4158.74,80,,4158.74,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,3638.9,70,,3638.9,percent of total billed charges,,3378.98,65,,3378.98,percent of total billed charges,,3378.98,65,,3378.98,percent of total billed charges,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,485.72,,,485.72,Other,New York Medicaid APG methodology,485.72,,,485.72,Other,100% New York Medicaid APG,485.72,,,485.72,Other,100% New York Medicaid APG,485.72,,,485.72,Other,100% New York Medicaid APG,1092.86,,,1092.86,Other,225% New York Medicaid APG,743.14,,,743.14,Other,153% New York Medicaid APG,1092.86,,,1092.86,Other,225% New York Medicaid APG,680,,,680,Other,140% New York Medicaid APG,1092.86,,,1092.86,Other,225% New York Medicaid APG,1262.86,,,1262.86,Other,260% New York Medicaid APG,1573.72,,,1573.72,Other,324% New York Medicaid APG,1044.29,,,1044.29,Other,215% New York Medicaid APG,1044.29,,,1044.29,Other,215% New York Medicaid APG,607.14,,,607.14,Other,125% New York Medicaid APG,485.72,7216,
Complex cystometrogram,51726,CPT,,,,,,,,both,,,5198.43,3846.84,74,,3846.84,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,2339.29,45,,2339.29,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,1478.55,,,1478.55,Fee Schedule,,1329.85,,,1329.85,Fee Schedule,,1256.91,,,1256.91,Fee Schedule,,2573.22,49.5,,2573.22,percent of total billed charges,110% of Medicare,3534.93,68,,3534.93,percent of total billed charges,,903.43,,,903.43,Other,186% of Medicaid,4158.74,80,,4158.74,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,4158.74,80,,4158.74,percent of total billed charges,,7216,,,7216,Case Rate,,3578,,"100% primary, 0% secondary procedures",3578,Other,MagnaCare ASC Grouper,3638.9,70,,3638.9,percent of total billed charges,,3378.98,65,,3378.98,percent of total billed charges,,3378.98,65,,3378.98,percent of total billed charges,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,485.72,,,485.72,Other,New York Medicaid APG methodology,485.72,,,485.72,Other,100% New York Medicaid APG,485.72,,,485.72,Other,100% New York Medicaid APG,485.72,,,485.72,Other,100% New York Medicaid APG,1092.86,,,1092.86,Other,225% New York Medicaid APG,743.14,,,743.14,Other,153% New York Medicaid APG,1092.86,,,1092.86,Other,225% New York Medicaid APG,680,,,680,Other,140% New York Medicaid APG,1092.86,,,1092.86,Other,225% New York Medicaid APG,1262.86,,,1262.86,Other,260% New York Medicaid APG,1573.72,,,1573.72,Other,324% New York Medicaid APG,1044.29,,,1044.29,Other,215% New York Medicaid APG,1044.29,,,1044.29,Other,215% New York Medicaid APG,607.14,,,607.14,Other,125% New York Medicaid APG,485.72,7216,
Cystometrogram w/up,51727,CPT,,,,,,,,both,,,14368.32,10632.56,74,,10632.56,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,6465.74,45,,6465.74,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,1325.04,,,1325.04,Fee Schedule,,1191.78,,,1191.78,Fee Schedule,,1126.41,,,1126.41,Fee Schedule,,7112.32,49.5,,7112.32,percent of total billed charges,110% of Medicare,9770.46,68,,9770.46,percent of total billed charges,,903.43,,,903.43,Other,186% of Medicaid,11494.66,80,,11494.66,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,11494.66,80,,11494.66,percent of total billed charges,,7216,,,7216,Case Rate,,3578,,"100% primary, 0% secondary procedures",3578,Other,MagnaCare ASC Grouper,10057.82,70,,10057.82,percent of total billed charges,,9339.41,65,,9339.41,percent of total billed charges,,9339.41,65,,9339.41,percent of total billed charges,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,485.72,,,485.72,Other,New York Medicaid APG methodology,485.72,,,485.72,Other,100% New York Medicaid APG,485.72,,,485.72,Other,100% New York Medicaid APG,485.72,,,485.72,Other,100% New York Medicaid APG,1092.86,,,1092.86,Other,225% New York Medicaid APG,743.14,,,743.14,Other,153% New York Medicaid APG,1092.86,,,1092.86,Other,225% New York Medicaid APG,680,,,680,Other,140% New York Medicaid APG,1092.86,,,1092.86,Other,225% New York Medicaid APG,1262.86,,,1262.86,Other,260% New York Medicaid APG,1573.72,,,1573.72,Other,324% New York Medicaid APG,1044.29,,,1044.29,Other,215% New York Medicaid APG,1044.29,,,1044.29,Other,215% New York Medicaid APG,607.14,,,607.14,Other,125% New York Medicaid APG,485.72,11494.66,
Cystometrogram w/vp,51728,CPT,,,,,,,,both,,,13756.02,10179.45,74,,10179.45,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,6190.21,45,,6190.21,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,1320.45,,,1320.45,Fee Schedule,,1187.65,,,1187.65,Fee Schedule,,1122.51,,,1122.51,Fee Schedule,,6809.23,49.5,,6809.23,percent of total billed charges,110% of Medicare,9354.09,68,,9354.09,percent of total billed charges,,903.43,,,903.43,Other,186% of Medicaid,11004.82,80,,11004.82,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,11004.82,80,,11004.82,percent of total billed charges,,7216,,,7216,Case Rate,,3578,,"100% primary, 0% secondary procedures",3578,Other,MagnaCare ASC Grouper,9629.21,70,,9629.21,percent of total billed charges,,8941.41,65,,8941.41,percent of total billed charges,,8941.41,65,,8941.41,percent of total billed charges,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,485.72,,,485.72,Other,New York Medicaid APG methodology,485.72,,,485.72,Other,100% New York Medicaid APG,485.72,,,485.72,Other,100% New York Medicaid APG,485.72,,,485.72,Other,100% New York Medicaid APG,1092.86,,,1092.86,Other,225% New York Medicaid APG,743.14,,,743.14,Other,153% New York Medicaid APG,1092.86,,,1092.86,Other,225% New York Medicaid APG,680,,,680,Other,140% New York Medicaid APG,1092.86,,,1092.86,Other,225% New York Medicaid APG,1262.86,,,1262.86,Other,260% New York Medicaid APG,1573.72,,,1573.72,Other,324% New York Medicaid APG,1044.29,,,1044.29,Other,215% New York Medicaid APG,1044.29,,,1044.29,Other,215% New York Medicaid APG,607.14,,,607.14,Other,125% New York Medicaid APG,485.72,11004.82,
Cystometrogram w/vp&up,51729,CPT,,,,,,,,both,,,16915.05,12517.14,74,,12517.14,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,7611.77,45,,7611.77,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,1366.25,,,1366.25,Fee Schedule,,1228.85,,,1228.85,Fee Schedule,,1161.44,,,1161.44,Fee Schedule,,8372.95,49.5,,8372.95,percent of total billed charges,110% of Medicare,11502.23,68,,11502.23,percent of total billed charges,,903.43,,,903.43,Other,186% of Medicaid,13532.04,80,,13532.04,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,13532.04,80,,13532.04,percent of total billed charges,,7216,,,7216,Case Rate,,3578,,"100% primary, 0% secondary procedures",3578,Other,MagnaCare ASC Grouper,11840.54,70,,11840.54,percent of total billed charges,,10994.78,65,,10994.78,percent of total billed charges,,10994.78,65,,10994.78,percent of total billed charges,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,485.72,,,485.72,Other,New York Medicaid APG methodology,485.72,,,485.72,Other,100% New York Medicaid APG,485.72,,,485.72,Other,100% New York Medicaid APG,485.72,,,485.72,Other,100% New York Medicaid APG,1092.86,,,1092.86,Other,225% New York Medicaid APG,743.14,,,743.14,Other,153% New York Medicaid APG,1092.86,,,1092.86,Other,225% New York Medicaid APG,680,,,680,Other,140% New York Medicaid APG,1092.86,,,1092.86,Other,225% New York Medicaid APG,1262.86,,,1262.86,Other,260% New York Medicaid APG,1573.72,,,1573.72,Other,324% New York Medicaid APG,1044.29,,,1044.29,Other,215% New York Medicaid APG,1044.29,,,1044.29,Other,215% New York Medicaid APG,607.14,,,607.14,Other,125% New York Medicaid APG,485.72,13532.04,
Urine flow measurement,51736,CPT,,,,,,,,both,,,2686.86,1988.28,74,,1988.28,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,1209.09,45,,1209.09,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,155.73,,,155.73,Fee Schedule,,140.07,,,140.07,Fee Schedule,,132.38,,,132.38,Fee Schedule,,1330,49.5,,1330,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,847.8,,,847.8,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,1880.8,70,,1880.8,percent of total billed charges,,1746.46,65,,1746.46,percent of total billed charges,,1746.46,65,,1746.46,percent of total billed charges,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,455.81,,,455.81,Other,New York Medicaid APG methodology,455.81,,,455.81,Other,100% New York Medicaid APG,455.81,,,455.81,Other,100% New York Medicaid APG,455.81,,,455.81,Other,100% New York Medicaid APG,1025.56,,,1025.56,Other,225% New York Medicaid APG,697.38,,,697.38,Other,153% New York Medicaid APG,1025.56,,,1025.56,Other,225% New York Medicaid APG,638.13,,,638.13,Other,140% New York Medicaid APG,1025.56,,,1025.56,Other,225% New York Medicaid APG,1185.1,,,1185.1,Other,260% New York Medicaid APG,1476.81,,,1476.81,Other,324% New York Medicaid APG,979.98,,,979.98,Other,215% New York Medicaid APG,979.98,,,979.98,Other,215% New York Medicaid APG,569.76,,,569.76,Other,125% New York Medicaid APG,132.38,9473,
Electro-uroflowmetry first,51741,CPT,,,,,,,,both,,,3263,2414.62,74,,2414.62,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,1468.35,45,,1468.35,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,178.6,,,178.6,Fee Schedule,,160.64,,,160.64,Fee Schedule,,151.83,,,151.83,Fee Schedule,,1615.19,49.5,,1615.19,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,903.43,,,903.43,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,2284.1,70,,2284.1,percent of total billed charges,,2120.95,65,,2120.95,percent of total billed charges,,2120.95,65,,2120.95,percent of total billed charges,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,485.72,,,485.72,Other,New York Medicaid APG methodology,485.72,,,485.72,Other,100% New York Medicaid APG,485.72,,,485.72,Other,100% New York Medicaid APG,485.72,,,485.72,Other,100% New York Medicaid APG,1092.86,,,1092.86,Other,225% New York Medicaid APG,743.14,,,743.14,Other,153% New York Medicaid APG,1092.86,,,1092.86,Other,225% New York Medicaid APG,680,,,680,Other,140% New York Medicaid APG,1092.86,,,1092.86,Other,225% New York Medicaid APG,1262.86,,,1262.86,Other,260% New York Medicaid APG,1573.72,,,1573.72,Other,324% New York Medicaid APG,1044.29,,,1044.29,Other,215% New York Medicaid APG,1044.29,,,1044.29,Other,215% New York Medicaid APG,607.14,,,607.14,Other,125% New York Medicaid APG,151.83,9473,
Anal/urinary muscle study,51784,CPT,,,,,,,,both,,,3285.56,2431.31,74,,2431.31,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,1478.5,45,,1478.5,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,855.95,,,855.95,Fee Schedule,,769.87,,,769.87,Fee Schedule,,727.64,,,727.64,Fee Schedule,,1626.35,49.5,,1626.35,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,428.16,,,428.16,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,2299.89,70,,2299.89,percent of total billed charges,,2135.61,65,,2135.61,percent of total billed charges,,2135.61,65,,2135.61,percent of total billed charges,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,230.2,,,230.2,Other,New York Medicaid APG methodology,230.2,,,230.2,Other,100% New York Medicaid APG,230.2,,,230.2,Other,100% New York Medicaid APG,230.2,,,230.2,Other,100% New York Medicaid APG,517.94,,,517.94,Other,225% New York Medicaid APG,352.2,,,352.2,Other,153% New York Medicaid APG,517.94,,,517.94,Other,225% New York Medicaid APG,322.27,,,322.27,Other,140% New York Medicaid APG,517.94,,,517.94,Other,225% New York Medicaid APG,598.51,,,598.51,Other,260% New York Medicaid APG,745.83,,,745.83,Other,324% New York Medicaid APG,494.92,,,494.92,Other,215% New York Medicaid APG,494.92,,,494.92,Other,215% New York Medicaid APG,287.74,,,287.74,Other,125% New York Medicaid APG,230.2,9473,
Anal/urinary muscle study,51785,CPT,,,,,,,,both,,,5198.43,3846.84,74,,3846.84,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,2339.29,45,,2339.29,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,990.97,,,990.97,Fee Schedule,,891.31,,,891.31,Fee Schedule,,842.42,,,842.42,Fee Schedule,,2573.22,49.5,,2573.22,percent of total billed charges,110% of Medicare,3534.93,68,,3534.93,percent of total billed charges,,428.16,,,428.16,Other,186% of Medicaid,4158.74,80,,4158.74,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,4158.74,80,,4158.74,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,3638.9,70,,3638.9,percent of total billed charges,,3378.98,65,,3378.98,percent of total billed charges,,3378.98,65,,3378.98,percent of total billed charges,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,230.2,,,230.2,Other,New York Medicaid APG methodology,230.2,,,230.2,Other,100% New York Medicaid APG,230.2,,,230.2,Other,100% New York Medicaid APG,230.2,,,230.2,Other,100% New York Medicaid APG,517.94,,,517.94,Other,225% New York Medicaid APG,352.2,,,352.2,Other,153% New York Medicaid APG,517.94,,,517.94,Other,225% New York Medicaid APG,322.27,,,322.27,Other,140% New York Medicaid APG,517.94,,,517.94,Other,225% New York Medicaid APG,598.51,,,598.51,Other,260% New York Medicaid APG,745.83,,,745.83,Other,324% New York Medicaid APG,494.92,,,494.92,Other,215% New York Medicaid APG,494.92,,,494.92,Other,215% New York Medicaid APG,287.74,,,287.74,Other,125% New York Medicaid APG,230.2,7216,
Urinary reflex study,51792,CPT,,,,,,,,both,,,1286.58,952.07,74,,952.07,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,578.96,45,,578.96,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,1183.17,,,1183.17,Fee Schedule,,1064.18,,,1064.18,Fee Schedule,,1005.8,,,1005.8,Fee Schedule,,636.86,49.5,,636.86,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,428.16,,,428.16,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,900.61,70,,900.61,percent of total billed charges,,836.28,65,,836.28,percent of total billed charges,,836.28,65,,836.28,percent of total billed charges,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,230.2,,,230.2,Other,New York Medicaid APG methodology,230.2,,,230.2,Other,100% New York Medicaid APG,230.2,,,230.2,Other,100% New York Medicaid APG,230.2,,,230.2,Other,100% New York Medicaid APG,517.94,,,517.94,Other,225% New York Medicaid APG,352.2,,,352.2,Other,153% New York Medicaid APG,517.94,,,517.94,Other,225% New York Medicaid APG,322.27,,,322.27,Other,140% New York Medicaid APG,517.94,,,517.94,Other,225% New York Medicaid APG,598.51,,,598.51,Other,260% New York Medicaid APG,745.83,,,745.83,Other,324% New York Medicaid APG,494.92,,,494.92,Other,215% New York Medicaid APG,494.92,,,494.92,Other,215% New York Medicaid APG,287.74,,,287.74,Other,125% New York Medicaid APG,230.2,9473,
Intraabdominal pressure test,51797,CPT,,,,,,,,both,,,9018.37,6673.59,74,,6673.59,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,4058.27,45,,4058.27,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,627.13,,,627.13,Fee Schedule,,564.06,,,564.06,Fee Schedule,,533.12,,,533.12,Fee Schedule,,4464.09,49.5,,4464.09,percent of total billed charges,110% of Medicare,6132.49,68,,6132.49,percent of total billed charges,,847.8,,,847.8,Other,186% of Medicaid,7214.7,80,,7214.7,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,7214.7,80,,7214.7,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,6312.86,70,,6312.86,percent of total billed charges,,5861.94,65,,5861.94,percent of total billed charges,,5861.94,65,,5861.94,percent of total billed charges,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,455.81,,,455.81,Other,New York Medicaid APG methodology,455.81,,,455.81,Other,100% New York Medicaid APG,455.81,,,455.81,Other,100% New York Medicaid APG,455.81,,,455.81,Other,100% New York Medicaid APG,1025.56,,,1025.56,Other,225% New York Medicaid APG,697.38,,,697.38,Other,153% New York Medicaid APG,1025.56,,,1025.56,Other,225% New York Medicaid APG,638.13,,,638.13,Other,140% New York Medicaid APG,1025.56,,,1025.56,Other,225% New York Medicaid APG,1185.1,,,1185.1,Other,260% New York Medicaid APG,1476.81,,,1476.81,Other,324% New York Medicaid APG,979.98,,,979.98,Other,215% New York Medicaid APG,979.98,,,979.98,Other,215% New York Medicaid APG,569.76,,,569.76,Other,125% New York Medicaid APG,455.81,7216,
Us urine capacity measure,51798,CPT,,,,,,,,both,,,1286.58,952.07,74,,952.07,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,578.96,45,,578.96,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,132.8,,,132.8,Fee Schedule,,119.45,,,119.45,Fee Schedule,,112.9,,,112.9,Fee Schedule,,636.86,49.5,,636.86,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,847.8,,,847.8,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,900.61,70,,900.61,percent of total billed charges,,52.48,,,52.48,Fee Schedule,,44.48,,,44.48,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,455.81,,,455.81,Other,New York Medicaid APG methodology,455.81,,,455.81,Other,100% New York Medicaid APG,455.81,,,455.81,Other,100% New York Medicaid APG,455.81,,,455.81,Other,100% New York Medicaid APG,1025.56,,,1025.56,Other,225% New York Medicaid APG,697.38,,,697.38,Other,153% New York Medicaid APG,1025.56,,,1025.56,Other,225% New York Medicaid APG,638.13,,,638.13,Other,140% New York Medicaid APG,1025.56,,,1025.56,Other,225% New York Medicaid APG,1185.1,,,1185.1,Other,260% New York Medicaid APG,1476.81,,,1476.81,Other,324% New York Medicaid APG,979.98,,,979.98,Other,215% New York Medicaid APG,979.98,,,979.98,Other,215% New York Medicaid APG,569.76,,,569.76,Other,125% New York Medicaid APG,44.48,9473,
Repair bladder neck,51845,CPT,,,,,,,,both,,,104619.92,77418.74,74,,77418.74,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,47078.96,45,,47078.96,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,51786.86,49.5,,51786.86,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3412.13,,,3412.13,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,73233.94,70,,73233.94,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,1834.48,,,1834.48,Other,New York Medicaid APG methodology,1834.48,,,1834.48,Other,100% New York Medicaid APG,1834.48,,,1834.48,Other,100% New York Medicaid APG,1834.48,,,1834.48,Other,100% New York Medicaid APG,4127.58,,,4127.58,Other,225% New York Medicaid APG,2806.75,,,2806.75,Other,153% New York Medicaid APG,4127.58,,,4127.58,Other,225% New York Medicaid APG,2568.27,,,2568.27,Other,140% New York Medicaid APG,4127.58,,,4127.58,Other,225% New York Medicaid APG,4769.65,,,4769.65,Other,260% New York Medicaid APG,5943.71,,,5943.71,Other,324% New York Medicaid APG,3944.13,,,3944.13,Other,215% New York Medicaid APG,3944.13,,,3944.13,Other,215% New York Medicaid APG,2293.1,,,2293.1,Other,125% New York Medicaid APG,1834.48,77418.74,
Repair of bladder wound,51860,CPT,,,,,,,,both,,,193769.26,143389.25,74,,143389.25,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,87196.17,45,,87196.17,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,95915.78,49.5,,95915.78,percent of total billed charges,110% of Medicare,131763.1,68,,131763.1,percent of total billed charges,,3412.13,,,3412.13,Other,186% of Medicaid,155015.41,80,,155015.41,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,155015.41,80,,155015.41,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,135638.48,70,,135638.48,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1834.48,,,1834.48,Other,New York Medicaid APG methodology,1834.48,,,1834.48,Other,100% New York Medicaid APG,1834.48,,,1834.48,Other,100% New York Medicaid APG,1834.48,,,1834.48,Other,100% New York Medicaid APG,4127.58,,,4127.58,Other,225% New York Medicaid APG,2806.75,,,2806.75,Other,153% New York Medicaid APG,4127.58,,,4127.58,Other,225% New York Medicaid APG,2568.27,,,2568.27,Other,140% New York Medicaid APG,4127.58,,,4127.58,Other,225% New York Medicaid APG,4769.65,,,4769.65,Other,260% New York Medicaid APG,5943.71,,,5943.71,Other,324% New York Medicaid APG,3944.13,,,3944.13,Other,215% New York Medicaid APG,3944.13,,,3944.13,Other,215% New York Medicaid APG,2293.1,,,2293.1,Other,125% New York Medicaid APG,1834.48,155015.41,
Repair of bladder opening,51880,CPT,,,,,,,,both,,,73326.88,54261.89,74,,54261.89,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,32997.1,45,,32997.1,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,36296.81,49.5,,36296.81,percent of total billed charges,110% of Medicare,49862.28,68,,49862.28,percent of total billed charges,,2876.72,,,2876.72,Other,186% of Medicaid,58661.5,80,,58661.5,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,58661.5,80,,58661.5,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,51328.82,70,,51328.82,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1546.62,,,1546.62,Other,New York Medicaid APG methodology,1546.62,,,1546.62,Other,100% New York Medicaid APG,1546.62,,,1546.62,Other,100% New York Medicaid APG,1546.62,,,1546.62,Other,100% New York Medicaid APG,3479.91,,,3479.91,Other,225% New York Medicaid APG,2366.34,,,2366.34,Other,153% New York Medicaid APG,3479.91,,,3479.91,Other,225% New York Medicaid APG,2165.27,,,2165.27,Other,140% New York Medicaid APG,3479.91,,,3479.91,Other,225% New York Medicaid APG,4021.22,,,4021.22,Other,260% New York Medicaid APG,5011.06,,,5011.06,Other,324% New York Medicaid APG,3325.24,,,3325.24,Other,215% New York Medicaid APG,3325.24,,,3325.24,Other,215% New York Medicaid APG,1933.28,,,1933.28,Other,125% New York Medicaid APG,1546.62,58661.5,
Laparo urethral suspension,51990,CPT,,,,,,,,both,,,121364.27,89809.56,74,,89809.56,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,54613.92,45,,54613.92,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,6125,,"100% primary, 50% secondary, 25% supplemental procedure",6125,Other,Blue Cross ASC Grouper,5513,,"100% primary, 50% secondary, 25% supplemental procedure",5513,Other,Blue Cross ASC Grouper,5206,,"100% primary, 50% secondary, 25% supplemental procedure",5206,Other,Blue Cross ASC Grouper,60075.31,49.5,,60075.31,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,1857.5,,,1857.5,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,84954.99,70,,84954.99,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,998.66,,,998.66,Other,New York Medicaid APG methodology,998.66,,,998.66,Other,100% New York Medicaid APG,998.66,,,998.66,Other,100% New York Medicaid APG,998.66,,,998.66,Other,100% New York Medicaid APG,2246.97,,,2246.97,Other,225% New York Medicaid APG,1527.94,,,1527.94,Other,153% New York Medicaid APG,2246.97,,,2246.97,Other,225% New York Medicaid APG,1398.12,,,1398.12,Other,140% New York Medicaid APG,2246.97,,,2246.97,Other,225% New York Medicaid APG,2596.5,,,2596.5,Other,260% New York Medicaid APG,3235.64,,,3235.64,Other,324% New York Medicaid APG,2147.11,,,2147.11,Other,215% New York Medicaid APG,2147.11,,,2147.11,Other,215% New York Medicaid APG,1248.32,,,1248.32,Other,125% New York Medicaid APG,998.66,89809.56,
Laparo sling operation,51992,CPT,,,,,,,,both,,,38182.29,28254.89,74,,28254.89,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,17182.03,45,,17182.03,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,6125,,"100% primary, 50% secondary, 25% supplemental procedure",6125,Other,Blue Cross ASC Grouper,5513,,"100% primary, 50% secondary, 25% supplemental procedure",5513,Other,Blue Cross ASC Grouper,5206,,"100% primary, 50% secondary, 25% supplemental procedure",5206,Other,Blue Cross ASC Grouper,18900.23,49.5,,18900.23,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,1857.5,,,1857.5,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,26727.6,70,,26727.6,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,998.66,,,998.66,Other,New York Medicaid APG methodology,998.66,,,998.66,Other,100% New York Medicaid APG,998.66,,,998.66,Other,100% New York Medicaid APG,998.66,,,998.66,Other,100% New York Medicaid APG,2246.97,,,2246.97,Other,225% New York Medicaid APG,1527.94,,,1527.94,Other,153% New York Medicaid APG,2246.97,,,2246.97,Other,225% New York Medicaid APG,1398.12,,,1398.12,Other,140% New York Medicaid APG,2246.97,,,2246.97,Other,225% New York Medicaid APG,2596.5,,,2596.5,Other,260% New York Medicaid APG,3235.64,,,3235.64,Other,324% New York Medicaid APG,2147.11,,,2147.11,Other,215% New York Medicaid APG,2147.11,,,2147.11,Other,215% New York Medicaid APG,1248.32,,,1248.32,Other,125% New York Medicaid APG,998.66,28254.89,
Cystoscopy,52000,CPT,,,,,,,,both,,,16926.21,12525.4,74,,12525.4,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,7616.79,45,,7616.79,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,8378.47,49.5,,8378.47,percent of total billed charges,110% of Medicare,11509.82,68,,11509.82,percent of total billed charges,,2876.72,,,2876.72,Other,186% of Medicaid,13540.97,80,,13540.97,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,13540.97,80,,13540.97,percent of total billed charges,,7216,,,7216,Case Rate,,3578,,"100% primary, 0% secondary procedures",3578,Other,MagnaCare ASC Grouper,11848.35,70,,11848.35,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,1546.62,,,1546.62,Other,New York Medicaid APG methodology,1546.62,,,1546.62,Other,100% New York Medicaid APG,1546.62,,,1546.62,Other,100% New York Medicaid APG,1546.62,,,1546.62,Other,100% New York Medicaid APG,3479.91,,,3479.91,Other,225% New York Medicaid APG,2366.34,,,2366.34,Other,153% New York Medicaid APG,3479.91,,,3479.91,Other,225% New York Medicaid APG,2165.27,,,2165.27,Other,140% New York Medicaid APG,3479.91,,,3479.91,Other,225% New York Medicaid APG,4021.22,,,4021.22,Other,260% New York Medicaid APG,5011.06,,,5011.06,Other,324% New York Medicaid APG,3325.24,,,3325.24,Other,215% New York Medicaid APG,3325.24,,,3325.24,Other,215% New York Medicaid APG,1933.28,,,1933.28,Other,125% New York Medicaid APG,1546.62,13540.97,
Cystoscopy removal of clots,52001,CPT,,,,,,,,both,,,35649.23,26380.43,74,,26380.43,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,16042.15,45,,16042.15,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,17646.37,49.5,,17646.37,percent of total billed charges,110% of Medicare,24241.48,68,,24241.48,percent of total billed charges,,2876.72,,,2876.72,Other,186% of Medicaid,28519.38,80,,28519.38,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,28519.38,80,,28519.38,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,24954.46,70,,24954.46,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1546.62,,,1546.62,Other,New York Medicaid APG methodology,1546.62,,,1546.62,Other,100% New York Medicaid APG,1546.62,,,1546.62,Other,100% New York Medicaid APG,1546.62,,,1546.62,Other,100% New York Medicaid APG,3479.91,,,3479.91,Other,225% New York Medicaid APG,2366.34,,,2366.34,Other,153% New York Medicaid APG,3479.91,,,3479.91,Other,225% New York Medicaid APG,2165.27,,,2165.27,Other,140% New York Medicaid APG,3479.91,,,3479.91,Other,225% New York Medicaid APG,4021.22,,,4021.22,Other,260% New York Medicaid APG,5011.06,,,5011.06,Other,324% New York Medicaid APG,3325.24,,,3325.24,Other,215% New York Medicaid APG,3325.24,,,3325.24,Other,215% New York Medicaid APG,1933.28,,,1933.28,Other,125% New York Medicaid APG,1546.62,28519.38,
Cystoscopy & ureter catheter,52005,CPT,,,,,,,,both,,,47893.05,35440.86,74,,35440.86,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,21551.87,45,,21551.87,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,23707.06,49.5,,23707.06,percent of total billed charges,110% of Medicare,32567.27,68,,32567.27,percent of total billed charges,,2876.72,,,2876.72,Other,186% of Medicaid,38314.44,80,,38314.44,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,38314.44,80,,38314.44,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,33525.14,70,,33525.14,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1546.62,,,1546.62,Other,New York Medicaid APG methodology,1546.62,,,1546.62,Other,100% New York Medicaid APG,1546.62,,,1546.62,Other,100% New York Medicaid APG,1546.62,,,1546.62,Other,100% New York Medicaid APG,3479.91,,,3479.91,Other,225% New York Medicaid APG,2366.34,,,2366.34,Other,153% New York Medicaid APG,3479.91,,,3479.91,Other,225% New York Medicaid APG,2165.27,,,2165.27,Other,140% New York Medicaid APG,3479.91,,,3479.91,Other,225% New York Medicaid APG,4021.22,,,4021.22,Other,260% New York Medicaid APG,5011.06,,,5011.06,Other,324% New York Medicaid APG,3325.24,,,3325.24,Other,215% New York Medicaid APG,3325.24,,,3325.24,Other,215% New York Medicaid APG,1933.28,,,1933.28,Other,125% New York Medicaid APG,1546.62,38314.44,
Cystoscopy and biopsy,52007,CPT,,,,,,,,both,,,73326.88,54261.89,74,,54261.89,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,32997.1,45,,32997.1,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,36296.81,49.5,,36296.81,percent of total billed charges,110% of Medicare,49862.28,68,,49862.28,percent of total billed charges,,2011.18,,,2011.18,Other,186% of Medicaid,58661.5,80,,58661.5,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,58661.5,80,,58661.5,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,51328.82,70,,51328.82,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1081.28,,,1081.28,Other,New York Medicaid APG methodology,1081.28,,,1081.28,Other,100% New York Medicaid APG,1081.28,,,1081.28,Other,100% New York Medicaid APG,1081.28,,,1081.28,Other,100% New York Medicaid APG,2432.88,,,2432.88,Other,225% New York Medicaid APG,1654.36,,,1654.36,Other,153% New York Medicaid APG,2432.88,,,2432.88,Other,225% New York Medicaid APG,1513.79,,,1513.79,Other,140% New York Medicaid APG,2432.88,,,2432.88,Other,225% New York Medicaid APG,2811.33,,,2811.33,Other,260% New York Medicaid APG,3503.35,,,3503.35,Other,324% New York Medicaid APG,2324.75,,,2324.75,Other,215% New York Medicaid APG,2324.75,,,2324.75,Other,215% New York Medicaid APG,1351.6,,,1351.6,Other,125% New York Medicaid APG,1081.28,58661.5,
Cystoscopy & duct catheter,52010,CPT,,,,,,,,both,,,14368.32,10632.56,74,,10632.56,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,6465.74,45,,6465.74,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,7112.32,49.5,,7112.32,percent of total billed charges,110% of Medicare,9770.46,68,,9770.46,percent of total billed charges,,1857.5,,,1857.5,Other,186% of Medicaid,11494.66,80,,11494.66,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,11494.66,80,,11494.66,percent of total billed charges,,7216,,,7216,Case Rate,,3578,,"100% primary, 0% secondary procedures",3578,Other,MagnaCare ASC Grouper,10057.82,70,,10057.82,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,998.66,,,998.66,Other,New York Medicaid APG methodology,998.66,,,998.66,Other,100% New York Medicaid APG,998.66,,,998.66,Other,100% New York Medicaid APG,998.66,,,998.66,Other,100% New York Medicaid APG,2246.97,,,2246.97,Other,225% New York Medicaid APG,1527.94,,,1527.94,Other,153% New York Medicaid APG,2246.97,,,2246.97,Other,225% New York Medicaid APG,1398.12,,,1398.12,Other,140% New York Medicaid APG,2246.97,,,2246.97,Other,225% New York Medicaid APG,2596.5,,,2596.5,Other,260% New York Medicaid APG,3235.64,,,3235.64,Other,324% New York Medicaid APG,2147.11,,,2147.11,Other,215% New York Medicaid APG,2147.11,,,2147.11,Other,215% New York Medicaid APG,1248.32,,,1248.32,Other,125% New York Medicaid APG,998.66,11494.66,
Cystoscopy w/biopsy(s),52204,CPT,,,,,,,,both,,,41108.08,30419.98,74,,30419.98,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,18498.64,45,,18498.64,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,20348.5,49.5,,20348.5,percent of total billed charges,110% of Medicare,27953.49,68,,27953.49,percent of total billed charges,,2876.72,,,2876.72,Other,186% of Medicaid,32886.46,80,,32886.46,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,32886.46,80,,32886.46,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,28775.66,70,,28775.66,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1546.62,,,1546.62,Other,New York Medicaid APG methodology,1546.62,,,1546.62,Other,100% New York Medicaid APG,1546.62,,,1546.62,Other,100% New York Medicaid APG,1546.62,,,1546.62,Other,100% New York Medicaid APG,3479.91,,,3479.91,Other,225% New York Medicaid APG,2366.34,,,2366.34,Other,153% New York Medicaid APG,3479.91,,,3479.91,Other,225% New York Medicaid APG,2165.27,,,2165.27,Other,140% New York Medicaid APG,3479.91,,,3479.91,Other,225% New York Medicaid APG,4021.22,,,4021.22,Other,260% New York Medicaid APG,5011.06,,,5011.06,Other,324% New York Medicaid APG,3325.24,,,3325.24,Other,215% New York Medicaid APG,3325.24,,,3325.24,Other,215% New York Medicaid APG,1933.28,,,1933.28,Other,125% New York Medicaid APG,1546.62,32886.46,
Cystoscopy and treatment,52214,CPT,,,,,,,,both,,,38081.64,28180.41,74,,28180.41,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,17136.74,45,,17136.74,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,18850.41,49.5,,18850.41,percent of total billed charges,110% of Medicare,25895.52,68,,25895.52,percent of total billed charges,,2876.72,,,2876.72,Other,186% of Medicaid,30465.31,80,,30465.31,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,30465.31,80,,30465.31,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,26657.15,70,,26657.15,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1546.62,,,1546.62,Other,New York Medicaid APG methodology,1546.62,,,1546.62,Other,100% New York Medicaid APG,1546.62,,,1546.62,Other,100% New York Medicaid APG,1546.62,,,1546.62,Other,100% New York Medicaid APG,3479.91,,,3479.91,Other,225% New York Medicaid APG,2366.34,,,2366.34,Other,153% New York Medicaid APG,3479.91,,,3479.91,Other,225% New York Medicaid APG,2165.27,,,2165.27,Other,140% New York Medicaid APG,3479.91,,,3479.91,Other,225% New York Medicaid APG,4021.22,,,4021.22,Other,260% New York Medicaid APG,5011.06,,,5011.06,Other,324% New York Medicaid APG,3325.24,,,3325.24,Other,215% New York Medicaid APG,3325.24,,,3325.24,Other,215% New York Medicaid APG,1933.28,,,1933.28,Other,125% New York Medicaid APG,1546.62,30465.31,
Cystoscopy and treatment,52224,CPT,,,,,,,,both,,,39655,29344.7,74,,29344.7,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,17844.75,45,,17844.75,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,19629.23,49.5,,19629.23,percent of total billed charges,110% of Medicare,26965.4,68,,26965.4,percent of total billed charges,,2876.72,,,2876.72,Other,186% of Medicaid,31724,80,,31724,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,31724,80,,31724,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,27758.5,70,,27758.5,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1546.62,,,1546.62,Other,New York Medicaid APG methodology,1546.62,,,1546.62,Other,100% New York Medicaid APG,1546.62,,,1546.62,Other,100% New York Medicaid APG,1546.62,,,1546.62,Other,100% New York Medicaid APG,3479.91,,,3479.91,Other,225% New York Medicaid APG,2366.34,,,2366.34,Other,153% New York Medicaid APG,3479.91,,,3479.91,Other,225% New York Medicaid APG,2165.27,,,2165.27,Other,140% New York Medicaid APG,3479.91,,,3479.91,Other,225% New York Medicaid APG,4021.22,,,4021.22,Other,260% New York Medicaid APG,5011.06,,,5011.06,Other,324% New York Medicaid APG,3325.24,,,3325.24,Other,215% New York Medicaid APG,3325.24,,,3325.24,Other,215% New York Medicaid APG,1933.28,,,1933.28,Other,125% New York Medicaid APG,1546.62,31724,
Cystoscopy and treatment,52234,CPT,,,,,,,,both,,,42962.38,31792.16,74,,31792.16,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,19333.07,45,,19333.07,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,21266.38,49.5,,21266.38,percent of total billed charges,110% of Medicare,29214.42,68,,29214.42,percent of total billed charges,,2876.72,,,2876.72,Other,186% of Medicaid,34369.9,80,,34369.9,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,34369.9,80,,34369.9,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,30073.67,70,,30073.67,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1546.62,,,1546.62,Other,New York Medicaid APG methodology,1546.62,,,1546.62,Other,100% New York Medicaid APG,1546.62,,,1546.62,Other,100% New York Medicaid APG,1546.62,,,1546.62,Other,100% New York Medicaid APG,3479.91,,,3479.91,Other,225% New York Medicaid APG,2366.34,,,2366.34,Other,153% New York Medicaid APG,3479.91,,,3479.91,Other,225% New York Medicaid APG,2165.27,,,2165.27,Other,140% New York Medicaid APG,3479.91,,,3479.91,Other,225% New York Medicaid APG,4021.22,,,4021.22,Other,260% New York Medicaid APG,5011.06,,,5011.06,Other,324% New York Medicaid APG,3325.24,,,3325.24,Other,215% New York Medicaid APG,3325.24,,,3325.24,Other,215% New York Medicaid APG,1933.28,,,1933.28,Other,125% New York Medicaid APG,1546.62,34369.9,
Cystoscopy and treatment,52235,CPT,,,,,,,,both,,,50035.16,37026.02,74,,37026.02,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,22515.82,45,,22515.82,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,24767.4,49.5,,24767.4,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2876.72,,,2876.72,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,35024.61,70,,35024.61,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1546.62,,,1546.62,Other,New York Medicaid APG methodology,1546.62,,,1546.62,Other,100% New York Medicaid APG,1546.62,,,1546.62,Other,100% New York Medicaid APG,1546.62,,,1546.62,Other,100% New York Medicaid APG,3479.91,,,3479.91,Other,225% New York Medicaid APG,2366.34,,,2366.34,Other,153% New York Medicaid APG,3479.91,,,3479.91,Other,225% New York Medicaid APG,2165.27,,,2165.27,Other,140% New York Medicaid APG,3479.91,,,3479.91,Other,225% New York Medicaid APG,4021.22,,,4021.22,Other,260% New York Medicaid APG,5011.06,,,5011.06,Other,324% New York Medicaid APG,3325.24,,,3325.24,Other,215% New York Medicaid APG,3325.24,,,3325.24,Other,215% New York Medicaid APG,1933.28,,,1933.28,Other,125% New York Medicaid APG,1546.62,37026.02,
Cystoscopy and treatment,52240,CPT,,,,,,,,both,,,49683.71,36765.95,74,,36765.95,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,22357.67,45,,22357.67,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,24593.44,49.5,,24593.44,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2876.72,,,2876.72,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,34778.6,70,,34778.6,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1546.62,,,1546.62,Other,New York Medicaid APG methodology,1546.62,,,1546.62,Other,100% New York Medicaid APG,1546.62,,,1546.62,Other,100% New York Medicaid APG,1546.62,,,1546.62,Other,100% New York Medicaid APG,3479.91,,,3479.91,Other,225% New York Medicaid APG,2366.34,,,2366.34,Other,153% New York Medicaid APG,3479.91,,,3479.91,Other,225% New York Medicaid APG,2165.27,,,2165.27,Other,140% New York Medicaid APG,3479.91,,,3479.91,Other,225% New York Medicaid APG,4021.22,,,4021.22,Other,260% New York Medicaid APG,5011.06,,,5011.06,Other,324% New York Medicaid APG,3325.24,,,3325.24,Other,215% New York Medicaid APG,3325.24,,,3325.24,Other,215% New York Medicaid APG,1933.28,,,1933.28,Other,125% New York Medicaid APG,1546.62,36765.95,
Cystoscopy and radiotracer,52250,CPT,,,,,,,,both,,,73326.88,54261.89,74,,54261.89,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,32997.1,45,,32997.1,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,36296.81,49.5,,36296.81,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2876.72,,,2876.72,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,51328.82,70,,51328.82,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1546.62,,,1546.62,Other,New York Medicaid APG methodology,1546.62,,,1546.62,Other,100% New York Medicaid APG,1546.62,,,1546.62,Other,100% New York Medicaid APG,1546.62,,,1546.62,Other,100% New York Medicaid APG,3479.91,,,3479.91,Other,225% New York Medicaid APG,2366.34,,,2366.34,Other,153% New York Medicaid APG,3479.91,,,3479.91,Other,225% New York Medicaid APG,2165.27,,,2165.27,Other,140% New York Medicaid APG,3479.91,,,3479.91,Other,225% New York Medicaid APG,4021.22,,,4021.22,Other,260% New York Medicaid APG,5011.06,,,5011.06,Other,324% New York Medicaid APG,3325.24,,,3325.24,Other,215% New York Medicaid APG,3325.24,,,3325.24,Other,215% New York Medicaid APG,1933.28,,,1933.28,Other,125% New York Medicaid APG,1546.62,54261.89,
Cystoscopy and treatment,52260,CPT,,,,,,,,both,,,34343.96,25414.53,74,,25414.53,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15454.78,45,,15454.78,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,17000.26,49.5,,17000.26,percent of total billed charges,110% of Medicare,23353.89,68,,23353.89,percent of total billed charges,,2876.72,,,2876.72,Other,186% of Medicaid,27475.17,80,,27475.17,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,27475.17,80,,27475.17,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,24040.77,70,,24040.77,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1546.62,,,1546.62,Other,New York Medicaid APG methodology,1546.62,,,1546.62,Other,100% New York Medicaid APG,1546.62,,,1546.62,Other,100% New York Medicaid APG,1546.62,,,1546.62,Other,100% New York Medicaid APG,3479.91,,,3479.91,Other,225% New York Medicaid APG,2366.34,,,2366.34,Other,153% New York Medicaid APG,3479.91,,,3479.91,Other,225% New York Medicaid APG,2165.27,,,2165.27,Other,140% New York Medicaid APG,3479.91,,,3479.91,Other,225% New York Medicaid APG,4021.22,,,4021.22,Other,260% New York Medicaid APG,5011.06,,,5011.06,Other,324% New York Medicaid APG,3325.24,,,3325.24,Other,215% New York Medicaid APG,3325.24,,,3325.24,Other,215% New York Medicaid APG,1933.28,,,1933.28,Other,125% New York Medicaid APG,1546.62,27475.17,
Cystoscopy and treatment,52265,CPT,,,,,,,,both,,,42841.82,31702.95,74,,31702.95,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,19278.82,45,,19278.82,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,21206.7,49.5,,21206.7,percent of total billed charges,110% of Medicare,29132.44,68,,29132.44,percent of total billed charges,,2876.72,,,2876.72,Other,186% of Medicaid,34273.46,80,,34273.46,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,34273.46,80,,34273.46,percent of total billed charges,,7216,,,7216,Case Rate,,3578,,"100% primary, 0% secondary procedures",3578,Other,MagnaCare ASC Grouper,29989.27,70,,29989.27,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,1546.62,,,1546.62,Other,New York Medicaid APG methodology,1546.62,,,1546.62,Other,100% New York Medicaid APG,1546.62,,,1546.62,Other,100% New York Medicaid APG,1546.62,,,1546.62,Other,100% New York Medicaid APG,3479.91,,,3479.91,Other,225% New York Medicaid APG,2366.34,,,2366.34,Other,153% New York Medicaid APG,3479.91,,,3479.91,Other,225% New York Medicaid APG,2165.27,,,2165.27,Other,140% New York Medicaid APG,3479.91,,,3479.91,Other,225% New York Medicaid APG,4021.22,,,4021.22,Other,260% New York Medicaid APG,5011.06,,,5011.06,Other,324% New York Medicaid APG,3325.24,,,3325.24,Other,215% New York Medicaid APG,3325.24,,,3325.24,Other,215% New York Medicaid APG,1933.28,,,1933.28,Other,125% New York Medicaid APG,1546.62,34273.46,
Cystoscopy & revise urethra,52270,CPT,,,,,,,,both,,,42841.82,31702.95,74,,31702.95,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,19278.82,45,,19278.82,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,21206.7,49.5,,21206.7,percent of total billed charges,110% of Medicare,29132.44,68,,29132.44,percent of total billed charges,,1857.5,,,1857.5,Other,186% of Medicaid,34273.46,80,,34273.46,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,34273.46,80,,34273.46,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,29989.27,70,,29989.27,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,998.66,,,998.66,Other,New York Medicaid APG methodology,998.66,,,998.66,Other,100% New York Medicaid APG,998.66,,,998.66,Other,100% New York Medicaid APG,998.66,,,998.66,Other,100% New York Medicaid APG,2246.97,,,2246.97,Other,225% New York Medicaid APG,1527.94,,,1527.94,Other,153% New York Medicaid APG,2246.97,,,2246.97,Other,225% New York Medicaid APG,1398.12,,,1398.12,Other,140% New York Medicaid APG,2246.97,,,2246.97,Other,225% New York Medicaid APG,2596.5,,,2596.5,Other,260% New York Medicaid APG,3235.64,,,3235.64,Other,324% New York Medicaid APG,2147.11,,,2147.11,Other,215% New York Medicaid APG,2147.11,,,2147.11,Other,215% New York Medicaid APG,1248.32,,,1248.32,Other,125% New York Medicaid APG,998.66,34273.46,
Cystoscopy & revise urethra,52275,CPT,,,,,,,,both,,,34791.72,25745.87,74,,25745.87,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15656.27,45,,15656.27,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,17221.9,49.5,,17221.9,percent of total billed charges,110% of Medicare,23658.37,68,,23658.37,percent of total billed charges,,1857.5,,,1857.5,Other,186% of Medicaid,27833.38,80,,27833.38,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,27833.38,80,,27833.38,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,24354.2,70,,24354.2,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,998.66,,,998.66,Other,New York Medicaid APG methodology,998.66,,,998.66,Other,100% New York Medicaid APG,998.66,,,998.66,Other,100% New York Medicaid APG,998.66,,,998.66,Other,100% New York Medicaid APG,2246.97,,,2246.97,Other,225% New York Medicaid APG,1527.94,,,1527.94,Other,153% New York Medicaid APG,2246.97,,,2246.97,Other,225% New York Medicaid APG,1398.12,,,1398.12,Other,140% New York Medicaid APG,2246.97,,,2246.97,Other,225% New York Medicaid APG,2596.5,,,2596.5,Other,260% New York Medicaid APG,3235.64,,,3235.64,Other,324% New York Medicaid APG,2147.11,,,2147.11,Other,215% New York Medicaid APG,2147.11,,,2147.11,Other,215% New York Medicaid APG,1248.32,,,1248.32,Other,125% New York Medicaid APG,998.66,27833.38,
Cystoscopy and treatment,52276,CPT,,,,,,,,both,,,35920.96,26581.51,74,,26581.51,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,16164.43,45,,16164.43,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,17780.88,49.5,,17780.88,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,1857.5,,,1857.5,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,25144.67,70,,25144.67,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,998.66,,,998.66,Other,New York Medicaid APG methodology,998.66,,,998.66,Other,100% New York Medicaid APG,998.66,,,998.66,Other,100% New York Medicaid APG,998.66,,,998.66,Other,100% New York Medicaid APG,2246.97,,,2246.97,Other,225% New York Medicaid APG,1527.94,,,1527.94,Other,153% New York Medicaid APG,2246.97,,,2246.97,Other,225% New York Medicaid APG,1398.12,,,1398.12,Other,140% New York Medicaid APG,2246.97,,,2246.97,Other,225% New York Medicaid APG,2596.5,,,2596.5,Other,260% New York Medicaid APG,3235.64,,,3235.64,Other,324% New York Medicaid APG,2147.11,,,2147.11,Other,215% New York Medicaid APG,2147.11,,,2147.11,Other,215% New York Medicaid APG,1248.32,,,1248.32,Other,125% New York Medicaid APG,998.66,26581.51,
Cystoscopy and treatment,52277,CPT,,,,,,,,both,,,73326.88,54261.89,74,,54261.89,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,32997.1,45,,32997.1,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,36296.81,49.5,,36296.81,percent of total billed charges,110% of Medicare,49862.28,68,,49862.28,percent of total billed charges,,1857.5,,,1857.5,Other,186% of Medicaid,58661.5,80,,58661.5,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,58661.5,80,,58661.5,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,51328.82,70,,51328.82,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,998.66,,,998.66,Other,New York Medicaid APG methodology,998.66,,,998.66,Other,100% New York Medicaid APG,998.66,,,998.66,Other,100% New York Medicaid APG,998.66,,,998.66,Other,100% New York Medicaid APG,2246.97,,,2246.97,Other,225% New York Medicaid APG,1527.94,,,1527.94,Other,153% New York Medicaid APG,2246.97,,,2246.97,Other,225% New York Medicaid APG,1398.12,,,1398.12,Other,140% New York Medicaid APG,2246.97,,,2246.97,Other,225% New York Medicaid APG,2596.5,,,2596.5,Other,260% New York Medicaid APG,3235.64,,,3235.64,Other,324% New York Medicaid APG,2147.11,,,2147.11,Other,215% New York Medicaid APG,2147.11,,,2147.11,Other,215% New York Medicaid APG,1248.32,,,1248.32,Other,125% New York Medicaid APG,998.66,58661.5,
Cystoscopy and treatment,52281,CPT,,,,,,,,both,,,35971.51,26618.92,74,,26618.92,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,16187.18,45,,16187.18,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,17805.9,49.5,,17805.9,percent of total billed charges,110% of Medicare,24460.63,68,,24460.63,percent of total billed charges,,2876.72,,,2876.72,Other,186% of Medicaid,28777.21,80,,28777.21,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,28777.21,80,,28777.21,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,25180.06,70,,25180.06,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1546.62,,,1546.62,Other,New York Medicaid APG methodology,1546.62,,,1546.62,Other,100% New York Medicaid APG,1546.62,,,1546.62,Other,100% New York Medicaid APG,1546.62,,,1546.62,Other,100% New York Medicaid APG,3479.91,,,3479.91,Other,225% New York Medicaid APG,2366.34,,,2366.34,Other,153% New York Medicaid APG,3479.91,,,3479.91,Other,225% New York Medicaid APG,2165.27,,,2165.27,Other,140% New York Medicaid APG,3479.91,,,3479.91,Other,225% New York Medicaid APG,4021.22,,,4021.22,Other,260% New York Medicaid APG,5011.06,,,5011.06,Other,324% New York Medicaid APG,3325.24,,,3325.24,Other,215% New York Medicaid APG,3325.24,,,3325.24,Other,215% New York Medicaid APG,1933.28,,,1933.28,Other,125% New York Medicaid APG,1546.62,28777.21,
Cystoscopy implant stent,52282,CPT,,,,,,,,both,,,73326.88,54261.89,74,,54261.89,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,32997.1,45,,32997.1,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,36296.81,49.5,,36296.81,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,1857.5,,,1857.5,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,51328.82,70,,51328.82,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,998.66,,,998.66,Other,New York Medicaid APG methodology,998.66,,,998.66,Other,100% New York Medicaid APG,998.66,,,998.66,Other,100% New York Medicaid APG,998.66,,,998.66,Other,100% New York Medicaid APG,2246.97,,,2246.97,Other,225% New York Medicaid APG,1527.94,,,1527.94,Other,153% New York Medicaid APG,2246.97,,,2246.97,Other,225% New York Medicaid APG,1398.12,,,1398.12,Other,140% New York Medicaid APG,2246.97,,,2246.97,Other,225% New York Medicaid APG,2596.5,,,2596.5,Other,260% New York Medicaid APG,3235.64,,,3235.64,Other,324% New York Medicaid APG,2147.11,,,2147.11,Other,215% New York Medicaid APG,2147.11,,,2147.11,Other,215% New York Medicaid APG,1248.32,,,1248.32,Other,125% New York Medicaid APG,998.66,54261.89,
Cystoscopy and treatment,52283,CPT,,,,,,,,both,,,42841.82,31702.95,74,,31702.95,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,19278.82,45,,19278.82,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,21206.7,49.5,,21206.7,percent of total billed charges,110% of Medicare,29132.44,68,,29132.44,percent of total billed charges,,1857.5,,,1857.5,Other,186% of Medicaid,34273.46,80,,34273.46,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,34273.46,80,,34273.46,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,29989.27,70,,29989.27,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,998.66,,,998.66,Other,New York Medicaid APG methodology,998.66,,,998.66,Other,100% New York Medicaid APG,998.66,,,998.66,Other,100% New York Medicaid APG,998.66,,,998.66,Other,100% New York Medicaid APG,2246.97,,,2246.97,Other,225% New York Medicaid APG,1527.94,,,1527.94,Other,153% New York Medicaid APG,2246.97,,,2246.97,Other,225% New York Medicaid APG,1398.12,,,1398.12,Other,140% New York Medicaid APG,2246.97,,,2246.97,Other,225% New York Medicaid APG,2596.5,,,2596.5,Other,260% New York Medicaid APG,3235.64,,,3235.64,Other,324% New York Medicaid APG,2147.11,,,2147.11,Other,215% New York Medicaid APG,2147.11,,,2147.11,Other,215% New York Medicaid APG,1248.32,,,1248.32,Other,125% New York Medicaid APG,998.66,34273.46,
Cystoscopy and treatment,52285,CPT,,,,,,,,both,,,14368.32,10632.56,74,,10632.56,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,6465.74,45,,6465.74,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,7112.32,49.5,,7112.32,percent of total billed charges,110% of Medicare,9770.46,68,,9770.46,percent of total billed charges,,1857.5,,,1857.5,Other,186% of Medicaid,11494.66,80,,11494.66,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,11494.66,80,,11494.66,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,10057.82,70,,10057.82,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,998.66,,,998.66,Other,New York Medicaid APG methodology,998.66,,,998.66,Other,100% New York Medicaid APG,998.66,,,998.66,Other,100% New York Medicaid APG,998.66,,,998.66,Other,100% New York Medicaid APG,2246.97,,,2246.97,Other,225% New York Medicaid APG,1527.94,,,1527.94,Other,153% New York Medicaid APG,2246.97,,,2246.97,Other,225% New York Medicaid APG,1398.12,,,1398.12,Other,140% New York Medicaid APG,2246.97,,,2246.97,Other,225% New York Medicaid APG,2596.5,,,2596.5,Other,260% New York Medicaid APG,3235.64,,,3235.64,Other,324% New York Medicaid APG,2147.11,,,2147.11,Other,215% New York Medicaid APG,2147.11,,,2147.11,Other,215% New York Medicaid APG,1248.32,,,1248.32,Other,125% New York Medicaid APG,998.66,11494.66,
Cystoscopy chemodenervation,52287,CPT,,,,,,,,both,,,31072.26,22993.47,74,,22993.47,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,13982.52,45,,13982.52,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,15380.77,49.5,,15380.77,percent of total billed charges,110% of Medicare,21129.14,68,,21129.14,percent of total billed charges,,2876.72,,,2876.72,Other,186% of Medicaid,24857.81,80,,24857.81,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,24857.81,80,,24857.81,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,21750.58,70,,21750.58,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1546.62,,,1546.62,Other,New York Medicaid APG methodology,1546.62,,,1546.62,Other,100% New York Medicaid APG,1546.62,,,1546.62,Other,100% New York Medicaid APG,1546.62,,,1546.62,Other,100% New York Medicaid APG,3479.91,,,3479.91,Other,225% New York Medicaid APG,2366.34,,,2366.34,Other,153% New York Medicaid APG,3479.91,,,3479.91,Other,225% New York Medicaid APG,2165.27,,,2165.27,Other,140% New York Medicaid APG,3479.91,,,3479.91,Other,225% New York Medicaid APG,4021.22,,,4021.22,Other,260% New York Medicaid APG,5011.06,,,5011.06,Other,324% New York Medicaid APG,3325.24,,,3325.24,Other,215% New York Medicaid APG,3325.24,,,3325.24,Other,215% New York Medicaid APG,1933.28,,,1933.28,Other,125% New York Medicaid APG,1546.62,24857.81,
Cystoscopy and treatment,52290,CPT,,,,,,,,both,,,42841.82,31702.95,74,,31702.95,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,19278.82,45,,19278.82,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,21206.7,49.5,,21206.7,percent of total billed charges,110% of Medicare,29132.44,68,,29132.44,percent of total billed charges,,2876.72,,,2876.72,Other,186% of Medicaid,34273.46,80,,34273.46,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,34273.46,80,,34273.46,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,29989.27,70,,29989.27,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1546.62,,,1546.62,Other,New York Medicaid APG methodology,1546.62,,,1546.62,Other,100% New York Medicaid APG,1546.62,,,1546.62,Other,100% New York Medicaid APG,1546.62,,,1546.62,Other,100% New York Medicaid APG,3479.91,,,3479.91,Other,225% New York Medicaid APG,2366.34,,,2366.34,Other,153% New York Medicaid APG,3479.91,,,3479.91,Other,225% New York Medicaid APG,2165.27,,,2165.27,Other,140% New York Medicaid APG,3479.91,,,3479.91,Other,225% New York Medicaid APG,4021.22,,,4021.22,Other,260% New York Medicaid APG,5011.06,,,5011.06,Other,324% New York Medicaid APG,3325.24,,,3325.24,Other,215% New York Medicaid APG,3325.24,,,3325.24,Other,215% New York Medicaid APG,1933.28,,,1933.28,Other,125% New York Medicaid APG,1546.62,34273.46,
Cystoscopy and treatment,52300,CPT,,,,,,,,both,,,73326.88,54261.89,74,,54261.89,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,32997.1,45,,32997.1,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,36296.81,49.5,,36296.81,percent of total billed charges,110% of Medicare,49862.28,68,,49862.28,percent of total billed charges,,3412.13,,,3412.13,Other,186% of Medicaid,58661.5,80,,58661.5,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,58661.5,80,,58661.5,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,51328.82,70,,51328.82,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1834.48,,,1834.48,Other,New York Medicaid APG methodology,1834.48,,,1834.48,Other,100% New York Medicaid APG,1834.48,,,1834.48,Other,100% New York Medicaid APG,1834.48,,,1834.48,Other,100% New York Medicaid APG,4127.58,,,4127.58,Other,225% New York Medicaid APG,2806.75,,,2806.75,Other,153% New York Medicaid APG,4127.58,,,4127.58,Other,225% New York Medicaid APG,2568.27,,,2568.27,Other,140% New York Medicaid APG,4127.58,,,4127.58,Other,225% New York Medicaid APG,4769.65,,,4769.65,Other,260% New York Medicaid APG,5943.71,,,5943.71,Other,324% New York Medicaid APG,3944.13,,,3944.13,Other,215% New York Medicaid APG,3944.13,,,3944.13,Other,215% New York Medicaid APG,2293.1,,,2293.1,Other,125% New York Medicaid APG,1834.48,58661.5,
Cystoscopy and treatment,52301,CPT,,,,,,,,both,,,35370.79,26174.38,74,,26174.38,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15916.86,45,,15916.86,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,17508.54,49.5,,17508.54,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2876.72,,,2876.72,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,24759.55,70,,24759.55,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1546.62,,,1546.62,Other,New York Medicaid APG methodology,1546.62,,,1546.62,Other,100% New York Medicaid APG,1546.62,,,1546.62,Other,100% New York Medicaid APG,1546.62,,,1546.62,Other,100% New York Medicaid APG,3479.91,,,3479.91,Other,225% New York Medicaid APG,2366.34,,,2366.34,Other,153% New York Medicaid APG,3479.91,,,3479.91,Other,225% New York Medicaid APG,2165.27,,,2165.27,Other,140% New York Medicaid APG,3479.91,,,3479.91,Other,225% New York Medicaid APG,4021.22,,,4021.22,Other,260% New York Medicaid APG,5011.06,,,5011.06,Other,324% New York Medicaid APG,3325.24,,,3325.24,Other,215% New York Medicaid APG,3325.24,,,3325.24,Other,215% New York Medicaid APG,1933.28,,,1933.28,Other,125% New York Medicaid APG,1546.62,26174.38,
Cystoscopy and treatment,52305,CPT,,,,,,,,both,,,108835.97,80538.62,74,,80538.62,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,48976.19,45,,48976.19,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,53873.81,49.5,,53873.81,percent of total billed charges,110% of Medicare,74008.46,68,,74008.46,percent of total billed charges,,3412.13,,,3412.13,Other,186% of Medicaid,87068.78,80,,87068.78,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,87068.78,80,,87068.78,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,76185.18,70,,76185.18,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1834.48,,,1834.48,Other,New York Medicaid APG methodology,1834.48,,,1834.48,Other,100% New York Medicaid APG,1834.48,,,1834.48,Other,100% New York Medicaid APG,1834.48,,,1834.48,Other,100% New York Medicaid APG,4127.58,,,4127.58,Other,225% New York Medicaid APG,2806.75,,,2806.75,Other,153% New York Medicaid APG,4127.58,,,4127.58,Other,225% New York Medicaid APG,2568.27,,,2568.27,Other,140% New York Medicaid APG,4127.58,,,4127.58,Other,225% New York Medicaid APG,4769.65,,,4769.65,Other,260% New York Medicaid APG,5943.71,,,5943.71,Other,324% New York Medicaid APG,3944.13,,,3944.13,Other,215% New York Medicaid APG,3944.13,,,3944.13,Other,215% New York Medicaid APG,2293.1,,,2293.1,Other,125% New York Medicaid APG,1834.48,87068.78,
Cystoscopy and treatment,52310,CPT,,,,,,,,both,,,29225.24,21626.68,74,,21626.68,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,13151.36,45,,13151.36,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,14466.49,49.5,,14466.49,percent of total billed charges,110% of Medicare,19873.16,68,,19873.16,percent of total billed charges,,2876.72,,,2876.72,Other,186% of Medicaid,23380.19,80,,23380.19,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,23380.19,80,,23380.19,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,20457.67,70,,20457.67,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1546.62,,,1546.62,Other,New York Medicaid APG methodology,1546.62,,,1546.62,Other,100% New York Medicaid APG,1546.62,,,1546.62,Other,100% New York Medicaid APG,1546.62,,,1546.62,Other,100% New York Medicaid APG,3479.91,,,3479.91,Other,225% New York Medicaid APG,2366.34,,,2366.34,Other,153% New York Medicaid APG,3479.91,,,3479.91,Other,225% New York Medicaid APG,2165.27,,,2165.27,Other,140% New York Medicaid APG,3479.91,,,3479.91,Other,225% New York Medicaid APG,4021.22,,,4021.22,Other,260% New York Medicaid APG,5011.06,,,5011.06,Other,324% New York Medicaid APG,3325.24,,,3325.24,Other,215% New York Medicaid APG,3325.24,,,3325.24,Other,215% New York Medicaid APG,1933.28,,,1933.28,Other,125% New York Medicaid APG,1546.62,23380.19,
Cystoscopy and treatment,52315,CPT,,,,,,,,both,,,40381.04,29881.97,74,,29881.97,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,18171.47,45,,18171.47,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,19988.61,49.5,,19988.61,percent of total billed charges,110% of Medicare,27459.11,68,,27459.11,percent of total billed charges,,2876.72,,,2876.72,Other,186% of Medicaid,32304.83,80,,32304.83,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,32304.83,80,,32304.83,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,28266.73,70,,28266.73,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1546.62,,,1546.62,Other,New York Medicaid APG methodology,1546.62,,,1546.62,Other,100% New York Medicaid APG,1546.62,,,1546.62,Other,100% New York Medicaid APG,1546.62,,,1546.62,Other,100% New York Medicaid APG,3479.91,,,3479.91,Other,225% New York Medicaid APG,2366.34,,,2366.34,Other,153% New York Medicaid APG,3479.91,,,3479.91,Other,225% New York Medicaid APG,2165.27,,,2165.27,Other,140% New York Medicaid APG,3479.91,,,3479.91,Other,225% New York Medicaid APG,4021.22,,,4021.22,Other,260% New York Medicaid APG,5011.06,,,5011.06,Other,324% New York Medicaid APG,3325.24,,,3325.24,Other,215% New York Medicaid APG,3325.24,,,3325.24,Other,215% New York Medicaid APG,1933.28,,,1933.28,Other,125% New York Medicaid APG,1546.62,32304.83,
Remove bladder stone,52317,CPT,,,,,,,,both,,,38038.46,28148.46,74,,28148.46,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,17117.31,45,,17117.31,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,18829.04,49.5,,18829.04,percent of total billed charges,110% of Medicare,25866.15,68,,25866.15,percent of total billed charges,,2876.72,,,2876.72,Other,186% of Medicaid,30430.77,80,,30430.77,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,30430.77,80,,30430.77,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,26626.92,70,,26626.92,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1546.62,,,1546.62,Other,New York Medicaid APG methodology,1546.62,,,1546.62,Other,100% New York Medicaid APG,1546.62,,,1546.62,Other,100% New York Medicaid APG,1546.62,,,1546.62,Other,100% New York Medicaid APG,3479.91,,,3479.91,Other,225% New York Medicaid APG,2366.34,,,2366.34,Other,153% New York Medicaid APG,3479.91,,,3479.91,Other,225% New York Medicaid APG,2165.27,,,2165.27,Other,140% New York Medicaid APG,3479.91,,,3479.91,Other,225% New York Medicaid APG,4021.22,,,4021.22,Other,260% New York Medicaid APG,5011.06,,,5011.06,Other,324% New York Medicaid APG,3325.24,,,3325.24,Other,215% New York Medicaid APG,3325.24,,,3325.24,Other,215% New York Medicaid APG,1933.28,,,1933.28,Other,125% New York Medicaid APG,1546.62,30430.77,
Remove bladder stone,52318,CPT,,,,,,,,both,,,37429.91,27698.13,74,,27698.13,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,16843.46,45,,16843.46,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,18527.81,49.5,,18527.81,percent of total billed charges,110% of Medicare,25452.34,68,,25452.34,percent of total billed charges,,2876.72,,,2876.72,Other,186% of Medicaid,29943.93,80,,29943.93,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,29943.93,80,,29943.93,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,26200.94,70,,26200.94,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1546.62,,,1546.62,Other,New York Medicaid APG methodology,1546.62,,,1546.62,Other,100% New York Medicaid APG,1546.62,,,1546.62,Other,100% New York Medicaid APG,1546.62,,,1546.62,Other,100% New York Medicaid APG,3479.91,,,3479.91,Other,225% New York Medicaid APG,2366.34,,,2366.34,Other,153% New York Medicaid APG,3479.91,,,3479.91,Other,225% New York Medicaid APG,2165.27,,,2165.27,Other,140% New York Medicaid APG,3479.91,,,3479.91,Other,225% New York Medicaid APG,4021.22,,,4021.22,Other,260% New York Medicaid APG,5011.06,,,5011.06,Other,324% New York Medicaid APG,3325.24,,,3325.24,Other,215% New York Medicaid APG,3325.24,,,3325.24,Other,215% New York Medicaid APG,1933.28,,,1933.28,Other,125% New York Medicaid APG,1546.62,29943.93,
Cystoscopy and treatment,52320,CPT,,,,,,,,both,,,73326.88,54261.89,74,,54261.89,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,32997.1,45,,32997.1,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,36296.81,49.5,,36296.81,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2876.72,,,2876.72,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,51328.82,70,,51328.82,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1546.62,,,1546.62,Other,New York Medicaid APG methodology,1546.62,,,1546.62,Other,100% New York Medicaid APG,1546.62,,,1546.62,Other,100% New York Medicaid APG,1546.62,,,1546.62,Other,100% New York Medicaid APG,3479.91,,,3479.91,Other,225% New York Medicaid APG,2366.34,,,2366.34,Other,153% New York Medicaid APG,3479.91,,,3479.91,Other,225% New York Medicaid APG,2165.27,,,2165.27,Other,140% New York Medicaid APG,3479.91,,,3479.91,Other,225% New York Medicaid APG,4021.22,,,4021.22,Other,260% New York Medicaid APG,5011.06,,,5011.06,Other,324% New York Medicaid APG,3325.24,,,3325.24,Other,215% New York Medicaid APG,3325.24,,,3325.24,Other,215% New York Medicaid APG,1933.28,,,1933.28,Other,125% New York Medicaid APG,1546.62,54261.89,
Cystoscopy stone removal,52325,CPT,,,,,,,,both,,,108835.97,80538.62,74,,80538.62,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,48976.19,45,,48976.19,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,53873.81,49.5,,53873.81,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3412.13,,,3412.13,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,76185.18,70,,76185.18,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1834.48,,,1834.48,Other,New York Medicaid APG methodology,1834.48,,,1834.48,Other,100% New York Medicaid APG,1834.48,,,1834.48,Other,100% New York Medicaid APG,1834.48,,,1834.48,Other,100% New York Medicaid APG,4127.58,,,4127.58,Other,225% New York Medicaid APG,2806.75,,,2806.75,Other,153% New York Medicaid APG,4127.58,,,4127.58,Other,225% New York Medicaid APG,2568.27,,,2568.27,Other,140% New York Medicaid APG,4127.58,,,4127.58,Other,225% New York Medicaid APG,4769.65,,,4769.65,Other,260% New York Medicaid APG,5943.71,,,5943.71,Other,324% New York Medicaid APG,3944.13,,,3944.13,Other,215% New York Medicaid APG,3944.13,,,3944.13,Other,215% New York Medicaid APG,2293.1,,,2293.1,Other,125% New York Medicaid APG,1834.48,80538.62,
Cystoscopy inject material,52327,CPT,,,,,,,,both,,,51504.42,38113.27,74,,38113.27,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,23176.99,45,,23176.99,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,25494.69,49.5,,25494.69,percent of total billed charges,110% of Medicare,35023.01,68,,35023.01,percent of total billed charges,,3412.13,,,3412.13,Other,186% of Medicaid,41203.54,80,,41203.54,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,41203.54,80,,41203.54,percent of total billed charges,,7216,,,7216,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,36053.09,70,,36053.09,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,1834.48,,,1834.48,Other,New York Medicaid APG methodology,1834.48,,,1834.48,Other,100% New York Medicaid APG,1834.48,,,1834.48,Other,100% New York Medicaid APG,1834.48,,,1834.48,Other,100% New York Medicaid APG,4127.58,,,4127.58,Other,225% New York Medicaid APG,2806.75,,,2806.75,Other,153% New York Medicaid APG,4127.58,,,4127.58,Other,225% New York Medicaid APG,2568.27,,,2568.27,Other,140% New York Medicaid APG,4127.58,,,4127.58,Other,225% New York Medicaid APG,4769.65,,,4769.65,Other,260% New York Medicaid APG,5943.71,,,5943.71,Other,324% New York Medicaid APG,3944.13,,,3944.13,Other,215% New York Medicaid APG,3944.13,,,3944.13,Other,215% New York Medicaid APG,2293.1,,,2293.1,Other,125% New York Medicaid APG,1834.48,41203.54,
Cystoscopy and treatment,52330,CPT,,,,,,,,both,,,73326.88,54261.89,74,,54261.89,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,32997.1,45,,32997.1,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,36296.81,49.5,,36296.81,percent of total billed charges,110% of Medicare,49862.28,68,,49862.28,percent of total billed charges,,2876.72,,,2876.72,Other,186% of Medicaid,58661.5,80,,58661.5,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,58661.5,80,,58661.5,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,51328.82,70,,51328.82,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1546.62,,,1546.62,Other,New York Medicaid APG methodology,1546.62,,,1546.62,Other,100% New York Medicaid APG,1546.62,,,1546.62,Other,100% New York Medicaid APG,1546.62,,,1546.62,Other,100% New York Medicaid APG,3479.91,,,3479.91,Other,225% New York Medicaid APG,2366.34,,,2366.34,Other,153% New York Medicaid APG,3479.91,,,3479.91,Other,225% New York Medicaid APG,2165.27,,,2165.27,Other,140% New York Medicaid APG,3479.91,,,3479.91,Other,225% New York Medicaid APG,4021.22,,,4021.22,Other,260% New York Medicaid APG,5011.06,,,5011.06,Other,324% New York Medicaid APG,3325.24,,,3325.24,Other,215% New York Medicaid APG,3325.24,,,3325.24,Other,215% New York Medicaid APG,1933.28,,,1933.28,Other,125% New York Medicaid APG,1546.62,58661.5,
Cystoscopy and treatment,52332,CPT,,,,,,,,both,,,35791.89,26486,74,,26486,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,16106.35,45,,16106.35,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,17716.99,49.5,,17716.99,percent of total billed charges,110% of Medicare,24338.49,68,,24338.49,percent of total billed charges,,2876.72,,,2876.72,Other,186% of Medicaid,28633.51,80,,28633.51,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,28633.51,80,,28633.51,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,25054.32,70,,25054.32,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1546.62,,,1546.62,Other,New York Medicaid APG methodology,1546.62,,,1546.62,Other,100% New York Medicaid APG,1546.62,,,1546.62,Other,100% New York Medicaid APG,1546.62,,,1546.62,Other,100% New York Medicaid APG,3479.91,,,3479.91,Other,225% New York Medicaid APG,2366.34,,,2366.34,Other,153% New York Medicaid APG,3479.91,,,3479.91,Other,225% New York Medicaid APG,2165.27,,,2165.27,Other,140% New York Medicaid APG,3479.91,,,3479.91,Other,225% New York Medicaid APG,4021.22,,,4021.22,Other,260% New York Medicaid APG,5011.06,,,5011.06,Other,324% New York Medicaid APG,3325.24,,,3325.24,Other,215% New York Medicaid APG,3325.24,,,3325.24,Other,215% New York Medicaid APG,1933.28,,,1933.28,Other,125% New York Medicaid APG,1546.62,28633.51,
Create passage to kidney,52334,CPT,,,,,,,,both,,,73326.88,54261.89,74,,54261.89,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,32997.1,45,,32997.1,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,36296.81,49.5,,36296.81,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2011.18,,,2011.18,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,51328.82,70,,51328.82,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1081.28,,,1081.28,Other,New York Medicaid APG methodology,1081.28,,,1081.28,Other,100% New York Medicaid APG,1081.28,,,1081.28,Other,100% New York Medicaid APG,1081.28,,,1081.28,Other,100% New York Medicaid APG,2432.88,,,2432.88,Other,225% New York Medicaid APG,1654.36,,,1654.36,Other,153% New York Medicaid APG,2432.88,,,2432.88,Other,225% New York Medicaid APG,1513.79,,,1513.79,Other,140% New York Medicaid APG,2432.88,,,2432.88,Other,225% New York Medicaid APG,2811.33,,,2811.33,Other,260% New York Medicaid APG,3503.35,,,3503.35,Other,324% New York Medicaid APG,2324.75,,,2324.75,Other,215% New York Medicaid APG,2324.75,,,2324.75,Other,215% New York Medicaid APG,1351.6,,,1351.6,Other,125% New York Medicaid APG,1081.28,54261.89,
Cysto w/ureter stricture tx,52341,CPT,,,,,,,,both,,,36893.08,27300.88,74,,27300.88,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,16601.89,45,,16601.89,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,18262.07,49.5,,18262.07,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2876.72,,,2876.72,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,25825.16,70,,25825.16,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1546.62,,,1546.62,Other,New York Medicaid APG methodology,1546.62,,,1546.62,Other,100% New York Medicaid APG,1546.62,,,1546.62,Other,100% New York Medicaid APG,1546.62,,,1546.62,Other,100% New York Medicaid APG,3479.91,,,3479.91,Other,225% New York Medicaid APG,2366.34,,,2366.34,Other,153% New York Medicaid APG,3479.91,,,3479.91,Other,225% New York Medicaid APG,2165.27,,,2165.27,Other,140% New York Medicaid APG,3479.91,,,3479.91,Other,225% New York Medicaid APG,4021.22,,,4021.22,Other,260% New York Medicaid APG,5011.06,,,5011.06,Other,324% New York Medicaid APG,3325.24,,,3325.24,Other,215% New York Medicaid APG,3325.24,,,3325.24,Other,215% New York Medicaid APG,1933.28,,,1933.28,Other,125% New York Medicaid APG,1546.62,27300.88,
Cysto w/up stricture tx,52342,CPT,,,,,,,,both,,,73326.88,54261.89,74,,54261.89,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,32997.1,45,,32997.1,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,36296.81,49.5,,36296.81,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2011.18,,,2011.18,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,51328.82,70,,51328.82,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1081.28,,,1081.28,Other,New York Medicaid APG methodology,1081.28,,,1081.28,Other,100% New York Medicaid APG,1081.28,,,1081.28,Other,100% New York Medicaid APG,1081.28,,,1081.28,Other,100% New York Medicaid APG,2432.88,,,2432.88,Other,225% New York Medicaid APG,1654.36,,,1654.36,Other,153% New York Medicaid APG,2432.88,,,2432.88,Other,225% New York Medicaid APG,1513.79,,,1513.79,Other,140% New York Medicaid APG,2432.88,,,2432.88,Other,225% New York Medicaid APG,2811.33,,,2811.33,Other,260% New York Medicaid APG,3503.35,,,3503.35,Other,324% New York Medicaid APG,2324.75,,,2324.75,Other,215% New York Medicaid APG,2324.75,,,2324.75,Other,215% New York Medicaid APG,1351.6,,,1351.6,Other,125% New York Medicaid APG,1081.28,54261.89,
Cysto w/renal stricture tx,52343,CPT,,,,,,,,both,,,73326.88,54261.89,74,,54261.89,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,32997.1,45,,32997.1,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,36296.81,49.5,,36296.81,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2011.18,,,2011.18,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,51328.82,70,,51328.82,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1081.28,,,1081.28,Other,New York Medicaid APG methodology,1081.28,,,1081.28,Other,100% New York Medicaid APG,1081.28,,,1081.28,Other,100% New York Medicaid APG,1081.28,,,1081.28,Other,100% New York Medicaid APG,2432.88,,,2432.88,Other,225% New York Medicaid APG,1654.36,,,1654.36,Other,153% New York Medicaid APG,2432.88,,,2432.88,Other,225% New York Medicaid APG,1513.79,,,1513.79,Other,140% New York Medicaid APG,2432.88,,,2432.88,Other,225% New York Medicaid APG,2811.33,,,2811.33,Other,260% New York Medicaid APG,3503.35,,,3503.35,Other,324% New York Medicaid APG,2324.75,,,2324.75,Other,215% New York Medicaid APG,2324.75,,,2324.75,Other,215% New York Medicaid APG,1351.6,,,1351.6,Other,125% New York Medicaid APG,1081.28,54261.89,
Cysto/uretero stricture tx,52344,CPT,,,,,,,,both,,,45216.91,33460.51,74,,33460.51,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,20347.61,45,,20347.61,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,22382.37,49.5,,22382.37,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2876.72,,,2876.72,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,31651.84,70,,31651.84,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1546.62,,,1546.62,Other,New York Medicaid APG methodology,1546.62,,,1546.62,Other,100% New York Medicaid APG,1546.62,,,1546.62,Other,100% New York Medicaid APG,1546.62,,,1546.62,Other,100% New York Medicaid APG,3479.91,,,3479.91,Other,225% New York Medicaid APG,2366.34,,,2366.34,Other,153% New York Medicaid APG,3479.91,,,3479.91,Other,225% New York Medicaid APG,2165.27,,,2165.27,Other,140% New York Medicaid APG,3479.91,,,3479.91,Other,225% New York Medicaid APG,4021.22,,,4021.22,Other,260% New York Medicaid APG,5011.06,,,5011.06,Other,324% New York Medicaid APG,3325.24,,,3325.24,Other,215% New York Medicaid APG,3325.24,,,3325.24,Other,215% New York Medicaid APG,1933.28,,,1933.28,Other,125% New York Medicaid APG,1546.62,33460.51,
Cysto/uretero w/up stricture,52345,CPT,,,,,,,,both,,,43912.97,32495.6,74,,32495.6,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,19760.84,45,,19760.84,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,21736.92,49.5,,21736.92,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3412.13,,,3412.13,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,30739.08,70,,30739.08,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1834.48,,,1834.48,Other,New York Medicaid APG methodology,1834.48,,,1834.48,Other,100% New York Medicaid APG,1834.48,,,1834.48,Other,100% New York Medicaid APG,1834.48,,,1834.48,Other,100% New York Medicaid APG,4127.58,,,4127.58,Other,225% New York Medicaid APG,2806.75,,,2806.75,Other,153% New York Medicaid APG,4127.58,,,4127.58,Other,225% New York Medicaid APG,2568.27,,,2568.27,Other,140% New York Medicaid APG,4127.58,,,4127.58,Other,225% New York Medicaid APG,4769.65,,,4769.65,Other,260% New York Medicaid APG,5943.71,,,5943.71,Other,324% New York Medicaid APG,3944.13,,,3944.13,Other,215% New York Medicaid APG,3944.13,,,3944.13,Other,215% New York Medicaid APG,2293.1,,,2293.1,Other,125% New York Medicaid APG,1834.48,32495.6,
Cystouretero w/renal strict,52346,CPT,,,,,,,,both,,,37179.82,27513.07,74,,27513.07,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,16730.92,45,,16730.92,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,18404.01,49.5,,18404.01,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2586.25,,,2586.25,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,26025.87,70,,26025.87,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1390.46,,,1390.46,Other,New York Medicaid APG methodology,1390.46,,,1390.46,Other,100% New York Medicaid APG,1390.46,,,1390.46,Other,100% New York Medicaid APG,1390.46,,,1390.46,Other,100% New York Medicaid APG,3128.53,,,3128.53,Other,225% New York Medicaid APG,2127.4,,,2127.4,Other,153% New York Medicaid APG,3128.53,,,3128.53,Other,225% New York Medicaid APG,1946.64,,,1946.64,Other,140% New York Medicaid APG,3128.53,,,3128.53,Other,225% New York Medicaid APG,3615.19,,,3615.19,Other,260% New York Medicaid APG,4505.09,,,4505.09,Other,324% New York Medicaid APG,2989.49,,,2989.49,Other,215% New York Medicaid APG,2989.49,,,2989.49,Other,215% New York Medicaid APG,1738.07,,,1738.07,Other,125% New York Medicaid APG,1390.46,27513.07,
Cystouretero & or pyeloscope,52351,CPT,,,,,,,,both,,,37162.02,27499.89,74,,27499.89,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,16722.91,45,,16722.91,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,18395.2,49.5,,18395.2,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2876.72,,,2876.72,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,26013.41,70,,26013.41,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1546.62,,,1546.62,Other,New York Medicaid APG methodology,1546.62,,,1546.62,Other,100% New York Medicaid APG,1546.62,,,1546.62,Other,100% New York Medicaid APG,1546.62,,,1546.62,Other,100% New York Medicaid APG,3479.91,,,3479.91,Other,225% New York Medicaid APG,2366.34,,,2366.34,Other,153% New York Medicaid APG,3479.91,,,3479.91,Other,225% New York Medicaid APG,2165.27,,,2165.27,Other,140% New York Medicaid APG,3479.91,,,3479.91,Other,225% New York Medicaid APG,4021.22,,,4021.22,Other,260% New York Medicaid APG,5011.06,,,5011.06,Other,324% New York Medicaid APG,3325.24,,,3325.24,Other,215% New York Medicaid APG,3325.24,,,3325.24,Other,215% New York Medicaid APG,1933.28,,,1933.28,Other,125% New York Medicaid APG,1546.62,27499.89,
Cystouretero w/stone remove,52352,CPT,,,,,,,,both,,,36808.59,27238.36,74,,27238.36,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,16563.87,45,,16563.87,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,18220.25,49.5,,18220.25,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2876.72,,,2876.72,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,25766.01,70,,25766.01,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1546.62,,,1546.62,Other,New York Medicaid APG methodology,1546.62,,,1546.62,Other,100% New York Medicaid APG,1546.62,,,1546.62,Other,100% New York Medicaid APG,1546.62,,,1546.62,Other,100% New York Medicaid APG,3479.91,,,3479.91,Other,225% New York Medicaid APG,2366.34,,,2366.34,Other,153% New York Medicaid APG,3479.91,,,3479.91,Other,225% New York Medicaid APG,2165.27,,,2165.27,Other,140% New York Medicaid APG,3479.91,,,3479.91,Other,225% New York Medicaid APG,4021.22,,,4021.22,Other,260% New York Medicaid APG,5011.06,,,5011.06,Other,324% New York Medicaid APG,3325.24,,,3325.24,Other,215% New York Medicaid APG,3325.24,,,3325.24,Other,215% New York Medicaid APG,1933.28,,,1933.28,Other,125% New York Medicaid APG,1546.62,27238.36,
Cystouretero w/lithotripsy,52353,CPT,,,,,,,,both,,,38384.49,28404.52,74,,28404.52,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,17273.02,45,,17273.02,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,19000.32,49.5,,19000.32,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2586.25,,,2586.25,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,26869.14,70,,26869.14,percent of total billed charges,,1874.52,,,1874.52,Fee Schedule,,1588.77,,,1588.77,Fee Schedule,,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,1390.46,,,1390.46,Other,New York Medicaid APG methodology,1390.46,,,1390.46,Other,100% New York Medicaid APG,1390.46,,,1390.46,Other,100% New York Medicaid APG,1390.46,,,1390.46,Other,100% New York Medicaid APG,3128.53,,,3128.53,Other,225% New York Medicaid APG,2127.4,,,2127.4,Other,153% New York Medicaid APG,3128.53,,,3128.53,Other,225% New York Medicaid APG,1946.64,,,1946.64,Other,140% New York Medicaid APG,3128.53,,,3128.53,Other,225% New York Medicaid APG,3615.19,,,3615.19,Other,260% New York Medicaid APG,4505.09,,,4505.09,Other,324% New York Medicaid APG,2989.49,,,2989.49,Other,215% New York Medicaid APG,2989.49,,,2989.49,Other,215% New York Medicaid APG,1738.07,,,1738.07,Other,125% New York Medicaid APG,1390.46,28404.52,
Cystouretero w/biopsy,52354,CPT,,,,,,,,both,,,43957.07,32528.23,74,,32528.23,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,19780.68,45,,19780.68,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,21758.75,49.5,,21758.75,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2586.25,,,2586.25,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,30769.95,70,,30769.95,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1390.46,,,1390.46,Other,New York Medicaid APG methodology,1390.46,,,1390.46,Other,100% New York Medicaid APG,1390.46,,,1390.46,Other,100% New York Medicaid APG,1390.46,,,1390.46,Other,100% New York Medicaid APG,3128.53,,,3128.53,Other,225% New York Medicaid APG,2127.4,,,2127.4,Other,153% New York Medicaid APG,3128.53,,,3128.53,Other,225% New York Medicaid APG,1946.64,,,1946.64,Other,140% New York Medicaid APG,3128.53,,,3128.53,Other,225% New York Medicaid APG,3615.19,,,3615.19,Other,260% New York Medicaid APG,4505.09,,,4505.09,Other,324% New York Medicaid APG,2989.49,,,2989.49,Other,215% New York Medicaid APG,2989.49,,,2989.49,Other,215% New York Medicaid APG,1738.07,,,1738.07,Other,125% New York Medicaid APG,1390.46,32528.23,
Cystouretero w/excise tumor,52355,CPT,,,,,,,,both,,,42146.56,31188.45,74,,31188.45,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,18965.95,45,,18965.95,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,20862.55,49.5,,20862.55,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2586.25,,,2586.25,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,29502.59,70,,29502.59,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1390.46,,,1390.46,Other,New York Medicaid APG methodology,1390.46,,,1390.46,Other,100% New York Medicaid APG,1390.46,,,1390.46,Other,100% New York Medicaid APG,1390.46,,,1390.46,Other,100% New York Medicaid APG,3128.53,,,3128.53,Other,225% New York Medicaid APG,2127.4,,,2127.4,Other,153% New York Medicaid APG,3128.53,,,3128.53,Other,225% New York Medicaid APG,1946.64,,,1946.64,Other,140% New York Medicaid APG,3128.53,,,3128.53,Other,225% New York Medicaid APG,3615.19,,,3615.19,Other,260% New York Medicaid APG,4505.09,,,4505.09,Other,324% New York Medicaid APG,2989.49,,,2989.49,Other,215% New York Medicaid APG,2989.49,,,2989.49,Other,215% New York Medicaid APG,1738.07,,,1738.07,Other,125% New York Medicaid APG,1390.46,31188.45,
Cysto/uretero w/lithotripsy,52356,CPT,,,,,,,,both,,,39439.09,29184.93,74,,29184.93,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,17747.59,45,,17747.59,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,19522.35,49.5,,19522.35,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3412.13,,,3412.13,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,27607.36,70,,27607.36,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,1834.48,,,1834.48,Other,New York Medicaid APG methodology,1834.48,,,1834.48,Other,100% New York Medicaid APG,1834.48,,,1834.48,Other,100% New York Medicaid APG,1834.48,,,1834.48,Other,100% New York Medicaid APG,4127.58,,,4127.58,Other,225% New York Medicaid APG,2806.75,,,2806.75,Other,153% New York Medicaid APG,4127.58,,,4127.58,Other,225% New York Medicaid APG,2568.27,,,2568.27,Other,140% New York Medicaid APG,4127.58,,,4127.58,Other,225% New York Medicaid APG,4769.65,,,4769.65,Other,260% New York Medicaid APG,5943.71,,,5943.71,Other,324% New York Medicaid APG,3944.13,,,3944.13,Other,215% New York Medicaid APG,3944.13,,,3944.13,Other,215% New York Medicaid APG,2293.1,,,2293.1,Other,125% New York Medicaid APG,1834.48,29184.93,
Cystouretero w/congen repr,52400,CPT,,,,,,,,both,,,73326.88,54261.89,74,,54261.89,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,32997.1,45,,32997.1,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,36296.81,49.5,,36296.81,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,1857.5,,,1857.5,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,51328.82,70,,51328.82,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,998.66,,,998.66,Other,New York Medicaid APG methodology,998.66,,,998.66,Other,100% New York Medicaid APG,998.66,,,998.66,Other,100% New York Medicaid APG,998.66,,,998.66,Other,100% New York Medicaid APG,2246.97,,,2246.97,Other,225% New York Medicaid APG,1527.94,,,1527.94,Other,153% New York Medicaid APG,2246.97,,,2246.97,Other,225% New York Medicaid APG,1398.12,,,1398.12,Other,140% New York Medicaid APG,2246.97,,,2246.97,Other,225% New York Medicaid APG,2596.5,,,2596.5,Other,260% New York Medicaid APG,3235.64,,,3235.64,Other,324% New York Medicaid APG,2147.11,,,2147.11,Other,215% New York Medicaid APG,2147.11,,,2147.11,Other,215% New York Medicaid APG,1248.32,,,1248.32,Other,125% New York Medicaid APG,998.66,54261.89,
Cystourethro cut ejacul duct,52402,CPT,,,,,,,,both,,,73326.88,54261.89,74,,54261.89,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,32997.1,45,,32997.1,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,36296.81,49.5,,36296.81,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,1857.5,,,1857.5,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,51328.82,70,,51328.82,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,998.66,,,998.66,Other,New York Medicaid APG methodology,998.66,,,998.66,Other,100% New York Medicaid APG,998.66,,,998.66,Other,100% New York Medicaid APG,998.66,,,998.66,Other,100% New York Medicaid APG,2246.97,,,2246.97,Other,225% New York Medicaid APG,1527.94,,,1527.94,Other,153% New York Medicaid APG,2246.97,,,2246.97,Other,225% New York Medicaid APG,1398.12,,,1398.12,Other,140% New York Medicaid APG,2246.97,,,2246.97,Other,225% New York Medicaid APG,2596.5,,,2596.5,Other,260% New York Medicaid APG,3235.64,,,3235.64,Other,324% New York Medicaid APG,2147.11,,,2147.11,Other,215% New York Medicaid APG,2147.11,,,2147.11,Other,215% New York Medicaid APG,1248.32,,,1248.32,Other,125% New York Medicaid APG,998.66,54261.89,
Incision of prostate,52450,CPT,,,,,,,,both,,,35499.75,26269.82,74,,26269.82,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15974.89,45,,15974.89,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,17572.38,49.5,,17572.38,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3486.98,,,3486.98,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,24849.83,70,,24849.83,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1874.72,,,1874.72,Other,New York Medicaid APG methodology,1874.72,,,1874.72,Other,100% New York Medicaid APG,1874.72,,,1874.72,Other,100% New York Medicaid APG,1874.72,,,1874.72,Other,100% New York Medicaid APG,4218.12,,,4218.12,Other,225% New York Medicaid APG,2868.32,,,2868.32,Other,153% New York Medicaid APG,4218.12,,,4218.12,Other,225% New York Medicaid APG,2624.61,,,2624.61,Other,140% New York Medicaid APG,4218.12,,,4218.12,Other,225% New York Medicaid APG,4874.27,,,4874.27,Other,260% New York Medicaid APG,6074.09,,,6074.09,Other,324% New York Medicaid APG,4030.65,,,4030.65,Other,215% New York Medicaid APG,4030.65,,,4030.65,Other,215% New York Medicaid APG,2343.4,,,2343.4,Other,125% New York Medicaid APG,1874.72,26269.82,
Revision of bladder neck,52500,CPT,,,,,,,,both,,,47447.14,35110.88,74,,35110.88,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,21351.21,45,,21351.21,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,23486.33,49.5,,23486.33,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2876.72,,,2876.72,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,33213,70,,33213,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1546.62,,,1546.62,Other,New York Medicaid APG methodology,1546.62,,,1546.62,Other,100% New York Medicaid APG,1546.62,,,1546.62,Other,100% New York Medicaid APG,1546.62,,,1546.62,Other,100% New York Medicaid APG,3479.91,,,3479.91,Other,225% New York Medicaid APG,2366.34,,,2366.34,Other,153% New York Medicaid APG,3479.91,,,3479.91,Other,225% New York Medicaid APG,2165.27,,,2165.27,Other,140% New York Medicaid APG,3479.91,,,3479.91,Other,225% New York Medicaid APG,4021.22,,,4021.22,Other,260% New York Medicaid APG,5011.06,,,5011.06,Other,324% New York Medicaid APG,3325.24,,,3325.24,Other,215% New York Medicaid APG,3325.24,,,3325.24,Other,215% New York Medicaid APG,1933.28,,,1933.28,Other,125% New York Medicaid APG,1546.62,35110.88,
Prostatectomy (turp),52601,CPT,,,,,,,,both,,,40724.65,30136.24,74,,30136.24,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,18326.09,45,,18326.09,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,20158.7,49.5,,20158.7,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,4645.5,,,4645.5,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,28507.26,70,,28507.26,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,2497.58,,,2497.58,Other,New York Medicaid APG methodology,2497.58,,,2497.58,Other,100% New York Medicaid APG,2497.58,,,2497.58,Other,100% New York Medicaid APG,2497.58,,,2497.58,Other,100% New York Medicaid APG,5619.56,,,5619.56,Other,225% New York Medicaid APG,3821.3,,,3821.3,Other,153% New York Medicaid APG,5619.56,,,5619.56,Other,225% New York Medicaid APG,3496.61,,,3496.61,Other,140% New York Medicaid APG,5619.56,,,5619.56,Other,225% New York Medicaid APG,6493.71,,,6493.71,Other,260% New York Medicaid APG,8092.16,,,8092.16,Other,324% New York Medicaid APG,5369.8,,,5369.8,Other,215% New York Medicaid APG,5369.8,,,5369.8,Other,215% New York Medicaid APG,3121.98,,,3121.98,Other,125% New York Medicaid APG,2497.58,30136.24,
Remove prostate regrowth,52630,CPT,,,,,,,,both,,,41807.35,30937.44,74,,30937.44,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,18813.31,45,,18813.31,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,20694.64,49.5,,20694.64,percent of total billed charges,110% of Medicare,28429,68,,28429,percent of total billed charges,,4645.5,,,4645.5,Other,186% of Medicaid,33445.88,80,,33445.88,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,33445.88,80,,33445.88,percent of total billed charges,,7216,,,7216,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,29265.15,70,,29265.15,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,2497.58,,,2497.58,Other,New York Medicaid APG methodology,2497.58,,,2497.58,Other,100% New York Medicaid APG,2497.58,,,2497.58,Other,100% New York Medicaid APG,2497.58,,,2497.58,Other,100% New York Medicaid APG,5619.56,,,5619.56,Other,225% New York Medicaid APG,3821.3,,,3821.3,Other,153% New York Medicaid APG,5619.56,,,5619.56,Other,225% New York Medicaid APG,3496.61,,,3496.61,Other,140% New York Medicaid APG,5619.56,,,5619.56,Other,225% New York Medicaid APG,6493.71,,,6493.71,Other,260% New York Medicaid APG,8092.16,,,8092.16,Other,324% New York Medicaid APG,5369.8,,,5369.8,Other,215% New York Medicaid APG,5369.8,,,5369.8,Other,215% New York Medicaid APG,3121.98,,,3121.98,Other,125% New York Medicaid APG,2232,33445.88,
Relieve bladder contracture,52640,CPT,,,,,,,,both,,,36213.63,26798.09,74,,26798.09,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,16296.13,45,,16296.13,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,17925.75,49.5,,17925.75,percent of total billed charges,110% of Medicare,24625.27,68,,24625.27,percent of total billed charges,,2876.72,,,2876.72,Other,186% of Medicaid,28970.9,80,,28970.9,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,28970.9,80,,28970.9,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,25349.54,70,,25349.54,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1546.62,,,1546.62,Other,New York Medicaid APG methodology,1546.62,,,1546.62,Other,100% New York Medicaid APG,1546.62,,,1546.62,Other,100% New York Medicaid APG,1546.62,,,1546.62,Other,100% New York Medicaid APG,3479.91,,,3479.91,Other,225% New York Medicaid APG,2366.34,,,2366.34,Other,153% New York Medicaid APG,3479.91,,,3479.91,Other,225% New York Medicaid APG,2165.27,,,2165.27,Other,140% New York Medicaid APG,3479.91,,,3479.91,Other,225% New York Medicaid APG,4021.22,,,4021.22,Other,260% New York Medicaid APG,5011.06,,,5011.06,Other,324% New York Medicaid APG,3325.24,,,3325.24,Other,215% New York Medicaid APG,3325.24,,,3325.24,Other,215% New York Medicaid APG,1933.28,,,1933.28,Other,125% New York Medicaid APG,1546.62,28970.9,
Laser surgery of prostate,52647,CPT,,,,,,,,both,,,108835.97,80538.62,74,,80538.62,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,48976.19,45,,48976.19,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,53873.81,49.5,,53873.81,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,4645.5,,,4645.5,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,76185.18,70,,76185.18,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,2497.58,,,2497.58,Other,New York Medicaid APG methodology,2497.58,,,2497.58,Other,100% New York Medicaid APG,2497.58,,,2497.58,Other,100% New York Medicaid APG,2497.58,,,2497.58,Other,100% New York Medicaid APG,5619.56,,,5619.56,Other,225% New York Medicaid APG,3821.3,,,3821.3,Other,153% New York Medicaid APG,5619.56,,,5619.56,Other,225% New York Medicaid APG,3496.61,,,3496.61,Other,140% New York Medicaid APG,5619.56,,,5619.56,Other,225% New York Medicaid APG,6493.71,,,6493.71,Other,260% New York Medicaid APG,8092.16,,,8092.16,Other,324% New York Medicaid APG,5369.8,,,5369.8,Other,215% New York Medicaid APG,5369.8,,,5369.8,Other,215% New York Medicaid APG,3121.98,,,3121.98,Other,125% New York Medicaid APG,2497.58,80538.62,
Laser surgery of prostate,52648,CPT,,,,,,,,both,,,44600.84,33004.62,74,,33004.62,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,20070.38,45,,20070.38,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,22077.42,49.5,,22077.42,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,4645.5,,,4645.5,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,31220.59,70,,31220.59,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,2497.58,,,2497.58,Other,New York Medicaid APG methodology,2497.58,,,2497.58,Other,100% New York Medicaid APG,2497.58,,,2497.58,Other,100% New York Medicaid APG,2497.58,,,2497.58,Other,100% New York Medicaid APG,5619.56,,,5619.56,Other,225% New York Medicaid APG,3821.3,,,3821.3,Other,153% New York Medicaid APG,5619.56,,,5619.56,Other,225% New York Medicaid APG,3496.61,,,3496.61,Other,140% New York Medicaid APG,5619.56,,,5619.56,Other,225% New York Medicaid APG,6493.71,,,6493.71,Other,260% New York Medicaid APG,8092.16,,,8092.16,Other,324% New York Medicaid APG,5369.8,,,5369.8,Other,215% New York Medicaid APG,5369.8,,,5369.8,Other,215% New York Medicaid APG,3121.98,,,3121.98,Other,125% New York Medicaid APG,2497.58,33004.62,
Prostate laser enucleation,52649,CPT,,,,,,,,both,,,42526.4,31469.54,74,,31469.54,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,19136.88,45,,19136.88,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,21050.57,49.5,,21050.57,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,4645.5,,,4645.5,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,29768.48,70,,29768.48,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,2497.58,,,2497.58,Other,New York Medicaid APG methodology,2497.58,,,2497.58,Other,100% New York Medicaid APG,2497.58,,,2497.58,Other,100% New York Medicaid APG,2497.58,,,2497.58,Other,100% New York Medicaid APG,5619.56,,,5619.56,Other,225% New York Medicaid APG,3821.3,,,3821.3,Other,153% New York Medicaid APG,5619.56,,,5619.56,Other,225% New York Medicaid APG,3496.61,,,3496.61,Other,140% New York Medicaid APG,5619.56,,,5619.56,Other,225% New York Medicaid APG,6493.71,,,6493.71,Other,260% New York Medicaid APG,8092.16,,,8092.16,Other,324% New York Medicaid APG,5369.8,,,5369.8,Other,215% New York Medicaid APG,5369.8,,,5369.8,Other,215% New York Medicaid APG,3121.98,,,3121.98,Other,125% New York Medicaid APG,2497.58,31469.54,
Drainage of prostate abscess,52700,CPT,,,,,,,,both,,,73326.88,54261.89,74,,54261.89,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,32997.1,45,,32997.1,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,36296.81,49.5,,36296.81,percent of total billed charges,110% of Medicare,49862.28,68,,49862.28,percent of total billed charges,,3486.98,,,3486.98,Other,186% of Medicaid,58661.5,80,,58661.5,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,58661.5,80,,58661.5,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,51328.82,70,,51328.82,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1874.72,,,1874.72,Other,New York Medicaid APG methodology,1874.72,,,1874.72,Other,100% New York Medicaid APG,1874.72,,,1874.72,Other,100% New York Medicaid APG,1874.72,,,1874.72,Other,100% New York Medicaid APG,4218.12,,,4218.12,Other,225% New York Medicaid APG,2868.32,,,2868.32,Other,153% New York Medicaid APG,4218.12,,,4218.12,Other,225% New York Medicaid APG,2624.61,,,2624.61,Other,140% New York Medicaid APG,4218.12,,,4218.12,Other,225% New York Medicaid APG,4874.27,,,4874.27,Other,260% New York Medicaid APG,6074.09,,,6074.09,Other,324% New York Medicaid APG,4030.65,,,4030.65,Other,215% New York Medicaid APG,4030.65,,,4030.65,Other,215% New York Medicaid APG,2343.4,,,2343.4,Other,125% New York Medicaid APG,1874.72,58661.5,
Incision of urethra,53000,CPT,,,,,,,,both,,,42841.82,31702.95,74,,31702.95,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,19278.82,45,,19278.82,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,21206.7,49.5,,21206.7,percent of total billed charges,110% of Medicare,29132.44,68,,29132.44,percent of total billed charges,,1857.5,,,1857.5,Other,186% of Medicaid,34273.46,80,,34273.46,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,34273.46,80,,34273.46,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,29989.27,70,,29989.27,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,998.66,,,998.66,Other,New York Medicaid APG methodology,998.66,,,998.66,Other,100% New York Medicaid APG,998.66,,,998.66,Other,100% New York Medicaid APG,998.66,,,998.66,Other,100% New York Medicaid APG,2246.97,,,2246.97,Other,225% New York Medicaid APG,1527.94,,,1527.94,Other,153% New York Medicaid APG,2246.97,,,2246.97,Other,225% New York Medicaid APG,1398.12,,,1398.12,Other,140% New York Medicaid APG,2246.97,,,2246.97,Other,225% New York Medicaid APG,2596.5,,,2596.5,Other,260% New York Medicaid APG,3235.64,,,3235.64,Other,324% New York Medicaid APG,2147.11,,,2147.11,Other,215% New York Medicaid APG,2147.11,,,2147.11,Other,215% New York Medicaid APG,1248.32,,,1248.32,Other,125% New York Medicaid APG,998.66,34273.46,
Incision of urethra,53010,CPT,,,,,,,,both,,,108835.97,80538.62,74,,80538.62,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,48976.19,45,,48976.19,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,53873.81,49.5,,53873.81,percent of total billed charges,110% of Medicare,74008.46,68,,74008.46,percent of total billed charges,,4377.94,,,4377.94,Other,186% of Medicaid,87068.78,80,,87068.78,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,87068.78,80,,87068.78,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,76185.18,70,,76185.18,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,2353.73,,,2353.73,Other,New York Medicaid APG methodology,2353.73,,,2353.73,Other,100% New York Medicaid APG,2353.73,,,2353.73,Other,100% New York Medicaid APG,2353.73,,,2353.73,Other,100% New York Medicaid APG,5295.9,,,5295.9,Other,225% New York Medicaid APG,3601.21,,,3601.21,Other,153% New York Medicaid APG,5295.9,,,5295.9,Other,225% New York Medicaid APG,3295.23,,,3295.23,Other,140% New York Medicaid APG,5295.9,,,5295.9,Other,225% New York Medicaid APG,6119.71,,,6119.71,Other,260% New York Medicaid APG,7626.1,,,7626.1,Other,324% New York Medicaid APG,5060.53,,,5060.53,Other,215% New York Medicaid APG,5060.53,,,5060.53,Other,215% New York Medicaid APG,2942.17,,,2942.17,Other,125% New York Medicaid APG,2053,87068.78,
Incision of urethra,53020,CPT,,,,,,,,both,,,36826.76,27251.8,74,,27251.8,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,16572.04,45,,16572.04,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,18229.25,49.5,,18229.25,percent of total billed charges,110% of Medicare,25042.2,68,,25042.2,percent of total billed charges,,1857.5,,,1857.5,Other,186% of Medicaid,29461.41,80,,29461.41,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,29461.41,80,,29461.41,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,25778.73,70,,25778.73,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,998.66,,,998.66,Other,New York Medicaid APG methodology,998.66,,,998.66,Other,100% New York Medicaid APG,998.66,,,998.66,Other,100% New York Medicaid APG,998.66,,,998.66,Other,100% New York Medicaid APG,2246.97,,,2246.97,Other,225% New York Medicaid APG,1527.94,,,1527.94,Other,153% New York Medicaid APG,2246.97,,,2246.97,Other,225% New York Medicaid APG,1398.12,,,1398.12,Other,140% New York Medicaid APG,2246.97,,,2246.97,Other,225% New York Medicaid APG,2596.5,,,2596.5,Other,260% New York Medicaid APG,3235.64,,,3235.64,Other,324% New York Medicaid APG,2147.11,,,2147.11,Other,215% New York Medicaid APG,2147.11,,,2147.11,Other,215% New York Medicaid APG,1248.32,,,1248.32,Other,125% New York Medicaid APG,998.66,29461.41,
Incision of urethra,53025,CPT,,,,,,,,both,,,42841.82,31702.95,74,,31702.95,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,19278.82,45,,19278.82,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,21206.7,49.5,,21206.7,percent of total billed charges,110% of Medicare,29132.44,68,,29132.44,percent of total billed charges,,1857.5,,,1857.5,Other,186% of Medicaid,34273.46,80,,34273.46,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,34273.46,80,,34273.46,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,29989.27,70,,29989.27,percent of total billed charges,,331.28,,,331.28,Fee Schedule,,280.78,,,280.78,Fee Schedule,,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,998.66,,,998.66,Other,New York Medicaid APG methodology,998.66,,,998.66,Other,100% New York Medicaid APG,998.66,,,998.66,Other,100% New York Medicaid APG,998.66,,,998.66,Other,100% New York Medicaid APG,2246.97,,,2246.97,Other,225% New York Medicaid APG,1527.94,,,1527.94,Other,153% New York Medicaid APG,2246.97,,,2246.97,Other,225% New York Medicaid APG,1398.12,,,1398.12,Other,140% New York Medicaid APG,2246.97,,,2246.97,Other,225% New York Medicaid APG,2596.5,,,2596.5,Other,260% New York Medicaid APG,3235.64,,,3235.64,Other,324% New York Medicaid APG,2147.11,,,2147.11,Other,215% New York Medicaid APG,2147.11,,,2147.11,Other,215% New York Medicaid APG,1248.32,,,1248.32,Other,125% New York Medicaid APG,280.78,34273.46,
Drainage of urethra abscess,53040,CPT,,,,,,,,both,,,73326.88,54261.89,74,,54261.89,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,32997.1,45,,32997.1,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,36296.81,49.5,,36296.81,percent of total billed charges,110% of Medicare,49862.28,68,,49862.28,percent of total billed charges,,1857.5,,,1857.5,Other,186% of Medicaid,58661.5,80,,58661.5,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,58661.5,80,,58661.5,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,51328.82,70,,51328.82,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,998.66,,,998.66,Other,New York Medicaid APG methodology,998.66,,,998.66,Other,100% New York Medicaid APG,998.66,,,998.66,Other,100% New York Medicaid APG,998.66,,,998.66,Other,100% New York Medicaid APG,2246.97,,,2246.97,Other,225% New York Medicaid APG,1527.94,,,1527.94,Other,153% New York Medicaid APG,2246.97,,,2246.97,Other,225% New York Medicaid APG,1398.12,,,1398.12,Other,140% New York Medicaid APG,2246.97,,,2246.97,Other,225% New York Medicaid APG,2596.5,,,2596.5,Other,260% New York Medicaid APG,3235.64,,,3235.64,Other,324% New York Medicaid APG,2147.11,,,2147.11,Other,215% New York Medicaid APG,2147.11,,,2147.11,Other,215% New York Medicaid APG,1248.32,,,1248.32,Other,125% New York Medicaid APG,998.66,58661.5,
Drainage of urethra abscess,53060,CPT,,,,,,,,both,,,42841.82,31702.95,74,,31702.95,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,19278.82,45,,19278.82,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,21206.7,49.5,,21206.7,percent of total billed charges,110% of Medicare,29132.44,68,,29132.44,percent of total billed charges,,1857.5,,,1857.5,Other,186% of Medicaid,34273.46,80,,34273.46,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,34273.46,80,,34273.46,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,29989.27,70,,29989.27,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,998.66,,,998.66,Other,New York Medicaid APG methodology,998.66,,,998.66,Other,100% New York Medicaid APG,998.66,,,998.66,Other,100% New York Medicaid APG,998.66,,,998.66,Other,100% New York Medicaid APG,2246.97,,,2246.97,Other,225% New York Medicaid APG,1527.94,,,1527.94,Other,153% New York Medicaid APG,2246.97,,,2246.97,Other,225% New York Medicaid APG,1398.12,,,1398.12,Other,140% New York Medicaid APG,2246.97,,,2246.97,Other,225% New York Medicaid APG,2596.5,,,2596.5,Other,260% New York Medicaid APG,3235.64,,,3235.64,Other,324% New York Medicaid APG,2147.11,,,2147.11,Other,215% New York Medicaid APG,2147.11,,,2147.11,Other,215% New York Medicaid APG,1248.32,,,1248.32,Other,125% New York Medicaid APG,998.66,34273.46,
Drainage of urinary leakage,53080,CPT,,,,,,,,both,,,14368.32,10632.56,74,,10632.56,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,6465.74,45,,6465.74,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,7112.32,49.5,,7112.32,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,903.43,,,903.43,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,10057.82,70,,10057.82,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,485.72,,,485.72,Other,New York Medicaid APG methodology,485.72,,,485.72,Other,100% New York Medicaid APG,485.72,,,485.72,Other,100% New York Medicaid APG,485.72,,,485.72,Other,100% New York Medicaid APG,1092.86,,,1092.86,Other,225% New York Medicaid APG,743.14,,,743.14,Other,153% New York Medicaid APG,1092.86,,,1092.86,Other,225% New York Medicaid APG,680,,,680,Other,140% New York Medicaid APG,1092.86,,,1092.86,Other,225% New York Medicaid APG,1262.86,,,1262.86,Other,260% New York Medicaid APG,1573.72,,,1573.72,Other,324% New York Medicaid APG,1044.29,,,1044.29,Other,215% New York Medicaid APG,1044.29,,,1044.29,Other,215% New York Medicaid APG,607.14,,,607.14,Other,125% New York Medicaid APG,485.72,10632.56,
Drainage of urinary leakage,53085,CPT,,,,,,,,both,,,42841.82,31702.95,74,,31702.95,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,19278.82,45,,19278.82,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,21206.7,49.5,,21206.7,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,1857.5,,,1857.5,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,29989.27,70,,29989.27,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,998.66,,,998.66,Other,New York Medicaid APG methodology,998.66,,,998.66,Other,100% New York Medicaid APG,998.66,,,998.66,Other,100% New York Medicaid APG,998.66,,,998.66,Other,100% New York Medicaid APG,2246.97,,,2246.97,Other,225% New York Medicaid APG,1527.94,,,1527.94,Other,153% New York Medicaid APG,2246.97,,,2246.97,Other,225% New York Medicaid APG,1398.12,,,1398.12,Other,140% New York Medicaid APG,2246.97,,,2246.97,Other,225% New York Medicaid APG,2596.5,,,2596.5,Other,260% New York Medicaid APG,3235.64,,,3235.64,Other,324% New York Medicaid APG,2147.11,,,2147.11,Other,215% New York Medicaid APG,2147.11,,,2147.11,Other,215% New York Medicaid APG,1248.32,,,1248.32,Other,125% New York Medicaid APG,998.66,31702.95,
Biopsy of urethra,53200,CPT,,,,,,,,both,,,42841.82,31702.95,74,,31702.95,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,19278.82,45,,19278.82,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,21206.7,49.5,,21206.7,percent of total billed charges,110% of Medicare,29132.44,68,,29132.44,percent of total billed charges,,1857.5,,,1857.5,Other,186% of Medicaid,34273.46,80,,34273.46,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,34273.46,80,,34273.46,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,29989.27,70,,29989.27,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,998.66,,,998.66,Other,New York Medicaid APG methodology,998.66,,,998.66,Other,100% New York Medicaid APG,998.66,,,998.66,Other,100% New York Medicaid APG,998.66,,,998.66,Other,100% New York Medicaid APG,2246.97,,,2246.97,Other,225% New York Medicaid APG,1527.94,,,1527.94,Other,153% New York Medicaid APG,2246.97,,,2246.97,Other,225% New York Medicaid APG,1398.12,,,1398.12,Other,140% New York Medicaid APG,2246.97,,,2246.97,Other,225% New York Medicaid APG,2596.5,,,2596.5,Other,260% New York Medicaid APG,3235.64,,,3235.64,Other,324% New York Medicaid APG,2147.11,,,2147.11,Other,215% New York Medicaid APG,2147.11,,,2147.11,Other,215% New York Medicaid APG,1248.32,,,1248.32,Other,125% New York Medicaid APG,998.66,34273.46,
Removal of urethra,53210,CPT,,,,,,,,both,,,73326.88,54261.89,74,,54261.89,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,32997.1,45,,32997.1,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,36296.81,49.5,,36296.81,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,1857.5,,,1857.5,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,51328.82,70,,51328.82,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,998.66,,,998.66,Other,New York Medicaid APG methodology,998.66,,,998.66,Other,100% New York Medicaid APG,998.66,,,998.66,Other,100% New York Medicaid APG,998.66,,,998.66,Other,100% New York Medicaid APG,2246.97,,,2246.97,Other,225% New York Medicaid APG,1527.94,,,1527.94,Other,153% New York Medicaid APG,2246.97,,,2246.97,Other,225% New York Medicaid APG,1398.12,,,1398.12,Other,140% New York Medicaid APG,2246.97,,,2246.97,Other,225% New York Medicaid APG,2596.5,,,2596.5,Other,260% New York Medicaid APG,3235.64,,,3235.64,Other,324% New York Medicaid APG,2147.11,,,2147.11,Other,215% New York Medicaid APG,2147.11,,,2147.11,Other,215% New York Medicaid APG,1248.32,,,1248.32,Other,125% New York Medicaid APG,998.66,54261.89,
Removal of urethra,53215,CPT,,,,,,,,both,,,108835.97,80538.62,74,,80538.62,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,48976.19,45,,48976.19,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,53873.81,49.5,,53873.81,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,4377.94,,,4377.94,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,76185.18,70,,76185.18,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,2353.73,,,2353.73,Other,New York Medicaid APG methodology,2353.73,,,2353.73,Other,100% New York Medicaid APG,2353.73,,,2353.73,Other,100% New York Medicaid APG,2353.73,,,2353.73,Other,100% New York Medicaid APG,5295.9,,,5295.9,Other,225% New York Medicaid APG,3601.21,,,3601.21,Other,153% New York Medicaid APG,5295.9,,,5295.9,Other,225% New York Medicaid APG,3295.23,,,3295.23,Other,140% New York Medicaid APG,5295.9,,,5295.9,Other,225% New York Medicaid APG,6119.71,,,6119.71,Other,260% New York Medicaid APG,7626.1,,,7626.1,Other,324% New York Medicaid APG,5060.53,,,5060.53,Other,215% New York Medicaid APG,5060.53,,,5060.53,Other,215% New York Medicaid APG,2942.17,,,2942.17,Other,125% New York Medicaid APG,2353.73,80538.62,
Treatment of urethra lesion,53220,CPT,,,,,,,,both,,,73326.88,54261.89,74,,54261.89,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,32997.1,45,,32997.1,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,36296.81,49.5,,36296.81,percent of total billed charges,110% of Medicare,49862.28,68,,49862.28,percent of total billed charges,,1857.5,,,1857.5,Other,186% of Medicaid,58661.5,80,,58661.5,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,58661.5,80,,58661.5,percent of total billed charges,,7216,,,7216,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,51328.82,70,,51328.82,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,998.66,,,998.66,Other,New York Medicaid APG methodology,998.66,,,998.66,Other,100% New York Medicaid APG,998.66,,,998.66,Other,100% New York Medicaid APG,998.66,,,998.66,Other,100% New York Medicaid APG,2246.97,,,2246.97,Other,225% New York Medicaid APG,1527.94,,,1527.94,Other,153% New York Medicaid APG,2246.97,,,2246.97,Other,225% New York Medicaid APG,1398.12,,,1398.12,Other,140% New York Medicaid APG,2246.97,,,2246.97,Other,225% New York Medicaid APG,2596.5,,,2596.5,Other,260% New York Medicaid APG,3235.64,,,3235.64,Other,324% New York Medicaid APG,2147.11,,,2147.11,Other,215% New York Medicaid APG,2147.11,,,2147.11,Other,215% New York Medicaid APG,1248.32,,,1248.32,Other,125% New York Medicaid APG,998.66,58661.5,
Removal of urethra lesion,53230,CPT,,,,,,,,both,,,40310.96,29830.11,74,,29830.11,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,18139.93,45,,18139.93,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,19953.93,49.5,,19953.93,percent of total billed charges,110% of Medicare,27411.45,68,,27411.45,percent of total billed charges,,4377.94,,,4377.94,Other,186% of Medicaid,32248.77,80,,32248.77,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,32248.77,80,,32248.77,percent of total billed charges,,7216,,,7216,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,28217.67,70,,28217.67,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,2353.73,,,2353.73,Other,New York Medicaid APG methodology,2353.73,,,2353.73,Other,100% New York Medicaid APG,2353.73,,,2353.73,Other,100% New York Medicaid APG,2353.73,,,2353.73,Other,100% New York Medicaid APG,5295.9,,,5295.9,Other,225% New York Medicaid APG,3601.21,,,3601.21,Other,153% New York Medicaid APG,5295.9,,,5295.9,Other,225% New York Medicaid APG,3295.23,,,3295.23,Other,140% New York Medicaid APG,5295.9,,,5295.9,Other,225% New York Medicaid APG,6119.71,,,6119.71,Other,260% New York Medicaid APG,7626.1,,,7626.1,Other,324% New York Medicaid APG,5060.53,,,5060.53,Other,215% New York Medicaid APG,5060.53,,,5060.53,Other,215% New York Medicaid APG,2942.17,,,2942.17,Other,125% New York Medicaid APG,2232,32248.77,
Removal of urethra lesion,53235,CPT,,,,,,,,both,,,108835.97,80538.62,74,,80538.62,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,48976.19,45,,48976.19,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,53873.81,49.5,,53873.81,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,4377.94,,,4377.94,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,76185.18,70,,76185.18,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,2353.73,,,2353.73,Other,New York Medicaid APG methodology,2353.73,,,2353.73,Other,100% New York Medicaid APG,2353.73,,,2353.73,Other,100% New York Medicaid APG,2353.73,,,2353.73,Other,100% New York Medicaid APG,5295.9,,,5295.9,Other,225% New York Medicaid APG,3601.21,,,3601.21,Other,153% New York Medicaid APG,5295.9,,,5295.9,Other,225% New York Medicaid APG,3295.23,,,3295.23,Other,140% New York Medicaid APG,5295.9,,,5295.9,Other,225% New York Medicaid APG,6119.71,,,6119.71,Other,260% New York Medicaid APG,7626.1,,,7626.1,Other,324% New York Medicaid APG,5060.53,,,5060.53,Other,215% New York Medicaid APG,5060.53,,,5060.53,Other,215% New York Medicaid APG,2942.17,,,2942.17,Other,125% New York Medicaid APG,2353.73,80538.62,
Surgery for urethra pouch,53240,CPT,,,,,,,,both,,,73326.88,54261.89,74,,54261.89,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,32997.1,45,,32997.1,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,36296.81,49.5,,36296.81,percent of total billed charges,110% of Medicare,49862.28,68,,49862.28,percent of total billed charges,,1857.5,,,1857.5,Other,186% of Medicaid,58661.5,80,,58661.5,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,58661.5,80,,58661.5,percent of total billed charges,,7216,,,7216,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,51328.82,70,,51328.82,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,998.66,,,998.66,Other,New York Medicaid APG methodology,998.66,,,998.66,Other,100% New York Medicaid APG,998.66,,,998.66,Other,100% New York Medicaid APG,998.66,,,998.66,Other,100% New York Medicaid APG,2246.97,,,2246.97,Other,225% New York Medicaid APG,1527.94,,,1527.94,Other,153% New York Medicaid APG,2246.97,,,2246.97,Other,225% New York Medicaid APG,1398.12,,,1398.12,Other,140% New York Medicaid APG,2246.97,,,2246.97,Other,225% New York Medicaid APG,2596.5,,,2596.5,Other,260% New York Medicaid APG,3235.64,,,3235.64,Other,324% New York Medicaid APG,2147.11,,,2147.11,Other,215% New York Medicaid APG,2147.11,,,2147.11,Other,215% New York Medicaid APG,1248.32,,,1248.32,Other,125% New York Medicaid APG,998.66,58661.5,
Removal of urethra gland,53250,CPT,,,,,,,,both,,,73326.88,54261.89,74,,54261.89,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,32997.1,45,,32997.1,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,36296.81,49.5,,36296.81,percent of total billed charges,110% of Medicare,49862.28,68,,49862.28,percent of total billed charges,,1857.5,,,1857.5,Other,186% of Medicaid,58661.5,80,,58661.5,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,58661.5,80,,58661.5,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,51328.82,70,,51328.82,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,998.66,,,998.66,Other,New York Medicaid APG methodology,998.66,,,998.66,Other,100% New York Medicaid APG,998.66,,,998.66,Other,100% New York Medicaid APG,998.66,,,998.66,Other,100% New York Medicaid APG,2246.97,,,2246.97,Other,225% New York Medicaid APG,1527.94,,,1527.94,Other,153% New York Medicaid APG,2246.97,,,2246.97,Other,225% New York Medicaid APG,1398.12,,,1398.12,Other,140% New York Medicaid APG,2246.97,,,2246.97,Other,225% New York Medicaid APG,2596.5,,,2596.5,Other,260% New York Medicaid APG,3235.64,,,3235.64,Other,324% New York Medicaid APG,2147.11,,,2147.11,Other,215% New York Medicaid APG,2147.11,,,2147.11,Other,215% New York Medicaid APG,1248.32,,,1248.32,Other,125% New York Medicaid APG,998.66,58661.5,
Treatment of urethra lesion,53260,CPT,,,,,,,,both,,,73326.88,54261.89,74,,54261.89,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,32997.1,45,,32997.1,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,36296.81,49.5,,36296.81,percent of total billed charges,110% of Medicare,49862.28,68,,49862.28,percent of total billed charges,,1857.5,,,1857.5,Other,186% of Medicaid,58661.5,80,,58661.5,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,58661.5,80,,58661.5,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,51328.82,70,,51328.82,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,998.66,,,998.66,Other,New York Medicaid APG methodology,998.66,,,998.66,Other,100% New York Medicaid APG,998.66,,,998.66,Other,100% New York Medicaid APG,998.66,,,998.66,Other,100% New York Medicaid APG,2246.97,,,2246.97,Other,225% New York Medicaid APG,1527.94,,,1527.94,Other,153% New York Medicaid APG,2246.97,,,2246.97,Other,225% New York Medicaid APG,1398.12,,,1398.12,Other,140% New York Medicaid APG,2246.97,,,2246.97,Other,225% New York Medicaid APG,2596.5,,,2596.5,Other,260% New York Medicaid APG,3235.64,,,3235.64,Other,324% New York Medicaid APG,2147.11,,,2147.11,Other,215% New York Medicaid APG,2147.11,,,2147.11,Other,215% New York Medicaid APG,1248.32,,,1248.32,Other,125% New York Medicaid APG,998.66,58661.5,
Treatment of urethra lesion,53265,CPT,,,,,,,,both,,,40279.92,29807.14,74,,29807.14,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,18125.96,45,,18125.96,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,19938.56,49.5,,19938.56,percent of total billed charges,110% of Medicare,27390.35,68,,27390.35,percent of total billed charges,,1857.5,,,1857.5,Other,186% of Medicaid,32223.94,80,,32223.94,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,32223.94,80,,32223.94,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,28195.94,70,,28195.94,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,998.66,,,998.66,Other,New York Medicaid APG methodology,998.66,,,998.66,Other,100% New York Medicaid APG,998.66,,,998.66,Other,100% New York Medicaid APG,998.66,,,998.66,Other,100% New York Medicaid APG,2246.97,,,2246.97,Other,225% New York Medicaid APG,1527.94,,,1527.94,Other,153% New York Medicaid APG,2246.97,,,2246.97,Other,225% New York Medicaid APG,1398.12,,,1398.12,Other,140% New York Medicaid APG,2246.97,,,2246.97,Other,225% New York Medicaid APG,2596.5,,,2596.5,Other,260% New York Medicaid APG,3235.64,,,3235.64,Other,324% New York Medicaid APG,2147.11,,,2147.11,Other,215% New York Medicaid APG,2147.11,,,2147.11,Other,215% New York Medicaid APG,1248.32,,,1248.32,Other,125% New York Medicaid APG,998.66,32223.94,
Removal of urethra gland,53270,CPT,,,,,,,,both,,,40917.43,30278.9,74,,30278.9,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,18412.84,45,,18412.84,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,20254.13,49.5,,20254.13,percent of total billed charges,110% of Medicare,27823.85,68,,27823.85,percent of total billed charges,,1857.5,,,1857.5,Other,186% of Medicaid,32733.94,80,,32733.94,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,32733.94,80,,32733.94,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,28642.2,70,,28642.2,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,998.66,,,998.66,Other,New York Medicaid APG methodology,998.66,,,998.66,Other,100% New York Medicaid APG,998.66,,,998.66,Other,100% New York Medicaid APG,998.66,,,998.66,Other,100% New York Medicaid APG,2246.97,,,2246.97,Other,225% New York Medicaid APG,1527.94,,,1527.94,Other,153% New York Medicaid APG,2246.97,,,2246.97,Other,225% New York Medicaid APG,1398.12,,,1398.12,Other,140% New York Medicaid APG,2246.97,,,2246.97,Other,225% New York Medicaid APG,2596.5,,,2596.5,Other,260% New York Medicaid APG,3235.64,,,3235.64,Other,324% New York Medicaid APG,2147.11,,,2147.11,Other,215% New York Medicaid APG,2147.11,,,2147.11,Other,215% New York Medicaid APG,1248.32,,,1248.32,Other,125% New York Medicaid APG,998.66,32733.94,
Repair of urethra defect,53275,CPT,,,,,,,,both,,,73326.88,54261.89,74,,54261.89,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,32997.1,45,,32997.1,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,36296.81,49.5,,36296.81,percent of total billed charges,110% of Medicare,49862.28,68,,49862.28,percent of total billed charges,,1857.5,,,1857.5,Other,186% of Medicaid,58661.5,80,,58661.5,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,58661.5,80,,58661.5,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,51328.82,70,,51328.82,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,998.66,,,998.66,Other,New York Medicaid APG methodology,998.66,,,998.66,Other,100% New York Medicaid APG,998.66,,,998.66,Other,100% New York Medicaid APG,998.66,,,998.66,Other,100% New York Medicaid APG,2246.97,,,2246.97,Other,225% New York Medicaid APG,1527.94,,,1527.94,Other,153% New York Medicaid APG,2246.97,,,2246.97,Other,225% New York Medicaid APG,1398.12,,,1398.12,Other,140% New York Medicaid APG,2246.97,,,2246.97,Other,225% New York Medicaid APG,2596.5,,,2596.5,Other,260% New York Medicaid APG,3235.64,,,3235.64,Other,324% New York Medicaid APG,2147.11,,,2147.11,Other,215% New York Medicaid APG,2147.11,,,2147.11,Other,215% New York Medicaid APG,1248.32,,,1248.32,Other,125% New York Medicaid APG,998.66,58661.5,
Revise urethra stage 1,53400,CPT,,,,,,,,both,,,108835.97,80538.62,74,,80538.62,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,48976.19,45,,48976.19,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,53873.81,49.5,,53873.81,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,4377.94,,,4377.94,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,76185.18,70,,76185.18,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,2353.73,,,2353.73,Other,New York Medicaid APG methodology,2353.73,,,2353.73,Other,100% New York Medicaid APG,2353.73,,,2353.73,Other,100% New York Medicaid APG,2353.73,,,2353.73,Other,100% New York Medicaid APG,5295.9,,,5295.9,Other,225% New York Medicaid APG,3601.21,,,3601.21,Other,153% New York Medicaid APG,5295.9,,,5295.9,Other,225% New York Medicaid APG,3295.23,,,3295.23,Other,140% New York Medicaid APG,5295.9,,,5295.9,Other,225% New York Medicaid APG,6119.71,,,6119.71,Other,260% New York Medicaid APG,7626.1,,,7626.1,Other,324% New York Medicaid APG,5060.53,,,5060.53,Other,215% New York Medicaid APG,5060.53,,,5060.53,Other,215% New York Medicaid APG,2942.17,,,2942.17,Other,125% New York Medicaid APG,2353.73,80538.62,
Revise urethra stage 2,53405,CPT,,,,,,,,both,,,108835.97,80538.62,74,,80538.62,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,48976.19,45,,48976.19,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,53873.81,49.5,,53873.81,percent of total billed charges,110% of Medicare,74008.46,68,,74008.46,percent of total billed charges,,4377.94,,,4377.94,Other,186% of Medicaid,87068.78,80,,87068.78,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,87068.78,80,,87068.78,percent of total billed charges,,7216,,,7216,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,76185.18,70,,76185.18,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,2353.73,,,2353.73,Other,New York Medicaid APG methodology,2353.73,,,2353.73,Other,100% New York Medicaid APG,2353.73,,,2353.73,Other,100% New York Medicaid APG,2353.73,,,2353.73,Other,100% New York Medicaid APG,5295.9,,,5295.9,Other,225% New York Medicaid APG,3601.21,,,3601.21,Other,153% New York Medicaid APG,5295.9,,,5295.9,Other,225% New York Medicaid APG,3295.23,,,3295.23,Other,140% New York Medicaid APG,5295.9,,,5295.9,Other,225% New York Medicaid APG,6119.71,,,6119.71,Other,260% New York Medicaid APG,7626.1,,,7626.1,Other,324% New York Medicaid APG,5060.53,,,5060.53,Other,215% New York Medicaid APG,5060.53,,,5060.53,Other,215% New York Medicaid APG,2942.17,,,2942.17,Other,125% New York Medicaid APG,2232,87068.78,
Reconstruction of urethra,53410,CPT,,,,,,,,both,,,69570.13,51481.9,74,,51481.9,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,31306.56,45,,31306.56,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,34437.21,49.5,,34437.21,percent of total billed charges,110% of Medicare,47307.69,68,,47307.69,percent of total billed charges,,4377.94,,,4377.94,Other,186% of Medicaid,55656.1,80,,55656.1,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,55656.1,80,,55656.1,percent of total billed charges,,7216,,,7216,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,48699.09,70,,48699.09,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,2353.73,,,2353.73,Other,New York Medicaid APG methodology,2353.73,,,2353.73,Other,100% New York Medicaid APG,2353.73,,,2353.73,Other,100% New York Medicaid APG,2353.73,,,2353.73,Other,100% New York Medicaid APG,5295.9,,,5295.9,Other,225% New York Medicaid APG,3601.21,,,3601.21,Other,153% New York Medicaid APG,5295.9,,,5295.9,Other,225% New York Medicaid APG,3295.23,,,3295.23,Other,140% New York Medicaid APG,5295.9,,,5295.9,Other,225% New York Medicaid APG,6119.71,,,6119.71,Other,260% New York Medicaid APG,7626.1,,,7626.1,Other,324% New York Medicaid APG,5060.53,,,5060.53,Other,215% New York Medicaid APG,5060.53,,,5060.53,Other,215% New York Medicaid APG,2942.17,,,2942.17,Other,125% New York Medicaid APG,2232,55656.1,
Reconstruct urethra stage 1,53420,CPT,,,,,,,,both,,,108835.97,80538.62,74,,80538.62,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,48976.19,45,,48976.19,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,53873.81,49.5,,53873.81,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,4377.94,,,4377.94,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,76185.18,70,,76185.18,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,2353.73,,,2353.73,Other,New York Medicaid APG methodology,2353.73,,,2353.73,Other,100% New York Medicaid APG,2353.73,,,2353.73,Other,100% New York Medicaid APG,2353.73,,,2353.73,Other,100% New York Medicaid APG,5295.9,,,5295.9,Other,225% New York Medicaid APG,3601.21,,,3601.21,Other,153% New York Medicaid APG,5295.9,,,5295.9,Other,225% New York Medicaid APG,3295.23,,,3295.23,Other,140% New York Medicaid APG,5295.9,,,5295.9,Other,225% New York Medicaid APG,6119.71,,,6119.71,Other,260% New York Medicaid APG,7626.1,,,7626.1,Other,324% New York Medicaid APG,5060.53,,,5060.53,Other,215% New York Medicaid APG,5060.53,,,5060.53,Other,215% New York Medicaid APG,2942.17,,,2942.17,Other,125% New York Medicaid APG,2353.73,80538.62,
Reconstruct urethra stage 2,53425,CPT,,,,,,,,both,,,108835.97,80538.62,74,,80538.62,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,48976.19,45,,48976.19,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,53873.81,49.5,,53873.81,percent of total billed charges,110% of Medicare,74008.46,68,,74008.46,percent of total billed charges,,4377.94,,,4377.94,Other,186% of Medicaid,87068.78,80,,87068.78,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,87068.78,80,,87068.78,percent of total billed charges,,7216,,,7216,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,76185.18,70,,76185.18,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,2353.73,,,2353.73,Other,New York Medicaid APG methodology,2353.73,,,2353.73,Other,100% New York Medicaid APG,2353.73,,,2353.73,Other,100% New York Medicaid APG,2353.73,,,2353.73,Other,100% New York Medicaid APG,5295.9,,,5295.9,Other,225% New York Medicaid APG,3601.21,,,3601.21,Other,153% New York Medicaid APG,5295.9,,,5295.9,Other,225% New York Medicaid APG,3295.23,,,3295.23,Other,140% New York Medicaid APG,5295.9,,,5295.9,Other,225% New York Medicaid APG,6119.71,,,6119.71,Other,260% New York Medicaid APG,7626.1,,,7626.1,Other,324% New York Medicaid APG,5060.53,,,5060.53,Other,215% New York Medicaid APG,5060.53,,,5060.53,Other,215% New York Medicaid APG,2942.17,,,2942.17,Other,125% New York Medicaid APG,2232,87068.78,
Reconstruction of urethra,53430,CPT,,,,,,,,both,,,44694.44,33073.89,74,,33073.89,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,20112.5,45,,20112.5,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,22123.75,49.5,,22123.75,percent of total billed charges,110% of Medicare,30392.22,68,,30392.22,percent of total billed charges,,4377.94,,,4377.94,Other,186% of Medicaid,35755.55,80,,35755.55,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,35755.55,80,,35755.55,percent of total billed charges,,7216,,,7216,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,31286.11,70,,31286.11,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,2353.73,,,2353.73,Other,New York Medicaid APG methodology,2353.73,,,2353.73,Other,100% New York Medicaid APG,2353.73,,,2353.73,Other,100% New York Medicaid APG,2353.73,,,2353.73,Other,100% New York Medicaid APG,5295.9,,,5295.9,Other,225% New York Medicaid APG,3601.21,,,3601.21,Other,153% New York Medicaid APG,5295.9,,,5295.9,Other,225% New York Medicaid APG,3295.23,,,3295.23,Other,140% New York Medicaid APG,5295.9,,,5295.9,Other,225% New York Medicaid APG,6119.71,,,6119.71,Other,260% New York Medicaid APG,7626.1,,,7626.1,Other,324% New York Medicaid APG,5060.53,,,5060.53,Other,215% New York Medicaid APG,5060.53,,,5060.53,Other,215% New York Medicaid APG,2942.17,,,2942.17,Other,125% New York Medicaid APG,2232,35755.55,
Reconstruct urethra/bladder,53431,CPT,,,,,,,,both,,,108835.97,80538.62,74,,80538.62,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,48976.19,45,,48976.19,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,53873.81,49.5,,53873.81,percent of total billed charges,110% of Medicare,74008.46,68,,74008.46,percent of total billed charges,,4377.94,,,4377.94,Other,186% of Medicaid,87068.78,80,,87068.78,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,87068.78,80,,87068.78,percent of total billed charges,,7216,,,7216,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,76185.18,70,,76185.18,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,2353.73,,,2353.73,Other,New York Medicaid APG methodology,2353.73,,,2353.73,Other,100% New York Medicaid APG,2353.73,,,2353.73,Other,100% New York Medicaid APG,2353.73,,,2353.73,Other,100% New York Medicaid APG,5295.9,,,5295.9,Other,225% New York Medicaid APG,3601.21,,,3601.21,Other,153% New York Medicaid APG,5295.9,,,5295.9,Other,225% New York Medicaid APG,3295.23,,,3295.23,Other,140% New York Medicaid APG,5295.9,,,5295.9,Other,225% New York Medicaid APG,6119.71,,,6119.71,Other,260% New York Medicaid APG,7626.1,,,7626.1,Other,324% New York Medicaid APG,5060.53,,,5060.53,Other,215% New York Medicaid APG,5060.53,,,5060.53,Other,215% New York Medicaid APG,2942.17,,,2942.17,Other,125% New York Medicaid APG,2232,87068.78,
Male sling procedure,53440,CPT,,,,,,,,both,,,79572.43,58883.6,74,,58883.6,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,35807.59,45,,35807.59,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,39388.35,49.5,,39388.35,percent of total billed charges,110% of Medicare,54109.25,68,,54109.25,percent of total billed charges,,4377.94,,,4377.94,Other,186% of Medicaid,63657.94,80,,63657.94,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,63657.94,80,,63657.94,percent of total billed charges,,7216,,,7216,Case Rate,,9196,,"100% primary, 0% secondary procedures",9196,Other,MagnaCare ASC Grouper,55700.7,70,,55700.7,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6956,,"100% primary, 50% secondary, 25% tertiary procedure",6956,Other,United Healthcare ASC Grouper,6261,,"100% primary, 50% secondary, 25% tertiary procedure",6261,Other,United Healthcare ASC Grouper,6956,,"100% primary, 50% secondary, 25% tertiary procedure",6956,Other,United Healthcare ASC Grouper,5913,,"100% primary, 50% secondary, 25% tertiary procedure",5913,Other,United Healthcare ASC Grouper,2353.73,,,2353.73,Other,New York Medicaid APG methodology,2353.73,,,2353.73,Other,100% New York Medicaid APG,2353.73,,,2353.73,Other,100% New York Medicaid APG,2353.73,,,2353.73,Other,100% New York Medicaid APG,5295.9,,,5295.9,Other,225% New York Medicaid APG,3601.21,,,3601.21,Other,153% New York Medicaid APG,5295.9,,,5295.9,Other,225% New York Medicaid APG,3295.23,,,3295.23,Other,140% New York Medicaid APG,5295.9,,,5295.9,Other,225% New York Medicaid APG,6119.71,,,6119.71,Other,260% New York Medicaid APG,7626.1,,,7626.1,Other,324% New York Medicaid APG,5060.53,,,5060.53,Other,215% New York Medicaid APG,5060.53,,,5060.53,Other,215% New York Medicaid APG,2942.17,,,2942.17,Other,125% New York Medicaid APG,2232,63657.94,
Remove/revise male sling,53442,CPT,,,,,,,,both,,,108835.97,80538.62,74,,80538.62,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,48976.19,45,,48976.19,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,53873.81,49.5,,53873.81,percent of total billed charges,110% of Medicare,74008.46,68,,74008.46,percent of total billed charges,,4377.94,,,4377.94,Other,186% of Medicaid,87068.78,80,,87068.78,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,87068.78,80,,87068.78,percent of total billed charges,,7216,,,7216,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,76185.18,70,,76185.18,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,2353.73,,,2353.73,Other,New York Medicaid APG methodology,2353.73,,,2353.73,Other,100% New York Medicaid APG,2353.73,,,2353.73,Other,100% New York Medicaid APG,2353.73,,,2353.73,Other,100% New York Medicaid APG,5295.9,,,5295.9,Other,225% New York Medicaid APG,3601.21,,,3601.21,Other,153% New York Medicaid APG,5295.9,,,5295.9,Other,225% New York Medicaid APG,3295.23,,,3295.23,Other,140% New York Medicaid APG,5295.9,,,5295.9,Other,225% New York Medicaid APG,6119.71,,,6119.71,Other,260% New York Medicaid APG,7626.1,,,7626.1,Other,324% New York Medicaid APG,5060.53,,,5060.53,Other,215% New York Medicaid APG,5060.53,,,5060.53,Other,215% New York Medicaid APG,2942.17,,,2942.17,Other,125% New York Medicaid APG,2053,87068.78,
Insert tandem cuff,53444,CPT,,,,,,,,both,,,424287.84,313973,74,,313973,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,190929.53,45,,190929.53,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,210022.48,49.5,,210022.48,percent of total billed charges,110% of Medicare,288515.73,68,,288515.73,percent of total billed charges,,4377.94,,,4377.94,Other,186% of Medicaid,339430.27,80,,339430.27,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,339430.27,80,,339430.27,percent of total billed charges,,7216,,,7216,Case Rate,,9196,,"100% primary, 0% secondary procedures",9196,Other,MagnaCare ASC Grouper,297001.49,70,,297001.49,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6956,,"100% primary, 50% secondary, 25% tertiary procedure",6956,Other,United Healthcare ASC Grouper,6261,,"100% primary, 50% secondary, 25% tertiary procedure",6261,Other,United Healthcare ASC Grouper,6956,,"100% primary, 50% secondary, 25% tertiary procedure",6956,Other,United Healthcare ASC Grouper,5913,,"100% primary, 50% secondary, 25% tertiary procedure",5913,Other,United Healthcare ASC Grouper,2353.73,,,2353.73,Other,New York Medicaid APG methodology,2353.73,,,2353.73,Other,100% New York Medicaid APG,2353.73,,,2353.73,Other,100% New York Medicaid APG,2353.73,,,2353.73,Other,100% New York Medicaid APG,5295.9,,,5295.9,Other,225% New York Medicaid APG,3601.21,,,3601.21,Other,153% New York Medicaid APG,5295.9,,,5295.9,Other,225% New York Medicaid APG,3295.23,,,3295.23,Other,140% New York Medicaid APG,5295.9,,,5295.9,Other,225% New York Medicaid APG,6119.71,,,6119.71,Other,260% New York Medicaid APG,7626.1,,,7626.1,Other,324% New York Medicaid APG,5060.53,,,5060.53,Other,215% New York Medicaid APG,5060.53,,,5060.53,Other,215% New York Medicaid APG,2942.17,,,2942.17,Other,125% New York Medicaid APG,2232,339430.27,
Insert uro/ves nck sphincter,53445,CPT,,,,,,,,both,,,110991.64,82133.81,74,,82133.81,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,49946.24,45,,49946.24,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,54940.86,49.5,,54940.86,percent of total billed charges,110% of Medicare,75474.32,68,,75474.32,percent of total billed charges,,3412.13,,,3412.13,Other,186% of Medicaid,88793.31,80,,88793.31,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,88793.31,80,,88793.31,percent of total billed charges,,7216,,,7216,Case Rate,,9196,,"100% primary, 0% secondary procedures",9196,Other,MagnaCare ASC Grouper,77694.15,70,,77694.15,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,7364,,"100% primary, 50% secondary, 25% tertiary procedure",7364,Other,United Healthcare ASC Grouper,6628,,"100% primary, 50% secondary, 25% tertiary procedure",6628,Other,United Healthcare ASC Grouper,7364,,"100% primary, 50% secondary, 25% tertiary procedure",7364,Other,United Healthcare ASC Grouper,6260,,"100% primary, 50% secondary, 25% tertiary procedure",6260,Other,United Healthcare ASC Grouper,1834.48,,,1834.48,Other,New York Medicaid APG methodology,1834.48,,,1834.48,Other,100% New York Medicaid APG,1834.48,,,1834.48,Other,100% New York Medicaid APG,1834.48,,,1834.48,Other,100% New York Medicaid APG,4127.58,,,4127.58,Other,225% New York Medicaid APG,2806.75,,,2806.75,Other,153% New York Medicaid APG,4127.58,,,4127.58,Other,225% New York Medicaid APG,2568.27,,,2568.27,Other,140% New York Medicaid APG,4127.58,,,4127.58,Other,225% New York Medicaid APG,4769.65,,,4769.65,Other,260% New York Medicaid APG,5943.71,,,5943.71,Other,324% New York Medicaid APG,3944.13,,,3944.13,Other,215% New York Medicaid APG,3944.13,,,3944.13,Other,215% New York Medicaid APG,2293.1,,,2293.1,Other,125% New York Medicaid APG,1834.48,88793.31,
Remove uro sphincter,53446,CPT,,,,,,,,both,,,108835.97,80538.62,74,,80538.62,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,48976.19,45,,48976.19,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,53873.81,49.5,,53873.81,percent of total billed charges,110% of Medicare,74008.46,68,,74008.46,percent of total billed charges,,4377.94,,,4377.94,Other,186% of Medicaid,87068.78,80,,87068.78,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,87068.78,80,,87068.78,percent of total billed charges,,7216,,,7216,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,76185.18,70,,76185.18,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,2353.73,,,2353.73,Other,New York Medicaid APG methodology,2353.73,,,2353.73,Other,100% New York Medicaid APG,2353.73,,,2353.73,Other,100% New York Medicaid APG,2353.73,,,2353.73,Other,100% New York Medicaid APG,5295.9,,,5295.9,Other,225% New York Medicaid APG,3601.21,,,3601.21,Other,153% New York Medicaid APG,5295.9,,,5295.9,Other,225% New York Medicaid APG,3295.23,,,3295.23,Other,140% New York Medicaid APG,5295.9,,,5295.9,Other,225% New York Medicaid APG,6119.71,,,6119.71,Other,260% New York Medicaid APG,7626.1,,,7626.1,Other,324% New York Medicaid APG,5060.53,,,5060.53,Other,215% New York Medicaid APG,5060.53,,,5060.53,Other,215% New York Medicaid APG,2942.17,,,2942.17,Other,125% New York Medicaid APG,2053,87068.78,
Remove/replace ur sphincter,53447,CPT,,,,,,,,both,,,424287.84,313973,74,,313973,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,190929.53,45,,190929.53,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,210022.48,49.5,,210022.48,percent of total billed charges,110% of Medicare,288515.73,68,,288515.73,percent of total billed charges,,3412.13,,,3412.13,Other,186% of Medicaid,339430.27,80,,339430.27,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,339430.27,80,,339430.27,percent of total billed charges,,7216,,,7216,Case Rate,,9196,,"100% primary, 0% secondary procedures",9196,Other,MagnaCare ASC Grouper,297001.49,70,,297001.49,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,7364,,"100% primary, 50% secondary, 25% tertiary procedure",7364,Other,United Healthcare ASC Grouper,6628,,"100% primary, 50% secondary, 25% tertiary procedure",6628,Other,United Healthcare ASC Grouper,7364,,"100% primary, 50% secondary, 25% tertiary procedure",7364,Other,United Healthcare ASC Grouper,6260,,"100% primary, 50% secondary, 25% tertiary procedure",6260,Other,United Healthcare ASC Grouper,1834.48,,,1834.48,Other,New York Medicaid APG methodology,1834.48,,,1834.48,Other,100% New York Medicaid APG,1834.48,,,1834.48,Other,100% New York Medicaid APG,1834.48,,,1834.48,Other,100% New York Medicaid APG,4127.58,,,4127.58,Other,225% New York Medicaid APG,2806.75,,,2806.75,Other,153% New York Medicaid APG,4127.58,,,4127.58,Other,225% New York Medicaid APG,2568.27,,,2568.27,Other,140% New York Medicaid APG,4127.58,,,4127.58,Other,225% New York Medicaid APG,4769.65,,,4769.65,Other,260% New York Medicaid APG,5943.71,,,5943.71,Other,324% New York Medicaid APG,3944.13,,,3944.13,Other,215% New York Medicaid APG,3944.13,,,3944.13,Other,215% New York Medicaid APG,2293.1,,,2293.1,Other,125% New York Medicaid APG,1834.48,339430.27,
Repair uro sphincter,53449,CPT,,,,,,,,both,,,193769.26,143389.25,74,,143389.25,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,87196.17,45,,87196.17,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,95915.78,49.5,,95915.78,percent of total billed charges,110% of Medicare,131763.1,68,,131763.1,percent of total billed charges,,4377.94,,,4377.94,Other,186% of Medicaid,155015.41,80,,155015.41,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,155015.41,80,,155015.41,percent of total billed charges,,7216,,,7216,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,135638.48,70,,135638.48,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,2353.73,,,2353.73,Other,New York Medicaid APG methodology,2353.73,,,2353.73,Other,100% New York Medicaid APG,2353.73,,,2353.73,Other,100% New York Medicaid APG,2353.73,,,2353.73,Other,100% New York Medicaid APG,5295.9,,,5295.9,Other,225% New York Medicaid APG,3601.21,,,3601.21,Other,153% New York Medicaid APG,5295.9,,,5295.9,Other,225% New York Medicaid APG,3295.23,,,3295.23,Other,140% New York Medicaid APG,5295.9,,,5295.9,Other,225% New York Medicaid APG,6119.71,,,6119.71,Other,260% New York Medicaid APG,7626.1,,,7626.1,Other,324% New York Medicaid APG,5060.53,,,5060.53,Other,215% New York Medicaid APG,5060.53,,,5060.53,Other,215% New York Medicaid APG,2942.17,,,2942.17,Other,125% New York Medicaid APG,2053,155015.41,
Revision of urethra,53450,CPT,,,,,,,,both,,,34741.59,25708.78,74,,25708.78,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15633.72,45,,15633.72,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,17197.09,49.5,,17197.09,percent of total billed charges,110% of Medicare,23624.28,68,,23624.28,percent of total billed charges,,1857.5,,,1857.5,Other,186% of Medicaid,27793.27,80,,27793.27,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,27793.27,80,,27793.27,percent of total billed charges,,7216,,,7216,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,24319.11,70,,24319.11,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,998.66,,,998.66,Other,New York Medicaid APG methodology,998.66,,,998.66,Other,100% New York Medicaid APG,998.66,,,998.66,Other,100% New York Medicaid APG,998.66,,,998.66,Other,100% New York Medicaid APG,2246.97,,,2246.97,Other,225% New York Medicaid APG,1527.94,,,1527.94,Other,153% New York Medicaid APG,2246.97,,,2246.97,Other,225% New York Medicaid APG,1398.12,,,1398.12,Other,140% New York Medicaid APG,2246.97,,,2246.97,Other,225% New York Medicaid APG,2596.5,,,2596.5,Other,260% New York Medicaid APG,3235.64,,,3235.64,Other,324% New York Medicaid APG,2147.11,,,2147.11,Other,215% New York Medicaid APG,2147.11,,,2147.11,Other,215% New York Medicaid APG,1248.32,,,1248.32,Other,125% New York Medicaid APG,998.66,27793.27,
Revision of urethra,53460,CPT,,,,,,,,both,,,35421.42,26211.85,74,,26211.85,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15939.64,45,,15939.64,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,17533.6,49.5,,17533.6,percent of total billed charges,110% of Medicare,24086.57,68,,24086.57,percent of total billed charges,,1857.5,,,1857.5,Other,186% of Medicaid,28337.14,80,,28337.14,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,28337.14,80,,28337.14,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,24794.99,70,,24794.99,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,998.66,,,998.66,Other,New York Medicaid APG methodology,998.66,,,998.66,Other,100% New York Medicaid APG,998.66,,,998.66,Other,100% New York Medicaid APG,998.66,,,998.66,Other,100% New York Medicaid APG,2246.97,,,2246.97,Other,225% New York Medicaid APG,1527.94,,,1527.94,Other,153% New York Medicaid APG,2246.97,,,2246.97,Other,225% New York Medicaid APG,1398.12,,,1398.12,Other,140% New York Medicaid APG,2246.97,,,2246.97,Other,225% New York Medicaid APG,2596.5,,,2596.5,Other,260% New York Medicaid APG,3235.64,,,3235.64,Other,324% New York Medicaid APG,2147.11,,,2147.11,Other,215% New York Medicaid APG,2147.11,,,2147.11,Other,215% New York Medicaid APG,1248.32,,,1248.32,Other,125% New York Medicaid APG,998.66,28337.14,
Urethrlys transvag w/ scope,53500,CPT,,,,,,,,both,,,38827.66,28732.47,74,,28732.47,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,17472.45,45,,17472.45,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,19219.69,49.5,,19219.69,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,1857.5,,,1857.5,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,27179.36,70,,27179.36,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,998.66,,,998.66,Other,New York Medicaid APG methodology,998.66,,,998.66,Other,100% New York Medicaid APG,998.66,,,998.66,Other,100% New York Medicaid APG,998.66,,,998.66,Other,100% New York Medicaid APG,2246.97,,,2246.97,Other,225% New York Medicaid APG,1527.94,,,1527.94,Other,153% New York Medicaid APG,2246.97,,,2246.97,Other,225% New York Medicaid APG,1398.12,,,1398.12,Other,140% New York Medicaid APG,2246.97,,,2246.97,Other,225% New York Medicaid APG,2596.5,,,2596.5,Other,260% New York Medicaid APG,3235.64,,,3235.64,Other,324% New York Medicaid APG,2147.11,,,2147.11,Other,215% New York Medicaid APG,2147.11,,,2147.11,Other,215% New York Medicaid APG,1248.32,,,1248.32,Other,125% New York Medicaid APG,998.66,28732.47,
Repair of urethra injury,53502,CPT,,,,,,,,both,,,73326.88,54261.89,74,,54261.89,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,32997.1,45,,32997.1,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,36296.81,49.5,,36296.81,percent of total billed charges,110% of Medicare,49862.28,68,,49862.28,percent of total billed charges,,1857.5,,,1857.5,Other,186% of Medicaid,58661.5,80,,58661.5,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,58661.5,80,,58661.5,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,51328.82,70,,51328.82,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,998.66,,,998.66,Other,New York Medicaid APG methodology,998.66,,,998.66,Other,100% New York Medicaid APG,998.66,,,998.66,Other,100% New York Medicaid APG,998.66,,,998.66,Other,100% New York Medicaid APG,2246.97,,,2246.97,Other,225% New York Medicaid APG,1527.94,,,1527.94,Other,153% New York Medicaid APG,2246.97,,,2246.97,Other,225% New York Medicaid APG,1398.12,,,1398.12,Other,140% New York Medicaid APG,2246.97,,,2246.97,Other,225% New York Medicaid APG,2596.5,,,2596.5,Other,260% New York Medicaid APG,3235.64,,,3235.64,Other,324% New York Medicaid APG,2147.11,,,2147.11,Other,215% New York Medicaid APG,2147.11,,,2147.11,Other,215% New York Medicaid APG,1248.32,,,1248.32,Other,125% New York Medicaid APG,998.66,58661.5,
Repair of urethra injury,53505,CPT,,,,,,,,both,,,108835.97,80538.62,74,,80538.62,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,48976.19,45,,48976.19,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,53873.81,49.5,,53873.81,percent of total billed charges,110% of Medicare,74008.46,68,,74008.46,percent of total billed charges,,1857.5,,,1857.5,Other,186% of Medicaid,87068.78,80,,87068.78,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,87068.78,80,,87068.78,percent of total billed charges,,7216,,,7216,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,76185.18,70,,76185.18,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,998.66,,,998.66,Other,New York Medicaid APG methodology,998.66,,,998.66,Other,100% New York Medicaid APG,998.66,,,998.66,Other,100% New York Medicaid APG,998.66,,,998.66,Other,100% New York Medicaid APG,2246.97,,,2246.97,Other,225% New York Medicaid APG,1527.94,,,1527.94,Other,153% New York Medicaid APG,2246.97,,,2246.97,Other,225% New York Medicaid APG,1398.12,,,1398.12,Other,140% New York Medicaid APG,2246.97,,,2246.97,Other,225% New York Medicaid APG,2596.5,,,2596.5,Other,260% New York Medicaid APG,3235.64,,,3235.64,Other,324% New York Medicaid APG,2147.11,,,2147.11,Other,215% New York Medicaid APG,2147.11,,,2147.11,Other,215% New York Medicaid APG,1248.32,,,1248.32,Other,125% New York Medicaid APG,998.66,87068.78,
Repair of urethra injury,53510,CPT,,,,,,,,both,,,108835.97,80538.62,74,,80538.62,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,48976.19,45,,48976.19,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,53873.81,49.5,,53873.81,percent of total billed charges,110% of Medicare,74008.46,68,,74008.46,percent of total billed charges,,4377.94,,,4377.94,Other,186% of Medicaid,87068.78,80,,87068.78,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,87068.78,80,,87068.78,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,76185.18,70,,76185.18,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,2353.73,,,2353.73,Other,New York Medicaid APG methodology,2353.73,,,2353.73,Other,100% New York Medicaid APG,2353.73,,,2353.73,Other,100% New York Medicaid APG,2353.73,,,2353.73,Other,100% New York Medicaid APG,5295.9,,,5295.9,Other,225% New York Medicaid APG,3601.21,,,3601.21,Other,153% New York Medicaid APG,5295.9,,,5295.9,Other,225% New York Medicaid APG,3295.23,,,3295.23,Other,140% New York Medicaid APG,5295.9,,,5295.9,Other,225% New York Medicaid APG,6119.71,,,6119.71,Other,260% New York Medicaid APG,7626.1,,,7626.1,Other,324% New York Medicaid APG,5060.53,,,5060.53,Other,215% New York Medicaid APG,5060.53,,,5060.53,Other,215% New York Medicaid APG,2942.17,,,2942.17,Other,125% New York Medicaid APG,2232,87068.78,
Repair of urethra injury,53515,CPT,,,,,,,,both,,,108835.97,80538.62,74,,80538.62,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,48976.19,45,,48976.19,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,53873.81,49.5,,53873.81,percent of total billed charges,110% of Medicare,74008.46,68,,74008.46,percent of total billed charges,,4377.94,,,4377.94,Other,186% of Medicaid,87068.78,80,,87068.78,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,87068.78,80,,87068.78,percent of total billed charges,,7216,,,7216,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,76185.18,70,,76185.18,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,2353.73,,,2353.73,Other,New York Medicaid APG methodology,2353.73,,,2353.73,Other,100% New York Medicaid APG,2353.73,,,2353.73,Other,100% New York Medicaid APG,2353.73,,,2353.73,Other,100% New York Medicaid APG,5295.9,,,5295.9,Other,225% New York Medicaid APG,3601.21,,,3601.21,Other,153% New York Medicaid APG,5295.9,,,5295.9,Other,225% New York Medicaid APG,3295.23,,,3295.23,Other,140% New York Medicaid APG,5295.9,,,5295.9,Other,225% New York Medicaid APG,6119.71,,,6119.71,Other,260% New York Medicaid APG,7626.1,,,7626.1,Other,324% New York Medicaid APG,5060.53,,,5060.53,Other,215% New York Medicaid APG,5060.53,,,5060.53,Other,215% New York Medicaid APG,2942.17,,,2942.17,Other,125% New York Medicaid APG,2232,87068.78,
Repair of urethra defect,53520,CPT,,,,,,,,both,,,108835.97,80538.62,74,,80538.62,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,48976.19,45,,48976.19,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,53873.81,49.5,,53873.81,percent of total billed charges,110% of Medicare,74008.46,68,,74008.46,percent of total billed charges,,4377.94,,,4377.94,Other,186% of Medicaid,87068.78,80,,87068.78,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,87068.78,80,,87068.78,percent of total billed charges,,7216,,,7216,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,76185.18,70,,76185.18,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,2353.73,,,2353.73,Other,New York Medicaid APG methodology,2353.73,,,2353.73,Other,100% New York Medicaid APG,2353.73,,,2353.73,Other,100% New York Medicaid APG,2353.73,,,2353.73,Other,100% New York Medicaid APG,5295.9,,,5295.9,Other,225% New York Medicaid APG,3601.21,,,3601.21,Other,153% New York Medicaid APG,5295.9,,,5295.9,Other,225% New York Medicaid APG,3295.23,,,3295.23,Other,140% New York Medicaid APG,5295.9,,,5295.9,Other,225% New York Medicaid APG,6119.71,,,6119.71,Other,260% New York Medicaid APG,7626.1,,,7626.1,Other,324% New York Medicaid APG,5060.53,,,5060.53,Other,215% New York Medicaid APG,5060.53,,,5060.53,Other,215% New York Medicaid APG,2942.17,,,2942.17,Other,125% New York Medicaid APG,2232,87068.78,
Dilate urethra stricture,53600,CPT,,,,,,,,both,,,5198.43,3846.84,74,,3846.84,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,2339.29,45,,2339.29,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,2573.22,49.5,,2573.22,percent of total billed charges,110% of Medicare,3534.93,68,,3534.93,percent of total billed charges,,847.8,,,847.8,Other,186% of Medicaid,4158.74,80,,4158.74,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,4158.74,80,,4158.74,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,3638.9,70,,3638.9,percent of total billed charges,,309.96,,,309.96,Fee Schedule,,262.71,,,262.71,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,455.81,,,455.81,Other,New York Medicaid APG methodology,455.81,,,455.81,Other,100% New York Medicaid APG,455.81,,,455.81,Other,100% New York Medicaid APG,455.81,,,455.81,Other,100% New York Medicaid APG,1025.56,,,1025.56,Other,225% New York Medicaid APG,697.38,,,697.38,Other,153% New York Medicaid APG,1025.56,,,1025.56,Other,225% New York Medicaid APG,638.13,,,638.13,Other,140% New York Medicaid APG,1025.56,,,1025.56,Other,225% New York Medicaid APG,1185.1,,,1185.1,Other,260% New York Medicaid APG,1476.81,,,1476.81,Other,324% New York Medicaid APG,979.98,,,979.98,Other,215% New York Medicaid APG,979.98,,,979.98,Other,215% New York Medicaid APG,569.76,,,569.76,Other,125% New York Medicaid APG,262.71,7216,
Dilate urethra stricture,53601,CPT,,,,,,,,both,,,2686.86,1988.28,74,,1988.28,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,1209.09,45,,1209.09,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,1330,49.5,,1330,percent of total billed charges,110% of Medicare,1827.06,68,,1827.06,percent of total billed charges,,847.8,,,847.8,Other,186% of Medicaid,2149.49,80,,2149.49,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,2149.49,80,,2149.49,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,1880.8,70,,1880.8,percent of total billed charges,,257.48,,,257.48,Fee Schedule,,218.23,,,218.23,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,455.81,,,455.81,Other,New York Medicaid APG methodology,455.81,,,455.81,Other,100% New York Medicaid APG,455.81,,,455.81,Other,100% New York Medicaid APG,455.81,,,455.81,Other,100% New York Medicaid APG,1025.56,,,1025.56,Other,225% New York Medicaid APG,697.38,,,697.38,Other,153% New York Medicaid APG,1025.56,,,1025.56,Other,225% New York Medicaid APG,638.13,,,638.13,Other,140% New York Medicaid APG,1025.56,,,1025.56,Other,225% New York Medicaid APG,1185.1,,,1185.1,Other,260% New York Medicaid APG,1476.81,,,1476.81,Other,324% New York Medicaid APG,979.98,,,979.98,Other,215% New York Medicaid APG,979.98,,,979.98,Other,215% New York Medicaid APG,569.76,,,569.76,Other,125% New York Medicaid APG,218.23,7216,
Dilate urethra stricture,53605,CPT,,,,,,,,both,,,73326.88,54261.89,74,,54261.89,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,32997.1,45,,32997.1,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,36296.81,49.5,,36296.81,percent of total billed charges,110% of Medicare,49862.28,68,,49862.28,percent of total billed charges,,903.43,,,903.43,Other,186% of Medicaid,58661.5,80,,58661.5,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,58661.5,80,,58661.5,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,51328.82,70,,51328.82,percent of total billed charges,,309.96,,,309.96,Fee Schedule,,262.71,,,262.71,Fee Schedule,,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,485.72,,,485.72,Other,New York Medicaid APG methodology,485.72,,,485.72,Other,100% New York Medicaid APG,485.72,,,485.72,Other,100% New York Medicaid APG,485.72,,,485.72,Other,100% New York Medicaid APG,1092.86,,,1092.86,Other,225% New York Medicaid APG,743.14,,,743.14,Other,153% New York Medicaid APG,1092.86,,,1092.86,Other,225% New York Medicaid APG,680,,,680,Other,140% New York Medicaid APG,1092.86,,,1092.86,Other,225% New York Medicaid APG,1262.86,,,1262.86,Other,260% New York Medicaid APG,1573.72,,,1573.72,Other,324% New York Medicaid APG,1044.29,,,1044.29,Other,215% New York Medicaid APG,1044.29,,,1044.29,Other,215% New York Medicaid APG,607.14,,,607.14,Other,125% New York Medicaid APG,262.71,58661.5,
Dilate urethra stricture,53620,CPT,,,,,,,,both,,,14368.32,10632.56,74,,10632.56,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,6465.74,45,,6465.74,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,7112.32,49.5,,7112.32,percent of total billed charges,110% of Medicare,9770.46,68,,9770.46,percent of total billed charges,,903.43,,,903.43,Other,186% of Medicaid,11494.66,80,,11494.66,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,11494.66,80,,11494.66,percent of total billed charges,,7216,,,7216,Case Rate,,3578,,"100% primary, 0% secondary procedures",3578,Other,MagnaCare ASC Grouper,10057.82,70,,10057.82,percent of total billed charges,,418.2,,,418.2,Fee Schedule,,354.45,,,354.45,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,485.72,,,485.72,Other,New York Medicaid APG methodology,485.72,,,485.72,Other,100% New York Medicaid APG,485.72,,,485.72,Other,100% New York Medicaid APG,485.72,,,485.72,Other,100% New York Medicaid APG,1092.86,,,1092.86,Other,225% New York Medicaid APG,743.14,,,743.14,Other,153% New York Medicaid APG,1092.86,,,1092.86,Other,225% New York Medicaid APG,680,,,680,Other,140% New York Medicaid APG,1092.86,,,1092.86,Other,225% New York Medicaid APG,1262.86,,,1262.86,Other,260% New York Medicaid APG,1573.72,,,1573.72,Other,324% New York Medicaid APG,1044.29,,,1044.29,Other,215% New York Medicaid APG,1044.29,,,1044.29,Other,215% New York Medicaid APG,607.14,,,607.14,Other,125% New York Medicaid APG,354.45,11494.66,
Dilate urethra stricture,53621,CPT,,,,,,,,both,,,5198.43,3846.84,74,,3846.84,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,2339.29,45,,2339.29,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,2573.22,49.5,,2573.22,percent of total billed charges,110% of Medicare,3534.93,68,,3534.93,percent of total billed charges,,903.43,,,903.43,Other,186% of Medicaid,4158.74,80,,4158.74,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,4158.74,80,,4158.74,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,3638.9,70,,3638.9,percent of total billed charges,,347.68,,,347.68,Fee Schedule,,294.68,,,294.68,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,485.72,,,485.72,Other,New York Medicaid APG methodology,485.72,,,485.72,Other,100% New York Medicaid APG,485.72,,,485.72,Other,100% New York Medicaid APG,485.72,,,485.72,Other,100% New York Medicaid APG,1092.86,,,1092.86,Other,225% New York Medicaid APG,743.14,,,743.14,Other,153% New York Medicaid APG,1092.86,,,1092.86,Other,225% New York Medicaid APG,680,,,680,Other,140% New York Medicaid APG,1092.86,,,1092.86,Other,225% New York Medicaid APG,1262.86,,,1262.86,Other,260% New York Medicaid APG,1573.72,,,1573.72,Other,324% New York Medicaid APG,1044.29,,,1044.29,Other,215% New York Medicaid APG,1044.29,,,1044.29,Other,215% New York Medicaid APG,607.14,,,607.14,Other,125% New York Medicaid APG,294.68,7216,
Dilation of urethra,53660,CPT,,,,,,,,both,,,3285.56,2431.31,74,,2431.31,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,1478.5,45,,1478.5,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,1626.35,49.5,,1626.35,percent of total billed charges,110% of Medicare,2234.18,68,,2234.18,percent of total billed charges,,847.8,,,847.8,Other,186% of Medicaid,2628.45,80,,2628.45,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,2628.45,80,,2628.45,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,2299.89,70,,2299.89,percent of total billed charges,,201.72,,,201.72,Fee Schedule,,170.97,,,170.97,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,455.81,,,455.81,Other,New York Medicaid APG methodology,455.81,,,455.81,Other,100% New York Medicaid APG,455.81,,,455.81,Other,100% New York Medicaid APG,455.81,,,455.81,Other,100% New York Medicaid APG,1025.56,,,1025.56,Other,225% New York Medicaid APG,697.38,,,697.38,Other,153% New York Medicaid APG,1025.56,,,1025.56,Other,225% New York Medicaid APG,638.13,,,638.13,Other,140% New York Medicaid APG,1025.56,,,1025.56,Other,225% New York Medicaid APG,1185.1,,,1185.1,Other,260% New York Medicaid APG,1476.81,,,1476.81,Other,324% New York Medicaid APG,979.98,,,979.98,Other,215% New York Medicaid APG,979.98,,,979.98,Other,215% New York Medicaid APG,569.76,,,569.76,Other,125% New York Medicaid APG,170.97,7216,
Dilation of urethra,53661,CPT,,,,,,,,both,,,2686.86,1988.28,74,,1988.28,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,1209.09,45,,1209.09,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,1330,49.5,,1330,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,847.8,,,847.8,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,1880.8,70,,1880.8,percent of total billed charges,,196.8,,,196.8,Fee Schedule,,166.8,,,166.8,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,455.81,,,455.81,Other,New York Medicaid APG methodology,455.81,,,455.81,Other,100% New York Medicaid APG,455.81,,,455.81,Other,100% New York Medicaid APG,455.81,,,455.81,Other,100% New York Medicaid APG,1025.56,,,1025.56,Other,225% New York Medicaid APG,697.38,,,697.38,Other,153% New York Medicaid APG,1025.56,,,1025.56,Other,225% New York Medicaid APG,638.13,,,638.13,Other,140% New York Medicaid APG,1025.56,,,1025.56,Other,225% New York Medicaid APG,1185.1,,,1185.1,Other,260% New York Medicaid APG,1476.81,,,1476.81,Other,324% New York Medicaid APG,979.98,,,979.98,Other,215% New York Medicaid APG,979.98,,,979.98,Other,215% New York Medicaid APG,569.76,,,569.76,Other,125% New York Medicaid APG,166.8,9473,
Dilation of urethra,53665,CPT,,,,,,,,both,,,42841.82,31702.95,74,,31702.95,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,19278.82,45,,19278.82,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,21206.7,49.5,,21206.7,percent of total billed charges,110% of Medicare,29132.44,68,,29132.44,percent of total billed charges,,903.43,,,903.43,Other,186% of Medicaid,34273.46,80,,34273.46,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,34273.46,80,,34273.46,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,29989.27,70,,29989.27,percent of total billed charges,,183.68,,,183.68,Fee Schedule,,155.68,,,155.68,Fee Schedule,,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,485.72,,,485.72,Other,New York Medicaid APG methodology,485.72,,,485.72,Other,100% New York Medicaid APG,485.72,,,485.72,Other,100% New York Medicaid APG,485.72,,,485.72,Other,100% New York Medicaid APG,1092.86,,,1092.86,Other,225% New York Medicaid APG,743.14,,,743.14,Other,153% New York Medicaid APG,1092.86,,,1092.86,Other,225% New York Medicaid APG,680,,,680,Other,140% New York Medicaid APG,1092.86,,,1092.86,Other,225% New York Medicaid APG,1262.86,,,1262.86,Other,260% New York Medicaid APG,1573.72,,,1573.72,Other,324% New York Medicaid APG,1044.29,,,1044.29,Other,215% New York Medicaid APG,1044.29,,,1044.29,Other,215% New York Medicaid APG,607.14,,,607.14,Other,125% New York Medicaid APG,155.68,34273.46,
Prostatic microwave thermotx,53850,CPT,,,,,,,,both,,,73326.88,54261.89,74,,54261.89,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,32997.1,45,,32997.1,percent of total billed charges,Medicare Ratio of cost to charges,7938,,"100% primary, 50% supplemental procedure",7938,Other,Aetna ASC Grouper,7144,,"100% primary, 50% supplemental procedure",7144,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,36296.81,49.5,,36296.81,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3486.98,,,3486.98,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,51328.82,70,,51328.82,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1874.72,,,1874.72,Other,New York Medicaid APG methodology,1874.72,,,1874.72,Other,100% New York Medicaid APG,1874.72,,,1874.72,Other,100% New York Medicaid APG,1874.72,,,1874.72,Other,100% New York Medicaid APG,4218.12,,,4218.12,Other,225% New York Medicaid APG,2868.32,,,2868.32,Other,153% New York Medicaid APG,4218.12,,,4218.12,Other,225% New York Medicaid APG,2624.61,,,2624.61,Other,140% New York Medicaid APG,4218.12,,,4218.12,Other,225% New York Medicaid APG,4874.27,,,4874.27,Other,260% New York Medicaid APG,6074.09,,,6074.09,Other,324% New York Medicaid APG,4030.65,,,4030.65,Other,215% New York Medicaid APG,4030.65,,,4030.65,Other,215% New York Medicaid APG,2343.4,,,2343.4,Other,125% New York Medicaid APG,1874.72,54261.89,
Prostatic rf thermotx,53852,CPT,,,,,,,,both,,,73326.88,54261.89,74,,54261.89,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,32997.1,45,,32997.1,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,36296.81,49.5,,36296.81,percent of total billed charges,110% of Medicare,49862.28,68,,49862.28,percent of total billed charges,,3486.98,,,3486.98,Other,186% of Medicaid,58661.5,80,,58661.5,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,58661.5,80,,58661.5,percent of total billed charges,,7216,,,7216,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,51328.82,70,,51328.82,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,1874.72,,,1874.72,Other,New York Medicaid APG methodology,1874.72,,,1874.72,Other,100% New York Medicaid APG,1874.72,,,1874.72,Other,100% New York Medicaid APG,1874.72,,,1874.72,Other,100% New York Medicaid APG,4218.12,,,4218.12,Other,225% New York Medicaid APG,2868.32,,,2868.32,Other,153% New York Medicaid APG,4218.12,,,4218.12,Other,225% New York Medicaid APG,2624.61,,,2624.61,Other,140% New York Medicaid APG,4218.12,,,4218.12,Other,225% New York Medicaid APG,4874.27,,,4874.27,Other,260% New York Medicaid APG,6074.09,,,6074.09,Other,324% New York Medicaid APG,4030.65,,,4030.65,Other,215% New York Medicaid APG,4030.65,,,4030.65,Other,215% New York Medicaid APG,2343.4,,,2343.4,Other,125% New York Medicaid APG,1874.72,58661.5,
Trurl dstrj prst8 tiss rf wv,53854,CPT,,,,,,,,both,,,36141.18,26744.47,74,,26744.47,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,16263.53,45,,16263.53,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,17889.88,49.5,,17889.88,percent of total billed charges,110% of Medicare,24576,68,,24576,percent of total billed charges,,3486.98,,,3486.98,Other,186% of Medicaid,28912.94,80,,28912.94,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,28912.94,80,,28912.94,percent of total billed charges,,7216,,,7216,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,25298.83,70,,25298.83,percent of total billed charges,,1849.92,,,1849.92,Fee Schedule,,1567.92,,,1567.92,Fee Schedule,,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1874.72,,,1874.72,Other,New York Medicaid APG methodology,1874.72,,,1874.72,Other,100% New York Medicaid APG,1874.72,,,1874.72,Other,100% New York Medicaid APG,1874.72,,,1874.72,Other,100% New York Medicaid APG,4218.12,,,4218.12,Other,225% New York Medicaid APG,2868.32,,,2868.32,Other,153% New York Medicaid APG,4218.12,,,4218.12,Other,225% New York Medicaid APG,2624.61,,,2624.61,Other,140% New York Medicaid APG,4218.12,,,4218.12,Other,225% New York Medicaid APG,4874.27,,,4874.27,Other,260% New York Medicaid APG,6074.09,,,6074.09,Other,324% New York Medicaid APG,4030.65,,,4030.65,Other,215% New York Medicaid APG,4030.65,,,4030.65,Other,215% New York Medicaid APG,2343.4,,,2343.4,Other,125% New York Medicaid APG,1567.92,28912.94,
Insert prost urethral stent,53855,CPT,,,,,,,,both,,,42841.82,31702.95,74,,31702.95,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,19278.82,45,,19278.82,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,21206.7,49.5,,21206.7,percent of total billed charges,110% of Medicare,29132.44,68,,29132.44,percent of total billed charges,,1857.5,,,1857.5,Other,186% of Medicaid,34273.46,80,,34273.46,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,34273.46,80,,34273.46,percent of total billed charges,,7216,,,7216,Case Rate,,3578,,"100% primary, 0% secondary procedures",3578,Other,MagnaCare ASC Grouper,29989.27,70,,29989.27,percent of total billed charges,,393.6,,,393.6,Fee Schedule,,333.6,,,333.6,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,998.66,,,998.66,Other,New York Medicaid APG methodology,998.66,,,998.66,Other,100% New York Medicaid APG,998.66,,,998.66,Other,100% New York Medicaid APG,998.66,,,998.66,Other,100% New York Medicaid APG,2246.97,,,2246.97,Other,225% New York Medicaid APG,1527.94,,,1527.94,Other,153% New York Medicaid APG,2246.97,,,2246.97,Other,225% New York Medicaid APG,1398.12,,,1398.12,Other,140% New York Medicaid APG,2246.97,,,2246.97,Other,225% New York Medicaid APG,2596.5,,,2596.5,Other,260% New York Medicaid APG,3235.64,,,3235.64,Other,324% New York Medicaid APG,2147.11,,,2147.11,Other,215% New York Medicaid APG,2147.11,,,2147.11,Other,215% New York Medicaid APG,1248.32,,,1248.32,Other,125% New York Medicaid APG,333.6,34273.46,
Transurethral rf treatment,53860,CPT,,,,,,,,both,,,42841.82,31702.95,74,,31702.95,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,19278.82,45,,19278.82,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,21206.7,49.5,,21206.7,percent of total billed charges,110% of Medicare,29132.44,68,,29132.44,percent of total billed charges,,1857.5,,,1857.5,Other,186% of Medicaid,34273.46,80,,34273.46,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,34273.46,80,,34273.46,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,29989.27,70,,29989.27,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,998.66,,,998.66,Other,New York Medicaid APG methodology,998.66,,,998.66,Other,100% New York Medicaid APG,998.66,,,998.66,Other,100% New York Medicaid APG,998.66,,,998.66,Other,100% New York Medicaid APG,2246.97,,,2246.97,Other,225% New York Medicaid APG,1527.94,,,1527.94,Other,153% New York Medicaid APG,2246.97,,,2246.97,Other,225% New York Medicaid APG,1398.12,,,1398.12,Other,140% New York Medicaid APG,2246.97,,,2246.97,Other,225% New York Medicaid APG,2596.5,,,2596.5,Other,260% New York Medicaid APG,3235.64,,,3235.64,Other,324% New York Medicaid APG,2147.11,,,2147.11,Other,215% New York Medicaid APG,2147.11,,,2147.11,Other,215% New York Medicaid APG,1248.32,,,1248.32,Other,125% New York Medicaid APG,998.66,34273.46,
Slitting of prepuce,54000,CPT,,,,,,,,both,,,73326.88,54261.89,74,,54261.89,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,32997.1,45,,32997.1,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,36296.81,49.5,,36296.81,percent of total billed charges,110% of Medicare,49862.28,68,,49862.28,percent of total billed charges,,903.43,,,903.43,Other,186% of Medicaid,58661.5,80,,58661.5,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,58661.5,80,,58661.5,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,51328.82,70,,51328.82,percent of total billed charges,,537.92,,,537.92,Fee Schedule,,455.92,,,455.92,Fee Schedule,,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,485.72,,,485.72,Other,New York Medicaid APG methodology,485.72,,,485.72,Other,100% New York Medicaid APG,485.72,,,485.72,Other,100% New York Medicaid APG,485.72,,,485.72,Other,100% New York Medicaid APG,1092.86,,,1092.86,Other,225% New York Medicaid APG,743.14,,,743.14,Other,153% New York Medicaid APG,1092.86,,,1092.86,Other,225% New York Medicaid APG,680,,,680,Other,140% New York Medicaid APG,1092.86,,,1092.86,Other,225% New York Medicaid APG,1262.86,,,1262.86,Other,260% New York Medicaid APG,1573.72,,,1573.72,Other,324% New York Medicaid APG,1044.29,,,1044.29,Other,215% New York Medicaid APG,1044.29,,,1044.29,Other,215% New York Medicaid APG,607.14,,,607.14,Other,125% New York Medicaid APG,455.92,58661.5,
Slitting of prepuce,54001,CPT,,,,,,,,both,,,42841.82,31702.95,74,,31702.95,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,19278.82,45,,19278.82,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,21206.7,49.5,,21206.7,percent of total billed charges,110% of Medicare,29132.44,68,,29132.44,percent of total billed charges,,1762.47,,,1762.47,Other,186% of Medicaid,34273.46,80,,34273.46,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,34273.46,80,,34273.46,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,29989.27,70,,29989.27,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,947.56,,,947.56,Other,New York Medicaid APG methodology,947.56,,,947.56,Other,100% New York Medicaid APG,947.56,,,947.56,Other,100% New York Medicaid APG,947.56,,,947.56,Other,100% New York Medicaid APG,2132.02,,,2132.02,Other,225% New York Medicaid APG,1449.77,,,1449.77,Other,153% New York Medicaid APG,2132.02,,,2132.02,Other,225% New York Medicaid APG,1326.59,,,1326.59,Other,140% New York Medicaid APG,2132.02,,,2132.02,Other,225% New York Medicaid APG,2463.67,,,2463.67,Other,260% New York Medicaid APG,3070.11,,,3070.11,Other,324% New York Medicaid APG,2037.26,,,2037.26,Other,215% New York Medicaid APG,2037.26,,,2037.26,Other,215% New York Medicaid APG,1184.46,,,1184.46,Other,125% New York Medicaid APG,947.56,34273.46,
Drain penis lesion,54015,CPT,,,,,,,,both,,,34101.75,25235.3,74,,25235.3,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15345.79,45,,15345.79,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,16880.37,49.5,,16880.37,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,1762.47,,,1762.47,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,23871.23,70,,23871.23,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,947.56,,,947.56,Other,New York Medicaid APG methodology,947.56,,,947.56,Other,100% New York Medicaid APG,947.56,,,947.56,Other,100% New York Medicaid APG,947.56,,,947.56,Other,100% New York Medicaid APG,2132.02,,,2132.02,Other,225% New York Medicaid APG,1449.77,,,1449.77,Other,153% New York Medicaid APG,2132.02,,,2132.02,Other,225% New York Medicaid APG,1326.59,,,1326.59,Other,140% New York Medicaid APG,2132.02,,,2132.02,Other,225% New York Medicaid APG,2463.67,,,2463.67,Other,260% New York Medicaid APG,3070.11,,,3070.11,Other,324% New York Medicaid APG,2037.26,,,2037.26,Other,215% New York Medicaid APG,2037.26,,,2037.26,Other,215% New York Medicaid APG,1184.46,,,1184.46,Other,125% New York Medicaid APG,947.56,25235.3,
Destruction penis lesion(s),54050,CPT,,,,,,,,both,,,8387.08,6206.44,74,,6206.44,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,3774.19,45,,3774.19,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,4151.6,49.5,,4151.6,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,903.43,,,903.43,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,5870.96,70,,5870.96,percent of total billed charges,,523.16,,,523.16,Fee Schedule,,443.41,,,443.41,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,485.72,,,485.72,Other,New York Medicaid APG methodology,485.72,,,485.72,Other,100% New York Medicaid APG,485.72,,,485.72,Other,100% New York Medicaid APG,485.72,,,485.72,Other,100% New York Medicaid APG,1092.86,,,1092.86,Other,225% New York Medicaid APG,743.14,,,743.14,Other,153% New York Medicaid APG,1092.86,,,1092.86,Other,225% New York Medicaid APG,680,,,680,Other,140% New York Medicaid APG,1092.86,,,1092.86,Other,225% New York Medicaid APG,1262.86,,,1262.86,Other,260% New York Medicaid APG,1573.72,,,1573.72,Other,324% New York Medicaid APG,1044.29,,,1044.29,Other,215% New York Medicaid APG,1044.29,,,1044.29,Other,215% New York Medicaid APG,607.14,,,607.14,Other,125% New York Medicaid APG,443.41,9473,
Destruction penis lesion(s),54055,CPT,,,,,,,,both,,,38357.55,28384.59,74,,28384.59,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,17260.9,45,,17260.9,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,18986.99,49.5,,18986.99,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,1762.47,,,1762.47,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,26850.29,70,,26850.29,percent of total billed charges,,469.04,,,469.04,Fee Schedule,,397.54,,,397.54,Fee Schedule,,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,947.56,,,947.56,Other,New York Medicaid APG methodology,947.56,,,947.56,Other,100% New York Medicaid APG,947.56,,,947.56,Other,100% New York Medicaid APG,947.56,,,947.56,Other,100% New York Medicaid APG,2132.02,,,2132.02,Other,225% New York Medicaid APG,1449.77,,,1449.77,Other,153% New York Medicaid APG,2132.02,,,2132.02,Other,225% New York Medicaid APG,1326.59,,,1326.59,Other,140% New York Medicaid APG,2132.02,,,2132.02,Other,225% New York Medicaid APG,2463.67,,,2463.67,Other,260% New York Medicaid APG,3070.11,,,3070.11,Other,324% New York Medicaid APG,2037.26,,,2037.26,Other,215% New York Medicaid APG,2037.26,,,2037.26,Other,215% New York Medicaid APG,1184.46,,,1184.46,Other,125% New York Medicaid APG,397.54,28384.59,
Cryosurgery penis lesion(s),54056,CPT,,,,,,,,both,,,4210.98,3116.13,74,,3116.13,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,1894.94,45,,1894.94,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,2084.44,49.5,,2084.44,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,903.43,,,903.43,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,2947.69,70,,2947.69,percent of total billed charges,,544.48,,,544.48,Fee Schedule,,461.48,,,461.48,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,485.72,,,485.72,Other,New York Medicaid APG methodology,485.72,,,485.72,Other,100% New York Medicaid APG,485.72,,,485.72,Other,100% New York Medicaid APG,485.72,,,485.72,Other,100% New York Medicaid APG,1092.86,,,1092.86,Other,225% New York Medicaid APG,743.14,,,743.14,Other,153% New York Medicaid APG,1092.86,,,1092.86,Other,225% New York Medicaid APG,680,,,680,Other,140% New York Medicaid APG,1092.86,,,1092.86,Other,225% New York Medicaid APG,1262.86,,,1262.86,Other,260% New York Medicaid APG,1573.72,,,1573.72,Other,324% New York Medicaid APG,1044.29,,,1044.29,Other,215% New York Medicaid APG,1044.29,,,1044.29,Other,215% New York Medicaid APG,607.14,,,607.14,Other,125% New York Medicaid APG,461.48,9473,
Laser surg penis lesion(s),54057,CPT,,,,,,,,both,,,38357.55,28384.59,74,,28384.59,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,17260.9,45,,17260.9,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,18986.99,49.5,,18986.99,percent of total billed charges,110% of Medicare,26083.13,68,,26083.13,percent of total billed charges,,1762.47,,,1762.47,Other,186% of Medicaid,30686.04,80,,30686.04,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,30686.04,80,,30686.04,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,26850.29,70,,26850.29,percent of total billed charges,,478.88,,,478.88,Fee Schedule,,405.88,,,405.88,Fee Schedule,,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,947.56,,,947.56,Other,New York Medicaid APG methodology,947.56,,,947.56,Other,100% New York Medicaid APG,947.56,,,947.56,Other,100% New York Medicaid APG,947.56,,,947.56,Other,100% New York Medicaid APG,2132.02,,,2132.02,Other,225% New York Medicaid APG,1449.77,,,1449.77,Other,153% New York Medicaid APG,2132.02,,,2132.02,Other,225% New York Medicaid APG,1326.59,,,1326.59,Other,140% New York Medicaid APG,2132.02,,,2132.02,Other,225% New York Medicaid APG,2463.67,,,2463.67,Other,260% New York Medicaid APG,3070.11,,,3070.11,Other,324% New York Medicaid APG,2037.26,,,2037.26,Other,215% New York Medicaid APG,2037.26,,,2037.26,Other,215% New York Medicaid APG,1184.46,,,1184.46,Other,125% New York Medicaid APG,405.88,30686.04,
Excision of penis lesion(s),54060,CPT,,,,,,,,both,,,38953.63,28825.69,74,,28825.69,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,17529.13,45,,17529.13,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,19282.05,49.5,,19282.05,percent of total billed charges,110% of Medicare,26488.47,68,,26488.47,percent of total billed charges,,1762.47,,,1762.47,Other,186% of Medicaid,31162.9,80,,31162.9,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,31162.9,80,,31162.9,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,27267.54,70,,27267.54,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,947.56,,,947.56,Other,New York Medicaid APG methodology,947.56,,,947.56,Other,100% New York Medicaid APG,947.56,,,947.56,Other,100% New York Medicaid APG,947.56,,,947.56,Other,100% New York Medicaid APG,2132.02,,,2132.02,Other,225% New York Medicaid APG,1449.77,,,1449.77,Other,153% New York Medicaid APG,2132.02,,,2132.02,Other,225% New York Medicaid APG,1326.59,,,1326.59,Other,140% New York Medicaid APG,2132.02,,,2132.02,Other,225% New York Medicaid APG,2463.67,,,2463.67,Other,260% New York Medicaid APG,3070.11,,,3070.11,Other,324% New York Medicaid APG,2037.26,,,2037.26,Other,215% New York Medicaid APG,2037.26,,,2037.26,Other,215% New York Medicaid APG,1184.46,,,1184.46,Other,125% New York Medicaid APG,947.56,31162.9,
Destruction penis lesion(s),54065,CPT,,,,,,,,both,,,38357.55,28384.59,74,,28384.59,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,17260.9,45,,17260.9,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,18986.99,49.5,,18986.99,percent of total billed charges,110% of Medicare,26083.13,68,,26083.13,percent of total billed charges,,1762.47,,,1762.47,Other,186% of Medicaid,30686.04,80,,30686.04,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,30686.04,80,,30686.04,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,26850.29,70,,26850.29,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,947.56,,,947.56,Other,New York Medicaid APG methodology,947.56,,,947.56,Other,100% New York Medicaid APG,947.56,,,947.56,Other,100% New York Medicaid APG,947.56,,,947.56,Other,100% New York Medicaid APG,2132.02,,,2132.02,Other,225% New York Medicaid APG,1449.77,,,1449.77,Other,153% New York Medicaid APG,2132.02,,,2132.02,Other,225% New York Medicaid APG,1326.59,,,1326.59,Other,140% New York Medicaid APG,2132.02,,,2132.02,Other,225% New York Medicaid APG,2463.67,,,2463.67,Other,260% New York Medicaid APG,3070.11,,,3070.11,Other,324% New York Medicaid APG,2037.26,,,2037.26,Other,215% New York Medicaid APG,2037.26,,,2037.26,Other,215% New York Medicaid APG,1184.46,,,1184.46,Other,125% New York Medicaid APG,947.56,30686.04,
Biopsy of penis,54100,CPT,,,,,,,,both,,,39273.29,29062.23,74,,29062.23,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,17672.98,45,,17672.98,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,19440.28,49.5,,19440.28,percent of total billed charges,110% of Medicare,26705.84,68,,26705.84,percent of total billed charges,,1762.47,,,1762.47,Other,186% of Medicaid,31418.63,80,,31418.63,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,31418.63,80,,31418.63,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,27491.3,70,,27491.3,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,947.56,,,947.56,Other,New York Medicaid APG methodology,947.56,,,947.56,Other,100% New York Medicaid APG,947.56,,,947.56,Other,100% New York Medicaid APG,947.56,,,947.56,Other,100% New York Medicaid APG,2132.02,,,2132.02,Other,225% New York Medicaid APG,1449.77,,,1449.77,Other,153% New York Medicaid APG,2132.02,,,2132.02,Other,225% New York Medicaid APG,1326.59,,,1326.59,Other,140% New York Medicaid APG,2132.02,,,2132.02,Other,225% New York Medicaid APG,2463.67,,,2463.67,Other,260% New York Medicaid APG,3070.11,,,3070.11,Other,324% New York Medicaid APG,2037.26,,,2037.26,Other,215% New York Medicaid APG,2037.26,,,2037.26,Other,215% New York Medicaid APG,1184.46,,,1184.46,Other,125% New York Medicaid APG,947.56,31418.63,
Biopsy of penis,54105,CPT,,,,,,,,both,,,59767.2,44227.73,74,,44227.73,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,26895.24,45,,26895.24,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,29584.76,49.5,,29584.76,percent of total billed charges,110% of Medicare,40641.7,68,,40641.7,percent of total billed charges,,1762.47,,,1762.47,Other,186% of Medicaid,47813.76,80,,47813.76,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,47813.76,80,,47813.76,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,41837.04,70,,41837.04,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,947.56,,,947.56,Other,New York Medicaid APG methodology,947.56,,,947.56,Other,100% New York Medicaid APG,947.56,,,947.56,Other,100% New York Medicaid APG,947.56,,,947.56,Other,100% New York Medicaid APG,2132.02,,,2132.02,Other,225% New York Medicaid APG,1449.77,,,1449.77,Other,153% New York Medicaid APG,2132.02,,,2132.02,Other,225% New York Medicaid APG,1326.59,,,1326.59,Other,140% New York Medicaid APG,2132.02,,,2132.02,Other,225% New York Medicaid APG,2463.67,,,2463.67,Other,260% New York Medicaid APG,3070.11,,,3070.11,Other,324% New York Medicaid APG,2037.26,,,2037.26,Other,215% New York Medicaid APG,2037.26,,,2037.26,Other,215% New York Medicaid APG,1184.46,,,1184.46,Other,125% New York Medicaid APG,947.56,47813.76,
Treatment of penis lesion,54110,CPT,,,,,,,,both,,,73326.88,54261.89,74,,54261.89,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,32997.1,45,,32997.1,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,36296.81,49.5,,36296.81,percent of total billed charges,110% of Medicare,49862.28,68,,49862.28,percent of total billed charges,,1762.47,,,1762.47,Other,186% of Medicaid,58661.5,80,,58661.5,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,58661.5,80,,58661.5,percent of total billed charges,,7216,,,7216,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,51328.82,70,,51328.82,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,947.56,,,947.56,Other,New York Medicaid APG methodology,947.56,,,947.56,Other,100% New York Medicaid APG,947.56,,,947.56,Other,100% New York Medicaid APG,947.56,,,947.56,Other,100% New York Medicaid APG,2132.02,,,2132.02,Other,225% New York Medicaid APG,1449.77,,,1449.77,Other,153% New York Medicaid APG,2132.02,,,2132.02,Other,225% New York Medicaid APG,1326.59,,,1326.59,Other,140% New York Medicaid APG,2132.02,,,2132.02,Other,225% New York Medicaid APG,2463.67,,,2463.67,Other,260% New York Medicaid APG,3070.11,,,3070.11,Other,324% New York Medicaid APG,2037.26,,,2037.26,Other,215% New York Medicaid APG,2037.26,,,2037.26,Other,215% New York Medicaid APG,1184.46,,,1184.46,Other,125% New York Medicaid APG,947.56,58661.5,
Treat penis lesion graft,54111,CPT,,,,,,,,both,,,108835.97,80538.62,74,,80538.62,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,48976.19,45,,48976.19,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,53873.81,49.5,,53873.81,percent of total billed charges,110% of Medicare,74008.46,68,,74008.46,percent of total billed charges,,1836.76,,,1836.76,Other,186% of Medicaid,87068.78,80,,87068.78,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,87068.78,80,,87068.78,percent of total billed charges,,7216,,,7216,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,76185.18,70,,76185.18,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,987.51,,,987.51,Other,New York Medicaid APG methodology,987.51,,,987.51,Other,100% New York Medicaid APG,987.51,,,987.51,Other,100% New York Medicaid APG,987.51,,,987.51,Other,100% New York Medicaid APG,2221.89,,,2221.89,Other,225% New York Medicaid APG,1510.88,,,1510.88,Other,153% New York Medicaid APG,2221.89,,,2221.89,Other,225% New York Medicaid APG,1382.51,,,1382.51,Other,140% New York Medicaid APG,2221.89,,,2221.89,Other,225% New York Medicaid APG,2567.51,,,2567.51,Other,260% New York Medicaid APG,3199.52,,,3199.52,Other,324% New York Medicaid APG,2123.14,,,2123.14,Other,215% New York Medicaid APG,2123.14,,,2123.14,Other,215% New York Medicaid APG,1234.38,,,1234.38,Other,125% New York Medicaid APG,987.51,87068.78,
Treat penis lesion graft,54112,CPT,,,,,,,,both,,,193769.26,143389.25,74,,143389.25,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,87196.17,45,,87196.17,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,95915.78,49.5,,95915.78,percent of total billed charges,110% of Medicare,131763.1,68,,131763.1,percent of total billed charges,,1836.76,,,1836.76,Other,186% of Medicaid,155015.41,80,,155015.41,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,155015.41,80,,155015.41,percent of total billed charges,,7216,,,7216,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,135638.48,70,,135638.48,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,987.51,,,987.51,Other,New York Medicaid APG methodology,987.51,,,987.51,Other,100% New York Medicaid APG,987.51,,,987.51,Other,100% New York Medicaid APG,987.51,,,987.51,Other,100% New York Medicaid APG,2221.89,,,2221.89,Other,225% New York Medicaid APG,1510.88,,,1510.88,Other,153% New York Medicaid APG,2221.89,,,2221.89,Other,225% New York Medicaid APG,1382.51,,,1382.51,Other,140% New York Medicaid APG,2221.89,,,2221.89,Other,225% New York Medicaid APG,2567.51,,,2567.51,Other,260% New York Medicaid APG,3199.52,,,3199.52,Other,324% New York Medicaid APG,2123.14,,,2123.14,Other,215% New York Medicaid APG,2123.14,,,2123.14,Other,215% New York Medicaid APG,1234.38,,,1234.38,Other,125% New York Medicaid APG,987.51,155015.41,
Treatment of penis lesion,54115,CPT,,,,,,,,both,,,59767.2,44227.73,74,,44227.73,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,26895.24,45,,26895.24,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,29584.76,49.5,,29584.76,percent of total billed charges,110% of Medicare,40641.7,68,,40641.7,percent of total billed charges,,1762.47,,,1762.47,Other,186% of Medicaid,47813.76,80,,47813.76,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,47813.76,80,,47813.76,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,41837.04,70,,41837.04,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,947.56,,,947.56,Other,New York Medicaid APG methodology,947.56,,,947.56,Other,100% New York Medicaid APG,947.56,,,947.56,Other,100% New York Medicaid APG,947.56,,,947.56,Other,100% New York Medicaid APG,2132.02,,,2132.02,Other,225% New York Medicaid APG,1449.77,,,1449.77,Other,153% New York Medicaid APG,2132.02,,,2132.02,Other,225% New York Medicaid APG,1326.59,,,1326.59,Other,140% New York Medicaid APG,2132.02,,,2132.02,Other,225% New York Medicaid APG,2463.67,,,2463.67,Other,260% New York Medicaid APG,3070.11,,,3070.11,Other,324% New York Medicaid APG,2037.26,,,2037.26,Other,215% New York Medicaid APG,2037.26,,,2037.26,Other,215% New York Medicaid APG,1184.46,,,1184.46,Other,125% New York Medicaid APG,947.56,47813.76,
Partial removal of penis,54120,CPT,,,,,,,,both,,,73326.88,54261.89,74,,54261.89,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,32997.1,45,,32997.1,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,36296.81,49.5,,36296.81,percent of total billed charges,110% of Medicare,49862.28,68,,49862.28,percent of total billed charges,,1836.76,,,1836.76,Other,186% of Medicaid,58661.5,80,,58661.5,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,58661.5,80,,58661.5,percent of total billed charges,,7216,,,7216,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,51328.82,70,,51328.82,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,987.51,,,987.51,Other,New York Medicaid APG methodology,987.51,,,987.51,Other,100% New York Medicaid APG,987.51,,,987.51,Other,100% New York Medicaid APG,987.51,,,987.51,Other,100% New York Medicaid APG,2221.89,,,2221.89,Other,225% New York Medicaid APG,1510.88,,,1510.88,Other,153% New York Medicaid APG,2221.89,,,2221.89,Other,225% New York Medicaid APG,1382.51,,,1382.51,Other,140% New York Medicaid APG,2221.89,,,2221.89,Other,225% New York Medicaid APG,2567.51,,,2567.51,Other,260% New York Medicaid APG,3199.52,,,3199.52,Other,324% New York Medicaid APG,2123.14,,,2123.14,Other,215% New York Medicaid APG,2123.14,,,2123.14,Other,215% New York Medicaid APG,1234.38,,,1234.38,Other,125% New York Medicaid APG,987.51,58661.5,
Circumcision w/regionl block,54150,CPT,,,,,,,,both,,,35318.53,26135.71,74,,26135.71,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15893.34,45,,15893.34,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,17482.67,49.5,,17482.67,percent of total billed charges,110% of Medicare,24016.6,68,,24016.6,percent of total billed charges,,1762.47,,,1762.47,Other,186% of Medicaid,28254.82,80,,28254.82,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,28254.82,80,,28254.82,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,24722.97,70,,24722.97,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,947.56,,,947.56,Other,New York Medicaid APG methodology,947.56,,,947.56,Other,100% New York Medicaid APG,947.56,,,947.56,Other,100% New York Medicaid APG,947.56,,,947.56,Other,100% New York Medicaid APG,2132.02,,,2132.02,Other,225% New York Medicaid APG,1449.77,,,1449.77,Other,153% New York Medicaid APG,2132.02,,,2132.02,Other,225% New York Medicaid APG,1326.59,,,1326.59,Other,140% New York Medicaid APG,2132.02,,,2132.02,Other,225% New York Medicaid APG,2463.67,,,2463.67,Other,260% New York Medicaid APG,3070.11,,,3070.11,Other,324% New York Medicaid APG,2037.26,,,2037.26,Other,215% New York Medicaid APG,2037.26,,,2037.26,Other,215% New York Medicaid APG,1184.46,,,1184.46,Other,125% New York Medicaid APG,947.56,28254.82,
Circumcision neonate,54160,CPT,,,,,,,,both,,,14368.32,10632.56,74,,10632.56,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,6465.74,45,,6465.74,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,7112.32,49.5,,7112.32,percent of total billed charges,110% of Medicare,9770.46,68,,9770.46,percent of total billed charges,,1762.47,,,1762.47,Other,186% of Medicaid,11494.66,80,,11494.66,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,11494.66,80,,11494.66,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,10057.82,70,,10057.82,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,947.56,,,947.56,Other,New York Medicaid APG methodology,947.56,,,947.56,Other,100% New York Medicaid APG,947.56,,,947.56,Other,100% New York Medicaid APG,947.56,,,947.56,Other,100% New York Medicaid APG,2132.02,,,2132.02,Other,225% New York Medicaid APG,1449.77,,,1449.77,Other,153% New York Medicaid APG,2132.02,,,2132.02,Other,225% New York Medicaid APG,1326.59,,,1326.59,Other,140% New York Medicaid APG,2132.02,,,2132.02,Other,225% New York Medicaid APG,2463.67,,,2463.67,Other,260% New York Medicaid APG,3070.11,,,3070.11,Other,324% New York Medicaid APG,2037.26,,,2037.26,Other,215% New York Medicaid APG,2037.26,,,2037.26,Other,215% New York Medicaid APG,1184.46,,,1184.46,Other,125% New York Medicaid APG,947.56,11494.66,
Circum 28 days or older,54161,CPT,,,,,,,,both,,,35519.59,26284.5,74,,26284.5,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15983.82,45,,15983.82,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,17582.2,49.5,,17582.2,percent of total billed charges,110% of Medicare,24153.32,68,,24153.32,percent of total billed charges,,1762.47,,,1762.47,Other,186% of Medicaid,28415.67,80,,28415.67,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,28415.67,80,,28415.67,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,24863.71,70,,24863.71,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,947.56,,,947.56,Other,New York Medicaid APG methodology,947.56,,,947.56,Other,100% New York Medicaid APG,947.56,,,947.56,Other,100% New York Medicaid APG,947.56,,,947.56,Other,100% New York Medicaid APG,2132.02,,,2132.02,Other,225% New York Medicaid APG,1449.77,,,1449.77,Other,153% New York Medicaid APG,2132.02,,,2132.02,Other,225% New York Medicaid APG,1326.59,,,1326.59,Other,140% New York Medicaid APG,2132.02,,,2132.02,Other,225% New York Medicaid APG,2463.67,,,2463.67,Other,260% New York Medicaid APG,3070.11,,,3070.11,Other,324% New York Medicaid APG,2037.26,,,2037.26,Other,215% New York Medicaid APG,2037.26,,,2037.26,Other,215% New York Medicaid APG,1184.46,,,1184.46,Other,125% New York Medicaid APG,947.56,28415.67,
Lysis penil circumic lesion,54162,CPT,,,,,,,,both,,,35190.53,26040.99,74,,26040.99,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15835.74,45,,15835.74,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,17419.31,49.5,,17419.31,percent of total billed charges,110% of Medicare,23929.56,68,,23929.56,percent of total billed charges,,1762.47,,,1762.47,Other,186% of Medicaid,28152.42,80,,28152.42,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,28152.42,80,,28152.42,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,24633.37,70,,24633.37,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,947.56,,,947.56,Other,New York Medicaid APG methodology,947.56,,,947.56,Other,100% New York Medicaid APG,947.56,,,947.56,Other,100% New York Medicaid APG,947.56,,,947.56,Other,100% New York Medicaid APG,2132.02,,,2132.02,Other,225% New York Medicaid APG,1449.77,,,1449.77,Other,153% New York Medicaid APG,2132.02,,,2132.02,Other,225% New York Medicaid APG,1326.59,,,1326.59,Other,140% New York Medicaid APG,2132.02,,,2132.02,Other,225% New York Medicaid APG,2463.67,,,2463.67,Other,260% New York Medicaid APG,3070.11,,,3070.11,Other,324% New York Medicaid APG,2037.26,,,2037.26,Other,215% New York Medicaid APG,2037.26,,,2037.26,Other,215% New York Medicaid APG,1184.46,,,1184.46,Other,125% New York Medicaid APG,947.56,28152.42,
Repair of circumcision,54163,CPT,,,,,,,,both,,,35023.11,25917.1,74,,25917.1,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15760.4,45,,15760.4,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,17336.44,49.5,,17336.44,percent of total billed charges,110% of Medicare,23815.71,68,,23815.71,percent of total billed charges,,1762.47,,,1762.47,Other,186% of Medicaid,28018.49,80,,28018.49,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,28018.49,80,,28018.49,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,24516.18,70,,24516.18,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,947.56,,,947.56,Other,New York Medicaid APG methodology,947.56,,,947.56,Other,100% New York Medicaid APG,947.56,,,947.56,Other,100% New York Medicaid APG,947.56,,,947.56,Other,100% New York Medicaid APG,2132.02,,,2132.02,Other,225% New York Medicaid APG,1449.77,,,1449.77,Other,153% New York Medicaid APG,2132.02,,,2132.02,Other,225% New York Medicaid APG,1326.59,,,1326.59,Other,140% New York Medicaid APG,2132.02,,,2132.02,Other,225% New York Medicaid APG,2463.67,,,2463.67,Other,260% New York Medicaid APG,3070.11,,,3070.11,Other,324% New York Medicaid APG,2037.26,,,2037.26,Other,215% New York Medicaid APG,2037.26,,,2037.26,Other,215% New York Medicaid APG,1184.46,,,1184.46,Other,125% New York Medicaid APG,947.56,28018.49,
Frenulotomy of penis,54164,CPT,,,,,,,,both,,,35753.88,26457.87,74,,26457.87,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,16089.25,45,,16089.25,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,17698.17,49.5,,17698.17,percent of total billed charges,110% of Medicare,24312.64,68,,24312.64,percent of total billed charges,,1762.47,,,1762.47,Other,186% of Medicaid,28603.1,80,,28603.1,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,28603.1,80,,28603.1,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,25027.72,70,,25027.72,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,947.56,,,947.56,Other,New York Medicaid APG methodology,947.56,,,947.56,Other,100% New York Medicaid APG,947.56,,,947.56,Other,100% New York Medicaid APG,947.56,,,947.56,Other,100% New York Medicaid APG,2132.02,,,2132.02,Other,225% New York Medicaid APG,1449.77,,,1449.77,Other,153% New York Medicaid APG,2132.02,,,2132.02,Other,225% New York Medicaid APG,1326.59,,,1326.59,Other,140% New York Medicaid APG,2132.02,,,2132.02,Other,225% New York Medicaid APG,2463.67,,,2463.67,Other,260% New York Medicaid APG,3070.11,,,3070.11,Other,324% New York Medicaid APG,2037.26,,,2037.26,Other,215% New York Medicaid APG,2037.26,,,2037.26,Other,215% New York Medicaid APG,1184.46,,,1184.46,Other,125% New York Medicaid APG,947.56,28603.1,
Treatment of penis lesion,54200,CPT,,,,,,,,both,,,5198.43,3846.84,74,,3846.84,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,2339.29,45,,2339.29,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,2573.22,49.5,,2573.22,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,847.8,,,847.8,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,3638.9,70,,3638.9,percent of total billed charges,,421.48,,,421.48,Fee Schedule,,357.23,,,357.23,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,455.81,,,455.81,Other,New York Medicaid APG methodology,455.81,,,455.81,Other,100% New York Medicaid APG,455.81,,,455.81,Other,100% New York Medicaid APG,455.81,,,455.81,Other,100% New York Medicaid APG,1025.56,,,1025.56,Other,225% New York Medicaid APG,697.38,,,697.38,Other,153% New York Medicaid APG,1025.56,,,1025.56,Other,225% New York Medicaid APG,638.13,,,638.13,Other,140% New York Medicaid APG,1025.56,,,1025.56,Other,225% New York Medicaid APG,1185.1,,,1185.1,Other,260% New York Medicaid APG,1476.81,,,1476.81,Other,324% New York Medicaid APG,979.98,,,979.98,Other,215% New York Medicaid APG,979.98,,,979.98,Other,215% New York Medicaid APG,569.76,,,569.76,Other,125% New York Medicaid APG,357.23,9473,
Treatment of penis lesion,54205,CPT,,,,,,,,both,,,108835.97,80538.62,74,,80538.62,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,48976.19,45,,48976.19,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,53873.81,49.5,,53873.81,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,1836.76,,,1836.76,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,76185.18,70,,76185.18,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,987.51,,,987.51,Other,New York Medicaid APG methodology,987.51,,,987.51,Other,100% New York Medicaid APG,987.51,,,987.51,Other,100% New York Medicaid APG,987.51,,,987.51,Other,100% New York Medicaid APG,2221.89,,,2221.89,Other,225% New York Medicaid APG,1510.88,,,1510.88,Other,153% New York Medicaid APG,2221.89,,,2221.89,Other,225% New York Medicaid APG,1382.51,,,1382.51,Other,140% New York Medicaid APG,2221.89,,,2221.89,Other,225% New York Medicaid APG,2567.51,,,2567.51,Other,260% New York Medicaid APG,3199.52,,,3199.52,Other,324% New York Medicaid APG,2123.14,,,2123.14,Other,215% New York Medicaid APG,2123.14,,,2123.14,Other,215% New York Medicaid APG,1234.38,,,1234.38,Other,125% New York Medicaid APG,987.51,80538.62,
Treatment of penis lesion,54220,CPT,,,,,,,,both,,,5198.43,3846.84,74,,3846.84,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,2339.29,45,,2339.29,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,2573.22,49.5,,2573.22,percent of total billed charges,110% of Medicare,3534.93,68,,3534.93,percent of total billed charges,,847.8,,,847.8,Other,186% of Medicaid,4158.74,80,,4158.74,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,4158.74,80,,4158.74,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,3638.9,70,,3638.9,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,455.81,,,455.81,Other,New York Medicaid APG methodology,455.81,,,455.81,Other,100% New York Medicaid APG,455.81,,,455.81,Other,100% New York Medicaid APG,455.81,,,455.81,Other,100% New York Medicaid APG,1025.56,,,1025.56,Other,225% New York Medicaid APG,697.38,,,697.38,Other,153% New York Medicaid APG,1025.56,,,1025.56,Other,225% New York Medicaid APG,638.13,,,638.13,Other,140% New York Medicaid APG,1025.56,,,1025.56,Other,225% New York Medicaid APG,1185.1,,,1185.1,Other,260% New York Medicaid APG,1476.81,,,1476.81,Other,324% New York Medicaid APG,979.98,,,979.98,Other,215% New York Medicaid APG,979.98,,,979.98,Other,215% New York Medicaid APG,569.76,,,569.76,Other,125% New York Medicaid APG,455.81,7216,
Prepare penis study,54230,CPT,,,,,,,,both,,,32432.1,23999.75,74,,23999.75,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,14594.45,45,,14594.45,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,16053.89,49.5,,16053.89,percent of total billed charges,110% of Medicare,22053.83,68,,22053.83,percent of total billed charges,,1762.47,,,1762.47,Other,186% of Medicaid,25945.68,80,,25945.68,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,25945.68,80,,25945.68,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,22702.47,70,,22702.47,percent of total billed charges,,385.4,,,385.4,Fee Schedule,,326.65,,,326.65,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,947.56,,,947.56,Other,New York Medicaid APG methodology,947.56,,,947.56,Other,100% New York Medicaid APG,947.56,,,947.56,Other,100% New York Medicaid APG,947.56,,,947.56,Other,100% New York Medicaid APG,2132.02,,,2132.02,Other,225% New York Medicaid APG,1449.77,,,1449.77,Other,153% New York Medicaid APG,2132.02,,,2132.02,Other,225% New York Medicaid APG,1326.59,,,1326.59,Other,140% New York Medicaid APG,2132.02,,,2132.02,Other,225% New York Medicaid APG,2463.67,,,2463.67,Other,260% New York Medicaid APG,3070.11,,,3070.11,Other,324% New York Medicaid APG,2037.26,,,2037.26,Other,215% New York Medicaid APG,2037.26,,,2037.26,Other,215% New York Medicaid APG,1184.46,,,1184.46,Other,125% New York Medicaid APG,326.65,25945.68,
Dynamic cavernosometry,54231,CPT,,,,,,,,both,,,5198.43,3846.84,74,,3846.84,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,2339.29,45,,2339.29,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,2573.22,49.5,,2573.22,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,1762.47,,,1762.47,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,3638.9,70,,3638.9,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,947.56,,,947.56,Other,New York Medicaid APG methodology,947.56,,,947.56,Other,100% New York Medicaid APG,947.56,,,947.56,Other,100% New York Medicaid APG,947.56,,,947.56,Other,100% New York Medicaid APG,2132.02,,,2132.02,Other,225% New York Medicaid APG,1449.77,,,1449.77,Other,153% New York Medicaid APG,2132.02,,,2132.02,Other,225% New York Medicaid APG,1326.59,,,1326.59,Other,140% New York Medicaid APG,2132.02,,,2132.02,Other,225% New York Medicaid APG,2463.67,,,2463.67,Other,260% New York Medicaid APG,3070.11,,,3070.11,Other,324% New York Medicaid APG,2037.26,,,2037.26,Other,215% New York Medicaid APG,2037.26,,,2037.26,Other,215% New York Medicaid APG,1184.46,,,1184.46,Other,125% New York Medicaid APG,947.56,9473,
Penile injection,54235,CPT,,,,,,,,both,,,5198.43,3846.84,74,,3846.84,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,2339.29,45,,2339.29,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,2573.22,49.5,,2573.22,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,847.8,,,847.8,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,3638.9,70,,3638.9,percent of total billed charges,,359.16,,,359.16,Fee Schedule,,304.41,,,304.41,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,455.81,,,455.81,Other,New York Medicaid APG methodology,455.81,,,455.81,Other,100% New York Medicaid APG,455.81,,,455.81,Other,100% New York Medicaid APG,455.81,,,455.81,Other,100% New York Medicaid APG,1025.56,,,1025.56,Other,225% New York Medicaid APG,697.38,,,697.38,Other,153% New York Medicaid APG,1025.56,,,1025.56,Other,225% New York Medicaid APG,638.13,,,638.13,Other,140% New York Medicaid APG,1025.56,,,1025.56,Other,225% New York Medicaid APG,1185.1,,,1185.1,Other,260% New York Medicaid APG,1476.81,,,1476.81,Other,324% New York Medicaid APG,979.98,,,979.98,Other,215% New York Medicaid APG,979.98,,,979.98,Other,215% New York Medicaid APG,569.76,,,569.76,Other,125% New York Medicaid APG,304.41,9473,
Penis study,54240,CPT,,,,,,,,both,,,6602.02,4885.49,74,,4885.49,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,2970.91,45,,2970.91,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,238.1,,,238.1,Fee Schedule,,214.15,,,214.15,Fee Schedule,,202.41,,,202.41,Fee Schedule,,3268,49.5,,3268,percent of total billed charges,110% of Medicare,4489.37,68,,4489.37,percent of total billed charges,,847.8,,,847.8,Other,186% of Medicaid,5281.62,80,,5281.62,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,5281.62,80,,5281.62,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,4621.41,70,,4621.41,percent of total billed charges,,4291.31,65,,4291.31,percent of total billed charges,,4291.31,65,,4291.31,percent of total billed charges,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,455.81,,,455.81,Other,New York Medicaid APG methodology,455.81,,,455.81,Other,100% New York Medicaid APG,455.81,,,455.81,Other,100% New York Medicaid APG,455.81,,,455.81,Other,100% New York Medicaid APG,1025.56,,,1025.56,Other,225% New York Medicaid APG,697.38,,,697.38,Other,153% New York Medicaid APG,1025.56,,,1025.56,Other,225% New York Medicaid APG,638.13,,,638.13,Other,140% New York Medicaid APG,1025.56,,,1025.56,Other,225% New York Medicaid APG,1185.1,,,1185.1,Other,260% New York Medicaid APG,1476.81,,,1476.81,Other,324% New York Medicaid APG,979.98,,,979.98,Other,215% New York Medicaid APG,979.98,,,979.98,Other,215% New York Medicaid APG,569.76,,,569.76,Other,125% New York Medicaid APG,202.41,7216,
Penis study,54250,CPT,,,,,,,,both,,,5198.43,3846.84,74,,3846.84,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,2339.29,45,,2339.29,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,80.21,,,80.21,Fee Schedule,,72.14,,,72.14,Fee Schedule,,68.19,,,68.19,Fee Schedule,,2573.22,49.5,,2573.22,percent of total billed charges,110% of Medicare,3534.93,68,,3534.93,percent of total billed charges,,847.8,,,847.8,Other,186% of Medicaid,4158.74,80,,4158.74,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,4158.74,80,,4158.74,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,3638.9,70,,3638.9,percent of total billed charges,,3378.98,65,,3378.98,percent of total billed charges,,3378.98,65,,3378.98,percent of total billed charges,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,455.81,,,455.81,Other,New York Medicaid APG methodology,455.81,,,455.81,Other,100% New York Medicaid APG,455.81,,,455.81,Other,100% New York Medicaid APG,455.81,,,455.81,Other,100% New York Medicaid APG,1025.56,,,1025.56,Other,225% New York Medicaid APG,697.38,,,697.38,Other,153% New York Medicaid APG,1025.56,,,1025.56,Other,225% New York Medicaid APG,638.13,,,638.13,Other,140% New York Medicaid APG,1025.56,,,1025.56,Other,225% New York Medicaid APG,1185.1,,,1185.1,Other,260% New York Medicaid APG,1476.81,,,1476.81,Other,324% New York Medicaid APG,979.98,,,979.98,Other,215% New York Medicaid APG,979.98,,,979.98,Other,215% New York Medicaid APG,569.76,,,569.76,Other,125% New York Medicaid APG,68.19,7216,
Revision of penis,54300,CPT,,,,,,,,both,,,34835.02,25777.91,74,,25777.91,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15675.76,45,,15675.76,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,17243.33,49.5,,17243.33,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,1762.47,,,1762.47,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,24384.51,70,,24384.51,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,947.56,,,947.56,Other,New York Medicaid APG methodology,947.56,,,947.56,Other,100% New York Medicaid APG,947.56,,,947.56,Other,100% New York Medicaid APG,947.56,,,947.56,Other,100% New York Medicaid APG,2132.02,,,2132.02,Other,225% New York Medicaid APG,1449.77,,,1449.77,Other,153% New York Medicaid APG,2132.02,,,2132.02,Other,225% New York Medicaid APG,1326.59,,,1326.59,Other,140% New York Medicaid APG,2132.02,,,2132.02,Other,225% New York Medicaid APG,2463.67,,,2463.67,Other,260% New York Medicaid APG,3070.11,,,3070.11,Other,324% New York Medicaid APG,2037.26,,,2037.26,Other,215% New York Medicaid APG,2037.26,,,2037.26,Other,215% New York Medicaid APG,1184.46,,,1184.46,Other,125% New York Medicaid APG,947.56,25777.91,
Revision of penis,54304,CPT,,,,,,,,both,,,34641.1,25634.41,74,,25634.41,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15588.5,45,,15588.5,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,17147.34,49.5,,17147.34,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,1762.47,,,1762.47,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,24248.77,70,,24248.77,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,947.56,,,947.56,Other,New York Medicaid APG methodology,947.56,,,947.56,Other,100% New York Medicaid APG,947.56,,,947.56,Other,100% New York Medicaid APG,947.56,,,947.56,Other,100% New York Medicaid APG,2132.02,,,2132.02,Other,225% New York Medicaid APG,1449.77,,,1449.77,Other,153% New York Medicaid APG,2132.02,,,2132.02,Other,225% New York Medicaid APG,1326.59,,,1326.59,Other,140% New York Medicaid APG,2132.02,,,2132.02,Other,225% New York Medicaid APG,2463.67,,,2463.67,Other,260% New York Medicaid APG,3070.11,,,3070.11,Other,324% New York Medicaid APG,2037.26,,,2037.26,Other,215% New York Medicaid APG,2037.26,,,2037.26,Other,215% New York Medicaid APG,1184.46,,,1184.46,Other,125% New York Medicaid APG,947.56,25634.41,
Reconstruction of urethra,54308,CPT,,,,,,,,both,,,108835.97,80538.62,74,,80538.62,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,48976.19,45,,48976.19,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,53873.81,49.5,,53873.81,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,1836.76,,,1836.76,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,76185.18,70,,76185.18,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,987.51,,,987.51,Other,New York Medicaid APG methodology,987.51,,,987.51,Other,100% New York Medicaid APG,987.51,,,987.51,Other,100% New York Medicaid APG,987.51,,,987.51,Other,100% New York Medicaid APG,2221.89,,,2221.89,Other,225% New York Medicaid APG,1510.88,,,1510.88,Other,153% New York Medicaid APG,2221.89,,,2221.89,Other,225% New York Medicaid APG,1382.51,,,1382.51,Other,140% New York Medicaid APG,2221.89,,,2221.89,Other,225% New York Medicaid APG,2567.51,,,2567.51,Other,260% New York Medicaid APG,3199.52,,,3199.52,Other,324% New York Medicaid APG,2123.14,,,2123.14,Other,215% New York Medicaid APG,2123.14,,,2123.14,Other,215% New York Medicaid APG,1234.38,,,1234.38,Other,125% New York Medicaid APG,987.51,80538.62,
Reconstruction of urethra,54312,CPT,,,,,,,,both,,,73326.88,54261.89,74,,54261.89,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,32997.1,45,,32997.1,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,36296.81,49.5,,36296.81,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,1836.76,,,1836.76,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,51328.82,70,,51328.82,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,987.51,,,987.51,Other,New York Medicaid APG methodology,987.51,,,987.51,Other,100% New York Medicaid APG,987.51,,,987.51,Other,100% New York Medicaid APG,987.51,,,987.51,Other,100% New York Medicaid APG,2221.89,,,2221.89,Other,225% New York Medicaid APG,1510.88,,,1510.88,Other,153% New York Medicaid APG,2221.89,,,2221.89,Other,225% New York Medicaid APG,1382.51,,,1382.51,Other,140% New York Medicaid APG,2221.89,,,2221.89,Other,225% New York Medicaid APG,2567.51,,,2567.51,Other,260% New York Medicaid APG,3199.52,,,3199.52,Other,324% New York Medicaid APG,2123.14,,,2123.14,Other,215% New York Medicaid APG,2123.14,,,2123.14,Other,215% New York Medicaid APG,1234.38,,,1234.38,Other,125% New York Medicaid APG,987.51,54261.89,
Reconstruction of urethra,54316,CPT,,,,,,,,both,,,193769.26,143389.25,74,,143389.25,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,87196.17,45,,87196.17,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,95915.78,49.5,,95915.78,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,1836.76,,,1836.76,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,135638.48,70,,135638.48,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,987.51,,,987.51,Other,New York Medicaid APG methodology,987.51,,,987.51,Other,100% New York Medicaid APG,987.51,,,987.51,Other,100% New York Medicaid APG,987.51,,,987.51,Other,100% New York Medicaid APG,2221.89,,,2221.89,Other,225% New York Medicaid APG,1510.88,,,1510.88,Other,153% New York Medicaid APG,2221.89,,,2221.89,Other,225% New York Medicaid APG,1382.51,,,1382.51,Other,140% New York Medicaid APG,2221.89,,,2221.89,Other,225% New York Medicaid APG,2567.51,,,2567.51,Other,260% New York Medicaid APG,3199.52,,,3199.52,Other,324% New York Medicaid APG,2123.14,,,2123.14,Other,215% New York Medicaid APG,2123.14,,,2123.14,Other,215% New York Medicaid APG,1234.38,,,1234.38,Other,125% New York Medicaid APG,987.51,143389.25,
Reconstruction of urethra,54318,CPT,,,,,,,,both,,,73326.88,54261.89,74,,54261.89,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,32997.1,45,,32997.1,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,36296.81,49.5,,36296.81,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,1836.76,,,1836.76,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,51328.82,70,,51328.82,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,987.51,,,987.51,Other,New York Medicaid APG methodology,987.51,,,987.51,Other,100% New York Medicaid APG,987.51,,,987.51,Other,100% New York Medicaid APG,987.51,,,987.51,Other,100% New York Medicaid APG,2221.89,,,2221.89,Other,225% New York Medicaid APG,1510.88,,,1510.88,Other,153% New York Medicaid APG,2221.89,,,2221.89,Other,225% New York Medicaid APG,1382.51,,,1382.51,Other,140% New York Medicaid APG,2221.89,,,2221.89,Other,225% New York Medicaid APG,2567.51,,,2567.51,Other,260% New York Medicaid APG,3199.52,,,3199.52,Other,324% New York Medicaid APG,2123.14,,,2123.14,Other,215% New York Medicaid APG,2123.14,,,2123.14,Other,215% New York Medicaid APG,1234.38,,,1234.38,Other,125% New York Medicaid APG,987.51,54261.89,
Reconstruction of urethra,54322,CPT,,,,,,,,both,,,35358.69,26165.43,74,,26165.43,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15911.41,45,,15911.41,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,17502.55,49.5,,17502.55,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,1836.76,,,1836.76,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,24751.08,70,,24751.08,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,987.51,,,987.51,Other,New York Medicaid APG methodology,987.51,,,987.51,Other,100% New York Medicaid APG,987.51,,,987.51,Other,100% New York Medicaid APG,987.51,,,987.51,Other,100% New York Medicaid APG,2221.89,,,2221.89,Other,225% New York Medicaid APG,1510.88,,,1510.88,Other,153% New York Medicaid APG,2221.89,,,2221.89,Other,225% New York Medicaid APG,1382.51,,,1382.51,Other,140% New York Medicaid APG,2221.89,,,2221.89,Other,225% New York Medicaid APG,2567.51,,,2567.51,Other,260% New York Medicaid APG,3199.52,,,3199.52,Other,324% New York Medicaid APG,2123.14,,,2123.14,Other,215% New York Medicaid APG,2123.14,,,2123.14,Other,215% New York Medicaid APG,1234.38,,,1234.38,Other,125% New York Medicaid APG,987.51,26165.43,
Reconstruction of urethra,54324,CPT,,,,,,,,both,,,35720.35,26433.06,74,,26433.06,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,16074.16,45,,16074.16,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,17681.57,49.5,,17681.57,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,1836.76,,,1836.76,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,25004.25,70,,25004.25,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,987.51,,,987.51,Other,New York Medicaid APG methodology,987.51,,,987.51,Other,100% New York Medicaid APG,987.51,,,987.51,Other,100% New York Medicaid APG,987.51,,,987.51,Other,100% New York Medicaid APG,2221.89,,,2221.89,Other,225% New York Medicaid APG,1510.88,,,1510.88,Other,153% New York Medicaid APG,2221.89,,,2221.89,Other,225% New York Medicaid APG,1382.51,,,1382.51,Other,140% New York Medicaid APG,2221.89,,,2221.89,Other,225% New York Medicaid APG,2567.51,,,2567.51,Other,260% New York Medicaid APG,3199.52,,,3199.52,Other,324% New York Medicaid APG,2123.14,,,2123.14,Other,215% New York Medicaid APG,2123.14,,,2123.14,Other,215% New York Medicaid APG,1234.38,,,1234.38,Other,125% New York Medicaid APG,987.51,26433.06,
Reconstruction of urethra,54326,CPT,,,,,,,,both,,,37150.74,27491.55,74,,27491.55,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,16717.83,45,,16717.83,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,18389.62,49.5,,18389.62,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,1836.76,,,1836.76,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,26005.52,70,,26005.52,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,987.51,,,987.51,Other,New York Medicaid APG methodology,987.51,,,987.51,Other,100% New York Medicaid APG,987.51,,,987.51,Other,100% New York Medicaid APG,987.51,,,987.51,Other,100% New York Medicaid APG,2221.89,,,2221.89,Other,225% New York Medicaid APG,1510.88,,,1510.88,Other,153% New York Medicaid APG,2221.89,,,2221.89,Other,225% New York Medicaid APG,1382.51,,,1382.51,Other,140% New York Medicaid APG,2221.89,,,2221.89,Other,225% New York Medicaid APG,2567.51,,,2567.51,Other,260% New York Medicaid APG,3199.52,,,3199.52,Other,324% New York Medicaid APG,2123.14,,,2123.14,Other,215% New York Medicaid APG,2123.14,,,2123.14,Other,215% New York Medicaid APG,1234.38,,,1234.38,Other,125% New York Medicaid APG,987.51,27491.55,
Revise penis/urethra,54328,CPT,,,,,,,,both,,,37096.03,27451.06,74,,27451.06,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,16693.21,45,,16693.21,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,18362.53,49.5,,18362.53,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,1836.76,,,1836.76,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,25967.22,70,,25967.22,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,987.51,,,987.51,Other,New York Medicaid APG methodology,987.51,,,987.51,Other,100% New York Medicaid APG,987.51,,,987.51,Other,100% New York Medicaid APG,987.51,,,987.51,Other,100% New York Medicaid APG,2221.89,,,2221.89,Other,225% New York Medicaid APG,1510.88,,,1510.88,Other,153% New York Medicaid APG,2221.89,,,2221.89,Other,225% New York Medicaid APG,1382.51,,,1382.51,Other,140% New York Medicaid APG,2221.89,,,2221.89,Other,225% New York Medicaid APG,2567.51,,,2567.51,Other,260% New York Medicaid APG,3199.52,,,3199.52,Other,324% New York Medicaid APG,2123.14,,,2123.14,Other,215% New York Medicaid APG,2123.14,,,2123.14,Other,215% New York Medicaid APG,1234.38,,,1234.38,Other,125% New York Medicaid APG,987.51,27451.06,
Revise penis/urethra,54332,CPT,,,,,,,,both,,,73326.88,54261.89,74,,54261.89,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,32997.1,45,,32997.1,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,36296.81,49.5,,36296.81,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,1836.76,,,1836.76,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,51328.82,70,,51328.82,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,987.51,,,987.51,Other,New York Medicaid APG methodology,987.51,,,987.51,Other,100% New York Medicaid APG,987.51,,,987.51,Other,100% New York Medicaid APG,987.51,,,987.51,Other,100% New York Medicaid APG,2221.89,,,2221.89,Other,225% New York Medicaid APG,1510.88,,,1510.88,Other,153% New York Medicaid APG,2221.89,,,2221.89,Other,225% New York Medicaid APG,1382.51,,,1382.51,Other,140% New York Medicaid APG,2221.89,,,2221.89,Other,225% New York Medicaid APG,2567.51,,,2567.51,Other,260% New York Medicaid APG,3199.52,,,3199.52,Other,324% New York Medicaid APG,2123.14,,,2123.14,Other,215% New York Medicaid APG,2123.14,,,2123.14,Other,215% New York Medicaid APG,1234.38,,,1234.38,Other,125% New York Medicaid APG,987.51,54261.89,
Revise penis/urethra,54336,CPT,,,,,,,,both,,,73326.88,54261.89,74,,54261.89,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,32997.1,45,,32997.1,percent of total billed charges,Medicare Ratio of cost to charges,5954,,"100% primary, 50% supplemental procedure",5954,Other,Aetna ASC Grouper,5359,,"100% primary, 50% supplemental procedure",5359,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,36296.81,49.5,,36296.81,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,1836.76,,,1836.76,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,51328.82,70,,51328.82,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,987.51,,,987.51,Other,New York Medicaid APG methodology,987.51,,,987.51,Other,100% New York Medicaid APG,987.51,,,987.51,Other,100% New York Medicaid APG,987.51,,,987.51,Other,100% New York Medicaid APG,2221.89,,,2221.89,Other,225% New York Medicaid APG,1510.88,,,1510.88,Other,153% New York Medicaid APG,2221.89,,,2221.89,Other,225% New York Medicaid APG,1382.51,,,1382.51,Other,140% New York Medicaid APG,2221.89,,,2221.89,Other,225% New York Medicaid APG,2567.51,,,2567.51,Other,260% New York Medicaid APG,3199.52,,,3199.52,Other,324% New York Medicaid APG,2123.14,,,2123.14,Other,215% New York Medicaid APG,2123.14,,,2123.14,Other,215% New York Medicaid APG,1234.38,,,1234.38,Other,125% New York Medicaid APG,987.51,54261.89,
Secondary urethral surgery,54340,CPT,,,,,,,,both,,,73326.88,54261.89,74,,54261.89,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,32997.1,45,,32997.1,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,36296.81,49.5,,36296.81,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,1762.47,,,1762.47,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,51328.82,70,,51328.82,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,947.56,,,947.56,Other,New York Medicaid APG methodology,947.56,,,947.56,Other,100% New York Medicaid APG,947.56,,,947.56,Other,100% New York Medicaid APG,947.56,,,947.56,Other,100% New York Medicaid APG,2132.02,,,2132.02,Other,225% New York Medicaid APG,1449.77,,,1449.77,Other,153% New York Medicaid APG,2132.02,,,2132.02,Other,225% New York Medicaid APG,1326.59,,,1326.59,Other,140% New York Medicaid APG,2132.02,,,2132.02,Other,225% New York Medicaid APG,2463.67,,,2463.67,Other,260% New York Medicaid APG,3070.11,,,3070.11,Other,324% New York Medicaid APG,2037.26,,,2037.26,Other,215% New York Medicaid APG,2037.26,,,2037.26,Other,215% New York Medicaid APG,1184.46,,,1184.46,Other,125% New York Medicaid APG,947.56,54261.89,
Secondary urethral surgery,54344,CPT,,,,,,,,both,,,35737.57,26445.8,74,,26445.8,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,16081.91,45,,16081.91,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,17690.1,49.5,,17690.1,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,1836.76,,,1836.76,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,25016.3,70,,25016.3,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,987.51,,,987.51,Other,New York Medicaid APG methodology,987.51,,,987.51,Other,100% New York Medicaid APG,987.51,,,987.51,Other,100% New York Medicaid APG,987.51,,,987.51,Other,100% New York Medicaid APG,2221.89,,,2221.89,Other,225% New York Medicaid APG,1510.88,,,1510.88,Other,153% New York Medicaid APG,2221.89,,,2221.89,Other,225% New York Medicaid APG,1382.51,,,1382.51,Other,140% New York Medicaid APG,2221.89,,,2221.89,Other,225% New York Medicaid APG,2567.51,,,2567.51,Other,260% New York Medicaid APG,3199.52,,,3199.52,Other,324% New York Medicaid APG,2123.14,,,2123.14,Other,215% New York Medicaid APG,2123.14,,,2123.14,Other,215% New York Medicaid APG,1234.38,,,1234.38,Other,125% New York Medicaid APG,987.51,26445.8,
Secondary urethral surgery,54348,CPT,,,,,,,,both,,,108835.97,80538.62,74,,80538.62,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,48976.19,45,,48976.19,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,53873.81,49.5,,53873.81,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,1836.76,,,1836.76,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,76185.18,70,,76185.18,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,987.51,,,987.51,Other,New York Medicaid APG methodology,987.51,,,987.51,Other,100% New York Medicaid APG,987.51,,,987.51,Other,100% New York Medicaid APG,987.51,,,987.51,Other,100% New York Medicaid APG,2221.89,,,2221.89,Other,225% New York Medicaid APG,1510.88,,,1510.88,Other,153% New York Medicaid APG,2221.89,,,2221.89,Other,225% New York Medicaid APG,1382.51,,,1382.51,Other,140% New York Medicaid APG,2221.89,,,2221.89,Other,225% New York Medicaid APG,2567.51,,,2567.51,Other,260% New York Medicaid APG,3199.52,,,3199.52,Other,324% New York Medicaid APG,2123.14,,,2123.14,Other,215% New York Medicaid APG,2123.14,,,2123.14,Other,215% New York Medicaid APG,1234.38,,,1234.38,Other,125% New York Medicaid APG,987.51,80538.62,
Reconstruct urethra/penis,54352,CPT,,,,,,,,both,,,43661.58,32309.57,74,,32309.57,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,19647.71,45,,19647.71,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,21612.48,49.5,,21612.48,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,1836.76,,,1836.76,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,30563.11,70,,30563.11,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,987.51,,,987.51,Other,New York Medicaid APG methodology,987.51,,,987.51,Other,100% New York Medicaid APG,987.51,,,987.51,Other,100% New York Medicaid APG,987.51,,,987.51,Other,100% New York Medicaid APG,2221.89,,,2221.89,Other,225% New York Medicaid APG,1510.88,,,1510.88,Other,153% New York Medicaid APG,2221.89,,,2221.89,Other,225% New York Medicaid APG,1382.51,,,1382.51,Other,140% New York Medicaid APG,2221.89,,,2221.89,Other,225% New York Medicaid APG,2567.51,,,2567.51,Other,260% New York Medicaid APG,3199.52,,,3199.52,Other,324% New York Medicaid APG,2123.14,,,2123.14,Other,215% New York Medicaid APG,2123.14,,,2123.14,Other,215% New York Medicaid APG,1234.38,,,1234.38,Other,125% New York Medicaid APG,987.51,32309.57,
Penis plastic surgery,54360,CPT,,,,,,,,both,,,34270.38,25360.08,74,,25360.08,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15421.67,45,,15421.67,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,16963.84,49.5,,16963.84,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,1762.47,,,1762.47,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,23989.27,70,,23989.27,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,947.56,,,947.56,Other,New York Medicaid APG methodology,947.56,,,947.56,Other,100% New York Medicaid APG,947.56,,,947.56,Other,100% New York Medicaid APG,947.56,,,947.56,Other,100% New York Medicaid APG,2132.02,,,2132.02,Other,225% New York Medicaid APG,1449.77,,,1449.77,Other,153% New York Medicaid APG,2132.02,,,2132.02,Other,225% New York Medicaid APG,1326.59,,,1326.59,Other,140% New York Medicaid APG,2132.02,,,2132.02,Other,225% New York Medicaid APG,2463.67,,,2463.67,Other,260% New York Medicaid APG,3070.11,,,3070.11,Other,324% New York Medicaid APG,2037.26,,,2037.26,Other,215% New York Medicaid APG,2037.26,,,2037.26,Other,215% New York Medicaid APG,1184.46,,,1184.46,Other,125% New York Medicaid APG,947.56,25360.08,
Repair penis,54380,CPT,,,,,,,,both,,,49175.08,36389.56,74,,36389.56,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,22128.79,45,,22128.79,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,24341.66,49.5,,24341.66,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,1762.47,,,1762.47,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,34422.56,70,,34422.56,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,947.56,,,947.56,Other,New York Medicaid APG methodology,947.56,,,947.56,Other,100% New York Medicaid APG,947.56,,,947.56,Other,100% New York Medicaid APG,947.56,,,947.56,Other,100% New York Medicaid APG,2132.02,,,2132.02,Other,225% New York Medicaid APG,1449.77,,,1449.77,Other,153% New York Medicaid APG,2132.02,,,2132.02,Other,225% New York Medicaid APG,1326.59,,,1326.59,Other,140% New York Medicaid APG,2132.02,,,2132.02,Other,225% New York Medicaid APG,2463.67,,,2463.67,Other,260% New York Medicaid APG,3070.11,,,3070.11,Other,324% New York Medicaid APG,2037.26,,,2037.26,Other,215% New York Medicaid APG,2037.26,,,2037.26,Other,215% New York Medicaid APG,1184.46,,,1184.46,Other,125% New York Medicaid APG,947.56,36389.56,
Repair penis,54385,CPT,,,,,,,,both,,,42841.82,31702.95,74,,31702.95,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,19278.82,45,,19278.82,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,21206.7,49.5,,21206.7,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,1762.47,,,1762.47,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,29989.27,70,,29989.27,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,947.56,,,947.56,Other,New York Medicaid APG methodology,947.56,,,947.56,Other,100% New York Medicaid APG,947.56,,,947.56,Other,100% New York Medicaid APG,947.56,,,947.56,Other,100% New York Medicaid APG,2132.02,,,2132.02,Other,225% New York Medicaid APG,1449.77,,,1449.77,Other,153% New York Medicaid APG,2132.02,,,2132.02,Other,225% New York Medicaid APG,1326.59,,,1326.59,Other,140% New York Medicaid APG,2132.02,,,2132.02,Other,225% New York Medicaid APG,2463.67,,,2463.67,Other,260% New York Medicaid APG,3070.11,,,3070.11,Other,324% New York Medicaid APG,2037.26,,,2037.26,Other,215% New York Medicaid APG,2037.26,,,2037.26,Other,215% New York Medicaid APG,1184.46,,,1184.46,Other,125% New York Medicaid APG,947.56,31702.95,
Insert semi-rigid prosthesis,54400,CPT,,,,,,,,both,,,270006.63,199804.91,74,,199804.91,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,121502.98,45,,121502.98,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,133653.28,49.5,,133653.28,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,8925.21,,,8925.21,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9196,,"100% primary, 0% secondary procedures",9196,Other,MagnaCare ASC Grouper,189004.64,70,,189004.64,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6956,,"100% primary, 50% secondary, 25% tertiary procedure",6956,Other,United Healthcare ASC Grouper,6261,,"100% primary, 50% secondary, 25% tertiary procedure",6261,Other,United Healthcare ASC Grouper,6956,,"100% primary, 50% secondary, 25% tertiary procedure",6956,Other,United Healthcare ASC Grouper,5913,,"100% primary, 50% secondary, 25% tertiary procedure",5913,Other,United Healthcare ASC Grouper,4798.5,,,4798.5,Other,New York Medicaid APG methodology,4798.5,,,4798.5,Other,100% New York Medicaid APG,4798.5,,,4798.5,Other,100% New York Medicaid APG,4798.5,,,4798.5,Other,100% New York Medicaid APG,10796.63,,,10796.63,Other,225% New York Medicaid APG,7341.71,,,7341.71,Other,153% New York Medicaid APG,10796.63,,,10796.63,Other,225% New York Medicaid APG,6717.9,,,6717.9,Other,140% New York Medicaid APG,10796.63,,,10796.63,Other,225% New York Medicaid APG,12476.1,,,12476.1,Other,260% New York Medicaid APG,15547.14,,,15547.14,Other,324% New York Medicaid APG,10316.78,,,10316.78,Other,215% New York Medicaid APG,10316.78,,,10316.78,Other,215% New York Medicaid APG,5998.13,,,5998.13,Other,125% New York Medicaid APG,3126,199804.91,
Insert self-contd prosthesis,54401,CPT,,,,,,,,both,,,424287.84,313973,74,,313973,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,190929.53,45,,190929.53,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,210022.48,49.5,,210022.48,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,8925.21,,,8925.21,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9196,,"100% primary, 0% secondary procedures",9196,Other,MagnaCare ASC Grouper,297001.49,70,,297001.49,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,7364,,"100% primary, 50% secondary, 25% tertiary procedure",7364,Other,United Healthcare ASC Grouper,6628,,"100% primary, 50% secondary, 25% tertiary procedure",6628,Other,United Healthcare ASC Grouper,7364,,"100% primary, 50% secondary, 25% tertiary procedure",7364,Other,United Healthcare ASC Grouper,6260,,"100% primary, 50% secondary, 25% tertiary procedure",6260,Other,United Healthcare ASC Grouper,4798.5,,,4798.5,Other,New York Medicaid APG methodology,4798.5,,,4798.5,Other,100% New York Medicaid APG,4798.5,,,4798.5,Other,100% New York Medicaid APG,4798.5,,,4798.5,Other,100% New York Medicaid APG,10796.63,,,10796.63,Other,225% New York Medicaid APG,7341.71,,,7341.71,Other,153% New York Medicaid APG,10796.63,,,10796.63,Other,225% New York Medicaid APG,6717.9,,,6717.9,Other,140% New York Medicaid APG,10796.63,,,10796.63,Other,225% New York Medicaid APG,12476.1,,,12476.1,Other,260% New York Medicaid APG,15547.14,,,15547.14,Other,324% New York Medicaid APG,10316.78,,,10316.78,Other,215% New York Medicaid APG,10316.78,,,10316.78,Other,215% New York Medicaid APG,5998.13,,,5998.13,Other,125% New York Medicaid APG,3126,313973,
Insert multi-comp penis pros,54405,CPT,,,,,,,,both,,,79905.35,59129.96,74,,59129.96,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,35957.41,45,,35957.41,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,39553.15,49.5,,39553.15,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,8925.21,,,8925.21,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9196,,"100% primary, 0% secondary procedures",9196,Other,MagnaCare ASC Grouper,55933.75,70,,55933.75,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,7364,,"100% primary, 50% secondary, 25% tertiary procedure",7364,Other,United Healthcare ASC Grouper,6628,,"100% primary, 50% secondary, 25% tertiary procedure",6628,Other,United Healthcare ASC Grouper,7364,,"100% primary, 50% secondary, 25% tertiary procedure",7364,Other,United Healthcare ASC Grouper,6260,,"100% primary, 50% secondary, 25% tertiary procedure",6260,Other,United Healthcare ASC Grouper,4798.5,,,4798.5,Other,New York Medicaid APG methodology,4798.5,,,4798.5,Other,100% New York Medicaid APG,4798.5,,,4798.5,Other,100% New York Medicaid APG,4798.5,,,4798.5,Other,100% New York Medicaid APG,10796.63,,,10796.63,Other,225% New York Medicaid APG,7341.71,,,7341.71,Other,153% New York Medicaid APG,10796.63,,,10796.63,Other,225% New York Medicaid APG,6717.9,,,6717.9,Other,140% New York Medicaid APG,10796.63,,,10796.63,Other,225% New York Medicaid APG,12476.1,,,12476.1,Other,260% New York Medicaid APG,15547.14,,,15547.14,Other,324% New York Medicaid APG,10316.78,,,10316.78,Other,215% New York Medicaid APG,10316.78,,,10316.78,Other,215% New York Medicaid APG,5998.13,,,5998.13,Other,125% New York Medicaid APG,3126,59129.96,
Remove muti-comp penis pros,54406,CPT,,,,,,,,both,,,73326.88,54261.89,74,,54261.89,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,32997.1,45,,32997.1,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,36296.81,49.5,,36296.81,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,1762.47,,,1762.47,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,51328.82,70,,51328.82,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,947.56,,,947.56,Other,New York Medicaid APG methodology,947.56,,,947.56,Other,100% New York Medicaid APG,947.56,,,947.56,Other,100% New York Medicaid APG,947.56,,,947.56,Other,100% New York Medicaid APG,2132.02,,,2132.02,Other,225% New York Medicaid APG,1449.77,,,1449.77,Other,153% New York Medicaid APG,2132.02,,,2132.02,Other,225% New York Medicaid APG,1326.59,,,1326.59,Other,140% New York Medicaid APG,2132.02,,,2132.02,Other,225% New York Medicaid APG,2463.67,,,2463.67,Other,260% New York Medicaid APG,3070.11,,,3070.11,Other,324% New York Medicaid APG,2037.26,,,2037.26,Other,215% New York Medicaid APG,2037.26,,,2037.26,Other,215% New York Medicaid APG,1184.46,,,1184.46,Other,125% New York Medicaid APG,947.56,54261.89,
Repair multi-comp penis pros,54408,CPT,,,,,,,,both,,,108835.97,80538.62,74,,80538.62,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,48976.19,45,,48976.19,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,53873.81,49.5,,53873.81,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,1762.47,,,1762.47,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,76185.18,70,,76185.18,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,947.56,,,947.56,Other,New York Medicaid APG methodology,947.56,,,947.56,Other,100% New York Medicaid APG,947.56,,,947.56,Other,100% New York Medicaid APG,947.56,,,947.56,Other,100% New York Medicaid APG,2132.02,,,2132.02,Other,225% New York Medicaid APG,1449.77,,,1449.77,Other,153% New York Medicaid APG,2132.02,,,2132.02,Other,225% New York Medicaid APG,1326.59,,,1326.59,Other,140% New York Medicaid APG,2132.02,,,2132.02,Other,225% New York Medicaid APG,2463.67,,,2463.67,Other,260% New York Medicaid APG,3070.11,,,3070.11,Other,324% New York Medicaid APG,2037.26,,,2037.26,Other,215% New York Medicaid APG,2037.26,,,2037.26,Other,215% New York Medicaid APG,1184.46,,,1184.46,Other,125% New York Medicaid APG,947.56,80538.62,
Remove/replace penis prosth,54410,CPT,,,,,,,,both,,,103369.65,76493.54,74,,76493.54,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,46516.34,45,,46516.34,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,51167.98,49.5,,51167.98,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,8925.21,,,8925.21,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9196,,"100% primary, 0% secondary procedures",9196,Other,MagnaCare ASC Grouper,72358.76,70,,72358.76,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,7364,,"100% primary, 50% secondary, 25% tertiary procedure",7364,Other,United Healthcare ASC Grouper,6628,,"100% primary, 50% secondary, 25% tertiary procedure",6628,Other,United Healthcare ASC Grouper,7364,,"100% primary, 50% secondary, 25% tertiary procedure",7364,Other,United Healthcare ASC Grouper,6260,,"100% primary, 50% secondary, 25% tertiary procedure",6260,Other,United Healthcare ASC Grouper,4798.5,,,4798.5,Other,New York Medicaid APG methodology,4798.5,,,4798.5,Other,100% New York Medicaid APG,4798.5,,,4798.5,Other,100% New York Medicaid APG,4798.5,,,4798.5,Other,100% New York Medicaid APG,10796.63,,,10796.63,Other,225% New York Medicaid APG,7341.71,,,7341.71,Other,153% New York Medicaid APG,10796.63,,,10796.63,Other,225% New York Medicaid APG,6717.9,,,6717.9,Other,140% New York Medicaid APG,10796.63,,,10796.63,Other,225% New York Medicaid APG,12476.1,,,12476.1,Other,260% New York Medicaid APG,15547.14,,,15547.14,Other,324% New York Medicaid APG,10316.78,,,10316.78,Other,215% New York Medicaid APG,10316.78,,,10316.78,Other,215% New York Medicaid APG,5998.13,,,5998.13,Other,125% New York Medicaid APG,3126,76493.54,
Remov/replc penis pros comp,54411,CPT,,,,,,,,both,,,424287.84,313973,74,,313973,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,190929.53,45,,190929.53,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,210022.48,49.5,,210022.48,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,8925.21,,,8925.21,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,297001.49,70,,297001.49,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,4798.5,,,4798.5,Other,New York Medicaid APG methodology,4798.5,,,4798.5,Other,100% New York Medicaid APG,4798.5,,,4798.5,Other,100% New York Medicaid APG,4798.5,,,4798.5,Other,100% New York Medicaid APG,10796.63,,,10796.63,Other,225% New York Medicaid APG,7341.71,,,7341.71,Other,153% New York Medicaid APG,10796.63,,,10796.63,Other,225% New York Medicaid APG,6717.9,,,6717.9,Other,140% New York Medicaid APG,10796.63,,,10796.63,Other,225% New York Medicaid APG,12476.1,,,12476.1,Other,260% New York Medicaid APG,15547.14,,,15547.14,Other,324% New York Medicaid APG,10316.78,,,10316.78,Other,215% New York Medicaid APG,10316.78,,,10316.78,Other,215% New York Medicaid APG,5998.13,,,5998.13,Other,125% New York Medicaid APG,2743,313973,
Remove self-contd penis pros,54415,CPT,,,,,,,,both,,,73326.88,54261.89,74,,54261.89,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,32997.1,45,,32997.1,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,36296.81,49.5,,36296.81,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,1762.47,,,1762.47,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,51328.82,70,,51328.82,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,947.56,,,947.56,Other,New York Medicaid APG methodology,947.56,,,947.56,Other,100% New York Medicaid APG,947.56,,,947.56,Other,100% New York Medicaid APG,947.56,,,947.56,Other,100% New York Medicaid APG,2132.02,,,2132.02,Other,225% New York Medicaid APG,1449.77,,,1449.77,Other,153% New York Medicaid APG,2132.02,,,2132.02,Other,225% New York Medicaid APG,1326.59,,,1326.59,Other,140% New York Medicaid APG,2132.02,,,2132.02,Other,225% New York Medicaid APG,2463.67,,,2463.67,Other,260% New York Medicaid APG,3070.11,,,3070.11,Other,324% New York Medicaid APG,2037.26,,,2037.26,Other,215% New York Medicaid APG,2037.26,,,2037.26,Other,215% New York Medicaid APG,1184.46,,,1184.46,Other,125% New York Medicaid APG,947.56,54261.89,
Remv/repl penis contain pros,54416,CPT,,,,,,,,both,,,47066.38,34829.12,74,,34829.12,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,21179.87,45,,21179.87,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,23297.86,49.5,,23297.86,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,8925.21,,,8925.21,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9196,,"100% primary, 0% secondary procedures",9196,Other,MagnaCare ASC Grouper,32946.47,70,,32946.47,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,7364,,"100% primary, 50% secondary, 25% tertiary procedure",7364,Other,United Healthcare ASC Grouper,6628,,"100% primary, 50% secondary, 25% tertiary procedure",6628,Other,United Healthcare ASC Grouper,7364,,"100% primary, 50% secondary, 25% tertiary procedure",7364,Other,United Healthcare ASC Grouper,6260,,"100% primary, 50% secondary, 25% tertiary procedure",6260,Other,United Healthcare ASC Grouper,4798.5,,,4798.5,Other,New York Medicaid APG methodology,4798.5,,,4798.5,Other,100% New York Medicaid APG,4798.5,,,4798.5,Other,100% New York Medicaid APG,4798.5,,,4798.5,Other,100% New York Medicaid APG,10796.63,,,10796.63,Other,225% New York Medicaid APG,7341.71,,,7341.71,Other,153% New York Medicaid APG,10796.63,,,10796.63,Other,225% New York Medicaid APG,6717.9,,,6717.9,Other,140% New York Medicaid APG,10796.63,,,10796.63,Other,225% New York Medicaid APG,12476.1,,,12476.1,Other,260% New York Medicaid APG,15547.14,,,15547.14,Other,324% New York Medicaid APG,10316.78,,,10316.78,Other,215% New York Medicaid APG,10316.78,,,10316.78,Other,215% New York Medicaid APG,5998.13,,,5998.13,Other,125% New York Medicaid APG,3126,34829.12,
Remv/replc penis pros compl,54417,CPT,,,,,,,,both,,,270006.63,199804.91,74,,199804.91,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,121502.98,45,,121502.98,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,133653.28,49.5,,133653.28,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,8925.21,,,8925.21,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,3578,,"100% primary, 0% secondary procedures",3578,Other,MagnaCare ASC Grouper,189004.64,70,,189004.64,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,4798.5,,,4798.5,Other,New York Medicaid APG methodology,4798.5,,,4798.5,Other,100% New York Medicaid APG,4798.5,,,4798.5,Other,100% New York Medicaid APG,4798.5,,,4798.5,Other,100% New York Medicaid APG,10796.63,,,10796.63,Other,225% New York Medicaid APG,7341.71,,,7341.71,Other,153% New York Medicaid APG,10796.63,,,10796.63,Other,225% New York Medicaid APG,6717.9,,,6717.9,Other,140% New York Medicaid APG,10796.63,,,10796.63,Other,225% New York Medicaid APG,12476.1,,,12476.1,Other,260% New York Medicaid APG,15547.14,,,15547.14,Other,324% New York Medicaid APG,10316.78,,,10316.78,Other,215% New York Medicaid APG,10316.78,,,10316.78,Other,215% New York Medicaid APG,5998.13,,,5998.13,Other,125% New York Medicaid APG,2743,199804.91,
Revision of penis,54420,CPT,,,,,,,,both,,,73326.88,54261.89,74,,54261.89,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,32997.1,45,,32997.1,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,36296.81,49.5,,36296.81,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,1762.47,,,1762.47,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,51328.82,70,,51328.82,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,947.56,,,947.56,Other,New York Medicaid APG methodology,947.56,,,947.56,Other,100% New York Medicaid APG,947.56,,,947.56,Other,100% New York Medicaid APG,947.56,,,947.56,Other,100% New York Medicaid APG,2132.02,,,2132.02,Other,225% New York Medicaid APG,1449.77,,,1449.77,Other,153% New York Medicaid APG,2132.02,,,2132.02,Other,225% New York Medicaid APG,1326.59,,,1326.59,Other,140% New York Medicaid APG,2132.02,,,2132.02,Other,225% New York Medicaid APG,2463.67,,,2463.67,Other,260% New York Medicaid APG,3070.11,,,3070.11,Other,324% New York Medicaid APG,2037.26,,,2037.26,Other,215% New York Medicaid APG,2037.26,,,2037.26,Other,215% New York Medicaid APG,1184.46,,,1184.46,Other,125% New York Medicaid APG,947.56,54261.89,
Revision of penis,54435,CPT,,,,,,,,both,,,73326.88,54261.89,74,,54261.89,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,32997.1,45,,32997.1,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,36296.81,49.5,,36296.81,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,1762.47,,,1762.47,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,51328.82,70,,51328.82,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,947.56,,,947.56,Other,New York Medicaid APG methodology,947.56,,,947.56,Other,100% New York Medicaid APG,947.56,,,947.56,Other,100% New York Medicaid APG,947.56,,,947.56,Other,100% New York Medicaid APG,2132.02,,,2132.02,Other,225% New York Medicaid APG,1449.77,,,1449.77,Other,153% New York Medicaid APG,2132.02,,,2132.02,Other,225% New York Medicaid APG,1326.59,,,1326.59,Other,140% New York Medicaid APG,2132.02,,,2132.02,Other,225% New York Medicaid APG,2463.67,,,2463.67,Other,260% New York Medicaid APG,3070.11,,,3070.11,Other,324% New York Medicaid APG,2037.26,,,2037.26,Other,215% New York Medicaid APG,2037.26,,,2037.26,Other,215% New York Medicaid APG,1184.46,,,1184.46,Other,125% New York Medicaid APG,947.56,54261.89,
Repair corporeal tear,54437,CPT,,,,,,,,both,,,73326.88,54261.89,74,,54261.89,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,32997.1,45,,32997.1,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,36296.81,49.5,,36296.81,percent of total billed charges,110% of Medicare,49862.28,68,,49862.28,percent of total billed charges,,1836.76,,,1836.76,Other,186% of Medicaid,58661.5,80,,58661.5,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,58661.5,80,,58661.5,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,51328.82,70,,51328.82,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,987.51,,,987.51,Other,New York Medicaid APG methodology,987.51,,,987.51,Other,100% New York Medicaid APG,987.51,,,987.51,Other,100% New York Medicaid APG,987.51,,,987.51,Other,100% New York Medicaid APG,2221.89,,,2221.89,Other,225% New York Medicaid APG,1510.88,,,1510.88,Other,153% New York Medicaid APG,2221.89,,,2221.89,Other,225% New York Medicaid APG,1382.51,,,1382.51,Other,140% New York Medicaid APG,2221.89,,,2221.89,Other,225% New York Medicaid APG,2567.51,,,2567.51,Other,260% New York Medicaid APG,3199.52,,,3199.52,Other,324% New York Medicaid APG,2123.14,,,2123.14,Other,215% New York Medicaid APG,2123.14,,,2123.14,Other,215% New York Medicaid APG,1234.38,,,1234.38,Other,125% New York Medicaid APG,987.51,58661.5,
Repair of penis,54440,CPT,,,,,,,,both,,,73326.88,54261.89,74,,54261.89,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,32997.1,45,,32997.1,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,36296.81,49.5,,36296.81,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,1762.47,,,1762.47,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,51328.82,70,,51328.82,percent of total billed charges,,47662.47,65,,47662.47,percent of total billed charges,,47662.47,65,,47662.47,percent of total billed charges,,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,947.56,,,947.56,Other,New York Medicaid APG methodology,947.56,,,947.56,Other,100% New York Medicaid APG,947.56,,,947.56,Other,100% New York Medicaid APG,947.56,,,947.56,Other,100% New York Medicaid APG,2132.02,,,2132.02,Other,225% New York Medicaid APG,1449.77,,,1449.77,Other,153% New York Medicaid APG,2132.02,,,2132.02,Other,225% New York Medicaid APG,1326.59,,,1326.59,Other,140% New York Medicaid APG,2132.02,,,2132.02,Other,225% New York Medicaid APG,2463.67,,,2463.67,Other,260% New York Medicaid APG,3070.11,,,3070.11,Other,324% New York Medicaid APG,2037.26,,,2037.26,Other,215% New York Medicaid APG,2037.26,,,2037.26,Other,215% New York Medicaid APG,1184.46,,,1184.46,Other,125% New York Medicaid APG,947.56,54261.89,
Preputial stretching,54450,CPT,,,,,,,,both,,,34263.79,25355.2,74,,25355.2,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15418.71,45,,15418.71,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,16960.58,49.5,,16960.58,percent of total billed charges,110% of Medicare,23299.38,68,,23299.38,percent of total billed charges,,903.43,,,903.43,Other,186% of Medicaid,27411.03,80,,27411.03,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,27411.03,80,,27411.03,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,23984.65,70,,23984.65,percent of total billed charges,,275.52,,,275.52,Fee Schedule,,233.52,,,233.52,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,485.72,,,485.72,Other,New York Medicaid APG methodology,485.72,,,485.72,Other,100% New York Medicaid APG,485.72,,,485.72,Other,100% New York Medicaid APG,485.72,,,485.72,Other,100% New York Medicaid APG,1092.86,,,1092.86,Other,225% New York Medicaid APG,743.14,,,743.14,Other,153% New York Medicaid APG,1092.86,,,1092.86,Other,225% New York Medicaid APG,680,,,680,Other,140% New York Medicaid APG,1092.86,,,1092.86,Other,225% New York Medicaid APG,1262.86,,,1262.86,Other,260% New York Medicaid APG,1573.72,,,1573.72,Other,324% New York Medicaid APG,1044.29,,,1044.29,Other,215% New York Medicaid APG,1044.29,,,1044.29,Other,215% New York Medicaid APG,607.14,,,607.14,Other,125% New York Medicaid APG,233.52,27411.03,
Biopsy of testis,54500,CPT,,,,,,,,both,,,59767.2,44227.73,74,,44227.73,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,26895.24,45,,26895.24,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,29584.76,49.5,,29584.76,percent of total billed charges,110% of Medicare,40641.7,68,,40641.7,percent of total billed charges,,903.43,,,903.43,Other,186% of Medicaid,47813.76,80,,47813.76,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,47813.76,80,,47813.76,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,41837.04,70,,41837.04,percent of total billed charges,,360.8,,,360.8,Fee Schedule,,305.8,,,305.8,Fee Schedule,,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,485.72,,,485.72,Other,New York Medicaid APG methodology,485.72,,,485.72,Other,100% New York Medicaid APG,485.72,,,485.72,Other,100% New York Medicaid APG,485.72,,,485.72,Other,100% New York Medicaid APG,1092.86,,,1092.86,Other,225% New York Medicaid APG,743.14,,,743.14,Other,153% New York Medicaid APG,1092.86,,,1092.86,Other,225% New York Medicaid APG,680,,,680,Other,140% New York Medicaid APG,1092.86,,,1092.86,Other,225% New York Medicaid APG,1262.86,,,1262.86,Other,260% New York Medicaid APG,1573.72,,,1573.72,Other,324% New York Medicaid APG,1044.29,,,1044.29,Other,215% New York Medicaid APG,1044.29,,,1044.29,Other,215% New York Medicaid APG,607.14,,,607.14,Other,125% New York Medicaid APG,305.8,47813.76,
Biopsy of testis,54505,CPT,,,,,,,,both,,,43881.96,32472.65,74,,32472.65,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,19746.88,45,,19746.88,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,21721.57,49.5,,21721.57,percent of total billed charges,110% of Medicare,29839.73,68,,29839.73,percent of total billed charges,,1762.47,,,1762.47,Other,186% of Medicaid,35105.57,80,,35105.57,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,35105.57,80,,35105.57,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,30717.37,70,,30717.37,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,947.56,,,947.56,Other,New York Medicaid APG methodology,947.56,,,947.56,Other,100% New York Medicaid APG,947.56,,,947.56,Other,100% New York Medicaid APG,947.56,,,947.56,Other,100% New York Medicaid APG,2132.02,,,2132.02,Other,225% New York Medicaid APG,1449.77,,,1449.77,Other,153% New York Medicaid APG,2132.02,,,2132.02,Other,225% New York Medicaid APG,1326.59,,,1326.59,Other,140% New York Medicaid APG,2132.02,,,2132.02,Other,225% New York Medicaid APG,2463.67,,,2463.67,Other,260% New York Medicaid APG,3070.11,,,3070.11,Other,324% New York Medicaid APG,2037.26,,,2037.26,Other,215% New York Medicaid APG,2037.26,,,2037.26,Other,215% New York Medicaid APG,1184.46,,,1184.46,Other,125% New York Medicaid APG,947.56,35105.57,
Excise lesion testis,54512,CPT,,,,,,,,both,,,35393.63,26191.29,74,,26191.29,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15927.13,45,,15927.13,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,17519.85,49.5,,17519.85,percent of total billed charges,110% of Medicare,24067.67,68,,24067.67,percent of total billed charges,,2347.14,,,2347.14,Other,186% of Medicaid,28314.9,80,,28314.9,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,28314.9,80,,28314.9,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,24775.54,70,,24775.54,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1261.9,,,1261.9,Other,New York Medicaid APG methodology,1261.9,,,1261.9,Other,100% New York Medicaid APG,1261.9,,,1261.9,Other,100% New York Medicaid APG,1261.9,,,1261.9,Other,100% New York Medicaid APG,2839.28,,,2839.28,Other,225% New York Medicaid APG,1930.71,,,1930.71,Other,153% New York Medicaid APG,2839.28,,,2839.28,Other,225% New York Medicaid APG,1766.66,,,1766.66,Other,140% New York Medicaid APG,2839.28,,,2839.28,Other,225% New York Medicaid APG,3280.94,,,3280.94,Other,260% New York Medicaid APG,4088.56,,,4088.56,Other,324% New York Medicaid APG,2713.09,,,2713.09,Other,215% New York Medicaid APG,2713.09,,,2713.09,Other,215% New York Medicaid APG,1577.38,,,1577.38,Other,125% New York Medicaid APG,1261.9,28314.9,
Removal of testis,54520,CPT,,,,,,,,both,,,35952.94,26605.18,74,,26605.18,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,16178.82,45,,16178.82,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,17796.71,49.5,,17796.71,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2347.14,,,2347.14,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,25167.06,70,,25167.06,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1261.9,,,1261.9,Other,New York Medicaid APG methodology,1261.9,,,1261.9,Other,100% New York Medicaid APG,1261.9,,,1261.9,Other,100% New York Medicaid APG,1261.9,,,1261.9,Other,100% New York Medicaid APG,2839.28,,,2839.28,Other,225% New York Medicaid APG,1930.71,,,1930.71,Other,153% New York Medicaid APG,2839.28,,,2839.28,Other,225% New York Medicaid APG,1766.66,,,1766.66,Other,140% New York Medicaid APG,2839.28,,,2839.28,Other,225% New York Medicaid APG,3280.94,,,3280.94,Other,260% New York Medicaid APG,4088.56,,,4088.56,Other,324% New York Medicaid APG,2713.09,,,2713.09,Other,215% New York Medicaid APG,2713.09,,,2713.09,Other,215% New York Medicaid APG,1577.38,,,1577.38,Other,125% New York Medicaid APG,1261.9,26605.18,
Orchiectomy partial,54522,CPT,,,,,,,,both,,,73326.88,54261.89,74,,54261.89,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,32997.1,45,,32997.1,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,36296.81,49.5,,36296.81,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,1762.47,,,1762.47,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,51328.82,70,,51328.82,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,947.56,,,947.56,Other,New York Medicaid APG methodology,947.56,,,947.56,Other,100% New York Medicaid APG,947.56,,,947.56,Other,100% New York Medicaid APG,947.56,,,947.56,Other,100% New York Medicaid APG,2132.02,,,2132.02,Other,225% New York Medicaid APG,1449.77,,,1449.77,Other,153% New York Medicaid APG,2132.02,,,2132.02,Other,225% New York Medicaid APG,1326.59,,,1326.59,Other,140% New York Medicaid APG,2132.02,,,2132.02,Other,225% New York Medicaid APG,2463.67,,,2463.67,Other,260% New York Medicaid APG,3070.11,,,3070.11,Other,324% New York Medicaid APG,2037.26,,,2037.26,Other,215% New York Medicaid APG,2037.26,,,2037.26,Other,215% New York Medicaid APG,1184.46,,,1184.46,Other,125% New York Medicaid APG,947.56,54261.89,
Removal of testis,54530,CPT,,,,,,,,both,,,46027.24,34060.16,74,,34060.16,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,20712.26,45,,20712.26,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,22783.48,49.5,,22783.48,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,1762.47,,,1762.47,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,32219.07,70,,32219.07,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,947.56,,,947.56,Other,New York Medicaid APG methodology,947.56,,,947.56,Other,100% New York Medicaid APG,947.56,,,947.56,Other,100% New York Medicaid APG,947.56,,,947.56,Other,100% New York Medicaid APG,2132.02,,,2132.02,Other,225% New York Medicaid APG,1449.77,,,1449.77,Other,153% New York Medicaid APG,2132.02,,,2132.02,Other,225% New York Medicaid APG,1326.59,,,1326.59,Other,140% New York Medicaid APG,2132.02,,,2132.02,Other,225% New York Medicaid APG,2463.67,,,2463.67,Other,260% New York Medicaid APG,3070.11,,,3070.11,Other,324% New York Medicaid APG,2037.26,,,2037.26,Other,215% New York Medicaid APG,2037.26,,,2037.26,Other,215% New York Medicaid APG,1184.46,,,1184.46,Other,125% New York Medicaid APG,947.56,34060.16,
Extensive testis surgery,54535,CPT,,,,,,,,both,,,73326.88,54261.89,74,,54261.89,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,32997.1,45,,32997.1,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,36296.81,49.5,,36296.81,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,1762.47,,,1762.47,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,51328.82,70,,51328.82,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,947.56,,,947.56,Other,New York Medicaid APG methodology,947.56,,,947.56,Other,100% New York Medicaid APG,947.56,,,947.56,Other,100% New York Medicaid APG,947.56,,,947.56,Other,100% New York Medicaid APG,2132.02,,,2132.02,Other,225% New York Medicaid APG,1449.77,,,1449.77,Other,153% New York Medicaid APG,2132.02,,,2132.02,Other,225% New York Medicaid APG,1326.59,,,1326.59,Other,140% New York Medicaid APG,2132.02,,,2132.02,Other,225% New York Medicaid APG,2463.67,,,2463.67,Other,260% New York Medicaid APG,3070.11,,,3070.11,Other,324% New York Medicaid APG,2037.26,,,2037.26,Other,215% New York Medicaid APG,2037.26,,,2037.26,Other,215% New York Medicaid APG,1184.46,,,1184.46,Other,125% New York Medicaid APG,947.56,54261.89,
Exploration for testis,54550,CPT,,,,,,,,both,,,36454.18,26976.09,74,,26976.09,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,16404.38,45,,16404.38,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,18044.82,49.5,,18044.82,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2347.14,,,2347.14,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,25517.93,70,,25517.93,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1261.9,,,1261.9,Other,New York Medicaid APG methodology,1261.9,,,1261.9,Other,100% New York Medicaid APG,1261.9,,,1261.9,Other,100% New York Medicaid APG,1261.9,,,1261.9,Other,100% New York Medicaid APG,2839.28,,,2839.28,Other,225% New York Medicaid APG,1930.71,,,1930.71,Other,153% New York Medicaid APG,2839.28,,,2839.28,Other,225% New York Medicaid APG,1766.66,,,1766.66,Other,140% New York Medicaid APG,2839.28,,,2839.28,Other,225% New York Medicaid APG,3280.94,,,3280.94,Other,260% New York Medicaid APG,4088.56,,,4088.56,Other,324% New York Medicaid APG,2713.09,,,2713.09,Other,215% New York Medicaid APG,2713.09,,,2713.09,Other,215% New York Medicaid APG,1577.38,,,1577.38,Other,125% New York Medicaid APG,1261.9,26976.09,
Exploration for testis,54560,CPT,,,,,,,,both,,,42841.82,31702.95,74,,31702.95,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,19278.82,45,,19278.82,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,21206.7,49.5,,21206.7,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,1762.47,,,1762.47,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,29989.27,70,,29989.27,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,947.56,,,947.56,Other,New York Medicaid APG methodology,947.56,,,947.56,Other,100% New York Medicaid APG,947.56,,,947.56,Other,100% New York Medicaid APG,947.56,,,947.56,Other,100% New York Medicaid APG,2132.02,,,2132.02,Other,225% New York Medicaid APG,1449.77,,,1449.77,Other,153% New York Medicaid APG,2132.02,,,2132.02,Other,225% New York Medicaid APG,1326.59,,,1326.59,Other,140% New York Medicaid APG,2132.02,,,2132.02,Other,225% New York Medicaid APG,2463.67,,,2463.67,Other,260% New York Medicaid APG,3070.11,,,3070.11,Other,324% New York Medicaid APG,2037.26,,,2037.26,Other,215% New York Medicaid APG,2037.26,,,2037.26,Other,215% New York Medicaid APG,1184.46,,,1184.46,Other,125% New York Medicaid APG,947.56,31702.95,
Reduce testis torsion,54600,CPT,,,,,,,,both,,,33768.86,24988.96,74,,24988.96,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15195.99,45,,15195.99,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,16715.59,49.5,,16715.59,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2347.14,,,2347.14,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,23638.2,70,,23638.2,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1261.9,,,1261.9,Other,New York Medicaid APG methodology,1261.9,,,1261.9,Other,100% New York Medicaid APG,1261.9,,,1261.9,Other,100% New York Medicaid APG,1261.9,,,1261.9,Other,100% New York Medicaid APG,2839.28,,,2839.28,Other,225% New York Medicaid APG,1930.71,,,1930.71,Other,153% New York Medicaid APG,2839.28,,,2839.28,Other,225% New York Medicaid APG,1766.66,,,1766.66,Other,140% New York Medicaid APG,2839.28,,,2839.28,Other,225% New York Medicaid APG,3280.94,,,3280.94,Other,260% New York Medicaid APG,4088.56,,,4088.56,Other,324% New York Medicaid APG,2713.09,,,2713.09,Other,215% New York Medicaid APG,2713.09,,,2713.09,Other,215% New York Medicaid APG,1577.38,,,1577.38,Other,125% New York Medicaid APG,1261.9,24988.96,
Suspension of testis,54620,CPT,,,,,,,,both,,,35695.25,26414.49,74,,26414.49,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,16062.86,45,,16062.86,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,17669.15,49.5,,17669.15,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2347.14,,,2347.14,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,24986.68,70,,24986.68,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1261.9,,,1261.9,Other,New York Medicaid APG methodology,1261.9,,,1261.9,Other,100% New York Medicaid APG,1261.9,,,1261.9,Other,100% New York Medicaid APG,1261.9,,,1261.9,Other,100% New York Medicaid APG,2839.28,,,2839.28,Other,225% New York Medicaid APG,1930.71,,,1930.71,Other,153% New York Medicaid APG,2839.28,,,2839.28,Other,225% New York Medicaid APG,1766.66,,,1766.66,Other,140% New York Medicaid APG,2839.28,,,2839.28,Other,225% New York Medicaid APG,3280.94,,,3280.94,Other,260% New York Medicaid APG,4088.56,,,4088.56,Other,324% New York Medicaid APG,2713.09,,,2713.09,Other,215% New York Medicaid APG,2713.09,,,2713.09,Other,215% New York Medicaid APG,1577.38,,,1577.38,Other,125% New York Medicaid APG,1261.9,26414.49,
Orchiopexy ingun/scrot appr,54640,CPT,,,,,,,,both,,,35467.74,26246.13,74,,26246.13,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15960.48,45,,15960.48,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,17556.53,49.5,,17556.53,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2347.14,,,2347.14,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,24827.42,70,,24827.42,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1261.9,,,1261.9,Other,New York Medicaid APG methodology,1261.9,,,1261.9,Other,100% New York Medicaid APG,1261.9,,,1261.9,Other,100% New York Medicaid APG,1261.9,,,1261.9,Other,100% New York Medicaid APG,2839.28,,,2839.28,Other,225% New York Medicaid APG,1930.71,,,1930.71,Other,153% New York Medicaid APG,2839.28,,,2839.28,Other,225% New York Medicaid APG,1766.66,,,1766.66,Other,140% New York Medicaid APG,2839.28,,,2839.28,Other,225% New York Medicaid APG,3280.94,,,3280.94,Other,260% New York Medicaid APG,4088.56,,,4088.56,Other,324% New York Medicaid APG,2713.09,,,2713.09,Other,215% New York Medicaid APG,2713.09,,,2713.09,Other,215% New York Medicaid APG,1577.38,,,1577.38,Other,125% New York Medicaid APG,1261.9,26246.13,
Orchiopexy (fowler-stephens),54650,CPT,,,,,,,,both,,,72769.69,53849.57,74,,53849.57,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,32746.36,45,,32746.36,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,36021,49.5,,36021,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,1762.47,,,1762.47,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,50938.78,70,,50938.78,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,947.56,,,947.56,Other,New York Medicaid APG methodology,947.56,,,947.56,Other,100% New York Medicaid APG,947.56,,,947.56,Other,100% New York Medicaid APG,947.56,,,947.56,Other,100% New York Medicaid APG,2132.02,,,2132.02,Other,225% New York Medicaid APG,1449.77,,,1449.77,Other,153% New York Medicaid APG,2132.02,,,2132.02,Other,225% New York Medicaid APG,1326.59,,,1326.59,Other,140% New York Medicaid APG,2132.02,,,2132.02,Other,225% New York Medicaid APG,2463.67,,,2463.67,Other,260% New York Medicaid APG,3070.11,,,3070.11,Other,324% New York Medicaid APG,2037.26,,,2037.26,Other,215% New York Medicaid APG,2037.26,,,2037.26,Other,215% New York Medicaid APG,1184.46,,,1184.46,Other,125% New York Medicaid APG,947.56,53849.57,
Revision of testis,54660,CPT,,,,,,,,both,,,41031.71,30363.47,74,,30363.47,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,18464.27,45,,18464.27,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,20310.7,49.5,,20310.7,percent of total billed charges,110% of Medicare,27901.56,68,,27901.56,percent of total billed charges,,1762.47,,,1762.47,Other,186% of Medicaid,32825.37,80,,32825.37,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,32825.37,80,,32825.37,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,28722.2,70,,28722.2,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,947.56,,,947.56,Other,New York Medicaid APG methodology,947.56,,,947.56,Other,100% New York Medicaid APG,947.56,,,947.56,Other,100% New York Medicaid APG,947.56,,,947.56,Other,100% New York Medicaid APG,2132.02,,,2132.02,Other,225% New York Medicaid APG,1449.77,,,1449.77,Other,153% New York Medicaid APG,2132.02,,,2132.02,Other,225% New York Medicaid APG,1326.59,,,1326.59,Other,140% New York Medicaid APG,2132.02,,,2132.02,Other,225% New York Medicaid APG,2463.67,,,2463.67,Other,260% New York Medicaid APG,3070.11,,,3070.11,Other,324% New York Medicaid APG,2037.26,,,2037.26,Other,215% New York Medicaid APG,2037.26,,,2037.26,Other,215% New York Medicaid APG,1184.46,,,1184.46,Other,125% New York Medicaid APG,947.56,32825.37,
Repair testis injury,54670,CPT,,,,,,,,both,,,73326.88,54261.89,74,,54261.89,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,32997.1,45,,32997.1,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,36296.81,49.5,,36296.81,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2347.14,,,2347.14,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,51328.82,70,,51328.82,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1261.9,,,1261.9,Other,New York Medicaid APG methodology,1261.9,,,1261.9,Other,100% New York Medicaid APG,1261.9,,,1261.9,Other,100% New York Medicaid APG,1261.9,,,1261.9,Other,100% New York Medicaid APG,2839.28,,,2839.28,Other,225% New York Medicaid APG,1930.71,,,1930.71,Other,153% New York Medicaid APG,2839.28,,,2839.28,Other,225% New York Medicaid APG,1766.66,,,1766.66,Other,140% New York Medicaid APG,2839.28,,,2839.28,Other,225% New York Medicaid APG,3280.94,,,3280.94,Other,260% New York Medicaid APG,4088.56,,,4088.56,Other,324% New York Medicaid APG,2713.09,,,2713.09,Other,215% New York Medicaid APG,2713.09,,,2713.09,Other,215% New York Medicaid APG,1577.38,,,1577.38,Other,125% New York Medicaid APG,1261.9,54261.89,
Relocation of testis(es),54680,CPT,,,,,,,,both,,,73326.88,54261.89,74,,54261.89,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,32997.1,45,,32997.1,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,36296.81,49.5,,36296.81,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,1762.47,,,1762.47,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,51328.82,70,,51328.82,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,947.56,,,947.56,Other,New York Medicaid APG methodology,947.56,,,947.56,Other,100% New York Medicaid APG,947.56,,,947.56,Other,100% New York Medicaid APG,947.56,,,947.56,Other,100% New York Medicaid APG,2132.02,,,2132.02,Other,225% New York Medicaid APG,1449.77,,,1449.77,Other,153% New York Medicaid APG,2132.02,,,2132.02,Other,225% New York Medicaid APG,1326.59,,,1326.59,Other,140% New York Medicaid APG,2132.02,,,2132.02,Other,225% New York Medicaid APG,2463.67,,,2463.67,Other,260% New York Medicaid APG,3070.11,,,3070.11,Other,324% New York Medicaid APG,2037.26,,,2037.26,Other,215% New York Medicaid APG,2037.26,,,2037.26,Other,215% New York Medicaid APG,1184.46,,,1184.46,Other,125% New York Medicaid APG,947.56,54261.89,
Laparoscopy orchiectomy,54690,CPT,,,,,,,,both,,,36925.31,27324.73,74,,27324.73,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,16616.39,45,,16616.39,percent of total billed charges,Medicare Ratio of cost to charges,5459,,"100% primary, 50% supplemental procedure",5459,Other,Aetna ASC Grouper,4913,,"100% primary, 50% supplemental procedure",4913,Other,Aetna ASC Grouper,6125,,"100% primary, 50% secondary, 25% supplemental procedure",6125,Other,Blue Cross ASC Grouper,5513,,"100% primary, 50% secondary, 25% supplemental procedure",5513,Other,Blue Cross ASC Grouper,5206,,"100% primary, 50% secondary, 25% supplemental procedure",5206,Other,Blue Cross ASC Grouper,18278.03,49.5,,18278.03,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,1762.47,,,1762.47,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,25847.72,70,,25847.72,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,947.56,,,947.56,Other,New York Medicaid APG methodology,947.56,,,947.56,Other,100% New York Medicaid APG,947.56,,,947.56,Other,100% New York Medicaid APG,947.56,,,947.56,Other,100% New York Medicaid APG,2132.02,,,2132.02,Other,225% New York Medicaid APG,1449.77,,,1449.77,Other,153% New York Medicaid APG,2132.02,,,2132.02,Other,225% New York Medicaid APG,1326.59,,,1326.59,Other,140% New York Medicaid APG,2132.02,,,2132.02,Other,225% New York Medicaid APG,2463.67,,,2463.67,Other,260% New York Medicaid APG,3070.11,,,3070.11,Other,324% New York Medicaid APG,2037.26,,,2037.26,Other,215% New York Medicaid APG,2037.26,,,2037.26,Other,215% New York Medicaid APG,1184.46,,,1184.46,Other,125% New York Medicaid APG,947.56,27324.73,
Laparoscopy orchiopexy,54692,CPT,,,,,,,,both,,,36506.42,27014.75,74,,27014.75,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,16427.89,45,,16427.89,percent of total billed charges,Medicare Ratio of cost to charges,5459,,"100% primary, 50% supplemental procedure",5459,Other,Aetna ASC Grouper,4913,,"100% primary, 50% supplemental procedure",4913,Other,Aetna ASC Grouper,6125,,"100% primary, 50% secondary, 25% supplemental procedure",6125,Other,Blue Cross ASC Grouper,5513,,"100% primary, 50% secondary, 25% supplemental procedure",5513,Other,Blue Cross ASC Grouper,5206,,"100% primary, 50% secondary, 25% supplemental procedure",5206,Other,Blue Cross ASC Grouper,18070.68,49.5,,18070.68,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,1762.47,,,1762.47,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,25554.49,70,,25554.49,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,947.56,,,947.56,Other,New York Medicaid APG methodology,947.56,,,947.56,Other,100% New York Medicaid APG,947.56,,,947.56,Other,100% New York Medicaid APG,947.56,,,947.56,Other,100% New York Medicaid APG,2132.02,,,2132.02,Other,225% New York Medicaid APG,1449.77,,,1449.77,Other,153% New York Medicaid APG,2132.02,,,2132.02,Other,225% New York Medicaid APG,1326.59,,,1326.59,Other,140% New York Medicaid APG,2132.02,,,2132.02,Other,225% New York Medicaid APG,2463.67,,,2463.67,Other,260% New York Medicaid APG,3070.11,,,3070.11,Other,324% New York Medicaid APG,2037.26,,,2037.26,Other,215% New York Medicaid APG,2037.26,,,2037.26,Other,215% New York Medicaid APG,1184.46,,,1184.46,Other,125% New York Medicaid APG,947.56,27014.75,
Drainage of scrotum,54700,CPT,,,,,,,,both,,,42841.82,31702.95,74,,31702.95,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,19278.82,45,,19278.82,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,21206.7,49.5,,21206.7,percent of total billed charges,110% of Medicare,29132.44,68,,29132.44,percent of total billed charges,,2347.14,,,2347.14,Other,186% of Medicaid,34273.46,80,,34273.46,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,34273.46,80,,34273.46,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,29989.27,70,,29989.27,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1261.9,,,1261.9,Other,New York Medicaid APG methodology,1261.9,,,1261.9,Other,100% New York Medicaid APG,1261.9,,,1261.9,Other,100% New York Medicaid APG,1261.9,,,1261.9,Other,100% New York Medicaid APG,2839.28,,,2839.28,Other,225% New York Medicaid APG,1930.71,,,1930.71,Other,153% New York Medicaid APG,2839.28,,,2839.28,Other,225% New York Medicaid APG,1766.66,,,1766.66,Other,140% New York Medicaid APG,2839.28,,,2839.28,Other,225% New York Medicaid APG,3280.94,,,3280.94,Other,260% New York Medicaid APG,4088.56,,,4088.56,Other,324% New York Medicaid APG,2713.09,,,2713.09,Other,215% New York Medicaid APG,2713.09,,,2713.09,Other,215% New York Medicaid APG,1577.38,,,1577.38,Other,125% New York Medicaid APG,1261.9,34273.46,
Biopsy of epididymis,54800,CPT,,,,,,,,both,,,34101.75,25235.3,74,,25235.3,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15345.79,45,,15345.79,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,16880.37,49.5,,16880.37,percent of total billed charges,110% of Medicare,23189.19,68,,23189.19,percent of total billed charges,,2347.14,,,2347.14,Other,186% of Medicaid,27281.4,80,,27281.4,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,27281.4,80,,27281.4,percent of total billed charges,,7216,,,7216,Case Rate,,3578,,"100% primary, 0% secondary procedures",3578,Other,MagnaCare ASC Grouper,23871.23,70,,23871.23,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,1261.9,,,1261.9,Other,New York Medicaid APG methodology,1261.9,,,1261.9,Other,100% New York Medicaid APG,1261.9,,,1261.9,Other,100% New York Medicaid APG,1261.9,,,1261.9,Other,100% New York Medicaid APG,2839.28,,,2839.28,Other,225% New York Medicaid APG,1930.71,,,1930.71,Other,153% New York Medicaid APG,2839.28,,,2839.28,Other,225% New York Medicaid APG,1766.66,,,1766.66,Other,140% New York Medicaid APG,2839.28,,,2839.28,Other,225% New York Medicaid APG,3280.94,,,3280.94,Other,260% New York Medicaid APG,4088.56,,,4088.56,Other,324% New York Medicaid APG,2713.09,,,2713.09,Other,215% New York Medicaid APG,2713.09,,,2713.09,Other,215% New York Medicaid APG,1577.38,,,1577.38,Other,125% New York Medicaid APG,1261.9,27281.4,
Remove epididymis lesion,54830,CPT,,,,,,,,both,,,46383.69,34323.93,74,,34323.93,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,20872.66,45,,20872.66,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,22959.93,49.5,,22959.93,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2347.14,,,2347.14,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,32468.58,70,,32468.58,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1261.9,,,1261.9,Other,New York Medicaid APG methodology,1261.9,,,1261.9,Other,100% New York Medicaid APG,1261.9,,,1261.9,Other,100% New York Medicaid APG,1261.9,,,1261.9,Other,100% New York Medicaid APG,2839.28,,,2839.28,Other,225% New York Medicaid APG,1930.71,,,1930.71,Other,153% New York Medicaid APG,2839.28,,,2839.28,Other,225% New York Medicaid APG,1766.66,,,1766.66,Other,140% New York Medicaid APG,2839.28,,,2839.28,Other,225% New York Medicaid APG,3280.94,,,3280.94,Other,260% New York Medicaid APG,4088.56,,,4088.56,Other,324% New York Medicaid APG,2713.09,,,2713.09,Other,215% New York Medicaid APG,2713.09,,,2713.09,Other,215% New York Medicaid APG,1577.38,,,1577.38,Other,125% New York Medicaid APG,1261.9,34323.93,
Remove epididymis lesion,54840,CPT,,,,,,,,both,,,33168.4,24544.62,74,,24544.62,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,14925.78,45,,14925.78,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,16418.36,49.5,,16418.36,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2347.14,,,2347.14,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,23217.88,70,,23217.88,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1261.9,,,1261.9,Other,New York Medicaid APG methodology,1261.9,,,1261.9,Other,100% New York Medicaid APG,1261.9,,,1261.9,Other,100% New York Medicaid APG,1261.9,,,1261.9,Other,100% New York Medicaid APG,2839.28,,,2839.28,Other,225% New York Medicaid APG,1930.71,,,1930.71,Other,153% New York Medicaid APG,2839.28,,,2839.28,Other,225% New York Medicaid APG,1766.66,,,1766.66,Other,140% New York Medicaid APG,2839.28,,,2839.28,Other,225% New York Medicaid APG,3280.94,,,3280.94,Other,260% New York Medicaid APG,4088.56,,,4088.56,Other,324% New York Medicaid APG,2713.09,,,2713.09,Other,215% New York Medicaid APG,2713.09,,,2713.09,Other,215% New York Medicaid APG,1577.38,,,1577.38,Other,125% New York Medicaid APG,1261.9,24544.62,
Removal of epididymis,54860,CPT,,,,,,,,both,,,38579.03,28548.48,74,,28548.48,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,17360.56,45,,17360.56,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,19096.62,49.5,,19096.62,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2347.14,,,2347.14,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,27005.32,70,,27005.32,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1261.9,,,1261.9,Other,New York Medicaid APG methodology,1261.9,,,1261.9,Other,100% New York Medicaid APG,1261.9,,,1261.9,Other,100% New York Medicaid APG,1261.9,,,1261.9,Other,100% New York Medicaid APG,2839.28,,,2839.28,Other,225% New York Medicaid APG,1930.71,,,1930.71,Other,153% New York Medicaid APG,2839.28,,,2839.28,Other,225% New York Medicaid APG,1766.66,,,1766.66,Other,140% New York Medicaid APG,2839.28,,,2839.28,Other,225% New York Medicaid APG,3280.94,,,3280.94,Other,260% New York Medicaid APG,4088.56,,,4088.56,Other,324% New York Medicaid APG,2713.09,,,2713.09,Other,215% New York Medicaid APG,2713.09,,,2713.09,Other,215% New York Medicaid APG,1577.38,,,1577.38,Other,125% New York Medicaid APG,1261.9,28548.48,
Removal of epididymis,54861,CPT,,,,,,,,both,,,73326.88,54261.89,74,,54261.89,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,32997.1,45,,32997.1,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,36296.81,49.5,,36296.81,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,1762.47,,,1762.47,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,51328.82,70,,51328.82,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,947.56,,,947.56,Other,New York Medicaid APG methodology,947.56,,,947.56,Other,100% New York Medicaid APG,947.56,,,947.56,Other,100% New York Medicaid APG,947.56,,,947.56,Other,100% New York Medicaid APG,2132.02,,,2132.02,Other,225% New York Medicaid APG,1449.77,,,1449.77,Other,153% New York Medicaid APG,2132.02,,,2132.02,Other,225% New York Medicaid APG,1326.59,,,1326.59,Other,140% New York Medicaid APG,2132.02,,,2132.02,Other,225% New York Medicaid APG,2463.67,,,2463.67,Other,260% New York Medicaid APG,3070.11,,,3070.11,Other,324% New York Medicaid APG,2037.26,,,2037.26,Other,215% New York Medicaid APG,2037.26,,,2037.26,Other,215% New York Medicaid APG,1184.46,,,1184.46,Other,125% New York Medicaid APG,947.56,54261.89,
Explore epididymis,54865,CPT,,,,,,,,both,,,73326.88,54261.89,74,,54261.89,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,32997.1,45,,32997.1,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,36296.81,49.5,,36296.81,percent of total billed charges,110% of Medicare,49862.28,68,,49862.28,percent of total billed charges,,2347.14,,,2347.14,Other,186% of Medicaid,58661.5,80,,58661.5,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,58661.5,80,,58661.5,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,51328.82,70,,51328.82,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1261.9,,,1261.9,Other,New York Medicaid APG methodology,1261.9,,,1261.9,Other,100% New York Medicaid APG,1261.9,,,1261.9,Other,100% New York Medicaid APG,1261.9,,,1261.9,Other,100% New York Medicaid APG,2839.28,,,2839.28,Other,225% New York Medicaid APG,1930.71,,,1930.71,Other,153% New York Medicaid APG,2839.28,,,2839.28,Other,225% New York Medicaid APG,1766.66,,,1766.66,Other,140% New York Medicaid APG,2839.28,,,2839.28,Other,225% New York Medicaid APG,3280.94,,,3280.94,Other,260% New York Medicaid APG,4088.56,,,4088.56,Other,324% New York Medicaid APG,2713.09,,,2713.09,Other,215% New York Medicaid APG,2713.09,,,2713.09,Other,215% New York Medicaid APG,1577.38,,,1577.38,Other,125% New York Medicaid APG,1261.9,58661.5,
Fusion of spermatic ducts,54900,CPT,,,,,,,,both,,,42841.82,31702.95,74,,31702.95,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,19278.82,45,,19278.82,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,21206.7,49.5,,21206.7,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2347.14,,,2347.14,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,29989.27,70,,29989.27,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1261.9,,,1261.9,Other,New York Medicaid APG methodology,1261.9,,,1261.9,Other,100% New York Medicaid APG,1261.9,,,1261.9,Other,100% New York Medicaid APG,1261.9,,,1261.9,Other,100% New York Medicaid APG,2839.28,,,2839.28,Other,225% New York Medicaid APG,1930.71,,,1930.71,Other,153% New York Medicaid APG,2839.28,,,2839.28,Other,225% New York Medicaid APG,1766.66,,,1766.66,Other,140% New York Medicaid APG,2839.28,,,2839.28,Other,225% New York Medicaid APG,3280.94,,,3280.94,Other,260% New York Medicaid APG,4088.56,,,4088.56,Other,324% New York Medicaid APG,2713.09,,,2713.09,Other,215% New York Medicaid APG,2713.09,,,2713.09,Other,215% New York Medicaid APG,1577.38,,,1577.38,Other,125% New York Medicaid APG,1261.9,31702.95,
Fusion of spermatic ducts,54901,CPT,,,,,,,,both,,,73326.88,54261.89,74,,54261.89,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,32997.1,45,,32997.1,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,36296.81,49.5,,36296.81,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,1762.47,,,1762.47,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,51328.82,70,,51328.82,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,947.56,,,947.56,Other,New York Medicaid APG methodology,947.56,,,947.56,Other,100% New York Medicaid APG,947.56,,,947.56,Other,100% New York Medicaid APG,947.56,,,947.56,Other,100% New York Medicaid APG,2132.02,,,2132.02,Other,225% New York Medicaid APG,1449.77,,,1449.77,Other,153% New York Medicaid APG,2132.02,,,2132.02,Other,225% New York Medicaid APG,1326.59,,,1326.59,Other,140% New York Medicaid APG,2132.02,,,2132.02,Other,225% New York Medicaid APG,2463.67,,,2463.67,Other,260% New York Medicaid APG,3070.11,,,3070.11,Other,324% New York Medicaid APG,2037.26,,,2037.26,Other,215% New York Medicaid APG,2037.26,,,2037.26,Other,215% New York Medicaid APG,1184.46,,,1184.46,Other,125% New York Medicaid APG,947.56,54261.89,
Drainage of hydrocele,55000,CPT,,,,,,,,both,,,14798.8,10951.11,74,,10951.11,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,6659.46,45,,6659.46,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,7325.41,49.5,,7325.41,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,847.8,,,847.8,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,3578,,"100% primary, 0% secondary procedures",3578,Other,MagnaCare ASC Grouper,10359.16,70,,10359.16,percent of total billed charges,,408.36,,,408.36,Fee Schedule,,346.11,,,346.11,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,455.81,,,455.81,Other,New York Medicaid APG methodology,455.81,,,455.81,Other,100% New York Medicaid APG,455.81,,,455.81,Other,100% New York Medicaid APG,455.81,,,455.81,Other,100% New York Medicaid APG,1025.56,,,1025.56,Other,225% New York Medicaid APG,697.38,,,697.38,Other,153% New York Medicaid APG,1025.56,,,1025.56,Other,225% New York Medicaid APG,638.13,,,638.13,Other,140% New York Medicaid APG,1025.56,,,1025.56,Other,225% New York Medicaid APG,1185.1,,,1185.1,Other,260% New York Medicaid APG,1476.81,,,1476.81,Other,324% New York Medicaid APG,979.98,,,979.98,Other,215% New York Medicaid APG,979.98,,,979.98,Other,215% New York Medicaid APG,569.76,,,569.76,Other,125% New York Medicaid APG,346.11,10951.11,
Removal of hydrocele,55040,CPT,,,,,,,,both,,,35509.29,26276.87,74,,26276.87,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15979.18,45,,15979.18,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,17577.1,49.5,,17577.1,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,1762.47,,,1762.47,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,24856.5,70,,24856.5,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,947.56,,,947.56,Other,New York Medicaid APG methodology,947.56,,,947.56,Other,100% New York Medicaid APG,947.56,,,947.56,Other,100% New York Medicaid APG,947.56,,,947.56,Other,100% New York Medicaid APG,2132.02,,,2132.02,Other,225% New York Medicaid APG,1449.77,,,1449.77,Other,153% New York Medicaid APG,2132.02,,,2132.02,Other,225% New York Medicaid APG,1326.59,,,1326.59,Other,140% New York Medicaid APG,2132.02,,,2132.02,Other,225% New York Medicaid APG,2463.67,,,2463.67,Other,260% New York Medicaid APG,3070.11,,,3070.11,Other,324% New York Medicaid APG,2037.26,,,2037.26,Other,215% New York Medicaid APG,2037.26,,,2037.26,Other,215% New York Medicaid APG,1184.46,,,1184.46,Other,125% New York Medicaid APG,947.56,26276.87,
Removal of hydroceles,55041,CPT,,,,,,,,both,,,37008.86,27386.56,74,,27386.56,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,16653.99,45,,16653.99,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,18319.39,49.5,,18319.39,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,1762.47,,,1762.47,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,25906.2,70,,25906.2,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,947.56,,,947.56,Other,New York Medicaid APG methodology,947.56,,,947.56,Other,100% New York Medicaid APG,947.56,,,947.56,Other,100% New York Medicaid APG,947.56,,,947.56,Other,100% New York Medicaid APG,2132.02,,,2132.02,Other,225% New York Medicaid APG,1449.77,,,1449.77,Other,153% New York Medicaid APG,2132.02,,,2132.02,Other,225% New York Medicaid APG,1326.59,,,1326.59,Other,140% New York Medicaid APG,2132.02,,,2132.02,Other,225% New York Medicaid APG,2463.67,,,2463.67,Other,260% New York Medicaid APG,3070.11,,,3070.11,Other,324% New York Medicaid APG,2037.26,,,2037.26,Other,215% New York Medicaid APG,2037.26,,,2037.26,Other,215% New York Medicaid APG,1184.46,,,1184.46,Other,125% New York Medicaid APG,947.56,27386.56,
Repair of hydrocele,55060,CPT,,,,,,,,both,,,35016.25,25912.03,74,,25912.03,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15757.31,45,,15757.31,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,17333.04,49.5,,17333.04,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2347.14,,,2347.14,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,24511.38,70,,24511.38,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1261.9,,,1261.9,Other,New York Medicaid APG methodology,1261.9,,,1261.9,Other,100% New York Medicaid APG,1261.9,,,1261.9,Other,100% New York Medicaid APG,1261.9,,,1261.9,Other,100% New York Medicaid APG,2839.28,,,2839.28,Other,225% New York Medicaid APG,1930.71,,,1930.71,Other,153% New York Medicaid APG,2839.28,,,2839.28,Other,225% New York Medicaid APG,1766.66,,,1766.66,Other,140% New York Medicaid APG,2839.28,,,2839.28,Other,225% New York Medicaid APG,3280.94,,,3280.94,Other,260% New York Medicaid APG,4088.56,,,4088.56,Other,324% New York Medicaid APG,2713.09,,,2713.09,Other,215% New York Medicaid APG,2713.09,,,2713.09,Other,215% New York Medicaid APG,1577.38,,,1577.38,Other,125% New York Medicaid APG,1261.9,25912.03,
Drainage of scrotum abscess,55100,CPT,,,,,,,,both,,,34101.75,25235.3,74,,25235.3,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15345.79,45,,15345.79,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,16880.37,49.5,,16880.37,percent of total billed charges,110% of Medicare,23189.19,68,,23189.19,percent of total billed charges,,2347.14,,,2347.14,Other,186% of Medicaid,27281.4,80,,27281.4,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,27281.4,80,,27281.4,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,23871.23,70,,23871.23,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1261.9,,,1261.9,Other,New York Medicaid APG methodology,1261.9,,,1261.9,Other,100% New York Medicaid APG,1261.9,,,1261.9,Other,100% New York Medicaid APG,1261.9,,,1261.9,Other,100% New York Medicaid APG,2839.28,,,2839.28,Other,225% New York Medicaid APG,1930.71,,,1930.71,Other,153% New York Medicaid APG,2839.28,,,2839.28,Other,225% New York Medicaid APG,1766.66,,,1766.66,Other,140% New York Medicaid APG,2839.28,,,2839.28,Other,225% New York Medicaid APG,3280.94,,,3280.94,Other,260% New York Medicaid APG,4088.56,,,4088.56,Other,324% New York Medicaid APG,2713.09,,,2713.09,Other,215% New York Medicaid APG,2713.09,,,2713.09,Other,215% New York Medicaid APG,1577.38,,,1577.38,Other,125% New York Medicaid APG,1261.9,27281.4,
Explore scrotum,55110,CPT,,,,,,,,both,,,73326.88,54261.89,74,,54261.89,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,32997.1,45,,32997.1,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,36296.81,49.5,,36296.81,percent of total billed charges,110% of Medicare,49862.28,68,,49862.28,percent of total billed charges,,1762.47,,,1762.47,Other,186% of Medicaid,58661.5,80,,58661.5,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,58661.5,80,,58661.5,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,51328.82,70,,51328.82,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,947.56,,,947.56,Other,New York Medicaid APG methodology,947.56,,,947.56,Other,100% New York Medicaid APG,947.56,,,947.56,Other,100% New York Medicaid APG,947.56,,,947.56,Other,100% New York Medicaid APG,2132.02,,,2132.02,Other,225% New York Medicaid APG,1449.77,,,1449.77,Other,153% New York Medicaid APG,2132.02,,,2132.02,Other,225% New York Medicaid APG,1326.59,,,1326.59,Other,140% New York Medicaid APG,2132.02,,,2132.02,Other,225% New York Medicaid APG,2463.67,,,2463.67,Other,260% New York Medicaid APG,3070.11,,,3070.11,Other,324% New York Medicaid APG,2037.26,,,2037.26,Other,215% New York Medicaid APG,2037.26,,,2037.26,Other,215% New York Medicaid APG,1184.46,,,1184.46,Other,125% New York Medicaid APG,947.56,58661.5,
Removal of scrotum lesion,55120,CPT,,,,,,,,both,,,42841.82,31702.95,74,,31702.95,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,19278.82,45,,19278.82,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,21206.7,49.5,,21206.7,percent of total billed charges,110% of Medicare,29132.44,68,,29132.44,percent of total billed charges,,2347.14,,,2347.14,Other,186% of Medicaid,34273.46,80,,34273.46,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,34273.46,80,,34273.46,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,29989.27,70,,29989.27,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1261.9,,,1261.9,Other,New York Medicaid APG methodology,1261.9,,,1261.9,Other,100% New York Medicaid APG,1261.9,,,1261.9,Other,100% New York Medicaid APG,1261.9,,,1261.9,Other,100% New York Medicaid APG,2839.28,,,2839.28,Other,225% New York Medicaid APG,1930.71,,,1930.71,Other,153% New York Medicaid APG,2839.28,,,2839.28,Other,225% New York Medicaid APG,1766.66,,,1766.66,Other,140% New York Medicaid APG,2839.28,,,2839.28,Other,225% New York Medicaid APG,3280.94,,,3280.94,Other,260% New York Medicaid APG,4088.56,,,4088.56,Other,324% New York Medicaid APG,2713.09,,,2713.09,Other,215% New York Medicaid APG,2713.09,,,2713.09,Other,215% New York Medicaid APG,1577.38,,,1577.38,Other,125% New York Medicaid APG,1261.9,34273.46,
Removal of scrotum,55150,CPT,,,,,,,,both,,,73326.88,54261.89,74,,54261.89,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,32997.1,45,,32997.1,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,36296.81,49.5,,36296.81,percent of total billed charges,110% of Medicare,49862.28,68,,49862.28,percent of total billed charges,,2347.14,,,2347.14,Other,186% of Medicaid,58661.5,80,,58661.5,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,58661.5,80,,58661.5,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,51328.82,70,,51328.82,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1261.9,,,1261.9,Other,New York Medicaid APG methodology,1261.9,,,1261.9,Other,100% New York Medicaid APG,1261.9,,,1261.9,Other,100% New York Medicaid APG,1261.9,,,1261.9,Other,100% New York Medicaid APG,2839.28,,,2839.28,Other,225% New York Medicaid APG,1930.71,,,1930.71,Other,153% New York Medicaid APG,2839.28,,,2839.28,Other,225% New York Medicaid APG,1766.66,,,1766.66,Other,140% New York Medicaid APG,2839.28,,,2839.28,Other,225% New York Medicaid APG,3280.94,,,3280.94,Other,260% New York Medicaid APG,4088.56,,,4088.56,Other,324% New York Medicaid APG,2713.09,,,2713.09,Other,215% New York Medicaid APG,2713.09,,,2713.09,Other,215% New York Medicaid APG,1577.38,,,1577.38,Other,125% New York Medicaid APG,1261.9,58661.5,
Revision of scrotum,55175,CPT,,,,,,,,both,,,35943.65,26598.3,74,,26598.3,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,16174.64,45,,16174.64,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,17792.11,49.5,,17792.11,percent of total billed charges,110% of Medicare,24441.68,68,,24441.68,percent of total billed charges,,2347.14,,,2347.14,Other,186% of Medicaid,28754.92,80,,28754.92,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,28754.92,80,,28754.92,percent of total billed charges,,7216,,,7216,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,25160.56,70,,25160.56,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,1261.9,,,1261.9,Other,New York Medicaid APG methodology,1261.9,,,1261.9,Other,100% New York Medicaid APG,1261.9,,,1261.9,Other,100% New York Medicaid APG,1261.9,,,1261.9,Other,100% New York Medicaid APG,2839.28,,,2839.28,Other,225% New York Medicaid APG,1930.71,,,1930.71,Other,153% New York Medicaid APG,2839.28,,,2839.28,Other,225% New York Medicaid APG,1766.66,,,1766.66,Other,140% New York Medicaid APG,2839.28,,,2839.28,Other,225% New York Medicaid APG,3280.94,,,3280.94,Other,260% New York Medicaid APG,4088.56,,,4088.56,Other,324% New York Medicaid APG,2713.09,,,2713.09,Other,215% New York Medicaid APG,2713.09,,,2713.09,Other,215% New York Medicaid APG,1577.38,,,1577.38,Other,125% New York Medicaid APG,1261.9,28754.92,
Revision of scrotum,55180,CPT,,,,,,,,both,,,35884.32,26554.4,74,,26554.4,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,16147.94,45,,16147.94,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,17762.74,49.5,,17762.74,percent of total billed charges,110% of Medicare,24401.34,68,,24401.34,percent of total billed charges,,1762.47,,,1762.47,Other,186% of Medicaid,28707.46,80,,28707.46,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,28707.46,80,,28707.46,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,25119.02,70,,25119.02,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,947.56,,,947.56,Other,New York Medicaid APG methodology,947.56,,,947.56,Other,100% New York Medicaid APG,947.56,,,947.56,Other,100% New York Medicaid APG,947.56,,,947.56,Other,100% New York Medicaid APG,2132.02,,,2132.02,Other,225% New York Medicaid APG,1449.77,,,1449.77,Other,153% New York Medicaid APG,2132.02,,,2132.02,Other,225% New York Medicaid APG,1326.59,,,1326.59,Other,140% New York Medicaid APG,2132.02,,,2132.02,Other,225% New York Medicaid APG,2463.67,,,2463.67,Other,260% New York Medicaid APG,3070.11,,,3070.11,Other,324% New York Medicaid APG,2037.26,,,2037.26,Other,215% New York Medicaid APG,2037.26,,,2037.26,Other,215% New York Medicaid APG,1184.46,,,1184.46,Other,125% New York Medicaid APG,947.56,28707.46,
Incision of sperm duct,55200,CPT,,,,,,,,both,,,73326.88,54261.89,74,,54261.89,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,32997.1,45,,32997.1,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,36296.81,49.5,,36296.81,percent of total billed charges,110% of Medicare,49862.28,68,,49862.28,percent of total billed charges,,2347.14,,,2347.14,Other,186% of Medicaid,58661.5,80,,58661.5,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,58661.5,80,,58661.5,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,51328.82,70,,51328.82,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1261.9,,,1261.9,Other,New York Medicaid APG methodology,1261.9,,,1261.9,Other,100% New York Medicaid APG,1261.9,,,1261.9,Other,100% New York Medicaid APG,1261.9,,,1261.9,Other,100% New York Medicaid APG,2839.28,,,2839.28,Other,225% New York Medicaid APG,1930.71,,,1930.71,Other,153% New York Medicaid APG,2839.28,,,2839.28,Other,225% New York Medicaid APG,1766.66,,,1766.66,Other,140% New York Medicaid APG,2839.28,,,2839.28,Other,225% New York Medicaid APG,3280.94,,,3280.94,Other,260% New York Medicaid APG,4088.56,,,4088.56,Other,324% New York Medicaid APG,2713.09,,,2713.09,Other,215% New York Medicaid APG,2713.09,,,2713.09,Other,215% New York Medicaid APG,1577.38,,,1577.38,Other,125% New York Medicaid APG,1261.9,58661.5,
Removal of sperm duct(s),55250,CPT,,,,,,,,both,,,35521.46,26285.88,74,,26285.88,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15984.66,45,,15984.66,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,17583.12,49.5,,17583.12,percent of total billed charges,110% of Medicare,24154.59,68,,24154.59,percent of total billed charges,,2347.14,,,2347.14,Other,186% of Medicaid,28417.17,80,,28417.17,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,28417.17,80,,28417.17,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,24865.02,70,,24865.02,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1261.9,,,1261.9,Other,New York Medicaid APG methodology,1261.9,,,1261.9,Other,100% New York Medicaid APG,1261.9,,,1261.9,Other,100% New York Medicaid APG,1261.9,,,1261.9,Other,100% New York Medicaid APG,2839.28,,,2839.28,Other,225% New York Medicaid APG,1930.71,,,1930.71,Other,153% New York Medicaid APG,2839.28,,,2839.28,Other,225% New York Medicaid APG,1766.66,,,1766.66,Other,140% New York Medicaid APG,2839.28,,,2839.28,Other,225% New York Medicaid APG,3280.94,,,3280.94,Other,260% New York Medicaid APG,4088.56,,,4088.56,Other,324% New York Medicaid APG,2713.09,,,2713.09,Other,215% New York Medicaid APG,2713.09,,,2713.09,Other,215% New York Medicaid APG,1577.38,,,1577.38,Other,125% New York Medicaid APG,1261.9,28417.17,
Prepare sperm duct x-ray,55300,CPT,,,,,,,,both,,,32432.1,23999.75,74,,23999.75,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,14594.45,45,,14594.45,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,16053.89,49.5,,16053.89,percent of total billed charges,110% of Medicare,22053.83,68,,22053.83,percent of total billed charges,,847.8,,,847.8,Other,186% of Medicaid,25945.68,80,,25945.68,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,25945.68,80,,25945.68,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,22702.47,70,,22702.47,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,455.81,,,455.81,Other,New York Medicaid APG methodology,455.81,,,455.81,Other,100% New York Medicaid APG,455.81,,,455.81,Other,100% New York Medicaid APG,455.81,,,455.81,Other,100% New York Medicaid APG,1025.56,,,1025.56,Other,225% New York Medicaid APG,697.38,,,697.38,Other,153% New York Medicaid APG,1025.56,,,1025.56,Other,225% New York Medicaid APG,638.13,,,638.13,Other,140% New York Medicaid APG,1025.56,,,1025.56,Other,225% New York Medicaid APG,1185.1,,,1185.1,Other,260% New York Medicaid APG,1476.81,,,1476.81,Other,324% New York Medicaid APG,979.98,,,979.98,Other,215% New York Medicaid APG,979.98,,,979.98,Other,215% New York Medicaid APG,569.76,,,569.76,Other,125% New York Medicaid APG,455.81,25945.68,
Repair of sperm duct,55400,CPT,,,,,,,,both,,,70514.14,52180.46,74,,52180.46,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,31731.36,45,,31731.36,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,34904.5,49.5,,34904.5,percent of total billed charges,110% of Medicare,47949.62,68,,47949.62,percent of total billed charges,,1762.47,,,1762.47,Other,186% of Medicaid,56411.31,80,,56411.31,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,56411.31,80,,56411.31,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,49359.9,70,,49359.9,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,947.56,,,947.56,Other,New York Medicaid APG methodology,947.56,,,947.56,Other,100% New York Medicaid APG,947.56,,,947.56,Other,100% New York Medicaid APG,947.56,,,947.56,Other,100% New York Medicaid APG,2132.02,,,2132.02,Other,225% New York Medicaid APG,1449.77,,,1449.77,Other,153% New York Medicaid APG,2132.02,,,2132.02,Other,225% New York Medicaid APG,1326.59,,,1326.59,Other,140% New York Medicaid APG,2132.02,,,2132.02,Other,225% New York Medicaid APG,2463.67,,,2463.67,Other,260% New York Medicaid APG,3070.11,,,3070.11,Other,324% New York Medicaid APG,2037.26,,,2037.26,Other,215% New York Medicaid APG,2037.26,,,2037.26,Other,215% New York Medicaid APG,1184.46,,,1184.46,Other,125% New York Medicaid APG,947.56,56411.31,
Removal of hydrocele,55500,CPT,,,,,,,,both,,,73326.88,54261.89,74,,54261.89,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,32997.1,45,,32997.1,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,36296.81,49.5,,36296.81,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2347.14,,,2347.14,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,51328.82,70,,51328.82,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1261.9,,,1261.9,Other,New York Medicaid APG methodology,1261.9,,,1261.9,Other,100% New York Medicaid APG,1261.9,,,1261.9,Other,100% New York Medicaid APG,1261.9,,,1261.9,Other,100% New York Medicaid APG,2839.28,,,2839.28,Other,225% New York Medicaid APG,1930.71,,,1930.71,Other,153% New York Medicaid APG,2839.28,,,2839.28,Other,225% New York Medicaid APG,1766.66,,,1766.66,Other,140% New York Medicaid APG,2839.28,,,2839.28,Other,225% New York Medicaid APG,3280.94,,,3280.94,Other,260% New York Medicaid APG,4088.56,,,4088.56,Other,324% New York Medicaid APG,2713.09,,,2713.09,Other,215% New York Medicaid APG,2713.09,,,2713.09,Other,215% New York Medicaid APG,1577.38,,,1577.38,Other,125% New York Medicaid APG,1261.9,54261.89,
Removal of sperm cord lesion,55520,CPT,,,,,,,,both,,,73326.88,54261.89,74,,54261.89,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,32997.1,45,,32997.1,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,36296.81,49.5,,36296.81,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2347.14,,,2347.14,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,51328.82,70,,51328.82,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1261.9,,,1261.9,Other,New York Medicaid APG methodology,1261.9,,,1261.9,Other,100% New York Medicaid APG,1261.9,,,1261.9,Other,100% New York Medicaid APG,1261.9,,,1261.9,Other,100% New York Medicaid APG,2839.28,,,2839.28,Other,225% New York Medicaid APG,1930.71,,,1930.71,Other,153% New York Medicaid APG,2839.28,,,2839.28,Other,225% New York Medicaid APG,1766.66,,,1766.66,Other,140% New York Medicaid APG,2839.28,,,2839.28,Other,225% New York Medicaid APG,3280.94,,,3280.94,Other,260% New York Medicaid APG,4088.56,,,4088.56,Other,324% New York Medicaid APG,2713.09,,,2713.09,Other,215% New York Medicaid APG,2713.09,,,2713.09,Other,215% New York Medicaid APG,1577.38,,,1577.38,Other,125% New York Medicaid APG,1261.9,54261.89,
Revise spermatic cord veins,55530,CPT,,,,,,,,both,,,36449.42,26972.57,74,,26972.57,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,16402.24,45,,16402.24,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,18042.46,49.5,,18042.46,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,1762.47,,,1762.47,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,25514.59,70,,25514.59,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,947.56,,,947.56,Other,New York Medicaid APG methodology,947.56,,,947.56,Other,100% New York Medicaid APG,947.56,,,947.56,Other,100% New York Medicaid APG,947.56,,,947.56,Other,100% New York Medicaid APG,2132.02,,,2132.02,Other,225% New York Medicaid APG,1449.77,,,1449.77,Other,153% New York Medicaid APG,2132.02,,,2132.02,Other,225% New York Medicaid APG,1326.59,,,1326.59,Other,140% New York Medicaid APG,2132.02,,,2132.02,Other,225% New York Medicaid APG,2463.67,,,2463.67,Other,260% New York Medicaid APG,3070.11,,,3070.11,Other,324% New York Medicaid APG,2037.26,,,2037.26,Other,215% New York Medicaid APG,2037.26,,,2037.26,Other,215% New York Medicaid APG,1184.46,,,1184.46,Other,125% New York Medicaid APG,947.56,26972.57,
Revise spermatic cord veins,55535,CPT,,,,,,,,both,,,159132.17,117757.81,74,,117757.81,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,71609.48,45,,71609.48,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,78770.42,49.5,,78770.42,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2347.14,,,2347.14,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,111392.52,70,,111392.52,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1261.9,,,1261.9,Other,New York Medicaid APG methodology,1261.9,,,1261.9,Other,100% New York Medicaid APG,1261.9,,,1261.9,Other,100% New York Medicaid APG,1261.9,,,1261.9,Other,100% New York Medicaid APG,2839.28,,,2839.28,Other,225% New York Medicaid APG,1930.71,,,1930.71,Other,153% New York Medicaid APG,2839.28,,,2839.28,Other,225% New York Medicaid APG,1766.66,,,1766.66,Other,140% New York Medicaid APG,2839.28,,,2839.28,Other,225% New York Medicaid APG,3280.94,,,3280.94,Other,260% New York Medicaid APG,4088.56,,,4088.56,Other,324% New York Medicaid APG,2713.09,,,2713.09,Other,215% New York Medicaid APG,2713.09,,,2713.09,Other,215% New York Medicaid APG,1577.38,,,1577.38,Other,125% New York Medicaid APG,1261.9,117757.81,
Revise hernia & sperm veins,55540,CPT,,,,,,,,both,,,72769.69,53849.57,74,,53849.57,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,32746.36,45,,32746.36,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,36021,49.5,,36021,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,1762.47,,,1762.47,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,50938.78,70,,50938.78,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,947.56,,,947.56,Other,New York Medicaid APG methodology,947.56,,,947.56,Other,100% New York Medicaid APG,947.56,,,947.56,Other,100% New York Medicaid APG,947.56,,,947.56,Other,100% New York Medicaid APG,2132.02,,,2132.02,Other,225% New York Medicaid APG,1449.77,,,1449.77,Other,153% New York Medicaid APG,2132.02,,,2132.02,Other,225% New York Medicaid APG,1326.59,,,1326.59,Other,140% New York Medicaid APG,2132.02,,,2132.02,Other,225% New York Medicaid APG,2463.67,,,2463.67,Other,260% New York Medicaid APG,3070.11,,,3070.11,Other,324% New York Medicaid APG,2037.26,,,2037.26,Other,215% New York Medicaid APG,2037.26,,,2037.26,Other,215% New York Medicaid APG,1184.46,,,1184.46,Other,125% New York Medicaid APG,947.56,53849.57,
Laparo ligate spermatic vein,55550,CPT,,,,,,,,both,,,36303.04,26864.25,74,,26864.25,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,16336.37,45,,16336.37,percent of total billed charges,Medicare Ratio of cost to charges,5459,,"100% primary, 50% supplemental procedure",5459,Other,Aetna ASC Grouper,4913,,"100% primary, 50% supplemental procedure",4913,Other,Aetna ASC Grouper,6125,,"100% primary, 50% secondary, 25% supplemental procedure",6125,Other,Blue Cross ASC Grouper,5513,,"100% primary, 50% secondary, 25% supplemental procedure",5513,Other,Blue Cross ASC Grouper,5206,,"100% primary, 50% secondary, 25% supplemental procedure",5206,Other,Blue Cross ASC Grouper,17970,49.5,,17970,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,1762.47,,,1762.47,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,25412.13,70,,25412.13,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,947.56,,,947.56,Other,New York Medicaid APG methodology,947.56,,,947.56,Other,100% New York Medicaid APG,947.56,,,947.56,Other,100% New York Medicaid APG,947.56,,,947.56,Other,100% New York Medicaid APG,2132.02,,,2132.02,Other,225% New York Medicaid APG,1449.77,,,1449.77,Other,153% New York Medicaid APG,2132.02,,,2132.02,Other,225% New York Medicaid APG,1326.59,,,1326.59,Other,140% New York Medicaid APG,2132.02,,,2132.02,Other,225% New York Medicaid APG,2463.67,,,2463.67,Other,260% New York Medicaid APG,3070.11,,,3070.11,Other,324% New York Medicaid APG,2037.26,,,2037.26,Other,215% New York Medicaid APG,2037.26,,,2037.26,Other,215% New York Medicaid APG,1184.46,,,1184.46,Other,125% New York Medicaid APG,947.56,26864.25,
Incise sperm duct pouch,55600,CPT,,,,,,,,both,,,42841.82,31702.95,74,,31702.95,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,19278.82,45,,19278.82,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,21206.7,49.5,,21206.7,percent of total billed charges,110% of Medicare,29132.44,68,,29132.44,percent of total billed charges,,2347.14,,,2347.14,Other,186% of Medicaid,34273.46,80,,34273.46,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,34273.46,80,,34273.46,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,29989.27,70,,29989.27,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1261.9,,,1261.9,Other,New York Medicaid APG methodology,1261.9,,,1261.9,Other,100% New York Medicaid APG,1261.9,,,1261.9,Other,100% New York Medicaid APG,1261.9,,,1261.9,Other,100% New York Medicaid APG,2839.28,,,2839.28,Other,225% New York Medicaid APG,1930.71,,,1930.71,Other,153% New York Medicaid APG,2839.28,,,2839.28,Other,225% New York Medicaid APG,1766.66,,,1766.66,Other,140% New York Medicaid APG,2839.28,,,2839.28,Other,225% New York Medicaid APG,3280.94,,,3280.94,Other,260% New York Medicaid APG,4088.56,,,4088.56,Other,324% New York Medicaid APG,2713.09,,,2713.09,Other,215% New York Medicaid APG,2713.09,,,2713.09,Other,215% New York Medicaid APG,1577.38,,,1577.38,Other,125% New York Medicaid APG,1261.9,34273.46,
Remove sperm pouch lesion,55680,CPT,,,,,,,,both,,,73326.88,54261.89,74,,54261.89,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,32997.1,45,,32997.1,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,36296.81,49.5,,36296.81,percent of total billed charges,110% of Medicare,49862.28,68,,49862.28,percent of total billed charges,,1762.47,,,1762.47,Other,186% of Medicaid,58661.5,80,,58661.5,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,58661.5,80,,58661.5,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,51328.82,70,,51328.82,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,947.56,,,947.56,Other,New York Medicaid APG methodology,947.56,,,947.56,Other,100% New York Medicaid APG,947.56,,,947.56,Other,100% New York Medicaid APG,947.56,,,947.56,Other,100% New York Medicaid APG,2132.02,,,2132.02,Other,225% New York Medicaid APG,1449.77,,,1449.77,Other,153% New York Medicaid APG,2132.02,,,2132.02,Other,225% New York Medicaid APG,1326.59,,,1326.59,Other,140% New York Medicaid APG,2132.02,,,2132.02,Other,225% New York Medicaid APG,2463.67,,,2463.67,Other,260% New York Medicaid APG,3070.11,,,3070.11,Other,324% New York Medicaid APG,2037.26,,,2037.26,Other,215% New York Medicaid APG,2037.26,,,2037.26,Other,215% New York Medicaid APG,1184.46,,,1184.46,Other,125% New York Medicaid APG,947.56,58661.5,
Biopsy of prostate,55700,CPT,,,,,,,,both,,,42130.06,31176.24,74,,31176.24,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,18958.53,45,,18958.53,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,20854.38,49.5,,20854.38,percent of total billed charges,110% of Medicare,28648.44,68,,28648.44,percent of total billed charges,,3486.98,,,3486.98,Other,186% of Medicaid,33704.05,80,,33704.05,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,33704.05,80,,33704.05,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,29491.04,70,,29491.04,percent of total billed charges,,624.84,,,624.84,Fee Schedule,,529.59,,,529.59,Fee Schedule,,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1874.72,,,1874.72,Other,New York Medicaid APG methodology,1874.72,,,1874.72,Other,100% New York Medicaid APG,1874.72,,,1874.72,Other,100% New York Medicaid APG,1874.72,,,1874.72,Other,100% New York Medicaid APG,4218.12,,,4218.12,Other,225% New York Medicaid APG,2868.32,,,2868.32,Other,153% New York Medicaid APG,4218.12,,,4218.12,Other,225% New York Medicaid APG,2624.61,,,2624.61,Other,140% New York Medicaid APG,4218.12,,,4218.12,Other,225% New York Medicaid APG,4874.27,,,4874.27,Other,260% New York Medicaid APG,6074.09,,,6074.09,Other,324% New York Medicaid APG,4030.65,,,4030.65,Other,215% New York Medicaid APG,4030.65,,,4030.65,Other,215% New York Medicaid APG,2343.4,,,2343.4,Other,125% New York Medicaid APG,529.59,33704.05,
Biopsy of prostate,55705,CPT,,,,,,,,both,,,73326.88,54261.89,74,,54261.89,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,32997.1,45,,32997.1,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,36296.81,49.5,,36296.81,percent of total billed charges,110% of Medicare,49862.28,68,,49862.28,percent of total billed charges,,3486.98,,,3486.98,Other,186% of Medicaid,58661.5,80,,58661.5,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,58661.5,80,,58661.5,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,51328.82,70,,51328.82,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1874.72,,,1874.72,Other,New York Medicaid APG methodology,1874.72,,,1874.72,Other,100% New York Medicaid APG,1874.72,,,1874.72,Other,100% New York Medicaid APG,1874.72,,,1874.72,Other,100% New York Medicaid APG,4218.12,,,4218.12,Other,225% New York Medicaid APG,2868.32,,,2868.32,Other,153% New York Medicaid APG,4218.12,,,4218.12,Other,225% New York Medicaid APG,2624.61,,,2624.61,Other,140% New York Medicaid APG,4218.12,,,4218.12,Other,225% New York Medicaid APG,4874.27,,,4874.27,Other,260% New York Medicaid APG,6074.09,,,6074.09,Other,324% New York Medicaid APG,4030.65,,,4030.65,Other,215% New York Medicaid APG,4030.65,,,4030.65,Other,215% New York Medicaid APG,2343.4,,,2343.4,Other,125% New York Medicaid APG,1874.72,58661.5,
Prostate saturation sampling,55706,CPT,,,,,,,,both,,,46242.51,34219.46,74,,34219.46,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,20809.13,45,,20809.13,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,22890.04,49.5,,22890.04,percent of total billed charges,110% of Medicare,31444.91,68,,31444.91,percent of total billed charges,,3486.98,,,3486.98,Other,186% of Medicaid,36994.01,80,,36994.01,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,36994.01,80,,36994.01,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,32369.76,70,,32369.76,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1874.72,,,1874.72,Other,New York Medicaid APG methodology,1874.72,,,1874.72,Other,100% New York Medicaid APG,1874.72,,,1874.72,Other,100% New York Medicaid APG,1874.72,,,1874.72,Other,100% New York Medicaid APG,4218.12,,,4218.12,Other,225% New York Medicaid APG,2868.32,,,2868.32,Other,153% New York Medicaid APG,4218.12,,,4218.12,Other,225% New York Medicaid APG,2624.61,,,2624.61,Other,140% New York Medicaid APG,4218.12,,,4218.12,Other,225% New York Medicaid APG,4874.27,,,4874.27,Other,260% New York Medicaid APG,6074.09,,,6074.09,Other,324% New York Medicaid APG,4030.65,,,4030.65,Other,215% New York Medicaid APG,4030.65,,,4030.65,Other,215% New York Medicaid APG,2343.4,,,2343.4,Other,125% New York Medicaid APG,1874.72,36994.01,
Drainage of prostate abscess,55720,CPT,,,,,,,,both,,,73326.88,54261.89,74,,54261.89,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,32997.1,45,,32997.1,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,36296.81,49.5,,36296.81,percent of total billed charges,110% of Medicare,49862.28,68,,49862.28,percent of total billed charges,,3486.98,,,3486.98,Other,186% of Medicaid,58661.5,80,,58661.5,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,58661.5,80,,58661.5,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,51328.82,70,,51328.82,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1874.72,,,1874.72,Other,New York Medicaid APG methodology,1874.72,,,1874.72,Other,100% New York Medicaid APG,1874.72,,,1874.72,Other,100% New York Medicaid APG,1874.72,,,1874.72,Other,100% New York Medicaid APG,4218.12,,,4218.12,Other,225% New York Medicaid APG,2868.32,,,2868.32,Other,153% New York Medicaid APG,4218.12,,,4218.12,Other,225% New York Medicaid APG,2624.61,,,2624.61,Other,140% New York Medicaid APG,4218.12,,,4218.12,Other,225% New York Medicaid APG,4874.27,,,4874.27,Other,260% New York Medicaid APG,6074.09,,,6074.09,Other,324% New York Medicaid APG,4030.65,,,4030.65,Other,215% New York Medicaid APG,4030.65,,,4030.65,Other,215% New York Medicaid APG,2343.4,,,2343.4,Other,125% New York Medicaid APG,1874.72,58661.5,
Drainage of prostate abscess,55725,CPT,,,,,,,,both,,,73326.88,54261.89,74,,54261.89,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,32997.1,45,,32997.1,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,36296.81,49.5,,36296.81,percent of total billed charges,110% of Medicare,49862.28,68,,49862.28,percent of total billed charges,,3486.98,,,3486.98,Other,186% of Medicaid,58661.5,80,,58661.5,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,58661.5,80,,58661.5,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,51328.82,70,,51328.82,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1874.72,,,1874.72,Other,New York Medicaid APG methodology,1874.72,,,1874.72,Other,100% New York Medicaid APG,1874.72,,,1874.72,Other,100% New York Medicaid APG,1874.72,,,1874.72,Other,100% New York Medicaid APG,4218.12,,,4218.12,Other,225% New York Medicaid APG,2868.32,,,2868.32,Other,153% New York Medicaid APG,4218.12,,,4218.12,Other,225% New York Medicaid APG,2624.61,,,2624.61,Other,140% New York Medicaid APG,4218.12,,,4218.12,Other,225% New York Medicaid APG,4874.27,,,4874.27,Other,260% New York Medicaid APG,6074.09,,,6074.09,Other,324% New York Medicaid APG,4030.65,,,4030.65,Other,215% New York Medicaid APG,4030.65,,,4030.65,Other,215% New York Medicaid APG,2343.4,,,2343.4,Other,125% New York Medicaid APG,1874.72,58661.5,
Surgical exposure prostate,55860,CPT,,,,,,,,both,,,108835.97,80538.62,74,,80538.62,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,48976.19,45,,48976.19,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,53873.81,49.5,,53873.81,percent of total billed charges,110% of Medicare,74008.46,68,,74008.46,percent of total billed charges,,4645.5,,,4645.5,Other,186% of Medicaid,87068.78,80,,87068.78,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,87068.78,80,,87068.78,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,76185.18,70,,76185.18,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,2497.58,,,2497.58,Other,New York Medicaid APG methodology,2497.58,,,2497.58,Other,100% New York Medicaid APG,2497.58,,,2497.58,Other,100% New York Medicaid APG,2497.58,,,2497.58,Other,100% New York Medicaid APG,5619.56,,,5619.56,Other,225% New York Medicaid APG,3821.3,,,3821.3,Other,153% New York Medicaid APG,5619.56,,,5619.56,Other,225% New York Medicaid APG,3496.61,,,3496.61,Other,140% New York Medicaid APG,5619.56,,,5619.56,Other,225% New York Medicaid APG,6493.71,,,6493.71,Other,260% New York Medicaid APG,8092.16,,,8092.16,Other,324% New York Medicaid APG,5369.8,,,5369.8,Other,215% New York Medicaid APG,5369.8,,,5369.8,Other,215% New York Medicaid APG,3121.98,,,3121.98,Other,125% New York Medicaid APG,2053,87068.78,
Laparo radical prostatectomy,55866,CPT,,,,,,,,both,,,74675.71,55260.03,74,,55260.03,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,33604.07,45,,33604.07,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,36964.48,49.5,,36964.48,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,4645.5,,,4645.5,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9196,,"100% primary, 0% secondary procedures",9196,Other,MagnaCare ASC Grouper,52273,70,,52273,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6956,,"100% primary, 50% secondary, 25% tertiary procedure",6956,Other,United Healthcare ASC Grouper,6261,,"100% primary, 50% secondary, 25% tertiary procedure",6261,Other,United Healthcare ASC Grouper,6956,,"100% primary, 50% secondary, 25% tertiary procedure",6956,Other,United Healthcare ASC Grouper,5913,,"100% primary, 50% secondary, 25% tertiary procedure",5913,Other,United Healthcare ASC Grouper,2497.58,,,2497.58,Other,New York Medicaid APG methodology,2497.58,,,2497.58,Other,100% New York Medicaid APG,2497.58,,,2497.58,Other,100% New York Medicaid APG,2497.58,,,2497.58,Other,100% New York Medicaid APG,5619.56,,,5619.56,Other,225% New York Medicaid APG,3821.3,,,3821.3,Other,153% New York Medicaid APG,5619.56,,,5619.56,Other,225% New York Medicaid APG,3496.61,,,3496.61,Other,140% New York Medicaid APG,5619.56,,,5619.56,Other,225% New York Medicaid APG,6493.71,,,6493.71,Other,260% New York Medicaid APG,8092.16,,,8092.16,Other,324% New York Medicaid APG,5369.8,,,5369.8,Other,215% New York Medicaid APG,5369.8,,,5369.8,Other,215% New York Medicaid APG,3121.98,,,3121.98,Other,125% New York Medicaid APG,2497.58,55260.03,
Electroejaculation,55870,CPT,,,,,,,,both,,,16909.26,12512.85,74,,12512.85,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,7609.17,45,,7609.17,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,1119.3,,,1119.3,Fee Schedule,,1006.73,,,1006.73,Fee Schedule,,951.51,,,951.51,Fee Schedule,,8370.08,49.5,,8370.08,percent of total billed charges,110% of Medicare,11498.3,68,,11498.3,percent of total billed charges,,903.43,,,903.43,Other,186% of Medicaid,13527.41,80,,13527.41,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,13527.41,80,,13527.41,percent of total billed charges,,7216,,,7216,Case Rate,,3578,,"100% primary, 0% secondary procedures",3578,Other,MagnaCare ASC Grouper,11836.48,70,,11836.48,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,485.72,,,485.72,Other,New York Medicaid APG methodology,485.72,,,485.72,Other,100% New York Medicaid APG,485.72,,,485.72,Other,100% New York Medicaid APG,485.72,,,485.72,Other,100% New York Medicaid APG,1092.86,,,1092.86,Other,225% New York Medicaid APG,743.14,,,743.14,Other,153% New York Medicaid APG,1092.86,,,1092.86,Other,225% New York Medicaid APG,680,,,680,Other,140% New York Medicaid APG,1092.86,,,1092.86,Other,225% New York Medicaid APG,1262.86,,,1262.86,Other,260% New York Medicaid APG,1573.72,,,1573.72,Other,324% New York Medicaid APG,1044.29,,,1044.29,Other,215% New York Medicaid APG,1044.29,,,1044.29,Other,215% New York Medicaid APG,607.14,,,607.14,Other,125% New York Medicaid APG,485.72,13527.41,
Cryoablate prostate,55873,CPT,,,,,,,,both,,,193769.26,143389.25,74,,143389.25,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,87196.17,45,,87196.17,percent of total billed charges,Medicare Ratio of cost to charges,5459,,"100% primary, 50% supplemental procedure",5459,Other,Aetna ASC Grouper,4913,,"100% primary, 50% supplemental procedure",4913,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,95915.78,49.5,,95915.78,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,4645.5,,,4645.5,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9196,,"100% primary, 0% secondary procedures",9196,Other,MagnaCare ASC Grouper,135638.48,70,,135638.48,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6956,,"100% primary, 50% secondary, 25% tertiary procedure",6956,Other,United Healthcare ASC Grouper,6261,,"100% primary, 50% secondary, 25% tertiary procedure",6261,Other,United Healthcare ASC Grouper,6956,,"100% primary, 50% secondary, 25% tertiary procedure",6956,Other,United Healthcare ASC Grouper,5913,,"100% primary, 50% secondary, 25% tertiary procedure",5913,Other,United Healthcare ASC Grouper,2497.58,,,2497.58,Other,New York Medicaid APG methodology,2497.58,,,2497.58,Other,100% New York Medicaid APG,2497.58,,,2497.58,Other,100% New York Medicaid APG,2497.58,,,2497.58,Other,100% New York Medicaid APG,5619.56,,,5619.56,Other,225% New York Medicaid APG,3821.3,,,3821.3,Other,153% New York Medicaid APG,5619.56,,,5619.56,Other,225% New York Medicaid APG,3496.61,,,3496.61,Other,140% New York Medicaid APG,5619.56,,,5619.56,Other,225% New York Medicaid APG,6493.71,,,6493.71,Other,260% New York Medicaid APG,8092.16,,,8092.16,Other,324% New York Medicaid APG,5369.8,,,5369.8,Other,215% New York Medicaid APG,5369.8,,,5369.8,Other,215% New York Medicaid APG,3121.98,,,3121.98,Other,125% New York Medicaid APG,2497.58,143389.25,
Tprnl plmt biodegrdabl matrl,55874,CPT,,,,,,,,both,,,47733.67,35322.92,74,,35322.92,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,21480.15,45,,21480.15,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,23628.17,49.5,,23628.17,percent of total billed charges,110% of Medicare,32458.9,68,,32458.9,percent of total billed charges,,4645.5,,,4645.5,Other,186% of Medicaid,38186.94,80,,38186.94,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,38186.94,80,,38186.94,percent of total billed charges,,7216,,,7216,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,33413.57,70,,33413.57,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,2497.58,,,2497.58,Other,New York Medicaid APG methodology,2497.58,,,2497.58,Other,100% New York Medicaid APG,2497.58,,,2497.58,Other,100% New York Medicaid APG,2497.58,,,2497.58,Other,100% New York Medicaid APG,5619.56,,,5619.56,Other,225% New York Medicaid APG,3821.3,,,3821.3,Other,153% New York Medicaid APG,5619.56,,,5619.56,Other,225% New York Medicaid APG,3496.61,,,3496.61,Other,140% New York Medicaid APG,5619.56,,,5619.56,Other,225% New York Medicaid APG,6493.71,,,6493.71,Other,260% New York Medicaid APG,8092.16,,,8092.16,Other,324% New York Medicaid APG,5369.8,,,5369.8,Other,215% New York Medicaid APG,5369.8,,,5369.8,Other,215% New York Medicaid APG,3121.98,,,3121.98,Other,125% New York Medicaid APG,2053,38186.94,
Transperi needle place pros,55875,CPT,,,,,,,,both,,,108835.97,80538.62,74,,80538.62,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,48976.19,45,,48976.19,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,53873.81,49.5,,53873.81,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,4645.5,,,4645.5,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,76185.18,70,,76185.18,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,2497.58,,,2497.58,Other,New York Medicaid APG methodology,2497.58,,,2497.58,Other,100% New York Medicaid APG,2497.58,,,2497.58,Other,100% New York Medicaid APG,2497.58,,,2497.58,Other,100% New York Medicaid APG,5619.56,,,5619.56,Other,225% New York Medicaid APG,3821.3,,,3821.3,Other,153% New York Medicaid APG,5619.56,,,5619.56,Other,225% New York Medicaid APG,3496.61,,,3496.61,Other,140% New York Medicaid APG,5619.56,,,5619.56,Other,225% New York Medicaid APG,6493.71,,,6493.71,Other,260% New York Medicaid APG,8092.16,,,8092.16,Other,324% New York Medicaid APG,5369.8,,,5369.8,Other,215% New York Medicaid APG,5369.8,,,5369.8,Other,215% New York Medicaid APG,3121.98,,,3121.98,Other,125% New York Medicaid APG,2497.58,80538.62,
Place rt device/marker pros,55876,CPT,,,,,,,,both,,,45265.72,33496.63,74,,33496.63,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,20369.57,45,,20369.57,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,22406.53,49.5,,22406.53,percent of total billed charges,110% of Medicare,30780.69,68,,30780.69,percent of total billed charges,,479.66,,,479.66,Other,186% of Medicaid,36212.58,80,,36212.58,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,36212.58,80,,36212.58,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,31686,70,,31686,percent of total billed charges,,492,,,492,Fee Schedule,,417,,,417,Fee Schedule,,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,257.88,,,257.88,Other,New York Medicaid APG methodology,257.88,,,257.88,Other,100% New York Medicaid APG,257.88,,,257.88,Other,100% New York Medicaid APG,257.88,,,257.88,Other,100% New York Medicaid APG,580.23,,,580.23,Other,225% New York Medicaid APG,394.56,,,394.56,Other,153% New York Medicaid APG,580.23,,,580.23,Other,225% New York Medicaid APG,361.03,,,361.03,Other,140% New York Medicaid APG,580.23,,,580.23,Other,225% New York Medicaid APG,670.49,,,670.49,Other,260% New York Medicaid APG,835.53,,,835.53,Other,324% New York Medicaid APG,554.44,,,554.44,Other,215% New York Medicaid APG,554.44,,,554.44,Other,215% New York Medicaid APG,322.35,,,322.35,Other,125% New York Medicaid APG,257.88,36212.58,
Abltj mal prst8 tiss hifu,55880,CPT,,,,,,,,both,,,193769.26,143389.25,74,,143389.25,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,87196.17,45,,87196.17,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,95915.78,49.5,,95915.78,percent of total billed charges,110% of Medicare,131763.1,68,,131763.1,percent of total billed charges,,4645.5,,,4645.5,Other,186% of Medicaid,155015.41,80,,155015.41,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,155015.41,80,,155015.41,percent of total billed charges,,7216,,,7216,Case Rate,,155015.41,80,,155015.41,percent of total billed charges,,135638.48,70,,135638.48,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,2497.58,,,2497.58,Other,New York Medicaid APG methodology,2497.58,,,2497.58,Other,100% New York Medicaid APG,2497.58,,,2497.58,Other,100% New York Medicaid APG,2497.58,,,2497.58,Other,100% New York Medicaid APG,5619.56,,,5619.56,Other,225% New York Medicaid APG,3821.3,,,3821.3,Other,153% New York Medicaid APG,5619.56,,,5619.56,Other,225% New York Medicaid APG,3496.61,,,3496.61,Other,140% New York Medicaid APG,5619.56,,,5619.56,Other,225% New York Medicaid APG,6493.71,,,6493.71,Other,260% New York Medicaid APG,8092.16,,,8092.16,Other,324% New York Medicaid APG,5369.8,,,5369.8,Other,215% New York Medicaid APG,5369.8,,,5369.8,Other,215% New York Medicaid APG,3121.98,,,3121.98,Other,125% New York Medicaid APG,2232,155015.41,
Place needles pelvic for rt,55920,CPT,,,,,,,,both,,,104619.92,77418.74,74,,77418.74,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,47078.96,45,,47078.96,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,51786.86,49.5,,51786.86,percent of total billed charges,110% of Medicare,71141.55,68,,71141.55,percent of total billed charges,,3412.13,,,3412.13,Other,186% of Medicaid,83695.94,80,,83695.94,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,83695.94,80,,83695.94,percent of total billed charges,,7216,,,7216,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,73233.94,70,,73233.94,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1834.48,,,1834.48,Other,New York Medicaid APG methodology,1834.48,,,1834.48,Other,100% New York Medicaid APG,1834.48,,,1834.48,Other,100% New York Medicaid APG,1834.48,,,1834.48,Other,100% New York Medicaid APG,4127.58,,,4127.58,Other,225% New York Medicaid APG,2806.75,,,2806.75,Other,153% New York Medicaid APG,4127.58,,,4127.58,Other,225% New York Medicaid APG,2568.27,,,2568.27,Other,140% New York Medicaid APG,4127.58,,,4127.58,Other,225% New York Medicaid APG,4769.65,,,4769.65,Other,260% New York Medicaid APG,5943.71,,,5943.71,Other,324% New York Medicaid APG,3944.13,,,3944.13,Other,215% New York Medicaid APG,3944.13,,,3944.13,Other,215% New York Medicaid APG,2293.1,,,2293.1,Other,125% New York Medicaid APG,1834.48,83695.94,
I & d of vulva/perineum,56405,CPT,,,,,,,,both,,,33103.16,24496.34,74,,24496.34,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,14896.42,45,,14896.42,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,16386.06,49.5,,16386.06,percent of total billed charges,110% of Medicare,22510.15,68,,22510.15,percent of total billed charges,,445.2,,,445.2,Other,186% of Medicaid,26482.53,80,,26482.53,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,26482.53,80,,26482.53,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,23172.21,70,,23172.21,percent of total billed charges,,628.12,,,628.12,Fee Schedule,,532.37,,,532.37,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,239.36,,,239.36,Other,New York Medicaid APG methodology,239.36,,,239.36,Other,100% New York Medicaid APG,239.36,,,239.36,Other,100% New York Medicaid APG,239.36,,,239.36,Other,100% New York Medicaid APG,538.55,,,538.55,Other,225% New York Medicaid APG,366.22,,,366.22,Other,153% New York Medicaid APG,538.55,,,538.55,Other,225% New York Medicaid APG,335.1,,,335.1,Other,140% New York Medicaid APG,538.55,,,538.55,Other,225% New York Medicaid APG,622.33,,,622.33,Other,260% New York Medicaid APG,775.52,,,775.52,Other,324% New York Medicaid APG,514.62,,,514.62,Other,215% New York Medicaid APG,514.62,,,514.62,Other,215% New York Medicaid APG,299.2,,,299.2,Other,125% New York Medicaid APG,239.36,26482.53,
Drainage of gland abscess,56420,CPT,,,,,,,,both,,,4191.33,3101.58,74,,3101.58,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,1886.1,45,,1886.1,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,2074.71,49.5,,2074.71,percent of total billed charges,110% of Medicare,2850.1,68,,2850.1,percent of total billed charges,,445.2,,,445.2,Other,186% of Medicaid,3353.06,80,,3353.06,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,3353.06,80,,3353.06,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,2933.93,70,,2933.93,percent of total billed charges,,549.4,,,549.4,Fee Schedule,,465.65,,,465.65,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,239.36,,,239.36,Other,New York Medicaid APG methodology,239.36,,,239.36,Other,100% New York Medicaid APG,239.36,,,239.36,Other,100% New York Medicaid APG,239.36,,,239.36,Other,100% New York Medicaid APG,538.55,,,538.55,Other,225% New York Medicaid APG,366.22,,,366.22,Other,153% New York Medicaid APG,538.55,,,538.55,Other,225% New York Medicaid APG,335.1,,,335.1,Other,140% New York Medicaid APG,538.55,,,538.55,Other,225% New York Medicaid APG,622.33,,,622.33,Other,260% New York Medicaid APG,775.52,,,775.52,Other,324% New York Medicaid APG,514.62,,,514.62,Other,215% New York Medicaid APG,514.62,,,514.62,Other,215% New York Medicaid APG,299.2,,,299.2,Other,125% New York Medicaid APG,239.36,7216,
Surgery for vulva lesion,56440,CPT,,,,,,,,both,,,33439.03,24744.88,74,,24744.88,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15047.56,45,,15047.56,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,16552.32,49.5,,16552.32,percent of total billed charges,110% of Medicare,22738.54,68,,22738.54,percent of total billed charges,,2338.92,,,2338.92,Other,186% of Medicaid,26751.22,80,,26751.22,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,26751.22,80,,26751.22,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,23407.32,70,,23407.32,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1257.49,,,1257.49,Other,New York Medicaid APG methodology,1257.49,,,1257.49,Other,100% New York Medicaid APG,1257.49,,,1257.49,Other,100% New York Medicaid APG,1257.49,,,1257.49,Other,100% New York Medicaid APG,2829.34,,,2829.34,Other,225% New York Medicaid APG,1923.95,,,1923.95,Other,153% New York Medicaid APG,2829.34,,,2829.34,Other,225% New York Medicaid APG,1760.48,,,1760.48,Other,140% New York Medicaid APG,2829.34,,,2829.34,Other,225% New York Medicaid APG,3269.46,,,3269.46,Other,260% New York Medicaid APG,4074.25,,,4074.25,Other,324% New York Medicaid APG,2703.59,,,2703.59,Other,215% New York Medicaid APG,2703.59,,,2703.59,Other,215% New York Medicaid APG,1571.86,,,1571.86,Other,125% New York Medicaid APG,1257.49,26751.22,
Lysis of labial lesion(s),56441,CPT,,,,,,,,both,,,44954.42,33266.27,74,,33266.27,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,20229.49,45,,20229.49,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,22252.44,49.5,,22252.44,percent of total billed charges,110% of Medicare,30569.01,68,,30569.01,percent of total billed charges,,2338.92,,,2338.92,Other,186% of Medicaid,35963.54,80,,35963.54,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,35963.54,80,,35963.54,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,31468.09,70,,31468.09,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1257.49,,,1257.49,Other,New York Medicaid APG methodology,1257.49,,,1257.49,Other,100% New York Medicaid APG,1257.49,,,1257.49,Other,100% New York Medicaid APG,1257.49,,,1257.49,Other,100% New York Medicaid APG,2829.34,,,2829.34,Other,225% New York Medicaid APG,1923.95,,,1923.95,Other,153% New York Medicaid APG,2829.34,,,2829.34,Other,225% New York Medicaid APG,1760.48,,,1760.48,Other,140% New York Medicaid APG,2829.34,,,2829.34,Other,225% New York Medicaid APG,3269.46,,,3269.46,Other,260% New York Medicaid APG,4074.25,,,4074.25,Other,324% New York Medicaid APG,2703.59,,,2703.59,Other,215% New York Medicaid APG,2703.59,,,2703.59,Other,215% New York Medicaid APG,1571.86,,,1571.86,Other,125% New York Medicaid APG,1257.49,35963.54,
Hymenotomy,56442,CPT,,,,,,,,both,,,35682.23,26404.85,74,,26404.85,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,16057,45,,16057,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,17662.7,49.5,,17662.7,percent of total billed charges,110% of Medicare,24263.92,68,,24263.92,percent of total billed charges,,1132.19,,,1132.19,Other,186% of Medicaid,28545.78,80,,28545.78,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,28545.78,80,,28545.78,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,24977.56,70,,24977.56,percent of total billed charges,,232.88,,,232.88,Fee Schedule,,197.38,,,197.38,Fee Schedule,,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,608.71,,,608.71,Other,New York Medicaid APG methodology,608.71,,,608.71,Other,100% New York Medicaid APG,608.71,,,608.71,Other,100% New York Medicaid APG,608.71,,,608.71,Other,100% New York Medicaid APG,1369.59,,,1369.59,Other,225% New York Medicaid APG,931.32,,,931.32,Other,153% New York Medicaid APG,1369.59,,,1369.59,Other,225% New York Medicaid APG,852.19,,,852.19,Other,140% New York Medicaid APG,1369.59,,,1369.59,Other,225% New York Medicaid APG,1582.63,,,1582.63,Other,260% New York Medicaid APG,1972.21,,,1972.21,Other,324% New York Medicaid APG,1308.72,,,1308.72,Other,215% New York Medicaid APG,1308.72,,,1308.72,Other,215% New York Medicaid APG,760.88,,,760.88,Other,125% New York Medicaid APG,197.38,28545.78,
Destroy vulva lesions sim,56501,CPT,,,,,,,,both,,,38357.55,28384.59,74,,28384.59,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,17260.9,45,,17260.9,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,18986.99,49.5,,18986.99,percent of total billed charges,110% of Medicare,26083.13,68,,26083.13,percent of total billed charges,,2338.92,,,2338.92,Other,186% of Medicaid,30686.04,80,,30686.04,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,30686.04,80,,30686.04,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,26850.29,70,,26850.29,percent of total billed charges,,660.92,,,660.92,Fee Schedule,,560.17,,,560.17,Fee Schedule,,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1257.49,,,1257.49,Other,New York Medicaid APG methodology,1257.49,,,1257.49,Other,100% New York Medicaid APG,1257.49,,,1257.49,Other,100% New York Medicaid APG,1257.49,,,1257.49,Other,100% New York Medicaid APG,2829.34,,,2829.34,Other,225% New York Medicaid APG,1923.95,,,1923.95,Other,153% New York Medicaid APG,2829.34,,,2829.34,Other,225% New York Medicaid APG,1760.48,,,1760.48,Other,140% New York Medicaid APG,2829.34,,,2829.34,Other,225% New York Medicaid APG,3269.46,,,3269.46,Other,260% New York Medicaid APG,4074.25,,,4074.25,Other,324% New York Medicaid APG,2703.59,,,2703.59,Other,215% New York Medicaid APG,2703.59,,,2703.59,Other,215% New York Medicaid APG,1571.86,,,1571.86,Other,125% New York Medicaid APG,560.17,30686.04,
Destroy vulva lesion/s compl,56515,CPT,,,,,,,,both,,,38357.55,28384.59,74,,28384.59,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,17260.9,45,,17260.9,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,18986.99,49.5,,18986.99,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2338.92,,,2338.92,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,26850.29,70,,26850.29,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1257.49,,,1257.49,Other,New York Medicaid APG methodology,1257.49,,,1257.49,Other,100% New York Medicaid APG,1257.49,,,1257.49,Other,100% New York Medicaid APG,1257.49,,,1257.49,Other,100% New York Medicaid APG,2829.34,,,2829.34,Other,225% New York Medicaid APG,1923.95,,,1923.95,Other,153% New York Medicaid APG,2829.34,,,2829.34,Other,225% New York Medicaid APG,1760.48,,,1760.48,Other,140% New York Medicaid APG,2829.34,,,2829.34,Other,225% New York Medicaid APG,3269.46,,,3269.46,Other,260% New York Medicaid APG,4074.25,,,4074.25,Other,324% New York Medicaid APG,2703.59,,,2703.59,Other,215% New York Medicaid APG,2703.59,,,2703.59,Other,215% New York Medicaid APG,1571.86,,,1571.86,Other,125% New York Medicaid APG,1257.49,28384.59,
Biopsy of vulva/perineum,56605,CPT,,,,,,,,both,,,43090.66,31887.09,74,,31887.09,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,19390.8,45,,19390.8,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,21329.88,49.5,,21329.88,percent of total billed charges,110% of Medicare,29301.65,68,,29301.65,percent of total billed charges,,1132.19,,,1132.19,Other,186% of Medicaid,34472.53,80,,34472.53,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,34472.53,80,,34472.53,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,30163.46,70,,30163.46,percent of total billed charges,,290.28,,,290.28,Fee Schedule,,246.03,,,246.03,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,608.71,,,608.71,Other,New York Medicaid APG methodology,608.71,,,608.71,Other,100% New York Medicaid APG,608.71,,,608.71,Other,100% New York Medicaid APG,608.71,,,608.71,Other,100% New York Medicaid APG,1369.59,,,1369.59,Other,225% New York Medicaid APG,931.32,,,931.32,Other,153% New York Medicaid APG,1369.59,,,1369.59,Other,225% New York Medicaid APG,852.19,,,852.19,Other,140% New York Medicaid APG,1369.59,,,1369.59,Other,225% New York Medicaid APG,1582.63,,,1582.63,Other,260% New York Medicaid APG,1972.21,,,1972.21,Other,324% New York Medicaid APG,1308.72,,,1308.72,Other,215% New York Medicaid APG,1308.72,,,1308.72,Other,215% New York Medicaid APG,760.88,,,760.88,Other,125% New York Medicaid APG,246.03,34472.53,
Biopsy of vulva/perineum,56606,CPT,,,,,,,,both,,,32432.1,23999.75,74,,23999.75,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,14594.45,45,,14594.45,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,16053.89,49.5,,16053.89,percent of total billed charges,110% of Medicare,22053.83,68,,22053.83,percent of total billed charges,,1132.19,,,1132.19,Other,186% of Medicaid,25945.68,80,,25945.68,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,25945.68,80,,25945.68,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,22702.47,70,,22702.47,percent of total billed charges,,144.32,,,144.32,Fee Schedule,,122.32,,,122.32,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,608.71,,,608.71,Other,New York Medicaid APG methodology,608.71,,,608.71,Other,100% New York Medicaid APG,608.71,,,608.71,Other,100% New York Medicaid APG,608.71,,,608.71,Other,100% New York Medicaid APG,1369.59,,,1369.59,Other,225% New York Medicaid APG,931.32,,,931.32,Other,153% New York Medicaid APG,1369.59,,,1369.59,Other,225% New York Medicaid APG,852.19,,,852.19,Other,140% New York Medicaid APG,1369.59,,,1369.59,Other,225% New York Medicaid APG,1582.63,,,1582.63,Other,260% New York Medicaid APG,1972.21,,,1972.21,Other,324% New York Medicaid APG,1308.72,,,1308.72,Other,215% New York Medicaid APG,1308.72,,,1308.72,Other,215% New York Medicaid APG,760.88,,,760.88,Other,125% New York Medicaid APG,122.32,25945.68,
Partial removal of vulva,56620,CPT,,,,,,,,both,,,43594.74,32260.11,74,,32260.11,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,19617.63,45,,19617.63,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,21579.4,49.5,,21579.4,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2338.92,,,2338.92,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,30516.32,70,,30516.32,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1257.49,,,1257.49,Other,New York Medicaid APG methodology,1257.49,,,1257.49,Other,100% New York Medicaid APG,1257.49,,,1257.49,Other,100% New York Medicaid APG,1257.49,,,1257.49,Other,100% New York Medicaid APG,2829.34,,,2829.34,Other,225% New York Medicaid APG,1923.95,,,1923.95,Other,153% New York Medicaid APG,2829.34,,,2829.34,Other,225% New York Medicaid APG,1760.48,,,1760.48,Other,140% New York Medicaid APG,2829.34,,,2829.34,Other,225% New York Medicaid APG,3269.46,,,3269.46,Other,260% New York Medicaid APG,4074.25,,,4074.25,Other,324% New York Medicaid APG,2703.59,,,2703.59,Other,215% New York Medicaid APG,2703.59,,,2703.59,Other,215% New York Medicaid APG,1571.86,,,1571.86,Other,125% New York Medicaid APG,1257.49,32260.11,
Complete removal of vulva,56625,CPT,,,,,,,,both,,,65759.04,48661.69,74,,48661.69,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,29591.57,45,,29591.57,percent of total billed charges,Medicare Ratio of cost to charges,5459,,"100% primary, 50% supplemental procedure",5459,Other,Aetna ASC Grouper,4913,,"100% primary, 50% supplemental procedure",4913,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,32550.72,49.5,,32550.72,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2611.37,,,2611.37,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,46031.33,70,,46031.33,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1403.96,,,1403.96,Other,New York Medicaid APG methodology,1403.96,,,1403.96,Other,100% New York Medicaid APG,1403.96,,,1403.96,Other,100% New York Medicaid APG,1403.96,,,1403.96,Other,100% New York Medicaid APG,3158.92,,,3158.92,Other,225% New York Medicaid APG,2148.07,,,2148.07,Other,153% New York Medicaid APG,3158.92,,,3158.92,Other,225% New York Medicaid APG,1965.55,,,1965.55,Other,140% New York Medicaid APG,3158.92,,,3158.92,Other,225% New York Medicaid APG,3650.31,,,3650.31,Other,260% New York Medicaid APG,4548.84,,,4548.84,Other,324% New York Medicaid APG,3018.52,,,3018.52,Other,215% New York Medicaid APG,3018.52,,,3018.52,Other,215% New York Medicaid APG,1754.96,,,1754.96,Other,125% New York Medicaid APG,1403.96,48661.69,
Partial removal of hymen,56700,CPT,,,,,,,,both,,,33094.53,24489.95,74,,24489.95,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,14892.54,45,,14892.54,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,16381.79,49.5,,16381.79,percent of total billed charges,110% of Medicare,22504.28,68,,22504.28,percent of total billed charges,,2338.92,,,2338.92,Other,186% of Medicaid,26475.62,80,,26475.62,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,26475.62,80,,26475.62,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,23166.17,70,,23166.17,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1257.49,,,1257.49,Other,New York Medicaid APG methodology,1257.49,,,1257.49,Other,100% New York Medicaid APG,1257.49,,,1257.49,Other,100% New York Medicaid APG,1257.49,,,1257.49,Other,100% New York Medicaid APG,2829.34,,,2829.34,Other,225% New York Medicaid APG,1923.95,,,1923.95,Other,153% New York Medicaid APG,2829.34,,,2829.34,Other,225% New York Medicaid APG,1760.48,,,1760.48,Other,140% New York Medicaid APG,2829.34,,,2829.34,Other,225% New York Medicaid APG,3269.46,,,3269.46,Other,260% New York Medicaid APG,4074.25,,,4074.25,Other,324% New York Medicaid APG,2703.59,,,2703.59,Other,215% New York Medicaid APG,2703.59,,,2703.59,Other,215% New York Medicaid APG,1571.86,,,1571.86,Other,125% New York Medicaid APG,1257.49,26475.62,
Remove vagina gland lesion,56740,CPT,,,,,,,,both,,,41024.22,30357.92,74,,30357.92,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,18460.9,45,,18460.9,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,20306.99,49.5,,20306.99,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2338.92,,,2338.92,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,28716.95,70,,28716.95,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1257.49,,,1257.49,Other,New York Medicaid APG methodology,1257.49,,,1257.49,Other,100% New York Medicaid APG,1257.49,,,1257.49,Other,100% New York Medicaid APG,1257.49,,,1257.49,Other,100% New York Medicaid APG,2829.34,,,2829.34,Other,225% New York Medicaid APG,1923.95,,,1923.95,Other,153% New York Medicaid APG,2829.34,,,2829.34,Other,225% New York Medicaid APG,1760.48,,,1760.48,Other,140% New York Medicaid APG,2829.34,,,2829.34,Other,225% New York Medicaid APG,3269.46,,,3269.46,Other,260% New York Medicaid APG,4074.25,,,4074.25,Other,324% New York Medicaid APG,2703.59,,,2703.59,Other,215% New York Medicaid APG,2703.59,,,2703.59,Other,215% New York Medicaid APG,1571.86,,,1571.86,Other,125% New York Medicaid APG,1257.49,30357.92,
Repair of vagina,56800,CPT,,,,,,,,both,,,65759.04,48661.69,74,,48661.69,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,29591.57,45,,29591.57,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,32550.72,49.5,,32550.72,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2338.92,,,2338.92,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,46031.33,70,,46031.33,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1257.49,,,1257.49,Other,New York Medicaid APG methodology,1257.49,,,1257.49,Other,100% New York Medicaid APG,1257.49,,,1257.49,Other,100% New York Medicaid APG,1257.49,,,1257.49,Other,100% New York Medicaid APG,2829.34,,,2829.34,Other,225% New York Medicaid APG,1923.95,,,1923.95,Other,153% New York Medicaid APG,2829.34,,,2829.34,Other,225% New York Medicaid APG,1760.48,,,1760.48,Other,140% New York Medicaid APG,2829.34,,,2829.34,Other,225% New York Medicaid APG,3269.46,,,3269.46,Other,260% New York Medicaid APG,4074.25,,,4074.25,Other,324% New York Medicaid APG,2703.59,,,2703.59,Other,215% New York Medicaid APG,2703.59,,,2703.59,Other,215% New York Medicaid APG,1571.86,,,1571.86,Other,125% New York Medicaid APG,1257.49,48661.69,
Repair clitoris,56805,CPT,,,,,,,,both,,,65759.04,48661.69,74,,48661.69,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,29591.57,45,,29591.57,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,32550.72,49.5,,32550.72,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2338.92,,,2338.92,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,46031.33,70,,46031.33,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1257.49,,,1257.49,Other,New York Medicaid APG methodology,1257.49,,,1257.49,Other,100% New York Medicaid APG,1257.49,,,1257.49,Other,100% New York Medicaid APG,1257.49,,,1257.49,Other,100% New York Medicaid APG,2829.34,,,2829.34,Other,225% New York Medicaid APG,1923.95,,,1923.95,Other,153% New York Medicaid APG,2829.34,,,2829.34,Other,225% New York Medicaid APG,1760.48,,,1760.48,Other,140% New York Medicaid APG,2829.34,,,2829.34,Other,225% New York Medicaid APG,3269.46,,,3269.46,Other,260% New York Medicaid APG,4074.25,,,4074.25,Other,324% New York Medicaid APG,2703.59,,,2703.59,Other,215% New York Medicaid APG,2703.59,,,2703.59,Other,215% New York Medicaid APG,1571.86,,,1571.86,Other,125% New York Medicaid APG,1257.49,48661.69,
Repair of perineum,56810,CPT,,,,,,,,both,,,39228.34,29028.97,74,,29028.97,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,17652.75,45,,17652.75,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,19418.03,49.5,,19418.03,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2338.92,,,2338.92,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,27459.84,70,,27459.84,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1257.49,,,1257.49,Other,New York Medicaid APG methodology,1257.49,,,1257.49,Other,100% New York Medicaid APG,1257.49,,,1257.49,Other,100% New York Medicaid APG,1257.49,,,1257.49,Other,100% New York Medicaid APG,2829.34,,,2829.34,Other,225% New York Medicaid APG,1923.95,,,1923.95,Other,153% New York Medicaid APG,2829.34,,,2829.34,Other,225% New York Medicaid APG,1760.48,,,1760.48,Other,140% New York Medicaid APG,2829.34,,,2829.34,Other,225% New York Medicaid APG,3269.46,,,3269.46,Other,260% New York Medicaid APG,4074.25,,,4074.25,Other,324% New York Medicaid APG,2703.59,,,2703.59,Other,215% New York Medicaid APG,2703.59,,,2703.59,Other,215% New York Medicaid APG,1571.86,,,1571.86,Other,125% New York Medicaid APG,1257.49,29028.97,
Exam of vulva w/scope,56820,CPT,,,,,,,,both,,,4191.33,3101.58,74,,3101.58,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,1886.1,45,,1886.1,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,2074.71,49.5,,2074.71,percent of total billed charges,110% of Medicare,2850.1,68,,2850.1,percent of total billed charges,,445.2,,,445.2,Other,186% of Medicaid,3353.06,80,,3353.06,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,3353.06,80,,3353.06,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,2933.93,70,,2933.93,percent of total billed charges,,413.28,,,413.28,Fee Schedule,,350.28,,,350.28,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,239.36,,,239.36,Other,New York Medicaid APG methodology,239.36,,,239.36,Other,100% New York Medicaid APG,239.36,,,239.36,Other,100% New York Medicaid APG,239.36,,,239.36,Other,100% New York Medicaid APG,538.55,,,538.55,Other,225% New York Medicaid APG,366.22,,,366.22,Other,153% New York Medicaid APG,538.55,,,538.55,Other,225% New York Medicaid APG,335.1,,,335.1,Other,140% New York Medicaid APG,538.55,,,538.55,Other,225% New York Medicaid APG,622.33,,,622.33,Other,260% New York Medicaid APG,775.52,,,775.52,Other,324% New York Medicaid APG,514.62,,,514.62,Other,215% New York Medicaid APG,514.62,,,514.62,Other,215% New York Medicaid APG,299.2,,,299.2,Other,125% New York Medicaid APG,239.36,7216,
Exam/biopsy of vulva w/scope,56821,CPT,,,,,,,,both,,,6747.72,4993.31,74,,4993.31,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,3036.47,45,,3036.47,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,3340.12,49.5,,3340.12,percent of total billed charges,110% of Medicare,4588.45,68,,4588.45,percent of total billed charges,,1132.19,,,1132.19,Other,186% of Medicaid,5398.18,80,,5398.18,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,5398.18,80,,5398.18,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,4723.4,70,,4723.4,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,608.71,,,608.71,Other,New York Medicaid APG methodology,608.71,,,608.71,Other,100% New York Medicaid APG,608.71,,,608.71,Other,100% New York Medicaid APG,608.71,,,608.71,Other,100% New York Medicaid APG,1369.59,,,1369.59,Other,225% New York Medicaid APG,931.32,,,931.32,Other,153% New York Medicaid APG,1369.59,,,1369.59,Other,225% New York Medicaid APG,852.19,,,852.19,Other,140% New York Medicaid APG,1369.59,,,1369.59,Other,225% New York Medicaid APG,1582.63,,,1582.63,Other,260% New York Medicaid APG,1972.21,,,1972.21,Other,324% New York Medicaid APG,1308.72,,,1308.72,Other,215% New York Medicaid APG,1308.72,,,1308.72,Other,215% New York Medicaid APG,760.88,,,760.88,Other,125% New York Medicaid APG,608.71,7216,
Exploration of vagina,57000,CPT,,,,,,,,both,,,65759.04,48661.69,74,,48661.69,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,29591.57,45,,29591.57,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,32550.72,49.5,,32550.72,percent of total billed charges,110% of Medicare,44716.15,68,,44716.15,percent of total billed charges,,2338.92,,,2338.92,Other,186% of Medicaid,52607.23,80,,52607.23,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,52607.23,80,,52607.23,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,46031.33,70,,46031.33,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1257.49,,,1257.49,Other,New York Medicaid APG methodology,1257.49,,,1257.49,Other,100% New York Medicaid APG,1257.49,,,1257.49,Other,100% New York Medicaid APG,1257.49,,,1257.49,Other,100% New York Medicaid APG,2829.34,,,2829.34,Other,225% New York Medicaid APG,1923.95,,,1923.95,Other,153% New York Medicaid APG,2829.34,,,2829.34,Other,225% New York Medicaid APG,1760.48,,,1760.48,Other,140% New York Medicaid APG,2829.34,,,2829.34,Other,225% New York Medicaid APG,3269.46,,,3269.46,Other,260% New York Medicaid APG,4074.25,,,4074.25,Other,324% New York Medicaid APG,2703.59,,,2703.59,Other,215% New York Medicaid APG,2703.59,,,2703.59,Other,215% New York Medicaid APG,1571.86,,,1571.86,Other,125% New York Medicaid APG,1257.49,52607.23,
Drainage of pelvic abscess,57010,CPT,,,,,,,,both,,,65759.04,48661.69,74,,48661.69,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,29591.57,45,,29591.57,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,32550.72,49.5,,32550.72,percent of total billed charges,110% of Medicare,44716.15,68,,44716.15,percent of total billed charges,,2338.92,,,2338.92,Other,186% of Medicaid,52607.23,80,,52607.23,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,52607.23,80,,52607.23,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,46031.33,70,,46031.33,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1257.49,,,1257.49,Other,New York Medicaid APG methodology,1257.49,,,1257.49,Other,100% New York Medicaid APG,1257.49,,,1257.49,Other,100% New York Medicaid APG,1257.49,,,1257.49,Other,100% New York Medicaid APG,2829.34,,,2829.34,Other,225% New York Medicaid APG,1923.95,,,1923.95,Other,153% New York Medicaid APG,2829.34,,,2829.34,Other,225% New York Medicaid APG,1760.48,,,1760.48,Other,140% New York Medicaid APG,2829.34,,,2829.34,Other,225% New York Medicaid APG,3269.46,,,3269.46,Other,260% New York Medicaid APG,4074.25,,,4074.25,Other,324% New York Medicaid APG,2703.59,,,2703.59,Other,215% New York Medicaid APG,2703.59,,,2703.59,Other,215% New York Medicaid APG,1571.86,,,1571.86,Other,125% New York Medicaid APG,1257.49,52607.23,
Drainage of pelvic fluid,57020,CPT,,,,,,,,both,,,104619.92,77418.74,74,,77418.74,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,47078.96,45,,47078.96,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,51786.86,49.5,,51786.86,percent of total billed charges,110% of Medicare,71141.55,68,,71141.55,percent of total billed charges,,1132.19,,,1132.19,Other,186% of Medicaid,83695.94,80,,83695.94,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,83695.94,80,,83695.94,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,73233.94,70,,73233.94,percent of total billed charges,,388.68,,,388.68,Fee Schedule,,329.43,,,329.43,Fee Schedule,,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,608.71,,,608.71,Other,New York Medicaid APG methodology,608.71,,,608.71,Other,100% New York Medicaid APG,608.71,,,608.71,Other,100% New York Medicaid APG,608.71,,,608.71,Other,100% New York Medicaid APG,1369.59,,,1369.59,Other,225% New York Medicaid APG,931.32,,,931.32,Other,153% New York Medicaid APG,1369.59,,,1369.59,Other,225% New York Medicaid APG,852.19,,,852.19,Other,140% New York Medicaid APG,1369.59,,,1369.59,Other,225% New York Medicaid APG,1582.63,,,1582.63,Other,260% New York Medicaid APG,1972.21,,,1972.21,Other,324% New York Medicaid APG,1308.72,,,1308.72,Other,215% New York Medicaid APG,1308.72,,,1308.72,Other,215% New York Medicaid APG,760.88,,,760.88,Other,125% New York Medicaid APG,329.43,83695.94,
I & d vaginal hematoma pp,57022,CPT,,,,,,,,both,,,59767.2,44227.73,74,,44227.73,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,26895.24,45,,26895.24,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,29584.76,49.5,,29584.76,percent of total billed charges,110% of Medicare,40641.7,68,,40641.7,percent of total billed charges,,1902.33,,,1902.33,Other,186% of Medicaid,47813.76,80,,47813.76,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,47813.76,80,,47813.76,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,41837.04,70,,41837.04,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1022.76,,,1022.76,Other,New York Medicaid APG methodology,1022.76,,,1022.76,Other,100% New York Medicaid APG,1022.76,,,1022.76,Other,100% New York Medicaid APG,1022.76,,,1022.76,Other,100% New York Medicaid APG,2301.2,,,2301.2,Other,225% New York Medicaid APG,1564.82,,,1564.82,Other,153% New York Medicaid APG,2301.2,,,2301.2,Other,225% New York Medicaid APG,1431.86,,,1431.86,Other,140% New York Medicaid APG,2301.2,,,2301.2,Other,225% New York Medicaid APG,2659.17,,,2659.17,Other,260% New York Medicaid APG,3313.73,,,3313.73,Other,324% New York Medicaid APG,2198.93,,,2198.93,Other,215% New York Medicaid APG,2198.93,,,2198.93,Other,215% New York Medicaid APG,1278.45,,,1278.45,Other,125% New York Medicaid APG,1022.76,47813.76,
I & d vag hematoma non-ob,57023,CPT,,,,,,,,both,,,59767.2,44227.73,74,,44227.73,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,26895.24,45,,26895.24,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,29584.76,49.5,,29584.76,percent of total billed charges,110% of Medicare,40641.7,68,,40641.7,percent of total billed charges,,2338.92,,,2338.92,Other,186% of Medicaid,47813.76,80,,47813.76,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,47813.76,80,,47813.76,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,41837.04,70,,41837.04,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1257.49,,,1257.49,Other,New York Medicaid APG methodology,1257.49,,,1257.49,Other,100% New York Medicaid APG,1257.49,,,1257.49,Other,100% New York Medicaid APG,1257.49,,,1257.49,Other,100% New York Medicaid APG,2829.34,,,2829.34,Other,225% New York Medicaid APG,1923.95,,,1923.95,Other,153% New York Medicaid APG,2829.34,,,2829.34,Other,225% New York Medicaid APG,1760.48,,,1760.48,Other,140% New York Medicaid APG,2829.34,,,2829.34,Other,225% New York Medicaid APG,3269.46,,,3269.46,Other,260% New York Medicaid APG,4074.25,,,4074.25,Other,324% New York Medicaid APG,2703.59,,,2703.59,Other,215% New York Medicaid APG,2703.59,,,2703.59,Other,215% New York Medicaid APG,1571.86,,,1571.86,Other,125% New York Medicaid APG,1257.49,47813.76,
Destroy vag lesions simple,57061,CPT,,,,,,,,both,,,35477.16,26253.1,74,,26253.1,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15964.72,45,,15964.72,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,17561.19,49.5,,17561.19,percent of total billed charges,110% of Medicare,24124.47,68,,24124.47,percent of total billed charges,,2338.92,,,2338.92,Other,186% of Medicaid,28381.73,80,,28381.73,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,28381.73,80,,28381.73,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,24834.01,70,,24834.01,percent of total billed charges,,570.72,,,570.72,Fee Schedule,,483.72,,,483.72,Fee Schedule,,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1257.49,,,1257.49,Other,New York Medicaid APG methodology,1257.49,,,1257.49,Other,100% New York Medicaid APG,1257.49,,,1257.49,Other,100% New York Medicaid APG,1257.49,,,1257.49,Other,100% New York Medicaid APG,2829.34,,,2829.34,Other,225% New York Medicaid APG,1923.95,,,1923.95,Other,153% New York Medicaid APG,2829.34,,,2829.34,Other,225% New York Medicaid APG,1760.48,,,1760.48,Other,140% New York Medicaid APG,2829.34,,,2829.34,Other,225% New York Medicaid APG,3269.46,,,3269.46,Other,260% New York Medicaid APG,4074.25,,,4074.25,Other,324% New York Medicaid APG,2703.59,,,2703.59,Other,215% New York Medicaid APG,2703.59,,,2703.59,Other,215% New York Medicaid APG,1571.86,,,1571.86,Other,125% New York Medicaid APG,483.72,28381.73,
Destroy vag lesions complex,57065,CPT,,,,,,,,both,,,65759.04,48661.69,74,,48661.69,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,29591.57,45,,29591.57,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,32550.72,49.5,,32550.72,percent of total billed charges,110% of Medicare,44716.15,68,,44716.15,percent of total billed charges,,2338.92,,,2338.92,Other,186% of Medicaid,52607.23,80,,52607.23,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,52607.23,80,,52607.23,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,46031.33,70,,46031.33,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1257.49,,,1257.49,Other,New York Medicaid APG methodology,1257.49,,,1257.49,Other,100% New York Medicaid APG,1257.49,,,1257.49,Other,100% New York Medicaid APG,1257.49,,,1257.49,Other,100% New York Medicaid APG,2829.34,,,2829.34,Other,225% New York Medicaid APG,1923.95,,,1923.95,Other,153% New York Medicaid APG,2829.34,,,2829.34,Other,225% New York Medicaid APG,1760.48,,,1760.48,Other,140% New York Medicaid APG,2829.34,,,2829.34,Other,225% New York Medicaid APG,3269.46,,,3269.46,Other,260% New York Medicaid APG,4074.25,,,4074.25,Other,324% New York Medicaid APG,2703.59,,,2703.59,Other,215% New York Medicaid APG,2703.59,,,2703.59,Other,215% New York Medicaid APG,1571.86,,,1571.86,Other,125% New York Medicaid APG,1257.49,52607.23,
Biopsy of vagina,57100,CPT,,,,,,,,both,,,42428.87,31397.36,74,,31397.36,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,19092.99,45,,19092.99,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,21002.29,49.5,,21002.29,percent of total billed charges,110% of Medicare,28851.63,68,,28851.63,percent of total billed charges,,1132.19,,,1132.19,Other,186% of Medicaid,33943.1,80,,33943.1,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,33943.1,80,,33943.1,percent of total billed charges,,7216,,,7216,Case Rate,,3578,,"100% primary, 0% secondary procedures",3578,Other,MagnaCare ASC Grouper,29700.21,70,,29700.21,percent of total billed charges,,318.16,,,318.16,Fee Schedule,,269.66,,,269.66,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,608.71,,,608.71,Other,New York Medicaid APG methodology,608.71,,,608.71,Other,100% New York Medicaid APG,608.71,,,608.71,Other,100% New York Medicaid APG,608.71,,,608.71,Other,100% New York Medicaid APG,1369.59,,,1369.59,Other,225% New York Medicaid APG,931.32,,,931.32,Other,153% New York Medicaid APG,1369.59,,,1369.59,Other,225% New York Medicaid APG,852.19,,,852.19,Other,140% New York Medicaid APG,1369.59,,,1369.59,Other,225% New York Medicaid APG,1582.63,,,1582.63,Other,260% New York Medicaid APG,1972.21,,,1972.21,Other,324% New York Medicaid APG,1308.72,,,1308.72,Other,215% New York Medicaid APG,1308.72,,,1308.72,Other,215% New York Medicaid APG,760.88,,,760.88,Other,125% New York Medicaid APG,269.66,33943.1,
Biopsy of vagina,57105,CPT,,,,,,,,both,,,65759.04,48661.69,74,,48661.69,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,29591.57,45,,29591.57,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,32550.72,49.5,,32550.72,percent of total billed charges,110% of Medicare,44716.15,68,,44716.15,percent of total billed charges,,2338.92,,,2338.92,Other,186% of Medicaid,52607.23,80,,52607.23,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,52607.23,80,,52607.23,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,46031.33,70,,46031.33,percent of total billed charges,,723.24,,,723.24,Fee Schedule,,612.99,,,612.99,Fee Schedule,,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1257.49,,,1257.49,Other,New York Medicaid APG methodology,1257.49,,,1257.49,Other,100% New York Medicaid APG,1257.49,,,1257.49,Other,100% New York Medicaid APG,1257.49,,,1257.49,Other,100% New York Medicaid APG,2829.34,,,2829.34,Other,225% New York Medicaid APG,1923.95,,,1923.95,Other,153% New York Medicaid APG,2829.34,,,2829.34,Other,225% New York Medicaid APG,1760.48,,,1760.48,Other,140% New York Medicaid APG,2829.34,,,2829.34,Other,225% New York Medicaid APG,3269.46,,,3269.46,Other,260% New York Medicaid APG,4074.25,,,4074.25,Other,324% New York Medicaid APG,2703.59,,,2703.59,Other,215% New York Medicaid APG,2703.59,,,2703.59,Other,215% New York Medicaid APG,1571.86,,,1571.86,Other,125% New York Medicaid APG,612.99,52607.23,
Remove vagina wall partial,57106,CPT,,,,,,,,both,,,65759.04,48661.69,74,,48661.69,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,29591.57,45,,29591.57,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,32550.72,49.5,,32550.72,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2338.92,,,2338.92,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,46031.33,70,,46031.33,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1257.49,,,1257.49,Other,New York Medicaid APG methodology,1257.49,,,1257.49,Other,100% New York Medicaid APG,1257.49,,,1257.49,Other,100% New York Medicaid APG,1257.49,,,1257.49,Other,100% New York Medicaid APG,2829.34,,,2829.34,Other,225% New York Medicaid APG,1923.95,,,1923.95,Other,153% New York Medicaid APG,2829.34,,,2829.34,Other,225% New York Medicaid APG,1760.48,,,1760.48,Other,140% New York Medicaid APG,2829.34,,,2829.34,Other,225% New York Medicaid APG,3269.46,,,3269.46,Other,260% New York Medicaid APG,4074.25,,,4074.25,Other,324% New York Medicaid APG,2703.59,,,2703.59,Other,215% New York Medicaid APG,2703.59,,,2703.59,Other,215% New York Medicaid APG,1571.86,,,1571.86,Other,125% New York Medicaid APG,1257.49,48661.69,
Remove vagina tissue part,57107,CPT,,,,,,,,both,,,65759.04,48661.69,74,,48661.69,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,29591.57,45,,29591.57,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,32550.72,49.5,,32550.72,percent of total billed charges,110% of Medicare,44716.15,68,,44716.15,percent of total billed charges,,2611.37,,,2611.37,Other,186% of Medicaid,52607.23,80,,52607.23,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,52607.23,80,,52607.23,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,46031.33,70,,46031.33,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1403.96,,,1403.96,Other,New York Medicaid APG methodology,1403.96,,,1403.96,Other,100% New York Medicaid APG,1403.96,,,1403.96,Other,100% New York Medicaid APG,1403.96,,,1403.96,Other,100% New York Medicaid APG,3158.92,,,3158.92,Other,225% New York Medicaid APG,2148.07,,,2148.07,Other,153% New York Medicaid APG,3158.92,,,3158.92,Other,225% New York Medicaid APG,1965.55,,,1965.55,Other,140% New York Medicaid APG,3158.92,,,3158.92,Other,225% New York Medicaid APG,3650.31,,,3650.31,Other,260% New York Medicaid APG,4548.84,,,4548.84,Other,324% New York Medicaid APG,3018.52,,,3018.52,Other,215% New York Medicaid APG,3018.52,,,3018.52,Other,215% New York Medicaid APG,1754.96,,,1754.96,Other,125% New York Medicaid APG,1403.96,52607.23,
Vaginectomy partial w/nodes,57109,CPT,,,,,,,,both,,,65759.04,48661.69,74,,48661.69,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,29591.57,45,,29591.57,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,32550.72,49.5,,32550.72,percent of total billed charges,110% of Medicare,44716.15,68,,44716.15,percent of total billed charges,,2611.37,,,2611.37,Other,186% of Medicaid,52607.23,80,,52607.23,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,52607.23,80,,52607.23,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,46031.33,70,,46031.33,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1403.96,,,1403.96,Other,New York Medicaid APG methodology,1403.96,,,1403.96,Other,100% New York Medicaid APG,1403.96,,,1403.96,Other,100% New York Medicaid APG,1403.96,,,1403.96,Other,100% New York Medicaid APG,3158.92,,,3158.92,Other,225% New York Medicaid APG,2148.07,,,2148.07,Other,153% New York Medicaid APG,3158.92,,,3158.92,Other,225% New York Medicaid APG,1965.55,,,1965.55,Other,140% New York Medicaid APG,3158.92,,,3158.92,Other,225% New York Medicaid APG,3650.31,,,3650.31,Other,260% New York Medicaid APG,4548.84,,,4548.84,Other,324% New York Medicaid APG,3018.52,,,3018.52,Other,215% New York Medicaid APG,3018.52,,,3018.52,Other,215% New York Medicaid APG,1754.96,,,1754.96,Other,125% New York Medicaid APG,1403.96,52607.23,
Closure of vagina,57120,CPT,,,,,,,,both,,,42611.09,31532.21,74,,31532.21,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,19174.99,45,,19174.99,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,21092.49,49.5,,21092.49,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2611.37,,,2611.37,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,29827.76,70,,29827.76,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1403.96,,,1403.96,Other,New York Medicaid APG methodology,1403.96,,,1403.96,Other,100% New York Medicaid APG,1403.96,,,1403.96,Other,100% New York Medicaid APG,1403.96,,,1403.96,Other,100% New York Medicaid APG,3158.92,,,3158.92,Other,225% New York Medicaid APG,2148.07,,,2148.07,Other,153% New York Medicaid APG,3158.92,,,3158.92,Other,225% New York Medicaid APG,1965.55,,,1965.55,Other,140% New York Medicaid APG,3158.92,,,3158.92,Other,225% New York Medicaid APG,3650.31,,,3650.31,Other,260% New York Medicaid APG,4548.84,,,4548.84,Other,324% New York Medicaid APG,3018.52,,,3018.52,Other,215% New York Medicaid APG,3018.52,,,3018.52,Other,215% New York Medicaid APG,1754.96,,,1754.96,Other,125% New York Medicaid APG,1403.96,31532.21,
Remove vagina lesion,57130,CPT,,,,,,,,both,,,65759.04,48661.69,74,,48661.69,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,29591.57,45,,29591.57,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,32550.72,49.5,,32550.72,percent of total billed charges,110% of Medicare,44716.15,68,,44716.15,percent of total billed charges,,2338.92,,,2338.92,Other,186% of Medicaid,52607.23,80,,52607.23,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,52607.23,80,,52607.23,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,46031.33,70,,46031.33,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1257.49,,,1257.49,Other,New York Medicaid APG methodology,1257.49,,,1257.49,Other,100% New York Medicaid APG,1257.49,,,1257.49,Other,100% New York Medicaid APG,1257.49,,,1257.49,Other,100% New York Medicaid APG,2829.34,,,2829.34,Other,225% New York Medicaid APG,1923.95,,,1923.95,Other,153% New York Medicaid APG,2829.34,,,2829.34,Other,225% New York Medicaid APG,1760.48,,,1760.48,Other,140% New York Medicaid APG,2829.34,,,2829.34,Other,225% New York Medicaid APG,3269.46,,,3269.46,Other,260% New York Medicaid APG,4074.25,,,4074.25,Other,324% New York Medicaid APG,2703.59,,,2703.59,Other,215% New York Medicaid APG,2703.59,,,2703.59,Other,215% New York Medicaid APG,1571.86,,,1571.86,Other,125% New York Medicaid APG,1257.49,52607.23,
Remove vagina lesion,57135,CPT,,,,,,,,both,,,36783.79,27220,74,,27220,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,16552.71,45,,16552.71,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,18207.98,49.5,,18207.98,percent of total billed charges,110% of Medicare,25012.98,68,,25012.98,percent of total billed charges,,2338.92,,,2338.92,Other,186% of Medicaid,29427.03,80,,29427.03,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,29427.03,80,,29427.03,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,25748.65,70,,25748.65,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1257.49,,,1257.49,Other,New York Medicaid APG methodology,1257.49,,,1257.49,Other,100% New York Medicaid APG,1257.49,,,1257.49,Other,100% New York Medicaid APG,1257.49,,,1257.49,Other,100% New York Medicaid APG,2829.34,,,2829.34,Other,225% New York Medicaid APG,1923.95,,,1923.95,Other,153% New York Medicaid APG,2829.34,,,2829.34,Other,225% New York Medicaid APG,1760.48,,,1760.48,Other,140% New York Medicaid APG,2829.34,,,2829.34,Other,225% New York Medicaid APG,3269.46,,,3269.46,Other,260% New York Medicaid APG,4074.25,,,4074.25,Other,324% New York Medicaid APG,2703.59,,,2703.59,Other,215% New York Medicaid APG,2703.59,,,2703.59,Other,215% New York Medicaid APG,1571.86,,,1571.86,Other,125% New York Medicaid APG,1257.49,29427.03,
Treat vagina infection,57150,CPT,,,,,,,,both,,,1286.58,952.07,74,,952.07,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,578.96,45,,578.96,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,636.86,49.5,,636.86,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,445.2,,,445.2,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,900.61,70,,900.61,percent of total billed charges,,126.28,,,126.28,Fee Schedule,,107.03,,,107.03,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,239.36,,,239.36,Other,New York Medicaid APG methodology,239.36,,,239.36,Other,100% New York Medicaid APG,239.36,,,239.36,Other,100% New York Medicaid APG,239.36,,,239.36,Other,100% New York Medicaid APG,538.55,,,538.55,Other,225% New York Medicaid APG,366.22,,,366.22,Other,153% New York Medicaid APG,538.55,,,538.55,Other,225% New York Medicaid APG,335.1,,,335.1,Other,140% New York Medicaid APG,538.55,,,538.55,Other,225% New York Medicaid APG,622.33,,,622.33,Other,260% New York Medicaid APG,775.52,,,775.52,Other,324% New York Medicaid APG,514.62,,,514.62,Other,215% New York Medicaid APG,514.62,,,514.62,Other,215% New York Medicaid APG,299.2,,,299.2,Other,125% New York Medicaid APG,107.03,9473,
Insert uteri tandem/ovoids,57155,CPT,,,,,,,,both,,,61324.15,45379.87,74,,45379.87,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,27595.87,45,,27595.87,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,30355.45,49.5,,30355.45,percent of total billed charges,110% of Medicare,41700.42,68,,41700.42,percent of total billed charges,,2506.06,,,2506.06,Other,186% of Medicaid,49059.32,80,,49059.32,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,49059.32,80,,49059.32,percent of total billed charges,,7216,,,7216,Case Rate,,3578,,"100% primary, 0% secondary procedures",3578,Other,MagnaCare ASC Grouper,42926.91,70,,42926.91,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,1347.34,,,1347.34,Other,New York Medicaid APG methodology,1347.34,,,1347.34,Other,100% New York Medicaid APG,1347.34,,,1347.34,Other,100% New York Medicaid APG,1347.34,,,1347.34,Other,100% New York Medicaid APG,3031.52,,,3031.52,Other,225% New York Medicaid APG,2061.43,,,2061.43,Other,153% New York Medicaid APG,3031.52,,,3031.52,Other,225% New York Medicaid APG,1886.28,,,1886.28,Other,140% New York Medicaid APG,3031.52,,,3031.52,Other,225% New York Medicaid APG,3503.09,,,3503.09,Other,260% New York Medicaid APG,4365.39,,,4365.39,Other,324% New York Medicaid APG,2896.79,,,2896.79,Other,215% New York Medicaid APG,2896.79,,,2896.79,Other,215% New York Medicaid APG,1684.18,,,1684.18,Other,125% New York Medicaid APG,1347.34,49059.32,
Ins vag brachytx device,57156,CPT,,,,,,,,both,,,31449.57,23272.68,74,,23272.68,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,14152.31,45,,14152.31,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,15567.54,49.5,,15567.54,percent of total billed charges,110% of Medicare,21385.71,68,,21385.71,percent of total billed charges,,1132.19,,,1132.19,Other,186% of Medicaid,25159.66,80,,25159.66,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,25159.66,80,,25159.66,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,22014.7,70,,22014.7,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,608.71,,,608.71,Other,New York Medicaid APG methodology,608.71,,,608.71,Other,100% New York Medicaid APG,608.71,,,608.71,Other,100% New York Medicaid APG,608.71,,,608.71,Other,100% New York Medicaid APG,1369.59,,,1369.59,Other,225% New York Medicaid APG,931.32,,,931.32,Other,153% New York Medicaid APG,1369.59,,,1369.59,Other,225% New York Medicaid APG,852.19,,,852.19,Other,140% New York Medicaid APG,1369.59,,,1369.59,Other,225% New York Medicaid APG,1582.63,,,1582.63,Other,260% New York Medicaid APG,1972.21,,,1972.21,Other,324% New York Medicaid APG,1308.72,,,1308.72,Other,215% New York Medicaid APG,1308.72,,,1308.72,Other,215% New York Medicaid APG,760.88,,,760.88,Other,125% New York Medicaid APG,608.71,25159.66,
Insert pessary/other device,57160,CPT,,,,,,,,both,,,4191.33,3101.58,74,,3101.58,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,1886.1,45,,1886.1,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,2074.71,49.5,,2074.71,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,445.2,,,445.2,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,2933.93,70,,2933.93,percent of total billed charges,,224.68,,,224.68,Fee Schedule,,190.43,,,190.43,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,239.36,,,239.36,Other,New York Medicaid APG methodology,239.36,,,239.36,Other,100% New York Medicaid APG,239.36,,,239.36,Other,100% New York Medicaid APG,239.36,,,239.36,Other,100% New York Medicaid APG,538.55,,,538.55,Other,225% New York Medicaid APG,366.22,,,366.22,Other,153% New York Medicaid APG,538.55,,,538.55,Other,225% New York Medicaid APG,335.1,,,335.1,Other,140% New York Medicaid APG,538.55,,,538.55,Other,225% New York Medicaid APG,622.33,,,622.33,Other,260% New York Medicaid APG,775.52,,,775.52,Other,324% New York Medicaid APG,514.62,,,514.62,Other,215% New York Medicaid APG,514.62,,,514.62,Other,215% New York Medicaid APG,299.2,,,299.2,Other,125% New York Medicaid APG,190.43,9473,
Fitting of diaphragm/cap,57170,CPT,,,,,,,,both,,,4191.33,3101.58,74,,3101.58,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,1886.1,45,,1886.1,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,2514.8,60,,2514.8,percent of total billed charges,,2347.14,56,,2347.14,percent of total billed charges,,2263.32,54,,2263.32,percent of total billed charges,,2074.71,49.5,,2074.71,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,445.2,,,445.2,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,2933.93,70,,2933.93,percent of total billed charges,,234.52,,,234.52,Fee Schedule,,198.77,,,198.77,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,239.36,,,239.36,Other,New York Medicaid APG methodology,239.36,,,239.36,Other,100% New York Medicaid APG,239.36,,,239.36,Other,100% New York Medicaid APG,239.36,,,239.36,Other,100% New York Medicaid APG,538.55,,,538.55,Other,225% New York Medicaid APG,366.22,,,366.22,Other,153% New York Medicaid APG,538.55,,,538.55,Other,225% New York Medicaid APG,335.1,,,335.1,Other,140% New York Medicaid APG,538.55,,,538.55,Other,225% New York Medicaid APG,622.33,,,622.33,Other,260% New York Medicaid APG,775.52,,,775.52,Other,324% New York Medicaid APG,514.62,,,514.62,Other,215% New York Medicaid APG,514.62,,,514.62,Other,215% New York Medicaid APG,299.2,,,299.2,Other,125% New York Medicaid APG,198.77,9473,
Treat vaginal bleeding,57180,CPT,,,,,,,,both,,,4191.33,3101.58,74,,3101.58,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,1886.1,45,,1886.1,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,2074.71,49.5,,2074.71,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,1132.19,,,1132.19,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,2933.93,70,,2933.93,percent of total billed charges,,600.24,,,600.24,Fee Schedule,,508.74,,,508.74,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,608.71,,,608.71,Other,New York Medicaid APG methodology,608.71,,,608.71,Other,100% New York Medicaid APG,608.71,,,608.71,Other,100% New York Medicaid APG,608.71,,,608.71,Other,100% New York Medicaid APG,1369.59,,,1369.59,Other,225% New York Medicaid APG,931.32,,,931.32,Other,153% New York Medicaid APG,1369.59,,,1369.59,Other,225% New York Medicaid APG,852.19,,,852.19,Other,140% New York Medicaid APG,1369.59,,,1369.59,Other,225% New York Medicaid APG,1582.63,,,1582.63,Other,260% New York Medicaid APG,1972.21,,,1972.21,Other,324% New York Medicaid APG,1308.72,,,1308.72,Other,215% New York Medicaid APG,1308.72,,,1308.72,Other,215% New York Medicaid APG,760.88,,,760.88,Other,125% New York Medicaid APG,508.74,9473,
Repair of vagina,57200,CPT,,,,,,,,both,,,65759.04,48661.69,74,,48661.69,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,29591.57,45,,29591.57,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,32550.72,49.5,,32550.72,percent of total billed charges,110% of Medicare,44716.15,68,,44716.15,percent of total billed charges,,2338.92,,,2338.92,Other,186% of Medicaid,52607.23,80,,52607.23,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,52607.23,80,,52607.23,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,46031.33,70,,46031.33,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1257.49,,,1257.49,Other,New York Medicaid APG methodology,1257.49,,,1257.49,Other,100% New York Medicaid APG,1257.49,,,1257.49,Other,100% New York Medicaid APG,1257.49,,,1257.49,Other,100% New York Medicaid APG,2829.34,,,2829.34,Other,225% New York Medicaid APG,1923.95,,,1923.95,Other,153% New York Medicaid APG,2829.34,,,2829.34,Other,225% New York Medicaid APG,1760.48,,,1760.48,Other,140% New York Medicaid APG,2829.34,,,2829.34,Other,225% New York Medicaid APG,3269.46,,,3269.46,Other,260% New York Medicaid APG,4074.25,,,4074.25,Other,324% New York Medicaid APG,2703.59,,,2703.59,Other,215% New York Medicaid APG,2703.59,,,2703.59,Other,215% New York Medicaid APG,1571.86,,,1571.86,Other,125% New York Medicaid APG,1257.49,52607.23,
Repair vagina/perineum,57210,CPT,,,,,,,,both,,,65759.04,48661.69,74,,48661.69,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,29591.57,45,,29591.57,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,32550.72,49.5,,32550.72,percent of total billed charges,110% of Medicare,44716.15,68,,44716.15,percent of total billed charges,,2338.92,,,2338.92,Other,186% of Medicaid,52607.23,80,,52607.23,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,52607.23,80,,52607.23,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,46031.33,70,,46031.33,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1257.49,,,1257.49,Other,New York Medicaid APG methodology,1257.49,,,1257.49,Other,100% New York Medicaid APG,1257.49,,,1257.49,Other,100% New York Medicaid APG,1257.49,,,1257.49,Other,100% New York Medicaid APG,2829.34,,,2829.34,Other,225% New York Medicaid APG,1923.95,,,1923.95,Other,153% New York Medicaid APG,2829.34,,,2829.34,Other,225% New York Medicaid APG,1760.48,,,1760.48,Other,140% New York Medicaid APG,2829.34,,,2829.34,Other,225% New York Medicaid APG,3269.46,,,3269.46,Other,260% New York Medicaid APG,4074.25,,,4074.25,Other,324% New York Medicaid APG,2703.59,,,2703.59,Other,215% New York Medicaid APG,2703.59,,,2703.59,Other,215% New York Medicaid APG,1571.86,,,1571.86,Other,125% New York Medicaid APG,1257.49,52607.23,
Revision of urethra,57220,CPT,,,,,,,,both,,,104619.92,77418.74,74,,77418.74,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,47078.96,45,,47078.96,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,51786.86,49.5,,51786.86,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,1857.5,,,1857.5,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,73233.94,70,,73233.94,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,998.66,,,998.66,Other,New York Medicaid APG methodology,998.66,,,998.66,Other,100% New York Medicaid APG,998.66,,,998.66,Other,100% New York Medicaid APG,998.66,,,998.66,Other,100% New York Medicaid APG,2246.97,,,2246.97,Other,225% New York Medicaid APG,1527.94,,,1527.94,Other,153% New York Medicaid APG,2246.97,,,2246.97,Other,225% New York Medicaid APG,1398.12,,,1398.12,Other,140% New York Medicaid APG,2246.97,,,2246.97,Other,225% New York Medicaid APG,2596.5,,,2596.5,Other,260% New York Medicaid APG,3235.64,,,3235.64,Other,324% New York Medicaid APG,2147.11,,,2147.11,Other,215% New York Medicaid APG,2147.11,,,2147.11,Other,215% New York Medicaid APG,1248.32,,,1248.32,Other,125% New York Medicaid APG,998.66,77418.74,
Repair of urethral lesion,57230,CPT,,,,,,,,both,,,65759.04,48661.69,74,,48661.69,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,29591.57,45,,29591.57,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,32550.72,49.5,,32550.72,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,1857.5,,,1857.5,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,46031.33,70,,46031.33,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,998.66,,,998.66,Other,New York Medicaid APG methodology,998.66,,,998.66,Other,100% New York Medicaid APG,998.66,,,998.66,Other,100% New York Medicaid APG,998.66,,,998.66,Other,100% New York Medicaid APG,2246.97,,,2246.97,Other,225% New York Medicaid APG,1527.94,,,1527.94,Other,153% New York Medicaid APG,2246.97,,,2246.97,Other,225% New York Medicaid APG,1398.12,,,1398.12,Other,140% New York Medicaid APG,2246.97,,,2246.97,Other,225% New York Medicaid APG,2596.5,,,2596.5,Other,260% New York Medicaid APG,3235.64,,,3235.64,Other,324% New York Medicaid APG,2147.11,,,2147.11,Other,215% New York Medicaid APG,2147.11,,,2147.11,Other,215% New York Medicaid APG,1248.32,,,1248.32,Other,125% New York Medicaid APG,998.66,48661.69,
Anterior colporrhaphy,57240,CPT,,,,,,,,both,,,39831.69,29475.45,74,,29475.45,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,17924.26,45,,17924.26,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,19716.69,49.5,,19716.69,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,1857.5,,,1857.5,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,27882.18,70,,27882.18,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,998.66,,,998.66,Other,New York Medicaid APG methodology,998.66,,,998.66,Other,100% New York Medicaid APG,998.66,,,998.66,Other,100% New York Medicaid APG,998.66,,,998.66,Other,100% New York Medicaid APG,2246.97,,,2246.97,Other,225% New York Medicaid APG,1527.94,,,1527.94,Other,153% New York Medicaid APG,2246.97,,,2246.97,Other,225% New York Medicaid APG,1398.12,,,1398.12,Other,140% New York Medicaid APG,2246.97,,,2246.97,Other,225% New York Medicaid APG,2596.5,,,2596.5,Other,260% New York Medicaid APG,3235.64,,,3235.64,Other,324% New York Medicaid APG,2147.11,,,2147.11,Other,215% New York Medicaid APG,2147.11,,,2147.11,Other,215% New York Medicaid APG,1248.32,,,1248.32,Other,125% New York Medicaid APG,998.66,29475.45,
Repair rectum & vagina,57250,CPT,,,,,,,,both,,,42205.47,31232.05,74,,31232.05,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,18992.46,45,,18992.46,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,20891.71,49.5,,20891.71,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2000.16,,,2000.16,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,29543.83,70,,29543.83,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1075.35,,,1075.35,Other,New York Medicaid APG methodology,1075.35,,,1075.35,Other,100% New York Medicaid APG,1075.35,,,1075.35,Other,100% New York Medicaid APG,1075.35,,,1075.35,Other,100% New York Medicaid APG,2419.55,,,2419.55,Other,225% New York Medicaid APG,1645.29,,,1645.29,Other,153% New York Medicaid APG,2419.55,,,2419.55,Other,225% New York Medicaid APG,1505.5,,,1505.5,Other,140% New York Medicaid APG,2419.55,,,2419.55,Other,225% New York Medicaid APG,2795.92,,,2795.92,Other,260% New York Medicaid APG,3484.15,,,3484.15,Other,324% New York Medicaid APG,2312.01,,,2312.01,Other,215% New York Medicaid APG,2312.01,,,2312.01,Other,215% New York Medicaid APG,1344.19,,,1344.19,Other,125% New York Medicaid APG,1075.35,31232.05,
Cmbn ant pst colprhy,57260,CPT,,,,,,,,both,,,39020.79,28875.38,74,,28875.38,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,17559.36,45,,17559.36,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,19315.29,49.5,,19315.29,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,1857.5,,,1857.5,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,27314.55,70,,27314.55,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,998.66,,,998.66,Other,New York Medicaid APG methodology,998.66,,,998.66,Other,100% New York Medicaid APG,998.66,,,998.66,Other,100% New York Medicaid APG,998.66,,,998.66,Other,100% New York Medicaid APG,2246.97,,,2246.97,Other,225% New York Medicaid APG,1527.94,,,1527.94,Other,153% New York Medicaid APG,2246.97,,,2246.97,Other,225% New York Medicaid APG,1398.12,,,1398.12,Other,140% New York Medicaid APG,2246.97,,,2246.97,Other,225% New York Medicaid APG,2596.5,,,2596.5,Other,260% New York Medicaid APG,3235.64,,,3235.64,Other,324% New York Medicaid APG,2147.11,,,2147.11,Other,215% New York Medicaid APG,2147.11,,,2147.11,Other,215% New York Medicaid APG,1248.32,,,1248.32,Other,125% New York Medicaid APG,998.66,28875.38,
Cmbn ap colprhy w/ntrcl rpr,57265,CPT,,,,,,,,both,,,45645.86,33777.94,74,,33777.94,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,20540.64,45,,20540.64,percent of total billed charges,Medicare Ratio of cost to charges,5954,,"100% primary, 50% supplemental procedure",5954,Other,Aetna ASC Grouper,5359,,"100% primary, 50% supplemental procedure",5359,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,22594.7,49.5,,22594.7,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2000.16,,,2000.16,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,31952.1,70,,31952.1,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,1075.35,,,1075.35,Other,New York Medicaid APG methodology,1075.35,,,1075.35,Other,100% New York Medicaid APG,1075.35,,,1075.35,Other,100% New York Medicaid APG,1075.35,,,1075.35,Other,100% New York Medicaid APG,2419.55,,,2419.55,Other,225% New York Medicaid APG,1645.29,,,1645.29,Other,153% New York Medicaid APG,2419.55,,,2419.55,Other,225% New York Medicaid APG,1505.5,,,1505.5,Other,140% New York Medicaid APG,2419.55,,,2419.55,Other,225% New York Medicaid APG,2795.92,,,2795.92,Other,260% New York Medicaid APG,3484.15,,,3484.15,Other,324% New York Medicaid APG,2312.01,,,2312.01,Other,215% New York Medicaid APG,2312.01,,,2312.01,Other,215% New York Medicaid APG,1344.19,,,1344.19,Other,125% New York Medicaid APG,1075.35,33777.94,
Insert mesh/pelvic flr addon,57267,CPT,,,,,,,,both,,,32432.1,23999.75,74,,23999.75,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,14594.45,45,,14594.45,percent of total billed charges,Medicare Ratio of cost to charges,5954,,"100% primary, 50% supplemental procedure",5954,Other,Aetna ASC Grouper,5359,,"100% primary, 50% supplemental procedure",5359,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,16053.89,49.5,,16053.89,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,4377.94,,,4377.94,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,22702.47,70,,22702.47,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,2353.73,,,2353.73,Other,New York Medicaid APG methodology,2353.73,,,2353.73,Other,100% New York Medicaid APG,2353.73,,,2353.73,Other,100% New York Medicaid APG,2353.73,,,2353.73,Other,100% New York Medicaid APG,5295.9,,,5295.9,Other,225% New York Medicaid APG,3601.21,,,3601.21,Other,153% New York Medicaid APG,5295.9,,,5295.9,Other,225% New York Medicaid APG,3295.23,,,3295.23,Other,140% New York Medicaid APG,5295.9,,,5295.9,Other,225% New York Medicaid APG,6119.71,,,6119.71,Other,260% New York Medicaid APG,7626.1,,,7626.1,Other,324% New York Medicaid APG,5060.53,,,5060.53,Other,215% New York Medicaid APG,5060.53,,,5060.53,Other,215% New York Medicaid APG,2942.17,,,2942.17,Other,125% New York Medicaid APG,2353.73,23999.75,
Repair of bowel bulge,57268,CPT,,,,,,,,both,,,39241.66,29038.83,74,,29038.83,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,17658.75,45,,17658.75,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,19424.62,49.5,,19424.62,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2000.16,,,2000.16,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,27469.16,70,,27469.16,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1075.35,,,1075.35,Other,New York Medicaid APG methodology,1075.35,,,1075.35,Other,100% New York Medicaid APG,1075.35,,,1075.35,Other,100% New York Medicaid APG,1075.35,,,1075.35,Other,100% New York Medicaid APG,2419.55,,,2419.55,Other,225% New York Medicaid APG,1645.29,,,1645.29,Other,153% New York Medicaid APG,2419.55,,,2419.55,Other,225% New York Medicaid APG,1505.5,,,1505.5,Other,140% New York Medicaid APG,2419.55,,,2419.55,Other,225% New York Medicaid APG,2795.92,,,2795.92,Other,260% New York Medicaid APG,3484.15,,,3484.15,Other,324% New York Medicaid APG,2312.01,,,2312.01,Other,215% New York Medicaid APG,2312.01,,,2312.01,Other,215% New York Medicaid APG,1344.19,,,1344.19,Other,125% New York Medicaid APG,1075.35,29038.83,
Colpopexy extraperitoneal,57282,CPT,,,,,,,,both,,,43146.62,31928.5,74,,31928.5,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,19415.98,45,,19415.98,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,21357.58,49.5,,21357.58,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2338.92,,,2338.92,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,30202.63,70,,30202.63,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,1257.49,,,1257.49,Other,New York Medicaid APG methodology,1257.49,,,1257.49,Other,100% New York Medicaid APG,1257.49,,,1257.49,Other,100% New York Medicaid APG,1257.49,,,1257.49,Other,100% New York Medicaid APG,2829.34,,,2829.34,Other,225% New York Medicaid APG,1923.95,,,1923.95,Other,153% New York Medicaid APG,2829.34,,,2829.34,Other,225% New York Medicaid APG,1760.48,,,1760.48,Other,140% New York Medicaid APG,2829.34,,,2829.34,Other,225% New York Medicaid APG,3269.46,,,3269.46,Other,260% New York Medicaid APG,4074.25,,,4074.25,Other,324% New York Medicaid APG,2703.59,,,2703.59,Other,215% New York Medicaid APG,2703.59,,,2703.59,Other,215% New York Medicaid APG,1571.86,,,1571.86,Other,125% New York Medicaid APG,1257.49,31928.5,
Colpopexy intraperitoneal,57283,CPT,,,,,,,,both,,,56441.72,41766.87,74,,41766.87,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,25398.77,45,,25398.77,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,27938.65,49.5,,27938.65,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2338.92,,,2338.92,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,39509.2,70,,39509.2,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,1257.49,,,1257.49,Other,New York Medicaid APG methodology,1257.49,,,1257.49,Other,100% New York Medicaid APG,1257.49,,,1257.49,Other,100% New York Medicaid APG,1257.49,,,1257.49,Other,100% New York Medicaid APG,2829.34,,,2829.34,Other,225% New York Medicaid APG,1923.95,,,1923.95,Other,153% New York Medicaid APG,2829.34,,,2829.34,Other,225% New York Medicaid APG,1760.48,,,1760.48,Other,140% New York Medicaid APG,2829.34,,,2829.34,Other,225% New York Medicaid APG,3269.46,,,3269.46,Other,260% New York Medicaid APG,4074.25,,,4074.25,Other,324% New York Medicaid APG,2703.59,,,2703.59,Other,215% New York Medicaid APG,2703.59,,,2703.59,Other,215% New York Medicaid APG,1571.86,,,1571.86,Other,125% New York Medicaid APG,1257.49,41766.87,
Repair paravag defect open,57284,CPT,,,,,,,,both,,,104619.92,77418.74,74,,77418.74,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,47078.96,45,,47078.96,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,51786.86,49.5,,51786.86,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2611.37,,,2611.37,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,73233.94,70,,73233.94,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,1403.96,,,1403.96,Other,New York Medicaid APG methodology,1403.96,,,1403.96,Other,100% New York Medicaid APG,1403.96,,,1403.96,Other,100% New York Medicaid APG,1403.96,,,1403.96,Other,100% New York Medicaid APG,3158.92,,,3158.92,Other,225% New York Medicaid APG,2148.07,,,2148.07,Other,153% New York Medicaid APG,3158.92,,,3158.92,Other,225% New York Medicaid APG,1965.55,,,1965.55,Other,140% New York Medicaid APG,3158.92,,,3158.92,Other,225% New York Medicaid APG,3650.31,,,3650.31,Other,260% New York Medicaid APG,4548.84,,,4548.84,Other,324% New York Medicaid APG,3018.52,,,3018.52,Other,215% New York Medicaid APG,3018.52,,,3018.52,Other,215% New York Medicaid APG,1754.96,,,1754.96,Other,125% New York Medicaid APG,1403.96,77418.74,
Repair paravag defect vag,57285,CPT,,,,,,,,both,,,158942.1,117617.15,74,,117617.15,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,71523.95,45,,71523.95,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,78676.34,49.5,,78676.34,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2338.92,,,2338.92,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,111259.47,70,,111259.47,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,1257.49,,,1257.49,Other,New York Medicaid APG methodology,1257.49,,,1257.49,Other,100% New York Medicaid APG,1257.49,,,1257.49,Other,100% New York Medicaid APG,1257.49,,,1257.49,Other,100% New York Medicaid APG,2829.34,,,2829.34,Other,225% New York Medicaid APG,1923.95,,,1923.95,Other,153% New York Medicaid APG,2829.34,,,2829.34,Other,225% New York Medicaid APG,1760.48,,,1760.48,Other,140% New York Medicaid APG,2829.34,,,2829.34,Other,225% New York Medicaid APG,3269.46,,,3269.46,Other,260% New York Medicaid APG,4074.25,,,4074.25,Other,324% New York Medicaid APG,2703.59,,,2703.59,Other,215% New York Medicaid APG,2703.59,,,2703.59,Other,215% New York Medicaid APG,1571.86,,,1571.86,Other,125% New York Medicaid APG,1257.49,117617.15,
Revise/remove sling repair,57287,CPT,,,,,,,,both,,,33689.25,24930.05,74,,24930.05,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15160.16,45,,15160.16,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,16676.18,49.5,,16676.18,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,1857.5,,,1857.5,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,23582.48,70,,23582.48,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,998.66,,,998.66,Other,New York Medicaid APG methodology,998.66,,,998.66,Other,100% New York Medicaid APG,998.66,,,998.66,Other,100% New York Medicaid APG,998.66,,,998.66,Other,100% New York Medicaid APG,2246.97,,,2246.97,Other,225% New York Medicaid APG,1527.94,,,1527.94,Other,153% New York Medicaid APG,2246.97,,,2246.97,Other,225% New York Medicaid APG,1398.12,,,1398.12,Other,140% New York Medicaid APG,2246.97,,,2246.97,Other,225% New York Medicaid APG,2596.5,,,2596.5,Other,260% New York Medicaid APG,3235.64,,,3235.64,Other,324% New York Medicaid APG,2147.11,,,2147.11,Other,215% New York Medicaid APG,2147.11,,,2147.11,Other,215% New York Medicaid APG,1248.32,,,1248.32,Other,125% New York Medicaid APG,998.66,24930.05,
Repair bladder defect,57288,CPT,,,,,,,,both,,,40467.29,29945.79,74,,29945.79,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,18210.28,45,,18210.28,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,20031.31,49.5,,20031.31,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,1857.5,,,1857.5,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,28327.1,70,,28327.1,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,998.66,,,998.66,Other,New York Medicaid APG methodology,998.66,,,998.66,Other,100% New York Medicaid APG,998.66,,,998.66,Other,100% New York Medicaid APG,998.66,,,998.66,Other,100% New York Medicaid APG,2246.97,,,2246.97,Other,225% New York Medicaid APG,1527.94,,,1527.94,Other,153% New York Medicaid APG,2246.97,,,2246.97,Other,225% New York Medicaid APG,1398.12,,,1398.12,Other,140% New York Medicaid APG,2246.97,,,2246.97,Other,225% New York Medicaid APG,2596.5,,,2596.5,Other,260% New York Medicaid APG,3235.64,,,3235.64,Other,324% New York Medicaid APG,2147.11,,,2147.11,Other,215% New York Medicaid APG,2147.11,,,2147.11,Other,215% New York Medicaid APG,1248.32,,,1248.32,Other,125% New York Medicaid APG,998.66,29945.79,
Repair bladder & vagina,57289,CPT,,,,,,,,both,,,158942.1,117617.15,74,,117617.15,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,71523.95,45,,71523.95,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,78676.34,49.5,,78676.34,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,1857.5,,,1857.5,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,111259.47,70,,111259.47,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,998.66,,,998.66,Other,New York Medicaid APG methodology,998.66,,,998.66,Other,100% New York Medicaid APG,998.66,,,998.66,Other,100% New York Medicaid APG,998.66,,,998.66,Other,100% New York Medicaid APG,2246.97,,,2246.97,Other,225% New York Medicaid APG,1527.94,,,1527.94,Other,153% New York Medicaid APG,2246.97,,,2246.97,Other,225% New York Medicaid APG,1398.12,,,1398.12,Other,140% New York Medicaid APG,2246.97,,,2246.97,Other,225% New York Medicaid APG,2596.5,,,2596.5,Other,260% New York Medicaid APG,3235.64,,,3235.64,Other,324% New York Medicaid APG,2147.11,,,2147.11,Other,215% New York Medicaid APG,2147.11,,,2147.11,Other,215% New York Medicaid APG,1248.32,,,1248.32,Other,125% New York Medicaid APG,998.66,117617.15,
Construction of vagina,57291,CPT,,,,,,,,both,,,104619.92,77418.74,74,,77418.74,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,47078.96,45,,47078.96,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,51786.86,49.5,,51786.86,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2611.37,,,2611.37,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,73233.94,70,,73233.94,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1403.96,,,1403.96,Other,New York Medicaid APG methodology,1403.96,,,1403.96,Other,100% New York Medicaid APG,1403.96,,,1403.96,Other,100% New York Medicaid APG,1403.96,,,1403.96,Other,100% New York Medicaid APG,3158.92,,,3158.92,Other,225% New York Medicaid APG,2148.07,,,2148.07,Other,153% New York Medicaid APG,3158.92,,,3158.92,Other,225% New York Medicaid APG,1965.55,,,1965.55,Other,140% New York Medicaid APG,3158.92,,,3158.92,Other,225% New York Medicaid APG,3650.31,,,3650.31,Other,260% New York Medicaid APG,4548.84,,,4548.84,Other,324% New York Medicaid APG,3018.52,,,3018.52,Other,215% New York Medicaid APG,3018.52,,,3018.52,Other,215% New York Medicaid APG,1754.96,,,1754.96,Other,125% New York Medicaid APG,1403.96,77418.74,
Construct vagina with graft,57292,CPT,,,,,,,,both,,,104619.92,77418.74,74,,77418.74,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,47078.96,45,,47078.96,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,51786.86,49.5,,51786.86,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2611.37,,,2611.37,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,73233.94,70,,73233.94,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1403.96,,,1403.96,Other,New York Medicaid APG methodology,1403.96,,,1403.96,Other,100% New York Medicaid APG,1403.96,,,1403.96,Other,100% New York Medicaid APG,1403.96,,,1403.96,Other,100% New York Medicaid APG,3158.92,,,3158.92,Other,225% New York Medicaid APG,2148.07,,,2148.07,Other,153% New York Medicaid APG,3158.92,,,3158.92,Other,225% New York Medicaid APG,1965.55,,,1965.55,Other,140% New York Medicaid APG,3158.92,,,3158.92,Other,225% New York Medicaid APG,3650.31,,,3650.31,Other,260% New York Medicaid APG,4548.84,,,4548.84,Other,324% New York Medicaid APG,3018.52,,,3018.52,Other,215% New York Medicaid APG,3018.52,,,3018.52,Other,215% New York Medicaid APG,1754.96,,,1754.96,Other,125% New York Medicaid APG,1403.96,77418.74,
Revise vag graft via vagina,57295,CPT,,,,,,,,both,,,37502.18,27751.61,74,,27751.61,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,16875.98,45,,16875.98,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,18563.58,49.5,,18563.58,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2338.92,,,2338.92,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,26251.53,70,,26251.53,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1257.49,,,1257.49,Other,New York Medicaid APG methodology,1257.49,,,1257.49,Other,100% New York Medicaid APG,1257.49,,,1257.49,Other,100% New York Medicaid APG,1257.49,,,1257.49,Other,100% New York Medicaid APG,2829.34,,,2829.34,Other,225% New York Medicaid APG,1923.95,,,1923.95,Other,153% New York Medicaid APG,2829.34,,,2829.34,Other,225% New York Medicaid APG,1760.48,,,1760.48,Other,140% New York Medicaid APG,2829.34,,,2829.34,Other,225% New York Medicaid APG,3269.46,,,3269.46,Other,260% New York Medicaid APG,4074.25,,,4074.25,Other,324% New York Medicaid APG,2703.59,,,2703.59,Other,215% New York Medicaid APG,2703.59,,,2703.59,Other,215% New York Medicaid APG,1571.86,,,1571.86,Other,125% New York Medicaid APG,1257.49,27751.61,
Repair rectum-vagina fistula,57300,CPT,,,,,,,,both,,,39120.59,28949.24,74,,28949.24,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,17604.27,45,,17604.27,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,19364.69,49.5,,19364.69,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2611.37,,,2611.37,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,27384.41,70,,27384.41,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1403.96,,,1403.96,Other,New York Medicaid APG methodology,1403.96,,,1403.96,Other,100% New York Medicaid APG,1403.96,,,1403.96,Other,100% New York Medicaid APG,1403.96,,,1403.96,Other,100% New York Medicaid APG,3158.92,,,3158.92,Other,225% New York Medicaid APG,2148.07,,,2148.07,Other,153% New York Medicaid APG,3158.92,,,3158.92,Other,225% New York Medicaid APG,1965.55,,,1965.55,Other,140% New York Medicaid APG,3158.92,,,3158.92,Other,225% New York Medicaid APG,3650.31,,,3650.31,Other,260% New York Medicaid APG,4548.84,,,4548.84,Other,324% New York Medicaid APG,3018.52,,,3018.52,Other,215% New York Medicaid APG,3018.52,,,3018.52,Other,215% New York Medicaid APG,1754.96,,,1754.96,Other,125% New York Medicaid APG,1403.96,28949.24,
Repair urethrovaginal lesion,57310,CPT,,,,,,,,both,,,158942.1,117617.15,74,,117617.15,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,71523.95,45,,71523.95,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,78676.34,49.5,,78676.34,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2611.37,,,2611.37,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,111259.47,70,,111259.47,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,1403.96,,,1403.96,Other,New York Medicaid APG methodology,1403.96,,,1403.96,Other,100% New York Medicaid APG,1403.96,,,1403.96,Other,100% New York Medicaid APG,1403.96,,,1403.96,Other,100% New York Medicaid APG,3158.92,,,3158.92,Other,225% New York Medicaid APG,2148.07,,,2148.07,Other,153% New York Medicaid APG,3158.92,,,3158.92,Other,225% New York Medicaid APG,1965.55,,,1965.55,Other,140% New York Medicaid APG,3158.92,,,3158.92,Other,225% New York Medicaid APG,3650.31,,,3650.31,Other,260% New York Medicaid APG,4548.84,,,4548.84,Other,324% New York Medicaid APG,3018.52,,,3018.52,Other,215% New York Medicaid APG,3018.52,,,3018.52,Other,215% New York Medicaid APG,1754.96,,,1754.96,Other,125% New York Medicaid APG,1403.96,117617.15,
Repair bladder-vagina lesion,57320,CPT,,,,,,,,both,,,49528.37,36650.99,74,,36650.99,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,22287.77,45,,22287.77,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,24516.54,49.5,,24516.54,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2611.37,,,2611.37,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,34669.86,70,,34669.86,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1403.96,,,1403.96,Other,New York Medicaid APG methodology,1403.96,,,1403.96,Other,100% New York Medicaid APG,1403.96,,,1403.96,Other,100% New York Medicaid APG,1403.96,,,1403.96,Other,100% New York Medicaid APG,3158.92,,,3158.92,Other,225% New York Medicaid APG,2148.07,,,2148.07,Other,153% New York Medicaid APG,3158.92,,,3158.92,Other,225% New York Medicaid APG,1965.55,,,1965.55,Other,140% New York Medicaid APG,3158.92,,,3158.92,Other,225% New York Medicaid APG,3650.31,,,3650.31,Other,260% New York Medicaid APG,4548.84,,,4548.84,Other,324% New York Medicaid APG,3018.52,,,3018.52,Other,215% New York Medicaid APG,3018.52,,,3018.52,Other,215% New York Medicaid APG,1754.96,,,1754.96,Other,125% New York Medicaid APG,1403.96,36650.99,
Repair bladder-vagina lesion,57330,CPT,,,,,,,,both,,,158942.1,117617.15,74,,117617.15,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,71523.95,45,,71523.95,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,78676.34,49.5,,78676.34,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2611.37,,,2611.37,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,111259.47,70,,111259.47,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1403.96,,,1403.96,Other,New York Medicaid APG methodology,1403.96,,,1403.96,Other,100% New York Medicaid APG,1403.96,,,1403.96,Other,100% New York Medicaid APG,1403.96,,,1403.96,Other,100% New York Medicaid APG,3158.92,,,3158.92,Other,225% New York Medicaid APG,2148.07,,,2148.07,Other,153% New York Medicaid APG,3158.92,,,3158.92,Other,225% New York Medicaid APG,1965.55,,,1965.55,Other,140% New York Medicaid APG,3158.92,,,3158.92,Other,225% New York Medicaid APG,3650.31,,,3650.31,Other,260% New York Medicaid APG,4548.84,,,4548.84,Other,324% New York Medicaid APG,3018.52,,,3018.52,Other,215% New York Medicaid APG,3018.52,,,3018.52,Other,215% New York Medicaid APG,1754.96,,,1754.96,Other,125% New York Medicaid APG,1403.96,117617.15,
Repair vagina,57335,CPT,,,,,,,,both,,,104619.92,77418.74,74,,77418.74,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,47078.96,45,,47078.96,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,51786.86,49.5,,51786.86,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2611.37,,,2611.37,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,73233.94,70,,73233.94,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1403.96,,,1403.96,Other,New York Medicaid APG methodology,1403.96,,,1403.96,Other,100% New York Medicaid APG,1403.96,,,1403.96,Other,100% New York Medicaid APG,1403.96,,,1403.96,Other,100% New York Medicaid APG,3158.92,,,3158.92,Other,225% New York Medicaid APG,2148.07,,,2148.07,Other,153% New York Medicaid APG,3158.92,,,3158.92,Other,225% New York Medicaid APG,1965.55,,,1965.55,Other,140% New York Medicaid APG,3158.92,,,3158.92,Other,225% New York Medicaid APG,3650.31,,,3650.31,Other,260% New York Medicaid APG,4548.84,,,4548.84,Other,324% New York Medicaid APG,3018.52,,,3018.52,Other,215% New York Medicaid APG,3018.52,,,3018.52,Other,215% New York Medicaid APG,1754.96,,,1754.96,Other,125% New York Medicaid APG,1403.96,77418.74,
Dilation of vagina,57400,CPT,,,,,,,,both,,,65759.04,48661.69,74,,48661.69,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,29591.57,45,,29591.57,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,32550.72,49.5,,32550.72,percent of total billed charges,110% of Medicare,44716.15,68,,44716.15,percent of total billed charges,,2338.92,,,2338.92,Other,186% of Medicaid,52607.23,80,,52607.23,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,52607.23,80,,52607.23,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,46031.33,70,,46031.33,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1257.49,,,1257.49,Other,New York Medicaid APG methodology,1257.49,,,1257.49,Other,100% New York Medicaid APG,1257.49,,,1257.49,Other,100% New York Medicaid APG,1257.49,,,1257.49,Other,100% New York Medicaid APG,2829.34,,,2829.34,Other,225% New York Medicaid APG,1923.95,,,1923.95,Other,153% New York Medicaid APG,2829.34,,,2829.34,Other,225% New York Medicaid APG,1760.48,,,1760.48,Other,140% New York Medicaid APG,2829.34,,,2829.34,Other,225% New York Medicaid APG,3269.46,,,3269.46,Other,260% New York Medicaid APG,4074.25,,,4074.25,Other,324% New York Medicaid APG,2703.59,,,2703.59,Other,215% New York Medicaid APG,2703.59,,,2703.59,Other,215% New York Medicaid APG,1571.86,,,1571.86,Other,125% New York Medicaid APG,1257.49,52607.23,
Pelvic examination,57410,CPT,,,,,,,,both,,,31115.46,23025.44,74,,23025.44,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,14001.96,45,,14001.96,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,15402.15,49.5,,15402.15,percent of total billed charges,110% of Medicare,21158.51,68,,21158.51,percent of total billed charges,,445.2,,,445.2,Other,186% of Medicaid,24892.37,80,,24892.37,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,24892.37,80,,24892.37,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,21780.82,70,,21780.82,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,239.36,,,239.36,Other,New York Medicaid APG methodology,239.36,,,239.36,Other,100% New York Medicaid APG,239.36,,,239.36,Other,100% New York Medicaid APG,239.36,,,239.36,Other,100% New York Medicaid APG,538.55,,,538.55,Other,225% New York Medicaid APG,366.22,,,366.22,Other,153% New York Medicaid APG,538.55,,,538.55,Other,225% New York Medicaid APG,335.1,,,335.1,Other,140% New York Medicaid APG,538.55,,,538.55,Other,225% New York Medicaid APG,622.33,,,622.33,Other,260% New York Medicaid APG,775.52,,,775.52,Other,324% New York Medicaid APG,514.62,,,514.62,Other,215% New York Medicaid APG,514.62,,,514.62,Other,215% New York Medicaid APG,299.2,,,299.2,Other,125% New York Medicaid APG,239.36,24892.37,
Remove vaginal foreign body,57415,CPT,,,,,,,,both,,,33811.25,25020.33,74,,25020.33,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15215.06,45,,15215.06,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,16736.57,49.5,,16736.57,percent of total billed charges,110% of Medicare,22991.65,68,,22991.65,percent of total billed charges,,2338.92,,,2338.92,Other,186% of Medicaid,27049,80,,27049,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,27049,80,,27049,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,23667.88,70,,23667.88,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1257.49,,,1257.49,Other,New York Medicaid APG methodology,1257.49,,,1257.49,Other,100% New York Medicaid APG,1257.49,,,1257.49,Other,100% New York Medicaid APG,1257.49,,,1257.49,Other,100% New York Medicaid APG,2829.34,,,2829.34,Other,225% New York Medicaid APG,1923.95,,,1923.95,Other,153% New York Medicaid APG,2829.34,,,2829.34,Other,225% New York Medicaid APG,1760.48,,,1760.48,Other,140% New York Medicaid APG,2829.34,,,2829.34,Other,225% New York Medicaid APG,3269.46,,,3269.46,Other,260% New York Medicaid APG,4074.25,,,4074.25,Other,324% New York Medicaid APG,2703.59,,,2703.59,Other,215% New York Medicaid APG,2703.59,,,2703.59,Other,215% New York Medicaid APG,1571.86,,,1571.86,Other,125% New York Medicaid APG,1257.49,27049,
Exam of vagina w/scope,57420,CPT,,,,,,,,both,,,34222.09,25324.35,74,,25324.35,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15399.94,45,,15399.94,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,16939.93,49.5,,16939.93,percent of total billed charges,110% of Medicare,23271.02,68,,23271.02,percent of total billed charges,,1132.19,,,1132.19,Other,186% of Medicaid,27377.67,80,,27377.67,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,27377.67,80,,27377.67,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,23955.46,70,,23955.46,percent of total billed charges,,436.24,,,436.24,Fee Schedule,,369.74,,,369.74,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,608.71,,,608.71,Other,New York Medicaid APG methodology,608.71,,,608.71,Other,100% New York Medicaid APG,608.71,,,608.71,Other,100% New York Medicaid APG,608.71,,,608.71,Other,100% New York Medicaid APG,1369.59,,,1369.59,Other,225% New York Medicaid APG,931.32,,,931.32,Other,153% New York Medicaid APG,1369.59,,,1369.59,Other,225% New York Medicaid APG,852.19,,,852.19,Other,140% New York Medicaid APG,1369.59,,,1369.59,Other,225% New York Medicaid APG,1582.63,,,1582.63,Other,260% New York Medicaid APG,1972.21,,,1972.21,Other,324% New York Medicaid APG,1308.72,,,1308.72,Other,215% New York Medicaid APG,1308.72,,,1308.72,Other,215% New York Medicaid APG,760.88,,,760.88,Other,125% New York Medicaid APG,369.74,27377.67,
Exam/biopsy of vag w/scope,57421,CPT,,,,,,,,both,,,33260,24612.4,74,,24612.4,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,14967,45,,14967,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,16463.7,49.5,,16463.7,percent of total billed charges,110% of Medicare,22616.8,68,,22616.8,percent of total billed charges,,1132.19,,,1132.19,Other,186% of Medicaid,26608,80,,26608,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,26608,80,,26608,percent of total billed charges,,7216,,,7216,Case Rate,,3578,,"100% primary, 0% secondary procedures",3578,Other,MagnaCare ASC Grouper,23282,70,,23282,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,608.71,,,608.71,Other,New York Medicaid APG methodology,608.71,,,608.71,Other,100% New York Medicaid APG,608.71,,,608.71,Other,100% New York Medicaid APG,608.71,,,608.71,Other,100% New York Medicaid APG,1369.59,,,1369.59,Other,225% New York Medicaid APG,931.32,,,931.32,Other,153% New York Medicaid APG,1369.59,,,1369.59,Other,225% New York Medicaid APG,852.19,,,852.19,Other,140% New York Medicaid APG,1369.59,,,1369.59,Other,225% New York Medicaid APG,1582.63,,,1582.63,Other,260% New York Medicaid APG,1972.21,,,1972.21,Other,324% New York Medicaid APG,1308.72,,,1308.72,Other,215% New York Medicaid APG,1308.72,,,1308.72,Other,215% New York Medicaid APG,760.88,,,760.88,Other,125% New York Medicaid APG,608.71,26608,
Repair paravag defect lap,57423,CPT,,,,,,,,both,,,216515.17,160221.23,74,,160221.23,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,97431.83,45,,97431.83,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,107175.01,49.5,,107175.01,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2611.37,,,2611.37,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,151560.62,70,,151560.62,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,1403.96,,,1403.96,Other,New York Medicaid APG methodology,1403.96,,,1403.96,Other,100% New York Medicaid APG,1403.96,,,1403.96,Other,100% New York Medicaid APG,1403.96,,,1403.96,Other,100% New York Medicaid APG,3158.92,,,3158.92,Other,225% New York Medicaid APG,2148.07,,,2148.07,Other,153% New York Medicaid APG,3158.92,,,3158.92,Other,225% New York Medicaid APG,1965.55,,,1965.55,Other,140% New York Medicaid APG,3158.92,,,3158.92,Other,225% New York Medicaid APG,3650.31,,,3650.31,Other,260% New York Medicaid APG,4548.84,,,4548.84,Other,324% New York Medicaid APG,3018.52,,,3018.52,Other,215% New York Medicaid APG,3018.52,,,3018.52,Other,215% New York Medicaid APG,1754.96,,,1754.96,Other,125% New York Medicaid APG,1403.96,160221.23,
Laparoscopy surg colpopexy,57425,CPT,,,,,,,,both,,,65062.69,48146.39,74,,48146.39,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,29278.21,45,,29278.21,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,32206.03,49.5,,32206.03,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2611.37,,,2611.37,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,45543.88,70,,45543.88,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,1403.96,,,1403.96,Other,New York Medicaid APG methodology,1403.96,,,1403.96,Other,100% New York Medicaid APG,1403.96,,,1403.96,Other,100% New York Medicaid APG,1403.96,,,1403.96,Other,100% New York Medicaid APG,3158.92,,,3158.92,Other,225% New York Medicaid APG,2148.07,,,2148.07,Other,153% New York Medicaid APG,3158.92,,,3158.92,Other,225% New York Medicaid APG,1965.55,,,1965.55,Other,140% New York Medicaid APG,3158.92,,,3158.92,Other,225% New York Medicaid APG,3650.31,,,3650.31,Other,260% New York Medicaid APG,4548.84,,,4548.84,Other,324% New York Medicaid APG,3018.52,,,3018.52,Other,215% New York Medicaid APG,3018.52,,,3018.52,Other,215% New York Medicaid APG,1754.96,,,1754.96,Other,125% New York Medicaid APG,1403.96,48146.39,
Revise prosth vag graft lap,57426,CPT,,,,,,,,both,,,158942.1,117617.15,74,,117617.15,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,71523.95,45,,71523.95,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,78676.34,49.5,,78676.34,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2611.37,,,2611.37,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,111259.47,70,,111259.47,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1403.96,,,1403.96,Other,New York Medicaid APG methodology,1403.96,,,1403.96,Other,100% New York Medicaid APG,1403.96,,,1403.96,Other,100% New York Medicaid APG,1403.96,,,1403.96,Other,100% New York Medicaid APG,3158.92,,,3158.92,Other,225% New York Medicaid APG,2148.07,,,2148.07,Other,153% New York Medicaid APG,3158.92,,,3158.92,Other,225% New York Medicaid APG,1965.55,,,1965.55,Other,140% New York Medicaid APG,3158.92,,,3158.92,Other,225% New York Medicaid APG,3650.31,,,3650.31,Other,260% New York Medicaid APG,4548.84,,,4548.84,Other,324% New York Medicaid APG,3018.52,,,3018.52,Other,215% New York Medicaid APG,3018.52,,,3018.52,Other,215% New York Medicaid APG,1754.96,,,1754.96,Other,125% New York Medicaid APG,1403.96,117617.15,
Exam of cervix w/scope,57452,CPT,,,,,,,,both,,,4191.33,3101.58,74,,3101.58,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,1886.1,45,,1886.1,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,2074.71,49.5,,2074.71,percent of total billed charges,110% of Medicare,2850.1,68,,2850.1,percent of total billed charges,,1132.19,,,1132.19,Other,186% of Medicaid,3353.06,80,,3353.06,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,3353.06,80,,3353.06,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,2933.93,70,,2933.93,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,608.71,,,608.71,Other,New York Medicaid APG methodology,608.71,,,608.71,Other,100% New York Medicaid APG,608.71,,,608.71,Other,100% New York Medicaid APG,608.71,,,608.71,Other,100% New York Medicaid APG,1369.59,,,1369.59,Other,225% New York Medicaid APG,931.32,,,931.32,Other,153% New York Medicaid APG,1369.59,,,1369.59,Other,225% New York Medicaid APG,852.19,,,852.19,Other,140% New York Medicaid APG,1369.59,,,1369.59,Other,225% New York Medicaid APG,1582.63,,,1582.63,Other,260% New York Medicaid APG,1972.21,,,1972.21,Other,324% New York Medicaid APG,1308.72,,,1308.72,Other,215% New York Medicaid APG,1308.72,,,1308.72,Other,215% New York Medicaid APG,760.88,,,760.88,Other,125% New York Medicaid APG,608.71,7216,
Bx/curett of cervix w/scope,57454,CPT,,,,,,,,both,,,6747.72,4993.31,74,,4993.31,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,3036.47,45,,3036.47,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,3340.12,49.5,,3340.12,percent of total billed charges,110% of Medicare,4588.45,68,,4588.45,percent of total billed charges,,1132.19,,,1132.19,Other,186% of Medicaid,5398.18,80,,5398.18,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,5398.18,80,,5398.18,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,4723.4,70,,4723.4,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,608.71,,,608.71,Other,New York Medicaid APG methodology,608.71,,,608.71,Other,100% New York Medicaid APG,608.71,,,608.71,Other,100% New York Medicaid APG,608.71,,,608.71,Other,100% New York Medicaid APG,1369.59,,,1369.59,Other,225% New York Medicaid APG,931.32,,,931.32,Other,153% New York Medicaid APG,1369.59,,,1369.59,Other,225% New York Medicaid APG,852.19,,,852.19,Other,140% New York Medicaid APG,1369.59,,,1369.59,Other,225% New York Medicaid APG,1582.63,,,1582.63,Other,260% New York Medicaid APG,1972.21,,,1972.21,Other,324% New York Medicaid APG,1308.72,,,1308.72,Other,215% New York Medicaid APG,1308.72,,,1308.72,Other,215% New York Medicaid APG,760.88,,,760.88,Other,125% New York Medicaid APG,608.71,7216,
Biopsy of cervix w/scope,57455,CPT,,,,,,,,both,,,6747.72,4993.31,74,,4993.31,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,3036.47,45,,3036.47,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,3340.12,49.5,,3340.12,percent of total billed charges,110% of Medicare,4588.45,68,,4588.45,percent of total billed charges,,1132.19,,,1132.19,Other,186% of Medicaid,5398.18,80,,5398.18,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,5398.18,80,,5398.18,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,4723.4,70,,4723.4,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,608.71,,,608.71,Other,New York Medicaid APG methodology,608.71,,,608.71,Other,100% New York Medicaid APG,608.71,,,608.71,Other,100% New York Medicaid APG,608.71,,,608.71,Other,100% New York Medicaid APG,1369.59,,,1369.59,Other,225% New York Medicaid APG,931.32,,,931.32,Other,153% New York Medicaid APG,1369.59,,,1369.59,Other,225% New York Medicaid APG,852.19,,,852.19,Other,140% New York Medicaid APG,1369.59,,,1369.59,Other,225% New York Medicaid APG,1582.63,,,1582.63,Other,260% New York Medicaid APG,1972.21,,,1972.21,Other,324% New York Medicaid APG,1308.72,,,1308.72,Other,215% New York Medicaid APG,1308.72,,,1308.72,Other,215% New York Medicaid APG,760.88,,,760.88,Other,125% New York Medicaid APG,608.71,7216,
Endocerv curettage w/scope,57456,CPT,,,,,,,,both,,,6747.72,4993.31,74,,4993.31,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,3036.47,45,,3036.47,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,3340.12,49.5,,3340.12,percent of total billed charges,110% of Medicare,4588.45,68,,4588.45,percent of total billed charges,,1132.19,,,1132.19,Other,186% of Medicaid,5398.18,80,,5398.18,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,5398.18,80,,5398.18,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,4723.4,70,,4723.4,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,608.71,,,608.71,Other,New York Medicaid APG methodology,608.71,,,608.71,Other,100% New York Medicaid APG,608.71,,,608.71,Other,100% New York Medicaid APG,608.71,,,608.71,Other,100% New York Medicaid APG,1369.59,,,1369.59,Other,225% New York Medicaid APG,931.32,,,931.32,Other,153% New York Medicaid APG,1369.59,,,1369.59,Other,225% New York Medicaid APG,852.19,,,852.19,Other,140% New York Medicaid APG,1369.59,,,1369.59,Other,225% New York Medicaid APG,1582.63,,,1582.63,Other,260% New York Medicaid APG,1972.21,,,1972.21,Other,324% New York Medicaid APG,1308.72,,,1308.72,Other,215% New York Medicaid APG,1308.72,,,1308.72,Other,215% New York Medicaid APG,760.88,,,760.88,Other,125% New York Medicaid APG,608.71,7216,
Bx of cervix w/scope leep,57460,CPT,,,,,,,,both,,,65759.04,48661.69,74,,48661.69,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,29591.57,45,,29591.57,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,32550.72,49.5,,32550.72,percent of total billed charges,110% of Medicare,44716.15,68,,44716.15,percent of total billed charges,,2506.06,,,2506.06,Other,186% of Medicaid,52607.23,80,,52607.23,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,52607.23,80,,52607.23,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,46031.33,70,,46031.33,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1347.34,,,1347.34,Other,New York Medicaid APG methodology,1347.34,,,1347.34,Other,100% New York Medicaid APG,1347.34,,,1347.34,Other,100% New York Medicaid APG,1347.34,,,1347.34,Other,100% New York Medicaid APG,3031.52,,,3031.52,Other,225% New York Medicaid APG,2061.43,,,2061.43,Other,153% New York Medicaid APG,3031.52,,,3031.52,Other,225% New York Medicaid APG,1886.28,,,1886.28,Other,140% New York Medicaid APG,3031.52,,,3031.52,Other,225% New York Medicaid APG,3503.09,,,3503.09,Other,260% New York Medicaid APG,4365.39,,,4365.39,Other,324% New York Medicaid APG,2896.79,,,2896.79,Other,215% New York Medicaid APG,2896.79,,,2896.79,Other,215% New York Medicaid APG,1684.18,,,1684.18,Other,125% New York Medicaid APG,1347.34,52607.23,
Conz of cervix w/scope leep,57461,CPT,,,,,,,,both,,,65759.04,48661.69,74,,48661.69,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,29591.57,45,,29591.57,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,32550.72,49.5,,32550.72,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2506.06,,,2506.06,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,46031.33,70,,46031.33,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1347.34,,,1347.34,Other,New York Medicaid APG methodology,1347.34,,,1347.34,Other,100% New York Medicaid APG,1347.34,,,1347.34,Other,100% New York Medicaid APG,1347.34,,,1347.34,Other,100% New York Medicaid APG,3031.52,,,3031.52,Other,225% New York Medicaid APG,2061.43,,,2061.43,Other,153% New York Medicaid APG,3031.52,,,3031.52,Other,225% New York Medicaid APG,1886.28,,,1886.28,Other,140% New York Medicaid APG,3031.52,,,3031.52,Other,225% New York Medicaid APG,3503.09,,,3503.09,Other,260% New York Medicaid APG,4365.39,,,4365.39,Other,324% New York Medicaid APG,2896.79,,,2896.79,Other,215% New York Medicaid APG,2896.79,,,2896.79,Other,215% New York Medicaid APG,1684.18,,,1684.18,Other,125% New York Medicaid APG,1347.34,48661.69,
Biopsy of cervix,57500,CPT,,,,,,,,both,,,16909.26,12512.85,74,,12512.85,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,7609.17,45,,7609.17,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,8370.08,49.5,,8370.08,percent of total billed charges,110% of Medicare,11498.3,68,,11498.3,percent of total billed charges,,1132.19,,,1132.19,Other,186% of Medicaid,13527.41,80,,13527.41,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,13527.41,80,,13527.41,percent of total billed charges,,7216,,,7216,Case Rate,,3578,,"100% primary, 0% secondary procedures",3578,Other,MagnaCare ASC Grouper,11836.48,70,,11836.48,percent of total billed charges,,365.72,,,365.72,Fee Schedule,,309.97,,,309.97,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,608.71,,,608.71,Other,New York Medicaid APG methodology,608.71,,,608.71,Other,100% New York Medicaid APG,608.71,,,608.71,Other,100% New York Medicaid APG,608.71,,,608.71,Other,100% New York Medicaid APG,1369.59,,,1369.59,Other,225% New York Medicaid APG,931.32,,,931.32,Other,153% New York Medicaid APG,1369.59,,,1369.59,Other,225% New York Medicaid APG,852.19,,,852.19,Other,140% New York Medicaid APG,1369.59,,,1369.59,Other,225% New York Medicaid APG,1582.63,,,1582.63,Other,260% New York Medicaid APG,1972.21,,,1972.21,Other,324% New York Medicaid APG,1308.72,,,1308.72,Other,215% New York Medicaid APG,1308.72,,,1308.72,Other,215% New York Medicaid APG,760.88,,,760.88,Other,125% New York Medicaid APG,309.97,13527.41,
Endocervical curettage,57505,CPT,,,,,,,,both,,,16909.26,12512.85,74,,12512.85,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,7609.17,45,,7609.17,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,8370.08,49.5,,8370.08,percent of total billed charges,110% of Medicare,11498.3,68,,11498.3,percent of total billed charges,,1132.19,,,1132.19,Other,186% of Medicaid,13527.41,80,,13527.41,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,13527.41,80,,13527.41,percent of total billed charges,,7216,,,7216,Case Rate,,3578,,"100% primary, 0% secondary procedures",3578,Other,MagnaCare ASC Grouper,11836.48,70,,11836.48,percent of total billed charges,,539.56,,,539.56,Fee Schedule,,457.31,,,457.31,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,608.71,,,608.71,Other,New York Medicaid APG methodology,608.71,,,608.71,Other,100% New York Medicaid APG,608.71,,,608.71,Other,100% New York Medicaid APG,608.71,,,608.71,Other,100% New York Medicaid APG,1369.59,,,1369.59,Other,225% New York Medicaid APG,931.32,,,931.32,Other,153% New York Medicaid APG,1369.59,,,1369.59,Other,225% New York Medicaid APG,852.19,,,852.19,Other,140% New York Medicaid APG,1369.59,,,1369.59,Other,225% New York Medicaid APG,1582.63,,,1582.63,Other,260% New York Medicaid APG,1972.21,,,1972.21,Other,324% New York Medicaid APG,1308.72,,,1308.72,Other,215% New York Medicaid APG,1308.72,,,1308.72,Other,215% New York Medicaid APG,760.88,,,760.88,Other,125% New York Medicaid APG,457.31,13527.41,
Cauterization of cervix,57510,CPT,,,,,,,,both,,,65759.04,48661.69,74,,48661.69,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,29591.57,45,,29591.57,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,32550.72,49.5,,32550.72,percent of total billed charges,110% of Medicare,44716.15,68,,44716.15,percent of total billed charges,,2506.06,,,2506.06,Other,186% of Medicaid,52607.23,80,,52607.23,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,52607.23,80,,52607.23,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,46031.33,70,,46031.33,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1347.34,,,1347.34,Other,New York Medicaid APG methodology,1347.34,,,1347.34,Other,100% New York Medicaid APG,1347.34,,,1347.34,Other,100% New York Medicaid APG,1347.34,,,1347.34,Other,100% New York Medicaid APG,3031.52,,,3031.52,Other,225% New York Medicaid APG,2061.43,,,2061.43,Other,153% New York Medicaid APG,3031.52,,,3031.52,Other,225% New York Medicaid APG,1886.28,,,1886.28,Other,140% New York Medicaid APG,3031.52,,,3031.52,Other,225% New York Medicaid APG,3503.09,,,3503.09,Other,260% New York Medicaid APG,4365.39,,,4365.39,Other,324% New York Medicaid APG,2896.79,,,2896.79,Other,215% New York Medicaid APG,2896.79,,,2896.79,Other,215% New York Medicaid APG,1684.18,,,1684.18,Other,125% New York Medicaid APG,1347.34,52607.23,
Cryocautery of cervix,57511,CPT,,,,,,,,both,,,6747.72,4993.31,74,,4993.31,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,3036.47,45,,3036.47,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,3340.12,49.5,,3340.12,percent of total billed charges,110% of Medicare,4588.45,68,,4588.45,percent of total billed charges,,1132.19,,,1132.19,Other,186% of Medicaid,5398.18,80,,5398.18,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,5398.18,80,,5398.18,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,4723.4,70,,4723.4,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,608.71,,,608.71,Other,New York Medicaid APG methodology,608.71,,,608.71,Other,100% New York Medicaid APG,608.71,,,608.71,Other,100% New York Medicaid APG,608.71,,,608.71,Other,100% New York Medicaid APG,1369.59,,,1369.59,Other,225% New York Medicaid APG,931.32,,,931.32,Other,153% New York Medicaid APG,1369.59,,,1369.59,Other,225% New York Medicaid APG,852.19,,,852.19,Other,140% New York Medicaid APG,1369.59,,,1369.59,Other,225% New York Medicaid APG,1582.63,,,1582.63,Other,260% New York Medicaid APG,1972.21,,,1972.21,Other,324% New York Medicaid APG,1308.72,,,1308.72,Other,215% New York Medicaid APG,1308.72,,,1308.72,Other,215% New York Medicaid APG,760.88,,,760.88,Other,125% New York Medicaid APG,608.71,7216,
Laser surgery of cervix,57513,CPT,,,,,,,,both,,,65759.04,48661.69,74,,48661.69,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,29591.57,45,,29591.57,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,32550.72,49.5,,32550.72,percent of total billed charges,110% of Medicare,44716.15,68,,44716.15,percent of total billed charges,,2506.06,,,2506.06,Other,186% of Medicaid,52607.23,80,,52607.23,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,52607.23,80,,52607.23,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,46031.33,70,,46031.33,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1347.34,,,1347.34,Other,New York Medicaid APG methodology,1347.34,,,1347.34,Other,100% New York Medicaid APG,1347.34,,,1347.34,Other,100% New York Medicaid APG,1347.34,,,1347.34,Other,100% New York Medicaid APG,3031.52,,,3031.52,Other,225% New York Medicaid APG,2061.43,,,2061.43,Other,153% New York Medicaid APG,3031.52,,,3031.52,Other,225% New York Medicaid APG,1886.28,,,1886.28,Other,140% New York Medicaid APG,3031.52,,,3031.52,Other,225% New York Medicaid APG,3503.09,,,3503.09,Other,260% New York Medicaid APG,4365.39,,,4365.39,Other,324% New York Medicaid APG,2896.79,,,2896.79,Other,215% New York Medicaid APG,2896.79,,,2896.79,Other,215% New York Medicaid APG,1684.18,,,1684.18,Other,125% New York Medicaid APG,1347.34,52607.23,
Conization of cervix,57520,CPT,,,,,,,,both,,,41976.39,31062.53,74,,31062.53,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,18889.38,45,,18889.38,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,20778.31,49.5,,20778.31,percent of total billed charges,110% of Medicare,28543.95,68,,28543.95,percent of total billed charges,,2506.06,,,2506.06,Other,186% of Medicaid,33581.11,80,,33581.11,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,33581.11,80,,33581.11,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,29383.47,70,,29383.47,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1347.34,,,1347.34,Other,New York Medicaid APG methodology,1347.34,,,1347.34,Other,100% New York Medicaid APG,1347.34,,,1347.34,Other,100% New York Medicaid APG,1347.34,,,1347.34,Other,100% New York Medicaid APG,3031.52,,,3031.52,Other,225% New York Medicaid APG,2061.43,,,2061.43,Other,153% New York Medicaid APG,3031.52,,,3031.52,Other,225% New York Medicaid APG,1886.28,,,1886.28,Other,140% New York Medicaid APG,3031.52,,,3031.52,Other,225% New York Medicaid APG,3503.09,,,3503.09,Other,260% New York Medicaid APG,4365.39,,,4365.39,Other,324% New York Medicaid APG,2896.79,,,2896.79,Other,215% New York Medicaid APG,2896.79,,,2896.79,Other,215% New York Medicaid APG,1684.18,,,1684.18,Other,125% New York Medicaid APG,1347.34,33581.11,
Conization of cervix,57522,CPT,,,,,,,,both,,,40520.37,29985.07,74,,29985.07,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,18234.17,45,,18234.17,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,20057.58,49.5,,20057.58,percent of total billed charges,110% of Medicare,27553.85,68,,27553.85,percent of total billed charges,,2506.06,,,2506.06,Other,186% of Medicaid,32416.3,80,,32416.3,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,32416.3,80,,32416.3,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,28364.26,70,,28364.26,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1347.34,,,1347.34,Other,New York Medicaid APG methodology,1347.34,,,1347.34,Other,100% New York Medicaid APG,1347.34,,,1347.34,Other,100% New York Medicaid APG,1347.34,,,1347.34,Other,100% New York Medicaid APG,3031.52,,,3031.52,Other,225% New York Medicaid APG,2061.43,,,2061.43,Other,153% New York Medicaid APG,3031.52,,,3031.52,Other,225% New York Medicaid APG,1886.28,,,1886.28,Other,140% New York Medicaid APG,3031.52,,,3031.52,Other,225% New York Medicaid APG,3503.09,,,3503.09,Other,260% New York Medicaid APG,4365.39,,,4365.39,Other,324% New York Medicaid APG,2896.79,,,2896.79,Other,215% New York Medicaid APG,2896.79,,,2896.79,Other,215% New York Medicaid APG,1684.18,,,1684.18,Other,125% New York Medicaid APG,1347.34,32416.3,
Removal of cervix,57530,CPT,,,,,,,,both,,,104619.92,77418.74,74,,77418.74,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,47078.96,45,,47078.96,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,51786.86,49.5,,51786.86,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2506.06,,,2506.06,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,73233.94,70,,73233.94,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1347.34,,,1347.34,Other,New York Medicaid APG methodology,1347.34,,,1347.34,Other,100% New York Medicaid APG,1347.34,,,1347.34,Other,100% New York Medicaid APG,1347.34,,,1347.34,Other,100% New York Medicaid APG,3031.52,,,3031.52,Other,225% New York Medicaid APG,2061.43,,,2061.43,Other,153% New York Medicaid APG,3031.52,,,3031.52,Other,225% New York Medicaid APG,1886.28,,,1886.28,Other,140% New York Medicaid APG,3031.52,,,3031.52,Other,225% New York Medicaid APG,3503.09,,,3503.09,Other,260% New York Medicaid APG,4365.39,,,4365.39,Other,324% New York Medicaid APG,2896.79,,,2896.79,Other,215% New York Medicaid APG,2896.79,,,2896.79,Other,215% New York Medicaid APG,1684.18,,,1684.18,Other,125% New York Medicaid APG,1347.34,77418.74,
Removal of residual cervix,57550,CPT,,,,,,,,both,,,104619.92,77418.74,74,,77418.74,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,47078.96,45,,47078.96,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,51786.86,49.5,,51786.86,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2506.06,,,2506.06,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,73233.94,70,,73233.94,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1347.34,,,1347.34,Other,New York Medicaid APG methodology,1347.34,,,1347.34,Other,100% New York Medicaid APG,1347.34,,,1347.34,Other,100% New York Medicaid APG,1347.34,,,1347.34,Other,100% New York Medicaid APG,3031.52,,,3031.52,Other,225% New York Medicaid APG,2061.43,,,2061.43,Other,153% New York Medicaid APG,3031.52,,,3031.52,Other,225% New York Medicaid APG,1886.28,,,1886.28,Other,140% New York Medicaid APG,3031.52,,,3031.52,Other,225% New York Medicaid APG,3503.09,,,3503.09,Other,260% New York Medicaid APG,4365.39,,,4365.39,Other,324% New York Medicaid APG,2896.79,,,2896.79,Other,215% New York Medicaid APG,2896.79,,,2896.79,Other,215% New York Medicaid APG,1684.18,,,1684.18,Other,125% New York Medicaid APG,1347.34,77418.74,
Remove cervix/repair vagina,57555,CPT,,,,,,,,both,,,104619.92,77418.74,74,,77418.74,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,47078.96,45,,47078.96,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,51786.86,49.5,,51786.86,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2506.06,,,2506.06,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,73233.94,70,,73233.94,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1347.34,,,1347.34,Other,New York Medicaid APG methodology,1347.34,,,1347.34,Other,100% New York Medicaid APG,1347.34,,,1347.34,Other,100% New York Medicaid APG,1347.34,,,1347.34,Other,100% New York Medicaid APG,3031.52,,,3031.52,Other,225% New York Medicaid APG,2061.43,,,2061.43,Other,153% New York Medicaid APG,3031.52,,,3031.52,Other,225% New York Medicaid APG,1886.28,,,1886.28,Other,140% New York Medicaid APG,3031.52,,,3031.52,Other,225% New York Medicaid APG,3503.09,,,3503.09,Other,260% New York Medicaid APG,4365.39,,,4365.39,Other,324% New York Medicaid APG,2896.79,,,2896.79,Other,215% New York Medicaid APG,2896.79,,,2896.79,Other,215% New York Medicaid APG,1684.18,,,1684.18,Other,125% New York Medicaid APG,1347.34,77418.74,
Remove cervix repair bowel,57556,CPT,,,,,,,,both,,,104619.92,77418.74,74,,77418.74,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,47078.96,45,,47078.96,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,51786.86,49.5,,51786.86,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3048.93,,,3048.93,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,73233.94,70,,73233.94,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,1639.21,,,1639.21,Other,New York Medicaid APG methodology,1639.21,,,1639.21,Other,100% New York Medicaid APG,1639.21,,,1639.21,Other,100% New York Medicaid APG,1639.21,,,1639.21,Other,100% New York Medicaid APG,3688.23,,,3688.23,Other,225% New York Medicaid APG,2507.99,,,2507.99,Other,153% New York Medicaid APG,3688.23,,,3688.23,Other,225% New York Medicaid APG,2294.9,,,2294.9,Other,140% New York Medicaid APG,3688.23,,,3688.23,Other,225% New York Medicaid APG,4261.95,,,4261.95,Other,260% New York Medicaid APG,5311.05,,,5311.05,Other,324% New York Medicaid APG,3524.31,,,3524.31,Other,215% New York Medicaid APG,3524.31,,,3524.31,Other,215% New York Medicaid APG,2049.02,,,2049.02,Other,125% New York Medicaid APG,1639.21,77418.74,
D&c of cervical stump,57558,CPT,,,,,,,,both,,,65759.04,48661.69,74,,48661.69,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,29591.57,45,,29591.57,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,32550.72,49.5,,32550.72,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2506.06,,,2506.06,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,46031.33,70,,46031.33,percent of total billed charges,,636.32,,,636.32,Fee Schedule,,539.32,,,539.32,Fee Schedule,,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1347.34,,,1347.34,Other,New York Medicaid APG methodology,1347.34,,,1347.34,Other,100% New York Medicaid APG,1347.34,,,1347.34,Other,100% New York Medicaid APG,1347.34,,,1347.34,Other,100% New York Medicaid APG,3031.52,,,3031.52,Other,225% New York Medicaid APG,2061.43,,,2061.43,Other,153% New York Medicaid APG,3031.52,,,3031.52,Other,225% New York Medicaid APG,1886.28,,,1886.28,Other,140% New York Medicaid APG,3031.52,,,3031.52,Other,225% New York Medicaid APG,3503.09,,,3503.09,Other,260% New York Medicaid APG,4365.39,,,4365.39,Other,324% New York Medicaid APG,2896.79,,,2896.79,Other,215% New York Medicaid APG,2896.79,,,2896.79,Other,215% New York Medicaid APG,1684.18,,,1684.18,Other,125% New York Medicaid APG,539.32,48661.69,
Revision of cervix,57700,CPT,,,,,,,,both,,,65759.04,48661.69,74,,48661.69,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,29591.57,45,,29591.57,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,32550.72,49.5,,32550.72,percent of total billed charges,110% of Medicare,44716.15,68,,44716.15,percent of total billed charges,,2506.06,,,2506.06,Other,186% of Medicaid,52607.23,80,,52607.23,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,52607.23,80,,52607.23,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,46031.33,70,,46031.33,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1347.34,,,1347.34,Other,New York Medicaid APG methodology,1347.34,,,1347.34,Other,100% New York Medicaid APG,1347.34,,,1347.34,Other,100% New York Medicaid APG,1347.34,,,1347.34,Other,100% New York Medicaid APG,3031.52,,,3031.52,Other,225% New York Medicaid APG,2061.43,,,2061.43,Other,153% New York Medicaid APG,3031.52,,,3031.52,Other,225% New York Medicaid APG,1886.28,,,1886.28,Other,140% New York Medicaid APG,3031.52,,,3031.52,Other,225% New York Medicaid APG,3503.09,,,3503.09,Other,260% New York Medicaid APG,4365.39,,,4365.39,Other,324% New York Medicaid APG,2896.79,,,2896.79,Other,215% New York Medicaid APG,2896.79,,,2896.79,Other,215% New York Medicaid APG,1684.18,,,1684.18,Other,125% New York Medicaid APG,1347.34,52607.23,
Revision of cervix,57720,CPT,,,,,,,,both,,,65759.04,48661.69,74,,48661.69,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,29591.57,45,,29591.57,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,32550.72,49.5,,32550.72,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2506.06,,,2506.06,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,46031.33,70,,46031.33,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1347.34,,,1347.34,Other,New York Medicaid APG methodology,1347.34,,,1347.34,Other,100% New York Medicaid APG,1347.34,,,1347.34,Other,100% New York Medicaid APG,1347.34,,,1347.34,Other,100% New York Medicaid APG,3031.52,,,3031.52,Other,225% New York Medicaid APG,2061.43,,,2061.43,Other,153% New York Medicaid APG,3031.52,,,3031.52,Other,225% New York Medicaid APG,1886.28,,,1886.28,Other,140% New York Medicaid APG,3031.52,,,3031.52,Other,225% New York Medicaid APG,3503.09,,,3503.09,Other,260% New York Medicaid APG,4365.39,,,4365.39,Other,324% New York Medicaid APG,2896.79,,,2896.79,Other,215% New York Medicaid APG,2896.79,,,2896.79,Other,215% New York Medicaid APG,1684.18,,,1684.18,Other,125% New York Medicaid APG,1347.34,48661.69,
Dilation of cervical canal,57800,CPT,,,,,,,,both,,,65759.04,48661.69,74,,48661.69,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,29591.57,45,,29591.57,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,32550.72,49.5,,32550.72,percent of total billed charges,110% of Medicare,44716.15,68,,44716.15,percent of total billed charges,,2506.06,,,2506.06,Other,186% of Medicaid,52607.23,80,,52607.23,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,52607.23,80,,52607.23,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,46031.33,70,,46031.33,percent of total billed charges,,232.88,,,232.88,Fee Schedule,,197.38,,,197.38,Fee Schedule,,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1347.34,,,1347.34,Other,New York Medicaid APG methodology,1347.34,,,1347.34,Other,100% New York Medicaid APG,1347.34,,,1347.34,Other,100% New York Medicaid APG,1347.34,,,1347.34,Other,100% New York Medicaid APG,3031.52,,,3031.52,Other,225% New York Medicaid APG,2061.43,,,2061.43,Other,153% New York Medicaid APG,3031.52,,,3031.52,Other,225% New York Medicaid APG,1886.28,,,1886.28,Other,140% New York Medicaid APG,3031.52,,,3031.52,Other,225% New York Medicaid APG,3503.09,,,3503.09,Other,260% New York Medicaid APG,4365.39,,,4365.39,Other,324% New York Medicaid APG,2896.79,,,2896.79,Other,215% New York Medicaid APG,2896.79,,,2896.79,Other,215% New York Medicaid APG,1684.18,,,1684.18,Other,125% New York Medicaid APG,197.38,52607.23,
Biopsy of uterus lining,58100,CPT,,,,,,,,both,,,37490.66,27743.09,74,,27743.09,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,16870.8,45,,16870.8,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,18557.88,49.5,,18557.88,percent of total billed charges,110% of Medicare,25493.65,68,,25493.65,percent of total billed charges,,1132.19,,,1132.19,Other,186% of Medicaid,29992.53,80,,29992.53,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,29992.53,80,,29992.53,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,26243.46,70,,26243.46,percent of total billed charges,,308.32,,,308.32,Fee Schedule,,261.32,,,261.32,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,608.71,,,608.71,Other,New York Medicaid APG methodology,608.71,,,608.71,Other,100% New York Medicaid APG,608.71,,,608.71,Other,100% New York Medicaid APG,608.71,,,608.71,Other,100% New York Medicaid APG,1369.59,,,1369.59,Other,225% New York Medicaid APG,931.32,,,931.32,Other,153% New York Medicaid APG,1369.59,,,1369.59,Other,225% New York Medicaid APG,852.19,,,852.19,Other,140% New York Medicaid APG,1369.59,,,1369.59,Other,225% New York Medicaid APG,1582.63,,,1582.63,Other,260% New York Medicaid APG,1972.21,,,1972.21,Other,324% New York Medicaid APG,1308.72,,,1308.72,Other,215% New York Medicaid APG,1308.72,,,1308.72,Other,215% New York Medicaid APG,760.88,,,760.88,Other,125% New York Medicaid APG,261.32,29992.53,
Bx done w/colposcopy add-on,58110,CPT,,,,,,,,both,,,32432.1,23999.75,74,,23999.75,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,14594.45,45,,14594.45,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,16053.89,49.5,,16053.89,percent of total billed charges,110% of Medicare,22053.83,68,,22053.83,percent of total billed charges,,1132.19,,,1132.19,Other,186% of Medicaid,25945.68,80,,25945.68,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,25945.68,80,,25945.68,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,22702.47,70,,22702.47,percent of total billed charges,,195.16,,,195.16,Fee Schedule,,165.41,,,165.41,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,608.71,,,608.71,Other,New York Medicaid APG methodology,608.71,,,608.71,Other,100% New York Medicaid APG,608.71,,,608.71,Other,100% New York Medicaid APG,608.71,,,608.71,Other,100% New York Medicaid APG,1369.59,,,1369.59,Other,225% New York Medicaid APG,931.32,,,931.32,Other,153% New York Medicaid APG,1369.59,,,1369.59,Other,225% New York Medicaid APG,852.19,,,852.19,Other,140% New York Medicaid APG,1369.59,,,1369.59,Other,225% New York Medicaid APG,1582.63,,,1582.63,Other,260% New York Medicaid APG,1972.21,,,1972.21,Other,324% New York Medicaid APG,1308.72,,,1308.72,Other,215% New York Medicaid APG,1308.72,,,1308.72,Other,215% New York Medicaid APG,760.88,,,760.88,Other,125% New York Medicaid APG,165.41,25945.68,
Dilation and curettage,58120,CPT,,,,,,,,both,,,37545.36,27783.57,74,,27783.57,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,16895.41,45,,16895.41,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,18584.95,49.5,,18584.95,percent of total billed charges,110% of Medicare,25530.84,68,,25530.84,percent of total billed charges,,2506.06,,,2506.06,Other,186% of Medicaid,30036.29,80,,30036.29,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,30036.29,80,,30036.29,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,26281.75,70,,26281.75,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1347.34,,,1347.34,Other,New York Medicaid APG methodology,1347.34,,,1347.34,Other,100% New York Medicaid APG,1347.34,,,1347.34,Other,100% New York Medicaid APG,1347.34,,,1347.34,Other,100% New York Medicaid APG,3031.52,,,3031.52,Other,225% New York Medicaid APG,2061.43,,,2061.43,Other,153% New York Medicaid APG,3031.52,,,3031.52,Other,225% New York Medicaid APG,1886.28,,,1886.28,Other,140% New York Medicaid APG,3031.52,,,3031.52,Other,225% New York Medicaid APG,3503.09,,,3503.09,Other,260% New York Medicaid APG,4365.39,,,4365.39,Other,324% New York Medicaid APG,2896.79,,,2896.79,Other,215% New York Medicaid APG,2896.79,,,2896.79,Other,215% New York Medicaid APG,1684.18,,,1684.18,Other,125% New York Medicaid APG,1347.34,30036.29,
Myomectomy vag method,58145,CPT,,,,,,,,both,,,38290.05,28334.64,74,,28334.64,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,17230.52,45,,17230.52,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,18953.57,49.5,,18953.57,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2182.4,,,2182.4,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,26803.04,70,,26803.04,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1173.33,,,1173.33,Other,New York Medicaid APG methodology,1173.33,,,1173.33,Other,100% New York Medicaid APG,1173.33,,,1173.33,Other,100% New York Medicaid APG,1173.33,,,1173.33,Other,100% New York Medicaid APG,2640,,,2640,Other,225% New York Medicaid APG,1795.2,,,1795.2,Other,153% New York Medicaid APG,2640,,,2640,Other,225% New York Medicaid APG,1642.67,,,1642.67,Other,140% New York Medicaid APG,2640,,,2640,Other,225% New York Medicaid APG,3050.66,,,3050.66,Other,260% New York Medicaid APG,3801.6,,,3801.6,Other,324% New York Medicaid APG,2522.66,,,2522.66,Other,215% New York Medicaid APG,2522.66,,,2522.66,Other,215% New York Medicaid APG,1466.67,,,1466.67,Other,125% New York Medicaid APG,1173.33,28334.64,
Vaginal hysterectomy,58260,CPT,,,,,,,,both,,,49369.2,36533.21,74,,36533.21,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,22216.14,45,,22216.14,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,24437.75,49.5,,24437.75,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2182.4,,,2182.4,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,34558.44,70,,34558.44,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1173.33,,,1173.33,Other,New York Medicaid APG methodology,1173.33,,,1173.33,Other,100% New York Medicaid APG,1173.33,,,1173.33,Other,100% New York Medicaid APG,1173.33,,,1173.33,Other,100% New York Medicaid APG,2640,,,2640,Other,225% New York Medicaid APG,1795.2,,,1795.2,Other,153% New York Medicaid APG,2640,,,2640,Other,225% New York Medicaid APG,1642.67,,,1642.67,Other,140% New York Medicaid APG,2640,,,2640,Other,225% New York Medicaid APG,3050.66,,,3050.66,Other,260% New York Medicaid APG,3801.6,,,3801.6,Other,324% New York Medicaid APG,2522.66,,,2522.66,Other,215% New York Medicaid APG,2522.66,,,2522.66,Other,215% New York Medicaid APG,1466.67,,,1466.67,Other,125% New York Medicaid APG,1173.33,36533.21,
Vag hyst including t/o,58262,CPT,,,,,,,,both,,,59177.42,43791.29,74,,43791.29,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,26629.84,45,,26629.84,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,29292.82,49.5,,29292.82,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2182.4,,,2182.4,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,41424.19,70,,41424.19,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1173.33,,,1173.33,Other,New York Medicaid APG methodology,1173.33,,,1173.33,Other,100% New York Medicaid APG,1173.33,,,1173.33,Other,100% New York Medicaid APG,1173.33,,,1173.33,Other,100% New York Medicaid APG,2640,,,2640,Other,225% New York Medicaid APG,1795.2,,,1795.2,Other,153% New York Medicaid APG,2640,,,2640,Other,225% New York Medicaid APG,1642.67,,,1642.67,Other,140% New York Medicaid APG,2640,,,2640,Other,225% New York Medicaid APG,3050.66,,,3050.66,Other,260% New York Medicaid APG,3801.6,,,3801.6,Other,324% New York Medicaid APG,2522.66,,,2522.66,Other,215% New York Medicaid APG,2522.66,,,2522.66,Other,215% New York Medicaid APG,1466.67,,,1466.67,Other,125% New York Medicaid APG,1173.33,43791.29,
Vag hyst w/t/o & vag repair,58263,CPT,,,,,,,,both,,,61845.31,45765.53,74,,45765.53,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,27830.39,45,,27830.39,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,30613.43,49.5,,30613.43,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2182.4,,,2182.4,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,43291.72,70,,43291.72,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1173.33,,,1173.33,Other,New York Medicaid APG methodology,1173.33,,,1173.33,Other,100% New York Medicaid APG,1173.33,,,1173.33,Other,100% New York Medicaid APG,1173.33,,,1173.33,Other,100% New York Medicaid APG,2640,,,2640,Other,225% New York Medicaid APG,1795.2,,,1795.2,Other,153% New York Medicaid APG,2640,,,2640,Other,225% New York Medicaid APG,1642.67,,,1642.67,Other,140% New York Medicaid APG,2640,,,2640,Other,225% New York Medicaid APG,3050.66,,,3050.66,Other,260% New York Medicaid APG,3801.6,,,3801.6,Other,324% New York Medicaid APG,2522.66,,,2522.66,Other,215% New York Medicaid APG,2522.66,,,2522.66,Other,215% New York Medicaid APG,1466.67,,,1466.67,Other,125% New York Medicaid APG,1173.33,45765.53,
Vag hyst w/enterocele repair,58270,CPT,,,,,,,,both,,,104619.92,77418.74,74,,77418.74,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,47078.96,45,,47078.96,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,51786.86,49.5,,51786.86,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2182.4,,,2182.4,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,73233.94,70,,73233.94,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1173.33,,,1173.33,Other,New York Medicaid APG methodology,1173.33,,,1173.33,Other,100% New York Medicaid APG,1173.33,,,1173.33,Other,100% New York Medicaid APG,1173.33,,,1173.33,Other,100% New York Medicaid APG,2640,,,2640,Other,225% New York Medicaid APG,1795.2,,,1795.2,Other,153% New York Medicaid APG,2640,,,2640,Other,225% New York Medicaid APG,1642.67,,,1642.67,Other,140% New York Medicaid APG,2640,,,2640,Other,225% New York Medicaid APG,3050.66,,,3050.66,Other,260% New York Medicaid APG,3801.6,,,3801.6,Other,324% New York Medicaid APG,2522.66,,,2522.66,Other,215% New York Medicaid APG,2522.66,,,2522.66,Other,215% New York Medicaid APG,1466.67,,,1466.67,Other,125% New York Medicaid APG,1173.33,77418.74,
Vag hyst complex,58290,CPT,,,,,,,,both,,,49648.56,36739.93,74,,36739.93,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,22341.85,45,,22341.85,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,24576.04,49.5,,24576.04,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3590.57,,,3590.57,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,34753.99,70,,34753.99,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,1930.42,,,1930.42,Other,New York Medicaid APG methodology,1930.42,,,1930.42,Other,100% New York Medicaid APG,1930.42,,,1930.42,Other,100% New York Medicaid APG,1930.42,,,1930.42,Other,100% New York Medicaid APG,4343.43,,,4343.43,Other,225% New York Medicaid APG,2953.54,,,2953.54,Other,153% New York Medicaid APG,4343.43,,,4343.43,Other,225% New York Medicaid APG,2702.58,,,2702.58,Other,140% New York Medicaid APG,4343.43,,,4343.43,Other,225% New York Medicaid APG,5019.08,,,5019.08,Other,260% New York Medicaid APG,6254.55,,,6254.55,Other,324% New York Medicaid APG,4150.39,,,4150.39,Other,215% New York Medicaid APG,4150.39,,,4150.39,Other,215% New York Medicaid APG,2413.02,,,2413.02,Other,125% New York Medicaid APG,1930.42,36739.93,
Vag hyst incl t/o complex,58291,CPT,,,,,,,,both,,,48303.82,35744.83,74,,35744.83,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,21736.72,45,,21736.72,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,23910.39,49.5,,23910.39,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3590.57,,,3590.57,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,33812.67,70,,33812.67,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,1930.42,,,1930.42,Other,New York Medicaid APG methodology,1930.42,,,1930.42,Other,100% New York Medicaid APG,1930.42,,,1930.42,Other,100% New York Medicaid APG,1930.42,,,1930.42,Other,100% New York Medicaid APG,4343.43,,,4343.43,Other,225% New York Medicaid APG,2953.54,,,2953.54,Other,153% New York Medicaid APG,4343.43,,,4343.43,Other,225% New York Medicaid APG,2702.58,,,2702.58,Other,140% New York Medicaid APG,4343.43,,,4343.43,Other,225% New York Medicaid APG,5019.08,,,5019.08,Other,260% New York Medicaid APG,6254.55,,,6254.55,Other,324% New York Medicaid APG,4150.39,,,4150.39,Other,215% New York Medicaid APG,4150.39,,,4150.39,Other,215% New York Medicaid APG,2413.02,,,2413.02,Other,125% New York Medicaid APG,1930.42,35744.83,
Vag hyst t/o & repair compl,58292,CPT,,,,,,,,both,,,158942.1,117617.15,74,,117617.15,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,71523.95,45,,71523.95,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,78676.34,49.5,,78676.34,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3590.57,,,3590.57,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,111259.47,70,,111259.47,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,1930.42,,,1930.42,Other,New York Medicaid APG methodology,1930.42,,,1930.42,Other,100% New York Medicaid APG,1930.42,,,1930.42,Other,100% New York Medicaid APG,1930.42,,,1930.42,Other,100% New York Medicaid APG,4343.43,,,4343.43,Other,225% New York Medicaid APG,2953.54,,,2953.54,Other,153% New York Medicaid APG,4343.43,,,4343.43,Other,225% New York Medicaid APG,2702.58,,,2702.58,Other,140% New York Medicaid APG,4343.43,,,4343.43,Other,225% New York Medicaid APG,5019.08,,,5019.08,Other,260% New York Medicaid APG,6254.55,,,6254.55,Other,324% New York Medicaid APG,4150.39,,,4150.39,Other,215% New York Medicaid APG,4150.39,,,4150.39,Other,215% New York Medicaid APG,2413.02,,,2413.02,Other,125% New York Medicaid APG,1930.42,117617.15,
Vag hyst w/enterocele compl,58294,CPT,,,,,,,,both,,,104619.92,77418.74,74,,77418.74,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,47078.96,45,,47078.96,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,51786.86,49.5,,51786.86,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3590.57,,,3590.57,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,73233.94,70,,73233.94,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,1930.42,,,1930.42,Other,New York Medicaid APG methodology,1930.42,,,1930.42,Other,100% New York Medicaid APG,1930.42,,,1930.42,Other,100% New York Medicaid APG,1930.42,,,1930.42,Other,100% New York Medicaid APG,4343.43,,,4343.43,Other,225% New York Medicaid APG,2953.54,,,2953.54,Other,153% New York Medicaid APG,4343.43,,,4343.43,Other,225% New York Medicaid APG,2702.58,,,2702.58,Other,140% New York Medicaid APG,4343.43,,,4343.43,Other,225% New York Medicaid APG,5019.08,,,5019.08,Other,260% New York Medicaid APG,6254.55,,,6254.55,Other,324% New York Medicaid APG,4150.39,,,4150.39,Other,215% New York Medicaid APG,4150.39,,,4150.39,Other,215% New York Medicaid APG,2413.02,,,2413.02,Other,125% New York Medicaid APG,1930.42,77418.74,
Remove intrauterine device,58301,CPT,,,,,,,,both,,,36346.93,26896.73,74,,26896.73,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,16356.12,45,,16356.12,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,17991.73,49.5,,17991.73,percent of total billed charges,110% of Medicare,24715.91,68,,24715.91,percent of total billed charges,,445.2,,,445.2,Other,186% of Medicaid,29077.54,80,,29077.54,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,29077.54,80,,29077.54,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,25442.85,70,,25442.85,percent of total billed charges,,323.08,,,323.08,Fee Schedule,,273.83,,,273.83,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,239.36,,,239.36,Other,New York Medicaid APG methodology,239.36,,,239.36,Other,100% New York Medicaid APG,239.36,,,239.36,Other,100% New York Medicaid APG,239.36,,,239.36,Other,100% New York Medicaid APG,538.55,,,538.55,Other,225% New York Medicaid APG,366.22,,,366.22,Other,153% New York Medicaid APG,538.55,,,538.55,Other,225% New York Medicaid APG,335.1,,,335.1,Other,140% New York Medicaid APG,538.55,,,538.55,Other,225% New York Medicaid APG,622.33,,,622.33,Other,260% New York Medicaid APG,775.52,,,775.52,Other,324% New York Medicaid APG,514.62,,,514.62,Other,215% New York Medicaid APG,514.62,,,514.62,Other,215% New York Medicaid APG,299.2,,,299.2,Other,125% New York Medicaid APG,239.36,29077.54,
Artificial insemination,58321,CPT,,,,,,,,both,,,6747.72,4993.31,74,,4993.31,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,3036.47,45,,3036.47,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,4048.63,60,,4048.63,percent of total billed charges,,3778.72,56,,3778.72,percent of total billed charges,,3643.77,54,,3643.77,percent of total billed charges,,3340.12,49.5,,3340.12,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,0.02,,,0.02,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,4723.4,70,,4723.4,percent of total billed charges,,237.8,,,237.8,Fee Schedule,,201.55,,,201.55,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% New York Medicaid APG,0.01,,,0.01,Other,100% New York Medicaid APG,0.01,,,0.01,Other,100% New York Medicaid APG,0.02,,,0.02,Other,225% New York Medicaid APG,0.02,,,0.02,Other,153% New York Medicaid APG,0.02,,,0.02,Other,225% New York Medicaid APG,0.01,,,0.01,Other,140% New York Medicaid APG,0.02,,,0.02,Other,225% New York Medicaid APG,0.03,,,0.03,Other,260% New York Medicaid APG,0.03,,,0.03,Other,324% New York Medicaid APG,0.02,,,0.02,Other,215% New York Medicaid APG,0.02,,,0.02,Other,215% New York Medicaid APG,0.01,,,0.01,Other,125% New York Medicaid APG,0.01,9473,
Artificial insemination,58322,CPT,,,,,,,,both,,,4191.33,3101.58,74,,3101.58,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,1886.1,45,,1886.1,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,2514.8,60,,2514.8,percent of total billed charges,,2347.14,56,,2347.14,percent of total billed charges,,2263.32,54,,2263.32,percent of total billed charges,,2074.71,49.5,,2074.71,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,0.02,,,0.02,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,2933.93,70,,2933.93,percent of total billed charges,,282.08,,,282.08,Fee Schedule,,239.08,,,239.08,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% New York Medicaid APG,0.01,,,0.01,Other,100% New York Medicaid APG,0.01,,,0.01,Other,100% New York Medicaid APG,0.02,,,0.02,Other,225% New York Medicaid APG,0.02,,,0.02,Other,153% New York Medicaid APG,0.02,,,0.02,Other,225% New York Medicaid APG,0.01,,,0.01,Other,140% New York Medicaid APG,0.02,,,0.02,Other,225% New York Medicaid APG,0.03,,,0.03,Other,260% New York Medicaid APG,0.03,,,0.03,Other,324% New York Medicaid APG,0.02,,,0.02,Other,215% New York Medicaid APG,0.02,,,0.02,Other,215% New York Medicaid APG,0.01,,,0.01,Other,125% New York Medicaid APG,0.01,9473,
Sperm washing,58323,CPT,,,,,,,,both,,,4191.33,3101.58,74,,3101.58,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,1886.1,45,,1886.1,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,2514.8,60,,2514.8,percent of total billed charges,,2347.14,56,,2347.14,percent of total billed charges,,2263.32,54,,2263.32,percent of total billed charges,,2074.71,49.5,,2074.71,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,0.02,,,0.02,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,2933.93,70,,2933.93,percent of total billed charges,,59.04,,,59.04,Fee Schedule,,50.04,,,50.04,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% New York Medicaid APG,0.01,,,0.01,Other,100% New York Medicaid APG,0.01,,,0.01,Other,100% New York Medicaid APG,0.02,,,0.02,Other,225% New York Medicaid APG,0.02,,,0.02,Other,153% New York Medicaid APG,0.02,,,0.02,Other,225% New York Medicaid APG,0.01,,,0.01,Other,140% New York Medicaid APG,0.02,,,0.02,Other,225% New York Medicaid APG,0.03,,,0.03,Other,260% New York Medicaid APG,0.03,,,0.03,Other,324% New York Medicaid APG,0.02,,,0.02,Other,215% New York Medicaid APG,0.02,,,0.02,Other,215% New York Medicaid APG,0.01,,,0.01,Other,125% New York Medicaid APG,0.01,9473,
Catheter for hysterography,58340,CPT,,,,,,,,both,,,32432.1,23999.75,74,,23999.75,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,14594.45,45,,14594.45,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,16053.89,49.5,,16053.89,percent of total billed charges,110% of Medicare,22053.83,68,,22053.83,percent of total billed charges,,966.93,,,966.93,Other,186% of Medicaid,25945.68,80,,25945.68,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,25945.68,80,,25945.68,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,22702.47,70,,22702.47,percent of total billed charges,,280.44,,,280.44,Fee Schedule,,237.69,,,237.69,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,519.86,,,519.86,Other,New York Medicaid APG methodology,519.86,,,519.86,Other,100% New York Medicaid APG,519.86,,,519.86,Other,100% New York Medicaid APG,519.86,,,519.86,Other,100% New York Medicaid APG,1169.68,,,1169.68,Other,225% New York Medicaid APG,795.38,,,795.38,Other,153% New York Medicaid APG,1169.68,,,1169.68,Other,225% New York Medicaid APG,727.8,,,727.8,Other,140% New York Medicaid APG,1169.68,,,1169.68,Other,225% New York Medicaid APG,1351.62,,,1351.62,Other,260% New York Medicaid APG,1684.33,,,1684.33,Other,324% New York Medicaid APG,1117.69,,,1117.69,Other,215% New York Medicaid APG,1117.69,,,1117.69,Other,215% New York Medicaid APG,649.82,,,649.82,Other,125% New York Medicaid APG,237.69,25945.68,
Reopen fallopian tube,58345,CPT,,,,,,,,both,,,65759.04,48661.69,74,,48661.69,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,29591.57,45,,29591.57,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,32550.72,49.5,,32550.72,percent of total billed charges,110% of Medicare,44716.15,68,,44716.15,percent of total billed charges,,2506.06,,,2506.06,Other,186% of Medicaid,52607.23,80,,52607.23,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,52607.23,80,,52607.23,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,46031.33,70,,46031.33,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1347.34,,,1347.34,Other,New York Medicaid APG methodology,1347.34,,,1347.34,Other,100% New York Medicaid APG,1347.34,,,1347.34,Other,100% New York Medicaid APG,1347.34,,,1347.34,Other,100% New York Medicaid APG,3031.52,,,3031.52,Other,225% New York Medicaid APG,2061.43,,,2061.43,Other,153% New York Medicaid APG,3031.52,,,3031.52,Other,225% New York Medicaid APG,1886.28,,,1886.28,Other,140% New York Medicaid APG,3031.52,,,3031.52,Other,225% New York Medicaid APG,3503.09,,,3503.09,Other,260% New York Medicaid APG,4365.39,,,4365.39,Other,324% New York Medicaid APG,2896.79,,,2896.79,Other,215% New York Medicaid APG,2896.79,,,2896.79,Other,215% New York Medicaid APG,1684.18,,,1684.18,Other,125% New York Medicaid APG,1347.34,52607.23,
Insert heyman uteri capsule,58346,CPT,,,,,,,,both,,,104619.92,77418.74,74,,77418.74,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,47078.96,45,,47078.96,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,51786.86,49.5,,51786.86,percent of total billed charges,110% of Medicare,71141.55,68,,71141.55,percent of total billed charges,,2506.06,,,2506.06,Other,186% of Medicaid,83695.94,80,,83695.94,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,83695.94,80,,83695.94,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,73233.94,70,,73233.94,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1347.34,,,1347.34,Other,New York Medicaid APG methodology,1347.34,,,1347.34,Other,100% New York Medicaid APG,1347.34,,,1347.34,Other,100% New York Medicaid APG,1347.34,,,1347.34,Other,100% New York Medicaid APG,3031.52,,,3031.52,Other,225% New York Medicaid APG,2061.43,,,2061.43,Other,153% New York Medicaid APG,3031.52,,,3031.52,Other,225% New York Medicaid APG,1886.28,,,1886.28,Other,140% New York Medicaid APG,3031.52,,,3031.52,Other,225% New York Medicaid APG,3503.09,,,3503.09,Other,260% New York Medicaid APG,4365.39,,,4365.39,Other,324% New York Medicaid APG,2896.79,,,2896.79,Other,215% New York Medicaid APG,2896.79,,,2896.79,Other,215% New York Medicaid APG,1684.18,,,1684.18,Other,125% New York Medicaid APG,1347.34,83695.94,
Reopen fallopian tube,58350,CPT,,,,,,,,both,,,104619.92,77418.74,74,,77418.74,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,47078.96,45,,47078.96,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,51786.86,49.5,,51786.86,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2506.06,,,2506.06,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,73233.94,70,,73233.94,percent of total billed charges,,472.32,,,472.32,Fee Schedule,,400.32,,,400.32,Fee Schedule,,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1347.34,,,1347.34,Other,New York Medicaid APG methodology,1347.34,,,1347.34,Other,100% New York Medicaid APG,1347.34,,,1347.34,Other,100% New York Medicaid APG,1347.34,,,1347.34,Other,100% New York Medicaid APG,3031.52,,,3031.52,Other,225% New York Medicaid APG,2061.43,,,2061.43,Other,153% New York Medicaid APG,3031.52,,,3031.52,Other,225% New York Medicaid APG,1886.28,,,1886.28,Other,140% New York Medicaid APG,3031.52,,,3031.52,Other,225% New York Medicaid APG,3503.09,,,3503.09,Other,260% New York Medicaid APG,4365.39,,,4365.39,Other,324% New York Medicaid APG,2896.79,,,2896.79,Other,215% New York Medicaid APG,2896.79,,,2896.79,Other,215% New York Medicaid APG,1684.18,,,1684.18,Other,125% New York Medicaid APG,400.32,77418.74,
Endometr ablate thermal,58353,CPT,,,,,,,,both,,,36275.62,26843.96,74,,26843.96,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,16324.03,45,,16324.03,percent of total billed charges,Medicare Ratio of cost to charges,5954,,"100% primary, 50% supplemental procedure",5954,Other,Aetna ASC Grouper,5359,,"100% primary, 50% supplemental procedure",5359,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,17956.43,49.5,,17956.43,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2506.06,,,2506.06,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,25392.93,70,,25392.93,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1347.34,,,1347.34,Other,New York Medicaid APG methodology,1347.34,,,1347.34,Other,100% New York Medicaid APG,1347.34,,,1347.34,Other,100% New York Medicaid APG,1347.34,,,1347.34,Other,100% New York Medicaid APG,3031.52,,,3031.52,Other,225% New York Medicaid APG,2061.43,,,2061.43,Other,153% New York Medicaid APG,3031.52,,,3031.52,Other,225% New York Medicaid APG,1886.28,,,1886.28,Other,140% New York Medicaid APG,3031.52,,,3031.52,Other,225% New York Medicaid APG,3503.09,,,3503.09,Other,260% New York Medicaid APG,4365.39,,,4365.39,Other,324% New York Medicaid APG,2896.79,,,2896.79,Other,215% New York Medicaid APG,2896.79,,,2896.79,Other,215% New York Medicaid APG,1684.18,,,1684.18,Other,125% New York Medicaid APG,1347.34,26843.96,
Endometrial cryoablation,58356,CPT,,,,,,,,both,,,104619.92,77418.74,74,,77418.74,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,47078.96,45,,47078.96,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,51786.86,49.5,,51786.86,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3048.93,,,3048.93,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,73233.94,70,,73233.94,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,1639.21,,,1639.21,Other,New York Medicaid APG methodology,1639.21,,,1639.21,Other,100% New York Medicaid APG,1639.21,,,1639.21,Other,100% New York Medicaid APG,1639.21,,,1639.21,Other,100% New York Medicaid APG,3688.23,,,3688.23,Other,225% New York Medicaid APG,2507.99,,,2507.99,Other,153% New York Medicaid APG,3688.23,,,3688.23,Other,225% New York Medicaid APG,2294.9,,,2294.9,Other,140% New York Medicaid APG,3688.23,,,3688.23,Other,225% New York Medicaid APG,4261.95,,,4261.95,Other,260% New York Medicaid APG,5311.05,,,5311.05,Other,324% New York Medicaid APG,3524.31,,,3524.31,Other,215% New York Medicaid APG,3524.31,,,3524.31,Other,215% New York Medicaid APG,2049.02,,,2049.02,Other,125% New York Medicaid APG,1639.21,77418.74,
Lsh uterus 250 g or less,58541,CPT,,,,,,,,both,,,72794.83,53868.17,74,,53868.17,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,32757.67,45,,32757.67,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,6125,,"100% primary, 50% secondary, 25% supplemental procedure",6125,Other,Blue Cross ASC Grouper,5513,,"100% primary, 50% secondary, 25% supplemental procedure",5513,Other,Blue Cross ASC Grouper,5206,,"100% primary, 50% secondary, 25% supplemental procedure",5206,Other,Blue Cross ASC Grouper,36033.44,49.5,,36033.44,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3590.57,,,3590.57,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,50956.38,70,,50956.38,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,1930.42,,,1930.42,Other,New York Medicaid APG methodology,1930.42,,,1930.42,Other,100% New York Medicaid APG,1930.42,,,1930.42,Other,100% New York Medicaid APG,1930.42,,,1930.42,Other,100% New York Medicaid APG,4343.43,,,4343.43,Other,225% New York Medicaid APG,2953.54,,,2953.54,Other,153% New York Medicaid APG,4343.43,,,4343.43,Other,225% New York Medicaid APG,2702.58,,,2702.58,Other,140% New York Medicaid APG,4343.43,,,4343.43,Other,225% New York Medicaid APG,5019.08,,,5019.08,Other,260% New York Medicaid APG,6254.55,,,6254.55,Other,324% New York Medicaid APG,4150.39,,,4150.39,Other,215% New York Medicaid APG,4150.39,,,4150.39,Other,215% New York Medicaid APG,2413.02,,,2413.02,Other,125% New York Medicaid APG,1930.42,53868.17,
Lsh w/t/o ut 250 g or less,58542,CPT,,,,,,,,both,,,74539.51,55159.24,74,,55159.24,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,33542.78,45,,33542.78,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,36897.06,49.5,,36897.06,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3590.57,,,3590.57,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,52177.66,70,,52177.66,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,1930.42,,,1930.42,Other,New York Medicaid APG methodology,1930.42,,,1930.42,Other,100% New York Medicaid APG,1930.42,,,1930.42,Other,100% New York Medicaid APG,1930.42,,,1930.42,Other,100% New York Medicaid APG,4343.43,,,4343.43,Other,225% New York Medicaid APG,2953.54,,,2953.54,Other,153% New York Medicaid APG,4343.43,,,4343.43,Other,225% New York Medicaid APG,2702.58,,,2702.58,Other,140% New York Medicaid APG,4343.43,,,4343.43,Other,225% New York Medicaid APG,5019.08,,,5019.08,Other,260% New York Medicaid APG,6254.55,,,6254.55,Other,324% New York Medicaid APG,4150.39,,,4150.39,Other,215% New York Medicaid APG,4150.39,,,4150.39,Other,215% New York Medicaid APG,2413.02,,,2413.02,Other,125% New York Medicaid APG,1930.42,55159.24,
Lsh uterus above 250 g,58543,CPT,,,,,,,,both,,,216515.17,160221.23,74,,160221.23,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,97431.83,45,,97431.83,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,107175.01,49.5,,107175.01,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3590.57,,,3590.57,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,151560.62,70,,151560.62,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,1930.42,,,1930.42,Other,New York Medicaid APG methodology,1930.42,,,1930.42,Other,100% New York Medicaid APG,1930.42,,,1930.42,Other,100% New York Medicaid APG,1930.42,,,1930.42,Other,100% New York Medicaid APG,4343.43,,,4343.43,Other,225% New York Medicaid APG,2953.54,,,2953.54,Other,153% New York Medicaid APG,4343.43,,,4343.43,Other,225% New York Medicaid APG,2702.58,,,2702.58,Other,140% New York Medicaid APG,4343.43,,,4343.43,Other,225% New York Medicaid APG,5019.08,,,5019.08,Other,260% New York Medicaid APG,6254.55,,,6254.55,Other,324% New York Medicaid APG,4150.39,,,4150.39,Other,215% New York Medicaid APG,4150.39,,,4150.39,Other,215% New York Medicaid APG,2413.02,,,2413.02,Other,125% New York Medicaid APG,1930.42,160221.23,
Lsh w/t/o uterus above 250 g,58544,CPT,,,,,,,,both,,,61808.81,45738.52,74,,45738.52,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,27813.96,45,,27813.96,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,30595.36,49.5,,30595.36,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3590.57,,,3590.57,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,43266.17,70,,43266.17,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,1930.42,,,1930.42,Other,New York Medicaid APG methodology,1930.42,,,1930.42,Other,100% New York Medicaid APG,1930.42,,,1930.42,Other,100% New York Medicaid APG,1930.42,,,1930.42,Other,100% New York Medicaid APG,4343.43,,,4343.43,Other,225% New York Medicaid APG,2953.54,,,2953.54,Other,153% New York Medicaid APG,4343.43,,,4343.43,Other,225% New York Medicaid APG,2702.58,,,2702.58,Other,140% New York Medicaid APG,4343.43,,,4343.43,Other,225% New York Medicaid APG,5019.08,,,5019.08,Other,260% New York Medicaid APG,6254.55,,,6254.55,Other,324% New York Medicaid APG,4150.39,,,4150.39,Other,215% New York Medicaid APG,4150.39,,,4150.39,Other,215% New York Medicaid APG,2413.02,,,2413.02,Other,125% New York Medicaid APG,1930.42,45738.52,
Laparoscopic myomectomy,58545,CPT,,,,,,,,both,,,55214.27,40858.56,74,,40858.56,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,24846.42,45,,24846.42,percent of total billed charges,Medicare Ratio of cost to charges,5459,,"100% primary, 50% supplemental procedure",5459,Other,Aetna ASC Grouper,4913,,"100% primary, 50% supplemental procedure",4913,Other,Aetna ASC Grouper,6125,,"100% primary, 50% secondary, 25% supplemental procedure",6125,Other,Blue Cross ASC Grouper,5513,,"100% primary, 50% secondary, 25% supplemental procedure",5513,Other,Blue Cross ASC Grouper,5206,,"100% primary, 50% secondary, 25% supplemental procedure",5206,Other,Blue Cross ASC Grouper,27331.06,49.5,,27331.06,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3590.57,,,3590.57,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,38649.99,70,,38649.99,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,1930.42,,,1930.42,Other,New York Medicaid APG methodology,1930.42,,,1930.42,Other,100% New York Medicaid APG,1930.42,,,1930.42,Other,100% New York Medicaid APG,1930.42,,,1930.42,Other,100% New York Medicaid APG,4343.43,,,4343.43,Other,225% New York Medicaid APG,2953.54,,,2953.54,Other,153% New York Medicaid APG,4343.43,,,4343.43,Other,225% New York Medicaid APG,2702.58,,,2702.58,Other,140% New York Medicaid APG,4343.43,,,4343.43,Other,225% New York Medicaid APG,5019.08,,,5019.08,Other,260% New York Medicaid APG,6254.55,,,6254.55,Other,324% New York Medicaid APG,4150.39,,,4150.39,Other,215% New York Medicaid APG,4150.39,,,4150.39,Other,215% New York Medicaid APG,2413.02,,,2413.02,Other,125% New York Medicaid APG,1930.42,40858.56,
Laparo-myomectomy complex,58546,CPT,,,,,,,,both,,,63611.71,47072.67,74,,47072.67,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,28625.27,45,,28625.27,percent of total billed charges,Medicare Ratio of cost to charges,5954,,"100% primary, 50% supplemental procedure",5954,Other,Aetna ASC Grouper,5359,,"100% primary, 50% supplemental procedure",5359,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,31487.8,49.5,,31487.8,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3590.57,,,3590.57,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,44528.2,70,,44528.2,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,1930.42,,,1930.42,Other,New York Medicaid APG methodology,1930.42,,,1930.42,Other,100% New York Medicaid APG,1930.42,,,1930.42,Other,100% New York Medicaid APG,1930.42,,,1930.42,Other,100% New York Medicaid APG,4343.43,,,4343.43,Other,225% New York Medicaid APG,2953.54,,,2953.54,Other,153% New York Medicaid APG,4343.43,,,4343.43,Other,225% New York Medicaid APG,2702.58,,,2702.58,Other,140% New York Medicaid APG,4343.43,,,4343.43,Other,225% New York Medicaid APG,5019.08,,,5019.08,Other,260% New York Medicaid APG,6254.55,,,6254.55,Other,324% New York Medicaid APG,4150.39,,,4150.39,Other,215% New York Medicaid APG,4150.39,,,4150.39,Other,215% New York Medicaid APG,2413.02,,,2413.02,Other,125% New York Medicaid APG,1930.42,47072.67,
Laparo-asst vag hysterectomy,58550,CPT,,,,,,,,both,,,121364.27,89809.56,74,,89809.56,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,54613.92,45,,54613.92,percent of total billed charges,Medicare Ratio of cost to charges,5459,,"100% primary, 50% supplemental procedure",5459,Other,Aetna ASC Grouper,4913,,"100% primary, 50% supplemental procedure",4913,Other,Aetna ASC Grouper,6125,,"100% primary, 50% secondary, 25% supplemental procedure",6125,Other,Blue Cross ASC Grouper,5513,,"100% primary, 50% secondary, 25% supplemental procedure",5513,Other,Blue Cross ASC Grouper,5206,,"100% primary, 50% secondary, 25% supplemental procedure",5206,Other,Blue Cross ASC Grouper,60075.31,49.5,,60075.31,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3590.57,,,3590.57,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,84954.99,70,,84954.99,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,1930.42,,,1930.42,Other,New York Medicaid APG methodology,1930.42,,,1930.42,Other,100% New York Medicaid APG,1930.42,,,1930.42,Other,100% New York Medicaid APG,1930.42,,,1930.42,Other,100% New York Medicaid APG,4343.43,,,4343.43,Other,225% New York Medicaid APG,2953.54,,,2953.54,Other,153% New York Medicaid APG,4343.43,,,4343.43,Other,225% New York Medicaid APG,2702.58,,,2702.58,Other,140% New York Medicaid APG,4343.43,,,4343.43,Other,225% New York Medicaid APG,5019.08,,,5019.08,Other,260% New York Medicaid APG,6254.55,,,6254.55,Other,324% New York Medicaid APG,4150.39,,,4150.39,Other,215% New York Medicaid APG,4150.39,,,4150.39,Other,215% New York Medicaid APG,2413.02,,,2413.02,Other,125% New York Medicaid APG,1930.42,89809.56,
Laparo-vag hyst incl t/o,58552,CPT,,,,,,,,both,,,66652.29,49322.69,74,,49322.69,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,29993.53,45,,29993.53,percent of total billed charges,Medicare Ratio of cost to charges,5954,,"100% primary, 50% supplemental procedure",5954,Other,Aetna ASC Grouper,5359,,"100% primary, 50% supplemental procedure",5359,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,32992.88,49.5,,32992.88,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3590.57,,,3590.57,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,46656.6,70,,46656.6,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,1930.42,,,1930.42,Other,New York Medicaid APG methodology,1930.42,,,1930.42,Other,100% New York Medicaid APG,1930.42,,,1930.42,Other,100% New York Medicaid APG,1930.42,,,1930.42,Other,100% New York Medicaid APG,4343.43,,,4343.43,Other,225% New York Medicaid APG,2953.54,,,2953.54,Other,153% New York Medicaid APG,4343.43,,,4343.43,Other,225% New York Medicaid APG,2702.58,,,2702.58,Other,140% New York Medicaid APG,4343.43,,,4343.43,Other,225% New York Medicaid APG,5019.08,,,5019.08,Other,260% New York Medicaid APG,6254.55,,,6254.55,Other,324% New York Medicaid APG,4150.39,,,4150.39,Other,215% New York Medicaid APG,4150.39,,,4150.39,Other,215% New York Medicaid APG,2413.02,,,2413.02,Other,125% New York Medicaid APG,1930.42,49322.69,
Laparo-vag hyst complex,58553,CPT,,,,,,,,both,,,71770.12,53109.89,74,,53109.89,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,32296.55,45,,32296.55,percent of total billed charges,Medicare Ratio of cost to charges,5954,,"100% primary, 50% supplemental procedure",5954,Other,Aetna ASC Grouper,5359,,"100% primary, 50% supplemental procedure",5359,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,35526.21,49.5,,35526.21,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3590.57,,,3590.57,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,50239.08,70,,50239.08,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,1930.42,,,1930.42,Other,New York Medicaid APG methodology,1930.42,,,1930.42,Other,100% New York Medicaid APG,1930.42,,,1930.42,Other,100% New York Medicaid APG,1930.42,,,1930.42,Other,100% New York Medicaid APG,4343.43,,,4343.43,Other,225% New York Medicaid APG,2953.54,,,2953.54,Other,153% New York Medicaid APG,4343.43,,,4343.43,Other,225% New York Medicaid APG,2702.58,,,2702.58,Other,140% New York Medicaid APG,4343.43,,,4343.43,Other,225% New York Medicaid APG,5019.08,,,5019.08,Other,260% New York Medicaid APG,6254.55,,,6254.55,Other,324% New York Medicaid APG,4150.39,,,4150.39,Other,215% New York Medicaid APG,4150.39,,,4150.39,Other,215% New York Medicaid APG,2413.02,,,2413.02,Other,125% New York Medicaid APG,1930.42,53109.89,
Laparo-vag hyst w/t/o compl,58554,CPT,,,,,,,,both,,,97317.14,72014.68,74,,72014.68,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,43792.71,45,,43792.71,percent of total billed charges,Medicare Ratio of cost to charges,5954,,"100% primary, 50% supplemental procedure",5954,Other,Aetna ASC Grouper,5359,,"100% primary, 50% supplemental procedure",5359,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,48171.98,49.5,,48171.98,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3590.57,,,3590.57,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,68122,70,,68122,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,1930.42,,,1930.42,Other,New York Medicaid APG methodology,1930.42,,,1930.42,Other,100% New York Medicaid APG,1930.42,,,1930.42,Other,100% New York Medicaid APG,1930.42,,,1930.42,Other,100% New York Medicaid APG,4343.43,,,4343.43,Other,225% New York Medicaid APG,2953.54,,,2953.54,Other,153% New York Medicaid APG,4343.43,,,4343.43,Other,225% New York Medicaid APG,2702.58,,,2702.58,Other,140% New York Medicaid APG,4343.43,,,4343.43,Other,225% New York Medicaid APG,5019.08,,,5019.08,Other,260% New York Medicaid APG,6254.55,,,6254.55,Other,324% New York Medicaid APG,4150.39,,,4150.39,Other,215% New York Medicaid APG,4150.39,,,4150.39,Other,215% New York Medicaid APG,2413.02,,,2413.02,Other,125% New York Medicaid APG,1930.42,72014.68,
Hysteroscopy dx sep proc,58555,CPT,,,,,,,,both,,,34430.83,25478.81,74,,25478.81,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15493.87,45,,15493.87,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,17043.26,49.5,,17043.26,percent of total billed charges,110% of Medicare,23412.96,68,,23412.96,percent of total billed charges,,2506.06,,,2506.06,Other,186% of Medicaid,27544.66,80,,27544.66,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,27544.66,80,,27544.66,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,24101.58,70,,24101.58,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1347.34,,,1347.34,Other,New York Medicaid APG methodology,1347.34,,,1347.34,Other,100% New York Medicaid APG,1347.34,,,1347.34,Other,100% New York Medicaid APG,1347.34,,,1347.34,Other,100% New York Medicaid APG,3031.52,,,3031.52,Other,225% New York Medicaid APG,2061.43,,,2061.43,Other,153% New York Medicaid APG,3031.52,,,3031.52,Other,225% New York Medicaid APG,1886.28,,,1886.28,Other,140% New York Medicaid APG,3031.52,,,3031.52,Other,225% New York Medicaid APG,3503.09,,,3503.09,Other,260% New York Medicaid APG,4365.39,,,4365.39,Other,324% New York Medicaid APG,2896.79,,,2896.79,Other,215% New York Medicaid APG,2896.79,,,2896.79,Other,215% New York Medicaid APG,1684.18,,,1684.18,Other,125% New York Medicaid APG,1347.34,27544.66,
Hysteroscopy biopsy,58558,CPT,,,,,,,,both,,,39392.83,29150.69,74,,29150.69,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,17726.77,45,,17726.77,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,19499.45,49.5,,19499.45,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2506.06,,,2506.06,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,27574.98,70,,27574.98,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1347.34,,,1347.34,Other,New York Medicaid APG methodology,1347.34,,,1347.34,Other,100% New York Medicaid APG,1347.34,,,1347.34,Other,100% New York Medicaid APG,1347.34,,,1347.34,Other,100% New York Medicaid APG,3031.52,,,3031.52,Other,225% New York Medicaid APG,2061.43,,,2061.43,Other,153% New York Medicaid APG,3031.52,,,3031.52,Other,225% New York Medicaid APG,1886.28,,,1886.28,Other,140% New York Medicaid APG,3031.52,,,3031.52,Other,225% New York Medicaid APG,3503.09,,,3503.09,Other,260% New York Medicaid APG,4365.39,,,4365.39,Other,324% New York Medicaid APG,2896.79,,,2896.79,Other,215% New York Medicaid APG,2896.79,,,2896.79,Other,215% New York Medicaid APG,1684.18,,,1684.18,Other,125% New York Medicaid APG,1347.34,29150.69,
Hysteroscopy lysis,58559,CPT,,,,,,,,both,,,36552.16,27048.6,74,,27048.6,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,16448.47,45,,16448.47,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,18093.32,49.5,,18093.32,percent of total billed charges,110% of Medicare,24855.47,68,,24855.47,percent of total billed charges,,2506.06,,,2506.06,Other,186% of Medicaid,29241.73,80,,29241.73,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,29241.73,80,,29241.73,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,25586.51,70,,25586.51,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1347.34,,,1347.34,Other,New York Medicaid APG methodology,1347.34,,,1347.34,Other,100% New York Medicaid APG,1347.34,,,1347.34,Other,100% New York Medicaid APG,1347.34,,,1347.34,Other,100% New York Medicaid APG,3031.52,,,3031.52,Other,225% New York Medicaid APG,2061.43,,,2061.43,Other,153% New York Medicaid APG,3031.52,,,3031.52,Other,225% New York Medicaid APG,1886.28,,,1886.28,Other,140% New York Medicaid APG,3031.52,,,3031.52,Other,225% New York Medicaid APG,3503.09,,,3503.09,Other,260% New York Medicaid APG,4365.39,,,4365.39,Other,324% New York Medicaid APG,2896.79,,,2896.79,Other,215% New York Medicaid APG,2896.79,,,2896.79,Other,215% New York Medicaid APG,1684.18,,,1684.18,Other,125% New York Medicaid APG,1347.34,29241.73,
Hysteroscopy resect septum,58560,CPT,,,,,,,,both,,,37501.05,27750.78,74,,27750.78,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,16875.47,45,,16875.47,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,18563.02,49.5,,18563.02,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2506.06,,,2506.06,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,26250.74,70,,26250.74,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1347.34,,,1347.34,Other,New York Medicaid APG methodology,1347.34,,,1347.34,Other,100% New York Medicaid APG,1347.34,,,1347.34,Other,100% New York Medicaid APG,1347.34,,,1347.34,Other,100% New York Medicaid APG,3031.52,,,3031.52,Other,225% New York Medicaid APG,2061.43,,,2061.43,Other,153% New York Medicaid APG,3031.52,,,3031.52,Other,225% New York Medicaid APG,1886.28,,,1886.28,Other,140% New York Medicaid APG,3031.52,,,3031.52,Other,225% New York Medicaid APG,3503.09,,,3503.09,Other,260% New York Medicaid APG,4365.39,,,4365.39,Other,324% New York Medicaid APG,2896.79,,,2896.79,Other,215% New York Medicaid APG,2896.79,,,2896.79,Other,215% New York Medicaid APG,1684.18,,,1684.18,Other,125% New York Medicaid APG,1347.34,27750.78,
Hysteroscopy remove myoma,58561,CPT,,,,,,,,both,,,40296.84,29819.66,74,,29819.66,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,18133.58,45,,18133.58,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,19946.94,49.5,,19946.94,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2182.4,,,2182.4,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,28207.79,70,,28207.79,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1173.33,,,1173.33,Other,New York Medicaid APG methodology,1173.33,,,1173.33,Other,100% New York Medicaid APG,1173.33,,,1173.33,Other,100% New York Medicaid APG,1173.33,,,1173.33,Other,100% New York Medicaid APG,2640,,,2640,Other,225% New York Medicaid APG,1795.2,,,1795.2,Other,153% New York Medicaid APG,2640,,,2640,Other,225% New York Medicaid APG,1642.67,,,1642.67,Other,140% New York Medicaid APG,2640,,,2640,Other,225% New York Medicaid APG,3050.66,,,3050.66,Other,260% New York Medicaid APG,3801.6,,,3801.6,Other,324% New York Medicaid APG,2522.66,,,2522.66,Other,215% New York Medicaid APG,2522.66,,,2522.66,Other,215% New York Medicaid APG,1466.67,,,1466.67,Other,125% New York Medicaid APG,1173.33,29819.66,
Hysteroscopy remove fb,58562,CPT,,,,,,,,both,,,37612.98,27833.61,74,,27833.61,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,16925.84,45,,16925.84,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,18618.43,49.5,,18618.43,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2506.06,,,2506.06,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,26329.09,70,,26329.09,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1347.34,,,1347.34,Other,New York Medicaid APG methodology,1347.34,,,1347.34,Other,100% New York Medicaid APG,1347.34,,,1347.34,Other,100% New York Medicaid APG,1347.34,,,1347.34,Other,100% New York Medicaid APG,3031.52,,,3031.52,Other,225% New York Medicaid APG,2061.43,,,2061.43,Other,153% New York Medicaid APG,3031.52,,,3031.52,Other,225% New York Medicaid APG,1886.28,,,1886.28,Other,140% New York Medicaid APG,3031.52,,,3031.52,Other,225% New York Medicaid APG,3503.09,,,3503.09,Other,260% New York Medicaid APG,4365.39,,,4365.39,Other,324% New York Medicaid APG,2896.79,,,2896.79,Other,215% New York Medicaid APG,2896.79,,,2896.79,Other,215% New York Medicaid APG,1684.18,,,1684.18,Other,125% New York Medicaid APG,1347.34,27833.61,
Hysteroscopy ablation,58563,CPT,,,,,,,,both,,,39521.04,29245.57,74,,29245.57,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,17784.47,45,,17784.47,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,19562.91,49.5,,19562.91,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2506.06,,,2506.06,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,27664.73,70,,27664.73,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1347.34,,,1347.34,Other,New York Medicaid APG methodology,1347.34,,,1347.34,Other,100% New York Medicaid APG,1347.34,,,1347.34,Other,100% New York Medicaid APG,1347.34,,,1347.34,Other,100% New York Medicaid APG,3031.52,,,3031.52,Other,225% New York Medicaid APG,2061.43,,,2061.43,Other,153% New York Medicaid APG,3031.52,,,3031.52,Other,225% New York Medicaid APG,1886.28,,,1886.28,Other,140% New York Medicaid APG,3031.52,,,3031.52,Other,225% New York Medicaid APG,3503.09,,,3503.09,Other,260% New York Medicaid APG,4365.39,,,4365.39,Other,324% New York Medicaid APG,2896.79,,,2896.79,Other,215% New York Medicaid APG,2896.79,,,2896.79,Other,215% New York Medicaid APG,1684.18,,,1684.18,Other,125% New York Medicaid APG,1347.34,29245.57,
Hysteroscopy sterilization,58565,CPT,,,,,,,,both,,,104619.92,77418.74,74,,77418.74,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,47078.96,45,,47078.96,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,51786.86,49.5,,51786.86,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3048.93,,,3048.93,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,73233.94,70,,73233.94,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,1639.21,,,1639.21,Other,New York Medicaid APG methodology,1639.21,,,1639.21,Other,100% New York Medicaid APG,1639.21,,,1639.21,Other,100% New York Medicaid APG,1639.21,,,1639.21,Other,100% New York Medicaid APG,3688.23,,,3688.23,Other,225% New York Medicaid APG,2507.99,,,2507.99,Other,153% New York Medicaid APG,3688.23,,,3688.23,Other,225% New York Medicaid APG,2294.9,,,2294.9,Other,140% New York Medicaid APG,3688.23,,,3688.23,Other,225% New York Medicaid APG,4261.95,,,4261.95,Other,260% New York Medicaid APG,5311.05,,,5311.05,Other,324% New York Medicaid APG,3524.31,,,3524.31,Other,215% New York Medicaid APG,3524.31,,,3524.31,Other,215% New York Medicaid APG,2049.02,,,2049.02,Other,125% New York Medicaid APG,1639.21,77418.74,
Tlh uterus 250 g or less,58570,CPT,,,,,,,,both,,,56767.61,42008.03,74,,42008.03,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,25545.42,45,,25545.42,percent of total billed charges,Medicare Ratio of cost to charges,5459,,"100% primary, 50% supplemental procedure",5459,Other,Aetna ASC Grouper,4913,,"100% primary, 50% supplemental procedure",4913,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,28099.97,49.5,,28099.97,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3590.57,,,3590.57,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,39737.33,70,,39737.33,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,1930.42,,,1930.42,Other,New York Medicaid APG methodology,1930.42,,,1930.42,Other,100% New York Medicaid APG,1930.42,,,1930.42,Other,100% New York Medicaid APG,1930.42,,,1930.42,Other,100% New York Medicaid APG,4343.43,,,4343.43,Other,225% New York Medicaid APG,2953.54,,,2953.54,Other,153% New York Medicaid APG,4343.43,,,4343.43,Other,225% New York Medicaid APG,2702.58,,,2702.58,Other,140% New York Medicaid APG,4343.43,,,4343.43,Other,225% New York Medicaid APG,5019.08,,,5019.08,Other,260% New York Medicaid APG,6254.55,,,6254.55,Other,324% New York Medicaid APG,4150.39,,,4150.39,Other,215% New York Medicaid APG,4150.39,,,4150.39,Other,215% New York Medicaid APG,2413.02,,,2413.02,Other,125% New York Medicaid APG,1930.42,42008.03,
Tlh w/t/o 250 g or less,58571,CPT,,,,,,,,both,,,69079.78,51119.04,74,,51119.04,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,31085.9,45,,31085.9,percent of total billed charges,Medicare Ratio of cost to charges,5459,,"100% primary, 50% supplemental procedure",5459,Other,Aetna ASC Grouper,4913,,"100% primary, 50% supplemental procedure",4913,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,34194.49,49.5,,34194.49,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3590.57,,,3590.57,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,48355.85,70,,48355.85,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,1930.42,,,1930.42,Other,New York Medicaid APG methodology,1930.42,,,1930.42,Other,100% New York Medicaid APG,1930.42,,,1930.42,Other,100% New York Medicaid APG,1930.42,,,1930.42,Other,100% New York Medicaid APG,4343.43,,,4343.43,Other,225% New York Medicaid APG,2953.54,,,2953.54,Other,153% New York Medicaid APG,4343.43,,,4343.43,Other,225% New York Medicaid APG,2702.58,,,2702.58,Other,140% New York Medicaid APG,4343.43,,,4343.43,Other,225% New York Medicaid APG,5019.08,,,5019.08,Other,260% New York Medicaid APG,6254.55,,,6254.55,Other,324% New York Medicaid APG,4150.39,,,4150.39,Other,215% New York Medicaid APG,4150.39,,,4150.39,Other,215% New York Medicaid APG,2413.02,,,2413.02,Other,125% New York Medicaid APG,1930.42,51119.04,
Tlh uterus over 250 g,58572,CPT,,,,,,,,both,,,66943.71,49538.35,74,,49538.35,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30124.67,45,,30124.67,percent of total billed charges,Medicare Ratio of cost to charges,5459,,"100% primary, 50% supplemental procedure",5459,Other,Aetna ASC Grouper,4913,,"100% primary, 50% supplemental procedure",4913,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,33137.14,49.5,,33137.14,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3590.57,,,3590.57,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,46860.6,70,,46860.6,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,1930.42,,,1930.42,Other,New York Medicaid APG methodology,1930.42,,,1930.42,Other,100% New York Medicaid APG,1930.42,,,1930.42,Other,100% New York Medicaid APG,1930.42,,,1930.42,Other,100% New York Medicaid APG,4343.43,,,4343.43,Other,225% New York Medicaid APG,2953.54,,,2953.54,Other,153% New York Medicaid APG,4343.43,,,4343.43,Other,225% New York Medicaid APG,2702.58,,,2702.58,Other,140% New York Medicaid APG,4343.43,,,4343.43,Other,225% New York Medicaid APG,5019.08,,,5019.08,Other,260% New York Medicaid APG,6254.55,,,6254.55,Other,324% New York Medicaid APG,4150.39,,,4150.39,Other,215% New York Medicaid APG,4150.39,,,4150.39,Other,215% New York Medicaid APG,2413.02,,,2413.02,Other,125% New York Medicaid APG,1930.42,49538.35,
Tlh w/t/o uterus over 250 g,58573,CPT,,,,,,,,both,,,65388.32,48387.36,74,,48387.36,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,29424.74,45,,29424.74,percent of total billed charges,Medicare Ratio of cost to charges,5459,,"100% primary, 50% supplemental procedure",5459,Other,Aetna ASC Grouper,4913,,"100% primary, 50% supplemental procedure",4913,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,32367.22,49.5,,32367.22,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3590.57,,,3590.57,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,45771.82,70,,45771.82,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,1930.42,,,1930.42,Other,New York Medicaid APG methodology,1930.42,,,1930.42,Other,100% New York Medicaid APG,1930.42,,,1930.42,Other,100% New York Medicaid APG,1930.42,,,1930.42,Other,100% New York Medicaid APG,4343.43,,,4343.43,Other,225% New York Medicaid APG,2953.54,,,2953.54,Other,153% New York Medicaid APG,4343.43,,,4343.43,Other,225% New York Medicaid APG,2702.58,,,2702.58,Other,140% New York Medicaid APG,4343.43,,,4343.43,Other,225% New York Medicaid APG,5019.08,,,5019.08,Other,260% New York Medicaid APG,6254.55,,,6254.55,Other,324% New York Medicaid APG,4150.39,,,4150.39,Other,215% New York Medicaid APG,4150.39,,,4150.39,Other,215% New York Medicaid APG,2413.02,,,2413.02,Other,125% New York Medicaid APG,1930.42,48387.36,
Division of fallopian tube,58600,CPT,,,,,,,,both,,,65759.04,48661.69,74,,48661.69,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,29591.57,45,,29591.57,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,32550.72,49.5,,32550.72,percent of total billed charges,110% of Medicare,44716.15,68,,44716.15,percent of total billed charges,,2506.06,,,2506.06,Other,186% of Medicaid,52607.23,80,,52607.23,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,52607.23,80,,52607.23,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,46031.33,70,,46031.33,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1347.34,,,1347.34,Other,New York Medicaid APG methodology,1347.34,,,1347.34,Other,100% New York Medicaid APG,1347.34,,,1347.34,Other,100% New York Medicaid APG,1347.34,,,1347.34,Other,100% New York Medicaid APG,3031.52,,,3031.52,Other,225% New York Medicaid APG,2061.43,,,2061.43,Other,153% New York Medicaid APG,3031.52,,,3031.52,Other,225% New York Medicaid APG,1886.28,,,1886.28,Other,140% New York Medicaid APG,3031.52,,,3031.52,Other,225% New York Medicaid APG,3503.09,,,3503.09,Other,260% New York Medicaid APG,4365.39,,,4365.39,Other,324% New York Medicaid APG,2896.79,,,2896.79,Other,215% New York Medicaid APG,2896.79,,,2896.79,Other,215% New York Medicaid APG,1684.18,,,1684.18,Other,125% New York Medicaid APG,1347.34,52607.23,
Occlude fallopian tube(s),58615,CPT,,,,,,,,both,,,65759.04,48661.69,74,,48661.69,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,29591.57,45,,29591.57,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,32550.72,49.5,,32550.72,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2506.06,,,2506.06,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,46031.33,70,,46031.33,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1347.34,,,1347.34,Other,New York Medicaid APG methodology,1347.34,,,1347.34,Other,100% New York Medicaid APG,1347.34,,,1347.34,Other,100% New York Medicaid APG,1347.34,,,1347.34,Other,100% New York Medicaid APG,3031.52,,,3031.52,Other,225% New York Medicaid APG,2061.43,,,2061.43,Other,153% New York Medicaid APG,3031.52,,,3031.52,Other,225% New York Medicaid APG,1886.28,,,1886.28,Other,140% New York Medicaid APG,3031.52,,,3031.52,Other,225% New York Medicaid APG,3503.09,,,3503.09,Other,260% New York Medicaid APG,4365.39,,,4365.39,Other,324% New York Medicaid APG,2896.79,,,2896.79,Other,215% New York Medicaid APG,2896.79,,,2896.79,Other,215% New York Medicaid APG,1684.18,,,1684.18,Other,125% New York Medicaid APG,1347.34,48661.69,
Laparoscopy lysis,58660,CPT,,,,,,,,both,,,121364.27,89809.56,74,,89809.56,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,54613.92,45,,54613.92,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,6125,,"100% primary, 50% secondary, 25% supplemental procedure",6125,Other,Blue Cross ASC Grouper,5513,,"100% primary, 50% secondary, 25% supplemental procedure",5513,Other,Blue Cross ASC Grouper,5206,,"100% primary, 50% secondary, 25% supplemental procedure",5206,Other,Blue Cross ASC Grouper,60075.31,49.5,,60075.31,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3048.93,,,3048.93,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,84954.99,70,,84954.99,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,1639.21,,,1639.21,Other,New York Medicaid APG methodology,1639.21,,,1639.21,Other,100% New York Medicaid APG,1639.21,,,1639.21,Other,100% New York Medicaid APG,1639.21,,,1639.21,Other,100% New York Medicaid APG,3688.23,,,3688.23,Other,225% New York Medicaid APG,2507.99,,,2507.99,Other,153% New York Medicaid APG,3688.23,,,3688.23,Other,225% New York Medicaid APG,2294.9,,,2294.9,Other,140% New York Medicaid APG,3688.23,,,3688.23,Other,225% New York Medicaid APG,4261.95,,,4261.95,Other,260% New York Medicaid APG,5311.05,,,5311.05,Other,324% New York Medicaid APG,3524.31,,,3524.31,Other,215% New York Medicaid APG,3524.31,,,3524.31,Other,215% New York Medicaid APG,2049.02,,,2049.02,Other,125% New York Medicaid APG,1639.21,89809.56,
Laparoscopy remove adnexa,58661,CPT,,,,,,,,both,,,47043.3,34812.04,74,,34812.04,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,21169.49,45,,21169.49,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,6125,,"100% primary, 50% secondary, 25% supplemental procedure",6125,Other,Blue Cross ASC Grouper,5513,,"100% primary, 50% secondary, 25% supplemental procedure",5513,Other,Blue Cross ASC Grouper,5206,,"100% primary, 50% secondary, 25% supplemental procedure",5206,Other,Blue Cross ASC Grouper,23286.43,49.5,,23286.43,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3048.93,,,3048.93,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,32930.31,70,,32930.31,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,1639.21,,,1639.21,Other,New York Medicaid APG methodology,1639.21,,,1639.21,Other,100% New York Medicaid APG,1639.21,,,1639.21,Other,100% New York Medicaid APG,1639.21,,,1639.21,Other,100% New York Medicaid APG,3688.23,,,3688.23,Other,225% New York Medicaid APG,2507.99,,,2507.99,Other,153% New York Medicaid APG,3688.23,,,3688.23,Other,225% New York Medicaid APG,2294.9,,,2294.9,Other,140% New York Medicaid APG,3688.23,,,3688.23,Other,225% New York Medicaid APG,4261.95,,,4261.95,Other,260% New York Medicaid APG,5311.05,,,5311.05,Other,324% New York Medicaid APG,3524.31,,,3524.31,Other,215% New York Medicaid APG,3524.31,,,3524.31,Other,215% New York Medicaid APG,2049.02,,,2049.02,Other,125% New York Medicaid APG,1639.21,34812.04,
Laparoscopy excise lesions,58662,CPT,,,,,,,,both,,,51210.47,37895.75,74,,37895.75,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,23044.71,45,,23044.71,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,6125,,"100% primary, 50% secondary, 25% supplemental procedure",6125,Other,Blue Cross ASC Grouper,5513,,"100% primary, 50% secondary, 25% supplemental procedure",5513,Other,Blue Cross ASC Grouper,5206,,"100% primary, 50% secondary, 25% supplemental procedure",5206,Other,Blue Cross ASC Grouper,25349.18,49.5,,25349.18,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3048.93,,,3048.93,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,35847.33,70,,35847.33,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,1639.21,,,1639.21,Other,New York Medicaid APG methodology,1639.21,,,1639.21,Other,100% New York Medicaid APG,1639.21,,,1639.21,Other,100% New York Medicaid APG,1639.21,,,1639.21,Other,100% New York Medicaid APG,3688.23,,,3688.23,Other,225% New York Medicaid APG,2507.99,,,2507.99,Other,153% New York Medicaid APG,3688.23,,,3688.23,Other,225% New York Medicaid APG,2294.9,,,2294.9,Other,140% New York Medicaid APG,3688.23,,,3688.23,Other,225% New York Medicaid APG,4261.95,,,4261.95,Other,260% New York Medicaid APG,5311.05,,,5311.05,Other,324% New York Medicaid APG,3524.31,,,3524.31,Other,215% New York Medicaid APG,3524.31,,,3524.31,Other,215% New York Medicaid APG,2049.02,,,2049.02,Other,125% New York Medicaid APG,1639.21,37895.75,
Laparoscopy tubal cautery,58670,CPT,,,,,,,,both,,,40404.53,29899.35,74,,29899.35,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,18182.04,45,,18182.04,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,6125,,"100% primary, 50% secondary, 25% supplemental procedure",6125,Other,Blue Cross ASC Grouper,5513,,"100% primary, 50% secondary, 25% supplemental procedure",5513,Other,Blue Cross ASC Grouper,5206,,"100% primary, 50% secondary, 25% supplemental procedure",5206,Other,Blue Cross ASC Grouper,20000.24,49.5,,20000.24,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3048.93,,,3048.93,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,28283.17,70,,28283.17,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,1639.21,,,1639.21,Other,New York Medicaid APG methodology,1639.21,,,1639.21,Other,100% New York Medicaid APG,1639.21,,,1639.21,Other,100% New York Medicaid APG,1639.21,,,1639.21,Other,100% New York Medicaid APG,3688.23,,,3688.23,Other,225% New York Medicaid APG,2507.99,,,2507.99,Other,153% New York Medicaid APG,3688.23,,,3688.23,Other,225% New York Medicaid APG,2294.9,,,2294.9,Other,140% New York Medicaid APG,3688.23,,,3688.23,Other,225% New York Medicaid APG,4261.95,,,4261.95,Other,260% New York Medicaid APG,5311.05,,,5311.05,Other,324% New York Medicaid APG,3524.31,,,3524.31,Other,215% New York Medicaid APG,3524.31,,,3524.31,Other,215% New York Medicaid APG,2049.02,,,2049.02,Other,125% New York Medicaid APG,1639.21,29899.35,
Laparoscopy tubal block,58671,CPT,,,,,,,,both,,,121364.27,89809.56,74,,89809.56,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,54613.92,45,,54613.92,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,6125,,"100% primary, 50% secondary, 25% supplemental procedure",6125,Other,Blue Cross ASC Grouper,5513,,"100% primary, 50% secondary, 25% supplemental procedure",5513,Other,Blue Cross ASC Grouper,5206,,"100% primary, 50% secondary, 25% supplemental procedure",5206,Other,Blue Cross ASC Grouper,60075.31,49.5,,60075.31,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3048.93,,,3048.93,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,84954.99,70,,84954.99,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,1639.21,,,1639.21,Other,New York Medicaid APG methodology,1639.21,,,1639.21,Other,100% New York Medicaid APG,1639.21,,,1639.21,Other,100% New York Medicaid APG,1639.21,,,1639.21,Other,100% New York Medicaid APG,3688.23,,,3688.23,Other,225% New York Medicaid APG,2507.99,,,2507.99,Other,153% New York Medicaid APG,3688.23,,,3688.23,Other,225% New York Medicaid APG,2294.9,,,2294.9,Other,140% New York Medicaid APG,3688.23,,,3688.23,Other,225% New York Medicaid APG,4261.95,,,4261.95,Other,260% New York Medicaid APG,5311.05,,,5311.05,Other,324% New York Medicaid APG,3524.31,,,3524.31,Other,215% New York Medicaid APG,3524.31,,,3524.31,Other,215% New York Medicaid APG,2049.02,,,2049.02,Other,125% New York Medicaid APG,1639.21,89809.56,
Laparoscopy fimbrioplasty,58672,CPT,,,,,,,,both,,,121364.27,89809.56,74,,89809.56,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,54613.92,45,,54613.92,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,6125,,"100% primary, 50% secondary, 25% supplemental procedure",6125,Other,Blue Cross ASC Grouper,5513,,"100% primary, 50% secondary, 25% supplemental procedure",5513,Other,Blue Cross ASC Grouper,5206,,"100% primary, 50% secondary, 25% supplemental procedure",5206,Other,Blue Cross ASC Grouper,60075.31,49.5,,60075.31,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3048.93,,,3048.93,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,84954.99,70,,84954.99,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,1639.21,,,1639.21,Other,New York Medicaid APG methodology,1639.21,,,1639.21,Other,100% New York Medicaid APG,1639.21,,,1639.21,Other,100% New York Medicaid APG,1639.21,,,1639.21,Other,100% New York Medicaid APG,3688.23,,,3688.23,Other,225% New York Medicaid APG,2507.99,,,2507.99,Other,153% New York Medicaid APG,3688.23,,,3688.23,Other,225% New York Medicaid APG,2294.9,,,2294.9,Other,140% New York Medicaid APG,3688.23,,,3688.23,Other,225% New York Medicaid APG,4261.95,,,4261.95,Other,260% New York Medicaid APG,5311.05,,,5311.05,Other,324% New York Medicaid APG,3524.31,,,3524.31,Other,215% New York Medicaid APG,3524.31,,,3524.31,Other,215% New York Medicaid APG,2049.02,,,2049.02,Other,125% New York Medicaid APG,1639.21,89809.56,
Laparoscopy salpingostomy,58673,CPT,,,,,,,,both,,,216515.17,160221.23,74,,160221.23,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,97431.83,45,,97431.83,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,6125,,"100% primary, 50% secondary, 25% supplemental procedure",6125,Other,Blue Cross ASC Grouper,5513,,"100% primary, 50% secondary, 25% supplemental procedure",5513,Other,Blue Cross ASC Grouper,5206,,"100% primary, 50% secondary, 25% supplemental procedure",5206,Other,Blue Cross ASC Grouper,107175.01,49.5,,107175.01,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3048.93,,,3048.93,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,151560.62,70,,151560.62,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,1639.21,,,1639.21,Other,New York Medicaid APG methodology,1639.21,,,1639.21,Other,100% New York Medicaid APG,1639.21,,,1639.21,Other,100% New York Medicaid APG,1639.21,,,1639.21,Other,100% New York Medicaid APG,3688.23,,,3688.23,Other,225% New York Medicaid APG,2507.99,,,2507.99,Other,153% New York Medicaid APG,3688.23,,,3688.23,Other,225% New York Medicaid APG,2294.9,,,2294.9,Other,140% New York Medicaid APG,3688.23,,,3688.23,Other,225% New York Medicaid APG,4261.95,,,4261.95,Other,260% New York Medicaid APG,5311.05,,,5311.05,Other,324% New York Medicaid APG,3524.31,,,3524.31,Other,215% New York Medicaid APG,3524.31,,,3524.31,Other,215% New York Medicaid APG,2049.02,,,2049.02,Other,125% New York Medicaid APG,1639.21,160221.23,
Laps abltj uterine fibroids,58674,CPT,,,,,,,,both,,,216515.17,160221.23,74,,160221.23,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,97431.83,45,,97431.83,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,107175.01,49.5,,107175.01,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3590.57,,,3590.57,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,151560.62,70,,151560.62,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,1930.42,,,1930.42,Other,New York Medicaid APG methodology,1930.42,,,1930.42,Other,100% New York Medicaid APG,1930.42,,,1930.42,Other,100% New York Medicaid APG,1930.42,,,1930.42,Other,100% New York Medicaid APG,4343.43,,,4343.43,Other,225% New York Medicaid APG,2953.54,,,2953.54,Other,153% New York Medicaid APG,4343.43,,,4343.43,Other,225% New York Medicaid APG,2702.58,,,2702.58,Other,140% New York Medicaid APG,4343.43,,,4343.43,Other,225% New York Medicaid APG,5019.08,,,5019.08,Other,260% New York Medicaid APG,6254.55,,,6254.55,Other,324% New York Medicaid APG,4150.39,,,4150.39,Other,215% New York Medicaid APG,4150.39,,,4150.39,Other,215% New York Medicaid APG,2413.02,,,2413.02,Other,125% New York Medicaid APG,1930.42,160221.23,
Create new tubal opening,58770,CPT,,,,,,,,both,,,65759.04,48661.69,74,,48661.69,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,29591.57,45,,29591.57,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,32550.72,49.5,,32550.72,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2506.06,,,2506.06,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,46031.33,70,,46031.33,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1347.34,,,1347.34,Other,New York Medicaid APG methodology,1347.34,,,1347.34,Other,100% New York Medicaid APG,1347.34,,,1347.34,Other,100% New York Medicaid APG,1347.34,,,1347.34,Other,100% New York Medicaid APG,3031.52,,,3031.52,Other,225% New York Medicaid APG,2061.43,,,2061.43,Other,153% New York Medicaid APG,3031.52,,,3031.52,Other,225% New York Medicaid APG,1886.28,,,1886.28,Other,140% New York Medicaid APG,3031.52,,,3031.52,Other,225% New York Medicaid APG,3503.09,,,3503.09,Other,260% New York Medicaid APG,4365.39,,,4365.39,Other,324% New York Medicaid APG,2896.79,,,2896.79,Other,215% New York Medicaid APG,2896.79,,,2896.79,Other,215% New York Medicaid APG,1684.18,,,1684.18,Other,125% New York Medicaid APG,1347.34,48661.69,
Drainage of ovarian cyst(s),58800,CPT,,,,,,,,both,,,65759.04,48661.69,74,,48661.69,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,29591.57,45,,29591.57,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,32550.72,49.5,,32550.72,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2506.06,,,2506.06,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,46031.33,70,,46031.33,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1347.34,,,1347.34,Other,New York Medicaid APG methodology,1347.34,,,1347.34,Other,100% New York Medicaid APG,1347.34,,,1347.34,Other,100% New York Medicaid APG,1347.34,,,1347.34,Other,100% New York Medicaid APG,3031.52,,,3031.52,Other,225% New York Medicaid APG,2061.43,,,2061.43,Other,153% New York Medicaid APG,3031.52,,,3031.52,Other,225% New York Medicaid APG,1886.28,,,1886.28,Other,140% New York Medicaid APG,3031.52,,,3031.52,Other,225% New York Medicaid APG,3503.09,,,3503.09,Other,260% New York Medicaid APG,4365.39,,,4365.39,Other,324% New York Medicaid APG,2896.79,,,2896.79,Other,215% New York Medicaid APG,2896.79,,,2896.79,Other,215% New York Medicaid APG,1684.18,,,1684.18,Other,125% New York Medicaid APG,1347.34,48661.69,
Drainage of ovarian cyst(s),58805,CPT,,,,,,,,both,,,65759.04,48661.69,74,,48661.69,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,29591.57,45,,29591.57,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,32550.72,49.5,,32550.72,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2506.06,,,2506.06,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,46031.33,70,,46031.33,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1347.34,,,1347.34,Other,New York Medicaid APG methodology,1347.34,,,1347.34,Other,100% New York Medicaid APG,1347.34,,,1347.34,Other,100% New York Medicaid APG,1347.34,,,1347.34,Other,100% New York Medicaid APG,3031.52,,,3031.52,Other,225% New York Medicaid APG,2061.43,,,2061.43,Other,153% New York Medicaid APG,3031.52,,,3031.52,Other,225% New York Medicaid APG,1886.28,,,1886.28,Other,140% New York Medicaid APG,3031.52,,,3031.52,Other,225% New York Medicaid APG,3503.09,,,3503.09,Other,260% New York Medicaid APG,4365.39,,,4365.39,Other,324% New York Medicaid APG,2896.79,,,2896.79,Other,215% New York Medicaid APG,2896.79,,,2896.79,Other,215% New York Medicaid APG,1684.18,,,1684.18,Other,125% New York Medicaid APG,1347.34,48661.69,
Drain ovary abscess open,58820,CPT,,,,,,,,both,,,65759.04,48661.69,74,,48661.69,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,29591.57,45,,29591.57,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,32550.72,49.5,,32550.72,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2506.06,,,2506.06,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,46031.33,70,,46031.33,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1347.34,,,1347.34,Other,New York Medicaid APG methodology,1347.34,,,1347.34,Other,100% New York Medicaid APG,1347.34,,,1347.34,Other,100% New York Medicaid APG,1347.34,,,1347.34,Other,100% New York Medicaid APG,3031.52,,,3031.52,Other,225% New York Medicaid APG,2061.43,,,2061.43,Other,153% New York Medicaid APG,3031.52,,,3031.52,Other,225% New York Medicaid APG,1886.28,,,1886.28,Other,140% New York Medicaid APG,3031.52,,,3031.52,Other,225% New York Medicaid APG,3503.09,,,3503.09,Other,260% New York Medicaid APG,4365.39,,,4365.39,Other,324% New York Medicaid APG,2896.79,,,2896.79,Other,215% New York Medicaid APG,2896.79,,,2896.79,Other,215% New York Medicaid APG,1684.18,,,1684.18,Other,125% New York Medicaid APG,1347.34,48661.69,
Biopsy of ovary(s),58900,CPT,,,,,,,,both,,,65759.04,48661.69,74,,48661.69,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,29591.57,45,,29591.57,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,32550.72,49.5,,32550.72,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2506.06,,,2506.06,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,46031.33,70,,46031.33,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1347.34,,,1347.34,Other,New York Medicaid APG methodology,1347.34,,,1347.34,Other,100% New York Medicaid APG,1347.34,,,1347.34,Other,100% New York Medicaid APG,1347.34,,,1347.34,Other,100% New York Medicaid APG,3031.52,,,3031.52,Other,225% New York Medicaid APG,2061.43,,,2061.43,Other,153% New York Medicaid APG,3031.52,,,3031.52,Other,225% New York Medicaid APG,1886.28,,,1886.28,Other,140% New York Medicaid APG,3031.52,,,3031.52,Other,225% New York Medicaid APG,3503.09,,,3503.09,Other,260% New York Medicaid APG,4365.39,,,4365.39,Other,324% New York Medicaid APG,2896.79,,,2896.79,Other,215% New York Medicaid APG,2896.79,,,2896.79,Other,215% New York Medicaid APG,1684.18,,,1684.18,Other,125% New York Medicaid APG,1347.34,48661.69,
Partial removal of ovary(s),58920,CPT,,,,,,,,both,,,158942.1,117617.15,74,,117617.15,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,71523.95,45,,71523.95,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,78676.34,49.5,,78676.34,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3048.93,,,3048.93,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,111259.47,70,,111259.47,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1639.21,,,1639.21,Other,New York Medicaid APG methodology,1639.21,,,1639.21,Other,100% New York Medicaid APG,1639.21,,,1639.21,Other,100% New York Medicaid APG,1639.21,,,1639.21,Other,100% New York Medicaid APG,3688.23,,,3688.23,Other,225% New York Medicaid APG,2507.99,,,2507.99,Other,153% New York Medicaid APG,3688.23,,,3688.23,Other,225% New York Medicaid APG,2294.9,,,2294.9,Other,140% New York Medicaid APG,3688.23,,,3688.23,Other,225% New York Medicaid APG,4261.95,,,4261.95,Other,260% New York Medicaid APG,5311.05,,,5311.05,Other,324% New York Medicaid APG,3524.31,,,3524.31,Other,215% New York Medicaid APG,3524.31,,,3524.31,Other,215% New York Medicaid APG,2049.02,,,2049.02,Other,125% New York Medicaid APG,1639.21,117617.15,
Removal of ovarian cyst(s),58925,CPT,,,,,,,,both,,,42664.12,31571.45,74,,31571.45,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,19198.85,45,,19198.85,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,21118.74,49.5,,21118.74,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3048.93,,,3048.93,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,29864.88,70,,29864.88,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1639.21,,,1639.21,Other,New York Medicaid APG methodology,1639.21,,,1639.21,Other,100% New York Medicaid APG,1639.21,,,1639.21,Other,100% New York Medicaid APG,1639.21,,,1639.21,Other,100% New York Medicaid APG,3688.23,,,3688.23,Other,225% New York Medicaid APG,2507.99,,,2507.99,Other,153% New York Medicaid APG,3688.23,,,3688.23,Other,225% New York Medicaid APG,2294.9,,,2294.9,Other,140% New York Medicaid APG,3688.23,,,3688.23,Other,225% New York Medicaid APG,4261.95,,,4261.95,Other,260% New York Medicaid APG,5311.05,,,5311.05,Other,324% New York Medicaid APG,3524.31,,,3524.31,Other,215% New York Medicaid APG,3524.31,,,3524.31,Other,215% New York Medicaid APG,2049.02,,,2049.02,Other,125% New York Medicaid APG,1639.21,31571.45,
Retrieval of oocyte,58970,CPT,,,,,,,,both,,,16909.26,12512.85,74,,12512.85,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,7609.17,45,,7609.17,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,8370.08,49.5,,8370.08,percent of total billed charges,110% of Medicare,11498.3,68,,11498.3,percent of total billed charges,,0.02,,,0.02,Other,186% of Medicaid,13527.41,80,,13527.41,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,13527.41,80,,13527.41,percent of total billed charges,,7216,,,7216,Case Rate,,3578,,"100% primary, 0% secondary procedures",3578,Other,MagnaCare ASC Grouper,11836.48,70,,11836.48,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% New York Medicaid APG,0.01,,,0.01,Other,100% New York Medicaid APG,0.01,,,0.01,Other,100% New York Medicaid APG,0.02,,,0.02,Other,225% New York Medicaid APG,0.02,,,0.02,Other,153% New York Medicaid APG,0.02,,,0.02,Other,225% New York Medicaid APG,0.01,,,0.01,Other,140% New York Medicaid APG,0.02,,,0.02,Other,225% New York Medicaid APG,0.03,,,0.03,Other,260% New York Medicaid APG,0.03,,,0.03,Other,324% New York Medicaid APG,0.02,,,0.02,Other,215% New York Medicaid APG,0.02,,,0.02,Other,215% New York Medicaid APG,0.01,,,0.01,Other,125% New York Medicaid APG,0.01,13527.41,
Transfer of embryo,58974,CPT,,,,,,,,both,,,16909.26,12512.85,74,,12512.85,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,7609.17,45,,7609.17,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,8370.08,49.5,,8370.08,percent of total billed charges,110% of Medicare,11498.3,68,,11498.3,percent of total billed charges,,0.02,,,0.02,Other,186% of Medicaid,13527.41,80,,13527.41,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,13527.41,80,,13527.41,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,11836.48,70,,11836.48,percent of total billed charges,,10991.02,65,,10991.02,percent of total billed charges,,10991.02,65,,10991.02,percent of total billed charges,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% New York Medicaid APG,0.01,,,0.01,Other,100% New York Medicaid APG,0.01,,,0.01,Other,100% New York Medicaid APG,0.02,,,0.02,Other,225% New York Medicaid APG,0.02,,,0.02,Other,153% New York Medicaid APG,0.02,,,0.02,Other,225% New York Medicaid APG,0.01,,,0.01,Other,140% New York Medicaid APG,0.02,,,0.02,Other,225% New York Medicaid APG,0.03,,,0.03,Other,260% New York Medicaid APG,0.03,,,0.03,Other,324% New York Medicaid APG,0.02,,,0.02,Other,215% New York Medicaid APG,0.02,,,0.02,Other,215% New York Medicaid APG,0.01,,,0.01,Other,125% New York Medicaid APG,0.01,13527.41,
Transfer of embryo,58976,CPT,,,,,,,,both,,,6747.72,4993.31,74,,4993.31,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,3036.47,45,,3036.47,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,3340.12,49.5,,3340.12,percent of total billed charges,110% of Medicare,4588.45,68,,4588.45,percent of total billed charges,,0.02,,,0.02,Other,186% of Medicaid,5398.18,80,,5398.18,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,5398.18,80,,5398.18,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,4723.4,70,,4723.4,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% New York Medicaid APG,0.01,,,0.01,Other,100% New York Medicaid APG,0.01,,,0.01,Other,100% New York Medicaid APG,0.02,,,0.02,Other,225% New York Medicaid APG,0.02,,,0.02,Other,153% New York Medicaid APG,0.02,,,0.02,Other,225% New York Medicaid APG,0.01,,,0.01,Other,140% New York Medicaid APG,0.02,,,0.02,Other,225% New York Medicaid APG,0.03,,,0.03,Other,260% New York Medicaid APG,0.03,,,0.03,Other,324% New York Medicaid APG,0.02,,,0.02,Other,215% New York Medicaid APG,0.02,,,0.02,Other,215% New York Medicaid APG,0.01,,,0.01,Other,125% New York Medicaid APG,0.01,7216,
Amniocentesis diagnostic,59000,CPT,,,,,,,,both,,,16909.26,12512.85,74,,12512.85,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,7609.17,45,,7609.17,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,8370.08,49.5,,8370.08,percent of total billed charges,110% of Medicare,11498.3,68,,11498.3,percent of total billed charges,,1453.49,,,1453.49,Other,186% of Medicaid,13527.41,80,,13527.41,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,13527.41,80,,13527.41,percent of total billed charges,,7216,,,7216,Case Rate,,3578,,"100% primary, 0% secondary procedures",3578,Other,MagnaCare ASC Grouper,11836.48,70,,11836.48,percent of total billed charges,,393.6,,,393.6,Fee Schedule,,333.6,,,333.6,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,781.45,,,781.45,Other,New York Medicaid APG methodology,781.45,,,781.45,Other,100% New York Medicaid APG,781.45,,,781.45,Other,100% New York Medicaid APG,781.45,,,781.45,Other,100% New York Medicaid APG,1758.26,,,1758.26,Other,225% New York Medicaid APG,1195.62,,,1195.62,Other,153% New York Medicaid APG,1758.26,,,1758.26,Other,225% New York Medicaid APG,1094.03,,,1094.03,Other,140% New York Medicaid APG,1758.26,,,1758.26,Other,225% New York Medicaid APG,2031.76,,,2031.76,Other,260% New York Medicaid APG,2531.89,,,2531.89,Other,324% New York Medicaid APG,1680.11,,,1680.11,Other,215% New York Medicaid APG,1680.11,,,1680.11,Other,215% New York Medicaid APG,976.81,,,976.81,Other,125% New York Medicaid APG,333.6,13527.41,
Amniocentesis therapeutic,59001,CPT,,,,,,,,both,,,6747.72,4993.31,74,,4993.31,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,3036.47,45,,3036.47,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,3340.12,49.5,,3340.12,percent of total billed charges,110% of Medicare,4588.45,68,,4588.45,percent of total billed charges,,1453.49,,,1453.49,Other,186% of Medicaid,5398.18,80,,5398.18,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,5398.18,80,,5398.18,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,4723.4,70,,4723.4,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,781.45,,,781.45,Other,New York Medicaid APG methodology,781.45,,,781.45,Other,100% New York Medicaid APG,781.45,,,781.45,Other,100% New York Medicaid APG,781.45,,,781.45,Other,100% New York Medicaid APG,1758.26,,,1758.26,Other,225% New York Medicaid APG,1195.62,,,1195.62,Other,153% New York Medicaid APG,1758.26,,,1758.26,Other,225% New York Medicaid APG,1094.03,,,1094.03,Other,140% New York Medicaid APG,1758.26,,,1758.26,Other,225% New York Medicaid APG,2031.76,,,2031.76,Other,260% New York Medicaid APG,2531.89,,,2531.89,Other,324% New York Medicaid APG,1680.11,,,1680.11,Other,215% New York Medicaid APG,1680.11,,,1680.11,Other,215% New York Medicaid APG,976.81,,,976.81,Other,125% New York Medicaid APG,781.45,7216,
Fetal cord puncture prenatal,59012,CPT,,,,,,,,both,,,6747.72,4993.31,74,,4993.31,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,3036.47,45,,3036.47,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,3340.12,49.5,,3340.12,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,1453.49,,,1453.49,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,4723.4,70,,4723.4,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,781.45,,,781.45,Other,New York Medicaid APG methodology,781.45,,,781.45,Other,100% New York Medicaid APG,781.45,,,781.45,Other,100% New York Medicaid APG,781.45,,,781.45,Other,100% New York Medicaid APG,1758.26,,,1758.26,Other,225% New York Medicaid APG,1195.62,,,1195.62,Other,153% New York Medicaid APG,1758.26,,,1758.26,Other,225% New York Medicaid APG,1094.03,,,1094.03,Other,140% New York Medicaid APG,1758.26,,,1758.26,Other,225% New York Medicaid APG,2031.76,,,2031.76,Other,260% New York Medicaid APG,2531.89,,,2531.89,Other,324% New York Medicaid APG,1680.11,,,1680.11,Other,215% New York Medicaid APG,1680.11,,,1680.11,Other,215% New York Medicaid APG,976.81,,,976.81,Other,125% New York Medicaid APG,781.45,9473,
Chorion biopsy,59015,CPT,,,,,,,,both,,,16909.26,12512.85,74,,12512.85,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,7609.17,45,,7609.17,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,8370.08,49.5,,8370.08,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,1453.49,,,1453.49,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,3578,,"100% primary, 0% secondary procedures",3578,Other,MagnaCare ASC Grouper,11836.48,70,,11836.48,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,781.45,,,781.45,Other,New York Medicaid APG methodology,781.45,,,781.45,Other,100% New York Medicaid APG,781.45,,,781.45,Other,100% New York Medicaid APG,781.45,,,781.45,Other,100% New York Medicaid APG,1758.26,,,1758.26,Other,225% New York Medicaid APG,1195.62,,,1195.62,Other,153% New York Medicaid APG,1758.26,,,1758.26,Other,225% New York Medicaid APG,1094.03,,,1094.03,Other,140% New York Medicaid APG,1758.26,,,1758.26,Other,225% New York Medicaid APG,2031.76,,,2031.76,Other,260% New York Medicaid APG,2531.89,,,2531.89,Other,324% New York Medicaid APG,1680.11,,,1680.11,Other,215% New York Medicaid APG,1680.11,,,1680.11,Other,215% New York Medicaid APG,976.81,,,976.81,Other,125% New York Medicaid APG,781.45,12512.85,
Fetal contract stress test,59020,CPT,,,,,,,,both,,,4191.33,3101.58,74,,3101.58,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,1886.1,45,,1886.1,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,2074.71,49.5,,2074.71,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,594.18,,,594.18,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,2933.93,70,,2933.93,percent of total billed charges,,2724.36,65,,2724.36,percent of total billed charges,,2724.36,65,,2724.36,percent of total billed charges,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,319.45,,,319.45,Other,New York Medicaid APG methodology,319.45,,,319.45,Other,100% New York Medicaid APG,319.45,,,319.45,Other,100% New York Medicaid APG,319.45,,,319.45,Other,100% New York Medicaid APG,718.76,,,718.76,Other,225% New York Medicaid APG,488.76,,,488.76,Other,153% New York Medicaid APG,718.76,,,718.76,Other,225% New York Medicaid APG,447.23,,,447.23,Other,140% New York Medicaid APG,718.76,,,718.76,Other,225% New York Medicaid APG,830.57,,,830.57,Other,260% New York Medicaid APG,1035.02,,,1035.02,Other,324% New York Medicaid APG,686.82,,,686.82,Other,215% New York Medicaid APG,686.82,,,686.82,Other,215% New York Medicaid APG,399.31,,,399.31,Other,125% New York Medicaid APG,319.45,9473,
Fetal non-stress test,59025,CPT,,,,,,,,both,,,4191.33,3101.58,74,,3101.58,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,1886.1,45,,1886.1,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,116.78,,,116.78,Fee Schedule,,105.04,,,105.04,Fee Schedule,,99.28,,,99.28,Fee Schedule,,2074.71,49.5,,2074.71,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,594.18,,,594.18,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,2933.93,70,,2933.93,percent of total billed charges,,2724.36,65,,2724.36,percent of total billed charges,,2724.36,65,,2724.36,percent of total billed charges,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,319.45,,,319.45,Other,New York Medicaid APG methodology,319.45,,,319.45,Other,100% New York Medicaid APG,319.45,,,319.45,Other,100% New York Medicaid APG,319.45,,,319.45,Other,100% New York Medicaid APG,718.76,,,718.76,Other,225% New York Medicaid APG,488.76,,,488.76,Other,153% New York Medicaid APG,718.76,,,718.76,Other,225% New York Medicaid APG,447.23,,,447.23,Other,140% New York Medicaid APG,718.76,,,718.76,Other,225% New York Medicaid APG,830.57,,,830.57,Other,260% New York Medicaid APG,1035.02,,,1035.02,Other,324% New York Medicaid APG,686.82,,,686.82,Other,215% New York Medicaid APG,686.82,,,686.82,Other,215% New York Medicaid APG,399.31,,,399.31,Other,125% New York Medicaid APG,99.28,9473,
Fetal scalp blood sample,59030,CPT,,,,,,,,both,,,6747.72,4993.31,74,,4993.31,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,3036.47,45,,3036.47,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,3340.12,49.5,,3340.12,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,594.18,,,594.18,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,4723.4,70,,4723.4,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,319.45,,,319.45,Other,New York Medicaid APG methodology,319.45,,,319.45,Other,100% New York Medicaid APG,319.45,,,319.45,Other,100% New York Medicaid APG,319.45,,,319.45,Other,100% New York Medicaid APG,718.76,,,718.76,Other,225% New York Medicaid APG,488.76,,,488.76,Other,153% New York Medicaid APG,718.76,,,718.76,Other,225% New York Medicaid APG,447.23,,,447.23,Other,140% New York Medicaid APG,718.76,,,718.76,Other,225% New York Medicaid APG,830.57,,,830.57,Other,260% New York Medicaid APG,1035.02,,,1035.02,Other,324% New York Medicaid APG,686.82,,,686.82,Other,215% New York Medicaid APG,686.82,,,686.82,Other,215% New York Medicaid APG,399.31,,,399.31,Other,125% New York Medicaid APG,319.45,9473,
Transabdom amnioinfus w/us,59070,CPT,,,,,,,,both,,,6747.72,4993.31,74,,4993.31,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,3036.47,45,,3036.47,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,3340.12,49.5,,3340.12,percent of total billed charges,110% of Medicare,4588.45,68,,4588.45,percent of total billed charges,,1453.49,,,1453.49,Other,186% of Medicaid,5398.18,80,,5398.18,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,5398.18,80,,5398.18,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,4723.4,70,,4723.4,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,781.45,,,781.45,Other,New York Medicaid APG methodology,781.45,,,781.45,Other,100% New York Medicaid APG,781.45,,,781.45,Other,100% New York Medicaid APG,781.45,,,781.45,Other,100% New York Medicaid APG,1758.26,,,1758.26,Other,225% New York Medicaid APG,1195.62,,,1195.62,Other,153% New York Medicaid APG,1758.26,,,1758.26,Other,225% New York Medicaid APG,1094.03,,,1094.03,Other,140% New York Medicaid APG,1758.26,,,1758.26,Other,225% New York Medicaid APG,2031.76,,,2031.76,Other,260% New York Medicaid APG,2531.89,,,2531.89,Other,324% New York Medicaid APG,1680.11,,,1680.11,Other,215% New York Medicaid APG,1680.11,,,1680.11,Other,215% New York Medicaid APG,976.81,,,976.81,Other,125% New York Medicaid APG,781.45,7216,
Umbilical cord occlud w/us,59072,CPT,,,,,,,,both,,,6747.72,4993.31,74,,4993.31,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,3036.47,45,,3036.47,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,3340.12,49.5,,3340.12,percent of total billed charges,110% of Medicare,4588.45,68,,4588.45,percent of total billed charges,,1376.72,,,1376.72,Other,186% of Medicaid,5398.18,80,,5398.18,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,5398.18,80,,5398.18,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,4723.4,70,,4723.4,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,740.17,,,740.17,Other,New York Medicaid APG methodology,740.17,,,740.17,Other,100% New York Medicaid APG,740.17,,,740.17,Other,100% New York Medicaid APG,740.17,,,740.17,Other,100% New York Medicaid APG,1665.39,,,1665.39,Other,225% New York Medicaid APG,1132.46,,,1132.46,Other,153% New York Medicaid APG,1665.39,,,1665.39,Other,225% New York Medicaid APG,1036.24,,,1036.24,Other,140% New York Medicaid APG,1665.39,,,1665.39,Other,225% New York Medicaid APG,1924.45,,,1924.45,Other,260% New York Medicaid APG,2398.16,,,2398.16,Other,324% New York Medicaid APG,1591.37,,,1591.37,Other,215% New York Medicaid APG,1591.37,,,1591.37,Other,215% New York Medicaid APG,925.21,,,925.21,Other,125% New York Medicaid APG,740.17,7216,
Fetal fluid drainage w/us,59074,CPT,,,,,,,,both,,,6747.72,4993.31,74,,4993.31,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,3036.47,45,,3036.47,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,3340.12,49.5,,3340.12,percent of total billed charges,110% of Medicare,4588.45,68,,4588.45,percent of total billed charges,,594.18,,,594.18,Other,186% of Medicaid,5398.18,80,,5398.18,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,5398.18,80,,5398.18,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,4723.4,70,,4723.4,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,319.45,,,319.45,Other,New York Medicaid APG methodology,319.45,,,319.45,Other,100% New York Medicaid APG,319.45,,,319.45,Other,100% New York Medicaid APG,319.45,,,319.45,Other,100% New York Medicaid APG,718.76,,,718.76,Other,225% New York Medicaid APG,488.76,,,488.76,Other,153% New York Medicaid APG,718.76,,,718.76,Other,225% New York Medicaid APG,447.23,,,447.23,Other,140% New York Medicaid APG,718.76,,,718.76,Other,225% New York Medicaid APG,830.57,,,830.57,Other,260% New York Medicaid APG,1035.02,,,1035.02,Other,324% New York Medicaid APG,686.82,,,686.82,Other,215% New York Medicaid APG,686.82,,,686.82,Other,215% New York Medicaid APG,399.31,,,399.31,Other,125% New York Medicaid APG,319.45,7216,
Fetal shunt placement w/us,59076,CPT,,,,,,,,both,,,6747.72,4993.31,74,,4993.31,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,3036.47,45,,3036.47,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,3340.12,49.5,,3340.12,percent of total billed charges,110% of Medicare,4588.45,68,,4588.45,percent of total billed charges,,1376.72,,,1376.72,Other,186% of Medicaid,5398.18,80,,5398.18,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,5398.18,80,,5398.18,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,4723.4,70,,4723.4,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,740.17,,,740.17,Other,New York Medicaid APG methodology,740.17,,,740.17,Other,100% New York Medicaid APG,740.17,,,740.17,Other,100% New York Medicaid APG,740.17,,,740.17,Other,100% New York Medicaid APG,1665.39,,,1665.39,Other,225% New York Medicaid APG,1132.46,,,1132.46,Other,153% New York Medicaid APG,1665.39,,,1665.39,Other,225% New York Medicaid APG,1036.24,,,1036.24,Other,140% New York Medicaid APG,1665.39,,,1665.39,Other,225% New York Medicaid APG,1924.45,,,1924.45,Other,260% New York Medicaid APG,2398.16,,,2398.16,Other,324% New York Medicaid APG,1591.37,,,1591.37,Other,215% New York Medicaid APG,1591.37,,,1591.37,Other,215% New York Medicaid APG,925.21,,,925.21,Other,125% New York Medicaid APG,740.17,7216,
Remove uterus lesion,59100,CPT,,,,,,,,both,,,104619.92,77418.74,74,,77418.74,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,47078.96,45,,47078.96,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,51786.86,49.5,,51786.86,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2860.37,,,2860.37,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,73233.94,70,,73233.94,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1537.83,,,1537.83,Other,New York Medicaid APG methodology,1537.83,,,1537.83,Other,100% New York Medicaid APG,1537.83,,,1537.83,Other,100% New York Medicaid APG,1537.83,,,1537.83,Other,100% New York Medicaid APG,3460.12,,,3460.12,Other,225% New York Medicaid APG,2352.88,,,2352.88,Other,153% New York Medicaid APG,3460.12,,,3460.12,Other,225% New York Medicaid APG,2152.96,,,2152.96,Other,140% New York Medicaid APG,3460.12,,,3460.12,Other,225% New York Medicaid APG,3998.36,,,3998.36,Other,260% New York Medicaid APG,4982.58,,,4982.58,Other,324% New York Medicaid APG,3306.34,,,3306.34,Other,215% New York Medicaid APG,3306.34,,,3306.34,Other,215% New York Medicaid APG,1922.29,,,1922.29,Other,125% New York Medicaid APG,1537.83,77418.74,
Treat ectopic pregnancy,59150,CPT,,,,,,,,both,,,121364.27,89809.56,74,,89809.56,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,54613.92,45,,54613.92,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,6125,,"100% primary, 50% secondary, 25% supplemental procedure",6125,Other,Blue Cross ASC Grouper,5513,,"100% primary, 50% secondary, 25% supplemental procedure",5513,Other,Blue Cross ASC Grouper,5206,,"100% primary, 50% secondary, 25% supplemental procedure",5206,Other,Blue Cross ASC Grouper,60075.31,49.5,,60075.31,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2860.37,,,2860.37,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,84954.99,70,,84954.99,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,1537.83,,,1537.83,Other,New York Medicaid APG methodology,1537.83,,,1537.83,Other,100% New York Medicaid APG,1537.83,,,1537.83,Other,100% New York Medicaid APG,1537.83,,,1537.83,Other,100% New York Medicaid APG,3460.12,,,3460.12,Other,225% New York Medicaid APG,2352.88,,,2352.88,Other,153% New York Medicaid APG,3460.12,,,3460.12,Other,225% New York Medicaid APG,2152.96,,,2152.96,Other,140% New York Medicaid APG,3460.12,,,3460.12,Other,225% New York Medicaid APG,3998.36,,,3998.36,Other,260% New York Medicaid APG,4982.58,,,4982.58,Other,324% New York Medicaid APG,3306.34,,,3306.34,Other,215% New York Medicaid APG,3306.34,,,3306.34,Other,215% New York Medicaid APG,1922.29,,,1922.29,Other,125% New York Medicaid APG,1537.83,89809.56,
Treat ectopic pregnancy,59151,CPT,,,,,,,,both,,,121364.27,89809.56,74,,89809.56,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,54613.92,45,,54613.92,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,6125,,"100% primary, 50% secondary, 25% supplemental procedure",6125,Other,Blue Cross ASC Grouper,5513,,"100% primary, 50% secondary, 25% supplemental procedure",5513,Other,Blue Cross ASC Grouper,5206,,"100% primary, 50% secondary, 25% supplemental procedure",5206,Other,Blue Cross ASC Grouper,60075.31,49.5,,60075.31,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2860.37,,,2860.37,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,84954.99,70,,84954.99,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,1537.83,,,1537.83,Other,New York Medicaid APG methodology,1537.83,,,1537.83,Other,100% New York Medicaid APG,1537.83,,,1537.83,Other,100% New York Medicaid APG,1537.83,,,1537.83,Other,100% New York Medicaid APG,3460.12,,,3460.12,Other,225% New York Medicaid APG,2352.88,,,2352.88,Other,153% New York Medicaid APG,3460.12,,,3460.12,Other,225% New York Medicaid APG,2152.96,,,2152.96,Other,140% New York Medicaid APG,3460.12,,,3460.12,Other,225% New York Medicaid APG,3998.36,,,3998.36,Other,260% New York Medicaid APG,4982.58,,,4982.58,Other,324% New York Medicaid APG,3306.34,,,3306.34,Other,215% New York Medicaid APG,3306.34,,,3306.34,Other,215% New York Medicaid APG,1922.29,,,1922.29,Other,125% New York Medicaid APG,1537.83,89809.56,
D & c after delivery,59160,CPT,,,,,,,,both,,,38362.92,28388.56,74,,28388.56,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,17263.31,45,,17263.31,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,18989.65,49.5,,18989.65,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,1902.33,,,1902.33,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,26854.04,70,,26854.04,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1022.76,,,1022.76,Other,New York Medicaid APG methodology,1022.76,,,1022.76,Other,100% New York Medicaid APG,1022.76,,,1022.76,Other,100% New York Medicaid APG,1022.76,,,1022.76,Other,100% New York Medicaid APG,2301.2,,,2301.2,Other,225% New York Medicaid APG,1564.82,,,1564.82,Other,153% New York Medicaid APG,2301.2,,,2301.2,Other,225% New York Medicaid APG,1431.86,,,1431.86,Other,140% New York Medicaid APG,2301.2,,,2301.2,Other,225% New York Medicaid APG,2659.17,,,2659.17,Other,260% New York Medicaid APG,3313.73,,,3313.73,Other,324% New York Medicaid APG,2198.93,,,2198.93,Other,215% New York Medicaid APG,2198.93,,,2198.93,Other,215% New York Medicaid APG,1278.45,,,1278.45,Other,125% New York Medicaid APG,1022.76,28388.56,
Insert cervical dilator,59200,CPT,,,,,,,,both,,,38886.96,28776.35,74,,28776.35,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,17499.13,45,,17499.13,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,19249.05,49.5,,19249.05,percent of total billed charges,110% of Medicare,26443.13,68,,26443.13,percent of total billed charges,,1453.49,,,1453.49,Other,186% of Medicaid,31109.57,80,,31109.57,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,31109.57,80,,31109.57,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,27220.87,70,,27220.87,percent of total billed charges,,216.48,,,216.48,Fee Schedule,,183.48,,,183.48,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,781.45,,,781.45,Other,New York Medicaid APG methodology,781.45,,,781.45,Other,100% New York Medicaid APG,781.45,,,781.45,Other,100% New York Medicaid APG,781.45,,,781.45,Other,100% New York Medicaid APG,1758.26,,,1758.26,Other,225% New York Medicaid APG,1195.62,,,1195.62,Other,153% New York Medicaid APG,1758.26,,,1758.26,Other,225% New York Medicaid APG,1094.03,,,1094.03,Other,140% New York Medicaid APG,1758.26,,,1758.26,Other,225% New York Medicaid APG,2031.76,,,2031.76,Other,260% New York Medicaid APG,2531.89,,,2531.89,Other,324% New York Medicaid APG,1680.11,,,1680.11,Other,215% New York Medicaid APG,1680.11,,,1680.11,Other,215% New York Medicaid APG,976.81,,,976.81,Other,125% New York Medicaid APG,183.48,31109.57,
Episiotomy or vaginal repair,59300,CPT,,,,,,,,both,,,65759.04,48661.69,74,,48661.69,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,29591.57,45,,29591.57,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,32550.72,49.5,,32550.72,percent of total billed charges,110% of Medicare,44716.15,68,,44716.15,percent of total billed charges,,1902.33,,,1902.33,Other,186% of Medicaid,52607.23,80,,52607.23,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,52607.23,80,,52607.23,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,46031.33,70,,46031.33,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1022.76,,,1022.76,Other,New York Medicaid APG methodology,1022.76,,,1022.76,Other,100% New York Medicaid APG,1022.76,,,1022.76,Other,100% New York Medicaid APG,1022.76,,,1022.76,Other,100% New York Medicaid APG,2301.2,,,2301.2,Other,225% New York Medicaid APG,1564.82,,,1564.82,Other,153% New York Medicaid APG,2301.2,,,2301.2,Other,225% New York Medicaid APG,1431.86,,,1431.86,Other,140% New York Medicaid APG,2301.2,,,2301.2,Other,225% New York Medicaid APG,2659.17,,,2659.17,Other,260% New York Medicaid APG,3313.73,,,3313.73,Other,324% New York Medicaid APG,2198.93,,,2198.93,Other,215% New York Medicaid APG,2198.93,,,2198.93,Other,215% New York Medicaid APG,1278.45,,,1278.45,Other,125% New York Medicaid APG,1022.76,52607.23,
Revision of cervix,59320,CPT,,,,,,,,both,,,36825.48,27250.86,74,,27250.86,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,16571.47,45,,16571.47,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,18228.61,49.5,,18228.61,percent of total billed charges,110% of Medicare,25041.33,68,,25041.33,percent of total billed charges,,1902.33,,,1902.33,Other,186% of Medicaid,29460.38,80,,29460.38,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,29460.38,80,,29460.38,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,25777.84,70,,25777.84,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1022.76,,,1022.76,Other,New York Medicaid APG methodology,1022.76,,,1022.76,Other,100% New York Medicaid APG,1022.76,,,1022.76,Other,100% New York Medicaid APG,1022.76,,,1022.76,Other,100% New York Medicaid APG,2301.2,,,2301.2,Other,225% New York Medicaid APG,1564.82,,,1564.82,Other,153% New York Medicaid APG,2301.2,,,2301.2,Other,225% New York Medicaid APG,1431.86,,,1431.86,Other,140% New York Medicaid APG,2301.2,,,2301.2,Other,225% New York Medicaid APG,2659.17,,,2659.17,Other,260% New York Medicaid APG,3313.73,,,3313.73,Other,324% New York Medicaid APG,2198.93,,,2198.93,Other,215% New York Medicaid APG,2198.93,,,2198.93,Other,215% New York Medicaid APG,1278.45,,,1278.45,Other,125% New York Medicaid APG,1022.76,29460.38,
Obstetrical care,59409,CPT,,,,,,,,both,,,65759.04,48661.69,74,,48661.69,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,29591.57,45,,29591.57,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,39455.42,60,,39455.42,percent of total billed charges,,36825.06,56,,36825.06,percent of total billed charges,,35509.88,54,,35509.88,percent of total billed charges,,32550.72,49.5,,32550.72,percent of total billed charges,110% of Medicare,44716.15,68,,44716.15,percent of total billed charges,,3499.83,,,3499.83,Other,186% of Medicaid,52607.23,80,,52607.23,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,52607.23,80,,52607.23,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,46031.33,70,,46031.33,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1881.63,,,1881.63,Other,New York Medicaid APG methodology,1881.63,,,1881.63,Other,100% New York Medicaid APG,1881.63,,,1881.63,Other,100% New York Medicaid APG,1881.63,,,1881.63,Other,100% New York Medicaid APG,4233.66,,,4233.66,Other,225% New York Medicaid APG,2878.89,,,2878.89,Other,153% New York Medicaid APG,4233.66,,,4233.66,Other,225% New York Medicaid APG,2634.28,,,2634.28,Other,140% New York Medicaid APG,4233.66,,,4233.66,Other,225% New York Medicaid APG,4892.23,,,4892.23,Other,260% New York Medicaid APG,6096.47,,,6096.47,Other,324% New York Medicaid APG,4045.5,,,4045.5,Other,215% New York Medicaid APG,4045.5,,,4045.5,Other,215% New York Medicaid APG,2352.03,,,2352.03,Other,125% New York Medicaid APG,1881.63,52607.23,
Antepartum manipulation,59412,CPT,,,,,,,,both,,,65759.04,48661.69,74,,48661.69,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,29591.57,45,,29591.57,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,32550.72,49.5,,32550.72,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,1453.49,,,1453.49,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,46031.33,70,,46031.33,percent of total billed charges,,503.48,,,503.48,Fee Schedule,,426.73,,,426.73,Fee Schedule,,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,781.45,,,781.45,Other,New York Medicaid APG methodology,781.45,,,781.45,Other,100% New York Medicaid APG,781.45,,,781.45,Other,100% New York Medicaid APG,781.45,,,781.45,Other,100% New York Medicaid APG,1758.26,,,1758.26,Other,225% New York Medicaid APG,1195.62,,,1195.62,Other,153% New York Medicaid APG,1758.26,,,1758.26,Other,225% New York Medicaid APG,1094.03,,,1094.03,Other,140% New York Medicaid APG,1758.26,,,1758.26,Other,225% New York Medicaid APG,2031.76,,,2031.76,Other,260% New York Medicaid APG,2531.89,,,2531.89,Other,324% New York Medicaid APG,1680.11,,,1680.11,Other,215% New York Medicaid APG,1680.11,,,1680.11,Other,215% New York Medicaid APG,976.81,,,976.81,Other,125% New York Medicaid APG,426.73,48661.69,
Deliver placenta,59414,CPT,,,,,,,,both,,,65759.04,48661.69,74,,48661.69,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,29591.57,45,,29591.57,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,39455.42,60,,39455.42,percent of total billed charges,,36825.06,56,,36825.06,percent of total billed charges,,35509.88,54,,35509.88,percent of total billed charges,,32550.72,49.5,,32550.72,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,1902.33,,,1902.33,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,46031.33,70,,46031.33,percent of total billed charges,,444.44,,,444.44,Fee Schedule,,376.69,,,376.69,Fee Schedule,,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1022.76,,,1022.76,Other,New York Medicaid APG methodology,1022.76,,,1022.76,Other,100% New York Medicaid APG,1022.76,,,1022.76,Other,100% New York Medicaid APG,1022.76,,,1022.76,Other,100% New York Medicaid APG,2301.2,,,2301.2,Other,225% New York Medicaid APG,1564.82,,,1564.82,Other,153% New York Medicaid APG,2301.2,,,2301.2,Other,225% New York Medicaid APG,1431.86,,,1431.86,Other,140% New York Medicaid APG,2301.2,,,2301.2,Other,225% New York Medicaid APG,2659.17,,,2659.17,Other,260% New York Medicaid APG,3313.73,,,3313.73,Other,324% New York Medicaid APG,2198.93,,,2198.93,Other,215% New York Medicaid APG,2198.93,,,2198.93,Other,215% New York Medicaid APG,1278.45,,,1278.45,Other,125% New York Medicaid APG,376.69,48661.69,
Vbac delivery only,59612,CPT,,,,,,,,both,,,65759.04,48661.69,74,,48661.69,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,29591.57,45,,29591.57,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,39455.42,60,,39455.42,percent of total billed charges,,36825.06,56,,36825.06,percent of total billed charges,,35509.88,54,,35509.88,percent of total billed charges,,32550.72,49.5,,32550.72,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3499.83,,,3499.83,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,46031.33,70,,46031.33,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1881.63,,,1881.63,Other,New York Medicaid APG methodology,1881.63,,,1881.63,Other,100% New York Medicaid APG,1881.63,,,1881.63,Other,100% New York Medicaid APG,1881.63,,,1881.63,Other,100% New York Medicaid APG,4233.66,,,4233.66,Other,225% New York Medicaid APG,2878.89,,,2878.89,Other,153% New York Medicaid APG,4233.66,,,4233.66,Other,225% New York Medicaid APG,2634.28,,,2634.28,Other,140% New York Medicaid APG,4233.66,,,4233.66,Other,225% New York Medicaid APG,4892.23,,,4892.23,Other,260% New York Medicaid APG,6096.47,,,6096.47,Other,324% New York Medicaid APG,4045.5,,,4045.5,Other,215% New York Medicaid APG,4045.5,,,4045.5,Other,215% New York Medicaid APG,2352.03,,,2352.03,Other,125% New York Medicaid APG,1881.63,48661.69,
Treatment of miscarriage,59812,CPT,,,,,,,,both,,,40386.74,29886.19,74,,29886.19,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,18174.03,45,,18174.03,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,19991.44,49.5,,19991.44,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,1455.92,,,1455.92,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,28270.72,70,,28270.72,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,782.75,,,782.75,Other,New York Medicaid APG methodology,782.75,,,782.75,Other,100% New York Medicaid APG,782.75,,,782.75,Other,100% New York Medicaid APG,782.75,,,782.75,Other,100% New York Medicaid APG,1761.19,,,1761.19,Other,225% New York Medicaid APG,1197.61,,,1197.61,Other,153% New York Medicaid APG,1761.19,,,1761.19,Other,225% New York Medicaid APG,1095.85,,,1095.85,Other,140% New York Medicaid APG,1761.19,,,1761.19,Other,225% New York Medicaid APG,2035.16,,,2035.16,Other,260% New York Medicaid APG,2536.12,,,2536.12,Other,324% New York Medicaid APG,1682.92,,,1682.92,Other,215% New York Medicaid APG,1682.92,,,1682.92,Other,215% New York Medicaid APG,978.44,,,978.44,Other,125% New York Medicaid APG,782.75,29886.19,
Care of miscarriage,59820,CPT,,,,,,,,both,,,39754.42,29418.27,74,,29418.27,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,17889.49,45,,17889.49,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,19678.44,49.5,,19678.44,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,1455.92,,,1455.92,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,27828.09,70,,27828.09,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,782.75,,,782.75,Other,New York Medicaid APG methodology,782.75,,,782.75,Other,100% New York Medicaid APG,782.75,,,782.75,Other,100% New York Medicaid APG,782.75,,,782.75,Other,100% New York Medicaid APG,1761.19,,,1761.19,Other,225% New York Medicaid APG,1197.61,,,1197.61,Other,153% New York Medicaid APG,1761.19,,,1761.19,Other,225% New York Medicaid APG,1095.85,,,1095.85,Other,140% New York Medicaid APG,1761.19,,,1761.19,Other,225% New York Medicaid APG,2035.16,,,2035.16,Other,260% New York Medicaid APG,2536.12,,,2536.12,Other,324% New York Medicaid APG,1682.92,,,1682.92,Other,215% New York Medicaid APG,1682.92,,,1682.92,Other,215% New York Medicaid APG,978.44,,,978.44,Other,125% New York Medicaid APG,782.75,29418.27,
Treatment of miscarriage,59821,CPT,,,,,,,,both,,,40901.98,30267.47,74,,30267.47,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,18405.89,45,,18405.89,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,20246.48,49.5,,20246.48,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,1455.92,,,1455.92,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,28631.39,70,,28631.39,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,782.75,,,782.75,Other,New York Medicaid APG methodology,782.75,,,782.75,Other,100% New York Medicaid APG,782.75,,,782.75,Other,100% New York Medicaid APG,782.75,,,782.75,Other,100% New York Medicaid APG,1761.19,,,1761.19,Other,225% New York Medicaid APG,1197.61,,,1197.61,Other,153% New York Medicaid APG,1761.19,,,1761.19,Other,225% New York Medicaid APG,1095.85,,,1095.85,Other,140% New York Medicaid APG,1761.19,,,1761.19,Other,225% New York Medicaid APG,2035.16,,,2035.16,Other,260% New York Medicaid APG,2536.12,,,2536.12,Other,324% New York Medicaid APG,1682.92,,,1682.92,Other,215% New York Medicaid APG,1682.92,,,1682.92,Other,215% New York Medicaid APG,978.44,,,978.44,Other,125% New York Medicaid APG,782.75,30267.47,
Abortion,59840,CPT,,,,,,,,both,,,37030.15,27402.31,74,,27402.31,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,16663.57,45,,16663.57,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,18329.92,49.5,,18329.92,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,1455.92,,,1455.92,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,25921.11,70,,25921.11,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,782.75,,,782.75,Other,New York Medicaid APG methodology,782.75,,,782.75,Other,100% New York Medicaid APG,782.75,,,782.75,Other,100% New York Medicaid APG,782.75,,,782.75,Other,100% New York Medicaid APG,1761.19,,,1761.19,Other,225% New York Medicaid APG,1197.61,,,1197.61,Other,153% New York Medicaid APG,1761.19,,,1761.19,Other,225% New York Medicaid APG,1095.85,,,1095.85,Other,140% New York Medicaid APG,1761.19,,,1761.19,Other,225% New York Medicaid APG,2035.16,,,2035.16,Other,260% New York Medicaid APG,2536.12,,,2536.12,Other,324% New York Medicaid APG,1682.92,,,1682.92,Other,215% New York Medicaid APG,1682.92,,,1682.92,Other,215% New York Medicaid APG,978.44,,,978.44,Other,125% New York Medicaid APG,782.75,27402.31,
Abortion,59841,CPT,,,,,,,,both,,,38231,28290.94,74,,28290.94,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,17203.95,45,,17203.95,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,18924.35,49.5,,18924.35,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,1455.92,,,1455.92,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,26761.7,70,,26761.7,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,782.75,,,782.75,Other,New York Medicaid APG methodology,782.75,,,782.75,Other,100% New York Medicaid APG,782.75,,,782.75,Other,100% New York Medicaid APG,782.75,,,782.75,Other,100% New York Medicaid APG,1761.19,,,1761.19,Other,225% New York Medicaid APG,1197.61,,,1197.61,Other,153% New York Medicaid APG,1761.19,,,1761.19,Other,225% New York Medicaid APG,1095.85,,,1095.85,Other,140% New York Medicaid APG,1761.19,,,1761.19,Other,225% New York Medicaid APG,2035.16,,,2035.16,Other,260% New York Medicaid APG,2536.12,,,2536.12,Other,324% New York Medicaid APG,1682.92,,,1682.92,Other,215% New York Medicaid APG,1682.92,,,1682.92,Other,215% New York Medicaid APG,978.44,,,978.44,Other,125% New York Medicaid APG,782.75,28290.94,
Abortion (mpr),59866,CPT,,,,,,,,both,,,6747.72,4993.31,74,,4993.31,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,3036.47,45,,3036.47,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,3340.12,49.5,,3340.12,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,1455.92,,,1455.92,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,4723.4,70,,4723.4,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,782.75,,,782.75,Other,New York Medicaid APG methodology,782.75,,,782.75,Other,100% New York Medicaid APG,782.75,,,782.75,Other,100% New York Medicaid APG,782.75,,,782.75,Other,100% New York Medicaid APG,1761.19,,,1761.19,Other,225% New York Medicaid APG,1197.61,,,1197.61,Other,153% New York Medicaid APG,1761.19,,,1761.19,Other,225% New York Medicaid APG,1095.85,,,1095.85,Other,140% New York Medicaid APG,1761.19,,,1761.19,Other,225% New York Medicaid APG,2035.16,,,2035.16,Other,260% New York Medicaid APG,2536.12,,,2536.12,Other,324% New York Medicaid APG,1682.92,,,1682.92,Other,215% New York Medicaid APG,1682.92,,,1682.92,Other,215% New York Medicaid APG,978.44,,,978.44,Other,125% New York Medicaid APG,782.75,9473,
Evacuate mole of uterus,59870,CPT,,,,,,,,both,,,41359.84,30606.28,74,,30606.28,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,18611.93,45,,18611.93,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,20473.12,49.5,,20473.12,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2860.37,,,2860.37,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,28951.89,70,,28951.89,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1537.83,,,1537.83,Other,New York Medicaid APG methodology,1537.83,,,1537.83,Other,100% New York Medicaid APG,1537.83,,,1537.83,Other,100% New York Medicaid APG,1537.83,,,1537.83,Other,100% New York Medicaid APG,3460.12,,,3460.12,Other,225% New York Medicaid APG,2352.88,,,2352.88,Other,153% New York Medicaid APG,3460.12,,,3460.12,Other,225% New York Medicaid APG,2152.96,,,2152.96,Other,140% New York Medicaid APG,3460.12,,,3460.12,Other,225% New York Medicaid APG,3998.36,,,3998.36,Other,260% New York Medicaid APG,4982.58,,,4982.58,Other,324% New York Medicaid APG,3306.34,,,3306.34,Other,215% New York Medicaid APG,3306.34,,,3306.34,Other,215% New York Medicaid APG,1922.29,,,1922.29,Other,125% New York Medicaid APG,1537.83,30606.28,
Remove cerclage suture,59871,CPT,,,,,,,,both,,,65759.04,48661.69,74,,48661.69,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,29591.57,45,,29591.57,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,32550.72,49.5,,32550.72,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,1902.33,,,1902.33,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,46031.33,70,,46031.33,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1022.76,,,1022.76,Other,New York Medicaid APG methodology,1022.76,,,1022.76,Other,100% New York Medicaid APG,1022.76,,,1022.76,Other,100% New York Medicaid APG,1022.76,,,1022.76,Other,100% New York Medicaid APG,2301.2,,,2301.2,Other,225% New York Medicaid APG,1564.82,,,1564.82,Other,153% New York Medicaid APG,2301.2,,,2301.2,Other,225% New York Medicaid APG,1431.86,,,1431.86,Other,140% New York Medicaid APG,2301.2,,,2301.2,Other,225% New York Medicaid APG,2659.17,,,2659.17,Other,260% New York Medicaid APG,3313.73,,,3313.73,Other,324% New York Medicaid APG,2198.93,,,2198.93,Other,215% New York Medicaid APG,2198.93,,,2198.93,Other,215% New York Medicaid APG,1278.45,,,1278.45,Other,125% New York Medicaid APG,1022.76,48661.69,
Drain thyroid/tongue cyst,60000,CPT,,,,,,,,both,,,32077.39,23737.27,74,,23737.27,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,14434.83,45,,14434.83,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,15878.31,49.5,,15878.31,percent of total billed charges,110% of Medicare,21812.63,68,,21812.63,percent of total billed charges,,2256.57,,,2256.57,Other,186% of Medicaid,25661.91,80,,25661.91,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,25661.91,80,,25661.91,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,22454.17,70,,22454.17,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1213.21,,,1213.21,Other,New York Medicaid APG methodology,1213.21,,,1213.21,Other,100% New York Medicaid APG,1213.21,,,1213.21,Other,100% New York Medicaid APG,1213.21,,,1213.21,Other,100% New York Medicaid APG,2729.72,,,2729.72,Other,225% New York Medicaid APG,1856.21,,,1856.21,Other,153% New York Medicaid APG,2729.72,,,2729.72,Other,225% New York Medicaid APG,1698.49,,,1698.49,Other,140% New York Medicaid APG,2729.72,,,2729.72,Other,225% New York Medicaid APG,3154.34,,,3154.34,Other,260% New York Medicaid APG,3930.79,,,3930.79,Other,324% New York Medicaid APG,2608.4,,,2608.4,Other,215% New York Medicaid APG,2608.4,,,2608.4,Other,215% New York Medicaid APG,1516.51,,,1516.51,Other,125% New York Medicaid APG,1213.21,25661.91,
Biopsy of thyroid,60100,CPT,,,,,,,,both,,,17214.5,12738.73,74,,12738.73,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,7746.53,45,,7746.53,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,8521.18,49.5,,8521.18,percent of total billed charges,110% of Medicare,11705.86,68,,11705.86,percent of total billed charges,,1037.55,,,1037.55,Other,186% of Medicaid,13771.6,80,,13771.6,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,13771.6,80,,13771.6,percent of total billed charges,,7216,,,7216,Case Rate,,3578,,"100% primary, 0% secondary procedures",3578,Other,MagnaCare ASC Grouper,12050.15,70,,12050.15,percent of total billed charges,,373.92,,,373.92,Fee Schedule,,316.92,,,316.92,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,557.82,,,557.82,Other,New York Medicaid APG methodology,557.82,,,557.82,Other,100% New York Medicaid APG,557.82,,,557.82,Other,100% New York Medicaid APG,557.82,,,557.82,Other,100% New York Medicaid APG,1255.1,,,1255.1,Other,225% New York Medicaid APG,853.47,,,853.47,Other,153% New York Medicaid APG,1255.1,,,1255.1,Other,225% New York Medicaid APG,780.95,,,780.95,Other,140% New York Medicaid APG,1255.1,,,1255.1,Other,225% New York Medicaid APG,1450.34,,,1450.34,Other,260% New York Medicaid APG,1807.35,,,1807.35,Other,324% New York Medicaid APG,1199.32,,,1199.32,Other,215% New York Medicaid APG,1199.32,,,1199.32,Other,215% New York Medicaid APG,697.28,,,697.28,Other,125% New York Medicaid APG,316.92,13771.6,
Remove thyroid lesion,60200,CPT,,,,,,,,both,,,39149.27,28970.46,74,,28970.46,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,17617.17,45,,17617.17,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,6125,,"100% primary, 50% secondary, 25% supplemental procedure",6125,Other,Blue Cross ASC Grouper,5513,,"100% primary, 50% secondary, 25% supplemental procedure",5513,Other,Blue Cross ASC Grouper,5206,,"100% primary, 50% secondary, 25% supplemental procedure",5206,Other,Blue Cross ASC Grouper,19378.89,49.5,,19378.89,percent of total billed charges,110% of Medicare,26621.5,68,,26621.5,percent of total billed charges,,5021.15,,,5021.15,Other,186% of Medicaid,31319.42,80,,31319.42,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,31319.42,80,,31319.42,percent of total billed charges,,7216,,,7216,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,27404.49,70,,27404.49,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,2699.54,,,2699.54,Other,New York Medicaid APG methodology,2699.54,,,2699.54,Other,100% New York Medicaid APG,2699.54,,,2699.54,Other,100% New York Medicaid APG,2699.54,,,2699.54,Other,100% New York Medicaid APG,6073.97,,,6073.97,Other,225% New York Medicaid APG,4130.3,,,4130.3,Other,153% New York Medicaid APG,6073.97,,,6073.97,Other,225% New York Medicaid APG,3779.36,,,3779.36,Other,140% New York Medicaid APG,6073.97,,,6073.97,Other,225% New York Medicaid APG,7018.81,,,7018.81,Other,260% New York Medicaid APG,8746.51,,,8746.51,Other,324% New York Medicaid APG,5804.01,,,5804.01,Other,215% New York Medicaid APG,5804.01,,,5804.01,Other,215% New York Medicaid APG,3374.43,,,3374.43,Other,125% New York Medicaid APG,2232,31319.42,
Partial thyroid excision,60210,CPT,,,,,,,,both,,,47061.73,34825.68,74,,34825.68,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,21177.78,45,,21177.78,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,6125,,"100% primary, 50% secondary, 25% supplemental procedure",6125,Other,Blue Cross ASC Grouper,5513,,"100% primary, 50% secondary, 25% supplemental procedure",5513,Other,Blue Cross ASC Grouper,5206,,"100% primary, 50% secondary, 25% supplemental procedure",5206,Other,Blue Cross ASC Grouper,23295.56,49.5,,23295.56,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5021.15,,,5021.15,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,32943.21,70,,32943.21,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,2699.54,,,2699.54,Other,New York Medicaid APG methodology,2699.54,,,2699.54,Other,100% New York Medicaid APG,2699.54,,,2699.54,Other,100% New York Medicaid APG,2699.54,,,2699.54,Other,100% New York Medicaid APG,6073.97,,,6073.97,Other,225% New York Medicaid APG,4130.3,,,4130.3,Other,153% New York Medicaid APG,6073.97,,,6073.97,Other,225% New York Medicaid APG,3779.36,,,3779.36,Other,140% New York Medicaid APG,6073.97,,,6073.97,Other,225% New York Medicaid APG,7018.81,,,7018.81,Other,260% New York Medicaid APG,8746.51,,,8746.51,Other,324% New York Medicaid APG,5804.01,,,5804.01,Other,215% New York Medicaid APG,5804.01,,,5804.01,Other,215% New York Medicaid APG,3374.43,,,3374.43,Other,125% New York Medicaid APG,2699.54,34825.68,
Partial thyroid excision,60212,CPT,,,,,,,,both,,,121364.27,89809.56,74,,89809.56,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,54613.92,45,,54613.92,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,6125,,"100% primary, 50% secondary, 25% supplemental procedure",6125,Other,Blue Cross ASC Grouper,5513,,"100% primary, 50% secondary, 25% supplemental procedure",5513,Other,Blue Cross ASC Grouper,5206,,"100% primary, 50% secondary, 25% supplemental procedure",5206,Other,Blue Cross ASC Grouper,60075.31,49.5,,60075.31,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5021.15,,,5021.15,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,84954.99,70,,84954.99,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,2699.54,,,2699.54,Other,New York Medicaid APG methodology,2699.54,,,2699.54,Other,100% New York Medicaid APG,2699.54,,,2699.54,Other,100% New York Medicaid APG,2699.54,,,2699.54,Other,100% New York Medicaid APG,6073.97,,,6073.97,Other,225% New York Medicaid APG,4130.3,,,4130.3,Other,153% New York Medicaid APG,6073.97,,,6073.97,Other,225% New York Medicaid APG,3779.36,,,3779.36,Other,140% New York Medicaid APG,6073.97,,,6073.97,Other,225% New York Medicaid APG,7018.81,,,7018.81,Other,260% New York Medicaid APG,8746.51,,,8746.51,Other,324% New York Medicaid APG,5804.01,,,5804.01,Other,215% New York Medicaid APG,5804.01,,,5804.01,Other,215% New York Medicaid APG,3374.43,,,3374.43,Other,125% New York Medicaid APG,2699.54,89809.56,
Partial removal of thyroid,60220,CPT,,,,,,,,both,,,46869.66,34683.55,74,,34683.55,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,21091.35,45,,21091.35,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,6125,,"100% primary, 50% secondary, 25% supplemental procedure",6125,Other,Blue Cross ASC Grouper,5513,,"100% primary, 50% secondary, 25% supplemental procedure",5513,Other,Blue Cross ASC Grouper,5206,,"100% primary, 50% secondary, 25% supplemental procedure",5206,Other,Blue Cross ASC Grouper,23200.48,49.5,,23200.48,percent of total billed charges,110% of Medicare,31871.37,68,,31871.37,percent of total billed charges,,5021.15,,,5021.15,Other,186% of Medicaid,37495.73,80,,37495.73,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,37495.73,80,,37495.73,percent of total billed charges,,7216,,,7216,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,32808.76,70,,32808.76,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,2699.54,,,2699.54,Other,New York Medicaid APG methodology,2699.54,,,2699.54,Other,100% New York Medicaid APG,2699.54,,,2699.54,Other,100% New York Medicaid APG,2699.54,,,2699.54,Other,100% New York Medicaid APG,6073.97,,,6073.97,Other,225% New York Medicaid APG,4130.3,,,4130.3,Other,153% New York Medicaid APG,6073.97,,,6073.97,Other,225% New York Medicaid APG,3779.36,,,3779.36,Other,140% New York Medicaid APG,6073.97,,,6073.97,Other,225% New York Medicaid APG,7018.81,,,7018.81,Other,260% New York Medicaid APG,8746.51,,,8746.51,Other,324% New York Medicaid APG,5804.01,,,5804.01,Other,215% New York Medicaid APG,5804.01,,,5804.01,Other,215% New York Medicaid APG,3374.43,,,3374.43,Other,125% New York Medicaid APG,2232,37495.73,
Partial removal of thyroid,60225,CPT,,,,,,,,both,,,121364.27,89809.56,74,,89809.56,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,54613.92,45,,54613.92,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,6125,,"100% primary, 50% secondary, 25% supplemental procedure",6125,Other,Blue Cross ASC Grouper,5513,,"100% primary, 50% secondary, 25% supplemental procedure",5513,Other,Blue Cross ASC Grouper,5206,,"100% primary, 50% secondary, 25% supplemental procedure",5206,Other,Blue Cross ASC Grouper,60075.31,49.5,,60075.31,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5021.15,,,5021.15,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,84954.99,70,,84954.99,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,2699.54,,,2699.54,Other,New York Medicaid APG methodology,2699.54,,,2699.54,Other,100% New York Medicaid APG,2699.54,,,2699.54,Other,100% New York Medicaid APG,2699.54,,,2699.54,Other,100% New York Medicaid APG,6073.97,,,6073.97,Other,225% New York Medicaid APG,4130.3,,,4130.3,Other,153% New York Medicaid APG,6073.97,,,6073.97,Other,225% New York Medicaid APG,3779.36,,,3779.36,Other,140% New York Medicaid APG,6073.97,,,6073.97,Other,225% New York Medicaid APG,7018.81,,,7018.81,Other,260% New York Medicaid APG,8746.51,,,8746.51,Other,324% New York Medicaid APG,5804.01,,,5804.01,Other,215% New York Medicaid APG,5804.01,,,5804.01,Other,215% New York Medicaid APG,3374.43,,,3374.43,Other,125% New York Medicaid APG,2699.54,89809.56,
Removal of thyroid,60240,CPT,,,,,,,,both,,,52929.92,39168.14,74,,39168.14,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,23818.46,45,,23818.46,percent of total billed charges,Medicare Ratio of cost to charges,5954,,"100% primary, 50% supplemental procedure",5954,Other,Aetna ASC Grouper,5359,,"100% primary, 50% supplemental procedure",5359,Other,Aetna ASC Grouper,6125,,"100% primary, 50% secondary, 25% supplemental procedure",6125,Other,Blue Cross ASC Grouper,5513,,"100% primary, 50% secondary, 25% supplemental procedure",5513,Other,Blue Cross ASC Grouper,5206,,"100% primary, 50% secondary, 25% supplemental procedure",5206,Other,Blue Cross ASC Grouper,26200.31,49.5,,26200.31,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5021.15,,,5021.15,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,37050.94,70,,37050.94,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,2699.54,,,2699.54,Other,New York Medicaid APG methodology,2699.54,,,2699.54,Other,100% New York Medicaid APG,2699.54,,,2699.54,Other,100% New York Medicaid APG,2699.54,,,2699.54,Other,100% New York Medicaid APG,6073.97,,,6073.97,Other,225% New York Medicaid APG,4130.3,,,4130.3,Other,153% New York Medicaid APG,6073.97,,,6073.97,Other,225% New York Medicaid APG,3779.36,,,3779.36,Other,140% New York Medicaid APG,6073.97,,,6073.97,Other,225% New York Medicaid APG,7018.81,,,7018.81,Other,260% New York Medicaid APG,8746.51,,,8746.51,Other,324% New York Medicaid APG,5804.01,,,5804.01,Other,215% New York Medicaid APG,5804.01,,,5804.01,Other,215% New York Medicaid APG,3374.43,,,3374.43,Other,125% New York Medicaid APG,2699.54,39168.14,
Removal of thyroid,60252,CPT,,,,,,,,both,,,71608.73,52990.46,74,,52990.46,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,32223.93,45,,32223.93,percent of total billed charges,Medicare Ratio of cost to charges,5954,,"100% primary, 50% supplemental procedure",5954,Other,Aetna ASC Grouper,5359,,"100% primary, 50% supplemental procedure",5359,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,35446.32,49.5,,35446.32,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5021.15,,,5021.15,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,50126.11,70,,50126.11,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,2699.54,,,2699.54,Other,New York Medicaid APG methodology,2699.54,,,2699.54,Other,100% New York Medicaid APG,2699.54,,,2699.54,Other,100% New York Medicaid APG,2699.54,,,2699.54,Other,100% New York Medicaid APG,6073.97,,,6073.97,Other,225% New York Medicaid APG,4130.3,,,4130.3,Other,153% New York Medicaid APG,6073.97,,,6073.97,Other,225% New York Medicaid APG,3779.36,,,3779.36,Other,140% New York Medicaid APG,6073.97,,,6073.97,Other,225% New York Medicaid APG,7018.81,,,7018.81,Other,260% New York Medicaid APG,8746.51,,,8746.51,Other,324% New York Medicaid APG,5804.01,,,5804.01,Other,215% New York Medicaid APG,5804.01,,,5804.01,Other,215% New York Medicaid APG,3374.43,,,3374.43,Other,125% New York Medicaid APG,2699.54,52990.46,
Repeat thyroid surgery,60260,CPT,,,,,,,,both,,,51516.16,38121.96,74,,38121.96,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,23182.27,45,,23182.27,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,25500.5,49.5,,25500.5,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5021.15,,,5021.15,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,36061.31,70,,36061.31,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,2699.54,,,2699.54,Other,New York Medicaid APG methodology,2699.54,,,2699.54,Other,100% New York Medicaid APG,2699.54,,,2699.54,Other,100% New York Medicaid APG,2699.54,,,2699.54,Other,100% New York Medicaid APG,6073.97,,,6073.97,Other,225% New York Medicaid APG,4130.3,,,4130.3,Other,153% New York Medicaid APG,6073.97,,,6073.97,Other,225% New York Medicaid APG,3779.36,,,3779.36,Other,140% New York Medicaid APG,6073.97,,,6073.97,Other,225% New York Medicaid APG,7018.81,,,7018.81,Other,260% New York Medicaid APG,8746.51,,,8746.51,Other,324% New York Medicaid APG,5804.01,,,5804.01,Other,215% New York Medicaid APG,5804.01,,,5804.01,Other,215% New York Medicaid APG,3374.43,,,3374.43,Other,125% New York Medicaid APG,2699.54,38121.96,
Removal of thyroid,60271,CPT,,,,,,,,both,,,60382.91,44683.35,74,,44683.35,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,27172.31,45,,27172.31,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,29889.54,49.5,,29889.54,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5021.15,,,5021.15,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,42268.04,70,,42268.04,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,2699.54,,,2699.54,Other,New York Medicaid APG methodology,2699.54,,,2699.54,Other,100% New York Medicaid APG,2699.54,,,2699.54,Other,100% New York Medicaid APG,2699.54,,,2699.54,Other,100% New York Medicaid APG,6073.97,,,6073.97,Other,225% New York Medicaid APG,4130.3,,,4130.3,Other,153% New York Medicaid APG,6073.97,,,6073.97,Other,225% New York Medicaid APG,3779.36,,,3779.36,Other,140% New York Medicaid APG,6073.97,,,6073.97,Other,225% New York Medicaid APG,7018.81,,,7018.81,Other,260% New York Medicaid APG,8746.51,,,8746.51,Other,324% New York Medicaid APG,5804.01,,,5804.01,Other,215% New York Medicaid APG,5804.01,,,5804.01,Other,215% New York Medicaid APG,3374.43,,,3374.43,Other,125% New York Medicaid APG,2699.54,44683.35,
Remove thyroid duct lesion,60280,CPT,,,,,,,,both,,,35344.62,26155.02,74,,26155.02,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15905.08,45,,15905.08,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,6125,,"100% primary, 50% secondary, 25% supplemental procedure",6125,Other,Blue Cross ASC Grouper,5513,,"100% primary, 50% secondary, 25% supplemental procedure",5513,Other,Blue Cross ASC Grouper,5206,,"100% primary, 50% secondary, 25% supplemental procedure",5206,Other,Blue Cross ASC Grouper,17495.59,49.5,,17495.59,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5021.15,,,5021.15,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,24741.23,70,,24741.23,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,2699.54,,,2699.54,Other,New York Medicaid APG methodology,2699.54,,,2699.54,Other,100% New York Medicaid APG,2699.54,,,2699.54,Other,100% New York Medicaid APG,2699.54,,,2699.54,Other,100% New York Medicaid APG,6073.97,,,6073.97,Other,225% New York Medicaid APG,4130.3,,,4130.3,Other,153% New York Medicaid APG,6073.97,,,6073.97,Other,225% New York Medicaid APG,3779.36,,,3779.36,Other,140% New York Medicaid APG,6073.97,,,6073.97,Other,225% New York Medicaid APG,7018.81,,,7018.81,Other,260% New York Medicaid APG,8746.51,,,8746.51,Other,324% New York Medicaid APG,5804.01,,,5804.01,Other,215% New York Medicaid APG,5804.01,,,5804.01,Other,215% New York Medicaid APG,3374.43,,,3374.43,Other,125% New York Medicaid APG,2699.54,26155.02,
Remove thyroid duct lesion,60281,CPT,,,,,,,,both,,,68111.61,50402.59,74,,50402.59,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30650.22,45,,30650.22,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,6125,,"100% primary, 50% secondary, 25% supplemental procedure",6125,Other,Blue Cross ASC Grouper,5513,,"100% primary, 50% secondary, 25% supplemental procedure",5513,Other,Blue Cross ASC Grouper,5206,,"100% primary, 50% secondary, 25% supplemental procedure",5206,Other,Blue Cross ASC Grouper,33715.25,49.5,,33715.25,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5021.15,,,5021.15,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,47678.13,70,,47678.13,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,2699.54,,,2699.54,Other,New York Medicaid APG methodology,2699.54,,,2699.54,Other,100% New York Medicaid APG,2699.54,,,2699.54,Other,100% New York Medicaid APG,2699.54,,,2699.54,Other,100% New York Medicaid APG,6073.97,,,6073.97,Other,225% New York Medicaid APG,4130.3,,,4130.3,Other,153% New York Medicaid APG,6073.97,,,6073.97,Other,225% New York Medicaid APG,3779.36,,,3779.36,Other,140% New York Medicaid APG,6073.97,,,6073.97,Other,225% New York Medicaid APG,7018.81,,,7018.81,Other,260% New York Medicaid APG,8746.51,,,8746.51,Other,324% New York Medicaid APG,5804.01,,,5804.01,Other,215% New York Medicaid APG,5804.01,,,5804.01,Other,215% New York Medicaid APG,3374.43,,,3374.43,Other,125% New York Medicaid APG,2699.54,50402.59,
Aspir/inj thyroid cyst,60300,CPT,,,,,,,,both,,,14798.8,10951.11,74,,10951.11,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,6659.46,45,,6659.46,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,7325.41,49.5,,7325.41,percent of total billed charges,110% of Medicare,10063.18,68,,10063.18,percent of total billed charges,,1037.55,,,1037.55,Other,186% of Medicaid,11839.04,80,,11839.04,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,11839.04,80,,11839.04,percent of total billed charges,,7216,,,7216,Case Rate,,3578,,"100% primary, 0% secondary procedures",3578,Other,MagnaCare ASC Grouper,10359.16,70,,10359.16,percent of total billed charges,,234.52,,,234.52,Fee Schedule,,198.77,,,198.77,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,557.82,,,557.82,Other,New York Medicaid APG methodology,557.82,,,557.82,Other,100% New York Medicaid APG,557.82,,,557.82,Other,100% New York Medicaid APG,557.82,,,557.82,Other,100% New York Medicaid APG,1255.1,,,1255.1,Other,225% New York Medicaid APG,853.47,,,853.47,Other,153% New York Medicaid APG,1255.1,,,1255.1,Other,225% New York Medicaid APG,780.95,,,780.95,Other,140% New York Medicaid APG,1255.1,,,1255.1,Other,225% New York Medicaid APG,1450.34,,,1450.34,Other,260% New York Medicaid APG,1807.35,,,1807.35,Other,324% New York Medicaid APG,1199.32,,,1199.32,Other,215% New York Medicaid APG,1199.32,,,1199.32,Other,215% New York Medicaid APG,697.28,,,697.28,Other,125% New York Medicaid APG,198.77,11839.04,
Explore parathyroid glands,60500,CPT,,,,,,,,both,,,51334.91,37987.83,74,,37987.83,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,23100.71,45,,23100.71,percent of total billed charges,Medicare Ratio of cost to charges,5954,,"100% primary, 50% supplemental procedure",5954,Other,Aetna ASC Grouper,5359,,"100% primary, 50% supplemental procedure",5359,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,25410.78,49.5,,25410.78,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5021.15,,,5021.15,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,35934.44,70,,35934.44,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,2699.54,,,2699.54,Other,New York Medicaid APG methodology,2699.54,,,2699.54,Other,100% New York Medicaid APG,2699.54,,,2699.54,Other,100% New York Medicaid APG,2699.54,,,2699.54,Other,100% New York Medicaid APG,6073.97,,,6073.97,Other,225% New York Medicaid APG,4130.3,,,4130.3,Other,153% New York Medicaid APG,6073.97,,,6073.97,Other,225% New York Medicaid APG,3779.36,,,3779.36,Other,140% New York Medicaid APG,6073.97,,,6073.97,Other,225% New York Medicaid APG,7018.81,,,7018.81,Other,260% New York Medicaid APG,8746.51,,,8746.51,Other,324% New York Medicaid APG,5804.01,,,5804.01,Other,215% New York Medicaid APG,5804.01,,,5804.01,Other,215% New York Medicaid APG,3374.43,,,3374.43,Other,125% New York Medicaid APG,2699.54,37987.83,
Re-explore parathyroids,60502,CPT,,,,,,,,both,,,123177.14,91151.08,74,,91151.08,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,55429.71,45,,55429.71,percent of total billed charges,Medicare Ratio of cost to charges,5954,,"100% primary, 50% supplemental procedure",5954,Other,Aetna ASC Grouper,5359,,"100% primary, 50% supplemental procedure",5359,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,60972.68,49.5,,60972.68,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5021.15,,,5021.15,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,86224,70,,86224,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,2699.54,,,2699.54,Other,New York Medicaid APG methodology,2699.54,,,2699.54,Other,100% New York Medicaid APG,2699.54,,,2699.54,Other,100% New York Medicaid APG,2699.54,,,2699.54,Other,100% New York Medicaid APG,6073.97,,,6073.97,Other,225% New York Medicaid APG,4130.3,,,4130.3,Other,153% New York Medicaid APG,6073.97,,,6073.97,Other,225% New York Medicaid APG,3779.36,,,3779.36,Other,140% New York Medicaid APG,6073.97,,,6073.97,Other,225% New York Medicaid APG,7018.81,,,7018.81,Other,260% New York Medicaid APG,8746.51,,,8746.51,Other,324% New York Medicaid APG,5804.01,,,5804.01,Other,215% New York Medicaid APG,5804.01,,,5804.01,Other,215% New York Medicaid APG,3374.43,,,3374.43,Other,125% New York Medicaid APG,2699.54,91151.08,
Autotransplant parathyroid,60512,CPT,,,,,,,,both,,,83504,61792.96,74,,61792.96,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,37576.8,45,,37576.8,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,41334.48,49.5,,41334.48,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5021.15,,,5021.15,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,58452.8,70,,58452.8,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,2699.54,,,2699.54,Other,New York Medicaid APG methodology,2699.54,,,2699.54,Other,100% New York Medicaid APG,2699.54,,,2699.54,Other,100% New York Medicaid APG,2699.54,,,2699.54,Other,100% New York Medicaid APG,6073.97,,,6073.97,Other,225% New York Medicaid APG,4130.3,,,4130.3,Other,153% New York Medicaid APG,6073.97,,,6073.97,Other,225% New York Medicaid APG,3779.36,,,3779.36,Other,140% New York Medicaid APG,6073.97,,,6073.97,Other,225% New York Medicaid APG,7018.81,,,7018.81,Other,260% New York Medicaid APG,8746.51,,,8746.51,Other,324% New York Medicaid APG,5804.01,,,5804.01,Other,215% New York Medicaid APG,5804.01,,,5804.01,Other,215% New York Medicaid APG,3374.43,,,3374.43,Other,125% New York Medicaid APG,2699.54,61792.96,
Removal of thymus gland,60520,CPT,,,,,,,,both,,,123177.14,91151.08,74,,91151.08,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,55429.71,45,,55429.71,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,60972.68,49.5,,60972.68,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,4046.72,,,4046.72,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,86224,70,,86224,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,2175.66,,,2175.66,Other,New York Medicaid APG methodology,2175.66,,,2175.66,Other,100% New York Medicaid APG,2175.66,,,2175.66,Other,100% New York Medicaid APG,2175.66,,,2175.66,Other,100% New York Medicaid APG,4895.23,,,4895.23,Other,225% New York Medicaid APG,3328.76,,,3328.76,Other,153% New York Medicaid APG,4895.23,,,4895.23,Other,225% New York Medicaid APG,3045.92,,,3045.92,Other,140% New York Medicaid APG,4895.23,,,4895.23,Other,225% New York Medicaid APG,5656.71,,,5656.71,Other,260% New York Medicaid APG,7049.13,,,7049.13,Other,324% New York Medicaid APG,4677.66,,,4677.66,Other,215% New York Medicaid APG,4677.66,,,4677.66,Other,215% New York Medicaid APG,2719.57,,,2719.57,Other,125% New York Medicaid APG,2175.66,91151.08,
Remove cranial cavity fluid,61000,CPT,,,,,,,,both,,,14545.81,10763.9,74,,10763.9,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,6545.61,45,,6545.61,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,7200.18,49.5,,7200.18,percent of total billed charges,110% of Medicare,9891.15,68,,9891.15,percent of total billed charges,,966.11,,,966.11,Other,186% of Medicaid,11636.65,80,,11636.65,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,11636.65,80,,11636.65,percent of total billed charges,,7216,,,7216,Case Rate,,3578,,"100% primary, 0% secondary procedures",3578,Other,MagnaCare ASC Grouper,10182.07,70,,10182.07,percent of total billed charges,,559.24,,,559.24,Fee Schedule,,473.99,,,473.99,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,519.42,,,519.42,Other,New York Medicaid APG methodology,519.42,,,519.42,Other,100% New York Medicaid APG,519.42,,,519.42,Other,100% New York Medicaid APG,519.42,,,519.42,Other,100% New York Medicaid APG,1168.69,,,1168.69,Other,225% New York Medicaid APG,794.71,,,794.71,Other,153% New York Medicaid APG,1168.69,,,1168.69,Other,225% New York Medicaid APG,727.18,,,727.18,Other,140% New York Medicaid APG,1168.69,,,1168.69,Other,225% New York Medicaid APG,1350.48,,,1350.48,Other,260% New York Medicaid APG,1682.91,,,1682.91,Other,324% New York Medicaid APG,1116.74,,,1116.74,Other,215% New York Medicaid APG,1116.74,,,1116.74,Other,215% New York Medicaid APG,649.27,,,649.27,Other,125% New York Medicaid APG,473.99,11636.65,
Remove cranial cavity fluid,61001,CPT,,,,,,,,both,,,14545.81,10763.9,74,,10763.9,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,6545.61,45,,6545.61,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,7200.18,49.5,,7200.18,percent of total billed charges,110% of Medicare,9891.15,68,,9891.15,percent of total billed charges,,966.11,,,966.11,Other,186% of Medicaid,11636.65,80,,11636.65,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,11636.65,80,,11636.65,percent of total billed charges,,7216,,,7216,Case Rate,,3578,,"100% primary, 0% secondary procedures",3578,Other,MagnaCare ASC Grouper,10182.07,70,,10182.07,percent of total billed charges,,528.08,,,528.08,Fee Schedule,,447.58,,,447.58,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,519.42,,,519.42,Other,New York Medicaid APG methodology,519.42,,,519.42,Other,100% New York Medicaid APG,519.42,,,519.42,Other,100% New York Medicaid APG,519.42,,,519.42,Other,100% New York Medicaid APG,1168.69,,,1168.69,Other,225% New York Medicaid APG,794.71,,,794.71,Other,153% New York Medicaid APG,1168.69,,,1168.69,Other,225% New York Medicaid APG,727.18,,,727.18,Other,140% New York Medicaid APG,1168.69,,,1168.69,Other,225% New York Medicaid APG,1350.48,,,1350.48,Other,260% New York Medicaid APG,1682.91,,,1682.91,Other,324% New York Medicaid APG,1116.74,,,1116.74,Other,215% New York Medicaid APG,1116.74,,,1116.74,Other,215% New York Medicaid APG,649.27,,,649.27,Other,125% New York Medicaid APG,447.58,11636.65,
Remove brain cavity fluid,61020,CPT,,,,,,,,both,,,19171.82,14187.15,74,,14187.15,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,8627.32,45,,8627.32,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,9490.05,49.5,,9490.05,percent of total billed charges,110% of Medicare,13036.84,68,,13036.84,percent of total billed charges,,1119.84,,,1119.84,Other,186% of Medicaid,15337.46,80,,15337.46,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,15337.46,80,,15337.46,percent of total billed charges,,7216,,,7216,Case Rate,,3578,,"100% primary, 0% secondary procedures",3578,Other,MagnaCare ASC Grouper,13420.27,70,,13420.27,percent of total billed charges,,521.52,,,521.52,Fee Schedule,,442.02,,,442.02,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,602.07,,,602.07,Other,New York Medicaid APG methodology,602.07,,,602.07,Other,100% New York Medicaid APG,602.07,,,602.07,Other,100% New York Medicaid APG,602.07,,,602.07,Other,100% New York Medicaid APG,1354.65,,,1354.65,Other,225% New York Medicaid APG,921.16,,,921.16,Other,153% New York Medicaid APG,1354.65,,,1354.65,Other,225% New York Medicaid APG,842.89,,,842.89,Other,140% New York Medicaid APG,1354.65,,,1354.65,Other,225% New York Medicaid APG,1565.37,,,1565.37,Other,260% New York Medicaid APG,1950.69,,,1950.69,Other,324% New York Medicaid APG,1294.44,,,1294.44,Other,215% New York Medicaid APG,1294.44,,,1294.44,Other,215% New York Medicaid APG,752.58,,,752.58,Other,125% New York Medicaid APG,442.02,15337.46,
Injection into brain canal,61026,CPT,,,,,,,,both,,,14545.81,10763.9,74,,10763.9,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,6545.61,45,,6545.61,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,7200.18,49.5,,7200.18,percent of total billed charges,110% of Medicare,9891.15,68,,9891.15,percent of total billed charges,,1119.84,,,1119.84,Other,186% of Medicaid,11636.65,80,,11636.65,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,11636.65,80,,11636.65,percent of total billed charges,,7216,,,7216,Case Rate,,3578,,"100% primary, 0% secondary procedures",3578,Other,MagnaCare ASC Grouper,10182.07,70,,10182.07,percent of total billed charges,,523.16,,,523.16,Fee Schedule,,443.41,,,443.41,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,602.07,,,602.07,Other,New York Medicaid APG methodology,602.07,,,602.07,Other,100% New York Medicaid APG,602.07,,,602.07,Other,100% New York Medicaid APG,602.07,,,602.07,Other,100% New York Medicaid APG,1354.65,,,1354.65,Other,225% New York Medicaid APG,921.16,,,921.16,Other,153% New York Medicaid APG,1354.65,,,1354.65,Other,225% New York Medicaid APG,842.89,,,842.89,Other,140% New York Medicaid APG,1354.65,,,1354.65,Other,225% New York Medicaid APG,1565.37,,,1565.37,Other,260% New York Medicaid APG,1950.69,,,1950.69,Other,324% New York Medicaid APG,1294.44,,,1294.44,Other,215% New York Medicaid APG,1294.44,,,1294.44,Other,215% New York Medicaid APG,752.58,,,752.58,Other,125% New York Medicaid APG,443.41,11636.65,
Remove brain canal fluid,61050,CPT,,,,,,,,both,,,6229.82,4610.07,74,,4610.07,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,2803.42,45,,2803.42,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,3083.76,49.5,,3083.76,percent of total billed charges,110% of Medicare,4236.28,68,,4236.28,percent of total billed charges,,966.11,,,966.11,Other,186% of Medicaid,4983.86,80,,4983.86,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,4983.86,80,,4983.86,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,4360.87,70,,4360.87,percent of total billed charges,,388.68,,,388.68,Fee Schedule,,329.43,,,329.43,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,519.42,,,519.42,Other,New York Medicaid APG methodology,519.42,,,519.42,Other,100% New York Medicaid APG,519.42,,,519.42,Other,100% New York Medicaid APG,519.42,,,519.42,Other,100% New York Medicaid APG,1168.69,,,1168.69,Other,225% New York Medicaid APG,794.71,,,794.71,Other,153% New York Medicaid APG,1168.69,,,1168.69,Other,225% New York Medicaid APG,727.18,,,727.18,Other,140% New York Medicaid APG,1168.69,,,1168.69,Other,225% New York Medicaid APG,1350.48,,,1350.48,Other,260% New York Medicaid APG,1682.91,,,1682.91,Other,324% New York Medicaid APG,1116.74,,,1116.74,Other,215% New York Medicaid APG,1116.74,,,1116.74,Other,215% New York Medicaid APG,649.27,,,649.27,Other,125% New York Medicaid APG,329.43,7216,
Injection into brain canal,61055,CPT,,,,,,,,both,,,6229.82,4610.07,74,,4610.07,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,2803.42,45,,2803.42,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,3083.76,49.5,,3083.76,percent of total billed charges,110% of Medicare,4236.28,68,,4236.28,percent of total billed charges,,966.11,,,966.11,Other,186% of Medicaid,4983.86,80,,4983.86,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,4983.86,80,,4983.86,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,4360.87,70,,4360.87,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,519.42,,,519.42,Other,New York Medicaid APG methodology,519.42,,,519.42,Other,100% New York Medicaid APG,519.42,,,519.42,Other,100% New York Medicaid APG,519.42,,,519.42,Other,100% New York Medicaid APG,1168.69,,,1168.69,Other,225% New York Medicaid APG,794.71,,,794.71,Other,153% New York Medicaid APG,1168.69,,,1168.69,Other,225% New York Medicaid APG,727.18,,,727.18,Other,140% New York Medicaid APG,1168.69,,,1168.69,Other,225% New York Medicaid APG,1350.48,,,1350.48,Other,260% New York Medicaid APG,1682.91,,,1682.91,Other,324% New York Medicaid APG,1116.74,,,1116.74,Other,215% New York Medicaid APG,1116.74,,,1116.74,Other,215% New York Medicaid APG,649.27,,,649.27,Other,125% New York Medicaid APG,519.42,7216,
Brain canal shunt procedure,61070,CPT,,,,,,,,both,,,31698,23456.52,74,,23456.52,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,14264.1,45,,14264.1,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,15690.51,49.5,,15690.51,percent of total billed charges,110% of Medicare,21554.64,68,,21554.64,percent of total billed charges,,966.11,,,966.11,Other,186% of Medicaid,25358.4,80,,25358.4,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,25358.4,80,,25358.4,percent of total billed charges,,7216,,,7216,Case Rate,,3578,,"100% primary, 0% secondary procedures",3578,Other,MagnaCare ASC Grouper,22188.6,70,,22188.6,percent of total billed charges,,275.52,,,275.52,Fee Schedule,,233.52,,,233.52,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,519.42,,,519.42,Other,New York Medicaid APG methodology,519.42,,,519.42,Other,100% New York Medicaid APG,519.42,,,519.42,Other,100% New York Medicaid APG,519.42,,,519.42,Other,100% New York Medicaid APG,1168.69,,,1168.69,Other,225% New York Medicaid APG,794.71,,,794.71,Other,153% New York Medicaid APG,1168.69,,,1168.69,Other,225% New York Medicaid APG,727.18,,,727.18,Other,140% New York Medicaid APG,1168.69,,,1168.69,Other,225% New York Medicaid APG,1350.48,,,1350.48,Other,260% New York Medicaid APG,1682.91,,,1682.91,Other,324% New York Medicaid APG,1116.74,,,1116.74,Other,215% New York Medicaid APG,1116.74,,,1116.74,Other,215% New York Medicaid APG,649.27,,,649.27,Other,125% New York Medicaid APG,233.52,25358.4,
Insert brain-fluid device,61215,CPT,,,,,,,,both,,,140115.1,103685.17,74,,103685.17,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,63051.8,45,,63051.8,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,69356.97,49.5,,69356.97,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5525.48,,,5525.48,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,98080.57,70,,98080.57,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,2970.69,,,2970.69,Other,New York Medicaid APG methodology,2970.69,,,2970.69,Other,100% New York Medicaid APG,2970.69,,,2970.69,Other,100% New York Medicaid APG,2970.69,,,2970.69,Other,100% New York Medicaid APG,6684.05,,,6684.05,Other,225% New York Medicaid APG,4545.16,,,4545.16,Other,153% New York Medicaid APG,6684.05,,,6684.05,Other,225% New York Medicaid APG,4158.97,,,4158.97,Other,140% New York Medicaid APG,6684.05,,,6684.05,Other,225% New York Medicaid APG,7723.79,,,7723.79,Other,260% New York Medicaid APG,9625.03,,,9625.03,Other,324% New York Medicaid APG,6386.98,,,6386.98,Other,215% New York Medicaid APG,6386.98,,,6386.98,Other,215% New York Medicaid APG,3713.36,,,3713.36,Other,125% New York Medicaid APG,2970.69,103685.17,
Decompress eye socket,61330,CPT,,,,,,,,both,,,67720.49,50113.16,74,,50113.16,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30474.22,45,,30474.22,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,33521.64,49.5,,33521.64,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,0.02,,,0.02,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,47404.34,70,,47404.34,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% New York Medicaid APG,0.01,,,0.01,Other,100% New York Medicaid APG,0.01,,,0.01,Other,100% New York Medicaid APG,0.02,,,0.02,Other,225% New York Medicaid APG,0.02,,,0.02,Other,153% New York Medicaid APG,0.02,,,0.02,Other,225% New York Medicaid APG,0.01,,,0.01,Other,140% New York Medicaid APG,0.02,,,0.02,Other,225% New York Medicaid APG,0.03,,,0.03,Other,260% New York Medicaid APG,0.03,,,0.03,Other,324% New York Medicaid APG,0.02,,,0.02,Other,215% New York Medicaid APG,0.02,,,0.02,Other,215% New York Medicaid APG,0.01,,,0.01,Other,125% New York Medicaid APG,0.01,50113.16,
Endovasc tempory vessel occl,61623,CPT,,,,,,,,both,,,231395.43,171232.62,74,,171232.62,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,104127.94,45,,104127.94,percent of total billed charges,Medicare Ratio of cost to charges,5459,,"100% primary, 50% supplemental procedure",5459,Other,Aetna ASC Grouper,4913,,"100% primary, 50% supplemental procedure",4913,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,114540.74,49.5,,114540.74,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,4555.38,,,4555.38,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9196,,"100% primary, 0% secondary procedures",9196,Other,MagnaCare ASC Grouper,161976.8,70,,161976.8,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6956,,"100% primary, 50% secondary, 25% tertiary procedure",6956,Other,United Healthcare ASC Grouper,6261,,"100% primary, 50% secondary, 25% tertiary procedure",6261,Other,United Healthcare ASC Grouper,6956,,"100% primary, 50% secondary, 25% tertiary procedure",6956,Other,United Healthcare ASC Grouper,5913,,"100% primary, 50% secondary, 25% tertiary procedure",5913,Other,United Healthcare ASC Grouper,2449.13,,,2449.13,Other,New York Medicaid APG methodology,2449.13,,,2449.13,Other,100% New York Medicaid APG,2449.13,,,2449.13,Other,100% New York Medicaid APG,2449.13,,,2449.13,Other,100% New York Medicaid APG,5510.54,,,5510.54,Other,225% New York Medicaid APG,3747.17,,,3747.17,Other,153% New York Medicaid APG,5510.54,,,5510.54,Other,225% New York Medicaid APG,3428.78,,,3428.78,Other,140% New York Medicaid APG,5510.54,,,5510.54,Other,225% New York Medicaid APG,6367.74,,,6367.74,Other,260% New York Medicaid APG,7935.18,,,7935.18,Other,324% New York Medicaid APG,5265.63,,,5265.63,Other,215% New York Medicaid APG,5265.63,,,5265.63,Other,215% New York Medicaid APG,3061.41,,,3061.41,Other,125% New York Medicaid APG,2449.13,171232.62,
Transcath occlusion non-cns,61626,CPT,,,,,,,,both,,,231395.43,171232.62,74,,171232.62,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,104127.94,45,,104127.94,percent of total billed charges,Medicare Ratio of cost to charges,5459,,"100% primary, 50% supplemental procedure",5459,Other,Aetna ASC Grouper,4913,,"100% primary, 50% supplemental procedure",4913,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,114540.74,49.5,,114540.74,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,4555.38,,,4555.38,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9196,,"100% primary, 0% secondary procedures",9196,Other,MagnaCare ASC Grouper,161976.8,70,,161976.8,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6956,,"100% primary, 50% secondary, 25% tertiary procedure",6956,Other,United Healthcare ASC Grouper,6261,,"100% primary, 50% secondary, 25% tertiary procedure",6261,Other,United Healthcare ASC Grouper,6956,,"100% primary, 50% secondary, 25% tertiary procedure",6956,Other,United Healthcare ASC Grouper,5913,,"100% primary, 50% secondary, 25% tertiary procedure",5913,Other,United Healthcare ASC Grouper,2449.13,,,2449.13,Other,New York Medicaid APG methodology,2449.13,,,2449.13,Other,100% New York Medicaid APG,2449.13,,,2449.13,Other,100% New York Medicaid APG,2449.13,,,2449.13,Other,100% New York Medicaid APG,5510.54,,,5510.54,Other,225% New York Medicaid APG,3747.17,,,3747.17,Other,153% New York Medicaid APG,5510.54,,,5510.54,Other,225% New York Medicaid APG,3428.78,,,3428.78,Other,140% New York Medicaid APG,5510.54,,,5510.54,Other,225% New York Medicaid APG,6367.74,,,6367.74,Other,260% New York Medicaid APG,7935.18,,,7935.18,Other,324% New York Medicaid APG,5265.63,,,5265.63,Other,215% New York Medicaid APG,5265.63,,,5265.63,Other,215% New York Medicaid APG,3061.41,,,3061.41,Other,125% New York Medicaid APG,2449.13,171232.62,
Incise skull/brain surgery,61720,CPT,,,,,,,,both,,,140115.1,103685.17,74,,103685.17,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,63051.8,45,,63051.8,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,69356.97,49.5,,69356.97,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,4659.19,,,4659.19,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,98080.57,70,,98080.57,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,2504.94,,,2504.94,Other,New York Medicaid APG methodology,2504.94,,,2504.94,Other,100% New York Medicaid APG,2504.94,,,2504.94,Other,100% New York Medicaid APG,2504.94,,,2504.94,Other,100% New York Medicaid APG,5636.11,,,5636.11,Other,225% New York Medicaid APG,3832.56,,,3832.56,Other,153% New York Medicaid APG,5636.11,,,5636.11,Other,225% New York Medicaid APG,3506.92,,,3506.92,Other,140% New York Medicaid APG,5636.11,,,5636.11,Other,225% New York Medicaid APG,6512.84,,,6512.84,Other,260% New York Medicaid APG,8116.01,,,8116.01,Other,324% New York Medicaid APG,5385.62,,,5385.62,Other,215% New York Medicaid APG,5385.62,,,5385.62,Other,215% New York Medicaid APG,3131.17,,,3131.17,Other,125% New York Medicaid APG,2504.94,103685.17,
Incise skull for treatment,61770,CPT,,,,,,,,both,,,140115.1,103685.17,74,,103685.17,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,63051.8,45,,63051.8,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,69356.97,49.5,,69356.97,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,4659.19,,,4659.19,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,98080.57,70,,98080.57,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,2504.94,,,2504.94,Other,New York Medicaid APG methodology,2504.94,,,2504.94,Other,100% New York Medicaid APG,2504.94,,,2504.94,Other,100% New York Medicaid APG,2504.94,,,2504.94,Other,100% New York Medicaid APG,5636.11,,,5636.11,Other,225% New York Medicaid APG,3832.56,,,3832.56,Other,153% New York Medicaid APG,5636.11,,,5636.11,Other,225% New York Medicaid APG,3506.92,,,3506.92,Other,140% New York Medicaid APG,5636.11,,,5636.11,Other,225% New York Medicaid APG,6512.84,,,6512.84,Other,260% New York Medicaid APG,8116.01,,,8116.01,Other,324% New York Medicaid APG,5385.62,,,5385.62,Other,215% New York Medicaid APG,5385.62,,,5385.62,Other,215% New York Medicaid APG,3131.17,,,3131.17,Other,125% New York Medicaid APG,2504.94,103685.17,
Scan proc cranial intra,61781,CPT,,,,,,,,both,,,51572.04,38163.31,74,,38163.31,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,23207.42,45,,23207.42,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,25528.16,49.5,,25528.16,percent of total billed charges,110% of Medicare,35068.99,68,,35068.99,percent of total billed charges,,0.02,,,0.02,Other,186% of Medicaid,41257.63,80,,41257.63,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,41257.63,80,,41257.63,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,36100.43,70,,36100.43,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% New York Medicaid APG,0.01,,,0.01,Other,100% New York Medicaid APG,0.01,,,0.01,Other,100% New York Medicaid APG,0.02,,,0.02,Other,225% New York Medicaid APG,0.02,,,0.02,Other,153% New York Medicaid APG,0.02,,,0.02,Other,225% New York Medicaid APG,0.01,,,0.01,Other,140% New York Medicaid APG,0.02,,,0.02,Other,225% New York Medicaid APG,0.03,,,0.03,Other,260% New York Medicaid APG,0.03,,,0.03,Other,324% New York Medicaid APG,0.02,,,0.02,Other,215% New York Medicaid APG,0.02,,,0.02,Other,215% New York Medicaid APG,0.01,,,0.01,Other,125% New York Medicaid APG,0.01,41257.63,
Scan proc cranial extra,61782,CPT,,,,,,,,both,,,51572.04,38163.31,74,,38163.31,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,23207.42,45,,23207.42,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,25528.16,49.5,,25528.16,percent of total billed charges,110% of Medicare,35068.99,68,,35068.99,percent of total billed charges,,0.02,,,0.02,Other,186% of Medicaid,41257.63,80,,41257.63,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,41257.63,80,,41257.63,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,36100.43,70,,36100.43,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% New York Medicaid APG,0.01,,,0.01,Other,100% New York Medicaid APG,0.01,,,0.01,Other,100% New York Medicaid APG,0.02,,,0.02,Other,225% New York Medicaid APG,0.02,,,0.02,Other,153% New York Medicaid APG,0.02,,,0.02,Other,225% New York Medicaid APG,0.01,,,0.01,Other,140% New York Medicaid APG,0.02,,,0.02,Other,225% New York Medicaid APG,0.03,,,0.03,Other,260% New York Medicaid APG,0.03,,,0.03,Other,324% New York Medicaid APG,0.02,,,0.02,Other,215% New York Medicaid APG,0.02,,,0.02,Other,215% New York Medicaid APG,0.01,,,0.01,Other,125% New York Medicaid APG,0.01,41257.63,
Scan proc spinal,61783,CPT,,,,,,,,both,,,51572.04,38163.31,74,,38163.31,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,23207.42,45,,23207.42,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,25528.16,49.5,,25528.16,percent of total billed charges,110% of Medicare,35068.99,68,,35068.99,percent of total billed charges,,5525.48,,,5525.48,Other,186% of Medicaid,41257.63,80,,41257.63,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,41257.63,80,,41257.63,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,36100.43,70,,36100.43,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,2970.69,,,2970.69,Other,New York Medicaid APG methodology,2970.69,,,2970.69,Other,100% New York Medicaid APG,2970.69,,,2970.69,Other,100% New York Medicaid APG,2970.69,,,2970.69,Other,100% New York Medicaid APG,6684.05,,,6684.05,Other,225% New York Medicaid APG,4545.16,,,4545.16,Other,153% New York Medicaid APG,6684.05,,,6684.05,Other,225% New York Medicaid APG,4158.97,,,4158.97,Other,140% New York Medicaid APG,6684.05,,,6684.05,Other,225% New York Medicaid APG,7723.79,,,7723.79,Other,260% New York Medicaid APG,9625.03,,,9625.03,Other,324% New York Medicaid APG,6386.98,,,6386.98,Other,215% New York Medicaid APG,6386.98,,,6386.98,Other,215% New York Medicaid APG,3713.36,,,3713.36,Other,125% New York Medicaid APG,2053,41257.63,
Treat trigeminal nerve,61790,CPT,,,,,,,,both,,,40611.5,30052.51,74,,30052.51,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,18275.18,45,,18275.18,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,20102.69,49.5,,20102.69,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,0.02,,,0.02,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,28428.05,70,,28428.05,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% New York Medicaid APG,0.01,,,0.01,Other,100% New York Medicaid APG,0.01,,,0.01,Other,100% New York Medicaid APG,0.02,,,0.02,Other,225% New York Medicaid APG,0.02,,,0.02,Other,153% New York Medicaid APG,0.02,,,0.02,Other,225% New York Medicaid APG,0.01,,,0.01,Other,140% New York Medicaid APG,0.02,,,0.02,Other,225% New York Medicaid APG,0.03,,,0.03,Other,260% New York Medicaid APG,0.03,,,0.03,Other,324% New York Medicaid APG,0.02,,,0.02,Other,215% New York Medicaid APG,0.02,,,0.02,Other,215% New York Medicaid APG,0.01,,,0.01,Other,125% New York Medicaid APG,0.01,30052.51,
Treat trigeminal tract,61791,CPT,,,,,,,,both,,,40611.5,30052.51,74,,30052.51,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,18275.18,45,,18275.18,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,20102.69,49.5,,20102.69,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,0.02,,,0.02,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,28428.05,70,,28428.05,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% New York Medicaid APG,0.01,,,0.01,Other,100% New York Medicaid APG,0.01,,,0.01,Other,100% New York Medicaid APG,0.02,,,0.02,Other,225% New York Medicaid APG,0.02,,,0.02,Other,153% New York Medicaid APG,0.02,,,0.02,Other,225% New York Medicaid APG,0.01,,,0.01,Other,140% New York Medicaid APG,0.02,,,0.02,Other,225% New York Medicaid APG,0.03,,,0.03,Other,260% New York Medicaid APG,0.03,,,0.03,Other,324% New York Medicaid APG,0.02,,,0.02,Other,215% New York Medicaid APG,0.02,,,0.02,Other,215% New York Medicaid APG,0.01,,,0.01,Other,125% New York Medicaid APG,0.01,30052.51,
Revise/remove neuroelectrode,61880,CPT,,,,,,,,both,,,71436.43,52862.96,74,,52862.96,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,32146.39,45,,32146.39,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,35361.03,49.5,,35361.03,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3388.68,,,3388.68,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,50005.5,70,,50005.5,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1821.87,,,1821.87,Other,New York Medicaid APG methodology,1821.87,,,1821.87,Other,100% New York Medicaid APG,1821.87,,,1821.87,Other,100% New York Medicaid APG,1821.87,,,1821.87,Other,100% New York Medicaid APG,4099.2,,,4099.2,Other,225% New York Medicaid APG,2787.46,,,2787.46,Other,153% New York Medicaid APG,4099.2,,,4099.2,Other,225% New York Medicaid APG,2550.62,,,2550.62,Other,140% New York Medicaid APG,4099.2,,,4099.2,Other,225% New York Medicaid APG,4736.86,,,4736.86,Other,260% New York Medicaid APG,5902.85,,,5902.85,Other,324% New York Medicaid APG,3917.02,,,3917.02,Other,215% New York Medicaid APG,3917.02,,,3917.02,Other,215% New York Medicaid APG,2277.34,,,2277.34,Other,125% New York Medicaid APG,1821.87,52862.96,
Insrt/redo neurostim 1 array,61885,CPT,,,,,,,,both,,,136359.6,100906.1,74,,100906.1,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,61361.82,45,,61361.82,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,67498,49.5,,67498,percent of total billed charges,110% of Medicare,92724.53,68,,92724.53,percent of total billed charges,,31375.51,,,31375.51,Other,186% of Medicaid,109087.68,80,,109087.68,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,109087.68,80,,109087.68,percent of total billed charges,,7216,,,7216,Case Rate,,9196,,"100% primary, 0% secondary procedures",9196,Other,MagnaCare ASC Grouper,95451.72,70,,95451.72,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,8589,,"100% primary, 50% secondary, 25% tertiary procedure",8589,Other,United Healthcare ASC Grouper,7730,,"100% primary, 50% secondary, 25% tertiary procedure",7730,Other,United Healthcare ASC Grouper,8589,,"100% primary, 50% secondary, 25% tertiary procedure",8589,Other,United Healthcare ASC Grouper,7301,,"100% primary, 50% secondary, 25% tertiary procedure",7301,Other,United Healthcare ASC Grouper,16868.56,,,16868.56,Other,New York Medicaid APG methodology,16868.56,,,16868.56,Other,100% New York Medicaid APG,16868.56,,,16868.56,Other,100% New York Medicaid APG,16868.56,,,16868.56,Other,100% New York Medicaid APG,37954.25,,,37954.25,Other,225% New York Medicaid APG,25808.89,,,25808.89,Other,153% New York Medicaid APG,37954.25,,,37954.25,Other,225% New York Medicaid APG,23615.98,,,23615.98,Other,140% New York Medicaid APG,37954.25,,,37954.25,Other,225% New York Medicaid APG,43858.24,,,43858.24,Other,260% New York Medicaid APG,54654.12,,,54654.12,Other,324% New York Medicaid APG,36267.39,,,36267.39,Other,215% New York Medicaid APG,36267.39,,,36267.39,Other,215% New York Medicaid APG,21085.69,,,21085.69,Other,125% New York Medicaid APG,2232,109087.68,
Implant neurostim arrays,61886,CPT,,,,,,,,both,,,127026.69,93999.75,74,,93999.75,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,57162.01,45,,57162.01,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,62878.21,49.5,,62878.21,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,31375.51,,,31375.51,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9196,,"100% primary, 0% secondary procedures",9196,Other,MagnaCare ASC Grouper,88918.68,70,,88918.68,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,15267,,"100% primary, 50% secondary, 25% tertiary procedure",15267,Other,United Healthcare ASC Grouper,13740,,"100% primary, 50% secondary, 25% tertiary procedure",13740,Other,United Healthcare ASC Grouper,15267,,"100% primary, 50% secondary, 25% tertiary procedure",15267,Other,United Healthcare ASC Grouper,12977,,"100% primary, 50% secondary, 25% tertiary procedure",12977,Other,United Healthcare ASC Grouper,16868.56,,,16868.56,Other,New York Medicaid APG methodology,16868.56,,,16868.56,Other,100% New York Medicaid APG,16868.56,,,16868.56,Other,100% New York Medicaid APG,16868.56,,,16868.56,Other,100% New York Medicaid APG,37954.25,,,37954.25,Other,225% New York Medicaid APG,25808.89,,,25808.89,Other,153% New York Medicaid APG,37954.25,,,37954.25,Other,225% New York Medicaid APG,23615.98,,,23615.98,Other,140% New York Medicaid APG,37954.25,,,37954.25,Other,225% New York Medicaid APG,43858.24,,,43858.24,Other,260% New York Medicaid APG,54654.12,,,54654.12,Other,324% New York Medicaid APG,36267.39,,,36267.39,Other,215% New York Medicaid APG,36267.39,,,36267.39,Other,215% New York Medicaid APG,21085.69,,,21085.69,Other,125% New York Medicaid APG,3126,93999.75,
Revise/remove neuroreceiver,61888,CPT,,,,,,,,both,,,215576.2,159526.39,74,,159526.39,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,97009.29,45,,97009.29,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,106710.22,49.5,,106710.22,percent of total billed charges,110% of Medicare,146591.82,68,,146591.82,percent of total billed charges,,3388.68,,,3388.68,Other,186% of Medicaid,172460.96,80,,172460.96,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,172460.96,80,,172460.96,percent of total billed charges,,7216,,,7216,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,150903.34,70,,150903.34,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1821.87,,,1821.87,Other,New York Medicaid APG methodology,1821.87,,,1821.87,Other,100% New York Medicaid APG,1821.87,,,1821.87,Other,100% New York Medicaid APG,1821.87,,,1821.87,Other,100% New York Medicaid APG,4099.2,,,4099.2,Other,225% New York Medicaid APG,2787.46,,,2787.46,Other,153% New York Medicaid APG,4099.2,,,4099.2,Other,225% New York Medicaid APG,2550.62,,,2550.62,Other,140% New York Medicaid APG,4099.2,,,4099.2,Other,225% New York Medicaid APG,4736.86,,,4736.86,Other,260% New York Medicaid APG,5902.85,,,5902.85,Other,324% New York Medicaid APG,3917.02,,,3917.02,Other,215% New York Medicaid APG,3917.02,,,3917.02,Other,215% New York Medicaid APG,2277.34,,,2277.34,Other,125% New York Medicaid APG,1821.87,172460.96,
Treat skull fracture,62000,CPT,,,,,,,,both,,,67720.49,50113.16,74,,50113.16,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30474.22,45,,30474.22,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,33521.64,49.5,,33521.64,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,4659.19,,,4659.19,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,47404.34,70,,47404.34,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,2504.94,,,2504.94,Other,New York Medicaid APG methodology,2504.94,,,2504.94,Other,100% New York Medicaid APG,2504.94,,,2504.94,Other,100% New York Medicaid APG,2504.94,,,2504.94,Other,100% New York Medicaid APG,5636.11,,,5636.11,Other,225% New York Medicaid APG,3832.56,,,3832.56,Other,153% New York Medicaid APG,5636.11,,,5636.11,Other,225% New York Medicaid APG,3506.92,,,3506.92,Other,140% New York Medicaid APG,5636.11,,,5636.11,Other,225% New York Medicaid APG,6512.84,,,6512.84,Other,260% New York Medicaid APG,8116.01,,,8116.01,Other,324% New York Medicaid APG,5385.62,,,5385.62,Other,215% New York Medicaid APG,5385.62,,,5385.62,Other,215% New York Medicaid APG,3131.17,,,3131.17,Other,125% New York Medicaid APG,2504.94,50113.16,
Neuroendoscopy add-on,62160,CPT,,,,,,,,both,,,51572.04,38163.31,74,,38163.31,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,23207.42,45,,23207.42,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,25528.16,49.5,,25528.16,percent of total billed charges,110% of Medicare,35068.99,68,,35068.99,percent of total billed charges,,4659.19,,,4659.19,Other,186% of Medicaid,41257.63,80,,41257.63,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,41257.63,80,,41257.63,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,36100.43,70,,36100.43,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,2504.94,,,2504.94,Other,New York Medicaid APG methodology,2504.94,,,2504.94,Other,100% New York Medicaid APG,2504.94,,,2504.94,Other,100% New York Medicaid APG,2504.94,,,2504.94,Other,100% New York Medicaid APG,5636.11,,,5636.11,Other,225% New York Medicaid APG,3832.56,,,3832.56,Other,153% New York Medicaid APG,5636.11,,,5636.11,Other,225% New York Medicaid APG,3506.92,,,3506.92,Other,140% New York Medicaid APG,5636.11,,,5636.11,Other,225% New York Medicaid APG,6512.84,,,6512.84,Other,260% New York Medicaid APG,8116.01,,,8116.01,Other,324% New York Medicaid APG,5385.62,,,5385.62,Other,215% New York Medicaid APG,5385.62,,,5385.62,Other,215% New York Medicaid APG,3131.17,,,3131.17,Other,125% New York Medicaid APG,2053,41257.63,
Replace/irrigate catheter,62194,CPT,,,,,,,,both,,,40611.5,30052.51,74,,30052.51,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,18275.18,45,,18275.18,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,20102.69,49.5,,20102.69,percent of total billed charges,110% of Medicare,27615.82,68,,27615.82,percent of total billed charges,,1116.35,,,1116.35,Other,186% of Medicaid,32489.2,80,,32489.2,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,32489.2,80,,32489.2,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,28428.05,70,,28428.05,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,600.19,,,600.19,Other,New York Medicaid APG methodology,600.19,,,600.19,Other,100% New York Medicaid APG,600.19,,,600.19,Other,100% New York Medicaid APG,600.19,,,600.19,Other,100% New York Medicaid APG,1350.43,,,1350.43,Other,225% New York Medicaid APG,918.29,,,918.29,Other,153% New York Medicaid APG,1350.43,,,1350.43,Other,225% New York Medicaid APG,840.26,,,840.26,Other,140% New York Medicaid APG,1350.43,,,1350.43,Other,225% New York Medicaid APG,1560.49,,,1560.49,Other,260% New York Medicaid APG,1944.61,,,1944.61,Other,324% New York Medicaid APG,1290.41,,,1290.41,Other,215% New York Medicaid APG,1290.41,,,1290.41,Other,215% New York Medicaid APG,750.24,,,750.24,Other,125% New York Medicaid APG,600.19,32489.2,
Replace/irrigate catheter,62225,CPT,,,,,,,,both,,,140115.1,103685.17,74,,103685.17,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,63051.8,45,,63051.8,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,69356.97,49.5,,69356.97,percent of total billed charges,110% of Medicare,95278.27,68,,95278.27,percent of total billed charges,,6048.62,,,6048.62,Other,186% of Medicaid,112092.08,80,,112092.08,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,112092.08,80,,112092.08,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,98080.57,70,,98080.57,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,3251.95,,,3251.95,Other,New York Medicaid APG methodology,3251.95,,,3251.95,Other,100% New York Medicaid APG,3251.95,,,3251.95,Other,100% New York Medicaid APG,3251.95,,,3251.95,Other,100% New York Medicaid APG,7316.88,,,7316.88,Other,225% New York Medicaid APG,4975.48,,,4975.48,Other,153% New York Medicaid APG,7316.88,,,7316.88,Other,225% New York Medicaid APG,4552.73,,,4552.73,Other,140% New York Medicaid APG,7316.88,,,7316.88,Other,225% New York Medicaid APG,8455.06,,,8455.06,Other,260% New York Medicaid APG,10536.31,,,10536.31,Other,324% New York Medicaid APG,6991.69,,,6991.69,Other,215% New York Medicaid APG,6991.69,,,6991.69,Other,215% New York Medicaid APG,4064.93,,,4064.93,Other,125% New York Medicaid APG,2053,112092.08,
Replace/revise brain shunt,62230,CPT,,,,,,,,both,,,96963.46,71752.96,74,,71752.96,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,43633.56,45,,43633.56,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,47996.91,49.5,,47996.91,percent of total billed charges,110% of Medicare,65935.15,68,,65935.15,percent of total billed charges,,6048.62,,,6048.62,Other,186% of Medicaid,77570.77,80,,77570.77,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,77570.77,80,,77570.77,percent of total billed charges,,7216,,,7216,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,67874.42,70,,67874.42,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,3251.95,,,3251.95,Other,New York Medicaid APG methodology,3251.95,,,3251.95,Other,100% New York Medicaid APG,3251.95,,,3251.95,Other,100% New York Medicaid APG,3251.95,,,3251.95,Other,100% New York Medicaid APG,7316.88,,,7316.88,Other,225% New York Medicaid APG,4975.48,,,4975.48,Other,153% New York Medicaid APG,7316.88,,,7316.88,Other,225% New York Medicaid APG,4552.73,,,4552.73,Other,140% New York Medicaid APG,7316.88,,,7316.88,Other,225% New York Medicaid APG,8455.06,,,8455.06,Other,260% New York Medicaid APG,10536.31,,,10536.31,Other,324% New York Medicaid APG,6991.69,,,6991.69,Other,215% New York Medicaid APG,6991.69,,,6991.69,Other,215% New York Medicaid APG,4064.93,,,4064.93,Other,125% New York Medicaid APG,2232,77570.77,
Csf shunt reprogram,62252,CPT,,,,,,,,both,,,6282.58,4649.11,74,,4649.11,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,2827.16,45,,2827.16,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,3109.88,49.5,,3109.88,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,339.51,,,339.51,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,4397.81,70,,4397.81,percent of total billed charges,,4083.68,65,,4083.68,percent of total billed charges,,4083.68,65,,4083.68,percent of total billed charges,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,182.53,,,182.53,Other,New York Medicaid APG methodology,182.53,,,182.53,Other,100% New York Medicaid APG,182.53,,,182.53,Other,100% New York Medicaid APG,182.53,,,182.53,Other,100% New York Medicaid APG,410.7,,,410.7,Other,225% New York Medicaid APG,279.28,,,279.28,Other,153% New York Medicaid APG,410.7,,,410.7,Other,225% New York Medicaid APG,255.55,,,255.55,Other,140% New York Medicaid APG,410.7,,,410.7,Other,225% New York Medicaid APG,474.59,,,474.59,Other,260% New York Medicaid APG,591.41,,,591.41,Other,324% New York Medicaid APG,392.45,,,392.45,Other,215% New York Medicaid APG,392.45,,,392.45,Other,215% New York Medicaid APG,228.17,,,228.17,Other,125% New York Medicaid APG,182.53,9473,
Epidural lysis mult sessions,62263,CPT,,,,,,,,both,,,19171.82,14187.15,74,,14187.15,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,8627.32,45,,8627.32,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,9490.05,49.5,,9490.05,percent of total billed charges,110% of Medicare,13036.84,68,,13036.84,percent of total billed charges,,1116.35,,,1116.35,Other,186% of Medicaid,15337.46,80,,15337.46,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,15337.46,80,,15337.46,percent of total billed charges,,7216,,,7216,Case Rate,,3578,,"100% primary, 0% secondary procedures",3578,Other,MagnaCare ASC Grouper,13420.27,70,,13420.27,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,600.19,,,600.19,Other,New York Medicaid APG methodology,600.19,,,600.19,Other,100% New York Medicaid APG,600.19,,,600.19,Other,100% New York Medicaid APG,600.19,,,600.19,Other,100% New York Medicaid APG,1350.43,,,1350.43,Other,225% New York Medicaid APG,918.29,,,918.29,Other,153% New York Medicaid APG,1350.43,,,1350.43,Other,225% New York Medicaid APG,840.26,,,840.26,Other,140% New York Medicaid APG,1350.43,,,1350.43,Other,225% New York Medicaid APG,1560.49,,,1560.49,Other,260% New York Medicaid APG,1944.61,,,1944.61,Other,324% New York Medicaid APG,1290.41,,,1290.41,Other,215% New York Medicaid APG,1290.41,,,1290.41,Other,215% New York Medicaid APG,750.24,,,750.24,Other,125% New York Medicaid APG,600.19,15337.46,
Epidural lysis on single day,62264,CPT,,,,,,,,both,,,19171.82,14187.15,74,,14187.15,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,8627.32,45,,8627.32,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,9490.05,49.5,,9490.05,percent of total billed charges,110% of Medicare,13036.84,68,,13036.84,percent of total billed charges,,1116.35,,,1116.35,Other,186% of Medicaid,15337.46,80,,15337.46,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,15337.46,80,,15337.46,percent of total billed charges,,7216,,,7216,Case Rate,,3578,,"100% primary, 0% secondary procedures",3578,Other,MagnaCare ASC Grouper,13420.27,70,,13420.27,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,600.19,,,600.19,Other,New York Medicaid APG methodology,600.19,,,600.19,Other,100% New York Medicaid APG,600.19,,,600.19,Other,100% New York Medicaid APG,600.19,,,600.19,Other,100% New York Medicaid APG,1350.43,,,1350.43,Other,225% New York Medicaid APG,918.29,,,918.29,Other,153% New York Medicaid APG,1350.43,,,1350.43,Other,225% New York Medicaid APG,840.26,,,840.26,Other,140% New York Medicaid APG,1350.43,,,1350.43,Other,225% New York Medicaid APG,1560.49,,,1560.49,Other,260% New York Medicaid APG,1944.61,,,1944.61,Other,324% New York Medicaid APG,1290.41,,,1290.41,Other,215% New York Medicaid APG,1290.41,,,1290.41,Other,215% New York Medicaid APG,750.24,,,750.24,Other,125% New York Medicaid APG,600.19,15337.46,
Interdiscal perq aspir dx,62267,CPT,,,,,,,,both,,,33788,25003.12,74,,25003.12,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15204.6,45,,15204.6,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,16725.06,49.5,,16725.06,percent of total billed charges,110% of Medicare,22975.84,68,,22975.84,percent of total billed charges,,1116.35,,,1116.35,Other,186% of Medicaid,27030.4,80,,27030.4,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,27030.4,80,,27030.4,percent of total billed charges,,7216,,,7216,Case Rate,,3578,,"100% primary, 0% secondary procedures",3578,Other,MagnaCare ASC Grouper,23651.6,70,,23651.6,percent of total billed charges,,746.2,,,746.2,Fee Schedule,,632.45,,,632.45,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,600.19,,,600.19,Other,New York Medicaid APG methodology,600.19,,,600.19,Other,100% New York Medicaid APG,600.19,,,600.19,Other,100% New York Medicaid APG,600.19,,,600.19,Other,100% New York Medicaid APG,1350.43,,,1350.43,Other,225% New York Medicaid APG,918.29,,,918.29,Other,153% New York Medicaid APG,1350.43,,,1350.43,Other,225% New York Medicaid APG,840.26,,,840.26,Other,140% New York Medicaid APG,1350.43,,,1350.43,Other,225% New York Medicaid APG,1560.49,,,1560.49,Other,260% New York Medicaid APG,1944.61,,,1944.61,Other,324% New York Medicaid APG,1290.41,,,1290.41,Other,215% New York Medicaid APG,1290.41,,,1290.41,Other,215% New York Medicaid APG,750.24,,,750.24,Other,125% New York Medicaid APG,600.19,27030.4,
Drain spinal cord cyst,62268,CPT,,,,,,,,both,,,19171.82,14187.15,74,,14187.15,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,8627.32,45,,8627.32,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,9490.05,49.5,,9490.05,percent of total billed charges,110% of Medicare,13036.84,68,,13036.84,percent of total billed charges,,1116.35,,,1116.35,Other,186% of Medicaid,15337.46,80,,15337.46,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,15337.46,80,,15337.46,percent of total billed charges,,7216,,,7216,Case Rate,,3578,,"100% primary, 0% secondary procedures",3578,Other,MagnaCare ASC Grouper,13420.27,70,,13420.27,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,600.19,,,600.19,Other,New York Medicaid APG methodology,600.19,,,600.19,Other,100% New York Medicaid APG,600.19,,,600.19,Other,100% New York Medicaid APG,600.19,,,600.19,Other,100% New York Medicaid APG,1350.43,,,1350.43,Other,225% New York Medicaid APG,918.29,,,918.29,Other,153% New York Medicaid APG,1350.43,,,1350.43,Other,225% New York Medicaid APG,840.26,,,840.26,Other,140% New York Medicaid APG,1350.43,,,1350.43,Other,225% New York Medicaid APG,1560.49,,,1560.49,Other,260% New York Medicaid APG,1944.61,,,1944.61,Other,324% New York Medicaid APG,1290.41,,,1290.41,Other,215% New York Medicaid APG,1290.41,,,1290.41,Other,215% New York Medicaid APG,750.24,,,750.24,Other,125% New York Medicaid APG,600.19,15337.46,
Needle biopsy spinal cord,62269,CPT,,,,,,,,both,,,34101.75,25235.3,74,,25235.3,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15345.79,45,,15345.79,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,16880.37,49.5,,16880.37,percent of total billed charges,110% of Medicare,23189.19,68,,23189.19,percent of total billed charges,,1116.35,,,1116.35,Other,186% of Medicaid,27281.4,80,,27281.4,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,27281.4,80,,27281.4,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,23871.23,70,,23871.23,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,600.19,,,600.19,Other,New York Medicaid APG methodology,600.19,,,600.19,Other,100% New York Medicaid APG,600.19,,,600.19,Other,100% New York Medicaid APG,600.19,,,600.19,Other,100% New York Medicaid APG,1350.43,,,1350.43,Other,225% New York Medicaid APG,918.29,,,918.29,Other,153% New York Medicaid APG,1350.43,,,1350.43,Other,225% New York Medicaid APG,840.26,,,840.26,Other,140% New York Medicaid APG,1350.43,,,1350.43,Other,225% New York Medicaid APG,1560.49,,,1560.49,Other,260% New York Medicaid APG,1944.61,,,1944.61,Other,324% New York Medicaid APG,1290.41,,,1290.41,Other,215% New York Medicaid APG,1290.41,,,1290.41,Other,215% New York Medicaid APG,750.24,,,750.24,Other,125% New York Medicaid APG,600.19,27281.4,
Dx lmbr spi pnxr,62270,CPT,,,,,,,,both,,,15589.61,11536.31,74,,11536.31,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,7015.32,45,,7015.32,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,7716.86,49.5,,7716.86,percent of total billed charges,110% of Medicare,10600.93,68,,10600.93,percent of total billed charges,,1116.35,,,1116.35,Other,186% of Medicaid,12471.69,80,,12471.69,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,12471.69,80,,12471.69,percent of total billed charges,,7216,,,7216,Case Rate,,3578,,"100% primary, 0% secondary procedures",3578,Other,MagnaCare ASC Grouper,10912.73,70,,10912.73,percent of total billed charges,,305.04,,,305.04,Fee Schedule,,258.54,,,258.54,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,600.19,,,600.19,Other,New York Medicaid APG methodology,600.19,,,600.19,Other,100% New York Medicaid APG,600.19,,,600.19,Other,100% New York Medicaid APG,600.19,,,600.19,Other,100% New York Medicaid APG,1350.43,,,1350.43,Other,225% New York Medicaid APG,918.29,,,918.29,Other,153% New York Medicaid APG,1350.43,,,1350.43,Other,225% New York Medicaid APG,840.26,,,840.26,Other,140% New York Medicaid APG,1350.43,,,1350.43,Other,225% New York Medicaid APG,1560.49,,,1560.49,Other,260% New York Medicaid APG,1944.61,,,1944.61,Other,324% New York Medicaid APG,1290.41,,,1290.41,Other,215% New York Medicaid APG,1290.41,,,1290.41,Other,215% New York Medicaid APG,750.24,,,750.24,Other,125% New York Medicaid APG,258.54,12471.69,
Ther spi pnxr drg csf,62272,CPT,,,,,,,,both,,,402930,298168.2,74,,298168.2,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,181318.5,45,,181318.5,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,199450.35,49.5,,199450.35,percent of total billed charges,110% of Medicare,273992.4,68,,273992.4,percent of total billed charges,,1116.35,,,1116.35,Other,186% of Medicaid,322344,80,,322344,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,322344,80,,322344,percent of total billed charges,,7216,,,7216,Case Rate,,3578,,"100% primary, 0% secondary procedures",3578,Other,MagnaCare ASC Grouper,282051,70,,282051,percent of total billed charges,,442.8,,,442.8,Fee Schedule,,375.3,,,375.3,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,600.19,,,600.19,Other,New York Medicaid APG methodology,600.19,,,600.19,Other,100% New York Medicaid APG,600.19,,,600.19,Other,100% New York Medicaid APG,600.19,,,600.19,Other,100% New York Medicaid APG,1350.43,,,1350.43,Other,225% New York Medicaid APG,918.29,,,918.29,Other,153% New York Medicaid APG,1350.43,,,1350.43,Other,225% New York Medicaid APG,840.26,,,840.26,Other,140% New York Medicaid APG,1350.43,,,1350.43,Other,225% New York Medicaid APG,1560.49,,,1560.49,Other,260% New York Medicaid APG,1944.61,,,1944.61,Other,324% New York Medicaid APG,1290.41,,,1290.41,Other,215% New York Medicaid APG,1290.41,,,1290.41,Other,215% New York Medicaid APG,750.24,,,750.24,Other,125% New York Medicaid APG,375.3,322344,
Inject epidural patch,62273,CPT,,,,,,,,both,,,3306,2446.44,74,,2446.44,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,1487.7,45,,1487.7,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,1636.47,49.5,,1636.47,percent of total billed charges,110% of Medicare,2248.08,68,,2248.08,percent of total billed charges,,1116.35,,,1116.35,Other,186% of Medicaid,2644.8,80,,2644.8,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,2644.8,80,,2644.8,percent of total billed charges,,7216,,,7216,Case Rate,,3578,,"100% primary, 0% secondary procedures",3578,Other,MagnaCare ASC Grouper,2314.2,70,,2314.2,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,600.19,,,600.19,Other,New York Medicaid APG methodology,600.19,,,600.19,Other,100% New York Medicaid APG,600.19,,,600.19,Other,100% New York Medicaid APG,600.19,,,600.19,Other,100% New York Medicaid APG,1350.43,,,1350.43,Other,225% New York Medicaid APG,918.29,,,918.29,Other,153% New York Medicaid APG,1350.43,,,1350.43,Other,225% New York Medicaid APG,840.26,,,840.26,Other,140% New York Medicaid APG,1350.43,,,1350.43,Other,225% New York Medicaid APG,1560.49,,,1560.49,Other,260% New York Medicaid APG,1944.61,,,1944.61,Other,324% New York Medicaid APG,1290.41,,,1290.41,Other,215% New York Medicaid APG,1290.41,,,1290.41,Other,215% New York Medicaid APG,750.24,,,750.24,Other,125% New York Medicaid APG,600.19,7216,
Treat spinal cord lesion,62280,CPT,,,,,,,,both,,,19171.82,14187.15,74,,14187.15,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,8627.32,45,,8627.32,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,9490.05,49.5,,9490.05,percent of total billed charges,110% of Medicare,13036.84,68,,13036.84,percent of total billed charges,,1116.35,,,1116.35,Other,186% of Medicaid,15337.46,80,,15337.46,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,15337.46,80,,15337.46,percent of total billed charges,,7216,,,7216,Case Rate,,3578,,"100% primary, 0% secondary procedures",3578,Other,MagnaCare ASC Grouper,13420.27,70,,13420.27,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,600.19,,,600.19,Other,New York Medicaid APG methodology,600.19,,,600.19,Other,100% New York Medicaid APG,600.19,,,600.19,Other,100% New York Medicaid APG,600.19,,,600.19,Other,100% New York Medicaid APG,1350.43,,,1350.43,Other,225% New York Medicaid APG,918.29,,,918.29,Other,153% New York Medicaid APG,1350.43,,,1350.43,Other,225% New York Medicaid APG,840.26,,,840.26,Other,140% New York Medicaid APG,1350.43,,,1350.43,Other,225% New York Medicaid APG,1560.49,,,1560.49,Other,260% New York Medicaid APG,1944.61,,,1944.61,Other,324% New York Medicaid APG,1290.41,,,1290.41,Other,215% New York Medicaid APG,1290.41,,,1290.41,Other,215% New York Medicaid APG,750.24,,,750.24,Other,125% New York Medicaid APG,600.19,15337.46,
Treat spinal cord lesion,62281,CPT,,,,,,,,both,,,19171.82,14187.15,74,,14187.15,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,8627.32,45,,8627.32,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,9490.05,49.5,,9490.05,percent of total billed charges,110% of Medicare,13036.84,68,,13036.84,percent of total billed charges,,1116.35,,,1116.35,Other,186% of Medicaid,15337.46,80,,15337.46,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,15337.46,80,,15337.46,percent of total billed charges,,7216,,,7216,Case Rate,,3578,,"100% primary, 0% secondary procedures",3578,Other,MagnaCare ASC Grouper,13420.27,70,,13420.27,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,600.19,,,600.19,Other,New York Medicaid APG methodology,600.19,,,600.19,Other,100% New York Medicaid APG,600.19,,,600.19,Other,100% New York Medicaid APG,600.19,,,600.19,Other,100% New York Medicaid APG,1350.43,,,1350.43,Other,225% New York Medicaid APG,918.29,,,918.29,Other,153% New York Medicaid APG,1350.43,,,1350.43,Other,225% New York Medicaid APG,840.26,,,840.26,Other,140% New York Medicaid APG,1350.43,,,1350.43,Other,225% New York Medicaid APG,1560.49,,,1560.49,Other,260% New York Medicaid APG,1944.61,,,1944.61,Other,324% New York Medicaid APG,1290.41,,,1290.41,Other,215% New York Medicaid APG,1290.41,,,1290.41,Other,215% New York Medicaid APG,750.24,,,750.24,Other,125% New York Medicaid APG,600.19,15337.46,
Treat spinal canal lesion,62282,CPT,,,,,,,,both,,,19171.82,14187.15,74,,14187.15,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,8627.32,45,,8627.32,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,9490.05,49.5,,9490.05,percent of total billed charges,110% of Medicare,13036.84,68,,13036.84,percent of total billed charges,,1116.35,,,1116.35,Other,186% of Medicaid,15337.46,80,,15337.46,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,15337.46,80,,15337.46,percent of total billed charges,,7216,,,7216,Case Rate,,3578,,"100% primary, 0% secondary procedures",3578,Other,MagnaCare ASC Grouper,13420.27,70,,13420.27,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,600.19,,,600.19,Other,New York Medicaid APG methodology,600.19,,,600.19,Other,100% New York Medicaid APG,600.19,,,600.19,Other,100% New York Medicaid APG,600.19,,,600.19,Other,100% New York Medicaid APG,1350.43,,,1350.43,Other,225% New York Medicaid APG,918.29,,,918.29,Other,153% New York Medicaid APG,1350.43,,,1350.43,Other,225% New York Medicaid APG,840.26,,,840.26,Other,140% New York Medicaid APG,1350.43,,,1350.43,Other,225% New York Medicaid APG,1560.49,,,1560.49,Other,260% New York Medicaid APG,1944.61,,,1944.61,Other,324% New York Medicaid APG,1290.41,,,1290.41,Other,215% New York Medicaid APG,1290.41,,,1290.41,Other,215% New York Medicaid APG,750.24,,,750.24,Other,125% New York Medicaid APG,600.19,15337.46,
Injection for myelogram,62284,CPT,,,,,,,,both,,,32979.4,24404.76,74,,24404.76,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,14840.73,45,,14840.73,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,16324.8,49.5,,16324.8,percent of total billed charges,110% of Medicare,22425.99,68,,22425.99,percent of total billed charges,,966.93,,,966.93,Other,186% of Medicaid,26383.52,80,,26383.52,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,26383.52,80,,26383.52,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,23085.58,70,,23085.58,percent of total billed charges,,408.36,,,408.36,Fee Schedule,,346.11,,,346.11,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,519.86,,,519.86,Other,New York Medicaid APG methodology,519.86,,,519.86,Other,100% New York Medicaid APG,519.86,,,519.86,Other,100% New York Medicaid APG,519.86,,,519.86,Other,100% New York Medicaid APG,1169.68,,,1169.68,Other,225% New York Medicaid APG,795.38,,,795.38,Other,153% New York Medicaid APG,1169.68,,,1169.68,Other,225% New York Medicaid APG,727.8,,,727.8,Other,140% New York Medicaid APG,1169.68,,,1169.68,Other,225% New York Medicaid APG,1351.62,,,1351.62,Other,260% New York Medicaid APG,1684.33,,,1684.33,Other,324% New York Medicaid APG,1117.69,,,1117.69,Other,215% New York Medicaid APG,1117.69,,,1117.69,Other,215% New York Medicaid APG,649.82,,,649.82,Other,125% New York Medicaid APG,346.11,26383.52,
Percutaneous diskectomy,62287,CPT,,,,,,,,both,,,40611.5,30052.51,74,,30052.51,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,18275.18,45,,18275.18,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,20102.69,49.5,,20102.69,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5525.48,,,5525.48,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,28428.05,70,,28428.05,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,2970.69,,,2970.69,Other,New York Medicaid APG methodology,2970.69,,,2970.69,Other,100% New York Medicaid APG,2970.69,,,2970.69,Other,100% New York Medicaid APG,2970.69,,,2970.69,Other,100% New York Medicaid APG,6684.05,,,6684.05,Other,225% New York Medicaid APG,4545.16,,,4545.16,Other,153% New York Medicaid APG,6684.05,,,6684.05,Other,225% New York Medicaid APG,4158.97,,,4158.97,Other,140% New York Medicaid APG,6684.05,,,6684.05,Other,225% New York Medicaid APG,7723.79,,,7723.79,Other,260% New York Medicaid APG,9625.03,,,9625.03,Other,324% New York Medicaid APG,6386.98,,,6386.98,Other,215% New York Medicaid APG,6386.98,,,6386.98,Other,215% New York Medicaid APG,3713.36,,,3713.36,Other,125% New York Medicaid APG,2970.69,30052.51,
Njx px discography lumbar,62290,CPT,,,,,,,,both,,,32432.1,23999.75,74,,23999.75,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,14594.45,45,,14594.45,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,16053.89,49.5,,16053.89,percent of total billed charges,110% of Medicare,22053.83,68,,22053.83,percent of total billed charges,,966.93,,,966.93,Other,186% of Medicaid,25945.68,80,,25945.68,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,25945.68,80,,25945.68,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,22702.47,70,,22702.47,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,519.86,,,519.86,Other,New York Medicaid APG methodology,519.86,,,519.86,Other,100% New York Medicaid APG,519.86,,,519.86,Other,100% New York Medicaid APG,519.86,,,519.86,Other,100% New York Medicaid APG,1169.68,,,1169.68,Other,225% New York Medicaid APG,795.38,,,795.38,Other,153% New York Medicaid APG,1169.68,,,1169.68,Other,225% New York Medicaid APG,727.8,,,727.8,Other,140% New York Medicaid APG,1169.68,,,1169.68,Other,225% New York Medicaid APG,1351.62,,,1351.62,Other,260% New York Medicaid APG,1684.33,,,1684.33,Other,324% New York Medicaid APG,1117.69,,,1117.69,Other,215% New York Medicaid APG,1117.69,,,1117.69,Other,215% New York Medicaid APG,649.82,,,649.82,Other,125% New York Medicaid APG,519.86,25945.68,
Njx px discography crv/thrc,62291,CPT,,,,,,,,both,,,36356.27,26903.64,74,,26903.64,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,16360.32,45,,16360.32,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,21813.76,60,,21813.76,percent of total billed charges,,20359.51,56,,20359.51,percent of total billed charges,,19632.39,54,,19632.39,percent of total billed charges,,17996.35,49.5,,17996.35,percent of total billed charges,110% of Medicare,24722.26,68,,24722.26,percent of total billed charges,,966.93,,,966.93,Other,186% of Medicaid,29085.02,80,,29085.02,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,29085.02,80,,29085.02,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,25449.39,70,,25449.39,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,519.86,,,519.86,Other,New York Medicaid APG methodology,519.86,,,519.86,Other,100% New York Medicaid APG,519.86,,,519.86,Other,100% New York Medicaid APG,519.86,,,519.86,Other,100% New York Medicaid APG,1169.68,,,1169.68,Other,225% New York Medicaid APG,795.38,,,795.38,Other,153% New York Medicaid APG,1169.68,,,1169.68,Other,225% New York Medicaid APG,727.8,,,727.8,Other,140% New York Medicaid APG,1169.68,,,1169.68,Other,225% New York Medicaid APG,1351.62,,,1351.62,Other,260% New York Medicaid APG,1684.33,,,1684.33,Other,324% New York Medicaid APG,1117.69,,,1117.69,Other,215% New York Medicaid APG,1117.69,,,1117.69,Other,215% New York Medicaid APG,649.82,,,649.82,Other,125% New York Medicaid APG,519.86,29085.02,
Njx chemonucleolysis lmbr,62292,CPT,,,,,,,,both,,,40611.5,30052.51,74,,30052.51,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,18275.18,45,,18275.18,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,20102.69,49.5,,20102.69,percent of total billed charges,110% of Medicare,27615.82,68,,27615.82,percent of total billed charges,,1116.35,,,1116.35,Other,186% of Medicaid,32489.2,80,,32489.2,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,32489.2,80,,32489.2,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,28428.05,70,,28428.05,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,600.19,,,600.19,Other,New York Medicaid APG methodology,600.19,,,600.19,Other,100% New York Medicaid APG,600.19,,,600.19,Other,100% New York Medicaid APG,600.19,,,600.19,Other,100% New York Medicaid APG,1350.43,,,1350.43,Other,225% New York Medicaid APG,918.29,,,918.29,Other,153% New York Medicaid APG,1350.43,,,1350.43,Other,225% New York Medicaid APG,840.26,,,840.26,Other,140% New York Medicaid APG,1350.43,,,1350.43,Other,225% New York Medicaid APG,1560.49,,,1560.49,Other,260% New York Medicaid APG,1944.61,,,1944.61,Other,324% New York Medicaid APG,1290.41,,,1290.41,Other,215% New York Medicaid APG,1290.41,,,1290.41,Other,215% New York Medicaid APG,750.24,,,750.24,Other,125% New York Medicaid APG,600.19,32489.2,
Injection into spinal artery,62294,CPT,,,,,,,,both,,,19171.82,14187.15,74,,14187.15,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,8627.32,45,,8627.32,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,9490.05,49.5,,9490.05,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,1116.35,,,1116.35,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,3578,,"100% primary, 0% secondary procedures",3578,Other,MagnaCare ASC Grouper,13420.27,70,,13420.27,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,600.19,,,600.19,Other,New York Medicaid APG methodology,600.19,,,600.19,Other,100% New York Medicaid APG,600.19,,,600.19,Other,100% New York Medicaid APG,600.19,,,600.19,Other,100% New York Medicaid APG,1350.43,,,1350.43,Other,225% New York Medicaid APG,918.29,,,918.29,Other,153% New York Medicaid APG,1350.43,,,1350.43,Other,225% New York Medicaid APG,840.26,,,840.26,Other,140% New York Medicaid APG,1350.43,,,1350.43,Other,225% New York Medicaid APG,1560.49,,,1560.49,Other,260% New York Medicaid APG,1944.61,,,1944.61,Other,324% New York Medicaid APG,1290.41,,,1290.41,Other,215% New York Medicaid APG,1290.41,,,1290.41,Other,215% New York Medicaid APG,750.24,,,750.24,Other,125% New York Medicaid APG,600.19,14187.15,
Myelography lumbar injection,62302,CPT,,,,,,,,both,,,16841.27,12462.54,74,,12462.54,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,7578.57,45,,7578.57,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,8336.43,49.5,,8336.43,percent of total billed charges,110% of Medicare,11452.06,68,,11452.06,percent of total billed charges,,1185.33,,,1185.33,Other,186% of Medicaid,13473.02,80,,13473.02,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,13473.02,80,,13473.02,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,11788.89,70,,11788.89,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,637.28,,,637.28,Other,New York Medicaid APG methodology,637.28,,,637.28,Other,100% New York Medicaid APG,637.28,,,637.28,Other,100% New York Medicaid APG,637.28,,,637.28,Other,100% New York Medicaid APG,1433.87,,,1433.87,Other,225% New York Medicaid APG,975.03,,,975.03,Other,153% New York Medicaid APG,1433.87,,,1433.87,Other,225% New York Medicaid APG,892.19,,,892.19,Other,140% New York Medicaid APG,1433.87,,,1433.87,Other,225% New York Medicaid APG,1656.92,,,1656.92,Other,260% New York Medicaid APG,2064.77,,,2064.77,Other,324% New York Medicaid APG,1370.14,,,1370.14,Other,215% New York Medicaid APG,1370.14,,,1370.14,Other,215% New York Medicaid APG,796.59,,,796.59,Other,125% New York Medicaid APG,637.28,13473.02,
Myelography lumbar injection,62303,CPT,,,,,,,,both,,,16841.27,12462.54,74,,12462.54,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,7578.57,45,,7578.57,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,8336.43,49.5,,8336.43,percent of total billed charges,110% of Medicare,11452.06,68,,11452.06,percent of total billed charges,,1185.33,,,1185.33,Other,186% of Medicaid,13473.02,80,,13473.02,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,13473.02,80,,13473.02,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,11788.89,70,,11788.89,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,637.28,,,637.28,Other,New York Medicaid APG methodology,637.28,,,637.28,Other,100% New York Medicaid APG,637.28,,,637.28,Other,100% New York Medicaid APG,637.28,,,637.28,Other,100% New York Medicaid APG,1433.87,,,1433.87,Other,225% New York Medicaid APG,975.03,,,975.03,Other,153% New York Medicaid APG,1433.87,,,1433.87,Other,225% New York Medicaid APG,892.19,,,892.19,Other,140% New York Medicaid APG,1433.87,,,1433.87,Other,225% New York Medicaid APG,1656.92,,,1656.92,Other,260% New York Medicaid APG,2064.77,,,2064.77,Other,324% New York Medicaid APG,1370.14,,,1370.14,Other,215% New York Medicaid APG,1370.14,,,1370.14,Other,215% New York Medicaid APG,796.59,,,796.59,Other,125% New York Medicaid APG,637.28,13473.02,
Myelography lumbar injection,62304,CPT,,,,,,,,both,,,4472.8,3309.87,74,,3309.87,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,2012.76,45,,2012.76,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,2214.04,49.5,,2214.04,percent of total billed charges,110% of Medicare,3041.5,68,,3041.5,percent of total billed charges,,1185.33,,,1185.33,Other,186% of Medicaid,3578.24,80,,3578.24,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,3578.24,80,,3578.24,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,3130.96,70,,3130.96,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,637.28,,,637.28,Other,New York Medicaid APG methodology,637.28,,,637.28,Other,100% New York Medicaid APG,637.28,,,637.28,Other,100% New York Medicaid APG,637.28,,,637.28,Other,100% New York Medicaid APG,1433.87,,,1433.87,Other,225% New York Medicaid APG,975.03,,,975.03,Other,153% New York Medicaid APG,1433.87,,,1433.87,Other,225% New York Medicaid APG,892.19,,,892.19,Other,140% New York Medicaid APG,1433.87,,,1433.87,Other,225% New York Medicaid APG,1656.92,,,1656.92,Other,260% New York Medicaid APG,2064.77,,,2064.77,Other,324% New York Medicaid APG,1370.14,,,1370.14,Other,215% New York Medicaid APG,1370.14,,,1370.14,Other,215% New York Medicaid APG,796.59,,,796.59,Other,125% New York Medicaid APG,637.28,7216,
Myelography lumbar injection,62305,CPT,,,,,,,,both,,,16841.27,12462.54,74,,12462.54,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,7578.57,45,,7578.57,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,8336.43,49.5,,8336.43,percent of total billed charges,110% of Medicare,11452.06,68,,11452.06,percent of total billed charges,,1185.33,,,1185.33,Other,186% of Medicaid,13473.02,80,,13473.02,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,13473.02,80,,13473.02,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,11788.89,70,,11788.89,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,637.28,,,637.28,Other,New York Medicaid APG methodology,637.28,,,637.28,Other,100% New York Medicaid APG,637.28,,,637.28,Other,100% New York Medicaid APG,637.28,,,637.28,Other,100% New York Medicaid APG,1433.87,,,1433.87,Other,225% New York Medicaid APG,975.03,,,975.03,Other,153% New York Medicaid APG,1433.87,,,1433.87,Other,225% New York Medicaid APG,892.19,,,892.19,Other,140% New York Medicaid APG,1433.87,,,1433.87,Other,225% New York Medicaid APG,1656.92,,,1656.92,Other,260% New York Medicaid APG,2064.77,,,2064.77,Other,324% New York Medicaid APG,1370.14,,,1370.14,Other,215% New York Medicaid APG,1370.14,,,1370.14,Other,215% New York Medicaid APG,796.59,,,796.59,Other,125% New York Medicaid APG,637.28,13473.02,
Njx interlaminar crv/thrc,62320,CPT,,,,,,,,both,,,14545.81,10763.9,74,,10763.9,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,6545.61,45,,6545.61,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,7200.18,49.5,,7200.18,percent of total billed charges,110% of Medicare,9891.15,68,,9891.15,percent of total billed charges,,1116.35,,,1116.35,Other,186% of Medicaid,11636.65,80,,11636.65,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,11636.65,80,,11636.65,percent of total billed charges,,7216,,,7216,Case Rate,,3578,,"100% primary, 0% secondary procedures",3578,Other,MagnaCare ASC Grouper,10182.07,70,,10182.07,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,600.19,,,600.19,Other,New York Medicaid APG methodology,600.19,,,600.19,Other,100% New York Medicaid APG,600.19,,,600.19,Other,100% New York Medicaid APG,600.19,,,600.19,Other,100% New York Medicaid APG,1350.43,,,1350.43,Other,225% New York Medicaid APG,918.29,,,918.29,Other,153% New York Medicaid APG,1350.43,,,1350.43,Other,225% New York Medicaid APG,840.26,,,840.26,Other,140% New York Medicaid APG,1350.43,,,1350.43,Other,225% New York Medicaid APG,1560.49,,,1560.49,Other,260% New York Medicaid APG,1944.61,,,1944.61,Other,324% New York Medicaid APG,1290.41,,,1290.41,Other,215% New York Medicaid APG,1290.41,,,1290.41,Other,215% New York Medicaid APG,750.24,,,750.24,Other,125% New York Medicaid APG,600.19,11636.65,
Njx interlaminar crv/thrc,62321,CPT,,,,,,,,both,,,4598.34,3402.77,74,,3402.77,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,2069.25,45,,2069.25,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,2276.18,49.5,,2276.18,percent of total billed charges,110% of Medicare,3126.87,68,,3126.87,percent of total billed charges,,1116.35,,,1116.35,Other,186% of Medicaid,3678.67,80,,3678.67,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,3678.67,80,,3678.67,percent of total billed charges,,7216,,,7216,Case Rate,,3578,,"100% primary, 0% secondary procedures",3578,Other,MagnaCare ASC Grouper,3218.84,70,,3218.84,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,600.19,,,600.19,Other,New York Medicaid APG methodology,600.19,,,600.19,Other,100% New York Medicaid APG,600.19,,,600.19,Other,100% New York Medicaid APG,600.19,,,600.19,Other,100% New York Medicaid APG,1350.43,,,1350.43,Other,225% New York Medicaid APG,918.29,,,918.29,Other,153% New York Medicaid APG,1350.43,,,1350.43,Other,225% New York Medicaid APG,840.26,,,840.26,Other,140% New York Medicaid APG,1350.43,,,1350.43,Other,225% New York Medicaid APG,1560.49,,,1560.49,Other,260% New York Medicaid APG,1944.61,,,1944.61,Other,324% New York Medicaid APG,1290.41,,,1290.41,Other,215% New York Medicaid APG,1290.41,,,1290.41,Other,215% New York Medicaid APG,750.24,,,750.24,Other,125% New York Medicaid APG,600.19,7216,
Njx interlaminar lmbr/sac,62322,CPT,,,,,,,,both,,,19171.82,14187.15,74,,14187.15,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,8627.32,45,,8627.32,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,9490.05,49.5,,9490.05,percent of total billed charges,110% of Medicare,13036.84,68,,13036.84,percent of total billed charges,,1116.35,,,1116.35,Other,186% of Medicaid,15337.46,80,,15337.46,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,15337.46,80,,15337.46,percent of total billed charges,,7216,,,7216,Case Rate,,3578,,"100% primary, 0% secondary procedures",3578,Other,MagnaCare ASC Grouper,13420.27,70,,13420.27,percent of total billed charges,,390.32,,,390.32,Fee Schedule,,330.82,,,330.82,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,600.19,,,600.19,Other,New York Medicaid APG methodology,600.19,,,600.19,Other,100% New York Medicaid APG,600.19,,,600.19,Other,100% New York Medicaid APG,600.19,,,600.19,Other,100% New York Medicaid APG,1350.43,,,1350.43,Other,225% New York Medicaid APG,918.29,,,918.29,Other,153% New York Medicaid APG,1350.43,,,1350.43,Other,225% New York Medicaid APG,840.26,,,840.26,Other,140% New York Medicaid APG,1350.43,,,1350.43,Other,225% New York Medicaid APG,1560.49,,,1560.49,Other,260% New York Medicaid APG,1944.61,,,1944.61,Other,324% New York Medicaid APG,1290.41,,,1290.41,Other,215% New York Medicaid APG,1290.41,,,1290.41,Other,215% New York Medicaid APG,750.24,,,750.24,Other,125% New York Medicaid APG,330.82,15337.46,
Njx interlaminar lmbr/sac,62323,CPT,,,,,,,,both,,,4568.12,3380.41,74,,3380.41,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,2055.65,45,,2055.65,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,2261.22,49.5,,2261.22,percent of total billed charges,110% of Medicare,3106.32,68,,3106.32,percent of total billed charges,,1116.35,,,1116.35,Other,186% of Medicaid,3654.5,80,,3654.5,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,3654.5,80,,3654.5,percent of total billed charges,,7216,,,7216,Case Rate,,3578,,"100% primary, 0% secondary procedures",3578,Other,MagnaCare ASC Grouper,3197.68,70,,3197.68,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,600.19,,,600.19,Other,New York Medicaid APG methodology,600.19,,,600.19,Other,100% New York Medicaid APG,600.19,,,600.19,Other,100% New York Medicaid APG,600.19,,,600.19,Other,100% New York Medicaid APG,1350.43,,,1350.43,Other,225% New York Medicaid APG,918.29,,,918.29,Other,153% New York Medicaid APG,1350.43,,,1350.43,Other,225% New York Medicaid APG,840.26,,,840.26,Other,140% New York Medicaid APG,1350.43,,,1350.43,Other,225% New York Medicaid APG,1560.49,,,1560.49,Other,260% New York Medicaid APG,1944.61,,,1944.61,Other,324% New York Medicaid APG,1290.41,,,1290.41,Other,215% New York Medicaid APG,1290.41,,,1290.41,Other,215% New York Medicaid APG,750.24,,,750.24,Other,125% New York Medicaid APG,600.19,7216,
Njx interlaminar crv/thrc,62324,CPT,,,,,,,,both,,,19171.82,14187.15,74,,14187.15,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,8627.32,45,,8627.32,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,9490.05,49.5,,9490.05,percent of total billed charges,110% of Medicare,13036.84,68,,13036.84,percent of total billed charges,,1116.35,,,1116.35,Other,186% of Medicaid,15337.46,80,,15337.46,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,15337.46,80,,15337.46,percent of total billed charges,,7216,,,7216,Case Rate,,3578,,"100% primary, 0% secondary procedures",3578,Other,MagnaCare ASC Grouper,13420.27,70,,13420.27,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,600.19,,,600.19,Other,New York Medicaid APG methodology,600.19,,,600.19,Other,100% New York Medicaid APG,600.19,,,600.19,Other,100% New York Medicaid APG,600.19,,,600.19,Other,100% New York Medicaid APG,1350.43,,,1350.43,Other,225% New York Medicaid APG,918.29,,,918.29,Other,153% New York Medicaid APG,1350.43,,,1350.43,Other,225% New York Medicaid APG,840.26,,,840.26,Other,140% New York Medicaid APG,1350.43,,,1350.43,Other,225% New York Medicaid APG,1560.49,,,1560.49,Other,260% New York Medicaid APG,1944.61,,,1944.61,Other,324% New York Medicaid APG,1290.41,,,1290.41,Other,215% New York Medicaid APG,1290.41,,,1290.41,Other,215% New York Medicaid APG,750.24,,,750.24,Other,125% New York Medicaid APG,600.19,15337.46,
Njx interlaminar crv/thrc,62325,CPT,,,,,,,,both,,,19171.82,14187.15,74,,14187.15,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,8627.32,45,,8627.32,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,9490.05,49.5,,9490.05,percent of total billed charges,110% of Medicare,13036.84,68,,13036.84,percent of total billed charges,,1116.35,,,1116.35,Other,186% of Medicaid,15337.46,80,,15337.46,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,15337.46,80,,15337.46,percent of total billed charges,,7216,,,7216,Case Rate,,3578,,"100% primary, 0% secondary procedures",3578,Other,MagnaCare ASC Grouper,13420.27,70,,13420.27,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,600.19,,,600.19,Other,New York Medicaid APG methodology,600.19,,,600.19,Other,100% New York Medicaid APG,600.19,,,600.19,Other,100% New York Medicaid APG,600.19,,,600.19,Other,100% New York Medicaid APG,1350.43,,,1350.43,Other,225% New York Medicaid APG,918.29,,,918.29,Other,153% New York Medicaid APG,1350.43,,,1350.43,Other,225% New York Medicaid APG,840.26,,,840.26,Other,140% New York Medicaid APG,1350.43,,,1350.43,Other,225% New York Medicaid APG,1560.49,,,1560.49,Other,260% New York Medicaid APG,1944.61,,,1944.61,Other,324% New York Medicaid APG,1290.41,,,1290.41,Other,215% New York Medicaid APG,1290.41,,,1290.41,Other,215% New York Medicaid APG,750.24,,,750.24,Other,125% New York Medicaid APG,600.19,15337.46,
Njx interlaminar lmbr/sac,62326,CPT,,,,,,,,both,,,19171.82,14187.15,74,,14187.15,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,8627.32,45,,8627.32,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,9490.05,49.5,,9490.05,percent of total billed charges,110% of Medicare,13036.84,68,,13036.84,percent of total billed charges,,1116.35,,,1116.35,Other,186% of Medicaid,15337.46,80,,15337.46,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,15337.46,80,,15337.46,percent of total billed charges,,7216,,,7216,Case Rate,,3578,,"100% primary, 0% secondary procedures",3578,Other,MagnaCare ASC Grouper,13420.27,70,,13420.27,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,600.19,,,600.19,Other,New York Medicaid APG methodology,600.19,,,600.19,Other,100% New York Medicaid APG,600.19,,,600.19,Other,100% New York Medicaid APG,600.19,,,600.19,Other,100% New York Medicaid APG,1350.43,,,1350.43,Other,225% New York Medicaid APG,918.29,,,918.29,Other,153% New York Medicaid APG,1350.43,,,1350.43,Other,225% New York Medicaid APG,840.26,,,840.26,Other,140% New York Medicaid APG,1350.43,,,1350.43,Other,225% New York Medicaid APG,1560.49,,,1560.49,Other,260% New York Medicaid APG,1944.61,,,1944.61,Other,324% New York Medicaid APG,1290.41,,,1290.41,Other,215% New York Medicaid APG,1290.41,,,1290.41,Other,215% New York Medicaid APG,750.24,,,750.24,Other,125% New York Medicaid APG,600.19,15337.46,
Njx interlaminar lmbr/sac,62327,CPT,,,,,,,,both,,,19171.82,14187.15,74,,14187.15,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,8627.32,45,,8627.32,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,9490.05,49.5,,9490.05,percent of total billed charges,110% of Medicare,13036.84,68,,13036.84,percent of total billed charges,,1116.35,,,1116.35,Other,186% of Medicaid,15337.46,80,,15337.46,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,15337.46,80,,15337.46,percent of total billed charges,,7216,,,7216,Case Rate,,3578,,"100% primary, 0% secondary procedures",3578,Other,MagnaCare ASC Grouper,13420.27,70,,13420.27,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,600.19,,,600.19,Other,New York Medicaid APG methodology,600.19,,,600.19,Other,100% New York Medicaid APG,600.19,,,600.19,Other,100% New York Medicaid APG,600.19,,,600.19,Other,100% New York Medicaid APG,1350.43,,,1350.43,Other,225% New York Medicaid APG,918.29,,,918.29,Other,153% New York Medicaid APG,1350.43,,,1350.43,Other,225% New York Medicaid APG,840.26,,,840.26,Other,140% New York Medicaid APG,1350.43,,,1350.43,Other,225% New York Medicaid APG,1560.49,,,1560.49,Other,260% New York Medicaid APG,1944.61,,,1944.61,Other,324% New York Medicaid APG,1290.41,,,1290.41,Other,215% New York Medicaid APG,1290.41,,,1290.41,Other,215% New York Medicaid APG,750.24,,,750.24,Other,125% New York Medicaid APG,600.19,15337.46,
Dx lmbr spi pnxr w/fluor/ct,62328,CPT,,,,,,,,both,,,13095.35,9690.56,74,,9690.56,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,5892.91,45,,5892.91,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,6482.2,49.5,,6482.2,percent of total billed charges,110% of Medicare,8904.84,68,,8904.84,percent of total billed charges,,1116.35,,,1116.35,Other,186% of Medicaid,10476.28,80,,10476.28,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,10476.28,80,,10476.28,percent of total billed charges,,7216,,,7216,Case Rate,,3578,,"100% primary, 0% secondary procedures",3578,Other,MagnaCare ASC Grouper,9166.75,70,,9166.75,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,600.19,,,600.19,Other,New York Medicaid APG methodology,600.19,,,600.19,Other,100% New York Medicaid APG,600.19,,,600.19,Other,100% New York Medicaid APG,600.19,,,600.19,Other,100% New York Medicaid APG,1350.43,,,1350.43,Other,225% New York Medicaid APG,918.29,,,918.29,Other,153% New York Medicaid APG,1350.43,,,1350.43,Other,225% New York Medicaid APG,840.26,,,840.26,Other,140% New York Medicaid APG,1350.43,,,1350.43,Other,225% New York Medicaid APG,1560.49,,,1560.49,Other,260% New York Medicaid APG,1944.61,,,1944.61,Other,324% New York Medicaid APG,1290.41,,,1290.41,Other,215% New York Medicaid APG,1290.41,,,1290.41,Other,215% New York Medicaid APG,750.24,,,750.24,Other,125% New York Medicaid APG,600.19,10476.28,
Ther spi pnxr csf fluor/ct,62329,CPT,,,,,,,,both,,,402933,298170.42,74,,298170.42,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,181319.85,45,,181319.85,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,199451.84,49.5,,199451.84,percent of total billed charges,110% of Medicare,273994.44,68,,273994.44,percent of total billed charges,,1116.35,,,1116.35,Other,186% of Medicaid,322346.4,80,,322346.4,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,322346.4,80,,322346.4,percent of total billed charges,,7216,,,7216,Case Rate,,3578,,"100% primary, 0% secondary procedures",3578,Other,MagnaCare ASC Grouper,282053.1,70,,282053.1,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,600.19,,,600.19,Other,New York Medicaid APG methodology,600.19,,,600.19,Other,100% New York Medicaid APG,600.19,,,600.19,Other,100% New York Medicaid APG,600.19,,,600.19,Other,100% New York Medicaid APG,1350.43,,,1350.43,Other,225% New York Medicaid APG,918.29,,,918.29,Other,153% New York Medicaid APG,1350.43,,,1350.43,Other,225% New York Medicaid APG,840.26,,,840.26,Other,140% New York Medicaid APG,1350.43,,,1350.43,Other,225% New York Medicaid APG,1560.49,,,1560.49,Other,260% New York Medicaid APG,1944.61,,,1944.61,Other,324% New York Medicaid APG,1290.41,,,1290.41,Other,215% New York Medicaid APG,1290.41,,,1290.41,Other,215% New York Medicaid APG,750.24,,,750.24,Other,125% New York Medicaid APG,600.19,322346.4,
Implant spinal canal cath,62350,CPT,,,,,,,,both,,,69692.06,51572.12,74,,51572.12,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,31361.43,45,,31361.43,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,34497.57,49.5,,34497.57,percent of total billed charges,110% of Medicare,47390.6,68,,47390.6,percent of total billed charges,,5525.48,,,5525.48,Other,186% of Medicaid,55753.65,80,,55753.65,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,55753.65,80,,55753.65,percent of total billed charges,,7216,,,7216,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,48784.44,70,,48784.44,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,2970.69,,,2970.69,Other,New York Medicaid APG methodology,2970.69,,,2970.69,Other,100% New York Medicaid APG,2970.69,,,2970.69,Other,100% New York Medicaid APG,2970.69,,,2970.69,Other,100% New York Medicaid APG,6684.05,,,6684.05,Other,225% New York Medicaid APG,4545.16,,,4545.16,Other,153% New York Medicaid APG,6684.05,,,6684.05,Other,225% New York Medicaid APG,4158.97,,,4158.97,Other,140% New York Medicaid APG,6684.05,,,6684.05,Other,225% New York Medicaid APG,7723.79,,,7723.79,Other,260% New York Medicaid APG,9625.03,,,9625.03,Other,324% New York Medicaid APG,6386.98,,,6386.98,Other,215% New York Medicaid APG,6386.98,,,6386.98,Other,215% New York Medicaid APG,3713.36,,,3713.36,Other,125% New York Medicaid APG,2232,55753.65,
Implant spinal canal cath,62351,CPT,,,,,,,,both,,,150476.65,111352.72,74,,111352.72,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,67714.49,45,,67714.49,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,74485.94,49.5,,74485.94,percent of total billed charges,110% of Medicare,102324.12,68,,102324.12,percent of total billed charges,,6658.36,,,6658.36,Other,186% of Medicaid,120381.32,80,,120381.32,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,120381.32,80,,120381.32,percent of total billed charges,,7216,,,7216,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,105333.66,70,,105333.66,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,3579.77,,,3579.77,Other,New York Medicaid APG methodology,3579.77,,,3579.77,Other,100% New York Medicaid APG,3579.77,,,3579.77,Other,100% New York Medicaid APG,3579.77,,,3579.77,Other,100% New York Medicaid APG,8054.47,,,8054.47,Other,225% New York Medicaid APG,5477.04,,,5477.04,Other,153% New York Medicaid APG,8054.47,,,8054.47,Other,225% New York Medicaid APG,5011.67,,,5011.67,Other,140% New York Medicaid APG,8054.47,,,8054.47,Other,225% New York Medicaid APG,9307.39,,,9307.39,Other,260% New York Medicaid APG,11598.44,,,11598.44,Other,324% New York Medicaid APG,7696.5,,,7696.5,Other,215% New York Medicaid APG,7696.5,,,7696.5,Other,215% New York Medicaid APG,4474.71,,,4474.71,Other,125% New York Medicaid APG,2232,120381.32,
Remove spinal canal catheter,62355,CPT,,,,,,,,both,,,40611.5,30052.51,74,,30052.51,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,18275.18,45,,18275.18,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,20102.69,49.5,,20102.69,percent of total billed charges,110% of Medicare,27615.82,68,,27615.82,percent of total billed charges,,1116.35,,,1116.35,Other,186% of Medicaid,32489.2,80,,32489.2,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,32489.2,80,,32489.2,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,28428.05,70,,28428.05,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,600.19,,,600.19,Other,New York Medicaid APG methodology,600.19,,,600.19,Other,100% New York Medicaid APG,600.19,,,600.19,Other,100% New York Medicaid APG,600.19,,,600.19,Other,100% New York Medicaid APG,1350.43,,,1350.43,Other,225% New York Medicaid APG,918.29,,,918.29,Other,153% New York Medicaid APG,1350.43,,,1350.43,Other,225% New York Medicaid APG,840.26,,,840.26,Other,140% New York Medicaid APG,1350.43,,,1350.43,Other,225% New York Medicaid APG,1560.49,,,1560.49,Other,260% New York Medicaid APG,1944.61,,,1944.61,Other,324% New York Medicaid APG,1290.41,,,1290.41,Other,215% New York Medicaid APG,1290.41,,,1290.41,Other,215% New York Medicaid APG,750.24,,,750.24,Other,125% New York Medicaid APG,600.19,32489.2,
Insert spine infusion device,62360,CPT,,,,,,,,both,,,94708.62,70084.38,74,,70084.38,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,42618.88,45,,42618.88,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,46880.77,49.5,,46880.77,percent of total billed charges,110% of Medicare,64401.86,68,,64401.86,percent of total billed charges,,23604.92,,,23604.92,Other,186% of Medicaid,75766.9,80,,75766.9,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,75766.9,80,,75766.9,percent of total billed charges,,7216,,,7216,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,66296.03,70,,66296.03,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,12690.82,,,12690.82,Other,New York Medicaid APG methodology,12690.82,,,12690.82,Other,100% New York Medicaid APG,12690.82,,,12690.82,Other,100% New York Medicaid APG,12690.82,,,12690.82,Other,100% New York Medicaid APG,28554.34,,,28554.34,Other,225% New York Medicaid APG,19416.95,,,19416.95,Other,153% New York Medicaid APG,28554.34,,,28554.34,Other,225% New York Medicaid APG,17767.14,,,17767.14,Other,140% New York Medicaid APG,28554.34,,,28554.34,Other,225% New York Medicaid APG,32996.12,,,32996.12,Other,260% New York Medicaid APG,41118.24,,,41118.24,Other,324% New York Medicaid APG,27285.25,,,27285.25,Other,215% New York Medicaid APG,27285.25,,,27285.25,Other,215% New York Medicaid APG,15863.52,,,15863.52,Other,125% New York Medicaid APG,2232,75766.9,
Implant spine infusion pump,62361,CPT,,,,,,,,both,,,63160.62,46738.86,74,,46738.86,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,28422.28,45,,28422.28,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,31264.51,49.5,,31264.51,percent of total billed charges,110% of Medicare,42949.22,68,,42949.22,percent of total billed charges,,23604.92,,,23604.92,Other,186% of Medicaid,50528.5,80,,50528.5,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,50528.5,80,,50528.5,percent of total billed charges,,7216,,,7216,Case Rate,,9196,,"100% primary, 0% secondary procedures",9196,Other,MagnaCare ASC Grouper,44212.43,70,,44212.43,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,8589,,"100% primary, 50% secondary, 25% tertiary procedure",8589,Other,United Healthcare ASC Grouper,7730,,"100% primary, 50% secondary, 25% tertiary procedure",7730,Other,United Healthcare ASC Grouper,8589,,"100% primary, 50% secondary, 25% tertiary procedure",8589,Other,United Healthcare ASC Grouper,7301,,"100% primary, 50% secondary, 25% tertiary procedure",7301,Other,United Healthcare ASC Grouper,12690.82,,,12690.82,Other,New York Medicaid APG methodology,12690.82,,,12690.82,Other,100% New York Medicaid APG,12690.82,,,12690.82,Other,100% New York Medicaid APG,12690.82,,,12690.82,Other,100% New York Medicaid APG,28554.34,,,28554.34,Other,225% New York Medicaid APG,19416.95,,,19416.95,Other,153% New York Medicaid APG,28554.34,,,28554.34,Other,225% New York Medicaid APG,17767.14,,,17767.14,Other,140% New York Medicaid APG,28554.34,,,28554.34,Other,225% New York Medicaid APG,32996.12,,,32996.12,Other,260% New York Medicaid APG,41118.24,,,41118.24,Other,324% New York Medicaid APG,27285.25,,,27285.25,Other,215% New York Medicaid APG,27285.25,,,27285.25,Other,215% New York Medicaid APG,15863.52,,,15863.52,Other,125% New York Medicaid APG,2232,50528.5,
Implant spine infusion pump,62362,CPT,,,,,,,,both,,,94208.46,69714.26,74,,69714.26,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,42393.81,45,,42393.81,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,46633.19,49.5,,46633.19,percent of total billed charges,110% of Medicare,64061.75,68,,64061.75,percent of total billed charges,,23604.92,,,23604.92,Other,186% of Medicaid,75366.77,80,,75366.77,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,75366.77,80,,75366.77,percent of total billed charges,,7216,,,7216,Case Rate,,9196,,"100% primary, 0% secondary procedures",9196,Other,MagnaCare ASC Grouper,65945.92,70,,65945.92,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,8589,,"100% primary, 50% secondary, 25% tertiary procedure",8589,Other,United Healthcare ASC Grouper,7730,,"100% primary, 50% secondary, 25% tertiary procedure",7730,Other,United Healthcare ASC Grouper,8589,,"100% primary, 50% secondary, 25% tertiary procedure",8589,Other,United Healthcare ASC Grouper,7301,,"100% primary, 50% secondary, 25% tertiary procedure",7301,Other,United Healthcare ASC Grouper,12690.82,,,12690.82,Other,New York Medicaid APG methodology,12690.82,,,12690.82,Other,100% New York Medicaid APG,12690.82,,,12690.82,Other,100% New York Medicaid APG,12690.82,,,12690.82,Other,100% New York Medicaid APG,28554.34,,,28554.34,Other,225% New York Medicaid APG,19416.95,,,19416.95,Other,153% New York Medicaid APG,28554.34,,,28554.34,Other,225% New York Medicaid APG,17767.14,,,17767.14,Other,140% New York Medicaid APG,28554.34,,,28554.34,Other,225% New York Medicaid APG,32996.12,,,32996.12,Other,260% New York Medicaid APG,41118.24,,,41118.24,Other,324% New York Medicaid APG,27285.25,,,27285.25,Other,215% New York Medicaid APG,27285.25,,,27285.25,Other,215% New York Medicaid APG,15863.52,,,15863.52,Other,125% New York Medicaid APG,2232,75366.77,
Remove spine infusion device,62365,CPT,,,,,,,,both,,,60516.25,44782.03,74,,44782.03,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,27232.31,45,,27232.31,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,29955.54,49.5,,29955.54,percent of total billed charges,110% of Medicare,41151.05,68,,41151.05,percent of total billed charges,,5525.48,,,5525.48,Other,186% of Medicaid,48413,80,,48413,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,48413,80,,48413,percent of total billed charges,,7216,,,7216,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,42361.38,70,,42361.38,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,2970.69,,,2970.69,Other,New York Medicaid APG methodology,2970.69,,,2970.69,Other,100% New York Medicaid APG,2970.69,,,2970.69,Other,100% New York Medicaid APG,2970.69,,,2970.69,Other,100% New York Medicaid APG,6684.05,,,6684.05,Other,225% New York Medicaid APG,4545.16,,,4545.16,Other,153% New York Medicaid APG,6684.05,,,6684.05,Other,225% New York Medicaid APG,4158.97,,,4158.97,Other,140% New York Medicaid APG,6684.05,,,6684.05,Other,225% New York Medicaid APG,7723.79,,,7723.79,Other,260% New York Medicaid APG,9625.03,,,9625.03,Other,324% New York Medicaid APG,6386.98,,,6386.98,Other,215% New York Medicaid APG,6386.98,,,6386.98,Other,215% New York Medicaid APG,3713.36,,,3713.36,Other,125% New York Medicaid APG,2232,48413,
Analyze spine infus pump,62367,CPT,,,,,,,,both,,,6282.58,4649.11,74,,4649.11,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,2827.16,45,,2827.16,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,3109.88,49.5,,3109.88,percent of total billed charges,110% of Medicare,4272.15,68,,4272.15,percent of total billed charges,,339.51,,,339.51,Other,186% of Medicaid,5026.06,80,,5026.06,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,5026.06,80,,5026.06,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,4397.81,70,,4397.81,percent of total billed charges,,119.72,,,119.72,Fee Schedule,,101.47,,,101.47,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,182.53,,,182.53,Other,New York Medicaid APG methodology,182.53,,,182.53,Other,100% New York Medicaid APG,182.53,,,182.53,Other,100% New York Medicaid APG,182.53,,,182.53,Other,100% New York Medicaid APG,410.7,,,410.7,Other,225% New York Medicaid APG,279.28,,,279.28,Other,153% New York Medicaid APG,410.7,,,410.7,Other,225% New York Medicaid APG,255.55,,,255.55,Other,140% New York Medicaid APG,410.7,,,410.7,Other,225% New York Medicaid APG,474.59,,,474.59,Other,260% New York Medicaid APG,591.41,,,591.41,Other,324% New York Medicaid APG,392.45,,,392.45,Other,215% New York Medicaid APG,392.45,,,392.45,Other,215% New York Medicaid APG,228.17,,,228.17,Other,125% New York Medicaid APG,101.47,7216,
Analyze sp inf pump w/reprog,62368,CPT,,,,,,,,both,,,6282.58,4649.11,74,,4649.11,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,2827.16,45,,2827.16,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,3109.88,49.5,,3109.88,percent of total billed charges,110% of Medicare,4272.15,68,,4272.15,percent of total billed charges,,339.51,,,339.51,Other,186% of Medicaid,5026.06,80,,5026.06,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,5026.06,80,,5026.06,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,4397.81,70,,4397.81,percent of total billed charges,,167.28,,,167.28,Fee Schedule,,141.78,,,141.78,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,182.53,,,182.53,Other,New York Medicaid APG methodology,182.53,,,182.53,Other,100% New York Medicaid APG,182.53,,,182.53,Other,100% New York Medicaid APG,182.53,,,182.53,Other,100% New York Medicaid APG,410.7,,,410.7,Other,225% New York Medicaid APG,279.28,,,279.28,Other,153% New York Medicaid APG,410.7,,,410.7,Other,225% New York Medicaid APG,255.55,,,255.55,Other,140% New York Medicaid APG,410.7,,,410.7,Other,225% New York Medicaid APG,474.59,,,474.59,Other,260% New York Medicaid APG,591.41,,,591.41,Other,324% New York Medicaid APG,392.45,,,392.45,Other,215% New York Medicaid APG,392.45,,,392.45,Other,215% New York Medicaid APG,228.17,,,228.17,Other,125% New York Medicaid APG,141.78,7216,
Anal sp inf pmp w/reprg&fill,62369,CPT,,,,,,,,both,,,6282.58,4649.11,74,,4649.11,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,2827.16,45,,2827.16,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,3109.88,49.5,,3109.88,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,339.51,,,339.51,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,4397.81,70,,4397.81,percent of total billed charges,,168.92,,,168.92,Fee Schedule,,143.17,,,143.17,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,182.53,,,182.53,Other,New York Medicaid APG methodology,182.53,,,182.53,Other,100% New York Medicaid APG,182.53,,,182.53,Other,100% New York Medicaid APG,182.53,,,182.53,Other,100% New York Medicaid APG,410.7,,,410.7,Other,225% New York Medicaid APG,279.28,,,279.28,Other,153% New York Medicaid APG,410.7,,,410.7,Other,225% New York Medicaid APG,255.55,,,255.55,Other,140% New York Medicaid APG,410.7,,,410.7,Other,225% New York Medicaid APG,474.59,,,474.59,Other,260% New York Medicaid APG,591.41,,,591.41,Other,324% New York Medicaid APG,392.45,,,392.45,Other,215% New York Medicaid APG,392.45,,,392.45,Other,215% New York Medicaid APG,228.17,,,228.17,Other,125% New York Medicaid APG,143.17,9473,
Anl sp inf pmp w/mdreprg&fil,62370,CPT,,,,,,,,both,,,32757.93,24240.87,74,,24240.87,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,14741.07,45,,14741.07,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,16215.18,49.5,,16215.18,percent of total billed charges,110% of Medicare,22275.39,68,,22275.39,percent of total billed charges,,339.51,,,339.51,Other,186% of Medicaid,26206.34,80,,26206.34,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,26206.34,80,,26206.34,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,22930.55,70,,22930.55,percent of total billed charges,,223.04,,,223.04,Fee Schedule,,189.04,,,189.04,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,182.53,,,182.53,Other,New York Medicaid APG methodology,182.53,,,182.53,Other,100% New York Medicaid APG,182.53,,,182.53,Other,100% New York Medicaid APG,182.53,,,182.53,Other,100% New York Medicaid APG,410.7,,,410.7,Other,225% New York Medicaid APG,279.28,,,279.28,Other,153% New York Medicaid APG,410.7,,,410.7,Other,225% New York Medicaid APG,255.55,,,255.55,Other,140% New York Medicaid APG,410.7,,,410.7,Other,225% New York Medicaid APG,474.59,,,474.59,Other,260% New York Medicaid APG,591.41,,,591.41,Other,324% New York Medicaid APG,392.45,,,392.45,Other,215% New York Medicaid APG,392.45,,,392.45,Other,215% New York Medicaid APG,228.17,,,228.17,Other,125% New York Medicaid APG,182.53,26206.34,
Ndsc dcmprn 1 ntrspc lumbar,62380,CPT,,,,,,,,both,,,65343.2,48353.97,74,,48353.97,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,29404.44,45,,29404.44,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,32344.88,49.5,,32344.88,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5525.48,,,5525.48,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,45740.24,70,,45740.24,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,2970.69,,,2970.69,Other,New York Medicaid APG methodology,2970.69,,,2970.69,Other,100% New York Medicaid APG,2970.69,,,2970.69,Other,100% New York Medicaid APG,2970.69,,,2970.69,Other,100% New York Medicaid APG,6684.05,,,6684.05,Other,225% New York Medicaid APG,4545.16,,,4545.16,Other,153% New York Medicaid APG,6684.05,,,6684.05,Other,225% New York Medicaid APG,4158.97,,,4158.97,Other,140% New York Medicaid APG,6684.05,,,6684.05,Other,225% New York Medicaid APG,7723.79,,,7723.79,Other,260% New York Medicaid APG,9625.03,,,9625.03,Other,324% New York Medicaid APG,6386.98,,,6386.98,Other,215% New York Medicaid APG,6386.98,,,6386.98,Other,215% New York Medicaid APG,3713.36,,,3713.36,Other,125% New York Medicaid APG,2879,48353.97,
Remove spine lamina 1/2 crvl,63001,CPT,,,,,,,,both,,,150476.65,111352.72,74,,111352.72,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,67714.49,45,,67714.49,percent of total billed charges,Medicare Ratio of cost to charges,5459,,"100% primary, 50% supplemental procedure",5459,Other,Aetna ASC Grouper,4913,,"100% primary, 50% supplemental procedure",4913,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,74485.94,49.5,,74485.94,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5525.48,,,5525.48,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,105333.66,70,,105333.66,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,2970.69,,,2970.69,Other,New York Medicaid APG methodology,2970.69,,,2970.69,Other,100% New York Medicaid APG,2970.69,,,2970.69,Other,100% New York Medicaid APG,2970.69,,,2970.69,Other,100% New York Medicaid APG,6684.05,,,6684.05,Other,225% New York Medicaid APG,4545.16,,,4545.16,Other,153% New York Medicaid APG,6684.05,,,6684.05,Other,225% New York Medicaid APG,4158.97,,,4158.97,Other,140% New York Medicaid APG,6684.05,,,6684.05,Other,225% New York Medicaid APG,7723.79,,,7723.79,Other,260% New York Medicaid APG,9625.03,,,9625.03,Other,324% New York Medicaid APG,6386.98,,,6386.98,Other,215% New York Medicaid APG,6386.98,,,6386.98,Other,215% New York Medicaid APG,3713.36,,,3713.36,Other,125% New York Medicaid APG,2970.69,111352.72,
Remove spine lamina 1/2 thrc,63003,CPT,,,,,,,,both,,,150476.65,111352.72,74,,111352.72,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,67714.49,45,,67714.49,percent of total billed charges,Medicare Ratio of cost to charges,5459,,"100% primary, 50% supplemental procedure",5459,Other,Aetna ASC Grouper,4913,,"100% primary, 50% supplemental procedure",4913,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,74485.94,49.5,,74485.94,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5525.48,,,5525.48,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,105333.66,70,,105333.66,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,2970.69,,,2970.69,Other,New York Medicaid APG methodology,2970.69,,,2970.69,Other,100% New York Medicaid APG,2970.69,,,2970.69,Other,100% New York Medicaid APG,2970.69,,,2970.69,Other,100% New York Medicaid APG,6684.05,,,6684.05,Other,225% New York Medicaid APG,4545.16,,,4545.16,Other,153% New York Medicaid APG,6684.05,,,6684.05,Other,225% New York Medicaid APG,4158.97,,,4158.97,Other,140% New York Medicaid APG,6684.05,,,6684.05,Other,225% New York Medicaid APG,7723.79,,,7723.79,Other,260% New York Medicaid APG,9625.03,,,9625.03,Other,324% New York Medicaid APG,6386.98,,,6386.98,Other,215% New York Medicaid APG,6386.98,,,6386.98,Other,215% New York Medicaid APG,3713.36,,,3713.36,Other,125% New York Medicaid APG,2970.69,111352.72,
Remove spine lamina 1/2 lmbr,63005,CPT,,,,,,,,both,,,150476.65,111352.72,74,,111352.72,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,67714.49,45,,67714.49,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,74485.94,49.5,,74485.94,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5525.48,,,5525.48,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,105333.66,70,,105333.66,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,2970.69,,,2970.69,Other,New York Medicaid APG methodology,2970.69,,,2970.69,Other,100% New York Medicaid APG,2970.69,,,2970.69,Other,100% New York Medicaid APG,2970.69,,,2970.69,Other,100% New York Medicaid APG,6684.05,,,6684.05,Other,225% New York Medicaid APG,4545.16,,,4545.16,Other,153% New York Medicaid APG,6684.05,,,6684.05,Other,225% New York Medicaid APG,4158.97,,,4158.97,Other,140% New York Medicaid APG,6684.05,,,6684.05,Other,225% New York Medicaid APG,7723.79,,,7723.79,Other,260% New York Medicaid APG,9625.03,,,9625.03,Other,324% New York Medicaid APG,6386.98,,,6386.98,Other,215% New York Medicaid APG,6386.98,,,6386.98,Other,215% New York Medicaid APG,3713.36,,,3713.36,Other,125% New York Medicaid APG,2970.69,111352.72,
Remove spine lamina 1/2 scrl,63011,CPT,,,,,,,,both,,,150476.65,111352.72,74,,111352.72,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,67714.49,45,,67714.49,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,74485.94,49.5,,74485.94,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5525.48,,,5525.48,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,105333.66,70,,105333.66,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,2970.69,,,2970.69,Other,New York Medicaid APG methodology,2970.69,,,2970.69,Other,100% New York Medicaid APG,2970.69,,,2970.69,Other,100% New York Medicaid APG,2970.69,,,2970.69,Other,100% New York Medicaid APG,6684.05,,,6684.05,Other,225% New York Medicaid APG,4545.16,,,4545.16,Other,153% New York Medicaid APG,6684.05,,,6684.05,Other,225% New York Medicaid APG,4158.97,,,4158.97,Other,140% New York Medicaid APG,6684.05,,,6684.05,Other,225% New York Medicaid APG,7723.79,,,7723.79,Other,260% New York Medicaid APG,9625.03,,,9625.03,Other,324% New York Medicaid APG,6386.98,,,6386.98,Other,215% New York Medicaid APG,6386.98,,,6386.98,Other,215% New York Medicaid APG,3713.36,,,3713.36,Other,125% New York Medicaid APG,2970.69,111352.72,
Remove lamina/facets lumbar,63012,CPT,,,,,,,,both,,,150476.65,111352.72,74,,111352.72,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,67714.49,45,,67714.49,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,74485.94,49.5,,74485.94,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5525.48,,,5525.48,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,105333.66,70,,105333.66,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,2970.69,,,2970.69,Other,New York Medicaid APG methodology,2970.69,,,2970.69,Other,100% New York Medicaid APG,2970.69,,,2970.69,Other,100% New York Medicaid APG,2970.69,,,2970.69,Other,100% New York Medicaid APG,6684.05,,,6684.05,Other,225% New York Medicaid APG,4545.16,,,4545.16,Other,153% New York Medicaid APG,6684.05,,,6684.05,Other,225% New York Medicaid APG,4158.97,,,4158.97,Other,140% New York Medicaid APG,6684.05,,,6684.05,Other,225% New York Medicaid APG,7723.79,,,7723.79,Other,260% New York Medicaid APG,9625.03,,,9625.03,Other,324% New York Medicaid APG,6386.98,,,6386.98,Other,215% New York Medicaid APG,6386.98,,,6386.98,Other,215% New York Medicaid APG,3713.36,,,3713.36,Other,125% New York Medicaid APG,2970.69,111352.72,
Remove spine lamina >2 crvcl,63015,CPT,,,,,,,,both,,,150476.65,111352.72,74,,111352.72,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,67714.49,45,,67714.49,percent of total billed charges,Medicare Ratio of cost to charges,5459,,"100% primary, 50% supplemental procedure",5459,Other,Aetna ASC Grouper,4913,,"100% primary, 50% supplemental procedure",4913,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,74485.94,49.5,,74485.94,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5525.48,,,5525.48,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,105333.66,70,,105333.66,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,2970.69,,,2970.69,Other,New York Medicaid APG methodology,2970.69,,,2970.69,Other,100% New York Medicaid APG,2970.69,,,2970.69,Other,100% New York Medicaid APG,2970.69,,,2970.69,Other,100% New York Medicaid APG,6684.05,,,6684.05,Other,225% New York Medicaid APG,4545.16,,,4545.16,Other,153% New York Medicaid APG,6684.05,,,6684.05,Other,225% New York Medicaid APG,4158.97,,,4158.97,Other,140% New York Medicaid APG,6684.05,,,6684.05,Other,225% New York Medicaid APG,7723.79,,,7723.79,Other,260% New York Medicaid APG,9625.03,,,9625.03,Other,324% New York Medicaid APG,6386.98,,,6386.98,Other,215% New York Medicaid APG,6386.98,,,6386.98,Other,215% New York Medicaid APG,3713.36,,,3713.36,Other,125% New York Medicaid APG,2970.69,111352.72,
Remove spine lamina >2 thrc,63016,CPT,,,,,,,,both,,,150476.65,111352.72,74,,111352.72,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,67714.49,45,,67714.49,percent of total billed charges,Medicare Ratio of cost to charges,5459,,"100% primary, 50% supplemental procedure",5459,Other,Aetna ASC Grouper,4913,,"100% primary, 50% supplemental procedure",4913,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,74485.94,49.5,,74485.94,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5525.48,,,5525.48,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,105333.66,70,,105333.66,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,2970.69,,,2970.69,Other,New York Medicaid APG methodology,2970.69,,,2970.69,Other,100% New York Medicaid APG,2970.69,,,2970.69,Other,100% New York Medicaid APG,2970.69,,,2970.69,Other,100% New York Medicaid APG,6684.05,,,6684.05,Other,225% New York Medicaid APG,4545.16,,,4545.16,Other,153% New York Medicaid APG,6684.05,,,6684.05,Other,225% New York Medicaid APG,4158.97,,,4158.97,Other,140% New York Medicaid APG,6684.05,,,6684.05,Other,225% New York Medicaid APG,7723.79,,,7723.79,Other,260% New York Medicaid APG,9625.03,,,9625.03,Other,324% New York Medicaid APG,6386.98,,,6386.98,Other,215% New York Medicaid APG,6386.98,,,6386.98,Other,215% New York Medicaid APG,3713.36,,,3713.36,Other,125% New York Medicaid APG,2970.69,111352.72,
Remove spine lamina >2 lmbr,63017,CPT,,,,,,,,both,,,150476.65,111352.72,74,,111352.72,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,67714.49,45,,67714.49,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,74485.94,49.5,,74485.94,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5525.48,,,5525.48,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,105333.66,70,,105333.66,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,2970.69,,,2970.69,Other,New York Medicaid APG methodology,2970.69,,,2970.69,Other,100% New York Medicaid APG,2970.69,,,2970.69,Other,100% New York Medicaid APG,2970.69,,,2970.69,Other,100% New York Medicaid APG,6684.05,,,6684.05,Other,225% New York Medicaid APG,4545.16,,,4545.16,Other,153% New York Medicaid APG,6684.05,,,6684.05,Other,225% New York Medicaid APG,4158.97,,,4158.97,Other,140% New York Medicaid APG,6684.05,,,6684.05,Other,225% New York Medicaid APG,7723.79,,,7723.79,Other,260% New York Medicaid APG,9625.03,,,9625.03,Other,324% New York Medicaid APG,6386.98,,,6386.98,Other,215% New York Medicaid APG,6386.98,,,6386.98,Other,215% New York Medicaid APG,3713.36,,,3713.36,Other,125% New York Medicaid APG,2970.69,111352.72,
Neck spine disk surgery,63020,CPT,,,,,,,,both,,,150476.65,111352.72,74,,111352.72,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,67714.49,45,,67714.49,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,74485.94,49.5,,74485.94,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5525.48,,,5525.48,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,105333.66,70,,105333.66,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,2970.69,,,2970.69,Other,New York Medicaid APG methodology,2970.69,,,2970.69,Other,100% New York Medicaid APG,2970.69,,,2970.69,Other,100% New York Medicaid APG,2970.69,,,2970.69,Other,100% New York Medicaid APG,6684.05,,,6684.05,Other,225% New York Medicaid APG,4545.16,,,4545.16,Other,153% New York Medicaid APG,6684.05,,,6684.05,Other,225% New York Medicaid APG,4158.97,,,4158.97,Other,140% New York Medicaid APG,6684.05,,,6684.05,Other,225% New York Medicaid APG,7723.79,,,7723.79,Other,260% New York Medicaid APG,9625.03,,,9625.03,Other,324% New York Medicaid APG,6386.98,,,6386.98,Other,215% New York Medicaid APG,6386.98,,,6386.98,Other,215% New York Medicaid APG,3713.36,,,3713.36,Other,125% New York Medicaid APG,2970.69,111352.72,
Low back disk surgery,63030,CPT,,,,,,,,both,,,83836.24,62038.82,74,,62038.82,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,37726.31,45,,37726.31,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,41498.94,49.5,,41498.94,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5525.48,,,5525.48,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,58685.37,70,,58685.37,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,2970.69,,,2970.69,Other,New York Medicaid APG methodology,2970.69,,,2970.69,Other,100% New York Medicaid APG,2970.69,,,2970.69,Other,100% New York Medicaid APG,2970.69,,,2970.69,Other,100% New York Medicaid APG,6684.05,,,6684.05,Other,225% New York Medicaid APG,4545.16,,,4545.16,Other,153% New York Medicaid APG,6684.05,,,6684.05,Other,225% New York Medicaid APG,4158.97,,,4158.97,Other,140% New York Medicaid APG,6684.05,,,6684.05,Other,225% New York Medicaid APG,7723.79,,,7723.79,Other,260% New York Medicaid APG,9625.03,,,9625.03,Other,324% New York Medicaid APG,6386.98,,,6386.98,Other,215% New York Medicaid APG,6386.98,,,6386.98,Other,215% New York Medicaid APG,3713.36,,,3713.36,Other,125% New York Medicaid APG,2970.69,62038.82,
Spinal disk surgery add-on,63035,CPT,,,,,,,,both,,,86591.4,64077.64,74,,64077.64,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,38966.13,45,,38966.13,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,6125,,"100% primary, 50% secondary, 25% supplemental procedure",6125,Other,Blue Cross ASC Grouper,5513,,"100% primary, 50% secondary, 25% supplemental procedure",5513,Other,Blue Cross ASC Grouper,5206,,"100% primary, 50% secondary, 25% supplemental procedure",5206,Other,Blue Cross ASC Grouper,42862.74,49.5,,42862.74,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5525.48,,,5525.48,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,60613.98,70,,60613.98,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,2970.69,,,2970.69,Other,New York Medicaid APG methodology,2970.69,,,2970.69,Other,100% New York Medicaid APG,2970.69,,,2970.69,Other,100% New York Medicaid APG,2970.69,,,2970.69,Other,100% New York Medicaid APG,6684.05,,,6684.05,Other,225% New York Medicaid APG,4545.16,,,4545.16,Other,153% New York Medicaid APG,6684.05,,,6684.05,Other,225% New York Medicaid APG,4158.97,,,4158.97,Other,140% New York Medicaid APG,6684.05,,,6684.05,Other,225% New York Medicaid APG,7723.79,,,7723.79,Other,260% New York Medicaid APG,9625.03,,,9625.03,Other,324% New York Medicaid APG,6386.98,,,6386.98,Other,215% New York Medicaid APG,6386.98,,,6386.98,Other,215% New York Medicaid APG,3713.36,,,3713.36,Other,125% New York Medicaid APG,2743,64077.64,
Laminotomy single cervical,63040,CPT,,,,,,,,both,,,150476.65,111352.72,74,,111352.72,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,67714.49,45,,67714.49,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,74485.94,49.5,,74485.94,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5525.48,,,5525.48,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,105333.66,70,,105333.66,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,2970.69,,,2970.69,Other,New York Medicaid APG methodology,2970.69,,,2970.69,Other,100% New York Medicaid APG,2970.69,,,2970.69,Other,100% New York Medicaid APG,2970.69,,,2970.69,Other,100% New York Medicaid APG,6684.05,,,6684.05,Other,225% New York Medicaid APG,4545.16,,,4545.16,Other,153% New York Medicaid APG,6684.05,,,6684.05,Other,225% New York Medicaid APG,4158.97,,,4158.97,Other,140% New York Medicaid APG,6684.05,,,6684.05,Other,225% New York Medicaid APG,7723.79,,,7723.79,Other,260% New York Medicaid APG,9625.03,,,9625.03,Other,324% New York Medicaid APG,6386.98,,,6386.98,Other,215% New York Medicaid APG,6386.98,,,6386.98,Other,215% New York Medicaid APG,3713.36,,,3713.36,Other,125% New York Medicaid APG,2970.69,111352.72,
Laminotomy single lumbar,63042,CPT,,,,,,,,both,,,52792.86,39066.72,74,,39066.72,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,23756.79,45,,23756.79,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,26132.47,49.5,,26132.47,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5525.48,,,5525.48,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,36955,70,,36955,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,2970.69,,,2970.69,Other,New York Medicaid APG methodology,2970.69,,,2970.69,Other,100% New York Medicaid APG,2970.69,,,2970.69,Other,100% New York Medicaid APG,2970.69,,,2970.69,Other,100% New York Medicaid APG,6684.05,,,6684.05,Other,225% New York Medicaid APG,4545.16,,,4545.16,Other,153% New York Medicaid APG,6684.05,,,6684.05,Other,225% New York Medicaid APG,4158.97,,,4158.97,Other,140% New York Medicaid APG,6684.05,,,6684.05,Other,225% New York Medicaid APG,7723.79,,,7723.79,Other,260% New York Medicaid APG,9625.03,,,9625.03,Other,324% New York Medicaid APG,6386.98,,,6386.98,Other,215% New York Medicaid APG,6386.98,,,6386.98,Other,215% New York Medicaid APG,3713.36,,,3713.36,Other,125% New York Medicaid APG,2970.69,39066.72,
Laminotomy addl cervical,63043,CPT,,,,,,,,both,,,86591.4,64077.64,74,,64077.64,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,38966.13,45,,38966.13,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,6125,,"100% primary, 50% secondary, 25% supplemental procedure",6125,Other,Blue Cross ASC Grouper,5513,,"100% primary, 50% secondary, 25% supplemental procedure",5513,Other,Blue Cross ASC Grouper,5206,,"100% primary, 50% secondary, 25% supplemental procedure",5206,Other,Blue Cross ASC Grouper,42862.74,49.5,,42862.74,percent of total billed charges,110% of Medicare,58882.15,68,,58882.15,percent of total billed charges,,5525.48,,,5525.48,Other,186% of Medicaid,69273.12,80,,69273.12,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,69273.12,80,,69273.12,percent of total billed charges,,7216,,,7216,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,60613.98,70,,60613.98,percent of total billed charges,,56284.41,65,,56284.41,percent of total billed charges,,56284.41,65,,56284.41,percent of total billed charges,,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,2970.69,,,2970.69,Other,New York Medicaid APG methodology,2970.69,,,2970.69,Other,100% New York Medicaid APG,2970.69,,,2970.69,Other,100% New York Medicaid APG,2970.69,,,2970.69,Other,100% New York Medicaid APG,6684.05,,,6684.05,Other,225% New York Medicaid APG,4545.16,,,4545.16,Other,153% New York Medicaid APG,6684.05,,,6684.05,Other,225% New York Medicaid APG,4158.97,,,4158.97,Other,140% New York Medicaid APG,6684.05,,,6684.05,Other,225% New York Medicaid APG,7723.79,,,7723.79,Other,260% New York Medicaid APG,9625.03,,,9625.03,Other,324% New York Medicaid APG,6386.98,,,6386.98,Other,215% New York Medicaid APG,6386.98,,,6386.98,Other,215% New York Medicaid APG,3713.36,,,3713.36,Other,125% New York Medicaid APG,2053,69273.12,
Laminotomy addl lumbar,63044,CPT,,,,,,,,both,,,86591.4,64077.64,74,,64077.64,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,38966.13,45,,38966.13,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,6125,,"100% primary, 50% secondary, 25% supplemental procedure",6125,Other,Blue Cross ASC Grouper,5513,,"100% primary, 50% secondary, 25% supplemental procedure",5513,Other,Blue Cross ASC Grouper,5206,,"100% primary, 50% secondary, 25% supplemental procedure",5206,Other,Blue Cross ASC Grouper,42862.74,49.5,,42862.74,percent of total billed charges,110% of Medicare,58882.15,68,,58882.15,percent of total billed charges,,6658.36,,,6658.36,Other,186% of Medicaid,69273.12,80,,69273.12,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,69273.12,80,,69273.12,percent of total billed charges,,7216,,,7216,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,60613.98,70,,60613.98,percent of total billed charges,,56284.41,65,,56284.41,percent of total billed charges,,56284.41,65,,56284.41,percent of total billed charges,,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,3579.77,,,3579.77,Other,New York Medicaid APG methodology,3579.77,,,3579.77,Other,100% New York Medicaid APG,3579.77,,,3579.77,Other,100% New York Medicaid APG,3579.77,,,3579.77,Other,100% New York Medicaid APG,8054.47,,,8054.47,Other,225% New York Medicaid APG,5477.04,,,5477.04,Other,153% New York Medicaid APG,8054.47,,,8054.47,Other,225% New York Medicaid APG,5011.67,,,5011.67,Other,140% New York Medicaid APG,8054.47,,,8054.47,Other,225% New York Medicaid APG,9307.39,,,9307.39,Other,260% New York Medicaid APG,11598.44,,,11598.44,Other,324% New York Medicaid APG,7696.5,,,7696.5,Other,215% New York Medicaid APG,7696.5,,,7696.5,Other,215% New York Medicaid APG,4474.71,,,4474.71,Other,125% New York Medicaid APG,2053,69273.12,
Remove spine lamina 1 crvl,63045,CPT,,,,,,,,both,,,58179.26,43052.65,74,,43052.65,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,26180.67,45,,26180.67,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,28798.73,49.5,,28798.73,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5525.48,,,5525.48,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,40725.48,70,,40725.48,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,2970.69,,,2970.69,Other,New York Medicaid APG methodology,2970.69,,,2970.69,Other,100% New York Medicaid APG,2970.69,,,2970.69,Other,100% New York Medicaid APG,2970.69,,,2970.69,Other,100% New York Medicaid APG,6684.05,,,6684.05,Other,225% New York Medicaid APG,4545.16,,,4545.16,Other,153% New York Medicaid APG,6684.05,,,6684.05,Other,225% New York Medicaid APG,4158.97,,,4158.97,Other,140% New York Medicaid APG,6684.05,,,6684.05,Other,225% New York Medicaid APG,7723.79,,,7723.79,Other,260% New York Medicaid APG,9625.03,,,9625.03,Other,324% New York Medicaid APG,6386.98,,,6386.98,Other,215% New York Medicaid APG,6386.98,,,6386.98,Other,215% New York Medicaid APG,3713.36,,,3713.36,Other,125% New York Medicaid APG,2970.69,43052.65,
Remove spine lamina 1 thrc,63046,CPT,,,,,,,,both,,,150476.65,111352.72,74,,111352.72,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,67714.49,45,,67714.49,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,74485.94,49.5,,74485.94,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5525.48,,,5525.48,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,105333.66,70,,105333.66,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,2970.69,,,2970.69,Other,New York Medicaid APG methodology,2970.69,,,2970.69,Other,100% New York Medicaid APG,2970.69,,,2970.69,Other,100% New York Medicaid APG,2970.69,,,2970.69,Other,100% New York Medicaid APG,6684.05,,,6684.05,Other,225% New York Medicaid APG,4545.16,,,4545.16,Other,153% New York Medicaid APG,6684.05,,,6684.05,Other,225% New York Medicaid APG,4158.97,,,4158.97,Other,140% New York Medicaid APG,6684.05,,,6684.05,Other,225% New York Medicaid APG,7723.79,,,7723.79,Other,260% New York Medicaid APG,9625.03,,,9625.03,Other,324% New York Medicaid APG,6386.98,,,6386.98,Other,215% New York Medicaid APG,6386.98,,,6386.98,Other,215% New York Medicaid APG,3713.36,,,3713.36,Other,125% New York Medicaid APG,2970.69,111352.72,
Remove spine lamina 1 lmbr,63047,CPT,,,,,,,,both,,,87385.96,64665.61,74,,64665.61,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,39323.68,45,,39323.68,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,43256.05,49.5,,43256.05,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5525.48,,,5525.48,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,61170.17,70,,61170.17,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,2970.69,,,2970.69,Other,New York Medicaid APG methodology,2970.69,,,2970.69,Other,100% New York Medicaid APG,2970.69,,,2970.69,Other,100% New York Medicaid APG,2970.69,,,2970.69,Other,100% New York Medicaid APG,6684.05,,,6684.05,Other,225% New York Medicaid APG,4545.16,,,4545.16,Other,153% New York Medicaid APG,6684.05,,,6684.05,Other,225% New York Medicaid APG,4158.97,,,4158.97,Other,140% New York Medicaid APG,6684.05,,,6684.05,Other,225% New York Medicaid APG,7723.79,,,7723.79,Other,260% New York Medicaid APG,9625.03,,,9625.03,Other,324% New York Medicaid APG,6386.98,,,6386.98,Other,215% New York Medicaid APG,6386.98,,,6386.98,Other,215% New York Medicaid APG,3713.36,,,3713.36,Other,125% New York Medicaid APG,2970.69,64665.61,
Remove spinal lamina add-on,63048,CPT,,,,,,,,both,,,95161.09,70419.21,74,,70419.21,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,42822.49,45,,42822.49,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,47104.74,49.5,,47104.74,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5525.48,,,5525.48,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,66612.76,70,,66612.76,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,2970.69,,,2970.69,Other,New York Medicaid APG methodology,2970.69,,,2970.69,Other,100% New York Medicaid APG,2970.69,,,2970.69,Other,100% New York Medicaid APG,2970.69,,,2970.69,Other,100% New York Medicaid APG,6684.05,,,6684.05,Other,225% New York Medicaid APG,4545.16,,,4545.16,Other,153% New York Medicaid APG,6684.05,,,6684.05,Other,225% New York Medicaid APG,4158.97,,,4158.97,Other,140% New York Medicaid APG,6684.05,,,6684.05,Other,225% New York Medicaid APG,7723.79,,,7723.79,Other,260% New York Medicaid APG,9625.03,,,9625.03,Other,324% New York Medicaid APG,6386.98,,,6386.98,Other,215% New York Medicaid APG,6386.98,,,6386.98,Other,215% New York Medicaid APG,3713.36,,,3713.36,Other,125% New York Medicaid APG,2743,70419.21,
Decompress spinal cord thrc,63055,CPT,,,,,,,,both,,,150476.65,111352.72,74,,111352.72,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,67714.49,45,,67714.49,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,74485.94,49.5,,74485.94,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5525.48,,,5525.48,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,105333.66,70,,105333.66,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,2970.69,,,2970.69,Other,New York Medicaid APG methodology,2970.69,,,2970.69,Other,100% New York Medicaid APG,2970.69,,,2970.69,Other,100% New York Medicaid APG,2970.69,,,2970.69,Other,100% New York Medicaid APG,6684.05,,,6684.05,Other,225% New York Medicaid APG,4545.16,,,4545.16,Other,153% New York Medicaid APG,6684.05,,,6684.05,Other,225% New York Medicaid APG,4158.97,,,4158.97,Other,140% New York Medicaid APG,6684.05,,,6684.05,Other,225% New York Medicaid APG,7723.79,,,7723.79,Other,260% New York Medicaid APG,9625.03,,,9625.03,Other,324% New York Medicaid APG,6386.98,,,6386.98,Other,215% New York Medicaid APG,6386.98,,,6386.98,Other,215% New York Medicaid APG,3713.36,,,3713.36,Other,125% New York Medicaid APG,2970.69,111352.72,
Decompress spinal cord lmbr,63056,CPT,,,,,,,,both,,,81823.59,60549.46,74,,60549.46,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,36820.62,45,,36820.62,percent of total billed charges,Medicare Ratio of cost to charges,5459,,"100% primary, 50% supplemental procedure",5459,Other,Aetna ASC Grouper,4913,,"100% primary, 50% supplemental procedure",4913,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,40502.68,49.5,,40502.68,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5525.48,,,5525.48,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,57276.51,70,,57276.51,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,2970.69,,,2970.69,Other,New York Medicaid APG methodology,2970.69,,,2970.69,Other,100% New York Medicaid APG,2970.69,,,2970.69,Other,100% New York Medicaid APG,2970.69,,,2970.69,Other,100% New York Medicaid APG,6684.05,,,6684.05,Other,225% New York Medicaid APG,4545.16,,,4545.16,Other,153% New York Medicaid APG,6684.05,,,6684.05,Other,225% New York Medicaid APG,4158.97,,,4158.97,Other,140% New York Medicaid APG,6684.05,,,6684.05,Other,225% New York Medicaid APG,7723.79,,,7723.79,Other,260% New York Medicaid APG,9625.03,,,9625.03,Other,324% New York Medicaid APG,6386.98,,,6386.98,Other,215% New York Medicaid APG,6386.98,,,6386.98,Other,215% New York Medicaid APG,3713.36,,,3713.36,Other,125% New York Medicaid APG,2970.69,60549.46,
Decompress spine cord add-on,63057,CPT,,,,,,,,both,,,86591.4,64077.64,74,,64077.64,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,38966.13,45,,38966.13,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,6125,,"100% primary, 50% secondary, 25% supplemental procedure",6125,Other,Blue Cross ASC Grouper,5513,,"100% primary, 50% secondary, 25% supplemental procedure",5513,Other,Blue Cross ASC Grouper,5206,,"100% primary, 50% secondary, 25% supplemental procedure",5206,Other,Blue Cross ASC Grouper,42862.74,49.5,,42862.74,percent of total billed charges,110% of Medicare,58882.15,68,,58882.15,percent of total billed charges,,5525.48,,,5525.48,Other,186% of Medicaid,69273.12,80,,69273.12,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,69273.12,80,,69273.12,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,60613.98,70,,60613.98,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,2970.69,,,2970.69,Other,New York Medicaid APG methodology,2970.69,,,2970.69,Other,100% New York Medicaid APG,2970.69,,,2970.69,Other,100% New York Medicaid APG,2970.69,,,2970.69,Other,100% New York Medicaid APG,6684.05,,,6684.05,Other,225% New York Medicaid APG,4545.16,,,4545.16,Other,153% New York Medicaid APG,6684.05,,,6684.05,Other,225% New York Medicaid APG,4158.97,,,4158.97,Other,140% New York Medicaid APG,6684.05,,,6684.05,Other,225% New York Medicaid APG,7723.79,,,7723.79,Other,260% New York Medicaid APG,9625.03,,,9625.03,Other,324% New York Medicaid APG,6386.98,,,6386.98,Other,215% New York Medicaid APG,6386.98,,,6386.98,Other,215% New York Medicaid APG,3713.36,,,3713.36,Other,125% New York Medicaid APG,2053,69273.12,
Decompress spinal cord thrc,63064,CPT,,,,,,,,both,,,150476.65,111352.72,74,,111352.72,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,67714.49,45,,67714.49,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,74485.94,49.5,,74485.94,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5525.48,,,5525.48,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,105333.66,70,,105333.66,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,2970.69,,,2970.69,Other,New York Medicaid APG methodology,2970.69,,,2970.69,Other,100% New York Medicaid APG,2970.69,,,2970.69,Other,100% New York Medicaid APG,2970.69,,,2970.69,Other,100% New York Medicaid APG,6684.05,,,6684.05,Other,225% New York Medicaid APG,4545.16,,,4545.16,Other,153% New York Medicaid APG,6684.05,,,6684.05,Other,225% New York Medicaid APG,4158.97,,,4158.97,Other,140% New York Medicaid APG,6684.05,,,6684.05,Other,225% New York Medicaid APG,7723.79,,,7723.79,Other,260% New York Medicaid APG,9625.03,,,9625.03,Other,324% New York Medicaid APG,6386.98,,,6386.98,Other,215% New York Medicaid APG,6386.98,,,6386.98,Other,215% New York Medicaid APG,3713.36,,,3713.36,Other,125% New York Medicaid APG,2970.69,111352.72,
Decompress spine cord add-on,63066,CPT,,,,,,,,both,,,86591.4,64077.64,74,,64077.64,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,38966.13,45,,38966.13,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,6125,,"100% primary, 50% secondary, 25% supplemental procedure",6125,Other,Blue Cross ASC Grouper,5513,,"100% primary, 50% secondary, 25% supplemental procedure",5513,Other,Blue Cross ASC Grouper,5206,,"100% primary, 50% secondary, 25% supplemental procedure",5206,Other,Blue Cross ASC Grouper,42862.74,49.5,,42862.74,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5525.48,,,5525.48,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,60613.98,70,,60613.98,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,2970.69,,,2970.69,Other,New York Medicaid APG methodology,2970.69,,,2970.69,Other,100% New York Medicaid APG,2970.69,,,2970.69,Other,100% New York Medicaid APG,2970.69,,,2970.69,Other,100% New York Medicaid APG,6684.05,,,6684.05,Other,225% New York Medicaid APG,4545.16,,,4545.16,Other,153% New York Medicaid APG,6684.05,,,6684.05,Other,225% New York Medicaid APG,4158.97,,,4158.97,Other,140% New York Medicaid APG,6684.05,,,6684.05,Other,225% New York Medicaid APG,7723.79,,,7723.79,Other,260% New York Medicaid APG,9625.03,,,9625.03,Other,324% New York Medicaid APG,6386.98,,,6386.98,Other,215% New York Medicaid APG,6386.98,,,6386.98,Other,215% New York Medicaid APG,3713.36,,,3713.36,Other,125% New York Medicaid APG,2743,64077.64,
Neck spine disk surgery,63075,CPT,,,,,,,,both,,,248791,184105.34,74,,184105.34,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,111955.95,45,,111955.95,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,123151.55,49.5,,123151.55,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,6658.36,,,6658.36,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,174153.7,70,,174153.7,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,3579.77,,,3579.77,Other,New York Medicaid APG methodology,3579.77,,,3579.77,Other,100% New York Medicaid APG,3579.77,,,3579.77,Other,100% New York Medicaid APG,3579.77,,,3579.77,Other,100% New York Medicaid APG,8054.47,,,8054.47,Other,225% New York Medicaid APG,5477.04,,,5477.04,Other,153% New York Medicaid APG,8054.47,,,8054.47,Other,225% New York Medicaid APG,5011.67,,,5011.67,Other,140% New York Medicaid APG,8054.47,,,8054.47,Other,225% New York Medicaid APG,9307.39,,,9307.39,Other,260% New York Medicaid APG,11598.44,,,11598.44,Other,324% New York Medicaid APG,7696.5,,,7696.5,Other,215% New York Medicaid APG,7696.5,,,7696.5,Other,215% New York Medicaid APG,4474.71,,,4474.71,Other,125% New York Medicaid APG,3343,184105.34,
Neck spine disk surgery,63076,CPT,,,,,,,,both,,,83504,61792.96,74,,61792.96,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,37576.8,45,,37576.8,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,41334.48,49.5,,41334.48,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,6658.36,,,6658.36,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,58452.8,70,,58452.8,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,3579.77,,,3579.77,Other,New York Medicaid APG methodology,3579.77,,,3579.77,Other,100% New York Medicaid APG,3579.77,,,3579.77,Other,100% New York Medicaid APG,3579.77,,,3579.77,Other,100% New York Medicaid APG,8054.47,,,8054.47,Other,225% New York Medicaid APG,5477.04,,,5477.04,Other,153% New York Medicaid APG,8054.47,,,8054.47,Other,225% New York Medicaid APG,5011.67,,,5011.67,Other,140% New York Medicaid APG,8054.47,,,8054.47,Other,225% New York Medicaid APG,9307.39,,,9307.39,Other,260% New York Medicaid APG,11598.44,,,11598.44,Other,324% New York Medicaid APG,7696.5,,,7696.5,Other,215% New York Medicaid APG,7696.5,,,7696.5,Other,215% New York Medicaid APG,4474.71,,,4474.71,Other,125% New York Medicaid APG,2743,61792.96,
Remove spinal cord lesion,63600,CPT,,,,,,,,both,,,40611.5,30052.51,74,,30052.51,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,18275.18,45,,18275.18,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,20102.69,49.5,,20102.69,percent of total billed charges,110% of Medicare,27615.82,68,,27615.82,percent of total billed charges,,5525.48,,,5525.48,Other,186% of Medicaid,32489.2,80,,32489.2,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,32489.2,80,,32489.2,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,28428.05,70,,28428.05,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,2970.69,,,2970.69,Other,New York Medicaid APG methodology,2970.69,,,2970.69,Other,100% New York Medicaid APG,2970.69,,,2970.69,Other,100% New York Medicaid APG,2970.69,,,2970.69,Other,100% New York Medicaid APG,6684.05,,,6684.05,Other,225% New York Medicaid APG,4545.16,,,4545.16,Other,153% New York Medicaid APG,6684.05,,,6684.05,Other,225% New York Medicaid APG,4158.97,,,4158.97,Other,140% New York Medicaid APG,6684.05,,,6684.05,Other,225% New York Medicaid APG,7723.79,,,7723.79,Other,260% New York Medicaid APG,9625.03,,,9625.03,Other,324% New York Medicaid APG,6386.98,,,6386.98,Other,215% New York Medicaid APG,6386.98,,,6386.98,Other,215% New York Medicaid APG,3713.36,,,3713.36,Other,125% New York Medicaid APG,2232,32489.2,
Stimulation of spinal cord,63610,CPT,,,,,,,,both,,,40611.5,30052.51,74,,30052.51,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,18275.18,45,,18275.18,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,20102.69,49.5,,20102.69,percent of total billed charges,110% of Medicare,27615.82,68,,27615.82,percent of total billed charges,,5525.48,,,5525.48,Other,186% of Medicaid,32489.2,80,,32489.2,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,32489.2,80,,32489.2,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,28428.05,70,,28428.05,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,2970.69,,,2970.69,Other,New York Medicaid APG methodology,2970.69,,,2970.69,Other,100% New York Medicaid APG,2970.69,,,2970.69,Other,100% New York Medicaid APG,2970.69,,,2970.69,Other,100% New York Medicaid APG,6684.05,,,6684.05,Other,225% New York Medicaid APG,4545.16,,,4545.16,Other,153% New York Medicaid APG,6684.05,,,6684.05,Other,225% New York Medicaid APG,4158.97,,,4158.97,Other,140% New York Medicaid APG,6684.05,,,6684.05,Other,225% New York Medicaid APG,7723.79,,,7723.79,Other,260% New York Medicaid APG,9625.03,,,9625.03,Other,324% New York Medicaid APG,6386.98,,,6386.98,Other,215% New York Medicaid APG,6386.98,,,6386.98,Other,215% New York Medicaid APG,3713.36,,,3713.36,Other,125% New York Medicaid APG,2053,32489.2,
Implant neuroelectrodes,63650,CPT,,,,,,,,both,,,100920.91,74681.47,74,,74681.47,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,45414.41,45,,45414.41,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,49955.85,49.5,,49955.85,percent of total billed charges,110% of Medicare,68626.22,68,,68626.22,percent of total billed charges,,23604.92,,,23604.92,Other,186% of Medicaid,80736.73,80,,80736.73,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,80736.73,80,,80736.73,percent of total billed charges,,7216,,,7216,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,70644.64,70,,70644.64,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,12690.81,,,12690.81,Other,New York Medicaid APG methodology,12690.81,,,12690.81,Other,100% New York Medicaid APG,12690.81,,,12690.81,Other,100% New York Medicaid APG,12690.81,,,12690.81,Other,100% New York Medicaid APG,28554.33,,,28554.33,Other,225% New York Medicaid APG,19416.95,,,19416.95,Other,153% New York Medicaid APG,28554.33,,,28554.33,Other,225% New York Medicaid APG,17767.14,,,17767.14,Other,140% New York Medicaid APG,28554.33,,,28554.33,Other,225% New York Medicaid APG,32996.12,,,32996.12,Other,260% New York Medicaid APG,41118.24,,,41118.24,Other,324% New York Medicaid APG,27285.25,,,27285.25,Other,215% New York Medicaid APG,27285.25,,,27285.25,Other,215% New York Medicaid APG,15863.52,,,15863.52,Other,125% New York Medicaid APG,2232,80736.73,
Implant neuroelectrodes,63655,CPT,,,,,,,,both,,,128738.78,95266.7,74,,95266.7,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,57932.45,45,,57932.45,percent of total billed charges,Medicare Ratio of cost to charges,5459,,"100% primary, 50% supplemental procedure",5459,Other,Aetna ASC Grouper,4913,,"100% primary, 50% supplemental procedure",4913,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,63725.7,49.5,,63725.7,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,31375.51,,,31375.51,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9196,,"100% primary, 0% secondary procedures",9196,Other,MagnaCare ASC Grouper,90117.15,70,,90117.15,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6956,,"100% primary, 50% secondary, 25% tertiary procedure",6956,Other,United Healthcare ASC Grouper,6261,,"100% primary, 50% secondary, 25% tertiary procedure",6261,Other,United Healthcare ASC Grouper,6956,,"100% primary, 50% secondary, 25% tertiary procedure",6956,Other,United Healthcare ASC Grouper,5913,,"100% primary, 50% secondary, 25% tertiary procedure",5913,Other,United Healthcare ASC Grouper,16868.56,,,16868.56,Other,New York Medicaid APG methodology,16868.56,,,16868.56,Other,100% New York Medicaid APG,16868.56,,,16868.56,Other,100% New York Medicaid APG,16868.56,,,16868.56,Other,100% New York Medicaid APG,37954.25,,,37954.25,Other,225% New York Medicaid APG,25808.89,,,25808.89,Other,153% New York Medicaid APG,37954.25,,,37954.25,Other,225% New York Medicaid APG,23615.98,,,23615.98,Other,140% New York Medicaid APG,37954.25,,,37954.25,Other,225% New York Medicaid APG,43858.24,,,43858.24,Other,260% New York Medicaid APG,54654.12,,,54654.12,Other,324% New York Medicaid APG,36267.39,,,36267.39,Other,215% New York Medicaid APG,36267.39,,,36267.39,Other,215% New York Medicaid APG,21085.69,,,21085.69,Other,125% New York Medicaid APG,3343,95266.7,
Remove spine eltrd perq aray,63661,CPT,,,,,,,,both,,,58200.2,43068.15,74,,43068.15,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,26190.09,45,,26190.09,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,28809.1,49.5,,28809.1,percent of total billed charges,110% of Medicare,39576.14,68,,39576.14,percent of total billed charges,,3388.68,,,3388.68,Other,186% of Medicaid,46560.16,80,,46560.16,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,46560.16,80,,46560.16,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,40740.14,70,,40740.14,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1821.87,,,1821.87,Other,New York Medicaid APG methodology,1821.87,,,1821.87,Other,100% New York Medicaid APG,1821.87,,,1821.87,Other,100% New York Medicaid APG,1821.87,,,1821.87,Other,100% New York Medicaid APG,4099.2,,,4099.2,Other,225% New York Medicaid APG,2787.46,,,2787.46,Other,153% New York Medicaid APG,4099.2,,,4099.2,Other,225% New York Medicaid APG,2550.62,,,2550.62,Other,140% New York Medicaid APG,4099.2,,,4099.2,Other,225% New York Medicaid APG,4736.86,,,4736.86,Other,260% New York Medicaid APG,5902.85,,,5902.85,Other,324% New York Medicaid APG,3917.02,,,3917.02,Other,215% New York Medicaid APG,3917.02,,,3917.02,Other,215% New York Medicaid APG,2277.34,,,2277.34,Other,125% New York Medicaid APG,1821.87,46560.16,
Remove spine eltrd plate,63662,CPT,,,,,,,,both,,,74313.89,54992.28,74,,54992.28,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,33441.25,45,,33441.25,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,36785.38,49.5,,36785.38,percent of total billed charges,110% of Medicare,50533.45,68,,50533.45,percent of total billed charges,,3388.68,,,3388.68,Other,186% of Medicaid,59451.11,80,,59451.11,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,59451.11,80,,59451.11,percent of total billed charges,,7216,,,7216,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,52019.72,70,,52019.72,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1821.87,,,1821.87,Other,New York Medicaid APG methodology,1821.87,,,1821.87,Other,100% New York Medicaid APG,1821.87,,,1821.87,Other,100% New York Medicaid APG,1821.87,,,1821.87,Other,100% New York Medicaid APG,4099.2,,,4099.2,Other,225% New York Medicaid APG,2787.46,,,2787.46,Other,153% New York Medicaid APG,4099.2,,,4099.2,Other,225% New York Medicaid APG,2550.62,,,2550.62,Other,140% New York Medicaid APG,4099.2,,,4099.2,Other,225% New York Medicaid APG,4736.86,,,4736.86,Other,260% New York Medicaid APG,5902.85,,,5902.85,Other,324% New York Medicaid APG,3917.02,,,3917.02,Other,215% New York Medicaid APG,3917.02,,,3917.02,Other,215% New York Medicaid APG,2277.34,,,2277.34,Other,125% New York Medicaid APG,1821.87,59451.11,
Revise spine eltrd perq aray,63663,CPT,,,,,,,,both,,,65841.59,48722.78,74,,48722.78,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,29628.72,45,,29628.72,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,32591.59,49.5,,32591.59,percent of total billed charges,110% of Medicare,44772.28,68,,44772.28,percent of total billed charges,,23604.92,,,23604.92,Other,186% of Medicaid,52673.27,80,,52673.27,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,52673.27,80,,52673.27,percent of total billed charges,,7216,,,7216,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,46089.11,70,,46089.11,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,12690.81,,,12690.81,Other,New York Medicaid APG methodology,12690.81,,,12690.81,Other,100% New York Medicaid APG,12690.81,,,12690.81,Other,100% New York Medicaid APG,12690.81,,,12690.81,Other,100% New York Medicaid APG,28554.33,,,28554.33,Other,225% New York Medicaid APG,19416.95,,,19416.95,Other,153% New York Medicaid APG,28554.33,,,28554.33,Other,225% New York Medicaid APG,17767.14,,,17767.14,Other,140% New York Medicaid APG,28554.33,,,28554.33,Other,225% New York Medicaid APG,32996.12,,,32996.12,Other,260% New York Medicaid APG,41118.24,,,41118.24,Other,324% New York Medicaid APG,27285.25,,,27285.25,Other,215% New York Medicaid APG,27285.25,,,27285.25,Other,215% New York Medicaid APG,15863.52,,,15863.52,Other,125% New York Medicaid APG,2053,52673.27,
Revise spine eltrd plate,63664,CPT,,,,,,,,both,,,286522.06,212026.32,74,,212026.32,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,128934.93,45,,128934.93,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,141828.42,49.5,,141828.42,percent of total billed charges,110% of Medicare,194835,68,,194835,percent of total billed charges,,31375.51,,,31375.51,Other,186% of Medicaid,229217.65,80,,229217.65,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,229217.65,80,,229217.65,percent of total billed charges,,7216,,,7216,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,200565.44,70,,200565.44,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,16868.56,,,16868.56,Other,New York Medicaid APG methodology,16868.56,,,16868.56,Other,100% New York Medicaid APG,16868.56,,,16868.56,Other,100% New York Medicaid APG,16868.56,,,16868.56,Other,100% New York Medicaid APG,37954.25,,,37954.25,Other,225% New York Medicaid APG,25808.89,,,25808.89,Other,153% New York Medicaid APG,37954.25,,,37954.25,Other,225% New York Medicaid APG,23615.98,,,23615.98,Other,140% New York Medicaid APG,37954.25,,,37954.25,Other,225% New York Medicaid APG,43858.24,,,43858.24,Other,260% New York Medicaid APG,54654.12,,,54654.12,Other,324% New York Medicaid APG,36267.39,,,36267.39,Other,215% New York Medicaid APG,36267.39,,,36267.39,Other,215% New York Medicaid APG,21085.69,,,21085.69,Other,125% New York Medicaid APG,2053,229217.65,
Insrt/redo spine n generator,63685,CPT,,,,,,,,both,,,143297.21,106039.94,74,,106039.94,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,64483.74,45,,64483.74,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,70932.12,49.5,,70932.12,percent of total billed charges,110% of Medicare,97442.1,68,,97442.1,percent of total billed charges,,31375.51,,,31375.51,Other,186% of Medicaid,114637.77,80,,114637.77,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,114637.77,80,,114637.77,percent of total billed charges,,7216,,,7216,Case Rate,,9196,,"100% primary, 0% secondary procedures",9196,Other,MagnaCare ASC Grouper,100308.05,70,,100308.05,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,8589,,"100% primary, 50% secondary, 25% tertiary procedure",8589,Other,United Healthcare ASC Grouper,7730,,"100% primary, 50% secondary, 25% tertiary procedure",7730,Other,United Healthcare ASC Grouper,8589,,"100% primary, 50% secondary, 25% tertiary procedure",8589,Other,United Healthcare ASC Grouper,7301,,"100% primary, 50% secondary, 25% tertiary procedure",7301,Other,United Healthcare ASC Grouper,16868.56,,,16868.56,Other,New York Medicaid APG methodology,16868.56,,,16868.56,Other,100% New York Medicaid APG,16868.56,,,16868.56,Other,100% New York Medicaid APG,16868.56,,,16868.56,Other,100% New York Medicaid APG,37954.25,,,37954.25,Other,225% New York Medicaid APG,25808.89,,,25808.89,Other,153% New York Medicaid APG,37954.25,,,37954.25,Other,225% New York Medicaid APG,23615.98,,,23615.98,Other,140% New York Medicaid APG,37954.25,,,37954.25,Other,225% New York Medicaid APG,43858.24,,,43858.24,Other,260% New York Medicaid APG,54654.12,,,54654.12,Other,324% New York Medicaid APG,36267.39,,,36267.39,Other,215% New York Medicaid APG,36267.39,,,36267.39,Other,215% New York Medicaid APG,21085.69,,,21085.69,Other,125% New York Medicaid APG,2232,114637.77,
Revise/remove neuroreceiver,63688,CPT,,,,,,,,both,,,54133.48,40058.78,74,,40058.78,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,24360.07,45,,24360.07,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,26796.07,49.5,,26796.07,percent of total billed charges,110% of Medicare,36810.77,68,,36810.77,percent of total billed charges,,3388.68,,,3388.68,Other,186% of Medicaid,43306.78,80,,43306.78,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,43306.78,80,,43306.78,percent of total billed charges,,7216,,,7216,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,37893.44,70,,37893.44,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1821.87,,,1821.87,Other,New York Medicaid APG methodology,1821.87,,,1821.87,Other,100% New York Medicaid APG,1821.87,,,1821.87,Other,100% New York Medicaid APG,1821.87,,,1821.87,Other,100% New York Medicaid APG,4099.2,,,4099.2,Other,225% New York Medicaid APG,2787.46,,,2787.46,Other,153% New York Medicaid APG,4099.2,,,4099.2,Other,225% New York Medicaid APG,2550.62,,,2550.62,Other,140% New York Medicaid APG,4099.2,,,4099.2,Other,225% New York Medicaid APG,4736.86,,,4736.86,Other,260% New York Medicaid APG,5902.85,,,5902.85,Other,324% New York Medicaid APG,3917.02,,,3917.02,Other,215% New York Medicaid APG,3917.02,,,3917.02,Other,215% New York Medicaid APG,2277.34,,,2277.34,Other,125% New York Medicaid APG,1821.87,43306.78,
Install spinal shunt,63741,CPT,,,,,,,,both,,,140115.1,103685.17,74,,103685.17,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,63051.8,45,,63051.8,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,69356.97,49.5,,69356.97,percent of total billed charges,110% of Medicare,95278.27,68,,95278.27,percent of total billed charges,,6048.62,,,6048.62,Other,186% of Medicaid,112092.08,80,,112092.08,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,112092.08,80,,112092.08,percent of total billed charges,,7216,,,7216,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,98080.57,70,,98080.57,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,3251.95,,,3251.95,Other,New York Medicaid APG methodology,3251.95,,,3251.95,Other,100% New York Medicaid APG,3251.95,,,3251.95,Other,100% New York Medicaid APG,3251.95,,,3251.95,Other,100% New York Medicaid APG,7316.88,,,7316.88,Other,225% New York Medicaid APG,4975.48,,,4975.48,Other,153% New York Medicaid APG,7316.88,,,7316.88,Other,225% New York Medicaid APG,4552.73,,,4552.73,Other,140% New York Medicaid APG,7316.88,,,7316.88,Other,225% New York Medicaid APG,8455.06,,,8455.06,Other,260% New York Medicaid APG,10536.31,,,10536.31,Other,324% New York Medicaid APG,6991.69,,,6991.69,Other,215% New York Medicaid APG,6991.69,,,6991.69,Other,215% New York Medicaid APG,4064.93,,,4064.93,Other,125% New York Medicaid APG,2232,112092.08,
Revision of spinal shunt,63744,CPT,,,,,,,,both,,,96667.79,71534.16,74,,71534.16,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,43500.51,45,,43500.51,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,47850.56,49.5,,47850.56,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,6048.62,,,6048.62,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,67667.45,70,,67667.45,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,3251.95,,,3251.95,Other,New York Medicaid APG methodology,3251.95,,,3251.95,Other,100% New York Medicaid APG,3251.95,,,3251.95,Other,100% New York Medicaid APG,3251.95,,,3251.95,Other,100% New York Medicaid APG,7316.88,,,7316.88,Other,225% New York Medicaid APG,4975.48,,,4975.48,Other,153% New York Medicaid APG,7316.88,,,7316.88,Other,225% New York Medicaid APG,4552.73,,,4552.73,Other,140% New York Medicaid APG,7316.88,,,7316.88,Other,225% New York Medicaid APG,8455.06,,,8455.06,Other,260% New York Medicaid APG,10536.31,,,10536.31,Other,324% New York Medicaid APG,6991.69,,,6991.69,Other,215% New York Medicaid APG,6991.69,,,6991.69,Other,215% New York Medicaid APG,4064.93,,,4064.93,Other,125% New York Medicaid APG,3126,71534.16,
Removal of spinal shunt,63746,CPT,,,,,,,,both,,,40611.5,30052.51,74,,30052.51,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,18275.18,45,,18275.18,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,20102.69,49.5,,20102.69,percent of total billed charges,110% of Medicare,27615.82,68,,27615.82,percent of total billed charges,,2391.2,,,2391.2,Other,186% of Medicaid,32489.2,80,,32489.2,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,32489.2,80,,32489.2,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,28428.05,70,,28428.05,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1285.59,,,1285.59,Other,New York Medicaid APG methodology,1285.59,,,1285.59,Other,100% New York Medicaid APG,1285.59,,,1285.59,Other,100% New York Medicaid APG,1285.59,,,1285.59,Other,100% New York Medicaid APG,2892.58,,,2892.58,Other,225% New York Medicaid APG,1966.96,,,1966.96,Other,153% New York Medicaid APG,2892.58,,,2892.58,Other,225% New York Medicaid APG,1799.83,,,1799.83,Other,140% New York Medicaid APG,2892.58,,,2892.58,Other,225% New York Medicaid APG,3342.54,,,3342.54,Other,260% New York Medicaid APG,4165.32,,,4165.32,Other,324% New York Medicaid APG,2764.02,,,2764.02,Other,215% New York Medicaid APG,2764.02,,,2764.02,Other,215% New York Medicaid APG,1606.99,,,1606.99,Other,125% New York Medicaid APG,1285.59,32489.2,
Njx aa&/strd trigeminal nrv,64400,CPT,,,,,,,,both,,,3311,2450.14,74,,2450.14,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,1489.95,45,,1489.95,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,1638.95,49.5,,1638.95,percent of total billed charges,110% of Medicare,2251.48,68,,2251.48,percent of total billed charges,,966.11,,,966.11,Other,186% of Medicaid,2648.8,80,,2648.8,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,2648.8,80,,2648.8,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,2317.7,70,,2317.7,percent of total billed charges,,246,,,246,Fee Schedule,,208.5,,,208.5,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,519.42,,,519.42,Other,New York Medicaid APG methodology,519.42,,,519.42,Other,100% New York Medicaid APG,519.42,,,519.42,Other,100% New York Medicaid APG,519.42,,,519.42,Other,100% New York Medicaid APG,1168.69,,,1168.69,Other,225% New York Medicaid APG,794.71,,,794.71,Other,153% New York Medicaid APG,1168.69,,,1168.69,Other,225% New York Medicaid APG,727.18,,,727.18,Other,140% New York Medicaid APG,1168.69,,,1168.69,Other,225% New York Medicaid APG,1350.48,,,1350.48,Other,260% New York Medicaid APG,1682.91,,,1682.91,Other,324% New York Medicaid APG,1116.74,,,1116.74,Other,215% New York Medicaid APG,1116.74,,,1116.74,Other,215% New York Medicaid APG,649.27,,,649.27,Other,125% New York Medicaid APG,208.5,7216,
Njx aa&/strd gr ocpl nrv,64405,CPT,,,,,,,,both,,,12430.65,9198.68,74,,9198.68,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,5593.79,45,,5593.79,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,6153.17,49.5,,6153.17,percent of total billed charges,110% of Medicare,8452.84,68,,8452.84,percent of total billed charges,,966.11,,,966.11,Other,186% of Medicaid,9944.52,80,,9944.52,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,9944.52,80,,9944.52,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,8701.46,70,,8701.46,percent of total billed charges,,257.48,,,257.48,Fee Schedule,,218.23,,,218.23,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,519.42,,,519.42,Other,New York Medicaid APG methodology,519.42,,,519.42,Other,100% New York Medicaid APG,519.42,,,519.42,Other,100% New York Medicaid APG,519.42,,,519.42,Other,100% New York Medicaid APG,1168.69,,,1168.69,Other,225% New York Medicaid APG,794.71,,,794.71,Other,153% New York Medicaid APG,1168.69,,,1168.69,Other,225% New York Medicaid APG,727.18,,,727.18,Other,140% New York Medicaid APG,1168.69,,,1168.69,Other,225% New York Medicaid APG,1350.48,,,1350.48,Other,260% New York Medicaid APG,1682.91,,,1682.91,Other,324% New York Medicaid APG,1116.74,,,1116.74,Other,215% New York Medicaid APG,1116.74,,,1116.74,Other,215% New York Medicaid APG,649.27,,,649.27,Other,125% New York Medicaid APG,218.23,9944.52,
Njx aa&/strd vagus nrv,64408,CPT,,,,,,,,both,,,6229.82,4610.07,74,,4610.07,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,2803.42,45,,2803.42,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,3083.76,49.5,,3083.76,percent of total billed charges,110% of Medicare,4236.28,68,,4236.28,percent of total billed charges,,966.11,,,966.11,Other,186% of Medicaid,4983.86,80,,4983.86,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,4983.86,80,,4983.86,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,4360.87,70,,4360.87,percent of total billed charges,,219.76,,,219.76,Fee Schedule,,186.26,,,186.26,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,519.42,,,519.42,Other,New York Medicaid APG methodology,519.42,,,519.42,Other,100% New York Medicaid APG,519.42,,,519.42,Other,100% New York Medicaid APG,519.42,,,519.42,Other,100% New York Medicaid APG,1168.69,,,1168.69,Other,225% New York Medicaid APG,794.71,,,794.71,Other,153% New York Medicaid APG,1168.69,,,1168.69,Other,225% New York Medicaid APG,727.18,,,727.18,Other,140% New York Medicaid APG,1168.69,,,1168.69,Other,225% New York Medicaid APG,1350.48,,,1350.48,Other,260% New York Medicaid APG,1682.91,,,1682.91,Other,324% New York Medicaid APG,1116.74,,,1116.74,Other,215% New York Medicaid APG,1116.74,,,1116.74,Other,215% New York Medicaid APG,649.27,,,649.27,Other,125% New York Medicaid APG,186.26,7216,
Njx aa&/strd brach plexus,64415,CPT,,,,,,,,both,,,19171.82,14187.15,74,,14187.15,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,8627.32,45,,8627.32,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,9490.05,49.5,,9490.05,percent of total billed charges,110% of Medicare,13036.84,68,,13036.84,percent of total billed charges,,1119.84,,,1119.84,Other,186% of Medicaid,15337.46,80,,15337.46,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,15337.46,80,,15337.46,percent of total billed charges,,7216,,,7216,Case Rate,,3578,,"100% primary, 0% secondary procedures",3578,Other,MagnaCare ASC Grouper,13420.27,70,,13420.27,percent of total billed charges,,336.2,,,336.2,Fee Schedule,,284.95,,,284.95,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,602.07,,,602.07,Other,New York Medicaid APG methodology,602.07,,,602.07,Other,100% New York Medicaid APG,602.07,,,602.07,Other,100% New York Medicaid APG,602.07,,,602.07,Other,100% New York Medicaid APG,1354.65,,,1354.65,Other,225% New York Medicaid APG,921.16,,,921.16,Other,153% New York Medicaid APG,1354.65,,,1354.65,Other,225% New York Medicaid APG,842.89,,,842.89,Other,140% New York Medicaid APG,1354.65,,,1354.65,Other,225% New York Medicaid APG,1565.37,,,1565.37,Other,260% New York Medicaid APG,1950.69,,,1950.69,Other,324% New York Medicaid APG,1294.44,,,1294.44,Other,215% New York Medicaid APG,1294.44,,,1294.44,Other,215% New York Medicaid APG,752.58,,,752.58,Other,125% New York Medicaid APG,284.95,15337.46,
Njx aa&/strd brach plex nfs,64416,CPT,,,,,,,,both,,,19171.82,14187.15,74,,14187.15,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,8627.32,45,,8627.32,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,9490.05,49.5,,9490.05,percent of total billed charges,110% of Medicare,13036.84,68,,13036.84,percent of total billed charges,,1119.84,,,1119.84,Other,186% of Medicaid,15337.46,80,,15337.46,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,15337.46,80,,15337.46,percent of total billed charges,,7216,,,7216,Case Rate,,3578,,"100% primary, 0% secondary procedures",3578,Other,MagnaCare ASC Grouper,13420.27,70,,13420.27,percent of total billed charges,,378.84,,,378.84,Fee Schedule,,321.09,,,321.09,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,602.07,,,602.07,Other,New York Medicaid APG methodology,602.07,,,602.07,Other,100% New York Medicaid APG,602.07,,,602.07,Other,100% New York Medicaid APG,602.07,,,602.07,Other,100% New York Medicaid APG,1354.65,,,1354.65,Other,225% New York Medicaid APG,921.16,,,921.16,Other,153% New York Medicaid APG,1354.65,,,1354.65,Other,225% New York Medicaid APG,842.89,,,842.89,Other,140% New York Medicaid APG,1354.65,,,1354.65,Other,225% New York Medicaid APG,1565.37,,,1565.37,Other,260% New York Medicaid APG,1950.69,,,1950.69,Other,324% New York Medicaid APG,1294.44,,,1294.44,Other,215% New York Medicaid APG,1294.44,,,1294.44,Other,215% New York Medicaid APG,752.58,,,752.58,Other,125% New York Medicaid APG,321.09,15337.46,
Njx aa&/strd axillary nrv,64417,CPT,,,,,,,,both,,,19171.82,14187.15,74,,14187.15,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,8627.32,45,,8627.32,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,9490.05,49.5,,9490.05,percent of total billed charges,110% of Medicare,13036.84,68,,13036.84,percent of total billed charges,,966.11,,,966.11,Other,186% of Medicaid,15337.46,80,,15337.46,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,15337.46,80,,15337.46,percent of total billed charges,,7216,,,7216,Case Rate,,3578,,"100% primary, 0% secondary procedures",3578,Other,MagnaCare ASC Grouper,13420.27,70,,13420.27,percent of total billed charges,,306.68,,,306.68,Fee Schedule,,259.93,,,259.93,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,519.42,,,519.42,Other,New York Medicaid APG methodology,519.42,,,519.42,Other,100% New York Medicaid APG,519.42,,,519.42,Other,100% New York Medicaid APG,519.42,,,519.42,Other,100% New York Medicaid APG,1168.69,,,1168.69,Other,225% New York Medicaid APG,794.71,,,794.71,Other,153% New York Medicaid APG,1168.69,,,1168.69,Other,225% New York Medicaid APG,727.18,,,727.18,Other,140% New York Medicaid APG,1168.69,,,1168.69,Other,225% New York Medicaid APG,1350.48,,,1350.48,Other,260% New York Medicaid APG,1682.91,,,1682.91,Other,324% New York Medicaid APG,1116.74,,,1116.74,Other,215% New York Medicaid APG,1116.74,,,1116.74,Other,215% New York Medicaid APG,649.27,,,649.27,Other,125% New York Medicaid APG,259.93,15337.46,
Njx aa&/strd sprscap nrv,64418,CPT,,,,,,,,both,,,3215,2379.1,74,,2379.1,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,1446.75,45,,1446.75,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,1591.43,49.5,,1591.43,percent of total billed charges,110% of Medicare,2186.2,68,,2186.2,percent of total billed charges,,966.11,,,966.11,Other,186% of Medicaid,2572,80,,2572,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,2572,80,,2572,percent of total billed charges,,7216,,,7216,Case Rate,,3578,,"100% primary, 0% secondary procedures",3578,Other,MagnaCare ASC Grouper,2250.5,70,,2250.5,percent of total billed charges,,270.6,,,270.6,Fee Schedule,,229.35,,,229.35,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,519.42,,,519.42,Other,New York Medicaid APG methodology,519.42,,,519.42,Other,100% New York Medicaid APG,519.42,,,519.42,Other,100% New York Medicaid APG,519.42,,,519.42,Other,100% New York Medicaid APG,1168.69,,,1168.69,Other,225% New York Medicaid APG,794.71,,,794.71,Other,153% New York Medicaid APG,1168.69,,,1168.69,Other,225% New York Medicaid APG,727.18,,,727.18,Other,140% New York Medicaid APG,1168.69,,,1168.69,Other,225% New York Medicaid APG,1350.48,,,1350.48,Other,260% New York Medicaid APG,1682.91,,,1682.91,Other,324% New York Medicaid APG,1116.74,,,1116.74,Other,215% New York Medicaid APG,1116.74,,,1116.74,Other,215% New York Medicaid APG,649.27,,,649.27,Other,125% New York Medicaid APG,229.35,7216,
Njx aa&/strd ntrcost nrv 1,64420,CPT,,,,,,,,both,,,3260.17,2412.53,74,,2412.53,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,1467.08,45,,1467.08,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,1613.78,49.5,,1613.78,percent of total billed charges,110% of Medicare,2216.92,68,,2216.92,percent of total billed charges,,966.11,,,966.11,Other,186% of Medicaid,2608.14,80,,2608.14,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,2608.14,80,,2608.14,percent of total billed charges,,7216,,,7216,Case Rate,,3578,,"100% primary, 0% secondary procedures",3578,Other,MagnaCare ASC Grouper,2282.12,70,,2282.12,percent of total billed charges,,283.72,,,283.72,Fee Schedule,,240.47,,,240.47,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,519.42,,,519.42,Other,New York Medicaid APG methodology,519.42,,,519.42,Other,100% New York Medicaid APG,519.42,,,519.42,Other,100% New York Medicaid APG,519.42,,,519.42,Other,100% New York Medicaid APG,1168.69,,,1168.69,Other,225% New York Medicaid APG,794.71,,,794.71,Other,153% New York Medicaid APG,1168.69,,,1168.69,Other,225% New York Medicaid APG,727.18,,,727.18,Other,140% New York Medicaid APG,1168.69,,,1168.69,Other,225% New York Medicaid APG,1350.48,,,1350.48,Other,260% New York Medicaid APG,1682.91,,,1682.91,Other,324% New York Medicaid APG,1116.74,,,1116.74,Other,215% New York Medicaid APG,1116.74,,,1116.74,Other,215% New York Medicaid APG,649.27,,,649.27,Other,125% New York Medicaid APG,240.47,7216,
Njx aa&/strd ntrcost nrv ea,64421,CPT,,,,,,,,both,,,19171.82,14187.15,74,,14187.15,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,8627.32,45,,8627.32,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,9490.05,49.5,,9490.05,percent of total billed charges,110% of Medicare,13036.84,68,,13036.84,percent of total billed charges,,1119.84,,,1119.84,Other,186% of Medicaid,15337.46,80,,15337.46,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,15337.46,80,,15337.46,percent of total billed charges,,7216,,,7216,Case Rate,,3578,,"100% primary, 0% secondary procedures",3578,Other,MagnaCare ASC Grouper,13420.27,70,,13420.27,percent of total billed charges,,118.08,,,118.08,Fee Schedule,,100.08,,,100.08,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,602.07,,,602.07,Other,New York Medicaid APG methodology,602.07,,,602.07,Other,100% New York Medicaid APG,602.07,,,602.07,Other,100% New York Medicaid APG,602.07,,,602.07,Other,100% New York Medicaid APG,1354.65,,,1354.65,Other,225% New York Medicaid APG,921.16,,,921.16,Other,153% New York Medicaid APG,1354.65,,,1354.65,Other,225% New York Medicaid APG,842.89,,,842.89,Other,140% New York Medicaid APG,1354.65,,,1354.65,Other,225% New York Medicaid APG,1565.37,,,1565.37,Other,260% New York Medicaid APG,1950.69,,,1950.69,Other,324% New York Medicaid APG,1294.44,,,1294.44,Other,215% New York Medicaid APG,1294.44,,,1294.44,Other,215% New York Medicaid APG,752.58,,,752.58,Other,125% New York Medicaid APG,100.08,15337.46,
Njx aa&/strd ii ih nerves,64425,CPT,,,,,,,,both,,,3245,2401.3,74,,2401.3,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,1460.25,45,,1460.25,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,1606.28,49.5,,1606.28,percent of total billed charges,110% of Medicare,2206.6,68,,2206.6,percent of total billed charges,,966.11,,,966.11,Other,186% of Medicaid,2596,80,,2596,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,2596,80,,2596,percent of total billed charges,,7216,,,7216,Case Rate,,3578,,"100% primary, 0% secondary procedures",3578,Other,MagnaCare ASC Grouper,2271.5,70,,2271.5,percent of total billed charges,,265.68,,,265.68,Fee Schedule,,225.18,,,225.18,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,519.42,,,519.42,Other,New York Medicaid APG methodology,519.42,,,519.42,Other,100% New York Medicaid APG,519.42,,,519.42,Other,100% New York Medicaid APG,519.42,,,519.42,Other,100% New York Medicaid APG,1168.69,,,1168.69,Other,225% New York Medicaid APG,794.71,,,794.71,Other,153% New York Medicaid APG,1168.69,,,1168.69,Other,225% New York Medicaid APG,727.18,,,727.18,Other,140% New York Medicaid APG,1168.69,,,1168.69,Other,225% New York Medicaid APG,1350.48,,,1350.48,Other,260% New York Medicaid APG,1682.91,,,1682.91,Other,324% New York Medicaid APG,1116.74,,,1116.74,Other,215% New York Medicaid APG,1116.74,,,1116.74,Other,215% New York Medicaid APG,649.27,,,649.27,Other,125% New York Medicaid APG,225.18,7216,
Njx aa&/strd pudendal nerve,64430,CPT,,,,,,,,both,,,19171.82,14187.15,74,,14187.15,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,8627.32,45,,8627.32,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,9490.05,49.5,,9490.05,percent of total billed charges,110% of Medicare,13036.84,68,,13036.84,percent of total billed charges,,1119.84,,,1119.84,Other,186% of Medicaid,15337.46,80,,15337.46,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,15337.46,80,,15337.46,percent of total billed charges,,7216,,,7216,Case Rate,,3578,,"100% primary, 0% secondary procedures",3578,Other,MagnaCare ASC Grouper,13420.27,70,,13420.27,percent of total billed charges,,265.68,,,265.68,Fee Schedule,,225.18,,,225.18,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,602.07,,,602.07,Other,New York Medicaid APG methodology,602.07,,,602.07,Other,100% New York Medicaid APG,602.07,,,602.07,Other,100% New York Medicaid APG,602.07,,,602.07,Other,100% New York Medicaid APG,1354.65,,,1354.65,Other,225% New York Medicaid APG,921.16,,,921.16,Other,153% New York Medicaid APG,1354.65,,,1354.65,Other,225% New York Medicaid APG,842.89,,,842.89,Other,140% New York Medicaid APG,1354.65,,,1354.65,Other,225% New York Medicaid APG,1565.37,,,1565.37,Other,260% New York Medicaid APG,1950.69,,,1950.69,Other,324% New York Medicaid APG,1294.44,,,1294.44,Other,215% New York Medicaid APG,1294.44,,,1294.44,Other,215% New York Medicaid APG,752.58,,,752.58,Other,125% New York Medicaid APG,225.18,15337.46,
Njx aa&/strd paracrv nrv,64435,CPT,,,,,,,,both,,,14545.81,10763.9,74,,10763.9,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,6545.61,45,,6545.61,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,7200.18,49.5,,7200.18,percent of total billed charges,110% of Medicare,9891.15,68,,9891.15,percent of total billed charges,,966.11,,,966.11,Other,186% of Medicaid,11636.65,80,,11636.65,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,11636.65,80,,11636.65,percent of total billed charges,,7216,,,7216,Case Rate,,3578,,"100% primary, 0% secondary procedures",3578,Other,MagnaCare ASC Grouper,10182.07,70,,10182.07,percent of total billed charges,,211.56,,,211.56,Fee Schedule,,179.31,,,179.31,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,519.42,,,519.42,Other,New York Medicaid APG methodology,519.42,,,519.42,Other,100% New York Medicaid APG,519.42,,,519.42,Other,100% New York Medicaid APG,519.42,,,519.42,Other,100% New York Medicaid APG,1168.69,,,1168.69,Other,225% New York Medicaid APG,794.71,,,794.71,Other,153% New York Medicaid APG,1168.69,,,1168.69,Other,225% New York Medicaid APG,727.18,,,727.18,Other,140% New York Medicaid APG,1168.69,,,1168.69,Other,225% New York Medicaid APG,1350.48,,,1350.48,Other,260% New York Medicaid APG,1682.91,,,1682.91,Other,324% New York Medicaid APG,1116.74,,,1116.74,Other,215% New York Medicaid APG,1116.74,,,1116.74,Other,215% New York Medicaid APG,649.27,,,649.27,Other,125% New York Medicaid APG,179.31,11636.65,
Njx aa&/strd sciatic nerve,64445,CPT,,,,,,,,both,,,4328,3202.72,74,,3202.72,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,1947.6,45,,1947.6,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,2142.36,49.5,,2142.36,percent of total billed charges,110% of Medicare,2943.04,68,,2943.04,percent of total billed charges,,966.11,,,966.11,Other,186% of Medicaid,3462.4,80,,3462.4,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,3462.4,80,,3462.4,percent of total billed charges,,7216,,,7216,Case Rate,,3578,,"100% primary, 0% secondary procedures",3578,Other,MagnaCare ASC Grouper,3029.6,70,,3029.6,percent of total billed charges,,355.88,,,355.88,Fee Schedule,,301.63,,,301.63,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,519.42,,,519.42,Other,New York Medicaid APG methodology,519.42,,,519.42,Other,100% New York Medicaid APG,519.42,,,519.42,Other,100% New York Medicaid APG,519.42,,,519.42,Other,100% New York Medicaid APG,1168.69,,,1168.69,Other,225% New York Medicaid APG,794.71,,,794.71,Other,153% New York Medicaid APG,1168.69,,,1168.69,Other,225% New York Medicaid APG,727.18,,,727.18,Other,140% New York Medicaid APG,1168.69,,,1168.69,Other,225% New York Medicaid APG,1350.48,,,1350.48,Other,260% New York Medicaid APG,1682.91,,,1682.91,Other,324% New York Medicaid APG,1116.74,,,1116.74,Other,215% New York Medicaid APG,1116.74,,,1116.74,Other,215% New York Medicaid APG,649.27,,,649.27,Other,125% New York Medicaid APG,301.63,7216,
Njx aa&/strd sciatic nrv nfs,64446,CPT,,,,,,,,both,,,19171.82,14187.15,74,,14187.15,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,8627.32,45,,8627.32,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,9490.05,49.5,,9490.05,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,1119.84,,,1119.84,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,3578,,"100% primary, 0% secondary procedures",3578,Other,MagnaCare ASC Grouper,13420.27,70,,13420.27,percent of total billed charges,,370.64,,,370.64,Fee Schedule,,314.14,,,314.14,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,602.07,,,602.07,Other,New York Medicaid APG methodology,602.07,,,602.07,Other,100% New York Medicaid APG,602.07,,,602.07,Other,100% New York Medicaid APG,602.07,,,602.07,Other,100% New York Medicaid APG,1354.65,,,1354.65,Other,225% New York Medicaid APG,921.16,,,921.16,Other,153% New York Medicaid APG,1354.65,,,1354.65,Other,225% New York Medicaid APG,842.89,,,842.89,Other,140% New York Medicaid APG,1354.65,,,1354.65,Other,225% New York Medicaid APG,1565.37,,,1565.37,Other,260% New York Medicaid APG,1950.69,,,1950.69,Other,324% New York Medicaid APG,1294.44,,,1294.44,Other,215% New York Medicaid APG,1294.44,,,1294.44,Other,215% New York Medicaid APG,752.58,,,752.58,Other,125% New York Medicaid APG,314.14,14187.15,
Njx aa&/strd femoral nerve,64447,CPT,,,,,,,,both,,,2169.93,1605.75,74,,1605.75,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,976.47,45,,976.47,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,1074.12,49.5,,1074.12,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,1119.84,,,1119.84,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,3578,,"100% primary, 0% secondary procedures",3578,Other,MagnaCare ASC Grouper,1518.95,70,,1518.95,percent of total billed charges,,305.04,,,305.04,Fee Schedule,,258.54,,,258.54,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,602.07,,,602.07,Other,New York Medicaid APG methodology,602.07,,,602.07,Other,100% New York Medicaid APG,602.07,,,602.07,Other,100% New York Medicaid APG,602.07,,,602.07,Other,100% New York Medicaid APG,1354.65,,,1354.65,Other,225% New York Medicaid APG,921.16,,,921.16,Other,153% New York Medicaid APG,1354.65,,,1354.65,Other,225% New York Medicaid APG,842.89,,,842.89,Other,140% New York Medicaid APG,1354.65,,,1354.65,Other,225% New York Medicaid APG,1565.37,,,1565.37,Other,260% New York Medicaid APG,1950.69,,,1950.69,Other,324% New York Medicaid APG,1294.44,,,1294.44,Other,215% New York Medicaid APG,1294.44,,,1294.44,Other,215% New York Medicaid APG,752.58,,,752.58,Other,125% New York Medicaid APG,258.54,9473,
Njx aa&/strd fem nerve nfs,64448,CPT,,,,,,,,both,,,19171.82,14187.15,74,,14187.15,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,8627.32,45,,8627.32,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,9490.05,49.5,,9490.05,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,1119.84,,,1119.84,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,3578,,"100% primary, 0% secondary procedures",3578,Other,MagnaCare ASC Grouper,13420.27,70,,13420.27,percent of total billed charges,,349.32,,,349.32,Fee Schedule,,296.07,,,296.07,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,602.07,,,602.07,Other,New York Medicaid APG methodology,602.07,,,602.07,Other,100% New York Medicaid APG,602.07,,,602.07,Other,100% New York Medicaid APG,602.07,,,602.07,Other,100% New York Medicaid APG,1354.65,,,1354.65,Other,225% New York Medicaid APG,921.16,,,921.16,Other,153% New York Medicaid APG,1354.65,,,1354.65,Other,225% New York Medicaid APG,842.89,,,842.89,Other,140% New York Medicaid APG,1354.65,,,1354.65,Other,225% New York Medicaid APG,1565.37,,,1565.37,Other,260% New York Medicaid APG,1950.69,,,1950.69,Other,324% New York Medicaid APG,1294.44,,,1294.44,Other,215% New York Medicaid APG,1294.44,,,1294.44,Other,215% New York Medicaid APG,752.58,,,752.58,Other,125% New York Medicaid APG,296.07,14187.15,
Njx aa&/strd lmbr plex nfs,64449,CPT,,,,,,,,both,,,19171.82,14187.15,74,,14187.15,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,8627.32,45,,8627.32,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,9490.05,49.5,,9490.05,percent of total billed charges,110% of Medicare,13036.84,68,,13036.84,percent of total billed charges,,1119.84,,,1119.84,Other,186% of Medicaid,15337.46,80,,15337.46,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,15337.46,80,,15337.46,percent of total billed charges,,7216,,,7216,Case Rate,,3578,,"100% primary, 0% secondary procedures",3578,Other,MagnaCare ASC Grouper,13420.27,70,,13420.27,percent of total billed charges,,300.12,,,300.12,Fee Schedule,,254.37,,,254.37,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,602.07,,,602.07,Other,New York Medicaid APG methodology,602.07,,,602.07,Other,100% New York Medicaid APG,602.07,,,602.07,Other,100% New York Medicaid APG,602.07,,,602.07,Other,100% New York Medicaid APG,1354.65,,,1354.65,Other,225% New York Medicaid APG,921.16,,,921.16,Other,153% New York Medicaid APG,1354.65,,,1354.65,Other,225% New York Medicaid APG,842.89,,,842.89,Other,140% New York Medicaid APG,1354.65,,,1354.65,Other,225% New York Medicaid APG,1565.37,,,1565.37,Other,260% New York Medicaid APG,1950.69,,,1950.69,Other,324% New York Medicaid APG,1294.44,,,1294.44,Other,215% New York Medicaid APG,1294.44,,,1294.44,Other,215% New York Medicaid APG,752.58,,,752.58,Other,125% New York Medicaid APG,254.37,15337.46,
Njx aa&/strd other pn/branch,64450,CPT,,,,,,,,both,,,3878.41,2870.02,74,,2870.02,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,1745.28,45,,1745.28,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,1919.81,49.5,,1919.81,percent of total billed charges,110% of Medicare,2637.32,68,,2637.32,percent of total billed charges,,966.11,,,966.11,Other,186% of Medicaid,3102.73,80,,3102.73,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,3102.73,80,,3102.73,percent of total billed charges,,7216,,,7216,Case Rate,,3578,,"100% primary, 0% secondary procedures",3578,Other,MagnaCare ASC Grouper,2714.89,70,,2714.89,percent of total billed charges,,203.36,,,203.36,Fee Schedule,,172.36,,,172.36,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,519.42,,,519.42,Other,New York Medicaid APG methodology,519.42,,,519.42,Other,100% New York Medicaid APG,519.42,,,519.42,Other,100% New York Medicaid APG,519.42,,,519.42,Other,100% New York Medicaid APG,1168.69,,,1168.69,Other,225% New York Medicaid APG,794.71,,,794.71,Other,153% New York Medicaid APG,1168.69,,,1168.69,Other,225% New York Medicaid APG,727.18,,,727.18,Other,140% New York Medicaid APG,1168.69,,,1168.69,Other,225% New York Medicaid APG,1350.48,,,1350.48,Other,260% New York Medicaid APG,1682.91,,,1682.91,Other,324% New York Medicaid APG,1116.74,,,1116.74,Other,215% New York Medicaid APG,1116.74,,,1116.74,Other,215% New York Medicaid APG,649.27,,,649.27,Other,125% New York Medicaid APG,172.36,7216,
Njx aa&/strd nrv nrvtg si jt,64451,CPT,,,,,,,,both,,,14545.81,10763.9,74,,10763.9,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,6545.61,45,,6545.61,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,7200.18,49.5,,7200.18,percent of total billed charges,110% of Medicare,9891.15,68,,9891.15,percent of total billed charges,,1119.84,,,1119.84,Other,186% of Medicaid,11636.65,80,,11636.65,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,11636.65,80,,11636.65,percent of total billed charges,,7216,,,7216,Case Rate,,3578,,"100% primary, 0% secondary procedures",3578,Other,MagnaCare ASC Grouper,10182.07,70,,10182.07,percent of total billed charges,,395.24,,,395.24,Fee Schedule,,334.99,,,334.99,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,602.07,,,602.07,Other,New York Medicaid APG methodology,602.07,,,602.07,Other,100% New York Medicaid APG,602.07,,,602.07,Other,100% New York Medicaid APG,602.07,,,602.07,Other,100% New York Medicaid APG,1354.65,,,1354.65,Other,225% New York Medicaid APG,921.16,,,921.16,Other,153% New York Medicaid APG,1354.65,,,1354.65,Other,225% New York Medicaid APG,842.89,,,842.89,Other,140% New York Medicaid APG,1354.65,,,1354.65,Other,225% New York Medicaid APG,1565.37,,,1565.37,Other,260% New York Medicaid APG,1950.69,,,1950.69,Other,324% New York Medicaid APG,1294.44,,,1294.44,Other,215% New York Medicaid APG,1294.44,,,1294.44,Other,215% New York Medicaid APG,752.58,,,752.58,Other,125% New York Medicaid APG,334.99,11636.65,
Njx aa&/strd gnclr nrv brnch,64454,CPT,,,,,,,,both,,,3540.73,2620.14,74,,2620.14,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,1593.33,45,,1593.33,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,1752.66,49.5,,1752.66,percent of total billed charges,110% of Medicare,2407.7,68,,2407.7,percent of total billed charges,,966.11,,,966.11,Other,186% of Medicaid,2832.58,80,,2832.58,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,2832.58,80,,2832.58,percent of total billed charges,,7216,,,7216,Case Rate,,3578,,"100% primary, 0% secondary procedures",3578,Other,MagnaCare ASC Grouper,2478.51,70,,2478.51,percent of total billed charges,,396.88,,,396.88,Fee Schedule,,336.38,,,336.38,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,519.42,,,519.42,Other,New York Medicaid APG methodology,519.42,,,519.42,Other,100% New York Medicaid APG,519.42,,,519.42,Other,100% New York Medicaid APG,519.42,,,519.42,Other,100% New York Medicaid APG,1168.69,,,1168.69,Other,225% New York Medicaid APG,794.71,,,794.71,Other,153% New York Medicaid APG,1168.69,,,1168.69,Other,225% New York Medicaid APG,727.18,,,727.18,Other,140% New York Medicaid APG,1168.69,,,1168.69,Other,225% New York Medicaid APG,1350.48,,,1350.48,Other,260% New York Medicaid APG,1682.91,,,1682.91,Other,324% New York Medicaid APG,1116.74,,,1116.74,Other,215% New York Medicaid APG,1116.74,,,1116.74,Other,215% New York Medicaid APG,649.27,,,649.27,Other,125% New York Medicaid APG,336.38,7216,
Njx aa&/strd pltr com dg nrv,64455,CPT,,,,,,,,both,,,6229.82,4610.07,74,,4610.07,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,2803.42,45,,2803.42,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,3083.76,49.5,,3083.76,percent of total billed charges,110% of Medicare,4236.28,68,,4236.28,percent of total billed charges,,966.11,,,966.11,Other,186% of Medicaid,4983.86,80,,4983.86,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,4983.86,80,,4983.86,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,4360.87,70,,4360.87,percent of total billed charges,,162.36,,,162.36,Fee Schedule,,137.61,,,137.61,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,519.42,,,519.42,Other,New York Medicaid APG methodology,519.42,,,519.42,Other,100% New York Medicaid APG,519.42,,,519.42,Other,100% New York Medicaid APG,519.42,,,519.42,Other,100% New York Medicaid APG,1168.69,,,1168.69,Other,225% New York Medicaid APG,794.71,,,794.71,Other,153% New York Medicaid APG,1168.69,,,1168.69,Other,225% New York Medicaid APG,727.18,,,727.18,Other,140% New York Medicaid APG,1168.69,,,1168.69,Other,225% New York Medicaid APG,1350.48,,,1350.48,Other,260% New York Medicaid APG,1682.91,,,1682.91,Other,324% New York Medicaid APG,1116.74,,,1116.74,Other,215% New York Medicaid APG,1116.74,,,1116.74,Other,215% New York Medicaid APG,649.27,,,649.27,Other,125% New York Medicaid APG,137.61,7216,
Pvb thoracic single inj site,64461,CPT,,,,,,,,both,,,4296.71,3179.57,74,,3179.57,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,1933.52,45,,1933.52,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,2126.87,49.5,,2126.87,percent of total billed charges,110% of Medicare,2921.76,68,,2921.76,percent of total billed charges,,1116.35,,,1116.35,Other,186% of Medicaid,3437.37,80,,3437.37,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,3437.37,80,,3437.37,percent of total billed charges,,7216,,,7216,Case Rate,,3578,,"100% primary, 0% secondary procedures",3578,Other,MagnaCare ASC Grouper,3007.7,70,,3007.7,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,600.19,,,600.19,Other,New York Medicaid APG methodology,600.19,,,600.19,Other,100% New York Medicaid APG,600.19,,,600.19,Other,100% New York Medicaid APG,600.19,,,600.19,Other,100% New York Medicaid APG,1350.43,,,1350.43,Other,225% New York Medicaid APG,918.29,,,918.29,Other,153% New York Medicaid APG,1350.43,,,1350.43,Other,225% New York Medicaid APG,840.26,,,840.26,Other,140% New York Medicaid APG,1350.43,,,1350.43,Other,225% New York Medicaid APG,1560.49,,,1560.49,Other,260% New York Medicaid APG,1944.61,,,1944.61,Other,324% New York Medicaid APG,1290.41,,,1290.41,Other,215% New York Medicaid APG,1290.41,,,1290.41,Other,215% New York Medicaid APG,750.24,,,750.24,Other,125% New York Medicaid APG,600.19,7216,
Pvb thoracic 2nd+ inj site,64462,CPT,,,,,,,,both,,,32432.1,23999.75,74,,23999.75,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,14594.45,45,,14594.45,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,16053.89,49.5,,16053.89,percent of total billed charges,110% of Medicare,22053.83,68,,22053.83,percent of total billed charges,,1116.35,,,1116.35,Other,186% of Medicaid,25945.68,80,,25945.68,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,25945.68,80,,25945.68,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,22702.47,70,,22702.47,percent of total billed charges,,236.16,,,236.16,Fee Schedule,,200.16,,,200.16,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,600.19,,,600.19,Other,New York Medicaid APG methodology,600.19,,,600.19,Other,100% New York Medicaid APG,600.19,,,600.19,Other,100% New York Medicaid APG,600.19,,,600.19,Other,100% New York Medicaid APG,1350.43,,,1350.43,Other,225% New York Medicaid APG,918.29,,,918.29,Other,153% New York Medicaid APG,1350.43,,,1350.43,Other,225% New York Medicaid APG,840.26,,,840.26,Other,140% New York Medicaid APG,1350.43,,,1350.43,Other,225% New York Medicaid APG,1560.49,,,1560.49,Other,260% New York Medicaid APG,1944.61,,,1944.61,Other,324% New York Medicaid APG,1290.41,,,1290.41,Other,215% New York Medicaid APG,1290.41,,,1290.41,Other,215% New York Medicaid APG,750.24,,,750.24,Other,125% New York Medicaid APG,200.16,25945.68,
Pvb thoracic cont infusion,64463,CPT,,,,,,,,both,,,14545.81,10763.9,74,,10763.9,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,6545.61,45,,6545.61,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,7200.18,49.5,,7200.18,percent of total billed charges,110% of Medicare,9891.15,68,,9891.15,percent of total billed charges,,1116.35,,,1116.35,Other,186% of Medicaid,11636.65,80,,11636.65,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,11636.65,80,,11636.65,percent of total billed charges,,7216,,,7216,Case Rate,,3578,,"100% primary, 0% secondary procedures",3578,Other,MagnaCare ASC Grouper,10182.07,70,,10182.07,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,600.19,,,600.19,Other,New York Medicaid APG methodology,600.19,,,600.19,Other,100% New York Medicaid APG,600.19,,,600.19,Other,100% New York Medicaid APG,600.19,,,600.19,Other,100% New York Medicaid APG,1350.43,,,1350.43,Other,225% New York Medicaid APG,918.29,,,918.29,Other,153% New York Medicaid APG,1350.43,,,1350.43,Other,225% New York Medicaid APG,840.26,,,840.26,Other,140% New York Medicaid APG,1350.43,,,1350.43,Other,225% New York Medicaid APG,1560.49,,,1560.49,Other,260% New York Medicaid APG,1944.61,,,1944.61,Other,324% New York Medicaid APG,1290.41,,,1290.41,Other,215% New York Medicaid APG,1290.41,,,1290.41,Other,215% New York Medicaid APG,750.24,,,750.24,Other,125% New York Medicaid APG,600.19,11636.65,
Njx aa&/strd tfrm epi c/t 1,64479,CPT,,,,,,,,both,,,3200.4,2368.3,74,,2368.3,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,1440.18,45,,1440.18,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,1584.2,49.5,,1584.2,percent of total billed charges,110% of Medicare,2176.27,68,,2176.27,percent of total billed charges,,1116.35,,,1116.35,Other,186% of Medicaid,2560.32,80,,2560.32,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,2560.32,80,,2560.32,percent of total billed charges,,7216,,,7216,Case Rate,,3578,,"100% primary, 0% secondary procedures",3578,Other,MagnaCare ASC Grouper,2240.28,70,,2240.28,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,600.19,,,600.19,Other,New York Medicaid APG methodology,600.19,,,600.19,Other,100% New York Medicaid APG,600.19,,,600.19,Other,100% New York Medicaid APG,600.19,,,600.19,Other,100% New York Medicaid APG,1350.43,,,1350.43,Other,225% New York Medicaid APG,918.29,,,918.29,Other,153% New York Medicaid APG,1350.43,,,1350.43,Other,225% New York Medicaid APG,840.26,,,840.26,Other,140% New York Medicaid APG,1350.43,,,1350.43,Other,225% New York Medicaid APG,1560.49,,,1560.49,Other,260% New York Medicaid APG,1944.61,,,1944.61,Other,324% New York Medicaid APG,1290.41,,,1290.41,Other,215% New York Medicaid APG,1290.41,,,1290.41,Other,215% New York Medicaid APG,750.24,,,750.24,Other,125% New York Medicaid APG,600.19,7216,
Njx aa&/strd tfrm epi c/t ea,64480,CPT,,,,,,,,both,,,32432.1,23999.75,74,,23999.75,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,14594.45,45,,14594.45,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,16053.89,49.5,,16053.89,percent of total billed charges,110% of Medicare,22053.83,68,,22053.83,percent of total billed charges,,1116.35,,,1116.35,Other,186% of Medicaid,25945.68,80,,25945.68,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,25945.68,80,,25945.68,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,22702.47,70,,22702.47,percent of total billed charges,,296.84,,,296.84,Fee Schedule,,251.59,,,251.59,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,600.19,,,600.19,Other,New York Medicaid APG methodology,600.19,,,600.19,Other,100% New York Medicaid APG,600.19,,,600.19,Other,100% New York Medicaid APG,600.19,,,600.19,Other,100% New York Medicaid APG,1350.43,,,1350.43,Other,225% New York Medicaid APG,918.29,,,918.29,Other,153% New York Medicaid APG,1350.43,,,1350.43,Other,225% New York Medicaid APG,840.26,,,840.26,Other,140% New York Medicaid APG,1350.43,,,1350.43,Other,225% New York Medicaid APG,1560.49,,,1560.49,Other,260% New York Medicaid APG,1944.61,,,1944.61,Other,324% New York Medicaid APG,1290.41,,,1290.41,Other,215% New York Medicaid APG,1290.41,,,1290.41,Other,215% New York Medicaid APG,750.24,,,750.24,Other,125% New York Medicaid APG,251.59,25945.68,
Njx aa&/strd tfrm epi l/s 1,64483,CPT,,,,,,,,both,,,5501.56,4071.15,74,,4071.15,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,2475.7,45,,2475.7,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,2723.27,49.5,,2723.27,percent of total billed charges,110% of Medicare,3741.06,68,,3741.06,percent of total billed charges,,1116.35,,,1116.35,Other,186% of Medicaid,4401.25,80,,4401.25,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,4401.25,80,,4401.25,percent of total billed charges,,7216,,,7216,Case Rate,,3578,,"100% primary, 0% secondary procedures",3578,Other,MagnaCare ASC Grouper,3851.09,70,,3851.09,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,600.19,,,600.19,Other,New York Medicaid APG methodology,600.19,,,600.19,Other,100% New York Medicaid APG,600.19,,,600.19,Other,100% New York Medicaid APG,600.19,,,600.19,Other,100% New York Medicaid APG,1350.43,,,1350.43,Other,225% New York Medicaid APG,918.29,,,918.29,Other,153% New York Medicaid APG,1350.43,,,1350.43,Other,225% New York Medicaid APG,840.26,,,840.26,Other,140% New York Medicaid APG,1350.43,,,1350.43,Other,225% New York Medicaid APG,1560.49,,,1560.49,Other,260% New York Medicaid APG,1944.61,,,1944.61,Other,324% New York Medicaid APG,1290.41,,,1290.41,Other,215% New York Medicaid APG,1290.41,,,1290.41,Other,215% New York Medicaid APG,750.24,,,750.24,Other,125% New York Medicaid APG,600.19,7216,
Njx aa&/strd tfrm epi l/s ea,64484,CPT,,,,,,,,both,,,32432.1,23999.75,74,,23999.75,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,14594.45,45,,14594.45,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,16053.89,49.5,,16053.89,percent of total billed charges,110% of Medicare,22053.83,68,,22053.83,percent of total billed charges,,1116.35,,,1116.35,Other,186% of Medicaid,25945.68,80,,25945.68,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,25945.68,80,,25945.68,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,22702.47,70,,22702.47,percent of total billed charges,,249.28,,,249.28,Fee Schedule,,211.28,,,211.28,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,600.19,,,600.19,Other,New York Medicaid APG methodology,600.19,,,600.19,Other,100% New York Medicaid APG,600.19,,,600.19,Other,100% New York Medicaid APG,600.19,,,600.19,Other,100% New York Medicaid APG,1350.43,,,1350.43,Other,225% New York Medicaid APG,918.29,,,918.29,Other,153% New York Medicaid APG,1350.43,,,1350.43,Other,225% New York Medicaid APG,840.26,,,840.26,Other,140% New York Medicaid APG,1350.43,,,1350.43,Other,225% New York Medicaid APG,1560.49,,,1560.49,Other,260% New York Medicaid APG,1944.61,,,1944.61,Other,324% New York Medicaid APG,1290.41,,,1290.41,Other,215% New York Medicaid APG,1290.41,,,1290.41,Other,215% New York Medicaid APG,750.24,,,750.24,Other,125% New York Medicaid APG,211.28,25945.68,
Tap block unil by injection,64486,CPT,,,,,,,,both,,,32432.1,23999.75,74,,23999.75,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,14594.45,45,,14594.45,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,16053.89,49.5,,16053.89,percent of total billed charges,110% of Medicare,22053.83,68,,22053.83,percent of total billed charges,,966.11,,,966.11,Other,186% of Medicaid,25945.68,80,,25945.68,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,25945.68,80,,25945.68,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,22702.47,70,,22702.47,percent of total billed charges,,267.32,,,267.32,Fee Schedule,,226.57,,,226.57,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,519.42,,,519.42,Other,New York Medicaid APG methodology,519.42,,,519.42,Other,100% New York Medicaid APG,519.42,,,519.42,Other,100% New York Medicaid APG,519.42,,,519.42,Other,100% New York Medicaid APG,1168.69,,,1168.69,Other,225% New York Medicaid APG,794.71,,,794.71,Other,153% New York Medicaid APG,1168.69,,,1168.69,Other,225% New York Medicaid APG,727.18,,,727.18,Other,140% New York Medicaid APG,1168.69,,,1168.69,Other,225% New York Medicaid APG,1350.48,,,1350.48,Other,260% New York Medicaid APG,1682.91,,,1682.91,Other,324% New York Medicaid APG,1116.74,,,1116.74,Other,215% New York Medicaid APG,1116.74,,,1116.74,Other,215% New York Medicaid APG,649.27,,,649.27,Other,125% New York Medicaid APG,226.57,25945.68,
Tap block uni by infusion,64487,CPT,,,,,,,,both,,,32432.1,23999.75,74,,23999.75,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,14594.45,45,,14594.45,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,16053.89,49.5,,16053.89,percent of total billed charges,110% of Medicare,22053.83,68,,22053.83,percent of total billed charges,,966.11,,,966.11,Other,186% of Medicaid,25945.68,80,,25945.68,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,25945.68,80,,25945.68,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,22702.47,70,,22702.47,percent of total billed charges,,306.68,,,306.68,Fee Schedule,,259.93,,,259.93,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,519.42,,,519.42,Other,New York Medicaid APG methodology,519.42,,,519.42,Other,100% New York Medicaid APG,519.42,,,519.42,Other,100% New York Medicaid APG,519.42,,,519.42,Other,100% New York Medicaid APG,1168.69,,,1168.69,Other,225% New York Medicaid APG,794.71,,,794.71,Other,153% New York Medicaid APG,1168.69,,,1168.69,Other,225% New York Medicaid APG,727.18,,,727.18,Other,140% New York Medicaid APG,1168.69,,,1168.69,Other,225% New York Medicaid APG,1350.48,,,1350.48,Other,260% New York Medicaid APG,1682.91,,,1682.91,Other,324% New York Medicaid APG,1116.74,,,1116.74,Other,215% New York Medicaid APG,1116.74,,,1116.74,Other,215% New York Medicaid APG,649.27,,,649.27,Other,125% New York Medicaid APG,259.93,25945.68,
Tap block bi injection,64488,CPT,,,,,,,,both,,,32432.1,23999.75,74,,23999.75,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,14594.45,45,,14594.45,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,16053.89,49.5,,16053.89,percent of total billed charges,110% of Medicare,22053.83,68,,22053.83,percent of total billed charges,,1119.84,,,1119.84,Other,186% of Medicaid,25945.68,80,,25945.68,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,25945.68,80,,25945.68,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,22702.47,70,,22702.47,percent of total billed charges,,331.28,,,331.28,Fee Schedule,,280.78,,,280.78,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,602.07,,,602.07,Other,New York Medicaid APG methodology,602.07,,,602.07,Other,100% New York Medicaid APG,602.07,,,602.07,Other,100% New York Medicaid APG,602.07,,,602.07,Other,100% New York Medicaid APG,1354.65,,,1354.65,Other,225% New York Medicaid APG,921.16,,,921.16,Other,153% New York Medicaid APG,1354.65,,,1354.65,Other,225% New York Medicaid APG,842.89,,,842.89,Other,140% New York Medicaid APG,1354.65,,,1354.65,Other,225% New York Medicaid APG,1565.37,,,1565.37,Other,260% New York Medicaid APG,1950.69,,,1950.69,Other,324% New York Medicaid APG,1294.44,,,1294.44,Other,215% New York Medicaid APG,1294.44,,,1294.44,Other,215% New York Medicaid APG,752.58,,,752.58,Other,125% New York Medicaid APG,280.78,25945.68,
Tap block bi by infusion,64489,CPT,,,,,,,,both,,,32432.1,23999.75,74,,23999.75,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,14594.45,45,,14594.45,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,16053.89,49.5,,16053.89,percent of total billed charges,110% of Medicare,22053.83,68,,22053.83,percent of total billed charges,,1119.84,,,1119.84,Other,186% of Medicaid,25945.68,80,,25945.68,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,25945.68,80,,25945.68,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,22702.47,70,,22702.47,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,602.07,,,602.07,Other,New York Medicaid APG methodology,602.07,,,602.07,Other,100% New York Medicaid APG,602.07,,,602.07,Other,100% New York Medicaid APG,602.07,,,602.07,Other,100% New York Medicaid APG,1354.65,,,1354.65,Other,225% New York Medicaid APG,921.16,,,921.16,Other,153% New York Medicaid APG,1354.65,,,1354.65,Other,225% New York Medicaid APG,842.89,,,842.89,Other,140% New York Medicaid APG,1354.65,,,1354.65,Other,225% New York Medicaid APG,1565.37,,,1565.37,Other,260% New York Medicaid APG,1950.69,,,1950.69,Other,324% New York Medicaid APG,1294.44,,,1294.44,Other,215% New York Medicaid APG,1294.44,,,1294.44,Other,215% New York Medicaid APG,752.58,,,752.58,Other,125% New York Medicaid APG,602.07,25945.68,
Inj paravert f jnt c/t 1 lev,64490,CPT,,,,,,,,both,,,3824.58,2830.19,74,,2830.19,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,1721.06,45,,1721.06,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,1893.17,49.5,,1893.17,percent of total billed charges,110% of Medicare,2600.71,68,,2600.71,percent of total billed charges,,1116.35,,,1116.35,Other,186% of Medicaid,3059.66,80,,3059.66,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,3059.66,80,,3059.66,percent of total billed charges,,7216,,,7216,Case Rate,,3578,,"100% primary, 0% secondary procedures",3578,Other,MagnaCare ASC Grouper,2677.21,70,,2677.21,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,600.19,,,600.19,Other,New York Medicaid APG methodology,600.19,,,600.19,Other,100% New York Medicaid APG,600.19,,,600.19,Other,100% New York Medicaid APG,600.19,,,600.19,Other,100% New York Medicaid APG,1350.43,,,1350.43,Other,225% New York Medicaid APG,918.29,,,918.29,Other,153% New York Medicaid APG,1350.43,,,1350.43,Other,225% New York Medicaid APG,840.26,,,840.26,Other,140% New York Medicaid APG,1350.43,,,1350.43,Other,225% New York Medicaid APG,1560.49,,,1560.49,Other,260% New York Medicaid APG,1944.61,,,1944.61,Other,324% New York Medicaid APG,1290.41,,,1290.41,Other,215% New York Medicaid APG,1290.41,,,1290.41,Other,215% New York Medicaid APG,750.24,,,750.24,Other,125% New York Medicaid APG,600.19,7216,
Inj paravert f jnt c/t 2 lev,64491,CPT,,,,,,,,both,,,32432.1,23999.75,74,,23999.75,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,14594.45,45,,14594.45,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,16053.89,49.5,,16053.89,percent of total billed charges,110% of Medicare,22053.83,68,,22053.83,percent of total billed charges,,1116.35,,,1116.35,Other,186% of Medicaid,25945.68,80,,25945.68,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,25945.68,80,,25945.68,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,22702.47,70,,22702.47,percent of total billed charges,,287,,,287,Fee Schedule,,243.25,,,243.25,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,600.19,,,600.19,Other,New York Medicaid APG methodology,600.19,,,600.19,Other,100% New York Medicaid APG,600.19,,,600.19,Other,100% New York Medicaid APG,600.19,,,600.19,Other,100% New York Medicaid APG,1350.43,,,1350.43,Other,225% New York Medicaid APG,918.29,,,918.29,Other,153% New York Medicaid APG,1350.43,,,1350.43,Other,225% New York Medicaid APG,840.26,,,840.26,Other,140% New York Medicaid APG,1350.43,,,1350.43,Other,225% New York Medicaid APG,1560.49,,,1560.49,Other,260% New York Medicaid APG,1944.61,,,1944.61,Other,324% New York Medicaid APG,1290.41,,,1290.41,Other,215% New York Medicaid APG,1290.41,,,1290.41,Other,215% New York Medicaid APG,750.24,,,750.24,Other,125% New York Medicaid APG,243.25,25945.68,
Inj paravert f jnt c/t 3 lev,64492,CPT,,,,,,,,both,,,32432.1,23999.75,74,,23999.75,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,14594.45,45,,14594.45,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,16053.89,49.5,,16053.89,percent of total billed charges,110% of Medicare,22053.83,68,,22053.83,percent of total billed charges,,1116.35,,,1116.35,Other,186% of Medicaid,25945.68,80,,25945.68,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,25945.68,80,,25945.68,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,22702.47,70,,22702.47,percent of total billed charges,,291.92,,,291.92,Fee Schedule,,247.42,,,247.42,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,600.19,,,600.19,Other,New York Medicaid APG methodology,600.19,,,600.19,Other,100% New York Medicaid APG,600.19,,,600.19,Other,100% New York Medicaid APG,600.19,,,600.19,Other,100% New York Medicaid APG,1350.43,,,1350.43,Other,225% New York Medicaid APG,918.29,,,918.29,Other,153% New York Medicaid APG,1350.43,,,1350.43,Other,225% New York Medicaid APG,840.26,,,840.26,Other,140% New York Medicaid APG,1350.43,,,1350.43,Other,225% New York Medicaid APG,1560.49,,,1560.49,Other,260% New York Medicaid APG,1944.61,,,1944.61,Other,324% New York Medicaid APG,1290.41,,,1290.41,Other,215% New York Medicaid APG,1290.41,,,1290.41,Other,215% New York Medicaid APG,750.24,,,750.24,Other,125% New York Medicaid APG,247.42,25945.68,
Inj paravert f jnt l/s 1 lev,64493,CPT,,,,,,,,both,,,4305.72,3186.23,74,,3186.23,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,1937.57,45,,1937.57,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,2131.33,49.5,,2131.33,percent of total billed charges,110% of Medicare,2927.89,68,,2927.89,percent of total billed charges,,1116.35,,,1116.35,Other,186% of Medicaid,3444.58,80,,3444.58,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,3444.58,80,,3444.58,percent of total billed charges,,7216,,,7216,Case Rate,,3578,,"100% primary, 0% secondary procedures",3578,Other,MagnaCare ASC Grouper,3014,70,,3014,percent of total billed charges,,437.88,,,437.88,Fee Schedule,,371.13,,,371.13,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,600.19,,,600.19,Other,New York Medicaid APG methodology,600.19,,,600.19,Other,100% New York Medicaid APG,600.19,,,600.19,Other,100% New York Medicaid APG,600.19,,,600.19,Other,100% New York Medicaid APG,1350.43,,,1350.43,Other,225% New York Medicaid APG,918.29,,,918.29,Other,153% New York Medicaid APG,1350.43,,,1350.43,Other,225% New York Medicaid APG,840.26,,,840.26,Other,140% New York Medicaid APG,1350.43,,,1350.43,Other,225% New York Medicaid APG,1560.49,,,1560.49,Other,260% New York Medicaid APG,1944.61,,,1944.61,Other,324% New York Medicaid APG,1290.41,,,1290.41,Other,215% New York Medicaid APG,1290.41,,,1290.41,Other,215% New York Medicaid APG,750.24,,,750.24,Other,125% New York Medicaid APG,371.13,7216,
Inj paravert f jnt l/s 2 lev,64494,CPT,,,,,,,,both,,,32432.1,23999.75,74,,23999.75,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,14594.45,45,,14594.45,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,16053.89,49.5,,16053.89,percent of total billed charges,110% of Medicare,22053.83,68,,22053.83,percent of total billed charges,,1116.35,,,1116.35,Other,186% of Medicaid,25945.68,80,,25945.68,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,25945.68,80,,25945.68,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,22702.47,70,,22702.47,percent of total billed charges,,247.64,,,247.64,Fee Schedule,,209.89,,,209.89,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,600.19,,,600.19,Other,New York Medicaid APG methodology,600.19,,,600.19,Other,100% New York Medicaid APG,600.19,,,600.19,Other,100% New York Medicaid APG,600.19,,,600.19,Other,100% New York Medicaid APG,1350.43,,,1350.43,Other,225% New York Medicaid APG,918.29,,,918.29,Other,153% New York Medicaid APG,1350.43,,,1350.43,Other,225% New York Medicaid APG,840.26,,,840.26,Other,140% New York Medicaid APG,1350.43,,,1350.43,Other,225% New York Medicaid APG,1560.49,,,1560.49,Other,260% New York Medicaid APG,1944.61,,,1944.61,Other,324% New York Medicaid APG,1290.41,,,1290.41,Other,215% New York Medicaid APG,1290.41,,,1290.41,Other,215% New York Medicaid APG,750.24,,,750.24,Other,125% New York Medicaid APG,209.89,25945.68,
Inj paravert f jnt l/s 3 lev,64495,CPT,,,,,,,,both,,,32432.1,23999.75,74,,23999.75,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,14594.45,45,,14594.45,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,16053.89,49.5,,16053.89,percent of total billed charges,110% of Medicare,22053.83,68,,22053.83,percent of total billed charges,,1116.35,,,1116.35,Other,186% of Medicaid,25945.68,80,,25945.68,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,25945.68,80,,25945.68,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,22702.47,70,,22702.47,percent of total billed charges,,250.92,,,250.92,Fee Schedule,,212.67,,,212.67,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,600.19,,,600.19,Other,New York Medicaid APG methodology,600.19,,,600.19,Other,100% New York Medicaid APG,600.19,,,600.19,Other,100% New York Medicaid APG,600.19,,,600.19,Other,100% New York Medicaid APG,1350.43,,,1350.43,Other,225% New York Medicaid APG,918.29,,,918.29,Other,153% New York Medicaid APG,1350.43,,,1350.43,Other,225% New York Medicaid APG,840.26,,,840.26,Other,140% New York Medicaid APG,1350.43,,,1350.43,Other,225% New York Medicaid APG,1560.49,,,1560.49,Other,260% New York Medicaid APG,1944.61,,,1944.61,Other,324% New York Medicaid APG,1290.41,,,1290.41,Other,215% New York Medicaid APG,1290.41,,,1290.41,Other,215% New York Medicaid APG,750.24,,,750.24,Other,125% New York Medicaid APG,212.67,25945.68,
N block spenopalatine gangl,64505,CPT,,,,,,,,both,,,6229.82,4610.07,74,,4610.07,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,2803.42,45,,2803.42,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,3083.76,49.5,,3083.76,percent of total billed charges,110% of Medicare,4236.28,68,,4236.28,percent of total billed charges,,966.11,,,966.11,Other,186% of Medicaid,4983.86,80,,4983.86,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,4983.86,80,,4983.86,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,4360.87,70,,4360.87,percent of total billed charges,,510.04,,,510.04,Fee Schedule,,432.29,,,432.29,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,519.42,,,519.42,Other,New York Medicaid APG methodology,519.42,,,519.42,Other,100% New York Medicaid APG,519.42,,,519.42,Other,100% New York Medicaid APG,519.42,,,519.42,Other,100% New York Medicaid APG,1168.69,,,1168.69,Other,225% New York Medicaid APG,794.71,,,794.71,Other,153% New York Medicaid APG,1168.69,,,1168.69,Other,225% New York Medicaid APG,727.18,,,727.18,Other,140% New York Medicaid APG,1168.69,,,1168.69,Other,225% New York Medicaid APG,1350.48,,,1350.48,Other,260% New York Medicaid APG,1682.91,,,1682.91,Other,324% New York Medicaid APG,1116.74,,,1116.74,Other,215% New York Medicaid APG,1116.74,,,1116.74,Other,215% New York Medicaid APG,649.27,,,649.27,Other,125% New York Medicaid APG,432.29,7216,
N block stellate ganglion,64510,CPT,,,,,,,,both,,,3927.29,2906.19,74,,2906.19,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,1767.28,45,,1767.28,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,1944.01,49.5,,1944.01,percent of total billed charges,110% of Medicare,2670.56,68,,2670.56,percent of total billed charges,,1119.84,,,1119.84,Other,186% of Medicaid,3141.83,80,,3141.83,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,3141.83,80,,3141.83,percent of total billed charges,,7216,,,7216,Case Rate,,3578,,"100% primary, 0% secondary procedures",3578,Other,MagnaCare ASC Grouper,2749.1,70,,2749.1,percent of total billed charges,,372.28,,,372.28,Fee Schedule,,315.53,,,315.53,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,602.07,,,602.07,Other,New York Medicaid APG methodology,602.07,,,602.07,Other,100% New York Medicaid APG,602.07,,,602.07,Other,100% New York Medicaid APG,602.07,,,602.07,Other,100% New York Medicaid APG,1354.65,,,1354.65,Other,225% New York Medicaid APG,921.16,,,921.16,Other,153% New York Medicaid APG,1354.65,,,1354.65,Other,225% New York Medicaid APG,842.89,,,842.89,Other,140% New York Medicaid APG,1354.65,,,1354.65,Other,225% New York Medicaid APG,1565.37,,,1565.37,Other,260% New York Medicaid APG,1950.69,,,1950.69,Other,324% New York Medicaid APG,1294.44,,,1294.44,Other,215% New York Medicaid APG,1294.44,,,1294.44,Other,215% New York Medicaid APG,752.58,,,752.58,Other,125% New York Medicaid APG,315.53,7216,
N block inj hypogas plxs,64517,CPT,,,,,,,,both,,,19171.82,14187.15,74,,14187.15,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,8627.32,45,,8627.32,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,9490.05,49.5,,9490.05,percent of total billed charges,110% of Medicare,13036.84,68,,13036.84,percent of total billed charges,,1119.84,,,1119.84,Other,186% of Medicaid,15337.46,80,,15337.46,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,15337.46,80,,15337.46,percent of total billed charges,,7216,,,7216,Case Rate,,3578,,"100% primary, 0% secondary procedures",3578,Other,MagnaCare ASC Grouper,13420.27,70,,13420.27,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,602.07,,,602.07,Other,New York Medicaid APG methodology,602.07,,,602.07,Other,100% New York Medicaid APG,602.07,,,602.07,Other,100% New York Medicaid APG,602.07,,,602.07,Other,100% New York Medicaid APG,1354.65,,,1354.65,Other,225% New York Medicaid APG,921.16,,,921.16,Other,153% New York Medicaid APG,1354.65,,,1354.65,Other,225% New York Medicaid APG,842.89,,,842.89,Other,140% New York Medicaid APG,1354.65,,,1354.65,Other,225% New York Medicaid APG,1565.37,,,1565.37,Other,260% New York Medicaid APG,1950.69,,,1950.69,Other,324% New York Medicaid APG,1294.44,,,1294.44,Other,215% New York Medicaid APG,1294.44,,,1294.44,Other,215% New York Medicaid APG,752.58,,,752.58,Other,125% New York Medicaid APG,602.07,15337.46,
N block lumbar/thoracic,64520,CPT,,,,,,,,both,,,4279.6,3166.9,74,,3166.9,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,1925.82,45,,1925.82,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,2118.4,49.5,,2118.4,percent of total billed charges,110% of Medicare,2910.13,68,,2910.13,percent of total billed charges,,1116.35,,,1116.35,Other,186% of Medicaid,3423.68,80,,3423.68,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,3423.68,80,,3423.68,percent of total billed charges,,7216,,,7216,Case Rate,,3578,,"100% primary, 0% secondary procedures",3578,Other,MagnaCare ASC Grouper,2995.72,70,,2995.72,percent of total billed charges,,408.36,,,408.36,Fee Schedule,,346.11,,,346.11,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,600.19,,,600.19,Other,New York Medicaid APG methodology,600.19,,,600.19,Other,100% New York Medicaid APG,600.19,,,600.19,Other,100% New York Medicaid APG,600.19,,,600.19,Other,100% New York Medicaid APG,1350.43,,,1350.43,Other,225% New York Medicaid APG,918.29,,,918.29,Other,153% New York Medicaid APG,1350.43,,,1350.43,Other,225% New York Medicaid APG,840.26,,,840.26,Other,140% New York Medicaid APG,1350.43,,,1350.43,Other,225% New York Medicaid APG,1560.49,,,1560.49,Other,260% New York Medicaid APG,1944.61,,,1944.61,Other,324% New York Medicaid APG,1290.41,,,1290.41,Other,215% New York Medicaid APG,1290.41,,,1290.41,Other,215% New York Medicaid APG,750.24,,,750.24,Other,125% New York Medicaid APG,346.11,7216,
N block inj celiac pelus,64530,CPT,,,,,,,,both,,,12137.22,8981.54,74,,8981.54,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,5461.75,45,,5461.75,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,6007.92,49.5,,6007.92,percent of total billed charges,110% of Medicare,8253.31,68,,8253.31,percent of total billed charges,,1119.84,,,1119.84,Other,186% of Medicaid,9709.78,80,,9709.78,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,9709.78,80,,9709.78,percent of total billed charges,,7216,,,7216,Case Rate,,3578,,"100% primary, 0% secondary procedures",3578,Other,MagnaCare ASC Grouper,8496.05,70,,8496.05,percent of total billed charges,,459.2,,,459.2,Fee Schedule,,389.2,,,389.2,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,602.07,,,602.07,Other,New York Medicaid APG methodology,602.07,,,602.07,Other,100% New York Medicaid APG,602.07,,,602.07,Other,100% New York Medicaid APG,602.07,,,602.07,Other,100% New York Medicaid APG,1354.65,,,1354.65,Other,225% New York Medicaid APG,921.16,,,921.16,Other,153% New York Medicaid APG,1354.65,,,1354.65,Other,225% New York Medicaid APG,842.89,,,842.89,Other,140% New York Medicaid APG,1354.65,,,1354.65,Other,225% New York Medicaid APG,1565.37,,,1565.37,Other,260% New York Medicaid APG,1950.69,,,1950.69,Other,324% New York Medicaid APG,1294.44,,,1294.44,Other,215% New York Medicaid APG,1294.44,,,1294.44,Other,215% New York Medicaid APG,752.58,,,752.58,Other,125% New York Medicaid APG,389.2,9709.78,
Implant neuroelectrodes,64553,CPT,,,,,,,,both,,,80880.22,59851.36,74,,59851.36,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,36396.1,45,,36396.1,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,40035.71,49.5,,40035.71,percent of total billed charges,110% of Medicare,54998.55,68,,54998.55,percent of total billed charges,,31375.51,,,31375.51,Other,186% of Medicaid,64704.18,80,,64704.18,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,64704.18,80,,64704.18,percent of total billed charges,,7216,,,7216,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,56616.15,70,,56616.15,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,16868.56,,,16868.56,Other,New York Medicaid APG methodology,16868.56,,,16868.56,Other,100% New York Medicaid APG,16868.56,,,16868.56,Other,100% New York Medicaid APG,16868.56,,,16868.56,Other,100% New York Medicaid APG,37954.25,,,37954.25,Other,225% New York Medicaid APG,25808.89,,,25808.89,Other,153% New York Medicaid APG,37954.25,,,37954.25,Other,225% New York Medicaid APG,23615.98,,,23615.98,Other,140% New York Medicaid APG,37954.25,,,37954.25,Other,225% New York Medicaid APG,43858.24,,,43858.24,Other,260% New York Medicaid APG,54654.12,,,54654.12,Other,324% New York Medicaid APG,36267.39,,,36267.39,Other,215% New York Medicaid APG,36267.39,,,36267.39,Other,215% New York Medicaid APG,21085.69,,,21085.69,Other,125% New York Medicaid APG,2053,64704.18,
Implant neuroelectrodes,64555,CPT,,,,,,,,both,,,39267.55,29057.99,74,,29057.99,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,17670.4,45,,17670.4,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,19437.44,49.5,,19437.44,percent of total billed charges,110% of Medicare,26701.93,68,,26701.93,percent of total billed charges,,23604.92,,,23604.92,Other,186% of Medicaid,31414.04,80,,31414.04,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,31414.04,80,,31414.04,percent of total billed charges,,7216,,,7216,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,27487.29,70,,27487.29,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,12690.81,,,12690.81,Other,New York Medicaid APG methodology,12690.81,,,12690.81,Other,100% New York Medicaid APG,12690.81,,,12690.81,Other,100% New York Medicaid APG,12690.81,,,12690.81,Other,100% New York Medicaid APG,28554.33,,,28554.33,Other,225% New York Medicaid APG,19416.95,,,19416.95,Other,153% New York Medicaid APG,28554.33,,,28554.33,Other,225% New York Medicaid APG,17767.14,,,17767.14,Other,140% New York Medicaid APG,28554.33,,,28554.33,Other,225% New York Medicaid APG,32996.12,,,32996.12,Other,260% New York Medicaid APG,41118.24,,,41118.24,Other,324% New York Medicaid APG,27285.25,,,27285.25,Other,215% New York Medicaid APG,27285.25,,,27285.25,Other,215% New York Medicaid APG,15863.52,,,15863.52,Other,125% New York Medicaid APG,2053,41118.24,
Implant neuroelectrodes,64561,CPT,,,,,,,,both,,,36824.15,27249.87,74,,27249.87,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,16570.87,45,,16570.87,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,18227.95,49.5,,18227.95,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,23604.92,,,23604.92,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,25776.91,70,,25776.91,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,12690.81,,,12690.81,Other,New York Medicaid APG methodology,12690.81,,,12690.81,Other,100% New York Medicaid APG,12690.81,,,12690.81,Other,100% New York Medicaid APG,12690.81,,,12690.81,Other,100% New York Medicaid APG,28554.33,,,28554.33,Other,225% New York Medicaid APG,19416.95,,,19416.95,Other,153% New York Medicaid APG,28554.33,,,28554.33,Other,225% New York Medicaid APG,17767.14,,,17767.14,Other,140% New York Medicaid APG,28554.33,,,28554.33,Other,225% New York Medicaid APG,32996.12,,,32996.12,Other,260% New York Medicaid APG,41118.24,,,41118.24,Other,324% New York Medicaid APG,27285.25,,,27285.25,Other,215% New York Medicaid APG,27285.25,,,27285.25,Other,215% New York Medicaid APG,15863.52,,,15863.52,Other,125% New York Medicaid APG,3126,41118.24,
Neuroeltrd stim post tibial,64566,CPT,,,,,,,,both,,,6229.82,4610.07,74,,4610.07,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,2803.42,45,,2803.42,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,3083.76,49.5,,3083.76,percent of total billed charges,110% of Medicare,4236.28,68,,4236.28,percent of total billed charges,,966.11,,,966.11,Other,186% of Medicaid,4983.86,80,,4983.86,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,4983.86,80,,4983.86,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,4360.87,70,,4360.87,percent of total billed charges,,145.96,,,145.96,Fee Schedule,,123.71,,,123.71,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,519.42,,,519.42,Other,New York Medicaid APG methodology,519.42,,,519.42,Other,100% New York Medicaid APG,519.42,,,519.42,Other,100% New York Medicaid APG,519.42,,,519.42,Other,100% New York Medicaid APG,1168.69,,,1168.69,Other,225% New York Medicaid APG,794.71,,,794.71,Other,153% New York Medicaid APG,1168.69,,,1168.69,Other,225% New York Medicaid APG,727.18,,,727.18,Other,140% New York Medicaid APG,1168.69,,,1168.69,Other,225% New York Medicaid APG,1350.48,,,1350.48,Other,260% New York Medicaid APG,1682.91,,,1682.91,Other,324% New York Medicaid APG,1116.74,,,1116.74,Other,215% New York Medicaid APG,1116.74,,,1116.74,Other,215% New York Medicaid APG,649.27,,,649.27,Other,125% New York Medicaid APG,123.71,7216,
Inc for vagus n elect impl,64568,CPT,,,,,,,,both,,,196832.52,145656.06,74,,145656.06,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,88574.63,45,,88574.63,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,97432.1,49.5,,97432.1,percent of total billed charges,110% of Medicare,133846.11,68,,133846.11,percent of total billed charges,,31375.51,,,31375.51,Other,186% of Medicaid,157466.02,80,,157466.02,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,157466.02,80,,157466.02,percent of total billed charges,,7216,,,7216,Case Rate,,9196,,"100% primary, 0% secondary procedures",9196,Other,MagnaCare ASC Grouper,137782.76,70,,137782.76,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,15267,,"100% primary, 50% secondary, 25% tertiary procedure",15267,Other,United Healthcare ASC Grouper,13740,,"100% primary, 50% secondary, 25% tertiary procedure",13740,Other,United Healthcare ASC Grouper,15267,,"100% primary, 50% secondary, 25% tertiary procedure",15267,Other,United Healthcare ASC Grouper,12977,,"100% primary, 50% secondary, 25% tertiary procedure",12977,Other,United Healthcare ASC Grouper,16868.56,,,16868.56,Other,New York Medicaid APG methodology,16868.56,,,16868.56,Other,100% New York Medicaid APG,16868.56,,,16868.56,Other,100% New York Medicaid APG,16868.56,,,16868.56,Other,100% New York Medicaid APG,37954.25,,,37954.25,Other,225% New York Medicaid APG,25808.89,,,25808.89,Other,153% New York Medicaid APG,37954.25,,,37954.25,Other,225% New York Medicaid APG,23615.98,,,23615.98,Other,140% New York Medicaid APG,37954.25,,,37954.25,Other,225% New York Medicaid APG,43858.24,,,43858.24,Other,260% New York Medicaid APG,54654.12,,,54654.12,Other,324% New York Medicaid APG,36267.39,,,36267.39,Other,215% New York Medicaid APG,36267.39,,,36267.39,Other,215% New York Medicaid APG,21085.69,,,21085.69,Other,125% New York Medicaid APG,2232,157466.02,
Revise/repl vagus n eltrd,64569,CPT,,,,,,,,both,,,214748.89,158914.18,74,,158914.18,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,96637,45,,96637,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,106300.7,49.5,,106300.7,percent of total billed charges,110% of Medicare,146029.25,68,,146029.25,percent of total billed charges,,31375.51,,,31375.51,Other,186% of Medicaid,171799.11,80,,171799.11,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,171799.11,80,,171799.11,percent of total billed charges,,7216,,,7216,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,150324.22,70,,150324.22,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,16868.56,,,16868.56,Other,New York Medicaid APG methodology,16868.56,,,16868.56,Other,100% New York Medicaid APG,16868.56,,,16868.56,Other,100% New York Medicaid APG,16868.56,,,16868.56,Other,100% New York Medicaid APG,37954.25,,,37954.25,Other,225% New York Medicaid APG,25808.89,,,25808.89,Other,153% New York Medicaid APG,37954.25,,,37954.25,Other,225% New York Medicaid APG,23615.98,,,23615.98,Other,140% New York Medicaid APG,37954.25,,,37954.25,Other,225% New York Medicaid APG,43858.24,,,43858.24,Other,260% New York Medicaid APG,54654.12,,,54654.12,Other,324% New York Medicaid APG,36267.39,,,36267.39,Other,215% New York Medicaid APG,36267.39,,,36267.39,Other,215% New York Medicaid APG,21085.69,,,21085.69,Other,125% New York Medicaid APG,2232,171799.11,
Remove vagus n eltrd,64570,CPT,,,,,,,,both,,,57908.89,42852.58,74,,42852.58,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,26059,45,,26059,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,28664.9,49.5,,28664.9,percent of total billed charges,110% of Medicare,39378.05,68,,39378.05,percent of total billed charges,,3388.68,,,3388.68,Other,186% of Medicaid,46327.11,80,,46327.11,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,46327.11,80,,46327.11,percent of total billed charges,,7216,,,7216,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,40536.22,70,,40536.22,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,1821.87,,,1821.87,Other,New York Medicaid APG methodology,1821.87,,,1821.87,Other,100% New York Medicaid APG,1821.87,,,1821.87,Other,100% New York Medicaid APG,1821.87,,,1821.87,Other,100% New York Medicaid APG,4099.2,,,4099.2,Other,225% New York Medicaid APG,2787.46,,,2787.46,Other,153% New York Medicaid APG,4099.2,,,4099.2,Other,225% New York Medicaid APG,2550.62,,,2550.62,Other,140% New York Medicaid APG,4099.2,,,4099.2,Other,225% New York Medicaid APG,4736.86,,,4736.86,Other,260% New York Medicaid APG,5902.85,,,5902.85,Other,324% New York Medicaid APG,3917.02,,,3917.02,Other,215% New York Medicaid APG,3917.02,,,3917.02,Other,215% New York Medicaid APG,2277.34,,,2277.34,Other,125% New York Medicaid APG,1821.87,46327.11,
Implant neuroelectrodes,64575,CPT,,,,,,,,both,,,286522.06,212026.32,74,,212026.32,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,128934.93,45,,128934.93,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,141828.42,49.5,,141828.42,percent of total billed charges,110% of Medicare,194835,68,,194835,percent of total billed charges,,31375.51,,,31375.51,Other,186% of Medicaid,229217.65,80,,229217.65,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,229217.65,80,,229217.65,percent of total billed charges,,7216,,,7216,Case Rate,,9196,,"100% primary, 0% secondary procedures",9196,Other,MagnaCare ASC Grouper,200565.44,70,,200565.44,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6956,,"100% primary, 50% secondary, 25% tertiary procedure",6956,Other,United Healthcare ASC Grouper,6261,,"100% primary, 50% secondary, 25% tertiary procedure",6261,Other,United Healthcare ASC Grouper,6956,,"100% primary, 50% secondary, 25% tertiary procedure",6956,Other,United Healthcare ASC Grouper,5913,,"100% primary, 50% secondary, 25% tertiary procedure",5913,Other,United Healthcare ASC Grouper,16868.56,,,16868.56,Other,New York Medicaid APG methodology,16868.56,,,16868.56,Other,100% New York Medicaid APG,16868.56,,,16868.56,Other,100% New York Medicaid APG,16868.56,,,16868.56,Other,100% New York Medicaid APG,37954.25,,,37954.25,Other,225% New York Medicaid APG,25808.89,,,25808.89,Other,153% New York Medicaid APG,37954.25,,,37954.25,Other,225% New York Medicaid APG,23615.98,,,23615.98,Other,140% New York Medicaid APG,37954.25,,,37954.25,Other,225% New York Medicaid APG,43858.24,,,43858.24,Other,260% New York Medicaid APG,54654.12,,,54654.12,Other,324% New York Medicaid APG,36267.39,,,36267.39,Other,215% New York Medicaid APG,36267.39,,,36267.39,Other,215% New York Medicaid APG,21085.69,,,21085.69,Other,125% New York Medicaid APG,2053,229217.65,
Implant neuroelectrodes,64580,CPT,,,,,,,,both,,,460124.54,340492.16,74,,340492.16,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,207056.04,45,,207056.04,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,227761.65,49.5,,227761.65,percent of total billed charges,110% of Medicare,312884.69,68,,312884.69,percent of total billed charges,,31375.51,,,31375.51,Other,186% of Medicaid,368099.63,80,,368099.63,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,368099.63,80,,368099.63,percent of total billed charges,,7216,,,7216,Case Rate,,9196,,"100% primary, 0% secondary procedures",9196,Other,MagnaCare ASC Grouper,322087.18,70,,322087.18,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6956,,"100% primary, 50% secondary, 25% tertiary procedure",6956,Other,United Healthcare ASC Grouper,6261,,"100% primary, 50% secondary, 25% tertiary procedure",6261,Other,United Healthcare ASC Grouper,6956,,"100% primary, 50% secondary, 25% tertiary procedure",6956,Other,United Healthcare ASC Grouper,5913,,"100% primary, 50% secondary, 25% tertiary procedure",5913,Other,United Healthcare ASC Grouper,16868.56,,,16868.56,Other,New York Medicaid APG methodology,16868.56,,,16868.56,Other,100% New York Medicaid APG,16868.56,,,16868.56,Other,100% New York Medicaid APG,16868.56,,,16868.56,Other,100% New York Medicaid APG,37954.25,,,37954.25,Other,225% New York Medicaid APG,25808.89,,,25808.89,Other,153% New York Medicaid APG,37954.25,,,37954.25,Other,225% New York Medicaid APG,23615.98,,,23615.98,Other,140% New York Medicaid APG,37954.25,,,37954.25,Other,225% New York Medicaid APG,43858.24,,,43858.24,Other,260% New York Medicaid APG,54654.12,,,54654.12,Other,324% New York Medicaid APG,36267.39,,,36267.39,Other,215% New York Medicaid APG,36267.39,,,36267.39,Other,215% New York Medicaid APG,21085.69,,,21085.69,Other,125% New York Medicaid APG,2053,368099.63,
Implant neuroelectrodes,64581,CPT,,,,,,,,both,,,54207.22,40113.34,74,,40113.34,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,24393.25,45,,24393.25,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,26832.57,49.5,,26832.57,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,23604.92,,,23604.92,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9196,,"100% primary, 0% secondary procedures",9196,Other,MagnaCare ASC Grouper,37945.05,70,,37945.05,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6956,,"100% primary, 50% secondary, 25% tertiary procedure",6956,Other,United Healthcare ASC Grouper,6261,,"100% primary, 50% secondary, 25% tertiary procedure",6261,Other,United Healthcare ASC Grouper,6956,,"100% primary, 50% secondary, 25% tertiary procedure",6956,Other,United Healthcare ASC Grouper,5913,,"100% primary, 50% secondary, 25% tertiary procedure",5913,Other,United Healthcare ASC Grouper,12690.81,,,12690.81,Other,New York Medicaid APG methodology,12690.81,,,12690.81,Other,100% New York Medicaid APG,12690.81,,,12690.81,Other,100% New York Medicaid APG,12690.81,,,12690.81,Other,100% New York Medicaid APG,28554.33,,,28554.33,Other,225% New York Medicaid APG,19416.95,,,19416.95,Other,153% New York Medicaid APG,28554.33,,,28554.33,Other,225% New York Medicaid APG,17767.14,,,17767.14,Other,140% New York Medicaid APG,28554.33,,,28554.33,Other,225% New York Medicaid APG,32996.12,,,32996.12,Other,260% New York Medicaid APG,41118.24,,,41118.24,Other,324% New York Medicaid APG,27285.25,,,27285.25,Other,215% New York Medicaid APG,27285.25,,,27285.25,Other,215% New York Medicaid APG,15863.52,,,15863.52,Other,125% New York Medicaid APG,3126,41118.24,
Revise/remove neuroelectrode,64585,CPT,,,,,,,,both,,,48312.19,35751.02,74,,35751.02,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,21740.49,45,,21740.49,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,23914.53,49.5,,23914.53,percent of total billed charges,110% of Medicare,32852.29,68,,32852.29,percent of total billed charges,,3388.68,,,3388.68,Other,186% of Medicaid,38649.75,80,,38649.75,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,38649.75,80,,38649.75,percent of total billed charges,,7216,,,7216,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,33818.53,70,,33818.53,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1821.87,,,1821.87,Other,New York Medicaid APG methodology,1821.87,,,1821.87,Other,100% New York Medicaid APG,1821.87,,,1821.87,Other,100% New York Medicaid APG,1821.87,,,1821.87,Other,100% New York Medicaid APG,4099.2,,,4099.2,Other,225% New York Medicaid APG,2787.46,,,2787.46,Other,153% New York Medicaid APG,4099.2,,,4099.2,Other,225% New York Medicaid APG,2550.62,,,2550.62,Other,140% New York Medicaid APG,4099.2,,,4099.2,Other,225% New York Medicaid APG,4736.86,,,4736.86,Other,260% New York Medicaid APG,5902.85,,,5902.85,Other,324% New York Medicaid APG,3917.02,,,3917.02,Other,215% New York Medicaid APG,3917.02,,,3917.02,Other,215% New York Medicaid APG,2277.34,,,2277.34,Other,125% New York Medicaid APG,1821.87,38649.75,
Insrt/redo pn/gastr stimul,64590,CPT,,,,,,,,both,,,79112.92,58543.56,74,,58543.56,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,35600.81,45,,35600.81,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,39160.9,49.5,,39160.9,percent of total billed charges,110% of Medicare,53796.79,68,,53796.79,percent of total billed charges,,31375.51,,,31375.51,Other,186% of Medicaid,63290.34,80,,63290.34,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,63290.34,80,,63290.34,percent of total billed charges,,7216,,,7216,Case Rate,,9196,,"100% primary, 0% secondary procedures",9196,Other,MagnaCare ASC Grouper,55379.04,70,,55379.04,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,8589,,"100% primary, 50% secondary, 25% tertiary procedure",8589,Other,United Healthcare ASC Grouper,7730,,"100% primary, 50% secondary, 25% tertiary procedure",7730,Other,United Healthcare ASC Grouper,8589,,"100% primary, 50% secondary, 25% tertiary procedure",8589,Other,United Healthcare ASC Grouper,7301,,"100% primary, 50% secondary, 25% tertiary procedure",7301,Other,United Healthcare ASC Grouper,16868.56,,,16868.56,Other,New York Medicaid APG methodology,16868.56,,,16868.56,Other,100% New York Medicaid APG,16868.56,,,16868.56,Other,100% New York Medicaid APG,16868.56,,,16868.56,Other,100% New York Medicaid APG,37954.25,,,37954.25,Other,225% New York Medicaid APG,25808.89,,,25808.89,Other,153% New York Medicaid APG,37954.25,,,37954.25,Other,225% New York Medicaid APG,23615.98,,,23615.98,Other,140% New York Medicaid APG,37954.25,,,37954.25,Other,225% New York Medicaid APG,43858.24,,,43858.24,Other,260% New York Medicaid APG,54654.12,,,54654.12,Other,324% New York Medicaid APG,36267.39,,,36267.39,Other,215% New York Medicaid APG,36267.39,,,36267.39,Other,215% New York Medicaid APG,21085.69,,,21085.69,Other,125% New York Medicaid APG,2232,63290.34,
Revise/rmv pn/gastr stimul,64595,CPT,,,,,,,,both,,,36457.37,26978.45,74,,26978.45,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,16405.82,45,,16405.82,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,18046.4,49.5,,18046.4,percent of total billed charges,110% of Medicare,24791.01,68,,24791.01,percent of total billed charges,,3388.68,,,3388.68,Other,186% of Medicaid,29165.9,80,,29165.9,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,29165.9,80,,29165.9,percent of total billed charges,,7216,,,7216,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,25520.16,70,,25520.16,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1821.87,,,1821.87,Other,New York Medicaid APG methodology,1821.87,,,1821.87,Other,100% New York Medicaid APG,1821.87,,,1821.87,Other,100% New York Medicaid APG,1821.87,,,1821.87,Other,100% New York Medicaid APG,4099.2,,,4099.2,Other,225% New York Medicaid APG,2787.46,,,2787.46,Other,153% New York Medicaid APG,4099.2,,,4099.2,Other,225% New York Medicaid APG,2550.62,,,2550.62,Other,140% New York Medicaid APG,4099.2,,,4099.2,Other,225% New York Medicaid APG,4736.86,,,4736.86,Other,260% New York Medicaid APG,5902.85,,,5902.85,Other,324% New York Medicaid APG,3917.02,,,3917.02,Other,215% New York Medicaid APG,3917.02,,,3917.02,Other,215% New York Medicaid APG,2277.34,,,2277.34,Other,125% New York Medicaid APG,1821.87,29165.9,
Injection treatment of nerve,64600,CPT,,,,,,,,both,,,19171.82,14187.15,74,,14187.15,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,8627.32,45,,8627.32,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,9490.05,49.5,,9490.05,percent of total billed charges,110% of Medicare,13036.84,68,,13036.84,percent of total billed charges,,1119.84,,,1119.84,Other,186% of Medicaid,15337.46,80,,15337.46,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,15337.46,80,,15337.46,percent of total billed charges,,7216,,,7216,Case Rate,,3578,,"100% primary, 0% secondary procedures",3578,Other,MagnaCare ASC Grouper,13420.27,70,,13420.27,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,602.07,,,602.07,Other,New York Medicaid APG methodology,602.07,,,602.07,Other,100% New York Medicaid APG,602.07,,,602.07,Other,100% New York Medicaid APG,602.07,,,602.07,Other,100% New York Medicaid APG,1354.65,,,1354.65,Other,225% New York Medicaid APG,921.16,,,921.16,Other,153% New York Medicaid APG,1354.65,,,1354.65,Other,225% New York Medicaid APG,842.89,,,842.89,Other,140% New York Medicaid APG,1354.65,,,1354.65,Other,225% New York Medicaid APG,1565.37,,,1565.37,Other,260% New York Medicaid APG,1950.69,,,1950.69,Other,324% New York Medicaid APG,1294.44,,,1294.44,Other,215% New York Medicaid APG,1294.44,,,1294.44,Other,215% New York Medicaid APG,752.58,,,752.58,Other,125% New York Medicaid APG,602.07,15337.46,
Injection treatment of nerve,64605,CPT,,,,,,,,both,,,40611.5,30052.51,74,,30052.51,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,18275.18,45,,18275.18,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,20102.69,49.5,,20102.69,percent of total billed charges,110% of Medicare,27615.82,68,,27615.82,percent of total billed charges,,1119.84,,,1119.84,Other,186% of Medicaid,32489.2,80,,32489.2,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,32489.2,80,,32489.2,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,28428.05,70,,28428.05,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,602.07,,,602.07,Other,New York Medicaid APG methodology,602.07,,,602.07,Other,100% New York Medicaid APG,602.07,,,602.07,Other,100% New York Medicaid APG,602.07,,,602.07,Other,100% New York Medicaid APG,1354.65,,,1354.65,Other,225% New York Medicaid APG,921.16,,,921.16,Other,153% New York Medicaid APG,1354.65,,,1354.65,Other,225% New York Medicaid APG,842.89,,,842.89,Other,140% New York Medicaid APG,1354.65,,,1354.65,Other,225% New York Medicaid APG,1565.37,,,1565.37,Other,260% New York Medicaid APG,1950.69,,,1950.69,Other,324% New York Medicaid APG,1294.44,,,1294.44,Other,215% New York Medicaid APG,1294.44,,,1294.44,Other,215% New York Medicaid APG,752.58,,,752.58,Other,125% New York Medicaid APG,602.07,32489.2,
Injection treatment of nerve,64610,CPT,,,,,,,,both,,,40611.5,30052.51,74,,30052.51,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,18275.18,45,,18275.18,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,20102.69,49.5,,20102.69,percent of total billed charges,110% of Medicare,27615.82,68,,27615.82,percent of total billed charges,,1119.84,,,1119.84,Other,186% of Medicaid,32489.2,80,,32489.2,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,32489.2,80,,32489.2,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,28428.05,70,,28428.05,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,602.07,,,602.07,Other,New York Medicaid APG methodology,602.07,,,602.07,Other,100% New York Medicaid APG,602.07,,,602.07,Other,100% New York Medicaid APG,602.07,,,602.07,Other,100% New York Medicaid APG,1354.65,,,1354.65,Other,225% New York Medicaid APG,921.16,,,921.16,Other,153% New York Medicaid APG,1354.65,,,1354.65,Other,225% New York Medicaid APG,842.89,,,842.89,Other,140% New York Medicaid APG,1354.65,,,1354.65,Other,225% New York Medicaid APG,1565.37,,,1565.37,Other,260% New York Medicaid APG,1950.69,,,1950.69,Other,324% New York Medicaid APG,1294.44,,,1294.44,Other,215% New York Medicaid APG,1294.44,,,1294.44,Other,215% New York Medicaid APG,752.58,,,752.58,Other,125% New York Medicaid APG,602.07,32489.2,
Chemodenerv saliv glands,64611,CPT,,,,,,,,both,,,31532.05,23333.72,74,,23333.72,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,14189.42,45,,14189.42,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,15608.36,49.5,,15608.36,percent of total billed charges,110% of Medicare,21441.79,68,,21441.79,percent of total billed charges,,966.11,,,966.11,Other,186% of Medicaid,25225.64,80,,25225.64,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,25225.64,80,,25225.64,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,22072.44,70,,22072.44,percent of total billed charges,,546.12,,,546.12,Fee Schedule,,462.87,,,462.87,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,519.42,,,519.42,Other,New York Medicaid APG methodology,519.42,,,519.42,Other,100% New York Medicaid APG,519.42,,,519.42,Other,100% New York Medicaid APG,519.42,,,519.42,Other,100% New York Medicaid APG,1168.69,,,1168.69,Other,225% New York Medicaid APG,794.71,,,794.71,Other,153% New York Medicaid APG,1168.69,,,1168.69,Other,225% New York Medicaid APG,727.18,,,727.18,Other,140% New York Medicaid APG,1168.69,,,1168.69,Other,225% New York Medicaid APG,1350.48,,,1350.48,Other,260% New York Medicaid APG,1682.91,,,1682.91,Other,324% New York Medicaid APG,1116.74,,,1116.74,Other,215% New York Medicaid APG,1116.74,,,1116.74,Other,215% New York Medicaid APG,649.27,,,649.27,Other,125% New York Medicaid APG,462.87,25225.64,
Destroy nerve face muscle,64612,CPT,,,,,,,,both,,,6229.82,4610.07,74,,4610.07,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,2803.42,45,,2803.42,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,3083.76,49.5,,3083.76,percent of total billed charges,110% of Medicare,4236.28,68,,4236.28,percent of total billed charges,,966.11,,,966.11,Other,186% of Medicaid,4983.86,80,,4983.86,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,4983.86,80,,4983.86,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,4360.87,70,,4360.87,percent of total billed charges,,580.56,,,580.56,Fee Schedule,,492.06,,,492.06,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,519.42,,,519.42,Other,New York Medicaid APG methodology,519.42,,,519.42,Other,100% New York Medicaid APG,519.42,,,519.42,Other,100% New York Medicaid APG,519.42,,,519.42,Other,100% New York Medicaid APG,1168.69,,,1168.69,Other,225% New York Medicaid APG,794.71,,,794.71,Other,153% New York Medicaid APG,1168.69,,,1168.69,Other,225% New York Medicaid APG,727.18,,,727.18,Other,140% New York Medicaid APG,1168.69,,,1168.69,Other,225% New York Medicaid APG,1350.48,,,1350.48,Other,260% New York Medicaid APG,1682.91,,,1682.91,Other,324% New York Medicaid APG,1116.74,,,1116.74,Other,215% New York Medicaid APG,1116.74,,,1116.74,Other,215% New York Medicaid APG,649.27,,,649.27,Other,125% New York Medicaid APG,492.06,7216,
Chemodenerv musc migraine,64615,CPT,,,,,,,,both,,,6229.82,4610.07,74,,4610.07,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,2803.42,45,,2803.42,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,3083.76,49.5,,3083.76,percent of total billed charges,110% of Medicare,4236.28,68,,4236.28,percent of total billed charges,,966.11,,,966.11,Other,186% of Medicaid,4983.86,80,,4983.86,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,4983.86,80,,4983.86,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,4360.87,70,,4360.87,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,519.42,,,519.42,Other,New York Medicaid APG methodology,519.42,,,519.42,Other,100% New York Medicaid APG,519.42,,,519.42,Other,100% New York Medicaid APG,519.42,,,519.42,Other,100% New York Medicaid APG,1168.69,,,1168.69,Other,225% New York Medicaid APG,794.71,,,794.71,Other,153% New York Medicaid APG,1168.69,,,1168.69,Other,225% New York Medicaid APG,727.18,,,727.18,Other,140% New York Medicaid APG,1168.69,,,1168.69,Other,225% New York Medicaid APG,1350.48,,,1350.48,Other,260% New York Medicaid APG,1682.91,,,1682.91,Other,324% New York Medicaid APG,1116.74,,,1116.74,Other,215% New York Medicaid APG,1116.74,,,1116.74,Other,215% New York Medicaid APG,649.27,,,649.27,Other,125% New York Medicaid APG,519.42,7216,
Chemodenerv musc neck dyston,64616,CPT,,,,,,,,both,,,6229.82,4610.07,74,,4610.07,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,2803.42,45,,2803.42,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,3083.76,49.5,,3083.76,percent of total billed charges,110% of Medicare,4236.28,68,,4236.28,percent of total billed charges,,966.11,,,966.11,Other,186% of Medicaid,4983.86,80,,4983.86,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,4983.86,80,,4983.86,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,4360.87,70,,4360.87,percent of total billed charges,,533,,,533,Fee Schedule,,451.75,,,451.75,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,519.42,,,519.42,Other,New York Medicaid APG methodology,519.42,,,519.42,Other,100% New York Medicaid APG,519.42,,,519.42,Other,100% New York Medicaid APG,519.42,,,519.42,Other,100% New York Medicaid APG,1168.69,,,1168.69,Other,225% New York Medicaid APG,794.71,,,794.71,Other,153% New York Medicaid APG,1168.69,,,1168.69,Other,225% New York Medicaid APG,727.18,,,727.18,Other,140% New York Medicaid APG,1168.69,,,1168.69,Other,225% New York Medicaid APG,1350.48,,,1350.48,Other,260% New York Medicaid APG,1682.91,,,1682.91,Other,324% New York Medicaid APG,1116.74,,,1116.74,Other,215% New York Medicaid APG,1116.74,,,1116.74,Other,215% New York Medicaid APG,649.27,,,649.27,Other,125% New York Medicaid APG,451.75,7216,
Chemodener muscle larynx emg,64617,CPT,,,,,,,,both,,,14545.81,10763.9,74,,10763.9,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,6545.61,45,,6545.61,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,7200.18,49.5,,7200.18,percent of total billed charges,110% of Medicare,9891.15,68,,9891.15,percent of total billed charges,,966.11,,,966.11,Other,186% of Medicaid,11636.65,80,,11636.65,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,11636.65,80,,11636.65,percent of total billed charges,,7216,,,7216,Case Rate,,3578,,"100% primary, 0% secondary procedures",3578,Other,MagnaCare ASC Grouper,10182.07,70,,10182.07,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,519.42,,,519.42,Other,New York Medicaid APG methodology,519.42,,,519.42,Other,100% New York Medicaid APG,519.42,,,519.42,Other,100% New York Medicaid APG,519.42,,,519.42,Other,100% New York Medicaid APG,1168.69,,,1168.69,Other,225% New York Medicaid APG,794.71,,,794.71,Other,153% New York Medicaid APG,1168.69,,,1168.69,Other,225% New York Medicaid APG,727.18,,,727.18,Other,140% New York Medicaid APG,1168.69,,,1168.69,Other,225% New York Medicaid APG,1350.48,,,1350.48,Other,260% New York Medicaid APG,1682.91,,,1682.91,Other,324% New York Medicaid APG,1116.74,,,1116.74,Other,215% New York Medicaid APG,1116.74,,,1116.74,Other,215% New York Medicaid APG,649.27,,,649.27,Other,125% New York Medicaid APG,519.42,11636.65,
Injection treatment of nerve,64620,CPT,,,,,,,,both,,,3105,2297.7,74,,2297.7,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,1397.25,45,,1397.25,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,1536.98,49.5,,1536.98,percent of total billed charges,110% of Medicare,2111.4,68,,2111.4,percent of total billed charges,,1119.84,,,1119.84,Other,186% of Medicaid,2484,80,,2484,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,2484,80,,2484,percent of total billed charges,,7216,,,7216,Case Rate,,3578,,"100% primary, 0% secondary procedures",3578,Other,MagnaCare ASC Grouper,2173.5,70,,2173.5,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,602.07,,,602.07,Other,New York Medicaid APG methodology,602.07,,,602.07,Other,100% New York Medicaid APG,602.07,,,602.07,Other,100% New York Medicaid APG,602.07,,,602.07,Other,100% New York Medicaid APG,1354.65,,,1354.65,Other,225% New York Medicaid APG,921.16,,,921.16,Other,153% New York Medicaid APG,1354.65,,,1354.65,Other,225% New York Medicaid APG,842.89,,,842.89,Other,140% New York Medicaid APG,1354.65,,,1354.65,Other,225% New York Medicaid APG,1565.37,,,1565.37,Other,260% New York Medicaid APG,1950.69,,,1950.69,Other,324% New York Medicaid APG,1294.44,,,1294.44,Other,215% New York Medicaid APG,1294.44,,,1294.44,Other,215% New York Medicaid APG,752.58,,,752.58,Other,125% New York Medicaid APG,602.07,7216,
Dstrj nulyt agt gnclr nrv,64624,CPT,,,,,,,,both,,,11278.42,8346.03,74,,8346.03,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,5075.29,45,,5075.29,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,5582.82,49.5,,5582.82,percent of total billed charges,110% of Medicare,7669.33,68,,7669.33,percent of total billed charges,,1119.84,,,1119.84,Other,186% of Medicaid,9022.74,80,,9022.74,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,9022.74,80,,9022.74,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,7894.89,70,,7894.89,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,602.07,,,602.07,Other,New York Medicaid APG methodology,602.07,,,602.07,Other,100% New York Medicaid APG,602.07,,,602.07,Other,100% New York Medicaid APG,602.07,,,602.07,Other,100% New York Medicaid APG,1354.65,,,1354.65,Other,225% New York Medicaid APG,921.16,,,921.16,Other,153% New York Medicaid APG,1354.65,,,1354.65,Other,225% New York Medicaid APG,842.89,,,842.89,Other,140% New York Medicaid APG,1354.65,,,1354.65,Other,225% New York Medicaid APG,1565.37,,,1565.37,Other,260% New York Medicaid APG,1950.69,,,1950.69,Other,324% New York Medicaid APG,1294.44,,,1294.44,Other,215% New York Medicaid APG,1294.44,,,1294.44,Other,215% New York Medicaid APG,752.58,,,752.58,Other,125% New York Medicaid APG,602.07,9022.74,
Rf abltj nrv nrvtg si jt,64625,CPT,,,,,,,,both,,,16895.98,12503.03,74,,12503.03,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,7603.19,45,,7603.19,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,8363.51,49.5,,8363.51,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2391.2,,,2391.2,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,11827.19,70,,11827.19,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1285.59,,,1285.59,Other,New York Medicaid APG methodology,1285.59,,,1285.59,Other,100% New York Medicaid APG,1285.59,,,1285.59,Other,100% New York Medicaid APG,1285.59,,,1285.59,Other,100% New York Medicaid APG,2892.58,,,2892.58,Other,225% New York Medicaid APG,1966.96,,,1966.96,Other,153% New York Medicaid APG,2892.58,,,2892.58,Other,225% New York Medicaid APG,1799.83,,,1799.83,Other,140% New York Medicaid APG,2892.58,,,2892.58,Other,225% New York Medicaid APG,3342.54,,,3342.54,Other,260% New York Medicaid APG,4165.32,,,4165.32,Other,324% New York Medicaid APG,2764.02,,,2764.02,Other,215% New York Medicaid APG,2764.02,,,2764.02,Other,215% New York Medicaid APG,1606.99,,,1606.99,Other,125% New York Medicaid APG,1285.59,12503.03,
Injection treatment of nerve,64630,CPT,,,,,,,,both,,,19171.82,14187.15,74,,14187.15,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,8627.32,45,,8627.32,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,9490.05,49.5,,9490.05,percent of total billed charges,110% of Medicare,13036.84,68,,13036.84,percent of total billed charges,,1119.84,,,1119.84,Other,186% of Medicaid,15337.46,80,,15337.46,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,15337.46,80,,15337.46,percent of total billed charges,,7216,,,7216,Case Rate,,3578,,"100% primary, 0% secondary procedures",3578,Other,MagnaCare ASC Grouper,13420.27,70,,13420.27,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,602.07,,,602.07,Other,New York Medicaid APG methodology,602.07,,,602.07,Other,100% New York Medicaid APG,602.07,,,602.07,Other,100% New York Medicaid APG,602.07,,,602.07,Other,100% New York Medicaid APG,1354.65,,,1354.65,Other,225% New York Medicaid APG,921.16,,,921.16,Other,153% New York Medicaid APG,1354.65,,,1354.65,Other,225% New York Medicaid APG,842.89,,,842.89,Other,140% New York Medicaid APG,1354.65,,,1354.65,Other,225% New York Medicaid APG,1565.37,,,1565.37,Other,260% New York Medicaid APG,1950.69,,,1950.69,Other,324% New York Medicaid APG,1294.44,,,1294.44,Other,215% New York Medicaid APG,1294.44,,,1294.44,Other,215% New York Medicaid APG,752.58,,,752.58,Other,125% New York Medicaid APG,602.07,15337.46,
N block inj common digit,64632,CPT,,,,,,,,both,,,32316.64,23914.31,74,,23914.31,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,14542.49,45,,14542.49,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,15996.74,49.5,,15996.74,percent of total billed charges,110% of Medicare,21975.32,68,,21975.32,percent of total billed charges,,966.11,,,966.11,Other,186% of Medicaid,25853.31,80,,25853.31,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,25853.31,80,,25853.31,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,22621.65,70,,22621.65,percent of total billed charges,,324.72,,,324.72,Fee Schedule,,275.22,,,275.22,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,519.42,,,519.42,Other,New York Medicaid APG methodology,519.42,,,519.42,Other,100% New York Medicaid APG,519.42,,,519.42,Other,100% New York Medicaid APG,519.42,,,519.42,Other,100% New York Medicaid APG,1168.69,,,1168.69,Other,225% New York Medicaid APG,794.71,,,794.71,Other,153% New York Medicaid APG,1168.69,,,1168.69,Other,225% New York Medicaid APG,727.18,,,727.18,Other,140% New York Medicaid APG,1168.69,,,1168.69,Other,225% New York Medicaid APG,1350.48,,,1350.48,Other,260% New York Medicaid APG,1682.91,,,1682.91,Other,324% New York Medicaid APG,1116.74,,,1116.74,Other,215% New York Medicaid APG,1116.74,,,1116.74,Other,215% New York Medicaid APG,649.27,,,649.27,Other,125% New York Medicaid APG,275.22,25853.31,
Destroy cerv/thor facet jnt,64633,CPT,,,,,,,,both,,,7145.41,5287.6,74,,5287.6,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,3215.43,45,,3215.43,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,3536.98,49.5,,3536.98,percent of total billed charges,110% of Medicare,4858.88,68,,4858.88,percent of total billed charges,,1119.84,,,1119.84,Other,186% of Medicaid,5716.33,80,,5716.33,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,5716.33,80,,5716.33,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,5001.79,70,,5001.79,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,602.07,,,602.07,Other,New York Medicaid APG methodology,602.07,,,602.07,Other,100% New York Medicaid APG,602.07,,,602.07,Other,100% New York Medicaid APG,602.07,,,602.07,Other,100% New York Medicaid APG,1354.65,,,1354.65,Other,225% New York Medicaid APG,921.16,,,921.16,Other,153% New York Medicaid APG,1354.65,,,1354.65,Other,225% New York Medicaid APG,842.89,,,842.89,Other,140% New York Medicaid APG,1354.65,,,1354.65,Other,225% New York Medicaid APG,1565.37,,,1565.37,Other,260% New York Medicaid APG,1950.69,,,1950.69,Other,324% New York Medicaid APG,1294.44,,,1294.44,Other,215% New York Medicaid APG,1294.44,,,1294.44,Other,215% New York Medicaid APG,752.58,,,752.58,Other,125% New York Medicaid APG,602.07,7216,
Destroy c/th facet jnt addl,64634,CPT,,,,,,,,both,,,32432.1,23999.75,74,,23999.75,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,14594.45,45,,14594.45,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,16053.89,49.5,,16053.89,percent of total billed charges,110% of Medicare,22053.83,68,,22053.83,percent of total billed charges,,966.11,,,966.11,Other,186% of Medicaid,25945.68,80,,25945.68,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,25945.68,80,,25945.68,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,22702.47,70,,22702.47,percent of total billed charges,,323.08,,,323.08,Fee Schedule,,273.83,,,273.83,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,519.42,,,519.42,Other,New York Medicaid APG methodology,519.42,,,519.42,Other,100% New York Medicaid APG,519.42,,,519.42,Other,100% New York Medicaid APG,519.42,,,519.42,Other,100% New York Medicaid APG,1168.69,,,1168.69,Other,225% New York Medicaid APG,794.71,,,794.71,Other,153% New York Medicaid APG,1168.69,,,1168.69,Other,225% New York Medicaid APG,727.18,,,727.18,Other,140% New York Medicaid APG,1168.69,,,1168.69,Other,225% New York Medicaid APG,1350.48,,,1350.48,Other,260% New York Medicaid APG,1682.91,,,1682.91,Other,324% New York Medicaid APG,1116.74,,,1116.74,Other,215% New York Medicaid APG,1116.74,,,1116.74,Other,215% New York Medicaid APG,649.27,,,649.27,Other,125% New York Medicaid APG,273.83,25945.68,
Destroy lumb/sac facet jnt,64635,CPT,,,,,,,,both,,,7323.18,5419.15,74,,5419.15,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,3295.43,45,,3295.43,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,3624.97,49.5,,3624.97,percent of total billed charges,110% of Medicare,4979.76,68,,4979.76,percent of total billed charges,,1119.84,,,1119.84,Other,186% of Medicaid,5858.54,80,,5858.54,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,5858.54,80,,5858.54,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,5126.23,70,,5126.23,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,602.07,,,602.07,Other,New York Medicaid APG methodology,602.07,,,602.07,Other,100% New York Medicaid APG,602.07,,,602.07,Other,100% New York Medicaid APG,602.07,,,602.07,Other,100% New York Medicaid APG,1354.65,,,1354.65,Other,225% New York Medicaid APG,921.16,,,921.16,Other,153% New York Medicaid APG,1354.65,,,1354.65,Other,225% New York Medicaid APG,842.89,,,842.89,Other,140% New York Medicaid APG,1354.65,,,1354.65,Other,225% New York Medicaid APG,1565.37,,,1565.37,Other,260% New York Medicaid APG,1950.69,,,1950.69,Other,324% New York Medicaid APG,1294.44,,,1294.44,Other,215% New York Medicaid APG,1294.44,,,1294.44,Other,215% New York Medicaid APG,752.58,,,752.58,Other,125% New York Medicaid APG,602.07,7216,
Destroy l/s facet jnt addl,64636,CPT,,,,,,,,both,,,32432.1,23999.75,74,,23999.75,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,14594.45,45,,14594.45,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,16053.89,49.5,,16053.89,percent of total billed charges,110% of Medicare,22053.83,68,,22053.83,percent of total billed charges,,1119.84,,,1119.84,Other,186% of Medicaid,25945.68,80,,25945.68,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,25945.68,80,,25945.68,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,22702.47,70,,22702.47,percent of total billed charges,,285.36,,,285.36,Fee Schedule,,241.86,,,241.86,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,602.07,,,602.07,Other,New York Medicaid APG methodology,602.07,,,602.07,Other,100% New York Medicaid APG,602.07,,,602.07,Other,100% New York Medicaid APG,602.07,,,602.07,Other,100% New York Medicaid APG,1354.65,,,1354.65,Other,225% New York Medicaid APG,921.16,,,921.16,Other,153% New York Medicaid APG,1354.65,,,1354.65,Other,225% New York Medicaid APG,842.89,,,842.89,Other,140% New York Medicaid APG,1354.65,,,1354.65,Other,225% New York Medicaid APG,1565.37,,,1565.37,Other,260% New York Medicaid APG,1950.69,,,1950.69,Other,324% New York Medicaid APG,1294.44,,,1294.44,Other,215% New York Medicaid APG,1294.44,,,1294.44,Other,215% New York Medicaid APG,752.58,,,752.58,Other,125% New York Medicaid APG,241.86,25945.68,
Injection treatment of nerve,64640,CPT,,,,,,,,both,,,8581.36,6350.21,74,,6350.21,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,3861.61,45,,3861.61,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,4247.77,49.5,,4247.77,percent of total billed charges,110% of Medicare,5835.32,68,,5835.32,percent of total billed charges,,1119.84,,,1119.84,Other,186% of Medicaid,6865.09,80,,6865.09,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,6865.09,80,,6865.09,percent of total billed charges,,7216,,,7216,Case Rate,,3578,,"100% primary, 0% secondary procedures",3578,Other,MagnaCare ASC Grouper,6006.95,70,,6006.95,percent of total billed charges,,574,,,574,Fee Schedule,,486.5,,,486.5,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,602.07,,,602.07,Other,New York Medicaid APG methodology,602.07,,,602.07,Other,100% New York Medicaid APG,602.07,,,602.07,Other,100% New York Medicaid APG,602.07,,,602.07,Other,100% New York Medicaid APG,1354.65,,,1354.65,Other,225% New York Medicaid APG,921.16,,,921.16,Other,153% New York Medicaid APG,1354.65,,,1354.65,Other,225% New York Medicaid APG,842.89,,,842.89,Other,140% New York Medicaid APG,1354.65,,,1354.65,Other,225% New York Medicaid APG,1565.37,,,1565.37,Other,260% New York Medicaid APG,1950.69,,,1950.69,Other,324% New York Medicaid APG,1294.44,,,1294.44,Other,215% New York Medicaid APG,1294.44,,,1294.44,Other,215% New York Medicaid APG,752.58,,,752.58,Other,125% New York Medicaid APG,486.5,7216,
Chemodenerv 1 extremity 1-4,64642,CPT,,,,,,,,both,,,14545.81,10763.9,74,,10763.9,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,6545.61,45,,6545.61,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,7200.18,49.5,,7200.18,percent of total billed charges,110% of Medicare,9891.15,68,,9891.15,percent of total billed charges,,966.11,,,966.11,Other,186% of Medicaid,11636.65,80,,11636.65,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,11636.65,80,,11636.65,percent of total billed charges,,7216,,,7216,Case Rate,,3578,,"100% primary, 0% secondary procedures",3578,Other,MagnaCare ASC Grouper,10182.07,70,,10182.07,percent of total billed charges,,518.24,,,518.24,Fee Schedule,,439.24,,,439.24,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,519.42,,,519.42,Other,New York Medicaid APG methodology,519.42,,,519.42,Other,100% New York Medicaid APG,519.42,,,519.42,Other,100% New York Medicaid APG,519.42,,,519.42,Other,100% New York Medicaid APG,1168.69,,,1168.69,Other,225% New York Medicaid APG,794.71,,,794.71,Other,153% New York Medicaid APG,1168.69,,,1168.69,Other,225% New York Medicaid APG,727.18,,,727.18,Other,140% New York Medicaid APG,1168.69,,,1168.69,Other,225% New York Medicaid APG,1350.48,,,1350.48,Other,260% New York Medicaid APG,1682.91,,,1682.91,Other,324% New York Medicaid APG,1116.74,,,1116.74,Other,215% New York Medicaid APG,1116.74,,,1116.74,Other,215% New York Medicaid APG,649.27,,,649.27,Other,125% New York Medicaid APG,439.24,11636.65,
Chemodenerv 1 extrem 1-4 ea,64643,CPT,,,,,,,,both,,,32432.1,23999.75,74,,23999.75,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,14594.45,45,,14594.45,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,16053.89,49.5,,16053.89,percent of total billed charges,110% of Medicare,22053.83,68,,22053.83,percent of total billed charges,,966.11,,,966.11,Other,186% of Medicaid,25945.68,80,,25945.68,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,25945.68,80,,25945.68,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,22702.47,70,,22702.47,percent of total billed charges,,342.76,,,342.76,Fee Schedule,,290.51,,,290.51,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,519.42,,,519.42,Other,New York Medicaid APG methodology,519.42,,,519.42,Other,100% New York Medicaid APG,519.42,,,519.42,Other,100% New York Medicaid APG,519.42,,,519.42,Other,100% New York Medicaid APG,1168.69,,,1168.69,Other,225% New York Medicaid APG,794.71,,,794.71,Other,153% New York Medicaid APG,1168.69,,,1168.69,Other,225% New York Medicaid APG,727.18,,,727.18,Other,140% New York Medicaid APG,1168.69,,,1168.69,Other,225% New York Medicaid APG,1350.48,,,1350.48,Other,260% New York Medicaid APG,1682.91,,,1682.91,Other,324% New York Medicaid APG,1116.74,,,1116.74,Other,215% New York Medicaid APG,1116.74,,,1116.74,Other,215% New York Medicaid APG,649.27,,,649.27,Other,125% New York Medicaid APG,290.51,25945.68,
Chemodenerv 1 extrem 5/> mus,64644,CPT,,,,,,,,both,,,14545.81,10763.9,74,,10763.9,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,6545.61,45,,6545.61,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,7200.18,49.5,,7200.18,percent of total billed charges,110% of Medicare,9891.15,68,,9891.15,percent of total billed charges,,966.11,,,966.11,Other,186% of Medicaid,11636.65,80,,11636.65,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,11636.65,80,,11636.65,percent of total billed charges,,7216,,,7216,Case Rate,,3578,,"100% primary, 0% secondary procedures",3578,Other,MagnaCare ASC Grouper,10182.07,70,,10182.07,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,519.42,,,519.42,Other,New York Medicaid APG methodology,519.42,,,519.42,Other,100% New York Medicaid APG,519.42,,,519.42,Other,100% New York Medicaid APG,519.42,,,519.42,Other,100% New York Medicaid APG,1168.69,,,1168.69,Other,225% New York Medicaid APG,794.71,,,794.71,Other,153% New York Medicaid APG,1168.69,,,1168.69,Other,225% New York Medicaid APG,727.18,,,727.18,Other,140% New York Medicaid APG,1168.69,,,1168.69,Other,225% New York Medicaid APG,1350.48,,,1350.48,Other,260% New York Medicaid APG,1682.91,,,1682.91,Other,324% New York Medicaid APG,1116.74,,,1116.74,Other,215% New York Medicaid APG,1116.74,,,1116.74,Other,215% New York Medicaid APG,649.27,,,649.27,Other,125% New York Medicaid APG,519.42,11636.65,
Chemodenerv 1 extrem 5/> ea,64645,CPT,,,,,,,,both,,,32432.1,23999.75,74,,23999.75,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,14594.45,45,,14594.45,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,16053.89,49.5,,16053.89,percent of total billed charges,110% of Medicare,22053.83,68,,22053.83,percent of total billed charges,,966.11,,,966.11,Other,186% of Medicaid,25945.68,80,,25945.68,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,25945.68,80,,25945.68,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,22702.47,70,,22702.47,percent of total billed charges,,398.52,,,398.52,Fee Schedule,,337.77,,,337.77,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,519.42,,,519.42,Other,New York Medicaid APG methodology,519.42,,,519.42,Other,100% New York Medicaid APG,519.42,,,519.42,Other,100% New York Medicaid APG,519.42,,,519.42,Other,100% New York Medicaid APG,1168.69,,,1168.69,Other,225% New York Medicaid APG,794.71,,,794.71,Other,153% New York Medicaid APG,1168.69,,,1168.69,Other,225% New York Medicaid APG,727.18,,,727.18,Other,140% New York Medicaid APG,1168.69,,,1168.69,Other,225% New York Medicaid APG,1350.48,,,1350.48,Other,260% New York Medicaid APG,1682.91,,,1682.91,Other,324% New York Medicaid APG,1116.74,,,1116.74,Other,215% New York Medicaid APG,1116.74,,,1116.74,Other,215% New York Medicaid APG,649.27,,,649.27,Other,125% New York Medicaid APG,337.77,25945.68,
Chemodenerv trunk musc 1-5,64646,CPT,,,,,,,,both,,,14545.81,10763.9,74,,10763.9,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,6545.61,45,,6545.61,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,7200.18,49.5,,7200.18,percent of total billed charges,110% of Medicare,9891.15,68,,9891.15,percent of total billed charges,,966.11,,,966.11,Other,186% of Medicaid,11636.65,80,,11636.65,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,11636.65,80,,11636.65,percent of total billed charges,,7216,,,7216,Case Rate,,3578,,"100% primary, 0% secondary procedures",3578,Other,MagnaCare ASC Grouper,10182.07,70,,10182.07,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,519.42,,,519.42,Other,New York Medicaid APG methodology,519.42,,,519.42,Other,100% New York Medicaid APG,519.42,,,519.42,Other,100% New York Medicaid APG,519.42,,,519.42,Other,100% New York Medicaid APG,1168.69,,,1168.69,Other,225% New York Medicaid APG,794.71,,,794.71,Other,153% New York Medicaid APG,1168.69,,,1168.69,Other,225% New York Medicaid APG,727.18,,,727.18,Other,140% New York Medicaid APG,1168.69,,,1168.69,Other,225% New York Medicaid APG,1350.48,,,1350.48,Other,260% New York Medicaid APG,1682.91,,,1682.91,Other,324% New York Medicaid APG,1116.74,,,1116.74,Other,215% New York Medicaid APG,1116.74,,,1116.74,Other,215% New York Medicaid APG,649.27,,,649.27,Other,125% New York Medicaid APG,519.42,11636.65,
Chemodenerv trunk musc 6/>,64647,CPT,,,,,,,,both,,,14545.81,10763.9,74,,10763.9,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,6545.61,45,,6545.61,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,7200.18,49.5,,7200.18,percent of total billed charges,110% of Medicare,9891.15,68,,9891.15,percent of total billed charges,,966.11,,,966.11,Other,186% of Medicaid,11636.65,80,,11636.65,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,11636.65,80,,11636.65,percent of total billed charges,,7216,,,7216,Case Rate,,3578,,"100% primary, 0% secondary procedures",3578,Other,MagnaCare ASC Grouper,10182.07,70,,10182.07,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,519.42,,,519.42,Other,New York Medicaid APG methodology,519.42,,,519.42,Other,100% New York Medicaid APG,519.42,,,519.42,Other,100% New York Medicaid APG,519.42,,,519.42,Other,100% New York Medicaid APG,1168.69,,,1168.69,Other,225% New York Medicaid APG,794.71,,,794.71,Other,153% New York Medicaid APG,1168.69,,,1168.69,Other,225% New York Medicaid APG,727.18,,,727.18,Other,140% New York Medicaid APG,1168.69,,,1168.69,Other,225% New York Medicaid APG,1350.48,,,1350.48,Other,260% New York Medicaid APG,1682.91,,,1682.91,Other,324% New York Medicaid APG,1116.74,,,1116.74,Other,215% New York Medicaid APG,1116.74,,,1116.74,Other,215% New York Medicaid APG,649.27,,,649.27,Other,125% New York Medicaid APG,519.42,11636.65,
Chemodenerv eccrine glands,64650,CPT,,,,,,,,both,,,6229.82,4610.07,74,,4610.07,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,2803.42,45,,2803.42,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,3083.76,49.5,,3083.76,percent of total billed charges,110% of Medicare,4236.28,68,,4236.28,percent of total billed charges,,966.11,,,966.11,Other,186% of Medicaid,4983.86,80,,4983.86,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,4983.86,80,,4983.86,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,4360.87,70,,4360.87,percent of total billed charges,,198.44,,,198.44,Fee Schedule,,168.19,,,168.19,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,519.42,,,519.42,Other,New York Medicaid APG methodology,519.42,,,519.42,Other,100% New York Medicaid APG,519.42,,,519.42,Other,100% New York Medicaid APG,519.42,,,519.42,Other,100% New York Medicaid APG,1168.69,,,1168.69,Other,225% New York Medicaid APG,794.71,,,794.71,Other,153% New York Medicaid APG,1168.69,,,1168.69,Other,225% New York Medicaid APG,727.18,,,727.18,Other,140% New York Medicaid APG,1168.69,,,1168.69,Other,225% New York Medicaid APG,1350.48,,,1350.48,Other,260% New York Medicaid APG,1682.91,,,1682.91,Other,324% New York Medicaid APG,1116.74,,,1116.74,Other,215% New York Medicaid APG,1116.74,,,1116.74,Other,215% New York Medicaid APG,649.27,,,649.27,Other,125% New York Medicaid APG,168.19,7216,
Chemodenerv eccrine glands,64653,CPT,,,,,,,,both,,,37692.12,27892.17,74,,27892.17,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,16961.45,45,,16961.45,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,18657.6,49.5,,18657.6,percent of total billed charges,110% of Medicare,25630.64,68,,25630.64,percent of total billed charges,,966.11,,,966.11,Other,186% of Medicaid,30153.7,80,,30153.7,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,30153.7,80,,30153.7,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,26384.48,70,,26384.48,percent of total billed charges,,252.56,,,252.56,Fee Schedule,,214.06,,,214.06,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,519.42,,,519.42,Other,New York Medicaid APG methodology,519.42,,,519.42,Other,100% New York Medicaid APG,519.42,,,519.42,Other,100% New York Medicaid APG,519.42,,,519.42,Other,100% New York Medicaid APG,1168.69,,,1168.69,Other,225% New York Medicaid APG,794.71,,,794.71,Other,153% New York Medicaid APG,1168.69,,,1168.69,Other,225% New York Medicaid APG,727.18,,,727.18,Other,140% New York Medicaid APG,1168.69,,,1168.69,Other,225% New York Medicaid APG,1350.48,,,1350.48,Other,260% New York Medicaid APG,1682.91,,,1682.91,Other,324% New York Medicaid APG,1116.74,,,1116.74,Other,215% New York Medicaid APG,1116.74,,,1116.74,Other,215% New York Medicaid APG,649.27,,,649.27,Other,125% New York Medicaid APG,214.06,30153.7,
Injection treatment of nerve,64680,CPT,,,,,,,,both,,,22394,16571.56,74,,16571.56,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,10077.3,45,,10077.3,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,11085.03,49.5,,11085.03,percent of total billed charges,110% of Medicare,15227.92,68,,15227.92,percent of total billed charges,,1119.84,,,1119.84,Other,186% of Medicaid,17915.2,80,,17915.2,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,17915.2,80,,17915.2,percent of total billed charges,,7216,,,7216,Case Rate,,3578,,"100% primary, 0% secondary procedures",3578,Other,MagnaCare ASC Grouper,15675.8,70,,15675.8,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,602.07,,,602.07,Other,New York Medicaid APG methodology,602.07,,,602.07,Other,100% New York Medicaid APG,602.07,,,602.07,Other,100% New York Medicaid APG,602.07,,,602.07,Other,100% New York Medicaid APG,1354.65,,,1354.65,Other,225% New York Medicaid APG,921.16,,,921.16,Other,153% New York Medicaid APG,1354.65,,,1354.65,Other,225% New York Medicaid APG,842.89,,,842.89,Other,140% New York Medicaid APG,1354.65,,,1354.65,Other,225% New York Medicaid APG,1565.37,,,1565.37,Other,260% New York Medicaid APG,1950.69,,,1950.69,Other,324% New York Medicaid APG,1294.44,,,1294.44,Other,215% New York Medicaid APG,1294.44,,,1294.44,Other,215% New York Medicaid APG,752.58,,,752.58,Other,125% New York Medicaid APG,602.07,17915.2,
Injection treatment of nerve,64681,CPT,,,,,,,,both,,,19171.82,14187.15,74,,14187.15,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,8627.32,45,,8627.32,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,9490.05,49.5,,9490.05,percent of total billed charges,110% of Medicare,13036.84,68,,13036.84,percent of total billed charges,,1119.84,,,1119.84,Other,186% of Medicaid,15337.46,80,,15337.46,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,15337.46,80,,15337.46,percent of total billed charges,,7216,,,7216,Case Rate,,3578,,"100% primary, 0% secondary procedures",3578,Other,MagnaCare ASC Grouper,13420.27,70,,13420.27,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,602.07,,,602.07,Other,New York Medicaid APG methodology,602.07,,,602.07,Other,100% New York Medicaid APG,602.07,,,602.07,Other,100% New York Medicaid APG,602.07,,,602.07,Other,100% New York Medicaid APG,1354.65,,,1354.65,Other,225% New York Medicaid APG,921.16,,,921.16,Other,153% New York Medicaid APG,1354.65,,,1354.65,Other,225% New York Medicaid APG,842.89,,,842.89,Other,140% New York Medicaid APG,1354.65,,,1354.65,Other,225% New York Medicaid APG,1565.37,,,1565.37,Other,260% New York Medicaid APG,1950.69,,,1950.69,Other,324% New York Medicaid APG,1294.44,,,1294.44,Other,215% New York Medicaid APG,1294.44,,,1294.44,Other,215% New York Medicaid APG,752.58,,,752.58,Other,125% New York Medicaid APG,602.07,15337.46,
Revise finger/toe nerve,64702,CPT,,,,,,,,both,,,39486.15,29219.75,74,,29219.75,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,17768.77,45,,17768.77,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,19545.64,49.5,,19545.64,percent of total billed charges,110% of Medicare,26850.58,68,,26850.58,percent of total billed charges,,2391.2,,,2391.2,Other,186% of Medicaid,31588.92,80,,31588.92,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,31588.92,80,,31588.92,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,27640.31,70,,27640.31,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1285.59,,,1285.59,Other,New York Medicaid APG methodology,1285.59,,,1285.59,Other,100% New York Medicaid APG,1285.59,,,1285.59,Other,100% New York Medicaid APG,1285.59,,,1285.59,Other,100% New York Medicaid APG,2892.58,,,2892.58,Other,225% New York Medicaid APG,1966.96,,,1966.96,Other,153% New York Medicaid APG,2892.58,,,2892.58,Other,225% New York Medicaid APG,1799.83,,,1799.83,Other,140% New York Medicaid APG,2892.58,,,2892.58,Other,225% New York Medicaid APG,3342.54,,,3342.54,Other,260% New York Medicaid APG,4165.32,,,4165.32,Other,324% New York Medicaid APG,2764.02,,,2764.02,Other,215% New York Medicaid APG,2764.02,,,2764.02,Other,215% New York Medicaid APG,1606.99,,,1606.99,Other,125% New York Medicaid APG,1285.59,31588.92,
Revise hand/foot nerve,64704,CPT,,,,,,,,both,,,40611.5,30052.51,74,,30052.51,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,18275.18,45,,18275.18,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,20102.69,49.5,,20102.69,percent of total billed charges,110% of Medicare,27615.82,68,,27615.82,percent of total billed charges,,2391.2,,,2391.2,Other,186% of Medicaid,32489.2,80,,32489.2,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,32489.2,80,,32489.2,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,28428.05,70,,28428.05,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1285.59,,,1285.59,Other,New York Medicaid APG methodology,1285.59,,,1285.59,Other,100% New York Medicaid APG,1285.59,,,1285.59,Other,100% New York Medicaid APG,1285.59,,,1285.59,Other,100% New York Medicaid APG,2892.58,,,2892.58,Other,225% New York Medicaid APG,1966.96,,,1966.96,Other,153% New York Medicaid APG,2892.58,,,2892.58,Other,225% New York Medicaid APG,1799.83,,,1799.83,Other,140% New York Medicaid APG,2892.58,,,2892.58,Other,225% New York Medicaid APG,3342.54,,,3342.54,Other,260% New York Medicaid APG,4165.32,,,4165.32,Other,324% New York Medicaid APG,2764.02,,,2764.02,Other,215% New York Medicaid APG,2764.02,,,2764.02,Other,215% New York Medicaid APG,1606.99,,,1606.99,Other,125% New York Medicaid APG,1285.59,32489.2,
Revise arm/leg nerve,64708,CPT,,,,,,,,both,,,44531.93,32953.63,74,,32953.63,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,20039.37,45,,20039.37,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,22043.31,49.5,,22043.31,percent of total billed charges,110% of Medicare,30281.71,68,,30281.71,percent of total billed charges,,2391.2,,,2391.2,Other,186% of Medicaid,35625.54,80,,35625.54,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,35625.54,80,,35625.54,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,31172.35,70,,31172.35,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1285.59,,,1285.59,Other,New York Medicaid APG methodology,1285.59,,,1285.59,Other,100% New York Medicaid APG,1285.59,,,1285.59,Other,100% New York Medicaid APG,1285.59,,,1285.59,Other,100% New York Medicaid APG,2892.58,,,2892.58,Other,225% New York Medicaid APG,1966.96,,,1966.96,Other,153% New York Medicaid APG,2892.58,,,2892.58,Other,225% New York Medicaid APG,1799.83,,,1799.83,Other,140% New York Medicaid APG,2892.58,,,2892.58,Other,225% New York Medicaid APG,3342.54,,,3342.54,Other,260% New York Medicaid APG,4165.32,,,4165.32,Other,324% New York Medicaid APG,2764.02,,,2764.02,Other,215% New York Medicaid APG,2764.02,,,2764.02,Other,215% New York Medicaid APG,1606.99,,,1606.99,Other,125% New York Medicaid APG,1285.59,35625.54,
Revision of sciatic nerve,64712,CPT,,,,,,,,both,,,66847.9,49467.45,74,,49467.45,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30081.56,45,,30081.56,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,33089.71,49.5,,33089.71,percent of total billed charges,110% of Medicare,45456.57,68,,45456.57,percent of total billed charges,,6048.62,,,6048.62,Other,186% of Medicaid,53478.32,80,,53478.32,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,53478.32,80,,53478.32,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,46793.53,70,,46793.53,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,3251.94,,,3251.94,Other,New York Medicaid APG methodology,3251.94,,,3251.94,Other,100% New York Medicaid APG,3251.94,,,3251.94,Other,100% New York Medicaid APG,3251.94,,,3251.94,Other,100% New York Medicaid APG,7316.87,,,7316.87,Other,225% New York Medicaid APG,4975.47,,,4975.47,Other,153% New York Medicaid APG,7316.87,,,7316.87,Other,225% New York Medicaid APG,4552.72,,,4552.72,Other,140% New York Medicaid APG,7316.87,,,7316.87,Other,225% New York Medicaid APG,8455.05,,,8455.05,Other,260% New York Medicaid APG,10536.3,,,10536.3,Other,324% New York Medicaid APG,6991.68,,,6991.68,Other,215% New York Medicaid APG,6991.68,,,6991.68,Other,215% New York Medicaid APG,4064.93,,,4064.93,Other,125% New York Medicaid APG,2232,53478.32,
Revision of arm nerve(s),64713,CPT,,,,,,,,both,,,67907.61,50251.63,74,,50251.63,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30558.42,45,,30558.42,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,33614.27,49.5,,33614.27,percent of total billed charges,110% of Medicare,46177.17,68,,46177.17,percent of total billed charges,,6048.62,,,6048.62,Other,186% of Medicaid,54326.09,80,,54326.09,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,54326.09,80,,54326.09,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,47535.33,70,,47535.33,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,3251.94,,,3251.94,Other,New York Medicaid APG methodology,3251.94,,,3251.94,Other,100% New York Medicaid APG,3251.94,,,3251.94,Other,100% New York Medicaid APG,3251.94,,,3251.94,Other,100% New York Medicaid APG,7316.87,,,7316.87,Other,225% New York Medicaid APG,4975.47,,,4975.47,Other,153% New York Medicaid APG,7316.87,,,7316.87,Other,225% New York Medicaid APG,4552.72,,,4552.72,Other,140% New York Medicaid APG,7316.87,,,7316.87,Other,225% New York Medicaid APG,8455.05,,,8455.05,Other,260% New York Medicaid APG,10536.3,,,10536.3,Other,324% New York Medicaid APG,6991.68,,,6991.68,Other,215% New York Medicaid APG,6991.68,,,6991.68,Other,215% New York Medicaid APG,4064.93,,,4064.93,Other,125% New York Medicaid APG,2232,54326.09,
Revise low back nerve(s),64714,CPT,,,,,,,,both,,,40611.5,30052.51,74,,30052.51,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,18275.18,45,,18275.18,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,20102.69,49.5,,20102.69,percent of total billed charges,110% of Medicare,27615.82,68,,27615.82,percent of total billed charges,,6048.62,,,6048.62,Other,186% of Medicaid,32489.2,80,,32489.2,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,32489.2,80,,32489.2,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,28428.05,70,,28428.05,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,3251.94,,,3251.94,Other,New York Medicaid APG methodology,3251.94,,,3251.94,Other,100% New York Medicaid APG,3251.94,,,3251.94,Other,100% New York Medicaid APG,3251.94,,,3251.94,Other,100% New York Medicaid APG,7316.87,,,7316.87,Other,225% New York Medicaid APG,4975.47,,,4975.47,Other,153% New York Medicaid APG,7316.87,,,7316.87,Other,225% New York Medicaid APG,4552.72,,,4552.72,Other,140% New York Medicaid APG,7316.87,,,7316.87,Other,225% New York Medicaid APG,8455.05,,,8455.05,Other,260% New York Medicaid APG,10536.3,,,10536.3,Other,324% New York Medicaid APG,6991.68,,,6991.68,Other,215% New York Medicaid APG,6991.68,,,6991.68,Other,215% New York Medicaid APG,4064.93,,,4064.93,Other,125% New York Medicaid APG,2232,32489.2,
Revision of cranial nerve,64716,CPT,,,,,,,,both,,,40611.5,30052.51,74,,30052.51,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,18275.18,45,,18275.18,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,20102.69,49.5,,20102.69,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,6048.62,,,6048.62,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,28428.05,70,,28428.05,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,3251.94,,,3251.94,Other,New York Medicaid APG methodology,3251.94,,,3251.94,Other,100% New York Medicaid APG,3251.94,,,3251.94,Other,100% New York Medicaid APG,3251.94,,,3251.94,Other,100% New York Medicaid APG,7316.87,,,7316.87,Other,225% New York Medicaid APG,4975.47,,,4975.47,Other,153% New York Medicaid APG,7316.87,,,7316.87,Other,225% New York Medicaid APG,4552.72,,,4552.72,Other,140% New York Medicaid APG,7316.87,,,7316.87,Other,225% New York Medicaid APG,8455.05,,,8455.05,Other,260% New York Medicaid APG,10536.3,,,10536.3,Other,324% New York Medicaid APG,6991.68,,,6991.68,Other,215% New York Medicaid APG,6991.68,,,6991.68,Other,215% New York Medicaid APG,4064.93,,,4064.93,Other,125% New York Medicaid APG,3126,30052.51,
Revise ulnar nerve at elbow,64718,CPT,,,,,,,,both,,,46351.11,34299.82,74,,34299.82,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,20858,45,,20858,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,22943.8,49.5,,22943.8,percent of total billed charges,110% of Medicare,31518.75,68,,31518.75,percent of total billed charges,,2391.2,,,2391.2,Other,186% of Medicaid,37080.89,80,,37080.89,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,37080.89,80,,37080.89,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,32445.78,70,,32445.78,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1285.59,,,1285.59,Other,New York Medicaid APG methodology,1285.59,,,1285.59,Other,100% New York Medicaid APG,1285.59,,,1285.59,Other,100% New York Medicaid APG,1285.59,,,1285.59,Other,100% New York Medicaid APG,2892.58,,,2892.58,Other,225% New York Medicaid APG,1966.96,,,1966.96,Other,153% New York Medicaid APG,2892.58,,,2892.58,Other,225% New York Medicaid APG,1799.83,,,1799.83,Other,140% New York Medicaid APG,2892.58,,,2892.58,Other,225% New York Medicaid APG,3342.54,,,3342.54,Other,260% New York Medicaid APG,4165.32,,,4165.32,Other,324% New York Medicaid APG,2764.02,,,2764.02,Other,215% New York Medicaid APG,2764.02,,,2764.02,Other,215% New York Medicaid APG,1606.99,,,1606.99,Other,125% New York Medicaid APG,1285.59,37080.89,
Revise ulnar nerve at wrist,64719,CPT,,,,,,,,both,,,55878.32,41349.96,74,,41349.96,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,25145.24,45,,25145.24,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,27659.77,49.5,,27659.77,percent of total billed charges,110% of Medicare,37997.26,68,,37997.26,percent of total billed charges,,2391.2,,,2391.2,Other,186% of Medicaid,44702.66,80,,44702.66,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,44702.66,80,,44702.66,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,39114.82,70,,39114.82,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1285.59,,,1285.59,Other,New York Medicaid APG methodology,1285.59,,,1285.59,Other,100% New York Medicaid APG,1285.59,,,1285.59,Other,100% New York Medicaid APG,1285.59,,,1285.59,Other,100% New York Medicaid APG,2892.58,,,2892.58,Other,225% New York Medicaid APG,1966.96,,,1966.96,Other,153% New York Medicaid APG,2892.58,,,2892.58,Other,225% New York Medicaid APG,1799.83,,,1799.83,Other,140% New York Medicaid APG,2892.58,,,2892.58,Other,225% New York Medicaid APG,3342.54,,,3342.54,Other,260% New York Medicaid APG,4165.32,,,4165.32,Other,324% New York Medicaid APG,2764.02,,,2764.02,Other,215% New York Medicaid APG,2764.02,,,2764.02,Other,215% New York Medicaid APG,1606.99,,,1606.99,Other,125% New York Medicaid APG,1285.59,44702.66,
Carpal tunnel surgery,64721,CPT,,,,,,,,both,,,35340.41,26151.9,74,,26151.9,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15903.18,45,,15903.18,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,17493.5,49.5,,17493.5,percent of total billed charges,110% of Medicare,24031.48,68,,24031.48,percent of total billed charges,,2391.2,,,2391.2,Other,186% of Medicaid,28272.33,80,,28272.33,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,28272.33,80,,28272.33,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,24738.29,70,,24738.29,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1285.59,,,1285.59,Other,New York Medicaid APG methodology,1285.59,,,1285.59,Other,100% New York Medicaid APG,1285.59,,,1285.59,Other,100% New York Medicaid APG,1285.59,,,1285.59,Other,100% New York Medicaid APG,2892.58,,,2892.58,Other,225% New York Medicaid APG,1966.96,,,1966.96,Other,153% New York Medicaid APG,2892.58,,,2892.58,Other,225% New York Medicaid APG,1799.83,,,1799.83,Other,140% New York Medicaid APG,2892.58,,,2892.58,Other,225% New York Medicaid APG,3342.54,,,3342.54,Other,260% New York Medicaid APG,4165.32,,,4165.32,Other,324% New York Medicaid APG,2764.02,,,2764.02,Other,215% New York Medicaid APG,2764.02,,,2764.02,Other,215% New York Medicaid APG,1606.99,,,1606.99,Other,125% New York Medicaid APG,1285.59,28272.33,
Relieve pressure on nerve(s),64722,CPT,,,,,,,,both,,,40611.5,30052.51,74,,30052.51,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,18275.18,45,,18275.18,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,20102.69,49.5,,20102.69,percent of total billed charges,110% of Medicare,27615.82,68,,27615.82,percent of total billed charges,,2391.2,,,2391.2,Other,186% of Medicaid,32489.2,80,,32489.2,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,32489.2,80,,32489.2,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,28428.05,70,,28428.05,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1285.59,,,1285.59,Other,New York Medicaid APG methodology,1285.59,,,1285.59,Other,100% New York Medicaid APG,1285.59,,,1285.59,Other,100% New York Medicaid APG,1285.59,,,1285.59,Other,100% New York Medicaid APG,2892.58,,,2892.58,Other,225% New York Medicaid APG,1966.96,,,1966.96,Other,153% New York Medicaid APG,2892.58,,,2892.58,Other,225% New York Medicaid APG,1799.83,,,1799.83,Other,140% New York Medicaid APG,2892.58,,,2892.58,Other,225% New York Medicaid APG,3342.54,,,3342.54,Other,260% New York Medicaid APG,4165.32,,,4165.32,Other,324% New York Medicaid APG,2764.02,,,2764.02,Other,215% New York Medicaid APG,2764.02,,,2764.02,Other,215% New York Medicaid APG,1606.99,,,1606.99,Other,125% New York Medicaid APG,1285.59,32489.2,
Release foot/toe nerve,64726,CPT,,,,,,,,both,,,40611.5,30052.51,74,,30052.51,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,18275.18,45,,18275.18,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,20102.69,49.5,,20102.69,percent of total billed charges,110% of Medicare,27615.82,68,,27615.82,percent of total billed charges,,2391.2,,,2391.2,Other,186% of Medicaid,32489.2,80,,32489.2,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,32489.2,80,,32489.2,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,28428.05,70,,28428.05,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1285.59,,,1285.59,Other,New York Medicaid APG methodology,1285.59,,,1285.59,Other,100% New York Medicaid APG,1285.59,,,1285.59,Other,100% New York Medicaid APG,1285.59,,,1285.59,Other,100% New York Medicaid APG,2892.58,,,2892.58,Other,225% New York Medicaid APG,1966.96,,,1966.96,Other,153% New York Medicaid APG,2892.58,,,2892.58,Other,225% New York Medicaid APG,1799.83,,,1799.83,Other,140% New York Medicaid APG,2892.58,,,2892.58,Other,225% New York Medicaid APG,3342.54,,,3342.54,Other,260% New York Medicaid APG,4165.32,,,4165.32,Other,324% New York Medicaid APG,2764.02,,,2764.02,Other,215% New York Medicaid APG,2764.02,,,2764.02,Other,215% New York Medicaid APG,1606.99,,,1606.99,Other,125% New York Medicaid APG,1285.59,32489.2,
Internal nerve revision,64727,CPT,,,,,,,,both,,,32432.1,23999.75,74,,23999.75,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,14594.45,45,,14594.45,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,16053.89,49.5,,16053.89,percent of total billed charges,110% of Medicare,22053.83,68,,22053.83,percent of total billed charges,,6048.62,,,6048.62,Other,186% of Medicaid,25945.68,80,,25945.68,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,25945.68,80,,25945.68,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,22702.47,70,,22702.47,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,3251.94,,,3251.94,Other,New York Medicaid APG methodology,3251.94,,,3251.94,Other,100% New York Medicaid APG,3251.94,,,3251.94,Other,100% New York Medicaid APG,3251.94,,,3251.94,Other,100% New York Medicaid APG,7316.87,,,7316.87,Other,225% New York Medicaid APG,4975.47,,,4975.47,Other,153% New York Medicaid APG,7316.87,,,7316.87,Other,225% New York Medicaid APG,4552.72,,,4552.72,Other,140% New York Medicaid APG,7316.87,,,7316.87,Other,225% New York Medicaid APG,8455.05,,,8455.05,Other,260% New York Medicaid APG,10536.3,,,10536.3,Other,324% New York Medicaid APG,6991.68,,,6991.68,Other,215% New York Medicaid APG,6991.68,,,6991.68,Other,215% New York Medicaid APG,4064.93,,,4064.93,Other,125% New York Medicaid APG,2053,25945.68,
Incision of brow nerve,64732,CPT,,,,,,,,both,,,40611.5,30052.51,74,,30052.51,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,18275.18,45,,18275.18,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,20102.69,49.5,,20102.69,percent of total billed charges,110% of Medicare,27615.82,68,,27615.82,percent of total billed charges,,2391.2,,,2391.2,Other,186% of Medicaid,32489.2,80,,32489.2,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,32489.2,80,,32489.2,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,28428.05,70,,28428.05,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1285.59,,,1285.59,Other,New York Medicaid APG methodology,1285.59,,,1285.59,Other,100% New York Medicaid APG,1285.59,,,1285.59,Other,100% New York Medicaid APG,1285.59,,,1285.59,Other,100% New York Medicaid APG,2892.58,,,2892.58,Other,225% New York Medicaid APG,1966.96,,,1966.96,Other,153% New York Medicaid APG,2892.58,,,2892.58,Other,225% New York Medicaid APG,1799.83,,,1799.83,Other,140% New York Medicaid APG,2892.58,,,2892.58,Other,225% New York Medicaid APG,3342.54,,,3342.54,Other,260% New York Medicaid APG,4165.32,,,4165.32,Other,324% New York Medicaid APG,2764.02,,,2764.02,Other,215% New York Medicaid APG,2764.02,,,2764.02,Other,215% New York Medicaid APG,1606.99,,,1606.99,Other,125% New York Medicaid APG,1285.59,32489.2,
Incision of cheek nerve,64734,CPT,,,,,,,,both,,,40611.5,30052.51,74,,30052.51,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,18275.18,45,,18275.18,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,20102.69,49.5,,20102.69,percent of total billed charges,110% of Medicare,27615.82,68,,27615.82,percent of total billed charges,,2391.2,,,2391.2,Other,186% of Medicaid,32489.2,80,,32489.2,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,32489.2,80,,32489.2,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,28428.05,70,,28428.05,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1285.59,,,1285.59,Other,New York Medicaid APG methodology,1285.59,,,1285.59,Other,100% New York Medicaid APG,1285.59,,,1285.59,Other,100% New York Medicaid APG,1285.59,,,1285.59,Other,100% New York Medicaid APG,2892.58,,,2892.58,Other,225% New York Medicaid APG,1966.96,,,1966.96,Other,153% New York Medicaid APG,2892.58,,,2892.58,Other,225% New York Medicaid APG,1799.83,,,1799.83,Other,140% New York Medicaid APG,2892.58,,,2892.58,Other,225% New York Medicaid APG,3342.54,,,3342.54,Other,260% New York Medicaid APG,4165.32,,,4165.32,Other,324% New York Medicaid APG,2764.02,,,2764.02,Other,215% New York Medicaid APG,2764.02,,,2764.02,Other,215% New York Medicaid APG,1606.99,,,1606.99,Other,125% New York Medicaid APG,1285.59,32489.2,
Incision of chin nerve,64736,CPT,,,,,,,,both,,,40611.5,30052.51,74,,30052.51,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,18275.18,45,,18275.18,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,20102.69,49.5,,20102.69,percent of total billed charges,110% of Medicare,27615.82,68,,27615.82,percent of total billed charges,,2391.2,,,2391.2,Other,186% of Medicaid,32489.2,80,,32489.2,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,32489.2,80,,32489.2,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,28428.05,70,,28428.05,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1285.59,,,1285.59,Other,New York Medicaid APG methodology,1285.59,,,1285.59,Other,100% New York Medicaid APG,1285.59,,,1285.59,Other,100% New York Medicaid APG,1285.59,,,1285.59,Other,100% New York Medicaid APG,2892.58,,,2892.58,Other,225% New York Medicaid APG,1966.96,,,1966.96,Other,153% New York Medicaid APG,2892.58,,,2892.58,Other,225% New York Medicaid APG,1799.83,,,1799.83,Other,140% New York Medicaid APG,2892.58,,,2892.58,Other,225% New York Medicaid APG,3342.54,,,3342.54,Other,260% New York Medicaid APG,4165.32,,,4165.32,Other,324% New York Medicaid APG,2764.02,,,2764.02,Other,215% New York Medicaid APG,2764.02,,,2764.02,Other,215% New York Medicaid APG,1606.99,,,1606.99,Other,125% New York Medicaid APG,1285.59,32489.2,
Incision of jaw nerve,64738,CPT,,,,,,,,both,,,40611.5,30052.51,74,,30052.51,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,18275.18,45,,18275.18,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,20102.69,49.5,,20102.69,percent of total billed charges,110% of Medicare,27615.82,68,,27615.82,percent of total billed charges,,2391.2,,,2391.2,Other,186% of Medicaid,32489.2,80,,32489.2,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,32489.2,80,,32489.2,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,28428.05,70,,28428.05,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1285.59,,,1285.59,Other,New York Medicaid APG methodology,1285.59,,,1285.59,Other,100% New York Medicaid APG,1285.59,,,1285.59,Other,100% New York Medicaid APG,1285.59,,,1285.59,Other,100% New York Medicaid APG,2892.58,,,2892.58,Other,225% New York Medicaid APG,1966.96,,,1966.96,Other,153% New York Medicaid APG,2892.58,,,2892.58,Other,225% New York Medicaid APG,1799.83,,,1799.83,Other,140% New York Medicaid APG,2892.58,,,2892.58,Other,225% New York Medicaid APG,3342.54,,,3342.54,Other,260% New York Medicaid APG,4165.32,,,4165.32,Other,324% New York Medicaid APG,2764.02,,,2764.02,Other,215% New York Medicaid APG,2764.02,,,2764.02,Other,215% New York Medicaid APG,1606.99,,,1606.99,Other,125% New York Medicaid APG,1285.59,32489.2,
Incision of tongue nerve,64740,CPT,,,,,,,,both,,,40611.5,30052.51,74,,30052.51,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,18275.18,45,,18275.18,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,20102.69,49.5,,20102.69,percent of total billed charges,110% of Medicare,27615.82,68,,27615.82,percent of total billed charges,,2391.2,,,2391.2,Other,186% of Medicaid,32489.2,80,,32489.2,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,32489.2,80,,32489.2,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,28428.05,70,,28428.05,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1285.59,,,1285.59,Other,New York Medicaid APG methodology,1285.59,,,1285.59,Other,100% New York Medicaid APG,1285.59,,,1285.59,Other,100% New York Medicaid APG,1285.59,,,1285.59,Other,100% New York Medicaid APG,2892.58,,,2892.58,Other,225% New York Medicaid APG,1966.96,,,1966.96,Other,153% New York Medicaid APG,2892.58,,,2892.58,Other,225% New York Medicaid APG,1799.83,,,1799.83,Other,140% New York Medicaid APG,2892.58,,,2892.58,Other,225% New York Medicaid APG,3342.54,,,3342.54,Other,260% New York Medicaid APG,4165.32,,,4165.32,Other,324% New York Medicaid APG,2764.02,,,2764.02,Other,215% New York Medicaid APG,2764.02,,,2764.02,Other,215% New York Medicaid APG,1606.99,,,1606.99,Other,125% New York Medicaid APG,1285.59,32489.2,
Incision of facial nerve,64742,CPT,,,,,,,,both,,,40611.5,30052.51,74,,30052.51,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,18275.18,45,,18275.18,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,20102.69,49.5,,20102.69,percent of total billed charges,110% of Medicare,27615.82,68,,27615.82,percent of total billed charges,,2391.2,,,2391.2,Other,186% of Medicaid,32489.2,80,,32489.2,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,32489.2,80,,32489.2,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,28428.05,70,,28428.05,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1285.59,,,1285.59,Other,New York Medicaid APG methodology,1285.59,,,1285.59,Other,100% New York Medicaid APG,1285.59,,,1285.59,Other,100% New York Medicaid APG,1285.59,,,1285.59,Other,100% New York Medicaid APG,2892.58,,,2892.58,Other,225% New York Medicaid APG,1966.96,,,1966.96,Other,153% New York Medicaid APG,2892.58,,,2892.58,Other,225% New York Medicaid APG,1799.83,,,1799.83,Other,140% New York Medicaid APG,2892.58,,,2892.58,Other,225% New York Medicaid APG,3342.54,,,3342.54,Other,260% New York Medicaid APG,4165.32,,,4165.32,Other,324% New York Medicaid APG,2764.02,,,2764.02,Other,215% New York Medicaid APG,2764.02,,,2764.02,Other,215% New York Medicaid APG,1606.99,,,1606.99,Other,125% New York Medicaid APG,1285.59,32489.2,
Incise nerve back of head,64744,CPT,,,,,,,,both,,,65635.43,48570.22,74,,48570.22,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,29535.94,45,,29535.94,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,32489.54,49.5,,32489.54,percent of total billed charges,110% of Medicare,44632.09,68,,44632.09,percent of total billed charges,,6048.62,,,6048.62,Other,186% of Medicaid,52508.34,80,,52508.34,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,52508.34,80,,52508.34,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,45944.8,70,,45944.8,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,3251.94,,,3251.94,Other,New York Medicaid APG methodology,3251.94,,,3251.94,Other,100% New York Medicaid APG,3251.94,,,3251.94,Other,100% New York Medicaid APG,3251.94,,,3251.94,Other,100% New York Medicaid APG,7316.87,,,7316.87,Other,225% New York Medicaid APG,4975.47,,,4975.47,Other,153% New York Medicaid APG,7316.87,,,7316.87,Other,225% New York Medicaid APG,4552.72,,,4552.72,Other,140% New York Medicaid APG,7316.87,,,7316.87,Other,225% New York Medicaid APG,8455.05,,,8455.05,Other,260% New York Medicaid APG,10536.3,,,10536.3,Other,324% New York Medicaid APG,6991.68,,,6991.68,Other,215% New York Medicaid APG,6991.68,,,6991.68,Other,215% New York Medicaid APG,4064.93,,,4064.93,Other,125% New York Medicaid APG,2232,52508.34,
Incise diaphragm nerve,64746,CPT,,,,,,,,both,,,40611.5,30052.51,74,,30052.51,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,18275.18,45,,18275.18,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,20102.69,49.5,,20102.69,percent of total billed charges,110% of Medicare,27615.82,68,,27615.82,percent of total billed charges,,6048.62,,,6048.62,Other,186% of Medicaid,32489.2,80,,32489.2,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,32489.2,80,,32489.2,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,28428.05,70,,28428.05,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,3251.94,,,3251.94,Other,New York Medicaid APG methodology,3251.94,,,3251.94,Other,100% New York Medicaid APG,3251.94,,,3251.94,Other,100% New York Medicaid APG,3251.94,,,3251.94,Other,100% New York Medicaid APG,7316.87,,,7316.87,Other,225% New York Medicaid APG,4975.47,,,4975.47,Other,153% New York Medicaid APG,7316.87,,,7316.87,Other,225% New York Medicaid APG,4552.72,,,4552.72,Other,140% New York Medicaid APG,7316.87,,,7316.87,Other,225% New York Medicaid APG,8455.05,,,8455.05,Other,260% New York Medicaid APG,10536.3,,,10536.3,Other,324% New York Medicaid APG,6991.68,,,6991.68,Other,215% New York Medicaid APG,6991.68,,,6991.68,Other,215% New York Medicaid APG,4064.93,,,4064.93,Other,125% New York Medicaid APG,2232,32489.2,
Incise hip/thigh nerve,64763,CPT,,,,,,,,both,,,40611.5,30052.51,74,,30052.51,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,18275.18,45,,18275.18,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,20102.69,49.5,,20102.69,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2391.2,,,2391.2,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,28428.05,70,,28428.05,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1285.59,,,1285.59,Other,New York Medicaid APG methodology,1285.59,,,1285.59,Other,100% New York Medicaid APG,1285.59,,,1285.59,Other,100% New York Medicaid APG,1285.59,,,1285.59,Other,100% New York Medicaid APG,2892.58,,,2892.58,Other,225% New York Medicaid APG,1966.96,,,1966.96,Other,153% New York Medicaid APG,2892.58,,,2892.58,Other,225% New York Medicaid APG,1799.83,,,1799.83,Other,140% New York Medicaid APG,2892.58,,,2892.58,Other,225% New York Medicaid APG,3342.54,,,3342.54,Other,260% New York Medicaid APG,4165.32,,,4165.32,Other,324% New York Medicaid APG,2764.02,,,2764.02,Other,215% New York Medicaid APG,2764.02,,,2764.02,Other,215% New York Medicaid APG,1606.99,,,1606.99,Other,125% New York Medicaid APG,1285.59,30052.51,
Incise hip/thigh nerve,64766,CPT,,,,,,,,both,,,40611.5,30052.51,74,,30052.51,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,18275.18,45,,18275.18,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,20102.69,49.5,,20102.69,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2391.2,,,2391.2,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,28428.05,70,,28428.05,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1285.59,,,1285.59,Other,New York Medicaid APG methodology,1285.59,,,1285.59,Other,100% New York Medicaid APG,1285.59,,,1285.59,Other,100% New York Medicaid APG,1285.59,,,1285.59,Other,100% New York Medicaid APG,2892.58,,,2892.58,Other,225% New York Medicaid APG,1966.96,,,1966.96,Other,153% New York Medicaid APG,2892.58,,,2892.58,Other,225% New York Medicaid APG,1799.83,,,1799.83,Other,140% New York Medicaid APG,2892.58,,,2892.58,Other,225% New York Medicaid APG,3342.54,,,3342.54,Other,260% New York Medicaid APG,4165.32,,,4165.32,Other,324% New York Medicaid APG,2764.02,,,2764.02,Other,215% New York Medicaid APG,2764.02,,,2764.02,Other,215% New York Medicaid APG,1606.99,,,1606.99,Other,125% New York Medicaid APG,1285.59,30052.51,
Sever cranial nerve,64771,CPT,,,,,,,,both,,,40611.5,30052.51,74,,30052.51,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,18275.18,45,,18275.18,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,20102.69,49.5,,20102.69,percent of total billed charges,110% of Medicare,27615.82,68,,27615.82,percent of total billed charges,,6048.62,,,6048.62,Other,186% of Medicaid,32489.2,80,,32489.2,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,32489.2,80,,32489.2,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,28428.05,70,,28428.05,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,3251.94,,,3251.94,Other,New York Medicaid APG methodology,3251.94,,,3251.94,Other,100% New York Medicaid APG,3251.94,,,3251.94,Other,100% New York Medicaid APG,3251.94,,,3251.94,Other,100% New York Medicaid APG,7316.87,,,7316.87,Other,225% New York Medicaid APG,4975.47,,,4975.47,Other,153% New York Medicaid APG,7316.87,,,7316.87,Other,225% New York Medicaid APG,4552.72,,,4552.72,Other,140% New York Medicaid APG,7316.87,,,7316.87,Other,225% New York Medicaid APG,8455.05,,,8455.05,Other,260% New York Medicaid APG,10536.3,,,10536.3,Other,324% New York Medicaid APG,6991.68,,,6991.68,Other,215% New York Medicaid APG,6991.68,,,6991.68,Other,215% New York Medicaid APG,4064.93,,,4064.93,Other,125% New York Medicaid APG,2232,32489.2,
Incision of spinal nerve,64772,CPT,,,,,,,,both,,,40611.5,30052.51,74,,30052.51,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,18275.18,45,,18275.18,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,20102.69,49.5,,20102.69,percent of total billed charges,110% of Medicare,27615.82,68,,27615.82,percent of total billed charges,,2391.2,,,2391.2,Other,186% of Medicaid,32489.2,80,,32489.2,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,32489.2,80,,32489.2,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,28428.05,70,,28428.05,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1285.59,,,1285.59,Other,New York Medicaid APG methodology,1285.59,,,1285.59,Other,100% New York Medicaid APG,1285.59,,,1285.59,Other,100% New York Medicaid APG,1285.59,,,1285.59,Other,100% New York Medicaid APG,2892.58,,,2892.58,Other,225% New York Medicaid APG,1966.96,,,1966.96,Other,153% New York Medicaid APG,2892.58,,,2892.58,Other,225% New York Medicaid APG,1799.83,,,1799.83,Other,140% New York Medicaid APG,2892.58,,,2892.58,Other,225% New York Medicaid APG,3342.54,,,3342.54,Other,260% New York Medicaid APG,4165.32,,,4165.32,Other,324% New York Medicaid APG,2764.02,,,2764.02,Other,215% New York Medicaid APG,2764.02,,,2764.02,Other,215% New York Medicaid APG,1606.99,,,1606.99,Other,125% New York Medicaid APG,1285.59,32489.2,
Remove skin nerve lesion,64774,CPT,,,,,,,,both,,,40611.5,30052.51,74,,30052.51,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,18275.18,45,,18275.18,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,20102.69,49.5,,20102.69,percent of total billed charges,110% of Medicare,27615.82,68,,27615.82,percent of total billed charges,,2391.2,,,2391.2,Other,186% of Medicaid,32489.2,80,,32489.2,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,32489.2,80,,32489.2,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,28428.05,70,,28428.05,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1285.59,,,1285.59,Other,New York Medicaid APG methodology,1285.59,,,1285.59,Other,100% New York Medicaid APG,1285.59,,,1285.59,Other,100% New York Medicaid APG,1285.59,,,1285.59,Other,100% New York Medicaid APG,2892.58,,,2892.58,Other,225% New York Medicaid APG,1966.96,,,1966.96,Other,153% New York Medicaid APG,2892.58,,,2892.58,Other,225% New York Medicaid APG,1799.83,,,1799.83,Other,140% New York Medicaid APG,2892.58,,,2892.58,Other,225% New York Medicaid APG,3342.54,,,3342.54,Other,260% New York Medicaid APG,4165.32,,,4165.32,Other,324% New York Medicaid APG,2764.02,,,2764.02,Other,215% New York Medicaid APG,2764.02,,,2764.02,Other,215% New York Medicaid APG,1606.99,,,1606.99,Other,125% New York Medicaid APG,1285.59,32489.2,
Remove digit nerve lesion,64776,CPT,,,,,,,,both,,,32128.65,23775.2,74,,23775.2,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,14457.89,45,,14457.89,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,15903.68,49.5,,15903.68,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2391.2,,,2391.2,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,22490.06,70,,22490.06,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1285.59,,,1285.59,Other,New York Medicaid APG methodology,1285.59,,,1285.59,Other,100% New York Medicaid APG,1285.59,,,1285.59,Other,100% New York Medicaid APG,1285.59,,,1285.59,Other,100% New York Medicaid APG,2892.58,,,2892.58,Other,225% New York Medicaid APG,1966.96,,,1966.96,Other,153% New York Medicaid APG,2892.58,,,2892.58,Other,225% New York Medicaid APG,1799.83,,,1799.83,Other,140% New York Medicaid APG,2892.58,,,2892.58,Other,225% New York Medicaid APG,3342.54,,,3342.54,Other,260% New York Medicaid APG,4165.32,,,4165.32,Other,324% New York Medicaid APG,2764.02,,,2764.02,Other,215% New York Medicaid APG,2764.02,,,2764.02,Other,215% New York Medicaid APG,1606.99,,,1606.99,Other,125% New York Medicaid APG,1285.59,23775.2,
Digit nerve surgery add-on,64778,CPT,,,,,,,,both,,,51572.04,38163.31,74,,38163.31,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,23207.42,45,,23207.42,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,25528.16,49.5,,25528.16,percent of total billed charges,110% of Medicare,35068.99,68,,35068.99,percent of total billed charges,,2391.2,,,2391.2,Other,186% of Medicaid,41257.63,80,,41257.63,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,41257.63,80,,41257.63,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,36100.43,70,,36100.43,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,1285.59,,,1285.59,Other,New York Medicaid APG methodology,1285.59,,,1285.59,Other,100% New York Medicaid APG,1285.59,,,1285.59,Other,100% New York Medicaid APG,1285.59,,,1285.59,Other,100% New York Medicaid APG,2892.58,,,2892.58,Other,225% New York Medicaid APG,1966.96,,,1966.96,Other,153% New York Medicaid APG,2892.58,,,2892.58,Other,225% New York Medicaid APG,1799.83,,,1799.83,Other,140% New York Medicaid APG,2892.58,,,2892.58,Other,225% New York Medicaid APG,3342.54,,,3342.54,Other,260% New York Medicaid APG,4165.32,,,4165.32,Other,324% New York Medicaid APG,2764.02,,,2764.02,Other,215% New York Medicaid APG,2764.02,,,2764.02,Other,215% New York Medicaid APG,1606.99,,,1606.99,Other,125% New York Medicaid APG,1285.59,41257.63,
Remove limb nerve lesion,64782,CPT,,,,,,,,both,,,40611.5,30052.51,74,,30052.51,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,18275.18,45,,18275.18,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,20102.69,49.5,,20102.69,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2391.2,,,2391.2,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,28428.05,70,,28428.05,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1285.59,,,1285.59,Other,New York Medicaid APG methodology,1285.59,,,1285.59,Other,100% New York Medicaid APG,1285.59,,,1285.59,Other,100% New York Medicaid APG,1285.59,,,1285.59,Other,100% New York Medicaid APG,2892.58,,,2892.58,Other,225% New York Medicaid APG,1966.96,,,1966.96,Other,153% New York Medicaid APG,2892.58,,,2892.58,Other,225% New York Medicaid APG,1799.83,,,1799.83,Other,140% New York Medicaid APG,2892.58,,,2892.58,Other,225% New York Medicaid APG,3342.54,,,3342.54,Other,260% New York Medicaid APG,4165.32,,,4165.32,Other,324% New York Medicaid APG,2764.02,,,2764.02,Other,215% New York Medicaid APG,2764.02,,,2764.02,Other,215% New York Medicaid APG,1606.99,,,1606.99,Other,125% New York Medicaid APG,1285.59,30052.51,
Limb nerve surgery add-on,64783,CPT,,,,,,,,both,,,51572.04,38163.31,74,,38163.31,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,23207.42,45,,23207.42,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,25528.16,49.5,,25528.16,percent of total billed charges,110% of Medicare,35068.99,68,,35068.99,percent of total billed charges,,2391.2,,,2391.2,Other,186% of Medicaid,41257.63,80,,41257.63,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,41257.63,80,,41257.63,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,36100.43,70,,36100.43,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,1285.59,,,1285.59,Other,New York Medicaid APG methodology,1285.59,,,1285.59,Other,100% New York Medicaid APG,1285.59,,,1285.59,Other,100% New York Medicaid APG,1285.59,,,1285.59,Other,100% New York Medicaid APG,2892.58,,,2892.58,Other,225% New York Medicaid APG,1966.96,,,1966.96,Other,153% New York Medicaid APG,2892.58,,,2892.58,Other,225% New York Medicaid APG,1799.83,,,1799.83,Other,140% New York Medicaid APG,2892.58,,,2892.58,Other,225% New York Medicaid APG,3342.54,,,3342.54,Other,260% New York Medicaid APG,4165.32,,,4165.32,Other,324% New York Medicaid APG,2764.02,,,2764.02,Other,215% New York Medicaid APG,2764.02,,,2764.02,Other,215% New York Medicaid APG,1606.99,,,1606.99,Other,125% New York Medicaid APG,1285.59,41257.63,
Remove nerve lesion,64784,CPT,,,,,,,,both,,,71512.33,52919.12,74,,52919.12,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,32180.55,45,,32180.55,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,35398.6,49.5,,35398.6,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2391.2,,,2391.2,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,50058.63,70,,50058.63,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1285.59,,,1285.59,Other,New York Medicaid APG methodology,1285.59,,,1285.59,Other,100% New York Medicaid APG,1285.59,,,1285.59,Other,100% New York Medicaid APG,1285.59,,,1285.59,Other,100% New York Medicaid APG,2892.58,,,2892.58,Other,225% New York Medicaid APG,1966.96,,,1966.96,Other,153% New York Medicaid APG,2892.58,,,2892.58,Other,225% New York Medicaid APG,1799.83,,,1799.83,Other,140% New York Medicaid APG,2892.58,,,2892.58,Other,225% New York Medicaid APG,3342.54,,,3342.54,Other,260% New York Medicaid APG,4165.32,,,4165.32,Other,324% New York Medicaid APG,2764.02,,,2764.02,Other,215% New York Medicaid APG,2764.02,,,2764.02,Other,215% New York Medicaid APG,1606.99,,,1606.99,Other,125% New York Medicaid APG,1285.59,52919.12,
Remove sciatic nerve lesion,64786,CPT,,,,,,,,both,,,140115.1,103685.17,74,,103685.17,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,63051.8,45,,63051.8,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,69356.97,49.5,,69356.97,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,6048.62,,,6048.62,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,98080.57,70,,98080.57,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,3251.94,,,3251.94,Other,New York Medicaid APG methodology,3251.94,,,3251.94,Other,100% New York Medicaid APG,3251.94,,,3251.94,Other,100% New York Medicaid APG,3251.94,,,3251.94,Other,100% New York Medicaid APG,7316.87,,,7316.87,Other,225% New York Medicaid APG,4975.47,,,4975.47,Other,153% New York Medicaid APG,7316.87,,,7316.87,Other,225% New York Medicaid APG,4552.72,,,4552.72,Other,140% New York Medicaid APG,7316.87,,,7316.87,Other,225% New York Medicaid APG,8455.05,,,8455.05,Other,260% New York Medicaid APG,10536.3,,,10536.3,Other,324% New York Medicaid APG,6991.68,,,6991.68,Other,215% New York Medicaid APG,6991.68,,,6991.68,Other,215% New York Medicaid APG,4064.93,,,4064.93,Other,125% New York Medicaid APG,3126,103685.17,
Implant nerve end,64787,CPT,,,,,,,,both,,,51572.04,38163.31,74,,38163.31,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,23207.42,45,,23207.42,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,25528.16,49.5,,25528.16,percent of total billed charges,110% of Medicare,35068.99,68,,35068.99,percent of total billed charges,,6048.62,,,6048.62,Other,186% of Medicaid,41257.63,80,,41257.63,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,41257.63,80,,41257.63,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,36100.43,70,,36100.43,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,3251.94,,,3251.94,Other,New York Medicaid APG methodology,3251.94,,,3251.94,Other,100% New York Medicaid APG,3251.94,,,3251.94,Other,100% New York Medicaid APG,3251.94,,,3251.94,Other,100% New York Medicaid APG,7316.87,,,7316.87,Other,225% New York Medicaid APG,4975.47,,,4975.47,Other,153% New York Medicaid APG,7316.87,,,7316.87,Other,225% New York Medicaid APG,4552.72,,,4552.72,Other,140% New York Medicaid APG,7316.87,,,7316.87,Other,225% New York Medicaid APG,8455.05,,,8455.05,Other,260% New York Medicaid APG,10536.3,,,10536.3,Other,324% New York Medicaid APG,6991.68,,,6991.68,Other,215% New York Medicaid APG,6991.68,,,6991.68,Other,215% New York Medicaid APG,4064.93,,,4064.93,Other,125% New York Medicaid APG,2232,41257.63,
Remove skin nerve lesion,64788,CPT,,,,,,,,both,,,40767.87,30168.22,74,,30168.22,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,18345.54,45,,18345.54,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,20180.1,49.5,,20180.1,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2391.2,,,2391.2,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,28537.51,70,,28537.51,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1285.59,,,1285.59,Other,New York Medicaid APG methodology,1285.59,,,1285.59,Other,100% New York Medicaid APG,1285.59,,,1285.59,Other,100% New York Medicaid APG,1285.59,,,1285.59,Other,100% New York Medicaid APG,2892.58,,,2892.58,Other,225% New York Medicaid APG,1966.96,,,1966.96,Other,153% New York Medicaid APG,2892.58,,,2892.58,Other,225% New York Medicaid APG,1799.83,,,1799.83,Other,140% New York Medicaid APG,2892.58,,,2892.58,Other,225% New York Medicaid APG,3342.54,,,3342.54,Other,260% New York Medicaid APG,4165.32,,,4165.32,Other,324% New York Medicaid APG,2764.02,,,2764.02,Other,215% New York Medicaid APG,2764.02,,,2764.02,Other,215% New York Medicaid APG,1606.99,,,1606.99,Other,125% New York Medicaid APG,1285.59,30168.22,
Removal of nerve lesion,64790,CPT,,,,,,,,both,,,40611.5,30052.51,74,,30052.51,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,18275.18,45,,18275.18,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,20102.69,49.5,,20102.69,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,6048.62,,,6048.62,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,28428.05,70,,28428.05,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,3251.94,,,3251.94,Other,New York Medicaid APG methodology,3251.94,,,3251.94,Other,100% New York Medicaid APG,3251.94,,,3251.94,Other,100% New York Medicaid APG,3251.94,,,3251.94,Other,100% New York Medicaid APG,7316.87,,,7316.87,Other,225% New York Medicaid APG,4975.47,,,4975.47,Other,153% New York Medicaid APG,7316.87,,,7316.87,Other,225% New York Medicaid APG,4552.72,,,4552.72,Other,140% New York Medicaid APG,7316.87,,,7316.87,Other,225% New York Medicaid APG,8455.05,,,8455.05,Other,260% New York Medicaid APG,10536.3,,,10536.3,Other,324% New York Medicaid APG,6991.68,,,6991.68,Other,215% New York Medicaid APG,6991.68,,,6991.68,Other,215% New York Medicaid APG,4064.93,,,4064.93,Other,125% New York Medicaid APG,3126,30052.51,
Removal of nerve lesion,64792,CPT,,,,,,,,both,,,74117.29,54846.79,74,,54846.79,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,33352.78,45,,33352.78,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,36688.06,49.5,,36688.06,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,6048.62,,,6048.62,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,51882.1,70,,51882.1,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,3251.94,,,3251.94,Other,New York Medicaid APG methodology,3251.94,,,3251.94,Other,100% New York Medicaid APG,3251.94,,,3251.94,Other,100% New York Medicaid APG,3251.94,,,3251.94,Other,100% New York Medicaid APG,7316.87,,,7316.87,Other,225% New York Medicaid APG,4975.47,,,4975.47,Other,153% New York Medicaid APG,7316.87,,,7316.87,Other,225% New York Medicaid APG,4552.72,,,4552.72,Other,140% New York Medicaid APG,7316.87,,,7316.87,Other,225% New York Medicaid APG,8455.05,,,8455.05,Other,260% New York Medicaid APG,10536.3,,,10536.3,Other,324% New York Medicaid APG,6991.68,,,6991.68,Other,215% New York Medicaid APG,6991.68,,,6991.68,Other,215% New York Medicaid APG,4064.93,,,4064.93,Other,125% New York Medicaid APG,3126,54846.79,
Biopsy of nerve,64795,CPT,,,,,,,,both,,,40611.5,30052.51,74,,30052.51,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,18275.18,45,,18275.18,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,20102.69,49.5,,20102.69,percent of total billed charges,110% of Medicare,27615.82,68,,27615.82,percent of total billed charges,,2391.2,,,2391.2,Other,186% of Medicaid,32489.2,80,,32489.2,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,32489.2,80,,32489.2,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,28428.05,70,,28428.05,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1285.59,,,1285.59,Other,New York Medicaid APG methodology,1285.59,,,1285.59,Other,100% New York Medicaid APG,1285.59,,,1285.59,Other,100% New York Medicaid APG,1285.59,,,1285.59,Other,100% New York Medicaid APG,2892.58,,,2892.58,Other,225% New York Medicaid APG,1966.96,,,1966.96,Other,153% New York Medicaid APG,2892.58,,,2892.58,Other,225% New York Medicaid APG,1799.83,,,1799.83,Other,140% New York Medicaid APG,2892.58,,,2892.58,Other,225% New York Medicaid APG,3342.54,,,3342.54,Other,260% New York Medicaid APG,4165.32,,,4165.32,Other,324% New York Medicaid APG,2764.02,,,2764.02,Other,215% New York Medicaid APG,2764.02,,,2764.02,Other,215% New York Medicaid APG,1606.99,,,1606.99,Other,125% New York Medicaid APG,1285.59,32489.2,
Sympathectomy cervical,64802,CPT,,,,,,,,both,,,40611.5,30052.51,74,,30052.51,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,18275.18,45,,18275.18,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,20102.69,49.5,,20102.69,percent of total billed charges,110% of Medicare,27615.82,68,,27615.82,percent of total billed charges,,2391.2,,,2391.2,Other,186% of Medicaid,32489.2,80,,32489.2,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,32489.2,80,,32489.2,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,28428.05,70,,28428.05,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1285.59,,,1285.59,Other,New York Medicaid APG methodology,1285.59,,,1285.59,Other,100% New York Medicaid APG,1285.59,,,1285.59,Other,100% New York Medicaid APG,1285.59,,,1285.59,Other,100% New York Medicaid APG,2892.58,,,2892.58,Other,225% New York Medicaid APG,1966.96,,,1966.96,Other,153% New York Medicaid APG,2892.58,,,2892.58,Other,225% New York Medicaid APG,1799.83,,,1799.83,Other,140% New York Medicaid APG,2892.58,,,2892.58,Other,225% New York Medicaid APG,3342.54,,,3342.54,Other,260% New York Medicaid APG,4165.32,,,4165.32,Other,324% New York Medicaid APG,2764.02,,,2764.02,Other,215% New York Medicaid APG,2764.02,,,2764.02,Other,215% New York Medicaid APG,1606.99,,,1606.99,Other,125% New York Medicaid APG,1285.59,32489.2,
Remove sympathetic nerves,64804,CPT,,,,,,,,both,,,40611.5,30052.51,74,,30052.51,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,18275.18,45,,18275.18,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,20102.69,49.5,,20102.69,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,6048.62,,,6048.62,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,28428.05,70,,28428.05,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,3251.94,,,3251.94,Other,New York Medicaid APG methodology,3251.94,,,3251.94,Other,100% New York Medicaid APG,3251.94,,,3251.94,Other,100% New York Medicaid APG,3251.94,,,3251.94,Other,100% New York Medicaid APG,7316.87,,,7316.87,Other,225% New York Medicaid APG,4975.47,,,4975.47,Other,153% New York Medicaid APG,7316.87,,,7316.87,Other,225% New York Medicaid APG,4552.72,,,4552.72,Other,140% New York Medicaid APG,7316.87,,,7316.87,Other,225% New York Medicaid APG,8455.05,,,8455.05,Other,260% New York Medicaid APG,10536.3,,,10536.3,Other,324% New York Medicaid APG,6991.68,,,6991.68,Other,215% New York Medicaid APG,6991.68,,,6991.68,Other,215% New York Medicaid APG,4064.93,,,4064.93,Other,125% New York Medicaid APG,3251.94,30052.51,
Sympathectomy digital artery,64820,CPT,,,,,,,,both,,,40611.5,30052.51,74,,30052.51,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,18275.18,45,,18275.18,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,20102.69,49.5,,20102.69,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2391.2,,,2391.2,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,28428.05,70,,28428.05,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1285.59,,,1285.59,Other,New York Medicaid APG methodology,1285.59,,,1285.59,Other,100% New York Medicaid APG,1285.59,,,1285.59,Other,100% New York Medicaid APG,1285.59,,,1285.59,Other,100% New York Medicaid APG,2892.58,,,2892.58,Other,225% New York Medicaid APG,1966.96,,,1966.96,Other,153% New York Medicaid APG,2892.58,,,2892.58,Other,225% New York Medicaid APG,1799.83,,,1799.83,Other,140% New York Medicaid APG,2892.58,,,2892.58,Other,225% New York Medicaid APG,3342.54,,,3342.54,Other,260% New York Medicaid APG,4165.32,,,4165.32,Other,324% New York Medicaid APG,2764.02,,,2764.02,Other,215% New York Medicaid APG,2764.02,,,2764.02,Other,215% New York Medicaid APG,1606.99,,,1606.99,Other,125% New York Medicaid APG,1285.59,30052.51,
Remove sympathetic nerves,64821,CPT,,,,,,,,both,,,68082.75,50381.24,74,,50381.24,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30637.24,45,,30637.24,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33700.96,49.5,,33700.96,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2391.2,,,2391.2,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,47657.93,70,,47657.93,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1285.59,,,1285.59,Other,New York Medicaid APG methodology,1285.59,,,1285.59,Other,100% New York Medicaid APG,1285.59,,,1285.59,Other,100% New York Medicaid APG,1285.59,,,1285.59,Other,100% New York Medicaid APG,2892.58,,,2892.58,Other,225% New York Medicaid APG,1966.96,,,1966.96,Other,153% New York Medicaid APG,2892.58,,,2892.58,Other,225% New York Medicaid APG,1799.83,,,1799.83,Other,140% New York Medicaid APG,2892.58,,,2892.58,Other,225% New York Medicaid APG,3342.54,,,3342.54,Other,260% New York Medicaid APG,4165.32,,,4165.32,Other,324% New York Medicaid APG,2764.02,,,2764.02,Other,215% New York Medicaid APG,2764.02,,,2764.02,Other,215% New York Medicaid APG,1606.99,,,1606.99,Other,125% New York Medicaid APG,1285.59,50381.24,
Remove sympathetic nerves,64822,CPT,,,,,,,,both,,,68082.75,50381.24,74,,50381.24,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30637.24,45,,30637.24,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33700.96,49.5,,33700.96,percent of total billed charges,110% of Medicare,46296.27,68,,46296.27,percent of total billed charges,,2391.2,,,2391.2,Other,186% of Medicaid,54466.2,80,,54466.2,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,54466.2,80,,54466.2,percent of total billed charges,,7216,,,7216,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,47657.93,70,,47657.93,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1285.59,,,1285.59,Other,New York Medicaid APG methodology,1285.59,,,1285.59,Other,100% New York Medicaid APG,1285.59,,,1285.59,Other,100% New York Medicaid APG,1285.59,,,1285.59,Other,100% New York Medicaid APG,2892.58,,,2892.58,Other,225% New York Medicaid APG,1966.96,,,1966.96,Other,153% New York Medicaid APG,2892.58,,,2892.58,Other,225% New York Medicaid APG,1799.83,,,1799.83,Other,140% New York Medicaid APG,2892.58,,,2892.58,Other,225% New York Medicaid APG,3342.54,,,3342.54,Other,260% New York Medicaid APG,4165.32,,,4165.32,Other,324% New York Medicaid APG,2764.02,,,2764.02,Other,215% New York Medicaid APG,2764.02,,,2764.02,Other,215% New York Medicaid APG,1606.99,,,1606.99,Other,125% New York Medicaid APG,1285.59,54466.2,
Sympathectomy supfc palmar,64823,CPT,,,,,,,,both,,,68082.75,50381.24,74,,50381.24,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30637.24,45,,30637.24,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33700.96,49.5,,33700.96,percent of total billed charges,110% of Medicare,46296.27,68,,46296.27,percent of total billed charges,,2391.2,,,2391.2,Other,186% of Medicaid,54466.2,80,,54466.2,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,54466.2,80,,54466.2,percent of total billed charges,,7216,,,7216,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,47657.93,70,,47657.93,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1285.59,,,1285.59,Other,New York Medicaid APG methodology,1285.59,,,1285.59,Other,100% New York Medicaid APG,1285.59,,,1285.59,Other,100% New York Medicaid APG,1285.59,,,1285.59,Other,100% New York Medicaid APG,2892.58,,,2892.58,Other,225% New York Medicaid APG,1966.96,,,1966.96,Other,153% New York Medicaid APG,2892.58,,,2892.58,Other,225% New York Medicaid APG,1799.83,,,1799.83,Other,140% New York Medicaid APG,2892.58,,,2892.58,Other,225% New York Medicaid APG,3342.54,,,3342.54,Other,260% New York Medicaid APG,4165.32,,,4165.32,Other,324% New York Medicaid APG,2764.02,,,2764.02,Other,215% New York Medicaid APG,2764.02,,,2764.02,Other,215% New York Medicaid APG,1606.99,,,1606.99,Other,125% New York Medicaid APG,1285.59,54466.2,
Repair of digit nerve,64831,CPT,,,,,,,,both,,,39185.65,28997.38,74,,28997.38,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,17633.54,45,,17633.54,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,19396.9,49.5,,19396.9,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2391.2,,,2391.2,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,27429.96,70,,27429.96,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1285.59,,,1285.59,Other,New York Medicaid APG methodology,1285.59,,,1285.59,Other,100% New York Medicaid APG,1285.59,,,1285.59,Other,100% New York Medicaid APG,1285.59,,,1285.59,Other,100% New York Medicaid APG,2892.58,,,2892.58,Other,225% New York Medicaid APG,1966.96,,,1966.96,Other,153% New York Medicaid APG,2892.58,,,2892.58,Other,225% New York Medicaid APG,1799.83,,,1799.83,Other,140% New York Medicaid APG,2892.58,,,2892.58,Other,225% New York Medicaid APG,3342.54,,,3342.54,Other,260% New York Medicaid APG,4165.32,,,4165.32,Other,324% New York Medicaid APG,2764.02,,,2764.02,Other,215% New York Medicaid APG,2764.02,,,2764.02,Other,215% New York Medicaid APG,1606.99,,,1606.99,Other,125% New York Medicaid APG,1285.59,28997.38,
Repair nerve add-on,64832,CPT,,,,,,,,both,,,32432.1,23999.75,74,,23999.75,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,14594.45,45,,14594.45,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,16053.89,49.5,,16053.89,percent of total billed charges,110% of Medicare,22053.83,68,,22053.83,percent of total billed charges,,6048.62,,,6048.62,Other,186% of Medicaid,25945.68,80,,25945.68,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,25945.68,80,,25945.68,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,22702.47,70,,22702.47,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,3251.94,,,3251.94,Other,New York Medicaid APG methodology,3251.94,,,3251.94,Other,100% New York Medicaid APG,3251.94,,,3251.94,Other,100% New York Medicaid APG,3251.94,,,3251.94,Other,100% New York Medicaid APG,7316.87,,,7316.87,Other,225% New York Medicaid APG,4975.47,,,4975.47,Other,153% New York Medicaid APG,7316.87,,,7316.87,Other,225% New York Medicaid APG,4552.72,,,4552.72,Other,140% New York Medicaid APG,7316.87,,,7316.87,Other,225% New York Medicaid APG,8455.05,,,8455.05,Other,260% New York Medicaid APG,10536.3,,,10536.3,Other,324% New York Medicaid APG,6991.68,,,6991.68,Other,215% New York Medicaid APG,6991.68,,,6991.68,Other,215% New York Medicaid APG,4064.93,,,4064.93,Other,125% New York Medicaid APG,2053,25945.68,
Repair of hand or foot nerve,64834,CPT,,,,,,,,both,,,140115.1,103685.17,74,,103685.17,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,63051.8,45,,63051.8,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,69356.97,49.5,,69356.97,percent of total billed charges,110% of Medicare,95278.27,68,,95278.27,percent of total billed charges,,6048.62,,,6048.62,Other,186% of Medicaid,112092.08,80,,112092.08,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,112092.08,80,,112092.08,percent of total billed charges,,7216,,,7216,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,98080.57,70,,98080.57,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,3251.94,,,3251.94,Other,New York Medicaid APG methodology,3251.94,,,3251.94,Other,100% New York Medicaid APG,3251.94,,,3251.94,Other,100% New York Medicaid APG,3251.94,,,3251.94,Other,100% New York Medicaid APG,7316.87,,,7316.87,Other,225% New York Medicaid APG,4975.47,,,4975.47,Other,153% New York Medicaid APG,7316.87,,,7316.87,Other,225% New York Medicaid APG,4552.72,,,4552.72,Other,140% New York Medicaid APG,7316.87,,,7316.87,Other,225% New York Medicaid APG,8455.05,,,8455.05,Other,260% New York Medicaid APG,10536.3,,,10536.3,Other,324% New York Medicaid APG,6991.68,,,6991.68,Other,215% New York Medicaid APG,6991.68,,,6991.68,Other,215% New York Medicaid APG,4064.93,,,4064.93,Other,125% New York Medicaid APG,2232,112092.08,
Repair of hand or foot nerve,64835,CPT,,,,,,,,both,,,140115.1,103685.17,74,,103685.17,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,63051.8,45,,63051.8,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,69356.97,49.5,,69356.97,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,6048.62,,,6048.62,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,98080.57,70,,98080.57,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,3251.94,,,3251.94,Other,New York Medicaid APG methodology,3251.94,,,3251.94,Other,100% New York Medicaid APG,3251.94,,,3251.94,Other,100% New York Medicaid APG,3251.94,,,3251.94,Other,100% New York Medicaid APG,7316.87,,,7316.87,Other,225% New York Medicaid APG,4975.47,,,4975.47,Other,153% New York Medicaid APG,7316.87,,,7316.87,Other,225% New York Medicaid APG,4552.72,,,4552.72,Other,140% New York Medicaid APG,7316.87,,,7316.87,Other,225% New York Medicaid APG,8455.05,,,8455.05,Other,260% New York Medicaid APG,10536.3,,,10536.3,Other,324% New York Medicaid APG,6991.68,,,6991.68,Other,215% New York Medicaid APG,6991.68,,,6991.68,Other,215% New York Medicaid APG,4064.93,,,4064.93,Other,125% New York Medicaid APG,3126,103685.17,
Repair of hand or foot nerve,64836,CPT,,,,,,,,both,,,140115.1,103685.17,74,,103685.17,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,63051.8,45,,63051.8,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,69356.97,49.5,,69356.97,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,6048.62,,,6048.62,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,98080.57,70,,98080.57,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,3251.94,,,3251.94,Other,New York Medicaid APG methodology,3251.94,,,3251.94,Other,100% New York Medicaid APG,3251.94,,,3251.94,Other,100% New York Medicaid APG,3251.94,,,3251.94,Other,100% New York Medicaid APG,7316.87,,,7316.87,Other,225% New York Medicaid APG,4975.47,,,4975.47,Other,153% New York Medicaid APG,7316.87,,,7316.87,Other,225% New York Medicaid APG,4552.72,,,4552.72,Other,140% New York Medicaid APG,7316.87,,,7316.87,Other,225% New York Medicaid APG,8455.05,,,8455.05,Other,260% New York Medicaid APG,10536.3,,,10536.3,Other,324% New York Medicaid APG,6991.68,,,6991.68,Other,215% New York Medicaid APG,6991.68,,,6991.68,Other,215% New York Medicaid APG,4064.93,,,4064.93,Other,125% New York Medicaid APG,3126,103685.17,
Repair nerve add-on,64837,CPT,,,,,,,,both,,,32432.1,23999.75,74,,23999.75,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,14594.45,45,,14594.45,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,16053.89,49.5,,16053.89,percent of total billed charges,110% of Medicare,22053.83,68,,22053.83,percent of total billed charges,,6048.62,,,6048.62,Other,186% of Medicaid,25945.68,80,,25945.68,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,25945.68,80,,25945.68,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,22702.47,70,,22702.47,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,3251.94,,,3251.94,Other,New York Medicaid APG methodology,3251.94,,,3251.94,Other,100% New York Medicaid APG,3251.94,,,3251.94,Other,100% New York Medicaid APG,3251.94,,,3251.94,Other,100% New York Medicaid APG,7316.87,,,7316.87,Other,225% New York Medicaid APG,4975.47,,,4975.47,Other,153% New York Medicaid APG,7316.87,,,7316.87,Other,225% New York Medicaid APG,4552.72,,,4552.72,Other,140% New York Medicaid APG,7316.87,,,7316.87,Other,225% New York Medicaid APG,8455.05,,,8455.05,Other,260% New York Medicaid APG,10536.3,,,10536.3,Other,324% New York Medicaid APG,6991.68,,,6991.68,Other,215% New York Medicaid APG,6991.68,,,6991.68,Other,215% New York Medicaid APG,4064.93,,,4064.93,Other,125% New York Medicaid APG,2053,25945.68,
Repair of leg nerve,64840,CPT,,,,,,,,both,,,140115.1,103685.17,74,,103685.17,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,63051.8,45,,63051.8,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,69356.97,49.5,,69356.97,percent of total billed charges,110% of Medicare,95278.27,68,,95278.27,percent of total billed charges,,6048.62,,,6048.62,Other,186% of Medicaid,112092.08,80,,112092.08,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,112092.08,80,,112092.08,percent of total billed charges,,7216,,,7216,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,98080.57,70,,98080.57,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,3251.94,,,3251.94,Other,New York Medicaid APG methodology,3251.94,,,3251.94,Other,100% New York Medicaid APG,3251.94,,,3251.94,Other,100% New York Medicaid APG,3251.94,,,3251.94,Other,100% New York Medicaid APG,7316.87,,,7316.87,Other,225% New York Medicaid APG,4975.47,,,4975.47,Other,153% New York Medicaid APG,7316.87,,,7316.87,Other,225% New York Medicaid APG,4552.72,,,4552.72,Other,140% New York Medicaid APG,7316.87,,,7316.87,Other,225% New York Medicaid APG,8455.05,,,8455.05,Other,260% New York Medicaid APG,10536.3,,,10536.3,Other,324% New York Medicaid APG,6991.68,,,6991.68,Other,215% New York Medicaid APG,6991.68,,,6991.68,Other,215% New York Medicaid APG,4064.93,,,4064.93,Other,125% New York Medicaid APG,2232,112092.08,
Repair/transpose nerve,64856,CPT,,,,,,,,both,,,140115.1,103685.17,74,,103685.17,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,63051.8,45,,63051.8,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,69356.97,49.5,,69356.97,percent of total billed charges,110% of Medicare,95278.27,68,,95278.27,percent of total billed charges,,6048.62,,,6048.62,Other,186% of Medicaid,112092.08,80,,112092.08,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,112092.08,80,,112092.08,percent of total billed charges,,7216,,,7216,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,98080.57,70,,98080.57,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,3251.94,,,3251.94,Other,New York Medicaid APG methodology,3251.94,,,3251.94,Other,100% New York Medicaid APG,3251.94,,,3251.94,Other,100% New York Medicaid APG,3251.94,,,3251.94,Other,100% New York Medicaid APG,7316.87,,,7316.87,Other,225% New York Medicaid APG,4975.47,,,4975.47,Other,153% New York Medicaid APG,7316.87,,,7316.87,Other,225% New York Medicaid APG,4552.72,,,4552.72,Other,140% New York Medicaid APG,7316.87,,,7316.87,Other,225% New York Medicaid APG,8455.05,,,8455.05,Other,260% New York Medicaid APG,10536.3,,,10536.3,Other,324% New York Medicaid APG,6991.68,,,6991.68,Other,215% New York Medicaid APG,6991.68,,,6991.68,Other,215% New York Medicaid APG,4064.93,,,4064.93,Other,125% New York Medicaid APG,2232,112092.08,
Repair arm/leg nerve,64857,CPT,,,,,,,,both,,,140115.1,103685.17,74,,103685.17,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,63051.8,45,,63051.8,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,69356.97,49.5,,69356.97,percent of total billed charges,110% of Medicare,95278.27,68,,95278.27,percent of total billed charges,,6048.62,,,6048.62,Other,186% of Medicaid,112092.08,80,,112092.08,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,112092.08,80,,112092.08,percent of total billed charges,,7216,,,7216,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,98080.57,70,,98080.57,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,3251.94,,,3251.94,Other,New York Medicaid APG methodology,3251.94,,,3251.94,Other,100% New York Medicaid APG,3251.94,,,3251.94,Other,100% New York Medicaid APG,3251.94,,,3251.94,Other,100% New York Medicaid APG,7316.87,,,7316.87,Other,225% New York Medicaid APG,4975.47,,,4975.47,Other,153% New York Medicaid APG,7316.87,,,7316.87,Other,225% New York Medicaid APG,4552.72,,,4552.72,Other,140% New York Medicaid APG,7316.87,,,7316.87,Other,225% New York Medicaid APG,8455.05,,,8455.05,Other,260% New York Medicaid APG,10536.3,,,10536.3,Other,324% New York Medicaid APG,6991.68,,,6991.68,Other,215% New York Medicaid APG,6991.68,,,6991.68,Other,215% New York Medicaid APG,4064.93,,,4064.93,Other,125% New York Medicaid APG,2232,112092.08,
Repair sciatic nerve,64858,CPT,,,,,,,,both,,,40611.5,30052.51,74,,30052.51,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,18275.18,45,,18275.18,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,20102.69,49.5,,20102.69,percent of total billed charges,110% of Medicare,27615.82,68,,27615.82,percent of total billed charges,,6048.62,,,6048.62,Other,186% of Medicaid,32489.2,80,,32489.2,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,32489.2,80,,32489.2,percent of total billed charges,,7216,,,7216,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,28428.05,70,,28428.05,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,3251.94,,,3251.94,Other,New York Medicaid APG methodology,3251.94,,,3251.94,Other,100% New York Medicaid APG,3251.94,,,3251.94,Other,100% New York Medicaid APG,3251.94,,,3251.94,Other,100% New York Medicaid APG,7316.87,,,7316.87,Other,225% New York Medicaid APG,4975.47,,,4975.47,Other,153% New York Medicaid APG,7316.87,,,7316.87,Other,225% New York Medicaid APG,4552.72,,,4552.72,Other,140% New York Medicaid APG,7316.87,,,7316.87,Other,225% New York Medicaid APG,8455.05,,,8455.05,Other,260% New York Medicaid APG,10536.3,,,10536.3,Other,324% New York Medicaid APG,6991.68,,,6991.68,Other,215% New York Medicaid APG,6991.68,,,6991.68,Other,215% New York Medicaid APG,4064.93,,,4064.93,Other,125% New York Medicaid APG,2232,32489.2,
Nerve surgery,64859,CPT,,,,,,,,both,,,32432.1,23999.75,74,,23999.75,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,14594.45,45,,14594.45,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,16053.89,49.5,,16053.89,percent of total billed charges,110% of Medicare,22053.83,68,,22053.83,percent of total billed charges,,6048.62,,,6048.62,Other,186% of Medicaid,25945.68,80,,25945.68,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,25945.68,80,,25945.68,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,22702.47,70,,22702.47,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,3251.94,,,3251.94,Other,New York Medicaid APG methodology,3251.94,,,3251.94,Other,100% New York Medicaid APG,3251.94,,,3251.94,Other,100% New York Medicaid APG,3251.94,,,3251.94,Other,100% New York Medicaid APG,7316.87,,,7316.87,Other,225% New York Medicaid APG,4975.47,,,4975.47,Other,153% New York Medicaid APG,7316.87,,,7316.87,Other,225% New York Medicaid APG,4552.72,,,4552.72,Other,140% New York Medicaid APG,7316.87,,,7316.87,Other,225% New York Medicaid APG,8455.05,,,8455.05,Other,260% New York Medicaid APG,10536.3,,,10536.3,Other,324% New York Medicaid APG,6991.68,,,6991.68,Other,215% New York Medicaid APG,6991.68,,,6991.68,Other,215% New York Medicaid APG,4064.93,,,4064.93,Other,125% New York Medicaid APG,2053,25945.68,
Repair of arm nerves,64861,CPT,,,,,,,,both,,,40611.5,30052.51,74,,30052.51,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,18275.18,45,,18275.18,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,20102.69,49.5,,20102.69,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,6048.62,,,6048.62,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,28428.05,70,,28428.05,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,3251.94,,,3251.94,Other,New York Medicaid APG methodology,3251.94,,,3251.94,Other,100% New York Medicaid APG,3251.94,,,3251.94,Other,100% New York Medicaid APG,3251.94,,,3251.94,Other,100% New York Medicaid APG,7316.87,,,7316.87,Other,225% New York Medicaid APG,4975.47,,,4975.47,Other,153% New York Medicaid APG,7316.87,,,7316.87,Other,225% New York Medicaid APG,4552.72,,,4552.72,Other,140% New York Medicaid APG,7316.87,,,7316.87,Other,225% New York Medicaid APG,8455.05,,,8455.05,Other,260% New York Medicaid APG,10536.3,,,10536.3,Other,324% New York Medicaid APG,6991.68,,,6991.68,Other,215% New York Medicaid APG,6991.68,,,6991.68,Other,215% New York Medicaid APG,4064.93,,,4064.93,Other,125% New York Medicaid APG,3126,30052.51,
Repair of low back nerves,64862,CPT,,,,,,,,both,,,140115.1,103685.17,74,,103685.17,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,63051.8,45,,63051.8,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,69356.97,49.5,,69356.97,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,6048.62,,,6048.62,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,98080.57,70,,98080.57,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,3251.94,,,3251.94,Other,New York Medicaid APG methodology,3251.94,,,3251.94,Other,100% New York Medicaid APG,3251.94,,,3251.94,Other,100% New York Medicaid APG,3251.94,,,3251.94,Other,100% New York Medicaid APG,7316.87,,,7316.87,Other,225% New York Medicaid APG,4975.47,,,4975.47,Other,153% New York Medicaid APG,7316.87,,,7316.87,Other,225% New York Medicaid APG,4552.72,,,4552.72,Other,140% New York Medicaid APG,7316.87,,,7316.87,Other,225% New York Medicaid APG,8455.05,,,8455.05,Other,260% New York Medicaid APG,10536.3,,,10536.3,Other,324% New York Medicaid APG,6991.68,,,6991.68,Other,215% New York Medicaid APG,6991.68,,,6991.68,Other,215% New York Medicaid APG,4064.93,,,4064.93,Other,125% New York Medicaid APG,3126,103685.17,
Repair of facial nerve,64864,CPT,,,,,,,,both,,,140115.1,103685.17,74,,103685.17,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,63051.8,45,,63051.8,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,69356.97,49.5,,69356.97,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,6048.62,,,6048.62,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,98080.57,70,,98080.57,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,3251.94,,,3251.94,Other,New York Medicaid APG methodology,3251.94,,,3251.94,Other,100% New York Medicaid APG,3251.94,,,3251.94,Other,100% New York Medicaid APG,3251.94,,,3251.94,Other,100% New York Medicaid APG,7316.87,,,7316.87,Other,225% New York Medicaid APG,4975.47,,,4975.47,Other,153% New York Medicaid APG,7316.87,,,7316.87,Other,225% New York Medicaid APG,4552.72,,,4552.72,Other,140% New York Medicaid APG,7316.87,,,7316.87,Other,225% New York Medicaid APG,8455.05,,,8455.05,Other,260% New York Medicaid APG,10536.3,,,10536.3,Other,324% New York Medicaid APG,6991.68,,,6991.68,Other,215% New York Medicaid APG,6991.68,,,6991.68,Other,215% New York Medicaid APG,4064.93,,,4064.93,Other,125% New York Medicaid APG,3126,103685.17,
Repair of facial nerve,64865,CPT,,,,,,,,both,,,140115.1,103685.17,74,,103685.17,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,63051.8,45,,63051.8,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,69356.97,49.5,,69356.97,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,6048.62,,,6048.62,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,98080.57,70,,98080.57,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,3251.94,,,3251.94,Other,New York Medicaid APG methodology,3251.94,,,3251.94,Other,100% New York Medicaid APG,3251.94,,,3251.94,Other,100% New York Medicaid APG,3251.94,,,3251.94,Other,100% New York Medicaid APG,7316.87,,,7316.87,Other,225% New York Medicaid APG,4975.47,,,4975.47,Other,153% New York Medicaid APG,7316.87,,,7316.87,Other,225% New York Medicaid APG,4552.72,,,4552.72,Other,140% New York Medicaid APG,7316.87,,,7316.87,Other,225% New York Medicaid APG,8455.05,,,8455.05,Other,260% New York Medicaid APG,10536.3,,,10536.3,Other,324% New York Medicaid APG,6991.68,,,6991.68,Other,215% New York Medicaid APG,6991.68,,,6991.68,Other,215% New York Medicaid APG,4064.93,,,4064.93,Other,125% New York Medicaid APG,3251.94,103685.17,
Subsequent repair of nerve,64872,CPT,,,,,,,,both,,,51572.04,38163.31,74,,38163.31,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,23207.42,45,,23207.42,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,25528.16,49.5,,25528.16,percent of total billed charges,110% of Medicare,35068.99,68,,35068.99,percent of total billed charges,,6048.62,,,6048.62,Other,186% of Medicaid,41257.63,80,,41257.63,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,41257.63,80,,41257.63,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,36100.43,70,,36100.43,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,3251.94,,,3251.94,Other,New York Medicaid APG methodology,3251.94,,,3251.94,Other,100% New York Medicaid APG,3251.94,,,3251.94,Other,100% New York Medicaid APG,3251.94,,,3251.94,Other,100% New York Medicaid APG,7316.87,,,7316.87,Other,225% New York Medicaid APG,4975.47,,,4975.47,Other,153% New York Medicaid APG,7316.87,,,7316.87,Other,225% New York Medicaid APG,4552.72,,,4552.72,Other,140% New York Medicaid APG,7316.87,,,7316.87,Other,225% New York Medicaid APG,8455.05,,,8455.05,Other,260% New York Medicaid APG,10536.3,,,10536.3,Other,324% New York Medicaid APG,6991.68,,,6991.68,Other,215% New York Medicaid APG,6991.68,,,6991.68,Other,215% New York Medicaid APG,4064.93,,,4064.93,Other,125% New York Medicaid APG,2232,41257.63,
Repair & revise nerve add-on,64874,CPT,,,,,,,,both,,,64479.48,47714.82,74,,47714.82,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,29015.77,45,,29015.77,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,31917.34,49.5,,31917.34,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,6048.62,,,6048.62,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,45135.64,70,,45135.64,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,3251.94,,,3251.94,Other,New York Medicaid APG methodology,3251.94,,,3251.94,Other,100% New York Medicaid APG,3251.94,,,3251.94,Other,100% New York Medicaid APG,3251.94,,,3251.94,Other,100% New York Medicaid APG,7316.87,,,7316.87,Other,225% New York Medicaid APG,4975.47,,,4975.47,Other,153% New York Medicaid APG,7316.87,,,7316.87,Other,225% New York Medicaid APG,4552.72,,,4552.72,Other,140% New York Medicaid APG,7316.87,,,7316.87,Other,225% New York Medicaid APG,8455.05,,,8455.05,Other,260% New York Medicaid APG,10536.3,,,10536.3,Other,324% New York Medicaid APG,6991.68,,,6991.68,Other,215% New York Medicaid APG,6991.68,,,6991.68,Other,215% New York Medicaid APG,4064.93,,,4064.93,Other,125% New York Medicaid APG,2743,47714.82,
Repair nerve/shorten bone,64876,CPT,,,,,,,,both,,,64479.48,47714.82,74,,47714.82,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,29015.77,45,,29015.77,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,31917.34,49.5,,31917.34,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,6048.62,,,6048.62,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,45135.64,70,,45135.64,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,3251.94,,,3251.94,Other,New York Medicaid APG methodology,3251.94,,,3251.94,Other,100% New York Medicaid APG,3251.94,,,3251.94,Other,100% New York Medicaid APG,3251.94,,,3251.94,Other,100% New York Medicaid APG,7316.87,,,7316.87,Other,225% New York Medicaid APG,4975.47,,,4975.47,Other,153% New York Medicaid APG,7316.87,,,7316.87,Other,225% New York Medicaid APG,4552.72,,,4552.72,Other,140% New York Medicaid APG,7316.87,,,7316.87,Other,225% New York Medicaid APG,8455.05,,,8455.05,Other,260% New York Medicaid APG,10536.3,,,10536.3,Other,324% New York Medicaid APG,6991.68,,,6991.68,Other,215% New York Medicaid APG,6991.68,,,6991.68,Other,215% New York Medicaid APG,4064.93,,,4064.93,Other,125% New York Medicaid APG,2743,47714.82,
Nerve graft head/neck </4 cm,64885,CPT,,,,,,,,both,,,140115.1,103685.17,74,,103685.17,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,63051.8,45,,63051.8,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,69356.97,49.5,,69356.97,percent of total billed charges,110% of Medicare,95278.27,68,,95278.27,percent of total billed charges,,6048.62,,,6048.62,Other,186% of Medicaid,112092.08,80,,112092.08,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,112092.08,80,,112092.08,percent of total billed charges,,7216,,,7216,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,98080.57,70,,98080.57,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,3251.94,,,3251.94,Other,New York Medicaid APG methodology,3251.94,,,3251.94,Other,100% New York Medicaid APG,3251.94,,,3251.94,Other,100% New York Medicaid APG,3251.94,,,3251.94,Other,100% New York Medicaid APG,7316.87,,,7316.87,Other,225% New York Medicaid APG,4975.47,,,4975.47,Other,153% New York Medicaid APG,7316.87,,,7316.87,Other,225% New York Medicaid APG,4552.72,,,4552.72,Other,140% New York Medicaid APG,7316.87,,,7316.87,Other,225% New York Medicaid APG,8455.05,,,8455.05,Other,260% New York Medicaid APG,10536.3,,,10536.3,Other,324% New York Medicaid APG,6991.68,,,6991.68,Other,215% New York Medicaid APG,6991.68,,,6991.68,Other,215% New York Medicaid APG,4064.93,,,4064.93,Other,125% New York Medicaid APG,2232,112092.08,
Nerve graft head/neck >4 cm,64886,CPT,,,,,,,,both,,,86224.88,63806.41,74,,63806.41,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,38801.2,45,,38801.2,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,42681.32,49.5,,42681.32,percent of total billed charges,110% of Medicare,58632.92,68,,58632.92,percent of total billed charges,,6048.62,,,6048.62,Other,186% of Medicaid,68979.9,80,,68979.9,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,68979.9,80,,68979.9,percent of total billed charges,,7216,,,7216,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,60357.42,70,,60357.42,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,3251.94,,,3251.94,Other,New York Medicaid APG methodology,3251.94,,,3251.94,Other,100% New York Medicaid APG,3251.94,,,3251.94,Other,100% New York Medicaid APG,3251.94,,,3251.94,Other,100% New York Medicaid APG,7316.87,,,7316.87,Other,225% New York Medicaid APG,4975.47,,,4975.47,Other,153% New York Medicaid APG,7316.87,,,7316.87,Other,225% New York Medicaid APG,4552.72,,,4552.72,Other,140% New York Medicaid APG,7316.87,,,7316.87,Other,225% New York Medicaid APG,8455.05,,,8455.05,Other,260% New York Medicaid APG,10536.3,,,10536.3,Other,324% New York Medicaid APG,6991.68,,,6991.68,Other,215% New York Medicaid APG,6991.68,,,6991.68,Other,215% New York Medicaid APG,4064.93,,,4064.93,Other,125% New York Medicaid APG,2232,68979.9,
Nerve graft hand/foot </4 cm,64890,CPT,,,,,,,,both,,,140115.1,103685.17,74,,103685.17,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,63051.8,45,,63051.8,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,69356.97,49.5,,69356.97,percent of total billed charges,110% of Medicare,95278.27,68,,95278.27,percent of total billed charges,,6048.62,,,6048.62,Other,186% of Medicaid,112092.08,80,,112092.08,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,112092.08,80,,112092.08,percent of total billed charges,,7216,,,7216,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,98080.57,70,,98080.57,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,3251.94,,,3251.94,Other,New York Medicaid APG methodology,3251.94,,,3251.94,Other,100% New York Medicaid APG,3251.94,,,3251.94,Other,100% New York Medicaid APG,3251.94,,,3251.94,Other,100% New York Medicaid APG,7316.87,,,7316.87,Other,225% New York Medicaid APG,4975.47,,,4975.47,Other,153% New York Medicaid APG,7316.87,,,7316.87,Other,225% New York Medicaid APG,4552.72,,,4552.72,Other,140% New York Medicaid APG,7316.87,,,7316.87,Other,225% New York Medicaid APG,8455.05,,,8455.05,Other,260% New York Medicaid APG,10536.3,,,10536.3,Other,324% New York Medicaid APG,6991.68,,,6991.68,Other,215% New York Medicaid APG,6991.68,,,6991.68,Other,215% New York Medicaid APG,4064.93,,,4064.93,Other,125% New York Medicaid APG,2232,112092.08,
Nerve graft hand/foot >4 cm,64891,CPT,,,,,,,,both,,,140115.1,103685.17,74,,103685.17,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,63051.8,45,,63051.8,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,69356.97,49.5,,69356.97,percent of total billed charges,110% of Medicare,95278.27,68,,95278.27,percent of total billed charges,,6048.62,,,6048.62,Other,186% of Medicaid,112092.08,80,,112092.08,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,112092.08,80,,112092.08,percent of total billed charges,,7216,,,7216,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,98080.57,70,,98080.57,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,3251.94,,,3251.94,Other,New York Medicaid APG methodology,3251.94,,,3251.94,Other,100% New York Medicaid APG,3251.94,,,3251.94,Other,100% New York Medicaid APG,3251.94,,,3251.94,Other,100% New York Medicaid APG,7316.87,,,7316.87,Other,225% New York Medicaid APG,4975.47,,,4975.47,Other,153% New York Medicaid APG,7316.87,,,7316.87,Other,225% New York Medicaid APG,4552.72,,,4552.72,Other,140% New York Medicaid APG,7316.87,,,7316.87,Other,225% New York Medicaid APG,8455.05,,,8455.05,Other,260% New York Medicaid APG,10536.3,,,10536.3,Other,324% New York Medicaid APG,6991.68,,,6991.68,Other,215% New York Medicaid APG,6991.68,,,6991.68,Other,215% New York Medicaid APG,4064.93,,,4064.93,Other,125% New York Medicaid APG,2232,112092.08,
Nerve graft arm/leg <4 cm,64892,CPT,,,,,,,,both,,,140115.1,103685.17,74,,103685.17,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,63051.8,45,,63051.8,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,69356.97,49.5,,69356.97,percent of total billed charges,110% of Medicare,95278.27,68,,95278.27,percent of total billed charges,,6048.62,,,6048.62,Other,186% of Medicaid,112092.08,80,,112092.08,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,112092.08,80,,112092.08,percent of total billed charges,,7216,,,7216,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,98080.57,70,,98080.57,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,3251.94,,,3251.94,Other,New York Medicaid APG methodology,3251.94,,,3251.94,Other,100% New York Medicaid APG,3251.94,,,3251.94,Other,100% New York Medicaid APG,3251.94,,,3251.94,Other,100% New York Medicaid APG,7316.87,,,7316.87,Other,225% New York Medicaid APG,4975.47,,,4975.47,Other,153% New York Medicaid APG,7316.87,,,7316.87,Other,225% New York Medicaid APG,4552.72,,,4552.72,Other,140% New York Medicaid APG,7316.87,,,7316.87,Other,225% New York Medicaid APG,8455.05,,,8455.05,Other,260% New York Medicaid APG,10536.3,,,10536.3,Other,324% New York Medicaid APG,6991.68,,,6991.68,Other,215% New York Medicaid APG,6991.68,,,6991.68,Other,215% New York Medicaid APG,4064.93,,,4064.93,Other,125% New York Medicaid APG,2232,112092.08,
Nerve graft arm/leg >4 cm,64893,CPT,,,,,,,,both,,,60558.97,44813.64,74,,44813.64,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,27251.54,45,,27251.54,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,29976.69,49.5,,29976.69,percent of total billed charges,110% of Medicare,41180.1,68,,41180.1,percent of total billed charges,,6048.62,,,6048.62,Other,186% of Medicaid,48447.18,80,,48447.18,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,48447.18,80,,48447.18,percent of total billed charges,,7216,,,7216,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,42391.28,70,,42391.28,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,3251.94,,,3251.94,Other,New York Medicaid APG methodology,3251.94,,,3251.94,Other,100% New York Medicaid APG,3251.94,,,3251.94,Other,100% New York Medicaid APG,3251.94,,,3251.94,Other,100% New York Medicaid APG,7316.87,,,7316.87,Other,225% New York Medicaid APG,4975.47,,,4975.47,Other,153% New York Medicaid APG,7316.87,,,7316.87,Other,225% New York Medicaid APG,4552.72,,,4552.72,Other,140% New York Medicaid APG,7316.87,,,7316.87,Other,225% New York Medicaid APG,8455.05,,,8455.05,Other,260% New York Medicaid APG,10536.3,,,10536.3,Other,324% New York Medicaid APG,6991.68,,,6991.68,Other,215% New York Medicaid APG,6991.68,,,6991.68,Other,215% New York Medicaid APG,4064.93,,,4064.93,Other,125% New York Medicaid APG,2232,48447.18,
Nerve graft hand/foot </4 cm,64895,CPT,,,,,,,,both,,,140115.1,103685.17,74,,103685.17,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,63051.8,45,,63051.8,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,69356.97,49.5,,69356.97,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,6048.62,,,6048.62,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,98080.57,70,,98080.57,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,3251.94,,,3251.94,Other,New York Medicaid APG methodology,3251.94,,,3251.94,Other,100% New York Medicaid APG,3251.94,,,3251.94,Other,100% New York Medicaid APG,3251.94,,,3251.94,Other,100% New York Medicaid APG,7316.87,,,7316.87,Other,225% New York Medicaid APG,4975.47,,,4975.47,Other,153% New York Medicaid APG,7316.87,,,7316.87,Other,225% New York Medicaid APG,4552.72,,,4552.72,Other,140% New York Medicaid APG,7316.87,,,7316.87,Other,225% New York Medicaid APG,8455.05,,,8455.05,Other,260% New York Medicaid APG,10536.3,,,10536.3,Other,324% New York Medicaid APG,6991.68,,,6991.68,Other,215% New York Medicaid APG,6991.68,,,6991.68,Other,215% New York Medicaid APG,4064.93,,,4064.93,Other,125% New York Medicaid APG,3126,103685.17,
Nerve graft hand/foot >4 cm,64896,CPT,,,,,,,,both,,,140115.1,103685.17,74,,103685.17,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,63051.8,45,,63051.8,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,69356.97,49.5,,69356.97,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,6048.62,,,6048.62,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,98080.57,70,,98080.57,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,3251.94,,,3251.94,Other,New York Medicaid APG methodology,3251.94,,,3251.94,Other,100% New York Medicaid APG,3251.94,,,3251.94,Other,100% New York Medicaid APG,3251.94,,,3251.94,Other,100% New York Medicaid APG,7316.87,,,7316.87,Other,225% New York Medicaid APG,4975.47,,,4975.47,Other,153% New York Medicaid APG,7316.87,,,7316.87,Other,225% New York Medicaid APG,4552.72,,,4552.72,Other,140% New York Medicaid APG,7316.87,,,7316.87,Other,225% New York Medicaid APG,8455.05,,,8455.05,Other,260% New York Medicaid APG,10536.3,,,10536.3,Other,324% New York Medicaid APG,6991.68,,,6991.68,Other,215% New York Medicaid APG,6991.68,,,6991.68,Other,215% New York Medicaid APG,4064.93,,,4064.93,Other,125% New York Medicaid APG,3126,103685.17,
Nerve graft arm/leg </4 cm,64897,CPT,,,,,,,,both,,,140115.1,103685.17,74,,103685.17,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,63051.8,45,,63051.8,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,69356.97,49.5,,69356.97,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,6048.62,,,6048.62,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,98080.57,70,,98080.57,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,3251.94,,,3251.94,Other,New York Medicaid APG methodology,3251.94,,,3251.94,Other,100% New York Medicaid APG,3251.94,,,3251.94,Other,100% New York Medicaid APG,3251.94,,,3251.94,Other,100% New York Medicaid APG,7316.87,,,7316.87,Other,225% New York Medicaid APG,4975.47,,,4975.47,Other,153% New York Medicaid APG,7316.87,,,7316.87,Other,225% New York Medicaid APG,4552.72,,,4552.72,Other,140% New York Medicaid APG,7316.87,,,7316.87,Other,225% New York Medicaid APG,8455.05,,,8455.05,Other,260% New York Medicaid APG,10536.3,,,10536.3,Other,324% New York Medicaid APG,6991.68,,,6991.68,Other,215% New York Medicaid APG,6991.68,,,6991.68,Other,215% New York Medicaid APG,4064.93,,,4064.93,Other,125% New York Medicaid APG,3126,103685.17,
Nerve graft arm/leg >4 cm,64898,CPT,,,,,,,,both,,,140115.1,103685.17,74,,103685.17,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,63051.8,45,,63051.8,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,69356.97,49.5,,69356.97,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,6048.62,,,6048.62,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,98080.57,70,,98080.57,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,3251.94,,,3251.94,Other,New York Medicaid APG methodology,3251.94,,,3251.94,Other,100% New York Medicaid APG,3251.94,,,3251.94,Other,100% New York Medicaid APG,3251.94,,,3251.94,Other,100% New York Medicaid APG,7316.87,,,7316.87,Other,225% New York Medicaid APG,4975.47,,,4975.47,Other,153% New York Medicaid APG,7316.87,,,7316.87,Other,225% New York Medicaid APG,4552.72,,,4552.72,Other,140% New York Medicaid APG,7316.87,,,7316.87,Other,225% New York Medicaid APG,8455.05,,,8455.05,Other,260% New York Medicaid APG,10536.3,,,10536.3,Other,324% New York Medicaid APG,6991.68,,,6991.68,Other,215% New York Medicaid APG,6991.68,,,6991.68,Other,215% New York Medicaid APG,4064.93,,,4064.93,Other,125% New York Medicaid APG,3126,103685.17,
Nerve graft add-on,64901,CPT,,,,,,,,both,,,51572.04,38163.31,74,,38163.31,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,23207.42,45,,23207.42,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,25528.16,49.5,,25528.16,percent of total billed charges,110% of Medicare,35068.99,68,,35068.99,percent of total billed charges,,6048.62,,,6048.62,Other,186% of Medicaid,41257.63,80,,41257.63,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,41257.63,80,,41257.63,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,36100.43,70,,36100.43,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,3251.94,,,3251.94,Other,New York Medicaid APG methodology,3251.94,,,3251.94,Other,100% New York Medicaid APG,3251.94,,,3251.94,Other,100% New York Medicaid APG,3251.94,,,3251.94,Other,100% New York Medicaid APG,7316.87,,,7316.87,Other,225% New York Medicaid APG,4975.47,,,4975.47,Other,153% New York Medicaid APG,7316.87,,,7316.87,Other,225% New York Medicaid APG,4552.72,,,4552.72,Other,140% New York Medicaid APG,7316.87,,,7316.87,Other,225% New York Medicaid APG,8455.05,,,8455.05,Other,260% New York Medicaid APG,10536.3,,,10536.3,Other,324% New York Medicaid APG,6991.68,,,6991.68,Other,215% New York Medicaid APG,6991.68,,,6991.68,Other,215% New York Medicaid APG,4064.93,,,4064.93,Other,125% New York Medicaid APG,2232,41257.63,
Nerve graft add-on,64902,CPT,,,,,,,,both,,,51572.04,38163.31,74,,38163.31,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,23207.42,45,,23207.42,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,25528.16,49.5,,25528.16,percent of total billed charges,110% of Medicare,35068.99,68,,35068.99,percent of total billed charges,,6048.62,,,6048.62,Other,186% of Medicaid,41257.63,80,,41257.63,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,41257.63,80,,41257.63,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,36100.43,70,,36100.43,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,3251.94,,,3251.94,Other,New York Medicaid APG methodology,3251.94,,,3251.94,Other,100% New York Medicaid APG,3251.94,,,3251.94,Other,100% New York Medicaid APG,3251.94,,,3251.94,Other,100% New York Medicaid APG,7316.87,,,7316.87,Other,225% New York Medicaid APG,4975.47,,,4975.47,Other,153% New York Medicaid APG,7316.87,,,7316.87,Other,225% New York Medicaid APG,4552.72,,,4552.72,Other,140% New York Medicaid APG,7316.87,,,7316.87,Other,225% New York Medicaid APG,8455.05,,,8455.05,Other,260% New York Medicaid APG,10536.3,,,10536.3,Other,324% New York Medicaid APG,6991.68,,,6991.68,Other,215% New York Medicaid APG,6991.68,,,6991.68,Other,215% New York Medicaid APG,4064.93,,,4064.93,Other,125% New York Medicaid APG,2232,41257.63,
Nerve pedicle transfer,64905,CPT,,,,,,,,both,,,143860.38,106456.68,74,,106456.68,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,64737.17,45,,64737.17,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,71210.89,49.5,,71210.89,percent of total billed charges,110% of Medicare,97825.06,68,,97825.06,percent of total billed charges,,6048.62,,,6048.62,Other,186% of Medicaid,115088.3,80,,115088.3,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,115088.3,80,,115088.3,percent of total billed charges,,7216,,,7216,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,100702.27,70,,100702.27,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,3251.94,,,3251.94,Other,New York Medicaid APG methodology,3251.94,,,3251.94,Other,100% New York Medicaid APG,3251.94,,,3251.94,Other,100% New York Medicaid APG,3251.94,,,3251.94,Other,100% New York Medicaid APG,7316.87,,,7316.87,Other,225% New York Medicaid APG,4975.47,,,4975.47,Other,153% New York Medicaid APG,7316.87,,,7316.87,Other,225% New York Medicaid APG,4552.72,,,4552.72,Other,140% New York Medicaid APG,7316.87,,,7316.87,Other,225% New York Medicaid APG,8455.05,,,8455.05,Other,260% New York Medicaid APG,10536.3,,,10536.3,Other,324% New York Medicaid APG,6991.68,,,6991.68,Other,215% New York Medicaid APG,6991.68,,,6991.68,Other,215% New York Medicaid APG,4064.93,,,4064.93,Other,125% New York Medicaid APG,2232,115088.3,
Nerve pedicle transfer,64907,CPT,,,,,,,,both,,,140115.1,103685.17,74,,103685.17,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,63051.8,45,,63051.8,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,69356.97,49.5,,69356.97,percent of total billed charges,110% of Medicare,95278.27,68,,95278.27,percent of total billed charges,,6048.62,,,6048.62,Other,186% of Medicaid,112092.08,80,,112092.08,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,112092.08,80,,112092.08,percent of total billed charges,,7216,,,7216,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,98080.57,70,,98080.57,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,3251.94,,,3251.94,Other,New York Medicaid APG methodology,3251.94,,,3251.94,Other,100% New York Medicaid APG,3251.94,,,3251.94,Other,100% New York Medicaid APG,3251.94,,,3251.94,Other,100% New York Medicaid APG,7316.87,,,7316.87,Other,225% New York Medicaid APG,4975.47,,,4975.47,Other,153% New York Medicaid APG,7316.87,,,7316.87,Other,225% New York Medicaid APG,4552.72,,,4552.72,Other,140% New York Medicaid APG,7316.87,,,7316.87,Other,225% New York Medicaid APG,8455.05,,,8455.05,Other,260% New York Medicaid APG,10536.3,,,10536.3,Other,324% New York Medicaid APG,6991.68,,,6991.68,Other,215% New York Medicaid APG,6991.68,,,6991.68,Other,215% New York Medicaid APG,4064.93,,,4064.93,Other,125% New York Medicaid APG,2053,112092.08,
Nerve repair w/allograft,64910,CPT,,,,,,,,both,,,59519.34,44044.31,74,,44044.31,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,26783.7,45,,26783.7,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,29462.07,49.5,,29462.07,percent of total billed charges,110% of Medicare,40473.15,68,,40473.15,percent of total billed charges,,6048.62,,,6048.62,Other,186% of Medicaid,47615.47,80,,47615.47,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,47615.47,80,,47615.47,percent of total billed charges,,7216,,,7216,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,41663.54,70,,41663.54,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,3251.94,,,3251.94,Other,New York Medicaid APG methodology,3251.94,,,3251.94,Other,100% New York Medicaid APG,3251.94,,,3251.94,Other,100% New York Medicaid APG,3251.94,,,3251.94,Other,100% New York Medicaid APG,7316.87,,,7316.87,Other,225% New York Medicaid APG,4975.47,,,4975.47,Other,153% New York Medicaid APG,7316.87,,,7316.87,Other,225% New York Medicaid APG,4552.72,,,4552.72,Other,140% New York Medicaid APG,7316.87,,,7316.87,Other,225% New York Medicaid APG,8455.05,,,8455.05,Other,260% New York Medicaid APG,10536.3,,,10536.3,Other,324% New York Medicaid APG,6991.68,,,6991.68,Other,215% New York Medicaid APG,6991.68,,,6991.68,Other,215% New York Medicaid APG,4064.93,,,4064.93,Other,125% New York Medicaid APG,2232,47615.47,
Neurorraphy w/vein autograft,64911,CPT,,,,,,,,both,,,140115.1,103685.17,74,,103685.17,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,63051.8,45,,63051.8,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,69356.97,49.5,,69356.97,percent of total billed charges,110% of Medicare,95278.27,68,,95278.27,percent of total billed charges,,6048.62,,,6048.62,Other,186% of Medicaid,112092.08,80,,112092.08,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,112092.08,80,,112092.08,percent of total billed charges,,7216,,,7216,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,98080.57,70,,98080.57,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,3251.94,,,3251.94,Other,New York Medicaid APG methodology,3251.94,,,3251.94,Other,100% New York Medicaid APG,3251.94,,,3251.94,Other,100% New York Medicaid APG,3251.94,,,3251.94,Other,100% New York Medicaid APG,7316.87,,,7316.87,Other,225% New York Medicaid APG,4975.47,,,4975.47,Other,153% New York Medicaid APG,7316.87,,,7316.87,Other,225% New York Medicaid APG,4552.72,,,4552.72,Other,140% New York Medicaid APG,7316.87,,,7316.87,Other,225% New York Medicaid APG,8455.05,,,8455.05,Other,260% New York Medicaid APG,10536.3,,,10536.3,Other,324% New York Medicaid APG,6991.68,,,6991.68,Other,215% New York Medicaid APG,6991.68,,,6991.68,Other,215% New York Medicaid APG,4064.93,,,4064.93,Other,125% New York Medicaid APG,2232,112092.08,
Nrv rpr w/nrv algrft 1st,64912,CPT,,,,,,,,both,,,124326.97,92001.96,74,,92001.96,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,55947.14,45,,55947.14,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,61541.85,49.5,,61541.85,percent of total billed charges,110% of Medicare,84542.34,68,,84542.34,percent of total billed charges,,6048.62,,,6048.62,Other,186% of Medicaid,99461.58,80,,99461.58,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,99461.58,80,,99461.58,percent of total billed charges,,7216,,,7216,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,87028.88,70,,87028.88,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,3251.94,,,3251.94,Other,New York Medicaid APG methodology,3251.94,,,3251.94,Other,100% New York Medicaid APG,3251.94,,,3251.94,Other,100% New York Medicaid APG,3251.94,,,3251.94,Other,100% New York Medicaid APG,7316.87,,,7316.87,Other,225% New York Medicaid APG,4975.47,,,4975.47,Other,153% New York Medicaid APG,7316.87,,,7316.87,Other,225% New York Medicaid APG,4552.72,,,4552.72,Other,140% New York Medicaid APG,7316.87,,,7316.87,Other,225% New York Medicaid APG,8455.05,,,8455.05,Other,260% New York Medicaid APG,10536.3,,,10536.3,Other,324% New York Medicaid APG,6991.68,,,6991.68,Other,215% New York Medicaid APG,6991.68,,,6991.68,Other,215% New York Medicaid APG,4064.93,,,4064.93,Other,125% New York Medicaid APG,2232,99461.58,
Nrv rpr w/nrv algrft ea addl,64913,CPT,,,,,,,,both,,,51572.04,38163.31,74,,38163.31,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,23207.42,45,,23207.42,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,25528.16,49.5,,25528.16,percent of total billed charges,110% of Medicare,35068.99,68,,35068.99,percent of total billed charges,,6048.62,,,6048.62,Other,186% of Medicaid,41257.63,80,,41257.63,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,41257.63,80,,41257.63,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,36100.43,70,,36100.43,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,3251.94,,,3251.94,Other,New York Medicaid APG methodology,3251.94,,,3251.94,Other,100% New York Medicaid APG,3251.94,,,3251.94,Other,100% New York Medicaid APG,3251.94,,,3251.94,Other,100% New York Medicaid APG,7316.87,,,7316.87,Other,225% New York Medicaid APG,4975.47,,,4975.47,Other,153% New York Medicaid APG,7316.87,,,7316.87,Other,225% New York Medicaid APG,4552.72,,,4552.72,Other,140% New York Medicaid APG,7316.87,,,7316.87,Other,225% New York Medicaid APG,8455.05,,,8455.05,Other,260% New York Medicaid APG,10536.3,,,10536.3,Other,324% New York Medicaid APG,6991.68,,,6991.68,Other,215% New York Medicaid APG,6991.68,,,6991.68,Other,215% New York Medicaid APG,4064.93,,,4064.93,Other,125% New York Medicaid APG,2053,41257.63,
Revise eye,65091,CPT,,,,,,,,both,,,39067.66,28910.07,74,,28910.07,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,17580.45,45,,17580.45,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,19338.49,49.5,,19338.49,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3349.26,,,3349.26,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,27347.36,70,,27347.36,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1800.68,,,1800.68,Other,New York Medicaid APG methodology,1800.68,,,1800.68,Other,100% New York Medicaid APG,1800.68,,,1800.68,Other,100% New York Medicaid APG,1800.68,,,1800.68,Other,100% New York Medicaid APG,4051.52,,,4051.52,Other,225% New York Medicaid APG,2755.03,,,2755.03,Other,153% New York Medicaid APG,4051.52,,,4051.52,Other,225% New York Medicaid APG,2520.95,,,2520.95,Other,140% New York Medicaid APG,4051.52,,,4051.52,Other,225% New York Medicaid APG,4681.76,,,4681.76,Other,260% New York Medicaid APG,5834.19,,,5834.19,Other,324% New York Medicaid APG,3871.45,,,3871.45,Other,215% New York Medicaid APG,3871.45,,,3871.45,Other,215% New York Medicaid APG,2250.84,,,2250.84,Other,125% New York Medicaid APG,1800.68,28910.07,
Revise eye with implant,65093,CPT,,,,,,,,both,,,81324.54,60180.16,74,,60180.16,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,36596.04,45,,36596.04,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,40255.65,49.5,,40255.65,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3349.26,,,3349.26,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,56927.18,70,,56927.18,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1800.68,,,1800.68,Other,New York Medicaid APG methodology,1800.68,,,1800.68,Other,100% New York Medicaid APG,1800.68,,,1800.68,Other,100% New York Medicaid APG,1800.68,,,1800.68,Other,100% New York Medicaid APG,4051.52,,,4051.52,Other,225% New York Medicaid APG,2755.03,,,2755.03,Other,153% New York Medicaid APG,4051.52,,,4051.52,Other,225% New York Medicaid APG,2520.95,,,2520.95,Other,140% New York Medicaid APG,4051.52,,,4051.52,Other,225% New York Medicaid APG,4681.76,,,4681.76,Other,260% New York Medicaid APG,5834.19,,,5834.19,Other,324% New York Medicaid APG,3871.45,,,3871.45,Other,215% New York Medicaid APG,3871.45,,,3871.45,Other,215% New York Medicaid APG,2250.84,,,2250.84,Other,125% New York Medicaid APG,1800.68,60180.16,
Removal of eye,65101,CPT,,,,,,,,both,,,81324.54,60180.16,74,,60180.16,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,36596.04,45,,36596.04,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,40255.65,49.5,,40255.65,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3349.26,,,3349.26,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,56927.18,70,,56927.18,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1800.68,,,1800.68,Other,New York Medicaid APG methodology,1800.68,,,1800.68,Other,100% New York Medicaid APG,1800.68,,,1800.68,Other,100% New York Medicaid APG,1800.68,,,1800.68,Other,100% New York Medicaid APG,4051.52,,,4051.52,Other,225% New York Medicaid APG,2755.03,,,2755.03,Other,153% New York Medicaid APG,4051.52,,,4051.52,Other,225% New York Medicaid APG,2520.95,,,2520.95,Other,140% New York Medicaid APG,4051.52,,,4051.52,Other,225% New York Medicaid APG,4681.76,,,4681.76,Other,260% New York Medicaid APG,5834.19,,,5834.19,Other,324% New York Medicaid APG,3871.45,,,3871.45,Other,215% New York Medicaid APG,3871.45,,,3871.45,Other,215% New York Medicaid APG,2250.84,,,2250.84,Other,125% New York Medicaid APG,1800.68,60180.16,
Remove eye/insert implant,65103,CPT,,,,,,,,both,,,49058.26,36303.11,74,,36303.11,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,22076.22,45,,22076.22,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,24283.84,49.5,,24283.84,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3349.26,,,3349.26,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,34340.78,70,,34340.78,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1800.68,,,1800.68,Other,New York Medicaid APG methodology,1800.68,,,1800.68,Other,100% New York Medicaid APG,1800.68,,,1800.68,Other,100% New York Medicaid APG,1800.68,,,1800.68,Other,100% New York Medicaid APG,4051.52,,,4051.52,Other,225% New York Medicaid APG,2755.03,,,2755.03,Other,153% New York Medicaid APG,4051.52,,,4051.52,Other,225% New York Medicaid APG,2520.95,,,2520.95,Other,140% New York Medicaid APG,4051.52,,,4051.52,Other,225% New York Medicaid APG,4681.76,,,4681.76,Other,260% New York Medicaid APG,5834.19,,,5834.19,Other,324% New York Medicaid APG,3871.45,,,3871.45,Other,215% New York Medicaid APG,3871.45,,,3871.45,Other,215% New York Medicaid APG,2250.84,,,2250.84,Other,125% New York Medicaid APG,1800.68,36303.11,
Remove eye/attach implant,65105,CPT,,,,,,,,both,,,55881.02,41351.95,74,,41351.95,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,25146.46,45,,25146.46,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,27661.1,49.5,,27661.1,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3349.26,,,3349.26,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,39116.71,70,,39116.71,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1800.68,,,1800.68,Other,New York Medicaid APG methodology,1800.68,,,1800.68,Other,100% New York Medicaid APG,1800.68,,,1800.68,Other,100% New York Medicaid APG,1800.68,,,1800.68,Other,100% New York Medicaid APG,4051.52,,,4051.52,Other,225% New York Medicaid APG,2755.03,,,2755.03,Other,153% New York Medicaid APG,4051.52,,,4051.52,Other,225% New York Medicaid APG,2520.95,,,2520.95,Other,140% New York Medicaid APG,4051.52,,,4051.52,Other,225% New York Medicaid APG,4681.76,,,4681.76,Other,260% New York Medicaid APG,5834.19,,,5834.19,Other,324% New York Medicaid APG,3871.45,,,3871.45,Other,215% New York Medicaid APG,3871.45,,,3871.45,Other,215% New York Medicaid APG,2250.84,,,2250.84,Other,125% New York Medicaid APG,1800.68,41351.95,
Removal of eye,65110,CPT,,,,,,,,both,,,81324.54,60180.16,74,,60180.16,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,36596.04,45,,36596.04,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,40255.65,49.5,,40255.65,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3349.26,,,3349.26,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,56927.18,70,,56927.18,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1800.68,,,1800.68,Other,New York Medicaid APG methodology,1800.68,,,1800.68,Other,100% New York Medicaid APG,1800.68,,,1800.68,Other,100% New York Medicaid APG,1800.68,,,1800.68,Other,100% New York Medicaid APG,4051.52,,,4051.52,Other,225% New York Medicaid APG,2755.03,,,2755.03,Other,153% New York Medicaid APG,4051.52,,,4051.52,Other,225% New York Medicaid APG,2520.95,,,2520.95,Other,140% New York Medicaid APG,4051.52,,,4051.52,Other,225% New York Medicaid APG,4681.76,,,4681.76,Other,260% New York Medicaid APG,5834.19,,,5834.19,Other,324% New York Medicaid APG,3871.45,,,3871.45,Other,215% New York Medicaid APG,3871.45,,,3871.45,Other,215% New York Medicaid APG,2250.84,,,2250.84,Other,125% New York Medicaid APG,1800.68,60180.16,
Remove eye/revise socket,65112,CPT,,,,,,,,both,,,81324.54,60180.16,74,,60180.16,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,36596.04,45,,36596.04,percent of total billed charges,Medicare Ratio of cost to charges,5954,,"100% primary, 50% supplemental procedure",5954,Other,Aetna ASC Grouper,5359,,"100% primary, 50% supplemental procedure",5359,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,40255.65,49.5,,40255.65,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3349.26,,,3349.26,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,56927.18,70,,56927.18,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1800.68,,,1800.68,Other,New York Medicaid APG methodology,1800.68,,,1800.68,Other,100% New York Medicaid APG,1800.68,,,1800.68,Other,100% New York Medicaid APG,1800.68,,,1800.68,Other,100% New York Medicaid APG,4051.52,,,4051.52,Other,225% New York Medicaid APG,2755.03,,,2755.03,Other,153% New York Medicaid APG,4051.52,,,4051.52,Other,225% New York Medicaid APG,2520.95,,,2520.95,Other,140% New York Medicaid APG,4051.52,,,4051.52,Other,225% New York Medicaid APG,4681.76,,,4681.76,Other,260% New York Medicaid APG,5834.19,,,5834.19,Other,324% New York Medicaid APG,3871.45,,,3871.45,Other,215% New York Medicaid APG,3871.45,,,3871.45,Other,215% New York Medicaid APG,2250.84,,,2250.84,Other,125% New York Medicaid APG,1800.68,60180.16,
Remove eye/revise socket,65114,CPT,,,,,,,,both,,,81324.54,60180.16,74,,60180.16,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,36596.04,45,,36596.04,percent of total billed charges,Medicare Ratio of cost to charges,5954,,"100% primary, 50% supplemental procedure",5954,Other,Aetna ASC Grouper,5359,,"100% primary, 50% supplemental procedure",5359,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,40255.65,49.5,,40255.65,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3349.26,,,3349.26,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,56927.18,70,,56927.18,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1800.68,,,1800.68,Other,New York Medicaid APG methodology,1800.68,,,1800.68,Other,100% New York Medicaid APG,1800.68,,,1800.68,Other,100% New York Medicaid APG,1800.68,,,1800.68,Other,100% New York Medicaid APG,4051.52,,,4051.52,Other,225% New York Medicaid APG,2755.03,,,2755.03,Other,153% New York Medicaid APG,4051.52,,,4051.52,Other,225% New York Medicaid APG,2520.95,,,2520.95,Other,140% New York Medicaid APG,4051.52,,,4051.52,Other,225% New York Medicaid APG,4681.76,,,4681.76,Other,260% New York Medicaid APG,5834.19,,,5834.19,Other,324% New York Medicaid APG,3871.45,,,3871.45,Other,215% New York Medicaid APG,3871.45,,,3871.45,Other,215% New York Medicaid APG,2250.84,,,2250.84,Other,125% New York Medicaid APG,1800.68,60180.16,
Revise ocular implant,65125,CPT,,,,,,,,both,,,49151.56,36372.15,74,,36372.15,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,22118.2,45,,22118.2,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,24330.02,49.5,,24330.02,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3349.26,,,3349.26,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,34406.09,70,,34406.09,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1800.68,,,1800.68,Other,New York Medicaid APG methodology,1800.68,,,1800.68,Other,100% New York Medicaid APG,1800.68,,,1800.68,Other,100% New York Medicaid APG,1800.68,,,1800.68,Other,100% New York Medicaid APG,4051.52,,,4051.52,Other,225% New York Medicaid APG,2755.03,,,2755.03,Other,153% New York Medicaid APG,4051.52,,,4051.52,Other,225% New York Medicaid APG,2520.95,,,2520.95,Other,140% New York Medicaid APG,4051.52,,,4051.52,Other,225% New York Medicaid APG,4681.76,,,4681.76,Other,260% New York Medicaid APG,5834.19,,,5834.19,Other,324% New York Medicaid APG,3871.45,,,3871.45,Other,215% New York Medicaid APG,3871.45,,,3871.45,Other,215% New York Medicaid APG,2250.84,,,2250.84,Other,125% New York Medicaid APG,1800.68,36372.15,
Insert ocular implant,65130,CPT,,,,,,,,both,,,81324.54,60180.16,74,,60180.16,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,36596.04,45,,36596.04,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,40255.65,49.5,,40255.65,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3349.26,,,3349.26,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,56927.18,70,,56927.18,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1800.68,,,1800.68,Other,New York Medicaid APG methodology,1800.68,,,1800.68,Other,100% New York Medicaid APG,1800.68,,,1800.68,Other,100% New York Medicaid APG,1800.68,,,1800.68,Other,100% New York Medicaid APG,4051.52,,,4051.52,Other,225% New York Medicaid APG,2755.03,,,2755.03,Other,153% New York Medicaid APG,4051.52,,,4051.52,Other,225% New York Medicaid APG,2520.95,,,2520.95,Other,140% New York Medicaid APG,4051.52,,,4051.52,Other,225% New York Medicaid APG,4681.76,,,4681.76,Other,260% New York Medicaid APG,5834.19,,,5834.19,Other,324% New York Medicaid APG,3871.45,,,3871.45,Other,215% New York Medicaid APG,3871.45,,,3871.45,Other,215% New York Medicaid APG,2250.84,,,2250.84,Other,125% New York Medicaid APG,1800.68,60180.16,
Insert ocular implant,65135,CPT,,,,,,,,both,,,81324.54,60180.16,74,,60180.16,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,36596.04,45,,36596.04,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,40255.65,49.5,,40255.65,percent of total billed charges,110% of Medicare,55300.69,68,,55300.69,percent of total billed charges,,3349.26,,,3349.26,Other,186% of Medicaid,65059.63,80,,65059.63,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,65059.63,80,,65059.63,percent of total billed charges,,7216,,,7216,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,56927.18,70,,56927.18,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1800.68,,,1800.68,Other,New York Medicaid APG methodology,1800.68,,,1800.68,Other,100% New York Medicaid APG,1800.68,,,1800.68,Other,100% New York Medicaid APG,1800.68,,,1800.68,Other,100% New York Medicaid APG,4051.52,,,4051.52,Other,225% New York Medicaid APG,2755.03,,,2755.03,Other,153% New York Medicaid APG,4051.52,,,4051.52,Other,225% New York Medicaid APG,2520.95,,,2520.95,Other,140% New York Medicaid APG,4051.52,,,4051.52,Other,225% New York Medicaid APG,4681.76,,,4681.76,Other,260% New York Medicaid APG,5834.19,,,5834.19,Other,324% New York Medicaid APG,3871.45,,,3871.45,Other,215% New York Medicaid APG,3871.45,,,3871.45,Other,215% New York Medicaid APG,2250.84,,,2250.84,Other,125% New York Medicaid APG,1800.68,65059.63,
Attach ocular implant,65140,CPT,,,,,,,,both,,,81324.54,60180.16,74,,60180.16,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,36596.04,45,,36596.04,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,40255.65,49.5,,40255.65,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3349.26,,,3349.26,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,56927.18,70,,56927.18,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1800.68,,,1800.68,Other,New York Medicaid APG methodology,1800.68,,,1800.68,Other,100% New York Medicaid APG,1800.68,,,1800.68,Other,100% New York Medicaid APG,1800.68,,,1800.68,Other,100% New York Medicaid APG,4051.52,,,4051.52,Other,225% New York Medicaid APG,2755.03,,,2755.03,Other,153% New York Medicaid APG,4051.52,,,4051.52,Other,225% New York Medicaid APG,2520.95,,,2520.95,Other,140% New York Medicaid APG,4051.52,,,4051.52,Other,225% New York Medicaid APG,4681.76,,,4681.76,Other,260% New York Medicaid APG,5834.19,,,5834.19,Other,324% New York Medicaid APG,3871.45,,,3871.45,Other,215% New York Medicaid APG,3871.45,,,3871.45,Other,215% New York Medicaid APG,2250.84,,,2250.84,Other,125% New York Medicaid APG,1800.68,60180.16,
Revise ocular implant,65150,CPT,,,,,,,,both,,,81324.54,60180.16,74,,60180.16,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,36596.04,45,,36596.04,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,40255.65,49.5,,40255.65,percent of total billed charges,110% of Medicare,55300.69,68,,55300.69,percent of total billed charges,,3349.26,,,3349.26,Other,186% of Medicaid,65059.63,80,,65059.63,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,65059.63,80,,65059.63,percent of total billed charges,,7216,,,7216,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,56927.18,70,,56927.18,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1800.68,,,1800.68,Other,New York Medicaid APG methodology,1800.68,,,1800.68,Other,100% New York Medicaid APG,1800.68,,,1800.68,Other,100% New York Medicaid APG,1800.68,,,1800.68,Other,100% New York Medicaid APG,4051.52,,,4051.52,Other,225% New York Medicaid APG,2755.03,,,2755.03,Other,153% New York Medicaid APG,4051.52,,,4051.52,Other,225% New York Medicaid APG,2520.95,,,2520.95,Other,140% New York Medicaid APG,4051.52,,,4051.52,Other,225% New York Medicaid APG,4681.76,,,4681.76,Other,260% New York Medicaid APG,5834.19,,,5834.19,Other,324% New York Medicaid APG,3871.45,,,3871.45,Other,215% New York Medicaid APG,3871.45,,,3871.45,Other,215% New York Medicaid APG,2250.84,,,2250.84,Other,125% New York Medicaid APG,1800.68,65059.63,
Reinsert ocular implant,65155,CPT,,,,,,,,both,,,81324.54,60180.16,74,,60180.16,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,36596.04,45,,36596.04,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,40255.65,49.5,,40255.65,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3349.26,,,3349.26,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,56927.18,70,,56927.18,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1800.68,,,1800.68,Other,New York Medicaid APG methodology,1800.68,,,1800.68,Other,100% New York Medicaid APG,1800.68,,,1800.68,Other,100% New York Medicaid APG,1800.68,,,1800.68,Other,100% New York Medicaid APG,4051.52,,,4051.52,Other,225% New York Medicaid APG,2755.03,,,2755.03,Other,153% New York Medicaid APG,4051.52,,,4051.52,Other,225% New York Medicaid APG,2520.95,,,2520.95,Other,140% New York Medicaid APG,4051.52,,,4051.52,Other,225% New York Medicaid APG,4681.76,,,4681.76,Other,260% New York Medicaid APG,5834.19,,,5834.19,Other,324% New York Medicaid APG,3871.45,,,3871.45,Other,215% New York Medicaid APG,3871.45,,,3871.45,Other,215% New York Medicaid APG,2250.84,,,2250.84,Other,125% New York Medicaid APG,1800.68,60180.16,
Removal of ocular implant,65175,CPT,,,,,,,,both,,,81324.54,60180.16,74,,60180.16,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,36596.04,45,,36596.04,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,40255.65,49.5,,40255.65,percent of total billed charges,110% of Medicare,55300.69,68,,55300.69,percent of total billed charges,,3349.26,,,3349.26,Other,186% of Medicaid,65059.63,80,,65059.63,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,65059.63,80,,65059.63,percent of total billed charges,,7216,,,7216,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,56927.18,70,,56927.18,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1800.68,,,1800.68,Other,New York Medicaid APG methodology,1800.68,,,1800.68,Other,100% New York Medicaid APG,1800.68,,,1800.68,Other,100% New York Medicaid APG,1800.68,,,1800.68,Other,100% New York Medicaid APG,4051.52,,,4051.52,Other,225% New York Medicaid APG,2755.03,,,2755.03,Other,153% New York Medicaid APG,4051.52,,,4051.52,Other,225% New York Medicaid APG,2520.95,,,2520.95,Other,140% New York Medicaid APG,4051.52,,,4051.52,Other,225% New York Medicaid APG,4681.76,,,4681.76,Other,260% New York Medicaid APG,5834.19,,,5834.19,Other,324% New York Medicaid APG,3871.45,,,3871.45,Other,215% New York Medicaid APG,3871.45,,,3871.45,Other,215% New York Medicaid APG,2250.84,,,2250.84,Other,125% New York Medicaid APG,1800.68,65059.63,
Remove foreign body from eye,65205,CPT,,,,,,,,both,,,2686.86,1988.28,74,,1988.28,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,1209.09,45,,1209.09,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,1330,49.5,,1330,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,351.84,,,351.84,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,1880.8,70,,1880.8,percent of total billed charges,,141.04,,,141.04,Fee Schedule,,119.54,,,119.54,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,189.16,,,189.16,Other,New York Medicaid APG methodology,189.16,,,189.16,Other,100% New York Medicaid APG,189.16,,,189.16,Other,100% New York Medicaid APG,189.16,,,189.16,Other,100% New York Medicaid APG,425.62,,,425.62,Other,225% New York Medicaid APG,289.42,,,289.42,Other,153% New York Medicaid APG,425.62,,,425.62,Other,225% New York Medicaid APG,264.83,,,264.83,Other,140% New York Medicaid APG,425.62,,,425.62,Other,225% New York Medicaid APG,491.82,,,491.82,Other,260% New York Medicaid APG,612.89,,,612.89,Other,324% New York Medicaid APG,406.7,,,406.7,Other,215% New York Medicaid APG,406.7,,,406.7,Other,215% New York Medicaid APG,236.45,,,236.45,Other,125% New York Medicaid APG,119.54,9473,
Remove foreign body from eye,65210,CPT,,,,,,,,both,,,8380.68,6201.7,74,,6201.7,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,3771.31,45,,3771.31,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,4148.44,49.5,,4148.44,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,351.84,,,351.84,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,5866.48,70,,5866.48,percent of total billed charges,,173.84,,,173.84,Fee Schedule,,147.34,,,147.34,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,189.16,,,189.16,Other,New York Medicaid APG methodology,189.16,,,189.16,Other,100% New York Medicaid APG,189.16,,,189.16,Other,100% New York Medicaid APG,189.16,,,189.16,Other,100% New York Medicaid APG,425.62,,,425.62,Other,225% New York Medicaid APG,289.42,,,289.42,Other,153% New York Medicaid APG,425.62,,,425.62,Other,225% New York Medicaid APG,264.83,,,264.83,Other,140% New York Medicaid APG,425.62,,,425.62,Other,225% New York Medicaid APG,491.82,,,491.82,Other,260% New York Medicaid APG,612.89,,,612.89,Other,324% New York Medicaid APG,406.7,,,406.7,Other,215% New York Medicaid APG,406.7,,,406.7,Other,215% New York Medicaid APG,236.45,,,236.45,Other,125% New York Medicaid APG,147.34,9473,
Remove foreign body from eye,65220,CPT,,,,,,,,both,,,8380.68,6201.7,74,,6201.7,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,3771.31,45,,3771.31,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,4148.44,49.5,,4148.44,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,351.84,,,351.84,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,5866.48,70,,5866.48,percent of total billed charges,,201.72,,,201.72,Fee Schedule,,170.97,,,170.97,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,189.16,,,189.16,Other,New York Medicaid APG methodology,189.16,,,189.16,Other,100% New York Medicaid APG,189.16,,,189.16,Other,100% New York Medicaid APG,189.16,,,189.16,Other,100% New York Medicaid APG,425.62,,,425.62,Other,225% New York Medicaid APG,289.42,,,289.42,Other,153% New York Medicaid APG,425.62,,,425.62,Other,225% New York Medicaid APG,264.83,,,264.83,Other,140% New York Medicaid APG,425.62,,,425.62,Other,225% New York Medicaid APG,491.82,,,491.82,Other,260% New York Medicaid APG,612.89,,,612.89,Other,324% New York Medicaid APG,406.7,,,406.7,Other,215% New York Medicaid APG,406.7,,,406.7,Other,215% New York Medicaid APG,236.45,,,236.45,Other,125% New York Medicaid APG,170.97,9473,
Remove foreign body from eye,65222,CPT,,,,,,,,both,,,2686.86,1988.28,74,,1988.28,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,1209.09,45,,1209.09,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,1330,49.5,,1330,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,351.84,,,351.84,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,1880.8,70,,1880.8,percent of total billed charges,,241.08,,,241.08,Fee Schedule,,204.33,,,204.33,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,189.16,,,189.16,Other,New York Medicaid APG methodology,189.16,,,189.16,Other,100% New York Medicaid APG,189.16,,,189.16,Other,100% New York Medicaid APG,189.16,,,189.16,Other,100% New York Medicaid APG,425.62,,,425.62,Other,225% New York Medicaid APG,289.42,,,289.42,Other,153% New York Medicaid APG,425.62,,,425.62,Other,225% New York Medicaid APG,264.83,,,264.83,Other,140% New York Medicaid APG,425.62,,,425.62,Other,225% New York Medicaid APG,491.82,,,491.82,Other,260% New York Medicaid APG,612.89,,,612.89,Other,324% New York Medicaid APG,406.7,,,406.7,Other,215% New York Medicaid APG,406.7,,,406.7,Other,215% New York Medicaid APG,236.45,,,236.45,Other,125% New York Medicaid APG,189.16,9473,
Remove foreign body from eye,65235,CPT,,,,,,,,both,,,34057.95,25202.88,74,,25202.88,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15326.08,45,,15326.08,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,16858.69,49.5,,16858.69,percent of total billed charges,110% of Medicare,23159.41,68,,23159.41,percent of total billed charges,,2901.86,,,2901.86,Other,186% of Medicaid,27246.36,80,,27246.36,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,27246.36,80,,27246.36,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,23840.57,70,,23840.57,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1560.14,,,1560.14,Other,New York Medicaid APG methodology,1560.14,,,1560.14,Other,100% New York Medicaid APG,1560.14,,,1560.14,Other,100% New York Medicaid APG,1560.14,,,1560.14,Other,100% New York Medicaid APG,3510.31,,,3510.31,Other,225% New York Medicaid APG,2387.01,,,2387.01,Other,153% New York Medicaid APG,3510.31,,,3510.31,Other,225% New York Medicaid APG,2184.19,,,2184.19,Other,140% New York Medicaid APG,3510.31,,,3510.31,Other,225% New York Medicaid APG,4056.36,,,4056.36,Other,260% New York Medicaid APG,5054.85,,,5054.85,Other,324% New York Medicaid APG,3354.3,,,3354.3,Other,215% New York Medicaid APG,3354.3,,,3354.3,Other,215% New York Medicaid APG,1950.17,,,1950.17,Other,125% New York Medicaid APG,1560.14,27246.36,
Remove foreign body from eye,65260,CPT,,,,,,,,both,,,49016.23,36272.01,74,,36272.01,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,22057.3,45,,22057.3,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,24263.03,49.5,,24263.03,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,1160.61,,,1160.61,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,34311.36,70,,34311.36,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,623.98,,,623.98,Other,New York Medicaid APG methodology,623.98,,,623.98,Other,100% New York Medicaid APG,623.98,,,623.98,Other,100% New York Medicaid APG,623.98,,,623.98,Other,100% New York Medicaid APG,1403.96,,,1403.96,Other,225% New York Medicaid APG,954.7,,,954.7,Other,153% New York Medicaid APG,1403.96,,,1403.96,Other,225% New York Medicaid APG,873.58,,,873.58,Other,140% New York Medicaid APG,1403.96,,,1403.96,Other,225% New York Medicaid APG,1622.36,,,1622.36,Other,260% New York Medicaid APG,2021.71,,,2021.71,Other,324% New York Medicaid APG,1341.57,,,1341.57,Other,215% New York Medicaid APG,1341.57,,,1341.57,Other,215% New York Medicaid APG,779.98,,,779.98,Other,125% New York Medicaid APG,623.98,36272.01,
Remove foreign body from eye,65265,CPT,,,,,,,,both,,,49016.23,36272.01,74,,36272.01,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,22057.3,45,,22057.3,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,24263.03,49.5,,24263.03,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,1160.61,,,1160.61,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,34311.36,70,,34311.36,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,623.98,,,623.98,Other,New York Medicaid APG methodology,623.98,,,623.98,Other,100% New York Medicaid APG,623.98,,,623.98,Other,100% New York Medicaid APG,623.98,,,623.98,Other,100% New York Medicaid APG,1403.96,,,1403.96,Other,225% New York Medicaid APG,954.7,,,954.7,Other,153% New York Medicaid APG,1403.96,,,1403.96,Other,225% New York Medicaid APG,873.58,,,873.58,Other,140% New York Medicaid APG,1403.96,,,1403.96,Other,225% New York Medicaid APG,1622.36,,,1622.36,Other,260% New York Medicaid APG,2021.71,,,2021.71,Other,324% New York Medicaid APG,1341.57,,,1341.57,Other,215% New York Medicaid APG,1341.57,,,1341.57,Other,215% New York Medicaid APG,779.98,,,779.98,Other,125% New York Medicaid APG,623.98,36272.01,
Repair of eye wound,65270,CPT,,,,,,,,both,,,33818.71,25025.85,74,,25025.85,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15218.42,45,,15218.42,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,16740.26,49.5,,16740.26,percent of total billed charges,110% of Medicare,22996.72,68,,22996.72,percent of total billed charges,,3169.18,,,3169.18,Other,186% of Medicaid,27054.97,80,,27054.97,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,27054.97,80,,27054.97,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,23673.1,70,,23673.1,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1703.86,,,1703.86,Other,New York Medicaid APG methodology,1703.86,,,1703.86,Other,100% New York Medicaid APG,1703.86,,,1703.86,Other,100% New York Medicaid APG,1703.86,,,1703.86,Other,100% New York Medicaid APG,3833.69,,,3833.69,Other,225% New York Medicaid APG,2606.91,,,2606.91,Other,153% New York Medicaid APG,3833.69,,,3833.69,Other,225% New York Medicaid APG,2385.41,,,2385.41,Other,140% New York Medicaid APG,3833.69,,,3833.69,Other,225% New York Medicaid APG,4430.04,,,4430.04,Other,260% New York Medicaid APG,5520.51,,,5520.51,Other,324% New York Medicaid APG,3663.3,,,3663.3,Other,215% New York Medicaid APG,3663.3,,,3663.3,Other,215% New York Medicaid APG,2129.83,,,2129.83,Other,125% New York Medicaid APG,1703.86,27054.97,
Repair of eye wound,65272,CPT,,,,,,,,both,,,49151.56,36372.15,74,,36372.15,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,22118.2,45,,22118.2,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,24330.02,49.5,,24330.02,percent of total billed charges,110% of Medicare,33423.06,68,,33423.06,percent of total billed charges,,2167.59,,,2167.59,Other,186% of Medicaid,39321.25,80,,39321.25,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,39321.25,80,,39321.25,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,34406.09,70,,34406.09,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1165.37,,,1165.37,Other,New York Medicaid APG methodology,1165.37,,,1165.37,Other,100% New York Medicaid APG,1165.37,,,1165.37,Other,100% New York Medicaid APG,1165.37,,,1165.37,Other,100% New York Medicaid APG,2622.08,,,2622.08,Other,225% New York Medicaid APG,1783.01,,,1783.01,Other,153% New York Medicaid APG,2622.08,,,2622.08,Other,225% New York Medicaid APG,1631.52,,,1631.52,Other,140% New York Medicaid APG,2622.08,,,2622.08,Other,225% New York Medicaid APG,3029.96,,,3029.96,Other,260% New York Medicaid APG,3775.79,,,3775.79,Other,324% New York Medicaid APG,2505.54,,,2505.54,Other,215% New York Medicaid APG,2505.54,,,2505.54,Other,215% New York Medicaid APG,1456.71,,,1456.71,Other,125% New York Medicaid APG,1165.37,39321.25,
Repair of eye wound,65275,CPT,,,,,,,,both,,,81324.54,60180.16,74,,60180.16,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,36596.04,45,,36596.04,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,40255.65,49.5,,40255.65,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5059.05,,,5059.05,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,56927.18,70,,56927.18,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,2719.92,,,2719.92,Other,New York Medicaid APG methodology,2719.92,,,2719.92,Other,100% New York Medicaid APG,2719.92,,,2719.92,Other,100% New York Medicaid APG,2719.92,,,2719.92,Other,100% New York Medicaid APG,6119.82,,,6119.82,Other,225% New York Medicaid APG,4161.48,,,4161.48,Other,153% New York Medicaid APG,6119.82,,,6119.82,Other,225% New York Medicaid APG,3807.89,,,3807.89,Other,140% New York Medicaid APG,6119.82,,,6119.82,Other,225% New York Medicaid APG,7071.8,,,7071.8,Other,260% New York Medicaid APG,8812.55,,,8812.55,Other,324% New York Medicaid APG,5847.83,,,5847.83,Other,215% New York Medicaid APG,5847.83,,,5847.83,Other,215% New York Medicaid APG,3399.9,,,3399.9,Other,125% New York Medicaid APG,2719.92,60180.16,
Repair of eye wound,65280,CPT,,,,,,,,both,,,109933.59,81350.86,74,,81350.86,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,49470.12,45,,49470.12,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,54417.13,49.5,,54417.13,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5059.05,,,5059.05,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,76953.51,70,,76953.51,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,2719.92,,,2719.92,Other,New York Medicaid APG methodology,2719.92,,,2719.92,Other,100% New York Medicaid APG,2719.92,,,2719.92,Other,100% New York Medicaid APG,2719.92,,,2719.92,Other,100% New York Medicaid APG,6119.82,,,6119.82,Other,225% New York Medicaid APG,4161.48,,,4161.48,Other,153% New York Medicaid APG,6119.82,,,6119.82,Other,225% New York Medicaid APG,3807.89,,,3807.89,Other,140% New York Medicaid APG,6119.82,,,6119.82,Other,225% New York Medicaid APG,7071.8,,,7071.8,Other,260% New York Medicaid APG,8812.55,,,8812.55,Other,324% New York Medicaid APG,5847.83,,,5847.83,Other,215% New York Medicaid APG,5847.83,,,5847.83,Other,215% New York Medicaid APG,3399.9,,,3399.9,Other,125% New York Medicaid APG,2719.92,81350.86,
Repair of eye wound,65285,CPT,,,,,,,,both,,,109933.59,81350.86,74,,81350.86,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,49470.12,45,,49470.12,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,54417.13,49.5,,54417.13,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5059.05,,,5059.05,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,76953.51,70,,76953.51,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,2719.92,,,2719.92,Other,New York Medicaid APG methodology,2719.92,,,2719.92,Other,100% New York Medicaid APG,2719.92,,,2719.92,Other,100% New York Medicaid APG,2719.92,,,2719.92,Other,100% New York Medicaid APG,6119.82,,,6119.82,Other,225% New York Medicaid APG,4161.48,,,4161.48,Other,153% New York Medicaid APG,6119.82,,,6119.82,Other,225% New York Medicaid APG,3807.89,,,3807.89,Other,140% New York Medicaid APG,6119.82,,,6119.82,Other,225% New York Medicaid APG,7071.8,,,7071.8,Other,260% New York Medicaid APG,8812.55,,,8812.55,Other,324% New York Medicaid APG,5847.83,,,5847.83,Other,215% New York Medicaid APG,5847.83,,,5847.83,Other,215% New York Medicaid APG,3399.9,,,3399.9,Other,125% New York Medicaid APG,2719.92,81350.86,
Repair of eye wound,65286,CPT,,,,,,,,both,,,49016.23,36272.01,74,,36272.01,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,22057.3,45,,22057.3,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,24263.03,49.5,,24263.03,percent of total billed charges,110% of Medicare,33331.04,68,,33331.04,percent of total billed charges,,2859.52,,,2859.52,Other,186% of Medicaid,39212.98,80,,39212.98,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,39212.98,80,,39212.98,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,34311.36,70,,34311.36,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1537.38,,,1537.38,Other,New York Medicaid APG methodology,1537.38,,,1537.38,Other,100% New York Medicaid APG,1537.38,,,1537.38,Other,100% New York Medicaid APG,1537.38,,,1537.38,Other,100% New York Medicaid APG,3459.1,,,3459.1,Other,225% New York Medicaid APG,2352.19,,,2352.19,Other,153% New York Medicaid APG,3459.1,,,3459.1,Other,225% New York Medicaid APG,2152.33,,,2152.33,Other,140% New York Medicaid APG,3459.1,,,3459.1,Other,225% New York Medicaid APG,3997.18,,,3997.18,Other,260% New York Medicaid APG,4981.1,,,4981.1,Other,324% New York Medicaid APG,3305.36,,,3305.36,Other,215% New York Medicaid APG,3305.36,,,3305.36,Other,215% New York Medicaid APG,1921.72,,,1921.72,Other,125% New York Medicaid APG,1537.38,39212.98,
Repair of eye socket wound,65290,CPT,,,,,,,,both,,,81324.54,60180.16,74,,60180.16,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,36596.04,45,,36596.04,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,40255.65,49.5,,40255.65,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3349.26,,,3349.26,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,56927.18,70,,56927.18,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1800.68,,,1800.68,Other,New York Medicaid APG methodology,1800.68,,,1800.68,Other,100% New York Medicaid APG,1800.68,,,1800.68,Other,100% New York Medicaid APG,1800.68,,,1800.68,Other,100% New York Medicaid APG,4051.52,,,4051.52,Other,225% New York Medicaid APG,2755.03,,,2755.03,Other,153% New York Medicaid APG,4051.52,,,4051.52,Other,225% New York Medicaid APG,2520.95,,,2520.95,Other,140% New York Medicaid APG,4051.52,,,4051.52,Other,225% New York Medicaid APG,4681.76,,,4681.76,Other,260% New York Medicaid APG,5834.19,,,5834.19,Other,324% New York Medicaid APG,3871.45,,,3871.45,Other,215% New York Medicaid APG,3871.45,,,3871.45,Other,215% New York Medicaid APG,2250.84,,,2250.84,Other,125% New York Medicaid APG,1800.68,60180.16,
Removal of eye lesion,65400,CPT,,,,,,,,both,,,35141.42,26004.65,74,,26004.65,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15813.64,45,,15813.64,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,17395,49.5,,17395,percent of total billed charges,110% of Medicare,23896.17,68,,23896.17,percent of total billed charges,,2859.52,,,2859.52,Other,186% of Medicaid,28113.14,80,,28113.14,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,28113.14,80,,28113.14,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,24598.99,70,,24598.99,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1537.38,,,1537.38,Other,New York Medicaid APG methodology,1537.38,,,1537.38,Other,100% New York Medicaid APG,1537.38,,,1537.38,Other,100% New York Medicaid APG,1537.38,,,1537.38,Other,100% New York Medicaid APG,3459.1,,,3459.1,Other,225% New York Medicaid APG,2352.19,,,2352.19,Other,153% New York Medicaid APG,3459.1,,,3459.1,Other,225% New York Medicaid APG,2152.33,,,2152.33,Other,140% New York Medicaid APG,3459.1,,,3459.1,Other,225% New York Medicaid APG,3997.18,,,3997.18,Other,260% New York Medicaid APG,4981.1,,,4981.1,Other,324% New York Medicaid APG,3305.36,,,3305.36,Other,215% New York Medicaid APG,3305.36,,,3305.36,Other,215% New York Medicaid APG,1921.72,,,1921.72,Other,125% New York Medicaid APG,1537.38,28113.14,
Biopsy of cornea,65410,CPT,,,,,,,,both,,,35214.66,26058.85,74,,26058.85,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15846.6,45,,15846.6,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,17431.26,49.5,,17431.26,percent of total billed charges,110% of Medicare,23945.97,68,,23945.97,percent of total billed charges,,2859.52,,,2859.52,Other,186% of Medicaid,28171.73,80,,28171.73,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,28171.73,80,,28171.73,percent of total billed charges,,7216,,,7216,Case Rate,,3578,,"100% primary, 0% secondary procedures",3578,Other,MagnaCare ASC Grouper,24650.26,70,,24650.26,percent of total billed charges,,490.36,,,490.36,Fee Schedule,,415.61,,,415.61,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,1537.38,,,1537.38,Other,New York Medicaid APG methodology,1537.38,,,1537.38,Other,100% New York Medicaid APG,1537.38,,,1537.38,Other,100% New York Medicaid APG,1537.38,,,1537.38,Other,100% New York Medicaid APG,3459.1,,,3459.1,Other,225% New York Medicaid APG,2352.19,,,2352.19,Other,153% New York Medicaid APG,3459.1,,,3459.1,Other,225% New York Medicaid APG,2152.33,,,2152.33,Other,140% New York Medicaid APG,3459.1,,,3459.1,Other,225% New York Medicaid APG,3997.18,,,3997.18,Other,260% New York Medicaid APG,4981.1,,,4981.1,Other,324% New York Medicaid APG,3305.36,,,3305.36,Other,215% New York Medicaid APG,3305.36,,,3305.36,Other,215% New York Medicaid APG,1921.72,,,1921.72,Other,125% New York Medicaid APG,415.61,28171.73,
Removal of eye lesion,65420,CPT,,,,,,,,both,,,49151.56,36372.15,74,,36372.15,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,22118.2,45,,22118.2,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,24330.02,49.5,,24330.02,percent of total billed charges,110% of Medicare,33423.06,68,,33423.06,percent of total billed charges,,2859.52,,,2859.52,Other,186% of Medicaid,39321.25,80,,39321.25,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,39321.25,80,,39321.25,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,34406.09,70,,34406.09,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1537.38,,,1537.38,Other,New York Medicaid APG methodology,1537.38,,,1537.38,Other,100% New York Medicaid APG,1537.38,,,1537.38,Other,100% New York Medicaid APG,1537.38,,,1537.38,Other,100% New York Medicaid APG,3459.1,,,3459.1,Other,225% New York Medicaid APG,2352.19,,,2352.19,Other,153% New York Medicaid APG,3459.1,,,3459.1,Other,225% New York Medicaid APG,2152.33,,,2152.33,Other,140% New York Medicaid APG,3459.1,,,3459.1,Other,225% New York Medicaid APG,3997.18,,,3997.18,Other,260% New York Medicaid APG,4981.1,,,4981.1,Other,324% New York Medicaid APG,3305.36,,,3305.36,Other,215% New York Medicaid APG,3305.36,,,3305.36,Other,215% New York Medicaid APG,1921.72,,,1921.72,Other,125% New York Medicaid APG,1537.38,39321.25,
Removal of eye lesion,65426,CPT,,,,,,,,both,,,37961.77,28091.71,74,,28091.71,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,17082.8,45,,17082.8,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,18791.08,49.5,,18791.08,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5059.05,,,5059.05,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,26573.24,70,,26573.24,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,2719.92,,,2719.92,Other,New York Medicaid APG methodology,2719.92,,,2719.92,Other,100% New York Medicaid APG,2719.92,,,2719.92,Other,100% New York Medicaid APG,2719.92,,,2719.92,Other,100% New York Medicaid APG,6119.82,,,6119.82,Other,225% New York Medicaid APG,4161.48,,,4161.48,Other,153% New York Medicaid APG,6119.82,,,6119.82,Other,225% New York Medicaid APG,3807.89,,,3807.89,Other,140% New York Medicaid APG,6119.82,,,6119.82,Other,225% New York Medicaid APG,7071.8,,,7071.8,Other,260% New York Medicaid APG,8812.55,,,8812.55,Other,324% New York Medicaid APG,5847.83,,,5847.83,Other,215% New York Medicaid APG,5847.83,,,5847.83,Other,215% New York Medicaid APG,3399.9,,,3399.9,Other,125% New York Medicaid APG,2719.92,28091.71,
Corneal smear,65430,CPT,,,,,,,,both,,,8380.68,6201.7,74,,6201.7,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,3771.31,45,,3771.31,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,4148.44,49.5,,4148.44,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,525.76,,,525.76,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,5866.48,70,,5866.48,percent of total billed charges,,487.08,,,487.08,Fee Schedule,,412.83,,,412.83,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,282.67,,,282.67,Other,New York Medicaid APG methodology,282.67,,,282.67,Other,100% New York Medicaid APG,282.67,,,282.67,Other,100% New York Medicaid APG,282.67,,,282.67,Other,100% New York Medicaid APG,636,,,636,Other,225% New York Medicaid APG,432.48,,,432.48,Other,153% New York Medicaid APG,636,,,636,Other,225% New York Medicaid APG,395.73,,,395.73,Other,140% New York Medicaid APG,636,,,636,Other,225% New York Medicaid APG,734.93,,,734.93,Other,260% New York Medicaid APG,915.84,,,915.84,Other,324% New York Medicaid APG,607.73,,,607.73,Other,215% New York Medicaid APG,607.73,,,607.73,Other,215% New York Medicaid APG,353.33,,,353.33,Other,125% New York Medicaid APG,282.67,9473,
Curette/treat cornea,65435,CPT,,,,,,,,both,,,38018.76,28133.88,74,,28133.88,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,17108.44,45,,17108.44,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,18819.29,49.5,,18819.29,percent of total billed charges,110% of Medicare,25852.76,68,,25852.76,percent of total billed charges,,2859.52,,,2859.52,Other,186% of Medicaid,30415.01,80,,30415.01,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,30415.01,80,,30415.01,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,26613.13,70,,26613.13,percent of total billed charges,,332.92,,,332.92,Fee Schedule,,282.17,,,282.17,Fee Schedule,,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1537.38,,,1537.38,Other,New York Medicaid APG methodology,1537.38,,,1537.38,Other,100% New York Medicaid APG,1537.38,,,1537.38,Other,100% New York Medicaid APG,1537.38,,,1537.38,Other,100% New York Medicaid APG,3459.1,,,3459.1,Other,225% New York Medicaid APG,2352.19,,,2352.19,Other,153% New York Medicaid APG,3459.1,,,3459.1,Other,225% New York Medicaid APG,2152.33,,,2152.33,Other,140% New York Medicaid APG,3459.1,,,3459.1,Other,225% New York Medicaid APG,3997.18,,,3997.18,Other,260% New York Medicaid APG,4981.1,,,4981.1,Other,324% New York Medicaid APG,3305.36,,,3305.36,Other,215% New York Medicaid APG,3305.36,,,3305.36,Other,215% New York Medicaid APG,1921.72,,,1921.72,Other,125% New York Medicaid APG,282.17,30415.01,
Curette/treat cornea,65436,CPT,,,,,,,,both,,,34632.26,25627.87,74,,25627.87,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15584.52,45,,15584.52,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,17142.97,49.5,,17142.97,percent of total billed charges,110% of Medicare,23549.94,68,,23549.94,percent of total billed charges,,2859.52,,,2859.52,Other,186% of Medicaid,27705.81,80,,27705.81,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,27705.81,80,,27705.81,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,24242.58,70,,24242.58,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1537.38,,,1537.38,Other,New York Medicaid APG methodology,1537.38,,,1537.38,Other,100% New York Medicaid APG,1537.38,,,1537.38,Other,100% New York Medicaid APG,1537.38,,,1537.38,Other,100% New York Medicaid APG,3459.1,,,3459.1,Other,225% New York Medicaid APG,2352.19,,,2352.19,Other,153% New York Medicaid APG,3459.1,,,3459.1,Other,225% New York Medicaid APG,2152.33,,,2152.33,Other,140% New York Medicaid APG,3459.1,,,3459.1,Other,225% New York Medicaid APG,3997.18,,,3997.18,Other,260% New York Medicaid APG,4981.1,,,4981.1,Other,324% New York Medicaid APG,3305.36,,,3305.36,Other,215% New York Medicaid APG,3305.36,,,3305.36,Other,215% New York Medicaid APG,1921.72,,,1921.72,Other,125% New York Medicaid APG,1537.38,27705.81,
Treatment of corneal lesion,65450,CPT,,,,,,,,both,,,6127.39,4534.27,74,,4534.27,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,2757.33,45,,2757.33,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,3033.06,49.5,,3033.06,percent of total billed charges,110% of Medicare,4166.63,68,,4166.63,percent of total billed charges,,2859.52,,,2859.52,Other,186% of Medicaid,4901.91,80,,4901.91,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,4901.91,80,,4901.91,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,4289.17,70,,4289.17,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,1537.38,,,1537.38,Other,New York Medicaid APG methodology,1537.38,,,1537.38,Other,100% New York Medicaid APG,1537.38,,,1537.38,Other,100% New York Medicaid APG,1537.38,,,1537.38,Other,100% New York Medicaid APG,3459.1,,,3459.1,Other,225% New York Medicaid APG,2352.19,,,2352.19,Other,153% New York Medicaid APG,3459.1,,,3459.1,Other,225% New York Medicaid APG,2152.33,,,2152.33,Other,140% New York Medicaid APG,3459.1,,,3459.1,Other,225% New York Medicaid APG,3997.18,,,3997.18,Other,260% New York Medicaid APG,4981.1,,,4981.1,Other,324% New York Medicaid APG,3305.36,,,3305.36,Other,215% New York Medicaid APG,3305.36,,,3305.36,Other,215% New York Medicaid APG,1921.72,,,1921.72,Other,125% New York Medicaid APG,1537.38,7216,
Revision of cornea,65600,CPT,,,,,,,,both,,,49151.56,36372.15,74,,36372.15,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,22118.2,45,,22118.2,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,24330.02,49.5,,24330.02,percent of total billed charges,110% of Medicare,33423.06,68,,33423.06,percent of total billed charges,,2859.52,,,2859.52,Other,186% of Medicaid,39321.25,80,,39321.25,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,39321.25,80,,39321.25,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,34406.09,70,,34406.09,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1537.38,,,1537.38,Other,New York Medicaid APG methodology,1537.38,,,1537.38,Other,100% New York Medicaid APG,1537.38,,,1537.38,Other,100% New York Medicaid APG,1537.38,,,1537.38,Other,100% New York Medicaid APG,3459.1,,,3459.1,Other,225% New York Medicaid APG,2352.19,,,2352.19,Other,153% New York Medicaid APG,3459.1,,,3459.1,Other,225% New York Medicaid APG,2152.33,,,2152.33,Other,140% New York Medicaid APG,3459.1,,,3459.1,Other,225% New York Medicaid APG,3997.18,,,3997.18,Other,260% New York Medicaid APG,4981.1,,,4981.1,Other,324% New York Medicaid APG,3305.36,,,3305.36,Other,215% New York Medicaid APG,3305.36,,,3305.36,Other,215% New York Medicaid APG,1921.72,,,1921.72,Other,125% New York Medicaid APG,1537.38,39321.25,
Corneal transplant,65710,CPT,,,,,,,,both,,,53411.26,39524.33,74,,39524.33,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,24035.07,45,,24035.07,percent of total billed charges,Medicare Ratio of cost to charges,5954,,"100% primary, 50% supplemental procedure",5954,Other,Aetna ASC Grouper,5359,,"100% primary, 50% supplemental procedure",5359,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,26438.57,49.5,,26438.57,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5059.05,,,5059.05,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,37387.88,70,,37387.88,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,2719.92,,,2719.92,Other,New York Medicaid APG methodology,2719.92,,,2719.92,Other,100% New York Medicaid APG,2719.92,,,2719.92,Other,100% New York Medicaid APG,2719.92,,,2719.92,Other,100% New York Medicaid APG,6119.82,,,6119.82,Other,225% New York Medicaid APG,4161.48,,,4161.48,Other,153% New York Medicaid APG,6119.82,,,6119.82,Other,225% New York Medicaid APG,3807.89,,,3807.89,Other,140% New York Medicaid APG,6119.82,,,6119.82,Other,225% New York Medicaid APG,7071.8,,,7071.8,Other,260% New York Medicaid APG,8812.55,,,8812.55,Other,324% New York Medicaid APG,5847.83,,,5847.83,Other,215% New York Medicaid APG,5847.83,,,5847.83,Other,215% New York Medicaid APG,3399.9,,,3399.9,Other,125% New York Medicaid APG,2719.92,39524.33,
Corneal transplant,65730,CPT,,,,,,,,both,,,50825.67,37611,74,,37611,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,22871.55,45,,22871.55,percent of total billed charges,Medicare Ratio of cost to charges,5954,,"100% primary, 50% supplemental procedure",5954,Other,Aetna ASC Grouper,5359,,"100% primary, 50% supplemental procedure",5359,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,25158.71,49.5,,25158.71,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5059.05,,,5059.05,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,35577.97,70,,35577.97,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,2719.92,,,2719.92,Other,New York Medicaid APG methodology,2719.92,,,2719.92,Other,100% New York Medicaid APG,2719.92,,,2719.92,Other,100% New York Medicaid APG,2719.92,,,2719.92,Other,100% New York Medicaid APG,6119.82,,,6119.82,Other,225% New York Medicaid APG,4161.48,,,4161.48,Other,153% New York Medicaid APG,6119.82,,,6119.82,Other,225% New York Medicaid APG,3807.89,,,3807.89,Other,140% New York Medicaid APG,6119.82,,,6119.82,Other,225% New York Medicaid APG,7071.8,,,7071.8,Other,260% New York Medicaid APG,8812.55,,,8812.55,Other,324% New York Medicaid APG,5847.83,,,5847.83,Other,215% New York Medicaid APG,5847.83,,,5847.83,Other,215% New York Medicaid APG,3399.9,,,3399.9,Other,125% New York Medicaid APG,2719.92,37611,
Corneal transplant,65750,CPT,,,,,,,,both,,,63976.41,47342.54,74,,47342.54,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,28789.38,45,,28789.38,percent of total billed charges,Medicare Ratio of cost to charges,5954,,"100% primary, 50% supplemental procedure",5954,Other,Aetna ASC Grouper,5359,,"100% primary, 50% supplemental procedure",5359,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,31668.32,49.5,,31668.32,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5059.05,,,5059.05,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,44783.49,70,,44783.49,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,2719.92,,,2719.92,Other,New York Medicaid APG methodology,2719.92,,,2719.92,Other,100% New York Medicaid APG,2719.92,,,2719.92,Other,100% New York Medicaid APG,2719.92,,,2719.92,Other,100% New York Medicaid APG,6119.82,,,6119.82,Other,225% New York Medicaid APG,4161.48,,,4161.48,Other,153% New York Medicaid APG,6119.82,,,6119.82,Other,225% New York Medicaid APG,3807.89,,,3807.89,Other,140% New York Medicaid APG,6119.82,,,6119.82,Other,225% New York Medicaid APG,7071.8,,,7071.8,Other,260% New York Medicaid APG,8812.55,,,8812.55,Other,324% New York Medicaid APG,5847.83,,,5847.83,Other,215% New York Medicaid APG,5847.83,,,5847.83,Other,215% New York Medicaid APG,3399.9,,,3399.9,Other,125% New York Medicaid APG,2719.92,47342.54,
Corneal transplant,65755,CPT,,,,,,,,both,,,56854.87,42072.6,74,,42072.6,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,25584.69,45,,25584.69,percent of total billed charges,Medicare Ratio of cost to charges,5954,,"100% primary, 50% supplemental procedure",5954,Other,Aetna ASC Grouper,5359,,"100% primary, 50% supplemental procedure",5359,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,28143.16,49.5,,28143.16,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5059.05,,,5059.05,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,39798.41,70,,39798.41,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,2719.92,,,2719.92,Other,New York Medicaid APG methodology,2719.92,,,2719.92,Other,100% New York Medicaid APG,2719.92,,,2719.92,Other,100% New York Medicaid APG,2719.92,,,2719.92,Other,100% New York Medicaid APG,6119.82,,,6119.82,Other,225% New York Medicaid APG,4161.48,,,4161.48,Other,153% New York Medicaid APG,6119.82,,,6119.82,Other,225% New York Medicaid APG,3807.89,,,3807.89,Other,140% New York Medicaid APG,6119.82,,,6119.82,Other,225% New York Medicaid APG,7071.8,,,7071.8,Other,260% New York Medicaid APG,8812.55,,,8812.55,Other,324% New York Medicaid APG,5847.83,,,5847.83,Other,215% New York Medicaid APG,5847.83,,,5847.83,Other,215% New York Medicaid APG,3399.9,,,3399.9,Other,125% New York Medicaid APG,2719.92,42072.6,
Corneal trnspl endothelial,65756,CPT,,,,,,,,both,,,49335.48,36508.26,74,,36508.26,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,22200.97,45,,22200.97,percent of total billed charges,Medicare Ratio of cost to charges,5954,,"100% primary, 50% supplemental procedure",5954,Other,Aetna ASC Grouper,5359,,"100% primary, 50% supplemental procedure",5359,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,24421.06,49.5,,24421.06,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5059.05,,,5059.05,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,34534.84,70,,34534.84,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,2719.92,,,2719.92,Other,New York Medicaid APG methodology,2719.92,,,2719.92,Other,100% New York Medicaid APG,2719.92,,,2719.92,Other,100% New York Medicaid APG,2719.92,,,2719.92,Other,100% New York Medicaid APG,6119.82,,,6119.82,Other,225% New York Medicaid APG,4161.48,,,4161.48,Other,153% New York Medicaid APG,6119.82,,,6119.82,Other,225% New York Medicaid APG,3807.89,,,3807.89,Other,140% New York Medicaid APG,6119.82,,,6119.82,Other,225% New York Medicaid APG,7071.8,,,7071.8,Other,260% New York Medicaid APG,8812.55,,,8812.55,Other,324% New York Medicaid APG,5847.83,,,5847.83,Other,215% New York Medicaid APG,5847.83,,,5847.83,Other,215% New York Medicaid APG,3399.9,,,3399.9,Other,125% New York Medicaid APG,2719.92,36508.26,
Prep corneal endo allograft,65757,CPT,,,,,,,,both,,,32432.1,23999.75,74,,23999.75,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,14594.45,45,,14594.45,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,16053.89,49.5,,16053.89,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5059.05,,,5059.05,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,22702.47,70,,22702.47,percent of total billed charges,,21080.87,65,,21080.87,percent of total billed charges,,21080.87,65,,21080.87,percent of total billed charges,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,2719.92,,,2719.92,Other,New York Medicaid APG methodology,2719.92,,,2719.92,Other,100% New York Medicaid APG,2719.92,,,2719.92,Other,100% New York Medicaid APG,2719.92,,,2719.92,Other,100% New York Medicaid APG,6119.82,,,6119.82,Other,225% New York Medicaid APG,4161.48,,,4161.48,Other,153% New York Medicaid APG,6119.82,,,6119.82,Other,225% New York Medicaid APG,3807.89,,,3807.89,Other,140% New York Medicaid APG,6119.82,,,6119.82,Other,225% New York Medicaid APG,7071.8,,,7071.8,Other,260% New York Medicaid APG,8812.55,,,8812.55,Other,324% New York Medicaid APG,5847.83,,,5847.83,Other,215% New York Medicaid APG,5847.83,,,5847.83,Other,215% New York Medicaid APG,3399.9,,,3399.9,Other,125% New York Medicaid APG,2719.92,23999.75,
Revise cornea with implant,65770,CPT,,,,,,,,both,,,260759.04,192961.69,74,,192961.69,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,117341.57,45,,117341.57,percent of total billed charges,Medicare Ratio of cost to charges,5954,,"100% primary, 50% supplemental procedure",5954,Other,Aetna ASC Grouper,5359,,"100% primary, 50% supplemental procedure",5359,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,129075.72,49.5,,129075.72,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5059.05,,,5059.05,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9196,,"100% primary, 0% secondary procedures",9196,Other,MagnaCare ASC Grouper,182531.33,70,,182531.33,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,2719.92,,,2719.92,Other,New York Medicaid APG methodology,2719.92,,,2719.92,Other,100% New York Medicaid APG,2719.92,,,2719.92,Other,100% New York Medicaid APG,2719.92,,,2719.92,Other,100% New York Medicaid APG,6119.82,,,6119.82,Other,225% New York Medicaid APG,4161.48,,,4161.48,Other,153% New York Medicaid APG,6119.82,,,6119.82,Other,225% New York Medicaid APG,3807.89,,,3807.89,Other,140% New York Medicaid APG,6119.82,,,6119.82,Other,225% New York Medicaid APG,7071.8,,,7071.8,Other,260% New York Medicaid APG,8812.55,,,8812.55,Other,324% New York Medicaid APG,5847.83,,,5847.83,Other,215% New York Medicaid APG,5847.83,,,5847.83,Other,215% New York Medicaid APG,3399.9,,,3399.9,Other,125% New York Medicaid APG,2719.92,192961.69,
Correction of astigmatism,65772,CPT,,,,,,,,both,,,21295.3,15758.52,74,,15758.52,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,9582.89,45,,9582.89,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,10541.17,49.5,,10541.17,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2859.52,,,2859.52,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,14906.71,70,,14906.71,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1537.38,,,1537.38,Other,New York Medicaid APG methodology,1537.38,,,1537.38,Other,100% New York Medicaid APG,1537.38,,,1537.38,Other,100% New York Medicaid APG,1537.38,,,1537.38,Other,100% New York Medicaid APG,3459.1,,,3459.1,Other,225% New York Medicaid APG,2352.19,,,2352.19,Other,153% New York Medicaid APG,3459.1,,,3459.1,Other,225% New York Medicaid APG,2152.33,,,2152.33,Other,140% New York Medicaid APG,3459.1,,,3459.1,Other,225% New York Medicaid APG,3997.18,,,3997.18,Other,260% New York Medicaid APG,4981.1,,,4981.1,Other,324% New York Medicaid APG,3305.36,,,3305.36,Other,215% New York Medicaid APG,3305.36,,,3305.36,Other,215% New York Medicaid APG,1921.72,,,1921.72,Other,125% New York Medicaid APG,1537.38,15758.52,
Correction of astigmatism,65775,CPT,,,,,,,,both,,,49151.56,36372.15,74,,36372.15,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,22118.2,45,,22118.2,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,24330.02,49.5,,24330.02,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2859.52,,,2859.52,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,34406.09,70,,34406.09,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1537.38,,,1537.38,Other,New York Medicaid APG methodology,1537.38,,,1537.38,Other,100% New York Medicaid APG,1537.38,,,1537.38,Other,100% New York Medicaid APG,1537.38,,,1537.38,Other,100% New York Medicaid APG,3459.1,,,3459.1,Other,225% New York Medicaid APG,2352.19,,,2352.19,Other,153% New York Medicaid APG,3459.1,,,3459.1,Other,225% New York Medicaid APG,2152.33,,,2152.33,Other,140% New York Medicaid APG,3459.1,,,3459.1,Other,225% New York Medicaid APG,3997.18,,,3997.18,Other,260% New York Medicaid APG,4981.1,,,4981.1,Other,324% New York Medicaid APG,3305.36,,,3305.36,Other,215% New York Medicaid APG,3305.36,,,3305.36,Other,215% New York Medicaid APG,1921.72,,,1921.72,Other,125% New York Medicaid APG,1537.38,36372.15,
Cover eye w/membrane,65778,CPT,,,,,,,,both,,,21295.3,15758.52,74,,15758.52,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,9582.89,45,,9582.89,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,10541.17,49.5,,10541.17,percent of total billed charges,110% of Medicare,14480.8,68,,14480.8,percent of total billed charges,,2859.52,,,2859.52,Other,186% of Medicaid,17036.24,80,,17036.24,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,17036.24,80,,17036.24,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,14906.71,70,,14906.71,percent of total billed charges,,254.2,,,254.2,Fee Schedule,,215.45,,,215.45,Fee Schedule,,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1537.38,,,1537.38,Other,New York Medicaid APG methodology,1537.38,,,1537.38,Other,100% New York Medicaid APG,1537.38,,,1537.38,Other,100% New York Medicaid APG,1537.38,,,1537.38,Other,100% New York Medicaid APG,3459.1,,,3459.1,Other,225% New York Medicaid APG,2352.19,,,2352.19,Other,153% New York Medicaid APG,3459.1,,,3459.1,Other,225% New York Medicaid APG,2152.33,,,2152.33,Other,140% New York Medicaid APG,3459.1,,,3459.1,Other,225% New York Medicaid APG,3997.18,,,3997.18,Other,260% New York Medicaid APG,4981.1,,,4981.1,Other,324% New York Medicaid APG,3305.36,,,3305.36,Other,215% New York Medicaid APG,3305.36,,,3305.36,Other,215% New York Medicaid APG,1921.72,,,1921.72,Other,125% New York Medicaid APG,215.45,17036.24,
Cover eye w/membrane suture,65779,CPT,,,,,,,,both,,,33053.92,24459.9,74,,24459.9,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,14874.26,45,,14874.26,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,16361.69,49.5,,16361.69,percent of total billed charges,110% of Medicare,22476.67,68,,22476.67,percent of total billed charges,,2859.52,,,2859.52,Other,186% of Medicaid,26443.14,80,,26443.14,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,26443.14,80,,26443.14,percent of total billed charges,,7216,,,7216,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,23137.74,70,,23137.74,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1537.38,,,1537.38,Other,New York Medicaid APG methodology,1537.38,,,1537.38,Other,100% New York Medicaid APG,1537.38,,,1537.38,Other,100% New York Medicaid APG,1537.38,,,1537.38,Other,100% New York Medicaid APG,3459.1,,,3459.1,Other,225% New York Medicaid APG,2352.19,,,2352.19,Other,153% New York Medicaid APG,3459.1,,,3459.1,Other,225% New York Medicaid APG,2152.33,,,2152.33,Other,140% New York Medicaid APG,3459.1,,,3459.1,Other,225% New York Medicaid APG,3997.18,,,3997.18,Other,260% New York Medicaid APG,4981.1,,,4981.1,Other,324% New York Medicaid APG,3305.36,,,3305.36,Other,215% New York Medicaid APG,3305.36,,,3305.36,Other,215% New York Medicaid APG,1921.72,,,1921.72,Other,125% New York Medicaid APG,1537.38,26443.14,
Ocular reconst transplant,65780,CPT,,,,,,,,both,,,38106.26,28198.63,74,,28198.63,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,17147.82,45,,17147.82,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,18862.6,49.5,,18862.6,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5059.05,,,5059.05,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,26674.38,70,,26674.38,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,2719.92,,,2719.92,Other,New York Medicaid APG methodology,2719.92,,,2719.92,Other,100% New York Medicaid APG,2719.92,,,2719.92,Other,100% New York Medicaid APG,2719.92,,,2719.92,Other,100% New York Medicaid APG,6119.82,,,6119.82,Other,225% New York Medicaid APG,4161.48,,,4161.48,Other,153% New York Medicaid APG,6119.82,,,6119.82,Other,225% New York Medicaid APG,3807.89,,,3807.89,Other,140% New York Medicaid APG,6119.82,,,6119.82,Other,225% New York Medicaid APG,7071.8,,,7071.8,Other,260% New York Medicaid APG,8812.55,,,8812.55,Other,324% New York Medicaid APG,5847.83,,,5847.83,Other,215% New York Medicaid APG,5847.83,,,5847.83,Other,215% New York Medicaid APG,3399.9,,,3399.9,Other,125% New York Medicaid APG,2719.92,28198.63,
Ocular reconst transplant,65781,CPT,,,,,,,,both,,,109933.59,81350.86,74,,81350.86,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,49470.12,45,,49470.12,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,54417.13,49.5,,54417.13,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5059.05,,,5059.05,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,76953.51,70,,76953.51,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,2719.92,,,2719.92,Other,New York Medicaid APG methodology,2719.92,,,2719.92,Other,100% New York Medicaid APG,2719.92,,,2719.92,Other,100% New York Medicaid APG,2719.92,,,2719.92,Other,100% New York Medicaid APG,6119.82,,,6119.82,Other,225% New York Medicaid APG,4161.48,,,4161.48,Other,153% New York Medicaid APG,6119.82,,,6119.82,Other,225% New York Medicaid APG,3807.89,,,3807.89,Other,140% New York Medicaid APG,6119.82,,,6119.82,Other,225% New York Medicaid APG,7071.8,,,7071.8,Other,260% New York Medicaid APG,8812.55,,,8812.55,Other,324% New York Medicaid APG,5847.83,,,5847.83,Other,215% New York Medicaid APG,5847.83,,,5847.83,Other,215% New York Medicaid APG,3399.9,,,3399.9,Other,125% New York Medicaid APG,2719.92,81350.86,
Ocular reconst transplant,65782,CPT,,,,,,,,both,,,81324.54,60180.16,74,,60180.16,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,36596.04,45,,36596.04,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,40255.65,49.5,,40255.65,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5059.05,,,5059.05,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,56927.18,70,,56927.18,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,2719.92,,,2719.92,Other,New York Medicaid APG methodology,2719.92,,,2719.92,Other,100% New York Medicaid APG,2719.92,,,2719.92,Other,100% New York Medicaid APG,2719.92,,,2719.92,Other,100% New York Medicaid APG,6119.82,,,6119.82,Other,225% New York Medicaid APG,4161.48,,,4161.48,Other,153% New York Medicaid APG,6119.82,,,6119.82,Other,225% New York Medicaid APG,3807.89,,,3807.89,Other,140% New York Medicaid APG,6119.82,,,6119.82,Other,225% New York Medicaid APG,7071.8,,,7071.8,Other,260% New York Medicaid APG,8812.55,,,8812.55,Other,324% New York Medicaid APG,5847.83,,,5847.83,Other,215% New York Medicaid APG,5847.83,,,5847.83,Other,215% New York Medicaid APG,3399.9,,,3399.9,Other,125% New York Medicaid APG,2719.92,60180.16,
Impltj ntrstrml crnl rng seg,65785,CPT,,,,,,,,both,,,85519.85,63284.69,74,,63284.69,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,38483.93,45,,38483.93,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,42332.33,49.5,,42332.33,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5059.05,,,5059.05,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,59863.9,70,,59863.9,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,2719.92,,,2719.92,Other,New York Medicaid APG methodology,2719.92,,,2719.92,Other,100% New York Medicaid APG,2719.92,,,2719.92,Other,100% New York Medicaid APG,2719.92,,,2719.92,Other,100% New York Medicaid APG,6119.82,,,6119.82,Other,225% New York Medicaid APG,4161.48,,,4161.48,Other,153% New York Medicaid APG,6119.82,,,6119.82,Other,225% New York Medicaid APG,3807.89,,,3807.89,Other,140% New York Medicaid APG,6119.82,,,6119.82,Other,225% New York Medicaid APG,7071.8,,,7071.8,Other,260% New York Medicaid APG,8812.55,,,8812.55,Other,324% New York Medicaid APG,5847.83,,,5847.83,Other,215% New York Medicaid APG,5847.83,,,5847.83,Other,215% New York Medicaid APG,3399.9,,,3399.9,Other,125% New York Medicaid APG,2719.92,63284.69,
Drainage of eye,65800,CPT,,,,,,,,both,,,49016.23,36272.01,74,,36272.01,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,22057.3,45,,22057.3,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,24263.03,49.5,,24263.03,percent of total billed charges,110% of Medicare,33331.04,68,,33331.04,percent of total billed charges,,2901.86,,,2901.86,Other,186% of Medicaid,39212.98,80,,39212.98,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,39212.98,80,,39212.98,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,34311.36,70,,34311.36,percent of total billed charges,,428.04,,,428.04,Fee Schedule,,362.79,,,362.79,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,1560.14,,,1560.14,Other,New York Medicaid APG methodology,1560.14,,,1560.14,Other,100% New York Medicaid APG,1560.14,,,1560.14,Other,100% New York Medicaid APG,1560.14,,,1560.14,Other,100% New York Medicaid APG,3510.31,,,3510.31,Other,225% New York Medicaid APG,2387.01,,,2387.01,Other,153% New York Medicaid APG,3510.31,,,3510.31,Other,225% New York Medicaid APG,2184.19,,,2184.19,Other,140% New York Medicaid APG,3510.31,,,3510.31,Other,225% New York Medicaid APG,4056.36,,,4056.36,Other,260% New York Medicaid APG,5054.85,,,5054.85,Other,324% New York Medicaid APG,3354.3,,,3354.3,Other,215% New York Medicaid APG,3354.3,,,3354.3,Other,215% New York Medicaid APG,1950.17,,,1950.17,Other,125% New York Medicaid APG,362.79,39212.98,
Drainage of eye,65810,CPT,,,,,,,,both,,,35561.95,26315.84,74,,26315.84,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,16002.88,45,,16002.88,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,17603.17,49.5,,17603.17,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2901.86,,,2901.86,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,24893.37,70,,24893.37,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1560.14,,,1560.14,Other,New York Medicaid APG methodology,1560.14,,,1560.14,Other,100% New York Medicaid APG,1560.14,,,1560.14,Other,100% New York Medicaid APG,1560.14,,,1560.14,Other,100% New York Medicaid APG,3510.31,,,3510.31,Other,225% New York Medicaid APG,2387.01,,,2387.01,Other,153% New York Medicaid APG,3510.31,,,3510.31,Other,225% New York Medicaid APG,2184.19,,,2184.19,Other,140% New York Medicaid APG,3510.31,,,3510.31,Other,225% New York Medicaid APG,4056.36,,,4056.36,Other,260% New York Medicaid APG,5054.85,,,5054.85,Other,324% New York Medicaid APG,3354.3,,,3354.3,Other,215% New York Medicaid APG,3354.3,,,3354.3,Other,215% New York Medicaid APG,1950.17,,,1950.17,Other,125% New York Medicaid APG,1560.14,26315.84,
Drainage of eye,65815,CPT,,,,,,,,both,,,49016.23,36272.01,74,,36272.01,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,22057.3,45,,22057.3,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,24263.03,49.5,,24263.03,percent of total billed charges,110% of Medicare,33331.04,68,,33331.04,percent of total billed charges,,2901.86,,,2901.86,Other,186% of Medicaid,39212.98,80,,39212.98,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,39212.98,80,,39212.98,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,34311.36,70,,34311.36,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1560.14,,,1560.14,Other,New York Medicaid APG methodology,1560.14,,,1560.14,Other,100% New York Medicaid APG,1560.14,,,1560.14,Other,100% New York Medicaid APG,1560.14,,,1560.14,Other,100% New York Medicaid APG,3510.31,,,3510.31,Other,225% New York Medicaid APG,2387.01,,,2387.01,Other,153% New York Medicaid APG,3510.31,,,3510.31,Other,225% New York Medicaid APG,2184.19,,,2184.19,Other,140% New York Medicaid APG,3510.31,,,3510.31,Other,225% New York Medicaid APG,4056.36,,,4056.36,Other,260% New York Medicaid APG,5054.85,,,5054.85,Other,324% New York Medicaid APG,3354.3,,,3354.3,Other,215% New York Medicaid APG,3354.3,,,3354.3,Other,215% New York Medicaid APG,1950.17,,,1950.17,Other,125% New York Medicaid APG,1560.14,39212.98,
Relieve inner eye pressure,65820,CPT,,,,,,,,both,,,36931.35,27329.2,74,,27329.2,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,16619.11,45,,16619.11,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,18281.02,49.5,,18281.02,percent of total billed charges,110% of Medicare,25113.32,68,,25113.32,percent of total billed charges,,2901.86,,,2901.86,Other,186% of Medicaid,29545.08,80,,29545.08,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,29545.08,80,,29545.08,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,25851.95,70,,25851.95,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1560.14,,,1560.14,Other,New York Medicaid APG methodology,1560.14,,,1560.14,Other,100% New York Medicaid APG,1560.14,,,1560.14,Other,100% New York Medicaid APG,1560.14,,,1560.14,Other,100% New York Medicaid APG,3510.31,,,3510.31,Other,225% New York Medicaid APG,2387.01,,,2387.01,Other,153% New York Medicaid APG,3510.31,,,3510.31,Other,225% New York Medicaid APG,2184.19,,,2184.19,Other,140% New York Medicaid APG,3510.31,,,3510.31,Other,225% New York Medicaid APG,4056.36,,,4056.36,Other,260% New York Medicaid APG,5054.85,,,5054.85,Other,324% New York Medicaid APG,3354.3,,,3354.3,Other,215% New York Medicaid APG,3354.3,,,3354.3,Other,215% New York Medicaid APG,1950.17,,,1950.17,Other,125% New York Medicaid APG,1560.14,29545.08,
Incision of eye,65850,CPT,,,,,,,,both,,,49016.23,36272.01,74,,36272.01,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,22057.3,45,,22057.3,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,24263.03,49.5,,24263.03,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3819.9,,,3819.9,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,34311.36,70,,34311.36,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,2053.71,,,2053.71,Other,New York Medicaid APG methodology,2053.71,,,2053.71,Other,100% New York Medicaid APG,2053.71,,,2053.71,Other,100% New York Medicaid APG,2053.71,,,2053.71,Other,100% New York Medicaid APG,4620.84,,,4620.84,Other,225% New York Medicaid APG,3142.17,,,3142.17,Other,153% New York Medicaid APG,4620.84,,,4620.84,Other,225% New York Medicaid APG,2875.19,,,2875.19,Other,140% New York Medicaid APG,4620.84,,,4620.84,Other,225% New York Medicaid APG,5339.64,,,5339.64,Other,260% New York Medicaid APG,6654.01,,,6654.01,Other,324% New York Medicaid APG,4415.47,,,4415.47,Other,215% New York Medicaid APG,4415.47,,,4415.47,Other,215% New York Medicaid APG,2567.13,,,2567.13,Other,125% New York Medicaid APG,2053.71,36272.01,
Trabeculoplasty laser surg,65855,CPT,,,,,,,,both,,,12226.3,9047.46,74,,9047.46,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,5501.84,45,,5501.84,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,6052.02,49.5,,6052.02,percent of total billed charges,110% of Medicare,8313.88,68,,8313.88,percent of total billed charges,,2901.86,,,2901.86,Other,186% of Medicaid,9781.04,80,,9781.04,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,9781.04,80,,9781.04,percent of total billed charges,,7216,,,7216,Case Rate,,3578,,"100% primary, 0% secondary procedures",3578,Other,MagnaCare ASC Grouper,8558.41,70,,8558.41,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,1560.14,,,1560.14,Other,New York Medicaid APG methodology,1560.14,,,1560.14,Other,100% New York Medicaid APG,1560.14,,,1560.14,Other,100% New York Medicaid APG,1560.14,,,1560.14,Other,100% New York Medicaid APG,3510.31,,,3510.31,Other,225% New York Medicaid APG,2387.01,,,2387.01,Other,153% New York Medicaid APG,3510.31,,,3510.31,Other,225% New York Medicaid APG,2184.19,,,2184.19,Other,140% New York Medicaid APG,3510.31,,,3510.31,Other,225% New York Medicaid APG,4056.36,,,4056.36,Other,260% New York Medicaid APG,5054.85,,,5054.85,Other,324% New York Medicaid APG,3354.3,,,3354.3,Other,215% New York Medicaid APG,3354.3,,,3354.3,Other,215% New York Medicaid APG,1950.17,,,1950.17,Other,125% New York Medicaid APG,1560.14,9781.04,
Incise inner eye adhesions,65860,CPT,,,,,,,,both,,,12226.3,9047.46,74,,9047.46,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,5501.84,45,,5501.84,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,6052.02,49.5,,6052.02,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2901.86,,,2901.86,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,3578,,"100% primary, 0% secondary procedures",3578,Other,MagnaCare ASC Grouper,8558.41,70,,8558.41,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,1560.14,,,1560.14,Other,New York Medicaid APG methodology,1560.14,,,1560.14,Other,100% New York Medicaid APG,1560.14,,,1560.14,Other,100% New York Medicaid APG,1560.14,,,1560.14,Other,100% New York Medicaid APG,3510.31,,,3510.31,Other,225% New York Medicaid APG,2387.01,,,2387.01,Other,153% New York Medicaid APG,3510.31,,,3510.31,Other,225% New York Medicaid APG,2184.19,,,2184.19,Other,140% New York Medicaid APG,3510.31,,,3510.31,Other,225% New York Medicaid APG,4056.36,,,4056.36,Other,260% New York Medicaid APG,5054.85,,,5054.85,Other,324% New York Medicaid APG,3354.3,,,3354.3,Other,215% New York Medicaid APG,3354.3,,,3354.3,Other,215% New York Medicaid APG,1950.17,,,1950.17,Other,125% New York Medicaid APG,1560.14,9473,
Incise inner eye adhesions,65865,CPT,,,,,,,,both,,,49016.23,36272.01,74,,36272.01,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,22057.3,45,,22057.3,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,24263.03,49.5,,24263.03,percent of total billed charges,110% of Medicare,33331.04,68,,33331.04,percent of total billed charges,,2901.86,,,2901.86,Other,186% of Medicaid,39212.98,80,,39212.98,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,39212.98,80,,39212.98,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,34311.36,70,,34311.36,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1560.14,,,1560.14,Other,New York Medicaid APG methodology,1560.14,,,1560.14,Other,100% New York Medicaid APG,1560.14,,,1560.14,Other,100% New York Medicaid APG,1560.14,,,1560.14,Other,100% New York Medicaid APG,3510.31,,,3510.31,Other,225% New York Medicaid APG,2387.01,,,2387.01,Other,153% New York Medicaid APG,3510.31,,,3510.31,Other,225% New York Medicaid APG,2184.19,,,2184.19,Other,140% New York Medicaid APG,3510.31,,,3510.31,Other,225% New York Medicaid APG,4056.36,,,4056.36,Other,260% New York Medicaid APG,5054.85,,,5054.85,Other,324% New York Medicaid APG,3354.3,,,3354.3,Other,215% New York Medicaid APG,3354.3,,,3354.3,Other,215% New York Medicaid APG,1950.17,,,1950.17,Other,125% New York Medicaid APG,1560.14,39212.98,
Incise inner eye adhesions,65870,CPT,,,,,,,,both,,,49016.23,36272.01,74,,36272.01,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,22057.3,45,,22057.3,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,24263.03,49.5,,24263.03,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2901.86,,,2901.86,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,34311.36,70,,34311.36,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1560.14,,,1560.14,Other,New York Medicaid APG methodology,1560.14,,,1560.14,Other,100% New York Medicaid APG,1560.14,,,1560.14,Other,100% New York Medicaid APG,1560.14,,,1560.14,Other,100% New York Medicaid APG,3510.31,,,3510.31,Other,225% New York Medicaid APG,2387.01,,,2387.01,Other,153% New York Medicaid APG,3510.31,,,3510.31,Other,225% New York Medicaid APG,2184.19,,,2184.19,Other,140% New York Medicaid APG,3510.31,,,3510.31,Other,225% New York Medicaid APG,4056.36,,,4056.36,Other,260% New York Medicaid APG,5054.85,,,5054.85,Other,324% New York Medicaid APG,3354.3,,,3354.3,Other,215% New York Medicaid APG,3354.3,,,3354.3,Other,215% New York Medicaid APG,1950.17,,,1950.17,Other,125% New York Medicaid APG,1560.14,36272.01,
Incise inner eye adhesions,65875,CPT,,,,,,,,both,,,49016.23,36272.01,74,,36272.01,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,22057.3,45,,22057.3,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,24263.03,49.5,,24263.03,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2901.86,,,2901.86,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,34311.36,70,,34311.36,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1560.14,,,1560.14,Other,New York Medicaid APG methodology,1560.14,,,1560.14,Other,100% New York Medicaid APG,1560.14,,,1560.14,Other,100% New York Medicaid APG,1560.14,,,1560.14,Other,100% New York Medicaid APG,3510.31,,,3510.31,Other,225% New York Medicaid APG,2387.01,,,2387.01,Other,153% New York Medicaid APG,3510.31,,,3510.31,Other,225% New York Medicaid APG,2184.19,,,2184.19,Other,140% New York Medicaid APG,3510.31,,,3510.31,Other,225% New York Medicaid APG,4056.36,,,4056.36,Other,260% New York Medicaid APG,5054.85,,,5054.85,Other,324% New York Medicaid APG,3354.3,,,3354.3,Other,215% New York Medicaid APG,3354.3,,,3354.3,Other,215% New York Medicaid APG,1950.17,,,1950.17,Other,125% New York Medicaid APG,1560.14,36272.01,
Incise inner eye adhesions,65880,CPT,,,,,,,,both,,,85519.85,63284.69,74,,63284.69,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,38483.93,45,,38483.93,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,42332.33,49.5,,42332.33,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3819.9,,,3819.9,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,59863.9,70,,59863.9,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,2053.71,,,2053.71,Other,New York Medicaid APG methodology,2053.71,,,2053.71,Other,100% New York Medicaid APG,2053.71,,,2053.71,Other,100% New York Medicaid APG,2053.71,,,2053.71,Other,100% New York Medicaid APG,4620.84,,,4620.84,Other,225% New York Medicaid APG,3142.17,,,3142.17,Other,153% New York Medicaid APG,4620.84,,,4620.84,Other,225% New York Medicaid APG,2875.19,,,2875.19,Other,140% New York Medicaid APG,4620.84,,,4620.84,Other,225% New York Medicaid APG,5339.64,,,5339.64,Other,260% New York Medicaid APG,6654.01,,,6654.01,Other,324% New York Medicaid APG,4415.47,,,4415.47,Other,215% New York Medicaid APG,4415.47,,,4415.47,Other,215% New York Medicaid APG,2567.13,,,2567.13,Other,125% New York Medicaid APG,2053.71,63284.69,
Remove eye lesion,65900,CPT,,,,,,,,both,,,35724.95,26436.46,74,,26436.46,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,16076.23,45,,16076.23,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,17683.85,49.5,,17683.85,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3819.9,,,3819.9,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,25007.47,70,,25007.47,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,2053.71,,,2053.71,Other,New York Medicaid APG methodology,2053.71,,,2053.71,Other,100% New York Medicaid APG,2053.71,,,2053.71,Other,100% New York Medicaid APG,2053.71,,,2053.71,Other,100% New York Medicaid APG,4620.84,,,4620.84,Other,225% New York Medicaid APG,3142.17,,,3142.17,Other,153% New York Medicaid APG,4620.84,,,4620.84,Other,225% New York Medicaid APG,2875.19,,,2875.19,Other,140% New York Medicaid APG,4620.84,,,4620.84,Other,225% New York Medicaid APG,5339.64,,,5339.64,Other,260% New York Medicaid APG,6654.01,,,6654.01,Other,324% New York Medicaid APG,4415.47,,,4415.47,Other,215% New York Medicaid APG,4415.47,,,4415.47,Other,215% New York Medicaid APG,2567.13,,,2567.13,Other,125% New York Medicaid APG,2053.71,26436.46,
Remove implant of eye,65920,CPT,,,,,,,,both,,,35663.57,26391.04,74,,26391.04,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,16048.61,45,,16048.61,percent of total billed charges,Medicare Ratio of cost to charges,5954,,"100% primary, 50% supplemental procedure",5954,Other,Aetna ASC Grouper,5359,,"100% primary, 50% supplemental procedure",5359,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,17653.47,49.5,,17653.47,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2901.86,,,2901.86,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,24964.5,70,,24964.5,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1560.14,,,1560.14,Other,New York Medicaid APG methodology,1560.14,,,1560.14,Other,100% New York Medicaid APG,1560.14,,,1560.14,Other,100% New York Medicaid APG,1560.14,,,1560.14,Other,100% New York Medicaid APG,3510.31,,,3510.31,Other,225% New York Medicaid APG,2387.01,,,2387.01,Other,153% New York Medicaid APG,3510.31,,,3510.31,Other,225% New York Medicaid APG,2184.19,,,2184.19,Other,140% New York Medicaid APG,3510.31,,,3510.31,Other,225% New York Medicaid APG,4056.36,,,4056.36,Other,260% New York Medicaid APG,5054.85,,,5054.85,Other,324% New York Medicaid APG,3354.3,,,3354.3,Other,215% New York Medicaid APG,3354.3,,,3354.3,Other,215% New York Medicaid APG,1950.17,,,1950.17,Other,125% New York Medicaid APG,1560.14,26391.04,
Remove blood clot from eye,65930,CPT,,,,,,,,both,,,49016.23,36272.01,74,,36272.01,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,22057.3,45,,22057.3,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,24263.03,49.5,,24263.03,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2901.86,,,2901.86,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,34311.36,70,,34311.36,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1560.14,,,1560.14,Other,New York Medicaid APG methodology,1560.14,,,1560.14,Other,100% New York Medicaid APG,1560.14,,,1560.14,Other,100% New York Medicaid APG,1560.14,,,1560.14,Other,100% New York Medicaid APG,3510.31,,,3510.31,Other,225% New York Medicaid APG,2387.01,,,2387.01,Other,153% New York Medicaid APG,3510.31,,,3510.31,Other,225% New York Medicaid APG,2184.19,,,2184.19,Other,140% New York Medicaid APG,3510.31,,,3510.31,Other,225% New York Medicaid APG,4056.36,,,4056.36,Other,260% New York Medicaid APG,5054.85,,,5054.85,Other,324% New York Medicaid APG,3354.3,,,3354.3,Other,215% New York Medicaid APG,3354.3,,,3354.3,Other,215% New York Medicaid APG,1950.17,,,1950.17,Other,125% New York Medicaid APG,1560.14,36272.01,
Injection treatment of eye,66020,CPT,,,,,,,,both,,,49016.23,36272.01,74,,36272.01,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,22057.3,45,,22057.3,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,24263.03,49.5,,24263.03,percent of total billed charges,110% of Medicare,33331.04,68,,33331.04,percent of total billed charges,,2901.86,,,2901.86,Other,186% of Medicaid,39212.98,80,,39212.98,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,39212.98,80,,39212.98,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,34311.36,70,,34311.36,percent of total billed charges,,633.04,,,633.04,Fee Schedule,,536.54,,,536.54,Fee Schedule,,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1560.14,,,1560.14,Other,New York Medicaid APG methodology,1560.14,,,1560.14,Other,100% New York Medicaid APG,1560.14,,,1560.14,Other,100% New York Medicaid APG,1560.14,,,1560.14,Other,100% New York Medicaid APG,3510.31,,,3510.31,Other,225% New York Medicaid APG,2387.01,,,2387.01,Other,153% New York Medicaid APG,3510.31,,,3510.31,Other,225% New York Medicaid APG,2184.19,,,2184.19,Other,140% New York Medicaid APG,3510.31,,,3510.31,Other,225% New York Medicaid APG,4056.36,,,4056.36,Other,260% New York Medicaid APG,5054.85,,,5054.85,Other,324% New York Medicaid APG,3354.3,,,3354.3,Other,215% New York Medicaid APG,3354.3,,,3354.3,Other,215% New York Medicaid APG,1950.17,,,1950.17,Other,125% New York Medicaid APG,536.54,39212.98,
Injection treatment of eye,66030,CPT,,,,,,,,both,,,49016.23,36272.01,74,,36272.01,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,22057.3,45,,22057.3,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,24263.03,49.5,,24263.03,percent of total billed charges,110% of Medicare,33331.04,68,,33331.04,percent of total billed charges,,2901.86,,,2901.86,Other,186% of Medicaid,39212.98,80,,39212.98,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,39212.98,80,,39212.98,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,34311.36,70,,34311.36,percent of total billed charges,,537.92,,,537.92,Fee Schedule,,455.92,,,455.92,Fee Schedule,,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1560.14,,,1560.14,Other,New York Medicaid APG methodology,1560.14,,,1560.14,Other,100% New York Medicaid APG,1560.14,,,1560.14,Other,100% New York Medicaid APG,1560.14,,,1560.14,Other,100% New York Medicaid APG,3510.31,,,3510.31,Other,225% New York Medicaid APG,2387.01,,,2387.01,Other,153% New York Medicaid APG,3510.31,,,3510.31,Other,225% New York Medicaid APG,2184.19,,,2184.19,Other,140% New York Medicaid APG,3510.31,,,3510.31,Other,225% New York Medicaid APG,4056.36,,,4056.36,Other,260% New York Medicaid APG,5054.85,,,5054.85,Other,324% New York Medicaid APG,3354.3,,,3354.3,Other,215% New York Medicaid APG,3354.3,,,3354.3,Other,215% New York Medicaid APG,1950.17,,,1950.17,Other,125% New York Medicaid APG,455.92,39212.98,
Remove eye lesion,66130,CPT,,,,,,,,both,,,49151.56,36372.15,74,,36372.15,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,22118.2,45,,22118.2,percent of total billed charges,Medicare Ratio of cost to charges,5954,,"100% primary, 50% supplemental procedure",5954,Other,Aetna ASC Grouper,5359,,"100% primary, 50% supplemental procedure",5359,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,24330.02,49.5,,24330.02,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2901.86,,,2901.86,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,34406.09,70,,34406.09,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1560.14,,,1560.14,Other,New York Medicaid APG methodology,1560.14,,,1560.14,Other,100% New York Medicaid APG,1560.14,,,1560.14,Other,100% New York Medicaid APG,1560.14,,,1560.14,Other,100% New York Medicaid APG,3510.31,,,3510.31,Other,225% New York Medicaid APG,2387.01,,,2387.01,Other,153% New York Medicaid APG,3510.31,,,3510.31,Other,225% New York Medicaid APG,2184.19,,,2184.19,Other,140% New York Medicaid APG,3510.31,,,3510.31,Other,225% New York Medicaid APG,4056.36,,,4056.36,Other,260% New York Medicaid APG,5054.85,,,5054.85,Other,324% New York Medicaid APG,3354.3,,,3354.3,Other,215% New York Medicaid APG,3354.3,,,3354.3,Other,215% New York Medicaid APG,1950.17,,,1950.17,Other,125% New York Medicaid APG,1560.14,36372.15,
Glaucoma surgery,66150,CPT,,,,,,,,both,,,85519.85,63284.69,74,,63284.69,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,38483.93,45,,38483.93,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,42332.33,49.5,,42332.33,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3819.9,,,3819.9,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,59863.9,70,,59863.9,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,2053.71,,,2053.71,Other,New York Medicaid APG methodology,2053.71,,,2053.71,Other,100% New York Medicaid APG,2053.71,,,2053.71,Other,100% New York Medicaid APG,2053.71,,,2053.71,Other,100% New York Medicaid APG,4620.84,,,4620.84,Other,225% New York Medicaid APG,3142.17,,,3142.17,Other,153% New York Medicaid APG,4620.84,,,4620.84,Other,225% New York Medicaid APG,2875.19,,,2875.19,Other,140% New York Medicaid APG,4620.84,,,4620.84,Other,225% New York Medicaid APG,5339.64,,,5339.64,Other,260% New York Medicaid APG,6654.01,,,6654.01,Other,324% New York Medicaid APG,4415.47,,,4415.47,Other,215% New York Medicaid APG,4415.47,,,4415.47,Other,215% New York Medicaid APG,2567.13,,,2567.13,Other,125% New York Medicaid APG,2053.71,63284.69,
Glaucoma surgery,66155,CPT,,,,,,,,both,,,85519.85,63284.69,74,,63284.69,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,38483.93,45,,38483.93,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,42332.33,49.5,,42332.33,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3819.9,,,3819.9,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,59863.9,70,,59863.9,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,2053.71,,,2053.71,Other,New York Medicaid APG methodology,2053.71,,,2053.71,Other,100% New York Medicaid APG,2053.71,,,2053.71,Other,100% New York Medicaid APG,2053.71,,,2053.71,Other,100% New York Medicaid APG,4620.84,,,4620.84,Other,225% New York Medicaid APG,3142.17,,,3142.17,Other,153% New York Medicaid APG,4620.84,,,4620.84,Other,225% New York Medicaid APG,2875.19,,,2875.19,Other,140% New York Medicaid APG,4620.84,,,4620.84,Other,225% New York Medicaid APG,5339.64,,,5339.64,Other,260% New York Medicaid APG,6654.01,,,6654.01,Other,324% New York Medicaid APG,4415.47,,,4415.47,Other,215% New York Medicaid APG,4415.47,,,4415.47,Other,215% New York Medicaid APG,2567.13,,,2567.13,Other,125% New York Medicaid APG,2053.71,63284.69,
Glaucoma surgery,66160,CPT,,,,,,,,both,,,49016.23,36272.01,74,,36272.01,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,22057.3,45,,22057.3,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,24263.03,49.5,,24263.03,percent of total billed charges,110% of Medicare,33331.04,68,,33331.04,percent of total billed charges,,3819.9,,,3819.9,Other,186% of Medicaid,39212.98,80,,39212.98,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,39212.98,80,,39212.98,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,34311.36,70,,34311.36,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,2053.71,,,2053.71,Other,New York Medicaid APG methodology,2053.71,,,2053.71,Other,100% New York Medicaid APG,2053.71,,,2053.71,Other,100% New York Medicaid APG,2053.71,,,2053.71,Other,100% New York Medicaid APG,4620.84,,,4620.84,Other,225% New York Medicaid APG,3142.17,,,3142.17,Other,153% New York Medicaid APG,4620.84,,,4620.84,Other,225% New York Medicaid APG,2875.19,,,2875.19,Other,140% New York Medicaid APG,4620.84,,,4620.84,Other,225% New York Medicaid APG,5339.64,,,5339.64,Other,260% New York Medicaid APG,6654.01,,,6654.01,Other,324% New York Medicaid APG,4415.47,,,4415.47,Other,215% New York Medicaid APG,4415.47,,,4415.47,Other,215% New York Medicaid APG,2567.13,,,2567.13,Other,125% New York Medicaid APG,2053.71,39212.98,
Glaucoma surgery,66170,CPT,,,,,,,,both,,,33203.28,24570.43,74,,24570.43,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,14941.48,45,,14941.48,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,16435.62,49.5,,16435.62,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3819.9,,,3819.9,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,23242.3,70,,23242.3,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,2053.71,,,2053.71,Other,New York Medicaid APG methodology,2053.71,,,2053.71,Other,100% New York Medicaid APG,2053.71,,,2053.71,Other,100% New York Medicaid APG,2053.71,,,2053.71,Other,100% New York Medicaid APG,4620.84,,,4620.84,Other,225% New York Medicaid APG,3142.17,,,3142.17,Other,153% New York Medicaid APG,4620.84,,,4620.84,Other,225% New York Medicaid APG,2875.19,,,2875.19,Other,140% New York Medicaid APG,4620.84,,,4620.84,Other,225% New York Medicaid APG,5339.64,,,5339.64,Other,260% New York Medicaid APG,6654.01,,,6654.01,Other,324% New York Medicaid APG,4415.47,,,4415.47,Other,215% New York Medicaid APG,4415.47,,,4415.47,Other,215% New York Medicaid APG,2567.13,,,2567.13,Other,125% New York Medicaid APG,2053.71,24570.43,
Incision of eye,66172,CPT,,,,,,,,both,,,49016.23,36272.01,74,,36272.01,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,22057.3,45,,22057.3,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,24263.03,49.5,,24263.03,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3819.9,,,3819.9,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,34311.36,70,,34311.36,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,2053.71,,,2053.71,Other,New York Medicaid APG methodology,2053.71,,,2053.71,Other,100% New York Medicaid APG,2053.71,,,2053.71,Other,100% New York Medicaid APG,2053.71,,,2053.71,Other,100% New York Medicaid APG,4620.84,,,4620.84,Other,225% New York Medicaid APG,3142.17,,,3142.17,Other,153% New York Medicaid APG,4620.84,,,4620.84,Other,225% New York Medicaid APG,2875.19,,,2875.19,Other,140% New York Medicaid APG,4620.84,,,4620.84,Other,225% New York Medicaid APG,5339.64,,,5339.64,Other,260% New York Medicaid APG,6654.01,,,6654.01,Other,324% New York Medicaid APG,4415.47,,,4415.47,Other,215% New York Medicaid APG,4415.47,,,4415.47,Other,215% New York Medicaid APG,2567.13,,,2567.13,Other,125% New York Medicaid APG,2053.71,36272.01,
Translum dil eye canal,66174,CPT,,,,,,,,both,,,85519.85,63284.69,74,,63284.69,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,38483.93,45,,38483.93,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,42332.33,49.5,,42332.33,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3819.9,,,3819.9,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,59863.9,70,,59863.9,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,2053.71,,,2053.71,Other,New York Medicaid APG methodology,2053.71,,,2053.71,Other,100% New York Medicaid APG,2053.71,,,2053.71,Other,100% New York Medicaid APG,2053.71,,,2053.71,Other,100% New York Medicaid APG,4620.84,,,4620.84,Other,225% New York Medicaid APG,3142.17,,,3142.17,Other,153% New York Medicaid APG,4620.84,,,4620.84,Other,225% New York Medicaid APG,2875.19,,,2875.19,Other,140% New York Medicaid APG,4620.84,,,4620.84,Other,225% New York Medicaid APG,5339.64,,,5339.64,Other,260% New York Medicaid APG,6654.01,,,6654.01,Other,324% New York Medicaid APG,4415.47,,,4415.47,Other,215% New York Medicaid APG,4415.47,,,4415.47,Other,215% New York Medicaid APG,2567.13,,,2567.13,Other,125% New York Medicaid APG,2053.71,63284.69,
Trnslum dil eye canal w/stnt,66175,CPT,,,,,,,,both,,,109933.59,81350.86,74,,81350.86,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,49470.12,45,,49470.12,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,54417.13,49.5,,54417.13,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3819.9,,,3819.9,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,76953.51,70,,76953.51,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,2053.71,,,2053.71,Other,New York Medicaid APG methodology,2053.71,,,2053.71,Other,100% New York Medicaid APG,2053.71,,,2053.71,Other,100% New York Medicaid APG,2053.71,,,2053.71,Other,100% New York Medicaid APG,4620.84,,,4620.84,Other,225% New York Medicaid APG,3142.17,,,3142.17,Other,153% New York Medicaid APG,4620.84,,,4620.84,Other,225% New York Medicaid APG,2875.19,,,2875.19,Other,140% New York Medicaid APG,4620.84,,,4620.84,Other,225% New York Medicaid APG,5339.64,,,5339.64,Other,260% New York Medicaid APG,6654.01,,,6654.01,Other,324% New York Medicaid APG,4415.47,,,4415.47,Other,215% New York Medicaid APG,4415.47,,,4415.47,Other,215% New York Medicaid APG,2567.13,,,2567.13,Other,125% New York Medicaid APG,2053.71,81350.86,
Aqueous shunt eye w/o graft,66179,CPT,,,,,,,,both,,,109933.59,81350.86,74,,81350.86,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,49470.12,45,,49470.12,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,54417.13,49.5,,54417.13,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3819.9,,,3819.9,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,76953.51,70,,76953.51,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,2053.71,,,2053.71,Other,New York Medicaid APG methodology,2053.71,,,2053.71,Other,100% New York Medicaid APG,2053.71,,,2053.71,Other,100% New York Medicaid APG,2053.71,,,2053.71,Other,100% New York Medicaid APG,4620.84,,,4620.84,Other,225% New York Medicaid APG,3142.17,,,3142.17,Other,153% New York Medicaid APG,4620.84,,,4620.84,Other,225% New York Medicaid APG,2875.19,,,2875.19,Other,140% New York Medicaid APG,4620.84,,,4620.84,Other,225% New York Medicaid APG,5339.64,,,5339.64,Other,260% New York Medicaid APG,6654.01,,,6654.01,Other,324% New York Medicaid APG,4415.47,,,4415.47,Other,215% New York Medicaid APG,4415.47,,,4415.47,Other,215% New York Medicaid APG,2567.13,,,2567.13,Other,125% New York Medicaid APG,2053.71,81350.86,
Aqueous shunt eye w/graft,66180,CPT,,,,,,,,both,,,37790.35,27964.86,74,,27964.86,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,17005.66,45,,17005.66,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,18706.22,49.5,,18706.22,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3819.9,,,3819.9,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,26453.25,70,,26453.25,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,2053.71,,,2053.71,Other,New York Medicaid APG methodology,2053.71,,,2053.71,Other,100% New York Medicaid APG,2053.71,,,2053.71,Other,100% New York Medicaid APG,2053.71,,,2053.71,Other,100% New York Medicaid APG,4620.84,,,4620.84,Other,225% New York Medicaid APG,3142.17,,,3142.17,Other,153% New York Medicaid APG,4620.84,,,4620.84,Other,225% New York Medicaid APG,2875.19,,,2875.19,Other,140% New York Medicaid APG,4620.84,,,4620.84,Other,225% New York Medicaid APG,5339.64,,,5339.64,Other,260% New York Medicaid APG,6654.01,,,6654.01,Other,324% New York Medicaid APG,4415.47,,,4415.47,Other,215% New York Medicaid APG,4415.47,,,4415.47,Other,215% New York Medicaid APG,2567.13,,,2567.13,Other,125% New York Medicaid APG,2053.71,27964.86,
Insert ant drainage device,66183,CPT,,,,,,,,both,,,40479.02,29954.47,74,,29954.47,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,18215.56,45,,18215.56,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,20037.11,49.5,,20037.11,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3819.9,,,3819.9,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,28335.31,70,,28335.31,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,2053.71,,,2053.71,Other,New York Medicaid APG methodology,2053.71,,,2053.71,Other,100% New York Medicaid APG,2053.71,,,2053.71,Other,100% New York Medicaid APG,2053.71,,,2053.71,Other,100% New York Medicaid APG,4620.84,,,4620.84,Other,225% New York Medicaid APG,3142.17,,,3142.17,Other,153% New York Medicaid APG,4620.84,,,4620.84,Other,225% New York Medicaid APG,2875.19,,,2875.19,Other,140% New York Medicaid APG,4620.84,,,4620.84,Other,225% New York Medicaid APG,5339.64,,,5339.64,Other,260% New York Medicaid APG,6654.01,,,6654.01,Other,324% New York Medicaid APG,4415.47,,,4415.47,Other,215% New York Medicaid APG,4415.47,,,4415.47,Other,215% New York Medicaid APG,2567.13,,,2567.13,Other,125% New York Medicaid APG,2053.71,29954.47,
Revision of aqueous shunt,66184,CPT,,,,,,,,both,,,49016.23,36272.01,74,,36272.01,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,22057.3,45,,22057.3,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,24263.03,49.5,,24263.03,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2901.86,,,2901.86,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,34311.36,70,,34311.36,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1560.14,,,1560.14,Other,New York Medicaid APG methodology,1560.14,,,1560.14,Other,100% New York Medicaid APG,1560.14,,,1560.14,Other,100% New York Medicaid APG,1560.14,,,1560.14,Other,100% New York Medicaid APG,3510.31,,,3510.31,Other,225% New York Medicaid APG,2387.01,,,2387.01,Other,153% New York Medicaid APG,3510.31,,,3510.31,Other,225% New York Medicaid APG,2184.19,,,2184.19,Other,140% New York Medicaid APG,3510.31,,,3510.31,Other,225% New York Medicaid APG,4056.36,,,4056.36,Other,260% New York Medicaid APG,5054.85,,,5054.85,Other,324% New York Medicaid APG,3354.3,,,3354.3,Other,215% New York Medicaid APG,3354.3,,,3354.3,Other,215% New York Medicaid APG,1950.17,,,1950.17,Other,125% New York Medicaid APG,1560.14,36272.01,
Revise aqueous shunt eye,66185,CPT,,,,,,,,both,,,49016.23,36272.01,74,,36272.01,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,22057.3,45,,22057.3,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,24263.03,49.5,,24263.03,percent of total billed charges,110% of Medicare,33331.04,68,,33331.04,percent of total billed charges,,2901.86,,,2901.86,Other,186% of Medicaid,39212.98,80,,39212.98,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,39212.98,80,,39212.98,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,34311.36,70,,34311.36,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1560.14,,,1560.14,Other,New York Medicaid APG methodology,1560.14,,,1560.14,Other,100% New York Medicaid APG,1560.14,,,1560.14,Other,100% New York Medicaid APG,1560.14,,,1560.14,Other,100% New York Medicaid APG,3510.31,,,3510.31,Other,225% New York Medicaid APG,2387.01,,,2387.01,Other,153% New York Medicaid APG,3510.31,,,3510.31,Other,225% New York Medicaid APG,2184.19,,,2184.19,Other,140% New York Medicaid APG,3510.31,,,3510.31,Other,225% New York Medicaid APG,4056.36,,,4056.36,Other,260% New York Medicaid APG,5054.85,,,5054.85,Other,324% New York Medicaid APG,3354.3,,,3354.3,Other,215% New York Medicaid APG,3354.3,,,3354.3,Other,215% New York Medicaid APG,1950.17,,,1950.17,Other,125% New York Medicaid APG,1560.14,39212.98,
Repair/graft eye lesion,66225,CPT,,,,,,,,both,,,109933.59,81350.86,74,,81350.86,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,49470.12,45,,49470.12,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,54417.13,49.5,,54417.13,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3819.9,,,3819.9,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,76953.51,70,,76953.51,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,2053.71,,,2053.71,Other,New York Medicaid APG methodology,2053.71,,,2053.71,Other,100% New York Medicaid APG,2053.71,,,2053.71,Other,100% New York Medicaid APG,2053.71,,,2053.71,Other,100% New York Medicaid APG,4620.84,,,4620.84,Other,225% New York Medicaid APG,3142.17,,,3142.17,Other,153% New York Medicaid APG,4620.84,,,4620.84,Other,225% New York Medicaid APG,2875.19,,,2875.19,Other,140% New York Medicaid APG,4620.84,,,4620.84,Other,225% New York Medicaid APG,5339.64,,,5339.64,Other,260% New York Medicaid APG,6654.01,,,6654.01,Other,324% New York Medicaid APG,4415.47,,,4415.47,Other,215% New York Medicaid APG,4415.47,,,4415.47,Other,215% New York Medicaid APG,2567.13,,,2567.13,Other,125% New York Medicaid APG,2053.71,81350.86,
Follow-up surgery of eye,66250,CPT,,,,,,,,both,,,35284.74,26110.71,74,,26110.71,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15878.13,45,,15878.13,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,17465.95,49.5,,17465.95,percent of total billed charges,110% of Medicare,23993.62,68,,23993.62,percent of total billed charges,,2901.86,,,2901.86,Other,186% of Medicaid,28227.79,80,,28227.79,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,28227.79,80,,28227.79,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,24699.32,70,,24699.32,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1560.14,,,1560.14,Other,New York Medicaid APG methodology,1560.14,,,1560.14,Other,100% New York Medicaid APG,1560.14,,,1560.14,Other,100% New York Medicaid APG,1560.14,,,1560.14,Other,100% New York Medicaid APG,3510.31,,,3510.31,Other,225% New York Medicaid APG,2387.01,,,2387.01,Other,153% New York Medicaid APG,3510.31,,,3510.31,Other,225% New York Medicaid APG,2184.19,,,2184.19,Other,140% New York Medicaid APG,3510.31,,,3510.31,Other,225% New York Medicaid APG,4056.36,,,4056.36,Other,260% New York Medicaid APG,5054.85,,,5054.85,Other,324% New York Medicaid APG,3354.3,,,3354.3,Other,215% New York Medicaid APG,3354.3,,,3354.3,Other,215% New York Medicaid APG,1950.17,,,1950.17,Other,125% New York Medicaid APG,1560.14,28227.79,
Incision of iris,66500,CPT,,,,,,,,both,,,49016.23,36272.01,74,,36272.01,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,22057.3,45,,22057.3,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,24263.03,49.5,,24263.03,percent of total billed charges,110% of Medicare,33331.04,68,,33331.04,percent of total billed charges,,2901.86,,,2901.86,Other,186% of Medicaid,39212.98,80,,39212.98,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,39212.98,80,,39212.98,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,34311.36,70,,34311.36,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,1560.14,,,1560.14,Other,New York Medicaid APG methodology,1560.14,,,1560.14,Other,100% New York Medicaid APG,1560.14,,,1560.14,Other,100% New York Medicaid APG,1560.14,,,1560.14,Other,100% New York Medicaid APG,3510.31,,,3510.31,Other,225% New York Medicaid APG,2387.01,,,2387.01,Other,153% New York Medicaid APG,3510.31,,,3510.31,Other,225% New York Medicaid APG,2184.19,,,2184.19,Other,140% New York Medicaid APG,3510.31,,,3510.31,Other,225% New York Medicaid APG,4056.36,,,4056.36,Other,260% New York Medicaid APG,5054.85,,,5054.85,Other,324% New York Medicaid APG,3354.3,,,3354.3,Other,215% New York Medicaid APG,3354.3,,,3354.3,Other,215% New York Medicaid APG,1950.17,,,1950.17,Other,125% New York Medicaid APG,1560.14,39212.98,
Incision of iris,66505,CPT,,,,,,,,both,,,49016.23,36272.01,74,,36272.01,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,22057.3,45,,22057.3,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,24263.03,49.5,,24263.03,percent of total billed charges,110% of Medicare,33331.04,68,,33331.04,percent of total billed charges,,2901.86,,,2901.86,Other,186% of Medicaid,39212.98,80,,39212.98,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,39212.98,80,,39212.98,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,34311.36,70,,34311.36,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1560.14,,,1560.14,Other,New York Medicaid APG methodology,1560.14,,,1560.14,Other,100% New York Medicaid APG,1560.14,,,1560.14,Other,100% New York Medicaid APG,1560.14,,,1560.14,Other,100% New York Medicaid APG,3510.31,,,3510.31,Other,225% New York Medicaid APG,2387.01,,,2387.01,Other,153% New York Medicaid APG,3510.31,,,3510.31,Other,225% New York Medicaid APG,2184.19,,,2184.19,Other,140% New York Medicaid APG,3510.31,,,3510.31,Other,225% New York Medicaid APG,4056.36,,,4056.36,Other,260% New York Medicaid APG,5054.85,,,5054.85,Other,324% New York Medicaid APG,3354.3,,,3354.3,Other,215% New York Medicaid APG,3354.3,,,3354.3,Other,215% New York Medicaid APG,1950.17,,,1950.17,Other,125% New York Medicaid APG,1560.14,39212.98,
Remove iris and lesion,66600,CPT,,,,,,,,both,,,85519.85,63284.69,74,,63284.69,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,38483.93,45,,38483.93,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,42332.33,49.5,,42332.33,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3819.9,,,3819.9,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,59863.9,70,,59863.9,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,2053.71,,,2053.71,Other,New York Medicaid APG methodology,2053.71,,,2053.71,Other,100% New York Medicaid APG,2053.71,,,2053.71,Other,100% New York Medicaid APG,2053.71,,,2053.71,Other,100% New York Medicaid APG,4620.84,,,4620.84,Other,225% New York Medicaid APG,3142.17,,,3142.17,Other,153% New York Medicaid APG,4620.84,,,4620.84,Other,225% New York Medicaid APG,2875.19,,,2875.19,Other,140% New York Medicaid APG,4620.84,,,4620.84,Other,225% New York Medicaid APG,5339.64,,,5339.64,Other,260% New York Medicaid APG,6654.01,,,6654.01,Other,324% New York Medicaid APG,4415.47,,,4415.47,Other,215% New York Medicaid APG,4415.47,,,4415.47,Other,215% New York Medicaid APG,2567.13,,,2567.13,Other,125% New York Medicaid APG,2053.71,63284.69,
Removal of iris,66605,CPT,,,,,,,,both,,,49016.23,36272.01,74,,36272.01,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,22057.3,45,,22057.3,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,24263.03,49.5,,24263.03,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3819.9,,,3819.9,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,34311.36,70,,34311.36,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,2053.71,,,2053.71,Other,New York Medicaid APG methodology,2053.71,,,2053.71,Other,100% New York Medicaid APG,2053.71,,,2053.71,Other,100% New York Medicaid APG,2053.71,,,2053.71,Other,100% New York Medicaid APG,4620.84,,,4620.84,Other,225% New York Medicaid APG,3142.17,,,3142.17,Other,153% New York Medicaid APG,4620.84,,,4620.84,Other,225% New York Medicaid APG,2875.19,,,2875.19,Other,140% New York Medicaid APG,4620.84,,,4620.84,Other,225% New York Medicaid APG,5339.64,,,5339.64,Other,260% New York Medicaid APG,6654.01,,,6654.01,Other,324% New York Medicaid APG,4415.47,,,4415.47,Other,215% New York Medicaid APG,4415.47,,,4415.47,Other,215% New York Medicaid APG,2567.13,,,2567.13,Other,125% New York Medicaid APG,2053.71,36272.01,
Removal of iris,66625,CPT,,,,,,,,both,,,49016.23,36272.01,74,,36272.01,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,22057.3,45,,22057.3,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,24263.03,49.5,,24263.03,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2901.86,,,2901.86,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,34311.36,70,,34311.36,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1560.14,,,1560.14,Other,New York Medicaid APG methodology,1560.14,,,1560.14,Other,100% New York Medicaid APG,1560.14,,,1560.14,Other,100% New York Medicaid APG,1560.14,,,1560.14,Other,100% New York Medicaid APG,3510.31,,,3510.31,Other,225% New York Medicaid APG,2387.01,,,2387.01,Other,153% New York Medicaid APG,3510.31,,,3510.31,Other,225% New York Medicaid APG,2184.19,,,2184.19,Other,140% New York Medicaid APG,3510.31,,,3510.31,Other,225% New York Medicaid APG,4056.36,,,4056.36,Other,260% New York Medicaid APG,5054.85,,,5054.85,Other,324% New York Medicaid APG,3354.3,,,3354.3,Other,215% New York Medicaid APG,3354.3,,,3354.3,Other,215% New York Medicaid APG,1950.17,,,1950.17,Other,125% New York Medicaid APG,1560.14,36272.01,
Removal of iris,66630,CPT,,,,,,,,both,,,49016.23,36272.01,74,,36272.01,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,22057.3,45,,22057.3,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,24263.03,49.5,,24263.03,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2901.86,,,2901.86,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,34311.36,70,,34311.36,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1560.14,,,1560.14,Other,New York Medicaid APG methodology,1560.14,,,1560.14,Other,100% New York Medicaid APG,1560.14,,,1560.14,Other,100% New York Medicaid APG,1560.14,,,1560.14,Other,100% New York Medicaid APG,3510.31,,,3510.31,Other,225% New York Medicaid APG,2387.01,,,2387.01,Other,153% New York Medicaid APG,3510.31,,,3510.31,Other,225% New York Medicaid APG,2184.19,,,2184.19,Other,140% New York Medicaid APG,3510.31,,,3510.31,Other,225% New York Medicaid APG,4056.36,,,4056.36,Other,260% New York Medicaid APG,5054.85,,,5054.85,Other,324% New York Medicaid APG,3354.3,,,3354.3,Other,215% New York Medicaid APG,3354.3,,,3354.3,Other,215% New York Medicaid APG,1950.17,,,1950.17,Other,125% New York Medicaid APG,1560.14,36272.01,
Removal of iris,66635,CPT,,,,,,,,both,,,34653.65,25643.7,74,,25643.7,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15594.14,45,,15594.14,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,17153.56,49.5,,17153.56,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2901.86,,,2901.86,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,24257.56,70,,24257.56,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1560.14,,,1560.14,Other,New York Medicaid APG methodology,1560.14,,,1560.14,Other,100% New York Medicaid APG,1560.14,,,1560.14,Other,100% New York Medicaid APG,1560.14,,,1560.14,Other,100% New York Medicaid APG,3510.31,,,3510.31,Other,225% New York Medicaid APG,2387.01,,,2387.01,Other,153% New York Medicaid APG,3510.31,,,3510.31,Other,225% New York Medicaid APG,2184.19,,,2184.19,Other,140% New York Medicaid APG,3510.31,,,3510.31,Other,225% New York Medicaid APG,4056.36,,,4056.36,Other,260% New York Medicaid APG,5054.85,,,5054.85,Other,324% New York Medicaid APG,3354.3,,,3354.3,Other,215% New York Medicaid APG,3354.3,,,3354.3,Other,215% New York Medicaid APG,1950.17,,,1950.17,Other,125% New York Medicaid APG,1560.14,25643.7,
Repair iris & ciliary body,66680,CPT,,,,,,,,both,,,49016.23,36272.01,74,,36272.01,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,22057.3,45,,22057.3,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,24263.03,49.5,,24263.03,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2901.86,,,2901.86,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,34311.36,70,,34311.36,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1560.14,,,1560.14,Other,New York Medicaid APG methodology,1560.14,,,1560.14,Other,100% New York Medicaid APG,1560.14,,,1560.14,Other,100% New York Medicaid APG,1560.14,,,1560.14,Other,100% New York Medicaid APG,3510.31,,,3510.31,Other,225% New York Medicaid APG,2387.01,,,2387.01,Other,153% New York Medicaid APG,3510.31,,,3510.31,Other,225% New York Medicaid APG,2184.19,,,2184.19,Other,140% New York Medicaid APG,3510.31,,,3510.31,Other,225% New York Medicaid APG,4056.36,,,4056.36,Other,260% New York Medicaid APG,5054.85,,,5054.85,Other,324% New York Medicaid APG,3354.3,,,3354.3,Other,215% New York Medicaid APG,3354.3,,,3354.3,Other,215% New York Medicaid APG,1950.17,,,1950.17,Other,125% New York Medicaid APG,1560.14,36272.01,
Repair iris & ciliary body,66682,CPT,,,,,,,,both,,,34563.38,25576.9,74,,25576.9,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15553.52,45,,15553.52,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,17108.87,49.5,,17108.87,percent of total billed charges,110% of Medicare,23503.1,68,,23503.1,percent of total billed charges,,2901.86,,,2901.86,Other,186% of Medicaid,27650.7,80,,27650.7,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,27650.7,80,,27650.7,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,24194.37,70,,24194.37,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1560.14,,,1560.14,Other,New York Medicaid APG methodology,1560.14,,,1560.14,Other,100% New York Medicaid APG,1560.14,,,1560.14,Other,100% New York Medicaid APG,1560.14,,,1560.14,Other,100% New York Medicaid APG,3510.31,,,3510.31,Other,225% New York Medicaid APG,2387.01,,,2387.01,Other,153% New York Medicaid APG,3510.31,,,3510.31,Other,225% New York Medicaid APG,2184.19,,,2184.19,Other,140% New York Medicaid APG,3510.31,,,3510.31,Other,225% New York Medicaid APG,4056.36,,,4056.36,Other,260% New York Medicaid APG,5054.85,,,5054.85,Other,324% New York Medicaid APG,3354.3,,,3354.3,Other,215% New York Medicaid APG,3354.3,,,3354.3,Other,215% New York Medicaid APG,1950.17,,,1950.17,Other,125% New York Medicaid APG,1560.14,27650.7,
Destruction ciliary body,66700,CPT,,,,,,,,both,,,49016.23,36272.01,74,,36272.01,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,22057.3,45,,22057.3,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,24263.03,49.5,,24263.03,percent of total billed charges,110% of Medicare,33331.04,68,,33331.04,percent of total billed charges,,2901.86,,,2901.86,Other,186% of Medicaid,39212.98,80,,39212.98,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,39212.98,80,,39212.98,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,34311.36,70,,34311.36,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1560.14,,,1560.14,Other,New York Medicaid APG methodology,1560.14,,,1560.14,Other,100% New York Medicaid APG,1560.14,,,1560.14,Other,100% New York Medicaid APG,1560.14,,,1560.14,Other,100% New York Medicaid APG,3510.31,,,3510.31,Other,225% New York Medicaid APG,2387.01,,,2387.01,Other,153% New York Medicaid APG,3510.31,,,3510.31,Other,225% New York Medicaid APG,2184.19,,,2184.19,Other,140% New York Medicaid APG,3510.31,,,3510.31,Other,225% New York Medicaid APG,4056.36,,,4056.36,Other,260% New York Medicaid APG,5054.85,,,5054.85,Other,324% New York Medicaid APG,3354.3,,,3354.3,Other,215% New York Medicaid APG,3354.3,,,3354.3,Other,215% New York Medicaid APG,1950.17,,,1950.17,Other,125% New York Medicaid APG,1560.14,39212.98,
Ciliary transsleral therapy,66710,CPT,,,,,,,,both,,,35866.05,26540.88,74,,26540.88,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,16139.72,45,,16139.72,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,17753.69,49.5,,17753.69,percent of total billed charges,110% of Medicare,24388.91,68,,24388.91,percent of total billed charges,,2901.86,,,2901.86,Other,186% of Medicaid,28692.84,80,,28692.84,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,28692.84,80,,28692.84,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,25106.24,70,,25106.24,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1560.14,,,1560.14,Other,New York Medicaid APG methodology,1560.14,,,1560.14,Other,100% New York Medicaid APG,1560.14,,,1560.14,Other,100% New York Medicaid APG,1560.14,,,1560.14,Other,100% New York Medicaid APG,3510.31,,,3510.31,Other,225% New York Medicaid APG,2387.01,,,2387.01,Other,153% New York Medicaid APG,3510.31,,,3510.31,Other,225% New York Medicaid APG,2184.19,,,2184.19,Other,140% New York Medicaid APG,3510.31,,,3510.31,Other,225% New York Medicaid APG,4056.36,,,4056.36,Other,260% New York Medicaid APG,5054.85,,,5054.85,Other,324% New York Medicaid APG,3354.3,,,3354.3,Other,215% New York Medicaid APG,3354.3,,,3354.3,Other,215% New York Medicaid APG,1950.17,,,1950.17,Other,125% New York Medicaid APG,1560.14,28692.84,
Ecp ciliary body destruction,66711,CPT,,,,,,,,both,,,49016.23,36272.01,74,,36272.01,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,22057.3,45,,22057.3,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,24263.03,49.5,,24263.03,percent of total billed charges,110% of Medicare,33331.04,68,,33331.04,percent of total billed charges,,2901.86,,,2901.86,Other,186% of Medicaid,39212.98,80,,39212.98,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,39212.98,80,,39212.98,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,34311.36,70,,34311.36,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1560.14,,,1560.14,Other,New York Medicaid APG methodology,1560.14,,,1560.14,Other,100% New York Medicaid APG,1560.14,,,1560.14,Other,100% New York Medicaid APG,1560.14,,,1560.14,Other,100% New York Medicaid APG,3510.31,,,3510.31,Other,225% New York Medicaid APG,2387.01,,,2387.01,Other,153% New York Medicaid APG,3510.31,,,3510.31,Other,225% New York Medicaid APG,2184.19,,,2184.19,Other,140% New York Medicaid APG,3510.31,,,3510.31,Other,225% New York Medicaid APG,4056.36,,,4056.36,Other,260% New York Medicaid APG,5054.85,,,5054.85,Other,324% New York Medicaid APG,3354.3,,,3354.3,Other,215% New York Medicaid APG,3354.3,,,3354.3,Other,215% New York Medicaid APG,1950.17,,,1950.17,Other,125% New York Medicaid APG,1560.14,39212.98,
Destruction ciliary body,66720,CPT,,,,,,,,both,,,49151.56,36372.15,74,,36372.15,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,22118.2,45,,22118.2,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,24330.02,49.5,,24330.02,percent of total billed charges,110% of Medicare,33423.06,68,,33423.06,percent of total billed charges,,2901.86,,,2901.86,Other,186% of Medicaid,39321.25,80,,39321.25,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,39321.25,80,,39321.25,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,34406.09,70,,34406.09,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1560.14,,,1560.14,Other,New York Medicaid APG methodology,1560.14,,,1560.14,Other,100% New York Medicaid APG,1560.14,,,1560.14,Other,100% New York Medicaid APG,1560.14,,,1560.14,Other,100% New York Medicaid APG,3510.31,,,3510.31,Other,225% New York Medicaid APG,2387.01,,,2387.01,Other,153% New York Medicaid APG,3510.31,,,3510.31,Other,225% New York Medicaid APG,2184.19,,,2184.19,Other,140% New York Medicaid APG,3510.31,,,3510.31,Other,225% New York Medicaid APG,4056.36,,,4056.36,Other,260% New York Medicaid APG,5054.85,,,5054.85,Other,324% New York Medicaid APG,3354.3,,,3354.3,Other,215% New York Medicaid APG,3354.3,,,3354.3,Other,215% New York Medicaid APG,1950.17,,,1950.17,Other,125% New York Medicaid APG,1560.14,39321.25,
Destruction ciliary body,66740,CPT,,,,,,,,both,,,49151.56,36372.15,74,,36372.15,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,22118.2,45,,22118.2,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,24330.02,49.5,,24330.02,percent of total billed charges,110% of Medicare,33423.06,68,,33423.06,percent of total billed charges,,2901.86,,,2901.86,Other,186% of Medicaid,39321.25,80,,39321.25,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,39321.25,80,,39321.25,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,34406.09,70,,34406.09,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1560.14,,,1560.14,Other,New York Medicaid APG methodology,1560.14,,,1560.14,Other,100% New York Medicaid APG,1560.14,,,1560.14,Other,100% New York Medicaid APG,1560.14,,,1560.14,Other,100% New York Medicaid APG,3510.31,,,3510.31,Other,225% New York Medicaid APG,2387.01,,,2387.01,Other,153% New York Medicaid APG,3510.31,,,3510.31,Other,225% New York Medicaid APG,2184.19,,,2184.19,Other,140% New York Medicaid APG,3510.31,,,3510.31,Other,225% New York Medicaid APG,4056.36,,,4056.36,Other,260% New York Medicaid APG,5054.85,,,5054.85,Other,324% New York Medicaid APG,3354.3,,,3354.3,Other,215% New York Medicaid APG,3354.3,,,3354.3,Other,215% New York Medicaid APG,1950.17,,,1950.17,Other,125% New York Medicaid APG,1560.14,39321.25,
Revision of iris,66761,CPT,,,,,,,,both,,,12226.3,9047.46,74,,9047.46,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,5501.84,45,,5501.84,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,6052.02,49.5,,6052.02,percent of total billed charges,110% of Medicare,8313.88,68,,8313.88,percent of total billed charges,,2901.86,,,2901.86,Other,186% of Medicaid,9781.04,80,,9781.04,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,9781.04,80,,9781.04,percent of total billed charges,,7216,,,7216,Case Rate,,3578,,"100% primary, 0% secondary procedures",3578,Other,MagnaCare ASC Grouper,8558.41,70,,8558.41,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,1560.14,,,1560.14,Other,New York Medicaid APG methodology,1560.14,,,1560.14,Other,100% New York Medicaid APG,1560.14,,,1560.14,Other,100% New York Medicaid APG,1560.14,,,1560.14,Other,100% New York Medicaid APG,3510.31,,,3510.31,Other,225% New York Medicaid APG,2387.01,,,2387.01,Other,153% New York Medicaid APG,3510.31,,,3510.31,Other,225% New York Medicaid APG,2184.19,,,2184.19,Other,140% New York Medicaid APG,3510.31,,,3510.31,Other,225% New York Medicaid APG,4056.36,,,4056.36,Other,260% New York Medicaid APG,5054.85,,,5054.85,Other,324% New York Medicaid APG,3354.3,,,3354.3,Other,215% New York Medicaid APG,3354.3,,,3354.3,Other,215% New York Medicaid APG,1950.17,,,1950.17,Other,125% New York Medicaid APG,1560.14,9781.04,
Revision of iris,66762,CPT,,,,,,,,both,,,12226.3,9047.46,74,,9047.46,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,5501.84,45,,5501.84,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,6052.02,49.5,,6052.02,percent of total billed charges,110% of Medicare,8313.88,68,,8313.88,percent of total billed charges,,2901.86,,,2901.86,Other,186% of Medicaid,9781.04,80,,9781.04,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,9781.04,80,,9781.04,percent of total billed charges,,7216,,,7216,Case Rate,,3578,,"100% primary, 0% secondary procedures",3578,Other,MagnaCare ASC Grouper,8558.41,70,,8558.41,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,1560.14,,,1560.14,Other,New York Medicaid APG methodology,1560.14,,,1560.14,Other,100% New York Medicaid APG,1560.14,,,1560.14,Other,100% New York Medicaid APG,1560.14,,,1560.14,Other,100% New York Medicaid APG,3510.31,,,3510.31,Other,225% New York Medicaid APG,2387.01,,,2387.01,Other,153% New York Medicaid APG,3510.31,,,3510.31,Other,225% New York Medicaid APG,2184.19,,,2184.19,Other,140% New York Medicaid APG,3510.31,,,3510.31,Other,225% New York Medicaid APG,4056.36,,,4056.36,Other,260% New York Medicaid APG,5054.85,,,5054.85,Other,324% New York Medicaid APG,3354.3,,,3354.3,Other,215% New York Medicaid APG,3354.3,,,3354.3,Other,215% New York Medicaid APG,1950.17,,,1950.17,Other,125% New York Medicaid APG,1560.14,9781.04,
Removal of inner eye lesion,66770,CPT,,,,,,,,both,,,12226.3,9047.46,74,,9047.46,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,5501.84,45,,5501.84,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,6052.02,49.5,,6052.02,percent of total billed charges,110% of Medicare,8313.88,68,,8313.88,percent of total billed charges,,2901.86,,,2901.86,Other,186% of Medicaid,9781.04,80,,9781.04,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,9781.04,80,,9781.04,percent of total billed charges,,7216,,,7216,Case Rate,,3578,,"100% primary, 0% secondary procedures",3578,Other,MagnaCare ASC Grouper,8558.41,70,,8558.41,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,1560.14,,,1560.14,Other,New York Medicaid APG methodology,1560.14,,,1560.14,Other,100% New York Medicaid APG,1560.14,,,1560.14,Other,100% New York Medicaid APG,1560.14,,,1560.14,Other,100% New York Medicaid APG,3510.31,,,3510.31,Other,225% New York Medicaid APG,2387.01,,,2387.01,Other,153% New York Medicaid APG,3510.31,,,3510.31,Other,225% New York Medicaid APG,2184.19,,,2184.19,Other,140% New York Medicaid APG,3510.31,,,3510.31,Other,225% New York Medicaid APG,4056.36,,,4056.36,Other,260% New York Medicaid APG,5054.85,,,5054.85,Other,324% New York Medicaid APG,3354.3,,,3354.3,Other,215% New York Medicaid APG,3354.3,,,3354.3,Other,215% New York Medicaid APG,1950.17,,,1950.17,Other,125% New York Medicaid APG,1560.14,9781.04,
Incision secondary cataract,66820,CPT,,,,,,,,both,,,36328.3,26882.94,74,,26882.94,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,16347.74,45,,16347.74,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,17982.51,49.5,,17982.51,percent of total billed charges,110% of Medicare,24703.24,68,,24703.24,percent of total billed charges,,2859.52,,,2859.52,Other,186% of Medicaid,29062.64,80,,29062.64,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,29062.64,80,,29062.64,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,25429.81,70,,25429.81,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,1537.38,,,1537.38,Other,New York Medicaid APG methodology,1537.38,,,1537.38,Other,100% New York Medicaid APG,1537.38,,,1537.38,Other,100% New York Medicaid APG,1537.38,,,1537.38,Other,100% New York Medicaid APG,3459.1,,,3459.1,Other,225% New York Medicaid APG,2352.19,,,2352.19,Other,153% New York Medicaid APG,3459.1,,,3459.1,Other,225% New York Medicaid APG,2152.33,,,2152.33,Other,140% New York Medicaid APG,3459.1,,,3459.1,Other,225% New York Medicaid APG,3997.18,,,3997.18,Other,260% New York Medicaid APG,4981.1,,,4981.1,Other,324% New York Medicaid APG,3305.36,,,3305.36,Other,215% New York Medicaid APG,3305.36,,,3305.36,Other,215% New York Medicaid APG,1921.72,,,1921.72,Other,125% New York Medicaid APG,1537.38,29062.64,
After cataract laser surgery,66821,CPT,,,,,,,,both,,,12226.3,9047.46,74,,9047.46,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,5501.84,45,,5501.84,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,6052.02,49.5,,6052.02,percent of total billed charges,110% of Medicare,8313.88,68,,8313.88,percent of total billed charges,,2859.52,,,2859.52,Other,186% of Medicaid,9781.04,80,,9781.04,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,9781.04,80,,9781.04,percent of total billed charges,,7216,,,7216,Case Rate,,3578,,"100% primary, 0% secondary procedures",3578,Other,MagnaCare ASC Grouper,8558.41,70,,8558.41,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,1537.38,,,1537.38,Other,New York Medicaid APG methodology,1537.38,,,1537.38,Other,100% New York Medicaid APG,1537.38,,,1537.38,Other,100% New York Medicaid APG,1537.38,,,1537.38,Other,100% New York Medicaid APG,3459.1,,,3459.1,Other,225% New York Medicaid APG,2352.19,,,2352.19,Other,153% New York Medicaid APG,3459.1,,,3459.1,Other,225% New York Medicaid APG,2152.33,,,2152.33,Other,140% New York Medicaid APG,3459.1,,,3459.1,Other,225% New York Medicaid APG,3997.18,,,3997.18,Other,260% New York Medicaid APG,4981.1,,,4981.1,Other,324% New York Medicaid APG,3305.36,,,3305.36,Other,215% New York Medicaid APG,3305.36,,,3305.36,Other,215% New York Medicaid APG,1921.72,,,1921.72,Other,125% New York Medicaid APG,1537.38,9781.04,
Reposition intraocular lens,66825,CPT,,,,,,,,both,,,34585.06,25592.94,74,,25592.94,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15563.28,45,,15563.28,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,17119.6,49.5,,17119.6,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3564.08,,,3564.08,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,24209.54,70,,24209.54,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1916.17,,,1916.17,Other,New York Medicaid APG methodology,1916.17,,,1916.17,Other,100% New York Medicaid APG,1916.17,,,1916.17,Other,100% New York Medicaid APG,1916.17,,,1916.17,Other,100% New York Medicaid APG,4311.39,,,4311.39,Other,225% New York Medicaid APG,2931.75,,,2931.75,Other,153% New York Medicaid APG,4311.39,,,4311.39,Other,225% New York Medicaid APG,2682.64,,,2682.64,Other,140% New York Medicaid APG,4311.39,,,4311.39,Other,225% New York Medicaid APG,4982.05,,,4982.05,Other,260% New York Medicaid APG,6208.4,,,6208.4,Other,324% New York Medicaid APG,4119.77,,,4119.77,Other,215% New York Medicaid APG,4119.77,,,4119.77,Other,215% New York Medicaid APG,2395.22,,,2395.22,Other,125% New York Medicaid APG,1916.17,25592.94,
Removal of lens lesion,66830,CPT,,,,,,,,both,,,36830.68,27254.7,74,,27254.7,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,16573.81,45,,16573.81,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,18231.19,49.5,,18231.19,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2859.52,,,2859.52,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,25781.48,70,,25781.48,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1537.38,,,1537.38,Other,New York Medicaid APG methodology,1537.38,,,1537.38,Other,100% New York Medicaid APG,1537.38,,,1537.38,Other,100% New York Medicaid APG,1537.38,,,1537.38,Other,100% New York Medicaid APG,3459.1,,,3459.1,Other,225% New York Medicaid APG,2352.19,,,2352.19,Other,153% New York Medicaid APG,3459.1,,,3459.1,Other,225% New York Medicaid APG,2152.33,,,2152.33,Other,140% New York Medicaid APG,3459.1,,,3459.1,Other,225% New York Medicaid APG,3997.18,,,3997.18,Other,260% New York Medicaid APG,4981.1,,,4981.1,Other,324% New York Medicaid APG,3305.36,,,3305.36,Other,215% New York Medicaid APG,3305.36,,,3305.36,Other,215% New York Medicaid APG,1921.72,,,1921.72,Other,125% New York Medicaid APG,1537.38,27254.7,
Removal of lens material,66840,CPT,,,,,,,,both,,,34704.95,25681.66,74,,25681.66,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15617.23,45,,15617.23,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,17178.95,49.5,,17178.95,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3564.08,,,3564.08,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,24293.47,70,,24293.47,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1916.17,,,1916.17,Other,New York Medicaid APG methodology,1916.17,,,1916.17,Other,100% New York Medicaid APG,1916.17,,,1916.17,Other,100% New York Medicaid APG,1916.17,,,1916.17,Other,100% New York Medicaid APG,4311.39,,,4311.39,Other,225% New York Medicaid APG,2931.75,,,2931.75,Other,153% New York Medicaid APG,4311.39,,,4311.39,Other,225% New York Medicaid APG,2682.64,,,2682.64,Other,140% New York Medicaid APG,4311.39,,,4311.39,Other,225% New York Medicaid APG,4982.05,,,4982.05,Other,260% New York Medicaid APG,6208.4,,,6208.4,Other,324% New York Medicaid APG,4119.77,,,4119.77,Other,215% New York Medicaid APG,4119.77,,,4119.77,Other,215% New York Medicaid APG,2395.22,,,2395.22,Other,125% New York Medicaid APG,1916.17,25681.66,
Removal of lens material,66850,CPT,,,,,,,,both,,,35390.55,26189.01,74,,26189.01,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15925.75,45,,15925.75,percent of total billed charges,Medicare Ratio of cost to charges,5954,,"100% primary, 50% supplemental procedure",5954,Other,Aetna ASC Grouper,5359,,"100% primary, 50% supplemental procedure",5359,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,17518.32,49.5,,17518.32,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3564.08,,,3564.08,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,24773.39,70,,24773.39,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1916.17,,,1916.17,Other,New York Medicaid APG methodology,1916.17,,,1916.17,Other,100% New York Medicaid APG,1916.17,,,1916.17,Other,100% New York Medicaid APG,1916.17,,,1916.17,Other,100% New York Medicaid APG,4311.39,,,4311.39,Other,225% New York Medicaid APG,2931.75,,,2931.75,Other,153% New York Medicaid APG,4311.39,,,4311.39,Other,225% New York Medicaid APG,2682.64,,,2682.64,Other,140% New York Medicaid APG,4311.39,,,4311.39,Other,225% New York Medicaid APG,4982.05,,,4982.05,Other,260% New York Medicaid APG,6208.4,,,6208.4,Other,324% New York Medicaid APG,4119.77,,,4119.77,Other,215% New York Medicaid APG,4119.77,,,4119.77,Other,215% New York Medicaid APG,2395.22,,,2395.22,Other,125% New York Medicaid APG,1916.17,26189.01,
Removal of lens material,66852,CPT,,,,,,,,both,,,36152.09,26752.55,74,,26752.55,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,16268.44,45,,16268.44,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,17895.28,49.5,,17895.28,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3564.08,,,3564.08,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,25306.46,70,,25306.46,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,1916.17,,,1916.17,Other,New York Medicaid APG methodology,1916.17,,,1916.17,Other,100% New York Medicaid APG,1916.17,,,1916.17,Other,100% New York Medicaid APG,1916.17,,,1916.17,Other,100% New York Medicaid APG,4311.39,,,4311.39,Other,225% New York Medicaid APG,2931.75,,,2931.75,Other,153% New York Medicaid APG,4311.39,,,4311.39,Other,225% New York Medicaid APG,2682.64,,,2682.64,Other,140% New York Medicaid APG,4311.39,,,4311.39,Other,225% New York Medicaid APG,4982.05,,,4982.05,Other,260% New York Medicaid APG,6208.4,,,6208.4,Other,324% New York Medicaid APG,4119.77,,,4119.77,Other,215% New York Medicaid APG,4119.77,,,4119.77,Other,215% New York Medicaid APG,2395.22,,,2395.22,Other,125% New York Medicaid APG,1916.17,26752.55,
Extraction of lens,66920,CPT,,,,,,,,both,,,49016.23,36272.01,74,,36272.01,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,22057.3,45,,22057.3,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,24263.03,49.5,,24263.03,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3564.08,,,3564.08,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,34311.36,70,,34311.36,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1916.17,,,1916.17,Other,New York Medicaid APG methodology,1916.17,,,1916.17,Other,100% New York Medicaid APG,1916.17,,,1916.17,Other,100% New York Medicaid APG,1916.17,,,1916.17,Other,100% New York Medicaid APG,4311.39,,,4311.39,Other,225% New York Medicaid APG,2931.75,,,2931.75,Other,153% New York Medicaid APG,4311.39,,,4311.39,Other,225% New York Medicaid APG,2682.64,,,2682.64,Other,140% New York Medicaid APG,4311.39,,,4311.39,Other,225% New York Medicaid APG,4982.05,,,4982.05,Other,260% New York Medicaid APG,6208.4,,,6208.4,Other,324% New York Medicaid APG,4119.77,,,4119.77,Other,215% New York Medicaid APG,4119.77,,,4119.77,Other,215% New York Medicaid APG,2395.22,,,2395.22,Other,125% New York Medicaid APG,1916.17,36272.01,
Extraction of lens,66930,CPT,,,,,,,,both,,,85519.85,63284.69,74,,63284.69,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,38483.93,45,,38483.93,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,42332.33,49.5,,42332.33,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3564.08,,,3564.08,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,59863.9,70,,59863.9,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1916.17,,,1916.17,Other,New York Medicaid APG methodology,1916.17,,,1916.17,Other,100% New York Medicaid APG,1916.17,,,1916.17,Other,100% New York Medicaid APG,1916.17,,,1916.17,Other,100% New York Medicaid APG,4311.39,,,4311.39,Other,225% New York Medicaid APG,2931.75,,,2931.75,Other,153% New York Medicaid APG,4311.39,,,4311.39,Other,225% New York Medicaid APG,2682.64,,,2682.64,Other,140% New York Medicaid APG,4311.39,,,4311.39,Other,225% New York Medicaid APG,4982.05,,,4982.05,Other,260% New York Medicaid APG,6208.4,,,6208.4,Other,324% New York Medicaid APG,4119.77,,,4119.77,Other,215% New York Medicaid APG,4119.77,,,4119.77,Other,215% New York Medicaid APG,2395.22,,,2395.22,Other,125% New York Medicaid APG,1916.17,63284.69,
Extraction of lens,66940,CPT,,,,,,,,both,,,34887.95,25817.08,74,,25817.08,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15699.58,45,,15699.58,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,17269.54,49.5,,17269.54,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3564.08,,,3564.08,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,24421.57,70,,24421.57,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1916.17,,,1916.17,Other,New York Medicaid APG methodology,1916.17,,,1916.17,Other,100% New York Medicaid APG,1916.17,,,1916.17,Other,100% New York Medicaid APG,1916.17,,,1916.17,Other,100% New York Medicaid APG,4311.39,,,4311.39,Other,225% New York Medicaid APG,2931.75,,,2931.75,Other,153% New York Medicaid APG,4311.39,,,4311.39,Other,225% New York Medicaid APG,2682.64,,,2682.64,Other,140% New York Medicaid APG,4311.39,,,4311.39,Other,225% New York Medicaid APG,4982.05,,,4982.05,Other,260% New York Medicaid APG,6208.4,,,6208.4,Other,324% New York Medicaid APG,4119.77,,,4119.77,Other,215% New York Medicaid APG,4119.77,,,4119.77,Other,215% New York Medicaid APG,2395.22,,,2395.22,Other,125% New York Medicaid APG,1916.17,25817.08,
Xcapsl ctrc rmvl cplx wo ecp,66982,CPT,,,,,,,,both,,,36521.55,27025.95,74,,27025.95,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,16434.7,45,,16434.7,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,18078.17,49.5,,18078.17,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3564.08,,,3564.08,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,25565.09,70,,25565.09,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1916.17,,,1916.17,Other,New York Medicaid APG methodology,1916.17,,,1916.17,Other,100% New York Medicaid APG,1916.17,,,1916.17,Other,100% New York Medicaid APG,1916.17,,,1916.17,Other,100% New York Medicaid APG,4311.39,,,4311.39,Other,225% New York Medicaid APG,2931.75,,,2931.75,Other,153% New York Medicaid APG,4311.39,,,4311.39,Other,225% New York Medicaid APG,2682.64,,,2682.64,Other,140% New York Medicaid APG,4311.39,,,4311.39,Other,225% New York Medicaid APG,4982.05,,,4982.05,Other,260% New York Medicaid APG,6208.4,,,6208.4,Other,324% New York Medicaid APG,4119.77,,,4119.77,Other,215% New York Medicaid APG,4119.77,,,4119.77,Other,215% New York Medicaid APG,2395.22,,,2395.22,Other,125% New York Medicaid APG,1916.17,27025.95,
Cataract surg w/iol 1 stage,66983,CPT,,,,,,,,both,,,49016.23,36272.01,74,,36272.01,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,22057.3,45,,22057.3,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,24263.03,49.5,,24263.03,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3564.08,,,3564.08,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,34311.36,70,,34311.36,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1916.17,,,1916.17,Other,New York Medicaid APG methodology,1916.17,,,1916.17,Other,100% New York Medicaid APG,1916.17,,,1916.17,Other,100% New York Medicaid APG,1916.17,,,1916.17,Other,100% New York Medicaid APG,4311.39,,,4311.39,Other,225% New York Medicaid APG,2931.75,,,2931.75,Other,153% New York Medicaid APG,4311.39,,,4311.39,Other,225% New York Medicaid APG,2682.64,,,2682.64,Other,140% New York Medicaid APG,4311.39,,,4311.39,Other,225% New York Medicaid APG,4982.05,,,4982.05,Other,260% New York Medicaid APG,6208.4,,,6208.4,Other,324% New York Medicaid APG,4119.77,,,4119.77,Other,215% New York Medicaid APG,4119.77,,,4119.77,Other,215% New York Medicaid APG,2395.22,,,2395.22,Other,125% New York Medicaid APG,1916.17,36272.01,
Xcapsl ctrc rmvl w/o ecp,66984,CPT,,,,,,,,both,,,35854.93,26532.65,74,,26532.65,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,16134.72,45,,16134.72,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,17748.19,49.5,,17748.19,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3564.08,,,3564.08,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,25098.45,70,,25098.45,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1916.17,,,1916.17,Other,New York Medicaid APG methodology,1916.17,,,1916.17,Other,100% New York Medicaid APG,1916.17,,,1916.17,Other,100% New York Medicaid APG,1916.17,,,1916.17,Other,100% New York Medicaid APG,4311.39,,,4311.39,Other,225% New York Medicaid APG,2931.75,,,2931.75,Other,153% New York Medicaid APG,4311.39,,,4311.39,Other,225% New York Medicaid APG,2682.64,,,2682.64,Other,140% New York Medicaid APG,4311.39,,,4311.39,Other,225% New York Medicaid APG,4982.05,,,4982.05,Other,260% New York Medicaid APG,6208.4,,,6208.4,Other,324% New York Medicaid APG,4119.77,,,4119.77,Other,215% New York Medicaid APG,4119.77,,,4119.77,Other,215% New York Medicaid APG,2395.22,,,2395.22,Other,125% New York Medicaid APG,1916.17,26532.65,
Insert lens prosthesis,66985,CPT,,,,,,,,both,,,36877,27288.98,74,,27288.98,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,16594.65,45,,16594.65,percent of total billed charges,Medicare Ratio of cost to charges,5459,,"100% primary, 50% supplemental procedure",5459,Other,Aetna ASC Grouper,4913,,"100% primary, 50% supplemental procedure",4913,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,18254.12,49.5,,18254.12,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3564.08,,,3564.08,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,25813.9,70,,25813.9,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1916.17,,,1916.17,Other,New York Medicaid APG methodology,1916.17,,,1916.17,Other,100% New York Medicaid APG,1916.17,,,1916.17,Other,100% New York Medicaid APG,1916.17,,,1916.17,Other,100% New York Medicaid APG,4311.39,,,4311.39,Other,225% New York Medicaid APG,2931.75,,,2931.75,Other,153% New York Medicaid APG,4311.39,,,4311.39,Other,225% New York Medicaid APG,2682.64,,,2682.64,Other,140% New York Medicaid APG,4311.39,,,4311.39,Other,225% New York Medicaid APG,4982.05,,,4982.05,Other,260% New York Medicaid APG,6208.4,,,6208.4,Other,324% New York Medicaid APG,4119.77,,,4119.77,Other,215% New York Medicaid APG,4119.77,,,4119.77,Other,215% New York Medicaid APG,2395.22,,,2395.22,Other,125% New York Medicaid APG,1916.17,27288.98,
Exchange lens prosthesis,66986,CPT,,,,,,,,both,,,36572.97,27064,74,,27064,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,16457.84,45,,16457.84,percent of total billed charges,Medicare Ratio of cost to charges,5459,,"100% primary, 50% supplemental procedure",5459,Other,Aetna ASC Grouper,4913,,"100% primary, 50% supplemental procedure",4913,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,18103.62,49.5,,18103.62,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3564.08,,,3564.08,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,25601.08,70,,25601.08,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1916.17,,,1916.17,Other,New York Medicaid APG methodology,1916.17,,,1916.17,Other,100% New York Medicaid APG,1916.17,,,1916.17,Other,100% New York Medicaid APG,1916.17,,,1916.17,Other,100% New York Medicaid APG,4311.39,,,4311.39,Other,225% New York Medicaid APG,2931.75,,,2931.75,Other,153% New York Medicaid APG,4311.39,,,4311.39,Other,225% New York Medicaid APG,2682.64,,,2682.64,Other,140% New York Medicaid APG,4311.39,,,4311.39,Other,225% New York Medicaid APG,4982.05,,,4982.05,Other,260% New York Medicaid APG,6208.4,,,6208.4,Other,324% New York Medicaid APG,4119.77,,,4119.77,Other,215% New York Medicaid APG,4119.77,,,4119.77,Other,215% New York Medicaid APG,2395.22,,,2395.22,Other,125% New York Medicaid APG,1916.17,27064,
Xcapsl ctrc rmvl cplx w/ecp,66987,CPT,,,,,,,,both,,,85519.85,63284.69,74,,63284.69,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,38483.93,45,,38483.93,percent of total billed charges,Medicare Ratio of cost to charges,5459,,"100% primary, 50% supplemental procedure",5459,Other,Aetna ASC Grouper,4913,,"100% primary, 50% supplemental procedure",4913,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,42332.33,49.5,,42332.33,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3564.08,,,3564.08,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,59863.9,70,,59863.9,percent of total billed charges,,55587.9,65,,55587.9,percent of total billed charges,,55587.9,65,,55587.9,percent of total billed charges,,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,1916.17,,,1916.17,Other,New York Medicaid APG methodology,1916.17,,,1916.17,Other,100% New York Medicaid APG,1916.17,,,1916.17,Other,100% New York Medicaid APG,1916.17,,,1916.17,Other,100% New York Medicaid APG,4311.39,,,4311.39,Other,225% New York Medicaid APG,2931.75,,,2931.75,Other,153% New York Medicaid APG,4311.39,,,4311.39,Other,225% New York Medicaid APG,2682.64,,,2682.64,Other,140% New York Medicaid APG,4311.39,,,4311.39,Other,225% New York Medicaid APG,4982.05,,,4982.05,Other,260% New York Medicaid APG,6208.4,,,6208.4,Other,324% New York Medicaid APG,4119.77,,,4119.77,Other,215% New York Medicaid APG,4119.77,,,4119.77,Other,215% New York Medicaid APG,2395.22,,,2395.22,Other,125% New York Medicaid APG,1916.17,63284.69,
Xcapsl ctrc rmvl w/ecp,66988,CPT,,,,,,,,both,,,85519.85,63284.69,74,,63284.69,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,38483.93,45,,38483.93,percent of total billed charges,Medicare Ratio of cost to charges,5459,,"100% primary, 50% supplemental procedure",5459,Other,Aetna ASC Grouper,4913,,"100% primary, 50% supplemental procedure",4913,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,42332.33,49.5,,42332.33,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3564.08,,,3564.08,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,59863.9,70,,59863.9,percent of total billed charges,,55587.9,65,,55587.9,percent of total billed charges,,55587.9,65,,55587.9,percent of total billed charges,,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,1916.17,,,1916.17,Other,New York Medicaid APG methodology,1916.17,,,1916.17,Other,100% New York Medicaid APG,1916.17,,,1916.17,Other,100% New York Medicaid APG,1916.17,,,1916.17,Other,100% New York Medicaid APG,4311.39,,,4311.39,Other,225% New York Medicaid APG,2931.75,,,2931.75,Other,153% New York Medicaid APG,4311.39,,,4311.39,Other,225% New York Medicaid APG,2682.64,,,2682.64,Other,140% New York Medicaid APG,4311.39,,,4311.39,Other,225% New York Medicaid APG,4982.05,,,4982.05,Other,260% New York Medicaid APG,6208.4,,,6208.4,Other,324% New York Medicaid APG,4119.77,,,4119.77,Other,215% New York Medicaid APG,4119.77,,,4119.77,Other,215% New York Medicaid APG,2395.22,,,2395.22,Other,125% New York Medicaid APG,1916.17,63284.69,
Ophthalmic endoscope add-on,66990,CPT,,,,,,,,both,,,32432.1,23999.75,74,,23999.75,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,14594.45,45,,14594.45,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,16053.89,49.5,,16053.89,percent of total billed charges,110% of Medicare,22053.83,68,,22053.83,percent of total billed charges,,0.02,,,0.02,Other,186% of Medicaid,25945.68,80,,25945.68,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,25945.68,80,,25945.68,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,22702.47,70,,22702.47,percent of total billed charges,,3387,,,3387,Case Rate,MVP ASC Grouper,2879,,,2879,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% New York Medicaid APG,0.01,,,0.01,Other,100% New York Medicaid APG,0.01,,,0.01,Other,100% New York Medicaid APG,0.02,,,0.02,Other,225% New York Medicaid APG,0.02,,,0.02,Other,153% New York Medicaid APG,0.02,,,0.02,Other,225% New York Medicaid APG,0.01,,,0.01,Other,140% New York Medicaid APG,0.02,,,0.02,Other,225% New York Medicaid APG,0.03,,,0.03,Other,260% New York Medicaid APG,0.03,,,0.03,Other,324% New York Medicaid APG,0.02,,,0.02,Other,215% New York Medicaid APG,0.02,,,0.02,Other,215% New York Medicaid APG,0.01,,,0.01,Other,125% New York Medicaid APG,0.01,25945.68,
Partial removal of eye fluid,67005,CPT,,,,,,,,both,,,38164.45,28241.69,74,,28241.69,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,17174,45,,17174,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,18891.4,49.5,,18891.4,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,1160.61,,,1160.61,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,26715.12,70,,26715.12,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,623.98,,,623.98,Other,New York Medicaid APG methodology,623.98,,,623.98,Other,100% New York Medicaid APG,623.98,,,623.98,Other,100% New York Medicaid APG,623.98,,,623.98,Other,100% New York Medicaid APG,1403.96,,,1403.96,Other,225% New York Medicaid APG,954.7,,,954.7,Other,153% New York Medicaid APG,1403.96,,,1403.96,Other,225% New York Medicaid APG,873.58,,,873.58,Other,140% New York Medicaid APG,1403.96,,,1403.96,Other,225% New York Medicaid APG,1622.36,,,1622.36,Other,260% New York Medicaid APG,2021.71,,,2021.71,Other,324% New York Medicaid APG,1341.57,,,1341.57,Other,215% New York Medicaid APG,1341.57,,,1341.57,Other,215% New York Medicaid APG,779.98,,,779.98,Other,125% New York Medicaid APG,623.98,28241.69,
Partial removal of eye fluid,67010,CPT,,,,,,,,both,,,37177.13,27511.08,74,,27511.08,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,16729.71,45,,16729.71,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,18402.68,49.5,,18402.68,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,1160.61,,,1160.61,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,26023.99,70,,26023.99,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,623.98,,,623.98,Other,New York Medicaid APG methodology,623.98,,,623.98,Other,100% New York Medicaid APG,623.98,,,623.98,Other,100% New York Medicaid APG,623.98,,,623.98,Other,100% New York Medicaid APG,1403.96,,,1403.96,Other,225% New York Medicaid APG,954.7,,,954.7,Other,153% New York Medicaid APG,1403.96,,,1403.96,Other,225% New York Medicaid APG,873.58,,,873.58,Other,140% New York Medicaid APG,1403.96,,,1403.96,Other,225% New York Medicaid APG,1622.36,,,1622.36,Other,260% New York Medicaid APG,2021.71,,,2021.71,Other,324% New York Medicaid APG,1341.57,,,1341.57,Other,215% New York Medicaid APG,1341.57,,,1341.57,Other,215% New York Medicaid APG,779.98,,,779.98,Other,125% New York Medicaid APG,623.98,27511.08,
Release of eye fluid,67015,CPT,,,,,,,,both,,,39587.11,29294.46,74,,29294.46,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,17814.2,45,,17814.2,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,19595.62,49.5,,19595.62,percent of total billed charges,110% of Medicare,26919.23,68,,26919.23,percent of total billed charges,,4783.4,,,4783.4,Other,186% of Medicaid,31669.69,80,,31669.69,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,31669.69,80,,31669.69,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,27710.98,70,,27710.98,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,2571.72,,,2571.72,Other,New York Medicaid APG methodology,2571.72,,,2571.72,Other,100% New York Medicaid APG,2571.72,,,2571.72,Other,100% New York Medicaid APG,2571.72,,,2571.72,Other,100% New York Medicaid APG,5786.37,,,5786.37,Other,225% New York Medicaid APG,3934.73,,,3934.73,Other,153% New York Medicaid APG,5786.37,,,5786.37,Other,225% New York Medicaid APG,3600.41,,,3600.41,Other,140% New York Medicaid APG,5786.37,,,5786.37,Other,225% New York Medicaid APG,6686.47,,,6686.47,Other,260% New York Medicaid APG,8332.37,,,8332.37,Other,324% New York Medicaid APG,5529.2,,,5529.2,Other,215% New York Medicaid APG,5529.2,,,5529.2,Other,215% New York Medicaid APG,3214.65,,,3214.65,Other,125% New York Medicaid APG,2053,31669.69,
Replace eye fluid,67025,CPT,,,,,,,,both,,,49016.23,36272.01,74,,36272.01,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,22057.3,45,,22057.3,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,24263.03,49.5,,24263.03,percent of total billed charges,110% of Medicare,33331.04,68,,33331.04,percent of total billed charges,,1160.61,,,1160.61,Other,186% of Medicaid,39212.98,80,,39212.98,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,39212.98,80,,39212.98,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,34311.36,70,,34311.36,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,623.98,,,623.98,Other,New York Medicaid APG methodology,623.98,,,623.98,Other,100% New York Medicaid APG,623.98,,,623.98,Other,100% New York Medicaid APG,623.98,,,623.98,Other,100% New York Medicaid APG,1403.96,,,1403.96,Other,225% New York Medicaid APG,954.7,,,954.7,Other,153% New York Medicaid APG,1403.96,,,1403.96,Other,225% New York Medicaid APG,873.58,,,873.58,Other,140% New York Medicaid APG,1403.96,,,1403.96,Other,225% New York Medicaid APG,1622.36,,,1622.36,Other,260% New York Medicaid APG,2021.71,,,2021.71,Other,324% New York Medicaid APG,1341.57,,,1341.57,Other,215% New York Medicaid APG,1341.57,,,1341.57,Other,215% New York Medicaid APG,779.98,,,779.98,Other,125% New York Medicaid APG,623.98,39212.98,
Implant eye drug system,67027,CPT,,,,,,,,both,,,331986.72,245670.17,74,,245670.17,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,149394.02,45,,149394.02,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,164333.43,49.5,,164333.43,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,4783.4,,,4783.4,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,232390.7,70,,232390.7,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,2571.72,,,2571.72,Other,New York Medicaid APG methodology,2571.72,,,2571.72,Other,100% New York Medicaid APG,2571.72,,,2571.72,Other,100% New York Medicaid APG,2571.72,,,2571.72,Other,100% New York Medicaid APG,5786.37,,,5786.37,Other,225% New York Medicaid APG,3934.73,,,3934.73,Other,153% New York Medicaid APG,5786.37,,,5786.37,Other,225% New York Medicaid APG,3600.41,,,3600.41,Other,140% New York Medicaid APG,5786.37,,,5786.37,Other,225% New York Medicaid APG,6686.47,,,6686.47,Other,260% New York Medicaid APG,8332.37,,,8332.37,Other,324% New York Medicaid APG,5529.2,,,5529.2,Other,215% New York Medicaid APG,5529.2,,,5529.2,Other,215% New York Medicaid APG,3214.65,,,3214.65,Other,125% New York Medicaid APG,2571.72,245670.17,
Injection eye drug,67028,CPT,,,,,,,,both,,,7123.45,5271.35,74,,5271.35,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,3205.55,45,,3205.55,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,3526.11,49.5,,3526.11,percent of total billed charges,110% of Medicare,4843.95,68,,4843.95,percent of total billed charges,,525.76,,,525.76,Other,186% of Medicaid,5698.76,80,,5698.76,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,5698.76,80,,5698.76,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,4986.42,70,,4986.42,percent of total billed charges,,441.16,,,441.16,Fee Schedule,,373.91,,,373.91,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,282.67,,,282.67,Other,New York Medicaid APG methodology,282.67,,,282.67,Other,100% New York Medicaid APG,282.67,,,282.67,Other,100% New York Medicaid APG,282.67,,,282.67,Other,100% New York Medicaid APG,636,,,636,Other,225% New York Medicaid APG,432.48,,,432.48,Other,153% New York Medicaid APG,636,,,636,Other,225% New York Medicaid APG,395.73,,,395.73,Other,140% New York Medicaid APG,636,,,636,Other,225% New York Medicaid APG,734.93,,,734.93,Other,260% New York Medicaid APG,915.84,,,915.84,Other,324% New York Medicaid APG,607.73,,,607.73,Other,215% New York Medicaid APG,607.73,,,607.73,Other,215% New York Medicaid APG,353.33,,,353.33,Other,125% New York Medicaid APG,282.67,7216,
Incise inner eye strands,67030,CPT,,,,,,,,both,,,49016.23,36272.01,74,,36272.01,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,22057.3,45,,22057.3,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,24263.03,49.5,,24263.03,percent of total billed charges,110% of Medicare,33331.04,68,,33331.04,percent of total billed charges,,1160.61,,,1160.61,Other,186% of Medicaid,39212.98,80,,39212.98,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,39212.98,80,,39212.98,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,34311.36,70,,34311.36,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,623.98,,,623.98,Other,New York Medicaid APG methodology,623.98,,,623.98,Other,100% New York Medicaid APG,623.98,,,623.98,Other,100% New York Medicaid APG,623.98,,,623.98,Other,100% New York Medicaid APG,1403.96,,,1403.96,Other,225% New York Medicaid APG,954.7,,,954.7,Other,153% New York Medicaid APG,1403.96,,,1403.96,Other,225% New York Medicaid APG,873.58,,,873.58,Other,140% New York Medicaid APG,1403.96,,,1403.96,Other,225% New York Medicaid APG,1622.36,,,1622.36,Other,260% New York Medicaid APG,2021.71,,,2021.71,Other,324% New York Medicaid APG,1341.57,,,1341.57,Other,215% New York Medicaid APG,1341.57,,,1341.57,Other,215% New York Medicaid APG,779.98,,,779.98,Other,125% New York Medicaid APG,623.98,39212.98,
Laser surgery eye strands,67031,CPT,,,,,,,,both,,,12226.3,9047.46,74,,9047.46,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,5501.84,45,,5501.84,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,6052.02,49.5,,6052.02,percent of total billed charges,110% of Medicare,8313.88,68,,8313.88,percent of total billed charges,,1160.61,,,1160.61,Other,186% of Medicaid,9781.04,80,,9781.04,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,9781.04,80,,9781.04,percent of total billed charges,,7216,,,7216,Case Rate,,3578,,"100% primary, 0% secondary procedures",3578,Other,MagnaCare ASC Grouper,8558.41,70,,8558.41,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,623.98,,,623.98,Other,New York Medicaid APG methodology,623.98,,,623.98,Other,100% New York Medicaid APG,623.98,,,623.98,Other,100% New York Medicaid APG,623.98,,,623.98,Other,100% New York Medicaid APG,1403.96,,,1403.96,Other,225% New York Medicaid APG,954.7,,,954.7,Other,153% New York Medicaid APG,1403.96,,,1403.96,Other,225% New York Medicaid APG,873.58,,,873.58,Other,140% New York Medicaid APG,1403.96,,,1403.96,Other,225% New York Medicaid APG,1622.36,,,1622.36,Other,260% New York Medicaid APG,2021.71,,,2021.71,Other,324% New York Medicaid APG,1341.57,,,1341.57,Other,215% New York Medicaid APG,1341.57,,,1341.57,Other,215% New York Medicaid APG,779.98,,,779.98,Other,125% New York Medicaid APG,623.98,9781.04,
Removal of inner eye fluid,67036,CPT,,,,,,,,both,,,39683.14,29365.52,74,,29365.52,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,17857.41,45,,17857.41,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,19643.15,49.5,,19643.15,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,4783.4,,,4783.4,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,27778.2,70,,27778.2,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,2571.72,,,2571.72,Other,New York Medicaid APG methodology,2571.72,,,2571.72,Other,100% New York Medicaid APG,2571.72,,,2571.72,Other,100% New York Medicaid APG,2571.72,,,2571.72,Other,100% New York Medicaid APG,5786.37,,,5786.37,Other,225% New York Medicaid APG,3934.73,,,3934.73,Other,153% New York Medicaid APG,5786.37,,,5786.37,Other,225% New York Medicaid APG,3600.41,,,3600.41,Other,140% New York Medicaid APG,5786.37,,,5786.37,Other,225% New York Medicaid APG,6686.47,,,6686.47,Other,260% New York Medicaid APG,8332.37,,,8332.37,Other,324% New York Medicaid APG,5529.2,,,5529.2,Other,215% New York Medicaid APG,5529.2,,,5529.2,Other,215% New York Medicaid APG,3214.65,,,3214.65,Other,125% New York Medicaid APG,2571.72,29365.52,
Laser treatment of retina,67039,CPT,,,,,,,,both,,,36633.79,27109,74,,27109,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,16485.21,45,,16485.21,percent of total billed charges,Medicare Ratio of cost to charges,5954,,"100% primary, 50% supplemental procedure",5954,Other,Aetna ASC Grouper,5359,,"100% primary, 50% supplemental procedure",5359,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,18133.73,49.5,,18133.73,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,4783.4,,,4783.4,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,25643.65,70,,25643.65,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,2571.72,,,2571.72,Other,New York Medicaid APG methodology,2571.72,,,2571.72,Other,100% New York Medicaid APG,2571.72,,,2571.72,Other,100% New York Medicaid APG,2571.72,,,2571.72,Other,100% New York Medicaid APG,5786.37,,,5786.37,Other,225% New York Medicaid APG,3934.73,,,3934.73,Other,153% New York Medicaid APG,5786.37,,,5786.37,Other,225% New York Medicaid APG,3600.41,,,3600.41,Other,140% New York Medicaid APG,5786.37,,,5786.37,Other,225% New York Medicaid APG,6686.47,,,6686.47,Other,260% New York Medicaid APG,8332.37,,,8332.37,Other,324% New York Medicaid APG,5529.2,,,5529.2,Other,215% New York Medicaid APG,5529.2,,,5529.2,Other,215% New York Medicaid APG,3214.65,,,3214.65,Other,125% New York Medicaid APG,2571.72,27109,
Laser treatment of retina,67040,CPT,,,,,,,,both,,,36695.92,27154.98,74,,27154.98,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,16513.16,45,,16513.16,percent of total billed charges,Medicare Ratio of cost to charges,5954,,"100% primary, 50% supplemental procedure",5954,Other,Aetna ASC Grouper,5359,,"100% primary, 50% supplemental procedure",5359,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,18164.48,49.5,,18164.48,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,4783.4,,,4783.4,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,25687.14,70,,25687.14,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,2571.72,,,2571.72,Other,New York Medicaid APG methodology,2571.72,,,2571.72,Other,100% New York Medicaid APG,2571.72,,,2571.72,Other,100% New York Medicaid APG,2571.72,,,2571.72,Other,100% New York Medicaid APG,5786.37,,,5786.37,Other,225% New York Medicaid APG,3934.73,,,3934.73,Other,153% New York Medicaid APG,5786.37,,,5786.37,Other,225% New York Medicaid APG,3600.41,,,3600.41,Other,140% New York Medicaid APG,5786.37,,,5786.37,Other,225% New York Medicaid APG,6686.47,,,6686.47,Other,260% New York Medicaid APG,8332.37,,,8332.37,Other,324% New York Medicaid APG,5529.2,,,5529.2,Other,215% New York Medicaid APG,5529.2,,,5529.2,Other,215% New York Medicaid APG,3214.65,,,3214.65,Other,125% New York Medicaid APG,2571.72,27154.98,
Vit for macular pucker,67041,CPT,,,,,,,,both,,,34629.14,25625.56,74,,25625.56,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15583.11,45,,15583.11,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,17141.42,49.5,,17141.42,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,4783.4,,,4783.4,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,24240.4,70,,24240.4,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,2571.72,,,2571.72,Other,New York Medicaid APG methodology,2571.72,,,2571.72,Other,100% New York Medicaid APG,2571.72,,,2571.72,Other,100% New York Medicaid APG,2571.72,,,2571.72,Other,100% New York Medicaid APG,5786.37,,,5786.37,Other,225% New York Medicaid APG,3934.73,,,3934.73,Other,153% New York Medicaid APG,5786.37,,,5786.37,Other,225% New York Medicaid APG,3600.41,,,3600.41,Other,140% New York Medicaid APG,5786.37,,,5786.37,Other,225% New York Medicaid APG,6686.47,,,6686.47,Other,260% New York Medicaid APG,8332.37,,,8332.37,Other,324% New York Medicaid APG,5529.2,,,5529.2,Other,215% New York Medicaid APG,5529.2,,,5529.2,Other,215% New York Medicaid APG,3214.65,,,3214.65,Other,125% New York Medicaid APG,2571.72,25625.56,
Vit for macular hole,67042,CPT,,,,,,,,both,,,36517.02,27022.59,74,,27022.59,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,16432.66,45,,16432.66,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,18075.92,49.5,,18075.92,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,4783.4,,,4783.4,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,25561.91,70,,25561.91,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,2571.72,,,2571.72,Other,New York Medicaid APG methodology,2571.72,,,2571.72,Other,100% New York Medicaid APG,2571.72,,,2571.72,Other,100% New York Medicaid APG,2571.72,,,2571.72,Other,100% New York Medicaid APG,5786.37,,,5786.37,Other,225% New York Medicaid APG,3934.73,,,3934.73,Other,153% New York Medicaid APG,5786.37,,,5786.37,Other,225% New York Medicaid APG,3600.41,,,3600.41,Other,140% New York Medicaid APG,5786.37,,,5786.37,Other,225% New York Medicaid APG,6686.47,,,6686.47,Other,260% New York Medicaid APG,8332.37,,,8332.37,Other,324% New York Medicaid APG,5529.2,,,5529.2,Other,215% New York Medicaid APG,5529.2,,,5529.2,Other,215% New York Medicaid APG,3214.65,,,3214.65,Other,125% New York Medicaid APG,2571.72,27022.59,
Vit for membrane dissect,67043,CPT,,,,,,,,both,,,34704.14,25681.06,74,,25681.06,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15616.86,45,,15616.86,percent of total billed charges,Medicare Ratio of cost to charges,5954,,"100% primary, 50% supplemental procedure",5954,Other,Aetna ASC Grouper,5359,,"100% primary, 50% supplemental procedure",5359,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,17178.55,49.5,,17178.55,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,4783.4,,,4783.4,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,24292.9,70,,24292.9,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,2571.72,,,2571.72,Other,New York Medicaid APG methodology,2571.72,,,2571.72,Other,100% New York Medicaid APG,2571.72,,,2571.72,Other,100% New York Medicaid APG,2571.72,,,2571.72,Other,100% New York Medicaid APG,5786.37,,,5786.37,Other,225% New York Medicaid APG,3934.73,,,3934.73,Other,153% New York Medicaid APG,5786.37,,,5786.37,Other,225% New York Medicaid APG,3600.41,,,3600.41,Other,140% New York Medicaid APG,5786.37,,,5786.37,Other,225% New York Medicaid APG,6686.47,,,6686.47,Other,260% New York Medicaid APG,8332.37,,,8332.37,Other,324% New York Medicaid APG,5529.2,,,5529.2,Other,215% New York Medicaid APG,5529.2,,,5529.2,Other,215% New York Medicaid APG,3214.65,,,3214.65,Other,125% New York Medicaid APG,2571.72,25681.06,
Repair detached retina crtx,67101,CPT,,,,,,,,both,,,49016.23,36272.01,74,,36272.01,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,22057.3,45,,22057.3,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,24263.03,49.5,,24263.03,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,4783.4,,,4783.4,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,34311.36,70,,34311.36,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,2571.72,,,2571.72,Other,New York Medicaid APG methodology,2571.72,,,2571.72,Other,100% New York Medicaid APG,2571.72,,,2571.72,Other,100% New York Medicaid APG,2571.72,,,2571.72,Other,100% New York Medicaid APG,5786.37,,,5786.37,Other,225% New York Medicaid APG,3934.73,,,3934.73,Other,153% New York Medicaid APG,5786.37,,,5786.37,Other,225% New York Medicaid APG,3600.41,,,3600.41,Other,140% New York Medicaid APG,5786.37,,,5786.37,Other,225% New York Medicaid APG,6686.47,,,6686.47,Other,260% New York Medicaid APG,8332.37,,,8332.37,Other,324% New York Medicaid APG,5529.2,,,5529.2,Other,215% New York Medicaid APG,5529.2,,,5529.2,Other,215% New York Medicaid APG,3214.65,,,3214.65,Other,125% New York Medicaid APG,2571.72,36272.01,
Repair detached retina pc,67105,CPT,,,,,,,,both,,,12226.3,9047.46,74,,9047.46,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,5501.84,45,,5501.84,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,6052.02,49.5,,6052.02,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,1160.61,,,1160.61,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,3578,,"100% primary, 0% secondary procedures",3578,Other,MagnaCare ASC Grouper,8558.41,70,,8558.41,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,623.98,,,623.98,Other,New York Medicaid APG methodology,623.98,,,623.98,Other,100% New York Medicaid APG,623.98,,,623.98,Other,100% New York Medicaid APG,623.98,,,623.98,Other,100% New York Medicaid APG,1403.96,,,1403.96,Other,225% New York Medicaid APG,954.7,,,954.7,Other,153% New York Medicaid APG,1403.96,,,1403.96,Other,225% New York Medicaid APG,873.58,,,873.58,Other,140% New York Medicaid APG,1403.96,,,1403.96,Other,225% New York Medicaid APG,1622.36,,,1622.36,Other,260% New York Medicaid APG,2021.71,,,2021.71,Other,324% New York Medicaid APG,1341.57,,,1341.57,Other,215% New York Medicaid APG,1341.57,,,1341.57,Other,215% New York Medicaid APG,779.98,,,779.98,Other,125% New York Medicaid APG,623.98,9473,
Repair detached retina,67107,CPT,,,,,,,,both,,,37944.14,28078.66,74,,28078.66,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,17074.86,45,,17074.86,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,18782.35,49.5,,18782.35,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,4783.4,,,4783.4,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,26560.9,70,,26560.9,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,2571.72,,,2571.72,Other,New York Medicaid APG methodology,2571.72,,,2571.72,Other,100% New York Medicaid APG,2571.72,,,2571.72,Other,100% New York Medicaid APG,2571.72,,,2571.72,Other,100% New York Medicaid APG,5786.37,,,5786.37,Other,225% New York Medicaid APG,3934.73,,,3934.73,Other,153% New York Medicaid APG,5786.37,,,5786.37,Other,225% New York Medicaid APG,3600.41,,,3600.41,Other,140% New York Medicaid APG,5786.37,,,5786.37,Other,225% New York Medicaid APG,6686.47,,,6686.47,Other,260% New York Medicaid APG,8332.37,,,8332.37,Other,324% New York Medicaid APG,5529.2,,,5529.2,Other,215% New York Medicaid APG,5529.2,,,5529.2,Other,215% New York Medicaid APG,3214.65,,,3214.65,Other,125% New York Medicaid APG,2571.72,28078.66,
Repair detached retina,67108,CPT,,,,,,,,both,,,37702.06,27899.52,74,,27899.52,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,16965.93,45,,16965.93,percent of total billed charges,Medicare Ratio of cost to charges,5954,,"100% primary, 50% supplemental procedure",5954,Other,Aetna ASC Grouper,5359,,"100% primary, 50% supplemental procedure",5359,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,18662.52,49.5,,18662.52,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,4783.4,,,4783.4,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,26391.44,70,,26391.44,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,2571.72,,,2571.72,Other,New York Medicaid APG methodology,2571.72,,,2571.72,Other,100% New York Medicaid APG,2571.72,,,2571.72,Other,100% New York Medicaid APG,2571.72,,,2571.72,Other,100% New York Medicaid APG,5786.37,,,5786.37,Other,225% New York Medicaid APG,3934.73,,,3934.73,Other,153% New York Medicaid APG,5786.37,,,5786.37,Other,225% New York Medicaid APG,3600.41,,,3600.41,Other,140% New York Medicaid APG,5786.37,,,5786.37,Other,225% New York Medicaid APG,6686.47,,,6686.47,Other,260% New York Medicaid APG,8332.37,,,8332.37,Other,324% New York Medicaid APG,5529.2,,,5529.2,Other,215% New York Medicaid APG,5529.2,,,5529.2,Other,215% New York Medicaid APG,3214.65,,,3214.65,Other,125% New York Medicaid APG,2571.72,27899.52,
Repair detached retina,67110,CPT,,,,,,,,both,,,34169.97,25285.78,74,,25285.78,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15376.49,45,,15376.49,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,16914.14,49.5,,16914.14,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,1160.61,,,1160.61,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,23918.98,70,,23918.98,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,623.98,,,623.98,Other,New York Medicaid APG methodology,623.98,,,623.98,Other,100% New York Medicaid APG,623.98,,,623.98,Other,100% New York Medicaid APG,623.98,,,623.98,Other,100% New York Medicaid APG,1403.96,,,1403.96,Other,225% New York Medicaid APG,954.7,,,954.7,Other,153% New York Medicaid APG,1403.96,,,1403.96,Other,225% New York Medicaid APG,873.58,,,873.58,Other,140% New York Medicaid APG,1403.96,,,1403.96,Other,225% New York Medicaid APG,1622.36,,,1622.36,Other,260% New York Medicaid APG,2021.71,,,2021.71,Other,324% New York Medicaid APG,1341.57,,,1341.57,Other,215% New York Medicaid APG,1341.57,,,1341.57,Other,215% New York Medicaid APG,779.98,,,779.98,Other,125% New York Medicaid APG,623.98,25285.78,
Repair retinal detach cplx,67113,CPT,,,,,,,,both,,,38858.37,28755.19,74,,28755.19,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,17486.27,45,,17486.27,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,19234.89,49.5,,19234.89,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,4783.4,,,4783.4,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,27200.86,70,,27200.86,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,2571.72,,,2571.72,Other,New York Medicaid APG methodology,2571.72,,,2571.72,Other,100% New York Medicaid APG,2571.72,,,2571.72,Other,100% New York Medicaid APG,2571.72,,,2571.72,Other,100% New York Medicaid APG,5786.37,,,5786.37,Other,225% New York Medicaid APG,3934.73,,,3934.73,Other,153% New York Medicaid APG,5786.37,,,5786.37,Other,225% New York Medicaid APG,3600.41,,,3600.41,Other,140% New York Medicaid APG,5786.37,,,5786.37,Other,225% New York Medicaid APG,6686.47,,,6686.47,Other,260% New York Medicaid APG,8332.37,,,8332.37,Other,324% New York Medicaid APG,5529.2,,,5529.2,Other,215% New York Medicaid APG,5529.2,,,5529.2,Other,215% New York Medicaid APG,3214.65,,,3214.65,Other,125% New York Medicaid APG,2571.72,28755.19,
Release encircling material,67115,CPT,,,,,,,,both,,,85519.85,63284.69,74,,63284.69,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,38483.93,45,,38483.93,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,42332.33,49.5,,42332.33,percent of total billed charges,110% of Medicare,58153.5,68,,58153.5,percent of total billed charges,,1160.61,,,1160.61,Other,186% of Medicaid,68415.88,80,,68415.88,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,68415.88,80,,68415.88,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,59863.9,70,,59863.9,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,623.98,,,623.98,Other,New York Medicaid APG methodology,623.98,,,623.98,Other,100% New York Medicaid APG,623.98,,,623.98,Other,100% New York Medicaid APG,623.98,,,623.98,Other,100% New York Medicaid APG,1403.96,,,1403.96,Other,225% New York Medicaid APG,954.7,,,954.7,Other,153% New York Medicaid APG,1403.96,,,1403.96,Other,225% New York Medicaid APG,873.58,,,873.58,Other,140% New York Medicaid APG,1403.96,,,1403.96,Other,225% New York Medicaid APG,1622.36,,,1622.36,Other,260% New York Medicaid APG,2021.71,,,2021.71,Other,324% New York Medicaid APG,1341.57,,,1341.57,Other,215% New York Medicaid APG,1341.57,,,1341.57,Other,215% New York Medicaid APG,779.98,,,779.98,Other,125% New York Medicaid APG,623.98,68415.88,
Remove eye implant material,67120,CPT,,,,,,,,both,,,34478.92,25514.4,74,,25514.4,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15515.51,45,,15515.51,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,17067.07,49.5,,17067.07,percent of total billed charges,110% of Medicare,23445.67,68,,23445.67,percent of total billed charges,,1160.61,,,1160.61,Other,186% of Medicaid,27583.14,80,,27583.14,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,27583.14,80,,27583.14,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,24135.24,70,,24135.24,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,623.98,,,623.98,Other,New York Medicaid APG methodology,623.98,,,623.98,Other,100% New York Medicaid APG,623.98,,,623.98,Other,100% New York Medicaid APG,623.98,,,623.98,Other,100% New York Medicaid APG,1403.96,,,1403.96,Other,225% New York Medicaid APG,954.7,,,954.7,Other,153% New York Medicaid APG,1403.96,,,1403.96,Other,225% New York Medicaid APG,873.58,,,873.58,Other,140% New York Medicaid APG,1403.96,,,1403.96,Other,225% New York Medicaid APG,1622.36,,,1622.36,Other,260% New York Medicaid APG,2021.71,,,2021.71,Other,324% New York Medicaid APG,1341.57,,,1341.57,Other,215% New York Medicaid APG,1341.57,,,1341.57,Other,215% New York Medicaid APG,779.98,,,779.98,Other,125% New York Medicaid APG,623.98,27583.14,
Remove eye implant material,67121,CPT,,,,,,,,both,,,49016.23,36272.01,74,,36272.01,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,22057.3,45,,22057.3,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,24263.03,49.5,,24263.03,percent of total billed charges,110% of Medicare,33331.04,68,,33331.04,percent of total billed charges,,1160.61,,,1160.61,Other,186% of Medicaid,39212.98,80,,39212.98,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,39212.98,80,,39212.98,percent of total billed charges,,7216,,,7216,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,34311.36,70,,34311.36,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,623.98,,,623.98,Other,New York Medicaid APG methodology,623.98,,,623.98,Other,100% New York Medicaid APG,623.98,,,623.98,Other,100% New York Medicaid APG,623.98,,,623.98,Other,100% New York Medicaid APG,1403.96,,,1403.96,Other,225% New York Medicaid APG,954.7,,,954.7,Other,153% New York Medicaid APG,1403.96,,,1403.96,Other,225% New York Medicaid APG,873.58,,,873.58,Other,140% New York Medicaid APG,1403.96,,,1403.96,Other,225% New York Medicaid APG,1622.36,,,1622.36,Other,260% New York Medicaid APG,2021.71,,,2021.71,Other,324% New York Medicaid APG,1341.57,,,1341.57,Other,215% New York Medicaid APG,1341.57,,,1341.57,Other,215% New York Medicaid APG,779.98,,,779.98,Other,125% New York Medicaid APG,623.98,39212.98,
Treatment of retina,67141,CPT,,,,,,,,both,,,6127.39,4534.27,74,,4534.27,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,2757.33,45,,2757.33,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,3033.06,49.5,,3033.06,percent of total billed charges,110% of Medicare,4166.63,68,,4166.63,percent of total billed charges,,525.76,,,525.76,Other,186% of Medicaid,4901.91,80,,4901.91,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,4901.91,80,,4901.91,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,4289.17,70,,4289.17,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,282.67,,,282.67,Other,New York Medicaid APG methodology,282.67,,,282.67,Other,100% New York Medicaid APG,282.67,,,282.67,Other,100% New York Medicaid APG,282.67,,,282.67,Other,100% New York Medicaid APG,636,,,636,Other,225% New York Medicaid APG,432.48,,,432.48,Other,153% New York Medicaid APG,636,,,636,Other,225% New York Medicaid APG,395.73,,,395.73,Other,140% New York Medicaid APG,636,,,636,Other,225% New York Medicaid APG,734.93,,,734.93,Other,260% New York Medicaid APG,915.84,,,915.84,Other,324% New York Medicaid APG,607.73,,,607.73,Other,215% New York Medicaid APG,607.73,,,607.73,Other,215% New York Medicaid APG,353.33,,,353.33,Other,125% New York Medicaid APG,282.67,7216,
Treatment of retina,67145,CPT,,,,,,,,both,,,36129.72,26735.99,74,,26735.99,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,16258.37,45,,16258.37,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,17884.21,49.5,,17884.21,percent of total billed charges,110% of Medicare,24568.21,68,,24568.21,percent of total billed charges,,1160.61,,,1160.61,Other,186% of Medicaid,28903.78,80,,28903.78,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,28903.78,80,,28903.78,percent of total billed charges,,7216,,,7216,Case Rate,,3578,,"100% primary, 0% secondary procedures",3578,Other,MagnaCare ASC Grouper,25290.8,70,,25290.8,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,623.98,,,623.98,Other,New York Medicaid APG methodology,623.98,,,623.98,Other,100% New York Medicaid APG,623.98,,,623.98,Other,100% New York Medicaid APG,623.98,,,623.98,Other,100% New York Medicaid APG,1403.96,,,1403.96,Other,225% New York Medicaid APG,954.7,,,954.7,Other,153% New York Medicaid APG,1403.96,,,1403.96,Other,225% New York Medicaid APG,873.58,,,873.58,Other,140% New York Medicaid APG,1403.96,,,1403.96,Other,225% New York Medicaid APG,1622.36,,,1622.36,Other,260% New York Medicaid APG,2021.71,,,2021.71,Other,324% New York Medicaid APG,1341.57,,,1341.57,Other,215% New York Medicaid APG,1341.57,,,1341.57,Other,215% New York Medicaid APG,779.98,,,779.98,Other,125% New York Medicaid APG,623.98,28903.78,
Treatment of retinal lesion,67208,CPT,,,,,,,,both,,,6127.39,4534.27,74,,4534.27,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,2757.33,45,,2757.33,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,3033.06,49.5,,3033.06,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,525.76,,,525.76,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,4289.17,70,,4289.17,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,282.67,,,282.67,Other,New York Medicaid APG methodology,282.67,,,282.67,Other,100% New York Medicaid APG,282.67,,,282.67,Other,100% New York Medicaid APG,282.67,,,282.67,Other,100% New York Medicaid APG,636,,,636,Other,225% New York Medicaid APG,432.48,,,432.48,Other,153% New York Medicaid APG,636,,,636,Other,225% New York Medicaid APG,395.73,,,395.73,Other,140% New York Medicaid APG,636,,,636,Other,225% New York Medicaid APG,734.93,,,734.93,Other,260% New York Medicaid APG,915.84,,,915.84,Other,324% New York Medicaid APG,607.73,,,607.73,Other,215% New York Medicaid APG,607.73,,,607.73,Other,215% New York Medicaid APG,353.33,,,353.33,Other,125% New York Medicaid APG,282.67,9473,
Treatment of retinal lesion,67210,CPT,,,,,,,,both,,,12226.3,9047.46,74,,9047.46,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,5501.84,45,,5501.84,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,6052.02,49.5,,6052.02,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,1160.61,,,1160.61,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,3578,,"100% primary, 0% secondary procedures",3578,Other,MagnaCare ASC Grouper,8558.41,70,,8558.41,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,623.98,,,623.98,Other,New York Medicaid APG methodology,623.98,,,623.98,Other,100% New York Medicaid APG,623.98,,,623.98,Other,100% New York Medicaid APG,623.98,,,623.98,Other,100% New York Medicaid APG,1403.96,,,1403.96,Other,225% New York Medicaid APG,954.7,,,954.7,Other,153% New York Medicaid APG,1403.96,,,1403.96,Other,225% New York Medicaid APG,873.58,,,873.58,Other,140% New York Medicaid APG,1403.96,,,1403.96,Other,225% New York Medicaid APG,1622.36,,,1622.36,Other,260% New York Medicaid APG,2021.71,,,2021.71,Other,324% New York Medicaid APG,1341.57,,,1341.57,Other,215% New York Medicaid APG,1341.57,,,1341.57,Other,215% New York Medicaid APG,779.98,,,779.98,Other,125% New York Medicaid APG,623.98,9473,
Treatment of retinal lesion,67218,CPT,,,,,,,,both,,,81324.54,60180.16,74,,60180.16,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,36596.04,45,,36596.04,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,40255.65,49.5,,40255.65,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,4783.4,,,4783.4,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,56927.18,70,,56927.18,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,2571.72,,,2571.72,Other,New York Medicaid APG methodology,2571.72,,,2571.72,Other,100% New York Medicaid APG,2571.72,,,2571.72,Other,100% New York Medicaid APG,2571.72,,,2571.72,Other,100% New York Medicaid APG,5786.37,,,5786.37,Other,225% New York Medicaid APG,3934.73,,,3934.73,Other,153% New York Medicaid APG,5786.37,,,5786.37,Other,225% New York Medicaid APG,3600.41,,,3600.41,Other,140% New York Medicaid APG,5786.37,,,5786.37,Other,225% New York Medicaid APG,6686.47,,,6686.47,Other,260% New York Medicaid APG,8332.37,,,8332.37,Other,324% New York Medicaid APG,5529.2,,,5529.2,Other,215% New York Medicaid APG,5529.2,,,5529.2,Other,215% New York Medicaid APG,3214.65,,,3214.65,Other,125% New York Medicaid APG,2571.72,60180.16,
Treatment of choroid lesion,67220,CPT,,,,,,,,both,,,12226.3,9047.46,74,,9047.46,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,5501.84,45,,5501.84,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,6052.02,49.5,,6052.02,percent of total billed charges,110% of Medicare,8313.88,68,,8313.88,percent of total billed charges,,1160.61,,,1160.61,Other,186% of Medicaid,9781.04,80,,9781.04,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,9781.04,80,,9781.04,percent of total billed charges,,7216,,,7216,Case Rate,,3578,,"100% primary, 0% secondary procedures",3578,Other,MagnaCare ASC Grouper,8558.41,70,,8558.41,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,623.98,,,623.98,Other,New York Medicaid APG methodology,623.98,,,623.98,Other,100% New York Medicaid APG,623.98,,,623.98,Other,100% New York Medicaid APG,623.98,,,623.98,Other,100% New York Medicaid APG,1403.96,,,1403.96,Other,225% New York Medicaid APG,954.7,,,954.7,Other,153% New York Medicaid APG,1403.96,,,1403.96,Other,225% New York Medicaid APG,873.58,,,873.58,Other,140% New York Medicaid APG,1403.96,,,1403.96,Other,225% New York Medicaid APG,1622.36,,,1622.36,Other,260% New York Medicaid APG,2021.71,,,2021.71,Other,324% New York Medicaid APG,1341.57,,,1341.57,Other,215% New York Medicaid APG,1341.57,,,1341.57,Other,215% New York Medicaid APG,779.98,,,779.98,Other,125% New York Medicaid APG,623.98,9781.04,
Ocular photodynamic ther,67221,CPT,,,,,,,,both,,,12226.3,9047.46,74,,9047.46,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,5501.84,45,,5501.84,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,6052.02,49.5,,6052.02,percent of total billed charges,110% of Medicare,8313.88,68,,8313.88,percent of total billed charges,,1160.61,,,1160.61,Other,186% of Medicaid,9781.04,80,,9781.04,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,9781.04,80,,9781.04,percent of total billed charges,,7216,,,7216,Case Rate,,3578,,"100% primary, 0% secondary procedures",3578,Other,MagnaCare ASC Grouper,8558.41,70,,8558.41,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,623.98,,,623.98,Other,New York Medicaid APG methodology,623.98,,,623.98,Other,100% New York Medicaid APG,623.98,,,623.98,Other,100% New York Medicaid APG,623.98,,,623.98,Other,100% New York Medicaid APG,1403.96,,,1403.96,Other,225% New York Medicaid APG,954.7,,,954.7,Other,153% New York Medicaid APG,1403.96,,,1403.96,Other,225% New York Medicaid APG,873.58,,,873.58,Other,140% New York Medicaid APG,1403.96,,,1403.96,Other,225% New York Medicaid APG,1622.36,,,1622.36,Other,260% New York Medicaid APG,2021.71,,,2021.71,Other,324% New York Medicaid APG,1341.57,,,1341.57,Other,215% New York Medicaid APG,1341.57,,,1341.57,Other,215% New York Medicaid APG,779.98,,,779.98,Other,125% New York Medicaid APG,623.98,9781.04,
Eye photodynamic ther add-on,67225,CPT,,,,,,,,both,,,32432.1,23999.75,74,,23999.75,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,14594.45,45,,14594.45,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,16053.89,49.5,,16053.89,percent of total billed charges,110% of Medicare,22053.83,68,,22053.83,percent of total billed charges,,1160.61,,,1160.61,Other,186% of Medicaid,25945.68,80,,25945.68,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,25945.68,80,,25945.68,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,22702.47,70,,22702.47,percent of total billed charges,,132.84,,,132.84,Fee Schedule,,112.59,,,112.59,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,623.98,,,623.98,Other,New York Medicaid APG methodology,623.98,,,623.98,Other,100% New York Medicaid APG,623.98,,,623.98,Other,100% New York Medicaid APG,623.98,,,623.98,Other,100% New York Medicaid APG,1403.96,,,1403.96,Other,225% New York Medicaid APG,954.7,,,954.7,Other,153% New York Medicaid APG,1403.96,,,1403.96,Other,225% New York Medicaid APG,873.58,,,873.58,Other,140% New York Medicaid APG,1403.96,,,1403.96,Other,225% New York Medicaid APG,1622.36,,,1622.36,Other,260% New York Medicaid APG,2021.71,,,2021.71,Other,324% New York Medicaid APG,1341.57,,,1341.57,Other,215% New York Medicaid APG,1341.57,,,1341.57,Other,215% New York Medicaid APG,779.98,,,779.98,Other,125% New York Medicaid APG,112.59,25945.68,
Dstrj extensive retinopathy,67227,CPT,,,,,,,,both,,,81324.54,60180.16,74,,60180.16,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,36596.04,45,,36596.04,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,40255.65,49.5,,40255.65,percent of total billed charges,110% of Medicare,55300.69,68,,55300.69,percent of total billed charges,,4783.4,,,4783.4,Other,186% of Medicaid,65059.63,80,,65059.63,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,65059.63,80,,65059.63,percent of total billed charges,,7216,,,7216,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,56927.18,70,,56927.18,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,2571.72,,,2571.72,Other,New York Medicaid APG methodology,2571.72,,,2571.72,Other,100% New York Medicaid APG,2571.72,,,2571.72,Other,100% New York Medicaid APG,2571.72,,,2571.72,Other,100% New York Medicaid APG,5786.37,,,5786.37,Other,225% New York Medicaid APG,3934.73,,,3934.73,Other,153% New York Medicaid APG,5786.37,,,5786.37,Other,225% New York Medicaid APG,3600.41,,,3600.41,Other,140% New York Medicaid APG,5786.37,,,5786.37,Other,225% New York Medicaid APG,6686.47,,,6686.47,Other,260% New York Medicaid APG,8332.37,,,8332.37,Other,324% New York Medicaid APG,5529.2,,,5529.2,Other,215% New York Medicaid APG,5529.2,,,5529.2,Other,215% New York Medicaid APG,3214.65,,,3214.65,Other,125% New York Medicaid APG,2053,65059.63,
Treatment x10sv retinopathy,67228,CPT,,,,,,,,both,,,32171.72,23807.07,74,,23807.07,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,14477.27,45,,14477.27,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,15925,49.5,,15925,percent of total billed charges,110% of Medicare,21876.77,68,,21876.77,percent of total billed charges,,1160.61,,,1160.61,Other,186% of Medicaid,25737.38,80,,25737.38,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,25737.38,80,,25737.38,percent of total billed charges,,7216,,,7216,Case Rate,,3578,,"100% primary, 0% secondary procedures",3578,Other,MagnaCare ASC Grouper,22520.2,70,,22520.2,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,623.98,,,623.98,Other,New York Medicaid APG methodology,623.98,,,623.98,Other,100% New York Medicaid APG,623.98,,,623.98,Other,100% New York Medicaid APG,623.98,,,623.98,Other,100% New York Medicaid APG,1403.96,,,1403.96,Other,225% New York Medicaid APG,954.7,,,954.7,Other,153% New York Medicaid APG,1403.96,,,1403.96,Other,225% New York Medicaid APG,873.58,,,873.58,Other,140% New York Medicaid APG,1403.96,,,1403.96,Other,225% New York Medicaid APG,1622.36,,,1622.36,Other,260% New York Medicaid APG,2021.71,,,2021.71,Other,324% New York Medicaid APG,1341.57,,,1341.57,Other,215% New York Medicaid APG,1341.57,,,1341.57,Other,215% New York Medicaid APG,779.98,,,779.98,Other,125% New York Medicaid APG,623.98,25737.38,
Tr retinal les preterm inf,67229,CPT,,,,,,,,both,,,12226.3,9047.46,74,,9047.46,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,5501.84,45,,5501.84,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,6052.02,49.5,,6052.02,percent of total billed charges,110% of Medicare,8313.88,68,,8313.88,percent of total billed charges,,1160.61,,,1160.61,Other,186% of Medicaid,9781.04,80,,9781.04,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,9781.04,80,,9781.04,percent of total billed charges,,7216,,,7216,Case Rate,,3578,,"100% primary, 0% secondary procedures",3578,Other,MagnaCare ASC Grouper,8558.41,70,,8558.41,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,623.98,,,623.98,Other,New York Medicaid APG methodology,623.98,,,623.98,Other,100% New York Medicaid APG,623.98,,,623.98,Other,100% New York Medicaid APG,623.98,,,623.98,Other,100% New York Medicaid APG,1403.96,,,1403.96,Other,225% New York Medicaid APG,954.7,,,954.7,Other,153% New York Medicaid APG,1403.96,,,1403.96,Other,225% New York Medicaid APG,873.58,,,873.58,Other,140% New York Medicaid APG,1403.96,,,1403.96,Other,225% New York Medicaid APG,1622.36,,,1622.36,Other,260% New York Medicaid APG,2021.71,,,2021.71,Other,324% New York Medicaid APG,1341.57,,,1341.57,Other,215% New York Medicaid APG,1341.57,,,1341.57,Other,215% New York Medicaid APG,779.98,,,779.98,Other,125% New York Medicaid APG,623.98,9781.04,
Reinforce eye wall,67250,CPT,,,,,,,,both,,,49151.56,36372.15,74,,36372.15,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,22118.2,45,,22118.2,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,24330.02,49.5,,24330.02,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,1160.61,,,1160.61,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,34406.09,70,,34406.09,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,623.98,,,623.98,Other,New York Medicaid APG methodology,623.98,,,623.98,Other,100% New York Medicaid APG,623.98,,,623.98,Other,100% New York Medicaid APG,623.98,,,623.98,Other,100% New York Medicaid APG,1403.96,,,1403.96,Other,225% New York Medicaid APG,954.7,,,954.7,Other,153% New York Medicaid APG,1403.96,,,1403.96,Other,225% New York Medicaid APG,873.58,,,873.58,Other,140% New York Medicaid APG,1403.96,,,1403.96,Other,225% New York Medicaid APG,1622.36,,,1622.36,Other,260% New York Medicaid APG,2021.71,,,2021.71,Other,324% New York Medicaid APG,1341.57,,,1341.57,Other,215% New York Medicaid APG,1341.57,,,1341.57,Other,215% New York Medicaid APG,779.98,,,779.98,Other,125% New York Medicaid APG,623.98,36372.15,
Reinforce/graft eye wall,67255,CPT,,,,,,,,both,,,85519.85,63284.69,74,,63284.69,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,38483.93,45,,38483.93,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,42332.33,49.5,,42332.33,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,1160.61,,,1160.61,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,59863.9,70,,59863.9,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,623.98,,,623.98,Other,New York Medicaid APG methodology,623.98,,,623.98,Other,100% New York Medicaid APG,623.98,,,623.98,Other,100% New York Medicaid APG,623.98,,,623.98,Other,100% New York Medicaid APG,1403.96,,,1403.96,Other,225% New York Medicaid APG,954.7,,,954.7,Other,153% New York Medicaid APG,1403.96,,,1403.96,Other,225% New York Medicaid APG,873.58,,,873.58,Other,140% New York Medicaid APG,1403.96,,,1403.96,Other,225% New York Medicaid APG,1622.36,,,1622.36,Other,260% New York Medicaid APG,2021.71,,,2021.71,Other,324% New York Medicaid APG,1341.57,,,1341.57,Other,215% New York Medicaid APG,1341.57,,,1341.57,Other,215% New York Medicaid APG,779.98,,,779.98,Other,125% New York Medicaid APG,623.98,63284.69,
Revise eye muscle,67311,CPT,,,,,,,,both,,,35853.95,26531.92,74,,26531.92,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,16134.28,45,,16134.28,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,17747.71,49.5,,17747.71,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3069.69,,,3069.69,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,25097.77,70,,25097.77,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1650.37,,,1650.37,Other,New York Medicaid APG methodology,1650.37,,,1650.37,Other,100% New York Medicaid APG,1650.37,,,1650.37,Other,100% New York Medicaid APG,1650.37,,,1650.37,Other,100% New York Medicaid APG,3713.34,,,3713.34,Other,225% New York Medicaid APG,2525.07,,,2525.07,Other,153% New York Medicaid APG,3713.34,,,3713.34,Other,225% New York Medicaid APG,2310.52,,,2310.52,Other,140% New York Medicaid APG,3713.34,,,3713.34,Other,225% New York Medicaid APG,4290.97,,,4290.97,Other,260% New York Medicaid APG,5347.21,,,5347.21,Other,324% New York Medicaid APG,3548.3,,,3548.3,Other,215% New York Medicaid APG,3548.3,,,3548.3,Other,215% New York Medicaid APG,2062.97,,,2062.97,Other,125% New York Medicaid APG,1650.37,26531.92,
Revise two eye muscles,67312,CPT,,,,,,,,both,,,36970.21,27357.96,74,,27357.96,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,16636.59,45,,16636.59,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,18300.25,49.5,,18300.25,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3069.69,,,3069.69,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,25879.15,70,,25879.15,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1650.37,,,1650.37,Other,New York Medicaid APG methodology,1650.37,,,1650.37,Other,100% New York Medicaid APG,1650.37,,,1650.37,Other,100% New York Medicaid APG,1650.37,,,1650.37,Other,100% New York Medicaid APG,3713.34,,,3713.34,Other,225% New York Medicaid APG,2525.07,,,2525.07,Other,153% New York Medicaid APG,3713.34,,,3713.34,Other,225% New York Medicaid APG,2310.52,,,2310.52,Other,140% New York Medicaid APG,3713.34,,,3713.34,Other,225% New York Medicaid APG,4290.97,,,4290.97,Other,260% New York Medicaid APG,5347.21,,,5347.21,Other,324% New York Medicaid APG,3548.3,,,3548.3,Other,215% New York Medicaid APG,3548.3,,,3548.3,Other,215% New York Medicaid APG,2062.97,,,2062.97,Other,125% New York Medicaid APG,1650.37,27357.96,
Revise eye muscle,67314,CPT,,,,,,,,both,,,38694.02,28633.57,74,,28633.57,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,17412.31,45,,17412.31,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,19153.54,49.5,,19153.54,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3069.69,,,3069.69,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,27085.81,70,,27085.81,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1650.37,,,1650.37,Other,New York Medicaid APG methodology,1650.37,,,1650.37,Other,100% New York Medicaid APG,1650.37,,,1650.37,Other,100% New York Medicaid APG,1650.37,,,1650.37,Other,100% New York Medicaid APG,3713.34,,,3713.34,Other,225% New York Medicaid APG,2525.07,,,2525.07,Other,153% New York Medicaid APG,3713.34,,,3713.34,Other,225% New York Medicaid APG,2310.52,,,2310.52,Other,140% New York Medicaid APG,3713.34,,,3713.34,Other,225% New York Medicaid APG,4290.97,,,4290.97,Other,260% New York Medicaid APG,5347.21,,,5347.21,Other,324% New York Medicaid APG,3548.3,,,3548.3,Other,215% New York Medicaid APG,3548.3,,,3548.3,Other,215% New York Medicaid APG,2062.97,,,2062.97,Other,125% New York Medicaid APG,1650.37,28633.57,
Revise two eye muscles,67316,CPT,,,,,,,,both,,,49151.56,36372.15,74,,36372.15,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,22118.2,45,,22118.2,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,24330.02,49.5,,24330.02,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3069.69,,,3069.69,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,34406.09,70,,34406.09,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1650.37,,,1650.37,Other,New York Medicaid APG methodology,1650.37,,,1650.37,Other,100% New York Medicaid APG,1650.37,,,1650.37,Other,100% New York Medicaid APG,1650.37,,,1650.37,Other,100% New York Medicaid APG,3713.34,,,3713.34,Other,225% New York Medicaid APG,2525.07,,,2525.07,Other,153% New York Medicaid APG,3713.34,,,3713.34,Other,225% New York Medicaid APG,2310.52,,,2310.52,Other,140% New York Medicaid APG,3713.34,,,3713.34,Other,225% New York Medicaid APG,4290.97,,,4290.97,Other,260% New York Medicaid APG,5347.21,,,5347.21,Other,324% New York Medicaid APG,3548.3,,,3548.3,Other,215% New York Medicaid APG,3548.3,,,3548.3,Other,215% New York Medicaid APG,2062.97,,,2062.97,Other,125% New York Medicaid APG,1650.37,36372.15,
Revise eye muscle(s),67318,CPT,,,,,,,,both,,,38658.01,28606.93,74,,28606.93,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,17396.1,45,,17396.1,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,19135.71,49.5,,19135.71,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3069.69,,,3069.69,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,27060.61,70,,27060.61,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1650.37,,,1650.37,Other,New York Medicaid APG methodology,1650.37,,,1650.37,Other,100% New York Medicaid APG,1650.37,,,1650.37,Other,100% New York Medicaid APG,1650.37,,,1650.37,Other,100% New York Medicaid APG,3713.34,,,3713.34,Other,225% New York Medicaid APG,2525.07,,,2525.07,Other,153% New York Medicaid APG,3713.34,,,3713.34,Other,225% New York Medicaid APG,2310.52,,,2310.52,Other,140% New York Medicaid APG,3713.34,,,3713.34,Other,225% New York Medicaid APG,4290.97,,,4290.97,Other,260% New York Medicaid APG,5347.21,,,5347.21,Other,324% New York Medicaid APG,3548.3,,,3548.3,Other,215% New York Medicaid APG,3548.3,,,3548.3,Other,215% New York Medicaid APG,2062.97,,,2062.97,Other,125% New York Medicaid APG,1650.37,28606.93,
Revise eye muscle(s) add-on,67320,CPT,,,,,,,,both,,,83504,61792.96,74,,61792.96,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,37576.8,45,,37576.8,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,41334.48,49.5,,41334.48,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3069.69,,,3069.69,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,58452.8,70,,58452.8,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,1650.37,,,1650.37,Other,New York Medicaid APG methodology,1650.37,,,1650.37,Other,100% New York Medicaid APG,1650.37,,,1650.37,Other,100% New York Medicaid APG,1650.37,,,1650.37,Other,100% New York Medicaid APG,3713.34,,,3713.34,Other,225% New York Medicaid APG,2525.07,,,2525.07,Other,153% New York Medicaid APG,3713.34,,,3713.34,Other,225% New York Medicaid APG,2310.52,,,2310.52,Other,140% New York Medicaid APG,3713.34,,,3713.34,Other,225% New York Medicaid APG,4290.97,,,4290.97,Other,260% New York Medicaid APG,5347.21,,,5347.21,Other,324% New York Medicaid APG,3548.3,,,3548.3,Other,215% New York Medicaid APG,3548.3,,,3548.3,Other,215% New York Medicaid APG,2062.97,,,2062.97,Other,125% New York Medicaid APG,1650.37,61792.96,
Eye surgery follow-up add-on,67331,CPT,,,,,,,,both,,,83504,61792.96,74,,61792.96,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,37576.8,45,,37576.8,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,41334.48,49.5,,41334.48,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3069.69,,,3069.69,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,58452.8,70,,58452.8,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,1650.37,,,1650.37,Other,New York Medicaid APG methodology,1650.37,,,1650.37,Other,100% New York Medicaid APG,1650.37,,,1650.37,Other,100% New York Medicaid APG,1650.37,,,1650.37,Other,100% New York Medicaid APG,3713.34,,,3713.34,Other,225% New York Medicaid APG,2525.07,,,2525.07,Other,153% New York Medicaid APG,3713.34,,,3713.34,Other,225% New York Medicaid APG,2310.52,,,2310.52,Other,140% New York Medicaid APG,3713.34,,,3713.34,Other,225% New York Medicaid APG,4290.97,,,4290.97,Other,260% New York Medicaid APG,5347.21,,,5347.21,Other,324% New York Medicaid APG,3548.3,,,3548.3,Other,215% New York Medicaid APG,3548.3,,,3548.3,Other,215% New York Medicaid APG,2062.97,,,2062.97,Other,125% New York Medicaid APG,1650.37,61792.96,
Rerevise eye muscles add-on,67332,CPT,,,,,,,,both,,,83504,61792.96,74,,61792.96,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,37576.8,45,,37576.8,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,41334.48,49.5,,41334.48,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3069.69,,,3069.69,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,58452.8,70,,58452.8,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,1650.37,,,1650.37,Other,New York Medicaid APG methodology,1650.37,,,1650.37,Other,100% New York Medicaid APG,1650.37,,,1650.37,Other,100% New York Medicaid APG,1650.37,,,1650.37,Other,100% New York Medicaid APG,3713.34,,,3713.34,Other,225% New York Medicaid APG,2525.07,,,2525.07,Other,153% New York Medicaid APG,3713.34,,,3713.34,Other,225% New York Medicaid APG,2310.52,,,2310.52,Other,140% New York Medicaid APG,3713.34,,,3713.34,Other,225% New York Medicaid APG,4290.97,,,4290.97,Other,260% New York Medicaid APG,5347.21,,,5347.21,Other,324% New York Medicaid APG,3548.3,,,3548.3,Other,215% New York Medicaid APG,3548.3,,,3548.3,Other,215% New York Medicaid APG,2062.97,,,2062.97,Other,125% New York Medicaid APG,1650.37,61792.96,
Revise eye muscle w/suture,67334,CPT,,,,,,,,both,,,83504,61792.96,74,,61792.96,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,37576.8,45,,37576.8,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,41334.48,49.5,,41334.48,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3069.69,,,3069.69,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,58452.8,70,,58452.8,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,1650.37,,,1650.37,Other,New York Medicaid APG methodology,1650.37,,,1650.37,Other,100% New York Medicaid APG,1650.37,,,1650.37,Other,100% New York Medicaid APG,1650.37,,,1650.37,Other,100% New York Medicaid APG,3713.34,,,3713.34,Other,225% New York Medicaid APG,2525.07,,,2525.07,Other,153% New York Medicaid APG,3713.34,,,3713.34,Other,225% New York Medicaid APG,2310.52,,,2310.52,Other,140% New York Medicaid APG,3713.34,,,3713.34,Other,225% New York Medicaid APG,4290.97,,,4290.97,Other,260% New York Medicaid APG,5347.21,,,5347.21,Other,324% New York Medicaid APG,3548.3,,,3548.3,Other,215% New York Medicaid APG,3548.3,,,3548.3,Other,215% New York Medicaid APG,2062.97,,,2062.97,Other,125% New York Medicaid APG,1650.37,61792.96,
Eye suture during surgery,67335,CPT,,,,,,,,both,,,83504,61792.96,74,,61792.96,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,37576.8,45,,37576.8,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,41334.48,49.5,,41334.48,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3069.69,,,3069.69,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,58452.8,70,,58452.8,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,1650.37,,,1650.37,Other,New York Medicaid APG methodology,1650.37,,,1650.37,Other,100% New York Medicaid APG,1650.37,,,1650.37,Other,100% New York Medicaid APG,1650.37,,,1650.37,Other,100% New York Medicaid APG,3713.34,,,3713.34,Other,225% New York Medicaid APG,2525.07,,,2525.07,Other,153% New York Medicaid APG,3713.34,,,3713.34,Other,225% New York Medicaid APG,2310.52,,,2310.52,Other,140% New York Medicaid APG,3713.34,,,3713.34,Other,225% New York Medicaid APG,4290.97,,,4290.97,Other,260% New York Medicaid APG,5347.21,,,5347.21,Other,324% New York Medicaid APG,3548.3,,,3548.3,Other,215% New York Medicaid APG,3548.3,,,3548.3,Other,215% New York Medicaid APG,2062.97,,,2062.97,Other,125% New York Medicaid APG,1650.37,61792.96,
Revise eye muscle add-on,67340,CPT,,,,,,,,both,,,83504,61792.96,74,,61792.96,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,37576.8,45,,37576.8,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,41334.48,49.5,,41334.48,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3069.69,,,3069.69,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,58452.8,70,,58452.8,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,1650.37,,,1650.37,Other,New York Medicaid APG methodology,1650.37,,,1650.37,Other,100% New York Medicaid APG,1650.37,,,1650.37,Other,100% New York Medicaid APG,1650.37,,,1650.37,Other,100% New York Medicaid APG,3713.34,,,3713.34,Other,225% New York Medicaid APG,2525.07,,,2525.07,Other,153% New York Medicaid APG,3713.34,,,3713.34,Other,225% New York Medicaid APG,2310.52,,,2310.52,Other,140% New York Medicaid APG,3713.34,,,3713.34,Other,225% New York Medicaid APG,4290.97,,,4290.97,Other,260% New York Medicaid APG,5347.21,,,5347.21,Other,324% New York Medicaid APG,3548.3,,,3548.3,Other,215% New York Medicaid APG,3548.3,,,3548.3,Other,215% New York Medicaid APG,2062.97,,,2062.97,Other,125% New York Medicaid APG,1650.37,61792.96,
Release eye tissue,67343,CPT,,,,,,,,both,,,49151.56,36372.15,74,,36372.15,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,22118.2,45,,22118.2,percent of total billed charges,Medicare Ratio of cost to charges,5954,,"100% primary, 50% supplemental procedure",5954,Other,Aetna ASC Grouper,5359,,"100% primary, 50% supplemental procedure",5359,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,24330.02,49.5,,24330.02,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3069.69,,,3069.69,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,34406.09,70,,34406.09,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1650.37,,,1650.37,Other,New York Medicaid APG methodology,1650.37,,,1650.37,Other,100% New York Medicaid APG,1650.37,,,1650.37,Other,100% New York Medicaid APG,1650.37,,,1650.37,Other,100% New York Medicaid APG,3713.34,,,3713.34,Other,225% New York Medicaid APG,2525.07,,,2525.07,Other,153% New York Medicaid APG,3713.34,,,3713.34,Other,225% New York Medicaid APG,2310.52,,,2310.52,Other,140% New York Medicaid APG,3713.34,,,3713.34,Other,225% New York Medicaid APG,4290.97,,,4290.97,Other,260% New York Medicaid APG,5347.21,,,5347.21,Other,324% New York Medicaid APG,3548.3,,,3548.3,Other,215% New York Medicaid APG,3548.3,,,3548.3,Other,215% New York Medicaid APG,2062.97,,,2062.97,Other,125% New York Medicaid APG,1650.37,36372.15,
Destroy nerve of eye muscle,67345,CPT,,,,,,,,both,,,35389.26,26188.05,74,,26188.05,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15925.17,45,,15925.17,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,17517.68,49.5,,17517.68,percent of total billed charges,110% of Medicare,24064.7,68,,24064.7,percent of total billed charges,,525.76,,,525.76,Other,186% of Medicaid,28311.41,80,,28311.41,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,28311.41,80,,28311.41,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,24772.48,70,,24772.48,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,282.67,,,282.67,Other,New York Medicaid APG methodology,282.67,,,282.67,Other,100% New York Medicaid APG,282.67,,,282.67,Other,100% New York Medicaid APG,282.67,,,282.67,Other,100% New York Medicaid APG,636,,,636,Other,225% New York Medicaid APG,432.48,,,432.48,Other,153% New York Medicaid APG,636,,,636,Other,225% New York Medicaid APG,395.73,,,395.73,Other,140% New York Medicaid APG,636,,,636,Other,225% New York Medicaid APG,734.93,,,734.93,Other,260% New York Medicaid APG,915.84,,,915.84,Other,324% New York Medicaid APG,607.73,,,607.73,Other,215% New York Medicaid APG,607.73,,,607.73,Other,215% New York Medicaid APG,353.33,,,353.33,Other,125% New York Medicaid APG,282.67,28311.41,
Biopsy eye muscle,67346,CPT,,,,,,,,both,,,81324.54,60180.16,74,,60180.16,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,36596.04,45,,36596.04,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,40255.65,49.5,,40255.65,percent of total billed charges,110% of Medicare,55300.69,68,,55300.69,percent of total billed charges,,3069.69,,,3069.69,Other,186% of Medicaid,65059.63,80,,65059.63,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,65059.63,80,,65059.63,percent of total billed charges,,7216,,,7216,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,56927.18,70,,56927.18,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1650.37,,,1650.37,Other,New York Medicaid APG methodology,1650.37,,,1650.37,Other,100% New York Medicaid APG,1650.37,,,1650.37,Other,100% New York Medicaid APG,1650.37,,,1650.37,Other,100% New York Medicaid APG,3713.34,,,3713.34,Other,225% New York Medicaid APG,2525.07,,,2525.07,Other,153% New York Medicaid APG,3713.34,,,3713.34,Other,225% New York Medicaid APG,2310.52,,,2310.52,Other,140% New York Medicaid APG,3713.34,,,3713.34,Other,225% New York Medicaid APG,4290.97,,,4290.97,Other,260% New York Medicaid APG,5347.21,,,5347.21,Other,324% New York Medicaid APG,3548.3,,,3548.3,Other,215% New York Medicaid APG,3548.3,,,3548.3,Other,215% New York Medicaid APG,2062.97,,,2062.97,Other,125% New York Medicaid APG,1650.37,65059.63,
Explore/biopsy eye socket,67400,CPT,,,,,,,,both,,,47822.67,35388.78,74,,35388.78,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,21520.2,45,,21520.2,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,23672.22,49.5,,23672.22,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3349.26,,,3349.26,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,33475.87,70,,33475.87,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1800.68,,,1800.68,Other,New York Medicaid APG methodology,1800.68,,,1800.68,Other,100% New York Medicaid APG,1800.68,,,1800.68,Other,100% New York Medicaid APG,1800.68,,,1800.68,Other,100% New York Medicaid APG,4051.52,,,4051.52,Other,225% New York Medicaid APG,2755.03,,,2755.03,Other,153% New York Medicaid APG,4051.52,,,4051.52,Other,225% New York Medicaid APG,2520.95,,,2520.95,Other,140% New York Medicaid APG,4051.52,,,4051.52,Other,225% New York Medicaid APG,4681.76,,,4681.76,Other,260% New York Medicaid APG,5834.19,,,5834.19,Other,324% New York Medicaid APG,3871.45,,,3871.45,Other,215% New York Medicaid APG,3871.45,,,3871.45,Other,215% New York Medicaid APG,2250.84,,,2250.84,Other,125% New York Medicaid APG,1800.68,35388.78,
Explore/drain eye socket,67405,CPT,,,,,,,,both,,,49151.56,36372.15,74,,36372.15,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,22118.2,45,,22118.2,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,24330.02,49.5,,24330.02,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3349.26,,,3349.26,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,34406.09,70,,34406.09,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1800.68,,,1800.68,Other,New York Medicaid APG methodology,1800.68,,,1800.68,Other,100% New York Medicaid APG,1800.68,,,1800.68,Other,100% New York Medicaid APG,1800.68,,,1800.68,Other,100% New York Medicaid APG,4051.52,,,4051.52,Other,225% New York Medicaid APG,2755.03,,,2755.03,Other,153% New York Medicaid APG,4051.52,,,4051.52,Other,225% New York Medicaid APG,2520.95,,,2520.95,Other,140% New York Medicaid APG,4051.52,,,4051.52,Other,225% New York Medicaid APG,4681.76,,,4681.76,Other,260% New York Medicaid APG,5834.19,,,5834.19,Other,324% New York Medicaid APG,3871.45,,,3871.45,Other,215% New York Medicaid APG,3871.45,,,3871.45,Other,215% New York Medicaid APG,2250.84,,,2250.84,Other,125% New York Medicaid APG,1800.68,36372.15,
Explore/treat eye socket,67412,CPT,,,,,,,,both,,,45885.35,33955.16,74,,33955.16,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,20648.41,45,,20648.41,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,22713.25,49.5,,22713.25,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3349.26,,,3349.26,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,32119.75,70,,32119.75,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1800.68,,,1800.68,Other,New York Medicaid APG methodology,1800.68,,,1800.68,Other,100% New York Medicaid APG,1800.68,,,1800.68,Other,100% New York Medicaid APG,1800.68,,,1800.68,Other,100% New York Medicaid APG,4051.52,,,4051.52,Other,225% New York Medicaid APG,2755.03,,,2755.03,Other,153% New York Medicaid APG,4051.52,,,4051.52,Other,225% New York Medicaid APG,2520.95,,,2520.95,Other,140% New York Medicaid APG,4051.52,,,4051.52,Other,225% New York Medicaid APG,4681.76,,,4681.76,Other,260% New York Medicaid APG,5834.19,,,5834.19,Other,324% New York Medicaid APG,3871.45,,,3871.45,Other,215% New York Medicaid APG,3871.45,,,3871.45,Other,215% New York Medicaid APG,2250.84,,,2250.84,Other,125% New York Medicaid APG,1800.68,33955.16,
Explore/treat eye socket,67413,CPT,,,,,,,,both,,,34994.66,25896.05,74,,25896.05,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15747.6,45,,15747.6,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,17322.36,49.5,,17322.36,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3349.26,,,3349.26,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,24496.26,70,,24496.26,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1800.68,,,1800.68,Other,New York Medicaid APG methodology,1800.68,,,1800.68,Other,100% New York Medicaid APG,1800.68,,,1800.68,Other,100% New York Medicaid APG,1800.68,,,1800.68,Other,100% New York Medicaid APG,4051.52,,,4051.52,Other,225% New York Medicaid APG,2755.03,,,2755.03,Other,153% New York Medicaid APG,4051.52,,,4051.52,Other,225% New York Medicaid APG,2520.95,,,2520.95,Other,140% New York Medicaid APG,4051.52,,,4051.52,Other,225% New York Medicaid APG,4681.76,,,4681.76,Other,260% New York Medicaid APG,5834.19,,,5834.19,Other,324% New York Medicaid APG,3871.45,,,3871.45,Other,215% New York Medicaid APG,3871.45,,,3871.45,Other,215% New York Medicaid APG,2250.84,,,2250.84,Other,125% New York Medicaid APG,1800.68,25896.05,
Explr/decompress eye socket,67414,CPT,,,,,,,,both,,,71687.2,53048.53,74,,53048.53,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,32259.24,45,,32259.24,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,35485.16,49.5,,35485.16,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3349.26,,,3349.26,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,50181.04,70,,50181.04,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1800.68,,,1800.68,Other,New York Medicaid APG methodology,1800.68,,,1800.68,Other,100% New York Medicaid APG,1800.68,,,1800.68,Other,100% New York Medicaid APG,1800.68,,,1800.68,Other,100% New York Medicaid APG,4051.52,,,4051.52,Other,225% New York Medicaid APG,2755.03,,,2755.03,Other,153% New York Medicaid APG,4051.52,,,4051.52,Other,225% New York Medicaid APG,2520.95,,,2520.95,Other,140% New York Medicaid APG,4051.52,,,4051.52,Other,225% New York Medicaid APG,4681.76,,,4681.76,Other,260% New York Medicaid APG,5834.19,,,5834.19,Other,324% New York Medicaid APG,3871.45,,,3871.45,Other,215% New York Medicaid APG,3871.45,,,3871.45,Other,215% New York Medicaid APG,2250.84,,,2250.84,Other,125% New York Medicaid APG,1800.68,53048.53,
Aspiration orbital contents,67415,CPT,,,,,,,,both,,,49151.56,36372.15,74,,36372.15,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,22118.2,45,,22118.2,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,24330.02,49.5,,24330.02,percent of total billed charges,110% of Medicare,33423.06,68,,33423.06,percent of total billed charges,,1160.61,,,1160.61,Other,186% of Medicaid,39321.25,80,,39321.25,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,39321.25,80,,39321.25,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,34406.09,70,,34406.09,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,623.98,,,623.98,Other,New York Medicaid APG methodology,623.98,,,623.98,Other,100% New York Medicaid APG,623.98,,,623.98,Other,100% New York Medicaid APG,623.98,,,623.98,Other,100% New York Medicaid APG,1403.96,,,1403.96,Other,225% New York Medicaid APG,954.7,,,954.7,Other,153% New York Medicaid APG,1403.96,,,1403.96,Other,225% New York Medicaid APG,873.58,,,873.58,Other,140% New York Medicaid APG,1403.96,,,1403.96,Other,225% New York Medicaid APG,1622.36,,,1622.36,Other,260% New York Medicaid APG,2021.71,,,2021.71,Other,324% New York Medicaid APG,1341.57,,,1341.57,Other,215% New York Medicaid APG,1341.57,,,1341.57,Other,215% New York Medicaid APG,779.98,,,779.98,Other,125% New York Medicaid APG,623.98,39321.25,
Explore/treat eye socket,67420,CPT,,,,,,,,both,,,81324.54,60180.16,74,,60180.16,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,36596.04,45,,36596.04,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,40255.65,49.5,,40255.65,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5482.74,,,5482.74,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,56927.18,70,,56927.18,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,2947.71,,,2947.71,Other,New York Medicaid APG methodology,2947.71,,,2947.71,Other,100% New York Medicaid APG,2947.71,,,2947.71,Other,100% New York Medicaid APG,2947.71,,,2947.71,Other,100% New York Medicaid APG,6632.35,,,6632.35,Other,225% New York Medicaid APG,4510,,,4510,Other,153% New York Medicaid APG,6632.35,,,6632.35,Other,225% New York Medicaid APG,4126.79,,,4126.79,Other,140% New York Medicaid APG,6632.35,,,6632.35,Other,225% New York Medicaid APG,7664.04,,,7664.04,Other,260% New York Medicaid APG,9550.58,,,9550.58,Other,324% New York Medicaid APG,6337.58,,,6337.58,Other,215% New York Medicaid APG,6337.58,,,6337.58,Other,215% New York Medicaid APG,3684.64,,,3684.64,Other,125% New York Medicaid APG,2947.71,60180.16,
Explore/treat eye socket,67430,CPT,,,,,,,,both,,,81324.54,60180.16,74,,60180.16,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,36596.04,45,,36596.04,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,40255.65,49.5,,40255.65,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,4398.22,,,4398.22,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,56927.18,70,,56927.18,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,2364.64,,,2364.64,Other,New York Medicaid APG methodology,2364.64,,,2364.64,Other,100% New York Medicaid APG,2364.64,,,2364.64,Other,100% New York Medicaid APG,2364.64,,,2364.64,Other,100% New York Medicaid APG,5320.43,,,5320.43,Other,225% New York Medicaid APG,3617.89,,,3617.89,Other,153% New York Medicaid APG,5320.43,,,5320.43,Other,225% New York Medicaid APG,3310.49,,,3310.49,Other,140% New York Medicaid APG,5320.43,,,5320.43,Other,225% New York Medicaid APG,6148.05,,,6148.05,Other,260% New York Medicaid APG,7661.42,,,7661.42,Other,324% New York Medicaid APG,5083.97,,,5083.97,Other,215% New York Medicaid APG,5083.97,,,5083.97,Other,215% New York Medicaid APG,2955.8,,,2955.8,Other,125% New York Medicaid APG,2364.64,60180.16,
Explore/drain eye socket,67440,CPT,,,,,,,,both,,,81324.54,60180.16,74,,60180.16,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,36596.04,45,,36596.04,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,40255.65,49.5,,40255.65,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5482.74,,,5482.74,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,56927.18,70,,56927.18,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,2947.71,,,2947.71,Other,New York Medicaid APG methodology,2947.71,,,2947.71,Other,100% New York Medicaid APG,2947.71,,,2947.71,Other,100% New York Medicaid APG,2947.71,,,2947.71,Other,100% New York Medicaid APG,6632.35,,,6632.35,Other,225% New York Medicaid APG,4510,,,4510,Other,153% New York Medicaid APG,6632.35,,,6632.35,Other,225% New York Medicaid APG,4126.79,,,4126.79,Other,140% New York Medicaid APG,6632.35,,,6632.35,Other,225% New York Medicaid APG,7664.04,,,7664.04,Other,260% New York Medicaid APG,9550.58,,,9550.58,Other,324% New York Medicaid APG,6337.58,,,6337.58,Other,215% New York Medicaid APG,6337.58,,,6337.58,Other,215% New York Medicaid APG,3684.64,,,3684.64,Other,125% New York Medicaid APG,2947.71,60180.16,
Explr/decompress eye socket,67445,CPT,,,,,,,,both,,,81324.54,60180.16,74,,60180.16,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,36596.04,45,,36596.04,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,40255.65,49.5,,40255.65,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5482.74,,,5482.74,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,56927.18,70,,56927.18,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,2947.71,,,2947.71,Other,New York Medicaid APG methodology,2947.71,,,2947.71,Other,100% New York Medicaid APG,2947.71,,,2947.71,Other,100% New York Medicaid APG,2947.71,,,2947.71,Other,100% New York Medicaid APG,6632.35,,,6632.35,Other,225% New York Medicaid APG,4510,,,4510,Other,153% New York Medicaid APG,6632.35,,,6632.35,Other,225% New York Medicaid APG,4126.79,,,4126.79,Other,140% New York Medicaid APG,6632.35,,,6632.35,Other,225% New York Medicaid APG,7664.04,,,7664.04,Other,260% New York Medicaid APG,9550.58,,,9550.58,Other,324% New York Medicaid APG,6337.58,,,6337.58,Other,215% New York Medicaid APG,6337.58,,,6337.58,Other,215% New York Medicaid APG,3684.64,,,3684.64,Other,125% New York Medicaid APG,2947.71,60180.16,
Explore/biopsy eye socket,67450,CPT,,,,,,,,both,,,81324.54,60180.16,74,,60180.16,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,36596.04,45,,36596.04,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,40255.65,49.5,,40255.65,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5482.74,,,5482.74,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,56927.18,70,,56927.18,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,2947.71,,,2947.71,Other,New York Medicaid APG methodology,2947.71,,,2947.71,Other,100% New York Medicaid APG,2947.71,,,2947.71,Other,100% New York Medicaid APG,2947.71,,,2947.71,Other,100% New York Medicaid APG,6632.35,,,6632.35,Other,225% New York Medicaid APG,4510,,,4510,Other,153% New York Medicaid APG,6632.35,,,6632.35,Other,225% New York Medicaid APG,4126.79,,,4126.79,Other,140% New York Medicaid APG,6632.35,,,6632.35,Other,225% New York Medicaid APG,7664.04,,,7664.04,Other,260% New York Medicaid APG,9550.58,,,9550.58,Other,324% New York Medicaid APG,6337.58,,,6337.58,Other,215% New York Medicaid APG,6337.58,,,6337.58,Other,215% New York Medicaid APG,3684.64,,,3684.64,Other,125% New York Medicaid APG,2947.71,60180.16,
Inject/treat eye socket,67500,CPT,,,,,,,,both,,,6127.39,4534.27,74,,4534.27,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,2757.33,45,,2757.33,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,3033.06,49.5,,3033.06,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,525.76,,,525.76,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,4289.17,70,,4289.17,percent of total billed charges,,308.32,,,308.32,Fee Schedule,,261.32,,,261.32,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,282.67,,,282.67,Other,New York Medicaid APG methodology,282.67,,,282.67,Other,100% New York Medicaid APG,282.67,,,282.67,Other,100% New York Medicaid APG,282.67,,,282.67,Other,100% New York Medicaid APG,636,,,636,Other,225% New York Medicaid APG,432.48,,,432.48,Other,153% New York Medicaid APG,636,,,636,Other,225% New York Medicaid APG,395.73,,,395.73,Other,140% New York Medicaid APG,636,,,636,Other,225% New York Medicaid APG,734.93,,,734.93,Other,260% New York Medicaid APG,915.84,,,915.84,Other,324% New York Medicaid APG,607.73,,,607.73,Other,215% New York Medicaid APG,607.73,,,607.73,Other,215% New York Medicaid APG,353.33,,,353.33,Other,125% New York Medicaid APG,261.32,9473,
Inject/treat eye socket,67505,CPT,,,,,,,,both,,,6127.39,4534.27,74,,4534.27,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,2757.33,45,,2757.33,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,3033.06,49.5,,3033.06,percent of total billed charges,110% of Medicare,4166.63,68,,4166.63,percent of total billed charges,,525.76,,,525.76,Other,186% of Medicaid,4901.91,80,,4901.91,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,4901.91,80,,4901.91,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,4289.17,70,,4289.17,percent of total billed charges,,349.32,,,349.32,Fee Schedule,,296.07,,,296.07,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,282.67,,,282.67,Other,New York Medicaid APG methodology,282.67,,,282.67,Other,100% New York Medicaid APG,282.67,,,282.67,Other,100% New York Medicaid APG,282.67,,,282.67,Other,100% New York Medicaid APG,636,,,636,Other,225% New York Medicaid APG,432.48,,,432.48,Other,153% New York Medicaid APG,636,,,636,Other,225% New York Medicaid APG,395.73,,,395.73,Other,140% New York Medicaid APG,636,,,636,Other,225% New York Medicaid APG,734.93,,,734.93,Other,260% New York Medicaid APG,915.84,,,915.84,Other,324% New York Medicaid APG,607.73,,,607.73,Other,215% New York Medicaid APG,607.73,,,607.73,Other,215% New York Medicaid APG,353.33,,,353.33,Other,125% New York Medicaid APG,282.67,7216,
Inject/treat eye socket,67515,CPT,,,,,,,,both,,,6127.39,4534.27,74,,4534.27,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,2757.33,45,,2757.33,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,3033.06,49.5,,3033.06,percent of total billed charges,110% of Medicare,4166.63,68,,4166.63,percent of total billed charges,,525.76,,,525.76,Other,186% of Medicaid,4901.91,80,,4901.91,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,4901.91,80,,4901.91,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,4289.17,70,,4289.17,percent of total billed charges,,227.96,,,227.96,Fee Schedule,,193.21,,,193.21,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,282.67,,,282.67,Other,New York Medicaid APG methodology,282.67,,,282.67,Other,100% New York Medicaid APG,282.67,,,282.67,Other,100% New York Medicaid APG,282.67,,,282.67,Other,100% New York Medicaid APG,636,,,636,Other,225% New York Medicaid APG,432.48,,,432.48,Other,153% New York Medicaid APG,636,,,636,Other,225% New York Medicaid APG,395.73,,,395.73,Other,140% New York Medicaid APG,636,,,636,Other,225% New York Medicaid APG,734.93,,,734.93,Other,260% New York Medicaid APG,915.84,,,915.84,Other,324% New York Medicaid APG,607.73,,,607.73,Other,215% New York Medicaid APG,607.73,,,607.73,Other,215% New York Medicaid APG,353.33,,,353.33,Other,125% New York Medicaid APG,193.21,7216,
Insert eye socket implant,67550,CPT,,,,,,,,both,,,81324.54,60180.16,74,,60180.16,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,36596.04,45,,36596.04,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,40255.65,49.5,,40255.65,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3349.26,,,3349.26,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,56927.18,70,,56927.18,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1800.68,,,1800.68,Other,New York Medicaid APG methodology,1800.68,,,1800.68,Other,100% New York Medicaid APG,1800.68,,,1800.68,Other,100% New York Medicaid APG,1800.68,,,1800.68,Other,100% New York Medicaid APG,4051.52,,,4051.52,Other,225% New York Medicaid APG,2755.03,,,2755.03,Other,153% New York Medicaid APG,4051.52,,,4051.52,Other,225% New York Medicaid APG,2520.95,,,2520.95,Other,140% New York Medicaid APG,4051.52,,,4051.52,Other,225% New York Medicaid APG,4681.76,,,4681.76,Other,260% New York Medicaid APG,5834.19,,,5834.19,Other,324% New York Medicaid APG,3871.45,,,3871.45,Other,215% New York Medicaid APG,3871.45,,,3871.45,Other,215% New York Medicaid APG,2250.84,,,2250.84,Other,125% New York Medicaid APG,1800.68,60180.16,
Revise eye socket implant,67560,CPT,,,,,,,,both,,,43213.48,31977.98,74,,31977.98,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,19446.07,45,,19446.07,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,21390.67,49.5,,21390.67,percent of total billed charges,110% of Medicare,29385.17,68,,29385.17,percent of total billed charges,,3349.26,,,3349.26,Other,186% of Medicaid,34570.78,80,,34570.78,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,34570.78,80,,34570.78,percent of total billed charges,,7216,,,7216,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,30249.44,70,,30249.44,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1800.68,,,1800.68,Other,New York Medicaid APG methodology,1800.68,,,1800.68,Other,100% New York Medicaid APG,1800.68,,,1800.68,Other,100% New York Medicaid APG,1800.68,,,1800.68,Other,100% New York Medicaid APG,4051.52,,,4051.52,Other,225% New York Medicaid APG,2755.03,,,2755.03,Other,153% New York Medicaid APG,4051.52,,,4051.52,Other,225% New York Medicaid APG,2520.95,,,2520.95,Other,140% New York Medicaid APG,4051.52,,,4051.52,Other,225% New York Medicaid APG,4681.76,,,4681.76,Other,260% New York Medicaid APG,5834.19,,,5834.19,Other,324% New York Medicaid APG,3871.45,,,3871.45,Other,215% New York Medicaid APG,3871.45,,,3871.45,Other,215% New York Medicaid APG,2250.84,,,2250.84,Other,125% New York Medicaid APG,1800.68,34570.78,
Decompress optic nerve,67570,CPT,,,,,,,,both,,,81324.54,60180.16,74,,60180.16,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,36596.04,45,,36596.04,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,40255.65,49.5,,40255.65,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3349.26,,,3349.26,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,56927.18,70,,56927.18,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1800.68,,,1800.68,Other,New York Medicaid APG methodology,1800.68,,,1800.68,Other,100% New York Medicaid APG,1800.68,,,1800.68,Other,100% New York Medicaid APG,1800.68,,,1800.68,Other,100% New York Medicaid APG,4051.52,,,4051.52,Other,225% New York Medicaid APG,2755.03,,,2755.03,Other,153% New York Medicaid APG,4051.52,,,4051.52,Other,225% New York Medicaid APG,2520.95,,,2520.95,Other,140% New York Medicaid APG,4051.52,,,4051.52,Other,225% New York Medicaid APG,4681.76,,,4681.76,Other,260% New York Medicaid APG,5834.19,,,5834.19,Other,324% New York Medicaid APG,3871.45,,,3871.45,Other,215% New York Medicaid APG,3871.45,,,3871.45,Other,215% New York Medicaid APG,2250.84,,,2250.84,Other,125% New York Medicaid APG,1800.68,60180.16,
Drainage of eyelid abscess,67700,CPT,,,,,,,,both,,,6127.39,4534.27,74,,4534.27,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,2757.33,45,,2757.33,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,3033.06,49.5,,3033.06,percent of total billed charges,110% of Medicare,4166.63,68,,4166.63,percent of total billed charges,,525.76,,,525.76,Other,186% of Medicaid,4901.91,80,,4901.91,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,4901.91,80,,4901.91,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,4289.17,70,,4289.17,percent of total billed charges,,562.52,,,562.52,Fee Schedule,,476.77,,,476.77,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,282.67,,,282.67,Other,New York Medicaid APG methodology,282.67,,,282.67,Other,100% New York Medicaid APG,282.67,,,282.67,Other,100% New York Medicaid APG,282.67,,,282.67,Other,100% New York Medicaid APG,636,,,636,Other,225% New York Medicaid APG,432.48,,,432.48,Other,153% New York Medicaid APG,636,,,636,Other,225% New York Medicaid APG,395.73,,,395.73,Other,140% New York Medicaid APG,636,,,636,Other,225% New York Medicaid APG,734.93,,,734.93,Other,260% New York Medicaid APG,915.84,,,915.84,Other,324% New York Medicaid APG,607.73,,,607.73,Other,215% New York Medicaid APG,607.73,,,607.73,Other,215% New York Medicaid APG,353.33,,,353.33,Other,125% New York Medicaid APG,282.67,7216,
Incision of eyelid,67710,CPT,,,,,,,,both,,,21295.3,15758.52,74,,15758.52,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,9582.89,45,,9582.89,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,10541.17,49.5,,10541.17,percent of total billed charges,110% of Medicare,14480.8,68,,14480.8,percent of total billed charges,,2167.59,,,2167.59,Other,186% of Medicaid,17036.24,80,,17036.24,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,17036.24,80,,17036.24,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,14906.71,70,,14906.71,percent of total billed charges,,475.6,,,475.6,Fee Schedule,,403.1,,,403.1,Fee Schedule,,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1165.37,,,1165.37,Other,New York Medicaid APG methodology,1165.37,,,1165.37,Other,100% New York Medicaid APG,1165.37,,,1165.37,Other,100% New York Medicaid APG,1165.37,,,1165.37,Other,100% New York Medicaid APG,2622.08,,,2622.08,Other,225% New York Medicaid APG,1783.01,,,1783.01,Other,153% New York Medicaid APG,2622.08,,,2622.08,Other,225% New York Medicaid APG,1631.52,,,1631.52,Other,140% New York Medicaid APG,2622.08,,,2622.08,Other,225% New York Medicaid APG,3029.96,,,3029.96,Other,260% New York Medicaid APG,3775.79,,,3775.79,Other,324% New York Medicaid APG,2505.54,,,2505.54,Other,215% New York Medicaid APG,2505.54,,,2505.54,Other,215% New York Medicaid APG,1456.71,,,1456.71,Other,125% New York Medicaid APG,403.1,17036.24,
Incision of eyelid fold,67715,CPT,,,,,,,,both,,,49151.56,36372.15,74,,36372.15,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,22118.2,45,,22118.2,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,24330.02,49.5,,24330.02,percent of total billed charges,110% of Medicare,33423.06,68,,33423.06,percent of total billed charges,,2167.59,,,2167.59,Other,186% of Medicaid,39321.25,80,,39321.25,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,39321.25,80,,39321.25,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,34406.09,70,,34406.09,percent of total billed charges,,526.44,,,526.44,Fee Schedule,,446.19,,,446.19,Fee Schedule,,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1165.37,,,1165.37,Other,New York Medicaid APG methodology,1165.37,,,1165.37,Other,100% New York Medicaid APG,1165.37,,,1165.37,Other,100% New York Medicaid APG,1165.37,,,1165.37,Other,100% New York Medicaid APG,2622.08,,,2622.08,Other,225% New York Medicaid APG,1783.01,,,1783.01,Other,153% New York Medicaid APG,2622.08,,,2622.08,Other,225% New York Medicaid APG,1631.52,,,1631.52,Other,140% New York Medicaid APG,2622.08,,,2622.08,Other,225% New York Medicaid APG,3029.96,,,3029.96,Other,260% New York Medicaid APG,3775.79,,,3775.79,Other,324% New York Medicaid APG,2505.54,,,2505.54,Other,215% New York Medicaid APG,2505.54,,,2505.54,Other,215% New York Medicaid APG,1456.71,,,1456.71,Other,125% New York Medicaid APG,446.19,39321.25,
Remove eyelid lesion,67800,CPT,,,,,,,,both,,,35091.21,25967.5,74,,25967.5,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15791.04,45,,15791.04,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,17370.15,49.5,,17370.15,percent of total billed charges,110% of Medicare,23862.02,68,,23862.02,percent of total billed charges,,525.76,,,525.76,Other,186% of Medicaid,28072.97,80,,28072.97,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,28072.97,80,,28072.97,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,24563.85,70,,24563.85,percent of total billed charges,,493.64,,,493.64,Fee Schedule,,418.39,,,418.39,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,282.67,,,282.67,Other,New York Medicaid APG methodology,282.67,,,282.67,Other,100% New York Medicaid APG,282.67,,,282.67,Other,100% New York Medicaid APG,282.67,,,282.67,Other,100% New York Medicaid APG,636,,,636,Other,225% New York Medicaid APG,432.48,,,432.48,Other,153% New York Medicaid APG,636,,,636,Other,225% New York Medicaid APG,395.73,,,395.73,Other,140% New York Medicaid APG,636,,,636,Other,225% New York Medicaid APG,734.93,,,734.93,Other,260% New York Medicaid APG,915.84,,,915.84,Other,324% New York Medicaid APG,607.73,,,607.73,Other,215% New York Medicaid APG,607.73,,,607.73,Other,215% New York Medicaid APG,353.33,,,353.33,Other,125% New York Medicaid APG,282.67,28072.97,
Remove eyelid lesions,67801,CPT,,,,,,,,both,,,21295.3,15758.52,74,,15758.52,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,9582.89,45,,9582.89,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,10541.17,49.5,,10541.17,percent of total billed charges,110% of Medicare,14480.8,68,,14480.8,percent of total billed charges,,2167.59,,,2167.59,Other,186% of Medicaid,17036.24,80,,17036.24,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,17036.24,80,,17036.24,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,14906.71,70,,14906.71,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1165.37,,,1165.37,Other,New York Medicaid APG methodology,1165.37,,,1165.37,Other,100% New York Medicaid APG,1165.37,,,1165.37,Other,100% New York Medicaid APG,1165.37,,,1165.37,Other,100% New York Medicaid APG,2622.08,,,2622.08,Other,225% New York Medicaid APG,1783.01,,,1783.01,Other,153% New York Medicaid APG,2622.08,,,2622.08,Other,225% New York Medicaid APG,1631.52,,,1631.52,Other,140% New York Medicaid APG,2622.08,,,2622.08,Other,225% New York Medicaid APG,3029.96,,,3029.96,Other,260% New York Medicaid APG,3775.79,,,3775.79,Other,324% New York Medicaid APG,2505.54,,,2505.54,Other,215% New York Medicaid APG,2505.54,,,2505.54,Other,215% New York Medicaid APG,1456.71,,,1456.71,Other,125% New York Medicaid APG,1165.37,17036.24,
Remove eyelid lesions,67805,CPT,,,,,,,,both,,,6127.39,4534.27,74,,4534.27,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,2757.33,45,,2757.33,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,3033.06,49.5,,3033.06,percent of total billed charges,110% of Medicare,4166.63,68,,4166.63,percent of total billed charges,,525.76,,,525.76,Other,186% of Medicaid,4901.91,80,,4901.91,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,4901.91,80,,4901.91,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,4289.17,70,,4289.17,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,282.67,,,282.67,Other,New York Medicaid APG methodology,282.67,,,282.67,Other,100% New York Medicaid APG,282.67,,,282.67,Other,100% New York Medicaid APG,282.67,,,282.67,Other,100% New York Medicaid APG,636,,,636,Other,225% New York Medicaid APG,432.48,,,432.48,Other,153% New York Medicaid APG,636,,,636,Other,225% New York Medicaid APG,395.73,,,395.73,Other,140% New York Medicaid APG,636,,,636,Other,225% New York Medicaid APG,734.93,,,734.93,Other,260% New York Medicaid APG,915.84,,,915.84,Other,324% New York Medicaid APG,607.73,,,607.73,Other,215% New York Medicaid APG,607.73,,,607.73,Other,215% New York Medicaid APG,353.33,,,353.33,Other,125% New York Medicaid APG,282.67,7216,
Remove eyelid lesion(s),67808,CPT,,,,,,,,both,,,34585.73,25593.44,74,,25593.44,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15563.58,45,,15563.58,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,17119.94,49.5,,17119.94,percent of total billed charges,110% of Medicare,23518.3,68,,23518.3,percent of total billed charges,,2167.59,,,2167.59,Other,186% of Medicaid,27668.58,80,,27668.58,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,27668.58,80,,27668.58,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,24210.01,70,,24210.01,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1165.37,,,1165.37,Other,New York Medicaid APG methodology,1165.37,,,1165.37,Other,100% New York Medicaid APG,1165.37,,,1165.37,Other,100% New York Medicaid APG,1165.37,,,1165.37,Other,100% New York Medicaid APG,2622.08,,,2622.08,Other,225% New York Medicaid APG,1783.01,,,1783.01,Other,153% New York Medicaid APG,2622.08,,,2622.08,Other,225% New York Medicaid APG,1631.52,,,1631.52,Other,140% New York Medicaid APG,2622.08,,,2622.08,Other,225% New York Medicaid APG,3029.96,,,3029.96,Other,260% New York Medicaid APG,3775.79,,,3775.79,Other,324% New York Medicaid APG,2505.54,,,2505.54,Other,215% New York Medicaid APG,2505.54,,,2505.54,Other,215% New York Medicaid APG,1456.71,,,1456.71,Other,125% New York Medicaid APG,1165.37,27668.58,
Biopsy eyelid & lid margin,67810,CPT,,,,,,,,both,,,6127.39,4534.27,74,,4534.27,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,2757.33,45,,2757.33,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,3033.06,49.5,,3033.06,percent of total billed charges,110% of Medicare,4166.63,68,,4166.63,percent of total billed charges,,525.76,,,525.76,Other,186% of Medicaid,4901.91,80,,4901.91,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,4901.91,80,,4901.91,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,4289.17,70,,4289.17,percent of total billed charges,,329.64,,,329.64,Fee Schedule,,279.39,,,279.39,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,282.67,,,282.67,Other,New York Medicaid APG methodology,282.67,,,282.67,Other,100% New York Medicaid APG,282.67,,,282.67,Other,100% New York Medicaid APG,282.67,,,282.67,Other,100% New York Medicaid APG,636,,,636,Other,225% New York Medicaid APG,432.48,,,432.48,Other,153% New York Medicaid APG,636,,,636,Other,225% New York Medicaid APG,395.73,,,395.73,Other,140% New York Medicaid APG,636,,,636,Other,225% New York Medicaid APG,734.93,,,734.93,Other,260% New York Medicaid APG,915.84,,,915.84,Other,324% New York Medicaid APG,607.73,,,607.73,Other,215% New York Medicaid APG,607.73,,,607.73,Other,215% New York Medicaid APG,353.33,,,353.33,Other,125% New York Medicaid APG,279.39,7216,
Revise eyelashes,67820,CPT,,,,,,,,both,,,2686.86,1988.28,74,,1988.28,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,1209.09,45,,1209.09,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,1330,49.5,,1330,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,351.84,,,351.84,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,1880.8,70,,1880.8,percent of total billed charges,,106.6,,,106.6,Fee Schedule,,90.35,,,90.35,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,189.16,,,189.16,Other,New York Medicaid APG methodology,189.16,,,189.16,Other,100% New York Medicaid APG,189.16,,,189.16,Other,100% New York Medicaid APG,189.16,,,189.16,Other,100% New York Medicaid APG,425.62,,,425.62,Other,225% New York Medicaid APG,289.42,,,289.42,Other,153% New York Medicaid APG,425.62,,,425.62,Other,225% New York Medicaid APG,264.83,,,264.83,Other,140% New York Medicaid APG,425.62,,,425.62,Other,225% New York Medicaid APG,491.82,,,491.82,Other,260% New York Medicaid APG,612.89,,,612.89,Other,324% New York Medicaid APG,406.7,,,406.7,Other,215% New York Medicaid APG,406.7,,,406.7,Other,215% New York Medicaid APG,236.45,,,236.45,Other,125% New York Medicaid APG,90.35,9473,
Revise eyelashes,67825,CPT,,,,,,,,both,,,6127.39,4534.27,74,,4534.27,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,2757.33,45,,2757.33,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,3033.06,49.5,,3033.06,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,525.76,,,525.76,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,4289.17,70,,4289.17,percent of total billed charges,,588.76,,,588.76,Fee Schedule,,499.01,,,499.01,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,282.67,,,282.67,Other,New York Medicaid APG methodology,282.67,,,282.67,Other,100% New York Medicaid APG,282.67,,,282.67,Other,100% New York Medicaid APG,282.67,,,282.67,Other,100% New York Medicaid APG,636,,,636,Other,225% New York Medicaid APG,432.48,,,432.48,Other,153% New York Medicaid APG,636,,,636,Other,225% New York Medicaid APG,395.73,,,395.73,Other,140% New York Medicaid APG,636,,,636,Other,225% New York Medicaid APG,734.93,,,734.93,Other,260% New York Medicaid APG,915.84,,,915.84,Other,324% New York Medicaid APG,607.73,,,607.73,Other,215% New York Medicaid APG,607.73,,,607.73,Other,215% New York Medicaid APG,353.33,,,353.33,Other,125% New York Medicaid APG,282.67,9473,
Revise eyelashes,67830,CPT,,,,,,,,both,,,33992.81,25154.68,74,,25154.68,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15296.76,45,,15296.76,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,16826.44,49.5,,16826.44,percent of total billed charges,110% of Medicare,23115.11,68,,23115.11,percent of total billed charges,,525.76,,,525.76,Other,186% of Medicaid,27194.25,80,,27194.25,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,27194.25,80,,27194.25,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,23794.97,70,,23794.97,percent of total billed charges,,664.2,,,664.2,Fee Schedule,,562.95,,,562.95,Fee Schedule,,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,282.67,,,282.67,Other,New York Medicaid APG methodology,282.67,,,282.67,Other,100% New York Medicaid APG,282.67,,,282.67,Other,100% New York Medicaid APG,282.67,,,282.67,Other,100% New York Medicaid APG,636,,,636,Other,225% New York Medicaid APG,432.48,,,432.48,Other,153% New York Medicaid APG,636,,,636,Other,225% New York Medicaid APG,395.73,,,395.73,Other,140% New York Medicaid APG,636,,,636,Other,225% New York Medicaid APG,734.93,,,734.93,Other,260% New York Medicaid APG,915.84,,,915.84,Other,324% New York Medicaid APG,607.73,,,607.73,Other,215% New York Medicaid APG,607.73,,,607.73,Other,215% New York Medicaid APG,353.33,,,353.33,Other,125% New York Medicaid APG,282.67,27194.25,
Revise eyelashes,67835,CPT,,,,,,,,both,,,33679.66,24922.95,74,,24922.95,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15155.85,45,,15155.85,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,16671.43,49.5,,16671.43,percent of total billed charges,110% of Medicare,22902.17,68,,22902.17,percent of total billed charges,,3169.18,,,3169.18,Other,186% of Medicaid,26943.73,80,,26943.73,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,26943.73,80,,26943.73,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,23575.76,70,,23575.76,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1703.86,,,1703.86,Other,New York Medicaid APG methodology,1703.86,,,1703.86,Other,100% New York Medicaid APG,1703.86,,,1703.86,Other,100% New York Medicaid APG,1703.86,,,1703.86,Other,100% New York Medicaid APG,3833.69,,,3833.69,Other,225% New York Medicaid APG,2606.91,,,2606.91,Other,153% New York Medicaid APG,3833.69,,,3833.69,Other,225% New York Medicaid APG,2385.41,,,2385.41,Other,140% New York Medicaid APG,3833.69,,,3833.69,Other,225% New York Medicaid APG,4430.04,,,4430.04,Other,260% New York Medicaid APG,5520.51,,,5520.51,Other,324% New York Medicaid APG,3663.3,,,3663.3,Other,215% New York Medicaid APG,3663.3,,,3663.3,Other,215% New York Medicaid APG,2129.83,,,2129.83,Other,125% New York Medicaid APG,1703.86,26943.73,
Remove eyelid lesion,67840,CPT,,,,,,,,both,,,35626.99,26363.97,74,,26363.97,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,16032.15,45,,16032.15,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,17635.36,49.5,,17635.36,percent of total billed charges,110% of Medicare,24226.35,68,,24226.35,percent of total billed charges,,2167.59,,,2167.59,Other,186% of Medicaid,28501.59,80,,28501.59,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,28501.59,80,,28501.59,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,24938.89,70,,24938.89,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1165.37,,,1165.37,Other,New York Medicaid APG methodology,1165.37,,,1165.37,Other,100% New York Medicaid APG,1165.37,,,1165.37,Other,100% New York Medicaid APG,1165.37,,,1165.37,Other,100% New York Medicaid APG,2622.08,,,2622.08,Other,225% New York Medicaid APG,1783.01,,,1783.01,Other,153% New York Medicaid APG,2622.08,,,2622.08,Other,225% New York Medicaid APG,1631.52,,,1631.52,Other,140% New York Medicaid APG,2622.08,,,2622.08,Other,225% New York Medicaid APG,3029.96,,,3029.96,Other,260% New York Medicaid APG,3775.79,,,3775.79,Other,324% New York Medicaid APG,2505.54,,,2505.54,Other,215% New York Medicaid APG,2505.54,,,2505.54,Other,215% New York Medicaid APG,1456.71,,,1456.71,Other,125% New York Medicaid APG,1165.37,28501.59,
Treat eyelid lesion,67850,CPT,,,,,,,,both,,,21295.3,15758.52,74,,15758.52,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,9582.89,45,,9582.89,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,10541.17,49.5,,10541.17,percent of total billed charges,110% of Medicare,14480.8,68,,14480.8,percent of total billed charges,,525.76,,,525.76,Other,186% of Medicaid,17036.24,80,,17036.24,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,17036.24,80,,17036.24,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,14906.71,70,,14906.71,percent of total billed charges,,637.96,,,637.96,Fee Schedule,,540.71,,,540.71,Fee Schedule,,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,282.67,,,282.67,Other,New York Medicaid APG methodology,282.67,,,282.67,Other,100% New York Medicaid APG,282.67,,,282.67,Other,100% New York Medicaid APG,282.67,,,282.67,Other,100% New York Medicaid APG,636,,,636,Other,225% New York Medicaid APG,432.48,,,432.48,Other,153% New York Medicaid APG,636,,,636,Other,225% New York Medicaid APG,395.73,,,395.73,Other,140% New York Medicaid APG,636,,,636,Other,225% New York Medicaid APG,734.93,,,734.93,Other,260% New York Medicaid APG,915.84,,,915.84,Other,324% New York Medicaid APG,607.73,,,607.73,Other,215% New York Medicaid APG,607.73,,,607.73,Other,215% New York Medicaid APG,353.33,,,353.33,Other,125% New York Medicaid APG,282.67,17036.24,
Closure of eyelid by suture,67875,CPT,,,,,,,,both,,,21295.3,15758.52,74,,15758.52,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,9582.89,45,,9582.89,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,10541.17,49.5,,10541.17,percent of total billed charges,110% of Medicare,14480.8,68,,14480.8,percent of total billed charges,,2167.59,,,2167.59,Other,186% of Medicaid,17036.24,80,,17036.24,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,17036.24,80,,17036.24,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,14906.71,70,,14906.71,percent of total billed charges,,459.2,,,459.2,Fee Schedule,,389.2,,,389.2,Fee Schedule,,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1165.37,,,1165.37,Other,New York Medicaid APG methodology,1165.37,,,1165.37,Other,100% New York Medicaid APG,1165.37,,,1165.37,Other,100% New York Medicaid APG,1165.37,,,1165.37,Other,100% New York Medicaid APG,2622.08,,,2622.08,Other,225% New York Medicaid APG,1783.01,,,1783.01,Other,153% New York Medicaid APG,2622.08,,,2622.08,Other,225% New York Medicaid APG,1631.52,,,1631.52,Other,140% New York Medicaid APG,2622.08,,,2622.08,Other,225% New York Medicaid APG,3029.96,,,3029.96,Other,260% New York Medicaid APG,3775.79,,,3775.79,Other,324% New York Medicaid APG,2505.54,,,2505.54,Other,215% New York Medicaid APG,2505.54,,,2505.54,Other,215% New York Medicaid APG,1456.71,,,1456.71,Other,125% New York Medicaid APG,389.2,17036.24,
Revision of eyelid,67880,CPT,,,,,,,,both,,,49151.56,36372.15,74,,36372.15,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,22118.2,45,,22118.2,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,24330.02,49.5,,24330.02,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2167.59,,,2167.59,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,34406.09,70,,34406.09,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1165.37,,,1165.37,Other,New York Medicaid APG methodology,1165.37,,,1165.37,Other,100% New York Medicaid APG,1165.37,,,1165.37,Other,100% New York Medicaid APG,1165.37,,,1165.37,Other,100% New York Medicaid APG,2622.08,,,2622.08,Other,225% New York Medicaid APG,1783.01,,,1783.01,Other,153% New York Medicaid APG,2622.08,,,2622.08,Other,225% New York Medicaid APG,1631.52,,,1631.52,Other,140% New York Medicaid APG,2622.08,,,2622.08,Other,225% New York Medicaid APG,3029.96,,,3029.96,Other,260% New York Medicaid APG,3775.79,,,3775.79,Other,324% New York Medicaid APG,2505.54,,,2505.54,Other,215% New York Medicaid APG,2505.54,,,2505.54,Other,215% New York Medicaid APG,1456.71,,,1456.71,Other,125% New York Medicaid APG,1165.37,36372.15,
Revision of eyelid,67882,CPT,,,,,,,,both,,,49151.56,36372.15,74,,36372.15,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,22118.2,45,,22118.2,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,24330.02,49.5,,24330.02,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3169.18,,,3169.18,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,34406.09,70,,34406.09,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1703.86,,,1703.86,Other,New York Medicaid APG methodology,1703.86,,,1703.86,Other,100% New York Medicaid APG,1703.86,,,1703.86,Other,100% New York Medicaid APG,1703.86,,,1703.86,Other,100% New York Medicaid APG,3833.69,,,3833.69,Other,225% New York Medicaid APG,2606.91,,,2606.91,Other,153% New York Medicaid APG,3833.69,,,3833.69,Other,225% New York Medicaid APG,2385.41,,,2385.41,Other,140% New York Medicaid APG,3833.69,,,3833.69,Other,225% New York Medicaid APG,4430.04,,,4430.04,Other,260% New York Medicaid APG,5520.51,,,5520.51,Other,324% New York Medicaid APG,3663.3,,,3663.3,Other,215% New York Medicaid APG,3663.3,,,3663.3,Other,215% New York Medicaid APG,2129.83,,,2129.83,Other,125% New York Medicaid APG,1703.86,36372.15,
Repair brow defect,67900,CPT,,,,,,,,both,,,32669.57,24175.48,74,,24175.48,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,14701.31,45,,14701.31,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,16171.44,49.5,,16171.44,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3169.18,,,3169.18,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,22868.7,70,,22868.7,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1703.86,,,1703.86,Other,New York Medicaid APG methodology,1703.86,,,1703.86,Other,100% New York Medicaid APG,1703.86,,,1703.86,Other,100% New York Medicaid APG,1703.86,,,1703.86,Other,100% New York Medicaid APG,3833.69,,,3833.69,Other,225% New York Medicaid APG,2606.91,,,2606.91,Other,153% New York Medicaid APG,3833.69,,,3833.69,Other,225% New York Medicaid APG,2385.41,,,2385.41,Other,140% New York Medicaid APG,3833.69,,,3833.69,Other,225% New York Medicaid APG,4430.04,,,4430.04,Other,260% New York Medicaid APG,5520.51,,,5520.51,Other,324% New York Medicaid APG,3663.3,,,3663.3,Other,215% New York Medicaid APG,3663.3,,,3663.3,Other,215% New York Medicaid APG,2129.83,,,2129.83,Other,125% New York Medicaid APG,1703.86,24175.48,
Repair eyelid defect,67901,CPT,,,,,,,,both,,,49151.56,36372.15,74,,36372.15,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,22118.2,45,,22118.2,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,24330.02,49.5,,24330.02,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3169.18,,,3169.18,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,34406.09,70,,34406.09,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1703.86,,,1703.86,Other,New York Medicaid APG methodology,1703.86,,,1703.86,Other,100% New York Medicaid APG,1703.86,,,1703.86,Other,100% New York Medicaid APG,1703.86,,,1703.86,Other,100% New York Medicaid APG,3833.69,,,3833.69,Other,225% New York Medicaid APG,2606.91,,,2606.91,Other,153% New York Medicaid APG,3833.69,,,3833.69,Other,225% New York Medicaid APG,2385.41,,,2385.41,Other,140% New York Medicaid APG,3833.69,,,3833.69,Other,225% New York Medicaid APG,4430.04,,,4430.04,Other,260% New York Medicaid APG,5520.51,,,5520.51,Other,324% New York Medicaid APG,3663.3,,,3663.3,Other,215% New York Medicaid APG,3663.3,,,3663.3,Other,215% New York Medicaid APG,2129.83,,,2129.83,Other,125% New York Medicaid APG,1703.86,36372.15,
Repair eyelid defect,67902,CPT,,,,,,,,both,,,81324.54,60180.16,74,,60180.16,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,36596.04,45,,36596.04,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,40255.65,49.5,,40255.65,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3169.18,,,3169.18,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,56927.18,70,,56927.18,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1703.86,,,1703.86,Other,New York Medicaid APG methodology,1703.86,,,1703.86,Other,100% New York Medicaid APG,1703.86,,,1703.86,Other,100% New York Medicaid APG,1703.86,,,1703.86,Other,100% New York Medicaid APG,3833.69,,,3833.69,Other,225% New York Medicaid APG,2606.91,,,2606.91,Other,153% New York Medicaid APG,3833.69,,,3833.69,Other,225% New York Medicaid APG,2385.41,,,2385.41,Other,140% New York Medicaid APG,3833.69,,,3833.69,Other,225% New York Medicaid APG,4430.04,,,4430.04,Other,260% New York Medicaid APG,5520.51,,,5520.51,Other,324% New York Medicaid APG,3663.3,,,3663.3,Other,215% New York Medicaid APG,3663.3,,,3663.3,Other,215% New York Medicaid APG,2129.83,,,2129.83,Other,125% New York Medicaid APG,1703.86,60180.16,
Repair eyelid defect,67903,CPT,,,,,,,,both,,,49151.56,36372.15,74,,36372.15,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,22118.2,45,,22118.2,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,24330.02,49.5,,24330.02,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3169.18,,,3169.18,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,34406.09,70,,34406.09,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1703.86,,,1703.86,Other,New York Medicaid APG methodology,1703.86,,,1703.86,Other,100% New York Medicaid APG,1703.86,,,1703.86,Other,100% New York Medicaid APG,1703.86,,,1703.86,Other,100% New York Medicaid APG,3833.69,,,3833.69,Other,225% New York Medicaid APG,2606.91,,,2606.91,Other,153% New York Medicaid APG,3833.69,,,3833.69,Other,225% New York Medicaid APG,2385.41,,,2385.41,Other,140% New York Medicaid APG,3833.69,,,3833.69,Other,225% New York Medicaid APG,4430.04,,,4430.04,Other,260% New York Medicaid APG,5520.51,,,5520.51,Other,324% New York Medicaid APG,3663.3,,,3663.3,Other,215% New York Medicaid APG,3663.3,,,3663.3,Other,215% New York Medicaid APG,2129.83,,,2129.83,Other,125% New York Medicaid APG,1703.86,36372.15,
Repair eyelid defect,67904,CPT,,,,,,,,both,,,33846.09,25046.11,74,,25046.11,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15230.74,45,,15230.74,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,16753.81,49.5,,16753.81,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3169.18,,,3169.18,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,23692.26,70,,23692.26,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1703.86,,,1703.86,Other,New York Medicaid APG methodology,1703.86,,,1703.86,Other,100% New York Medicaid APG,1703.86,,,1703.86,Other,100% New York Medicaid APG,1703.86,,,1703.86,Other,100% New York Medicaid APG,3833.69,,,3833.69,Other,225% New York Medicaid APG,2606.91,,,2606.91,Other,153% New York Medicaid APG,3833.69,,,3833.69,Other,225% New York Medicaid APG,2385.41,,,2385.41,Other,140% New York Medicaid APG,3833.69,,,3833.69,Other,225% New York Medicaid APG,4430.04,,,4430.04,Other,260% New York Medicaid APG,5520.51,,,5520.51,Other,324% New York Medicaid APG,3663.3,,,3663.3,Other,215% New York Medicaid APG,3663.3,,,3663.3,Other,215% New York Medicaid APG,2129.83,,,2129.83,Other,125% New York Medicaid APG,1703.86,25046.11,
Repair eyelid defect,67906,CPT,,,,,,,,both,,,81324.54,60180.16,74,,60180.16,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,36596.04,45,,36596.04,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,40255.65,49.5,,40255.65,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3169.18,,,3169.18,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,56927.18,70,,56927.18,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1703.86,,,1703.86,Other,New York Medicaid APG methodology,1703.86,,,1703.86,Other,100% New York Medicaid APG,1703.86,,,1703.86,Other,100% New York Medicaid APG,1703.86,,,1703.86,Other,100% New York Medicaid APG,3833.69,,,3833.69,Other,225% New York Medicaid APG,2606.91,,,2606.91,Other,153% New York Medicaid APG,3833.69,,,3833.69,Other,225% New York Medicaid APG,2385.41,,,2385.41,Other,140% New York Medicaid APG,3833.69,,,3833.69,Other,225% New York Medicaid APG,4430.04,,,4430.04,Other,260% New York Medicaid APG,5520.51,,,5520.51,Other,324% New York Medicaid APG,3663.3,,,3663.3,Other,215% New York Medicaid APG,3663.3,,,3663.3,Other,215% New York Medicaid APG,2129.83,,,2129.83,Other,125% New York Medicaid APG,1703.86,60180.16,
Repair eyelid defect,67908,CPT,,,,,,,,both,,,43046.76,31854.6,74,,31854.6,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,19371.04,45,,19371.04,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,21308.15,49.5,,21308.15,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3169.18,,,3169.18,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,30132.73,70,,30132.73,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1703.86,,,1703.86,Other,New York Medicaid APG methodology,1703.86,,,1703.86,Other,100% New York Medicaid APG,1703.86,,,1703.86,Other,100% New York Medicaid APG,1703.86,,,1703.86,Other,100% New York Medicaid APG,3833.69,,,3833.69,Other,225% New York Medicaid APG,2606.91,,,2606.91,Other,153% New York Medicaid APG,3833.69,,,3833.69,Other,225% New York Medicaid APG,2385.41,,,2385.41,Other,140% New York Medicaid APG,3833.69,,,3833.69,Other,225% New York Medicaid APG,4430.04,,,4430.04,Other,260% New York Medicaid APG,5520.51,,,5520.51,Other,324% New York Medicaid APG,3663.3,,,3663.3,Other,215% New York Medicaid APG,3663.3,,,3663.3,Other,215% New York Medicaid APG,2129.83,,,2129.83,Other,125% New York Medicaid APG,1703.86,31854.6,
Revise eyelid defect,67909,CPT,,,,,,,,both,,,49151.56,36372.15,74,,36372.15,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,22118.2,45,,22118.2,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,24330.02,49.5,,24330.02,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3169.18,,,3169.18,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,34406.09,70,,34406.09,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1703.86,,,1703.86,Other,New York Medicaid APG methodology,1703.86,,,1703.86,Other,100% New York Medicaid APG,1703.86,,,1703.86,Other,100% New York Medicaid APG,1703.86,,,1703.86,Other,100% New York Medicaid APG,3833.69,,,3833.69,Other,225% New York Medicaid APG,2606.91,,,2606.91,Other,153% New York Medicaid APG,3833.69,,,3833.69,Other,225% New York Medicaid APG,2385.41,,,2385.41,Other,140% New York Medicaid APG,3833.69,,,3833.69,Other,225% New York Medicaid APG,4430.04,,,4430.04,Other,260% New York Medicaid APG,5520.51,,,5520.51,Other,324% New York Medicaid APG,3663.3,,,3663.3,Other,215% New York Medicaid APG,3663.3,,,3663.3,Other,215% New York Medicaid APG,2129.83,,,2129.83,Other,125% New York Medicaid APG,1703.86,36372.15,
Revise eyelid defect,67911,CPT,,,,,,,,both,,,35896.32,26563.28,74,,26563.28,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,16153.34,45,,16153.34,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,17768.68,49.5,,17768.68,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2167.59,,,2167.59,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,25127.42,70,,25127.42,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1165.37,,,1165.37,Other,New York Medicaid APG methodology,1165.37,,,1165.37,Other,100% New York Medicaid APG,1165.37,,,1165.37,Other,100% New York Medicaid APG,1165.37,,,1165.37,Other,100% New York Medicaid APG,2622.08,,,2622.08,Other,225% New York Medicaid APG,1783.01,,,1783.01,Other,153% New York Medicaid APG,2622.08,,,2622.08,Other,225% New York Medicaid APG,1631.52,,,1631.52,Other,140% New York Medicaid APG,2622.08,,,2622.08,Other,225% New York Medicaid APG,3029.96,,,3029.96,Other,260% New York Medicaid APG,3775.79,,,3775.79,Other,324% New York Medicaid APG,2505.54,,,2505.54,Other,215% New York Medicaid APG,2505.54,,,2505.54,Other,215% New York Medicaid APG,1456.71,,,1456.71,Other,125% New York Medicaid APG,1165.37,26563.28,
Correction eyelid w/implant,67912,CPT,,,,,,,,both,,,36009.67,26647.16,74,,26647.16,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,16204.35,45,,16204.35,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,17824.79,49.5,,17824.79,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2167.59,,,2167.59,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,25206.77,70,,25206.77,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1165.37,,,1165.37,Other,New York Medicaid APG methodology,1165.37,,,1165.37,Other,100% New York Medicaid APG,1165.37,,,1165.37,Other,100% New York Medicaid APG,1165.37,,,1165.37,Other,100% New York Medicaid APG,2622.08,,,2622.08,Other,225% New York Medicaid APG,1783.01,,,1783.01,Other,153% New York Medicaid APG,2622.08,,,2622.08,Other,225% New York Medicaid APG,1631.52,,,1631.52,Other,140% New York Medicaid APG,2622.08,,,2622.08,Other,225% New York Medicaid APG,3029.96,,,3029.96,Other,260% New York Medicaid APG,3775.79,,,3775.79,Other,324% New York Medicaid APG,2505.54,,,2505.54,Other,215% New York Medicaid APG,2505.54,,,2505.54,Other,215% New York Medicaid APG,1456.71,,,1456.71,Other,125% New York Medicaid APG,1165.37,26647.16,
Repair eyelid defect,67914,CPT,,,,,,,,both,,,33626.66,24883.73,74,,24883.73,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15132,45,,15132,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,16645.2,49.5,,16645.2,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2167.59,,,2167.59,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,23538.66,70,,23538.66,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1165.37,,,1165.37,Other,New York Medicaid APG methodology,1165.37,,,1165.37,Other,100% New York Medicaid APG,1165.37,,,1165.37,Other,100% New York Medicaid APG,1165.37,,,1165.37,Other,100% New York Medicaid APG,2622.08,,,2622.08,Other,225% New York Medicaid APG,1783.01,,,1783.01,Other,153% New York Medicaid APG,2622.08,,,2622.08,Other,225% New York Medicaid APG,1631.52,,,1631.52,Other,140% New York Medicaid APG,2622.08,,,2622.08,Other,225% New York Medicaid APG,3029.96,,,3029.96,Other,260% New York Medicaid APG,3775.79,,,3775.79,Other,324% New York Medicaid APG,2505.54,,,2505.54,Other,215% New York Medicaid APG,2505.54,,,2505.54,Other,215% New York Medicaid APG,1456.71,,,1456.71,Other,125% New York Medicaid APG,1165.37,24883.73,
Repair eyelid defect,67915,CPT,,,,,,,,both,,,49151.56,36372.15,74,,36372.15,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,22118.2,45,,22118.2,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,24330.02,49.5,,24330.02,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2167.59,,,2167.59,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,34406.09,70,,34406.09,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1165.37,,,1165.37,Other,New York Medicaid APG methodology,1165.37,,,1165.37,Other,100% New York Medicaid APG,1165.37,,,1165.37,Other,100% New York Medicaid APG,1165.37,,,1165.37,Other,100% New York Medicaid APG,2622.08,,,2622.08,Other,225% New York Medicaid APG,1783.01,,,1783.01,Other,153% New York Medicaid APG,2622.08,,,2622.08,Other,225% New York Medicaid APG,1631.52,,,1631.52,Other,140% New York Medicaid APG,2622.08,,,2622.08,Other,225% New York Medicaid APG,3029.96,,,3029.96,Other,260% New York Medicaid APG,3775.79,,,3775.79,Other,324% New York Medicaid APG,2505.54,,,2505.54,Other,215% New York Medicaid APG,2505.54,,,2505.54,Other,215% New York Medicaid APG,1456.71,,,1456.71,Other,125% New York Medicaid APG,1165.37,36372.15,
Repair eyelid defect,67916,CPT,,,,,,,,both,,,49151.56,36372.15,74,,36372.15,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,22118.2,45,,22118.2,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,24330.02,49.5,,24330.02,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2167.59,,,2167.59,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,34406.09,70,,34406.09,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1165.37,,,1165.37,Other,New York Medicaid APG methodology,1165.37,,,1165.37,Other,100% New York Medicaid APG,1165.37,,,1165.37,Other,100% New York Medicaid APG,1165.37,,,1165.37,Other,100% New York Medicaid APG,2622.08,,,2622.08,Other,225% New York Medicaid APG,1783.01,,,1783.01,Other,153% New York Medicaid APG,2622.08,,,2622.08,Other,225% New York Medicaid APG,1631.52,,,1631.52,Other,140% New York Medicaid APG,2622.08,,,2622.08,Other,225% New York Medicaid APG,3029.96,,,3029.96,Other,260% New York Medicaid APG,3775.79,,,3775.79,Other,324% New York Medicaid APG,2505.54,,,2505.54,Other,215% New York Medicaid APG,2505.54,,,2505.54,Other,215% New York Medicaid APG,1456.71,,,1456.71,Other,125% New York Medicaid APG,1165.37,36372.15,
Repair eyelid defect,67917,CPT,,,,,,,,both,,,34560.91,25575.07,74,,25575.07,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15552.41,45,,15552.41,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,17107.65,49.5,,17107.65,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3169.18,,,3169.18,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,24192.64,70,,24192.64,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1703.86,,,1703.86,Other,New York Medicaid APG methodology,1703.86,,,1703.86,Other,100% New York Medicaid APG,1703.86,,,1703.86,Other,100% New York Medicaid APG,1703.86,,,1703.86,Other,100% New York Medicaid APG,3833.69,,,3833.69,Other,225% New York Medicaid APG,2606.91,,,2606.91,Other,153% New York Medicaid APG,3833.69,,,3833.69,Other,225% New York Medicaid APG,2385.41,,,2385.41,Other,140% New York Medicaid APG,3833.69,,,3833.69,Other,225% New York Medicaid APG,4430.04,,,4430.04,Other,260% New York Medicaid APG,5520.51,,,5520.51,Other,324% New York Medicaid APG,3663.3,,,3663.3,Other,215% New York Medicaid APG,3663.3,,,3663.3,Other,215% New York Medicaid APG,2129.83,,,2129.83,Other,125% New York Medicaid APG,1703.86,25575.07,
Repair eyelid defect,67921,CPT,,,,,,,,both,,,49151.56,36372.15,74,,36372.15,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,22118.2,45,,22118.2,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,24330.02,49.5,,24330.02,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2167.59,,,2167.59,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,34406.09,70,,34406.09,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1165.37,,,1165.37,Other,New York Medicaid APG methodology,1165.37,,,1165.37,Other,100% New York Medicaid APG,1165.37,,,1165.37,Other,100% New York Medicaid APG,1165.37,,,1165.37,Other,100% New York Medicaid APG,2622.08,,,2622.08,Other,225% New York Medicaid APG,1783.01,,,1783.01,Other,153% New York Medicaid APG,2622.08,,,2622.08,Other,225% New York Medicaid APG,1631.52,,,1631.52,Other,140% New York Medicaid APG,2622.08,,,2622.08,Other,225% New York Medicaid APG,3029.96,,,3029.96,Other,260% New York Medicaid APG,3775.79,,,3775.79,Other,324% New York Medicaid APG,2505.54,,,2505.54,Other,215% New York Medicaid APG,2505.54,,,2505.54,Other,215% New York Medicaid APG,1456.71,,,1456.71,Other,125% New York Medicaid APG,1165.37,36372.15,
Repair eyelid defect,67922,CPT,,,,,,,,both,,,49151.56,36372.15,74,,36372.15,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,22118.2,45,,22118.2,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,24330.02,49.5,,24330.02,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2167.59,,,2167.59,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,34406.09,70,,34406.09,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1165.37,,,1165.37,Other,New York Medicaid APG methodology,1165.37,,,1165.37,Other,100% New York Medicaid APG,1165.37,,,1165.37,Other,100% New York Medicaid APG,1165.37,,,1165.37,Other,100% New York Medicaid APG,2622.08,,,2622.08,Other,225% New York Medicaid APG,1783.01,,,1783.01,Other,153% New York Medicaid APG,2622.08,,,2622.08,Other,225% New York Medicaid APG,1631.52,,,1631.52,Other,140% New York Medicaid APG,2622.08,,,2622.08,Other,225% New York Medicaid APG,3029.96,,,3029.96,Other,260% New York Medicaid APG,3775.79,,,3775.79,Other,324% New York Medicaid APG,2505.54,,,2505.54,Other,215% New York Medicaid APG,2505.54,,,2505.54,Other,215% New York Medicaid APG,1456.71,,,1456.71,Other,125% New York Medicaid APG,1165.37,36372.15,
Repair eyelid defect,67923,CPT,,,,,,,,both,,,35662.66,26390.37,74,,26390.37,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,16048.2,45,,16048.2,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,17653.02,49.5,,17653.02,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3169.18,,,3169.18,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,24963.86,70,,24963.86,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1703.86,,,1703.86,Other,New York Medicaid APG methodology,1703.86,,,1703.86,Other,100% New York Medicaid APG,1703.86,,,1703.86,Other,100% New York Medicaid APG,1703.86,,,1703.86,Other,100% New York Medicaid APG,3833.69,,,3833.69,Other,225% New York Medicaid APG,2606.91,,,2606.91,Other,153% New York Medicaid APG,3833.69,,,3833.69,Other,225% New York Medicaid APG,2385.41,,,2385.41,Other,140% New York Medicaid APG,3833.69,,,3833.69,Other,225% New York Medicaid APG,4430.04,,,4430.04,Other,260% New York Medicaid APG,5520.51,,,5520.51,Other,324% New York Medicaid APG,3663.3,,,3663.3,Other,215% New York Medicaid APG,3663.3,,,3663.3,Other,215% New York Medicaid APG,2129.83,,,2129.83,Other,125% New York Medicaid APG,1703.86,26390.37,
Repair eyelid defect,67924,CPT,,,,,,,,both,,,34504.61,25533.41,74,,25533.41,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15527.07,45,,15527.07,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,17079.78,49.5,,17079.78,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3169.18,,,3169.18,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,24153.23,70,,24153.23,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1703.86,,,1703.86,Other,New York Medicaid APG methodology,1703.86,,,1703.86,Other,100% New York Medicaid APG,1703.86,,,1703.86,Other,100% New York Medicaid APG,1703.86,,,1703.86,Other,100% New York Medicaid APG,3833.69,,,3833.69,Other,225% New York Medicaid APG,2606.91,,,2606.91,Other,153% New York Medicaid APG,3833.69,,,3833.69,Other,225% New York Medicaid APG,2385.41,,,2385.41,Other,140% New York Medicaid APG,3833.69,,,3833.69,Other,225% New York Medicaid APG,4430.04,,,4430.04,Other,260% New York Medicaid APG,5520.51,,,5520.51,Other,324% New York Medicaid APG,3663.3,,,3663.3,Other,215% New York Medicaid APG,3663.3,,,3663.3,Other,215% New York Medicaid APG,2129.83,,,2129.83,Other,125% New York Medicaid APG,1703.86,25533.41,
Repair eyelid wound,67930,CPT,,,,,,,,both,,,49151.56,36372.15,74,,36372.15,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,22118.2,45,,22118.2,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,24330.02,49.5,,24330.02,percent of total billed charges,110% of Medicare,33423.06,68,,33423.06,percent of total billed charges,,2167.59,,,2167.59,Other,186% of Medicaid,39321.25,80,,39321.25,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,39321.25,80,,39321.25,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,34406.09,70,,34406.09,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1165.37,,,1165.37,Other,New York Medicaid APG methodology,1165.37,,,1165.37,Other,100% New York Medicaid APG,1165.37,,,1165.37,Other,100% New York Medicaid APG,1165.37,,,1165.37,Other,100% New York Medicaid APG,2622.08,,,2622.08,Other,225% New York Medicaid APG,1783.01,,,1783.01,Other,153% New York Medicaid APG,2622.08,,,2622.08,Other,225% New York Medicaid APG,1631.52,,,1631.52,Other,140% New York Medicaid APG,2622.08,,,2622.08,Other,225% New York Medicaid APG,3029.96,,,3029.96,Other,260% New York Medicaid APG,3775.79,,,3775.79,Other,324% New York Medicaid APG,2505.54,,,2505.54,Other,215% New York Medicaid APG,2505.54,,,2505.54,Other,215% New York Medicaid APG,1456.71,,,1456.71,Other,125% New York Medicaid APG,1165.37,39321.25,
Repair eyelid wound,67935,CPT,,,,,,,,both,,,49151.56,36372.15,74,,36372.15,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,22118.2,45,,22118.2,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,24330.02,49.5,,24330.02,percent of total billed charges,110% of Medicare,33423.06,68,,33423.06,percent of total billed charges,,2167.59,,,2167.59,Other,186% of Medicaid,39321.25,80,,39321.25,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,39321.25,80,,39321.25,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,34406.09,70,,34406.09,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1165.37,,,1165.37,Other,New York Medicaid APG methodology,1165.37,,,1165.37,Other,100% New York Medicaid APG,1165.37,,,1165.37,Other,100% New York Medicaid APG,1165.37,,,1165.37,Other,100% New York Medicaid APG,2622.08,,,2622.08,Other,225% New York Medicaid APG,1783.01,,,1783.01,Other,153% New York Medicaid APG,2622.08,,,2622.08,Other,225% New York Medicaid APG,1631.52,,,1631.52,Other,140% New York Medicaid APG,2622.08,,,2622.08,Other,225% New York Medicaid APG,3029.96,,,3029.96,Other,260% New York Medicaid APG,3775.79,,,3775.79,Other,324% New York Medicaid APG,2505.54,,,2505.54,Other,215% New York Medicaid APG,2505.54,,,2505.54,Other,215% New York Medicaid APG,1456.71,,,1456.71,Other,125% New York Medicaid APG,1165.37,39321.25,
Remove eyelid foreign body,67938,CPT,,,,,,,,both,,,35326.8,26141.83,74,,26141.83,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15897.06,45,,15897.06,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,17486.77,49.5,,17486.77,percent of total billed charges,110% of Medicare,24022.22,68,,24022.22,percent of total billed charges,,525.76,,,525.76,Other,186% of Medicaid,28261.44,80,,28261.44,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,28261.44,80,,28261.44,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,24728.76,70,,24728.76,percent of total billed charges,,572.36,,,572.36,Fee Schedule,,485.11,,,485.11,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,282.67,,,282.67,Other,New York Medicaid APG methodology,282.67,,,282.67,Other,100% New York Medicaid APG,282.67,,,282.67,Other,100% New York Medicaid APG,282.67,,,282.67,Other,100% New York Medicaid APG,636,,,636,Other,225% New York Medicaid APG,432.48,,,432.48,Other,153% New York Medicaid APG,636,,,636,Other,225% New York Medicaid APG,395.73,,,395.73,Other,140% New York Medicaid APG,636,,,636,Other,225% New York Medicaid APG,734.93,,,734.93,Other,260% New York Medicaid APG,915.84,,,915.84,Other,324% New York Medicaid APG,607.73,,,607.73,Other,215% New York Medicaid APG,607.73,,,607.73,Other,215% New York Medicaid APG,353.33,,,353.33,Other,125% New York Medicaid APG,282.67,28261.44,
Revision of eyelid,67950,CPT,,,,,,,,both,,,38209.71,28275.19,74,,28275.19,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,17194.37,45,,17194.37,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,18913.81,49.5,,18913.81,percent of total billed charges,110% of Medicare,25982.6,68,,25982.6,percent of total billed charges,,2167.59,,,2167.59,Other,186% of Medicaid,30567.77,80,,30567.77,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,30567.77,80,,30567.77,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,26746.8,70,,26746.8,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1165.37,,,1165.37,Other,New York Medicaid APG methodology,1165.37,,,1165.37,Other,100% New York Medicaid APG,1165.37,,,1165.37,Other,100% New York Medicaid APG,1165.37,,,1165.37,Other,100% New York Medicaid APG,2622.08,,,2622.08,Other,225% New York Medicaid APG,1783.01,,,1783.01,Other,153% New York Medicaid APG,2622.08,,,2622.08,Other,225% New York Medicaid APG,1631.52,,,1631.52,Other,140% New York Medicaid APG,2622.08,,,2622.08,Other,225% New York Medicaid APG,3029.96,,,3029.96,Other,260% New York Medicaid APG,3775.79,,,3775.79,Other,324% New York Medicaid APG,2505.54,,,2505.54,Other,215% New York Medicaid APG,2505.54,,,2505.54,Other,215% New York Medicaid APG,1456.71,,,1456.71,Other,125% New York Medicaid APG,1165.37,30567.77,
Revision of eyelid,67961,CPT,,,,,,,,both,,,32676.36,24180.51,74,,24180.51,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,14704.36,45,,14704.36,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,16174.8,49.5,,16174.8,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3169.18,,,3169.18,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,22873.45,70,,22873.45,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1703.86,,,1703.86,Other,New York Medicaid APG methodology,1703.86,,,1703.86,Other,100% New York Medicaid APG,1703.86,,,1703.86,Other,100% New York Medicaid APG,1703.86,,,1703.86,Other,100% New York Medicaid APG,3833.69,,,3833.69,Other,225% New York Medicaid APG,2606.91,,,2606.91,Other,153% New York Medicaid APG,3833.69,,,3833.69,Other,225% New York Medicaid APG,2385.41,,,2385.41,Other,140% New York Medicaid APG,3833.69,,,3833.69,Other,225% New York Medicaid APG,4430.04,,,4430.04,Other,260% New York Medicaid APG,5520.51,,,5520.51,Other,324% New York Medicaid APG,3663.3,,,3663.3,Other,215% New York Medicaid APG,3663.3,,,3663.3,Other,215% New York Medicaid APG,2129.83,,,2129.83,Other,125% New York Medicaid APG,1703.86,24180.51,
Revision of eyelid,67966,CPT,,,,,,,,both,,,45328.93,33543.41,74,,33543.41,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,20398.02,45,,20398.02,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,22437.82,49.5,,22437.82,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3169.18,,,3169.18,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,31730.25,70,,31730.25,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1703.86,,,1703.86,Other,New York Medicaid APG methodology,1703.86,,,1703.86,Other,100% New York Medicaid APG,1703.86,,,1703.86,Other,100% New York Medicaid APG,1703.86,,,1703.86,Other,100% New York Medicaid APG,3833.69,,,3833.69,Other,225% New York Medicaid APG,2606.91,,,2606.91,Other,153% New York Medicaid APG,3833.69,,,3833.69,Other,225% New York Medicaid APG,2385.41,,,2385.41,Other,140% New York Medicaid APG,3833.69,,,3833.69,Other,225% New York Medicaid APG,4430.04,,,4430.04,Other,260% New York Medicaid APG,5520.51,,,5520.51,Other,324% New York Medicaid APG,3663.3,,,3663.3,Other,215% New York Medicaid APG,3663.3,,,3663.3,Other,215% New York Medicaid APG,2129.83,,,2129.83,Other,125% New York Medicaid APG,1703.86,33543.41,
Reconstruction of eyelid,67971,CPT,,,,,,,,both,,,37061.66,27425.63,74,,27425.63,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,16677.75,45,,16677.75,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,18345.52,49.5,,18345.52,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3169.18,,,3169.18,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,25943.16,70,,25943.16,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1703.86,,,1703.86,Other,New York Medicaid APG methodology,1703.86,,,1703.86,Other,100% New York Medicaid APG,1703.86,,,1703.86,Other,100% New York Medicaid APG,1703.86,,,1703.86,Other,100% New York Medicaid APG,3833.69,,,3833.69,Other,225% New York Medicaid APG,2606.91,,,2606.91,Other,153% New York Medicaid APG,3833.69,,,3833.69,Other,225% New York Medicaid APG,2385.41,,,2385.41,Other,140% New York Medicaid APG,3833.69,,,3833.69,Other,225% New York Medicaid APG,4430.04,,,4430.04,Other,260% New York Medicaid APG,5520.51,,,5520.51,Other,324% New York Medicaid APG,3663.3,,,3663.3,Other,215% New York Medicaid APG,3663.3,,,3663.3,Other,215% New York Medicaid APG,2129.83,,,2129.83,Other,125% New York Medicaid APG,1703.86,27425.63,
Reconstruction of eyelid,67973,CPT,,,,,,,,both,,,44410.93,32864.09,74,,32864.09,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,19984.92,45,,19984.92,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,21983.41,49.5,,21983.41,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3169.18,,,3169.18,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,31087.65,70,,31087.65,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1703.86,,,1703.86,Other,New York Medicaid APG methodology,1703.86,,,1703.86,Other,100% New York Medicaid APG,1703.86,,,1703.86,Other,100% New York Medicaid APG,1703.86,,,1703.86,Other,100% New York Medicaid APG,3833.69,,,3833.69,Other,225% New York Medicaid APG,2606.91,,,2606.91,Other,153% New York Medicaid APG,3833.69,,,3833.69,Other,225% New York Medicaid APG,2385.41,,,2385.41,Other,140% New York Medicaid APG,3833.69,,,3833.69,Other,225% New York Medicaid APG,4430.04,,,4430.04,Other,260% New York Medicaid APG,5520.51,,,5520.51,Other,324% New York Medicaid APG,3663.3,,,3663.3,Other,215% New York Medicaid APG,3663.3,,,3663.3,Other,215% New York Medicaid APG,2129.83,,,2129.83,Other,125% New York Medicaid APG,1703.86,32864.09,
Reconstruction of eyelid,67974,CPT,,,,,,,,both,,,81324.54,60180.16,74,,60180.16,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,36596.04,45,,36596.04,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,40255.65,49.5,,40255.65,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3169.18,,,3169.18,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,56927.18,70,,56927.18,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1703.86,,,1703.86,Other,New York Medicaid APG methodology,1703.86,,,1703.86,Other,100% New York Medicaid APG,1703.86,,,1703.86,Other,100% New York Medicaid APG,1703.86,,,1703.86,Other,100% New York Medicaid APG,3833.69,,,3833.69,Other,225% New York Medicaid APG,2606.91,,,2606.91,Other,153% New York Medicaid APG,3833.69,,,3833.69,Other,225% New York Medicaid APG,2385.41,,,2385.41,Other,140% New York Medicaid APG,3833.69,,,3833.69,Other,225% New York Medicaid APG,4430.04,,,4430.04,Other,260% New York Medicaid APG,5520.51,,,5520.51,Other,324% New York Medicaid APG,3663.3,,,3663.3,Other,215% New York Medicaid APG,3663.3,,,3663.3,Other,215% New York Medicaid APG,2129.83,,,2129.83,Other,125% New York Medicaid APG,1703.86,60180.16,
Reconstruction of eyelid,67975,CPT,,,,,,,,both,,,49151.56,36372.15,74,,36372.15,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,22118.2,45,,22118.2,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,24330.02,49.5,,24330.02,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3169.18,,,3169.18,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,34406.09,70,,34406.09,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1703.86,,,1703.86,Other,New York Medicaid APG methodology,1703.86,,,1703.86,Other,100% New York Medicaid APG,1703.86,,,1703.86,Other,100% New York Medicaid APG,1703.86,,,1703.86,Other,100% New York Medicaid APG,3833.69,,,3833.69,Other,225% New York Medicaid APG,2606.91,,,2606.91,Other,153% New York Medicaid APG,3833.69,,,3833.69,Other,225% New York Medicaid APG,2385.41,,,2385.41,Other,140% New York Medicaid APG,3833.69,,,3833.69,Other,225% New York Medicaid APG,4430.04,,,4430.04,Other,260% New York Medicaid APG,5520.51,,,5520.51,Other,324% New York Medicaid APG,3663.3,,,3663.3,Other,215% New York Medicaid APG,3663.3,,,3663.3,Other,215% New York Medicaid APG,2129.83,,,2129.83,Other,125% New York Medicaid APG,1703.86,36372.15,
Incise/drain eyelid lining,68020,CPT,,,,,,,,both,,,21295.3,15758.52,74,,15758.52,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,9582.89,45,,9582.89,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,10541.17,49.5,,10541.17,percent of total billed charges,110% of Medicare,14480.8,68,,14480.8,percent of total billed charges,,2167.59,,,2167.59,Other,186% of Medicaid,17036.24,80,,17036.24,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,17036.24,80,,17036.24,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,14906.71,70,,14906.71,percent of total billed charges,,533,,,533,Fee Schedule,,451.75,,,451.75,Fee Schedule,,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1165.37,,,1165.37,Other,New York Medicaid APG methodology,1165.37,,,1165.37,Other,100% New York Medicaid APG,1165.37,,,1165.37,Other,100% New York Medicaid APG,1165.37,,,1165.37,Other,100% New York Medicaid APG,2622.08,,,2622.08,Other,225% New York Medicaid APG,1783.01,,,1783.01,Other,153% New York Medicaid APG,2622.08,,,2622.08,Other,225% New York Medicaid APG,1631.52,,,1631.52,Other,140% New York Medicaid APG,2622.08,,,2622.08,Other,225% New York Medicaid APG,3029.96,,,3029.96,Other,260% New York Medicaid APG,3775.79,,,3775.79,Other,324% New York Medicaid APG,2505.54,,,2505.54,Other,215% New York Medicaid APG,2505.54,,,2505.54,Other,215% New York Medicaid APG,1456.71,,,1456.71,Other,125% New York Medicaid APG,451.75,17036.24,
Treatment of eyelid lesions,68040,CPT,,,,,,,,both,,,6127.39,4534.27,74,,4534.27,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,2757.33,45,,2757.33,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,3033.06,49.5,,3033.06,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,525.76,,,525.76,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,4289.17,70,,4289.17,percent of total billed charges,,227.96,,,227.96,Fee Schedule,,193.21,,,193.21,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,282.67,,,282.67,Other,New York Medicaid APG methodology,282.67,,,282.67,Other,100% New York Medicaid APG,282.67,,,282.67,Other,100% New York Medicaid APG,282.67,,,282.67,Other,100% New York Medicaid APG,636,,,636,Other,225% New York Medicaid APG,432.48,,,432.48,Other,153% New York Medicaid APG,636,,,636,Other,225% New York Medicaid APG,395.73,,,395.73,Other,140% New York Medicaid APG,636,,,636,Other,225% New York Medicaid APG,734.93,,,734.93,Other,260% New York Medicaid APG,915.84,,,915.84,Other,324% New York Medicaid APG,607.73,,,607.73,Other,215% New York Medicaid APG,607.73,,,607.73,Other,215% New York Medicaid APG,353.33,,,353.33,Other,125% New York Medicaid APG,193.21,9473,
Biopsy of eyelid lining,68100,CPT,,,,,,,,both,,,47374.26,35056.95,74,,35056.95,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,21318.42,45,,21318.42,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,23450.26,49.5,,23450.26,percent of total billed charges,110% of Medicare,32214.5,68,,32214.5,percent of total billed charges,,2167.59,,,2167.59,Other,186% of Medicaid,37899.41,80,,37899.41,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,37899.41,80,,37899.41,percent of total billed charges,,7216,,,7216,Case Rate,,3578,,"100% primary, 0% secondary procedures",3578,Other,MagnaCare ASC Grouper,33161.98,70,,33161.98,percent of total billed charges,,459.2,,,459.2,Fee Schedule,,389.2,,,389.2,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,1165.37,,,1165.37,Other,New York Medicaid APG methodology,1165.37,,,1165.37,Other,100% New York Medicaid APG,1165.37,,,1165.37,Other,100% New York Medicaid APG,1165.37,,,1165.37,Other,100% New York Medicaid APG,2622.08,,,2622.08,Other,225% New York Medicaid APG,1783.01,,,1783.01,Other,153% New York Medicaid APG,2622.08,,,2622.08,Other,225% New York Medicaid APG,1631.52,,,1631.52,Other,140% New York Medicaid APG,2622.08,,,2622.08,Other,225% New York Medicaid APG,3029.96,,,3029.96,Other,260% New York Medicaid APG,3775.79,,,3775.79,Other,324% New York Medicaid APG,2505.54,,,2505.54,Other,215% New York Medicaid APG,2505.54,,,2505.54,Other,215% New York Medicaid APG,1456.71,,,1456.71,Other,125% New York Medicaid APG,389.2,37899.41,
Remove eyelid lining lesion,68110,CPT,,,,,,,,both,,,37675.27,27879.7,74,,27879.7,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,16953.87,45,,16953.87,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,18649.26,49.5,,18649.26,percent of total billed charges,110% of Medicare,25619.18,68,,25619.18,percent of total billed charges,,2901.86,,,2901.86,Other,186% of Medicaid,30140.22,80,,30140.22,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,30140.22,80,,30140.22,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,26372.69,70,,26372.69,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1560.14,,,1560.14,Other,New York Medicaid APG methodology,1560.14,,,1560.14,Other,100% New York Medicaid APG,1560.14,,,1560.14,Other,100% New York Medicaid APG,1560.14,,,1560.14,Other,100% New York Medicaid APG,3510.31,,,3510.31,Other,225% New York Medicaid APG,2387.01,,,2387.01,Other,153% New York Medicaid APG,3510.31,,,3510.31,Other,225% New York Medicaid APG,2184.19,,,2184.19,Other,140% New York Medicaid APG,3510.31,,,3510.31,Other,225% New York Medicaid APG,4056.36,,,4056.36,Other,260% New York Medicaid APG,5054.85,,,5054.85,Other,324% New York Medicaid APG,3354.3,,,3354.3,Other,215% New York Medicaid APG,3354.3,,,3354.3,Other,215% New York Medicaid APG,1950.17,,,1950.17,Other,125% New York Medicaid APG,1560.14,30140.22,
Remove eyelid lining lesion,68115,CPT,,,,,,,,both,,,49151.56,36372.15,74,,36372.15,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,22118.2,45,,22118.2,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,24330.02,49.5,,24330.02,percent of total billed charges,110% of Medicare,33423.06,68,,33423.06,percent of total billed charges,,3169.18,,,3169.18,Other,186% of Medicaid,39321.25,80,,39321.25,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,39321.25,80,,39321.25,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,34406.09,70,,34406.09,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1703.86,,,1703.86,Other,New York Medicaid APG methodology,1703.86,,,1703.86,Other,100% New York Medicaid APG,1703.86,,,1703.86,Other,100% New York Medicaid APG,1703.86,,,1703.86,Other,100% New York Medicaid APG,3833.69,,,3833.69,Other,225% New York Medicaid APG,2606.91,,,2606.91,Other,153% New York Medicaid APG,3833.69,,,3833.69,Other,225% New York Medicaid APG,2385.41,,,2385.41,Other,140% New York Medicaid APG,3833.69,,,3833.69,Other,225% New York Medicaid APG,4430.04,,,4430.04,Other,260% New York Medicaid APG,5520.51,,,5520.51,Other,324% New York Medicaid APG,3663.3,,,3663.3,Other,215% New York Medicaid APG,3663.3,,,3663.3,Other,215% New York Medicaid APG,2129.83,,,2129.83,Other,125% New York Medicaid APG,1703.86,39321.25,
Remove eyelid lining lesion,68130,CPT,,,,,,,,both,,,49151.56,36372.15,74,,36372.15,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,22118.2,45,,22118.2,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,24330.02,49.5,,24330.02,percent of total billed charges,110% of Medicare,33423.06,68,,33423.06,percent of total billed charges,,3169.18,,,3169.18,Other,186% of Medicaid,39321.25,80,,39321.25,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,39321.25,80,,39321.25,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,34406.09,70,,34406.09,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1703.86,,,1703.86,Other,New York Medicaid APG methodology,1703.86,,,1703.86,Other,100% New York Medicaid APG,1703.86,,,1703.86,Other,100% New York Medicaid APG,1703.86,,,1703.86,Other,100% New York Medicaid APG,3833.69,,,3833.69,Other,225% New York Medicaid APG,2606.91,,,2606.91,Other,153% New York Medicaid APG,3833.69,,,3833.69,Other,225% New York Medicaid APG,2385.41,,,2385.41,Other,140% New York Medicaid APG,3833.69,,,3833.69,Other,225% New York Medicaid APG,4430.04,,,4430.04,Other,260% New York Medicaid APG,5520.51,,,5520.51,Other,324% New York Medicaid APG,3663.3,,,3663.3,Other,215% New York Medicaid APG,3663.3,,,3663.3,Other,215% New York Medicaid APG,2129.83,,,2129.83,Other,125% New York Medicaid APG,1703.86,39321.25,
Remove eyelid lining lesion,68135,CPT,,,,,,,,both,,,49151.56,36372.15,74,,36372.15,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,22118.2,45,,22118.2,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,24330.02,49.5,,24330.02,percent of total billed charges,110% of Medicare,33423.06,68,,33423.06,percent of total billed charges,,2167.59,,,2167.59,Other,186% of Medicaid,39321.25,80,,39321.25,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,39321.25,80,,39321.25,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,34406.09,70,,34406.09,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1165.37,,,1165.37,Other,New York Medicaid APG methodology,1165.37,,,1165.37,Other,100% New York Medicaid APG,1165.37,,,1165.37,Other,100% New York Medicaid APG,1165.37,,,1165.37,Other,100% New York Medicaid APG,2622.08,,,2622.08,Other,225% New York Medicaid APG,1783.01,,,1783.01,Other,153% New York Medicaid APG,2622.08,,,2622.08,Other,225% New York Medicaid APG,1631.52,,,1631.52,Other,140% New York Medicaid APG,2622.08,,,2622.08,Other,225% New York Medicaid APG,3029.96,,,3029.96,Other,260% New York Medicaid APG,3775.79,,,3775.79,Other,324% New York Medicaid APG,2505.54,,,2505.54,Other,215% New York Medicaid APG,2505.54,,,2505.54,Other,215% New York Medicaid APG,1456.71,,,1456.71,Other,125% New York Medicaid APG,1165.37,39321.25,
Treat eyelid by injection,68200,CPT,,,,,,,,both,,,8380.68,6201.7,74,,6201.7,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,3771.31,45,,3771.31,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,4148.44,49.5,,4148.44,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,351.84,,,351.84,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,5866.48,70,,5866.48,percent of total billed charges,,164,,,164,Fee Schedule,,139,,,139,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,189.16,,,189.16,Other,New York Medicaid APG methodology,189.16,,,189.16,Other,100% New York Medicaid APG,189.16,,,189.16,Other,100% New York Medicaid APG,189.16,,,189.16,Other,100% New York Medicaid APG,425.62,,,425.62,Other,225% New York Medicaid APG,289.42,,,289.42,Other,153% New York Medicaid APG,425.62,,,425.62,Other,225% New York Medicaid APG,264.83,,,264.83,Other,140% New York Medicaid APG,425.62,,,425.62,Other,225% New York Medicaid APG,491.82,,,491.82,Other,260% New York Medicaid APG,612.89,,,612.89,Other,324% New York Medicaid APG,406.7,,,406.7,Other,215% New York Medicaid APG,406.7,,,406.7,Other,215% New York Medicaid APG,236.45,,,236.45,Other,125% New York Medicaid APG,139,9473,
Revise/graft eyelid lining,68320,CPT,,,,,,,,both,,,38099.24,28193.44,74,,28193.44,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,17144.66,45,,17144.66,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,18859.12,49.5,,18859.12,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2167.59,,,2167.59,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,26669.47,70,,26669.47,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1165.37,,,1165.37,Other,New York Medicaid APG methodology,1165.37,,,1165.37,Other,100% New York Medicaid APG,1165.37,,,1165.37,Other,100% New York Medicaid APG,1165.37,,,1165.37,Other,100% New York Medicaid APG,2622.08,,,2622.08,Other,225% New York Medicaid APG,1783.01,,,1783.01,Other,153% New York Medicaid APG,2622.08,,,2622.08,Other,225% New York Medicaid APG,1631.52,,,1631.52,Other,140% New York Medicaid APG,2622.08,,,2622.08,Other,225% New York Medicaid APG,3029.96,,,3029.96,Other,260% New York Medicaid APG,3775.79,,,3775.79,Other,324% New York Medicaid APG,2505.54,,,2505.54,Other,215% New York Medicaid APG,2505.54,,,2505.54,Other,215% New York Medicaid APG,1456.71,,,1456.71,Other,125% New York Medicaid APG,1165.37,28193.44,
Revise/graft eyelid lining,68325,CPT,,,,,,,,both,,,81324.54,60180.16,74,,60180.16,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,36596.04,45,,36596.04,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,40255.65,49.5,,40255.65,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3169.18,,,3169.18,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,56927.18,70,,56927.18,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1703.86,,,1703.86,Other,New York Medicaid APG methodology,1703.86,,,1703.86,Other,100% New York Medicaid APG,1703.86,,,1703.86,Other,100% New York Medicaid APG,1703.86,,,1703.86,Other,100% New York Medicaid APG,3833.69,,,3833.69,Other,225% New York Medicaid APG,2606.91,,,2606.91,Other,153% New York Medicaid APG,3833.69,,,3833.69,Other,225% New York Medicaid APG,2385.41,,,2385.41,Other,140% New York Medicaid APG,3833.69,,,3833.69,Other,225% New York Medicaid APG,4430.04,,,4430.04,Other,260% New York Medicaid APG,5520.51,,,5520.51,Other,324% New York Medicaid APG,3663.3,,,3663.3,Other,215% New York Medicaid APG,3663.3,,,3663.3,Other,215% New York Medicaid APG,2129.83,,,2129.83,Other,125% New York Medicaid APG,1703.86,60180.16,
Revise/graft eyelid lining,68326,CPT,,,,,,,,both,,,81324.54,60180.16,74,,60180.16,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,36596.04,45,,36596.04,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,40255.65,49.5,,40255.65,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3169.18,,,3169.18,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,56927.18,70,,56927.18,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1703.86,,,1703.86,Other,New York Medicaid APG methodology,1703.86,,,1703.86,Other,100% New York Medicaid APG,1703.86,,,1703.86,Other,100% New York Medicaid APG,1703.86,,,1703.86,Other,100% New York Medicaid APG,3833.69,,,3833.69,Other,225% New York Medicaid APG,2606.91,,,2606.91,Other,153% New York Medicaid APG,3833.69,,,3833.69,Other,225% New York Medicaid APG,2385.41,,,2385.41,Other,140% New York Medicaid APG,3833.69,,,3833.69,Other,225% New York Medicaid APG,4430.04,,,4430.04,Other,260% New York Medicaid APG,5520.51,,,5520.51,Other,324% New York Medicaid APG,3663.3,,,3663.3,Other,215% New York Medicaid APG,3663.3,,,3663.3,Other,215% New York Medicaid APG,2129.83,,,2129.83,Other,125% New York Medicaid APG,1703.86,60180.16,
Revise/graft eyelid lining,68328,CPT,,,,,,,,both,,,49151.56,36372.15,74,,36372.15,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,22118.2,45,,22118.2,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,24330.02,49.5,,24330.02,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3169.18,,,3169.18,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,34406.09,70,,34406.09,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1703.86,,,1703.86,Other,New York Medicaid APG methodology,1703.86,,,1703.86,Other,100% New York Medicaid APG,1703.86,,,1703.86,Other,100% New York Medicaid APG,1703.86,,,1703.86,Other,100% New York Medicaid APG,3833.69,,,3833.69,Other,225% New York Medicaid APG,2606.91,,,2606.91,Other,153% New York Medicaid APG,3833.69,,,3833.69,Other,225% New York Medicaid APG,2385.41,,,2385.41,Other,140% New York Medicaid APG,3833.69,,,3833.69,Other,225% New York Medicaid APG,4430.04,,,4430.04,Other,260% New York Medicaid APG,5520.51,,,5520.51,Other,324% New York Medicaid APG,3663.3,,,3663.3,Other,215% New York Medicaid APG,3663.3,,,3663.3,Other,215% New York Medicaid APG,2129.83,,,2129.83,Other,125% New York Medicaid APG,1703.86,36372.15,
Revise eyelid lining,68330,CPT,,,,,,,,both,,,49016.23,36272.01,74,,36272.01,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,22057.3,45,,22057.3,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,24263.03,49.5,,24263.03,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2167.59,,,2167.59,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,34311.36,70,,34311.36,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1165.37,,,1165.37,Other,New York Medicaid APG methodology,1165.37,,,1165.37,Other,100% New York Medicaid APG,1165.37,,,1165.37,Other,100% New York Medicaid APG,1165.37,,,1165.37,Other,100% New York Medicaid APG,2622.08,,,2622.08,Other,225% New York Medicaid APG,1783.01,,,1783.01,Other,153% New York Medicaid APG,2622.08,,,2622.08,Other,225% New York Medicaid APG,1631.52,,,1631.52,Other,140% New York Medicaid APG,2622.08,,,2622.08,Other,225% New York Medicaid APG,3029.96,,,3029.96,Other,260% New York Medicaid APG,3775.79,,,3775.79,Other,324% New York Medicaid APG,2505.54,,,2505.54,Other,215% New York Medicaid APG,2505.54,,,2505.54,Other,215% New York Medicaid APG,1456.71,,,1456.71,Other,125% New York Medicaid APG,1165.37,36272.01,
Revise/graft eyelid lining,68335,CPT,,,,,,,,both,,,81324.54,60180.16,74,,60180.16,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,36596.04,45,,36596.04,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,40255.65,49.5,,40255.65,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3169.18,,,3169.18,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,56927.18,70,,56927.18,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1703.86,,,1703.86,Other,New York Medicaid APG methodology,1703.86,,,1703.86,Other,100% New York Medicaid APG,1703.86,,,1703.86,Other,100% New York Medicaid APG,1703.86,,,1703.86,Other,100% New York Medicaid APG,3833.69,,,3833.69,Other,225% New York Medicaid APG,2606.91,,,2606.91,Other,153% New York Medicaid APG,3833.69,,,3833.69,Other,225% New York Medicaid APG,2385.41,,,2385.41,Other,140% New York Medicaid APG,3833.69,,,3833.69,Other,225% New York Medicaid APG,4430.04,,,4430.04,Other,260% New York Medicaid APG,5520.51,,,5520.51,Other,324% New York Medicaid APG,3663.3,,,3663.3,Other,215% New York Medicaid APG,3663.3,,,3663.3,Other,215% New York Medicaid APG,2129.83,,,2129.83,Other,125% New York Medicaid APG,1703.86,60180.16,
Separate eyelid adhesions,68340,CPT,,,,,,,,both,,,49151.56,36372.15,74,,36372.15,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,22118.2,45,,22118.2,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,24330.02,49.5,,24330.02,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2167.59,,,2167.59,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,34406.09,70,,34406.09,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1165.37,,,1165.37,Other,New York Medicaid APG methodology,1165.37,,,1165.37,Other,100% New York Medicaid APG,1165.37,,,1165.37,Other,100% New York Medicaid APG,1165.37,,,1165.37,Other,100% New York Medicaid APG,2622.08,,,2622.08,Other,225% New York Medicaid APG,1783.01,,,1783.01,Other,153% New York Medicaid APG,2622.08,,,2622.08,Other,225% New York Medicaid APG,1631.52,,,1631.52,Other,140% New York Medicaid APG,2622.08,,,2622.08,Other,225% New York Medicaid APG,3029.96,,,3029.96,Other,260% New York Medicaid APG,3775.79,,,3775.79,Other,324% New York Medicaid APG,2505.54,,,2505.54,Other,215% New York Medicaid APG,2505.54,,,2505.54,Other,215% New York Medicaid APG,1456.71,,,1456.71,Other,125% New York Medicaid APG,1165.37,36372.15,
Revise eyelid lining,68360,CPT,,,,,,,,both,,,81324.54,60180.16,74,,60180.16,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,36596.04,45,,36596.04,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,40255.65,49.5,,40255.65,percent of total billed charges,110% of Medicare,55300.69,68,,55300.69,percent of total billed charges,,3169.18,,,3169.18,Other,186% of Medicaid,65059.63,80,,65059.63,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,65059.63,80,,65059.63,percent of total billed charges,,7216,,,7216,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,56927.18,70,,56927.18,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1703.86,,,1703.86,Other,New York Medicaid APG methodology,1703.86,,,1703.86,Other,100% New York Medicaid APG,1703.86,,,1703.86,Other,100% New York Medicaid APG,1703.86,,,1703.86,Other,100% New York Medicaid APG,3833.69,,,3833.69,Other,225% New York Medicaid APG,2606.91,,,2606.91,Other,153% New York Medicaid APG,3833.69,,,3833.69,Other,225% New York Medicaid APG,2385.41,,,2385.41,Other,140% New York Medicaid APG,3833.69,,,3833.69,Other,225% New York Medicaid APG,4430.04,,,4430.04,Other,260% New York Medicaid APG,5520.51,,,5520.51,Other,324% New York Medicaid APG,3663.3,,,3663.3,Other,215% New York Medicaid APG,3663.3,,,3663.3,Other,215% New York Medicaid APG,2129.83,,,2129.83,Other,125% New York Medicaid APG,1703.86,65059.63,
Revise eyelid lining,68362,CPT,,,,,,,,both,,,49151.56,36372.15,74,,36372.15,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,22118.2,45,,22118.2,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,24330.02,49.5,,24330.02,percent of total billed charges,110% of Medicare,33423.06,68,,33423.06,percent of total billed charges,,3169.18,,,3169.18,Other,186% of Medicaid,39321.25,80,,39321.25,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,39321.25,80,,39321.25,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,34406.09,70,,34406.09,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1703.86,,,1703.86,Other,New York Medicaid APG methodology,1703.86,,,1703.86,Other,100% New York Medicaid APG,1703.86,,,1703.86,Other,100% New York Medicaid APG,1703.86,,,1703.86,Other,100% New York Medicaid APG,3833.69,,,3833.69,Other,225% New York Medicaid APG,2606.91,,,2606.91,Other,153% New York Medicaid APG,3833.69,,,3833.69,Other,225% New York Medicaid APG,2385.41,,,2385.41,Other,140% New York Medicaid APG,3833.69,,,3833.69,Other,225% New York Medicaid APG,4430.04,,,4430.04,Other,260% New York Medicaid APG,5520.51,,,5520.51,Other,324% New York Medicaid APG,3663.3,,,3663.3,Other,215% New York Medicaid APG,3663.3,,,3663.3,Other,215% New York Medicaid APG,2129.83,,,2129.83,Other,125% New York Medicaid APG,1703.86,39321.25,
Harvest eye tissue alograft,68371,CPT,,,,,,,,both,,,49151.56,36372.15,74,,36372.15,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,22118.2,45,,22118.2,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,24330.02,49.5,,24330.02,percent of total billed charges,110% of Medicare,33423.06,68,,33423.06,percent of total billed charges,,2167.59,,,2167.59,Other,186% of Medicaid,39321.25,80,,39321.25,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,39321.25,80,,39321.25,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,34406.09,70,,34406.09,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1165.37,,,1165.37,Other,New York Medicaid APG methodology,1165.37,,,1165.37,Other,100% New York Medicaid APG,1165.37,,,1165.37,Other,100% New York Medicaid APG,1165.37,,,1165.37,Other,100% New York Medicaid APG,2622.08,,,2622.08,Other,225% New York Medicaid APG,1783.01,,,1783.01,Other,153% New York Medicaid APG,2622.08,,,2622.08,Other,225% New York Medicaid APG,1631.52,,,1631.52,Other,140% New York Medicaid APG,2622.08,,,2622.08,Other,225% New York Medicaid APG,3029.96,,,3029.96,Other,260% New York Medicaid APG,3775.79,,,3775.79,Other,324% New York Medicaid APG,2505.54,,,2505.54,Other,215% New York Medicaid APG,2505.54,,,2505.54,Other,215% New York Medicaid APG,1456.71,,,1456.71,Other,125% New York Medicaid APG,1165.37,39321.25,
Incise/drain tear gland,68400,CPT,,,,,,,,both,,,21295.3,15758.52,74,,15758.52,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,9582.89,45,,9582.89,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,10541.17,49.5,,10541.17,percent of total billed charges,110% of Medicare,14480.8,68,,14480.8,percent of total billed charges,,2167.59,,,2167.59,Other,186% of Medicaid,17036.24,80,,17036.24,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,17036.24,80,,17036.24,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,14906.71,70,,14906.71,percent of total billed charges,,633.04,,,633.04,Fee Schedule,,536.54,,,536.54,Fee Schedule,,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1165.37,,,1165.37,Other,New York Medicaid APG methodology,1165.37,,,1165.37,Other,100% New York Medicaid APG,1165.37,,,1165.37,Other,100% New York Medicaid APG,1165.37,,,1165.37,Other,100% New York Medicaid APG,2622.08,,,2622.08,Other,225% New York Medicaid APG,1783.01,,,1783.01,Other,153% New York Medicaid APG,2622.08,,,2622.08,Other,225% New York Medicaid APG,1631.52,,,1631.52,Other,140% New York Medicaid APG,2622.08,,,2622.08,Other,225% New York Medicaid APG,3029.96,,,3029.96,Other,260% New York Medicaid APG,3775.79,,,3775.79,Other,324% New York Medicaid APG,2505.54,,,2505.54,Other,215% New York Medicaid APG,2505.54,,,2505.54,Other,215% New York Medicaid APG,1456.71,,,1456.71,Other,125% New York Medicaid APG,536.54,17036.24,
Incise/drain tear sac,68420,CPT,,,,,,,,both,,,49151.56,36372.15,74,,36372.15,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,22118.2,45,,22118.2,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,24330.02,49.5,,24330.02,percent of total billed charges,110% of Medicare,33423.06,68,,33423.06,percent of total billed charges,,3169.18,,,3169.18,Other,186% of Medicaid,39321.25,80,,39321.25,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,39321.25,80,,39321.25,percent of total billed charges,,7216,,,7216,Case Rate,,3578,,"100% primary, 0% secondary procedures",3578,Other,MagnaCare ASC Grouper,34406.09,70,,34406.09,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,1703.86,,,1703.86,Other,New York Medicaid APG methodology,1703.86,,,1703.86,Other,100% New York Medicaid APG,1703.86,,,1703.86,Other,100% New York Medicaid APG,1703.86,,,1703.86,Other,100% New York Medicaid APG,3833.69,,,3833.69,Other,225% New York Medicaid APG,2606.91,,,2606.91,Other,153% New York Medicaid APG,3833.69,,,3833.69,Other,225% New York Medicaid APG,2385.41,,,2385.41,Other,140% New York Medicaid APG,3833.69,,,3833.69,Other,225% New York Medicaid APG,4430.04,,,4430.04,Other,260% New York Medicaid APG,5520.51,,,5520.51,Other,324% New York Medicaid APG,3663.3,,,3663.3,Other,215% New York Medicaid APG,3663.3,,,3663.3,Other,215% New York Medicaid APG,2129.83,,,2129.83,Other,125% New York Medicaid APG,1703.86,39321.25,
Incise tear duct opening,68440,CPT,,,,,,,,both,,,6127.39,4534.27,74,,4534.27,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,2757.33,45,,2757.33,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,3033.06,49.5,,3033.06,percent of total billed charges,110% of Medicare,4166.63,68,,4166.63,percent of total billed charges,,525.76,,,525.76,Other,186% of Medicaid,4901.91,80,,4901.91,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,4901.91,80,,4901.91,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,4289.17,70,,4289.17,percent of total billed charges,,483.8,,,483.8,Fee Schedule,,410.05,,,410.05,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,282.67,,,282.67,Other,New York Medicaid APG methodology,282.67,,,282.67,Other,100% New York Medicaid APG,282.67,,,282.67,Other,100% New York Medicaid APG,282.67,,,282.67,Other,100% New York Medicaid APG,636,,,636,Other,225% New York Medicaid APG,432.48,,,432.48,Other,153% New York Medicaid APG,636,,,636,Other,225% New York Medicaid APG,395.73,,,395.73,Other,140% New York Medicaid APG,636,,,636,Other,225% New York Medicaid APG,734.93,,,734.93,Other,260% New York Medicaid APG,915.84,,,915.84,Other,324% New York Medicaid APG,607.73,,,607.73,Other,215% New York Medicaid APG,607.73,,,607.73,Other,215% New York Medicaid APG,353.33,,,353.33,Other,125% New York Medicaid APG,282.67,7216,
Removal of tear gland,68500,CPT,,,,,,,,both,,,81324.54,60180.16,74,,60180.16,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,36596.04,45,,36596.04,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,40255.65,49.5,,40255.65,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3169.18,,,3169.18,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,56927.18,70,,56927.18,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1703.86,,,1703.86,Other,New York Medicaid APG methodology,1703.86,,,1703.86,Other,100% New York Medicaid APG,1703.86,,,1703.86,Other,100% New York Medicaid APG,1703.86,,,1703.86,Other,100% New York Medicaid APG,3833.69,,,3833.69,Other,225% New York Medicaid APG,2606.91,,,2606.91,Other,153% New York Medicaid APG,3833.69,,,3833.69,Other,225% New York Medicaid APG,2385.41,,,2385.41,Other,140% New York Medicaid APG,3833.69,,,3833.69,Other,225% New York Medicaid APG,4430.04,,,4430.04,Other,260% New York Medicaid APG,5520.51,,,5520.51,Other,324% New York Medicaid APG,3663.3,,,3663.3,Other,215% New York Medicaid APG,3663.3,,,3663.3,Other,215% New York Medicaid APG,2129.83,,,2129.83,Other,125% New York Medicaid APG,1703.86,60180.16,
Partial removal tear gland,68505,CPT,,,,,,,,both,,,81324.54,60180.16,74,,60180.16,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,36596.04,45,,36596.04,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,40255.65,49.5,,40255.65,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3169.18,,,3169.18,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,56927.18,70,,56927.18,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1703.86,,,1703.86,Other,New York Medicaid APG methodology,1703.86,,,1703.86,Other,100% New York Medicaid APG,1703.86,,,1703.86,Other,100% New York Medicaid APG,1703.86,,,1703.86,Other,100% New York Medicaid APG,3833.69,,,3833.69,Other,225% New York Medicaid APG,2606.91,,,2606.91,Other,153% New York Medicaid APG,3833.69,,,3833.69,Other,225% New York Medicaid APG,2385.41,,,2385.41,Other,140% New York Medicaid APG,3833.69,,,3833.69,Other,225% New York Medicaid APG,4430.04,,,4430.04,Other,260% New York Medicaid APG,5520.51,,,5520.51,Other,324% New York Medicaid APG,3663.3,,,3663.3,Other,215% New York Medicaid APG,3663.3,,,3663.3,Other,215% New York Medicaid APG,2129.83,,,2129.83,Other,125% New York Medicaid APG,1703.86,60180.16,
Biopsy of tear gland,68510,CPT,,,,,,,,both,,,49151.56,36372.15,74,,36372.15,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,22118.2,45,,22118.2,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,24330.02,49.5,,24330.02,percent of total billed charges,110% of Medicare,33423.06,68,,33423.06,percent of total billed charges,,3169.18,,,3169.18,Other,186% of Medicaid,39321.25,80,,39321.25,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,39321.25,80,,39321.25,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,34406.09,70,,34406.09,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1703.86,,,1703.86,Other,New York Medicaid APG methodology,1703.86,,,1703.86,Other,100% New York Medicaid APG,1703.86,,,1703.86,Other,100% New York Medicaid APG,1703.86,,,1703.86,Other,100% New York Medicaid APG,3833.69,,,3833.69,Other,225% New York Medicaid APG,2606.91,,,2606.91,Other,153% New York Medicaid APG,3833.69,,,3833.69,Other,225% New York Medicaid APG,2385.41,,,2385.41,Other,140% New York Medicaid APG,3833.69,,,3833.69,Other,225% New York Medicaid APG,4430.04,,,4430.04,Other,260% New York Medicaid APG,5520.51,,,5520.51,Other,324% New York Medicaid APG,3663.3,,,3663.3,Other,215% New York Medicaid APG,3663.3,,,3663.3,Other,215% New York Medicaid APG,2129.83,,,2129.83,Other,125% New York Medicaid APG,1703.86,39321.25,
Removal of tear sac,68520,CPT,,,,,,,,both,,,35849.33,26528.5,74,,26528.5,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,16132.2,45,,16132.2,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,17745.42,49.5,,17745.42,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3169.18,,,3169.18,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,25094.53,70,,25094.53,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1703.86,,,1703.86,Other,New York Medicaid APG methodology,1703.86,,,1703.86,Other,100% New York Medicaid APG,1703.86,,,1703.86,Other,100% New York Medicaid APG,1703.86,,,1703.86,Other,100% New York Medicaid APG,3833.69,,,3833.69,Other,225% New York Medicaid APG,2606.91,,,2606.91,Other,153% New York Medicaid APG,3833.69,,,3833.69,Other,225% New York Medicaid APG,2385.41,,,2385.41,Other,140% New York Medicaid APG,3833.69,,,3833.69,Other,225% New York Medicaid APG,4430.04,,,4430.04,Other,260% New York Medicaid APG,5520.51,,,5520.51,Other,324% New York Medicaid APG,3663.3,,,3663.3,Other,215% New York Medicaid APG,3663.3,,,3663.3,Other,215% New York Medicaid APG,2129.83,,,2129.83,Other,125% New York Medicaid APG,1703.86,26528.5,
Biopsy of tear sac,68525,CPT,,,,,,,,both,,,49151.56,36372.15,74,,36372.15,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,22118.2,45,,22118.2,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,24330.02,49.5,,24330.02,percent of total billed charges,110% of Medicare,33423.06,68,,33423.06,percent of total billed charges,,2167.59,,,2167.59,Other,186% of Medicaid,39321.25,80,,39321.25,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,39321.25,80,,39321.25,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,34406.09,70,,34406.09,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1165.37,,,1165.37,Other,New York Medicaid APG methodology,1165.37,,,1165.37,Other,100% New York Medicaid APG,1165.37,,,1165.37,Other,100% New York Medicaid APG,1165.37,,,1165.37,Other,100% New York Medicaid APG,2622.08,,,2622.08,Other,225% New York Medicaid APG,1783.01,,,1783.01,Other,153% New York Medicaid APG,2622.08,,,2622.08,Other,225% New York Medicaid APG,1631.52,,,1631.52,Other,140% New York Medicaid APG,2622.08,,,2622.08,Other,225% New York Medicaid APG,3029.96,,,3029.96,Other,260% New York Medicaid APG,3775.79,,,3775.79,Other,324% New York Medicaid APG,2505.54,,,2505.54,Other,215% New York Medicaid APG,2505.54,,,2505.54,Other,215% New York Medicaid APG,1456.71,,,1456.71,Other,125% New York Medicaid APG,1165.37,39321.25,
Clearance of tear duct,68530,CPT,,,,,,,,both,,,6127.39,4534.27,74,,4534.27,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,2757.33,45,,2757.33,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,3033.06,49.5,,3033.06,percent of total billed charges,110% of Medicare,4166.63,68,,4166.63,percent of total billed charges,,525.76,,,525.76,Other,186% of Medicaid,4901.91,80,,4901.91,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,4901.91,80,,4901.91,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,4289.17,70,,4289.17,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,282.67,,,282.67,Other,New York Medicaid APG methodology,282.67,,,282.67,Other,100% New York Medicaid APG,282.67,,,282.67,Other,100% New York Medicaid APG,282.67,,,282.67,Other,100% New York Medicaid APG,636,,,636,Other,225% New York Medicaid APG,432.48,,,432.48,Other,153% New York Medicaid APG,636,,,636,Other,225% New York Medicaid APG,395.73,,,395.73,Other,140% New York Medicaid APG,636,,,636,Other,225% New York Medicaid APG,734.93,,,734.93,Other,260% New York Medicaid APG,915.84,,,915.84,Other,324% New York Medicaid APG,607.73,,,607.73,Other,215% New York Medicaid APG,607.73,,,607.73,Other,215% New York Medicaid APG,353.33,,,353.33,Other,125% New York Medicaid APG,282.67,7216,
Remove tear gland lesion,68540,CPT,,,,,,,,both,,,49151.56,36372.15,74,,36372.15,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,22118.2,45,,22118.2,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,24330.02,49.5,,24330.02,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3169.18,,,3169.18,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,34406.09,70,,34406.09,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1703.86,,,1703.86,Other,New York Medicaid APG methodology,1703.86,,,1703.86,Other,100% New York Medicaid APG,1703.86,,,1703.86,Other,100% New York Medicaid APG,1703.86,,,1703.86,Other,100% New York Medicaid APG,3833.69,,,3833.69,Other,225% New York Medicaid APG,2606.91,,,2606.91,Other,153% New York Medicaid APG,3833.69,,,3833.69,Other,225% New York Medicaid APG,2385.41,,,2385.41,Other,140% New York Medicaid APG,3833.69,,,3833.69,Other,225% New York Medicaid APG,4430.04,,,4430.04,Other,260% New York Medicaid APG,5520.51,,,5520.51,Other,324% New York Medicaid APG,3663.3,,,3663.3,Other,215% New York Medicaid APG,3663.3,,,3663.3,Other,215% New York Medicaid APG,2129.83,,,2129.83,Other,125% New York Medicaid APG,1703.86,36372.15,
Remove tear gland lesion,68550,CPT,,,,,,,,both,,,81324.54,60180.16,74,,60180.16,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,36596.04,45,,36596.04,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,40255.65,49.5,,40255.65,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3169.18,,,3169.18,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,56927.18,70,,56927.18,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1703.86,,,1703.86,Other,New York Medicaid APG methodology,1703.86,,,1703.86,Other,100% New York Medicaid APG,1703.86,,,1703.86,Other,100% New York Medicaid APG,1703.86,,,1703.86,Other,100% New York Medicaid APG,3833.69,,,3833.69,Other,225% New York Medicaid APG,2606.91,,,2606.91,Other,153% New York Medicaid APG,3833.69,,,3833.69,Other,225% New York Medicaid APG,2385.41,,,2385.41,Other,140% New York Medicaid APG,3833.69,,,3833.69,Other,225% New York Medicaid APG,4430.04,,,4430.04,Other,260% New York Medicaid APG,5520.51,,,5520.51,Other,324% New York Medicaid APG,3663.3,,,3663.3,Other,215% New York Medicaid APG,3663.3,,,3663.3,Other,215% New York Medicaid APG,2129.83,,,2129.83,Other,125% New York Medicaid APG,1703.86,60180.16,
Repair tear ducts,68700,CPT,,,,,,,,both,,,51267.66,37938.07,74,,37938.07,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,23070.45,45,,23070.45,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,25377.49,49.5,,25377.49,percent of total billed charges,110% of Medicare,34862.01,68,,34862.01,percent of total billed charges,,2167.59,,,2167.59,Other,186% of Medicaid,41014.13,80,,41014.13,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,41014.13,80,,41014.13,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,35887.36,70,,35887.36,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1165.37,,,1165.37,Other,New York Medicaid APG methodology,1165.37,,,1165.37,Other,100% New York Medicaid APG,1165.37,,,1165.37,Other,100% New York Medicaid APG,1165.37,,,1165.37,Other,100% New York Medicaid APG,2622.08,,,2622.08,Other,225% New York Medicaid APG,1783.01,,,1783.01,Other,153% New York Medicaid APG,2622.08,,,2622.08,Other,225% New York Medicaid APG,1631.52,,,1631.52,Other,140% New York Medicaid APG,2622.08,,,2622.08,Other,225% New York Medicaid APG,3029.96,,,3029.96,Other,260% New York Medicaid APG,3775.79,,,3775.79,Other,324% New York Medicaid APG,2505.54,,,2505.54,Other,215% New York Medicaid APG,2505.54,,,2505.54,Other,215% New York Medicaid APG,1456.71,,,1456.71,Other,125% New York Medicaid APG,1165.37,41014.13,
Revise tear duct opening,68705,CPT,,,,,,,,both,,,6127.39,4534.27,74,,4534.27,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,2757.33,45,,2757.33,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,3033.06,49.5,,3033.06,percent of total billed charges,110% of Medicare,4166.63,68,,4166.63,percent of total billed charges,,525.76,,,525.76,Other,186% of Medicaid,4901.91,80,,4901.91,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,4901.91,80,,4901.91,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,4289.17,70,,4289.17,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,282.67,,,282.67,Other,New York Medicaid APG methodology,282.67,,,282.67,Other,100% New York Medicaid APG,282.67,,,282.67,Other,100% New York Medicaid APG,282.67,,,282.67,Other,100% New York Medicaid APG,636,,,636,Other,225% New York Medicaid APG,432.48,,,432.48,Other,153% New York Medicaid APG,636,,,636,Other,225% New York Medicaid APG,395.73,,,395.73,Other,140% New York Medicaid APG,636,,,636,Other,225% New York Medicaid APG,734.93,,,734.93,Other,260% New York Medicaid APG,915.84,,,915.84,Other,324% New York Medicaid APG,607.73,,,607.73,Other,215% New York Medicaid APG,607.73,,,607.73,Other,215% New York Medicaid APG,353.33,,,353.33,Other,125% New York Medicaid APG,282.67,7216,
Create tear sac drain,68720,CPT,,,,,,,,both,,,42835.34,31698.15,74,,31698.15,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,19275.9,45,,19275.9,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,21203.49,49.5,,21203.49,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3169.18,,,3169.18,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,29984.74,70,,29984.74,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1703.86,,,1703.86,Other,New York Medicaid APG methodology,1703.86,,,1703.86,Other,100% New York Medicaid APG,1703.86,,,1703.86,Other,100% New York Medicaid APG,1703.86,,,1703.86,Other,100% New York Medicaid APG,3833.69,,,3833.69,Other,225% New York Medicaid APG,2606.91,,,2606.91,Other,153% New York Medicaid APG,3833.69,,,3833.69,Other,225% New York Medicaid APG,2385.41,,,2385.41,Other,140% New York Medicaid APG,3833.69,,,3833.69,Other,225% New York Medicaid APG,4430.04,,,4430.04,Other,260% New York Medicaid APG,5520.51,,,5520.51,Other,324% New York Medicaid APG,3663.3,,,3663.3,Other,215% New York Medicaid APG,3663.3,,,3663.3,Other,215% New York Medicaid APG,2129.83,,,2129.83,Other,125% New York Medicaid APG,1703.86,31698.15,
Create tear duct drain,68745,CPT,,,,,,,,both,,,81324.54,60180.16,74,,60180.16,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,36596.04,45,,36596.04,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,40255.65,49.5,,40255.65,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3169.18,,,3169.18,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,56927.18,70,,56927.18,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1703.86,,,1703.86,Other,New York Medicaid APG methodology,1703.86,,,1703.86,Other,100% New York Medicaid APG,1703.86,,,1703.86,Other,100% New York Medicaid APG,1703.86,,,1703.86,Other,100% New York Medicaid APG,3833.69,,,3833.69,Other,225% New York Medicaid APG,2606.91,,,2606.91,Other,153% New York Medicaid APG,3833.69,,,3833.69,Other,225% New York Medicaid APG,2385.41,,,2385.41,Other,140% New York Medicaid APG,3833.69,,,3833.69,Other,225% New York Medicaid APG,4430.04,,,4430.04,Other,260% New York Medicaid APG,5520.51,,,5520.51,Other,324% New York Medicaid APG,3663.3,,,3663.3,Other,215% New York Medicaid APG,3663.3,,,3663.3,Other,215% New York Medicaid APG,2129.83,,,2129.83,Other,125% New York Medicaid APG,1703.86,60180.16,
Create tear duct drain,68750,CPT,,,,,,,,both,,,36863.66,27279.11,74,,27279.11,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,16588.65,45,,16588.65,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,18247.51,49.5,,18247.51,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3169.18,,,3169.18,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,25804.56,70,,25804.56,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1703.86,,,1703.86,Other,New York Medicaid APG methodology,1703.86,,,1703.86,Other,100% New York Medicaid APG,1703.86,,,1703.86,Other,100% New York Medicaid APG,1703.86,,,1703.86,Other,100% New York Medicaid APG,3833.69,,,3833.69,Other,225% New York Medicaid APG,2606.91,,,2606.91,Other,153% New York Medicaid APG,3833.69,,,3833.69,Other,225% New York Medicaid APG,2385.41,,,2385.41,Other,140% New York Medicaid APG,3833.69,,,3833.69,Other,225% New York Medicaid APG,4430.04,,,4430.04,Other,260% New York Medicaid APG,5520.51,,,5520.51,Other,324% New York Medicaid APG,3663.3,,,3663.3,Other,215% New York Medicaid APG,3663.3,,,3663.3,Other,215% New York Medicaid APG,2129.83,,,2129.83,Other,125% New York Medicaid APG,1703.86,27279.11,
Close tear duct opening,68760,CPT,,,,,,,,both,,,6127.39,4534.27,74,,4534.27,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,2757.33,45,,2757.33,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,3033.06,49.5,,3033.06,percent of total billed charges,110% of Medicare,4166.63,68,,4166.63,percent of total billed charges,,525.76,,,525.76,Other,186% of Medicaid,4901.91,80,,4901.91,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,4901.91,80,,4901.91,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,4289.17,70,,4289.17,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,282.67,,,282.67,Other,New York Medicaid APG methodology,282.67,,,282.67,Other,100% New York Medicaid APG,282.67,,,282.67,Other,100% New York Medicaid APG,282.67,,,282.67,Other,100% New York Medicaid APG,636,,,636,Other,225% New York Medicaid APG,432.48,,,432.48,Other,153% New York Medicaid APG,636,,,636,Other,225% New York Medicaid APG,395.73,,,395.73,Other,140% New York Medicaid APG,636,,,636,Other,225% New York Medicaid APG,734.93,,,734.93,Other,260% New York Medicaid APG,915.84,,,915.84,Other,324% New York Medicaid APG,607.73,,,607.73,Other,215% New York Medicaid APG,607.73,,,607.73,Other,215% New York Medicaid APG,353.33,,,353.33,Other,125% New York Medicaid APG,282.67,7216,
Close tear duct opening,68761,CPT,,,,,,,,both,,,6127.39,4534.27,74,,4534.27,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,2757.33,45,,2757.33,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,3033.06,49.5,,3033.06,percent of total billed charges,110% of Medicare,4166.63,68,,4166.63,percent of total billed charges,,525.76,,,525.76,Other,186% of Medicaid,4901.91,80,,4901.91,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,4901.91,80,,4901.91,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,4289.17,70,,4289.17,percent of total billed charges,,567.44,,,567.44,Fee Schedule,,480.94,,,480.94,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,282.67,,,282.67,Other,New York Medicaid APG methodology,282.67,,,282.67,Other,100% New York Medicaid APG,282.67,,,282.67,Other,100% New York Medicaid APG,282.67,,,282.67,Other,100% New York Medicaid APG,636,,,636,Other,225% New York Medicaid APG,432.48,,,432.48,Other,153% New York Medicaid APG,636,,,636,Other,225% New York Medicaid APG,395.73,,,395.73,Other,140% New York Medicaid APG,636,,,636,Other,225% New York Medicaid APG,734.93,,,734.93,Other,260% New York Medicaid APG,915.84,,,915.84,Other,324% New York Medicaid APG,607.73,,,607.73,Other,215% New York Medicaid APG,607.73,,,607.73,Other,215% New York Medicaid APG,353.33,,,353.33,Other,125% New York Medicaid APG,282.67,7216,
Close tear system fistula,68770,CPT,,,,,,,,both,,,49151.56,36372.15,74,,36372.15,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,22118.2,45,,22118.2,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,24330.02,49.5,,24330.02,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3169.18,,,3169.18,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,3578,,"100% primary, 0% secondary procedures",3578,Other,MagnaCare ASC Grouper,34406.09,70,,34406.09,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,1703.86,,,1703.86,Other,New York Medicaid APG methodology,1703.86,,,1703.86,Other,100% New York Medicaid APG,1703.86,,,1703.86,Other,100% New York Medicaid APG,1703.86,,,1703.86,Other,100% New York Medicaid APG,3833.69,,,3833.69,Other,225% New York Medicaid APG,2606.91,,,2606.91,Other,153% New York Medicaid APG,3833.69,,,3833.69,Other,225% New York Medicaid APG,2385.41,,,2385.41,Other,140% New York Medicaid APG,3833.69,,,3833.69,Other,225% New York Medicaid APG,4430.04,,,4430.04,Other,260% New York Medicaid APG,5520.51,,,5520.51,Other,324% New York Medicaid APG,3663.3,,,3663.3,Other,215% New York Medicaid APG,3663.3,,,3663.3,Other,215% New York Medicaid APG,2129.83,,,2129.83,Other,125% New York Medicaid APG,1703.86,36372.15,
Dilate tear duct opening,68801,CPT,,,,,,,,both,,,34022.66,25176.77,74,,25176.77,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15310.2,45,,15310.2,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,16841.22,49.5,,16841.22,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,525.76,,,525.76,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,23815.86,70,,23815.86,percent of total billed charges,,382.12,,,382.12,Fee Schedule,,323.87,,,323.87,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,282.67,,,282.67,Other,New York Medicaid APG methodology,282.67,,,282.67,Other,100% New York Medicaid APG,282.67,,,282.67,Other,100% New York Medicaid APG,282.67,,,282.67,Other,100% New York Medicaid APG,636,,,636,Other,225% New York Medicaid APG,432.48,,,432.48,Other,153% New York Medicaid APG,636,,,636,Other,225% New York Medicaid APG,395.73,,,395.73,Other,140% New York Medicaid APG,636,,,636,Other,225% New York Medicaid APG,734.93,,,734.93,Other,260% New York Medicaid APG,915.84,,,915.84,Other,324% New York Medicaid APG,607.73,,,607.73,Other,215% New York Medicaid APG,607.73,,,607.73,Other,215% New York Medicaid APG,353.33,,,353.33,Other,125% New York Medicaid APG,282.67,25176.77,
Probe nasolacrimal duct,68810,CPT,,,,,,,,both,,,35689.63,26410.33,74,,26410.33,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,16060.33,45,,16060.33,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,17666.37,49.5,,17666.37,percent of total billed charges,110% of Medicare,24268.95,68,,24268.95,percent of total billed charges,,525.76,,,525.76,Other,186% of Medicaid,28551.7,80,,28551.7,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,28551.7,80,,28551.7,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,24982.74,70,,24982.74,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,282.67,,,282.67,Other,New York Medicaid APG methodology,282.67,,,282.67,Other,100% New York Medicaid APG,282.67,,,282.67,Other,100% New York Medicaid APG,282.67,,,282.67,Other,100% New York Medicaid APG,636,,,636,Other,225% New York Medicaid APG,432.48,,,432.48,Other,153% New York Medicaid APG,636,,,636,Other,225% New York Medicaid APG,395.73,,,395.73,Other,140% New York Medicaid APG,636,,,636,Other,225% New York Medicaid APG,734.93,,,734.93,Other,260% New York Medicaid APG,915.84,,,915.84,Other,324% New York Medicaid APG,607.73,,,607.73,Other,215% New York Medicaid APG,607.73,,,607.73,Other,215% New York Medicaid APG,353.33,,,353.33,Other,125% New York Medicaid APG,282.67,28551.7,
Probe nasolacrimal duct,68811,CPT,,,,,,,,both,,,34474.4,25511.06,74,,25511.06,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15513.48,45,,15513.48,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,17064.83,49.5,,17064.83,percent of total billed charges,110% of Medicare,23442.59,68,,23442.59,percent of total billed charges,,2167.59,,,2167.59,Other,186% of Medicaid,27579.52,80,,27579.52,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,27579.52,80,,27579.52,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,24132.08,70,,24132.08,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1165.37,,,1165.37,Other,New York Medicaid APG methodology,1165.37,,,1165.37,Other,100% New York Medicaid APG,1165.37,,,1165.37,Other,100% New York Medicaid APG,1165.37,,,1165.37,Other,100% New York Medicaid APG,2622.08,,,2622.08,Other,225% New York Medicaid APG,1783.01,,,1783.01,Other,153% New York Medicaid APG,2622.08,,,2622.08,Other,225% New York Medicaid APG,1631.52,,,1631.52,Other,140% New York Medicaid APG,2622.08,,,2622.08,Other,225% New York Medicaid APG,3029.96,,,3029.96,Other,260% New York Medicaid APG,3775.79,,,3775.79,Other,324% New York Medicaid APG,2505.54,,,2505.54,Other,215% New York Medicaid APG,2505.54,,,2505.54,Other,215% New York Medicaid APG,1456.71,,,1456.71,Other,125% New York Medicaid APG,1165.37,27579.52,
Probe nasolacrimal duct,68815,CPT,,,,,,,,both,,,35564.69,26317.87,74,,26317.87,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,16004.11,45,,16004.11,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,17604.52,49.5,,17604.52,percent of total billed charges,110% of Medicare,24183.99,68,,24183.99,percent of total billed charges,,2167.59,,,2167.59,Other,186% of Medicaid,28451.75,80,,28451.75,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,28451.75,80,,28451.75,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,24895.28,70,,24895.28,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1165.37,,,1165.37,Other,New York Medicaid APG methodology,1165.37,,,1165.37,Other,100% New York Medicaid APG,1165.37,,,1165.37,Other,100% New York Medicaid APG,1165.37,,,1165.37,Other,100% New York Medicaid APG,2622.08,,,2622.08,Other,225% New York Medicaid APG,1783.01,,,1783.01,Other,153% New York Medicaid APG,2622.08,,,2622.08,Other,225% New York Medicaid APG,1631.52,,,1631.52,Other,140% New York Medicaid APG,2622.08,,,2622.08,Other,225% New York Medicaid APG,3029.96,,,3029.96,Other,260% New York Medicaid APG,3775.79,,,3775.79,Other,324% New York Medicaid APG,2505.54,,,2505.54,Other,215% New York Medicaid APG,2505.54,,,2505.54,Other,215% New York Medicaid APG,1456.71,,,1456.71,Other,125% New York Medicaid APG,1165.37,28451.75,
Probe nl duct w/balloon,68816,CPT,,,,,,,,both,,,37327.44,27622.31,74,,27622.31,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,16797.35,45,,16797.35,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,18477.08,49.5,,18477.08,percent of total billed charges,110% of Medicare,25382.66,68,,25382.66,percent of total billed charges,,2167.59,,,2167.59,Other,186% of Medicaid,29861.95,80,,29861.95,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,29861.95,80,,29861.95,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,26129.21,70,,26129.21,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1165.37,,,1165.37,Other,New York Medicaid APG methodology,1165.37,,,1165.37,Other,100% New York Medicaid APG,1165.37,,,1165.37,Other,100% New York Medicaid APG,1165.37,,,1165.37,Other,100% New York Medicaid APG,2622.08,,,2622.08,Other,225% New York Medicaid APG,1783.01,,,1783.01,Other,153% New York Medicaid APG,2622.08,,,2622.08,Other,225% New York Medicaid APG,1631.52,,,1631.52,Other,140% New York Medicaid APG,2622.08,,,2622.08,Other,225% New York Medicaid APG,3029.96,,,3029.96,Other,260% New York Medicaid APG,3775.79,,,3775.79,Other,324% New York Medicaid APG,2505.54,,,2505.54,Other,215% New York Medicaid APG,2505.54,,,2505.54,Other,215% New York Medicaid APG,1456.71,,,1456.71,Other,125% New York Medicaid APG,1165.37,29861.95,
Explore/irrigate tear ducts,68840,CPT,,,,,,,,both,,,34394.38,25451.84,74,,25451.84,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15477.47,45,,15477.47,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,17025.22,49.5,,17025.22,percent of total billed charges,110% of Medicare,23388.18,68,,23388.18,percent of total billed charges,,525.76,,,525.76,Other,186% of Medicaid,27515.5,80,,27515.5,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,27515.5,80,,27515.5,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,24076.07,70,,24076.07,percent of total billed charges,,567.44,,,567.44,Fee Schedule,,480.94,,,480.94,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,282.67,,,282.67,Other,New York Medicaid APG methodology,282.67,,,282.67,Other,100% New York Medicaid APG,282.67,,,282.67,Other,100% New York Medicaid APG,282.67,,,282.67,Other,100% New York Medicaid APG,636,,,636,Other,225% New York Medicaid APG,432.48,,,432.48,Other,153% New York Medicaid APG,636,,,636,Other,225% New York Medicaid APG,395.73,,,395.73,Other,140% New York Medicaid APG,636,,,636,Other,225% New York Medicaid APG,734.93,,,734.93,Other,260% New York Medicaid APG,915.84,,,915.84,Other,324% New York Medicaid APG,607.73,,,607.73,Other,215% New York Medicaid APG,607.73,,,607.73,Other,215% New York Medicaid APG,353.33,,,353.33,Other,125% New York Medicaid APG,282.67,27515.5,
Injection for tear sac x-ray,68850,CPT,,,,,,,,both,,,32432.1,23999.75,74,,23999.75,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,14594.45,45,,14594.45,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,16053.89,49.5,,16053.89,percent of total billed charges,110% of Medicare,22053.83,68,,22053.83,percent of total billed charges,,966.93,,,966.93,Other,186% of Medicaid,25945.68,80,,25945.68,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,25945.68,80,,25945.68,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,22702.47,70,,22702.47,percent of total billed charges,,250.92,,,250.92,Fee Schedule,,212.67,,,212.67,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,519.86,,,519.86,Other,New York Medicaid APG methodology,519.86,,,519.86,Other,100% New York Medicaid APG,519.86,,,519.86,Other,100% New York Medicaid APG,519.86,,,519.86,Other,100% New York Medicaid APG,1169.68,,,1169.68,Other,225% New York Medicaid APG,795.38,,,795.38,Other,153% New York Medicaid APG,1169.68,,,1169.68,Other,225% New York Medicaid APG,727.8,,,727.8,Other,140% New York Medicaid APG,1169.68,,,1169.68,Other,225% New York Medicaid APG,1351.62,,,1351.62,Other,260% New York Medicaid APG,1684.33,,,1684.33,Other,324% New York Medicaid APG,1117.69,,,1117.69,Other,215% New York Medicaid APG,1117.69,,,1117.69,Other,215% New York Medicaid APG,649.82,,,649.82,Other,125% New York Medicaid APG,212.67,25945.68,
Drain external ear lesion,69000,CPT,,,,,,,,both,,,14798.8,10951.11,74,,10951.11,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,6659.46,45,,6659.46,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,7325.41,49.5,,7325.41,percent of total billed charges,110% of Medicare,10063.18,68,,10063.18,percent of total billed charges,,423.06,,,423.06,Other,186% of Medicaid,11839.04,80,,11839.04,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,11839.04,80,,11839.04,percent of total billed charges,,7216,,,7216,Case Rate,,3578,,"100% primary, 0% secondary procedures",3578,Other,MagnaCare ASC Grouper,10359.16,70,,10359.16,percent of total billed charges,,615,,,615,Fee Schedule,,521.25,,,521.25,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,227.45,,,227.45,Other,New York Medicaid APG methodology,227.45,,,227.45,Other,100% New York Medicaid APG,227.45,,,227.45,Other,100% New York Medicaid APG,227.45,,,227.45,Other,100% New York Medicaid APG,511.76,,,511.76,Other,225% New York Medicaid APG,348,,,348,Other,153% New York Medicaid APG,511.76,,,511.76,Other,225% New York Medicaid APG,318.43,,,318.43,Other,140% New York Medicaid APG,511.76,,,511.76,Other,225% New York Medicaid APG,591.37,,,591.37,Other,260% New York Medicaid APG,736.94,,,736.94,Other,324% New York Medicaid APG,489.02,,,489.02,Other,215% New York Medicaid APG,489.02,,,489.02,Other,215% New York Medicaid APG,284.31,,,284.31,Other,125% New York Medicaid APG,227.45,11839.04,
Drain external ear lesion,69005,CPT,,,,,,,,both,,,34101.75,25235.3,74,,25235.3,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15345.79,45,,15345.79,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,16880.37,49.5,,16880.37,percent of total billed charges,110% of Medicare,23189.19,68,,23189.19,percent of total billed charges,,2256.57,,,2256.57,Other,186% of Medicaid,27281.4,80,,27281.4,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,27281.4,80,,27281.4,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,23871.23,70,,23871.23,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1213.21,,,1213.21,Other,New York Medicaid APG methodology,1213.21,,,1213.21,Other,100% New York Medicaid APG,1213.21,,,1213.21,Other,100% New York Medicaid APG,1213.21,,,1213.21,Other,100% New York Medicaid APG,2729.72,,,2729.72,Other,225% New York Medicaid APG,1856.21,,,1856.21,Other,153% New York Medicaid APG,2729.72,,,2729.72,Other,225% New York Medicaid APG,1698.49,,,1698.49,Other,140% New York Medicaid APG,2729.72,,,2729.72,Other,225% New York Medicaid APG,3154.34,,,3154.34,Other,260% New York Medicaid APG,3930.79,,,3930.79,Other,324% New York Medicaid APG,2608.4,,,2608.4,Other,215% New York Medicaid APG,2608.4,,,2608.4,Other,215% New York Medicaid APG,1516.51,,,1516.51,Other,125% New York Medicaid APG,1213.21,27281.4,
Drain outer ear canal lesion,69020,CPT,,,,,,,,both,,,14798.8,10951.11,74,,10951.11,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,6659.46,45,,6659.46,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,7325.41,49.5,,7325.41,percent of total billed charges,110% of Medicare,10063.18,68,,10063.18,percent of total billed charges,,423.06,,,423.06,Other,186% of Medicaid,11839.04,80,,11839.04,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,11839.04,80,,11839.04,percent of total billed charges,,7216,,,7216,Case Rate,,3578,,"100% primary, 0% secondary procedures",3578,Other,MagnaCare ASC Grouper,10359.16,70,,10359.16,percent of total billed charges,,713.4,,,713.4,Fee Schedule,,604.65,,,604.65,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,227.45,,,227.45,Other,New York Medicaid APG methodology,227.45,,,227.45,Other,100% New York Medicaid APG,227.45,,,227.45,Other,100% New York Medicaid APG,227.45,,,227.45,Other,100% New York Medicaid APG,511.76,,,511.76,Other,225% New York Medicaid APG,348,,,348,Other,153% New York Medicaid APG,511.76,,,511.76,Other,225% New York Medicaid APG,318.43,,,318.43,Other,140% New York Medicaid APG,511.76,,,511.76,Other,225% New York Medicaid APG,591.37,,,591.37,Other,260% New York Medicaid APG,736.94,,,736.94,Other,324% New York Medicaid APG,489.02,,,489.02,Other,215% New York Medicaid APG,489.02,,,489.02,Other,215% New York Medicaid APG,284.31,,,284.31,Other,125% New York Medicaid APG,227.45,11839.04,
Biopsy of external ear,69100,CPT,,,,,,,,both,,,5137.73,3801.92,74,,3801.92,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,2311.98,45,,2311.98,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,2543.18,49.5,,2543.18,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,423.06,,,423.06,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,3596.41,70,,3596.41,percent of total billed charges,,227.96,,,227.96,Fee Schedule,,193.21,,,193.21,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,227.45,,,227.45,Other,New York Medicaid APG methodology,227.45,,,227.45,Other,100% New York Medicaid APG,227.45,,,227.45,Other,100% New York Medicaid APG,227.45,,,227.45,Other,100% New York Medicaid APG,511.76,,,511.76,Other,225% New York Medicaid APG,348,,,348,Other,153% New York Medicaid APG,511.76,,,511.76,Other,225% New York Medicaid APG,318.43,,,318.43,Other,140% New York Medicaid APG,511.76,,,511.76,Other,225% New York Medicaid APG,591.37,,,591.37,Other,260% New York Medicaid APG,736.94,,,736.94,Other,324% New York Medicaid APG,489.02,,,489.02,Other,215% New York Medicaid APG,489.02,,,489.02,Other,215% New York Medicaid APG,284.31,,,284.31,Other,125% New York Medicaid APG,193.21,9473,
Biopsy of external ear canal,69105,CPT,,,,,,,,both,,,32077.39,23737.27,74,,23737.27,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,14434.83,45,,14434.83,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,15878.31,49.5,,15878.31,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2256.57,,,2256.57,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,22454.17,70,,22454.17,percent of total billed charges,,311.6,,,311.6,Fee Schedule,,264.1,,,264.1,Fee Schedule,,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1213.21,,,1213.21,Other,New York Medicaid APG methodology,1213.21,,,1213.21,Other,100% New York Medicaid APG,1213.21,,,1213.21,Other,100% New York Medicaid APG,1213.21,,,1213.21,Other,100% New York Medicaid APG,2729.72,,,2729.72,Other,225% New York Medicaid APG,1856.21,,,1856.21,Other,153% New York Medicaid APG,2729.72,,,2729.72,Other,225% New York Medicaid APG,1698.49,,,1698.49,Other,140% New York Medicaid APG,2729.72,,,2729.72,Other,225% New York Medicaid APG,3154.34,,,3154.34,Other,260% New York Medicaid APG,3930.79,,,3930.79,Other,324% New York Medicaid APG,2608.4,,,2608.4,Other,215% New York Medicaid APG,2608.4,,,2608.4,Other,215% New York Medicaid APG,1516.51,,,1516.51,Other,125% New York Medicaid APG,264.1,23737.27,
Remove external ear partial,69110,CPT,,,,,,,,both,,,44858,33194.92,74,,33194.92,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,20186.1,45,,20186.1,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,22204.71,49.5,,22204.71,percent of total billed charges,110% of Medicare,30503.44,68,,30503.44,percent of total billed charges,,2965.83,,,2965.83,Other,186% of Medicaid,35886.4,80,,35886.4,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,35886.4,80,,35886.4,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,31400.6,70,,31400.6,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1594.53,,,1594.53,Other,New York Medicaid APG methodology,1594.53,,,1594.53,Other,100% New York Medicaid APG,1594.53,,,1594.53,Other,100% New York Medicaid APG,1594.53,,,1594.53,Other,100% New York Medicaid APG,3587.7,,,3587.7,Other,225% New York Medicaid APG,2439.64,,,2439.64,Other,153% New York Medicaid APG,3587.7,,,3587.7,Other,225% New York Medicaid APG,2232.35,,,2232.35,Other,140% New York Medicaid APG,3587.7,,,3587.7,Other,225% New York Medicaid APG,4145.78,,,4145.78,Other,260% New York Medicaid APG,5166.29,,,5166.29,Other,324% New York Medicaid APG,3428.25,,,3428.25,Other,215% New York Medicaid APG,3428.25,,,3428.25,Other,215% New York Medicaid APG,1993.17,,,1993.17,Other,125% New York Medicaid APG,1594.53,35886.4,
Removal of external ear,69120,CPT,,,,,,,,both,,,123177.14,91151.08,74,,91151.08,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,55429.71,45,,55429.71,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,60972.68,49.5,,60972.68,percent of total billed charges,110% of Medicare,83760.46,68,,83760.46,percent of total billed charges,,4119.28,,,4119.28,Other,186% of Medicaid,98541.71,80,,98541.71,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,98541.71,80,,98541.71,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,86224,70,,86224,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,2214.67,,,2214.67,Other,New York Medicaid APG methodology,2214.67,,,2214.67,Other,100% New York Medicaid APG,2214.67,,,2214.67,Other,100% New York Medicaid APG,2214.67,,,2214.67,Other,100% New York Medicaid APG,4983,,,4983,Other,225% New York Medicaid APG,3388.44,,,3388.44,Other,153% New York Medicaid APG,4983,,,4983,Other,225% New York Medicaid APG,3100.53,,,3100.53,Other,140% New York Medicaid APG,4983,,,4983,Other,225% New York Medicaid APG,5758.13,,,5758.13,Other,260% New York Medicaid APG,7175.52,,,7175.52,Other,324% New York Medicaid APG,4761.53,,,4761.53,Other,215% New York Medicaid APG,4761.53,,,4761.53,Other,215% New York Medicaid APG,2768.33,,,2768.33,Other,125% New York Medicaid APG,2214.67,98541.71,
Remove ear canal lesion(s),69140,CPT,,,,,,,,both,,,35546.28,26304.25,74,,26304.25,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15995.83,45,,15995.83,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,17595.41,49.5,,17595.41,percent of total billed charges,110% of Medicare,24171.47,68,,24171.47,percent of total billed charges,,4119.28,,,4119.28,Other,186% of Medicaid,28437.02,80,,28437.02,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,28437.02,80,,28437.02,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,24882.4,70,,24882.4,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,2214.67,,,2214.67,Other,New York Medicaid APG methodology,2214.67,,,2214.67,Other,100% New York Medicaid APG,2214.67,,,2214.67,Other,100% New York Medicaid APG,2214.67,,,2214.67,Other,100% New York Medicaid APG,4983,,,4983,Other,225% New York Medicaid APG,3388.44,,,3388.44,Other,153% New York Medicaid APG,4983,,,4983,Other,225% New York Medicaid APG,3100.53,,,3100.53,Other,140% New York Medicaid APG,4983,,,4983,Other,225% New York Medicaid APG,5758.13,,,5758.13,Other,260% New York Medicaid APG,7175.52,,,7175.52,Other,324% New York Medicaid APG,4761.53,,,4761.53,Other,215% New York Medicaid APG,4761.53,,,4761.53,Other,215% New York Medicaid APG,2768.33,,,2768.33,Other,125% New York Medicaid APG,2214.67,28437.02,
Remove ear canal lesion(s),69145,CPT,,,,,,,,both,,,35810.3,26499.62,74,,26499.62,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,16114.64,45,,16114.64,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,17726.1,49.5,,17726.1,percent of total billed charges,110% of Medicare,24351,68,,24351,percent of total billed charges,,2965.83,,,2965.83,Other,186% of Medicaid,28648.24,80,,28648.24,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,28648.24,80,,28648.24,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,25067.21,70,,25067.21,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1594.53,,,1594.53,Other,New York Medicaid APG methodology,1594.53,,,1594.53,Other,100% New York Medicaid APG,1594.53,,,1594.53,Other,100% New York Medicaid APG,1594.53,,,1594.53,Other,100% New York Medicaid APG,3587.7,,,3587.7,Other,225% New York Medicaid APG,2439.64,,,2439.64,Other,153% New York Medicaid APG,3587.7,,,3587.7,Other,225% New York Medicaid APG,2232.35,,,2232.35,Other,140% New York Medicaid APG,3587.7,,,3587.7,Other,225% New York Medicaid APG,4145.78,,,4145.78,Other,260% New York Medicaid APG,5166.29,,,5166.29,Other,324% New York Medicaid APG,3428.25,,,3428.25,Other,215% New York Medicaid APG,3428.25,,,3428.25,Other,215% New York Medicaid APG,1993.17,,,1993.17,Other,125% New York Medicaid APG,1594.53,28648.24,
Extensive ear canal surgery,69150,CPT,,,,,,,,both,,,123177.14,91151.08,74,,91151.08,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,55429.71,45,,55429.71,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,60972.68,49.5,,60972.68,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,4119.28,,,4119.28,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,86224,70,,86224,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,2214.67,,,2214.67,Other,New York Medicaid APG methodology,2214.67,,,2214.67,Other,100% New York Medicaid APG,2214.67,,,2214.67,Other,100% New York Medicaid APG,2214.67,,,2214.67,Other,100% New York Medicaid APG,4983,,,4983,Other,225% New York Medicaid APG,3388.44,,,3388.44,Other,153% New York Medicaid APG,4983,,,4983,Other,225% New York Medicaid APG,3100.53,,,3100.53,Other,140% New York Medicaid APG,4983,,,4983,Other,225% New York Medicaid APG,5758.13,,,5758.13,Other,260% New York Medicaid APG,7175.52,,,7175.52,Other,324% New York Medicaid APG,4761.53,,,4761.53,Other,215% New York Medicaid APG,4761.53,,,4761.53,Other,215% New York Medicaid APG,2768.33,,,2768.33,Other,125% New York Medicaid APG,2214.67,91151.08,
Clear outer ear canal,69200,CPT,,,,,,,,both,,,2686.86,1988.28,74,,1988.28,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,1209.09,45,,1209.09,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,1330,49.5,,1330,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,0.02,,,0.02,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,1880.8,70,,1880.8,percent of total billed charges,,231.24,,,231.24,Fee Schedule,,195.99,,,195.99,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% New York Medicaid APG,0.01,,,0.01,Other,100% New York Medicaid APG,0.01,,,0.01,Other,100% New York Medicaid APG,0.02,,,0.02,Other,225% New York Medicaid APG,0.02,,,0.02,Other,153% New York Medicaid APG,0.02,,,0.02,Other,225% New York Medicaid APG,0.01,,,0.01,Other,140% New York Medicaid APG,0.02,,,0.02,Other,225% New York Medicaid APG,0.03,,,0.03,Other,260% New York Medicaid APG,0.03,,,0.03,Other,324% New York Medicaid APG,0.02,,,0.02,Other,215% New York Medicaid APG,0.02,,,0.02,Other,215% New York Medicaid APG,0.01,,,0.01,Other,125% New York Medicaid APG,0.01,9473,
Clear outer ear canal,69205,CPT,,,,,,,,both,,,34377.37,25439.25,74,,25439.25,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15469.82,45,,15469.82,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,17016.8,49.5,,17016.8,percent of total billed charges,110% of Medicare,23376.61,68,,23376.61,percent of total billed charges,,2256.57,,,2256.57,Other,186% of Medicaid,27501.9,80,,27501.9,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,27501.9,80,,27501.9,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,24064.16,70,,24064.16,percent of total billed charges,,472.32,,,472.32,Fee Schedule,,400.32,,,400.32,Fee Schedule,,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1213.21,,,1213.21,Other,New York Medicaid APG methodology,1213.21,,,1213.21,Other,100% New York Medicaid APG,1213.21,,,1213.21,Other,100% New York Medicaid APG,1213.21,,,1213.21,Other,100% New York Medicaid APG,2729.72,,,2729.72,Other,225% New York Medicaid APG,1856.21,,,1856.21,Other,153% New York Medicaid APG,2729.72,,,2729.72,Other,225% New York Medicaid APG,1698.49,,,1698.49,Other,140% New York Medicaid APG,2729.72,,,2729.72,Other,225% New York Medicaid APG,3154.34,,,3154.34,Other,260% New York Medicaid APG,3930.79,,,3930.79,Other,324% New York Medicaid APG,2608.4,,,2608.4,Other,215% New York Medicaid APG,2608.4,,,2608.4,Other,215% New York Medicaid APG,1516.51,,,1516.51,Other,125% New York Medicaid APG,400.32,27501.9,
Remove impacted ear wax uni,69209,CPT,,,,,,,,both,,,33401,24716.74,74,,24716.74,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15030.45,45,,15030.45,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,16533.5,49.5,,16533.5,percent of total billed charges,110% of Medicare,22712.68,68,,22712.68,percent of total billed charges,,0.02,,,0.02,Other,186% of Medicaid,26720.8,80,,26720.8,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,26720.8,80,,26720.8,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,23380.7,70,,23380.7,percent of total billed charges,,75.44,,,75.44,Fee Schedule,,63.94,,,63.94,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% New York Medicaid APG,0.01,,,0.01,Other,100% New York Medicaid APG,0.01,,,0.01,Other,100% New York Medicaid APG,0.02,,,0.02,Other,225% New York Medicaid APG,0.02,,,0.02,Other,153% New York Medicaid APG,0.02,,,0.02,Other,225% New York Medicaid APG,0.01,,,0.01,Other,140% New York Medicaid APG,0.02,,,0.02,Other,225% New York Medicaid APG,0.03,,,0.03,Other,260% New York Medicaid APG,0.03,,,0.03,Other,324% New York Medicaid APG,0.02,,,0.02,Other,215% New York Medicaid APG,0.02,,,0.02,Other,215% New York Medicaid APG,0.01,,,0.01,Other,125% New York Medicaid APG,0.01,26720.8,
Remove impacted ear wax uni,69210,CPT,,,,,,,,both,,,34338.86,25410.76,74,,25410.76,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15452.49,45,,15452.49,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,16997.74,49.5,,16997.74,percent of total billed charges,110% of Medicare,23350.42,68,,23350.42,percent of total billed charges,,0.02,,,0.02,Other,186% of Medicaid,27471.09,80,,27471.09,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,27471.09,80,,27471.09,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,24037.2,70,,24037.2,percent of total billed charges,,159.08,,,159.08,Fee Schedule,,134.83,,,134.83,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% New York Medicaid APG,0.01,,,0.01,Other,100% New York Medicaid APG,0.01,,,0.01,Other,100% New York Medicaid APG,0.02,,,0.02,Other,225% New York Medicaid APG,0.02,,,0.02,Other,153% New York Medicaid APG,0.02,,,0.02,Other,225% New York Medicaid APG,0.01,,,0.01,Other,140% New York Medicaid APG,0.02,,,0.02,Other,225% New York Medicaid APG,0.03,,,0.03,Other,260% New York Medicaid APG,0.03,,,0.03,Other,324% New York Medicaid APG,0.02,,,0.02,Other,215% New York Medicaid APG,0.02,,,0.02,Other,215% New York Medicaid APG,0.01,,,0.01,Other,125% New York Medicaid APG,0.01,27471.09,
Clean out mastoid cavity,69220,CPT,,,,,,,,both,,,4210.98,3116.13,74,,3116.13,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,1894.94,45,,1894.94,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,2084.44,49.5,,2084.44,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,423.06,,,423.06,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,2947.69,70,,2947.69,percent of total billed charges,,250.92,,,250.92,Fee Schedule,,212.67,,,212.67,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,227.45,,,227.45,Other,New York Medicaid APG methodology,227.45,,,227.45,Other,100% New York Medicaid APG,227.45,,,227.45,Other,100% New York Medicaid APG,227.45,,,227.45,Other,100% New York Medicaid APG,511.76,,,511.76,Other,225% New York Medicaid APG,348,,,348,Other,153% New York Medicaid APG,511.76,,,511.76,Other,225% New York Medicaid APG,318.43,,,318.43,Other,140% New York Medicaid APG,511.76,,,511.76,Other,225% New York Medicaid APG,591.37,,,591.37,Other,260% New York Medicaid APG,736.94,,,736.94,Other,324% New York Medicaid APG,489.02,,,489.02,Other,215% New York Medicaid APG,489.02,,,489.02,Other,215% New York Medicaid APG,284.31,,,284.31,Other,125% New York Medicaid APG,212.67,9473,
Clean out mastoid cavity,69222,CPT,,,,,,,,both,,,11572.85,8563.91,74,,8563.91,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,5207.78,45,,5207.78,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,5728.56,49.5,,5728.56,percent of total billed charges,110% of Medicare,7869.54,68,,7869.54,percent of total billed charges,,2256.57,,,2256.57,Other,186% of Medicaid,9258.28,80,,9258.28,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,9258.28,80,,9258.28,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,8101,70,,8101,percent of total billed charges,,674.04,,,674.04,Fee Schedule,,571.29,,,571.29,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,1213.21,,,1213.21,Other,New York Medicaid APG methodology,1213.21,,,1213.21,Other,100% New York Medicaid APG,1213.21,,,1213.21,Other,100% New York Medicaid APG,1213.21,,,1213.21,Other,100% New York Medicaid APG,2729.72,,,2729.72,Other,225% New York Medicaid APG,1856.21,,,1856.21,Other,153% New York Medicaid APG,2729.72,,,2729.72,Other,225% New York Medicaid APG,1698.49,,,1698.49,Other,140% New York Medicaid APG,2729.72,,,2729.72,Other,225% New York Medicaid APG,3154.34,,,3154.34,Other,260% New York Medicaid APG,3930.79,,,3930.79,Other,324% New York Medicaid APG,2608.4,,,2608.4,Other,215% New York Medicaid APG,2608.4,,,2608.4,Other,215% New York Medicaid APG,1516.51,,,1516.51,Other,125% New York Medicaid APG,571.29,9258.28,
Revise external ear,69300,CPT,,,,,,,,both,,,37965.27,28094.3,74,,28094.3,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,17084.37,45,,17084.37,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,18792.81,49.5,,18792.81,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,4119.28,,,4119.28,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,26575.69,70,,26575.69,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,2214.67,,,2214.67,Other,New York Medicaid APG methodology,2214.67,,,2214.67,Other,100% New York Medicaid APG,2214.67,,,2214.67,Other,100% New York Medicaid APG,2214.67,,,2214.67,Other,100% New York Medicaid APG,4983,,,4983,Other,225% New York Medicaid APG,3388.44,,,3388.44,Other,153% New York Medicaid APG,4983,,,4983,Other,225% New York Medicaid APG,3100.53,,,3100.53,Other,140% New York Medicaid APG,4983,,,4983,Other,225% New York Medicaid APG,5758.13,,,5758.13,Other,260% New York Medicaid APG,7175.52,,,7175.52,Other,324% New York Medicaid APG,4761.53,,,4761.53,Other,215% New York Medicaid APG,4761.53,,,4761.53,Other,215% New York Medicaid APG,2768.33,,,2768.33,Other,125% New York Medicaid APG,2214.67,28094.3,
Rebuild outer ear canal,69310,CPT,,,,,,,,both,,,35952.72,26605.01,74,,26605.01,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,16178.72,45,,16178.72,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,17796.6,49.5,,17796.6,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5841.74,,,5841.74,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,25166.9,70,,25166.9,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,3140.72,,,3140.72,Other,New York Medicaid APG methodology,3140.72,,,3140.72,Other,100% New York Medicaid APG,3140.72,,,3140.72,Other,100% New York Medicaid APG,3140.72,,,3140.72,Other,100% New York Medicaid APG,7066.62,,,7066.62,Other,225% New York Medicaid APG,4805.3,,,4805.3,Other,153% New York Medicaid APG,7066.62,,,7066.62,Other,225% New York Medicaid APG,4397.01,,,4397.01,Other,140% New York Medicaid APG,7066.62,,,7066.62,Other,225% New York Medicaid APG,8165.87,,,8165.87,Other,260% New York Medicaid APG,10175.93,,,10175.93,Other,324% New York Medicaid APG,6752.54,,,6752.54,Other,215% New York Medicaid APG,6752.54,,,6752.54,Other,215% New York Medicaid APG,3925.9,,,3925.9,Other,125% New York Medicaid APG,3126,26605.01,
Rebuild outer ear canal,69320,CPT,,,,,,,,both,,,123177.14,91151.08,74,,91151.08,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,55429.71,45,,55429.71,percent of total billed charges,Medicare Ratio of cost to charges,5954,,"100% primary, 50% supplemental procedure",5954,Other,Aetna ASC Grouper,5359,,"100% primary, 50% supplemental procedure",5359,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,60972.68,49.5,,60972.68,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,4119.28,,,4119.28,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,86224,70,,86224,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,2214.67,,,2214.67,Other,New York Medicaid APG methodology,2214.67,,,2214.67,Other,100% New York Medicaid APG,2214.67,,,2214.67,Other,100% New York Medicaid APG,2214.67,,,2214.67,Other,100% New York Medicaid APG,4983,,,4983,Other,225% New York Medicaid APG,3388.44,,,3388.44,Other,153% New York Medicaid APG,4983,,,4983,Other,225% New York Medicaid APG,3100.53,,,3100.53,Other,140% New York Medicaid APG,4983,,,4983,Other,225% New York Medicaid APG,5758.13,,,5758.13,Other,260% New York Medicaid APG,7175.52,,,7175.52,Other,324% New York Medicaid APG,4761.53,,,4761.53,Other,215% New York Medicaid APG,4761.53,,,4761.53,Other,215% New York Medicaid APG,2768.33,,,2768.33,Other,125% New York Medicaid APG,2214.67,91151.08,
Incision of eardrum,69420,CPT,,,,,,,,both,,,5137.73,3801.92,74,,3801.92,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,2311.98,45,,2311.98,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,2543.18,49.5,,2543.18,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,423.06,,,423.06,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,3596.41,70,,3596.41,percent of total billed charges,,593.68,,,593.68,Fee Schedule,,503.18,,,503.18,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,227.45,,,227.45,Other,New York Medicaid APG methodology,227.45,,,227.45,Other,100% New York Medicaid APG,227.45,,,227.45,Other,100% New York Medicaid APG,227.45,,,227.45,Other,100% New York Medicaid APG,511.76,,,511.76,Other,225% New York Medicaid APG,348,,,348,Other,153% New York Medicaid APG,511.76,,,511.76,Other,225% New York Medicaid APG,318.43,,,318.43,Other,140% New York Medicaid APG,511.76,,,511.76,Other,225% New York Medicaid APG,591.37,,,591.37,Other,260% New York Medicaid APG,736.94,,,736.94,Other,324% New York Medicaid APG,489.02,,,489.02,Other,215% New York Medicaid APG,489.02,,,489.02,Other,215% New York Medicaid APG,284.31,,,284.31,Other,125% New York Medicaid APG,227.45,9473,
Incision of eardrum,69421,CPT,,,,,,,,both,,,37342.12,27633.17,74,,27633.17,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,16803.95,45,,16803.95,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,18484.35,49.5,,18484.35,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2256.57,,,2256.57,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,26139.48,70,,26139.48,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1213.21,,,1213.21,Other,New York Medicaid APG methodology,1213.21,,,1213.21,Other,100% New York Medicaid APG,1213.21,,,1213.21,Other,100% New York Medicaid APG,1213.21,,,1213.21,Other,100% New York Medicaid APG,2729.72,,,2729.72,Other,225% New York Medicaid APG,1856.21,,,1856.21,Other,153% New York Medicaid APG,2729.72,,,2729.72,Other,225% New York Medicaid APG,1698.49,,,1698.49,Other,140% New York Medicaid APG,2729.72,,,2729.72,Other,225% New York Medicaid APG,3154.34,,,3154.34,Other,260% New York Medicaid APG,3930.79,,,3930.79,Other,324% New York Medicaid APG,2608.4,,,2608.4,Other,215% New York Medicaid APG,2608.4,,,2608.4,Other,215% New York Medicaid APG,1516.51,,,1516.51,Other,125% New York Medicaid APG,1213.21,27633.17,
Remove ventilating tube,69424,CPT,,,,,,,,both,,,34127.61,25254.43,74,,25254.43,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15357.42,45,,15357.42,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,16893.17,49.5,,16893.17,percent of total billed charges,110% of Medicare,23206.77,68,,23206.77,percent of total billed charges,,2256.57,,,2256.57,Other,186% of Medicaid,27302.09,80,,27302.09,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,27302.09,80,,27302.09,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,23889.33,70,,23889.33,percent of total billed charges,,295.2,,,295.2,Fee Schedule,,250.2,,,250.2,Fee Schedule,,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1213.21,,,1213.21,Other,New York Medicaid APG methodology,1213.21,,,1213.21,Other,100% New York Medicaid APG,1213.21,,,1213.21,Other,100% New York Medicaid APG,1213.21,,,1213.21,Other,100% New York Medicaid APG,2729.72,,,2729.72,Other,225% New York Medicaid APG,1856.21,,,1856.21,Other,153% New York Medicaid APG,2729.72,,,2729.72,Other,225% New York Medicaid APG,1698.49,,,1698.49,Other,140% New York Medicaid APG,2729.72,,,2729.72,Other,225% New York Medicaid APG,3154.34,,,3154.34,Other,260% New York Medicaid APG,3930.79,,,3930.79,Other,324% New York Medicaid APG,2608.4,,,2608.4,Other,215% New York Medicaid APG,2608.4,,,2608.4,Other,215% New York Medicaid APG,1516.51,,,1516.51,Other,125% New York Medicaid APG,250.2,27302.09,
Create eardrum opening,69433,CPT,,,,,,,,both,,,11572.85,8563.91,74,,8563.91,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,5207.78,45,,5207.78,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,5728.56,49.5,,5728.56,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,423.06,,,423.06,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,8101,70,,8101,percent of total billed charges,,652.72,,,652.72,Fee Schedule,,553.22,,,553.22,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,227.45,,,227.45,Other,New York Medicaid APG methodology,227.45,,,227.45,Other,100% New York Medicaid APG,227.45,,,227.45,Other,100% New York Medicaid APG,227.45,,,227.45,Other,100% New York Medicaid APG,511.76,,,511.76,Other,225% New York Medicaid APG,348,,,348,Other,153% New York Medicaid APG,511.76,,,511.76,Other,225% New York Medicaid APG,318.43,,,318.43,Other,140% New York Medicaid APG,511.76,,,511.76,Other,225% New York Medicaid APG,591.37,,,591.37,Other,260% New York Medicaid APG,736.94,,,736.94,Other,324% New York Medicaid APG,489.02,,,489.02,Other,215% New York Medicaid APG,489.02,,,489.02,Other,215% New York Medicaid APG,284.31,,,284.31,Other,125% New York Medicaid APG,227.45,9473,
Create eardrum opening,69436,CPT,,,,,,,,both,,,34207.45,25313.51,74,,25313.51,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15393.35,45,,15393.35,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,16932.69,49.5,,16932.69,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2256.57,,,2256.57,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,23945.22,70,,23945.22,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1213.21,,,1213.21,Other,New York Medicaid APG methodology,1213.21,,,1213.21,Other,100% New York Medicaid APG,1213.21,,,1213.21,Other,100% New York Medicaid APG,1213.21,,,1213.21,Other,100% New York Medicaid APG,2729.72,,,2729.72,Other,225% New York Medicaid APG,1856.21,,,1856.21,Other,153% New York Medicaid APG,2729.72,,,2729.72,Other,225% New York Medicaid APG,1698.49,,,1698.49,Other,140% New York Medicaid APG,2729.72,,,2729.72,Other,225% New York Medicaid APG,3154.34,,,3154.34,Other,260% New York Medicaid APG,3930.79,,,3930.79,Other,324% New York Medicaid APG,2608.4,,,2608.4,Other,215% New York Medicaid APG,2608.4,,,2608.4,Other,215% New York Medicaid APG,1516.51,,,1516.51,Other,125% New York Medicaid APG,1213.21,25313.51,
Exploration of middle ear,69440,CPT,,,,,,,,both,,,67720.49,50113.16,74,,50113.16,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30474.22,45,,30474.22,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,33521.64,49.5,,33521.64,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2965.83,,,2965.83,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,47404.34,70,,47404.34,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1594.53,,,1594.53,Other,New York Medicaid APG methodology,1594.53,,,1594.53,Other,100% New York Medicaid APG,1594.53,,,1594.53,Other,100% New York Medicaid APG,1594.53,,,1594.53,Other,100% New York Medicaid APG,3587.7,,,3587.7,Other,225% New York Medicaid APG,2439.64,,,2439.64,Other,153% New York Medicaid APG,3587.7,,,3587.7,Other,225% New York Medicaid APG,2232.35,,,2232.35,Other,140% New York Medicaid APG,3587.7,,,3587.7,Other,225% New York Medicaid APG,4145.78,,,4145.78,Other,260% New York Medicaid APG,5166.29,,,5166.29,Other,324% New York Medicaid APG,3428.25,,,3428.25,Other,215% New York Medicaid APG,3428.25,,,3428.25,Other,215% New York Medicaid APG,1993.17,,,1993.17,Other,125% New York Medicaid APG,1594.53,50113.16,
Eardrum revision,69450,CPT,,,,,,,,both,,,67720.49,50113.16,74,,50113.16,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30474.22,45,,30474.22,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,33521.64,49.5,,33521.64,percent of total billed charges,110% of Medicare,46049.93,68,,46049.93,percent of total billed charges,,2965.83,,,2965.83,Other,186% of Medicaid,54176.39,80,,54176.39,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,54176.39,80,,54176.39,percent of total billed charges,,7216,,,7216,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,47404.34,70,,47404.34,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,1594.53,,,1594.53,Other,New York Medicaid APG methodology,1594.53,,,1594.53,Other,100% New York Medicaid APG,1594.53,,,1594.53,Other,100% New York Medicaid APG,1594.53,,,1594.53,Other,100% New York Medicaid APG,3587.7,,,3587.7,Other,225% New York Medicaid APG,2439.64,,,2439.64,Other,153% New York Medicaid APG,3587.7,,,3587.7,Other,225% New York Medicaid APG,2232.35,,,2232.35,Other,140% New York Medicaid APG,3587.7,,,3587.7,Other,225% New York Medicaid APG,4145.78,,,4145.78,Other,260% New York Medicaid APG,5166.29,,,5166.29,Other,324% New York Medicaid APG,3428.25,,,3428.25,Other,215% New York Medicaid APG,3428.25,,,3428.25,Other,215% New York Medicaid APG,1993.17,,,1993.17,Other,125% New York Medicaid APG,1594.53,54176.39,
Mastoidectomy,69501,CPT,,,,,,,,both,,,123177.14,91151.08,74,,91151.08,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,55429.71,45,,55429.71,percent of total billed charges,Medicare Ratio of cost to charges,5954,,"100% primary, 50% supplemental procedure",5954,Other,Aetna ASC Grouper,5359,,"100% primary, 50% supplemental procedure",5359,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,60972.68,49.5,,60972.68,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5841.74,,,5841.74,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,86224,70,,86224,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,3140.72,,,3140.72,Other,New York Medicaid APG methodology,3140.72,,,3140.72,Other,100% New York Medicaid APG,3140.72,,,3140.72,Other,100% New York Medicaid APG,3140.72,,,3140.72,Other,100% New York Medicaid APG,7066.62,,,7066.62,Other,225% New York Medicaid APG,4805.3,,,4805.3,Other,153% New York Medicaid APG,7066.62,,,7066.62,Other,225% New York Medicaid APG,4397.01,,,4397.01,Other,140% New York Medicaid APG,7066.62,,,7066.62,Other,225% New York Medicaid APG,8165.87,,,8165.87,Other,260% New York Medicaid APG,10175.93,,,10175.93,Other,324% New York Medicaid APG,6752.54,,,6752.54,Other,215% New York Medicaid APG,6752.54,,,6752.54,Other,215% New York Medicaid APG,3925.9,,,3925.9,Other,125% New York Medicaid APG,3140.72,91151.08,
Mastoidectomy,69502,CPT,,,,,,,,both,,,123177.14,91151.08,74,,91151.08,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,55429.71,45,,55429.71,percent of total billed charges,Medicare Ratio of cost to charges,5954,,"100% primary, 50% supplemental procedure",5954,Other,Aetna ASC Grouper,5359,,"100% primary, 50% supplemental procedure",5359,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,60972.68,49.5,,60972.68,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5841.74,,,5841.74,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,86224,70,,86224,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,3140.72,,,3140.72,Other,New York Medicaid APG methodology,3140.72,,,3140.72,Other,100% New York Medicaid APG,3140.72,,,3140.72,Other,100% New York Medicaid APG,3140.72,,,3140.72,Other,100% New York Medicaid APG,7066.62,,,7066.62,Other,225% New York Medicaid APG,4805.3,,,4805.3,Other,153% New York Medicaid APG,7066.62,,,7066.62,Other,225% New York Medicaid APG,4397.01,,,4397.01,Other,140% New York Medicaid APG,7066.62,,,7066.62,Other,225% New York Medicaid APG,8165.87,,,8165.87,Other,260% New York Medicaid APG,10175.93,,,10175.93,Other,324% New York Medicaid APG,6752.54,,,6752.54,Other,215% New York Medicaid APG,6752.54,,,6752.54,Other,215% New York Medicaid APG,3925.9,,,3925.9,Other,125% New York Medicaid APG,3140.72,91151.08,
Remove mastoid structures,69505,CPT,,,,,,,,both,,,123177.14,91151.08,74,,91151.08,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,55429.71,45,,55429.71,percent of total billed charges,Medicare Ratio of cost to charges,5954,,"100% primary, 50% supplemental procedure",5954,Other,Aetna ASC Grouper,5359,,"100% primary, 50% supplemental procedure",5359,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,60972.68,49.5,,60972.68,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,4119.28,,,4119.28,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,86224,70,,86224,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,2214.67,,,2214.67,Other,New York Medicaid APG methodology,2214.67,,,2214.67,Other,100% New York Medicaid APG,2214.67,,,2214.67,Other,100% New York Medicaid APG,2214.67,,,2214.67,Other,100% New York Medicaid APG,4983,,,4983,Other,225% New York Medicaid APG,3388.44,,,3388.44,Other,153% New York Medicaid APG,4983,,,4983,Other,225% New York Medicaid APG,3100.53,,,3100.53,Other,140% New York Medicaid APG,4983,,,4983,Other,225% New York Medicaid APG,5758.13,,,5758.13,Other,260% New York Medicaid APG,7175.52,,,7175.52,Other,324% New York Medicaid APG,4761.53,,,4761.53,Other,215% New York Medicaid APG,4761.53,,,4761.53,Other,215% New York Medicaid APG,2768.33,,,2768.33,Other,125% New York Medicaid APG,2214.67,91151.08,
Extensive mastoid surgery,69511,CPT,,,,,,,,both,,,123177.14,91151.08,74,,91151.08,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,55429.71,45,,55429.71,percent of total billed charges,Medicare Ratio of cost to charges,5954,,"100% primary, 50% supplemental procedure",5954,Other,Aetna ASC Grouper,5359,,"100% primary, 50% supplemental procedure",5359,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,60972.68,49.5,,60972.68,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5841.74,,,5841.74,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,86224,70,,86224,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,3140.72,,,3140.72,Other,New York Medicaid APG methodology,3140.72,,,3140.72,Other,100% New York Medicaid APG,3140.72,,,3140.72,Other,100% New York Medicaid APG,3140.72,,,3140.72,Other,100% New York Medicaid APG,7066.62,,,7066.62,Other,225% New York Medicaid APG,4805.3,,,4805.3,Other,153% New York Medicaid APG,7066.62,,,7066.62,Other,225% New York Medicaid APG,4397.01,,,4397.01,Other,140% New York Medicaid APG,7066.62,,,7066.62,Other,225% New York Medicaid APG,8165.87,,,8165.87,Other,260% New York Medicaid APG,10175.93,,,10175.93,Other,324% New York Medicaid APG,6752.54,,,6752.54,Other,215% New York Medicaid APG,6752.54,,,6752.54,Other,215% New York Medicaid APG,3925.9,,,3925.9,Other,125% New York Medicaid APG,3140.72,91151.08,
Extensive mastoid surgery,69530,CPT,,,,,,,,both,,,123177.14,91151.08,74,,91151.08,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,55429.71,45,,55429.71,percent of total billed charges,Medicare Ratio of cost to charges,5954,,"100% primary, 50% supplemental procedure",5954,Other,Aetna ASC Grouper,5359,,"100% primary, 50% supplemental procedure",5359,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,60972.68,49.5,,60972.68,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5841.74,,,5841.74,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,86224,70,,86224,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,3140.72,,,3140.72,Other,New York Medicaid APG methodology,3140.72,,,3140.72,Other,100% New York Medicaid APG,3140.72,,,3140.72,Other,100% New York Medicaid APG,3140.72,,,3140.72,Other,100% New York Medicaid APG,7066.62,,,7066.62,Other,225% New York Medicaid APG,4805.3,,,4805.3,Other,153% New York Medicaid APG,7066.62,,,7066.62,Other,225% New York Medicaid APG,4397.01,,,4397.01,Other,140% New York Medicaid APG,7066.62,,,7066.62,Other,225% New York Medicaid APG,8165.87,,,8165.87,Other,260% New York Medicaid APG,10175.93,,,10175.93,Other,324% New York Medicaid APG,6752.54,,,6752.54,Other,215% New York Medicaid APG,6752.54,,,6752.54,Other,215% New York Medicaid APG,3925.9,,,3925.9,Other,125% New York Medicaid APG,3140.72,91151.08,
Remove ear lesion,69540,CPT,,,,,,,,both,,,32077.39,23737.27,74,,23737.27,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,14434.83,45,,14434.83,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,15878.31,49.5,,15878.31,percent of total billed charges,110% of Medicare,21812.63,68,,21812.63,percent of total billed charges,,2256.57,,,2256.57,Other,186% of Medicaid,25661.91,80,,25661.91,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,25661.91,80,,25661.91,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,22454.17,70,,22454.17,percent of total billed charges,,646.16,,,646.16,Fee Schedule,,547.66,,,547.66,Fee Schedule,,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1213.21,,,1213.21,Other,New York Medicaid APG methodology,1213.21,,,1213.21,Other,100% New York Medicaid APG,1213.21,,,1213.21,Other,100% New York Medicaid APG,1213.21,,,1213.21,Other,100% New York Medicaid APG,2729.72,,,2729.72,Other,225% New York Medicaid APG,1856.21,,,1856.21,Other,153% New York Medicaid APG,2729.72,,,2729.72,Other,225% New York Medicaid APG,1698.49,,,1698.49,Other,140% New York Medicaid APG,2729.72,,,2729.72,Other,225% New York Medicaid APG,3154.34,,,3154.34,Other,260% New York Medicaid APG,3930.79,,,3930.79,Other,324% New York Medicaid APG,2608.4,,,2608.4,Other,215% New York Medicaid APG,2608.4,,,2608.4,Other,215% New York Medicaid APG,1516.51,,,1516.51,Other,125% New York Medicaid APG,547.66,25661.91,
Remove ear lesion,69550,CPT,,,,,,,,both,,,37626.87,27843.88,74,,27843.88,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,16932.09,45,,16932.09,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,18625.3,49.5,,18625.3,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,4119.28,,,4119.28,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,26338.81,70,,26338.81,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,2214.67,,,2214.67,Other,New York Medicaid APG methodology,2214.67,,,2214.67,Other,100% New York Medicaid APG,2214.67,,,2214.67,Other,100% New York Medicaid APG,2214.67,,,2214.67,Other,100% New York Medicaid APG,4983,,,4983,Other,225% New York Medicaid APG,3388.44,,,3388.44,Other,153% New York Medicaid APG,4983,,,4983,Other,225% New York Medicaid APG,3100.53,,,3100.53,Other,140% New York Medicaid APG,4983,,,4983,Other,225% New York Medicaid APG,5758.13,,,5758.13,Other,260% New York Medicaid APG,7175.52,,,7175.52,Other,324% New York Medicaid APG,4761.53,,,4761.53,Other,215% New York Medicaid APG,4761.53,,,4761.53,Other,215% New York Medicaid APG,2768.33,,,2768.33,Other,125% New York Medicaid APG,2214.67,27843.88,
Remove ear lesion,69552,CPT,,,,,,,,both,,,123177.14,91151.08,74,,91151.08,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,55429.71,45,,55429.71,percent of total billed charges,Medicare Ratio of cost to charges,5954,,"100% primary, 50% supplemental procedure",5954,Other,Aetna ASC Grouper,5359,,"100% primary, 50% supplemental procedure",5359,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,60972.68,49.5,,60972.68,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5841.74,,,5841.74,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,86224,70,,86224,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,3140.72,,,3140.72,Other,New York Medicaid APG methodology,3140.72,,,3140.72,Other,100% New York Medicaid APG,3140.72,,,3140.72,Other,100% New York Medicaid APG,3140.72,,,3140.72,Other,100% New York Medicaid APG,7066.62,,,7066.62,Other,225% New York Medicaid APG,4805.3,,,4805.3,Other,153% New York Medicaid APG,7066.62,,,7066.62,Other,225% New York Medicaid APG,4397.01,,,4397.01,Other,140% New York Medicaid APG,7066.62,,,7066.62,Other,225% New York Medicaid APG,8165.87,,,8165.87,Other,260% New York Medicaid APG,10175.93,,,10175.93,Other,324% New York Medicaid APG,6752.54,,,6752.54,Other,215% New York Medicaid APG,6752.54,,,6752.54,Other,215% New York Medicaid APG,3925.9,,,3925.9,Other,125% New York Medicaid APG,3140.72,91151.08,
Mastoid surgery revision,69601,CPT,,,,,,,,both,,,123177.14,91151.08,74,,91151.08,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,55429.71,45,,55429.71,percent of total billed charges,Medicare Ratio of cost to charges,5954,,"100% primary, 50% supplemental procedure",5954,Other,Aetna ASC Grouper,5359,,"100% primary, 50% supplemental procedure",5359,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,60972.68,49.5,,60972.68,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5841.74,,,5841.74,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,86224,70,,86224,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,3140.72,,,3140.72,Other,New York Medicaid APG methodology,3140.72,,,3140.72,Other,100% New York Medicaid APG,3140.72,,,3140.72,Other,100% New York Medicaid APG,3140.72,,,3140.72,Other,100% New York Medicaid APG,7066.62,,,7066.62,Other,225% New York Medicaid APG,4805.3,,,4805.3,Other,153% New York Medicaid APG,7066.62,,,7066.62,Other,225% New York Medicaid APG,4397.01,,,4397.01,Other,140% New York Medicaid APG,7066.62,,,7066.62,Other,225% New York Medicaid APG,8165.87,,,8165.87,Other,260% New York Medicaid APG,10175.93,,,10175.93,Other,324% New York Medicaid APG,6752.54,,,6752.54,Other,215% New York Medicaid APG,6752.54,,,6752.54,Other,215% New York Medicaid APG,3925.9,,,3925.9,Other,125% New York Medicaid APG,3140.72,91151.08,
Mastoid surgery revision,69602,CPT,,,,,,,,both,,,123177.14,91151.08,74,,91151.08,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,55429.71,45,,55429.71,percent of total billed charges,Medicare Ratio of cost to charges,5954,,"100% primary, 50% supplemental procedure",5954,Other,Aetna ASC Grouper,5359,,"100% primary, 50% supplemental procedure",5359,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,60972.68,49.5,,60972.68,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5841.74,,,5841.74,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,86224,70,,86224,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,3140.72,,,3140.72,Other,New York Medicaid APG methodology,3140.72,,,3140.72,Other,100% New York Medicaid APG,3140.72,,,3140.72,Other,100% New York Medicaid APG,3140.72,,,3140.72,Other,100% New York Medicaid APG,7066.62,,,7066.62,Other,225% New York Medicaid APG,4805.3,,,4805.3,Other,153% New York Medicaid APG,7066.62,,,7066.62,Other,225% New York Medicaid APG,4397.01,,,4397.01,Other,140% New York Medicaid APG,7066.62,,,7066.62,Other,225% New York Medicaid APG,8165.87,,,8165.87,Other,260% New York Medicaid APG,10175.93,,,10175.93,Other,324% New York Medicaid APG,6752.54,,,6752.54,Other,215% New York Medicaid APG,6752.54,,,6752.54,Other,215% New York Medicaid APG,3925.9,,,3925.9,Other,125% New York Medicaid APG,3140.72,91151.08,
Mastoid surgery revision,69603,CPT,,,,,,,,both,,,123177.14,91151.08,74,,91151.08,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,55429.71,45,,55429.71,percent of total billed charges,Medicare Ratio of cost to charges,5954,,"100% primary, 50% supplemental procedure",5954,Other,Aetna ASC Grouper,5359,,"100% primary, 50% supplemental procedure",5359,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,60972.68,49.5,,60972.68,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5841.74,,,5841.74,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,86224,70,,86224,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,3140.72,,,3140.72,Other,New York Medicaid APG methodology,3140.72,,,3140.72,Other,100% New York Medicaid APG,3140.72,,,3140.72,Other,100% New York Medicaid APG,3140.72,,,3140.72,Other,100% New York Medicaid APG,7066.62,,,7066.62,Other,225% New York Medicaid APG,4805.3,,,4805.3,Other,153% New York Medicaid APG,7066.62,,,7066.62,Other,225% New York Medicaid APG,4397.01,,,4397.01,Other,140% New York Medicaid APG,7066.62,,,7066.62,Other,225% New York Medicaid APG,8165.87,,,8165.87,Other,260% New York Medicaid APG,10175.93,,,10175.93,Other,324% New York Medicaid APG,6752.54,,,6752.54,Other,215% New York Medicaid APG,6752.54,,,6752.54,Other,215% New York Medicaid APG,3925.9,,,3925.9,Other,125% New York Medicaid APG,3140.72,91151.08,
Mastoid surgery revision,69604,CPT,,,,,,,,both,,,123177.14,91151.08,74,,91151.08,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,55429.71,45,,55429.71,percent of total billed charges,Medicare Ratio of cost to charges,5954,,"100% primary, 50% supplemental procedure",5954,Other,Aetna ASC Grouper,5359,,"100% primary, 50% supplemental procedure",5359,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,60972.68,49.5,,60972.68,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5841.74,,,5841.74,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,86224,70,,86224,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,3140.72,,,3140.72,Other,New York Medicaid APG methodology,3140.72,,,3140.72,Other,100% New York Medicaid APG,3140.72,,,3140.72,Other,100% New York Medicaid APG,3140.72,,,3140.72,Other,100% New York Medicaid APG,7066.62,,,7066.62,Other,225% New York Medicaid APG,4805.3,,,4805.3,Other,153% New York Medicaid APG,7066.62,,,7066.62,Other,225% New York Medicaid APG,4397.01,,,4397.01,Other,140% New York Medicaid APG,7066.62,,,7066.62,Other,225% New York Medicaid APG,8165.87,,,8165.87,Other,260% New York Medicaid APG,10175.93,,,10175.93,Other,324% New York Medicaid APG,6752.54,,,6752.54,Other,215% New York Medicaid APG,6752.54,,,6752.54,Other,215% New York Medicaid APG,3925.9,,,3925.9,Other,125% New York Medicaid APG,3140.72,91151.08,
Repair of eardrum,69610,CPT,,,,,,,,both,,,33921.46,25101.88,74,,25101.88,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15264.66,45,,15264.66,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,16791.12,49.5,,16791.12,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2256.57,,,2256.57,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,23745.02,70,,23745.02,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1213.21,,,1213.21,Other,New York Medicaid APG methodology,1213.21,,,1213.21,Other,100% New York Medicaid APG,1213.21,,,1213.21,Other,100% New York Medicaid APG,1213.21,,,1213.21,Other,100% New York Medicaid APG,2729.72,,,2729.72,Other,225% New York Medicaid APG,1856.21,,,1856.21,Other,153% New York Medicaid APG,2729.72,,,2729.72,Other,225% New York Medicaid APG,1698.49,,,1698.49,Other,140% New York Medicaid APG,2729.72,,,2729.72,Other,225% New York Medicaid APG,3154.34,,,3154.34,Other,260% New York Medicaid APG,3930.79,,,3930.79,Other,324% New York Medicaid APG,2608.4,,,2608.4,Other,215% New York Medicaid APG,2608.4,,,2608.4,Other,215% New York Medicaid APG,1516.51,,,1516.51,Other,125% New York Medicaid APG,1213.21,25101.88,
Repair of eardrum,69620,CPT,,,,,,,,both,,,33597.07,24861.83,74,,24861.83,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15118.68,45,,15118.68,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,16630.55,49.5,,16630.55,percent of total billed charges,110% of Medicare,22846.01,68,,22846.01,percent of total billed charges,,2965.83,,,2965.83,Other,186% of Medicaid,26877.66,80,,26877.66,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,26877.66,80,,26877.66,percent of total billed charges,,7216,,,7216,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,23517.95,70,,23517.95,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1594.53,,,1594.53,Other,New York Medicaid APG methodology,1594.53,,,1594.53,Other,100% New York Medicaid APG,1594.53,,,1594.53,Other,100% New York Medicaid APG,1594.53,,,1594.53,Other,100% New York Medicaid APG,3587.7,,,3587.7,Other,225% New York Medicaid APG,2439.64,,,2439.64,Other,153% New York Medicaid APG,3587.7,,,3587.7,Other,225% New York Medicaid APG,2232.35,,,2232.35,Other,140% New York Medicaid APG,3587.7,,,3587.7,Other,225% New York Medicaid APG,4145.78,,,4145.78,Other,260% New York Medicaid APG,5166.29,,,5166.29,Other,324% New York Medicaid APG,3428.25,,,3428.25,Other,215% New York Medicaid APG,3428.25,,,3428.25,Other,215% New York Medicaid APG,1993.17,,,1993.17,Other,125% New York Medicaid APG,1594.53,26877.66,
Repair eardrum structures,69631,CPT,,,,,,,,both,,,36367.95,26912.28,74,,26912.28,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,16365.58,45,,16365.58,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,18002.14,49.5,,18002.14,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,4119.28,,,4119.28,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,25457.57,70,,25457.57,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,2214.67,,,2214.67,Other,New York Medicaid APG methodology,2214.67,,,2214.67,Other,100% New York Medicaid APG,2214.67,,,2214.67,Other,100% New York Medicaid APG,2214.67,,,2214.67,Other,100% New York Medicaid APG,4983,,,4983,Other,225% New York Medicaid APG,3388.44,,,3388.44,Other,153% New York Medicaid APG,4983,,,4983,Other,225% New York Medicaid APG,3100.53,,,3100.53,Other,140% New York Medicaid APG,4983,,,4983,Other,225% New York Medicaid APG,5758.13,,,5758.13,Other,260% New York Medicaid APG,7175.52,,,7175.52,Other,324% New York Medicaid APG,4761.53,,,4761.53,Other,215% New York Medicaid APG,4761.53,,,4761.53,Other,215% New York Medicaid APG,2768.33,,,2768.33,Other,125% New York Medicaid APG,2214.67,26912.28,
Rebuild eardrum structures,69632,CPT,,,,,,,,both,,,37346.62,27636.5,74,,27636.5,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,16805.98,45,,16805.98,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,18486.58,49.5,,18486.58,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5841.74,,,5841.74,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,26142.63,70,,26142.63,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,3140.72,,,3140.72,Other,New York Medicaid APG methodology,3140.72,,,3140.72,Other,100% New York Medicaid APG,3140.72,,,3140.72,Other,100% New York Medicaid APG,3140.72,,,3140.72,Other,100% New York Medicaid APG,7066.62,,,7066.62,Other,225% New York Medicaid APG,4805.3,,,4805.3,Other,153% New York Medicaid APG,7066.62,,,7066.62,Other,225% New York Medicaid APG,4397.01,,,4397.01,Other,140% New York Medicaid APG,7066.62,,,7066.62,Other,225% New York Medicaid APG,8165.87,,,8165.87,Other,260% New York Medicaid APG,10175.93,,,10175.93,Other,324% New York Medicaid APG,6752.54,,,6752.54,Other,215% New York Medicaid APG,6752.54,,,6752.54,Other,215% New York Medicaid APG,3925.9,,,3925.9,Other,125% New York Medicaid APG,3140.72,27636.5,
Rebuild eardrum structures,69633,CPT,,,,,,,,both,,,39184.76,28996.72,74,,28996.72,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,17633.14,45,,17633.14,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,19396.46,49.5,,19396.46,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5841.74,,,5841.74,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,27429.33,70,,27429.33,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,3140.72,,,3140.72,Other,New York Medicaid APG methodology,3140.72,,,3140.72,Other,100% New York Medicaid APG,3140.72,,,3140.72,Other,100% New York Medicaid APG,3140.72,,,3140.72,Other,100% New York Medicaid APG,7066.62,,,7066.62,Other,225% New York Medicaid APG,4805.3,,,4805.3,Other,153% New York Medicaid APG,7066.62,,,7066.62,Other,225% New York Medicaid APG,4397.01,,,4397.01,Other,140% New York Medicaid APG,7066.62,,,7066.62,Other,225% New York Medicaid APG,8165.87,,,8165.87,Other,260% New York Medicaid APG,10175.93,,,10175.93,Other,324% New York Medicaid APG,6752.54,,,6752.54,Other,215% New York Medicaid APG,6752.54,,,6752.54,Other,215% New York Medicaid APG,3925.9,,,3925.9,Other,125% New York Medicaid APG,3140.72,28996.72,
Repair eardrum structures,69635,CPT,,,,,,,,both,,,123177.14,91151.08,74,,91151.08,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,55429.71,45,,55429.71,percent of total billed charges,Medicare Ratio of cost to charges,5954,,"100% primary, 50% supplemental procedure",5954,Other,Aetna ASC Grouper,5359,,"100% primary, 50% supplemental procedure",5359,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,60972.68,49.5,,60972.68,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,4119.28,,,4119.28,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,86224,70,,86224,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,2214.67,,,2214.67,Other,New York Medicaid APG methodology,2214.67,,,2214.67,Other,100% New York Medicaid APG,2214.67,,,2214.67,Other,100% New York Medicaid APG,2214.67,,,2214.67,Other,100% New York Medicaid APG,4983,,,4983,Other,225% New York Medicaid APG,3388.44,,,3388.44,Other,153% New York Medicaid APG,4983,,,4983,Other,225% New York Medicaid APG,3100.53,,,3100.53,Other,140% New York Medicaid APG,4983,,,4983,Other,225% New York Medicaid APG,5758.13,,,5758.13,Other,260% New York Medicaid APG,7175.52,,,7175.52,Other,324% New York Medicaid APG,4761.53,,,4761.53,Other,215% New York Medicaid APG,4761.53,,,4761.53,Other,215% New York Medicaid APG,2768.33,,,2768.33,Other,125% New York Medicaid APG,2214.67,91151.08,
Rebuild eardrum structures,69636,CPT,,,,,,,,both,,,123177.14,91151.08,74,,91151.08,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,55429.71,45,,55429.71,percent of total billed charges,Medicare Ratio of cost to charges,5954,,"100% primary, 50% supplemental procedure",5954,Other,Aetna ASC Grouper,5359,,"100% primary, 50% supplemental procedure",5359,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,60972.68,49.5,,60972.68,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5841.74,,,5841.74,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,86224,70,,86224,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,3140.72,,,3140.72,Other,New York Medicaid APG methodology,3140.72,,,3140.72,Other,100% New York Medicaid APG,3140.72,,,3140.72,Other,100% New York Medicaid APG,3140.72,,,3140.72,Other,100% New York Medicaid APG,7066.62,,,7066.62,Other,225% New York Medicaid APG,4805.3,,,4805.3,Other,153% New York Medicaid APG,7066.62,,,7066.62,Other,225% New York Medicaid APG,4397.01,,,4397.01,Other,140% New York Medicaid APG,7066.62,,,7066.62,Other,225% New York Medicaid APG,8165.87,,,8165.87,Other,260% New York Medicaid APG,10175.93,,,10175.93,Other,324% New York Medicaid APG,6752.54,,,6752.54,Other,215% New York Medicaid APG,6752.54,,,6752.54,Other,215% New York Medicaid APG,3925.9,,,3925.9,Other,125% New York Medicaid APG,3140.72,91151.08,
Rebuild eardrum structures,69637,CPT,,,,,,,,both,,,52926.47,39165.59,74,,39165.59,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,23816.91,45,,23816.91,percent of total billed charges,Medicare Ratio of cost to charges,5954,,"100% primary, 50% supplemental procedure",5954,Other,Aetna ASC Grouper,5359,,"100% primary, 50% supplemental procedure",5359,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,26198.6,49.5,,26198.6,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5841.74,,,5841.74,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,37048.53,70,,37048.53,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,3140.72,,,3140.72,Other,New York Medicaid APG methodology,3140.72,,,3140.72,Other,100% New York Medicaid APG,3140.72,,,3140.72,Other,100% New York Medicaid APG,3140.72,,,3140.72,Other,100% New York Medicaid APG,7066.62,,,7066.62,Other,225% New York Medicaid APG,4805.3,,,4805.3,Other,153% New York Medicaid APG,7066.62,,,7066.62,Other,225% New York Medicaid APG,4397.01,,,4397.01,Other,140% New York Medicaid APG,7066.62,,,7066.62,Other,225% New York Medicaid APG,8165.87,,,8165.87,Other,260% New York Medicaid APG,10175.93,,,10175.93,Other,324% New York Medicaid APG,6752.54,,,6752.54,Other,215% New York Medicaid APG,6752.54,,,6752.54,Other,215% New York Medicaid APG,3925.9,,,3925.9,Other,125% New York Medicaid APG,3140.72,39165.59,
Revise middle ear & mastoid,69641,CPT,,,,,,,,both,,,40642.42,30075.39,74,,30075.39,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,18289.09,45,,18289.09,percent of total billed charges,Medicare Ratio of cost to charges,5954,,"100% primary, 50% supplemental procedure",5954,Other,Aetna ASC Grouper,5359,,"100% primary, 50% supplemental procedure",5359,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,20118,49.5,,20118,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5841.74,,,5841.74,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,28449.69,70,,28449.69,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,3140.72,,,3140.72,Other,New York Medicaid APG methodology,3140.72,,,3140.72,Other,100% New York Medicaid APG,3140.72,,,3140.72,Other,100% New York Medicaid APG,3140.72,,,3140.72,Other,100% New York Medicaid APG,7066.62,,,7066.62,Other,225% New York Medicaid APG,4805.3,,,4805.3,Other,153% New York Medicaid APG,7066.62,,,7066.62,Other,225% New York Medicaid APG,4397.01,,,4397.01,Other,140% New York Medicaid APG,7066.62,,,7066.62,Other,225% New York Medicaid APG,8165.87,,,8165.87,Other,260% New York Medicaid APG,10175.93,,,10175.93,Other,324% New York Medicaid APG,6752.54,,,6752.54,Other,215% New York Medicaid APG,6752.54,,,6752.54,Other,215% New York Medicaid APG,3925.9,,,3925.9,Other,125% New York Medicaid APG,3140.72,30075.39,
Revise middle ear & mastoid,69642,CPT,,,,,,,,both,,,41363.34,30608.87,74,,30608.87,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,18613.5,45,,18613.5,percent of total billed charges,Medicare Ratio of cost to charges,5954,,"100% primary, 50% supplemental procedure",5954,Other,Aetna ASC Grouper,5359,,"100% primary, 50% supplemental procedure",5359,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,20474.85,49.5,,20474.85,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5841.74,,,5841.74,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,28954.34,70,,28954.34,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,3140.72,,,3140.72,Other,New York Medicaid APG methodology,3140.72,,,3140.72,Other,100% New York Medicaid APG,3140.72,,,3140.72,Other,100% New York Medicaid APG,3140.72,,,3140.72,Other,100% New York Medicaid APG,7066.62,,,7066.62,Other,225% New York Medicaid APG,4805.3,,,4805.3,Other,153% New York Medicaid APG,7066.62,,,7066.62,Other,225% New York Medicaid APG,4397.01,,,4397.01,Other,140% New York Medicaid APG,7066.62,,,7066.62,Other,225% New York Medicaid APG,8165.87,,,8165.87,Other,260% New York Medicaid APG,10175.93,,,10175.93,Other,324% New York Medicaid APG,6752.54,,,6752.54,Other,215% New York Medicaid APG,6752.54,,,6752.54,Other,215% New York Medicaid APG,3925.9,,,3925.9,Other,125% New York Medicaid APG,3140.72,30608.87,
Revise middle ear & mastoid,69643,CPT,,,,,,,,both,,,38155.74,28235.25,74,,28235.25,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,17170.08,45,,17170.08,percent of total billed charges,Medicare Ratio of cost to charges,5954,,"100% primary, 50% supplemental procedure",5954,Other,Aetna ASC Grouper,5359,,"100% primary, 50% supplemental procedure",5359,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,18887.09,49.5,,18887.09,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5841.74,,,5841.74,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,26709.02,70,,26709.02,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,3140.72,,,3140.72,Other,New York Medicaid APG methodology,3140.72,,,3140.72,Other,100% New York Medicaid APG,3140.72,,,3140.72,Other,100% New York Medicaid APG,3140.72,,,3140.72,Other,100% New York Medicaid APG,7066.62,,,7066.62,Other,225% New York Medicaid APG,4805.3,,,4805.3,Other,153% New York Medicaid APG,7066.62,,,7066.62,Other,225% New York Medicaid APG,4397.01,,,4397.01,Other,140% New York Medicaid APG,7066.62,,,7066.62,Other,225% New York Medicaid APG,8165.87,,,8165.87,Other,260% New York Medicaid APG,10175.93,,,10175.93,Other,324% New York Medicaid APG,6752.54,,,6752.54,Other,215% New York Medicaid APG,6752.54,,,6752.54,Other,215% New York Medicaid APG,3925.9,,,3925.9,Other,125% New York Medicaid APG,3140.72,28235.25,
Revise middle ear & mastoid,69644,CPT,,,,,,,,both,,,43513.63,32200.09,74,,32200.09,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,19581.13,45,,19581.13,percent of total billed charges,Medicare Ratio of cost to charges,5954,,"100% primary, 50% supplemental procedure",5954,Other,Aetna ASC Grouper,5359,,"100% primary, 50% supplemental procedure",5359,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,21539.25,49.5,,21539.25,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5841.74,,,5841.74,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,30459.54,70,,30459.54,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,3140.72,,,3140.72,Other,New York Medicaid APG methodology,3140.72,,,3140.72,Other,100% New York Medicaid APG,3140.72,,,3140.72,Other,100% New York Medicaid APG,3140.72,,,3140.72,Other,100% New York Medicaid APG,7066.62,,,7066.62,Other,225% New York Medicaid APG,4805.3,,,4805.3,Other,153% New York Medicaid APG,7066.62,,,7066.62,Other,225% New York Medicaid APG,4397.01,,,4397.01,Other,140% New York Medicaid APG,7066.62,,,7066.62,Other,225% New York Medicaid APG,8165.87,,,8165.87,Other,260% New York Medicaid APG,10175.93,,,10175.93,Other,324% New York Medicaid APG,6752.54,,,6752.54,Other,215% New York Medicaid APG,6752.54,,,6752.54,Other,215% New York Medicaid APG,3925.9,,,3925.9,Other,125% New York Medicaid APG,3140.72,32200.09,
Revise middle ear & mastoid,69645,CPT,,,,,,,,both,,,53911.16,39894.26,74,,39894.26,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,24260.02,45,,24260.02,percent of total billed charges,Medicare Ratio of cost to charges,5954,,"100% primary, 50% supplemental procedure",5954,Other,Aetna ASC Grouper,5359,,"100% primary, 50% supplemental procedure",5359,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,26686.02,49.5,,26686.02,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5841.74,,,5841.74,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,37737.81,70,,37737.81,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,3140.72,,,3140.72,Other,New York Medicaid APG methodology,3140.72,,,3140.72,Other,100% New York Medicaid APG,3140.72,,,3140.72,Other,100% New York Medicaid APG,3140.72,,,3140.72,Other,100% New York Medicaid APG,7066.62,,,7066.62,Other,225% New York Medicaid APG,4805.3,,,4805.3,Other,153% New York Medicaid APG,7066.62,,,7066.62,Other,225% New York Medicaid APG,4397.01,,,4397.01,Other,140% New York Medicaid APG,7066.62,,,7066.62,Other,225% New York Medicaid APG,8165.87,,,8165.87,Other,260% New York Medicaid APG,10175.93,,,10175.93,Other,324% New York Medicaid APG,6752.54,,,6752.54,Other,215% New York Medicaid APG,6752.54,,,6752.54,Other,215% New York Medicaid APG,3925.9,,,3925.9,Other,125% New York Medicaid APG,3140.72,39894.26,
Revise middle ear & mastoid,69646,CPT,,,,,,,,both,,,51043.02,37771.83,74,,37771.83,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,22969.36,45,,22969.36,percent of total billed charges,Medicare Ratio of cost to charges,5954,,"100% primary, 50% supplemental procedure",5954,Other,Aetna ASC Grouper,5359,,"100% primary, 50% supplemental procedure",5359,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,25266.29,49.5,,25266.29,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5841.74,,,5841.74,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,35730.11,70,,35730.11,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,3140.72,,,3140.72,Other,New York Medicaid APG methodology,3140.72,,,3140.72,Other,100% New York Medicaid APG,3140.72,,,3140.72,Other,100% New York Medicaid APG,3140.72,,,3140.72,Other,100% New York Medicaid APG,7066.62,,,7066.62,Other,225% New York Medicaid APG,4805.3,,,4805.3,Other,153% New York Medicaid APG,7066.62,,,7066.62,Other,225% New York Medicaid APG,4397.01,,,4397.01,Other,140% New York Medicaid APG,7066.62,,,7066.62,Other,225% New York Medicaid APG,8165.87,,,8165.87,Other,260% New York Medicaid APG,10175.93,,,10175.93,Other,324% New York Medicaid APG,6752.54,,,6752.54,Other,215% New York Medicaid APG,6752.54,,,6752.54,Other,215% New York Medicaid APG,3925.9,,,3925.9,Other,125% New York Medicaid APG,3140.72,37771.83,
Release middle ear bone,69650,CPT,,,,,,,,both,,,38340.88,28372.25,74,,28372.25,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,17253.4,45,,17253.4,percent of total billed charges,Medicare Ratio of cost to charges,5954,,"100% primary, 50% supplemental procedure",5954,Other,Aetna ASC Grouper,5359,,"100% primary, 50% supplemental procedure",5359,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,18978.74,49.5,,18978.74,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,4119.28,,,4119.28,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,26838.62,70,,26838.62,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,2214.67,,,2214.67,Other,New York Medicaid APG methodology,2214.67,,,2214.67,Other,100% New York Medicaid APG,2214.67,,,2214.67,Other,100% New York Medicaid APG,2214.67,,,2214.67,Other,100% New York Medicaid APG,4983,,,4983,Other,225% New York Medicaid APG,3388.44,,,3388.44,Other,153% New York Medicaid APG,4983,,,4983,Other,225% New York Medicaid APG,3100.53,,,3100.53,Other,140% New York Medicaid APG,4983,,,4983,Other,225% New York Medicaid APG,5758.13,,,5758.13,Other,260% New York Medicaid APG,7175.52,,,7175.52,Other,324% New York Medicaid APG,4761.53,,,4761.53,Other,215% New York Medicaid APG,4761.53,,,4761.53,Other,215% New York Medicaid APG,2768.33,,,2768.33,Other,125% New York Medicaid APG,2214.67,28372.25,
Revise middle ear bone,69660,CPT,,,,,,,,both,,,37994.47,28115.91,74,,28115.91,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,17097.51,45,,17097.51,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,18807.26,49.5,,18807.26,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,4119.28,,,4119.28,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,26596.13,70,,26596.13,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,2214.67,,,2214.67,Other,New York Medicaid APG methodology,2214.67,,,2214.67,Other,100% New York Medicaid APG,2214.67,,,2214.67,Other,100% New York Medicaid APG,2214.67,,,2214.67,Other,100% New York Medicaid APG,4983,,,4983,Other,225% New York Medicaid APG,3388.44,,,3388.44,Other,153% New York Medicaid APG,4983,,,4983,Other,225% New York Medicaid APG,3100.53,,,3100.53,Other,140% New York Medicaid APG,4983,,,4983,Other,225% New York Medicaid APG,5758.13,,,5758.13,Other,260% New York Medicaid APG,7175.52,,,7175.52,Other,324% New York Medicaid APG,4761.53,,,4761.53,Other,215% New York Medicaid APG,4761.53,,,4761.53,Other,215% New York Medicaid APG,2768.33,,,2768.33,Other,125% New York Medicaid APG,2214.67,28115.91,
Revise middle ear bone,69661,CPT,,,,,,,,both,,,123177.14,91151.08,74,,91151.08,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,55429.71,45,,55429.71,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,60972.68,49.5,,60972.68,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,4119.28,,,4119.28,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,86224,70,,86224,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,2214.67,,,2214.67,Other,New York Medicaid APG methodology,2214.67,,,2214.67,Other,100% New York Medicaid APG,2214.67,,,2214.67,Other,100% New York Medicaid APG,2214.67,,,2214.67,Other,100% New York Medicaid APG,4983,,,4983,Other,225% New York Medicaid APG,3388.44,,,3388.44,Other,153% New York Medicaid APG,4983,,,4983,Other,225% New York Medicaid APG,3100.53,,,3100.53,Other,140% New York Medicaid APG,4983,,,4983,Other,225% New York Medicaid APG,5758.13,,,5758.13,Other,260% New York Medicaid APG,7175.52,,,7175.52,Other,324% New York Medicaid APG,4761.53,,,4761.53,Other,215% New York Medicaid APG,4761.53,,,4761.53,Other,215% New York Medicaid APG,2768.33,,,2768.33,Other,125% New York Medicaid APG,2214.67,91151.08,
Revise middle ear bone,69662,CPT,,,,,,,,both,,,41026.91,30359.91,74,,30359.91,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,18462.11,45,,18462.11,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,20308.32,49.5,,20308.32,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,4119.28,,,4119.28,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,28718.84,70,,28718.84,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,2214.67,,,2214.67,Other,New York Medicaid APG methodology,2214.67,,,2214.67,Other,100% New York Medicaid APG,2214.67,,,2214.67,Other,100% New York Medicaid APG,2214.67,,,2214.67,Other,100% New York Medicaid APG,4983,,,4983,Other,225% New York Medicaid APG,3388.44,,,3388.44,Other,153% New York Medicaid APG,4983,,,4983,Other,225% New York Medicaid APG,3100.53,,,3100.53,Other,140% New York Medicaid APG,4983,,,4983,Other,225% New York Medicaid APG,5758.13,,,5758.13,Other,260% New York Medicaid APG,7175.52,,,7175.52,Other,324% New York Medicaid APG,4761.53,,,4761.53,Other,215% New York Medicaid APG,4761.53,,,4761.53,Other,215% New York Medicaid APG,2768.33,,,2768.33,Other,125% New York Medicaid APG,2214.67,30359.91,
Repair middle ear structures,69666,CPT,,,,,,,,both,,,67720.49,50113.16,74,,50113.16,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30474.22,45,,30474.22,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,33521.64,49.5,,33521.64,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2965.83,,,2965.83,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,47404.34,70,,47404.34,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1594.53,,,1594.53,Other,New York Medicaid APG methodology,1594.53,,,1594.53,Other,100% New York Medicaid APG,1594.53,,,1594.53,Other,100% New York Medicaid APG,1594.53,,,1594.53,Other,100% New York Medicaid APG,3587.7,,,3587.7,Other,225% New York Medicaid APG,2439.64,,,2439.64,Other,153% New York Medicaid APG,3587.7,,,3587.7,Other,225% New York Medicaid APG,2232.35,,,2232.35,Other,140% New York Medicaid APG,3587.7,,,3587.7,Other,225% New York Medicaid APG,4145.78,,,4145.78,Other,260% New York Medicaid APG,5166.29,,,5166.29,Other,324% New York Medicaid APG,3428.25,,,3428.25,Other,215% New York Medicaid APG,3428.25,,,3428.25,Other,215% New York Medicaid APG,1993.17,,,1993.17,Other,125% New York Medicaid APG,1594.53,50113.16,
Repair middle ear structures,69667,CPT,,,,,,,,both,,,67720.49,50113.16,74,,50113.16,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30474.22,45,,30474.22,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,33521.64,49.5,,33521.64,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2965.83,,,2965.83,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,47404.34,70,,47404.34,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1594.53,,,1594.53,Other,New York Medicaid APG methodology,1594.53,,,1594.53,Other,100% New York Medicaid APG,1594.53,,,1594.53,Other,100% New York Medicaid APG,1594.53,,,1594.53,Other,100% New York Medicaid APG,3587.7,,,3587.7,Other,225% New York Medicaid APG,2439.64,,,2439.64,Other,153% New York Medicaid APG,3587.7,,,3587.7,Other,225% New York Medicaid APG,2232.35,,,2232.35,Other,140% New York Medicaid APG,3587.7,,,3587.7,Other,225% New York Medicaid APG,4145.78,,,4145.78,Other,260% New York Medicaid APG,5166.29,,,5166.29,Other,324% New York Medicaid APG,3428.25,,,3428.25,Other,215% New York Medicaid APG,3428.25,,,3428.25,Other,215% New York Medicaid APG,1993.17,,,1993.17,Other,125% New York Medicaid APG,1594.53,50113.16,
Remove mastoid air cells,69670,CPT,,,,,,,,both,,,123177.14,91151.08,74,,91151.08,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,55429.71,45,,55429.71,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,60972.68,49.5,,60972.68,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5841.74,,,5841.74,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,86224,70,,86224,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,3140.72,,,3140.72,Other,New York Medicaid APG methodology,3140.72,,,3140.72,Other,100% New York Medicaid APG,3140.72,,,3140.72,Other,100% New York Medicaid APG,3140.72,,,3140.72,Other,100% New York Medicaid APG,7066.62,,,7066.62,Other,225% New York Medicaid APG,4805.3,,,4805.3,Other,153% New York Medicaid APG,7066.62,,,7066.62,Other,225% New York Medicaid APG,4397.01,,,4397.01,Other,140% New York Medicaid APG,7066.62,,,7066.62,Other,225% New York Medicaid APG,8165.87,,,8165.87,Other,260% New York Medicaid APG,10175.93,,,10175.93,Other,324% New York Medicaid APG,6752.54,,,6752.54,Other,215% New York Medicaid APG,6752.54,,,6752.54,Other,215% New York Medicaid APG,3925.9,,,3925.9,Other,125% New York Medicaid APG,3126,91151.08,
Remove middle ear nerve,69676,CPT,,,,,,,,both,,,67720.49,50113.16,74,,50113.16,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30474.22,45,,30474.22,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,33521.64,49.5,,33521.64,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,4119.28,,,4119.28,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,47404.34,70,,47404.34,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,2214.67,,,2214.67,Other,New York Medicaid APG methodology,2214.67,,,2214.67,Other,100% New York Medicaid APG,2214.67,,,2214.67,Other,100% New York Medicaid APG,2214.67,,,2214.67,Other,100% New York Medicaid APG,4983,,,4983,Other,225% New York Medicaid APG,3388.44,,,3388.44,Other,153% New York Medicaid APG,4983,,,4983,Other,225% New York Medicaid APG,3100.53,,,3100.53,Other,140% New York Medicaid APG,4983,,,4983,Other,225% New York Medicaid APG,5758.13,,,5758.13,Other,260% New York Medicaid APG,7175.52,,,7175.52,Other,324% New York Medicaid APG,4761.53,,,4761.53,Other,215% New York Medicaid APG,4761.53,,,4761.53,Other,215% New York Medicaid APG,2768.33,,,2768.33,Other,125% New York Medicaid APG,2214.67,50113.16,
Close mastoid fistula,69700,CPT,,,,,,,,both,,,32077.39,23737.27,74,,23737.27,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,14434.83,45,,14434.83,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,15878.31,49.5,,15878.31,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2965.83,,,2965.83,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,22454.17,70,,22454.17,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1594.53,,,1594.53,Other,New York Medicaid APG methodology,1594.53,,,1594.53,Other,100% New York Medicaid APG,1594.53,,,1594.53,Other,100% New York Medicaid APG,1594.53,,,1594.53,Other,100% New York Medicaid APG,3587.7,,,3587.7,Other,225% New York Medicaid APG,2439.64,,,2439.64,Other,153% New York Medicaid APG,3587.7,,,3587.7,Other,225% New York Medicaid APG,2232.35,,,2232.35,Other,140% New York Medicaid APG,3587.7,,,3587.7,Other,225% New York Medicaid APG,4145.78,,,4145.78,Other,260% New York Medicaid APG,5166.29,,,5166.29,Other,324% New York Medicaid APG,3428.25,,,3428.25,Other,215% New York Medicaid APG,3428.25,,,3428.25,Other,215% New York Medicaid APG,1993.17,,,1993.17,Other,125% New York Medicaid APG,1594.53,23737.27,
Nps surg dilat eust tube uni,69705,CPT,,,,,,,,both,,,42766.21,31647,74,,31647,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,19244.79,45,,19244.79,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,21169.27,49.5,,21169.27,percent of total billed charges,110% of Medicare,29081.02,68,,29081.02,percent of total billed charges,,2982.31,,,2982.31,Other,186% of Medicaid,34212.97,80,,34212.97,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,34212.97,80,,34212.97,percent of total billed charges,,7216,,,7216,Case Rate,,34212.97,80,,34212.97,percent of total billed charges,,29936.35,70,,29936.35,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,1603.39,,,1603.39,Other,New York Medicaid APG methodology,1603.39,,,1603.39,Other,100% New York Medicaid APG,1603.39,,,1603.39,Other,100% New York Medicaid APG,1603.39,,,1603.39,Other,100% New York Medicaid APG,3607.64,,,3607.64,Other,225% New York Medicaid APG,2453.19,,,2453.19,Other,153% New York Medicaid APG,3607.64,,,3607.64,Other,225% New York Medicaid APG,2244.75,,,2244.75,Other,140% New York Medicaid APG,3607.64,,,3607.64,Other,225% New York Medicaid APG,4168.82,,,4168.82,Other,260% New York Medicaid APG,5195,,,5195,Other,324% New York Medicaid APG,3447.3,,,3447.3,Other,215% New York Medicaid APG,3447.3,,,3447.3,Other,215% New York Medicaid APG,2004.24,,,2004.24,Other,125% New York Medicaid APG,1603.39,34212.97,
Nps surg dilat eust tube bi,69706,CPT,,,,,,,,both,,,41447.35,30671.04,74,,30671.04,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,18651.31,45,,18651.31,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,20516.44,49.5,,20516.44,percent of total billed charges,110% of Medicare,28184.2,68,,28184.2,percent of total billed charges,,2982.31,,,2982.31,Other,186% of Medicaid,33157.88,80,,33157.88,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,33157.88,80,,33157.88,percent of total billed charges,,7216,,,7216,Case Rate,,33157.88,80,,33157.88,percent of total billed charges,,29013.15,70,,29013.15,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,1603.39,,,1603.39,Other,New York Medicaid APG methodology,1603.39,,,1603.39,Other,100% New York Medicaid APG,1603.39,,,1603.39,Other,100% New York Medicaid APG,1603.39,,,1603.39,Other,100% New York Medicaid APG,3607.64,,,3607.64,Other,225% New York Medicaid APG,2453.19,,,2453.19,Other,153% New York Medicaid APG,3607.64,,,3607.64,Other,225% New York Medicaid APG,2244.75,,,2244.75,Other,140% New York Medicaid APG,3607.64,,,3607.64,Other,225% New York Medicaid APG,4168.82,,,4168.82,Other,260% New York Medicaid APG,5195,,,5195,Other,324% New York Medicaid APG,3447.3,,,3447.3,Other,215% New York Medicaid APG,3447.3,,,3447.3,Other,215% New York Medicaid APG,2004.24,,,2004.24,Other,125% New York Medicaid APG,1603.39,33157.88,
Remove/repair hearing aid,69711,CPT,,,,,,,,both,,,67720.49,50113.16,74,,50113.16,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30474.22,45,,30474.22,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,33521.64,49.5,,33521.64,percent of total billed charges,110% of Medicare,46049.93,68,,46049.93,percent of total billed charges,,4119.28,,,4119.28,Other,186% of Medicaid,54176.39,80,,54176.39,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,54176.39,80,,54176.39,percent of total billed charges,,7216,,,7216,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,47404.34,70,,47404.34,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,2214.67,,,2214.67,Other,New York Medicaid APG methodology,2214.67,,,2214.67,Other,100% New York Medicaid APG,2214.67,,,2214.67,Other,100% New York Medicaid APG,2214.67,,,2214.67,Other,100% New York Medicaid APG,4983,,,4983,Other,225% New York Medicaid APG,3388.44,,,3388.44,Other,153% New York Medicaid APG,4983,,,4983,Other,225% New York Medicaid APG,3100.53,,,3100.53,Other,140% New York Medicaid APG,4983,,,4983,Other,225% New York Medicaid APG,5758.13,,,5758.13,Other,260% New York Medicaid APG,7175.52,,,7175.52,Other,324% New York Medicaid APG,4761.53,,,4761.53,Other,215% New York Medicaid APG,4761.53,,,4761.53,Other,215% New York Medicaid APG,2768.33,,,2768.33,Other,125% New York Medicaid APG,2053,54176.39,
Implant temple bone w/stimul,69714,CPT,,,,,,,,both,,,66923.42,49523.33,74,,49523.33,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30115.54,45,,30115.54,percent of total billed charges,Medicare Ratio of cost to charges,7938,,"100% primary, 50% supplemental procedure",7938,Other,Aetna ASC Grouper,7144,,"100% primary, 50% supplemental procedure",7144,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,33127.09,49.5,,33127.09,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5841.74,,,5841.74,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9196,,"100% primary, 0% secondary procedures",9196,Other,MagnaCare ASC Grouper,46846.39,70,,46846.39,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6956,,"100% primary, 50% secondary, 25% tertiary procedure",6956,Other,United Healthcare ASC Grouper,6261,,"100% primary, 50% secondary, 25% tertiary procedure",6261,Other,United Healthcare ASC Grouper,6956,,"100% primary, 50% secondary, 25% tertiary procedure",6956,Other,United Healthcare ASC Grouper,5913,,"100% primary, 50% secondary, 25% tertiary procedure",5913,Other,United Healthcare ASC Grouper,3140.72,,,3140.72,Other,New York Medicaid APG methodology,3140.72,,,3140.72,Other,100% New York Medicaid APG,3140.72,,,3140.72,Other,100% New York Medicaid APG,3140.72,,,3140.72,Other,100% New York Medicaid APG,7066.62,,,7066.62,Other,225% New York Medicaid APG,4805.3,,,4805.3,Other,153% New York Medicaid APG,7066.62,,,7066.62,Other,225% New York Medicaid APG,4397.01,,,4397.01,Other,140% New York Medicaid APG,7066.62,,,7066.62,Other,225% New York Medicaid APG,8165.87,,,8165.87,Other,260% New York Medicaid APG,10175.93,,,10175.93,Other,324% New York Medicaid APG,6752.54,,,6752.54,Other,215% New York Medicaid APG,6752.54,,,6752.54,Other,215% New York Medicaid APG,3925.9,,,3925.9,Other,125% New York Medicaid APG,3140.72,49523.33,
Temple bone implant revision,69717,CPT,,,,,,,,both,,,66227.05,49008.02,74,,49008.02,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,29802.17,45,,29802.17,percent of total billed charges,Medicare Ratio of cost to charges,7938,,"100% primary, 50% supplemental procedure",7938,Other,Aetna ASC Grouper,7144,,"100% primary, 50% supplemental procedure",7144,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,32782.39,49.5,,32782.39,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5841.74,,,5841.74,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,46358.94,70,,46358.94,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,3140.72,,,3140.72,Other,New York Medicaid APG methodology,3140.72,,,3140.72,Other,100% New York Medicaid APG,3140.72,,,3140.72,Other,100% New York Medicaid APG,3140.72,,,3140.72,Other,100% New York Medicaid APG,7066.62,,,7066.62,Other,225% New York Medicaid APG,4805.3,,,4805.3,Other,153% New York Medicaid APG,7066.62,,,7066.62,Other,225% New York Medicaid APG,4397.01,,,4397.01,Other,140% New York Medicaid APG,7066.62,,,7066.62,Other,225% New York Medicaid APG,8165.87,,,8165.87,Other,260% New York Medicaid APG,10175.93,,,10175.93,Other,324% New York Medicaid APG,6752.54,,,6752.54,Other,215% New York Medicaid APG,6752.54,,,6752.54,Other,215% New York Medicaid APG,3925.9,,,3925.9,Other,125% New York Medicaid APG,3140.72,49008.02,
Release facial nerve,69720,CPT,,,,,,,,both,,,123177.14,91151.08,74,,91151.08,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,55429.71,45,,55429.71,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,60972.68,49.5,,60972.68,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,0.02,,,0.02,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,86224,70,,86224,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% New York Medicaid APG,0.01,,,0.01,Other,100% New York Medicaid APG,0.01,,,0.01,Other,100% New York Medicaid APG,0.02,,,0.02,Other,225% New York Medicaid APG,0.02,,,0.02,Other,153% New York Medicaid APG,0.02,,,0.02,Other,225% New York Medicaid APG,0.01,,,0.01,Other,140% New York Medicaid APG,0.02,,,0.02,Other,225% New York Medicaid APG,0.03,,,0.03,Other,260% New York Medicaid APG,0.03,,,0.03,Other,324% New York Medicaid APG,0.02,,,0.02,Other,215% New York Medicaid APG,0.02,,,0.02,Other,215% New York Medicaid APG,0.01,,,0.01,Other,125% New York Medicaid APG,0.01,91151.08,
Release facial nerve,69725,CPT,,,,,,,,both,,,123177.14,91151.08,74,,91151.08,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,55429.71,45,,55429.71,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,60972.68,49.5,,60972.68,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,0.02,,,0.02,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,86224,70,,86224,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% New York Medicaid APG,0.01,,,0.01,Other,100% New York Medicaid APG,0.01,,,0.01,Other,100% New York Medicaid APG,0.02,,,0.02,Other,225% New York Medicaid APG,0.02,,,0.02,Other,153% New York Medicaid APG,0.02,,,0.02,Other,225% New York Medicaid APG,0.01,,,0.01,Other,140% New York Medicaid APG,0.02,,,0.02,Other,225% New York Medicaid APG,0.03,,,0.03,Other,260% New York Medicaid APG,0.03,,,0.03,Other,324% New York Medicaid APG,0.02,,,0.02,Other,215% New York Medicaid APG,0.02,,,0.02,Other,215% New York Medicaid APG,0.01,,,0.01,Other,125% New York Medicaid APG,0.01,91151.08,
Repair facial nerve,69740,CPT,,,,,,,,both,,,123177.14,91151.08,74,,91151.08,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,55429.71,45,,55429.71,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,60972.68,49.5,,60972.68,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,0.02,,,0.02,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,86224,70,,86224,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% New York Medicaid APG,0.01,,,0.01,Other,100% New York Medicaid APG,0.01,,,0.01,Other,100% New York Medicaid APG,0.02,,,0.02,Other,225% New York Medicaid APG,0.02,,,0.02,Other,153% New York Medicaid APG,0.02,,,0.02,Other,225% New York Medicaid APG,0.01,,,0.01,Other,140% New York Medicaid APG,0.02,,,0.02,Other,225% New York Medicaid APG,0.03,,,0.03,Other,260% New York Medicaid APG,0.03,,,0.03,Other,324% New York Medicaid APG,0.02,,,0.02,Other,215% New York Medicaid APG,0.02,,,0.02,Other,215% New York Medicaid APG,0.01,,,0.01,Other,125% New York Medicaid APG,0.01,91151.08,
Repair facial nerve,69745,CPT,,,,,,,,both,,,123177.14,91151.08,74,,91151.08,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,55429.71,45,,55429.71,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,60972.68,49.5,,60972.68,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,0.02,,,0.02,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,86224,70,,86224,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% New York Medicaid APG,0.01,,,0.01,Other,100% New York Medicaid APG,0.01,,,0.01,Other,100% New York Medicaid APG,0.02,,,0.02,Other,225% New York Medicaid APG,0.02,,,0.02,Other,153% New York Medicaid APG,0.02,,,0.02,Other,225% New York Medicaid APG,0.01,,,0.01,Other,140% New York Medicaid APG,0.02,,,0.02,Other,225% New York Medicaid APG,0.03,,,0.03,Other,260% New York Medicaid APG,0.03,,,0.03,Other,324% New York Medicaid APG,0.02,,,0.02,Other,215% New York Medicaid APG,0.02,,,0.02,Other,215% New York Medicaid APG,0.01,,,0.01,Other,125% New York Medicaid APG,0.01,91151.08,
Incise inner ear,69801,CPT,,,,,,,,both,,,32077.39,23737.27,74,,23737.27,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,14434.83,45,,14434.83,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,15878.31,49.5,,15878.31,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2256.57,,,2256.57,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,22454.17,70,,22454.17,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1213.21,,,1213.21,Other,New York Medicaid APG methodology,1213.21,,,1213.21,Other,100% New York Medicaid APG,1213.21,,,1213.21,Other,100% New York Medicaid APG,1213.21,,,1213.21,Other,100% New York Medicaid APG,2729.72,,,2729.72,Other,225% New York Medicaid APG,1856.21,,,1856.21,Other,153% New York Medicaid APG,2729.72,,,2729.72,Other,225% New York Medicaid APG,1698.49,,,1698.49,Other,140% New York Medicaid APG,2729.72,,,2729.72,Other,225% New York Medicaid APG,3154.34,,,3154.34,Other,260% New York Medicaid APG,3930.79,,,3930.79,Other,324% New York Medicaid APG,2608.4,,,2608.4,Other,215% New York Medicaid APG,2608.4,,,2608.4,Other,215% New York Medicaid APG,1516.51,,,1516.51,Other,125% New York Medicaid APG,1213.21,23737.27,
Explore inner ear,69805,CPT,,,,,,,,both,,,123177.14,91151.08,74,,91151.08,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,55429.71,45,,55429.71,percent of total billed charges,Medicare Ratio of cost to charges,5954,,"100% primary, 50% supplemental procedure",5954,Other,Aetna ASC Grouper,5359,,"100% primary, 50% supplemental procedure",5359,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,60972.68,49.5,,60972.68,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5841.74,,,5841.74,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,86224,70,,86224,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,3140.72,,,3140.72,Other,New York Medicaid APG methodology,3140.72,,,3140.72,Other,100% New York Medicaid APG,3140.72,,,3140.72,Other,100% New York Medicaid APG,3140.72,,,3140.72,Other,100% New York Medicaid APG,7066.62,,,7066.62,Other,225% New York Medicaid APG,4805.3,,,4805.3,Other,153% New York Medicaid APG,7066.62,,,7066.62,Other,225% New York Medicaid APG,4397.01,,,4397.01,Other,140% New York Medicaid APG,7066.62,,,7066.62,Other,225% New York Medicaid APG,8165.87,,,8165.87,Other,260% New York Medicaid APG,10175.93,,,10175.93,Other,324% New York Medicaid APG,6752.54,,,6752.54,Other,215% New York Medicaid APG,6752.54,,,6752.54,Other,215% New York Medicaid APG,3925.9,,,3925.9,Other,125% New York Medicaid APG,3140.72,91151.08,
Explore inner ear,69806,CPT,,,,,,,,both,,,123177.14,91151.08,74,,91151.08,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,55429.71,45,,55429.71,percent of total billed charges,Medicare Ratio of cost to charges,5954,,"100% primary, 50% supplemental procedure",5954,Other,Aetna ASC Grouper,5359,,"100% primary, 50% supplemental procedure",5359,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,60972.68,49.5,,60972.68,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,4119.28,,,4119.28,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,86224,70,,86224,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,2214.67,,,2214.67,Other,New York Medicaid APG methodology,2214.67,,,2214.67,Other,100% New York Medicaid APG,2214.67,,,2214.67,Other,100% New York Medicaid APG,2214.67,,,2214.67,Other,100% New York Medicaid APG,4983,,,4983,Other,225% New York Medicaid APG,3388.44,,,3388.44,Other,153% New York Medicaid APG,4983,,,4983,Other,225% New York Medicaid APG,3100.53,,,3100.53,Other,140% New York Medicaid APG,4983,,,4983,Other,225% New York Medicaid APG,5758.13,,,5758.13,Other,260% New York Medicaid APG,7175.52,,,7175.52,Other,324% New York Medicaid APG,4761.53,,,4761.53,Other,215% New York Medicaid APG,4761.53,,,4761.53,Other,215% New York Medicaid APG,2768.33,,,2768.33,Other,125% New York Medicaid APG,2214.67,91151.08,
Remove inner ear,69905,CPT,,,,,,,,both,,,123177.14,91151.08,74,,91151.08,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,55429.71,45,,55429.71,percent of total billed charges,Medicare Ratio of cost to charges,5954,,"100% primary, 50% supplemental procedure",5954,Other,Aetna ASC Grouper,5359,,"100% primary, 50% supplemental procedure",5359,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,60972.68,49.5,,60972.68,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,4119.28,,,4119.28,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,86224,70,,86224,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,2214.67,,,2214.67,Other,New York Medicaid APG methodology,2214.67,,,2214.67,Other,100% New York Medicaid APG,2214.67,,,2214.67,Other,100% New York Medicaid APG,2214.67,,,2214.67,Other,100% New York Medicaid APG,4983,,,4983,Other,225% New York Medicaid APG,3388.44,,,3388.44,Other,153% New York Medicaid APG,4983,,,4983,Other,225% New York Medicaid APG,3100.53,,,3100.53,Other,140% New York Medicaid APG,4983,,,4983,Other,225% New York Medicaid APG,5758.13,,,5758.13,Other,260% New York Medicaid APG,7175.52,,,7175.52,Other,324% New York Medicaid APG,4761.53,,,4761.53,Other,215% New York Medicaid APG,4761.53,,,4761.53,Other,215% New York Medicaid APG,2768.33,,,2768.33,Other,125% New York Medicaid APG,2214.67,91151.08,
Remove inner ear & mastoid,69910,CPT,,,,,,,,both,,,123177.14,91151.08,74,,91151.08,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,55429.71,45,,55429.71,percent of total billed charges,Medicare Ratio of cost to charges,5954,,"100% primary, 50% supplemental procedure",5954,Other,Aetna ASC Grouper,5359,,"100% primary, 50% supplemental procedure",5359,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,60972.68,49.5,,60972.68,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5841.74,,,5841.74,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,86224,70,,86224,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,3140.72,,,3140.72,Other,New York Medicaid APG methodology,3140.72,,,3140.72,Other,100% New York Medicaid APG,3140.72,,,3140.72,Other,100% New York Medicaid APG,3140.72,,,3140.72,Other,100% New York Medicaid APG,7066.62,,,7066.62,Other,225% New York Medicaid APG,4805.3,,,4805.3,Other,153% New York Medicaid APG,7066.62,,,7066.62,Other,225% New York Medicaid APG,4397.01,,,4397.01,Other,140% New York Medicaid APG,7066.62,,,7066.62,Other,225% New York Medicaid APG,8165.87,,,8165.87,Other,260% New York Medicaid APG,10175.93,,,10175.93,Other,324% New York Medicaid APG,6752.54,,,6752.54,Other,215% New York Medicaid APG,6752.54,,,6752.54,Other,215% New York Medicaid APG,3925.9,,,3925.9,Other,125% New York Medicaid APG,3140.72,91151.08,
Incise inner ear nerve,69915,CPT,,,,,,,,both,,,67720.49,50113.16,74,,50113.16,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30474.22,45,,30474.22,percent of total billed charges,Medicare Ratio of cost to charges,5954,,"100% primary, 50% supplemental procedure",5954,Other,Aetna ASC Grouper,5359,,"100% primary, 50% supplemental procedure",5359,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,33521.64,49.5,,33521.64,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,4119.28,,,4119.28,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,47404.34,70,,47404.34,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,2214.67,,,2214.67,Other,New York Medicaid APG methodology,2214.67,,,2214.67,Other,100% New York Medicaid APG,2214.67,,,2214.67,Other,100% New York Medicaid APG,2214.67,,,2214.67,Other,100% New York Medicaid APG,4983,,,4983,Other,225% New York Medicaid APG,3388.44,,,3388.44,Other,153% New York Medicaid APG,4983,,,4983,Other,225% New York Medicaid APG,3100.53,,,3100.53,Other,140% New York Medicaid APG,4983,,,4983,Other,225% New York Medicaid APG,5758.13,,,5758.13,Other,260% New York Medicaid APG,7175.52,,,7175.52,Other,324% New York Medicaid APG,4761.53,,,4761.53,Other,215% New York Medicaid APG,4761.53,,,4761.53,Other,215% New York Medicaid APG,2768.33,,,2768.33,Other,125% New York Medicaid APG,2214.67,50113.16,
Implant cochlear device,69930,CPT,,,,,,,,both,,,144542.65,106961.56,74,,106961.56,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,65044.19,45,,65044.19,percent of total billed charges,Medicare Ratio of cost to charges,5954,,"100% primary, 50% supplemental procedure",5954,Other,Aetna ASC Grouper,5359,,"100% primary, 50% supplemental procedure",5359,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,71548.61,49.5,,71548.61,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,51118.3,,,51118.3,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9196,,"100% primary, 0% secondary procedures",9196,Other,MagnaCare ASC Grouper,101179.86,70,,101179.86,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,15267,,"100% primary, 50% secondary, 25% tertiary procedure",15267,Other,United Healthcare ASC Grouper,13740,,"100% primary, 50% secondary, 25% tertiary procedure",13740,Other,United Healthcare ASC Grouper,15267,,"100% primary, 50% secondary, 25% tertiary procedure",15267,Other,United Healthcare ASC Grouper,12977,,"100% primary, 50% secondary, 25% tertiary procedure",12977,Other,United Healthcare ASC Grouper,27482.96,,,27482.96,Other,New York Medicaid APG methodology,27482.96,,,27482.96,Other,100% New York Medicaid APG,27482.96,,,27482.96,Other,100% New York Medicaid APG,27482.96,,,27482.96,Other,100% New York Medicaid APG,61836.66,,,61836.66,Other,225% New York Medicaid APG,42048.93,,,42048.93,Other,153% New York Medicaid APG,61836.66,,,61836.66,Other,225% New York Medicaid APG,38476.14,,,38476.14,Other,140% New York Medicaid APG,61836.66,,,61836.66,Other,225% New York Medicaid APG,71455.69,,,71455.69,Other,260% New York Medicaid APG,89044.78,,,89044.78,Other,324% New York Medicaid APG,59088.36,,,59088.36,Other,215% New York Medicaid APG,59088.36,,,59088.36,Other,215% New York Medicaid APG,34353.7,,,34353.7,Other,125% New York Medicaid APG,3343,106961.56,
Release facial nerve,69955,CPT,,,,,,,,both,,,123177.14,91151.08,74,,91151.08,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,55429.71,45,,55429.71,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,60972.68,49.5,,60972.68,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,4659.19,,,4659.19,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,86224,70,,86224,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,2504.94,,,2504.94,Other,New York Medicaid APG methodology,2504.94,,,2504.94,Other,100% New York Medicaid APG,2504.94,,,2504.94,Other,100% New York Medicaid APG,2504.94,,,2504.94,Other,100% New York Medicaid APG,5636.11,,,5636.11,Other,225% New York Medicaid APG,3832.56,,,3832.56,Other,153% New York Medicaid APG,5636.11,,,5636.11,Other,225% New York Medicaid APG,3506.92,,,3506.92,Other,140% New York Medicaid APG,5636.11,,,5636.11,Other,225% New York Medicaid APG,6512.84,,,6512.84,Other,260% New York Medicaid APG,8116.01,,,8116.01,Other,324% New York Medicaid APG,5385.62,,,5385.62,Other,215% New York Medicaid APG,5385.62,,,5385.62,Other,215% New York Medicaid APG,3131.17,,,3131.17,Other,125% New York Medicaid APG,2504.94,91151.08,
Release inner ear canal,69960,CPT,,,,,,,,both,,,123177.14,91151.08,74,,91151.08,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,55429.71,45,,55429.71,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,60972.68,49.5,,60972.68,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,4659.19,,,4659.19,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,86224,70,,86224,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,2504.94,,,2504.94,Other,New York Medicaid APG methodology,2504.94,,,2504.94,Other,100% New York Medicaid APG,2504.94,,,2504.94,Other,100% New York Medicaid APG,2504.94,,,2504.94,Other,100% New York Medicaid APG,5636.11,,,5636.11,Other,225% New York Medicaid APG,3832.56,,,3832.56,Other,153% New York Medicaid APG,5636.11,,,5636.11,Other,225% New York Medicaid APG,3506.92,,,3506.92,Other,140% New York Medicaid APG,5636.11,,,5636.11,Other,225% New York Medicaid APG,6512.84,,,6512.84,Other,260% New York Medicaid APG,8116.01,,,8116.01,Other,324% New York Medicaid APG,5385.62,,,5385.62,Other,215% New York Medicaid APG,5385.62,,,5385.62,Other,215% New York Medicaid APG,3131.17,,,3131.17,Other,125% New York Medicaid APG,2504.94,91151.08,
Remove inner ear lesion,69970,CPT,,,,,,,,both,,,123177.14,91151.08,74,,91151.08,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,55429.71,45,,55429.71,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,60972.68,49.5,,60972.68,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5482.74,,,5482.74,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,86224,70,,86224,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,2947.71,,,2947.71,Other,New York Medicaid APG methodology,2947.71,,,2947.71,Other,100% New York Medicaid APG,2947.71,,,2947.71,Other,100% New York Medicaid APG,2947.71,,,2947.71,Other,100% New York Medicaid APG,6632.35,,,6632.35,Other,225% New York Medicaid APG,4510,,,4510,Other,153% New York Medicaid APG,6632.35,,,6632.35,Other,225% New York Medicaid APG,4126.79,,,4126.79,Other,140% New York Medicaid APG,6632.35,,,6632.35,Other,225% New York Medicaid APG,7664.04,,,7664.04,Other,260% New York Medicaid APG,9550.58,,,9550.58,Other,324% New York Medicaid APG,6337.58,,,6337.58,Other,215% New York Medicaid APG,6337.58,,,6337.58,Other,215% New York Medicaid APG,3684.64,,,3684.64,Other,125% New York Medicaid APG,2947.71,91151.08,
Microsurgery add-on,69990,CPT,,,,,,,,both,,,32432.1,23999.75,74,,23999.75,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,14594.45,45,,14594.45,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,16053.89,49.5,,16053.89,percent of total billed charges,110% of Medicare,22053.83,68,,22053.83,percent of total billed charges,,0.02,,,0.02,Other,186% of Medicaid,25945.68,80,,25945.68,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,25945.68,80,,25945.68,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,22702.47,70,,22702.47,percent of total billed charges,,3933,,,3933,Case Rate,MVP ASC Grouper,3343,,,3343,Case Rate,MVP ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% New York Medicaid APG,0.01,,,0.01,Other,100% New York Medicaid APG,0.01,,,0.01,Other,100% New York Medicaid APG,0.02,,,0.02,Other,225% New York Medicaid APG,0.02,,,0.02,Other,153% New York Medicaid APG,0.02,,,0.02,Other,225% New York Medicaid APG,0.01,,,0.01,Other,140% New York Medicaid APG,0.02,,,0.02,Other,225% New York Medicaid APG,0.03,,,0.03,Other,260% New York Medicaid APG,0.03,,,0.03,Other,324% New York Medicaid APG,0.02,,,0.02,Other,215% New York Medicaid APG,0.02,,,0.02,Other,215% New York Medicaid APG,0.01,,,0.01,Other,125% New York Medicaid APG,0.01,25945.68,
Insert/place heart catheter,93503,CPT,,,,,,,,both,,,33686.28,24927.85,74,,24927.85,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,15158.83,45,,15158.83,percent of total billed charges,Medicare Ratio of cost to charges,14237,,"100% primary, 50% supplemental procedure",14237,Other,Aetna ASC Grouper,12813,,"100% primary, 50% supplemental procedure",12813,Other,Aetna ASC Grouper,12219,,"100% primary, 50% secondary, 25% supplemental procedure",12219,Other,Blue Cross ASC Grouper,10997,,"100% primary, 50% secondary, 25% supplemental procedure",10997,Other,Blue Cross ASC Grouper,10386,,"100% primary, 50% secondary, 25% supplemental procedure",10386,Other,Blue Cross ASC Grouper,16674.71,49.5,,16674.71,percent of total billed charges,110% of Medicare,22906.67,68,,22906.67,percent of total billed charges,,586.68,,,586.68,Other,186% of Medicaid,26949.02,80,,26949.02,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,26949.02,80,,26949.02,percent of total billed charges,,7216,,,7216,Case Rate,,15214,,,15214,Case Rate,Cardiac Cath Case Rate,23580.4,70,,23580.4,percent of total billed charges,,15035,,,15035,Case Rate,Cardiac Cath Case Rate,12780,,,12780,Case Rate,Cardiac Cath Case Rate,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,315.42,,,315.42,Other,New York Medicaid APG methodology,315.42,,,315.42,Other,100% New York Medicaid APG,315.42,,,315.42,Other,100% New York Medicaid APG,315.42,,,315.42,Other,100% New York Medicaid APG,709.7,,,709.7,Other,225% New York Medicaid APG,482.6,,,482.6,Other,153% New York Medicaid APG,709.7,,,709.7,Other,225% New York Medicaid APG,441.59,,,441.59,Other,140% New York Medicaid APG,709.7,,,709.7,Other,225% New York Medicaid APG,820.1,,,820.1,Other,260% New York Medicaid APG,1021.97,,,1021.97,Other,324% New York Medicaid APG,678.16,,,678.16,Other,215% New York Medicaid APG,678.16,,,678.16,Other,215% New York Medicaid APG,394.28,,,394.28,Other,125% New York Medicaid APG,315.42,26949.02,
Biopsy of heart lining,93505,CPT,,,,,,,,both,,,72939.09,53974.93,74,,53974.93,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,32822.59,45,,32822.59,percent of total billed charges,Medicare Ratio of cost to charges,14237,,"100% primary, 50% supplemental procedure",14237,Other,Aetna ASC Grouper,12813,,"100% primary, 50% supplemental procedure",12813,Other,Aetna ASC Grouper,12219,,"100% primary, 50% secondary, 25% supplemental procedure",12219,Other,Blue Cross ASC Grouper,10997,,"100% primary, 50% secondary, 25% supplemental procedure",10997,Other,Blue Cross ASC Grouper,10386,,"100% primary, 50% secondary, 25% supplemental procedure",10386,Other,Blue Cross ASC Grouper,36104.85,49.5,,36104.85,percent of total billed charges,110% of Medicare,49598.58,68,,49598.58,percent of total billed charges,,3170.73,,,3170.73,Other,186% of Medicaid,58351.27,80,,58351.27,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,58351.27,80,,58351.27,percent of total billed charges,,7216,,,7216,Case Rate,,15214,,,15214,Case Rate,Cardiac Cath Case Rate,51057.36,70,,51057.36,percent of total billed charges,,15035,,,15035,Case Rate,Cardiac Cath Case Rate,12780,,,12780,Case Rate,Cardiac Cath Case Rate,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1704.69,,,1704.69,Other,New York Medicaid APG methodology,1704.69,,,1704.69,Other,100% New York Medicaid APG,1704.69,,,1704.69,Other,100% New York Medicaid APG,1704.69,,,1704.69,Other,100% New York Medicaid APG,3835.56,,,3835.56,Other,225% New York Medicaid APG,2608.18,,,2608.18,Other,153% New York Medicaid APG,3835.56,,,3835.56,Other,225% New York Medicaid APG,2386.57,,,2386.57,Other,140% New York Medicaid APG,3835.56,,,3835.56,Other,225% New York Medicaid APG,4432.2,,,4432.2,Other,260% New York Medicaid APG,5523.21,,,5523.21,Other,324% New York Medicaid APG,3665.09,,,3665.09,Other,215% New York Medicaid APG,3665.09,,,3665.09,Other,215% New York Medicaid APG,2130.87,,,2130.87,Other,125% New York Medicaid APG,1704.69,58351.27,
Right heart cath,93451,CPT,,,,,,,,both,,,61830.11,45754.28,74,,45754.28,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,27823.55,45,,27823.55,percent of total billed charges,Medicare Ratio of cost to charges,14237,,"100% primary, 50% supplemental procedure",14237,Other,Aetna ASC Grouper,12813,,"100% primary, 50% supplemental procedure",12813,Other,Aetna ASC Grouper,12219,,"100% primary, 50% secondary, 25% supplemental procedure",12219,Other,Blue Cross ASC Grouper,10997,,"100% primary, 50% secondary, 25% supplemental procedure",10997,Other,Blue Cross ASC Grouper,10386,,"100% primary, 50% secondary, 25% supplemental procedure",10386,Other,Blue Cross ASC Grouper,30605.9,49.5,,30605.9,percent of total billed charges,110% of Medicare,42044.47,68,,42044.47,percent of total billed charges,,3170.73,,,3170.73,Other,186% of Medicaid,49464.09,80,,49464.09,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,49464.09,80,,49464.09,percent of total billed charges,,7216,,,7216,Case Rate,,15214,,,15214,Case Rate,Cardiac Cath Case Rate,43281.08,70,,43281.08,percent of total billed charges,,15035,,,15035,Case Rate,Cardiac Cath Case Rate,12780,,,12780,Case Rate,Cardiac Cath Case Rate,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,1704.69,,,1704.69,Other,New York Medicaid APG methodology,1704.69,,,1704.69,Other,100% New York Medicaid APG,1704.69,,,1704.69,Other,100% New York Medicaid APG,1704.69,,,1704.69,Other,100% New York Medicaid APG,3835.56,,,3835.56,Other,225% New York Medicaid APG,2608.18,,,2608.18,Other,153% New York Medicaid APG,3835.56,,,3835.56,Other,225% New York Medicaid APG,2386.57,,,2386.57,Other,140% New York Medicaid APG,3835.56,,,3835.56,Other,225% New York Medicaid APG,4432.2,,,4432.2,Other,260% New York Medicaid APG,5523.21,,,5523.21,Other,324% New York Medicaid APG,3665.09,,,3665.09,Other,215% New York Medicaid APG,3665.09,,,3665.09,Other,215% New York Medicaid APG,2130.87,,,2130.87,Other,125% New York Medicaid APG,1704.69,49464.09,
Left hrt cath w/ventrclgrphy,93452,CPT,,,,,,,,both,,,68539.72,50719.39,74,,50719.39,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30842.87,45,,30842.87,percent of total billed charges,Medicare Ratio of cost to charges,14237,,"100% primary, 50% supplemental procedure",14237,Other,Aetna ASC Grouper,12813,,"100% primary, 50% supplemental procedure",12813,Other,Aetna ASC Grouper,12219,,"100% primary, 50% secondary, 25% supplemental procedure",12219,Other,Blue Cross ASC Grouper,10997,,"100% primary, 50% secondary, 25% supplemental procedure",10997,Other,Blue Cross ASC Grouper,10386,,"100% primary, 50% secondary, 25% supplemental procedure",10386,Other,Blue Cross ASC Grouper,33927.16,49.5,,33927.16,percent of total billed charges,110% of Medicare,46607.01,68,,46607.01,percent of total billed charges,,3170.73,,,3170.73,Other,186% of Medicaid,54831.78,80,,54831.78,percent of total billed charges,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,54831.78,80,,54831.78,percent of total billed charges,,9473,,,9473,Case Rate,,15214,,,15214,Case Rate,Cardiac Cath Case Rate,47977.8,70,,47977.8,percent of total billed charges,,15035,,,15035,Case Rate,Cardiac Cath Case Rate,12780,,,12780,Case Rate,Cardiac Cath Case Rate,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,1704.69,,,1704.69,Other,New York Medicaid APG methodology,1704.69,,,1704.69,Other,100% New York Medicaid APG,1704.69,,,1704.69,Other,100% New York Medicaid APG,1704.69,,,1704.69,Other,100% New York Medicaid APG,3835.56,,,3835.56,Other,225% New York Medicaid APG,2608.18,,,2608.18,Other,153% New York Medicaid APG,3835.56,,,3835.56,Other,225% New York Medicaid APG,2386.57,,,2386.57,Other,140% New York Medicaid APG,3835.56,,,3835.56,Other,225% New York Medicaid APG,4432.2,,,4432.2,Other,260% New York Medicaid APG,5523.21,,,5523.21,Other,324% New York Medicaid APG,3665.09,,,3665.09,Other,215% New York Medicaid APG,3665.09,,,3665.09,Other,215% New York Medicaid APG,2130.87,,,2130.87,Other,125% New York Medicaid APG,1704.69,54831.78,
R&l hrt cath w/ventriclgrphy,93453,CPT,,,,,,,,both,,,75685.6,56007.34,74,,56007.34,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,34058.52,45,,34058.52,percent of total billed charges,Medicare Ratio of cost to charges,14237,,"100% primary, 50% supplemental procedure",14237,Other,Aetna ASC Grouper,12813,,"100% primary, 50% supplemental procedure",12813,Other,Aetna ASC Grouper,12219,,"100% primary, 50% secondary, 25% supplemental procedure",12219,Other,Blue Cross ASC Grouper,10997,,"100% primary, 50% secondary, 25% supplemental procedure",10997,Other,Blue Cross ASC Grouper,10386,,"100% primary, 50% secondary, 25% supplemental procedure",10386,Other,Blue Cross ASC Grouper,37464.37,49.5,,37464.37,percent of total billed charges,110% of Medicare,51466.21,68,,51466.21,percent of total billed charges,,3170.73,,,3170.73,Other,186% of Medicaid,60548.48,80,,60548.48,percent of total billed charges,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,60548.48,80,,60548.48,percent of total billed charges,,9473,,,9473,Case Rate,,15214,,,15214,Case Rate,Cardiac Cath Case Rate,52979.92,70,,52979.92,percent of total billed charges,,15035,,,15035,Case Rate,Cardiac Cath Case Rate,12780,,,12780,Case Rate,Cardiac Cath Case Rate,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,1704.69,,,1704.69,Other,New York Medicaid APG methodology,1704.69,,,1704.69,Other,100% New York Medicaid APG,1704.69,,,1704.69,Other,100% New York Medicaid APG,1704.69,,,1704.69,Other,100% New York Medicaid APG,3835.56,,,3835.56,Other,225% New York Medicaid APG,2608.18,,,2608.18,Other,153% New York Medicaid APG,3835.56,,,3835.56,Other,225% New York Medicaid APG,2386.57,,,2386.57,Other,140% New York Medicaid APG,3835.56,,,3835.56,Other,225% New York Medicaid APG,4432.2,,,4432.2,Other,260% New York Medicaid APG,5523.21,,,5523.21,Other,324% New York Medicaid APG,3665.09,,,3665.09,Other,215% New York Medicaid APG,3665.09,,,3665.09,Other,215% New York Medicaid APG,2130.87,,,2130.87,Other,125% New York Medicaid APG,1704.69,60548.48,
Coronary artery angio s&i,93454,CPT,,,,,,,,both,,,65729.71,48639.99,74,,48639.99,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,29578.37,45,,29578.37,percent of total billed charges,Medicare Ratio of cost to charges,14237,,"100% primary, 50% supplemental procedure",14237,Other,Aetna ASC Grouper,12813,,"100% primary, 50% supplemental procedure",12813,Other,Aetna ASC Grouper,12219,,"100% primary, 50% secondary, 25% supplemental procedure",12219,Other,Blue Cross ASC Grouper,10997,,"100% primary, 50% secondary, 25% supplemental procedure",10997,Other,Blue Cross ASC Grouper,10386,,"100% primary, 50% secondary, 25% supplemental procedure",10386,Other,Blue Cross ASC Grouper,32536.21,49.5,,32536.21,percent of total billed charges,110% of Medicare,44696.2,68,,44696.2,percent of total billed charges,,3170.73,,,3170.73,Other,186% of Medicaid,52583.77,80,,52583.77,percent of total billed charges,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,52583.77,80,,52583.77,percent of total billed charges,,9473,,,9473,Case Rate,,15214,,,15214,Case Rate,Cardiac Cath Case Rate,46010.8,70,,46010.8,percent of total billed charges,,15035,,,15035,Case Rate,Cardiac Cath Case Rate,12780,,,12780,Case Rate,Cardiac Cath Case Rate,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,1704.69,,,1704.69,Other,New York Medicaid APG methodology,1704.69,,,1704.69,Other,100% New York Medicaid APG,1704.69,,,1704.69,Other,100% New York Medicaid APG,1704.69,,,1704.69,Other,100% New York Medicaid APG,3835.56,,,3835.56,Other,225% New York Medicaid APG,2608.18,,,2608.18,Other,153% New York Medicaid APG,3835.56,,,3835.56,Other,225% New York Medicaid APG,2386.57,,,2386.57,Other,140% New York Medicaid APG,3835.56,,,3835.56,Other,225% New York Medicaid APG,4432.2,,,4432.2,Other,260% New York Medicaid APG,5523.21,,,5523.21,Other,324% New York Medicaid APG,3665.09,,,3665.09,Other,215% New York Medicaid APG,3665.09,,,3665.09,Other,215% New York Medicaid APG,2130.87,,,2130.87,Other,125% New York Medicaid APG,1704.69,52583.77,
Coronary art/grft angio s&i,93455,CPT,,,,,,,,both,,,74923,55443.02,74,,55443.02,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,33715.35,45,,33715.35,percent of total billed charges,Medicare Ratio of cost to charges,14237,,"100% primary, 50% supplemental procedure",14237,Other,Aetna ASC Grouper,12813,,"100% primary, 50% supplemental procedure",12813,Other,Aetna ASC Grouper,12219,,"100% primary, 50% secondary, 25% supplemental procedure",12219,Other,Blue Cross ASC Grouper,10997,,"100% primary, 50% secondary, 25% supplemental procedure",10997,Other,Blue Cross ASC Grouper,10386,,"100% primary, 50% secondary, 25% supplemental procedure",10386,Other,Blue Cross ASC Grouper,37086.89,49.5,,37086.89,percent of total billed charges,110% of Medicare,50947.64,68,,50947.64,percent of total billed charges,,3170.73,,,3170.73,Other,186% of Medicaid,59938.4,80,,59938.4,percent of total billed charges,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,59938.4,80,,59938.4,percent of total billed charges,,9473,,,9473,Case Rate,,15214,,,15214,Case Rate,Cardiac Cath Case Rate,52446.1,70,,52446.1,percent of total billed charges,,15035,,,15035,Case Rate,Cardiac Cath Case Rate,12780,,,12780,Case Rate,Cardiac Cath Case Rate,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,1704.69,,,1704.69,Other,New York Medicaid APG methodology,1704.69,,,1704.69,Other,100% New York Medicaid APG,1704.69,,,1704.69,Other,100% New York Medicaid APG,1704.69,,,1704.69,Other,100% New York Medicaid APG,3835.56,,,3835.56,Other,225% New York Medicaid APG,2608.18,,,2608.18,Other,153% New York Medicaid APG,3835.56,,,3835.56,Other,225% New York Medicaid APG,2386.57,,,2386.57,Other,140% New York Medicaid APG,3835.56,,,3835.56,Other,225% New York Medicaid APG,4432.2,,,4432.2,Other,260% New York Medicaid APG,5523.21,,,5523.21,Other,324% New York Medicaid APG,3665.09,,,3665.09,Other,215% New York Medicaid APG,3665.09,,,3665.09,Other,215% New York Medicaid APG,2130.87,,,2130.87,Other,125% New York Medicaid APG,1704.69,59938.4,
R hrt coronary artery angio,93456,CPT,,,,,,,,both,,,80496.47,59567.39,74,,59567.39,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,36223.41,45,,36223.41,percent of total billed charges,Medicare Ratio of cost to charges,14237,,"100% primary, 50% supplemental procedure",14237,Other,Aetna ASC Grouper,12813,,"100% primary, 50% supplemental procedure",12813,Other,Aetna ASC Grouper,12219,,"100% primary, 50% secondary, 25% supplemental procedure",12219,Other,Blue Cross ASC Grouper,10997,,"100% primary, 50% secondary, 25% supplemental procedure",10997,Other,Blue Cross ASC Grouper,10386,,"100% primary, 50% secondary, 25% supplemental procedure",10386,Other,Blue Cross ASC Grouper,39845.75,49.5,,39845.75,percent of total billed charges,110% of Medicare,54737.6,68,,54737.6,percent of total billed charges,,3170.73,,,3170.73,Other,186% of Medicaid,64397.18,80,,64397.18,percent of total billed charges,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,64397.18,80,,64397.18,percent of total billed charges,,9473,,,9473,Case Rate,,15214,,,15214,Case Rate,Cardiac Cath Case Rate,56347.53,70,,56347.53,percent of total billed charges,,15035,,,15035,Case Rate,Cardiac Cath Case Rate,12780,,,12780,Case Rate,Cardiac Cath Case Rate,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,1704.69,,,1704.69,Other,New York Medicaid APG methodology,1704.69,,,1704.69,Other,100% New York Medicaid APG,1704.69,,,1704.69,Other,100% New York Medicaid APG,1704.69,,,1704.69,Other,100% New York Medicaid APG,3835.56,,,3835.56,Other,225% New York Medicaid APG,2608.18,,,2608.18,Other,153% New York Medicaid APG,3835.56,,,3835.56,Other,225% New York Medicaid APG,2386.57,,,2386.57,Other,140% New York Medicaid APG,3835.56,,,3835.56,Other,225% New York Medicaid APG,4432.2,,,4432.2,Other,260% New York Medicaid APG,5523.21,,,5523.21,Other,324% New York Medicaid APG,3665.09,,,3665.09,Other,215% New York Medicaid APG,3665.09,,,3665.09,Other,215% New York Medicaid APG,2130.87,,,2130.87,Other,125% New York Medicaid APG,1704.69,64397.18,
R hrt art/grft angio,93457,CPT,,,,,,,,both,,,77610,57431.4,74,,57431.4,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,34924.5,45,,34924.5,percent of total billed charges,Medicare Ratio of cost to charges,14237,,"100% primary, 50% supplemental procedure",14237,Other,Aetna ASC Grouper,12813,,"100% primary, 50% supplemental procedure",12813,Other,Aetna ASC Grouper,12219,,"100% primary, 50% secondary, 25% supplemental procedure",12219,Other,Blue Cross ASC Grouper,10997,,"100% primary, 50% secondary, 25% supplemental procedure",10997,Other,Blue Cross ASC Grouper,10386,,"100% primary, 50% secondary, 25% supplemental procedure",10386,Other,Blue Cross ASC Grouper,38416.95,49.5,,38416.95,percent of total billed charges,110% of Medicare,52774.8,68,,52774.8,percent of total billed charges,,3170.73,,,3170.73,Other,186% of Medicaid,62088,80,,62088,percent of total billed charges,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,62088,80,,62088,percent of total billed charges,,9473,,,9473,Case Rate,,15214,,,15214,Case Rate,Cardiac Cath Case Rate,54327,70,,54327,percent of total billed charges,,15035,,,15035,Case Rate,Cardiac Cath Case Rate,12780,,,12780,Case Rate,Cardiac Cath Case Rate,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,1704.69,,,1704.69,Other,New York Medicaid APG methodology,1704.69,,,1704.69,Other,100% New York Medicaid APG,1704.69,,,1704.69,Other,100% New York Medicaid APG,1704.69,,,1704.69,Other,100% New York Medicaid APG,3835.56,,,3835.56,Other,225% New York Medicaid APG,2608.18,,,2608.18,Other,153% New York Medicaid APG,3835.56,,,3835.56,Other,225% New York Medicaid APG,2386.57,,,2386.57,Other,140% New York Medicaid APG,3835.56,,,3835.56,Other,225% New York Medicaid APG,4432.2,,,4432.2,Other,260% New York Medicaid APG,5523.21,,,5523.21,Other,324% New York Medicaid APG,3665.09,,,3665.09,Other,215% New York Medicaid APG,3665.09,,,3665.09,Other,215% New York Medicaid APG,2130.87,,,2130.87,Other,125% New York Medicaid APG,1704.69,62088,
L hrt artery/ventricle angio,93458,CPT,,,,,,,,both,,,72973.25,54000.21,74,,54000.21,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,32837.96,45,,32837.96,percent of total billed charges,Medicare Ratio of cost to charges,14237,,"100% primary, 50% supplemental procedure",14237,Other,Aetna ASC Grouper,12813,,"100% primary, 50% supplemental procedure",12813,Other,Aetna ASC Grouper,12219,,"100% primary, 50% secondary, 25% supplemental procedure",12219,Other,Blue Cross ASC Grouper,10997,,"100% primary, 50% secondary, 25% supplemental procedure",10997,Other,Blue Cross ASC Grouper,10386,,"100% primary, 50% secondary, 25% supplemental procedure",10386,Other,Blue Cross ASC Grouper,36121.76,49.5,,36121.76,percent of total billed charges,110% of Medicare,49621.81,68,,49621.81,percent of total billed charges,,3170.73,,,3170.73,Other,186% of Medicaid,58378.6,80,,58378.6,percent of total billed charges,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,58378.6,80,,58378.6,percent of total billed charges,,9473,,,9473,Case Rate,,15214,,,15214,Case Rate,Cardiac Cath Case Rate,51081.28,70,,51081.28,percent of total billed charges,,15035,,,15035,Case Rate,Cardiac Cath Case Rate,12780,,,12780,Case Rate,Cardiac Cath Case Rate,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,1704.69,,,1704.69,Other,New York Medicaid APG methodology,1704.69,,,1704.69,Other,100% New York Medicaid APG,1704.69,,,1704.69,Other,100% New York Medicaid APG,1704.69,,,1704.69,Other,100% New York Medicaid APG,3835.56,,,3835.56,Other,225% New York Medicaid APG,2608.18,,,2608.18,Other,153% New York Medicaid APG,3835.56,,,3835.56,Other,225% New York Medicaid APG,2386.57,,,2386.57,Other,140% New York Medicaid APG,3835.56,,,3835.56,Other,225% New York Medicaid APG,4432.2,,,4432.2,Other,260% New York Medicaid APG,5523.21,,,5523.21,Other,324% New York Medicaid APG,3665.09,,,3665.09,Other,215% New York Medicaid APG,3665.09,,,3665.09,Other,215% New York Medicaid APG,2130.87,,,2130.87,Other,125% New York Medicaid APG,1704.69,58378.6,
L hrt art/grft angio,93459,CPT,,,,,,,,both,,,79193.42,58603.13,74,,58603.13,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,35637.04,45,,35637.04,percent of total billed charges,Medicare Ratio of cost to charges,14237,,"100% primary, 50% supplemental procedure",14237,Other,Aetna ASC Grouper,12813,,"100% primary, 50% supplemental procedure",12813,Other,Aetna ASC Grouper,12219,,"100% primary, 50% secondary, 25% supplemental procedure",12219,Other,Blue Cross ASC Grouper,10997,,"100% primary, 50% secondary, 25% supplemental procedure",10997,Other,Blue Cross ASC Grouper,10386,,"100% primary, 50% secondary, 25% supplemental procedure",10386,Other,Blue Cross ASC Grouper,39200.74,49.5,,39200.74,percent of total billed charges,110% of Medicare,53851.53,68,,53851.53,percent of total billed charges,,3170.73,,,3170.73,Other,186% of Medicaid,63354.74,80,,63354.74,percent of total billed charges,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,63354.74,80,,63354.74,percent of total billed charges,,9473,,,9473,Case Rate,,15214,,,15214,Case Rate,Cardiac Cath Case Rate,55435.39,70,,55435.39,percent of total billed charges,,15035,,,15035,Case Rate,Cardiac Cath Case Rate,12780,,,12780,Case Rate,Cardiac Cath Case Rate,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,1704.69,,,1704.69,Other,New York Medicaid APG methodology,1704.69,,,1704.69,Other,100% New York Medicaid APG,1704.69,,,1704.69,Other,100% New York Medicaid APG,1704.69,,,1704.69,Other,100% New York Medicaid APG,3835.56,,,3835.56,Other,225% New York Medicaid APG,2608.18,,,2608.18,Other,153% New York Medicaid APG,3835.56,,,3835.56,Other,225% New York Medicaid APG,2386.57,,,2386.57,Other,140% New York Medicaid APG,3835.56,,,3835.56,Other,225% New York Medicaid APG,4432.2,,,4432.2,Other,260% New York Medicaid APG,5523.21,,,5523.21,Other,324% New York Medicaid APG,3665.09,,,3665.09,Other,215% New York Medicaid APG,3665.09,,,3665.09,Other,215% New York Medicaid APG,2130.87,,,2130.87,Other,125% New York Medicaid APG,1704.69,63354.74,
R&l hrt art/ventricle angio,93460,CPT,,,,,,,,both,,,78047.52,57755.16,74,,57755.16,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,35121.38,45,,35121.38,percent of total billed charges,Medicare Ratio of cost to charges,14237,,"100% primary, 50% supplemental procedure",14237,Other,Aetna ASC Grouper,12813,,"100% primary, 50% supplemental procedure",12813,Other,Aetna ASC Grouper,12219,,"100% primary, 50% secondary, 25% supplemental procedure",12219,Other,Blue Cross ASC Grouper,10997,,"100% primary, 50% secondary, 25% supplemental procedure",10997,Other,Blue Cross ASC Grouper,10386,,"100% primary, 50% secondary, 25% supplemental procedure",10386,Other,Blue Cross ASC Grouper,38633.52,49.5,,38633.52,percent of total billed charges,110% of Medicare,53072.31,68,,53072.31,percent of total billed charges,,3170.73,,,3170.73,Other,186% of Medicaid,62438.02,80,,62438.02,percent of total billed charges,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,62438.02,80,,62438.02,percent of total billed charges,,9473,,,9473,Case Rate,,15214,,,15214,Case Rate,Cardiac Cath Case Rate,54633.26,70,,54633.26,percent of total billed charges,,15035,,,15035,Case Rate,Cardiac Cath Case Rate,12780,,,12780,Case Rate,Cardiac Cath Case Rate,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,1704.69,,,1704.69,Other,New York Medicaid APG methodology,1704.69,,,1704.69,Other,100% New York Medicaid APG,1704.69,,,1704.69,Other,100% New York Medicaid APG,1704.69,,,1704.69,Other,100% New York Medicaid APG,3835.56,,,3835.56,Other,225% New York Medicaid APG,2608.18,,,2608.18,Other,153% New York Medicaid APG,3835.56,,,3835.56,Other,225% New York Medicaid APG,2386.57,,,2386.57,Other,140% New York Medicaid APG,3835.56,,,3835.56,Other,225% New York Medicaid APG,4432.2,,,4432.2,Other,260% New York Medicaid APG,5523.21,,,5523.21,Other,324% New York Medicaid APG,3665.09,,,3665.09,Other,215% New York Medicaid APG,3665.09,,,3665.09,Other,215% New York Medicaid APG,2130.87,,,2130.87,Other,125% New York Medicaid APG,1704.69,62438.02,
R&l hrt art/ventricle angio,93461,CPT,,,,,,,,both,,,92590.93,68517.29,74,,68517.29,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,41665.92,45,,41665.92,percent of total billed charges,Medicare Ratio of cost to charges,14237,,"100% primary, 50% supplemental procedure",14237,Other,Aetna ASC Grouper,12813,,"100% primary, 50% supplemental procedure",12813,Other,Aetna ASC Grouper,12219,,"100% primary, 50% secondary, 25% supplemental procedure",12219,Other,Blue Cross ASC Grouper,10997,,"100% primary, 50% secondary, 25% supplemental procedure",10997,Other,Blue Cross ASC Grouper,10386,,"100% primary, 50% secondary, 25% supplemental procedure",10386,Other,Blue Cross ASC Grouper,45832.51,49.5,,45832.51,percent of total billed charges,110% of Medicare,62961.83,68,,62961.83,percent of total billed charges,,3170.73,,,3170.73,Other,186% of Medicaid,74072.74,80,,74072.74,percent of total billed charges,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,74072.74,80,,74072.74,percent of total billed charges,,9473,,,9473,Case Rate,,15214,,,15214,Case Rate,Cardiac Cath Case Rate,64813.65,70,,64813.65,percent of total billed charges,,15035,,,15035,Case Rate,Cardiac Cath Case Rate,12780,,,12780,Case Rate,Cardiac Cath Case Rate,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,1704.69,,,1704.69,Other,New York Medicaid APG methodology,1704.69,,,1704.69,Other,100% New York Medicaid APG,1704.69,,,1704.69,Other,100% New York Medicaid APG,1704.69,,,1704.69,Other,100% New York Medicaid APG,3835.56,,,3835.56,Other,225% New York Medicaid APG,2608.18,,,2608.18,Other,153% New York Medicaid APG,3835.56,,,3835.56,Other,225% New York Medicaid APG,2386.57,,,2386.57,Other,140% New York Medicaid APG,3835.56,,,3835.56,Other,225% New York Medicaid APG,4432.2,,,4432.2,Other,260% New York Medicaid APG,5523.21,,,5523.21,Other,324% New York Medicaid APG,3665.09,,,3665.09,Other,215% New York Medicaid APG,3665.09,,,3665.09,Other,215% New York Medicaid APG,2130.87,,,2130.87,Other,125% New York Medicaid APG,1704.69,74072.74,
"Microwave bronch, 3d, ebus",C9751,HCPCS,,,,,,,,both,,,82795.68,61268.8,74,,61268.8,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,37258.06,45,,37258.06,percent of total billed charges,Medicare Ratio of cost to charges,5954,,"100% primary, 50% supplemental procedure",5954,Other,Aetna ASC Grouper,5359,,"100% primary, 50% supplemental procedure",5359,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,40983.86,49.5,,40983.86,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2328.45,,,2328.45,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9196,,"100% primary, 0% secondary procedures",9196,Other,MagnaCare ASC Grouper,57956.98,70,,57956.98,percent of total billed charges,,53817.19,65,,53817.19,percent of total billed charges,,53817.19,65,,53817.19,percent of total billed charges,,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,1251.86,,,1251.86,Other,New York Medicaid APG methodology,1251.86,,,1251.86,Other,100% New York Medicaid APG,1251.86,,,1251.86,Other,100% New York Medicaid APG,1251.86,,,1251.86,Other,100% New York Medicaid APG,2816.67,,,2816.67,Other,225% New York Medicaid APG,1915.34,,,1915.34,Other,153% New York Medicaid APG,2816.67,,,2816.67,Other,225% New York Medicaid APG,1752.6,,,1752.6,Other,140% New York Medicaid APG,2816.67,,,2816.67,Other,225% New York Medicaid APG,3254.82,,,3254.82,Other,260% New York Medicaid APG,4056.01,,,4056.01,Other,324% New York Medicaid APG,2691.49,,,2691.49,Other,215% New York Medicaid APG,2691.49,,,2691.49,Other,215% New York Medicaid APG,1564.82,,,1564.82,Other,125% New York Medicaid APG,1251.86,61268.8,
Blind interatrial shunt ide,C9758,HCPCS,,,,,,,,both,,,386339.36,285891.13,74,,285891.13,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,173852.71,45,,173852.71,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,191237.98,49.5,,191237.98,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,4727.53,,,4727.53,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,309071.49,80,,309071.49,percent of total billed charges,,270437.55,70,,270437.55,percent of total billed charges,,251120.58,65,,251120.58,percent of total billed charges,,251120.58,65,,251120.58,percent of total billed charges,,8589,,"100% primary, 50% secondary, 25% tertiary procedure",8589,Other,United Healthcare ASC Grouper,7730,,"100% primary, 50% secondary, 25% tertiary procedure",7730,Other,United Healthcare ASC Grouper,8589,,"100% primary, 50% secondary, 25% tertiary procedure",8589,Other,United Healthcare ASC Grouper,7301,,"100% primary, 50% secondary, 25% tertiary procedure",7301,Other,United Healthcare ASC Grouper,2541.68,,,2541.68,Other,New York Medicaid APG methodology,2541.68,,,2541.68,Other,100% New York Medicaid APG,2541.68,,,2541.68,Other,100% New York Medicaid APG,2541.68,,,2541.68,Other,100% New York Medicaid APG,5718.79,,,5718.79,Other,225% New York Medicaid APG,3888.77,,,3888.77,Other,153% New York Medicaid APG,5718.79,,,5718.79,Other,225% New York Medicaid APG,3558.36,,,3558.36,Other,140% New York Medicaid APG,5718.79,,,5718.79,Other,225% New York Medicaid APG,6608.37,,,6608.37,Other,260% New York Medicaid APG,8235.05,,,8235.05,Other,324% New York Medicaid APG,5464.62,,,5464.62,Other,215% New York Medicaid APG,5464.62,,,5464.62,Other,215% New York Medicaid APG,3177.1,,,3177.1,Other,125% New York Medicaid APG,2541.68,309071.49,
Prosth retina receive&gen,0100T,HCPCS,,,,,,,,both,,,98219.64,72682.53,74,,72682.53,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,44198.84,45,,44198.84,percent of total billed charges,Medicare Ratio of cost to charges,5954,,"100% primary, 50% supplemental procedure",5954,Other,Aetna ASC Grouper,5359,,"100% primary, 50% supplemental procedure",5359,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,48618.72,49.5,,48618.72,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,4783.4,,,4783.4,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9196,,"100% primary, 0% secondary procedures",9196,Other,MagnaCare ASC Grouper,68753.75,70,,68753.75,percent of total billed charges,,63842.77,65,,63842.77,percent of total billed charges,,63842.77,65,,63842.77,percent of total billed charges,,15267,,"100% primary, 50% secondary, 25% tertiary procedure",15267,Other,United Healthcare ASC Grouper,13740,,"100% primary, 50% secondary, 25% tertiary procedure",13740,Other,United Healthcare ASC Grouper,15267,,"100% primary, 50% secondary, 25% tertiary procedure",15267,Other,United Healthcare ASC Grouper,12977,,"100% primary, 50% secondary, 25% tertiary procedure",12977,Other,United Healthcare ASC Grouper,2571.72,,,2571.72,Other,New York Medicaid APG methodology,2571.72,,,2571.72,Other,100% New York Medicaid APG,2571.72,,,2571.72,Other,100% New York Medicaid APG,2571.72,,,2571.72,Other,100% New York Medicaid APG,5786.37,,,5786.37,Other,225% New York Medicaid APG,3934.73,,,3934.73,Other,153% New York Medicaid APG,5786.37,,,5786.37,Other,225% New York Medicaid APG,3600.41,,,3600.41,Other,140% New York Medicaid APG,5786.37,,,5786.37,Other,225% New York Medicaid APG,6686.47,,,6686.47,Other,260% New York Medicaid APG,8332.37,,,8332.37,Other,324% New York Medicaid APG,5529.2,,,5529.2,Other,215% New York Medicaid APG,5529.2,,,5529.2,Other,215% New York Medicaid APG,3214.65,,,3214.65,Other,125% New York Medicaid APG,2571.72,72682.53,
Rmvl impltbl glucose sensor,0447T,HCPCS,,,,,,,,both,,,4210.98,3116.13,74,,3116.13,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,1894.94,45,,1894.94,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,2084.44,49.5,,2084.44,percent of total billed charges,110% of Medicare,2863.47,68,,2863.47,percent of total billed charges,,733.11,,,733.11,Other,186% of Medicaid,3368.78,80,,3368.78,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,3368.78,80,,3368.78,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,2947.69,70,,2947.69,percent of total billed charges,,319.8,,,319.8,Fee Schedule,,271.05,,,271.05,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,394.14,,,394.14,Other,New York Medicaid APG methodology,394.14,,,394.14,Other,100% New York Medicaid APG,394.14,,,394.14,Other,100% New York Medicaid APG,394.14,,,394.14,Other,100% New York Medicaid APG,886.83,,,886.83,Other,225% New York Medicaid APG,603.04,,,603.04,Other,153% New York Medicaid APG,886.83,,,886.83,Other,225% New York Medicaid APG,551.8,,,551.8,Other,140% New York Medicaid APG,886.83,,,886.83,Other,225% New York Medicaid APG,1024.78,,,1024.78,Other,260% New York Medicaid APG,1277.03,,,1277.03,Other,324% New York Medicaid APG,847.41,,,847.41,Other,215% New York Medicaid APG,847.41,,,847.41,Other,215% New York Medicaid APG,492.68,,,492.68,Other,125% New York Medicaid APG,271.05,7216,
Esw integ wnd hlg 1st wnd,0512T,HCPCS,,,,,,,,both,,,4210.98,3116.13,74,,3116.13,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,1894.94,45,,1894.94,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,2084.44,49.5,,2084.44,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,1352.53,,,1352.53,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,2947.69,70,,2947.69,percent of total billed charges,,2737.14,65,,2737.14,percent of total billed charges,,2737.14,65,,2737.14,percent of total billed charges,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,727.17,,,727.17,Other,New York Medicaid APG methodology,727.17,,,727.17,Other,100% New York Medicaid APG,727.17,,,727.17,Other,100% New York Medicaid APG,727.17,,,727.17,Other,100% New York Medicaid APG,1636.12,,,1636.12,Other,225% New York Medicaid APG,1112.56,,,1112.56,Other,153% New York Medicaid APG,1636.12,,,1636.12,Other,225% New York Medicaid APG,1018.03,,,1018.03,Other,140% New York Medicaid APG,1636.12,,,1636.12,Other,225% New York Medicaid APG,1890.63,,,1890.63,Other,260% New York Medicaid APG,2356.02,,,2356.02,Other,324% New York Medicaid APG,1563.41,,,1563.41,Other,215% New York Medicaid APG,1563.41,,,1563.41,Other,215% New York Medicaid APG,908.96,,,908.96,Other,125% New York Medicaid APG,727.17,9473,
Dstrj neurofibroma xtnsv,0419T,HCPCS,,,,,,,,both,,,13210.22,9775.56,74,,9775.56,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,5944.6,45,,5944.6,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,6539.06,49.5,,6539.06,percent of total billed charges,110% of Medicare,8982.95,68,,8982.95,percent of total billed charges,,733.11,,,733.11,Other,186% of Medicaid,10568.18,80,,10568.18,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,10568.18,80,,10568.18,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,9247.15,70,,9247.15,percent of total billed charges,,8586.64,65,,8586.64,percent of total billed charges,,8586.64,65,,8586.64,percent of total billed charges,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,394.14,,,394.14,Other,New York Medicaid APG methodology,394.14,,,394.14,Other,100% New York Medicaid APG,394.14,,,394.14,Other,100% New York Medicaid APG,394.14,,,394.14,Other,100% New York Medicaid APG,886.83,,,886.83,Other,225% New York Medicaid APG,603.04,,,603.04,Other,153% New York Medicaid APG,886.83,,,886.83,Other,225% New York Medicaid APG,551.8,,,551.8,Other,140% New York Medicaid APG,886.83,,,886.83,Other,225% New York Medicaid APG,1024.78,,,1024.78,Other,260% New York Medicaid APG,1277.03,,,1277.03,Other,324% New York Medicaid APG,847.41,,,847.41,Other,215% New York Medicaid APG,847.41,,,847.41,Other,215% New York Medicaid APG,492.68,,,492.68,Other,125% New York Medicaid APG,394.14,10568.18,
Dstrj neurofibroma xtnsv,0420T,HCPCS,,,,,,,,both,,,13210.22,9775.56,74,,9775.56,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,5944.6,45,,5944.6,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,6539.06,49.5,,6539.06,percent of total billed charges,110% of Medicare,8982.95,68,,8982.95,percent of total billed charges,,733.11,,,733.11,Other,186% of Medicaid,10568.18,80,,10568.18,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,10568.18,80,,10568.18,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,9247.15,70,,9247.15,percent of total billed charges,,8586.64,65,,8586.64,percent of total billed charges,,8586.64,65,,8586.64,percent of total billed charges,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,394.14,,,394.14,Other,New York Medicaid APG methodology,394.14,,,394.14,Other,100% New York Medicaid APG,394.14,,,394.14,Other,100% New York Medicaid APG,394.14,,,394.14,Other,100% New York Medicaid APG,886.83,,,886.83,Other,225% New York Medicaid APG,603.04,,,603.04,Other,153% New York Medicaid APG,886.83,,,886.83,Other,225% New York Medicaid APG,551.8,,,551.8,Other,140% New York Medicaid APG,886.83,,,886.83,Other,225% New York Medicaid APG,1024.78,,,1024.78,Other,260% New York Medicaid APG,1277.03,,,1277.03,Other,324% New York Medicaid APG,847.41,,,847.41,Other,215% New York Medicaid APG,847.41,,,847.41,Other,215% New York Medicaid APG,492.68,,,492.68,Other,125% New York Medicaid APG,394.14,10568.18,
Fxjl abl lsr 1st 100 sq cm,0479T,HCPCS,,,,,,,,both,,,38421.99,28432.27,74,,28432.27,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,17289.9,45,,17289.9,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,19018.89,49.5,,19018.89,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,1352.53,,,1352.53,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,26895.39,70,,26895.39,percent of total billed charges,,24974.29,65,,24974.29,percent of total billed charges,,24974.29,65,,24974.29,percent of total billed charges,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,727.17,,,727.17,Other,New York Medicaid APG methodology,727.17,,,727.17,Other,100% New York Medicaid APG,727.17,,,727.17,Other,100% New York Medicaid APG,727.17,,,727.17,Other,100% New York Medicaid APG,1636.12,,,1636.12,Other,225% New York Medicaid APG,1112.56,,,1112.56,Other,153% New York Medicaid APG,1636.12,,,1636.12,Other,225% New York Medicaid APG,1018.03,,,1018.03,Other,140% New York Medicaid APG,1636.12,,,1636.12,Other,225% New York Medicaid APG,1890.63,,,1890.63,Other,260% New York Medicaid APG,2356.02,,,2356.02,Other,324% New York Medicaid APG,1563.41,,,1563.41,Other,215% New York Medicaid APG,1563.41,,,1563.41,Other,215% New York Medicaid APG,908.96,,,908.96,Other,125% New York Medicaid APG,727.17,28432.27,
Low cost skin substitute app,C5271,HCPCS,,,,,,,,both,,,13210.22,9775.56,74,,9775.56,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,5944.6,45,,5944.6,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,6539.06,49.5,,6539.06,percent of total billed charges,110% of Medicare,8982.95,68,,8982.95,percent of total billed charges,,2593.54,,,2593.54,Other,186% of Medicaid,10568.18,80,,10568.18,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,10568.18,80,,10568.18,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,9247.15,70,,9247.15,percent of total billed charges,,8586.64,65,,8586.64,percent of total billed charges,,8586.64,65,,8586.64,percent of total billed charges,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,1394.38,,,1394.38,Other,New York Medicaid APG methodology,1394.38,,,1394.38,Other,100% New York Medicaid APG,1394.38,,,1394.38,Other,100% New York Medicaid APG,1394.38,,,1394.38,Other,100% New York Medicaid APG,3137.35,,,3137.35,Other,225% New York Medicaid APG,2133.39,,,2133.39,Other,153% New York Medicaid APG,3137.35,,,3137.35,Other,225% New York Medicaid APG,1952.13,,,1952.13,Other,140% New York Medicaid APG,3137.35,,,3137.35,Other,225% New York Medicaid APG,3625.38,,,3625.38,Other,260% New York Medicaid APG,4517.78,,,4517.78,Other,324% New York Medicaid APG,2997.91,,,2997.91,Other,215% New York Medicaid APG,2997.91,,,2997.91,Other,215% New York Medicaid APG,1742.97,,,1742.97,Other,125% New York Medicaid APG,1394.38,10568.18,
Low cost skin substitute app,C5275,HCPCS,,,,,,,,both,,,42128.5,31175.09,74,,31175.09,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,18957.83,45,,18957.83,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,20853.61,49.5,,20853.61,percent of total billed charges,110% of Medicare,28647.38,68,,28647.38,percent of total billed charges,,2593.54,,,2593.54,Other,186% of Medicaid,33702.8,80,,33702.8,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,33702.8,80,,33702.8,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,29489.95,70,,29489.95,percent of total billed charges,,27383.53,65,,27383.53,percent of total billed charges,,27383.53,65,,27383.53,percent of total billed charges,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,1394.38,,,1394.38,Other,New York Medicaid APG methodology,1394.38,,,1394.38,Other,100% New York Medicaid APG,1394.38,,,1394.38,Other,100% New York Medicaid APG,1394.38,,,1394.38,Other,100% New York Medicaid APG,3137.35,,,3137.35,Other,225% New York Medicaid APG,2133.39,,,2133.39,Other,153% New York Medicaid APG,3137.35,,,3137.35,Other,225% New York Medicaid APG,1952.13,,,1952.13,Other,140% New York Medicaid APG,3137.35,,,3137.35,Other,225% New York Medicaid APG,3625.38,,,3625.38,Other,260% New York Medicaid APG,4517.78,,,4517.78,Other,324% New York Medicaid APG,2997.91,,,2997.91,Other,215% New York Medicaid APG,2997.91,,,2997.91,Other,215% New York Medicaid APG,1742.97,,,1742.97,Other,125% New York Medicaid APG,1394.38,33702.8,
Low cost skin substitute app,C5277,HCPCS,,,,,,,,both,,,13210.22,9775.56,74,,9775.56,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,5944.6,45,,5944.6,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,6539.06,49.5,,6539.06,percent of total billed charges,110% of Medicare,8982.95,68,,8982.95,percent of total billed charges,,2593.54,,,2593.54,Other,186% of Medicaid,10568.18,80,,10568.18,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,10568.18,80,,10568.18,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,9247.15,70,,9247.15,percent of total billed charges,,8586.64,65,,8586.64,percent of total billed charges,,8586.64,65,,8586.64,percent of total billed charges,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,1394.38,,,1394.38,Other,New York Medicaid APG methodology,1394.38,,,1394.38,Other,100% New York Medicaid APG,1394.38,,,1394.38,Other,100% New York Medicaid APG,1394.38,,,1394.38,Other,100% New York Medicaid APG,3137.35,,,3137.35,Other,225% New York Medicaid APG,2133.39,,,2133.39,Other,153% New York Medicaid APG,3137.35,,,3137.35,Other,225% New York Medicaid APG,1952.13,,,1952.13,Other,140% New York Medicaid APG,3137.35,,,3137.35,Other,225% New York Medicaid APG,3625.38,,,3625.38,Other,260% New York Medicaid APG,4517.78,,,4517.78,Other,324% New York Medicaid APG,2997.91,,,2997.91,Other,215% New York Medicaid APG,2997.91,,,2997.91,Other,215% New York Medicaid APG,1742.97,,,1742.97,Other,125% New York Medicaid APG,1394.38,10568.18,
Reloc skin pocket pls gen,0416T,HCPCS,,,,,,,,both,,,38357.55,28384.59,74,,28384.59,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,17260.9,45,,17260.9,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,18986.99,49.5,,18986.99,percent of total billed charges,110% of Medicare,26083.13,68,,26083.13,percent of total billed charges,,4536.91,,,4536.91,Other,186% of Medicaid,30686.04,80,,30686.04,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,30686.04,80,,30686.04,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,26850.29,70,,26850.29,percent of total billed charges,,24932.41,65,,24932.41,percent of total billed charges,,24932.41,65,,24932.41,percent of total billed charges,,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,2439.2,,,2439.2,Other,New York Medicaid APG methodology,2439.2,,,2439.2,Other,100% New York Medicaid APG,2439.2,,,2439.2,Other,100% New York Medicaid APG,2439.2,,,2439.2,Other,100% New York Medicaid APG,5488.2,,,5488.2,Other,225% New York Medicaid APG,3731.98,,,3731.98,Other,153% New York Medicaid APG,5488.2,,,5488.2,Other,225% New York Medicaid APG,3414.88,,,3414.88,Other,140% New York Medicaid APG,5488.2,,,5488.2,Other,225% New York Medicaid APG,6341.92,,,6341.92,Other,260% New York Medicaid APG,7903.01,,,7903.01,Other,324% New York Medicaid APG,5244.28,,,5244.28,Other,215% New York Medicaid APG,5244.28,,,5244.28,Other,215% New York Medicaid APG,3049,,,3049,Other,125% New York Medicaid APG,2232,30686.04,
Insj impltbl glucose sensor,0446T,HCPCS,,,,,,,,both,,,38357.55,28384.59,74,,28384.59,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,17260.9,45,,17260.9,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,18986.99,49.5,,18986.99,percent of total billed charges,110% of Medicare,26083.13,68,,26083.13,percent of total billed charges,,1240.83,,,1240.83,Other,186% of Medicaid,30686.04,80,,30686.04,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,30686.04,80,,30686.04,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,26850.29,70,,26850.29,percent of total billed charges,,272.24,,,272.24,Fee Schedule,,230.74,,,230.74,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,667.11,,,667.11,Other,New York Medicaid APG methodology,667.11,,,667.11,Other,100% New York Medicaid APG,667.11,,,667.11,Other,100% New York Medicaid APG,667.11,,,667.11,Other,100% New York Medicaid APG,1501,,,1501,Other,225% New York Medicaid APG,1020.68,,,1020.68,Other,153% New York Medicaid APG,1501,,,1501,Other,225% New York Medicaid APG,933.96,,,933.96,Other,140% New York Medicaid APG,1501,,,1501,Other,225% New York Medicaid APG,1734.49,,,1734.49,Other,260% New York Medicaid APG,2161.44,,,2161.44,Other,324% New York Medicaid APG,1434.29,,,1434.29,Other,215% New York Medicaid APG,1434.29,,,1434.29,Other,215% New York Medicaid APG,833.89,,,833.89,Other,125% New York Medicaid APG,230.74,30686.04,
Remvl insj impltbl gluc sens,0448T,HCPCS,,,,,,,,both,,,38357.55,28384.59,74,,28384.59,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,17260.9,45,,17260.9,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,18986.99,49.5,,18986.99,percent of total billed charges,110% of Medicare,26083.13,68,,26083.13,percent of total billed charges,,1240.83,,,1240.83,Other,186% of Medicaid,30686.04,80,,30686.04,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,30686.04,80,,30686.04,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,26850.29,70,,26850.29,percent of total billed charges,,455.92,,,455.92,Fee Schedule,,386.42,,,386.42,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,667.11,,,667.11,Other,New York Medicaid APG methodology,667.11,,,667.11,Other,100% New York Medicaid APG,667.11,,,667.11,Other,100% New York Medicaid APG,667.11,,,667.11,Other,100% New York Medicaid APG,1501,,,1501,Other,225% New York Medicaid APG,1020.68,,,1020.68,Other,153% New York Medicaid APG,1501,,,1501,Other,225% New York Medicaid APG,933.96,,,933.96,Other,140% New York Medicaid APG,1501,,,1501,Other,225% New York Medicaid APG,1734.49,,,1734.49,Other,260% New York Medicaid APG,2161.44,,,2161.44,Other,324% New York Medicaid APG,1434.29,,,1434.29,Other,215% New York Medicaid APG,1434.29,,,1434.29,Other,215% New York Medicaid APG,833.89,,,833.89,Other,125% New York Medicaid APG,386.42,30686.04,
Low cost skin substitute app,C5273,HCPCS,,,,,,,,both,,,59774.55,44233.17,74,,44233.17,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,26898.55,45,,26898.55,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,29588.4,49.5,,29588.4,percent of total billed charges,110% of Medicare,40646.69,68,,40646.69,percent of total billed charges,,2593.54,,,2593.54,Other,186% of Medicaid,47819.64,80,,47819.64,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,47819.64,80,,47819.64,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,41842.19,70,,41842.19,percent of total billed charges,,38853.46,65,,38853.46,percent of total billed charges,,38853.46,65,,38853.46,percent of total billed charges,,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1394.38,,,1394.38,Other,New York Medicaid APG methodology,1394.38,,,1394.38,Other,100% New York Medicaid APG,1394.38,,,1394.38,Other,100% New York Medicaid APG,1394.38,,,1394.38,Other,100% New York Medicaid APG,3137.35,,,3137.35,Other,225% New York Medicaid APG,2133.39,,,2133.39,Other,153% New York Medicaid APG,3137.35,,,3137.35,Other,225% New York Medicaid APG,1952.13,,,1952.13,Other,140% New York Medicaid APG,3137.35,,,3137.35,Other,225% New York Medicaid APG,3625.38,,,3625.38,Other,260% New York Medicaid APG,4517.78,,,4517.78,Other,324% New York Medicaid APG,2997.91,,,2997.91,Other,215% New York Medicaid APG,2997.91,,,2997.91,Other,215% New York Medicaid APG,1742.97,,,1742.97,Other,125% New York Medicaid APG,1394.38,47819.64,
Extracorp shockwv tx hi enrg,0101T,HCPCS,,,,,,,,both,,,4960.23,3670.57,74,,3670.57,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,2232.1,45,,2232.1,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,2455.31,49.5,,2455.31,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,1031.43,,,1031.43,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,3472.16,70,,3472.16,percent of total billed charges,,3224.15,65,,3224.15,percent of total billed charges,,3224.15,65,,3224.15,percent of total billed charges,,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,554.53,,,554.53,Other,New York Medicaid APG methodology,554.53,,,554.53,Other,100% New York Medicaid APG,554.53,,,554.53,Other,100% New York Medicaid APG,554.53,,,554.53,Other,100% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,848.43,,,848.43,Other,153% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,776.34,,,776.34,Other,140% New York Medicaid APG,1247.69,,,1247.69,Other,225% New York Medicaid APG,1441.78,,,1441.78,Other,260% New York Medicaid APG,1796.68,,,1796.68,Other,324% New York Medicaid APG,1192.24,,,1192.24,Other,215% New York Medicaid APG,1192.24,,,1192.24,Other,215% New York Medicaid APG,693.16,,,693.16,Other,125% New York Medicaid APG,554.53,9473,
Extracorp shockwv tx anesth,0102T,HCPCS,,,,,,,,both,,,68082.75,50381.24,74,,50381.24,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30637.24,45,,30637.24,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33700.96,49.5,,33700.96,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3960.57,,,3960.57,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,47657.93,70,,47657.93,percent of total billed charges,,44253.79,65,,44253.79,percent of total billed charges,,44253.79,65,,44253.79,percent of total billed charges,,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,2129.34,,,2129.34,Other,New York Medicaid APG methodology,2129.34,,,2129.34,Other,100% New York Medicaid APG,2129.34,,,2129.34,Other,100% New York Medicaid APG,2129.34,,,2129.34,Other,100% New York Medicaid APG,4791.01,,,4791.01,Other,225% New York Medicaid APG,3257.89,,,3257.89,Other,153% New York Medicaid APG,4791.01,,,4791.01,Other,225% New York Medicaid APG,2981.08,,,2981.08,Other,140% New York Medicaid APG,4791.01,,,4791.01,Other,225% New York Medicaid APG,5536.28,,,5536.28,Other,260% New York Medicaid APG,6899.06,,,6899.06,Other,324% New York Medicaid APG,4578.08,,,4578.08,Other,215% New York Medicaid APG,4578.08,,,4578.08,Other,215% New York Medicaid APG,2661.67,,,2661.67,Other,125% New York Medicaid APG,2129.34,50381.24,
Rmvl sinus tarsi implant,0510T,HCPCS,,,,,,,,both,,,68082.75,50381.24,74,,50381.24,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30637.24,45,,30637.24,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33700.96,49.5,,33700.96,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2891.15,,,2891.15,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,47657.93,70,,47657.93,percent of total billed charges,,44253.79,65,,44253.79,percent of total billed charges,,44253.79,65,,44253.79,percent of total billed charges,,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1554.38,,,1554.38,Other,New York Medicaid APG methodology,1554.38,,,1554.38,Other,100% New York Medicaid APG,1554.38,,,1554.38,Other,100% New York Medicaid APG,1554.38,,,1554.38,Other,100% New York Medicaid APG,3497.36,,,3497.36,Other,225% New York Medicaid APG,2378.21,,,2378.21,Other,153% New York Medicaid APG,3497.36,,,3497.36,Other,225% New York Medicaid APG,2176.14,,,2176.14,Other,140% New York Medicaid APG,3497.36,,,3497.36,Other,225% New York Medicaid APG,4041.4,,,4041.4,Other,260% New York Medicaid APG,5036.2,,,5036.2,Other,324% New York Medicaid APG,3341.93,,,3341.93,Other,215% New York Medicaid APG,3341.93,,,3341.93,Other,215% New York Medicaid APG,1942.98,,,1942.98,Other,125% New York Medicaid APG,1554.38,50381.24,
Perq sacral augmt unilat inj,0200T,HCPCS,,,,,,,,both,,,150476.65,111352.72,74,,111352.72,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,67714.49,45,,67714.49,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,74485.94,49.5,,74485.94,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5525.48,,,5525.48,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,105333.66,70,,105333.66,percent of total billed charges,,97809.82,65,,97809.82,percent of total billed charges,,97809.82,65,,97809.82,percent of total billed charges,,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,2970.69,,,2970.69,Other,New York Medicaid APG methodology,2970.69,,,2970.69,Other,100% New York Medicaid APG,2970.69,,,2970.69,Other,100% New York Medicaid APG,2970.69,,,2970.69,Other,100% New York Medicaid APG,6684.05,,,6684.05,Other,225% New York Medicaid APG,4545.16,,,4545.16,Other,153% New York Medicaid APG,6684.05,,,6684.05,Other,225% New York Medicaid APG,4158.97,,,4158.97,Other,140% New York Medicaid APG,6684.05,,,6684.05,Other,225% New York Medicaid APG,7723.79,,,7723.79,Other,260% New York Medicaid APG,9625.03,,,9625.03,Other,324% New York Medicaid APG,6386.98,,,6386.98,Other,215% New York Medicaid APG,6386.98,,,6386.98,Other,215% New York Medicaid APG,3713.36,,,3713.36,Other,125% New York Medicaid APG,2970.69,111352.72,
Perq sacral augmt bilat inj,0201T,HCPCS,,,,,,,,both,,,150476.65,111352.72,74,,111352.72,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,67714.49,45,,67714.49,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,74485.94,49.5,,74485.94,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5525.48,,,5525.48,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,105333.66,70,,105333.66,percent of total billed charges,,97809.82,65,,97809.82,percent of total billed charges,,97809.82,65,,97809.82,percent of total billed charges,,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,2970.69,,,2970.69,Other,New York Medicaid APG methodology,2970.69,,,2970.69,Other,100% New York Medicaid APG,2970.69,,,2970.69,Other,100% New York Medicaid APG,2970.69,,,2970.69,Other,100% New York Medicaid APG,6684.05,,,6684.05,Other,225% New York Medicaid APG,4545.16,,,4545.16,Other,153% New York Medicaid APG,6684.05,,,6684.05,Other,225% New York Medicaid APG,4158.97,,,4158.97,Other,140% New York Medicaid APG,6684.05,,,6684.05,Other,225% New York Medicaid APG,7723.79,,,7723.79,Other,260% New York Medicaid APG,9625.03,,,9625.03,Other,324% New York Medicaid APG,6386.98,,,6386.98,Other,215% New York Medicaid APG,6386.98,,,6386.98,Other,215% New York Medicaid APG,3713.36,,,3713.36,Other,125% New York Medicaid APG,2970.69,111352.72,
Plmt post facet implt lumb,0221T,HCPCS,,,,,,,,both,,,150476.65,111352.72,74,,111352.72,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,67714.49,45,,67714.49,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,74485.94,49.5,,74485.94,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5525.48,,,5525.48,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,105333.66,70,,105333.66,percent of total billed charges,,97809.82,65,,97809.82,percent of total billed charges,,97809.82,65,,97809.82,percent of total billed charges,,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,2970.69,,,2970.69,Other,New York Medicaid APG methodology,2970.69,,,2970.69,Other,100% New York Medicaid APG,2970.69,,,2970.69,Other,100% New York Medicaid APG,2970.69,,,2970.69,Other,100% New York Medicaid APG,6684.05,,,6684.05,Other,225% New York Medicaid APG,4545.16,,,4545.16,Other,153% New York Medicaid APG,6684.05,,,6684.05,Other,225% New York Medicaid APG,4158.97,,,4158.97,Other,140% New York Medicaid APG,6684.05,,,6684.05,Other,225% New York Medicaid APG,7723.79,,,7723.79,Other,260% New York Medicaid APG,9625.03,,,9625.03,Other,324% New York Medicaid APG,6386.98,,,6386.98,Other,215% New York Medicaid APG,6386.98,,,6386.98,Other,215% New York Medicaid APG,3713.36,,,3713.36,Other,125% New York Medicaid APG,2970.69,111352.72,
Perq lamot/lam crv/thrc,0274T,HCPCS,,,,,,,,both,,,150476.65,111352.72,74,,111352.72,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,67714.49,45,,67714.49,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,74485.94,49.5,,74485.94,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5525.48,,,5525.48,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,105333.66,70,,105333.66,percent of total billed charges,,97809.82,65,,97809.82,percent of total billed charges,,97809.82,65,,97809.82,percent of total billed charges,,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,2970.69,,,2970.69,Other,New York Medicaid APG methodology,2970.69,,,2970.69,Other,100% New York Medicaid APG,2970.69,,,2970.69,Other,100% New York Medicaid APG,2970.69,,,2970.69,Other,100% New York Medicaid APG,6684.05,,,6684.05,Other,225% New York Medicaid APG,4545.16,,,4545.16,Other,153% New York Medicaid APG,6684.05,,,6684.05,Other,225% New York Medicaid APG,4158.97,,,4158.97,Other,140% New York Medicaid APG,6684.05,,,6684.05,Other,225% New York Medicaid APG,7723.79,,,7723.79,Other,260% New York Medicaid APG,9625.03,,,9625.03,Other,324% New York Medicaid APG,6386.98,,,6386.98,Other,215% New York Medicaid APG,6386.98,,,6386.98,Other,215% New York Medicaid APG,3713.36,,,3713.36,Other,125% New York Medicaid APG,2970.69,111352.72,
Perq lamot/lam lumbar,0275T,HCPCS,,,,,,,,both,,,152786.49,113062,74,,113062,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,68753.92,45,,68753.92,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,75629.31,49.5,,75629.31,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5525.48,,,5525.48,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,106950.54,70,,106950.54,percent of total billed charges,,99311.22,65,,99311.22,percent of total billed charges,,99311.22,65,,99311.22,percent of total billed charges,,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,2970.69,,,2970.69,Other,New York Medicaid APG methodology,2970.69,,,2970.69,Other,100% New York Medicaid APG,2970.69,,,2970.69,Other,100% New York Medicaid APG,2970.69,,,2970.69,Other,100% New York Medicaid APG,6684.05,,,6684.05,Other,225% New York Medicaid APG,4545.16,,,4545.16,Other,153% New York Medicaid APG,6684.05,,,6684.05,Other,225% New York Medicaid APG,4158.97,,,4158.97,Other,140% New York Medicaid APG,6684.05,,,6684.05,Other,225% New York Medicaid APG,7723.79,,,7723.79,Other,260% New York Medicaid APG,9625.03,,,9625.03,Other,324% New York Medicaid APG,6386.98,,,6386.98,Other,215% New York Medicaid APG,6386.98,,,6386.98,Other,215% New York Medicaid APG,3713.36,,,3713.36,Other,125% New York Medicaid APG,2970.69,113062,
Insj sinus tarsi implant,0335T,HCPCS,,,,,,,,both,,,150476.65,111352.72,74,,111352.72,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,67714.49,45,,67714.49,percent of total billed charges,Medicare Ratio of cost to charges,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Aetna ASC Grouper,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,74485.94,49.5,,74485.94,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2891.15,,,2891.15,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,105333.66,70,,105333.66,percent of total billed charges,,97809.82,65,,97809.82,percent of total billed charges,,97809.82,65,,97809.82,percent of total billed charges,,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1554.38,,,1554.38,Other,New York Medicaid APG methodology,1554.38,,,1554.38,Other,100% New York Medicaid APG,1554.38,,,1554.38,Other,100% New York Medicaid APG,1554.38,,,1554.38,Other,100% New York Medicaid APG,3497.36,,,3497.36,Other,225% New York Medicaid APG,2378.21,,,2378.21,Other,153% New York Medicaid APG,3497.36,,,3497.36,Other,225% New York Medicaid APG,2176.14,,,2176.14,Other,140% New York Medicaid APG,3497.36,,,3497.36,Other,225% New York Medicaid APG,4041.4,,,4041.4,Other,260% New York Medicaid APG,5036.2,,,5036.2,Other,324% New York Medicaid APG,3341.93,,,3341.93,Other,215% New York Medicaid APG,3341.93,,,3341.93,Other,215% New York Medicaid APG,1942.98,,,1942.98,Other,125% New York Medicaid APG,0.01,111352.72,
Rmvl&rinsj sinus tarsi implt,0511T,HCPCS,,,,,,,,both,,,150476.65,111352.72,74,,111352.72,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,67714.49,45,,67714.49,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,74485.94,49.5,,74485.94,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3642.86,,,3642.86,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,105333.66,70,,105333.66,percent of total billed charges,,97809.82,65,,97809.82,percent of total billed charges,,97809.82,65,,97809.82,percent of total billed charges,,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1958.52,,,1958.52,Other,New York Medicaid APG methodology,1958.52,,,1958.52,Other,100% New York Medicaid APG,1958.52,,,1958.52,Other,100% New York Medicaid APG,1958.52,,,1958.52,Other,100% New York Medicaid APG,4406.68,,,4406.68,Other,225% New York Medicaid APG,2996.54,,,2996.54,Other,153% New York Medicaid APG,4406.68,,,4406.68,Other,225% New York Medicaid APG,2741.93,,,2741.93,Other,140% New York Medicaid APG,4406.68,,,4406.68,Other,225% New York Medicaid APG,5092.16,,,5092.16,Other,260% New York Medicaid APG,6345.62,,,6345.62,Other,324% New York Medicaid APG,4210.83,,,4210.83,Other,215% New York Medicaid APG,4210.83,,,4210.83,Other,215% New York Medicaid APG,2448.16,,,2448.16,Other,125% New York Medicaid APG,1958.52,111352.72,
Osteot hum xtrnl lngth dev,0594T,HCPCS,,,,,,,,both,,,150476.65,111352.72,74,,111352.72,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,67714.49,45,,67714.49,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,74485.94,49.5,,74485.94,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3960.57,,,3960.57,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,120381.32,80,,120381.32,percent of total billed charges,,105333.66,70,,105333.66,percent of total billed charges,,97809.82,65,,97809.82,percent of total billed charges,,97809.82,65,,97809.82,percent of total billed charges,,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,2129.34,,,2129.34,Other,New York Medicaid APG methodology,2129.34,,,2129.34,Other,100% New York Medicaid APG,2129.34,,,2129.34,Other,100% New York Medicaid APG,2129.34,,,2129.34,Other,100% New York Medicaid APG,4791.01,,,4791.01,Other,225% New York Medicaid APG,3257.89,,,3257.89,Other,153% New York Medicaid APG,4791.01,,,4791.01,Other,225% New York Medicaid APG,2981.08,,,2981.08,Other,140% New York Medicaid APG,4791.01,,,4791.01,Other,225% New York Medicaid APG,5536.28,,,5536.28,Other,260% New York Medicaid APG,6899.06,,,6899.06,Other,324% New York Medicaid APG,4578.08,,,4578.08,Other,215% New York Medicaid APG,4578.08,,,4578.08,Other,215% New York Medicaid APG,2661.67,,,2661.67,Other,125% New York Medicaid APG,2129.34,120381.32,
Perq njx algc fluor lmbr 1st,0627T,HCPCS,,,,,,,,both,,,276827.87,204852.62,74,,204852.62,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,124572.54,45,,124572.54,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,137029.8,49.5,,137029.8,percent of total billed charges,110% of Medicare,188242.95,68,,188242.95,percent of total billed charges,,1116.35,,,1116.35,Other,186% of Medicaid,221462.3,80,,221462.3,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,221462.3,80,,221462.3,percent of total billed charges,,7216,,,7216,Case Rate,,221462.3,80,,221462.3,percent of total billed charges,,193779.51,70,,193779.51,percent of total billed charges,,179938.12,65,,179938.12,percent of total billed charges,,179938.12,65,,179938.12,percent of total billed charges,,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,600.19,,,600.19,Other,New York Medicaid APG methodology,600.19,,,600.19,Other,100% New York Medicaid APG,600.19,,,600.19,Other,100% New York Medicaid APG,600.19,,,600.19,Other,100% New York Medicaid APG,1350.43,,,1350.43,Other,225% New York Medicaid APG,918.29,,,918.29,Other,153% New York Medicaid APG,1350.43,,,1350.43,Other,225% New York Medicaid APG,840.26,,,840.26,Other,140% New York Medicaid APG,1350.43,,,1350.43,Other,225% New York Medicaid APG,1560.49,,,1560.49,Other,260% New York Medicaid APG,1944.61,,,1944.61,Other,324% New York Medicaid APG,1290.41,,,1290.41,Other,215% New York Medicaid APG,1290.41,,,1290.41,Other,215% New York Medicaid APG,750.24,,,750.24,Other,125% New York Medicaid APG,600.19,221462.3,
Perq njx algc ct lmbr 1st,0629T,HCPCS,,,,,,,,both,,,276827.87,204852.62,74,,204852.62,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,124572.54,45,,124572.54,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,137029.8,49.5,,137029.8,percent of total billed charges,110% of Medicare,188242.95,68,,188242.95,percent of total billed charges,,1116.35,,,1116.35,Other,186% of Medicaid,221462.3,80,,221462.3,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,221462.3,80,,221462.3,percent of total billed charges,,7216,,,7216,Case Rate,,221462.3,80,,221462.3,percent of total billed charges,,193779.51,70,,193779.51,percent of total billed charges,,179938.12,65,,179938.12,percent of total billed charges,,179938.12,65,,179938.12,percent of total billed charges,,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,600.19,,,600.19,Other,New York Medicaid APG methodology,600.19,,,600.19,Other,100% New York Medicaid APG,600.19,,,600.19,Other,100% New York Medicaid APG,600.19,,,600.19,Other,100% New York Medicaid APG,1350.43,,,1350.43,Other,225% New York Medicaid APG,918.29,,,918.29,Other,153% New York Medicaid APG,1350.43,,,1350.43,Other,225% New York Medicaid APG,840.26,,,840.26,Other,140% New York Medicaid APG,1350.43,,,1350.43,Other,225% New York Medicaid APG,1560.49,,,1560.49,Other,260% New York Medicaid APG,1944.61,,,1944.61,Other,324% New York Medicaid APG,1290.41,,,1290.41,Other,215% New York Medicaid APG,1290.41,,,1290.41,Other,215% New York Medicaid APG,750.24,,,750.24,Other,125% New York Medicaid APG,600.19,221462.3,
Spine/lumbar disk surgery,C9757,HCPCS,,,,,,,,both,,,276827.87,204852.62,74,,204852.62,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,124572.54,45,,124572.54,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,137029.8,49.5,,137029.8,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,6658.36,,,6658.36,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,221462.3,80,,221462.3,percent of total billed charges,,193779.51,70,,193779.51,percent of total billed charges,,179938.12,65,,179938.12,percent of total billed charges,,179938.12,65,,179938.12,percent of total billed charges,,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,3579.77,,,3579.77,Other,New York Medicaid APG methodology,3579.77,,,3579.77,Other,100% New York Medicaid APG,3579.77,,,3579.77,Other,100% New York Medicaid APG,3579.77,,,3579.77,Other,100% New York Medicaid APG,8054.47,,,8054.47,Other,225% New York Medicaid APG,5477.04,,,5477.04,Other,153% New York Medicaid APG,8054.47,,,8054.47,Other,225% New York Medicaid APG,5011.67,,,5011.67,Other,140% New York Medicaid APG,8054.47,,,8054.47,Other,225% New York Medicaid APG,9307.39,,,9307.39,Other,260% New York Medicaid APG,11598.44,,,11598.44,Other,324% New York Medicaid APG,7696.5,,,7696.5,Other,215% New York Medicaid APG,7696.5,,,7696.5,Other,215% New York Medicaid APG,4474.71,,,4474.71,Other,125% New York Medicaid APG,3579.77,221462.3,
Tmpst auto tube dlvr sys,0583T,HCPCS,,,,,,,,both,,,32077.39,23737.27,74,,23737.27,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,14434.83,45,,14434.83,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,15878.31,49.5,,15878.31,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2256.57,,,2256.57,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,25661.91,80,,25661.91,percent of total billed charges,,22454.17,70,,22454.17,percent of total billed charges,,20850.3,65,,20850.3,percent of total billed charges,,20850.3,65,,20850.3,percent of total billed charges,,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1213.21,,,1213.21,Other,New York Medicaid APG methodology,1213.21,,,1213.21,Other,100% New York Medicaid APG,1213.21,,,1213.21,Other,100% New York Medicaid APG,1213.21,,,1213.21,Other,100% New York Medicaid APG,2729.72,,,2729.72,Other,225% New York Medicaid APG,1856.21,,,1856.21,Other,153% New York Medicaid APG,2729.72,,,2729.72,Other,225% New York Medicaid APG,1698.49,,,1698.49,Other,140% New York Medicaid APG,2729.72,,,2729.72,Other,225% New York Medicaid APG,3154.34,,,3154.34,Other,260% New York Medicaid APG,3930.79,,,3930.79,Other,324% New York Medicaid APG,2608.4,,,2608.4,Other,215% New York Medicaid APG,2608.4,,,2608.4,Other,215% New York Medicaid APG,1516.51,,,1516.51,Other,125% New York Medicaid APG,1213.21,25661.91,
Insert palate implants,C9727,HCPCS,,,,,,,,both,,,32077.39,23737.27,74,,23737.27,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,14434.83,45,,14434.83,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,15878.31,49.5,,15878.31,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2256.57,,,2256.57,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,22454.17,70,,22454.17,percent of total billed charges,,20850.3,65,,20850.3,percent of total billed charges,,20850.3,65,,20850.3,percent of total billed charges,,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,1213.21,,,1213.21,Other,New York Medicaid APG methodology,1213.21,,,1213.21,Other,100% New York Medicaid APG,1213.21,,,1213.21,Other,100% New York Medicaid APG,1213.21,,,1213.21,Other,100% New York Medicaid APG,2729.72,,,2729.72,Other,225% New York Medicaid APG,1856.21,,,1856.21,Other,153% New York Medicaid APG,2729.72,,,2729.72,Other,225% New York Medicaid APG,1698.49,,,1698.49,Other,140% New York Medicaid APG,2729.72,,,2729.72,Other,225% New York Medicaid APG,3154.34,,,3154.34,Other,260% New York Medicaid APG,3930.79,,,3930.79,Other,324% New York Medicaid APG,2608.4,,,2608.4,Other,215% New York Medicaid APG,2608.4,,,2608.4,Other,215% New York Medicaid APG,1516.51,,,1516.51,Other,125% New York Medicaid APG,1213.21,23737.27,
Repos car modulj tranvns elt,0415T,HCPCS,,,,,,,,both,,,13213.53,9778.01,74,,9778.01,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,5946.09,45,,5946.09,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,6540.7,49.5,,6540.7,percent of total billed charges,110% of Medicare,8985.2,68,,8985.2,percent of total billed charges,,4536.91,,,4536.91,Other,186% of Medicaid,10570.82,80,,10570.82,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,10570.82,80,,10570.82,percent of total billed charges,,7216,,,7216,Case Rate,,3578,,"100% primary, 0% secondary procedures",3578,Other,MagnaCare ASC Grouper,9249.47,70,,9249.47,percent of total billed charges,,8588.79,65,,8588.79,percent of total billed charges,,8588.79,65,,8588.79,percent of total billed charges,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,2439.2,,,2439.2,Other,New York Medicaid APG methodology,2439.2,,,2439.2,Other,100% New York Medicaid APG,2439.2,,,2439.2,Other,100% New York Medicaid APG,2439.2,,,2439.2,Other,100% New York Medicaid APG,5488.2,,,5488.2,Other,225% New York Medicaid APG,3731.98,,,3731.98,Other,153% New York Medicaid APG,5488.2,,,5488.2,Other,225% New York Medicaid APG,3414.88,,,3414.88,Other,140% New York Medicaid APG,5488.2,,,5488.2,Other,225% New York Medicaid APG,6341.92,,,6341.92,Other,260% New York Medicaid APG,7903.01,,,7903.01,Other,324% New York Medicaid APG,5244.28,,,5244.28,Other,215% New York Medicaid APG,5244.28,,,5244.28,Other,215% New York Medicaid APG,3049,,,3049,Other,125% New York Medicaid APG,2232,10570.82,
Ev cath dir chem abltj w/img,0524T,HCPCS,,,,,,,,both,,,67044.74,49613.11,74,,49613.11,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,30170.13,45,,30170.13,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,33187.15,49.5,,33187.15,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,4156.45,,,4156.45,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,46931.32,70,,46931.32,percent of total billed charges,,43579.08,65,,43579.08,percent of total billed charges,,43579.08,65,,43579.08,percent of total billed charges,,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,2234.65,,,2234.65,Other,New York Medicaid APG methodology,2234.65,,,2234.65,Other,100% New York Medicaid APG,2234.65,,,2234.65,Other,100% New York Medicaid APG,2234.65,,,2234.65,Other,100% New York Medicaid APG,5027.97,,,5027.97,Other,225% New York Medicaid APG,3419.02,,,3419.02,Other,153% New York Medicaid APG,5027.97,,,5027.97,Other,225% New York Medicaid APG,3128.51,,,3128.51,Other,140% New York Medicaid APG,5027.97,,,5027.97,Other,225% New York Medicaid APG,5810.1,,,5810.1,Other,260% New York Medicaid APG,7240.28,,,7240.28,Other,324% New York Medicaid APG,4804.5,,,4804.5,Other,215% New York Medicaid APG,4804.5,,,4804.5,Other,215% New York Medicaid APG,2793.32,,,2793.32,Other,125% New York Medicaid APG,2234.65,49613.11,
Trnscth renal symp denrv unl,0338T,HCPCS,,,,,,,,both,,,120221.84,88964.16,74,,88964.16,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,54099.83,45,,54099.83,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,7266,,"100% primary, 50% secondary, 25% supplemental procedure",7266,Other,Blue Cross ASC Grouper,6539,,"100% primary, 50% secondary, 25% supplemental procedure",6539,Other,Blue Cross ASC Grouper,6176,,"100% primary, 50% secondary, 25% supplemental procedure",6176,Other,Blue Cross ASC Grouper,59509.81,49.5,,59509.81,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2757.95,,,2757.95,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,84155.29,70,,84155.29,percent of total billed charges,,78144.2,65,,78144.2,percent of total billed charges,,78144.2,65,,78144.2,percent of total billed charges,,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1482.77,,,1482.77,Other,New York Medicaid APG methodology,1482.77,,,1482.77,Other,100% New York Medicaid APG,1482.77,,,1482.77,Other,100% New York Medicaid APG,1482.77,,,1482.77,Other,100% New York Medicaid APG,3336.23,,,3336.23,Other,225% New York Medicaid APG,2268.64,,,2268.64,Other,153% New York Medicaid APG,3336.23,,,3336.23,Other,225% New York Medicaid APG,2075.88,,,2075.88,Other,140% New York Medicaid APG,3336.23,,,3336.23,Other,225% New York Medicaid APG,3855.2,,,3855.2,Other,260% New York Medicaid APG,4804.18,,,4804.18,Other,324% New York Medicaid APG,3187.96,,,3187.96,Other,215% New York Medicaid APG,3187.96,,,3187.96,Other,215% New York Medicaid APG,1853.46,,,1853.46,Other,125% New York Medicaid APG,1482.77,88964.16,
Trnscth renal symp denrv bil,0339T,HCPCS,,,,,,,,both,,,120221.84,88964.16,74,,88964.16,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,54099.83,45,,54099.83,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,7266,,"100% primary, 50% secondary, 25% supplemental procedure",7266,Other,Blue Cross ASC Grouper,6539,,"100% primary, 50% secondary, 25% supplemental procedure",6539,Other,Blue Cross ASC Grouper,6176,,"100% primary, 50% secondary, 25% supplemental procedure",6176,Other,Blue Cross ASC Grouper,59509.81,49.5,,59509.81,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2757.95,,,2757.95,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,84155.29,70,,84155.29,percent of total billed charges,,78144.2,65,,78144.2,percent of total billed charges,,78144.2,65,,78144.2,percent of total billed charges,,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1482.77,,,1482.77,Other,New York Medicaid APG methodology,1482.77,,,1482.77,Other,100% New York Medicaid APG,1482.77,,,1482.77,Other,100% New York Medicaid APG,1482.77,,,1482.77,Other,100% New York Medicaid APG,3336.23,,,3336.23,Other,225% New York Medicaid APG,2268.64,,,2268.64,Other,153% New York Medicaid APG,3336.23,,,3336.23,Other,225% New York Medicaid APG,2075.88,,,2075.88,Other,140% New York Medicaid APG,3336.23,,,3336.23,Other,225% New York Medicaid APG,3855.2,,,3855.2,Other,260% New York Medicaid APG,4804.18,,,4804.18,Other,324% New York Medicaid APG,3187.96,,,3187.96,Other,215% New York Medicaid APG,3187.96,,,3187.96,Other,215% New York Medicaid APG,1853.46,,,1853.46,Other,125% New York Medicaid APG,1482.77,88964.16,
Prq cardiac angioplast 1 art,92920,CPT,,,,,,,,both,,,120221.84,88964.16,74,,88964.16,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,54099.83,45,,54099.83,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,7266,,"100% primary, 50% secondary, 25% supplemental procedure",7266,Other,Blue Cross ASC Grouper,6539,,"100% primary, 50% secondary, 25% supplemental procedure",6539,Other,Blue Cross ASC Grouper,6176,,"100% primary, 50% secondary, 25% supplemental procedure",6176,Other,Blue Cross ASC Grouper,59509.81,49.5,,59509.81,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,4605.54,,,4605.54,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,84155.29,70,,84155.29,percent of total billed charges,,2523.96,,,2523.96,Fee Schedule,,2139.21,,,2139.21,Fee Schedule,,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,2476.1,,,2476.1,Other,New York Medicaid APG methodology,2476.1,,,2476.1,Other,100% New York Medicaid APG,2476.1,,,2476.1,Other,100% New York Medicaid APG,2476.1,,,2476.1,Other,100% New York Medicaid APG,5571.22,,,5571.22,Other,225% New York Medicaid APG,3788.43,,,3788.43,Other,153% New York Medicaid APG,5571.22,,,5571.22,Other,225% New York Medicaid APG,3466.54,,,3466.54,Other,140% New York Medicaid APG,5571.22,,,5571.22,Other,225% New York Medicaid APG,6437.85,,,6437.85,Other,260% New York Medicaid APG,8022.56,,,8022.56,Other,324% New York Medicaid APG,5323.61,,,5323.61,Other,215% New York Medicaid APG,5323.61,,,5323.61,Other,215% New York Medicaid APG,3095.12,,,3095.12,Other,125% New York Medicaid APG,2139.21,88964.16,
Revasc intravasc lithotripsy,C9764,HCPCS,,,,,,,,both,,,119648,88539.52,74,,88539.52,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,53841.6,45,,53841.6,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,7266,,"100% primary, 50% secondary, 25% supplemental procedure",7266,Other,Blue Cross ASC Grouper,6539,,"100% primary, 50% secondary, 25% supplemental procedure",6539,Other,Blue Cross ASC Grouper,6176,,"100% primary, 50% secondary, 25% supplemental procedure",6176,Other,Blue Cross ASC Grouper,59225.76,49.5,,59225.76,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3853.44,,,3853.44,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,95718.4,80,,95718.4,percent of total billed charges,,83753.6,70,,83753.6,percent of total billed charges,,77771.2,65,,77771.2,percent of total billed charges,,77771.2,65,,77771.2,percent of total billed charges,,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,2071.74,,,2071.74,Other,New York Medicaid APG methodology,2071.74,,,2071.74,Other,100% New York Medicaid APG,2071.74,,,2071.74,Other,100% New York Medicaid APG,2071.74,,,2071.74,Other,100% New York Medicaid APG,4661.42,,,4661.42,Other,225% New York Medicaid APG,3169.77,,,3169.77,Other,153% New York Medicaid APG,4661.42,,,4661.42,Other,225% New York Medicaid APG,2900.44,,,2900.44,Other,140% New York Medicaid APG,4661.42,,,4661.42,Other,225% New York Medicaid APG,5386.53,,,5386.53,Other,260% New York Medicaid APG,6712.45,,,6712.45,Other,324% New York Medicaid APG,4454.25,,,4454.25,Other,215% New York Medicaid APG,4454.25,,,4454.25,Other,215% New York Medicaid APG,2589.68,,,2589.68,Other,125% New York Medicaid APG,2071.74,95718.4,
Ev fempop artl revsc,0505T,HCPCS,,,,,,,,both,,,231395.43,171232.62,74,,171232.62,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,104127.94,45,,104127.94,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,114540.74,49.5,,114540.74,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,4605.53,,,4605.53,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9196,,"100% primary, 0% secondary procedures",9196,Other,MagnaCare ASC Grouper,161976.8,70,,161976.8,percent of total billed charges,,150407.03,65,,150407.03,percent of total billed charges,,150407.03,65,,150407.03,percent of total billed charges,,6956,,"100% primary, 50% secondary, 25% tertiary procedure",6956,Other,United Healthcare ASC Grouper,6261,,"100% primary, 50% secondary, 25% tertiary procedure",6261,Other,United Healthcare ASC Grouper,6956,,"100% primary, 50% secondary, 25% tertiary procedure",6956,Other,United Healthcare ASC Grouper,5913,,"100% primary, 50% secondary, 25% tertiary procedure",5913,Other,United Healthcare ASC Grouper,2476.09,,,2476.09,Other,New York Medicaid APG methodology,2476.09,,,2476.09,Other,100% New York Medicaid APG,2476.09,,,2476.09,Other,100% New York Medicaid APG,2476.09,,,2476.09,Other,100% New York Medicaid APG,5571.21,,,5571.21,Other,225% New York Medicaid APG,3788.42,,,3788.42,Other,153% New York Medicaid APG,5571.21,,,5571.21,Other,225% New York Medicaid APG,3466.53,,,3466.53,Other,140% New York Medicaid APG,5571.21,,,5571.21,Other,225% New York Medicaid APG,6437.84,,,6437.84,Other,260% New York Medicaid APG,8022.54,,,8022.54,Other,324% New York Medicaid APG,5323.6,,,5323.6,Other,215% New York Medicaid APG,5323.6,,,5323.6,Other,215% New York Medicaid APG,3095.12,,,3095.12,Other,125% New York Medicaid APG,2476.09,171232.62,
Prq card stent w/angio 1 vsl,92928,CPT,,,,,,,,both,,,231395.43,171232.62,74,,171232.62,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,104127.94,45,,104127.94,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,114540.74,49.5,,114540.74,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,4605.54,,,4605.54,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,161976.8,70,,161976.8,percent of total billed charges,,2814.24,,,2814.24,Fee Schedule,,2385.24,,,2385.24,Fee Schedule,,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,2476.1,,,2476.1,Other,New York Medicaid APG methodology,2476.1,,,2476.1,Other,100% New York Medicaid APG,2476.1,,,2476.1,Other,100% New York Medicaid APG,2476.1,,,2476.1,Other,100% New York Medicaid APG,5571.22,,,5571.22,Other,225% New York Medicaid APG,3788.43,,,3788.43,Other,153% New York Medicaid APG,5571.22,,,5571.22,Other,225% New York Medicaid APG,3466.54,,,3466.54,Other,140% New York Medicaid APG,5571.22,,,5571.22,Other,225% New York Medicaid APG,6437.85,,,6437.85,Other,260% New York Medicaid APG,8022.56,,,8022.56,Other,324% New York Medicaid APG,5323.61,,,5323.61,Other,215% New York Medicaid APG,5323.61,,,5323.61,Other,215% New York Medicaid APG,3095.12,,,3095.12,Other,125% New York Medicaid APG,2385.24,171232.62,
Perc drug-el cor stent sing,C9600,HCPCS,,,,,,,,both,,,100522.73,74386.82,74,,74386.82,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,45235.23,45,,45235.23,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,49758.75,49.5,,49758.75,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,4605.54,,,4605.54,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9196,,"100% primary, 0% secondary procedures",9196,Other,MagnaCare ASC Grouper,70365.91,70,,70365.91,percent of total billed charges,,65339.77,65,,65339.77,percent of total billed charges,,65339.77,65,,65339.77,percent of total billed charges,,6956,,"100% primary, 50% secondary, 25% tertiary procedure",6956,Other,United Healthcare ASC Grouper,6261,,"100% primary, 50% secondary, 25% tertiary procedure",6261,Other,United Healthcare ASC Grouper,6956,,"100% primary, 50% secondary, 25% tertiary procedure",6956,Other,United Healthcare ASC Grouper,5913,,"100% primary, 50% secondary, 25% tertiary procedure",5913,Other,United Healthcare ASC Grouper,2476.1,,,2476.1,Other,New York Medicaid APG methodology,2476.1,,,2476.1,Other,100% New York Medicaid APG,2476.1,,,2476.1,Other,100% New York Medicaid APG,2476.1,,,2476.1,Other,100% New York Medicaid APG,5571.22,,,5571.22,Other,225% New York Medicaid APG,3788.43,,,3788.43,Other,153% New York Medicaid APG,5571.22,,,5571.22,Other,225% New York Medicaid APG,3466.54,,,3466.54,Other,140% New York Medicaid APG,5571.22,,,5571.22,Other,225% New York Medicaid APG,6437.85,,,6437.85,Other,260% New York Medicaid APG,8022.56,,,8022.56,Other,324% New York Medicaid APG,5323.61,,,5323.61,Other,215% New York Medicaid APG,5323.61,,,5323.61,Other,215% New York Medicaid APG,3095.12,,,3095.12,Other,125% New York Medicaid APG,2476.1,74386.82,
Perc d-e cor revasc t cabg s,C9604,HCPCS,,,,,,,,both,,,120990,89532.6,74,,89532.6,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,54445.5,45,,54445.5,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,59890.05,49.5,,59890.05,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,4605.54,,,4605.54,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9196,,"100% primary, 0% secondary procedures",9196,Other,MagnaCare ASC Grouper,84693,70,,84693,percent of total billed charges,,78643.5,65,,78643.5,percent of total billed charges,,78643.5,65,,78643.5,percent of total billed charges,,6956,,"100% primary, 50% secondary, 25% tertiary procedure",6956,Other,United Healthcare ASC Grouper,6261,,"100% primary, 50% secondary, 25% tertiary procedure",6261,Other,United Healthcare ASC Grouper,6956,,"100% primary, 50% secondary, 25% tertiary procedure",6956,Other,United Healthcare ASC Grouper,5913,,"100% primary, 50% secondary, 25% tertiary procedure",5913,Other,United Healthcare ASC Grouper,2476.1,,,2476.1,Other,New York Medicaid APG methodology,2476.1,,,2476.1,Other,100% New York Medicaid APG,2476.1,,,2476.1,Other,100% New York Medicaid APG,2476.1,,,2476.1,Other,100% New York Medicaid APG,5571.22,,,5571.22,Other,225% New York Medicaid APG,3788.43,,,3788.43,Other,153% New York Medicaid APG,5571.22,,,5571.22,Other,225% New York Medicaid APG,3466.54,,,3466.54,Other,140% New York Medicaid APG,5571.22,,,5571.22,Other,225% New York Medicaid APG,6437.85,,,6437.85,Other,260% New York Medicaid APG,8022.56,,,8022.56,Other,324% New York Medicaid APG,5323.61,,,5323.61,Other,215% New York Medicaid APG,5323.61,,,5323.61,Other,215% New York Medicaid APG,3095.12,,,3095.12,Other,125% New York Medicaid APG,2476.1,89532.6,
Revasc intra lithotrip-stent,C9765,HCPCS,,,,,,,,both,,,183637,135891.38,74,,135891.38,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,82636.65,45,,82636.65,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,90900.32,49.5,,90900.32,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,4605.53,,,4605.53,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,146909.6,80,,146909.6,percent of total billed charges,,128545.9,70,,128545.9,percent of total billed charges,,119364.05,65,,119364.05,percent of total billed charges,,119364.05,65,,119364.05,percent of total billed charges,,6956,,"100% primary, 50% secondary, 25% tertiary procedure",6956,Other,United Healthcare ASC Grouper,6261,,"100% primary, 50% secondary, 25% tertiary procedure",6261,Other,United Healthcare ASC Grouper,6956,,"100% primary, 50% secondary, 25% tertiary procedure",6956,Other,United Healthcare ASC Grouper,5913,,"100% primary, 50% secondary, 25% tertiary procedure",5913,Other,United Healthcare ASC Grouper,2476.09,,,2476.09,Other,New York Medicaid APG methodology,2476.09,,,2476.09,Other,100% New York Medicaid APG,2476.09,,,2476.09,Other,100% New York Medicaid APG,2476.09,,,2476.09,Other,100% New York Medicaid APG,5571.21,,,5571.21,Other,225% New York Medicaid APG,3788.42,,,3788.42,Other,153% New York Medicaid APG,5571.21,,,5571.21,Other,225% New York Medicaid APG,3466.53,,,3466.53,Other,140% New York Medicaid APG,5571.21,,,5571.21,Other,225% New York Medicaid APG,6437.84,,,6437.84,Other,260% New York Medicaid APG,8022.54,,,8022.54,Other,324% New York Medicaid APG,5323.6,,,5323.6,Other,215% New York Medicaid APG,5323.6,,,5323.6,Other,215% New York Medicaid APG,3095.12,,,3095.12,Other,125% New York Medicaid APG,2476.09,146909.6,
Revasc intra lithotrip-ather,C9766,HCPCS,,,,,,,,both,,,368828.98,272933.45,74,,272933.45,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,165973.04,45,,165973.04,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,182570.35,49.5,,182570.35,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,4605.53,,,4605.53,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,295063.18,80,,295063.18,percent of total billed charges,,258180.29,70,,258180.29,percent of total billed charges,,239738.84,65,,239738.84,percent of total billed charges,,239738.84,65,,239738.84,percent of total billed charges,,6956,,"100% primary, 50% secondary, 25% tertiary procedure",6956,Other,United Healthcare ASC Grouper,6261,,"100% primary, 50% secondary, 25% tertiary procedure",6261,Other,United Healthcare ASC Grouper,6956,,"100% primary, 50% secondary, 25% tertiary procedure",6956,Other,United Healthcare ASC Grouper,5913,,"100% primary, 50% secondary, 25% tertiary procedure",5913,Other,United Healthcare ASC Grouper,2476.09,,,2476.09,Other,New York Medicaid APG methodology,2476.09,,,2476.09,Other,100% New York Medicaid APG,2476.09,,,2476.09,Other,100% New York Medicaid APG,2476.09,,,2476.09,Other,100% New York Medicaid APG,5571.21,,,5571.21,Other,225% New York Medicaid APG,3788.42,,,3788.42,Other,153% New York Medicaid APG,5571.21,,,5571.21,Other,225% New York Medicaid APG,3466.53,,,3466.53,Other,140% New York Medicaid APG,5571.21,,,5571.21,Other,225% New York Medicaid APG,6437.84,,,6437.84,Other,260% New York Medicaid APG,8022.54,,,8022.54,Other,324% New York Medicaid APG,5323.6,,,5323.6,Other,215% New York Medicaid APG,5323.6,,,5323.6,Other,215% New York Medicaid APG,3095.12,,,3095.12,Other,125% New York Medicaid APG,2476.09,295063.18,
Revasc lithotrip tibi/perone,C9772,HCPCS,,,,,,,,both,,,231395.43,171232.62,74,,171232.62,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,104127.94,45,,104127.94,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,114540.74,49.5,,114540.74,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,4605.53,,,4605.53,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,185116.34,80,,185116.34,percent of total billed charges,,161976.8,70,,161976.8,percent of total billed charges,,150407.03,65,,150407.03,percent of total billed charges,,150407.03,65,,150407.03,percent of total billed charges,,6956,,"100% primary, 50% secondary, 25% tertiary procedure",6956,Other,United Healthcare ASC Grouper,6261,,"100% primary, 50% secondary, 25% tertiary procedure",6261,Other,United Healthcare ASC Grouper,6956,,"100% primary, 50% secondary, 25% tertiary procedure",6956,Other,United Healthcare ASC Grouper,5913,,"100% primary, 50% secondary, 25% tertiary procedure",5913,Other,United Healthcare ASC Grouper,2476.09,,,2476.09,Other,New York Medicaid APG methodology,2476.09,,,2476.09,Other,100% New York Medicaid APG,2476.09,,,2476.09,Other,100% New York Medicaid APG,2476.09,,,2476.09,Other,100% New York Medicaid APG,5571.21,,,5571.21,Other,225% New York Medicaid APG,3788.42,,,3788.42,Other,153% New York Medicaid APG,5571.21,,,5571.21,Other,225% New York Medicaid APG,3466.53,,,3466.53,Other,140% New York Medicaid APG,5571.21,,,5571.21,Other,225% New York Medicaid APG,6437.84,,,6437.84,Other,260% New York Medicaid APG,8022.54,,,8022.54,Other,324% New York Medicaid APG,5323.6,,,5323.6,Other,215% New York Medicaid APG,5323.6,,,5323.6,Other,215% New York Medicaid APG,3095.12,,,3095.12,Other,125% New York Medicaid APG,2476.09,185116.34,
Trluml perip athrc iliac art,0238T,HCPCS,,,,,,,,both,,,368828.98,272933.45,74,,272933.45,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,165973.04,45,,165973.04,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,182570.35,49.5,,182570.35,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,4605.54,,,4605.54,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9196,,"100% primary, 0% secondary procedures",9196,Other,MagnaCare ASC Grouper,258180.29,70,,258180.29,percent of total billed charges,,239738.84,65,,239738.84,percent of total billed charges,,239738.84,65,,239738.84,percent of total billed charges,,6956,,"100% primary, 50% secondary, 25% tertiary procedure",6956,Other,United Healthcare ASC Grouper,6261,,"100% primary, 50% secondary, 25% tertiary procedure",6261,Other,United Healthcare ASC Grouper,6956,,"100% primary, 50% secondary, 25% tertiary procedure",6956,Other,United Healthcare ASC Grouper,5913,,"100% primary, 50% secondary, 25% tertiary procedure",5913,Other,United Healthcare ASC Grouper,2476.1,,,2476.1,Other,New York Medicaid APG methodology,2476.1,,,2476.1,Other,100% New York Medicaid APG,2476.1,,,2476.1,Other,100% New York Medicaid APG,2476.1,,,2476.1,Other,100% New York Medicaid APG,5571.22,,,5571.22,Other,225% New York Medicaid APG,3788.43,,,3788.43,Other,153% New York Medicaid APG,5571.22,,,5571.22,Other,225% New York Medicaid APG,3466.54,,,3466.54,Other,140% New York Medicaid APG,5571.22,,,5571.22,Other,225% New York Medicaid APG,6437.85,,,6437.85,Other,260% New York Medicaid APG,8022.56,,,8022.56,Other,324% New York Medicaid APG,5323.61,,,5323.61,Other,215% New York Medicaid APG,5323.61,,,5323.61,Other,215% New York Medicaid APG,3095.12,,,3095.12,Other,125% New York Medicaid APG,2476.1,272933.45,
Evasc ven artlz tibl/prnl vn,0620T,HCPCS,,,,,,,,both,,,607098.41,449252.82,74,,449252.82,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,273194.28,45,,273194.28,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,300513.71,49.5,,300513.71,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,4605.54,,,4605.54,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,485678.73,80,,485678.73,percent of total billed charges,,424968.89,70,,424968.89,percent of total billed charges,,394613.97,65,,394613.97,percent of total billed charges,,394613.97,65,,394613.97,percent of total billed charges,,6956,,"100% primary, 50% secondary, 25% tertiary procedure",6956,Other,United Healthcare ASC Grouper,6261,,"100% primary, 50% secondary, 25% tertiary procedure",6261,Other,United Healthcare ASC Grouper,6956,,"100% primary, 50% secondary, 25% tertiary procedure",6956,Other,United Healthcare ASC Grouper,5913,,"100% primary, 50% secondary, 25% tertiary procedure",5913,Other,United Healthcare ASC Grouper,2476.1,,,2476.1,Other,New York Medicaid APG methodology,2476.1,,,2476.1,Other,100% New York Medicaid APG,2476.1,,,2476.1,Other,100% New York Medicaid APG,2476.1,,,2476.1,Other,100% New York Medicaid APG,5571.22,,,5571.22,Other,225% New York Medicaid APG,3788.43,,,3788.43,Other,153% New York Medicaid APG,5571.22,,,5571.22,Other,225% New York Medicaid APG,3466.54,,,3466.54,Other,140% New York Medicaid APG,5571.22,,,5571.22,Other,225% New York Medicaid APG,6437.85,,,6437.85,Other,260% New York Medicaid APG,8022.56,,,8022.56,Other,324% New York Medicaid APG,5323.61,,,5323.61,Other,215% New York Medicaid APG,5323.61,,,5323.61,Other,215% New York Medicaid APG,3095.12,,,3095.12,Other,125% New York Medicaid APG,2476.1,485678.73,
Perq tcat us abltj nrv p-art,0632T,HCPCS,,,,,,,,both,,,368828.98,272933.45,74,,272933.45,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,165973.04,45,,165973.04,percent of total billed charges,Medicare Ratio of cost to charges,5954,,"100% primary, 50% supplemental procedure",5954,Other,Aetna ASC Grouper,5359,,"100% primary, 50% supplemental procedure",5359,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,182570.35,49.5,,182570.35,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,4605.54,,,4605.54,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,295063.18,80,,295063.18,percent of total billed charges,,258180.29,70,,258180.29,percent of total billed charges,,239738.84,65,,239738.84,percent of total billed charges,,239738.84,65,,239738.84,percent of total billed charges,,6956,,"100% primary, 50% secondary, 25% tertiary procedure",6956,Other,United Healthcare ASC Grouper,6261,,"100% primary, 50% secondary, 25% tertiary procedure",6261,Other,United Healthcare ASC Grouper,6956,,"100% primary, 50% secondary, 25% tertiary procedure",6956,Other,United Healthcare ASC Grouper,5913,,"100% primary, 50% secondary, 25% tertiary procedure",5913,Other,United Healthcare ASC Grouper,2476.1,,,2476.1,Other,New York Medicaid APG methodology,2476.1,,,2476.1,Other,100% New York Medicaid APG,2476.1,,,2476.1,Other,100% New York Medicaid APG,2476.1,,,2476.1,Other,100% New York Medicaid APG,5571.22,,,5571.22,Other,225% New York Medicaid APG,3788.43,,,3788.43,Other,153% New York Medicaid APG,5571.22,,,5571.22,Other,225% New York Medicaid APG,3466.54,,,3466.54,Other,140% New York Medicaid APG,5571.22,,,5571.22,Other,225% New York Medicaid APG,6437.85,,,6437.85,Other,260% New York Medicaid APG,8022.56,,,8022.56,Other,324% New York Medicaid APG,5323.61,,,5323.61,Other,215% New York Medicaid APG,5323.61,,,5323.61,Other,215% New York Medicaid APG,3095.12,,,3095.12,Other,125% New York Medicaid APG,2476.1,295063.18,
Perc d-e cor stent ather s,C9602,HCPCS,,,,,,,,both,,,131418,97249.32,74,,97249.32,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,59138.1,45,,59138.1,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,65051.91,49.5,,65051.91,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,4605.54,,,4605.54,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9196,,"100% primary, 0% secondary procedures",9196,Other,MagnaCare ASC Grouper,91992.6,70,,91992.6,percent of total billed charges,,85421.7,65,,85421.7,percent of total billed charges,,85421.7,65,,85421.7,percent of total billed charges,,6956,,"100% primary, 50% secondary, 25% tertiary procedure",6956,Other,United Healthcare ASC Grouper,6261,,"100% primary, 50% secondary, 25% tertiary procedure",6261,Other,United Healthcare ASC Grouper,6956,,"100% primary, 50% secondary, 25% tertiary procedure",6956,Other,United Healthcare ASC Grouper,5913,,"100% primary, 50% secondary, 25% tertiary procedure",5913,Other,United Healthcare ASC Grouper,2476.1,,,2476.1,Other,New York Medicaid APG methodology,2476.1,,,2476.1,Other,100% New York Medicaid APG,2476.1,,,2476.1,Other,100% New York Medicaid APG,2476.1,,,2476.1,Other,100% New York Medicaid APG,5571.22,,,5571.22,Other,225% New York Medicaid APG,3788.43,,,3788.43,Other,153% New York Medicaid APG,5571.22,,,5571.22,Other,225% New York Medicaid APG,3466.54,,,3466.54,Other,140% New York Medicaid APG,5571.22,,,5571.22,Other,225% New York Medicaid APG,6437.85,,,6437.85,Other,260% New York Medicaid APG,8022.56,,,8022.56,Other,324% New York Medicaid APG,5323.61,,,5323.61,Other,215% New York Medicaid APG,5323.61,,,5323.61,Other,215% New York Medicaid APG,3095.12,,,3095.12,Other,125% New York Medicaid APG,2476.1,97249.32,
Perc d-e cor revasc chro sin,C9607,HCPCS,,,,,,,,both,,,131274,97142.76,74,,97142.76,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,59073.3,45,,59073.3,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,64980.63,49.5,,64980.63,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,4605.54,,,4605.54,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9196,,"100% primary, 0% secondary procedures",9196,Other,MagnaCare ASC Grouper,91891.8,70,,91891.8,percent of total billed charges,,85328.1,65,,85328.1,percent of total billed charges,,85328.1,65,,85328.1,percent of total billed charges,,6956,,"100% primary, 50% secondary, 25% tertiary procedure",6956,Other,United Healthcare ASC Grouper,6261,,"100% primary, 50% secondary, 25% tertiary procedure",6261,Other,United Healthcare ASC Grouper,6956,,"100% primary, 50% secondary, 25% tertiary procedure",6956,Other,United Healthcare ASC Grouper,5913,,"100% primary, 50% secondary, 25% tertiary procedure",5913,Other,United Healthcare ASC Grouper,2476.1,,,2476.1,Other,New York Medicaid APG methodology,2476.1,,,2476.1,Other,100% New York Medicaid APG,2476.1,,,2476.1,Other,100% New York Medicaid APG,2476.1,,,2476.1,Other,100% New York Medicaid APG,5571.22,,,5571.22,Other,225% New York Medicaid APG,3788.43,,,3788.43,Other,153% New York Medicaid APG,5571.22,,,5571.22,Other,225% New York Medicaid APG,3466.54,,,3466.54,Other,140% New York Medicaid APG,5571.22,,,5571.22,Other,225% New York Medicaid APG,6437.85,,,6437.85,Other,260% New York Medicaid APG,8022.56,,,8022.56,Other,324% New York Medicaid APG,5323.61,,,5323.61,Other,215% New York Medicaid APG,5323.61,,,5323.61,Other,215% New York Medicaid APG,3095.12,,,3095.12,Other,125% New York Medicaid APG,2476.1,97142.76,
Revasc lithotrip-stent-ather,C9767,HCPCS,,,,,,,,both,,,368828.98,272933.45,74,,272933.45,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,165973.04,45,,165973.04,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,182570.35,49.5,,182570.35,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,4605.54,,,4605.54,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,295063.18,80,,295063.18,percent of total billed charges,,258180.29,70,,258180.29,percent of total billed charges,,239738.84,65,,239738.84,percent of total billed charges,,239738.84,65,,239738.84,percent of total billed charges,,6956,,"100% primary, 50% secondary, 25% tertiary procedure",6956,Other,United Healthcare ASC Grouper,6261,,"100% primary, 50% secondary, 25% tertiary procedure",6261,Other,United Healthcare ASC Grouper,6956,,"100% primary, 50% secondary, 25% tertiary procedure",6956,Other,United Healthcare ASC Grouper,5913,,"100% primary, 50% secondary, 25% tertiary procedure",5913,Other,United Healthcare ASC Grouper,2476.1,,,2476.1,Other,New York Medicaid APG methodology,2476.1,,,2476.1,Other,100% New York Medicaid APG,2476.1,,,2476.1,Other,100% New York Medicaid APG,2476.1,,,2476.1,Other,100% New York Medicaid APG,5571.22,,,5571.22,Other,225% New York Medicaid APG,3788.43,,,3788.43,Other,153% New York Medicaid APG,5571.22,,,5571.22,Other,225% New York Medicaid APG,3466.54,,,3466.54,Other,140% New York Medicaid APG,5571.22,,,5571.22,Other,225% New York Medicaid APG,6437.85,,,6437.85,Other,260% New York Medicaid APG,8022.56,,,8022.56,Other,324% New York Medicaid APG,5323.61,,,5323.61,Other,215% New York Medicaid APG,5323.61,,,5323.61,Other,215% New York Medicaid APG,3095.12,,,3095.12,Other,125% New York Medicaid APG,2476.1,295063.18,
Revasc lithotr-stent tib/per,C9773,HCPCS,,,,,,,,both,,,368828.98,272933.45,74,,272933.45,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,165973.04,45,,165973.04,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,182570.35,49.5,,182570.35,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,4605.54,,,4605.54,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,295063.18,80,,295063.18,percent of total billed charges,,258180.29,70,,258180.29,percent of total billed charges,,239738.84,65,,239738.84,percent of total billed charges,,239738.84,65,,239738.84,percent of total billed charges,,6956,,"100% primary, 50% secondary, 25% tertiary procedure",6956,Other,United Healthcare ASC Grouper,6261,,"100% primary, 50% secondary, 25% tertiary procedure",6261,Other,United Healthcare ASC Grouper,6956,,"100% primary, 50% secondary, 25% tertiary procedure",6956,Other,United Healthcare ASC Grouper,5913,,"100% primary, 50% secondary, 25% tertiary procedure",5913,Other,United Healthcare ASC Grouper,2476.1,,,2476.1,Other,New York Medicaid APG methodology,2476.1,,,2476.1,Other,100% New York Medicaid APG,2476.1,,,2476.1,Other,100% New York Medicaid APG,2476.1,,,2476.1,Other,100% New York Medicaid APG,5571.22,,,5571.22,Other,225% New York Medicaid APG,3788.43,,,3788.43,Other,153% New York Medicaid APG,5571.22,,,5571.22,Other,225% New York Medicaid APG,3466.54,,,3466.54,Other,140% New York Medicaid APG,5571.22,,,5571.22,Other,225% New York Medicaid APG,6437.85,,,6437.85,Other,260% New York Medicaid APG,8022.56,,,8022.56,Other,324% New York Medicaid APG,5323.61,,,5323.61,Other,215% New York Medicaid APG,5323.61,,,5323.61,Other,215% New York Medicaid APG,3095.12,,,3095.12,Other,125% New York Medicaid APG,2476.1,295063.18,
Revasc lithotr-ather tib/per,C9774,HCPCS,,,,,,,,both,,,368828.98,272933.45,74,,272933.45,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,165973.04,45,,165973.04,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,182570.35,49.5,,182570.35,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,4605.54,,,4605.54,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,295063.18,80,,295063.18,percent of total billed charges,,258180.29,70,,258180.29,percent of total billed charges,,239738.84,65,,239738.84,percent of total billed charges,,239738.84,65,,239738.84,percent of total billed charges,,6956,,"100% primary, 50% secondary, 25% tertiary procedure",6956,Other,United Healthcare ASC Grouper,6261,,"100% primary, 50% secondary, 25% tertiary procedure",6261,Other,United Healthcare ASC Grouper,6956,,"100% primary, 50% secondary, 25% tertiary procedure",6956,Other,United Healthcare ASC Grouper,5913,,"100% primary, 50% secondary, 25% tertiary procedure",5913,Other,United Healthcare ASC Grouper,2476.1,,,2476.1,Other,New York Medicaid APG methodology,2476.1,,,2476.1,Other,100% New York Medicaid APG,2476.1,,,2476.1,Other,100% New York Medicaid APG,2476.1,,,2476.1,Other,100% New York Medicaid APG,5571.22,,,5571.22,Other,225% New York Medicaid APG,3788.43,,,3788.43,Other,153% New York Medicaid APG,5571.22,,,5571.22,Other,225% New York Medicaid APG,3466.54,,,3466.54,Other,140% New York Medicaid APG,5571.22,,,5571.22,Other,225% New York Medicaid APG,6437.85,,,6437.85,Other,260% New York Medicaid APG,8022.56,,,8022.56,Other,324% New York Medicaid APG,5323.61,,,5323.61,Other,215% New York Medicaid APG,5323.61,,,5323.61,Other,215% New York Medicaid APG,3095.12,,,3095.12,Other,125% New York Medicaid APG,2476.1,295063.18,
Revasc lith-sten-ath tib/per,C9775,HCPCS,,,,,,,,both,,,368828.98,272933.45,74,,272933.45,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,165973.04,45,,165973.04,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,182570.35,49.5,,182570.35,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,4605.54,,,4605.54,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,295063.18,80,,295063.18,percent of total billed charges,,258180.29,70,,258180.29,percent of total billed charges,,239738.84,65,,239738.84,percent of total billed charges,,239738.84,65,,239738.84,percent of total billed charges,,6956,,"100% primary, 50% secondary, 25% tertiary procedure",6956,Other,United Healthcare ASC Grouper,6261,,"100% primary, 50% secondary, 25% tertiary procedure",6261,Other,United Healthcare ASC Grouper,6956,,"100% primary, 50% secondary, 25% tertiary procedure",6956,Other,United Healthcare ASC Grouper,5913,,"100% primary, 50% secondary, 25% tertiary procedure",5913,Other,United Healthcare ASC Grouper,2476.1,,,2476.1,Other,New York Medicaid APG methodology,2476.1,,,2476.1,Other,100% New York Medicaid APG,2476.1,,,2476.1,Other,100% New York Medicaid APG,2476.1,,,2476.1,Other,100% New York Medicaid APG,5571.22,,,5571.22,Other,225% New York Medicaid APG,3788.43,,,3788.43,Other,153% New York Medicaid APG,5571.22,,,5571.22,Other,225% New York Medicaid APG,3466.54,,,3466.54,Other,140% New York Medicaid APG,5571.22,,,5571.22,Other,225% New York Medicaid APG,6437.85,,,6437.85,Other,260% New York Medicaid APG,8022.56,,,8022.56,Other,324% New York Medicaid APG,5323.61,,,5323.61,Other,215% New York Medicaid APG,5323.61,,,5323.61,Other,215% New York Medicaid APG,3095.12,,,3095.12,Other,125% New York Medicaid APG,2476.1,295063.18,
Rmvl cardiac modulj pls gen,0412T,HCPCS,,,,,,,,both,,,82599.65,61123.74,74,,61123.74,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,37169.84,45,,37169.84,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,40886.83,49.5,,40886.83,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3946.83,,,3946.83,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,57819.76,70,,57819.76,percent of total billed charges,,53689.77,65,,53689.77,percent of total billed charges,,53689.77,65,,53689.77,percent of total billed charges,,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,2121.95,,,2121.95,Other,New York Medicaid APG methodology,2121.95,,,2121.95,Other,100% New York Medicaid APG,2121.95,,,2121.95,Other,100% New York Medicaid APG,2121.95,,,2121.95,Other,100% New York Medicaid APG,4774.4,,,4774.4,Other,225% New York Medicaid APG,3246.59,,,3246.59,Other,153% New York Medicaid APG,4774.4,,,4774.4,Other,225% New York Medicaid APG,2970.74,,,2970.74,Other,140% New York Medicaid APG,4774.4,,,4774.4,Other,225% New York Medicaid APG,5517.08,,,5517.08,Other,260% New York Medicaid APG,6875.13,,,6875.13,Other,324% New York Medicaid APG,4562.2,,,4562.2,Other,215% New York Medicaid APG,4562.2,,,4562.2,Other,215% New York Medicaid APG,2652.44,,,2652.44,Other,125% New York Medicaid APG,2121.95,61123.74,
Rmvl car modulj tranvns elt,0413T,HCPCS,,,,,,,,both,,,82599.65,61123.74,74,,61123.74,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,37169.84,45,,37169.84,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,40886.83,49.5,,40886.83,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,4536.91,,,4536.91,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,57819.76,70,,57819.76,percent of total billed charges,,53689.77,65,,53689.77,percent of total billed charges,,53689.77,65,,53689.77,percent of total billed charges,,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,2439.2,,,2439.2,Other,New York Medicaid APG methodology,2439.2,,,2439.2,Other,100% New York Medicaid APG,2439.2,,,2439.2,Other,100% New York Medicaid APG,2439.2,,,2439.2,Other,100% New York Medicaid APG,5488.2,,,5488.2,Other,225% New York Medicaid APG,3731.98,,,3731.98,Other,153% New York Medicaid APG,5488.2,,,5488.2,Other,225% New York Medicaid APG,3414.88,,,3414.88,Other,140% New York Medicaid APG,5488.2,,,5488.2,Other,225% New York Medicaid APG,6341.92,,,6341.92,Other,260% New York Medicaid APG,7903.01,,,7903.01,Other,324% New York Medicaid APG,5244.28,,,5244.28,Other,215% New York Medicaid APG,5244.28,,,5244.28,Other,215% New York Medicaid APG,3049,,,3049,Other,125% New York Medicaid APG,2439.2,61123.74,
Rmvl pg compnt wcs,0518T,HCPCS,,,,,,,,both,,,82599.65,61123.74,74,,61123.74,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,37169.84,45,,37169.84,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,40886.83,49.5,,40886.83,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3946.83,,,3946.83,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,57819.76,70,,57819.76,percent of total billed charges,,53689.77,65,,53689.77,percent of total billed charges,,53689.77,65,,53689.77,percent of total billed charges,,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,2121.95,,,2121.95,Other,New York Medicaid APG methodology,2121.95,,,2121.95,Other,100% New York Medicaid APG,2121.95,,,2121.95,Other,100% New York Medicaid APG,2121.95,,,2121.95,Other,100% New York Medicaid APG,4774.4,,,4774.4,Other,225% New York Medicaid APG,3246.59,,,3246.59,Other,153% New York Medicaid APG,4774.4,,,4774.4,Other,225% New York Medicaid APG,2970.74,,,2970.74,Other,140% New York Medicaid APG,4774.4,,,4774.4,Other,225% New York Medicaid APG,5517.08,,,5517.08,Other,260% New York Medicaid APG,6875.13,,,6875.13,Other,324% New York Medicaid APG,4562.2,,,4562.2,Other,215% New York Medicaid APG,4562.2,,,4562.2,Other,215% New York Medicaid APG,2652.44,,,2652.44,Other,125% New York Medicaid APG,2121.95,61123.74,
Rmvl & rplcmt pg compnt wcs,0519T,HCPCS,,,,,,,,both,,,224603.78,166206.8,74,,166206.8,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,101071.7,45,,101071.7,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,111178.87,49.5,,111178.87,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,10683.75,,,10683.75,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,157222.65,70,,157222.65,percent of total billed charges,,145992.46,65,,145992.46,percent of total billed charges,,145992.46,65,,145992.46,percent of total billed charges,,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,5743.95,,,5743.95,Other,New York Medicaid APG methodology,5743.95,,,5743.95,Other,100% New York Medicaid APG,5743.95,,,5743.95,Other,100% New York Medicaid APG,5743.95,,,5743.95,Other,100% New York Medicaid APG,12923.9,,,12923.9,Other,225% New York Medicaid APG,8788.25,,,8788.25,Other,153% New York Medicaid APG,12923.9,,,12923.9,Other,225% New York Medicaid APG,8041.54,,,8041.54,Other,140% New York Medicaid APG,12923.9,,,12923.9,Other,225% New York Medicaid APG,14934.28,,,14934.28,Other,260% New York Medicaid APG,18610.41,,,18610.41,Other,324% New York Medicaid APG,12349.5,,,12349.5,Other,215% New York Medicaid APG,12349.5,,,12349.5,Other,215% New York Medicaid APG,7179.94,,,7179.94,Other,125% New York Medicaid APG,4061,166206.8,
Removal complete iims,0530T,HCPCS,,,,,,,,both,,,82599.65,61123.74,74,,61123.74,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,37169.84,45,,37169.84,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,40886.83,49.5,,40886.83,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3946.83,,,3946.83,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,57819.76,70,,57819.76,percent of total billed charges,,53689.77,65,,53689.77,percent of total billed charges,,53689.77,65,,53689.77,percent of total billed charges,,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,2121.95,,,2121.95,Other,New York Medicaid APG methodology,2121.95,,,2121.95,Other,100% New York Medicaid APG,2121.95,,,2121.95,Other,100% New York Medicaid APG,2121.95,,,2121.95,Other,100% New York Medicaid APG,4774.4,,,4774.4,Other,225% New York Medicaid APG,3246.59,,,3246.59,Other,153% New York Medicaid APG,4774.4,,,4774.4,Other,225% New York Medicaid APG,2970.74,,,2970.74,Other,140% New York Medicaid APG,4774.4,,,4774.4,Other,225% New York Medicaid APG,5517.08,,,5517.08,Other,260% New York Medicaid APG,6875.13,,,6875.13,Other,324% New York Medicaid APG,4562.2,,,4562.2,Other,215% New York Medicaid APG,4562.2,,,4562.2,Other,215% New York Medicaid APG,2652.44,,,2652.44,Other,125% New York Medicaid APG,2121.95,61123.74,
Removal iims electrode only,0531T,HCPCS,,,,,,,,both,,,82599.65,61123.74,74,,61123.74,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,37169.84,45,,37169.84,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,40886.83,49.5,,40886.83,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,4536.91,,,4536.91,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,57819.76,70,,57819.76,percent of total billed charges,,53689.77,65,,53689.77,percent of total billed charges,,53689.77,65,,53689.77,percent of total billed charges,,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,2439.2,,,2439.2,Other,New York Medicaid APG methodology,2439.2,,,2439.2,Other,100% New York Medicaid APG,2439.2,,,2439.2,Other,100% New York Medicaid APG,2439.2,,,2439.2,Other,100% New York Medicaid APG,5488.2,,,5488.2,Other,225% New York Medicaid APG,3731.98,,,3731.98,Other,153% New York Medicaid APG,5488.2,,,5488.2,Other,225% New York Medicaid APG,3414.88,,,3414.88,Other,140% New York Medicaid APG,5488.2,,,5488.2,Other,225% New York Medicaid APG,6341.92,,,6341.92,Other,260% New York Medicaid APG,7903.01,,,7903.01,Other,324% New York Medicaid APG,5244.28,,,5244.28,Other,215% New York Medicaid APG,5244.28,,,5244.28,Other,215% New York Medicaid APG,3049,,,3049,Other,125% New York Medicaid APG,2439.2,61123.74,
Removal iims implt mntr only,0532T,HCPCS,,,,,,,,both,,,82599.65,61123.74,74,,61123.74,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,37169.84,45,,37169.84,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,40886.83,49.5,,40886.83,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3946.83,,,3946.83,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,57819.76,70,,57819.76,percent of total billed charges,,53689.77,65,,53689.77,percent of total billed charges,,53689.77,65,,53689.77,percent of total billed charges,,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,2121.95,,,2121.95,Other,New York Medicaid APG methodology,2121.95,,,2121.95,Other,100% New York Medicaid APG,2121.95,,,2121.95,Other,100% New York Medicaid APG,2121.95,,,2121.95,Other,100% New York Medicaid APG,4774.4,,,4774.4,Other,225% New York Medicaid APG,3246.59,,,3246.59,Other,153% New York Medicaid APG,4774.4,,,4774.4,Other,225% New York Medicaid APG,2970.74,,,2970.74,Other,140% New York Medicaid APG,4774.4,,,4774.4,Other,225% New York Medicaid APG,5517.08,,,5517.08,Other,260% New York Medicaid APG,6875.13,,,6875.13,Other,324% New York Medicaid APG,4562.2,,,4562.2,Other,215% New York Medicaid APG,4562.2,,,4562.2,Other,215% New York Medicaid APG,2652.44,,,2652.44,Other,125% New York Medicaid APG,2121.95,61123.74,
Insj/rplc car modulj atr elt,0410T,HCPCS,,,,,,,,both,,,178695.84,132234.92,74,,132234.92,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,80413.13,45,,80413.13,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,88454.44,49.5,,88454.44,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,4536.91,,,4536.91,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9196,,"100% primary, 0% secondary procedures",9196,Other,MagnaCare ASC Grouper,125087.09,70,,125087.09,percent of total billed charges,,116152.3,65,,116152.3,percent of total billed charges,,116152.3,65,,116152.3,percent of total billed charges,,6956,,"100% primary, 50% secondary, 25% tertiary procedure",6956,Other,United Healthcare ASC Grouper,6261,,"100% primary, 50% secondary, 25% tertiary procedure",6261,Other,United Healthcare ASC Grouper,6956,,"100% primary, 50% secondary, 25% tertiary procedure",6956,Other,United Healthcare ASC Grouper,5913,,"100% primary, 50% secondary, 25% tertiary procedure",5913,Other,United Healthcare ASC Grouper,2439.2,,,2439.2,Other,New York Medicaid APG methodology,2439.2,,,2439.2,Other,100% New York Medicaid APG,2439.2,,,2439.2,Other,100% New York Medicaid APG,2439.2,,,2439.2,Other,100% New York Medicaid APG,5488.2,,,5488.2,Other,225% New York Medicaid APG,3731.98,,,3731.98,Other,153% New York Medicaid APG,5488.2,,,5488.2,Other,225% New York Medicaid APG,3414.88,,,3414.88,Other,140% New York Medicaid APG,5488.2,,,5488.2,Other,225% New York Medicaid APG,6341.92,,,6341.92,Other,260% New York Medicaid APG,7903.01,,,7903.01,Other,324% New York Medicaid APG,5244.28,,,5244.28,Other,215% New York Medicaid APG,5244.28,,,5244.28,Other,215% New York Medicaid APG,3049,,,3049,Other,125% New York Medicaid APG,2439.2,132234.92,
Insj/rplc car modulj vnt elt,0411T,HCPCS,,,,,,,,both,,,178695.84,132234.92,74,,132234.92,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,80413.13,45,,80413.13,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,88454.44,49.5,,88454.44,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,4536.91,,,4536.91,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9196,,"100% primary, 0% secondary procedures",9196,Other,MagnaCare ASC Grouper,125087.09,70,,125087.09,percent of total billed charges,,116152.3,65,,116152.3,percent of total billed charges,,116152.3,65,,116152.3,percent of total billed charges,,6956,,"100% primary, 50% secondary, 25% tertiary procedure",6956,Other,United Healthcare ASC Grouper,6261,,"100% primary, 50% secondary, 25% tertiary procedure",6261,Other,United Healthcare ASC Grouper,6956,,"100% primary, 50% secondary, 25% tertiary procedure",6956,Other,United Healthcare ASC Grouper,5913,,"100% primary, 50% secondary, 25% tertiary procedure",5913,Other,United Healthcare ASC Grouper,2439.2,,,2439.2,Other,New York Medicaid APG methodology,2439.2,,,2439.2,Other,100% New York Medicaid APG,2439.2,,,2439.2,Other,100% New York Medicaid APG,2439.2,,,2439.2,Other,100% New York Medicaid APG,5488.2,,,5488.2,Other,225% New York Medicaid APG,3731.98,,,3731.98,Other,153% New York Medicaid APG,5488.2,,,5488.2,Other,225% New York Medicaid APG,3414.88,,,3414.88,Other,140% New York Medicaid APG,5488.2,,,5488.2,Other,225% New York Medicaid APG,6341.92,,,6341.92,Other,260% New York Medicaid APG,7903.01,,,7903.01,Other,324% New York Medicaid APG,5244.28,,,5244.28,Other,215% New York Medicaid APG,5244.28,,,5244.28,Other,215% New York Medicaid APG,3049,,,3049,Other,125% New York Medicaid APG,2439.2,132234.92,
Insj wcs lv eltrd only,0516T,HCPCS,,,,,,,,both,,,224603.78,166206.8,74,,166206.8,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,101071.7,45,,101071.7,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,111178.87,49.5,,111178.87,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,4536.91,,,4536.91,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9196,,"100% primary, 0% secondary procedures",9196,Other,MagnaCare ASC Grouper,157222.65,70,,157222.65,percent of total billed charges,,145992.46,65,,145992.46,percent of total billed charges,,145992.46,65,,145992.46,percent of total billed charges,,6956,,"100% primary, 50% secondary, 25% tertiary procedure",6956,Other,United Healthcare ASC Grouper,6261,,"100% primary, 50% secondary, 25% tertiary procedure",6261,Other,United Healthcare ASC Grouper,6956,,"100% primary, 50% secondary, 25% tertiary procedure",6956,Other,United Healthcare ASC Grouper,5913,,"100% primary, 50% secondary, 25% tertiary procedure",5913,Other,United Healthcare ASC Grouper,2439.2,,,2439.2,Other,New York Medicaid APG methodology,2439.2,,,2439.2,Other,100% New York Medicaid APG,2439.2,,,2439.2,Other,100% New York Medicaid APG,2439.2,,,2439.2,Other,100% New York Medicaid APG,5488.2,,,5488.2,Other,225% New York Medicaid APG,3731.98,,,3731.98,Other,153% New York Medicaid APG,5488.2,,,5488.2,Other,225% New York Medicaid APG,3414.88,,,3414.88,Other,140% New York Medicaid APG,5488.2,,,5488.2,Other,225% New York Medicaid APG,6341.92,,,6341.92,Other,260% New York Medicaid APG,7903.01,,,7903.01,Other,324% New York Medicaid APG,5244.28,,,5244.28,Other,215% New York Medicaid APG,5244.28,,,5244.28,Other,215% New York Medicaid APG,3049,,,3049,Other,125% New York Medicaid APG,2439.2,166206.8,
Insj wcs lv pg compnt,0517T,HCPCS,,,,,,,,both,,,224603.78,166206.8,74,,166206.8,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,101071.7,45,,101071.7,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,111178.87,49.5,,111178.87,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,10683.75,,,10683.75,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9196,,"100% primary, 0% secondary procedures",9196,Other,MagnaCare ASC Grouper,157222.65,70,,157222.65,percent of total billed charges,,145992.46,65,,145992.46,percent of total billed charges,,145992.46,65,,145992.46,percent of total billed charges,,6956,,"100% primary, 50% secondary, 25% tertiary procedure",6956,Other,United Healthcare ASC Grouper,6261,,"100% primary, 50% secondary, 25% tertiary procedure",6261,Other,United Healthcare ASC Grouper,6956,,"100% primary, 50% secondary, 25% tertiary procedure",6956,Other,United Healthcare ASC Grouper,5913,,"100% primary, 50% secondary, 25% tertiary procedure",5913,Other,United Healthcare ASC Grouper,5743.95,,,5743.95,Other,New York Medicaid APG methodology,5743.95,,,5743.95,Other,100% New York Medicaid APG,5743.95,,,5743.95,Other,100% New York Medicaid APG,5743.95,,,5743.95,Other,100% New York Medicaid APG,12923.9,,,12923.9,Other,225% New York Medicaid APG,8788.25,,,8788.25,Other,153% New York Medicaid APG,12923.9,,,12923.9,Other,225% New York Medicaid APG,8041.54,,,8041.54,Other,140% New York Medicaid APG,12923.9,,,12923.9,Other,225% New York Medicaid APG,14934.28,,,14934.28,Other,260% New York Medicaid APG,18610.41,,,18610.41,Other,324% New York Medicaid APG,12349.5,,,12349.5,Other,215% New York Medicaid APG,12349.5,,,12349.5,Other,215% New York Medicaid APG,7179.94,,,7179.94,Other,125% New York Medicaid APG,4109,166206.8,
Insj/rplcmt iims eltrd only,0526T,HCPCS,,,,,,,,both,,,178695.84,132234.92,74,,132234.92,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,80413.13,45,,80413.13,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,88454.44,49.5,,88454.44,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,4536.91,,,4536.91,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,125087.09,70,,125087.09,percent of total billed charges,,116152.3,65,,116152.3,percent of total billed charges,,116152.3,65,,116152.3,percent of total billed charges,,6956,,"100% primary, 50% secondary, 25% tertiary procedure",6956,Other,United Healthcare ASC Grouper,6261,,"100% primary, 50% secondary, 25% tertiary procedure",6261,Other,United Healthcare ASC Grouper,6956,,"100% primary, 50% secondary, 25% tertiary procedure",6956,Other,United Healthcare ASC Grouper,5913,,"100% primary, 50% secondary, 25% tertiary procedure",5913,Other,United Healthcare ASC Grouper,2439.2,,,2439.2,Other,New York Medicaid APG methodology,2439.2,,,2439.2,Other,100% New York Medicaid APG,2439.2,,,2439.2,Other,100% New York Medicaid APG,2439.2,,,2439.2,Other,100% New York Medicaid APG,5488.2,,,5488.2,Other,225% New York Medicaid APG,3731.98,,,3731.98,Other,153% New York Medicaid APG,5488.2,,,5488.2,Other,225% New York Medicaid APG,3414.88,,,3414.88,Other,140% New York Medicaid APG,5488.2,,,5488.2,Other,225% New York Medicaid APG,6341.92,,,6341.92,Other,260% New York Medicaid APG,7903.01,,,7903.01,Other,324% New York Medicaid APG,5244.28,,,5244.28,Other,215% New York Medicaid APG,5244.28,,,5244.28,Other,215% New York Medicaid APG,3049,,,3049,Other,125% New York Medicaid APG,2439.2,132234.92,
Insj/rplcmt iims implt mntr,0527T,HCPCS,,,,,,,,both,,,178695.84,132234.92,74,,132234.92,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,80413.13,45,,80413.13,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,88454.44,49.5,,88454.44,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,10683.75,,,10683.75,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,125087.09,70,,125087.09,percent of total billed charges,,116152.3,65,,116152.3,percent of total billed charges,,116152.3,65,,116152.3,percent of total billed charges,,6956,,"100% primary, 50% secondary, 25% tertiary procedure",6956,Other,United Healthcare ASC Grouper,6261,,"100% primary, 50% secondary, 25% tertiary procedure",6261,Other,United Healthcare ASC Grouper,6956,,"100% primary, 50% secondary, 25% tertiary procedure",6956,Other,United Healthcare ASC Grouper,5913,,"100% primary, 50% secondary, 25% tertiary procedure",5913,Other,United Healthcare ASC Grouper,5743.95,,,5743.95,Other,New York Medicaid APG methodology,5743.95,,,5743.95,Other,100% New York Medicaid APG,5743.95,,,5743.95,Other,100% New York Medicaid APG,5743.95,,,5743.95,Other,100% New York Medicaid APG,12923.9,,,12923.9,Other,225% New York Medicaid APG,8788.25,,,8788.25,Other,153% New York Medicaid APG,12923.9,,,12923.9,Other,225% New York Medicaid APG,8041.54,,,8041.54,Other,140% New York Medicaid APG,12923.9,,,12923.9,Other,225% New York Medicaid APG,14934.28,,,14934.28,Other,260% New York Medicaid APG,18610.41,,,18610.41,Other,324% New York Medicaid APG,12349.5,,,12349.5,Other,215% New York Medicaid APG,12349.5,,,12349.5,Other,215% New York Medicaid APG,7179.94,,,7179.94,Other,125% New York Medicaid APG,3148,132234.92,
Insj/rplcmt compl iims,0525T,HCPCS,,,,,,,,both,,,224603.78,166206.8,74,,166206.8,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,101071.7,45,,101071.7,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,111178.87,49.5,,111178.87,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,10683.75,,,10683.75,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,157222.65,70,,157222.65,percent of total billed charges,,145992.46,65,,145992.46,percent of total billed charges,,145992.46,65,,145992.46,percent of total billed charges,,6956,,"100% primary, 50% secondary, 25% tertiary procedure",6956,Other,United Healthcare ASC Grouper,6261,,"100% primary, 50% secondary, 25% tertiary procedure",6261,Other,United Healthcare ASC Grouper,6956,,"100% primary, 50% secondary, 25% tertiary procedure",6956,Other,United Healthcare ASC Grouper,5913,,"100% primary, 50% secondary, 25% tertiary procedure",5913,Other,United Healthcare ASC Grouper,5743.95,,,5743.95,Other,New York Medicaid APG methodology,5743.95,,,5743.95,Other,100% New York Medicaid APG,5743.95,,,5743.95,Other,100% New York Medicaid APG,5743.95,,,5743.95,Other,100% New York Medicaid APG,12923.9,,,12923.9,Other,225% New York Medicaid APG,8788.25,,,8788.25,Other,153% New York Medicaid APG,12923.9,,,12923.9,Other,225% New York Medicaid APG,8041.54,,,8041.54,Other,140% New York Medicaid APG,12923.9,,,12923.9,Other,225% New York Medicaid APG,14934.28,,,14934.28,Other,260% New York Medicaid APG,18610.41,,,18610.41,Other,324% New York Medicaid APG,12349.5,,,12349.5,Other,215% New York Medicaid APG,12349.5,,,12349.5,Other,215% New York Medicaid APG,7179.94,,,7179.94,Other,125% New York Medicaid APG,3148,166206.8,
Insj/rplc cardiac modulj sys,0408T,HCPCS,,,,,,,,both,,,691990.86,512073.24,74,,512073.24,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,311395.89,45,,311395.89,percent of total billed charges,Medicare Ratio of cost to charges,5954,,"100% primary, 50% supplemental procedure",5954,Other,Aetna ASC Grouper,5359,,"100% primary, 50% supplemental procedure",5359,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,342535.48,49.5,,342535.48,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,10683.75,,,10683.75,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9196,,"100% primary, 0% secondary procedures",9196,Other,MagnaCare ASC Grouper,484393.6,70,,484393.6,percent of total billed charges,,449794.06,65,,449794.06,percent of total billed charges,,449794.06,65,,449794.06,percent of total billed charges,,15267,,"100% primary, 50% secondary, 25% tertiary procedure",15267,Other,United Healthcare ASC Grouper,13740,,"100% primary, 50% secondary, 25% tertiary procedure",13740,Other,United Healthcare ASC Grouper,15267,,"100% primary, 50% secondary, 25% tertiary procedure",15267,Other,United Healthcare ASC Grouper,12977,,"100% primary, 50% secondary, 25% tertiary procedure",12977,Other,United Healthcare ASC Grouper,5743.95,,,5743.95,Other,New York Medicaid APG methodology,5743.95,,,5743.95,Other,100% New York Medicaid APG,5743.95,,,5743.95,Other,100% New York Medicaid APG,5743.95,,,5743.95,Other,100% New York Medicaid APG,12923.9,,,12923.9,Other,225% New York Medicaid APG,8788.25,,,8788.25,Other,153% New York Medicaid APG,12923.9,,,12923.9,Other,225% New York Medicaid APG,8041.54,,,8041.54,Other,140% New York Medicaid APG,12923.9,,,12923.9,Other,225% New York Medicaid APG,14934.28,,,14934.28,Other,260% New York Medicaid APG,18610.41,,,18610.41,Other,324% New York Medicaid APG,12349.5,,,12349.5,Other,215% New York Medicaid APG,12349.5,,,12349.5,Other,215% New York Medicaid APG,7179.94,,,7179.94,Other,125% New York Medicaid APG,5359,512073.24,
Insj/rplc car modulj pls gn,0409T,HCPCS,,,,,,,,both,,,495795.01,366888.31,74,,366888.31,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,223107.75,45,,223107.75,percent of total billed charges,Medicare Ratio of cost to charges,5954,,"100% primary, 50% supplemental procedure",5954,Other,Aetna ASC Grouper,5359,,"100% primary, 50% supplemental procedure",5359,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,245418.53,49.5,,245418.53,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,25102.82,,,25102.82,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9196,,"100% primary, 0% secondary procedures",9196,Other,MagnaCare ASC Grouper,347056.51,70,,347056.51,percent of total billed charges,,322266.76,65,,322266.76,percent of total billed charges,,322266.76,65,,322266.76,percent of total billed charges,,15267,,"100% primary, 50% secondary, 25% tertiary procedure",15267,Other,United Healthcare ASC Grouper,13740,,"100% primary, 50% secondary, 25% tertiary procedure",13740,Other,United Healthcare ASC Grouper,15267,,"100% primary, 50% secondary, 25% tertiary procedure",15267,Other,United Healthcare ASC Grouper,12977,,"100% primary, 50% secondary, 25% tertiary procedure",12977,Other,United Healthcare ASC Grouper,13496.14,,,13496.14,Other,New York Medicaid APG methodology,13496.14,,,13496.14,Other,100% New York Medicaid APG,13496.14,,,13496.14,Other,100% New York Medicaid APG,13496.14,,,13496.14,Other,100% New York Medicaid APG,30366.31,,,30366.31,Other,225% New York Medicaid APG,20649.09,,,20649.09,Other,153% New York Medicaid APG,30366.31,,,30366.31,Other,225% New York Medicaid APG,18894.6,,,18894.6,Other,140% New York Medicaid APG,30366.31,,,30366.31,Other,225% New York Medicaid APG,35089.96,,,35089.96,Other,260% New York Medicaid APG,43727.49,,,43727.49,Other,324% New York Medicaid APG,29016.7,,,29016.7,Other,215% New York Medicaid APG,29016.7,,,29016.7,Other,215% New York Medicaid APG,16870.17,,,16870.17,Other,125% New York Medicaid APG,5359,366888.31,
Rmvl & rpl car modulj pls gn,0414T,HCPCS,,,,,,,,both,,,495795.01,366888.31,74,,366888.31,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,223107.75,45,,223107.75,percent of total billed charges,Medicare Ratio of cost to charges,5954,,"100% primary, 50% supplemental procedure",5954,Other,Aetna ASC Grouper,5359,,"100% primary, 50% supplemental procedure",5359,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,245418.53,49.5,,245418.53,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,25102.82,,,25102.82,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9196,,"100% primary, 0% secondary procedures",9196,Other,MagnaCare ASC Grouper,347056.51,70,,347056.51,percent of total billed charges,,322266.76,65,,322266.76,percent of total billed charges,,322266.76,65,,322266.76,percent of total billed charges,,15267,,"100% primary, 50% secondary, 25% tertiary procedure",15267,Other,United Healthcare ASC Grouper,13740,,"100% primary, 50% secondary, 25% tertiary procedure",13740,Other,United Healthcare ASC Grouper,15267,,"100% primary, 50% secondary, 25% tertiary procedure",15267,Other,United Healthcare ASC Grouper,12977,,"100% primary, 50% secondary, 25% tertiary procedure",12977,Other,United Healthcare ASC Grouper,13496.14,,,13496.14,Other,New York Medicaid APG methodology,13496.14,,,13496.14,Other,100% New York Medicaid APG,13496.14,,,13496.14,Other,100% New York Medicaid APG,13496.14,,,13496.14,Other,100% New York Medicaid APG,30366.31,,,30366.31,Other,225% New York Medicaid APG,20649.09,,,20649.09,Other,153% New York Medicaid APG,30366.31,,,30366.31,Other,225% New York Medicaid APG,18894.6,,,18894.6,Other,140% New York Medicaid APG,30366.31,,,30366.31,Other,225% New York Medicaid APG,35089.96,,,35089.96,Other,260% New York Medicaid APG,43727.49,,,43727.49,Other,324% New York Medicaid APG,29016.7,,,29016.7,Other,215% New York Medicaid APG,29016.7,,,29016.7,Other,215% New York Medicaid APG,16870.17,,,16870.17,Other,125% New York Medicaid APG,5359,366888.31,
Insj wcs lv compl sys,0515T,HCPCS,,,,,,,,both,,,495795.01,366888.31,74,,366888.31,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,223107.75,45,,223107.75,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,245418.53,49.5,,245418.53,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,10683.75,,,10683.75,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9196,,"100% primary, 0% secondary procedures",9196,Other,MagnaCare ASC Grouper,347056.51,70,,347056.51,percent of total billed charges,,322266.76,65,,322266.76,percent of total billed charges,,322266.76,65,,322266.76,percent of total billed charges,,15267,,"100% primary, 50% secondary, 25% tertiary procedure",15267,Other,United Healthcare ASC Grouper,13740,,"100% primary, 50% secondary, 25% tertiary procedure",13740,Other,United Healthcare ASC Grouper,15267,,"100% primary, 50% secondary, 25% tertiary procedure",15267,Other,United Healthcare ASC Grouper,12977,,"100% primary, 50% secondary, 25% tertiary procedure",12977,Other,United Healthcare ASC Grouper,5743.95,,,5743.95,Other,New York Medicaid APG methodology,5743.95,,,5743.95,Other,100% New York Medicaid APG,5743.95,,,5743.95,Other,100% New York Medicaid APG,5743.95,,,5743.95,Other,100% New York Medicaid APG,12923.9,,,12923.9,Other,225% New York Medicaid APG,8788.25,,,8788.25,Other,153% New York Medicaid APG,12923.9,,,12923.9,Other,225% New York Medicaid APG,8041.54,,,8041.54,Other,140% New York Medicaid APG,12923.9,,,12923.9,Other,225% New York Medicaid APG,14934.28,,,14934.28,Other,260% New York Medicaid APG,18610.41,,,18610.41,Other,324% New York Medicaid APG,12349.5,,,12349.5,Other,215% New York Medicaid APG,12349.5,,,12349.5,Other,215% New York Medicaid APG,7179.94,,,7179.94,Other,125% New York Medicaid APG,4109,366888.31,
Rmvl&rplcmt pg wcs new eltrd,0520T,HCPCS,,,,,,,,both,,,224603.78,166206.8,74,,166206.8,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,101071.7,45,,101071.7,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,111178.87,49.5,,111178.87,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,25102.82,,,25102.82,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9196,,"100% primary, 0% secondary procedures",9196,Other,MagnaCare ASC Grouper,157222.65,70,,157222.65,percent of total billed charges,,145992.46,65,,145992.46,percent of total billed charges,,145992.46,65,,145992.46,percent of total billed charges,,15267,,"100% primary, 50% secondary, 25% tertiary procedure",15267,Other,United Healthcare ASC Grouper,13740,,"100% primary, 50% secondary, 25% tertiary procedure",13740,Other,United Healthcare ASC Grouper,15267,,"100% primary, 50% secondary, 25% tertiary procedure",15267,Other,United Healthcare ASC Grouper,12977,,"100% primary, 50% secondary, 25% tertiary procedure",12977,Other,United Healthcare ASC Grouper,13496.14,,,13496.14,Other,New York Medicaid APG methodology,13496.14,,,13496.14,Other,100% New York Medicaid APG,13496.14,,,13496.14,Other,100% New York Medicaid APG,13496.14,,,13496.14,Other,100% New York Medicaid APG,30366.31,,,30366.31,Other,225% New York Medicaid APG,20649.09,,,20649.09,Other,153% New York Medicaid APG,30366.31,,,30366.31,Other,225% New York Medicaid APG,18894.6,,,18894.6,Other,140% New York Medicaid APG,30366.31,,,30366.31,Other,225% New York Medicaid APG,35089.96,,,35089.96,Other,260% New York Medicaid APG,43727.49,,,43727.49,Other,324% New York Medicaid APG,29016.7,,,29016.7,Other,215% New York Medicaid APG,29016.7,,,29016.7,Other,215% New York Medicaid APG,16870.17,,,16870.17,Other,125% New York Medicaid APG,4109,166206.8,
Rmvl&rplcmt ss impl dfb pg,0614T,HCPCS,,,,,,,,both,,,495795.01,366888.31,74,,366888.31,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,223107.75,45,,223107.75,percent of total billed charges,Medicare Ratio of cost to charges,5459,,"100% primary, 50% supplemental procedure",5459,Other,Aetna ASC Grouper,4913,,"100% primary, 50% supplemental procedure",4913,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,245418.53,49.5,,245418.53,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,25102.82,,,25102.82,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,396636.01,80,,396636.01,percent of total billed charges,,347056.51,70,,347056.51,percent of total billed charges,,322266.76,65,,322266.76,percent of total billed charges,,322266.76,65,,322266.76,percent of total billed charges,,15267,,"100% primary, 50% secondary, 25% tertiary procedure",15267,Other,United Healthcare ASC Grouper,13740,,"100% primary, 50% secondary, 25% tertiary procedure",13740,Other,United Healthcare ASC Grouper,15267,,"100% primary, 50% secondary, 25% tertiary procedure",15267,Other,United Healthcare ASC Grouper,12977,,"100% primary, 50% secondary, 25% tertiary procedure",12977,Other,United Healthcare ASC Grouper,13496.14,,,13496.14,Other,New York Medicaid APG methodology,13496.14,,,13496.14,Other,100% New York Medicaid APG,13496.14,,,13496.14,Other,100% New York Medicaid APG,13496.14,,,13496.14,Other,100% New York Medicaid APG,30366.31,,,30366.31,Other,225% New York Medicaid APG,20649.09,,,20649.09,Other,153% New York Medicaid APG,30366.31,,,30366.31,Other,225% New York Medicaid APG,18894.6,,,18894.6,Other,140% New York Medicaid APG,30366.31,,,30366.31,Other,225% New York Medicaid APG,35089.96,,,35089.96,Other,260% New York Medicaid APG,43727.49,,,43727.49,Other,324% New York Medicaid APG,29016.7,,,29016.7,Other,215% New York Medicaid APG,29016.7,,,29016.7,Other,215% New York Medicaid APG,16870.17,,,16870.17,Other,125% New York Medicaid APG,4913,396636.01,
Im b1 mrw cel ther cmpl,0263T,HCPCS,,,,,,,,both,,,97340.17,72031.73,74,,72031.73,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,43803.08,45,,43803.08,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,48183.38,49.5,,48183.38,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3573.86,,,3573.86,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,68138.12,70,,68138.12,percent of total billed charges,,63271.11,65,,63271.11,percent of total billed charges,,63271.11,65,,63271.11,percent of total billed charges,,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,1921.43,,,1921.43,Other,New York Medicaid APG methodology,1921.43,,,1921.43,Other,100% New York Medicaid APG,1921.43,,,1921.43,Other,100% New York Medicaid APG,1921.43,,,1921.43,Other,100% New York Medicaid APG,4323.22,,,4323.22,Other,225% New York Medicaid APG,2939.79,,,2939.79,Other,153% New York Medicaid APG,4323.22,,,4323.22,Other,225% New York Medicaid APG,2690.01,,,2690.01,Other,140% New York Medicaid APG,4323.22,,,4323.22,Other,225% New York Medicaid APG,4995.72,,,4995.72,Other,260% New York Medicaid APG,6225.44,,,6225.44,Other,324% New York Medicaid APG,4131.08,,,4131.08,Other,215% New York Medicaid APG,4131.08,,,4131.08,Other,215% New York Medicaid APG,2401.79,,,2401.79,Other,125% New York Medicaid APG,1921.43,72031.73,
Im b1 mrw cel ther xcl hrvst,0264T,HCPCS,,,,,,,,both,,,97340.17,72031.73,74,,72031.73,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,43803.08,45,,43803.08,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,48183.38,49.5,,48183.38,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3573.86,,,3573.86,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,68138.12,70,,68138.12,percent of total billed charges,,63271.11,65,,63271.11,percent of total billed charges,,63271.11,65,,63271.11,percent of total billed charges,,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,1921.43,,,1921.43,Other,New York Medicaid APG methodology,1921.43,,,1921.43,Other,100% New York Medicaid APG,1921.43,,,1921.43,Other,100% New York Medicaid APG,1921.43,,,1921.43,Other,100% New York Medicaid APG,4323.22,,,4323.22,Other,225% New York Medicaid APG,2939.79,,,2939.79,Other,153% New York Medicaid APG,4323.22,,,4323.22,Other,225% New York Medicaid APG,2690.01,,,2690.01,Other,140% New York Medicaid APG,4323.22,,,4323.22,Other,225% New York Medicaid APG,4995.72,,,4995.72,Other,260% New York Medicaid APG,6225.44,,,6225.44,Other,324% New York Medicaid APG,4131.08,,,4131.08,Other,215% New York Medicaid APG,4131.08,,,4131.08,Other,215% New York Medicaid APG,2401.79,,,2401.79,Other,125% New York Medicaid APG,1921.43,72031.73,
Im b1 mrw cel ther hrvst onl,0265T,HCPCS,,,,,,,,both,,,97340.17,72031.73,74,,72031.73,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,43803.08,45,,43803.08,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,48183.38,49.5,,48183.38,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3573.86,,,3573.86,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,68138.12,70,,68138.12,percent of total billed charges,,63271.11,65,,63271.11,percent of total billed charges,,63271.11,65,,63271.11,percent of total billed charges,,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,1921.43,,,1921.43,Other,New York Medicaid APG methodology,1921.43,,,1921.43,Other,100% New York Medicaid APG,1921.43,,,1921.43,Other,100% New York Medicaid APG,1921.43,,,1921.43,Other,100% New York Medicaid APG,4323.22,,,4323.22,Other,225% New York Medicaid APG,2939.79,,,2939.79,Other,153% New York Medicaid APG,4323.22,,,4323.22,Other,225% New York Medicaid APG,2690.01,,,2690.01,Other,140% New York Medicaid APG,4323.22,,,4323.22,Other,225% New York Medicaid APG,4995.72,,,4995.72,Other,260% New York Medicaid APG,6225.44,,,6225.44,Other,324% New York Medicaid APG,4131.08,,,4131.08,Other,215% New York Medicaid APG,4131.08,,,4131.08,Other,215% New York Medicaid APG,2401.79,,,2401.79,Other,125% New York Medicaid APG,1921.43,72031.73,
Thxp apheresis w/hdl delip,0342T,HCPCS,,,,,,,,both,,,97340.17,72031.73,74,,72031.73,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,43803.08,45,,43803.08,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,48183.38,49.5,,48183.38,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3573.86,,,3573.86,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,68138.12,70,,68138.12,percent of total billed charges,,63271.11,65,,63271.11,percent of total billed charges,,63271.11,65,,63271.11,percent of total billed charges,,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,1921.43,,,1921.43,Other,New York Medicaid APG methodology,1921.43,,,1921.43,Other,100% New York Medicaid APG,1921.43,,,1921.43,Other,100% New York Medicaid APG,1921.43,,,1921.43,Other,100% New York Medicaid APG,4323.22,,,4323.22,Other,225% New York Medicaid APG,2939.79,,,2939.79,Other,153% New York Medicaid APG,4323.22,,,4323.22,Other,225% New York Medicaid APG,2690.01,,,2690.01,Other,140% New York Medicaid APG,4323.22,,,4323.22,Other,225% New York Medicaid APG,4995.72,,,4995.72,Other,260% New York Medicaid APG,6225.44,,,6225.44,Other,324% New York Medicaid APG,4131.08,,,4131.08,Other,215% New York Medicaid APG,4131.08,,,4131.08,Other,215% New York Medicaid APG,2401.79,,,2401.79,Other,125% New York Medicaid APG,1921.43,72031.73,
Egd flx transnasal dx br/wa,0652T,HCPCS,,,,,,,,both,,,40023.39,29617.31,74,,29617.31,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,18010.53,45,,18010.53,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,19811.58,49.5,,19811.58,percent of total billed charges,110% of Medicare,27215.91,68,,27215.91,percent of total billed charges,,0.02,,,0.02,Other,186% of Medicaid,32018.71,80,,32018.71,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,32018.71,80,,32018.71,percent of total billed charges,,7216,,,7216,Case Rate,,32018.71,80,,32018.71,percent of total billed charges,,28016.37,70,,28016.37,percent of total billed charges,,26015.2,65,,26015.2,percent of total billed charges,,26015.2,65,,26015.2,percent of total billed charges,,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% New York Medicaid APG,0.01,,,0.01,Other,100% New York Medicaid APG,0.01,,,0.01,Other,100% New York Medicaid APG,0.02,,,0.02,Other,225% New York Medicaid APG,0.02,,,0.02,Other,153% New York Medicaid APG,0.02,,,0.02,Other,225% New York Medicaid APG,0.01,,,0.01,Other,140% New York Medicaid APG,0.02,,,0.02,Other,225% New York Medicaid APG,0.03,,,0.03,Other,260% New York Medicaid APG,0.03,,,0.03,Other,324% New York Medicaid APG,0.02,,,0.02,Other,215% New York Medicaid APG,0.02,,,0.02,Other,215% New York Medicaid APG,0.01,,,0.01,Other,125% New York Medicaid APG,0.01,32018.71,
Egd flx transnasal bx 1/ml,0653T,HCPCS,,,,,,,,both,,,40023.39,29617.31,74,,29617.31,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,18010.53,45,,18010.53,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,19811.58,49.5,,19811.58,percent of total billed charges,110% of Medicare,27215.91,68,,27215.91,percent of total billed charges,,0.02,,,0.02,Other,186% of Medicaid,32018.71,80,,32018.71,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,32018.71,80,,32018.71,percent of total billed charges,,7216,,,7216,Case Rate,,32018.71,80,,32018.71,percent of total billed charges,,28016.37,70,,28016.37,percent of total billed charges,,26015.2,65,,26015.2,percent of total billed charges,,26015.2,65,,26015.2,percent of total billed charges,,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3649,,"100% primary, 50% secondary, 25% tertiary procedure",3649,Other,United Healthcare ASC Grouper,4055,,"100% primary, 50% secondary, 25% tertiary procedure",4055,Other,United Healthcare ASC Grouper,3448,,"100% primary, 50% secondary, 25% tertiary procedure",3448,Other,United Healthcare ASC Grouper,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% New York Medicaid APG,0.01,,,0.01,Other,100% New York Medicaid APG,0.01,,,0.01,Other,100% New York Medicaid APG,0.02,,,0.02,Other,225% New York Medicaid APG,0.02,,,0.02,Other,153% New York Medicaid APG,0.02,,,0.02,Other,225% New York Medicaid APG,0.01,,,0.01,Other,140% New York Medicaid APG,0.02,,,0.02,Other,225% New York Medicaid APG,0.03,,,0.03,Other,260% New York Medicaid APG,0.03,,,0.03,Other,324% New York Medicaid APG,0.02,,,0.02,Other,215% New York Medicaid APG,0.02,,,0.02,Other,215% New York Medicaid APG,0.01,,,0.01,Other,125% New York Medicaid APG,0.01,32018.71,
Place endorectal app,C9725,HCPCS,,,,,,,,both,,,19223.92,14225.7,74,,14225.7,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,8650.76,45,,8650.76,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,9515.84,49.5,,9515.84,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2000.16,,,2000.16,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,3578,,"100% primary, 0% secondary procedures",3578,Other,MagnaCare ASC Grouper,13456.74,70,,13456.74,percent of total billed charges,,12495.55,65,,12495.55,percent of total billed charges,,12495.55,65,,12495.55,percent of total billed charges,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,1075.35,,,1075.35,Other,New York Medicaid APG methodology,1075.35,,,1075.35,Other,100% New York Medicaid APG,1075.35,,,1075.35,Other,100% New York Medicaid APG,1075.35,,,1075.35,Other,100% New York Medicaid APG,2419.55,,,2419.55,Other,225% New York Medicaid APG,1645.29,,,1645.29,Other,153% New York Medicaid APG,2419.55,,,2419.55,Other,225% New York Medicaid APG,1505.5,,,1505.5,Other,140% New York Medicaid APG,2419.55,,,2419.55,Other,225% New York Medicaid APG,2795.92,,,2795.92,Other,260% New York Medicaid APG,3484.15,,,3484.15,Other,324% New York Medicaid APG,2312.01,,,2312.01,Other,215% New York Medicaid APG,2312.01,,,2312.01,Other,215% New York Medicaid APG,1344.19,,,1344.19,Other,125% New York Medicaid APG,1075.35,14225.7,
Ca screen;flexi sigmoidscope,G0104,HCPCS,,,,,,,,both,,,19223.92,14225.7,74,,14225.7,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,8650.76,45,,8650.76,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,9515.84,49.5,,9515.84,percent of total billed charges,110% of Medicare,13072.27,68,,13072.27,percent of total billed charges,,1478.54,,,1478.54,Other,186% of Medicaid,15379.14,80,,15379.14,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,15379.14,80,,15379.14,percent of total billed charges,,7216,,,7216,Case Rate,,3578,,"100% primary, 0% secondary procedures",3578,Other,MagnaCare ASC Grouper,13456.74,70,,13456.74,percent of total billed charges,,270.6,,,270.6,Fee Schedule,,229.35,,,229.35,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,794.91,,,794.91,Other,New York Medicaid APG methodology,794.91,,,794.91,Other,100% New York Medicaid APG,794.91,,,794.91,Other,100% New York Medicaid APG,794.91,,,794.91,Other,100% New York Medicaid APG,1788.55,,,1788.55,Other,225% New York Medicaid APG,1216.22,,,1216.22,Other,153% New York Medicaid APG,1788.55,,,1788.55,Other,225% New York Medicaid APG,1112.88,,,1112.88,Other,140% New York Medicaid APG,1788.55,,,1788.55,Other,225% New York Medicaid APG,2066.77,,,2066.77,Other,260% New York Medicaid APG,2575.52,,,2575.52,Other,324% New York Medicaid APG,1709.06,,,1709.06,Other,215% New York Medicaid APG,1709.06,,,1709.06,Other,215% New York Medicaid APG,993.64,,,993.64,Other,125% New York Medicaid APG,229.35,15379.14,
Colorectal scrn; hi risk ind,G0105,HCPCS,,,,,,,,both,,,18767.42,13887.89,74,,13887.89,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,8445.34,45,,8445.34,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,9289.87,49.5,,9289.87,percent of total billed charges,110% of Medicare,12761.85,68,,12761.85,percent of total billed charges,,1478.54,,,1478.54,Other,186% of Medicaid,15013.94,80,,15013.94,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,15013.94,80,,15013.94,percent of total billed charges,,7216,,,7216,Case Rate,,3578,,"100% primary, 0% secondary procedures",3578,Other,MagnaCare ASC Grouper,13137.19,70,,13137.19,percent of total billed charges,,888.88,,,888.88,Fee Schedule,,753.38,,,753.38,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,794.91,,,794.91,Other,New York Medicaid APG methodology,794.91,,,794.91,Other,100% New York Medicaid APG,794.91,,,794.91,Other,100% New York Medicaid APG,794.91,,,794.91,Other,100% New York Medicaid APG,1788.55,,,1788.55,Other,225% New York Medicaid APG,1216.22,,,1216.22,Other,153% New York Medicaid APG,1788.55,,,1788.55,Other,225% New York Medicaid APG,1112.88,,,1112.88,Other,140% New York Medicaid APG,1788.55,,,1788.55,Other,225% New York Medicaid APG,2066.77,,,2066.77,Other,260% New York Medicaid APG,2575.52,,,2575.52,Other,324% New York Medicaid APG,1709.06,,,1709.06,Other,215% New York Medicaid APG,1709.06,,,1709.06,Other,215% New York Medicaid APG,993.64,,,993.64,Other,125% New York Medicaid APG,753.38,15013.94,
Colon ca scrn not hi rsk ind,G0121,HCPCS,,,,,,,,both,,,17927.96,13266.69,74,,13266.69,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,8067.58,45,,8067.58,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,8874.34,49.5,,8874.34,percent of total billed charges,110% of Medicare,12191.01,68,,12191.01,percent of total billed charges,,1478.54,,,1478.54,Other,186% of Medicaid,14342.37,80,,14342.37,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,14342.37,80,,14342.37,percent of total billed charges,,7216,,,7216,Case Rate,,3578,,"100% primary, 0% secondary procedures",3578,Other,MagnaCare ASC Grouper,12549.57,70,,12549.57,percent of total billed charges,,890.52,,,890.52,Fee Schedule,,754.77,,,754.77,Fee Schedule,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,794.91,,,794.91,Other,New York Medicaid APG methodology,794.91,,,794.91,Other,100% New York Medicaid APG,794.91,,,794.91,Other,100% New York Medicaid APG,794.91,,,794.91,Other,100% New York Medicaid APG,1788.55,,,1788.55,Other,225% New York Medicaid APG,1216.22,,,1216.22,Other,153% New York Medicaid APG,1788.55,,,1788.55,Other,225% New York Medicaid APG,1112.88,,,1112.88,Other,140% New York Medicaid APG,1788.55,,,1788.55,Other,225% New York Medicaid APG,2066.77,,,2066.77,Other,260% New York Medicaid APG,2575.52,,,2575.52,Other,324% New York Medicaid APG,1709.06,,,1709.06,Other,215% New York Medicaid APG,1709.06,,,1709.06,Other,215% New York Medicaid APG,993.64,,,993.64,Other,125% New York Medicaid APG,754.77,14342.37,
Exc rectal tumor endoscopic,0184T,HCPCS,,,,,,,,both,,,119876.35,88708.5,74,,88708.5,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,53944.36,45,,53944.36,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,59338.79,49.5,,59338.79,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2732.76,,,2732.76,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,83913.45,70,,83913.45,percent of total billed charges,,77919.63,65,,77919.63,percent of total billed charges,,77919.63,65,,77919.63,percent of total billed charges,,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1469.23,,,1469.23,Other,New York Medicaid APG methodology,1469.23,,,1469.23,Other,100% New York Medicaid APG,1469.23,,,1469.23,Other,100% New York Medicaid APG,1469.23,,,1469.23,Other,100% New York Medicaid APG,3305.76,,,3305.76,Other,225% New York Medicaid APG,2247.91,,,2247.91,Other,153% New York Medicaid APG,3305.76,,,3305.76,Other,225% New York Medicaid APG,2056.92,,,2056.92,Other,140% New York Medicaid APG,3305.76,,,3305.76,Other,225% New York Medicaid APG,3819.99,,,3819.99,Other,260% New York Medicaid APG,4760.29,,,4760.29,Other,324% New York Medicaid APG,3158.83,,,3158.83,Other,215% New York Medicaid APG,3158.83,,,3158.83,Other,215% New York Medicaid APG,1836.53,,,1836.53,Other,125% New York Medicaid APG,1469.23,88708.5,
Ire abltj 1+tum organ perq,0600T,HCPCS,,,,,,,,both,,,216515.17,160221.23,74,,160221.23,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,97431.83,45,,97431.83,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,6125,,"100% primary, 50% secondary, 25% supplemental procedure",6125,Other,Blue Cross ASC Grouper,5513,,"100% primary, 50% secondary, 25% supplemental procedure",5513,Other,Blue Cross ASC Grouper,5206,,"100% primary, 50% secondary, 25% supplemental procedure",5206,Other,Blue Cross ASC Grouper,107175.01,49.5,,107175.01,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2588.91,,,2588.91,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,173212.14,80,,173212.14,percent of total billed charges,,151560.62,70,,151560.62,percent of total billed charges,,140734.86,65,,140734.86,percent of total billed charges,,140734.86,65,,140734.86,percent of total billed charges,,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,1391.89,,,1391.89,Other,New York Medicaid APG methodology,1391.89,,,1391.89,Other,100% New York Medicaid APG,1391.89,,,1391.89,Other,100% New York Medicaid APG,1391.89,,,1391.89,Other,100% New York Medicaid APG,3131.75,,,3131.75,Other,225% New York Medicaid APG,2129.59,,,2129.59,Other,153% New York Medicaid APG,3131.75,,,3131.75,Other,225% New York Medicaid APG,1948.64,,,1948.64,Other,140% New York Medicaid APG,3131.75,,,3131.75,Other,225% New York Medicaid APG,3618.91,,,3618.91,Other,260% New York Medicaid APG,4509.72,,,4509.72,Other,324% New York Medicaid APG,2992.56,,,2992.56,Other,215% New York Medicaid APG,2992.56,,,2992.56,Other,215% New York Medicaid APG,1739.86,,,1739.86,Other,125% New York Medicaid APG,1391.89,173212.14,
Ire abltj 1+tumors open,0601T,HCPCS,,,,,,,,both,,,216515.17,160221.23,74,,160221.23,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,97431.83,45,,97431.83,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,6125,,"100% primary, 50% secondary, 25% supplemental procedure",6125,Other,Blue Cross ASC Grouper,5513,,"100% primary, 50% secondary, 25% supplemental procedure",5513,Other,Blue Cross ASC Grouper,5206,,"100% primary, 50% secondary, 25% supplemental procedure",5206,Other,Blue Cross ASC Grouper,107175.01,49.5,,107175.01,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2588.91,,,2588.91,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,173212.14,80,,173212.14,percent of total billed charges,,151560.62,70,,151560.62,percent of total billed charges,,140734.86,65,,140734.86,percent of total billed charges,,140734.86,65,,140734.86,percent of total billed charges,,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,1391.89,,,1391.89,Other,New York Medicaid APG methodology,1391.89,,,1391.89,Other,100% New York Medicaid APG,1391.89,,,1391.89,Other,100% New York Medicaid APG,1391.89,,,1391.89,Other,100% New York Medicaid APG,3131.75,,,3131.75,Other,225% New York Medicaid APG,2129.59,,,2129.59,Other,153% New York Medicaid APG,3131.75,,,3131.75,Other,225% New York Medicaid APG,1948.64,,,1948.64,Other,140% New York Medicaid APG,3131.75,,,3131.75,Other,225% New York Medicaid APG,3618.91,,,3618.91,Other,260% New York Medicaid APG,4509.72,,,4509.72,Other,324% New York Medicaid APG,2992.56,,,2992.56,Other,215% New York Medicaid APG,2992.56,,,2992.56,Other,215% New York Medicaid APG,1739.86,,,1739.86,Other,125% New York Medicaid APG,1391.89,173212.14,
Temp fml iu vlv-pmp 1st insj,0596T,HCPCS,,,,,,,,both,,,14368.32,10632.56,74,,10632.56,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,6465.74,45,,6465.74,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,7112.32,49.5,,7112.32,percent of total billed charges,110% of Medicare,9770.46,68,,9770.46,percent of total billed charges,,903.43,,,903.43,Other,186% of Medicaid,11494.66,80,,11494.66,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,11494.66,80,,11494.66,percent of total billed charges,,7216,,,7216,Case Rate,,11494.66,80,,11494.66,percent of total billed charges,,10057.82,70,,10057.82,percent of total billed charges,,9339.41,65,,9339.41,percent of total billed charges,,9339.41,65,,9339.41,percent of total billed charges,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,485.72,,,485.72,Other,New York Medicaid APG methodology,485.72,,,485.72,Other,100% New York Medicaid APG,485.72,,,485.72,Other,100% New York Medicaid APG,485.72,,,485.72,Other,100% New York Medicaid APG,1092.86,,,1092.86,Other,225% New York Medicaid APG,743.14,,,743.14,Other,153% New York Medicaid APG,1092.86,,,1092.86,Other,225% New York Medicaid APG,680,,,680,Other,140% New York Medicaid APG,1092.86,,,1092.86,Other,225% New York Medicaid APG,1262.86,,,1262.86,Other,260% New York Medicaid APG,1573.72,,,1573.72,Other,324% New York Medicaid APG,1044.29,,,1044.29,Other,215% New York Medicaid APG,1044.29,,,1044.29,Other,215% New York Medicaid APG,607.14,,,607.14,Other,125% New York Medicaid APG,485.72,11494.66,
Temp fml iu valve-pmp rplcmt,0597T,HCPCS,,,,,,,,both,,,14368.32,10632.56,74,,10632.56,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,6465.74,45,,6465.74,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,7112.32,49.5,,7112.32,percent of total billed charges,110% of Medicare,9770.46,68,,9770.46,percent of total billed charges,,903.43,,,903.43,Other,186% of Medicaid,11494.66,80,,11494.66,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,11494.66,80,,11494.66,percent of total billed charges,,7216,,,7216,Case Rate,,11494.66,80,,11494.66,percent of total billed charges,,10057.82,70,,10057.82,percent of total billed charges,,9339.41,65,,9339.41,percent of total billed charges,,9339.41,65,,9339.41,percent of total billed charges,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,485.72,,,485.72,Other,New York Medicaid APG methodology,485.72,,,485.72,Other,100% New York Medicaid APG,485.72,,,485.72,Other,100% New York Medicaid APG,485.72,,,485.72,Other,100% New York Medicaid APG,1092.86,,,1092.86,Other,225% New York Medicaid APG,743.14,,,743.14,Other,153% New York Medicaid APG,1092.86,,,1092.86,Other,225% New York Medicaid APG,680,,,680,Other,140% New York Medicaid APG,1092.86,,,1092.86,Other,225% New York Medicaid APG,1262.86,,,1262.86,Other,260% New York Medicaid APG,1573.72,,,1573.72,Other,324% New York Medicaid APG,1044.29,,,1044.29,Other,215% New York Medicaid APG,1044.29,,,1044.29,Other,215% New York Medicaid APG,607.14,,,607.14,Other,125% New York Medicaid APG,485.72,11494.66,
Cysto w/prst8 commissurotomy,0619T,HCPCS,,,,,,,,both,,,193769.26,143389.25,74,,143389.25,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,87196.17,45,,87196.17,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,95915.78,49.5,,95915.78,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,4645.5,,,4645.5,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,155015.41,80,,155015.41,percent of total billed charges,,135638.48,70,,135638.48,percent of total billed charges,,125950.02,65,,125950.02,percent of total billed charges,,125950.02,65,,125950.02,percent of total billed charges,,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,2497.58,,,2497.58,Other,New York Medicaid APG methodology,2497.58,,,2497.58,Other,100% New York Medicaid APG,2497.58,,,2497.58,Other,100% New York Medicaid APG,2497.58,,,2497.58,Other,100% New York Medicaid APG,5619.56,,,5619.56,Other,225% New York Medicaid APG,3821.3,,,3821.3,Other,153% New York Medicaid APG,5619.56,,,5619.56,Other,225% New York Medicaid APG,3496.61,,,3496.61,Other,140% New York Medicaid APG,5619.56,,,5619.56,Other,225% New York Medicaid APG,6493.71,,,6493.71,Other,260% New York Medicaid APG,8092.16,,,8092.16,Other,324% New York Medicaid APG,5369.8,,,5369.8,Other,215% New York Medicaid APG,5369.8,,,5369.8,Other,215% New York Medicaid APG,3121.98,,,3121.98,Other,125% New York Medicaid APG,2497.58,155015.41,
Cystoscopy prostatic imp 1-3,C9739,HCPCS,,,,,,,,both,,,52017.94,38493.28,74,,38493.28,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,23408.07,45,,23408.07,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,25748.88,49.5,,25748.88,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,4645.5,,,4645.5,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5266,,"100% primary, 0% secondary procedures",5266,Other,MagnaCare ASC Grouper,36412.56,70,,36412.56,percent of total billed charges,,33811.66,65,,33811.66,percent of total billed charges,,33811.66,65,,33811.66,percent of total billed charges,,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,2497.58,,,2497.58,Other,New York Medicaid APG methodology,2497.58,,,2497.58,Other,100% New York Medicaid APG,2497.58,,,2497.58,Other,100% New York Medicaid APG,2497.58,,,2497.58,Other,100% New York Medicaid APG,5619.56,,,5619.56,Other,225% New York Medicaid APG,3821.3,,,3821.3,Other,153% New York Medicaid APG,5619.56,,,5619.56,Other,225% New York Medicaid APG,3496.61,,,3496.61,Other,140% New York Medicaid APG,5619.56,,,5619.56,Other,225% New York Medicaid APG,6493.71,,,6493.71,Other,260% New York Medicaid APG,8092.16,,,8092.16,Other,324% New York Medicaid APG,5369.8,,,5369.8,Other,215% New York Medicaid APG,5369.8,,,5369.8,Other,215% New York Medicaid APG,3121.98,,,3121.98,Other,125% New York Medicaid APG,2497.58,38493.28,
"Cysto, litho, vacuum kidney",C9761,HCPCS,,,,,,,,both,,,193769.26,143389.25,74,,143389.25,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,87196.17,45,,87196.17,percent of total billed charges,Medicare Ratio of cost to charges,3969,,"100% primary, 50% supplemental procedure",3969,Other,Aetna ASC Grouper,3572,,"100% primary, 50% supplemental procedure",3572,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,95915.78,49.5,,95915.78,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2586.25,,,2586.25,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,155015.41,80,,155015.41,percent of total billed charges,,135638.48,70,,135638.48,percent of total billed charges,,125950.02,65,,125950.02,percent of total billed charges,,125950.02,65,,125950.02,percent of total billed charges,,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1390.46,,,1390.46,Other,New York Medicaid APG methodology,1390.46,,,1390.46,Other,100% New York Medicaid APG,1390.46,,,1390.46,Other,100% New York Medicaid APG,1390.46,,,1390.46,Other,100% New York Medicaid APG,3128.53,,,3128.53,Other,225% New York Medicaid APG,2127.4,,,2127.4,Other,153% New York Medicaid APG,3128.53,,,3128.53,Other,225% New York Medicaid APG,1946.64,,,1946.64,Other,140% New York Medicaid APG,3128.53,,,3128.53,Other,225% New York Medicaid APG,3615.19,,,3615.19,Other,260% New York Medicaid APG,4505.09,,,4505.09,Other,324% New York Medicaid APG,2989.49,,,2989.49,Other,215% New York Medicaid APG,2989.49,,,2989.49,Other,215% New York Medicaid APG,1738.07,,,1738.07,Other,125% New York Medicaid APG,1390.46,155015.41,
Cysto w/temp pros implant,C9769,HCPCS,,,,,,,,both,,,46339.76,34291.42,74,,34291.42,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,20852.89,45,,20852.89,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,22938.18,49.5,,22938.18,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,4645.5,,,4645.5,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,37071.81,80,,37071.81,percent of total billed charges,,32437.83,70,,32437.83,percent of total billed charges,,30120.84,65,,30120.84,percent of total billed charges,,30120.84,65,,30120.84,percent of total billed charges,,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,2497.58,,,2497.58,Other,New York Medicaid APG methodology,2497.58,,,2497.58,Other,100% New York Medicaid APG,2497.58,,,2497.58,Other,100% New York Medicaid APG,2497.58,,,2497.58,Other,100% New York Medicaid APG,5619.56,,,5619.56,Other,225% New York Medicaid APG,3821.3,,,3821.3,Other,153% New York Medicaid APG,5619.56,,,5619.56,Other,225% New York Medicaid APG,3496.61,,,3496.61,Other,140% New York Medicaid APG,5619.56,,,5619.56,Other,225% New York Medicaid APG,6493.71,,,6493.71,Other,260% New York Medicaid APG,8092.16,,,8092.16,Other,324% New York Medicaid APG,5369.8,,,5369.8,Other,215% New York Medicaid APG,5369.8,,,5369.8,Other,215% New York Medicaid APG,3121.98,,,3121.98,Other,125% New York Medicaid APG,2497.58,37071.81,
Waterjet prostate abltj cmpl,0421T,HCPCS,,,,,,,,both,,,193769.26,143389.25,74,,143389.25,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,87196.17,45,,87196.17,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,95915.78,49.5,,95915.78,percent of total billed charges,110% of Medicare,131763.1,68,,131763.1,percent of total billed charges,,4645.5,,,4645.5,Other,186% of Medicaid,155015.41,80,,155015.41,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,155015.41,80,,155015.41,percent of total billed charges,,7216,,,7216,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,135638.48,70,,135638.48,percent of total billed charges,,125950.02,65,,125950.02,percent of total billed charges,,125950.02,65,,125950.02,percent of total billed charges,,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,2497.58,,,2497.58,Other,New York Medicaid APG methodology,2497.58,,,2497.58,Other,100% New York Medicaid APG,2497.58,,,2497.58,Other,100% New York Medicaid APG,2497.58,,,2497.58,Other,100% New York Medicaid APG,5619.56,,,5619.56,Other,225% New York Medicaid APG,3821.3,,,3821.3,Other,153% New York Medicaid APG,5619.56,,,5619.56,Other,225% New York Medicaid APG,3496.61,,,3496.61,Other,140% New York Medicaid APG,5619.56,,,5619.56,Other,225% New York Medicaid APG,6493.71,,,6493.71,Other,260% New York Medicaid APG,8092.16,,,8092.16,Other,324% New York Medicaid APG,5369.8,,,5369.8,Other,215% New York Medicaid APG,5369.8,,,5369.8,Other,215% New York Medicaid APG,3121.98,,,3121.98,Other,125% New York Medicaid APG,2232,155015.41,
Cysto impl 4 or more,C9740,HCPCS,,,,,,,,both,,,50923.5,37683.39,74,,37683.39,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,22915.58,45,,22915.58,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,25207.13,49.5,,25207.13,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,4645.5,,,4645.5,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,35646.45,70,,35646.45,percent of total billed charges,,33100.28,65,,33100.28,percent of total billed charges,,33100.28,65,,33100.28,percent of total billed charges,,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,2497.58,,,2497.58,Other,New York Medicaid APG methodology,2497.58,,,2497.58,Other,100% New York Medicaid APG,2497.58,,,2497.58,Other,100% New York Medicaid APG,2497.58,,,2497.58,Other,100% New York Medicaid APG,5619.56,,,5619.56,Other,225% New York Medicaid APG,3821.3,,,3821.3,Other,153% New York Medicaid APG,5619.56,,,5619.56,Other,225% New York Medicaid APG,3496.61,,,3496.61,Other,140% New York Medicaid APG,5619.56,,,5619.56,Other,225% New York Medicaid APG,6493.71,,,6493.71,Other,260% New York Medicaid APG,8092.16,,,8092.16,Other,324% New York Medicaid APG,5369.8,,,5369.8,Other,215% New York Medicaid APG,5369.8,,,5369.8,Other,215% New York Medicaid APG,3121.98,,,3121.98,Other,125% New York Medicaid APG,2497.58,37683.39,
Abltj perc uxtr/perph nrv,0440T,HCPCS,,,,,,,,both,,,40611.5,30052.51,74,,30052.51,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,18275.18,45,,18275.18,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,20102.69,49.5,,20102.69,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2391.2,,,2391.2,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,28428.05,70,,28428.05,percent of total billed charges,,26397.48,65,,26397.48,percent of total billed charges,,26397.48,65,,26397.48,percent of total billed charges,,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,1285.59,,,1285.59,Other,New York Medicaid APG methodology,1285.59,,,1285.59,Other,100% New York Medicaid APG,1285.59,,,1285.59,Other,100% New York Medicaid APG,1285.59,,,1285.59,Other,100% New York Medicaid APG,2892.58,,,2892.58,Other,225% New York Medicaid APG,1966.96,,,1966.96,Other,153% New York Medicaid APG,2892.58,,,2892.58,Other,225% New York Medicaid APG,1799.83,,,1799.83,Other,140% New York Medicaid APG,2892.58,,,2892.58,Other,225% New York Medicaid APG,3342.54,,,3342.54,Other,260% New York Medicaid APG,4165.32,,,4165.32,Other,324% New York Medicaid APG,2764.02,,,2764.02,Other,215% New York Medicaid APG,2764.02,,,2764.02,Other,215% New York Medicaid APG,1606.99,,,1606.99,Other,125% New York Medicaid APG,1285.59,30052.51,
Abltj perc lxtr/perph nrv,0441T,HCPCS,,,,,,,,both,,,40611.5,30052.51,74,,30052.51,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,18275.18,45,,18275.18,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,20102.69,49.5,,20102.69,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2391.2,,,2391.2,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,28428.05,70,,28428.05,percent of total billed charges,,26397.48,65,,26397.48,percent of total billed charges,,26397.48,65,,26397.48,percent of total billed charges,,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,1285.59,,,1285.59,Other,New York Medicaid APG methodology,1285.59,,,1285.59,Other,100% New York Medicaid APG,1285.59,,,1285.59,Other,100% New York Medicaid APG,1285.59,,,1285.59,Other,100% New York Medicaid APG,2892.58,,,2892.58,Other,225% New York Medicaid APG,1966.96,,,1966.96,Other,153% New York Medicaid APG,2892.58,,,2892.58,Other,225% New York Medicaid APG,1799.83,,,1799.83,Other,140% New York Medicaid APG,2892.58,,,2892.58,Other,225% New York Medicaid APG,3342.54,,,3342.54,Other,260% New York Medicaid APG,4165.32,,,4165.32,Other,324% New York Medicaid APG,2764.02,,,2764.02,Other,215% New York Medicaid APG,2764.02,,,2764.02,Other,215% New York Medicaid APG,1606.99,,,1606.99,Other,125% New York Medicaid APG,1285.59,30052.51,
Rev/remvl crtd sns dev total,0269T,HCPCS,,,,,,,,both,,,140115.1,103685.17,74,,103685.17,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,63051.8,45,,63051.8,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,69356.97,49.5,,69356.97,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2391.2,,,2391.2,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7900,,"100% primary, 0% secondary procedures",7900,Other,MagnaCare ASC Grouper,98080.57,70,,98080.57,percent of total billed charges,,91074.82,65,,91074.82,percent of total billed charges,,91074.82,65,,91074.82,percent of total billed charges,,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5698,,"100% primary, 50% secondary, 25% tertiary procedure",5698,Other,United Healthcare ASC Grouper,6331,,"100% primary, 50% secondary, 25% tertiary procedure",6331,Other,United Healthcare ASC Grouper,5381,,"100% primary, 50% secondary, 25% tertiary procedure",5381,Other,United Healthcare ASC Grouper,1285.59,,,1285.59,Other,New York Medicaid APG methodology,1285.59,,,1285.59,Other,100% New York Medicaid APG,1285.59,,,1285.59,Other,100% New York Medicaid APG,1285.59,,,1285.59,Other,100% New York Medicaid APG,2892.58,,,2892.58,Other,225% New York Medicaid APG,1966.96,,,1966.96,Other,153% New York Medicaid APG,2892.58,,,2892.58,Other,225% New York Medicaid APG,1799.83,,,1799.83,Other,140% New York Medicaid APG,2892.58,,,2892.58,Other,225% New York Medicaid APG,3342.54,,,3342.54,Other,260% New York Medicaid APG,4165.32,,,4165.32,Other,324% New York Medicaid APG,2764.02,,,2764.02,Other,215% New York Medicaid APG,2764.02,,,2764.02,Other,215% New York Medicaid APG,1606.99,,,1606.99,Other,125% New York Medicaid APG,1285.59,103685.17,
Abltj perc plex/trncl nrv,0442T,HCPCS,,,,,,,,both,,,140115.1,103685.17,74,,103685.17,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,63051.8,45,,63051.8,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,69356.97,49.5,,69356.97,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2391.2,,,2391.2,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,98080.57,70,,98080.57,percent of total billed charges,,91074.82,65,,91074.82,percent of total billed charges,,91074.82,65,,91074.82,percent of total billed charges,,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,1285.59,,,1285.59,Other,New York Medicaid APG methodology,1285.59,,,1285.59,Other,100% New York Medicaid APG,1285.59,,,1285.59,Other,100% New York Medicaid APG,1285.59,,,1285.59,Other,100% New York Medicaid APG,2892.58,,,2892.58,Other,225% New York Medicaid APG,1966.96,,,1966.96,Other,153% New York Medicaid APG,2892.58,,,2892.58,Other,225% New York Medicaid APG,1799.83,,,1799.83,Other,140% New York Medicaid APG,2892.58,,,2892.58,Other,225% New York Medicaid APG,3342.54,,,3342.54,Other,260% New York Medicaid APG,4165.32,,,4165.32,Other,324% New York Medicaid APG,2764.02,,,2764.02,Other,215% New York Medicaid APG,2764.02,,,2764.02,Other,215% New York Medicaid APG,1606.99,,,1606.99,Other,125% New York Medicaid APG,1285.59,103685.17,
Autol cell implt adps njx,0566T,HCPCS,,,,,,,,both,,,64479.48,47714.82,74,,47714.82,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,29015.77,45,,29015.77,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,31917.34,49.5,,31917.34,percent of total billed charges,110% of Medicare,43846.05,68,,43846.05,percent of total billed charges,,685.67,,,685.67,Other,186% of Medicaid,51583.58,80,,51583.58,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,51583.58,80,,51583.58,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,45135.64,70,,45135.64,percent of total billed charges,,41911.66,65,,41911.66,percent of total billed charges,,41911.66,65,,41911.66,percent of total billed charges,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,368.64,,,368.64,Other,New York Medicaid APG methodology,368.64,,,368.64,Other,100% New York Medicaid APG,368.64,,,368.64,Other,100% New York Medicaid APG,368.64,,,368.64,Other,100% New York Medicaid APG,829.44,,,829.44,Other,225% New York Medicaid APG,564.02,,,564.02,Other,153% New York Medicaid APG,829.44,,,829.44,Other,225% New York Medicaid APG,516.1,,,516.1,Other,140% New York Medicaid APG,829.44,,,829.44,Other,225% New York Medicaid APG,958.46,,,958.46,Other,260% New York Medicaid APG,1194.39,,,1194.39,Other,324% New York Medicaid APG,792.58,,,792.58,Other,215% New York Medicaid APG,792.58,,,792.58,Other,215% New York Medicaid APG,460.8,,,460.8,Other,125% New York Medicaid APG,368.64,51583.58,
Inj for sacroiliac jt anesth,G0260,HCPCS,,,,,,,,both,,,4530.6,3352.64,74,,3352.64,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,2038.77,45,,2038.77,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,2242.65,49.5,,2242.65,percent of total billed charges,110% of Medicare,3080.81,68,,3080.81,percent of total billed charges,,1079.62,,,1079.62,Other,186% of Medicaid,3624.48,80,,3624.48,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,3624.48,80,,3624.48,percent of total billed charges,,7216,,,7216,Case Rate,,3578,,"100% primary, 0% secondary procedures",3578,Other,MagnaCare ASC Grouper,3171.42,70,,3171.42,percent of total billed charges,,2944.89,65,,2944.89,percent of total billed charges,,2944.89,65,,2944.89,percent of total billed charges,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,580.44,,,580.44,Other,New York Medicaid APG methodology,580.44,,,580.44,Other,100% New York Medicaid APG,580.44,,,580.44,Other,100% New York Medicaid APG,580.44,,,580.44,Other,100% New York Medicaid APG,1306,,,1306,Other,225% New York Medicaid APG,888.08,,,888.08,Other,153% New York Medicaid APG,1306,,,1306,Other,225% New York Medicaid APG,812.62,,,812.62,Other,140% New York Medicaid APG,1306,,,1306,Other,225% New York Medicaid APG,1509.15,,,1509.15,Other,260% New York Medicaid APG,1880.64,,,1880.64,Other,324% New York Medicaid APG,1247.95,,,1247.95,Other,215% New York Medicaid APG,1247.95,,,1247.95,Other,215% New York Medicaid APG,725.55,,,725.55,Other,125% New York Medicaid APG,580.44,7216,
Njx paravert w/us cer/thor,0213T,HCPCS,,,,,,,,both,,,3238,2396.12,74,,2396.12,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,1457.1,45,,1457.1,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,1602.81,49.5,,1602.81,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,1116.35,,,1116.35,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,3578,,"100% primary, 0% secondary procedures",3578,Other,MagnaCare ASC Grouper,2266.6,70,,2266.6,percent of total billed charges,,2104.7,65,,2104.7,percent of total billed charges,,2104.7,65,,2104.7,percent of total billed charges,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,600.19,,,600.19,Other,New York Medicaid APG methodology,600.19,,,600.19,Other,100% New York Medicaid APG,600.19,,,600.19,Other,100% New York Medicaid APG,600.19,,,600.19,Other,100% New York Medicaid APG,1350.43,,,1350.43,Other,225% New York Medicaid APG,918.29,,,918.29,Other,153% New York Medicaid APG,1350.43,,,1350.43,Other,225% New York Medicaid APG,840.26,,,840.26,Other,140% New York Medicaid APG,1350.43,,,1350.43,Other,225% New York Medicaid APG,1560.49,,,1560.49,Other,260% New York Medicaid APG,1944.61,,,1944.61,Other,324% New York Medicaid APG,1290.41,,,1290.41,Other,215% New York Medicaid APG,1290.41,,,1290.41,Other,215% New York Medicaid APG,750.24,,,750.24,Other,125% New York Medicaid APG,600.19,9473,
Njx paravert w/us lumb/sac,0216T,HCPCS,,,,,,,,both,,,19171.82,14187.15,74,,14187.15,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,8627.32,45,,8627.32,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3228,,"100% primary, 50% secondary, 25% supplemental procedure",3228,Other,Blue Cross ASC Grouper,2905,,"100% primary, 50% secondary, 25% supplemental procedure",2905,Other,Blue Cross ASC Grouper,2744,,"100% primary, 50% secondary, 25% supplemental procedure",2744,Other,Blue Cross ASC Grouper,9490.05,49.5,,9490.05,percent of total billed charges,110% of Medicare,13036.84,68,,13036.84,percent of total billed charges,,1116.35,,,1116.35,Other,186% of Medicaid,15337.46,80,,15337.46,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,15337.46,80,,15337.46,percent of total billed charges,,7216,,,7216,Case Rate,,3578,,"100% primary, 0% secondary procedures",3578,Other,MagnaCare ASC Grouper,13420.27,70,,13420.27,percent of total billed charges,,12461.68,65,,12461.68,percent of total billed charges,,12461.68,65,,12461.68,percent of total billed charges,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,600.19,,,600.19,Other,New York Medicaid APG methodology,600.19,,,600.19,Other,100% New York Medicaid APG,600.19,,,600.19,Other,100% New York Medicaid APG,600.19,,,600.19,Other,100% New York Medicaid APG,1350.43,,,1350.43,Other,225% New York Medicaid APG,918.29,,,918.29,Other,153% New York Medicaid APG,1350.43,,,1350.43,Other,225% New York Medicaid APG,840.26,,,840.26,Other,140% New York Medicaid APG,1350.43,,,1350.43,Other,225% New York Medicaid APG,1560.49,,,1560.49,Other,260% New York Medicaid APG,1944.61,,,1944.61,Other,324% New York Medicaid APG,1290.41,,,1290.41,Other,215% New York Medicaid APG,1290.41,,,1290.41,Other,215% New York Medicaid APG,750.24,,,750.24,Other,125% New York Medicaid APG,600.19,15337.46,
Implt/rpl crtd sns dev lead,0267T,HCPCS,,,,,,,,both,,,71567.87,52960.22,74,,52960.22,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,32205.54,45,,32205.54,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,35426.1,49.5,,35426.1,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,6048.62,,,6048.62,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,50097.51,70,,50097.51,percent of total billed charges,,46519.12,65,,46519.12,percent of total billed charges,,46519.12,65,,46519.12,percent of total billed charges,,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,3251.94,,,3251.94,Other,New York Medicaid APG methodology,3251.94,,,3251.94,Other,100% New York Medicaid APG,3251.94,,,3251.94,Other,100% New York Medicaid APG,3251.94,,,3251.94,Other,100% New York Medicaid APG,7316.87,,,7316.87,Other,225% New York Medicaid APG,4975.47,,,4975.47,Other,153% New York Medicaid APG,7316.87,,,7316.87,Other,225% New York Medicaid APG,4552.72,,,4552.72,Other,140% New York Medicaid APG,7316.87,,,7316.87,Other,225% New York Medicaid APG,8455.05,,,8455.05,Other,260% New York Medicaid APG,10536.3,,,10536.3,Other,324% New York Medicaid APG,6991.68,,,6991.68,Other,215% New York Medicaid APG,6991.68,,,6991.68,Other,215% New York Medicaid APG,4064.93,,,4064.93,Other,125% New York Medicaid APG,3251.94,52960.22,
Rev/remvl crtd sns dev lead,0270T,HCPCS,,,,,,,,both,,,71567.87,52960.22,74,,52960.22,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,32205.54,45,,32205.54,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,35426.1,49.5,,35426.1,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2391.2,,,2391.2,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,50097.51,70,,50097.51,percent of total billed charges,,46519.12,65,,46519.12,percent of total billed charges,,46519.12,65,,46519.12,percent of total billed charges,,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1285.59,,,1285.59,Other,New York Medicaid APG methodology,1285.59,,,1285.59,Other,100% New York Medicaid APG,1285.59,,,1285.59,Other,100% New York Medicaid APG,1285.59,,,1285.59,Other,100% New York Medicaid APG,2892.58,,,2892.58,Other,225% New York Medicaid APG,1966.96,,,1966.96,Other,153% New York Medicaid APG,2892.58,,,2892.58,Other,225% New York Medicaid APG,1799.83,,,1799.83,Other,140% New York Medicaid APG,2892.58,,,2892.58,Other,225% New York Medicaid APG,3342.54,,,3342.54,Other,260% New York Medicaid APG,4165.32,,,4165.32,Other,324% New York Medicaid APG,2764.02,,,2764.02,Other,215% New York Medicaid APG,2764.02,,,2764.02,Other,215% New York Medicaid APG,1606.99,,,1606.99,Other,125% New York Medicaid APG,1285.59,52960.22,
Rev/remvl crtd sns dev gen,0271T,HCPCS,,,,,,,,both,,,71567.87,52960.22,74,,52960.22,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,32205.54,45,,32205.54,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,4778,,"100% primary, 50% secondary, 25% supplemental procedure",4778,Other,Blue Cross ASC Grouper,4300,,"100% primary, 50% secondary, 25% supplemental procedure",4300,Other,Blue Cross ASC Grouper,4061,,"100% primary, 50% secondary, 25% supplemental procedure",4061,Other,Blue Cross ASC Grouper,35426.1,49.5,,35426.1,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2391.2,,,2391.2,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,5743,,"100% primary, 0% secondary procedures",5743,Other,MagnaCare ASC Grouper,50097.51,70,,50097.51,percent of total billed charges,,46519.12,65,,46519.12,percent of total billed charges,,46519.12,65,,46519.12,percent of total billed charges,,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,1285.59,,,1285.59,Other,New York Medicaid APG methodology,1285.59,,,1285.59,Other,100% New York Medicaid APG,1285.59,,,1285.59,Other,100% New York Medicaid APG,1285.59,,,1285.59,Other,100% New York Medicaid APG,2892.58,,,2892.58,Other,225% New York Medicaid APG,1966.96,,,1966.96,Other,153% New York Medicaid APG,2892.58,,,2892.58,Other,225% New York Medicaid APG,1799.83,,,1799.83,Other,140% New York Medicaid APG,2892.58,,,2892.58,Other,225% New York Medicaid APG,3342.54,,,3342.54,Other,260% New York Medicaid APG,4165.32,,,4165.32,Other,324% New York Medicaid APG,2764.02,,,2764.02,Other,215% New York Medicaid APG,2764.02,,,2764.02,Other,215% New York Medicaid APG,1606.99,,,1606.99,Other,125% New York Medicaid APG,1285.59,52960.22,
Revision/removal isdns ptn,0588T,HCPCS,,,,,,,,both,,,71567.87,52960.22,74,,52960.22,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,32205.54,45,,32205.54,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,35426.1,49.5,,35426.1,percent of total billed charges,110% of Medicare,48666.15,68,,48666.15,percent of total billed charges,,966.11,,,966.11,Other,186% of Medicaid,57254.3,80,,57254.3,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,57254.3,80,,57254.3,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,50097.51,70,,50097.51,percent of total billed charges,,46519.12,65,,46519.12,percent of total billed charges,,46519.12,65,,46519.12,percent of total billed charges,,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4422,,"100% primary, 50% secondary, 25% tertiary procedure",4422,Other,United Healthcare ASC Grouper,4913,,"100% primary, 50% secondary, 25% tertiary procedure",4913,Other,United Healthcare ASC Grouper,4176,,"100% primary, 50% secondary, 25% tertiary procedure",4176,Other,United Healthcare ASC Grouper,519.42,,,519.42,Other,New York Medicaid APG methodology,519.42,,,519.42,Other,100% New York Medicaid APG,519.42,,,519.42,Other,100% New York Medicaid APG,519.42,,,519.42,Other,100% New York Medicaid APG,1168.69,,,1168.69,Other,225% New York Medicaid APG,794.71,,,794.71,Other,153% New York Medicaid APG,1168.69,,,1168.69,Other,225% New York Medicaid APG,727.18,,,727.18,Other,140% New York Medicaid APG,1168.69,,,1168.69,Other,225% New York Medicaid APG,1350.48,,,1350.48,Other,260% New York Medicaid APG,1682.91,,,1682.91,Other,324% New York Medicaid APG,1116.74,,,1116.74,Other,215% New York Medicaid APG,1116.74,,,1116.74,Other,215% New York Medicaid APG,649.27,,,649.27,Other,125% New York Medicaid APG,519.42,57254.3,
Perq impltj/rplcmt isdns ptn,0587T,HCPCS,,,,,,,,both,,,143852.77,106451.05,74,,106451.05,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,64733.75,45,,64733.75,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,71207.12,49.5,,71207.12,percent of total billed charges,110% of Medicare,97819.88,68,,97819.88,percent of total billed charges,,966.11,,,966.11,Other,186% of Medicaid,115082.22,80,,115082.22,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,115082.22,80,,115082.22,percent of total billed charges,,7216,,,7216,Case Rate,,3148,,"100% primary, 0% secondary procedures",3148,Other,MagnaCare ASC Grouper,100696.94,70,,100696.94,percent of total billed charges,,93504.3,65,,93504.3,percent of total billed charges,,93504.3,65,,93504.3,percent of total billed charges,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,519.42,,,519.42,Other,New York Medicaid APG methodology,519.42,,,519.42,Other,100% New York Medicaid APG,519.42,,,519.42,Other,100% New York Medicaid APG,519.42,,,519.42,Other,100% New York Medicaid APG,1168.69,,,1168.69,Other,225% New York Medicaid APG,794.71,,,794.71,Other,153% New York Medicaid APG,1168.69,,,1168.69,Other,225% New York Medicaid APG,727.18,,,727.18,Other,140% New York Medicaid APG,1168.69,,,1168.69,Other,225% New York Medicaid APG,1350.48,,,1350.48,Other,260% New York Medicaid APG,1682.91,,,1682.91,Other,324% New York Medicaid APG,1116.74,,,1116.74,Other,215% New York Medicaid APG,1116.74,,,1116.74,Other,215% New York Medicaid APG,649.27,,,649.27,Other,125% New York Medicaid APG,519.42,115082.22,
Implt/rpl crtd sns dev total,0266T,HCPCS,,,,,,,,both,,,993426.73,735135.78,74,,735135.78,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,447042.03,45,,447042.03,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,491746.23,49.5,,491746.23,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,31375.51,,,31375.51,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,794741.38,80,,794741.38,percent of total billed charges,,695398.71,70,,695398.71,percent of total billed charges,,645727.37,65,,645727.37,percent of total billed charges,,645727.37,65,,645727.37,percent of total billed charges,,8589,,"100% primary, 50% secondary, 25% tertiary procedure",8589,Other,United Healthcare ASC Grouper,7730,,"100% primary, 50% secondary, 25% tertiary procedure",7730,Other,United Healthcare ASC Grouper,8589,,"100% primary, 50% secondary, 25% tertiary procedure",8589,Other,United Healthcare ASC Grouper,7301,,"100% primary, 50% secondary, 25% tertiary procedure",7301,Other,United Healthcare ASC Grouper,16868.56,,,16868.56,Other,New York Medicaid APG methodology,16868.56,,,16868.56,Other,100% New York Medicaid APG,16868.56,,,16868.56,Other,100% New York Medicaid APG,16868.56,,,16868.56,Other,100% New York Medicaid APG,37954.25,,,37954.25,Other,225% New York Medicaid APG,25808.89,,,25808.89,Other,153% New York Medicaid APG,37954.25,,,37954.25,Other,225% New York Medicaid APG,23615.98,,,23615.98,Other,140% New York Medicaid APG,37954.25,,,37954.25,Other,225% New York Medicaid APG,43858.24,,,43858.24,Other,260% New York Medicaid APG,54654.12,,,54654.12,Other,324% New York Medicaid APG,36267.39,,,36267.39,Other,215% New York Medicaid APG,36267.39,,,36267.39,Other,215% New York Medicaid APG,21085.69,,,21085.69,Other,125% New York Medicaid APG,4109,794741.38,
Implt/rpl crtd sns dev gen,0268T,HCPCS,,,,,,,,both,,,653144.11,483326.64,74,,483326.64,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,293914.85,45,,293914.85,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,323306.33,49.5,,323306.33,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,31375.51,,,31375.51,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9196,,"100% primary, 0% secondary procedures",9196,Other,MagnaCare ASC Grouper,457200.88,70,,457200.88,percent of total billed charges,,424543.67,65,,424543.67,percent of total billed charges,,424543.67,65,,424543.67,percent of total billed charges,,8589,,"100% primary, 50% secondary, 25% tertiary procedure",8589,Other,United Healthcare ASC Grouper,7730,,"100% primary, 50% secondary, 25% tertiary procedure",7730,Other,United Healthcare ASC Grouper,8589,,"100% primary, 50% secondary, 25% tertiary procedure",8589,Other,United Healthcare ASC Grouper,7301,,"100% primary, 50% secondary, 25% tertiary procedure",7301,Other,United Healthcare ASC Grouper,16868.56,,,16868.56,Other,New York Medicaid APG methodology,16868.56,,,16868.56,Other,100% New York Medicaid APG,16868.56,,,16868.56,Other,100% New York Medicaid APG,16868.56,,,16868.56,Other,100% New York Medicaid APG,37954.25,,,37954.25,Other,225% New York Medicaid APG,25808.89,,,25808.89,Other,153% New York Medicaid APG,37954.25,,,37954.25,Other,225% New York Medicaid APG,23615.98,,,23615.98,Other,140% New York Medicaid APG,37954.25,,,37954.25,Other,225% New York Medicaid APG,43858.24,,,43858.24,Other,260% New York Medicaid APG,54654.12,,,54654.12,Other,324% New York Medicaid APG,36267.39,,,36267.39,Other,215% New York Medicaid APG,36267.39,,,36267.39,Other,215% New York Medicaid APG,21085.69,,,21085.69,Other,125% New York Medicaid APG,4109,483326.64,
"Dstry eye lesn,fdr vssl tech",G0186,HCPCS,,,,,,,,both,,,12226.3,9047.46,74,,9047.46,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,5501.84,45,,5501.84,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,6052.02,49.5,,6052.02,percent of total billed charges,110% of Medicare,8313.88,68,,8313.88,percent of total billed charges,,1160.61,,,1160.61,Other,186% of Medicaid,9781.04,80,,9781.04,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,9781.04,80,,9781.04,percent of total billed charges,,7216,,,7216,Case Rate,,3578,,"100% primary, 0% secondary procedures",3578,Other,MagnaCare ASC Grouper,8558.41,70,,8558.41,percent of total billed charges,,7947.1,65,,7947.1,percent of total billed charges,,7947.1,65,,7947.1,percent of total billed charges,,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2904,,"100% primary, 50% secondary, 25% tertiary procedure",2904,Other,United Healthcare ASC Grouper,3227,,"100% primary, 50% secondary, 25% tertiary procedure",3227,Other,United Healthcare ASC Grouper,2743,,"100% primary, 50% secondary, 25% tertiary procedure",2743,Other,United Healthcare ASC Grouper,623.98,,,623.98,Other,New York Medicaid APG methodology,623.98,,,623.98,Other,100% New York Medicaid APG,623.98,,,623.98,Other,100% New York Medicaid APG,623.98,,,623.98,Other,100% New York Medicaid APG,1403.96,,,1403.96,Other,225% New York Medicaid APG,954.7,,,954.7,Other,153% New York Medicaid APG,1403.96,,,1403.96,Other,225% New York Medicaid APG,873.58,,,873.58,Other,140% New York Medicaid APG,1403.96,,,1403.96,Other,225% New York Medicaid APG,1622.36,,,1622.36,Other,260% New York Medicaid APG,2021.71,,,2021.71,Other,324% New York Medicaid APG,1341.57,,,1341.57,Other,215% New York Medicaid APG,1341.57,,,1341.57,Other,215% New York Medicaid APG,779.98,,,779.98,Other,125% New York Medicaid APG,623.98,9781.04,
Insertion of iris prosthesis,0616T,HCPCS,,,,,,,,both,,,364923.31,270043.25,74,,270043.25,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,164215.49,45,,164215.49,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,180637.04,49.5,,180637.04,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,2901.86,,,2901.86,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,291938.65,80,,291938.65,percent of total billed charges,,255446.32,70,,255446.32,percent of total billed charges,,237200.15,65,,237200.15,percent of total billed charges,,237200.15,65,,237200.15,percent of total billed charges,,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,1560.14,,,1560.14,Other,New York Medicaid APG methodology,1560.14,,,1560.14,Other,100% New York Medicaid APG,1560.14,,,1560.14,Other,100% New York Medicaid APG,1560.14,,,1560.14,Other,100% New York Medicaid APG,3510.31,,,3510.31,Other,225% New York Medicaid APG,2387.01,,,2387.01,Other,153% New York Medicaid APG,3510.31,,,3510.31,Other,225% New York Medicaid APG,2184.19,,,2184.19,Other,140% New York Medicaid APG,3510.31,,,3510.31,Other,225% New York Medicaid APG,4056.36,,,4056.36,Other,260% New York Medicaid APG,5054.85,,,5054.85,Other,324% New York Medicaid APG,3354.3,,,3354.3,Other,215% New York Medicaid APG,3354.3,,,3354.3,Other,215% New York Medicaid APG,1950.17,,,1950.17,Other,125% New York Medicaid APG,1560.14,291938.65,
Insert aqueous drain device,0253T,HCPCS,,,,,,,,both,,,85519.85,63284.69,74,,63284.69,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,38483.93,45,,38483.93,percent of total billed charges,Medicare Ratio of cost to charges,4565,,"100% primary, 50% supplemental procedure",4565,Other,Aetna ASC Grouper,4109,,"100% primary, 50% supplemental procedure",4109,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,42332.33,49.5,,42332.33,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,5415.62,,,5415.62,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,59863.9,70,,59863.9,percent of total billed charges,,55587.9,65,,55587.9,percent of total billed charges,,55587.9,65,,55587.9,percent of total billed charges,,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,2911.62,,,2911.62,Other,New York Medicaid APG methodology,2911.62,,,2911.62,Other,100% New York Medicaid APG,2911.62,,,2911.62,Other,100% New York Medicaid APG,2911.62,,,2911.62,Other,100% New York Medicaid APG,6551.15,,,6551.15,Other,225% New York Medicaid APG,4454.78,,,4454.78,Other,153% New York Medicaid APG,6551.15,,,6551.15,Other,225% New York Medicaid APG,4076.27,,,4076.27,Other,140% New York Medicaid APG,6551.15,,,6551.15,Other,225% New York Medicaid APG,7570.22,,,7570.22,Other,260% New York Medicaid APG,9433.66,,,9433.66,Other,324% New York Medicaid APG,6259.99,,,6259.99,Other,215% New York Medicaid APG,6259.99,,,6259.99,Other,215% New York Medicaid APG,3639.53,,,3639.53,Other,125% New York Medicaid APG,2911.62,63284.69,
Insj aqueous drain dev 1st,0449T,HCPCS,,,,,,,,both,,,109933.59,81350.86,74,,81350.86,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,49470.12,45,,49470.12,percent of total billed charges,Medicare Ratio of cost to charges,3473,,"100% primary, 50% supplemental procedure",3473,Other,Aetna ASC Grouper,3126,,"100% primary, 50% supplemental procedure",3126,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,54417.13,49.5,,54417.13,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3819.9,,,3819.9,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,6751,,"100% primary, 0% secondary procedures",6751,Other,MagnaCare ASC Grouper,76953.51,70,,76953.51,percent of total billed charges,,71456.83,65,,71456.83,percent of total billed charges,,71456.83,65,,71456.83,percent of total billed charges,,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,2053.71,,,2053.71,Other,New York Medicaid APG methodology,2053.71,,,2053.71,Other,100% New York Medicaid APG,2053.71,,,2053.71,Other,100% New York Medicaid APG,2053.71,,,2053.71,Other,100% New York Medicaid APG,4620.84,,,4620.84,Other,225% New York Medicaid APG,3142.17,,,3142.17,Other,153% New York Medicaid APG,4620.84,,,4620.84,Other,225% New York Medicaid APG,2875.19,,,2875.19,Other,140% New York Medicaid APG,4620.84,,,4620.84,Other,225% New York Medicaid APG,5339.64,,,5339.64,Other,260% New York Medicaid APG,6654.01,,,6654.01,Other,324% New York Medicaid APG,4415.47,,,4415.47,Other,215% New York Medicaid APG,4415.47,,,4415.47,Other,215% New York Medicaid APG,2567.13,,,2567.13,Other,125% New York Medicaid APG,2053.71,81350.86,
Insj iris prosth w/rmvl&insj,0617T,HCPCS,,,,,,,,both,,,364923.31,270043.25,74,,270043.25,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,164215.49,45,,164215.49,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,180637.04,49.5,,180637.04,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3819.9,,,3819.9,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,291938.65,80,,291938.65,percent of total billed charges,,255446.32,70,,255446.32,percent of total billed charges,,237200.15,65,,237200.15,percent of total billed charges,,237200.15,65,,237200.15,percent of total billed charges,,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,2053.71,,,2053.71,Other,New York Medicaid APG methodology,2053.71,,,2053.71,Other,100% New York Medicaid APG,2053.71,,,2053.71,Other,100% New York Medicaid APG,2053.71,,,2053.71,Other,100% New York Medicaid APG,4620.84,,,4620.84,Other,225% New York Medicaid APG,3142.17,,,3142.17,Other,153% New York Medicaid APG,4620.84,,,4620.84,Other,225% New York Medicaid APG,2875.19,,,2875.19,Other,140% New York Medicaid APG,4620.84,,,4620.84,Other,225% New York Medicaid APG,5339.64,,,5339.64,Other,260% New York Medicaid APG,6654.01,,,6654.01,Other,324% New York Medicaid APG,4415.47,,,4415.47,Other,215% New York Medicaid APG,4415.47,,,4415.47,Other,215% New York Medicaid APG,2567.13,,,2567.13,Other,125% New York Medicaid APG,2053.71,291938.65,
Insj iris prosth sec io lens,0618T,HCPCS,,,,,,,,both,,,41438.26,30664.31,74,,30664.31,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,18647.22,45,,18647.22,percent of total billed charges,Medicare Ratio of cost to charges,4827,,"100% primary, 50% supplemental procedure",4827,Other,Aetna ASC Grouper,4344,,"100% primary, 50% supplemental procedure",4344,Other,Aetna ASC Grouper,5305,,"100% primary, 50% secondary, 25% supplemental procedure",5305,Other,Blue Cross ASC Grouper,4775,,"100% primary, 50% secondary, 25% supplemental procedure",4775,Other,Blue Cross ASC Grouper,4509,,"100% primary, 50% secondary, 25% supplemental procedure",4509,Other,Blue Cross ASC Grouper,20511.94,49.5,,20511.94,percent of total billed charges,110% of Medicare,6152,,,6152,Case Rate,,3819.9,,,3819.9,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,33150.61,80,,33150.61,percent of total billed charges,,29006.78,70,,29006.78,percent of total billed charges,,26934.87,65,,26934.87,percent of total billed charges,,26934.87,65,,26934.87,percent of total billed charges,,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,6232,,"100% primary, 50% secondary, 25% tertiary procedure",6232,Other,United Healthcare ASC Grouper,6924,,"100% primary, 50% secondary, 25% tertiary procedure",6924,Other,United Healthcare ASC Grouper,5885,,"100% primary, 50% secondary, 25% tertiary procedure",5885,Other,United Healthcare ASC Grouper,2053.71,,,2053.71,Other,New York Medicaid APG methodology,2053.71,,,2053.71,Other,100% New York Medicaid APG,2053.71,,,2053.71,Other,100% New York Medicaid APG,2053.71,,,2053.71,Other,100% New York Medicaid APG,4620.84,,,4620.84,Other,225% New York Medicaid APG,3142.17,,,3142.17,Other,153% New York Medicaid APG,4620.84,,,4620.84,Other,225% New York Medicaid APG,2875.19,,,2875.19,Other,140% New York Medicaid APG,4620.84,,,4620.84,Other,225% New York Medicaid APG,5339.64,,,5339.64,Other,260% New York Medicaid APG,6654.01,,,6654.01,Other,324% New York Medicaid APG,4415.47,,,4415.47,Other,215% New York Medicaid APG,4415.47,,,4415.47,Other,215% New York Medicaid APG,2567.13,,,2567.13,Other,125% New York Medicaid APG,2053.71,33150.61,
Insj ocular telescope prosth,0308T,HCPCS,,,,,,,,both,,,364923.31,270043.25,74,,270043.25,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,164215.49,45,,164215.49,percent of total billed charges,Medicare Ratio of cost to charges,2480,,"100% primary, 50% supplemental procedure",2480,Other,Aetna ASC Grouper,2232,,"100% primary, 50% supplemental procedure",2232,Other,Aetna ASC Grouper,8517,,"100% primary, 50% secondary, 25% supplemental procedure",8517,Other,Blue Cross ASC Grouper,7665,,"100% primary, 50% secondary, 25% supplemental procedure",7665,Other,Blue Cross ASC Grouper,7239,,"100% primary, 50% secondary, 25% supplemental procedure",7239,Other,Blue Cross ASC Grouper,180637.04,49.5,,180637.04,percent of total billed charges,110% of Medicare,248147.85,68,,248147.85,percent of total billed charges,,5415.62,,,5415.62,Other,186% of Medicaid,291938.65,80,,291938.65,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,291938.65,80,,291938.65,percent of total billed charges,,7216,,,7216,Case Rate,,9196,,"100% primary, 0% secondary procedures",9196,Other,MagnaCare ASC Grouper,255446.32,70,,255446.32,percent of total billed charges,,237200.15,65,,237200.15,percent of total billed charges,,237200.15,65,,237200.15,percent of total billed charges,,8589,,"100% primary, 50% secondary, 25% tertiary procedure",8589,Other,United Healthcare ASC Grouper,7730,,"100% primary, 50% secondary, 25% tertiary procedure",7730,Other,United Healthcare ASC Grouper,8589,,"100% primary, 50% secondary, 25% tertiary procedure",8589,Other,United Healthcare ASC Grouper,7301,,"100% primary, 50% secondary, 25% tertiary procedure",7301,Other,United Healthcare ASC Grouper,2911.62,,,2911.62,Other,New York Medicaid APG methodology,2911.62,,,2911.62,Other,100% New York Medicaid APG,2911.62,,,2911.62,Other,100% New York Medicaid APG,2911.62,,,2911.62,Other,100% New York Medicaid APG,6551.15,,,6551.15,Other,225% New York Medicaid APG,4454.78,,,4454.78,Other,153% New York Medicaid APG,6551.15,,,6551.15,Other,225% New York Medicaid APG,4076.27,,,4076.27,Other,140% New York Medicaid APG,6551.15,,,6551.15,Other,225% New York Medicaid APG,7570.22,,,7570.22,Other,260% New York Medicaid APG,9433.66,,,9433.66,Other,324% New York Medicaid APG,6259.99,,,6259.99,Other,215% New York Medicaid APG,6259.99,,,6259.99,Other,215% New York Medicaid APG,3639.53,,,3639.53,Other,125% New York Medicaid APG,2232,291938.65,
Colgn cross-link crn med sep,0402T,HCPCS,,,,,,,,both,,,42122.79,31170.86,74,,31170.86,percent of total billed charges,150% of Medicare + 9.63% HCRA Surcharge,18955.26,45,,18955.26,percent of total billed charges,Medicare Ratio of cost to charges,2281,,"100% primary, 50% supplemental procedure",2281,Other,Aetna ASC Grouper,2053,,"100% primary, 50% supplemental procedure",2053,Other,Aetna ASC Grouper,3894,,"100% primary, 50% secondary, 25% supplemental procedure",3894,Other,Blue Cross ASC Grouper,3505,,"100% primary, 50% secondary, 25% supplemental procedure",3505,Other,Blue Cross ASC Grouper,3310,,"100% primary, 50% secondary, 25% supplemental procedure",3310,Other,Blue Cross ASC Grouper,20850.78,49.5,,20850.78,percent of total billed charges,110% of Medicare,28643.5,68,,28643.5,percent of total billed charges,,1464.68,,,1464.68,Other,186% of Medicaid,33698.23,80,,33698.23,percent of total billed charges,,7216,,,7216,Case Rate,,7216,,,7216,Case Rate,,33698.23,80,,33698.23,percent of total billed charges,,7216,,,7216,Case Rate,,4252,,"100% primary, 0% secondary procedures",4252,Other,MagnaCare ASC Grouper,29485.95,70,,29485.95,percent of total billed charges,,27379.81,65,,27379.81,percent of total billed charges,,27379.81,65,,27379.81,percent of total billed charges,,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,4079,,"100% primary, 50% secondary, 25% tertiary procedure",4079,Other,United Healthcare ASC Grouper,4531,,"100% primary, 50% secondary, 25% tertiary procedure",4531,Other,United Healthcare ASC Grouper,3852,,"100% primary, 50% secondary, 25% tertiary procedure",3852,Other,United Healthcare ASC Grouper,787.46,,,787.46,Other,New York Medicaid APG methodology,787.46,,,787.46,Other,100% New York Medicaid APG,787.46,,,787.46,Other,100% New York Medicaid APG,787.46,,,787.46,Other,100% New York Medicaid APG,1771.78,,,1771.78,Other,225% New York Medicaid APG,1204.81,,,1204.81,Other,153% New York Medicaid APG,1771.78,,,1771.78,Other,225% New York Medicaid APG,1102.44,,,1102.44,Other,140% New York Medicaid APG,1771.78,,,1771.78,Other,225% New York Medicaid APG,2047.4,,,2047.4,Other,260% New York Medicaid APG,2551.37,,,2551.37,Other,324% New York Medicaid APG,1693.04,,,1693.04,Other,215% New York Medicaid APG,1693.04,,,1693.04,Other,215% New York Medicaid APG,984.32,,,984.32,Other,125% New York Medicaid APG,787.46,33698.23,